NCE Prep Flashcards
Damage to the ulnar nerve presents how?
as a claw hand
- digit affected- 4th and 5th
- inability to extend pinky and ring finger
- inability to abduct pinky finger
Motor innervation of tibial nerve is?
Plantar flexion and inversion
Fail Safe-something about adding a 3rd gas
?
What risk is it to the patient if the positive pressure relief valve dosnet work?
can cause barotrauma
What innervates the Biceps?
Musculocutaneous
What innervates the Triceps?
Radial
What drugs should not be given to Parkinson’s patients?
-Antidopaminergic drugs such as metoclopramide. butyrophenones(haloperidol & •droperidol), and phenothiazines(promethazine) may exacerbate extrapyramidal s/sx. These drugs are contraindicated.
•aspiration. Levodopa has a half-life of 6-12 hours. It must be given the morning of surgery to prevent •worsening of symptoms such as rigidity, which can impact ventilation. For longer procedures, levodopa may be administered via an OG tube. Anticholinergics may be used to treat acute exacerbation of Parkinsonian symptoms. •Diphenhydramine has anticholinergic properties and is useful for sedation and reduction of •tremor. Hypotension should be treated with intravascular volume expansion and direct-acting •agents, such as phenylephrine. Alfentanil may cause an acute dystonic reaction due to interruption of central •dopaminergic neurotransmission. Ketamine is controversial due to its effects on the SNS. •There is no contraindication to succinylcholine or non-depolarizers. •Monitor for postoperative ventilatory failure
In the patient with Parkinson’s disease, the dopaminergic neurons in the basal ganglia are destroyed. This favors a relative increase in cholinergic activity. 1.Increased Ach in the basal ganglia increases GABA activity in the thalamus. 2.Recall that GABA is an inhibitor neurotransmitter, so increased GABA suppresses the thalamus. Thalamic inhibition suppresses the cortical motor system and motor areas in the 3.brainstem. The end result is an over activity of the extrapyramidal system
WPW can be recognized by this wave on an EKG and what Ca Channel blocker should not be given?
Delta Wave
Verapamil
Order of decreased SVR/MAP? “SVR is down” of the volatile agents?
- Iso
- Sevo
- Des
(Apex) Sevoflurane causes the least reduction in SVR
N2O and B12-aplastic anemia??
?
Why might patients with Treacher Colins/VSD have a difficult AW?
Treacher Collins-small underdeveloped maniple
VSD-Trisomoy 21?-large tongue/C-spine(C1/C2 possible subluxation!) abnormaliites
Diaphragmatic hernia
Congenital diaphragmatic hernia is a diaphragmatic defect that allows the abdominal contents to enter the thoracic cavity. The formation of Bochdalek is the most common site of herniation(usually •on the left side). Other sites of herniation include the foramen of Morgagni and around the •esophagus
Pathophysiology and Anesthetic Management The mass effect of abdominal contents within the chest impairs lung development, leading to pulmonary hypoplasia. One or both lungs can be affected. Consequences include poor pulmonary vascular development, •increased pulmonary vascular resistance, pulmonary hypertension, impaired airway development and airway reactivity. Keep PIP < 25 - 30 cm H2O to minimize barotrauma and the risk of •pneumothorax of the “good” lung. This may require permissive hypercapnia; and while it will increase PVR, it’s the lesser of two evils in this situation. Avoid other conditions that increase PVR(hypoxia, acidosis, •hypothermia). Abdominal closure may increase PIP. The surgeon can create a •temporary ventral hernia to increase the abdominal volume. A pulse oximeter placed on a lower extremity can warn of increased •intra-abdominal pressure. Right-to-left shunting through the ductus arteriousus leads to hypoxemia and cyanosis, and this gives rise to a positive feedback loop where PVR increases even further. Use the right upper extremity to monitor pre ductal SpO2 and BP. •Pre ductal SpO2 should be > 90% •Surgery is delayed 5 - 15 days to allow for stabilization of the pulmonary, cardiac, and metabolic status.
TEF—–>
Esophageal atresia is the most common congenital defect of the esophagus, and most of these children also have a tracheoesophageal fistula. Esophageal atresia prevents the fetus from swallowing amniotic fluid, this maternal polyhydramnios is a key diagnostic indicator for TEF. Diagnosis is confirmed by the inability to pass a gastric tube into the stomach. Other symptoms include: choking, coughing, and cyanosis during oral feeding.
Discuss the anesthetic management of TEF.Head up position and frequent suctioning minimize the •risk of gastric aspiration. Awake intubation or inhalation induction with •spontaneous ventilation. Positive-pressure ventilation -> Gastric distention -> •decreased Thoracic compliance -> increased PIP required to ventilate -> repeat Placement of g-tube allows for gastric decompression. If •the patient already has a g-tube, open it to atmosphere before induction. Place the endotracheal tube below the fistula but above •the carina. If placed too high, respiratory gas is delivered to the •stomach. If placed too low, endobronchial intubation is likely. •A precordial stethoscope placed on the left chest will •immediately detect a right mainstem intubation. Right lung compression during surgical repair is •common. Right mainstem intubation will cause rapid desaturation.
Epiglottis vs Croup
Epiglottis: age2-6 Rapid onset supra glottis structures CXRAY: thumb sign High fever tripoding drooling
Croup: age <2 gradual onset laryngeal structures CXRAY: steeple sign mild fever mild stridor barking cough
Phase 2 block hotspot?
?
What are the ingredients of EMLA cream?
- 5 lido
2. 5 prilocaine
What are the dangers of sevo in the presence of desiccated soda lime?
fire
What is the osmolarity of CSF?
295…the osmolarity of plasma also is295
What type of bond is the strongest?
Covalent bond
What tendons is the ulnar nerve block between?
flexor carpi lunaris tendon
palmaris longus tendon
Block of the ulnar nerve is achieved by abducting the arm and flexing the elbow to 90°. The needle is inserted 1–2 cm proximal to the ulnar sulcus and directed 45° cephalad. When optimal needle position has been achieved, 5–10 ml of LA should be injected. Injection into the tight ulnar sulcus should be avoided as this can cause pressure-induced neuropraxia. Within the ulnar sulcus, the nerve is relatively immobile and is at risk of needle trauma.
What tendons is the median nerve block between?
flexor carpi radius tendon
palmaris longus tendon
The median nerve is found approximately 1 cm medial to the brachial artery on the elbow crease, lying at a depth of 1–2 cm. The needle is advanced at 45° cephalad to the skin, and a click may be felt as it passes through the bicipital aponeurosis. When optimal motor stimulation is achieved, 5–10 ml of LA is injected. The needle is then redirected subcutaneously along the medial border of the biceps tendon where the medial cutaneous nerve of the forearm is blocked by injecting a further 5–10 ml of LA.
What tendons is close to the radial nerve block
extensor pollicus longus
extensor pollicus brevis
What are the T3, T4, TSH differences between hypothyroid and hyperthyroid?
Hyperthyroidism: low TSH, High T3 and T4
Hypothyroidism: high TSH, low T3 and T4
What abnormal laboratory values are seen with Addison’s disease?
hyponatremia
hyperkalemia
normal glucose
I present with:
Hypertension(Na+ and water retention)
Hypokalemia(K+ wasting)
Metabolic alkalosis(H+ wasting)
Etiology is:
Primary hyperaldosteronism
-increased aldosterone release from adrenal glands(renin activity is normal)
Causes: aldosteronoma, pheochromocytoma, primary hyperthryoidism
What am I
Conn’s Sydrome
I present with- Glucocorticoid effects: -hyperglycemia -weight gain -increases risk of infection -osteoporosis -muscle weakness -mood disorder
Mineralocorticoid effects:
-HTN
hypokalemia
-metabolic alkalosis
Adrongenic effects:
- women become masculine
- men become feminized
etiology: the result of cortisol excess either from overproduction or exogenous administration.
what am I?
Cushing’s Syndrome
Cushing’s disease is a result of excess ACTH
I present with- Adrenal insufficiency: -muscle weakness/fatigue -hypotension -hypoglycemia -hyponatremia/hyperkalemia/metabolic acidosis -anorexia/weight loss -n/v -hyperpigmenation of the knees, elbows, knuckles, lips
what am I?
Addison’s disease
Decreased ACTH
What’s the treatment for Addison’s disease?
Adrenal insufficiency:
-steroid replacement therapy
Acute adrenal crisis:
- steroid replacement therapy
- ECF volume expansion
- hemodynamic support
What is the treatment for Conn’s Syndrome?
Anesthetic Implications?
Removal of aldosterone secreting tumor
Aldosterone antagonist-spironolactone/eplerenone
Potassium supplemenatation
Na+ restriction
Anesthetic implication:
Hypokalemia
Hypertension
What is the treatment and anesthetic implications for Cushing’s Syndrome?
Treatment:
Transsphenoidal resection of anterior pituitary gland
Pituitary radiation
Adrenalectomy(if adrenal tumor)
Anesthetic Implications:
In addition to considerations for hyperaldosteronism covered on last page:
-special attention to aseptic technique
-careful positioning to reduce akin and bone injury
-consider postop steroid supplementation
-diabetes insidious may develop after removal of anterior pituitary gland
What is peripheral edema a sign of?
right sided heart failure
What drug is toxic to the lungs?
Bleomycin
What drug causes headaches(cns)?
Vincristine
What drug can be nephrogenic?
Cisplastin
What drug is cardiotoxic?
Danunorubicin
What in the kidneys does Acetazolamide and Dorzolamide location of action?
Mechanism of Action: Carbonic anhydrase inhibitors non competitively inhibit carbonic anhydrase in the proximal tubule. Let’s view the reaction: Bicarbonate accepts H+ to form carbonic acid. In the presence of carbonic anhydrase(an enzyme), carbonic acid dissociates into CO2 and H20. This favors a concentration gradient where HCO3- flows from the lumen of the tubule and into the cells of the proximal tubule. Inhibiting carbonic anhydrase disrupts this mechanism. As a result, HCO3- isn’t reabsorbed. Since H+ isn’t used to produce carbonic acid, it is retained by the body. Chloride is retained to maintain electroneutrality. This is the mechanism for hyperchloremic metabolic acidosis(non-gap). There is a net loss of bicarbonate and sodium with a net gain of hydrogen and chloride. Dose: Acetazolamide 250 - 500 mg Clinical Use: Open-angle glaucoma-Inhibition of carbonic anhydrase reduces •aqueous humor production and reduces intraocular pressure. High-altitude sickness - A mild metabolic acidosis increases •respiratory drive. Central sleep apnea-A mild metabolic acidosis increases •respiratory drive. Complications: Metabolic acidosis •Hypokalemia •In patients with COPD, loss of bicarbonate ions in the •urine(reduced by buffer) may exacerbate CNS depression from hypercarbi
Where in the kidneys do Mannitol, Glycerin and Isosorbide act?
Mechanism of Action: Osmotic diuretics are sugars that undergo filtration but not reabsorption. They inhibit water reabsorption in the proximal tubule(primary site) as well as the loop of Henle. Water is excreted excess of electrolytes. Osmotic diuretics pull ECF volume into the intravascular space. This increases plasma osmolarity, which reduces brain water(decreases ICP) as well as augments RBF. In the patient with poor myocardial function, expansion of the intravascular volume can precipitate heart failure and pulmonary edema. Mannitol is a free radical scavenger. This may limit cellular edema and decrease obstruction of the renal tubules. Dose: Mannitol 0.25 - 1 g/kg Clinical Use: Prevention of acute kidney injury - there is little evidence to •support the efficacy of this Intracranial hypertension •Differential diagnosis of acute oliguria(mannitol increases UOP if •pre renal but has no effect with intrinsic injury) Complications: Congestive heart failure •Pulmonary edema •If the blood-brain barrier is disrupted, mannitol will enter the •brain and cause cerebral edema.
Where is the location of action of Furosemide, Bumetanide and Ethacrynic acid in the kidneys?
Mechanism of Action: The ascending limb of the loop of Henle is impermeable to water. As the ultra filtrate flows upward, the Na-K-2Cl transporter removes these ions from the ultra filtrate and dilutes the urine. This region is responsible for 25% of the sodium reabsorption in the nephron. Loop diuretics poison the Na-K-2Cl transporter in the medullary region of the thick portion of the ascending loop of Henle)primary site). The amount of sodium that remains in the tubule overwhelms the distal tubule’s reabsorption capability. Thus, a large volume of dilute urine is excreted. Potassium, calcium, magnesium, and chloride are lost to the urine as well. Dose: Furosemide 20 - 200 mg Bumetanide 0.5 - 2 mg Ethacrynic acid 25 - 100 mg Clinical Use: Acute pulmonary edema •Acute kidney injury •Congestive heart failure •Hypercalcemia •Hypertension •Anion overdose •Intracranial hypertension(not as effective as mannitol) •Mobilization of edema fluid •Complications: Hypokalemic, hypochloremic, metabolic alkalosis •Hypokalemia can increase risk of dysrhythmias when combined •with digitalis, skeletal muscle weakness, and potentiate the effect of neuromuscular blockers. Hypocalcemia •Hypomagnesemia •Hypovolemia •Ototoxicity(ethacrynic acid > furosemide) •Reduced lithium clearance
Where in the kidneys does Hydrochloride, Chlorthalidone, Metolazone, and Indapamide act?
Mechanism of Action: Thiazides inhibit the Na-Cl transporter in the distal tubule. Stoeltingsays their primary site of action is the cortical region of the thick ascending loop of Henle, but this book seems to be an outlier. Inhibition of the Na-Cl exchanger in the distal tubule activates the Na-Ca anti porter. This increases Ca+ reabsorption, ultimately increasing serum calcium. A unique feature of thiazide diuretics is that they cause hyperglycemia. Possible mechanisms for this include reduced insulin release from the pancreas or impaired cellular glucose utilization in the body. Dose: Hydrochlorothiazide 12.5 - 50 mg Chlorthalidone 12.5 - 5 mg Metolazone 1.25 - 5 mg Indapamide 1.25 - 5 mg Clinical Use: Essential hypertension •Mobilize edema fluid •Heart failure •Osteoporosis(reduces Ca+ excretion) •And wrap your head around this….thiazides are used to treat •nephrogenic diabetes insipidus. Complications: Hyperglycemia-caution with diabetes mellitus •Hypercalcemia •Hperuricemia-caution with gouty arthritis •Hypokalemic, hypochloremic, metabolic alkalosis •Hypovolemia •Hyperlipidemia •Sexual dysfunction
Where does Spironolactone, Amiloride, Triamterene act in the kidneys?
Mechanism of Action: Amiloride and triamterene inhibit potassium secretion and •sodium reabsorption in the collecting ducts. Their function is independent of aldosterone. Spironolactone exists in a subclass of potassium-sparing •diuretics called aldosterone antagonists. By blocking aldosterone at mineralocorticoid receptors, spironolactone inhibits potassium secretion and sodium reabsorption in the collecting dust. Dose: Spironolactone 12.5 - 100 mg Amiloride 5 - 10 mg Triamterene 50 - 150 mg Clinical Use: To reduce potassium loss in a patient receiving a loop or •thiazide diuretic Secondary hyperaldosteronism•Complications: Hyperkalemia(risk increased with concurrent use of NSAIDs, •beta-blockers, and ACE inhibitors) Metabolic acidosis •Gynecomastia •Libido changes(spironolactone) •Nephrolithiasis(triamterene)
Pickwickian-choose 3
?
What are the effects of thromboxane A2?
- 4 choices (chose vasoconstriction)
ECG, 3rd beat had no pwave, regular rhythm
-4 choices
chose junctional escape beat)
What drug lasts the longest in the elderly?
- benzodiapines
- induction agents
- NDMR
- ?
benzodiapines
D&D: what dermatome ?
C-sec- ?
TURP-?
Appendectomy- ?
Hemmorhoidectomy- ?
D&D
C-sec- T4
TURP-T10
Appendectomy- T6
Hemmorhoidectomy- L1-L2
. What nerve block is this?
- superficial peroneal
- saphenous
- sural
- posterior tibial
Know nerve blocks
Contraindication for Combitube
- > 6ft tall
- ingestion of caustic substances
- unconsious with no gag reflex
> 6 foot tall
How is hepatic blood flow regulated? can’t completely remember the choices so look this up
- portal hyoxia?
- systemic hypercarbia
- other options about O2 and CO2
Hepatic Blood FlowThe liver receivesThe liver is supplied by1.2.The portal veins suppliesThe hepatic artery suppliesHepatic Venous Flow:Hepatic Arterial Flow:Effects of Anesthesia:~ 30% of the cardiac output(1500 mL).2 vessels: portal vein & hepatic arteryAorta —> Splanchnic organs —> Portal vein —> LiverAorta —> Hepatic artery —> Liver75% of liver blood flow •50% of oxygen content(lower O2 saturation)•25% of liver blood flow •50% of oxygen content(higher O2 saturation
Hepatic Venous Flow:~ 30% of the cardiac output(1500 mL).2 vessels: portal vein & hepatic arteryAorta —> Splanchnic organs —> Portal vein —> LiverAorta —> Hepatic artery —> Liver75% of liver blood flow •50% of oxygen content(lower O2 saturation)•25% of liver blood flow •50% of oxygen content(higher O2 saturation)•Splanchnic vascular resistance determines how much blood is delivered to the portal vein. The splanchnic circulation is richly innervated by •the SNS, so SNS activation(hypoxia, hypercarbia, pain and surgical stress) increase splanchnic vascular resistance and reduce portal vein pressure
Hepatic Arterial Flow: This is a fancy way of saying that a reduction in portal vein flow is compensated by an increased hepatic artery flow. This response is mediated by adenosine. •Severe liver disease impairs this response.
General anesthesia as well as neuraxial anesthesia reduce liver blood flow as a function of decreased MAP. Induction of general anesthesia can reduce hepatic blood flow by 30-50%.
Calculation- O2sat was 100% and hgb 15
Hgb x 1.34 x sat% / 100 = bound
Calculation- O2sat was 100% and hgb 15
Hgb x 1.34 x sat% / 100 = bound
FRC? definition and normal value?
RV + ERV
2300
Vital Capacity? definition and normal value?
IRV + TV + ERV
4500
Residual Volume? definition and normal value?
Vol of gas that remains in the lungs after complete exhalation
cannot be exhaled from lungs
Vol of alveolar gas that serves as oxygen reservoir during apnea
1200
Closing Capacity?
RV + CV
variable
IC?
IRV + TV
3500
TLC?
IRV+TV+ERV+RV
5800
Pt had liposuction and is now in PACU, hypertension and dyspneic
- lido toxicity
- fluid volume overload
- ?
- ?
fluid volume overload
What affects uptake of inhalation agents in pregnant women?
- decreased VD
- increased circulatory volume-chose this but wasn’t sure
- estrogen?
- decreased FRC
increased circulatory volume-chose this but wasn’t sure
Hot spot- Select 2 landmarks for lateral sciatic block
Hot spot- Select 2 landmarks for lateral sciatic block
3-in-1 block- select 3
obturator
femoral
lateral femoral cutaneous
. If FRC decreases, what else decreases?
ERV/RV??
What drug wouldn’t you give to nursing mother?
- Tylenol
- Meperidine
- fentanyl
- morphine
meperidine
S/S of PE-pick several
- decreased etCO2
- tachycardia
- can’t remember the other options but they were obvious
S/S of PE-pick several
- decreased etCO2
- tachycardia
- can’t remember the other options but they were obvious
In the elderly, the time needed for clinical recovery from neuromuscular blockade is significantly increased for: A. Cisatracurium B. Vecuronium C. Pipecuronium D. Mivacurium
Vecuronium
Which of the following neuromuscular blocking agents is a benzylisoquinoline compound? A. Vecuronium B. Succinylcholine C. Pancuronium D. Mivacurium
Mivacurium
Considerations for the management of a patient with myotonic dystrophy under general anesthesia should include a(an): A. Anticholinesterase reversal B. Midazolam premedication C. Short-acting nondepolarizer D. Succinylcholine infusion
Short-acting nondepolarizer
When providing positive pressure ventilation via a bag-valve-mask device, inspiratory pressure should be limited to: A. 15 cm H20 B. 25 cm H20 C. 40 cm H20 D. 50 cm H20
25 cm H20
Which drug would have a normal pharmacokinetic profile in a patient with severe liver disease? A. Pancuronium B. Succinylcholine C. Mivacurium D. Atracurium
Atracurium
What is the first sign of magnesium toxicity when used for seizure prophylaxis in preeclampsia?
Respiratory depression
Hypotension
Cardiac conduction defects
Loss of deep tendon reflexes
Loss of deep tendon reflexes
In the hypothermic patient undergoing left atrial to femoral bypass for repair of a thoracolumbar aneurysm, the most common dysrhythmia encountered with atrial cannulation is: A. Atrial fibrillation. B. Bradycardia. C. Junctional rhythm. D. Ventricular tachycardia.
Atrial fibrillation.
An increase in the drug half-life in the geriatric population is usually due to:
A. Age-associated induction of cytochrome P450 activity
B. A shift from first-order to zero-order kinetics
C. Reduced liver blood flow
D. Increased volume of distribution
Increased volume of distribution
Intrathecal narcotic administration is associated with:
A. Loss of proprioception
B. Skeletal muscle weakness
C. Selective sensory blockade
D. Sympathetic nervous system denervation
Selective sensory blockade
What is the MOST likely complication of combined spinal/epidural analgesia during labor and delivery?
A. Higher than anticipated dermatome level of analgesia
B. Epidural catheter insertion into the intrathecal space
C. Epidurally administered drug leakage into the intrathecal space
D. Higher incidence of fetal bradycardia
Epidurally administered drug leakage into the intrathecal space
The BEST indicator for CAD in the pre-operative assessment for vascular surgery patients is: A. Electrocardiogram B. History and physical C. Presence of S3 gallop D. Exercise tolerance
Exercise tolerance
Which agent is MOST likely to maintain renal blood flow during periods of induced hypotension?
Nitroglycerin
Nitroprusside
Fenoldopam
Trimethaphan
Fenoldopam
What is the threshold pressure (PSI) for a primary pressure fail-safe device on an anesthesia machine?
A. 10 B. 20 C. 30 D. 40
20
Autonomic hyperreflexia can:
A. Develop immediately after spinal cord injury
B. Result in hypotension and tachycardia
C. Be prevented by “light” anesthesia
D. Be treated with vasodilators or alpha blockers
Be treated with vasodilators or alpha blockers
Radial nerve block often can be determined by the patient’s inability to perform which of the following actions of the arm? A. Flexion B. Extension C. Pronation D. Adduction
Extension
The MOST common preventable critical incident associated with anesthesia equipment is:
A. Failure to ventilate caused by circuit disconnection
B. Barotrauma caused by excessive positive pressures
C. Hypoxia caused by a delivery piping misconnection
D. Overdose due to vaporizer cross fill contamination
Failure to ventilate caused by circuit disconnection
The check valve in the low pressure system is designed to:
A. Prevent excessive airway pressures
B. Prevent scavenged gases from reentering the circuit
C. Facilitate equipment testing before induction of anesthesia
D. Minimize the pumping effect associated with positive-pressure ventilation
Minimize the pumping effect associated with positive-pressure ventilation
A patient in the PACU is found to have residual neuromuscular blockade despite reversal with neostigmine and glycopyrrolate. Which of the following would further impair reversal?
Hyperkalemia
Hypoalbuminemia
Respiratory acidosis due to hypoventilation
Residual synthetic opioids
Respiratory acidosis due to hypoventilation
A mass spectrometer measures the concentrations of inhaled agents by measuring: A. Intensity of transmitted light B. Paramagnetism C. Molecular weight D. pH sensitivity
A mass spectrometer measures the concentrations of inhaled agents by measuring: A. Intensity of transmitted light B. Paramagnetism C. Molecular weight D. pH sensitivity
