Midterm Review Flashcards
What type of immunity is this?—antibodies given to provide protection via transfusion
Passive immunity
How long does passive immunity last?
Hours to weeks
What type of immunity is this?—takes minutes or hours; macrophages, neutrophils, basophils, eosinophils; several processes to destroy bacteria [integument, phagocytosis, killer T cells]
Innate immunity
What type of immunity is this?—destruction of toxins by antibodies and specific lymphocytes
Acquired (adaptive) immunity
How long does it take for acquired/adaptive immunity to take effect?
Takes days for the body to respond
In acquired/adaptive immunity, no ___ immunity exists
Innate
Antigen + B lymphocyte = ___; called ___, has ___
Antibodies; called immunoglobulin; has memory
The humoral branch of the immune system consists of ___ lymphocytes; these originate in the ___ and ___ cells
B lymphocytes; originate in the bone marrow and plasma cells
The cell-mediated branch of the immune system consists of ___ lymphocytes; these originate in the ___ and mature in ___
T lymphocytes; originate in the bone marrow and mature in the thymus
Vaccination produces ___ immunity
Acquired/adaptive immunity
What type of immunity is this?—a person who has survived disease gives antibodies to someone who hasn’t been exposed
Humoral immunity
What type of immunity is this?—acquired through T cells from someone who is immune to the target disease or infection; response is carried out by cytotoxic cells
Cell-mediated immunity
Vaccines are an example of ___ immunity
Acquired/adaptive immunity—pathogen is deliberately administered for the purpose of stimulating the immune system
Protection from passive immunity is ___ but ___ lived
Immediate but short-lived
IgA given to the fetus via mom’s breast milk is an example of ___ immunity
Passive immunity
IgG given to the fetus via the placenta from mom is an example of ___ immunity
Passive immunity
Rh immune globulin (RhoGAM) given to Rh negative mothers to prevent their immune system from developing antibodies to a fetal Rh antigen (fetus with Rh + blood) is an example of ___ immunity
Passive
Neutrophils, basophils, and eosinophils are all types of ___
Granulocytes
What is the most numerous granulocyte/WBC?
Neutrophils
What is the least common granulocyte?
Basophils
What type of granulocyte is involved with hypersensitivity reactions; releases histamine, leukotrienes, cytokines, and prostaglandins; and stimulates smooth muscle contraction (resulting in bronchospasm)?
Basophils* LEAST common granulocyte!
What type of granulocyte is heavy in GI tract mucosa?
Eosinophils
Monocytes and lymphocytes are two types of ___
Agranulocytes
B lymphocytes are involved in ___ immunity and produce ___
Humoral immunity; produce antibodies
T lymphocytes are involved in ___ immunity and do not produce ___
Cell-mediated immunity; do NOT produce antibodies
Inflammation results in ___ (increased/decreased) blood flow, vaso___, ___ (increased/decreased) capillary permeability, ___ of plasma proteins, ___ to the site of injury
Increased blood flow, vasodilation, increased capillary permeability, extravasated of plasma proteins, leukocytes to the site of injury
Antibodies are also called ___
Immunoglobulins (Ig)
In an allergic reaction, antibodies attach to ___ cells and ___phils; causes the release of ___ and other substances causing urticaria, hay-fever like symptoms
Mast cells and basophils; causes the release of histamine and other substances
What are 4 types of allergic reactions?
Types I-IV
Type I allergic reaction
Anaphylaxis, IgE-mediated
Type II allergic reaction
Cytotoxic (think blood transfusion reactions)
Type III allergic reaction
Immune complex (i.e.: SLE, rheumatoid arthritis)
Type IV allergic reaction
Delayed sensitivity (i.e.: contact dermatitis)
What is the main difference between anaphylaxis/anaphylactoid reactions?
Anaphylactoid reaction does NOT rely on IgE-mediated response…anaphylaxis does
Are anaphylaxis/anaphylactoid reactions distinguishable from one another?
NO!
Anaphylactoid reaction may occur with first exposure—T/F?
TRUE
Anaphylactoid reaction is generally dependent on systemic exposure/amount greater than for anaphylaxis—T/F?
True
What drug is the most common cause of anaphylaxis in the OR?
Muscle relaxants—rocuronium!
What other drugs may cause anaphylactic reactions in the OR?
Latex»_space; antibiotics»_space; opioids
What food allergies may be associated with latex allergy?
mango, kiwi, passion fruit, banana, avocado, chestnut
Latex can cause type I or type IV allergic reaction—T/F?
True
Anesthesia enhances the immune system—T/F?
False—anesthesia depresses the immune system
Surgical site infections occur at or near incision within ___ days to ___ year from implant
30 days to 1 year
___ immune system is activated during surgery
Innate
___glycemia and ___thermia are associated with surgical site infections
Hyperglycemia and hypothermia
Blood transfusion is associated with enhancement or depression of the immune system; ___ (increased/decreased) risk of SSI
Depression of immune system; increased risk of SSI
HIV/AIDS is transmitted through ___
Blood or body fluids
What is one major anesthetic concern in patients with HIV/AIDS?
Patients on NNRTI therapy—CYP450 inducer…so they will need HIGHER doses of medications
Patients with HIV/AIDS—abnormal EKG in ___%, pericardial effusion in ___%
Abnormal EKG in 50%, pericardial effusion in 25%
What is the most common opportunistic pathogen that causes pneumonia and is responsible for most deaths of HIV/AIDS patients?
Pneumocystic carinii
What is the most common method of HIV/AIDS exposure to healthcare workers?
Open bore needles
What is the most common cause of death in patients with SLE?
Renal disease
Patients with SLE are at ___ (higher/lower) risk for seizures, stroke, dementia, neuorpathy, psychosis, pericardial effusion
HIGHER
Treatment for SLE (3):
- Corticosteroids
- Antimalarial
- Immunosuppressants
What are (5) major anesthesia complications in patients with SLE?—prone to ___, ___itis, ___ hemorrhage, ___ HTN, ___ disease
Prone to PE, pneumonitis, alveolar hemorrhage, pulmonary HTN, restrictive disease
How does cyclophosphamide (a medication that may be given to a patient with SLE) affect anesthesia?—cyclophosphamide inhibits ___
Cyclophosphamide INHIBITS plasma cholinesterase, which could prolong the activity of ester local anesthetics and succinylcholine
1/3 of SLE patients have ___ arthritis and ___ palsy
Cricoartyenoid arthritis and RLN palsy (caution when intubating)
Scleroderma is a ___ disease that leads to fibrosis of ___ and ___
Collagen vascular disease that leads to fibrosis of skin and organs
Anesthetic implications for patients with scleroderma—may require ___ intubation, may have ___ in airway, chronic ___ (think BP), ___ (think GI disease), ___ abrasion, ___ HTN
Fiber optic intubation, may have bleeding in airway, chronic HTN, GERD, corneal abrasion, pulmonary HTN
Scleroderma patients—___ anesthesia offers advantage of peripheral ___ and post-op pain control
Regional anesthesia offers advantage of peripheral vasodilation and post-op pain control
Treatment of rheumatoid arthritis includes what (4) meds:
- Corticosteroids
- Methotrexate
- Immunosuppressants
- NSAIDs
Anesthesia considerations for RA patients—___ supplementation intraop; patient is likely taking ___s and ___mide—plasma cholinesterase inhibitor
Steroid supplementation intraop; patient is likely taking NSAIDs and cyclophosphamide—plasma cholinesterase inhibitor (will affect metabolism of succs/ester locals)
Airway for RA patients—neck ___ restriction, A-O ___, small ___ opening, swelling of ___ joints
Neck extension restriction, A-O subluxation (dislocation), small mouth opening, swelling of laryngeal joints
Consider ___ or ___ intubation of RA patients
Glidescope or fiberoptic intubation
Urologic endoscopy is performed to visualize/evaluate the ___ and ___ urinary tracts
Upper and lower
Ureter and kidney make up the ___ urinary tract
Upper
Bladder, prostate, and urethra make up the ___ urinary tract
Lower
What position are urologic procedures done in?
Lithotomy position
What is a major concern with the lithotomy position?
Nerve injuries!
What nerve is injured from compression of fibular head (outer knee) on leg brace?
Common peroneal nerve
What nerve is injured from compression of medial tibial condyle (inner knee)?
Saphenous nerve
What nerve is injured from excessive external rotation of legs and/or excessive extension of the knees?
Sciatic nerve
What two nerves are injured from excessive flexion of the groin?
Obturator and femoral nerves
___ of blood occurs in lithotomy position, so you will see an immediate pressure drop when the legs are put down
Pooling
The obturator reflex results in bladder ___ secondary to adductor muscle contraction from obturator nerve stimulation from cautery
Bladder rupture/injury
Risk of the obturator reflex is increased when resecting ___ tumors
Lateral wall
Cystoscopy is passage of a rigid scope through the ___
Urethra
If using regional anesthesia during cystoscopy, what sensory level block is required?
T9-T10 sensory level is required
What level block is required for ureters?
T8
Transurethral resection of the bladder (TURBT) is done to treat ___
Superficial bladder tumors
What type of anesthesia is usually used during TURBT procedure?
General
What is the benefit of using general anesthesia for TURBT?
Inhibits coughing/straining, which could cause bladder perforation
If using regional anesthesia for TURBT, the bladder becomes ___ and may become ___ when distended, ___ (increasing/decreasing) the risk for perforation
Atonic (no tone) and may become thinner when distending, increasing the risk for perforation
Why is regional anesthesia preferred for TURBT (even though general is typically used)?
With regional, patient is awake so they can report symptoms of discomfort sooner
If bladder perforation occurs, ___ discomfort, ___, and ___ may occur in the awake patient
Shoulder discomfort, nausea, and vomiting may occur
If high grade malignancy is present and bladder is perforated, then there is risk for ___ into the peritoneum
Seeding into the peritoneum (aka malignant cancer spreads into the peritoneal cavity)
Bladder perforation—awake patient will experience ___ fullness, abdominal ___, and ___
Suprapubic fullness, abdominal spasm, and pain
What are two EARLY signs of bladder perforation in the anesthetized patient?—___tension and ___cardia
Hypertension and tachycardia
What is a LATE sign of bladder perforation in the anesthetized patient?
Severe hypotension
Cool irrigation used during TURBT causes vaso___ and systemic ___
Vasoconstriction and systemic cooling (hypothermia)
Bladder perforation—what is triggered by release of prostatic thrombogenic substances, especially with cancer of prostate?
DIC
If bladder perforation occurs, convert to ___ procedure
Open procedure
Transurethral resection of the prostate (TURP)—hemostasis is achieved by sealing the vessels with the ___ current
Coagulation current
TURP—an optically clear, nonconductive, nonhemolytic, nontoxic solution is required to ___ the bladder
Distend
TURP is done under ___ anesthesia
General
TURP—general anesthesia is used because ___ must be avoided because it increases the risk of bleeding
Coughing
Even though general anesthesia is often used for TURP, spinal anesthesia is preferred because awake patients may supply early detection of ___
Awake patients may supply early detection of complications
What are two possible complications of TURP?—___ loss and ___ of irrigation fluid
Blood loss and venous absorption of irrigation fluid
TURP—what are (4) early signs of venous absorption of irrigation fluid? ___tension, ___cardia, ___nea, ___ea
- Hypertension
- Tachycardia
- Dyspnea
- Nausea
What is TURP syndrome?
Water intoxication/glycine toxicity—bladder irrigation goes from the venous system to the entire body
What (2) things cause TURP syndrome?
Hypoxia and hyponatremia
What are (4) neurological signs of TURP syndrome?
- Apprehension
- Disorientation
- Convulsions
- Coma
What are (3) irrigating solutions used for TURP?
- Glycine (1.5%)
- Sorbitol (3.3%)
- Mannitol (5%)
What irrigating solution has less incidence of TURP syndrome but can cause transient post-op visual impairment?
Glycine
What irrigating solution can cause hyperglycemia and lactic acidosis?
Sorbitol
What irrigating solution causes osmotic diuresis, leading to hypervolemia? (not hypovolemia, as you might think)
Mannitol—as it is being used for bladder irrigation, it pulls fluid in, leading to a hypervolemic effect
When TURP syndrome occurs, what is the first thing you should do?
Ask the surgeon to control the bleeding and finish the surgery
TURP syndrome—if Na is less than ___, it’s SERIOUS
< 120
TURP syndrome—hypervolemia and hyponatremia need to be corrected with fluid ___ and ___
Fluid restrictions and diuretics (lasix 10-20 mg IVP)
TURP syndrome—to treat hyponatremia (that results from water intoxication), can give ___ solutions cautiously
Hypertonic (i.e.: 3% NS)
Postpone surgery if Na is < ___
125 meq/L
Resection of prostate (simple prostatectomy is removal of some prostate tissue, radical prostatectomy is removal of entire prostate)—we use ___ robot on these; patient is in ___ position; watch ___; can get ___; keep patient ___tensive
We use DaVinci robot on these; patient is in trendelenburg position; watch BP; can get retinal neuropathy; keep patient normotensive
Two approaches for prostatectomy—___pubic (___pubic) approach or ___ approach
Suprapubic/retropubic approach—patient is supine/trendelenburg (incision made through abdomen)
Perineal approach—patient is in extreme lithotomy position
Prostatectomy—more hemorrhage occurs with ___ approach
Retropubic approach
Prostatectomy—___ is a must!
Large IV—have blood ready
50% of prostatectomy cases will cause ___
Impotence
___ can occur d/t low pressures during prostatectomy
Retinal neuropathy
Prostatectomy—treat low pressures ___
Agressively!!!
Prostatectomy—methylene blue used to identify ureters can cause ___tension and ___saturation
Hypotension and desaturation
Methylene blue used during prostatectomy—sat will drop to ___ for ___ minutes
65% for 1-2 minutes
Indigo carmine dye 0.8% used for prostatectomy has an ___ effect, will ___ (increase/decrease) BP
Alpha sympathomimetic effect, will increase BP
Nephrectomy is performed in lateral ___ position or anterior ___ incision
Lateral retroperitoneal position or anterior abdominal incision
If in lateral retroperitoneal position for nephrectomy, will use ___ bar, which can cause vena cava ___ and ___tension
Will use kidney bar, which can cause vena cava compression and hypotension
Goal for renal transplant patients—___ prior to transplant! Make sure serum K is ___ and metabolic ___ is corrected
Optimize prior to transplant! Make sure serum K is normal and metabolic acidosis is corrected
___ is common in renal transplant patients
Anemia
Renal transplant—positioned supine with ___ under hip
Roll
IV access for renal transplant patients—do NOT use ___ side!
Fistula side
Renal transplant—for induction of general anesthesia, do NOT give ___ (which induction agent?)
Succs—it can cause hyperkalemia
For induction of general anesthesia for renal transplant patients, use ___curium or ___curium d/t ___ elimination
Atracurium or cisatracurium d/t Hoffman elimination—drug is metabolized into laudanosine metabolite, which is safe in hepatic/renal patients
IVF for renal transplant patients—use ___, not ___
Use NS, not LR (contains K+)
Adequate ___ is critical for renal transplant patients—use crystalloid, colloid, and blood for revascularization of kidney
Hydration
Renal transplant patients—___ and ___ help to discourage rejection and encourage diuresis, respectively
Methylprednisolone and diuretics
Renal transplant patients—low dose ___ used if patient is oliguric
Low dose dopamine
Preservation of donor kidney—___ degrees C is goal to reduce metabolic demand and provide nutrients to maintain metabolic activity
4 degrees C
Preservation of donor kidney—cold storage ___ hours before necrosis jeopardizes graft survival
48 hours
Radical cystectomy = removal of ___
Bladder
Anesthetic considerations for radical cystectomy—fluid shifting can be extensive and you are unable to monitor ___ output, so need to monitor ___ to assess patient’s fluid status
Unable to monitor urine output, so need to monitor CVP to assess patient’s fluid status
Complications of radical cystectomy—___thermia (because open belly case), inadequate ___ replacement (because you can’t monitor urine output, using CVP for monitoring)
Hypothermia, inadequate fluid replacement
What procedure is this?—moving undescended testicle into scrotum and permanently fixing it there
Orchidopexy
What procedure is this?—testicular removal done after testicular torsion (usually occurs in kids, testicle becomes necrotic, kid will be sterilized and not be able to reproduce)
Ochiectomy
What level block is needed for ochidopexy/ochiectomy?
T9 sensory block
Extracorporeal shock wave lithotripsy (ESWL) is used to break upper urinary tract ___ with external ___
Used to break upper urinary tract stones with external shock waves
ESWL—shock delivery is triggered by ___ wave
QRS wave
Shock waves in ESWL are usually timed to occur 20 milliseconds after the ___ wave [QUIZ QUESTION!!!]
R wave
What is the most common cause of occlusive disease in the lower extremity?
Peripheral vascular disease
What are top (3) risk factors associated with development of atherosclerotic disease?
- Cigarette smoking
- Diabetes mellitus
- Gender (male > female)
Other risk factors [that are pretty obvious]: hypercholesterolemia, elevated triglycerides, HTN, obesity, genetic predisposition
What are two interesting risk factors for development of atherosclerotic disease?—Elevated ___ and ___
- Elevated homocysteine—amino acid, high levels correlated with eating meat
- Elevated C-reactive protein—identified relationship between inflammatory processes and the development of atherosclerosis
(4) symptoms of PVD: ___cation, skin ___, ___ene, ___ence
Claudication, skin ulceration, gangrene, impotence
Extent of disability from PVD is primarily influenced by the development of collateral blood vessels and adequate flow—T/F?
TRUE
PVD—initially, collateral blood flow adequately meets demands for tissue oxygen; as the disease progresses, O2 supply is ___ (able/unable) to meet demand and limb ischemia is symptomatic
Unable
Therapeutic intervention for PVD is often initiated when…
O2 supply is unable to meet demand
5-year mortality rate for PVD = ___%
30%
10-year mortality rate for PVD = ___%
70%
Atherosclerotic disease is not limited to the peripheral arterial beds and should be expected to be present in the coronary, cerebral, and renal arteries—T/F? [QUIZ QUESTION]
True
Preoperative assessment PVD—more than half of the mortality associated with PVD is from perioperative ___ events
Cardiac
Preoperative assessment PVD—work to optimize ___ function preoperatively to decrease related perioperative cardiac morbidity and mortality
Cardiac
Preoperative assessment PVD—the use of beta blockers is recommended in patients at high risk for myocardial ischemia and infarction—T/F?
TRUE
Beta blockers ___ (increase/decrease) myocardial O2 demand and bring the supply-demand system into ___
Decrease myocardial O2 demand and bring the supply-demand system into balance
PVD—preoperatively, the greater the number of comorbidities that exist, the ___ (lesser/greater) the risk of morbidity and mortality during the perioperative time frame
GREATER
Anesthetic technique PVD—currently, there is no existing evidence to suggest a superior anesthetic technique (MAC vs. regional vs. general)—T/F?
True
Anesthetic technique PVD—some studies suggest that regional anesthesia for surgeries on the lower extremities may decrease the overall morbidity and mortality in patients with PVD—T/F?
True
Monitoring patients with PVD—the primary objective should be detection of ___
Myocardial ischemia!!! Because more than half of the mortality associated with PVD is from perioperative cardiac events!!!
Monitoring patients with PVD—pulmonary artery catheter has been determined to have NO effect on mortality or length of stay—T/F?
True…routine use of PAC is NOT warranted!
Postoperative considerations for PVD—pain management is a vital issue related to vascular surgery, and post-operative administration of narcotics improves patient comfort and contributes to cardiac stability—T/F? [QUIZ QUESTION]
True
AAA—___ (increased/decreased) detection of asymptomatic aneurysms d/t noninvasive diagnostic modalities, i.e.: CT scans, MRI, and ultrasound
Increased
Aging population and vascular changes that occur d/t aging have led to ___ (increased/decreased) incidence of AAA
Increased incidence
AAA occurs more often in men than women—T/F?
True
What is thought to be the primary cause of AAA in 90% of patients?
Atherosclerosis
___ is a contributing factor to AAA in 60% of patients
HTN
Cigarette smoking results in an 8-fold increased incidence of AAA—T/F?
True
___ may mask the signs and symptoms of AAA
Obesity
Patient may be asymptomatic and have AAA detected incidentally during routine physical exam or on abdominal CT, MRI, ultrasound—T/F?
True
What is the best method for evaluating suprarenal aneurysms?
Digital subtraction angiography
Risk of rupture is very low for AAAs less than ___ cm in diameter
< 4 cm
Risk of rupture increases dramatically for aneurysms greater than ___ cm in diameter
> 5 cm
Surgical intervention is recommended for aneurysms greater than ___ cm in diameter [QUIZ QUESTION]
> 5.5 cm
HTN, COPD, DM, renal impairment, and CAD are frequent comorbidities of patients with AAA—T/F?
True
ACC/AHA guidelines for AAA repair emphasize preoperative ___ control, ___ maintenance, and ___ optimization
Preoperative glucose control, temperature maintenance, and cardiac optimization
What requires consideration before AAA repair? ___ dysfunction—EVAR can cause stent migration to renal arteries; contrast dye exposure; open AAA causes alterations in renal hemodynamics d/t cross clamping of aorta
Renal dysfunction
EVAR = ___
Endovascular AAA repair
EVAR has proven to be much safer than open AAA repair—T/F?
True
There is no evidence to suggest that one anesthesia technique (GETA, MAC, neuraxial blockade) is better than another for EVAR—T/F?
True
Complications of EVAR—endograft migration can cause renal artery ___ and post-op renal ___
Renal artery occlusion and post-op renal failure
What is a serious complication of EVAR?
Endoleak
What does this describe?—persistent blood flow and pressure between the endovascular graft and the aortic aneurysm
Endoleak—serious complication of EVAR!
How is endoleak diagnosed?
Postoperative CT scan
Long-term results of EVAR are good, but overall durability of conventional surgical technique (open AAA repair) is superior—T/F?
True
Post-op care for endovascular AAA—physical exam and contrast enhanced CT at ___, ___, ___, and ___ months post-procedure, then annually
1, 6, 12, and 18 months post-procedure, then annually
Types of endoleak
Types I-IV
What type of endoleak is this?—caused by device related problems; most frequent intervention used to correct is implantation of a second endograft or open repair
Types I and III
What type of endoleak is this?—most common; caused by collateral retrograde perfusion; spontaneously close within the first month of implantation
Type II
What type of endoleak only requires observation?
Type IV
(4) contraindications to elective surgical AAA repair—intractable ___, recent ___, severe ___ dysfunction, chronic ___ insufficiency
Intractable angina, recent MI, severe pulmonary dysfunction, chronic renal insufficiency
High risk surgical AAA repair—age > ___ years
> 85 years
High risk surgical AAA repair—pulmonary—on home ___, PaO2 < ___ mm Hg, FEV1 < ___ L/s
On home O2, PaO2 < 50 mm Hg, FEV1 < 1 L/s
High risk surgical AAA repair—renal—serum creatinine > ___ mg/dL
> 3 mg/dL
High risk surgical AAA repair—cardiac—class ___ angina; resting LVEF < ___%; recent ___; complex ventricular ___; severe, uncorrected ___
- Class III-IV angina
- Resting LVEF < 30%
- Recent CHF
- Complex ventricular ectopy
- Severe, uncorrected CAD
Law of LaPlace =
T = P x r
T = wall tension P = transmural pressure r = vessel radius
Law of LaPlace—as the radius of a vessel increases, the wall tension ___ (increases/decreases)
Wall tension increases
Law of LaPlace—the larger the aneurysm, the more likely the risk of ___
Spontaneous rupture
Aneurysms measuring more than ___ cm in diameter generally require surgical intervention
More than 4-5 cm
Aneurysms less than 4-5 cm should not be considered benign—they may rupture regardless of size—T/F?
True
Anesthesia concerns for open AAA—restoration of ___
Intravascular fluid volume
Anesthesia concerns for open AAA—need reliable ___
Venous access
Anesthesia concerns for open AAA—anticipate massive ___
Hemorrhage—have blood products available (2 units PRBCs in room)
AAA required monitors—EKG lead ___ allows for detection of dysrhythmias
Lead II
AAA required monitors—lead ___ allows analysis of ischemic ST changes
V5
AAA required monitors—monitor ___ segment
ST
What poses the greatest risk of mortality after AAA reconstruction?
Myocardial ischemia
What is the standard approach for AAA procedure?—___ incision, allows for exposure of ___ and ___ vessels
Transperitoneal incision, allows for exposure of infrarenal and iliac vessels
What is a complication that may occur with transperitoneal incision?—___ syndrome—___tension, ___ (increased/decreased) SVR, ___cardia, ___ increased/decreased CO, facial ___
Mesenteric traction syndrome—hypotension, decreased SVR, tachycardia, increased CO, facial flushing
AAA procedure—retroperitoneal incision offers excellent exposure of ___ or ___renal aneurysm
Juxtarenal/suprarenal aneurysm
Retroperitoneal incision for AAA repair (compared to transperitoneal incision) results in ___ (increased/decreased) fluid loss; ___ (more/less) incisional pain; ___ (more/less) postop pulmonary and intestinal complications
Decreased fluid loss; less incisional pain; less postop pulmonary and intestinal complications
Retroperitoneal incision for AAA repair does NOT result in mesenteric traction syndrome—T/F?
True
What is the most common site for aortic cross clamp application?
Infrarenal—because most aneurysms develop below the level of the renal arteries
Juxtarenal/suprarenal are less common
Higher levels of aortic occlusion (i.e.: juxtarenal, suprarenal) have a significant impact on the CV system, as well as on other vital organs rendered ischemic or hypoperfused—T/F?
True
Ischemic complications from aortic cross clamping during AAA repair may result in renal failure, hepatic ischemia and coagulopathy, bowel infarction, and paraplegia—T/F?
True
___tension above the cross-clamp
Hypertension
___tension below the cross-clamp
Hypotension
Organs ___ (proximal/distal) to the aortic occlusion may experience a redistribution of blood volume
Proximal
There is an ___ of blood flow distal to the clamp
Absence
Increase in afterload from aortic cross-clamp will cause a ___ (increase/decrease) in myocardial wall tension
Increase in myocardial wall tension
MAP and SVR ___ (increase/decrease) above clamp
Increase
CO ___ (increases/decreases/remains unchanged) during aortic cross-clamp
Remains unchanged
PAOP may ___ or ___ during aortic cross-clamp
Increase or remain unchanged
The more proximal the clamp/the higher on the aortic arch = ___ (lesser/greater) magnitude/severity of these responses
Greater
___ medications must be available throughout AAA surgery
Vasoactive
AAA repair/aortic cross-clamp—___ is often the drug of choice because of its primary effect on decreasing preload and thus decreasing myocardial O2 demand
Nitroglycerin
AAA repair/aortic cross-clamp—___ and ___ are two inotropy agents used to improve cardiac output
Dopamine and dobutamine
AAA repair/aortic cross-clamp—___ decreases afterload
Nipride (sodium nitroprusside)
AAA repair/aortic cross-clamp—___ (volatile agent) may decrease SVR
Isoflurane
Metabolic alterations from aortic cross clamp—___ of tissues distal to clamp
Hypoxia
Metabolic alterations from aortic cross clamp—accumulation of ___
Anaerobic metabolites—i.e.: lactate
Metabolic alterations from aortic cross clamp—significant increase in plasma ___
Catecholamines
Epi and norepi stimulate beta 1 receptors that increase heart rate and myocardial oxygen demand
Juxtarenal/suprarenal cross clamp may be associated with higher incidence of ___ morbidity
Renal
AAA repair—preoperative evaluation of renal function is one of the most significant predictors of post-operative renal dysfunction—T/F?
True
AAA intraoperative goals for kidney—mannitol 20 to 30 mins ___ (before/during/after) aortic cross clamp to maintain a vigorous urinary output
Before
After aorta cross clamp is removed, if/when patient is hemodynamically stable, consider ___ to ensure diuresis and urinary output of ___ cc/kg/hr
Furosemide; urinary output of 1 cc/kg/hr
Avoid ___ in AAA cases
Hypovolemia
AAA neuro effects—spinal cord damage to the artery of ___ in the absence of blood flow
Artery of adamkiewicz (aka the greater radicular artery)
AAA neuro effects—interruption of collateral blood flow has caused post-operative paraplegia—T/F?
True—maintain MAP to perfuse spinal cord
The incidence of neurologic complications decreases as the clamp is positioned higher on the aorta—T/F?
False—increases
___ have been advocated as a method of identifying spinal cord ischemia in AAA repair
SSEPs
SSEPs only reflect the ___ cord, not the ___ cord
Dorsal/sensory cord, not the anterior/motor cord
Why can’t MEPs be used during AAA repair to detect anterior/motor cord function?
MEPs require intact neuromuscular function for analysis, and neuromuscular blockade is required during AAA repair
AAA bowel effects—ischemic colon results from ischemia of the ___ artery, the primary blood supply of the left colon
Ischemia of the inferior mesenteric artery
Aortic cross-clamp release—declamping shock syndrome—results from liberation of ___; causes ___ (increased/decreased) SVR; ___ (increased/decreased) venous return; reactive ___; further ___ (increases/decreases) preload/afterload
Liberation of anaerobic metabolites (serum lactate); causes decreased SVR; decreased venous return; reactive hyperemia; further decreases preload/afterload
The magnitude of response to unclamping the aorta can be manipulated—T/F?
True
Restoration of circulating blood volume is paramount in providing circulatory stability before release of aortic clamp—T/F?
True
Expect severe ___tension and ___ (increase/decrease) in cardiac output when the aortic cross-clamp is released
Hypotension and decrease in cardiac output
Severe hypotension and decrease in cardiac output after aortic cross-clamp release can be prevented or decreased in severity by ___
Volume loading—raise the CVP 3-5 mm Hg or raise the PAOP by 3-4 mm Hg just prior to clamp release
Cross-clamp release—if severe acidosis is present, ___ may be administered
Sodium bicarbonate
Cross-clamp release—minute ventilation should be ___ (increased/decreased) to assist with acidosis
Increased
Minute ventilation = tidal volume x RR
Cross-clamp release—have ___ ready and do not hesitate to use!
Vasopressors
Initial blood loss during AAA repair is replaced with crystalloids at ___ ratio
3:1 ratio
Anesthetic plan for AAA—a superior plan has not been established—T/F?
True, GETA often selected
Anesthetic plan for AAA repair—___ may be suitable for patients with minimal cardiac reserve
Etomidate
Ruptured AAA—___ principles apply
Trauma anesthesia
Ruptured AAA—___ must be the primary objective
Hemodynamic stability
Lumbar intrathecal catheter to drain CSF prior to clamping thoracic aorta—has been effective in reducing incidence of post-op ___
Paraplegia
What does the following describe?—last for seconds to minutes; often recur over a 24 hour period; completely resolve within 24 hours; the patient does NOT experience a LOC
Transient ischemic attack
More than half of all strokes are preceded by a TIA—T/F?
True
Risk of stroke is greatest in the week following a TIA, particularly if the event lasted more than 10 minutes or caused weakness or speech impairment, or if the person is older than 60 years or has diabetes—T/F?
True
TIA ___ involvement usually leads to confusion or dizziness, or affects vision in both eyes
Vertebral involvement
TIA ___ involvement may cause unilateral blindness or weakness
Carotid involvement
Definitive diagnosis of carotid artery stenosis = ___
Duplex ultrasonography—noninvasive diagnostic tool that combines ultrasound and Doppler techniques
Treatment of carotid artery stenosis—symptomatic patient with low-grade carotid stenosis (<50% occluded)
Optimal medical therapy
Treatment of carotid artery stenosis—symptomatic patient with moderate-to-severe carotid stenosis (>50% occluded)
Carotid endarterectomy + medical therapy
Carotid artery stenting is a potential alternative if patient is a high perioperative risk
Treatment of carotid artery stenosis—asymptomatic patient with low-grade carotid stenosis (<60% occluded)
Optimal medical therapy
Treatment of carotid artery stenosis—asymptomatic patient with moderate-to-severe carotid stenosis (>60% occluded)
Carotid endarterectomy + medical therapy if low perioperative risk
Recommendation against carotid artery stenting; possible exception to do stents if patient has >80% stenosis and high risk of stroke or death from carotid endarterectomy
What type of procedure is this?—atherosclerotic plaque is removed from carotid artery to restore blood flow to the brain
Carotid endarterectomy
Although stroke is a devastating consequence of CEA, ___ contributes more frequently to poor surgical outcomes than stroke
Myocardial infarction
CEA mortality d/t stroke = ___%
15%
CEA mortality d/t MI = ___%
49%
CEA—when abnormal cardiac history is present, ___ should occur
Further evaluation
Anesthetic technique for CEA
No consensus on technique
Regional anesthesia for CEA
Local infiltration or superficial and deep cervical plexus block
Greatest advantage of regional anesthesia for CEA—direct assessment of ___ status in the awake patient
Direct assessment of neuro status in the awake patient
General anesthesia for CEA—disadvantage of ___ patient
Asleep/uncooperative patient
___% of cerebral blood flow is supplied via the carotid arteries; when the carotid artery is clamped, CBF is ___
80%; compromised
Maintenance of CPP during CEA is dependent on ___ blood flow
Collateral
Cerebral blood flow remains relatively constant at different cerebral perfusion pressures as a result of cerebrovascular autoregulation—T/F?
True
CPP = ___ - ___ [QUIZ QUESTION]
MAP - ICP
At a MAP of ___ - ___ mm Hg, CBF remains constant [QUIZ QUESTION]
60-100 mm Hg
Adverse effects of chronic HTN shift the cerebral auto regulatory curve to the ___ (right/left), and ___ (lower/higher) than normal MAP may be required to ensure adequate cerebral perfusion
Right, higher
Cerebral blood flow is also influenced by arterial CO2 and O2 levels—T/F?
True
CEA postop considerations—carotid artery hemorrhage—intubate ___ (sooner/later) because it can cause ___
Intubate sooner because it can cause tracheal deviation and make intubation difficult!!!
CEA postop considerations—cerebral hyperperfusion syndrome—severe ___, ___ disturbances, altered ___, ___
Severe headache, visual disturbances, altered LOC, seizures
Carotid artery stenting may be associated with increased risk of ___
Stroke
CAS is routinely done under ___
Local anesthesia
CAS requires anticoagulation ___ units/kg to achieve ACT [activated clotting time] greater than ___ seconds
50-100 units/kg to achieve ACT greater than 250 seconds
The process of digestion begins with ___ [QUIZ QUESTION]
Mastication
What is the biggest concern for patients with GI disorders/symptoms?
Pulmonary aspiration of oropharyngeal, esophageal, or gastric contents
What nerve innervates the nasopharynx?
Trigeminal nerve
What nerve innervates the posterior third of tongue and oral pharynx?
Glossopharyngeal
What nerve innervates the base of the tongue and inferior epiglottis to the vocal cords?
Superior laryngeal nerve
What nerve innervates the vocal cords distally?
Recurrent laryngeal nerve
Branches of the ___ nerve innervate the remainder of the larynx/trachea
Vagus nerve
The esophagus originates at the pharynx at approximately the level of the ___ cervical vertebra and extends to the stomach
6th cervical vertebra
What are the three functional zones of the esophagus?
- Upper esophageal sphincter (UES)
- Esophageal body
- Lower esophageal sphincter (LES)
___ muscle in the upper third of the esophagus
Skeletal
___ and ___ muscles in the middle third of the esophagus
Skeletal and smooth muscles
___ muscle in the lower third of the esophagus
Smooth
Blood supply of the esophagus—the inferior thyroid arteries supply the ___ esophagus
Cervical esophagus
Blood supply of the esophagus—the bronchial arteries [esophageal branches of the thoracic aorta] supply the ___ esophagus
Thoracic esophagus
Intrinsic innervation of the esophagus is comprised of what two interconnected plexuses?
- Myenteric of Auerbach plexus
- Submucosal or Meisser plexus
Intrinsic innervation of the esophagus extends from the esophagus to the anus—T/F?
True
Extrinsic innervation of the esophagus is made up of what (3) components?
- Sympathetic
- Parasympathetic
- Somatic
Sympathetic innervation acts on the ___ plexus to modulate rather than control motor activity
Myenteric/Auerbach plexus
Parasympathetic innervation of the esophagus comes from cranial nerves ___, ___, ___
IX (glossopharyngeal), X (vagus), XI (accessory)
Parasympathetic innervation of the esophagus causes ___ and ___
Esophageal muscular contraction and relaxation of LES
Both the UES and LES are ___ (open/closed) at rest
Closed
What initiates peristalsis?
Swallowing
Swallowing ___ (increases/decreases) LES tone
Decreases
Ingestion of a meal or increased abdominal pressure ___ (increases/decreases) LES tone via vagal afferent pathways
Increases
Normal LES tone is ___ mm Hg [QUIZ QUESTION]
20 mm Hg
___ innervation is predominant in the LES
Vagal
Chronic alcoholism causes LES hypotonia and degeneration of the Auerbach plexus in the esophagus—T/F?
True
Mallory Weiss Tears result from wretching/vomiting—T/F [QUIZ QUESTION]
True
What esophageal disorder does this describe?—failure of the lower esophageal sphincter to relax during swallowing, accompanied by a lack of peristalsis; develops secondary to chronic disease states (i.e.: diabetes, stroke, ALS, connective tissue diseases)
Achalasia
What esophageal disorder does this describe?—normal squamous epithelium changes to metaplastic columnar epithelium
Barrett’s esophagus
Barrett’s esophagus is caused by what (3) things?
- GERD
- Chronic alcohol abuse
- Smoking
Barrett’s esophagus is closely associated with eventual development of ___
Esophageal carcinoma
What esophageal disorder is this describing?—failure of the lower esophageal sphincter to function properly, permitting stomach contents to reflux into the esophagus and possibly the pharynx
GERD
Current management of GERD includes what (2) medications?
- PPIs
- H2 blockers
What esophageal disorder is this describing?—occurs d/t weakness in the diaphragm that allows a portion of the stomach to migrate upward into the thoracic cavity
Hiatal hernia
Types of hiatal hernia
Types I-IV
Type I hiatal hernia
Sliding
Types II-IV hiatal hernia
All are paraesophageal
What is the primary symptom of hiatal hernia?
Retrosternal pain of a burning quality that commonly occurs after meals
Treatment of hiatal hernia
Treated surgically, with the primary goal to reestablish gastroesophageal competence
Esophageal diverticula are classified according to ___
Location
Epiphrenic diverticula are located near ___
LES
Traction diverticula are located ___
Mid-esophagus
Zenker diverticula [this one was on quiz] are located in the ___
Upper esophagus
Esophageal diverticula place patient at risk for ___
Pulmonary aspiration
Esophageal carcinoma = esophageal ___
Malignancy
Chemo for esophageal carcinoma—daunorubicin, doxorubicin/adriamycin cause chemotherapy induced ___
Cardiomyopathy
Chemo for esophageal carcinoma—bleomycin causes ___, which increases the potential for ___
Pulmonary fibrosis, which increases the potential for oxygen toxicity
Anesthesia considerations in esophageal disease—patients with history of GERD with active reflux symptoms warrants a plan for ___ prophylaxis during induction/emergence
Aspiration prophylaxis
Patients with hx of GERD and active reflux symptoms require an ___
Endotracheal tube to create a sealed airway
What technique should be used for induction for patients with active GERD?
Rapid sequence induction (RSI) with cricoid pressure [Sellick’s maneuver]
The patient with active reflux must be ___ prior to extubation
Fully awake
Aspiration pneumonia should always be corrected preoperatively—T/F?
True
What are (4) serious complications of esophageal tumor resection?
- Anastomotic leak
- Mediastinitis
- Sepsis
- Respiratory failure
Two sections of the stomach:
- Fundus
- Distal stomach
What section of the stomach is this?—thin-walled and distensible; located in upper abdomen; primary function is storage
Fundus
What section of the stomach is this?—thick-walled; mixing of food; slow release of chyme through pyloric sphincter into duodenum
Distal stomach
4 major arteries that supply the stomach:
- Right and left gastric arteries
- Right and left gastroepiploic arteries
Major innervation of the stomach is ___
Autonomic
Innervation of the stomach comes from what (2) branches of the vagus nerve?
- Right posterior (celiac) branch
- Left anterior (hepatic) branch
What gastric disorder does this describe?—caused by erosion of protective mucous layer of the stomach and duodenum; chronic oversupply of gastric hydrochloride acid and pepsin
Peptic ulcer disease
What is the major etiologic factor in peptic ulcer disease?
Helicobacter pylori bacterium
Overuse of what (2) medications can cause peptic ulcer disease?
NSAIDs and corticosteroids
What are (4) other risk factors for peptic ulcers?
- Excessive alcohol consumption
- Tobacco use
- Stress
- Radiation therapy
Treatment of peptic ulcers—3 main classes of medications:
- Oral antacids
- H2-receptor antagonists
- Proton pump inhibitors
Oral antacids may produce an acid rebound in which gastric acid secretion may increase after existing acids are neutralized by calcium containing antacids—T/F?
True
Oral antacids for peptic ulcers may cause acute hypophosphatemia, which manifests as skeletal muscle weakness, fatigue, pathologic fractures, osteoporosis—T/F?
True—but this usually occurs with chronic use of antacids
Milk-alkali syndrome from oral antacids—___calcemia, ___osis, ___ (increased/decreased) BUN; manifests as skeletal muscle weakness and polyuria
Hypercalcemia, alkalosis, increased BUN
H2-receptor antagonists for peptic ulcers block secretion of hydrochloric acid, which promotes healing of duodenal ulcers—T/F
True
H2-receptor antagonists are CYP450 ___
Inhibitors—may prolong effects of concurrently administered drugs that rely on hepatic metabolism/elimination
___ (H2 receptor antagonist) is the least likely H2 antagonist offender
Famotidine
What type of medication is the most effective anti-secretory agent?
Proton pump inhibitors
This medication binds to ulcer, increases gastric mucous layer, promotes the healing process, and is devoid of side effects
Sucralfate
This medication is a synthetic prostaglandin that is used as secondary therapy to prevent ulcers in patients requiring NSAIDs
Misoprostol
Majority of gastric neoplasms are malignant—T/F?
True—95% are adenocarcinomas
The gallbladder empties ___ into the duodenum to assist in digestion
Bile
Regulation of gallbladder contraction is primarily hormonal through the action of ___, which is released from the duodenum and mediated by the presence of intraluminal amino acids and fats
Cholecystokinin
Cholecystitis is acute obstruction of the ___
Cystic duct
Cholelithiasis is acute obstruction of the ___
Common bile duct
Cholecystitis—patients present with acute, severe midepigastric pain that often radiates to the ___ (left/right) abdomen
Right
Cholecystitis—ask the patient to take in and hold a deep breath while palpating the right upper quadrant…if pain occurs on inspiration, this is known as a positive ___ sign
Murphy’s
Labs in cholecystitis—increases in what (4) things?
- Plasma bilirubin
- Alkaline phosphatase
- Amylase
- WBCs
Cholecystitis—___ suggests complete obstruction of the cystic duct
Jaundice
Patients with cholecystitis often present with symptoms that are confused with myocardial infarction—T/F?
True…r/o cardiac event with serial enzymes and EKGs
Diagnosis of cholecystitis
Gallbladder ultrasound or contrast study
Treatment of cholecystitis
Emergency ex-lap
Cholelithiasis and Charcot triangle
- Fever
- Chills
- Upper quadrant pain
Charcot triangle is indicative of ___
Acute ductal obstruction
Diagnostic studies for cholelithiasis demonstrate a ___ biliary tree
Dilated
Major concern with cholecystectomy =
Insufflation of the abdomen
Laparoscopic surgery considerations—high intraabdominal pressure = ___ risk
Aspiration
Laparoscopic surgery considerations—large volume of intraabdominal ___ = ___capnea
Intraabdominal CO2 = hypercapnea
Laparoscopic surgery considerations—___ venous return from increased intraabdominal pressure/patient position
Decreased
Laparoscopic surgery considerations—manipulation of abdominal viscera may cause ___cardia and ___tension
Bradycardia and hypotension
The large intestine is where most chemical digestion takes place—T/F?
False—small intestine is where most chemical digestion takes place
Food is pushed through the small intestine by a process of muscular-wavelike contractions called ___
Peristalsis
The hormone ___ causes bicarbonate to be released into the small intestine from the pancreas in order to neutralize the potentially harmful acid coming from the stomach
Secretin
Vitamins B, K, some electrolytes (Na+ and Cl-) and most of the remaining water is absorbed by the large intestine—T/F
True
The large intestine absorbs 1-2 L of water per day—T/F
True
Avoid ___ (what inhalation agent?) in intestinal surgery
Nitrous oxide
The ___ is the largest lymphatic organ
Spleen
What is the process by which the body maintains a delicate balance between bleeding and clotting?
Hemostasis
What blood vessel layer forms a barrier separating fluid contents within the blood vessel from the highly thrombogenic material that lies in the tunica media?
Tunica intima
The tunica intima is made up of ___ cells
Endothelial cells
Endothelial cells synthesize and secrete procoagulants, anticoagulants, and fibrinolytics—T/F
True
What are (2) procoagulants [substances that promote clotting] secreted by endothelial cells in the tunica intima?
- von Willebrand Factor (vWF)
- Tissue factor
This procoagulant is a necessary cofactor for adherence of platelets to the subendothelial layer
VWF—von Willebrand Factor
This procoagulant activates the clotting cascade pathway when injury to the vessel occurs
Tissue factor
What (3) substances [secreted by endothelial cells] cause vasoconstriction in the tunica intima?
- Thromboxane A2
- Adenosine diphosphate (ADP)
- Serotonin
What (2) substances [secreted by endothelial cells] cause vasodilation in the tunica intima?
- Nitric oxide
- Prostacyclin
What substance [secreted by endothelial cells in the tunica intima] inhibits coagulation?
Tissue factor pathway inhibitor
What blood vessel layer is this?—extremely thrombogenic, very active, contains collagen and fibronectin
Tunica media (subendothelial, middle layer)
What blood vessel layer is this?—controls blood flow by influencing the vessel’s degree of contraction via vasodilation by nitric oxide and prostacyclin
Tunica adventitia [outermost]
Intima = ___ layer
Endothelial
Media = ___ layer
Subendothelial [middle]
Adventitia = ___ layer
Outermost
(4) intima mediators:
- vWF
- Tissue factor
- Prostacylin
- Nitric oxide
(2) media mediators:
- Collagen
- Fibronectin
(2) adventitia mediators:
- Nitric oxide
- Prostacyclin
Platelet cells contain ___
Mitochondria
Platelet cells produce ___, activate ___ factors, influence the recruitment of ___
Produce thrombin, activate coagulation factors, influence the recruitment of platelets
Platelets have no ___, ___, ___
Nucleus, RNA, DNA
Platelets are ___ (active/inactive)
Inactive unless activate as a result of tissue trauma
Adequate hemostasis is possible in the absence of activated platelets—T/F?
False—adequate hemostasis is NOT possible in the absence of activated platelets
What are (3) parts of the formation of a plug?
- Adhesion
- Activation
- Aggregation
Adhesion—___ mobilizes from the endothelial cells and emerges from the endothelial lining; ___ makes platelets “sticky” and allows them to adhere to the site of injury
VWF; vWF
Adhesion—___ attaches to vWF and attracts additional platelets to the endothelial lining
GpIb
Activation—___ causes the platelet to undergo a conformational change and become “activated”
Tissue factor
Activation—once the platelet becomes activated, two additional glycoproteins extend from the platelet—Gp___ and Gp___
GpIIb and GpIIIa
Activation—activated platelets show little cell feet called pseudopodia; pseudopods link activated platelets together with ___ to form a mound to “patch” injury to vessel walls
Fibrinogen
Aggregation—the ___-___ receptor complex links activated platelets together (aggregation) to form a primary platelet plug
GpIIb-GpIIIa receptor complex
Aggregation—the platelets mound together to seal and heal the site of injury within the blood vessel; as platelets undergo this “activation” process, they also release ___ and ___ granules, contractile granules, thrombin, and procoagulant mediators in the blood
Alpha and dense granules
Coagulation/clotting cascade—activation of cofactors, also known as ___
Zymogens
Coagulation/clotting cascade—coagulation cofactors (zymogens) circulate in an ___ state until they are activated to assist in the process of coagulation
Inactive
Coagulation/clotting cascade—what activates the zymogens?
Tissue or organ damage
Two clotting pathways, extrinsic and intrinsic pathway, are two separate and distinct pathways; they function independently of each other but in conjunction with platelet activity and the common coagulation pathway—T/F?
True
Conversion of prothrombin to ___ is an important step for both the extrinsic and intrinsic pathways
Thrombin
___ recruits platelets to the injured area
Thrombin
Adequate ___ must be present to activate sufficient fibrin to form a “stable” or “secondary clot
Thrombin
Thrombin (the anticoagulant) prevents ___ formation by releasing ___
Prevents runaway clot formation by releasing tPA
Thrombin stimulates proteins ___ and ___
Proteins C and S
Proteins C and S inhibit ___ formation
Clot formation
Thrombin works with ___ to interfere with coagulation
Antithrombin III
___ is involved in many parts of the common pathway; most of it is formed by the liver
Calcium
What are the (3) stages of the cell based theory of coagulation?
- Initiation
- Amplification
- Propagation
During initiation, injury to the endothelial surface exposes ___ to the site of injury
Tissue factor (TF)
During amplification, ___ generation increases and the activation of clotting factors persists
Thrombin
During amplification, ___ promotes aggregation
VWF
Specifically…GpIb binds to vWF to hold activated platelet against the tissue wall; GpIIb/GpIIIa hold the activated platelets together
During propagation, all factors influence each other to promote coagulation; finally activate ___, resulting in large burst of thrombin; promotes fibrinogen to ___, creating a secondary plug
Prothrombin, resulting in large burst of thrombin
Fibrinogen to fibrin, creating a secondary plug
Once the disrupted vessel is sealed, there is no further need for the hemostatic plug—T/F?
True
The fibrinolytic system exists to degrade the ___
Fibrin (this occurs once the disrupted vessel is sealed and there is no longer a need for a hemostatic plug)
First step in the fibrinolytic system—___ (increase/decrease) blood flow to the site of injury; ___ (addition/removal) of procoagulant mediators, ADP, and thromboxane from the vessel
Increase blood flow to the site of injury; addition of procoagulant mediators, ADP, and thromboxane from the vessel
Fibrinolytic system—thrombin, which first acted as a coagulant, now acts as an ___ and activates other anticoagulant mediators
Anticoagulant
Fibrinolytic system—___ prevents “runaway” clot formation by release of tissue plasminogen activator (tPA) from endothelial cells
Thrombin
Fibrinolytic system—thrombin stimulates proteins ___ and ___ to inhibit clot formation
Proteins C and S
Fibrinolytic system—___ interferes with coagulation by removing clotting factors from the clotting cascade
Antithrombin III
Fibrinolytic system—what stops the action of tissue factor (TF)?
Tissue factor pathway inhibitor (TFPI)
Fibrinolytic system—___ is a mediator that removes factors from the clotting cascade and disrupts the clot
Antithrombin III
Fibrinolytic system—fibrinolysis is controlled by ___
Plasma proteins
Fibrinolytic system—“clots” are composed of ___, ___, ___, and ___
Plasminogen, plasmin, fibrin, and fibrin degradation products
What is this?—enzyme synthesized in the liver; stored in its inactive form; incorporates itself into forming a clot; in the presence of tPA and urokinase, is activated to plasmin
Plasminogen
___ degrades fibrin into fibrin degradation products
Plasmin
Waste products of the clot are removed with the circulating blood—T/F?
True
___ mediators stop the fibrinolysis process
Fibrinolytic mediators
When the clot is digested, ___ and ___ halt fibrinolysis (think what 2 thinks stop plasmin and tPA?)
Alpha-antiplasmin and tissue plasminogen activator inhibitor (tPA inhibitor)
Meds that affect coagulation—heparins, LMWHs, Coumadin and derivatives, and direct thrombin inhibitors are all ___
Anticoagulants
Meds that affect coagulation—Vitamin K is a ___
Procoagulant
Meds that affect coagulation—NSAIDs, persantine, and thienopyridine (placid, ticlid) are all ___
Antiplatelets
Meds that affect coagulation—amicar and tranexmic acid are ___
Antifibrinolytics
Nonherbal dietary substances that affect coagulation—vitamins ___ and ___; Co___; Z___; ___ acids
Vitamins E and K; CoQ10; Zinc; omega 3 fatty acids
(4) herbal substances that affect coagulation:
Gingko biloba, garlic, ginger, feverfew
No matter what the surgical bleeding risk (low vs. high), warfarin therapy should be stopped ___ days before surgery; INR should return to ___ before surgery
4-5 days before surgery; INR should return to normal before surgery
If there is a risk for thromboembolism, LMWH or unfractionated heparin can be started ___ days before surgery
2-3 days before surgery
Bleeding time lab test—normal = ___ minutes
3-7 minutes
Bleeding time lab test is not considered a routine test; results can be altered by aspirin and NSAIDs—T/F?
True
Normal platelet count
150-350k
Thrombocytopenic platelet count < ___
< 100k
Surgical risk platelet count < ___
< 50k
Spontaneous bleeding platelet count < ___
< 20k
Normal prothrombin time (PT) = ___ seconds
12-14 seconds
PT can be altered (prolonged) with ___ or ___ pathway disorders; ___ derivatives
Extrinsic or common pathway disorders; Coumadin derivatives
Normal activated partial thromboplastin time (aPTT) = ___ seconds
25-32 seconds
aPTT can be altered (prolonged) with ___ or ___ pathway disorders; ___ and ___
Intrinsic or common pathway disorders; heparin and lovenox
Normal thrombin time = ___ seconds
8-12 seconds
Thrombin time measures ___ to ___ reaction
Fibrinogen to fibrin
Normal activated clotting time (ACT) = ___ seconds
80-150 seconds
ACT guides ___ dosing
Anticoagulation
Normal fibrinogen = > ___ mg/dL
> 150 mg/dL; 200-350 mg/mL
Normal fibrinogen degradation products = < ___ mcg/mL
< 10 mcg/mL
Fibrinogen degradation products measures byproducts from ___
Clot dissolution
Normal d-Dimer = < ___ mg/mL
< 500 mg/mL
D-Dimer measures degradation products secondary to ___
Fibrinolysis
Normal antithrombin III = ___%-___%
80-120%
Decreased antithrombin III levels may explain sub therapeutic ___
Heparin
Antithrombin III levels are severely depressed in ___
DIC
In von Willebrand Disease, ___ and ___ are abnormal
APTT and bleeding time
What is the treatment for von Willebrand disease?
DDAVP and cryoprecipitate
Platelet count evaluates platelet function—T/F
FALSE—only tells you the number of platelets in the blood, not their function
Platelets < 100k
Thrombocytopenia
Platelets < 50k
Expect bleeding
Platelets < 20k
Spontaneous bleeding
PT measures efficiency of ___ and ___ pathways
Extrinsic and common pathways
PT is most commonly measured for patients on oral therapy like ___
Coumadin
INR evaluates ___ and ___ pathways, independent of various reagents used in different laboratories
Extrinsic and common pathways
PTT measures efficiency of ___ and ___ pathways
Intrinsic and common pathways
Transfusion guidelines—PRBCs hemoglobin < ___ for high risk patients
< 7 g/dL
Transfusion guidelines—platelets < ___ transfuse for low risk procedure
< 20k
Transfusion guidelines—platelets < ___ transfuse for average risk procedure
< 50k
Transfusion guidelines—platelets < ___ transfuse for CNS procedure
< 100k
Transfusion guidelines—FFP is given for urgent reversal of ___ or correction of known ___ deficiencies
Urgent reversal of warfarin or correction of known coagulation factor deficiencies
Transfusion guidelines—cryoprecipitate should be given for fibrinogen levels < ___-___ mg/dL in the presence of bleeding or to patients with congenital ___ deficiencies
< 80-100 mg/dL; congenital fibrinogen deficiencies
What is the most common inherited coagulation disorder?
von Willebrand Disease (vWD)
What is the main function of vWF?
Facilitate platelet adhesion (remember, vWF binds to GpIb so that the platelet adheres to the vessel wall)
What clotting disorder is this?—a result of intravascular coagulation activation with micro vascular thrombi formation, which causes thrombocytopenia and clotting factors depletion, leading to bleeding and multi organ failure
Disseminated intravascular coagulation (DIC)
What is the clinical presentation of DIC?
- Thrombosis
- Hemorrhage
- Possibly both
DIC—score > 5 = ___
Overt DIC
DIC—score < 5 = ___
Non-overt DIC…so does not confirm DIC
What is the main treatment for DIC?
Treat the underlying cause!!!
All of the following clinical conditions are associated with which disorder?—sepsis, cancers, trauma, obstetric complications***, inflammatory diseases, liver failure, cerebral injury, viremias, prosthetic devices, snake venom, toxic/immunologic reactions
DIC
Sickle cell trait (SCT)—___zygous disorder observed in 10% of African Americans
Heterozygous disorder observed in 10% of African Americans
Sickle cell disease (SCD)—___zygous disorder observed in 0.5-1.0% of African Americans
Homozygous
Sickle cell crisis can be triggered by ___emia, ___thermia, ___, ___, venous ___, ___osis
Hypoxemia, hypothermia, infection, dehydration, venous stasis, acidosis
Anesthesia management for sickle cell disease—adequate ___ and ___, ___thermia, maintain ___ balance, proper ___
Adequate hydration and oxygenation, normothermia, maintain acid-base balance, proper positioning
Hydration for patients with sickle cell disease is usually ___x maintenance, depending on renal status
1.5x maintenance
Controlled ventilation/titration of sedation is crucial to maintain normo___ in patients with sickle cell disease
Normocapnia
SCD—maintain O2 saturation > ___% at all times
> 95%
SCD—transfuse if necessary to replace surgical blood loss, avoid increasing the Hgb > ___ g/dL
> 11 g/dL
What disorder is this?—immune response that can progress to severe thrombosis, amputation, and possibly death
Heparin-induced thrombocytopenia (HIT)
Clinical presentation of HIT—___penia, resistance to ___ anticoagulation, ___osis, and ___ assay test
Thrombocytopenia, resistance to heparin anticoagulation, thrombosis, and positive assay test
Two types of HIT:
- Type I
- Type II
Which type of HIT is more severe?
Type II
Type I HIT is ___ mediated
Non-immune mediated
Onset of type I HIT = ___ days
1-4 days
Type I HIT—___ (mild/moderate/severe) thrombocytopenia that usually resolves ___
Mild thrombocytopenia that usually resolves on its own with continued heparin administration
Type I HIT usually occurs with ___ (low/high) dose heparin
High
Type I HIT ___ (is/is not) associated with thrombosis and serious clinical outcomes
Is not
Type II HIT is ___ mediated
Immune
Onset of type II HIT = ___ days
5-14 days
Type II HIT results in ___ (mild/moderate/severe) thrombocytopenia even when heparin is ___
Severe thrombocytopenia even when heparin is stopped
Type II HIT occurs with ___ (low/high) dose heparin
Low dose
Type II HIT ___ (is/is not) associated with thrombosis and serious clinical outcomes
Is
