SHIT TO KNOW Flashcards
How is FRC affected in aging?
FRC is increased. Due to loss of elastic recoil and increase in lung compliance
Where is the proximal and distal balloon of the combitube placed?
Proximal balloon is placed in hypopharynx.
Distal balloon is placed in esophagus. If it’s place here, the lungs can be ventilated
What are these symptoms of?
- Decreased ETCO2
- Tachycardia
- Deadspace = arterial hypoxemia
- Bronchospasm = increasing PIP
P.E.
Retrograde tracheal intubation contraindications:
- Goiter
- Coagulopathy
- Neck flexion deformity
Where do you puncture for retrograde tracheal intubation?
Puncture cricothyroid membrane, pass wire through cords and out of mouth, put ETT over wire and advance into trachea
Where is a transtracheal nerve blocked?
Cricothyroid membrane
Indications for retrograde tracheal intubation
- Unstable cervical spine
- Upper airway bleeding and you can’t see the glottis, but this takes time and only used when ventilation is still possible.
- It can be performed in awake pt
AVOID: in goiter, coagulopathy, and neck deformities
Short term benefits of smoking cessation
- Reduction in carboxyhemoglobin (this is usually a left shift on the curve)
- improved P50
- It does NOT reduce the risk of postop pulmonary complications
- Carbon monoxide t 1/2 = 4-6 hours
Intermediate-terms effects of smoking cessation
Return of pulmonary function takes at least 6 weeks:
- Airway function
- Mucociliary function
- Sputum production
- Pulmonary immune function
- Hepatic enzyme induction also subsides
4 main nerves related to respiratory
1) Glossopharyngeal (innervated by CN 9)
(All are innervated by Vagus):
2) Internal SLN- sensory only
3) External SLN- motor
4) RLN- acute issue: Dyspnea, chronic issue: aphonia
LMA size for:
- 70-100kg
- 50-70 kg
- 30-50 kg
- 20-30 kg
- 10-20 kg
- 5-10 kg
- < 5 kg
- 70-100kg: 5
- 50-70 kg: 4
- 30-50 kg: 3
- 20-30 kg: 2.5
- 10-20 kg: 2
- 5-10 kg: 1.5
- < 5 kg: 1
LMA size for 5-10kg
1.5
LMA size for 20-30kg
2.5
LMA size for 10-20kg
2
Changes to due inadequate pain management?
- SVR
- Platelet aggregation
- Urinary spinchter tone
- TV, VC, TLC, FRC
- Ability to clear secretions
- SVR increased
- Platelet aggregation increased
- Urinary spinchter tone increased
- TV, VC, TLC, FRC decreased
- Ability to clear secretions decreased
Respiratory center is located where in which system?
Medulla and Pons in the Reticular activating system
Dorsal respiratory center is located? What is it?
In the medulla and it is the inspiratory pacemaker
Ventral respiratory center is located? What is it?
Medulla. Active exhalation
Apneustic respiratory center is located? What is it?
Pons. Stimulates DRC, triggers inhalation
What fracture runs horizontal across the maxilla: nose and hard palate?
Le fort 1
What fracture is located at the bridge of the nose and lateral wall maxilla?
Le fort 2
What fracture separates mid facial skull from the cranial bae. Transversing root of the nose, ethmoid bone, eye orbits, and sphenopalatine fossa?
Le Fort 3
What are the basilar skull fractures that disrupt the cribiform palate?
Le fort 2 and 3
Name 2 nerves that innervates the occuloardiac reflex
Five & a dime
CN V & CN X
Afferent occulocardiac reflex includes
- Long and short ciliary nerves= bradycardia and hypotension
- Ciliary ganglion
- Opthalamic division of trigeminal nerve
- Gasserian ganglion
Is this Afferent or Efferent occulocardiac reflex?
- Long and short ciliary nerves
- Ciliary ganglion
- Opthalamic division of trigeminal nerve
- Gasserian ganglion
Afferent
Efferent occulocardiac reflex
Vagus nerve -> SA node
What situations would you need prophylaxis antibiotics for endocarditis?
- Prothetic heart valve
- Unrepaired cyanotic congenital heart disease
- Cardiac transplantation with valvuloplasty
- Previous ineffective endocarditis
- Repaired congenital heart defect within 6 months of procedure
- Dental procedures involving gingival manipulation or damage to mucosal lining
Heart transplanted schedule for surgery. What is the cardiac output dependent on? Heart rate or preload?
Preload. Heart rate is fixed, and not affected by autonomic nervous system because it’s severed. (The heart rate is usually determined by the intrinsic rate of phase 4 depolarization of the SA node)
For every 1 unit of PRBCs, Hgb and Hct change by?
Hgb is 1g/dL
Hct is 2-3%
A pt’s HCT is 24% and you gave 2 units of PRBCs what is the expected new Hgb?
Hgb is 1/3 of Hct.
Convert Hct to hgb = 24 / 3 = 8 Hgb
We know 1 unit of PRBC increases Hgb by 1g/dL
8 + 2 = 10 g/dL
Spinal cord has how many anterior and posterior spinal arteries?
1 anterior spinal artery: motor
2 posterior spinal arteries: sensory
How to protect spinal cord during aortic aneurysm repair
- Want hypertension during cross clamping
- CSF drain
- Hypothermia
- Avoid hyperglycemia
ARBS: side effects
It is a Angiotension 2 blocker
- Hyperkalemia
- Lithium toxicity (increases absorption in kidneys)
- Maternal and fetal mortality
- Can cause vasoplegia (refractory hypotension)
A.flutter. Do you defibrillate or cardiovert? How many joules?
- Cardiovert sync on the R wave
- 1st shock 50 -100 joules
- 2nd shock increase incrementally
- Max 360 joules
We can cardiovert for: Afib, A.flutter, AV node re-entry tachycardia
How long should you delay surgery for pt who just had a drug eluding coronary stent?
What about for bare metal stent?
Delay sx for 6 months for drug eluding coronary stent
Delay sx for bare metal stent for 30 days
How much is eliminated and remaining?
1 half life
2 halve lives
3 halve lives
4 halve lives
5 halve lives
1 half life: 50% eliminated, 50% remains
2 halve lives 75% eliminated, 25% remains
3 halve lives 87.5% eliminated, 12.5% remains
4 halve lives 93.75% eliminated, 6.25% remains
5 halve lives 96.875% eliminated, 3.125% remains
3 halve lives how much is eliminated and remains?
87.5% eliminated, 12.5% remains
2 halve lives, how much is eliminated and remains?
75% eliminated, 25% remains
4 halve lives, how much is eliminated and remains?
93.75% eliminated, 6.25% remains
Drugs that interfere with SSEP monitoring
They cause DAIL: Decrease amplitude, increase latency
- Volatile gases, nitrous the most
- Benzos
- Barbituates
- Propofol (less)
SSEPs directly monitor the integrity of the dorsal (sensory) of the spinal
Drugs that DON’T interfere with (DAIL) decrease amplitude and increased latency in SSEPs
So these drugs would increase amplitude
- Ketamine
- Etomidate
- Opioids
- Precedex??
The lower a gas coefficient is
Less soluble it is in blood and prefers to stay in the air
Higher the gas coefficient is more likely to
Dissolve in blood but it’s slower to work
Partition coefficients are temperature dependent. When the temperature is increased the solubility is:
Decreased..
When temperature is decreased and cold, the solubility is increased. It likes staying in the blood and this is why it takes longer for the patient to wake up.
Does left-to-right shunt or right-to-left shunt affect inhalation induction time?
Right- to- left shunt. It decreases inhalation induction time. Desflurane is affected the most over nitrous
Left-to-right shunt does not affect inhalation induction time
In a right-to-left shunt will an agent with higher solubility or lower solubility be affected more?
An agent with lower solubility will undergo little uptake by the blood and is most affected by the right to left shunt and it decreases inhalation induction time
Therapeutic index formula
Therapeutic index = LD 50/ ED 50
Effective dose= is the dose to produce given affect in 50% of population not the dose required to produce maximum affect
Which is more likely to cause allergic reaction?
Ester at the intermediate chain
Morphine binds to the mu receptor in?
The dorsal horn
When morphine binds to mu receptor on the dorsal horn:
What does morphine inhibit?
What happens in the presynaptic and post synaptic nerve?
Opioid receptor is a G protein coupled receptor that inhibits adenylcylase and blocks the conversion of ATP to cAMP
- Presynaptic nerve: reduced calcium conductance and decrease neurotransmitter release
- Post synaptic nerve: increased potassium conductance = Hyperpolarization and makes neuron less response it stimulation
Does morphine cause Depolarization or Hyperpolarization of potassium?
Hyperpolarization of potassium
On the post synaptic nerve: increased potassium conductance = Hyperpolarization and makes neuron less response it stimulation
Cocaine dose mg/kg and max
3mg/kg
Max 200mg
For cocaine overdose, don’t give BB. They have super high SVR and a BB can decrease SVR = cardiac arrest
Best to give them nitroglycerin instead
Ingestion of Bella Donna S/S:
Treatment:
- Flushing
- Confusion
- Mydriasis
- Dry mouth
TOO MUCH ANTICHOLINGERGIC!
Treatment: Physostigmine. AchE inhibitor its the only one that works in the brain but it’s the slowest
Blockade: what occurs?
50%
60%
70%
80%
50% Most sensitive. Bite on tongue blade
60% Double burst without fade (2 burst at 50 Hz)
70% TOF 4/4 4 pulses at 2 Hz
80% TV at 5mL/kg
Blockade of 60%
Double burst without fade (2 burst at 50 Hz)
Blockade 70%
TOF 4/4 4 pulses at 2 Hz
Blockade 50%
Bite on tongue blade most sensitive
Blockade 80%
TV at 5ml/kg
ETCO2 is 49 and isn’t returning to baseline what should you do?
Fix or replace the inspiratory valve
As pt exhales gas with CO2 fills inspiratory limb, when they take a breath some exhaled gas is mixed with fresh gas
CVC catheter tip does not reside in right atrium = Dysrhythmias
- R. Subclavian
- R. IJ
- L. IJ
- Femoral vein
- Right median basilic vein
- Left median basilic vein
- R. Subclavian 10 cm
- R. IJ 15 cm
- L. IJ 20 cm
- Femoral vein 40 cm
- Right median basilic vein 40 cm
- Left median basilic vein 50 cm
Torsades de pointes can occur from administration of which narcotic?
Methadone, can cause QT prolongation
CVC is placed for pneumectomy in lateral postion, which side is it placed on the pt?
CVC is placed on the same side of the operative side
IJ > EJ
Elevated pressures predispose to lung injury**
Review
Circumflex is extremity is 20 inches and BP is width BP is 8 inches. Is it too big or too small?
Recommended cuff is 40% of circumflex of extremity
20 x 0.40 = 8 inches
Near infrared spectroscopy (NIRS)
- don’t think of the infrared one like pulse ox
- Measures venous oxygen saturation for cerebral oxygenation extraction
- It detects regional oxygenation only
- Relies on cerebral blood volume is 1 part arterial to 3 parts venous. 75% of of blood in the brain is on the venous side of circulation
What antiarhythmmic can increase airway resistance in asthmatic pt?
Adenosine
Given 6mg, 12mg, 18mg for SVT
Piston driven machine, how much positive pressure opens it?
75 cm H20
Doesn’t need O2 tank to fill like a bellow
Final products of soda lime
Sodium hydroxide NaOH
Calcium carbonate CaCO3
Sodium nitroprusside can cause a reduction in SpO2: true or false?
True. It increases intrapulmonary shunt in zone 3. It also dilates pulmonary vascular and counteracts HPV
Bruguda
Right bundle branch with ST elevation V1-V3, problem with sodium ion channel
Seen in southeast Asians
Treatment for cerebral vasospasm
Triple H therapy:
- Hypertension
- Hypervolemia
- Hemodilution
Also can use nimodipine CCB
Myasthenia Gravis:
- Pregnancy makes it worse
- Anti-Ach IgG antibodies pass through placenta and can cause weakness in neonates
- Post synaptic nicotinic receptors are reduced
- More tired throughout day
- Resistant to sux, sensitive to roc
- AchE FIRST LINE TX
Cerebral blood flow is directly proportional to PaCO2.
For every 1mmHg change in PaCO2, CBF changes 1-2 ml/100g/min
If pt’s PaCO2 went from 40mmHg to 34 mmHg. What is the CBF change?
40 - 34 = Pt’s PaCO2 changed by 6 mmHg.
For every 1mmHg change in PaCO2, CBF changes 1-2 ml/100g/min
6 x 1 = 6
6 x 2 = 12
CBF decreased by 6-12 ml/100g/min
For every 1mmHg change in PaCO2, CBF changes
1-2 ml/100g/min
For every 1mmHg change in PaCO2, CBF changes
1-2 ml/100g/min
Pt is undergoing spinal fusion. What increases risk of ischemic optic neuropathy?
- Wilson frame see pic
- Male
- Low ratio colloid: crystalloid resuscitation
- > EBL
- Long sx duration
- Obesity
Spinal hematoma needs to be decompressed within how many hours?
What are the S/S?
8 hours
- Bowel and bladder weakness
- Lower extremity weakness
- Back pain
- Sensory deficit
Where is the zygophophyseal joint?
Aka face joint
Where is the posterior cord?
Name cutting tip needles
- Quincke
- Pitkin
Name pencil point needles
- Sprotte
- Pencan
- Whitacre
Name lipophilic opioids
- Fentanyl
- Sufentanil
Provides analgesia systemically
Name lipophilic opioids
- Fentanyl
- Sufentanil
Provides analgesia systemically if given in epidural
Name hydrophilic opioids, do they act systemically or on the spinal cord?
- Morphine
- Hydromorphone
Act on the spinal cord, superior analgesia in epidural catheter
C 1 esterase inhibitor deficiency is a common heredity form of Angioedema. Treatment?
FFP- it has C1 esterase inhibitor
Why do you want to avoid giving bicarb to someone that is respiratory acidotic?
Bicarb is the treatment for metabolic acidosis not respiratory acidosis.
If you give it to someone with respiratory acidosis:
They are hypoventilating and have a lot of CO2 in their system. Giving them bicarb will dissociate into more CO2 and can worsen the condition.
Treatment for respiratory acidosis is to improve their ventilation: O2, Bronchodilation, mechanical ventilation
Ph is 7.2
70kg
Serum bicarb is 20 meq/L
How much bicarb should be given to correct a serum of bicarb of 25 meq/L?
25-20 = 5
Multiply by weight and 0.3 and divide by 2
5 x 70 x 0.3 = 105 meq/dl
105 / 2 = 53 meq/dl
Causes of hypocalcemia in the OR:
S/S?
- Hyperventilation
- Given blood products (nitrates)
S/S:
- QT prolongation
- Tetany
- Laryngospasm
ABG full compensation
Full compensation: pH has to be normal 7.35-7-45
ABG uncompensated:
Uncompensated: pH is NOT normal, and another 1 arrow pointing that direction
Ex:
- opioid overdose - uncompensated respiratory acidosis
- untreated pain - uncompensated alkalosis
ABG?
pH: 7.22 acidosis
pCO2: 49 respiratory acidosis
HCO3: 28 respiratory alkalosis
Partially compensated acidosis: pH abnormal: 2 arrows going one way and 1 arrow going another way
Rapid correction of chronic hyponatremia can cause
Central poutine myelinolysis (demyelination upper motor dysfunction)
BB overdose treatment
Glucagon- stimulates gluconeogensis in the liver
It increases myocardial contractility by increasing intracellular concentration of cAMP
Useful in CHF, BB overdose, low cardiac following MI, or CPB
Primary hyperparathyroidism
Signs of hypercalcemia:
- HTN
- Short QT
- Kidney stones
- Bone pain
- > 12 mg/dL
- Hypotonia muscle tone weakness
Match hepatic function test with abnormality
- Hepatic injury
- Cholelithiasis
- Synthetic function
- Hepatic injury- Aspartate amniotransferase
- Cholelithiasis- Y glutamyl transpeptidase
- Synthetic function- Prothrombin time
Y glutamyl transpeptidase tests for
- Cholelithiasis
Aspartame amniotransferase tests for
Hepatocelluar injury
What level do you block for these sx?
- Bladder procedures
- Prostate
- TURP
- Bladder procedures- t11-l2
- Prostate- s2-s3
- TURP- t10
What level do you block for prostate sx?
S2-S3
What level do you block for bladder procedures?
T11-L2
Drugs to avoid for carcinoid crisis?
- Epi
- Sux
- Thiopental
- NE
- Isoproterenol
Things that cause histamine release, tachycardia, stress! Avoid tachycardia
They occur in GI and spread
Metabolic changes in pyloric stenosis:
- Hypokalemia
- Hypochloremia
- Metabolic alkalosis
Why do you need to decrease etomidate dose in elderly?
- Decreased clearance
- Decreased Vd
Pt is experiencing postpartum hemorrhage secondary to retained placenta. What is the best medication to help with manual removal of the placenta?
Nitroglycerin it relaxes uterus
Pregnant pt needs GA. The fetus is at risk for?
- Fetal demise
- Low birth weight
- Growth restriction
- Preterm labor
- Avoid nitrous and benzos!
It doesn’t cause congenital abnormalities in second trimester
Early, late, variable decals for FHT
MIDLINE protrusion of organs with sac and associated with triosomies, CHD, Beckwith Syndrome:
Omphalocele:
- Trimosomies
- CHD
- Beckwith syndrome
Phenalzine- avoid with what drugs? Is morphine okay?
- Inhibits MAO
- Increases 5HT and NE
- Relieves depression
- Avoid: Cocaine, ephedrine, meperidine = serotonin syndrome
- some questions will ask is phenalzine ok with MAOIs? Yes bc it is an MAOI
Morphine is ok
Serotonin syndrome S/S:
- Hyperpyrexia
- Respiratory depression
- Hypotension
- Coma
Meperidine inhibits SSRIs and can lead to SS
Law of Laplace formula and give an example of
T = P x R
Abdominal aneurysm is more likely to rupture during hypotension
Also it can relate to atelectasis (saw this on Valley)
Aldrete score to safely discharge from PACU
> 9
O2 cylinder is cold after the valve is open, gas is released from high pressure container and loses speed
What law or effect is this?
Joule-Thompson
Which nerve fibers transmit tourniquet pain?
C fibers
Slow pain
Allodynia
Absent painful stimuli causing pain
Dyesthesia
Unpleasant/abnormal pain
Tourniquet release causes the ETCO2 increase or decrease?
To increase. CO2 builds up in ischemic limb
Closed claim data, incidence of anesthetic malpractice claims is increasing for all:
- Regional anesthesia
- Acute anesthesia
- Chronic anesthesia
EXCEPT SURGICAL ANESTHESIA
Overweight BMI:
Obesity 1 BMI:
Obesity 2 BMI:
Obesity 3 BMI:
Overweight BMI: 25-29
Obesity 1 BMI: 30-34
Obesity 2 BMI: >35-39
Obesity 3 BMI: > 40
CN 3 for the eye
- Superior rectus
- Inferior rectus
- Medial rectus
- Inferior oblique (extortion and elevation)
CN 4 for the eye
Superior oblique (intorsion and depression)
CN 6 for the eye
Lateral rectus (abduction)
CN 6 for the eye
Lateral rectus (abduction)
Chemo drugs that belong in antitumor class
- Bleomycin- affects lungs
- Doxorubicin- affects heart
Abdominal compartment syndrome:
How does it affect CO, diaphragm excursion, SVR, HR, pulmonary shunt?
Reduces CO and diaphragm excursion
Increases SVR, HR, pulmonary shunt zone 3, pulmonary edema
Things that worsen tracheobronchial compression:
- Supine
- Induction of GA
- Positive pressure ventilation
Celiac plexus block complications:
At what level is it performed at?
- Paralysis
- Hypotension
- Bowel puncture
- Subarchnoid epidural injection can occur
- Increased peristalsis/ diarrhea due to increased PNS
It’s performed at L1
Management with pt receiving bleomycin
They’re at risk of O2 toxicity
You want FiO2 < 30%
Lungs lack hydrolase enzyme, and it’s inactivated by bleomycin
High concentrations of bleomycin accumulate in the lungs
The lungs lack hydrolase enzyme, which is the primary mode of inactivation of bleomycin. This means that high concentrations of bleomycin accumulate in the lungs. This can damage the pulmonary capillary endothelium and later to the alveolar epithelium. In the lungs, hyperoxia stimulates production of oxygen free radicals, which may ultimately increase the risk of pulmonary fibrosis**
NR3
RCOOR
ROH
ROR
NR3- Amine
RCOOR- Ester
ROH- Alcohol
ROR- Ether
ROR
Ether
Rank most common to least common of allergic reactions:
Protamine, ABX, latex, muscle relaxants
1) Muscle relaxants
2) Latex
3) Abx
4) Protamine
Glyco increases or decreases LES tone?
Decreases
Glycopyrrolate lowers LES tone by blocking acetylcholine, a chemical that helps the sphincter stay tight. Without it, the muscle relaxes, making reflux more likely.
Think PCA: pregnancy, cricoid pressure, and anticholinergics decrease LES tone
What drug increases LES tone?
Reglan
Anatacids
Sux
AchE inhibitors
What drug increases LES tone? (Tightens it to prevent reflux)
Reglan
Anatacids
Sux
AchE inhibitors: neostigmine
Myexedema s/s:
Myxedema coma is a complication characterized by coma, hypoventilation, hyponatremia, and hypothermia
Severe hypothyroidism (myxedema) is an indication to cancel the surgical procedure.
Single lung transplant capnography
A double lung transplant in a patient with COPD should reveal a normal-appearing capnography tracing, assuming the transplanted lungs are healthy and no rejection has developed. SO CHOOSE A SINGLE LUNG TRANSPLANT
Dibucaine
Dibucaine inhibits normal pseudocholinesterase activity by 80%, meaning a normal patient has a dibucaine number of 80.
- Typical homozygous: 80
- heterozygous: 50-60.
- atypical homozygous: 20-30
In obese pts how do you dose sux?
Total body weight
Label the circle of Willis
CSF circulation
Love My 3 And 4 Little Miniature Schnauzers
Lateral Ventricles
Monro (Foramen of Monro)
3rd ventricle
Aqueduct of Sylvius
4th ventricle
Luschka (Foramen of Luschka)
OR
Magendie (Foramen of Megendie)
Subarachnoid space
Meds to dose LBW
Roc and Vec
Remi
Propofol induction
Sufentanil maintenance
Meds to dose by TBW:
Sux
Cis and atracurium
Versed
Fentanyl
Lipophilic drugs dose TBW
Hydrophilic drugs dose LBW
Obesity:
decrease in what lung volumes?
FRC and thoracic volume
Obesity:
decrease in?
FRC and thoracic volume
Asynchronous PACING:
Underlying ventricular activity is a risk for R on T phenomenon
Best used for pts without an intrinsic rhythm
Example is AOO or VOO this only paces
What rhythm is this?
WPW: AV nodal reentry tachycardia along the conduction pathway creates a delta wave, it’s antidromic QRS
What rhythm is this? Treatment?
It’s going LEFT so it’s AVNRT with WIDE QRS:
1) Procainamide
2) Cardioversion
Absorbed volume for TURP:
Blood loss:
Absorbed 10-30ml/min can lead to TURP syndrome. Fluid overload, hyponatremia, water intoxication. Hypertension, bradycardia, loss of consciousness
Blood loss 2-5 ml/min
Diseases associated with MH
King Denborough syndrome
Minicore disease
Central core disease
Treatment for tetanus
Debride infected area, antitoxin, intubate
Do not give things that increase SNS like phenylnephrine
Hemophilia A: what lab does it prolong?
PTT
Drug A and B are:
A: Hydrophilic: Meperidine, morphine, hydromorphone. When injected into CSF has higher block and stays there longer. Think it likes water and travels up spinal cord
B: Lipophilic: Fentanyl, Sufentanil. Goes to system circulation
Name some hypertonic solutions, what does it do to the cell size?
D5 NaCl 0.45
D5LR
D5 NaCl 0.9
NaCl 3%
They cause the cell to shrink
D5W is what kind of solution? What does it to do the cell size?
Hypotonic solution and
NaCl 0.45%
Causes cell to swell
Label this graph: context sensitive half time of each opioid
A: Fentanyl
B: Alfentanil
C: Sufentanil
D: Remi
Complications with acute pancreatitis:
Myocardial depression
Pericardial effusion
Thrombophlebitis
Loss of portions: hypovolemia
DIC
In elderly, which characteristic is associated with greatest risk of 30 day mortality?
A. Acute renal impairment
B. Unplanned ICU admission
C. Emergent surgery
D. ASA 4
D. ASA 4
Where is CSF reabsorbed?
Arachnoid villi of the superior sagittal sinus
Nitrous oxide CV effects:
Increase SNS: BP, SVR, HR
But it can cause myocardial depression!!!
What factor will decrease in the elderly?
A. Work of breathing
B. Dead space
C. PaO2
D. Degree of small airway closure
C. PaO2
Which lead is for diagnosing Dysrhythmias?
Lead 2
Which changes in SSEPs suggest increased risk of nerve injury? Select 2
A. 10 % increase in latency
B. 10% decrease in amplitude
C. 50% increase in latency
D. 50% decrease in amplitude
A & D
Which nerves are the highest risk for injury?
Superficial peroneal bottom leg
Sural top leg
When properly placed the distal tip of the LMA sits at:
A. Base of tongue
B. Pyriform sinus
C. Upper esophageal sphincter
C.
Compared to an adult what is higher in a newborn? What is lower?
- Extracellular fluid volume
- Volume of distribution for water soluble drugs
Alpha 1 acid glycoprotein concentration is lower till about 5-6 months. Also intracellular fluid remains the same!
Drugs that are not safe to give to pt with porphyria?
What can worsen it?
Name 2 drugs that ARE safe to give
AVOID BEKKACB: Barbs, etomidate, ketorlac, ketamine, CCB, birth control
Stimulation of ALA synthetase, emotional stress, prolonged NPO, CYP450 induction
OK TO GIVE: Nitrous and Sux
Clearance is directly proportional to:
Extraction ratio
Blood flow to the clearing organ
Clearance is inversely proportional to:
Half life
Concentration in the central compartment
(Complex regional pain syndrome)
Type 1 CRPS used to be called
Type 2 CRPS used to be called
Which type is preceded by nerve injury??
CRPS neuropathic pain with autonomic involvement
Type 1: reflex sympathetic dystrophy
Type 2: causalgia. Type 2 is always preceded by a NERVE INJURY!!!!!
Methionine synthase
Inhibits Vitamin B 12 metabolism and DNA synthesis for Nitrous Oxide
11-beta-hydroxylase
Inhibits steroid synthesis in Etomidate
Pulmonary hypertsion is defined as a mean PAP of at least:
25 mmHg
It increases work load of the right heart and can lead to cor pulmonale
Levodopa side effect
Orthostatic hypotension
take it day of surgery
Triggers of sickle cell crisis
Pain
Hypothermia
Acidosis
Dehydration
Intercostal line/Tuffer’s line
L4
What labs suggest prerenal cause of oliguria?
Fractional excretion of sodium <1% Pt is holding onto sodium and water
Urine sodium < 20 mEq/L
Increased urine osmolality (concentrated urine)
What increases or decreases as a result of pneumoperitoneum during laproscopic surgery?
- ICP
- MAP
- A-a gradient
- Renal and liver blood flow
- Cardiac output
Increased:
- ICP
- MAP due to hypercarbia, and increased afterload
- A-a gradient
Decreased:
- Renal and liver blood flow
- Cardiac output due to decreased afterload and venous return
What’s most likely to occur in Autonomic hyperreflex? (Select 2)
A. Hypothermia
B. Pulmonary edema
C. Tachycardia
D. Seizures
B and D
Most potent amnestic?
Diazepam, Midazolam, or lorazepam?
Lorazepam
Read and review this
What choices increase after placement of an infra renal aortic cross clamp?
A. Mixed venous oxygen saturation
B. Cardiac output
C. Preload
D. Renal blood flow
Preload and mixed venous oxygen saturation
Preload- blood volume is shifted proximal to the clamp
Mixed venous O2 saturation- it increases as a function of decreased O2 consumption, you are putting same amount into the lungs but cells distal to the clamp aren’t receiving it
List 2 examples of intrinsic restrictive disease
Aspiration pneumonia
Pulmonary edema
Review the lines on this graph:
Where is ICP, PaCO2, PaO2, cerebral perfusion pressure?
Highlighted line is ICP!
Black line: PaCO2
Purple line: PaO2
Non highlighted green line: cerebral perfusion pressure
What should be avoided in pt’s with myelomeningocele?
This is also called spina bifida high risk of latex allergy
Avoid latex
What part is this that correlates with the CVP wave form?
A wave on CVP: atrial contraction
P wave on EKG: atrial depolarization
Hypothyroidism anesthesia implications
Hypotension
Aspiration
THYROID ISSUES DON’T AFFECT MAC
Rank speed of local anesthetic uptake after injection fastest to slowest
Intercostals, brachial plexus, caudal, interpleural
Interpleural
Intercostal
Caudal
Brachial plexus
What is each peripheral nerve’s function?
A alpha
A beta
A delta
A gamma
A alpha: Motor
A beta: Pressure
A delta: Temperature
A gamma: Muscle tone
AB has what antibodies?
B has what antibodies?
A has what antibodies?
AB has what antibodies? None
B has what antibodies? Anti A
A has what antibodies? Anti B
O has both A and B
Which of these pulmonary functions will increase during pregnancy?
FRC, TV, IRV
Tidal volume
Inspiratory reserve volume
Polyhydramnios should raise suspicion for:
Tracheoesophageal fistula
VACTREL: “T”
Precedex on the peripheral post synaptic cause cause:
- centrally presynaptic- vasodilation/sedation/analgesia
- peripherally postsynaptic- vasoconstriction
Reduces Adenylate cyclase activity and reduce cAMP
Tripling radius will cause flow to increase by
81
R = 3x3x3x3
In experimental models all of the following associated with apoptosis in the developing brain except:
A. Sevo
B. Ketamine
C. Dexmedetomidine
D. Midazolam
C.
What do these drugs work on arteries or veins or both?
- nitroglycerin, nitroprusside, prazosin
Nitroglycerin- venules
Nitroprusside- works on arterioles and venules
Prazosin- works on arterioles
What conditions are consistent with this capnograph?
MH, opioid overdose, seizures
Notice how baseline returns so it rules out rebreathing
If it was rebreathing it could be: exhausted soda lime, incompetent unidirectional valve, hole in the inner tubing of a Bain circuit
A drug has a volume of distribution of 0.5 L/kg. In an 85kg pt what load dose must be administer to achieve a plasma concentration of 6mg/L
Loading dose formula = Vd x desired Cp / Bioavailability which is 1
42.5 x 6 = 255 mg
TOF monitoring for pt with hemiparesis
TOF monitoring on the hemiparetic limb yields falsely elevated response
Mass spectrometry
Bombarding gas sample with electrons using it’s weight (mass)
Raman scatter spectrometry
Aragon laser to produce photons which collide with the gas molecules
Treatment for gout
Gastrin
CCK
Motilin
Secretin
Pulmonary edema:
Is it left-to-right shunt or right-to-left shunt?
Right to left shunt
And it will not respond to supplemental O2
What are contraindications of hypokalemic periodic paralysis?
Glucose infusion and Lasix
What is ok is:
- Acetazolamide is useful in both hypo and Hyperkalemia
Following retinal detachment surgery how long should nitrous be avoided?
- Silicone oil
- Sulfur
- Air bubble
- Silicone oil 0 days
- Sulfur 10 days
- Air bubble 5 days
Impaired bile production is a source of
Coagulopathy
If its impaired it reduces absorption of fat soluble vitamins, D, A, K, E
K is important in producing factor 2, 7, 9, 10
What causes non gap metabolic acidosis?
(Due to lose of HCO3- or increased Cl-)
Diarrhea
Renal tubular acidosis
Excessive sodium chloride administration
FGF coupling
FGF COUPLING:
1) Convert L to ml
2) multiply by fraction of a minute spent in inspiratory time
3) divide by RR
4) Add to volume set on bellows
Where as FGF DE-COUPLING: set tidal volumes and delivered tidal volumes are equal
Cyproheptadaine
5HT anatagonist
Treatment for serotonin syndrome but it’s only in PO form
Ecstasy intoxication
Sepsis:
Pulmonary wedge pressure:
CO:
SVR:
Pulmonary wedge pressure: Decreased
CO: Increased
SVR: Increased
Patients with which 2 viral infections have a higher incidence of type IV allergic reactions?
Patients with Epstein-Barr and cytomegalovirus infections have an increased incidence of type IV allergic reactions.
Neostigmine reverses the effects of neuromuscular blockade primarily by
preventing the metabolism of acetylcholine
The lateral femoral cutaneous nerve is composed of fibers from?
L2 and L3
What drug is recommended for intravenous treatment of serotonin syndrome?
Intravenous chlorpromazine is a serotonin receptor antagonist that is administered for the treatment of serotonin syndrome.
Cyproheptadine is an oral serotonin antagonist that is the drug of choice for treating serotonin syndrome. However, it is available only in an oral formulation.
The 3 most important factors in determining spread of local anesthetics in the epidural space
1) Local anesthetic volume
2) Level of injection**
3) Drug dose
Less impact:
Concentration
Patient position
Hepatopulmonary syndrome is a triad composed of
liver dysfunction
intrapulmonary vascular shunting/dilation
unexplained hypoxemia
The definitive treatment is liver transplantation, which resolves the hypoxemia within 1 year.
The temperature of an ideal gas in a closed system is held constant. If the volume is doubled, the pressure of the gas:
decreases by one-half.
Boyle’s law shows that, at a constant temperature, changes in a gas’s volume (V) are inversely proportional to changes in pressure (P): P1V1 = P2V2.
If the volume doubles, the pressure must decrease to maintain the balance in the equation. For instance, if P1 is 1 atm and V1 is 1 L, when V2 doubles to 2 L, the resulting pressure (P2) will be 1/2 atm, indicating a decrease by one-half.
Carbon dioxide is primarily transported in blood as dissolved carbon dioxide as well as:
- bicarbonate 70%
- plasma 7%
- bound to hemoglobin as carbamino compounds 23%
Respiratory effects in obesity?
MV, ERV, FRC, VC, RV, CC:
Minute ventilation (via an increase in respiratory rate) must increase to maintain normal blood gas tensions.***
ERV is decreased, resulting in lower FRC and VC.
RV and closing capacity are unchanged in obese individuals (unlike in restrictive diseases, where it is decreased).**
The Fick equation
[CO = VO2 / (CaO2—CvO2)] can be used to calculate cardiac output
total oxygen consumption/ differences between arterial and mixed oxygen content
Hydrophilic opioids in epidurals
Slower onset
Longer duration
Higher CSF solubility**
Extensive CSF spread**
Somatosensory-evoked potentials (SSEP) monitor? Where does signal takes place?
MEPS monitor? What does signal take place?
SSEPs assess lateral and posterior spinal cord perfusion. Signal takes place in the patient’s brain
Motor-evoked potentials (MEP) are used to evaluate anterior spinal cord perfusion
Mapleson circuit A FGF:
Mapleson circuit D FGF:
A Mapleson A: 20 L/min to prevent rebreathing during controlled ventilation.
The Mapleson A circuit is best used for spontaneous ventilation.
Mapleson D: FGF rate of ≥ 2.5 times the patient’s minute ventilation rate is required to prevent rebreathing. Best for controlled ventilation
5-hydroxyindoleacetic acid is the metabolite of
serotonin used to diagnose carcinoid syndrome. This syndrome typically presents with flushing, diarrhea, and wheezing.
Acknowledging only information that supports the suspected diagnosis
Confirmation bias
Performing unindicated maneuvers and deviating from protocol
Commission bias
Performing unindicated maneuvers and deviating from protocol
Commission bias
Unwillingness to let go of a failing diagnosis or decision
Sunk cost
Risk factors for carbon monoxide production following volatile anesthetics administration include:
Risk factors for carbon monoxide production following volatile anesthetics administration include
1) dry absorbent
2) type and concentration of the volatile anesthetic
3) the type of absorbent.
Risk factors for soda lime desiccation include using the anesthesia machine for the first case on Monday morning when the oxygen flowmeter was discovered to flow at high rates all weekend, and cannister is warm to touch
A bronchial blocker is advantageous rather than a double-lumen tube (DLT) for selective lobar collapse in patients with:
- prior oral or neck surgery and with challenging airways
- in patients with a tracheostomy
- in children younger than 8 years of age
- when postoperative mechanical ventilation is anticipated
Bronchial blockers are not as reliable as DLTs for providing lung isolation, and DLTs are generally used if there is no specific indication for bronchial blocker placement.
3 types of protamine reactions
Type 1: Histamine: hypotension
Type 2: Anaphylaxis (previous use of NPH insulin, fish allergy, or vasectomy) Epinephrine should be the first-line
Type 3: Heparin–protamine complexes release arachidonic acid byproducts, including thromboxane A2, which causes pulmonary vasoconstriction and systemic hypotension and can lead to right ventricle failure. Give epinephrine or milrinone. May need reheparinization to decrease the number of heparin–protamine complexes and, ultimately, reinstitution of cardiopulmonary bypass.(Low BP, low CO, high PCWP, low LVEDP)
What is the MOST LIKELY side effect following a successful diagnostic stellate ganglion block?
Signs of Successful Stellate Ganglion Block:
Flushing of the conjunctiva and skin of the face and arm
Horner syndrome (miosis, ptosis, anhidrosis, pseudoenophthalmos, hyperemia)
Nasal congestion
Temperature increase in the ipsilateral arm
What type of tracheostomy tube should be used when performing a bedside tracheostomy?
A cuffed low-pressure tracheostomy tube is required to avoid aspiration
What type of tracheostomy tube should be used when performing a bedside tracheostomy?
A cuffed low-pressure tracheostomy tube is required to avoid aspiration
After an average induction dose of succinylcholine, prolonged recovery from the neuromuscular blockade is observed. Which patient medication is MOST likely attributed to the prolonged neuromuscular blockade?
A. Magnesium
B. Sodium
C. Lithium
Lithium potentiates neuromuscular blockade after dosing depolarizing and nondepolarizing neuromuscular blocking drugs, decreases the minimum alveolar concentration of inhalational anesthetics, and potentiates the action of anesthetic agents.
The proposed mechanism is the presynaptic inhibition of neuromuscular transmission and muscular contraction postsynaptically through the activation of potassium channels.
After an average induction dose of succinylcholine, prolonged recovery from the neuromuscular blockade is observed. Which patient medication is MOST likely attributed to the prolonged neuromuscular blockade?
Lithium potentiates neuromuscular blockade after dosing depolarizing and nondepolarizing neuromuscular blocking drugs.
Through presynaptic inhibition of neuromuscular transmission and muscular contraction postsynaptically through the activation of potassium channels.
What adverse events can occur with intraoperative blood salvage transfusion?
hypervolemia
bacterial contamination
hypotension
nonimmune hemolysis
febrile nonhemolytic reactions, allergic reactions
disseminated intravascular coagulation
coagulopathies
air embolus
and nonspecific temperature increases that include chills and skin flushing.
Local anesthetics have a higher rate of absorption when injected in areas of higher vascularity:
Greatest to least:
“In The ICU, Patients Easily Breathe So Smoothly.”
intravenous > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > sciatic/femoral > subcutaneous
Leak pressure in uncuffed ett in peds
The ideal leak pressure of an uncuffed endotracheal tube (ETT) in pediatric patients is < 25 cm H2O.
With a leak pressure > 40 cm H2O, the ETT should be replaced with a smaller ETT**
A continuous fentanyl epidural gtt provides analgesia by acting
Systemtically
Anesthetic considerations for patient with Pheochromocytoma: Select 3
A. Morphine
B.Droperidol
C. Nitroprusside
D. Phenoxybenzamine
E. Dextrose
Nitroprusside, Phenoxybenzamine, dextrose
Plasma NE falls after tumor is removed and it increases the risk of hypoglycemia. Dextrose is essential
What condition is most closely associated with this?
Gastroishisis. It’s to the right of the umbilicus and not covered by a sac. It’s common in prematurity
What chemo drugs are in these drug classes? What does it affect?
Alkylating agent-
Tubulin-binding drug-
Alkylating agent- Cisplantin (affects ears and kidneys)
Tubulin-binding drug-Vincristine (Affects neuropathy)
Blood gas coefficient for Sevoflurane
0.65
Which gas is most affected by right to left shunt?
Desflurane compared to nitrous
What happens to SVR with inadequate pain management?
SVR increases
Know which NT are exitatory vs inhibitory
- Excitatory: Sub P, glutamate, acetylcholine, dopamine
- Inhibitory: GABA, glycine, enkephalin, serotonin, NE (CNS inhibitory, PNS excitatory)
Which gas law states that at a constant temperature, the amount of gas dissolved in a liquid is directly proportional to the partial pressure of that gas at equilibrium above the gas-liquid interface?
Henrys
Hormones that use the phospholipase C system include:
APOV
- Alpha receptor catecholamines
- Parathyroid hormone
- Oxytocin
- Vasopressin V1
Hormones that use the adenylyl cyclase system include:
- calcitonin
- ACTH
- glucagon
- secretin
- somatostatin
- vasopressin V2
- parathyroid hormone
- luteinizing hormone
- beta-receptor catecholamines
Stimulation of GABA receptors results in an influx of which electrolyte
influx of chloride ions into the cell
Which of the following conditions is known to produce increased latency in brainstem auditory evoked potentials?
Low PCO2 (hypocapnia) exaggerates BAEPs, resulting in an increased latency and Hypothermia
What cardiac reflex?:
Traction on the mesentary=
Increased ICP=
Traction on the medial rectus=
Increase in Intrathoracic pressure=
Traction on the mesentary= celiac reflex
Increased ICP= cushing’s reflex
Traction on the medial rectus= oculocardiac reflex
Increase in Intrathoracic pressure= valsalva reflex
Which of the following are reliable tests that can be used to determine whether or not a patient has muscle strength adequate enough to sustain ventilation and take a large enough breath to cough effectively?
1) TV of 10-12 ml/kg
2) Negative inspiratory force of -25 cm H2O
3) Ability to perform sustained head lift
What is the most common cause of an acute increase in deadspace in the acute care setting?
Decreased cardiac output
(Got this off prodigy)
What are the fundamental factors that reduce the mixed systemic partial pressure of oxygen (PvO2)? (select two)
- decrease in arterial oxygen content
- increase in oxygen extraction
How is patient morbidity related to the volume and pH of aspirated material? What is it directly and indirectly related to?
- directly related to volume
- indirectly related to pH
Sign’s of diabetes inspidus:
- urine specific gravity less than 1.005
- a urine osmolality of 200 mOsm/kg or less.
Pediatrics pt with what condition increases their risk of Propofol syndrome?
Mitochondrial disease
Risk factors: 4mg/kg/hr for 48 hours in pediatric pts
A patient presents for liver transplantation due to hepatopulmonary syndrome (HPS). This disease is characterized by the triad of:
Hepatopulmonary syndrome (HPS) is characterized by the triad of
- hypoxemia
- portal hypertension
- pulmonary vascular dilations
A preoperative finding of nystagmus would be consistent with potential abuse of which drug?
Phencyclidine (PCP)
Repeat stimulation caused by nerve damage or chronic inflammation can cause a condition known as
Windup
Repeat stimulation caused by nerve damage or chronic inflammation can cause a condition known as windup. This cyclical response to pain ultimately leads to abnormal pain responses and a chronic pain sensation. Due to the chronic discharge of neurons, the inhibitory systems of neuropathways become overwhelmed.
You are preparing to induce a patient with a large anterior mediastinal mass for general anesthesia. Which device should you have at your immediate disposal?
Rigid bronchoscope cus they’re at risk of immediate airway obstruction
A patient is placed in steep Trendelenburg position for a robotically-assisted procedure. This will cause a decrease in lung volumes or lung compliance?
Decrease in lung compliance
How is an epidural catheter size typically related to the needle?
2 gauges smaller
Which patient safety initiative outlines a list of serious, reportable adverse outcomes such as surgery on the wrong site?
The National Quality Forum
The duration of action of ester local anesthetics within the subarachnoid space is primarily dependent upon
Systemic absorption
Select two laboratory studies that appear to be associated with increased risk of perioperative pulmonary morbidity.
- low serum albumin
- increased BUN
Where should the tip of a central venous pressure catheter be located?
above the junction of the superior vena cava and the right atrium
A patient exhibits a sodium level of 130 mEq/L and a serum osmolarity of 315 mOsm/L. Previous administration of which drug would most likely explain these findings?
Mannitol
This patient has a low serum sodium concentration but a high serum osmolarity. Hyponatremia with a normal or high serum osmolarity results from the presence of non-sodium solutes such as glucose or mannitol.
How long after a single epidural injection of methylprednisolone 80 mg would you expect the patient’s ability to secrete cortisol to be impaired?
A single epidural injection of 80 mg of methylprenisolone can suppress plasma cortisol and the ability to secrete it for 3 weeks after the injection
Which opioid should not be used in a neuraxial block?
Remifentanil contains glycine as a buffer. Because glycine can cause neurotoxicity, it cannot be administered epidurally or intrathecally.
Maximum total dose of lidocaine mg/kg?
55mg/kg
What is the most common manifestation of sickle cell disease as a result of tissue hypoxia and infarction?
Vaso-occlusive crisis
What is the pKA for:
Chloroprocaine:
Tetracaine:
Bupivacaine:
Lidocaine:
Chloroprocaine: 8.7
Tetracaine: 8.5
Bupivacaine: 8.1
Lidocaine: 7.9
Nerves that are most likely to be injured due to improper lithotomy positioning:
Sciatic, common peroneal, posterior tibial, saphenous, obturator
Carbon dioxide laser can cause what kind of injury?
Corneal because it’s a longer wavelength and can’t penetrate deep tissue
Other lasers like ruby, nd-yag, argon can cause retinal injury
Which area of myocardium is most susceptible to myocardial ischemia?
Left ventricular subendocardium
Where would Reynold’s number be the lowest?
Terminal and respiratory bronchioles < 2,000
It would be greatest in the trachea and the main stem bronchioles > 4,000
How many days to hold?
- Clopidogrel
- Ticlopidine
- Abciximab
- NSAIDs
- Clopidogrel 7 days
- Ticlopidine 14 days
- GP IIb/IIIa receptor antagonist: Abciximab 3 days
- NSAIDS: 1-2 days, ASA is 7 days
Absolute indications for single lung ventilation?
- Massive hemorrhage
- Bronchopleural fistula
- Unilateral lung lavage
Which drugs show a prolonged effect in the patients with a dibucaine number of 20?
Benzocaine, Sux, and mivacurium
These drugs are metabolized by PchE
the patient has atypical homozygous pseudocholinesterase deficiency
Match each pain modulating neurotransmitter with its target receptor:
- Glycine
- Glutamate
- Substance P
- Serotonin
- Glycine: Chloride linked GlyR
- Glutamate: N-methyl-D-aspartate
- Substance P: Neurokinin 1
- Serotonin: 5HT
A: Trigeminal nerve V2
B: Trigeminal nerve 3
C: Glossopharyngeal nerve
D: Vagus nerve
Muscular dystrophy (Duchenne’s): Absence of dystrophin
Myotonic dystrophy: excess calcium sequestration
Acute idiopathic polyneuritis: immunologic assault on myelin in the peripheral nerve
Hyperkalemia periodic paralysis: Alteration of sodium channels
What does each WBC do?
- Basophil
- T cell
- B cell
- Neutrophil
- Basophil: releases histamine
- T cell: cell mediated immunity
- B cell: humoral immunity with antibodies
- Neutrophil: most abundant WBC
How many valves are present?
- Ayre’s T piece:
- Jackson-Reese:
- Circle breathing system:
- Ayre’s T piece: 0 valves
- Jackson-Reese: 1 valve
- Circle breathing system: 3 valves
Ways to reduce systemic absorption of opthalamic medication:
- Keep eye shut for 1 minute
- Avoid blinking
- Compress the medial canthus of the eye
Which volatile agent is most likely to cause a fire inside the breathing circuit?
Sevoflurane
Which laws are illustrated in the Fick equation? What things are directly proportional to Fick’s?
- Graham and Henry
Directly proportional to:
- Partial pressure difference
- Diffusion coefficient
- Membrane surface area
Indirectly proportional to:
- Membrane thickness
- Weight
Which laws are illustrated in the Fick equation? What things are directly proportional to Fick’s?
- Graham and Henry
Directly proportional to:
- Partial pressure difference
- Diffusion coefficient
- Membrane surface area
What things are indirectly proportional to Fick’s law?
- Membrane thickness
- Molecular weight
DOPA decarboxylase facilitates the conversion of:
DOPA to dopamine
Dopamine-beta-hydroxylase facilitates the conversion of:
Dopamine to NE
Tyrosine hydroxylase facilitates the conversion of:
Tyrosine to DOPA
What are the steps involved in the synthesis of NE and EPI?
1) Tyrosine to DOPA: tyrosine hydroxylase
2) DOPA to dopamine: DOPA decarboxylase
3) Dopamine to NE: Dopamine-beta-hydroxylase
4) NE to EPI: Phenylethanolamine N- methyltransferase
Which steroid has the most potent glucocorticoid properties?
Decadron and Betamethasone are the only ones affected by glucocorticoid
Debakey
Type 1:
Type 2:
Type 3:
Type 1: involves ascending and descending aorta
Type 2: ascending aorta
Type 3: descending aorta
Crawford classifications
Which type is least likely to cause aortic insufficiency?
Type 1-4 involve descending thoracoabdominal aorta only and type 1 is the least likely to cause aortic insufficiency
Stanford classification for aneurysms:
Type A: ascending and may or may not involve descending aorta
Type B: descending aorta
Superior hypogastric plexus block
useful for cancer pain in pelvic organs
Bronchial blocker
- Allows isolated lung to be suctioned
- Can be used if pt requires nasotracheal intubation
- Can be used for lung separation in the pt with a trach
- < 12 years
- Placed with a FOB for assistance
Common cause of death with an LVAD
SEPSIS
Spinothalamic tract:
1st order neuron- dorsal root
2nd order neuron- dorsal horn
3rd order neuron- thalamus
Vanco must be started within how many minutes of surgical incision?
Vanco needs to be started within 120 minutes (2 hours) of surgical incision. All other abx need to be started within in 1 hour
Rank lowest to greatest amount of pain caused by the procedure:
Topical, retrobulbar, peribulbar, sub tendon block
Lowest to greatest pain:
1) Topical
2) Sub-tenon block
3) Peribulbar block
4) Retrobulbar block
Pt is undergoing masectomy with the sentinel node biopsy:
What electrolyte change is commonly seen? What monitor may be inaccurate?
- Hypercalcemia is common
- SpO2 may be inaccurate during the surgery
Laminae 1-6 reside in:
Laminae 1-6 reside in dorsal grey matter and they are sensory
Laminae 7-9 reside in:
Laminae 7-9 reside in the ventral grey matter and are motor
Which agents are oxybarbituates?
Methohexital, phenobarbital, secobarbital
They have an O2 at the 2nd position
Which agents are thiobarbiuates?
Thiopental and thiamylal
They have a sulfur at the 2nd position.
Is MAC changed by obesity?
No
Drug class?
- Amiodarone
- Diltiazem
- Phenytoin
- Metoprolol
- Amiodarone: Class 3
- Diltiazem: Class 4
- Phenytoin: Class 1B
- Metoprolol: Class 2
What is associated with radial nerve injury?
- Wrist drop
- External pressure at the spiral groove of the humerus
- Caused by surgical retractor or an IV pole that puts pressure on the arm
When would coronary artery stenting be best over a CEA?
- EF < 30%
- Unstable angina, abnormal stress test or MI < 1 month
- Valve disease
- Severe obesity
- Contralateral RLN dysfunction
Effects on the eyes:
- Heroin
- Methampetamine
- Phencyclidine
- Heroin: miosis
- Methampetamine: mydriasis
- Phencyclidine: nystagmus
What % of morbidity and mortality is associated with the following events?
- CV events
- Resp events
- Regional events
- Equipment failure
- CV events: 13%
- Resp events 17%
- Regional events 20%
- Equipment failure 10%
Nerves blocked by axillary approach to the brachial plexus approach?
- Radial, ulnar, musculocutaneous, median nerve
Axillary nerve is not blocked by the axillary block!!!!!!!
Second messenger of nitric oxide
Cyclic guanosine monophosphate
NO activates cGMP, this activates protein kinase = vascular smooth relaxation
Diclofenic
Non-selective COX inhibitor
it can cause thromboxane platelet dysfunction and bleeding, tissue protective prostanoids with gastric ulcers, and renal vasodilates prostanoids with renal impairment
Atrial natriuretic peptide increases what 3 things?
- GFR
- Water excretion
- Sodium excretion
ANP is released in response to atrial distention from increased volume
A patient who experiences malignant hyperthermia requires active cooling. When should active cooling be discontinued?
When the core temp drops below 38C
Bourdan pressure gauge can be used to calculate the cylinder volume for:
Helium and nitrogen
Which valve issue is most common in ankylosing spondylitis?
Aortic insufficiency
Max inflation pressure for an LMA classic?
60 cm H2O
Aortic stenosis is considered severe aortic valve
< 0.8cm^2
Cortisol synthesis is dependent on
Cholesterol
Fibromyalgia is associated with
Allodynia: non noxious stimulus that produces pain
Choose the letter that represents the hormone produced in the supraoptic nucleus’s of the hypothalamus
D: Antidiuretic hormone
ADH is produced in the paraventricular nuclei of the hypothalamus
According to American Society of Anesthesiologists what is the incidence of anesthetic mortality in the ASA 1 patient population?
ASA 1: 0.04 per 10,000 anesthetics
ASA 2: 0.5 per 10,000 anesthetics
ASA 3: 2.7 per 10,000 anesthetics
ASA 4: 5.5 per 10,000 anesthetics
Components in cryoprecipitate?
1) Fibrinogen and fibronectin
2) Von willebrand factor
3) Factor 8 and 13
During shoulder surgery, in the beach chair position the MAP in the upper arm is 60 mmHg. If the external auditory meatus is 14 inches higher than the blood pressure cuff. What is the MAP in the circle of Willis?
For every 1 inch above the heart the real MAP is 2 mmHg less than what you see on the monitor.
For every 1 inch blow the heart, the real MAP is 2 mmHg more than what you see on the monitor.
There is a 14 inch difference. So 14 x 2 = 28
MAP is 60 so 60-28 = 32 mmHg!
How many oxygen atoms are bound to 1 hemoglobin molecule when mixed venous oxygen saturation is 75%?
Each hemoglobin molecule can carry 4 oxygen molecules, oxygen is diatomic so this means 8 oxygen atoms
If hgb saturation is 100% it carries 4 O2 molecules (8 oxygen atoms)
If hgb saturation is 75% it carries 3 O2 molecules (6 oxygen atoms)
If hgb saturation is 50% it carries 2 O2 molecules (4 oxygen atoms)
If hgb saturation is 25% it carries 1 O2 molecule (2 oxygen atoms)
Highest to lowest protein bound local anesthetics:
larry brown runs monster trucks like prince phillip and charles (highest to lowest)
Levobupivacaine (most)
Bupivacaine
Ropivacaine
Mepivacaine
Tetracaine
Lidocaine
Prilocaine
Procaine
&
Chloroprocaine 0% (least)
You ran out of D50 amps. But you have a D5NS liter bag how many ml can you give to achieve the same amount as 25mL of D50?
D50 is prepared as 50% glucose in water. It has 25g of dextrose in 50 ml of water.
D5NS is 5% glucose in 0.9% NaCl. It contains 50g of dextrose in 1 liter of 0.9% NaCl. So each g/ml is 0.05g/ml. Because 50/1000 = 0.05
You were asked to give 25mL of D50 which is 12.5G of dextrose
12.5g/ml = x/ ml = 0.05 g / 1ml = 250 ml
What hemodynamic change is this?
Increased CVP + Increased PADP + normal PAOP=
Is it right ventricular failure or pulmonary hypertension?
Pulmonary hypertension
What hemodynamic change is this?
Normal CVP + Increased PADP + Increased PAOP
Is it left ventricular failure or right ventricular failure?
Left ventricular failure
What hemodynamic change is this?
Increased CVP + normal PADP + normal PAOP
Is it pulmonary hypertension or right ventricular failure?
Right ventricular failure
When performing an infraclavicular block, which 2 muscles will be penetrated before reaching the target for blockade?
Pec major and pec minor are penetrated
When blood flows through a nonatherosclerotic section of the artery, what vascular or fluid change would lead to the GREATEST reduction in flow?
A. Double the blood viscosity
B. Double the length of the tube
C. Halving the radius of the artery
D. Half the blood viscosity
Halving the radius of the artery reduces flow exponentially THE MOST!
ICU Management of Patients with Severe TBI: Parameters
- ICP:
- Glucose:
- CPP:
- PaCO2:
- ICP: 10-20 mmHg. Want it less than 20
- Glucose: <180
- CPP: 50-70 mmHg
- PaCO2: PaCO2: 35–40 mm Hg, not lower than 35
Hyperventilation leads to hypocapnia, which reduces intracranial pressure (ICP) via a reduction in the cerebral blood flow (CBF). However, this is typically a transient fix, and prolonged hyperventilation has been shown to potentially worsen cerebral ischemia. Therefore, **it is not recommended for indefinite management of a traumatic brain injury (TBI).*8
Instead, recommendations call for keeping TBI patients normocapnic (PaCO2 of 35–40 mm Hg).
Things that can cause overdamping of art line:
- Stopcocks
- Tubing size
- Air in the pressure monitoring system.
- Disappearance of the dicrotic notch is a sign of overdamping
What condition will MOST likely increase the plateau pressure during positive-pressure mechanical ventilation?
A. Anaphylaxis
B. Endotracheal tube partial obstruction
C. Acute asthma attack
D. Transfusion-related acute lung injury
D. Transfusion-related acute lung injury
Plateau pressure is the pressure in the small airways and alveoli after reaching the target tidal volume.
Since there is no airflow when the target tidal volume has been reached, airway resistance does not affect the plateau pressure.
Complications of elevated plateau pressures include pulmonary edema (such as seen with transfusion-related acute lung injury), ventilator-associated lung injury, pneumothorax, pneumomediastinum, and subcutaneous emphysema
Review the dermatomes
What organs can the celiac plexus block be good for?
- stomach
- pancreas
- diaphragm
- liver
- spleen
- small intestine
- large colon
- transverse colon
- adrenal glands
- kidney
Hypogastric plexus is good for: distal colon, uterus, prostate
What is the action of each structure?
- Frontal lobe : Cognition
- Globus pallidus : Fine motor movement
- Amygdala: Emotion
- Hippocampus: Learning
How does ketamine affect CMRO2 and CBF?
↑ CMRO2 ↑ CBF
Increases both
How does sevo affect CMRO2 and CBF?
↓CMRO2 ↑CBF
How does Propofol affect CMRO2 and CBF?
↓CMRO2 ↓CBF
Decreases both
How does benzos and Etomidate affect CMRO2 and CBF?
Decreases both like propofol
How does precedex affect CMRO2 and CBF?
No affect on CMRO2, decreases CBF
D is MA: clot strength
The maximum amplitude (D) of the thromboelastogram indicates the mechanical strength of the fibrin clot and, thus, platelet function. A value lower than 50-60 mm indicates a possible problem with thrombocytopenia, thrombocytopathy, or the presence of antiplatelet agents.
What type of nerves are responsible for the transmission of burning pain?
The C fibers are nonmyelinated fibers that slowly carry mechanical, chemical, and thermal pain perceived as a dull, prolonged burning sensation.
A. In Eaton-Lambert syndrome, IgG autoantibodies directly attack voltage-gated calcium channels
The primary tactile landmark for the placement of a stellate ganglion block is the ____________________ which is the transverse process of ______.
Tubercle of Chassaignac, C6
The lateral approach to sciatic nerve blockade that involves the external landmarks of the:
- greater trochanter
- the posterior superior iliac spine
- and the sacral hiatus
is refered to as the approach of:
Labat
For most blocks, when using a nerve stimulator, stimulation should be acquired below ________ mA but above _______ mA to insure adequate blockade while minimizing risk of intraneuronal injection.
0.5, and 0.2
The initial bolus dose of 20% intralipid used for treatment of local anesthetic systemic toxicity is:
1.5ml/kg
Not mg!
In performing an intercostal nerve block, it is important to remember that:
a) the nerve travels just below the artery on the superior surface of the rib
b) the nerve travels just above the artery on the superior surface of the rib
c) the nerve travels just below the artery on the inferior surface of the rib
d) the nerve travels just above the artery on the inferior surface of the rib
d) the nerve travels just above the artery on the inferior surface of the rib
In performing an intercostal nerve block, it is important to remember that:
a) the nerve travels just below the artery on the superior surface of the rib
b) the nerve travels just above the artery on the superior surface of the rib
c) the nerve travels just below the artery on the inferior surface of the rib
d) the nerve travels just above the artery on the inferior surface of the rib
d) the nerve travels just above the artery on the inferior surface of the rib
A deep cervical plexus block can be performed by (select two):
a) Injecting 12 mL of local anesthetic at the C4 transverse processes
b) Injecting 5 mL of local anesthetic along the posterior border of the sternocleidomastoid
c) Injecting 3-4 mL of local anesthetic at the C2, C3, and C4 transverse processes
d) Injecting 10 mL of local anesthetic in the epidural space at the C3 level
a) Injecting 12 mL of local anesthetic at the C4 transverse processes
c) Injecting 3-4 mL of local anesthetic at the C2, C3, and C4 transverse processes
Para-aminobenzoic acid is a metabolite of:
Procaine
In the performance of an ankle block, which 3 nerves are blocked by a subcutaneous injection?
Saphenous, Sural, Superficial Peroneal
The duration of action of which local anesthetic would be prolonged the least by the addition of epinephrine prior to injection?
Bupivacaine
The _______________ block is the least likely to significantly raise intraocular pressure because it involves the lowest volume of local anesthetic.
a) retrobulbar
b) peribulbar
c) Sub-Tenon’s
d) Tenaculam
a) retrobulbar
Expiratory valve incompetence, the capnograph tracing does not return to 0 during inspiration.
Expiratory valve incompetence results in marked elevation of the inspiratory segment of the end-tidal carbon dioxide capnography waveform.
The capnograph tracing does not return to zero during inspiration.
This is because of the rebreathing of exhaled gases from the expiratory limb in a reverse direction, which also results in a mildly elevated expiratory segment.
A similar tracing may also occur in the setting of exhausted carbon dioxide absorbent.
Late FHT decelerations
Drop in beats/min for how long?
A deceleration is described as a temporary decline in fetal heart monitoring, with a drop of > 15 beats/min for a maximum of 2 minutes
If a deceleration lasts 2-10 minutes, it is considered a prolonged deceleration caused by severe uteroplacental insufficiency.
An incompetent inspiratory valve allows exhaled gas to enter the inspiratory limb. The capnograph in the stem demonstrates a decreased slope (a widening beta angle). A portion of the exhaled breath reenters the inspiratory limb, and the patient will breathe the previously exhaled carbon dioxide. The waveform may reach 0, depending on the fresh gas flow.
Which congenital heart defect MOST favorably responds to the administration of prostaglandin E2 for the maintenance of pulmonary blood flow?
A. Atrial septal defect
B. Pulmonary atresia
C. Hypoplastic left heart
D. Ventricular septal defect
B. Pulmonary atresia
Prostaglandin E2 administration maintains ductal patency and pulmonary blood flow in neonates with pulmonary atresia.
Cardiac lesions that depend on a patent ductus arteriosus to provide pulmonary circulation include pulmonary atresia, tetralogy of Fallot, and tricuspid atresia.
Which congenital heart defect MOST favorably responds to the administration of prostaglandin E2 for the maintenance of pulmonary blood flow?
A. Atrial septal defect
B. Pulmonary atresia
C. Hypoplastic left heart
D. Ventricular septal defect
B. Pulmonary atresia
Prostaglandin E2 administration maintains ductal patency and pulmonary blood flow in neonates with pulmonary atresia.
Cardiac lesions that depend on a patent ductus arteriosus to provide pulmonary circulation include pulmonary atresia, tetralogy of Fallot, and tricuspid atresia.
Draw out cardiac AP and ionic movement
Depolarization: Sodium influx
Initial repolarization: Chloride influx and potassium efflux
Plateau: Calcium influx and potassium efflux
Final repolarization: Potassium efflux and sodium-potassium ATPase pump
Name the order of the fibers
B, C, alpha gamma, alpha delta, alpha a, alpha b
Weak acids:
◦ Lower pH than pKa = nonionized
◦ Higher pH than pKa = ionized
Barbiturates and Propofol
• Weak bases:
◦ Higher pH than pKa = nonionized
◦ Lower pH than pKa = ionized
Local anesthetics, benzos, opioids, ketamine
Inserting PA cath can cause
Pulmonary infarction and complete heart block
What to avoid for SSEP monitoring?
Nitrous oxide, it depresses it the signal amplitude the most
What drug is a partial mu agonist and difficult to reverse with Narcan?
buprenorphine
- only partial mu agonist
- greater analgesia than morphine
- difficult narcan reversal (d/t high affinity for mu receptor)
- long DOA (8hrs), available transdermal
Other facts:
Nalbuphine:
- kappa agonist, mu antagonist
- similar analgesia to morphine
- reversed by narcan
- no CV changes, useful w/ hx heart disease
Butorphanol:
- kappa agonist, mu antagonist
- stronger than morphine
- good for shivering
Steps of Soda lime
I just memorized the last parts of each step
1) It uses water = H2CO3
2) = Na2CO3 + 2H2O + energy
3) = CaCO3 + 2NaOH
Line isolation monitor
Alarms at 2-5 MA means OR is grounded
Label the colored lines
The pulse oximeter is based on the Beer-Lambert law, which relates the intensity of light transmitted through a solution and the concentration of the solute within the solution.
A pulse oximeter emits two wavelengths of light:
- red 660 nm (better absorbed by reduced Hgb)
- infrared 940 nm (better absorbed by oxyhemoglobin).
I think of MODC:
- Methhgb, oxyhgb infrared 940 nm, deoxyhgb red light 660nm, carboxyhgb
Pt has small cell carcinoma, says his weakness improved with exercise. What do you suspect he has?
Eaton Lambert!
- His weakness improves with exercise, he’s sensitive to both Sux and ROC!
- He’s resistant to neostigmine reversal.
- IgG mediated destruction of the v-gated Ca++ channel at the presynaptic nerve terminal. presynaptic!!!
- they’re sensitive to both depolarizers and non depolarizers
- Volatile anesthetics also provide enough muscle relaxation for most surgical procedures like in MG
- association with small cell lung carcinoma
- Treatment: 3,4-diaminopyridine (DAP) increases ACh release from the presynaptic nerve terminal and improves the strength of contraction.
Which condition is associated with muscle weakness when core temperature reaches 38 degrees Celsius?
A) Osteogenesis imperfecta
B) Ehlers-Danlos syndrome
C) Myotonic dystrophy
D) Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis is a demyelinated disease of the CNS.
• Patients experience sensory and motor deficiencies as well as autonomic instability.
•Cranial nerve involvement causes bulbar muscle dysfunction (aspiration risk).
• Patients are treated with corticosteroids, interferon, and azathioprine.
• S/sx can be exacerbated by stress and increased body temperature (as small as 1 degree C).
• Classic teaching suggests that, while epidural anesthesia is safe, spinal anesthesia may exacerbate symptoms. The supporting evidence is weak.
• Succinylcholine can cause life-threatening hyperkalemia.
Hyperventilating can cause the curve to shift LEFT
You dont want a PaCO2 less than 30!
Findings in TIPS procedure
- decreased SVR, increased cardiac output
- increased BUN
- hyponatremia
- thrombocytopenia
Synthetic function: PT, INR, albumin
Biliary duct obstruction: alkaline phosphatase and GGTP
Most potent ADH stimulators
- hypovolemia
- increased serum osmolarity
Steroids that promote water retention
Mineralocorticoids: Aldosterone and prednisone
Aldosterone is a pure mineralocorticoid, and prednisone serves both functions.
(Decadron and bethamethasone are glucocorticoids they don’t promote water retention)
If you have high phosphate levels how can you treat it?
Calcium carbonate (tums)
