ITE QBANK Misc 2 Flashcards
Common side effects of Zofran
- QTc prolongation (20%)
- Headache (11%)
- Transient inc in AST and ALT (5%)
- Constipation (4%)
In ECHOs, dP/dt is the _,
E/A is the _
dP/dt: rate of rise in ventricular pressure
- good measure of cardiac contractility
- Estimated using simplified bernoulli eq.
E/A: diastolic mreasurement
Majority of pts with myelomeningocele (spina bifida), where meninges and spinal cord are exposed, also have concommitant ___
Chiari II malformation (herniation of brainstem thru foramen magnum) and hydrocephalus secondary to blockage of fourth ventricle
- freq require VP shunt placement
Oxygen consumption in an adult is ~ __ mL/kg/min
and FRC is _ mL/kg.
How do you calculate min until hypoxemia?
3-4 mL/kg/min
30 mL/kg
*multiply above by pts body weight (kg) to get O2 consumption and FRC
Min until hypoxemia = (FRC/O2 consumption)
FRC is reduced by _% when going upright to supine and _% with induction of GA
15%
10%
*If pt obese, FRC is even more reduced and they desat faster.
How should congenital diagphragmatic hernia be managed to prevent worsening of pulmonary HTN?
- Low tidal volume ventilation
- Permissive hypercapnia (PaCO2 up to 65)
- Normothermia
Ketamine MOA
NMDA receptor antagonist - receptors are a class of excitatory glutamate receptors
Etomidate and propofol MOA
GABA agonist
Etomidate adverse events
- Burning on injection
- Post op nausea
- Superficial thrombophlebitis
Acute Intermittent Porphyria
- What is it
- preop treatment?
AIP: deficiency in enzyme required for heme synthesis
- 4 types
IV fluids + GLucose (avoid starvation states)
Avoid exacerbating attack
- Avoid: barbiturates, sulfonamides, ethyl alcohol, ergotamine
How does uremia (ie; a pt not having dialysis for several days) affect clotting?
Uremia causes impaired platelet production, function, and aggregation
- Interferes with vWF formation and release -> impaired platelet activation
- Abnl GPIIb-IIIa function on surface of platelets -> impaired platelet activation and aggregation
- Prostacyclin and NO is increased -> platelet inhibitory effects
- Decreased Tissue Factor -> cannot activate factor X -> cannot convert prothrombin to thrombin
Which one has higher risk of pneumothorax, supraclavicular or infraclavicular blocks?
Supraclavicular
- “do it all block”
- “spinal of the arm”
- Nerves are closely packed and readily blocked
1-6% risk of PTX
Which block is associated with:
- ipsilateral phrenic nerve and recurrent laryngeal nerve blockade
- ulnar nerve (C8-T1) sparing
- vertebral artery puncture
- Horner’s syndrome
Interscalene brachial plexus block
Most common complication of supraclavicular nerve block?
phrenic nerve blockade
PTT tests the integrity of the ______ pathways and is more sensitive to lower levels of heparin than ACT. PTT will be prolonged when there are deficiencies in factors ______.
Intrinsic and final coagulation pathways
XII, XI, IX, or VIII
Things that result in variable ACT during coagulation in cardiac cases
- Hemodilution
- Hypothermia
- Platelet count < 50
- Concomitant admin of meds (Prostaglandin, ASA, glycoprotein IIb/IIIa inhibitors)
Systemic Vascular Resistance (SVR) equation
SVR = 80 * (MAP - RAP) / CO
*R = R atrial P
Options for analgesia for stage II of labor
- Pudendal block
- Neuraxial anesthesia
- IV anesthesia (nitrous oxide)
Labor pains during the first stage of labor primarily arises from __, and is felt in __ dermatomes
uterus and cervix
- (visceral pain - Paracervical and hypogastric plexus)
T10-L1
Labor pains during the second stage of labor primarily arises from __, and is felt in __ dermatomes
perineum and vaginal stretch
- (Hypogastric plexus and pudendal nerve)
T12-L1 and S2-S4
Remifentanil is metabolized by ___ and has a half life of ___
plasma esterases
- not the liver
1-20 min
GCS Score
Eye
Verbal
Motor
Eye 4
Verbal 5
Motor 6
Where are these sweat glands found? What type of postsynaptic receptors are found at these sites?
- Eccrine
- Apocrine
Eccrine: Everywhere (except lips, tips of penis and clit)
- cholinergic
Apocrine: Armpits and perineum
- Adrenergic
A sudden (Increase/Decrease) in EtCO2 and SpO2 after tourniquet release should raise suspicion for PE from preop DVT
Decrease
*normally, EtCO2 is acutely Increased after
Propofol infusion syndrome
rare complication of high dose (>4 mg/k/hr or > 65 mcg/kg/min), long term (>24h) propofol infusion
Prop impairs cellular FFA utilization and mitochondrial activity -> inc reliance on anaerobic metabolism
- Cardiac and skeletal m and pancreas particularly susceptible to dmg
Multifocal atrial tachycardia (MAT) defined by HR > 100 and 3 or more diff P waves
- Most likely associated with pts with ___
Pulmonary (COPD exacerbation, pulm HTN) and cardiac pathology (atrial distention)
The lungs play a significant role in the metabolism of multiple hormones
- Which ones does it activate?
Angiotensin I
Arachidonic acid
The lungs play a significant role in the metabolism of multiple hormones
- Which ones does it inactivate? (8)
- Adenosine
- ATP
3, Bradykinin - Endothelin
- Leukotrienes
- Norepi
- PGD, PGE, PGF
- Serotonin
The lungs play a significant role in the metabolism of multiple hormones
- Which ones does it not affect? (7)
- Angiotensin II
- Dopamine
- Epi
- Histamine
- Oxytocin
- PGI2 and PGA2
- Vasopressin
Perioperative conditions leading to sickling
SIX H’s cause SICKling (HbS)
- Hypothermia
- Hyperthermia
- Hypoxemia
- Hypotension
- Hypovolemia
- H+ ions (acidosis)
*HTN does NOT cause sickling
Altered mental status
Non pitting edema
Hypothermia
Myxedema Coma
- Pitting edema from mucin deposit in the skin
- Life threatening - mortality rate of 30-60%
SIADH (Euvolemic Hyponatremia) Urine Osmolality? FENa? Ur Na+? Serum Uric acid and BUN?
Ur Osm: > 100 mOsm
FENa: >1%
Ur Na+: >20 mEq
Low serum Uric acid and BUN
- *Elevated ADH = concentrated urine
Elevated ADH (SIADH), (Promotes/Prevents) diuresis but PERMITS natriuresis and other solutes
prevents
- *Elevated ADH = concentrated urine
SIADH is a _______, ________ hyponatremia
dilutional, euvolemic
Fenoldopam is a ______ receptor agonist with direct _____ and _____ properties
Selective dopamine (D1) receptor agonist
Natriuretic
Diuretic
Large molecules (are/are not) able to pass through the semipermeable membrane used for hemodialysis (HD).
Serum bicarb, Na, Glucose, protein concentrations (increase/decrease) following HD
Are NOT
Increase d/t concentrating effect
*HD uses ultrafiltration, only allows small molecules to cross.
Fenoldopam is a selective D1 receptor agonist that directly causes _______ vasodilation and produces ______ at higher doses
Renal vasodilator
Hypotension
*Renal protector when renal vasoconstriction is anticipated
Substances commonly removed from pts blood: (7)
calcium magnesium phosphate potassium urea creatinine water
Extracorporeal shock wave lithotripsy (ESWL) can cause dysrhythmias if shock travels through heart and disrupts nl conduction. The best way to prevent dysrhythmias is by synchronization of shock to the _____ wave on ECG
R wave (refractory period of cardiac cycle)
Prerenal
- FENa
- BUN:Cr
- FENa: <1
- BUN:Cr >20
Intrinsic and Postrenal
- FENa
- BUN:Cr
- FENa >2
- BUN:Cr < 20
FENa < 1
Prerenal
BUN:Cr > 20
Prerenal
Large amts of blood products containing sodium citrate can lead to _______ as it can be metabolized into ________
metabolic alkalosis
sodium bicarbonate
Peritoneal dialysis is the preferred dialysis mode for pts who cannot tolerate ___________
the hemodynamic challenges of hemodialysis
ie. unstable angina, severe AS, HFrEF
Pts needing long term dialysis for ESRD usually get (peritoneal/traditional) hemodialysis
traditional
- better clearance of solutes
- better volume management
Pts with autosomal dominant polycystic kidney disease should get _____ prior to robotic surgeries
CT angiogram of the head
- d/t increased risk of intracranial aneurysms
- Steep trendelenburg increases risk of cerebral aneurysm rupture
Post-cardiopulmonary bypass AKI risk factors:
- Preop cr > 1.2
- Combined valve + bypass procedures
- emergency sx
- Pre-op intraaortic balloon pump
Main sx of bladder perforation is _________. If TURP procedures are done under spinal anesthesia, it should be below the level of ___ to recognize CNS sx.
abdominal pain
T10
___________ is the best perioperative test to predict AKI in the setting of suprarenal aortic cross-clamping for repair of ruptured abdominal aortic aneurysm
Creatinine clearance
- 24 hr ideal, but 2 hr collection reasonable
*BUN and Cr ideal to determine preexisting renal dmg and will not reflect failure until well established
_________ and ________ helps prevent the remodeling that occurs secondary to angiotensin II and are beneficial in CHF
ACEi and ARBs
*remodeling: cardiomyocyte proliferation and fibroblast activity
Kidneys receive __% of cardiac output.
Renal cortex gets ___% of cardiac output and has oxygen extraction ratio of __%.
Renal medulla gets __% of cardiac output and has oxygen extraction ratio of __%.
20%
Cortex: 95%, 20%
Medulla: 5%, 80%
- A small change in total blood flow to the kidney can has exaggerated effects in the medulla -> local hypoxia/injury
(Hypervolemia/Hypovolemia) can increase risk of afib
both
Hypervolemia: mechanical stim of RA -> myocardial stretch -> increase atrial cell triggering
Hypovolemia: decrease venous return to RA -> reduce SV and CO -> dec tissue O2 delivery -> induce catecholamine release
High amts of excess H+ ion in serum results in (Higher/Lower) free bicarbonate ion levels. This causes a _______ in pts w/ metabolic acidosis
Lower
- bicarb buffering effect
High anion gap
d/t loss of free bicarb ion
Renal failure often causes _______ d/t the kidney’s inability to regulate extracellular fluid H+ ion [ ]
metabolic acidosis
*normal kidney fxn reabsorbs filtered bicarb, secretes H+ ions, and produces new bicarb ions
Renal replacement therapy is a broad term that encompasses: (4)
- hemodialysis “dialysis”
- peritoneal dialysis
- hemofiltration
- renal transplantation
Continuous Renal Replacement therapy includes: (3)
- The concept of CRRT is to dialyze slowly, over 24h, just like the kidney does
- Continuous venous hemodialysis (CVVHD)
- Continuous venous hemofiltration (CVVH)
- Continuous venous hemodiafiltration (CVVHDF)
Newer irrigation solns used for TURP like glycine, cytal (mannitol and sorbitol) decrease the incidence of cerebral edema and hemolysis, but the incidence of _______ are unchanged
Hyponatremia and fluid overload
Time of onset for local anesthetic systemic toxicity with CNS sx?
Immediately
Steroid induced myopathy usually involves ______ muscles. Usually occurs after _____ weeks
proximal
3-4 weeks
3 hormones that counteract the action of insulin (and increase hepatic gluconeogenesis)
Cortisol
Catecholamine
Glucagon
SIRS is associated with (catabolism/anabolism) d/t increase in beta 2 adrenergic stimulation, and increased energy expenditures
Catabolism
- increase in lipolysis and proteolysis
Exposure to ______ has the highest risk for seroconversion
Hep B surface antigen +
- 30-60%
*HIV and HCV is 0.3%
Ventilator associated pneumonia is associated with a ____ times mortality in pts vs pts without it.
Abx?
5x
3 drug combo
- Beta lactam/beta-lactamase inhibitor
- Antipseudomonal FQ
- Either Linezolid or Vanc
______ is effective at reducing I-131 uptake by the thyroid and reduces the incidence of radiation exposure related thyroid complications
Potassium iodide
________ is the treatment choice of methemoglobinemia in pts with G6PD deficiency by reducing ___ to ____
ascorbic acid
*reduces Fe3+ to Fe2+
Methemoglobinemia occurs when hgb becomes ______ from Fe2+ to Fe3+.
oxidized
Methemoglobin is unable to bind ____ and causes a funcational _____, it also shifts the oxygen dissociation curve to the ______
oxygen
anemia
Left shift
______ can be used to treat cyanide toxicity, by oxidizing Fe2+ to Fe3+.
Amyl Nitrite
_______ can all cause transient decreases in SpO2 lasting any where from ____ to ____ minutes
methylene blue
indocyanine green
indigo carmine
Why is the R IJ central line more common than L?
Increased incidence of arterial puncture d/t more venous overlay over the artery
Carotid embolization from carotid artery cannulation on the (Right/Left) poses greater risk as the (Right/Left) cerebral hemisphere is dominant in the majority of the population
Left
Left
*R sided carotid massage is preferred over L sided
TPN is most associated with which two complications?
#2 Thrombophlebitis #1 infection
Acid-base status can be managed during cardiopulmonary bypass (CPB) by ____ and ____
pH-stat and alpha-stat
There is a natural (Acidic/Alkaline) drift associated with hypothermia d/t the increase in gas solubility and reduction of the _____
Alkaline
PaCO2
pH-stat corrects for the alkaline drift during CPB by maintaining _______.
neutral pH during hypothermia
*alpha-stat allows natural alkaline drift to occur
Alpha-stat is able to maintain autoregulation and the embolic load to the brain is minimized through coupling ___ with ____
CBF and Cerebral metabolic rate of oxygen demand (CMRO2)
Corticosteroid deficiency in the ICU is most likely secondary to ____
functional adrenal insufficiency (not primary)
Abx used to treat GNB (ie: cefepime) can worsen hypotension by _______
directly lysing outer bacterial membrane, releasing Lipopolysaccharide (LPS)
Theory of drowning is persistent _____ following aspiration of fluid
laryngospasm
Mg is excreted by the (liver/kidney)
kidney
*pts with RF high risk of hypermag
Theopylline is a methylxanthine drug similar to ____. Pt is at risk for ___ and ____ d/t preeclampsia and hypermagnesemia.
caffeine
sz and arrhythmias
Magnesium potentiates ________ drugs and ________
nondepolarizing NMBs
Local anesthetics
How much sodium bicarbonate should be administered to pts to correct a metabolic acidosis?
(Only if they are mechanically ventilated or else their respiratory acidosis will worsen!)
Sodium bicarbonate (mEq) = 0.2 * pt weight * base deficit
Sodium bicarb should not be administered to a pt with respiratory depression or respiratory failure unless _________.
Sodium bicarb will be converted to ___ and if a respiratory compensation cannot occur, respiratory acidosis will worsen the acidosis
the pt is intubated
CO2
Narrowest part of the pediatric airway?
GLOTTIC OPENING
How are infants able to feed and breathe at same time?
- posteriorly displaced sphincter
- large omega shaped epiglottis
- cephalic position of the larynx
2 (surface tension)
_____________
Radius
La place’s law
What type of apnea is more assoc w/ preterm infants?
central apnea - immaturity of respiratory centers
average o2 consumption in neonates and adults in ml/kg/min?
Neonate: 6.4 ml/kg/min
Adult: 3.5 ml/kg/min
EMLA cream is made of ____ and _____
Lidocaine 2.5%
Prilocaine 2.5%
age based formula for uncuffed ETT size
(age/4) + 4
*cuffed size is a half size off at the end
What type of shock is seen with:
- hypotension for > 30 min,
- SBP < 90 mmHg
- PCWP > 18 mmHg
- Cardiac index < 2.2
cardiogenic shock
