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Basic Principles > Module 1 > Flashcards

Module 1 Flashcards

1
Q

What causes Myasthenia Gravis?

A

Autoimmune B cell activation d/t infectious agent attacks acetylcholine receptors

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2
Q

What is Myasthenic Syndrome?

What causes it?

A

Decreased release of acetylcholine.

Usually paraneoplastic

Strength actually increases with exercise.

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3
Q

What is Neostigmine?

A

Acetylcholinesterase Inhibitor.

Increases amount of circulating acetylcholine.

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4
Q

What is HyperPP?

What channel does it effect?

A

Hyperkalemic Periodic Paralysis.

Na channel defect.

Basically can’t regulate changes in K level greater than 5.

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5
Q

What is HypoPP?

What channel is effected?

A

Hypokalemic Periodic Paralysis

Can’t tolerate K less than 3.0

CALCIUM or SODIUM CHANNEL DEFECT

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6
Q

What should be considered when administering anesthesia to a patient with any skeletal muscle channelopathy?

A

No succ. Susceptible to MH.

Optimize electrolytes

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7
Q

What is Anderson - Tawil Syndrome?

A

K channel defect with LOTS of cardiac conduction issues.

Develop periodic paralysis with that may or may not be associated with K level (hypo/hyper/normo).

Ten percent suffer a cardiac arrest!

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8
Q

What is Myotonic Dystrophy?

What considerations should be made for their anesthesia? (3)

A

Skeletal muscles are unable to repolarize after contraction.

  1. Extreme reaction to succ.
  2. PNS unreliable.
  3. Can get resp depression from narcs
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9
Q

What is Congenital Myopathy?

What anesthesia considerations should be made? (2)

A

Hypotonia and weakness at birth.

  1. Lots of respiratory mm dysfunction.
  2. SUSCEPTIBLE TO MH.
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10
Q

What is Duchenne Muscular Dystrophy?

How does it manifest?

What anesthesia considerations should be made? (3)

A

X linked recessive.

absence of Dystrophan.

Progressive paralysis, starts around age 12.

  1. Need cardiac eval every 2 years.
  2. No succ (rhabdo and hyperkalemia). Avoid halogenated inhalants
  3. Dysfunctional GI tract means increased risk of aspiration.
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11
Q

What is Becker Muscular Dystrophy?

A

Less severe than DMD. Later onset. Reduced cardiac risk, eval every 5 years.

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12
Q

What causes Guillain - Barre?

What are the manifestations?

Anesthesia considerations?

A

Autoimmune response to an infection causes the body to attack your nerves, moving from distal to proximal.

Resp dysfunction. Autonomic dysfunction can cause hypotension/tachycardia.

Noxious stimuli like intubation can cause large autonomic response.

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13
Q

Malignant Hyperthermia Common Triggers (4)

A

Succinylcholine

Halogenated Inhalants

Extreme physiologic stress

Heat exhaustion

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14
Q

MH Cause

A

Mutation of the ryanodine recepter

permits uncontrolled releast of Ca from sarcoplasmic reticulum

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15
Q

First Sign of MH

A

Increased ETCO2 that does not respond to increased ventilation

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16
Q

Acute Malignant Hyperthermia S/S

A

Muscle rigidity

Masseter Spasm

Respiratory AND metabolic acidosis

Hyperthermia may develop early or late

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17
Q

Dantrolene

A

Inhibits pathologic release of Ca

Initial dose 2.5mg/kg

May require up to 10-20 mg/kg

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18
Q

Which drugs are safe for MH susceptible patients?

What precautions should be taken in MH susceptibility?

A

OK: prop, benzos, opioids, NDMA, Nitrous

Remove or close all vaporizers

Flush machine with 100% O2

Charcoal filters

Have dantrolene readily available

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19
Q

What is Porphyria?

Manifestations?

A

Enzyme deficiencies in the Heme synthesis pathway cause a buildup of heme precursors that are toxic to the nervous system

Acute: Fever, tachycardia, N/V, ab pain, weakness, seizures, confusion, hallucinations

SEVERE Muscle weakness with resp failure

Hyponatremia (2/2 SIADH)

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20
Q

What drugs should be avoided with Porphyria?

When should porphyria be suspected?

A

barbituates and etomidate.

Delayed emergence or prolonged mm weakness after anesthesia

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21
Q

How is Acute Porphyria detected?

A

Urinary porphobilinogen detected within 5 minutes

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22
Q

What is Plasma Cholinesterase?

A

Enzyme synthesized in the liver to break down acetylcholine

ALSO Breaks down succinylcholine, mivacurium, procaine, chloroprocaine, tetracaine and cocaine.

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23
Q

What usually causes Cholinesterase Disorders?

What are some anesthetic concerns?

A

Usually caused by hepatic disease (cholinesterase is synthesized in the liver)

It hydrolyzes certain drugs, making them much more potent and long lasting

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24
Q

Since cholinesterase disorders are often undiagnosed until surgery, what is a prudent practice to prevent prolonged apnea?

A

Be certain that recovery from the initial dose of succ has occured before administering more muscle relaxant (succ or nondepolarizing)

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25
Q

What are Glycogen Storage Diseases?

A

Inherited

Caused by abnormal enzymes regulating glycogen synthesis and breakdown

LOTS OF DIFFERENT TYPES

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26
Q

What are the critical components of all Glycogen Storage Disease?

A

Acidosis (from fat and protein metabolism)

Hypoglycemia

Cardiac and hepatic dysfunction (2/2 destruction and replacement of normal tissue with accumulated glycogen)

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27
Q

What is Mucopolysaccharidosis?

A

autosomal recessive deficiency of lysosomal enzyme that cleaves mucopolysaccharides

MPSs accumulate in the brain, heart, bone, liver, cornea, and tracheobronchial tree

Progressive craniofacial deformities, joint and skeletal anomalies, cardiac involvemtn, early death

Tough to intubate d/t lots of facial abnormalities

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28
Q

What are some anesthetic considerations for patients with muchopolysacharidoses?

A
  1. Upper airway deformities make intubation difficult
  2. Cardiorespiratory Dysfunction d/t fat deposits in the heart
  3. Best to do a slow induction with sevo
  4. May want preop echo
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29
Q

What are the hallmarks of Osteogensis Imperfecta?

A

Brittle bones

lax joints

tendon weakness

cardiac problems

blue sclera

platelet dysfunction, abnormal airway anatomy, pectus deformities

CAREFUL POSITIONING DURING ANESTHESIA

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30
Q

What are the four Nutritional Anemias?

A

Iron

Vit B12

Folate

Anemia of Chronic Illness

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31
Q

What is Hereditary Spherocytosis?

What are some manifestations?

A

HEMOLYTIC ANEMIA caused by misshapen and fragile RBCs

cholelithiasis, splenomegaly, jaundice

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32
Q

What is G6PD?

What does it cause?

A

most common human enzymopathy

HEMOLYTIC ANEMIA caused by deficient NADPH in RBCs

Oxidative stress d/t inability to buffer FRs leads to hemolysis of RBCs

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33
Q

What is Pyruvate Kinase?

What does a deficiency cause

A

enzyme responsible for half of the ATP production in RBCs

HEMOLYTIC ANEMIA

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34
Q

Sickle Cell Disease is a _________.

A

HEMOGLOBINOPATHY

Reduces life cycle of RBCs from 12o days to 12 days

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35
Q

What is Thalassemia?

What causes it?

A

HEMOGLOBINOPATHY

Either a or b globin production is inhibited, and the other is over produced

Excess unpaired globins cause cellular and tissue damage

Causes iron overload

Bone marrow deposits in spinal cord. Difficult airway.

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36
Q

What are some anesthetic considerations for patients with SLE?

A
  1. CXR, PFT, Echo
  2. Renal function tests
  3. Increased risk of infection
  4. Will most likely need steroids continued intraop
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37
Q

What is Scleroderma?

A

Systemic sclerosis

swelling and thickening of skin and organs, which eventually become fibrotic

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38
Q

What is Dermatomyositis?

What are the s/s?

What organ is heavily effected?

A

INFLAMMATORY MYOPATHY

Autoimmune muscle necrosis

Proximal mm weakness and heliotrope rash, periorbital edema, lesions on knuckles

50% have pulmonary disease

Aspiration pneumonia common

Avoid succ. May need postop mech vent

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39
Q

What are some anesthetic considerations for patients with Epidermolysis Bullosa?

A

May have undiagnosed cardiomyopathy

Minimize trauma to skin and mucous membranes

AVOID LATERAL SHEARING

Pad BP cuff

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40
Q

What is Pemphigus?

A

Autoimmune blistering disease

Oral lesions in most

larynx, esophagus, urethra, conjunctiva, cervix and anal lesions too

Corticosteroid therapy helps

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41
Q

Causes of decreased WBC (4)

A

SLE

Overhwelming Sepsis

Autoimmune disease

Decreased Bone marrow

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42
Q

Causes of Increased WBC (5)

A

Steroids

Inflammation

Infection

Leukemia

Severe Stress

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43
Q

Causes of Hyperkalemia (5)

A

Dietary

Renal Failure

ACE inhibitors, aldactone, bactrim

Reduced aldosterone

Rhabdo

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44
Q

Causes of Hypokalemia (4)

A

Excess Aldosterone

Excess Sweat

Diuretics

Dietary, GI Loss

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45
Q

What are the three Primary Mechanisms of Nerve Injury?

A

Transection

Stretch

Compression

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46
Q

What are Fascicles?

A

Bundles of Nerve Fibers

Building blocks of peripheral nerves

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47
Q

What are Schwann Cells?

What are the two types?

A

Cells that form a nerve sheath (or neurolemma) over axons in nerve fibers.

Myelinated or non-myelinated

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48
Q

What is Ischemic Optic Neuropathy?

What causes it?

A

Optic n is in a watershed area, particularly vulnerable to ischemia during hypoperfusion

Not caused by pressure directly on the globe, but by decreased oxygen delivery

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49
Q

What is Central Retinal Artery Occlusion?

What causes it?

A

CRAO

The entire retina’s blood flow is completely cut off

Causes: Emboli, External pressure on the globe,

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50
Q

What are the components of the BURP manuever?

A

B: Larynx displaced Backward

U: Upward

R: to the Right, using

P: Pressure over the thyroid cartilage

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51
Q

What is Mendelson Syndrome?

What are the s/s?

A

Another name for Aspiration Pneumonitis

SOB

Wheezing/Coughing

hypoxemia

cyanosis

pulmonary edema

hypotension

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52
Q

What is the treatment for an upper Airway Obstruction?

A

decadron 0.1-0.5 mg/kg

humidified O2

Epi

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53
Q

When RLN is unilaterally damaged, the vocal cords adjust by shifting their midline to the _______ side

A

uninjured

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54
Q

The larynx begins with the _____ and extends to the ______

A

Epiglottis, Cricord Cartilage

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55
Q

The nasopharynx lies anterior to ___ and is bound superiorly by _______ and inferiorly by the ______.

A

C1

Base of the skull

Soft Palate

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56
Q

The oropharynx lies at the ____ level and is bound superiorly by ______ and inferiorly by the ____.

A

C2-C3

Soft Palate

Epiglottis

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57
Q

The hypopharynx lies posterior to the ___ and is bound by the superior border of the ____ and the inferior border of the ______ at the ____ level.

A

larynx

epiglottis

cricoid cartilate

C5-C6

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58
Q

Extrinsic Muscles that elevate the larynx

A

• Stylohyoid • Digastric • Mylohyoid • Geniohyoid • Stylopharyngeus • Thyrohyoid

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59
Q

External Muscles that lower the larynx

A

Omohyoid • Sternohyoid • Sternothyroid

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60
Q

What does ADVISE stand for?

A

Anticipate

Differential Diagnosis

Vigilance

Internal Sense of Suspicion

Safety Routine

Evidence Based

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61
Q

What is the IV Flow Rate 16#?

18#?

20#?

A

180 ml/min

90 ml/min

60 ml/min

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62
Q

What does MSMAIDS stand for?

A

Machine

Suction

Monitors

Airway, Alarms, Ambu

IV Lines

Drugs

Special Considerations

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63
Q

What does PRIDE stand for?

A

Personal

Responsibility

In

Developing Excellence

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64
Q

ASA 1

A

Normal Health Patient

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65
Q

ASA 2

A

Mild Systemic Disease

No Functional Limitations

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66
Q

ASA 3

A

Severe systemic disease with functional limitations

Angina, Severe COPD, uncontrolled HTN

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67
Q

ASA 4

A

Severe systemic disease that is a constant threat to life

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68
Q

ASA 5

A

Moribund, not expected to survive without operation (ruptured AAA, PE, Head Injury with increased ICP)

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69
Q

ASA 6

A

Organ Donor

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70
Q

Sensitivity

A

e.g. recall rate, true positive

How capable a test is of telling whether or not someone HAS the disease

Percentage of sick people who are correctly identified as having the condition

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71
Q

Specificity

A

Probability of a negative test result if the patient DOESN’T have the disease

How many not pregnant women does it determine are not pregnant?

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72
Q

Who should always get a preop CBC?

A

Neonates

Malignancy

Age > 75

Renal/Liver Dz

Tobacco Use

Anticoag use

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73
Q

Who should always get a coag panel?

A

Anticoag Use

Chemo

Liver/Renal Dz

Bleeding Disorder

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74
Q

Who should get a preop chem panel

A

CNS disease

Diuretics, dig, steroids

Elderly

Malnutrition

Diabetes

Renal/Liver Dz

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75
Q

Who should get a pre-op BUN/Cr

A

Elderly (>75)

Renal Dz

Diabetes

Diuretics, Dig Use

CV disease

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76
Q

Who should always get a preop BG?

A

Diabetic

Steroid Use

CNS disease

> 75yo

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77
Q

Who should get a preop CXR?

A

CV disease

>75

Pulm Disease

Malignancy

Radiation Therapy

Tobacco > 20 py history

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78
Q

Who should get a preop ECG

A

CNS disease

Cardiac disease

Pulmonary Disease

Radiation

DM
Digoxin Use

High Risk Procedure

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79
Q

What is the calculation for Male IBW?

A

105 + 6 for each inch over 5 ft

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80
Q

What is the calculation for Female IBW?

A

100 + 5 per inch over 5 feet

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81
Q

What is the 3-3-2 Rule?

A

3 mouth opening

3 HyoMental

2 Thyromental Distance

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82
Q

Malampati 1

A

Soft Pallate, Uvula, Tonsilar Pillars

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83
Q

Malampati 2

A

Soft palate, upper portion of uvula

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84
Q

Malampati 3

A

Soft Palate

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85
Q

Malampati 4

A

Hard Palate

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86
Q

List 9 Nonreassuring Airway Exam Findings

A

Long upper incisors (front teeth)

Prominent overbite

Unable to move mandibular incisors anterior to maxillary incisors

Uvula not visible when tongue out sitting up

Highly arched or narrow palate

Noncompliant Mandibular Space

Thyromental > 3 fingerbreadths

Short or thick neck

Limited ROM

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87
Q

Why should you get an ECG on a diabetic patient?

A

High risk for silent ischemia, especially with autonomic dysfunction

Check ECG for Q waves (signs of old infarct)

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88
Q

Metabolic Syndrome

A

Combo of HTN, HLD, hyperglycemia, obesity

higher rates of cardiac/pulm/renal events

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89
Q

1 MET

A

Poor functional Capacity

Can walk 1-2 blocks and perform self care

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90
Q

4 METS

A

Good functional capacity

run short distance, light to heavy housework, throwing a ball, dancing

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91
Q

10 METS

A

high functional capacity

strenuous sports

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92
Q

A patient who is scheduled for a knee replacement just had balloon angioplasty. How long should they wait?

A

Elective procedure –> 14 days

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93
Q

What is the optimal waiting period for noncardiac elective surgery after DES placement?

A

6-12 months

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94
Q

What are risk factors for requiring postop reintubation?

A

ASA > 3

Emergency Procedure

High Risk Sx

Hx of CHF

Chronic Pulm Disease

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95
Q

Should nicotine patches be used perioperatively?

A

No! Associated with increased mortality

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96
Q

What do statins do?

A
  1. Lower lipids
  2. Enhance nitric oxide mediated pathways
  3. Reduce expression of cytokines and adhesion molecules
  4. Lower CRP

Anti-inflammatory, vasodilatory, antithrombotic

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97
Q

Top ten risk factors for aspiration

A

Emergency

Inadequate Anesthesia

Obesity

Opiods

Lithotomy

Neuro deficit

Reflux

Hiatal Hernia

Abdominal Pathology

Difficult intubation/airway

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98
Q

What’s the fasting time for breastmilk vs formula?

A

BM 4 hrs

formula 6 hours

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99
Q

Ranitidine

Classification

Dose

Onset

Duration

A

H2 receptor antagonist

150 PO, 50 IV

Effective in an hour

lasts 9 hours

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100
Q

Omeprazole

Classification

Dose

Onset

Duration

A

PPI

40mg IV 30 min preop

Lasts up to 24 hours

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101
Q

Reglan

Classification

Dose

Onset

Duration

A

Dopamine Antagonist, increases motility

Handy in pregnant ladies and other suspected to have large gastric volume (slowed emptying)

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102
Q

Midazolam

A

Onset 1-2 min

Peak 0.5-1 hour

Duration: 1-4 hours

Anxiolysis, sedation, amnesia

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103
Q

Why does Lorazepam have such a long duration?

A

5-10x more potent than diazepam

LONG duration d/t increased affinity for GABA receptor

Well suited for chronic anxiety or long case

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104
Q

What are indications for anticholinergics?

A

Antisialagogue (glycopyrrolate)

Sedation and Amnesia (scopolamine)

Vagolytic Effect (atropine)

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105
Q

Side effects of anti-cholinergics

A

Anticholinergic Syndrome (delirium, hallucinations)

Intraocular Pressure (mostly scop)

Hyperthermia (interferes with sweating)

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106
Q

When should preop Vanc be given?

A

2 hours preop

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107
Q

If a tourniquet is used, when should preop ABX be given?

A

BEFORE inflation

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108
Q

ABX with broadest skin coverage

A

cephalosporins

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109
Q

Vertical Location of the Larynx in an infant

A

C3-C5

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110
Q

Why is limited jaw protrusion concerning?

A

Difficult tongue displacement

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111
Q

Why are large central incisors concerning?

A

Obstructed view

112
Q

Retrognathia

A

Overbite

Makes tongue displacement difficult

113
Q

What does the thryomental distance tell you?

A

Neck mobility

degree of retrognathia

114
Q

Prognath

A

Bring lower incisors anterior to upper incisors

115
Q

Are the components of an airway exam more sensitive or specific?

A

More specific! If a patient has an indicator of a difficult airway, they may or may not end up being difficult. But if they DON’T have that component, it’s very reassuring

116
Q

What neck positioning should be used for VIDEO laryngoscopy?

A

Supine neutral rather than sniffing

117
Q

What is Dystrophan?

A

Large protein

Stabilizes the muscle membrane

Enable signaling between cytoskeleton and and ECM

118
Q

What drug should be given to Parkinson’s patients if they can’t take oral levadopa?

A

Apomorphine

119
Q

What drugs should be avoided in Parkinson’s?

A

Dopamine antagonists: reglan, droperidol, phenothiazines (compazine)

120
Q

Which anticholinergic does not cross the blood brain barrier?

A

Glycopyrrolate (Ideal for alzheimer’s patients)

121
Q

HypoPP Precipitating Factors

A

High Glucose Meals

Strenuous Exercise

Glucose-Insulin infusions

Stress

Hypothermia

122
Q

Huntington Disease

Cause

Onset

Symptoms

Inheritance

A

Autosomal Dominant

Mutant huntingtin protein

Onset at 35-40

Choreifrom movements, depression, dementia

123
Q

What is Amyotrophic Lateral Sclerosis?

Which drugs should be avoided?

A

UMN and LMN dysfunction

Autonomic Dysfunction

Only use short acting drugs. No succ.

124
Q

Creutzfelt Jacob Disease

A

Prion Infection

Vacuolization of brain

Dementria, myoclonus, EEG changes

HIGHLY INFECTIOUS

125
Q

When should porphyria be suspected?

A

Patients with unexplained elayed emergence from anesthesia or postop muscular weakness

Susceptible patients are rarely identified pre-op

126
Q

Why aren’t infants able to modulate their CO?

A

No ability to change their stroke volume. Can only change their heart rate. That’s why bradycardia is so scary and dangerous in babies

127
Q

What factors increase CO2 production?

A

Anything that increased metabolic rate:

Hyperthermia

Sepsis

Hyperthyroidism

MH

Shivering

128
Q

What factors decrease CO2 production?

A

Anything that decreases metabolic rate:

Hypothermia

Hypothyroidism

129
Q

Do you see elevated or decreased ETCO2 during Pulmonary Embolism?

Hypoventilation?

Hypoperfusion?

A

Decreased

Increased

Decreased

130
Q

What does the MAC value demonstrate?

A

the MINIMUM ALVEOLAR CONCENTRATION

the end-tidal gas concentration that when maintained constant for 15 minutes at a pressure of one atmosphere, inhibits movement in response to a midline laparotomy incision in 50% of patients

131
Q

What do cardiac oscillations on ETCO2 indicate?

A

That CO2 flow is low enough that the movement of the heart is detected. Generally represents a need for mechanical ventilation

132
Q

When is the relationship between ETCO2 and PaCO2 not reliable?

A

When there is an increase in dead space ventilation or V/Q mismatch

Emphysema, Very low CO states,

iatrogenic single lung ventilation

pulmonary embolism

Capnography will UNDERESTIMATE ETCO2 levels

133
Q

Why does ETCO2 monitoring on neonates become problematic

A

The side-flow monitor sucks up 200ml/min to assess ETCO2, but a neonate MV may only be 300. The machine may not be getting a good sample.

134
Q

Where is the art line transducer zeroed during neurosurgical sitting cases?

A

Circle of Willis

135
Q

What Art Line practices should be avoided in peds?

A

Minimize flushing

No power flushing (may cause retrograde flow in cerebral arteries)

Blood wasted should be returned through the vascular system, not the arterial system

136
Q

NIBP MAP Calculation

A

MAP = DP + (SP − DP)/3

137
Q

As the site of NIBP is moved peripherally, what happens to the SBP and DBP?

A

SBP increases, DBP decreases

Increased pulse pressure

138
Q

In what population is NIBP arm pressure not reliably similar to ankle pressure?

A

pregnant women

139
Q

Where should a BP cuff be placed on a preemie?

A

R upper arm (preductal)

140
Q

What does pulmonary wedge pressure estimate?

A

LV EDP

Left Ventricular End Diastolic Pressure

141
Q

CVP waveform: Changes with A Fib

A

No A waves

142
Q

CVP waveform: Large A waves

A

increased RA pressure (tricuspid stenosis, RV hypertrophy, lung disease, PHTN)

143
Q

What do CVP a, c and v waves represent?

A

Atrial contraction

Tricuspid closure/RV contraction

RA filling

144
Q

What are the pros of a subclavian CVC?

A

Lower rates of infection

145
Q

When should a Subclavian CVC be used with caution?

A

Coagulopathic patients. Can’t be effectively compressed if the vessel is ruptured.

146
Q

In what population are femoral CVCs NOT associated with increased infection?

A

Pediatrics

147
Q

What are s/s of PA rupture?

A

Sudden cough

hemoptysis

hypotension

148
Q

Who is most at risk for PA catheter rupture?

A

Elderly

pHTN

Anticoagulants

149
Q

What abnormalities make CO monitoring via PA unreliable?

A

Anything that changes flow such that retrograde flow along the catheter can occur:

Intracardiac shunts

Tricuspid Regurg

150
Q

What is FATD?

A

femoral artery Thermodilution

Used in pediatrics

Pretty accurate, way less risky

151
Q

During PPV, what will happen to your SBP?

A

SBP will decrease during inspiration because intrathoracic pressure is higher

If the difference is dramatic, may indicate hypovolemia

152
Q

Four modes of heat loss

A

radiation (like the sun radiates heat)

evaporation (0.58 kcal lost per gram H2o evap)

convection (breeze blowing)

conduction (cold OR table)

153
Q

What effect does ketamine have on processed EEG

A

Causes fluctuations in the oscillations that don’t correlate with depth of anesthesia

154
Q

Processed EEG monitoring is unreliable when using what drugs?

A

Ketamine and Nitrous Oxide

155
Q

What is the role of processed EEG in assessing for cerebral ischemia

A

Not helpful

Only analyzes the frontal lobes

at best serves as regional perfusion monitor

156
Q

What range of BIS monitor readings represent general anesthesia?

A

40-60

157
Q

What range of SedLine EEG readings correlate with general anesthesia?

A

25-50

158
Q

If given together, will an EEG reading change in response to opiods or propofol?

A

Propofol only. Opiods usually don’t effect EEG

159
Q

What surgeries represent a higher risk of awakeness?

A

Any surgery where you can’t administer a lot of anesthetics safely:

C-Sections

Hemodynamic Instability

Trauma Laparotomies

160
Q

What patient position presents dangerous use of EEG monitoring?

A

Prone. May damage skin. Use carefully.

161
Q

What is the incidence of intraop awakeness in pediatrics?

A

three times higher than adults!

162
Q

What effect may anesthetic gases have on children?

A

decline in IQ and listening comprehension

163
Q

What happens when nerves are stretched beyond their resting length?

A

Even 5% stretch can cause kinking of arterioles and cause ischemia

164
Q

If shoulder braces are needed, where should they be placed?

A

Over the acromioclavicular joint

Brachial plexus injury less likely there than over the traps

165
Q

What factor is responsible for brachial plexus injuries in median sternotomies?

A

The degree of rib displacement by retractors

Not reliably related to patient positioning

166
Q

What is the etiology of long thoracic nerve dysfunction after surgery?

A

Likely due to viral/inflammatory origins

Not related to positioning

167
Q

Why is abducting the arm >90 degrees dangerous?

A

Both compresses and stretches the axillary a/v/n bundle

Thrusts the head of the humerus into the axillary a/v/n bundle

168
Q

What are common causes of post op radial nn damage?

A

Pressure from vertical bar of anesthesia screen

excessive NIBP cycling

Compression at midhumerus from sheets/towels

169
Q

What is the likely cause of median nerve damage?

A

Forcible extension of the elbow

170
Q

What is the most common post op neuropathy

A

Ulnar nn damage

171
Q

Causes of ulnar nn damage

A

Prolonged Elbow Flexion

Inflammation

172
Q

Why is ulnar n damage more common in men?

A

Larger tubercle of coronoid process

Less adipose tissue over medial elbow

173
Q

What is hyperlordosis

A

Hyperextension of the lumbar spine

If greater than 10 degress may cause spinal nn ischemia

174
Q

What are some positioning related causes of compartment syndrome

A
  1. Systemic hypotension and loss of driving pressure to extremity (i.e. elevation)
  2. Vascular obstruction of major leg vessels
  3. External compression of the elevated extremity
175
Q

Why is the lateral jacknife position used?

A

Widen intracostal space

Should take patient out of this position once the rib spreader is placed

176
Q

V/Q in AWAKE Lateral Decubitus Positioning

A

In an awake patient, when they are placed in LD both perfusion (which is gravity dependent) and ventilation (which is increased by diaphragm displacement) increase in the DEPENDENT lung, and a V/Q mismatch is avoided

177
Q

V/Q in ANESTHETIZED Lateral Decubitus Positioning

A

Perfusion in dependent lung is increased by gravity,

BUT

when anesthesia is given, there is a reduction in lung volume in BOTH lungs. This causes the UPPER lung to be compliant but underperfused, and the LOWER lung to have decreased compliance but increased perfusion

V/Q Mismatch

178
Q

Why do long spinal cases have increased incidence of ischemic optic neuropathy?

A

Prone positioning

If head is lower than heart, leads to venous and lymphatic congestion in optic nn

179
Q

How long should a lateral head displacement while prone be continued?

A

Should be less than three hours. If procedure is longer, consider keeping the head in the sagittal plane

180
Q

What are some methods to reduce the likelihood of post op blindness in prone cases?

A
  1. Allow patients’ head to be above the heart
  2. Use colloids AND crystalloid for volume management
  3. Position to reduce intra-abdominal pressure
  4. Be cautious with wilson frame
  5. Consider staging procedures longer than 5 hours to reduce risk
181
Q

Thoracic Outlet Syndrome

A

Patients will have pain when lifting arms above head

Before pronating patients, make sure they can clasp their hands behind their neck to rule this out

182
Q

Why can prone positioning cause increased spinal bleeding?

A

If abdominal pressure approaches or exceeds venous pressure, vertebral venous plexuses that empty directly into the IVC back up into the perivertebral and intraspinal circulation, causing venous congestion and increased bleeding

183
Q

What are the most common risk factors of venous air embolism?

A
  1. Neuro and ENT surgeries (especially if surgical incision is located 2 in or more above the level of the RA)
  2. Surgeries on noncollapsed veins or sinuses
  3. Procedures causing a pressure gradient (CVC placement)
184
Q

How is a diagnosis of venous air embolism obtained?

A
  1. Most sensitive: Echo
  2. Highly sensitive: Transthoracic Doppler
  3. low sensitivity: Esophageal stethoscope, PA, ECG
185
Q

Why are patients with venous air emboli placed in L Lateral Decubitis or Trendelenburg position?

A

Moves air embolus from the RVOT into the RV, decreasing risk of cardiovascular collapse

186
Q

What should be done if a venous air embolism is suspected?

A

Cover surgical field with soaked dressing and flush with saline

100% O2

D/C Inhalants

Vasopressors for hypotension

Attempt manual removal of air (not normally effective)

187
Q

What should be done to prevent venous air embolism in cases where the risk is known?

A

CVC and transthoracic doppler placement

Avoid nitrous oxide

Consider alternative patient positioning

188
Q

Why is face/neck/tongue edema a complication of a head-elevated position?

A

Prolonged, marked neck flexion can cause venous and lymphatic obstruction resulting in macroglossia

189
Q

What is midcervical tetraplegia?

A

Hyperflexion of the neck stretches the spinal cord resulting in ischemia to the midcervical region. Causes paralysis below C5.

Associated with any prolonged flexion of the head (sitting or supine, forced or nonforced)

190
Q

Which structure is most frequently injured during a nasal intubation?

A

inferior nasal concha

191
Q

What is the role of the Genioglossus?

A

Attaches the tongue to the mandible, prevents it from falling back during jaw-thrust

192
Q

What is the role of the Internal branch of SLN?

A

provides sensory innervation to the posterior epiglottis, arytenoids, and vocal cords

193
Q

Croup involves edema of the

A

airway below the vocal cords

194
Q

You are applying local anesthetic soaked pledgets to the middle turbinates of a patient’s nasal cavity prior to a nasal intubation. What nerves are you anesthetizing?

A

Trigeminal Nerve

195
Q

what is the vertical location of the adult larynx?

The pediatric larynx?

A

C3-C6

C2-C4

196
Q

What are the objective criteria for routine extubation? (5)

A

vital capacity of at least 10 mL/kg, a

peak NIP of at least -20 cm H2O

sustained tetanic contraction

tidal volume of at least 6 mL/kg

TOF ratio of at least 0.7.

197
Q

When is retrograde intubation useful?

A

situations where traditional intubation is not possible, but ventilation is possible.

198
Q

How is a cricothyrotomy performed?

A

inserting a large-bore intravenous catheter or cannula into the cricothyroid membrane which lies between the inferior border of the thyroid cartilage and the superior border of the cricoid cartilage.

199
Q

What is the invasive airway technique of choice in emergency airway situations?

A

surgical cric

200
Q

Following a difficult intubation, you suspect that a patient may have obstruction of the submandibular duct due to trauma establishing the airway. This condition would present as

A

swelling of the tongue

201
Q

Laryngotracheobronchitis (croup) most commonly appears _____ after extubation.

A

3 hours

202
Q

Which nerves should be assessed for onset of NMBA and why?

A

Blood, thus drug, distribution to the facial muscles mirrors distribution in the larynx and diaphragm where relaxation is required for intubation and airway manipulation.

203
Q

Which nerves should be assessed to discern recovery from NMBA

A

Recovery is best measured in the hand. The hand muscles are more sensitive to relaxant than the diaphragm, so if recovery is evident in the hand, the larynx, and the diaphragm, the upper airway muscles will be recovered as well.

204
Q

What is Fade?

A

Inability to sustain a muscular response to repetitive nerve stimulation

205
Q

Why is fade an assessment of NMBA activity?

A

NMBAs block the presynaptic Ach receptors as well as postsynaptic

When the nerve can’t continue producing Ach to stimulate contraction, that’s the effect of the NMDA and its called fade

206
Q

When the fourth twitch disappears in ToF, what is the percentage of block?

A

75-80%

207
Q

If T3 and T4 are absent in ToF, what is the percentage of block?

T2?

0 Twitches?

A

80-85%

90-95%

100%

208
Q

What is Tetanus Testing?

A

Allows assessment of NM blockade when there is a deep block needed

continuous electrical stimulation for 5 seconds at 50 or 100 Hz. If the muscle contraction produced is sustained for the entire 5 seconds of stimulation without fade, significant paralysis is unlikely. If fade is present, clinically significant block remains.

209
Q

Which drugs are helpful in slowing Alzheimer’s?

A

Cholinesterase Inhibitors

210
Q

Which form of hemoglobin is most commonly seen in the bloodstream

A

Hgb A is 97% of RBCs

Hemoglobin C is implicated in a type of hemolytic anemia, hemoglobin F is found in fetuses, and hemoglobin S is found in patients with sickle cell anemia

211
Q

What pulmonary complications would you most likely see in a patient with systemic lupus erythematosus?

A

Restrictive defects such as:

Pleural Effusion

pHTN

212
Q

What is the most common cause of death in lupus?

A

Renal Disease

The most common presenting symptoms of SLE are polyarthritis and dermatitis. A malar rash occurs in about 1/3 of SLE patients. Renal disease occurs in over half of the patients with SLE and is the most common cause of death. About 10-20% of patients with lupus erythematosus require dialysis. Because of the increased risk of vasculitis, these patients have a higher risk of CNS disorders such as seizures, stroke, dementia, peripheral neuropathy, and psychosis. A diffuse serositis results in pericardial effusion in over half of these patients, but pericardial tamponade is rare.

213
Q

With its decline in age, which neurotransmitter is noted for its connection to Alzheimer’s disease?

A

Acetylcholine

214
Q

What are two non-depolarizing muscle relaxants useful for patients with Guillain-Barre syndrome?

A

Cis and Roc

215
Q

What is the preferred treatment for hereditary Spherocytosis?

A

Splenectomy

216
Q

Considering the elimination half life of carbon monoxide, what is the minimal time of smoking cessation to substantially decrease carboxyhemoglobin levels?

A

18 hours

217
Q

How long should a patient refrain from smoking before the ability of the lungs to respond to pulmonary infection returns to normal?

A

8 weeks

218
Q

How long prior to surgery should aspirin be discontinued?

A

7-10 days

219
Q

What food allergies are associated with an increased risk for latex allergy?

A

Papaya

Kiwi

Chestnuts

Avocado

220
Q

What is the overall risk for a perioperative MI in the general population undergoing general anesthesia?

A

0.3%

221
Q

characteristics of unstable angina

A

substernal chest pain that began less than 2 months ago,

has progressively increased in severity, duration, or frequency,

is less responsive to pharmacologic therapy,

occurs at rest,

lasts longer than half an hour, or

exhibits transient T-wave or ST segment changes.

222
Q

Ideally, a pulmonary artery catheter should be positioned in

A

West Lung Zone III

223
Q

Which disease are associated with cannon ‘a’ waves on the central venous pressure waveform

A

junctional rhythms, complete AV block, or PVCs,

triscupid stenosis, mitral stenosis,

myocardial ischemia, diastolic dysfunction, and ventricular hypertrophy

224
Q

How is the post-tetanic count used?

A

Used in deep anesthesia to determine how long it will be until a response to stimulation will occur

The number of visible twitches correlates inversely with the amount of time required for return of the first twitch of a TOF stimulation.

225
Q

how do you elicit a post-tetanic count?

A

5 second 50 Hz tetanic stimulation followed by a 3-second pause, then 1 Hz twitch stimulations

226
Q

Which clotting factors are not synthesized by the liver?

A

factors III (tissue thromboplastin), IV (calcium), and von Willebrand factor

227
Q

Sugammedex has the highest affinity for what paralytic?

A

Rocuronium

228
Q

To what degree can succ increase intraocular pressure?

A

as much as 15mmHg for 5 minutes

229
Q

Which two laboratory studies appear to be associated with increased risk of perioperative pulmonary morbidity?

A

High BUN and low Albumin

230
Q

What is the appropriate intravenous dose for succinylcholine in a 3 month-old patient?

A

2-3 mg/kg

Require a higher dose than adults

Defasciculating doses of nondepolarizing neuromuscular blockers are rarely given because fasciculations are uncommon in children.

231
Q

Which agents have been noted to delay the onset of rocuronium?

A

Beta Blockers

232
Q

Methemoglobinemia tends to drive the pulse oximetry measurement towards _____ regardless of the actual oxygen saturation

A

85%

can occur due to large doses of benzocaine, prilocaine, or EMLA cream

absorbs the two frequencies of light used in pulse oximetry in a 1:1 ratio, which corresponds to an oxygen saturation of 85%

233
Q

The prothrombin time and INR are good indicators of hepatic dysfunction due to the short half-life of clotting factor:

A

7

234
Q

What is the most serious side effect of sugammedex?

A

Hypersensitivity

235
Q

Why is edrophonium a weaker reversal agent than neostigmine?

A

Binds with ionic bonds

236
Q

How does severe anemia affect SpO2 readings?

A

Overestimates

237
Q

What causes underestimation of SpO2?

A

Prominent venous pulsations and injection of certain dyes such as indigo carmine, lymphazurin, nitrobenzene, indocyamine green, methylene blue, and patent blue can result in underestimation

238
Q

What is the half life of ancef?

A

2 hours

239
Q

What nerve passes between the medial epicondyle of the humerus and the olecranon?

A

Ulnar

240
Q

What percentage of MIs occur without symptoms?

A

30%

241
Q

Which muscle relaxant would be LEAST appropriate for a patient with a history of severe asthma?

A

Atracurium

242
Q

What inhaled anesthetic potentiates the effects of neuromuscular relaxants the most?

A

Desflurane

243
Q

Why is pancuronium popular in cardiac surgery?

A

has direct sympathomimetic and vagolytic effects

capable of counteracting bradycardia that is induced by a high dose narcotic technique.

244
Q

How is potency of NMBA agents expressed?

A

By ED95: the dose required for supression of 95% of baseline twitch height

245
Q

What is a Phase II Block of Succ?

A

Pardoxic Non-paralysis

246
Q

What causes phase II block?

A

Large doses (>10 times ED95)

prolonged (>30 minutes) exposure

presence of abnormal (atypical) plasma cholinesterases (pseudocholinesterase/butyrylcholinesterase deficiency)

247
Q

What is the ED95 and DUR25 of succ?

A

ED95 0.3mg/kg

DUR25 10-12 min

248
Q

What are risks of Succ, specifically in children?

A

Bradycardia and Asystole

249
Q

Most effective treatment to prevent myalgia (other than Non-depolarizing agents)

A

NSAIDS

250
Q

Pediatric myotonias and dystrophies should never received which NMBA?

A

Succ

Associated with hyperkalemia and rhabdo

In peds succ should only be used in emergency intubation

251
Q

Initiation dose of succ in

Adults

Children

Infants

A

1 mg/kg

1.5-2 mg/kg

3 mg/kg

252
Q

-Curonium

A

Aminosteroids

253
Q

-Acurium

A

Benzylisoquinolinium

254
Q

What does an ETCO2 alpha angle greater than 90 indicate?

A

V/Q mismatch

255
Q

What is phase 1 of ETCO2 tracing?

A

Flat beginning of expiration, dead space air escaping

256
Q

What is phase II of ETCO2 tracing?

A

Sharp upslope as CO2 rich air from alveoli is expired

If it’s slanted it means there’s something blocking expiration, either in the tube (Valve issue or kink) or the lungs (COPD, emphysema, air entrainment from asthma)

257
Q

What is phase III of ETCO2 tracing?

A

Plateau

Usually slightly upward since the deepest areas of the lung have the highest cocentration of CO2 exchange

258
Q

What does an ETCO2 B angle greater than 90 indicate?

A

Malfunctioning inspiratory unidirectional valves

rebreathing

low-tidal volume with a rapid respiratory rate

259
Q
A
260
Q

Andrews Table

A

Abdomen hangs free

Prevents epidural hemorrhage

261
Q

Causes of vision loss (5)

A

central retinal vein occlusion

glycine toxicity

ischemic optic neuropathy

sentinel retinal artery occlusion

cortical blindness

262
Q

Which has a better chance of recovery: sensory or motor deficits?

A

Sensory

263
Q

When do sensory deficits usually resolve?

A

Within 5 days

If it lasts longer, contact neurologist

264
Q

What should you do if the patient has a motor deficit?

A

Contact neurology right away

265
Q

What nerves are included in the brachial plexus?

A

axillary

radial

median

musculocutaneous

ulnar

266
Q

Second most common cause of PNI across anesthesia types

A

Brachial Plexus injury

267
Q

What are the manifestations of a radial nerve injury?

A

Inability to:

Abduct thumb

Extend wrist

extend metacarpals

268
Q

What is the single greatest predictor of a difficult airway in an obese patient

A

Neck circumference > 40cm

269
Q

Common Peroneal injury primarily manifests as

A

Foot drop

270
Q

What nerve injury is associated with a difficult forceps delivery?

A

Obturator

271
Q

What damage can occur from a jaw thrust manuever?

A

Facial nerve damage from compression of the ascending ramus

272
Q

What are the top three leads you should monitor if the pre-op 12 lead is normal?

A

III, V3, V4

273
Q

What is the TOFR for full reversal?

A

0.9

274
Q

What is the treatment for Myasthenia Gravis?

A

Anticholinesterases, IVIG, Thymus removal

275
Q

What are some clinical considerations for patients with sickle cell disease?

A
  1. High incidence of Vaso-occlusive crisis (VOC) and Acute Chest Syndrome (ACS)
  2. MUST remain well oxygenated at all times
  3. Avoid tourniquets wherever possible
  4. Avoid narcotics as much as possible
276
Q

What are some systemic complications of scleroderma?

A

80% develop ILD leading to pHTN and RV failure!!!

Renal dysfunction

Decreased GI motility

May need invasive cardia monitoring intraop

Basic Principles (15 decks)

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