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Oral Boards > Oral Boards > Flashcards

Oral Boards Flashcards

1
Q

How are pheochromocytomas diagnosed?

A

Urinary Tests for neuroendocrine tumors
- Homovanillic and vanillylmandelic acids
- 5-HIAA (5-hydroxyindoleacetic acid) - Byproduct of serotonin

Serum Tests
- Plasma Metanephrines (Highest sensitivity)

Imaging - CT, MRI

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2
Q

What does of Phenoxybenzamine is used for pheo?

A

A standard protocol for adrenergic blockade is to administer phenoxybenzamine, starting at a dose of 40 mg per day and gradually increasing to 80 to 120 mg per day.

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3
Q

Why should you wait 2 weeks and have alpha blockade for pheo?

A

Patients with pheochromocytoma are chronically vasoconstricted as a result of the high levels of circulating catecholamines and have a secondary decrease in their blood volume. Preparation for surgery should begin at least 2 weeks prior to allow full alpha-blockade along with gradual restoration of blood volume.

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4
Q

What is a Bezold-Jarisch Reflex?

A

Cardioinhibitory Mechanoreceptors due to a reduction in preload with a hyperdynamic state

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5
Q

What are the axis of the cerebral autoregulation curve?

A

Y axis = Cerebral Blood flow
X axis = Mean Arterial Pressure (MAP)

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6
Q

What are some negative consequences of hypothermia?

A
  1. Delayed Emergence
  2. Decresed Drug Metabolism
  3. Decrease in Cerebral Blood Flow
  4. Reduced Platelet Function & Activation of Coagulation cascade
  5. Decreased Blood Flow cutaneously
  6. Shivering (MVO2, CO)
  7. Arrythmias
  8. Decrease in pH
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7
Q

What are the 3 criteria for ARDS?

A

1.** Timing within 1 week of clinical insult** or new/worsening respiratory symptoms

  1. Chest XR shows bilateral opacities not fully explained by effusions, lobar/lung collapse, or nodules
  2. Respiratory failure not fully explained by cardiac failure/fluid overload
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8
Q

For Stabilization of an acute stroke, what are the first immediate steps?

A
  1. ABCs
  2. Establish time of onset (time last seen normal).
  3. Supplemental oxygen to maintain saturation >94% (hyperoxia may be detrimental in stroke)
  4. Brain imaging (noncontrast CT scan)
  5. Neurology Consultation
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9
Q

What are the indications for IV tPA?

A
  1. Within 3 hours of symptoms onset (May consider 4.5 hours)
  2. SBP needs to be ≤185 mmHg and DBP ≤110 mm Hg

Review Contraindications

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10
Q

What are the usual inclusion criteria of Neuro IR mechanical clot extractions?

A

Indicated for major stroke within 6 hours, due to occlusion of the middle cerebral artery, especially for those with contraindications for intravenous thrombolysis.

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11
Q

What are blood pressure goals during mechanical thrombectomy in neuro IR?

A

Avoid hypotension: maintain SBP > 140 mm Hg and <180 mm Hg.

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12
Q

What are the first stabilizing factors of neuro IR ruptured aneurysm?

A
  1. Secure the Airway
  2. Oxygenation Increase FiO2 to avoid hypoxia
  3. Ventilation - Hyperventilate the patient
  4. Bed Positioning - If possible, elevate head of bed (reverse Trendelenburg)
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13
Q

What medications should be administered if ruptured aneurysm in IR?

A
  1. Protamine to reverse Heparin (Discuss with Neuro IR)
  2. Mannitol (0.25 - 2 gram / kg )
  3. TIVA
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14
Q

What is blood pressure goal for Neuro IR aneurysm rupture?

A

Maintain blood pressure near baseline levels until bleeding is controlled.

Once hemostasis is achieved consider increasing BP (SBP 140 - 180 mmHg) to maintain cerebral perfusion pressure in context of increased ICP

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15
Q

What logistically should be called for during aneurysm rupture in IR?

A
  1. Neurosurgery for EVD
  2. Front desk for OR for cranitotomy
  3. MTP for blood products
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16
Q

What are thee first stabilizing measures for intraopreative aneurysm rupture (Not in Neuro IR)?

A
  1. Communicate with the surgeon regarding anticipated blood loss and surgical visibility
  2. Increse FiO2 (Oxygenate)
  3. Ventilate (ETCO2 35)
  4. IV Resuscitation - Initiate vasopressor support, infuse volume
  5. Call for Blood Products and Potentially MTP
17
Q

What is the key surgical step that is a “Cross a rubicon step” when doing an aneurysm clipping?

A

**Opening the Dura
**

Rupture before dural opening vs After Dural Opening during dissection or clip placement

18
Q

What is the treatment when you have rupture of an intracranial aneurysm before the dura is open?

A

Rupture before dural opening (IAR mainly occurs during hemodynamic swings and rapid changes in transmural pressure):

  1. Control abrupt increases in ICP with modest hyperventilation
  2. FiO2 100%
  3. Immediate blood pressure control (SBP 140 - 180 mmHg)
  4. Switch to TIVA (Minimize CMRO2 using IV anesthetic agents including propofol & barbiturates)
  5. Surgical decompression
  6. Osmotherapy with mannitol (0.25 - 2 grams / kg) +/- 3% saline (100cc)
19
Q

What is the treatment of a rupture of aneurysm after the duralhas been open (During dissection or clip placement)?

A

Rupture after dural opening (IAR mainly occurs during dissection or clip placement):

* Reduce MAPs to ~50s acutely to decrease bleeding, improve visualization and soften aneurysm neck for clipping
* Consider Transient Flow Arrest with Adenosine
* TIVA Minimize CMRO2 using IV anesthetic agents (propofol, barbiturates)

20
Q

Is Hypothermia warranted for aneurysm rupture?

A

Hypothermia is not recommended regardless of Hunt and Hess Grade according to the Society for Neuroscience in Anesthesia and Critical Care 2018

21
Q

What patients are at increased risk of developing autonomic hyperreflexia?

When can the process occur temporally in relation to the injury?

A

Patients with spinal cord injury at T6 or higher are at increased risk

Can appear 2-3 weeks after injury, typically will manifest within 1 yr

22
Q

What is the dosing strategy of esmolol?

Bolus dosing vs. Max Dose Infusion

A

A bolus of 1000 mcg/kg over 30 seconds, followed by 150 mcg/kg per minute infusion, with a max dose of 300 mcg/kg per minute.

A bolus of 500 mcg/kg over 1 minute, followed by 50 mcg/kg per minute infusion for 4 minutes.

If the desired effect is not reached, it may increase in 50 mcg/kg per minute increments until the max dose of 300 mcg/kg per minute. (10-50 mcg/kg/min)

23
Q

What are the first stabilizing steps of Autonomic Hyperreflexia?

A
  1. Immediately inform the surgeon and ask the surgeon to stop operating
  2. Deepen level of anesthetic
  3. Increase FiO2 to avoid hypoxia
24
Q

What is the treatment for autonomic hyperreflexia?

A
  1. Nitroglycerin, Nicardipine, or Nitroprusside
  2. Eliminate stimulus if applicable (i.e. empty bladder or bowel)
  3. Maintain deeper plane of anesthesia
  4. Position patient with head up
  5. Monitor for signs of: MI, hemorrhage, seizure, dysrhythmias (can progress to heart block) and treat accordingly * Consider invasive monitoring
25
Q

What is the infusion rate for nitroglycerin infusion?

A

10 - 100 mcg/min

26
Q

What is the loading dose and infusion dose of TXA

A

Low Dose:
- Load 10 mg/kg
- Infusion 1 mg/kg/hr

High Dose:
- Load 30 mg/kg
- Infusion 1-10 mg/kg/hr

27
Q

What is the THI TXA Protocol for:

Low Dose Bolus?

A

10 mg/kg

28
Q

What is the THI TXA Protocol for:

High Dose Bolus?

A

30 mg/kg

29
Q

What is the THI TXA Protocol for:

Low Dose Infusion?

A

3 mg/kg/hour

30
Q

What is the THI TXA Protocol for:

High Dose Infusion?

A

16 mg/kg/hr

31
Q

What is the THI TXA Protocol for:

Low Dose CPB Prime?

A

1 gram

32
Q

What is the THI TXA Protocol for:

High Dose CPB Prime?

A

2 grams

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