TL2 Flashcards
Protamine reactions
type 1: Systemic hypotension from mast cell degranulation and histamine release caused by rapid administration
Type 2: Anaphylaxis from IgE-mediated dose-independent reaction. Previous exposure to protamine or a similar protein (such as neutral protamine Hagedorn found in NPH insulin
Type 3: Pulmonary hypertensive crisis causing pulmonary hypertension, vasoconstriction, and possible right heart failure. The mechanism for this reaction is thromboxane A2 released from platelets and macrophages stimulated by protamine-heparin complexes
hypokalemic periodic paralysis triggers
stress, cold environment or hypothermia, carbohydrate load, infection, glucose infusion, metabolic alkalosis, alcohol, strenuous exercise, and steroids
hyperkalemic periodic paralysis triggers
hyperkalemia, potassium-rich meals or exogenous potassium administration, rest after exercise, stress, metabolic acidosis, and succinylcholine use. Factors that can worsen a HKPP episode include acetylcholinesterase inhibitors, extremes of temperature, and hypoglycemia.
most sensitive for detecting cardiac ischemia
TEE>EKG>PCWP
Vec metabolite
Vecuronium has three active metabolites, 3-desacetyl-, 17-desacetyl-, and 3,17-desacetyl vecuronium. Among these, the 3-desacetyl metabolite is the most important since it has nearly 80% of the activity of vecuronium
types of von willebrands
Type 1 VWD: partial decrease in VWF concentrations
Type 2 VWD: qualitative defect in VWF
Type 3 VWD: total depletion of VWF
von Willebrand intraop bleeding
- von Willebrand factor concentrates or desmopressin.
- cryoprecipitate may also be used to replete von Willebrand factor
- Adjuvant therapies include antifibrinolytics (TXA and aminocaproic acid) and topical clotting products.
SVT in WPW treatmen
- procainamide
Carotid body chemoreceptors
When PaO2 is around 55
- afferent impulses via the glossopharyngeal nerve to CNS ventilatory centers
- impaired by opioids, benzos and volatiles (b/l CEA also)
Adult blood:gas coefficients
higher than peds
- leads to a slower rise in the FA:FI ration
Faster inhalational induction in peds
- Increased minute ventilation relative to FRC (most important)
- Increased blood flow to vessel-rich organs
- Decreased blood:gas partition coefficients
- Decreased tissue:blood partition coefficients
Cushings triad
-HTN, bradycardia and irregular respiratory pattern 2/2 to elevated ICP
CPDA for blood storage
- Citrate is the anticoagulant (binds calcium necessary for clot formation
- Phosphate is incorporated for cellular function and ATP production
- Dextrose is the nutrition source for glycolysis
- Adenine is incorporated for ATP production
imaging for retained epidural catheter
CT scan
ETCO2 measured
by infrared spectrophotometry.
-inverse relation between amount of energy detected and gas partial pressure
American Spinal Injury Association (ASIA) score
A Complete cord injury with complete motor and sensory deficits in S4 and S5 nerve roots
B Incomplete cord injury with sensation preserved below the level of injury; intact S4 and S5 nerve roots
C Incomplete cord injury with motor function preserved below the level of injury; < 3 out of 5 motor strength in half of the major muscle groups
D Incomplete cord injury with motor function preserved below the level of injury; ≥3 out of 5 motor strength in half of the major muscle groups
E No evidence of cord injury with intact motor and sensory innervation
SIADH lab values
Hyponatremia with urine sodium greater than 20 mmol/L
LES and RSI
- Sux increases LES
- cricoid pressure decreases LES tone
qSOFA
Hypotension SBP < 100
AMS
Tachypnia RR>22
Decreased FRC
PANGOS
pregnancy, ascites, neonates, GETA, Obesity, Supine
patient population to be concerned with vasopressin administration
Caution must be used when administering vasopressin to patients with coronary artery disease as it may precipitate myocardial ischemia by vasoconstriction of the coronary arteries.
Exacerbation of MS
in the perioperative period caused by surgery and the use of general or spinal anesthesia. Succinylcholine should be used cautiously or avoided
Neonatal life support
Infants with a heart rate < 60/min despite adequate ventilation should be treated with chest compressions and endotracheal intubation. Epinephrine and volume expansion can also be considered if the infant is not showing improvement. Naloxone and sodium bicarbonate are not recommended.
pyloric stenosis
Correction of hypovolemia and electrolyte abnormalities is best achieved with an infusion of 10 to 20 mL/kg/hr of normal saline with 20 mEq/L of potassium.
Posterior fossa brain ischemia monitoring
Auditory evoked potentials
gabapentin side effect
nausea, sedation, dizziness, ataxia, nystagmus, peripheral edema, and weight gain.
gabapentin MOA
Gabapentin is an anticonvulsant originally approved for the treatment of partial seizure epilepsy and later for treatment of neuropathic pain. It binds and inhibits the alpha2-delta subunit of the voltage-gated calcium channel. This results in a decreased release of the excitatory neurotransmitter glutamate.
albumin in pregnancy
Serum albumin concentration decreases during pregnancy because of plasma expansion. Many other serum constituents such as fibrinogen, transferrin, and globulins increase, most likely due to the hormonal changes secondary to the pregnant state.
Hemophilia A
- deficient factor VIII
- treat with desmopressin, cryo
- if antibodies to factor VIII: porcine factor VIII, recombinant factor VIIa, or recombinant factor IIa
risk for accreta with prior c sections
0 = 3% incidence, 1 = 11%, 2 = 40%, 3 = 61%, 4+ = 67%
pulses paradoxus
- seen in cardiac tamponade
- A decrease >10 mm Hg of systemic blood pressure during inspiration
persistent fetal circulation
Hypoxemia, hypothermia, and acidosis are all associated with persistent fetal circulation. This is due to increased pulmonary pressures, which favor flow through shunts that are only functionally closed and not yet anatomically closed
premature ductal closure
maternal NSAID use
long term TPN
Hyperalimentation is commonly associated with hypophosphatemia, hypo or hyperglycemia, and acute liver injury. Patients on total parenteral nutrition (TPN) require vitamin K supplementation and often have an elevated prothrombin time.
Cryo contains
von Willebrand factor (vWF), fibrinogen, fibronectin, factor VIII, and factor XIII.
Cryo indications
- Microvascular bleeding with hypofibrinogenemia *
- Bleeding due to uremia that is unresponsive to DDAVP
- Factor XIII deficiency
- Prophylaxis before surgery or treatment of bleeding with congenital dysfibrinogenemias
- Prophylaxis before surgery or treatment of bleeding with Von Willebrand disease **
- Prophylaxis before surgery or treatment of bleeding with hemophilia A **
- Use in fibrin sealant production
mid-esophageal aortic valve short axis view (ME AV SAX cusps
The non-coronary cusp of the aortic valve is adjacent to the inter-atrial septum, the right coronary cusp is most anterior, and the left coronary cusp is adjacent to the pulmonary artery
cerebral palsy
Cerebral palsy (CP) patients have an increased incidence of gastroesophageal reflux and aspiration. “Succinylcholine has been used in children with CP for more than 50 yr without a single report of a hyperkalaemic response.
Uremia and clotting
Uremia interferes with platelet activation and aggregation (primarily via effects on vWF and GPIIb-IIIa) and leads to increased production of platelet inhibitors (e.g. prostacyclin and nitric oxide)
Fenoldopam
- DA-1 receptor agonist
- Decreases peripheral vascular resistance
- Increases renal blood flow
- Increases diuresis (urine production)
- Increases natriuresis (urine sodium excretion)
(will lead to intraocular pressure)
MELD vs Child Pughs
MELD: “I Crush Beer Daily” - INR, Creatinine, Bilirubin, Dialysis
Child-Pugh: “Pour Another Beer At Eleven” - PT, Ascites, Bilirubin, Albumin, Encephalopathy
GERD in parturients
due to increase in progesterone
transdermal fentanyl patches
patient with chronic/cancer pain taking more than 45mg morphine daily
Coronary perfusion
LV during diastole
RV continuously as RV pressure does not normally exceed systemic pressures
muscle dystrophy
avoid sux, neostigmine and potassium containing solutions
ECT
elevations in CBF and ICP, long and short-term memory loss, and autonomic stimulation with initial bradycardia, followed by hypertension and tachycardia
Evoked potential sensativity
BAEP < SSEP < MEP < VEP, (SSEP = somatosensory evoked potential, MEP = motor evoked potential). Another way to remember: BAEP are Barely affected, SSEP are Somewhat affected, MEP are Mostly affected, and VEP are Very affected.
Sickle cell avoid
hypothermia, hyperthermia, hypoxemia, hypotension, hypovolemia, and acidosis can all promote erythrocyte sickling
improve defibrillation
quick defibrillation, the use of electrode gel, biphasic defibrillation, and larger electrodes
Regional in TURP
1) monitoring for bladder/prostatic perforation (nit higher than T 10)
2) decreased blood loss
3) decreases DVT
Autonomic hyperreflexia
Anesthetic management of patients at high risk for AH includes neuraxial anesthesia with local anesthetic and/or deep general anesthesia. Opioid-only anesthetics administered intravenously or neuraxially do not reliably prevent AH. Symptoms of AH are related to the profound vasoconstriction that occurs below the level of the lesion (e.g. headaches, hypertensive crisis, MI) and the vasodilation that occurs above the level of the SCI (e.g. diaphoresis of upper body, nasal congestion). Treatment includes fast-acting vasodilating agents such as nitroprusside, nitroglycerin, and nicardipine.
Ductus arteriosus
- Indomethacin to close
- prostaglandins (PGE1) to keep open: Side effects include apnea, hypotension, fevers, and CNS irritability.
Dantrolene doses
- 5mg/kg up to 10mg/kg
- infusion at 0.25mg/kg/hr
most accurate in predicting AKI
creatine clearance= urine cr * urine volume/ Plasma creatine
FENA
FENa = (Urine sodium * Plasma creatinine) / (Urine creatinine * Plasma sodium)
FENa < 1% = Prerenal
FENa >1% = Intrinsic (e.g., acute tubular necrosis)
FENa >4% = Postrenal
Differentiate ESLD vs DIC
Factor VIII
- Consumed in DIC, normal or high in liver disease
Maternal side effects of B adrenergic receptor agonists
Hypotension Tachycardia Increased cardiac output Hyperglycemia Hypokalemia Pulmonary edema
Factors that decrease in pregnancy
factor XI and factor XIII
Obtorator nerve block
inject between add longus and brevis (primary location)
and between addbrevis and magnus
Radiation intensity
I ∝ 1 / r^2
Triggers for nonshivering thermogenesis in neonates and infants
- Norepinephrine, glucocorticoids, and thyroxine
- inhibited by inhalational anesthetics and β-blockers
caudal dosing for kids
0.5 mL/kg of local anesthetic will cover the sacral dermatomes, 1 mL/kg will cover up to the low thoracic dermatomes, and 1.25 mL/kg will cover up to the mid thoracic dermatomes
spinal stimulation contraindications
sepsis, coagulopathy, previous surgery or trauma obliterating the spinal canal, localized infection, and spinal bifida
- relatively contraindicated in the setting of cognitive and psychological disability
chronic opioid therapy
increased prolactin levels, and decreased testosterone, estrogen, cortisol, LH, and FSH.
Risk factors for acute MR following MI
- Advanced age
- Prior myocardial infarction
- Infarct extension
- Inferior or posterior MI
- Multiple vessel coronary artery disease
- Recurrent ischemia
femoral triangle anatomy
femoral triangle is bordered by the inguinal ligament superiorly, the adductor longus muscle medially, and sartorius muscle laterally
calculated on ABG
base deficit, bicarb and SAO2
breast milk vs clears
- breast milk leads to higher gastric volumes
Superior laryngeal nerve damage
- most common during thyroid or parathyroid surgery
- voice easily tires
- no respiratory distress
jugular bulb venous oxygenation
- measure global cerebral oxygen extraction
- balance between oxygen supply and demand
Nuclear detonation
- potassium iodine to save the thyroid
- strontium lactate for bones
Soidum Nitroprusside toxicity
elevated mixed venous oxygen (PVO2), SNP tachyphylaxis, and metabolic acidosis
VonWilllebrands treatments
Type I: trial of DDAVP
Type II: trial of DDAVP, avoid if known type IIB
Type III: vWF concentrate (DDAVP has no effect)
Acquired vWF Deficiency: trial of DDAVP, switch to vWF concentrate if not responding
Antibody-Mediated Acquired vWF Deficiency: IVIG
Minor Bleeding/Surgery: DDAVP, follow clinically, vWF concentrate if bleeding continues
Major Bleeding/Surgery: use vWF concentrate and continue in the perioperative period
when is fetal heart rate monitoring feasable
18-20 weeks
Blood volume
Premature infant 90-105 mL/kg Full-term newborn 80-90 mL/kg Infant 3-12 months 70-80 mL/kg Child 1-12 years 70-75 mL/kg Adult male 65-70 mL/kg Adult female 60-65 mL/kg
increases cerebral perfusion and oxygenation
Of the vasoactive medications that cause vasoconstriction, vasopressin may preserve cerebral blood flow and oxygenation while also increasing cerebral perfusion pressure. This effect is likely mediated by local nitric oxide release stimulated by the direct action of vasopressin on the cerebral vasculature
temp vs pH and CO2
pH is increased by 0.015 for each degree below 37 °C. PaCO2 is decreased by 2 mm Hg for each degree below 37 °C.
Spinal cord stimulators
Spinal cord stimulators activate the larger Aα and Aβ fibers to a greater degree compared with the smaller nociceptive Aδ and C fibers. This closes the gate in and impedes conduction of pain sensation past the substantia gelatinosa of the dorsal horn of the spinal cord.
HIgh frequency ventilation
High frequency ventilation utilizes the delivery of rapid subphysiologic tidal volumes to achieve gas exchange via multiple complex mechanisms including: cardiogenic mixing, Pendelluft ventilation, Venturi effect, and Taylor dispersion
Carbamazepime overdose
neurological, cardiac and anticholinergic symptoms
acromegaly
skeletal overgrowth, soft-tissue overgrowth, connective tissue overgrowth, peripheral neuropathy, visceromegaly, glucose intolerance, osteoarthritis, osteoporosis, hyperhidrosis, skeletal muscle weakness, and increased lung volumes
adenosine doesn’t terminate what?
atrial flutter
refeeding syndrome
Refeeding syndrome is a term that refers to various metabolic abnormalities that may complicate carbohydrate administration in subnourished patient populations. Hypophosphatemia is the most well known, and perhaps most significant, element of the refeeding syndrome, and may result in sudden death, rhabdomyolysis, red cell dysfunction, and respiratory insufficiency.
ALS anesthesia options
Denervating neuromuscular disease can result in extrajunctional receptor formation, which leaves patients susceptible to exacerbated hyperkalemic response to depolarizing neuromuscular blocking drugs. Strokes, CNS tumors, burns, crush injuries, and prolonged immobility are among other causes of the formation of extrajunctional acetylcholine receptors. Spinal anesthesia is typically avoided in patients with ALS
diagnostic signs of compartment syndrome
compartment pressure >30 mmHg, creatine phosphokinase level >5000 U/ml (possibly as little as >1000 U/ml), loss of normal phasic patterns of tibial venous blood flow, loss of distal pulses in the setting of closed extremity injury, and compartment perfusion pressure < 21 mmHg.
leading maternal cause of death with preeclampsia
-stroke
treat and prevent myotinic crisis
phenytoin
-phenytoin, quinine, procainamide, direct infiltration of the affected muscle with local anesthetic, or a high concentration of volatile anesthetic
myotonic crisis cause in myotonic dystrophy
shivering from hypothermia, succinylcholine, neostigmine, and direct surgical stimulation of muscle
salicylate poisoning
mixed respiratory alkalosis and metabolic acidosis
adult to ped liver donation
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