Prodigy Films A to F Flashcards
What hormones use cAMP?
Beta receptor catecholamines, PTH, Glucagon, TSH, FSH, LH
How is cAMP action terminated?
Phosphodiesterase
What is Adrenal outer-layer?
Zona Glomerulosa
Adrenal Glomerulosa secretes what?
Mineralocorticoids - aldosterone
Zona fasciculata secretes what?
Glucocorticoids
Zona reticularis secretes what?
androgens
what controls release of glucocorticoids?
ACTH
what controls release of mineralocorticoids ?
Renin/ Angiotensin system
drug potency determined by what?
determined by the affinity of the drug for its receptor
Desflurane at altitude, do you need to turn dial up or down?
At elevation ( high altitude), lower partial pressure (lower barometric pressure) so need to turn up Tec 6
amides vs esters lipophilicity and PB?
more lipophilic and more protein bound than esters
amides metabolized how and which are fast and which are slow and why?
CYP 450, prilocaine fastest, ropivacaine slowest
bupivacaine = enzyme activity, prilocaine = hepatic blood flow, metabolism altered by liver disease
Amide toxicity more or less likely than ester and why?
toxicity more likely with amide than ester, rely on hepatic clearance
Normal aortic valve area ?
2.5-3.5 cm2
Atrial Natriuretic Factor acts where and why, how does it work?
on collecting ducts of kidneys because of increased fluid in atria to inhibit water and sodium reabsorption, inhibits renin release
what is bilirubin and how is it broken down?
breakdown of heme metabolism, heme broken down to unconjugated bilirubin which is water insoluble @ high level neurotoxic, than uncog is delivered to liver bound to albumin, liver then metabolizes it with glucoronic acid and conjugates it and eliminates it thru bile
how is TBW composition made up?
60% is TBW, 40% intracellular , 20% extracellular, (extracellular than broken into plasma and interstitial)
what is anion ?
A -A N- negative ion ( mnemonic to remember it by)
Major intracellular cation and anion ?
Anion= Phosphate PO4, Cation = K+
Major extracellular anion and cation ?
anion = Chloride. cation = Na+
What is Bohr effect ?
describes how CO2 and decreased pH promote o2 release into tissues.
pH is lower, Temperature is higher, Increased CO2, O2HGB shift curve to RIGHT
What is Boyles Law?
pressure and Volume, P1V1 = P2V2, inverse relationship
as P up, volume down and vice versa,
which Bronchi leaves at less of an angle?
Right, why more likely to mainstem
how does calcium calmodulin system work?
once 3 calcium bind onto calmodulin receptors, the calmodulin then changes shape and is now able to bind to protein kinases that are able to exert an effect. it can activate myosin light kinases that are able to stimulate smooth muscle contraction
what do carcinoid peptides release?
histamine, serotonin, kinins
what are carcinoid symptoms?
hypo/HTN, flushing, diarrhea, bronchoconstriction
how does carcinoid syndrome affect the heart?
can cause fibrosis of right sided valves (TV & PV), (left sided valves not affected as lungs deactivate peptides
what is treatment of carcinoid syndrome?
octreotide & surgical excision of tumor
what is anesthesia keys to carcinoid syndrome ( what to avoid)?
avoid adrenergic stimulation (USE PHENYLEPHRINE), avoid histamine release - morphine, pancuronium, atracurium, & avoid increased RV work = hypoxia, hypercarbia, & light anesthesia
where is PMI and what is it?
point of maximal impulse, best place to listen to S1, heard at apex at 5th intercostal space midclavicular line
what is CO during labor? when does it peak? why is this important?
can be as high as 12-14 L/min,
peaks at 80% above baseline right after delivery
pt’s with cardiac hx at most risk for decompensation
how long until CO returns to normal after delivery?
2 weeks
what are cardiac changes at term?
diaphragm shifts heart up & left
increased risk of dysrhythmias (PACs, SVTs, Vent Dysrhythmias,
Left axis shift
Larger cardiac silhouette or CXR
How does pregnancy affect SVR, CO, DBP, MAP. . . ?
SVR decreases 20%, CO increases 40% mostly from 50% SV, diastolic BP decreases by 15 mm Hg and thus MAP can decrease
the supra-tentorial brain is composed of what
cerebral hemispheres and diencephalon
the infra-tentorial brain is made up of what?
cerebellum and brainstem
what are 4 lobes of brain
frontal, parietal, temporal and occipital (temporal over ear, Parietal over bald-spot area)
what is diencephalon made up of?
thalamus and hypothalamus
what does hypothalamus do
relay for sensory and and motor information, connected to pituitary, does endocrine and autonomic functions
what makes up limbic system & what is it responsible for
hippocampus, amygdala, and part of cortex,
for cognition, memory and emotion
what makes up brainstem & what is it responsible for
Midbrain, Pons & medulla,
responsible for consciousness, respiratory and cardiac control & many reflexes
what is cerebellum function for?
proprioception and maintaining posture and gait
discuss cerebral metabolism % (#’s bodyweight, )2 & glucose consumption)
makes up 2% of body weight
20% of O2 consumption
25% of glucose consumption
what is normal cerebral metabolism CMRO2, glucose & % CO ( #’s)
3-4 mL/100g/min
glucose consumption 5g / 100 g / min
15% of CO or 750 ml / min
when is MAP autoregulated values?
between a MAP of 60-160 mm Hg
what is CPP formula (cerebral)?
MAP - ICP (CVP)
how does ventilation affect CBF?
hypoventilation = increases CBF & increases CO2 Hyperventialion = decreases CBF & decreases CO2
how do Volatiles affect CMRO2, CBF?
cause cerebral vasodilation
impair CBF auto-regulation
decrease CMRO2
minimal increase CBF at low doses
how does Nitrous affect CMRO2 & autoregulation (important for brain & heart cases which is when we avoid it)
causes cerebral vasodilation
potentially increases CMRO2
preserves autoregulation with propofol
impairs autoregulation with VA
what is Charles’ Law?
V1T2 = V2T1,
direct relationship like a hot air balloon
what are examples of weak drug bonds?
hydrogen bonds, ionic bonds & van der Waals bonds (weakest, distant dependent )
examples of strong bonds?
covalent bond, permanent bond, ASA & COX
what is the chemical structure of inhaled anesthetics
VA are ethers, meaning R-O-R structure,
what are iso, des and sevo chemical structures
Iso 5 F, Des 6 (like tec 6), Sevo 7 (seven Sevo)
Isoflurane has Cl
adding fluorines increases potency as does heavier halogens
adding halogens increases arrhythmias
how does fluorine affect flammability and metabolism
adding more F ions decreases flammability and metabolism (even tho sevo 2%, iso 0.2 & Des 0.02%)
describe liver cirrhosis
increase in resistance to blood flow from fibrous tissue = portal HTN
what are dangers of portal HTN?
cardiac, renal and pulmonary disorders
hemostasis alterations
ascites and varices
hepatic encephalopathy
what are cardiac effects of cirrhosis
hyperdynamic state Decreased SVR Decreased BP Increased HR Increased CO
what are systemic effects of cirrhosis
hyponatremia anemia thrombocytopenia hyperbilirubinemia hypoalbuminemia
how is cirrhosis scored
MELD score - provides 3 month mortality risk
Child Pugh score as well
what is a critical incident
powerful and overwhelming event that lies outside the range of human experience
what is an adverse event
an unintended patient injury, harm or complication that results in a prolonged hospitalization, disability or death
what is a medical error
the failure to take a known & planned action or using the wrong plan of action to achieve an outcome
what is closing capacity
closing volume + residual volume
what is FRC
volume left in lungs at end of normal exhalation
what factors lower FRC
obesity
sedation
supine position
what is closing capacity at 45 & 65
CC at 45 = supine
CC at 65 = sitting position
what factors increase closing capacity
COPD,
Asthma
pulmonary edemas
CO2 and blood brain barrier
CO2 + H20 —> H2CO3
H2CO3 —> H + HCO3
CO2 INDIRECTLY influences ventilation as H can’t cross BBB but CO2
H+ DIRECTLY influences ventilation
Describe CO2 ventilatory curve
its a linear relationship from 20-80 mm Hg
Combined Spinal EPidural benefits
Spinal fast on
Epidural long term pain control that can be converted to surgical anesthesia if needed
Opioid only spinal advantage
produces no motor block, good in aortic stenosis and preload dependent conditions
give example of Competitive antagonism
NDMR (ROC) compete with acetylcholine at NMJ
Shifts effective dose curve RIGHT ONLY
Describe noncompetitive antagonism
binds permanently
Shifts effective dose curve RIGHT & DOWN
What is Tort
civil wrongdoing,
Negligence & malpractice
What must plaintiff prove (4 things)
Duty
Breach of Duty
Causation
Damages
what is acceptable standard
reasonable & prudent manner must be demonstrated
WHat is proving proximate cause
‘But for’ Test
Substantial Factor Test
what is Res Ipsa Loquitur
Only occurred due to negligence
Factors only under CRNA control
Can’t be attributed to the patient
Evidence more accessible to the CRNA
What are the damages seen in court?
Pain & suffering
Special damages: actual expenses due to the injury
Punitive damages : from CRNA Fault, rare in medical malpractice, could lose CRNA license
What is vicarious liability?
this affects the employer
respondeat superior - the employer has a duty for the reasonable oversight of the employee
what is concentration effect
inhaled partial pressure (PI) influences alveolar partial pressure (PA)
Higher the PI than faster PA approaches PI
WHat is Conn Syndrome
Primary hyperaldosteronism
What does aldosterone do
Increases Na reabsorption & K excretion in DCT / CT
What are s/s of Conn Syndrome
Fluid volume excess / HTN - from Inc Na levels
Hypokalemic metabolic alkalosis - K excretion
Muscle weakness - K excretion
Decreased renin levels - From HTN feedback loop
WHat is treatment of Conn’s syndrome?
Spironolactone/ Eplerenone (get rid of Na & retain K)
Tumor removal as most likely from adrenal tumor
What is conscientious objection?
What do you do about it?
unwilling to provide care because of advanced directive - consult ethics committee
- transfer care to another CRNA
- honor pt’s decision and deliver care
- Cannot remove self if result in harm of breach of duty
what is countercurrent mechanism?
WHat part of kidney is in cortex vs medulla?
how kidney concentrates urine
cortex - DT, PCT, Glomerulus
medulla - Loop of Henle, CD
What are cardiovascular effects of VA?
What about N20?
Decrease MAP, CO, CI mainly from decreased SVR
exception is N20 = increases sympathetic stimulation, increases SVRM CVP and arterial pressure
What are HR effects of VA & N20?
HR increases with VA & N20
Seen more with rapid dose increase like Des
Sevo least effect on HR
What are Desflurane CI effects?
maintains CI more effectively than ISO / Sevo - likely due to increased HR
how to VA affect Myocardial contractility
all produce dose dependent decrease
does not affect myocardial functional reserve
How do VA affect RAP?
ISO/DES/N20 all increase RAP
Sevo does not affect RAP (right atrial pressure)
what is diabetic ketoacidosis triad?
more common in Type 1
-Hyperglycemia, ketonemia, acidosis
what are DKA s/s?
Elevated Anion Gap Hyperosmolarity Glucose 250+ Electrolyte depletion lethargy/ Kussmaul breathing
what factors affect diffusion?
of molecules,
opening in membrane
molecular velocity
What are regulatory proteins?
proteins that control gene expression
targeted by hormones and drugs such as antineoplastic agents
ESRD and drug pharmacokinetics
- ESRD pt’s have less proteins, so highly protein bound drugs may require a lower dose due to higher free fraction of the drug
- ESRD pt’s are acidoic which can change drug ionization & pKa
- renally excreted metabolites can prolong duration of action
what is the ED50 vs LD50?
ED50 - dose that produces the desired response in 50% of patients
LD50 - dose tha tis lethal in 50% of patients
why is ED50 important?
ED50 is used to compare potency, lower ED50 the greater the potency, yes lower ED50 increased potency
What is LD50/ED50?
therapeutic index
how do you calculate Safety margin of a drug?
LD1 - ED99 / ED99 x 100 = safety margin
what is first order kinetics
half drug eliminated per half life
how long until a drug is completely eliminated from system?
4 half lifes (only 5% remains then)
how are half life and clearance and Vd related?
Half life is inversely proportional to clearance.
directly proportional to volume of distribution
What are ester local anestehtics & how are they metabolized
one i in name - procaine, tetracaine, cocaine. . .
metabolized by plasma and tissue cholinesterase’s (except cocaine which is metabolized in liver)
Ester metabolites & metabolism
- PABA and thus allergy more common,
- cross sensitivity more common within esters
- impaired metabolism with liver disease and elevated BUN, pregnancy, chemo agents & atypical plasma cholinesterase
what is an example of a variable extra-thoracic obstruction
- unilateral vocal cord paralysis
- on flow volume loop shows normal expiraotyr pattern but inspiratory pattern is chopped off
