OB Final Comprehensive Flashcards
1
Q
EKG changes associated with aging
A
Left Ventricular Hypertrophy - Left axis deviation
2
Q
Aging and Diastolic dysfunction: LV
A
LV is thicker and less compliant
Complete relaxation later in diastole
3
Q
Aging and Diastolic dysfunction: Passive ventricular filling
A
Passive ventricular filling compromised
4
Q
Aging and Diastolic dysfunction:atrial kick
A
Atrial kick becomes very important
5
Q
Aging and PPVs
A
Greater sensitivity to PPV, hemorrhage, venodilators
6
Q
Aging and perioperative pressure
A
Perioperative hypotension common
7
Q
Changes with Aging Systolic
A
There is systolic hypertension
Progressive, gender independent
8
Q
Systolic HTN due to
A
Due to fibrosis of elastic tissues
9
Q
Ventricular wall tension
A
Raises ventricular wall tensions, workload
Causes hypertrophy of ventricle
10
Q
It takes pts c/obstructive dz
A
twice as long to exhale: I:E is 1:2
11
Q
ETCO2 look like
A
Shark fin
12
Q
Obstructive airway shark pattern
A
Can be seen before actual attack
13
Q
Shark fin CO2 waveform indicative of
A
Asthma, COPD, allergic reaction
14
Q
MAC changes with aging
A
↓ 6% per decade of age over 40 yrs.
15
Q
Calculating MAC reduction
A
Relative MAC or ED50 = 114% - 0.5* (age)
16
Q
Treating Hypotension
A
Use direct acting vasopressors
17
Q
For older adults, Therefore volume of distribution
for lipid soluble is _____
A
Greater for lipid soluble agents
18
Q
For older adults, Therefore volume of distribution
for WATER soluble is _____
A
Decreased
19
Q
For Older adults, Lipid soluble drugs take
A
longer to clear because of the larger volume of distribution
20
Q
MAC of anesthetics is____in the elderly
A
↓
21
Q
Most prominent pharmacokinetic effect of aging:
A
decrease in drug metabolism
22
Q
Pharmacokinetics: Clearance and Vd
Metabolism
A
Decrease in clearance and increased volume of distribution at steady state
23
Q
↓ intravascular volume leads to _____Vd of water soluble drugs = __________ = ___action = _____Dosage
A
↓ Vd for water soluble drugs = more drug remains available = ↑ action = need to ↓ dosage (i.e. Neuromuscular blockers)
24
Q
Drug metabolism , there is
A
Modest reduction in phase I drug metabolism
25
Decreased liver mass
20-40% decrease in blood flow
26
Water soluble drugs
Decrease the dose
27
Lipid soluble drugs
Decrease the dose
28
Greater effects are seen when drugs encounter a
lower volume of distribution
29
Lipid soluble drugs take
longer to clear because of the larger volume of distribution
30
When choosing an anesthetic technique
Pay attention to doses (less is more = A minimal approach is more effective)
31
Need to ↓ dosage
(i.e. Neuromuscular blockers)
32
↑ sensitivity to
respiratory depression with non-narcotics
| like benzodiazepines.
33
β adrenergic response in elderly
Marked ↓ in β adrenergic response in elderly
34
Activity of MAO and COMT
Increase
35
CBF in elder is
Decrease
36
Up regulation mechanisms
Depressed in elderly patients
| Usually respond to ↓ in neurotransmitters
37
CSF volume is
Decreased in elderly, greater LA spread (reduce dose)
38
Epidural space volume is
Decrease
39
Law of laplace --> Cylinders Applies to ______, formula is
Applies to two situations Laplace
• Cyliners (veins/arteries)
• T = P X R
40
Law of laplace --> Spheres Applies to ______, formula is
* Spheres (heart)
| * T = (P X R)/2
41
Laplace, What does this mean?
At the same radius and internal pressure, a sphere has half the wall tension as a cylinder
42
La place, variable
* T = tension in newtons per meter
* P = pressure
* R = radius of cylinder or sphere in meters
43
Elderly patients
Cannot compensate by increasing CO and HR. They
| compensate by vasoconstriction
44
Elderly patients cannot? how do they compensate?
Cannot compensate by increasing CO and HR. They
| compensate by vasoconstriction
45
Elderly and RV
↑ RV,
46
Elderly and TLC
stays the same TLC,
47
Elderly and RR
↑ respiratory rate
48
Elderly VC and FEV1
↓ VC and FEV1
49
•Heart rate changes are
usually blunted in elderly
50
HR changes Affects ability to
compensate for volatiles causing vasodilation
51
HTN and elderly
Aorta to arterioles stiffen = HTN
| • Pressure must ↑ to stretch stiffer vessel
52
Vital signs changes
RR increase
| BP increase
53
Max HR should =
220 – age
54
Max HR normally
↓ approximately 1 beat/min/year after 50 yo
55
Men and women both gain adipose tissue
Men gain 12kg of fat
| • Men lose 8kg of muscle
56
Muscle and elderly
Reduction in muscle mass limits drug removal by muscle
57
Skeletal muscle mass
Progressive, generalized ↓ of skeletal muscle mass
58
Total body water and elderly
Total body water is ↓
59
ALbumin and elderly
↓ Albumin Production
60
Elderly and bony thorax
↓ of elasticity of bony thorax
61
ELderly and lung compliance
While lung compliance ↑ → air trapping
62
Elderly and alveolar gas surgace
↓ alveolar gas surface area
63
Elderly and nervous system response
• ↓ in nervous system response to hypoxemia and hypercarbia
64
Elderly and parenchymal compliance
↑ parenchymal compliance
| • Takes longer to passively exhale
65
Vital capacity (VC) and elderly
↓ because of the ↓ in IC and the ↑ in residual
| volume.
66
Elderly and dead space
Increase
67
Most dramatic change with aging is the
↑ in closing volume (CV) and closing capacity (CC) such
that in very old pts, closing capacity exceeds functional
residual capacity
68
• Responses to hypoxemia
Decrease
69
GFR and Cr clearance are
↓
70
• Renal mass is
↓
71
Renal blood flow
↓
72
Serum Cr
remains the same
73
Creatinine production is
↓
74
Explain GFR and muscle mass
GFR decreases (should really increase Cr but because there is decrease in muscle mass so less cr)
75
Parkinson Pathophysiology•
Adult onset degenerative disease of the CNS (extra pyramidal system), characterized by the loss of dopaminergic fibers normally present in the substantia nigra of the brain
76
The cause is unknown, and males between
The ages of 40 –70 are most typically afflicted.
77
Parkinson's and autonomic dysfunction
Autonomic dysfunction (risk for aspiration)
78
Parkinson short
Decrease Dopamine in the basal ganglia
79
Parkinson's and BP
• Labile blood pressure and cardiac dysrhythmias from the
| disease and the treatment (levodopa, MAO inhibitors)
80
Medication exacerbations with levodopa
Be aware of possible orthostatic hypotension,
| cardiac dysrhythmias associated with levodopa
81
Hemodynamics monitoring for Parkinsons : anesthetic management may need
Arterial line
82
Medication exacerbations with levodopa : Avoid those 2 meds
Avoid droperidol and metoclopramide
83
Phenothiazines, butyrophenones, and metoclopramide
exacerbate symptoms because antagonism of dopamine in the basal ganglia
84
Antagonism of dopamine in the basal ganglia 3 meds
Phenothiazines, butyrophenones, and metoclopramide
85
Ketamine and Parkinson effect:
Exaggerated sympathetic response
86
Anticholinergics and Parkinson
control the tremors
87
Post Operative Cogniitive dysfunction
Increased risk from Bypass and Cataract Surgeries
| 10-60% Hip fractures
88
Post op delirium Causes
```
***Advanced Age a strong predictor***
• Polypharmacy
• Anticholinergics
• Intra op hypotension
• Perioperative Arterial Hypoxemia
• Opioids or benzodiazepines
• Central Cholinergic System always
```
89
What is the most important risk factor for delirium?
Co existing dementia most important risk factor
90
Causes of Delirium (PIA HAH)
```
• Psycho active drugs
• Infections
• Alcohol withdrawal
• Hypoxemia
Acute physical stress
• Hypotension
```
91
Cortical Dementias
Alzheimer’s, Pick’s, Frontal Lobar degeneration
92
Sub cortical Dementia
Parkinson’s, Huntington’s, Creutzfeldt Jacob
93
Progeria also known as
Hutchinson-Gilford Syndrome
94
Progeria is associated with
Premature Aging
95
Genetic with Progeria
Autosomal Recessive Disorder
96
Mean Survival for Progeria
13 years
97
Progeria Death by
25 common
98
Progeria difficult airway due to
* Micrognathia
| * Mandibular Hypoplasia
99
Fetal shunt in the liver blood flow through the
Ductus venosus
100
When Ductus Venosus closes remnant is
LIGAMENTUM VENOSUS
101
When Ductus Arteriosus closes it becomes
LIGAMENTUM ARTERIOSUM
102
DUCTUS venosus shunt is
Liver
103
What are the 4 shunts
Ductus Venosus : Joins IVC blood, blood bypasses liver
Foramen Ovale : right atrium to Left atrium
Ductus Arteriosus: pulmonary artery to Aorta
Placenta
104
What is the ratio of R to left contribution in fetal circulation
2:1 Right to left ration
| Right is 2x LV output because of R to L shunt
105
Functional closure of shunt happens
Immediately after birth
106
Order of shunt
```
Ductus venosus
IVC
Foramen Ovale
Ductus Arteriosus
Umbilical arteries (return to placenta)
```
107
1st stage pain comes from
T10-L1(L2) DERMATOMES
108
2nd second stage pain is mediated by
THE SACRAL PLEXUS
| T12-L1, S2-S4
109
This nerve block provides sensory to perineum
The Pudental Block
110
Not always completely anesthetized with epidural
The Pudental NERVE
111
Dull, diffuse midline define
Visceral
112
Sharp, pricking, throbbing,and/or burning sensation
Somatic
113
1st stage of labor
onset of true labor until cervix is completely dilated (10 cm)
114
2nd stage of labor
period after cervix dilated to 10cm until the baby is delivered.
115
1st stage subdivisions
Early labor phase: time of onset until cervix dilated
3cm
Active labor phase: cervix dilates from 3cm to 7cm
Transition phase: cervix dilates from 7cm to 10 cm
116
1st stage Dull pain transmitters are the
| Cervical dilation mediated by
unmyelinated C fibers
117
Onset perineal pain is associated with
2nd stage.
118
4 types of Placenta Previa
| TPML
Total
Partial
Marginal
Low-lying placenta
119
What is a TOTAL placenta previa?
Internal cervical OS covered completed by placenta
120
What is a PARTIAL placenta previa>?
Internal cervical OS partially covered by placenta
121
What is a MARGINAL placenta previa?
Edge of placenta at margin of internal os
122
What is a low lying placenta?
Placenta is implanted in lower uterine segment --> Placental edge does not actually reach internal os but in close proximity to it
123
VASA Previa is
rare condition where fetal vessels from placenta cross entrance of birth canal
124
3 typical causes of Vasa previa
Bi-lobed placenta
Velamentous insertion of umbilicord
Succenturiate (accessory lobe)
125
Placenta Accreta vera is
Adherence of basal plate of placenta directly to uterine myometrium without penetrating the decidua layer
126
Placenta Accreta increta is
Chorionic villi invade myometrium
127
Placenta accreta percreta is
Invasion through MYOMETRIUM into SEROSA and even adjacent ORGANS (bladder)
128
Weight estimation (less than 8 )
Wg (kg) = 2 x age (years) + 9 if less than 8
129
Weight estimation (more than 8 )
age (year) x 3
130
Weight double by
6 months
131
Pediatric tongue
larger in proportion to mouth
132
Pediatric Epiglottis
Floppier more U shaped
133
Vocal cord pediatric
Upward slant
134
Larynx of pediatric
Anterior, superior and located between C2-C4
135
Pediatric
Obligate Nose breathers
136
Premie EBV
100
137
Newborn EBV
90
138
3 months to 1 year
80
139
3 months to 1 year EBV
80
140
1 year + EBV
75
141
Adult EBV
65-75
142
ABL
EBV (starting - final / starting)
143
Distance for ETT
age (years) /2 +12
weight (kg)/5 + 12
ETT ID x 3
144
Succinylcholine dose is
1-2mg/kg IV
| 4mg/kg IM
145
Methohexital dose is
1-2mg/kg IV
146
Propofol dose is
3mg /kg IV
147
Ketamine IV
1mg/kg IV
148
Etomidate
0.2-0.3 mkg/kg
149
Ketamine IM
3-4 mg/kg
150
Midazolam dose IV/IM
0.1mg/kg
151
MAX MIDAZOLAM
12 MG
152
Ketamine PO and rectal dose
6-10mg/kg
153
Ketamine IM dose for GENERAL INDUCTION
6-10MG/KG
154
Fentanyl dose is
1MCG/KG
155
Morphine
0.1mg/kg
156
Midazolam dose intranasal
0.2mg/kg
157
Versed+ ketamine
0.4 and 4 mg for successful separation
158
Airway position and levels
| Airway cartilages
Airway Anterior , C2-C3
159
Afferent signaling provided by
1. Peripheral arterial
2. Upper airway
3. Chest wall
+ central brainstem chemoreceptors
+intrapulmonary receptors
+ muscle mechanoreceptors
160
Nose, pharynx, larynx contain what?
| what can they cause?
pressure, chemical, temperature, and flow receptors
| Can cause apnea, coughing, changes in ventilation
161
Pulmonary receptors in lung parenchyma
What kind of receptors are they ? aka_______
Where are they located?
What do they balance?
These receptors may be involved and Cause what reflex?
That reflex Prevents what?
Slowly adaption receptors (stretch receptors)
In airway smooth muscle
Balance of inspiration/expiration
Might cause Hering-Breuer reflex
Prevents overdistention of lungs via vagal stimulation/ and prevents COLLAPSE OF THE LUNGS
162
Rapidly adapting receptors located where ?
Triggered by ___________
such as _____________
Between airway epithelial
Triggered by noxious stimuli
Dust, smoke, histamine
163
Parenchymal receptors located __________
| next _________
Juxtacapillary receptors
| • Next to alveolar blood vessels
164
Parenchymal receptors respond to what? (3)
• Respond to hyperinflation, chemical stimuli in pulmn.
| circ., interstitial congestion
165
Chest wall Receptors are
Located in?
Sense changes in
Also have
* Mechanoreceptors
* In muscle spindle endings and tendons of resp. muscles
* Sense change in length, tension, and movement
* Joint properioreceptors
166
Aryepiglottic fold (paired)
❑Epiglottis to arytenoids
167
❑False cords
Vestibular folds (Thyroid cartilage to arytenoids)
168
❑Interarytenoid fold (single)
Bridge
169
❑True vocal cords
Thyroid cartilage to arytenoids
170
Larynx position in kids
❑Higher @ C3-4
❑Higher in premature infants
❑Adult @ C4-5
171
```
The Larynx of Peds
One bone =
How many cartilages?
What are the single cartilages?
Single:
Paired:
```
Hyoid
11
thyroid, cricoid, epiglottic
arytenoid, corniculate, cuneiform, triticeal
172
* Arytenoid rest on ______
| * Suspended by
rest on top, connects with superoposterior part of cricoid cartilage
173
To access high epidural assess
C6 , around thumb
174
1st stage of labor mediated by what fibers
Unmyelinated C fibers
175
Fetal blood flow
```
Umbilical veins
Ductus venosus
Foramen Ovale
Ductus Arteriosus
Umbilical Artery.
```
176
Majority of blood flow to uterine
intervillous space
177
Low fetal O2
Placental HIGH O2 consumption
| Admixture of Oxygenated and Unoxygenated blood.
178
3 parameters increased in the elderly (RESP)
Residual volume
FRC
Closing Capacity
179
Elastic recoil of lung in the elderly
Loss of elastic recoil
180
In the elderly , loss of elastic recoil leads to
Air trapping
181
Why is there no change in TLC
Decreased VC
Increase RV
No net change
182
Venous capacitance is______Which leads to
decreased (greater lability with BP in OR,
183
Hypertrophy of LV is
Eccentric
184
BP and aging
Increase BP
185
Pulse pressure and aging
Increase
186
Baroreceptor sensitivity is
DECREASE
187
Parasympathetic Tone is _______therefore response to anticholinergic is ______
Decreased (decrease response to anticholinergic such as atropine)
188
Onset of postop Cognitive dysfunction
Weeks to month after surgery
189
Ease of identificiation delirium vs post op cog
Delirium easy
| Post op Cog dys subtle and difficult to pinpoint
190
Most significant risk factor for post op cog
Advanced age
191
Neuraxial change in the elderly EPIDURAL why?
Greater spread of LA; reduction of epidural space
192
Neuraxial change in the elderly SPINAL why?
Greater spread of LA; reduction of in CSF VOLUME
193
Higher rate of false negative test dose with EPInephrine why?
Decrease beta receptor sensitivity
194
Aldosterone sensitivity
decreased.
195
Pseudocholinesterase and aging
decreased
196
Larger VD for
Lipophillic drugs (may prolong their elimination)
197
Smaller Vd for
Hydrophillic drugs
198
Decrease CO prolongs circulation time which leads to
Faster Inhalation inductions
| SLOWER IV INDUCTION
199
Lung compliance and aging
Increase
200
Chest wall compliance
Decrease
201
Local anesthetics dose should be
Decreased
202
Spinal anesthesia duration is
longer
203
Airway protective reflexes in elderly are
Decreased
204
Residual volume to lung capacity ration
Increased.
205
No significant change in PharmoK. Profile of
NMB such as atracurium
206
Uncuff formula
Age/ 4 + 4
207
Cuff formul
Age/4 + 3
208
Insertion distance
Age/2 + 12
Weight/5 + 12
ID x 3
