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
