ITE CA2 General 2

Question 1

Arterial blood gas analysis directly measures …

Answer 1

Arterial blood gas analysis directly measures pH, PaCO2, and PaO2.

Question 2

Most common lab finding in DIC

Answer 2

Thrombocytopenia is the most common laboratory diagnostic feature of DIC

Question 3

Nerve palsies from LMA

Risk factors

Answer 3

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.

Question 4

Infective endocarditis prophylaxis when?

Answer 4

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

Question 5

Smoking cessation benefits timeline

Answer 5

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.

Question 6

Apnea hypopnea index categories for OSA

Answer 6

Normal: AHI<5
Mild sleep apnea: 5≤AHI<15
Moderate sleep apnea: 15≤AHI<30
Severe sleep apnea: AHI≥30

Question 7

organism for Croup

Answer 7

parainfluenza

Question 8

organisms for epiglottitis

Answer 8

H influenza B
S pneumoniae
S Aureas

Question 9

STOP BANG

Answer 9

Snoring
Tired
Observed
Pressure
BMI > 35
Age > 50
Neck > 17in or 43cm male or >16/41 female
Gender (Male worse)

Question 10

The jaw-thrust maneuver relieves upper airway obstruction by

Answer 10

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.

Question 11

The ____ muscle is the attachment point of the tongue to the mandible.

Answer 11

The genioglossus muscle is the attachment point of the tongue to the mandible.

Question 12

symptoms of carcinoid syndrome can include:

Answer 12

symptoms of carcinoid syndrome can include: flushing, tachycardia, arrhythmias, diarrhea, malnutrition, bronchospasm, and potential for carcinoid heart disease (specifically right-sided).

Question 13

O2 consumption in an adult

Answer 13

3-4 ml/kg/min

Question 14

FRC estimate

Answer 14

30 ml/kg

Question 15

Upright to supine reduction in FRC

Answer 15

10-15%

Question 16

Reduction of FRC with induction of GA

Answer 16

10%

Question 17

Things that increase MAC requirements

Answer 17

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.

Question 18

Things that decrease MAC requirements

Answer 18

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.

Question 19

What is thought to be cause of ischemia reperfusion injury during liver transplant surgery?

Answer 19

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.

Question 20

Pseudocholinesterase deficiency prolongs the actions of what neuromuscular blockers

Answer 20

Pseudocholinesterase deficiency prolongs the actions of succinylcholine and mivacurium which can lead to prolonged neuromuscular blockade and apnea.

Question 21

What drug can prolong sux action

Answer 21

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.

Question 22

Other names for pseudocholinesterase

Answer 22

Butyrylcholinesterase (alternately pseudocholinesterase or plasma cholinesterase)

Question 23

Genetic variants of psedocholinesterase deficiency

Answer 23

Approximately 20 genetic variants of the BCHE gene exist with the A- and K-variants being the most common.

Question 24

Indications for hyperbaric oxygen therapy

Answer 24

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

Question 25

11 non-reassuring findings for predictors of difficult airway

Answer 25

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

Question 26

Definition of difficult intubation

Answer 26

The American Society of Anesthesiologists defines difficult endotracheal intubation as three attempts at endotracheal intubation that takes ten or more minutes.

Question 27

Patient with preop acute viral hepatitis

Answer 27

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.

Question 28

MH stuff in surgery center?

Answer 28

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.

Question 29

How prevent arrhythmia with extracorporeal shock wave lithotripsy

Answer 29

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.

Question 30

Residents who developed substance use disorder were ...

Answer 30

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.

Question 31

% 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

Answer 31

- 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

Question 32

Risk factors for determining postoperative hepatic dysfunction

Answer 32

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.

Question 33

stridor 24-96 hours after thyroidectomy

Answer 33

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.

Question 34

first line vasopressor in septic shock

Answer 34

Norepinephrine is the first-line vasopressor for treatment of septic shock after adequate intravascular volume expansion.

Question 35

Lab tests in antiphospholipid syndrome | and why

Answer 35

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.

Question 36

Antiphospholipid syndrome what is it what causes it is there a bleeding tendency?

Answer 36

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.

Question 37

Down syndrome associations

Answer 37

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.

Question 38

Muscle relaxant requirements in down syndrome

Answer 38

Down syndrome is associated with decreased, not increased, muscle relaxant requirement. These patients often present with hypotonia and require less muscle relaxants.

Question 39

Allergies ass'd with latex allergy

Answer 39

``` 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. ```

Question 40

frequent cosmetic use ass'd with allergy to what drug

Answer 40

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.

Question 41

Cause of increased SVR in insuflation

Answer 41

Increased systemic vasopressin levels are primarily responsible for increased SVR during pneumoperitoneum for laparoscopic surgery.

Question 42

Hetastarch vs tetrastarch coagulopathy max dose contraindication

Answer 42

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

Question 43

SVT in patient with WPW treatment

Answer 43

Supraventricular tachycardia in patients with WPW can be safely managed with procainamide.

Question 44

Guillain-Barré is associated with

Answer 44

SIADH - hyponatremia Autonomic dysfunction - hypotension, HTN, dysrhythmias, ileus DVT Neuropathic pain

Question 45

Phosgene what is it morbidity and mortality related to treatment

Answer 45

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

Question 46

Common physiological changes seen after brain death include

Answer 46

Common physiological changes seen after brain death include myocardial dysfunction, catecholamine storm followed by hemodynamic instability, hypovolemia, pulmonary edema, hyperglycemia, and polyuria.

Question 47

Hemodynamic goals for brain-dead donors for organ procurement include also, goal hct?

Answer 47

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

Question 48

First order elimination

Answer 48

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.

Question 49

Drugs with zero-order kinetics

Answer 49

``` PEA: phenytoin ethanol aspirin also thiopental ```

Question 50

Most drugs are first or zero order elimination?

Answer 50

first

Question 51

zero-order elimination

Answer 51

maximum amount per unit time

Question 52

Carcinoid syndrome definition | detection

Answer 52

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.

Question 53

5 HIAA levels

Answer 53

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.

Question 54

nerve conduction studies motor or sensory?

Answer 54

Nerve conduction studies are beneficial in evaluating both motor and sensory deficits.

Question 55

Risk factors for ulnar nerve injury

Answer 55

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.

Question 56

EMG timeline for ulnar neuropathy

Answer 56

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.

Question 57

How many category 1 CME credits do you need per cycle

Answer 57

250 Category 1 CME credits are required every MOCA cycle

Question 58

ACGME fellowship is how many CME credits

Answer 58

50

Question 59

expected oxygen saturation reading using a standard pulse oximeter in the setting of methemoglobinemia in a patient with a normal PaO2

Answer 59

Pulse oximetry (SpO2) values of conventional two-wavelength pulse oximeters trend towards 85% in the presence of high methemoglobin (MetHgb) levels.

Question 60

Methemoglobinemia treatment

Answer 60

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

Question 61

Common acquired causes of methemoglobinemia include:

Answer 61

``` Common acquired causes of methemoglobinemia include: prilocaine, benzocaine, metoclopramide, nitrites (including nitric oxide and nitroglycerin), aniline dyes, benzene, chloroquine, dapsone, and sulfonamides ```

Question 62

Methemoglobinemia prilocaine vs benzocaine

Answer 62

When methemoglobinemia is associated with prilocaine use it is a dose-dependent (>500 mg) phenomenon, while methemoglobinemia associated with benzocaine is not dose-dependent.

Question 63

Methylene blue pulse ox reading

Answer 63

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.

Question 64

Quadriplegia what level

Answer 64

Quadriplegia occurs with injury above the first thoracic vertebra and paraplegia occurs with injury below the first thoracic spinal level.

Question 65

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

Answer 65

diphenhydramine (or benztropine) help resolve dopaminergic-cholinergic balance next line: benzos

Question 66

When preop EKG

Answer 66

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.

Question 67

zoster typical locations

Answer 67

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.

Question 68

In instances of pulmonary edema caused by obstruction (e.g. laryngospasm), called negative pressure pulmonary edema or postobstructive pulmonary edema, treatment

Answer 68

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.

Question 69

CO2 tank color

Answer 69

gray

Question 70

Nitrogen tank color

Answer 70

black

Question 71

Helium tank color

Answer 71

brown

Question 72

Hypophosphatemia effect on 2,3-diphosphoglycerate (2,3-DPG)

Answer 72

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.

Question 73

hypophosphatemia effects

Answer 73

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.

Question 74

Refeeding syndrome causes what metabolic derrangements

Answer 74

Refeeding syndrome causes hypophosphatemia, hyponatremia, hypocalcemia, hypomagnesemia, hypokalemia, and hyperglycemia.

Question 75

``` Effect on PDA closure Hypoxemia maternal NSAID use, hypothermia acidosis ```

Answer 75

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.

Question 76

plasmin

Answer 76

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

Question 77

thromboxane

Answer 77

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)

Question 78

The 4T clinical scoring system is used to clinically diagnose HIT prior to laboratory confirmation. The 4Ts include: how many points each category

Answer 78

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

Question 79

normal P50 of oxygen hemoglobin curve

Answer 79

27

Question 80

P50 of oxygen for fetal hemoglobin

Answer 80

19

Question 81

``` How long wait for elective surgery after: balloon angiography without stenting BMS implantation DES implantation MI with no coronary intervention ```

Answer 81

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.

Question 82

New onset LBBB represents ______ until proven otherwise

Answer 82

New onset LBBB also represents myocardial ischemia until proven otherwise

Question 83

ST segment depression is an indicator of

Answer 83

ST segment depression is an indicator of acute subendocardial myocardial ischemia

Question 84

Q waves

Answer 84

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.

Question 85

T wave inversions

Answer 85

T wave inversions (D) are a sign of acute myocardial ischemia but do not specifically pertain to a subendocardial or transmural injury.

Question 86

Renin in cirrhotic patients

Answer 86

increased release

Question 87

Hemodynamics in cirrhosis

Answer 87

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

Question 88

Conditions where mixed venous oxygen saturation is increased are

Answer 88

Conditions where mixed venous oxygen saturation is increased are: septic shock, AV fistulas, cirrhosis, hypothermia, and hyperoxia.

Question 89

What is leukoreduction? | What benefits does it have

Answer 89

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.

Question 90

Normal CVP tracing summary:

Answer 90

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

Question 91

what part of CVP tracing corresponds with systolic filling of the RA

Answer 91

v wave

Question 92

The causes of hypoxemia which ones have low A-a gradient

Answer 92

``` 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.

Question 93

A-a gradient =

Answer 93

A-a gradient = PAO2 – PaO2

Question 94

CAM-ICU

Answer 94

screen for delirium requires inattention and either altered level of consciousness (RASS) or disorganized thinking

Question 95

test for suspected anaphylaxis

Answer 95

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

Question 96

reversal, pair edrophonium with

Answer 96

atropine

Question 97

Neostigmine Paradoxical muscular weakness affected by glyco?

Answer 97

Paradoxical muscular weakness is also possible with neostigmine, but appears independent of anticholinergic use.

Question 98

Anaphylactic reactions to blood transfusions are likely due to ________________ treatment?

Answer 98

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.

Question 99

anaphylactic symptoms during blood transfusion

Answer 99

urticaria, angioedema, dyspnea

Question 100

delayed hemolytic transfusion reaction mechanism

Answer 100

allo-antibodies directed against red blood cell antigens such as Kidd

Question 101

Acute hemolytic transfusion reaction mechanism

Answer 101

IgM antigen-antibody complex activation complement

Question 102

Minor allergic reaction in blood transfusion. mechanism

Answer 102

presence of foreign protein in the transfused blood