ITE QBANK Misc 3 Flashcards
Early adult onset ventilator assoc. PNA is typically d/t _____
MSSA
TCAs primary MOA is the inhibition of presynaptic neurotransmitter uptake _______ and _______
Norepi and serotonin
Treatment for TCA toxicity with ECG showing wide QRS interval
Sodium bicarb
Common metabolic changes seen with TPN (6)
- Hypercarbia
- Hyperglycemia
- Hyperinsulinemia
- Hypophosphatemia
- Hypokalemia
- Hypomagnesemia
*NOT sodium
Can hepatic steatosis be seen in TPN?
Yes - common
- liver will store excess sugar as fat in liver
Can hypocarbia or hypocapnia occur with TPN infusion?
No - HYPERcarbia or HYPERcapnia
- Pt will metabolize excess carbs into sugar and increase CO2 production.
Can hypernatremia occur with TPN?
Unlikely
- more common in pts not receiving enough free water (calculate deficit and give as free water bolus)
Is low dose corticosteroids good for tx of septic shock?
No - not Recommended unless pt is unresponsive to fluids and vasopressors
No mortality benefit, but does reduce dependence of vasopressors and speed resolution of shock
____________ is defined as intrapulmonary vascular dilatations and increased A-a oxygen gradient, in the setting of end-stage liver disease
Hepatopulmonary syndrome
*Pts with hepatic failure have excessive circulating levels of NO –> excessive pulmonary vasodilators.
In hepatopulmonary syndrome, hypoxia is _____ when the pt lies flat, and ______ when the pt stands
Improved (platypnea)
worsened (orthodeoxia)
*worsened by increasing VP mismatch
Mean PAP > __ mmHg in a liver failure pt is suggestive of high perioperative mortality risk.
Mean PAP > __ mmHg is an absolute contraindication to liver transplantation.
> 35 mmHg
> 50 mmHg
Septic shock is a dyregulated response to infection, causing a metabolic _______ with compensatory ______
acidosis
respiratory alkalosis
Phosgene (chemical warfare agent) exposure can cause severe ________, which can cause significant morbidity and mortality
pulmonary edema
*targets type I and II pneumocytes
Inflammatory mediators cause:
- Prostaglandin:
- Bradykinin:
- Thromboxane A2
- Complement
- Prostaglandin: vasodilation/constriction, platelet disaggregation
- Bradykinin: inc capillary permeability
- Thromboxane A2: Vasoconstriction
- Complement: attraction of leukocyte and leukotriene release
Renin release is (Increased/Decreased) in cirrhotic pts secondary to _______ factors that are released
Increased
- Cirrhosis: hyperdynamic circulatory system (high Cardiac output, reduced systemic vascular resistance, reduced arterial pressure), secondary to vasodilating factors (NO, VIP)
In hepatopulmonary syndrome, _______is d/t an increased shunting of blood through the lungs, causing dyspnea.
platypnea (dyspnea while sitting)
the ____ wave on a central venous pressure (CVP) tracing is a result of increased venous return and systolic filling of the RA
v wave
Central venous pressure (CVP) waveforms are classically defined by 5 phasic events:
a, c , v waves (peaks)
x, y (descents)
Central Venous Pressure (CVP) is used to assess _____ and evaluate ____
R heart function
blood volume
The most prominant wave of the CVP tracing occurs during ___ which is noted by the ___ wave
atrial contraction, “atrial kick”
a wave
Central venous pressure (CVP) waveform changes in:
- a fib
loss of a wave
Central venous pressure (CVP) waveform changes in:
- AV dissociation
cannon a wave
Central venous pressure (CVP) waveform changes in:
- Tricuspid regurg
Tall C & V waves
Loss of x descent
Central venous pressure (CVP) waveform changes in:
- Tricuspid stenosis
tall a & v waves
minimal y descent
Central venous pressure (CVP) waveform changes in:
- RV ischemia
Tall a & v waves
Steep x & y descent
M or W configuration
Central venous pressure (CVP) waveform changes in:
- Pericardial constriction
Tall a & v waves
Steep x & y descent
M or W config
Central venous pressure (CVP) waveform changes in:
- Cardiac tamponade
dominant x descent
minimal y descent
Normal Central venous pressure (CVP) tracing:
____: atrial contraction
____: TV buldging into RA during RV isovol contraction
____: TV descends into RV with vent. ejection and atrial relaxation
____: venous return to and systolic filling of the RA
____: atrial emptying into RV through open TV
a wave : atrial contraction
c wave: TV buldging into RA during RV isovol contraction
x descent: TV descends into RV with vent. ejection and atrial relaxation
v wave: venous return to and systolic filling of the RA
y descent: atrial emptying into RV through open TV
First line treatment in cyanide toxicity
hydroxocobalamin
Sodium thiosulfate (older and slower)
Pts with cyanide toxicity may show normal oxygenation with metabolic ______.
acidosis
but could be masked by respiratory compensation
Hydrocortisone (promotes/inhibits) nitric oxide synthesis
inhibits
Of the 4 etiologies of hypoxemia, _____ is the only one which shows a normal a-a gradient
hypoventilation
______ is the most common cause of hypoxemia and will response to increased FiO2
V/P mismatch
- atelectasis, bronchospasm, COPD, airway obstruction, PNA
Strong Ion Difference (SID) in pts can be reduced by _______.
infusing lg volumes of fluid that has a SID of zero (ie: NS) to create dilutional acidosis
ie: cl-, lactate, HCO3-, PO34-, Albumin
Strong ion difference (SID) is normally ___ mEq/L
40
Tx for infant < 1 yr and adult botulism
Infant < 1 yr: Hu Ig
Age > 1 yr: equine derived antitoxin
onset of paralysis for botulism toxin is ____, and peaks at ____, and stabilizes at _____
6 - 72 hrs
2 weeks
10 weeks
(Hyper/Hypo)phosphatemia causes muscle weakness d/t lack of energy source. Cause difficulty weaning off mechanical ventilation.
Hypophosphatemia
Drugs common with drug fever
- amphotericin
- cephalosporins
- PCN
- phenytoin
- procainamide
- quinidine
ARDS net uses TV of ___ mL/kg of PBW and plateau pressures of ___ cm H2O
6 mL/kg
< 30 cm H2O
Use of vasopressin in pts with CAD can ppt _________ d/t ______
MI
- Vasoconstriction of coronary arteries
Vasopressin aka _____, promotes reabsorption of water in kidney tubules by increasing cell membrane permeability
ADH
Is it safe to give vaso in pts with renal dysfunction and liver failure secondary to hepatitis?
Yes
Calcium gluconate is used to treat (Hyper/Hypo) magnesemia.
Ca can raise BP quickly, easily titratable, and is readily available
Hypermag
PLasma OSM equation
2 * Na + Glucose/18 + BUN/2.8
Significant increase in angiotensin II in approximately ___ (time) after a blood pressure decrease is sensed by juxtaglomerular apparatus
20 minutes
*after anesthetic induction in nl pts, transient hypotension is offset by RAAS in ~20 min
Renin, a protease synthesized in the JGA, cleaves _____ in the blood to yield _____
Angiotensinogen
Angiotensin I
Angiotensin I is cleaved to Angiotensin II by ____
ACE
Angiotensin II (Directly/Indirectly) increases BP by stimulating the secretion of ______ from the zona glomerula of the adrenal glands
Indirectly
Aldosterone
Anuria is u/o < __mL per day
50 mL
Pre-Renal
FeNa = ___
Urine Na = __
< 1
< 20
Renal
FeNa = ___
Urine Na = __
> 2
> 40
__% of rocuronium is renally excreted.
30%
______ and _____ have minimal renal excretion and predictable durations of action in pts with renal failure
Succinylcholine and cistatracurium
(Hyper/Hypo)calcemia is expected in pts with ESRD.
Hypocalcemia
- Kidney loses ability to reabsorb Ca
- Kidney converts less 25-hydroxycholecalciferol -> 1,25-hydroxycholecalciferol -> less Ca absorption
Which electrolytes are elevated in ESRD?
K+
Mg2+
PO4
Urea
K+ < __ mEq/L warrants delay of non-emergent surgery
2.5
KDIGO guidelines define AKI as _____ (3 things)
increase in Cr by 0.3mg/dL over 48 h.
or
Increase in serum Cr to < 1.5 baseline in 7d
or
Urine volume < 0.5 ml/kg/hr for >6h
Sevoflurane produces ______ and ____, which has potential nephrotoxicity (controversial as it is not linked in humans
Compound A and Fl-
*FDA: use at least 2L/min fresh gas flow to reduce compound A and increase washout
Nephrotoxic volatile agents
methoxyflurane and enflurane
Quickest way to improve oxygenation during 1 lung ventilation?
resume two lung ventilation
Hypoxemia primarily occurs during one lung ventilation d/t the perfusion of the _____ lung, even in the setting of appropriate hypoxic pulmonary vasoconstriction
non-dependent (non-ventilated) lung
What is the quickest way to improve oxygenation during 1 lung ventilation IF you cannot resume two lung ventilation?
Ligate or clamp the pulmonary artery supplying the non-dependent lung
CPAP can improve oxygenation with the exception of: (2)
- Occlusion of main bronchus
2. Bronchopleural fistula
Flow volume loop of COPD
- The _____ curve looks normal.
- The _____ phase quickly peaks then falls to a lower than nl plateau pressure
Inspiratory curve
Expiratory
Severe hypoxia under one lung ventilation, after confirming DLT position, assuring 100% O2, and maintaining nl CO, is treated by applying ____ to the dependent lung, and ____ to the non-dependent lung.
PEEP
CPAP
*for pts w/o COPD
Head down (Trendelenburg) is associated with an (Increase/Decrease) in Cardiac index and (Increase/Decrease) in FRC
Increase
*increase venous return -> increase in stroke volume -> increase in cardiac index/output
Decrease
- d/t reduction in ERV
Head down (Trendelenburg) is associated with an (Increase/Decrease) in Cardiac index
Increase
*increase venous return -> increase in stroke volume -> increase in cardiac index/output
After smoking cessation, carbon monoxide levels normalize after ___, mucociliary function begin to normalize after ___ , and risk of post op complications are maxed at ____.
24 hours
3 weeks
8 weeks
The greatest benefit of smoking cessation is seen after ___ weeks
8 weeks
Prone pulmonary changes after heart and abdomen is able to hang freely and relieve the diaphragm of upward pressure and positive pressure is more evenly distributed.
- Increase ERV and FRC
- Improved pulmonary compliance!
- Decrease atelectasis
- Improved V/Q matching
- Decreased lung stress and strain
Maximum voluntary ventilation (MVV) of > ___ % of the predicted value is shown to be associated w/ good postoperative prognosis after pneumonectomy
> 50%
Preoperative ABG criteria that predict increased perioperative morbidity and mortality in pneumonectomy include:
- PaO2
- PaCO2
PaO2 < 50 mmHg on RA
PaCO2 > 45
Preoperative spirometry criteria that predict increased perioperative morbidity and mortality in pneumonectomy include:
- FVC ___
- FEV1 ___
- FEV1/FVC ___
- MVV ___
- DLCO ___
FVC < 50%
FEV1 < 2L
FEV1/FVC < 50%
MVV < 50%
DLCO < 50
Pneumonectomy preop critheria:
- Phase 1 testing what happens if pts fail vs pass?
Phase 1 fail: start second phase of testing (split lung function)
Phase 1 pass: proceed to lung resection
Shunt is also known as ________. Portion of the lungs that are ____ but not _____
venous admixture
Perfused, but not ventilated
______ can be defined as a passage of blood from the systemic venous system to the arterial system without being exposed to alveolar gas
Shunt
In the perioperative period, the most common cause of shunt is ______, and is a very important cause of hypoxemia
atelectasis
Increasing inspired concentration of oxygen increases shunt fraction secondary to ___________
the attenuation of hypoxic pulmonary vasoconstriction and microatelectasis
Leftward shift of oxyhemoglobin dissociation curve is a feature of
(Alpha-stat ABG / pH-Stat), by allowing pH to rise naturally during cooler body temperatures, and is not corrected for pt body temperature
alpha-stat ABG
During _____ ABG management, CO2 is added to overcome hypothermia induced alkalosis and maintain pH at 7.4
pH-stat
_______ is a well documented effect that can be observed following the cessation of an inhaled anesthetic involving the use of high [ ]s of nitrous oxide. The flooding of NO results in the displacement of oxygen and carbon dioxide in the alveoli, leading to temporary hypoxia.
Diffusion Hypoxia (“Fink Effect”)
Nitrous Oxide blood:gas coefficient
0.47
Ketamine MOA
NMDA antagonist
~80% o f resistance to gas flow during ventilation occurs in the _________
large airways including upper bronchi
- Lower cross sectional area, greater resistance to flow
- more turbulent flow
As temperature decreases, PaCO2 will (Increase/Decrease) since partial pressure is proportional to temperature and pH will (Increase/Decrease)
decrease
alkalotic
The gradient btwn PaCO2 and ETCO2 normally reflects ______
dead space
normall __CO2 is slightly higher than __CO2 and is a result of deadspace ventilation
PaCO2 > ETCO2
most common complication of celiac plexus blockade (done from the back or retrocrural approach under flouroscopy)
orthostatic hypotension
- d/t vasocilation of splanchnic vessels, increasing venous capacitance
_____ is a sympathetic plexus that provides sympathetic output and receives sensory innervation from much of the abdominal viscera
celiac plexus block
Orthostatic hypotension occurs when systolic BP drops by ___ mmHg or diastolic BP drops by __ mmHg
20 mmHg
10 mmHg
second most common complication of celiac plexus blockade (done from the back or retrocrural approach under flouroscopy)
Diarrhea
- d/t autonomic imbalance favoring parasympathetic over sympathetic
- (greater sympathetic blockade)
Stellate ganglion blocks in the neck are performed to diagnose _______
sympathetically mediated pain of the upper extremity
______ is a sympathetic ganglion comprised of the inferior cervical and first thoracic sympathetic ganglia and lies in close proximity to the carotid artery, internal jugular vein, lung, and brachial plexus
stellate ganglion
Horner syndrome a complication of (stellate/ celiac) ganglion blocks
stellate
*ptosis, miosis, anhydrosis
_____ is the enzyme that produces prostaglandins which have general ‘housekeeping” functions such as gastric protection and hemostasis
Cox-1
__ is the enzyme that produces prostaglandins that mediate pain, inflammation, fever, and carcinogenesis
Cox-2
Which drugs have ceiling effect, and are ineffective beyond a certain dose
- NSAIDs
- Mixed agonist-antagonist opioids
- Pure mu-agonist opioids
NSAIDS and mixed agonist-antagonist
_______ is considered first line tx and standard of care in pts w/ moderate-severe cancer pain
morphine
__________ is the major metabolite of morphine, but does not bind opioid rcptrs and possess little or no analgesic activity
Morphine - 3 - glucuronide
_______is the major metabolite of morphine, and contributes substantially to its analgesic effects
morphine - 6 - glucuronide
Phantom limb pain is a type of which pain?
Neuropathic pain
Most common indication for epidural steroid injections
radicular back pain along
a nerve distribution caused by herniated disc
_______ is herpes zoster pain that persists beyond vesicular rash and can last 4-6 weeks. Sympathetic blocks are effective for acute herpes zoster, but this.
postherpetic neuralgia
________ pain is decreased with standing and increased with bending/sitting
discogenic
peripheral neuropathy in diabetes mellitus is related to __________
microangiopathy ( ischemia in axonal nerve tissue)
Pain is conducted along three neuronal pathways from peripheral transduction to the __________ cortex, through first, second, and third order neurons.
cerebral somatosensory
First order neurons secrete chemical mediators of pain and signals begin with transduction and ends with synapse traveling to the _____.
dorsal horn
Second-order neuron begins at the ______ and ends at the ______
dorsal horn,
thalamus
Third-order neuron begins at the ______ and follows the axonal pathway to the ______
Thalamus
postcentral gyrus
Signals carried by the spinothalamic tract
crude touch, pain, temp
Metabolism by most opioids are by the hepatic CYP ___ enzyme
CYP3A4
Remifentanil is metabolized by ________
plasma esterases
Negative immune effects of opioids include:
Inhibition of ___ transcription
and ____
IL-2 transcription
cancer recurrence
Oxycodone, tramadol, and hydrocodone is metabolized by CYP ___
CYP 450 2D6
