TL round 2 Flashcards
1
Q
How much of the cardiac output goes to uterus at full term?
A
20%
2
Q
BF supply to uterus during pregnancy
A
85% uterine arteries
15% ovarian arteries
-> terminate as spiral arteries -> supply intervillous space
3
Q
Which side of placental has villi?
A
Fetal side
4
Q
Where does the umbilical artery originate off of?
A
fetal internal iliac arteries
-that’s why there’s two!
5
Q
Best way to assist in proper positioning of thoracic aortic aneurysm stent?
A
- induced hypoTN (MAP goal 70-80) -> dec likelihood of migratation
- transient asystole (adenosine)
- rapid ventricular pacing (> 180)
6
Q
When to have elective repair of TAA or AAA?
A
size > 5.5 cm or grows >1cm in 1 year
7
Q
When to cautiously use adenosine?
A
Asthma, upper resp dx
***adenosine causes bronchoconstriction
8
Q
which neuraxial opioids are lipophilic?
A
fentanyl and sufentanil (diffuse away faster)
9
Q
Which epidural opioids cause more N/V?
A
Morphine
-hydrophilic opioids
10
Q
which epidural opioids cause less pruritis?
A
fentanyl
-lipophilic opioids
11
Q
Monitoring for OB hydrophilic epidural opioids?
A
hourly for 1st 12 hours
every 2 hours for next 12 hours
12
Q
A
Klippel-Feil syndrome
-congenital condition assoc w/ fusion of the cervical spine
13
Q
Klippel Feil Syndrome
A
congenital fusion of cervical spine
-limited neck motion
-difficult to intubate
-scoliosis, strabismus, or scapular defects
14
Q
Trisomy 21 airway concerns
A
macroglossia
subglottic stenosis
atlanto-axial instability
**assoc w/ endocardial cushion defects
15
Q
newborn hypoglycemia, macroglossia, organomegaly
A
Beckwith-Wiedemann Syndrome
-assoc w/ omphalocele
16
Q
Pierre Robin sequence
A
micrognathia
macroglossia
severe upper airway obstruction
17
Q
Confirm brain death cerebral angio results
A
-absence of intracerebral filling at level of carotid bifurcation or circle of Willis
-patency of external carotid circulation
-delayed filling of superior longitudinal sinus
18
Q
Clinical criteria for dx brain death
A
-known cause and evidence of acute, catostrophic, irreversible brain injury
-reversible conditions must be excluded
-temp > 36C
-not have any chance of drug intoxication, NMB or shock
19
Q
RF for developing fat emboli syndrome
A
closed long bone fx or pts undergoing intramedullary instrumentation (inside bone) during ortho procedures
20
Q
Triad for fat embolic syndrome
A
petechiae (head, neck, axillae)
hypoxemia
neuro abnormalities (altered LOC, sz)
21
Q
diagnosis of fat embolic syndrome
A
at least 1 major and 4 minor criteria
MAJOR: axillary/subconjuctival petechiae, hypoxemia (PaO2 < 60), CNS dep, pulm edema
MINOR
tachycardia, hyperthermia, retinal fat emboli
-urinary fat globules, dec plts/Hct, inc ESR, fat globules in sputum
22
Q
how to prevent fat emobli syndrome
A
minimizing delay to reduction of long bone fx
23
Q
treatment of fat emobli syndrome
A
aggressive resp support (high flow O2, PEEP)
-crystalloids and albumin (can bind fatty acids, dec lung injury and replace lost blood volume)
24
Q
in recovery after c/s:
SpO2 dec to 85%, BP hypoTN, diffuse bleeding at surgical site
A
amniotic fluid embolism
25
criteria for amniotic fluid emoblism
1. acute hypoTN or cardiac arrest
2. acute hypoxia
3. coagulopathy, or severe hemorrhage
26
2 phases of amniotic fluid emoblism
1st: amniotic fluid in maternal circulation -> release of inflammatory mediators -> coronary constriction, bronchoconstriction, pulm vasoconstriction -> pulm HTN and RV dyzfxn -> hypoxemia and hypoTN
-systemic vasodilation from inflammatory resp
2nd: LV fails b/c not filling and septal deviation -> hypoTN and inc pulm pressures -> pulm edema
-massive consumptive coag --> hemorrhage
27
tx of amniotic fluid embolism
resuscitative -> ETT, fluids, vasopressors/inotropes, blood products
28
Myasthenic syndrome
Lambert Eaton
-Ab to VG Ca channels
29
NMB and myasthenia gravis
inc succ needed
dec roc needed
30
Intraop mannitol and renal transplant
-shown to dec post-transplant kidney injury, but non effect on graft rejection
-***b/c renal vasodilation, renal PG release and scavenging of free radicals
31
Goals for renal transplant flluids
maintain intravascul volume!!
-hypovolemia and hypoTN -> impaired graft perfusion w/ injury
-mannitol dec incidence of post-transplant renal injury req HD
32
Normal Mg level
1.4-2
33
Mg 4-6
lethargy
drowsiness
flushing
N/V
diminished Deep tendon reflex
34
Mg 6-10
somnolence
loss of DTR at 10
hypoTN
ECG changes
35
HypoCa/hyperMg EKG
prolonged QT
lengthened ST
36
Mg 10-20
Resp arrest
AV conduction block
progressive QRS widening and bradycardia
37
Mg >25
cardiac arrest
38
Tx of hyperMg w/ hemodynamic collapse
Calciuim chloride/gluconate
HD is definitive tx, but may take a long time to make happen
39
Dialyzable toxins
Lithium
Toxic alcohols
Salicylates
40
Reasons for emergent dialysis
AEIOU
Acidosis: pH < 7.1
Electrolytes: K > 6.5
Ingestions (toxins)
Overload (fluid)
Uremia (pericarditis, encephalopathy, bleeding)
41
RF for post-cardiopulm bypass acute kidney inury
-preop Cr greater than 1.2
-combined valve, bypass procedures
-preop intraaortic balloon pump
minor: female, CHF, COPD, IDDM, dec LVEF
42
How kidneys and calcium
-kidney converts 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol
-1,25-hydroxycholecalciferol is resp for inc Ca absorption into GI tract
43
Changes in ESRD
Anemia
hypoCa
hyperK
hyperMg
hyperlipidemia
HTN
hyperphos
2ndary hyperparathyroidism
uremic bleeding diathesis
***can be hyper/hypoNa -> no definitive!
44
prealbumin pre and post HD
higher post due to concentration effects
45
electrolytes post HD
determined by the composition of the dialysate! which substances move
46
Endothelin
vasoconstrictor
-inc w/ damage to endothelial cells
47
Nephrotoxic substances and can cause ATN:
-Aminoglycosides
-hemoglobinuria
-myoglobinuria
-IV contrast
-hetastarch
-mannitol
48
Gold standard for differentiation b/w ATN and prerenal
response to fluid repletion
-Cr responds to baseline in 1-3 days if repletion adequate
-persistent AKI despite repletion = ATN
49
FeNa calculation
(UNa*SCr)/ (UCr*SNa) * 100
50
Intrarenal FENa
>1%
51
Prerenal FENa
<1%
52
Prerenal UNa
< 20
53
Intrarenal UNa
>40 b/c tubules can't retain sodium
54
BUN to Cr ratio ATN
10:1 - 15:1
55
Urine specific gravity ATN
same as plasma b/c can't conc
1.001-1.0035
56
Prerenal Urinen osmolality
> 500
57
intrarenal urine osm
< 350
58
prerenal specific gravity
1.015
59
Fractional excretion of urea prerenal
< 35%
60
fractional excretion of urea ATN
> 50%
61
urine to plasma osmolar ratio prerenal
> 1.5
-makes sense! urine is more concentrated than blood
62
Sodium deficit equation
Sodium deficit = (140 - serum Na) * total body water
total body water = kg * 0.6
63
When to use hypertonic saline
symptomatic pt w/ Na < 120
-stop Hypertoni when Na above 120
64
Concern w/ rapid inc in serum Na if hypoNa
central pontine myelinolysis
65
Oliguria
inadequate production of urine
<0.3 cc/kg/hr
in OR: < 0.5 cc/kg/hr
66
Prerenal oliguria causes
HypoTN
hypovolemia
inadeq circulating volume
renal artery/vein stenosis
67
intrarenal causes of oliguria
ATN
ischemia
nephrotoxins
inflammatory conditions: vasculitis, interstitial nephritis
68
Postrenal oliguria
occlusion or uterers, bladder, or urethra
69
Best way to differentiate b/w prerenal and intrarenal causes of oliguria in pts taking diuretics
fractional excretion of urea b/c diuretics will causes pt to have high excretion of sodium
70
What channel is mutated in hypoK periodic paralysis?
Na or Ca
71
pt presents w/ flaccid paralysis after carb heavy meal
hypoK periodic paralysis
72
Triggers for hypoK periodic paralysis
-high-salt containing meals
-strenuous activity
-stress
-hypothermia
-menstruation
-glucose-insulin infusions
K < 3
73
PPx for hypoK periodic paralysis
-prevention!
-ppx: acetazolamide and K sparing diuertics
74
anesthetic triggers for hypoK periodic paralysis
long-acting NMB assoc w/ attacks
75
Myotonia congenita
mutations in VG Chloride channels
-sustained muscle tensing, prevents m from relaxing normally
76
inheritance of hypoK periodic parlysis
Auto Dom w/ incomplete penetrance
77
MOA of hyperK periodic paralysis
Na channel mutation -> prolonged muscle membrane depolarization and flaccid paralysis
78
Triggers for hyperK periodic paralysis
K infusions
rest after exercise
metabolic acidosis
hypothermia
K > 5.5
79
What type of drugs cross placenta?
small (<500 Daltons)
lipophilic
nonionized at physiological pH
80
subendocardial ischemia
imbalance of myocardial O2 supply and demand
-more commonly seen b/c small capillaries and arterioles blocked by high intraventricular pressures
81
EKG subendocardial ischemia shown as
ST depressiosn
82
Acute transmural myocardial injury
STEMI
-suggests injury or infarction, not just ischemia
83
ST elevation criteria in women
New ST elevations in 2 contiguous points > 0.15 mV in women
84
ST elevation criteria in men
New ST elevation 2 contiguous leads
>0.2 mV in men > 40
>0.25 in men < 40
85
ST depression def
> 0.05 mV in 2 contiguous leads
86
T wave inversion def
> 0.1 mV in 2 contiguous leads
87
Dx of brugada syndrome
EKG abnormality: ST elevation >2mm followed by negative T wave
-VF or polymorphic V tach
-family hx of sudden cardiac death at < 45
-inducibility of VT w/ electrical stim
-syncope
-nocturnal agonal respiration
88
Tx for brugada syndrome
ICD
89
Tx for unstable SVT in transplanted heart
Synchronized cardioversion
90
Alveolar gas equation
PAO2 = (FiO2 x [Patm - PH2O]) - (PaCO2/0.8)
-room air FiO2 = 21 or 0.21
91
Normal alveolar-arterial gradient
< 10
92
How to get alveolar-arterial gradient
Calculate PAO2 using alveolar gas equation
PAO2 = (FiO2 * [Patm - PH2O]) - (PaCO2/0.8)
PH2O is water vapor pressure
Then do PAO2- PaO2, < 10 is normal
93
Infraorbital n block good for what type of surgery?
Cleft lip repair
94
Infraorbital n branch of
maxillary division of trigeminal nerve (CN V2)
95
Infraorbital n provides sensation to
skin and mucosa of lower eyelid, lateral nose, cheek, and upper lip
96
Infraorbital n block
-emerges from infraorbital foramen inferior to orbital rim
-extraoral: cover foramen w/ finger, superomedial orientation until bone, 1-3 cc
-intraoral: needle via buccal mucosa at level of upper canines w/ cephalad and lateral advancement
97
What nerve to block for maxillary oral procedures
superior alveolar and palatine nerve branches (off V2)
98
Palatine n block
99
nasal septoplasty, which nerves to block?
nasopalatine and/or nasociliary nerve blocks
100
insufflation -> hypoTN, cyanosis, arrhythmia, asystole
-inc in EtCO2 followed by profound decrease
CO2 embolus
101
why dec perfusion in kidneys w/ inc in intraabd pressure?
compression of renal vasculature/parenchyma
inc ADH release
activation of renin-angio-aldo
Dec cardiac output
102
TPN and liver
monitor LFTs
-TPN assoc w/ hyperlipidemia -> liver dysfxn
103
TPN OR considerations
-continue running it in the OR
-do not run anything else through that line
-monitor lytes beforehand
-close glucose monitoring throughout the case
104
Respiratory quotient
ratio b/w CO2 produced to O2 consumed
105
Respiratory quotient and TPN
Inc in CO2 production w/ TPN -> hypercarbia
106
TPN concern w/ cardiac or renal failure
***pay attention to the volume of the solutioN!
107
TPN and pRBCs
do NOT give through the same line, TPN destroys pRBCs
108
Anemias effect on coagulation
-delay in initiation of coag cascade
-greater clot strenght
-clot w/ superior viscoelastic properties
-inc bleeding time
109
effect on coagulation w/ pRBC transfusion
-initiation of fibrin clot shortened
-clot strength and quality dec
-bleeding time dec
110
difference b/w pH stat and alpha stat
alpha stat: maintains normocarbia and normal pH based on the assumption the pt is 37C
-pH stat: normocarbia and pH at actual temp -> if cooled to 27C, partial pressures of CO2 and O2 decrease -> run at temp of patient -> CPB circuit infusions CO2 into blood to maintain normal pH despite temp
111
pH stat and CO2
CO2 will be low and dissolved at temp run -> so CO2 added in -> decrease in pH, R shift of O2 dissoc curve, inc cerebral BF
112
Roc precurarization prior to succ dose
10% of ED95 dose
.03 mg/kg
113
ED95 for NDNMB
dose that causes a 95% twitch suppression in 50% of the population
-dose for tracheal intubation is used 2x ED 95
114
Sentinel event
an unexpected occurence involving death or serious physical or psychological injury or risk thereof
ex: medication error, blood products w/ incorrect ABO type, wrong side procedure
115
Root cause analysis
determine cause of sentinel event
-examines cause, timing, nature, magnitude to prevent future events from occurring
116
Negligence
failure to use reasonable care that then results in harm to another person
-ex: medical malpractice
117
Medical malpractice
type of negligence that results in npatient harm due to a medical professional not following generally accepted professional standards
118
Maleficence
act of committing intentional harm to a patient
119
Consequences of tourniquet release
-inc in CO2 tension
-inc in heart rate
-inc in serium potassium
***lactic acidosis -> metabolic acidosis
-dec in venous O2 saturation
-dec in central venous and arterial BP
120
What carries pain from tourniquet inflation?
unmyelinated C fibers
121
Dx of postherpetic neuralgia
pain must have a duration of >3 months at original location of herpes zoster eruption
122
RF for postherpetic neuralgia
-adv age (>60, higher w/ older age)
-severity of pain during acute herpes zoster eruption
-greater severity of skin lesions
-greater severity of prodromal pain
-location of eruption (CN V1 opthalmic, brachial plexus)
-immunosuppresion
123
1st line tx for postherptic neuralgia
gabapentinoids
124
what gets added together for anesthesia reimbursement?
base units + time units + certain modifying factors "qualifying circumstances"
base units: based on surgery type and complexity
time units: 1 unit = 15 minutes
QC: ASA 3-5 or E, invasive monitoring or lines, intentional hypoTN or hypthermia
125
Lab abnormalities in kids w/ pyloric stenosis
hyponatremic hypokalemic hypochloremic metabolic alkalosis
126
how to tell if child w/ pyloric stenosis is ready for surgery
adequately rehydrated!!
Look at Cl and bicarb, goal for normal
Cl > 100 (ideal 106)
bicarb < 30
**Na, K, and pH are NOT good indicators**
127
hemodynamic changes w/ ECT
parasympathetic resp first immediately after initiation of sz activity (bradycardia, asystole, excessive salivation)
2nd symp resp: HTN and tachycardia (occ T wave inversion/ST dep -> transient give esmolol or untx)
**major cardiac events are rare
-only pre-tx w/ glyco/atropine if known prior hx of bradycardia, asystole, excessive salivation
128
ALS anesthesia concerns
1. high risk for pulm complications in periop period (esp adv dx)
2. at risk for pulm asp when bulbar symp present
3. no succ: extrajunctional ACh receptors
4. no neuraxial -> thought to exacerbate ALS -> if benefits outweight risk, do epidural no spinal (lower drug conc exposed to nerves, less toxicity change)
129
Diagnostic criteria for ARDS
1. hypoxemia (PaO2/FiO2 < 300)
2. acute onset w/i 7 days of known clinical insult (MC sepsis)
3. b/l opacities on chest images
4. pulm edema not explained by other cause (cardiac)
130
Most common cause of ARDS
sepsis
131
Oxygenation cut offs for ARDS mild mod severe
mild: < 300
mod: < 200
severe: < 100
PaO2/FiO2 ratio w/ PEEP > 5
132
Drug characteristics more likely to croiss placenta
1. small < 500 daltons
2. lipophilic
3. not ionized
4. not highly protein bound
5. uncharged
6. high free drug fraction (lots in moms circulation, not in fetus)
133
Why does bupivacaine not easily cross the placenta
highly protein bound
pKa of 8.1 -> exists more ionized
134
Normal vital capacity for a 70kg pt
~5 L
135
When does gas rebreathing occur w/ preoxygenation?
When minute ventilation is greater than FGF -> rebreathing of exhaled gases -> lower FiO2
136
What preoxygentation technique is best to avoid rebreathing of gases?
TV breathing for 3 minutes
-when you start to take vital capacity breaths, you risk rebreathing -> lowers the FiO2
137
Preoxygenation technique during emergency
4 deep breaths over 30 seconds
138
Options to assist w/ O2 flow rates during emergency preoxygenation
1. Use suppl O2 by nasal cannula
2. Holding the O2 flush on the anesthesia machine
139
infant "noisy breathing" during feeding and when she lies on her back, laryngoscopy does shortened aryepiglottic folds and omega-shaped epiglottis
laryngomalacia
140
laryngoscopy w/ shortened aryepiglottic folds, omega-shaped epiglottis, or redundant arytenoid tissues prolapses over glottis
infants: laryngomalacia
141
Laryngomalacia DL findings
shortened aryepiglottic folds, omega-shaped epiglottis
redundant arytenoid tissue that prolapses over glottis
142
Causes of laryngotracheobronchitis
Croup
-caused by: parainfluenza, influenza A and B, and RSV
143
mild croup tx
humidification of air, fever control, and hydration
144
severe croup tx
racemic epi by intermittent positive pressure breathing
or nebulizer mask
145
most common accident in kids < 3
foreign body airway obstruction
146
What dx casuses epiglottitis
haemophilus influenza type B
-less common than croup b/c of vaccination
147
peds pt leaning froward, open mouth, cough, stridor, fever, dysphagia
epiglottitis
-thumb-print sign on CXR
148
peds vascular rings
congenital abnormality of aortic arch system -> compresses trachea and esophagus
-dx w/ CT scan
149
Which hormones req dynamic stimulation tests to dx hypopituitarism?
ACTH
GH
ADH
150
What's stored in posterior pituitary
oxytocin
ADH/vasopressin
(made in hypothalamus)
151
neonates failure to thrive, hypoglycemia, sz, and cholestatic jaundice
ACTH def
152
peds fatigue, weight loss, hypoTN, N/V, hypoglycemia
ACTH def
153
normal morning serum cortisol levels
5-25 mcg/dL
154
Evaluation of ACTH levels
-AM cortisol level (norm 5-25) -> if low on multiple occasions -> ACTH level -> if low, metyrapone, coosyntropic stim, insulin-induced hypoglycemia test (stress enough to inc cortisol)
155
neonate hypoglycemia, micropenis, prolonged jaunice
GH def
156
older child short stature, dec height velocity, red in lean body mass, excess fat
GH def
157
GH def testing
-lack of appropriate serum GH (< 4.1 inc) w/ administration of GHRH and arginine, or def in insulin-like GF
158
tx of PDA
NSAIDs ex: indomethacin or ibuprofen
159
what keeps the ductus arteriosus open
low O2 and PGE-2 released by placenta
-at birth inc in both causes ductus to constrict and close
160
What n most likely to get injured in a PDA repair
recurrent laryngeal n (wraps under aortic arch)
161
injury above what level is likely to give you autonomic hyperreflexia
T5-7
162
Why do pts get autonomic hyperreflexia
spinal cord reflexes from stimuli trigger symp NS activity (pregang symp n) along splanchnic outflow, but b/c of spinal cord injury, inhibitory impulses from higher CNS centers can't reach the site below the injury
--> intense vasoconstnriction blow SCI and reflex vasodilation above SCI
163
symptoms of autonomic hyperreflexi
acute HTN, reflex bradycardia, cardiac arrhythmias, MI, HA, retinal hemorrhages, pallor
-coolness of lower extremities
-sweating of upper extremities
-nasal congestion
**possible intracranial hemorrhage, stroke, cerebral edema due to HTN
164
when after injury can pts start getting autonomic hyperreflexia
2 weeks to 6 months after injury
165
tx of autonomic hyperreflexia
-cessation of triggering event and fast-acting vasodilators: nitroprusside, nicardipine, NG
166
What nerve roots are missed in an interscalene block
C8 and T1 -> no ulnar coverage
167
Dx for prerenal causes of oliguria
1. FENa < 1%
2. BUN/Cr > 20:1
3. Inc Cr
4. Elevated urine osmolality/specific gravity w/ concentrated urine
168
AKI def
acute dec in GFR -> inability to maintain fluid, electrolyte, and acid-base homeostasis
169
Complete loss of kidney fx and Cr
-Cr doubles during the first day
170
Normal urine osmolality
300-900
171
Urine osmolality after several hours of fluid intake restriction
> 800
172
What is in cryo
vWF
fibrinogen
fibronectin
factor VIII
factor XIII
173
Indications for cryo
-microvascular bleeding w/ hypofibrinogenemia (DIC)
-bleeding due to uremia unresponsive to DDAVP
-factor XIII def
-ppx before surgery or tx of bleeding w/ congenital dysfibrinogenemias
-ppx before surgery or tx of bleeding w/ vWD
-ppx before surgery or tx of bleeding w/ hemophilia A
-use in fibrin sealant production
174
conversion of intrathecal morphine to epidural
1 mg IT = 10 mg epidural
175
conversion of epidural morphine to IV
1 mg epidural = 10 mg IV
176
conversion of IV morphine to PO
1 mg of IV morphine = 3 mg PO morphine
177
conversion of intrathecal morphine to IV
1 mg IT = 10 mg epidural
1 mg epidural = 10 mg IV
intrathecal x 100 = IV
**1 mg IV = 3 mg PO
178
How quickly an opioid diffuses out of intrathecal space depends on son what?
lipophilicity
-highly lipophilic: fentanyl -> diffuses out faster
-highly hydrophilic: morphine -> diffuses out slowly
179
conversion ratio fent compared to morphine
b/c fentanyl is more hydrophilic -> diffuses out of the intrathecal space faster -> smaller difference between intrathecal and IV fentanyl -> smaller conversion ratio compared to morphine
180
most to least liphophilic fent, morphine, hydromorphone
MOST: fent > hydromorphone > morphine
181
What are transient neurologic symptoms
back pain w/ radiation of pain to buttocks, thighs, hips, and calves w/o motor dysfxn occuring w/i 24 hours after block recovery
-last 1-3 days w/o n injury or long term damage
-usually resolves spontaneously w/o intervention
182
Inc risk of transient neurologic symptoms
-lidocaine!
-lithotomy position durin gsurgery
-single orifice needles
-spinal (doesn't happen w/ epidural)
183
more effective in anxiolysis midaz or parents present
midazolam
184
when is parental presence most effective as an anxiolytic?
when the child is anxious and the parent is calm
**if parent anxious, can make it worse*
185
potential benefits of parental presence during induction in peds
-dec req for premeds
-dec anxiety in child
-inc mask acceptance for induction
186
When to use a confirmatory test for brain death
-Cranial n can't be properly examined
-apnea test can't be completed (CO2 retainers)
-shorten duration of observation period
187
Confirmatory tests for brain deaht
-cerebral angiography (invasive)
-transcranial doppler (noninvasive, can do at bedsite)
-magnetic resonance angiography (observation can be difficult)
-CT angio
-radionucleotide imaging (99T, penetrates proportional to blood flow, no redistribution will be seen)
-EEG (more common in peds)
188
Flat EEG in brain damage def
no nonartifactual electrical potentials > 2 microV w/i 30 minutes
189
Hollow skull phenomenon
Way to confirm brain death: radionucleotide imaging: tracer 99mTc -> tracer penetrates brain proportional to blood flow -> if brain dead, no redistribution = hollow skull
190
qsofa score
0-3
AMS (GSC < 15)
RR > 22
systolic BP <100
score >= to 2 indicates worse prognosis
191
What is qSOFA used for?
quick sequential organ failure assessment
-identify adult ICU pts w/ suspected infxn likely to have prolonged ICU or poor outcome
-ER, ward w/ suspected infection likely to have poor outcomes from sepsis
192
sepsis def
life-threatening organ dysfunction caused by a dysregulated host response to infection
193
septic shock
subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality
194
Rhabdomyolysis can occur after succ
and volatile anesthetics in which pts?
Becker and Duchenne muscular dystrophy
195
effects of hypothermia on newborns
-pulm vasoconstriction
-hypoxia due to inc O2 consumption (non-shivering thermogenesis)
-metabolic acidosis
-right to left shunt
196
nonshivering thermogenesis
neonates primary way to generate heat, oxidation of brown fat
-inc glucose consumption -> inc risk of hypoglycemia
-inc O2 consumption -> inc risk of hypoxia
-inc risk of heat loss for preterm or SGA b/c low fat stores
197
risks of periop hypothermia
inc risk of morbidity from cardiac disturbances
inc risk of wound infection
inc blood loss
198
How newborns lose heat
evaporation: amniotic fluid evaporating off skin (why we dry baby off)
-conduction: cold objects contact their skin
-radiation: colder objects in vicinity
-convection: air currents around baby
199
EKG changes hyperMg
prolonged PR interval and widened QRS
200
Goal Mg levels for preeclampsia
5-9
201
Symptoms if Mg level is 5-7
N, HA, lethargy, diminished deep tendon reflexes
202
Symptoms if Mg level is 7-12
somnolence, bradycardia, hypoTN, EKG changes (prolonged PR, wide QRS, prolonged QT), absent deep tendon reflexes
203
Symptoms if Mg level is 12-15
muscle paralysis, resp failure, complete heart block
204
Symptoms if Mg level is > 15
cardiac arrest
205
contrast induced nephropathy
Cr inc by > 0.5 or 25% inc from baseline w/i 2-3 days of contrast administration
206
RF for contrast-induced nephropathy
**most impt: hx of CKD (esp GFR < 30 w/ no HD)
-DM, gout, HTN, hypovolemia, nephrotoxic meds
207
Meds considered nephrotoxic and should be avoided in CKD
Acyclovir
Ampicillin
ACE/ARBs
cyclosporins
NSAIDS
Tacrolimus
Aminoglycosides
Amphotericin B
Cisplatin
Foscarnet
Calcineurin inh (anti-rejection cyclosporine, tacro)
Lithium
NSAIDs
Rifampin
208
anesthetic for actively hemorrhaging retained products
GA
209
anesthetic for retained products no active hemorrhage
spinal
210
Certificate issued by ABA is subject to revocation if person certified
1. violated any rule or regulation of the board
2. was found not to have been eligible to receive certificate originally
3. made any misstatement or omission of fact in their registration
4. failed to maintain a satisfactory professional standing
211
Perks of placing an epidural laterally
-more comfortable for pt
-lessen the requirement of having a person for stabilization
-minimizes vagal reflexes
-supports better toleration of hemodynamic changes
-permits sedation if such is required
-onset quicker
212
best position to place epidural if sedation req
laterally
-minimal assistance, tongue displaced, harm less likely
213
neonatal resp distress syndrome
grunting respirations, nasal flaring, chest retractions soon after birth
-intrapulm shunt and systemic hypoxemia
-tx: exogenous surfactant
214
when does surfactant production occur
after 32 weeks gestation
215
lecithin and sphinogomyelin and surfactant
lecithin and sphingomyelin: primary phospholipids in surfactants
-early pregnancy: sphingomyelin > lecithin
-lecithin secreted into amniotic fluid to develop fetal lung 24-26 weeks
-at 32-33 weeks lecithin and sphingomyelin conc equal
-at 35 weeks lecithin abruptly rises
216
How to tell if fetal lungs mature
lecithin/sphingomyelin ratio inc to 2 or more (3.5 or more for mothers w/ DM)
217
Fetal premature lung characteristics
higher surface tension -> instability of lung at end-expiration, low lung volume, dec compliance
-alveolar collapse and diffuse atelectasis
218
Premed PO midaz dosing
.25-5 mg/kg
219
what age does separation anxiety start?
9 months
220
infants w/ beta thalassemia at birth
asymptomatic b/c predominate fetal Hg has no beta chains (does have alpha and gamma)
-stasrts presenting w/ symptoms at 6 months of age
221
Symptoms of beta-thalassemia minor
one defective beta globin allele
-asymptomatic but microcytic anemia
222
Symp beta thalassemia major
symptomatic anemia requiring transfusions
-bone marrow expansion to compensate -> skeletal deformities and inc fracture risk
-extramedullary hematopoiesis -> skeletal abnormalities, hepatomegaly
-splenomegaly (inc RBC destruction)
-iron overload
223
sequelae from iron overload 2/2 chronic infusions
DM from pancreatic distruction
cardiac abnormalities from iron deposition
chronic infections
224
initial infant presentation of beta thalassemia
pallor, irritability, growth retardation, hepatosplenomegaly, jaundice
hemolysis and anemiai
225
how beta thalassemia dx
hemoglobin electrophoriess
226
neonates born w/ jaundice, mild to mod anemia, hepatosplenomegaly dx
Hemoglobin H
-defect in alpha globin alleles -> since alpha in fetal Hg present as a neonate (beta thalassemia at 6 mo)
227
7.5 MHz and 5 MHz probe: which one has better penetration v resolution
penetration: 5 Hz (longer wavelength, shorter frequency)
resolution: 7.5 Hz (shorter wavelength, higer freq)
228
Axial resolution u/s
function of probe freq, pulse width
-resolution along vertical projection of u/s beam
-better w/ higher freq, lower wavelength, and shorter pulse width
-improved w/ higher freq, lower wavelength, and shorter pulse width
229
lateral resolution u/s
resolution along horizontal axis of u/s image and function of beam formation
-near-field: columnar, length inc w/ higher frequency (higher near field in better resolution images)
-far-field: divergence of beam and blurring of u/s image
-diverge inc w/ lower freq and wider u/s probes
230
temporal resolution u/s
ability to differentiate moving objects in time
-"frame rate" of u/s
-dec scan depth, temporal resolutino inc
231
neck pain and strained voice after surgery , no stridor
arytenoid dislocation
232
part of larynx post susceptibe to pressure injury
posterior larynx
233
parathyroidectomy, extubated in OR no prob, stridor w/ inh and exh in PACU, dx?
Laryngeal edema
-pressure of ETT on the mucosa
(can occur if ETT too large, cuff overinflation, and prolonged intubation time)
234
Poiseuille's law regarding radius and resitance to flow
R = (8*n*L)/(pi *P*r^4)
-if radius cut in half, resistance will inc by 16 times
235
most common complication w/ TURP
hypothermia if irrigation fluids not warmed
236
What determines irrigating fluid absorption during TURP?
1. number of open prostatic venous sinuses
2. resection time
3. height b/w pt and irrigating fluid (hydrostatic pressure)
4. pressures w/i exposed prostatic venous sinuses
237
TURP pt HTN, bradycardic
Initial signs of TURP syndrome due to hypervolemia
-> dilutional hypoNa and cerebral edema are next
238
Symptoms post TURP w/ Na > 120
none
239
Symptoms post TURP w/ Na < 115
somnolence, N/V
240
Symptoms post TURP w/ Na < 110
sz and coma
241
TURP triad
Elevated systolic and diastolic pressures w/ inc pulse pressure
bradycardia
mental status changes
