Principles of Anesthesia II Unit III Flashcards
What type of immunity does not have “memory”, but the response to the pathogen is always identical?
Innate immunity
What are the non-cellular elements of innate immunity?
Epithelial and mucous membranes
Complement system
Acute phase proteins
What are the cellular elements of innate immunity?
Neutrophils, macrophages, monocytes and natural killer cells
What cellular element has the fastest response?
Neutrophils
What cellular element has a slower but more sustained response?
Macrophages
What is the complement system?
A large number of distinct plasma proteins that react with one another to opsonize pathogens and induce a series of inflammatory responses that help to fight infection
What augments phagocytes and antibodies?
The complement system
Where are the proteins for the complement system produced?
Most in the liver
What activates the complement system?
C1 or C3
What is the most numerous type of WBC?
Neutrophils
What cell releases cytokines and phagocytizes pathogens?
Neutrophils
Why do neutrophils break down quickly in the presence of infection?
An infection likely creates an acidic environment which neutrophils are sensitive to so they break down quickly
this breakdown of neutrophils is also what creates pus
What is the largest blood cell?
Monocytes
What type of monocytes are found in the: epidermis, liver, lung and CNS?
Epidermis = Langerhans
Liver = Kupffer
Lung = Alveolar cells
CNS = Microglia
Where would you expect to find Langerhans cells?
The skin (epidermis specifically)
Where would you expect to find Kupffer cells?
Liver
Monocytes/macrophages produce what 2 substances in response to infection?
Cytokines and NO
What is the least common blood granulocyte?
Basophils
Where would you expect to find mast cells?
In connective tissue close to blood vessels
Basophils and mast cells have high affinity receptors for what substance?
IgE
Basophils and mast cells release what in a hypersensitivity reaction?
Histamine, leukotrienes, cytokines, prostaglandins
Where would you expect to find the highest concentration of eosinophils?
In the GI tract (they protect against parasites and degrade mast cell inflammation)
What type of immunity has a “memory” to specific antigen response?
Adaptive immunity
only present in vertebrates
Adaptive immunity is derived from what cell?
Hematopoietic stem cells
Adaptive immunity primarily uses what cells to respond to pathogens?
T-cells, B-cells and NK cells
What role do T and B cells perform in adaptive immunity?
B cell = make antibodies
T cell = make interferon/interleukin and has a role in chronic inflammation and responding to infection as well as activating IgE
What cell activates IgE?
T-cells
A vaccine is what category of immunity?
Active
What is an example of passive immunity?
Getting antibodies from another - such as from maternal breast milk (this only lasts for a few weeks/months)
IvIG and IV immunoglobin are examples of what kind of immunity when used in a hospital setting?
Passive immunity
Neutropenia is what category of immune response?
Inadequate
Asthma is an example of what category of immune response?
Excessive/exaggerated
Autoimmune disorders are an example of what category of immune response?
Misdirection
What drugs commonly cause a hypersensitivity reaction?
NSAIDs, ABX and PPIs
What is a type I allergic response?
Immediate hypersensitivity, think asthma or response to a bee sting
Anaphylaxis, asthma, angioedema, conjunctivitis, dermatitis are all examples of what type of allergic response?
Type I
What interventions can be performed to reduce the effects of histamine in a type I allergic response?
First step is stop/remove trigger, then:
Prevent histamine effects:
Antihistamines
Cromolyn sodium
Bronchodilators
COX pathway inhibitors
Diagnostic tests
Small doses of allergen to desensitize (slightly controversial, must be done with an immunologist present)
Hemolytic anemia, myasthenia gravis, transfusion reactions are examples of what type of allergic response?
Type II
Treatment of a type II allergic response?
Anti-inflammatories and immunosuppressives
Systemic lupus erythematosus (SLE), and rheumatoid arthritis are examples of what type of allergic response?
Type III
Failure of the immune system to eliminate antibody-antigen complex causes is the classic presentation of what type of allergic response?
Type III
This also causes complexes to be deposited in the joints, kidneys, skin and eyes
What type of allergic response is mediated by IgG and IgM?
Type III
What type of allergic response does not involve antibodies?
Type IV
Contact dermatitis, tuberculosis, Stevens-Johnson syndrome (allergy response to NSAIDs) are examples of what type of allergic response?
Type IV
What types of allergic reactions are treated with Anti-inflammatories and immunosuppressives?
Type II and IV
What is biphasic anaphylaxis?
When a secondary anaphylactic episode occurs after the primary episode
Risk factors for a secondary anaphylactic episode?
Severe initial response and the initial response required multiple doses of epinephrine
Risk factors for perioperative anaphylaxis?
Asthma
Longer duration of anesthesia
Females (Not in teen years)
Multiple past surgeries
Presence of other allergic conditions
What are 3 tests that can be used to diagnose whether or not you have an anaphylaxis response to a certain irritant?
Plasma tryptase concentration, plasma histamine concentration and skin testing (wheal/flare response)
What lab test verifies mast cell activation/release?
Plasma tryptase concentration
If an anaphylactic response is resistant to epi, what are the other drugs you can give?
Give vasopressin, methylene blue
to inhibit NO production
What does epinephrine do in an anaphylactic response that makes it the DOC?
Decreases degranulation of mast cells and basophils which ↓ effect of degranulation causing less vasodilation
Alpha1: supports BP
Beta 1: inotropic and chronotropic effects
Beta 2: bronchodilation
What are 3 common examples of specific immune reactions?
Transfusion reactions, transplant rejection and Graves disease (d/t antibodies activating the TSH receptors too much)
Hereditary angioedema has a deficiency/dysfunction of what part of the immune system response?
C1 (complement 1) esterase inhibitor deficiency/dysfunction = excessive production of bradykinin (which is usually limited by C1)
Why is angioedema a medical emergency?
They are not responsive to anti-histamines, so they lose their airway FAST
What drug class can cause acquired angioedema?
ACE inhibitors
Acquired angioedema r/t ACE inhibitors mimics the s/sx of hereditary angioedema except for what symptoms?
Urticaria (hives) and itching
Angioedema treatment?
Airway maintenance
FFP
C1 inhibitor concentrate
Epinephrine
Antihistamines, glucocorticoids
What tests can be used to diagnose HIV/AIDS?
ELISA: 4-8 weeks after infection
Viral load
CD4/helper T lymphocytes <200,000
HAART agent sensitivity
What CV issues are common with immune system disease?
Abnormal EKG
LV dilation
Pulmonary hypertension
MI
Pericardial effusions (25%)
What neurological issues are common with immune system disease?
Dementia
Increased ICP
Autonomic nervous dysfunction
Peripheral neuropathy (35%)
Why is the rule of thumb to “start your dose low and work up” commonly used with immune system dysfunction?
It is very common for cytochrome P-450 to be inhibited in immune system disease, so drugs stick around longer
What population does scleroderma most commonly affect?
Women in their 20s - 40s
Why is scleroderma a red flag for anesthesia?
Aspiration risk: they have hypo-motility of the GI tract and their LES tone is decreased
What are the general anesthesia implications/concerns for scleroderma?
Organ system dysfunction
Arterial catheter concerns (Continue preop calcium channel blockers)
Contracted intravascular volume
Aspiration risk
Limited neck mobility/Pulmonary compliance
What anesthetic agent suppresses NK cells, induce apoptosis of T-cells, impairs phagocytes and has an unclear impact on tumor cells?
Inhalation agents
What anesthetic agent decreases migration of neutrophils?
Versed
What anesthetic agents depress NK cell activity?
Ketamine and opioids
What anesthetic agent decreases cytokines and promotes NK cells?
Propofol
What opioids in particular are notorious for suppressing NK cells?
Morphine and fentanyl
Why are NSAIDs helpful with anesthesia and the immunesystem?
They inhibit prostaglandin synthesis
What are the drawbacks of the BMI measurement?
It can’t differentiate between overweight and overfat, and doesn’t take into account waist circumference, waist-hip ratio or age
Per Cornholio, waist circumference is a more reliable measure of the severity of obesity in terms of weight gain
What obese body type is more associated with increased O2 consumption and CV disease?
Android (central obesity or upper body truncal)
What obese body type is more peripheral obesity, less metabolically active and not associated with CV disease?
Gynecoid (more accumulation in the hips, butt and thighs)
What are 3 CV system changes that occur as a result of obesity?
Total blood volume increased (On a volume-to-weight ratio is lower 50ml/kg and most is distributed to adipose tissue)
Cardiac output ↑ by20-30ml/kg of excess body fat d/t LV dilation and ↑ stroke volume
Cardiac dysrhythmias d/t fatty infiltrates of conduction system, CAD,
Low QRS voltage, LVH, left axis
What change on an 12-lead is very common in obesity?
Left axis deviation
How is the clotting cascade affected by obesity?
Increased levels of fibrinogen, factor VII, VII and von Willebrand = hypercoagulability. There is also endothelial dysfunction d/t levels of factor VIII and von Willebrand.
combine this with immobility r/t obesity = perfect storm to create clots
What gastric changes make obese patients an aspiration risk with anesthesia?
Gastric volume and acidity both increase along with delayed gastric emptying. Intra-gastric pressure increases which causes relaxation of the LES and hiatal hernia formation
What volume and pH of the stomach are risk factors for aspiration pneumonitis?
Volume greater than 25 ml and pH less than 2.5
What renal changes are common to obesity?
Increased GFR and RBF, increased renal tubular reabsorption which impairs natriuresis and activates the RAAS
Which is more common in obese patients: hyper or hypo thyroidism?
Hypothyroidism d/t thyroid hormone resistance
T/F: the SNS activity level is increased in obesity
True: so you’ll have insulin resistance, enhanced pressor activity and sodium retention
What are the abnormalities r/t DM that are progressive in nature that constitute metabolic syndrome (you must have at least 3 of the starred ones to have metabolic syndrome)?
*Abdominal obesity
*Decreases levels of HDL
*Hypertriglyceridemia
Hyperinsulinemia
*Glucose intolerance
*Hypertension
Proinflammatory state
Prothrombotic state
What are some risk factors for metabolic syndrome?
Increased age, male and hispanic or south asian ethnicity
What drug classes may cause metabolic syndrome?
Chronic corticosteroids, antidepressants, antipsychotics, protease inhibitors
What can resolve metabolic syndrome 98% of the time?
Weight loss (either via diet/exercise or bariatric surgery, it doesn’t matter if it’s one or the other, the important part is losing the weight)
What is the basic difference between OSA and hypopnea?
OSA = actual apnea
Hypopnea = decreased airflow
How many apnea/hypopnea events constitute mild/moderate/severe disease states?
Mild: 5-15/hr
Moderate: 15-30/hr
Severe: > 30/hr
Treatment for both OSA/hypopnea is CPAP and weight loss to reduce the risk of what conditions?
Systemic/Pulmonary hypertension
LVH
Cardiac dysrhythmias
Cognitive impairment
Obesity hypoventilation syndrome can result in what over time?
Pulm HTN and Cor pulmonale
How is obesity hypoventilation diagnosed?
BMI greater than 30 along with awake hypercapnia
What medical therapy worked as an appetite suppressant, but only approved for 3 months at a time d/t CV system concerns?
Phentermine (CV issues were because this drug was a sympathomimetic)
What medical therapy worked by blocking the absorption of fat (but also had a LOT of GI s/e)?
Orlistat
What medical therapy causes issues with clotting disorders from fat soluble vitamin deficiency and vitamin K deficiency?
Orlistat
What is the one common effect of all GLP-1 drugs?
Delays gastric emptying
If a GLP-1 is being used for DM management, what should be done if you are holding it longer than it’s dosing schedule?
Consult an endocrinologist for bridge therapy to avoid hyperglycemia
A CPAP usage of what pressure is predictive of difficult mask ventilation?
Greater than 10 cm H2O
What health conditions should you focus on finding evidence of in a pre-op evaluation of an obese patient?
HTN, DM, heart failure and hypoventilation syndrome
What surgical history information from an obese patient would you want to explore/know?
Compare past/current weight
Ease/difficult intubations
Intravenous access (they don’t have bad veins, just have a lot of tissue covering them)
Need for ICU admission
Surgical outcomes
What home meds do you generally discontinue for obese patients prior to surgery?
Anti-hypertensives, insulin, oral hypoglycemics
What lung capacities/volumes are changed in obesity?
VC, IC, ERV and FRC all decrease
compliance is also low
The closing capacity is close to or the same as what volume/capacity in obesity?
Vt (especially when supine/recumbent) = rapid desaturation
Why is propofol generally not the first choice anesthetic agent for obese patients?
Because it redistributes to fat, it can greatly delay awakening in obese patients
What are the risks of supine position in obese patients?
Ventilatory impairment
Compression of IVC and Aorta, diaphragm is also compressed
Reports of rhabdomyolysis on gluteal muscles (can occur in as little as 3 – 4 hours) - reposition if possible
How does supine position in obese patients cause CV instability/changes?
From compression of the IVC and aorta
How does the oropharynx change in obesity?
It becomes more of an ellipse shape
Is BMI an independent predictor of difficult intubation?
No: for example, you could have a BMI of say 35, but if you are a powerlifter than its more muscle than fat
What are the independent predictors of difficult intubation?
Small mouth opening
Large/protuberant teeth
Limited neck mobility
Retrognathia (lower mandible protrudes forward)
What steps can you take to prevent atelectasis and desaturation throughout the perioperative period in obese patients?
CPAP during preoxygenation… 10cm
Positioning 25-30 degrees head up for obese patients (30 degrees reverse Trendelenburg even better)
Recruitment maneuvers then PEEP 10cm
Mechanical ventilation after induction rather than hand ventilate
Why does neuraxial anesthesia have a higher incidence of hypotension in obese patient’s relative to normal BMI patients?
The IVC and aorta are compressed in obesity
Why are epidural doses generally smaller in obesity?
They have a smaller epidural space d/t compression, this also increases the risk of cephalad spread
What are some anesthetic monitoring techniques that may be warranted from common disease pathologies in obesity?
Pulmonary hypertension…pulmonary artery catheter or TEE
Difficult IV access…central line placement
High risk of DVT and PE…IVC filter
Difficult non-invasive BP…arterial line
Need to monitor ventilation/ABG’s…arterial line
What anesthetic drugs have an exaggerated effect on obese patients?
Opioids, propofol and BZDs
short acting opioids like fentanyl and remi are favored as is precedex
Why is nitrous use generally not favored with obese patients?
Because it will dilute oxygen, and obese patients have a much higher oxygen demand
What are some anesthetic drugs that are dosed on IBW (focus on the ones listed in this units powerpoint)?
Propofol
Vecuronium
Rocuronium
Remifentanil
What are some anesthetic drugs that are dosed on TBW?
Midazolam
Succinylcholine
Cisatracurium
Fentanyl
Sufentail
Based on tissue solubility, which volatile is generally a better choice for obese patients?
Desflurane (suprane)
What are the IV fluid requirements of obese patients relative to normal BMI patients?
Increased IV fluid needs to prevent ATN
NICOM is a good choice in these patients
T/F: you should fully reverse the majority of your obese patients with Sugammadex?
True
When does N/V peak and persist?
Peak = 6 hours
Persist = 24 - 48 hours
What are the adult specific risk factors for PONV?
*Female
*Non-smokers
*History of PONV
*History of motion sickness
Delayed gastric emptying
Preoperative anxiety
What reversal agent carries an increased risk of PONV?
Neostigmine
this is part of the reason why Sugammadex is becoming so popular
What are the 2 primary adult surgical factors that increase PONV?
Longer duration of surgery and high risk surgery
high risk surgery examples: Laparotomy, ENT surgery, neurosurgery and breast/strabismus/plastics
What pediatric procedures carry an increased risk of PONV?
Adenotonsillectomy
Strabismus repair
Hernia repair
Orchiopexy
Penile surgery
How much higher is the PONV risk in pediatrics relative to adults?
2 times higher than adults
What anesthetic gas should be avoided if PONV is of great concern?
Nitrous
T/F: early ambulation reduces PONV risk
False
Where is the emetic center located?
Located in lateral reticular formation of brainstem
How does the emetic center cause N/V?
No substances directly act on it, but it does receive afferent input from other areas of the body (Pharynx, GI tract, mediastinum)
Afferent nerves from higher brain centers that can modulate N/V emerge from what 2 areas?
The CTZ from the area postrema and the vestibular portion of the 8th cranial nerve
T/F: the CTZ has no BBB
True
What receptors make up the CTZ?
Dopamine
Serotonin
5-HT3
Opioid
Histamine
Muscarinic
Neurokinin-1?
Cannabinoid?
T/F: there is a gold standard PONV drug
False
there are so many different receptors contributing to N/V, it is almost impossible for one drug to become THE standard
What drugs in pre-op can reduce PONV risk?
BZDs
During induction, what drugs increase PONV risk?
Volatiles, ketamine and etomidate
What percentage of nitrous greatly increases PONV risk?
50% or greater
What anti-muscarinic agent can directly reduce the risk of PONV?
Atropine
List the prophylaxis for PONV for: low, moderate and high risk PONV
Low = 5HT3 antagonist
Mod = 5HT3 antagonist and a steroid
High = 5HT3 antagonist, steroid, propofol TIVA and scop patch
Via the PONV algorithm, what are the rescue drugs for low risk or higher?
Phenothiazines, anti-histamines and reglan
What is the theory behind acupuncture/pressure reducing PONV?
P6 region stimulation causes hypophyseal secretion of beta-endorphins which inhibits the CTZ and reduces acid secretion
What are the anti-dopaminergic subtypes?
Butyrophenones (Haldol, Droperidol) and phenothiazines (Prochlorperazine, chlorpromazine and promethazine)
What anti-dopaminergic carries a hypotension risk?
Droperidol
What are the black box warnings of promethazine?
Vesicant and respiratory arrest in those younger than 2
What do 5HT3 receptors antagonize?
Serotonin in the vagal nerve and CTZ
Ideal timing for PONV prophylaxis with Zofran?
15 - 20 minutes of surgery end
Ideal timing to administer a steroid for PONV prophylaxis?
During or just after induction
What is the NK-1 antagonist drug?
Aprepitant
What PONV drug depresses neural activity of the nucleus tractus solitarius and may interfere with afferent messages from enterochromaffin cells?
Aprepitant
When is the ideal time to administer aprepitant?
2 - 3 hours prior to induction
How does propofol exert its anti-emetic effects?
At the 5HT3 receptors by blocking serotonin release, it may also inhibit the CTR (chemo trigger zone)
What aromatherapy is effective in reducing nausea?
Isopropyl alcohol
What are the “other” causes of PONV that should be considered, particularly if the PONV is refractory to pharmacologic intervention?
Hypotension
Hypoxemia
Elevated ICP
Gastric bleeding
Hypoglycemia
What type of cancer does not form solid tumors?
Leukemias
What genes are the “drivers” of cancer?
Proto-oncogenes, tumor suppressor genes and DNA repair genes
What type of cancer originates in the base of the epidermis?
Basal cell
What type of cancer originates in the epithelial cells?
Squamous cell
Where can squamous cell cancer originate?
The epithelial layer of the skin, stomach, intestines, lung and bladder
What type of cancer originates in glandular tissue such as the breast or prostate?
Adenocarcinoma
What type of cancer originates in the bone and soft tissue?
Sarcoma
What type of cancer originates in blood forming tissue?
Leukemia
What type of cancer originates in the T and B cells?
Lymphoma
T and B cells are lymphocytes
What cancer screenings are standards of care and readily covered by insurance?
Colonoscopy, mammograms and Pap smears/tests
What does each letter of the TNM for tumor staging evaluate?
T: size/extent of primary tumor
N: # of nearby lymph nodes which are +
M: is there metastasis
Define this tumor staging: TX N3 M1
Tumor cannot be measured, it has spread to 3 lymph nodes and has metastasized to one other part of the body
Define this tumor staging: T1 NX M0
A small tumor, we can’t measure it’s spread to lymph nodes with no metastasis
Define this tumor staging: T3, N0, MX
A larger tumor, no cancer in the lymph nodes and we cannot measure metastasis
Describe in SITU cancer staging
Abnormal cells are present but have not spread to nearby tissue
Describe localized cancer staging
Limited to place where it started; no sign of spread
Describe regional cancer staging
Has spread to nearby lymph nodes, tissues, or organs
Describe distant cancer staging
It has spread to distant parts of the body
What block may be used to help with Unresectable pancreatic cancer, hepatic or gastric cancer?
A celiac plexus block
What block uses alcohol to provide pain relief for 3 - 6 months?
A celiac plexus block
Why does a celiac plexus block have s/e of diarrhea and hypotension?
Because it causes neurolysis of the sympathetic fibers of T5-T12 and parasympathetic celiac plexus fibers
What block would be helpful for metastasis to the ribs?
An intercostal block
What block would be helpful for pain related to pelvic tumors?
A block targeting the lumbar sympathetic ganglion
What non-cancer related conditions can chemotherapy help treat?
Control of overactive immune diseases such as lupus or RA
What class of chemotherapeutics can cause dose-dependent leukemia?
Alkylating agents (the -platins)
What class of chemotherapeutics works in all phases of the cell cycle?
Alkylating agents. This also means it can treat many different types of cancers
What class of alkylating agents can treat brain cancer?
Nitrosoureas because they can cross the BBB
What alkylating agent can cause renal failure and neuropathy?
Cisplatin
What class of chemotherapeutics works by interfering with DNA and RNA?
Anti-metabolites
What class of chemotherapeutics is indicated for treating breast, ovary, intestinal and leukemia?
Anti-metabolites
Methotrexate and 5-FU are what class of chemotherapeutics?
Anti-metabolites
What class of chemotherapeutics interferes with enzymes copying DNA?
Anti-tumor antibiotics
What class of chemotherapeutics can cause damage to the heart with large doses?
Anti-tumor antibiotics
Doxorubicin, bleomycin and mitomycin-C are part of what class of chemotherapeutics?
Anti-tumor antibiotics
What classes of chemotherapeutics can work on a wide variety of cancer types?
Alkylating agents, mitotic inhibitors and anti-tumor antibiotics
What class of chemotherapeutics are plant alkaloids that prevent strands of DNA from being separated to copy?
Topoisomerase inhibitors
What class of chemotherapeutics increases your risk of a second cancer?
Topoisomerase inhibitors
What class of chemotherapeutics treat leukemias, lung, ovarian, GI, colorectal and pancreatic cancers?
Topoisomerase inhibitors
What class of chemotherapeutics are plant alkaloids that damage cells in all phases by preventing protein synthesis?
Mitotic inhibitors
Hormone therapy works well for what kinds of cancer?
Breast, prostate and uterine
What cells are most likely to be damaged during chemotherapy?
Blood forming in bone marrow
Hair follicles
Cells in mouth, digestive tract, and reproductive systems
What is the concern with use of aprepitant to control N/V?
May inhibit hormonal contraceptives x 28 days
What are the anesthesia related changes that we need to be aware of related to radiation treatment for cancer of the head/neck?
D/t peripheral vascular damage you are x6 more likely to have embolic events, increased risk of hypothyroidism, carotid artery disease likely and neck ROM is likely impaired
What chemotherapeutic can cause cardiomyopathy?
Adriamycin
What chemotherapeutic can cause pulmonary toxicity?
Bleomycin
What chemotherapeutics can case peripheral neuoropathy?
Cisplatin and vincristine
What lab abnormalities are common s/e of chemo?
Preoperative anemia, neutropenia, and/or thrombocytopenia
Preoperative hypercalcemia (Many drugs toxic to bone marrow, liver, and kidneys)
Adrenal insufficiency (r/t steroid treatment
Assess ACTH stimulation test)
How does inflammation from tissue trauma and physiological stress promote cancer growth?
Activate overexpression of COX2 genes
Catalyzes prostaglandins and thromboxane from arachidonic acid
Elevated levels promote cell survival and growth of cancer cells
May suppress NK cells
How does beta adrenergic stimulation promote cancer growth?
The tumors have beta receptors, stimulation allows for upregulation of the biological activity
What anesthetic agent has the ability to reduce cancer growth/spread?
Propofol
What effect does long term NSAID use have on cancer?
Decreased proliferation
What is the most common type of lung cancer?
Non-small cell
What is the origin of small cell cancer?
Generally neuroendocrine
What type of cancer always recurs and is resistant to further treatment?
Small cell cancers
What are the secondary conditions related to small cell lung cancer?
Hyponatremia (d/t SIADH), hypercortisolism and lambert-eaton syndrome
How does Lambert-Eaton syndrome differ from myasthenia gravis?
Improves with exercise, ACh inhibitors don’t work and they are very sensitive to non-depolarizers
What condition would you expect if the patient exhibits extreme lower limb fatigue that does not improve with exercise?
Myasthenia gravis
What neuroendocrine tumor is usually benign with a high survival rate?
Carcinoid tumors
What is carcinoid syndrome?
A carcinoid tumor likely of GI origin releasing serotonin, histamine, tachykinins, kallikrein, prostaglandins causing hemodynamic collapse and coronary artery spasm
Treatment of carcinoid syndrome?
Octreotide
What type of cancer is pathologically heterogenous?
Non-small cell lung cancer
40% chance of survival with surgery, without surgery its 10%
What type of cancer grows to a large size but metastasizes late?
Squamous cell
What s/sx are common to squamous cell cancer?
Hemoptysis
Obstructive pneumonia
Superior vena cava syndrome
Endobronchial tumor
This is d/t the mass effect of the tumors
What type of cancer tends to metastasize early?
Adenocarcinomas
What cancer tends to secrete growth hormone and secrete ACTH?
Adenocarinomas
What type of cancer would you expect to find insulin resistance, a buffalo hump and avascular necrosis of the femoral head?
An adenocarcinoma
What type of non-small cell cancer tends to metastasize rapidly and cause large cavitating tumors?
Large cell
What are the “M’s” of assessing a patient with lung cancer?
Mass effect
Metabolic abnormalities - Hypercalcemia, hyponatremia, hyperglycemia (Cushings)
Metastases
Medications - Bleomycin: oxygen-induced pulmonary toxicity, Cisplatin: ARF with NSAIDS
What factors predict desaturation during 1 lung ventilation?
- High % of ventilation or perfusion to the operative lung on preop V/Q scan
- Poor PaO2 during 2-lung ventilation
Especially in the lateral position - Right-sided thoracotomy
How many dermatomes can a paravertebral block cover?
4 - 6
Contraindications to a paravertebral block?
Infection at site
Empyema
Tumor in the paravertebral space
Chest deformities (kyphoscoliosis)
What level of paravertebral block is indicated for a sternotomy?
T4
What level of paravertebral block is indicated for a thoracotomy?
T6
What level of paravertebral block is indicated for an abdominal procedure?
T10
Indications for an intercostal block?
Thorax and upper abdomen surgery and mastectomy
How many dermatomes require blockade if an intercostal block is performed?
2 dermatomes above/below incision
Risks of a paravertebral block?
Pneumothorax and LA toxicity
What cells are the initiators of hypersensitivity?
Basophils and mast cells
What medication should you continue through pre-op for a scleroderma patient?
CCBs
