ITE CA2 General 3

Question 1

What happens to potassium in met alkalosis

Answer 1

Potassium repletion is important for treatment of the metabolic alkalosis since the alkalosis causes hypokalemia. Recall that K+ is driven into cells and exchanged for intracellular H+ in an attempt to buffer the alkalosis. In an attempt to correct the hypokalemia, an H-K-ATPase in the renal collecting tubules then reabsorbs K+ in exchange for secreting H+, thus worsening the alkalosis. Potassium repletion therefore improves an alkalosis by reversing these two processes. First, as the intracellular K+ deficit is restored, H+ moves out of the cells as the K+ moves in. Second, potassium repletion decreases the H-K-ATPase activity and allows bicarbonate, and not H+, to be excreted in the urine.

Question 2

MTHFR deficiency avoid what drug

Answer 2

Nitrous oxide (C) should be avoided in patients with MTHFR deficiency

Question 3

Etomidate side effect mechanism

Answer 3

Etomidate (B) is an induction agent that is relatively hemodynamically stable. However etomidate has been shown to inhibit 11-beta-hydroxylase. 11-beta-hydroxylase is used by the adrenal glands to produce corticosteroids, because of this etomidate has been linked to adrenal suppression and insufficiency. It should be avoided in septic patients.

Question 4

Following neostigmine administration, a dose of succinylcholine will

Answer 4

Following neostigmine administration, a dose of succinylcholine will result in an increased duration of phase I blockade when compared to the duration of action of succinylcholine administered alone. Phase I augmentation lasts about 30 minutes on average.

Question 5

In the hemodynamically unstable patient with SVT, what is the best treatment

Answer 5

In the hemodynamically unstable patient with SVT, synchronized cardioversion is the best treatment. For regular narrow complex tachycardia, a starting dose of 50-100 J is appropriate. For irregular narrow complex tachycardia, 120-200 J of biphasic or 200 J of monophasic is used. Unsynchronized cardioversion is the best treatment for irregular wide complex tachycardia (like ventricular fibrillation).

Question 6

For regular narrow complex tachycardia, a starting dose of ____ J is appropriate.
For irregular narrow complex tachycardia, _____ J of biphasic or ____ J of monophasic is used.
________________ is the best treatment for irregular wide complex tachycardia (like ventricular fibrillation).

Answer 6

In the hemodynamically unstable patient with SVT, synchronized cardioversion is the best treatment. For regular narrow complex tachycardia, a starting dose of 50-100 J is appropriate. For irregular narrow complex tachycardia, 120-200 J of biphasic or 200 J of monophasic is used. Unsynchronized cardioversion is the best treatment for irregular wide complex tachycardia (like ventricular fibrillation).

Question 7

What lab check before place epidural if patient on heparin for more than 5 days

Answer 7

Patients receiving heparin for more than five days should have a platelet count checked prior to epidural placement or catheter removal. ASRA guidelines recommend waiting 4-6 hours before epidural placement in patients receiving 5000 U subcutaneous heparin BID or TID.

Question 8

C diff testing

Answer 8

A C. difficile bacterial antigen enzyme immunoassay (EIA) can rapidly detect the presence of the bacteria, although asymptomatic carriers will also be positive.

Follow-up to a positive antigen EIA is typically done with the gold standard C. difficile cell culture cytotoxin assay.

The latter is highly sensitive and specific for C. difficile infection but does not provide results quickly.

A C. difficile toxin A/B EIA has moderately high sensitivity and specificity, produces results quickly, and may be used as a solitary test.

Question 9

carbon monoxide shift oxy hemo curve

Answer 9

left

Question 10

Bohr effect

Answer 10

The Bohr effect states that oxygen is more readily released from hemoglobin in the face of acidosis or hypercarbia.

Question 11

ionized form of weak base

Answer 11

HB+

Question 12

unionized form of weak base

Answer 12

B

Question 13

ionized or unionized lidocaine crosses lipid bilayer

Answer 13

unionized

Question 14

the higher the pH of a solution, the ____ of a weak base such as lidocaine will exist in its unionized fraction.

Answer 14

the higher the pH of a solution, the more of a weak base such as lidocaine will exist in its unionized fraction.

Question 15

permanent pacemaker, lower extremity surgery, not pacer dependent, what do with pacer?

Answer 15

This patient has a permanent pacemaker (PPM) and it should be confirmed to be functioning properly prior to proceeding. If a recent interrogation report is not available, a qualified practitioner should interrogate the device. She is having a lower extremity surgery which has a low risk of electromagnetic interference (EMI), and her ECG indicates that she is not pacemaker dependent. As such, there is not a need to reprogram her device into an asynchronous mode prior to proceeding.

Question 16

Most common reasons for discharge delay after ambulatory surgery

Answer 16

Pain and postoperative nausea and vomiting are the two most common reasons for discharge delay.

Question 17

Sign of bladder perf during TURP

Answer 17

When TURP procedures are done under spinal anesthesia up to T10 level and not deeply sedated, bladder perforation can be recognized by abdominal pain (may be referred to shoulder or chest) (and TURP syndrome can be recognized by CNS symptoms).

Question 18

Test indicated prior to robot assisted radical prostatectomy

Answer 18

Cerebrovascular imaging should be obtained prior to a RARP in patients with an increased risk for intracranial aneurysm. The required steep Trendelenburg positioning significantly increases the risk of cerebral aneurysm rupture.

Marfan, Ehlers-Danlos, polycycstic kidney disease ass’d with aneurysms

Question 19

TIVA pancreatitis?

Answer 19

Propofol is a good antiemetic agent, but theoretically can cause or worsen pancreatitis and therefore should be avoided or limited in situations where pancreatitis is likely. The mechanism of propofol induced pancreatitis is thought to be related to hypertriglyceridemia.

Question 20

Acute mountain sickness
Pathophys
Adaptation
Severe manifestations
Presentation typical
prophylaxis
treatment

Answer 20

Ascent to high altitudes leads to hypoxia and a resultant respiratory alkalosis.
However, the body is able to acutely adapt over 2-3 days and reequilibrates PaO2, PaCO2, arterial pH, and CSF pH primarily by changes in ventilatory drive and increased bicarbonate excretion.
However, a person may experience AMS, high altitude pulm edema HAPE, and/or high altitude cerebral edema HACE prior to achieving an equilibrium driven by hypoxic ventilatory drive.
AMS presents with non-specific symptoms including headache, nausea, vomiting, insomnia, and malaise.
Prophylaxis can be accomplished with staged ascent and acetazolamide.
Treatment includes descent, supplemental oxygen, and dexamethasone. More severe manifestations include HAPE and HACE, both of which should be treated with descent and supplemental oxygen.

Question 21

Nitrous oxide administration after intraocular injection of
Air
Sulfur hexafluoride
other perfluoropropane

Answer 21

Nitrous oxide administration should be avoided for five days after intraocular air injection, 10 days after sulfur hexafluoride injection, or 30-90 days or longer after other perfluoropropane injection

Question 22

Ischemic optic neuritis presentation

Answer 22

ION following surgery generally presents with painless visual loss, visual field deficits, and sluggish pupils.

Question 23

Negative pressure pulmonary edema
incidence
Risks

Answer 23

Negative pressure pulmonary edema has an incidence of 0.05-0.1% in all general anesthetics.
Risk increases to 4% if airway obstruction occurs in a spontaneously breathing patient. Other risks include young age, male gender, physical fitness, and HEENT surgery.

Question 24

Methanol poisoning
sources
treatment

Answer 24

Methanol poisoning can occur following ingestion of substances including paint thinners, antifreeze, windshield washer fluid, and improperly distilled alcohol.

Hepatic alcohol dehydrogenase converts methanol to highly toxic formaldehyde and formic acid. Treatment of acute methanol poisoning consists of supportive care (securing an airway, maintaining hemodynamic stability, treating metabolic acidosis), prevention of the conversion of methanol to toxic metabolites (ethanol or fomepizole), and in severe cases, rapid elimination of methanol and its metabolites via hemodialysis.

Question 25

Difficult airway exam

Answer 25

On examination, risk factors for difficult laryngoscopy include increasing Mallampati score (strongest association with class III-IV), inter-incisor distance less than 4 to 4.5 cm, thyromental distance less than 6 to 6.5 cm, neck movement less than 80 degrees, inability to prognath the mandible, obesity of more than 110 kg or BMI of more than 25 to 30, neck circumference of greater than 43 cm, sternomental distance of less than 12.5 to 13.5 cm, and reduced submental compliance.

Question 26

The AFFERENT nerve impulses of carotid sinus baroreceptors are transmitted by

Answer 26

The AFFERENT nerve impulses of carotid sinus baroreceptors are transmitted by the Hering’s nerves to the glossopharyngeal nerve (CN IX)

Question 27

Carotid sinus baroreceptor stimulation

Answer 27

Carotid sinus baroreceptor stimulation leads to direct sympathetic inhibition and indirect predominance of vagal tone on cardiac performance.

Question 28

Things that increase LES tone

Answer 28

``` acetylcholine antacids anticholinesterases alpha agonists cholinergics gastrin histamine metaclopramide metoprolol pancreatic polypeptide serotonin succinylcholine ```

Question 29

Early onset adult VAP bugs

Answer 29

first 72 hours of intubation Early onset adult VAP is typically due to antibiotic-sensitive flora (Methicillin-sensitive Staphylococcus aureus (MSSA), H. influenzae, S. pneumoniae, and Proteus, Klebsiella, and Enterobacter species) and does not typically affect morbidity and mortality.

Question 30

Late-onset VAP bugs

Answer 30

Late-onset VAP is associated with a fairly high mortality rate and is caused by more virulent organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter species.

Question 31

Least stable factors in FFP

Answer 31

Factors V and VIII are the least stable factors in FFP. Factor VIII is produced in the vascular endothelium and sinusoidal cells of the liver. Von Willebrand factor serves as a carrier molecule for factor VIII, which is ultimately activated by IIa.

Question 32

Where is factor VIII produced what carries it what activates it

Answer 32

Factors V and VIII are the least stable factors in FFP. Factor VIII is produced in the vascular endothelium and sinusoidal cells of the liver. Von Willebrand factor serves as a carrier molecule for factor VIII, which is ultimately activated by IIa.

Question 33

Hepatopulmonary syndrome (HPS) is characterized by the triad of

Answer 33

Hepatopulmonary syndrome (HPS) is characterized by the triad of liver dysfunction, unexplained hypoxemia, and intrapulmonary vascular dilations. One of the unique features of this syndrome is orthodeoxia, which is increased dyspnea when transitioning from the supine to upright position.

Question 34

Orthodeoxia

Answer 34

Hepatopulmonary syndrome (HPS) is characterized by the triad of liver dysfunction, unexplained hypoxemia, and intrapulmonary vascular dilations. One of the unique features of this syndrome is orthodeoxia, which is increased dyspnea when transitioning from the supine to upright position.

Question 35

How many mg of fibrinogen in 1 unit cryo | Ten units of cryo raise 70 kg person fibrinogen by how much

Answer 35

Cryoprecipitate contains about 200 mg of product in each unit. Ten units of cryoprecipitate will typically raise a 70kg patient's fibrinogen by 70 mg/dL.

Question 36

Electrolyte abnormalities in alcoholic patients include:

Answer 36

Electrolyte abnormalities in alcoholic patients include: hypocalcemia, hypomagnesemia, hypophosphatemia, and hypoglycemia.

Question 37

hemostatic abnormalities in cirrhosis

Answer 37

Thrombocytopenia is a well-known feature of cirrhosis. Other hemostatic abnormalities in cirrhosis include a decrease in pro- and anti-coagulants (potentially causing bleeding or thrombotic complications) and low-grade fibrinolysis. TrueLearn Insight : Since INR does not necessarily reflect bleeding propensity in cirrhosis, products such as fresh frozen plasma (FFP) should not be given simply to "correct" an INR number. Studies such as the thromboelastogram (TEG) can help better determine bleeding vs clotting ability.

Question 38

cirrhosis hemodynamics

Answer 38

Cirrhosis hemodynamics are characterized by a hyperdynamic state, with increased cardiac output and low peripheral vascular resistance.

Question 39

volatile effect on hypoxic pulm vasoconstriction

Answer 39

Increasing volatile anesthetics (greater than 1 MAC) will inhibit hypoxic pulmonary vasoconstriction

Question 40

Clinical signs and symptoms of carcinoid syndrome | how diagnosed

Answer 40

Clinical signs and symptoms of carcinoid syndrome include bronchoconstriction, episodic cutaneous flushing, abdominal pain, diarrhea, hemodynamic instability, hepatomegaly, hyperglycemia, and dysthymia. Also right sided heart disease These tumors can be diagnosed by the presence of excessive amounts of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in urine

Question 41

renal changes with age

Answer 41

Changes to the renal system in the geriatric population include a decreasing renal mass, blood flow, creatinine clearance, and ability to effectively dilute and concentrate urine placing them at risk for prolonged medication effects and dehydration. Note: Serum creatinine remains the same because of reduced muscle mass

Question 42

MH inheritance

Answer 42

autosomal dominant

Question 43

3 muscle diseases which confer increased susceptibility to MH

Answer 43

central core disease, multiminicore disease, and King-Denborough syndrome. Most people with MH susceptibility do not have a specific phenotype, but there are three muscle diseases which confer increased susceptibility to MH, namely central core disease, multiminicore disease, and King-Denborough syndrome. Many other muscle diseases have been suggested to confer MH susceptibility, but only these three are supported by the evidence. Note succinylcholine and volatile anesthetics are avoided in Duchenne muscular dystrophy because of the risk of rhabdomyolysis, not because of an increased susceptibility to MH.

Question 44

Hepatic arterial buffer | what happens and by what key player

Answer 44

With a functioning hepatic arterial buffer response, hepatic arterial tone is modulated by portal venous flow, via adenosine, in order to maintain hepatic perfusion. A reduction of blood flow in the portal vein leads to an increase of adenosine in the liver and subsequent local arteriole dilation and an increase in blood flow from the hepatic artery.

Question 45

Effect on hepatic blood flow Glucagon Angiotensin II Vasopressin

Answer 45

Glucagon causes dose-dependent hepatic arterial vasodilation. Angiotensin II causes vasoconstriction of hepatic arterial and portal venous systems. Vasopressin increases splanchnic vasoconstriction while decreasing resistance to portal venous flow.

Question 46

Meralgia paresthetica

Answer 46

Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve, a purely sensory nerve. Retractor-related nerve injury may involve the brachial plexus (sternotomy), femoral nerve (gynecologic surgery), or lateral femoral cutaneous nerve (pregnancy or use of pelvic retractors).

Question 47

Typical hemodynamics in ECT

Answer 47

During electroconvulsive therapy, there is a brief initial parasympathetic surge followed by a sympathetic response. This is manifested by a brief episode of bradycardia followed by significant tachycardia and hypertension.

Question 48

The hallmarks of autonomic hyperreflexia are

Answer 48

The hallmarks of autonomic hyperreflexia are hypertension and reflexive bradycardia

Question 49

The Meyer-Overton correlation related the potency of anesthetics with solubility in

Answer 49

The Meyer-Overton correlation related the potency of anesthetics with solubility in olive oil.

Question 50

CMS regulations state that | Every patient that receives anesthesia must have the following:

Answer 50

Every patient that receives anesthesia must have the following: 1) A pre-anesthesia evaluation when general, regional, or monitored anesthesia care is planned. This must be performed by a physician, dentist, oral surgeon, certified registered nurse anesthetist, anesthesiologist’s assistant, or podiatrist. 2) This evaluation must be completed and documented within 48 hours immediately prior to any surgery requiring anesthesia services, however some elements may be performed prior but under no circumstances should they be performed more than 30 days prior to surgery. 3) This evaluation must have certain criteria – review of medical and surgical history, medications, allergies, notation of anesthesia risk, identification of problems if relevant, and development of a plan. 4) A post anesthesia evaluation completed by personnel who is qualified to administer anesthesia no later than 48 hours after surgery. This should not be performed until the patient is sufficiently recovered from the anesthesia administered. This is not possible for all patients and notation stating the patient was unable to participate is adequate. The requirements list that the post-anesthetic evaluation must be performed by an anesthesiologist, other doctor of medicine/osteopathy (who is not an anesthesiologist), certified nurse anesthetists, anesthesia assistant, dentist, oral surgeon, or podiatrist.

Question 51

Meningomyelocele is commonly associated with

Answer 51

Meningomyelocele is commonly associated with Chiari II malformation and care must be taken to ensure no neurologic deficits or other congenital anomalies exist that may alter anesthetic management. Also renal abnormalities

Question 52

22q 11 deletion

Answer 52

DiGeorge Syndrome which includes the "CATCH - 22" conglomeration of findings: cardiac abnormalities, abnormal facies, thymic aplasia, cleft palate, and hypocalcemia.

Question 53

possible complications of tumescent lidocaine liposuction

Answer 53

Patients should be monitored postoperatively to assess for possible circulatory overload and pulmonary edema as well as several other potential serious complications (e.g. acute heart failure, body cavity perforation, fat emboli, pulmonary emboli, and local anesthetic toxicity). If pulmonary edema is suspected, initial treatment options include diuretics, head of bed elevation and/or reverse Trendelenburg positioning, supplemental FiO2, and possibly noninvasive positive pressure ventilation (e.g. CPAP). Severe pulmonary edema leading to respiratory distress should prompt intubation and mechanical ventilation with PEEP. Usually, pulmonary edema associated with tumescent liposuction is mild, self-limited, and resolves without invasive supportive care.

Question 54

algorithm for bronchospasm

Answer 54

Anesthesia management of bronchospasm should have a stepwise approach: - Use hand assisted ventilation to assess compliance - Confirm bronchoconstriction and assure that no other causes are contributing - The patient should be placed on 100% oxygen - Deepen anesthetic: increase volatile agents and consider intravenous ketamine - Administration of beta-2-agonist - Administration of intravenous epinephrine (use small doses to start) - Consider high dose steroids - Magnesium sulfate 1 to 2 grams - Consider Heliox if patient will tolerate lower oxygen concentrations

Question 55

Transplanted lungs differences

Answer 55

Transplanted lungs are denervated and cough reflex and mucociliary function will likely be impaired. Lymphatic drainage is also absent and may affect fluid clearance during subsequent anesthetics.

Question 56

``` normal values CVP: PCWP: CI: SVR: ```

Answer 56

CVP: 2-6 mmHg PCWP: 6-12 mmHg CI: 2.5-4 L/min/m2 SVR: 800-1200 dynes*sec/cm5

Question 57

Bone cement implantation syndrome

Answer 57

Bone cement implantation syndrome is characterized by hypoxia, hypotension, cardiac dysrhythmias, and increased pulmonary vascular resistance after methyl methacrylate implantation. The definitive mechanism is unknown

Question 58

The preoptic anterior hypothalamus

Answer 58

The preoptic anterior hypothalamus plays a key role in temperature homeostasis and thermoregulation.

Question 59

The medial tuberal hypothalamus

Answer 59

The medial tuberal hypothalamus contains neurons that extend into the posterior pituitary and secrete vasopressin and oxytocin. paraventricular and supraoptic nuclei are in medial tuberal

Question 60

TRALI mechanism

Answer 60

antibodies in the donor blood bind to the recipient’s leukocytes, which then adhere to the vascular capillary bed in the pulmonary circulation. This causes damage and extravasation of intravascular fluid. TRALI results in a non-cardiogenic pulmonary edema that usually occurs within 6 hours of transfusion. TRALI is characterized by respiratory distress/failure with bilateral infiltrates seen on CXR. The incidence of TRALI is 1:5000 transfusions and occurs more often in blood donated by multiparous females.

Question 61

non-hemolytic febrile reaction mechanism

Answer 61

native host antibodies bind to donor leukocytes (HLA antigens) in the transfused blood. The antibodies cause cell lysis which allows for a cytokine release. The released cytokines include IL-1 and TNF-alpha, which increase the hypothalamic temperature set point causing shivering and fever. Red blood cell-leukocyte reduction and premedication with acetaminophen can help prevent a non-hemolytic febrile reaction.

Question 62

mechanism by which transfusion-related immunomodulation (TRIM) occurs

Answer 62

Transfusion of soluble leukocyte mediators is the mechanism by which transfusion-related immunomodulation (TRIM) occurs

Question 63

Latex-induced allergic reactions result from a type ___ what mediated how long after exposure

Answer 63

Latex-induced allergic reactions result from a type I IgE-mediated antibody response, typically having a delayed onset longer than 30 minutes after exposure to latex.

Question 64

botox mechanism

Answer 64

The Clostridium botulinum toxin cleaves SNARE proteins which prevents the release of ACh from storage vesicles into the NMJ. This results in significant muscle weakness or a flaccid paralysis.

Question 65

detection of HIT

Answer 65

Detection of antiplatelet factor 4 antibodies is commonly used to diagnose HIT. Antiplatelet factor 4 detection has a high sensitivity for HIT. The serotonin release assay has a high specificity for HIT.

Question 66

HIT mechanism

Answer 66

Heparin induced thrombocytopenia (HIT) is an antibody mediated process in which the patient develops antibodies against platelet factor 4 (PF4). Platelet factor 4 is exposed when heparin binds to platelets HIT typically develops 4-10 days following the initiation of heparin therapy. The platelet count of a patient with HIT often drops by more than 50% of pre-heparin values. Additionally, HIT is a hypercoagulable condition associated with DVTs and occasionally arterial thrombosis. The 5 T’s of HIT are: timing, thrombocytopenia, type of heparin, thrombosis, and type of patient (surgical > medical).

Question 67

main mechanism for patient heat loss in the operating room following initial redistribution of heat.

Answer 67

Redistribution of heat from the core to the periphery is the largest contributor to the initial reduction in core temperature during general anesthesia. Prevention or reduction of this can be accomplished by pre-warming the patient’s extremities prior to the induction of general anesthesia. Radiation is the main mechanism for patient heat loss in the operating room following this initial redistribution of heat.

Question 68

The acute discontinuation of TPN is associated with

Answer 68

The acute discontinuation of TPN is associated with hypoglycemia.

Question 69

respiratory quotients and what it means is being used

Answer 69

For patients on TPN, a respiratory quotient of 0.7 is consistent with pure fat oxidation and results in fat accumulation in the liver. A quotient of 1.0 is consistent with pure carbohydrate oxidation with subsequent respiratory distress.

Question 70

phantom pain risk factors prevalence how long it lasts

Answer 70

Phantom sensations (non-painful sensations) are nearly universal among amputees, and phantom pain is also very common with a prevalence of 65-85% of amputees. In most studies, phantom pain was independent of age, gender, side, previous health status, and cause of amputation (civilian versus traumatic). Phantom pain is not only very prevalent, but also long-lasting and difficult to treat. In one study, 60% of amputees had phantom pain two years after the amputation. Although it will usually decrease in severity and intensity within the first 6 months after amputation, phantom pain will typically become stable after 6 months and is extremely difficult to treat. The one thing found to be a risk factor is preamputation pain, with many amputees indicating that phantom pain resembled preamputation pain, at least initially. Based on this finding, several studies have focused on treating pre-amputation pain as a way to try to prevent the development of phantom pain. Some (but not all) studies showed that epidural analgesia for 2-3 days pre-amputation decreased the incidence of phantom pain.

Question 71

moving on the frank-starling curve

Answer 71

The Frank-Starling curve is shifted down and to the right with increased afterload or decreased inotropy (e.g. systolic heart failure). Decreased afterload and increased inotropy with shift the curve up and to the left. Increased end diastolic volume for a given state of inotropy and afterload will shift right along the curve. Decreases in end diastolic volume (e.g. diuretics) will cause a left shift along the curve.

Question 72

what causes vagal response to pneumoperitoneum

Answer 72

acute stretching of the peritoneum

Question 73

most common blood product to cause transfusion-associated sepsis

Answer 73

Transfusion-associated sepsis is the third leading cause of transfusion-related deaths in the United States and is most commonly caused by bacterial infection from contaminated platelets. Unlike other blood products, platelets are stored at room temperature which leads to increased bacterial growth.

Question 74

Blood transfusion in IgA deficient patients

Answer 74

IgA deficient patients are at risk for anaphylactic response to IgA antigens in donor blood, as they may have anti-IgA antibodies from prior blood exposure or pregnancy. To avoid this reaction, these patients should receive washed red blood cells or blood from IgA deficient donors. Since plasma cannot be washed of IgA, it must come from a deficient donor.

Question 75

hemolytic transfusion reaction pathway

Answer 75

The complement system is activated in a hemolytic transfusion reaction that typically occurs when ABO incompatible blood is given.

Question 76

Croup other name

Answer 76

laryngotracheobronchitis

Question 77

more important to prevent burn in MRI | straight wires or towel between wires and skin

Answer 77

straight wires

Question 78

airway neurofibromatosis

Answer 78

In patients with neurofibromatosis, careful airway planning may be required. Neurofibromas may be present in the airway and depending on their size may lead to complete airway collapse with induction. Neurofibromas are highly vascularized lesions that can bleed profusely if disrupted. Extreme care must be taken when present in the airway because damage may result in bleeding which is difficult to tamponade and may make visualization of the larynx impossible.

Question 79

Carotid body pathway

Answer 79

The carotid bodies are one of the most highly vascular areas of the body, and these chemosensitive cells are exquisitely sensitive to changes in arterial oxygen consumption. At PaO2 values of around 55-60 mmHg, these cells generate nerve impulses that are transmitted to the central respiratory centers in the medulla via the sinus nerve of Hering, which is an afferent branch of CN IX, also known as the glossopharyngeal nerve.

Question 80

carotid and aortic bodies detect what

Answer 80

Both the carotid and aortic bodies are areas of chemosensitive cells which primarily detect decreases in arterial partial pressures of oxygen (secondary CO2)

Question 81

aortic body pathway and effects

Answer 81

In contrast to carotid bodies, signals that originate in the aortic body primarily cause downstream circulatory effects. While aortic bodies also detect changes in arterial PaO2, they transmit afferent nerve impulses via CN X, the vagus nerve. The end-organs which these signals are transmitted to include the heart, peripheral vasculature, adrenal glands, and the lungs themselves. Detection of arterial hypoxia (PaO2 less than about 60 mmHg) will result in bradycardia, hypertension, bronchoconstriction, and eventual steroid release from the adrenal glands. While the aortic bodies generate a parasympathetic response to hypoxia, decreasing oxygen consumption throughout the body, prolonged hypoxia will stimulate central chemoreceptors and will result in sympathetic activation.

Question 82

where in the brain is the central respiratory center

Answer 82

medulla

Question 83

medulla respiratory center is sensitive to what

Answer 83

dissolved CO2

Question 84

two groups of neurons in medulla and what they do

Answer 84

The ventral respiratory group is active during expiration. Meanwhile, the dorsal respiratory group is active during inspiration and is regulated by the pons.

Question 85

The sites at which core temperature can be measured

Answer 85

The sites at which core temperature can be measured are the pulmonary artery, distal aspect of the esophagus, tympanic membrane, and nasopharynx

Question 86

how many acetylcholine molecules does it take to activate the nAChR on the neuromuscular postjuntional membrane How many succ molecules?

Answer 86

Two separate acetylcholine molecules or a single succinylcholine molecule must bind to the two alpha subunits of the nicotinic acetylcholine receptor for activation

Question 87

chylothorax from central line on left or right

Answer 87

Thoracic duct injury should be suspected if the patient develops ipsilateral supraclavicular swelling or unilateral (very rarely, bilateral) pleural effusions after left-sided central venous catheterization. The pleural effusion will most likely exhibit as gradually worsening dyspnea and pleuritic chest pain.

Question 88

The classic clinical findings in cardiogenic shock include

Answer 88

The classic clinical findings in cardiogenic shock include (1) low cardiac output with jugular venous distension, (2) hypotension with peripheral and pulmonary venous congestion, (3) peripheral vasoconstriction, (4) cool extremities, (5) poor urine output, and (6) altered mental status.

Question 89

requirements for MAC anesthesia

Answer 89

MAC requires anesthesia physician supervision with postoperative care and the provider must be qualified and prepared to convert to GA, if necessary. Spontaneous ventilation may be impaired and require intervention for a patent airway.

Question 90

``` Conn's syndrome what is it what electrolyte derrangements acidosis vs alkalosis presentation anesthetic management ```

Answer 90

Conn’s syndrome is primary hyperaldosteronism. It results in elevated serum Na+, reduced serum K+, and reduced renin activity. Patients typically present with increased blood pressure, fatigue, and a hypokalemic metabolic alkalosis. Anesthetic management includes preoperative K+ repletion and volume management. Intraoperatively, hyperventilation should be avoided and cortisol may need to be administered if both adrenal glands are being excised.

Question 91

Aldosterone where does it function and what ions go where

Answer 91

Aldosterone is the mineralocorticoid produced in the zona glomerulosa of the adrenal cortex. It functions in the distal renal tubules by absorbing Na+ ions in exchange for urinary loss of K+ and H+ ions. The effect of aldosterone is volume expansion as H2O follows Na+ ions.

Question 92

sepsis vs septic shock

Answer 92

According to the Sepsis-3 guidelines, sepsis should be defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection." Under this definition, all cases of sepsis should be considered, by definition, severe and thus, the designation of "severe sepsis" was eliminated from the diagnostic spectrum. Septic shock remains defined as a subset with "profound circulatory, cellular, and metabolic abnormalities" that are associated with greater mortality risk (approximately 40%) than sepsis alone. Under Sepsis-3, a patient with documented organ dysfunction in the setting of suspected infection should be diagnosed with sepsis.

Question 93

SOFA scoring and threshold for sepsis

Answer 93

These patients can be identified by an increase of the "Sequential [Sepsis-related] Organ Failure Assessment" or SOFA score of 2 or more points, with each of the values in the following categories scoring 1-4 points (using the worst values in the past 24 hours): PaO2/FiO2 ratio, Platelet count, Glasgow Coma Scale, Bilirubin, Mean arterial pressure or administration of vasopressors required, Creatinine level.

Question 94

Septic shock is defined as a diagnosis of sepsis as above with the following, in the absence of hypovolemia:

Answer 94

Septic shock is defined as a diagnosis of sepsis as above with the following, in the absence of hypovolemia: vasopressor requirement to maintain mean arterial pressure of at least 65 mmHg, and serum lactate level greater than 2 mmol/L.

Question 95

(qSOFA) score in which two of the following are noted:

Answer 95

(qSOFA) score in which two of the following are noted: respiratory rate of ≥ 22/min, altered mentation, or systolic blood pressure ≤ 100 mmHg.

Question 96

``` How is PAO2 affected by Patm FiO2 PH2O PACO2 ```

Answer 96

The alveolar gas equation is used to determine alveolar oxygen tension. PAO2 = [(Patm – PH2O) * FiO2] – (PACO2 / R). Increases in Patm and FiO2 and decreases in PH2O and PACO2 lead to increases in PAO2.

Question 97

A normal A-a gradient is | and a normal a-A ratio is

Answer 97

By comparing the PAO2 and the PaO2 (A-a gradient and A:a ratio), a determination of oxygenation can be made. A normal A-a gradient is < 10 mm Hg, and a normal a-A ratio is >0.75.

Question 98

Trendelenburg position effects

Answer 98

Trendelenburg position reduces FRC, TLC, lung compliance, and chest wall compliance. Abdominal contents are shifted cephalad, which may potentially relocate the end of a fixed ETT into the right mainstem bronchus. The Trendelenburg position is associated with a rise in intrapulmonary shunt (perfusion without ventilation).

Question 99

Functional residual capacity (FRC) is

Answer 99

Functional residual capacity (FRC) is the sum of the expiratory reserve volume (ERV) and the residual volume (RV), (FRC = ERV + RV).

Question 100

For a patient failing an initial SBT,

Answer 100

For a patient failing an initial SBT, an appropriate and simple weaning strategy would be the continuation of daily SBTs with inspiratory pressure support.