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
