ITE block 9 Flashcards
Leading cause of ASA malpractice claims in 2000s
Death
Alpha error
Type I error
Incorrect rejection of null hypothesis
Beta error
type II error
Maintaining null hypothesis when there is actually a difference
Controlled Substance Act Schedule I substances
high abuse potential, no medical use
Cannabis, LSD, MDMA
Controlled Substance Act Schedule II
high abuse potential, severe physcial or psychological depedence
ex: Topical cocaine, morphine, oxycodone, hydrocodone
Controlled Substance Act Schedule III
Less abuse than I, low to moderate physical dependance
ex: ketamine, buprenorphine, thiopental, codeine
Controlled Substance Act Schedule IV
limited physical or psych depedence
ex: benzos, phenobarbital, tramadol, methohexital, zolpidem
Controlled Substance Act Schedule V
limited pyshical or psych dept less than IV
antitussives or antidiarrheals ex: cough syrup w/ codeine
Osmolality equation
(2 x Na) + (Glucose/18) + BUN/2.8
gap > 10
What causes osmolar gap?
> 10
ethanol, methanol
sugars: mannitol and sorbitol
ketones
lactate
intrapulm percussive ventilator
high-flow, high-freq air jets to airway through mouthpiece
Difficulty weaning from vent, no other issues, how to change TPN?
Inc % of lipids -> lower RQ to dec CO2 production
0.7
versus .8 for protein, or 1 for carbs
Chronic change in bicarb for inc in PaCO2
1 PaCO2 = .4 bicarb
-add to normal bicarb of 24
Acute change in bicarb for inc in PaCO2
1 PaCO2 = .2 bicarb
-add to normal bicarb of 24
Statistical test for categorical values
Chi-square
Post CPB pt bleeding, but protamine used and normal ACT, tx?
Plts!
plts dysfxn post bypass due to activation/degranulation of plts during CPB
Lyte changes during pyloric stenosis
hypoK hypoCl met alkalosis
How to decide when to proceed w/ pyloric stenosis case?
Normalization of chloride shows best optimization
Baroreceptor reflex
dec BP sensed by stretch receptors in carotid sinus and aortic arch -> glossopharyneal n -> inc HR and vasoconstriction
**carotid sinus = baroreceptor
Chemoreceptor reflex
low partial pressure of O2 inc resp drive and red HR and contractility
**carotid body = chemoreceptor
-afferent: glossopharyngeal n
Normal cardiac output
~5-6 L/min
Locus ceruleus
communicates wakefulness
Best way to reduce risk of transfusion related immunomodulation
Leukocyte reduction
Best way to avoid G v H disease
irradiation
When to use washing of PRBCs?
IgA def
Bronchopulm dysplasia and RDS
RDS -> bronchopulm dysplasia
RF for bronchopulm dysplasia
neonates < 32 weeks
O2 toxicity
sepsis
inflammation
infxn
barotrauma
Meds to avoid w/ hyperthyroidism
Things that stimulate the symp NS
PANcuronium
ketamine
atropine
ephedrine
epi
Which NMB is degraded by pseudocholinesterase
succ
mivacurium
Concerns for PPN, which pts won’t tolerate
-solutions w/ osmolarity > 750 mOsm/L cant be given peripherally -> needs HIGH VOLUMES at lower osmolairty
-need to be careful in pts w/ CHF, ESRD, liver dx, burn pts (issue w/ peripheral IV)
Absolute indications for TPN
Short bowel syndrome
small bowel obstruction
Active GI bleed
pseudo-obstruction w/ intolerance to food
-high output enter-cutaneous fistulas
Post anesthetic d/c scoring system
Vital Signs (stable BP and pulse w/i 20% of normal
Activity level (gait steady)
N/V
Pain (tolerable or nah)
Surgical site bleeding
Meds trigger acute intermittent porphyria
Ketamine
Etomidate
Barbs
CCB
Amiodarone
estrogens
metabolic stress (infxn, surgery0
Burn resuscitation
4 cc/kg x weight in kg x % TBSA over 24 hrs
-1st half in8 hours
Post burn when to avoid succ
after 48 hours
-avoid for 3 months post burn
Coagulation changes w/ burns
inc in fibronogen b/c acute phase reactant -> activation of plts and aggregation -> thrombocytopenia
Na and GBS
HypoNa -> can get SIADH post GBS
epidural opioids and gastric emptying in pregnancy
decreased when opioids used
-no change if just local anesthesia
gastric emptying in pregnancy
normal in non-laboring pt, dec w/ labor
Klippel-Feil syndrome
fusion of cervical spine
scoliosis
strabismus
heart and spine conditions likely
Beckwith-Wiedemann
hypoglycemia
macroglossia
organomealy
omphalocele
high altitude pulm edema ppx
Nifedipine, PDE 5inh like sildenafil
-prevents hypoxic pulm vasoconstriction
Static compliance of lungs
measured during periods of zero airflow: plateu pressure
-so no change w/ bronchospasm
-diff b/w plateau pressure and PEEP
Dynamic compliance
resistance to airflow through small airways of the lung
-diff b/w peak pressure and plateau pressures
V-A v V-V ECMO
V-A: cardioresp suport
V-V: resp failure
CVVHF how are solutes cleared
Convection
hydrostatic pressure gradient that drives solutes and water across a semipermeable membrane into a filter
-no dialysate
Ultrafiltration
movement of plasma water *NOT solute clearance
CVVHD solute transport mechanism
Diffusion
solutes move across a semipermeable membrane down concentration gradient
-facilitated by dialysate
spastic diplegia
MC form of cerebral palsy
-isolated lower extremity spasticity -> not progressive
Spinobulbar muscular atrophy
progressive neurodeg d/o w/ degen of neurons in SC and brain stem
Hereditary spastic paraplegia
group of progressive neurodegen d/o that affect axons of neurons w/i corticospinal and bulbar tracts in SC
Goals of hypertrophic cardiomyopathy anesthesia
-reduced myocardial contractility
-maintenance of SVR
-inc preload and cardiac output
why etomidate is a good choice
Acute v delayed hemolytic anemia intravasc or extravascular?
Acute: both intravascular and extravascular
delayed: extravascular
What anatomic structure most responsible for regulation of temp in humans?
Hypothalamic nuclei
When u/s beam reaches interface of 2 tissues w/ diff acoustic impedance at angle of incidence of 90 deg, what happens?
Reflection
-reflection = image, refraction is artifact -> occurs w/ acute angles
CO2 transported in blood in which forms?
dissolved CO2
bicarb
carbamino compounds
What percentage of SC blood supply comes from anterior spinal artery?
75%
When do you get cannon A waves?
When an atria contracts against closed valve -> complete AV block
When do you have no a waves o nCVP?
a fib
When do you get a and v waves of equal size and sharp y descent with no c wave on CVP?
constrictive pericarditis
-b/c stiff pericardium limits vent relaxation -> diastolic pressures in heart are elevated and equal
When do you get blunting of y wave and elevated a and v wave son CVP?
cardiac tamponade
Kussmaul sign
constrictive pericarditis
during inspiration there is an inc in JVD
Morphine epidural onset time and duration
onset 30-60 minutes
duration: 24 hours
fentanyl epidural onset time and duration
onset: 5-15 minutes
duration: 2-3 hours
Reversal agent for dabigatran
Idarucizumab
Reversal for apixaban
Andexanet alfa
Which pts more likely to have anaphylactoid rxn or anaphylaxis to protamine
prev protamine exposure
NPH insulin
fish allergy
vassectomy
Type II rxn
What protamine reaction mediated by thromboxane A2
pulm HTN, systemic hypoTN, R heart failure
-heparin-protamine complexes in pulm circulation -> release of thromboxane A2
Type III rxn
Protamine type I reaction
systemic hypoTN
give pressors and slow admin
due to histamine release
Tx for type III protamine rxn
stop protamine
RV support w/ epi or milrinone
Above critical temp of a gas what happens
a substance can no longer be converted to a liquid no matter how much pressure is applied to it
-heat of vaporization is zero at this point b/c no diff b/w liquid and gas
Above critical pressure what happens
prev incompressible liquids become compressible
solubility characteristics of a liquid may change
PAO2 equation
PAO2 = (Patm - 47) x FiO2 - (PaCO2/.8)
Electromagnetic ray emission from the skin
Radiation
MOST SIGNIFICANT source of heat loss from body
peribulbar v retrobulbar block: more reliable akinesia of the orbicularis oculi?
Peribulbar
-b/c larger volume of local anesthetic -> greater distribution
-if doing retrobular -> need supplemental facial n block
Which anesthestic gas most augments NMB?
DES
DES DOES MORE with NMB esp aminosteroids like roc
where oxytocin made and released from?
made: supraoptic and paraventricular nuclei of hypothalamus
released: posterior pituitary
(same as vasopressin)
Neurophysins
inactive carrier proteins that bind oxytocin and vasopressin to transport it from hypothalamus to pituitary
Where is growth hormone synthesized?
Anterior pituitary
When do you see K complexes on EEG?
w/ sleep spindles -> stage 2 of non-REM sleep
Beta waves assoc w/?
wakefulness
waves w/ > 12 Hz freq
When to check anti-factor Xa activity w/ rivaroxaban?
Altered GI anatomy
morbid obesity
potential drug-drug interactions
concerns regarding drug regimen adherence
morbid obesity
Bier block and bupivicaine
Never use as LA for block b/c cardiotoxic and risk for cardiac arrest
-but can use to infiltrate surgical site to assist w/ postop analgesia prior to torniquet deflation
First line therapy for trigeminal neuralgia
Carbamazepine
Carbamazepine toxicity symp
cardiac: widening of QRS, prlonged QT, vent arrythmias, hypoTN
Anticholinergic: hyperthermia, flushing, mydriasis
nystagmus
urinary retention
Behind the larynx b/w the epiglottis and cricoid cartilage
hypopharynx
region from soft palate to epiglottis
oropharynx
Morquio syndrome
lysosomal storage d/o
short trunk dwarfism
corneal deposits
skeletal dysplasia
-odontoid hypoplasia w/ atlantoaxial instability
What causes the most secretion of vasopressin?
hypoTN
w/ transsphenoidal pituitary surgery CO2 goals
hypercapnia to inc ICP to bring pituitary gland down into the sella
Acromegaly and art lines
a radial artery line should be avoided if carpal tunnel present
-ligament hypertrophy causes ulnar a to become occluded -> reliant on radial, if flow compromised could lose blood flow to hand
Which hyperfxn pit adenoma MC?
prolacintoma
more common in women 20:1
Tx for prolactinoma
Bromocriptine
DA agonist
lumbar catheters and pituitary surgerys
lumbar intrathecal catheter may be placed preop to allow for better visualization of tumor by removing CSF or injecting contrast
post brain surgery hyperNa, polyuria w/ diluate and voluminous urine
diabetes insipidous
tx: desmopressin
post brain surgery hypoNa, hypoosmolar serum, hyperosmolar urine, and euvolemic state
SIADH
-fluid restriction!
Dantrolene dose for MH
2.5 mg/kg
obese kids v normal BMI kids: wheezing post op
obese kids have dec FRC and inc wheezing after GA
obese kids v normal BMI kids: propofol clearance
inc plasma clearance in obese children
Medical standard entity to practice anesthesia
there is NO centralized standard or medical exam entity that indicates who is safe to practice anesthesia
-if practitioner has a possibly disabling condition, up pto provider to tailor practice
BIS 80
light/mod sedation
BIS 60
GA, low probability of recall
BIS 40
deep hypnotic state
BIS 20
burst suppression
How long after injxn is peak plasma lidocaine conc after tumescent liposuction?
12-16 hrs
Max dose of epi for tumescent lipo?
0.07 mg/kg
1:1,000:000 conc
Max dose of lidocaine for tumescent lipo?
55 mg/kg
0.1% or 1 mg/cc
Pt on ticagrelor and ASA 6 month post DES and want to do spinal, when to hold each?
Ticagrelor 5-7 days prior
ASA continue
dx of septic shock requires
lactate > 2
vasopressors to keep MAP > 65 despite adequate fluids
Lab changes after 6L NS
hyperchloremic metabolic acidosis
-inc K
-dilutional dec in Hct and albumin
dec in bicarb
DLCO assoc w/improved outcomes in lung resection?
> 40%
FVC assoc w/improved outcomes in lung resection?
> 50%
FEV1 assoc w/ poor outcomes in lung resection?
< 30%
MVV assoc w/ poor outcomes in lung resection?
< 50%
RV/TLC assoc w/ poor outcomes in lung resection?
> 50%
vital capacity assoc w/ poor outcomes in lung resection?
< 2L
ABG values assoc w/ poor outcomes in lung resection?
PaO2 < 60
PaCO2 > 46
Req for a change in baseline of fetal HR
decel/accel 2-10 min prolonged
change of baseline if they last > 10 minutes
