ITE CA2 General 3 Flashcards
What happens to potassium in met alkalosis
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.
MTHFR deficiency avoid what drug
Nitrous oxide (C) should be avoided in patients with MTHFR deficiency
Etomidate side effect mechanism
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.
Following neostigmine administration, a dose of succinylcholine will
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.
In the hemodynamically unstable patient with SVT, what is the best treatment
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).
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).
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).
What lab check before place epidural if patient on heparin for more than 5 days
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.
C diff testing
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.
carbon monoxide shift oxy hemo curve
left
Bohr effect
The Bohr effect states that oxygen is more readily released from hemoglobin in the face of acidosis or hypercarbia.
ionized form of weak base
HB+
unionized form of weak base
B
ionized or unionized lidocaine crosses lipid bilayer
unionized
the higher the pH of a solution, the ____ of a weak base such as lidocaine will exist in its unionized fraction.
the higher the pH of a solution, the more of a weak base such as lidocaine will exist in its unionized fraction.
permanent pacemaker, lower extremity surgery, not pacer dependent, what do with pacer?
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.
Most common reasons for discharge delay after ambulatory surgery
Pain and postoperative nausea and vomiting are the two most common reasons for discharge delay.
Sign of bladder perf during TURP
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).
Test indicated prior to robot assisted radical prostatectomy
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
TIVA pancreatitis?
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.
Acute mountain sickness Pathophys Adaptation Severe manifestations Presentation typical prophylaxis treatment
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.
Nitrous oxide administration after intraocular injection of
Air
Sulfur hexafluoride
other perfluoropropane
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
Ischemic optic neuritis presentation
ION following surgery generally presents with painless visual loss, visual field deficits, and sluggish pupils.
Negative pressure pulmonary edema
incidence
Risks
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.
Methanol poisoning
sources
treatment
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.
Difficult airway exam
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.
The AFFERENT nerve impulses of carotid sinus baroreceptors are transmitted by
The AFFERENT nerve impulses of carotid sinus baroreceptors are transmitted by the Hering’s nerves to the glossopharyngeal nerve (CN IX)
Carotid sinus baroreceptor stimulation
Carotid sinus baroreceptor stimulation leads to direct sympathetic inhibition and indirect predominance of vagal tone on cardiac performance.
Things that increase LES tone
acetylcholine antacids anticholinesterases alpha agonists cholinergics gastrin histamine metaclopramide metoprolol pancreatic polypeptide serotonin succinylcholine
Early onset adult VAP bugs
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.
Late-onset VAP bugs
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.
Least stable factors in FFP
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.
Where is factor VIII produced
what carries it
what activates it
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.
Hepatopulmonary syndrome (HPS) is characterized by the triad of
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.
Orthodeoxia
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.
How many mg of fibrinogen in 1 unit cryo
Ten units of cryo raise 70 kg person fibrinogen by how much
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.
Electrolyte abnormalities in alcoholic patients include:
Electrolyte abnormalities in alcoholic patients include: hypocalcemia, hypomagnesemia, hypophosphatemia, and hypoglycemia.
hemostatic abnormalities in cirrhosis
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.
cirrhosis hemodynamics
Cirrhosis hemodynamics are characterized by a hyperdynamic state, with increased cardiac output and low peripheral vascular resistance.
volatile effect on hypoxic pulm vasoconstriction
Increasing volatile anesthetics (greater than 1 MAC) will inhibit hypoxic pulmonary vasoconstriction
Clinical signs and symptoms of carcinoid syndrome
how diagnosed
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
