RANDOM FACTS for SEE 2 Flashcards
Dexamethasone should be avoided in patient having what type of surgery and why?
Pituitary surgery: because it can suppress the HPA axis leading false post op test for hypopituitarism.
Protease inhibitors examples are
Ritonavir and sapinavir
How does protease inhibitors affect anesthetic drugs?
They are inhibitors of Cyp450 and can alter duration and effect of sedatives.
DDAVP causes
vWF to split from Factor VIII and increases the serum levels of both components.
A chemical that can bind with a protein to form a new complex is a
Ligand
Typically, it is a signal triggering molecule that binds with a target protein.
Ligand
Renal failure is associated with main electrolyte imbalances. Mnemonic to remember?
Kphos High
CaNa low
Acid
hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, and metabolic acidosis.
Which herbal supplement is used to treat depression and anxiety?
St John’s wort
Herbal used for the treatment of gastritis, ulcers, cough, and bronchitis.
Licorice i
Herbal used for the treatment of gastritis, ulcers, cough, and bronchitis.
Licorice
Which is the most important factor in the rate of rise of FA/FI?
Uptake
Select two factors that may decrease the minimum alveolar concentration (MAC).
Metabolic acidosis and HYPOXIA
Increasing age on MAC
Decrease
Metabolic acidosis and HYPOXIA on MAC
Decrease
Hypothermia on MAC
Decrease
Hyponatremia on MAC
Decrease
Hypo-osmolality on MAC
Decrease
Acute ethanol intoxication on MAC
Decrease
Lidocaine administration on MAC
Decrease
Decreased central neurotransmitter levels on MAC
may decrease MAC levels.
What is myasthenia Gravis?
autoimmune disorder in which acetylcholine receptors are destroyed or inactivated by circulating antibodies at the neuromuscular junction
What is the The clinical hallmark of Myasthenia Gravis?
skeletal muscle weakness.
Myasthenia Gravis has early signs of
ocular and bulbar nerve involvement followed by extremity weakness.
What is the difference between Myasthenia Gravis (MG) and Myasthenic Syndrome?
Myasthenia gravis is an autoimmune disorder affecting the postsynaptic ach receptors at the NMJ. Myasthenic syndrome (sometimes referred to as Lambert-Eaton syndrome) is an autoimmune disorder where there are antibodies formed against the voltage-gated calcium channels in the NMJ.
75% of LEMS (Lambert Eaton Myasthenic syndrome) patients have involvement of the
autonomic nervous system resulting in ataxia, impaired sweating, orthostatic hypotension, and metallic taste in mouth.
Eye muscle weakness in MG vs LEMS(Lambert eaton myasthenic syndrome)
LEMS is uncommon with LEMS
Autoimmune disorder where there are antibodies formed against the voltage-gated calcium channels in the NMJ.
Lambert-Easton syndrome
Channels in the NMJ affected by Lambert eaton syndrome?
Voltage gated Calcium channels.
Myasthenia Gravis is associated with ______and LEMS is associated with _________
Thymoma; Small cell lung CA
Small cell lung CA is associated with MG or LEMS
LEMS
LEMS symptoms are worst __________and improves when and why?
in the morning, improves throughoutthe day as exercise and repetitive movements will lead to increasing accumulation of presynaptic calcium
MG vs LEMS: Autonomic dysfunction
Common with LEMS
Pt with MG and bulbar involvement are at risk of
Aspiration
Myasthenic syndrome and NMBAs
They are sensitive to both Depolarizing and non-depolarizing NMB agents.
MG and LEMS: reflexes
MG normal reflexes
LEMS decrease reflexes
Myasthenia gravis and Depolarizing agents
The ED95 dose of Succinylcholine has been measured at 2.6 times higher than normal.
Avoid this block if you can in MG
ISB because the phrenic nerve paresis may lead to dyspnea.
AminoESTER local anesthetics and myasthenia gravis?
Amino esters LA duration of action will be prolonged because they are metabolized by pseudocholinesterase ,which would be inhibited by anticholinesterase drugs.
How do you differentiate myasthenic crisis vs cholinergic crisis with what test?
Tensilon (Edrophonium) test
Tensilon (Edrophonium) test: if symptoms improves
Myasthenic crisis
Tensilon (Edrophonium) test: if symptoms Worsens
Cholinergic crisis
How is myasthenia gravis diagnosed?
Short acting anticholinesterases (neostigmine and pyridostigmine) are given to the patient and if there is an increase in strength, though temporary, that supports the diagnosis of myasthenia gravis.
Indicated for Pt with MG with generalized symptoms and Thymoma
Thymomectomy.
Select two rapid-acting anticonvulsants readily available when a perioperative seizure occurs.
Benzodiazepines
propofol
The classic triad of symptoms that accompany severe aortic stenosis are SAC
angina, syncope, and congestive heart failure (dyspnea).
Which drugs are selective beta-1 adrenergic blockers?
Atenolol, propranolol, metoprolol
Which calcium channel blocker can be titrated intravenously as an antihypertensive agent?
Nicardipine
Select two agents that may shorten neuromuscular blockade in patients treated with chronic anticonvulsant therapy.
Phenytoin
Carbamazepine
Patients with pericardial tamponade present with ____triad and what other 3 symptoms
Beck’s Triad
Hypotension
JVD (distended neck veins)
Muffled/distant heart tones,
tachycardia, pulsus alternans, or pulsus paradoxus.
Pulse ____or ______ are associated with pericardial tamponade
pulsus alternans, or pulsus paradoxus.
In adults, burn each arm represents__%
9%,
In adults, burn each leg represents__%
18%
In adults, burn the entire trunk is___%
36% (front 18% and Back 18%
In adults, burn the head is___%
10%
Which agent is a carbonic anhydrase inhibitor used in the treatment of metabolic alkalosis?
Acetazolamide
ECG changes related to hypokalemia include
flattened T-waves and prominent U-waves.
The most serious manifestations in acute liver failure are
acute cerebral edema and intracranial hypertension.
Select two relative contraindications to shock wave lithotripsy (SWL).
Large calcified aortic aneurysm
Implantable cardiac defibrillator
Most lipophillic opioids are
Fentanyl and sufentanil
Most Hydrophillic opioids are
Morphine and meperidine
Which calcium channel blockers inhibit CYP450? (select two)
Diltiazem
Verapamil
Where in the body does metoclopramide block dopamine receptors?
Chemoreceptor Trigger zone
Equation that explains that by increasing the internal diameter of an ETT, the resistance to flow through the tube is decreased exponentially.
Poiseuille’s equation
Adenylyl cyclase functions as part of a secondary messenger system within the cell by converting adenosine triphosphate into
cyclic AMP
During the third trimester of pregnancy, the cardiac output______primarily due to_________
increases primarily due to an increase in stroke volume
Serum Creatinine and pregnancy
Decrease
Enzymes activity that decrease during preganncy
Plasma cholinesterase decrease by 1/3
Plasma cholinesterase activity decreases by about one-third by the second trimester. The duration of action of _____is rarely affected
succinylcholine is rarely affected, however.
During pregnancy, The increase in cardiac output increases
renal blood flow and the glomerular filtration rate.
BUN and CR, during pregnancy
BUN and creatinine both decrease as a result.
The increased renal blood flow can result in the renal
excretion of small amounts of glucose and protein.
Liver enzymes and pregnancy
Enzymes are increased slightly by pregnancy.
2 predictors of difficult epidural placement in obese parturients?
The ability of the patient to flex their back
The ability to palpate bony landmarks
You have administered ephedrine 10 mg IV to treat hypotension in a laboring parturient. How long would you expect the effects of the drug to last?
5 minutes
effects of mannitol when administered during vascular surgery
induces osmotic diuresis
decreases endothelial cell swelling
Mannitol and diuresis
Induces OSMOTIC diuresis
Mannitor and cell swelling
Decreases endothelial cell swelling
Mannitol and prostaglandins
increases prostaglandin synthesis which causes renal vasodilation.
It acts as a hydroxyl free radical scavenger
Mannitol
In 75 percent of the population, the artery of Adamkiewicz joins the anterior spinal artery between In 10 percent of the population, it connects between L1 and L2.
T8 and T12.
The artery of Adamkiewictz joins the
Anterior spinal artery between T8 and T2
In 10 percent of the population, the artery of adamkiewiciz connects
between L1 and L2.
Which of the following agents decreases hepatic glucose production?
Biguanides (Metformin)
Medications for diabetics that enhance tissue sensitivity to insulin.
Thiazolinediones (pioglitazone) and metformin (a biguanide) e
Antidiabetes medications that increase insulin secretion.
Meglitinides such as repaglinide
Antidiabetes medication that increase insulin secretion.
Sulfonylureas such as glipizide
What class of medication is Glipizide
Sulfonylureas
The foot is innervated by branches of the
Femoral and sciatic nerves,
A patient is undergoing shoulder surgery. He is awake and in the sitting position and you have performed an adequate brachial plexus block for the procedure. He suddenly experiences severe bradycardia and hypotension and complains of feeling faint. What would most likely explain this phenomenon?
Bezold-Jarisch reflex
What is cardiac stunning?
When the cardiac muscle is ischemic for less than 20 minutes, cell death is not likely to occur, but the tissue exhibits reversible contractile dysfunction known as cardiac stunning. Because of this, many patients require inotropic support for 12-24 hours following cardiac surgery.
Diastolic dysfunction is associated with
a normal ejection fraction
Another name for diastolic heart failure is heart failure with
preserved ejection fraction.
You are preparing to implement controlled hypotension in a patient undergoing an extensive neck dissection. Which agent would best maintain cerebral blood flow?
Nicardipine
Which statement represents an accurate understanding of anesthesia for middle ear surgery?
Local anesthesia is appropriate for middle ear surgery
A patient is undergoing cataract surgery and the surgeon plans to use topical anesthesia. You know that the topical anesthetic will
will not provide akinesia of the eyelids or ocular muscles, however, and some practitioners will augment the anesthetic with ocular regional anesthesia for motor control.
The O’Brien and Nadbath blocks are used to anesthetize cranial nerve
VII and prevent eyelid movement for ocular surgery.
The O’Brien and Nadbath blocks side effects such as
unilateral facial paralysis, they are beginning to be replaced with the orbicularis oculi block.
A cold laser can penetrate as deep as two inches into tissue without producing damage or generating a large amount of heat. It is used as a method of biostimulation to increase healing rates in soft tissues. A cold laser may be used in the treatment of
carpal tunnel syndrome.
Fusion of the coccyx into two bones is complete by
25-30 years of age.
The cauda equina normally extends from
L1 to S5
What is the potential space outside the dural sac that is continuous from the base of the cranium to the base of the sacrum at the sacrococcygeal membrane?
Epidural space
The average distance from the skin to the lumbar epidural space using a midline approach is
5 cm.
The lumbar lordosis and thoracic kyphosis seen in extreme obesity produce what changes in lung parameters?
a decrease in pulmonary compliance
Extreme obesity can also produce a decrease in the
FRC and ERV and premature airway closure.
In adults, about_____ ml/hour of CSF is produced by the choroid plexus of the cerebral ventricles every day.
21
______ ml of CSF produced per day
500 mL a day.
What can both cause an increase in the specific gravity of CSF, which is normally
Hyperglycemia and uremia
Normal CSF specific gravity is
1.004-1.009.
Cauda equina syndrome consists of
lower back pain, sciatica, motor and sensory loss, and bladder and bowel dysfunction that has been associated with the use of hyperbaric lidocaine 5 percent in spinal anesthesia.
Sympathetic innervation to the gastrointestinal tract arises from the
T5 to L2 spinal cord segments.
Which would be considered the definitive treatment for postdural puncture headache?
Epidural blood patch
Which complication occurs more frequently with an epidural than with a spinal anesthetic?
Backache
During a brachial plexus block, the nerve stimulator used in regional anesthesia is adjusted to _______milliamps after the needle has been introduced into the subcutaneous tissues.
2
Which nerve roots are associated with the musculocutaneous nerve?
C5-C7
The cricoid cartilage is an anatomic landmark that corresponds to the vertebral body of
C6.
Which agent is used for IV Bier block?
0.5% Lidocaine
Which nerve roots are associated with the obturator nerve?
L2-L4
Which medication is used for the management of postherpetic neuralgia and chronic pain syndromes?
Gabapentin
Brody’s number is used to calculate
oxygen consumption
Carbon dioxide production
Brody’s number, called the three-quarter power rule, uses the
patient weight in kilograms to estimate oxygen consumption, cardiac output, carbon dioxide production, and free water requirement. It is used to calculate oxygen and ventilatory requirements in closed circuit anesthesia.
It is used to calculate oxygen and ventilatory requirements in closed circuit anesthesia.
Brody’s number
Which component of the anesthesia machine can serve as a useful indicator of neuromuscular blockade in a mechanically-ventilated patient?
Bellows because As a patient’s respiratory efforts begin to increase, movement in the bellows may be noted between ventilator cycles. The breathing bag is excluded from the circuit when the machine is set to mechanical ventilation.
Could be a sign of carbon monoxide accumulation and would need to be investigated further.
Signs of myocardial hypoxia such as T wave inversion, ST segment changes, or alterations in rhythm
Laryngoscope that has a lever that allows for the flexion of the tip of the blade to further elevate the vallecula and epiglottis.
The McCoy
A Macintosh blade with an altered angle between the handle and blade to accommodate patients with abnormal anatomy is called
Polio blade
What is the straight blade with a flange that looks like two-thirds of a circle when viewed in cross section?
Wisconsin blade
Invasive aline substitute
Arterial tonometer
What is the gold standard in expired gas analysis?
Mass spectroscopy
The monitor determines the degree to which the charged particles are deflected by the magnetic field.
Mass spectroscopy
Some ECG monitors are able to measure respiratory rate and depth using the principle of
impedance plethysmography
Using Impedance plethysmography, how does it work?
increase the electrical impedance of the thorax. As the patient exhales, the impedance decreases
ECG Lead ____evaluates upper chest breaths while lead ____evaluates the lower chest and diaphragm.
ECG lead I; lead II
For PNS monitoring The use of needle electrodes is preferred for patients with
burn injuries over the monitoring location.
Method that assess the number of action potentials occurring in a measured muscle group?
Electromyography
Electromyography measures the action potentials in a muscle group. It uses
two stimulus electrodes, two sensing electrodes, and a ground electrode in between them. It can be used to calculate the number of action potentials that occur after administration of a neuromuscular blocking agent.
What method measures the acceleration of a muscle across a joint?
Acceleromyography
Bispectral index is a measurement of
level of consciousness.
NMBDs will ______the number of action potentials produced during stimulation
decrease; action potentials produced during stimulation.
What are the most common anatomical sites for invasive arterial monitoring line placement?
Radial
Femoral
The factors that determine the response of peripheral nerves to electrical stimulation are :
Placement of electrode
The duration the current is applied
The amount of current applied
Current is measured in
amps or milliamps, not volts.
Rank the order in which the structures would exhibit paralysis after administration of a neuromuscular blocking agent. Abdominal muscles, diaphragm, Eyes and extremities
First - Eye muscles
Second - Extremities
Third - Abdominal muscles
Fourth - Diaphragm
With NMBA Eye muscles are the first to be paralyzed, the extremities are affected next, followed by the trunk, abdominal muscles, and lastly, the diaphragm. Recovery is restored in EyeExAdDi
reverse order.
IV anesthetics of degree of Protein-binding PMEK
From greatest to least, the degree of protein-binding is as follows: Propofol > Midazolam > Etomidate > Ketamine
Select the two most likely causes of hypocalcemia in the intraoperative period.
Hyperventilation
Massive transfusion of citrated blood
GAS embolism Symptoms include
decreased ETCO2, increased end-tidal nitrogen levels, decreased oxygen saturation, increased pulmonary artery pressures, hypoxia, cyanosis, hypotension, pulmonary edema, a mill-wheel murmur, and detection of air via doppler ultrasound or transesophageal echo.
During extracorporeal shock-wave lithotripsy (ESWL), what component of the ECG waveform is used to trigger the shocks?
R-wave
What types of EEG waves are seen in an alert, awake individual? (select two)
alpha waves
beta waves
ForCed air warmers transfer heat to the patient via\_\_\_\_\_ Resistive heaters (such as warming blankets) use
convection; conduction
ForCed air warmers transfer heat to the patient via which heat transfer process?
convection
Heat lamps and radiant heaters use what type of heat transfer?
radiation
Resistive heaters (such as warming blankets) use what type of heat transfer?
conduction.
Fluids that are preferred when performing volume resuscitation in patients with traumatic brain injury.
Isotonic crystalloids. Normal saline is probably the best option because it can be mixed with packed red blood cells.
Solutions to avoid with patient with traumatic brain injury?
Any solution containing glucose should be avoided.
Any unintended patient injury, harm, or complication that results in a prolonged hospitalization, disability, or death
An adverse event
A powerful and overwhelming event that lies outside the range of human experience
critical incident
Failure to take a known and planned action or using the wrong plan of action to achieve an outcome is known as a
Medical error
According to the Critical Incident Stress Management model, education to help strengthen coping and stress management skills before an incident ever occurs is referred to as
pre-crisis stage interventions
Intervention strategy designed to help healthcare providers involved in a critical incident return to their normal state of health.
pre-crisis stage interventions
Pre-crisis stage interventionsIt is broken down into interventions that occur in three stages:
the pre-crisis stage, the acute crisis stage, and the post-crisis stage.
Interventions in the pre-crisis stage are designed to help
strengthen coping skills before a critical incident ever happens. Education techniques in stress management and relaxation techniques are included.
WPW SYNDROME PATIENTS with afib treatment and why?
Cardioversion ; Because tx with amiodarone, adenosine, digoxin, and non-DHP can cause accelerated ventricular that leads to vfib.
What is SVV?
Stroke volume variation used to estimate fluid responsiveness, in ventilated patients using cyclic changes in the intrathoracic pressures during PPV
Positive pressure ventilation induces changes in
SV and Pulse pressure variation
SVV represents variability of SV during resp cycle”
increase during inspiration and decreases during expiration. Opposite with spontaneous ventilation
4 parameters with EV1000
SV, SVV, CO, CI
3 Goals of management with afib
Correct underlying cause
Rate control
AC
CHA2-DS,VASC
To know who needs AC
AF > 48 h concerns
Thrombus in Left atrial appendage.
IS digoxin use for afib acutely?
NO; itsmore for chronic afib caused by HF
Do not use in decompensated HF
Beta blockers
If pt with afib unresponsive to CB and BB, use
Amiodarone
What is the minimum seizure duration recommended to ensure adequate antidepressant efficacy when performing electroconvulsive therapy?
25 seconds
The most common anesthetic for electroconvulsive therapy is
General anethesia
Electroconvulsive therapy (ECT) is associated with
Bradycardia followed by hypertension and tachycardia
What medications would shorten the seizure duration of electroconvulsive therapy? (select four)
Fentanyl
Midazolam
Lidocaine
Diltiazem
Which condition is an absolute contraindication to electroconvulsive therapy?
Pheochomocytoma
What are the two most common causes of death related to electroconvulsive therapy? (select two)
Myocardial infarction
Cardiac dysrhythmias
The increase in peripheral vascular resistance (afterload) in the elderly occurs primarily due to progressive loss of arterial distensibility and leads to
concentric left ventricular hypertrophy
Obesity is most closely associated with which kind of hypertropy
Eccentric Cardiac hypertrophy
Hypertension produces what kind of hypertrophy?
concentric hypertrophy of the left ventricle,
Do Heparin, protamine, or insulin CROSS PLACENTA?
do not cross the placenta,
Succinylcholine and nondepolarizing muscle relaxants., CROSS PLACENTA
Do not cross the placenta
When an anesthetized patient is placed in the lateral decubitus position, the upper lung is ____less or more compliants?
shifted to a more compliant position and the dependent lung into a less compliant position.
When an anesthetized patient is placed in the lateral decubitus position the upper lung receives
more ventilation.
A ventilation perfusion defect occurs when lateral decubitus position because
because the lower lung is perfused more than the upper lung. The functional residual capacity in the lateral decubitus position is decreased.
The tourniquet should be inflated to about what mmHG ?
100 mmHg above the systolic blood pressure.
Tourniquet pain typically begins after
45-60 minutes
Which of the following is increased during pregnancy? Endocrine? by how much and when?
T3 T4 increased by end of first trimester by 50%
Follicular hyperplasia leads to 50-70 % increase in the thyroid gland
Epidural space changes during pregnancy?
Because the volume of epidural fat increases and epidural veins enlarge, the volume of spinal CSF is decreased in pregnancy. The size of the liver does not change with pregnancy.
In a primiparous patient, LEAST preferred anesthetic and why?
Single shot spinal? is it is highly likely that labor would last longer than the duration of the spinal. Intravenous opioids or opioid agonist-antagonists such as nalbuphine or butorphanol would be appropriate options, as would an epidural as long as the patient is not in the latent stage of labor.
The Triple-H therapy used in the treatment of cerebral vasospasm includes
hypertension, hypervolemia, and hemodilution
MEdications that should be dosed based on lean body weight? 4 nmbs, 3 opioids, one anesthetics
Rocuronium, vecuronium, atracurium, cisatracurium, fentanyl, sufentanil, remifentanil, and induction doses of propofol should be based on lean body weight.
Should be based on total body weight.
Succinylcholine, dexmedetomidine, neostigmine, and sugammadex doses
MAC decreases by when in life
about 6% percent per decade after the age of 40.
Compared to adult patients, you would expect a term neonate to exhibit (select four)
TBW, body fat, muscle mass,
decreased responsiveness to dopamine
a higher proportion of body water
a decreased proportion of body fat
decreased proportion of muscle mass
Neonates responsiveness to cardiac drugs? example?
Decreased responsiveness. The dose of dopamine required to increase blood pressure and urine output in neonates may be as high as 50 mcg/kg/min.
Which arrhythmia would you most likely see in a patient following surgical repair of tetralogy of Fallot?
Right bundle branch block
A right bundle branch block is common following surgical correction of tetralogy of Fallot why?
due to damage to the conduction system during repair.
One method of defining frailty is as a syndrome in which at least three of the following criteria are met:
unintentional weight loss of more than 10 lbs in the past 12 months, exhaustion, weakness, slow walking speed, and a low physical activity level.
The decreased ability to retain or eliminate sodium in elderly patients is partially attributed to reductions in
aldosterone secretion
The most common lung abnormalities in obese patients are decreases in the
ERV and FRC
Which would be most likely to be decreased in an elderly patient? As far as HR
Heart rate variability
CO: It returns to prelabor values within______and to pre-pregnancy values within about_______
24 hours; 3 months
Compared to adults , neonates GFR
reduced glomerular filtration rate
Neonates have decreased ability to
decreased ability of the renal tubules to absorb BAGS
bicarbonate,amino acids.glucose,sodium
Which of the following are major side effects of meperidine administration to parturients? (select four)
maternal nausea and vomiting
Maternal sedation
Fetal Tachycardia
Neonatal depression
Can cause decrease beat to beat variability
Meperidine
The classic symptom triad of TUR syndrome seen in awake patients under regional anesthesia is
elevated systolic and diastolic pressures accompanying an increase in pulse pressure, bradycardia, and changes in mental status.
The average amount of fluid absorbed during a TURP is about
20 mL/min of resection time.
For a 25 minute resection, the total amount of fluid absorbed would be estimated as
(20 mL/min X 25 minutes) = 500 mL.
Which irrigating solution for transurethral resection procedures has the highest risk for producing hyperglycemia when absorbed?
Sorbitol and glucose irrigation solutions can produce hyperglycemia when absorbed.
A patient undergoing a TURP begins to exhibit widening of the QRS complex and ST segment elevation on the electrocardiogram. Based on this evidence, you would estimate the serum sodium to be
115 mEq/L
Hyponatremia, vomiting begin to appear at about ____mEq/L with and
120 mEq/L,
ECG changes for hyponatremia, occurring at_____ mEq/L,
115
Ventricular tachycardia and fibrillation occurring below
100 mEq/L.
The primary purpose of an intra-aortic balloon pump is to (select two)
decrease afterload
augment myocardial oxygenation
Which is the most single effective maneuver to increase Pa02 during one-lung ventilation?
Application of CPAP to the nondependent lung
A patient is undergoing general anesthesia for strabismus surgery. Which of the following is not true regarding anesthesia during this procedure?
Hyperventilation increases the risk for sudden bradycardia
What is the most common pediatric ocular surgery and may be an indicator that there is underlying disease?
Strabismus surgery
Pediatric ocular surgery is associated with a high incidence of
prematurity, cerebral palsy, and craniofacial abnormalities.
Strabismus surgery is also associated with a higher than normal incidence of
malignant hyperthermia.
Hypoventilation resulting in hypercapnia increases the risk of _____Due to the oculocardiac reflex which can occur due to ________
bradycardia due to the oculocardiac reflex which can occur due to traction on the ocular muscles.
Bradycardia during eye surgery can be due to
oculocardiac reflex which can occur due to traction on the ocular muscles.
When does the foramen ovale typically close?
1 hour; as left atrial pressure exceeds right atrial pressure.
A patient with symptomatic hyperparathyroidism is presenting for a parathyroidectomy. What electrolyte disorders would you expect to see in this patient preoperatively? (select two)
Hypercalcemia
Hypophosphatemia
The most common airway problem in pediatric patients is upper airway obstruction due to
Laryngomalacia
Most of the decrease in hepatic blood flow associated with aging is due to
Decreased liver mass
What accounts for most of the 20-40% decrease in hepatic blood flow with age.
Decreased liver mass
Age associated decrease in hepatic blood flow
20-40% in hepatic blood flow
The obturator reflex results in.
external rotation and adduction of the thigh from stimulation of the obturator nerve. Administration of muscle relaxants is required to prevent its occurrence.
Electrocautery current applied to the lateral wall of the bladder as may occur during a transurethral resection of a bladder tumor can stimulate
obturator reflex which could result in bladder perforation due to patient movement while instruments are in the bladder
Regional anesthesia and obturator reflex
Regional anesthesia does not reliably block this reflex.
What is the preferred blood glucose range in the management of pregnant diabetics?
60-120 mg/dL
What ECG changes are associated with a subarachnoid hemorrhage? (select two)
ST segment depression and T wave inversion are often noted within 48 hours of a subarachnoid hemorrhage and are associated with the increase in catecholamine release.
The recommended tidal volume for an obese patient should be estimated as
6-8 mL/kg predicted body weight.The recommended tidal volume for obese patients is typically 6-8 mL/kg of the predicted body weight (PBW).
Larger tidal volumes have not been shown to offer any advantages and result in _______airway pressure without an ______In oxygenation
and result in increased airway pressures without an increase in oxygenation.
The principal morbidity and mortality considerations of obesity center around what issues?
Cardiovascular disease (ischemic heart disease, hypertension, and heart failure).
The formation and maintenance of the extra adipose mass requires an extra
0.1 L/min of cardiac output for each additional kilogram of fat.
A child presents to the emergency department with a diagnosis of epiglottitis. He is drooling, complains of sore throat, and exhibits stridor. Your preoperative exam for this patient should include what kind of induction?
. A plan for an inhalation induction
A child presents to the emergency department with a diagnosis of epiglottitis. He is drooling, complains of sore throat, and exhibits stridor. Your preoperative exam for this patient should include:
A plan for an inhalation induction. Also, the importance of a complete blood count and chest x-ray are secondary to securing the airway. The preoperative evaluation should be brief and the efforts of the anesthesia staff should be focused on rapidly securing a difficult airway. Inhalation induction, especially for a pediatric patient, is a suitable induction method.
Which of the following characteristics do geriatric patients share with neonates?
A higher body surface area to body mass ratio
Both classes of patients have a high body surface area to body mass ratio.
Neonates and geriatric patients. have a higher concentration of body water, and geriatric patients have a lower proportion of body water. Although neonates can have a lower alpha-1 acid glycoprotein level than adults, this value is not normally altered in geriatric patients.
The risk of anesthesia-related maternal death is higher in obese patients, primarily due to an increased incidence of
airway difficulties
The risk of maternal death is higher in obese patients due to an
increased incidence of diabetes, infection, preeclampsia, and thromboembolism.
You are performing an anesthetic for a patient undergoing a hepatic resection near the portal vessels. For which complication should you be prepared?
air embolus
From the patient’s right to left, the three major vessels leaving the superior aspect of the aorta are:
the brachiocephalic trunk (also known as the innominate artery), the left common carotid artery, and the left subclavian artery.
Ascending vs descending bellows?
Ascending (standing) bellows are considered safer than descending (also known as hanging) bellows.
Both ascending AND standing are correct because they are
synonymous terms for the same type of bellows.
In the event of a circuit disconnect, ascending bellows will
fail to rise whereas descending bellows will continue to descend due to gravity and ascend during the inspiratory phase.
All sympathetic neurotransmitters are synthesized from
tyrosine.
The synthesis of neurotransmitters from tyrosine takes place in the
postganglionic sympathetic nerve ending.
Select two laboratory studies that appear to be associated with increased risk of perioperative pulmonary morbidity.
Reduced serum albumin levels
Increased creatinine level
The only machine safety device that evaluates the integrity of the low-pressure circuit in an ongoing fashion.
The oxygen analyzer
It is the only machine monitor that can detect problems downstream from the flow control valves.
The oxygen analyzer
The latent heat of vaporization is the
amount of energy lost by a given liquid as it is converted to a vapor. Specifically, it is defined as the
Number of calories required to change 1 gram of liquid into vapor without a temperature change.
Latent heat of vaporization
Factors that may help prevent optic ischemia
The use of crystalloids and colloids to maintain intravascular volume and reduction of intra-abdominal pressure to prevent venous congestion
Washout of high concentrations of N20 can lower alveolar concentrations of oxygen and carbon dioxide in ?
Diffusion Hypoxia
Describes the diversion of blood from a myocardial bed with limited or inadequate perfusion to a bed with more adequate perfusion?
Coronary Steal
2 primary determinant of coronary blood flow.
Perfusion pressure and vascular resistance
What is the appropriate initial dose of dantrolene in mg/kg for the treatment of malignant hyperthermia?
2.5mg/kg
Esmolol is metabolized quickly in the
blood by an esterase found in the RBC cytoplasm and has a half-life of
Esmolol half life
9.5 minutes.
Which part of the brain is responsible for increasing the rate and amplitude of ventilation when stimulated?
Reticular activating system
What is the most frequent cause of an acute increase in physiologic dead space?
A decrease in cardiac output
Mrs. Frank is considered a full stomach and is scheduled for surgery. Which two agents would raise Mrs. Frank’s gastric pH?
Sodium Citrate
Famotidine
Action of Pepcid?
Famotidine increases gastric pH and reduces gastric volume.
Sodium citrate dose and action
(15-30ml) increases gastric pH to >2.5. This dose should be administered within 1 hour prior to surgery.
What is the most reliable technique for verifying the proper position of a double-lumen endotracheal tube?
Visualization with a fiberoptic bronchoscope
What is the primary area for relay of afferent chemoreceptor and baroreceptor information from the vagus and glossopharyngeal nerves?
Nucleus tractus solitarius
The nucleus tractus solitarius is the main area responsible for
relaying afferent chemoreceptor and baroreceptor information from the vagus and glossopharyngeal nerves.
Where is the nucleus tractus solitarious located?
Located within the medulla
Which neuromuscular blocking agent is metabolized via Hofmann and ester hydrolysis?
Cisatracurium
What nerve provides better prediction for intubating conditions and gives visual observation of the response over the eyebrow.
Facial nerve stimulation (corrugator supercilii )
Specifically, the corrugator supercilii is the muscle responsible for
moving the eyebrow (not the orbicularis oculi).
The corrugator supercilli most closely parallels
the laryngeal adductors.
Which evoked potential is useful in evaluating descending motor pathways?
Motor evoked potential
What is the intraoperative target glucose range for adults undergoing emergent craniotomy for traumatic brain injury?
target blood glucose level of 90 to 180 mg/dL is appropriate for patients undergoing neurosurgical procedures.
The recommended minimum platelet count for a patient having a non-emergent neurosurgical procedure is
100,000/mm3.
The Glasgow Coma Scale (GCS) evaluates the best
verbal response, eye response, and motor response
GCS min and max
with a minimum score of 3 and a maximum score of 15. A GCS score less than 9 indicates severe brain injury
GCS indicating severe brain injury
less than 9
How is the spinal cord perfusion pressure (SCPP) determined?
SCPP = MAP - Cerebrospinal fluid pressure
What are the most important parameters to normalize in patients with brain injury? (select two)
Intracranial pressure
Cerebral perfusion pressure
Which value is primarily increased in metabolic alkalosis and decreased in metabolic acidosis?
Metabolic alkalosis and acidosis are described as alterations where primarily HC03- is shifted up or down, respectively.
Laparoscopy on RESP
Pulmonary changes associated with laparoscopy include decreased lung volumes
increased V/Q mismatch, increased pleural and airway pressures, and CEPHALAD displacement of carina.
You are evaluating a patient in the recovery room who experienced subcutaneous emphysema during a laparoscopy. What clinical signs should you monitor for postoperatively? (select two)
If subcutaneous emphysema persists in the recovery area, the patient should be kept on oxygen therapy and monitored for respiratory acidosis and somnolence.
Select two characteristics of a cirrhotic patient.
High cardiac output
Low arterial blood pressure
Sildenafil, tadalfil, and vardenafil inhibit
cyclic GMP (cGMP)-specific phosphodiasterase type-5 (PDE5) in vascular smooth muscle.
Blocking PDE5 stops
cGMP breakdown.
With its decline in age, which neurotransmitter is noted for its connection to Alzheimer’s disease?
Ach
Select the two most dramatic changes in lung volumes seen with increased age ? what are the other important Resp changes
Although decreases in total lung capacity and increases in the functional residual capacity are associated with aging, the most significant changes are the increases in both closing volume and closing capacity.
You are concerned about the postoperative fluid status of an elderly patient with a history of congestive heart failure. On what postoperative day would you expect third space fluid to mobilize into the vascular system?
Day 2
Signs of fluid volume excess such as
Rales, crackles, tachypnea, and orthopnea.
Select two physiologic characteristics that you would expect to be increased in an obstetric patient at term.
Minute ventilation
Oxygen consumption
For the parturient, By term, oxygen demand increases by about_________and minute ventilation increase by ________mostly due to an increase in
33 percent and minute ventilation increases by about 50 percent;
Tidal volume
The PaCO2 is usually between at term
30 and 32 mmHg, and the PaO2 is higher than 100 mmHg at term.
The most popular opioid agonist-antagonists are
butorphanol and nalbuphine for labor analgesia due to their proposed benefits including less nausea, vomiting, and dysphoria.
What is the most common complication of central neuraxial blockade in the obstetric patient?
Hypotension
Effective analgesia can be achieved with low concentrations of local anesthetic during the first stage of labor if the ____ dermatomes are blocked.
T10-L1
Select two long-acting amides that can provide analgesia in neuraxial blocks for obstetric patients while sparing motor function.
Bupivacaine
Ropivacaine
The diagnostic feature of eclampsia that is not present in preeclampsia is
convulsions
Severe preeclampsia is defined by the presence of a systolic pressure of at least
160 mmHg, a diastolic pressure of at least 110 mmHg, proteinuria of at least 5 grams per 24 hours or evidence of end-organ damage.
Eclampsia is present if
seizures occur.
Is the most frequently abused substance among pregnant patients?
Tobacco (smoking)
When should chest compressions be initiated in the neonate?
Heart rate < 60 bpm
In the normal, full-term infant, you would expect the glottis to be at the level of
C4
What are the two most commonly used interventions for the treatment of apnea in premature neonates?
CPAP
Caffeine
What is the major metabolite of fentanyl?
The inactive metabolite norfentanyl
Fibers associated with
Muscle tone
A-delta fibers are associated with
pain and touch.
Select two true statements about nerve fibers.
Myelinated fibers conduct faster
A-delta and C nerve fibers are associated with pain transmission
At which plasma concentration of lidocaine would analgesia first be achieved?
3 mcg/mL
Through what interlaminar space would you direct your needle when using the Taylor approach to the subarachnoid and epidural space?
L5-S1
Which local anesthetic would be prolonged the most by adding an adrenergic agonist?
Tetracaine
What electrolyte disorders are most common in patients on chronic immunosuppressive therapy following organ transplantation? (select two)
Hyperkalemia
Hypomagnesemia
Select two narcotic agents appropriate for administration to a renal transplant patient.
Morphine
Meperidine
In adults, how long should surgery be delayed following a viral respiratory infection?
6 weeks
Which is the most significant cause of perioperative morbidity and mortality from an office-based surgical procedure?
Pulmonary embolism
What are the three components of the ‘fire triad’?
Oxidizer, ignition source, and fuel
What is the maximum recommended aspirant amount in an office based liposuction procedure?
5000 mL
Contrast-induced nephropathy is defined as an increase in serum creatinine of _____ mg/dL or a ____ percent increase from the baseline within the first 24 hours.
0.5 mg/dL; 25 percent
Which is the most sensitive indicator of the effect of obesity on pulmonary function?
Expiratory reserve volume
What is the most common mononeuropathy after bariatric surgery?
Carpal tunnel syndrome
What is the maximum cuff volume for a size 4 LMA?
30 cc
Which statement regarding the Wisconsin blade is false?
It is available in 3 sizes
You are preparing to insert a microlaryngeal endotracheal tube for a patient undergoing surgery of the larynx. You anticipate that the use of this tube will likely require (select two)
McGill forceps for correct placement
the use of mechanical ventilation
Which laryngoscope blade has a handle-operated, articulating tip designed to elevate the vallecula and epiglottis?
McCoy blade
The Soper blade is a
straight blade with a left-facing flange that makes it a blend between the Miller and Macintosh blades.
Which endotracheal tube is designed to deflect laser beams
Mallinckrodt tube
The criteria for diagnosing metabolic syndrome are:
waist circumference greater than 102 cm in men or 88 cm in women triglyceride level > 150 mg/dL HDL cholesterol < 40 mg/dL in men or < 50 mg/dL in women a blood pressure > 130/85 mm Hg fasting glucose > 110 mg/dl.
Osmotic diuretic that decrease intraocular pressure.
Mannitol is an osmotic diuretic that can
Pilocarpine eye drops can produce pupillary
constriction.
Phenylephrine topical eyedrops can produce pupillary
dilation
What is the most common workplace injury attributed to working 12 hour shifts?
Needlestick injury
Term that defines longitundinal protrusion of sternum?
Pectus Carinatum
Intracellular Na+ content
12
Supratentorium pressure best measured in
Lateral ventricle
Off Pump cardiac surgery facilitated by device called
Octopus
OSA is sleep apnea lasting more than
10 seconds or more
Permanent remission of 50% of patient associated with this disorder
Sarcoidosis
Cerebral cortex is divided into
50 anatomical segments called BRODMAN’S AREAS
Predominant inhibitory biogenic amines of CNS
Dopamine
80% of acute pancreatitis is caused by
Gallbladder or alcohol
Most important evoked potential to monitor during pituitary surgery is
VISION
Overestimation o2 sat
severe anemia
After acute spinal cord injury, Below the level of injury, the patient will exhibit
flaccid paralysis
total absence of sensation, and
loss of temperature regulation and spinal cord reflexes.
After acute spinal cord injury, Below the level of injury, the patient will exhibit
flaccid paralysis
total absence of sensation, and
loss of temperature regulation and spinal cord reflexes.
Dehydration in patients with thyroid storm should be treated with .
glucose-containing intravenous fluids. Cooling measures should be instituted.
GOAL HR during Thyroid storm
Beta-blockers should be titrated to reduce the heart rate less than 90 beats per minute
What can be administered to reduce circulating levels of thyroid hormones during thyroid storm?
Steroids and anti-thyroid medications
Which is the best method for defining coronary anatomy and evaluating ventricular and valvular function?
CORONARY ANGIOGRAPHY not TEE
What is the half-life of cefazolin?
2 hours
Absorbtion of Co2 soda lime
26L/ 100g
Which test checks the integrity of the unidirectional valves and detects obstruction in the circle system?
Flow test
How do you perform flow test on anesthesia machine?
It is performed by removing the y-piece and breathing through each individual hose to observe the movement of each valve.
In some patients, what position of the elbow can lead to ulnar nerve compression?
flexion of the elbow more than 110 degrees can compress the ulnar nerve between the aponeurosis of the flexor carpi ulnaris muscle and the cubital tunnel retinaculum.
In about 15% of the population, flexion of the elbow will cause she supine position is correct placement of the arms.
Subluxation of the ulnar nerve over the medial epicondyle of the humerus.
Placement of the arms on armboards at more than 180 degrees would be more likely to injure the
brachial plexus than the ulnar nerve.
Can result in compression of the ulnar nerve.
Pronation of the forearm
Which term describes the administration of a higher partial pressure of anesthetic than the alveolar concentration actually desired for the patient?
Overpressuring
Overpressuring describes the administration of a higher partial pressure of anesthetic than the alveolar concentration actually desired for the patient, what is it used for?
to speed up induction
Nagelhout,Normally, the CBF remains constant between MAPs of
60 to 140 mmHg. As the MAP decreases within this range, the cerebral vessels dilate to keep CBF constant.
The resting adult coronary blood flow is about
250 mL/min or 5 percent of the cardiac output.
The QRS complex of the electrocardiogram indicates that ________________ has occurred.
Right ventricular and left ventricular depolarization
Patients with Becker muscular dystrophy have dystrophin, but it is reduced in amount. What is prevalent in these patients?
Cardiac involvement is
Which muscular dystrophy is characterized by a reduced amount of dystrophin?
Becker MD
Unintentional endobronchial intubation is more likely to occur in the
right main bronchus
The right main bronchus is about l_____ong before it initially branches into_____
2.5 cm; lobar bronchi
The right main bronchus leaves the trachea approximately______degrees from the vertical tracheal axis in the adult.
25
The left bronchus leaves the trachea at about___ degrees.
45
Adult vs pediatric epiglottis?
The epiglottis is relatively longer and more narrow than in the adult
The maximum recommended cuff pressure for a laryngeal mask airway is ______ If an adequate seal cannot be obtained with that amount of pressure, then the
60 cm H20. size of the device selected for the patient should be re-evaluated.
Two contraindications for cricoid pressure.
cervical spine fracture, laryngeal fracture, or who exhibit active vomiting due to the risk of an esophageal rupture.
Absolute indications for OLV
Massive hemorrhage, infection, unilateral bullae, unilateral lung lavage, bronchopleural fistula, and video-assisted thoracoscopy are absolute indications for one-lung ventilation.
Temperature regulation is facilitated by the
anterior hypothalamus.
Water metabolism regulation is via the
supraoptic hypothalamus.
Muscarinic stimulation causes HR , contractility, EYES< Bronchioles, Gastric secretions an d
bradycardia, decreased inotropism, miosis, salivation, bronchoconstriction,
Muscarinic stimulation on gastric secretion and GI hypermotility?
increased gastric secretion, and GI hypermotility.
Parasympathetic on EYE
MIOSIS
Besides using a defasculating dose of a non-depolarizing neuromuscular blocking agent, what is the most effective way to prevent myalgia from succinylcholine administration?
. Pretreatment with an NSAID
Adductor Pollicis is supplied by which nerve?
ULNAR
What is the goal temperature in patients undergoing circulatory arrest for a complicated cardiac procedure?
The goal for circulatory arrest is 12-18 degrees Celsius. Profound hypothermia provides greater protection against cerebral ischemia than oxygen administration or anesthetic agents.
Some cardiac and cerebral procedures such as aneurysm repair can be performed under complete circulatory arrest using profound hypothermia. What C degrees
12- 18C
During neurosurgical procedures where the brain is at risk for ischemic damage, a goal temperature of
35C to 36C is acceptable.
What is the recommended minimum cerebral perfusion pressure for traumatic brain injury patients?
60 mmHg
You are preparing to emergently intubate a patient with a traumatic brain injury. What associated injury must you assume this patient also has?
Cervical spine injury
Hemorrhagic shock class III, is characterized with
Blood loss between 1500 and 2000 mL
Pulse rate >120/min
When using the Henderson-Hasselbach equation, what number is used to represent the solubility coefficient in blood of carbon dioxide (C02)?
0.03
The solubility coefficient in blood of C02 is
0.03.
Which is the appropriate fluid treatment for patients that acutely develop water intoxication or seizures due to IV fluid administration?
3% saline
Magnesium levels of less than 1.2 is associated with
Seizures, tetany, and arrhythmias
Hemodynamic changes during laparoscopic surgery include, SVR, MAP, afterload, Venous return
increased systemic vascular resistance, increased mean arterial pressure, increased afterload, and decreased venous return.
The introduction of a pneumoperitoneum and 45-degree head-down positioning during a laparoscopic procedure will result in a decrease in lung compliance by about ____ percent.
50%
The liver receives how much of the CO
25%
What is the LARGEST INTERNAL ORGAN?
Liver
What is the method of choice to determine whether liver damage is due to necrosis, inflammation, steatosis or fibrosis?
Liver biopsy
You should be cautious in administering a high neuraxial block to a patient with chronic hepatic disease because the block can result in
reduction in hepatic blood flow
Select the two most prominent effects of aging on the pulmonary system.
Increased stiffness of the chest wall
Decreased stiffness of the parenchyma
Haloperidol is an antipsychotic agent that doesn’t exhibit any significant
alpha-adrenergic activity.
The principal use of haloperidol is the treatment of
delirium and agitation in the intensive care unit.
Which physiologic characteristic would you expect to be doubled by term in an obstetric patient?
FIBRINOGEN
Rapid sequence induction, cricoid pressure, and a cuffed endotracheal tube are recommended for pregnant women receiving general anesthesia from ____ weeks on even if no symptoms of reflux are present.
20 weeks
In general, a platelet count of _____is considered suitable for neuraxial anesthesia.
100,000
Which opioid agent should not be used in a neuraxial block?
Remifentanil
Which APGAR score reflects some flexion of extremities, grimace, heart rate >100 bpm, completely pink color, and crying?
8
The four principal causes for low renal blood flow and GFR in utero are
low systemic arterial pressure
high renal vascular resistance
low permeability of the glomerular capillaries
small size and number of glomeruli.
What is the most common cause of upper gastrointestinal tract obstruction in the neonate?
Pyloric stenosis
What is the most commonly used IV induction agent in children?
Diisopropylphenol (PROPOFOL)
Which agent exhibits N-methyl-d-aspartate (NMDA) receptor antagonism?
METHADONE
Methadone exhibits NMDA blocking properties and
inhibits the reuptake of norepinephrine and serotonin.
Which agent has both opioidergic and monoaminergic activity in the nociceptive pathways?
Tramadol
Tramadol enhances
spinal inhibition of 5HT and norepinephrine reuptake.
The accumulation of 5HT and norepinephrine in the dorsal spinal horn produces
analgesia.
The negative membrane potential of a resting peripheral nerve is
-70 to -90 mV.This can be measured with an electrode placed in the axoplasm of the nerve.
What is the suggested block height for patients undergoing cesarean section?
T4
With a spinal block, which factors have the most significant influence on local anesthetic spread?
Patient position and solution baricity
two adrenergic agonists that can be added to local anesthetics to prolong the duration of spinal anesthesia.
Clonidine and Phenylephrine.
Select the two variables that influence the spread and quality of an epidural block the most.
Local anesthetic dose
Site of injection
You are performing anesthesia for an organ harvest on a brain-dead donor. What is the target blood glucose range for maintaining donor kidney graft quality?
120-180 mg/dL
What is the most common organ transplanted in the U.S.?
Cornea
A patient who has had outpatient arm surgery under a brachial plexus block complains of persistent numbness to the arm during the discharge evaluation. You should
reassurance that sensation will return
What is the most commonly performed cosmetic procedure?
Liposuction
Moderate sedation
the patient responds purposefully to verbal commands either alone or with light tactile stimulation
You are anesthetizing a patient for CT scan with contrast. What is an appropriate measure to help prevent contrast-induced nephropathy?
Administer a sodium bicarbonate infusion
An obese patient is taking phentermine as an appetite suppressant. What are likely side effects of this drug? (select two)
Tachycardia
Hypertension
What is the preferred bariatric procedure for the treatment of severe obesity?
. Roux-en Y gastric bypass
What is the reservoir size of a simple adult face mask?
100-250 cc
Which of the following statements reflects a correct understanding of the use of a combitube? (select two)
The proximal pharyngeal cuff is filled with 100 cc of air
It is not available in pediatric sizes
How many sizes for the combitube?
It is not available in pediatric sizes
Combitude lumen
It consists of two lumens and 2 cuffs. The proximal pharyngeal cuff is filled with 100 cc of air, but the distal cuff only contains 15 cc of air. It is available in two adult sizes.
Proximal pharyngeal cuff of Combitube filled with
The proximal pharyngeal cuff is filled with 100 cc of air, but the distal cuff only contains 15 cc of air. It is available in two adult sizes.
Nitrous oxide will diffuse into an endotracheal cuff more quickly if
A high pressure endotracheal cuff is used
What device is a one-way valve for tracheostomy tubes that enables the patient to speak during exhalation?
Passy-Muir valve
What device is used as a ventilation-exchange bougie that allows fiberoptic intubation through an LMA or other supraglottic airway?
Aintree exchange catheter
The Aintree intubation catheter was developed by The
Cook to be used as a ventilation-exchange bougie that allows fiberoptic intubation through an LMA or other supraglottic airway.
The Glidescope and Airtraq laryngoscope are
video laryngoscopes.
LAs that areare all 95 percent protein-bound.
RBL Ropivacaine, bupivacaine, and levobupivacaine
Lidocaine is approximately ___protein bound, mepivacine is about LMRBL
55-65 percent protein-bound in the adult. Mepivacaine is 75-80 percent protein-bound.
Protein binding of LAs from LEAST to MOST
LiMRBLe Lidocaine Mepivacaine Ropivacaine Bupivacaine Levobupivacaine.
The half life of rocuronium is..
0.7 hours
The half life of Vecuronium is
0.9 hours.
The half life of Pancuronium is
1.7 hours
A minor medical error is discovered during the course of an anesthetic. The error does not pose any present or future threat to the patient. The CRNA
is not required to disclose the error to the patient
Which patient safety initiative seeks to lessen the incidence of surgical errors through techniques such as time outs and marking the surgical site
The Joint Commission Universal Protocol
Compared to a standard Bain circuit, the longer Bain modification exhibits.
increased static compliance, PEEP, and resistance to spontaneous respiration
The longer BAIN , If the ventilator settings are kept the same,
the peak inspiratory pressure and tidal volume are decreased.
Which of the following actions would help prolong the life of an electrochemical oxygen analyzer sensor?
Removing the sensor from the breathing system when not being used
What are the factors that are associated with the likelihood of a difficult mask ventilation?
History of snoring Limited ability to protrude the jaw Sleep apnea Elevated body mass index age greater than 57 years
Endotracheal tubes made from which of the following materials typically have a high-pressure endotracheal cuff?
Red rubber
Red rubber endotracheal tubes are
opaque endotracheal tubes that can be cleaned and sterilized for reuse.
Red rubber ETT tubes are more prone to
kinking, occlusion by secretions, have high-pressure cuffs, and can be a trigger for patients with latex allergy.
Polyvinyl chloride endotracheal tubes are
transparent, soften when warmed, and are less prone to kinking than red rubber tubes.
Polyurethane tubes are a more
recent adaptation.
Studies show that endotracheal tubes with a POLYURETHANE CUFF
polyurethane cuff have a decreased association with early postoperative pneumonia.
What is the first step you should take if you notice hypoventilation in a mechanically-ventilated patient?
Switch to manual ventilation
Which of the following represents the ideal position for the respirometer?
On the CO2 absorber
A Wright respirometer is located in the I
expiratory limb and contains vanes that cause it to rotate when exhaled gas passes across it.
If the respirometer is positioned close to the patient, then a
proximal circuit disconnection may go unnoticed because it would still register tidal volume. This is unlikely to happen if the respirometer is positioned on the CO2 absorber.
Which of the following values are necessary to calculate pulmonary static compliance?
Positive end-expiratory pressure
Tidal volume
Plateau pressure
Static compliance represents
lung compliance during a period of zero gas flow, such as during an inspiratory hold.
Static compliance =
Tidal Volume/(Plateau Pressure - PEEP)
A medical ultrasound machine functions between the frequencies of ____MHz.
2-13
An ultrasound can identify structures as small as_____ in diameter, but doesn’t have the resolution to accurately identify smaller structures.
1 mm
Tissue that reflects ultrasound waves poorly appears
gray to black on the monitor.
A high-frequency ultrasound is best for viewing
superficial structures.
You administer midazolam rapidly via the IV route to a pediatric patient. The patient begins to exhibit seizure-like activity. What is the most likely cause of this?
Myoclonic reaction. Rapid IV or nasal administration of midazolam can produce myoclonus that may have the appearance of seizure-like activity.
Compared to adult patients, you would expect a term neonate to exhibit (select four) Responsiveness to dopamine Muscle mass Body water Body fat
Decrease responsiveness to dopamine
Decreased muscle mass
a higher proportion of body water
a decreased proportion of body fat
Kids, As a result, the volume of distribution for water-soluble drugs is
greater.
Because their VD is greater, kids often require a higher loading dose of water-soluble drugs such as
digoxin, succinylcholine, and some antibiotics
You administer an intramuscular dose of midazolam to a pediatric patient without an IV who cannot cooperate to take PO midazolam. What is the minimum amount of time should you wait before considering a supplemental dose
20 minutes
The onset time of IM midazolam is ______and the time to peak effect is______
3-5 minutes. 10-20 minutes.
The volume of distribution and the total body clearance are bothB
significantly greater in pediatric patients, which accounts for the faster recovery in children.
Premedication with_____ has been shown to reduce the incidence of emergence delirium in pediatric patients.
ketamine
Increases placental arterial pressure the most, followed by e have
Ephedrine; phenylephrine.
VASOPRESSORS with no effect on placental arterial pressure when administered to the mother.
Epinephrine, norepinephrine, and methoxamin
Decreases placental and fetal arterial pressure.
Enalaprilat
Which of the following agents does not produce fetal vasodilation?
CLONIDINE
What is the most reliable test for detecting an inadvertent intrathecal or intravascular epidural catheter placement in a laboring parturient?
Negative aspiration for CSF or blood
The closing volume is ______in the elderly patient.
increased
Functional residual capacity also_____with age due to an in_____ residual volume.
increases ; increase
The total lung capacity is_____in elderly
decreases slightly or is unchanged.
In elderly The loss of elastic recoil around the alveoli results in a
decrease in the forced vital capacity and FEV1.
FEV1 in elderly
Decreased
FVC in elderly
Decreased
For which of the following situations would a rigid bronchoscopy be preferred? 5
The patient is a small child
Massive hemoptysis is present
The patient has a foreign body in the airway
An endobronchial resection is anticipated
vascular tumors,
Flexible fiberoptic bronchoscopes are preferred when a patient has
pneumonia and selective cultures need to be obtained, for the positioning of double-lumen tubes, if the patient has limited mobility of the neck, for the use of difficult intubations, if bronchial blockade is needed, if endotracheal tube position needs to be checked, if the patient has peripheral and upper lobe lesions, or if the amount of hemoptysis is limited
Positioning of double-lumen tubes: Flexible vs rigid
Flexible
Use for difficult intubation: Flexible vs rigid
Flexible
A patient is presenting for surgical treatment of a perianal fistula. The most common cause of perianal fistulae is
Infection within the rectal wall at the dentate line is the most common cause of perianal fistulae.
In what patient population should premedication be avoided prior to a tonsillectomy?
Patient with OSA
What nerve is at risk for damage during ablative electrophysiological procedures?
Phrenic (The phrenic nerve is in close proximity to the right upper pulmonary veins and is at risk for damage during ablation)
Portal triad clamping is effective in reducing blood loss during a hepatic resection. What structures would be occluded during this procedure? (select three)
hepatic artery
portal vein
common bile duct
The portal triad is actual a misnomer as it contains five structures:
a hepatic artery, hepatic portal vein, common bile duct, lymphatic vessels, and a branch of the vagus nerve.
Which of the following has been shown to reduce blood loss during a hepatic resection?
Slight Trendelenburg position can help reduce intraoperative blood loss by decreasing intrahepatic venous pressure as well as decreasing the risk of air embolism though severed hepatic veins. Vasopressors will constrict splanchnic vessels and reduce splanchnic pressure.
Which of the following is an advantage of the Sanders injection system of oxygenation during rigid bronchoscopy?
It allows continuous ventilation
When the balloon of a pulmonary artery catheter is inflated, what pressure can be obtained indirectly during ventricular systole? During diastole?
left atrial filling pressure; ventricular filling pressure
During ventricular systole, the left atrial filling pressure is reflected. During ventricular diastole, the
left ventricular filling pressure is measured. When the balloon is inflated, it is referred to as wedged.
Which needle has a curved tip that helps guide the direction of an epidural catheter?
Tuohy
Femoral nerve roots are
The L2-L4 nerve roots contribute fibers to the femoral nerve.
It is not necessary to cross-match prior to administration
FFPs
Fresh frozen plasma (FFP) is evaluated for
atypical antibodies and should be the same type as the patient.
For which application would a particulate steroid be INAPPROPRIATE
. Cervical epidural steroid injection
A properly performed popliteal block will anesthetize which of the following nerves? (select four) CDTS
common peroneal nerve
tibial nerve
deep peroneal nerve
sural nerve
A nerve block in the popliteal fossa will anesthetize both
he common peroneal and tibial branches of the sciatic nerve which terminate as the superficial peroneal, deep peroneal, sural, and posterior tibial nerves.
Common causes of hypercalcemia
Prolonged immobilization
Sarcoidosis
Hyperthyroidism
Vitamin D intoxification
The normal specific gravity of CSF is
1.004 to 1.009.
All result in a decreased ETCO2.
Temperature, thyroid, ventilation, perfusion, and lung disorder
Hypothermia, hypothyroidism, hyperventilation, hypoperfusion, and pulmonary embolism
What is a leading cause of mortality in patients who have suffered a ruptured cerebral aneurysm?
cerebral vasospasm
The incidence of cerebral vasospasm after ruptured cerebral aneurysm?
peaks between the 3rd and 14th day following the rupture.
A patient presents for a total laryngectomy. Which of the following represents an accurate understanding of this procedure?
The most common indication for this procedure is malignancy
Because the trachea is anastomosed directly to the skin surface, a tracheostomy tube or ETT is not necessary unless the patient has
severe stomal edema or will require postoperative mechanical ventilation, which is typically not the case.
Necessary for a partial laryngectomy.
A tracheostomy or endotracheal tube
The thyroid gland may be preserved during a
total laryngectomy.
Laryngectomy, Muscle relaxation may be preferred at the
beginning of the case, but nerve monitoring may be used during the neck dissection phase which would preclude its use.
Is the most common cause for total laryngectomy.
Malignancy of the head and neck
You are performing anesthesia for a total laryngectomy. The surgeon intends to perform a tracheostomy using a wire-reinforced endotracheal tube at the beginning of the procedure. What is the most likely complication during this part of the procedure?
Endobronchial intubation
A patient with hepatorenal syndrome and severe ascites is about to undergo a large-volume paracentesis (approximately 5 liters). What action is recommended to prevent the renal decompensation as a result of the removal of such a large volume of abdominal fluid?
Administer 30-40 grams of albumin
Albumin______ per liter of ascites removed should be administered to help prevent renal decompensation when performing large-volume paracentesis in a patient with hepatorenal syndrome.
6-8 grams
You are performing the anesthetic for a patient undergoing a liver transplant. Because of the risk for coagulopathy and resultant bleeding, you should
Administer cryoprecipitate to maintain a fibrinogen level greater than 150 mg/dL
Platelet transfusion is typically instituted to maintain platelet levels higherg/dL
than 50,000/mm3 (although some studies now indicate that platelet infusion may be detrimental to the liver graft), and cryoprecipitate is administered to maintain a fibrinogen level > 150 m
Cardiac myocytes possess low resistance communication channels between one another called
intercalated discs that allow for the quick and even spread of electrochemical signals.
House the pituitary gland____in what bone?
Sella turcica; Sphenoid bone
Theoretically, if a hyperbaric spinal anesthetic is injected at the L3 interspace and then the patient is positioned supine, how will the drug spread through the subarachnoid space?
It would move both in the cephalad and caudal directions
If a patient has a true allergic reaction to a spinal anesthetic, how is it most likely to present
pruritus and erythema
Where are T-helper lymphocytes predominantly located?
the lymph nodes
Ankylosing Spondylitis associated with this antigen ? Who is it more common in ?
histocompatibility antigen HLA-B27, the presence of which is detected in more than 90% of Caucasians with the disease
Because insertion of a DLT is more complicated, bronchial blockers are more useful in patients with a
difficult airway or a tracheostomy.
Patient needing tracheostomy are
patients who suffered a complete CSI above C-5 should undergo an elective tracheostomy.
During Tracheostomy
• Do not use
electrosurgery to cut into the trachea.
After insertion of the tracheostomy
A reassessment of the ventilation should be performed, including the entire procedure of listening to bilateral breath sounds, observing chest excursion, and checking end-tidal CO2 and positive inspiratorypressure, or negative inspiratory pressure. After the anesthesia provider has validated tube placement, the ETT is sutured to the chest wall for the entire surgical duration. At the end of surgery, the reinforced tube
may be switched for a tracheostomy cannula.
May be prevented by early tracheostomy
Supraglottic complications induced by long-term intubation
the anesthetist should consider avoiding surgical cricothyrotomy in favor of needle cricothyrotomy
and PTJV in infants and small children younger than
12 years of age. The child’s larynx is small, pliable, and movable, which can make cricothyrotomy very difficult in this population
Tracheostomy better for
Carotid artery stenting
Anterograde amnesia is
(i.e., loss of memory for a period after administration of the drug)
What kind of amnesia is loss of memory for events before administration of the drug
Retrograde
Platelets Typical dosing for an adult is a pool of _________ , or ________. This is expected to raise the platelet count by
six whole blood derived (sometimes referred to as random donor) platelets, or one apheresis platelet concentrate. This is expected to raise the platelet count by 30,000 to 60,000/uL in a 70 kg patient
Clinical Benefits of Leukoreduction
Reduced risk of HLA alloimmunization and platelet refraction
Reduce NHFTRs, nonhemolytic febrile transfusion
reactions;
Leukoreduction
What system generates the first-line of defense?
The innate system
Risk of HIV with blood transfusion
1: 1,500,000–1 : 2,000,000
Likewise, the concomitant use of SNRIs with SSRIs or triptans is not recommended because this may precipitate
a serotonin syndrome
2 SNRIs
SNRIs (duloxetine, venlafaxine)
Two theories have been proposed to describe TRALI syndrome. First one is –> The second theory explains TRALI syndrome as a
- antibodies in donor plasma activate recipient neutrophils, leading to pulmonary capillary leakage.
- Two-event model in which a physiologic stressor such as sepsis, leads to sequestration of neutrophils in the lungs. The transfusion of biologically active mediators (the second event) leads to activation of the neutrophils and capillary leakage.
Metabolism of methadone is primarily via the
CYP450 enzyme, specifically CYP3A4 and CYP2B6, into inactive metabolites that are excreted in the urine
____ are probably the most commonly used adjunct analgesics in the management of both neuropathic and
somatic chronic pain.
TCA
TCAs side effects
The TCAs commonly cause anticholinergic effects (urinary retention, constipation, dry mouth, blurred vision, and confusion), orthostatic hypotension, weight gain, sedation, and sexual dysfunction.
What is the most common spinal deformity?
Scoliosis
Should be considered to treat inflammatory pain or neuropathic pain
Nonopioid analgesics
Pain caused by post-herpetic neuralgia may be treated with neuropathic pain medications including
anticonvulsants (gabapentin, pregabalin), antidepressants (TCAs), topical agents (lidocaine), capsacin and opioids.
HERPES ZOSTER pain treat with
Amitriptyline (TCA)
Defined as facial pain in the affected nerve distribution that remains 3 months after skin vesicles resolve. POST HERPETIC NEURALGIA
Dorsal root ganglion necrosis,
CONTROL of PAIN after abdominal surgery best with
GABAPENTIN
CONTROL of PAIN after BREAST surgery best with
EPIDURAL
CONTROL OF PAIN for NERVE PAIN best with
VENLAFAXINE
HPV: 2 gases have also been shown to only slightly affect arterial oxygenation in patients placed in a lateral position while undergoing esophagogastrectomy
Desflurane and sevoflurane delivered at 1 MAC
without N2O
Which gas has the GREATEST EFFECT ON HPV?
Isoflurane
HPV helps to match
Regional ventilation and perfusion
HPV will cause which action in the lungs?
DECREASE BLOOD FLOW to NON-VENTILATED LUNG>
This effect explains why deoxygenated blood carry more CO2
Haldane
Average weight of a 6-year old
9 + (age x2)
HF resulting from obesity is caused by
LV Systolic dysfunction
Resting cerebral O2 consumption
3.5ml/100g/min
Protamine dosing is
1mg per 100 units of heparin
For which heart rhythm is cardioversion not indicated?
Pulseless Vtach
Peribulbar block , patient become agitate and complains of pain you suspect
Globe punctures
Lowest recommended PaCo2 if hyperventilation is used during intracranial tumor resection?
30 mmhg
Absolute contraindications for ECT
MI < 6 weeks
Pheochromocytoma
CVA< 3monhts
Valvular disorder with the largest LV volume?
Aortic Regurgitation
What patient do the anesthetist most want to maintain spontaneous ventilation while undergoing GA
Severe AS
The mediastinoscope can compress the ______and you have concern about decrease blood flow to the
innominate artery ; Right coronary artery
Where to place BP and Radial artery during mediastinoscope
left arm BP
A-line R hand.
When dosing mediations for obese patients, what is the best weight parameters to use
Lean body weight.
Pyloric stenosis metabolic disturbance
HypoKALEMIC HYPOCHLOREMIC META ALKALOSIS
Valve disorder that predisposes to Coronary ischemia with hypotension
AS
Pyloric stenosis metabolic disturbance
HypoKALEMIC HypoCHLOREMIC METABOLIC ALKALOSIS
HypoKCMA
OMPHALOCELE is less or more common
More common
Most common type of TEF
Type IIIb, Esophageal atresia with a fistula. between the distal esophagus and trachea
Is omphalocele midline
nO
OMPHALOCELE covered?
Yes covered with peritoneum.
Omphalocele defects lies
within the umbilical cord
HTN during aortic cross-clamping, the more proximar
The more increase the pressure
Which induction agent produces effects desirable in patients with Tetralogy of Fallot>
Ketamine
After epidural test dose, patient complains of heavy legs, what is the cause?
Unintentional intrathecal block
The patient is receiving echothiophate eye drops for glaucoma, you plan to use succinylcholine. wha tshould you expect
PROLONGED DURATION because it decreases cholinesterase activity.
Plt count to avoid neuraxial
Platelt 75K
How does propofol affect uterine blood flow
NO CHANGE
2 things that increases intraocular pressure
Hypoventilation
hypertension
A patient is scheduled for ECT what is your main anesthetic concern when calculating dosages for inductions agents
SEIZURE QUALITY
Cardioversion Electrical shock is synchronized with
R wave
What emergency medication is essential for penile surgery?
Glycopyrrolate or atropine
In which valvular disorder is the LV volume approximately normla, but LV pressure is higher than normal
Aortic stenosis
Which law explain postintubation airway edema
Poiseuille’s equation
Relative contraindication to PAC placement
LBBB
Which opioids causes the greatest respiratory depression in newborns?
MORPHINE
Fetal scalp PHis
> 7.25 normal
Fetal scalp pH associated with neonatal depression
<7.20
AT highest risk of DI post what surgery
Transphenoidal Hypophysectomy
Hypovolemia on SVO2
decrease the SvO2
LARGE V WAVE on the CVP waveform
TRICUSPID REGURGITATION
Other name for T4 is
Thyroxine
The accumulation of frost on a nitrous oxide cannister that is in use is an example of
JOULE-THOMPSON effect
Life threatening bronchospasm that is unresolved despite treatment is called
Status asthmaticus
Cor pulmonale is
Right sided HF
What is the main stay drug therapy for COPD
Bronchodilators
What disease is seen with eosinophillic glaucoma? HISTOCYTOSIS X
PULMONARY FIBROSIS
Acoustic neuromas are typically associated with
BENIGN TUMORS called SCHWANNOMAS
What is a chiari?
Congenital displacement of the cerebellum
Idiophathic facial paralysis is known as
Bell’s palsy
Good pasture’s syndrome manifestas as
Worsening Glomerulonephritis
lung hemorrhage
Transient blindness during TURP syndrome is the result of what neurotransmitter ?
GLYCINE
Where is the majority of the total body calcium?
Stored in bone
How many lobes are in the thyroid gland?
2
HAART Is the drug treatment employed with what condition?
HIV
Syndrome X is also knowns as
Metabolic syndrome
Type II chiari is associated with
Cerebellar vermis and brainstem herniate into the cervical spinal canal.
It is a Dopamine agonist drug
Bromocriptine
Water soluble vitamin
C
Vitamin B12 also known as
Cobalamin
What is the most common cause of acute liver failure worldwide?
Hepatitis A
Condition results from an enzyme deficiency required for HEME synthesis
PORPHYRIA
Exaggerated anterior FLEXION of the spine is known as
KYPHOSIS
Normal magnesium
1.2-1.8
What catalyzes the conversion of fibrinogen to fibrin?
Thrombin
Alveolar pressure =
intrapleural pressure + alveolar elastic recoil pressure.
The slope between 2 points on a pressure-volume curve represents
COMPLIANCE
The primary component of surfactant is
DIPALMITOL PHOSPHATIDYLCHOLINE
The muscularis mucosae is found in the
GUT WALL.
Hormone released from the duodenum?
Secretin
Glucose + Fructose =
Sucrose
2 skeletal muscles in the inner ear are the
tensor tympani AND STAPEDIUS
Preload a.k.a
End diastolic ventricular pressure
The portion of the lung supplied by a PRIMARY RESPIRATORY BRONCHIOLE IS CALLED
AN ACINUS
The effect of pH on the ability of Hgb to bind with oxygen is known as the ___effect
bohr effect
% of resting CO goes to the kidneys
20%
The calcium stored in bone is in the form of
HYDROXYAPATITE
Phagocytic cells in the liver responsible for removing particulates from blood are
Kuffer cells
Fluid drains from the Bowman’s capsules directly into the
PROXIMAL TUBULE
Class of compound of NE
Monoamine
Endothelium-derived relaxing factors
Nitrous oxide
Methohexital avoided in patients with a hx of
EPILEPSY (or seizures)
What drug is an example of a BUTYPHENONE ANTIPSYCHOTIC?
Haloperidol
The parasympathetics nervous system does not include fibers from
CN 8
Normodyne is another name for
Labetalol.
Which drugs can decrease MAC
Ketamine
Opioids with the highest degree of plasma protein binding?
Sufentanil
Prolonged in the hypothermic patient.
Anesthetic emergence is
Describes the transfer rate of gas through a tissue medium.
Fick’s law of diffusion
Fick’s law of diffusion : RATE OF TRANSFER directly proportional to (PDM)
partial pressure difference (driving force)
Diffusion coefficient (solubility)
Membrane surface area
Fick’s law of diffusion : RATE OF TRANSFER INVERSELY proportional to
Membrane thickness
Molecular weight
Diffusion hypoxia what law
Fick’s law of diffusion
A patient with COPD has a reduced alveolar surface area, and therefore has a (faster/slower)_____ inhalation induction
a slower rate of inhalation induction
Calculation of cardiac output follow which law
Fick’s law of diffusion
Drug transfer across the placenta follow which law
Fick’s law of diffusion
Diaphragm contraction increases tidal volume follow which law
Boyles
Squeezing an Ambu bag follows which law
Boyle’s
Pneumatic bellows follows which law
Boyles
Using the bourdon pressure gauge to calculate how much O2 is left in a cylinder (assumes a given flow rate) because of which law?
Boyles
Ohm’s law says that the current passing through a
conductor is directly proportional to the voltage and inversely proportional to the resistance. We can adapt Ohm’s law to understand fluid flow.
Omh’s Law Q=
Q = Change in P/ R
Poiseuille’s law is a modification of Ohm’s law that incorporate.
s vessel diameter, viscosity, and tube length
There are 3 types of flow:
Re 2,000 - 4,000: Transitional flow
laminar, turbulent, and transitional.
Re < 2,000: Laminar flow is dependent on(LG)
gas viscosity (Poiseuille’s Law)
Re > 4,000:___flow (TD)
Turbulent flow is dependent on gas density (Graham’s law)
Re < 2,000: ___flow
Laminar flow i
Reynold’s number is calculated
Viscosity
Explain how understanding Reynold’s number helps you treat status asthmaticus.
The patient with status asthmaticus suffers from an increased airway resistance, and this increases flow turbulence and the work of breathing. Because turbulent flow is primarily dependent on gas density, we can improve flow by having the patient inhale a lower density gas.
The key here is that we are converting turbulent flow to laminar flow. Helium does NOT improve flow if it is already laminar.
An oxygen/helium mixture (Heliox) improves Reynold’s number by
reducing density.
Key drug interactions that increase the risk of serotonin syndrome include:
SSRI and:
Meperidine
Fentanyl
Methylene blue
Key drug interactions that increase the risk of serotonin syndrome include:
MAOI and:
Meperidine
Ephedrine
Neuralgia is ___examples is____
pain localized to a dermatome.
Ex: Herpes zoster (shingles)
BMI is calculated with
Weight (kg) / Height in (m2)
Calculate ideal body weight for men and women
Men (kg) = Height (cm) - 100
Women (kg) = Height (cm) - 105
The key changes that lead to the cardiovascular complications of obesity.
The expansion of intravascular blood volume and a high cardiac output state
What are the key issues regarding re-entry to clinical practice following a substance abuse disorder?
One full year in recovery is recommended prior to returning to anesthesia practice.
Of the ten criteria that should be met prior to considering re-entry, the most salient point is participation in a monitoring program at least 5 years in length with random drug testing.
A characteristic syndrome that is the direct result of stopping or reducing the use of a drug.
Withdrawal.
More drug is needed to achieve a given effect (intoxication) – or – a lesser effect is produced by a given dose of a drug.
Tolerance
The inability to safely participate in life (or professional) activities.
Impairement
A need (psychological or compulsive) for a substance. There is often a loss of self-control, where the user continues using a drug despite the desire to stop drug use. This represents a severe stage of chronic substance abuse disorder.
Addiction
The OSHA limit for an 8-hour span is
90 dB, and single noise levels should not exceed 115 dB.
What are the physiologic effects of MRI exposure?
Lower frequency electromagnetic fields from MRI can cause transient symptoms of nausea, dizziness, vertigo, or light flashes. There are no published regulations limiting occupational exposure to MRI fields.
What is the OSHA limit for occupational exposure to ionizing radiation?
Annual = 5 rem Lifetime = (N-18) x 5 rem
N= age in years
Research has also shown that 24-hours of wakefulness is equivalent to a blood alcohol content of%).
0.1% (legal impairment for driving is blood alcohol content is 0.08
Families should be informed that, despite all reasonable efforts to eliminate the need for transfusion, if an emergency occurs,
a court order for transfusion will be sought.
Emancipated minors are
patients younger than 18 years of age who are legally given the rights of an adult by a state court.
Although variable by state law, criteria for emancipating a minor may include the fact that they are:
Married
A parent, or is currently pregnant
In the military
Economically independent
What is a schedule II drug? List some examples.
Opioid agonists (fentanyl, morphine, hydromorphone, etc.)
Cocaine
Methamphetamine
Phencyclidine
This act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition (EMC) regardless of an individual’s ability to pay.
Emergency in Medical Treatment and Active Labor Act?
What is vicarious liability? What’s another name for this concept?
Tne person (or entity) may be liable for the actions of another person. For instance, a physician might be held liable for the actions of a PA. This concept typically does not apply to CRNAs working under a physician. Respondeat superior is often used interchangeably with vicarious liability.
What is the difference between assault and battery?
Assault is the attempt to touch another person.
Battery is touching a person without either expressed or implied consent.
What is the difference between assault and battery?
Assault is the attempt to touch another person.
Battery is touching a person without either expressed or implied consent.
What is the difference between libel and slander?
Libel is defamation in the written form.
Slander is defamation in the verbal form.
Res ipsa loquitur can shift the burden of proof from the plaintiff to the defendant. This can occur if 4 conditions can be established:
(“the thing speaks for itself”)
1) If the injury would not have occurred in the absence of negligence.
2) The injury was caused by something under the complete control of the defendant (provider).
3) The patient did not contribute in any way to the injury.
4) The evidence for the explanation of events is solely under the control of the provider
List the 4 things that must be proven in a law suit asserting malpractice.
Duty
Breach of duty
Causation
Damages
Principle that providers should take action for the benefit of others
Beneficence
asserts that a provider has an obligation not to inflict hurt or harm—in other words, the Hippocratic oath primum non nocere (first do no harm)
Nonmaleficence
refers to the patient’s ability to choose without controlling interference by others, and without limitations that prevent meaningful choices.
Autonomy
are authoritative statements that describe minimum rules and responsibilities for which anesthetists are held accountable.
Practice standards
systematically developed statements to assist providers in clinical decision making that are commonly accepted within the anesthesia community.
practice guidelines?
dictates the principles of conduct and professional integrity that guide the decision making and behavior of nurse anesthetists. This document speaks to the anesthetist’s responsibilities as a professional, which holds the individual CRNA accountable for his or her own actions and judgments, regardless of institutional policy or physician orders.
AANA Code Of Ethics?
What are your options if you lose the airway during induction in the patient with an anterior mediastinal mass?
repositioning the patient laterally or prone may restore patency to the airway. A ridged bronchoscope should be available. Emergent femoral-femoral cardiopulmonary bypass may be required if ventilation via the lungs becomes impossible.
What is the best induction technique for a patient with an anterior mediastinal mass?
Spontaneous ventilation preserves the normal airway distending pressure gradient, but this gradient is often abolished during positive pressure ventilation. The sitting position and maintenance of spontaneous ventilation will minimize, but not always prevent, compression of the vital chest structures.
List 3 factors that worsen tracheobronchial compression in the patient with an anterior mediastinal mass.
Supine position
Induction of general anesthesia
Positive pressure ventilation
Which position provides the most optimal V/Q matching in the patient with ARDS?
The prone position provides optimal V/Q matching, which explains why we use the prone position for patients with ARDS.
Midcervical tetraplegia is associated with
hyperflexion of the neck (chin to chest). Ischemia occurs as a result of stretching and/or compression of the midcervical spinal cord (usually C5).
Although the sitting position is most commonly associated with venous air entrainment, this complication can occur in any position that produces a
pressure gradient between the atmosphere and the veins at the surgical site.
Venous air embolism →
right heart → pulmonary vasculature → ↑ dead space & ↑ RV workload
Paradoxical air embolism →
right heart → patient foramen ovale → left heart → systemic circulation → stroke
Compartment syndrome is most common in the
lithotomy position.
Reduced sensation over anteromedial aspect of the leg
Saphenous nerve injury
Patient present with Foot drop, nerve injury
Common peroneal nerve injury
Inability to evert the foot
Common peroneal nerve injury
Inability to extend the toes dorsally
Common peroneal nerve injury
Presentation:
Foot drop
Common peroneal OR SCIATIC
Reduced sensation over the medial aspect of the thigh
Obturator nerve injury
Inability to ADDuct the leg
Obturator nerve injury
Excessive cycling of the NIBP cuff, what kind of injury
Ulnar nerve injury
Upper extremity tourniquet what kind of injury
Ulnar nerve injury
Sheets that are too tight (if the arms are tucked)
Ulnar nerve injury
Presentation = Wrist drop
radial nerve injury.
Unable to oppose the thumb (chronic injury can lead to the ape hand deformity).
Median nerve injury
the most commonly injured peripheral nerve.
The ulnar nerve
hich type of nerve injury provides a greater risk for long term injury (sensory or motor)?
Sensory deficits are more common, less serious, and tend to resolve on their own (usually 5 days or less).
Motor deficits are less common and more serious.
Who is at risk for ulnar nerve injury?
Male gender (especially if > 50 years old)
Preexisting ulnar neuropathy
Extremes of body habitus (very thin or obese)
Prolonged hospital stay / bedrest
most common signs of an anastomotic leak following gastric bypass?The most common signs and symptoms include
Tachycardia (72%)
Fever (63%)
Abdominal pain (54%)
Ketorolac probably increases the incidence of this complication, so it should be avoided in the perioperative period
What is the definitive test for OSA.
Polysomnography
The results of this test Polysomnography allow for the calculation of the
apnea-hypopnea index (AHI), which is used to quantify the severity of OSA.
The American Academy of Sleep Medicine defines OSA as:
Mild =
Moderate =
Severe =
5 – 15 episodes/hr
15 – 30 episodes/hr
> 30 episodes/hr
Apnea-hypopnea index (AHI) is calculated by
Number of episodes of apnea or hypopnea/ hours of sleep
Patients with severe sleep apnea are at higher risk of
difficult mask ventilation and difficult intubation.
is a bedside tool that allows you to predict the likelihood that a patient has undiagnosed OS
The STOP-BANG scoring system
STOP BANG for OSA results
High risk = > 3 questions answered yes
Low risk = < 3 questions answered yes
Ma huang is a natural
source of ephedrine, an indirect acting adrenergic agonist and thermogenic agent.
Ma huang Any drug interactions that would occur with ephedrine will apply here as well. Complications of
adrenergic overstimulation, including hypertension, CVAs, seizures, and death, have occurred with the use Ma huang containing drugs.
Orilistat is a ? what must be supplemented?
lipase inhibitor that reversibly binds to lipase and hinders the absorption and digestion of consumed fats. Since fat and the vitamins it contains (D, A, K, E) are not absorbed by the gut, they must be supplemented orally. Insufficient quantities of vitamin K will impair synthesis of clotting factors 2, 7, 9, and 10 and may cause a coagulopathy.
Insufficient quantities of vitamin K will impair synthesis of clotting factors ,,,
s 2, 7, 9, and 10 and may cause a coagulopathy.
During the preoperative interview, ask the patient to do what when assessing for thoracic outlet syndrome?
clasp her hands behind her head. If she complains of pain, this may suggest an increased risk of thoracic outlet syndrome. It may be prudent to tuck the arms while in the prone position.
Cubital tunnel
Medial epicondyle of the humerus
Olecranon process of the ulna
Cubital tunnel retinaculum (creates the roof of the cubital tunnel)
How does obesity affect the dosing of an epidural?
Engorgement of the epidural veins and an increased epidural fat content will cause a greater spread of local anesthetic in the epidural space. For this reason, the dose should be reduced to 75% of the normal dose.
How does obesity affect the dosing of opioids?
Because of their fat solubility and large Vd, the initial doses of fentanyl and sufentanil are based according to TBW. Maintenance dosing is based on LBW. An increased Vd correlates with a prolonged elimination half-life.
How does obesity affect the dosing of opioids?
Because of their fat solubility and large Vd, the initial doses of fentanyl and sufentanil are based according to TBW. Maintenance dosing is based on LBW. An increased Vd correlates with a prolonged elimination half-life .Remifentanil is the exception. Since it is rapidly cleared by plasma esterases, it does not behave like a high Vd drug, so remifentanil is always based on LBW.
How does obesity affect the dosing of nondepolarizing neuromuscular blockers?
Roc/Vec
Induction: LBW
Maintenance: LBW
Cis/Atracurium
Induction: TBW
Maintenance: TBW or LBW
How does obesity affect the dosing of succinylcholine?
Even though succinylcholine is a water soluble drug, the dose for intubation is calculated with TBW/ This is a clear exception to the rule for water soluble drugs. Shortly stated, the combination of an increased blood volume (increased Vd) and increased pseudocholinesterase activity (increased clearance) necessitates a TBW dose be given to ensure adequate paralysis.
How does obesity affect the dosing of propofol?
The loading dose of propofol is based on lean body weight. This is because its offset is caused by redistribution and not clearance (which would depend on Vd).
Induction: LBW
Maintenance: TBW
How does obesity impact your selection of inhaled anesthetic agents?
Sevoflurane or desflurane provide a faster emergence than isoflurane or propofol.
Nitrous oxide is generally avoided, because it restricts the maximum FiO2 that can be delivered.
What valvular defect is highly suggestive of pulmonary hypertension in the obese patient?
The presence of tricuspid regurgitation on TEE may be the most useful confirmation of pulmonary hypertension.
Metabolic syndrome diagnosis: one must have at least
3 of the following signs:
Large waist circumference (men > 40 inches & women > 35 inches)
Triglycerides > 150 mg/dL
High density lipoprotein (HDL) < 40 mg/dL for men and < 50 mg/dL for women
Blood pressure > 130/85
Fasting glucose > 100 mg/dL
Metabolic syndrome (syndrome X) incorporatesIn order to be diagnosed with metabolic syndrome,
a number of disease states that coincide with obesity.
Cardiovascular risk in patients with metabolic syndrome is
50-60% greater than the general population.
Android Obesity ; more common in
Apple Shape): men
Gynecoid Obesity
(Pear Shape): women
Characterized by central or abdominal visceral fat accumulation.
Android obesity
The modified Aldrete scoring system is used to
assess readiness for PACU discharge. A score of 0 – 2 is awarded in 5 areas, where a score of 9 or more is generally accepted as discharge ready.
Chronic ingestion of which herbal medication can mimic Conn’s syndrome?
Licorice
List 2 herbal supplements that reduce MAC.
Kava kava
Valerian
List 4 herbal supplements that increase bleeding risk.
Garlic
Ginger
Gingko biloba
Saw palmetto
Compare the equianalgesic dose of ketorolac and morphine.
Ketorolac 30 mg IV ~ morphine 10 mg IV
Transplant rejection is a response to
Antigen, primarily HLA antigens on the donor organ
Hyperacute Tranplant rejection
Hyperacute occurs immediately following transplant and is due to preexisting antibodies in the recipient from a prior graft or blood transfusion of platelet or leukocytes that contains HLA antigens.
Avoid hyperacute tranplant rejection by
Preop screening for antigraft antibodies
Acute transplant rejection is
Cell mediated immune response
Hypersensitivity reaction Type I
Immediate Drugs allergy, hay fever and asthma
Hypersensitivity reaction Type II
Cytotoxic (cell mediated)
Examples of type II hypersensitivty
Blood transfusion
Erythroblastosis fetalis
Acute transplant rejection is an example of
Cytotoxic hypersensitivity type II reaction
SLE and RA are what type of Hypersensitivity reaction
Type III Immune complex
Delayed Transplant rejections and poison ivy
Type IV Hypersensitivty reaction
Type V hypersensitivity reactions
Grave’s disease
Intraoperative anaphylaxis grade I
Cutaneous signs , generalized erythema, urticaria, angioedema
Intraoperative anaphylaxis grade II
Cutaneous signs , with hypotenion, tachycardia, cough, difficult ventilation
Intraoperative anaphylaxis grade III
Hypotension , tachycardia or bradycardia, arrhythmia bronchospasm
Intraoperative anaphylaxis grade IV
Cardiac and/or resp arrest, PEA.
Advanced trauma life support classification of Shock blood loss %
Class 1 < 15 %
Class 2 15-30%
Class 3 30-40%
Class 4 >40%
Advanced trauma life support classification of Shock HR
Class 1 < 100
Class 2 >100
Class 3 >120
Class 4 > 140
Advanced trauma life support classification of Shock SBP CLASS 1 and 2
Normal
Advanced trauma life support classification of Shock SBP CLASS 3 and 4
Decreased
At the trauma, RBCs are replaced to
provide oxygen-carrying capacity
During trauma, Shed blood replaced with a ratio
1: 1 VOLUME OF PRBCS
3: 1 VOLUME OF CRYSTALLOIDS
TRAUMA PRIMARY survery ABCDE
Airway Breathing Circulation Disability Environment/Exposure
Discuss the role of the cyclooxygenase enzyme in the arachidonic acid cascade.
COX-1 is always present.
It maintains normal physiologic function.
COX-2 is not always present.
It is expressed during inflammation.
Inhibition of the COX-2 enzyme produces
analgesic, antiinflammatory, and antipyretic effects. Unlike opioids, there is a ceiling effect to analgesia.
Inhibition of the COX-1 enzyme impairs
platelet function, causes gastric irritation, and reduces renal blood flow.
Inhibition of the COX-1 enzyme impairs
platelet function, causes gastric irritation, and reduces renal blood flow.
What type of reaction is contact dermatitis,
Type IV delayed
What type of reaction is graft-vs-host reaction
Type IV delayed
Snake venom reaction, protamine induced vasoconstriction: What type of rection :
Type III immune complx mediated
ABO-incompatibility, what type of reaction
Type II
heparin-induced thrombocytopenia What type of reaction
Type II
Make up 60% of all WBCs (most abundant WBC type).
Neutrophils
Defend against parasites.
Eosinophils
B-lymphocytes:
Humoral immunity (produce antibodies).
T-lymphocytes:
Cell mediated immunity (does not produce antibodies).
Lymphocytes that does not produce antibodies?
T-lymphocytes.
H1 receptor function
Vasodilation
Increased vascular permeability
SMOOTH MUSCLE CONTRACTION (not vascular)
H2 receptor function?
Cardiac stimulaion
H2 receptor function?
Cardiac stimulation
Which H receptor is associated with gastric secretion
H2
TAP block from superficial to deep
Subcutaneous tissue → External oblique muscle → Internal oblique muscle → Transverse abdominis muscle → Peritoneum
BLOCK that provides analgesia for breast surgery, thoracotomy, and rib fracture.
The thoracic paravertebral block
Celiac Plexus BlocK: useful what type of procedures? Which part does it not innervate?
It does NOT innervate the pelvic organs.
Therefore, it is useful for pain from the upper abdominal organs, but not the pelvic organs (useful in cancer patients).
The celiac plexus innervates the _____EXCEPT:
upper abdominal viscera (except the left side of the colon).
Superior Hypogastric Plexus Block innnervates the
pelvic organs.
Blockade of the superior hypogastric plexus is useful in patients with pain involving the
pelvic organs (useful in cancer patients).
Aside from an epidural blood patch, which regional technique is used to release post-dural puncture headache?
Sphenopalatine block
If a patient reports an allergy to PCN, then s/he may receive a cephalosporin if the reaction:
Was NOT IgE mediated (anaphylaxis, bronchospasm, urticaria).
Did NOT produce exfoliative dermatitis (Stevens-Johnson syndrome
The most common cause of occupational exposure to HIV is a
needle-stick injury with a hollow-bore needle.
Seroconversion rates after exposure to HIV-infected blood
Percutaneous injury (needle-stick) = 0.3% Mucus membrane exposure = 0.09%
Pain due to a stimulus that does not normally produce pain. Ex:
Allodynia; Fibromyalgia
Abnormal and unpleasant sense of touch.
Ex:
Dysesthesia ; Burning sensation from diabetic neuropathy
Abnormal and unpleasant sense of touch.
Ex:
Dysesthesia ;
Burning sensation from diabetic neuropathy
Pain localized to a dermatome.
Ex:
Neuralgia Herpes zoster (shingles)
There are 2 types of CRPS:
Type I (reflex sympathetic dystrophy) Type II (causalgia)
The key distinction is that type II CRPS is always preceded by
nerve injury (type I is not).
Complex regional pain syndrome is characterized by
neuropathic pain with autonomic involvement.
Caffeine-halothane contracture test is used to help diagnose
malignant hyperthermia
Explain what is done during the caffeine-halothane contracture test
A muscle biopsy is obtained from the patient and tested. High-doses of caffeine release calcium from the sarcolemma. This effect is enhanced by halothane. When the muscle tissue in patients with malignant hyperthermia is exposed to these two agents it contracts abnormally, confirming a diagnosis of MH.
Which muscles would a deep cervical plexus block affect? (select two)
The strap muscles of the neck
The prevertebral muscles
Hyperalgesia, allodynia, autonomic abnormalities, and pain that occurs spontaneously without an apparent stimulus are features characteristic of
Complex regional pain syndrome
According to the Critical Incident Stress Management model, what is the term for the intervention that occurs at the end of the day before involved healthcare workers leave for home that allows them to recount the event and express their concerns?
defusing
is designed to assess the immediate reactions to the event and determine the next course of action. It is led by an authority figure, typically lasts about and should allow the.
Demobilization; 10-15 minutes, involved individuals about 20 minutes to relax before returning to work
Defusing occurs at the end of the day, but before the involved individuals have left for work. It is an extension of the
demobilization phase, is led by an authority figure, and typically last about an hour.
Originally designed for emergency service employees and has proven useful to healthcare workers as well. It involves a structured group discussion that occurs
Critical Incident Stress Debriefing; 1-3 days after the event
The use of counseling or psychological support to an individual throughout the crisis spectrum to help return the individual to a normal level of functioning.
One-on-One Intervention
It is designed to recount the details of the event, allow individuals to express their concerns, and offer support. . It should include the anesthesia staff involved in the event and is designed to assess for symptoms of acute distress and provide closure.
Critical Incident Stress Debriefing;
How long should a patient refrain from smoking before the ability of the lungs to respond to pulmonary infection returns to normal?
8 weeks
Improves significantly at about 8 weeks of smoking cessation.
Mucociliary and immune function i
Airway management may be made even more difficult prior to that amount of time as there is an __________during the first month of smoking cessation.
increase in pulmonary secretions
Aspirin inhibits the production of
Aspirin and other NSAIDs acetylate and inactivate platelet cyclooxygenase.
thromboxane A2.
Aspirin inactivates______what about NSAIDS?
cyclooxygenase for the life of the platelet but other NSAIDs inactivate them reversibly, and the effect lasts only about 24 hours.
Factor X deficiency is
Stuart-Prower deficiency
. It also offers greater protection against aspiration. Because this results in an increased risk for tracheal ischemia, it is not suitable for long-term intubations.
It offers increased visibility during intubation
It offers better protection against aspiration
offers increased visibility during intubation because the cuff lies flat against the tube when not inflated
low-volume, high pressure cuff
Low volume High pressure cuff : assessing how much pressure is being applied to tracheal wall.
Because it requires a high intracuff pressure to overcome the decreased compliance of the cuff wall, it is difficult to assess how much pressure is being applied to the tracheal wall.
Not suitable for long-term intubation?
Low volume high pressure cuff.
What type of cuff provides better protection against aspiration?
Low volume high pressure cuff.
Phenoxybenzamine administration can produce______ The recommended treatment is ______
tachyarrhythmias. beta-blockers
Which of the following would be an Appropriate intervention for a patient with acute intermittent porphyria?
Administering D5NS while the patient is NPO
Medications to avoid with acute intermittent porphyria ? Are beta blockers safe to use?
Both ketorolac and barbiturates should be avoided. Beta-blockers are safe for use in these patients.
Fasting and acute porphyria?
Fasting has been identified as a precipitating factor for As such, prolonged NPO times should be avoided, and the administration of a glucose-saline solution during the NPO time should be considered
The overall risk for a perioperative MI in the general population undergoing general anesthesia is
0.3%.
In the face of chronic vasoconstriction, the juxtaglomerular apparatus does what?
releases renin. The end result of renin release is the conversion of angiotensin I to angiotensin II.
What is the primary stimulus for the release of aldosterone by the adrenal cortex?
Angiotensin II is
Aldosterone results in increased
sodium and water retention.
What is the most common cause of heart failure?
CAD
As many as 10% of patients with hepatitis B
chronic and up to 40% of patients with hepatitis C will develop chronic hepatitis.
Hepatitis D can convert into a chronic form but only occurs in patients who
already have hepatitis B.
Hepatitis B is associated with hepatits
D
What are the major factors that determine the rate of elimination of amide local anesthetics? (select two)
Hepatic blood flow and Enzyme activity
The speed at which Hofmann elimination acts to degrade atracurium depends primarily on (select two)
ph and temperature
What is the recommended intravenous dose of ketamine used for preemptive analgesia?
10-20mg
A patient in postanesthesia recovery is exhibiting signs of an acute myocardial infarction with cardiac failure. Which of the following agents is contraindicated?
Metoprolol
Beta-blockers reduce the risk of reinfarction and death by
decreasing myocardial oxygen demand.
They should only be administered in a hemodynamically stable patient and should not be administered if the patient exhibits low cardiac output or heart failure.
Beta blockers
All of the serotonin receptors arewith the exception of the 5-HT3 receptor which is a ligand-gated ion channel.
G-protein-coupled and affect either adenylyl cyclase or phospholipase C
All of the serotonin receptors are___
G-protein-coupled and affect either adenylyl cyclase or phospholipase C
What is the most common cause of mitral stenosis?
Rheumatic heart disease
The incidence of mitral stenosis is higher in males vs females?
Females
In mitral stenosis, Over a period of 20-30 years, rheumatic fever causes the
mitral valve leaflets to become thickened, the commissure may fuse, and the leaflets and annulus may become calcified.
What 2 aspects of the induction of general anesthesia would have detrimental effects on the patient with cardiac tamponade?
Peripheral vasodilation from administration of an inhaled anesthetic
Positive pressure ventilation
PPV on cardiac tamponate
Detrimental
The agents of choice of treating HTN, if it is primarily an epinephrine-secreting tumor.
Esmolol or labetolol are
Esmolol offers the advantage of a
short duration of action.
What is the chief indicator that diabetes-associated renal impairment has progressed to advanced glomerulonephritis?
PROTEINURIA
Patients can be asymptomatic for as long as 15 years, but the appearance of proteinuria is the hallmark sign the glomerulosclerosis is severe.
Appearance of proteinuria is the hallmark sign the
glomerulosclerosis is severe.
What is the most common adverse event in patients receiving hemodialysis?
Hypotension
Rheumatoid arthritis is characterized by. It is typically In the most severe forms, every joint can be affected except for the lumbar and thoracic spine.
symmetric polyarthropathy that affects weight-bearing joints and proximal interphalangeal and metacarpophalangeal joints
Rheumatoid arthritis is characterized by.
symmetric polyarthropathy that affects weight-bearing joints and proximal interphalangeal and metacarpophalangeal joints
Rheumatoid arthritis It is typically In the most severe forms, every joint can be affected except for the
lumbar and thoracic spine.
Autoimmune destruction of pancreatic beta cells is associated with
Type I DM
Type I diabetes is associated with
T cell-mediated destruction of beta cells although the exact mechanism that triggers the destruction is unknown.
A patient has been diagnosed with an ischemic stroke. Which agent should be avoided in the care of this patient?
Glucose
Patients with SLE are prone to (4). 3PPPs A The end result is what type of defect (restrictive vs obstructive) ?
Pleural effusion Pulmonary HTN Pneumonitis Alveolar hemorrhage The end result is a restrictive defect.
What treatment modality should you give the highest priority in the care of a patient with acute pancreatitis?
AGGRESSIVE HYDRATION
The four subtypes of schizophrenia are:
DCUP
1. Disorganized 2. Catatonic 3. Paranoid 4. Undifferentiated
Intravenous propofol will have what effect of CBF
. decrease cerebral blood flow
The most common presenting symptoms of SLE are. . Renal disease occurs in over half of the patients with SLE and is the most common cause of death. About 10-20% of patients with lupus erythematosus require dialysis. Because of the increased risk of vasculitis, these patients have a higher risk of CNS disorders such as seizures, stroke, dementia, peripheral neuropathy, and psychosis. A diffuse serositis results in pericardial effusion in over half of these patients, but pericardial tamponade is rare.
polyarthritis and dermatitis. A malar rash occurs in about 1/3 of SLE patients
The most common presenting symptoms of SLE are. . Renal disease occurs in over half of the patients with SLE and is the most common cause of death. . Because of the increased risk of vasculitis, these patients have a higher risk of CNS disorders such as seizures, stroke, dementia, peripheral neuropathy, and psychosis. A diffuse serositis results in pericardial effusion in over half of these patients, but pericardial tamponade is rare.
polyarthritis and dermatitis. A malar rash occurs in about 1/3 of SLE patients
About 10-20% of patients with lupus erythematosus require
dialysis.
SLE Because of the increased risk of ______these patients have a higher risk of CNS disorders such as
vasculitis; seizures, stroke, dementia, peripheral neuropathy, and psychosis.
Pericardial effusion and SLE
A diffuse serositis results in pericardial effusion in over half of these patients, but pericardial tamponade is rare.
About 90% of the body’s phosphorus is found in bone.
bone
The Bain circuit is a modification of the
D
When carbon dioxide absorbent is exhausted, what chemical accumulates in the cannister?
Carbonic acid
Formed as the byproduct of the exposure of water to carbon dioxide.
Carbonic acid
Which factors would result in higher tidal volumes than are set for the patient when the anesthesia machine ventilator is in use? (select two)
High I:E ratio
Low Respiratory rate
Unless you are using an anesthesia machine that is designed to compensate for it, when the ventilator is being used, a portion of the _______? what increases this effect?
fresh gas flow will contribute to the tidal volume. This effect increases if the fresh gas flow rates are high, if the I:E ratio is high, and if the patient has a slower respiratory rate.
Pipeline inlet connections –: part of what system (low, high or intermediate)
Intermediate
Oxygen flush valve : part of what system (low, high or intermediate)
Intermediate
Flow control valve part of what system (low, high or intermediate)
intermediate
Pipeline pressure indicators part of what system (low, high or intermediate)
Intermediate
Pneumatic part of the master switch part of what system?
Intermediate
Oxygen pressure failure devices, part of what system?
Intermediate
What is the principal indication for using an armored endotracheal tube?
. Situations where the tube may get kinked easily
contains an embedded wire that is designed to prevent kinking when the tube is bent.
The anode (or armored) tube
What coagulation factors are present in fresh frozen plasma?
ALL
From the options below, which is the most common indication for the administration of cryoprecipitate?
Von willebrand disease.
Cryoprecipitate is most commonly administered in the treatment of patients with
von Willebrand disease or patients with low fibrinogen levels (less than 80 mg/dL).
Hemolytic transfusion reaction S?S
Hemoglobinuria
Fever
Microvascular bleeding
Changes in Banked Blood –> comment of 2,3 DPG, ATP and oxidative
- Depletion of 2,3-diphosphoglycerate (DPG)
- Depletion of ATP (adenosine triphosphate)
- Oxidative damage
Changes in Banked Blood : metabolic disturbances?
Acidosis, Hyperkalemia (as high as 17.2 mEq/L)
Changes in bankd blood, Accumulation of what
proinflammatory metabolic and breakdown products such as lysophospholipids
Changes in bankd blood, Morphology. of RBC
Altered morphology of red blood cells (change in shape, decreased flexibility,membrane loss)
Hemolysis
Factors absent in banked blood
• Absence of factors V and VIII
LY30 > 3% what should you administer?
Tranexamic acid
ACT > 128 OR R value >1.1 Blood transfusion products should be
Plasma and RBCs
Fibrinogen < 150 give
Cryo / Fibrinogen
Reversal of WARFARIN, FFP should only be used for the reversal of warfarin anticoagulation when? and only if what is not available?
in the presence of major bleeding if prothrombin complex concentrate is not available.
In the absence of bleeding, over-anticoagulation with warfarin should be managed by
withholding warfarin therapy and initiating oral/intravenous Vitamin K.
A common assumption is one unit of PRBCs increases Hgb _____ and HCT _____
1 g/dL and Hct 2% to 3%
Factor VIII (antihemophilic factor) inheritance pattern?
X-linked recessive
FFP is usually administered in doses of ______for reversal of warfarin, and ____for all other purposes, a
5 to 8 mL/kg; 10 to 20 mL/kg
FFPs increases coagulation levels by
20% to 30%
One unit of FFP typically contains.
200 to 250 mL
PRBCs are the component of choice for improving.
oxygen-carrying capacity
Depending on the blood bank, a typical unit of PRBC is good for how many days? PRBC volume _____and Hct _____
good for 35 to 42 days, and contains 200 mL of RBCs and a Hct of 65%.
PRBC infusions are generally administered in a ratio of
1 mL for each 2 mL of blood loss (along with crystalloids or colloids for
volume).
Cryoprecipitate is stored for _____at __C and for room temperature ____
1 year at −18°C; 4–6 hours at room
temperature once thawe
Platelets are stored at what temperature?
room temperature
Storage of platelets : you should know that
Have a relatively short shelf life of 5 days, and are prone to bacterial growth.
Platelets Typical dosing for an adult is a pool of
six whole blood derived (sometimes referred to as
Clinical Benefits of Leukoreduction
Reduced risk of HLA alloimmunization and platelet refraction
Reduced risk of CMV transmission
Leukoreduction
Risk of HIV with blood transfusion
Human immunodeficiency virus (HIV) 1 : 1,500,000–1 : 2,000,000
Risk of Hepatitis B virus (HBV) with blood transfusion
1 : 200,000–1 : 360,000
Hepatitis C virus (HCV) with blood tranfusion
1 : 1,000,000–1 : 2,000,000
Two theories have been proposed to describe TRALI syndrome. First one is –> The second theory explains TRALI syndrome as a t
- antibodies in donor plasma activate recipient neutrophils, leading to pulmonary capillary leakage.
- Two-event model in which a physiologic stressor such as sepsis, leads to sequestration of neutrophils in the lungs. The transfusion of biologically active mediators (the second event) leads to activation of the neutrophils and capillary leakage.
Graft vs Host Disease is manifested as
Rash, leukopenia, and thrombocytopenia
GVHD is when
donor lymphocytes incorporate themselves into
the recipient tissues causing an immune system attack on the embedded lymphocytes and surrounding tissue.
Nonhemolytic transfusion reactions occur in about___% of all transfusion
1-5% of all transfusions.
Nonhemolytic transfusion reactions symptoms
The patient typically exhibits symptoms such as fever, urticaria, and chills.
What is the most common causative factor in the mortality of patients undergoing surgery for vaso-occlusive disease?
Atherosclerotic disease
What is the most common cause of perioperative mortality following an abdominal aortic aneurysm repair?
MI
Myocardial infarction is responsible for 40-70% of the deaths surrounding
abdominal aortic aneurysm repair.
In general, regional anesthesia is not contraindicated in obstetric patients with mild preeclampsia if the platelet count is at least
A platelet count less than 75,000-80,000 is considered too low to perform a neuraxial anesthetic.
What is the advantage of combining opioids with local anesthetics in combined spinal/epidural analgesia?
. it improves anesthesia without significant motor block
You are administering chloroprocaine via an epidural. What would give the suspicion that the epidural was placed intravascularly?
the patient would begin to experience CNS symptoms such as tinnitus, dizziness, and circumoral numbness.
What is the caution regarding the use of intranasal ketamine?
it can result in neurotoxicity
The IM induction dose of ketamine of
5-10 mg/kg.
The intravenous induction dose of ketamine is
1-3 mg/kg.
The pediatric dose of intranasal midazolam is
0.2-0.3 mg/kg
Administration of a large dose of which of the following drugs would be most likely to produce seizures in a pediatric patient?
Flumazenil
Using normal concentrations and dosages, which ROUTE type of local anesthetic administration would be most likely to affect uterine blood flow?
Paracervical
Local anesthetics exert a vasoconstrictor property that can.
reduce uterine blood flow
LAs can exert a vasocontrictor property on uterine blood flow.The normal concentrations used do not normally have this effect with two exceptions
: 1) inadvertent intravenous injection of a local anesthetic, and 2) paracervical block.
The elimination of hydrophilic agents is prolonged in the elderly primarily due to a
decrease glomerular filtration rate and decreased renal blood flow.
Strasbismus surgery patient are at increased risk for
N/V
During opthalmic surgery, the surgeon requests that you administer mannitol. What is the rationale for this?
. To decrease intraocular pressure
Which of the following are acceptable interventions for lowering intracranial pressure in the treatment of cerebral edema? (select four)
mannitol
hyperventilation
Which of the following are acceptable interventions for lowering intracranial pressure in the treatment of cerebral edema? (select four)
mannitol
hyperventilation
fluid restriction
Corticosteroids
When the balloon of a PA catheter is not inflated, what pressures are reflected during diastole?
Pulmonary artery diastolic pressure
PAC –> Right ventricular systolic pressure is transduced during and PA diastolic pressure is transduced during
systole,; diastole.
The PA diastolic pressure is also a representation of
left atrial (LA) pressure.
If the NIBP cuff is not level with the heart, then a correction must be made to compensate for the difference between arm and systemic pressure. For every.
10 cm the cuff is above the level of the heart, you must add 7.5 mm Hg to estimate the systemic pressure accurately
Likewise, for every 10 cm the NIBP cuff is below the level of the heart, you must
subtract 7.5 mm Hg to correctly estimate the systemic pressure.
You are using a non-invasive blood pressure cuff that cannot automatically compensate for position changes in the arm. If the machine displays a pressure of 80 mm Hg and the arm is 20 cm below the level of the heart, what would you estimate the pressure to actually be?
65 mm Hg
THORACOSCOPY The patient is typically placed in the
supine position.
During thoracoscopy, The video thoracoscope is inserted into a
small incision so that the pleural cavity can be assessed.
Thoracoscopy : what must be used and why?
A double-lumen tube must be used so that the ipsilateral lung is collapsed and proper visualization of the pleural cavity is achieved
What are potential complications of Thoracoscopy?
Hemorrhage, air embolism, air leak from lung, and damage to intrathoracic structures are potential complications.
Which of the following chemotherapy agents would be most likely to produce hypercalemia?
Tamoxifen
antiestrogen chemotherapy agent used to treat breast cancer.
Tamoxifen
Potential side effects of TAMOXIFEN include
venous thrombosis and hypercalcemia.
Splenectomy is the primary treatment for
hereditary spherocytosis
What is hereditary spherocytosis?
the most common RBC membrane defect in which the cells are abnormally shaped and are destroyed by the spleen, resulting in anemia.
You are preparing to perform a femoral nerve block. You know that in most patients the femoral nerve can be located at the inguinal crease
. about 0.5 cm lateral to the femoral artery
What muscles receive innervation from the femoral nerve? (select two)
Quadriceps
sartorius
The posterior branches of the femoral nerve provide. .
motor input to the quadriceps
The anterior division of the femoral nerve innvervates the
sartorius muscle
The psoas major is innervated by
anterior rami of L1-L3.
The gluteus maximus is innervated by the
inferior gluteal nerve.
The circle system test evaluates the integrity of the circle breathing system from the
common gas outlet to the y-piece
The circle system test evaluates the circle breathing system from the common gas outlet to the y-piece and consists of two parts,
the leak test and the flow test.
The leak test is performed by
closing the pop-off valve, occluding the y-piece, and evaluating for a drop in pressure after pressurizing the circuit to 30 cm H2O using the flush valve.
The flow test checks the integrity of the
unidirectional valves by removing the y-piece and breathing through each individual hose to observe the movement of each valve.
Antiepileptic drugs such as phenytoin, carbamazepine, and lamotrigine exert a significant part of their anti-seizure effects by
blocking sodium channels
Which of the following is representative of normal anion gap acidosis?
Hyperchloremic metabolic acidosis
Another term for normal anion gap acidosis.
Hyperchloremic metabolic acidosis
Addison’s disease is characterized by the inadequate release of (select three)
GLUCOCORTICOIDS
MINERALCORTICOIDS
androgen hormones
Primary adrenal insufficiency AKA_____ results in the inadequate release of glucocorticoid, mineralocorticoid, and androgen hormones.
Addison’s disease
Secondary adrenal insufficiency results in the inadequate release of
glucocorticoid only.
Primary vs secondary adrenal insufficiency?
Primary adrenal insufficiency results in the inadequate release of glucocorticoid, mineralocorticoid, and androgen hormones. Secondary adrenal insufficiency results in the inadequate release of glucocorticoid only.
The hallmark symptoms of autonomic hyperreflexia are
hypertension and bradycardia. DILATION ABOVE LEVEL OF INJURY CONSTRICTION BELOW> NASAL STUFINESS COMMON
What congenital heart disorders create mechanical obstruction to the trachea? (select three)
Absent pulmonic valve
Double aortic arch
Partial anomalous pulmonary venous return
What is an appropriate minimum urinary output for a 70 kg patient who has suffered a high-voltage electrical burn?
70 mL/hour
In patients with high-voltage electrical burns, the minimum urinary output to maintain is
1-1.5 mL/kg/hour. In this patient, the minimum would be between 70 and 105 mL/hour.
In ordinary burns in adults, the minimum urinary output is
0.5 mL/kg/hour.
In pediatric patients less than 30 Kg, the minimum is
1 mL/kg/hou
Abrupt discontinuation of clonidine during the perioperative period can result in (select two)
HTN and Tachycardia
EKG signs of unstable angina?
Transient T wave changes
Transient ST segment changes
Unstable angina chest pain characteristics
Anginal chest pain that
- began less than 2 months ago
- progressively increased in severity, duration, or frequency,
- responsive to pharmacologic therapy
- occurs at rest, lasts longer than half an hour, or exhibits - transient T-wave or ST segment changes.
Pt with spinal shock will exhibit (warm vs. cold) extremities, pink extremities, what kind of shock
Because spinal shock disrupts the compensatory vasoconstrictive response, patients with spinal shock will exhibit warm, pink extremities whereas patients with hemorrhagic or cardiogenic will exhibit cool, clammy extremities.
It is generally accepted, however, that patients above a BMI of 50 should undergo
Awake intubation or intubation with propofol alone and no muscle relaxation.
Which of the following parameters are decreased in patients with extreme obesity? (select four)
Chest wall compliance
Total lung capacity
Expiratory reserve volume
FRC
The plasma half-life of a drug is inversely proportional to its
. rate of clearance
Compared to nalbuphine, butorphanol exhibits (select two)
greater analgesic qualities
greater sedative effects
are the three major factors contributing to the negative chronotropic and inotropic effects of local anesthetics.
Hypoxia, hypercarbia, and acidosis
Colloids should be administered in a____ratio
1:1 ratio for blood loss (for every 1 mL of blood loss, administer 1 mL of colloid).
What are the major contributing factors to the development of peripheral vascular disease?
DM and SMOKING
Which of the following are recommended infusion rates for continuous epidural analgesia for a laboring parturient? (select two)
Bupivacaine 0.0625% at 10 mL/hour
Ropivacaine 0.2% at 10 mL/hour
