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Truelearn Advanced Exam > TL round 2 > Flashcards

TL round 2 Flashcards

1
Q

How much of the cardiac output goes to uterus at full term?

A

20%

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2
Q

BF supply to uterus during pregnancy

A

85% uterine arteries
15% ovarian arteries
-> terminate as spiral arteries -> supply intervillous space

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3
Q

Which side of placental has villi?

A

Fetal side

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4
Q

Where does the umbilical artery originate off of?

A

fetal internal iliac arteries
-that’s why there’s two!

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5
Q

Best way to assist in proper positioning of thoracic aortic aneurysm stent?

A
  1. induced hypoTN (MAP goal 70-80) -> dec likelihood of migratation
  2. transient asystole (adenosine)
  3. rapid ventricular pacing (> 180)
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6
Q

When to have elective repair of TAA or AAA?

A

size > 5.5 cm or grows >1cm in 1 year

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7
Q

When to cautiously use adenosine?

A

Asthma, upper resp dx
***adenosine causes bronchoconstriction

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8
Q

which neuraxial opioids are lipophilic?

A

fentanyl and sufentanil (diffuse away faster)

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9
Q

Which epidural opioids cause more N/V?

A

Morphine
-hydrophilic opioids

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10
Q

which epidural opioids cause less pruritis?

A

fentanyl
-lipophilic opioids

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11
Q

Monitoring for OB hydrophilic epidural opioids?

A

hourly for 1st 12 hours
every 2 hours for next 12 hours

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12
Q
A

Klippel-Feil syndrome
-congenital condition assoc w/ fusion of the cervical spine

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13
Q

Klippel Feil Syndrome

A

congenital fusion of cervical spine
-limited neck motion
-difficult to intubate
-scoliosis, strabismus, or scapular defects

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14
Q

Trisomy 21 airway concerns

A

macroglossia
subglottic stenosis
atlanto-axial instability
**assoc w/ endocardial cushion defects

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15
Q

newborn hypoglycemia, macroglossia, organomegaly

A

Beckwith-Wiedemann Syndrome
-assoc w/ omphalocele

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16
Q

Pierre Robin sequence

A

micrognathia
macroglossia
severe upper airway obstruction

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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

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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

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19
Q

RF for developing fat emboli syndrome

A

closed long bone fx or pts undergoing intramedullary instrumentation (inside bone) during ortho procedures

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20
Q

Triad for fat embolic syndrome

A

petechiae (head, neck, axillae)
hypoxemia
neuro abnormalities (altered LOC, sz)

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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

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22
Q

how to prevent fat emobli syndrome

A

minimizing delay to reduction of long bone fx

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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)

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24
Q

in recovery after c/s:
SpO2 dec to 85%, BP hypoTN, diffuse bleeding at surgical site

A

amniotic fluid embolism

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25
Q

criteria for amniotic fluid emoblism

A
  1. acute hypoTN or cardiac arrest
  2. acute hypoxia
  3. coagulopathy, or severe hemorrhage
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26
Q

2 phases of amniotic fluid emoblism

A

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

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27
Q

tx of amniotic fluid embolism

A

resuscitative -> ETT, fluids, vasopressors/inotropes, blood products

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28
Q

Myasthenic syndrome

A

Lambert Eaton
-Ab to VG Ca channels

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29
Q

NMB and myasthenia gravis

A

inc succ needed
dec roc needed

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30
Q

Intraop mannitol and renal transplant

A

-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

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31
Q

Goals for renal transplant flluids

A

maintain intravascul volume!!
-hypovolemia and hypoTN -> impaired graft perfusion w/ injury
-mannitol dec incidence of post-transplant renal injury req HD

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32
Q

Normal Mg level

A

1.4-2

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33
Q

Mg 4-6

A

lethargy
drowsiness
flushing
N/V
diminished Deep tendon reflex

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34
Q

Mg 6-10

A

somnolence
loss of DTR at 10
hypoTN
ECG changes

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35
Q

HypoCa/hyperMg EKG

A

prolonged QT
lengthened ST

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36
Q

Mg 10-20

A

Resp arrest
AV conduction block
progressive QRS widening and bradycardia

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37
Q

Mg >25

A

cardiac arrest

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38
Q

Tx of hyperMg w/ hemodynamic collapse

A

Calciuim chloride/gluconate
HD is definitive tx, but may take a long time to make happen

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39
Q

Dialyzable toxins

A

Lithium
Toxic alcohols
Salicylates

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40
Q

Reasons for emergent dialysis

A

AEIOU
Acidosis: pH < 7.1
Electrolytes: K > 6.5
Ingestions (toxins)
Overload (fluid)
Uremia (pericarditis, encephalopathy, bleeding)

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41
Q

RF for post-cardiopulm bypass acute kidney inury

A

-preop Cr greater than 1.2
-combined valve, bypass procedures
-preop intraaortic balloon pump

minor: female, CHF, COPD, IDDM, dec LVEF

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42
Q

How kidneys and calcium

A

-kidney converts 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol
-1,25-hydroxycholecalciferol is resp for inc Ca absorption into GI tract

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43
Q

Changes in ESRD

A

Anemia
hypoCa
hyperK
hyperMg
hyperlipidemia
HTN
hyperphos
2ndary hyperparathyroidism
uremic bleeding diathesis

***can be hyper/hypoNa -> no definitive!

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44
Q

prealbumin pre and post HD

A

higher post due to concentration effects

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45
Q

electrolytes post HD

A

determined by the composition of the dialysate! which substances move

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46
Q

Endothelin

A

vasoconstrictor
-inc w/ damage to endothelial cells

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47
Q

Nephrotoxic substances and can cause ATN:

A

-Aminoglycosides
-hemoglobinuria
-myoglobinuria
-IV contrast
-hetastarch
-mannitol

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48
Q

Gold standard for differentiation b/w ATN and prerenal

A

response to fluid repletion
-Cr responds to baseline in 1-3 days if repletion adequate
-persistent AKI despite repletion = ATN

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49
Q

FeNa calculation

A

(UNaSCr)/ (UCrSNa) * 100

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50
Q

Intrarenal FENa

A

> 1%

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51
Q

Prerenal FENa

A

<1%

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52
Q

Prerenal UNa

A

< 20

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53
Q

Intrarenal UNa

A

> 40 b/c tubules can’t retain sodium

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54
Q

BUN to Cr ratio ATN

A

10:1 - 15:1

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55
Q

Urine specific gravity ATN

A

same as plasma b/c can’t conc
1.001-1.0035

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56
Q

Prerenal Urinen osmolality

A

> 500

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57
Q

intrarenal urine osm

A

< 350

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58
Q

prerenal specific gravity

A

1.015

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59
Q

Fractional excretion of urea prerenal

A

< 35%

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60
Q

fractional excretion of urea ATN

A

> 50%

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61
Q

urine to plasma osmolar ratio prerenal

A

> 1.5
-makes sense! urine is more concentrated than blood

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62
Q

Sodium deficit equation

A

Sodium deficit = (140 - serum Na) * total body water

total body water = kg * 0.6

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63
Q

When to use hypertonic saline

A

symptomatic pt w/ Na < 120
-stop Hypertoni when Na above 120

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64
Q

Concern w/ rapid inc in serum Na if hypoNa

A

central pontine myelinolysis

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65
Q

Oliguria

A

inadequate production of urine
<0.3 cc/kg/hr
in OR: < 0.5 cc/kg/hr

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66
Q

Prerenal oliguria causes

A

HypoTN
hypovolemia
inadeq circulating volume
renal artery/vein stenosis

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67
Q

intrarenal causes of oliguria

A

ATN
ischemia
nephrotoxins
inflammatory conditions: vasculitis, interstitial nephritis

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68
Q

Postrenal oliguria

A

occlusion or uterers, bladder, or urethra

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69
Q

Best way to differentiate b/w prerenal and intrarenal causes of oliguria in pts taking diuretics

A

fractional excretion of urea b/c diuretics will causes pt to have high excretion of sodium

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70
Q

What channel is mutated in hypoK periodic paralysis?

A

Na or Ca

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71
Q

pt presents w/ flaccid paralysis after carb heavy meal

A

hypoK periodic paralysis

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72
Q

Triggers for hypoK periodic paralysis

A

-high-salt containing meals
-strenuous activity
-stress
-hypothermia
-menstruation
-glucose-insulin infusions

K < 3

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73
Q

PPx for hypoK periodic paralysis

A

-prevention!
-ppx: acetazolamide and K sparing diuertics

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74
Q

anesthetic triggers for hypoK periodic paralysis

A

long-acting NMB assoc w/ attacks

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75
Q

Myotonia congenita

A

mutations in VG Chloride channels
-sustained muscle tensing, prevents m from relaxing normally

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76
Q

inheritance of hypoK periodic parlysis

A

Auto Dom w/ incomplete penetrance

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77
Q

MOA of hyperK periodic paralysis

A

Na channel mutation -> prolonged muscle membrane depolarization and flaccid paralysis

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78
Q

Triggers for hyperK periodic paralysis

A

K infusions
rest after exercise
metabolic acidosis
hypothermia

K > 5.5

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79
Q

What type of drugs cross placenta?

A

small (<500 Daltons)
lipophilic
nonionized at physiological pH

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80
Q

subendocardial ischemia

A

imbalance of myocardial O2 supply and demand
-more commonly seen b/c small capillaries and arterioles blocked by high intraventricular pressures

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81
Q

EKG subendocardial ischemia shown as

A

ST depressiosn

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82
Q

Acute transmural myocardial injury

A

STEMI
-suggests injury or infarction, not just ischemia

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83
Q

ST elevation criteria in women

A

New ST elevations in 2 contiguous points > 0.15 mV in women

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84
Q

ST elevation criteria in men

A

New ST elevation 2 contiguous leads
>0.2 mV in men > 40
>0.25 in men < 40

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85
Q

ST depression def

A

> 0.05 mV in 2 contiguous leads

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86
Q

T wave inversion def

A

> 0.1 mV in 2 contiguous leads

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87
Q

Dx of brugada syndrome

A

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

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88
Q

Tx for brugada syndrome

A

ICD

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89
Q

Tx for unstable SVT in transplanted heart

A

Synchronized cardioversion

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90
Q

Alveolar gas equation

A

PAO2 = (FiO2 x [Patm - PH2O]) - (PaCO2/0.8)
-room air FiO2 = 21 or 0.21

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91
Q

Normal alveolar-arterial gradient

A

< 10

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92
Q

How to get alveolar-arterial gradient

A

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

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93
Q

Infraorbital n block good for what type of surgery?

A

Cleft lip repair

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94
Q

Infraorbital n branch of

A

maxillary division of trigeminal nerve (CN V2)

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95
Q

Infraorbital n provides sensation to

A

skin and mucosa of lower eyelid, lateral nose, cheek, and upper lip

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96
Q

Infraorbital n block

A

-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

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97
Q

What nerve to block for maxillary oral procedures

A

superior alveolar and palatine nerve branches (off V2)

98
Q

Palatine n block

A
99
Q

nasal septoplasty, which nerves to block?

A

nasopalatine and/or nasociliary nerve blocks

100
Q

insufflation -> hypoTN, cyanosis, arrhythmia, asystole
-inc in EtCO2 followed by profound decrease

A

CO2 embolus

101
Q

why dec perfusion in kidneys w/ inc in intraabd pressure?

A

compression of renal vasculature/parenchyma
inc ADH release
activation of renin-angio-aldo
Dec cardiac output

102
Q

TPN and liver

A

monitor LFTs
-TPN assoc w/ hyperlipidemia -> liver dysfxn

103
Q

TPN OR considerations

A

-continue running it in the OR
-do not run anything else through that line
-monitor lytes beforehand
-close glucose monitoring throughout the case

104
Q

Respiratory quotient

A

ratio b/w CO2 produced to O2 consumed

105
Q

Respiratory quotient and TPN

A

Inc in CO2 production w/ TPN -> hypercarbia

106
Q

TPN concern w/ cardiac or renal failure

A

***pay attention to the volume of the solutioN!

107
Q

TPN and pRBCs

A

do NOT give through the same line, TPN destroys pRBCs

108
Q

Anemias effect on coagulation

A

-delay in initiation of coag cascade
-greater clot strenght
-clot w/ superior viscoelastic properties
-inc bleeding time

109
Q

effect on coagulation w/ pRBC transfusion

A

-initiation of fibrin clot shortened
-clot strength and quality dec
-bleeding time dec

110
Q

difference b/w pH stat and alpha stat

A

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
Q

pH stat and CO2

A

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
Q

Roc precurarization prior to succ dose

A

10% of ED95 dose
.03 mg/kg

113
Q

ED95 for NDNMB

A

dose that causes a 95% twitch suppression in 50% of the population
-dose for tracheal intubation is used 2x ED 95

114
Q

Sentinel event

A

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
Q

Root cause analysis

A

determine cause of sentinel event
-examines cause, timing, nature, magnitude to prevent future events from occurring

116
Q

Negligence

A

failure to use reasonable care that then results in harm to another person
-ex: medical malpractice

117
Q

Medical malpractice

A

type of negligence that results in npatient harm due to a medical professional not following generally accepted professional standards

118
Q

Maleficence

A

act of committing intentional harm to a patient

119
Q

Consequences of tourniquet release

A

-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
Q

What carries pain from tourniquet inflation?

A

unmyelinated C fibers

121
Q

Dx of postherpetic neuralgia

A

pain must have a duration of >3 months at original location of herpes zoster eruption

122
Q

RF for postherpetic neuralgia

A

-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
Q

1st line tx for postherptic neuralgia

A

gabapentinoids

124
Q

what gets added together for anesthesia reimbursement?

A

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
Q

Lab abnormalities in kids w/ pyloric stenosis

A

hyponatremic hypokalemic hypochloremic metabolic alkalosis

126
Q

how to tell if child w/ pyloric stenosis is ready for surgery

A

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
Q

hemodynamic changes w/ ECT

A

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
Q

ALS anesthesia concerns

A
  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
Q

Diagnostic criteria for ARDS

A
  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
Q

Most common cause of ARDS

A

sepsis

131
Q

Oxygenation cut offs for ARDS mild mod severe

A

mild: < 300
mod: < 200
severe: < 100
PaO2/FiO2 ratio w/ PEEP > 5

132
Q

Drug characteristics more likely to croiss placenta

A
  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
Q

Why does bupivacaine not easily cross the placenta

A

highly protein bound
pKa of 8.1 -> exists more ionized

134
Q

Normal vital capacity for a 70kg pt

A

~5 L

135
Q

When does gas rebreathing occur w/ preoxygenation?

A

When minute ventilation is greater than FGF -> rebreathing of exhaled gases -> lower FiO2

136
Q

What preoxygentation technique is best to avoid rebreathing of gases?

A

TV breathing for 3 minutes
-when you start to take vital capacity breaths, you risk rebreathing -> lowers the FiO2

137
Q

Preoxygenation technique during emergency

A

4 deep breaths over 30 seconds

138
Q

Options to assist w/ O2 flow rates during emergency preoxygenation

A
  1. Use suppl O2 by nasal cannula
  2. Holding the O2 flush on the anesthesia machine
139
Q

infant “noisy breathing” during feeding and when she lies on her back, laryngoscopy does shortened aryepiglottic folds and omega-shaped epiglottis

A

laryngomalacia

140
Q

laryngoscopy w/ shortened aryepiglottic folds, omega-shaped epiglottis, or redundant arytenoid tissues prolapses over glottis

A

infants: laryngomalacia

141
Q

Laryngomalacia DL findings

A

shortened aryepiglottic folds, omega-shaped epiglottis
redundant arytenoid tissue that prolapses over glottis

142
Q

Causes of laryngotracheobronchitis

A

Croup
-caused by: parainfluenza, influenza A and B, and RSV

143
Q

mild croup tx

A

humidification of air, fever control, and hydration

144
Q

severe croup tx

A

racemic epi by intermittent positive pressure breathing
or nebulizer mask

145
Q

most common accident in kids < 3

A

foreign body airway obstruction

146
Q

What dx casuses epiglottitis

A

haemophilus influenza type B
-less common than croup b/c of vaccination

147
Q

peds pt leaning froward, open mouth, cough, stridor, fever, dysphagia

A

epiglottitis
-thumb-print sign on CXR

148
Q

peds vascular rings

A

congenital abnormality of aortic arch system -> compresses trachea and esophagus
-dx w/ CT scan

149
Q

Which hormones req dynamic stimulation tests to dx hypopituitarism?

A

ACTH
GH
ADH

150
Q

What’s stored in posterior pituitary

A

oxytocin
ADH/vasopressin
(made in hypothalamus)

151
Q

neonates failure to thrive, hypoglycemia, sz, and cholestatic jaundice

A

ACTH def

152
Q

peds fatigue, weight loss, hypoTN, N/V, hypoglycemia

A

ACTH def

153
Q

normal morning serum cortisol levels

A

5-25 mcg/dL

154
Q

Evaluation of ACTH levels

A

-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
Q

neonate hypoglycemia, micropenis, prolonged jaunice

A

GH def

156
Q

older child short stature, dec height velocity, red in lean body mass, excess fat

A

GH def

157
Q

GH def testing

A

-lack of appropriate serum GH (< 4.1 inc) w/ administration of GHRH and arginine, or def in insulin-like GF

158
Q

tx of PDA

A

NSAIDs ex: indomethacin or ibuprofen

159
Q

what keeps the ductus arteriosus open

A

low O2 and PGE-2 released by placenta
-at birth inc in both causes ductus to constrict and close

160
Q

What n most likely to get injured in a PDA repair

A

recurrent laryngeal n (wraps under aortic arch)

161
Q

injury above what level is likely to give you autonomic hyperreflexia

A

T5-7

162
Q

Why do pts get autonomic hyperreflexia

A

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
Q

symptoms of autonomic hyperreflexi

A

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
Q

when after injury can pts start getting autonomic hyperreflexia

A

2 weeks to 6 months after injury

165
Q

tx of autonomic hyperreflexia

A

-cessation of triggering event and fast-acting vasodilators: nitroprusside, nicardipine, NG

166
Q

What nerve roots are missed in an interscalene block

A

C8 and T1 -> no ulnar coverage

167
Q

Dx for prerenal causes of oliguria

A
  1. FENa < 1%
  2. BUN/Cr > 20:1
  3. Inc Cr
  4. Elevated urine osmolality/specific gravity w/ concentrated urine
168
Q

AKI def

A

acute dec in GFR -> inability to maintain fluid, electrolyte, and acid-base homeostasis

169
Q

Complete loss of kidney fx and Cr

A

-Cr doubles during the first day

170
Q

Normal urine osmolality

A

300-900

171
Q

Urine osmolality after several hours of fluid intake restriction

A

> 800

172
Q

What is in cryo

A

vWF
fibrinogen
fibronectin
factor VIII
factor XIII

173
Q

Indications for cryo

A

-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
Q

conversion of intrathecal morphine to epidural

A

1 mg IT = 10 mg epidural

175
Q

conversion of epidural morphine to IV

A

1 mg epidural = 10 mg IV

176
Q

conversion of IV morphine to PO

A

1 mg of IV morphine = 3 mg PO morphine

177
Q

conversion of intrathecal morphine to IV

A

1 mg IT = 10 mg epidural
1 mg epidural = 10 mg IV

intrathecal x 100 = IV
**1 mg IV = 3 mg PO

178
Q

How quickly an opioid diffuses out of intrathecal space depends on son what?

A

lipophilicity
-highly lipophilic: fentanyl -> diffuses out faster
-highly hydrophilic: morphine -> diffuses out slowly

179
Q

conversion ratio fent compared to morphine

A

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
Q

most to least liphophilic fent, morphine, hydromorphone

A

MOST: fent > hydromorphone > morphine

181
Q

What are transient neurologic symptoms

A

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
Q

Inc risk of transient neurologic symptoms

A

-lidocaine!
-lithotomy position durin gsurgery
-single orifice needles
-spinal (doesn’t happen w/ epidural)

183
Q

more effective in anxiolysis midaz or parents present

A

midazolam

184
Q

when is parental presence most effective as an anxiolytic?

A

when the child is anxious and the parent is calm
**if parent anxious, can make it worse*

185
Q

potential benefits of parental presence during induction in peds

A

-dec req for premeds
-dec anxiety in child
-inc mask acceptance for induction

186
Q

When to use a confirmatory test for brain death

A

-Cranial n can’t be properly examined
-apnea test can’t be completed (CO2 retainers)
-shorten duration of observation period

187
Q

Confirmatory tests for brain deaht

A

-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
Q

Flat EEG in brain damage def

A

no nonartifactual electrical potentials > 2 microV w/i 30 minutes

189
Q

Hollow skull phenomenon

A

Way to confirm brain death: radionucleotide imaging: tracer 99mTc -> tracer penetrates brain proportional to blood flow -> if brain dead, no redistribution = hollow skull

190
Q

qsofa score

A

0-3
AMS (GSC < 15)
RR > 22
systolic BP <100

score >= to 2 indicates worse prognosis

191
Q

What is qSOFA used for?

A

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
Q

sepsis def

A

life-threatening organ dysfunction caused by a dysregulated host response to infection

193
Q

septic shock

A

subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality

194
Q

Rhabdomyolysis can occur after succ
and volatile anesthetics in which pts?

A

Becker and Duchenne muscular dystrophy

195
Q

effects of hypothermia on newborns

A

-pulm vasoconstriction
-hypoxia due to inc O2 consumption (non-shivering thermogenesis)
-metabolic acidosis
-right to left shunt

196
Q

nonshivering thermogenesis

A

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
Q

risks of periop hypothermia

A

inc risk of morbidity from cardiac disturbances
inc risk of wound infection
inc blood loss

198
Q

How newborns lose heat

A

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
Q

EKG changes hyperMg

A

prolonged PR interval and widened QRS

200
Q

Goal Mg levels for preeclampsia

A

5-9

201
Q

Symptoms if Mg level is 5-7

A

N, HA, lethargy, diminished deep tendon reflexes

202
Q

Symptoms if Mg level is 7-12

A

somnolence, bradycardia, hypoTN, EKG changes (prolonged PR, wide QRS, prolonged QT), absent deep tendon reflexes

203
Q

Symptoms if Mg level is 12-15

A

muscle paralysis, resp failure, complete heart block

204
Q

Symptoms if Mg level is > 15

A

cardiac arrest

205
Q

contrast induced nephropathy

A

Cr inc by > 0.5 or 25% inc from baseline w/i 2-3 days of contrast administration

206
Q

RF for contrast-induced nephropathy

A

**most impt: hx of CKD (esp GFR < 30 w/ no HD)
-DM, gout, HTN, hypovolemia, nephrotoxic meds

207
Q

Meds considered nephrotoxic and should be avoided in CKD

A

Acyclovir
Ampicillin
ACE/ARBs
cyclosporins
NSAIDS
Tacrolimus
Aminoglycosides
Amphotericin B
Cisplatin
Foscarnet
Calcineurin inh (anti-rejection cyclosporine, tacro)
Lithium
NSAIDs
Rifampin

208
Q

anesthetic for actively hemorrhaging retained products

A

GA

209
Q

anesthetic for retained products no active hemorrhage

A

spinal

210
Q

Certificate issued by ABA is subject to revocation if person certified

A
  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
Q

Perks of placing an epidural laterally

A

-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
Q

best position to place epidural if sedation req

A

laterally
-minimal assistance, tongue displaced, harm less likely

213
Q

neonatal resp distress syndrome

A

grunting respirations, nasal flaring, chest retractions soon after birth
-intrapulm shunt and systemic hypoxemia
-tx: exogenous surfactant

214
Q

when does surfactant production occur

A

after 32 weeks gestation

215
Q

lecithin and sphinogomyelin and surfactant

A

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
Q

How to tell if fetal lungs mature

A

lecithin/sphingomyelin ratio inc to 2 or more (3.5 or more for mothers w/ DM)

217
Q

Fetal premature lung characteristics

A

higher surface tension -> instability of lung at end-expiration, low lung volume, dec compliance
-alveolar collapse and diffuse atelectasis

218
Q

Premed PO midaz dosing

A

.25-5 mg/kg

219
Q

what age does separation anxiety start?

A

9 months

220
Q

infants w/ beta thalassemia at birth

A

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
Q

Symptoms of beta-thalassemia minor

A

one defective beta globin allele
-asymptomatic but microcytic anemia

222
Q

Symp beta thalassemia major

A

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
Q

sequelae from iron overload 2/2 chronic infusions

A

DM from pancreatic distruction
cardiac abnormalities from iron deposition
chronic infections

224
Q

initial infant presentation of beta thalassemia

A

pallor, irritability, growth retardation, hepatosplenomegaly, jaundice
hemolysis and anemiai

225
Q

how beta thalassemia dx

A

hemoglobin electrophoriess

226
Q

neonates born w/ jaundice, mild to mod anemia, hepatosplenomegaly dx

A

Hemoglobin H
-defect in alpha globin alleles -> since alpha in fetal Hg present as a neonate (beta thalassemia at 6 mo)

227
Q

7.5 MHz and 5 MHz probe: which one has better penetration v resolution

A

penetration: 5 Hz (longer wavelength, shorter frequency)
resolution: 7.5 Hz (shorter wavelength, higer freq)

228
Q

Axial resolution u/s

A

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
Q

lateral resolution u/s

A

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
Q

temporal resolution u/s

A

ability to differentiate moving objects in time
-“frame rate” of u/s
-dec scan depth, temporal resolutino inc

231
Q

neck pain and strained voice after surgery , no stridor

A

arytenoid dislocation

232
Q

part of larynx post susceptibe to pressure injury

A

posterior larynx

233
Q

parathyroidectomy, extubated in OR no prob, stridor w/ inh and exh in PACU, dx?

A

Laryngeal edema
-pressure of ETT on the mucosa
(can occur if ETT too large, cuff overinflation, and prolonged intubation time)

234
Q

Poiseuille’s law regarding radius and resitance to flow

A

R = (8nL)/(pi Pr^4)
-if radius cut in half, resistance will inc by 16 times

235
Q

most common complication w/ TURP

A

hypothermia if irrigation fluids not warmed

236
Q

What determines irrigating fluid absorption during TURP?

A
  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
Q

TURP pt HTN, bradycardic

A

Initial signs of TURP syndrome due to hypervolemia
-> dilutional hypoNa and cerebral edema are next

238
Q

Symptoms post TURP w/ Na > 120

A

none

239
Q

Symptoms post TURP w/ Na < 115

A

somnolence, N/V

240
Q

Symptoms post TURP w/ Na < 110

A

sz and coma

241
Q

TURP triad

A

Elevated systolic and diastolic pressures w/ inc pulse pressure
bradycardia
mental status changes

Truelearn Advanced Exam (15 decks)

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