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Anes Oral Boards > Memorize This > Flashcards

Memorize This Flashcards

1
Q

What are the five types of shock (at least one example of each)?

A

Think CHOND

1) Cardiogenic (MI, arrhythmia, CHF, acute valve issue)
2) Hypovolemic (Bleeding, adrenal insufficiency)
3) Obstructive (PE, tamponade, VAE, tension pneumothorax)
4) Neurogenic (spinal cord injury)
5) Distributive (Sepsis, anaphylaxis, adrenal crisis, liver disease)

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2
Q

Extubation Criteria? (10)

A

1) Awake/following commands
2) sedatives/gasses off or resvered
3) muscle relaxant reversed (TOF >0.9 with sustained tetany)
4) Head lift x5 seconds
5) hemodynamically stable
6) cough/gag/swallow reflexes intact
7) Tidal volumes of at least 5 mL/kg
8) ETCO2 at baseline
9) Negative inspiratory force at least -20
10) Respiratory Rate <30 (10-25)

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3
Q

What is the definition of aspiration? What does it result in?

A

Chemical pneumonitis that causes damage to surfactant-producing cells and the pulmonary capillary endothelium.
Results in atelectasis, wheezing, pulmonary edema, intrapulmonary shunting, and hypoxemia.

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4
Q

Immediate treatment of aspiration event? (7)

A

Head down position
suction oropharynx
intubate if hypoxic (if already intubated can add air to cuff)
Bronch to remove particulate matter (but not lavage)
Serial CXR and ABGs
Consider transfer to ICU and continued Intubation if hypoxemic

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5
Q

Ventilatory strategy for aspiration?

A

Pressure control, plateau pressures less than 30, target tidal volumes of 6 ml/kg
Permissive hypercapnia OK
PEEP
Low FiO2

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6
Q

Equation for expected PaO2 on Room Air?
Equation for expected PaO2 with supplemental O2?

A

Room air: PaO2 = 100 - (Age/3)
Supplemental O2 = 5 x FiO2 (ex 50% FiO2 would expect PaO2 of 250)

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7
Q

Normal A-a (Alveolar - arterial) gradient?
Age-adjusted estimate?

A

Usually 5-15, but increases with age
Age adjusted = 0.3xage

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8
Q

Equation for Partial pressure of alveolar oxygen (PAO2)

A

PAO2 = (FiO2 x (Patmos - PH20)) - (PaCo2/Q)

FiO2 = inspired O2 concentration, 0.21 at room air
Patmos = atmospheric pressure, 760mmHg at sea level
PH20 = vapor pressure of water, 47 mmHg at normal temp
PaCO2 = partial pressure of CO2, taken from ABG
Q = respiratory quotient, usually 0.8

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9
Q

Equation for minutes of O2 left in a cylinder?

A

Minutes left = PSI / (3 x flow rate in LPM)

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10
Q

Equation for Coronary perfusion pressure (CPP)?
Approximate normal CPP?

A

Coronary perfusion pressure = ADP - LVEDP

ADP = Aortic diastolic pressure, usually around 60-80
LVEDP = left ventricular end diastolic pressure , usually 5 - 10 ish

Normal CPP is approx 60-70 mmHg

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11
Q

Equation for maximum allowable blood loss?

A

MABL = EBV x [(Hgbi - Hgbt)/Hgbi]

MABL = Maximum allowable blood loss
EBV = estimated blood volume
Hgbi = starting hemoglobin
Hgbt = minimum hemoglobin

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12
Q

Risks of central line placement?

A

Bleeding
Infection
Injury to surrounding structures (pneumothorax, thoracic duct injury)
Air embolism

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13
Q

Risk of PA catheter placement?

A

Bleeding
Infection
Injury to surrounding structures ( PA rupture, valves)
Arrhythmia
Valve damage

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14
Q

Indications for PA line? (6)

A

1) Monitoring of cardiac indicies
2) High PVR (pulm HTN)
3) Severe CHF
4) Need for postop hemodynamic monitoring in the ICU
5) Unable to use a TEE
6) Patient refusal (of TEE?)

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15
Q

How would you evaluate fluid status?

A

History: complaining of thirst, orthostatic symptoms
Exam: skin turgor, chapped lips, cap refill, lung crackles
Vitals: Decreased urine output, hypotension, tachycardia, orthostatic BP, pulse pressure variation (if A-line), weight (CHF, ESRD)
Labs: Metabolic acidosis, hematocrit level (increased if hemoconcentrated), BUN:Cr >20

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16
Q

How do you evaluate a patient’s airway? (10 things)

A

1) History of past anesthetics/airway management
2) Teeth (chipped, missing, loose, long)
3) Inter-Incisor distance (mouth opening)
4) Palate (high arched, narrow, cleft)
5) Mallampati score (1-4)
6) Ability to prognath (cover upper lip with lower teeth)
7) TM Distance (<6cm)
8) Neck Girth (>17in or >43cm)
9) Neck length
10) Neck ROM

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17
Q

Risk factors for difficult mask ventilation?

A

OBESE
O = Obese, BMI > 26
B = Beard
E = Edentulous
S = Snoring (OSA)
E = Elderly (Age >55)

Also: Neck radiation, poor neck ROM, large neck, macroglossia, Mallampati 3-4, inability to prognath

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18
Q

Five causes of low mixed venous oxygen saturation (SV02)?

A

Hypoxemia
Low cardiac output
Anemia
Left shift of Hgb dissociation curve
Increased utilization of O2 by peripheral tissues (fever, seizures, shivering, hyperthyroid, pain)

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19
Q

Indications for dialysis?

A

“AEIOU”

A = Acidosis (pH <7.1)
E = Electrolytes (K >6.5)
I = Ingestions (toxins that can be dialyzed out, like lithium, salicylates, types of alcohols, etc.)
O = Overload (volume overload)
U = Uremia (uremic bleeding, pericarditis, encephalopathy)

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20
Q

Negative effects of hyperglycemia? (5)

A

Infection
Delayed wound healing
Neuronal injury/neuropathy
DKA
Dehydration (osmotic diuresis)

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21
Q

When to give stress dose steroids?

A

=> 20mg prednisone daily for 2 weeks or more

taking any dose with either a low AM cortisol level or hemodynamic instability intraop

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22
Q

What things will negatively impact neuromonitoring (MEP, SSEP) signals? (6)

A

Volatile anesthetics (esp. higher MAC levels)
Propofol boluses (temporarily decrease signals)
Hypothermia
Hypotension
Hypoxia
Acidosis

23
Q

What to do if get a decrease in neuromonitoring (MEPs, SSEPs) signals? (7)

A

Alert surgical team
Increase MAP
Ventilate with 100% O2
Correct acidosis
Switch to TIVA (If not already using)
Ensure normothermia
If using partial bypass, can ask perfusionist to increase flows

24
Q

Contraindications to MEPs? (3)

A

Cochlear Implant
Vascular clip
Active seizures

25
Q

Negative effects of hypothermia? (10)

A

1) Infection
2) delayed wound healing
3) impaired metabolism of meds
4) delayed emergence
5) Increased afterload on heart
6) arrhythmias
7) leftward shift of Hgb dissociation curve (less delivery of O2 to peripheral tissues)
8) Increased catecholamines/myocardial oxygen demand
9) Coagulopathy (impaired platelet function <37C, impaired coagulation factors <33C)
10) shivering increases O2 consumption and CO2 production, can lead to acidosis

26
Q

Indications for TPN? (3 categories, at least one example)

A

7 days of NPO

Cant take PO:
SBO
complete food intolerance
active GI bleed
IBD flare
pancreatitis

Can’t meet metabolic demands:
severe burns
premature babies with inadequate nutrition

27
Q

Complications of TPN? (7)

A
  1. Line infections
  2. Blood clots / thrombophlebitis
  3. Hypophosphatemia
  4. Hypercapnia (may need to adjust carbohydrate component of TPN)
  5. Vit. K depletion / coagulopathy
  6. cholestasis and steatosis
  7. hypoglycemia (if paused and insulin infusion continues)
28
Q

PFT cutoffs for Obstructive and Restrictive disease?

A

Obstructive:
FEV1/FVC < 70% predicted (mild)
FEV1/FVC <50% predicted (severe)

Restrictive:
FVC <80% predicted

29
Q

Treatment of acute hyperkalemia? (7)

A
  • Calcium (chloride 20mg/kg, gluconate 100mg/kg)
  • Insulin (0.1 U/kg) and Dextrose (0.5-1g/kg)
  • Albuterol
  • Hyperventilation (correct acidosis, shifts K+ into cells)
  • Lasix
  • Defibrillation pads
  • Dialysis
    +/- Kayexalate (slow, questionable benefit)
30
Q

EKG changes associated with hyperkalemia (in order of occurrence)?

A

1) Peaked T-waves
2) Prolonged PR segment
3) Loss of P waves
4) Prolonged QRS complex
5) ST elevation
6) Sine wave
7) V-fib and then asystole

31
Q

Ventilator high pressure alarm differential? (4 + 7)

A

High peak inspiratory pressure (resistance problem) vs. high plateau pressures (compliance problem)

High PiP (resistance):
- Kinked ETT
- Mucous Plug
- bronchospasm
- Foreign body

High Plateau Pressure (compliance):
- Fibrosis
- Pneumonia
- Pulmonary edema
- Mainstem intubation
- atelectasis
- Tension Pneumothorax
- Increased abdominal pressure (ascites, pneumoperitoneum, etc.)

32
Q

Differential for intraop hypoxia? (7)

A
  • Low FiO2
  • Inadequate ventilation (ETT disconnect, ventilator settings changed, ventilator malfunction)
  • Diffusion impairment (gas cannot be exchanged, like with pulm edema)
  • V/Q mismatch (PE, low cardiac output/failure, atelectasis, ARDS, Pneumonia, etc.)
  • Shunt (kinked ETT, mucous plug, atelectasis, mainstem intubation, aspiration)
  • Anemia
    Artifact
33
Q

Differential for PACU hypoxia or dyspnea ? (Start at head and go down, 12)

A
  • Sedated (too much narcotics, possibly given by RN)
  • Inadequate reversal of neuromuscular blockade
  • Airway edema
  • laryngospasm
  • recurrent laryngeal nerve injury (if applicable for surg)
  • fluid overload/pulm edema
  • mucous plug
  • PE
  • pneumothorax (if central line placed)
  • Anaphylaxis
  • MI, possibly causing cardiogenic shock
  • Procedural (expanding neck hematoma, nerve injury, etc.)
34
Q

Differential for delayed emergence from anesthesia?

A

“TEAR It Up”

Temperature
Electrolytes and glucose
Acid/base (esp. CO2 narcosis)
Residual volatile, NMB, etc.

Intracranial - Hemorrhage, ischemia, mass lesion, post-ictal

Undiagnosed underlying neuromuscular disease

35
Q

How to evaluate delayed emergence in the PACU?

A

BMP, ABG, temperature, TOF, naloxone, +/- flumazenil (if benzos given), CT head, EEG (for seizures)

36
Q

Neuroleptic malignant syndrome (NMS) vs. Serotonin syndrome: similarities and differences?

A

Similarities:
Fever, AMS, rigidity. Both can present postop

Differences:
Serotonin syndrome: hyperreactivity (tremor, clonus, hyperreflexes), GI symptoms can be present (nausea/vomiting, diarrhea). Tx = benzos, cyproheptadine

NMS: “lead pipe” rigidity, decreased reflexes, no GI symptoms. Tx = benzos, bromocriptine

37
Q

Differential for postop (PACU) fever? (With rigidity 3 vs without rigidity 9)

A

With rigidity: Malignant hyperthermia (MH), Serotonin syndrome (SS), Neuroleptic malignant syndrome (NMS)

Without rigidity: Sepsis/SIRS response, thyroid storm, anticholinergic syndrome, delirium tremens/alcohol withdrawal, atelectasis, PE, adrenal insufficiency, drug fever, transfusion-related (if blood products given)

38
Q

Rate of local anesthetic uptake based on location?

A

Fastest to slowest:

Intravenous
Tracheal
Intercostal
Caudal
Paracervical
Epidural
Brachial plexus
Sciatic / Femoral
Subcutaneous

Tumescent is least

39
Q

For local anesthetics, what factors contribute to the potency, duration of action, and speed of onset?

A

Potency: Lipid solubility
Duration of action: Protein binding
Speed of onset: lower pKa, higher concentration of drug

40
Q

Postop vision loss: Differential? (8)

A
  • Posterior ischemic optic neuropathy (PION)
  • Anterior ischemic optic neuropathy (AION)
  • Central retinal artery occlusion (CRAO)
  • Cortical blindness
  • Corneal abrasion
  • Acute Glaucoma
  • glycine toxicity (associated with TURP/cysto fluid)
  • Hemorrhagic retinopathy
41
Q

Posterior ischemic optic neuropathy (PION): What causes it and how to diagnose?

A
  • Caused by venous congestion
  • Sudden painless vision loss, can be unilateral of bilateral, pupillary defect, PALE OPTIC DISC
42
Q

Anterior ischemic optic neuropathy (AION): what causes it and how to diagnose

A
  • Caused by inflammation and/or thrombosis/emboli
  • Usually painless vision loss, can be unilateral or bilateral, with optic disc edema

Think: A and E are both vowels, AION, edema, emboli.

43
Q

Central retinal artery occlusion (CRAO):
what causes it (3) and how to diagnose?

A
  • blockage of central retinal artery. Caused by embolism, hemorrhage, or external eye compression
  • sudden painless UNILATERAL vision loss. “Cherry Red Macula”
44
Q

Cortical blindness: What causes it and how to diagnose?

A
  • Caused by ischemia to the visual cortex or afferent pathways. Usually from emboli, severe hypotension, acute anemia, hypoxia,
  • Painless vision loss, but normal pupillary reactions
  • Normal fundoscopic exam
45
Q

Risk factors for Ischemic optic neuropathy? (7)

A
  • relative hypotension
  • significant blood loss
  • longer anesthetic/surgery
  • type of surgery. (AION a/w cardiac, PION a/w spine)
  • Positioning (Prone, steep Trendelenberg)
  • Obesity
  • Male gender
46
Q

Differential diagnosis for postop hoarseness ( 4+1) and typical timing for each?

A
  • Nerve injury (immediate). Unilateral RNL will cause hoarseness, bilateral RNL causes stridor on inspiration)
  • Airway edema (fast, within a few hours of surgery). Steroids and time will help
  • Hematoma (usually takes hours to build up, may have associated airway edema)
  • hypocalcemia (usually 24 - 96 hours after thyroidectomy removal, from loss of parathyroids), also a/w muscle spasms, long QT, prolonged QRS

***“Tiring voice/vocal fatigue” with “breathy voice/change in pitch” can be due to SUPERIOR LARYNGEAL NERVE (SLN) injury causing dysfunction of CRICOTHYROID muscle

47
Q

How do you deliver jet ventilation?
Settings for adult vs. child?

A

Position the suspension laryngoscope with attached jet ventilator needle.
Initiate jet ventilation with an inspiratory time of less than one second and a pressure of 5-10 PSI (Child) or 15-25 PSI (adult) and titrate upwards until adequate chest rise and fall is noted.

48
Q

Potential complications of jet ventilation? (7)
Complications of supraglottic jet ventilation? (3)

A

Pneumothorax
pneumomediastinum
pneumoperitoneum
Pneumopericardium
SubQ emphysema
Inadequate gas exchange (hypercarbia / hypoxia)
Aspiration of resected debris

For supraglottic jet ventilation:
risks of gastric distention regurgitation
gastric rupture

49
Q

Treatment for laryngospasm? (6 steps)

A

1) Call for assistance
2) suction any oral secretions/material
3) Perform Larson’s maneuver (jaw thrust and firm pressure at ascending ramus of mandible)
4) Initiate gentle PPV to splint open airway
5) attempt to blunt the exaggerated glottic closure reflex by deepening the anesthetic or giving IV lidocaine
6) If all else fails, can give paralytic (sux)

50
Q

Treatment of malignant hyperthermia (MH)? (8 steps)

A

1) Call for help
2) Administer 2.5 mg/kg dantrolene (can repeat q5-10 minutes until symptoms improve)
3) Hyperventilate with 100% oxygen
4) initiate active cooling measures
5) Maintain urine output with fluids, lasix, mannitol
6) Prepare to treat hyperkalemia, acidosis, hyperthermia, rhabdomyolysis, and dysrhythmias as needed
7) Continue Dantrolene 1mg/kg q6 hrs for 24-48 hours
8) Monitor patient for up to 72 hours in ICU

51
Q

What are the components of the MELD score?

A

Serum bilirubin, serum creatinine, and INR.

52
Q

Signs/symptoms of citrate toxicity / hypocalcemia while under anesthesia? (7)

A

1) Hypotension
2) Narrow pulse pressure
3) Prolonged QT interval
4) Widened QRS complex
5) Flattening of T-Waves
6) Elevated intraventricular end-diastolic pressure
7) Elevated CVP

53
Q

What are the steps of Quality Improvement / Practice-based learning? (5)

A

1) measure
2) Devise change (get input of all shareholders)
3) educate/train
4) implement
5) measure again - if you get expected change, good. If not, then re-evaluate/consider why and come up with new plan

Anes Oral Boards (3 decks)

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