TL block 8 Flashcards
1
Q
4 S’s of distaster
A
-staff: make sure to have enough, can pull stuff into ICU areas w/ proper mentoring and guidance
-stuff: be okay w/ no help for 72 hours w/ equipment
-space: might have to expand ICU coverage into ED and PACU
-strategy: coordination of surrounding population, location of hospital system w/ asking for help at a state, federal level
2
Q
CRPS I v II
A
I: no prior nerve injury
II: after nerve injury (extra I for injury)
3
Q
pacemaker set up?
-electrocautery used and pt 3rd degree block when cautery active
A
DDD
4
Q
difference b/w magnet with PM and AICD
A
-PM: puts it into asynchronous mode
-AICD: turns off defib, but PM still functional
5
Q
How to avoid R on T phenomenon w/ PM
A
-ensure that the pacemaker rate is faster that the intrinsic heart rate
6
Q
Contraindications to therapeutic hypothermia
A
-GCS > 8
-uncontrolled bleeding
-hemodynamically unstable rhythms
-hemorrhagic stroke
7
Q
dehydration and jet ventilation
A
-long periods of jet ventilation dry out the respiratory mucosa -> impairs ciliary action -> inc mucous aggregation
-rarely can cause necrotizing tracheobronchitis
8
Q
first step when discovering a bronchoplural fistula
A
lung isolation! to prevent infxn going to healthy lung
-double lumen tube or bronchial blocker
9
Q
goal of hyperbaric oxygen
A
to increase the amount of O2 dissolved in the blood
10
Q
cyanotic congenital heart disease and hyperbaric O2
A
not indicated
11
Q
Indications for hyperbaric O2
A
-ischemia (skin flaps, retinal artery occlusions)
-treatment of C perfringens
-anemia that can’t be transfused
-pulmonary lavage due to alveolar protein buildup
-air embolism
-decompression sickness
-carbon monoxoide poisoning/cyanide
-intracranial abscesses
-burn injuries
-chronic osteomyelitis
-burns
12
Q
Order of activation of heart w/ transcutaneous pacing
A
RV -> LV
-loss of atrial kick ( ~20% dec in cardiac output)
-similar to VOO
13
Q
spread of local anesthetic intrathecal v epidural
A
intrathecal: baricity
epidural: volume
14
Q
pKa and anesthetics
A
time of onset
-why sodium bicarb added to make it faster
15
Q
protein binding and drugs
A
duration of action
16
Q
Cryoanalgesia
A
-extreme cold burning of intercostal nerves for thoracotomy
-quick procedure ~30sec
-lasts 1-3 months -> assoc w/ neuropathic pain
-not enough for pain control -> need supplemental w/ thoracic epidurall/paraverteberal/opioids
-has been shown to decrease opioid use and improve pulm fxn
17
Q
post exposure ppx for Hep B
A
Hep B hyperimmune globulin
18
Q
When to decide to place a magnet for a surgery
A
-How PM dpt pt is -> if not using, not needed and asynchronous mode could be catastrophic
-location of surgery: if above umilicus need to consider, if below no need
19
Q
pacemaker capture and elctrolytes
A
-PM capture is harder if pt is hypokalemic
20
Q
Most sensitive test for MH?
A
Contracture test
(halothane or caffeine)
21
Q
Multiple sclerosis anesthesia concerns
A
inc risk of respiratory complications due to resp muscles weakness -> impaired cough, diff vent weaning, inc risk of aspiration PNA
22
Q
What % improvement in FEV1with bronchodilators would someone w/ obstructive dx need to have to be recommended chronic bronchodilator therapy?
A
> 10%
23
Q
Equation for pressure gradient across aortic valve
A
P gradient = 4 * (peak velocity)^2
24
Q
Triad of tamponade
A
far away heart sounds
JVD
hypoTN
25
Anesthesia considerations w/ cardiac tamponade
-Cardiac output dpt on preload, HR
-maintain HR and BP
-if fluid depleted, give fluids prior to induction
-best agents: ketamine (symp activation), and etomidate
-sympathetic surge after pericardiocentesis -> have NG available for then
-keep breathing spontaneously if possible -> minimize TV and PEEP (dec venous return w/ PPV)
26
Pulsus paradoxus
w/ tamponade
-dec in systolic BP by 10 w/ inspiration
-inc venous return due to neg intrathroacic Pressure w/ inspiration -> bulging of RV into LV -> limited forward flow out of LV -> dec BP
27
dx of pulm HTN
pulm artery systolic pressure > 35
-mean pulm artery pressure > 25 at rest
-mean pulm artery pressure > 30 w/ exercise
28
Goals for anesthesia w/ pulm HTN
AVOID: hypoxia, hypercapnia, acidosis, inc sympathetic tone
-minimal TV and minimal PEEP
-euvolemia
29
Considerations for transplanted heart
-dennervated -> no parasympathetic input
-resting HR Is 90-110 w/ little variability
-HR dependent on DONOR atrium -> not connected w/ recipient atrium
-no response to anticholinergics, only respond to direct acting receptors
-Frank-starling curve remains intact
**preload dependent!!
30
Dichrotic notch on aline
aortic valve closure
31
aortic a line v peripheral a line MAP?
lower in peripheral
32
area under the waveform tracing: aorta a line v peripheral a line
higher area under the waveform in aorta
33
What is myelomeninogcele commonly assoc w/?
Hydrocephalus (Chiari II malformation: brain herniates through foramen magnum blocking 4th ventrile)
34
Indications for cardiac resynchronization therapy
1. EF < 35%
2. Intraventricular conduction delay > 120 msec
3. HF symptoms
4. sinus rhythm
ALL must be met
35
tricuspid annular plane systolic excursion
measure of R ventricular function
1.1 cm: moderately depressed
36
Carbamazepine toxicity
-cardiac: widening of QRS, prolonged QT, tachycardia, hypoTN
-neuro: AMS, delirium, paradoxical dec in sz threshold, nystagmus
-anticholinergic: mydriasis, hyperthermia, urinary retention, dry mouth
37
Best way to augment cardiac output in pt w/ aortic stenosis, preserved EF, and new onset a fib
conversion to NSR!
-loses 20-30% of CO w/ a fib
38
how to tell apart central sleep apnea from OSA
CSA: no respiratory effort during apneic episodes, OSA: always has respiratory effort w/ apneic episodes
-CSA more assoc w/ stroke, opioid use d/o
-snoring more assoc w/ OSA
39
Treatment for central sleep apnea
CPAP
-resp stimulants: theophylline and acetazolamide
40
what is a hypoglossal n stimulator used for?
treatment for OSA
41
compared to aortic a line, a peripheral a line will have:
1. higher systolic pressure
2. lower diastolic pressure
3. inc pulse pressure
4. delayed and slurred dichrotic notch
5. more pronounced diastolic wave
42
Anesthesia concerns for rheumatoid arthritis
airway: TMJ hypomobility, atlantoaxial subluxation
pulm: fibrosis, restrictive dx due to arthritis in costochondral
cardiac: pericarditis, tamponade
renal: chronic NSAIDs -> insuff
43
physiologic changes w/ ECT
-inc inn CMR -> inc in CBF -> inc in ICP
-bradycardia -> tachycardia and HTN
-short term memory loss
44
best lab for detection of intraop MI
troponin
45
Factors predicting high success w/ epidural steroid injxns
-shorter symptom duration
-no psychopathology
-assoc w/ disc herniation plus n root irritation or compression
46
Factors predicting decreased success w/ epidural steroid injxns
-chronic symptoms
-assoc w/ spinal surgery
-psychopathology
47
ischemic optic neuropathy symptoms
-sluggish pupils
-dec visual field
-painless vision loss
48
anterior vs posterior ischemic optic neuropathy types of surgery assoc
anterior, anterior part of body: assoc w/ cardiac surgery
-posterior, posterior part of body: assoc w/ spine surgery
49
Spinal stenosis: worse and better
better: squatting, walking uphill
worse: walking downhill, back extension
50
dx of abd compartment syndrome
intra-abd pressures > 20
51
Sites correlating w/ core temp
-distal 1/3 esophagus
-tympanic
-nasopharyngeal
-pulm artery
52
how far is skin temp off from core temp?
2C
53
most likely cause of adverse outcome related to anesthesia equipment?
misuse of equipment
54
Dosing for etomidate should be
lean body weight
55
dosing for thiopental should be
lean body weight
56
What medications for morbidly obese pts should be dosed on actual body weight?
dexmedetomidine
succinylcholine
synthetic opioids
57
What medication to avoid if concern for increased intracranial pressure and trying to dec BP?
NG
nitroprusside
->causes vasodilation in cerebral vessels -> inc ICP
58
Nitrous oxide CMF CMRO2
increases both
59
how to blunt inc in CBF with nitrous oxide
simultaneous admin of IV anesthetics
60
nitrous oxide plus volatile anesthetics CBF
higher CBF
61
Why does autonomic dysreflexia occur?
Pt's w/ spinal cord injuries T5-T7 or higher have unopposed sympathetic activation below the level of the injury
-pain from below T7 (full bladder, surgical stimulation) -> activation of sympathetic reflexes -> no parasympathetics to even out -> extreme HTN
-so severe vasoconstriction/sympathetic activation below the injury level
-severe HTN is sensed by carotid baroreceptor (carotid sinus) -> vagal response -> vasodilation above level of injury, bradycardia, heart block
62
Symptoms in autonomic hyperreflexia
BP >20-40 from baseline
-unopposed symp below injury -> cold, vasoconstricted lower extremities
-reflex vagal activation to inc in BP -> bradycardia, heart block
-vasodilation in upper extremities, flushing, sweating (diaphoresis), nasal congestion
-HA, risk of hemorrhagic stroke, sz, cerebral edema
63
How long after spinal cord injury can you get autonomic hyperreflexia?
2 weeks to 6 months
64
normal intraabd pressure
< 5-7
65
intrabd HTN def
intra-abd pressures > 12
66
RF for intraabdominal HTN
-dec ability of abd to expand: burns, surgery, trauma
-inc vascular leakage: sepsis, large fluid resuscitation, acidosis, hypothermia
-inc intraluminal contents: gastroparesis
-inc intraabd contents: laparoscopic surgery, acute pancreatitis
-age, coagulopathy, high PEEP, shock
67
chronic renal insuff and intraabd HTN
-is NOT an independent RF, but decreases threshold for intraabd HTN (because easier to put into organ failure if already compromised) -> same w/ cardiomyopathy and pulm dx
68
How do spinal cord stimulators work?
activate the larger Aalpha and Abeta fibers to a larger degree to that this impedes the conduction of the smaller nociceptive Adelta and C fibers past the substania gelatinosa of the dorsal horn of the spinal cord
69
Treatment for cerebral vasospasm after subarachnoid hemorrhage?
Nimodipine
70
After subarachnoid hemorrhage, when is vasospasm likely
-can occur after 72 hours, but peaks at 7-8 days
71
If trauma, but no nerve injury, what type of CRPS?
Type I (nociceptive pain)
72
What type of pain is CRPS type II associated with?
Neuropathic
73
most common events precipitating CRPS
bone fracture
-upper extremities more commonly affected
74
Elderly response to dobutamine stress test
elderly pts have dec elasticity in vessels -> inc in SVR -> inc in afterload -> LVH -> dec ability to relax during diastole -> inability to compensate as well w/ exercise and inc HR
-so inc in HR w/ dobutamine stress test -> less cardiac output -> hypoTN
**elderly very dpt on atrial kick
75
resting stroke volume 80 v 30
same resting stroke volume, but the elderly can't compensate to increase their stroke volume w/ exercise (diastolic dysfxn and dec beta receptor activity)
76
Cardiac changes w/ elderly
-dec beta receptor sensitivity
-LVH
-diastolic dysfxn
-less elastic vasculature
--> more dpt on atrial kick, impaired ability to augment cardiac output w/ stress or exercise, poor tolerance of inc in heart rate
77
Large diff b/w peak and plateau pressure
-bronchospasm
-mucus plug
-ETT kinking
(inc airway resistance)
78
Small diff b/w plateau pressure and peak pressure
-issue w/ lung compliance
-pulm fibrosis
-inc abd pressure
-poor positioning
-PTX
-obesity
-chest wall deformity
-pulm edema
79
Why do pts w/ myotonic dystrophy have inc risk of aspiration
-weakness in pharyngeal muscles
-delayed gastric emptying, intestinal hypomobility, gastric atony
-thyroid dysfxn, DM, adrenal insuff
80
Def of functional residual capacity
amount of air left in lungs at end of passive TV breath
81
Inc in PEEP on FRC
inc in PEEP opens more alveoli -> volume of air in lungs will be inc -> inc in FRC
82
I:E ratio w/ COPD
dec I:E ratio is a method to prevent auto-PEEP from occuring
-require a longer expiratory time to empty air from their lungs
83
Causes of low FRC
PANGOS
Pregnancy
Ascites
Neonate
General anesthesia
Obesity
Supine
84
pts w/ duchenne muscular dystrophy preop
everyone gets an EKG and echo
-EKG is likely to have Q waves -> progression of cardiac dx, does not need a cath
-if arrhythmias, may need a holter
-severity of muscular dx is NOT assoc w/ severity of cardiac
-biggest correlation w/ morality is LV fxn
85
EKG in newly transplanted heart
May have 2 P waves -> recipient and donor atriums, but they do not communicate
86
cardiopulm bypass priming solution
-primarily crystalloid w/ some additive
-heparin: prevent clotting on circuit
-mannitol -> osmotic diuresis, preventing tissue edema
-colloid: also help limit tissue edema, but is an additive, not primary solution
-calcium: risk of hypoca w/ large amt of blood products
87
chronic opioids and endocrine
-inc in prolactin
-dec in cortisol, testosterone, estrogen, FSH, LH
-immunosuppression
88
intraaortic balloon pumps
-inflate during diastole -> inc Aortic DBP -> inc coronary perfusion
-deflates during systole -> dec afterload, helps inc cardiac output
89
when doing PFTs, those with ____ COPD will have the biggest change in FEV1 w/ bronchodilator therapy
moderate
-minimal change w/ mild or severe COPD and bronchodilators
90
when does resting PFTs predict exercise performance in lung dx?
those with MILD lung dx
91
PFTs and pneumonectomy
-if PFTs initially show that pneumonectomy might not be tolerated -> next step is to do split-function lung testing and see how involved each lung is , to see if pneumonectomy will be tolerated now
92
Phantom limb pain is what type of pain?
Neuropathic
93
dysesthesias
abnormal sensations
94
acid-base w/ salicylate poisoning
combined anion-gap metabolic acidosis w/ respiratory alkalosis (direct stimulator of respiratory drive)
95
Treatment of salicylate toxicity
-supportive (ABCs)
-activated charcoal
-fluids
-dextrose (avoid CSF hypoglycemia)
-bicarb admin -> raises systemic pH dec tissue distribution, raises urine pH inc clearance
-HD if severe
96
tinnitus, AMS, tachypnea, what intox?
Salicylates
97
Stridor post extubation and concern for airway edema
-racemic epi
-heliox
-tx cause -> if unsure nasopharyngeal fiberoptic gold standard to determine
98
causes of supraglottic airway edema
-too much fluid admin
-surgical hematoma
-prone positioning (impaired venous drainage)
99
causes of subglottic airway edema
-traumatic intubation
-damage from ETT (prolonged, excessive cuff pressure, tight-fitting tube)
100
cuff-leak test: results indicating airway edema
-< 130cc diff from inh and exp
-< 24% diff from inh and exp volume
101
SSEPS: assess where? and detected where?
assess lateral and posterior SC perfusion
-detected in the brain
102
MEPs used to assess? and where detected?
assess anterior spinal cord perfusion
detected: peripheral musculature
103
sepsis TEE
RV and LV dilation w/ global hypokinesesis with no regional wall abnormalities
-dec EF but normal cardiac output
104
pituitary adenoma symptoms
-dec peripheral vision
-galactorrhea, amenorrhea
-hypothyroidism
-dec cortisol, FSH, LH, hypogonadal
-dec cardiac output -> due to dec thyroid (dec SV) and adrenal (hypoTN)
***doesn't affect posterior pituitary, ADH and oxytocin normal
105
PaCO2 and temp
Each degree below 37C, PaCO2 dec by 2
106
stress response proteins
proteins initially anabolism -> catabolism (incl breakdown of skeletal m) to mobilize amino acids for gluconeogenesis in liver
107
first step in airway fire w/ no advanced airway (Nasal cannula in place)
turn off airway gas flow!
108
first steps in ETT in place airway fire
simultaneously extubate pt and turn off flows
-next steps: remove flammable materials -> poor saline down fire (unclamp IV bag and just pour) -> if no lung fire extinguisher
109
GCS
eyes, vocal, motors
4, 5, 6 points
eyes
1: none, 2: open to pain 3: open to voice 4: open spontaneous
vocal
1: none, 2: incomprehensible, 3: inappropriate, 4: confused, 5: appropraite
motores:
1: none, 2: extends to pain, 3: flexes to apin, 4: withdraw from pain, 5: localized pain, 6: follows commands
110
PEEP application in a pt w/ systolic heart failure
PEEP causes a dec in preload -> is beneficial in pt overloaded from HF
-inc in CVP and PVR -> better V/Q matching -> less preload and forward flow -> improve cardiac index, and dec PCWP (LA)
-b/c of inc intrathoracic pressure, afterload is decreased
111
what fluids to avoid in neurosurgery?
anything w/ glucose in it -> inc cerebral edema
112
cannot be allowed in MRI
-cochlear implants
-spinal cord stimulators
-aneurysm clips
-intrathecal pumps
-metal fragments
-bullets
113
OK for MRI:
-vascular clips
-ortho implants
-staples
-heart valves
-other prostheses
114
Obesity and respiratory things
-inc in minute ventilation (bec inc O2 need, inc CO2 prod due to inc metabolism from inc adipose tissue)
-Restrictive lung dx
-Dec FRC (same RV, so dec in ERV)
-high closing volume to FRC -> atelectasis, and hypoxemia
-no change: RV and closing capacity
115
HOCM hemodynamic goals
-maintain preload
-low HR -> inc diastolic filling time, less LVOT obstruction
-red contractility
-adequate SVR
116
if pharm not working for HOCM next steps
septal reduction by myectomy or ethanol ablation
117
MOA pertussis toxin
ribosylation of Gi protein -> inhibits the inhibitor of cAMP -> inc in cAMP
**whooping cough
118
heroin and what toxin?
tetanus spores have been found in heroin
119
Neuromotor pathway for MEPs
cortex -> internal capsule -> brainstem -> corticospinal tract -> peripheral n -> muscle
120
SSEPs pathway
peripheral n -> dorsal root ganglia -> posterior spinal cord -> brainstem -> thalamus -> cortex
121
cardiac dysfxn w/ acromagly
LVH!
122
Anesthesia concerns for acromegaly
***difficult DL and mask laryngoscopy
-HTN
-DM
-LVH
-OSA
123
congential diaphragmatic hernia, sudden severe hypoxemia w/ doubling of peak inspi pressure
PTX -> chest tube or needle thoracotomy
124
D: milrinone
A: furosemide
C: hydralazine
E: Norepi/epi
125
Normal cardiac output
4-8 L/min
126
Normal Cardiac index
2.5-4 L/min/m^2
127
Normal Stroke volume
60-100 cc/beat
128
Normal stroke volume index
33-47 cc/m^2/beat
129
Complications w/ subarachnoid hemorrhage
first 24 hrs: rebleeding
first few days: hypoNa (SIADH or cerebral salt wasting)
after 3 days, peak 5-10 days: vasospasm
130
Which of the neurologic monitors LEAST affected by volatiles?
Auditory evoked potentials
131
Neurological monitor most sensitive to volatile anesethetics
visual evoked potentials > MEPs > SSEPs > auditory
132
Normal lung change s w/ age
-dec elastic recoil in lungs -> inc compliance but dec in chest wall compliance -> dec alveolar surface area
-INCREASE: RV, FRC, CC, dead space
-DECREASE: FEV1, FVC, VC
-dec muscle mass -> flattening of diaphragm -> forced exhalation harder
-PVR inc (hardening of vasculature)
-PaO2 dec, PaCO2 no change
-blunted hypoxic pulm vasoconstriction
***TLC unchanged
133
ppx to treat and reduce hypoxic pulm vasoconstriction
Nifedipine
B2 agonists
134
Adjustment body makes w/ inc altitude
-hypoxia: inc ventilation -> resp alkalosis -> eliminate bicarb out of CSF and out through kidneys
-Inc in Hct
-severe complications: hypoxic pulm edema (inc risk of pulm HTN) or hypoxic cerebral edema
135
tx for altitude sickness
descent
O2
dexamethasone
136
MOA Xenon gas
NMDA receptor antagonist
137
Which inhalation anesthetic causes the LEAST inc in ICP?
sevo
138
In setting of severe hypoxemia w/ one lung ventilation and dual lung vent cannot occur?
Surgery needs to clamp nondependent pulmonary artery
139
Critical closing pressure of the upper airway
-if pt obstructing and has no air flow, but has air flow w/ a CPAP of 5 -> Pcrit is 5
-negative in awake individuals, becomes positive during anesthesia
140
Carotid sinus
baroreceptor
141
carotid body
chemoreceptor
142
How do carotid body chemoreceptors work?
If chemoreceptor senses PaO2 < 55 -> afferent glossopharyngeal n -> CNS ventilation centers
143
Why would there be an impairment of chemoreceptor inc in ventilation?
-impaired glossopharyneal n
-b/l carotid endarterectomy
-opioids, benzos, volatile anesthesics (down to 0.1 MAC)
144
If you have a pt w/ a AICD and they get into a life threatening arrythmia, steps?
1. take off magnet -> let AICD doing its shock
-tell surgeon to stop w/ electrocautery
2. if it doesn't work, put pads on and shock
145
A alpha fibers
convey proprioception
146
A beta fibers
convey touch sensation
147
A delta
sharp, lancating, easily localizable pain
-because faster, usually what you feel first
148
C fibers
mechanical, thermal, and chemical pain
-usually burning sensation you feel 2nd because slower than A delta
149
Symptoms of discogenic pain
-worse w/ sitting, better w/ standing
-worse w/ flexion, coughing, sneezing
-better w/ sitting tall (takes pressure off discs)
150
Morning stiffness, pain dx?
Ankylosing spondylitis
151
Inc postop morbidity and mortality in post-pneumonectomy if they failed phase 1 testing:
1. Combined FEV1 < 35% with DLCO < 35%
2. Inability to climb 2 flights of stairs
3. FEV1 < 30% by itself
1. mean pulm artery pressure > 35
2. PaCO2 >45
3. PaO2 < 60
Values during exercise
1. PVR > 190
2. Max VO2 < 15
3. Dec in arterial O2 sat > 2-4%
152
elderly people and lusitropy
-ability for LV to relax -> old people have LVH and diastolic dysfxn -> neg lusiotropy
153
Sign of cerebral protection w/ barbiturate coma, EEG pattern?
burst suppression
154
What brain waves are present in deep coma and deep anesthesia?
Delta
155
What brain waves are present in encephalopathy?
Theta
156
What brain waves are present w/ relaxation and eyes closed?
Alpha
157
What brain waves are present during awake arousal?
Beta
158
Why burst suppression over isoelectric EEG for barb coma?
burst suppression means the brain is still firing, more predictable wake up once meds turned off, with still max reduction in CMRO2
159
Best way to intraop monitor LVADs?
Put an aline in if anything other than minor surgery (BP cuffs and pulse ox not reliable) -> w/ intermittent ABG to assess oxygenation
160
Pulsatility index LVAD
-normal 3-6, if lower indicationg hypovolemia or impaired cardiac fxn
-pulsatility of LV in real time, higher number means LV is pushing more blood
161
pump speed LVAD
revolutions per minute, set by cardiologys, we dont touch
162
If you double your distance from radiation, your exposure dec by factor of what?
4
163
Catecholamines and the elderly
-higher levels of baseline catecholamines in elderly -> why less significant resp during stress
164
Acute lumbosacral radiculopathy, now what?
-NSAIDs, acetaminophen, maybe muscle relaxants first -> conservative measures first (b/c most resolve in 3 months!)
-then if imaging :CT or MRI
-consider steroids PO
165
To reduce intaop AICD firing
-place dispertion pad near surgical site
-bipolar cautery
-short bits of monopolar if needed
**in emergency have device interrogated after surgery
166
Myofascial pain syndrome
-taut muscle bands
-radiation of pain, but NON-dermatomal when trigger points palpated
-autonomic symp: piloerection, vasoconstriction
-spontaneous EMG activity
167
lung volumes and acromegaly
INCREASE
-get an inc in size of lung volumes due to inc in organ size
168
acromegaly and mandibular length
increased!
-can get skeletal overgrowth
169
acromegaly and insulin
glucose intolerance, insulin resistance, and DM
-dx of acromegaly: inc insulin like growth factor 1 -> test confirmed w/ oral glucose load and no suppression of growth hormone
170
acromegaly and sweating
hyperhidrosis!
171
Lung/airway closure in normal people
-small airways close first, then larger airways
-dependent lung areas have airway closer first (higher positive intrathoracic pressure causing airways to close) compared to non-dpt regions
172
airway closure emphysema
-def of emphysema is damage to alveoli and distal airways
-so alveoli and distal airways close earlier than normal airways when inc in intrathoracic pressure -> air trapping
-airway closure occurs closest to alveoli b/c that's where the damage is, and where the airways are the thinnest
173
Resistance to airway and radius
-resistance inversely proportional to radius to the 4th power!
1/2 side of radius -> resistance inc 16 fold
174
Why atelectasis w/ 100% FiO2
-alveoli quickly absorb the O2 and then collapse -> atelectasis
-w/ lower FiO2, still some nitrogen in alveoli keeping them open
175
Cerebral palsy and inhalational anesthetics
-have decreased MAC requirements, inc sensitivity to inh anesthetics
176
cerebral palsy and NDNMB
inc resistance
177
Anesthesia concerns for CP
-dec MAC for inh gases
-opioid sensitivity
-GERD
-OSA
-diff IV
-altered thermoregulation
-impaired airway reflexes
-malnutrition
178
Def of long QT
QTc:
men: > 440
women > 460
** > 500 inc risk of torsades
179
treatment of congenital long QT
-fix lytes, remove offending dx
-1st: beta blockers
2nd: implantable defib if CI to beta blockers, or life threatening cardiac arrest, or high risk
180
what meds improve SSEP amplitude?
ketamine
etomidate
181
what neurologic monitoring is best for posterior fossa surgery to look for brain stem ischemia?
auditory evoked potentials
-closest to surgical site
-often GA w/ inh anes is used and auditory is the most resistant
182
SSEP signs of ischemia
Latency inc by 10%
amplitude dec by 50%
183
MEP sign of ischemia
Amplitude dec by 50%
184
What pressor inc cerebral perfusion pressure and inc cerebral oxygenation?
Vasopressin
-inc MAP
-inc nitric oxide causes cerebral vasodilation -> inc oxygenation
185
Phenylephrine cerebral perfusion pressure and cerebral oxygenation
inc CPP by inc MAP
-dec cerebral oxygenation b/c cerebral vasoconstriction and dec cardiac output
186
PaCO2 and SSEPs
if < 50 and above 25, no changes
187
in pts intubated, how does GCS change?
verbal becomes 1 T or I
188
in pt w/ extreme eye/facial swelling how is GCS altered?
eye 1 C -> indicates eye is closed
189
def of dead space
ventilation w/o perfusion
190
shunt def
perfusion w/o ventilation
191
sudden dec in SpO2 and EtCO2 after tourniquet release
pulm embolism
192
Best anesthetic plan to limit exacerbation of MS
epidural
-spinal, GA have all been assoc w/ exacerbations due to inc stress -> may require extended postop care
-**maintain normothermia, hyperthermia assoc w/ exacerbations
193
postop pneumonectomy, white lung field, air-fluid level inferiorly, febrile, copious sputum production
bronchopleural fistula
194
if patient has a bronchopleural fistula and chest tube, what needs to be done before induction?
put chest tube on water seal
195
How above systolic BP should an upper extremity tourniquet be?
50 above
196
How high above systolic BP should a lower extremity tourniquet be?
100 above
197
What causes ANP to be released?
hypervolemia -> released by cardiac myocytes in RA in resp to increased stretching
198
What does ANP do?
-natriuresis
-peripheral vasodilation
-inhibit renin and aldo secretion
-prevent ATII from activating
-inc GSF
199
how is BNP released?
Brain Natriuretic peptide
-released in response to inc stretching in ventricular myocytes
-similar fxn to ANP
200
How does MOCA work?
-over 10 years
-250 CME credits, must be category one, no more than 60 credits per year
-30 ? per quarter
-unrestricted license to practice
-participate in 2 activities of evaluation and improvement of practice
201
Contraindications to aortic balloon pump
-aortic dissection
-aortic insufficiency (AR)
-severe PVD
202
Indications for aortic balloon pump
-cardiogenic shock
-failure to wean from CPB
-R heart failure
-bridge to transplant or VAD
-augment during PCI
203
Indications for aortic balloon pump
-cardiogenic shock
-failure to wean from CPB
-R heart failure
-bridge to transplant or VAD
-augment during PCI
-severe MR
204
Gas used to inflate intraaortic balloon pump
helium
205
obesity and DLCO
increased! -> due to inc pulm blood flow
206
Mechanical ventilation O2 consumption in obesity
mechanical ventilation decreases O2 consumption compared to
207
RV obesity
unchanged
208
Resp changes w/ obesity
DECREASED: FRC, RV, TV
INCREASED: total and pulm blood volume, cardiac output, LVEDP, DLCO, work of breathing, O2 consumption
209
Increases sz duration during ECT
etomidate
210
no effect/minimal effect on sz duration
methohexital
ketamine
211
Tumescent liposuction: max dose of lidocaine
35-55 mg/kg
212
Tumescent liposuction: max dose of epi
0.07 mg/kg
213
Tumescent liposuction: when does blood lidocaine levels peak?
12-16 hours
214
TCA MOA
-inhibition of serotonin reuptake
-NMDA blockade
-opioidergic effects
215
celiac plexus block tx cancer pain where?
pancreas
216
superior hypogastric plexus blocked for pain where?
bladder, pelvic pain
217
common SE from celiac plexus block
-orthostatic hypoTN (MC)
-diarrhea (2nd MC)
218
Cervical epidural steroid injxns and surgery
reduces rate of surgery!
219
Inflammatory pain
following tissue injury -> dull, aching, poorly localized
220
Paresthesia of S3-S5 also known as
saddle anesthesia -> concern for cauda equina syndrome
221
MCC of acute liver failure
acetaminophen toxicity
222
Max recommended doses of acetaminophen
< 3 g: healthy adults
< 2.6 g: peds, elderly
< 2: alcoholic, liver dx
223
What is ganglion impar blocks used for?
perineal pain
224
elderly cancer pt, chronic opioid therapy, confusion and myoclonus after inc morphine dose
opioid induced neurotoxicity
225
If pt presenting w/ opioid induced neurotoxicity what to do?
-d/c and switch to opioid w/ no active metabolite (ie fentanyl)
-if symptoms severe and sz is a concern: start a trial of benzos to increase sz threshold
226
safest opioids in elderly and ESRD
fentanyl
methadone
**no active metabolites!
227
Neuropathic pain pathophys
-inflammation in afferent pathway -> central and peripheral sensitization
228
Tramadol MOA
weak opioid agonist
-serotonin reuptake inhibitor
-NE reuptake inh
-NDMA antagonist
-directly increases basal release of serotonin
229
pt post thoracotomy pain, morphine making no difference, on heparin infusion, options?
TENS
230
At what dose of chronic ER morphine can you switch over to fentanyl patches
> 45mg
231
SNARE proteins cleaved by botox
synaptobrevin
SNAP-25 (MC)
syntaxin
232
TENS contraindications
-demand type pacemakers
-cardiac dysrythmias
-mentally incompetent pts
-pregnancy
233
What is required for a diagnostic block to be successful
30-80% reduction in pain for hours-days
234
How long is the suspected relief for a nerve radiofreq ablation?
6 months
235
MOA gabapentin
inhibits VG Ca channels -> prevents release of glutamate (excitatory NT)
236
Gabepentin SE
-peripheral edema
-ataxia
-nausea
-nystagmus
-weight gain
-dizziness
-sedation
**cardiac and resp SE uncommon
237
what is the NT mediative afferent nociceptive transmission from dorsal root ganglia to SC?
Glutamate
238
What muscle is closest to the needle tip during a lumbar symp block?
psoas major
239
Alternative to celiac plexus block for cancer in upper abd and retroperitoneum
splanchnic nerve block
240
Goal cerebral perfusion pressure for TBI
50-70
241
At what ICP level should tx be initiated?
> 20
242
Mytonic dystrophy anesthesia concerns
-preop: TTE, EKG
-if any type of AV conduction issue -> get cardiology involved incl 1st degree (rapid and unpredictable progression)
-pacing equipment should be available
-avoid succ, minimize NDNMB
-prop, methohexital, etomidate, neostigmine, can precipitate myotonia
243
ppx for myotonic crisis in myotonic dystrophy?
Phenytoin
Quinidiine
Procainamide
244
Pregnancy w/ idiopathic intracranial HTN -> vision symp, what is the plan for vaginal delivery analgesia?
Intrathecal catheter w/ intermittent boluses
245
Carbon monoxide poisoning and arterioles
Carbon monoxide poisoning assoc w/ inc in nitric oxide -> vasodilation
246
high dose steroids and TBI
increases morbidity and mortality
