ITE block 8 Flashcards
RF for diff mask ventilation
BMI > 30
male gender
age over 55
no teeth
mallampati III or IV
beard
OSA/ hx of snoring
most significant source of radiation exposure for clinicians
Scatter radiation
(radiant energy scattered after contact w/ pt
most significant source of radiation exposure for patients
primary radiation
(direct beam)
Dosimeter
Quantification of radiation exposure at a specific site
(usually attached to lead aprons)
Recommendations from CDC to minimize radiation exposure
-use dosimeter (quantification of radiation exposure)
-wear lead
-inc distance from source (1/distance^2)
-dec exposure time
Hemodynamic changes in neg pressure pulm edema
Neg intrathrocic pressure -> inc v return to R heart -> inc pulm BF
-symp activation from hypoxia -> inc afterload
-inc pulm vascular resistance b/c of hypoxic pulm vasoconstriction
Statistical analysis
End-systolic pressure volume relationship
slope of the line indicates inotropy -> shift to L inotropy inc (inc contractility)
-as becomes flatter and to the R, contractility dec
Change in PV loop w/ diastolic dysfxn
PV loop compliance curve shifts up in initial diastolic dysfxn -> b/c heart can compensate to maintain volumes but requires inc pressure
-eventual dec in LVEDV and dec in SV
P-V loop stroke work
area under the curve
What does burst suppression look like on EEG?
alternating episodes of isoelectricity and active oscillations
EEG freq of 8 to 12 Hz
alpha waves -> relaxed and alert pt
EEG freq of 13 to 25
beta waves, arousable state of sedation
EEG freq of 13 to 25
beta waves, arousable state of sedation
Dantrolene dose for MH
2.5 mg/kg IV boluss
Intralipid dose for LAST
1.5 cc/kg IV bolus repeat 1-2 times, infusion .25 cc/kg/min
Get room MH ready
Remove vaporizers, flush machine w/o filters 1 hour of high flows, w/ filters 1.5 min before filters -> filters last 12 hours w/ FGF of at least 3
claims made malpractice insurance policies
Covers the provider if claim made during the year the insurance policy is active
ex: policy active in 2017, get sued in 2017 -> still covers if paid in 2018
-NEED tail coverage
Claims paid malpractice insurance policies
Cover claims that are paid during the year the policy is active
Occurrence malpractice insurance policies
Cover claims for the year the policy is active
ex: in 2018 you get sued for a case in 2015, but policy active in 2015, will cover
What’s in cryoprecipitate
fibrinogen (factor I)
factors VIII, XIII, vWF, fibronectin
Thrombotic thrombocytopenic purpura
microangiopathic hemolyic anemia, thrombocytopenia, and consumption of coag factors
-tx: plasmapheresis w/ donor FFP
When to use FFP
-TTP or hemolytic uremic syndrome
-mult coag factor def w/ microvascular bleeding, and -PT/PTT >1.5-2x normal
-urgent warfarin reversal
-correction of microvascular bledding during MTP
-tx of heparin resistance in pt req heparin
-single coag factor def when specific conc not available
-trauma-related or massive blood loss
**ideally not for hemophilia A -> too much volume, and cyro has more conc factor VIII
Goals for sickle cell anemia surgey
avoid hypoxia, manage pain, avoid hypothermia, avoid acidosis -> inc sickling
**can use a tourniquet!!
tourniquet and SCD
can use!
beta thalassemia
-dec beta, inc alpha -> inc in unbount globin changes -> accumulates in cell -> destruction -> inc risk of cardiomyopathy
Why induction of inh anesthetics faster in infants
greater fraction of cardiac output to vessel rich groups
-lower blood gas solubility in infants
co-oximeter
blood gas analyzer that measures conc of carboxyHg, oxyHg, deoxyHg, and metHg
Treatment of cyanide toxicity
hydroxocobalamin (B12)
-or amyl and Na nitrite to induce Met-Hg -> CI in carbon monoxide poisoning
Labs for pyloric stenosis
hypoCl, hypoK, hypoNa, met alkalosis
v-wave on CVP correlates w/ what on EKG?
end of T wave
Normal PaCO2 and EtCO2 difference
PaCO2 2-5 higher due to dead sapce
When would EtCO2 be higher than PaCO2
inspiring CO2 (rebreathing, incompetent expiratory valve)
exogenous admin (laparoscopic insuff)
When would the PaCO2 EtCO2 be larger than 2-5?
V/Q mismatch (airway/lung dx, dec cardiac ouput, PE)
-diff b/w alveolar CO2 and CO2 delivered to sampling line -> very high RR, may not reach upper airway (peds)
-Y pieces inc circuit dead space -> widens the gap
mechanism of carbon monoxide poisoning?
Disrupting oxidative phosphorylation
Induction of GA for preeclampsia emergent c/s
succ, prop, fast acting anit-HTN (nitroglycerin, esmolol, remifent)
Why do pts get preeclampsia
abnormal placentation regarding spiral arteries -> needs inc in BP to overcome inc peripheral vascular resistance
what teratogenic effect does ACEinh have on a fetus?
oligohydramnios
Treatment for polyhydramnios
Indomethacin
Antenatal Bartter Syndrome
defect in Na/K cotransporter in fetal kidney -> fetal polyuria and polyhydramnios
Twin-to-twin transfusion syndrome
BF from placenta is disproportionate b/c monochorionic twins
-1 twin gets more blood: polyhydramnios
-1 gets less: oligo
Donor Management Goals for donation after brain death:
-MAP 60-120
-CVP 4-12
-Na < 155
-pressors <1 or low dose
-PaO2/FiO2 > 300
-pH on ABG: 7.25-7.5
-Glucose < 150
-UOP .5-3 cc/kg/hr
-LV EF > 50%
-Hg > 10
Echothiophate
cholinesterase inhibitor used by optho to induce miosis
-if absorbed systemically can impair cholinesterase and inc duration of succ
oculocardiac reflex
afferent: ophthalmic branch of trigeminal n
efferent: vagus n
non-hemolytic febrile transfusion rxn
antibodies in recipient to donor leukocytes
MC transfusion related fatality
TRALI
Concern for acute hemolytic transfusion rxn, which labs?
Direct Coombs test
repeat crossmatching
serum haptoglobin, bilirubin
urine Hg levels
Timeframe for delayed hemolytic transfusion reaction
2-21 days
-suspect w/ acute drop in Hg
main RF for emergence delirium
age 2-6 yrs old
inh anesthetics: sevo and des
pain worse w/ spine flexion, coughs, sneezes
discogenic pain
-inc in intraabd pressure puts more pressure on disc
which inh gas most significantly augments NMB
DES!!
Des delays reversal of NMB
-more likely to occur w/ aminosteroids than benzylisoquinoline NMBDs
Max lose of tumescent lidocaine for liposuction
0.1% lidocaine 35-55 cc/kg
Epi 0.07 mg/kg or 1:1,000,000
Obturator n provides innervation where
medial aspect of the thigh
-motor innervation for adductor of lower limb
Alloimmunization
when you’ve had multiple blood transfusions and you’ve developed antibodies to prior antigens from prev blood transfusions
-inc risk of delayed hemolytic rxn
Intrapulmonary percussive ventilation
high freq (100-300 cycles/min) of high-flow jets of air to pts respiratory system
-helps loosen mucus and facilitates mobilization w/i airway
Acapella device
exhalation through a handheld device that results in oscillations that aid in mucus clearance
Mechanical insufflator-exsufflator
alternates positive and negative pressure to pts airway to stimulate a natural cough
Symp of autonomic hyperreflexia
severe HTN and tachycardia
below lesion: vasoconstriction, piloerection, spastic m contraction, inc m tone
above lesion: vasodilation, mydriasis, face/neck flushing, diaphoresis
HA, dyspnea, blurred vision, N, CP
Enzyme for rate-determining step in cholesterol synthesis
hydroxy-methylglutaryl-CoA reductase
statins inhibit enzyme
management of acute MR after MI w/ pulm congestion and edema
-give vasodilator 1st: nitroprusside b/c vasodilation dec regurge flow and lowers afterload
-if contractility impaired and need inotrope -> use milrinone since it also causes vasodilation
3 day hx of elevated troponins, TTE secure acute MR w/ anteriorly directed regurge jet, which vessel?
RCA
-posteriomedial papillary m rupture
Difficult intubation predictors
overbite
can’t protrude manibular incisors anterior to maxillary incisors
inter-incisor distasnce < 3 cm
high arches or narrow palate
long upper incisors
thyromental distance < 3 finger breadth
what is the subglycocalyceal layer
700-1000 cc b/w the vascular endothelial cells and the interstitial fluid space (separates intravasc from interstitial)
-fenestrations, protein poor, only water and lytes pass through
-lytes same as plasma
What determines transcapillary flow?
plasma to subglycocalyceal layer colloid oncotic pressure gradient not plasma to interstitial fluid colloid pressure
***when expanding volume intraprocedure, crystalloid is 1.5:1 w/ colloids
Hydralazine and ICP
inc ICP
Hydralazine MOA
-direct alpha rec antagonist
direct arteriolar smooth m relaxant -> inc CGMP
-metab in liver
-duration of action 2-6 hours
**reflexive tachycardia
metabolism of clevidipine
plasma esterases
metabolism of esmolol
erythrocyte esterases
Factors that decrease DLCO
sarcoid
asbestosis
berylliosis
O2 toxicity
COPD
anemia
pulm edema
fibrosis
Inc risk w/ pulm resection assoc w/
DLCO < 40%
VC < 2L
FVC < 50% of predicted
FEV1 <30%
Maximal voluntary ventilation <50%
RV/TLC >50%
VC < 2L
VO2 Max < 10 mL/kg/min
ABG: PCO2 > 46, PO2 < 60
Cardiac output equation if given O2 consumption, hg, and art O2 sat
CO = O2 consumption/arteriovenous difference
AV difference = 1.34 x 10 x Hg x (art O2 sat - mixed venous O2 sat)
What causes pain in pancreatic cancer
-neuronal secretion of substasnce P and CGRP
-pressure on n from tumor growth
Distal site to block saphenous n
around great saphneous vein
-superior and medial to medial malleolus and toward achilles tendon
Where is posterior tibial n
behind medial malleolus
Where is sural n
behind lateral malleolus
Med to tx opioid-induced pruritis w/o affecting analgesia
Nalbuphine
-mixed opioid agonist/antagonist
lipophilic more: fent or hydromorphone/morphine
fentanyl
What is urinary 5-HIAA used to dx?
Carcinoid syndrome
5-hydroxy-indole-acetic-acid
What valve issue is most likely to be assoc w/ carcinoid syndrome?
Tricuspid regurge
What is urinary vanillylmandelic acid used to dx?
pheo and neuroblastoma
What is urinary normetanephine used to dx?
pheo
fever, neck stiffness, AMS
bacterial meningitis
LP from bacterial meniingitis
inc WBC, inc protein, dec glucose
Proper ppx for PONV
1-2 RF: 2 agents
3-4 RF: 3-4 agents
MOA of carbonic anhydrase inh
blocks reabsorption of bicarb in PCT -> inc excretion in urine
-metabolic acidosis
Goldenhar syndrome
oculo-auriculo-vertebral spectrum
-hemifacial microsomia, mandibular hypoplasia, epibulbar dermoid, vertebral anomalies
Which opioid has the least amount of first=pass uptake and retention by lungs?
Morphone
**hydrophilic, lipophobic -> does not cross barrier easily
Which opioid has the largest percentage of first pass uptake and retention by lungs?
Fentanyl -> highly lipophililc
Critically ill pt extubsed w/ HFNC tarnsitioned to NC O2 sat 100%, day 4 she gets gait instability and a sz, w/ pulm edema and gets reintubated, why?
Hyperoxia
-ROS -> tracheobronchitis, pulm edema, ARDS, when PaO2 > 100
-ROS central tox: retinal damage, neuropathies, paralysis, sz
Vasopressin and plts
mild dec in plt conc and inc in plt aggregation
Vasopressin and pulm vasculature
no V1 receptors in lungs -> no change or causes pulm vasoconstriction
Limb-girdle muscular dystrophy
-proximal weakness in shoulder and pelvic girdle
-cardiomyopathy and AV donuction defects -> short lie span
-large range of weakness and morbitidy, mortalities
-avoid succ and volatiles
Why inc in SVR and MAP w/ abd insufflation
Vasopressin release
sympathetic d/c -> activation of renin-angiotensin-aldo
WHich opioids have greater migration in CSF?
Most hydophilic opioids -> take longer to get taken up by blood -> spread further in CSF
-sufent and fent more lipophilic -> gets taken up by blood faster, so spreads less
RF for transient neuro symptoms (pain in legs or butt after spinal anesthesia)
use of lidocaine
-lithotomy position w/ knee flexion
-adding phenyleprhine to .5% tetracaine
-outpt procedures
Crouzon syndrome
premature closure of cranial sutures
-small uper mandible, airway narrowing
-prominent underbite
-developmental delay and intracranial HTN from premature closure
Klippel-Feil Syndrome
lack of segmentation of cervical spine -> presents w/ fused cervical spine
Pierre Robin
micgrognathia, glossoptosis (tongue falls into back of throat), cleft palate
-airway imrpves as child ages, intubating easier w/ age
Treacher Collins
Auto Dom w/ variable penetrance
-zygoma and mandibular hypoplasia
-ear deforminty, deafness, mental retardation
-harder to intubate w/ older age
Doubling of H+ ions, dec pH by what?
0.3
Z test
determines whether or not the difference b/w the 2 proportions is significant
-ex: diff b/w man and women
-if calculated is higher than critical z score -> difference b/w groups
Eisenmenger Syndrome
L to R cardiac shunt causes pulm HTN and eventaul reversal to R to L shunt
Anesthetic goal of Eisenmenger syndrome
avoid a fall in arterial BP by maintaing cardiac output and SVR
Pregnancy in Eisenmenger syndrome
Morbidity and mortality is 30-50%
Bronchopulm dysplasia
if needing suppl O2 at > 28 days after birth
-assoc w/ subglottic stenosis
-obstructive lung dx!
Tx of bronchopulm dysplasia
supplemental O2 and ventilation
diuretics
steroids
bronchodilators
Vit K dpt factors
X, IX, VII, II
1972
Which electrodes measure pH, PCO2, and PO2?
pH: Sanz
pCO2: Severinghaus
PO2: Clark
**longer names correspond w/ more letters*
Acquired hemophilias
antibodies against clotting factors
more common in pts w/ AI condition, malignancy, or recent birth
Why bradycardia w/ neonatal apnea?
hypoxic stimulation of the carotid body chemoreceptors
Recently had TMP-S and now experiencing severe abd pain, numbness, paresthesias, weakness in extremities, N/V/ psychosis
acute intermittent porphyria
Anesthetic triggers for acute intermittent porphyria
Ketamine
Etomidate
Barbiturates
Ketorolac
metabolic surgical stress
Accumulation of delta-aminolevulinic acid in urine
Mutation in prophobilinogen deaminase
-Acute intermittent porphyria
Porphobilinogen in urine
Acute intermittent porphyria
Treatment for acute intermittent prophyria
Hemin and glucose -> dec activity of delta-aminolevulinate
-IVF, lyte repletion, pain management
Predictors of hypoxia during one lung ventilation
normal or inc FEV1
High % of V/Q on operative lung
supine position
low partial pressure of O2 on 2 lung ventilation
R sidied thoractomy
Myotonic dystrophy
slowly progressive m weakness, cataracts, endocrine distrubances, issues w/ cardioresp and GI
MC symp w/ ondansetron
HA
nitrous oxide washout
emergency -> washout can lead to hypocarbia and hypoxia
NM d/o w/ no inc risk of MH but avoid succ anyway
Myotonic dystrophy
Inc risk of MH NM mdx
King-Denborough dx
central core and multiminocore dx
nemaline rod myopathy
Zones of hepatic acinus
organized based on proximity to portal triaid
-zone 1 closest
-zone 3 furthest, most sensitive to hypoxia
QT shortening lyte change
HyperK
QT prolongation lyte change
HypoCa
Reduced PR interval lyte change
HypoCa
Dx v severity of COPD
dx: FEV1/FVC
severity: FEV1
If you have a wet tap, what layers did you just cross?
Dura mater and arachnoid mater
Layer deep to meningeal layers that are punctured w/ a wet tap
Below L1: filum terminale (extension of pia mater after SC ends at conus medullaris)
above L1: pia mater
Normal CVP
2-6 mmHg
Normal PCWP
6-12 mmHg
Normal Cardiac index
2.5-4 L/min/m^2
Normal SVR
800-1200 dynes*sec/cm^5
Type of pain that is poorly localized and described as achy or colicky
visceral pain: inflmmation or damage of internal organs
pain well localized and sharp in nature
somatic pain: inflammation or dx in soft tissue or bone
What is the major mechanism of solute clearance in CVVHF? continuous venovenous hemofiltration
Convection
-hydrostatic pressure gradient drives solutes and water across a semipermeable membrane into a filter compartment
-dialysate not used
