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Anesthesia Oral Boards > Oral Boards Background info > Flashcards

Oral Boards Background info Flashcards

1
Q

GCS scoring

A

EYES
4: spontaneous
3: voice
2: pain
1: none

VOICE
5: comprehensible
4: confused
3: inappropriate
2: incomprehensible (sounds)
1: none

MOTORS
6: spontaneous
5: localizes pain
4: withdraws to pain
3: decorticate flexion
2: decerebrate extension
1: none

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2
Q

Trauma difficult airway, but spontaneously ventilating, AMS, inc ICP, intubate?

A

Due to significant head injury pt would not tolerate hypercapnia induced increase in CBF, subsequent inc in ICP assoc with hypoventilation or apnea
-dec risk of aspiration
-avoid having to manage potentially difficult airawy in more emergent circumstances
-ensure difficult airway equipment availabilty and surgeon at bedside ready to perform trach if needed

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3
Q

how to intubate AMS combative difficult airway

A

-ensure availability of difficult airway equipment
-surgeon at bedside ready to perform trach
-pt in 30 deg RT to improve respiratory mechanics, facilitate intubation, red passive regurgitation (if hemodynamically will tolerate)
-pre oxygenate
-carefully titrate IV ketamine to maintain spontaneous ventilation but adequate depth of anesthesia
-ensure manual in line stabilization
-remove front of c collar to allow for cricoid pressure
-perform larygnscopy for ETT placement

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4
Q

Inc ICP, head trauma and intubation avoid:

A

-factors that will inc ICP: hypoxia, hypercapnia, sympathetic stimulation
-hypoTN: decrease CPP (MAP-ICP)
-c spine injury
-aspiration of gastric contents

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5
Q

Head trauma, high ICP, difficult airway, ketamine?

A

-benefits outweigh risk, to maintain spontaneous respirations throughout induction and intubation
-acknowledge that ketamine inc sympathetic tone, inc CRBG and regional CMRO2, which is undesirable in this patient, outweighs the possibly inc in ICP assoc w/ hypoxia, hypercarbia, and loss of airway

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6
Q

succinylcholine in trauma with high ICP and difficult airway

A

no
-want to maintain spontaneous resp to avoid hypoxia and hypercarbia, inc ICP
-avoid transient inc in ICP with succ and fasciculations
-instead, i would give aspiration ppx, apply cricoid pressure, and secure airway as quickly as possible without succ

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7
Q

how to clear C-spine

A
  1. absence of cervical pain or tenderness
  2. absence of paresthesias or neuro deficits
  3. normal mental status
  4. no distracting pain
  5. age > 4
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8
Q

if can’t meet criteria for c spine clearance, what imaging?

A

cross-table lateral c spine film showing C1 to T1, open mouth odontoid view, and thoracolumbar, anterior/posterior and lateral plain films

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9
Q

periorbital ecchymosis and hemotympanum, difficulty w/ DL, nasal intubation suggested, response?

A

No, periorbital ecchymosis and hemotympanum suggest basilar skull fracture -> run the risk of putting the ETT in the brain w/ nasal intubation
-instead, call for help, release cricoid pressure, use a video laryngoscopy, if still unsuccessful ventilate as necessary and attempt with fiberoptic bronchoscope, boughie, lighted stylet or surgical access

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10
Q

trauma w/ AMS and bleeding into leg, VS:
HR 134, RR 24, BP 178/108 O2 96% on NRB temp 33C

A

-can get hyperdynamic circulatory response w/ head surgery -> surge of epinephrine
-pain, hypoxia, hypercarbia, anemia, or hypovolemia can contribute
-optimize by controlling pain, replacing fluid losses w/ blood products or crystalloid as necessary and ensure adequate ventilation
-mild hypothermia beneficial dec CMRO2

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11
Q

head trauma, fluids currently D5LR, what woudl you do w/ fluids?

A

-D/c D5LR, hyperglycemia can worsen ischemic brain injury, switch to normal saline
-access fluid status w/ UOP, mucous membranes, cap refill, blood loss (taking into accound that there could be blood in abd compartmet or possible femur fx)
-goal is to maintain CPP by restoring circulating blood volume and avoiding hypotension, while reducing risk of cerebral edema by maintaining serum osmolality and avoid reduction in colloid oncotic pressure

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12
Q

head injury BP inc to 205/118, what to do?

A

difficult to tell if part of the reflex of inc ICP, or due to hypoxia, hypercarbia, pain, anemia, hypovolemia
-but needs to be addressed due to concern for MI and/or cerebral infarction
-1. take steps to dec ICP, consult neurosurgeon for possible ICP monitoring
2. ensure adequate analgesia, intravasc volume replacemet, and ventilation
-if need to give a medication i would use something short acting: esmolol, nicardipine, clevidipine

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13
Q

ideal CPP for traumatic head injury

A

optimal unknown
normal is 70-85
some studies show > 70 inc ARDS, w/ cerebral ischemia below 50-60, so ideal 60-70

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14
Q

cerebral autoregulation

A

absence of chronic HTN, maintains CBR w/ MAP 60-150

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15
Q

Causes of tachycardia

A
  1. Primary: SVT, VT
  2. Secondary: hypoxia, hypercarbia, hypovolemia, pain, dec O2 delivery (anemia, dec cardiac output)
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16
Q

bradycardia causes

A
  1. primary: sick sinus syndrome, complete HB
  2. secondary: medication induced (beta blockers, dig, anticholinesterases, dexmedetomidine, narcotics), vagal stimulation (oculocardiac reflex, baroreceptor reflex [carotid surgery], larygnscopy, traction on viscera)
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17
Q

hypotension causes

A

-dec preload
-inc intrathoracic pressure (tamponade, PPV, PEEP, TPX, aorto-caval compression)
-heart itself: cardiomyopathy, infarcted muscle, HR too low or too high, arrhythmia
-afterload low: anaphylaxis, spinal show
-blood: not enough, not enough viscosity

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18
Q
A
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19
Q

Open femur fx, surgeon wants to go to OR, but head trauma, req ICP monitoring?

A

-If result in a significant delay, would not necessarily require
-However, would allow me to improve CPP, by knowing MAP required to combat inc ICP
-would also allow for CSF drainage to optimize CPP
-discuss w/ ortho and neurosurgeon feasibility in case delay to establish

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20
Q

MOA mannitol

A

Reduces ICP by osmotically shifting fluid from brain compartment to intravascular compartment
-Dec production of CSF
-induces reflex cerebral vasoconstriction 2/2 decreased blood viscosity
***if BBB not intact, could worsen cerebral edema, could result in expansion of intracranial hematoma

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21
Q

Reduce ICP in head trauma victim

A
  1. Elevate HOB 15-30 deg as hemodynamically tolerated
  2. Ensure no venous obstruction (esp w c Collar in place)
  3. Mannitol: osmotic diuresis
  4. Furosemide (acknowledge can cause hypoTN in Hypovolemic, possible worsening of cerebral ischemia)
  5. Barbiturates by Dec CMRO2 and red ICP -> likely hypoTN w/ doses required for cerebral protection

**do not hyperventilate in TRAUMA b/c red in CBR in head trauma in the first 24 hours -> but if nothing else works, yes.

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22
Q

Hyperventilate w/ head trauma

A

If other methods to reduce ICP unsuccessful, and ICP enough to be concerned fro brainstem herniation, yes to CO2 25-30 b/c cerebral vasoconstriction would Dec ICP
-however risk of cerebral ischemia, esp in the first 24 hours
-hyperventilation effects temporary, HCO3 levels in CSF adjust to compensate in 24-48 hours

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23
Q

Hypothermia effects

A

Coagulopathy
Poor wound healing
Arrhythmias
Impaired renal function
-theoretical neuro protection, but not enough evidence to show improved neurological outcomes

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24
Q

N2O w/ TBI

A

-NO
-want them breathing 100% O2, inc CBF, could expand air pocket furthering inc ICP

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25
Q

DDx w/ femur fx, TBI, hypoTN, PIP 40s, O2 Dec to 80s

A

-ETT migration
-PTX
-cardiac tamponade
-fat emboli
-allergic reaction
-aspiration pneumonia is

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26
Q

Next steps if femur fx, TBI, hypoTN, inc in peak insp pressure, O2 falls

A

-hand ventilate, auscultation, make sure FiO2 100%, verify ETT positioning, order CXR
-if still unclear, ABG, TTE, consider pulm a catheter

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27
Q

Femur fx, TBI, PAC: PA pressure 55/47, PWCP 16, Mixed venous 60%, CI 1.7, subconjunctival petechiae

A

Fat embolism Syndrome
-however to confirm you need 1 major, and 4 minor criteria
-MAJOR: petechial rash, hypoxia PaO2 <60 w/ fiO2 <.4, CNS depression unexp by hypoxia, pulm edema
-MINOR: tachypnea > 110, pyre is, jaundice, unexpl anemia, unexpl thrombocytopenia, inc ESR, retinal fat emboli, fat microglobulinemia, fat globules in sputum, urinary fat globules

**acknowledge that these criteria can be confounded by conditions w/ trauma

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28
Q

Normal cardiac index

A

2.6 - 4.2

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29
Q

Normal PCWP

A

2-15

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30
Q

Normal PA pressure

A

15-30/4-12

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31
Q

Mixed venous O2 saturation

A

65-75%

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32
Q

What to do if dx fat emboli syndrome?

A

-administer 100% O2
-treat hypoTN
-correct Hypovolemic
-replace blood and plts as needeD
-continue mechanical ventilation
-monitor pt for further deterioration
-inform surgeon of condition

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33
Q

PaO2 68 with FiO2 50%, CXR shows b/l infiltrates ddx?

A

-ARDS (2/2 fat embolism syndrome, head trauma, or aspiration)
-Aspiration pneumonia
-Pulmonary edema (cardiogenic, neurogenic)
-if req blood products: TRALI or TACO

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34
Q

Pathophysiology of ARDS

A

Pulm manifestation of systemic inflammatory response syndrome
-injury to capillary-alveolar membrane -> b/l diffuse infiltrates, severe dyspnea, and hypoxemia

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35
Q

Req for diagnosis of ARDS

A
  1. PaO2: FiO2 ratio < 300 (300-200: mild, 200-100:mod, <100:severe)
  2. Diffuse b/l infiltrates on CXR
  3. Acute onset (w/i 7 days of event [sepsis, trauma, aspiration])
  4. Respiratory failure not explained by cardiac failure or fluid overload
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36
Q

Treatment of ARDS

A

-Treat causative events (DIC, sepsis, hypoTN)
-supportive mechanical ventilation
-sufficient PEEP to recruit collapsed alveoli and improve gas exchange, while avoiding high pressures and large volumes
-goal: TV 6 cc/kg or less and static airway pressures < 30
-permissive hypercapnia may be needed to avoid higher TV and airway pressures
-FiO2 < 50
nitric oxide, prone, temporarily improve, none show long term outcome differences

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37
Q

Steroids in ARDS?

A

Giving steroids early has been assoc w/ increased mortality

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38
Q

Post TBI, POD 5, Na is 129, urinary Na high. Dx?

A

Cerebral salt wasting or SIADH
-can best be differentiated by volume status of the patient
-CSW Hypovolemic, SIADH euvolemia

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39
Q

Diff b/w SIADH and CSW?

A

SIADH: euvolemia, inc ADH levels, urine Na rarely >100
CSW: hypovolemic, normal ADH levels, UNa > 100

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40
Q

Why important to distinguish b/w CSW and SIADH

A

Treatment is different!
-SIADH: water restriction, diuresis, DEMECLOCYCLINE (inh ADH effect on renal tubules), Na replacement
-CSW: water restriction, direusis could worsen the Hypovolemic

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41
Q

Proper Machine Check

A
  1. Turn on the machine and monitors -> verify presence of emergency ventilation equipment
  2. Calibrate or set the capnometer, pulse oximeter, O2 analyzer, and pressure monitors and alarms
  3. Check the high pressure system: opening the E-cylinders to ensure adequate gas pressure (O2 must be half full, 1000 pasig)
  4. Verify the central pipeline hoses properly connected -> confirm pipeline gauges read 50 psig
  5. Check the low pressure system by ensuring filled vaporizers, check for leaks (machine dpt), testing flow meters
  6. Check scavenging system, calibrate the O2 monitor, ensure proper ventilator function
  7. Check integrity of unidirectional valves, inspect circuit, verify adequate CO2 absorbent
  8. Ensure availability of airway equipment and suctioning
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42
Q

How to check for leaks in the low pressure system?

A

Low-pressure leak test used to verify integrity from flow control valves to the common outlet
-verify the proper method of testing for the workstation I’m using

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43
Q

Low-pressure leak test in a machine without a check valve near the common outlet

A

Ex: Drager
-traditional positive pressure leak reset

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44
Q

Low-pressure leak test for machines w/ a check valve near the common outlet

A

Ex: Datex-Ohmeda
-perform negative-pressure leak test by turning off the anesthesia machine, attach a suction bulb to common gas outlet, squeeze bulb until collapsed, and observing stayed collapsed for 10 seconds
-repeat w/ each vaporizer opened one at a time

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45
Q

Protects against delivery of hypoxic mixture?

A

Safety devices
-fail safe alarms: sound if the pressure in the O2 pipeline falls below 30 psig
-O2 failure cut off valves, Dec of d/c the flow of other gasses when O2 pressure Dec below the a certain threshold
***do not definitively prevent -> best is vigilance and proper monitoring of the O2 analyzer

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46
Q

Desflurane vaporizer

A

Electrically heated to create a vapor pressure of 2 atms -> pure des vapor is mixed w/ fresh gas prior to exiting vaporizer

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47
Q

Sevoflurane vaporizer

A

Variable-bypass vaporizer -> variable amount of gas is directed into vaporizing chamber -> mixes w/ volatile agent -> returns to mix w/ the rest of the carrier gas directed to bypass chamber

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48
Q

Pathogenesis of SCD

A

Hemoglobinopathy mutation of chromosome 11 (substitution of valine for glutamic acid) in beta changes of Hg -> HgS
-deformation of RBC membrane into sickled shape -> hemolysis (shorted RBC lifespan), microvascular occlusion, ischemic injury to organs, infarcts, hemolytic crisis

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49
Q

Comorbidities w/ SCD

A

Chronic hypoxia, anemia, hemochromatosis (iron overload)
-cardiomegaly
-CHF, pulm HTN
-neuro deficits
-renal insuff/failure
-painful crisis
-acute chest syndrome
-retinopathy
-aseptic necrosis of femoral head
-asplenic (multiple infarcts) -> in fxn from encapsulated organisms

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50
Q

Exchange transfusion prior to surgery

A

If moderate or high risk surgery, transfuse to a Hct > 30% w/ goals of increasing O2 carrying capacity and prevent suckling

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51
Q

Prevent sickling in SCD

A

-avoid hypoxemia, hypotension, hypothermia, acidosis, Hypovolemic
-use suppl O2, adequate hydration, Hct 30-40%, avoid hypothermia w/ fluid warmers and forced warming units, provide adequate postoperative pain control

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52
Q

Treatment of sickle cell crisis

A

-ensure adequate pain control
-provide adequate IV hydration
-supplemental O2
-adequate Hct levels
-to infection
-consider exchange transfusion to reduce HgbS to less than 40%

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53
Q

Morbidly obese pt, BMI >50, do to at an outpatient facility

A

-Assuming medically optimized and no hx of OSA possibly, because outpt reduces costs on pt and inc convenience
-need to perform a thorough history and physical exam to determine extent/severity of coexisting disease, incl OSA, type of surgery performed, capabilities of outpt facility, adequacy of post-d/c care (family, friends), post op opioid requirements

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54
Q

Identify pts w/ undiagnosed OSA

A

Large # of patients w/ undiagnosed OSA
-STOPBANG
-Snoring, daytime Tiredness, Observed apnea, Pressure (HTN), BMI >35, Age > 50, Neck circ >40, gender male
**< 3: low risk, >3 high risk, 5-8: mod to severe OSA

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55
Q

BMI 70s, asthma, DM, mod to severe OSA, possible periop complications?

A

-difficult airway management
-aspiration
-bronchospasm
-labile BP
-hyperglycemia
-difficulty evaluating cardiac/pulm status due sedentary lifestyle
-difficult patient position, rapid desaturation (Dec FRC), obesity hypoventilation syndrome
-OSA, postop apnea, stroke, CAD, altered drug effete, DVT/PE

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56
Q

Preop labs for low risk surgery DM, BMI 50s

A

Pregnancy, blood glucose, results of sleep study, hx of difficult airway

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57
Q

Premeds for DM, BMI 50s, HTN, asthma, GERD

A

-obesity, possible diabetic neuropathy, gastric reflex -> inc risk of aspiration -> H2 rec agonist, metochlopramide, nonparticulate antacid
-discuss w/ surgeon abx, DVT ppx
-beta 2 agonist to optimize breathing

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58
Q

BMI 50s, asthma, DM, crying, give Midas?

A

Yes, small dose, since excessive anxiety, crying -> complicate airway conditions,
-also possible undiagnosed OSA -> assess risk for OSA and consider risk of respiratory depression 1st

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59
Q

BMI 50s, asthma, HTN, IDDM, how to evaluated her given concerns of cardiac disease?

A

-thorough H&P -> r/o any active cardiac issues unstable angina, decompensated HF, severe arrhythmias
-access her risk for a major adverse cardiac event using revised cardiac risk index
-determine functional capacity -> given hx of diabetes possible she cannot experience angina warning signs -> if > 4 METs proceed, if < 4 -> discussion w/ patient and surgeon if prep stress test PCI/CBG considerations would alter surgical plan

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60
Q

Revised Cardiac risk index

A

2 or more assoc w/ inc risk of major adverse cardiac event
-IDDM
-hx of ischemic heart disease
-hx of compensated or prior HF
-hx of cerebral vascular dx
-renal insuff
-Supra-inguinal vascular, intraperitoneal, or intrathoracic surgery

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61
Q

Umbilical hernia repair, BMI 50s, asthma, HTN, GERD, IDDM. Monitors?

A

Standard ASA monitors, paying special attention to BP cuff fitting -> ensure bladder of cuff encircled at least 75% of upper arm -> too small, falsely elevated BP
-if unable to get adequate BP cuff -> consider a line

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62
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM neuraxial?

A

Yes -> avoid airway instrumentation and GA in obese pt w/ inc risk of aspiration
-reduce periop requirements for opioids
-would avoid opioids in the spinal straight local anesthesia

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63
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, induce?

A

Assuming reassuring airway:
-aspiration ppx w/ H2 blocker, metochlopramide, nonparticulate antacid
-beta 2 agonist to optimize asthma
-place in RT (improves resp mechanics, red risk of passive reg)
-preoxygenate
-apply cricoid pressure
-IV lidocaine blunt resp to laryngoscope
-RSI
-rapidly secure airway w/ cuffed ETT
-RSI inc risk of bronchospasm due to inadequate depth of anesthesia -> be prepared to treat this complication

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64
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, mallampati III on airway, induction plan?

A

-While Mallampati is only part of airway exam, inc concern w/ super morbid obesity
-inc risk for aspiration, with difficult intubation
-aspiration ppx, and discuss awake fiber optic intubation
-minimal sedation (avoid risk of resp depression), adequately anesthetize airway to prevent bronchospasm

***if pt refuses, difficult airway equipment in room, asp ppx, Albuterol, RT, cricoid pressure, no muscle realaxant, adequate depth of anesthesia to avoid bronchospasm

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65
Q

Obese pt, pts closing capacity when moved to supine?

A

Closing capacity is unaffected -> relationship w/ FRC worsening -> early airway closure and shunting -> rapid desaturation

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66
Q

Morbid obesity, adjust protocol dose?

A

-induction dose of propofol is based on ideal body weight, maintenance on total body weight
-lipophilic drugs in obese pts have a higher volume of distribution -> start w/ ideal body weight, and titration to effect

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67
Q

Midazolam dosing in obese pts

A

Loading and maintenance based on TBW

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68
Q

succinylcholine dosing in obese pts

A

Based on TBW

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69
Q

Vec/roc dosing in obese pts

A

IBW

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70
Q

atracurium/cisatracurium dosing in obese pts

A

TBW

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71
Q

Fentanyl dosing obese pts

A

Loading dose: TBW
Maintenance: IBW

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72
Q

Remifentanil dosing obese pts

A

Ideal body weight

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73
Q

Ideal body weight in men

A

IBW = 50 kg + 2.3kg/in over 5 ft

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74
Q

ideal body weight in women

A

IBW = 45.5 kg + 2.3 kg/in over 5 feet

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75
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, opioids on induction?

A

I would use a small dose of narcotics at induction to reach depth of anesthesia to avoid bronchospasm during laryngoscope
-recognize w/ mod-sever OSA inc risk for postop opioid induced resp depression -> only small dose of short acting narcotic

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76
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, give muscle relaxant?

A

-avoid atracurium/mivacurium b/c histamine release avoid in asthmatics
-atracurium/cisatracurium: dose on TBW
-vec/roc dose to ideal body weight

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77
Q

Inhalational agents in obesity

A

If less than four hours, no delay in wakening w/ more soluble agents like iso (compared to less soluble sevo)

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78
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, during case pulse o Dec to high 80s, what to do?

A

-switch to 100% O2, hand ventilate, auscultation chest, ensure adequate ETT placement, check airway pressures, check circuit and machine
-assess pt position, if trendelenberg -> flatten or RT
-consider giving albuterol
-if ETT in good place, and no wheezing -> consider inc PEEP

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79
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, wheezing, what to do?

A

100% O2 -> inc conc of inh agent -> give albuterol (bronchodilation and inc depth of anesthesia to avoid stimulation-induced bronchospasm)
-if no improvement -> give epi

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80
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, how to extubate?

A

Deep plane of anesthesia to prevent further bronchospasm
-understand inc risk of aspiration due to obesity, DM, GERD, empty stomach w/ OGT and have suction nearby in case

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81
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, how to transport to PACU?

A

obesity and OSA: optimize resp mechanics: suppl O2, applying CPAP, HOB up

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82
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, pulse ox 83% in PACU, ddx?

A

-airway obstruction due to OSA
-bronchospasm
-resp depression 2/2 narcotics
-aspiration
-atelectasis w/ pulm shutting
-possible PE

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83
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, desalting to 80s after morphine

A

-position head of bed up, administer 100% O2, apply CPAP
-consider narcan, while giving non-opioid analgesics (acetaminophen, ketorloac)
-monitor for extended period of time -> consider redoing narcan

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84
Q

Umbilical hernia repair, BMI 50s, asthma, GERD, IDDM, epidural for analgesia? Dosing?

A

If pain insufficient w/ non-opioid analgesics, yes I would place
-however given risk for DVT and resp depression -> use low conc of local anesthetic only, non opioid
-minimize m weakness and inc mobility

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85
Q

Peds pt, hx of massester muscle spams, periop questions?

A

Complete H&P -> circumstances related to muscle spasm -> type of anesthesia provided, severity of spasm, how treated -> any work up?
-family hx of anesthesia complications, incl master spasm or malignant hyperthermia

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86
Q

Hx of masseter muscle spasm, mom had no surgery, and family have no history of anesthetic complications

A

Assuming no testing has been done to r/o MH -> provide TIVA with non-trigger agents including fentanyl and prop infusions
-massester muscle regidity following triggering agents (succ or volatiles) -> susceptibility to MH

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87
Q

MH concern, succ is given, cant open pts jaw, what now?

A

-mask ventilate w/ 100%
-if difficult -> call for help, place nasal airway, attempt nasal intubation, prepare for surgical airway
-consider risk of MH rhabdo
-admit to hospital for 12-24 hours, monitor EtCO2, CK, temp, acid-base status, electrolyte levels (concern for rhabdo induced hyperK)
-continued evaluation of pigmenturia, myoglobinuria, generalized rigidity, signs of hyper metabolism
-order neuro c/s for preexisting myopathies
-recommend testing for MH susceptibility

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88
Q

Succ-induced trismus, cancel the case?

A

Yes, d/c all triggering agents, cancel case, monitor pt for 12-24 hours
Recommend caffeine halothane contracture test

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89
Q

pregnant pt, obtunded, bite bark on tongue

A

likely seizure -> preeclampsia until proven otherwise
ddx: cerebral hemorrhage, cerebral infarction, placental abruption (AFFE), medication, trauma, encephalitis, epilepsy, meningitis, hypoNa, hypoglycemia

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90
Q

Diagnostic criteria for PEC

A
  1. 2 BP readings > 4 hours apart, systolic > 140, diastolic > 90
  2. proteinuria 24 hour urine level > 300, Urine protein:Cr ratio of 0.3
  3. > 20 weeks gestation
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91
Q

Severe PEC

A
  1. BP > 160 or d > 110 4 hours apart
  2. renal insuff, Cr > 1.1 or x2
  3. new CNS disturbance (HA, vision changes)
  4. pulm edema
  5. liver dysfxn (AST/ALT x2)
  6. epigastric or RUQ pain
  7. thrombocytopenia < 100
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92
Q

pregnant pt obtunded, bit her tongue, what to do?

A

-quickly assess VS, O2 sat, EKG
-ensure adequate oxygenation, uterine displacement, and IV access
-eval baby’s FH tracting
-quick physical exam fosuing on neuro (MS, signs of in ICP), airway, cardiopulm fxn, signs of coagulopathy
-if felt her mental status was impaired -> secure her airway ASAP to reduce risk of aspiration
-adequate ventilation more important if concerned w/ ICH -> hypoventilation -> acidosis, hypoxia, worsening ICP

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93
Q

pregnant pt, concerns for difficult airway, awake fiberoptic intubation, use benzocaine?

A

-benefit: rapid onset and short duration of action
-risk: inc risk for Met-Hg, dec O2 carrying capacity and impaired O2 delivery to tissues -> confuse clinical picture w/ airway management
-alternative: give glyco to dec secretions, apply topical anesthetic w. spray or local-anesthetic soaked gauze, supplement w/ appropriate airway blocks

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94
Q

Airway blocks:

A

glossopharyngeal, SLN, and transtracheal blocks

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95
Q

Glossopharyngeal nerve block

A

sens: posterior 1/3 of tongue, vallecula, gag reflex
-submucosa at posterior tonsillar pillar (caudal aspect) -> 2 to 5 cc of 2% lidocaine

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96
Q

Superior Laryngeal nerve block

A

sens: laryngeal structures above VC
-inferior to greater cornu of the hyoid bone -> 2cc of 2% lidocaine

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97
Q

Recurrent laryngeal nerve block

A

sens: VC and trachea, motor supply to all m of larynx except cricothyroid
-transtracheal block -> cricothyroid membrane -> 22 or 20 guage needle continuous aspiration of syringe -> rapid injxn of 5cc 4% lidocaine -> coughing normal and helps disperse LA

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98
Q

pulse ox and Met-Hg

A

-false reading of 85% b/c Met-hg absorbs the same amount of light at the 660nm and 960nm wavelength

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99
Q

Met-Hg and toxicity

A

<30%: no tissue hypoxia
30-50%: signs and symptoms of tissue hypoxia
> 50%: lead to coma and death

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100
Q

tx for Met-Hg in G6PD

A

-Met-Hg were mild -> identify and avoid any additional oxidizing agent
-tissue hypoxia does not develop until Met-Hg until levels > 30%
-Can’t use Methylene Blue in G6PD -> IV Vitamin C

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101
Q

Methylene Blue Dosing

A

2 mg/kg of 1% solution in saline over 3-5 minutes, may be repeated after 30 minutes if needed

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102
Q

What is G6PD def?

A

-enzymatic disorder, inhibits regeneration of glutathione in red blood cells -> more susceptible to oxidative damage -> shortening RBC half-life
-X-linked d/o
-can cause: fatigue, cyanosis, jaundice, anemia, hypoTN, lumbar and abd pain, hemolysis, hematuria, renal failure
-normocytic anemia, inc serum bili, inc retic count, Heinz bodies

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103
Q

Meds to avoid in G6PD def

A

Benzocaine
Lidocaine
Prilocaine
Sodium nitroprusside
Siler Nitrate
Nitrofurnatoin
Methylene Blue
High Dose Aspirin
Methyldopa
Hydralazine
Procainamide
Quinidine
can precipitate hemolysis

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104
Q

Anesthetic Management Changes in G6PD def

A

-Disease hx (hemolysis, precipitating factors, renal failure)
-Hct and retic count preop
-avoid drugs that induce Met–Hg (benzocaine, prilocaine, sodium nitroprusside)
-avoid specific abx (nitrofurnatoin, chloramphenicol, cotrimoxazole)
-avoid/treat factors known to precipitate hemolysis: hypothermia, acidosis, hypoxia, hyperglycemia, infxn
-continue to monitor pt’s Hg, retic count, and UOP

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105
Q

GA and G6PD def

A

-no anesethetics implicating as hemolytic agents
-can mask hemolysis: important to monitor postop for signs and labs ofhemolysis
-CPB has initiated hemolysis

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106
Q

Factors that precipitate hemolysis in G6PD def

A

Hypothermia
Acidosis
Hypoxia
Blood products
Stress
Hyperglycemia
Infection
Food (fava beans)
Methylene Blue, antimaliral drugs
Abx (nitrofurantoin)
High dose ASA
Procainamide
Quinidine

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107
Q

awake fiberoptic impossible, found down, with swollen tongue, spontaneous breathing, do you intubate? how?

A

-yes intubate, while spontaneously ventilating
-ensure presence of difficult airway equipment
-position pt in 30 deg RT (dec risk of aspiration, venous drainage from intracranial compartment, improve resp mechanics)
-be prepared for emergency trach
-apply cricoid pressure
-maintain spontaneous vent: slow controlled induction w/ ketamine, recognizing that could potentially inc CBF and/or CMRO2 -> inc ICP

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108
Q

OB, found down, AMS, CT scan prior to her c/s?

A

I would recommend she obtain CT scan of her head -> benefit from neurosurgical consult and treatment prior to undergoing stresses assoc with delivery
-however would require transporting her to a location -> secure airway and ensure hemodynamic stability prior to transport (optimize uteroplacental BF)
-FHR monitoring -> be prepared to quickly return

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109
Q

OB, AMS, babys heart tones down, consider c/s prior to head CT/MRI?

A

-if heart tones down: lay mom flat, left uterine displacement, give O2, assure adequate blood pressure
-proceed with GA for emergent c/s, using a high narcotic neuroprotective technique -> goal to avoid inc ICP or compromise cerebral perfusion pressure -> notify the neonatologi giving large amount of narcotics since likely to depress compromised neonate

110
Q

Pt found down, AMS, pregnant, baby heart tones down, emergency c/s needed, regional anesthetic?

A

No, mental status can deteriorate -> inc risk for hypoventilation and aspiration
-GA help in avoiding hypovent-induced hypercapnia, hypoxia, resp acidosis -> inc risk for inadequate CPP and/or hemolysis
-regional would cause sympathectomy-induced hypotension -> compromise CPP w/ elevated ICP
-difficult airway -> prior to inducing have difficult airway equipment available and surgeon establishing airway if needed

111
Q

HIV okay in neuraxial?

A

-HIV is not a contraindication to regional anesthesia -> no evidence that HIV progression is increased by CNS blockade

112
Q

AMS, PEC, emergent c/s, place an a line?

A

-yes do want an arterial line to monitor and tx BP to avoid inc in ICP, and maintain adequate CPP
-understand delay in intubation and c/s for arterial placement inc risk of aspiration and poor outcome -> proceed with case and place a line as soon as feasible

113
Q

OB AMS, baby delivered, BP 189/105, HR dec to 48, L pupil dilated, not reactive to light, thoughts?

A

Consistent w/ Cushing response -> inc in ICP -> inc in BP, reflex slowing of HR, and irregular respirations
-dilated, non reactive pupil suggests CN III compression 2/2 uncal herniation
-take measures to reduce ICP -> d/c volatile agents, make sure no venous obstruction, elevate HOB to 30 deg, and give mannitol
-last resort hyperventilation

114
Q

Hyperventilation in TBI

A

hyperventilation not recommended due to risk of inducing cerebral ischemia (reduction in CBF during the first 24 hours) -> warranted a as a treatment of last resort in this situation if uncal herniation eminent

115
Q

How does mannitol dec ICP

A

-osmotically shifting fluid from intracranial compartment to intravascular compartment
-dec production of CSF
-inducing reflex cerebral vasoconstriction
-potential complications: worsening cerebral edema if BBB not intact, or expansion of intracranial hematoma where intracranial bleeding (osm diuresis -> shrinkage of surrounding brain)

116
Q

OB crash c/s, TBI, GA with ETT, pt taking longer to wake up than expected, what to do?

A

-check vital signs
-ensure adequate BP, O2, ventilation
-possible manifestation of worsening cerebral pathology -> c/s neurosurgeon plan for immediate transport to get a CT scan -> take steps to dec ICP and maintain CPP
-other possible causes: Mg tox, or high dose narcotics

117
Q

OB crash c/s, TBI, GA with ETT, concern for inc ICP, going to CT, widened QRS on EKG, what to do?

A

-check her vital signs
-compare current EKG to previous one to rule in/out previous condition
-continue efforts to control ICP, recognizing inc ICP -> widened QRS complex
-plan for CT head to r/o ICH
-another cause could be Mg toxicity -> order Mg level and check Deep tendon reflexes
-if Mg toxicity -> d/c infusion, prepare to treat sz, give diuretic to inc renal excretion of Mg, give calcium gluconate

118
Q

Serum Mg level, SE?
1.4-2.5

A

Normal

119
Q

Serum Mg level, SE?
4-7

A

Therapeutic Range

120
Q

Serum Mg level, SE?
7-10

A

loss of patellar reflexes, hypoTN, CNS depression

121
Q

Serum Mg level, SE?
13-15

A

Respiratory Paralysis

122
Q

Serum Mg level, SE?
16-25

A

EKG changes (prolonged PR interval, widened QRS, prolonged QT interval)

123
Q

Serum Mg level, SE?
20-25

A

cardiac arrest

124
Q

POD2 OB PEC, jaundice and develops dark urine

A

signs/symp with hemolytic anemia
-evaluate pt for signs of hemolytic anemia: pallor, SOB, fatigue, substernal pain
-CBC, retic count, peripheral blood smear (Heinz bodies), LFTs (inc bili), urinalsysi (hemosiderin, urobilinogen, brown)
-eliminate any preciptating factors: hypothermia, acidosis, hypoxia, hyperglycemia, infxn
-give fluids and mannitol to maintain UOP
-consider transfusion if needed

125
Q

Hemolysis POD 2-5 with no blood products given, thoughts?

A

G6PD deficiency

126
Q
A
127
Q

Nurse sticks herself with needle after drawing on HIV positive pt, what to tell her?

A

-immediately wash the wound with soap and water, and report to employee health to get blood draw for testing
-reassure her telling her the transmission rate even with HIV positive source 0.3%
-likely to get post exposure ppx and should avoid risk transmitting dx like blood donation or sexual activity until labs are negative for HIV

128
Q

PEA what to do?

A

-Call for help
-Start CPR
-verify rhythm is not v fib or v tach
-secure airway with ETT
-ensure PIV access
-give 1mg epi, repeating every 3-5 minutes as needed
-treat any reversible causes: Hypovolemic, hypoxia, acidosis, hyper/hypoK, hypothermia, drug tox, tamponade, PTX, MI, PE
-continue to check for shockable rhythm
**consider TTE

129
Q

When to use post ROSC hypothermia?

A

-unable to meaningfully respond to verbal commands after treating precipitating causes, optimizing vent and oxygenation and optimizing cardio pulm fxn (fluids, introns, vasopressors MAP > 65)
-believed to provide protection for the brain and organs in comatose pts post cardiac arrest

130
Q

ROSC determined by:

A

-presence of pulse and BP
-abrupt inc in EtCO2 > 40
-spontaneous arterial pressure waves on a line

131
Q

When to use hypothermia post cardiac arrest?

A

-comatose post ROSC after being resuscitated for out of hospital v fib cardiac arrest
-in hospital arrest w/ any initial rhythm
-out of hospital arrest w/ initial rhythm PEA

132
Q

How to induce therapeutic hypothermia

A

-cooling blankets
-ice packs
-rapid infusion of 30 cc/kg ice cold LR or normal saline
-goal temp: 32-34 C
-monitor temperature (esophageal, bladder, or pulm a catheter (if already in place))
-maintain 12-24 hours

133
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometimes, what causes her SOB?

A

-compression of the airways 2/2 mediastinal mass
-mass compression of heart or great vessels
-mass-induced V/Q mismatch
-mass obstructive PNA
-SVC syndrome (obstruction of venous drainage)
-possible myasthenia gravis (assoc w/ thymoma MC anterior mediastinal mass)
-poorly controlled asthma
-severe GERD, aspiration, aspiration PNA
-cardiac assoc w/ Down Syndrome (endocardial cushion defects)

134
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometime, next steps?

A

History and Physical
-CT scan, CXR, PFTs, and TTE -> identify any airway and/or cardiac compression, signs of COPD
-signs/sym of SVC: JVD, head and upper limb edema, dysphagia, nasal stuffiness, papilledema, CP, lightheadedness, orthopnea
-Sym of myasthenia gravis: dyspnea, diplopia, ptosis, dysphagia, slurred speech, m weakness
-H&P on severity, course, to of HERD and asthma

135
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometimes, could SOB due to myasthenia gravis?

A

-Yes, resp m compromise assoc w/ MG can contribute to SOB
-thymoma is one of the MC anterior mediastinal masses, and significant number of pts w/ thymoma develop MG
-if after further examination concerned for MG: c/s neurologist for definitive dx and tx

136
Q

Pathophys of myasthenia gravis

A

-autoimmune disease
-antibodies to postsynaptic ACh receptors -> Dec in number of receptors in NMJ -> m weakness, esp in eyes, face, throat. Neck, limbs
-weakness worsens with activity and improves w/ rest
-symp: diplopia, ptosis, dysphagia, diff chewing, slurred speech, dyspnea
-can affect heart: mild HTN, 1st deg AV block, a fib, myocarditis, cardiomyopathy, diastolic dysfunction

137
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometimes. She says that she gets lightheaded while laying down, concerned?

A

-very concerning -> setting of anterior mediastinal mass, hx of presyncope w/ supine position -> assoc w/ inc periop risk of cardiovascular collapse
-likely caused by mass compression of heart, SVC, or pulm artery > inc risk for complete cardiovascular collapse in periop period
-other causes contributory: cardiac manifestations (mild HTN, 1st deg AV block, a fib, diastolic dysfunction

138
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometime. Says she gets lightheaded when lying on her back, what do you do?

A

-examine pt, and review CXR, CT scan, TTE, PFTs
-looking for any mass involvement in heart or great vessels and identify RF for periop cardiopulm complications:
-tracheal compression > 50%
-tracheal compression > 30% with bronchial compression
-strider
-orthopnea
-cyanosis
-jugular distinction
-SVC syndrome
-pericardial effusion
-pleural effusion
-combined obstructive and restrictive pattern on PFTs

139
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometimes, CT scan shows 50% tracheal compression, concerning?

A

Yes, this degree of tracheal compression is assoc w/ inc risk of complete airway collapse
-this w/ SOB, presyncope in supine position, and possible subglottic tracheal stenosis assoc w/ down syndrome -> substantial risk of periop airway compromise
-chronic compression or tumor invasion of tracheobronchial tree can affect structural integrity of trachea -> more susceptible to collapse w/ direct mass compression, forced expiration, inc negative intraluminal pressures
-review CT scan -> airway compression below carina may inc her risk making passage of ETT beyond area of compression impossible

140
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometime, Per CT compression of trachea 50%, next steps?

A

-ask pt symp of airway compression: dyspnea, tachypnea, wheezing (recognizing confounded by asthma/COPD) and if worsened w/ laying flat
-discussion w/ surgeon about performing surgery under local anesthesia
-attempting to reduce size of tumor w/ chemo, radiation or steroids before proceeding

141
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometime, TTE?

A

-SOB could be cardiac in nature, esp if compression involved -> TTE sitting up and supine to see effects of mass and positioning on cardiac function
-can identify any cardiac defects or dysfunction assoc w/ Down syndrome or myasthenia gravis

142
Q

Anterior mediastinal mass, Down syndrome, mod to severe asthma, severe GERD, smoker, SOB sometime, flow volume loops?

A

-i would not, flow volume loops for this patient b/c poor predictors of periop resp complications, provide little info that can’t be obtained from CT, and do not alter anesthetic plan
-INSTEAD, review CT, perform H&P, observe pt in sitting and supine positions

Benefit: PFTs to know effect on position on pulm fxn, location (intrathoracic or extrathoracic), and nature (fixed or variable), and if there is a reversible component

143
Q

What flow volume loop results show inc risk of airway collapse during induction of anesthesia

A

Increased mix-expiratory plateau noted when position is changed from upright to supine = variable intrathoracic airway obstruction

144
Q

Flow volume loop for fixed obstruction

A

Dec exp and insp loops

145
Q

Flow volume loop for extrathoracic obstruction

A

(VC paralysis, tracheomalacia)
-Dec insp curve, normal exp curve
-neg pressure pulls in, causes obstruction, positive pressure pushes out

146
Q

Flow volume loop for intrathoracic obstruction

A

Dec exp loop, more normal insp loop
-b/c positive pressure causes compression in intrathoracic cvavity, but opens up w/ neg pressure in insp

147
Q

36 YOF, anterior mediastinal mass, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, anesthesia?

A

-local anesthesia w/ little to no sedation if possible
-concerns for general anesthesia: occurrence of presyncope and dyspnea with supine position, FEV1 and FVC < 50% of esp, 50% tracheal compression -> suggest significant risk of pulm or cardiovascular collapse on induction of GA
-abnormalities of airway w/ DS: macroglossia, subglottic stenosis, micrognathia, atlantoaxial instability, compl mask ventilation, DL
-severe GERD, dysphagia, severe asthma inc bronchospasm

148
Q

Airway abnormalities assoc w/ Down syndrome -

A

Macroglossia
Subglottic stenosis
Micrognathia
Atlanta-axial instability

149
Q

36 YOF, anterior mediastinal mass, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, pt refuses just local anesthesia, what to do?

A

-Would make the surgeon, pt, and her family aware of my concerns and suggest chemo, radiation or steroid therapy to reduce size of the mass prior to surgery
-and then f/u scan to see resolution of concerning symptoms and successful reduction of tumor prior to rescheduling
-acknowledge this can affect risk of diagnostic inaccuracy, risk of proceeding w/o pretreatment

150
Q

36 YOF, anterior mediastinal mass, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, would you give anticholinergic for aspiration ppx

A

-no, reduce LES tone and have not been shown to Dec acidity or gastric volume in pts at inc risk for aspiration
-instead give H2 blocker (famotidine), metochlopramide, and nonparticulate antacid (sodium citrate)
-would also avoid anticholinergic drugs since could possible lead to inc m weakness and bulbar symptomaology in someone w/ MG

151
Q

How to evaluate for Atlanta-axial instability?

A

-review previous anesthesia records for indication of difficult airway or Atlanta-axial instability?
-anterior atlantodental interval > 4-5 mm in any lateral view
-H&P to identify signs of symp of cord compression (gait anomalies, clumsiness, fatigue w/ ambulating, numbness/tingling, hyperreflexia
-full neck flexion and extension to see if symp -> if any symptoms would delay the case and request repeat cervical imaging and a neurosurgeon eval

152
Q

36 YOF, anterior mediastinal mass, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, has never undergone cervical imaging, would you require?

A

-while it it’s reasonable to obtain cervical imaging in a pt with Down’s syndrome who’s never been screened, I would not require it assuming that the history and physical did not identify any signs or symptoms consistent w/ cervical instability
-however would proceed w/ extreme caution and make every effort to avoid excessive flexion, rotation or neck extension -> especially concerned b/c DS freq are difficult airways

153
Q

36 YOF, anterior mediastinal mass, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected. Previous XR at 4 years old showing anterior atlantodental interval of 6mm, never had symp, would you delay the case for repeat imaging?

A

Would not delay needed surgical procedure unless H&P show cord compression
-would take caution to minimize head and neck movement during the case, esp w/ laryngoscopy

154
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, c/o numbness and tingling in her arms w/ full neck extension, what would you do?

A

Recognizing consistent w/ cervical spine instability -> delay nonemergent case until she could have full service l spine eval by neurosurgeon
-if surgical procedure cannot be delayed -> goal to minimize neck flexion, extension and rotation

155
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, how to intubate and induce this patient?

A

-asp ppx, pre-induction albuterol
-ensure adequate IV access, and presence of fluids, inotropes, and vasopressors
-difficult airway equipment available incl fiber optic, multiple micro laryngeal ETT sizes, surgeon in room w/ rigid bronchoscope
-put pt in position she’s the most comfortable in to minimize mass compression -> leave bed in room in event prone positioning necessary
-cannulate femoral arteries under local anesthesia w/ CPB in the room and ready
-adequate airway anesthesia
-awake fiber optic

156
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, awake fiber optic best approach?

A

Assuming GA was required, awake FOB gets
-adv: minimize movement of cervical spine w/ possible atlantoaxial instability, minimize asp b/c airway secure prior to induction, allows assessment of level and degree of compression, ensure ETT distal to obstruction
-avoids deleterious effects of general anesthesia (red preload and altered resp mechanics)

157
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, pt refuses awake intubation, what will you do?

A

-attempt to explain benefits of placing ETT prior to induction and reassure her that I would do everything I could to make her comfortable
-if still refused: optimize medical conditions (asp ppx, albuterol), ensure difficult airway equipment, surgeon present in the room with rigid bronch and eternal saw
-minimize head movement
-place her in position she is most comfortable
-cannulate femoral arteries under local anesthesia w/ CPB pump on standby
-reduce airway secretions
-induce the pt w/ small dose of ketamine followed by volatile agent -> goal to maintain depth of anesthesia sufficient to prevent bronchospasm while maintaining sp respriations and avoiding pulm asp and neck movement
-reinforced ETT

158
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, shortly after induction but prior to placement of ETT airway movement ceases, can’t ventilate, what to do?

A

-place OPA and attempt to hand ventilate w/ 100 FiO2 and CPAP, auscultation the chest
-put pt in position preop tha minimizes dyspnea and presyncope
-minimize head and neck movement
-perform laryngoscope to see if larygnoasm -> if none place an ETT
-if unable to ventilate -> pass fiber optic through ETT to identify any mass-induced obstruction
-could be. Bornchospasm -> PPV, deepen anesthetic, give albuterol, and epi

-if unable to ventilate due to obstruction, wake pt up, if unable to: attempt to advance ETT or bronchoscope beyond obstruction
-consider prone position to relieve mass obstruction
-ask surgeon to perform emergency stereo to my and manually elevate mass -> and start cardiopulm bypass

159
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, intubated, mass identified as thymoma, attempt to extubate?

A

-return of sp ventilation and chest wall tone should help maintain airway latency -> providing pt meet standard extubate on criteria, remove in RT position
-given risk of aspiration, possibility of MG and risk of airway compression from mass (since just biopsy) -> prepare for emergent reintubation, delay extubate on until fully awake
-consider ACHE inh should help w/ resp m weakness if concerned for MG
-risk of bronchospasm consider IV lidocaine or albuterol prior to extubate on
-vigilant monitoring postoperative

160
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, you give pyridostigmine to treat MG, after ETT removal she Delors laryngospasm and can’t ventilate

A

-suction airway to remove debris, blood, secretions
-apply positive pressure mask ventilation
-deepen anesthetic w/ volatile agent
-give IV lidocaine to blunt glottic closure reflex
-forceful jaw thrust (careful to avoid changes in cervical spine)
-call for help, gently attempt to pass ETT through closed CV
-avoid succ or roc if at all possible -> concern of airway collapse after cessation of spontaneous ventilation
-if last resort would give succ -> acknowledging that MG tend to be resistant, duration can be prolonged

161
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, larygnospasm, no succ available, would you give a nondepolarizer medication to break spasm

A

Due to concern for airway collapse in this pt, this would be a last resort
-MG she would be very sentisitve to NDM
-would give small dose, only if laryngospasm persisted despite other interventions (half or 1/3 dose)-> she was becoming hypoxic, intubation w/o m relaxation proved impossible and succ was unavailable
-make sure ETT beyond mass compression area

162
Q

36 YOF, anterior mediastinal mass for biopsy, smoker, DS, SOB asthma mod to severe, diff swallowing, severe GERD, 50% tracheal obstruction, FEV1, PEF less than 50% expected, postop dyspneic, differential?

A

-mass obstruction compressing tracheal structures, cardiac structures
-bronchospasm 2/2 asthma/COPD
-laryngospasm
-upper airway obstruction 2/2 macroglossia/subglottic stenosis with DS
-airway edema
-exacerbation of myasthenia gravis or cholinergic crisis
-residual anesthesia
-pulmonary edema (neg pressure, cardiogenic)
-inadequate pain control
-aspiration pneumonitis
-cardiac tamponade/PE

163
Q

Tonsilon test

A

Edrophonium test
-positive is muscle strengthening after edrophonium adminstration
-if symptoms worsen - > cholinergic crisis
-2-10mg of edrophonium, improvement in 5 minutes, only lasts around 10 minutes

164
Q

Signs/symptoms of cholinergic crisis

A

-diaphoriess/diarrhea
-urinary freq and urgency
-miosis: constricted pupil size
-bradycardia, excess mucous in lungs
-emesis
-lacrimation
-lethargy
-salivation/sweating (vomiting)

-weakness/muscle fasciculations

165
Q

MG and NMB

A

-avoid long acting nondepolarizers
-use minimum dose needed for effect
-plan to let the affects wear off, avoid giving a reversal agent

166
Q

Negative pressure pulm edema

A

-noncardiogenic form
-large inspiratory effort against obstructed upper airway
-negative intrathoracic pressure in alveoli -> inc transcapillary pressure gradient
-may occur w/i a few minutes up to 3 hours -> coughing, tachypnea, hypoxia

167
Q

Treatment of neg pressure pulm edema

A

Maintain upper airway latency, provide suppl O2, give diuretics, and start mechanical ventilation if necessary

168
Q

Would you give steroids for SC injury?

A

No, not recommended, lack of evidence w/ clinical improvement
-large complications incl fluid retention, hypertension, electrolyte imbalances, hyperglycemia, impaired wound healing and immunosuppression

169
Q

Hx of tobacco use, how to evaluate pulm status/fxn?

A

H&P!
-s/s of COPD: cough, sputum production
-freq of pulm infections, freq and severity of exacerbations, exercise tolerance, # and course of hospitalizations, efficacy of past treatments
-CXR, PFTs, ABG, consider pulm consult

170
Q

When to order PFTs w/ lung hx?

A

Hx of long smoking hx, is hypoxic on room air, and about to undergoing surgery w/ inc risk of postop pulm complications
-PFTs give type and severity of dx, baseline pulm fxn, and presence of reversible component

171
Q

FEV1/FVC < 70%, type of lung dx?

A

Obstructive

172
Q

FEV1/FVC 50% with mild improvement w/ bronchodilator therapy

A

Severe COPD

173
Q

Smoker, hypoxia on room air, case w/ postop pulm issues, benefit of case being delayed?

A

Pulm status benefits from smoking cessation 8 weeks prior to surgery
Preop chest physiotherapy
Bronchodilators
Glucocorticoids
And abx if evidence of in fxn all for optimization

174
Q

Timeline for symptoms for alcohol withdrawal

A

Tremulousness: 6-8 hours
Hallucinations and so: 24-36 hours
DTs: confusion, perceptual distortions, agitation, autonomic instability: 72 hours

175
Q

Concern of alcohol hx, w/u?

A

History: type, frequency, quantity of alcohol consumed, last time of alcohol intake
-physical exam: looking for cirrhosis, hepatic encephalopathy, wernicke-korsakoff syndrome, gait disturbance, cardiomyopathy
-CBC, BUN, Cr, lutes, glucose, coats, LFTs
-EKG, CXR
-benzos

176
Q

Anesthesia concerns w/ chronic alcohol abuse

A

-inc MAC req
-tolerance to other anesthetic drugs
-cognitive impairment
-cerebral atrophy
-cerebella degeneration
-peripheral neuropathy
-cardiomyopathy, cirrhosis, hypoglycemia
-thrombocytopenia, electrolyte abnormalities, GI bleeding, w/d symp, risk for aspiration, nutrition def

177
Q

Risk of poor periop glucose control

A

Poor wound healing
Inc rate of infection
Osmotic diuresis

178
Q

lab work for diabetes

A

CBC, BMP, glucose level, UA
-potential for arthrosclerosis and silent ischemia: EKG

179
Q

Cervical Laminectomy: DM2, HTN, active smoker, daily alcohol consumption. How to optimize prior to surgery?

A

-c/s pul for dx and optimization of pulm dx (steroids, bronchodilator’s, abx?)
-recommend smoking cessation at least 8 weeks prior to surgery (red in carboxyHg), improved ciliary fxn, red nicotine level, red airway hyperreactivity, Dec sputum production, Dec periop pulm complications
-d/c and detox of alcohol -> correct any metabolic abnormalities or nutritional def from alcohol
-evaluate for s/s of diabetic autonomic neuropathy, eval glycemic control, see endo if inadequate

180
Q

Posterior cervical laminectomy, DM, HTN, active smoker, severe spinal stenosis, poor airway, orthostatic hypoTN, wheezing, special monitors?

A

ASA standard (5 lead KEG): monitor for cardiac ischemia
-arterial line : hemodynamic changes
-SSEPS/MEPS: intraop SC ischemia
-foley

181
Q

When to avoid MEP monitoring

A

Cochlea implants, active so, or vascular clips in the brain

182
Q

Why do MEPS in addition to SSEPS for SC surgery?

A

-SSEPS anterior SC function
-possibility of false neg with SSEPs, and inc sensitive of MEPS for detecting motor injury
-would do both if SC ischemia is a significant risk

183
Q

Posterior cervical laminectomy, DM, HTN, active smoker, severe spinal stenosis, poor airway, orthostatic hypoTN, wheezing, how to intubate?

A

-asp ppx, beta blocker, place pt in RT, ensure adequate airway analgesia prior to awake FOB w/ manual in-line stabilization

184
Q

Posterior cervical laminectomy, DM, HTN, active smoker, severe spinal stenosis, poor airway, orthostatic hypoTN, wheezing, maintenance of anesthesia?

A

TIVA w/ prop, remi, and ketamine
-allowing an adequate depth of anesthesia w/ minimal depression of SSEPs, MEPs

**MEPs more sensitive to volatiles than SSEPs -> if volatile given use less than 0.5 MAC

185
Q

How do anesthetic agents affect MEPs?

A

-Dec amplitude and inc latency w/ opioids, sedative hypnotics, and volatile agents
-similarly seen with SC ischemia
-no muscle relaxants

186
Q

What change in MEPs are significant?

A

50-80% Dec in amplitude, changes in latency are less reliable

187
Q

Anesthesia affect SSEPs

A

Decreased amplitude and inc latency
-anesthesia suppression, hypothermia, hypercarbia, hypoxia, and hypoTN have similar effects

188
Q

What monitored in MEPs?

A

Descending motor pathways in anterior spinal cord

189
Q

What monitored in SSEPs

A

Ascending sensory neural pathways in posterior spinal cord

190
Q

After induction and prone positioning, pt hypoTN, 62/48, tx with ephedrine ineffective

A

-100% O2, ensure adequate ventilation, look at EKG
-give fluid bolus -> ensure positioning not obstructing venous return
-likely has significant autonomic neuropathy: small bolus of direct acting vasopressors like phenylephrine

191
Q

Autonomic Neuropathy

A

-long standing DM -> excessive glycosylation can lead to neuropathy in Autonomic neuro us system
-Gastroporesis, GERD
-exercise intolerance
-early satiety
-bloating
-no sweating
-peripheral neuropathy
-dysrythmias
-diarrhea
-N/V, epigastric pain
-orthostasis, HTN
-lack of reflex tachycardia w/ Hypovolemic
-resistant to ephedrine (indirect)
**often affects parasympathetic 1st

192
Q

Dec amplitude and inc latency in SSEP and MEPs, what do you do?

A

-correct any hypoxemia, hypoTN (up to 20% above normal), Hypovolemic, anemia, hypo/hypercarbia
-make sure depth of anesthesia was stable
-r/o SC injury due to excessive traction
-if no improvement as removal of instruments and consider wake up test

193
Q

What change in SSEP is considered significant

A

50% Dec in amplitude, 10% inc in latency

194
Q

What part of SC most vulnerable to ischemic injury?

A

Anterior spinal cord -> limited blood supply from anterior spinal artery
-additional supplied by radicular arteries: Artery of Adamkiewicz

195
Q

Delayed emergence with NMB fully reversed, adequate TV, and low conc of volatile, ddx?

A

-neurological deficits
-hyper/hypoglycemia
-alcohol w/d
-hypoxia
-hyper/hypocarbia
-residual anesthetic
-residual NMB
-metanbolic derangements

196
Q

What to do in delayed emergence?

A

-ensure adequate ventilation and oxygenation
-review meds given during the case
-confirm complete NMB with twitch monitor
-serum glucose and lutes
-check temp
-still unknown c/s neuro, EEG, and CT head/neck

197
Q

Expected pH on PaCO2 on acute respiratory

A

-inc in 10 PaCO2 = Dec 0.08 pH

7.40/40
7.32/50
7.24/60
7.16/70

Difference b/w expected and actual is metabolic

198
Q

Inc anion gap metabolic acidosis

A

Diabetic or alcoholic ketoacidosis
Accumulation of lactic acid (poor tissue oxygenation) or liver dysfunction
Intravascular dilution (hypotonic fluids )
Renal failure
Rhabdomyolsysis

199
Q

How to calculate anion gap

A

Na - (Cl and bicarb)
12 +/- 4 is normal 8-16

200
Q

How to treat combined AG metabolic acidosis

A

-adjust ventilator to maintain PaCO2 in low 30s to compensate for academia
-identify cause of metabolic acidosis: lactate, UOP, Cr, BUN, blood glucose and urine ketones, blood alcohol level
-treat metabolic derangement
-only if bicarb if pH < 7.1, bicarb < 10 or life threatening hyperK

201
Q

Concerns of treatment w/ sodium bicarb

A

-generates additional CO2 (reacts w/ hydrogen ions) -> worsen acidosis
-L shift of O2 dissociation curve -> inc Hg affinity for O2 -> Dec O2 offloading
-hyperosmolar state 2/2 excessive Na
-hypoK (K moves from Extracellular to intracellular)

202
Q

Patient wakes up after prone case and can’t see, what to do?

A

-assess pt
-correct any metabolic disturbances
-elevate HOB (facilitate venous drainage)
-ensure adequate BP, Hg, O2, and cardiac function
-urgent potholes c/s
-talk to pt and family: all precautions had been taken to minimize risk, everything being don to treat

203
Q

What is posterior ischemic optic neuropathy?

A

-postop vision loss believed to occur when Dec O2 delivery to RETROLAMINAR PART OF THE OPTIC NERVE
-MCC of postop vision loss, 24-48 hours postop
-painless vision loss, Afferent pupillary defect, visual field defect, optic disc normal

204
Q

Which pts high risk for developing posterior ischemic optic neuropathy?

A

Spine surgery:
-prolonged case > 6.5 hours
-substantial blood loss (45% of EBV)

RF:
Anemia, substantial blood loss, hypoTN, Hypovolemic, hypoxia, hemodilution, external ocular pressure, inc ocular venous pressure, release of endogenous vasoconstrictors, prone head-down positioning, prolonged surgery, massive fluid resuscitation

205
Q

How to reduce risk of periop vision loss for a high risk patient undergoing spine surgery in prone position

A

-ensure head is neutral forward position, level or higher than heart
-monitor BP continuously, and maintain BP a baseline
-consider CVP and monitor and maintain intravascular volume w/ crystalloids and colloids
-monitor Hg and Hct levels (goal Hg > 9 and Hct 28%)
-consider staging spinal surgeries that are anticipated to be long and complex

206
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Concerns?

A

-cardiac status: hx of MI and HF, exertional angina and orthopnea
-poorly controlled HTN -> periop hemodynamic instability and inc postop compl
-periop complications w/ DM: hyper/hypoglycemia, hemodynamic instability (DM autonomic neuropathy), silent ischemia, neurological injury (inc risk of ischemic neural injury), and aspiration
-TIAs: inadequate collaterals through circle of Willis
-periop MI or stroke

207
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. How to eval preop?

A

-neuro exam: deficits?
-acute cardiac condition: unstable angina, unstable CHF -> both require surgical delay
-Hg, UA, EKG, CXR, ABG (baseline PaCO2)
-TTE if not done in 12 months or symp worsened
-eval signs for autonomic neuropathy (BP and HR)
-optimize blood sugar, BP, and cardiac function
-reassurance and minimal sedation to avoid any inc in HR, BP, and myocardial O2 consumption
-continue cardiac meds

208
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. How to eval her cardiac status?

A

H&P
-assess severity and stability of her cardiac disease
-r/o any acute cardiac conditions
-any previous cardiac interventions
-determine functional status (> 4 METs proceed)
-if METS < 4 -> c/s with surgeon and patient to see if results of further cardiac testing would alter care (CABG or PCI)
-consider pharmacological stress test

209
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Can’t determine functional capacity. Recommend testing for cardiac ischemia?

A

-if cardiac risk outweighed benefits of immediate surgery, and if a positive test would alter management -> dob stress test

210
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Would cardiac revascularization be indicated prior to CEA?

A

It would if the vascular surgeon and cardiologist believed her overall outcome would be improved
-important to realize risk of periop stroke during revascularization of heart
-decision in conjunction w/ cardiologist and vascular surgeon

211
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Benefits/disadvantage of GA

A

-Benefits: still patient and operative field, definitive control of airway and ventilation, pharmacological interaction for brain protection
-Disavd: can’t perform repeated neuro exams, possibility of greater hemodynamic instability 2/2 induction, intubation, extubate on

212
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Regional benefits/disadvantages

A

Benefits: greater hemodynamic stability, avoid MI depression w/ GA, avoid tracheal intubation and symp response, reduce risk for vasopressors, continuous neurological monitoring

Disadvantages: phrenic n paralysis (commonly associated w/ cervical plexus block), limited access to unsecured airway, high level of pt cooperation (need same language). Can be insufficient if pts carotid disease extends so high incision must be extended

213
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Premeds?

A

-if pt anxious despite reassurance, small amount of narcotic prior to line placements -> periop anxiety can cause detrimental effects on heart
-give any chronic cardiovascular med pt is taking at home (make sure they get their ASA if on at home)

214
Q

Regional anesthesia for carotid endarterectomy

A

-deep and superficial cervical plexus blocks to anesthetize C2-4 dermatomes
-superficial: posteriori border of the SCM
-deep: draw a line from mastoid process to Chassaignacs tubercle and level of cricoid cartilage -> palpate C2 transverse process 1-2 cm caudate of mastoid process with transverse process of C3 and C4 -> inject 10cc at each transverse process

215
Q

Complications of deep and superficial cervical plexu blocks

A

-epidural and subarachnoid in Jan
-phrenic n blockade
-intravascular injection into vertebral artery
-recurrent largyneal nerve blockade
-horners syndrome (ptosis, miosis, anhydrosis)
-local anesthetic toxicity
-bleeding
Infection

216
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. CEA, can you use superficial cervical plexus blocks alone?

A

I would not
-poorly controlled HTN, CAD, CHF would not tolerate sympathetic response from inadequate analgesia

217
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. Monitors?

A

A line
5 leads EKG
computerized ST segment analysis
-central line
-possible TEE
-EEG, SSEPs

218
Q

Options for neuromonitoring with CEA?

A

-most reliable: intraoperative exam of awake patient
-indirect if under GA: EEG, SEEPs, transcrnaial Doppler, stump pressure determinations, cerebral oximetry, measurements of regional CBF, jugular venous O2 sats

219
Q

Stump pressure in CEA

A

Internal carotid artery
-placing a needle in the artery above the clamp to measure back pressure from collaterals through circle of Willis
-adv: inexpensive, easy to obtain, continuously available during cross-clamping

220
Q

EEG in CEA

A

-requires stable anesthetic
-disadvantage: may not detect subcortical or small cortical infarcts, not specific for ischemia
-can be altered with changes in temp, BP, and anesthetic depth

221
Q

SSEP monitoring

A

measures the response of the sensory cortex to electrical impulses from from peripheral n stimulation
-ascending sensory neural pathways in posterior SC
-affected by hypothermia, BP, anesthetic depth

222
Q

Transcranial Doppler CEA

A

TCD of ipsilateral MCA: continuous measurement of mean BF velocity and detection of micro-embolic events
-helpful in evaluating shunt function, identifying shunt malfunction, determine need for shunt placement (if Dec flow during cross-clamp)

223
Q

68 YOF, recurrent TIAs, presenting L CEA. PMH MI 1 year ago, poorly controlled HTN, HF, DM, tobacco, orthopnea, and angina. How to induce GA?

A

Goal to maintain adequate cerebral perfusion and minimize stress to heart
-avoid any hypercarbia or hypoxia
-prepare to treat any hypertension, tachycardia, bradycardia, or hypoTN that occurs during induction
-place monitors and lines
-preoxygenate patient
-start remifentanil drip
-give esmolol and lidocaine to blunt symp response to laryngoscope
-slowly titration ETT I’d ate until patient no longer responsive (Dec CMRO2 more than CBF)
-after able to mask ventilate, give a muscle relaxant
-ventilate w/ volatile agent
-perform laryngoscope after sufficient depth of anesthesia

224
Q

Isoelectric EEG w/ iso during CEA correct?

A

-no, dose required to produce isoelectric EEG can cause significant cardiac depression and interfere with EEG monitoring for cerebral perfusion
-can use remi and low dose sevo (0.5 MAC) to allow for EEG monitoring and maintain energy of BP in the high-normal range during cross clamp

225
Q

Myocardial preconditioning

A

-exposure to certain drugs serve to protect myocardium against subsequent myocardial ischemia and reperfusion injury
-volatiles w/ conc as low as 0.25 MAC may limit infarct size, prevent dysrhythmias, and preserve myocardial function
-done w/ iso, sevo, and does

226
Q

Why is inc in PaCO2 an issue in CEA?

A

Can cause cerebral vasodilation in normally reactive, non-ischemic vascular beds, diverting VF away from hypoperfusion areas where vascular use is already maximally dilated (“steal phenomenon”)
-acknowledge that too low PaCO2 would cause intense vasoconstriction and L shift of the oxyHg dissociation curve -> normalize while avoiding hypocarbia

227
Q

CEA, w/ dissection pts HR Dec to 48 and BP 88/40, ddx?

A

Reflex bradycardia 2/2 enhanced vagal tone from surgical manipulation of carotid sinus with activation of baroreceptors
-myocardial depression
-cardiac ischemia
-dysrhythmia
-preexisting autonomic neuropathy

228
Q

CEA w/ dissection HR Dec to 48 bpm, BP 88/40, what do you do?

A

Ask surgeon to stop any further dissection, evaluate the EKG, cardiac output
-make sure adequate ventilation and oxygenation
-depending on cause I would treat w/ glyco, fluids, and/or inotropic agents
-if etiology surgical manipulation: can ask surgeon to give local anesthetic to prevent further episodes

229
Q

CEA, after carotid cross clamp, ipisilateral EEG slowing is noted, significance?

A

May indicate cerebral ischemia
-could also be due to hypoterhmia, inc depth of anesthesia (but those are usually b/l)
-ask surgeon to remove cross clamp and consider placing a shunt
-ventilate w/ 100% FiO2, ensure adequate MAP, ensure normal apnea

230
Q

CEA EEG shows slowing and surgeon wants BP at 180 (preop BP 170), agree?

A

If baseline 170/95 was close to her baseline -> cautiously raise her BP while monitoring EKG and CVP to improve cerebral perfusion
-inc BP could cause MI 2/2 inc myocardial O2 consumption w/ inc afterload
-10-15% above baseline

231
Q

CEA, EEG slowing, Inc BP, and now new onset SET segment depression?

A

-optimize myocardial O2 supply and demand
-ventilate 100% FiO2
-correct any anemia, to any tachycardia -> carefully reduce afterload -> acknowledging that I might compromise cerebral perfusion
-carefully titrate NTG due to short duration of action and beneficial effects on coronary circulation

232
Q

Delayed emergence ddx?

A

Residual anesthetic effects
Inadequate muscle relaxation
Cerebral ischemia
Hypoxia
Hypercarbia
Hypotension
Metabolic derangements
Hyperglycemia/hypo
Hypothermia
Cerebral hyperperfusion syndrome (usually several days later)

233
Q

Delayed emergence after CEA, what to do?

A

-check vitals: EKG, CVP, EtCO2
-ensure adequate ventilation, oxygenation, and perfusion
-any neuro deficits
-reverse any residual anesthetics
-correct any hyper/hypoglycemia, hypothermia, hypoxemia, hypercarbia, HTN/hypoTN
-make surgeon aware and Doppler s for carotid blood follow
-CT scan and cerebral angio

234
Q

Cerebral hyperperfusion syndrome

A

When previously hypoperfused areas of the brain have lost ability to autoregulate BF -> exposed to high systolic BP w/ restoration of blood flow
-HA, sz, focal neurological signs, brain edema, ICH

235
Q

Post CEA BP 195/97 what to do?

A

Correct any hypoxemia, hypercapnia, bladder distention
-ensure adequate pain control
-could be a result of the enervation of the carotid sinus baroreceptors -> give hydral, beta blocker, NG
-goal systolic BP < 160 or w/i 20% of preop values

236
Q

Post CEA HTN, while treating pt becomes dyspneic, what’s going on?

A

Most concerning: airway obstruction 2/2 airway edema or wound hematoma
MI
CHF
PTX
-other: bronchospasm, atelectasiis, autonomic neuropathy, carotid body denervation (impaired ventilator response to hypoxia and hypercarbia)
-undx OSA
-narocis
-inadequate reversal of NMB

237
Q

Post CEA, inspiratory strider, pressure in neck underneath dressing, are you going to intubate her?

A

Yes, consistent with airway obstruction 2/2 expanding neck hematoma
-transport pt to OR, call surgeon, presence of difficult airway equipment, continue to tax hypertension
-have someone apply pressure to wound

238
Q

Post CEA, inspiratory stridor, expanding neck hematoma, do you open the wound

A

-if i felt there was time, I would not open the wound prior to transport surgical and anesthesia equipment not available
-difficult airway equipment, send for surgeon, and attempt to intubate the patient

239
Q

33 weeks gestational infant, copious oral secretions, gastric distention w/ PPV, polyhydramnios intern, can’t advance OGT, next steps?

A

Consistent w/ estophageal atresia and tracheoesophageal fistula
-nurse d/c PPV -> further gastric distention can impair ventilation
-call for surgeon to eval neonate for possible gastrostomy tube to decompress the stomach
-consider placing an ETT beyond the fistula
-neonate in head up position (minimize resurgence)
-obtain IV access
-initiate suctioning of upper esophageal pouch to prevent aspiration
-neonate NPO
-CXR to confirm dx

240
Q

Tracheoesophageal fistula, gastrostomy tube placed, ETT removed, need to replace it?

A

-if following decompression, neonate showed no signs of respiratory distress (tachypnea, tachycardia, IC retractions, rales, cyanosis) -> spontaneous ventilation okay
-i would not replace ETT to avoid PPV and worsen gastric distention
-monitor neonate carefully —> if needed decompress gastrostomy tube and PPV

241
Q

Types of tracheoesophageal fistula, most common?

A

Type A-E
Type C most common: esophageal atresia w/ blind upper pouch and a lower segment tracheal fistula

242
Q

Neonate prematurity concerns

A

-respiratory distress syndrome
-persistent pulm HTN of newborn
-Apneic spells
-bronchopulm dysplasia
-NEC
-retinopathy of prematurity
-intraventricular hemorrhage
-red renal fxn
-impaired glucose regulation
-immature hepatic fxn
-inc susceptibility to hypothermia

243
Q

Congenital abnormalities assoc w/ esophageal atresia and TEF?

A

VACTERL
Vertebral defects
Anal atresia
Cardiac anomalies
TEF
Radial and renal dysplasia
Limb anomalies

244
Q

TEF, how to eval preop?

A

-identify/optimize any aspiration PNA, pneumonitis, RDS, Hypovolemic
-CXR and ABG to determine extent of pulm dx
-TTE eval cardiac defects
Renal u/s
Spinal films
CBC, BMP
-optimize pulm and cardiac fxn, avoid asp, ensure adequate hydration, establish a plan for intubation, vent, and extubate on

245
Q

TEF repair, what monitors for the case?

A

Arterial line (femoral or umbilical)
Precordial stethoscope in L axilla
Foley
Place the gastrostomy tube under a water seal (ensure placement of ETT)
-temp monitoring

246
Q

TEF repair, how to induce and intubate

A

-ensure proper monitors and IV access
-pt in HOB up position
-suction proximal esophageal segment, suction gastrostomy tube
-topically anesthetize the airway (minimize sympathetic stimulation)
-atropine (ablate vagal resp to laryngoscope)
-RSI
-advance ETT into R main stem bronchus and slowly w/d until breath sounds b/l
-verify PPV with ETT w/o causing excessive bubbling from submerged gastric tube (confirm w/ fiber optic)

247
Q

TEF repair, if pt did not have gastrostomy tube, awake intubation?

A

Yes, awake intubation to minimize risk of PPV induced gastric distention and aspiration
-airway analgesia w/ topical local anesthesia and if neonate stable give minimal sedation I
-goal to blunt sympathetic response could lead too intraventricular hemorrhage in premature neonate
-consider inhalational induction to maintain spontaneous respiration

248
Q

TEF, does intubation protect child from aspiration?

A

Not entirely, placement and inflation of cuff provides some protection, however if cuff not placed distal to fistula it will provide no protection

249
Q

TEF, ex-33 weeks, what size ETT and cuffed v uncuffeD?

A

3.0 mm ETT to minimize risk of aspiration with goal to place ETT cuff distal to fistula
-no need for repeated laryngoscope
-acknowledge means smaller diameter -> could lead to inc airway resistance, risk of post extubate on croup
-largest allow for adequate air leak around cuff at 20-25

250
Q

TEF repair, SpO2 Dec to 89%, airway pressure inc

A

-displacement of ETT into R mainstream
-surgical retraction of trachea, bronchus or lug
-gastric distention from PPV
-bronchospasm
-PTX
-V/Q mismatch from RDS, PNA,
-mucous plug or clot in ETT

251
Q

TEF repair, SpO2 85%, inc airway pressures, what to do?

A

-inform surgeon
-hand ventilate w/ 100% oxygen
-auscultation breath sounds in all lung fields
-suction ETT
-peds bronch to verify placement
-check for gastric distention
-check for bubbling w/ gastric tube under wet seal
-ask surgeon to relieve traction
-check ABG
-consider POCUS or intraop CXR

252
Q

TEF repair on TPN, how to manage intraop fluid replacement

A

-continue TPN and maintenance fluids separately
-goal of Hct > 35%, blood loss 3:1 crystalloid
-monitor UOP, HR, BP, ABGs adjust as needed

253
Q

TEF repair, temp is 36.3 concerning?

A

Yes, while not meeting the definition of hypothermia, it is lower than normal
-neonate limited ability to maintain normothermia
-prone to hypothermia: thin skin, large surface area to body mass ratio, low sub fat, inefficient mechanism of heat production (brown fat metabolism)
-hypothermia effects: inc O2 consumption, in PVR, inc cardiac shunting, altered drug response, postop hypoventilation, apnea, coagulopathy, delayed wakening, cardiac irritability, wound healing, metabolic acidosis

254
Q

Extubate pt post TEF repair?

A

-I would not extubate due to high risk of reintubation, causing inc risk for airway trauma, intraventricular hemorrhage (sympathetic response), disruption of anastomatic suture line
-infants often require re-intubation 2/2 atelectasis, aspiration PNA, aspiration pneumonitis, RDS, tracheomalacia, resp depression, excessive secretions

255
Q

Extubation goals for TEF repair

A

Cardiopulm status stable
AWake
Complete reversal of NMB
Cough and gag reflex intact
Spontaneous TV of 5-7 cc/kg on CPAP
Peak inspiratory pressures below 30
O2 requirements were below 40% with a PEEP of 3-5

256
Q

Regional w/ TEF repairs

A

Caudal anesthesia
-allows for reduction in volatiles, intraop narcotics, and NMB

257
Q

Post TEF, intubated transport to NICU, hand ventilation through ETT difficult, pt hypoxic, what do you do?

A

-quickly transport back to NICU or back to OR, whichever is closer
-continue ventilation w/ 100% FiO2
-auscultation all over lung fields
-confirm presense of EtCO2 (possible extubation()
-confirm ETT positioning
-suction ETT
-consider CXR/bronchodilator

258
Q

TEF repair ICU vent settings

A

SIMV
-PEEP 2
-FiO2 as low as necessary to maintain PaO2 of 60-80 mmHg
-minimize Peak inspiratory pressures to Dec stress on anastomotic suture line and Dec risk of anastomotic leak

259
Q

RF for retinopathy of prematurity -

A

-age younger than 44 weeks post conception
-excessive FiO2
-multiple blood transfusions
-parenteral nutrition
-hypoxia
-hypercapnia/hypo

260
Q

Neonate postop Hct 30%, transfuse?

A

Yes, I would want to avoid potential consequences of tissue hypoxia -> metabolic acidosis, necrotizing enterocolitis, impaired wound healing, MI, cerebral ischemia
-risks assoc w/ transfusions: TRALI, TACO, hemolytic transfusion reactions,
-transfuse only pRBCs O neg, irradiated (minimize transfusion gvh), leukokreduced, sickle cell negative
-goal Hct 35%

261
Q

TEF 2 hours post extubation, barking cough w/ inspiratory stridor

A

Post-intubation croup (highest on my differential)
-also consider: epiglottis, laryngotracheobronchitis, or laryngeal foreign body

262
Q

RF for post-intubation croup

A

Traumatic intubation
Excessively tight ETT
Prolonged intubation
Surgery yof head and neck
Intra-op changes in kid’s position
Hx of croup
Coughing w/ ETT in place

263
Q

Treatment for post intubation croup

A

Racemic epi and IV dexamethasone

264
Q

Tracheomalacia

A

Cartilage in the trachea has not developed properly or was damaged and collapses w/ exhalation
-expiratory stridor (intrathoracic obstruction)

265
Q

TEF postop pain management

A

-lumbar or caudal epidural catheter w/ bulk 0.1% and feet 0.5 mcg/cc at 0.1 to 0.1 cc/kg per hour
-if neuraxial CI or technically difficult, tylenol, IV fentanyl

266
Q

Postop and long term complications of TEF repair

A

-anastomatic leak
-recurrent laryngeal or vagal n injury
-tracheal or esophageal stricture
-GERD
-dysphagia
-tracheomalacia
-esophageal dysmotility
-recurrent or missed fistula
-recurrent aspiration pneumonitis
-Barrett’s esophagus
-freq bronchitis
-PNA
-sepsis
-mortality

267
Q

What is TRALI short for

A

Transfusion Related Acute Lung Injury

268
Q

What is TACO short for

A

Transfusion Associated Circulatory Overload

269
Q

64 YOM 118 kg, ex lap, rupture diverticulum. HTN-induced chronic renal failure on HD. K 5.6. Temp 38.1. Concerns?

A

-urgency of the case -> limit the time I have to eval and optimize the pt
-chronic renal failure: inc risk for metabolic abnormalities, metabolic acidosis, cardiac conduction issues, LVH/CHF, hyperglycemia, bleeding (uremia, impaired vWF, impaired plt fxn)
-chronic HTN, anemia, Hypovolemia,
-inc risk for aspiration
-obesity: complicate airway management, surgical duration, postop pain control
-risks w/ laparoscopic surgery: capnothorax, grocer-induced trauma, hypoTN, CO2 emphysema

270
Q

64 YOM 118 kg, ex lap, rupture diverticulum. HTN-induced chronic renal failure on HD. K 5.6. Temp 38.1. How to assess volume status?

A

Pts on HD are hypovolemic following HD, and hypervolemic prior to next session
-ask how often he was dialysed, when last HD session was, and how much fluid taken off at that time
-signs/symp of fluid overload or hypovolemia: pulm edema, HTN, peripheral edema, JVD
-versus dry mucous membranes, hhypoTN, and orthostasis

271
Q

64 YOM 118 kg, ex lap, rupture diverticulum. HTN-induced chronic renal failure on HD. K 5.6. Temp 38.1. Cancel the case if K was 5.6

A

Assuming he’s not symptomatic or showings signs of hyperK on EKG (peaked T waves, wide QRS, prolonged PR interval), would not cancel due to urgency of procedure
-I understand hyperK inc risk for cardiac irritability and arrhythmias -> often delay elective when K > 5.5
-plan to correct any metabolic acidosis or hypoCa, avoid succ and Kk containing solutions (LR), prepare to treat hyperK w/ Calcium, glucose/insulin, albuterol, hypervent
-defibrillator in room
-proceed w/ case carefully while monitoring EKG and K

Anesthesia Oral Boards (8 decks)

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