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Anesthesia based on Nebuchanedzzer II > ITE Gen Clin Sciences 2 > Flashcards

ITE Gen Clin Sciences 2 Flashcards

1
Q

Inheritance pattern of Malignant Hyperthermia

A

Autosomal dominant with variable penetrance

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2
Q

MH is a (heterogeneous/homogenous) disorder

A

heterogeneous

- more than 1 gene defect is responsible for expression of disease

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3
Q

Two receptors involved in MH

A

RYR1 gene - ryanodine receptor

VG calcium channel

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4
Q

In cardiac surgery, when is awareness/recall most likely?

A

During rewarming and departure from CPB.

  • Anesthetic requirement is higher
  • MAC > 0.7 can help
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5
Q

Benefits of double lumen tube > bronchial blocker

A
  1. More reliable lung isolation

2. selective lobar collapse

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6
Q

Benefits of bronchial blocker > double lumen tube

A
  1. Smaller
    - better for pts with trachs or oral/neck sx
    - children < 12
  2. Does not require Endotracheal tube exchange (like DLT)
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7
Q

Benefits of airway exchange catheter > gum elastic bougies?

A
  1. Ability to jet ventilate

2. ETCO2 monitoring

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8
Q

Why are diuretics (furosemide) d/c in preop period?

A
  1. Hypokalemia
  2. Blood loss/fluid shifts -> worsen hypokalemia
  3. Predispose to arrhythmias

*ACE-i and ARBs are also often stopped

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9
Q

What BP meds should NOT be stopped in periop period?

A

BB
CCB
alpha - 2 agonists (clonidine)

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10
Q

(Barium hydroxide / Soda lime) produces more carbon monoxide and more Compound A d/t decreased water content in the absorbents

A

Barium hydroxide

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11
Q

Soda lime is made of ____

A

80% calcium hydroxide
15% water
4% sodium hydroxide

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12
Q

Only medication preventing aspiration pneumonitis when given immediately prior to anesthesia

A

Sodium citrate

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13
Q

Medications used perioperatively for pts high risk of aspiration

A
  1. Sodium citrate
    - immediately b4
  2. H2-blockers
    - 1 - 2 hrs b4
  3. Metoclopramide
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14
Q

Anthrax treatment

A

Ciprofloxacin
or
Doxycycline

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15
Q

Anthrax clinical course

A

1-7 days incubation - asymptomatic

Nonspecific influenza-like sx

Gets better, but then gets worse again

  • CP
  • Cyanosis
  • Dyspea
  • Hemoptysis
  • Necrotizing hemorrhagic mediastinitis
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16
Q

Drugs dosed on ideal body weight

A

Vecuronium
Rocuronium
Cisatracurium

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17
Q

Drugs dosed on total body weight

A

Succinylcholine

Propofol MAINTENANCE not induction (LWB)

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18
Q

Maximum lidocaine dosing

A

55mg/kg

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19
Q

When is LAST (neurologic decline and hemodynamic instability) most likely to occur perioperatively?

A

10-16 hours after a procedure when [ ] of local anesthetic peaks

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20
Q

Largest # of closed claims for death and brain damage?

A
  1. Cardiovascular events
    - PE, Stroke, MI, Arrythmia
  2. RESPIRATORY EVENTS
    - inadequate ventilation
    - esophageal intubation
    - diff airway
  3. Equipment issues
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21
Q

How does aspirin prevent clots?

A

permanently inactivates COX enzyme

  • short half life 15 min
  • long duration of action
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22
Q

What does inhibiting COX do?

A

conversion of arachidonic acid to prostaglandin

Prostaglandin -> Thromboxane A2, vital for platelet aggregation and vasoconstriction

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23
Q

Platelet life span is _____, and ____% of circulating platelets are replaced daily

A

5-10 days

20%

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24
Q

What does clopidogrel and prasugrel do?

A

Platelet receptor inhibitors

- platelet is inactivated for remainder of its lifespan

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25
Q

Pts who had a coronary cath with bare metal stents can stop taking dual antiplatelet therapy when if postponing surgery -> sig morbidity?

A

1 month

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26
Q

Pts who had a coronary cath with drug eluting stents can stop taking dual antiplatelet therapy when if postponing surgery -> sig morbidity?

A

3 mo after stent placement

- preferable 6 months

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27
Q

What is dual antiplatelet therapy?

A

Clopidogrel + ASA

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28
Q

_____ is primarily responsible for increased systemic vascular resistance and MAP during pneumoperitoneum (CO2 Insufflation) for laparoscopic surgery

A

Increased vasopressin release

  • decreased RH filling
  • Decreased renal/splanchnic blood flow -> RAAS system activated -> vasopressin response
  • CO2 absorption -> sympathetic response
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29
Q

Absolute contraindications to electroconvulsive therapies?

A
  1. Pheochromocytoma
  2. Recent MI
  3. Recent CVA
  4. Recent intracranial sx
  5. Intracranial mass lesion
  6. Unstable cervical spine

*Cerebral blood flow increases 400% during ECT secondary to increased metabolic rate and BP -> increases ICP

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30
Q

Why does pulmonary edema result in pts with CHF?

A

Increased hydrostatic pressure and activation of RAAS

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31
Q

Maximum lidocaine dose with and without epinephrine

A

55 mg/kg max

7mg/kg with epi

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32
Q

Which one provides better intubating conditions during RSI, rocuronium or succinylcholine?

A

No difference

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33
Q

How is Roc and Suc dosed based on body weight?

A

Roc - IBW

Suc - TBW

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34
Q

How many working days are residents allowed to take off during their training?

A

60 days
(12 weeks)
- 4 weeks/year

+ 5 days for scientific meetings

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35
Q

Physiologic changes in CNS that makes geriatric population more sensitive to neuraxial anes?

A
  1. Smaller epidural space
  2. Less myelinated fibers in dorsal and ventral nerve roots
    3, More permeability of dura
  3. Less volume of CSF
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36
Q

The solubility of gases in the serum will (increase/decrease) as a pts temperature is decreased.

A

increase

*when pts temp drops, more gas remains dissolved in serum like CO2 and value is lower on ABG

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37
Q

In hypothermic pts, what type of metabolic derangement will you see?

A

Hypocapneic respiratory alkalosis

**when pts temp drops, more gas remains dissolved in serum like CO2 and value is lower on ABG

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38
Q

When do you use pH-stat vs Alpha stat?

A

pH-stat : Pediatrics

Alpha stat : Adult

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39
Q

A standard dose of succinylcholine (1-2mg/kg) will produce a (phase I / Phase II) block, which means _____

A

Phase I

- sustained depolarizing block

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40
Q

What antagonizes a phase I block, and what augments it?

A

Nondepolarizing NMB antagonizes it

Depolarizing blockers and cholinesterase inhibitors will augment the block

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41
Q

In Phase I vs Phase II block, Train of four ratio is typically ___

A

Phase I: > 0.7

Phase II: < 0.3

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42
Q

Pts with pseudocholinesterase deficiency will affect succinylcholine how?

A

May create a phase II block
- increase DOA by several hours

*Depolarizing blockers and cholinesterase inhibitors will augment the block

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43
Q

Equipment standards for surgical facilities and office practices (5)

A
  1. reliable oxygen source
  2. suction
  3. resuscitation equipment
  4. emergency meds
  5. back up power source
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44
Q

5 Standard monitors for GA

A
  1. ECG
  2. BP
  3. Pulse ox
  4. Ventilation (ETCO2)
  5. Body temp
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45
Q

Endotracheal intubation is contraindicated in laryngeal disruption or laryngotracheal separation. What should you do instead?

A

Wake surgical tracheostomy

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46
Q

Le Fort fractures

A

Le Fort I: roof of mouth and palate separated from face

Le Fort II: nose and palate sep from face

Le Fort III: entire face affected

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47
Q

What should you pay attention to regarding Le Fort II and III fractures?

A

II and III are assoc. w/ cribriform plate disruption

  • presence of hemotympanum
  • CSF rhinorrhea
  • Racoon eyes
  • mastoid ecchymosis (battle signed
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48
Q

Pts on antithrombotic or thrombolytic therapy for > __ days need to have platelet counts checked before neuraxial block or catheter removal

A

4 days

- pts at risk of HIT

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49
Q

Cholinesterase inhibitors (or anticholinesterases) affect nondepolarizing and depolarizing NMBs how? Why?

A

increase resistance to nondepolarizing MRs: ie: roc
- Anticholinesterase inhibit acetylcholinesterase -> increases ACh at NMJ -> makes nondepolarizing muscular blockers less effective since they are competitive antagonists

potentiates depolarizing MRs: ie: succ
- Anticholinesterases partially inhibit pseudocholinesterases -> less breakdown of succinylcholine -> potentiates its effects

50
Q

Phenytoin use affects muscle relaxants how?

A

Acute use: augments NMB

Chonic use: increases resistance to nondepolarizing blockade

51
Q

Central anticholinergic syndrome aka atropine toxicity treatment

A

1-2mg of physostigmine (anticholinesterase w/ tertiary amine that passes into CNS)

52
Q

How does trendelenburg affect aspiration intraoperatively?

A

Can increase risk for aspiration

If aspiration has already occurred, positioning them in T burg helps avoid worsening of aspiration

53
Q

How do H2 blockers and PPIs affect gastric contents?

A

Increases gastric pH, but only newly secreted volume (not pH of gastric contents already in stomach)

54
Q

Most likely source of ignition for airway fire

A

Laser

55
Q

Neck (flexion/extension) can result in endobronchial intubation

A

flexion

  • ETT tip follows the chin
  • chin down pushes the ETT down
  • chin up pulls the ETT up
56
Q

(True/False) abdominal compartment syndrome is associated with increased ICP

A

True

57
Q

__% of anesthesiology residents successfully re-enter anesthesiology training programs.

__% of anesthesiologists abuse drugs

A

34%

1%

58
Q

_______ blocks carry the highest risk of nerve injury following peripheral nerve block

A

Interscalene blocks for shoulder sx

59
Q

______ pressure monitoring is a method used to prevent peripheral nerve injury. What PSI is a sign of intrafascicular needle tip placement (bad)?

A

Injection pressure monitoring

Intrafascicular = > 20 PSI
- Extrafascicular has lower pressures < 20 PSI

60
Q

Electrical stimulation with a motor response at ____ mA occurs with an intraneural needle tip (bad).

A

< 0.2 mA

61
Q

Most likely initial symptom of malignant hyperthermia?

A

Respiratory acidosis

- Rising CO2

62
Q

Aphonia after a thyroidectomy only occurs if _____ injury occurs.

A

b/l recurrent laryngeal n.

63
Q

Which pts are at higher risk for cardiac perforation during lead extraction?

A
  1. Pts with lower BMI < 25
    - thinner vessel walls
  2. Females
    - thinner vessel walls
  3. Duration of oldest lead
  4. Removal of ICD leads > pacemaker leads
64
Q

(Motor/Somatosensory) evoked potentials are extremely sensitive to volatile anesthetics

A

Motor

*Somatosensory can still be monitored as long as MAC < 0.5

65
Q

Two tests for diagnosing MH

A
  1. Genetic testing
    - Mutation in RYR1 gene
  2. Caffeine/Halothane contracture test
    - muscle biopsy
    - GOld standard
66
Q

You should avoid which type of solutions during repair of an AVM?

A

Hypotonic and glucose-containing solutions

- both can exacerbate cerebral edema

67
Q

What is pneumoperitoneum?

A

Gas in the peritoneal cavity

  • perforated ulcer
  • subcutaneous emphysema
68
Q

How does a pneumothorax affect the:

  • pulse ox
  • airway pressures
  • ETCO2
A

Desaturation
- decrease blood to pulm capillaries

Increased airway pressures

ETCO2 decrease

69
Q

Name that pulmonary change during laparoscopy!

  • Desaturation
  • Increased airway pressure
  • Clinical exam: reduced air entry
A

Endobronchial intubation

70
Q

Name that pulmonary change during laparoscopy!

  • Desaturation
  • Increased airway pressure
  • Clinical exam: reduced air entry, hyperresonance, possible crepitus
A

Pneumothorax

  • air leak in space btwn lung and chest wall (pleural space)
  • Dont use PEEP, will make it worse

or

Capnothorax

  • a pneumothorax via CO2
  • Can use PEEP
71
Q

Name that pulmonary change during laparoscopy!

  • Desaturation
  • No change in airway pressure
  • Clinical exam: murmur, hypotension, ECG changes
A

Massive CO2 embolism

72
Q

Name that pulmonary change during laparoscopy!

  • No change in pulse ox
  • No change in airway pressure
  • Clinical exam: swelling or crepitus
  • Sudden RIse in ETCO2 w/in 15 min of insufflation
A

Subcutaneous emphysema

73
Q

Aspirin MOA

A

Irreversible COX inhibitor in platelets

  • COX enzyme is required for production of prostaglandins (TXA2)
  • New platelets are created every 2-5 days
74
Q

ASA should be continued for most surgeries except:

A
  1. Intracranial neuro procedures
  2. Middle ear surgery
  3. Posterior eye surgery
  4. Spine surgery
  5. Prostate surgery
75
Q

Stopping Dual antiplatelet therapy (ASA and ADP receptor antagonist) prior to scheduled surgery:
Bare metal stents
vs
Drug eluting stents

A

Bare metal stents

  • continue for at least 1 month post op
  • continue ASA perioperatively

vs
Drug eluting stents
- continue for at least 6 mo post op
- continue ASA perioperatively

76
Q

Name that side effect!!

Echinacea

A
  1. Activation of cell-mediated immunity

2. Chronic immunosuppression

77
Q

Name that side effect!!

Ephedra

A
  1. Ventricular arrythmias

2. Endogenous catecholamine depletion

78
Q

Name that side effect!!
Garlic + Ginger + Ginko + Ginseng
(Four G’s)

A
  1. Inhibition of platelet aggregation
  2. Bleeding

*only gingseng can cause hypoglycemia

79
Q

Name that side effect!!

Ginseng

A
  1. Inhibition of platelet aggregation
  2. Bleeding
  3. HYPOGLYCEMIA!
80
Q

Name that side effect!!

Kava

A

Increased sedation

81
Q

Name that side effect!!

Saw palmetto

A
  1. COX inhibition

2. Bleeding

82
Q

Name that side effect!!

St. John’s wort

A
  1. CYP450 inducer

2. Delayed emergence

83
Q

Name that side effect!!

Valerian root

A
  1. INcreased sedation

2. Increased MAC requirement

84
Q

Benefits of using vasoconstrictor prior to nasotracheal intubation?

A
  1. Minimize mucosal bleeding
  2. Increases diameter of nasal passages by shrinking nasal mucosa

*does not decrease nasal trauma

85
Q

Most commonly used agent to reduce aspiration

A

Metoclopramide

  • central dopamine blocker
  • stimulating upper GI function
  • accelerate gastric emptying

*but mostly not necessary to give to all pts (except pregnant pts undergoing c/s)

86
Q

Physiologic changes in elderly regarding neuraxial anesthesia

*all leads to faster onset and greater spread of LA in epidural space

A
  1. Increased dura permeability
  2. Decreased CSF volume
  3. Decreased fatty tissue in epidural space
  4. Increased compliance and decreased resistance
    - leads to increased spread of LA
87
Q

What is the sodium concentration in 5% albumin?

A

145 meq/L

88
Q

Treatment for negative pressure pulmonary edema

A
  1. PEEP
  2. Diuretics
  3. Supportive
89
Q

Dosing for dantrolene

A

2.5 mg/kg, up to 10 mg/kg

Older formulation of dantrolene is 20mg/vial

  • may need 9-36 vials in a 70 kg pts
  • Resonstitute in 60mL sterile water

Newer formulation Ryanodex contains 250mg
- reconstitute in 5mL sterile water

90
Q

Do you continue MOAis perioperatively?

A

Yes

  • if they are on it, they are probably refractory to other meds, and you can risk worsening depression/suicide
  • but be careful of drug interactions (increased MAC, decrease cholinesterase activity)
91
Q

What preop test does a pt taking apixaban need? What is its MOA?

A

None

NOAC
- direct factor Xa inhibitor ->
inhibit conversion of prothrombin to thrombin

92
Q

What type of solutions are typically avoided for pts with an acute traumatic brain injury?

A

Colloids (4% albumin)

- SAFE trial: twofold risk of mortality

93
Q

Why do pts with gastric banding procedures have lower risk of malabsorption compared to gastric bypass?

A

Stomach and small intestines remain intact

94
Q

Peak plasma levels of lidocaine occur after ____ hours following injection

A

12 hours

- LAST manifests

95
Q

Why is neuraxial anesthesia contraindicated in liposuction using tumescent anesthesia?

A

Risk for vasodilation
Hypotension
Volume overload

96
Q

How does hepatorenal syndrome develop?

A

It’s a prerenal response to late stage cirrhosis

End stage cirrhotic pts develop portal HTN d/t liver fibrosis and splanchnic arterial vessels dilate to promote more blood flow in portal vasculature ->
Kidneys become hypoperfused -> renal arterial vasoconstriction -> retention of sodium and water.

97
Q

25% albumin is ___x more [ ] than std human serum albimin, and can restore intravascular oncotic pressure

A

5x

- give 25% albumin at 1g/kg

98
Q

Why do you have to consider cyanide toxicity in pts with recent burns or smoke exposure?

A

Release of cyanide from burning plastics

99
Q

Classic finding of cyanide toxicity

A

elevated mixed venous oxygen saturation despite progressively worsening metabolic acidosis
- oxygen effectively bypasses tissues and returns to venous circulation without being utilized

100
Q

Classic finding of methemoglobinemia

A

fixed oxygen sat on pulse ox of 85%

- d/t how methemoglobin absorbs the wavelengths of light

101
Q

Abdominal compartment syndrome is an increase in intraabdominal pressures _______ mmHg that results in organ damage. It is measured via ______

A

greater than 20 mmHg

bladder pressure

102
Q

The most common organ affected by Abdominal compartment syndrome is the _____

A

kidney

- most susceptible to hypoperfusion

103
Q

_____ is the preferred imaging modality used for radiation planning

A

CT scan

- provides 3D electron density values to calculate radiation doses

104
Q

Implants contraindicated in MRI suite

A
  1. ICDs (some)
  2. Cochlear implants
  3. Pain pumps
  4. Peripheral n. stimulators
  5. Aneurysm clips
105
Q

Most significant risk factors for perioperative VTE (5)

A
  1. Major lower extremity arthroplasty
  2. Recent stroke w/in 1 mo
  3. Spinal cord injury
  4. Multiple trauma
  5. Fx of hip, pelvis or LE
106
Q

Normal shunt fraction during a case where one lung ventilation is required is around ____% in an otherwise healthy pt

A

20-30%

107
Q

Pulmonary vascular resistance is lowest when the lung is at its _____

A

Functional residual capacity

108
Q

The physiologic response to endobronchial intubation and one lung ventilation is to increase PVR in the (ventilated/nonventilated) lung through _______, in an effort to decrease the shunt fraction

A

non-ventilated

Hypoxic pulmonary vasoconstriction

109
Q

Most significant risk factor for emergence delirium?

A

Age - children (2-6 y.o)

*h.o emergence delirium is NOT a risk factor

110
Q

Which volatile anesthetics are more likely to cause emergency dilirium?

A

Sevo/Des/Iso&raquo_space; TIVA > Halothane

111
Q

Methohexital is commonly used for LA of the vocal cords prior to medialization procedures, retrobulbar or peribulbar block.

What is its MOA?

A

Ultra short acting barbiturate

112
Q

Pts with an Aldrete score of ___ can be discharged from phase I.

A

9 or higher

113
Q

5 Parameters of the Aldrete score

A
  1. Respirations
  2. Color
  3. Consciousness
  4. Circulation
  5. Activity
114
Q

Why does GFR decrease as pts age, but not Creatinine?

A

GFR decreases by 30-40%,
but Lean body mass also decreases
- Overall, no net change in plasma creatinine

115
Q

Explain what happens physiologically when a pts undergoes electroconvulsive therapy (inducing a tonic clonic sz w/ large increase in cerebral blood flow and metabolism)

A

Initial parasympathetic response

  • bradycardia
  • asystole

Followed by sympathetic outflow

  • HTN
  • Tachycardia
116
Q

Gold standard induction agent for electroconvulsive therapy

A

Methohexital 1 mg/kg

  • does not change sz duration
  • can blunt the hemodynamic response to sz
117
Q

Factors ____ and ____ are produced in endothelial cells and are thought to be increased in liver disease

A

Factor VIII and vWF

118
Q

Liver disease reduces factors ______.

A

II, V, VII, IX, X, XI

119
Q

Liver disease affects (procoagulants / anticoagulants)

A

both

120
Q

In liver disease pts, when is it necessary to give FFP for elevated INR levels?

A

almost never

  • do not chase INR levels
  • Does not reflect risk of bleeding

Anesthesia based on Nebuchanedzzer II (38 decks)

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