ITE CA2 General 2 Flashcards
Arterial blood gas analysis directly measures …
Arterial blood gas analysis directly measures pH, PaCO2, and PaO2.
Most common lab finding in DIC
Thrombocytopenia is the most common laboratory diagnostic feature of DIC
Nerve palsies from LMA
Risk factors
Lingual nerve, recurrent laryngeal nerve, and hypoglossal nerve palsies have been reported following LMA use. Risk factors include overinflation of a small-fitting cuff, prolonged operative times (>2-4 hours), lidocaine lubrication, difficult insertion, use of nitrous oxide, and cervical joint disease.
Infective endocarditis prophylaxis when?
Infective endocarditis prophylaxis is recommended for cardiac conditions listed below PLUS:
1) Dental (mucosal, gingival) procedures or
2) Respiratory tract (tonsillectomy, adenoidectomy, bronchoscopy with incision/biopsy) procedures or
3) Infected skin/musculoskeletal tissue procedures
High risk cardiac conditions:
1) Prosthetic cardiac valve or prosthetic material used in valve repair
2) Previous endocarditis
3) CHD only in the following categories:
- Unrepaired cyanotic congenital heart disease
- Completely repaired congenital heart disease with prosthetic material or device within six months
- Repaired congenital heart disease with residual defects
4) Cardiac transplantation recipients with cardiac valvular disease
Infective endocarditis prophylaxis is NOT recommended for:
1) Routine/simple dental procedures without infected tissue
2) Gastrointestinal/Genitourinary procedures
3) Bronchoscopy without mucosal incision
4) Mitral valve prolapse, HOCM, bicuspid aortic valve
Smoking cessation benefits timeline
Twelve to 24 hours is enough to decrease carboxyhemoglobin levels and shift the dissociation curve rightward (increasing oxygen availability to tissues).
2-4 weeks improved mucociliary function
2-3 weeks increased sputum production
3-4 weeks decreased sputum production
6-8 weeks improved pulmonary immune function and normalization of hepatic enzyme activity
abstinence of at least 3 to 4 weeks reduced wound healing complications.
Apnea hypopnea index categories for OSA
Normal: AHI<5
Mild sleep apnea: 5≤AHI<15
Moderate sleep apnea: 15≤AHI<30
Severe sleep apnea: AHI≥30
organism for Croup
parainfluenza
organisms for epiglottitis
H influenza B
S pneumoniae
S Aureas
STOP BANG
Snoring Tired Observed Pressure BMI > 35 Age > 50 Neck > 17in or 43cm male or >16/41 female Gender (Male worse)
The jaw-thrust maneuver relieves upper airway obstruction by
The jaw-thrust maneuver relieves upper airway obstruction by providing anterior movement of the mandible and tongue. The genioglossus muscle is the attachment point of the tongue to the mandible.
The ____ muscle is the attachment point of the tongue to the mandible.
The genioglossus muscle is the attachment point of the tongue to the mandible.
symptoms of carcinoid syndrome can include:
symptoms of carcinoid syndrome can include: flushing, tachycardia, arrhythmias, diarrhea, malnutrition, bronchospasm, and potential for carcinoid heart disease (specifically right-sided).
O2 consumption in an adult
3-4 ml/kg/min
FRC estimate
30 ml/kg
Upright to supine reduction in FRC
10-15%
Reduction of FRC with induction of GA
10%
Things that increase MAC requirements
Hyperthermia, hypernatremia, chronic ethanol abuse, and increased central neurotransmitter levels (e.g. MAOIs, amphetamine, cocaine, ephedrine, and levodopa use) increase MAC requirements for anesthetic agents.
Things that decrease MAC requirements
Many factors decrease the MAC of anesthetic agents including acute ethanol ingestion, pregnancy, metabolic acidosis, and hyponatremia. Other factors include increasing age (especially > 40), hypoxia, hypothermia, induced hypotension, anemia, and certain drugs including α-2 agonists, lithium, large doses of cholinesterase inhibitors, lidocaine, opioids, barbiturates, and calcium channel blockers.
What is thought to be cause of ischemia reperfusion injury during liver transplant surgery?
When the blood supply to the liver is altered, inadequate oxygen and nutrients are supplied to the liver. Once the blood flow is reestablished, reperfusion enhances the injury caused during the ischemic period, aggravating the damage caused at the cellular level. This is known as ischemia-reperfusion injury and is thought to be caused by disruption of the sodium potassium pumps secondary to decreased adenosine triphosphate and glycogen.
Pseudocholinesterase deficiency prolongs the actions of what neuromuscular blockers
Pseudocholinesterase deficiency prolongs the actions of succinylcholine and mivacurium which can lead to prolonged neuromuscular blockade and apnea.
What drug can prolong sux action
Echothiophate is an anticholinesterase used to treat refractory glaucoma by causing miosis. Since it inhibits BCHE (butyrylcholinesterase), systemic absorption can cause up to a 95% decrease in BCHE function, thereby potentiating the effects of succinylcholine.
Other names for pseudocholinesterase
Butyrylcholinesterase (alternately pseudocholinesterase or plasma cholinesterase)
Genetic variants of psedocholinesterase deficiency
Approximately 20 genetic variants of the BCHE gene exist with the A- and K-variants being the most common.
Indications for hyperbaric oxygen therapy
air embolism, decompression sickness, poisoning, envenomation, soft tissue necrotizing infections refractory chronic osteomyelitis intracranial abscess mucormycosis crush injury compromised skin flaps central retinal artery/vein occlusion ischemia ulcers radiation necrosis oxygenation support during tehrapeutic lung lavage, significant blood loss anemia if transfusion delayed/unavailable burns
11 non-reassuring findings for predictors of difficult airway
The 11 non-reassuring findings are:
1) Relatively long incisors
2) Prominent “overbite”
3) Patient cannot bring mandibular incisors anterior to maxillary incisors
4) Less than 3 cm interincisor distance
5) Uvula is not visible when tongue is protruded with patient in sitting position
6) Highly arched or very narrow palate
7) Mandibular space that is stiff, indurated or occupied by a mass
8) Less than three ordinary finger breadth thyromental distance
9) Short neck length
10) Thick neck circumference
11) Decreased extension or flexion of the neck
Definition of difficult intubation
The American Society of Anesthesiologists defines difficult endotracheal intubation as three attempts at endotracheal intubation that takes ten or more minutes.
Patient with preop acute viral hepatitis
If a patient has acute preoperative viral hepatitis, surgery should not proceed unless deemed an emergency since the risk of morbidity and mortality is significantly elevated in these patients.
MH stuff in surgery center?
Medications, protocols, and equipment for malignant hyperthermia are only needed in office-based anesthesia in centers that use triggering agents such as succinylcholine or volatile anesthetics.
How prevent arrhythmia with extracorporeal shock wave lithotripsy
Immersion extracorporeal shock wave lithotripsy ESWL is performed by passing external shocks through the patient to break up renal calculi. The best way to prevent dysrhythmias is by synchronization of the shock to the R wave on the ECG.
Residents who developed substance use disorder were …
Residents who developed substance use disorder were more likely to be male, American medical graduates, and have lower ITE scores at the end of CA-1 year.
% of residence with e/o addiction during training
% of those who died during training
% who relapse w/i 30 years
% of those who relapse with death as presenting manifestation of relapse
- 0.86% of residents had evidence of addiction during training
- 7.3% of those died during the training period
- There is a 43% cumulative proportion of relapse at 30 years after the initial episode
- In 13% of those who relapsed, death was the presenting manifestation of relapse
Risk factors for determining postoperative hepatic dysfunction
The type of surgery (CT is worst) is most likely the biggest risk factor in determining whether postoperative hepatic dysfunction will occur. Following that is the presence of acute or chronic hepatitis and cirrhosis.
stridor 24-96 hours after thyroidectomy
Hypocalcemia occurs in approximately 20% of patients undergoing total thyroidectomy and develops 24-96 hours after surgery. Stridor can be a sign of hypocalcemia, and should be treated with IV calcium.
first line vasopressor in septic shock
Norepinephrine is the first-line vasopressor for treatment of septic shock after adequate intravascular volume expansion.
Lab tests in antiphospholipid syndrome
and why
Prothrombin time is typically normal, however, activated partial thromboplastin time (aPTT) may be elevated in antiphospholipid syndrome.
The elevated aPTT results from an inhibitor directed against phospholipid rather than specific coagulation factors.
Antiphospholipid syndrome
what is it
what causes it
is there a bleeding tendency?
Antiphospholipid syndrome is a prothrombotic disorder resulting in both venous and arterial thrombosis.
It is characterized by the presence of two autoantibodies, lupus anticoagulant and anticardiolipin antibody. Lupus anticoagulant has no true anticoagulant activity; instead, the anticoagulant activity is a laboratory artifact that affects the phospholipid-dependent coagulation assays. In the absence of an underlying coagulation deficit or anticoagulant therapy, the prolonged aPTT does not suggest a bleeding tendency and neuraxial anesthesia may be administered in this setting.
Down syndrome associations
Down syndrome patients frequently have cardiovascular defects (40-50%). The most common of these is endocardial cushion defects. Down syndrome is associated with atlantoaxial instability, hypotonia, and gastrointestinal, genitourinary, respiratory, vascular, and metabolic defects.
Muscle relaxant requirements in down syndrome
Down syndrome is associated with decreased, not increased, muscle relaxant requirement. These patients often present with hypotonia and require less muscle relaxants.
Allergies ass’d with latex allergy
Health care workers, children with spina bifida and urogenital syndromes, and people with allergies to banana, avocado, kiwi, pineapple, mango, and other tropical fruits have an increased risk for development of a latex allergy.
frequent cosmetic use ass’d with allergy to what drug
Frequent cosmetic use may be related to antibodies against aminosteroid NMBDs (pancuronium, pipercurium, rocuronium, and vecuronium), but there is no increased association with a latex allergy.
Cause of increased SVR in insuflation
Increased systemic vasopressin levels are primarily responsible for increased SVR during pneumoperitoneum for laparoscopic surgery.
Hetastarch vs tetrastarch
coagulopathy
max dose
contraindication
Hetastarches are traditionally associated with a higher risk of coagulopathies (platelet adhesion interference, reduced factor VIII:C and vWF levels, and PTT prolongation) than the newer, lower molecular weight tetrastarches.
The maximum daily doses of hetastarches (~20 mL/kg) are generally less than tetrastarches (~50 mL/kg).
both contraindicated in renal failure; hetastarches are contraindictaed in von willebrand dz
SVT in patient with WPW treatment
Supraventricular tachycardia in patients with WPW can be safely managed with procainamide.
Guillain-Barré is associated with
SIADH - hyponatremia
Autonomic dysfunction - hypotension, HTN, dysrhythmias, ileus
DVT
Neuropathic pain
Phosgene
what is it
morbidity and mortality related to
treatment
Phosgene is a chemical warfare agent that can lead to significant pulmonary damage. There is no specific antidote and treatment is generally centered around providing supportive care and minimizing the effects of the inflammatory mediator cascade.
M&M related to degree of pulm damage
Common physiological changes seen after brain death include
Common physiological changes seen after brain death include myocardial dysfunction, catecholamine storm followed by hemodynamic instability, hypovolemia, pulmonary edema, hyperglycemia, and polyuria.
Hemodynamic goals for brain-dead donors for organ procurement include
also, goal hct?
Hemodynamic goals for brain-dead donors for organ procurement include mean arterial blood pressure of 60mmHg or greater, urinary output of 1 mL/kg/hr or greater, and left ventricular ejection fraction of 45% or greater.
Transfusion to goal hct of 30
First order elimination
With first-order elimination, the amount of drug eliminated is directly proportional to the serum drug concentration. All enzymes and clearance mechanisms are working below their maximum capacity, and the rate of drug elimination is directly proportional to drug concentration. Most drugs are eliminated in a first-order elimination process.
Drugs with zero-order kinetics
PEA: phenytoin ethanol aspirin also thiopental
Most drugs are first or zero order elimination?
first
zero-order elimination
maximum amount per unit time
Carcinoid syndrome definition
detection
Carcinoid syndrome is due to an excess secretion of serotonin into the systemic circulation. The diagnosis of carcinoid syndrome can be made by measuring 24-hour urinary levels of 5-HIAA.
5 HIAA levels
A 24-hour urine sample containing 30mg or more of 5-HIAA suggests carcinoid syndrome. Normal urinary levels of 5-HIAA in a 24-hour period are between 3 to 15 mg. Following serial levels of 5-HIAA can help to monitor tumor progression.
nerve conduction studies motor or sensory?
Nerve conduction studies are beneficial in evaluating both motor and sensory deficits.
Risk factors for ulnar nerve injury
Risk factors for injury include: very thin or obese patients, prolonged postoperative bed rest, male gender, older age, hyperflexion of the elbow, and compression of the nerve within the condylar groove between the humerus and the operating room table or within the cubital tunnel (or “ulnar groove”) against the posterior aspect of the medial epicondyle of the humerus.
EMG timeline for ulnar neuropathy
Since abnormal spontaneous activity (suggestive of denervation) typically takes 1-4 weeks to develop, the presence of abnormal findings immediately postoperatively suggests nerve injury was likely present preoperatively. A normal immediately postoperative EMG neither suggests nor rules out intraoperative nerve injury and a repeat study should be performed in a few weeks. A new abnormal finding at that time would suggest a perioperative injury.
How many category 1 CME credits do you need per cycle
250 Category 1 CME credits are required every MOCA cycle
ACGME fellowship is how many CME credits
50
expected oxygen saturation reading using a standard pulse oximeter in the setting of methemoglobinemia in a patient with a normal PaO2
Pulse oximetry (SpO2) values of conventional two-wavelength pulse oximeters trend towards 85% in the presence of high methemoglobin (MetHgb) levels.
Methemoglobinemia treatment
Methylene blue (1-2 mg/kg) is the primary pharmacologic treatment of methemoglobinemia. However, methylene blue can cause hemolysis in patients with G6PD-deficiency. Therefore ascorbic acid (vitamin C) is the treatment of choice of methemoglobinemia in the setting of G6PD-deficiency
Common acquired causes of methemoglobinemia include:
Common acquired causes of methemoglobinemia include: prilocaine, benzocaine, metoclopramide, nitrites (including nitric oxide and nitroglycerin), aniline dyes, benzene, chloroquine, dapsone, and sulfonamides
Methemoglobinemia prilocaine vs benzocaine
When methemoglobinemia is associated with prilocaine use it is a dose-dependent (>500 mg) phenomenon, while methemoglobinemia associated with benzocaine is not dose-dependent.
Methylene blue pulse ox reading
A pulse oximetry value of 65% is associated with the use of methylene blue. Methylene blue transiently decreases the observed pulse oximetry reading in a dose dependent manner. Pulse oximetry reading approach 65% for roughly 10 minutes.
Quadriplegia what level
Quadriplegia occurs with injury above the first thoracic vertebra and paraplegia occurs with injury below the first thoracic spinal level.
This patient is most likely having an acute dystonic reaction due to dopamine antagonism from metoclopramide and prochlorperazine administration. This can quickly and reliably be treated with
diphenhydramine
(or benztropine)
help resolve dopaminergic-cholinergic balance
next line: benzos
When preop EKG
Preoperative ECG is not indicated for low-risk surgery and is not indicated based on age. According to the 2014 guidelines, it is reasonable to perform a preoperative ECG in patients with
coronary heart disease,
significant arrhythmia,
peripheral arterial disease,
cerebrovascular disease,
or other significant structural heart disease who are undergoing elevated-risk surgery.
zoster typical locations
Acute herpes zoster typically affects thoracic nerve roots, followed in descending order by:
ophthalmic division of the trigeminal nerve (V1),
maxillary division of the trigeminal nerve (V2),
cervical spinal roots, and
sacral spinal roots.
In instances of pulmonary edema caused by obstruction (e.g. laryngospasm), called negative pressure pulmonary edema or postobstructive pulmonary edema,
treatment
In instances of pulmonary edema caused by obstruction (e.g. laryngospasm), called negative pressure pulmonary edema or postobstructive pulmonary edema, positive pressure ventilation should be instituted in most cases in order to maintain oxygen saturation.
CO2 tank color
gray
Nitrogen tank color
black
Helium tank color
brown
Hypophosphatemia effect on 2,3-diphosphoglycerate (2,3-DPG)
Hypophosphatemia decreases 2,3-diphosphoglycerate (2,3-DPG) causing a left shift in the oxyhemoglobin curve. These patients will have poor oxygen release at the level of the peripheral tissues as a result.
hypophosphatemia effects
Low phosphate decreases cardiac contractility, and can precipitate arrhythmias.
From a neurological standpoint, hypophosphatemia can result in altered mental status, seizures, and central pontine myelinolysis.
Refeeding syndrome causes what metabolic derrangements
Refeeding syndrome causes hypophosphatemia, hyponatremia, hypocalcemia, hypomagnesemia, hypokalemia, and hyperglycemia.
Effect on PDA closure Hypoxemia maternal NSAID use, hypothermia acidosis
Hypoxemia, hypothermia, and acidosis are all associated with persistent fetal circulation. This is due to increased pulmonary pressures, which favors flow through shunts that are only functionally closed and not yet anatomically closed. Maternal NSAID use is associated with premature ductal closure and not persistent fetal circulation.
plasmin
Plasmin is an important enzyme present in blood that degrades many blood plasma proteins, including fibrin clots. The degradation of fibrin is termed fibrinolysis. In humans, the plasmin protein is encoded by the PLG gene
thromboxane
Thromboxane is a member of the family of lipids known as eicosanoids. The two major thromboxanes are thromboxane A2 and thromboxane B2. The distinguishing feature of thromboxanes is a 6-membered ether-containing ring. Thromboxane is named for its role in clot formation (thrombosis)
The 4T clinical scoring system is used to clinically diagnose HIT prior to laboratory confirmation. The 4Ts include:
how many points each category
The 4T clinical scoring system is used to clinically diagnose HIT prior to laboratory confirmation. The 4Ts include:
1) Thrombocytopenia
2) Timing of the reduced platelet count
3) Presence of thrombosis
4) The exclusion of other causes for thrombocytopenia
2 points in each category
normal P50 of oxygen hemoglobin curve
27
P50 of oxygen for fetal hemoglobin
19
How long wait for elective surgery after: balloon angiography without stenting BMS implantation DES implantation MI with no coronary intervention
After an MI wait 14 days after balloon angioplasty, 30 days after BMS, 60 days if no coronary intervention, and 180 days after DES for elective noncardiac surgery.
Wait 180 days after DES implantation for elective surgery and continue dual-antiplatelet therapy (DAPT) until that point. Some guidelines suggest waiting 90 days in certain patient groups where further surgery delay would be detrimental. The recommendation to wait 365 days after DES was decreased to 180 in the 2016 update by the ACC/AHA.
New onset LBBB represents ______ until proven otherwise
New onset LBBB also represents myocardial ischemia until proven otherwise
ST segment depression is an indicator of
ST segment depression is an indicator of acute subendocardial myocardial ischemia
Q waves
Pathologic Q waves (A) are an indicator of transmural myocardial infarction and may be remnant of an old myocardial infarction. A significant Q wave requires the width to be at least 1 mm or 0.04 milliseconds and at least one-third the amplitude of the QRS complex.
T wave inversions
T wave inversions (D) are a sign of acute myocardial ischemia but do not specifically pertain to a subendocardial or transmural injury.
Renin in cirrhotic patients
increased release
Hemodynamics in cirrhosis
In cirrhotic patients, portal hypertension is often associated with a hyperdynamic circulatory syndrome, with high cardiac output, reduced systemic vascular resistance, and reduced arterial pressure
Conditions where mixed venous oxygen saturation is increased are
Conditions where mixed venous oxygen saturation is increased are: septic shock, AV fistulas, cirrhosis, hypothermia, and hyperoxia.
What is leukoreduction?
What benefits does it have
Leukoreduction is the process of depleting donor blood products of leukocytes in an effort to reduce immunosuppression associated with blood product transfusion.
Confirmed benefits of leukoreduction include
decreased transmission of CMV,
decreased inflammatory response,
decreased febrile reactions to packed red blood cell (PRBC) transfusions, and
reduced inflammatory mediator accumulation during storage.
Normal CVP tracing summary:
Normal CVP tracing summary:
a wave: atrial contraction, absent in atrial fibrillation
c wave: TV bulging into RA during RV isovolumetric contraction
x descent: TV descends into RV with ventricular ejection and atrial relaxation
v wave: venous return to and systolic filling of the RA
y descent: atrial emptying into RV through open TV
what part of CVP tracing corresponds with systolic filling of the RA
v wave
The causes of hypoxemia
which ones have low A-a gradient
The causes of hypoxemia generally fall into one of five main categories: hypoventilation, ventilation/perfusion mismatch, right-to-left shunt, diffusion impairment, and low inspired partial pressure of oxygen.
Low PO2 and hypoventilation are associated with a normal A-a gradient whereas the other categories are associated with an increased A-a gradient.
A-a gradient =
A-a gradient = PAO2 – PaO2
CAM-ICU
screen for delirium
requires inattention and
either altered level of consciousness (RASS)
or disorganized thinking
test for suspected anaphylaxis
tryptase within 15-60 minutes for grade I/II, 30-120 minutes for grade III/IV (life-threatening)
and then redraw at least 24h later for baseline comparison
reversal, pair edrophonium with
atropine
Neostigmine Paradoxical muscular weakness affected by glyco?
Paradoxical muscular weakness is also possible with neostigmine, but appears independent of anticholinergic use.
Anaphylactic reactions to blood transfusions are likely due to ________________
treatment?
Anaphylactic reactions to blood transfusions are likely due to IgA-containing blood being transfused to a deficient recipient. The transfusion should be discontinued and future red blood cells should be washed to remove all traces of IgA from the blood.
anaphylactic symptoms during blood transfusion
urticaria, angioedema, dyspnea
delayed hemolytic transfusion reaction mechanism
allo-antibodies directed against red blood cell antigens such as Kidd
Acute hemolytic transfusion reaction mechanism
IgM antigen-antibody complex activation complement
Minor allergic reaction in blood transfusion. mechanism
presence of foreign protein in the transfused blood
