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Master List Flashcards

1
Q

complications of celiac plexus block

A

Most serious = paralysis: d/t spread of neurolytic agent into spinal or epidural space, or damage to blood supply of spinal cord
MC: postural hypoT
Accidental intravascular injection, retroperitoneal hemorrhage

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2
Q

issues seen with obesity

A
  • Difficult airway
  • Increased risk of aspiration
  • Bronchospasm
  • Labile BPs
  • Hyper/hypoglycemia
  • Decreased FRC = rapid desat with apnea
  • Undiagnosed OSA, obesity hypoventilation

Other issues for obese pts in general: DM2, HTN, CAD, CVA, DVT/PE, NASH, altered drug effects

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3
Q

allowable blood loss equation

A

Allowable blood loss = EBV x (Hi - Hf)/Hi

Preemie: 95 mL/kg; FT neonate: 85 mL/kg; infants: 80 mL/kg
Adult men: 75 mL/kg; adult women: 65 mL/kg

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4
Q

most to least systemic absorption of local

A

IV > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > sciatic > subcutaneous

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5
Q

Define: variable bypass vaporizer

A

variable amt of gas is directed into a vaporizing chamber where it mixes with volatile, and then returns to mix with the rest of carrier gas that was directed to bypass the chamber

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6
Q

What happens if you put iso in sevo vaporizer?

A

overdose: If fill vaporizer with agent having higher vapor pressure (iso in sevo container), delivered concentration is higher than expected

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7
Q

Vapor pressure of iso, sevo, des

A

Des (681) > iso (240) > sevo (160)

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8
Q

concerns for MRI anes

A
  • bringing in magnetic things
  • equip malfunction
  • issues with implantable devices
  • burns
  • temp/permanent hearing loss
  • kidney damage (nephrogenic systemic fibrosis)
  • anxiety
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9
Q

interscalene complications

A

Ipsilateral diaphragmatic paralysis (may be bad in someone with severe lung dz)
Horner’s (ipsilat myosis, ptosis, anhidrosis)
LAST
Pneumo
Neuraxial blockade
Nerve injury
Hematoma formation
Severe hypoT/brady: 2/2 Bezold-Jarisch reflex (occurs when decreased venous return to heart => reduced sympathetic tone, enhanced parasympathetic tone)

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10
Q

pathophys and s/sx of aspiration pneumonitis

A

Aspiration of gastric material => damage to surfactant-producing cells and pulmonary capillary endothelium => atelectasis, pulm edema, alveolar hemorrhage, pulm HTN (2/2 hypoxic pulmonary vasoC)

s/sx: arterial hypoxemia, tachypnea, wheezing, tachy, coughing, cyanosis, bronchospasm

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11
Q

What pathways to these test:

  • PTT
  • PT
A 
PTT = common and intrinsic
PT = common and extrinsic
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12
Q

Systemic effects of liver dz

A

vasodilated state:
Pulm: intrapulmonary shunts, reduced FRC, restrictive lung dz, pleural effusions, attenuation of hypoxic pulm vasoC

Cerebral: accumulation of ammonia/other toxins => encephalopathy

CV: decreased SVR, increased CO, cardiomyopathy

Heme: thrombocytopenia, clotting factor deficiencies => coagulopathy

Metabolic: dilutional hypoNa, hypoK, hypoglycemia, hypoalbuminemia

Various: portal HTN, varices, delayed gastric emptying, ascites, HRS

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13
Q

Presentation of cyanide tox, tx

A

Cyanide toxicity: metabolic acidosis + increased venous O2 content + arrhythmias + tachyphylaxis; risk is minimal if stay below doses 0.5 mg/kg/hr

Treatment: discontinue, 100% FiO2; sodium thiosulfate, amyl nitrate, sodium nitrate, or hydroxycobalamin

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14
Q

What happens to nitroprusside?

A

Nitroprusside enters RBC => nonenzymatic rxn releases nitric oxide + forms cyanide ions

Possible routes for cyanide ions:

1) React with methemoglobin => cyanmetHgb
2) React with thiosulfate => thiocyanate
3) Bind to tissue cytochrome oxidase, which impairs normal tissue O2 utilization; this causes cyanide toxicity

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15
Q

What leads are best for:

  • arrhythmia
  • ischemia
A

V5 = ischemia

lead II = arrhythmia

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16
Q

Causes of postop vision loss

A

AION = MC with cardiac (anterior part of body)
PION = MC with spine (posterior part of body); normal-appearing optic disc
-both likely 2/2 impaired O2 delivery (hypoxia, hypoT); painless; poor prognosis

CRAO = painful, unilat, 2/2 compression

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17
Q

Risk factors for PION, prevention

A

surgery >6.5 hrs
substantial blood loss
spine surg

head in neutral forward position
watch BP closely with a-line
consider CVP monitoring
monitor H/H: goal 9/28%
consider staged surg
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18
Q

bone cement implantation syndrome

A

Signs/sx: hypoT, hypoxia, dysrhythmias, pulm HTN, decreased CO, possibly arrest

occurs during rodding of femoral shaft while using methyl methacryalte

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19
Q

Anaphylaxis vs anaphylactoid

A

clinically identical

anaphylaxis is IgE antibody-mediated, so requires sensitization; anaphylactoid is due to direct antigen-binding

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20
Q

tx anaphylaxis

A

epi = key

  • alpha: causes vasoC, which improves hypoT
  • beta: causes bronchodilation

antihistamines: benadryl, pepcid
albuterol

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21
Q

s/sx fat embolism syndrome

A

hypoxia + elevated PA pressures + decr CI + petechiae; in pt with long bone fx

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22
Q

vWF purpose

A
  • Plt adhesion to subendothelial surface of blood vessels
  • Facilitates plt-to-plt aggregation
  • carrier protein/stabilizer for factor VIII
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23
Q

Actions if can’t ventilate after tubing pt with mediastinal mass

A
  • try to advance tip of ETT past obstruction, or rigid bronch
  • turn pt lateral or prone
  • initiate CPB
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24
Q

citrate tox s/sx

A

hypoT

increased CVP, narrow pulse pressure, prolonged QT, flattened T waves, widened QRS, and increased LV end-diastolic pressure

usually after multiple transfusions

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25
Q

how to do needle thoracostomy

A

angiocatheter into 2nd intercostal space at midclavicular line

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26
Q

causes of hypoT intra/postop

A 
Shock: hemorrhagic, neurogenic, cardiogenic
Hypovolemia
Allergic reaction/anaphylaxis 
Vagal response
Tension pneumo
Hypothermia
Tamponade
Too much anes
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27
Q

s/sx significant hypoNa

A

n/v, fatigue, confusion, anorexia, restlessness, weakness, mental status changes
Severe (<120): cerebral edema, sz, coma, brain stem herniation, arrest

Hyponatremia < 130 = at risk for cerebral edema

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28
Q

c-spine clearance requirements

A 
Absence of cervical pain or tenderness
Absence of paresthesias or neuro deficits
Normal mental status
No distracting pain
Age >4 years
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29
Q

stridor causes

A
  • Laryngospasm
  • Mass obstruction from lung ca or hematoma
  • Recurrent laryngeal n injury: obstruction d/t unopposed tension of vocal cords by cricothyroid muscle

Others: incomplete reversal, allergic rxn, narcosis, tracheomalacia, airway edema

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30
Q

mgmt of intraop desat

A 
100% FiO2 and hand-ventilate
Listen
Ensure proper ETT placement
Check airway pressures
Check circuit/machine
Level out if in Trendelenburg
Beta-2 agonist like albuterol
If all else seems fine, would adjust vent settings, try to optimize PEEP
Expiratory wheezing + desat = bronchospasm
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31
Q

mgmt of intraop desat during OLV

A
  • 100% FiO2, confirm proper placement (capnogram, auscultation, direct confirmation with fiberoptic scope), check a-line/EKG for adequate perfusion
  • If due to R-to-L shunting from collapsed lung, can apply CPAP (10 cm H2O) to nonventilated lung after slightly expanding it; if this is OK for surgical field

-If no improvement or not surgically acceptable, apply PEEP to ventilated lung
This could result in pressure-induced shunting of blood to nondependent lung and therefore worsen PaO2

If nothing works, come back on 2-lung ventilation and discuss with surgeon the possibility of ligating PA to eliminate the shunt

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32
Q

MC surgeries with intraop awareness

A

CBP, trauma, obstetric surg

TIVA

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33
Q

mgmt of intraop awareness

A

Discuss that this is rare and poorly understood, and empathize with patient

Explain what measures we took to make sure that didn’t happen

Arrange counseling if needed

Fully document this incident

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34
Q

Fluids used for TURPs

A

Ideal: nonhemolytic, isotonic, electrically inert, nontoxic, clear for visualization, inexpensive, minimal metabolism/rapid excretion if absorbed

Hypotonic fluids = hemolysis

Balanced solutions (like LR) can interfere with cautery, placing surgeon/pt at risk for burns

Glycine: hyperglycinemia, hyperammonemia, transient blindness

Sorbitol: hyperglycemia

Don’t use distilled water now: hypotonic

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35
Q

definition: dibucaine #

A

used to dx pseudochol deficiency; % that dibucaine inhibits hydrolysis of benzoylcholine by pseudocholinesterase

Dibucaine inhibits pseudocholinesterase activity of normal pts by 80%; higher dibucaine # = more normal pseudochol
Normal = 80%
Heterozygote = 40 - 60%
Homozygote = 20% or less

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36
Q

issues caused by hypothermia

A

Coagulopathy
Dysrhythmias
Poor wound healing, infection

Theoretically mild hypothermia reduces CMRO2 by 7% per deg C below 36, but not proven to help after TBI

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37
Q

ddx delayed awakening

A

Any anes: prolonged NMB, residual anes, acid-base issues, lyte imbalance, hypoglycemia, hypothermia

Neuro: hematoma, tension pneumocephalus, cerebral edema, sz, CVA
Can still have tension pneumocephalus without nitrous use: air is moving over surface of brain and can get trapped in upper cranium

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38
Q

risk factors for intraop nerve injury

A
  • Male
  • Hosp stay >14 days
  • Intraop hypoT
  • Hx vasc dz, HTN, DM2, smoking
  • Very thin or obese body habitus
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39
Q

renal dz systemic fx

A

CV: HTN, CAD, HF, arrhythmias

Pulm: pulm edema (2/2 volume overload)

GI: delayed gastric emptying, anorexia

Endo: insulin resistance

Neuro: CVD, periph/autonomic neuropathy

Metabolic: hyperK, hyperMg, hypoNa, hypoCa, hypoalbuminemia, uric acid accumulation, metabolic acidosis

Heme: anemia, impaired plt fxn

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40
Q

AFOI steps

A

1) Aspiration ppx: metoclopramide to facilitate gastric emptying, glyco to dry upper airway secretions
2) Place appropriate monitors (including art line)
3) Ensure presence of difficult airway equip
4) Adequate analgesia: nebulized lidocaine, peripheral blockade of superior laryngeal n, recurrent laryngeal n
5) Preoxygenate in 30 deg reverse T
6) Fiberoptic intubation with minimal sedation while pt remains spontaneous
7) Verify ETT placement and then induce

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41
Q

RSI steps

A

Ensure appropriate airway equip available
IV lidocaine and narcotics to blunt sympathetic response, reduce risk of bronchospasm
Reverse trendelenburg (improved resp mechanics, facilitates intubation, reduces risk of passive regurg)
Apply cricoid pressure
Perform RSI with (insert induction agent and paralytic of choice here)

Roc: 1.2 mg/kg IBW is the RSI dose

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42
Q

how to do cricothyroidotomy

A

1) pass needle thru cricothyroid membrane until air aspirated => pass wire thru needle
2) Skin incision next to wire
3) Advance tracheostomy or ETT over wire into airway
4) Confirm ventilation after airway in place

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43
Q

mechanism of PEEP

A

recruits atelectatic, fluid-filled alveoli, which decreases intrapulmonary shunting and possibly increasing compliance

Moves fluid in the lungs to areas where gas exchange is not taking place

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44
Q

issues with jet vent

A

Misalignment of gas jet to glottic inlet = poor ventilation, gastric distention
Transmission of blood, smoke, debris (and virus) to distal airways
Excessive vocal cord vibration
Barotrauma: pneumo, subq emphysema, pneumomediastinum

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45
Q

mgmt airway fire

A

Immediately alert OR, disconnect circuit from airway, remove ETT
If flames persist, flood surgical field with saline
Once fire is out, ventilate with 100% FiO2 and perform DL with rigid bronch to evaluate airway and remove any debris
Consider bronchial lavage and fiberoptic assessment of distal airways
Reintubate and leave intubated for minimum of 24 hrs
Risk of delayed airway edema
CXR, consider brief course of high-dose steroids, pulm consult

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46
Q

anes concerns with lithium

A

Toxicity: muscle weakness, cognitive changes (sedation), ataxia, widened QRS, AV block, hypoT, sz

Avoid drugs that can lead to tox: thiazides, NSAIDs, ACEi

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47
Q

how to prep machine for MH

A

Physically disengage vaporizers, or lock/put tape over them
Replace anes circuit and CO2 absorbent
Flush with 10L/min of O2 for at least 10 mins (newer machines might need longer)
Ensure presence of ice, appropriate monitors, adequate supply of dantrolene

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48
Q

MH s/sx

A

rigidity, tachypnea, BP changes, arrhythmias, incr temp, periph mottling, rhabdo, sweating, cyanosis

If concerned, get ABG: decreased PO2, metabolic and resp acidosis

check for hyperK, hyperCa, myoglobinemia, elevated serum CK

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49
Q

MH mgmt

A

Call for help, MH hotline

Dantrolene 2.5 mg/kg bolus, then continue 1 mg/kg every 6 hrs for 24-48 hrs

Cool pt to goal 38 - 38.5: ice packs, cold IVFs, peritoneal lavage, CPB

Monitor UOP, K, Ca, serum CK, LFTs, coag
Treat hyperK, hyperthermia, acidosis, rhabdo (mannitol), dysrhythmias

Send to ICU for up to 72 hrs to monitor for DIC, myoglobinuric renal failure, relapse

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50
Q

intralipid dosing

A

bolus 1.5 ml/kg of 20% intralipid over 1st minute, followed by 0.25 ml/kg/min infusion

repeat bolus and double infusion rate if sz/arrhythmia persist

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51
Q

dantrolene dosing

A

rapid bolus of 2.5 mg/kg, then continue 1 mg/kg q6h for 24-48 hrs

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52
Q

dx pheo

A

Most reliable = measurement of plasma-free metanephrines

Others: urinary vanillylmandelic acid (VMA)

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53
Q

s/sx pheo

A

HTN - continuous or paroxysmal
HA, palpitations, sweating
Catechol-induced cardiomyopathy or HF (decreased energy)
Stroke, MI, sugar intolerance, acute renal failure

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54
Q

drugs to manage pheo

A

Prazosin or phenoxybenzamine: alpha-blockade BEFORE beta-blockade

If you beta-block, you can get unopposed alpha action, which translates to unopposed vasoconstriction => HTNsive crisis, HF

Optimal duration of alpha-blockade before surgery: at least 10-14 days (time to stabilize BP and normalize intravasc vol)

Phenoxybenzamine: Irreversible antagonist of a1>a2 receptors
Phentolamine: reversible antagonist of a1=a2 Rs
Alpha-2 antagonism can cause +inotropic/chronotropic effect

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55
Q

drugs to avoid with pheo

A

Those that directly stimulate tumor cells: metoclopramide, sux, histamine-releasing drugs like morphine, atracurium

Those that cause increased sympathetic activity: atropine, ephedrine, ketamine, pancuronium

Those that sensitize myocardium to catechol (halothane)

Droperidol: assoc w/ significant hypertensive response in pheo pts

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56
Q

2 hrs postop, pt develops barking cough + inspiratory stridor = ?

Tx?

A

post-extubation croup: 2/2 glottic or tracheal edema formation

risk factors: traumatic intubation, too-tight ETT, prolonged intubation, head/neck surg, intraop changes in child’s positioning, small larynx, hx croup, coughing with ETT in place

tx: nebulized racemic epi, IV steroids

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57
Q

type and screen vs. type and cross

A

Type and screen = mixes recipient plasma with panel of commercial RBCs to detect presence of various known antibodies
Advantage: IDs rare antibodies

Type and cross = mixes recipient plasma with donor RBCs to detect incompatibility with specific unit to be given

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58
Q

hemolytic transfusion rxn

A

hematuria + hypoT + tachy shortly after admin of blood; MCC ABO incompatibility (clerical error)

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59
Q

neuraxial OK with MS?

A

yes, but epidural > spinal (also prefer lower conc of local in epidural)

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60
Q

pathophys of myasthenia gravis

A

Autoimmune dz of NMJ; post-synaptic AChRs at endplates of affected muscles are destroyed or inactivated => weakness, easy fatigability

Improves with rest

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61
Q

s/sx with myasthenia

A

ocular involvement (ptosis, diplopia)
dysarthria
difficulty chewing and swallowing inability to effectively clear secretions difficulty breathing, pulm aspiration

tx = anticholinesterase drugs, immunosuppressive drugs, thymectomy

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62
Q

Avoid metaclopramide in setting of ______

A

pheo

SBO

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63
Q

s/sx PE

A

Dyspnea, tachypnea
HypoT, tachy
Hypoxemia

Others: cough, hemoptysis, fever, accentuated or split 2nd heart sound, pleuritic CP, rales, hypoxemia, JVD, hemodynamic instability, palpitations

EKG changes: new RBBB, ST-T wave changes, peaked P waves, R-axis deviation, T-wave inversion

64
Q

definition: carcinoid syndrome

A

constellation of sx 2/2 carcinoid tumor releasing excessive amt of circulating hormones like histamine, serotonin, and bradykinin

Flushing, diarrhea, bronchoconstriction, R-sided heart dz (serotonin-induced plaques on valves), HTN
Valve prob = tricuspid regurg > pulm regurg > tricuspid/pulm stenosis)

65
Q

dx carcinoid syndrome

A

24hr urinary 5-HIAA level

octreoscan, CT/PET scan

66
Q

pre-pneumonectomy eval of pulm fxn

A

three-legged stool:

1) Resp mechanics, as determined by FEV1 and ppoFEV1
2) Cardio-pulm reserve: VO2 max, stair climbing, or 6 min walk test
3) Lung parenchymal fxn: DLCO

Main thing to look at is ppoFEV1%: <40% means high risk R heart failure following pneumonectomy
Order V/Q scan (helps assess preop contribution of lung to be resected), get echo (at higher risk for RV failure)

67
Q

normal parts of CVP waveform

A

A wave = atrial contraction; end diastole

C wave = elevation of MV; early systole

X descent = downward displacement of atrium during ventricular ctxn; mid-systole

V wave = venous return against closed mitral valve; late systole

Y descent = decline in atrial pressure as MV opens; early diastole

68
Q

centrifugal vs roller pumps

A

Roller pump: forward flow produced with partial compression of tubing by 2 roller heads
Not sensitive to preload/afterload, can deliver pulsatile flow, reliably produces certain amt of flow based on pump speed
Cons: more damage to RBCs, keeps going if lots of air entrained, risk of over-pressurization (tubing can sep or rupture), preload occlusion can cause negative pressure-induced cavitation

Centrifugal pump: forward flow produced by rotational force
Less damaging to RBCs
Stop functioning if large amt of air is entrained
Sensitive to changes in preload/afterload
Con: incapable of delivering pulsatile flow

69
Q

____ = only intervention that both reduces myocardial O2 demand, while also increasing myocardial O2 supply

A

IABP

70
Q

How to position/time IABP

A

Positioning: tip is at junction of aortic arch and descending aorta

Synchronize with cardiac cycle: use either arterial waveform or electrocardiographic QRS complex

Timed so that balloon inflation occurs with aortic valve closure: occur at start of diastole

71
Q

I would not place a PAC in pt with (what pathology)?

A

mitral stenosis and tricuspid regurg

inaccurate data associated with this + difficulty of passing catheter thru regurgitant tricuspid

72
Q

____: midsystolic crescendo-decrescendo murmur best heard over R upper sternal border

A

Aortic stenosis

73
Q

____: midsystolic click and loud systolic ejection murmur

A

MVP

74
Q

____: rumbling diastolic murmur best heard at apex

A

MS

75
Q

___: pansystolic murmur best heard at L sternal border

A

tricuspid regurg

76
Q

Ddx hypoT just after CBP initiation

A

MCC: hemodilution, sudden decrease in SVR that occurs with injection of priming solution

Others: monitor malfunction, anes-induced decr in vasc tone, pump malfunction, inadequate venous return to pump, aortic dissection, kinking/clamping of arterial cannula

Malpositioning of arterial cannula = unilat face blanching, R-sided mydriasis, chemosis

77
Q

checklist for weaning off CBP

A

Normothermia
Correct any anemia, lyte/metabolic issues
Turn monitors back on
Check lung compliance and begin ventilation again
Make sure heart is de-aired
Assess cardiac function using TEE/PAC, use inotropes/vasodilators as needed
Make sure pacing device, resuscitation drugs are available
Give benzo/propofol during rewarming to prevent awareness
Check UOP

78
Q

types of protamine rxns

A

Type I = pharmacologic
Histamine-induced venoD, decr SVR, reduced preload

Type II = immunologic
IIA: anaphylactic (antibody-mediated)
IIB: anaphylactoid (not antibody-mediated)
IIC: delayed anaphylactoid; noncardiogenici pulm edema

Type III = catastrophic pulm HTN d/t TXA2 released by protamine-heparin complex

79
Q

what is Beck’s triad (cardiac)?

A

hypoT + JVD +muffled heart sounds = tamponade

pulsus paradoxus: exaggerated BP variation with resp cycle (BP drops more than usually with inspiration)

80
Q

anes goals for tamponade mgmt

A

keep spontaneous; keep full, fast, and tight (maintain SVR, BP)

ketamine is good; try to just use local until pressure around heart relieved

81
Q

criteria for severity of AS: severe, critical

A

Severe: valve area 0.7 - 1, mean transvalv gradient 40 - 50

Critical: valve area <0.7, mean transvalv. gradient >50

82
Q

anes goals with severe AS

A

slow, full

don’t significantly drop SVR (e.g. spinal)

83
Q

What will magnet do to AICD

A

will NOT turn off automatic pacing fxn of ICD

84
Q

Mgmt of CIED preop

A

Identify and call person who manages this pt’s device:
Indication for placement
Model and type
Whether pt is pacemaker-dependent
Programmed pacing mode and any special prog
Behavior of device when magneted
Number, types, and ages of leads (more likely to be dislodged if placed <3 months prev)
Battery status

85
Q

Cautery issues with CIED

A

can cause inhibition of pacing function, reprogramming of ICD, triggering of tachydysrhythmia tx, microshock, internal damage to device

Recommend ultrasonic harmonic scalpel or bipolar electrocautery forceps

keep grounding pad as far away from device as possible

magnet if surgery is not >6” away (below diaphgram)

86
Q

failure to capture

A

2/2 lead failure or myocardial changes that lengthen refractory period or incr energy needed to achieve depolarization; brady + hypotensive

87
Q

aortic aneurysm types

A

Debakey:

  • Type 1: ascending aorta and extending distally to abd aorta
  • Type 2: starting in ascending aorta and don’t extend beyond innominate artery

Stanford:
Type A = all dissections involving ascending aorta
Type B = all dissections not involving asc aorta

BB before nitroprusside: otherwise shear forces might cause rupture

88
Q

mgmt vtach on EKG

A

If unstable: start chest compressions, cardiovert with biphasic defib

If stable with HR >150: no compressions, still cardiovert and then amiodarone

If stable with HR <150, give amiodarone

89
Q

Ddx if ACT still low post-heparin

A 
wrong med/dose
infiltration of IV
ACT machine malfunction
heparin resistance (d/t ATIII deficiency; tx FFP)
90
Q

what needs IE abx ppx?

A

Prosthetic valve
Previous endocarditis hx
Unrepaired congenital cyanotic dz
6 month postop period after repaired congenital heart defect
Repaired congenital heart defect with residual defect
Cardiac transplant pts with cardiac valvulopathy

91
Q

what pathology is seen with HOCM?

A

LVH, systolic anterior movement of mitral valve (SAM), dynamic LVOT obstruction, decreased LV cavity size, diastolic dysfunction, arrhythmias

EKG changes: LVH, LA enlargement, high QRS voltage, ST- and T-wave changes, abnormal Q waves

92
Q

what makes HOCM worse?

A

hypovolemia, sympathectomy and/or vasoD, increased contractility, sympathetic stimulation (tachy, incr inotropy), dysrhythmia, too much PPV/PEEP, inadequate L uterine displacement

93
Q

Cushing’s triad

A

HTN
brady
change in resp pattern

94
Q

formula for CPP; normal value

A

CPP = MAP - ICP (or CVP, whatever is higher)

normal: 70-80

95
Q

ways to decrease ICP

A

Hyperventilation to EtCO2 25-30

Ensure no venous obstruction, e.g. c-collar too tight

HOB 15-30 degrees (if tolerated)

Mannitol (may worsen cerebral edema if BBB not intact)

Lasix

Barbiturate: reduces ICP (vasoC), reduces CMRO2

Ask surgeon to consider ventriculostomy (drainage of CSF, means of ICP measurement)

If tumor, steroids: stabilizes cap membranes around tumor

96
Q

SIADH vs CSWS

A

both = hypoNa

CSWS = hypovolemic; urine Na >100

SIADH = euvolemic, urine Na usually <100; tx water restriction + diuresis

97
Q

tx cerebral vasospasm

A

triple H therapy: hypervolemia, HTN, hemodilution

98
Q

mgmt VAE

A

Immediately have surgeon flood the field with saline
Stop any nitrous if you are using this, give 100% O2
Try to aspirate air thru CVC if one is present
Direct jugular venous compression to incr venous pressure at surgical site
Supportive care with vasoC, inotropes, etc

Tx bronchospasm with beta-2 adrenergic agonists
Reflex bronchospasm can happen with air entry into pulm artery

99
Q

what is diabetes insipidus

A

affects ~40% of pts after pit surg; marked impairment in renal concentrating ability 2/2 decreased ADH secretion

Lots of urine despite rising serum Na

100
Q

tx DI

A

fluid replacement

Replace urinary loss of hypo-osmolar, low Na fluids with ½ NS at rate equal to hourly maintenance + ⅔ of previous hour’s UOP

101
Q

(good) mag fx

A

sz ppx

may decrease SVR, increase ureteroplacental perfusion

102
Q

safe mag goal

A

Goal: 4-6 mEq/L

watch for: loss of patellar reflexes, visual changes, muscle weakness, somnolence

Tx for too much = Ca

103
Q

AFE s/sx

A

Early phase: pulm HTN (2/2 pulm vasospasm), hypoT (RHF), hypoxia (V/Q mismatch), sz, cardiac arrest

Second phase: LV failure, pulm edema, coagulopathy

104
Q

tx postpartum hemorrhage

A

MCC: uterine atony
Manual compression
Oxytocin, hemabate, methergen: cause contraction of myometrial smooth muscle by increasing intracellular Ca
Hemabate = avoid in asthmatics, can cause bronchospasm; IM
Methergine = avoid in preE/hypertensive pts, can cause HTN; IM
Oxytocin can give as IV bolus, give in dilute solution (20u in 1L); hypoT/tachy
Bacri balloon, B-lynch suture
Ligation of internal iliac a, uterine a, ovarian a
Emergent hyst = ultimate tx

105
Q

blocks for labor

A

Paracervical - 1st stage
Rarely performed 2/2 high risk of fetal bradycardia, decreased uteroplacental perfusion

Pudendal - 2nd stage
Less common complications: intravasc injxn, retroperitoneal hematoma, retropsoas/subgluteal abscess
Can work for 1st stage if coupled with other means of analgesia

106
Q

s/sx PDPH

A 
Fronto-occipital HA
Decreased pain with recumbent position
N/v
Neck stiffness
Photophobia, diplopia
Cranial nerve palsies (d/t stretching)
Hearing loss (hair cell position changes)
Rare = sz (due to cerebral vasospasm)
107
Q

tx PDPH

A

Most effective tx = epidural blood patch; injection of 15-20 mL of her blood into epidural space
However, can’t do this if pt on anticoag

Conservative: hydration, caffeine, placement of abd binder, pain control

Tell her they’re self-limited and almost always resolve within 1 week

108
Q

what happens to PDA after birth?

A

when ventilation begins, arterial O2 levels increase + pulm vasc resistance drops.
The increased O2 results in functional closure of PDA; permanent closure over a few months

Hypoxic infants: lungs don’t make enough bradykinin to induce closure

109
Q

how to monitor for PDA ligation surg

A

BP on R arm, SpO2 on R hand + on lower limb

110
Q

risk factors for postop apnea (peds)

A

<50 weeks postconceptual age

Low birth weight, hx chronic lung dz, hx apnea/brady, multiple congenital anomalies, sepsis, anemia

need to monitor 12-24 hrs

111
Q

criteria indicating staged closure for omphalocele

A

Intragastric/intravesicular pressure >20
Peak inspiratory pressure >35
EtCO2 >50

112
Q

MC type of TEF

A

type C: esoph atresia, blind upper pouch, lower segment tracheal fistula

113
Q

cyanotic congenital heart diseases

A 
Truncus arteriosis (1 trunk)
Transposition of great vessels (2 great vessels)
Tricuspid atresia (tri = 3)
Tetralogy of Fallot (tetra = 4)
TAPVR (5 letters)
114
Q

ToF constellation

A

VSD
RVOT
Overriding aorta
RVH

115
Q

Why do tet spells happen?

A

Paroxysmal spells of hypercyanosis due to increased R-to-L shunting

Sudden increase in PVR, dynamic outflow obstruction of RV, or decrease in SVR

116
Q

issues with proceeding w/ surgery with current/recent URI

A

Risks of proceeding with current/recent URI = increased risk of periop resp complications
Laryngospasm, bronchospasm, desaturation

Risk is higher with severe sx, requirement of GA, requirement of ETT, and other risk factors like asthma/reactive airway dz

117
Q

how to intubate foreign body aspiration (peds)

A

I would choose to induce and keep spontaneous, vs. RSI for full stomach

PPV can 1) push the foreign body further down, 2) cause hyperinflation or pneumo, and 3) foreign body produces ball-valve effect

Use O2 and sevo

118
Q

causes of neonatal sz

A 
ICH
hypoxic-ischemic encephalopathy
cerebral edema
hypoglycemia, hypoCa, hypoMag
benign sz
OB history of TORCH (toxo, rubella, CMV, herpes), sepsis
119
Q

omphalocele vs gastroschisis

A

Omphalocele: gut fails to return to abd cavity during gestation
At base of umbilicus (midline), has memb covering; normally fxn bowel; often IS associated with other congenital defects
Diaphragmatic hernia, trisomy 21, bladder exstrophy, cardiac abnorm

Gastroschisis: occlusion of omphalomesenteric artery
Lateral to umbilicus; exposed viscera/intestines; functionally abnormal bowel; less likely assoc w/ congenital abnormalities

120
Q

mgmt peds SVT

A

Peds SVT: HR >180, absent/abnormal P waves

Supplemental O2, attempt to convert with vagal maneuver (ice to face)
IV access and give 0.1 mg/kg of adenosine: interrupts any reentry circuit involving the AV node (usual cause of SVT in kids)
IO if can’t get IV quickly

If persistent or recurred: successive doses of 0.2 and 0.4 mg/kg every 1-2 mins as needed
Can’t get IV, HR jumps to 260 and pressure drops
SVT + hemodynamic instability = immediate synchronized cardioversion, starting at 0.5 J/kg and doubling energy dose as required up to 2J/kg
While this is being prepared, secure airway, apply 100% FiO2, try to get IV/IO access

121
Q

tx thyroid storm

A

Tylenol, cooling measures
Titrate in BB to control tachy (esmolol, propranolol)
Ensure adequate intravasc volume, nml lytes
PTU, sodium iodide, and hydrocortisone = reduce circulating levels of active thyroid hormone
Consider giving catechol-depleting agent, like reserpine

122
Q

MH vs NMS

A

Thyroid storm vs MH vs NMS: all with tachy, hypertherm, mental status changes

MH and NMS = metabolic acidosis, hypercarbia, musc rigidity
Not seen in thyroid storm

Hard to distinguish between MH and NMS in this pt who has received triggering agent and receiving meds that could lead to dopamine depletion

NMS usually has slower progression to critical temp and multisystem organ failure
Non-depolarizing NMBs will produce flaccid paralysis in NMS, but not in pts with MH

If can’t distinguish between MH and NMS: treat with dantrolene, intubate pt (with nontriggering agent), hyperventilate
Consider bromocriptine (often used to tx NMS)
123
Q

substances from anterior pit

A

ACTH stimulates adrenal cortex secretion
Prl: secretion of breast milk, inhibits ovulation
FSH: ovarian follicle growth, spermatogenesis
LH: ovulation in females, testosterone secretion
HGH
TSH

124
Q

substances from posterior pit

A

ADH: promotes water retention, reg plasma osmolarity
Oxytocin: uterine ctx, ejection of breast milk

125
Q

possible meds to tx pit tumors

A

Bromocriptine: synthetic dopamine-2 R agonist; inhibits secretion of both growth hormone and prolactin; can cause gastroparesis

Octreotide: somatostatin analogue; inhibits release of growth hormone

126
Q

Dx ARDS

A

Acute onset
Bilat infiltrates on CXR
PaO2:FiO2 ratio <200
PAOP <18, or no clinical evidence of cardiac cause

127
Q

definition and Dx: DIC

A

pathologic activation of coagulation cascade associated with several conditions (burns, head trauma, preE); widespread formation of small clots in blood vessels throughout body => consumption of coag factors, thrombocytopenia, hemolysis, diffuse bleeding, thromboembolic phenomena

increased PT/PTT, fibrinogen <100, thrombocytopenia, decreased antithrombin III levels, presence of FDPs and D-dimer

128
Q

complications of TPN

A

Fatty liver
Venous thrombosis 2/2 fat infusion
Cholecystitis 2/2 inactive GI system
Metabolic issues: hypoK, hypophos, hypomag, hypo/hypergly, acidosis/alkalosis, hypo/hyperCa, hypercarbia
Catheter placement: infxn/sepsis, pneumo, arterial puncture

129
Q

complications of bicarb

A

Generation of additional CO2 (bicarb + H ions = CO2) => diffuse into cells, causing worsening intracellular acidosis

Left-shift of oxyHgb dissociation curve (impaired tissue delivery)

Hyperosmolar state 2/2 excess sodium load

Hypokalemia 2/2 movement from extracellular => intracellular compartment

130
Q

CRPS types

A

Type 1 = minor injury; crush, lacs, fx, surgery, sprains, burns

Type 2 = nerve injury; sx not necessarily limited to distribution of that nerve

131
Q

CRPS dx

A

initiating noxious event, followed by burning pain, allodynia or hyperalgesia out of proportion to degree of injury, edema, cutaneous vasomotor instability, sweating

132
Q

how to do superior laryngeal n block

A

sensation to the laryngeal structures above the vocal cords; located inferior to the greater cornu of the hyoid bone

needle inserted lateral to hyoid bone, directed toward greater cornu => walk off inferiorly, inject 2cc of 2% lido here

make sure to aspirate (carotid nearby)

133
Q

extubation criteria

A 
awake pt with intact airway reflexes
muscle relaxant fully reversed
appropriate Vt and RR on min. settings
adequate oxygenation, normocarbia
HDS

VC > 10cc/kg, Vt > 6cc/kg, NIF > 20 cmH20

134
Q

postop jaundice ddx

A

prehepatic = hemolysis, hematoma breakdown

intrahepatic = TPN, hypoxia, ischemia, drugs, new viral hepatitis, sepsis
-drugs = inhaled anes, abx

posthepatic = obstruction of biliary tree
-stones, strictures, abd surg trauma

MCC = 1) hematoma breakdown, 2) hemolysis after transfusion

135
Q

Dx VAE

A

Precordial doppler mill wheel murmur + EtCO2 monitoring drop
-left or right parasternal, between 2nd and 3rd ribs

Most sensitive = TEE

PA pressure will also rise

136
Q

epidural dosing

A

thoracic: ropi 0.2% or bupi 0.125%, start 4 mL/hr
lumbar: can do a little higher rate
can combine with narcs, esp if concerned with BP

137
Q

Benefits of circle system

A

Low fresh gas flow requirements

Conservation of heat, humidity, and volatile

Minimal environmental pollution

shorter, narrower-caliber tubing and Y-pieces help to minimize compliance and dead space in peds circuits

138
Q

Which mitral pathology is better tolerated in preg?

A

Mitral regurg > mitral stenosis

Gradient worsens as CO incr; need more time for diastolic filling, so avoid tachy

Would be OK with a controlled epidural; avoid spinal in MS (vasoD => reflex tachy)

139
Q

Pt with mitral stenosis needs c/s, what’s your plan?

A

Assuming no contraindications to neuraxial, would prefer carefully dosed epidural > GA.

GA is potentially fine if blunt sympathetic stim to laryngoscopy with narcs/lido/BBs. Would have to be deep enough to avoid tachy/HTN, so potentially could use remi instead of higher doses of volatile. Also could use a TEE.

Would think carefully about placing PAC unless she had something like pulm HTN as well as the MS

140
Q

Goal level for c/s

A

T4

141
Q

Why is 5 lead better than 3?

A

Better ST monitoring

142
Q

Cancer pain mgmt?

A

Follow the WHO Analgesic Ladder, initially starts with non-opioid therapies like Tylenol

143
Q

What happens when put magnet on ICD?

A

Anti-tachyarrhythmia detection is suspended, but not pacing

144
Q

Physiologic changes in preg

A 
Increased CO (incr HR, incr SV)
Decr FRC, incr RR and Vt => resp alkalosis
Rightward shift of oxyHgb dissoc curve
50% incr in plasma volume, dilutional anemia
Incr most coag factors = hypercoag state
Incr renal blood flow (incr GFR)
Decr MAC requirements
Incr upper airway edema
145
Q

synchronized cardioversion doses

A

Narrow reg: 50-100J
Narrow irreg: 120-200 biphasic or 200J monophasic
Wide reg: 100J
Wide irreg: unsynchronized reg defib dose

146
Q

defibrillation dose

A

unsychronized shock at 200J vs 360J

shockable rhythms: pulseless Vtach or Vfib (both wide complex); polymorphic wide complex

147
Q

Issues with brachial art line

A

Median nerve injury
Ischemia 2/2 lack of collateral flow

All: thrombosis, infection

148
Q

Pros/cons of iso

A

Pro: minimal cardiac depression
-CO maintained by rise in HR

Con: high blood and lipid solubility = slower onset/emergence

  • may produce tachycardia
  • risk of coronary steal syndrome
149
Q

Myxedema coma presentation/tx

A 
Confusion, lethargy
Loss of DTRs
Hypothermia, hypoventilation
Hyponatremia
Hemodynamic instability
Coma, death

Admit to ICU
IV levothyroxine, symptomatic tx
IV hydrocortisone 100 mg, then 25 mg q6h

150
Q

preggo with dyspnea, chest pain; diastolic murmur

EKG with LA enlargement, paroxysmal atrial tach

A

mitral stenosis

151
Q

Preferred anes for c/s in:
AS
MS

A

both = epidural (slow titration)

152
Q 
Hemodynamic goals for each lesion:
AS
AI
MS
MR
A

AS: HR slow/baseline, adequate fluids, normal rhythm; don’t drop afterload (depend on this for coronary perfusion)

AI: slight tachy, careful with fluids; mild afterload reduction is good (promotes fwd flow)

MS: HR goal 70-90 (like AS); need adequate preload; fixed lesion so don’t drop afterload

MR: slight tachy, mild afterload reduction is good

153
Q

tx negative pressure pulm edema

A

Supportive resp care, supplemental O2
Trial of CPAP (NPPV)
Reintubate if severe, PEEP
Consider albuterol, diuretics

154
Q

Heparin dosing

ACT goal for bypass

A

Heparin dose: 3-4 units/kg

ACT goal: >300

155
Q

Protamine dosing

A

Protamine dose = 1 mg per 100u heparin

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