Midterm Review Flashcards
What are (2) formulas that can be used to calculate BMI?
BMI = weight (kg) / height (m^2)
BMI = [weight (lbs) / height (in^2)] x 703
BMI class (ASA)–overweight = ___-___
25-29.9
BMI class (ASA)–obese class I = ___-___
30-34.9
BMI class (ASA)–obese class II = ___-___
35-39.9
BMI class (ASA)–obese class III/extreme obese = ___-___
40-44.9
BMI class (ASA)–obese class IV/severe obesity = > ___
> 45
What type of fat distribution is central or abdominal visceral; patients are apple shaped?
Android
What type of fat distribution is gluteal, femoral, or peripheral; patients are pear shaped?
Gynecoid
Which type of obesity (android or gynecoid) is associated with more comorbidities?
Android
Increased cardiac output of ___ L/min for each kg of fat
Increased CO of 0.1 L/min for each kg of fat
Respiratory–obese patients have ___ (increased/decreased) lung compliance; why?
Obese patients have DECREASED lung compliance; d/t pressure from abdominal, diaphragmatic, and thoracic fat
Obese patients have a ___ F/V loop pattern
Obese patients have a RESTRICTIVE F/V loop pattern
Obese patients have ___ (increased/decreased) FRC, ERV, VC, TLC; ___ (increased/decreased) dead space; ___ (increased/decreased/no change) in RV, CC, FVC, and FEV1
Obese patients have DECREASED FRC, ERV, VC, TLC; increased dead space; no change in RV, CC, FVC, and FEV1
Obese patients ___ventilate, which leads to ___carbia and ___osis
Obese patients HYPOventilate, which leads to HYPERcarbia and acidosis
What volumes/capacities are decreased in obese patients?
Decreased
- FRC
- VC
- TLC
- ERV
What volumes/capacities show no change in obese patients?
No change
- RV
- CC
- FVC
- FEV1
What is OSA defined as?
Excessive episodes of apnea (10 seconds) and hypopnea
OSA includes > ___ episodes of apnea per hour or ___ per night
OSA includes > 5 episodes of apnea per hour or 30 per night
OSA leads to ___ia, ___carbia, ___ and ___ hypertension, and cardiac ___
OSA leads to hypoxia, hypercarbia, systemic and pulmonary hypertension, and cardiac arrhythmias
What is the gold standard test for OSA?
Polysomnography (PSG)
What questionnaire can we use to evaluate patients for OSA and has up to 93% sensitivity?
STOP-BANG
What does STOP-BANG stand for?
S-Snoring (Do you snore loudly?)
T-Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)
O-Observed apnea (Has anyone observed that you stop breathing, or choke or gasp during your sleep?)
P-high blood Pressure (Do you have or are you being treated for high blood pressure?)
B-BMI (Is your body mass index more than 35 kg per m^2?)
A-Age (Are you older than 50 years?)
N-Neck circumference (Is your neck circumference greater than 40 cm [15.75 inches]?)
G-Gender (Are you male?)
What syndrome does this describe?–inappropriate and sudden somnolence, OSA, hypoxia, hypercapnia, arterial hypoxemia, cyanosis-induced polycythemia, respiratory acidosis, pulmonary hypertension, right sided heart failure
Obese hypoventilation (Pickwickian) syndrome
Obese hypoventilation (Pickwickian) syndrome can lead to what? How?
Right heart failure d/t hypoxic pulmonary vasoconstriction (AKA cor pulmonate)
Pharmacology in obese patients–___ (increased/decreased) volume of distribution; ___ (increased/decreased) blood volume; ___ (increased/decreased) total body water
increased volume of distribution; increased blood volume; decreased total body water
Pharmacokinetic changes associated with obesity–___ (increased/decreased) fat mass; ___ (increased/decreased) cardiac output; ___ (increased/decreased) blood volume; ___ (increased/decreased) lean body weight; ___ (increased/decreased) total body water; ___ (increased/decreased) renal clearance; ___ (increased/decreased) volume of distribution of lipid-soluble drugs
increased fat mass; increased cardiac output; increased blood volume; increased lean body weight; decreased total body water; increased renal clearance; increased volume of distribution of lipid-soluble drugs
Effects of general anesthesia–obese patients have __% reduction in FRC compared to ___% in non-obese patients
Obese patients have 50% reduction in FRC compared to 20% in non-obese patients
Tidal volumes in obese patients–___-___ ml/kg of ___ (IBW or TBW) for volumes
6-10 ml/kg of IBW for volumes
Volume replacement for obese patients–increased ___ volume, but proportionately decreased ___ volume
increased total body volume, but proportionately decreased estimated blood volume
EBV in obese patients–use ___-___ ml/kg
use 45-55 ml/kg
What is the first priority of anesthetic management in a burn patient?
Diagnose and treat airway injury
EARLY intubation if necessary–may be extremely difficult, consider awake/fiberoptic, surgical airway, succs?
What is the denervation-like phenomenon that occurs during the resuscitative phase of burn patients?–proliferation of ___ receptors, ___ release
Proliferation of acetylcholine receptors, K+ release
Do NOT give succs to a burn patient after ___ hours
Do NOT give succs to a burn patient after 24 hours
When is it okay to give succs to a burn patient?
When the wound is closed and the patient is gaining weight
If you are using a NDNMB in a burn patient, you have to give ___-___x the ED95 dose for proper intubating conditions
2-3x the ED95 dose
CO has ___x affinity for hemoglobin than O2
CO has 200x affinity for hemoglobin than O2
CO poisoning–tissues are unable to extract ___, leads to metabolic ___osis
CO poisoning–tissues are unable to extract O2, leads to metabolic acidosis
Labs for CO poisoning–SaO2 is ___; ABG has ___ total oxygen
SaO2 is normal; ABG has decreased total oxygen
What device is needed to show true oxygen saturation in a patient with CO poisoning?
Co-oximeter
Treatment of CO poisoning = ___
100% O2–decreases CO half-life from 4 hours to 40 mins
Fluid loss/shifts are greatest in the first ___ hours in burn patients; begin to stabilize after ___ hours
fluid loss/shifts are greatest in the first 12 hours in burn patients; begin to stabilize after 24 hours
Fluid shifts from ___ to ___
Fluid shifts from intravascular to interstitial
Result of fluid shifts in burn patients–severe depletion of ___; marked increase in ___ volume
severe depletion of plasma (hypovolemia); marked increase in extracellular volume (edema)
Parkland formula for burn patients–in the first 24 hours, give ___ ml LR/% burn/kg; give 1/2 in the first ___ hours, give 1/2 in the next ___ hours; ___ (yes/no) colloid
In the first 24 hours, give 4 ml LR/% burn/kg; give 1/2 in the first 8 hours, give 1/2 in the next 16 hours; no colloid
Parkland formula for burn patients–in the second 24 hours, ___ maintenance fluid
In the second 24 hours, D5W maintenance fluid
The hypermetabolic/hyperdynamic phase usually occurs after ___ hours
after 48 hours
Increased CO, tachycardia, lower SVR
CV changes in burn patients–immediate IV fluid loss can occur for up to ___ hours; after ___ hours, get hypermetabolic
Immediate IV fluid loss can occur for up to 36 hours (most in first 12 hours, usually stabilize after 24 hours); after 48 hours, get hyper metabolic
What is the hallmark of burn shock?
Decreased cardiac output–occurs within minutes of burn
Pulmonary function is decreased in burn patients, even without inhalation burns–T/F?
True
What (3) pulmonary things are reduced in burn patients?
- FRC
- Lung and chest wall compliance
Ventilation can increase from ___ L/min to ___ L/min in burn patients
Ventilation can increase from 6 L/min to 40 L/min in burn patients
What is the leading cause of death in burn patients?
SEPSIS
Adults–75%
Peds–near 100%
Max cold ischemic times–heart and lungs = ___-___ hours; liver = ___-___ hours; kidneys = ___ hours
Heart and lungs = 4-6 hours; liver = 12-24 hours; kidneys = 72 hours
What is donation after cardiac death?–non-___ donors; severe ___ dysfunction; have ___ activity in the brain; death is defined by cessation of ___ and ___
- Non-heart-beating donors
- Severe whole brain dysfunction
- Have electrical activity in the brain
- Death is defined by cessation of circulation and respiration
DCD donors meet the criteria for brain death–T/F?
False–DCD donors do NOT meet the complete criteria for brain death
For DCD, after the patient’s heart stops beating and the physician declares death, the transplant team waits no less than ___ minutes following pulselessness before starting organ recovery
The transplant team waits no less than 5 minutes following pulselessness before starting organ recovery
Anesthesia management ___ (is/is not) required for organ donation after brain death (DBD)
Anesthesia management IS required for organ donation after brain death
Anesthesia management ___ (is/is not) required for organ donation after cardiac death (DCD)
Anesthesia management IS NOT required for organ donation after cardiac death
Anesthesia for organ recovery–anesthesia support of donor organ systems is necessary until the ___
until the proximal aorta is clamped (after which the ventilator, IVs, and cardiac monitors may be discontinued)
Anesthesia for organ recovery–if the lungs are to be recovered for transplantation, anesthesia support ___ (will/will not) be required post cross-clamp
if the lungs are to be recovered for transplantation, anesthesia support will be required post cross-clamp
Why is anesthesia needed post cross-clamp if the lungs are to be recovered?
Anesthesia will hyperventilate the lungs to ensure that the perfusion is delivered at the cellular level
Living organ donors are frequently related to the recipient, healthy individual between ___-___
18-60
Living organ donors must have no history of what (5) things?
- HTN
- Diabetes
- Cancer
- Kidney disease
- Heart disease
Absolute contraindications to organ implantation–active uncontrolled ___; ___; inability to tolerate ___ suppression; severe ___/___ condition (pt unfit for surgery); continued ___ or ___ abuse; ___ malignancy; inability to comply with ___ regimen; lack of ___ support
active uncontrolled infection; AIDS; inability to tolerate immune suppression; severe cardiopulmonary/medical condition (pt unfit for surgery); continued drug or alcohol abuse; extrahepatic malignancy; inability to comply with medical regimen; lack of psychosocial support
What is the most frequent solid organ transplant (order from greatest to least)?
Kidney > Liver > Heart > Lung > Heart/Lung
Gastroparesis, another complication of autonomic neuropathy, increases the risk of ___ during induction of GETA
increases the risk of aspiration during induction of GETA
CRF is characterized by Hgb ___-___; Hgb of ___% or greater is needed for adequate O2 delivery to the heart and transplanted graft
CRF is characterized by Hgb 6-8%; Hgb of 8% or greater is needed for adequate O2 delivery to the heart and transplanted graft
___ evaluation is very important for patients with type 1 insulin dependent diabetes mellitus (IDDM); why?
Airway evaluation because these patients often manifest with stiff joint syndrome, characterized by a fixation of the AO joint, along with limited head extension
Pulmonary function impairment (for patients with type 1 IDDM) is characterized by a decrease in ___ reactivity, a significant restriction of lung volumes, with reduced ___ volume and forced ___ ventilation
Pulmonary function impairment (for patients with type 1 IDDM) is characterized by a decrease in cough reactivity, a significant restriction of lung volumes, with reduced tidal volume and forced expired ventilation
What gas should NOT be used for living kidney donors? Why?
Nitrous oxide–can distend the bowel which can get in surgeons way (because it is done laparoscopically)
What med(s) should be given when the clamps are released from the external iliac vein/artery?
Mannitol or lasix
Be attentive to ___tension after reperfusion of donor kidney because graft function is critically dependent on ___
Be attentive to hypotension after reperfusion of donor kidney because graft function is critically dependent on perfusion pressure
What drugs should be avoided in kidney transplant patients? Why?
Avoid alpha adrenergic drugs b/c transplanted kidney is sensitive to sympathomimetics
Alpha adrenergic drugs enhance blood flow to transplanted organs–T/F?
FALSE–alpha adrenergic drugs compromise blood flow to transplanted organs
Choice of muscle relaxant in kidney transplant patients depends on what electrolyte?
K+ level
In normokalemic patients, ___ (what muscle relaxant?) is safe
Succs– 1-1.5 mg/kg
What are (2) other muscle relaxants that can be used in kidney transplant patients?
- Cisatracurium (Hoffman elimination) (0.1 mg/kg)
- Mivacurium (0.15-0.2 mg/kg)
___ (depolarizing/nondepolarizing) muscle relaxant is preferred in patients who are at high risk of pulmonary aspiration in ESRD d/t autonomic gastropathy, obesity, or on peritoneal dialysis with significant volume of dialysate fluid left in
Depolarizing–succs
Reversal of muscle relaxants with neostigmine and robinul is safe in patients with ESRD–T/F?
True–but sugammadex is even better
If diabetic gastroparesis is a concern, what can be administered immediately prior to the induction of anesthesia to decrease the gastric acid content?
Sodium citrate/citric acid oral solution
What drug can be given to increase gastric emptying and lower esophageal sphincter tone?
Metoclopramide
What drug can be given 6-12 hours prior to induction to decrease gastric acid production?
H2 blocker
What (2) drugs should be given before unclamping vascular supply to transplanted kidney?
- Mannitol
- Loop diuretics
Reperfusion of kidney graft may be associated with ___tension; this is most often related to a reduction in the ___load as a consequence of unclamping the ___; how should you treat?
Reperfusion of kidney graft may be associated with hypotension; this is most often related to a reduction in the preload as a consequence of unclamping the iliac artery; treat with crystalloid, colloid, or low-dose dopamine
Moderate to severe ___tension may accompany emergence from anesthesia for renal transplant; treat with ___ (short/long) acting antihypertensives
hypertension; treat with short acting antihypertensives
Should long acting beta-blockers be used to treat hypertension on emergence from anesthesia for renal transplant?
NO–because they can raise K+ levels
Use short-acting antihypertensives
How is the excretion of drugs affected by a prior renal transplant?
Renal excretion of drugs is usually decreased in patients with a prior renal transplant
Patients with chronic liver dysfunction and cirrhosis have a ___ (hyper/hypo) dynamic circulation with ___ (low/high) peripheral vascular resistance and a/an ___ (increased/decreased) cardiac index
Patients with chronic liver dysfunction and cirrhosis have a hyperdynamic circulation with low peripheral vascular resistance and an increased cardiac index
What are the (3) phases of liver transplantation surgery?
- Preanhepatic phase
- Anhepatic phase
- Neohepatic phase
Preanhepatic phase involves what?
- Lysis of adhesions and exploration of abdomen
- Mobilization of liver and careful dissection of hepatic artery, common bile duct, supra and infra hepatic vena cava and portal vein
Preanhepatic phase–if portal HTN is severe to the degree that mobilizing the liver may result in significant blood loss or the patient is unstable, then what (2) things may be instituted?
- Portocaval shunt
- Venous bypass
Preanhepatic phase–non-shunting procedures are aimed at controlling ___ from ___
non-shunting procedures are aimed at controlling hemorrhage from portosystemic varices
Preanhepatic phase–shunting procedures redirect the portal venous flow into the systemic ___ circulation via a ___ conduit, thus relieving ___, decompressing ___, and at the same time relieving ___
shunting procedures redirect the portal venous flow into the systemic venous circulation via a nonvariceal conduit, thus relieving portal hypertension, decompressing varices, and at the same time relieving ascites
Anesthesia management of preanhepatic phase–hemorrhage leads to ___ instability; ___ problems occur at this stage; impaired ___ from surgical retraction and IVC clamping; ___calcemia, ___kalemia, and metabolic ___osis
hemorrhage leads to CV instability; coagulation problems occur at this stage; impaired venous return from surgical retraction and IVC clamping; hypocalcemia, hyperkalemia, and metabolic acidosis
Anhepatic phase begins with ___
clamping of hepatic blood flow
What (2) big things occur during anhepatic phase?
removal of native liver, implantation of donor liver
Bicaval clamp used during the anhepatic phase clamps what?
Clamps vena cava above and below the liver
Bicaval clamp drops ___, leading to profound ___tension and ___cardia
Bicaval clamp drops preload, leading to profound hypotension and tachycardia
Piggyback technique for anhepatic phase ___ clamps the IVC; what is the benefit of this?
Piggyback technique for anhepatic phase side clamps the IVC; benefit is that it preserves some caval flow/preload
Considerations during anhepatic phase–___, increasing ___lysis, ___pathy, ___osis, ___thermia, and decreased ___ function
hemorrhage, increasing fibrinolysis, coagulopathy, acidosis, hypothermia, and decreased renal function
Anhepatic phase–cardiac output and systemic blood pressure may need to be supported with ___ and ___
inotropes and vasopressors
Anhepatic phase–___ intoxication may occur from rapid infusion of large volumes of blood in absence of liver function
citrate intoxication
What electrolyte abnormality may occur during anhepatic phase? How should you treat?
Hypocalcemia–give calcium
Neohepatic phase begins with what?
Unclamping of the portal vein, hepatic artery, vena cava and reperfusion of the donor liver
What may occur with unclamping of portal vein?
Severe hemodynamic instability–post reperfusion syndrome
Neohepatic phase–before unclamping of portal vein, ___ should be normal, ___ should be corrected, and K+ should be ___
ionized calcium should be normal, acidosis should be corrected, and K+ should be < 4.5
What vasopressors should be used during neohepatic phase? What should be avoided?
Epi, norepi, or both
Avoid fluid overload prior to unclamping
Neohepatic phase–hemodynamics typically stabilize once ___
allograft begins to function
Reperfusion syndrome is characterized by decreased ___, ___, and ___; ___ defects (___arrhythmias, ___); ___ HTN; ___ (increased/decreased) SVR
decreased CO, HR, and BP; conduction defects (bradyarrhythmias, asystole); pulmonary HTN; decreased SVR
Reperfusion syndrome–a rapid increase in ___ can occur, ensure normal pH and electrolytes prior to unclamping
a rapid increase in K+
Reperfusion syndrome–severe coagulopathies occur d/t ___lysis, release of ___, and ___thermia
severe coagulopathies occur d/t fibrinolysis, release of heparin, and hypothermia
Initial indirect signs of a functioning graft = intraoperative ___ production; intraoperative spontaneous correction of ___; improvement in ___
intraoperative bile production; intraoperative spontaneous correction of negative base excess; improvement in coagulation
Interventional radiology–these procedures (i.e.: embolization of cerebral and dural AVMs, coiling of cerebral aneurysms, angioplasty of sclerotic lesions, thrombolysis of acute thromboembolic stroke) often require deliberate ___tension and deliberate ___capnia
often require deliberate hypotension and deliberate hypocapnia
Interventional radiology–deliberate ___tension is called for during cerebral ischemia in an attempt to maximize collateral flow
deliberate hypertension
ECT is performed ___ times a week for ___-___ treatments
ECT is performed 3 times a week for 6-12 treatments
Followed by weekly or monthly maintenance therapy to prevent relapses
MOA of ECT–ECT therapeutic effects are thought to result from the release of ___ during the electrically induced ___
ECT therapeutic effects are thought to result from the release of neurotransmitters during the electrically induced grand-mal seizure
ECT–___ and ___ levels increase immediately after; ___ levels decrease more rapidly thereafter
norepi and epi levels increase immediately after; epi levels decrease more rapidly thereafter
ECT–___ homeostasis is variably affected by ECT; improvement in control of ___ (insulin/non-insulin) dependent diabetes is generally noted, whereas hyperglycemia may be seen when the diabetes is ___ (insulin/non-insulin) dependent
glucose homeostasis is variably affected by ECT; improvement in control of non-insulin dependent diabetes is generally noted, whereas hyperglycemia may be seen when the diabetes is insulin dependent
Physiologic response to ECT–grand mal seizure with ___-___ second ___ phase; ___-___ second ___ phase
grand mal seizure with 10-15 second tonic phase; 30-60 second clonic phase
Other physiologic responses to ECT–___ (increased/decreased) CBF and ICP; CV–initial ___cardia followed by ___tension and ___cardia, ___rhythmias, myocardial ___; ___-term memory loss; muscle ___/___/___; status ___; sudden ___
increased CBF and ICP; CV–initial bradycardia followed by hypertension and tachycardia, dysrhythmias, myocardial ischemia; short-term memory loss; muscle aches/fractures/dislocations; status epilepticus; sudden death
What is one absolute contraindication to ECT?
Pheochromocytoma
Relative contraindications to ECT–increased ___ pressure; recent ___; CV ___ defects; high-risk ___; ___ and ___ aneurysms
Relative contraindications to ECT–increased intracranial pressure; recent CVA; CV conduction defects; high-risk pregnancy; aortic and cerebral aneurysms
What muscle relaxant is preferred for ECT to prevent fractures/dislocations during the seizure?
Succs–0.75-1.5 mg/kg
Preferable to the longer acting nondepolarizing agents
What medication helps reduce ECT-induced myalgia in younger patients?
Toradol 15-30 mg
What (2) medications can prevent the parasympathetic effects of ECT (i.e.: salivation, bradycardia, asystole)?
Robinul and atropine
What (2) meds lessen hemodynamic responses to ECT? Which of the two has less of an effect on seizure duration?
- Labetalol (0.3 mg/kg)
- Esmolol (1 mg/kg)
Esmolol has a lesser effect on seizure duration
What (2) meds administered before induction of anesthesia for ECT are effective in controlling BP without affecting seizure duration?
- Clonidine (1 mcg/kg over 10 mins)
- Dexmedetomidine (1 mcg/kg over 10 mins)
Complications of ECT–seizure activity causes an initial ___ discharge, manifested by ___cardia, occasional ___, premature ___, or a combo of these abnormalities; ___tension and ___ may be noted, and then ___ activity
seizure activity causes an initial parasympathetic discharge, manifested by bradycardia, occasional asystole, premature atrial or ventricular contractions, or a combo of these abnormalities; hypotension and salivation may be noted, and then sympathetic activity
What (2) ECG changes may be seen after ECT? Do these changes indication myocardial infarction?
- ST-segment depression
- T-wave inversion
Occur without any myocardial enzyme changes consistent with myocardial infarction
Arrhythmias associated with ECT, even in patients with preexisting arrhythmias, are self-limited and not in themselves a contraindication to treatment–T/F?
True
What are the most common causes of death from ECT?
MI and arrhythmia
ECT–goal is a seizure that is ___-___ seconds long
30-60 seconds long
