MM Lightning Bolts Flashcards
Describe the murmurs heard, and specify the stethoscope location where they are best heard, if the patient has AS?
Systolic murmur at the 2nd right intercostal space with transmission to the neck often mimicking a carotid bruit
Name the organs in the VRG. What percent of CO goes to each of these organs?
VRG: Brain, Kidneys, Liver, Heart, Digestive Tract, and Endocrine tissue.
25% of CO to Liver; 5% Heart; 15% Brain; 20% Kidneys; 100% Lungs
What nerves carry afferent and efferent signals of the Bainbridge reflex?
Stretch (in RA) receptors send afferent signals to the medulla via the vagus
Efferent signals travel form the medulla via sympathetic nerves
What does the Bainbridge reflex help prevent?
Helps prevent damming up of blood in veins, atria, and Pulmonary Circulation.
What happens with the Bainbridge reflex?
Increases HR up to 75% and Increases contractility
The lungs have a dual blood supply, bronchial arteries and pulmonary arteries.
Where do the bronchial arteries arise and which lung tissues are supplied by bronchial arteries?
The bronchial arteries arise from the descending thoracic aorta and supply the bronchi and bronchioles.
Also supply supporting tissue such as nerves, pulmonary vessels, and visceral pleura. (High Pressure, Low Flow)
The lungs have a dual blood supply, bronchial arteries and pulmonary arteries.
Where do pulmonary arteries arise and what lung tissues are supplied by pulmonary arteries?
Arise from the RV and branch into R and L.
Supply venous blood to structures distal to the terminal bronchioles.
Low Pressure, High Flow
Describe the venous drainage of the lungs
Drainage occurs via bronchial, azygous, hemiazygos, and intercostal veins-> then drain into brachiocephalic veins of the neck -> finally the SVC
Where do preganglionic parasympathetic nerves originate?
From Nuclei of CN III, VII, IX, and X in the brainstem (3, 7, 9, 10)
Also from S2-S4. (AKA Craniosacral Division)
How much cerebrospinal fluid is produced per day?
500-750 mL/day (15-30mL/hr)
Myasthenia Gravis is characterized by what symptoms?
Characterized by weakness and fatigue of skeletal muscle. Can be asymmetric, confined to one group of muscles, or generalized.
What is the cause of Myasthenia graves symptoms?
Caused by autoimmune destruction of the nicotinic AcH receptors at the neuromuscular junction
Identify the biochemical triad that defines diabetic keto acidosis
Ketonemia,
Hyperglycemia,
Acidemia
What are the diagnostic criteria for diabetic ketoacidosis?
Diagnostic criteria include
- Ketonemia or ketonuria;
- BG > 250 mg/dL or known DM;
- Serum BiCarb < 18mmol/L or arterial pH < 7.3
It is generally recommended to cancel non urgent or elective surgery in the patient with DM if the serum glucose rises above what value?
If there is an acute rise above 400 mg/dL
Describe an individuals fluid and electrolyte status during diabetic keto acidosis?
Dehydration and hypovolemic shock from hyperglycemic osmotic diuresis
Compensatory hyperventilation (kuss maul)
Life threatening electrolyte depletion (hypokalemia & hypophosphatemia)
Anion gap > 10
An important early step in hemostasis is vasoconstriction of damaged vessels.
Platelets play a key role in this initial vasoconstriction by release of what substances?
Vascular contraction is a result of autonomic reflexes and the release of thromboxane A2 and ADP from platelets.
The endothelium releases many procoagulant factors following vascular injury: Name two key procoagulants released by the endothelium
Procoagulant factors release by the endothelium include Tissue factor (Factor III), and Factor VIII:vWF (von Willibrands Factor)
In addition to its role in early vasoconstriction, thromboxane A2 plays a key role in activation and aggregation of platelets. Describe the action of TxA2 in activation and adhesion of platelets
Platelets are activate by ADP and TxA2. They are ligand for GPCR’s that trigger signal transduction pathways leading to expression of GPIIb/IIIA receptors (Fibrinogen receptors) on platelet surface. TxA2 amplifies platelet agonist such as thombin (IIa) and ADP.
If their immune system overreacts to an allergen, a hypersensitivity reaction occurs.
Immune-mediated hypersensitivity reactions are classified into four groups by mechanism of act: list each type of allergic reaction and give a one sentence description of the reaction
Type I: Anaphylactic or immediate-type hypersensitivity reactions
Type II: Cytotoxic reactions (antibody-dependent cell-mediated cytotoxicity)
Type III: Immune complex reactions that produce tissue damage by deposition of immune complexes
Type IV: Delayed type hypersensitivity reactions resulting from the interaction of sensitized lymphocytes with specific antigens
Describe Type I allergic reactions: include participating cells and antibody and list common examples
An allergen interacts with IgE antibodies on mast cells or circulating basophils to trigger mediator release.
The key mediator is histamine.
Example of Type I reactions include allergic rhinitis, extrinsic asthma, and anaphylaxis
Describe Type II hypersensitive reactions: include participating cells and antibodies and list common examples
IgM and IgG mediated against antigens on the surface of foreign cells or extracellular tissue components.
Cell damage is produced by (1) direct cell lysis after complete complement cascade activation, (2) increased phagocytosis by macrophages, or (3) Killer T-Cell lymphocytes producing antibody dependent cell mediated cytotoxic effects.
Examples: ABO-Incompatability, Drug-induced immune hemolytic anemia, HIT, Myasthenia Gravis, and Goodpasture’s syndrome
Describe Type III allergic reactions, participating cells and antibodies and common examples
Result from circulating soluble antigens and antibodies that bind to form insoluble complexes which then deposit in the micro-vasculature.
Mechanism of tissue injury involves activation of complement and recruitment of phagocytes.
Examples: SLE, RA, glomerulonephritis and classic serum sickness
Describe Type IV allergic reactions, participating cells and antibodies and common examples
Result from sensitized lymphocytes with specific antigens.
Cytotoxic T-Cells are produced specifically to kill target cells that bear antigens identical with those that trigger the reactions.
Examples include tissue rejection, graft-vs-host, contact dermatitis, tuberculin immunity, and Johnson-Stevens syndrome. Another form is granulomatous hypersensitivity such as TB, Sarcoidosis, and Crohn’s disease.
What is anaphylaxis?
A severe, generalized, life-threatening immediate hypersensitivity reaction marked by interstitial edema -particularly laryngeal edema- bronchospasm, and CV collapse.
How does non-immune mediated anaphylaxis compare with anaphylaxis?
(aka anaphylactoid reaction) The triggering antigen directly stimulates mast cell and basophils; NO IgE mediated trigger. Symptoms are less severe.
Where is the J-Point in the ECG waveform?
The point where the QRS complex ends and the ST segment begins
How is the J-Point used in ECG interpretation?
ST segment changes are measured lead voltage at 60 to 80 milliseconds after the J-Point to the isoelectic value
What features uniquely identify LBBB?
(1) Broad, notched R wave in left side leads
(2) Deep S waves in the right precordial leads
(3) absent septal Q waves
What features uniquely identify RBBB?
(1) Prominent notched R-wave with “M” pattern and rsr’, rsR’ or rSR’ on the right side leads (V1)
(2) wide S on left side leads (V6)
Which is more prevalent, RBBB or LBBB? Which is more ominous?
RBBB is more prevalent. LBBB is more ominous and is associated with ischemic heart Dz, HTN, and valvular Dz.
What is one concern with PA catheter placement in a patient with LBBB?
May precipitate a RBBB which would lead to complete heart block (3rd degree heart block)
Which volatile agents most depress the baroreceptor reflex and which least depress it?
Most depressed by Halothane and Sevo.
Least depressed by Iso and Des.
What are the minimum alveolar concentration (MAC) requirements for a full-term infant, compared to the adult?
MAC for a full term infant is the same as for an adult
At what age is the MAC highest? Which agent is the exception to this rule?
At 6 months, MAC is 50% greater that adult (1.5x). The exception to this rule is sevoflurane which has a MAC value that is greatest in the neonate (3.3%).
Which IV sedative hypnotic inhibits platelet aggregation?
Propofol inhibits platelet aggregation that is induced by TxA2 and platelet activation factor.
List the local anesthetics that are amides?
(two "i") Lidocaine, Prilocaine, Mepivacaine, Bupivacaine, Levobupivacaine, Ropivacaine
The alpha-2 adrenergic receptor agonist, clonidine, acts where centrally to produce what therapeutic effect?
Stimulation of Alpha-2 receptors in the Vasomotor center of the medulla to inhibit SNS outflow. (Decreases BP)
Alpha-2 adrenergic receptor agonists antagonize the SNS peripherally. How?
Alpha-2 receptors are found on the surface membrane of NE containing presynaptic nerve terminals of sympathetic postganglionic neurons
Patient is on continuous sodium nitroprusside drip with the following ABG: pH= 7.21, PaCO2= 32mmHg, PaO2= 104mmHg, Base Excess= -10mEq/L. What is your next action?
Turn off Drip. ABG suggest cyanide toxicity. BE suggest metabolic acidosis, Low PaCO2 demonstrates partial respect compensation.
Define autacoid and list examples
They are biological factors that act like hormones (they have paracrine effect).
Produced in minute quantities and have only brief local effects.
Examples: eicosanoids, angiotensin, NO, kinins, histamine, serotonin, and endothelins.
What are eicosanoids?
Signaling molecules derived from omega-3 and omega-6 fatty acids including arachidonic acid.
Examples: prostaglandins, thromboxane, leukotrienes, and lipoxins.
They are not stores but are stored on demand.
How are prostanoids related to eicosanoids?
Prostanoids are metabolic derivatives of arachidonic acid (a category of eicosanoids). Examples: prostaglandins, prostacyclin, & thomboxanes.
Arachidonic acid, an omega-6 fatty acid, is liberated from membrane phospholipids by the action of what enzyme?
Phospholipase A2 (PLA2), a calcium-dependent enzyme, acts upon membrane phospholipids to release arachidonic acid. This is the rate limiting step in eicosanoid synthesis.
Which prostanoid is implicated in the rebound prothrombotic state often seen following discontinuation of anti platelet therapy?
An increase in TxA2 activity is seen during rebound period.
Name two prostanoids that are potent inhibitors of platelet aggregation and thus promote and maintain an anti thrombotic state in vessels?
Prostacyclin (PGI2) and PGD2 along with NO are released by vascular endothelium.
Which prostanoid produces vascular smooth muscle contraction and is thus a potent vasoconstrictor?
TxA2
List two prostanoids that cause bronchodilation and three that cause bronchoconstriction.
- Bronchodilation: PGE2 & Prostacyclin (PGI2)
- Bronchoconstriction: PGF2a, PGD2, & TxA2
How are leukotrienes related to eicosanoids?
Leukotrienes are metabolic derivatives of arachidonic acid (produced by LOX)
What action do leukotrienes (LK) have on the lungs? What cells synthesize and release LTs?
Activated mast cells and basophils synthesize/release LK.
LK evoke inflammatory response in the lungs including intense bronchoconstriction and increase pulmonary vascular permeability.
They also promote eosinophil degranulation and attract neutrophils.
What is another name for the mixture of leukotrienes C4, D4, and E4?
The classic slow reacting substance of anaphylaxis (SRS-A)
Which herbal supplement is a potent inhibitor of Thromboxane synthetase and thus has synergistic effects with other anti platelet agents?
Ginger: increases bleeding time and morbidity
Which dopamine antagonist is the only FDA-approves agent for treatment of diabetic gastroparesis?
Metoclopramide -> Cholinergic stimulation
List seven common adverse effects of metoclopramide?
(1) Treatable hypotension and tachycardia (most common)
(2) Sedation
(3) Restlessness
(4) Extrapyramidal symptoms
(5) ABD cramping after rapid injection
(6) Inhibition of plasma cholinesterase
(7) Galactorrhea
State four contraindications to administration of metoclopramide?
(1) Parkinsons Dz
(2) Restless Leg
(3) Movement disorders related to dopamine inhibition or depletion
(4) Intestinal obstruction
For what conditions are Alpha-Glucosidase inhibitors administered?
Insulin resistance and hyperglycemia in metabolic syndrome, DM-II, & obesity
How do Alpha-Glucosidase inhibitors work?
Decrease postprandial carb digestion and absorption
List the most common side effects of Alpha-glucosidase inhibitors?
Flatulance, ABD cramping, and diarrhea
Bleomycin is toxic to what body organ?
Pulmonary system
Why does bleomycin accumulate in the lungs?
The enzyme that inactivates bleomycin, hydrolase, is relatively deficient in lung tissue.
Antiemetic agents typically block which receptors?
(1) Dopamine receptors (D2)
(2) Histamine receptors (H1)
(3) Muscarinic AcH receptors
(4) Serotonin receptors (5-HT3)
(5) GABA(A) receptors
(6) Neurokinin-1 Receptors (NK1)
Correlate the clinically used antimemetics with their primary receptor
D2: Metoclopramide, droperidol, haloperidol, alizapride, perphenazine, prochlorperazine
H1: Dimenhydrinate, diphenhydramine, cyclizing, Promethazine
Muscarinic: Hyoscine
Serotonin receptors (setron): Odansetron, Dolasetron, granisetron…..
GABA(A): Midazolam, Diazepam, Lorazepam
NK1: Aprepitant
What effect does hypothermia have on gas solubility?
Causes an increase in gas solubility
Define the inverse square law
The strength of emanating energy is inversely proportional to the square of its distance from the source (Isaac Newton)
Occupational exposure to radiation comes primarily from X-Rays scattered by the patient and the surrounding equipment, rather than directly from the X-Ray generator itself.
State 4 methods to minimize exposure to scattered radiation
(1) Limit Duration
(2) Increase Distance
(3) Deflect: i.e. Protective shielding
(4) Dosimeter to monitor exposure
What is the minimum safe distance from the X-Ray source
6 feet (and behind or to the side)
What is the annual dose limit for occupational exposure to radiation? The lifetime dose limit?
50 mSv/yr (5 rem) or 10 mSv (1 rem) x age in years
What is daltons law?
Law of partial Pressure: Total Press = P1 + P2 + P3……
If atmospheric pressure is 710mmHg and the O2:N2O delivery is 2L:4L, what PP of O2 and what PP of N2O are delivered to the patient? Whose law permits these calculations?
1/3 x 710 mmHg = O2
2/3 x 710 mmHg = N2O
Daltons Law
In which publication is the purity of medical gases specified and who enforces purity of gases?
US Pharmacopoeia and the FDA
Which US government agency regulates matters affecting the safety and health of employees in all industries?
Department of Labor (DOL)
Which two executive-branch agencies were created to carry out the provisions of OSHA?
(1) NIOSH (part of CDC)
2) OSHA (part of DOL
What volume of anesthetic vapor is produced by 1 mL of volatile anesthetic liquid?
1mL of liquid = ~200mL of anesthetic vapor at 20 C and 1 atm
Describe SIMV
Intermittent mandatory breaths are given in synchrony with and triggered by the patients spont. efforts
Is SIMV pressure or volume mode? What aspect of ventilation is detected to trigger synchronization with the patient ventilatory effort?
either pressure or volume cycled. Trigger window controls amount of time vent is sensitive to spont. breaths. Senses neg pressure of spont breath.
Compare and contrast the Effects of IV vs IHA on sensory evoked potentials
(1) IHA’s Generally have more depressant effect that IV agents
(2) Combinations of drugs produce additive effects
(3) Prop and thiopental attenuate the amplitude of all evoked potentials but do not obliterate them
(4) Opioids and Benzos have negligible effects
(5) Ketamine and Etomidate enhance the quality of signals in patients with weak baseline SSEP signals
Rank the three major sensory evoked responses- SSEP, VEP, and BAPE - based upon sensitivity to anesthetic agents
BAEP (Barely)
Somatosensory (Somewhat)
Visual (Very)
Describe the placement of the 5 lead ECG cables?
Limb electrodes on corresponding limb (LA, RA, LL, RL) with a 5th chest electrode placed in any of the standard precordial (V1-V6) locations
Describe the proper placement of RA, LA, LL, and RL electrodes according to the Mason-Likar lead position scheme
RA: Over the outer RT clavicle
LA: over the outer LT clavicle
LL: Placed near the left iliac crest or midway b/w the costal margin and LT iliac crest alone the anterior racial line
RL: Placed at an convenient location on the body
Which unipolar lead in the 5-Lead monitoring system is preferred when arrhythmias are anticipated? Which unipolar leads are preferred for monitoring ischemia?
V1 for arrhythmia.
V3-V5 for ischemia
What advantage does CO2 monitoring have over pulse oximetry or VS monitoring?
Detects acute, complete airway obstruction and extubation more rapidly
What issues may increase the Beta angle of the CO2 waveform? Decrease the Beta angle?
Increase: rebreathing (CO2 absorbent issue, malfunctioning unidirectional valve)
Decrease: if the slope of phase III is decreased
Why might low or poor perfusion states interfere with accurate pulse oximeter readings?
They require adequate pulsation to distinguish light absorbed from arterial blood from venous blood and tissue light (plethysmographic analysis)
List two factors that lead to falsely HIGH pulse oximeter readings
Carboxyhemoglobin and methemoglobin ( when true SaO2 < 85%)
Explain how the presence of methemoglobin can lead to both falsely high and falsely low pulse oximeter readings
Absorbs both 660 and 940 nm so the pulse ox detect equal amounts of oxygen and deoxy-hemoglobin (readings of 80-85%)
List 5 factors that generally have no significant effect on pulse oximeter readings
(1) Polycythemia
(2) Skin Pigmentation
(3) Alternate hemoglobins
(4) Red henna dye
(5) Jaundice
Define MET
Metabolic Equivalent is defined as the amount of oxygen consumed while sitting at rest. They are used to evaluate functional capacity and reserve.
Correlate equivalent level of activity with MET 1-4
(1) eating, working at a computer, or dressing
(2) Walking down stairs, walking in your house, or cooking
(3) Walking one or two blocks on level ground
(4) Raking leaves, gardening
Correlate equivalent level of activity with MET 5-8
(5) climing one flight of stairs, bicycling, or dancing
(6) playing golf, or carrying golf clubs
(7) playing singles tennis
(8) rapidly climbing stairs or jogging
Correlate equivalent level of activity with MET 9-12
(9) Jumping rope slowly or moderate cycling
(10) swimming quickly, running, or jogging briskly
(11) cross country skiing or playing full court basketball
(12) running rapidly for moderate to long distances
Define the physical status index “ASA PS class 6.”
A declared brain dead patient whose organs are being removed for donor purposes
How much dextrose is in a 1 L bag of D5W? What is the dextrose concentration (mg/mL)?
50 grams of dextrose/L
or
50mg/mL
In addition to sodium and potassium, what three electrolytes does Normosol-R contain?
Na 140 mEq/L K 5 mEq/L Mg 3 mEq/L Acetate 27 mEq/L Gluconate 23 mEq/L
List 4 reasons why dextran are of limited use nowadays?
(1) Antithrombotic effects, particularly inhibition of platelet aggregation
(2) interference with blood cross matching- dextran coat RBC membranes
(3) Anaphylactic and anaphylactoid reactions
(4) Renal Dysfunction resulting from osmotic nephrosis
Which blood components are found in pRBC’s?
Contains RBCs in anti coagulated plasma. contains citrated phosphate dextrose adenine-1 (CPDA-1)
The addition of adenine to pRBC’s stored in CPD extend extend the storage time from ____ days to _____ days
From 21 to 35 days
Name three preservatives that extend the storage time of pRBC’s form 35 to 42 days
As-1 (adsol)
AS-3 (Nutricel)
AS-5 (Optisol)
Describe the biochemical alterations of stored blood
Acidic,
Hyponatremic,
Hyperkalemic,
Hypoglycemic plasma (inc lactate) with increased free HgB
Decreased 2-3 DPG
Which blood components are present in FFP?
ALL clotting factors, naturally occurring inhibitors of coagulation, and antithrombin
Which blood components are present in Cryoprecipitate?
Contains concentrated factors I, VIII, vWF, XIII, Fibronectin
Which blood product contains the greatest concentration of fibrinogen (Factor I)?
Cryo 15g/L > FFP 2.5g/L
State the threshold for fibrinogen replacement?
Less than 80-100 mg/dL
How many bags of cryo constitute a single dose? What is the expected fibrinogen increase after a single dose?
A single dose = 5 bags of cryo
Raises fibrinogen by 50 mg/dL
According to the ASA’s 2006 updated practice guidelines, at what hemoglobin level is RBC transfusion rarely indicated? At what level is it always indicated?
Rarely >10 g/dL
Always <6 g/dL
According to the ASA’s 2006 updated practice guidelines, what factor justifies RBC transfusion when HgB levels are intermediate (6-10 mg/dL)?
Should be based on patients risk of complications of inadequate oxygenation
List four (4) variations of head-elevated surgical positions
(1) sitting, including lounge chair and beach chair variations
(2) supine- tilted head up
(3) lateral- tilted head up (aka park bench)
(4) Prone- tilted head up
VAE is the most feared complication of head up surgical positions. Edema of the face, neck, and tongue in the head up positions may compromise the airway. What is the cause of edema in these areas in a head up position?
Edema is due to obstruction of venous and lymphatic system cause by prolonged marked neck flexion
What precautions should be taken to minimize the occurrence of face, neck, and tongue edema in the head up positions?
Avoid placing the patients chin against the chest and use and oral airway to protect the endotracheal tube
What nerve injury may occur from a sternal notch retractor?
Brachial Plexus (pinching): most often manifest as sensory deficit in the distribution of the ulnar nerve
Describe the method and rationale for denitrogenation (pre-oxygenation) of the airway
tight mask seal, 100% O2 at high flow rate (10-12 L/min),
How is an oropharyngeal airway sized? What problems may be seen with their usage?
From the corner of the mouth to the angle of the jaw or earlobe. Poorly sized can cause worse obstruction, lingual nerve palsy, and damage to teeth
Name 4 types of supraglottic airways?
LMA,
Perilaryngeal sealers (air-Q SP),
Cuffless reshaped sealers (i-Gel),
Cuffed pharyngeal sealers (Combitube/ King LTS)
Describe the advantages and disadvantages of supraglottic airways?
Advantages: Ease and speed of placement, reduced anesthetic requirements and resulting hemodynamic stability, less airway manipulation, less dental trauma, less coughing on emergence, less risk of bronchospasm
Disadvantages: ineffective ventilation when higher airway pressures are req, no protection from laryngospasm, no protection from gastric secretions.
Describe the benefits of alternative LMAs including the i-gel and Air-Q
i-Gel is cuff less and is simpler to insert and position
Air-Q has a self pressurized cuff that eliminates overinflation.
Both reduce incidence of soar throat
What is the “RODS” mnemonic?
Used to identify difficult extraglottic device situation R: Restricted mouth opening O: Obstruction D: Distorted airway or disrupted airway S: Stiff Lung or Stiff cervical spine
Pediatric LMA sizing for LMA 1-3
1: <5kg
1. 5: 5-10kg
2: 10-20kg
2. 5: 20-30kg
3: 30-50kg
List indications for using an esophageal-tracheal combitube (ETC)?
Supraglottic obstruction,
Morbid obesity,
Vomiting,
Regurgitation,
Massive airway or upper GI bleeding,
Acute bronchospasm.
Describe the functions of the Air-Q perilaryngeal tube?
Acts as a conduit for blind, or more likely fiberoptic placement of an ETT
How is the King LT positioned for proper ventilation?
1 cuff in esophagus and one above the cords with the hole in the larynx
Describe removal of a supraglottic device?
Deep or fully awake with cuff remaining inflated
Describe the passing of the ETT and the depth of its insertion in the adult
Advanced 2cm past the glottic opening.i.e halfway between vocal cords and carina with approx. depth of 21-23 cm at teeth
Describe the Cormack-Lehane laryngeal view scoring system
Grade 1: Entire glottic opening
Grade 2: Only post glottic opening
Grade 3: Only tip of epiglottis
Grade 4: only the soft palate
What is BURP?
Backward Upward Rightward Pressure on the thydroid Cartilage
Describe the Mallampati/Samsoon-Young class I-IV
PUSH Class I: fascial Pillars, Uvula, Soft/hard palate Class II: Uvula, Soft/Hard palate Class III: Soft/Hard palate Class IV: Hard Palate
What is the “LEMON” mnemonic?
Look externally Evaluate 3-3-2 rule Mallampati Obstruction Neck Mobility
Identify 9 anatomical characteristics that can indicate a potentially difficult intubation
(1) Short muscular Neck
(2) Short thyromental distance
(3) Mallampati III or IV
(4) Receding mandible
(5) Protruding maxillary incisors
(6) Prominent overbite
(7) Limited temporomandibular joint mobility
(8) Limited cervical spine mobility
(9) High arched palate
State 7 risk factors for difficult mask ventilation
(1) Beard
(2) BMI>30kg/m2
(3) lack of teeth
(4) age >55years
(5) OSA or Hx of snoring
(6) Male Gender
(7) Mallampati III or IV
What are the advantages and disadvantages of cricoid pressure?
Advantages: Prevent aspiration
Disadvantages: may worsen laryngoscopes view
What are the advantages of indirect (video) laryngoscopy over direct laryngoscopy?
Vastly improved visualization, feat learning curve, magnification of airway, allows others to see airway, recording capabilities.
What disadvantages have been encountered when using a video laryngoscope?
Directing the tube into the trachea may be difficult. blood and secretions can obscure the camera. cost a lot more
How can we prevent water and heat loss for an intubated patient? Why is this important?
Using an HME device
After induction, you are unable to intubate and unable to ventilate with 2 hand mask ventilation. What is your next immediate step?
Place an LMA and regain ventilation
Describe positioning the obese patient for airway management
Wedge-shaped lift is recommended when positioning the obese patient for intubation. This helps align the external auditory meatus with the sternal notch and allows gravity to pull excess weight away from the airway
What is considered the primary anesthetic for awake airway management?
Topicalization of the airway is considered the primary anesthetic. Focuses on base of tongue, oropharynx, hypo pharynx, and laryngeal structures.
After anesthetizing the nasal cavity, using nasal pledgets soaked in 4% cocaine, a 34F nasal airway coated in 4% viscous lidocaine is inserted into the nasal cavity. Besides topicalization of the airway, what is accomplished by using this technique?
Dilation of the nasal cavity, prediction of the angle of insertion of ETT and prediction of the easy passage of a 7.0 ETT (due to the 34-F nasal airway)
Describe the approach to the superior laryngeal nerve Block
Palpate the superior notch of the thyroid cartilage and locate the position 2cm laterally on each side. B/L insert 25g Needle in a posterior and cephalic direction, 1-1.5 cm deep. Inject 2 mL of 2% lidocaine.
Describe the approach to the trans-tracheal nerve block
Identify the CTM. Using a 5cc syringe with a 20-22g needle, insert posteriorly and slightly caudally, until air is aspirated. Inject 4 mL of 2-4% lidocaine. (during inspiration)
What are the disadvantages to the superior laryngeal nerve bock?
(1) Laryngeal edema and airway obstruction from accidental injection into the thyroid cartilage
(2) Increased Risk of aspiration
(3) Rupture of ETT cuff in a patient already intubated
(4) Hypotension and bradycardia
(5) Hematoma formation
List 6 supportive criteria for awake tracheal extubation?
Follows commands,
Intact gag reflex, oropharynx clear of secretions,
Minimal end-tidal percent of Inhaled anesthetic,
Adequate pain control and RR,
Adequate NMB reversal (TV>6mL/Kg, Sustained titanic contractions,
T1-T4 ratio > 0.7, and sustained head lift and hand grasp.
What three criteria should be met before proceeding with a deep extubation?
(1) Easy mask ventilation after induction
(2) Non-Airway surgery
(3) an empty stomach
List 10 respiratory complications of tracheal extubation?
(1) Resp. drive failure,
(2) hypoxia,
(3) upper airway obstruction,
(4) laryngospasm,
(5) reduced airway tone,
(6) vocal cord paralysis,
(7) vocal cord edema,
(8) tracheal obstruction,
(9) bronchospasm,
(10) aspiration
List 5 systemic complications of tracheal extubation?
(1) HTN
(2) Increased ICP
(3) Increased IOP
(4) wound dehiscence
(5) Increased PA pressure
What is the mechanism of action of sugammadex?
Cyclodextrin that encapsulates rocuronium and vecuronium > pancuronium. Has no effect on acetylcholinesterase or any receptor system
How does the use of sugammadex impact airway management?
as an alternative reversal agent when profound relaxation is still present
What is routinely found in a pre-pack-aged cricothyrotomy kit?
Tracheostomy tube, dilator, scalpel, syringe, introducer needle, firm guide wire, tracheal hook, forceps and ties to secure the device.
What size scalpel is preferred when performing an open surgical cricothyrotomy?
A #20 scalpel
Why is surgical cricothyrotomy contraindicated in the younger pediatric population? What is used instead?
B/C the cricoid cartilage is the narrowest portion of the airway in children under 6, and the thyroid glad typically extents over the cricothyroid membrane.
Use needle cricothyrotomy with transtracheal jet ventilation
In a patient with atlantoaxial subluxation, displacement of what anatomical structure can cause compression of the spinal cord and/or vertebral arteries?
Movement of head and neck displaces the odontoid process causing damage to the spinal cord and compression of the vertebral arteries.
During tracheotomy surgery, a fire develops at the surgical site. What is your course of action?
Immediate removal or ETT and stop flow of all airway gasses, Remove flammable material from airway, pour saline to extinguish the fire. re-establish ventilation and assess for airway injury
Damage of what nerve can also cause airway issues in the post-thyroidectomy patient?
Acute B/L RLN injury causes coughing, stridor, airway obstruction, and respiratory distress
What is the action of dexmedetomidine? Describe
- Short acting Alpha-2 adrenergic agonist
- The predominance of Alpha-2 receptors are located in the pontine locus cerulean of the brainstem. This area mediates vigilance, memory, analgesia, and arousal.
- Concomitant use with GABA (versed, propofol) can cause paradoxical agitation.
In what clinical situations are fiberoptic intubations useful?
(1) anatomic abnormalities of the upper airway,
(2) Cervical spine immobilization,
(3) Failed intubation attempts where ventilation is possible
(4) Anticipated difficult airway
(5) Placement of double lumen ETT
(6) Visualizing the airway below the cords
After induction of a patient scheduled for laparoscopic cholecystectomy, direct laryngoscopy has failed 3 times. Mask ventilation with 100% O2 is adequately achieved. What is your next course of action?
Intubating LMA, Fiberoptic through LMA, Video laryngoscope, Gum elastic bougie, retrograde wire intubation, lighted stylet.
What is the “SHORT” Mnemonic?
To identify difficult cricothyrotomy Surgical obstruction Hematoma/Abscess Obesity Radiation distortion Tumors
Define Sleep apnea. What are the symptoms and physiologic changes associates with it?
The cessation of breathing for more than 10 seconds during sleep.
Symptoms: frequent arousal during sleep, snoring, impaired concentration, memory issues, headaches.
Physiologic changes: hypoxemia, hypercarbia, pHTN, and systemic vasoconstriction
What is the gold standard diagnostic test for OSA?
Overnight polysomnography
Clinical Diagnostic indicators:
Witnessed apnea during sleep, Neck circumference >= 16 in, BMI >=35, Hyperinsulinemia, Elevated glycosylated hemoglobin
What is pickwickian syndrome?
Results from long term OSA
What are the postoperative airway considerations in a patient with pickwickian syndrome?
Highly sensitive to the respiratory depressant effects of anesthesia.
Continuous regional > opioids.
Avoid benzos.
CPAP placed immediately after extubation (before transfer to PACU) have shown greater lung function 24 hours postoperatively.
List otolaryngology airway disorders that can present difficult airway management for the anesthetic
(1) Airway infections,
(2) Airway tumors,
(3) angioedema,
(4) other pathologic conditions (i.e. congenital malformations, RLN injury, fascial trauma, and OSA)
What is the result of blocking each of the nerve fiber types?
B: ventilation with hypotension
C and A-delta: Loss of pain and temp
A-gamma: loss of muscle tone
A-Beta: loss of motor function and proprioception
A-Alpha: loss of motor function and proprioception
What is the suggested volume per spinal nerve segment at cervical and thoracic levels to provide epidural blockade
0.7-1 mL per segment to be anesthetized
Which four local anesthetics (and concentration) provide potent sensory analgesia and minimal motor block when administered epidural?
- 5% Bupi,
- 5% Ropi,
- 5% Levobupi,
2% lidocaine plain
How much LA is required for a fascia iliac block?
30-40 mL (0.5-1mL/kg in peds)
Describe the anatomy of the fascia iliac block?
The 3 distal nerves of the lumbar plexus the femoral, lateral femoral cutaneous, and obturator nerves all emerge from the poses muscle and run along the inner surface of the fascia iliac. It delivers LA between the fascia iliac and iliacus muscles.
What are the indications for a fascia iliac block?
Provides analgesia for the femoral, lateral femoral cutaneous, and obturator nerves.
Useful for anterior thigh and knee surgery and to provide analgesia following hip and knee procedures.
What is a fascia iliac block?
Low-tech alternative to femoral or a lumbar plexus block. Target is the lateral cutaneous and femoral nerves as well as the obturator n.
You have just performed intercostal nerve blocks at 5 levels to provide analgesia for fractured ribs. The patient becomes hypotension, bradycardia, and has a seizure. Describe 7 actions to manage the situation.
(1) get Help,
(2) Airway management ventilate with 100% Oxygen,
(3) Seizure suppression, benzodiazepine are preferred,
(4) BLS/ACLS with medication adjustments,
(5) Infuse 20% lipid emulsion,
(6) alert the nearest facility having CPB,
(7) post LAST events at Lipidrescue.org and report use of lipids.
Describe the recommended lipid emulsion dosing for treatment of local anesthetic systemic toxicity (LAST)?
(1) IV bolus of 1.5 mL/kg (LBW) of 20% lipid emulsion, such as intralipid 20% over 1 minute,
(2) continuous infusion at 0.25 mL/kg/min for at least 10 minutes after cardiac function returns,
(3) if CV instability continues, repeat bolus once or twice and consider increasing infusion to 0.5mL/kg/min,
(4) recommended upper limit is 10 mL/kg lipid emulsion over the first 30 minutes.
What are specific medication adjustments for BLS/ACLS in treatment of LAST? What drugs should be avoided?
(1) reduce individual epinephrine dose to less than 1 mcg/kg
(2) avoid vasopressin
(3) avoid CCB
(4) avoid BB
(5) avoid LA (amiodarone preferred for ventricular dysrhythmias)
(6) propofol should be avoided in the presence of CV instability
List the 6 MOA’s of lipid emulsion rescue
(1) Capture of LA in the blood (lipid sink),
(2) increased fatty acid uptake by mitochondria (metabolic effect),
(3) interference with LA binding to NA channels (membrane effect),
(4) activation of Act cascade leading to inhibition of GSK-3 which is glycogen synthase kinase (cytoprotective effect),
(5) promotion of calcium entry via voltage-dependent calcium channels (inotropic/ionotropic effects),
(6) accelerated shunting
List 9 complications of spinal anesthesia
(1) PDPH,
(2) backache,
(3) High epidural,
(4) nausea,
(5) urinary retention,
(6) hearing loss,
(7) spinal hematoma,
(8) shivering, and
(9) neurologic injury (rare)
What is the incidence of PDPH with spinal anesthesia?
up to 25%
Pain after total joint replacement, particularly total knee arthroplasty (TKA), is severe. Describe three newer techniques for postoperative pain management following total doing replacement
(1) Single dose and continuous peripheral nerve blocks of the lumbar plexus (with or without sciatic nerve blockade). i.e femoral, fascia iliaca and poses compartment block.
(2) Unilateral peripheral nerve blocks
(3) high volume local wound infiltration/infusion techniques with a combined administration of LA, NSAIDS, and epinephrine for THA or TKA.
Inadequate IV volume during the preoperative period can cause a range of adverse physiologic effects: describe these effects
The major complications of hypovolemia, aside from hemodynamic instability, include decreased oxygenation of surgical wounds, decrease collagen formation, impaired wound healing, and increase wound breakdown.
What are the adverse effects of preoperative hypervolemia?
Pulmonary edema, CHF, edema of gut with prolonged ileum, and possibly an increase in cardiac arrhythmias. Also reduced tissue oxygenation, pulmonary congestion, and increased myocardial work (starting curve)
When is the best time to institute PCA in the perioperative period?
In the PACU after initial pain level is under control (pain score <=3)
What 4 criteria must a patient meet in order to receive patient-controlled analgesia?
(1) be cooperative,
(2) be able to understand the concept,
(3) follow the directions of use,
(4) be able to push the demand button
List 5 variables current PCA models have for allowing selective dosing of agents?
(1) an initial loading dose, (2) a demand dose or bolus dose, (3) a lockout interval, (4) a basal continuous infusion rate, (5) 1-hour and 4-hour max dose limits.
List 6 advantages of robotic assisted surgery from the patient perspective
(1) smallest possible incision, (2) less surgical stress, (3) less pain, (4) faster recovery, (5) shorter hospital stays, (6) improved overall satisfaction
State 6 advantages of robot-assisted surgery from the surgeons prospective
(1) less blood loss, (2) improved ergonomics, (3) enhanced and magnified 3-dimensional view of surgical field, (4) superior manual dexterity, (5) decreased fatigue, (6) shorter learning curve
List and describe 7 major anesthetic considerations during robot-assisted surgery
(1) risk of thromboembolism
(2) maximize protection over pressure areas to avoid nerve injury and protect face from direct pressure,
(3) Prolonged T-Burg: increase MAP, in brain, increased cerebral blood volume, decreased CO and perfusion to LE,
(4) potential common peroneal nerve damage due to lithotomy position,
(5) difficulties with peritoneal insulation are present,
(6) BP reduction may be necessary,
(7) UO may be decreased and generally respond to fluid challenge
Describe the obturator reflex
Violent contraction of ipsilateral thigh causing adduction of the thigh (occurs during TURBT)
List 2 anesthetic techniques to abolish the obturator reflex during TURBT
(1) General with NMB (2) neuraxial anesthesia to T9-T10
What are 4 goals of adding hyaluronidase to peritubular LA blocks
(1) Improve the quality of the block,
(2) increase speed of onset,
(3) limit the acute increase in IOP,
(4) decrease the incidence of postoperative strabismus
What is a major dilemma in the patient with an open eye injury and a full stomach?
weigh the risk of aspiration vs the risk of blindness
Describe the plan for induction in an open eye full stomach patient. Is succ contraindicated?
RSI with high dose rocuronium if it is an easy airway. Succ is not contraindicated but should be avoided if possible due to increased IOP
What volume of air (mL) will fill the tracheal and bronchial cuffs of a double-lumen tube?
Tracheal cuff 10 mL (can accommodate up to 20 mL), Bronchial cuff 1-2 mL
Identify 2 major perioperative goals for the patient with graves disease
(1) Patient euthyroid before surgery (most important)
2) prevent SNS stimulation (Maintain adequate anesthetic depth and avoid medications that stem SNS
What is the best induction method for the patient with Graves disease?
No benefit of one over the other but careful titration of NMB with peripheral nerve stimulators is warranted.
Which agents must be avoided during induction in the patient with Graves disease? Why?
Avoid ketamine because of SNS stimulation.
Avoid Pancuronium d/t increase in HR
Describe the CV responses during the tonic and clonic phases of ECT?
Tonic Phase: 10-15 seconds of parasympathetic NS producing bradycardia, bradydysrhythmias, and decrease BP
Clonic Phase: sympathetic activation resulting in tachycardia, tachydysrhythmias and increased BP lasting for minutes
How would you manage the tonic and clonic CV responses in ECT?
Tonic phase: premedication with glycopyrolate or atropine
Clonic phase: labetalol, esmolol, and CCB (nifedipine, diltiazem, and nicardipine)
Define hypertensive crisis
arterial BP >= 180/120 mmHg
What differentiates hypertensive urgency from hypertensive emergency?
based on the presence of impending or progressive target organ damage. Pt with chronic HTN may tolerate increases in pressures and experience urgencies over emergencies
What is the treatment goal for the patient in a hypertensive emergency
to decrease BP promptly but gradually. General guideline is to decrease BP by 20-25% within 30-60 min
What is the drug of choice for hypertensive emergency?
IV Sodium nitroprusside (SNP) 0.5-10.0 mcg/kg/min (cyanid toxicity and lactic acidosis).
Other treatment options include nicardipine, fenoldopam, esmolol, and labetalol
What recently FDA approved drug may be the new drug of choice for treating a hypertensive emergency?
Clevidipine a 3rd generation dihydropyridine CCB with ultra short DOA and selective arteriolar vasodilating properties
What is the leading cause of postoperative hospital admission?
Inadequate pain relief
Postoperative HTN is common and multifactorial: what factors contribute to postoperative HTN?
(1) respiratory compromise or distress,
(2) Stimulation of the SNS,
(3) visceral distention, & volume overload
How does intraoperative bronchospasm manifest?
Wheezing, increased PAP, decreased TV, slowly rising ETCO2 wave from, and eventually hypoxemia.
What commonly used anesthetic agents have a favorable influence on bronchomotor tone?
Isoflurane, sevoflurane, propofol, ketamine, and midazolam (all have bronchoprotective properties)
Describe subglottic stenosis
Can be acquired or congenital. most are acquired from trauma associated with intubation, damage to tracheal mucosa, or improperly sized ETT, or over inflation of ETT cuff
What is the best choice to alleviate the upper airway obstruction in a conscious patient?
NPA>OPA (less stimulating). complications include nose bleeding
What is laryngospasm?
A maladaptive over-exaggeration of the glottic closure reflex.
Administration of what drugs in indicated if postoperative inspiratory stridor is due to laryngeal edema?
Nebulized racemic Epinephrine. IV steroids may also be used. Observation should continue for up to 2 hours post treatment
What are the risk factors for pulmonary aspiration?
Increased gastric fluid volume with acid pH, delayed gastric emptying, decreased lower and upper esophageal sphincter tone, and loss of laryngeal and pharyngeal reflexes
What is the pharmacologic treatment for prevention of pulmonary aspiration?
routine use of drugs are not currently recommended. But may use non-particulate antacids, pro-motility drugs, and H2 antagonists (goal to decrease gastric volume and increase gastric pH)
If prevention of aspiration is critical, why have the fasting guidelines changed to be more liberal?
Research shows that clear liquids 2-4 hours before surgery decreases gastric volume and increases gastric pH
What are the preoperative fasting guidelines?
Clear liquids 2 hours
Breast Milk: 4 hours
Infant formula: 6 hours
Fried or fatty meals: 8 hour or more
What is the treatment for pulmonary aspiration once hypoxemia is evident?
Administer O2 (only to extent it is needed), Lidocaine 1.5 mg/kg (as a neutrophil aggregate),
intubate as needed,
bronchodilators,
PEEP to support ventilation
Abx (only if WBC elevation or fever longer than 48 hour)
In which population is a cemented prosthesis preferred?
Older (>80yrs) and less active patients. Cementless prosthesis require natural bone to grow into them.
Describe the treatment plan if bone cement implantation syndrome (BCIS) is suspected?
Increase O2 to 100% (continued into post operative period), if CV collapse then treat as RT sided heart failure: aggressive fluid resuscitation along with Alpha- agonists
The trauma patient has suffered massive blood loss and is unconscious. Describe the fluid resuscitation for this patient. What fluids should be avoided?
Should administer whole blood or blood products. (ratio of 1:1:1, pRBC:FFP:Platelet) Avoid hydroxyethyl starch and dextrose containing solutions.
State the guidelines for fluid replacement when the thermal injury is <15% total body surface area?
150% of calculated maintenance rate
State the guidelines for fluid replacement when the thermal injury is >15% of total body surface area?
calculated by modified Brooke formula, Parkland formula, or the ABA census formula
What fluids are preferred for the first day following thermal injury?
Crystalloid solutions, particularly LR
Describe the modified Brooke formula for fluid resuscitation in adults and children >20 kg
2mL of LR x kg x %TBSA burned for the first 24 hours. 1/2 given in the first 8 hours and 1/2 given in the following 16 hours
Describe the parkland formula for fluid resuscitation in adults and children >20kg
4 mL of LR x kg x % TBSA burned
Describe the ABA consensus formula for fluid replacement in adult burn patients
2-4mL of LR x kg x % TBSA burned
What are the guidelines for fluid resuscitation following thermal injury in the first 24 hours for children <20kg?
2-3mL Crystalloid x kg x % TBSA burned OR with 5 % dextrose maintenance rate of 100 mL/kg for first 10kg and 50ml/kg for the next 10 kg for 24 hours.
What colloid may be administered after the first day following thermal injury? What is the rate of administration of this colloid?
Albumin 5% at a rate of 0.3 (30-50% TBSA),
- 4 (50-70%),
- 5 (70-100%) mL/kg x % burned for 24 hours
List 3 cystoscopic and one noninvasive therapy that have largely replaced open surgical and invasive treatment of kidney stones
(1) Flexible ureteroscopy with stone extraction
(2) Cystoscopic stent placement
(3) Intracorporeal Lithotripsy (Laser or electro hydraulic)
(4) Noninvasive = medical expulsive therapy (primary treatment of choice)
Describe medical expulsion treatment for kidney stones
promotes ureter relaxation and the spontaneous passage of small ureteral stones involves treatment with CCB (nifedipine), Alpha-Blockers (tamsulosin, doxazosin, or terazosin), & Corticosteroids
ESWL is the treatment of choice for what two kidney stone situations?
For disintegration of infrarenal stones of 4mm to 2cm and kidney stones in the upper part of the ureter
What challenges and complications are associated with water bath immersion during ESWL?
prone to hypothermia, dysrhythmias can cause issue with delivery, significant responses and hemodynamic changes are associate with immersion and emergence from the water bath.
List 3 CV and 5 respiratory changes on immersion in the water bath of a first-generation lithotripter
CV: (1) Increased CVP
(2) Increased central BV
(3) Increased PAP
Resp: (1) Inc Puls BF
(2) decreased vital capacity
(3) decreased FRC
(4) decreased TV
(5) increased RR
List 9 complications from all forms of shockwave lithotripsy
(1) skin bruising,
(2) flank ecchymoses at entry site,
(3) painful hematoma in the flank muscles,
(4) hematuria,
(5) lung tissue is susceptible to injury,
(6) damage to colon and small intestines,
(7) diabetes,
(8) new-onset HTN,
(9) permanently decreased renal function
State 2 absolute contraindications to shock wave lithotripsy
(1) bleeding disorder or anticoagulation
(2) pregnancy
What are 5 relative contraindications to shock wave lithotripsy
(1) Unrelated UTI,
(2) Lg calcified aortic or renal artery aneurysm,
(3) obstruction distal to the calculi,
(4) pacemaker,ICD, or neurostim device
(5) morbid obesity
What special concern exist in children undergoing ESWL? How is this concern addressed?
more likely to sustain pulmonary damage. It is recommended that a styrofoam sheet or styrofoam board be placed under the back in children to shield the lung base from shock.
In what ways is the premature infant different from the full-term neonate?
Immature organ systems. Complications include anemia, apnea, bradycardia, temperature instability, multi system organ complications, intraventricular hemorrhage, and death
The ratio of minute ventilation to FRC is 2-3 times higher in the newborn. What is the clinical significance of this?
The decrease in FRC means there is less oxygen reserve. Also explains more rapid inhalation induction and faster emergence in the newborn
What is the normal HR range of the term infant? What are the normal HR ranges through childhood development?
Infant to 3 months 100-150 bpm 3-6 months 90-120 bpm 6-12 months 80-120 bpm 1-3 yrs 70-110 bpm 3-6 yrs 65-110 bpm 6-12 yrs 60-95 bpm >12 yrs 55-85 bpm
What is the caloric need in relation to BSA for the full term infant? At what age does caloric need in relation to BSA peak and how does this compare to adult caloric need?
Full term 30kcal/m2/hr;
2 y/o 50kcal/m2/hr;
Adult 35-40 kcal/m2/hr
List 14 factors that contribute to persistent pHTN of the newborn (aka persistent fetal circulation)
(1) premature birth,
(2) pulmonary disease,
(3) hypoxemia,
(4) hypercarbia,
(5) congenital heart disease,
(6) sepsis,
(7) acidosis,
(8) hypothermia,
(9) meconium aspiration,
(10) polycythemia,
(11) congenital diaphragmatic hernia,
(12) severe hypotension,
(13) high altitude,
(14) prolonged stress
List 5 congenital defects in which there is a simple left-to-right shunt
(1) ASD,
(2) VSD,
(3) atrioventricular canal defects,
(4) patent ductus arteriosus (PDA) ,
(5) sort-pulmonary syndrome
What 11 factors decrease PVR and will increase left to right shunt?
(1) 100% O2,
(2) hypocarbia,
(3) alkalosis,
(4) normothermia,
(5) hypothermia,
(6) low mean airway pressure or spont ventilation,
(7) avoiding catecholamine release,
(8) medications (iNO, prostaglandins, milrinone),
(9) increased SVR,
(10) sympathetic stimulation,
(11) Alpha-1 agonists
What 11 factors increase PVR and will decrease left to right shunt?
(1) hypoxia,
(2) hypercarbia,
(3) acidosis,
(4) hypothermia,
(5) high mean airway pressure,
(6) catecholamine release,
(7) medications (phenylephrine, N2O, ketamine),
(8) decreased SVR,
(9) B2 agonist,
(10) neuraxial anesthesia
(11) deep general anesthesia
What comorbidities may be associated with Downs syndrome and should be taken into consideration when formulating your anesthetic plan?
(1) difficult mask airway,
(2) atlantoaxial instability,
(3) congenital heart defects,
(4) macroglossia,
(5) cognitive impairment,
(6) hypotonia,
(7) tracheoesophageal fistula,
(8) chronic pulmonary infections/post intubation croup
(9) GI anomalies (GERD)
What ETT size is needed for the pediatric patient with epiglottitis?
1-2 sizes smaller than usual (cherry red epiglottis)
List 9 anesthesia considerations for the patient with congenital diaphragmatic hernia (CDH)?
(1) Place NG tube,
(2) Do not apply positive ventilation via mask,
(3) intubate with controlled ventilation, (4) use an opioid (1-3mcg/kg) and a NMB once chest is open,
(5) avoid NO,
(6) DO NOT re-expand lung (excessive PPV can damage contralateral lung,
(7) monitor PaCO2 and SaO2,
(8) use 100% O2,
(9) anticipate the need for postoperative support ventilation
What are the anesthesia-related considerations in caring for an infant with retinopathy of prematurity?
Limit O2 supplementation to all neonates.
How is succinylcholine currently used in the pediatric population? What prompted this change?
It is an emergency airway rescue drug in children less than 8 y/o due to risk of severe hyperkalemia
What 4 medications have a prophylactic effect in prevention agitation and treating acute episodes of emergence delirium in the pediatric patient?
Propofol,
Fentanyl,
Precedex,
Preoperative analgesics
What is the most commonly administered premedication in the pediatric patient?
Midazolam is the most common
What are the classifications of the hypertensive disorders in pregnancy
Gestational HTN
Preeclampsia (1) w/o severe features (2) severe (eclampsia)
Chronic HTN
Chronic HTN w/ superimpose preeclampsia
Define gestational HTN
(aka PIH) BP >= 140/90 after the 19th week of gestation
Define eclampsia
Present if seizures or coma occur with PIH (aka preeclampsia with severe features)
What are the risk factors for preeclampsia?
CKD, chronic HTN, obesity, nulliparity, family hx, and advanced maternal age
What is the cause of preeclampsia?
Hallmark is abnormal placental implantation. This releases vasoactive substances causing dysfunction of maternal vasculature
What is the drug of choice for seizure prophylaxis in a patient with preeclampsia? Why?
Mag sulfate. It is 50% more effective in preventing new onset and recurrent seizures than commonly used anticonvulsants.
The patient with preeclampsia is in danger of developing serious complications.
Name 8 serious complications of preeclampsia
(1) pulmonary edema,
(2) airway obstruction,
(3) placental abruption,
(4) cerebral hemorrhage,
(5) cerebral edema,
(6) disseminated intravascular coagulopathy,
(7) HELLP syndrome,
(8) CHF
List medications used to blunt the hemodynamic response to laryngoscopy and intubation during induction of general anesthesia
Labetalol, Esmolol, NTG, Sodium nitroprusside, Remifentanyl
Why is hydralazine a commonly used antihypertensive in preeclampsia?
a vasodilator that also increases utrine-placental flow and renal blood flow. NTG and labetalol are also commonly used.
Is regional anesthesia contraindicated in preeclamptic patients?
No, so long as there is no severe clotting deficit or plasma volume deficit
What 3 anesthetic considerations must be taken in the parturient receiving magnesium sulfate?
(1) causes prolonged duration and intensity of NMB, (2) causes uterine vasodilation causing postpartum uterine atony and hemorrhage,
(3) interacts with calcium entry blocking agents
Once the fetus and placenta are delivered the mother is no longer at risk for complications of preeclampsia. True or False
False. it can present up to 4 weeks postpartum.
Which drugs commonly used in anesthesia readily cross the placenta?
Atropine, Scopolamine, BB, Nitroprusside, NTG, Diazepam, midazolam, Propofol, Ketamine, Etomidate, Thiopental, Halothane, isoflurane, desflurane, N2O, LA, opioids, Ephedrine
Which medications commonly used during anesthesia do not cross the placenta and would need to be given directly into the fetal vein?
Glycolic, heparin, depolarizing and NDNMB, phenylephrine
What are the four key factors that influence the rate of drug diffusion to the fetus?
(1) physiochemical characteristics of the drug (protein binding, molecular weight, lipid solubility),
(2) the dose and mode of administration,
(3) placental maturation,
(4) the hemodynamic events within the fetomaternal unit
Which is more lipophilic, the ionized or nonionized form of a drug?
the nonionized form a drug is more lipophilic and can more easily cross through biological membranes.
magnesium sulfate is a commonly used drug in pregnancy. Name 3 advantageous effects of magnesium sulfate in pregnancy
Mag sulfate is a tocolytic, an anticonvulsants, and a fetal neuroprotective agent
Why is sodium bicarbonate routinely added to a prepackaged lidocaine with epinephrine for epidural anesthesia prior to C-Section?
alkalization hastens the onset of neural block and improves quality of block. (increases lipid soluble form i.e. non ionized)
What is the impact of adding epinephrine to LA used for epidural anesthesia during C-Section?
Prolongs DOA, Increases intensity of block and decreases systemic absorption
When is ketamine used for C-Section? Specify the ketamine dose
1mg/kg is used for induction in mothers who are hypotensive.
0.25-0.5 mg/kg for rapid analgesia
Besides induction of labor, what else is oxytocin routinely used for in obstetric anesthesia?
First line treatment for uterine atony. Stimulates uterine smooth muscle. Can cause hypotension
Obese parturients are at increased risk for what 8 complications? What fetal risks are associated with these maternal complications?
(1) Gestational HTN,
(2) gestational diabetes,
(3) preeclampsia,
(4) infection,
(5) thromboembolism,
(6) stillbirth/fetal demise,
(6) difficult vaginal delivery/Cesarean delivery,
(8) difficult airway
What is the preferred method of pain relief for the obese parturient?
Early placement of continuous neuraxial analgesia
Which trimester is the safest to provide non-obstetric surgery and anesthesia for the parturient?
The second trimester (1st trimester highest risk for teratogenicity; 3rd trimester preterm labor)
Describe the use of a paracervical block during labor and delivery?
It has a high incidence of fetal asphyxia, fetal bradycardia, and systematic anesthesia toxicity. Blocks pain impulses to the cervix and uterus during the 1st stage of labor (not effective during second stage)
What APGAR score signifies mild to moderate depressed function? and what noninvasive interventions can be used in this instance if the HR is above 100?
3-7.
keep warm and dry, administer O2 via facemark w/o PPV, stimulation.
List two actions that should be taken if the newborns HR falls below 100 bpm
Begin PPV via mask and SpO2 monitoring
What intervention is recommended when the neonates HR falls below 60 bpm?
Intubate, continue PPV and begin chest compressions and cardiac monitoring. If bradycardia persist administer epinephrine
What is an EXIT procedure and what are the anesthetic considerations?
Ex utero intrapartum procedure i.e. correction of a fetus during partial delivery.
Anesthetic considerations: maintaining uterine relaxation, provide anesthesia for both mother and fetus, VAA and IV narcotic that cross the placenta are used, usually 2 anesthesia teams are needed
What are the two leading causes of peripartum hemorrhage?
(1) uterine atony, (2) Placenta accreta
FHR tracing is indeterminate. the obstetrician employs digital stimulation of the fetal scalp and subsequent FHR accelerations are seen. What information does this suggest?
FHR accelerations after digital scalp stimulation gives assurance that fetal acidosis is unlikely.
Name 5 anatomic or physiologic change that can lead to a difficult airway in the obstetric patient.
(1) Fluid retention leading to airway edema,
(2) decreased FRC (by 20%) with and increase in O2 consumption (by 60%) resulting in a more rapid hypoxemia after induction,
(3) breast enlargement impeding laryngoscopy,
(4) full dentition impending view,
(5) need for RSI which can lead to unanticipated difficult airway
Your patient has AS and is being prepared for an emergent C-Section. The patient has not been adequately hydrated and hypotension is a major concern- which anesthetic technique will you use?
GA is the gold standard with AS.
