TL1 Flashcards
TEE findings in sepsis
Normal or increased CO with myocardial depression (due to released cytokines) It is now well accepted that most patients with sepsis have a degree of myocardial depression. Myocardial depression often occurs early and can be present despite a normal or increased cardiac output
Vaporizers and altitude
the delivered partial pressure remains the same however there is an increase in delivered concentration due to a decrease in barometric pressure
Carbon monoxide poisoning
- 200-300 higher affinity than O2
- displaces O2
- leftward shit
- creates lactic acidosis
- PaO2 is normal
- Pulse ox is falsely elevated
Abdominal compartment syndrome (risk factors)
- Decreased abdominal wall compliance: abdominal surgery, prone positioning, major trauma or burns
- Increased intraluminal contents: gastroparesis, ileus, volvulus
- Increased intraabdominal contents: acute pancreatitis, distended abdomen, intra-abdominal infection/abscess/tumors, laparoscopy with excessive inflation pressures, peritoneal dialysis
- Capillary leakage: acidosis, hypothermia, increased APACHE-II score, massive fluid resuscitation, massive transfusion
- Miscellaneous risk factors: age, bacteremia, coagulopathy, elevated head of the bed, obesity, PEEP > 10, peritonitis, pneumonia, sepsis, shock
Bronchialpleural fistula presentation
acute dyspnea, subcutaneous emphysema, tracheal deviation, and a lower or more inferior air-fluid level. Initially, serous fluid fills the lung after pneumonectomy. After the development of a BPF, this fluid is displaced by the entrained air from the BPF, thus lowering the air-fluid level. Classically, serial chest radiographs show initially a white-out except for a small apical fluid level, which is an appropriate postsurgical change, followed by an “improved” appearing chest radiograph that has a more caudad air-fluid level.
diabetic autonomic intability
loss of heart rate variability, resting tachycardia, dysrhythmias, impaired ventilatory responses, gastroparesis with increased risk of aspiration on induction, and unawareness of hypoglycemia
Sepsis treatment
Broad-spectrum antibiotics should be initiated within the first hour. Sepsis-induced hypoperfusion should be treated with at least 30 mL/kg of intravenous crystalloid within the first three hours (now a weak recommendation). For patients with septic shock, vasopressor therapy should be used in combination with volume resuscitation to target an initial MAP of 65 mmHg and the recommended initial vasopressor is norepinephrine
C section decreases risk for?
uterine rupture
Magnesium levels
Normal 1.8-2.5
5-6 mg/dL: Hypotension and bradycardia, lethargy, NV, diminished DTR
6-12 mg/dL: ECG changes including prolonged PR interval and widened QRS , somnolence, absent DTR, hypotension
18 mg/dL, the SA and AV node can become blocked leading to complete heart block., respiratory depression
20-25: Cardiac arrest (asystole) is generally seen
Increased risk for transient neurologic symptoms
lidocaine spinal anesthesia, the lithotomy position, and ambulatory surgery with early ambulation
anemia and coagulation cascade
Anemia is associated with a delay in the initiation of the coagulation cascade, a stronger clot, and a clot with superior viscoelastic properties
Hypoxic pulmonary vasoconstriction
Hypoxic pulmonary vasoconstriction occurs as a result of exposure of the pulmonary arteries to hypoxic lung segments and low alveolar oxygen tension. Direct inhibitors of the HPV mechanism include: hypocarbia, vasodilating drugs, infection, metabolic alkalemia, and volatile anesthetics >1 MAC. Indirect inhibitors of HPV include: hypervolemia, vasoconstricting drugs, hypothermia, thromboembolism, and a large hypoxic lung segment.
ECT and meds
- etomidate prolongs seizure
- brevital, ketamine, alfent and remi = no change
- thiopental, versed, propofol, lidocaine decrease
hyperoslmolar hyperglycemic state
- T2DM
- can progress to seizures
pediatrics tachycardias
- wide complex: synchronized cardioversion
- Narrow: adenosine or vagal (SVT)
QRS >0.9 seconds =wide
RLN damage
- complete cords are stuck in paramedian= aspiration risk, aphonia
- unilateral: hoarseness (may be delayed)
- bilateral partial: cords stuck with unopposed adduction- airway emergency
faster anesthesia induction in peds
- high percentage blood flow to vessel rich
preeclampsia
- elevated thromboxane A2 levels
- decreased prostacyclin levels
- decreased platelets
- leads to vasoconstriction, increased SVR, decreased blood flow,
tourniquet pressure
UE: 50 mmHg above systolic
LE: 100 mmHg above systolic
hypoxic ventilatory drive
-Peripheral O2 chemoreceptors are most sensitive to reductions in PaO2 between 65 and 50 mm Hg and respond by increasing minute ventilation. This is why patients who are dependent on a hypoxic ventilatory drive (COPD, people at high altitudes) typically have a resting PaO2 between 50-65 mm Hg.
induction in cardiac tamponade
keep it “fast, full, and tight.” Cardiac output is heart rate dependent (“fast”), stroke volume is fixed and dependent on adequate preload (“full”), and the vascular tone should be (“tight”). Transesophageal echocardiography is the best diagnostic tool for detecting a pericardial fluid collection.
- afterload reduction can be detrimental
- positive pressure can be bad- most likely awake intubation AVOID coughing
PAC
- endocarditis risk is increased two fold with non heparin coated catheter
- can cause both LBBB and RBBB and complete block
- hypothermia increases risk of PA rupture
hypothermia s/p ROSC
Induced hypothermia following cardiac arrest can reduce ischemic injury and improve neurologic outcomes. It is accomplished by various cooling methods for a duration of 12-24 hours post-resuscitation with a goal temperature of 32 °C to 36 °C. Rewarming should occur slowly to avoid major complications.
pyloric stenosis resuscitation
- best indicator is normalized chloride ( > 100)
- Patients with pyloric stenosis often develop a hyponatremic hypokalemic hypochloremic metabolic alkalosis
- bicarb < 30
risk factors for dialysis post cardiac bypass
Elevated preoperative creatinine, complex cardiac procedures, emergency surgery, and preoperative intraaortic balloon pump carry the highest risk for post cardiopulmonary bypass acute kidney injury
Beir block anesthesia
- Diffusion of LA to from the veins into the capillaries and vasa nervora surrounding the peripheral nerves
- Ischemia from tourniquet also adds anesthesia
meds that can lower seizure threshold
- TCAs (amtryptaline), tramadol
most common cause of fire ignition in OR
- electrocautery
Sentinel event
“an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”
MH vs thyroid storm
-Malignant hyperthermia (MH) and thyroid storm both cause hyperthermia, tachycardia, and cardiac arrhythmia but can be differentiated by the metabolic changes associated with MH, such as hypercarbia, which are not present in thyroid storm, lactic acidosis, elevated creatine kinase and rigidity also are unique to MH
treatment for cyanide toxicity
-amyl nitrate, sodium nitrate, hydroxycobolamin
hyPeR
hyper- kalemia/calcemia/ magnesemia cause prolonged PR
- opposite happens to QRS
alpha blockade
- selective alpha one blockers: prazosin, doxazosin, trazosin
- selective alpha 2: mirtazapine
- 1/2: phenoxybenzamine, phentolamine
heparin resistance risk factors
AT3 levels < 60% of normal, platelet count ≥ 300,000/mm^3, preoperative heparin therapy, use of low molecular weight heparin, and age ≥ 65 years. Treatment includes supplemental heparin, AT3, or FFP administration
uterine rupture risk factors
prior uterine surgery (upper segment scar»_space; lower segment scar), uterine hypercontractility, oxytocin use, prostaglandin use, prolonged labor, dystocia, multiparity, multiple gestations, congenital uterine anomalies, polyhydramnios, and trauma.
OB uterotonics/ contraindications
- methergene - HTN
- hemabate/carboprost tromethamine/ 15- methyl prostagladin F2-a= asthmatics
a/oli/poly- uria
anuria - <50-100/day
oliguria- <0.5cc/kg for several hours
passes unchanged through lungs
- epinephrine
- dopamine
- histamine
- vasopressin
hyponatremic correction
Symptomatic patients with serum Na+ = 120 mEq/L should have the serum osmolality corrected with 3% hypertonic saline (not normal saline) and loop diuretics
Respiratory changes in obesity
increased work of breathing, oxygen consumption, and carbon monoxide diffusion capacity DLCO. Expiratory reserve volume, functional residual capacity, and tidal volume are decreased. Mechanical ventilation decreases oxygen consumption dedicated to respiratory work in obese by ~15%.
Anesthetic choice for cerclage when membranes ar buldging
-GETA, induces uterine relaxation
Lung changes in elderly
Increased chest wall stiffness, loss of muscle mass, flattening of the diaphragm, and increased compliance of lung parenchyma lead to several physiologic changes in elderly respiration. The volume at which small airways collapse increases with aging, such that by the mid-60s, closing capacity surpasses functional residual capacity and will eventually surpass tidal volume
placental abruption risk factors
maternal hypertension, preeclampsia, advanced maternal age (age >35 years at time of delivery), increasing parity, maternal and paternal tobacco use, cocaine use, trauma, premature rupture of membranes, chorioamnionitis, bleeding in early pregnancy, and history of prior abruption. Increased incidence of placental abruption has been noted in African-American populations and in patients hospitalized for acute and chronic respiratory disease.
changes in cardiovascular system in elderly
- increased levels of catecholamines
- increased reliance on atrial kick
- decreased beta receptor sensitivity
- patients have a normal resting left ventricular function (stroke volume and EF)
Alpha 2 receptors
- agonism causes bradycardia, sedation and lower BP via inhibition of norepinephrine from presynaptic nerve terminals
- Antagonism will increase norepinephrine
Highest risk of pneumothorax (nerve block)
supraclavicular
obese patients have increased adipose tissue leading to
increase of bioactive mediators resulting in abnormal lipids, insulin resistance, inflammation, and coagulopathies
- higher levels of fibrinogen, factor VII, factor VIII, von Willebrand factor, and plasminogen activator inhibitor-1. This all leads to a hypercoagulable state.
A-a gradient increases
-shunting, dead space and diffusion defects
a fib risk factors
- atrial injury, ischemia, inflammation, increased catecholamines, hypovolemia, atrial stretch from volume overload, and electrolyte disturbances
- advancing age, male sex, the presence of hypertension, prior history of AF, obesity, chronic obstructive pulmonary disease, asthma, valvular disease, left atrial size, and left ventricular ejection fraction
Carcinoid syndrome diagnosis
- 24 hours 5-HIAA
Myasthenia Gravis postop ventilation risk factors
- Duration of myasthenia gravis > 6 years
- Chronic respiratory disease
- Pyridostigmine dose greater than or equal to 750 mg/day
- Vital capacity less than or equal to 2.9 L
oxytocin stimultates
- contraction
- also antidiuresis and natriuresis
Donor management goals
- MAP 60-120 mmHg
- CVP 4-12
- Final Na ≤ 155, or 135-160 mmol/L
- Pressors < 1 ideal, or low dose pressor
- PaO2/FiO2 ratio > 300 (PaO2 > 300 on 100% FiO2, 5 PEEP)
- pH on ABG 7.25-7.5
- Glucose < 150
- Urine Output 0.5-3 mL/kg/h
- LV EF (%) > 50
- Hgb > 10 mg/dL
ADPKD and robotic prostatectomy
- CT angio to screen for intracranial aneurysms
- also with Marfans
Versed bioavailbility
intravenous > intramuscular > intranasal > rectal > oral.
Klippel-feil syndrome
fusion of cervical spine
-associated scoliosis, strabismus, or scapular defects
CRPS II treatment
physical therapy, tricyclic antidepressants, gabapentin, sympathetic blocks, somatic blocks, spinal cord stimulators, and intrathecal medications.
Hyperkalemia mechanism post Sux
1) Extrajunctional receptors: this is commonly seen with burns, spinal cord injury, etc.
2) Rhabdomyolysis: seen with muscular dystrophies
Treatment for succinylcholine-induced hyperkalemia included calcium, hyperventilation, insulin, bicarbonate, and beta-agonists.
hypo/hyperkalemic periodic paralysis cause
hyper: sodium channels
hypo: calcium channels
Pericardial tamponade and CVP tracing
exaggerated X-descent and an attenuated Y-descent
Sodium bicarb and ACLS
It can cause extracellular alkalosis (intracellular acidosis), which will shift the oxygen-hemoglobin dissociation curve to the left making unloading of oxygen more difficult. It produces hypernatremia and hyperosmolarity. It may inactivate administered catecholamines such as epinephrine by exacerbating venous acidosis.
PTH- metabolic changes
- hyperchloremia
- increase renal bicarb loss
post op apnea
- general anesthesia or regional anesthesia with IV sedation, a history of prematurity, PCA < 60 weeks (especially < 42-44 weeks), a history of apnea, and anemia.
- Being small for gestational age has been found to be somewhat protective against postoperative apnea.
Neuropathic pain treatment
First-line pharmacologic treatments for neuropathic pain are TCAs, SNRIs, gabapentin, and pregabalin.
Second-line pharmacologic treatments for neuropathic pain are oral tramadol, 8% capsaicin patches, and 5% lidocaine patches.
Third-line pharmacologic treatment for neuropathic pain are strong opioid and botulinum toxin injection.
amide LA allergic reactions
- epinephrine: metabisulfate
- preservatives: methylparaben
Salicylate overdose
- altered mental status, nausea, tachypnea, and ringing in the ears
- treat with activated charcoal, gastric lavage, urine alkalinization, and severe toxicity is treated with hemodialysis
Trisomy 21
-sub glottic stenosis, atlantoaxial occipital joint instability, macroglossia, floppy soft palate, and enlarged tonsils and adenoids
simplified shunt equation
Qs / Qt = (1 − SaO2) / (1 − SvO2)
methanol poisoning
Hepatic alcohol dehydrogenase converts methanol to highly toxic formaldehyde and formic acid. Treatment of acute methanol poisoning consists of supportive care (securing an airway, maintaining hemodynamic stability, treating metabolic acidosis), prevention of the conversion of methanol to toxic metabolites (ethanol or fomepizole), and in severe cases, rapid elimination of methanol and its metabolites via hemodialysis.
infant increased work of breathing
smaller diameter airways causing increased airflow resistance, increased oxygen consumption per kilogram of body weight, and a highly compliant chest wall leading to functional airway closure with each breath. In addition, due to the decreased proportion of diaphragmatic type I muscle fibers, infants are more susceptible to early fatigue of respiratory muscles
CVP wave pathology
Atrial fibrillation: loss of a wave
AV dissociation: cannon a wave (large a wave with loss of C)
Tricuspid regurgitation: tall c and v waves, loss of x descent
Tricuspid stenosis: tall a and v waves, minimal y descent
RV ischemia: tall a and v waves, steep x and y descent, M or W configuration
Pericardial constriction: tall a and v waves, steep x and y descent, M or W configuration
Cardiac tamponade: dominant x descent, minimal y descent
Roc precurization
-10% of ED 95 dose
lead premoval complication predictors
Longer implant duration, physician inexperience, large number of leads needing extraction, use of laser techniques, and female sex were predictors for complications
Idiopathic intracranial hypertension (pseudotumor cerebri)
- treatment is steroids and acetazolamide (in decrease CSF)
- for labor want to treat pain to lower ICP. Continuous spinal allows for drawing CSF off as needed.
Methmoglobinemia treatment
- methylene blue
- for patients with G6pD deficiency- ascorbic acid
postherpetic neuralgia treatment
- gabapentinoids
Decrease IOP
benzos, barbituates and volatiles
calculated pressure gradient
Transvalvular pressure is estimated as 4 * (peak velocity)^2 using the Bernoulli equation
Addisons disease
- primary adrenal insufficiency
- chronic fatigue, weight loss, muscle wasting, nausea/vomiting, diarrhea, and hyperpigmentation
- hyponatremia, hyperkalemia, hypoglycemia, hyperchloremic metabolic acidosis, and hypercalcemia
placenta accreta risk factors
Placenta previa, prior uterine surgery, multiparity, advanced maternal age, and smoking
Respiratory quotient
.7 Lipids
.8 Protein
1 carbohydrates
Spinal opioids
Neuraxial opioids provide analgesia via inhibition of excitatory neurotransmitters and hyperpolarization of postsynaptic neurons in the substantia gelatinosa of the dorsal horn of the spinal cord. Lipid soluble (fentanyl)- do have some systemic absorption and transfer to brain -hydrophilic (morphine) - do have some migration to brain via CSF
Central retinal artery occlusion
Macular and retinal edema with cherry red spot and attenuated retinal vessels
Sodium bicarb for normalization
2kgbase deficit
Central diabetes insipidus
Common presenting signs are polydipsia, polyuria (from 4-20 L/day), and hypernatremia, without hyperglycemia or glycosuria. A urine osmolality less than 200 mOsm/kg and a urine specific gravity ≤1.005 are hallmarks of diabetes insipidus.
-treat with desmopressin
Conns syndrome
- primary hyperaldosteronism
- fatigue, muscle cramps/weakness, polyuria, and headache.
- treated with spironolactone, a competitive aldosterone receptor antagonist and potassium-sparing diuretic
Aortic cross clamp physiology
Increased arterial blood pressure above the level of the clamp
Increased coronary artery blood flow
Increased left ventricular wall stress
Increased central venous pressure
Increased pulmonary artery wedge pressure
Decreased arterial blood pressure below the clamp
Decreased cardiac output
Decreased renal blood flow
post adenotonsillectomy obstruction risk factors
- Severe OSA on polysomnography
- History of prematurity
- Age <3 years
- Morbid obesity
- Mallampati score of 3-4
- Nasal pathology (e.g. deviated septum or enlarged turbinates)
- Neuromuscular disorders
- Craniofacial disorders and genetic disorders
- Enlarged lingual tonsils
- Upper respiratory infection (URI) within 4 weeks of surgery (D)
- Cor pulmonale
- Systemic hypertension
- Marked obstruction on inhalational induction (C)
- Disordered breathing in the PACU
- Difficulty breathing during sleep
- Growth impairment resulting from chronic obstructed breathing
Which nerve of ankle is not a sciatic branch
saphenous (femoral)
Eye glasses and lazers
CO2- clear plastic
argon/krypton- amber-orange
nd:YAG: green
ktp:ng:YAG - red
persistent vegetative state
- Cerebral cortical function (e.g. communication, thinking, purposeful movement, etc) is lost
- brainstem functions (e.g. breathing, maintaining circulation and hemodynamic stability, etc) preserved Non-cognitive upper brainstem functions such as eye-opening, occasional vocalizations (e.g. crying, laughing), maintaining normal sleep patterns, and spontaneous non-purposeful movements often remain intact.
4T heparin induce thrombocytopenia
1) Thrombocytopenia
2) Timing of the reduced platelet count
3) Presence of Thrombosis
4) The exclusion of other causes for thrombocytopenia
Troponins tell you what
Troponin levels provide significant predictive and prognostic value for short-term and long-term outcome following acute coronary crisis, cardiac surgery, and major vascular surgery.
TEE contraindications
perforated injury to the esophagus, active upper GI bleed, esophageal tumor, esophageal stricture, and esophageal diverticulum
