RANDOM/ PRODIGY TRIVIA/VALLEY BOOK 2 Flashcards
Where is the DORSAL RESPIRATORY GROUP located
Medulla
Ventral Respiratory Group can influence both
Inspiratory and expiratory
Pneumotaxic located in (thinkPP)
PONS
Pneumotaxic center now called
PRG (Pontine Respiratory GROUP)
Peripheral chemoreceptors are found MOSTLY in the
Carotid bodies but also in aortic bodies
Peripheral chemoreceptors responds to
Decreased PaO2 < 60 mmHg
Increased H+ (low pH)
increased PaCO2
Peripheral chemoreceptors ARE MOST RESPONSIVE TO
Decrease in arterial blood O2, when PaO2, falls below 60mmHg
The glossopharyngeal nerve carries afferent information from the
CAROTID BODIES
VAGUS nerve carries afferent information from the
AORITC BODIES and LUNG STRETCH receptors
Central chemoreceptors response to
Hydrogen ions
WHat normally drives Co2
VENTILATON
The pleural membranes couple the
Lungs to the chest wall
What is intrapleural pressure
The pressure in the space between the inside of the chest wall and the lungs
Intrapleural pressure is always
NEGATIVE (subatmospheric) during normal Tidal breathing.
Intrapleural pressure becomes more negative during ______and more less negative during
during inspiration; Expiration
Intrapulmonary pressure is ______during inspiration and______during expiration .
negative, positive
When does INTRAPLEURAL PRESSURE BECOMES POSITIVE
Forced expiration OR during exp effort against a closed glottis, such as the Valsava maneuver.
1 atm = ____mmhg = _____cm H2O
760; 1033 cm H2O
MV is normally____
4Lmin
CO is normally
5L min
The average V/Q for the lungs is
0.8
In the upright position, the dependent lung is at the
Base
In the upright position, the nondependent lung is at the
APEX
When the patient in the lateral decubitus position is anesthesized and paralyzed what occurs
a V/Q mismatch develops, ventilation is the non-dependent lung increases (because the dependent lung is difficult to insufflate) but the distribution of blood flow does not changes, compared to the awake, spontaneously breathing patient.
Always decreases whenever there is a V/Q mismatch
PaO2
The decrease in PaO2 seen with V/Q mismatch may be accompanied with
Hypocapnia,
Normocapnia
Hypercapnia
A-A gradient change with age
PAO2 - PaO2 = 0.21 x (age + 2.5)
Estimating PaO2
Multiple percent O2 in the inspirate gas mixture by 5 ( EX: 0.6 FiO2 is 60 x 5 = 300mmhg
Estimating PAO2
Multiple percent O2 in the inspirate gas mixture by 5
When V/Q is 0 there is
ABSOLUTE right to Left shunt
Normal PAO2 - PaO2 when breathing room air
5-15 mmHg
Normal PAO2 - PaO2 when 100 % O2
100 mmHg
Do you CPAP the dependent or nondependent lung
the NONDEPENDENT
Do you PEEP the dependent or nondependent lung
DEPENDENT
Most effective intervention for the NONdependent lung
CPAP
West zone describe _______in the lung
PERFUSION
West zone are not
Anatomically fixed zones, they are variable, functional zones, dependent upon body position
Compared with zone 1, zone 3 is
Better ventilated, better perfused has a lower V/Q ratio
Zone 1 vs Zone 3 negative intrapleural pressure
less negative intrapleural pressure
Zone 1 vs Zone 3 size alveoli
Zone 3 smaller alveoli
The zone 4 lung requires
4th pressure, P interstitial fluid
Zone1, 2, 3 , 4
Zone 1: PA>Pa.Pv
Zone 2: Pa> PA>Pv
Zone 3: Pa> Pv> PA
Zone 4: Pa>Pisf>Pv> PA
Zone 4 mnemonic
aiVA
The patient is preoxygenated to
Fill the FRC with O2,
What is oxygen consumption
250 ml O2/min
Found in the FRC
2500 ml so divided by 250 per min, you have 10 minutes
In response to alveolar hypoxia, The alveolar arterioles constrict
thereby decreasing shunt blood flow
When does VA inhibit HPV
> 1 MAC
Cannot be measured by spirometry
FRC, RV and TLC
Ratio that is useful in distinguishing between restrictive and obstructive disease
FEV1/FRC
What is the best lung volume test for assessing for small airway disease>
FEF 25-75 (MMEF) MidMaximal expiratory flow
Normal FEV1/FVC
4 L / 5 L =0.8 FEV1/FVC ratio
Obstructive FEV1/FVC Examples
FEV1 = 1.3 L/ FVC 3.1
FEV1/FRC ratio is 0.42 (42%)
Obstructive disease is present when
Both FEV1 and FVC are low
What is the Normal FEV1/FVC ratio
> 0.7
Restrictive disease is present when
both FEV1 and FVC are LOW but the RATION is equal or greater than 0.7
For restrictive and obstructive disease always calculate
the FEV1/FRC ratio
Criteria to cancel case FEV1 and FEV1/FRC ratio
If FEV1 < 2L and FEV1/FRC ratio < 50% more sophisticated lung fuction tests are needed.
Restricted loop are associated with
smaller volume
Intrapleural pressure increases with
FORCED VITAL EXPIRATION or VALSAVA maneuvers.
During forced expiration , intrapleural pressure becomes
Positive
AS liquid flow through a tube, the pressure Increases or decreases
DECREASES (falls)
In the airway pressure
decreases, as gas flow along the bronchioles. THIS IS THE PHYSICAL BASES or airway closure.
US 65-45
Upright closing capacity = FRC upright at 65
Sitting ———————–= ——— sitting at 45
Lung compliance with aging
INCREASES
FRC with aginst
Increases
Except for the cricothyroid muscle, the instrinsic muscles of the larynx are innervated by WHAT MOTOR NERVE/
RLN
Oxyhemoglobin curve becomes steep when PaO2 falls below
60 mmhg
The patient is given meperidine for premedication , what happens to the oxyhemoglobin dissociation curve and the Co2 Blood dissociation curve?
Oxyhgb curve to the right
CO2 shifts left
What is the PaO2 when the SaO2 is 90%?
Think 40-90 rule
40mmHg - 70% SPO2
50mmHg - 80% SPO2
60mmHg - 90% SPO2
What % of Co2 is carried in the blood as bicarbonate?
90%
What enzyme (s) is (are) responsible for producing Bicarbonate in the rbc?
Carbonic Anhydrase
If PaCo2 is 30 mmhg how much Co2 is dissolved in blood . Give answer to 2 decimal places
30 x 0.067 = 2.01 mL
Peripheral chemoreceptors are most sensitive to
Decreased PaO2 (< 60 mmHg )
What nerve carries sensory information from the carotid and what nerve carries sensory information from the aortic bodies?
Carotid - Glossopharyngeal
Aortic - VAVUS
What nerve carries sensory information from the carotid and what nerve carries sensory information from the aortic bodies?
Carotid - Glossopharyngeal
Aortic - VAVUS
CGAV
Where are ventilation and perfusion greatest in the normal healthy lung in the awake individuals?
Ventilation greatest in the Dependent lung
Perfusion greatest in the DEPENDENT lung
Compare PACO2 in the base with PACO2 in the apex when the patient is in the prone position?
PACO2 is the same in the base of the supplies
Compared with non-dependent lung each of the following is greater in dependent lung, except:
ALVEOLAR DIAMETER
Compared with non-dependent lung each of the following is greater in dependent lung
Ventilation
Perfusion
PACO2
A patient breathing room air has a PaO2 of 45 mmHg , a PAO2 of 80 mmhg and a PaCO2 of 75 mmHg what is the problem?
There is a Ventilation;perfusion abnormality.
What is the problem if the patient has a segment of the lung with a ventilation:perfusion ratio of zero?
Patient has a RIGHT to LEFT SHUNT
The patient’s spirometric recordings reveal an FEV1 of 2L and an FVC of 4 L that values indicates
Obstructive disease (ratio is 50%)
For obstruction loop : top is _________ and bottom is _______
Expiratory bottom is Inspiratory (it’s flipped compared to volume capacity graph)
To remember if the APEX triangle points more toward EXPIRTORY it
Extrathoracic obstruction
What happens to pulmonary (lung) compliance and chest wall compliance as you age?
Pulmonary compliance increase
Chest wall compliance decrease
Vd is
Theoretical volume, Drug in body / concentration in plasma
Clearance (Cl) is
Theoretical volume of plasma completed cleared of drug in a given period of time.
Elimination half life vs elimination half time
half life –> time it takes for the total amount of drug, in the body to decrease by one half.
elimination half time –> plasma concentration of a drug to fall by one-half.
What the BODY does to the drug
PharmacoKINETICS
Time is
CONCENTRATION
Life is
AMOUNT
TCLA
Time–>concentration
Life –> Amount
Constant amount of drug eliminated per unit of time
Zero Order kinetics
Drugs that undergo zero order kinteics
Phenytoin, Alcohol, ASA
When the plasma concentration of any drugs exceeds the capacity of metabolizing enzymes
Zero Order kinteics.
First order kinetics (think FF)
CONSTANT FRACTION
Alpha phase is
Distribution
bEta phase is
ELIMINATION (B-e)
T 1/2 B (half time Beta) =
0.693 Vd/ Cl
How many half lives are required to eliminates at LEAST 98% of a drug?
6
Type I phase reaction
Oxidation
Reduction
Hydrolysis
Methylation
What is the important pathway of metabolism for PROCAINAMIDE , hydralazine and isoniazid
ACETYLATION
Acid better absorbed in
Acidic
Basic better absorbed in
Basic
For acid , if pH < pka =
if pH > pKa =
Nonionized
IONIZED
For basic, if pH< Pka=
if pH>pKa
Ionized
Nonionized
ANother way to say that a substance has accepted a hYDROGEN H+ ion is to say that the susbtance in
PROTONATED>
What combination will most facilitate trapping of LA by the fetus?
Maternal alkalosis AND fetal acidosis
What combination will most PREVENT PASSAGE of LA to the UTERUS
Fetal ACIDOSIS
Weak acids and weak bases are provided in solution as
SALTS
Weak acids name has the
Cation first (calcium…, mag this, sodium this)
Weak bases name has the
anion last (drug chloride, drug sulfate)
Propofol is a (weak acid or weak base)
WEAK ACID
Propofol in physiologic ph
99.98 % nonionized.
All LAs are
Weak bases
Base + acid
MORE IONIZED
In general the lower the pKa of the local anesthetic, the_____the proportion of LA in ______form
GREATER the proportion of LA in NONIONIZED form at physiologic pH of 7.4 and FASTER ONSET OF BLOC
Potency of LA is based on
LIPID solubility (SLP)
> 90 % protein binding La
Ropivacaine 94%
Bupivacaine 95%
The duration of ACTION is longer for LA that exhibit ______protein and _______lipid solubility
GREATEST PROTEIN BINDING and HIGHEST LIPID SOLUBILITY
More important than lipid solubility when it comes to duration of action
PROTEIN BINDING
LA absorption : generally
the greater the tissue blood flow, the greater the rate of absorption
Mnemonic to remember absorptbion
IvTicPEBSubAC
IV –>Tracheal –>Intercostal—> Paracervical –> Epidural –> Brachial plexus –> Subarachonid,sciatic fem –>Subcutaneous.
Sympathetic block compared to sensory block
2-6 dermatomes HIGHER than sensory block
MOTOR block compared to sensory block
2 dermatomes lower than sensory bloc
For myelinated axons, _____nodes of Ranvier must be blocked to stop nerve conduction
2-3 nodes
The greater the frequency of action potentials, the
Faster the nerve is blocked, by local anesthetic
The LA must attach to the sodium channel when it is in the
INACTIVATED STATE
Both required to a conduciton block
Both nonionized, and ionized forms of LA
the nonionized cross the lipid bilary the ionized form attaches to the inside of sodium channel and LOCKS it shut in the INACTIVATED STATE
Key target of LA is the
Voltage-gated sodium channels.
LA degree of blockade depends on both
Concentration and volume.
Max dose of bupivacaine w/ EPI
2.5 mg/kg
Max dose of bupivacaine w/O EPI
2mg/kg
Max single dose of Bupivacaine
175 mg
Max single dose LIDOCAINE
300 mg
Max single dose of ROPIVACAINE
200
Max dose of Lidocaine w/o epinephrine is
4.5 mg/kg
Max dose of Lidocaine w/ epinephrine is
7mg/kg
Ropivacaine dose per kg
3 mg/kg
Lidocaine plasma concentration 1-5 mcg/ml
Analgesia therapeutic
What is the therapeutic lidocaine plasma concentration?
1-5 mcg/ml
Lidocaine plasma concentration 5-10 mcg/ml
Light headedness Tinnitus Visual disturbances' Tongue numbness Muscle twitching
The recommended maximum leakage current allowed in operating room equipment is:
10 μA
Lidocaine plasma concentration 10-15 mcg/ml
Seizures
Convulsions
Lidocaine plasma concentration 15-25 mcg/ml
Unconsciousness
Coma
Respiratory arrest
Lidocaine plasma concentration >25 mcg/ml
Cardiovascular depression
Drug will be eliminated slowly it is back
Clearance is small and Vd is large
Potency is directly related to
Lipid solubility
MAC to potency
INVERSELY related to potency
Oil gas partition coefficeints
NDSIEH (nitrous, des, sevo, iso, enflu, halothane)
1.4, 18, 55, 98,98, 224
Greatest sensitization to catecholamines occur with
Halothane.
Oil gas partition coefficients is a measure of
LIPID SOLUBILITY
Decrease CO induction is
FAST
Increase CO induction is
SLOW
Sevoflurane decrease arterial BP and SVR vs des/iso
Greater decrease with des and iso than sevo
Solubility of a gas and temperature
Inverse relationship
as temperature increases, solubility decreases
More inhlational agent will dissolve in blood if the patient is
HYPOTHERMIC
More inhlational agent will dissolve in blood if the patient is HYPOTHERMIC , what explains this phenomenon
Le Chatelier’s principle.
Blood/ Gas coefficient HIGH to low
HIS ND Halothane 2.54 Isoflurane 1.46 Sevoflurane 0.69 Nitrous oxide 0.46 Desflurane 0.42
Alveoli are
WINDOWS TO THE BRAIN
Speed of uptake of anesthetic and elimination from the brain is________ related to blood solubility
INVERSELY RELATED
Mirror the brain partial pressure at steady state.
Alveolar partial pressure of the anesthetic
The CNS effects after bolus injection of an IV anesthetic are terminated primarily by
REDISTRIBUTION
Diazepam and protein binding
98%
2 that ketamine causes
nystagmus
Hypertonous
IV anesthetic with bronchodilation properties
Ketamine
Meperidine to morphine potency
1/10th
Meperidine metabolite
Normeperidine
Phenylpiperidine derivative
Fentanyl, meperidine
Fentanyl to morphine potency
Fentanyl 75-125x more potent
Fentanyl what organ serve as inactive storage site?
LUNGS with 75% of the INITIAL DOSE UNDERGOING FIRST PASS PULMONARY UPTAKE.
Meperidine crosses placenta
YES ALL OPIOIDS DO
Thienyl analogue of fentanyl
Sufentanil
Sufentanil potency
5-10x more than fentanyl
Alfentanil potency
1/5 to 1/10 less potent than fentanyl
VP pressure measure at
20C
VP pressure of gases: HIGH to low (DHIES)
Desflurane Halothane Isoflurane Enflurane Sevoflurane
VP pressure of gases: Des (mmHg)
669
VP pressure of gases: Halothane
244
VP pressure of gases: Isoflurane
240
VP pressure of gases: Enflurane
172
VP pressure of gases: Sevo
157 -170
Vapor pressure and output MNEMONIC (HLH)
Higher vapor pressure agent PLACED in a vaporizer with LOWER vapor pressure agent , the concentration of agent delivered to the patient will be HIGHER than the dial setting
Vapor pressure and output MNEMONIC (LHL)
Lower vapor pressure agent placed in a vaporizer with HIGHER vapor pressure agent, the concentration of agent delivered to the patient will be LOWER than the dial setting.
The partial pressure of saturated water vapor at 37C is
47 mmHg
Law of LAPLACE
T = (P x r) /2
Law that. applied to blood vessels
Law of Laplace
LAW of laplace explains why smaller alveoli empty into
LARGE ALVEOLI causing atelectasis in patients with ARDS
POISEUILLE”S law
Q = Pi r^4 Change in P/ 8 n L
Diffusion hypoxia explains by which law
GRAHAM’s
Boyles is the
VP (Volume/Pressure relationship)
Charles goes into
Vtach (Volume to Temperature)
Gay Lussac’s law is the
PT (pressure to Temp)
Is uterine blood flow autoregulated
NO
TI =
TD50/ED 50
What is the number that shows how much a gas will dissolve in a liquid at a certain temperature?
OSTWALD.
A principle for calculating CO from oxygen uptake or CO elimination and Oxygen or CO2 concentration in arterial and venous blood
Fick principle
Describe behavior of non-ideal gases
Van der waal
Gas pressure is inversely proportion to gas volume at constant Temperature?
Boyle’s
Total pressure of a mixture of gases is equal to the sum of all partial pressure
DALTON”s
6.02 x 10 ^23
AVOGADRO
Gas pressure increase if temperature increases and volume does not change.
Gay-lussac
One mole of ideal gas occupies 22. 4 L at 0C and 1 atm
Avogadro
Law”: Volume increases when temperature increases , if pressure is constant
Charles
Twice as much O2 will dissolve in arterial blood if alveolar pressure of O2 is doubled
HENRY’s LAW
if alveolar pressure of O2 is doubled, how much O2 will dissove
twice as much
Number revealing laminar vs turbulent flow
Reynolds
Concentration effect which law
FICK’s law of diffusion
Explained how pressure, tube radius, length and fluid viscosity contribute to laminar flow
Hagen-Poiseuille law
Tension in the wall of blood vessel is_______ to the radius
PROPORTIONAL
Tension in the wall of blood vessel is proportional to the radius which law
Laplace
The lateral pressure of fluid flowing through a CONSTRICTED SEGMENT of tubing is decrease
Bernoulli principe
What law explains normal tidal breathing?
Boyles’
Muscle relaxants are what kind of compounds
Quarternary ammonium
Desflurane, enflurane isoflurane and sevoflurane are
halogenated ETHERS
SVR = MAP - CVP/CO x80 which law permits this calculation
OHM’s LAW
Salt form or a weak acid naming examples
Sodium “drug” example
If ph of stomach is 2.0 which orally admininstered drug will be most NONIONIZED
A weak acid with pKa 6.2
A local anesthetics is a
WEAK BASE with a PKA greater than 7.4
4-8 mesh soda lime prevents
Channeling while providing an adequate surface area for CO2 absorption.
What is the partial pressure of a gas if its concentration is 5%?
38 mmHg (760 mmHg x 5/ 100)
If a gas exerts a partial pressure of 15 mmHg its concentration is ____%
2.0 % (1.97 % to be exact)
set up proportion
760mmHg/100% = 15 mmHg/ x
In the reaction of CO2 with soda lime the final producs are
CARBONATES
Which pulmonary function test uses boyle’s law?
Plethysmotraphy for determination of FRC
THE GENERATION OF colloid osmotic pressure in the plasma is the principle function of
Albumin
A 3% stock solution of drug is available. You need to make 50 ml of a 0.6 mg/ml solution. How many mL will you take from stock solution to make the dilute solution
1ml
0.6 mg = 1 ml for 50 ml you need 30 mg
3% solution is 30 mg/ml
Sevoflurane is added to a flask sitting on a table, what is the concentration of sevoflurane above the liquid?
22%
The lipid bilayer of the cell membrane is most IMPERMEABLE to what
Charged ion such as Potassium ions
Between gases not including Nitrous which one has the lowest Blood gas coefficient
Desflurane
What is the relative humidity of alveolar gas?
100%
When the tank pressure gauge on a tank of N2O begins to fall, the tank
NO LONGER CONTAINS N2O liquid form
The rotator flowmeter is an example of
Variable orifice flowmeter
An agent with a Blood gas partition of 12 an an oil gas partition coefficient of 0.5 builds up ______and ____potency
Slowly; and lacks potency
Substance that most readily cross the placenta or blood/brain barrier?
highly lipid soluble, NONIONIZED
Lowest oil:gas partition coefficient
Desflurane
Immediately after onset of 50% N2O administration, the volume of the stomach may
Increase
If flow is laminar and the radius of a tube is tripled , the flow through the tube will increase
81 fold HOw: Lets assume to radius you started with was 2 so r^4 of 2 is 16 Now: radius tripled (2 x3 =6 ) so r^4 of 6 is 1296
When you divide 1296 / 16 = 81
What can be measured with a wright respirometer?
Tidal Volume
1: 500,000 concentration is _____mcg/ml
2 mcg/ml. (remember all ratio divide 1,000,000 by the :xxxxxxx )
What property of helium makes it a useful agent?
LOW DENSITY (makes flow more laminar)
When halothane is added to a flask containing 100% O2, the new concentration of O2 will be
68%
How: use VP of desflurane which is 244 mmHg /760 mmHg x 100 % = 32%
100%-32% = 68% for O2
The cylinder of N2O cools after it is turned on , what explains this cooling?
Joule-Thompson effect
Tension in the blood vessel wall will be lowest in the
Capillary
During diastole, the tension in the LV wall increases, what explains this
Law of laplace
When you put an ETT in an autoclave, the cuff expans, this is an application of
Charles LAW
When the length of an IV needle is doubled, what happens to flow from the IV bag, and what law applies?
Flow is halved, Hagen-poiseuilles’ law applies
How much Co2 is dissolved in arterial blood when PaCo2 is 70 mmHg
4.69 mL CO2/ 100 mL blood
When is the partial pressure of CO2 increases, more hydrogen ions and bicarbonate ions are produced: Which law or principle applies?
Le Chatelier’s principle
The reaction of CO2 with soda lime is a
NEUTRALIZATION
What is the concentration of a solution in % if 250mg is added to 50ml of water?
250/50 = 5 mg/ml
the way i do it
I know 2% lidocaine is 20 mg /ml
2 % = 20 mg/ml
x = 5 mg/ml
(5 x2) / 20 = 0.5%
Soda lime greatest concentration is
Calcium Hydroxide Ca(OH)2
Which law explains atelectasis with patient with ARDS
LAPLACE
If MAP is 100mmHg , CVP is 10mmHg, CO is 4.5L/min , the resistance to flow through the Systemic circulation in dynes-cm^-5 is
1600
Formula is : MAP-CVP/CO x 80
When flow is turbulent, the resistance to flow is dependent on what property of the fluid?
DENSITY
What important changes occurs when laminar flow changes to turbulent flow?
Resistance increases
Carbonic anhydrase inhibitors decrease the ability of the kidneys to reabsorb bicarbonate, resulting a
hyperchloremic acidosis.
Carbonic anhydrase inhibitors would be avoided in patients with
acidosis, especially a normal-anionic-gap acidosis
As a result, because bicarbonate is filtered by the ciliary process in the formation of aqueous humor,
carbonic anhydrase inhibitors reduce the formation of aqueous humor and can be used to decrease intraocular pressure
Bicarbonate is filtered by the
ciliary process in the formation of aqueous humor,
A bourdon gauge reads 100 psi, what is the pressure inside the cylinder ? 1 atm= 14.5 psi
114.5 psi. (it is the pressure GAUGE reading + 14.5)
If your tire gauge reads 34 psi (pounds per square inch), then the absolute pressure is
34 psi plus 14.7 psi = 48.7
2 bubbles, one with a radius of 2mm called P(s) and the other one with a radius of 4mm P (L) how does the pressure inside the large bubble compared to the pressure inside the small bubble (Ps)
The pressure of the large bubble is half the pressure of the small bubble
VP from Low to HIGH (SEI-HD)
170-172-240-244-669
Sevoflurane, 170 mmHg Enflurane, 172 mmHg Isoflurane, 240 mmHg Halothane, 244 mmHg Desflurane, 669 mmHg
What happens to alveoli that do not have surfactant?
Smaller alveoli collapse into larger ones.
Parameters used to calculate reynold’s number ?
Velocity of the fluid
Viscosity
Diameter of the tube
With laminar flow the gas flow rate is
directly proportional to the pressure gradient along the tube
Nebulizers use
venturi tubes
As an E-cylinder of oxygen empties, ice crystals form near the outlet, this is explained by what?
Joule-Thompson
What explains why opening a cylinder slower , allow the expanding gas to draw energy from the environment to maintain an equal distribution of energy, we observe no changes in temperature of the gas
2nd law of Thermodynamics (Entropy)
Rapid expansion of a gas causes the temperature to ________as explains by the ______Effect
decrease ; Joule-Thompson Effect
Reynolds number formula is
Vpd/n
v: velocity
d: diameter
p density
When sevoflurane is accidentally placed in a halothane vaporizer and the dial is set a 1% , the % delivered will be
less than 2%
What volume will be occupied by 16 g (half a mole) of O2 at standard temperature and pressure (Assume o2 is an ideal gas?
11.2 ( Full mole at STP is 22.4)
When Nitrous is turned on, gas bubbles in the body expand, what law applies?
Fick’s Law of diffusion
What is the partial pressure of isoflurane when the concentration delivered to the patient is 1.5%?
760 mmHg x 1.5% = 11.4 mmHg
The desflurane vaporizer is electrically heated to _______which creates a vapor pressure of ________inside the vaporizer, regardless of ambient pressure
39 degrees centigrade, 2 atmospheres
For desflurane, The number on the dial reflects the percentage that will be delivered. So at any altitude, when you dial 5%, it will give you _______ But when that 5% desflurane leaves the vaporizer at high altitude, what happens?
It will give you 5%; is delivered to the patient is 5% of a decreased ambient pressure, so the partial pressure of desflurane in the alveoli will be much less that it would be at sea level. Thus, you will need to dial a higher concentration at high elevation to attain the same clinical effect as at sea level with desflurane (Tec-9) vaporizer.
If desflurane is HIGH ALTITUDE, when you dial 5%, the vaporizer will give you______%. The partial pressure delivered will be ______
5% , the
Desflurane at HIGH altitude
dial a HIGHER concentration at HIGHER elevation to attain the same clinical effect ,
For gases, What is physiologically important is the
partial pressure (mm Hg), not the concentration.
What determines whether a patient is anesthetized,
The partial pressure of the anesthetic agent
Does the partial pressure of the anesthetic change with altitude?
Does not change at different altitudes.
At a higher altitude where the barometric pressure is _______of that at sea level. The amount of isoflurane Vapor output ______due to ______barometric pressure.
½ that at sea level, the amount of isoflurane vapor output increases due to the lower barometric pressure. Therefore, the settings that delivered 2% isoflurane now deliver 4% isoflurane. However, according to Dalton’s law, the partial pressure of isoflurane delivered would be approximately the same at both altitudes since 2% isoflurane at 760mm Hg (15.2 mm Hg) is the same as 4% isoflurane at 380mm Hg (15.2 mm Hg).
What conditions will optimize the amount of gas dissolved in a liquid?
INCREASED PARIAL PRESSURE
DECREASED TEMPERATURE
The buildup of an inhalational anesthetic in the brain is fastest for an agent that has
Low blood solubility
The most potent inhalational anesthetics have
HIGH lipid solubility
If the Ostwald blood: gas partition coefficient is 2, then each liter of blood will have as many molecules as one liter of alveolar gas?
TWICE
If the partial pressure of a gas over a liquid doubles, the amount of gas dissolved in the liquid
DOUBLES
Henry’s law
gas law that states that the amount of dissolved gas in a liquid is proportional to its partial pressure above the liquid. The proportionality factor is called Henry’s law constant.
Which gas can be liquified at room temperature?
Nitrous oxide
When a gas cylinder connected to an anesthetic machine is turned on quickly and the pressure in the connecting pipes and gauges rises rapidly, the process is
ADIABATIC and temperature increases substantially
What is Adiabatic changes?
Rapid expansion OR compression of a gas WITHOUT equillibration of energy with the surrounding environment NO increase or decrease in energy. BUT THE TEMPERATURE WILL BE HIGHER
Medical air at atmospheric pressure is composed of _____and _____? what are the partial pressures and how are they calculated ?
Nitrogen and Oxygen
79% x 760 mmHg = 600.4mmHg
21% x 760mm Hg= 159.6 mmHg
Which inhalational anesthetic has a blood:gas partition coefficient of 1.4?
Isoflurane
Recovery from which of the following inhalational agents will be fastest?
Desflurane
What happens to pressure in the middle ear when the N2O is turned off?
It decreases
Substance “X” will diffuse at a faster rate across the alveolar-capillary wall than substance “Y” if substance “ X is more _________
Lipid soluble
The rate of diffusion of a gas accross the alveolar capillary membrane is inversely proportional to the
THICKNESS OF THE MEMBRANE
The factors that determine the amount of gas diffusing across the alveolar capillary membrane are described by
FICK’s LAW
Which of the following substances does not penetrate the BBB?
Mannitol
Graham’s law
Rate of effusion of a gas is INVERSELY PROPORTIONAL To the square root of its molecular weight.
N2 and N2O are diffusing through the air (not across a membrane). N2 will diffuse fast than N2O. Whose law applies>
GRAHAM’s LAW
IV infusion of which of the following substances would be most effective in promoting the osmotic movement of water into the circulation from the extracellular space>
ALbumin
The pressure in a cylinder of O2 decreases at it empties, what law applies?
IDEAL
When a full E-cylinder of Oxygen is brought from the loading dock where the temperature is 40C to the OR where the temperature is set at 21C. the pressure in the cylinder will increase or decrease, whose law applies?
pressure will decrease, GAY lussacs law (P1/T1 = P2/T2)
Helium/oxygen mixture are used medically for
UPPER AIRWAY OBSTRUCTION
What is the water vapor pressure in the alveoli?
47 mmHg
The clinically significant different between N2 and N2O is their
BLOOD SOLUBILITIES
When the partial pressure of O2 in arterial blood increase from 100 to 600mmHg the amount of dissolved O2 increases BY how much.?
100 x 0.003 = 0.3
600 x 0.003 = 1.8
1.8 - 0.3 = 1.5 mL O2/100ml blood
What 2 parameters are used to calculate RESISTANCE to flow through a tube?
UM NOT SURE That’s the right answer (PRESSURE and gradient) per valley
In venturi tube, the lateral pressure upstream from the narrowing is
GREATER than in the narrowed region
High temperature may be generated when empty cylinders are
Transfilled from larger cylinders
High temperature may be generated when empty cylinders are Transfilled from larger cylinders . This is called the
ADIABATIC EFFECT
The Joule-Thompson effect describes the decrease in temperature when a
Gas exiting a compressed cylinder expands freely
Soda lime consists of silica, water
Sodium hydroxide
Potassium hydroxide
Calcium hydroxide
What law permits calculation of resistance to flow through at tube?
Omh’s LAW
If isoflurane is placed in an enflurane vaporizer and the dial is set at 2% what will be the delivered concentration of isoflurane?
Greater than 2%
The Jet ventilator operates on
Le chatelier’s principle
A mechanism used to reduce the pressure of a gas as it rises from a compressed gas cylinder to a usable, nearly constant pressure is a.
REGULATOR
The greater the distance between an Xray source and the anesthetist , the lower the intensity of exposure tot the xrays. The law describing this is the
INVERSE SQUARE LAW
The density of a gas determines
ITS FLOW THROUGH an ORIFICE
In the supine individual, the pressure in the dorsalis pedis is greater than in the aorta. This is explained by
The SUPERIMPOSITION PRINCIPLE
Which of the following principles is utilized in the delivery of a gas through a side arm port?
Bernoulli’s
The partial pressure of Oxygen in air at one atmosphere is
159mmHg
The mass spectometer is reading 5% for ETCO2, what is approximate equivalent in mmHg?
38 mmHg (0.05x760)
Lipid bilayer is made up of
Cholesterol
Phospholipids
Proteins
Symmetrical
Competitive antagonists attach to receptors and
Prevents attachment of agonists
Flow is 5L/min, (2.5L /min O2, and 2.5L/min of N2O) through a copper kettle vaporizer, and a 2% concentration of halothane is achieved. If N2o runs out, the halothane concentration delivered to the patient will be?
4%
If halothane is added to a flask sitting on a lab bench containing 100% O2, what will be the resulting partial pressure of O2 in the gas above the halothane liquid?
760mmhg-243 (halothane) =517
If isoflurane is placed in an enflurane and you set the dial at 2% what will happen the % of anesthetic delivered?
A higher concentration of isoflurane will be delivered than the 2% dialed in (HLH)
Purity of gases
Pharmacopeia + National formulary
O2 has a critical temperature _____room temperature
BELOW
Standards for medical devices and gases set by
FDA
Sets basic performance and SAFETY REQUIREMENTS for components of anesthesia machines, endotracheal tubes, and connections, pressure and vaccum and gas pressure regulators
American National Standards Institutes (ANSI)(
Each cylinder test by interior hydrostatic pressure once every
5 years
ALl cylinders must be marked according to
Interstate commerce commissions regulations.
The cylinder should be open slightly for a moment to
clear the outlet of possible dust. CRACKING the cylinder
Can generate heat and cause combustion with cylinder
ADIABATIC heat of compression.
The cylinder safety device is a simple plus of
SOFT METAL ALLOY called WOOD’s metal,
At what temperature would the wood’s metal melt
200F
Prevents cylinder gas from escaping machine through pipeline supply hoses?
Check valve in DISS
Check valve in pipeline inlet assembly is a
Floating valve and seats according to pressure.
What is the name of the gauge that shows Oxygen tank pressure?
Bourdon
In a dual hanger yoke system, what prevents one cylinder from emptying into the other?
There is a free-floating valve for each cylinder and the Oxygen E cylinder with the greater pressure closes the free-floating valve of the other
The 1st and 2nd stage regulator are what kind of valve
DIAPHRAGM
1st stage regular decrease pressure to
45psig
Cylinder vs pipeline pressure
Cylinder pressure decreased to slighly less than pipeline pressure to prevent depletion of cylinder contents when attached to pipeline.
2nd stage regulator
Reduces pressure from 50psig to 16
Oxygen flush valve flow rate____at what pressure ___
35-75 ml/min; 50 psig
Oxygen failure cut off valve, where do O2 and N2O mix
They don’t mix
Gases are joined for the first time in the
COMMON MANIFOLD
Oxygen failure cutoff valve : oxygen pressure must be maintain at least
25 psig to keep valve open
Fail safe systems analyze O2 pipeline content?
NO they only analyze pressure.
Does the fail-safe protect from cross over pipeline
NO
Read ball float at the
middle
Thorpe tube largest at the
TOP
What happens if inspiratory valve sticks open?
Exp volume will exhaust through the insp limb. ETCO2 waveform will be elevated.
What happens if expiratory valve sticks open?
Insp volume will not enter the ETT but instead will bypass and exhaust through the exp limb.
Desflurane boils at
22.8C.
What happen when the vaporizer is tipped then leveled?
Liquid vapor will get into the VAPORIZER CHAMBER and the carrier flow will carry MORE AGENT to the patient
What happen when the vaporizer is tipped then leveled?
Liquid vapor will get into the VAPORIZER CHAMBER and the carrier flow will carry MORE AGENT to the patient. MORE AGENT picked up means HIGHER CONCENTRATION of agent delivered to the patient. It may be a lethal dose.
Largely eliminated the tipping problem?
Cassette vaporizer and TEC 6
Low pressure is ___psi
16 psi
Yoke check valve is part of _____pressure system
HIGH
Vaporizer check valves part of ____pressure system
Low.
When does scavenging occur?
After exhalation
2 actions in case of a suspected pipeline crossover
turn on back up O2
Disconnect pipeline
Oxygen FLUSH valve is
BALL/SPRING valve
PRIMARY function of ANY free floating valve is to
Prevent gases from leaking out of the system.
Ball and spring valve function
ALL OR NONE
Permits gas flow after you have made a connection.
Open system reservoir, rebreathing
No reservoir, no rebreathing
Examples of open system
Nasal cannula
simple face mask
Open drop ether an ______system
Open
Insufflation is an example of what type of breathing system?
Open
The only system without reservoir is
OPEN
This breathing system requires INCREASES GAS FLOW
SEMI OPEN
Semi Closed and rebreathing , reservoir
Partial rebreathing
Reservoir
Mapleson worst for controlled ventilation
Mapleson A
Mapleson BEST for spontaneous ventilation
Mapleson A
Mapleson E
NO bag and valve
Maplesons mnemonic
A- APL by the patient B- Both APL and FGF by the Patient C- No corrugation D- APL Distant from the patient E- no bagee no valvee F- F***No valve
The most common CIRCUIT SYSTEM used today
BAIN circuit, which is a modified Mapleson D.
In the BAIN circuit, FGF is through a
SMOOTH tube not the corrugated tubing
Mapleson used in both spontaneous and controlled ventilation
BAIN
BAIN: FGF must be
2.5 X patient’s MV
During controlled ventilation: best to least maplson
DFE>BC>A
Best mapleson preventing rebreathing during spontaneous ventilation
A>DFE>CB
LMA and coughing
less coughing on ermergence
Less risk of bronchospasm
LMA and airway reflexes
contraindicated with intact airway reflexes due to the risk of laryngospasm
LMA classic can it be used to facilitate fiberoptic or blind oral intubation
YES : LARGEST tube allowed is 6.0
LMA to establish an _____airway
EMERGENCY
The RODS mnemonic is used to
Identify difficulty extraglottic device situation
RODS stands for
Restricted mouth opening
Obstruction
Distorted airway or disrupted airway
Stiff lung or stiff cervical spine
Peak airway pressure and LMA?
PAP < 20 cmH20 indicated
Initial cuff pressures will vary with the patient
LMA size, head position, anesthetic depth
LMA cuff pressure shouldd not exceed
60cm H20
What is the MOST COMMON ADVERSE EFFECT of Using LMA
SORE THROAT
FASTRACH LMA features
CURVED RIGID AIRWAY tube
Integrated GUIDING HANDLE
EPIGLOTTIS ELEVATING BAR
GUIDING RAMP
What part of the FASTTRACH LMA is used for insertion , reposition and removal?
The Intergrated handle at the proximal end of the barrel.
The position of the FASTrach LMA can be optimized by
LaAN P(Lateral - anterior Posterior manipulation by using the INTERGRATED handle.
What is the CHANDY maneuver?
lateral , anterior posterior manipulation of the handle.
What is the LMA Proseal
The first DOUBLE lumen SGA
The 2nd lumen of the LMA proseal is used for
Diagnosis of malposition
passive emptying of stomach
Active emptying of stomach
The LMA proseal vs LMA supreme
LMA supreme is a single use version of the proseal
When selecting an LMA proseal , you should
SIZE DOWN from the LMA classic size
KING Laryngeal tube: cuffs
SMALL ESOPHAGEAL CUFF
Larger HYPOPHARYNGEAL CUFF
After insertion of King Laryngeal cuff
BOTh CUFF INFLATED by injecting air into JUST ONE inFLATION PORT
King Laryngeal tube if ventilation is inadequate
tube too deep
Cannot intubate cannot ventilate tube
Esophageal tracheal combitube ( ETC)
Adverse effects of SGAs
Aspiration
Sore throate
Single use SGAs/
Most SGAs are not disposable, single use.
SGA specific cleaner
Endozime
Max use per LMA
40
When fully inserted the LMA rest agains the
UPPER esophageal sphincter
Largest ETT tube through size 3-6 LMA
3- 6.0 mm
4- 6.00
5 -7mm
6- 7mm
LMA size and largest ETT size 1-2.5> how to remember?
Add "2.5 to each size" Size 1 + 2.5 = 3.5 Size 1.5 + 2.5 = 4 Size 2 + 2.5 = 4.5 Size 2.5 + 2.5 = 5
Neonates to children up to 30 kg (<5, 5-10, 10-20, 20-30) Max cuff volume
4, 7, 10, 14
LMA size 3 - 6 max cuff volume
3, 4, 5, 6
20,30,40,50
Fiberoptic size (mm) for LMA neonate <5kg up to 30kg
2.7, 3, 3.5, 4.0
Which nerve when stimulated will cause laryngospasm?
Stimulation of vagus nerve during light anesthesia (S
LMA vs ETT bronchospasm and laryngospasm is
LESS with ETT
BIS with low probability of explicit recall
70-60
GA BIS
40-60
DEEP hypnotic state BIS
40-20
FLAT LINE EEG BIS
0-10
Light anesthesia BIS
90-70
Large V wave
TR
RV failure
Constrictive pericarditis
Tamponade.
RA pressure range
1-8mmhg
Hypovolemia CVP_____PCWP____
Low low
LV failure CVP ________ PCWP ____
Normal or high
High
Cardiac Tamponate: CVP ______PCWP___
High; high
PE: CVP_______PCWP
High; nomral
Max wedge time
15 seconds
Insertion site PAC
- Su (Subclavian)
- RIJ (Right IJ)
- LIJ (Left IJ)
- RA (Right Antecubital)
- LA(Left Antecubital)
- Femoral
To RIGHT ATRIUM 15 (+10 for RV, + 15 for PA) 20 (+10 for RV, + 15 for PA) 25 (+10 for RV, + 15 for PA) 40 (+10 for RV, + 15 for PA) 45 (+10 for RV, + 15 for PA) 50 (+10 for RV, + 15 for PA)
Aline upstrokes reflects 2
Contractility and SVR
Upstroke is faster is contractility is_____and SVR is_____
Increased; decreasd
Function of valve is to change pressure
Diaphragm
This valve regulates the flow of N2O vial oxygen pressure
Fail safe valve
Free floating valve
Cylinder valve
Pulse ox is used to assess
Oxygenation
May cause falsely elevated pulse ox reading
Methemoglobin
Assessing a patient’s CO2 elimination by END tideal CO2 measurement is called
CAPNOMETRY
DISS PREVENTS accidental misconnections by altering
Size of connection, type of pipe thread
CYLINDER REGULATOR first stage convert cylinder pressure to
45 pSI
The most fragile part of the gas machine is the
FLOW TUBES
Cauda equina extends
L1 to S5
Epidural space widest at
L2
Narrowest at level
C5
The epidural space is a
POTENTIAL SPACE that is bound by the DURA and LIGAMENTUM FLAVUM
The principle site of action of neuraxial blockade is the
NERVE ROOT within the spinal cord.
The best means for treating HYPOTENSION during spinal anesthesia is
PHYSIOLOGIC not pharmacologic. GIVE IV FLUIDS if not normovolemic, if NORMOVOLEMIC give ephedrine.
Fibrinolytic or thrombolytic no neuraxial for
10 days
Heparinization can occur
1 hour after catheter removal
Clavicles level
C4
Skin to epidural space average adult
4-6cm
Order of sensitivity to LA block is
large myelinated > smaller myelinated > unmyelinated
To assess lost of temperature sensation: most sensitive indicator
ALCOHOL swab to assess loss of temperature sensation is the most sensitive indicator of initial onset of sensory block. PINPRICK MOST ACCURATE OVERALL>
Anechoic
Appears black on image
Hyperechoic
Appears bright
HOW MUCH TO INJECT FOR AXILLARY BLOCK
40 ML
CERVICAL PLEXUS BLOCK
4 ML
HOW MUCH TO INJECT FOR ISB ?
40 ML
SUPRACLAVICULAR + INFRACLAVICULAR
20-30 ML
Medial RADIAl nerve how much
4 ML
Ankle BLOCK
Posterior tibial DEEP PERONEAL SURAL Saphenous Superficial PERONEAL
Common nerve aka
fibular nerve
Responsible for pain and temperature
C and unmyelinated
The most common causative organism in epidural abscesses is
Staphylococcus aureus
The posterior dermatomes located at L4 correst to
Intercristal line
Tuffers line
Superior iliac crest
Hypobaric
sterile water
Isobaric
CSF
Hyperbaric
Dextrose
To avoid catheter migration during or following the combined spinal epidural anesthetic, which spinal needle gauge size would be appropriate
28Ga
3 in one block is (LOM)
Lateral femoral cutaneous
Obturator
Femoral
1sst and 2nd most common nerve injury post op
Ulnar nerve
Brachial plexus.
Claw hand associated with
Ulnar nerve injury
Foot drop associated with
Lithotomy
Results in permanent vision loss
Ischemic optic neuropathy
Left arm abducted > 90 degrees
Brachial plexus
Opposition of the first and fifth finger is preclcuded
median nerve injury
Weakened skeletal muscle below the knee is a symptom of what injury
SCIATIC
Most common injured nerve of the lower extremity
common peroneal
Plantar flexion for a long time which nerve at risk
anterior tibial
Compression of this nerve against the pelvic brim
Femoral
Saphenous nerve is a branch of the
FEMORAL
Unable to adduct leg, decrease sensation medial thigh
OBTURATOR ( saphenous is only sensory)
IM injection vein in UPPER outer quadrant of the buttock to prevent injury to the
SCIATIC
3 nerves causing foot drop
Sciatic
Common peroneal
Anterior tibial.
Pregnancy and FRC
Decreased by 20%
Lungs that remains unchanged
TLC, VC, IC
Ventilation and pregnancy
MV increases 45%
Alveolar ventilation increase 45%
Oxygen consumption
Increase 20% to 30% at rest
100% in 2nd stage of labor
HR and pregnancy
Increase 20-30%
CO increases mainly due to
increase in SV
Coagulation and fibrinogen in pregnancy
increased
Considered full stomach starting week
12
Dilutional anemia is due to
Increased in Plasma volume to a greater extend than Red blood cell volume.
CO , SV, HR
CO up 40-50%
SV up 20-50%
HR up 20-
Decreased factor in pregnancy
11 and 13
Unchanged factor
2 and 5
UBF at term is
700-800ml/min
2 factors causing decrease UBFl
decrease perfusion pressure
Pregnancy GFR, CO and RBF
ALL increased
BUN and CR in pregnancy
Normal due to increase in RBF and GFR
GFR increase by____% by ____th gestational week and remains elevated until delivery
50% ;16th,
Uterine artery pressure is determined by
Maternal systemic arterial pressure.
Definitive treatment for preeclampsia is
DELIVERY of the fetus
Diagnosis of preeclampsia can be made if
Thrombocytopenia <100000, Cr, 1.1
BEST Indicator of coagulopathy in the pre-eclamptic patient
PLATELET COUNT ON ADMISSION
Earliest sign of magnesium toxicity ?
Marked depresion of DTRs.
Level needed to be secured for a c-section
T-4
How much of the total uterine blood flow goes to the intervillous space?
550ml/min
Plasma fibrinogen DIC
<150 (in pregnancy 400-650)
Most serious in GASTROCHISIS
Dehydration and infection
high fever croup vs epiglotittis
Epiglottitis
Rapid vs slow progress croup vs epiglotittis
Rapid epiglottitis
Within umbilical vs lateral to umbilitus
Omphalocele(within)
Gastrochisis (Lateral )
Omphalocele mortality related to
CaRdiac and chromosomal abnormalities.
No amnion with
Gastrochisis
Cystic fibrosis: resp pattern
Obstruction pattern
Early symptoms NOT SIGN of MH
Masseter spasm
Tachycardia
Early SIGN of MH
Increased ETCO2
peaked t waves on ECG
HYPERKALEMIA
Hallmark of intravascular fluid depletion in neonate and infants is
Hypotension without tachycardia
Major cause of perioperative morbidity and mortality in pediatric patients
Hypoxia
Congenital diaphragmatic hernia profound arterial hypoxemia is due to
RIGHT TO LEFT SHUNT
Pediatric major mechanism for heat production
Nonshivering thermogenesis
Concern for paradoxical air embolism may occur in the neonate because of
Patent foramen ovale
Correct ETT tube is confirmed by
Bilateral breath sounds
In a patient with congenital diaphragmatic hernia, peak inspiratory airway pressure be
20
A child is born with congenital diaphragmatic hernia, which pathways allow blood to bypass the lung completely
Patent Foramen of fallot
Patent ductus arteriosus
PRevent hypothermia with gastrochisis vs omphalocele
Gastrochisis
Correct dose of dandrolene
2-3 mg/kg every 5-10 minutes
Obese surgical patients leads that are best to detect cardiac ischemia
Lead V5, Lead I
Do not exceed this PEEP for obese patient
15cmH2o
What is the most common cause of postoperative mortality after bariatric surgery?
THROMBOEMBOLISM
Appropriate pre-op anesthetic plan for cardiac tamponade
Positive inotrope
Accidental SUBARACHNOID injection occurs during intended epidural, RAPID early sign is
DYSPNEA
Max dose of dandrolene treat MH
10 mg/kg
In PACU patient stated that she remembers some stuff you should
Tell the patient what happened
Stimulation of what receptor explains why arterial diastolic BP may decrease when epinephrine is administered with a local anesthetic?
Beta 2 adrenergic receptor
At NMJ, aminophylline
INCREASES THE RELEASE OF ACH from the motor nerve terminal
Votalge gated sodium channel is in the INACTIVATED state in all but which of the following situation>
Severe hypokalemia
Patient cannot ADDUCT the thumb what nerve is blocked by LAs
ULNAR
Aspiration is a risk associated with anesthesia for patients with each of the following diseases except
MS
Immediate deliver if decelerations are
LATE with no beat to beat variability
Applying pressure for the patient who has already lost consciousness how much pressure in KG?
4 kg
ANSI standards for reservoir bag require that the pressure not exceed _____when the bag is distended how many times its normal capacity ?
50cm H2O ; 4
The American national standards institute Z79.9 1979 was replaced in ________ with
1988; American Society for TESTING and materials F1161-88 standard.
2 year old ETT tube + suction catheter
4.0 at 8F
Muscle that DILATES the vocal cords
Posterior cricoarytenoids (thought thryroarytenoids)
Hypoxemia during one-lung anesthesia is most effectively treated by:
periodic inflation of the collapsed lung with oxygen, early ligation of the ipsilateral pulmonary artery and CPAP to the collapsed lung offer consistently effective improvement in oxygenation.
The application of PEEP to the ventilated lung, changes in the ventilatory parameters and oxygen insufflation to the collapsed lung may offer marginal improvement in oxygenation.
FEV 1 of 2L and FVC of 2.5 L suggest
RESTRICTIVE (ratio is 0.8 but volumes are low )
What happens to blood flow and the diameter of arterial blood vessels in ischemia region of the brain when the patient is hyperventilated?
Blood flow increase
Arterial vessel diameter NO CHANGE
Produce the GREATER blockade when in the epidural space?
3% Chlorprocaine
In chronic respiratory acidosis, the PaCO2 is
elevated above the upper limit of the reference range, with a normal or near-normal pH secondary to renal compensation and an elevated serum bicarbonate levels (ie, >30 mEq/L).
Incidence of PERIOPERATIVE reinfarction for a patient who had an MI 7 months ago is
5%
Protamine dose and bond
1.1 -1.3 mg per 100 units of heaprin. IONIC BOND
3 in 1 block FOL
Femoral
Obturator
Lateral femoral cutaneous nerve.
Hernial sac Gastrochisis
ABSENT
Is a Hernial sac present with omphalocele?
Yes it’s Present
Congenital abnormalities gastrochisis
PRESENT
Omphalocele congenital abnormalities
Absent
TEC 6 VAPORIZER calibrated in LA is brought to colorado springs, the % delivered willbe
HIGHER than the dial setting.
Concentration and dose of mannitol is
20%, 1g/kg
Who is responsible for quality assurance?
The hospital
What drug would you not give in the perioperative period to the patient undergoing surgery for pheochromocytoma
DROPERINOL.However, droperidol when used in pheochromocytoma, has been reported to produce a paradoxical hypertensive response.
Most SENSITIVE for VAE?
TEE
What drug for altering hemodynamic status should generally be avoided in the patient with idiopathy subaortic hypertrophic stenosis?
NITROGLYCERIN (REDUCE CO)
Drugs to be avoided in the patient with cystic fibrosis?
ATROPINE
INCREASE with aging
PaCO2
Vital capacity with aging
Decreases
Bladder cancer removal procedure
Controlled Cystectomy
Bladder cancer removal procedure
Radical Cystectomy
Needed for RADICAL CYSTECTOMY
Controlled hypotension
Pulmonary parameters that decrease in geriatric
Total lung capacity.
breast milk fasting
4 hours
3 months to 3 years EBV
75-80ml
At what point during pregnancy does the maternal intragastric pressure increase, often resulting in heartburn?
3rd trimester
Breathing circuit pressure is limited to
125cm H2O
Which of the following are part of the intrinsic laryngeal muscles
Cricothyroid
Oblique artytenoid
Thyroarytenoid
Prominent pathophysiologic derangements associated with MR?
LV volume overload
End result of INCREASED in HR in patient with Mitral stenosis?
PULMONARY EDEMA
Signs and symptoms of RA include
Pain on swallowing
HYPERVENTILATION produces which electrolyte disturbance
HYPOCALCEMIA
Not a Quaternary ammonium
Physostigmine
How many unidirectional valves does the semiclosed anesthetic breathing system have?
2
Compare the difference between MEANS of three of more NORMALLY DISTRIBUTED DATA SETS would be
ANALYSIS of VARIANCE
Not a contraindication to Jet ventilation
Patient under 2 years of age.
IMPORTANT CV effect of pneumoperitoneum
Distention of the vagus nerve during insufflation
2, 3 DPG is which biochemical pathway
GLYCOLYSIS
Nominal data
yes or no
Eye color
Blood type
Male or female
without providing any quantitative value.
Interval data
statistical research, school grading, scientific studies and probability
Ordinal data?
well-known example of ordinal data is the Likert scale.
Ordinal data example
Age, gender
Test is most appropriate to evaluate the difference between expected and observed frequencies from nominal data?
Chi-squared analysis
Electrolyte disturbances are expected during WHIPPLE ? low CKM
HYPOCALCEMIA
HYPOKALEMIA
HYPOMAGNESEMIA
Nerve supplies motor innervation to the superior oblique muscle of the eye?
TROCHLEAR
St john’s wort is an inducer, what else should you know about it?
CNS Stimulation
Echinacea is associated with
Immunosuppression
Hepatic dysfunction
Black Cohosh is associated with
Hypotension
Garlic, Ginseng, Ginger , Gingko all associated with
increased bleeding
Ginseng is associated with increased bleeding, what else should you know about it?
CNS stimulation
Hoodia herbal supplements is associated with
Altered glucose control
Kava herbal supplements anesthetic considerations:
CNS depression, decreased MAC
Valerian herbal supplements anesthetic considerations:
CNS depression, decreased MAC
Herbal meds and supplements are stopped
2 weeks before surgery.
Herbal meds and supplements: REGULATED by FDA
No!!!
Catechol-O-methyltransferase (COMT) metabolizes epinephrine to and
metanephrine
Catechol-O-methyltransferase (COMT) metabolizes
norepinephrine to
normetanephrine.
Subsequently, monamine oxidase (MAO) further metabolizes metanephrine and normetanephrine to
vanillymandelic acid (VMA).
What enzyme further metabolizes metanephrine and normetanephrine to
vanillymandelic acid (VMA).
The sensory neuropathies associated with HIV include.
distal sensory polyneuropathy and antiretroviral toxic neuropathy (ATN) secondary to the treatment
Occurs in 10% to 35% of patients who are seropositive for human immunodeficiency virus (HIV).
Symptomatic neuropathy o
Occurs in 10% to 35% of patients who are seropositive for human immunodeficiency virus (HIV).
Symptomatic neuropathy
Characteristics of human immunodeficiency virus neuropathy include:
Distal polyneuropathy
Allodynia
The clinical features of HIV sensory neuropathy typically include.
painful allodynia and hyperalgesia. The onset is gradual and most commonly involves the lower extremities
The neuropathy and dysesthesia associated with HIV progress from the
distal to the more proximal structures.
Postintubation croup: is secondary to
inflammation of subglottic structures
Postintubation croup usually occurs at the
level of the cricoid, since this is the narrowest part of the pediatric airway.
Postintubation croup is associated with
early childhood (1 - 4 years).
Unlike laryngospasm, postintubation croup is seen
some time after extubation, usually within 3 hours.
Evoked motor response of the tibial nerve using a nerve stim would most expected to elicit
Plantar flexion at the ankle and foot inversion
Intraosseous access for babies
Tibial 1-2 cm below but also medial to the tibial tuberosity
Highest sensitivity vs highest specificity for pheochromocytoma tests
Highest specificity is Urinary VMA
Highest sensitivity is Plasma free metanephrines.
The web space between first and 2nd toes are innervated by
Deep peroneal nerve
Child with Epiglotittis induction of anesthesia should occur where?
In the operating room with the presence of a skilled surgeon as well as advanced airway management equipment
Child with Epiglotittis induction of anesthesia preferred method and whY?
Inhalation induction, allows for spontaneous ventilation . MAINTAINING INTACT AIRWAY TAKES PRIORITY since patient at high risk for airway compromise.
Most common complication occuring in the PACU
NAUSEA
Most common complication following a retrobulbar block prior to cataract surgery
HEMATOMA because of close proximity of the ophtalmic artery
Most important aspect of a successful TAP BLOCK
Using adequate volume of LA. Spread throughout a fascial plane
Blood loss spinal vs GA for THA
Less blood loss with spinal
Spinal stenosis patients report pain that
Exacerbates by standing or walking
Hallmark of spinal stenosis
relief of symptoms with bending forward.
The apneic oxygenation technique affords adequate oxygen delivery, but progressive respiratory acidosis limits the use of this technique to 10 - 20 minutes in most patients. Arterial PaCO2 rises
rises 6 mm Hg in the first minute followed by a rise of 3 - 4 mm Hg during each subsequent minute. In this patient this will produce a 27 - 34 mm Hg increase, resulting in a PaCO2 of 67 to 74 mm Hg.
Insulin secretion is increased by
stimulation of the parasympathetic nervous system through the vagus nerves.
Key elements in the AANA’s definition of wellness include: (Select 3)
effective adaptation, resilience, coping mechanisms
IntraOcular pressure with succinylcholine
Increase
IntraOcular pressure with hypoxemia
increase
IntraOcular pressure with laryngoscopy
increase
The most powerful inspiratory muscles are the
external intercostals.
Raise the sternum and contribute to inspiration_______ as do the _______and ______
The sternocleidomastoid muscles ; anterior serratus and scalene muscles.
The primary muscles of expiration are the
abdominus rectus muscles and the internal intercostals.
A patient is undergoing a pulmonary function test in which they are asked to inhale and exhale as deeply as possible for 15 seconds. What is the test called?
Maximum voluntary ventilation
Because the partial pressure of oxygen in the alveoli is higher than it is in the blood, it will move across the pulmonary capillary membrane into the blood by
diffusion.
The carotid bodies are capable of sending messages to the central respiratory centers to increase ventilation via the
glossopharyngeal nerve
Under what structure does the right recurrent laryngeal nerve pass?
Innominate artery
These are the only causes of true hyperventilation (where the patient’s minute ventilation increases to the point that respiratory alkalosis results). They are:
arterial hypoxemia
metabolic acidosis, and
central nervous system alteration.
Respiratory Alkalosis electrolyte disturbances:
K+; Ca2+, BP, Phosphate , _____and ______
hypokalemia, hypocalcemia, hypotension, hypophosphatemia, cardiac dysrhythmias, and potentiation of digoxin toxicity.
Serotonin is a vasoconstrictor in most vascular beds, but has vasodilatory properties in the
vasculature of the heart and skeletal muscle.
Local anesthetics produce an ordered progression of blockade of
Temperature sensation first Proprioception (kinesthetic sense) Motor function Sharp pain Light touch.
The primary mechanism by which gastroesophageal reflux occurs is a
transient lowering of the lower esophageal sphincter pressure, not a chronic decrease in the lower esophageal sphincter pressure.
NSAIDs fundamentally inhibit the synthesis of
Prostaglandins
Which of the following calcium channel blockers would be most effective at relieving chest pain due to myocardial ischemia? (select two)
nifedipine
nicardipine
The profound hypotension seen with spinal shock is related to the level at which the lesion is located (cervical injuries produce more severe hypotension than do lumbar injuries) and is due primarily to a
drop in preload caused by dilation of the capacitance vessels.
Pt had a stroke about 3 months ago ,should you proceed with surgery?
Patients who have a perioperative stroke are eight times more likely to die within 30 days of surgery. Because of this, elective surgery should be delayed for at least 9 months following a stroke
Injecting 2 mL of local anesthetic at the base of the palatoglossal arch will anesthetize which branches of the glossopharyngeal nerve? (select two)
Pharyngeal and lingual
Upon what factors does the composition of the inspired gas mixture a patient receives depend? (select four)
The vaporizer dial setting
The fresh gas flow rate
The volume of the breathing circuit
Gas absorption by the circuit
The response of the orbicularis oculi most closely represents that of the
adductor pollicis
Monitoring the corrugator supercilii muscles will most closely parallel that of what muscles?
the laryngeal adductor muscles.
At an increased altitude, an older Tec isoflurane vaporizer will deliver
a higher volume percent than the dial setting. For example, at 10,000 feet the atmospheric pressure is about a third less at 500 mmHg. If we turn on our isoflurane vaporizer at 0.89%, the decrease in ambient pressure results in a doubling in the volume percent output of the gas from 0.89% to 1.75%. But, if we multiply that 1.75% times 500 mmHg (the new atmospheric pressure) we get a partial pressure of isoflurane of 8.77 mmHg. So despite a huge jump in the percent output, the partial pressure doesn’t increase that much.
A decrease in the in the single twitch response isn’t seen until what % of the receptors are blocked? When does the response disappear?
75-80% of the receptors are blocked, and the response disappears when 90% of the receptors are blocked
Which alteration would be consistent with the development of a leak in the bellows in a system using an oxygen-driven ventilator? (select two)
An increase in the FiO2
An increase in peak inspiratory pressure
At standard pressure, the boiling points for inhalation anesthetics in degrees Celsius are: Desflurane-Isoflurane-48.5, Halothane-50.2, Enflurane-56.5, and Sevoflurane-58.5.
22.8,
At standard pressure, the boiling points for inhalation anesthetics in degrees Celsius are : ISO
48.5
At standard pressure, the boiling points for inhalation anesthetics in degrees Celsius are : Halothane-
50.2,
At standard pressure, the boiling points for inhalation anesthetics in degrees Celsius are :Enflurane
56.5,
At standard pressure, the boiling points for inhalation anesthetics in degrees Celsius are Sevoflurane
-58.5.
At standard pressure, the boiling points for inhalation anesthetics in degrees Celsius are : HIGH to low mnemonic
DI -HES
Rh(D) immune globulin is administered to prevent Rh sensitization in
Rh-negative women.
Induction of general anesthesia for which of the following procedures carries the highest risk for aspiration?
Zencker’s Diverticulostomy
Zencker’s Diverticulostomy induction
Always RSI
Contraindication to the administration of intravenous contrast media : women
Pregnancy is
The onset of neuromuscular blocking agents is prolonged in the elderly primarily because of (select two)
an increase in circulatory time
a decrease in skeletal muscle blood flow
What are the three most common entry sites for an amniotic fluid embolism?
Placenta
Endocervical veins
Uterine trauma site
What hemodynamic change would you expect to see when the anhepatic phase of a liver transplant is initiated?
Hypotension
What is the drug of choice for the treatment of acute myocardial ischemia?
Nitroglycerin
The formula for PBW for males is:
PBW (male kg) = 50 + 0.91 X (height (cm) - 152.4).
The formula for PBW for females is:
PBW (female kg) = 45.5 + 0.91 X (height (cm) - 152.4).
The PR interval should be measured from the ___ of the P wave to the ___ of the QRS.
beginning, beginning
What are the only intravenous anesthetics that can produce burst suppression?
Etomidate and propofol
When inserting an Eschmann stylet during intubation, the stylet should be advanced into the trachea until
the 25 cm marking is at the lip
