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Basic Exam > Oral Boards SOE > Flashcards

Oral Boards SOE Flashcards

1
Q

Left uterine displacement

A

When 18 weeks…1.5 trimester

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2
Q

RhoGam MOA

A

Stop mom from forming antibodies to attack Rh+ cells

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3
Q

Therapeutic mag in preeclampia

A

Therapeuatic mag: 4-7
Respiratory paralysis: 13-15

*Give calcium if sufficiently concerned for mag tox in mom (PEA arrest) or baby
*May see wide QRS on EKG

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4
Q

5Hs, 5Ts

A

-Hypoxia
-Hypothermia
-Hacidosis
-Hypo/hyperklaemia
-Hypovolemia

Tamponade
Tension PTX
Toxin
PE
MI

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5
Q

Are you concerned about a neonate airway…

A

Yes, you can do an awake fiberoptic

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6
Q

Beckwith-Widemann

A

Big baby with big tongue…anticipate difficult airway

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7
Q

Retinopathy of prematurity…until when

A

44 weeks gestation…O2 sat 90-95% is fine

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8
Q

Foot pulse ox reading lower…ddx

A

-R to L shunt
-Aortic coaractation
-Increased intraabdominal pressure

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9
Q

Duchenne muscular dystrophy

(anesthesia considerations)

A

-Cardiac Issues
-Lung issues including pulm HTN
No volatile or succinylcholine…risk of life-threatening hyperkalemia/rhabdo

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10
Q

Cobb Angle

A

-A measure of scoliosis severity
-Greater 60 degrees: think restrictive lung disease/pulm HTN

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11
Q

Aspiration cocktail

A

Famotidine + Reglan + Bicitra (non-particulate antacid)

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12
Q

Prone positioning…precautions

A

-Head neutral
-Eyes and ears free of presure
-Arms not abducted more than 90 degrees (to avoid brachial plexus injury)
-Ulnar nerve padding

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13
Q

EMG

A

Should do to monitor for peripheral nerve injury

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14
Q

Child with cough…delay the nonemergent case?

A

Yes
2-4 weeks if mild sxs
4-6 weeks if more severe sxs

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15
Q

LMA vs ETT

A

LMA: cannot paralyze, not protected airway, less effective in delivering positive pressure, may unseat

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16
Q

MMR (muscle masseter rigidity)

A

-Cancel case
-Monitor for s/s MH (hyperthermia, elevated PaCO2, electrolyte deranagements, rhabdo)

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17
Q

MH precautions

A

-Disengage vaporizers/remove succincylcholine
-Change out circuit and CO2 absorbent
-Flush the machine with O2
-Dantrolene avaiable

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18
Q

MH management

A

-Dantrolene (2.5mg/kg q5-10 min per sxs)
-Cool the patient
-Electrolyte management
…
Must cont IV dantrolene for 24-48 hrs to prevent relapse

How does dantrolene work? blocks the release of calcium from muscle

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19
Q

Cervical spine injury..can’t move/can’t breathe

A

Injury above C6….

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20
Q

How many PVC/min is concerning

A

> 6 PVC/min

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21
Q

Spinal shock

A

-Typical lasts for 1-3 weeks after injury
-Expect paralysis, bowel/bladder dysfxn below the level of injury

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22
Q

Elective noncardiac surgery after intervention..

A

Balloon: 14 days
BMS: 1 months
DES: 6 months, maybe 3 months

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23
Q

Autonomic hyperreflexia

A

Lesion above T7
S/s: Hypertension, reflex bradycardia

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24
Q

COPD: PFTs

A

-FEV1/FVC <70% is diagnostic
<50% is severe

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25
Q

Smoking cessation: ideal timing

A

8 weeks
-Improves airway hyperreactivity and sputum production

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26
Q

Issues with giving unnecessary bicarb…

A

-sodium load
-hypokalemia
-shift oxy-hemoglobin curve left

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27
Q

Most common cause of post-op vision loss

A

PION (posterior ischemic optic neuropathy) …painless vision loss within 24-48 hrs

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28
Q

Down syndrome considerations

A

Airway: cranio-cervical instability, subglottic stenosis, macroglossia
Cardiac: defects
Pulm: OSA (think big tongue)

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29
Q

Can you dart the patient…

A

IM ketamine (5mg/kg)
or IM precedex (2mcg/kg)
or IM midazolam (0.1mg/kg)

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30
Q

WPW…stable…

A

Orthodromic:
Esmolol/amio is fine
(looks like SVT)

Antidromic:
Or Orthodromic with AFfib
*Procanimide only
(looks like VT)

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31
Q

Elevated PTT ddx

A

VWD, Hemophilia

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32
Q

Hemophilia A vs B

A

A: factor 8 deficiency…85% cases
B: factor 9 deficiency…14% cases

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33
Q

DDAVP…txt for

A

Hemophilia A and VWD….increases VWF and Factor 8

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34
Q

Who not to deep extubate…

A

Obesity/OSA
Difficult airway
Bloody secretions in airway…
Full stomach

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35
Q

Stress dose steroids…

A

Hydrocort 100mg, then Hydrocort 50 q6hr

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36
Q

Burn and inhalational injury

A

Signs of inhalational injury: burns to lip/mouth, sooth in the mouth, stridor….

If there is any sign of inhalational injury OR major burns in general…intubate urgently

Otherwise should do serial airway exams for 24 hrs with fiberoptic scope

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37
Q

Burns rule of 9

A

Each arm: 9%
Torso: 36%
Each leg: 18%
Head: 9%
***
In kids, HEADS are bigger (18%), legs are smaller.(9%)..

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38
Q

Burn shock

A

Basically, severe hypovolemic shock

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39
Q

Parkland formula

A

4 x kg x BSA
-Half in the first 8hrs after injury
-The rest in the following 16 hrs hrs after injury

*
In kids, 3 x kg x BSA

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40
Q

Inhalation injury…

A

Have to think about carbon monoxide poisoning, cyanide poisoning

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41
Q

Carbon Monoxide Posioning Txt

A

-100% FiO2
-Hyperbaric oxygen if CO-hg level >25%

Pulse ox and PaO2 will be nl
O2 sat on ABG will not (since less heme binding sites will be bound by oxygen)

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42
Q

Where to monitor temp

A

Esophagus, nasopharynx, bladder

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43
Q

Jet ventilator

A

Can jet ventilate through cook catheter (don’t advance cook catheter too far), or supraglottic

Risk of supraglottic: gastric distension, aspiration, rupture

Risk in general: PTX (avoid in severe COPD), inadequate gas excahgne (hypoxia, hypercarbia)

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44
Q

MH, distinsiguish features

A

-Extreme rigidity
-Hypercarbia

(vs NMS vs SSS)

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45
Q

Cola-colored urine ddx

A

Rhabdo…
Acute hemolytic trf rxn (from ABO incompatibility)

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46
Q

TAAA repair…features

A

-OLV to facilitiate surgical access by left thoracotomy
-Sometimes LHB for distal aortic perfusion
-Hypothermia for spinal cord protection
-Lumbar drain
-Epidural

**
Med managment:
-Strict HR and BP control

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47
Q

PFTs suggesting need for postop ventilation

A

-FEV1 <2L
-MMEFR (maximal mid expiratory flow rate)<50%

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48
Q

TAAA monitors

A

Right radial Aline
Femoral Aline (+/-)…LHB
TEE
Belmont
Lumbar drain
*some add SSEP/MEP (but then need 0.5 MAC gas)

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49
Q

Cross-clamp applied..signals decreased

A

-Release cross-clamp
-Check ABG
-Drain from lumbar drain
-Fluid load, vasopressor….maintain euvolemia
-LHB (increase flows), create shunt, reimplant arteries to perfuse vital organs
-Hypothermia

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50
Q

Spinal cord blood supply

A

-Anterior spinal artery, single supply of anterior spinal cord
-2 posterior spinal arteries suplying posterior spinal cord (sensory)

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51
Q

Hypotension after cross-clamp release

A

/-Reapply clamp, release more slowly next time
-Fluid load, pressor
-TEE/PA cahteter to guide…r/o ischemia
-Send ABG
-Decrease anesthesia depth

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52
Q

Parameters for Extubation

A

TV>6cc/kg
VC>10cc/kg
NIF>20
RR<30
O2sat>90%, on FiO2 50%, PEEP 5-8
Neg cuff leak

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53
Q

Leg weakness post-TAAA ddx

A

-Is this epidural hematoma, spinal cord ischemia, inadvertent intrathecal infusion

*
Get imaging, drive up BP, drain CSF

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54
Q

How does cross-clamp drive spinal cord ischemia

A

-Drop blood flow to spinal cord
-May increase CSF pressure

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55
Q

DeBakey classification of TAAA

A

Type 1: ascending aorta and beyond
Type 2: ascending aorta only
Type 3: distal to left subclavian…

*Type 1 and 2 are surgical emergencies
*Type 3 is medical

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56
Q

HD changes with cross-clamp

A

Pre: increased afterload, decrease CO, increase filling pressures
Post: decreased preload

-Try to maintain MAP>100 above, MAP>50 below (only applies if you are doing LHB)

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57
Q

EVAR vs Open Aneurysm Repair Outcomes

A

EVAR outcomes better in short-term, likely worse in the long-term

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58
Q

EVAR vs open repair….difrences

A

-No cross-clamp
-No epidural
-No one-lung ventilation
-1 A-line (ideally in RUE…may manipulate left subclavian)
*
Yes, consider lumbar drain

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59
Q

What is aneurysm vs dissection

A

Aneurysm: involves dilation of all 3 layers of aorta
Dissection: involves tear in intima, resulting in false tract of blood flow

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60
Q

EVAR complications

A

Same as open procedure
+Endoleak (blood leaks through stent graft into the aneurysmal sac)

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61
Q

Aortic Dissection: Goal BP/HR

A

HR<65
SBP<110

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62
Q

Sodium Nitroprusside toxicity

A

Think: cyanide toxicity (prevent cells from using O2)…give Vitamin B12

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63
Q

Cross-clamp and renal protection for OPEN REPAIR

A

-Ideally, cross-clamp should be infrarenal, minimize cross-clamp time…but infrafrenal cross-clamp is no guarantee against AKI
-Mannitol, lasix before cross-clamp
-Shunt blood to distal aorta
-Reimplant arteries

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64
Q

EVAR spinal cord protection strategies

A

-SSEP/MEPs (0.5 MAC of gas)
-Lumbar drain
-Reimplanting critical intercostal arteries

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65
Q

Why might you give adenosine during EVAR…

A

To create a hemodynamically still field for stent/graft deployment

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66
Q

Cross-clamp is about to be released…what do you do

A

-Come down on gas
-Fluid bolus
-Vasopressor
-Use PA cathter and TEE to ensure euvolemia
-Reapply clamp and gradually release

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67
Q

Airway exam

A

Mouth opening
Mallampati
Jaw protrusion
ROM
Large tongue
Short neck, thick neck?

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68
Q

Cerebral Aneurysm Monitors

A

Aline
SSEP, EEG

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69
Q

Hunt and Hess

A

Grades severity of non-traumatic SAH

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70
Q

Before clip placement for cerebral aneurysm….

A

Surgeron may request deliberate hypotension..

With temporary clip placement, may request hypertension to support collateral blood flow…may also request burst suppression

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71
Q

Brain relaxation techniques

A

-HOB up
-Low PEEP
-Hyperventilate
-Steroid
-Lasix/mannitol/hypertonic saline
-TIVA
-Lumbar drain

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72
Q

Which is higher, PaCO2 or EtCO2…

A

ALWAYS PaCO2, 2/2 dead space ventilation

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73
Q

How to treat cerebral vasospasm?

A

-Supportive care
-Normovolemia
-Drive up pressure
-Intraarterial CCB

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74
Q

SAH complications

A

First 24 hrs: rebleed
Next 2-14 days: vasospasm watch

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75
Q

Causes of low sodium in NSG

A

-SIADH vs cerebral salt wasting

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76
Q

Neonatal TEF patient…in respiratory distress…what to do

A

-Stop mask ventilation…you are insufflating the stomach
-Cuffed ETT (distal to fistula, proximal to the carina)
-G tube
-Maybe fogarty catheter to seal off fistula

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77
Q

Types of TEF fistulas…

A

Type A: estophageal atresia, no fistula
Type B: esophageal atresia, proximal fistula
Type C: esophageal atresia, distal fistula (most common)
Type D: esophageal atresia, both proximal and distal fistula
Type E: no atresia, single esophagus, single fistula

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78
Q

Prematurity Neonate Concerns (ie before 37 weeeks)

A

Neuro: IVH, reintopathy of the newborn
Cardiac: defects
Pulm: insufficiency (RDS)
GI: necrotizing enterocolitis
GU: reduced renal fxn
MSK: susceptibel to hypothermia

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79
Q

Preop optimization for TEF

A

Think VACTERL
-Spinal films (for caudal anesthesia
-ECHO for cardiac anomalies
-Renal u/s for renal anomalies

Other:

Fluids given likely poor PO intake

Continous suctioning of esophagus to minimize aspiration risk

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80
Q

What TEF monitors?

A

-Aline (anywhere)
-Precordial stethoscope (listen over left chest, stomach)
-Consider central line for CVP monitoring

Other:
**-Plan for caudal anesthesia for post-op pain

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81
Q

How to induce and intubate

A

RSI..continous suctioning beforehand…bronchoscope to guide placement

or awake intubation (however may be difficult, risk of sympathetic response and IVH)

Inhalation induction without paralytic…risk of aspiration…however, spontaneous ventilation minimizes gastric distension

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82
Q

What size ETT for TEF…

A

3.0 cuffed…

How to place ETT tube? Bronchoscope, vs right mainstem and pull back

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83
Q

TEF patient desats

A

Check ETT with bronchoscopy…

Is G tube venting?

–
Could also be surgical compression of heart/great vessels…PTX/atelectasis

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84
Q

Intraop neonatal fluid managment

A

4-2-1 for maintainance: D51/2 NS
Bolus with isotonic
HCT>35

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85
Q

Would you extubate TEF patient?

A

No, high-risk for reintubation, protect suture lines, avoid aspiration

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86
Q

Neonatal extubation critiera

A

TV 6cc/kg
RR 30-40
O2 sat 90%, 50% FiO2, PEEP 5
Awake, reflexes intact

AVOID RETINOPATHY

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87
Q

Neonatal vent settings

A

-O2 sat >90% (no hyperoxia)
-RR 30-40
-PIP <25

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88
Q

TEF complications

A

-GERD
-Anastaomotic leak
-Tracheomalacia
-Recurrence

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89
Q

Neonatal vitals

A

HR: 120-160
BP: 80 and 60/30
O2 sat: 95% in newborn, 90% in premies
RR: 40-60

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90
Q

Fetal circulation

A

Ductus venosus (bypasses liver)
Foramen ovale (RA to LA)
Ductus arteriosus (Pulmonary Artery to aorta)

With first breath of life, PVR drops, facilitating closure of DA

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91
Q

Tetralogy of Fallot…4 features

Goal O2 sat

A

-RVH
-Pulmonary stenosis
-VSD
-Overriding aorta

Pre surgery: 75-80%
Post surgery: 90%

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92
Q

Tetralogy of Fallot…how to induce

A

Slow controlled IV induction…less control with mask induction (could overly reduce SVR)

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93
Q

Nitrous oxide and kids

A

-Can increased ICP
-Can increase PVR (bad in RTL shunt)

*
Why do we use? It is fast and odorless

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94
Q

CDH

A

Diaphragram fails to form…
Causing pulmonary hypoplasia and pulm HTN…assume RTL shunt until proven otherwise

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95
Q

Med management CDH

A

Intubate early on to control ventilation…
-Lung protective ventilation
-Permissive hypercapnia

*
Ventilatory goals:
**-Goal O2 sat, preductal 85%
**-PIP <25
-pH>7.25

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96
Q

How to intubate CDH…

A

RSI vs awake fiberoptic…do not want to insufflate stomach and worsen gastric distension

If still hypoxic…gotta think RTL shunt from pulm HTN…correct the usual/increase afterload (vasopressin)/pulm vasodilators…ECMO

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97
Q

CDH monitors

A

-Central line (umbilical vein, in case need ECMO…for fluid shift management)
-R Aline
-Preductal and postductal O2 sat (R arm and L foot)
-Precordial stethoscope over R chest

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98
Q

CDH: cause of hypoxia

A

-R to L shuting worse
-Atelectasis
-Pulmonary hypoplasia

**
What is HFOV:
Lung-protective ventilation involving high frequency, low TVs…risk

**
These patient may need ECMO, consider placing umbilival central line

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99
Q

Would you extubate CDH patient?

A

No…high risk for cardio-pulm complications, shunting, PTX, etc….

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100
Q

ACLS for pregnant patient

A

The same except:
-Maintain left uterine displacement
-stop magnesium infusion, give calcium to reverse
-If no ROSC after 4 minutes, proceed with C section

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101
Q

OB considerations

A

-Decreased FRC
-Lower MAC requirement
-Opioids and benzos ok
-Never NSAIDS…NO TORADOL
-Reverse with sugammadex, otherwise neostigmine and atropine (glyco does not cross)
-Maintain left uterine displacement (starting 2nd trimester)
-Full stomach
-If viable…have OB and neonatal team available
-if pre-viable, check uterine contraction/FHR before and after

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102
Q

Drugs that do not cross the placenta

A

Heparin
Insulin
Nondepolarizing
Glycopyrrolate
Succinylcholine

(HE IS NOT GOING SOON)

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103
Q

When to monitor uterine contractions and FHR intratop?

A

At viability (24 weeks)

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104
Q

Pneumoperitoneum complications…

A

-RIght mainsteam intubation
-PTX
-Capnothorax (CO2 hemothorax)->EtCO2 elevated

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105
Q

ECT physiology/contraindications

A

Physiology: parasympathatetic followed by sympathetic surge

Absoluate contraindications:
Recent MI/stroke, Elevated ICP, intracranial mass

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106
Q

Anesthesia for ECT

A

-Induce (prop/etomidate/methohexital)
-Paralyze to minimize harm of seizure
-Hyperventilate to prolong seizure

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107
Q

Thoracic preanesthetic assessment…

A

Must review imaging studies, lookg for possible mass effect

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108
Q

Thoracic PFTs…predictors of badness

A

FEV1<30%
DLCO<40%
VO2 max <10cc/kg/min
***
Consider leaving intubated with any of these

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109
Q

Thoracic primer: complications

A

-Cardiac herniation
-PTX
-Broncho-pleural fistula
-RHF (2/2 chronic hypoxia, pHTN)
-Post-op afib (from stress of surgery, fluids, manipulation of the heart)

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110
Q

L-sided DLT for Left Lung surgery…can you do?

A

Discuss with surgeon…
-Could injure bronchial stump following closure with inadvertent advancement of DLT
-Significant left bronchial involvement may preclude L DLT placement….would need to place R-side DLT or bronchial blocker

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111
Q

OLV desaturation

A

-100% FiO2
-Confirm placement
-PEEP to dependent lung
-CPAP or blow-by O2 to the non-dependent
-Pulmonary artery clamping to non-dependent lung
-Switch back to 2-lung ventilation

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111
Q

Thoracic case, maintenance plan

A

Either gas or TIVA is fine…but MAC>1 inhibits hypoxic pulm vasoconstriction

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112
Q

After thoracic surgery, blood pressure drops…don’t miss…?

A

Cardiac herniation
**Immediate txt: shift the patient such that non-operative side is down…can help return heart into pericardial sac…must ultimately reopen chest…put heart back into pericardium…close the defect…

50% mortality rate 2/2 incomplete closure of pericardium…sxs appear within 24 hrs..right-sided defect presents with obstruction of venous return….left-sided with MI and arrhythmias…

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113
Q

4 Absolute indications for OLV

A

-To prevent contamination of a healthy lung
-To control ventilation distribution (bp fistula)
-For VATS surgery
-To facilitate single lung lavage (cystic fibrosis)

-
Relative indications:
TAAA
Esophagectomy
Pneumonectomy

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114
Q

DLT, do you switch to SLT at the end of the case

A

Yes
Less bulky->less edema and risk of mucosal ischemia

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115
Q

Throacic pain plan: best…

A

1: EPIDURAL

Paravertebral block

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116
Q

Advantage of DLT over bronchial blocker

A

-Less likely to dislodge
-Able to suction operative lung

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117
Q

Transplant heart…spinal or epidural?

A

Would do epidural…
Transplanted heart is preload-dependent…may not tolerate abrupt drop in preload with rapid sympathectomy
Hence, for pregnant patient…would slowly raise level with epidural

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118
Q

Transplanted heart…tell me about drugs…

A

Parasympathetic denervation…hence, less minimal response to glyco, atropine…also less response to indirect actors of sympthateic nervous system (including ephedrine)

*
Should I give glyco with neostigmine…yes, there is some cardiac reinnervation over time….also want to reverse the other muscarinic effects

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119
Q

Why 3-6 months for DAPT for DES vs BMS?

A

The drugs inhibit endothelialization…this means less restenosis in the long run…however in short-run there is risk of rethrombosis

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120
Q

How to long to wash out Aspirin? Plavix?

A

Aspirin 10 days
Plavix 7 days
*In general, should continue aspirin…exception: neurosurgery….bleeding into brain/spine could be catastrophic

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121
Q

Laparoscopic surgery and hypotension…ddx

A

-Vagal response
-Tension PTX
-Capnothorax
-Mainstem intubation
-CO2 embolus

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122
Q

Anaphylaxis vs Anaphylactoid rxn

A

Anaphylaxis: IgE mediated…requires prior exposure to antigen

Anaphylactoid rxn: non-IgE mediated…mast cell degranulates 2/2 direct interaction….

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123
Q

Anaphylaxis txt

A

-Fluid
-Pressor
-Epinephrine, mag, albuterol (think bronchospasm)
-Steroid, H2 bloker

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124
Q

Esophagectomy…pain control plan…even for minimally invasive eophagectomy…

A

EPIDURAL

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125
Q

Esophagectomy: unique risks

A

Blunt dissection is blind…
Injury to heart, lungs, airway, great vessels

*Must protect newly constructed gastric tube:
avoid hypotension, fluids over pressor per some

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126
Q

OLV is often required for esophagectomy via thoracic approach…What are your OLV ventilation goals?

A

4-6 cc/kg TVs
PEEP 5-10
PPlt <25

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127
Q

T&S vs T&C

A

T&S…blood is selected based on screening for antibodies

T&C…blood actually selected for patient is screened for final confirmation of compatibility…

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128
Q

Cell saver in cancer patient…

A

Many say no…risk of metatsis of tumor cells…maybe even after washing…

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129
Q

Cell Saver…complications

A

This is just pRBC…can result in coagulopathy

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130
Q

CRPS Type 1 vs Type 2

A

Type 1: negative for definite nerve injury…90% of cases

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131
Q

ESOPHAGECTOMY: 1- thoraic epidural 2- OLV

A

May have more issues with ventilation/oxygention with OLV compared to lung resection cases…
*The diseased lung requiring lung resection usually has baseline diminished blood flow…so less V/Q mismatch to start

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132
Q

High risk aspiration concent

A

Low pH, high volume

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133
Q

Myasthenia gravis

-Etiology?
-Edrophonium?
-What condition?
-What drugs to avoid?

A

-Etiology: autoimmune destruction of postsynaptic ACh receptors
-Edrophonium..rapid-acting but works like pyridostigmine…if myasthenic crisis, will fix quickly…if cholinergic crisis…will worsen
-Thymoma
-Avoid glyco/atropine (anticholinergic effect not ideal)
-Other: “RS”…use half dose of rocuronium

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134
Q

Protamine rxn

A

Type 1: Hypotension (histamine-related) from rapid administration
Type 2: Anaphylaxis (IgE mediated)
Type 3: Pulm HTN crisis (IgG/complement)…supposedly dose-dependent, maybe less risk with lower dose of protamine

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135
Q

Protamine: Type 3 rxn

A

Supportive care
Epinephrine
Pulm vasodilator
Reheparinize, go back on bypasss

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136
Q

How to prevent airway fire?

A

-Laser-resistant ETT
-Inflate cuff with saline
-Low FiO2

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137
Q

OSA vs Obesity Hypoventilation Syndrome

A

OSA: hypoventilation during sleep, but will often hyperventilate between apnea episodes..often obesity related, not always

Obesity hypoventilation syndrome: hypoventilate including during the day…often don’t hyperventilate…always obesity related

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138
Q

Crichothyrotomy

A

-Incision through cricothyroid membrane

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139
Q

Respiratory distress syndrome of the newborn

A

In premies (before 37 weeks)
2/2 undeveloped lungs

Txt: maternal steroids while in utero, exogenous surfactant

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140
Q

Is PDA LTR or RTL shunt, normally

*Murmur

A

LTR

*Continuous murmur

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141
Q

Premie considerations

A

Neuro: IVH, retinopathy of prematuirty
Cards: cardiac anomalies,
Pulm: respiratory insufficency, RDS, postop apnea
GI: necrotizing enterocolitis
GU: AKI
MSK: hypothermia
Endocrine: Hypoglycemia

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142
Q

Ligation of PDA complications…

A

Bleeding
Nerve injury (vagus, recurrent laryngeal nerve)
Fluid shifts, left heart failure, pulm hypertensive crisis

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143
Q

Ligation of PDA-monitors

A

R Radial A line
Central line
Precordial stethoscope
Pre and postductal O2 sat

*
Goal O2 sat: 90%

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144
Q

Ligation of PDA…how to maintain anesthesia…

A

Low dose gas (0.2-0.3 MAC gas), remi gtt, some fentanyl/dilaudid at end of case

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145
Q

When to maintain PDA?

A

Ductal dependent lesions (eg hypoplastic left heart syndrome)

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146
Q

Sick premie goal HCT…

A

HCT>35…

Why? (Fetal Hgb causes leftward shift of oxygen-hemoglobin dissociation curve)

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147
Q

How do infants maintain temperature?

A

Nonshivering thermogenesis via brown fat metabolism….

Neonates have mimimal brown fat stores…must take care to warm them

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148
Q

Pheochromocytoma: anesthesia plan

A

-Get them deep with induction..consider remi gtt
-Have antihypertensivies: nicardipine gtt, nitroglycerin…
-Have uppers as well, including vaso
-Avoid morphine (may cause histamine release)
-Magnesium is great…may decrease catecholamien release

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149
Q

Pheochromocytoma: med optimiziation

A

Alpha blockade 10 days prior
Then add beta blocker
(Avoid unopposed alpha receptor stimulation)

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150
Q

Robotic surgery precautions…

A

-Keep paralyzed…don’t want patient to injure themselves while instruments are in the boody
-Pad the patient, to protect from robotic arms

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151
Q

Hypercarbia from pneumoperitoneum…ddx

A

-May be normal…CO2 being absorbed into the bloodstream->increase ventilation
-But must rule out CO2 capnothoroax

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152
Q

Subcutaneous emphyema with abdominal insufflation…

A

-Must rule out capnothorax/pneumothorax
-Surgeon should use lower insufflation pressure
-Raises concern for laryngeal edema->delay extubation until hypercapnia resolves, +cuff leak

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153
Q

CKD…which drugs to be careful with

A

Morphine, meperidine, **benzos (use lower dose) **

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154
Q

How to treat HyperKalemia

A

Insulin, Calcium

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155
Q

Sniffing position

A

Aligns the tragus of the ear with the sternal notch
*consider placing shoulder roll, head rest

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156
Q

Resusciation, colloids vs crystalloid

A

Crystalloid 3:1, Colloid 1:1

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157
Q

What does VWF do?

A

Mediates platelet aggregation, stabilized Factor 8

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158
Q

VWD disease…most common type

A

Type 1: mild

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159
Q

Management of undifferentiated VWF

A

Prepare for bleeding…
Plan to give DDAVP (stimulates release of VWF), FFP, cryoprecipitate, HUMATE P (vWF-Factor 8 concentrate)

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160
Q

DDAVP and VWD

A

DDAVP stimulates the release of vWF…

Side effect: hyponatremia

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161
Q

MAC gas and CBF

A

MAC >1, increased CBF
MAC <1, no effect on CBF

*
Inhaled gas always reduces CMRO2

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162
Q

Sitting crani…exclusion criteria

A

MUST get ECHO to rule out PFO…

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163
Q

Infective endocarditis ppx

A

Think: oral and respiratory procedures

*Amoxicillin is abx of chocie

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164
Q

Sitting crani…monitors

A

A line (transducer at the level of tragus)
Central line
TEE
Precordial Doppler
EEG, SSEP, MEP, EMG

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165
Q

Induction for elevated ICP

A

RSI is the preferred method:
Etomidate, roc, lidocaine, high-dose fent

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166
Q

Neuro patient…deep extubate?

A

Never
Wide awake, following commands, confirm no new neuro deficit

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167
Q

Tension pneumocephalus…what is it

A

Air accumulates, causing mass effect
Hence, never use nitrous

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168
Q

Posterior fossa crani…

A

Specific concern: post-op swelling causing impingement on cardiac/respiratory centers

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169
Q

Sitting position precautions…

A

-Neutral neck
-Avoid hip flexion greater than 90 degrees
-Pad pressure points

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170
Q

Laryngeal papillomatosis…remember they use a laser

A

*they use a laser for debulking/surgical excision

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171
Q

Laryngospasm management

A

-Jaw thrust +Larson’s maneuver (firm pressure behind the earlobes)
-Positive pressure
-Deepen anesthetic + lV idocaine
-paralyze

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172
Q

MH inheritance

A

Autosomal dominant…

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173
Q

Caffeine Halothane Test

A

Kid must be older than 7…if they can’t be tested, can test family member

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174
Q

Laryngeal papillomatosis airway management

A

-ETT (oral vs nasal)
-Intermittent apnea (mask up, surgeon works quickly, TIVA)
-Jet ventilation

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175
Q

Desaturation with jet ventilation…ddx

A

-Inappropriately aligned
-Inadequate ventilation (increase jet pressure)

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176
Q

SCD: why take hydroxyurea

A

Increases the amount of Fetal Hgb, thereby decreasing the amount of HgbS sickling

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177
Q

SCD: types of Hemoglobin

A

80-90%, HgbS
Normal people have HgbA

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178
Q

Preop eval of SCD patient

A

Any recent vaso-occlusive crises…MI / renal infarct/ stroke /acute chest syndrome

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179
Q

Acute chest syndrome: management

A

What is it? Vaso-occlusive crisis of the pulmonary vasculature

Abx (superimposed PNA), simple transfusion to correct anemia, exchange transfusion …

Goal of exchange transfusion is to refuse Hgb S to 30-40% (from 80-90%)

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180
Q

Hgb goal for major surgery in SCD

A

Goal of ~30
Def Type &C blood given difficulty of obtaining compatible blood

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181
Q

Precipitants of sickle cell crisis

A

-Hypoxia
-Hypotension
-Hypothermia
-Acidosis
-Pain/anxiety

182
Q

Sympathetectomy in preeclamptic patient

A

They are intravascularly deplete…may not tolerate super well…fluid replete before attempting

183
Q

OB patient..mom is seizing post delivery…ddx

A

-Eclampic seizure
-AFE (hypoxia, hypotension/RVF failure, AMS, DIC)
-LAST from epidural

184
Q

SCD post-op pain after OB

A

High risk for pain…need to treat to avoid vaso-occlusive crisis…low threshold to split epidural, start PCA

185
Q

Lung Mass H&P

A

Must consider:
-Airway compression
-Compression of the heart and great vessels (if SVC compression, must get LE IV acecess)
-SVC compression may lead to airway edema, may be best to attempt AFOI

186
Q

Lambert Eaton

A

Associated with lung cancer
Sensitive to both roc and sux
May develop respiratory failure after anesthesia

187
Q

Mediastinoscopy Complications

A

-Brachiocephalic compression (consider R brain stroke)
-Recurrent laryngeal nerve injury->would need to be bilateral for airway obstruction
-PTX
-Hemorrhage->would need DLT for thoracotomy, or just sternotomy

188
Q

Contraindications to mediastinoscopy

A

Absolute: prior mediastinoscopy
Relative: thoracic aorta aneurysm

189
Q

Mediastinoscopy monitors

A

RUE pulse ox (to monitor for brachial compression)
L UE A-line or femoral A line

190
Q

Patient is HYPERTENSIVE…elective procedure

A

Ok to delay for 6-8 weeks

191
Q

Meds to hold before surgery

A

Day before: ace, arb, lasix
3 days before: SGLT inhibitors (can cause euglycemic ketoacidosis)

192
Q

SVC Syndrome: anesthesia consideration

A

-Airway: edema (consider awake fiberoptic)
-Consider lower extremity IV access

193
Q

Cystic Fibrosis…Organ involvement

A

Respiratory: Obstructive lung disease (bronchiectasis) (obstructive lung disease), PTX
GI: Diabetes and Vitamin K deficiency (pancreas involvement)
Heme: Coagulopathy

*
Newborn may develop meconium ileus

194
Q

Obstructive vs Restrictive Lung Disease: PFTs

A

Obstructive: FEV/FVC reduced, TLC increased
Restrictive: FEV/FVC nl to increased, TLC decreased

195
Q

Cystic pathophysiology

A

-Autosomal recessive
-Defect in ion channel regulating movement of Na and Cl->results in thick secretions (pulmonary, pancreas, GI)

196
Q

Cystic Fibrosis Txt

A

Pulm: Chest PT, mucolytic, abx
GI: insulin, Vitamin K supplementation

197
Q

Cystic fibrosis, appendectomy…do this under regional?

A

Advantage: avoid airway manipulation
Disadantage: with preexist lung dysfxn, may not tolerate given the high level of neuraxial level blockade required

198
Q

Cystic Fibrosis: high airway pressures…ddx

A

-mucus plugging
-PTX (ruptured bullae)

199
Q

Emergence Delirium

A

Appears in kids 1-5 yo
Inconsolable, unable to recognize surroundings
Txt: precedex, prop, midaz

200
Q

Acute dystonic. rxn from reglan…txt

A

-Diphenhydramine, benztropine

201
Q

Carotid Endarterectomy: Major Concern

A

Stroke, MI

202
Q

Carotid Endarectomy…anesthetic approach

A

Ideally, done under regional…would allow for the continuous neuro assessment of an awake patient

*speech, consciousness, contrallateral hand grip

203
Q

Carotid Endarterectomy: what type of regional anesthesia?

Risks:

A

Superficial and deep cervical block
***
Risks of deep cervical block:
-phrenic nerve paralysis, recurrent laryngeal nerve block
-Intravascular injection (vertebral arteries)
-Epidural or intrathecal injection
-Horner’s syndrome (miosis, ptosis, anhyidrosis)

204
Q

Why is hypercarbia bad in someone with cerebral ischemia?

A

May shunt blood away to well-perfused areas due to vasodilation of non-ischemci vasculature

205
Q

Carotid endarterectomy: Monitors

A

Aline
If asleep: EEG, SSEP, cerebral oximeter
If sick cardiac patient, consider femoral central line, to avoid obstructing venous return from brain

206
Q

Carotid endarterectomy: if asleep….for maintainance

A

Consider a remifentanil gtt for smooth wake up

207
Q

Carotid endarterectomy:
Carotid sinus
vs Carotid Body

A

Carotid Sinus: regulates BP/HR…can see reflex brady 2/2 surgical manipulation

Carotid body: regulates respiration (response to hypoxia, hypercarbia)

208
Q

Carotid Endarterectomy: EEG changes…

A

Ask surgeon to release clamp
Consider driving up MAP (not more than 20%)
Correct anemia, hypocarbia, etc

209
Q

Carotid Endarterectomy, post-op complications

A

-Neck hematoma
-HD lability 2/2 carotid sinus manipulation
-Impaired ventilatory response 2/2 carotid body manipulation
-Cerebral hyperperfusion syndrome (vasculature has lost ability to autoregulate blood flow, increased blood flow following stenosis reveresal results in edema/bleeding)…txt: avoid HTN!

210
Q

Can you use a temporary dilaysis catheter in a pinch for pressors/etc…

A

Yes
Aspirate before use, re-heparing the line after

211
Q

What type of block for AV fistula?

A

Supraclav block (for distal humerus and beyond)

*Don’t forget to check CBC/coags before attempt block

Risks:
PTX
Phrenic nerve paralysis

212
Q

When to give neosigmine, how many twitches

A

Ideally 4 twitches, but can after give after 2 twitches

213
Q

Pituitary Tumor, H&P

A

-Any neuro deficits
-Is the tumor secretory?
GH->Acromegaly
ACTH->Cushing

214
Q

Acromegaly, anesthesia considerations

A

Difficult mask, Difficult intubation
-Large tongue, tracheal stenosis
-Cardiomyopathy, HF
-OSA

215
Q

PDPH, sign and symptoms

A

Positional headache (worse sitting up)
Photophobia
N/V

Etiology:
Loss of CSF, causes loss of bouyant support of the brain

216
Q

SLE and seizure in pregnant woman

A

Is this embolic stroke? Eclampsia?

SLE is ofen associated with hypercoaguable state (both venous and arterial thrombosis)

217
Q

Autonomic hyperreflexia…
What is it?
Management?

A

-Occurs with spinal cord lesions T7 and above
-Noxious stimuli results in sympathetic discharge (cannot be inhibited by higher CNS center) with hypertension and bradycardia

Management:
-Stop surgical stimulus, empty bladder
-Deepen sedation
-Antihypertensives

218
Q

FHR monitoring

What is nl HR?
What is nl variability?
What is early decels?

A

-Nl HR: 120-160
-Nl variability: 6-25 bpm..less could be a sign of fetal distress/acidosis/hypxoia
-Early decels…decel coincides with uterine contraction…benign

219
Q

Porphyria

What is it?
Why you care?
Txt?

A

-Accumulation of prophyrins 2/2 deficiency in heme synthesis pathway
-CP: abd pain, n/v
-Think: muscle weakness, respiratory failure
-Txt: fluids, oxygenate, hematin (inhibits porphyrin synthesis)

220
Q

Common tocolytic

A

Terbutaline, Ritodrine…both Beta-2 agonists

221
Q

Laryngectomy…

How to achieve airway prior to surgery?

What happens if trach comes out postop?

A

-Maybe AFOI (may be challening to achieve good airway topicalization…also, could injure vascular friable tumor)
-Otherwise, surgical airway under local anesthesia….

*
Try to reinsert with fiberoptic scope
Otherwise mask ventilate over stoma, place LMA through stoma
(Obvi can’t intubate or mask ventilate from above)

222
Q

Dyspnea in a 2yo…ddx (4)

A

-Foreign body aspiration
-Asthma
-URI (croup, epiglottitis)
-Anaphylaxis

223
Q

Foreign body aspiration, induction plan

A

Plan 1:
Inhaled induction…maintain spontaneous ventilation…ENT to place rigid bronchoscope (can ventilate through it)
(of course risk of laryngospasm/aspiration etc)

->would need TIVA for maintenance

Plan 2:
RSI…risk of pushing the foreign body distally, complicating retrieval…

224
Q

Foreign body aspiration…now cannot ventilate during retrieval…WTD?

A

-Either quickly remove or push past carina
-Modify patient position
-V-V ECMO

225
Q

Ischemic cardiomyopathy and pregnancy…vaginal delivery or C-section

A

Vaginal delivery whenever possible…less fluid shifts, blood loss, HD changes…with each uterine contraction, auto-tranfusion of 300-500cc of blood back into the circulation

When to favor C-section: aortic aneurysm, cerebral aneurysm, dissection

226
Q

Ischemic cardiomyopathy and epidural…tell more

A

Gentle sympathectomy…slowly raise the level of epidural to T4…no epinephine (or ketamine)

227
Q

Platelet cutoff for epidural

A

Per SOAP, >70k….with reassuring trend

228
Q

Ischemic cardiomyopathy and OB, what monitors

A

A line, Central Line, PA catheter

229
Q

Reversible causes of arrest…

A

5Hs:
-Hypoxia
-Hypovolemia
-Hyperkalemia/Hypokalemia
-Hacidosis
-Hypothermia

5Ts:
-Toxin
-Tension PTx
-Tamponade
-MI
-PE

230
Q

Cardiac Arrest in OB patient..ddx

A

AFE, LAST

231
Q

Stable monomorphic VT….med management

A

Adenosine, lidocaine, amio, mag

232
Q

Newborn SOB, ddx

A

-Transient tachypnea of newborn (retain fluid, benign)
-Meconium Aspiration
-Respiratory Distress Syndrome (premie, immature lungs)

Other:
-Mag tox
-Acute uteroplacental deficiency
-Hypoglcyemia
-Undiagnosed congential anomaly

233
Q

Patient has blurry vision, headache, rhinorrhea…ddx

A

Elevated ICP vs pituitary compression on the optic chiasm

234
Q

Pituitary adenoma…meds

A

Bromocriptine/octreodtide for acromegaly->inhibits GH

Bromocripine for prolactinoma->inhibits prolactin

235
Q

Diagnosis of Acromegaly

A

Serum IGF-1
Oral glucose load challenge

236
Q

Trasphenoid Pituitary Approach: monitors

A

-Aline (in close proximity to the interal carotid artery…risk of massive hemorrhage)
-Consider VEPs (if optic nerve compression, need TIVA)

**
Anytime surgical field is elevated above level of the heart…VAE risk

237
Q

Transphenoidal approach: unique anesthesia considerations

A

-No PPV (risk of pneumocephalus)…CSF leak especially increases risk
-No coughing/bucking
*
-TIVA wake up, lidocaine down the tube
-Surgeon can suture nasal trumpets to help with OSA

238
Q

Treatment of VAE

A

-Flood the field with saline
-Lower surgical field to level of the heart
-Maybe left lateral decubitus position

239
Q

Treatment of LAST

A

-20% Lipid emulsion (1.5cc/kg bolus, followed by infusion)…if CV instability persists, re-bolus and double infusion
-Benzos for seizure
-Lower dose epi (1mcg/kg to start)

240
Q

Transphenoidal Pituitary Surgery…unique post-op considerations

A

Refractory hypotension->2/2 decreased ACTH and cortisol

Diabetes insipidus->2/2 decreased ADH…treatment DDAVP

241
Q

JW what are they ok with…

A

Many are ok with derivatives…

Albumin
Factor concentrate (K centra)
Intraop cell saver
DDAVP, TXA

242
Q

Prolonged motor/sensory loss after epidural…

A

If beyond 24hrs,
unlikely to be anesthesia related…more likely obstetric in origin (positioning, nerve compression as the baby is delivered)

243
Q

Alternative to epidural anesthesia

A

-PCA: fentanyl, dilaudid, remifenantil
-Nitrous oxide
-Paracervical block in 1st stage (high risk for fetal bradycardia)
-Pudendal block in 2nd stage (pushing)

244
Q

Where can you place IO

A

Proximal tibia
Proximal humerus

245
Q

What is TRALI?

How to manage?

A

-Pulmonary edema developing within 1-6 hrs following blood transfusion (2/2 FFP, platelets
-Donor abs activaite recipient lung neutrophils, causing lung injury

How to manage?
-Notify blood bank: no more blood from that donor
-Supportive

246
Q

STOP-BANG

A

-Snoring
-Tired
-Observed apnea
-Blood pressure

**
-BMI
-Age
-Neck circumference
-Gender

247
Q

Obesity: FRC and closing capacity

A

-Decreased FRC (hence, rapid desaturation with apnea)
-Increased closing capacity (hence, more atelectasis/shunting)

–
Consider inducing with reverse trendelenburg to improve respiratory mechanics

248
Q

> 4 METS

A

-can climb a flight of stairs
-can walk on level ground at 4mph

249
Q

Propofol vs rocuronium (TBW vs IBW)

A

-Prop: induce per IBW, maintain per TBW
-Rocuronium: per TBW, maintain per TBW

250
Q

C-spine clearance

A

May need CT (first-line) and possibly MRI….MRI is more sensitive at detecting ligamentous injury

251
Q

FAST EXAM…looking for

A

-Tamponade
-Morrison pouch (liver-kidney)
-Perisplenic bleeding (Spleen and diaphgram)
-Suprapubic bleeding

252
Q

Abdominal compartment syndrome physiology

A

Decreases preload, lung compliance
Increase afterload (pressures are transmitted across the diaphgram)

*
Hence, with laparotomy, don’t be surprised by marked reduction in afterload

253
Q

Why is ok to give Rh+ blood to a man (who has not received a prior transfusion) rather than woman…

A

The risk of Rh sensitization in a man (eg delayed transfuion rxn) is much less than in a child-bearing female (hemolytic disease of the newborn, stillbirth)

254
Q

Do platelets and FFP have to be ABO compatible?

A

Yes, suspend in plasma, will have anti-A and anti-B abs

255
Q

Hypocalcemia, (citrate-tox), EKG

A

Look for prolonged QT on EKG

256
Q

PRIS (propofol-related infusion syndrome)

A

A life-thretening complication associated with rhabdo, cardiac collapse, death

257
Q

Carcinoid Syndrome

*diagnosis
*s/s

A

S/s: flushing, diarrhea, bronchospasm, hypotension

Diagnosis: Urine 5-HIAA, a serotonin metabolite

Tumor mostly releases serotonin, but also histamine

258
Q

Triggers of carcinoid crisis

A

-Hypovolemia, hypoxia
-Tumor manipulation
-Succinylcholine (possible histamine release)
-Adrenergic agents (epipnephrine, ephdrine)
*favor phenyl, vasopressin

259
Q

Treatment of carcinoid crisis:

A

-Ocreotide bolus, followed by infusion
-Bendaryl (H1 block) 25-50mg IV
-Fluid

260
Q

Carcinoid syndrome: most common heart lesion

A

-Tricuspid regrugitation
(pulmonary circulation degrade serotonin, left heart is relatively protected)

261
Q

Preop optimization for carcinoid syndrome

A

-Octreotide 2 days prior to surgery and continue a week out
-Fluids
-Albuterol nebulizer
-Minimize pain and anxiety

262
Q

Carcinoid crisis vs anaphylaxis

A

May present similarly…hypotension/bronchospasm

Who care? Epinephrine would worsen carcinoid crisis

263
Q

Nitrous oxide and bowel surgery

A

Avoid…will increase bowel distension (ischemia/perforation/n/v), could complicate closure

264
Q

Osteogenesis Imperfecta..workup

A

-Cervical spine imaging…or just assume instability
-TTE to r/o cardiac abrnoamlities

*
A collagen defect…results in brittle bones, teeth, blue sclerae

*
Consider intubating awake to minimize trauma vs RSI

*
Epidural placement is laboring woman is more high-risk

265
Q

Pyloric stenosis: electrolyte abnormalities

A

-Nonbilious projectile vomiting
-Hypochloremic, hypokalemic, hyponatremia metabolic alkalosis

266
Q

Preop management for Pyloric Stenosis

*When to proceed with surgery?

A

Fluid resuscitate with NS until euvolemic
Have dextrose-containing fluid running in the background for maintenance (also replete lytes)

*
This is a med emergency, not surgical one

Why NS? LR has lactate-can be converted to bicarbonate

When to proceed with surgery?
Appears euvolemic, pH 7.3-7.5, Bicarb <30

267
Q

Induction plan for Pyloric Stenosis

A

-RSI vs AFOI
-Must suction out stomach with baby in multiple positions

268
Q

Pyloric Stenosis Post-Op Conerns

A

-Postop apnea (possibly 2/2 persistent CSF alkalosis)

*newborns <60 weeks postconceptual age are at increased risk of postop anea

269
Q

Management of post-extubation stridor

A

-Steroids
-Humidified air
-Racemic epinephrine

270
Q

Circle Anesthetic System (what we use)

A

Advantage: preserves humidity, heat, volatile anesthetic…less dead space

Disadvtange: can rebreathe CO2 if failure of CO2 absorbent system

271
Q

Multiple Sclerosis: epidural and spinal

A

-Epidural and spinal should be ok…possibly slightly increased risk of MS flare with spinal

*
Def no succinylcholine

272
Q

Multiple Sclerosis Flares

A

Less common in pregnancy
Elevated risk post-partum, also post-op

273
Q

SEVERE AS…diagnosis

A

-Valve area under 1.0, transvalvular gradient >40 (subject to LV fxn, hemodynamics)

274
Q

Severe AS and OB

A

-Epidural is fine…slowly raise the level…
*no epinephrine or ketamine (don’t want tachycardia)
-Def no spinal (would not tolerate rapid drop in afterload/preload)

275
Q

Epidural and therapeutic enoxaparin (LWMH), also prophylactic enoxaparin

A

-Must wait 24hrs (12 hrs for prophlactic)
-What about therapeutic heparin…also need to wait 24hrs (12 hrs for prophlactic)

*Def check platelets
*No can’t try to reverse
*Many OBs switch from enoxaprin to heparin at 36 weeks…supposedly shorter half-life

276
Q

STAT C section in AS

A

-General is best bet
-Unlikely to be able to safely raise level with epidural in time
-Etomidate, high-dose fent, roc…phenylephrine…pads on patient

*
High-dose fent may affect baby…try to dose fent/benzos after baby comes out
*
Avoid methergine…would increase myocardial oxygen demand

277
Q

Boggy uterus txt

A

-Manual massage
-Uterotonic (oxytocin, misoprostol, methergine, hemabate)
-Uterine balloon
-Emergent hysterectom
-Uterine artery embolization

278
Q

Shoulder surgery, beach chair position, monitors

A

-A line, transducer zeroed at the tragus
*Obvi BP cuff on arm will overestimate BP to the brain
-Get TTE to rule out PFO…risk of paradoxical air embolus

279
Q

Shoulder, beach chair position, physiology

A

Decreased venous return, preload…increases risk of ischemia to brain

280
Q

Ok to quit smoking a day before surgery…?

A

-Ideally should quick 6-8 weeks beforehand
-But quitting even just before has some benefits, including decreasing CO levels in the blood, improving mucus clearance

281
Q

Severe COPD and supraclav/interscale block?

A

Think twice! All associated with phrenic nerve paralysis

282
Q

What is the Bezold-Jarish reflex?

A

A reflex characterized by bradycardia and hypotension 2/2 stimulation of cardiac receptors…

may explain CV collapse after spinal

283
Q

Corneal abrasion…TXT

A

TXT: saline eye drops, abx ointment
Confirm diagnosis: blink eyes, sxs should be worse

284
Q

What shifts oxyhemoglobin dissociation curve left?

A

-Carbon monoxide
-Methemoglobinemia
-Fetal Hemoglobin

285
Q

Methemoglobinemia:
how does it cause cyanosis
how to diagnosis
how to treat

A

1-shift oxyhemoglobin dissociation curve left, methemoglobin does not bind O2
2-not pulse ox, but blood gas, co-oximeter
3-methylene blue…if G6PD, ascorbic acid

286
Q

G6PD deficiency, anesthesia considerations

A

Enzyme deficiency rendering RBCs more susceptible to hemolysis

-Avoid certain meds, abx
-Avoid hypoxia, hypercarbia, acidosis, etc

287
Q

Preeclampsia diagnosis

A

@20 weeks
140/90 +proteinuria or signs of end/organ damage

prior to 20 weeks…chronic HTN

after 20 weeks…gestational HTN

288
Q

Preeclampsia physiology

A

-Hypovolemia
-Increased SVR
-Decrease uteroplacental perfusion…baby could come out more floppy

289
Q

TTM post-cardiac arrest

Who?
How long?

A

Comatose patient
Avoid fever
24-72 hrs

290
Q

PA catheter contraindications

A

Absolute:
Right-sided endocarditis

Relative:
Coagulopathy
Severe TR
LBBB

291
Q

Pharmacalogic Stress Test

A

Adenosine is first-line….dilates coronary vessels, unmasking stenotic vessels

292
Q

Diabetic: hypotension after induction…surprised?

A

Nah…c/w autonomic neuropathy

293
Q

How to prevent contrast nephropathy?

A

Fluid load before

294
Q

Pacemaker settings:
VV-DDDR

A

-Ventricular shock
-Ventricular anti-tachycardia pacing

*
AV paced
AV sensed
V-lead response to atrial sensing
Rate responsive per patient physical activity

295
Q

Patient has a PPM…what to ask?

A

-Are they pacer depedent? ->switch to asynchronous mode
-Response to magnet?

296
Q

Pacemaker management

A

Below umbiliculus->leave pace maker

*otherwise
Favor bipolar cautery
Place grounding pad appropriately

when surgery is done, must reprogram…otherwise, leave pads on

297
Q

Rupture globe surgery…deep extubate?

A

-Think twice: full stomach precautions
-Can do TIVA wake up

*Remember: no succinylcholine

298
Q

ACLS meds: pVT/VF

A

-Epi
-Amio 300/lidocaine 1.5mg/kg
-Amio 150/lidocaine 0.75mg/kg

299
Q

Epi dosing for bradycardia

A

2-10mcg/min gtt

*for bronchospasm, would do 4mcg pushes at time

300
Q

Neonatal Resuscitation

A

Step 1: warm, dry, stimulate
.

Step 2: suction, supplemental O2 per preductal saturation (start low and go high)

Still struggling…(HR<100, apenic, or gasping)

Step 3: PPV

If after 30 seconds, HR< 60

Step 4:
-Chest compressions (3:1, 120bpm)
-Intubate
-Venous access (umbilical vein vs proximal tibia IO)

If after 60 seconds of chest compression, HR<60

Step 5:
-GIve epi 0.01mg/kg (IV or down ETT)

*
Other considerations:
Mag tox->calcium
Hypoglycemia->glucose
Narcosis->Naloxone
Rule out PTX, hypovolemia

Where to place pulse ox? RUE (preductal)…make take 1-2 minutes for an accurate reading

301
Q

Epiglottis..airway management

A

-Transfer to OR
-Difficult airway equipment
-In sitting position: Inhalation induction vs ketamine, maintain spontaneous ventilation, avoid paralysis,
-Slowly lower supine, gentle laryngoscopy
-Surgical airway vs perc transtracheal jet ventilation

**
Try to avoid upsetting the child and worsening distress

302
Q

Epiglottitis…when to extubate

A

-After at least 24hrs of abx (H influenzae type B)
-Extubate in OR
-Airway exam before, cuff leak

303
Q

Hyperthyroidism…which labs to send

A

TSH
Free T4 and Free T3

T3 is the active form

304
Q

Hyperthyroidism in emergent surgery

A

Block thyroid hormone synthesis:
-Methimazole/propylthiouracil

Block peripheral conversion:
-Steroids
-Beta blocker

*propylthiouracil is safer in pregnancy
*no role for iodine, except in thyoird storm

305
Q

MRI

A

-Thermal injury
-Dislogement/malfxn of implantable devices (PPM, spinal cord stimulator)
-Projectile injury from magnetic objects
-Limited access to airway

306
Q

When to hold TFs for anesthesia…

A

Varies by hospital policy…

-If intubated, I would continue
-Otherwise, could hold for 6hrs…or attempt RSI

307
Q

TPN indications

A

Bowel rest/bowel obstruction

308
Q

TPN complications

A

-Cholecystitis
-Pancreatitis
-Ifxn
-Endopthalmitis

*
Can also increase CO2 production…consider increasing lipid component to TPN

309
Q

TPN and difficulty weaning from the vent…

A

-Hypophosphatemia (refeeding syndrome)
-Increased CO2 production

310
Q

Who needs stress dose steroids?

A

Prednisone 5mg/day for more than 3 weeks

311
Q

Cervical spine bone 1 and bone 2

A

C1: Atlas (holds up the head)
C2: Axial bone

312
Q

Rheumatoid Arthritis considerations

A

-Cervical spine instability
-TMJ dysfxn (limited mouth opening)

*
-Stress-dose steroids

*
Sjogren syndrome->dry eyes->corneal abrasion

313
Q

Stellate Ganglion block…what is it? risks?

A

Stellate ganglion is a sympathetic ganglion in the neck, block may help with complex pain

Side effects:
-Nerve palsy
-Intravascular injection
-Epidural/Spinal injection
-Horner Syndrome
-Parasympathetic s/s

314
Q

Stellate Ganglion Block SOB ddx

A

-Nerve palsy (phrenic nerve, recurrent laryngeal nerve)
-LAST
-Epidural/spinal injection

315
Q

LAST sxs

A

1: metallic taste, ringing in ears, perioral numbness
2: CNS tox (seizures)
3: Cardiac tox

316
Q

Treatment of LAST

A

-20% Lipid emulsion (1.5cc/kg bolus, followed by infusion)…if CV instability persists, re-bolus and double infusion
-Benzos for seizure
-Lower dose epi (1mcg/kg to start)

*
Patient should be monitored for at least 12 hrs following LAST becuase local anesthetic will continue redistributing from tissue depots, resulting in recurrence

317
Q

What factors affect absorption of local anesthetic?

A

-Blood flow to site of injection (IV > Tracheal > Intercostal)
-Addition of epinephrine (vasoconstriction inhibits systemic absoprtion)

318
Q

How to avoid LAST?

A

-Aspirate
-Inject a little at a time
-Stay under max recommended dosing
-Epi to minimize systemic absorption, also surveil for systemic absorption
-Awake patient

319
Q

Most cardiotox local anesthetic

A

Bupivicaine…the cardiotox dose is only 3 times higher than the CNS tox dose

320
Q

Centrifugal vs roller pump

A

Centrifugal:
-less damage to RBCs
-sensitive to preload and afterload
-will not entrain a significant amount of air

321
Q

Alpha vs pH-stat

A

Alkaline drift 2/2 hypothermia…

pH stat: add CO2, to protect ped brain

Alpha stat: let it ride

322
Q

Why vigorously inflate lung when coming off bypass

A

-Reverse atelectasis
-Shunt air into the left heart, where it can be more easily deaired…

323
Q

Why can’t we come off bypass

A

-Graft down
-Valvulopathy
-Preload issue/bleeding
-Vasoplegia
-Heart dysfxn
-Malignant arrhythmia
-Electrolyte abnormalities

324
Q

Why does radial a-line poorly correlate with central aortic pressure coming off bypass…

A

Peripheral vasodilation while rewarming

325
Q

Cardiac Tamponade…ECHO Findings

A

RV diastolic collapse

Pulsus paradoxus (>10 point drop in systolic pressure with inspiration)

Equalization of diastolic pressures

326
Q

ESLD vs DIC

A

Factor 8….

327
Q

Thyroidectomy: concerns

A

-Difficult airway management
-?Hyperthyroid

328
Q

Sick Euthyroid

A

Nl TSH, low T3 and T4

329
Q

Thyroidectomy: Airway management

A

-ETT with nerve monitoring capability (to monitor recurrent laryngeal nerve…requires TIVA
-Reinforced ETT (so can paay beyond point of compression)
-Rigid bronchoscope as back up
==
AFOI->if they refuse, consider inhalation induction (maintain spontaneous breathing)
Capability for surgical airway

330
Q

Thyroidectomy: How to maintain anesthesia

Do they need to be wide awake?

A

-Consider TIVA for smooth wake up, to avoid coughing and bucking, also for recurrent laryngeal nerve monitoring

-Yes, extubate awake, high risk for airway complications including stridor, obstruction, laryngospasm

331
Q

New stridor in the PACU, s/p thyroidectomy

A

-Is this 2/2 inadvertent removal of PTH glands, causing hypocalcemia…txt with calcium, airway support

ALso on ddx:
-Edema (steroid, racemic epinpehrine)
-Upper airway obstruction
-Recurrent laryngeal injury (**MUST BE B/L injury)
-Hematoma

332
Q

What is Chvosek’s sign?

A

-Facial nerve excitability 2/2 hypocalcemia

333
Q

TURP (transurethral resection of the prostate)…anesthesia plan

A

-Regional or general is fine…

Advantage of regional:
Awake patient…allow 1) early detection of TURP syndrome->AMS 2) bladder perforation

334
Q

TURP syndrome

What is the ideal irrigation solution?

A

AMS developing after systemic absorption of hypotonic irrigation syndrome

Distilled water->Hyponatremia
Glycine-> hyperammonia (vision changes)
Sorbitol->Hyperglycemia

The ideal irrigation solutions is electrically inert and isotonic

335
Q

TURP and spinal…what level/what anesthetic

A

-Hyperbaric bupi
-T10 level (do not want to mask bladder perforation)

336
Q

Succinylcholine…Phase I vs Phase II

A

Phase I: no fade (no difference in twitch amplitude)

Phase 2: yes, fade

337
Q

GCS

A

Eyes, verbal, motor

-Decerebrate is worse

338
Q

Trauma: periorbital ecchymosis and hemotympanum

A

Basilar skull fxr

339
Q

ICP crisis numbres

A

ICP>20
CPP>60

*
Hypertonic saline <160
Mannitol Serum Osm<320
PaCO2 30

340
Q

NSG: hyponatremia…urine sodium is high, ddx

A

Cerebral salt wasting
SIADH (euvolemic)

341
Q

What is HELLP?

A

A variant of preeclampsia…RUQ pain is suggestive

Txt:
Mag for seizure ppx
BP management

342
Q

OB and mag indications

A

-Preeclamptic/HELLP moms
-Preterm babies for neuroprotection (24-32 week gestational age)

343
Q

Spinal/epidural for OB is not working…WTD

A

-Redose
-Reposition the patient
-Replace catheter
-General anesthesia

344
Q

Mom has delivered, baby needs help…WTD

A

Mom is my primary patient
Will only help if she is stable
They should wheel the baby over to me

345
Q

How do uterotonics work?

A

They increase intracellular calcium in uterine smooth muscle cells…causing contraction

346
Q

Eclamptic seizure..txt

A

Mag bolus, midaz, low threshold to intubate

347
Q

Cardiac ablation: anesthesia plan

A

MAC or GA…GA if this is a complex case, higher risk for complications

348
Q

Cardiac ablation complications

A

-Arrythmia, atrial perforation, cardiac rupture, heart block
-Stroke

349
Q

Stroke workup

A

ECHO
Holter monitor
Carotid doppler study

350
Q

Syncope workup

A

Brain imaging (?stroke)
Holter monitor
ECHO (?AS)

351
Q

Rheumatic heart disease, which valves

A

Mitral #1, Aortic #2…can cause stenosis or regurg

352
Q

PA catheter in mitral stenosis

A

Would overestimate LVEDP

353
Q

Antiemetics MOA

A

Zofran (serotonin antagonist)
Reglan (dopamine antagonist)
Aprepitant (neurokinin antagonist)

354
Q

When to delay an elective case for hyperK?

A

K+ 5.5, although ideally under 5

355
Q

Reason to avoid regional anesthesia for boards…

A

I think it would be hard to achieve a high enough surgical block without compromise respiratory function…would be better to have a secure airway in the event of a complication

356
Q

Kidney transplant: monitors

A

A-line
Central line (for pressor, immunosuppressants, volume monitoring)

357
Q

Pulse pressure variation cutoff for fluid responsiveness

A

> 12%

358
Q

Fluid managment for kidney transplant

What fluid?

A

Usually 2-3L
Maintain euvolemia, keep kidney perfused
Consider volume loading during (iliac vein) clamp placement…for when clamp is released

Isotonic fluid is fine….maybe avoid NS since large volumes can result in acidosis and hyperK

359
Q

Kidney transplant, what meds prior to iliac vein clamping

A

-Lasix/mannitol to increase renal blood flow
-Heparin to prevent clotting

360
Q

PACU patient in respiratory distress, would you immediately intubate?

A

If I was concerned for imminent airway collapse

361
Q

Uremic coagulopathy…
Txt?

A

Cause platelet dysfxn by decreasing amount of vWF

txt: platelet
Also, FFP, cryo, DDAVP (to increase vWF)

362
Q

Ascites in liver disease, pathophys

HRS pathophys

A

2/2 portal HTN and activation of RAAS
*
2/2 renal vasoconstriction
Txt: volume loading, raise BP (midodrine)

363
Q

*

Cirrhosis hemodynamics

A

Splanchnic vasodilation->decreased SVR->increased CO

(Hyperdynamic circulatory state)

364
Q

Liver TXP…why V-V bypass

A

To maintain preload when completely clamping the IVC, shunts blood from the IVC to UE veins

Thanks to piggy-back technique, where this only partial occlusion of the IVC, preload is maintained

365
Q

Liver txp: 3 stages

A

Preanhepatic (removing old liver)
Anhepatic (no liver->working on vascular anastamoses)
Reperfusion (portal vein is opened)

366
Q

What is reperfusion syndrome? Liver txp

How to prevent?

A

The introduction of cold, hyperkalemic blood and vasoactive substances into the systemic circulation causes hypotension, arrhythmias, pulm HTN

Treat hyperkalemia, hypocalcemia, acidosis prior

367
Q

What happens when bypass is initiated?

A

1-Heparin is administered
2-Arterial cannula placed in ascending aorta
3-Venous cannula in RA
4-Initiate blood flow
5-Aortic cross-clamp, then give cardioplegia
6-Discontinue ventilation

368
Q

Nl dig level…

A

0.5-2.0

DIGIFab, not dialyzable

369
Q

Why does the patient’s BP drop with initiation of bypass…

A

The dilute priming solution drops the SVR…however, always must wonder about positioning of the venous and arterial cannula

370
Q

How to wean off bypass?

A

-Rewarm the patient (give midaz)
-Correct anemia
-Correct electrolyte derangement, give mag and calcium
-TEE to guide preload, afterload, inotropy
-Reinitiate lung ventilation
-Pacer and pads for chronotropy, arrhythmia

371
Q

4Ts of Anerior Mediastinal Mass

A

-Teratoma
-Thymoma->myasthenia gravis (30-65% of patients)
-Thyroid
-Terrible lymphoma

372
Q

Down Syndrome Considerations

A

Airway: Cervical instability, macroglossia, subglottic stenosis
Cardiac: Defects

*Down syndrome kids should be screened at age 3-5 for cervical spine film

373
Q

How to evaluate for cervical instability?

A

-Review airway history
-Review imaging
-Any exremity numbness/tingling/weakness with neck mvmt->if concerned and can delay, get NSG consult

374
Q

Anteior mediastinal mass: H&P

A

-Reviewing imaging, to determine airway compression, level of compression
-Compression of heart or great vessels

Thus, can cause airway and circulatory collapse

*
-Reviewing CT imaging, any recent fiberoptic exam findings
-ECHO in supine and upright position

375
Q

Anterior Mediastinal Mass: Airway Equipment

A

-Armored ETT (to get back obstruction…multiple sizes, lenghts
-RIgid bronchoscope
-Surgeon with sternal saw for emergent sternotomy
-Line for V-A ECMO

376
Q

Anterior Mediastinal Mass: How to approach airway

A

-Awake fiberoptic, that way can assess level of compression, get tube distal (may even have to advance to patent bronchus)

-If they refuse, ketamine or inhalation induction

377
Q

Anterior Mediastinal Mass: Airway Attempted, running into issues…ddx

A

Apnea
Laryngospasm
Bronchospasm
Mass Compression

*
If apnea->try to expeditious place ETT

If laryngospasm->try to break with jaw thrust, PPV, avoid paralyzing

If mass compression->try to advance tube past obstruction, prone patient, emergent sternotomy to elevate mass, initiate ECMO

378
Q

Would you extubate anterior mediastinal mass airway?

A

Nah, would want them to recover in ICU, would want airway hyperactivty from recent manipulation, also edema to subside

379
Q

Interscalene block

Complications

A

Coverage: shoulder…if need forearm (block ulnar nerve separately)

Complications:
Phrenic paralysis 100% time
Intrasvascular injection
Epidural/spinal anesthesia
Horners syndrome

*Just like stellate ganglion block

380
Q

5 Causes of RTL in 1st year of life

A

1-Persistent truncus arteriosus (pulmonary trunk and aorta fail to divide)
2-Transposition of the great vessels (Aorta off RV, PA off LV)
3-Tricuspid Atresia
4-Tetralogy of Fallot (RV hypertrophy, pulmonary stenosis, overriding aorta, VSD)
5-Total anomalous pulmonary venous return (pulmonary vein drains into right heart)

381
Q

RTL shunting (inhalational vs IV induction)

A

Inhalational: slowed
IV: Hastened

Inhalational decreases SVR, not a good idea for RTL shunt

382
Q

Tet spell, physiology

A

-Increased RV outflow obstruction
-Decreased SVR

*
Txt:
-increase SVR (knees to chest)
-esmolol to decrease inotropy (relieve RV outflow obstruction)

383
Q

Axillary Nerve Block

Indications
Complications

A

Covers: distal humerus and beyond (like supraclav, infraclav)

Complication: very safe

What nerve is often missed? Musculocutaneous nerve

384
Q

Cirrhosis…paralysis plan?

A

Cisatracurium
Undergoes hoffman degradation in the plasma, independent of kidney and liver

385
Q

Extracorporeal Shock Wave Lithotripsy: anesthesia plan, considerations for PPM/ICD

A

Any anesthesia (MAC, GA, regional)
If ICD, turn off, put pads on, PPM put in asyncrhonous mode

*
Pregnancy is a contraindication

386
Q

Liposuction…anesthesia plan, risks, dosing

A

Tumescent technique…inject large amount of lidocaine and epinephrine into fat

Max dose lidocaine: 55mg/kg…(fat is poorly vascularized, much of it is absorbed with the procedure)

Complications: LAST (usually 14-16 hrs after procedure), volume overload

387
Q

Child declines blood products…

A

-I am ethically bound to provide life-saving care, does not have capacity
-I am ethically bound to take the child’s considerations into account, if surgery is elective, could defer until she is an adult and make her own decisions

388
Q

Retrobulbar block: (unique) complications

A

Local anesthetic spread to the CNS->apnea/unconscious

389
Q

SCD

Sickle cell crisis…txt

Goal HCT for big surgery…

A

-Consider exchange transfusion

-Goal HCT ~30

390
Q

HOCM and epidural…plan

A

Hydrate first

Gentle sympathectomy

No epi or ketamine

*
Benefit of epidural: avoids pain, tachycardia

*
Avoid methergine: increase myocardinal oxygen demand

391
Q

HOCM, hemodyanmic goals

A

LV hypertrophy, dynamic LVOT, and SAM

-Maintain preload
-Maintain afterload
-Avoid tachycardia
-Avoid inotropy

392
Q

HOCM, pulm edema after delivery

A

2/2 abrupt autotransfusion of blood into the systemic circulation in the setting of diastolic dysfxn

393
Q

1.

Conscious sedation

A

Sedation where the patient is still arousable, no airway manipulation is happening

-
Always need to have backup airway equipment available, under the supervision of someone who can convert to GA

394
Q

Standard ASA monitors

A

-EKG
-Pulse
-BP cuff
-EtCO2 monitor
-Temp probe

395
Q

Status Asthmaticus txt

A

-Steroids (methylprednisolone)
-Nebulizing treatment
-Mag/epinephrine infusion

396
Q

Celiac plexus block

Complications

A

A bundle of nerve innervating the visceral organs

Bleeding, infxn, nerve injury, IV injection, paralysis, parasympathetic s/s

397
Q

Txt of COPD exacerbation

A

-Steroids
-Abx
-Scheduled nebulizing treatment
-Vent management (low RR, increase time in expiration, 6-8cc/kg TVs)….if overbreathing the vent, sedate

398
Q

**

Trouble of auto-PEEP

A

-decreases venous return
-increased PVR
-PTX
-Makes it harder for the patient to trigger the vent

399
Q

Pediatric CPR

A

Big differences:
-Less depth to compressions
-Less energy for shocks
-epi dose 0.01mg/kg

Same:
Compression rate (100-120)

400
Q

Stable narrow complex SVT…txt

A

-Vagal maneuver
-Adenosine

401
Q

Anesthesia machine: how do you do a machine check

A

-Check monitors
-Calibrate CO2 and O2-analyzers
-Check for leaks in the high and low-pressure system
-Confirm adequate CO2 absorbent

402
Q

How do you check for leaks in the low-pressure system?

A

-Postive pressure leak test

403
Q

How to avoid delivering a hypoxic mixture?

A

-Alarms
-O2 analyzer
-The machine should shut off flow of other gases if O2 pressure drops too low

404
Q

Sevoflurane vs Desflurane vaproizer

A

Sevoflurane is a variable-bypass vaporizer… a variable amount of fresh gas flow mixes with the volatile agent

Desflurane is a gas-vapor blender

405
Q

Main cause of PPH

A

Uterine atony

406
Q

4 causes of bleeding in OB women

A

-Tone (Uterine atony)
-Tissue (retained placenta)
-Thrombosis (DIC)
-Tear (surgical)

407
Q

CF complications in newborn

A

Pulmonary and GI sxs…meconium ileus may be the first sign

408
Q

Contraindicatons to epidural placement

A

-Coagulopathy
-Severe hypovolemia
-Increased ICP

409
Q

**

HD changes of pregnancy

A

Increased cardiac output (from increase circulating volume), Decreased SVR

410
Q

Open aortic dissection surgery: how many A-lines

A

2: RUE radial, femoral ( to monitor MAP below the clamp)

411
Q

Aortic dissection, you are trying to lower the pressure above the clamp, but the pressure below the clamp is already low..wdyd

A

Ask the surgeon: to reimplant arteries to important organs, place shunt

412
Q

CABG, starting dose of heparin

A

300units/kg
Goal ACT>400

413
Q

CABG, BP is low on bypass

A

-Increase CO->can perfusionist increased pump flow rate
-Phenylephrine gtt

414
Q

How to protect the spinal cord during aortic clamping?

A

-Maintain MAP >50
-Drain CSF
-Reimplant arteries, shunt
-Hypothermia

415
Q

Anesthesia plan for pericardial window…

A

-Only local
-Otherwise, ketamine to maintain spotaneous ventilation, only paralyze after effusion is drained

416
Q

Cooractation of aorta in pregnancy…risks

A

-Risk of aortic dissection with swings in BP

417
Q

Newborn vs Adult Airway

A

-Large tongue
-Omega shaped epiglottis
-More cephald larynx (C3-C4, vs C6 in adult)
-Angled vocal cords

418
Q

Size of ETT in newborn

A

Premie: 2.5
Newborn: 3

General rule: 1/4 age+ 4

419
Q

Newborns and apnea

A

High risk for apnea until 60 weeks postconceptual age

420
Q

ECMO risks

A

-Coagulopathy (bleeding/hemorrhage)
-Cannula dislodgement
-Sepsis

421
Q

Neonates and hypoglycemia

A

They have limited glycogen stores…hence, always should have maintenance running at D51/2 NS

422
Q

Premature neonate concerns

A

N: IVH, retinopathy of prematurity
C: Defects
P: Hypoplasia, pulm HTN
GI: necrotizing enterocolitis
Endo: Hypoglycemia
MSK: temperature

423
Q

King-Denbourough Syndrome

A

Rare congenital myopathy
Patients are susceptible to MH

424
Q

MH and nitrous

A

Yes, nitrous is fine

425
Q

Treacher Collins syndrome/Pierre Robin syndrome

A

Difficult airway 2/2 mandibular hypoplasia

426
Q

Beckwith-Wiedemann Syndrome

A

Omphalocele + large tonuge

427
Q

Why are newborns prone to hypothermia

A

-High surface area to volume ratio
-Limited subcutaneous fat

428
Q

**

Fontan/single ventricle physiology

A

Cardiac output is dependent on preload/PVR

*Avoid PPV

429
Q

How to preoxygenate

A

-8 deep breaths over 1 minutes
-3 minutes of TV breathing
-ETO2 80-90%

430
Q

vWF and epidural placement

A

-vWF and Factor 8 level should be 80%
-If needed, give DDAVP or replacement

*
If Type 1 and no signs of abnormal bleeding, don’t have to check a level necessarily

431
Q

Local anesthetic allergy…

A

Esters 2/2 PABA metabolite

431
Q

Is cardiac workup indicated…?

A

Poor exercise tolerance + high risk surgery

432
Q

Hyperoxia complications

A

-Absorption atelectasis
-Inhibits hypoxic pulmonary vasoconstriction
-Free radical generation

433
Q

Hemophilia A txt

A

-Factor 8 concetnrate
-FFP
-Cryo

434
Q

TEG

A

Prolonged R->give FFP
Prolonged K/decreased alpha angle->give cryoprecipitate
Short MA->give platelets
Rapid loss of amplitude->give TXA

435
Q

Caudal Anesthesia

A

-The lowest portion of the epidural space
-Passes through the sacrococcygeal ligament

436
Q

Midline epidural placement

A

Skin->Supraspinous ligament->interspinous ligament->Ligamentum flavum…

Epidural space is between ligamentum flavum and dura mater

vs paramedian approach:
skin->muscle->ligamentum flavum

437
Q

Where does the spinal cord terminate

A

Adults: L1-L2
Kids: L3-L4

437
Q

Asymmetric epidural level

A

-Confirm epidural is in place
-Reposition the patient
-Give volume to raise level
-Pull catheter back, replace catheter

**
For spinal: use hyperbarci bupivicaine

438
Q

Why neuraxial morphine?

A

Morphine is hydrophilic…sticks around, hence good for post-op pain

(tho slow onset)

439
Q

Opioid speed of onset

A

-Lipid soluble
-Uninonized

Alfentanil is lipid soluble and unionized->hence, rapid onset

439
Q

Tramadol

A

SNRI + partial opioid agonist

440
Q

NPO guidelines

A

2hrs-clear liquid
4hrs-breast milk
6hrs-light meal, including milk
8hr-full meal

441
Q

Peds volume resucitation

A

20cc/kg…maybe 10cc/kg for card patients

442
Q

Caudal Anesthesia

A

->single-shot…for intraop as adjunct, and post-op
->might make sense to do just after induction to help with intraop pain management, may have to redose after 4hrs
->landmarks: find sacral hiatus (between 2 sacral cornu), go through sacrococcygeal ligament…

…confirm LE mvmt and urination before discharge

443
Q

IM darting

A

IM midaz: 0.1mg/kg
IM precedex dosing: 2mcg/kg
IM Ketamine: 5mg/kg

444
Q

ST changes during OR…what drug to give?

A

Nitroglycerin…coronary vasodilator

445
Q

DIC vs dilutional coaguloapthy…

A

HYPERFIBRINOLYSIS…give TXA

446
Q

ISCHEMIA to hand

A

-Elevate the hand
-Topical nitroglycerin
-Stellate ganglion block

447
Q

PaCO2-EtCO2 gradient…

A

2/2 dead space ventilation

447
Q

LINE-ISOLATION

A

MACRO-SHOCK
Faulty equipment vs too many pieces plugged in

448
Q

For epidural steroid

A

Use non-particulate steroid, like dexamethasone

Basic Exam (5 decks)

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