ITE TL block 2 Flashcards
Best way to assess hepatic synthetic function
factor VII (1/2 life of 4 hours) so 1st to change if there is an issue w/ hepatic fxn
-fibrinogen changes 2nd (1/2 life 4 days), albumin 1/2 life is 20 days
measure hepatic excretory function
bilirubin
What is Gilbert Syndrome?
MC inherited hyperbili (indirect hyperbili) usually elevated but < 3 after trigger (trauma, surgery, illness, fasting, alcohol)
-due to dec in UDP-glucuronosyltransferase activity causing dec in conjugation of bili
How to diagnose Gilbert Syndrome and symptoms
PCR gene mutation
symp: fatigue, loss of appetite w/ transient, mild, jaundice
labs: mild indirect hyperbili (high but < 3), no evidence of hemolysis, and otherwise normal liver fxn
sudden, painless bright red vaginal bleeding after 20 weeks gestation
placenta previa
-abnormal placenta implantation partially or completely blocking internal cervical os
RF for placenta previa
previous c/s
prev pregnancy termination
prev uterine surgery
smoking
adv maternal age
multiple gestation
multiparity
cocaine abuse
-higher risk w/ higher # of c/s and parity
sudden painful vaginal bleeding
placental abruption
-premature separation of placenta from uterus
-fetal distres
severe sudden abd pain during labor, pause in contractions, vaginal bleeding, hemodynamic instability
uterine rupture
sudden, painless vaginal bleeding after rupture of mebranes
vasa previa
-fetal blood vessels overlying internal cerival os not protected by placenta or umbilical cord
-can cause fetal exsanguination
When to get an EKG for a preop workup
hx of cardiovascular dx, resp dx and type of surgery
-routine testing not indicated
When to get electrolytes/chemistry panels before surgery
endocrine, renal, liver d/o, certain medication use, potential for periop therapies that would alter a chemistry
hg/hct preop testing when
hx of known liver dx, history of anemia, hematologic d/c, type and invasiveness of procedure
Why dec DLCO on spirometry
Increased thickness of alveolar membrane
Dec alveolar membrane surface area
small pressure gradient b/w alveolar gas partial press and capillary gas tension
Why dec DLCO in pulm HTN
remodeling and loss of pulm vasculature -> thickened alveolar membrane and dec blood volume to participate in gas exchange
solubility of anesthetics w/ tempm, and hydrophobilicity
-solubility of inh anesthetics inc as temp decreases, and decreases as temp inc (as temp inc, exists as a gas, not soluble)
-hydrophobic nature of inh anesthetics -> higher solubility in tissues w/ higher lipid content than blood
Maintanence of Certification 2.0 requirements
Must occur in every 10 year period:
-must hold an active, unrestricted medical license in 1 jurisdiction in US or Canada
-Complete 250 Category 1 CME credits (125 must be done by year 5), 20 must be ABA-approved patient safety
-30 MOCA MC questions every calendar quarter for 120 questions per year
-points awarded for activities include clinical practice assessments and systems-based practices (QI): 25 points in 1st 5 years and 25 more in second 5 years 50 total
FEV1/FVC ratios for normal, obstructive, and restrictive dx
Normal ratio: 85%
Restrictive: 90% (normal ratio, but dec FEV1 and FVC)
Obstructive: 53%
Obstructive lung dx PFTs
-FEV1/FVC ratio of < 70% of predicted
-FEV1 < 50% predicted
-only slight dec/maintain FVC
FEV1, FVC, FEV1:FVC ratio for norm, obst, rest
COPD severity scale
Stage 1 mild: FEV1 80% or greater of predicted
Stage 2 moderate: FEV1 50-79% predicted
Stage 3 severe: FEV1 30-49% predicted
Stage 4 very severe: FEV1 less than 30% of predicted
Difference b/w gastric volumes and pH when clear liquids NPO >4 hrs or 2-4 hours
equivocal volumes and pH
NPO guidelines clear liquids, breast milk, reg milk, fatty foods
clear liquids: 2 hours
breast milk: 4 hours
milk formula or light meal: 6 hours
fatty foods: 8 hours
Why dec FRC in pregnancy?
-large uterus pushes diaphgram cephalad -> dec FRC
-dec FRC b/c dec ERV and RV
How long does it take for ventilation to return to normal
1-3 weeks postpartum
Airway in preegnancy
friable due to capillary engorgement
-edema of oropharynx, larynx and trachea begin 1st trimester
-b/c edema: mask, DL, intubation harder
-edema on extubation can compromise airway
-use 6-7 ETT
treatment of opioid-induced pruritis w/o ruining pain from opioids
Nalbuphine
Tx for opioid induced constipation (opioid agonist)
Methylnaltrexone
-peripheral mu-opioid antagonist
Nalbuphine MOA
mixed opioid agonist/anatagonist
-agonist of kappa opioid, antagonist of mu
Why urinary retention w/ spinal
Blockade of S2-4: dec strength of detrusor muscle -> weak/inh urinary function
-reduces sensation of urinary urge
What is hyperkalemic periodic paralysis? inheritance pattern?
Auto Dom
-weawkness accompanied by hyperkalemia w/ K up to 6
How to prevent hyperK periodic paralysis attack
avoid K-containing solutions
-avoid hypothermia (further impairs ion channel)
-give glucose or insulin
-albuterol
-mild exercise
-HCTZ (K wasting diuretic used as ppx)
Succ and GI effects
-inc intragastric pressure < inc in lower esophageal sphincter tone
-concern due to LES incompetence -> give NDNM pre-succ to avoid inc in intragastric pressure
Milrinone mechanism of action
selective PDE III inhibitor -> dec hydrolysis of cAMP -> inc cAMP causes inc contractility, HR, and conduction velocity
Best medications to inc HR in a denervated heart
isoproterneol and epi
Levosimendan MOA
Ca sensitizing medication (inc cardiac sens to Ca) -> inc inotropy and CO
-SE: tachyarrhythmias and hypoTN
Dromotropy
conduction velocity
Milrinone effects
-inc contractility (inotropy), inc HR (chronotropy), inc conduction velocity (dromotropy) -> inc CO
-smooth m relaxation, dec EVEDP, improves pulm BF and LV filling (dec afterload)
Difference in flow volume loops w/ COPD, restrictive dx, fixed upper airway obstruction, intrathoracic/extrathoracic obstruction
COPD
mediastinal mass changes to flow volume loop
INTRAthoracic
-insp normal, exp problem
-b/c can pass w/ negative intrathoracic pressure, blocked w/ positive intrathoracic pressure during exp
proximal tracheal tumor flow volume loop
-flat insp curve, normal exp curve
-b/c neg intrathoracic pressure pulls in causing it to obstruct more, postive intrathrocic pressure causes it to move
fixed upper airway obstruction curves
impairs both insp and exp
What nerve likely to get injured during PDA repair
recurrent laryngeal n (branch of vagus: CN X)
Why does PDA close when infant born
inc in arterial O2 and decreased PG ->constriction of ductus
tx of PDA
NSAIDS (indomethacin, ibuprofen) or surgery
Best way to dec cardiac demand and inc O2 supply
Dec HR
-less m use when beating slower
-dec O2 demand w/ dec HR
-inc time in diastole, allowing longer for O2 to get to heart
O2 content of blood equation
CAO2 = (Hgb x 1.34 x SaO2) + (.003 x PaO2)
Cardiac Perfusion pressure
CPP = Aortic DBP - LVEDP
Heart wall tension equation
Tension = (LVEDP x radius) / (2 x LV wall thickness)
When is RV perfused?
Throughout cardiac cycle
-greatest perfusion during peak/late systole and early diastole
Botulinum toxin MOA
Blocks release of ACh at muscarinic and nicotinic receptors
-inh fusion of ACh vesicles to nerve terminal -> can’t release into synapse (cleaves SNARE proteins)
Sarin MOA
inhibits AChE -> continual transmission of n impulses and can’t control resp muscles
Tetrodotoxin MOA
inhibits fast Na currents in myocytes and prevents contraction of resp muscles
MCC of fire ignition in OR
electrocautery unit
What do you need for fire in OR?
-ignition source (laser, cautery)
-fuel (surgical prep, drapes, ETT, O2 tubing)
-oxidizer (O2, nitrous oxide)
RF for OR fires
-MAC w/ open O2 delivery system
-outpt surgery
-head/neck/upper chest surgeries
-older pt age
MOA enoxaparin
binds and enhances antithrombin 3 (like heparin), difference is it preferentially inhibits factor Xa
If long heparin infusion and bolusing pt’s heparin and it’s not working tx?
ATIII (prob def) or if they don’t have FFP
RF for PDPH
-age, more common < 30, uncommon > 60
-women 2x more likely
-skinny (less likely in morbidly obese)
-pregnancy
-previous hx
-inc risk w/ inc needle gauge
Chronic opioid therapy and hormones
-unbalanced hypothalamic-adrenal axis and hypothalamic-gonadal axis
-inc prolactin levels, dec testosterone, estrogen, cortisol, LH and FSH
-male/female infertility, red libido, galactorrhea, menstrual changes
-Addisonian sym from dec cortisol: orthostatic hypoTN, m weakness, hyperpigmentation
-immunosuppression
MC side effects of ondansetron
QTc prolongation > HA
-prolongation is 20-30 msec or less
Rocuronium excretion
-25-30% renally excreted, majority cleared by hepatic uptake and hepatobiliary excretion
***prolonged paralysis in pts with cirrhosis and liver failure
closing capacity
volume remaining in the lungs during expiration when alveoli BEGIN to close
-CC = closing volume + RV
Why inc small airway collapse in elderly
-inc closing capacity
-small airways not stiff enough to remain open and depend on elastance of lung parenchyma to stay open -> dec elasticity w/ age -> CC surpasses FRV
Resp change sin elderly
-inc chest wall stiffness, loss of m mass, flattening of diagram, and inc compliance of lung
-inc CC, inc RV, inc FRC
-dec TLC, dec IC
RF of phantom limb pain
preamputation pain
APGAR score
max: 10
2 pst for each category
Appearance, Pulse, Grimace, Activity, Respiration
When using oral dantrolene what lab should be monitored?
LFTs!!
CI: cirrhosis, hepatitis B or C, nonalcoholic stateohepatitis
-d/c if LFTs elevated or s/s of hepatic issues ie jaundice or RUQ pain
What local anesthestics cause methemoglobinemia
Prilocaine or Benzocaine
Tx for Met-Hg if G6PD def
Ascorbic Acid (Vit C)
Acquired cases of MetHg
-prilocaine, benzocaine
-metoclopramide
-nitrites (nitric ocide and NG)
-aniline dyes
-benzene
-chloroquine
-dapsone (abx for leprosy, dermatitis herpetiformis)
-sulfonamides
Methylene Blue MOA and risks
monoamine oxidase inhibitor
-can cause serotonin crisis w/ SSRI
PFTs in restrictive lung dx
Dec FEV1, Dec FVC, FEV1/FVC ratio > 0.7
What cysto fluid during TURP causes hypoNa and inc ammonia
Glycine solution
-may cause neuro complications incl encephalopathy and coma
-can also have vision changes due to brainstem or CN inh w/ glycine (structurally similar to GABA)
what cysto fluid TURP causes hyperglycemia and osmotic diuresis
sorbitol solutions
cyto fluid TURP causes hypoNa, hemolysis, hemoglobinuria
Distilled water
Best way to monitor recurrent laryngeal n fxn during thyroid surgery
intermittent/continuous EMG
afferent/efferent for corneal reflex
afferent: trigeminal nerve (ophthalmic branch)
efferent: facial (temporal and zygomatic)
goes Away Afferent to cause an Effect Efferent
afferent/efferent pupillary light reflex
Afferent: optic n
Efferent: Oculomotor n
three surgeons want to compare intraop times, what statistical analysis?
ANOVA
(more than 2 groups)
How does PE occur?
Triad: endothelial injury, venous stasis, hypercoagulability
-get thrombus -> embolizes travels to R heart and into pulm circ
orthopedic long bone fracture, petechial rash, resp compromise
fat embolism syndrome
-showering of fat/bone marrow into systemic circulation -> lodges in capillaries of organs (mostly skin and lungs)
what happens in amniotic fluid embolism?
amniotic fluid in circulation -> massive activation of systemic inflammation
-b/c amniotic fluid has so many vasoactive and procoag -> when in systemic circ massive inflammation and DIC
-endothelin causes bronchoconstriction and pulm/coronary vasoconstriction
fenestrated trach tube
openings in outer cannula -> allows air tot pass through pts oral/nasal pharynx to speak and cough
-inc risk risk of oral/gastric aspiration
-cant be used for PPV
what is a laryngectomy stoma tube
they’ve had part of their trachea removed, so there is no connection b/w trach and mouth/nose so can only be intubated through stoma
Myotonic dystrophy
Muscles cant relax: Ca doesn’t return to SR so sustained contraction
-symp: m degen, cataracts, DM, thyroid prob, adrenal insuff, gonadal atropy, heart abnorm (conduction dysfxn, cardiomyopathy, MVP)
-resp m weakness : restrictive dx, ineffective coughing, hypoxemia and hypercapnia
-GI m weakness: delayed emptying, hypomotility, pharyngeal m weakness -> inc aspiration risk
Triggers for myotonic episodes
shivering 2/2 hypothermia
neostigmine
succ
directly surgical stimulation of m (esp by cautery)
Treatment of myotonia or myotonic crises
phenytoin
quinine
procainamide
-direct infiltration of affected m w/ local anesthetics
-high conc of volatile anesthetics
**can also be used as ppx
-dec Na influx into myoctyes, and delaying return of membrane excitability
post SAH, hypoNa, euvolemic, high urine Na and high urine osmolarity, dx?
SIADH
-tx: free water restriction
post SAH, hypoNa, hypovolemic, high urine Na and high urine osmolarity, dx?
cerebral salt wasting
-tx: free water and Na administration
Difference b/w traditionally CAB and minimally invasive directly CAB
minimally invasive: small thoracotomy invasion may require single lung ventilation for visualization, can’t use paddles against heart, so external defib pads
-CBG avoided
-b/c no cardioplegia may require pharm bradycardia w/ transvenous pacing
Advantages of minimally invasive CBG as opposed to traditional CBG
dec arrythmias
dec post-op wound infxn
dec coag d/o
dec blood transfusions
dec renal failure, stroke, hospital stay, cost
MOA of uterotonicsc
carboprost: PG (bronchoconstriction)
misoprostol: PG
methylergometrine: ergot alkaloid (HTN)
Why does Mg lower BP in preeclampsia
vasodilation w/ Mg -> dec in BP
-Mg competes w/ Calcium inside vascular smooth m -> prevents actin-myosin crosslinking -> dec SVR
-Mg also inc nitric oxide and PG -> vasodilation
How does Mg help pain?
NMDA antag
Tx for Mg toxicity
Give Ca (antag Mg) Cl central, gluconate PIV
-and supportive: support O2, ventilation and hemodynamics
How does inhalation anesthesia potentiate NMB
-augmentation of antagonist affinity at the receptor site
-central effects on alpha motor neurons and interneuron synapses
-inhibition of postsynp nicotinic ACh receptors
Which gas potentiates NMB the most?
Des > Sevo > Iso > halothane > nitrous oxide > TIVA w/ prop
How is ACh broken down?
Cholinesterase into acetate and choline
-choline recycled by being transported back into neuron by Na+/choline transporters
what makes the single largest difference on function after pancreatic transplant
donation after brain death allows for longer graft perfusion times compared to donation after cardiac death
Pancreatic transplant considerations
-performed in conjuction w/ kidney transplant
-sensitive and require constant blood flow, graft thrombosis = re-exploration
-monitoring glucose essential after reperfusion -> releases insulin into circulation w/i minutes -> blood glucose every 30-60 minutes
pain three neuronal pathways
first order neuron w/ transduction and ends w/ synapse at the dorsal horn
-second-order beings at dorsal horn ends at thalamus
-third-order involves thalamus and its axonal pathway to postcentral gyrus
**crude touch, pain, and temp along same pathway
molecules that modulate pain in dorsal horn transmission
Adenosine
-substance P is also secreted
Urine to plasma osmolar ratio indicated prerenal oliguira
> 1.5
Myofascial pain syndrome
-trigger points in skeletal muscles 2/2 repetitive use or trauma
-localized pain, can get radiation non-dermatomal
-taut muscle, limited ROM
-can get autonomic dysfxn: piloerection, vasoconstrcition
-spontaneous activity on EMG can occur
Tx of Myofascial pain syndrome
cold sprays (ethyl chloride) to relax m
-stretching exercises
-PT
-massage
-dry needling, injxn of local anesthetic
-trigger point injxn
how to screen fo rcerebral vasospasm
transcranial doppler every 24-48 hours
-assesses flow velocity of the MCA and ICA
-vasospasm considered if FVMCA > 120 cm/s or FVMCA: FVICA > 3
Compl of SAH and time frame
rebleeding: 24-48 hours
vasospasm: 3-15 days
-more bleeding, more risk of vasospasm
tx of cerebral vasospasm
nimodipine
Uterine blood flow
> 20 weeks: uterine blood vessels maximally dilated and entirely pressure-dependent
-autoregulation plays no role
-anesthesia can cause systemic vasodilation and myocardial depression -> dec uterine BF
What nerve is blocked for cleft lip repair?
Infraorbital nerve
-maxillary branch of trigeminal (V2)
-sensory for lower eyelid, lateral nose, cheek, and upper lip
Infraorbical nerve block
-intraoral: upper canine insert into buccal mucose move cephalad and lateral
-extraoral: preferred, palpate infraorbical foramen advance to bone, and inject
When would you nerve block the ethmoidal foramen
nasociliary block for nasal septoplasty
pregnancy and myotonic dystrophy
exacerbates it due to inc progesterone
-high incidence of OB complications (polyhydramnios, premature onset of labor, breech presentation, impaired cervical dilation, uterine atony, PPH_
Myotonic dystrophy complications
progressive m weakness, cataracts
pulm restrictive lung dx due to contractures
-insulin resistasnce
issues w/ cardiac conduction
testicular atrophy
Normal fetal a ABG
pH: 7.27
pCO2: 50
PO2 18
base excess - 2.7
-represents acid-base status of fetus
-lowo PO2 not a concern, pH, CO2 and base deficit more important
diff in info b/w umbilical a and v
artery: acid-base of fetus
v: placental function
Normal PCO2 and O2 in umbilical artery and vein
why is a des vaporizer heated
-very high saturated vapor pressure (669 mmHg at 20C)
-to maintain constant vaporizer output, control temp -> vaporzier heated to 39C
Peds laparoscopy compared to adults
-lower insufflation pressures needed (thinner peritoneum)
-lower risk of ileus w/ llaparoscopy compared to laparotomy
-inc uptake of CO2 due to thinner peritoneum and less act to act as a buffer -> inc MV!
-more cardiopulm disruptions -> inc pressure in abd causes IVC compression, movement of carina cephalad, dec UOP, inc ICP
what test do you need before omphalocele repair done
TTE!
-20% have congenital haert disease
Concerns for gastroschisis and omphalocele surgeries
-fluid balance! severe dehydration huge risk
-early parenteral feeding helps speed return of bowel fxn, dec infxn and improve wound healing
-liberal m relaxation
-when contents in abd, aortocaval compression => hypoTN
-inc intraabd pressures dec BF to liver and kidney -> dec metabolism of drugs
-postop ventation always required
surgical blood loss in neonates replacement
1:1 colloid
1:1.5 isotonic crystalloidd
Periop fluids in neonates
-higher rate of evaporative losses due to inc body surface area to mass ratio
-higher body water content
-higher metabolic rate (inc enzymatic activity) -> higher water requirement
-immature renal system -> poorly tolerated fluid shifts (takes 1 year to be almost equal to adult)
Treatment of neonatal respiratory distress syndrome
Administration of CPAP (PEEP 3-8)
-endotracheal intubation despite CPAP, intratracheal admin of exogenous surfactant
Anesthesia dolorosa
pain in an area that lacks sensation
-compl of neurolytic blocks for trigeminal neuralgia
Treatment of anesthesia dolorosa
anticonvulsants, antidepressants, opiates, and psych support
Allodynia
perception of ordinarily nonnoxious stimulus as being painful
MC injured nerve in lithotomy position
common peroneal nerve
-more likely w/ low BMI and prolonged surgery
Meralgia paresthetica
entrapment of the LFCN
What is considered to be an anion gap metabolic acidosis
AG > 16
normal is 8-12
Equation for anion gap
Na + K - (Cl + bicarb)
Causes of non-gap acidosis
admin of NS
GI loss (diarrhea, fistula)
renal loss (renal tubular acidosis)
Acetazolamide
Process for diagnosis of AG acidosis
- gap > 10?
- lactate -> if lactate above 2, it lactane from tissue hypoxia
- if lactate <2 look at ketones -> ddx DKA, starvation or alcohol ketoacidosis
- If ketones not present, renal failure? Look at osmolar gap
Neuron action potential termination
-Na channels close (preventing further + input into cell)
-opening K channels to promote K efflux -> they overshoot to hyperpolarization (refractory period)
MOA of local anesthetics
block n impulse transmission by reversibly binding to the intracellular potion of the VG Na channels and preventing Na influx
Why does phenylephrine cause inc BP?
inc venous return (inc preload) and inv SVR
-arterial and venous constriction
Pain ladder
- NSAIDS, acetaminophen
- mild opioids: codeine, tramadol
- strong opioids: morphine and hydromorphone
What drug causes bronchospasm w/ asthma and nasal polyps
Ketorolac and Aspirin
-inc risk w/ histamine release (morphine, atracurium)
In emergency type and screen completed and antibody screen negative, best way to proceed?
Transfuse w/ ABO and Rh compatible blood
-save O for emergencies w/o known blood type
What is a type and screen
mix pt’s plasma with 2 or 3 regent samples of RBCs which have all the clinically impt RBC antigens
what is a cross-match
mixing of donor and recipient cells occur
What is antibody screening w/ blood
pt’s plasma w/ blood group “regents” expressing commonly encountered RBC antigens: Duffy, Kidd, Kell, SsU antigens
Steps for crossmatch
- Immediate phase: check ABO typing errors (5 min)
- Incubation: first phase reaction products and incubating them in albumin or salt ->detect antibodies that donot cause agglutination in 1st phase (Rh)
- Antiglobulin phase: detects incomplete antibodies (Rh, Kell, Kidd, Duffy)
What is added to blood for storage
Phosphate: buffer
Dextrose: RBC energy source
Citrate: anticoag
Adenine (possibly): helps RBC synthesize ATP
Factors assoc w/ inc survival rate of neuroblastoma
extra-abd location
lower international neuroblastoma risk group score
under 18 months presentation
primary tumor
no mets
small tumor
good surgical resectability
Anesthesia for neuroblatoma
-if catecholamine secreting tumors both alpha and beta blockade preop
-a line, Central line
-keep euvolemic
-BP control!!
-rapid transfusion device
What test used for neuroblatoma dx?
elevated urinary catecholamines
vaporizer output proportion of sevo, iso
sevo: 1/4
iso: 1/2
if 100 cc/min goes through sevo vaporizer -> 25cc of sevo
CVP waveform interpretation
CVP venous waveform
a: atrial contraction
c: closure of tricuspid valve
x: atria relaX
v: ventricles prepare yourself
y: yes we ready! emptYing of RA
S4 heart sound
dec LV compliance (diastolic dysfxn and LVH)
What electrolyte change assoc w/ Guillane Barre
Hyponatremia
-pts get SIADH
-degree of hypoNa has a relationship w/ severity
Guillian Barre sym
post GI or resp illness -> autoimmune demyelinating polyneuropathy
-ascending weakness
-hypoNa (SIADH)
-DVT inc risk
-autonomic dysfxn: hypoTN, HTN, dysrhythmias
LP for guillan barre
increased protein w/ normal cell ct and normal glucose
What opioids accumulate in renal failure and what SE do they have?
hydromorphone and morphine, meperidine
neurotxicity -> sz
What opioids accumulate in renal failure and what SE do they have?
hydromorphone and morphine, meperidine
neurotxicity -> sz
Which opiods are assoc w/ serotonin syndrome
meperidine and tramadol
Hirsutism
Where women start to grow hair in more manly locations: lip and on chin
What is Cushing Syndrome
prolonged exposure to excess cortisol
Symptoms of Cushing Syndrome
Due to exces cortisol -> massive protein breakdown -> moon faces, buffalo hump, abd weight gain, thinning of extremities
-hirsuitism (cortisol mimics androgens)
elevated blood sugar
-mood disturbances
-lytes changes: HypoK
Triad of forgein body in trachea
asthmatoid wheeze, audible slap from foreign body against the trachea during ventilation, and palpable thud over the trachea
where is foreign body w/ drooling and inspiratory stridor
upper airway obstruction
Anesthesia plan for removal of an upper airway obstruction
-minimize agitation of pt (forced inhalation after crying can cause dynamic collapse of the airway)
-PPV cautiously to stent open airway
-parent present slow inhalation induction, topical cream to put IV in while pt lighter
-once IV deepend and CPAP
-give to surgeon
-no NMB, keep pt breathing
Which volume expanding fluid can produce a coagulopathy at large doses?
Hydroxyethyl starch
Dextran
Aldrete scale for d/x pts from Phase 1 recovery
Activity: moving voluntarily or on command
Respiratory: breaths deeply and coughs well
Circulation: BP w/ i 20 of preop
Consciousness: awake and alrter
O2 sat: > 92% on room air
What age are peds required to stay overnight after anesthesia
if they are less than 60 weeks post-conceptual age
-inc risk of postop apnea, desat and bradycardia
***spinal decreases risk compared to GA
13 YOM fever, sore throat, trismus and difficulty swallowing dx?
peritonsillar abscess
-Group A beta hemolytic Strep MCC
-trismus: pain and m spasm
MCC of epiglottitis
H influenza
-NO NMB -> risk of pharyngeal m relaxation and complete airway obstruction
-remain intubation 24-48 hrs until inflammation subsides
Renal fxn changes in elderly
-renal mass at age 80 dec by 30%
-RBF dec about 10% per decade
-Cr normal b/c dec muscle mass
-impaired concentrating and diluting urine -> risk of dehydration and electrolyte abnormalities
RF for failed neuraxial anesthesia during c/s
increasing maternal BMI
late labor epidural placement
rapid decision to incision interval
What fluid should be used w/ neurosurgical pts and acute neurologic trauma
NS
-slightly hypertonic compared to normal plasma
-greater ability to lower ICP -> brain relaxation
What fluids in pts w/ advanced hepatic dx?
normal saline b/c can’t metabolize lactate from LR -> will confuse resuscitation measures
What fluids in pts w/ ESRD
use LR -> they can clear the K and the hyperchloremic met acidosis from NS is worse and will inc K by a higher amount
Strong Ion Difference Equation
(Na + K + Ca + Mg) - (Cl and lactate)
sum of strong cations - sum of strong anions
Normal strong ion difference
~40 due to unmeasured ions (ie lactate)
-when > 0 -> alkalosis
< 0 -> acidosis
Increasing the strong ion difference
alkalosis b/c SID > 0
-Inc Na -> inc SID -> alkalosis
-vomiting causes an inc b/c getting rid of a lot of Cl -> inc difference b/w cations and anions -> alkalosis
Decreasing the strong ion difference
acidosis b/c SID < 0
-Dec Na -> dec SID -> acidosis
-Inc Cl -> dec SID -> acidosis
-Inc in organic acidosis like latate or ketoacids -> dec SID and acidosis
strong ion difference w/ NS bolus
NONE b/c they have equal conc of Na and Cl -> no change in strong ion
Acetazolamide MOA
carbonic anhydrase inhibitor
-prevents the reabsorption of bicarb -> metabolic acidosis
-accompanied by dec in CO2 to respiratory compensate
(usually results in reabsorption of Na, Cl, bicarb)
Indications for Acetazolamide
glaucoma
idiopathic intracranial HTN
altitude sickness
epilepsy
periodic paralysis
CHF
Strong ion difference in dehydration and overhydration
Dehydration: SID inc -> concentrates the unmeasured ions -> alkalosis
Overhydration: dilution of ions, SID decreases -> dilutional acidosis
NSAIDs and kidneys
NSAIDs dec PG through inh of COX 1
-vasoconstriction on afferent arteriole and nada on efferent arteriole -> dec GFR
-can get kidney failure if chronic kidney dx, on vasopressors, or hypoTN b/c can’t get GFR high enough to perfuse
Cold ischemia times for transplant
Heart: 4-6
Liver: 6-10
Lungs: 4-6
Kidneys: 24
Causes of AG met acidosis
Methanol
Uremia
DKA
Propylene glycol
Isoniazid, Iron
Lactic Acidosis
Ethylene glycol, Ethanol
Salicylates (ASA)
Muddy brown casts in urine
Acute Tubular Necrosis
-usually ischemia and reperfusion injury
FENa equation
(UNa x PCr) / (UCr x PNa)
FENa prerenal cutoff
< 1%
Prerenal BUN: Cr ratio
> 20
UNa prerenal cutoff
<20
Uosm prerenal cutoff
> 400
Post TURP, awake, following commands, neuro intact, Na 131 what do you do?
Observation
-Its <5 from normal, pt neuro intact, they have normal kidneys so the body will appropriately correct
Post TURP pt confused, resp distress, and pts Na is 125, what do you do?
Fluid restrict and give IV loop diuretics
-If Na b/w 120-130
Post TURP pt confused, neuro not intact, hypoNa 118, what to do?
If Na < 120 -> give hypertonic saline, stop w/ saline once Na > 120
Inc conc of which solute in IVF is assoc w/ highest development of AKI in critically ill pts
Cl -> don’t use NS
Ataxic gait disturbance, AMS, and oculomotor dysfxn guy who smells like alcohol
Wernicke Encephalopathy
-Thiamine def
Lyte derangements in chronic alcoholics
-Low thiamine, pyridoxine, and folate
-AST> 2x ALT
-hypoglycemia -> give thiamine before glucose
-hypoCa (2/2 hypoMg can’t absorb Ca from kidney w/o Mg)
-hypoMg
-hypoPhos
Fresh Gas Flows and acutely intoxicated adults
Pt will exhale alcohol, acetone, carbon monoxide and methane
-So keep your FGF higher!! to prevent rebreathing
-FGF high in intoxicated, uncompensated DM, Carbon monoxide poisoning
Mivacurium metabolism
plasma cholinesterases
Pancuronium metabolism
primarily by kidney (80%) -> avoid in renal failure
Reversal of NMB and kidneys
Neo preliminarily limited by kidneys (50%) -> so sticks around to prevent recurarization
Treatment for AKI
No one way that works -> usually supportive and let it fix itself -> give HD or CCVH if it needs help along the way
-No pharmacologic benefit
-cessation of renal insult
Common ESRD labs
hyperK
hyperMg
hyperphos
hypoCa
anemia
HTN
2ndary hyperparathyroidism
immediately post-HD labs
HypoK more common -> most K is intracellular -> post HD hasn’t had time to re-equilibrize yet
inc PTT from heparin AC used during dialysis
RF for contrast induced nephropathy
pre-existing renal dysfunction
hypovolemia
admin of additional nephrotoxic meds
volume and type of contrast
Periop a fib RF
atrial injury
ischemia
inc catecholamines
hypervolemia or hypovolemia
lyte disturbances
Pt RF for a fib in postop period
male sex
advanced age
HTN
prev A fib
obesity
COPD
asthma
valvular issues
LA size
LVEF
Best way to prevent a fib in the periop period
pay attention to volume status!! -> one of the biggest influences
pre-emptive rate control w/ beta blockers -> also lowers catecholamine responses to surgical stress
Causes of metabolic alkalosis
GI losses: vomiting, NGT suctioning
Kidney losses: diuretics
Prevention of contrast induced nephropathy
only give contrast to those who need it
give IVF
Nephrogenic systemic fibrosis
gadolinium-induced contrast nephropathy in pts undergoing MRI
-MC in pts w/ kidney failure, liver transplant, hepatorenal syndrome, or acute inflammatory condition (sepsis)
Inc risk of periop resp complications in setting of URI
Reactive airway dx
Prematurity
Airway surgery
ETT if pt < 5
LMA insertion
copioius secretions and nasal congestion
2nd hand smoke
Breakdown of amino acids in body and issues w/ kidney and liver failure
Amino acids initially break down to ammonia -> the liver converts the ammonia to urea -> eliminated in the urine
-hepatic failure -> build up of ammonia -> asterixis and confusion w/ hepatic encephalopathy (inc ammonia)
-kidney failure -> build up of urea
Shift of the Hg curve for anemia
to the RIGHT
-inc in 2,3 biphosphoglycerate and tissue acidosis
Cryotherapy
relieving acute or chronic pain w/ cooling peripheral n to -50 to -70C
-induces axonal disintegration -> n disintegration lasting weeks to months
OSA and AHI indices
mild: 5-15
moderate: 15-20
severe > 30
lowest migration in CSF means
fastest uptake in the blood and tissues -> is the most lipophilic
ex: sufentanil in CSF
