RANDOM FACTS for SEE 1 Flashcards
Soda lime equation
CO2 + Ca(OH)2 → CaCO3 + H2O + heat (in the presence of water
How would excessive tubing affect a-line waveform
OVERDAMPING
How would multiple stopcocks affect the a-lie waveform
Overdamping
Dandrolene use to treat 2 conditions
MH and Neuroleptic Malignant syndrome
MOA of Dandrolene is
Reduces Calcium (Ca2+) release from SR, relaxes skeletal muscle
How do you mix dandrolene is?
20 mg in 60 mLs
Preparation for a patient with known MH include
Change breathing circuit
CO2 absorbent
Disable or remove vaporizers
Filters use for MH include
Charcoal filters
Malignant Hyperthermia Association of US recommends for patients with MH
Charcoal filters
High Fresh gas flow (10L/min) throughout maintenance phase of anesthesia.
Malignant Hyperthermia Association of US (MHAUS) recommends for patients with MH
Charcoal filters
High Fresh gas flow (10L/min) throughout maintenance phase of anesthesia.
Receptor involves in MH
Ryanodine Receptor.
MH triggers are
VA
Succinylcholine
Acute MH sequence of action (nagelhout)
- Immediately d/c Va and succinylcholine
- Call for help and tell surgeon to conclude the procedure promptly
- Prepare and administer DANTROLENE 2.5mg/kg and repeat every 5-10 minutes until symptoms go away
- Hyperventilate with 100% O2
Cushing’s reflex triad is
Bradycardia
Hypertension
Widening Pulse pressure (rising SBP, declining DBP)
Cushing’s reflex triad is
Bradycardia
Hypertension Widening Pulse pressure (rising SBP, declining DBP)
Irregular respirations
What does 2 main things cushing reflex presence means?
- Late signs of increased ICP
2. Herniation is IMMINENT
Focused Neurological exam first sign of ICP increase is
Papilledema
EEG: Order in which Frequency DECREASE and Amplitude Increases: (FDAI) BAT Drink
Beta
Alpha
Teta
Delta
EEG: Order in which DECREASE Frequency and Amplitude Increases (DFAI) BAT Drink
Beta (low)
Alpha (high)
Teta (high)
Delta (Max)
Wave for AWAKE with EYE OPEN
Beta waves
BAT DRINK BLOOD- in sleep (EEG waveform for awake –> DEEP SLEEP)
Awake with eyes open--> BETA Awake with eyes closed--> ALPHA Stage I light sleep: Theta waves Stage II Intermediate sleep: SLEEP SPINDLES Stage 3/4 Delta waves REM / Paradoxical SLEEP: Beta waves.
CBF is kept constant by________range of _____to _____
Autoregulation 65 mmHg to 150 mmHg
Autoregulation of CBF is
Arterioles adjust keep CPP and MAP over wide range of pressure changes.
When the MAP is < 65 OR greater than 150mmHg what happens in the brain?
brain is not able to autoregulation and becomes dependent on MAP
As long as CPP>60 mmHg, what is more important to control?
ICP control is more important than further increases In CPP
What is the MONRO-KELLIE hypothesis?
Cranial compartment is enclosed in a NONexpandable case of bone, thus the volume inside the cranium is fixed, , BLOOD , CSF and BRAIN exists in the state of equillibrium.
When Should CVP measurement be measured? why?
End exhalation; lowest negative intrathoracic pressure.
2 main determinants of CVP
- Right ventricular function
2. Venous return.
What can determine venous return (TV CRI)
Total blood volume Venous tone CO Right ventricular contractility Intrathoracic pressure.
3 contraindications to PAC insertion
LBBB
WPW and Epsteins anomaly
What is Mixed venous O2 saturation (SvO2)?
% of Oxygen BOUND TO HGB returning to the right side of the heart.
Factors that LOWER SvO2? 2 main reasons;
Decrease O2 delivery
Increase O2 consumptiom
Factors that INCREASE SvO2? 2 main reasons;
Increasing O2 delivery (high FiO2, hyperoxia)
Decreasing O2 demand (Hypothermia, NMB)
High FLOW states (sepsis, liver disease)
High Flow states occurs in
Sepsis
liver disease
When does the diastolic PAOP offers the best approximation of the LVEDP when what wave is present ?
LARGE v Waves
SVR formula
MAP-CVP/CO x 80
When do you see large V waves? MiMrDacIs
MI
MR
DAC (decrease atrial compliance)
IS Increased SVR
Calorimeter CO2 detector requires how many breaths to detect?
6 breaths
Factors that increase CO2?
Hypoventilation Hyperthermia Hyperthyroidism Rebreathing (baseline elevation) Release of cross clamp
Factors that decrease CO2?
Hyperventilation
Low cardiac output
Hypothyroidism
PE
How does PE affect CO2?
Decrease CO2
Calorimeter turns ____in people with intact circulation
yellow
Flat ETCO2 waveform
Cardiac arrest
Vent disconnect
Airway misplaced in esophagus
Pulse Ox explained by the
Beer Lambert law
Pulse oximetry work on the principle of
Absorption spectophotometry
How does Methemoglobin affect O2 saturation?
Tends to trends toward < 85%
Methemoglobin shifts the O2 oxhemoglobin curve to the
LEFT
Methemoglobinemia is confirmed by
COoximetry
CO and O2 affinity to Hg
CO has 200X the affinity as O2
High levels of Carboxyhemoglobin (COHgb) on the oxygen carrying capacity
Reduced Oxygen carrying capacity of blood. and will give FALSE HIGH pulse ox reading.
If COHgb is > 25%
Hyperbaric oxygen
Low SPO2 by dyes, name 3
Methylene blue
Indigo Carmine
Indicyanine green
4 phases of capnogram: Phase I
Exhalation of CO2 free gas from dead space
4 phases of capnogram: Phase II
Combination of dead space and alveolar gas
4 phases of capnogram: Phase III
Exhalation of mostly alveolar gas
4 phases of capnogram: Phase IV
inhalation of Co2 free gases
Types of capnometers: 2
mainstream
sidestream
Cuvette heated to 40C is what type of capnoeter
Mainstream
Mainstream capnometer is placed between E
ET tube and breathing circuit
Response time of MAINSTREAM is
Fast
RESPONSE time of Sidestream is
Slow
Capnography vs capnometer
Capnography shows WAVEFORM
Capnometry shows numbers
Dicrotic notch is the
closure of the aortic valve.
Late sign of hypoxemia is
Cyanosis
IABP provide counter pulsation during ______for 2 main reasons which are?
Diastole
INCREASE Coronary perfusion, Decrease afterload.
Cerebral oximetry measures global or regional ? how does it work?
REGIONAL ; Transcutaneous measure of the cerebral cortex.
Cerebral oximetry uses measure oximetry through
NIRS (Near Infrared spectroscopy)
Cerebral oxygen supply is determined by what 2 things?
Cerebral blood flow
Arterial oxygen content
Cerebral oxygen demand is determined by
CMRO2
First alert of impending organ dysfunction: Which monitor?
Cerebral oximetry
What is the part of the brain with limited oxygen supply and is more susceptible to ischemic injury?
Cerebral cortex.
SSEP signals recordings are obtained from which 3 different points?
Peripheral nerve at a proximal level (integrity of peripheral nerve) Brainstem (sensory tracks of the spinal cord) Cerebral cortex (sensory cortex)
Intraparturm fetal monitoring mnemonic :
VEAL CHOP MINE
Variable deceleration –> Cord compression/prolapse
Early deceleration –> Head compression
Acceleration –> Okay or O2
Late decelerations –> Placental insufficiency.
Move position
Initiate secondary measures
Nothing
Emergency delivery
Normal fetal heart rate varies from
110-160 bpm
Fetal monitoring DECELERATIONS means
Decrease in O2 delivery to the fetus.
Decelerations are characterized by
decrease from baseline of at least 15 minutes lasting 15s or longer than 2 min
Most common heart arrythmia
Atrial fibrillation
When to use a pacemaker magnet?
Surgical Site within 6 inches to the pacemaker
If you don’t have enough time to interrogate pacemaker, what are your course of action?
Place A-line
Magnet over PM
Tell surgeon to use SHORT BURSTS with electrocautery.
Traditional GOLD standard modality among ANCILLARY test for brain death is
Four-vessel cerebral angiography
Are CONFIRMATORY /Ancillary test that confirm the loss of bioelectrical activity of the brain in brain death always mandatory?
NO/
Most IMPORTANT and MANDATORY test for the determination of brain death is
APNEA TESTING
Absent corneal reflex in brain death is demonstrated by
touching cornea with a piece of tissue or paper or a cotton swab, NO EYELID MOVEMENT SHOULD BE SEEN
Apnea testing : the patient must have
complete absence of documented respiratory effort by formal apnea testing, demonstrating a PaCO2 60mmHg and 20 mmHg or greater increase above baseline. if NO respiratory effort is observed after initiation of the time of PaCO2 60mmHg or 20 mmHg above baseline, the APNEA test is consistent with BRAIN DEATH
Brain death , pt should be what before the test?
Preoxygenate with 100% oxygen for 5-10 minutes before the test.
In brain death: Absent oculovestibular test is tested by
irrigating each ear with ice water 10-15ml (caloric testing), after patency of the external auditory canal is confirmed. Head is elevated 30 degrees. MOVEMENT OF THE EYE SHOULD BE ABSENT during 1 minute of observation.
Temperature in brain death testing
Normothermia > 36C ; hypothermia must be corrected before the criteria for brain death are applied.
Doll’s test in brain death is
The oculocephalic reflex, also known as Doll’s eyes response, is elicited upon brisk turning of the head from middle position to 90° on both sides. In comatose patients without lesions of the brainstem, the eyes normally conjugately deviate to the other side. In BD no eye movements are observed
Normal caloric test in brain death, eyes deviate to
Side of ice water application
if BRAIN DEATH, no eyes deviation occur.
Normal caloric test for NON BRAIN death patient? What about in brain dead patients?
Head to the right, EYES to the left
Head to the left, eyes to the right
NO EYE MOVEMENT in brain death patients.
ASA I
A normal healthy patient
Healthy, non-smoking, no or minimal alcohol use
ASA II
A patient with mild systemic disease
Mild diseases only without substantive functional limitations.
ASA II
Current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease
ASA II
ASA III
A patient with severe systemic disease
Classify this ASA poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse,,
III
ESRD undergoing regular dialysis ASA
III
Pt with implanted pacemaker, moderate reduction of ejection fraction no other issues ASA
III
Premature infant PCA < 60 weeks, ASA is
III
History (>3 months) of MI, CVA, TIA, or CAD/stents.ASA
III
A patient with severe systemic disease that is a constant threat to life –> ASA
IV
ASA for recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or
IV
ESRD not undergoing regularly scheduled dialysis ASA
IV
A moribund patient who is not expected to survive without the operation ASA
V
ASA Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect
V
ASA for ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
V
A declared brain-dead patient whose organs are being removed for donor purposes ASA
ASA VI
MRI safety zone I is
All areas freely accessible to staff with no restrictions
MRI safety zone II is
Restricted , under supervision of radiology personnel.
Designated for Screening and safe from the magnet field, which MRI zone
Zone II
MRI safety zone III is
Restricted, ONLY MR personnel and patients FOLLOWING screening and interview have access.
MRI control room and monitoring areas is what zone?
Zone III
MRI safety zone IV is
Immediate area around the scanner
OMPHALOCELE how to remember whether or not covered by peritoneum
Big O to remember a circle and that the abdominal contents are sealed by the O, and thus are covered by the peritoneum
GASTROCHICIS how to remember whether or not covered by peritoneum
G is a almost a circle but has an OPENING, meaning the abdominal contents come out of that little opening therefore the ABDOMINAL contents NOT covered by peritoneum.
What remains intact during brain death? what is one implication?
SPINAL and AUTONOMIC reflexes? Still need NMB agents.
Organ procurement drugs used are LMH TV
Lasix
Mannitol
Heparin
T3 hormone and /or Vasopressin.
When is anesthetic concluded during organ procurement surgery?
Once aortic cross clamp isapplied, COLD CARDIOPLEGIA solution is infused, Ventilation is D/C’d and the anesthetic management is concluded.
What principle is based on patient’s RIGHT to make decision about their medical care?
Autonomy
What principle is based on obligation of Clinicians to NOT HARM PATIENTS?
Nonmaleficence.
Clearly defined codes of conducts that govern the actions of all clinicians and to novel moral dilemmas is
ETHICS
What does HIPAA stands for?
Health Insurance Portability and Accountability Act
When was HIPAA enacted
1996
2 provisions of HIPAA
- define procedures and guidelines for covered entities protecting privacy and security of individuals
- Setting civil and criminal penalties for guidelines violations.
What rule of the HIPAA regulates the use and disclosure of Protected Health Information (PHI)?
Privacy rule
The security rule of HIPAA only covers
PHI in electronic form only
All medical records, be they be oral written, electronic are covered by the
HIPAA Privacy rule.
Name 2 class III antidysrhtymics
Amiodarone
Sotalol
90% of congenital diaphragmatic hernias occur: through the
left posterolateral foramen of Bochdalek
What are the hallmarks of diaphragmatic herniation (HBS)
Hypoxia
Bowel in the thorax (evidence of )
Scaphoid abdomen
During Diaphragmatic herniation repair, Peak airway pressures should not _______why?
exceed 30 cm H2O to minimize the risk of pneumothorax during surgical correction.
Severity of injury in malpractice claims is decreasing as indicated by the lower claims for death and brain damage due to
Use of pulse oximetry
Capnography
2 most frequents sites of injury nerve related
ULNAR nerve
Brachial plexus
Adverse outcomes associated with ________ events were found as the SINGLE LARGEST CLASS INJURY with ____% in the ASA CLOSED CLAIMS PROJECTS
Respiratory ; 37%
Most common eye injury under anesthesia is
CORNEAL ABRASION.
3 causes of postop visual loss
1.Retinal artery occlusion
2. Ischemic optic neuropathy
Cortical blindness.
Why is a magnet place over a pacemaker?
Convert from SYNCHRONOUS to asynchronous or Fixed rate
Minimize pacemaker interference Unipolar or bipolar?
Bipolar
Remembering the factors mnemonic
What factors isn’t included or is non existent: Factor VI.
Foolish- Fibrinogen - I People - Prothrombin - II Try - Tissue thromboplastin - III Climbing - Calcium - IV Long - labile factor - V Slopes - Stable FACTOR - VII After - Anti Hemophilliac Factor A - VIII Christmas - Christmas factor - IX Some - Stuart PROWER FACTOR - X People - Plasma Thromboplastin antecedent - XI Have - Hageman factor - XII Fallen - Fibrin stabilizing factor - XIII
Pain originating from abnormal function of an internal organ is
Visceral pain
Pain arising from nociceptive input from the skin , subcutaneous tissues, and mucous membrane. characterized by sharp, throbbing and burning
Somatic.
Chemical mediators of pain (2)
Substance P
Glutamate
Goal of management in the patient with CRPS (Complex regional pain synrome)
Restore movement and strength in the region.
What is POSTHERPETIC NEURALGIA?
Common pain syndrome that transpire after an episode of herpex zoster.
What is shingles?
Reactivation of the latent VARICELLA ZOSTER VIRUS, that remains in the DORSAL ROOT GANGLION>
Shingles follow or spread
Spread within a sensory dermatome.
Pain induced by a stimulus not normally painful is defined as
Allodynia
What is the major disadvantage of the traditional circle systems in a pediatric patient is
Unpredictability of and accuracy of TV delivery .
Only anesthetic that can be administered IM
Ketamine.
Parkland formula
total fluid requirement in 24 hours is as follows:
4ml x TBSA (%) x body weight (kg);
50% given in first 8 hours; 50% given in next 16 hours.
The risk of Postanesthetic respiratory depression is _________related to ______-age and ________ at the time of anesthesia
Inversely related
Gestational age and Postconceptual age.
Central apnea MOSTLY associated with top 3 factors
Opioids
Sepsis
Anemia
Central apnea from immaturity of the respiratory drive center is treated with
Xanthine derivatives such as CAFFEINE and THEOPHILLINE
Most practical way to manage infant at risk for central apena
Admit and monitor all infants less than 60 weeks PCA until they are free of symptoms
Neonates are obligate______breathers
NOSE
Bronchopulmonary dysplagia treatment is
Supportive
4 classic findings of Tetralogy of Fallot
- VSD
- RV outflow tract obstruction (RVOT)
- RV hypertrophy
- Overriding aorta
Patients with Tetralogy of fallot are at risk for
TET SPELLS cause by acute spasm of the infundibulum, brought on by crying, feeding or ANY THING THAT INCREASE OXYGEN CONSUMPTION
What to do with patient with Tetralogy of fallot having a tet spell?
Increase SVR
Decrease PVR in order to reverse the shunt from R TO LEFT to left to right and allow for better oxygenation
TET spell : infants having tet spells what position
Knee to chest to increase SVR
Transposition of the great arteries main goal
Maintenance of CO
VACTERL mnemonic vs VATER associated with what 2 condictions
Esophageal Atresia and TrancheoEsophageal Fistula.
Vertebral defects Anus imperforated Cardiovascular abnormalities TEF Radial and renal Limb anomalies
VATER excludes, LIMB and Cardiovascular abnormalities.
Most common type of TEF
Type IIIB/ C
Diagnosis of TEF is made by
Chest and abddominal radiography reveal inability to pass an Orogastric tube which lodges in the blind esophageal pouch.
How should the infant with TEF be nurse
Prone or in lateral position an an incline of 30 degrees to decrease the risk of aspiration.
Staged repair of what lesion ?
TEF
How do you intubate the patient with TEF, first step is to
Suction the upper esophageal pouch and adminsitration of oxygen
What is intentionally done when intubating a child with TEF?
An intentional right mainstem endobronchial intubation is initially performed. Then the ETT is slowly withdrawn while auscultating. the left thorax until breath sound are heard to make sure you are just above the carina and past or below the fistula.
Common way of feeding infant with TEF include
Gastrotomy and TPN .
Pyloric stenosis is
Gastric outlet obstruction
Cardinal features of Pyloric stenosis
Persistent Projective NONbilious vomiting
Peristalsis (visible)
HYPOCHLOREMIC METABOLIC ALKALOSIS
Acid base disorder associated with pyloris stenosis is
HYPOCHLOREMIC METABOLIC ALKALOSIS>
Diagnosis of pyloric stenosis is
Abdominal US and PALPABLE OLIVE-SIZED mass in the UPPER ABDOMEN or distal pylorus.
Anesthetic management in pyloric stenosis
Full stomach, RSI
even if children comes with NG tube, stomach should be suctioned with a red rubber catheter.
How do you suction the patient with pyloric stenosis before induction?
SUPINE, RIGHT, and LEFT lateral positions immediately before induction of anesthesia to cover all 4 quadrants of the stomach
What is the most common surgical emergency in neonates?
Necrotizing Enterocolitis (NEC)
What is necrotizing enterocolitis? who is more at risk?
Inflammatory necrosis of the bowel. micropremies
2 things that confirm NEC is
Pneumatosis Intestinalis
Portal venous air.
A line isolation monitor – > An alarm does not mean there
is imminent danger to the patient or anyone else.
Line Isolation Monitor, The alarm therefore simply calls
attention to the fact that the system has converted
to a partially grounded system
Microshock: As little as_____ can cause VF.
100 μA
Threshold of perception, a slight tingling at the fingertips
1 milliA (mA)
mA—maximum harmless current.
5 milliA (mA)
pain, fainting, and exhaustion.
50 mA
Ventricular fibrillation (VF) will likely result. with ____mA
100 mA
Single-twitch stimulation: A single supramaximal electric current is applied at a frequency ranging from
1.0 Hz ((one every second) to 0.1 Hz (one every
10 s)
Train-of-four stimulation:
Four stimuli at 2 Hz are applied (four stimuli in 2 s) that are repeated every 10 to 12 s if needed
NMB blockade degree is measuredd.
The ratio of the fourth response to the first response (T4/T1 ratio) is used to assess the presence of
neuromuscular blockade and its degree.
What concerns are there whenever a patient with persistent AF is cardioverted? What test is needed?
There is a concern that a thrombus could be located in the left atrial appendage which could embolize to the brain and cause a stroke. A transthoracic echocardiogram or transesophageal echocardiogram is usually performed to rule out the existence of a thrombus.
The major causes of maternal cardiac arrest are: From most to least common
Pulmonary embolism 29%
Hemorrhage 17%
Sepsis 13%
Peripartum cardiomyopathy 8%
Measures of the extrinsic coagulation pathway
Prothrombin time (PT) and its derivative the international normalized ratio (INR)
Factors that are made in the liver are
Factors I (fibrinogen), II (prothrombin),V, VII, and X are made in the liver. (1,2,5,7,10)
For liver issues: The Child-Pugh score considers five factors, three of which assess the synthetic function of
the liver ____,____,_____along with two more
subjective clinical factors ____and _____
(total bilirubin level, serum albumin, and INR) (degree of ascites and hepatic encephalopathy).
The Model for End-Stage Liver Disease (“MELD”) score uses (BIC)
Bilirubin
INR
Creatinine
Management of DIC should involve:
- Treatment of the underlying cause
2. Supportive therapy and replacement of blood components
The major focus of management of DIC is
specific and vigorous treatment of the underlying disorder.
The platelet count is expected to rise by
30–50 × 10−9/L after the transfusion of a single pooled unit.
Fresh frozen plasma: a standard dose of____ml/kg for active hemorrhage
10–15 mL/kg should be used during active hemorrhage
What coagulation factors would most likely be elevated in obese patients? (select two)
Fibrinogen, factors VII, VIII, von Willebrand factor, and plasminogen activator inhibitor are elevated in obese patients.
NDMA -When stimulated by the excitatory neurotransmitter, glutamate, the ion channel
opens and allows calcium, potassium, and sodium ions to enter the cell.
CaKNa
The development of the central sensitization of chronic pain syndromes which receptor
NDMA
What is the largest interlaminar space?
L5
The sensory innervation for the nasal cavity is provided by the
opthalmic (V1) and maxillary (V2) branches of the trigeminal nerve.
The muscles that elevate the ribs are
inspiratory muscles.
The muscles that lower the ribs are .
expiratory muscles.
The most powerful Inspiratory muscles are the
external intercostals
The sternocleidomastoid muscles raise the sternum and contribute to inspiration as do the
anterior serratus and scalene muscles.
A good example of a variable intrathoracic obstruction is
tracheomalacia.
C1 esterase deficiency is responsible for a condition called The primary concern is airway obstruction. Even slight trauma to the airway can produce severe airway edema.
hereditary angioedema.
C1 esterase deficiency is responsible for a condition called
hereditary angioedema.
Primary concern for patient with C1 esterase deficiency at risk for angioedema.
The primary concern is airway obstruction. Even slight trauma to the airway can produce severe airway edema.
Which of the following explains why children have a faster uptake and more rapid increase in alveolar levels of inhaled anesthetic? (select two)
Increased cardiac output
Increased minute ventilation
The kidney position is similar to the _____position but utilizes ___________ to increase exposure of the kidney
lateral jackknife position but utilizes an elevated rest under the iliac crest to increase exposure of the kidney.
In the extrinsic coagulation pathway, disruption of the endothelium leads to exposure of tissue factor which binds to
Factor VII
Tissue Factor forms a complex with Factor VII, and in an enzymatic reaction requiring
Calcium, catalyzes the activation of Factor X.
Which of the following is most likely to occur as a result of respiratory alkalosis from hyperventilation?
Hypophosphatemia
Respiratory alkalosis from hyperventilation decreases phosphate levels because it
increases the use of ATP by the cells.
Respiratory alkalosis from hyperventilation decreases phosphate levels because it
increases the use of ATP by the cells.
The appropriate preoperative dose of cimetidine is
150 mg- 300 mg oral or IV.
The most common resident flora are
diphtheroids and coagulase-negative Staphylococci
Hallmark manifestations of the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
DUO UOH SOL
Decreased urine
UrineOsmoHigh
SerumOsmo Low
Large hepatic resections or resections of tumors near the vena cava or portal vessels carries a significant risk for
air embolism.
A tool for assessing the severity of liver disease.
MELD
End stage liver disease is generally associated with ____SVRvery low SVR,and increased mixed venous oxygen saturation. .
VERY low SVR
End Stage Liver Disease is associated with _____CI and ______resting HR
increased cardiac index, increased resting heart rate,
INR in liver disease
Increase
Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof is referred to as
Sentinel event
Process variation that didn’t affect patient outcomes, but carries a high risk for serious injur
A near miss
Identifies three components to quality: SOP
structure, process, and outcomes.
Is the facilities and environment in which care is administered and includes policies and procedures, governance, noise levels, ease of access, privacy, etc.
Structure
Is how the care is actually delivered and includes concepts such as compassion, communication, development of trust, etc.
Process
Involve the measurements of results of the care provided and includes elements such as mortality, morbidity, and speed of recovery.
Outcomes
The amount of time that a plaintiff has to file an action is called the
statute of limitation
When is the statute of limitation determined?
It is determined by state law and usually begins at the time the plaintiff discovers the negligent act,
The normal plasma osmolarity is about _______ mOsm, and most of this is due to _______ and its related ions.
290; Sodium
What are the primary inhibitory transmitters used by interneurons in the dorsal horn to modulate pain information? (select two)
GABA
Glycine
is a descending pathway involved in the modulation of pain signals.
The periaqueductal gray-rostral ventromedial medulla
Ascending spinal pathways are
The spinothalamic, spinohypothalamic, spinobulbar, and spinomedullary tracts
The majority of visceral afferent fibers are
A-delta and unmyelinated C fibers
You are inducing a patient for coronary artery bypass surgery and administer a large loading dose of fentanyl. The patient becomes difficult to mask ventilate and you suspect chest wall rigidity from the narcotic. What step should you take?
administer succinylcholine
Large doses of narcotics, particularly fentanyl, sufentanil, and alfentanil, can result in
chest wall rigidity that can make ventilation difficult or impossible.
Which of the following corticosteroids has the shortest elimination half-time?
Cortisone
Corticosteroids have elimination half-times between 3.5 and 5 hours.
Triamcinolone, betamethasone, and dexamethasone
Elimination half time of Dexamethasone
3.5-5 h
Much of the initial dose of local anesthetics such as lidocaine, bupivacaine, and prilocaine are removed from the circulation by the
Lungs
What is the initial bolus dose of 20% lipid emulsion therapy for a patient suffering from severe local anesthetic toxicity?
The initial bolus dose of 20% lipid emulsion for the treatment of local anesthetic toxicity should be 1.5 mL/kg followed by an infusion of 0.25 mL/kg/min continued for at LEAST 10 MINUTES AFTER hemodynamic stability is achieved.
Which H2 receptor antagonist would be most likely to interfere with drug metabolism by cytochrome P450 enzymes?
CIMETIDINE
As a result, cimetidine administration can result in increased plasma concentrations of several drugs including
LiQuiThe PPP W
lidocaine, quinidine, theophylline,,
procainamide, propranolol, phenytoin.warfarin, and
Most antiepileptic drugs are highly bound to
albumin.
As a result, hypoalbuminemia can result in an
increased concentration of the free form of the drug.
Medications that are also highly bound to albumin such as thyroxine and salicylates can do what to antiepileptic drugs.
can displace antiepileptic drugs from the protein and result in increased plasma concentrations as well.
Chlorpropamide is a long-acting sulfonylurea. It will produce ______
hyponatremia with serum sodium levels less than 129 mEq/L in about 5% of patients
Factors that increase the incidence of hyponatremia in patients taking chlorpropamide include age ________, gender? and use of what medications?
60 years, female gender, and the use of thiazide diuretics.
The most common events that result in anesthesia malpractice claims include
regional blocks (1/5 of all claims), respiratory issues (17%), cardiovascular problems (13%), and equipment problems (10%).
Occupational exposure to methyl methacrylate can produce
skin irritation, burns, allergic reactions, headache, neurologic symptoms, and reproductive disorders.
In patients, exposure to methyl methacrylate can produce
pulmonary hypertension, bradycardia, and hypotension.
A large, metal piece of equipment has become attached to an MRI magnet. The staff are preparing to turn off the magnet so that it can be removed. You know that (select two): How long does it take to turn of the magnet? What must happens before ?
It normally takes a few minutes to turn off the magnet
all personnel must vacate the scanner room while it is being turned off Because helium gas is vented,
Croup involves edema of the Airway above or BELOW the vocal cord
airway below the vocal cords (Thick C is below B)
The actual level at which shock (meaning the lack to oxygen delivery to the tissues) occurs is known as
Critical DO2 level.
In a patient who is otherwise healthy, the critical DO2 level can be reached at a hemoglobin level between
3 and 3.5 g/dL.
What preoperative criteria is the strongest predisposing factor to postoperative delirium?
Pre-existing delirium
During an inhalation induction, the presence of a right-to-left shunt will
decrease the arterial partial pressure of the anesthetic
The volatile anesthetics all produce a dose-dependent decrease in mean arterial pressure. This is due primarily to a decrease in
systemic vascular resistance
What component of the hanger yoke prevents the cross-filling of gas from one cylinder to another?
Check valve
Prevents the backflow of gas out of the anesthesia machine or the cross-filling from one tank to another.
Check valve.
The oxygen low-pressure alarm on your anesthesia machine begins sounding. What is the first step you should take?
Switch on the backup oxygen cylinder and consider switching to manual ventilation since many ventilators use the oxygen supply to drive the ventilator bellows.
The gases from the anesthesia flowmeters are first mixed in the
Common manifold
Oxygen should be positioned where in the flowmeters and why?
last in the flowmeters. That way, in case there is a crack in the flowmeter, it decreases the chance that a hypoxic gas mixture will be administered since it is added to the common manifold last.
Compared to sea level, if you turn on a Tec 6 vaporizer at a high altitude, it will
deliver a LOWER partial pressure of desflurane
If you set a Tec 6 vaporizer to 6% at 10,000 feet, it will still output a constant 6%, but since the atmospheric pressure is only 500 mmHg, the partial pressure will decrease from about 45 mmHg to 30 mmHg.
For example, in both the non-rebreathing circuits and circle system, the circuit is considered SEMI-OPEN if the
fresh gas flow rate is greater than the minute ventilation.
FG > MV
Circuit class is considered semi-closed.
If the FG < MV then the patient must be rebreathing some of the exhaled gases
Most mishaps related to the anesthesia machine scavenging system occur due to
user error.
What component in a gas-driven ventilator is responsible for producing the 2-3 cm H2O of PEEP seen when mechanical ventilation is applied?
The ventilator relief valve
During inspiration, the pressure from the driving gas closes the ____Valve.The APL valve and the breathing bag are both eliminated from the circuit when the ventilator is in mechanical ventilation mode.
ventilator relief valve so that the circuit can pressurize and inflate the patient’s lungs.
During the early part of expiration, a weight in the ventilatory relief valve holds the valve open until the bellows have filled. This weight against the patient’s expiration creates what ?
creates a PEEP of 2-3 cm H2O.
The inspiratory valve______on inspiration and ______on expiration to prevent the backflow of exhaled gas into the inspiratory limb.
opens ; closes
The expiratory valve ______on expiration and ______on inspiration and prevents rebreathing of gases in the expiratory limb. By opening and closing in this way, the unidirectional valves prevent the
opens; Closes ; rest of the circle system from contributing to the circuit deadspace.
The pressure gauge on your oxygen E-cylinder shows that it is at exactly half of the full service pressure. How many minutes will the tank last if you are using 10 liters of oxygen a minute? (Calculate your answer to the nearest whole number)
33 minutes
The most commonly used patient assessment scoring tool in PACUs is the T
Aldrete postanesthetic scoring system.
The Aldrete score includes assessments of blood
Blood pressure Level of consciousness Oxygen saturation Ability to move extremities on command, and the ability to Breathe deeply and cough.
A patient experiences an anaphylactic reaction to an antibiotic while under anesthesia. The patient remains hypotensive despite epinephrine and hydration. The next appropriate step would be to administer
Arginine Vasopressin
Increasing the mechanical deadspace in an anesthesia circuit will make what more likely ?
Make rebreathing of CO2 more likely
The introduction of tubing or some other respiratory apparatus between the patient and the y-piece of the circuit will
increase the deadspace
What are the primary goals for the anesthetic of a patient with sickle cell disease? (select two)
Adequate hydration
Adequate pain control
Avoid hypoxia
Maintain hgb 10-11
The drugs most commonly involved in anesthesia-related allergic reactions are (select two)
NMBA
ABTs
The Tec-6 vaporizer is heated because
desflurane has a high vapor pressure
TEC 6 vs Variable bypass vaporizer?
Unlike a variable-bypass vaporizer, the fresh gas flow does not come into contact with the liquid desflurane
The variable-bypass vaporizer you were about to install and use on your next case gets tilted onto its side. What should you do before this vaporizer can be used? (select two)
Drain the anesthetic from the vaporizer
Run fresh gas flow through the vaporizer for a period of time
The normal thyromental distance should be,
at least 7 cm or about the length of three fingerbreadths.
A normal intercisor distance is
at least 4 cm.
Rocuronium, vecuronium, atracurium, cisatracurium, fentanyl, sufentanil, remifentanil, and induction doses of propofol should be based on
lean body weight.
Succinylcholine, dexmedetomidine, neostigmine, and sugammadex doses should be based on
total body weight.
The normal aortic valve area is
2.0-2.5 square cm.
The normal flow rate or aortic valve during systole is
250 mL/min.
Following a parathyroidectomy, a patient is suspected of having bilateral recurrent laryngeal nerve damage. Your chief concern is that this patient may require
REINTUBATION
Can result from bilateral paralysis of the recurrent laryngeal nerve, and the patient may require reintubation.
Acute airway compromise
Unilateral paralysis of the RLN can result in
of the recurrent laryngeal nerve can result in hoarseness.
Which value will decrease in response to the pneumoperitoneum for a laparoscopy?
Stroke volume
Myasthenia gravis is characterized by autoimmune destruction of
acetylcholine receptors
The current treatment of choice for myasthenia gravis is
thymectomy.
Succinylcholine is contraindicated when for burn injury?
more than 24 hours after a significant burn injury
Why should succinylcholine avoided more than 24 hours after a burn injury?
The upregulation may take a few days to occur, so succinylcholine should be avoided more than 24 hours after a burn injury.
ECG changes with Pregnancy
This makes the heart appear larger on chest xray and produces a left axis shift on the ECG. I
Supine hypotensive syndrome in a parturient is most likely to occur at
36-38 weeks of gestation
Hyperglycemia in the parturient can produce _____ in the fetus soon after delivery.
HYPOGLYCEMIA
Why do parturients with Hyperglycemia have neonates with hypoglycemia?
As increased levels of glucose pass through the placenta, the fetus is stimulated to produce more insulin. This can result in fetal hypoglycemia after delivery.
A total spinal typically occurs very rapidly. The patient may exhibit dyspnea and difficulty speaking or swallowing. If the local anesthetic blocks the cardioacceleratory fibers in the T1-T4 spinal cord segments, then ____ and _____may ensue.
severe hypotension and bradycardia
The addition of epinephrine does not significantly affect the duration of action what 3 local anesthetics?
bupivacaine, etidocaine, or prilocaine
The addition of epinephrine Significantly prolong duration of what 3 LAs?
procaine, mepivacaine, and lidocaine are significantly prolonged.
Accounts for most of the heat lost in a surgical patient.
Radiant heat loss (radiation)
Patient factors associated with an increased risk of postoperative nausea and vomiting include: ASIDE from What I already know?
- large body habitus
- young age Laparoscopic surgeries are prone to - – producing nausea as are procedures greater than one hour.
I already know:
Nonsmoker
female gender
prior history of postoperative vomiting, and a history of motion sickness.
The primary mechanisms responsible for peripheral nerve injury are (3) , but the component that stems from these mechanisms and is common to all peripheral nerve injuries is.
CKST
Compression, Kinking, Stretch, Transection;
Ischemia
When placed in the seated position, the cardiac index, pulmonary artery wedge pressure, and central venous pressure (Increase/decrease) ?
decrease substantially
The only parameter that increases when patient is in the Seated position?
SVR
A patient with severe peripheral vascular disease exhibits a blood pressure that is higher in the left arm than in the right arm. In this instance, you should
RECORD the higher BP
If the blood pressure readings between two extremities vary significantly in patients with peripheral vascular disease, you should record the
higher pressure.
Factors associated with increased MAC values.
Increased catecholamines Hyperthermia, Cyclosporine, red hair hypernatremia, history of chronic ethanol abuse are
What does increase catecholamines do to MAC?
Increase
What does hypernatremia do to MAC?
Increase
Modern volatile anesthetics decrease the blood pressure primarily by their effect on
systemic vascular resistance
Modern volatile anesthetics decrease the blood pressure in a dose-dependent fashion by decreasing
vascular resistance.
What is coronary reserve?
Coronary reserve is the difference between maximal and resting coronary blood flow.
Which intravenous anesthetic has the fastest elimination half-life?
Propofol 30 minutes to 1.5 hr.
midazolam elimination half-life of
2-4 hours. (
The elimination half-life of ketamine is about
2-3 hours.
Etomidate elimination half-life of
elimination half-life of
Select two potassium-sparing diuretics that block the epithelial sodium channel.
Amiloride
Triamterene
What is the most common cause of acute kidney injury (AKI) in surgical patients?
Acute tubular necrosis
TRIAD of DKA? HAK
Acidemia, ketonemia, hyperglycemia
Nerve fibers are associated with motor and proprioception.
A-alpha
Fibers are associated with pain and touch
A-delta
Fibers are associated with muscle tone.
A-gamma
Which of the following statements reflects an accurate understanding of the respiratory changes that occur during pregnancy? B/G disturbance and TLC
Metabolic acidosis
No change in TLC
Which epidural techniques would be effective in preserving motor function in a laboring parturient without compromising analgesia? (select two)
Add a lipid-soluble opioid to the local anesthetic
Administering a large volume of dilute local anesthetic
What are changes that occur in banked blood?
Acidosis and the absence of factors V and VIII
Banked blood and potassium levels of
Hyperkalemia,
Banked blood changes in endothelium?
increased adhesion to the vascular endothelium, oxidative damage, depletion
Banked blood and 2,3 DPG, ATP depletion
2,3 DPG (also known as 2,3 BPG), depletion of ATP, hemolysis, accumulation of microaggregates, absence of viable platelets after 2 days of refrigerated storage, and altered morphology of RBCs also occur.
Which agent is an analog of somatostatin that is administered to blunt the bronchoconstrictive and vasoactive effects of carcinoid tumor products?
Octreotide
What is the medication octreotide?
Octreotide is an analog of somatostatin and is administered to blunt the bronchoconstrictive and vasoactive effects of carcinoid tumor products.
Inflation of an IABP balloon is timed to occur with the of the______ arterial waveform just after closure of the
dicrotic notch; aortic valve.
Most significant predictor of a difficult mask ventilation?In order of importance: BBLAH
Beard (most significant) Body mass index > 26 Lack of teeth Age > 55 years, and a History of snoring are independent risk factors associated with difficult mask ventilation.
By what weeks of gestation is surfactant production is sufficient in most cases.
35 weeks gestation
Which intravenous agents would be most capable of producing burst suppression on the EEG? (select two)
Etomidate and Propofol.
Which sign or symptom has the most ominous prognosis in a patient experiencing malignant hyperthermia?
The development of DIC has an ominous prognosis when associated with malignant hyperthermia and is common in cases that are fatal.
common features of malignant hyperthermia.
Hypercarbia
increase in body temperature
increase in serum potassium
According to the Vortex approach to the difficult airway, which of the following should be done between each noninvasive airway attempt?
Make a change in the airway visualization conditions
According to the Vortex approach to the difficult airway, between each noninvasive airway attempt, a change should be made that would affect the airway visualization conditions. These would constitute a
Manipulation of the position of the head, neck, or larynx, and change in device or device size, a change in the operator, implementation of airway adjuncts such as oral or nasal airways, or pharmacologic adjuncts such as muscle relaxants or reversal of muscle relaxants.
Both seen with Dextemedetomidine
Hypertension –> Hypotension
What factors have the greatest effect on the composition of the inspired gas mixture a patient receives? (select two)
Vaporizer dial setting
FGF
Branches of what nerve provide sensation to the ANTERIOR two-thirds of the tongue?
Lingual nerve of the TRIGEMINAL NERVE>
Hyperchloremic metabolic acidosis can worsen that is _______already present in renal patient population.
hyperkalemia
There are three phases involved in a liver transplant:Induction of anesthesia,
the preanhepatic, anhepatic, and neohepatic phases.
Liver Transplant : Anhepatic Phase
Clamping of the hepatic blood supply would occur during the anhepatic phase.
Occur during the preanhepatic phase of a liver transplant?
- isolation of the infrahepatic and suprahepatic vena cava
- exposure of the hilar structures of the liver
Liver Transplant: The neohepatic phase would include
reperfusion of the new liver.
Common outlet internal diameter
There is only one common gas outlet which has a 15 mm inner diameter and an
Common outlet outer diameter of.
22 mm
The common gas outlet is designed to help
prevent accidental disconnection.
Metabolic disturbances associated with OSA include
dyslipidemia, glucose intolerance, and insulin resistance.
Compared to a VATS, the Robotic VATS procedure has similar lengths of hospital stay and risk of perioperative morbidity. The risks of _______and _______ are actually increased with an RVATS.
chylothorax and recurrent laryngeal nerve injury
What information can a Doppler provide that a two-dimensional echocardiogram cannot?
Information about blood flow velocities within the heart
Which of the following is caused by an anterior pituitary tumor?
Cushing’s disease.
Cushing’s disease is distinct from Cushing’s syndrome in that it is due specifically to
an anterior pituitary tumor.
The production of excess growth hormone is also often caused by a tumor in the anterior pituitary gland.
Acromegaly
Cushing syndrome refers to any condition involving
corticosteroid excess.
BUN levels of 20 to 40 mg/dL suggest
decreased GFR
dehydration
high nitrogen levels.
Levels < 8 mg/dL are seen in
overhydration or an underproduction of urea,
The first day postop following a large hepatic resection, a patient exhibits a prolonged INR. You know that this
is typical and usually resolves in 5 days
You are preparing to anesthetize a patient for emergency trauma surgery. What intervention would exert the most protective influence on postoperative renal status in this patient?
Maintaining the intravascular volume
Which law of thermodynamics states that the entropy of a system approaches a constant value at absolute zero?
3rd law of thermodynamics
The law of entropy states that all energy moves towards a state of greater entropy, which means it moves toward a greater state of randomness.
2nd law of thermodynamics
Patients who suffer a myocardial infarction following noncardiac surgery have an elevated in-hospital mortality rate of
15-25%
Compared to suprarenal and infrarenal clamping, a______________ is associated with the most significant changes in hemodynamics including alterations in mean arterial pressure, pulmonary capillary wedge pressure, and ejection fraction.
supraceliac aortic cross clamp
92% of patients undergoing supraceliac clamping will exhibit
abnormal cardiac wall motion.
A typical, tertiary amine local anesthetic needs to be _____ to enter an axon and _____ to exert its effect once inside the neuron.
nonionized, ionized
A condition in which painful stimuli are perceived as much more painful than expected.
hyperalgesia,
Several areas of the brain are activated by painful stimuli including the
Prefrontal cortex
Insular cortex
Anterior cingulate cortex
Hypothalamus, and the somatosensory cortices (SI and SII).
All of these except for the _________ receive somatosensory input from thalamic neurons
the prefrontal cortex
What supraspinal regions contribute to the emotional and motivational aspects of pain sensation? (select two)
anterior cingulate cortex
insular cortex
The limbic and paralimbic regions (anterior cingulate cortex and insular cortex) are involved in the
emotional and motivational aspect of pain sensation.
The SI and SII somatosensory cortices are involved in determining
the location and intensity of pain sensations.
Which ascending spinal pathway is most involved in the homeostatic and behavioral aspects of pain?
Spinobulbar
The major ascending spinal pathways involved in the transmission of nociceptive information include the
spinothalamic, spinohypothalamic, spinomedullar, and spinobulbar tracts.
The spinothalamic tract is most important for transmission of
most important for the transmission of pain, temperature, and itch sensations.
The spinobulbar tract is important in integrating pain information with
homeostasis and behavior mechanisms
The spinohypothalamic tract is involved in the
autonomic, neuroendocrine, and emotional aspects of pain.
The effect-site equilibration time of alfentanil is compared to and as long as
1.4 minutes
The effect-site equilibration time ____ for fentanyl,
6.8 minutes
The effect-site equilibration time ____ for sufentanil,
6.2 minutes for sufentanil
The effect-site equilibration time ______for morphine.
15-30 minutes
Tramadol administered intrathecally provides analgesia via 2 mechanisms.
mu receptor activity and the inhibition of serotonin and norepinephrine uptake.
Capsaicin exerts its analgesic effects on
Capsaicin is a component of hot chili peppers that agonizes TRPV1 receptors on the endings of unmyelinated C fibers.
It is available as a cream and a transdermal patch and has been proven efficacious in the treatment of postherpetic neuralgia.
CAPSAICIN
The primary mechanism by which digitalis glycosides produce their inotropic effect is by increasing
intracellular calcium levels
You are administering large amounts of banked blood intraoperatively to a patient who takes calcium channel blockers. This patient is at an increased risk for developing
HYPERKALEMIA
Calcium channel blockers slow the movement of
potassium into the cell.
Can occur occasionally with the use of a transdermal scopolamine patch.
Anisocoria (unequal pupil size). It can produce visual disturbances and is most likely due to contamination of the eye after manipulating the patch. In 90% of cases, the dilated pupil is on the same side as the patch.
The primary etiologic factor in the development of retinopathy of prematurity (ROP) is
the gestational age.
Factors such as (3) are also associated with an increased risk of developing ROP.
hyperoxia, hypocarbia, and acidemia
Which test is most widely used to assess the intrinsic coagulation pathway?
PTT
Which test is most widely used to assess the Extrinsic coagulation pathway?
PT
The primary cellular difference between smooth muscle cells and skeletal muscle cells are that smooth muscle cells lack
visible cross striations. This is because, unlike skeletal muscle, actin and myosin are not arranged in regular arrays. Instead of T-tubules, smooth muscle cells contain pockets called caveoli.
Flow should be read at the____of a bobbin or in the ____ of a ball TBoMBa
top; middle
Soda lime is manufactured to have a mesh size between 4 and 8 to (select two)
optimize surface area
optimize gas flow resistance
Before installing a new oxygen cylinder on your anesthesia machine, you should
crack the valve open slightly for a second. This will clean away any grease, dust, or debris that would otherwise be released into the anesthesia machine. Because of the serious consequences that occur should a pressurized cylinder fall and break the valve off, you should lay a tank flat on the ground if it cannot be secured in an upright position.
The total response time has two components:
the transit time (also known as the lag time) that it takes for the gas sample to get to the analyzer and the rise time. The rise time represents how long it takes the analyzer to respond to a change in the gas composition.
Specifically, the rise time is defined as the
time it takes for the analyzer to change from 10% of the total change in gas composition to 90% of the total change in gas composition.
What is the most frequent cause of hospitalization in patients older than 65?
HF
The drug of choice for infections caused by methicillin-resistant staphylococcus aureus is
. vancomycin (60 minutes before case)
Class of vancomycin
bactericidal glycopeptide.
Compared to the aortic root pressure, as the location of the arterial catheter gets more distal, the
diastolic pressure decreases, systolic pressure increases
For optimal positioning in an adult, an esophageal temperature probe sensor should be positioned about ______ cm from the nose.
45
This will place the probe in the distal third or distal fourth of the esophagus of the average adult, which will help avoid
cooling by respiratory gases in the trachea.
The main purpose of
disconnection in the breathing circuit.
When monitoring neuromuscular blockade after induction to determine optimum intubating conditions, it is recommended that you set the peripheral nerve stimulator to deliver
. single twitches at 0.1 Hz every 10 seconds
Using train of four at 10 to 12 second intervals may falsely accelerate the
apparent blockade at the site of monitoring and misrepresent the blockade of the laryngeal muscles.
The most common cause of hyperthermia in a patient under general anesthesia is
iatrogenic overwarming
You are preparing to purge an anesthesia machine prior to administering an anesthetic for a patient with malignant hyperthermia. When performing a purge, you should use a fresh gas flow rate of
10 L/min
Four crystalloids considered to be isotonic include:
Normal saline (308 mOsm/L)
D51/4NS (283 mOsm/L)
Lactated Ringer’s solution (273 mOsm/L)
Plasmalyte (294 mOsm/L)
Normal saline_____ mOsm/L)
308
D51/4NS (____mOsm/L)
283
Plasmalyte (______mOsm/L)
294
Lactated Ringer’s solution (____mOsm/L)
273
Green-tinted protected eyewear with the markings ‘OD5 or greater for 1,064 nm’ would be appropriate for which type of laser?
Eyewear with the markings ‘OD5 or greater for 1,064 nm’ would be appropriate protection for potential exposure to a Nd:YAG laser. Note: although the lenses are often green for this type of lens, the color cannot be relied upon as some Nd:YAG glasses are clear.
Why is the threshold for local anesthetic toxicity lower when injected intra-arterially than when injected intravenously?
Because the lungs account for a significant portion of local anesthetic uptake
Segmental spread of an epidural block is primarily dependent upon what factor? DES
DES (Dose and Site)
Segmental spread of an epidural block is primarily dependent upon what factor? SBP (SpinaL)
baricity of the solution, and the patient’s position to determine the spread of the anesthetic
Epidural steroid injection has been demonstrated to be effective at
- reducing leg pain
- the degree of sensory deficit
- need for opioids during the acute phase of the injury.
The speed of emergence following an inhalational anesthetic is: (select two)
Solubility and MV
Directly proportional to alveolar ventilation
Inversely proportional to the agent’s blood solubility
The most common cause of delayed awakening following surgery is
prolonged action of anesthetic drugs
In order of incidence, the most common causes of delayed awakening following surgery are:
1) prolonged action of anesthetic drugs, 2) metabolic causes, and 3) neurologic injury.
An anesthetized patient undergoing neurologic surgery has a monitor in place that utilizes a stroboscopic flash with recording electrodes placed on the scalp. What intraoperative test is being performed?
Visual evoked potentials
In visual evoked potentials, a stroboscopic flash
stimulus is used, with recording electrodes placed on the patient’s scalp.
The mixing of the donor and recipient blood in a trial transfusion prior to administering the donor blood to the patient is referred to as
crossmatching
Determines the patient’s blood type and predicts compatible transfusions 99.94% of the time.
Blood typing (a type and screen)
Actual mixing of the donor and recipient blood in a trial transfusion increases the possibility of a compatible transfusion by only one-hundredth of 1%.
Crossmatching
Banked blood contains an
anticoagulant containing sodium citrate which binds to calcium in the bloodstream
The ETCO2 waveform suddenly drops to near zero and the waveform disappears. What are the potential causes you must immediately consider? (select four)
Malposition of the endotracheal tube cardiac arrest pulmonary embolism circuit disconnection obstruction of the sampling line are potential causes that must be immediately considered if the ETCO2 waveform drops to zero or disappears.
The chief danger in performing a cervical transforaminal steroid injection is
vascular injury
The path of the needle for these blocks has been demonstrated to be within 2 millimeters of the vertebral, ascending cervical, and
deep cervical artery making intra-arterial injection or vascular trauma a significant risk.
What percent of the cardiac output is supplied to the vessel-rich group (brain, heart, kidney, liver, and GI tract)?
75%
Which IV sedative-hypnotic agent has the highest degree of protein binding?
From greatest to least, the degree of protein-binding is as follows: Propofol > Midazolam > Etomidate > Ketamine
When given in low doses, which two muscarinic antagonists may produce paradoxical bradycardia?
Atropine Scopolamine (when administered in low dosages)
When given in low doses, which two muscarinic antagonists may produce paradoxical bradycardia?
Atropine Scopolamine (when administered in low dosages)
Which narcotic is rapidly metabolized by blood and tissue esterases?
Remifentanyl
Depolarizing agents work at the end plate and desensitize the channel to which they bind. At what type of receptor does this occur? On what type of voltage-gated channel does this take place?
Nicotinic, sodium voltage-gated channel
What side effect would you most expect to see from high doses of oxytocin?
. Diastolic hypotension
What side effect would you most expect to see from high doses of oxytocin?
Diastolic hypotension
High doses of oxytocin can produce
diastolic hypotension (and some degree of systolic hypotension), flushing, and tachycardia.
What clotting factor has decreased activity in pregnant patients?
Factors XI and XIII are decreased in pregnancy.
Factors unchanged in pregnancy?
II and V
What would be considered an advantage of combined spinal-epidural analgesia?
It is highly effective when initiated during fast progressing labor
Combined spinal-epidural analgesia results in a
rapid onset of analgesia with minimal motor block.
Which of the following statements is true of a continuous brachial plexus block? (select two)
It prevents vasospasm in revascularization procedures
It decreases the need for postoperative opioids
Twitch depression results in the blockage of what type of receptor?
Postsynaptic nicotinic acetylcholine receptor
Rapid correction of serum sodium in a chronically hyponatremic patient can produce
myelinosis
Which structure is most likely to be injured during a nasal intubation?
inferior nasal concha
The tough, fibrous tissue positioned around the atrioventricular valves and at the base of the aortic and pulmonary trunks is called the
annulus fibrosus
The pulmonary circulation is considered to be what type of system? Presssure_ volume___
low pressure, high volume
According to the difficult airway algorithm, if you are unable to ventilate an induced patient via mask or supraglottic airway, what is the next step you should take?
. Call for help
According to the difficult airway algorithm, if you are unable to ventilate an induced patient via mask or supraglottic airway, what is the next step you should take?
Call for help; If a two-man approach is not successful, then you may have to consider invasive airway management methods.
What nerve provides sensory innervation to the base of the tongue, the posterior epiglottis, the aryepiglottic folds, and the arytenoids?
The internal branch of the superior laryngeal nerve
Which anesthetic agent undergoes the greatest degree of metabolism?
5-8 % of sevoflurane undergoes metabolism
Isoflurane and nitrous oxide undergo less than 1% and desflurane undergoes less than 0.1% metabolism.
Which of the following statements regarding the use of a first generation laryngeal mask airway (LMA) is true?
The presence of a pharyngeal abscess is a contraindication to its use
You are transporting a patient on oxygen by face mask at 3 L/min. The pressure gauge on the E-cylinder oxygen tank you are using shows that 1/2 of the tank remains. How many minutes do you have before the tank is empty? Calculate your answer to the nearest whole number.
110
Which condition is an absolute contraindication to electroconvulsive therapy?
Pheochromocytoma
Approximately what percentage of pulmonary blood flow goes to the dependent lung in a healthy, mechanically-ventilated patient in the lateral decubitus position?
60%
Which of the following would be predisposing factors to obstructive sleep apnea? (Select two)
Obesity
Genetic inheritance
A pulse oximeter alarms that a patient’s saturation has dropped below the alarm threshold. This is an example of what type of an alarm?
Unlatched
Sound only as long as the criteria (in this case a saturation threshold) for sounding are met. If the patient’s saturation rises above threshold, the alarm will quit sounding on its own.
Unlatched alarms
Once triggered, a latched alarm will sound until it is
silenced by interaction with the monitor.
Which method would be most appropriate for cleaning a TEE probe?
Disinfection with glutaraldehyde-based solution
A 12 French catheter would have an outer diameter of
4 mm
Transesophageal pacing is possible because the esophagus is directly posterior to what structure(s)?
the atria
Upon what structure in the nephron do loop diuretics work?
The thick, ascending segment of the loop of Henle
Loop diuretics-> exert their action in the thick, ascending segment of the loop of Henle by
furosemide, ethacrynic acid, and bumetanide
Loop diuretics work by
inhibiting the sodium, chloride, potassium co-transport system.
In what position is the patient typically placed for an open nephrectomy?
Lateral jackknife
What physiologic change in patients with chronic kidney disease is most often responsible for increasing the free fraction of administered drugs?
Hypoalbuminemia
Which intervention has the highest incidence of acute kidney injury (AKI)?
Thoracic aortic surgery
The most common cause of cholecystitis is
gallstones
Symptoms associated with cholecystitis most frequently are the result of an
obstruction, infection, or combination of the two.
Are the most common cause of acute cholecystitis.
Gallstones
Biliary colic results from the
obstruction of the cystic duct, which if prolonged, causes the gallbladder to distend and become edematous and inflamed.
The primary function of phase II conjugation reactions are to make the molecule more
water-soluble
Which factor is most associated with an increased risk for gallstones?
Female gender
The most common risk factors for the development of cholelithiasis include:
female gender, increasing age; obesity; pregnancy; rapid weight loss; consumption of a Western diet.
The most common risk factors for the development of cholelithiasis include:
female gender, increasing age; obesity; pregnancy; rapid weight loss; consumption of a Western diet.
The hepatic venous pressure gradient is calculated using the portal venous pressure and the
hepatic vein pressure
Portal hypertension is defined as a hepatic venous pressure gradient (HVPG) greater than
5-6 mmHg,
Portal HTN which is calculated by the
difference between portal and hepatic vein pressure.
Portal hypertension results in
Ascites Formation of varices, Hepatorenal syndrome Splenomegaly Splanchnic vasodilation, and gastropathy.
Hepatic venous pressure gradient (HVPG) HVPGs in excess of
12 mmHg place the patient at risk for variceal bleeding.
Chronic administration of exogenous glucocorticoids can suppress the HPA axis and produce
Adrenal insufficiency
Secondary adrenal insufficiency occurs due to suppression of the HPA axis by administration of exogenous glucocorticosteroids or
ACTH deficiency due to dysfunction of either the hypothalamus or pituitary gland
What is the best assessment for long-term glucose control in a diabetic?
Hemoglobin A1C
The normal hemoglobin A1C level is between
4 and 6 percent.
What is the approximate blood loss per minute during the resection phase of a transurethral prostate resection?
2-4 mL
The tendency for a gas to flow along a curved path at a bifurcation point is known as the
Coanda effect
The substantial factor test is a component of which of the four elements of assignment of malpractice?
Causation
Failure to obtain informed consent prior to anesthesia would be an example of
Breach of duty
Following a carotid endarterectomy, a patient in the recovery area exhibits significant headache and slurred speech followed by the onset of seizures. This would be consistent with
cerebral hyperperfusion syndrome
The primary goals are the treatment of
hypertension and control of cerebral perfusion.
What is the most common reason for reintervention following an endovascular aneurysm repair?
Endoleak
A transcranial doppler (TCD) measures the velocity of blood flow through the
middle cerebral artery
Which local anesthetic only exists in a nonionized state?
Benzocaine
What initial arrhythmia would you most likely see in a patient experiencing cardiovascular toxicity from a local anesthetic?
Bradycardia
LA : a safer cardiovascular profile than bupivacaine.
It should be noted that levobupivacaine and ropivacaine (although potent/lipid soluble) have
Spontaneous ventilation will ______ the uptake of inhalation anesthetics by ________ alveolar ventilation.
decrease, decreasing
Afferent fibers from peripheral nociceptors enter the spinal cord through the
dorsal root
Central sensitization characterized by a progressive increase in the response of neurons to successive stimulations is known as
wind-up
Which ascending spinal pathway is most associated with pain, temperature, and itch sensation?
spinothalamic tract
Prolonged opioid therapy can produce an increase in plasma concentrations of
prolactin
Prolonged opioid therapy can suppress the
hypothalamic-pituitary-adrenal axis resulting in decreased concentrations of cortisol, follicle-stimulating hormone, estrogen, testosterone and increased levels of prolactin.
The major side effects of neuraxial alpha-2 adrenergic agonists are (select two)
hypotension
bradycardia
The proposed mechanism by which glucocorticoids reduce inflammation is by decreasing the production of inflammatory mediators and by
inhibiting phospholipase A2
Which calcium channel blocker produces the greatest amount of coronary artery dilation?
Nicardipine
Verapamil, nifedipine, nicardipine, and diltiazem all produce coronary artery vasodilation, but ______exerts the greatest effect.
nicardipine
You are preparing to induce general anesthesia in a patient taking propranolol for hypertension. Which drug would you anticipate to have substantially higher than normal plasma concentrations after administration?
Fentanyl
Propranolol decreases the clearance of amide local anesthetics, but not ester anesthetics such as chloroprocaine. As a result,
plasma concentrations shortly after injection can be 2-4 times higher than normal.
H2 receptor antagonists act by what?
decrease hydrogen ion secretion from parietal cells by
H2 receptor antagonists decrease hydrogen ion secretion from parietal cells by
decreasing intracellular cAMP levels
In parietal cells, histamine
activates adenylate cyclase, which increases cAMP levels.
The increased cAMP levels activate the
proton pumps in the parietal cells causing an increase in the secretion of hydrogen ions.
By blocking the effect of histamine, H2 receptor antagonists result in a
decrease in intracellular cAMP levels and a decrease in hydrogen ion secretion.
You are preparing to induce a patient who takes phenytoin for the treatment of seizures. You know that this patient would likely require a higher dose of
Chronic administration of phenytoin can result in hepatic enzyme induction and result in higher dose requirements for nondepolarizing neuromuscular blockers such as vecuronium.
What is the major intracellular ANION?
Phosphate
The primary intracellular cation is
potassium
The primary extracellular cation is
sodium.
Class I antidysrhythmics drugs are as
Quinidine, lidocaine, and flecainide
Class I antidysrhythmics drugs work by
inhibit fast sodium channels.
Class I antidysrhythmics drugs are
Quinidine, lidocaine, and flecainide
Class I antidysrhythmics drugs work by
inhibit fast sodium channels.
Class II antidysrhythmics drugs such as_______ and ______
esmolol and propranolol
Class II antidysrhythmics work by
decrease the rate of depolarization.
Class III antidysrhythmics is
amiodarone
Class III antidysrhythmics work by
inhibit potassium ion channels.
Which of the following agents is an HMG-CoA reductase inhibitor?
Atorvastatin
Gemfibrozil is a
derivative of fibric acid used to lower triglyceride levels.
Cholestyramine is
a bile acid resin which binds bile in the intestines and increases hepatic bile synthesis from cholesterol, resulting in a decrease in the blood cholesterol level.
Which of the following decreases during pregnancy?
plasma protein concentration
Compared to the adult, the neonatal myocardium
more sensitive to NE
Cholestyramine is
a bile acid resin which binds bile in the intestines and increases hepatic bile synthesis from cholesterol, resulting in a decrease in the blood cholesterol level.
Heparin produces its anticoagulant effects by binding to
antithrombin
The ratio of units of packed red blood cells to fresh frozen plasma to platelets recommended by the US military for massive transfusion is
1:1:1
Acetylcholine is synthesized in the cytoplasm of the nerve terminal from (select two)
acetyl coenzyme A
choline
When zeroing a right atrial pressure transducer, it ideally should be level with the
Tricuspid valve (phlebotaxis _
The anesthesia machine fail-safe mechanism will
interrupt nitrous oxide flow if the oxygen supply pressure drops
If a Tec-6 vaporizer is tilted while operational,
it will sound an alarm, shut off the vapor output, and flash a NO OUTPUT warning.
The pressure gauge on an E-cylinder nitrous oxide tank registers 745 psig. The most accurate way to determine how much nitrous oxide is left in the tank is to
weigh
What is the gold standard for measuring core body temperature?
pulmonary artery catheter
Which setting on a peripheral nerve stimulator will produce an electrical stimulation once every ten seconds?
0.1 Hz
Intraoperative somatosensory evoked potential monitoring during anesthesia can produce electrical interference on the ECG that would most likely appear as
pacemaker spikes
The Jackson-Rees circuit is also known as the
Mapleson F
LMA size:
3
4
5
30-50 kg
50-70 kg
70-100 kg
When using a combitube, ventilation is attempted through the
Longer (blue) lumen [blue first!!!],
A low–birth-weight (LBW) neonate weighs
regardless of the duration of the pregnancy. and an
less than 2500 g
A very low–birth-weight (VLBW) neonate weighs
less than 1500 g,
More recently, neonates that weigh
less than 750 g at birth are referred to as “micropremies”;
extremely low–birthweight neonate weighs less than
1000 g.
2 Most common complication of infant with low Gestational age infants? In order of
Preterm (<37 weeks) SGA
1. Respiratory distress syndrome AND 2.Apnea
2 Most common complication for normal term children
Congenital anomalies
Viral infections
Prenatal growth is the most important phase in development, comprising
organogenesis in the first 8 weeks
By convention, the term prematurity has been applied to neonates who
weigh less than 2500 g at birth
By convention, the term prematurity has been applied to neonates who
weigh less than 2500 g at birth
born before 37 completed weeks of gestation.
The most accurate means of assessing gestational age is by measuring the
crown-rump length of the fetus during a first-trimester ultrasonographic examination.
Corresponding equation for 18 months to 8 years of age is:
Wt (kg) = 2 × Age(years) + 9.
For age >8 years: Wt (kg) =
3 × Age (years).
The anterior fontanel closes between
9 and 18 months of age;
The posterior fontanel closes by
2 to 4 months of age
The critical event in the change from placental to pulmonary gas exchange is
the first inspiration
The first breath is a gasp that generates a transpulmonary distending pressure
of 40 to 80 cm H2O
What are the two crucial events involved in the immediate transition from the fetal circulation to the normal postnatal pattern
Decreased pulmonary vascular resistance (PVR) and
increased peripheral systemic vascular resistance SVR (loss of the umbilical circulation)
During fetal circulation, The increase in systemic afterload causes an
immediate closure of the flap valve mechanism of the foramen ovale and reverses the direction of shunt through the ductus arteriosus.
Hyperbilirubinemia (defined as a total serum bilirubin level
> 5 mg/dL)
Infants: The cause of nonhemolytic physiologic hyperbilirubinemia is
excessive bilirubin production from breakdown of red blood cells and increased enterohepatic circulation of bilirubin with deficient hepatic conjugation as a result of decreased uridine 5-diphospho-glucuronyl transferase activity
The placenta is impermeable to 2 (endocrine)
insulin and glucagon
Studies have defined values abnormal glucose
concentrations as follows: plasma glucose concentrations_________ in the first _____after birth; and less than ____mg/dL after _____hours
less than 35 mg/dL; 3 hours
45 mg/dL after 24 hours
Studies have defined values abnormal glucose
concentrations as follows: plasma glucose concentrations of _________in the first 3 hours
less than 35 mg/dL
Abnormal glucose concentration as follows between 3 and 24 hours, plasma glucose concentrations
less than 40 mg/dL
Abnormal glucose concentration as follows less than_____ mg/dL after 24 hours
45
The blood volume in a full-term neonate depends on the
time of cord clamping, which modifies the volume of placental transfusion.
The blood volume is 93 mL/kg when cord clamping is____________ compared with 82 mL/kg with
delayed after delivery; immediate cord clamping.
Venipuncture vs capillary sampling in infants
venipuncture is preferred over capillary sampling.Capillary sampling (e.g., heel stick) generally overestimates the true hemoglobin concentration
because of stasis in peripheral vessels that decreases the volume of plasma and causes hemoconcentration. The net effect may be an increase in hemoglobin concentration by as much as 6 g/dL;
Physiologic anemia in children and why ? Is oxygen delivery to the tissues compromised? why or why not
This “anemia” (physiologic anemia of the newborn) is a normal physiologic adjustment to extrauterine life. Despite the reduction in hemoglobin, the oxygen delivery to the tissues may not be compromised because of a shift of the oxygen-hemoglobin dissociation curve (to the right), secondary to an increase of 2,3 diphosphoglycerate
Thus all neonates should receive prophylactic this vitamin
vitamin K soon after birth to prevent hemorrhagic disease of the neonate.
Its omission could lead to serious and life-threatening consequences, especially if surgery is undertaken.
Infants Myelination is usually complete by.
7 years of age
The nervous system is___________ at birth; functionally it with the continuation of myelination and synaptogenesis
anatomically complete; remains immature
The brain has two growth spurts: neuronal cell
multiplication between _________and ______of gestations and glial cell multiplication commencing at
15 and 20 weeks of gestation; 25 weeks and extending into the second year of life.
Brain contains 2 growth spurts:
Neuronal cell multiplication
Glial cell multiplication
The strongest predictors of cerebral palsy appear to be
congenital anomaly (congenital heart disease in particular), low birth weight, low placental weight, multiple fetuses, preterm delivery, intrauterine infection, or abnormal fetal position before labor and delivery
The match between parent and child anxiety level also
appears to be important. Calm children with anxious parents do
more poorly during induction compared with calm children with calm parents or anxious children with either calm or anxious parents
Is a very useful and simple device to monitor heart sounds and the quality of breath sounds, even when our attention is focused away from physiologic monitors.
A precordial or esophageal stethoscope
With monitoring The focus must always be on the.
child and the surgical field. Electronic monitors may fail, and if the anesthesiologist focuses too much attention on the monitor in an effort to interpret it, rather than
attending directly to the child, the child may suffer.
In an infant, the rate of uptake of inhalation anesthetic agents is _______ than in an adult
more rapid
The most important consideration in the safe practice of pediatric anesthesia is to
ensure a patent airway
The most important factor in the morbidity and mortality of children undergoing anesthesia
Failure to ventilate adequately
Transporting to PACU, These children should be transported in the _________for two major reasons:
tonsil position” or “recovery position” (lateral decubitus position) (1) the dimensions of the upper airway are greater in this position than supine (2) should vomiting occur, the regurgitant material will flow out of the mouth, away from the larynx and will be identified immediately.
Child length doubled when?
Length doubles by 4 years of age.
Simple way to remember how rapidly infants grow is that birth weight doubles when____and triples when _____
doubles by 6 months of age and triples by 1 year.
The anterior fontanel should be palpated to assess whether it is sunken which indicates?
dehydration
Permanent teeth begin to appear by
6 years, with the shedding of the deciduous teeth
Epiglottis and vocal cords description in the neonate?
long, omega-shaped epiglottis and the pearly white vocal cords in the neonate.
Alveoli develop mainly after birth, increasing in number until approximately
8 years of life and in size until growth of the chest wall
ceases.
The bronchial tree down to and including the terminal
bronchioles forms by week
16 of gestation
In neonate, removal of lung fluid may be delayed producing the syndrome called
transient tachypnea of the newborn
Respiratory muscles ineffective in infants
The accessory muscles of inspiration are relatively ineffective in infants
Muscle strength depends on the presence of an adequate number of.
type I (slow twitch, high oxidative capacity) muscle fibers to respond to an increased workload
What increases risk for respiratory failure in the developing infant?
The diaphragm of the neonate and more
critically, the preterm infant, has limited number type I (slow twitch, high oxidative capacity) muscle fibers .
Newborn total lung capacity (ml)
160
VO2 (mL/kg per minute) infants
6–8
An adult can generate negative pressures in excess of a ______neonate can generate pressures as
great as
70 cm H2O,100 cm H2O;
It is not possible to measure closing volume in children that are
younger than 5 years, but because the elastic recoil pressure is small in infancy some airways likely remain closed throughout tidal breathing. This notion is supported by the finding that infants have a large “trapped gas volume”
What are “central airways”?
Trachea to the twelfth to fifteenth bronchial generation
What are “peripheral airways”
distal to the twelfth to fifteenth generation to the alveoli).
In neonates as in adults, 3 things that control ventilation are?
, PaO2, PaCO2, and pH
PaO2 acting mainly through what chemoreceptors?
peripheral chemoreceptors in the carotid and aortic bodies
PaCO2 and pH acting on what type of chemoreceptors and where?
central chemoreceptors in the medulla
In contrast to the adult, an infant’s response to hypercapnia is not potentiated by
hypoxia,
This actually depress the hypercapnic ventilatory response in term and preterm infants
Hypoxia
Commonly occurs in neonates. This should be distinguished from clinical apnea,
Periodic breathing
Important risk factor for life-threatening apnea in
neonates and infants undergoing general anesthesia.
Prematurity is
The risk of post-anesthetic respiratory depression is inversely related to
gestational age and post-conception age at the time of anesthesia
The position of the oxyhemoglobin dissociation curve depends on the ratio of
adult to fetal hemoglobin.
At birth, the increased fetal hemoglobin content shifts the curve to the
left of the adult curve (from a P50 of 27 for Hb A to a P50 of 19 for Hb F). During the first week after birth, the curve
shifts to the right, reflecting the transition from fetal to adult hemoglobin formation
Premature HR range
111
120–170
0–3 months HR range
100–150
3–6 months HR range
90–120
6–12 months HR range
80–120
1–3 years HR range
70–110
3–6 years HR range
65–110
6–12 years HR range
60–95
> 12 years HR range
55–85
Premature normal BP
Premature SBP 55–75 / 35–45
0–3 months Normal BP
SBP 65–85 /45–55
3–6 months Normal BP
SBP 70–90/50–65
6–12 months Normal BP
SBP 80–100/ 55–65
1–3 years Normal BP
SBP 90–105/ 55–70
The range of cardiac output in both full-term
and preterm neonates is
220 to 350 mL/kg per minute
Urine production begins in utero at
10 to 12 weeks of gestation
Tubular function begins to develop after ____weeks of gestation and reaches adult levels by_____
34 weeks of gestation and reaches adult levels by 2 years of age
Nephrogenesis is complete by ___weeks of gestation
36
Children –> Adult GFR rates are achieved by approximately
2 years of age
In utero, the fetus maintains acid base balance
mild respiratory acidosis
Most umbilical venous blood from the placenta passes through the ________to the
ductus venosus; inferior vena cava.
3 top causes of jaundice in neonates
Excess bilirubin production
Impaired uptake of bilirubin
Impaired conjugation of bilirubin
Phototherapy reduces serum bilirubin concentrations by converting
bilirubin through structural photoisomerization and photooxidation into excretable products
Lower esophageal sphincter pressures are reduced at birth but increase steadily, reaching adult values by
3 to 6 weeks postnatal age. Dailyvomiting or “spitting up” is reported in half of all infants between 0-3 months happy spitters
Maternal hyperglycemia, particularly when uncontrolled, results in
hypertrophy and hyperplasia of the fetal islets of Langerhans. This leads to increased levels of insulin in the fetus, affecting lipid metabolism and giving rise to a large, overweight neonate characteristic of a mother with
diabetes (infant of a diabetic mother, IDM).
Hyperglycemia in neonates is a level of glucose
(plasma glucose ≥150 mg/dL) occurs in stressed
neonates,
At birth, vitamin K–dependent factors
(i.e., II, VII, IX, and X) are 20% to 60% of adult values
Preoperative Fasting Recommendations in Infants and Children
Clear liquidsa 2 hours
Breast milk 4 hours
Infant formula 6 hours
Solids (fatty or fried foods) 8 hours
Latex ALLERGY - It occurs more frequently in atopic individuals and in those with certain fruit and vegetable allergies PBACK
(e.g., banana, chestnut, avocado, kiwi, pineapple).
% cross-reactivity between first-generation cephalosporins and penicillin, there is no similar cross-reactivity with second- and thirdgeneration cephalosporins
5% to 10%
Premedication for children with anesthesia(mg/kg) of ketamine, oral, nasla, rectal, IM>
Ketamine Oral 3–6
Nasal 3
Rectal 6–10
Intramuscular 2–10
Is the most widely used premedication for children
Midazolam, a short-acting, water-soluble benzodiazepine
IV, IM, PO, nasal, rectal midazolam dose,
0.025 to 0.1 mg/kg IV
0.1 to 0.2 mg/kg IM
0.25 to 0.75 mg/kg PO
0.2 mg/kg nasal
1mg /kg rectal
CV effects of ECT Explain
initial Parasympathetic discharge 5-10 seconds -> HoTN, and transient Bradycardia, which can progress to Asystole. Then Prominent sympathetic response, that peaks 1-2 minutes, can be observed 5-10 minutes. the sympathetic response is associated with Tachycardia, HTN, and Increased myocardial oxygen demand.
ECT is accomplished by
using electrical current creating a bilateral generalized seizures.
Exact mechanism of ECT is
unknown.
Relative contraindications to ECT
Recent MI, CVA, angina , CHF
TCA mechanism of action
Blocking the reuptake of NE, serotonin, dopamine therefore increasing sympathetic tone.
ECT why is ketamine avoided?
Worsens sympathetic response
HTN and tachycardia seen with ECT is
Self limited. If using medications to treat use ESMOLOL>
One drawback of NMB with ECT is that
It can be difficult to assess for generalized seizures. A BP cuff is INFLATED ON AN EXTREMITY to ISOLATE the BLOOD SUPPLY prior to administering the NMB agents. This allow for visualizztion of seizure activity in the isolated extremity.
What is the GOLD STANDARD, and first choice hypnotic for ECT? What is the dose?
Methohexital (0.75-1mg/kg) because it does not change seizure activity and has more favorable side effect profile than etomidate.
Another key need for ECT is the use of a
Bite BLOCK because dental damage is a common side effect of ECT if precautions are not taken.
Lithium anesthetic considerations?
Prolongs NMB
How do you assess for OSA in preop area
STOP BANG QUESTIONNAIRE Snoring Tired Observe(STOP BREATHING DURING SLEEP) Pressure Blood pressure
BMI > 35
Age > 50
Neck circumference >40
Gender.
STOP BANG SCORE AT risk for OSA
3 and up
What is an independent risk factor:
A variable is called an independent risk factor if it has a significant contribution to an outcome in a statistical model that includes established risk factors.
Classic physical feature of pyloric stenosis?
Palpable olive size mass in the upper abdomen or distal pylorus.
Formula of Anion gap (AG) =
Na − (Cl + HCO3)
OSA patients minimize use of
Respiratory depressants , and extubate awake.
What is the gold standard for Foreign body retrieval?
Rigid Bronchoscopy
Child with FB aspiration, most important anesthetic considerations is
Inhalation induction
Congenital disease associated with Big Tongue (Macroglossia)
Beckwithin syndrome
Trisomy 21
Small underdeveloped chin (retrognathia) congenital diseases?
PGTC (please Get that Chin) Pierre Robin Goldenhar Trisomy 21 Cri du chat
Congenital disease associated with Cervical spine anomalies?
Kids Try Gold
Klipper Feil
Trisomy 21
Goldenhar.
The Osborn wave or J wave is characterized by
positive deflection at the J point (the point where the QRS complex finishes and the ST segment begins)
What is the J point?
the point where the QRS complex finishes and the ST segment begins)
Causes that produce RIGHT AXIS deviation? nclude but are not limited to Right PRB LeftPO AW
physiologic inspiration
Right bundle branch block
Left posterior fascicular block
ASD secundum, or WPW syndrome
Determining the heart axis will have to take into account leads
I and II and AVF.
If the QRS complex is negative in lead I but positive in lead II, it is
right axis
If the QRS complex is positive in lead I but negative in lead II, it is left axis
left axis
If the QRS complex in leads I/II is positive—the heart axis is______and between ___ and ___degrees
normal and between 30 and 90°.
What is Brugada (think BrugaNA) syndrome
Genetic sodium ion channel abnormality associated with sudden death
All anesthesia machines have failsafe valves which shut off or decrease gas flows when the O2 pressure
drops below 30 PSI, although this system will not prevent the delivery of 100% N2O (thus an oxygen analyzer is necessary).
Unlike sodalime, Amsorb does not contain
NaOH or KOH.
Amsorb does not degrade
inhaled anesthetics, but soda lime can degrade sevo, des, and isoflurane into CO.
Soda lime can degrade inhaled anesthetic gases to
Carbon monoxidee
Channeling can be minimized by
shaking the canister before use.
What is the principal heat and moisture exchanger of inspired gases?
The upper respiratory tract (mostly the nose) is the principal heat and moisture exchanger of inspired gases.
What is the most common cause of post-intubation laryngeal edema?
ETT that is too large.
Tongue that falls backwards is known as Glossoptosis and is seen with this anormaly?
Pierre Robin
What is the treatment of CROUP?
Racemic epinephrine
What is the dose and concentration of the racemic epinephrine use to treat croup ?
0.5ml of 2.25% epinephrine diluted in 2.5ml of 0.9% NaCL
What provide the stimulus for vasopressin (ADH) release ?
Osmoreceptors in the anterior hypothalamus
What provide the stimulus for vasopressin (ADH) release?
Osmoreceptors in the anterior hypothalamus
Osmolarity vs OsmoLALITY
LARI LA(Liters) osmol per liter LALI Ki (kilograms) osmol per kilo
As long as CPP > 60 mm Hg, keeping ICP
< 20 mm Hg is more important than further increases in CPP
Calculating serum osmolality
2 x [Na+] + [BUN]/2.8 [glucose]/18.
The syndrome of inappropriate ADH secretion (SIADH) treatment
Fluid restriction
2 cornerstone treatment of croup
Racemic epinephrine
Dexamethasone
Children: The dose of dexamethasone for the treatment of croup?
0.25-0.5 mg/kg
Supraglottic obstruction is associated with _______while infraglottic obstruction is associated with ________
Stridor; wheezing.
Subluxation in down syndrome is located where?
C1 and C2.
Cleft lip repair surgery is performed close to
1 month of age
Cleft palate repair surgery is performed close to
12 months of age.
What is FENA
ratio between the quantity of Na excreted in the urine
relative to the amount filtered at the glomerulus.
Prerenal AKI FENA will be
Less than 1 %
When is FENA used?
FENa is often used in the setting of acute renal failure to help distinguish between prerenal (decreased renal perfusion) and intrinsic renal (ATN due to renal hypoperfusion) causes.
What FENA determines INTRARENAL causes of AKI?
> 2% between 1 and 2% is indeterminate, and >2% suggests ATN.
Systemic Hypotension will stimulate 3 different mechanisms what are they?
RAAS, SNS, ADH
Neurohumoral axis with stimulation of the
renin–angiotensin–aldosterone system (RAAS), sympathetic nervous system (SNS), and arginine vasopressin (AVP).
What is the RIFLE CRITERIA?
Risk (Cr > or equal 50%) Injury (Cr > or equal to 100%) Failure(Cr > or equal to 200%) Loss of function End Stage Renal Disease.
Definition of AKI based on CR and UO
Serum Cr 2–3 times or GFR >50%
UO decrease <0.5 mL/kg/h for > 12 h
Cocaine on MAC
increased MAC
Criteria for EKG changes consistent with MI
New significant ST-segment
T wave changes
New left bundle branch block
Development of pathological Q wave
Three types of troponins exist—What are they?
troponin I, troponin T, and troponin C
State the 3 different functions of the 3 types of troponin?
- Troponin T binds the troponin components to tropomyosin
- Troponin I inhibits the interaction of myosin with actin,
- Troponin C contains the binding sites for
Ca2+ that help initiate contraction
What determines AKI with aortic surgery
Aortic clamp proximity to the renal arteries is critical.
2 patients at increased risk for Contrast-induced Nephropathy are?
Diabetics
Preexisting renal insufficiency Serum Cr > 1.2
Stages of CKD
- Increased GFR only
- GFR 60-89
- GFR 30 - 59
- GFR 15-29
- GFR < 15
What is the chief end product of protein metabolism? where is it formed?
UREA; liver
Why is BUN level not a good indicator of renal disease?
Because it does not increase in most patients until the GF is reduced by more than 50%
What is the most specific test of GFR and the most reliable assessment tool for renal function ?
Creatinine Clearance.
What is the normal CrCl?
95-150 ml/min
Classify renal dysfunction as mild , mod and dialysis level with CrCl
Mild 50-80
Mod <25
less than 15 requires dialysis
Describe Zone I to Zone III Of the lungs: Relationship of PA, Pv, and Pa
Zone 1 : PA > Pa > Pv (Upper)
Zone 2 : Pa > PA > Pv (middle)
Zone 3: Zone 3 Pa > Pv > PA (lower)
Zone 1 is not seen in _____Why? when is it seen?
normal lungs. It may be seen in positive pressure ventilation or after hemorrhage or HIGH PEAK PRESSURE Alveolar pressure exceeds pulmonary vascular pressures. Hence the pulmonary vessels are collapsed, and no flow occurs causing alveolar dead space.
Zone 2 occurs about
3 cm above the level of the heart.
Adding activated charcoal filters to the airway circuit is effective in keeping anesthetic agent concentration
below 5 ppm for up to 12 hours with fresh gas flows of at least 3 L/min
During measurement of the pulmonary wedge pressure (PAOP, PWCP), an assumption is made
that _______What is the implication of that?
here is a clear unobstructed communication between the pulmonary artery and veins, as the wedge pressure is measured from the right side of the heart.For the wedge pressure to be an accurate reflection of the left atrial pressure, the measurement needs to be performed in west’s zone 3. If
For the wedge pressure to be an accurate reflection of the left atrial pressure, the measurement needs to be performed in
west’s zone 3
Closing volume is measured by
nitrogen washout.
2 types of DI
Central DI
Nephrogenic DI.
What is central DI?
Central DI – decreased secretion of antidiuretic hormone (ADH, aka AVP)
What isNephrogenic DI ?
decrease in the ability to concentrate urine due to a resistance to ADH action in the kidney.
ADH: Actions are mediated through at least 2 receptors
V1 mediates vasoconstriction, enhancement of corticotrophin release, and renal prostaglandin synthesis V2 mediates the antidiuretic response
DI treatment
Desmopressin
Antidiuretic hormone (ADH) is synthesized in the________ and transported to the
supraoptic and periventricular nuclei of the hypothalamus; posterior pituitary by the hypothalamoneurohypophyseal tract.
In the kidney, ADH opens
aquaporins in the distal and collecting tubules (in a cAMP-dependent mechanism) resulting in an increase in water resorption.
Among the inhaled anesthetic agents, Which agent appears to preserve autoregulation at all doses
sevoflurane
In healthy individuals, which 2 anesthetics tend to maintain cerebral autoregulation ?
propofol and remifentanil
Define cerebral autoregulation?
The brain maintains a constant blood flow to itself despite changes in cerebral perfusion pressure
Cerebral perfusion pressure (CPP) is defined as the difference between the
mean arterial pressure (MAP) and intracranial pressure (ICP) {CPP = MAP − ICP}.
If the central venous pressure (CVP) is greater than the ICP, then CPP =
MAP − CVP.
The cerebral flow is then modulated by the greater of the two pressures—
CVP or ICP
The Mapleson ____system is best for spontaneous respiration with the advantage of less waste of fresh gas flows.
A
Overzealous treatment of DI results in
SIADH.
Oversecretion of ADH can result in ______while under-secretion of ADH results in _______
the syndrome of inappropriate ADH (SIADH); diabetes insipidus (DI).
Digoxin toxicity can occur with High/ low potassium levels?
Low
What is Zollinger-Ellison
Gastrinoma, gastric tumor
How does Loop diuretics work vs thiazide diuretics? what is the mnemonic to remember?
Loop diuretics block the sodium-potassium-
chloride cotransporter in the THICK Ascending limb of the loop of Henle, while thiazides block the sodium-chloride co-transporter in the distal convoluted tubule
LOOP -TA, THIA-Di
How do you diagnosed LVH on an ECG?
Increased QRS voltage
What is the definitive diagnosis of hypertrophic cardiomyopathy?
Myocardia biopsy with subsequent DNA analysis.
Most common cardiomyopathy with genetic origin?
Hypertrophic Cardiomyopathy
What are features of HYPERTROPHIC CARDIOMYOPATHY?
Asymmetric hypertrophy of the UPPER interventricular septum which leads to dynamic OBSTRUCTION OF THE LEFT VENTRICULAR OUTFLOW TRACT.
What happens to the mitral valve leaflets with Hypertrophyic cardiomyopathy?
Anterior and posterior mitral leaflets moves anteriorly into the LVOT, producing systolic anterior motion (SAM), incomplete closure of mitral valve leaflets, MR , diminishes effect antegrade CO –> HYPOTENSION
List 4 things that worsens SAM (Systolic anterior motion with hypertrophic cardiomyopathy?
Positive Inotropy
Decrease preload and afterload.
Arterial vasodilators.
CaO2 is calculated by
Sum of Oxygen bound to Hgb + oxygen dissolved in plasma.
O2 dissociation curve is _____on the x-axis and _____on the y-axis
Partial pressure, O2 saturation.
Explain the O2 dissociation curve?
The graph is sigmoid or S shaped. Initially, in the steep portion of the curve, the hemoglobin’s affinity for oxygen increases with maximum O2 loading, and then the graph
levels off around PO2 of 60 mmHg with little change even when the PO2 is increased significantly.
What is P50? P
50 is the oxygen tension at which hemoglobin is 50% saturated which is typically around 26.5 mm Hg and is a measure of hemoglobin’s affinity for oxygen.
What is P50 a measure of?
Hemoglobin’s affinity for oxygen.
What is the formula for CaO2?
CaO2 = (1.39 × Hb × SaO2/100) + (PaO2 × 0.003).
Cyanosis can be detected at an SaO2 of approximately
80%
Shifting the OxyHgb to the the right P50
Increasing P50
Shifting the OxyHgb to the left effect of P50
decreasing P50
Define right shift and left shit meaning on oxygenation?
A rightward shift indicates that a higher PO2 is required for the same 50% Hb saturation. This means lower
oxygen affinity. This is seen in the peripheral tissues where oxygen “unloading” happens. Conversely, a leftward shift increases hemoglobin’s affinity for oxygen
[1, 2]. This is seen in the lungs where oxygen “loading” happens.
The Fick equation expresses the relationship between
oxygen consumption (VO2), arteriovenous oxygen content difference (CaO2 − CvO2), and cardiac output
CaO2 = arterial oxygen content =
20 m/dL
CvO2 = mixed venous oxygen content =
15 mL/dL
CaO2 − CvO2 = normal extraction for oxygen =
5 mL/dL
Is a good measure of the overall adequacy of
oxygen delivery.
The arteriovenous difference
Normal extraction ratio for oxygen (CaO2 − CvO2)/CaO2 is______; What is the meaning of that?
5 mL/20 mL or 25%; the body normally consumes
only 25% of the oxygen carried on hemoglobin
The Bohr effect is a physiological phenomenon, and it describes the.
inverse relationship of the hemoglobin’s affinity for oxygen to acidity and to the concentration of carbon dioxide
An increase in CO2 (which reacts with water to form
carbonic acid) increases acid and lowers pH which leads to
O2 unloading by hemoglobin.
High CO2 and acid effect on O2
O2 unloading by hgb This effect facilitates the oxygen transport as hemoglobin binds to oxygen in the lung (less CO2 and acid) and releases it in the tissues (more CO2 and acid).
What is the Haldane effect?
Oxygenated hemoglobin has a reduced capacity for CO2, and conversely reduced Hb has an increased capacity.
What is the haldane effect important for?
physiologic importance in governing CO2 transport. Reduced Hb in the tissues facilitates CO2 “pickup,” and in the oxygen-rich capillaries of the lung, this property promotes dissociation of CO2 from the Hb and thereby elimination
Which lung volume cannot be measured by spirometry and how can it be obtained?
The residual volume (RV) cannot be measured by spirometry. Radiographic planimetry, nitrogen washout, helium dilution, and body plethysmography may
all be used to calculate residual volume
The five causes of vision loss during prone procedures in patients undergoing nonopthalmologic surgery are
central retinal vein occlusion, 2) glycine toxicity, 3) ischemic optic neuropathy, 4) central retinal artery occlusion, and 5) cortical blindness.
A patient is undergoing general anesthesia for a colon resection. During manipulation of the mesentery, a patient suddenly exhibits hypotension, tachycardia, cutaneous hyperemia, and the oxygen saturation drops from 99% to 88%. This reaction is most likely mediated by
Prostacyclin/prostaglandin
Seventy percent of anesthesia-related allergic reactions are
IgE-mediated type I reactions
Common cause of type I reactions and the incidence is highest with
Neuromuscular blocking agents; succinylcholine.
What is the definitive treatment for anaphylaxis?
Epinephrine
All of the following are factors contributing to the development of rhabdomyolysis in the lateral decubitus position except
Tachycardia
Rhabdomyolysis is associated with the lateral decubitus position. Factors that are considered to contribute to this phenomenon include.
prolonged surgical time, hypotension, and the pressure of the operating room table against the gluteal and flank muscles
Position associated with rhabdomyolosis
Lateral decubitus
What is the most common cause of postoperative vision loss from a spine operation?
Ischemic optic neuropathy
The sternal retractor used during cardiac surgery can compress the brachial plexus between the_____and the _______
clavicle and the first rib.
To avoid cervical injury from hyperflexion of the neck in the sitting or prone positions, it is recommended that you maintain a distance of at least _____ fingerbreadth(s) between the mandible and sternum.
two
What surgical position carries the highest risk for compartment syndrome?
Lithotomy
What worsens GLOBAL and focal hypoxic brain injury
Hyperglycemia
Neuronal cell use what as the main energy source?
Glucose
Other than glucose as main energy source, other sources are
Ketone bodies and lactate
Dexdemetomidine act where ?
Locus ceruleus of brain and spinal
What make precedex a good drug?
Sedation
NO SIGNIFICANT RESPIRATORY DEPRESSION
Side effects of Precedex
Hypotension and bradycardia
2 treatments for von willebrand?
Cryoprecipitate
Desmopressin
Explain differential blockade,
sympathetic nerve fibers are blocked by the lowest concentration of local anesthetic followed by nerve fibers responsible for pain, touch and finally motor function.
Most common pipeline supply problem?
Crossover
2 main action in order of priority when crossover is suspected?
Turn on backup oxygen supply
Disconnect pipeline supply hose from the wall.
Why should you disconnect the pipeline when you suspect a crossover?
Gas will flow from whichever source is at a higher pressure — the pipeline(at 50 psi, containing, for example, nitrous oxide) or the emergency tank supply of oxygen (supplied to the machine at 45 psi).So you must disconnect the pipeline supply.
Decrease CO and onset of action of VA
Faster
Increase CO and onset of action of VA
Slower
What is ANP ?
Atrial natriuretic peptide (ANP) is a peptide hormone released by cardiac myocytes in response to atrial stretching due to increased extracellular volume/volume overload. This stretch leads to the precursor ProANP being cleaved and released.
What 2 disorders account for 81% of all cases of POVL with prone positioning?
Ischemic optic neuropathy and central retinal artery occlusion
Carcinoid tumor arise from _________and they secrete excessive______
neuroendocrine cells; Serotonin
Carcinoid tumors typically secrete excessive amounts ofhey arise from neuroendocrine cells throughout the body.
the hormone serotonin (although they may secrete many hormones)
Serotonin causes
Vasodilation, increased blood clotting (stimulation of platelet aggregation
With carcinoid syndrome, excessive production of serotonin both lead to
red hot flushing of face, severe and debilitating diarrhea, and asthma attacks (tachykinins).
Carcinoid tumors that are isolated to the gastrointestinal tract usually
do not result in the systemic manifestations of the carcinoid syndrome
Carcinoid tumors are usually on which side of the heart?
Right side of the heart
Histamine-stimulating drugs and adrenergic agonists may precipitate the
flushing, hypotension, and tachyarrhythmias related to serotonin release.
Carcinoid tumors commonly found in
GI tract
Carcinoid tumors diagnosis
Elevated levels of 5-HIAA in the urine are a marker of excess serotonin production and, therefore, the presence of a carcinoid tumor
Patient with 5-hydroxyindoleacetic acid (5-HIAA) in urine is an indication of
Carcinoid tumor
What probably responsible for the bronchospasm seen in some carcinoid patients, and it also may be the cause of flushing
Histamine
The most common site of metastasis is the
Liver
Anesthesia may precipitate a carcinoid crisis
characterized by
hypotension, bronchospasm, flushing, and tachycardia
predisposing to arrhythmias
Drugs of choice for carcinoid symptoms control
(octreotide and lanreotide) are now the drugs of choice for symptom control. 150–200 mcg of octreotide is administered every 6–8 hours for 24–48 hours prior to
surgery and continued throughout the procedure
Pt with carcinoid syndrome and tumors, what is mandatory for monitoring?
Invasive monitors should be inserted before the induction of anesthesia, and their use should be continued postoperatively. The hypotension commonly associated with induction agents may trigger a carcinoid crisis, so the insertion of an arterial catheter is mandatory
prior to the induction of anesthesia
Atm = psi = kpa= cmH20= mmHg
1 atm = 14.7 psi = 100 Kpa = 1030cmH20 = 760 mmHg
Empty E-cylinder is how many lbs?
14
E-cylinder of O2 : L and PSI
660L and 1900-2200psi
E-cylinder of N2O : L and PSI
1590 L and 745 psi
E-cylinder of Air: L and PSI
625 L and 1900 Psi-2200 Psi
What is the most reliable means of IDENTIFYING O2 content?
The label.
Should the cylinder color be relied upon for identification ?
NO
Pipeline failure best to
Switch to manual ventilation to conserve oxygen
Negative consequences to instilling saline into the trachea are
it can dislodge bacteria or secretions from the tracheal tube wall and wash them into the lower airways.
2 main system of the anesthesia machine
pneumatic and electrical
If the power indicator shows loss of mains electrical power or that the battery is in use what should you do?
First check the power line has not become loose or disconnected.
Backup anesthesia machines will provide power for how long
30 minutes depending on usage.
The yoke should not be left
Vacant. Put a plug to prevent gas from escaping from the machine.
What is the role of the check valve?
Allows gas from cylinder to enter the machine but prevent gas from exiting the machine when there is no cylinder in the yoke.
Cylinder valve Contaminated with oil or grease, because it can cause
fire.
4 Components of High pressure system
Hanger yoke
Check valve
Cylinder pressure Gauge(Indicator)
Pressure Regulator.
Intermediate pressure system
Master switch pneumatic component Pipeline inlet connections Pipeline pressure gauge Oxygen pressure failure device. 2nd stage pressure regulator Oxygen flush
Oxygen failure safety valve other name
Fail safe
The fail safe valve does what?
Shuts off or proportionally decreases and ultimately interrupts the supply of other gas if the oxygen supply pressure decreases.
How do you determine whether a machine has a properly functioning oxygen failure safety device?
Turn oxygen and nitrous on
The source of Oxygen pressure is then removed (Pipeline or cylinder)
if the oxygen failure safety device is functioning properly, the flow indicator for the other gas will fall to the bottom of the tube just before the oxygen indicator falls to the bottom of its tube.
Oxygen supply failure alarm will sound within
5 seconds of the oxygen pressure falling below 30 psi.
When do you not use the oxygen flush valve?
Do not use upon inspiration when using a ventilator. This can result in delivery of HIGH tidal volumes and possible barotrauma. Ventilator that excludes fresh gas flow from the breathing system during inspiration prevent that risk.
Low pressure system components –>
Flowmeters
Unidirectional check valves
pressure relief device
Common gas outlet
Float read on
Top
Ball read at
Center
What is the difference between hypoxia prevention device and oxygen pressure failure device?
the oxygen pressure failure device prevents hypoxia due to a loss of oxygen pressure in the machine, whereas the Hypoxia prevention devices prevent the operator from accidentally setting a hypoxic gas mixture.
If the concentration of O2 is less 25%, the device will lower the
nitrous oxide flow to maintain an O2 concentration of at least 25 %.
Carcinoid patients have chronic
Right ventricular (RV) valvular lesions and heart failure, anesthetic factors that increase RV work and may precipitate acute RV failure should be avoided.
Factors that increase RV work in carcinoid syndrome patients and that should be avoided
include hypoxemia, hypercarbia, and a light anesthetic plane.
For Carcinoid tumor, Hypotension should be treated with
an α-receptor agonist such as Neo- Synephrine to avoid β-adrenergic activation.
Why is 2- Chlorprocaine use in OB?
Quick onset, rapidly metabolized, ester, NO TOXICITY
Does not cross placenta
Universal recipient type
AB
Universal donor
O type
What is the only volatile agent that facilitates CSF absorption and has a favorable effect on CSF dynamics.
Isoflurane
When doing controlled hypotension , which is best suited for preservation of CO?
nitroprusside is best suited for the preservation of cardiac output
Sympathomimetics such as ephedrine and histamine-releasing drugs such as (4) should be avoided if possible as they can trigger the release of hormones from the tumor as well.
morphine, succinylcholine, thiopental, and atracurium
Sympathomimetics to be avoided with carcinoid syndrome are
Ephedrine (because you want Beta stimulation prevention)
Norepinephrine (unpredictable response)
Which of the Rexed laminae are located in the dorsal horn of the spinal cord?
Lamina VI
Rexed laminae I through laminae VI are located in the. Laminae VII, VIII, and IX comprise the ventral horn.
dorsal horn of the spinal column
With SIMV 2 parameters that must be selected
A mandatory tidal volume and ventilatory rate must be selected
2 herbal supplements with bleeding potential?
Garlic and ginseng (Inhibit platelet aggregation)
Ginseng risk
Inhibit platelet aggregation
Gas law stating: the temperature is held constant, the amount of gas dissolved in a liquid is directly proportional to the partial pressure of the gas above the gas-liquid interface.
ording to Henry’s law
Gas law stating: the temperature is held constant, the amount of gas dissolved in a liquid is directly proportional to the partial pressure of the gas above the gas-liquid interface.
Henry’s law
With multiple sclerosis what is associated with relapse
Studies have demonstrated that general anesthesia and regional anesthesia do not increase the incidence of exacerbation of multiple sclerosis. Pregnancy is associated with a reduced incidence of exacerbation, while the postpartum period is associated with an increased risk of relapse.
Pregnancy on MS
Reduced incidence of exacerbation
Signs of cyanide toxicity include:
increased mixed venous 02
increased nitroprusside dosage requirements (tachyphylaxis),
and metabolic acidosis.
CCB with the greatest negative inotropic effect?
Verapamil
Risk for damage during a carotid endarterectomy.
The recurrent laryngeal nerve is
After CEA, Damage to the RLN nerve could manifest as
inspiratory stridor following emergence.
Flumazenil has an elimination half-life of approximately
1 hour.
Which narcotic has been reported to produce hypertensive crisis, convulsions, and coma in patients taking MAO inhibitors?
Meperidine
The use of hyperbaric local anesthetics such as lidocaine 5% in spinal anesthesia is associated with
cauda equina syndrome
What cross allergy is of concern with a DM patient on NPH insulin presenting for cardiac surgery?
Protamine exhibits an increased risk of allergic reaction in patients taking NPH insulin.
Remifentanil has a context-sensitive half-life of
2 to 4 minutes.
Its plasma concentration can decrease by nearly half in as little as 40 seconds.
Remifentanil
3 that may be used for the treatment of spasms of sphincter of Oddi.
Naloxone, nitroglycerin, or glucagon
Which nerve fibers will have their function attenuated when opioids are administered via spinal?
Spinal administration of opioids gives analgesia primarily by attenuating the transmission of C-fiber nociceptive impulses.
Intravenous agents whose induction or initial doses should be calculated according to total body weight in the obese individual are
succinylcholine, neostigmine, sugammadex, and dexmedetomidine.
What is the single biggest predictor of problematic intubation in morbidly obese patients?
Neck circumference
Single best predictor of a difficult airway
Neck circumference
Hormones that use the phospholipase C system include:
Parathyroid hormone
Alpha receptor catecholamines
Vasopressin V1.
Oxytocin
Hormones that use the adenylyl cyclase system include
Calcitonin ACTH Glucagon, secretin, somatostatin, vasopressin V2 parathyroid hormone luteinizing hormone, and beta-receptor catecholamines.
Although the addition of bicarbonate will speed the onset of a lidocaine epidural, the addition of bicarbonate to
bupivacaine will cause it to precipitate.
Opthalmologists may inject expanding gases such as sulfur hexafluoride or perfluoropropane into the eye to press a torn retina back into place. The use of nitrous oxide can cause the injected bubble to expand rapidly, causing a dramatic increase in intraocular pressure and possibly interrupting retinal blood flow. Nitrous oxide should be avoided for up to
3 months in these patients.
Opthalmologists may inject expanding gases such as 2
sulfur hexafluoride or perfluoropropane
Which local anesthetic has the highest potency and longest duration?
Tetracaine
LA both intermediate in potency and duration,
Lidocaine and mepivacaine are
The terminal branch of the femoral nerve is the
saphenous nerve
A nondepolarizing block is characterized by several factors when assessed by a peripheral nerve stimulator. What are three of the factors?
Decrease in twitch tension, fade during repetitive stimulation, post-tetanic potentiation
Tetanic fade is a response to blocking which type of receptor?
Presynaptic nicotinic acetylcholine receptors
A patient in the anesthesia preop clinic informs you that they were slow to wake up after their last procedure and needed a breathing tube for a few hours afterward. They cannot provide any additional information. You suspect a pseudocholinesterase deficiency. Your hospital does not have the ability to test for a dibucaine number. What test could you order?
A fluoride resistance test can help confirm a diagnosis of atypical pseudocholinesterase function. . A result of 36 is consistent with the homozygous atypical pseudocholinesterase function.
A fluoride resistance test: A result of 60 indicates
normal pseudocholinesterase function
A fluoride resistance test: A result of 30 indicate
homozygous atypical pseudocholinesterase function.
You notice that the pulse oximeter waveform of an anesthetized patient undergoing an elective colon resection varies greatly and skips occasional beats. When you pause mechanical ventilation, the waveform appears normal. You should
administer a fluid bolus
Hypovolemia has been cited as a cause of the pulse oximeter waveform to
skip beats, perform erratically, and cause variation in the pulse waveform during positive-pressure ventilation.
If pausing ventilation causes the waveform to return to normal, then a fluid bolus trial should be attempted to see if hypovolemia is the underlying cause when having issues with
Pulse ox reading
The esophageal doppler technique is based on the principle that states that the
flow within a cylinder is equal to the cross-sectional area of the cylinder multiplied by the velocity of fluid flowing through it. By placing an ultrasound probe into the esophagus, the doppler can detect changes in the frequency of sound waves flowing through the descending aorta. This allows determination of the blood velocity and an estimation of stroke volume and cardiac output.
What happens when there is hyponatremia?
intracellular space is hyperosmolar relative to the extracellular space and fluid shifts intracellularly
The absolute contraindications to shock wave lithotripsy include
bleeding disorder (or anticoagulation) and pregnancy.
Which of the following EEG changes would most likely be seen during periods of circulatory compromise to the brain?
Low frequency, high voltage activity
You are preparing your anesthesia machine for a general anesthetic on a small child. You should select a breathing bag with a volume that is approximately
three times the patient tidal volume
HOw to remember trigeminal branches top to bottom
O MAX MAN
Ophtalmic V1
Maxillary V2
Mandibular V3
Sensory innervation to the anterior two-thirds of the tongue is provided by the
mandibular (V3) branch of the trigeminal nerve. S
Sensory innvervation to the
posterior one-third of the tongue is provided by the glossopharyngeal nerve.
A fixed airway obstruction can be caused by a foreign body in the airway, a lesion like
tracheal stenosis, or anatomical compression by a tumor or goiter.
In a fixed obstruction, the flow-volume loop exhibits decreased flow during
both inspiration and expiration. It looks as if the top and bottom of the loop are chopped off.
There are three potential reasons that the CO2-ventilatory response curve would shift to the left and/or develop a steeper slope. These are the only causes of true hyperventilation (where the patient’s minute ventilation increases to the point that respiratory alkalosis results). They are:
Metabolic acidosis
Arterial hypoxemia
Central nervous system alteration.,
The celiac reflex can produce hypotension and bradycardia and is caused by
pressure on the mesentery or the gallbladder.
The Cushing reflex is an
increase in arterial blood pressure in response to an increase in intracranial pressure.
What can elicit the oculocardiac reflex which will produce sinus bradycardia and other bradydysrhythmias?
Pressure on the globe of the eye or the extraocular muscles (especially the medial rectus) will
The Valsalva reflex is a
decrease in heart rate, cardiac contractility, and blood pressure caused by an increase in intrathoracic pressure (usually by forced expiration against a closed glottis).
Which inhalation treatment would be least appropriate for patient with CAD?
Racemic epinephrine
Tests that indicate that a patient has muscle strength adequate enough to sustain ventilation and take a large enough breath to cough effectively include:
the ability to perform a sustained head lift, a negative inspiratory force of -25 cm H2O, a successful train-of-four stimulation, and a forced vital capacity of 10-12 mL/kg.
The most common cause of an acute increase in deadspace.
Decreased cardiac output
PvO2 reduction is a result of
A decrease in arterial oxygen content or an increase in arterial oxygen extraction will reduce the
The hallmark signs that help identify diabetes insipidus are a u
rine specific gravity less than 1.005 and a urine osmolality of 200 mOsm/kg or less.
Separation anxiety begins at about
8-10 months of age.
What is the most common metabolic disorder seen in newborns and young infants?
Hypoglycemia
Which of the following should take priority in your airway management plan for a pediatric patient with bronchopulmonary dysplasia?
Choose an endotracheal tube that has an internal diameter 0.5-1.0 smaller than normal
What is considered the minimum adequate interincisor gap in an adult?
4cm
Dysfunction of the serratus anterior muscle and winging of the scapula are consistent with injury to the
long thoracic nerve
You are applying local anesthetic soaked pledgets to the middle turbinates of a patient’s nasal cavity prior to a nasal intubation. What nerves are you anesthetizing?
Branches of the trigeminal nerve
Which of the following is considered a retroglottic airway device?
Combitube
What is the largest size ETT the LMA Fastrach (intubating LMA) will accommodate?
8.5mm
When using jet ventilation through an airway exchange catheter, it is appropriate to
administer a neuromuscular blocker to prevent the glottis from closing around the catheter and leading to possible barotrauma due to lack of egress of insufflated air.
Crossmatching blood involves
mixing the blood of the donor and recipient together in the lab
Blood typing (a type and screen) determines the patient’s
blood type and predicts compatible transfusions 99.94% of the time.
Crossmatching, which is the actual
mixing of the donor and recipient blood in a trial transfusion increases the possibility of a compatible transfusion by only one-hundredth of 1%.
A patient presents for liver transplantation due to hepatopulmonary syndrome (HPS). This disease is characterized by the triad of:
Hypoxemia
portal hypertension
pulmonary vascular dilatations
Which would be considered a contraindication to lung transplantation?
Malignancy within the last 2 years
A patient’s BMI 35 or greater
When the N2O tank pressure drops below 745psi The amount of nitrous oxide in the gas phase at that point
is about a quarter of the tank or around 400 liters. At 2 liters per minute, you would have approximately 200 minutes of nitrous oxide left.
A preoperative finding of nystagmus would be consistent with potential abuse of which drug?
PCP Phencyclidine
Shorten the seizure duration of electroconvulsive therapy.
Fentanyl, midazolam, lidocaine, and diltiazem
Prolong the seizure duration of ECTs
Caffeine, ketamine, aminophylline, and clozapine
Repeat stimulation caused by nerve damage or chronic inflammation can cause a condition known as
Windup
Which surgical procedure is most commonly associated with chronic postsurgical pain (CPSP)?
Thoracotomy
Laryngospasm that is unresponsive to positive pressure ventilation can be treated with
0.15-0.5 mg/kg succinylcholine IV or 4 mg/kg IM. In this case, the patient weighs 60 kg, so the appropriate intramuscular dose would be 240 mg.
The most common cause of arterial hypoxemia in the postoperative period is
atelectasis
You are preparing to induce a patient with a large anterior mediastinal mass for general anesthesia. Which device should you have at your immediate disposal?
Rigid bronchoscope
Cardiac is performed in the supine position.
Thoracoscopic sympathectomy for hyperhydrosis
It is an outpatient procedure and involves no chest tubes.
Thoracoscopic sympathectomy for hyperhydrosis
he most reliable stimulator of arousal in persons with obstructive sleep apnea is
work of breathing
You administer scopolamine preoperatively to an elderly patient. The patient becomes agitated, confused, and severely obtunded. Which drug would be the most appropriate agent to alleviate these symptoms?
physostigmine
A patient is placed in steep Trendelenburg position for a robotically-assisted procedure. This will cause a decrease in which parameter?
Lung compliance
Which epidural needle has wings at the hub in order to stabilize the needle and assist grip during insertion?
Weiss
Which patient safety initiative outlines a list of serious, reportable adverse outcomes such as surgery on the wrong site?
The National Quality Forum
are involved in elevating the degree of inflammation due to injury.
Neuropeptides such as substance P
The composition of the inspired gas mixture a patient receives depends primarily upon the
fresh gas flow rate, the volume of the breathing circuit, and any absorption by the circuit.
The inspired gas concentration will be closer to the fresh gas concentration if the
circuit volume and level of absorption by the circuit are low and the fresh gas flow is high
What anesthesia machine alarms are based on the circuit pressure?
The disconnect alarm
The high pressure alarm
What substance is responsible for transmission of fast pain in the central nervous system?
Glutamate
A series of electron transfers coupled to the formation of adenosine triphosphate
Oxidative phosphorylation
Responsible for about 90% of all oxygen consumed in the body.
Oxidative phosphorylation
What are the two primary determinants of coronary perfusion pressure? (select two)
Left ventricular end-diastolic pressure
Aortic diastolic pressure
It is most commonly due to an adenoma in the anterior pituitary gland.
Acromegaly
The underlying cause of organ failure due to disseminated intravascular coagulation is
The widespread bleeding and thrombosis from DIC can cut off the blood supply to tissues and organs, resulting in ischemia.
Dexmedetomidine provides
anxiolysis, sedation, analgesia, and sympatholysis.
Dexmedetomidine does not produce
significant respiratory depression.
Potential side effects of dexmedetomidine include:
hypotension, bradycardia, oversedation, and delayed recovery.
EF is calculated by
EF = SV/EDV
How is SV calculated?
SV= EDV -ESV
Heat that is lost as body moisture converts from the liquid phase to gas phase is referred to as
Evaporative heat loss
Pulmonary function tests should be performed in
patients with severe scoliosis as a vital capacity < 40% of predicted is associated with the likelihood of postoperative ventilatory support.
Factors that decrease the amount of prolapse in patients with mitral valve prolapse include
Drug-induced myocardial depression
Increased preload
Hypertension
Vasoconstriction
Both intrinsic and extrinsic restrictive disorders produce resistance to
lung expansion.
Chronic intrinsic restrictive lung disease includes pathologies that alter the lung parenchyma such as
pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, and alveolar proteinosis.
Chronic extrinsic restrictive lung disease is typically due to disorders of the thoracic cage such as
kyphosis, scoliosis, flail chest, and ankylosing spondylitis.
The initial signs and symptoms of Duchenne muscular dystrophy are due to the effect of the disease on
proximal skeletal muscle groups
The initial signs of Duchenne muscular dystrophy are related to weakness in the proximal skeletal muscle groups and manifest as an
alteration in gait, difficulty climbing stairs, and frequent falls.
The progressive and symmetric deterioration in muscle strength is associated with fatty infiltration of the muscles which results in pseudohypertrophy of the muscles.
Duchenne muscular dystrophy
Which of the following characteristics are consistent with Cushing’s syndrome?
Hypertension
Rounded facial appearance
Spontaneous bruising
Glucose intolerance
Are all symptoms consistent with Cushing’s syndrome.
Sudden onset of weight gain, thickening of the facial fat giving a rounded shape to the face, facial telangiectasias, glucose intolerance, hypertension, decreased libido in men, oligomenorrhea, and spontaneous bruising
Which of the following clinical signs are consistent with a diagnosis of hypothyroidism? (select four)
Listlessness
Decreased cardiac output
Peripheral edema
Decreased serum levels of free T4
Patients with hypothyroidism often exhibit
thick skin and periorbital and peripheral edema.
In hypothyroidism, CO
There is a decrease in cardiac output due to reductions in both heart rate and stroke volume.
Peripheral vascular resistance is increased, and blood volume is reduced in HYPERTHYROIDISM or hypothyroidism
Hypothyroidism
It is diagnosed by the presence of decreased levels of free T4, total T4, T3, R-T3U, free T4 index, and an elevated TSH level.
Hypothyroidism
MR that have minimal if any prolongation of effect in patients with renal disease.
Mivacurium, atracurium, and cisatracurium
Laudanosine, the principal metabolite of
atracurium and cisatracurium, does rely on renal excretion.
Which of the following are consistent with a diagnosis of ACTH-independent Cushing’s disease? (select two)
high cortisol levels
low corticotropin levels
2 valvular disorders associated with carcinoid
pulmonic stenosis
tricuspid regurgitation
What is the most common long-term effect associated with the use of electroconvulsive therapy?
Memory impairment
What primarily determines the resistance to gas flow in an anesthesia circuit?
Circuit diameter and length
What are the 3 advantages of the use of a lighted stylet over traditional laryngoscopy?
less affected by anterior airway
It is associated with a lower incidence of sore throat
It is less stimulating than traditional laryngoscopy
What ventilator modality is described by a setting that has a target gas delivery pressure and where the tidal volume varies from breath to breath depending upon the patient’s resistance and compliance?
PCV
At the beginning of inspiration, the ventilator rapidly increases the pressure to the determined level and maintains that pressure until the beginning of exhalation.
PCV
Which test assesses the integrity of the extrinsic hemostasis pathway?
PT
All preganglionic neurons are
Cholinergic
Sympathetic nerve fibers originate between the spinal levels of
T1-L2 (Thoracolumbar)
Which hematologic alteration is associated with hyperthyroidism?
anemia and thrombocytopenia.
Which of the following is true of an oxygen concentrator?
High humidity can reduce the oxygen concentration delivered by a concentrator
An oxygen concentrator utilizes a technology called. High humidity can reduce the oxygen concentration delivered by a concentrator. A concentrator requires a compressor, and the device can stop delivering oxygen if the compressor fails.
pressure swing adsorption which filters out nitrogen, carbon dioxide, carbon monoxide, water, and hydrocarbons while allowing oxygen and trace gases such as argon to pass through
For an oxygen concentrator, The FiO2 delivered ranges between
Ranges between 90 and 96 percent. Although argon concentrations can reach as high as 5%, there are no known detrimental effects from short-term or long-term exposure to argon.
A manual resuscitator with a self-expanding bag is not the ideal choice for spontaneously breathing patients because
It cannot exert a sufficient negative pressure to open the inspiratory port, they may inhale room air via the expiratory port.
