I NEVER seem TO remember... Flashcards
List the cardioselective Beta-Blockers –>MAN BABE
Metoproplol
Atenolol
Nebivolol
Bisoprolol
Acebutolol
Betaxolol
Esmolol
What is the most common tachydysrhythmia seen in patients with WPW syndrome?
AVNRT
AVNRT is classified as either
orthodromic (narrow QRS complex)
antidromic (wide QRS complex).
Ortho”dRROW”mic AVNRT is much more common (90%–95% of cases) and has _______(narrow/wide)QRS complex
naRROW QRS complex because the cardiac impulse is conducted from the atrium through the normal AV node–His-Purkinje system.
Orthodromic AVNRT vs Antidromic which is more common ?
Orthodromic AVNRT is much more common (90%–95% of cases
In orthodromic AVNRT, what occurs?
Cardiac impulse is conducted from the atrium through the normal AV node–His-Purkinje system. These impulses return from the ventricle to the atrium using the accessory pathway.
In antidromic AVNRT, what occurs?
In the less common antidromic form of AVNRT the cardiac impulse is conducted from the atrium to the ventricle through the accessory pathway and returns from the ventricles to the atria via the normal AV node
What drugs are contraindicated with antidromic form of AVNRT? why?
Drugs that SLOW AV nodal conduction (BAC- LiDig)
β-blockers, Adenosine Calcium channel blockers Lidocaine Digoxin
Because they may increase conduction along the accessory pathway and are contraindicated.
Multifocal atrial tachycardia (MAT) is most commonly seen in patients experiencing
an acute exacerbation of chronic lung disease.
Treatment of antidromic AVNRT in patients with stable vital signs includes
IV administration of procainamide 10 mg/kg IV infused at a rate not to exceed 50 mg/min.
Treatment of orthodromic AVNRT in conscious patients in stable condition should begin with
vagal maneuvers such as carotid sinus massage or a Valsalva maneuver.
If vagal maneuvers are unsuccessful in a patient with AVNRT,–> VABA
Verapamil
Adenosine
β-blockers
Amiodarone may be used as clinically appropriate.
Wolff-Parkinson-White (WPW) syndrome is an inherited disorder characterized by
reentrant tachycardias.
The diagnosis of WPW syndrome is reserved for conditions characterized by
both preexcitation and tachydysrhythmia.
In WPW , Ventricular preexcitation causes an earlier-than-normal deflection of the QRS complex called a
delta wave.
ECG changes indicative of new ischemia
new ST-T changes,
new left bundle branch block
CABG is preferred over PCI in patients with
- significant left main coronary artery disease
- 3- vessel CAD
- patients with diabetes mellitus who have two- or three-vessel coronary artery disease.
Levels of cardiac troponins (troponin T or I) increase within_____hours
3 hours after myo- cardial injury and remain elevated for 7–10 days
Levels of cardiac troponins (troponin T or I) remain elevated for how long after MI
7-10 days
The criteria for the definition of an AMI have been revised Now this diagnosis requires detection of a rise and/or fall in cardiac biomarkers (preferably troponin with at least one value above the 99th percentile of the upper reference AND what?
(1) symptoms of ischemia
(2) ECG changes indicative of new ischemia, such as new ST-T changes or new left bundle branch block (LBBB)
(3) development of pathologic Q waves on the ECG, or (4) imaging evidence of a new loss of viable myocardium or a new regional wall motion abnormality.
Reperfusion / Thrombolytic therapy with tissue plasminogen activator (tPA) such as (name 3 )
alteplase, reteplase, or tenecteplase
Thrombolytic therapy with tissue plasminogen activator (tPA) should be initiated when?
should be initiated within 30–60 minutes of hospital arrival and within 12 hours of symptom onset.
The primary goal in management of STEMI is to
reestablish blood flow in the obstructed coronary artery as soon as possible.
What may be preferable to thrombolytic therapy for restoring flow to an occluded coronary artery if appropriate resources are available?
PCI
What are the 2 most common atrial dysrhythmias seen with AMI?
Atrial fibrillation and atrial flutter
The classic presentation is a hypercyanotic spell (“tet spell”) during which profound
cyanosis develops rapidly, accompanied by hyperpnea, possible loss of consciousness, stroke, seizures, or even death.
Treatment of tet spells
Treatment focuses on relieving the RVOT obstruction and reversing (or ameliorating) the right-to-left shunt.
Acute or emergent treatment entails (in escalating order) administration of 100% oxygen, fluid administration, and positioning (bending at the hip or gentle pressure on the abdomen
Absolute Indications for Lung separation
A. Isolation of one lung from the other to avoid spillage or contamination (INFECTION and MASSIVE Hemorrhage)
B. Control of the distribution of ventilation: Bronchopleural fistula, Bronchopleural Cutaneous fistula, Surgical opening of major conducting airway
Giant unilateral lung cyst or bulla relative vs absolute OLV
Absolute
Unilateral bronchopulmonary lavage 1. Pulmonary alveolar proteinosis: relative vs absolute OLV
Absolute
Relative indication for one-lung ventilation (OLV)
-
Surgical exposure—high priority*
1. Thoracic aortic aneurysm 2. Pneumonectomy
3. Thoracoscopy
4. Upper lobectomy
5. Mediastinal exposure
Absolute OR relative OLV –> –Postcardiopulmonary bypass pulmonary edema/hemorrhage after removal of totally occluding -unilateral chronic pulmonary emboli.
All Relative contraindication
The most common complication associated with a DLT is _______
malpositioning
Mediastinal Masses: What is the major anesthetic goal?
to maintain spontaneous ventilation, which retains normal airway-distending pressure gradients and can maintain airway patency when positive-pressure ventilation will not.
Left axis deviation is associated with what kind of fascicular block?
RIGHT axis deviation is associated with what kind of fascicular block?
Left axis –> LAft ANTERIOR Fascicular block
Right axis –> Left POSTERIOR Fascicular (LA-RP)
What is the most common hemiblock?
Left anterior fascicle (LAHB)
Why is a LEFT POSTERIOR HEMIBLOCK is uncommon when compared to LEFT ANTERIOR hemiblock?
Left posterior hemiblock (LPHB) is uncommon because the posterior fascicle of the LBB is larger and better perfused than the anterior fascicle.
Criteria for RBBB
widened QRS complex (≥120 ms in adults)
rSR′ configuration in leads V1 and V2
Deep S wave (>40 ms) in leads I and V6.
Criteria for LBBB
QRS complex of longer than 120 ms in duration in the -absence of Q waves in leads I and V5 and V6, a broad notched or slurred R wave in leads I, aVL, V5, and V6.
Crossmatching blood involves
mixing the blood of the donor and recipient together in the lab
What are 2 indications for lung transplantation?
Both cystic fibrosis and sarcoidosis
Which surgical procedure is most commonly associated with chronic postsurgical pain (CPSP)?
Thoracotomy
The most reliable stimulator of arousal in persons with obstructive sleep apnea is
Work of breathing
Which epidural needle has wings at the hub in order to stabilize the needle and assist grip during insertion?
Weiss
Where in the nephron do thiaziDe diuretics work? and how?
Thiazide diuretics work in the EARLY distal tubule by interfering with this sodium-chloride pump.
Part of the nephrons that contains sodium-chloride transporters that move sodium chloride out of the filtrate into the cells of the tubule walls.
The early distal tubule
During two-lung ventilation, about _____% of the pulmonary blood flow goes to the dependent lung. Therefore, when one-lung ventilation is instituted, you would expect the patient to experience approximately a____% shunt as blood that is unable to be oxygenated travels through the nondependent lung.
60% ; 40%
The recommended initial treatment for portal hypertensive ascites is
salt restriction (2 g/day) and diuretics.
Gas exchange occurs in the airways across which type of cells?
Squamous epithelial
Thiazide-type diuretics include: (MICH)
Metolazone
Indapamide
Chlorthalidone,
Hydrochlorothiazide
Spironolactone and eplerenone inhibit the hormone aldosterone directly in the
collecting duct
Amiloride and triamterene inhibit the opening of sodium channels where?
collecting duct, which blocks sodium reab- sorption and potassium secretion.
Examples of loop diuretics include: BEF-TO
bumetanide
ethacrynic acid,
furosemide
torsemide.
Loops diuretics work how and where in the nephron?
Inhibit sodium and chloride reabsorption at the Na+-K+-2Cl− channel in the thick ascending limb of the loop of Henle.
Intravascular injection of epinephrine 10 to 15 mcg/mL in adults produces a
10-beat or greater heart rate increase, or a 15 or greater mm Hg systolic blood pressure (SBP) increase in the absence of BAAG (β blockade, active labor, advanced age, or general/neuraxial anesthesia)
• Intravascular injection of epinephrine 0.5 mcg/kg in children produces a__________ in SBP
15 or greater mm Hg increase in SBP.
What can produce sedation if injected intravascularly in laboring patients.
• Fentanyl 100 mcg
The minimum recommended seizure duration for ECT is
25 seconds.
What nerve fibers are thought to exhibit dysfunctional activity in the setting of neuropathic pain? (select two)
A and C fibers
The most common congenital abnormality that can result in aortic dissection is
Bicuspid aortic valve
Tricuspid atresia is a congenital heart defect that is characterized by a (SEDPA)
Small right ventricle
Enlarged left ventricle
Decreased pulmonary blood flow (that occurs via a
ventricular septal defect,
Patent ductus arteriosus, or bronchial vessels)
Arterial hypoxemia
The recommended maximum leakage current allowed in operating room equipment is:
10 μA
Bupi- vacaine or ropivacaine, in concentrations of 0.125% to 0.5%, are usually administered with epinephrine 1 : 200,000, to a maximum dose of
2.5 mg/kg body weight.
A normal anion gap acidosis is often called a.
hyperchloremic metabolic acidosis
The 2 most common causes of a normal–anion gap acidosis are
IV infusion of sodium chloride
GI and renal losses of bicarbonate (diarrhea, renal tubular acidosis, early renal failure).
The most common cardiac side effects of tricyclic antidepressants are
increased heart rate and orthostatic hypotension.
What congenital disorder is highly suspected if maternal polyhydramnios is present?
TEF
Contrast-induced nephropathy is defined as an increase in serum creatinine of _____ mg/dL or a ____ percent increase from the baseline within the first 24 hours.
0.5 mg/dL; 25 percent
Hypoplastic left heart syndrome is characterized by 5 things? What are they ? Extracardiac congenital anomalies are typically ________
Left ventricular hypoplasia
Mixing of systemic venous and pulmonary venous blood in a single ventricle which communicates directly with the pulmonary and systemic circulatory systems, Hypoplasia of the ascending aorta
Mitral valve hypoplasia
Aortic valve atresia.
not present.
With Hypoplastic left heart syndrome, there is a Rapid decreases in _____ that can result in a
PVR; Decrease in coronary and systemic blood flow Metabolic acidosis High-output cardiac failure Ventricular arrhythmias.
The veins that contribute to the hepatic portal vein include:
- superior mesenteric vein 2. inferior mesenteric vein 3. Splenic vein.
The renal veins drain into the
inferior vena cava.
Preterm infants often display hyperkalemia. The causes of this are principally related to (select two)
immature distal tubule function
relative HYPOALDOSTERONISM
Nearly all of the skin of the leg is innervated by the _______nerve.
sciatic
When inserting an Eschmann stylet during intubation, the stylet should be advanced into the trachea until
the 25 cm marking is at the lip????
COMMON GIVEN MEDICATION Avoided preoperatively in the patient with significantly increased intracranial pressure?
MIDAZOLAM
The contraction of the gallbladder is primarily stimulated by the release of
CHOLECYSTOKIN
Cortisone has a _____short half-time of only _____
very; only 30 minutes.
Triamcinolone, betamethasone, and dexamethasone have elimination half-times between
3.5 and 5 hours.
Which of the following substances is the principal neurotransmitter in the activation of dorsal horn neurons following painful stimuli?
Glutamate
A 56-year-old man is undergoing a right carotid endarterectomy with intraoperative EEG monitoring. Which of the following cerebral blood flow rates BEST defines the range where signs of ischemia first appear on EEG?
15-20 mL/min/100 gm
12 French catheter would have an outer diameter of
To determine the outer diameter of the French gauge system, the French gauge is divided by 3, and the answer will be in millimeters. Therefore, a 12-Fr catheter would have an outer diameter of 4 mm.
Portal hypertension is defined as a
hepatic venous pressure gradient (HVPG) greater than 5-6 mmHg,
Hepatic venous pressure gradient (HVPG) is calculated by the calculating the
difference between portal and hepatic vein pressure.
Portal hypertension results in 6 things: Name 2 LESS OBVIOUS
ascites formation of varices hepatorenal syndrome splenomegaly ***splanchnic vasodilation*** ***gastropathy****
HVPGs in excess of_____ mmHg place the patient at risk for variceal bleeding.
12
Where does Aldosterone work in the nephron?
CD
Collecting duct
Distal tubule
What is the predisposing factor doubles the risk of bladder cancer?
Smoking
The mainstay of treatment of disseminated intravascular coagulation is the administration of
FFP
Can infrared gas analyzers directly measure oxygen content?
NO
It is an INTRAumbilical abdominal herniation in pediatrics
omphalocele
Associated with projectile vomiting in pediatric
Pyloric stenosis
Factors decrease in pregnancy
11 and 13 (XI and XIII) (think decrease pregnancy risk in 11 and 13 yrs old)
Factors UNCHANGED in pregnancy
2, 5 (II, and V)
It is (also known as congenital aganglionic megacolon) in pediatrics
Hirschsprungs disease
It is a lack of parasympathetic ganglion cells in the large intestine with resulting distention of the colon and intestinal obstruction in pediatrics?
Hirschsprungs disease
It is lateral to the umbilicus (usually to the right side) of pediatric patients? (GI condition)
gastroschisis
It is an PERIumbilical abdominal herniation in pediatrics
Gastrochisis
The gallbladder normally stores about _____ mL of bile.
50
Which of the following Acid / base abnormality is associated with hypoaldosteronism?
Hyperchloremic metabolic acidosis
At birth, the T waves are_______ in all chest leads, but become isoelectric or inverted in leads V1-V4 by when? .
upright; one week of age. They remain isoelectric or inverted until adolescence when they become upright again.
Failure of the V1-V4 T waves to invert by one week of age can indicate
right ventricular hypertrophy.
Which Laminae are located in the dorsal horn of the spinal column.
Rexed laminae I through laminae VI
Which laminae are located location in the comprise the ventral horn.
Laminae VII, VIII, and IX
When you see a question about shunt or venous admixture, think about _____. Explain.
FRC.
When your FRC is less, the amount of pulmonary blood that comes into contact with oxygenated alveoli per unit time is DECREASED which INCREASES the venous admixture (shunt)
In the clinical, when FRC is decreased the patient is at risk for rapid _________and the A-a gradient is
Desaturation ; INCREASED
% of RV in total lung capacity
20%
How much oxygen is consumed by a 70kg healthy adult at rest? Give your answer in ml/100g/min
Classic formula is 3.5 ml/kg/min
Classic answer of O2 consumption at rest for a 70kg adult is
250 mL/min
Phenomenon responsible for tachypnea that accompanies pulmonary embolism
J receptor stimulation
Phenomenon responsible for tachypnea that accompanies vascular congestion such as CHF
J receptor stimulation
Stop inspiration when lungs is hyper inflated?
Hering Bruer Inflation reflex
Peak effect of HPV
15 minutes
HPV inhibited by
Vasodilators
HPV inhibited by 3 med classes
Vasodilators,PDE inhibitors, CCBs
HPV during OLV is effective in decreasing the cardiac output to the nonventilated lung by approximately
50%
During * two-lung* ventilation, blood flow to the dependent lung averages approximately
60%
During OLV Without autoregulation of pulmonary blood flow, a ___% shunt would be anticipated.
40%
HPV is a reflex intrapulmonary feedback mechanism in homogeneous lungs that does 2 main things?
Improves gas exchange
Improves arterial oxygenation.
Hypoxemia causes________ (dilation vs constriction) in the general circulation
vasodilation
Alveolar hypoxia effect on pulmonary arteries.
Vasoconstriction
HPV can increase the PVR by
50% to 300%, and the response can persist for long periods of time in the face of chronic hypoxia
HPV occurs whether the lung is rendered hypoxic by atelectasis or by ventilation with a hypoxic mixture. It is initiated within _______and reaches its maximum effect in approximately
seconds of hypoxia; 15 minutes.
HPV improves arterial oxygenation when the amount of hypoxic lung is between____and ____%
20% and 80%, which occurs during OLV.
*****Factors That Reduce Effectiveness of Hypoxic Pulmonary Vasoconstriction. (4HA PEAS)
- Hemodilution
- Hypervolemia (LAP > 25 mm Hg), atrial natriuretic peptide
- Hypocapnia
- Hypothermia
- Prostacyclin
- Excessive tidal volume or PEEP
- Alkalosis
- Shunt fraction < 20% or > 80%
*****Medications that Reduce Effectiveness of Hypoxic Pulmonary Vasoconstriction (VCV 1.5 P)
Vasodilators
Calcium channel blockers
Volatile anesthetics > 1.5 MAC
Phosphodiesterase inhibitors
Hypoxemia when Oxygen does not help?
Right to left shunt (VET) : VSD, Eisenmenger, Tetralogy
The single best predictor of post operative PULMONARY complications is
VO2 max (also hypoalbuminemia and INCREASED BUN are able to do so)
Pneumonectomy, how much fluid to be given within the first 24 hours?
< 3L
Best predictor test of airflow in the medium size airways?
MMEF
Normal MMEF is
> or equal to 75%
Severe MMEF is
less or equal to 30%
What is the 2 most common ABG finding during an asthmatic attack are
Hypocarbia
Respiratory Alkalosis.
When does CO2 retention starts doing an asthmatic attack?
When FEV1 < 25% and it is a sign of IMPENDING RESPIRATORY FAILURE
FEV1 in asthmatic that indicates impending respiratory failure is
FEV1 < 25%
What does the diffusion capacity for carbon monoxide measure?
How well the lung can exchange gas.
DLCO measures the partial pressure
Different between the inspired and expired CO after a known quantity of CO has been inhaled
What is a normal DLCO?
17-25 ml/CO/min/mmHg
DLCO : higher/lower values correlate with a
significant reduction in diffusing capacity.
DLCO Using this law
Fick’s law of diffusion
Using Fick’s law of diffusion, the DLCO tell us 2 key characteristics about the alveolocapillary interface, what are they?
Surface area (emphysema) Thickness (increased by fibrosis and pulmonary edema)
Does asthma affect DLCO
NO
Chronic Bronchitis : what happens to Blood?
Polycythemia
Increased RBC mass compensates for chronically low PaO2 (tend to retain CO2 (BLUE BLOATERS)
Which heart issue is common with chronic bronchitis, what is it a result of ?
Right heart failure, results of pulmonary HTN (think all signs of RV failure)
With pulmonary embolism prevents
Blood in the affected vessels form reaching the
Best ventilatory strategy for restrictive lung disease ?
Smaller TV 6 ml/kg/IBW
Faster RR 14-18 breaths/min
There are five causes of hypoxemia, which ones are associated with normal A-a gradient?
- High altitude
2. Hypoventilation
There are five causes of hypoxemia, which ones are associated with INCREASED A-a gradient?
Diffusion defect
V/Q mismatch
Right to left shunt (O2 not helpful)
What is an example of acute intrinsic restrictive lung disease>
Negative pressure pulmonary edema
Flail chest chest movement during inspiration and expiration?
Inward during inspiration
Outward during expiration.
Best measurement of gas EXchange
DLCO
Best measurement of RESPIRATORY MECHANICS
FEV1
Best measurement of cardiorespiratory interaction is
VO2 max
6 steps (in order of preference) to reverse hypoxemia during OLV. (FDC- PLR)
FIO2 to 100% DLT position check with fiberoptic CPAP 10cm H2O non-dep lung PEEP 5-10 dependent lung Ligate/clamp pulmonary artery of non-dependent lung (not always poss) Resume 2-lung ventilation
What are the 2 CLINICALLY SIGNIFICANT examples of the baroreceptor reflex during surgery include
- Carotid sinus manipulation reflex during CEA (carotid endarterectomy.)
- Aortic baroreceptor stimulation from pressure exerted on the aortic arch during mediastinoscopy
During mediastinoscopy, which receptor can be stimulated?
Aortic baroreceptor stimulation from pressure exerted on aortic arch
Mediastinoscopy which site for aline monitoring and why?
Right radial because it provides indication of innominate artery
5 possible complications of mediastinoscopy?
hemorrhage Pneumothorax dysrhythmias (bradycardia) bronchospasm Left RLN Laceration of trachea or esophagus
Chylothorax from mediastinoscopy can occur secondary to
Laceration of the thoracic duct
Mediastinoscope can put pressure on the
Innominate (brachiocephalic artery) prior to its division to right common carotid and right subclavian artery>
2 things that can be played to monitor perfusion to Right arm during mediastinoscope
Pulse ox or radial artery catheter (a-line)
All sympathetic neurotransmitters are synthesized from _______ The synthesis takes place where ?
tyrosine ; in the post-ganglionic sympathetic nerve ending.
What is the local anesthetic that is prolonged the most by adding an adrenergic agonist.
Tetracaine
Which endotracheal tube is designed to deflect laser beams?
Mallinckrodt tube
Constrast-induced neuropathy is can be seen with 2 changes from the baseline what are they?
Serum Creatinine increase by 0.5
BUN increase by 25%
At what blood carboxyhemoglobin level is hyperbaric oxygen indicated?
> 30%
In the brain, As the MAP decreases within this autoregulation range, the cerebral vessels
dilate to keep CBF constant. (DD : decrease, dilate)
During renal transplant, where is the donor kidney anastoamosed?
The donor kidney is anastamosed to the recipient’s external iliac artery and vein
When the glomerular filtration reaches____of normal, serum potassium begins to elevate.
10%
the QRS axis is_____-sided at birth
right; It shifts leftward by about one month of age. The T waves are upright in all chest leads at birth, but become isoelectric or inverted in leads V1-V4 by one week of age
Barbiturates on cerebrovascular resistance
INCREASES cerebrovascular resistance
One way to estimate the approximate MAC of an agent is to divide
150 by the oil:gas coefficient. In this case, 150 divided by 100 would equal an estimated MAC of 1.5%.
The secretion of hydrogen ions and reabsorption of bicarbonate ions occurs all along the tubules with the exception of the
thin segments of the loop of Henle
Deleterious effects of hypothermia include:
Effect on hemoglobin-oxygen saturation Curve
left shift of the hemoglobin-oxygen saturation curve
Deleterious effects of hypothermia include:
Effect on Platelet
reversible platelet dysfunction
Deleterious effects of hypothermia include: Effect on wound
poor wound healing
increased incidence of infection
Deleterious effects of hypothermia include: Effect on Heart
cardiac arrhythmias
increased PVR
Deleterious effects of hypothermia include: Effect on Protein
postoperative protein catabolism
Deleterious effects of hypothermia include: Effect on drug metabolism
decreased drug metabolism
Deleterious effects of hypothermia include: mental status
altered mental status
Deleterious effects of hypothermia include: Effect on Kidney
impaired renal function
What is the Formula for Closing Capacity?
Closing volume + Residual volume
The closing volume does increase from approximately of ____% of the TLC at age 20 years to approximately at ______%age 70 years
30% ; 55%
CO2 solubility is _____ mL
0.06 mL
This reaction : CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3- is catalyzed by which enzyme? Where does this reaction occurs? and is it slower or faster and why?
Carbonic anhydrase;
Outside the RBC’s, in the plasma, but it is much slower due to lack of CA.
CO2 dissociation curve and INHALED anesthetics effect? What about HIGH concentration of inhaled anesthetics?
All inhaled anesthetics depress the ventilatory response to hypercarbia in a dose-dependent fashion.
High concentrations of volatile anesthetics may almost entirely eliminate hypercarbia-induced increases in ventilatory drive.
The response of two common classes of IV anesthetics are subtly different – OPIOIDS create a_______ward-shift in the CO2 response curves, whereas benzodiazepines and propofol affect the slope?
Right (OPIOIDS)
Left (Benzodiazepines and Propofol) ; decrease the slope
How does Hypoxemia affect the CO2 dissociation curve?
Hypoxemia (paO2 < 65 mm Hg) leads to a LEFT-shift in the CO2 response curve.
What are other two causes of left-shift of the CO2 curve?
metabolic acidemia and central etiologies
Both of the medications that decrease the slope of the ventilatory response curves
Propofol
Benzodiazepines
Inspiration of CO2 in the alert and awake patients ventilatory response.
carbon dioxide in healthy, awake subjects INCREASES minute ventilation by approximately 3 L/min per 1 mm Hg of arterial carbon dioxide tension
CO2 dissociation curve as compared to the O2 dissociation curve
The CO2 dissassociation curve is linear in shape and steep compared to O2 dissociation curve
What is the appropriate mainstay of initial perioperative management in patients with carcinoid tumors?
somatostatin analog therapy
Carcinoid tumors release a variety of subtances (ex. serotonin, catecholamines, histamine) which can cause both
hypertension and hypotension.
How do you treat Hypotension in the patients with carcinoid tumors?
vasopressin (β-agonists may increase the release of vasoactive substances) or phenylephrine
How do you treat Hypertension in the patients with carcinoid tumors?
α and β-adrenergic receptor blockers
Clonidine has intrinsic ability to block conduction in ____- AND____FIBERS
C and Aδ fibers
A single induction dose OF ETOMIDATE may inhibit THIS ENZYME LEADING TO _______how long does it last
11β-hydroxylase ⇒Adrenocortical suppression
4-8 hours
Etomidate on EEG
initial increase α amplitude followed by progressive decrease in activity
The transplanted kidney is attached to the recipient’s vasculature via _____________ (which artery and vein) and the ureter is anastomosed
- **vascular anastomoses of the external iliac artery and vein
- *directly to the bladder
Why do many transplant recipients require a central line?
because of the administration of immunosuppressive and vasoactive medications.
2 medications that are calcineurin inhibitors used post transplant
Cyclosporine
Tacrolimus,
MOA of Calcineurin inhibitors?
Both Inhibits calcineurin and IL-2 production
Patients with ESRD are at risk for aspiration due to
Gastroparesis
What is the primary stimulus for the release of aldosterone by the adrenal cortex?
Angiotensin II
Aldosterone results in increased
sodium and water retention.
The circle system test evaluates the circle breathing system from the
common gas outlet to the y-piece and consists of two parts, the leak test and the flow tes
The hanging drop technique is used to verify that the epidural needle has passed through the
ligamentum flavum into the epidural space.
Write the SODA lime equation
- CO2 + H2O ↔ H2CO3
- H2CO3 + NaOH ↔ Na2CO3 + H2O + energy
- Na2CO3 + Ca (OH)2 → CaCO3↓ + NaOH
Water content of the Soda lime is
15-20%
Last phase of the soda lime
Na2CO3 + Ca (OH)2 → CaCO3↓ + NaOH
Baralyme + Sevoflurane leads to
FIRE
What 2 things reduce the production of Compound A
Addition of Ca(OH)2
removal of NaOH
High pressure system include
Back up cylinders
Cylinders yoke
Cylinder gauge
Cylinder regulator
Monitor lead ____for rhythm, and ____for ischemia
II;
V5
Anterior Axillary line
Nagelhout says V1-V2 to be placed at
4th ICS
Nagelhout says V4-V5 to be placed at
5th ICS
Intermediate pressure system include
Pipeline inlet Check valves Pressure gauges Ventilator power inlet Oxygen pressure system
FLOWMETER CONTROL VALVE is part of _______pressure system
Intermediate
Pipeline inlet is part of the
Intermediate pressure system
Oxygen 2nd stage regulator is part of the
Intermediate pressure system
Oxygen flush valve is part of the
intermediate pressure system
Part of the Low pressure system
Flowmeters
Vaporizers
Common gas outlets
Check valves (if present)
Higher temperature leads to ______vapor pressure
Higher VP
SA node primarily in 55% of us
RCA
AV node primarily in 90% of us
RCA
AV node is supplied by the RCA in
90% of people
SA node is supplied by the RCA in
55%
When ambient temperature goes high, what happens to fresh gas flow and the vaporizing chamber/ bypass chamber?
Less fresh gas flow to the VAPORIZING CHAMBER
More Fresh gas flow to the BYPASS CHAMBER
High pressure system begins and ends where?
Begins at the cylinder
Ends at the cylinder regulators
Intermediate pressure system begins and ends where?
Begins at the pipeline
Ends at the flowmeter valve
Intermediate pressure system begins and ends where?
Begins at the pipeline
Ends at the flowmeter valve
Low pressure system begins and ends where?
Begin at the flowmeter tubes
Ends at the common gas outlet
Best test to determine the vaporizer leak is
The negative pressure test
Low pressure leak test measure what?
Integrity of the low pressure circuit from the flowmeter valve to the CGO
Low pressure system fails if the bulb inflates within _____seconds
10
Low pressure leak test is the _____pressure test
NEGATIVE
For the low pressure leak test, If there is a minimum FGF when the machine is turned on, then what should be done
the machine must be turned On
With the pressure leak test, the FGF and ventilator must be on/off?
off
With the pressure leak test, should the vaporizer be on or off, explain
Should be off at first, then the test should be repeated as each vaporizer is turned on. The negative pressure test is best way of detecting a vaporizer leak
The high pressure leak test is conducted how?
Closing APL
Pressurize circuit to 30cm H2O
Observe the airway pressure gauge (should remain constant)
With the high pressure leak test, what determines which components of the low pressure system are test?
The presence or absence of a check valve.
Nagelhout proper placement of V5
Horizontal to V4 on the ANTERIOR AXILLARY line; or, if the anterior axillary line is difficult to identify, then midway between V4 and V6
So if you open a cylinder and you hear a hissing sound, what is it ? what should you do?
There is a leak
Tighten the connection.
Non metallic cylinder box is
Aluminum
Max temperature gas cylinder
130F (57C)
Fusible plug up made up of BLT
Bismuth
Lead
Tin
Cylinders must be checked every
5 years
Set Standards for compressed gas cylinder
US DOT
Pre-use checkout procedures created by
FDA
Set required components of anesthesia machine
American society for testing and material
Oiling valve increases risk of
Fire
Cracking a cylinder means
slowly opening the cylinder flush the valve outlet clean of dust and debris.
Oxygen fail safe device what oxygen pressure will completely stop the flow of N20?
< 20 psi
HYPOXIA prevention safety device is a
Proportioning device
It prevents you from setting a hypoxic mixture with the flow control valves.
The annular space is the
area between the WIDEST AREA of the indicator float and side wall of the flowmeter
Left axis deviation is
-45 to -90
Reynolds’ number formula
Density x diameter x velocity/ viscosity
How to calculate Fresh gas coupling
- first convert FGF from L/min to ml/min
- I:E ratio of 1:2 would be 20 seconds in inspiration and 40 seconds in expiration so 1/3 of time in inspiration SO –> 1/3 of the ml/min value
- Divide the ml/min value by the RR
- Add the results of step 3 to the TV
If compliance and peak pressure are given multiople
compliance by peak pressure then substract number from TV.
Variable bypass 4 things to think about ?
Flow over
Temperature compensated
Out of circuit
Agent specific
Determines splitting ration
Concentration set on the dial
Most common cause of a vaporizer leak
loose filler cap
ml of liquid anesthetic used an hour
Vol % x FGF x 3
Types of oxygen analyzers that must be calibrated daily
Galvanic fuel Cell
Types of oxygen analyzers that must is self-calibrating
Paramagnetic device
Oxygen analyzers resides in the _______limb
Inspiration
Increasing oxygen tension generates a current accross 2 electrodes? what type of oxygen analyzers
Galvanic Fuel cell
IS calcium a TREATMENT for hyperkalemia?
No , it stabilizes the membrane till you can treat
Sugammadex in order of affinity to NMB
Roc, vec, pancuronium
At what pH does ethyl violet change to purple
10.3
How many Kilocalories calories with each breath?
1.67 Kcal/breath
Exelon patch should be off _______
24 hours
Prolong effect of rocuronium
Dehydration
Labetalol Beta to alpha
7:1 beta to alpha
Control sympathetic output beta blocker
esmolol
Post op shivering treatment
Meperidine and Clonidine
Clonidine: and warming?
Inhibit warming patient may be shivering
ACE Inhibitors overdose antidotes : Name 2?
methelyne BLUE
NOREPINEPHRINE (BEST ANSWER, nitric oxide inhibition)
Hydralazine onset
10-15 minutes
Cyanide toxicity medication
Nitroprusside
Clinical manifestations of neonates born with congenital diaphragmatic hernia include
Dyspnea
Absent breath sounds on the affected side, a
Barrel-shaped chest
Scaphoid abdomen
Tachypnea
Dextrocardia
Severe retractions.
Clevidipine contraindicated in
Aortic Stenosis.
ARBs major side effect
Hyperkalemia
The pediatric dose of intranasal midazolam is
0.1-0.2 mg/kg.
After 2 PRBCs you should give
Calcium
Heparin needs
AT III
Pradaxa inhibits factor
X
Antithrombin III deficiency give
FFP
A peripheral nerve stimulator used to assess neuromuscular blockade is designed to produce what type of wave signal?
monophasic, square wave signals
Vitamin K dependent factors?
2, 7, 9 10 Protein C, Protein S
TXA inhibits conversion of
Plasminogen to plasmin
TXA inhibits conversion of
Plasminogen to plasmin (and plasmin itself dissolves clot)
Which of the following are known side effects of the use of fenoldapam as an agent for producing controlled hypotension?
Increased intraocular pressure
extrusion of the abdominal contents into the extraembryonic coelom is known as
Omphalocele
Tumescent lidocaine max
50-55mg/kg
Max dose of bupivacaine
2.5mg/kg without EPI (3mg/kg WITH EPI)
PONV dose of epinephrine
0.5 mg/kg
Chloroprocaine pka is high but still works fast why?
because of high concentrations
Contact with birds may contract _______pneumonia.
Chlamydia
Cancer medication Tamoxifen associated
Hypercalcemia (think Camoxifen)
Cancer medication Tamoxifen associated
Hypercalcemia; venous thrombosis.
Cancer medication Bleomycin associated
Pulmonary Fibrosis
Cisplatin side effects
ototoxicity and renal failure
Mitomycin side effects
hemolytic uremic failure and cardiac failure,
Which of the following interventions should be avoided in an infant with a congenital diaphragmatic hernia?
MASK VENTILATION –> stomach inflation and worsen mediastinal displacement.
Cirrhosis is associated with
Comment on : Na, albumin, anemia, Platelets, Bilirubin
Hyponatremia Hypoalbuminemia. Anemia Thrombocytopenia Hyperbilirubinemia
According to the standards set by the American Society for Testing and Materials (ASTM), a reservoir bag of ____liters that is distended to ____times its size shall not exert pressures that are (select two) less than ______or greater than ____
3L
four times
Less than 35 cm H20
Greater than 60 cm H2O
Tension pneumothorax percussion :
Hyperresonance to percussion
In what rexed laminae does the 2nd order neurons reside
Lamina V
When a GAS embolism is suspected, the patient should be placed in the
left lateral decubitus position. This is called the Durant Maneuver.
An increased BUN:creatinine ratio is consistent with
Decreased blood volume
Underdosing can lead to myasthenic crisis
Pyridostigmine
only cells in the renal tubules that do not synthesize ammonia to be used in the buffer system are the epithelial cells in the
Loop of Henle
What anatomic structures collect urine from the papilla and funnel it into the renal pelvis?
Major and minor calyces
Forced air warmers transfer heat to the patient via
convection.
Heat lamps and radiant heaters use
radiation.
Resistive heaters (such as warming blankets) use
conduction.
Resistive heat devices such as a heating blanket transfer heat via
conduction.
Pacemaker code letters meaning:VOID- TA
V = Ventricle A = Atria 0 = Neither I = Inhibited T = Triggered D = Dual. A pacemaker that paces the ventricle and does not sense is designated VOO.
Most effective at controlling gastric ACIDITY and VOLUME?
PPIs
MELD score that is consistent with a 100 percent mortality rate at three months?
40
1 thing that will cause the respirometer to register falsely ELEVATED tidal volumes
High flow rates
What flow rate will cause the respirometer to register falsely DECREASED tidal volumes?
low flow rates will register falsely decreased tidal volumes.
What is the functional unit of the liver?
Lobule
heated humidifier is typically set to heat the inspiratory gas to between
34-40 C
What are the 8 risk factors for intraoperative awareness?
Female gender
Obesity
Surgery after normal hours
Emergency surgery
Previous awareness
Use of nondepolarizing muscle relaxants
High-risk procedures such as cardiac, thoracic, or obstetric surgery
Young age (young adults, not children),
The risk for local anesthetic systemic toxicity is directly related to the _____ of the drug.
Potency
Biphosphonates such as pamidronate are administered for the management of
HYPERcalcemia
With age, renal cortical mass decreases by as much as
25%
Also, by age ___approximately ___%of the glomeruli are lost.
80 yo
50%
Extreme flexion of the thighs can result in injury to which nerve? (select two)
Obturator
Sciatic
The dose of neuromuscular blocking agents for obese patients should be based upon: Rocuronium, Vecuronium, cisatracurium?
IDEAL BODY WEIGHT (IBW)
The use of meperidine in elderly patients is not generally recommended because it is associated with an increased incidence of
Post of delirium
Expected side effect of intrathecal ketorolac is
mild decrease in heart rate 15-60 minutes after administration
What is the compensatory mechanism that maintains stroke volume in patients with mild mitral stenosis?
An increase in left atrial pressure
Infants have a much______proportion of body water than adults and a ______proportion of muscle tissue and______
higher ; lower; body fat.
As a result, water-soluble medications have a_______ volume of distribution in neonates.
larger relative
Weight-based loading doses for water-soluble drugs such as digoxin, aminoglycosides, and succinylcholine are for _______infants to achieve the same target concentration in the bloodstream.
higher
Weight-based loading doses for water-soluble drugs in infants include for drugs such as
digoxin, aminoglycosides, and succinylcholine (DAS)
For infants, Because of the lower muscle mass, drugs whose termination of action depends upon redistribution into the muscle tissue may have a _____ (higher/lower) initial peak plasma concentration and ______duration of action.
higher; longer
This mediation should be administered per liter of ascites removed to help prevent renal decompensation when performing large-volume paracentesis in a patient with hepatorenal syndrome.
Albumin 6-8 grams per L removed
Which of the following represents the normal cerebrospinal fluid pressure?
10-20
At an increased altitude, an older Tec isoflurane vaporizer will deliver a______Volume percent than the dial setting.
higher volume
The oxygen proportioning system on an anesthesia machine limits the FiO2 when using nitrous oxide to a minimum of
25%
The primary site of action for neuromuscular blocking agents is the (pre vs post )
postsynaptic nicotinic cholinergic receptor on the muscle endplate.
Retrograde cardioplegia is administered into the
coronary sinus via a catheter placed through the right atrium. (RCSRA)
Anterograde cardioplegia is administered directly into the
AAA- CO (Anterograde, Ascending, Aorta, Coronary ostia)
coronary ostia or into a cannula placed in the ascending aorta.
Following thoracic aortic surgery, a patient exhibits anterior spinal artery syndrome. What symptoms are associated with this disorder? (select two)
Bowel and bladder dysfuntion
Flaccid paralysis to LE
One method postulated to help decrease blood loss from a liver resection is
CVP < 5
The BODE index stands for
Body mass index
airflow Obstruction
Dyspnea
Exercise.
What does the BODE score assess?
It is a scoring system that uses these variables to predict long-term outcomes for individuals diagnosed with COPD and would be used as criteria for determining lung transplant eligibility.
Reflex responses to painful stimuli begin at about
24 weeks gestation
Intrathecal adenosine has been shown to be effective at treating (select two)
Allodynia
Hyperalgesia
Intrathecal adenosine appears to have antinociceptive activity at adenosine
A1 receptors in laminae I and II of the spinal cord.
Adenosine has been shown to be effective at treating
hyperalgesia, allodynia, and neuropathic pain, but not acute pain.
Intercalated cells play an important role in what? There are two types of intercalated cells: type A and type B. . ou can remember the function of each cell by its name. Type A cells get rid of Acid and Type B cells get rid of bicarbonate.
Acid-base balance by controlling the reabsorption and secretion of hydrogen ions, bicarbonate, and potassium.
2 Types of intercalated cells:
type A and type B.
Type A Intercalated cells play an important role in the
presence of acidosis by secreting hydrogen ions and reabsorbing bicarbonate
Type B intercalated cells are essentially the opposite of type A cells. Their role becomes important in states of
alkalosis because they secrete bicarbonate and reabsorb hydrogen ions
How you can remember the function of each cell by its name. Type A cells get rid ofand Type B cells get rid of bicarbonate.
Acid (A-A)
Bicarbonate (B-B)
Sepsis, PCWP, CO and SVR ?
Low pulmonary capillary wedge pressure
high cardiac output
low systemic vascular resistance
Endobronchial intubation can occur at any point during a procedure. It is more likely to occur in the right mainstem and can produce asymmetrical
chest expansion, unilateral breath sounds, hypoxemia, and increased peak airway pressures.
Calcium and phosphate in ESRD
Low calcium
High phosphate
What factor is most closely associated with an increased risk of mortality in patients over the age of 80 who undergo surgery?
ASA status
The pediatric dose of 0.3 M sodium citrate is
0.4 mL/kg.
The hospital pipeline system has a defect in which the oxygen lines are switched with the nitrogen lines. Which device would detect the presence of such an error the soonest?
Oxygen analyzer
TEC 6 features: what if it were loads into a standard vaporizer? is it heated? to what temperature? What is the pressure within the chamber.
if loaded into a standard vaporizer, the amount of vapor produced would be completely out of control.
To prevent that, the Tec 6 vaporizer is electrically heated, and a thermostat maintains the temperature at 39 degrees Celsius. At this temperature, the pressure within the desflurane chamber is at 1500 mmHg or 2 atmosphere
Hepatic blood flow can decrease substantially during abdominal surgery. This is most likely due to
Histamine release
You are contemplating using ketamine in suppository form for induction of anesthesia. What would be an appropriate dose?
5mg/kg
Which condition is characterized by loss of structural integrity of the laryngeal cartilages or abnormal neural control of the laryngeal muscles?
Laryngomalacia
Following an anesthetic, preterm infants should be monitored
For at least 12 hours
What is the most potent mineralocorticoid produced by the adrenal gland?
ALDOSTERONE
You identified an airway fire, removed the endotracheal tube, and rapidly checked for any debris in the oropharynx. What step should you take next?
POUR SALINE IN THE AIRWAY
Hepatic venous blood supply is responsible for _____of blood flow to the normal liver (approximately 1 L/min), but only _____of the liver’s oxygen supply.
70%; 50%
IS the largest internal organ,
LIVER
The functional unit of the liver is the
hepatic lobule or acinus.
Blood from the gut contains large quantities of colonic bacilli, and more than 99% of the bacterial load is removed by _________that line the hepatic sinuses
Kupffer cells (mac- rophages)
Initiated by epinephrine and glucagon, glycogenolysis is the process of
liberating glucose from glycogen stores found in the liver (and skeletal muscle).
Gluconeogenesis is the formation of.
glucose from the noncarbohy- drate molecules lactate and pyruvate, as well as amino acids, all of which are products of anaerobic and catabolic metabolism
Gluconeogenesis is stimulated by
A decrease in glycogen stores.
________may therefore be encountered in patients with severe liver disease due to
Hypoglycemia
Why do people with severe liver disease has an decrease in blood sugar?
Dysfunctions in insulin clearance
Decrease in glycogen capacities
Impaired gluconeogenesis.
Preferred energy source for brain
Glucose
Once in the liver, the unconjugated bilirubin is conjugated with
glucuronic acid.
Heme is converted to_________bilirubin in the
unconjugated bilirubin;
reticuloendothelial cells of the spleen
In response to the intestinal hormone__________bile is released by the gallbladder.
cholecystokinin (CCK),
The liver aids intestinal digestion by forming bile and secreting it into the
common bile duct (CBD).
What is the end product of hemoglobin metabolism?
conjugated bilirubin
The common bile duct merges with the pancreatic duct where?
At the ampulla of vater
These two ducts merge at the ampulla of Vater
Common bile duct and Pancreatic duct
CPA–> Common bile duct, pancreatic duct –> Ampulla
Which factors Is NOT PRODUCED by the liver
Factor VIII
In the presence of biliary deficiency, parenteral vitamin K administration helps correct coagulopathy. However, significant hepatocellular disease may dictate the need for _______for IMMEDIATE correction of coagulation factor deficits.
fresh frozen plasma (FFP)
Four techniques for Brachial plexus appraoch
Interscalene
Supraclavicular
Infraclavicula
Axillary
This block provides anesthesia for Upper arm, shoulder, and clavicular surgeries
ISB
ISB landmarks are
Clavicle
Acromion
Sternocleidomastoid muscle
ISB contraindications
COPD
ISB depth
1-2 cm
Horner syndrome
Miosis
Ptosis
anhidrosis (loss hemifacial sweating)
Retrobular and ISB block has a risk of
High spinal
Elbow surgery , arm, FA and wrist hand surgery what approach of ISB?
Supraclavicular
Landmark for Supraclavicular
Subclavian artery
Least reliable for return of
Tibial
Only block you can do under GA
TAP block
Correct sequence for the cuff BIER BLOCK
- PULSE CHECK (ALLENS test)
- Inflate cuff, deflate cuff
- IV
- Dual bladder cuff
- Arm elevated, eachar
- inflate cuff, make sure
IF shorter than 45 mins you
deflate for 3 minutes than reinflate
Tourniquet is ______above what pressure?
75-100;
SBP
For the upper extremity,_________ more than the patient’s systolic blood pressure should be used.
70–90 mm Hg
For the lower extremity,
twice the patient’s systolic pressure should be used
Bier block anesthesia, a minimum standard tourniquet pressure of _______mm Hg should be used unless the tourniquet is on the upper leg. In this instance, twice the patient’s systolic pressure should be used unless that amount is less than 300 mm Hg.
250
absolute contraindications to mediastinoscopy
Previous mediastinocopy
Absolute contraindications to mediastinoscopy
Previous mediastinocopy
Systemic Effects of Tourniquet Release
core temperature ? electrolyte disturbances?
central venous oxygen tension ?
Systemic Effects of Tourniquet Release
• Transient decrease in core temperature occurs.
• Transient metabolic acidosis occurs.
• Transient decrease in central venous oxygen tension occurs, but systemic
hypoxemia is unusual.
What happens to the pulmonary and systemic arterial What happens to end-tidal carbon dioxide ?
- Acid metabolites (e.g., thromboxane) are released into the central circulation.
- Transient fall in pulmonary and systemic arterial pressures occurs.
- Transient increase in end-tidal carbon dioxide occurs.
CO2 after releasing of tourniquet?
Transient increase in end-tidal carbon dioxide occurs.
Upon releasing the tourniquet, what acid metabolites are released in the circulation?
• Acid metabolites (e.g., thromboxane) are released into the central circulation.
What happens to pulmonary and systemic arterial pressures when tourniquet is released?
• Transient fall in pulmonary and systemic arterial pressures occurs.
Ayres T-piece being able to create
BLOW by O2 providsion
Ayres T-piece being able to create
BLOW by O2 provision
LVOT seen with Hypertrophic cardiomyophaty worsened by________ heart rate or ______myocardial contractility as well as in_____ preload or _____afterload.
increased; increased
decreases; increased
Hypertrophic cardiomyopathy –> Anesthesia is usually maintained by
controlled myocardial depression using volatile anesthetics.
Mnemonic for HCM /LVOT
Keep slow, lazy, and full, and relaxed
Poiseuile’s law
Pi * r^4 Change in P / 8nl
When in doubt , 3 to consider?
Circle
Bain
Modified Jackson release
Femoral nerve Mnemonic: Lame Soup –> SAIL
Lateral : Sartorius
Medial: Adductor Longus
Superior: Inguinal ligament
Break laryngospasm with APL at
20-40 cm H2O
Femoral : LATE ME NAVEL
Lateral to medial Nerve Artery Vein Empty space L
Desflurane and tachycardia.
Turn on to quick, NE release
Least pungent is
ISOFLURANE (not sevo)
Halothane must know
MOST pungent High MAC longer onset last forever Sensitize myocardium to catecholamines
Fast way to preoxygenate and dinitrogenate
3-5 TV breaths
Carbon monoxide worst with which agent?
Desflurane
Laser tube use
Blue dye
Laser tube use ____to fill the cuff
Blue dye
Cardioversion on ________
R wave
Measure PA pressure at
END Expiration
Big to maintain with AS
Afterload.
Phenylephrine , reflex bradycardia and HR increase
Bainbridge reflex
Spinal bP drop
Bezold parish
Alpha angle increase in EtCO2
Increase angle can be obstructed ETT or exp airflow obstruction
Elevate mandible and hyoid bone______maneuver
Larson’s maneuver
Larson’s maneuver Landmarks
Base of skull
Condyle
mastoid process
MH signs on EKG
Sinus Tachycardia
Dr CUMA for hand nerve lesions
Drop –Radial
Claw –> Ulnar
Median nerve –> Ape hand. (Dr. CUMA)
Interscalene Block done at the level of the
ROOTS
Sufraclavicular at the level of the
Trunks/ Division
Supraclavicular at the level of the
TRUNKS
Mnemonic to remember
RealTexansColdBeers
I-Sup-In-fA
Mnemonic to remember
RealTexansColdBeers
I-Sup-Inf- A
Count back for 300 ECG HR rule
300, 150, 100, 75, 60, 50
An useful mnemonic to remember the modalities of the lateral spinothalamic tract is “
Pa-Te-La” (Pain, Temperature via Lateral spinothalamic).
_____Fibers may be more difficult to anesthe- tize than A-delta fibers;
C fibers
ACyanotic are
LRA (think NRA) left to right acyanotic
Intracardiac R-L shunt. (RL-TEPE-C)
Tetralogy of Fallot
Ebstein anomaly Decreased pulmonary blood flow Pulmonary stenosis with atrial or ventricular septal
defects
Eisenmenger syndrome
With intracardiac R-L are there cyanosis
yes (therefore decrease pulmonary blood flow)
With intracardiac L-R are there cyanosis?
NO ; how to remember. –> (LR - Lactated Ringers gives O2) (not physiologically right)
The shunt lesion with the RVOT
RL TEPEC
Right to left shunt
Tetralogy of Fallot
Ebstein anomaly Decreased pulmonary blood flow Pulmonary stenosis with atrial or ventricular septal
defects
Eisenmenger syndrome
CYANOSIS
Shunt lesion with RVOT obstruction
RL (right to left) shunt
In which issue is the Intracardiac L-R and R-L shunts equal?
Dextro-transposition of the great arteries
Dextro-transposition of the great arteries : is there Cyanosis?
yes
Foot surgery additional combination block
Popliteal and Saphenous BLOCK
What nerves are block with the ankle Block?
Super Sa Su Doctor of Podiatry Tibs
DPT (Doctor of Podiatry Tips)
Superficial peroneal Saphenous Sural Deep Peroneal Posterial tibial
Lipid emulsion dosing
1.5 ML/ KG for lipid 20% over 1 minute F/ b 0.25
MAX dose 10 ml /kg
Max pressure for classic LMA
60mg.
Partial pressure of air
760 * 21 % = 160 mmHg
Contraindications of Nasal intubation
Le fort fracture
Hates vwf
Hespan
Hespan contraindications: and max dose
Renal failure and anaphylactoid reaction
Max dose 20cc/kg
Desmopressin dose
0.3 mcg/kg
Anaphylactoid reactions
First reaction full blown reaction
Anaphylaxis Top 1
NDNMBs
Anaphylactoid reactions vs anaphylaxis
First reaction full blown reaction
Propofol infusion syndrome : 1st
Unexplainable tachycardia (short lived, transient) then PROFOUND BRADYCARDIA Resistant to treatment
Propofol infusion syndrome what cause it
> 12-24 hours propofol infusion
2 main bacteria that grows after propofol out in 6 hours
E. coli and pseudomonas
Rule of 3 for UTERUS relaxation
3 units IVP
wait 3 minutes (is uterus still boggy ) yes (repeat 3 times)
Methergine IM or IV? what is the dose
IM, 0.2 mg
Hypertensive patients : hemabate vs methergine
Hemabate because High blood pressure
Hemabate releases a lot of histamine so
No for asthma
A OK for
Atropine
Ondansetron
Ketorolac
Amplitude is a measurement of the
intensity of the response to the signal.
Latency is measured in milliseconds and represents the
delay in the response to the stimulus.
The latency indicates how long it takes for the
signal and response to travel along the neural pathyway.
Pt is on Phenelzine (Nardil). Her anesthetic plan should include: t
The avoidance of meperidine, the avoidance of indirect acting vasopressors
Pt is on Phenelzine (Nardil). Her anesthetic plan should include:
The avoidance of meperidine, the avoidance of indirect acting vasopressors
What class is phenelzine (Nardil)
MAOI
The key factors determining the spread of an epidural block are the
Drug dose
Site of injection, and certain differences among patients.
Pediatric The oral dose of dexmedetomidine is.
2-4 mcg/kg and exhibits an onset of 30-60 minutes. Intravenous infusion is usually begun with a loading dose of 1 mcg/kg over 10 minutes followed by a continuous infusion of 0.3-0.7 mcg/kg per hour.
The intranasal dose of dexmedetomidine is
1-2 mcg/kg.
Precedex 1 mcg/kg dose results in sedation in most children within 60 minutes.
1
A one degree reduction in skin temperature correlates to an approximate ___ degree reduction in core body temperature.
0.2
Infants COMPARED to Adults : What are the difference in O2 consumption, Closing volume, MV:FRC?
Higher O2 consumption
Higher closing volume
Higher MV:FRC (ie have to maintain elevated RR)
Compliant ribs and less Type 1 muscle in the diaphragm
With aortic cross clamping, The most consistent effect is an increase in systemic vascular resistance. The blood pressure can increase by____ with an infrarenal clamp and as much as _____with a supraceliac clamp.
2-10%
50%
What are probably the most commonly used adjunct analgesics in the management of both neuropathic and somatic chronic pain? Which medication is the prototype?
TCAs
Amitriptyline is the prototype antidepressant
Patients treated with TCAs may have altered responses to anesthesia related drugs. An increase in CNS catecholamine levels may____-(increased/decreased) the minimum alveolar concentration (MAC) of the inhalation anes- thetics.
increase
With TCAs, the Increased peripheral catecholamines may produce exaggerated responses to what kind of vasopressors? This exaggerated response is prevalent upon initial TCA administration and lasts for how long?
If a vasopressor is administered, which one is preferred?
indirect acting pressors such as ephedrine.4 to 6 weeks.
A direct acting drug such as phenyl- ephrine
NE stimulates____________ to inhibit the further release of NE.
presynaptic alpha2-adrenergic receptors
Pal2
Epinephrine (E) and isoproterenol stimulate
Presynapticl beta2-adrenergic receptors to facilitate further NE release.
EpiBet2
The suggested spinal block height for lower extremity procedure such as a knee replacement is about
T12.
Mechanism/ cause of Serotonin syndrome
Overstimulation of 5-HT1A and possibly also 5-HT2 receptors through an excess of serotonin precursors or agonists, increased serotonin release, reduced serotonin uptake, and decreased serotonin metabolism
Name TCAs
-“end” with triptylines
- “end” with pramine
-doxepine
Amitriptyline
Desipramine Imipramine Nortriptyline Protriptyline Doxepin
Name MAOIs
Phenelzine
Isocarboxazid
Tranylcypromine
Selegiline
SSRIs are (CeLexPaProZoLu)
Prozac Paxil Zoloft Luvox
Celexa Lexapro
Hunter Serotonin Toxicity Criteria used to diagnosed
Serotonin syndrome
Most important Hunter Serotonin Toxicity Criteria
Clonus is strongly associated with serotonin toxicity.76
First-line therapy of treatment of serotonin syndrome is with
Cryproheptadine, an H1-receptor antagonist with antiserotonergic and anticholinergic properties.
Cyproheptadine initial dose and subsequent dose. How often and what is the max?
Started at a dose of 12 mg orally or through a nasogastric tube.An additional 2 mg dose is given every 2 hours until symptoms improve or the maximal dose of 32 mg has been reached. The usual maintenance dose of cyproheptadine is 8 mg three times daily.
Cyproheptadine, the first line of treatment for serotonin syndrome is what class of drug?
H1-receptor antagonist
Because of the risk of serotonin syndrome, serotonergic drugs and MAOIs should not be used together or within how long of each other?
2 weeks of each other.
Antimicrobial agents with MAOi activity
linezolid (Zyvox)
Serotonergic drugs used for cough
he cough suppres- sant dextromethorphan, sumatriptan (Imitrex, and generics),
Serotonergic drugs used for pain
Tramadol
Methadone
Herbal with seronertic active
St John’s Wort
Normal Lithium level
For acute treatment, target serum concentrations are 0.8 to 1.2 mEq/L.
Warfarin should NOT be used past how many weeks of gestation?
36 weeks gestation
inability to adduct the legs? damage to
Obturator
Caudal block concentration is
0.175% bupivacaine
Pregnancy produces an increase in the minute ventilation and a decrease in the functional residual capacity. That, combined with a decrease in MAC, results in both a
faster inhalation induction AND a faster emergence from anesthesia.
The MAC generally begins to decrease by the____or _____week of pregnancy.
8th or 10th
For Bier Block, To avoid a rapid bolus of intravenous local anesthetic that could result in local anesthetic toxicity, the tourniquet should remain inflated for a minimum of _____mns.
20 minutes.
For Bier block, If 40 minutes has elapsed, the tourniquet can be deflated in a single maneuver. If the duration is between 20 and 40 minutes, the tourniquet should be
deflated, reinflated immediately, and then deflated 1 minute later to prevent the rapid absorption of local anesthetic into the circulation.
A decrease in amplitude by _____percent or an increase in latency by _____percent commonly define a significant change in SSEPs.
DA50%IL10% (Decrease Amplitude 50% and Increased Latency 10%)
The maximum recommended bupivacaine dose for caudal or epidural injection is ___ mg/kg in neonates and ___ mg/kg in older children
2; 4
For Ductus Arteriosus Circulating __________ cause the muscle in the ductus to relax, promoting the continued patency of the ductus.
prostaglandins
For Ductus Arteriosus, the administration of ____________, can block this effect and allow the muscle to contract and close the ductus arterioles
Indomethacin, a prostaglandin inhibitor
The alveoli and pulmonary vasculature are not mature enough to produce acceptable gas exchange until about _____weeks gestation.
24 to 26 weeks gestation
With the first breaths after delivery, the alveoli rapidly convert from being filled with _______ to being filled with _____
being filled with fluid to being filled with air
The infant will generate a ________(positive/negative) intrathoracic pressures between_____and _____cm H20 in order to expand the alveoli and clear them of fluid.
negative 40 and 60 cm H2O
Within about _____minutes of delivery, the infant will have established a 3 things?
20 minutes
Normal ventilatory pattern
Stable blood gases
Near normal functional residual capacity.
For every 1 degree Celsius that the core body temperature decreases, the cerebral metabolic rate of oxygen consumption _____by how much>
Decreases by 8%
Which is the MOST SINGLE effective maneuver to increase Pa02 during one-lung ventilation?
Application of CPAP to the nondependent lung
Midazolam pediatric PO dose
0.5 mg/kg
Propofol and remifentanil are dosed based upon
LBW.
Hepatic mass does decrease with age, but the clearance of drugs with a high hepatic extraction ratio relies on
hepatic blood flow not hepatic mass. Hepatic blood flow decreases by as much as 40% by 80 years of age.
Hepatic blood flow decreases by as much as
40% by 80 years of age.
The segmental spread of an epidural relies primarily upon the _______ and the ______ This is in contrast to spinal anesthesia, which relies more on the
Epidural Spread EDS
Dose of local anesthetic solution used
Site of injection
Spinal Spread (SDBP)
Dose in milligrams of the local anesthetic
Baricity of the solution
Position to determine the spread of the anesthetic.
Prior to a Bier block, the tourniquet should be inflated to
300 torr or 2.5 times the patient’s systolic blood pressure.
Naloxone dose for fetus at risk for respiratory depression
0.1 mg/kg
The ability of newborns to metabolize amide local anesthetics is underdeveloped until about _____ of age.
3 months
Succinylcholine dosing for obese based on _______and NDNMB agents dosing for obese based on
TBW for succinylcholine
LBW for NDNMB agents
LA that is no longer used for obstetric epidurals because of the higher risk for local anesthetic systemic toxicity.
Bupivacaine
Emergence delirium in children between the ages of 2 and 6 years is most common with which VA?
Sevoflurane
The neonatal response to hypoxia is typically a short period of _____ followed by _____.
Hyperventilation to Hypoventilation
GOC TIM are all typically repaired within the first week following delivery
Gastroschisis Omphalocele Congenital diaphragmatic hernia Tracheoesophageal fistula Intestinal obstruction Myelomeningocele
The most common congenital primary neural tube defect is
meningomyelocele.
Leading cause of maternal death WORLWIDE?
postpartum hemorrhage
Compare to an adult with a TV around 7 mL/kg, the tidal volume of an infant is
similar to that of an adult
When should chest compressions be initiated in the neonate?
< 60
What is the peak onset of heparin for normothermic patients?
<5 minutes
You plan to administer acetaminophen to a pediatric patient as part of the postoperative analgesia plan. You know that the maximum dose is _____ in a 24 hour period.
100mg/kg
High tracheal resection patient position?
Patient should be kept in the head-down position to prevent aspiration of blood and surgical debris during
The 2 hormones in the mother create a tendency towards hyperglycemia and ketosis.
lactogen and cortisol in the mother
Emery-Dreifuss syndrome is also a milder form of muscular dystrophy in which the primary concern is
cardiac conduction defects and resulting syncope. In these patients, a preoperative echocardiogram and electrocardiogram are warranted
You are preparing to perform a Bier block. After starting an IV in the dorsum of the hand, placing a double pneumatic tourniquet on the arm and exsanguinating the extremity with an Eschmark bandage, you should inflate which cuff first? Then what is inflated?
DISTAL. (in alphabet, D before P)
The distal cuff is inflated first followed by the proximal cuff. The distal cuff is then deflated to allow the area under it to become anesthetized. If the proximal cuff of the tourniquet becomes too painful for the patient to tolerate, the distal cuff can be inflated and then the proximal cuff deflated to allow the surgeon more time to complete the procedure.
For children younger than 8 years, the formula for IBW in kilograms is:
IBW = 2 X Age in years + 9.
For children 8 years of age or older, the formula for IBW in kilograms is: IBW =
3 X Age in years.
The decrease in total body water that occurs with aging is primarily due to
Decrease in muscle mass
Select two prominent peripheral vasodilators that are effective in the treatment of postoperative hypertension in cardiac surgical patients.
Nicardipine
Nifedipine
Latex allergy can be either a type ___hypersensitivity reaction to chemicals used in latex rubber processing or a type _____ immediate hypersensitivity reaction with_____antibodies formed in response to latex rubber protein.
IV
I
IgE
SLE Clinical manifestations include AVM
althralgias, vasculitis and malar rash on the face.
What type of allergic reaction: Systemic lupus erhthematosus, serum sickness after a snake bite
Type III Immune complex mediation reaction
What type of allergic reaction: serum sickness after a snake bite
Type III Immune complex mediation reaction
What type of allergic reaction: Contact sensitivity to poison ivy and metals (jewelry)
Type IV Cell mediation reaction
What type of allergic reaction:graft-vs-host reaction
Type IV Cell mediation reaction
What type of allergic reaction: Autoimmune thrombocytopenic purpura,
Type II Tissue specific reaction
What type of allergic reaction :Graves disease
Type II Tissue specific reaction
What type of allergic reaction: Autoimmune hemolytic anemia
Type II Tissue specific reaction
What type of allergic reaction: ABO incompatibiliy
Type II Tissue specific reaction
What type of allergic reaction Seasonal allergic rhinitis, Anaphylaxis
Type I IgE mediated reaction
hallmark is morning stiffness that generally improves with activity. The joints are painful, swollen and warm.
Rheumatoid Arthritis
Anaphylaxis causes degranulation of:
Mast cells and basophils
What forms of insulin are considered intermediate-acting? (select two)
Human NPH
Lente
The incidence of heparin-induced thrombocytopenia is higher
in patients receiving bovine heparin
Most common functioning tumor of the pancreas?
Insulinoma
What is the cardinal feature of myxedema coma?
Hypothermia
Renal failure ______calcium, _____phosphate
Low calcium HIGH phosphate
Disulfiram and Alcohol.
inhibits aldehyde dehydrogenase. When alcohol is ingested, acetaldehyde accumulates and produces nausea, vomiting, flushing, diaphoresis, and vertigo.
Chronic RF signs consistent with the diagnosis DHS
Hypertension, Dyslipidemia
Silent myocardial ischemia
Chronic Renal Failure Electrolyte disturbances:
HIGH MKP
LOW Cal
The cardiovascular effects of chronic kidney disease (CKD) are primarily the result of
sodium and water retention.
What is the most significant Risk factor for CKD because it contributes to the increased risk for congestive heart failure, coronary artery disease, and cerebrovascular disease seen in patients with CKD.
Congestive heart failure
Coronary artery disease, and c
Cerebrovascular disease seen in patients with CKD.
What is the most significant Risk factor for CKD because it contributes to the increased risk for
Congestive heart failure
Coronary artery disease, and c
Cerebrovascular disease seen in patients with CKD.
Addison’s disease : Signs and symptoms.
Weakness, Anorexia, Nausea, Vomiting (WANV) hyperpigmentation chronic hypotension hypovolemia hyponatremia, and hyperkalemia
The only metabolite increase with Addison’s disease is
POTASSIUM (hyperkalemia)
BP of Addison’s disease and BV
chronic hypotension
hypovolemia
hyponatremia
HYPOCALCEMIA QT
prolonged QT interval
muscle spasms, hypotension, and decreased responsiveness to beta agonist
HYPERCALCEMIA : QT and PR.
Calcium short quart and Long pickle
SHORT QT , LONG PR
Which condition would be most likely to occur as a result of lithium therapy?
Hypothyroidism
Tumor Lysis Syndrome : Elevated levels of (PUP)
Phosphate
Uric acid
Potassium
Difficult intubation official definition
3 attempts with a trained provider OR intubation taking
10 minutes or more.
BONES DIFFICULT MAS
BEARD OBESITY NO TEETH ELDERLY SNORES
CAN’T INTUBate can’t ventilate: sugammadex dosing.
Sugammadex 16 mg/kg
Prayer sign :
Hypothyroidism (hypocalcemia)
Cricoid pressure to apply while they are awake
Start at 10N while they are awake
ASA closed claim study % of respiratory events
34% adverse respiratory events
Point of insertion of the tongue
Mandible AND hyoid bones
Prognathia bad grade
C
During nasal intubation, The ETT should be inserted
PARALLEL to the roof of the mouth. SHOULD NOT BE DIRECTED Upwards into the turbinates rather along the floor of the nose formed by the superior aspect of the palatine bone
Mandibular protrusion test scoring (1-2-3)
Move past upper lip is Class I
Align with upper lip is Class II
unable to perform class III
Awake intubation , first drug to administer
GLYCOPYRROLATE (dry up secretions) give it early about 30 minutes
Prognathia test scoring (ABC)
Move past upper lip is Class A
Align with upper lip is Class B
unable to perform class C
Angioedema seen order
FFP
FRC is _____ml
2500
Dose based on weight for mendelson’s syndrome
0.4 ml/kg
3 drugs for mendelson’s syndrome
famotidine
reglan
Bicitra
Pepcid works on
Parietal cells
H2 blockers with CYP
Inhibit
Tagamet will affect
CYP 450 and inhibit, give Pepcid instead
Reusing LMA (which law)
Deflate before you sterilized (Boyles)
Glidescope curve
60 degrees
Retrograde intubation (r”Ce”)
45 degree toward hear CEPHALAD
Cricothyroidomy intubation degrees
45 degrees toward CAUDAL (CRI-CAUD)
Heparin MOA
Binds to AT III and thrombin
Cardiac dose of heparin for CPB
Heparin 300-400 units/kg
ACT > is needed for CPB
400
Protamine Sulfate
Profound pulmonary Edema
Joules to administer directly to heart
10-12 J
Do not give until patient is
decannulated
WIth stents, bare metal
30 days
WIth stents, drug eluting stents
6 months
5 days of enoxoparin
bridging
CPP formula
Aortic DBP - LVEDP
CPP autoregulation
60-140 mmhg
Tetralogy spell
Tet spells : Push on the belly and KNEE TO CHEST position
CPB maintenance The mixed venous O2 saturation should be monitored and maintained at
70%.
How do you know rewarming completed
Nasopharyngeal temperature_________
b. Rectal/bladder temperature________
36°C to 37°C
≥ 35°C, but ≤ 37°C
Giving protamine over a period of 10 to 15 minutes will decrease the probability of both.
type I (systemic vasodilation-histamine release) and type III (pulmonary vasoconstriction- delayed anaphylactoid) protamine reactions.
However, an anaphylactic reaction (type II) can occur at any rate of administration of
Protmaine sulfate
Alpha angle of TEG
Rate of Clot formation
Max amplitudee
50-73 mm
The normal dose of protamine is
1 mg of protamine to reverse every 100 units of heparin that was given.
Factors produced by CryoprecipitateL
Fibronectin
fibrinogen
Factor XIII
Trauma patients give those :
5 PRBCs
5 FFPs
5 Platelets
After group of 5 plus, RBCs, FFPs.
Fibrinogen level, if less than 200, give CRYOPRECIPITATE (some people say < 150).
First indicator of transfusion reaction
Urine color change
Pain from unpainful things
Allodynia (fibromyalgia)
Cation for pain
K and Calcium
Succinylcholine and burn when you can’t give and when you can give
Past 24 hours don’t give
Wait 1 year then you can give
Duschenne carried by
Female , pass on to male children
Normal IOP
20 mmHg
Lateral , medial, movement of eye
3, 4, 6
Cuff in sitting
never in the lower extremity
Pain transmission fibers
A delta (SHARP nociception) A -beta C fibers (dull, throbbing pain)
Octreotide Too quickly for carcinoid
Bradycardia
Aminoglycosies associated with
Ototoxicity
Furosemide max mg per minutes
20 mg/min
Furosemide associated with
Ototoxicity
Blocks prostaglandins meds
NSAIDs
Dexamethasone
MA (maximal amplitude):
50-60 mm
R (reaction time):
measures from time zero to the beginning of clot formation
Rep isor liquitor
Things speak for itself.
Tolerance to the analgesic, sedative, and emetic effects of opioids may occur, but the _______and ______seen with opioid use is unlikely to be affected by tolerance to the drugs.
MIOSIS and CONSTIPATION
Which factor deficiency is associated with persons descended from the Ashkenazi Jewish population of Eastern Europe?
Factor XI
Factor XI deficiency PTT and PT
The PTT is prolonged and the PT is normal
Factors associated with an increased risk for postoperative ventilation following thymectomy include:
daily pyridostigmine dose greater than 750 mg
disease duration greater than 6 years, COPD
a negative inspiratory pressure less than -25 cm H2O, and a vital capacity less than 2.9 L.
The symptoms of organophosphate poisoning are similar to the effects of cholinesterase inhibitors and the treatment of choice for this condition is
Atropine.
Factor IX has a half-life of __________As a result, doses may need to be repeated to sustain sufficient factor IX levels.
18-24 hours.
II (prothrombin), factor V, or factor X are rare, autosomal recessive diseases. Patients with severe deficiencies will exhibit prolongation of
both the prothrombin time (PT) and the partial thromboplastin time (PTT).
Hypercalcemia QT and PR
SQPP (Short Q, Prolonged PR)
Where are T-helper lymphocytes predominantly located?
Lymph nodes
The treatment for patients with an overdose to cocaine should include the management of myocardial ischemia through the administration of an alpha-adrenergic antagonist such as
phentolamine or a nitrate such as nitroglycerin or nitroprusside. Administering a beta-blocker can result in cardiac decompensation by decreasing myocardial contractility in the face of an elevated afterload.
The treatment for patients with an overdose to cocaine should include the management of myocardial ischemia through the administration of an alpha-adrenergic antagonist such as
phentolamine or a nitrate such as nitroglycerin or nitroprusside. Administering a beta-blocker can result in cardiac decompensation by decreasing myocardial contractility in the face of an elevated afterload.
In patients with hypothyroidism, the administration of alpha agonists such as phenylephrine coulde.
substantially increase the systemic vascular resistance against a heart that has limited capacity to compensate by increasing its contractility. The best option for these patients is to administer epinephrine, ephedrine, or dopamin
Vasopressor of choice for Hypothyroidism patient?
EPHEDRINE
Metabolic/ Electrolyte disturbance associated with hypoaldosterone?
Hyperchloremic metabolic acidosis
mainstay of treatment of disseminated intravascular coagulation is the administration of
FFP
Phenoxybenzamine administration can produce _________The recommended treatment is beta-blockers.
tachyarrhythmias. beta-blockers.
In thalassemia what is the major problem?
The alteration in globin chain synthesis results in the production of defective red blood cells in the bone marrow.
In thalassemia there is what with RBCs?
clearance of red blood cells (hemolytic anemia).
Hypo(n)aldosteronism Side effects are : 1 hypo
Hyperkalemia
hyponatremia, hyperchloremic metabolic acidosis, and often, hyperglycemia.
Typically, the administration of 15-20 mL/kg of FFP will increase the factor levels by about 20-30%.
20-30%.
Addison’s disease is a
autoimmune destruction of the adrenal glands causing a decrease in glucocorticoid and mineralocorticoid production.
This results in
hyperpigmentation
hyperkalemia
increased urinary sodium excretion
decreased androgen production.
Patients with Cushing’s disease have increased serum cortisol levels resulting in
hypokalemia, hyperglycemia, and skeletal muscle relaxation which may require a DECREASED non-depolarizing muscle relaxant dose.
Initial signs and symptoms of Duchenne muscular dystrophy are due to the effect of the disease on
weakness in the proximal skeletal muscle groups and manifest as an alteration in gait, difficulty climbing stairs, and frequent falls
What are 2 significant risks in hyperglycemic hyperosmolar syndrome?
Intravascular coagulation
Mesenteric thrombosis
The four subtypes of schizophrenia are:
- Disorganized 2. Catatonic 3. Paranoid 4. Undifferentiated
In DKA, Hyperglycemia results in
hyponatremia
hypophosphatemia
hypokalemia
hypomagnesemia.
In all muscular dystrophies, there is a symmetric atrophy of skeletal muscle tissue, however, there is no
denervation of skeletal tissue, meaning that sensation and reflexes are intac
Competitive alpha-1 and alpha-2 receptor antagonist used primarily in the preoperative treatment of pheochromocytoma.
Phentolamine
You know that the half-life of desmopressin is approximately
12-24 hrs
What is the treatment of choice in the U.S. for factor XI deficiency?
FFP; Factor XI concentrate is not available in the United States, so the treatment of choice in patients with active bleeding is fresh frozen plasma.
What is the other name for hypothyroidism?
Myxedema
Nonselective alpha-antagonist agents used to manage pheochromocytoma.
Phentolamine
Phenoxybenzamine
Concomitant condition is most closely associated with thalassemia?
Splenomegaly
Primary adrenal insufficiency (Addison’s) results in the inadequate release of
glucocorticoid, mineralocorticoid, and androgen hormones. (think add 2)
Cause of Graves’ disease?
Thyroid-stimulating antibodies
Which of the following conditions is associated with chronic renal failure?
hyperlipidemia
HYPOCALCEMIA and elevated potassium, magnesium, and phosphate levels. (PMPlipids)
The hypokalemia associated with hyperaldosteronism can result in
skeletal muscle weakness and potentiation of nondepolarizing muscle relaxants.
Which clotting factor mechanically stabilizes fibrin to help protect it from fibrinolysis?
Factor XIII
The sphincter of Oddi is located where the ______And _______ meet to empty into the ______
common bile duct and pancreatic duct meet to empty into the duodenum. (CPD)
Hepatocytes synthesize all of the clotting factors except
von Willebrand factor and factor VIIIC.
Prothrombin complex concentrates contain a concentration of factors.
II, VII, IX, and X
Transfusion-related acute lung injury is more likely to occur when the donated blood is from
a female donor
Chemo drugs that can lead to both produce renal and hepatic dysfunction.
Methotrexate
Doxarubicin (Adriamycin) can result in cardiomyopathy and congestive heart failure.
cardiomyopathy and congestive heart failure.
think DoxCARDIArubicin
Cyclophosphamide is an alkylating agent that can produce ______ and ______
pulmonary toxicity and pulmonary fibrosis
CycloPULMphosphamide
Paclitaxel is a taxane that can produce
peripheral neuropathy.
2 common cardiac side effects of tricyclic antidepressants are (select two)
TACHYCARDIA and orthostatic hypotension.
Metformin (a biguanide) MOA
enhance tissue sensitivity to insulin
decreases hepatic glucose production
Alpha-glucosidase inhibitors MOA
DECREASE postprandial glucose absorption.
Requires tyramine-free diet what kind of mediation
MAOI
Can produce polyuria medication for bipolar
Lithium
The organisms responsible for most surgical site infections are
staphylococcus aureus and staphylococcus epidermidis.
Enteral feedings should be discontinued how long preoperatively?
6 hours preoperatively
Total parenteral nutrition (TPN) should be continued
perioperatively. If TPN is to be discontinued at all, it should be decreased gradually over 60-90 minutes to avoid hypoglycemia.
Insulin preparation has the fastest onset time when administered subcutaneously?
Lispro
The most serious immediate effects of diabetes insipidus are
hypovolemia and hypernatremia
Fludrocortisone is primarily administered for its ______ properties.
mineralocorticoid properties
2 opioid receptors are most responsible for producing respiratory DE(UX)pression? (select two)
Mu 2
Kappa
The Mu-1 and kappa receptors both produce
miosis.
Which local anesthetic would have the fastest onset when used on the oral mucosa?
Benzocaine
A panendoscopy includes what 3 procedures?
laryngoscopy, bronchoscopy, and esophagoscopy.
During a panendoscopy, To provide adequate visualization for the surgeon, intubation with a
microlaryngeal tube may be used as can jet ventilation.
Carotid body chemoreceptor stimulation produces an
increase in vasomotor tone and ventilatory activity.
What are 4 signs of mesenteric traction syndrome? which is caused by the release of vasoactive amines (principally prostacyclin) from the vascular bed of the mesentery. As a result, serum prostaglandin levels increase substantially. Non-steroidal anti-inflammatory agents such as aspirin and ketorolac ameliorate these symptoms. Stimulation of the vagus nerve will often cause bradycardia and hypotension, but would not result in hyperemia or hypoxia. Occult blood loss would typically result in tachycardia and hypotension, and possibly hypoxia if severe, but hyperemia would not be present. Norepinephrine release (although not associated with mesenteric traction) would result in bradycardia and hypertension.
Hypotension, tachycardia, cutaneous hyperemia, and hypoxia
What are 4 signs of mesenteric traction syndrome?
Norepinephrine release (although not associated with mesenteric traction) would result in bradycardia and hypertension.
Hypotension, tachycardia, cutaneous hyperemia, and hypoxia
Mesenteric traction syndrome is caused by the ____what increase?
Release of vasoactive amines (principally prostacyclin) from the vascular bed of the mesentery. As a result, serum prostaglandin levels increase substantially.
Norepinephrine release (although not associated with mesenteric traction) would result in (HR and BP)
bradycardia and hypertension.
Renal parameter increased in obesity?
GFR
Midthoracic levels of neuraxial anesthesia typically leave the tidal volume, respiratory rate, minute ventilation, PaO2, and PaCO2 levels largely
unaffected.
To achieve their maximum effectiveness, how long prior to induction of anesthesia should an antacid such as sodium citrate be administered?
15-30 minutes
Cessation for ____ weeks prior to general anesthesia produces a substantial decrease in the risk for postoperative pulmonary complications.
8
Because normalization of mucociliary function takes ______weeks and sputum production increases during that time, cessation for less than ____weeks may increase the risk for postoperative pulmonary complications.
2-3 ; 4
Carbon monoxide levels can be up to ____ times normal in smokers, but can return to normal within ____hours, thus improving oxygenation.
10; 24
A patient who exhibits an anaphylactic reaction to propofol on their first exposure to the drug most likely was sensitized previously to
the diisopropyl radicals in dermatologic agents
The only cells in the renal tubules that do not synthesize ammonia to be used in the buffer system are the epithelial cells in the
Loop of Henle
increased BUN:creatinine ratio is consistent with
Decreased Blood volume
expected genitourinary effect of morphine is
. increased urinary sphincter tone
Expected genitourinary effect of morphine is
increased urinary sphincter tone
The osmolarity of the solutions are: From high to Low LR, NS, D5W , D5LR
D5LR (525 mOsm/L),
D5W (252 mOsm/L),
LR ((273 )
NS ((154 mOsm/L)
A tracheostomy mask is considered to be a
LOW capacity
Side effect is most associated with topiramate administration?
Paresthesias
Cyclical response to pain that produces an abnormal pain response and chronic pain sensation is known as
Windup
Hepatic blood flow can decrease substantially during abdominal surgery. This is most likely due to
PROSTAGLANDINS release
The volatile agents ________ hepatic blood flow and oxygenation primarily by
increase ;
by increasing blood flow through the portal circulation.
ncreased pulmonary vascularity and a normal heart size on chest x-ray in a patient with blunt chest trauma could be indicative of a
ventral septal defect caused by trauma.
Retrobulbar and peribulbar block would not be indicated for a patient who is
anticoagulated.
What is the ovoid-shaped filamentous protein found in cardiac muscle?
actin
According to U.S. standards, the maximum contact surface temperature a forced-air device cannot exceed
48 degrees Celsius.
Medications to decrease portal pressures include
nonselective beta-blockers, vasopressin, and somastatin.
Is calcium increase or decrease in renal failure?
Decrease
This medication can cause naloxone-resistant respiratory depression
buprenorphine
What alteration in anesthetic response would you expect to see in a patient who suffers from Conn’s syndrome (hyperaldosteronism)?
Decreased nondepolarizing muscle relaxant dose requirements
When performing a controlled hypotension technique, which of the following agents would be best suited for a patient with a history of congestive heart failure?
Nitroprusside
nitroprusside is best suited for the preservation of cardiac output.
Specific gravity refers to the The normal specific gravity of CSF is between 1.004 to 1.009. When the two specific gravities are equal, the baricity is equal to 1.0.
density of a substance compared to that of water.
Baricity is the ratio of the
specific gravity of the local anesthetic to that of CSF
Largest interlaminar space?
L5
The level of activity in the reticular activating system is primarily determined by the
amount of sensory information from the body
The musculocutaneous nerve is situated between the
pectoralis major and coracobrachialis muscles
The risk for dural puncture, vascular injury, and neural damage is greatest when performing
cervical epidural blocks
Which herbal agent would disrupt platelet aggregation for the longest period of time after discontinuation?
Garlic
Umbilical area is directly anterior to which vertebra?
L3
What two factors are the primary determinants of the duration of action of a spinal anesthetic? (select two)
The specific drug used
What two factors are the primary determinants of the duration of action of a spinal anesthetic? (select two)
The specific drug used
The dose of the drug given
What is the appropriate volume of 1:1000 epinephrine to add to a spinal anesthetic to prolong the duration of the block?
0.1-0.2 mL
Total lung capacity and OBESITY
Decreased TLC
What is the primary advantage of using an Andrews frame for lumbar spine surgery?
Decrease bleeding
Sciatic divides into (SCT)
Common perineal Nerve
Tibial nerve
A properly performed popliteal block will anesthetize which of the following nerves? (select four)
SUdeepTico
Common peroneal nerve
Tibial nerve
Deep peroneal nerve
sural nerve
A cold laser may be used in the treatment of
carpal tunnel syndrome.
The term laser is actually an acronym that stands for LASER
Light Amplification Stimulated Emission Radiation.
What is the only additive to the local anesthetic for a Bier block that has been proven effective?
ketorolac
Approximately how much cerebrospinal fluid is normally contained in the subarachnoid space of the spinal canal?
80-120 mL
Kahler disease is also known
Multiple Myeloma
What two muscles form the crease in the axilla in which the ultrasound probe is placed during an ultrasound-guided axillary block?
Pectoralis major
Biceps
Which one of the following metabolic reactions is typically enhanced in obese patients?
Conjugation
Following weight loss drugs is a serotonin antagonist?
Lorsacerin
Shock index (SI) formula?
Heart rate/systolic blood pressure
Alcoholic hepatitis is characterized by the combination of he
liver dysfunction and jaundice with a history of excessive alcohol use.
Alcoholic hepatitis AST is typically elevated more than the ALT, with most patients exhibiting an AST/ALT ratio
greater than 2.
The estimated blood volume for an obese patient should be calculated as ____ mL/kg.
50
drug distributes equally to both lean and adipose tissues, then its loading dose should be calculated based on the patient’s
TBW
In fact, a mean PA pressure greater than 50 mmHg is considered an absolute contraindication to
liver transplant surgery.
Which spinal segments supply parasympathetic innervation to the ureters?
S2-S4
The hallmark signs that help identify diabetes insipidus are a urine specific gravity
less than 1.005 and a urine osmolality of 200 mOsm/kg or less.
The half-life of thyroxine (T4) in the circulation is:
6-7 days
Although this patient exhibits symptoms associated with epiglottitis, the diagnosis is a misnomer. The patient with epiglottitis actually suffers from
generalized irritation and severe edema of all of the supraglottic structures.
The defining characteristic of oliguric acute kidney injury (AKI)?
<400ml/day
Factors that are elevated in obese patients.
Fibrinogen
factors VII, VIII, von Willebrand factor,
plasminogen activator inhibitor
Forces that moves fluid from the capillary to the interstitium?
Capillary hydrostatic Pressure
Interstitial Oncotic pressure
Forces that moves fluid from the interstitium to the capillary?
Interstitial Hydrostatic pressre
Plasma Oncotic pressure
Net filtration pressure =
(Pc-Pif) (πc - πif)
The Brice Questionnaire is used to assess for
intraoperative awareness
What is the preferred procedure for MID-ureteral and distal stones that have been UNsuccessfully treated with conservative management. URS is also recommended in patients for whom stopping anticoagulation is not possible.
URS
Portal triad clamping is effective in reducing blood loss during a hepatic resection. What structures would be occluded during this procedure? (select three)The portal triad is actual a misnomer as it contains five structures:
Hepatic A-PV : CBD-lymph-branch
Hepatic artery Hepatic portal vein Common bile duct Lymphatic vessels Branch of the vagus nerve.
most serious immediate effects of diabetes insipidus are
Hypovolemia AND Hypernatremia
During which phase of a liver transplant surgery would you expect to see the greatest degree of hemodynamic instability? Reperfusion of which structure is hard?
NEOHEPATIC
Reperfusion of the vena cava is usually well tolerated, but reperfusion of the PORTAL VEIN is associated with a drop in the systemic vascular resistance that is even greater than that seen with vena cava cross-clamp. Severe bradycardia may also be seen,
Retrobulbar block associated with
Retrograde injection through circle of willis.
Hepatorenal syndrome is renal dysfunction associated with hepatic disease. Type I is acute renal decompensation, exhibits a creatinine
> 2.5 mg/dL and is often fatal.
Type II hepatorenal syndrome is acute/chronic? Creatinine level? GFR?
Chronic, exhibits a creatinine > 1.5 mg/dL, and a glomerular filtration rate < 40 mL/min.
2 medications that can help with Hepatorenal syndrome include?
Norepinephrine and the alpha-1 agonist midodrine have both been shown to improve renal function during liver transplant, however. Creatinine levels can severely underestimate the severity of renal dysfunction in these patients.
What medications would you be prepared to administer prior to the reperfusion of a newly transplanted liver?
Bicarbonate
Calcium
Which agent produces a paradoxical antidiuretic effect in patients with diabetes insipidus?
Thiazide diuretics
Forced vital capacity that indicate muscle strength adequate enough to sustain ventilation and take a large enough breath to cough effectively?
Forced vital capacity of 10-12 mL/kg.
The risk of postoperative morbidity is higher in obese patients. However, the risk is more closely linked to the presence of ______diseases rather than the BMI alone.
pre-existing diseases
PheNOxybenzamine competitive or noncompetititive antagonist?
NON-competitive
The cell membrane is freely permeable to ______ but impermeable to ______.
water; ions
The addition of CPDA to whole blood is responsible for
CPDA (citrate-phosphate-dextrose-adenine) is added to whole blood when collected to act as an anticoagulant and provide the blood with a shelf-life of about 35 days.
Most water get’s asborbed in the
Thin descending LOOP of HENLE
