Review Questions to know Flashcards
what are the pros of DLT vs bronchial blocker? What are the con’s of bronchial blocker?
DLT (Pros)
- bigger lumen -> easier to deflate lung
- less risk of dislodgement (L DLT has less risk than R DLT 2/2 RUL)
Bronchial Blocker (Pros)
- requires SLT (avoid converting back and forth with induction and emergence)
Bronchial Blocker (Cons)
- smaller lumen -> longer time to deflate lung
- high risk of dislodgement
- unfamiliarity / difficult to place
What are issues that can occur when leaving a DLT place in the ICU?
Cons of DLT in ICU
- malpositioned during pt movement or care (ex in ICU)
- mucosal ischemia or trauma or tracheo-bronchial stenosis from cuff inflation and repositioning
- risk of bronchial rupture
- unfamiliarity of DLT with nursing care
- need ready avaialibity of FOB
What is the difference in technique of jet ventilation vs apenic oxygenation during ENT surgery?
Jet Ventilation
- supraglottic vs subglottic
- 100% O2 at < 20 PSI
- can only use TIVA
- need to maintain upper airway patency for eggresion of air during expiration
- at risk for barotrauma and pneumo if unable to allow eggression
Apenic oxygenation
- intermittent facemask or ETT insertion
- voltaile vs TIVA
- periodically interrupt surgery to maintain SaO2 > 95% and/or EtO2 > 90%
What are LBP red flags?
Red flags for LBP
- history of trauma
- fever
- incontinence
- unexplained weight loss
- cancner history
- parenteral drug abuse
What is your ddx of LBP?
- Red Flags: cancer, hematoma, abscess, CES
- herniated disk -> radiculopathy in 1-2 dermatomes
- spinal cord stenosis
- lig flavum hypertrophy, bulging disk, posterior facet joint enlargement, osteophytes
- abdominal aortic aneurysm
- ankolysing spondylitiis
- spine fx
- neprholithiasis
Why do you give a LA and non-particulate steroid for transforaminal injection? Thoughts of steroid for interlaminar injections?
transforaminal
- local anesthetic to ensure that we are not Intrathecal or (more importantly) intra arterial (artery of Adam)
- non-particulate
- embolization of particulate matter into the arterial supply of the cord. particles are large enough to occlude arterioiles/capillaries
interlaminar
- particulate steroid (no vasculature that we are concerned about and some think it works better/longer).
is blood pat
ch contraindicated in HIV patients?
NO!
- no evidence to contraindicate use of blood patch in HIV patients
- ACE exam: no evidence that spinal or epidural anesthesia worsens CNS infection or symptoms.
- Similarly, concern about infecting the CNS should not be an issue when considering the use of an epidural blood patch for the treatment of a postdural puncture headache in an HIV-positive patient.
-
However, AIDS associated with peripheral neruopathy and thrombocytopenia –> Document this before considering neuraxial anesthesia (Risks vs benefits)
- immune thrombocytopenia and bone marrow suppression caused by antiretroviral drugs
Is there a limit to mannitol?
- 2 gm/kg is limit
- Reason:
- osmotic diuresis -> hypovolemia
- resultant metabolic derangements
- transient increase in intravascular volume -> CHF and pulm edema
- 2/2 water shift from intracellular to extracell space
goals of tx in pulm edmea?
Goals:
1) Preload reduction - reduce pulmonary blood flow
* avoid pulm congestion -> inc pulm hydrostatic capill pressure -> worsen interstital and alveolar edema
2) Afterload reduction - promote forward flow
3) inotropic support - promote forward flow
Indications and contraindications for NIPPV
Indications
- COPD exacerbation
- cardiogenic pulm edema
- hypoxemic resp failure
Contra
- ARDS
- HD unstable patients
- Impeding resp failure (fatigue, diaphoresis, lethargic, exhausted)
- impaired gastric emptying (SBO, pregnancy, ileus)
- gastric bypass (disrupts surgical anastomosis)
How does NIPPV improve oxygenation and ventilation?
Mech of action
benefits of PPV
-
improve intrapulm shunting
- Recruits alveoli and maintains patency
- *prevents fluid-filled alveoli from collapsing during exhalation, maintains patency *
- decrease work of breathing
- maintaining alveoli patency -> improve FRC -> improve lung compliance -> improve gas exchange -> less work of breathing
- decrease preload and afterload
- by increasing intrathoracic pressure (dec venous return)
- increases pericardial pressure, reduces transmural pressure, and thus decreases afterload
What is OSHA guidelines for volatile and N2O PPM?
Occupational Safety & Health Administration
- Volatile anesthetic with no N2O
- use levels < 2 PPM
- Volatile anes used in combination with nitrous oxide
- use levels < 0.5 ppm
- Nitrous oxide as sole anesthetic
- use levels < 25 PPM
Who is at higher risk for anesthesia recall, what are anesthetic factors that can contribute to anesthesia awareness?
Patient population
- HD unstable patient (you have to uselower dose of anesthesia to maintain pressure)
- cardiac
- OB
- major trauma
Anes factors
- IV delievery of anesthesia (inadequate dose, pump failure, infiltrated IV, kinking of IV line)
- emergence of anesthesia (especially if quick emergence desired)
what is your mgmt of anesthesia recall?
1) Interview the patient after the procedure and record what the patient has experienced
2) Apologize to the patient if anesthesia awareness has occurred and sympathize with the patient’s suffering
3) Explain what happened and its reasons, e.g., the necessity to administer light anesthesia in the presence of significant HD instability
4) Offer the patient psychological or psychiatric support, including referral of the patient to a psychiatrist or psychologist
5) Notify the patient’s surgeon, nurse and other key personnel about the incident and the subsequent interview with the patient
6) Surgical team members should also be educated about anesthesia awareness and its management
Benefits of epidural
CNS
- reduce symp stim - > reduce risk of stroke (hemorrhagic)
Cardiac
- reduce symp stim -> dec HTN/tachy (o2 consumption)
- reduce symp stim –> Reduce risk of acute flash pulm edema from acute increase in afterload
- sympathetectomy -> dec blood flow to surgical site -> dec blood loss
- reduce catecholamine surge
- reduce stress response of surgery (hyperglycemia)
Heme
- reduce inflammation -> reduce risk of hypercoagulability (DVT) and tumor recurrence
GI
- sympathetctomy -> unopposed parasymp activitiy -> prevent ileus
Resp
- reduce splinting, improved breathing
Pain
- pt satisfaction, reduce opioid SE, better ambulation (dec DVT/PE)
what meds (name, dose, route of admin, SE) are used for uterine atony?
Uterine Atony Meds
Oxytocin
- 20-40 units/L of IV fluid
- SE: Hypotension
Methylergonovine
- 0.2 mg IM
- SE: N/V, severe HTN
Prostaglandin F2 alpha (Carboprost)
- 250 mcg IM, intramyometrially, IV
- SE: Severe bronchospasm
- considered only AFTER methylergo and oxytoc
Misoprostol (cytotec)
- 600 mcg PO or sub-lingual
- SE: shivering, n/v, diarrhea
what is the concern for cell saver (autologous) and allogenic blood (homologous) transfusion in cancer surgery patients? How can you avoid this complication?
Cancer surgery and blood tx:
Complication of tumor recurrence
- cell saver -> concern of viable tumor cells being transfused back to patient (controversial)
- allogenic blood tx -> produce immunosuppresive effects -> early tumor recurrence.
Anes Considerations:
- possible to compromise by using the cell salvage suction during dissection of tumor-free areas, while employing a separate suction to collect and discard material during actual tumor dissection
patient is delirious and agitated post-operatively, how will you manage this patient?
1) Ensure adequate ventilation and oxygenation
-
Hypoxemia and hypercarbia can cause this!
2) ensure patient safety - If violent or severely agitated, provide restraints
3) Verbal support and reassurance and reorientation - Voicing patient’s name, current location, surgeon name, time of day
4) rule out physiologic causes of delirium - Physiologic causes of delirium -> distended bladder, nausea, uncomfortable positioning, or the possibility of the patient lying on a foreign object.
5) reverse anesthetic agents - Flumazenil (0.2mg), naloxone (40mcg increments), physostigmine (1-2mg)
- Physo – used for tx of central anticholinergic syndrome
- Consider haloperidol -> will reduce severity, but not the incidence of delirium
What is coarctation of aorta, what are the s/sx?
Define:
- coarctation extends just distal to left subclavian artery at the site of previous ductus arteriosus
S/Sx:
- BP higher in arms then legs
- weak and delayed femoral pulse
what is the mgmt of coarctation of aorta?
1) perfusion to lower portion of body during aortic-cross clamp
- 2 a-line: radial and femoral
- need minimum of at least 40 mm Hg to perfuse kidney and spinal cord
- consider partial CPB
2) avoid systemic HTN during cross-clamping of aorta
- will increase afterload and LV wall tension
- Tx: deepen voltaile anes, IV SNP
- risk - dec perfus pressure of lower body
3) ischemia of spinal cord
- SSEP, MEPs
- maintain lower body MAP
how to evaluate fever in child?
- URI – coughing, sneezing, rhinorrhea, sore throat
- Otitis Media – tugging ear
- UTI – burning urination
- Confusion/AMS – meningitis
- Cuts/scrapes that may be infected
- Look at patients surgical site to see if it is grossly swollen, erythematous, tender.
how to assess fluid status/dehydration in ped patients?
- Vital signs
- UOP
- Skin perfusion (cold, clammy, mottled)
- Pulses – weak and thready
- Mentation – lethargic, fatigue, somnolent
- Activity
what is an example of peds trauma fluid resusiciation algorithm?
- Bolus crystalloid NS or LR – 20 cc/kg
- Obtain large bore IV access x 2
- Re bolus with crystalloid – 20 cc/kg
- If hemodynamically unstable, then transfuse PRBC 10cc/kg
- If less than 4 months old: PRBC -> irradiated and CMV negative blood (immature immune system) and fresh blood product (new blood – less hyperkalemia, less acidosis, inc 2-3 DPG).
How to manage delirium tremens?
2 to 4 days after the cessation of alcohol
- hallucinations, combativeness, hyperthermia, tachycardia, hypertension or hypotension, and grand mal seizures.
Tx:
- Aggressive Tx
-
Benzodiazepines
- until patient becomes sedated but remains awake
- **β-adrenergic antagonists (propranolol or esmolol) **
- suppress sympathetic hyperreactivity (goal of HR < 100 BPM)
-
protection of the patient’s airway
- cuffed ETT – may need to do this in some patients
-
supplemental thiamine
- (for the treatment of Wernicke encephalopathy
-
correction of electrolyte abnormalities
- especially magnesium and potassium
- **CIWA PROTOCOL**
scores yields an aggregate value that correlates to the severity of alcohol withdrawal, with ranges of scores designed to prompt specific
