ITE block 6 Flashcards
Post MTP and QT shortening what eletrolyte issue?
HyperK
EKG changes in hypoCa
prolonged QT due to prolonged ST segment
reduced PR interval
T wave flattening and inversion
J waves
Caused by hypercalcemia and hypothermia
One of the highest risk of leading to malpractice claims in anesthesia
residual anesthetic agents in PACU -> significant hypoxia
*resp events are one of the main causes
-so is cardiovasc d/o in relation to anesthetic medication
Effects of acute normovolemic hemodilution
Take some of pts own blood and replace with saline
-Inc in HR -> inc in CO to compensate
-Dec in blood viscosity -> Peripheral vasodilation -> inc in regional blood flow
no increase in O2 delivery, just the same with less Hg
O2 content equation
CaO2 = (SaO2 x Hg x 1.34) + (PaO2 x 0.003)
Maximum dose of lidocaine w/ Epi 1:200,000
7 mg/kg
-dose used for regional anesthesia
Maximum dose of lidocaine w/ epi 1:1,000,000
This is the dose used in tumescent anesthesia
-for liposuction
-dose is 35-55 mg/kg !!
-max: 5L of fat removal
Dermatome for medial knee
L3
Dermatome for medial malleolus
L4
Dermatome for lateral malleolus
S1
Lumbar n root that causes flexion of the lower extremity at the hip
L1-L2
Lumbar n root that causes extension of the knee
L3 and L4
Lumbar n root that causes flexion of the knee
L5 (S1-2)
Early decelerations in OB caused by?
Head compression w/ contraction -> activation of vagal resp
Late decels in OB caused by
Uteroplacental insuff -> fetal hypoxia and acidosis
Variable decels in OB caused by
umbilical cord compression -> baroreceptor or chemoreceptor med vagal activation -> dec blood supply and transient hypoxemia
Relative contraindications to MAC
unable to lie still
unable to follow instructions
unable to communicate w/ care team
What stimulates carotid body chemoreceptors
arterial partial pressure of O2
what innervates the carotid body chemoreceptor
glossopharyngeal nerve
-activated when partial pressure of O2 < 60-65 -> augment ventilation
Causes an increase in SvO2
Cyanide tox, Met-Hg (dec O2 extraction)
Increased cardiac output
blood transfusion
Inc oxyHg saturation
Dec SvO2
Decreased cardiac output
Inc catabolic state -> sepsis, shivering, fever, pain
Anemia
Dec arterial O2 saturation (PNA, pulm edema)
Pt w/ concern for possible aspiration PNA, but hemodynamically stable what now?
If pt is reliable and able to follow instructions, can send home w/ outpt f/u
if not reliable -> keep admitted to monitor for fevers, labs, f/u CXRs
-can get initial decompensation at time of event or 4-6 hrs later
*it pt hasn’t developed PNA by 12-24 hrs unlikely, and only give abx if actually has PNA
Mitral regurge hemodynamic goals
Normal to inc HR
Dec PVR
Dec afterload
Normovolemia
aortic stenosis hemodynamic goals
inc preload
inc afterload
dec HR
**maintain diastolic pressure
Mitral stenosis hemodynamic goals
Dec HR
Inc preload
Normal afterload
HOCM hemodynamic goals
Inc preload -> lots of volume
inc afterload
HR down
contractility down
Most rapid form of cooling for post cardiac arrest hypothermia
endovascular cooling (put in a central line and cold things)
Post cardiac arrest hypothermia
Goal temp: 32-36 for 12-24 hrs
cooling: endovascular fastest
-ppl most likely to die if you rewarm too fast
-use meperidine to dec shivering and dec O2 demand
Leading cause of malpractice claims in the 2000s?
Death (29%)
Then n injruy, permanent brain damage and airway injuries
DKA lytes
HypoNa (dilutional, water pulled into extracellular space due to hyperglycemia)
hyperphos (insulin def, P shifted out of cells by acidosis) -> total body phos be decreased
hyperK (but total body deficit)
Hyperglcyemia
hyperosmolality
elevated ketones
Anionn gap acidosis
on arrival to ED pt w/ depression is hyperthermic, tachycardia, HTN, cleaning jaw, disinhibited what drug?
3,4-Methylenedioxymethamphetamine (MDMA) -> ecstasy
-jaw clenching possible serotonin syndrome
Flunitrazepam
Rohypnol aka the date rape drug
-benzo -> amnesia and muscle relaxation
When will retrograde cardioplegia be ineffective
persistent L SVC b/c solution will be lost to the upper extremity and head instead of coronary vasculature
Cuffed cricothryoidotomy
-larger possibility for trauma b/c scalpel and placement
-compression on airway while placing -> inc risk of damage or perforation of the posterior trachea wall
-but cuffed so no risk of aspiration
-attaches to anesthesia vent and can be used w/ low pressures
Needle cricothyroidotomy cannula
involves needle placement, wire, and dilation
-only allows inspiration through cannula, expiration done passively requiring open upper airway
-less likelihood of tracheal trauma, but inc risk of complications like PTX, malposition
-requires large pressure to get TV through small cannula
Why does nitrous oxide cause air space expansion
because it is more soluble than nitrogen -> enters the space faster than N can leave
Insulin response
glycogenesis
fatty acid synthesis
TG synthesis
glucose uptake
protein synthesis
PDA murmur
in the first few weeks of life is systolic ->becomes continuous later on
premature neonate w/ apnea, bradycardia, diff weaning from vent, systolic murmur, dx? tx?
Patent PDA -> systolic in first few weeks
if symp (diff vent weaning) -> get echo and then possibly indomethacin
Where does aerobic glycolysis produce the majority of its ATP
mitochondria!
-NOT cytoplasm :* -> anearobic in cytosol
Starting substrate for aerobic and anaerobic glycolysis
Glucose!
End products of aerobic metabolism
CO2 and H2O
end products of anaerobic metabolism
lactate
What is a univent tube
ETT with smaller lumen for bronchial blocker to pass through -> ETT have smaller internal diameters
-smallest have internal diameters of 3.5-4 designed for peds 6 or older -> w/ internal diameter of 3.5-4, external diamter is 7.5
Smallest double lumen tube
designed for kids 8+
26 Fr
insulin and glucagon mediated in hepatocytes by which secondary messenger?
cAMP
-glucagon inc cAMP
-insulin dec
cGMP
secondary messenger for NG, nitroprusside, nitric oxide, sildenafil
IP-3
secondary messenger in cardiac myocytes -> inc in cytoplasmic Ca ions -> inc in Ca activates ryanodine receptors on SR -> promotes Ca release
ICAM-1
intracellular adhesion molecule
-promotes adhesion of neutrophils, monocytes, T cells and B cells
Tx for Met-Hg in pts w/ G6PD def
Ascorbic acid
Vit C
-acts as electron donor to aid in reduction of Fe 3+ to Fe 2+
-slower than methylene blue, but can be used safely in G6PD
Amyl nitrite
used to tx cyanide toxicty by oxidizing Fe 2+ to 3+
-cyanide binds more readily to Met-Hg -> this induces it and hopefully binds up all the cyanide
Why does indigo carmine dye dec pulse ox?
b/c absorption closer to 600nm range -> falsely lowering saturation
sinusoidal patterns on FHR
assoc w/ placental abruption -> very ominous sign
When does a fetal heart rate tracing -> change in baseline FHR?
When you have an acceleration or deceleration that lasts longer than 10 minutes
Normal baseline fetal HR
110-160
Propofol elimination kinetics order and graphic representation
1st order
so on logarithmic graph, straight incline down
on linear graph, curve down
HIPAA and email
compliant email: providers and pts include authentication, encryption, time-stamping and INFORMED CONSENT!
What triggers nonshivering thermogenesis in neonates
norepinephrine, glucocorticoids, thyroxine
What inhibits nonshivering thermogenesis in neonates
inhaled anesthetics and beta blockers
Terminology related to drowning: distress
precursor to drowning: resp impaired from being in/under liquid
Terminology related to drowning: active drowning
non-swimmer, unable to maintain airway above water
Terminology related to drowning: passive drowning
loss of consciousness
Terminology related to drowning: w/ or w/o ungoing health problems
what you’re seeing is related entirely to drowning or other ongoing health issues
BISreadings and anesthesia
100: awake
80: light/mod sedation
60:GA, low probability of recall
40: deep hypnotic state
20: burst suppression
0: isoelectric EEG
target for GA: 40-60
Anrep effect
inc in ventricular contractility following acute in afterload (Frank-sterling(
Bainbridge reflex
R atrial stretch receptors
-Inc R sided filling pressure -> parasymp inhibition -> inc in HR
-so if lots of water flowing under the bridge overloaded, it’s going to inc how fast it lifts up the bridge -> inc in HR
Bezold-Jarisch reflex
hypoTN, bradycardia, coronary artery dilatation in resp to noxious stimuli w/i LV wall sensed by chemo and mechanoreceptors
Dec in Hr reflex w/ laryngospasm
Baroreceptor reflex
-transient inc in LV output 2/2 compression of thoracic aorta
neuraxial v IV opioids
neuraxial may increase duration of 2nd stage of labor, but no inc in morbidity or mortality and no effect on c/s rates
How does the body compensate quickly for inc ICP?
redistribution of blood in intracranial v to extracranial v
redistribution of CSF from brain to spinal column.
Normal serum osmolality
275-295
post neurosurg polyuria, plasma osmolality over 290
Diabetes insipidus
-def of ADH
-tx: DDAVP, isotonic fluids to maintain euvolemia
post neurosurg, polyuria, dehydration, osmolality 250
cerebral salt wasting
RF for postop cognitive delerium
lower education
older age
previous hx of CVA w/ no residual deficits
Antecubital anatomy med -> lateral
median n ->ulnar v -> brachial artery
Spica casting
lower chest to the calves -> if inadequate space b/w cast and lower chest or abd -> restrictive resp defect
-airway will be disconnected due to placement on board
-hips cast in flexed, externally rotated and abducted
According to ASA physical exam MUST include
airway exam
lung auscultation
cardiovascular exam (no req auscultation)
vital signs
RF for emergence delirium
ages 2-6
use of volatile anesthetic
SE of methylergonovine
HTN
vasoconstriction
coronary vasospasm
Misoprostol
used to ripen cervix and induce labor usually in low-resources areas (b/c doesn’t need to be refrigerated)
-not as effective as oxytocin
What do you not have to disclose as part of a COI
personal relationships
paid expert testimony
travel grants
relationships w/ outside oragnizations
Uteroplacental circulation
-Ovarian arteries supply up to 15% of uterine BF, rest uterine arteries
-uterus receives 20% of cardiac output at term
-terminal villi on FETAL side of placenta exchange gas, nutrients, and waste products
0primary villi form during 1st trimester
-umbilical arteries originate off fetal internal iliac arteries -> carry deoxygenated blood from fetus to placenta (paired arteries)
-single umbilical v carries oxygenated blood back to fetus
Coagulation changes in pregnancy
Decreased fibrinolysis
Dec anticoagulations -> dec protein C and S
Dec plts (dilutional)
Inc D-dimer
inc thrombin-antithrombin complexes
Goldenhar Syndrome
micrognathia, hypoplastici zygomatic arch, facial asymmetry, fascial hypoplasia
mod to severe congenital cardiac defects
resp problems
at risk for C1-2 subluxation
usually intellectually intact (15% not)
**possibility for pseudocholinesterase def*
Limb-girdle muscular dystrophy
weakness in shoulders, hips, proximal muscles
-some ppl can have normal life, others severe dx
-likely to have cardiac issues -> arrhythmias, cardiomyopathies
-avoid succ and volatiles anesthetics
Effect of dilute epi in bupi for epidural analgesia
causes a more profound motor block -> why is not used frequently
-possible reduction in uterine activity by beta agonism
-dec uterine and SC BF
minimum local anesthetic concentration of epidural
measure of the potency of local anesthetics and is the median effective neuraxial conc of local anesthetic solution
minimum local anesthetic concentration of epidural effect of adding epi to bupi
lowers it, because epi has some direct agonism in dorsal horn as well
MOA of renin
converts angiotensinogen to ATI
What triggers renin secretion
Dec in serum NaCl sensed by kidneys
Dec in BF sensed by kidney baroreceptors
activation of beta 1 receptors by NE
AT II
acts directly on BV to cause vasoconstriction
acgts on kidneys to stimulate reabsorptin of water and NaCl
stimulates release of aldo from adrenal glands
effect of lorazepam on pt satisfaction
NO EFFECT and prolongs extubation time -> why it’s not used
Fentanyl premedication and postop pain control
-only use if pt has pain porior to surgery
-admin w/o pain -> sensitize pts ot pain -> postop hyperalgesia
Concerns for down syndrome and ear tubes
Pt ha sa more narrow external auditory meatus -> procedures will take longer
tilt table instead o neck due to possible atlantoaxial instability
-worth it to put an LMA in b/c lots of issues, want to have hands free
-put the IV in
Hepatic extraction ratio
extraction ratio = (mixed hepatic arterial-portal drug conc - hepatic v drug conc)/mixe dhepatic arterial-portal drug conversation
How to tell if a drug clearance is dpt on BF or not
If a drug has high intrinsic clearance -> dept on blood flow (b/c more BF, can clear more drug) -> flow dependent
If drug has low intrinsic clearance -> not dpt on blood flow (b/c increased BF wouldn’t change anything) -> flow independent
Commonly used drugs with high hepatic extraction ratio
FLOW DEPENDENT
Fentanyl
Ketamine
Meperidine
Bupivacaine
Diltiazem
Metoprolol
Morphone
Nifedipine
Propofol
Commonly used drugs w/ low hepatic extraction ratio
FLOW INDEPENDENT
Diazepam
Methadone
Rocuronium
Alfentanil
Thiopental
Ex of a laser-resistant ETT
dual cuffed tracheal tube
-nonflammable and laser resistance -> stainless steel shaft and 2 indpt cuffs in series
How does methylene blue treat Met-Hg
Acts as an electron receptor for NADPH-methemoglobin reductase -> enhances enzyme -> reduction nof MetHg to Hg
Oxygen delivery
cardiac output x CaO2
CaO2= (1.34 x Hg x SaO2) + (.0031 x PaO2)
Thrombotic thrombocytopenic purpursa
Plt destruction d/o
-Def in vWF-cleaving protease activity (ADAMSTS13 def)
-FFP repeltes enzyme
**plasmapheresis may used to tx the acquired type, to remove antibodies that damages the enzyme
Emergent reversal of warfarin
prothrombin compledx concentrate
(FFP if it isn’t available, but PCC is better!)
Indications for FFP
-Coag d/o once whole body blood volume has been replaced
-Factor def when there isn’t isolated factor concentrate
-microvascular bleeding when PT, PTT, and INR elevated (2x normal)
-When giving heparin, but pt has dec ATIII (heparin resistasnce)
-Thrombotic thrombocytopenic purpura
-Urgent reversal of warfarin if PCC isn’t available
What J do you shock a pt w/ in SVT for synchronixed cardiovesrion
50-100 J
Tx of unstable SVT in a pt post heart transplant
synchronized cardioversion
-vagal carotid massage won’t work
-phenylephrine won’t dec it
-esmolol won’t really help in transplanted heart
Ion movement during depol at NM
Na in
Ca in
K out
Hydrostatic pressure
pressure exerted by blood plasma and interstitial fluid on capillary walls
(force that pushes fluid out of blood)
-hydrostatic P > oncotic pressure-> fluid leaks out into periphery
Oncotic pressure
pressure exerted by proteins in blood plasma
(force that pushes fluid into blood)
-oncotic P > hydrostatic pressure -> fluid stakes in bllod
Clinical findings of cardiogenic shock
Low cardiac output with JVD
vascular and pulm vascular congestion
peripheral vasoconstriction
cold extremities
poor urine output
AMS
hypoTN
Which factor decreased in pregnancy?
Factor XI
Factors for inc neuroblastoma survival
Dx < 18 months
extraabd tumors
low INHRG (international neuroblastoma risk group) score
good tumor resectability
primary tumor
no mets
small tumor
favorable tumor biology
Dx of neuroblastsoma what lab test?
elevated urinary catecholamines
Anesthetic concerns for neuroblastoma removal
-If catecholamine secreting -> alpha and beta blockade prior to surgery
-A line and central line
-euvolemia (pt is dehydrated from chronic symp activation)
-blood available and rapid transfuser
-good BP control esp during tumor manipulation
Vaporizer output
1/4 for sevo
1/2 for iso
-If 100 mL/min of O2 inflow through sevo vaporizer -> 1/4 will be sevo -> 25 mL
CVP tracing in relation to EKG
Guillain-Barre and Na
often accompanied w/ SIADH in 50% of pts -> hypoNa
GBS LP
inc protein, normal glucose and cell count
Earliest indication of respiratory failure in GBS
spirometry! should be followed throughout hospitalization
-1/3 of pts have respiratory failure
Autonomic symp and GBS
autonomic dysfunction
hypoTN, HTN, cardiac dysrhythmias, ileus
Cushing syndrome
excess cortisol
-hirsuitism (minimics androgen hormones)
-elevated blood glucose
-inc protein breakdown -> moon facies, buffalo hump, abd weight gain
-mood changes
-thinning of extremities
-HTN
-hypoK
signs of extrathoracic airway object
inspiratory stridor, drooling
object has migrated to trachea/lower airways signs
asthmatoid wheeze
expiratory wheeze
audible slap w/ expiration
palpable thud over suprasternal notch
What fluid at large doses can cause a coagulopathy
Hydroxyethyl startch
What type of conversations b/w attorney and physician are privileged
oral, print, or electronic
as long as only intended for them to be the only parties
13 YOM fever, sore throat, trismus, diff swallowing, normal voice dx? cause?
peritonsillar abscess
Group A beta-hemolytic Strep
abscess more common in older children and adults
Anesthesia considerations for peritonsillar abscesses
if trismus:
inhalational induction -> keep breathing
-reassess airway after inhalational induction -> adequate mask vent and can open mouth okay -> give NMB and prop to intubate
if no trismus: RSI to avoid oral airway placement and risk rupture
RF for failed neuraxial in OB
fast decision to incision interval
late labor epidural placement
maternal obesity
terbutaline lyte changes
hypoK
hyperglycemia
If ETT is unable to pass off fiberoptic, most likely cause?
tip impinged on R arytenoid cartilage
Assist-control ventilation
has a set TV and RR
if pt not spontaneously breathing -> looks like VCV
if pt initiates -> delivers positive pressure w/ set TV
**be careful in pts w/ rapid resp rate -> auto PEEP and breath stacking
Elevated DLCO
DLCO is a function of: diffusion rate and binding capacity
Asthma
Obesity
Cardiac Output
Polycythemia
Pulm vasodilation
L to R shunting
Propofol v sevo for airway reflexes
propfol more likely to mitigate laryngospasm
sevo more likely to mitigate cough, spasmodic panting reflex
MOCA questions per year
120 -> 30 max per quarter
Allodynia
mild sensory stimulations elicit severe pain
-ordinarily non-noxious stimulus perceived as painful
anesthesia dolorosa
pain in an area that lacks sensation (usually the face)
feared complication of radiofreq ablation for treatment of trigeminal neuralgia
Pacemaker indications
sick sinus syndrome
congenital long QT syndrome
supraventricular tachycardias responsive to pacing and nothing else working
Heart block: Mobitz type II or type III
HF as part of resynchronization therapy
Dilated cardiomyopathy
HOCM
sinus node dysfxn w/ symp bradycardia
anxious pt starts getting extremity numbness, cramping, why?
Hyperventilation -> hypocarbia -> resp alk -> functional hypoCa
pt w/ placenta previa, what inc risk of PPH?
Prior hx of c/s -> inc risk of placenta accreta
