MISC-misc topics 12-23 Flashcards
1
Q
What are 3 causes of Creutzfeldt-Jakob disease
A
- consumption of contaminated animal protein
- contaminated implants (corneal or dural tissue)
- cadaveric pituitary hormone supplement
2
Q
What is the most common source of bloodstream infection in hospitalized patients
A
central venous cath
3
Q
What is the preferred method of skin prep for central line placement
A
chlorhexidine
4
Q
What type of precautions are required for mycobacterium tuberculosis
A
airborne
5
Q
How do positive TB findings appear on CXR
A
apical infiltrates and nodules
6
Q
What is the first line treatment for TB
A
isoniazid
7
Q
What are side effects of isoniazid
A
hepatotoxicity
8
Q
What are side-effects of rifampin
A
- thrombocytopenia
- leukopenia
- anemia
- kidney failure
- orange color of urine, sweat, and tears
9
Q
What procedure incurs the highest risk for transmission of TB
A
bronchoscopy
intubation is the second highest risk
10
Q
How should the TB pt be cared for in the OR
A
- wear N95 for intubation
- HEPA filter in y-piece
- bacterial filter in expiratory limb
- dedicated anesthesia machine
- negative pressure isolation room
11
Q
When can elective surgery in the TB pt proceed
A
- pt on anti-TB meds w/ 3 negative AFB tests
2. demonstrates symptom improvement
12
Q
What defines a positive Mantoux test
A
Induration >10 mm at site of injection
13
Q
How are WBCs divided
A
- Granulocytes (neutrophils, basophils, and eosinophils)
2. agranulocytes (monocytes, lymphocytes)
14
Q
What are neurtophils
A
Immune defense, fighting bacteria and fungal infections
15
Q
What type of cell makes up 60% of WBCs
A
neutrophils
16
Q
What are basophils
A
Essential component of allergic reactions
17
Q
What do 3 chemicals do basophils release
A
- histamine
- leukotrienes
- prostaglandins
18
Q
How does epinephrine impact basophils
A
It prevents degranulation by binding to beta-2 receptors on cell membrane
19
Q
What are eosinophils
A
they defend against parasites
20
Q
What are monocytes
A
They fight bacterial, viral, and fungal infection via phagocytosis
Then present pieces of pathogens to T-lymphocytes
21
Q
What chemical do monocytes release
A
cytokines
22
Q
What are lymphocytes
A
cells that take part in immunity
23
Q
What are 3 types of lymphocytes
A
B-lymphocytes
T-Lymphocytes
Natural killer cells
24
Q
What are the following cells:
B-lymphocytes=
T-Lymphocytes=
Natural killer cells=
A
B-lymphocytes= humoral immunity producing antibodies
T-Lymphocytes= cell-mediated immunity
Natural killer cells= limits spread of tumor and microbial cells
25
What drug class reduces natural killer cells
opioids
26
Which type of lymphocyte produces anti-bodies
B-lymphocytes
27
Which lymphocyte is responsible for cell-mediated versus humoral immunity
humoral = B-lymphocyte
| cell mediated = T-lymphocytes
28
What is the difference between anaphylaxis and anaphylactoid reaction
```
anaphylaxis = requires prior sensitization or cross-reactivity
anaphylactoid = no prior exposure needed
```
29
What are 3 H1 receptor effects of hypersensitivity reactions
1. vasodilation
2. increased vascular permeability
3. smooth muscle contraction
30
What are 2 H2 receptor effects of hypersensitivity reactions
1. cardiac stimulation (tachy)
| 2. gastric acid secretion
31
What arachidonic acid metabolites participate in hypersensitivity reactions
1. leukotrienes
| 2. prostaglandins
32
What are the effects of the following Leukotrienes
| and Prostaglandins
bronchoconstriction and vasodilation
33
What are 4 CV effects of hypersensitivity reactions
1. HoTN
2. Tachycardia
3. Arrhythmia
4. cardiac arrest
34
What are 2 pulmonary effects of hypersensitivity reaction
1. bronchospasm
| 2. laryngeal edema
35
What are 3 physiologic results of bronchospasm
1. dec EtCO2
2. dec SaO2
3. inc PIP
36
What is the cause of laryngeal edema with hypersensitivity reactions
increased mucus production
37
What are 4 skin effects of hypersensitivity reactions
1. flushing
2. urticaria (hives)
3. erythema
4. pruritus
38
What are 3 GI effects of hypersensitivity reactions
1. abdominal cramping
2. N/V
3. Diarrhea
39
How many types of hypersensitivity reactions exist
4
| types 1-4
40
What are the 4 types of hypersensitivity reactions
Type 1= immediate hypersensitivity
Type 2= antibody-mediated
Type 3= immune complex mediated
Type 4= delayed
41
What is type 1 hypersensitivity reaction
Immediate hypersensitivity
Antigen + antibody interaction due to prior antigen sensitization
IgE mediated
42
Which hypersensitivity reaction is IgE mediated
Type 1
43
What lab test determines if an allergic response occurred
Tryptase b/c it is release from mast cells during an allergic reaction
44
What mediates a type 2 reaction
IgG and IgM antibodies
45
What is a type 2 reaction
anti-body mediated by IgG and IgM binding to cell surfaces
46
What does the type 2 reaction result in
activation of the complement cascade
47
What are 2 examples of a type 2 reaction
1. ABO-incompatibility
| 2. HIT
48
What is a type 3 reaction
immune complex mediated
immune complex is formed and deposited into the patient's tissue vs being cleared
49
What is the result of a type 3 reaction
activation of complement cascade
50
What is an example of type 3 reaction
snake venom reaction
51
What is a type 4 reaction
Allergic reaction delayed at least 12 hours following exposure
52
What are 3 examples of type 4 reactions
1. contact dermatitis
2. graft-v-host reaction
3. tissue rejection
53
What pharmacologic treatment is used for intraoperative anaphylaxis
1. epinephrine 5-10 mcg for HoTN or 0.1-1 mg for CV collapse
2. H1-receptor antagonist (diphenhydramine)
3. H2-receptor antagonist (ranitidine, famotidine)
4. hydrocortisone
5. albuterol
6. vasopressin
54
What 3 ways does epinephrine treat anaphylaxis
1. prevents degranulation
2. provides CV support
3. dilate airways
55
What supportive treatment is used for anaphylaxis (non-pharmacologic)
1. discontinue offending agent
2. Increase FiO2
3. Provide airway support
4. Liberal IV hydration
56
What is the most common cause of perioperative anaphylaxis
NMB drugs w/ succinylcholine as the most common
57
What are the top 3 causes of intraoperative anaphylaxis
NMB, latex, and abx
58
What are high risk groups for latex allergy
1. spina bifida, myelomeningocele
2. atopy
3. health care worker
4. allergy to banana, kiwi, mango, papaya, pineapple or tomato
59
Which chemotherapeutic drug does not suppress bone marrow or cause thrombocytopenia
bleomycin
60
```
Name the most pertinent side-effect for anesthesia and the following chemotherapeutic agents:
Cisplatin=
Vincristine=
Bleomycin=
Doxorubicin=
5-fluorouracil=
Methotrexate=
```
```
Cisplatin= acoustic n. injury, nephrotoxic
Vincristine= peripheral neuropathy
Bleomycin= pulmonary fibrosis
Doxorubicin= cardiotoxic
5-fluorouracil= bone marrow suppression
Methotrexate= bone marrow suppression
```
61
History of which chemotherapeutic agent would require an FiO2 <30% and why
bleomycin d/t pulmonary fibrosis
62
Which 2 chemotherapeutic agents are antitumor antibiotics
bleomycin
| doxorubicin
63
What are 5 hormones that regulate digestive activity
1. gastrin
2. secretin
3. cholecystokinin
4. gastric inhibitory peptide
5. somatostatin
64
What are the functions for the following digestive hormones:
gastrin=
secretin=
gastrin= increases stomach acid when food enters stomach and stimulates chief cells to secrete pepsinogen
secretin= signals the pancreas to secrete HCO3 and the liver to secrete bile
65
What are the functions for the following digestive hormones:
Cholecystokinin=
Gastric inhibitory peptide=
Somatostatin=
Cholecystokinin= signals pancreas to release digestive enzymes and GB to contract
Gastric inhibitory peptide= slows gastric emptying, stimulates insulin release
Somatostatin= universal off switch for digestion
66
Gastrin:
production site=
stimulus=
function=
production site= G cells of stomach
stimulus= food in stomach
function= inc gastric acid, inc pepsinogen
67
Secretin:
production site=
stimulus=
function=
production site= S cells of small intestines
stimulus= acid in duodenum
function= inc pancreatic HCO3, dec gastrin secretion
68
Cholecystokinin:
production site=
stimulus=
function=
production site= I cells of small intestines
stimulus= food in duodenum
function= inc GB contraction, release bile, inc pancreatic enzymes, dec gastric emptying
69
Gastric inhibitory peptide:
production site=
stimulus=
function=
production site= K cells of small intestines
stimulus= food in duodenum
function= inc insulin release, dec gastric acid, dec gastric motility
70
Somatostatin:
production site=
stimulus=
function=
production site= D cells pancreatic islet, stomach, small intestines
stimulus= food in gut, gastrin, CCK
function= dec all GI fxns
71
Which GI hormone is increased in pts with Zollinger-Ellison syndrome
Gastrin d/t gastrin secreting tumor
72
What is the cause of GB following a fatty meal
increased CCK release
73
What gastric hormone treats carcinoid tumors
somatostatin
74
What are the 2 factors that affect gastric barrier pressure
1. LES tone
| 2. intragastric pressure
75
What measure can decrease barrier pressure
1. reduced LES tone
| 2. increase intragastric pressure
76
What 3 things can decrease barrier pressure by decreasing LES tone
1. anticholinergics
2. cricoid pressure
3. pregnancy
77
What medication can increase barrier pressure by increasing LES tone
Metoclopramide
78
How does succinylcholine affect gastric barrier pressure
It has a net 0 effect d/t increase in LES tone and increase in intragastric pressure that cancel each other out
79
VIEW VIDEO of PONV
VIEW video on ponv 72 of 85
80
Where does the vomiting center reside
the nucleus tractus solitarius in the MEDULLA
81
3 sites that sensory input for the vomiting center originate
1. chemoreceptor trigger zone
2. GI tract
3. Vestibular system
82
How does sensory input from the GI tract stimulate nausea
Via 5-HT3 and NK-1 receptors
83
How does sensory input from the CRT zone stimulate nausea
Via 4 mediators; 5-HT3, NK-1, DA-2 receptors, and noxious chemicals
84
How does sensory input from the vestibular apparatus stimulate nausea
Via H1 and M1 receptors
85
What are 6 anti-emetic drug classes
1. 5-Ht3 antagonists
2. Neurokinin-1 antagonists
3. dopamine antagonists
4. antihistamines
5. anticholinergics
6. steroids
86
5-HT3 antagonists:
Receptor target=
Ligand=
examples=
Receptor target= 5-HT3
Ligand= serotonin
examples= ondansetron, dolasetron
87
Neurokinin-1 antagonists:
Receptor target=
Ligand=
examples=
Receptor target= NK-1
Ligand= substance P
examples= Aprepitant
88
Dopamine antagonist:
Receptor target=
Ligand=
examples=
Receptor target= D2
Ligand= dopamine
examples= droperidol, haloperidol, metoclopramide, prochlorperazine
89
Antihistamines:
Receptor target=
Ligand=
examples=
Receptor target= H1, M1
Ligand= histamine, ACh
examples= scopolamine
90
Steroids:
Receptor target=
Ligand=
examples=
Receptor target= intracellular steroid receptors
Ligand= steroids
examples= dexamethasone
91
```
Dose range for the following antiemetics:
Ondansetron=
Granisetron=
Dolasetron=
Aprepitant=
```
```
Ondansetron= 4-8 mg
Granisetron= 1 mg
Dolasetron= 12.5 mg
Aprepitant= 40 mg
```
92
```
Dose range for the following antiemetics:
Droperidol=
Haloperidol=
Metoclopramide=
Prochlorperazine=
```
Droperidol= 0.625-1.25 mg
Haloperidol= 0.5-2 mg
Metoclopramide= 10-20 mg
Prochlorperazine=10 mg
93
Dose range for the following antiemetics:
Diphenhydramine=
hydroxyzine=
promethazine=
```
Diphenhydramine= 25 mg
hydroxyzine= 12.5-25 mg
promethazine= 12.5-25 mg
```
94
What are 6 patient risk factors for PONV
1. female
2. nonsmoker
3. h/o motion sickness
4. previous PONV
5. age youth>elderly
95
What are 8 procedures that increase risk for PONV
1. Long duration
2. GYN procedures
3. laparoscopy
4. breast
5. plastics
6. strabismus
7. orchiopexy
8. T&A
96
What are 5 anesthetic factors that increase PONV risk
1. halogenated anesthetics
2. N2O
3. opioids
4. etomidate
5. neostigmine
97
What anesthetic types can decrease PONV
RA or TIVA
98
Why is the CTZ prone to emetic stimulation
The BBB is poorly developed around the CTZ so noxious chemicals can stimulate it (i.e. etoh, chemo)
99
When should the timing of administration for dexamethasone and ondansetron occur intraoperatively
```
dexa = with induction
zof = 30 min p/t emergence
```
100
Which antiemetics can prolong QT
5-HT3 antagonists and droperidol
101
Which antiemetics have the potential to cause extrapyramidal effects
1. butyrophenones (droperidole)
| 2. metoclopramide
102
Which antiemetic is contraindicated with bowel obstruction
metoclopramide d/t prokinetic effect
103
Which antiemetics are contraindicated in pts w/ parkinsons and why
Dopamine antagonists d/t possibility of extrapyramidal effects (and pts are already on dopamine agonists)
104
What causes motion induced nasuea
M1 and H1 stimulation in the vestibular system of the inner ear
105
Which antiemetic target the vestibular system
scopolamine
diphenhydramine
hydroxyzine
promethazine
106
Which anesthetic agent can produce antiemetic effects
Propofol 10 - 20 mg
107
How is ephedrine used for PONV
25 mg IM can maintain BP and cerebral perfusion and decrease HoTN associated N/V
108
what is a nonpharmacologic measure against PONV
P6 acupressure point
| 3 finger breadths below the wrist on inner forearm in between the 2 tendons
109
What is the technical name for bone cement
Methyl methacrylate
110
What is the purpose of bone cement
to bind implants to bones during ortho surgery
111
What is bone cement effect on intramedullary pressures
It can be increased up to 500 mmHg
112
What is the result of increased intramedullary pressure from bone cement
It can cause microemboli of fat, bone marrow, or cement, which can travel to the lungs
113
What is the result of microemboli caused by bone cement
V/Q mismatch, increase in deadspace (V > Q)
114
What is are 6 effects of methyl methacrylate if it enters the systemic circulation
1. Bradycardia
2. Dysrhythmias
3. HoTN d/t dec SVR
4. pulmonary HTN d/t inc PVR
5. hypoxia
6. cardiac arrest
115
Which orthopedic procedure is associated with the highest risk of bone cement implantation syndrome
hip arthroplasty
116
What are secondary procedures that increase risk for bone cement implantation syndrome
1. knee arthroplasty
2. vertebroplasty
3. kyphoplasty
117
What are the first 2 signs of BCIS in an awake pt under regional anesthesia
1. dyspnea
| 2. AMS
118
What is the first sign of BCIS in the pt under GA
decreased EtCO2
119
What is the treatment process for BCIS
1. 100% FiO2
2. IV hydration
3. phenylephrine (inc SVR)
120
Fat embolism is a complication of what type of trauma
| when is the risk greatest
long bone trauma
risk = greatest in first 72 hours after injury
121
What are 3 risk factors for fat embolism
1. pelvic fracture
2. femoral fracture
3. instrumentation of femoral medullary canal
122
What is the triad of FES
1. respiratory insufficiency
2. neurologic involvement
3. Petechial rash of neck, axilla, oral mucosa, and conjunctiva
123
How does respiratory insufficiency from FES present
1. hypoxemia
2. bilat infiltrates on CXR
3. ARDS
124
Where does the petechial rash associated with FES present
Skin of neck and axilla
Oral mucosa
Conjunctiva
125
Why is the maximum time for tourniquet inflation 2 horus
to decrease risk of ischemic damage
126
Describe cell metabolism distal to tourniquets and the risks associated with it
Cells shift to anaerobic metabolism and byproducts accumulate as long as the tourniquet is inflated
127
What are 2 ways that tourniquet release stresses the body
1. restored blood flow to extremities produces a relative decrease in circulating blood volume
2. Products of cellular hypoxia enter systemic circulation
Both can cause HoTN
128
When the tourniquet is released, what are 5 transient physiologic changes that can occur
1. increased EtCO2
2. dec core body temp
3. HoTN
4. Dec SvO2
5. Metabolic acidosis
129
When can tourniquet pain begin following inflation
about 45-60 minutes
130
What is the cause of tourniquet pain and how is it transmitted
```
Cause = tissue ischemia
Transmission = C-fibers (slow pain)
```
131
How does tourniquet pain respond to analgesia
It is unresponsive and can even breakthrough regional anesthesia
132
How does tourniquet pain manifest under GA
1. HTN
| 2. Tachycardia
133
What are 3 results of COX-1 inhibition
1. impaired plt function
2. gastric irritation
3. reduced renal BF
134
When is COX-2 normally expressed
during inflammation
135
What are 3 results of COX-2 inhibition
1. analgesia
2. anti-inflammatory
3. antipyretic
136
How is arachidonic acid activated
Phospholipase A2 acts on membrane phospholipids, producing AA
137
Which COX enzymes are affected by NSAIDs and ASA
Both COX-1 and 2
138
Name 6 non-selective COX inhibitors
1. ASA
2. ibuprofen
3. naproxen
4. ketorolac
5. diclofenac
6. indomethacin
139
Name a COX-2 selective inhibitors
1. celecoxib
140
What are 3 CV complications associated with COX inhibitors
Inc risk for
1. HTN
2. MI
3. HF
141
Which COX inhibitor type is more prone to CV risks
COX-2 > COX-1
142
How do COX inhibitors affect the pulmonary system
They decrease PGs which eventually cause bronchospasm
143
What are hematologic complications associated with COX inhibitors
Plt inhibition and increased bleeding risk
144
What are renal complications associated with COX inhibitors
Decreased PGs can cause dec renal BF
| They should be avoided in pts with renal disease
145
What pt should COX inhibitors be avoided
Pts with renal disease
146
What CNS symptoms are associated with COX inhibitors
Tinnitus
147
How can COX inhibitors affect bones
They can dec osteoclast and osteoblast activity and impair bone healing
148
What are GI complications associated with COX inhibitors
gastric ulcers and bleeding
149
How can COX inhibitors affect other drugs
NSAIDs displace albumin bound drugs and increase their concentration
Such drugs include warfarin, phenytoin, and valproic acid
150
what is the morphine equivalent dose of ketorolac 30 mg
morphine 10 mg
151
What is Samter's triad
1. asthma
2. allergic rhinitis
3. nasal polyps
152
Which COX inhibitor exacerbates respiratory disease
ASA
153
Which 5 herbal supplements can increase bleeding risk
1. garlic
2. ginkgo biloba
3. ginger
4. ginseng
5. Saw palmetto
154
Which 2 herbal supplements have sympathomimetic effects
1. Ephedra (Ma Huang)
| 2. Ginseng
155
How does long-term use of ephedra affect hemodynamic stability
It can deplete catecholamines and contribute to hemodynamic instability
156
Which 2 herbal supplements can interact with MAOis and contribute to serotonin syndrome
1. ephedra
| 2. St John's Wort
157
Which herbal supplement mimics the effect of aldosterone
Licorice
158
Which 3 herbal supplements can prolong duration of anesthetic agents
1. Kava Kava
2. St John's Wort
3. Valerian
159
Which herbal supplements can decrease MAC
| By what mechanism
1. Kava Kava
2. Valerian
Mechanism = increases GABA
160
```
What are the key interactions of the following herbal supplements:
Garlic=
Ginger=
Ginkgo biloba=
Ginseng=
```
Garlic= inc bleeding, dec glucose
Ginger= inc bleeding
Ginkgo biloba= inc bleeding
Ginseng= inc bleeding, enhanced SNS effects of sympathomimetics, dec glucose
161
What are the key interactions of the following herbal supplements:
Ephedra=
Kava kava=
licorice=
Ephedra= MAOi interactions leading to serotonin sx, catecholamine depletion, sympathomimetic
Kava kava= dec MAC, prolong anesthetic
licorice= mimic aldosterone, Na+ and h2o retention
162
What are the key interactions of the following herbal supplements:
Saw palmetto=
St. John's Wort=
Valerian=
Saw palmetto= inc bleeding
St. John's Wort= CYP3A4 induction, prolong anesthetic, interacts w/ MAOis causing SS
Valerian= dec MAC, prolong anesthetic
163
Which herbal supplement can cause induction of CYP 3A4. What medications can be affected by this
St. John's Wort
Meds = dec serum level of warfarin, protease inhibitors, and digoxin
164
What are 4 MRI safe metals
1. stainless steel
2. titanium
3. aluminum
4. copper
165
What 4 implants or debris should be verified before MRI
1. PM/AICD
2. aneurysm clipping
3. metal implants
4. implantable pumps
5. shrapnel
166
What color are MRI safe cylinders
Silver, with the color coded top
167
According to closed claims analysis, what are the 4 most common causes of injury that result in claims
1. regional anesthesia
2. respiratory events
3. CV events
4. equipment failure
168
What is the modified Aldrete scoring system
a measure to quantify readiness for discharge from PACU
169
What Aldrete score indicates readiness for discharge
9 or greater
170
What are the 5 domains of the Aldrete assessment
1. activity
2. respirations
3. circulation
4. consciousness
5. O2 saturation
