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Question 1

qSofa (quick sequential organ failure assessment) score

Answer 1

Help help identify adult ICU patients with a suspected infection. It is scored 0 to 3 with one point each for altered mental status respiratory rate above 22 systolic blood pressure below 100. A score of greater than to indicates a worse prognosis

Question 2

PONV options

Answer 2

Aprepitant - NK1 Receptor antagonist. Associated with nausea and rash

Droperidol - antidopa. Associated with dystonic reactions, QT, black box.

Scope- antimusc. Crosses BBB. Dry mouth, blurry vision.

Propofol- not for pancreatitis

Question 3

Surviving sepsis - guidelines

Answer 3

Antibiotics within 1st hour, aggressive hydration (>30 ml per kg within first 3 hours, pressors to map > 65

Question 4

Absolute indications for TPN

Answer 4

Short bowel syndrome. Small bowel obstruction. Active gastrointestinal bleeding. Pseudo-obstruction. High output enteric-cutaneous fistula

Question 5

TPN Complications

Answer 5

Hyperglycemia

Question 6

Ischemia-reperfusion injury during liver tx

Answer 6

Disruption of Na-K pump

Question 7

Absolute contraindication for TPN

Answer 7

TPN should not be started within first 7 days of ICU admission

Question 8

Marker of liver synthetic function

Answer 8

PT is best. Albumin is not used bc if it’s long half life (3 weeks)

Question 9

Use of FFP to reverse elevated INR due to warfarin

Answer 9

Urgent or emergent cases when INR is above 1.5.

Use Vit K for elective surgery that can be delayed for 24 hours

Question 10

Elemental diets

Answer 10

Originally developed as a treatment for diarrhea and patients with diarrhea on polymeric and high fiber but have fallen out of favor

Question 11

Laryngospasm reflex

Answer 11

Mediated by internal branch of SLN. Provides sensation to entire larynx above glottis

Question 12

Gas laws

Answer 12

Henry - at constant temp, the Concentration of a gas dissolved in a solution is directly proportional to the partial pressure of the gas

Boyle - A fixed mass of gas at constant temperature will have a constant pressure volume product. PV = PV

Question 13

Albumin and pregnancy

Answer 13

Albumin concentration decreases during pregnancy because of plasma expansion. Many other serum constituents such as fibrinogen, tranferrin and globulins increase

Question 14

Frequency and resolution

Answer 14

Higher frequency means better resolution but worse penetration. Lower frequency gives better penetration but sacrifices resolution

Question 15

Viral cardiomyopathy (coxsackie b)

Answer 15

Viral cardiomyopathy is he dilated cardiomyopathy with signs and symptoms including peripheral edema, dyspnea on exertion orthopnea and decreased functional status

Other causes of dilated cardiomyopathy include alcohol, cocaine, HIV, hypertension, and peripartum state

Question 16

Standard error

Answer 16

SE = SD/square root N

The standard error is a type of standard deviation and is a measure of the precision of the sample mean

Question 17

Decreases and increases in P50

Answer 17

P50 on the oxy-HGB curve Is the oxygen tension at which hemoglobin is 50% saturated

Decrease in P50 (left shift) = less unloading of oxygen. Alkalosis, decr temp, decr 2,3 DPG, CO and MetHgb

Increase of P50 (right shift) = more unloading if oxygen. RIGHT - rise in 2,3 DPG, hydrogen ions (acidosis) and temperature.

Question 18

Use of helium/oxygen 70/30

Answer 18

Heliox Is useful in situations where airway radius is decreased with resultant turbulent gas flow (subglottic
stenosis). Helium has a decreased gas density as compared to oxygen or air and dust resistant to gas flow is reduced. The low gas density decreases resistance with the turbulent flow and increases the chance for development of laminar flow

Question 19

Venous air embolisms

Answer 19

VAE occur when air enters the low pressure venous system. Most common sites during cranis include venous sinuses, bone, and spinal epidural veins.

More likely to occur when surgical site above heart.

Can cause circulatory collapse by impeding RV filling leading to hypotension and decr CO

Pedi patients can develop VAE in both supine and prone position Since they are relatively large head sits above the level of the heart in both positions. Children are also more likely to become symptomatic from VAE since their smaller circulatory volume and heart size arw more easily overwhelmed by smaller volumes of entrained air

Question 20

Detecting VAE

Answer 20

Most sensitive: TEE (adults) or precordial Doppler (kids)

Others EtCO2 (sudden drop), cardiac output/CVP (inc), pulse ox changes

Question 21

Treatment of VAE

Answer 21

Hemodynamic support and preventing more air from entering. To stop air entrainment, surgical field can be flooded with saline and surgical site lowered below level of heart.

Question 22

Static respiratory compliance

Answer 22

Static compliance of the respiratory system indicates the stiffness of the respiratory system which includes the lungs and chest wall. It is determined at the end of inspiration When there is no airflow, hence “static”

Static compliance = tidal volume/plateau pressure - peep.

Dynamic respiratory compliance = TV/peak pressure - peep

Question 23

Superior laryngeal nerve

Answer 23

Branch of vagus

Divides into internal and external

External is a motor nerve. Innervates cricothyroid muscle

Internal is sensory. Lower pharynx, inferior epiglottis and vallecula (ie larynx above VC

Question 24

Recurrent laryngeal nerve

Answer 24

From vagus

Mixed motor and sensory. Sensation to VC and below. Motor to all laryngeal mm except cricothyroid

Question 25

Glossopharyngeal n

Answer 25

CN 9. Afferent limb of gag

Question 26

AHA definition of hypotension and hypertension

Answer 26

Hypo - SBP < 90, map < 65

Hyper- SBP > 130

Question 27

Flow of ions of nAChR

Answer 27

K out and Na in

Question 28

Barbiturates and the brain

Answer 28

Decr CBF and ICP via constricting cerebral vasculature

Also will decr CMRO2 up to suppressing all EEG activity

Question 29

Sux and bradycardia

Answer 29

Repeat doses and young age are the greatest risk factors bradycardia with sux use. Bradycardia with repeat administration is a result of myocardium being sensitized by metabolic products of sux

Question 30

Postobstructive pulmonary edema - Rx

Answer 30

Can follow laryngospasm. Rx is positive pressure ventilation with peep

Question 31

Barbiturates - contraindications

Answer 31

1. Pt with resp obstruction or inadequate airway, barb may worsen resp depr
2. Severe CV instability, shock or hypovolemia
3. Status asthmaticus
4. Porphyria may be precipitated

Question 32

TPN electrolyte disturbances

Answer 32

Hypophos, hypo and hyperglycemia, hypomag, liver injury

Question 33

Post herpetic neuralgia- prevention

Answer 33

Prior vaccination

Question 34

Factors that are reduced in liver dz

Answer 34

2, 7, 9, 10, 5, 11 and thrombin

Note - F8 and vWF are increased. These two factors are produced extra-hepatically

Question 35

Coagulation mgmt in liver dz

Answer 35

Keep plts at 50-60. If high risk surgery, >100

Fibrinogen >100

Transfuse to maintain hgb > 7

Do not give FFP ppx or chase INR

Question 36

Lowest p50

Answer 36

Lowest (18) in newborns. Oxygen affinity is high. Hgb F and low levels of 2,3 DPG

P50 is highest (30) in children over 1 yo. After age 10, p50 goes to adult level (27)

Question 37

Only 2 factors that decrease during pregnancy

Answer 37

11 and 13

Question 38

First order vs second order kinetics

Answer 38

First order - amount of drug removed is a constant fraction per time. Most drugs are done this way.

Zero order - constant amount removed. Phenytoin, etoh, aspirin

Question 39

SAH complications

Answer 39

MCC is death is initial bleeding. Followed by re-bleeding on second day which peaks at 24 hours. Vasospasm rarely occurs within the first three days Typically peaks in 5 to 10 days. Other complications include hydrocephalus (via blood blocking ability to drain CSF). HypoNAT (siadh and csw)

MCC is SAH is cerebral aneurysm