Midterm Flashcards
What is the maximum amount of time a tourniquet should be used?
2 hours
Describe anesthesia management during endovascular aortic repair
can use general or regional, use A-line and carefully monitor u.o., maintain large bore IV access, may give heparin
What are anesthesia considerations for colonoscopies, EGD, and ERCP?
NPO, pre-emptive viscous lidocaine to decrease gag reflex, short acting sedatives (Versed, prop), may require glyco for upper endoscopy, possible vagal stimulation with colonoscopy
How does aging affect endocrine function?
decreased insulin secretion due to decreased beta cells, pheripheral insulin resistance, decreased hormone production
What considerations should you have with elderly and regional anesthesia?
less reliable epi test dose because of decreased end organ responsiveness
What are some congenital conditions associated with difficult airway?
Pierre Robin, Treacher Collins, Goldenhar, mucopolysaccharidosis, Klippel Feil, Down syndrome
Which lung does ventilation prefer when in lateral decubitus?
nondependent lung (perfusion favors dependent lung)
What is autonomic dysreflexia?
injury above T6, sudden sympathetic response to noxious stimuli such as a full bowel or bladder- severe HTN, sz, pulmonary edema, MI, ARI, intracranial hemorrhage
What are anesthetic management options for asthma?
assess severity pre-op and effectiveness of pharm treatment, continue antiinflammatory and bronchodilator therapy (stress dose steroids if treated with systemic steroids in last 6 months), propofol if stable, ketamine if unstable, sevo, IV or tracheal lidocaine, opioids to suppress cough, adequate hydration, extubate deep
How does aging affect the respiratory system?
decreased chest wall compliance, flattened diaphragm,, decreased elastic recoil but increased lung compliance, decreased O2 exchange, increased closing volume, decreased response to hypoxemia and hypercarbia, decreased laryngeal/pharyngeal support (airway obstruction), decreased cough/gag
What paralytic is preferred in older adults?
cisatracurium (Hoffman elimination and not organ dependent)
What is cystic fibrosis?
autosomal recessive disorder, characterized by decreased Cl (Na and H20) transport, thick secretions, scarring of glands and tissues
What are some concerns with kyphoscoliosis?
may have SC damage and respiratory dysfunction, respiratory alterations may occur when asleep, may have CV abnormalities (MVP most common), may have PH and RV hypertrophy
What does deflation of a tourniquet cause?
releases metabolic wastes into systemic circulation- metabolic acidosis, hyperkalemia, myoglobinemia, myoglobinuria, renal failure
What are some anesthetic management considerations with ARDS?
carefully manage vascular volume (avoid pulmonary edema), avoid air in vascular lines due to R to L shunt, assess for s/s of RV dysfunction, use PEEP, may prone, oscillation
What are some ways to extubate patients that are high risk for a failed airway?
extubate over FOB, extubate and follow with LMA, use AEC, leave ETT until all extubation criteria are met
What are some criteria for extubation?
optimized HD and labs, adequate muscle strength, positive reflexes, analgesia, VC at least 15 ml/kg, NIF -20, TV 4-5 ml/kg, spontaneous ventilation
What is neurogenic pulmonary edema?
massive outpour of sympathetic impulses that leads to vasoconstriction, shift of blood volume into pulmonary circulation
Describe the heat exchanger of CPB
stainless steel tubes filled with hot or cold water, blood flows around it (patient’s temp usually allowed to drop naturally but may use active cooling)
What provides sensory innervation of the airway above the vocal cords?
SLN, glossopharyngeal, trigeminal
Describe a glossopharyngeal block
blocks posterior 1/3 of tongue (lingual branch of glossopharyngeal), 2% lidocaine injected into “gutter” (posterior side under tongue), should not aspirate air or blood
What is used to monitor neuro function during aorta repair? How is the spine “protected”?
SEPs and EEGs (may not detect SC ischemia)- spinal cooling and drainage
What are some anesthesia considerations for hysteroscopy?
pretreat with NSAIDs, ensure negative pregnancy test, give pre-op anxiolytics, may do paracervical block
How does pulmonary edema look on CXR?
Kerley A lines (long, irregular lines from hila to periphery), Kerley B lines (short, horizontal lines at bases), Kerley C lines (reticular opacities at lung bases), peribronchial cuffing (doughnut densities), widened vascular pedicle
What drugs should you avoid during assisted reproductive technologies?
morphine (adverse effects), NSAIDs (inhibit prostaglandin synthesis and embryo implantation), sevo, des, droperidol, Reglan
What muscles abduct and adduct the VC?
Posterior CricoArytenoid (please come apart) Lateral CricoArytenoid (lets close airway)
What are signs of a tension pneumo?
hypotension, sub Q emphysema, unilateral breath sounds, tracheal shift, distended neck veins
What is anesthesia management like for aorta repair?
may use DLT to collapse lung for better exposure, use GA to decrease CMR, choose NMB based on renal function, use A-line and TEE, monitor u.o., may use epidural for post-op pain management, use a combination of balanced salt and colloid solutions (infused during clamp to increase volume reserve)
How do you pretreat patients with a high risk of contrast reaction?
steroids within 6 hours, benadryl
Where should the tip of your CVC be?
junction of the SVC and RA, 4 cm below the carina or 1-2 cm below the superior R heart border (tip should be slightly above the RA, NOT inside)
What are some anesthesia considerations with mediastinal masses?
extensive pre-op eval (flow volume loops, chest imaging, evaluation for compression), use FOB to check for obstruction, tumor may increase in size during anesthesia due to venous engorgement, use spontaneous ventilation whenever possible
What are airway exchange catheters? Are they capable of gas exchange?
used for interchanging ETTs or extubating; yes
What are some ABG findings you might see with asthma? What about CXR? EKG?
hypocarbia and alkalosis; hyperinflation and hilar vascular congestion; R heart strain during attack
What is ATLS Class III of shock?
blood loss 30-40%, HR >120, SBP decreased, PP decreased, RR 30-40, anxious/confused
Which population should you avoid doing a cricothyrotomy in?
young children under 12 (larynx small and pliable)
What is bronchiolitis obliterans?
disease of small airways and alveoli in childhood as result of RSV
What may happen if patients still have residual NMB? What should you give?
upper airway obstruction, hypoxemia, aspiration, muscle weakness; Sugammadex for roc and vec
What are some concerns with ankylosing spondylitis?
inflammation of spinal column and soft tissues, may have valve dysfunction, conduction delays, BBB, restrictive lung disease- may be on corticosteroids and NSAIDs
What is used to anticoagulate the patient during CPB and what are the lab parameters? How often should you check it?
heparin; should have ACT at least 400 (normal is 80-120)- check 3-5 minutes after heparin administration and q20-30 minutes after
What is pulmonary oxygen toxicity? What are predisposing factors?
prolonged use (>24 hours) of high FiO2 (>50%) causes excessive production of free O2 radicals that have toxic effect on cells and organelles- increased exposure, advanced age, radiation therapy, chemo
What is anesthesia management like for tracheal stenosis?
tracheal dilation with balloon dilators, may use helium to decrease density of gas and improve flow, may do translaryngeal endotracheal intubation
What are the 4 M’s in consideration for lung cancer patients?
mass effects, metabolic effects, metastases, meds
What drugs can cause cytotoxic drug induced pulmonary disease? What are s/s?
bleomycin, methotrexate- dyspnea, dry cough, fever, fatigue, malaise
How does aging affect the CNS?
loss of neurons and NT activity, decreased brain volume (esp gray matter and thalamus) and CSF, slower nerve conduction, increased sensitivity to anesthetic agents (increased POD), increased permeability of BBB, increased risk of neural damage with regional anesthetics
What is a risk of glossopharyngeal block?
intracarotid injection
What are indications for a cricothyrotomy?
failed airway, traumatic injuries where intubation is impossible, relief of upper airway obstruction, need for definitive airway for neck/facial surgery
Describe a SLN block
blocks supraglottic region, 2% lido injected into inferior border or greater cornu of hyoid, should not aspirate air or blood
When would you consider postponing outpatient surgery?
lack of med compliance (wide fluctuations in BP), did not fast appropriately, pregnancy, URI
Describe TRALI and its predisposing factors
acute onset of pulmonary infiltrates and hypoxemia from to blood transfusion due to neutrophils becoming trapped in pulmonary vasculature- recent surgery, malignancy, sepsis, alcoholism, liver disease
What is ATLS Class II of shock?
blood loss 15-30%, HR >100, SBP normal, PP decreased, RR 20-30, mildly anxious
What characteristics place patients at high risk for post-op delirium?
over 65/70, chronic cognitive decline, dementia, poor hearing/vision, infection, hip fracture, aortic and ortho procedures, depression, ETOH, pre-op narcotics
What are idiosyncratic reactions to contrast media?
ranges from urticaria to hypotension, laryngospasm- NOT allergic, history of asthma may predispose
Describe a transtracheal block
needle inserted through cricothyroid membrane into the tracheal lumen (SHOULD get air on aspiration), 2% lido injected on pt inspiration- pt will cough, anesthetizes cords
What is anesthesia management for bronchiectasis?
get extensive history and date of last exacerbation, delay elective procedures if active infection, may need DLT, avoid nasal intubation due to increased incidence of chronic sinusitis
What are some things you should monitor for during shoulder arthroscopy?
sub Q emphysema, tension pneumo, pneumomediastinum
What is Buerger’s and what are anesthesia considerations for it?
occlusion of small and medium vessels in extremities due to autoimmune response to tobacco- appropriate positioning and padding, keep warm, noninvasive BP monitoring, avoid using epi in LA
What are some anesthesia management considerations for cystic fibrosis?
optimize until adequate, give Vit K if hepatic function is poor, use high FiO2 and humidify it, frequent tracheal suctioning, adequate pain control for C&DB exercises
What are some ways to prevent aspiration?
NPO guidelines, pharm prophylaxis (antacids, PPIs, antiemetics), cricoid pressure, RSI if aspiration risk, ensure adequate reflexes prior to extubation
What is primary ciliary dyskinesia? What are its characteristics?
congenital impairment of ciliary activity; chronic sinusitis, recurrent respiratory infections, bronchiectasis, infertility
What is ATLS Class I of shock?
blood loss <15%, HR <100, normal SBP and PP, RR 14-20, slightly anxious
What does anesthesia look like for a PCI?
mild to deep sedation with analgesia, possible LA infiltration
What are s/s of TRALI? How is it treated?
PaO2/FiO2 <300, fever, chills, dyspnea, variable BP; supportive measures, stop transfusion, give fluids
When should you recommend smoking cessation?
minimum of 4 weeks pre-op
How do you manage autonomic dysreflexia?
remove noxious stimuli, admin nitrates, hydralazine, labetalol
What drugs can cause drug induced pulmonary edema?
opioids and cocaine
What are some considerations for the pre-bypass period?
anticoagulation, cannulation (arterial and venous), pull back PAC, TEE, supplemental meds (NMBs, anesthetics), inspect head and neck
Where should the lumens of a DLT be?
tracheal- terminates above carina
bronchial- angled to fit appropriate mainstem bronchus
What are the 5 components of CPB?
venous reservoir, main pump, oxygenator, heat exchanger, arterial filler
How do you alleviate tension pneumo?
large bore needle 2nd intercostal space midclavicular (4-5th midaxillary)
What is the treatment for bronchospasm?
100% FiO2, beta agonists, proventil inhaler, epi, steroids, aminophylline
What is a consideration with myasthenia gravis and NMBs?
resistant to succs, sensitive to nondepolarizing NMBs
What is asthma? What are its inflammatory mediators?
reversible airflow obstruction caused by bronchial hyperreactivity, constriction, and inflammation- histamine, prostaglandin D2, leukotrienes
What are some considerations about sizing and proper placement of LMAs?
black line should be near upper lip when properly placed, size is based on kg weight, intracuff pressure should not exceed 60 cmH20, avoid PIP of >20
What is considered the best imaging?
MRI
What are s/s of COPD?
DOE or DAR, chronic cough and sputum production, decreased breath sounds, expiratory wheeze, flattened diaphragm and bullae on CXR
What are some physiologic effects of CPB?
SIRS/stress response, ischemic cardiac injury, brain injury (type 1 death, type 2 declined intellectual function), atelectasis to ARDS, AKI, hypoperfusion of GI, impaired coagulation
How does aging affect body composition and thermoregulation?
decreased BMR, decreased blood volume, increased body fat, decreased TBW, impaired thermoregulation (decreased hypothalamus function, prone to hypothermia)
What are some anesthetic considerations with sarcoidosis?
give inhaled prostacyclin or sildenafil to decrease PH, anticipate difficult airway, may be on corticosteroids, methotrexate
What are risk factors for contrast induced nephropathy? What do you expect to see?
pre-existing renal insufficiency, DM, dehydration, CV disease, increased age and exposure to contrast agents within 24 hours; expect increased creat within 24 h, peaks within 4 days, returns to baseline within 7-10 days
What is atelectasis? What causes it?
collapse of pulmonary tissue that prevents alveolar exchange of O2 and CO2- compression of lung tissue, abscense of diaphragmatic induced negative pressure, impaired surfactant, absorption of O2 from N free alveoli
Where is a tracheotomy performed?
4th-6th tracheal ring
What are special considerations when doing prone spinal cases?
increased intraabdominal and thoracic pressure decreases venous return (decreased CO and increased SVR), prefer pressure control vs VC to avoid high PIP, maintain neutral head alignment
What is nuclear scintography used for?
perfusion and infarct scanning (lungs, heart, GI)
What are risk factors for POVL?
male, obesity, use of Wilson frame, anesthesia >6 hours, large blood loss, primary crystalloid replacement
How does atelectasis look on a CXR?
linear bands of opacity, focal patchy opacities, dense homogenous opacities
What is COPD?
irreversible progressive loss of alveolar tissue and progressive airflow obstruction (loss of elastic recoil)
What provides motor innervation to cricothyroid?
SLN
How do you ensure adequate perfusion to tissues distal to aortic clamp?
maintain proximal aortic pressure as high as heart can safely withstand (MAP near 100 above clamp, >50 distal)
What should you avoid using with thoracic trauma?
nitrous