Truelearn Flashcards
Carcinoid tumor
1 cause of death is cardiac failure with carcinoid
Mainly in gi tract
High 5 hiaa in urine
Excess of serotonin in systemic circulation
Flushing diarrhea abdominal pain hypotension right heart lesions
Ulnar neuropathy
Thin males
Don’t put pressure on condylar groove of humerus
Most common perioperative neuropathy is ulnar
Nerve conduction studies look at both motor and sensory
Decrease smoking for two days
Less carboxyhemoglobin and oxyhemoglobin curve shifts to the right
Takes two months to see reduced sputum increased ciliary function improved closing volume
Causes of failed neuraxial block during c-section
Maternal obesity
Late labor epidural placement
Rapid conversion from labor to C section
Hyperparathyroidism main cause
Single adenoma
Leads to hypercalcemia with abdominal pain nephrolothiasis
Parathyroid stimulates osteoclast activity
Familial hypocalcemic hypocalciuria is due to
Decreased excretion of calcium and magnesium
Normal creatinine and BUN I’m pregnant patient
In pregnancy
GFR
Blood clotting factors increase/decrease
Hemoglobin
Increases
Increase
Decrease -physiologic anemia
Sitting pain =
Discogenic
Morning stiffness back pain
Anklyosing spondylitis
Primary hyperthyroidism
High serum and urinary calcium
Low phosphorus
Causes non anion gap acidosis
Non parathyroid causes of hypercalcemia
Multiple myeloma, vitamin d intoxicating
Renal failure
Secondary hyperthyroidism
Caliciun low phosphorus hugh
Gas score verbal
5 normal
4 confused
3 inappropriate words
2 incomprehensible words
GCS score
Movement
6 normal 5 localize to pain 4 withdraw to pain 3 flex ion 2 extension 1 nothing
An acute drop in ventilation during a single lung case is to
Ventilate with both lungs
Dependent lung is the
Ventilated lung
Can give peep if hypoxemic
Septic shock
More glucose formation with insulin resistance
Sepsis leads to hyper metabolism which increases protein catabolism
SVT with WPW syndrome slanted R wave
ProcainAmide
Paroxysmal SVT first line
Adenosine
Elimination half life of labetolol
5.5 hrs
Diltiazem increases
AV nodal conduction
Anyicholingeric
Tachycardia
Mydriasis
Carbamazepine side effects
Widened qrs
Hypotension
Seizures
Anti-cholinergic symptoms
Antiphospholipid syndrome
Recurrent pregnancy loss
Leads to arterial/venous thrombosis
Increase in PTT but no change to PT time
Bowel obstruction of my tubes
Decrease viscosity of feeds
Flush them through
Refeeding syndrome
All electrolytes are down mainly hypophasphatemia
ASIA scoring system for spine injury
A = complete cord transection
E = normal
PCNS = p alveoli = p blood
At equilibrium
LAD supplies
Left anterior wall of left ventricle
Lateral wall of LV is by the circumflex
IVRA
Tourniquet on its own provides distal ischemia without local anesthetic
Provides motor and sensory anesthesia
Bier block provides extremity anesthesia by diffusion of local anesthetic from veins to capillaries to vasa vasorum
C section when compared to vaginal delivery
Lower risk of maternal hemorrhage or uterine rupture if u do a c section
C section will increase uterine rupture risks in further pregnancies
Infection risk is higher in c section
Phosgene chemical warefare agent
Severe pulmonary damage
Can’t give hydroxyethyl starch to a patient with
Renal failure
Acute systolic reaction from dopamine antagonism from which drugs
Metochlopramide and procholrperazine
Anticholinergic such as diphenhydramine or benztropine can be used for treatment
Sarcoplasmic reticulum calcium goes into the
Cytoplasm
Calcium binds troponin c and displaced tropomyosin to allow actin-myosin binding
Lactate
Can not replenish ATP in muscle fiber
Binding of what molecule to myosin head allows for detachment from actin
ATP
Kappa opioid receptor provides relief from opioid induced
Itching
NMDA receptor antagonism
Methadone
Ketamine
Memantine
The substance seen most in the epidural space is
Fat
Dopamine
Increases Cardiac output and svr and doesn’t help with renal function
First line pressor for septic shock is
Norepinephrine
First line therapy In all forms of shock is
Intravascular volume replacement
Midazolam/diazepam method of bio transformation
Oxidation
Lorazepam/oxazepam method of bio transformation
Glucoronidation
Latex allergy
Tropical fruits
Banana, mango, kiwi, pineapple, mango
Also more with spina bifida, healthcare workers
How many category 1 credits are needed per cycle by MOCA
250
Fellowship gives 50
Quadraplegia occurs if lesion is above
T1 if not it is paraplegia
Above C4 they will need ventilator support
During forced exhalation
The apices of the lungs are emptied first
Unilateral intrascalene block causes
Unilateral phrenic nerve blockade
ERV with atelectasis
Is less. The ERV difference between expiring with and without atelectasis is closing volume. Closing volume plus RV = closing capacity
Closing capacity is the volume remaining in the lungs
When alveoli begin to close
FRC =
ERV plus RR
Most safe volatile anesthetic with renal failure
Desflurane
Sevoflurane produces compound A which could be determinate in kidneys
Methemoglobin
Ferrous form of heme is oxidized to the ferric form
Prilocaine and benzocaine can cause it
Treat with methylene blue 1-2 mg/kg
If patient has G6PD defieciency treat methemoglobinemja with ascorbic acid(vitamin c)
Dibucaine number of 20 is homozygous for pseudo holiness erase deficiency
40-70 is heterozygous
Phase 2 block with succ is after multiple doses and resembles neuromuscular block
Yes
Higher dibucaine =
More psuedocholinesterase
Pneumothorax
Sudden hypoxemia and high peak pressures
Post obstructive pulmonary edema
Young males after Extubation
Treat with positive pressure ventilation
Hyperesthesia allodynia autonomic changes with previous fracture and damage to nerve
CPRS type 2! Cprs occurs in the abscence of apparent nerve injury
Palpable taut band, pain when nodule pressed on band
Myofascial pain syndrome
Treatment cprs
Physical therapy
Memantine gabapentin
Sympathetic nerve blocks
Jaw thrust to relieve upper airway obstruction affects what muscle
Genioglossus
General anesthesia can do what to uterine musculature
Vagina and perineum is what dermatome
Relax it
S2-S4
Registries are good bc they can tell us about
Rare events
Closed claims project was made to help with
Patient safety
Bumenorphine is a _____ my agonist
Partial
Meaning it only get to a partial point if it’s full potential
In procurement give PRBCs to achieve hematocrit of
30%
Try to have procurement as soon as possible
Always perform echocardiogram on heart before doing a heart transplant
ACT
Used to evaluate intrinsic and final common pathway of coagulation system
Normal ACT is 107
ACT 400-480 in order to go on cardiopulmonary bypass
Hypothermia, thrombocytopenia, hemodilution prong the AcT
Common pathway of coagulation
Factors 10, 5, 2
7 extrinsic
Intrinsic 12 11 9 8
Liver produces all vitamin k dependent factors
2, 7 9 10 protein c and s
Factor 7 has shortest half life of vitamin k dependent factors
Second degree AV block type 2 requires a
Pacemaker
Also third degree
Refractory SVT
Symptomatic bradycardia with sinus node dysfunction
Hypocalcemia
Distal paresthesia
Tetany
Hypokalemia = U waves
Emphysema = hyperinflation
With pulmonary bleh on child want to avoid use of
Nitrous oxide
Child vs adult airway
Child has larger tounge cephalad larynx, slanted vocal cords floppy epiglottis
Infant larynx is at c3-c4 adult is at c5-c6
On TEE cephalad structures
Are on the right side
Hardest valve to visualize via TEE
Pulmonic valve - easier to see with TTE as it is more anterior
Precedex is mainly metabolized in the
Liver
Precedex causes inhibition of presynaptic norepinephrine release
Elimination half life is 2-3 hours
Pregnancy related mortality number one cause is
Cardiovascular disease
Transient neurologic syndrome is not affected by the
Baricity of the local anesthetic
Back pain with radiation to buttocks thighs and calves occurring 24 hours after spinal and gets better within 1-3 days
TNS is associated with liocaine spinal anesthesia, lithotomy position, same day surgery, and early ambulation after surgery
Sensory level of spinal anesthetic affected by
Baricity of solution
Dosage of local anesthetic
Patient position
Motor evoked potentials
Procedures involving anterior spinal cord blood supply and anterior spinal artery
Artery of adamkowitz
Thoracolumbar spinal cord is supplied by it
Brainstein evoked potentials start in the ____ and end in the _______
Cochlea/auditory cortex
The first step if someone hyperkalemic with ecg changes and mental status change
Stabilize myocardium with calcium and give insulin other measures, can’t do dialysis first even though it’s the definitive treatment
Furosemide takes 30 minutes to start working
Thermal neutral zone for new newborn
32-35 degrees C
The range of ambient temperature where metabolic rate is at a minimum
Supfhemoglobin and acidosis shift oxyhemoglobin curve to the
Right
Methemoglobin shifts it to the left
FRC is described as
Volume of air left in the lungs at the end of breathing, during normal tidal volume breathing
Below closing capacity
The lungs start to collapse
Musculochtaneous nerve is not within the
Axillary sheath
That’s why it often doesn’t get blocked
Peak and plateau pressures both increase from
C02 insufflation Ascites Obesity pulmonary edema Tension pneumothorax
Best opioid for chronic neuropathic pain
Methadone
Has nmda activity and serotonin reuptake
Hypophosphatemia
Dysfunction of skeletal muscle
Hypophosphatemia decreases 2 3 DPG which causes left shift of oxyhemoglobin curve
Replacing phosphate can lead to what electrolyte abnormality
Hypocalcemia
DLCO looks at
Diffusion capacity of lung
It is decreased by pulmonary embolism
Higher cardiac output or bigger lung volumes increases it as well such as with exercise will increase dlco and so will asthma
Vasopressin doesn’t directly affect
Potassium concentration
What ventricle is continually perfused during cardiac cycle
Right Ventricle
Resting coronary blood flow is 250 ml/min
Coronary perfusion pressure is difference between aortic and ventricular pressures
LV is primarily perfused during diastole
Alveolar dead space decreases during pregnancy due to increase in
Cardiac output
Spinal anesthesia leads to
Decreased hearing, hypothermia due to redistribution of heat from core to periphery,
PVR is highest at
Extremes of lung volumes. Lowest at normal tidal volumes
As alveoli close get resistance of blood vessels due to decreased flow
Pulmonary vascular resistance is lowest at FRC*****
Fluid flow pousielle law determined by
Viscosity, length of tubing, pressure exerted on tubing
Coffee with creamer and soy milk how long yo fast
6 hours
Phase 1 metabolism
Oxidation, reduction, hydrolysis
Elimination of drug is proportional to
Serum drug concentration
Constant fraction per unit time is lost in
First order kinetics
Most drugs are eliminated by zero order kinetics
Aging lung tissue has decreased elasticity and thus increased
Compliance
FRC and Closing Capacity _________ in the elderly
Increase
Bohr effect describes
Hemoglobins affinity for oxygen at varying conditions
Absolute indications one lung ventilation
Protective isolation
Uniteral lung lavage
Vats
Relative indications are pneumonectomy, love tiny, thoracic aneurysm
Hepatic artery supplies and Portal vein supplies how much of blood supply to liver
20/80
Synthetic function of liver is based off PT
Half life of albumin is
20 days
Which clotting factor has the shortest half life
7 - half life 3-6 hours
Midesophageal two chamber view shows
Anterior and inferior walls of LV
Anterior supplies by LAd and inferior by RCA
Can also see left atrial appendage
Hypercarbia causes
Rightward shirt of oxyhemoglobin dissociation curve
Long acting non selective alpha blocker
Phenoxybenzamine
Catecholamine resistant vasoplegic shock give
Methylene blue which is contraindicated relative to fluoxetine
At rest CMR02 is 3.5ml/100g/min
Brain gets how much cardiac output
10-15%
If CBF higher than CMR get
Luxury perfusion
If CBF is lower than CMR you get ischemia
Leukocyte reduction means
Depleting donor blood products of leukocytes
Leads to decreased Febrile reaction s, decreased CMV transmission, reduced inflammatory mediators
In patients with high anion gap metabolic acidosis the reason bicarbonate is low as due to
Binding the excessive H+ ions
Approximately 85% of bicarbonate is reabsorbed in the
Proximal tubule
4T to diagnose HIT
Thrombocytopenia
Timing of reduced platelets- 5 to 11 days
Presence of thrombosis
Exclusion of other causes of thrombocytopenia- other cause not apparent
Tetanus
Inhibiting neurotransmitter release from inhibitory neurons of the CNS
Treat with tetanus immunoglobulin
Botulism
Inhibition of acetylcholine release from the nerves at the neuromuscular junction
Inhibition of elongation factor 2
Diptheria
Maternal ACEI use is associated with
Oligohydraminos not polyhydraminos
Polyhydraminos treatment of choice is
Indomethacin
Usually due to fetal structural abnormalities like TEF or duodenal atresia
Method of treatment that could alone worsen thyrotoxicosis
Thyrotoxicosis due to over abundance of thyroid hormone
Radioactive iodine- don’t give alone bc can lead to more hyperthyroid the first few days after bc it releases thyroid hormone in the bloodstream
PTU and methimazole act to lower
T4
Can’t do radioactive idodine in patients who are
Pregnant or breastfeeding
Ace inhibitor causes
Decreased cardiomyocyte proliferation
Left ij and carotid artery overlap more on the
Left side
Most common complication with central line is
Infection
Best and first way to diagnose c dif
C dif toxin enzyme immunoassay
First cause is clindamycin and quinolone
Fenoldopam MOA
Dopamine 1 agonist
Causes sodium and free water excretion
Renal vasodilator
Non coronary cusp is on the
Right on mid esophageal aortic short axis view
RCC is posterior
Causes of needing postop mechanical ventilation in patients with myasthenia gravis
Duration of disease>6 years Presence of pulmonary disease like copd Vital capacity<2.9L NIF<20cm H20 Daily pyridostigmine dose>750mg
Many patient with MG have thymoma
Patients with MG are resistant to succinylcholine
Sensitive to NMBlockers because less receptors available
Hypovemia leads to
Decreased venous return and cardiac output
Leads to decreased 02 delivery and can lead to postop afib
Occurs commonly after cardiothoracic surgery
Sotalol
Beta blocker
Potassium blocker-leads to less potassium
Apgar score
Heart rate Muscle tone Skin color Reflex irratibility- grimace and/or small cry is a 1 Breathing
Code dose epinephrine
0.01mg/kg
50-100 mcg iv I typical dose
Give epi 1 mcg/kg after anaphylaxis
If you suspect latex allergy with anaphylaxis
Mast cell tryptase should be drawn
Epi
Fluid bolus
Remove latex materials
Cessation of anesthetic agents
Amiodarone can not be
Dialyzed
What hemodynamic parameter does not change during pregnancy
Central venous pressure
SVR decreases in pregnancy
Cardiac output is highest right after
Delivery
Hemodialysis requires large fluid shifts and may not be tolerated in ppl with
Aortic stenosis, unstable angina and other cardiac conditions
Hypercalcemia symptoms
Polyuria, polydypsia, weakness, psychic disturbance, kidney stone, constipation, shortened qt, prolonged pr, heart block
Neostigmine side effect that isn’t reversed by anti-cholinergics
Paradoxical muscle weakness
Neostigmine causes decreased LES tone and can lead to BRONCHOSPASM
Seperation anxiety starts
After 6 to 8 months
Spirometers can’t tell u
Residual volume
Negative pressure pulmonary edema
Hypoxia, pink frothy fluid, and bilateral patchy infiltrates on cxr
Treat with Ppv or cpap
Leads to increased preload and afterload
Trendelenberg does not increase
Dead space
Can cause endobronchial intubation/total lung capacity can go down/trendelenberg leads to rise in shunt
ARDS
Non-cardiogenic pulmonary edema with hypoxemia
Increase PEEP to help patients with
ARDS
High peep lowers cardiac output due to decreased venous return to right heart
Sodium nitroprusside causes
Cerebral vasodilation
Spinal cord stimulator affects
Dorsal horn of spinal cord
After mi without coronary intervention should wait
2 months before elective surgery
Emergency procedure is those defined as needing to take place within
Urgent procedure is described as those needing to take place
6 hours
6 to 24 hours
After MI
14 days for balloon angioplasty
30 days after BMS
60 days after no intervention
180 days for DES
CAM ICU first look at
Inattention to diagnose delirium
Sinusitis is a complication of
NG tube feeding for prolonged times
Need CT Max face
Carbohydrates generate more ______ than lipids
C02
Headache with focal neurologic symptoms do
MRI
Storage of RBCs shifts oxygen dissociation curve to the
Left
Fever, nuchal rigidity, and altered mental status =
Meningitis
Epidural hematoma
Lower extremity neurologic signs, such as decreased motor function
Botulism
Blocks intracelluar fusion acetylcholine vesicles to the nerve terminal membrane
Botulism toxin works at the
Neuromuscular junction
Amniotic fluid embolus
Cardiovascular collapse and then consumptive coagulopathy
Pain in an area that lacks sensation
Anesthesia dolorosa
Hypalgisia
Decreased response to noxious stimuli
Mannitol May cause cerebral vasodilation
If given too quickly. Give over 10 to 15 minutes
Valproic acid doesn’t help In treatment of
CRPS type 2
First line for CRPS
Physical therapy- cornerstone
TCA
Gabapentin
Sympathetic block
Terbutaline can cause
Hyperglycemia
Preterm labor
Before 37 weeks
Terbutaline side effects
Tachycardia
Hypokalemia
Hyperglycemia
Indomethacin side effect
Renal and platelet dysfunction
Fetal fibronectin can be used to screen for
Preterm labor
Absolute indicators for TPN
Short bowel syndrome
Small bowel obstruction
Active GI bleed
Enteric fistula
Use lower glucose in tpn solution to prevent
Hypoglycemia
Leads to less insulin secretion
High dose oxytocin leads to
Hyponatremia and hypotension
High dose oxytocin leads to
Hyponatremia
Hyperchloremic metabolic acidosis lowers
SID
Lactate levels stay normal
Elderly patients have increased
Resting sympathetic tone and a decrease in parasympathetic tone
TPN metabolic changes
Hypercarbia/hyperglycemia/hypophosphatemia
Hepatic steatosis is common with TPN
TPN can lead to
Hepatic steatosis- AST/ALT will increase
RQ of 1 =
RQ of 0.7 equals
Carbohydrate Oxidation
Lipid oxidation
If patient has been getting any form of heparin for over 5 days
Need to check platelet count prior to neuraxial placement or epidural catheter removal
If patient is getting 5000 subq heparin BID or TID
Need to wait 6 hours until neuraxial placement
Most sensitive for detecting venous air embolus
TEE than precordial Doppler
Nicardipine is extensively metabolized by
The Liver
Nicardipine side effect
Flushing
Headache
Peripheral Edema
Renal insufficiency has no affect on nicardipine
Diabetes inspidus with.m hypernatremia and seizures first line is
Free water slowly and then if needed desmopressin
Acute respiratory acidosis what helps first
Plasma protein buffers
Renal retention of bicarbonate happens later
Bladder distention during surgery leads to
HTN
Anterior wall of left ventricle =
LAD
Drowning
Breath holding then laryngospasmtgen involuntary efforts then desat inhalationof water then cardiac arrest
With no leak on icu patient with good respiratory parameters you want to extubate
Give methylprednisolone prior to Extubation
Sensory below vocal cords
Recurrent laryngeal nerve which is a branch of the vagus
Infants risk for apnea increase with
Anemia
General anesthesia
Regional anesthesia with IV sedation
Volatile anesthetics above 1 MAC
Increase CBF and decrease CMR02
CMR02 decreases with
Hypothermia and sleep
Nitrous oxide increases
CMR02 and CBF
IV anesthetics all
Lower CBF and CMR02
Adult poly cystic kidney disease
Before doing surgery need to get
CT angiogram of head to check for cerebral aneurysm
Specifically Berry/Saccular aneurysms
Steep trendelenberg
Less blood to legs, reduced cardiac output, more central blood volume
Steep trendelenberg increases risk of rupture
Increased ICP and IOP
Reduced FRC/vital capacity
Mar fans
Mutation in fibrillin1
Get echo and CT angiogram prior bc they have high risk for aneurysm and heart issues
Loop and thiazides cause a
Hypochloremic metabolic alkalosis
Volatile anesthetics increase CBF only at
1.5-2.0 MAC
Pressure within alveolus =
2T/R
Surfactant concentration increases when
Alveoli become smaller
In pregnancy minute ventilation is
FRC below closing capacity leads to
Increased
Atelectasis
Urticaria angioedema dyspnea after blood transfusion usually due to
IgA deficiency
Continued use of opioids even after adverse consequences =
Addiction
Delay in latent phase of labor mainly due to
Unripe cervix
20 hours for first
14 if multigravida
Gradient between pac02 and Etc02 =
Dead Space
Stellate ganglion block complications
Vasovagal reaction Ptosis Miosis Spinal injection Horners syndrome
Duration of action of neuromuscular blockers in elderly is
Less
Thus can give less
If patients intrinsic HR is above pacemaker HR and on asynchronous mode(DOO) can lead to
R on T phenomenon leading to V Tach or V fib
Can change to DOO
Periop to prevent electromagnetic interference
Need DDD for complete heart block
Don’t give propofol to patients suspected of having
Pancreatitis
PRISyndrome
Metabolic acidosis, rhabdomyolysis, CHF, bradycardia and affects mitochondrial and fatty acid metabolism
Related to high dose propofol infusions
In awake patient, first line medication to cause uterine relaxation is
Nitroglycerin-usually happens during cases of retained placenta
Glycine toxicity causes
Hyper ammonia and can cause transient blindness
Number one risk factor for placenta accreta
Former C section
If leak pressure of uncuffed endotracheal tube is high replace with
SMALLER endotracheal tube
Too much pressure can lead to tracheal ischemia
Optimal cuff pressure is
20 cm H20
Opioid addiction is more likely in
Non cancer pain
Highest risk for AKI
Aortic aneurysms
Total hepatic blood flow preservation is least with
Halothane
Moderate to severe cancer pain can use
Morphine
Morphine 6 glucoronide also provides
Analgesic effect
Morphine 3 glucoronide provides adverse affects
PONV
Female
Non smoker
Previous PONV
Use of postop opioids
Ambulatory surgery shouldn’t require
Overnight stay
Main reason for delay in discharge is pain or PONV
Type 1HRS
Happens fast. Usually due to some problem with spontaneous bacterial peritonitis
First fluid for severe dehydration in Peds patient
20 mg/kg of isotonic fluid like NS
Risk factors for placenta accreta
Multiparity Smoking Advanced maternal age Placenta previa Prior uterine surgery
Fibrinogen half life is
4 days
Only drugs that must be continued are
Beta blockers and statins
Nicardipine
Arteriolar vasodilator and decreases left ventricular afterload with minimal affect on preload
Fenoldopam
Vasodilator that causes reductions in preload and afterload
Nitroglycerin
Vasodilator via cGMP. Reduces preload and causes greater venous dilation
Neseritide
Vasodilation, naturesis, diuresis
A delta are the
Fastest conducting nociceptive fibers
Immediate transmission of painful stimuli and are myelinated
Small unmyelinated fibers
C fibers
A alpha fibers
Proprioceptive and motor
Reuptake of serotonin and norepinephrine
Tramadol
Herpes zoster treat with
Antiepileptics
TCA
SNRIs
Tramadol
Phantom limb pain is a type of
Neuropathic pain
Hypoplastic left heart is associated with
ASDs
Hyoplastic left heart
Systemic blood flow is dependent on retrograde flow from PDA
Severe stenosis of mitral or aortic valves
The greatest metabolism of anesthetivs gases
Sevoflurane>isoflurane>desflurane
Desflurane is least metabolized
Celiac plexus block most common complication
Orthostatic hypotension and diarrhea
Infragluteal sciatic nerve block anatomical landmarks
Greater trochanter of the femur
Ischial tuberosity
Sciatic groove
Any form of carotid sinus manipulation such as carotid stent deployment stimulates carotid baroceptors and leads to
Bradycardia!
Chemoceptors
Ventilation in response to hypoxia
Intense vasoconstriction during
Autonomic hyperreflexia(causes skin pallor not flushing below level of lesion
You get vasodilaton above lesion
Nitroprusside nicardipine for treatment
Glucagon causes
Increased hepatic artery blood flow
Major disadvantage of paracervical nerve block is
Fetal bradycardia
Diabetes insipidus
Hyponatremia and hypovolemia
Give fluids to pending organ donor to maintain intravascular volume
Oral midazolam is better than parental prescence to prevent
Preop anxiety
Early onset adult ventilator pneumonia associated with
MSSA
Strep pneumoniae
H influenzae
Mannitol is not a good treatment for
Carcinogenic pulmonary edema
PEEP helps oxygenation by
Increasing FRC and decreasing airway resistance and increasing lung compliance
High Fa/Fi =
Lower solubility
Lower extremity CRPS is treated with
Serial lumbar plexus sympathetic blocks
Can mess up ejaculation
Memantine is an
NMDA antagonist which can be used for CRPS
Elevated ICP is an absolute contraindication to
Neuraxial anesthesia
Permanent pacemaker
Should be checked prior to surgery
No need to convert a pacemaker to asynchronous mode if not pacemaker dependent
Alfentanyl acts faster than fentanyl because of its low
PkA
Going too deep on intrascalene block leads to
Intrathecal placement
Most specific sign of fat embolus is
Petechial rash on body
Fenoldopam causes a decrease in
Arterial blood pressure
Triiodothyronine is higher with
Graves’ disease
Thyrotoxic heart failure
Decreased SVR and increased PVR
Precedex effect
Hypotension
Bradycardia
Sedation
Analgesia
What step starts coagulation cascade
Tissue factor converts factor 7 to factor 7a
Intraoperative anaphylaxis most likely cause
NMBDs
Carotid bodies respond to
PA02
Central chemoceptors in medulla respond to
pH
Which nerve travels posterior to lateral malleolus
Sural
What innervates toes
Deep perineal
Sural
Superficial peroneal
Saphenous does medial ankle and median foot but not the toes
Femoral nerve terminates to form the
Saphenous nerve
Paravertebral space is continuous with
Epidural and intercostal space
Not intrapleural
Thyroid storm start treatment with
IV propranolol
GA decreases FRC by
5-10%
What drugs are metabolized the fastest
High clearance
Low volume of distribution
Vasopressin doesn’t affect pulmonary hypertension bc
It has no alpha affect
Unfractionated heparin best monitored by
Unfractionated heparin binds
LMWH binds factor
PTT
AT3
10a
Reversal of LMWH is not as predictable and good as it is with
Unfractionated heparin
HIT shows up at
5-10 days
HIT2 is mediated by
IgG antibodies binding to heparin pf 4 complex on surface of platelets
Argatroban is metabolized by the liver
Drug affect of direct thrombin inhibitors is via
PTT or ACT
Dabigatran
Renally excreted
Stop 24 hr before minor surgery
Stop 48 hours before major surgery
Trans ex’s mic acid
Inhibits binding site of plasminogen so cant break down fibrin so cant anti colt
TXA is renally excreted
PCC
Has a faster correction than FFP
Fondaparinux acts on
Factor 10a
Can be used for prophylaxis and treatment of DVT
Aspirin is a non competitive inhibitor of
COX1 and COX2
COX2 is responsible for pain and inflammation
Can only fix its affects with platelet transfusion
If at high risk for cardiac events continue
Aspirin perioperatively
Plavix
Inhibition of GP 2b/3a
Integrillin is an inhibitor of
G2b/3a
Intraoperative salvage
Withdraw blood from field with suction and goes through machine to anti-coagulate and then will centrifuge and wash before giving red cells back to patient
Problem with autologous blood transfusion
Dilutional coagulopathy
Use periop blood salvage if expected blood loss is
> 1000 mL
EPOs levels to start release are if hematocrit falls below
30%
Neuraxial anesthesia platelet threshold
> 50000
PRBC store at
1-6 degrees
Blood donors in the US need a minimum hemoglobin of
12.5
FFP contains all the factors for
Hemostasis
Cryopreciptate has more ________ than fibrinogen
Fibrinogen
Delayed hemolytic reactions occur at day
3-10
Acute hemolytic reaction need to do a
Direct Coombs test
Best way to avoid IgA transfusion reaction is to use
Washed cells
Prevent graft vs host disease by doing what to blood
Irradiate
Anaphylactoid reactions are commonly seen in
IgA deficient patients
Hypotension
Bronchospasm
Hemodynamic instability
Citrate chelates
Calcium
Most likely blood component to get passed is
CMV and thenHepatitis B
Platelet transfusion has
Highest rate of infection
Septic shock
Need vasopressor to maintain MAP>65
Lactate>2
Temporary reversal of magnesium toxicity with hypotension is to give
Calcium gluconate
Magnesium affects
Normal is 1.4-2.1
Acts at NMDA receptor so has analgesic properties
Acts at nicotinic Ach receptor and thus prolongs neuromuscular blockade
Methanol affects
Anion gap metabolic acidosis
Hemodialysis
Iv ethanol
Sodium bicarbonate
for treatment
After HBV exposure give
Hep B immunoglobulin and offer Hep B vaccine
Lusitropy is
Myocardial relaxation
Inodilator therapy increases lusitropy and inotropy
Infant breathing work is much higher than adults bc their lungs are
More compliant. Thus it isn’t supported by the ribs or surrounding structures and the airway closes easily
Pousielle law
8nl/pi x r to the fourth
What is not affected by aging
Ejection fraction
Efferent branch of laryngospasm
Recurrent laryngeal nerve
Adduction of vocal cords
Lateral cricoarytenoid
Afferent Limb of laryngospasm
Superior laryngeal nerve
Pulmonary hypertension worsened by
Acidosis
Hypoxia
Hypercarbia
First step in total spinal in infant is
Intubation due to apnea
First sign is usually dyspnea for high spinal
T1-T4are cardiac accelerator fibers if blocked lead to
Bradycardia
Tumuscent lidocaine Max dosage
55 mg/kg
Conns syndrome
Too much aldosterone
Hypokalemic metabolic alkalosis
Plasma renin is reduced secondary to feedback by aldosterone
Treat with spirnolactone and potassium supplementation
Hypokalemic periodic paralysis due to
Calcium channel defect
One benefit of MLT tube over standard tube is
Increased length
MLT tube is not safe for use with
Lasers
Airway obstruction 24 hours post thyroidectomy can be due to
Hypocalcemia
Hematoma will show up within first 24 hours of thyroidectomy!
Acute mountain sickness prophylaxis is with
Acetazolamide
High altitude decreases partial pressures of both
Activates
P02 and PC02
Peripheral chemoceptors to stimulate increased respiration
Acute epiglottis is
Extrathoracic obstruction
Just do inhalational induction with Sevoflurane. No nitrous
Carotid bodies respond to
Arterial partial pressure of oxygen
Causes of post cardiac renal failure
Preop creatinine grater than 1.2
Combined valve and bypass procedure
Preop intraaortic balloon pump
Emergency procedures
Full E cylinder of oxygen
2200 psig 660L
Nitrous oxide
1590 L
745 psig
With nitrous oxide the psig stays at 750 until
Less than 400L
25% is left
Only inhalational agent that doesn’t cause uterine relaxation is
Nitrous oxide
Exocytosis of AcH does not occur in patients with
Botulism
Treatment is equine serum antitoxin
Hypercarbia can lead to
Arrhythmia like atrial fibrillation post op
Systolic function doesn’t change in normal
Healthy heart
Carob Prost better known as prostaglandin F 2 alpha can’t be used on patients with
Asthma
MAC vs moderate sedation
MAC requires a qualified anesthesia provider able to convert to GA
Elevated hemidiaphragm on ipisateral side
Ruptured diaphragm
If ruptured diaphragm not fixed it leads to
Bowel ischemia as all the abdominal organs shift up
Loos ECG
Leads to wandering baselines
Left leg and right arm
Lead 2
Alternating current on ECG
Will make it go up and down multiple times a second
Exanatide
GLP1 analogue
After giving iodine therapy for thyroid elevation can get first
More hyperthyroid symptoms bc the mediators go out into bloodstream
Treat first with ptu or methimazole
Octreotide MOA
Inhibit release of GH and IGF-1
Bromocriptine
Dopamine agonist
Neurohypophysis = posterior pituitary
Release ADH and oxytocin
Treatment of SIADH may include
Demeocycline
SIADH type of hyponatremia
Euvolemic
For chronic hyponatremia from SIADH treatment of choice is fluid restriction
Microadenomas
Tend to present as hypersecretion syndromes such as galactorrhea from prolactin excess, Cushing disease from ACTH excess
Prolactinoma
Amenorrhea, impotence
Sub clinical hypothyroidism
High TSH and normal free T4
Should still treat if TSH too high
Secondary hypothyroidism
Both TSH and T4 are low
Thyroid storm mortality is greater than
20%
Criteria for thyroid storm
Hyperthermia
Tachycardia
Cerebral dysfunction
What is most likely to be seen in hypothyroidism patient under GA
Bradycardia
Thyroid doesn’t affect neuromuscular blockade
Post thyroid hypocalcemia shows up after
24-48 hours
Can manifest as stridor or laryngospasm
Graves’ disease
Radioactive iodine studies show diffusely increased uptake,
PTH
Activates osteoclasts to promote bone resorption
PTH increases renal calcium reabsorption
PTH increases 1alpha hydroxylase which makes vitamin D active
PTH increases excretion of phosphate, bicarbonate, potassium, sodium
Calcitonin MOA
Excreted by parafollicular cells
Inhibits osteoclast activity to lower calcium levels
Hypercalcemia
NS is first choice
Use calcitonin if tachyphylaxis
Plasma calcium levels are higher in states of
Hypoalbuminemia
Phenoxybenzomaine half life
Main side effect
12 hr
Orthostatic hypotension
Which corticosteroid lacks mineralocorticoid activity
Dexamethasone
Give stress dose steroids to
Patients at risk for HPA axis suppression bc of chronic steroid administration
Should be done if getting greater than 20mg of prednisone for more then 3 weeks
Patients undergoing more than superficial procedures
Glucocorticoids increase
Protein catabolism
Explaining muscle wearing seen during Cushings
Decrease eosinophils and basophils
Nonketotic hyperosmolar coma
Type 2 diabetics
Profound hyperglycemia
Dehydration
Symptoms of hyperosmolarity
Long term diabetes type 1 is an indicator of
Difficult airway
Surgery affects on sympathetic tone and glucose
Leads to more sympathetic tone and hyperglycemia via glucagon, ACTH and GH
Alpha receptors inhibit insulin release
Beta receptors stimulate insulin release and thus lower glucose
Metformin inhibits
Hepatic gluconeogenesis andglycogenolysis
Metfirmin can be taken the night before surgery but not on the day of surgery
What is shown to decrease MI risk in diabetics
Aspirin
Calcium activates
Pyruvate dehydrogenase and accelerates the Krebs cycle
Final acceptor of electrons in electron transport chain
Oxygen
Gluconeogenesis mainly occurs in the
Liver
To a lesser extent the kidneys and small intestine
Lipids can not be absorbed
CCK
Directly
Slows gastric emptying
Pancreatic exocrine insufficiency are at risk for
Fat soluble vitamin deficiencies such as A, D, E, or K
Glucagon activates
Beta oxidation of fatty acids
In times of starvation without glucose
Most tissues in human body can use fatty acids for energy except for the brain which uses ketone bodies
Liver converts cholesterol into
Bile salts
Ezetimibe
Inhibits intestinal absorption of TAGs
Gemfibrozil
Stimulate beta oxidation of fatty acids in peroxisomes and mitochondria
cGMP activates
cGMP protein kinase G to produce vascular relaxation
PDE5 inhibitors act by
Increasing levels of cGMP leading to vasodilation which is therapeutic to patients with pulmonary hypertension
Activating beta 1 receptor
Activates Adenylate Cyclase converting ATP to cAMP
As you get older closing capacity
increases thus collapse of small airways occurs even after normal tidal volume exhalation
Aging increases RV, CC, FRC and loss of lung elasticity
Proper positioning of thoracic aortic aneurysm stent
When to take care of elective aneurysm
hypotension helps, transient asystole,
If greater increase than 1 cm in one day
Or greater than 5.5 cm
Be careful using adenosine in asthma patients bc it can cause
Bronchoconstriction
Cricothyroid muscle innervated by
External laryngeal of superior laryngeal nerve
Succinylcholine is dosed off
Total body weight
Fentanyl
Remifentanyl
Propofol dose by
Lean body weight
Before doing elective surgery on infant, you must have
6 month period without apnea or bradycardia
Need endocarditis prophylaxis for these procedures
Dental procedures messing with gingival tissue
Respiratory tract procedures such as a bronchoscopy
Patients with infected skin
Don’t need prophylaxis for GI or GU procedures
Buprenorphine
U receptor partial agonist
Most effective at helping with opioid withdrawal
Clonidine is good for symptomatic treatment with
Opiate withdrawal
Does not directly agonize u receptors
Sunglottic stenosis
Heliox can help with gas delivery to lungs
Manual in line stabilization of cervical spine
Operator 1 stabilizes head and neck in neutral position
Operator 2 stabilizes the shoulders
No sniffing position in suspected spinal injury as this can hurt the neck
Hypoalbumin will increase free fraction of
Benzodiazepines
During burns get a proliferation of acetylcholine receptors and
Neuromuscular blockade resistance
Aspirin irreversibly blocks platelet function by blocking
Thromboxane A2
Only get about 10% of platelets back each day
Apixaban =
Elaquis and blocks factor 10a levels
JG apparatus in glomeruli senses hypotension
And increases angiotensin 2 levels in roughly 20 minutes
Plasma concentrations increase most
8-10 hours after infusion of tumescent lidocaine
Tumescent lidocaine complications if using
More than 5L
Doing other procedures at same time
Giving sedation as well - usually doesn’t require sedation to be given
Cerebral salt wasting
Hyponatremia and hypovolemia due to low intravascular volume
Conns syndrome definitive treatment
Excision of adrenal adenoma tumor
Spirnolactone
Competitive aldosterone receptor antagonist and potassium sparing diuretic
Midodrine
Alpha 1 receptor agonist
Treat acromegaly with
Octreotide
Permanent nerve injury usually due to
Improper positioning
Critical temperature
Temperature above which a gas can’t be converted to liquid with increasing pressure alone
At standard temp and pressure nitrous oxide is a gas
Laryngeal papillomatosis can do
jet ventilation
Patients with long QT and history of cardiac arrest require
AICD
Mainstay of treatment with long QT
Beta blockers and possible pacing
Alpha stat
Add c02 to oxygenation and leads to embolus phenomenon
Volatile anesthetics increase duration of NMBDs
Volatile anesthetics decrease sensitivity of the postjunctional skeletal muscle cell membrane to depolarization
ARDS
Tidal volume of 6 ml/kg
Plateau pressure<30 cm H20
Coronary artery disease and cerebrovascular disease are need for
Preop ECG
Loose filler cap most common source of
Vaporizer leak
Will have overdose of volatile anesthetic if sevoflurame vaporizer is filled with
Isoflurane due to its higher vapor pressure and higher potency
If you tip a vaporizer
Clinically don’t use for 20 to 30 minutes and set fresh gas flow high rate with high volatile concentration to fix
Children with stribasmis 4 times more likely to get what when given succinylcholine
Massager muscle rigidity
Strabismus surgery commonly leads to
Bradycardia and PONV in pediatric population
Reason succinylcholine isn’t given to Peds patients
Hyperkalemic response with undiagnosed myopathies
If you fail initial SBT
Good strategy is to continue SBTs with pressure support
Down syndrome
Atlantoaxial insyability
Hypothyroidism
Macroglossia
OSA
Full term baby in first minute if cyanotic and HR<100
Positive pressure ventilation
Do PPV before chest compressions
3 compressions to 1 ventilation
FHR normal values
110-160
Acceleration is defined as
Higher than 15 bpm for at least 15 seconds
Decrease in RBF leads to decrease in GFR which causes decrease in chloride concentration and JGA is activated
Causes efferent arteriole constriction
JGA senses the decrease in chloride concentration
Decrease in GFR leads to
Afferent after dilation and efferent arteriole constriction
Epinephrine added to local anesthetic does not affect the
Onset time
Local anesthetics are weak bases
Local anesthetic
Lipid soluble is faster
Higher concentration is faster
Lower pKa and higher environment pH is faster
Clevidipine
Short acting calcium channel blocker leading to arteriolar vasodilation
Broken down by plasma esterases
Ester local anesthetics, succinylcholine, mivacurium breakdown is by
Psuedocholinesterase
Renal medulla
Has a high O2 extraction ratio
Compared to renal cortex which does not
Kidney gets 20% of cardiac output
Need to have good blood flow
To renal medulla
Diarrhea
Metabolic acidosis
CHF
Cold extremities
Poor urine output
Delirium
Contraindications to epidural
Increased ICP
Patient refusal
Uncorrected hypovolemia
Etomidate inhibits
11 beta hydroxylase and 17 alpha hydroxylase in a reversal dose dependent fashion
Secondary adrenal insuffiency
ACTH is down
Adults without adrenal insufficiency secrete
20 mg cortisol and 0.1mg aldosterone daily
Acute adrenal insufficiency management
Hydrocortisone 25mg should be given as stress dose in surgery
Hydrocortisone 100mg bolus IV and then q6
Weakness with adduction of the thumb
Ulnar nerve
Reduce risk of ulnar neuropathy by
Keeping hands supinated
Proper padding of all pressure points
During mass causality situation
Need a system to implement to identify patient injuries
Lethal triad
Coagulopathy acidosis hypothermia
Can have tracheal deviation with
Tension pneumo
Mediastinal Mass- see widened mediastinum
Difficult to lay supine
If data are not normally distributed best measure of central tendency is the
Median
Mean is best to use for central tendency if data is
Normally distributed
Peripheral TPN is most associated with
Infection and thrombophlebitis
Give TPN for
Short bowel
Bowel obstruction
Active GI bleeding
Give TPN through central catheter if possible
Meperidine
Can reduce oxygen demand in hypothermic patients
Goal temp is 32-36 for 12-24 hours and then you do rewarming
Most patients die during the rewarming phase
Shorter QT and widening of QRS seen with
Hyperkalemia
Lithium toxicity
Hypermagnesium
Potassium sparing
Spirnolactone triamterene amiloride
Opioids are best dosed by
Lean body weight
OSA is a risk factor for
Postop hypoxemia
Chronic hypoxemia can cause
Polycythemia and this increase in total blood volume
Hypercarbia
Decreases the alveolar partial pressure of oxygen
Cystic fibrosis
Autosomal recessive
Chronic pulmonary infections
Hepatobiliary tract disease
Diabetes
Pancreatic insuffiency
When defibrillating use electrode pads size
8-12 cm
You can apply electrode gel and biphasic defibrillator is preferred
After placing endobronchial left sided double lumen tube
When you inflate both tracheal and bronchial cuffs
You will only get breath sounds on the right hand side
Bronchial cuff is herniated at carina
If you have resistance ventilating the side your trying to ventilate
Tobacco use causes carbon monoxide levels to increase thus
Shift of oxyhemoglobin curve to the left
Cyanide increases so less mitochondrial oxidation and you get acidosis
Causes vasoconstriction
Carbon monoxide from c02 absorbent is increased with
Low fresh gas flow
Dessicated absorbent
Increased temperature
What absorbent are the best
Calcium hydroxide
Soda lime
Worse is barium hydroxide
Hypocalcemia leads to
Prolonged QT
Critical temp above room temp
Why nitrous oxide is both liquid and gas at room temp
Critical temp is temp where a gas can’t be turned into liquid no matter how much pressure is applied
Epidural 2 chloroprocaine has an onset of action of
6-12 minutes as a result of the high concentration used
Chloroprocaine duration of action
45-60 minutes plain
60-90 minutes when used with epi
MG, Lambert Eaton and chronic renal failure
Do not upregulate the number of AcH receptors
Scopolamine somnolence can be counteracted with
Physostigmine
Stimulation of central nicotinic Ach receptors can lead to
Seizures
For main stem obstruction in child
Prefer inhalational induction because PPV can potentially move the object down further
Increased intensity of motor block seen when adding epi to
Epidural local anesthetic
Epi also increases onset time and duration by vasoconstricting the blood vessels in the epidural space that take up the local anesthetic
Morphine given through epidural space causes pruritis best treatment is with
Nalbuphine
Give in small dose of 3 mg
Ketamine is best induction medication for
Cardiac tamponade
Want quick heart rate, maximize preload, and forward(avoid cardiac depressants)
Ketamine also helps maintain spontaneous ventilation
Pulses paradoxus
During inspiration, drop in systolic of 10 or more
Botulism
Prevent vesicular release of Ach at the neuromuscular junction
C Tetani
Travels through retrograde transport up the motor neurin
Upward shift in frank starling curve due to an increase in
Contractility
Ratio of potency intrathecal, epidural, iv fentanyl
0.01, 0.1, 1
Thus intrathecal is the most potent
Same ratios with morphine
Iv morphine is more potent than oral morphine by a ratio of 3:1
Three anesthesia time units are equal to
45 minutes
Pudendal nerve
S2-S4
Single shot spinal lasts 1 to 2 hours so great to give right when close to
Delivery
SA node
Increase sympathetic activation increases the slope of phase 4 of the action potential
Factors that increase the SA node firing rate include
Sympathetic stimulation, muscarinic receptor antagonism, beta receptor agonism, catecholamines, hypokalemia
Multifocal atrial tachycardia is associated with
Severe lung disease
COPD exacerbation is most common cause
Sinus tachycardia with 3 different morphologies of the P waves
In settings of poor oxygen extraction like methemoglobinemia
Mixed venous will be normal or elevated
Normal Sv02 is
75%
Higher mixed venous means you
Extract less oxygen
Klippfel feil syndrome associated with
Fusion of cervical spine
Larger extra cellular volume seen in
Infants than adults
How much of lean body mass is total body water
55-60%
TBW =
Extracellular plus intracellular volume
Amiodarone class 3 antiarrhythmic that blocks
Potassium channels
Myasthenic syndrome is also known as
Lambert-Eaton syndrome
Landmark for lateral femoral cutaneous nerve block
ASIS
Femoral nerve L2-L4
Best sites to measure core temperature
Pulmonary artery
Distal esophagus
Nasopharynx
Tympanic membrane
Goal level of neuraxial block for C Section is
T4-S4 is what should be covered
Acetazolamide can lead to
Metabolic acidosis
Psuedotumor cerebri high ICP treat with
LP
For precurarization
Use 10% of the ED95
Stops muscle fasiculations which can increase intraabdominal pressure leading to aspiration
ED95
Median effective dose in 95% of population
Dose that causes 95% twitch suppression in 50% of population.
Metochlopromide affect on LES tone
Increases LES tone
Most anesthetics such as propofol, anticholinergics and fentanyl affect on LES tone
Decrease
CPAP
Keeps airways and alveoli option
Decreases depletion of surfactant
Increases FRC
Increases minute ventilation
What is an absolute contraindication to shock wave lithotripsy
Pregnancy
Hypoxia and hypercarbia are found during
Pulmonary embolus
Which patients won’t tolerate awake crani
Children, psych patients, claustrophobic
Corneal reflex afferent and motor reflex
Trigeminal, facial
Airway exchange catheters better than bougie
Can do jetventilation
Monitor ETC02
Prefer for elective surgery to commence hemoglobinA1C should be under
8%
Give 2/3 insulin the night before
And 1/2 the day of
Most evaporative heat loss is via
Tissue exposure from the surgical incision
What is responsible for most heat loss in OR
Radiation
Pre warm heat blanket to blunt
Affect of redistribution on temperature
Citrate can be metabolized to
Sodium bicarbonate leading to metabolic alkalosis
What coagulation factors decrease in pregnancy
13, 9, antithrombin 3 and tPA
Dose of oral midazolam for Peds patients
0.5 mg/kg
Onset of action is 15-30 minutes
IV form is 0.05-0.1 mg/kg
Hyperparathyroidism
Normal anion gap metabolic acidosis
With hyperchloremia
Most the claims in the ASA closed claims database are
Non respiratory events
If mother comes in for elective C Section and she and baby are fine. You induce with prop and succ and have three difficult intubation attempts and mom and baby are good and you can bag mask what should you do?
Since it is elective you should wake the mother up. Baby is also ok so more reason to do so
Don’t try to intubate any more after how many unsuccessful attempts
3
cDH
More common on left side
Do not bag mask! Leads to more insufflation and possible contralatral pneumothorax
ASA 4 is a severe illness
Unstable angina falls in this
Which is a constant threat to life
ASA looks at
Not to predict operative risk
Used to look at patients commorbisitues and overall physical state
ASA 2
Smoker
Pregnant
Controlled diabetes
ASA 3
Morbid obesity
Regular dialysis
ASA 5
Won’t survive without the operation
Angiotensin 2 will
Construct efferent arteriole and increase GFR
Also increases intravascular volume through sodium
MAC of nitrous oxide =
105%
Side effect of terbutaline is
Hypokalemia
Hyperglycemia
Hypotension
Pulmonary edema
Platelets can lead to
RH sensitization
Infants usually require larger doses of succinylcholine due to their
Higher volumes of distribution
In Peds succinylcholine first dose can cause
Sinus arrest
Bradycardia
Premature closure of cranial sutures is seen In
Crouzon syndrome
Due to mutation in fibroblast growth factor
Donepezil
Increases Ach levels thus making you more resistant to NMDBs and sensitive to succinylcholine
MH vs thyroid storm
Muscle rigidity
Higher rate of temp rise
Higher ETC02 rise
Hyperkalemia
Elevated CK
Lactic Acidosis
All these are seen mainly in MH
Drug you shouldn’t give to children after tonsillectomy
Codeine
Acetaminophen dose if under 12
75 mg/kg
Based on ideal body weight
Above 10L 02 pt is breathing
Cold dry oxygen leading to discomfort for the patient
High flow NC
Contributes PEEP
Can get rid of co2
Provides oxygen
NO
Dilates pulmonary vasculature when administered by inhalation
Half life of 15-30 sec
Too much NO leads to NO2 which can lead to pulmonary edema/alveolar hemorrhage
Cannon A waves are seen with
Complete heart block
Wedge pressure reflects
Left atrial pressure
Best time to look at it is at end of diastole when blood goes from atrium to ventricles
CVP c wave
Isovolumetric contraction of right ventricle
A wave is first rise building up blood in ventricle
C wave is small rise
Then descent during systole
X descent
Blood into atria
Papillary muscle rupture leads to
Mitral regurgitation and large v waves
MAP
The cuff pressure where the highest pulse amplitude is detected
Square wave test
Pull flush valve
If 1 or 2 oscillations your good
3 or more is dampened
In children slower heat loss from core to periphery
Due to greater proportion of body mass in core
Thermogenesis in infant occurs by metabolism of
Brown fat
Hypothermia
Reduces the MAC of an agent and can lead to anesthetic overdose
Hypothermia leads to
Norepinephrine release
Shivering increases
Oxygen consumption
Don’t give succ or volatile anesthetic to patient with pseudohypertrophic muscular dystrophy
Risk of rhabdomyolysis and hyperkalemia
Mixed venous
Percentage of oxygen bound to hgb in blood returning to right side of heart
It’s what’s left after body extracts what it needs
Increased Fi02 or hgb will increase mixed venous
Hypothermia affect on mixed venous
Increases even with increased shivering
Neostigmine crosses placenta leading to bradycardia
Use atropine to reverse
Glycopyrolate does not cross placenta
Muscarinic receptors are found at the
SA node
Neostigmine dose for reversal is
0.07 mg/kg
Giving too much leads to prolonged weakness. Leads to presynaptic nicotinic receptor desensitization
Cardiogenic shock
Systolic<90
Pcwp>18
Cardiac index<2.2
Spinal cord injury is a type of
Distributive shock
Desflurane can augment neuromuscular blockade by as much as
60%
Relax skeletal muscle and act indirectly at NMJ
Sodium bicarbonate deficit to treat pH
0.2 x patient weight kg x base excess =
MeQ of sodium bicarbonate needed to correct acidosis
Acidosis causes
Reduced cardiac contractility, decreased SVR and QT abnormalities
Only give sodium bicarbonate if
Patient is ventilated bc if not can lead to respiratory depression
Norepinephrine does not cause
Significant bronchodilation
M3 receptor stimulation leads to
Bronchial constriction
Rightward shift of hemoglobin P50 shifts
Immediately when you stop smoking
Normal P50 of hemoglobin is
27 mmHg
Hypophosphatemia shifts hemoglobin dissociation curve to the
Left
A pneumothorax will double in size when breathing 75% nitrous oxide In
10 minutes
Arterial pressure variation is an accurate measure for
SVV>13% will be responsive to fluids
Chronic dantrolene therapy
Need to check LFTs
Malignant hyperthermia
Autosomal dominant with variable penetrance
TIVA costs
10 to 100 times more than inhaled anesthetic
End point of root cause analysis does not involve knowing
Who is causing the event
Increased latency or decreased amplitude on SSEPs can indicate
Cortex ischemia
Rapidly giving sodium bicarbonate
Increases affinity of C02 for oxygen shifting curve to left
Can actually worsen hypoxia and increase lactate
Increases preload
Decreased contractility
Increases cerebral hemorrhage
Treatment for organophosphate poisoning
Pralidoxime and atropine
Take off all clothes
Don’t use succ
Tylenol overdose
N-Acetylcysteine
Placental abruption
Painful vaginal bleeding
Uterine tenderness
Risk factors Maternal HTN Maternal cocaine Tobacco use Trauma
Caution should be taken before giving vasopressin to a patient with
Coronary artery disease. Can lead to vasoconstriction and ischemia
Desmopressin is preferred over vasopressin bc it doesn’t cause
HTN
Vasopressin increases
VwF and factor 8
One anterior and two posterior spinal arteries
Supply spinal cord
Anterior spinal cord provides 75%
If nuclear explosion give
Sodium iodine
Large R wave in lead V1 due to
Right ventricular hypertrophy Posterior wall MI WPW syndrome Muscular dystrophy Right atrial enlargement
Subnormal corticosteroid production is called
Functional adrenal insuffiency
Most common adrenal insufficiency in the ICU
Mineralocorticoid is produced by
Zona glomerulosa
Increased flow rate =
Turbulent flow
Decrease radius
Increases laminar flow
Severe sepsis
30 ml/kg iv crystalloud in first 3 hours
Hydroxyethyk starch don’t give with
Sepsis
High Stenotic lesion along the PDA leads to
AV Nodal Blockade
Valsalva Maneuver
Increased intrathoracic pressire by forced expiration against closed glottis. Increased intrathoracic pressure will force blood out the heart, to the svc to the IJ
Improvement of how much with bronchodilator therapy in FEV1 is an indication for chronic bronchodilator therapy
15%
PRIS
Heart failure Metabolic acidosis 4 mg/kg/hr is max dose of propofol Rhabdomyolysis Lactic acidosis
Does not lead to pulmonary edema
Alfentanil acts quick
Low pKA leads to high unionized fraction
Given small dose of neuromuscular blocker before succ does not decrease the rise In
IOP
Myalgia
Giving pre roc dose 3-5 minutes before succ
To prevent fasiculations
Rise in intragastric pressure
Rise in ICP can also be blunted
In patient with unknown status of hiv and needlestick injury
No postexposure prophylaxis is necessary
If someone had HIV with viral load and symptomatic need to give
Triple drug therapy
Give two drug if HIV unknown but high risk of infection
Head down position
More likely endobronchial intubation
Increases cardiac index increases venous return back to heart
Decreases FRC
Decrease TLC
If a nerve in a paralyzed extremity is tested, the TOF will be
Higher
Premature closure of PDA
Associated with maternal NSAID usage
Acidosis can lead to reversion to
Fetal circulation as well as hypoxemia and hypothermia
Preventing post op nausea or vomiting best medication in peds
Ondansetron
Causes of nausea vomiting Peds
Age>3
Procedure>30 min
Type of procedure
Family history of PONV
First stage in correction of pulmonary atresia
Blalock Taussing shunt is first stage. It moves subclavian to pulmonary artery blood flow
Hypermagnesium
Theophylline does not help
Can cause bradycardia and hypotension
Loop diuretics with D5 help remove magnesium
Prolongs local anesthetics and NMDBs and succ
Gastroschsis
Has no enclosing membrane
More heat loss, dehydration, and infection
Patients with normal body mass index have higher rate of tourniquet than those who are
Obese
Upper extremity nerve injuries are more common with tourniquet than
Lower
Metochlpramide
Increases LES tone
Iv metochlopramide
acts within 1-3 minutes
Preterm infants have problems with
Decreased surfactant
Respiratory distress syndrome in infants mainly due to
Surfactant deficiency
Fetal lung maturity with L/S ratio
> 2
Increases A-a gradient with
Atelectasis
V/q mismatch or diffusion problem, shunting or dead space with increased A-a gradient
Pediatric endotracheal tube size
(Age/4) + 4
Hal Dane effect
Increased ability for hemoglobin to carry carbon dioxide from tissues to lungs for exhalation
Bohr effect relates to
H+
High H+ lower affinity of hemoglobin for O2
Alpha stat management
Leftward shift of oxyhemoglobin
PaC02 is maintained on 40
C02 is not added so it stays down and get a left shift
Multi drug resistant organisms
More than 5 days in hospital
Prior abx
Recent hospitalization
Ventilator associated or hospital acquired pneumonia treatment
Lineziolid/vancomycin
And floroquinolone/aminoglycoside
And zosyn/cefepine/cephalosporins
High blood solubility from high cardiac output mainly affects
Isoflurane bc more is taken up by the blood
Reduce cardiac output makes isoflurane much faster
Intrinsic INR of FFP is
1.6-1.8
Reverse Coumadin with
Vitamin K
If can wait 24 hours reverse Coumadin with
Vitamin K
Mannitol can have deleterious effects on patient with
CHF bc it increases intravascular volume
ICP management
Keep ICP 20-25
CPP > 60
Guillan barre drug contraindicated
Ascending motor paralysis w/wo sensory
Succinylcholine
It is autoimmune demyelination treat with plasmapharesis or ivig
Adductor similar analgesia
To femoral nerve for knee surgery
Adductor has a lower risk of falls
Saphenous nerve is purely
Sensory
Cross clamping of aorta hemodynamic changes
CVP higher More catecolamines Decrease in oxygen extraction Increased coronary artery blood flow Decreased arterial pressure below clamp Decreased cardiac output Decreased in renal blood flow
First thing to do if malfunctioning inspiratory valve
Increase fresh gas flow will help decrease exhaled gas going retrograde
Inspiratory valve opens letting fresh gas go into patient
If it doesn’t close fully some of the exhaled gas will go into it
Increased plateau on capnography and more slope on downstroke
Causes of preop anxiety
Higher cognitive Multiple personnel Anxious mothers Shy children Younger children
LMWH better than UFH
Bc better at blocking factor 10a
Acute normovolemic hemodilution
Good for ppl who can’t get allogenic blood, or if they have rare antibodies
Can’t do it if active infection, cardiac disease, preop anemia
What ion contributes most to serum osmolality
Sodium
Hyponatremia
Check extracellular free water level
Plasma osmolality
Urine sodium
PDPH definitive therapy
Epidural blood patch
Usually use autologous blood
If they are a cancer patient or have bad active infection use allogenic blood
Celiac plexus
Pancreas Liver Spleen Gall bladder Biliary tract Ascending and transverse colon
Celiac plexus block most common complication
Orthostatic hypotension
Pheno is
Painless on injection
Used for neurolytic block
Step 2 of pain ladder
Weak opioid including
Codeine, oxycodone, tramadol hydrocodone
WHO ladder
Should give oral administration whenever it’s possible
In type 2 CRPS
Clear preceding nerve injury
Greatest risk factor for development of posthrrpetic neuralgia
Older age
Phantom limb pain
Risk factors
Pain before amputation
Proximal amputation
Psychological problems
Facet joint pain, spinal stenosis pain is
Radiating
Usually t ipsilateral posteroir thigh
Facet joint innervation
Medial branch of the dorsal ramus of spinal nerves
Pain that radiates into ipsilateral buttocks
SI joint pain
Numbness of anterolateral thigh
Meralgia parenthetica
Piroformis and sciatic nerve
Whole sciatic nerve passes below the piriformis muscle
Trigeminal neuralgia
V2 and V3 distribution
Spinal anesthesia failure most common cause
Displacement of the top of the needle
Pudendal nerve
S2-S4
Superficial cervical plexus contains nerves that arise from
C1-C4
Causes 100% chance of ipsilateral diaphragmatic palsy
TENS
Has not been shown to help with chronic pain
Impact of warming IV fluids in neonate on thermal homeostasis is
Minimal
Fix radiant heat loss by heating the room
Midazolam rapid onset
Due to ability to convert to lipophilic form at high pH
Midazolam
Younger children need a higher dose. Highest bioavailability is when given rectal
Time to peak concentration after giving is 50 minutes orally
Mapleleson circuit
Type A has the fresh gas flow inlet at the end of the resevior tubing distal from t piece that connects to patients mask or endotracheal tube
Mapleson D has distal pop off valve
Allows for excess expired gas to be released during expiration prevent revreathing
Desflurane isn’t given too children
Leads to airway irritability
Don’t give for mask induction as can lead to laryngospasm
Ketamine IM dose for induction
2-4 mg/kg
Formula NPO time =
6 hours
Rapid sequence succ in children
2 mg/kg bc children have higher volume of distribution
Intramuscular succ dose is 4 mg/kg
Preschool age 3-5 best blade is
MAC-2
Age/4 plus 4 =
Pediatric endotracheal tube uncuffed
Lower by .5 to get cuffed tube size
Sevoflurane in Peds leads to
Emergence delirium
What helps with emergence delirium
Propofol
Precedex
Fentanyl
For each 1 degree decrease in body temp
MAC decreases 5%
I Mac of isoflurane in adults
- 2% end tidal isoflurane
1. 6% in Peds
Which group of population requires highest level of NMDB
Children require the most
Next is adults
Finally neonates
Full term neonate EBV
80-90 ml/kg
Leukoreduction
Useful to prevent CMV, HLA, non hemolytic febrile transfusion
Doesn’t help with graft vs host
Cefepime causes hypotension by
Lipopolysacharide release
Vancomycin release leads to hypotension via
Histamine release
Stellate ganglion is between
C6-C7
Cerebral auto regulation of blood flow is
Maintained in elderly
SIRS leads to more
Cortisol and thus hyperglycemia
Ischemic optic neuropathy
Painless vision loss
Dual chamber pacemakers
Right atrial and ventricular septum
P wave followed by left bundle branch
Persistent vegetative state
Can open eyes unconsciously
It is seen in comas
CO x svr
MAP
Hypokalemia leads to
ST and T wave depression
Terbutaline leads to
Hypokalemia
RCA supplies
Inferior wall of left ventricle
LAd
Supplies apex of right ventricle
Increase CK and myoglobinuria
Rhabdomyolysis
On intubated patients in regard to feeds
Continue enteral and parenteral
Neonates need to evaluated overnight until
60 weeks
Risk of apnea and bradycardia
Succ is safe in ppl with
Myasthenia gravis
Lambert Eaton
Renal failure with normal potassium
Don’t use succ on patients immobilized for longer than
24 hrs
Full tank of N20
1590 L O2
745 psig
MAP =
2/3 diastolic plus 1/3 systolic
Coiling cables is
Bad in MRI
IV calcium chloride is needed when giving lots of
Blood
Citrate toxicity electrolyte problems
Hypocalcemia
Hypomagnesium
Femoral nerve block with parenthesia in sartorius
Deeper and more lateral
Plasma elimination half time of flumazinil is the shortest of all benzos at about
1 hr
Plasma elimination half life of midazolam is 2 hrs
Absolute contraindication to ECT
Intracranial mass lesion
Pheo
Recent MI
Bow ditch reflex
Increase in HR by increase in myocardial tension
Hyperchloremic metabolic acidosis
Excessive fluid
SID down
Decreased bicarbonate
ACE inhibitors will increase
Bradykinin leading to vasodilation
Decreases effefent arteriole contriction leading to lower GFR
Treat neuraxial nausea with
Atropine
Next choice is glycopyrolate
Aspiration suspected what to do
Place in head down or left lateral
Do bronch if possible to suction out as much aspirate as possible
Tocolytic agents like beta 2 agents like midodrine
Relax uterine contractions
Increase uterine blood flow
Uterine vasoconstriction with severe hypocapnea
Early post partum hemorrhage
Uterine stony
NG tubes can lead
To more sinusitis and otitis media
Lidocaine decreases
Seizure duration do not good to use if getting ECT
First sign of good normalization for surgery
Cl- coming close to normal
Pyloric stenosis
Hypokalemic, hypochloremic, metabolic alkalosis
AV node supplied by the
RCA
Anterior 2/3 of septum supplied by the
LAD
Phase 2 block with succinylcholine apnea best way to reverse is with
0.03 mg/kg
First compensatory state in anemia
Rightward shift of oxyhemoglobin dissociation curve
ERAS protocol
Start orals an soon as possible
Giving ritodrune to mother
Increases her glucose levels
Causes hypoglycemia in infant as more insulin is released
MH
High end tidal co2
Tachycardia
Acidosis
At high altitude you get
Increased minute ventilation as a result of hypoxia stimulation of peripheral chemoceptors
At high altitude
Lower partial pressure of 02 so you increase respiratory rate
Increased hemoglobin
Give 20-40 ml/kg of lactated ringers
For replacement in surgery for infants
Which drug is Sch 3
Ketamine
Cochin morphine oxycodone
Sch 2
Salicylate toxicity- aspirin
Mixed respiratory alkalosis and metabolic acidosis
Carbohydrate load increases chance for
Hypokalemic periodic paralysis
Keep neurosurgical patients euvolemic or hypervolemic to maintain
Cerebral perfusion pressure
Discovery
Exchanging documents
Depositions
Statements made under oath about the case
Sunmons
Beginning of case notify the defendant there is a law suit against him
First step after aspiration
Suction endotracheal tube
Gram negative and anaerobic coverage should start if aspiration of
Fecal material
Hypercalcemia
Iv fluids and lasix
Hypetcalcemia
Stones bones abdominal pain psych issues
Excessive diresis
Don’t get respiratory alkalosis
Metabolic constriction alkalosis
When giving lasix
Garlic neuraxial anesthesia
Can just do it without more tests
Same with factor 10a inhibitors
For warfarin pts and neuraxial anesthesia
Wait 4-5 days and check inr prior to doing it to make sure it’s normalized
Myotonic dystrophy
Avoid neostigmine, succinylcholine, potassium
Myopathy leads to you being in hyperkalemic state
Neostigmine leads to more Ach leading to more contractions of muscles which isn’t what u want
Cryoanalgesia
Nerve regeneration in 1-3 months
Takes about 90 sec to do
Intercostal nerve analgesia post thoracotomy
In esld what do you look for
Factor 8 is great to look for coagulation disorder bc it is high
Factor 8 is low in DIC
Down syndrome goes with
Pyloric stenosis
Infants pulling knees to chest and currant jelly stool
Intussception
Duodenal atresia
Double bubble sign
In down syndrome on inhalational induction the common response is
Bradycardia
Infants desaturate faster than adults due to
Their lower FRC
Low FRC means
The lungs really collapse due to force of chest wall so harder to reopen
Incidence of PONV is related to
Age
Lower age has lower risk of PONV
Epiglottis induction
Inhalational direct laryngoscopy with rigid bronch, surgical personnel present
Coarctatuon repair use pulse of on
RUE
Central core disease at risk for
Malignant hyperthermia
Morphine dose for pediatric patient
.05-.2 mg/kg
Connie medularris at infants lies at
L3
End of spinal cord
Caudal block landmark
At the corpus of the sacral hiatus
Where the crease of buttocks begins
In cardiac transplant
HR generation is dependent on donor atrium
Frank starling stays intact
Less HR variability
First step in treating dka
Iv hydration
Need hourly glucose
Don’t use CPAP of non ventilated lung in
VATS case bc leads to less surgical exposure
Instead add be to the dependent(ventilated lung)
Carotid duplex us
Easy in ppl with lots of commorbidities
Retrobulbar block
Posterior glove rupture
Ocular pain wo increase in IOP
Leading cause of periop morbidity I’m obese patients
DVT
Obturator nerve block
Weakness of thigh adductor muscles
Combined sensory/motor block
Persistent headache after 20 weeks gestation goes with
Preeclampsia
No spinal anesthesia on someone with
Neural tube defect
Jehovah’s Witness won’t get
Allogenic autolougois platelets
Epidural anesthesia is safe in patient with
MS
Hyperthermia leads to
MS exacerbation
Local anesthetic absorption
Intercostal then causal then epidural
Patients with mild of severe PFTs show the
Least response to bronchodilator therapy
If PFTs show pneumonectomy might not be tolerated next test is
Split function tests
When placing Caudal block you pass which ligament before epidural space
Sacrococcygeal ligament
Adenosine blocks the
AV node
Adenosine doesn’t help with tachycardia in
Atrial glitter bc AV node is not involved
Acetazolamide inhibitor of
Carbonic anhydrase
Waste sodium in bicarbonate in proximal tubule leading to
Hyperchloremic metabolic acidosis
Meds not ok with history of malignant hyperthermia
Succinylcholine
Inhalational anesthetics like Sevoflurane
Pituitary does not have an affect on
Parathyroid hormone and hypercalcemia
GH secreting tumor
Consider patient a difficult airway
What has shown to help pre-delivery
Corticosteroids either betametgasone or dexamethasone
Frank starling curve
Y axis - cardiac output
X axis- end diastolic volume
Loop diuretics
Lower filling pressures but don’t help with iontropy or cardiac output
Furosemide acts at
Ascending limb of loop of Henle
Increases venous capacitance and increases venous volume
Decreased stroke volume leadin to increase in contractility
Lowers diastolic blood volume and pressure
Reduces svr and increases venous capacitance to allow fluid to move
What drug is not associated with pain on injection
Ketamine
ASA criteria for discharge home from pacu
Take care of
Nausea
Return to baseline consciousness
Pain control
Stable bp and hr
Voiding is not a part of the criteria
Beckeith-weidsman
Macrosomia, perinatal hypoglycemia, omphalocele
Hurler syndrkme
Most difficult airway management
ARDS of newborn if born early
Diffuse ground glass opacities and reduced lung volumes
Dose of ketorolac in children
0.5 mg/kg
Adult hemoglobin p50
Infant hemoglobin p50
27
Infant is 20
Oxygenated blood from placenta travels from the umbilical vein to the
IVC - this is where oxygenated blood is highest in the fetus. Everywhere else the blood is mixed
Give blood to children even if the family are
Jehovahs witnesses
Propofol clearance rates are similar to
Adults
But children have higher Vd
Child have higher redistribution from vessel rich organs
Precedex loading dose can lead to
Bradycardia
Don’t use precedex for induction in children
Moderate sedation
Airway patent
Children respond to verbal or touch
Which parameter increases with pregnancy
LVEDV
CVP and pulmonary artery diastolic pressure don’t change
Supine hypotensive syndrome of pregnancy due to
Compression of IVC
Pregnant women have more neural sensitivity to local andsthetics
Faster onset and prolonged duration in pregnant vs non pregnant patients
In pregnancy
Decreased FRC and decreased MAC
Pregnancy you see increase in
Tidal volume
Pac02 degrees to about 30 at 12 weeks gestation
Renal changes in pregnancy
GFR increase RBF increase Creating clearance increase More protein excretion Bicarb excretion increase to compensate for respiratory alkalosis Glucose excretion increases
Pregnancy leads to
Biliary stasis and changes in bile composition
Estrogen increases cholesterol production
Pregnancy
Decreased LES tone
Same fasting guidelines in pregnant patients
Intestinal transit and pariestalsis are slowed
Fibrinolytic activity is increased
WBC don’t work as well in pregnancy leading to more infections
Platelet consumption is higher in pregnancy
Oxytocin can lead to
Hyponatremia
Misoprostol is commonly associated with fever
CVS and amniocentesis
Look at fetal karyotype
CVS is safer if performed 9-14 weeks
Oligohydramonos
Most common cause is fetal anomalies
Hydros fetalis
Fluid in two or more compartments
Elective C Section May be warranted if
> 4500 g in diabetic or 5000 g in non diabetic
Can do neuraxial anesthesia for
Preeclampsia
Placenta previa
My second stage of labor oxygen consumption has increased
70%
Tidal volume in pregnancy
Increase
So does minute ventilation but respiratory rate stays the same
Best way to help patient with atrial fibrillation increase cardiac output
Convert to normal sinus rhythm
PPV increases intrathoracic pressure and thus IVC pressure which can lead to
Decreased renal perfusion and oliguria
Oliguria= <0.5 ml/kg/hr
Causes decreased preload and increased afterload
Midazolam bioavailability
IV>intramuscular>intrascalar>rectal>oral
RA is not sssociated with
Bronchospastic disease
RA most commonly leads to
Pleural effusions
Detecting pericardial fluid is best with
TEE
Eclampsia is a preeclampsia patient with
Grand mal seizures
Increased cardiac output
Decreases speed of inhalational induction
At above what level does autonomic dusteflexia start
T6
Best way to treat intraoperative hypothermia in Peds patient
Forced air blanket
Obese patients have
Higher lean body weight
Higher cardiac output
Lithium increases blockafage of
Neuromuscular and depolarizing agents
Fastest way to restore cerebral perfusion pressure
Drain CSF from evd
Hypertonic
Draws fluid from intracellular space as osmotic
Head up increases venous drainage and is helpful
Lusitropy is different from preload how?
In preload volume goes up but pressure stays the same
In lusitropy volume goes up and pressure goes down
ASA physical status classification was originally used for
Anesthetic data comparison
Intravesical pressure =
Bladder pressure
If high can signify compartment syndrome correlated with increase in ICP
Mild dehydration of newborn
< 2 ml/kg/hr urine output
Prolonged second stage of anesthesia
2 hours without neuraxial in first pregnancy and 3 hours if neuraxial
Prior c section with pfannenstiel incision. Can have a
TOLAC attempted the next time
In multiple sclerosis patients
Epidural and spinal anesthesia are safe
Best method to look for ectopic pregnancy
Transvaginal US
VwF normally aids in
Platelet binding
Most common valvular disease in pregnancy
Mitral valve stenosis
Diagnosis of umbilical cord prolapse
Deliver fetus as soon as possible
Zofran does not help against
Aspiration pneumonia
Nitroglycerin can help take out
Retained placenta
For breech delivery
C section preferred
Anesthesia helps with a version
Give nitroglycerin for fetal head entrapment during Vaginal delivery of breech infant
Umbilical artery pH less than 7.0 associates with
Neonatal morbidity
Hemodynamic instability is a contraindication to
NIPPV as is recent vomiting or copious secretions
After intubation in COPD patients especially can get auto-peep
First step is to disconnect from ambu bag
HR will go down as will BP
In ARDS want plateau pressure below
30
Ability to follow commands is not required for
Extubation
Want
RSBI<100
Cuff leak
Minimal secretions
Successful SBT at inspiratory pressure of 5
RSBI =
RR/tidal volume
PPV
Decreases preload and LV afterload
Increases RV afterload
Increasing inspiratory flows helps in COPD patients bc it
Allows a longer time for expiration
In volume control ventilation tidal volume is determined by
Set inspiratory flow
Ventilator associated pneumonia
Best way to prevent vap is reduce duration of mechanical ventilation
Use NIPPV
Daily sbt
Chlorhrxjdjbd
Head of bed up
Catheter related blood stream infection
Diagnosis- positive blood culture from catheter site and another site
Don’t routinely replace CVC
Avoid femoral line placement
Avoid subclavian in renal disease patients
Chlorhrxidine is best
Use guidewire on cvc if
Lack of blood return
According to the CDC reasons for indwelling urinary catheter includes
Acute urinary retention
Close monitoring of urine output in Ill patient
Comfort care
Fick equation calculates
Oxygen consumption
Metochlopramide affect on les tone
Increases
Increases gastric ph
Dopamine receptor antagonist
Antiemetic
Nonshivering theogenesis In adults
Brown fat/skeletal muscle
Imminent acute renal failure is best seen with
Creatinine clearance
FenA checks for the cause of
Renal failure
Pregnancy
Unchanged vital capacity
Biggest predictor of difficult intubation in morbidly obese
Neck circumference
Neuraxial anesthesia causes
Vasodilation and decrease in core temp
Ventilation and perfusion are lower in
Apical alveoli
In adults and elderly what stays the same
Total lung capacity
Closing capacity is higher in elderly
Gold standard for pain
Continuous labor epidural
Treatment of choice for lung abscess
Broad spectrum abx
Formation of atelectasis does not increase with
Increasing age
Causes of atelectasis
High Fi02
Obesity
General anesthesia
Oral H2 blockers have an onset time of
One hour
Strongest predictor of perioperative outcome in patient on TPN
Albumin
Fetal academia
pH 7.2 or lower
Lactate greater than 4.8
Claims made insurance policy
Covers claims made that calendar year
Vertebral arteries originate from
Subclavian arteries
Oropharynx
Soft palate to epiglottis =
Epiglottis to crocoid cartlidge
Larynx
TCD ultrasound monitoring
Measures blood flow velocity in large arteries in head
Detects number of atherosclerotic plaques in the vessels
Active humidificatijn vs passive humidification
Active is more effective at humidification of gases
ARDS you want vcv bc
Can set tidal volume perfectly
Tidal volume in vcv determined by
Inspiratory flow
Do not replace indwelling catheters regularly only take them out when
No longer needed
C diff is transmitted by
Spores
If you suspect c diff
Only chlorine containing products such as bleach should be used for cleaning
Give oral vancomycin for severe cases
PPIs are associated with c diff
Endotracheal intubation/bronchoscopy
Need face shield to protect for mucous membranes
Mycobacterium tuberculosus
Transmitted through respiratory droplets
Start airborne precautions
Start 4drug regimen if you think they have it
If needlestick injury to patient with hepatitis B
Get anti HBs titers
If low give HBV vaccine and immunoglobulin
If normal give nothing
CA pneumonia
Ceftriaxone is great for pneumococcal
Macrolide or flouroquinolone for atypical
Vancomycin plus cefepime for HA pneumonia
Parasternal short axis
RV on top
LV to the right
Left third to fifth intercostal and facing left shoulder
Distributive shock underfilled ventricles and hyper dynamic
In PE RV dilated and almost same size as LV
Contraindications to systemic fibrinolysis
Active bleeding
Intracranial lesion
Recent ischemic cva
These ppl need embolectomy
Subcostal view
Can show pericardial effusion
Elevated SVR, HR, CVP
If tamponade post CABG
Need redo sternotomy if tamponade post CABG to figure out source of bleeding
Lactate is a marker for
Organ hypoperfusion
Dobutsmine has beta1 and beta2 and is preferred in
Cardiogenic shock- inotrope and chronotrope
Can cause decrease in svr and hypotension
PAC can be used to get
Stroke volume
SV02
SVR
Oxygen consumption
Not ejection fraction
Look out for urosepsis
After taking out stones
Sepsis is considered a
Medical emergency
Septic shock
Lactate greater than 2 and hypotension despite fluid resuscitation
Next step is start norepinephrine
Start with 30 cc/kg
Straight leg test and look at IVC
Spinal cord injury below C4 still have diaphragm but
Lose accessory muscles which are crucial for adequate cough and deep breathing
If high risk for DVT
Use LMWH instead of subq heparin
High risk is spinal cord injury, major trauma, leg trauma
ASPEN guidelines
Early enteral feeding in ICU 24-48 hours of admission advocated
Elevate head of bed to reduce
Aspiration risk
Brain death
Abscence of spontaneous respiration’s at pac02 of 60 or greater
Absent brainstem reflexes
Normotension
Etiology of coma
Complete absence of motor function not needed
Gold standard ancillary test for brain death
Abscence of cerebral vessel filling on cerebral angiography
Brain death is defined as
Irreversible loss of brain function and need 2 brain death exams 6 hours apart
First step I hyponatremia
Check serum osmolality
Mannitol draws water into extracellular fluid leading to hyponatremia
Normal serum osmolality 280-290
SIADH treatment remove sources of excess free water
Fluid restrict!
Pleautaeud expiratory flow
Mediastinal mass
Jet ventilator
Maximum of 35 psi
Seldinger technique 12 to 16 gauge catheter
Minimum pressure to ventilate patient is 15 psi
Thoracic epidural allows for deep breathing
Without pain
Ethosuximide
Blockage of T type calcium channels
Air in the sample syringe for blood gas artificially increases the
Pa02
20 minute delay of reading blood gas sample leads to
Lowering of Pa02
Communication between doctor and lawyer is always
Privledged information
AcH binds to
Alpha 1 subunit of the postjunctional nicotinic receptor at the nmj
Airway resistance affects the
Ppeak
Endotracheal tube obstruction, bronghosoasn ashthma attack
Pulmonary edema, ARDS affects
Pleateau pressure
Chronic high flow AVM getting embolized
Cerebral dysautoregulation post avm can lead to profound cerebral edema often requiring decompressive craniotomy
Hypothermia decreases
CMR02 and ICP
QT prolongation
Erythromycin
Hypocalcemia
In refeeding treatment includes
Stop tube feeds and replace electrolytes
In drowning patient
Don’t do the heimlich as can lead to pulmonary aspiration
Hypothermic drowning patients tend to do better
Reduced cerebral oxygen consumption
Antidotes
Methanol/ethylene glycol poisoning - fomepizole
Organophosphate- glycopyrolate/atropine
Diltiazem- insulin
Cyanide poisoning and carbon monoxide poisoning is seen in
Burn victims
Can see lactic acidosis
Hydroxycobalamin is first line against cyanide poisoning. Also administer 100% oxygen
Sarin gas =
Organophosphate poisoning
Intimal flap in aorta
Descending aortic dissection
Type B dissections are distal to subclavian
Type A involve ascending aorta with or without descending
Need to increase preload, decrease afterload,
Midesopageal short axis
Aorta Mercedes Benz sign
AI
Increase preload
Decrease afterload to maximize forward stroke volume
High normal HR
Maintain sinus rhythm
Bicuspid aortic valve see
Aortic root dilation
Aortic stenosis hemodynamics
Preload- full
Afterload- don’t decrease. Maintain it to sustain coronary perfusion
Electromagnetic interference to pacemakers
Inhibition of pacemaker
Loss of capture
Inappropriate icd firing
Myocardial burns
Pacemaker code
Position 1 designates chamber being paced
Position 2 chamber being sensed
Position 3 is response to sensing
Atrial fibrillation initiates in
Pulmonary vein
Phrenic nerve injury
Elevated hemidiaphragm
RICI score to assesss
Periop major cardiac events
If emergency procedure like perforated bowel just go to or!
U use this for intermediate procedures with multiple risk factors
3 RICI risk factors
Recommend starting a beta blocker prior to procedure
Intraoperative MI is seen best with which lead
V5
Type 2 MI due to
Increased myocardial demand or decrease oxygen supply
VAD device
Close to stomach so leads to delayed gastric emptying thus do rapid sequences
CBP vs ECMO
CBP uses lower flow rates thus requires more anti coagulation
A line will lack pulsatility
Prior exposure to Protamine
Puts you at greater risk for anaphylaxis when you get protamine again
Fixed upper obstruction
Foreign body
Tracheal stenosis
Large airway tumor
Extra thoracic airway obstruction
Goiter
Lumbar nerve roots exit
Below the numbered Pedicle
Benzos and opioids may cause marked
Synergistic vasodilation
Pons injury
Respiratory dysfunction
NIF > -20 such as -15 is associated with a
Difficult wean
BUN with uremia
Give lower dose of versed
Cyp 2D6
Coeidine
Lactate ringers is made up of sodium and lactate and has a little glucose
The lactate is converted to bicarbonate leading to an alkalosis
Chi square doesn’t work for
Continuous variables
Works well for categorical variables
Best for DVT prophylaxis and prevention of post-op bleeding
LMWH
Do not give midazolam to
Pregnant patient
Dexamethasone anti-emetic site
Nucleus tractus solatarii
Increased epinephrine
Increased blood glucose levels
Serum osmolality is high in HHS but low in
DKA
<320 in dka and above 350 with HHS
Give IV ketamine if worried about patients
Respiratory status
100% of intrascalene blocks get
Phrenic nerve blockade
Ketamine can induce
Seizures
Rigid laryngoscopy/bronchoscopy
Foreign body
Don’t give glucose containing fluid to
Burn patients
Hypocalcemia
Hypokalemic
Hypo magnesium all cause
Prolonged QT
During fasting on liver it
Increases glycogenolysis and does gluconeogenesis
Which anti muscarinic increases HR the most
Atropine
Zone fasiculata makes
Glucocorticoids
Glucocorticoids are made in adrenal cortex
Water moves freely acriiss
BBB
Lipophilic substances move freely as well
Pa02 above 100 can have
Deleterious affects on patients
Prolonged exposure to high levels of oxygen can lead to
Tracheobronchitis/pulmonary edema/eventual respiratory failure
Volatile anesthetics
Increase RR
Decreased TV
Fa/Fi increases most with higher minute ventilation
In highly soluble agents like isoflurane
Which evoked potential is mode sensitive to volatile anesthetics
Visual evoked. Brainstem auditory most resistant
Left ventricular diastolic dysfunction goes with
LV hypertrophy
Patients with diastolic dysfunction and normal ejection fraction
Have normal volume but high diastolic pressures
Myofascial pain
Multiple taut bands with radiating pain
Esophageal monometry
It is used to calculate transpleural pressure gradient
1 mg of protamine per
1 mg of heparin(100 units)
What is made in liver?
Angiotensinogen
BNP is released from heart
Response to myocardial stretch receptors
Vascular rings are due to failure of
Embryonic structures to regress
Occur with right sided aortic arches
Video laryngoscopy helps with
Glottis visualization
Where do you sample to get mixed venous saturation
Proximal pulmonary artery
Keeping OR humidity 50-55% helps with
Mitigating increased risk of static discharge
Cryotherapy delays
Nerve conduction
Neostigmine causes
Fetal bradycardia
Increasing gain increases
Black white and gray on screen
Addiction
Significant physical or emotional dependence on drug and craving despite negative or even harmful consequences
Chylothorax
Left IJ you can injure thoracic duct
Phospholipoprotein surfactant made by
Type 2 alveolar cells
Pulmonary surfactant is also called
Phospholipoprotein
Posterior pituitary also called
Neurohypophysis
Beta stimulation and pain or emotional stress increase
ADH secretion
In SIADH
Urine must be inappropriately concentrated plasma osmolality <280 and urine osmolality >100
Primary therapy for SIADH is
Fluid restriction.
Chronic SIADH may require demeocycline
Severe risk for acid aspiration give
Metochlopramide/ranitidine- better than cimetidine with fewer side effects
IABP is out
Put into descending aorta
Should end up above renal arteries and 2cm distal to origin of left subclavian artery
IABP increases DBP and coronary perfusion
During systole increase output and decrease afterload
Hyperkalemic periodic paralysis patient
Potassium free dextrose solutions help
More glucose leads to more insulin formed to decrease potassium level
Diffusion hypoxia
Due to high amounts of nitrous oxide coming out on emergence displaces 02 and c02
Cyp2D6
Converts codeine to morphine
Waste gas scavenging
Vaccum rate must exceed the rate of waste gas flow
Airway procedures such as blank are at higher risk for adverse events with pediatric sedation
Bronchoscopy
Also ASA 3 or greater and obesity
Etomidate
Enhance affinity of GABA binding to Gabaa receptor
Does not directly activate GABA
Biggest adverse risk with midazolam is
Respiratory depression
Alanine is a substrate for
Glucose synthesis
Max amplitude on TEG is low give
Platelets
Want R time 6 minutes
Alpha angle 60 degrees
Max amplitude 6 mm
Prolongation of R value requires FFP
CBP with bypass flow of how much replicates normal cardiac output
4.5 L/min
Physician have the highest blank of any profession
Suicide
First leading cause of death in residents
Cancer second is suicide
Hypotonia of neonate can be caused by administration of what to the mother
Magnesium
Diltiazem good for
Hemodynamically stable A fib
Non-dihydropyridine calcium channel blocker
Labetalol
Alpha1/beta1 antagonist don’t use beta blockers for a fib if patient has bad COPD
When a patient is anemic
Blood viscosity is deceased helping improve blood flow aiding in oxygen delivery
Blood flow goes more to vital organs and not to kidneys skin and muscle
Propofol decreases amplitude of
SSEPs
Coagulatiopathy happens in 1/3 of bleeding patients
J
Burst suppression helps mortality in patients with
Status epilepticus
Help prevent medication errors with
Prefilled syringes
TR will affect
Thermodilution
Check temp in pulmonary artery to get cardiac output
Postop myalgia after succinylcholine
Do not correlate with fasiculations
LY30 elevates is a sign of
Coagulopathy
Protamine MOA
Direct binding of large negatively charged molecules in serum. Heparin is negatively charged
Gabapentin blocks
Calcium channels
Change in portal venous flow will result in
Compensatory flow changes in hepatic artery
Adenosine produces
Hepatic arterial dilation
Inhalational induction is most slower by
Right to left shunt
What muscle contracts during forced exhalation.
External obliques and internal obliques
Diaphragm and external intercostal swirl during
Inspiration
Acute anemia lowers
SV02
Dexamethasone
Is the most potent glucocorticoid
Can lead to adrenal suppression
Fludocortsone
Potent mineralocorticoid
Dermatome spread if local anesthetic injection is based on
Baricity of medication
Propofol acts through
Posysynaptic GabaA receptors increasing chloride conductance
APRV can lead to
Hypercarbia In paralyzed patients due to inverse 2:1 I to E ratio
Polyvinyl chloride endotracheal tube most likely to undergo
Ignition when exposed to c02 laser
Concentration calibrated bypass vaporizer uses blank to achieve desired percentage of volatile anesthetic
Splitting ratio
Cornual placenta predisposes to
Breech delivery
As well as multiple gestation and macrosomia
Opioid with highest side effects in epidural space
Morphine
Very hydrophilic and produces longer duration of action
Cephalad movement of opioids in CSF principally depends on lipid solubility
In MRI suite after starting
CPR
Remove patient from scanner immediately
DBS electrodes for refractory Parkinson’s avoid
Midazolam
Need to stop on day of surgery
Diuretics
Selective beta 2 agonist
Terbutaline
Treacherous Collins
About 50% have hearing loss
Hyperparathyroidism leads to
Skeletal muscle weakness
And hypophosphatemia
If looking at facial nerve can’t use
Neuromuscular blocking agents
NMBD work at postsynaptic receptors
Mediastinal mass
Don’t use nmbd can lead to tracheal collapse
Acetylcholine synthesis is catalyze by choline acetyltransferase at
Presynaptic neuron
Psuedochilineeease is found in
Plasma- not the neuromuscular junction
For Ach release
Need ca2+ influx
Feverfew has additive effect with
Warfarin
DIC is associated with
Elevated PT time
Alvimopan
U receptor antagonist which does not cross BBB.
BAEP
Most resistant evoked potentials to volatile anesthetics
Only need meds for malignant hyperthermia if
Triggering agents are used - succ or inhalational agents
Fade on train of four is associated with
Progressively decreased Ach release on successive twitches
Beta agonist leads to increased
cAMP
Hydralaxine mainly dilates arteriole
Duration of action 1-4 hrs
Inability to extend neck and create sternomental distance >12.5 leads to
Difficult intubation
Mallampati 3 or 4
Interincisor distance < 3 cm
Thyromental distance < 6.5 cm
Febrile Rxn to platelets caused by
Cytokines released by donor leukocytes
Third and fourth generation cephalosporins have very little cross reactivity with
Penicillins
Secondary Adrenal Insuffiency
Direct result of inadequate ACTH production by the anterior pituitary
CRH from hypothalamus is first
Sanz electrode for
PH
Clark for P02
Severinghouse for C02
Median aperture drains CSF into
Cisterna magma
Epinephrine leads to
Vasodilation
Transpulmonary pressures are high in patients with
Restrictive lung disease
Distal to subclavian descending thoracic aortic aneurysms treat with
Endovascular repair
More magnesium leads to decreased calcium leading to less Ach release which results in
Muscle weakness
Endotracheal cuff pressures based on
Boyle’s law
Bedside percutaneous tracheostomy what type of tracheostomy tube
Cuffed low pressure tracheostomy tube
Gum elastic boogie vs airway exchange catheter
Anterior angulation at distal end
Nitroglycerin calcium channel blocks can cause
Direct cerebral vasodilation
Infants and patients with sickle cell do poorly when getting blood
With defective hemoglobins
Surgical manipulation of carotid sinus may lead to
Sudden Bradycardia and hypotension
Atropine crosses the
BBB
High volume low pressure
ETT cuff is the standard
Polyurethane cuffs are used which are ultra thin
Desmopressin leads to rease of
VwF from endothelial cells
In VWF patients check
VwF legend, factor 8 levels, VwF ristocetin cofactors
Three phases of liver transplant
Dissection anhepatuc repercussion
Anhepatic clamp portal vein/hepatic artery remove liver and anastomosis to IVC and portal vein
Reperfusion
Anastomosis hepatic artery and biliary systems
Regional is better than neuraxial in
Bad liver patients
General is the worst messes up hepatic blood flow
Neuraxial anesthesia
Reduces rate of perioperative vte
Decrease stress response as well as improves venous blood flow
Post op after retroperitoneal carcinoma resection continue LMWH for
28 days
PE
Increased dead space
Most common acid base disturbance in acute PE is
Respiratory alkalosis
Most sensitive ECG change is sinus tachycardia
Most common cause of HTN is
Essential HTN
AceI and Arbs block
RAS which releases vasopressin. Cause vasopressin depleted state but treat with vasopressin
CSF drainage is recommended as spinal cord protective strategy in
Open and endivascular thoracic aortic repair
Aortic cross clamp release
Venous return decreases as blood goes to distal tissues
Cardiac output is thus decreased
Clopidogrel should be held how long for epidural
7 days
Acute lung injury is a risk in patients
With acute alcohol intoxication
Preop spirometry for delineating risk in thoracic surgery
FEV1<800
FEV1<30% of normal
RV/TLC>50% are all associated with increased postop risk for lung resection procedures
Theophylline toxicity
Low therapeutic window and used in COPD patients
Can lead to tachyarhythmias
V02 max greater than 20 ml/kg/min has
Low risk of postop complications
Surgery on which lung is more likely to lead to desaturation
Right
Significant lunch parenchyma disease is evident with a low Pa02/fi02!ratio
25 vs 5% albumin
25% has much higher osmotic pressure so moves fluid into intravascular space better
Hydroxyetgyl starch is
Renally excreted
Increases PTT
Normal serum osmolality
285-305
Diltiazem is unique why?
Can act on both smooth muscle and cardiac muscle
Vasodilator and cardiac depressant thus dilating corinarues and decreaseing PVR
Dihydroperidines end in dine
Amlodipine
Acts as vasodilator but has no cardiac depressant effect
Best way to avoid upper extremity injury during spine case
Use somatosensory evoked potentials
Can’t measure oxygen level with
Infrared absorption spectrophotometer
Treat high spinal quickly with
Epinephrine
Pacemaker leads go through subclavian axillary veins to svc ra rv or both . The end of the lead is placed in the
Endocardium
Ventricular arrhythmias are common as you float PAC into
Right ventricle
Awake fiber optic is best for
Clinically stable pt
In general the higher the pH of solution the more will exist in
Unionized form
Atrial fibrillation
Loss of A wave
Serotonin syndrome
Clonus
Tachycardia
Hyperpyrexia
Diaphoresis
As gas flow through rotamer increases so does
Cross sectional area of orifice
Density and viscosity of gases aren’t affected by flow
Periodic recruitment maneuvers are known as
Sighs
Flail chest
Conservative treatment is standard of care. Not surgical.
Thoracic epidural not intubation unless required
CPAp provides continuous pressure throughout inspiration and expiration and is analogous to
PEEP
Prevents collapse of airways
Bipap adds pressure support to
Cpap
Don’t do Bipap if
Severe agitation
Vomiting
Gold standard analysis of platelet function is
Optical aggregometry
First step in work up of anemia
Peripheral smear and reticulocyte
Hexamethonium
Neuronal type nicotinic antagonist
Blood transfusion from first degree relative can lead to
Graft vs host disease
Intrinsic peep goes down with
Lower minute ventilation and longer expiratory time
Myofascial pain best treated by trigger point injection and
TENS
Myofascial pain is at a particular point in the muscle
Lateral cricoarytenoid and transverse arytenoid result in
Adduction of vocal cords
Increase bradykinin with ace inhibitor use can lead to
Facial edema
Pipeline pressure of oxygen nitrous and air ranges at
50 psig
Mapleson D is the most
Efficient and requires the least gas flow
General contraindication to MRI include
Pacemaker or CID
Bronchiectasis is an
Obstructive pulmonary disease
FEV1/FVC is down in
Obstructive lung disease
Pneumonia and ARDS are
Restrictive lung disease
Gray rami carry postganglionic sympathetic fibers
From the sympathetic ganglia to the spinal nerves
White rami carry
Preganglionic sympathetic fibers from spinal nerves to paravertebral ganglia
Hunt Hess 1
No blood detected
Hunt Hess 2 diffuse thin layer of blood < 1 mm
Risk of airway fire is higher in MAC cases bc they are never intubated and thus don’t have a secure airway
In Mac must be ready to convert to general.
Purposeful to painful stimuli and usually maintain cardiac function
Biggest risk is respirator depression
Thoracic duct drains into
Subclavian vein
You should suspect injury if unilateral pleural effusion or ipsilateral supraclavicular swelling
Pneumothorax presents as sudden onset chest pain and immediate dyspnea
Temperature regulation by
Hypothalamic nuclei
This is where most of it occurs centrally
For airways with limited neck extension should use
Flexible laryngoscopy
Video Laryngoscopy requires some neck flexibility
With three twitches in TOF approximate blockade of
75% of receptors
Gold standard TOF ratio is
0.9 for reversal
1 twitch on TOF
90% of nicotinic Ach receptors are blocked
Inhibits breakdown of midazolam
Fluoxetine
When performing a circuit leak test the APL valve should be
Closed
Closed means 30-70 cm H20
If you leave APL closed on spontaneous ventilation can lead to
Barotrauma
Epinephrine and dopamine both
Decrease renal blood flow
Angiotensin 2 effects efferent vasculature thius increasing renal blood flow
Morphine 3 glucoronide contains
No analgesic activity in humans
May cause hyperalgesia
M6G more likely to cause nausea/pruritis/respiratory depression
The larynx is located at the
C3-4 interspace
In adult it’s at C4-C5
What reflex stays intact after inducing general anesthesia
Pupillary response to light
Corneal reflex/gag reflex/
Gel warming mattresses are
Ideal for transport and don’t need a power supply
Hypernatremia increases
MAC
Delay elective cases if serum sodium > 150
Lower potassium
Beta agonists
Insulin
Alkalosis
Barbiturate coma
Construction of cerebral vasculature leading to decreased ICP
Duration of action dependent on redistribution to peripheral compartments
Skin surface warning before induction of anesthesia
Increase body heat content
Parasympathetic pre and post ganglionic receptors are both
Ach
Single most important risk factor for developing postoperative cognitive dysfunction is
Increasing age
In trauma give
1:1:1 prbc, FFP, plts to maintain coagulation pathways
Increasing abdominal distention from small bowel obstruction can lead to
Ischemia or perforation
Smart to put NG tube if lots of vomiting to decompress prior to starting case
Certain drugs such as nitrous oxide and metochlopramide can lead to higher risk of bowel perforation so don’t use
Metochlopramide is a promotility agent and causes increases gastric emptying
Warfarin half life
38 hours
Precedex is highly selective for
Alpha2
Much more than clonidine
Naloxone has greatest affinity for which receptor
Mu
Hydromorphone and morphine intrathecal can lead to formation of
Granulomas intrathecally
All Duran sinuses drain into the
Internal jugular vein.
The veins of the brain drain into the Dural venous sinuses
Invasive arterial blood pressure monitoring involves
Electromechanical pressure transducer
When can you do an SBT
GCS>13
Pa02 150-200 on fi02 50% or less peep of 8 or less
No sepsis or electrolyte issues
HR<140 beats per minute
Post op in Peds for fluid replacement use the
2-1-.5 rule
Propofol is Safe to use in patients high risk for
Hepatic encephalopathy
Precedex is mainly based on
Liver metabolism
Succinylcholine increases
Tracheal tone
Which nerve most attenuated hypoxia ventilatory drive
Peripheral response to acute hypoxia
Glossopharyngeal nerve
Carotid and aortic bodies detect decrease in arterial partial pressures of oxygen
Large left atrium will show as bigger RA on CXR
RA at bottom of heart on cxr can’t see RV
Can see LV at bottom
Nicotinic Ach receptors increase in
Skeletal muscle with Guilin barre and burns
Severe metabolic acidosis in hypovolemia can lead to
Severe hyperkalemia due to GI tract - not skeletal muscle
Warfarin has
Narrow therapeutic window
Tylenol can make you supratheraputic
Termination of local anesthetic drug effect when used in neuraxial anesthesia
Vascular absorption and redistribution is primarily responsible for termination of effect
No local anesthetic
Gets metabolized in CSF
Dobutamine acts on
Beta1 receptor
Hyperkalemia with potassium above 6 should be corrected before
Elective cases
Sodium bicarbonate insulin beta agonists can lower
Potassium
Body excretion of potassium takes time
Diuretics kayexelate dialysis
95% of mag is
Renally absorbed
High normal saline leads to
Hyperchloremic metabolic acidosis
Platelets are stored at highest temp with highest risk for
Bacterial infection of all blood components
Febrile rxn to blood due to
Leukocyte antibodies
Trali
Non cardiogenic pulmonary edema
Hypoxia SOB fever
Urticaria rxn to blood
Don’t stop transfusion!
TRALI criteria
Within 2 to 6 hours of transfusion
PA occlusion pressure low
Bilateral infiltrates
No acute lung injury prior to transfusion
Diuretics and steroids are contraindicated in Trali
AB universal for giving
Plasma bc they have no antibodies
In cross match a small amount of donors blood is mixed to see if
Compatible
Type and screen
Add blood from donor to specially made red cells with all the antigens to see what antibodies are on the donor blood
Hypothermia increases blood loss by
20%
First step in blood transfusion rxn
Stop the transfusion
Coagulation cascade always involves
Conversion of fibrinogen to fibrin
When clot is formed
Plasminogen is concerted to plasmin by tPa to break down clot
Spontaneous bleeding occurs at plt count less than
20,000
Minimum recommended plt count before surgery is 75,000
Thrombocytopenia
Dilution after massive transfusion
Uremia cirrhosis and aspirin can also cause it
ASA stops platelet aggregation by inhibiting platelet
Cyclooxygenase
Factor with shortest half life
Factor 7
Warfarin competes with vitamin K for binding sites on the
Hepatocyte
Heparin activates
Antithrombin 3
Normal PTT
40-100 seconds
Normal PT time
10-12 seconds
Cryoprecipitate is thawed
FFP
Less thick TEG
Severe plt dysfunction
R time increase in coagulation factor deficiency
Hypercoagulable state will be more thick
Glossopharyngeal nerve
Provides sensory innervation to base of tounge and vallecula
Jet ventilation
Can’t expire and can lead to barotrauma or decrease in cardiac output
Negative inspiratory force should exceed blank for Extubation
Risk of pressure injury is higher with
Mask ventilation
LMA can affect the lingual
Nerve
Prolonged heparin use leads to
Hypoaldosteronism
Warfarin
Vitamin K antagonist
Near infrared uses
Longer wavelengths than visible light spectroscopy
IgA deficiency
Recurrent infections of respiratory and GI tract
Lvads can be
Long term
RVADs and bivad can not
Bupivicaine induced cardiac arrest
T wave amplitude increases
Onset of action of IV fentanyl
3 to 5 minutes
Onset of action with hydromorphone is 8 minutes
Midazolam benzos will Lower
Seizure duration so don’t use in ECT
Most resistance to gas flow
Occurs in large airways including the upper bronchi
Adrenergic agonists like
Norepinephrine
Phenylephrine
Dopamine
Can’t cross BBB
Adolescents are more likely to get opioid
Addiction
Recombinant hemoglobins does not require
Typing or crossmatch
C tetani
Exotoxin binds peripheral nerves
Blocks GABA leading to spasticity
Isoproterenol
Beta agonist
During labor most common causes of fever are
Chorionionitis and epidural catheter placement
Chorio you get foul smelling amniotic fluid
Stellate ganglion
Increased blood flow to arm you place it on
Alcohol leads to
Afonso demyelination
Medial branch innervates
Multifidus, facet joint, interspinous
Before injection of epidural steroid injection hold xarelto for
Three days
C6 nerve exits from
C5-C6 foramen
Tension headache
First line are NSAIDs
If NSAIDs don’t work can do anti-depressants
Stellate ganglion block occurs at level of
C6
Spinal cord stimulator should be placed at
Posterior epidural space
Opioid withdrawal
Diarrhea
Central chemoceptors detect
PH and pac02
Renal blood flow is controlllrd by
Endotheliin 1 and nitric oxide
PPV greater than
15% means you will be responsive to fluid bolus
Increased aortic clamp times(ischemic time) leads to
Renal injury
Hemodilution promotes
Anemia
Muddy brown casts go with diagnosis of
ATN
Liver transplant pts do poorly with
Hyponatremia
Sodium hypochlorite for disinfecting
C diff
Meperidine
Synthetic opioid agonist
If aspiration want head
Lateral and down
No change in RR during
Pregnancy
Etomidate is associated with
General myoclonus
Congenital diaphragmatic hernia can lead to
Pulmonary HTN
Decreased total lung capacity in
Obese patients- makes them restricted
Dexmetodimine
Total body weight
Heparin stops conversion of
Prothrombin to thrombin
In utero Pa02 of fetus is
20 mm Hg
Haldol
D2 receptor antagonist
FEV1 greater than 12% increase is good response to
Bronchodilator
Emphysema doesn’t get better after
Bronchodilator therapy
Abscence of breath sounds and high peak pressures post intubation think
Bronchospasm
Give 5-10 mcg epinephrine
Which nerve supplies trachea
Vagus
In hypoxia respiratory failure you usually use
Venovenous ECMO
Hypoxia and hypocarbia are classic for
Pulmonary embolus
Spinal stenosis
Relief when bending forward
Fibrinogen and vwf are normal inpatients with
Liver disease
Acidosis messes up
Clotting factors from working correctly
Longer storage of blood leads to more co2 and
Metabolic acidosis
Look at calcium on blood gas by looking at
Ionized calcium
Enlarged cardiac sillhoute on patients with
Hypothyroidism
Vasogrnic edema messes up BBB by
Moving fluid from intravascular to extravascular compartment
Canulas of LVAD placement
Left ventricular apex for inflow
Outflow to ascending aorta
PTU acts on thyroperoxidsse
Thus inhibiting new thyroid hormone from forming
Also stops conversion of T4 to T3
In ARDS
Tital volume is based on ideal body weight
Barotrauma
Overdistension of alveoli
Side effects of PEEP
Barotrauma
Cardiac output decrease
Increase in ICP and fluid retention
Red on pulse of
Infrared
660
940 nm
Methemoglobin converts oxygen dissociation ratio to the
Left
Co oximeter blood gas analysis is test to look for
Methemoglobin
Pulse of only tells you about
Oxygenation not ventilation
Thus might be hypocapnic but pulse ox is fine
Et c02 less than
10 after 20 minutes cpr is 100% sign of death
Causes of rebreathinh
Exhausted C02 absorber Incompetent expiratory or inspiratory valve Accidental administration of c02 Giving bicarbonate Tourniquet release Inadequate fresh gas flow
Sudden loss of capnographic waveform
Esophageal intubation Ventilator disconnect Capnigeaph doscinnect Obstructed ETT Cardiac arrest
Cause of increased ETC02
Hypoventilation Increased body temp Airway obstruction Revreatginh Bronchial intubationi adequate fresh gas flow
Don’t give what during thyroid storm
Aspirin
Compensation for metabolic acidosis in humans that acts quickly
Hyperventilation
Dilation of ascending aorta seen in patients with
Bicuspid aortic valve
Decelerating flow is seen in
Pressure control ventilation
This is why it’s better than volume in morbidly obese undergoing laparoscopic surgery
Brain death leads to decrease in
Temperature
Brain dead patients still have spinal reflexes so need to give
Muscle relaxant
Pa02>200 is needed before doing
Apnea test
Vagal blockade during glossopharyngeal nerve block leads to
Tachycardia
Acute chest syndrome
New pulmonary infiltrate involving at least one lung segment not due to atelectasis
Treat with exchange transfusion
In VSD give
Preload up
CPP=
MAp-ICP
Complete heart block is known complication of
TAVR
Below level of aortic annulus caused by the prosthesis
Treat complete heart block with transvenous pacing
Tizanidine
Alpha 2 agonist
Primary metabolite of oxycodone is
Oxymorphone
Bivalirudin
Thrombin inhibitor that blocks thrombin mediated cleavage of fibrinogen to fibrin
Steroids cause
Decreased wound healing
Best way to see if facets are cause of back pain is
Medial branch block
Postop period following craniotomy patients who have a seizure should be investigated with
Head CT
1 amp 50% dextrose solution first line for hypoglycemia in
Teen patient
Tranexamic acid
Decreases risk of bleeding or blood transfusions
PO to IV hydromorphone conversion is
5:1
Meconium inactivated surfactant making
Ventilation perfusion mismatch
Head to body ratio of infants is higher so need to raise
Shoulders to get into sniffing position
Lingual nerve is a branch of the
Trigeminal
Laryngeal manipulation can lead to
Bradycardia
For jet ventilation
Avoid breath stacking
Hard to measure exact Fi02 so pulse ox important
TIVA is required
Pressure monitoring distal tip of jet ventilation catheter
During microlaryngoscopy patient need to be
Immobile
Increased airway pressure
Wheezing
Hypotension
Anaphylaxis
Give epinephrine 50-100 ug
Begin low dose epinephrine infusion
For anaphylaxis if refractory to medication and blood pressures stay decreased
Tryptase is a marker for
Mast cell activation and degranulation
Need to keep anaphylactic patient in icu for minimum 24 hrs
Thumbprint sign shows
Epiglottis
Mostly associated with h influenza
For aspiration in child
Want to keep patient spontaneous as long as possible flexible bronchoscope is placed
Can pass a flexible bronchoscope through an
LMA
Malpositioned trach
If trach falls out within first 24 hours there is a risk for false passage so don’t just stick it back in
Sign of difficult intubation
Inability to bring mandibular incisors anterior to maxillary incisors
Class 3 mallampati
Soft palate only season
Lambert Eaton gets better with
Exercise
Mechanical pump to circulate blood from machine to patient either
Centrifugal or roller pump
Diffusion constant of a gas is proportional to
Solubility and inversely proportional to the square root of the molecular weight
PEEP
Decreases afterload
Anterior wall on rigt side of
Left ventricle
Inferior wall on further left side
Complete heart block due to
Inferior wall
Difference between end diastolic and end systolic =
Stroke volume
Don’t give positive pressure to side of lung with
Bronchopleural fistula
Can lead to pneumothorax
Alk phos is increased in
Pregnancy
If blood is found in subarachnoid lumbar catheter
Stop draining CSF
Need to look for spinal hematoma or intracerebral hemorrhage
Leading cause of death worldwide is
Maternal hemorrhage
Increased FRC when placed in
Reverse trendelenberg vs supine
Decrease SVR to compensate for
Anemia
Gastric pH increases in
Pregnancy
HR no change BP will increase when giving phenylephrine
To pt s/p heart transplant
Tranexamic acid
Inhibits activation of plasmin
Desired magnesium range is
4-8
Hypermagnesium
More sensitive to depolarizing/nondepolarizing neuromuscular blockers
In acute tubular necrosis FenA >
3%
BUN:Creatinine<15
Prosthetic valve and cardiac transplant pts should get
Endocarditis prophylaxis
Least sensitive evoked potential
Brainstem auditory evoked potentials
Deep peroneal
Superficial peroneal
Sural
Innervate foot
Nitroglycerin not good with aortic stenosis
Leads to decrease in BP and increase in HR thus increasing myocardial oxygen demand
18% for front of torso
18% for back of torso
9% for each leg
Homozygous atypical dibucaine 20
Bad in psuedocholinesterase deficiency
Fa/Fi ratio most important factor is
Blood gas partition coefficient
T10-L1 visceral sympathetic
Pain transmission for first stage of labor
Thoracic epidural
Lower FEV1
Lower FVC
V/Q ratio doesn’t change
SAH ecg
QT prolongation
70 ml/kg for
Children blood volume
Phenelzine
Tranylcypromine
Are MAOi inhibitors along with selegeline
Be careful giving to patients with meperidine
SOMA
Highly addictive
Email between medical record must be
Encrypted
PaO2 is higher and PaC02 is lower without
Air bubble
Retrobulbar block biggest complication
Hematoma
Least cerebral vasodilation is seen when giving
Sevoflurane
Medullary thyroid cancer comes from
Parafollicular cells
Best to check preop for pheochromocytoma because part of the MEN family of syndromes
Bronchospasm leads to decreased breath sounds
Bilaterally
Induction of ECT use
Methohexital
Anterior ischemic optic neuropathy
Optic disk edema
Stroke volume decrease in
Aortic stenosis due to increase afterload
Mapleson circuit has less
Airway resistance than circle system
PKa
Where 50% are unionized
Right laryngeal nerve off of
Right subclavian
Left laryngeal comes off aortic arch
Total thyroidectomy respiratory distress in day 1 mainly due to
Hypocalcemia
Prolonged oxytocin can lead to
Hyponatremia
5% albumin has as much sodium as
Normal saline
Decrease in
Protein S with pregnancy
Become resistant to protein C
Biggest limitation to using peripheral iv for giving TPN is
Can’t give high osmolality
Thus have to give a lot of volume that can’t be tolerated by critically ill patients
PRESS
MRI findings vasogenic edema localized to posterior cerebral hemispheres
Reversible
If pre eclamptic do delivery
C02 crosses
BBB. It affects pH by combining with bicarbonate
CBF changes 5-7% per 1 degreee change in
Temperature
Biggest maximal depression in CMR with
Isoflurane
Most vasodilator increase
ICP
Use labetalol or esmolol
Compromise blood flow increases
Latency of SSEPs
Precedex activates
EEG
Awake crani
Must be able to rapidly control ventilation and general anesthesia
LMA is good option
Precedex for placement of
Deep brain stimulator placement
Cerebral vasospasm after ansurysmal SAH
3-14 days
Hunt Hess grade
0 is best
Grade 1 fisher scale for SAH
No SAH blood
Grade 2 thin SAH
Grade 4 is intraventricular
Nimodipine
For ruptured aneurysm BP management
SAH hypertensive due to
Catecholamine release
Can cause cardiomyopathy
Decreased MAP reduces
Transmural pressure on aneurysm
Treat ruptured SAH
And treat BP
Give nimodipine as soon as aneurysmal SAH diagnosis made
DI
Urine specific gravity < 1.005 is confirmatory
Don’t do elective if above 150
Neurogenic pulmonary edema
CNS injury occurring usually after a few hours to days after injury
Draining CSF
Quickest way to decrease ICP
Better than phenobarbital coma, hypothermia, nimbex
Siting position crani
A line for cardiac issues, closely monitor SBP and CPP, repeated gases
CVL for better venous access to remove air
Right side better to
Aspirate venous air
Right subclavian best so don’t need to put head down even though risk for pneumothorax
Increased PaC02 and decreased EtC02 with
Thrombotic pulmonary embolus
IABP
Increase
Ejection fraction
Cardiac output
MAP
Coronary blood flow
Decrease
Aortic systolic pressure
Heart rate
Left atrial pressure
Mitral valve stenosis
Beta blockade helps
Codeine is inactive and must undergo O demethylation CYP2D6 to create
Morphine
Ultra rapid metabolized are at increased risk to develop respiratory depression
Ascending bellow ventilator is
Safer
Fail safe valve can reduce risk of delivery of hypoxia gas mixture to patient
Low pressure curcuit includes
Flow control tubes and vaporizers
Minimize anticholinergic drugs in ppl with
Alzheimer’s
All opioids except remifentanyl gave anticholinergic properties
Transdermal buprenorphine for
Moderate to severe chronic pain in adults
Very high u opioid receptor binding affinity
Partial agonist
Histamine antagonists decrease gastric acid secretion but do not altar gastric emptying
Dopamine D2 antagonists increase gastric emptying
Dopamine antagonists like metochlopramide increase
Gastric emptying
Cyclosporine toxicity affects
The kidneys
Incretins
Delay gastric emptying
Bier block
Lidocaine causes more toxicity than prilocaine
Use manual pads for
Newborn defibrillation
Beta 2 agonists like ritodrine
Hypokakemia
Hyperglycemia
Milrinone PDE3 inhibitor that
Increases cAMP and decreases SVR
Way to treat TET spell
More preload
Increase SVR
Shift blood from left to right
Opioids tramadol gabapentin for
Phantom limb pain
Hypersensitivity to contrast dye due to
Complement activity
Lusitropy
Ability of myocardium to relax
Myotonic dystrophy need to look for
Cardiac conduction abnormalities
RA on bottom of
Modesophageal bicabal view
LA is above
SVCcomes into right atrium from the left
Collecting duct
Produces ammonia
With hypoxia
Immediate increase in ventilation within 5 minutes
Hypoxia detected in carotid bodies
Hepatic extraction ratio
Hepatic clearance/hepatic blood flow
Therapeutic hypothermia for ppl who have experienced
V fib or v tach cardiac arrest
Intracranial hemorrhage pregnancy refractory hypotension are reasons not to do therapeutic hypothermia
Verapamil is a negative inotrope and not good for patients with
Heart failure
Hypotension due to
Air trapping and breath stacking with asthma exacerbation
4-5 days of Coumadin for
Epidural catheter
T test in normally distributed populations to look at the
Mean
Permeability of dura mater increased in
Elderly
Laryngeal edema common after
Surgery of the neck
Unilateral recurrent laryngeal nerve transectionyou get
Hoarseness but not stridor
Hypocalcemia hypoxia seen after 24 hrs
Fascia iliaca does not block
Obturator nerve
5HT 1 and 2 inhibition by
Cyproheptadine
Succinylcholine binds to
Nicotinic Ach receptors at neuromuscular junction
Post carotid endarterectomy headache give
Labetalol to lower BP
QRS length increased
In bundle branch blocks
Transplanted heart
Isoproterenol dobutamine epinephrine still act the same
No tone so don’t get reflex tachy
Almost all of the carbamino carriage of c02 is my
Hemoglobin
Zero order kinetics
Fixed amount of drug eliminated per unit time not percentage
Decreases linearly
Occurs when all the pathways for drug elimination are saturated
Vapor pressure decreases proportional to
Temperature
Meconium stained amniotic fluid
Higher with maternal cocaine usage
Iugr
Chorio
Elimination half life of neostigmine is
77 min
Magnesium
Potentiates NMDBs
Intravascular injection signs
HR>10
SBP>15
Bradycardia
T wave amplitude
Not ventricular ectopy
More likely uterine rupture if
Classical incision
Age>30 yes
1 previous c section
History of chorio with prior c section
Musculaocutaneous my injecting local into
Coracobrachialis muscle
Alveolar gas equation to get alveolar oxygen pressure
PA02 = 760 x fi02 - PaC02/.8
E size and smaller cylinders have
PISS
Most common side effect of intrathecal opioids is
Pruritis
Both epidural and spinal decrease gastric motility
Methadone
NMDA antagonist
Inhibits serotonin and norepinephrine reuptake
Ultrasound guided stellate ganglioni block
You see longus colli muscle
70% of innervation to shoulder joint is from
Suprascapular nerve
Dorsal foot and toes innervated by
Superficial peroneal
Predicted postop FEV1 and postop diffusing capacity of lung for carbon Dioxide
Postop respiratory complications after lung resection best tests
Within 24 hours of acetaminophen toxicity you get
Nausea/vomiting, abdominal pain, anorexia
Pallor/fatigue
Oil gas partition coefficient
Most closely associated with MAC of local Anesthetic
Inverse to MAC
Bronchiectasis
Hemoptysis
Decreased FEV1
Dilated bronchi
Which gas shortest period of time followining injection to vitreous
Air
Sulfhemoglobin
Right shift in curve
Measure by gas chromatography
Remains until red blood cell until destroyed
Doesn’t respond to methylene blue
Vasopressin better for severe AS then dobutamine or milrinone
Bc doesn’t decrease SVR and doesn’t affect PVR
Hypertrophy
Increase wall stress and higher myocardial oxygen demand
Refeeding
Hypophosphatemia
Hyperglycemia
Etomidate
Increases epileptiform activitybinduced by ECT
Enhanced amplitude of SSEPs
Maintains CPP
Prednisone doesn’t cause
Renal dysfunction
Cyclosporine does
Treat brain dead with
Steroids
NMDBs
Volatile anesthetics
No benzos
In ascites you compensate with increase in
Respiratory rate
Due to restrictive lung disease
DLCO decreases in ascites
Cross reactivity of penicillin allergy is highest with
First generation cephalosporins
SSEP latency increase with
Hypotension
Decrease cardiac output
Hypothermia
Hypoxemia decrease amplitude increases in latency
Dexamethasone increases metabolism of codeine to its
Active form
Remifentanyl won’t change with
Lower dibucaine number
Gentamicin
Increases neuromuscular blockade
Profound bradycardia and hypotension with
Manipulation carotid sinus
Prior to neuraxial block if plt count less than 100000 get
Coagulation studies
Desflurane leads to transient increase in
HR and BP
N20 leads to transient increase in
Cardiac output
Isoflurane maintains
Cardiac output
Use expired concentrations when calculating for
MAC
Brain
Heart
Kidney
Are part of
Vessel rich group
Lungs are not
Recovery from inhaled anesthesia from
Blood/gas solubility
After long N20 you cancause
Anemia seen in bone marrow
Oxygen and nitrous
Nitrous will cause oxygen to be taken up by second gas effect
Halothane
Only gas that has a preservative
Isoflurane has solubility in
Rubber and plastic
Sevoflurane forms
Compound A
Sevoflurane undergoes 2% metabolism
Which is the most of the gases
Washing of circuit equals priming circuit includes
Anesthesia bag
Hoses
Absorbent component
Prolonged PT can be helped by
Vitamin K
Cryoprecipitate
FFP
For platelets only need
RH matching
Platelets don’t contain RBCs
VwD
Most inherited coagulopathy
Can store erythrocytes for
Ten years frozen
Leukocyte reduction doesn’t help with
TRALI
Occurs within 6 hrs
Non cardiogenic pulmonary edema
TRALI more likely with
Female donor
Longer blood cells more than 14 days
Pooled plts
Infant blood volume
80 ml/kg
Hep B
Most common infection
Hemophilia A
X linked recesssive
Hematocrit
40%
Plasma volume 60%
During stress of surgery ADH
Increases
Causes decrease in urine output
Plts are most stored at
Higher temps to optimize function
Citrate toxicity
Decrease in ionized calcium
Leads to prolonged QT arterial hypotension
Calculate dose of sodium needed to raise by
Body weight kg x 0.6 x desired Na - Current Na
Intravascular half life of crystallography is
20 to 30 minutes
Colloid is 3-6 hrs
Abrupt discontinuation can lead to bad
Hypoglycemia which can show up as severe tachycardia
Heyastarch agfects
Factor 8 and vWf
Leftward shift due to less 2 3 DPG in
Stored blood
Stored blood hyperkalemia acidosis
Liver does not produce
Factor 8
Liver produces protein c s and antithrombin 3
LMWH acts on factor 10a best monitored by factor 10 assay
Unfractionated heparin activates antithrombin best seen with
PTT
Reduction of leukocytes prevents
CMV
Regular insulin
Peak effect 2 to 3 hours after subq administration and lasts 8 hrs
Cholpropramide is a sulfonurea that lasts 3 days
Normal Pv02 in mixed venous is
40
If higher due to increase in cardiac output etc
25 to 30
Normal tracheal capillary pressure
Coedine must be metabolized to morphine in order to
Work via the CYP2D6 enzyme
Balloon angioplasty without a stent
2 wks
Retinal artery thrombosis higher in
Glaucoma patients because already have high ICP
Naloxone
Competitive inhibitor at all opioid u receptors acts for 1 hour
Naltrexone is long acting only oral and lasts half life 8-12 hrs
Airway problems from hypocalcemia show at
24-72 hours post op
Bronchiectasis
Main cause is air pollution
Permanently dilated bronchi that often contain secretions
Extravasation of drugs in anyecubital fossa affects
Median nerve
Delirium tremens shows up
2 to 4 days since last drink
Relative contraindication to tracheal surgery if
Post op mechanical ventilation needed bc can lead to wound dehiscence
Green eye drops
Miosis
CBF reserve is substantial
First signs of cerebral ischemia aren’t seen until cbf has fallen to 22 ml/100g/min
Closest to Mac value
Oil/gas partition coefficient
High oil/gas=
Low MAC
Central diabetes insipidus will
Pee a lot
Anticholinesterases used to reverse neuromuscular blockade also act on
Psuedocholinesterase thus if you give succ after reversing it will last longer
Trendelenberg causes pooling of
Fluid in dome of bladder
Decrease in blood volume =
Decrease in DLCO
Increased end expiratory C02 one of the first signs in
MH
If you don’t get MH it is still likely you can get it the
Next time you get an anesthetic
Trismus
Rigidity of jaw muscles
Indicates MH in less than 50% of patients
Prevent pulmonary fibrosis from bleomycin by using lower
Fi02 levels
Can use N20 10 days after
Intravtreal injection of air and SF6
Volume overload can be seen with
TURP procedure
Trigeminal does muscles of mastication including
Clenching the teeth
02 carrying capacity goes up when you give
Hemoglobin
Huntington chorea
Decreased psuedocholinesterase
PaC02 going up out of normal range will increase
IOP
Apnea hypopnea index
AHI greater than 30 is severe osa
Shows number of incidences in 1 hr
Bad pulmonary function tests
Residual volume/TLC > 50%
Pa02 is actually lower than abg
I’d pt is cold
Supfhemoglobin and methemoglobin both cause low Sa02 with good Pa02
Sulfasalazine can cause sulfhemoglobin
LMWH
Only partially reversed by protamine
Longer half life than unfractionated heparin
Scopolamine
Anticholinergic so can lead to mydriasis
NMS and MH both causes
Hyperthermia
Generalized muscular rigidity
Effectively treated with dantrolene
Most common reason outpatient gets admitted post surgery is due to
Nausea vomiting
Don’t give tramadol to
Depressed/suicidal patients
High nausea/vomiting
Urine sodium less than 20=
Prerenal disease
N20 MAC
104%
Fenoldopam can be used besides
Nitroprusside
Prolonged insulin in pts with
Renal disease
Gabapentin is similar to
Carbamazepine
Stuck inspiratory valve will lead to
Old gases and C02 coming through inspiratory valve leading to increased inspired C02
After transphenoidal hypophysectomy
CPAP is contraindicated
Malignant hyperthermia
Mixed venous is low
Most hemodynamic instability in liver transplant during
Reperfusion phase
Need epi atropine calcium and sodium bicarbonate
Female is the strongest predictor of
PONV
Ketorolac has affects on
Bone healing
X syndrome
Insulin resistance
Pulses are last to go in
Compartment syndrome
Anterior spinal artery syndrome affects
Motor but not SSEPs
Botulism prevents release of
AcH
Most common injury with lithotomy
Common peroneal
Fetal hemoglobin for first
6 mo
Glottis of feel newborn is at
C4
Water content 75% in
Term newborns
ROP In fetus not affected by giving mother
Oxygen
Much less unlikely to get ROP in
Term infant
Spontaneous breathing easier in
Uncuffed tube bc it’s bigger
Usually cuffed tubes are a little smaller
Want a leak at 15 to 25 cm h20
Allows for adequate ventilation and reduces incidence of postintubation croup
Age/2 plus 12
Tube length inserted in cm
Or tube length x 3
Normal saline
Hyperchloremic metabolic acidosis
Best maintenance fluid in Peds is LR
High Vd in children means
You need more of drugs
Less than 60 wks gestational age watch patient overnight looking for
Apnea
Spinal cord of infant ends at
L2-L3
Wait 4-6 weeks if child
Has cough and sore throat
Healthy full term neonate blood volume
80-90 ml/kg
Parkland formula for first 24 hrs
4 x weight kg x percent burned
Epiglottis induction
Transfer to or inhalation induction tracheal intubation
Rapid sequence can be done in infants
With GERD
First expand fluids in child
With dehydration
Infants younger than 3 months produce heat by
Metabolism of brown fat
Normal RR for 6 mo old
Is 25-35
Don’t use loss of air in child bc of risk of
Air embolus
Anemia nephropathy hemolytic anemia in child
Hemolytic uremic syndrome
Terbutaline does not cause
HTN
Organogenesis at
3-8 weeks
Pregnancy
Minute ventilation
Tidal volume increase
Placing central pine give IV abx prior to
Immunosuppressed patients or neonates
Moderate sedation
Check verbal response each 5 minutes
Need pulse ox and bp every 5 minutes
Don’t need ecg unless cardiovascular risks
Capnography is preferred
Reynolds number for turbulent flow
Velocity x radius x density/ viscosity
SEM =
SD/square of sample size
Paired t test
Same subjects
Selectivity bias
Who responds to survey
P value
Probability of obtaining certain data set if the NULl hypothesis is true and correct
Not alternative hypothesis
Type 1
Accepting alternative when null is true
Alpha value
Power =
1-beta
Ability of study to detect a true difference
Incidence
Number of new events in period of time/number at risk
Relative risk
Indidence In exposed/incidence in unexposed
1 = no difference
Difficult mask ventilation
Age>65
Edebturloss
Mallalptaei 3 4
Beard
Obesity
I’m
Difficult airway
Mallampati 3-4
Thyromenral distance small
Inter incisor distance < 3cm
Supine position
Decreases FRC
PaC02 drops in
Pregnant patient
In pregnant
EF increases, CVP pcwp unchanged
Need
Left uterine displacement in pregnancy
Hypercoaguable In
Pregnancy
More plasminogen leads to enhanced fibrinolysis
Most coagulation factors go up including fibrinogen
Pregnancy
WBC Count goes up mainly postpartum
Risk of infection actually higher bc less ability of neutrophils to function
Npo except
Clears during labor
Creatinine clearance increases
Pregnancy
Pregnancy decrease
MAC
Psuedocholinesterase
Decrease in pregnancy
More sensitive to roc and vecuronium
Neuraxial
Further decreases in FRC
UBF increase
100 to 700-900 ml min at term
Uteroplacental low resistance circuit based on pressure and can auto regulate
Fetal hemoglobin
Lower Pa02
Insulin requirement
Decreases postpartum
Depomedrol contains
Methylpresnisolone
Cannabidiol for
Pediatric seizures
Warm sensation from
C fibers
Neostigmine causes
PONV
PONV
0 risk just zofran
1 risk zofran dexamethasone
2 is zofran dexamethasone and prop infusion
3 or more get scopolamine patch as well
APFEL score Female History PONV No smoker Post op opioids
Dexamethasone mainly
Glucocorticoid activity
Minimal mineralocorticoid
Promethazine
Dopamine antagonist as is metochlopramide(increase LES fine and gut motility, don’t give to patient with bowel obstruction)
Droperidol black box warning against
QT interval prolongation
Aprepitabt
Nk1 antagonist
Ephedrine is also an antiemetic
BMI
Kg/meters squared
PONV
Avoid hypervolemia
Median nerve is
Above axillary artery
Naloxone start with 0.04 and can give every
2 minutes
Flumazinil start with
0.2mg
What nerve mediates laryngospasm
Superior laryngeal
Laryngospasm
Just thrustbhead lift
Oral/nasal airway succ more prop
Failsafe prevents
Hypoxia mixture
Stop nitrous if ppm<30
02
Sodium binds
Alpha intracellular receptors
Lower pKa of local anesthetic =
Unionized
The ionized form! It changes once it goes in the membrane is what binds
Sodium channel
In infected environment pH of environment is lowered so
More ionized and slower onset
Lidocaine pKa
7.9
Local anesthetic decrease MAC requirement by
40%
Inhibit inflammation
Max dose of bupi
2.5 mg/kg
Local anesthetic systemic absorption
Iv>tracheal>intercostal etc
Systemic absorption depends on the
Dose of local anesthetic
It’s pharmacokinetic propertied
Addition of vasoactive agent like epi
Local anesthetics regularly cross
BBB
Malignant hyperthermia
Autosomal dominant with variable penetrate and expression
C02 production and metabolic acidosis =
Malignant hyperthermia
Malignant hyperthermia not cause by
Nitrous
Masseter muscle rigidity trismus due to increased calcium
Increase o2 consumption with
Malignant hyperthermia
See rhabdomyolysis
Usually first sign is hypercarbia
Immediate actions MH
Call for help my cart
Stop anesthetics
Call MH hotline
Get ABG Ck coags
Give 2.5 mg/kg dantrolene
Dantrolene has
Mannitol in it
MH leads to
Hyperkalemia due to acidosis
Watch patient for 24 hours look for DIC ortenal failure
Gold standard to rule out MH
Caffeine halothane contracture test
Give abx within
60 minutes prior to surgical excision
All the antibiotic should be in before tourniquet is inflated!
Give cipro
Slowly over 60 minutes
History of anaphylactic to penicillins is absolute contraindication to giving
Cephalosporins
Anaphylactoid reaction Is
Dose dependent
Anaphylactic reaction is not
HOCM/MVP does need
Bacterial endocarditis prophylaxis
Radial nerve below
Median nerve above!
Axillary artery
Curare cleft
Muscle strength coming back
Large molecules like albumin or prealbumin don’t get
Hemolysis
St segment depression
Subendocardial ischemia
Acute normovolemuc hemodilution
Compensate with higher cardiac output and lower PVR
Blood viscosity goes down
PSV only on
Spontaneously breathing pt
Brachial artery cannulatoo big complication is
Thrombosis
Lose first stage regulator could
Depleted oxygen tank
Cardiac output is
Maintained with desflurane usage
Mivacurium broken down by
Psuedocholinesterase
Psuedocholinesterase levels are lower in
Burn patients
Metochlopramide contraindicated in patients with
Bowel obstruction
Antibodies formed against donor
Leukocytes after massive transfusion
Cause febrile reaction
To Hla leukocytes
Palatoglossal fold
Glossopharyngeal nerve
Fully compensated means the pH is in
Normal range
A delta most sensitive to local
Anesthetics
C fibers least sensitive
Atropine works best with
Edrophonium
Insulin causes
Active transport of glucose and potassium into the cell
Citrate intoxication leads to
Hypomagnesium
Separation anxiety starts at
6 months
Worsening hypoxemia whole standing with
Hepatopulmknary syndrome
PVR is lower in this syndrome
Standing up blood goes lower into areas of no ventilation
mean PAP above 50 is
Absolute contraindication to liver transplant
Sodium potassium pumps require
ATP so fucked up during ischemia
Zofran main side effect
Headache
Preeclampsia
Intravascular volume depletion
High SVR
Decreased uterine or placental blood flow
Greater Cornu of hyoid bone gets
Internal branch of superior laryngeal
Don’t give hydrocortisone if septic shock is responsive to fluid or
Vasopressors
Prerenal oliguria
Urine to plasma osmolar ratio >1.5
Non shivering thermogenesis trigger in infants
Norepinephrine thyroxine
PDPH gold standard
EEG
MAOi use
Increase MAC
Carboprost
Uterine contraction not relaxation
Don’t use it pulmknary HTN or reactive airway disease
Logistic regression analysis use
Adjusted odds ratio
Cohort use
Relative risk
Warfarin
Teratogenic
Use heparin first to get inr within range bc it is usually thrombotic
HBOxygen for
Air embolism
CO poisoning
Chronic ischemic ulcers
Excessive growth hormone patients have
Normal lung volumes
IGF1 looks for acromegaly
Most cardiac myxomas are found in
Left atrium
Infant blood volume
70-80 ml/kg
Closing of mitral valve occurs at
R wave of QRS
Ectothiphate blocks
Psuedocholinesterase
Posteromedial papillary muscle is supplied by the
RCA
Polyhydraminos risk factor for
Placenta accreta
Discoverable info includes
Conversations with friends, charting about patient, emails
L5 =
Big toe
Lambert Eaton
More sensitive to NMDB and succ
Lambert Eaton
More sensitive to NMDB and succ
MS exacerbation likely
Post partum
Most common is relapsing remitting
Beta interferon treatment
Mid humerus
Radial nerve damage
Extension of elbow
Median nerve injury
Synchronize shocks in ecg during shock wave lithotripsy to
R waves
Vasospasm most likely at
2-14 days
MCA and ICA tested in
Transcranial doppler
<1mm of blood in
Hunt Hess for SAH
Hematoma absorption or lots of blood given
Increase bilirubin
Not hepatic enzymes
Coracobrachialis
Musculocutaneois nerve
Increase FRC
Increased age increase height
Pangos=
Low FRC
Coma
A scene of brain stem reflexes
Apnea in
Brain death
Don’t give what med intramuscular
Norepinephrine
Can lead to tissue necrosis
Normal dibucaine number =
80
Phenotoyin increases
Neuromuscular blockade
OSA hypoxemia can lead to
Polycythemia
Preop anemia is independent risk factor for morbidity/mortality
Septic shock
Decrease end tidal c02
Cortisol release leads to hyperglycemia
Uterine relaxation doesn’t happen with
Neuraxial blockade
Uterine rupture
Fetal bradycardia
AST is not a good indicator of just
Liver disease
Diaphragm moves more
Cephalad in pregnant patient leading to reduced FRC
Down syndrome
Cervical instability
45% have CV deficits-endocardial cushion deficits most common
PVR is highest at
Extremes of lung volumes
Familial hypocalcemic hypocalciuria
Autosomal dominant
PDPH is
Positional
Fever nuchal rigidity altered mental status
Meningitis
Ace inhibitor use
Maternal oligohydraminos
Acidosis
Decrease SVR increase PVR
Botulism moa
Inhibition of intracellular fusion Ach containing vesicles
Fena
Plasma creatinine x urine sodium/urine creatinine x plasma sodium
Continue dantrolene for
24 hour after acute mh resolved
Initial dose 2.5 mg/kg
Paresthesia/cant void think
Cauda equina
More renin
Cirrhotic pts
Spread of local anesthetic in epidural space mainly effected by
Volume of anesthetic
DLCO is higher in
Asthma exercise left to right shunt(more blood to lungs)
Chi square
Acts on one discrete variable
T test is one continuous variable like BP
Central diabetes insipidus start with
Free water
Periop hyperglycemia associated with
Sympathy adrenergic activity and not bradycardia
Hyperglycemia
More immunosuppressive Infections Sympatho adrenergic activity Increase catabolism Delayed gastric emptying
Need endocarditis prophylaxis
Hearty transplant with cardiac valvular disease
Only beta blocker metabolized by kidneys
Atenolol
Peritoneal dialysis has less hemodynamic changes than
Hemodialysis
Duration of action of nmdb and onset is delayed in
Elderly
Want a leak of
20-30 cm
4-6 hrs before epidural with
Subq heparin
Desflurane
Prolongs neuromuscular blockade the most
If patients intrinsic hr higher than pacemaker on asynchronous can lead to
R on T
Inferior wall on transgastric short acix on top
Anterior wall on bottom
NMDA receptor
Increases serum calcium
Organophosphate poisoning
Atropine
Pralidoxime
Dobutamine best for cardiogenic shock if BP good
Increase CI / decrease afterload
CBF changes with
C02
Separation anxiety starts at
6-8 mo in age
Don’t give potassium or dextrose in infant solutions
Until initial bolus given
Glucagon released from
Alpha cells and increases hepatic artery blood flow
Trigeminal neuralgia
Anesthesia dolorosa
Hypalgisua
Decreased response to noxious stimulus
Neostigmine for reversal than giving succ
Increases phase 1 block
If pacemaker dependent convert to
Asynchronous
Unripe and false labor
Delay in latent stage of labor
Increase CBF only after
1.5 MAC
Etc02 doesn’t change with
Tourniquet release
Metochlopramide inhibits
Plasma cholinesterase
Hepatic steatosis common with
TPN
Type 1 hepatirebal syndrome
Acute onset
Type 2 is gradual
Aminoester allergy think
PABA
Aminoamide think methylparaben
Bronchospasm
Kinked tube think
High peak pressure
Abdominal insufflation and obesity
Increased plateau and peak
A alpha divers
Propioception
Decreased SID =
Decreased pH
Norepinephrine broken down in
Lungs
Milrinone
Pde3 inhibitor
Higher length of tubing
Underdampening
Beta blocker affects the numbers on the
BIS
Transducer on us
Goes through bone the most
Increase in temp to platelets due to
Cytokines
Inhalational anesthetics act at
Amphilic cavities of proteins
Quinolone sulfa can lead to
G6PD hemolysis
Non shivering thermogenesis in adults
Skeletal muscle
Infants at brown fat
Boiling point of desflurane
Lower than Sevoflurane so needs a heated vaporizer to keep at constant temp so stays as liquid so you have predictable concentration
Precedex and opioids lower
BIS
Give first blood taken
Last
Has the most RBCs
Moonlight clinical activity at home patient educational activity
Counts as part of 80 hr workweek
Catecholamines are higher at rest and during stress in
Elderly
This is why they can’t mount a good response
Hypoplastic left heart
ASDs associated
Left ventricle is nonfunctional
Muscarinic activation
Decreased cAMP which opposes sympathetic activation
Ketamine
NMDA receptor antagonist
Also increases myocardial oxygen demand therefore not indicated with ischemic heart disease
Botulism treat with
Antitoxin
Airway reflexes and respiratory drive is preserved with
Ketamine
St. John’s wart promotes
Cytyrome p450
Stop 5 days before surgery and don’t continue it
Autonomic hyperreflexis
Vasoconstriction below
Vasodilation above lesion and flushing
Lidocaine reduces duration of seizures so don’t use during
ECT
Hypothermia increasss
Alveolar partial pressure
Decrease arterial partial pressure
As you age decrease
Arterial and venous vasculature compliance
Palatoglosal fold
Glossopharyngeal nerve
CPAP reduces
Surfactant depletion
Respiratory rate is typically decreased
Oropharynx
Soft palate to epiglottis
Nasopharynx
Base of skull to soft palate
Opioids are best dosed by
Lean body weight
Febrile rxn due to
HLA antibodies
Resting tachycardia seen with
Diabetic autonomic neuropathy
Don’t see sweating
Kleppil feil
Cervical spine fusion
Large blood volumes containing sodium citrate lead to
Metabolic alkalosis
Cystic fibrosis
Autosomal recessive
Mutation on chromosome 7 defective chloride channel in epithelium
Greater bronchial reactivity
Keep Fi02 up want to avoid pulmonary vasoconstriction and HTN
Pancreatic insufficiency
Buprenorphine for opioid
Withdrawal
LV mainly perfused during
Diastole
Anterior spinal artery
75% of spinal blood supply
Pulmonary surfactant increases when
Alveoli shrink
Donepizol increaeed
Succ
TPN associated with
Thrombophlebitis and infection
When placed under pressure nitrous oxidebis in
Liquid form
Ulnar nerve for adduction of
Thumb
Catecholamines are higher at rest and during stress in
Elderly
This is why they can’t mount a good response
White rain communicates
Preganglionic neuron
Parasympathetic CN 3
Ciliary ganglion
Halothane
Most likely to cause arrhythmia
Slows conduction through SA node leading to bradycardia
Decreases MAP and CO
Unchanged HR due to blunting of baroceptor reflex
Isoflurane maintains cardiac output due to
Preserved carotid baroceotor reflex which responds to decreased SVR with increase in HR to maintain cardiac output
Compound A accumulation associated with
Long duration anesthetic, low fresh gas flow, higher inhaled concentration Sevoflurane and absorbent dessication
Desflurane
Increased CBF
DECREASED CMR02
decrease MAP and SVR increase HR maintain CO
Increased RR
Decreased TV
Speed of induction based on
Rate of rise of Fa/Fi
Desflurane has lowest blood gas partition coefficient and is the least soluble and will result in quickest induction
Nitrous oxide should be discontinued how many minutes prior to the placement of gas bubble in the eye
15 minutes
Wait ten days to use nitrous oxide after
Bubble formed from SF6
For air causing intraocular bubble can wait 5 days
SSEPS act on peripheral nerves
Increase in latency and decrease in amplitude of the response
SSEP most common nerves
Posterior tibial, median, ulnar nerve
Increase in latency OR decrease in amplitude from BASELINE indicate neurologic decline
Gas exchange worsens with higher anesthetic concentrations and PaC02 rises
Dead space ventilation increases compared to alveolar ventilation due to decrease in tidal volume
Gas blunts hypoxic/hypercarbic respiratory drive
Desflurane vapor pressure of 660 very close to atmospheric pressure of 760 so minimal changes
Can have large effect on vaporizer output
Desflurane is close to boiling even at room temp
Higher altitudes
Partial pressure of inhaled agent will be decreased
Desflurane vaporizer dial must be set HIGHER at higher elevation to ensure same anesthetic effect due to decrease in partial pressure
Partial pressure is what’s important not the concentration
Nitrous oxide 34 times more soluble than
Nitrogen in blood
Contraindications to nitrous oxide use
Venous air embolus Pneumothorax Pneumocepahlus COPD with blebs Acute intestinal obstruction Tympanic membrane grafting
MAC to describe
Potency or volatile anesthetics
Alveolar concentration that will stop movement in 50% of patients response to standard surgical stimulation
MAC decreases 6% per decade
Things not affecting MAC
Thyroid state
Gender
Duration of anesthetic
PH alterations
Emergence coincides with
Decreasing inhalation anesthetic BRAIN CONCENTRATION
Emergence is faster than induction
Continues to be absorbed by adipose tissue during emergence
Which is not part of the vital organs that gets 75% of cardiac output
Lungs
Vessel rich organs get
75% of cardiac output
Small volume, moderate solubility, rapid saturation
Slowest metabolism is seen with
Desflurane
Enflurane can produce
Fluoride ions which can lead to high output renal failure
Nitrous oxide cylinder will stay at constant pressure 750 psi until about
400 liters is left in the cylinder
Nitrous oxide
Macrocytic anemia
Hepatic necrosis seen with
Halothane
CMR02 increases with
Nitrous oxide administration
0.5 MAC of volatile anesthetic
For maternal amnesia
Fetal presentation of anesthetic overdose includes cardiopulmonary depression and hypotonia
Neuraxial opioids act on
Mu receptors substantiatia gelatinosa
Less soluble opioids remain in CSF
Transfer to more cephalad locations
Binding of alpha 2 delta subunit calcium
Mechanism of gabapentin
Uremia lower dose of
Midazolam
Esmolol broken down by
Red blood cell esterases
Desmopressin
Improves perioperative platelet dysfunction in uremic patients
Propofol causes dose dependent decrease in amplitude of
SSEPs and increases SSEP latency
Synthesis and release of angiotensinogen
Liver
Most resistant evoked potential
BAEP
Most sensitive to volatile anesthetics
VEPs
Atrial fibrillation can see loss of
A wave
Pneumothorax
No lung sliding and no B lines
Most selective for alpha 2 receptors
Precedex is much more selective than Clonidine
Alpha 2
Found presynaptic ally and inhibit norepinephrine release
Dobutamine acts on Beta 1 more than
Beta 2
Terbutaline
Beta 2 selective
Nicardipine causes
Direct cerebral vasodilation
MAP 60 to 160
Cerebral auto regulation
Muscarinic receptor activation leads to
Diaphoresis
Bradycardia bronchospasm
Muscarinic receptors round mainly at
Parasympathetic postganionic innervating target organs
Preganglionic neurons of sympathetic nervous system
Ach
Eccrine sweat glands
AcH
Pulse pressure equal to SBP-DBP
As bp cuff moves more distally sbp increases and dbp thus decreases
MAP
Cuff pressure at which the amplitude or the magnitude of the oscillations is greatest
Lumbar nerve roots exit
Same pedicle
Clevidipine broken down by
Plasma esterases
Most common complication of retrobulbar block
Retrobulbar hemorrhage
Phospholipoprotein surfactant
Type 2 alveolar cells
Muscle weakness with high doses of magnesium
Blockade of calcium channels
Sudden polymorphic V tach in patient undergoing asynchronous ventricular pacing think
R on T phenomenon
Postop elevated liver enzymes due to
Surgical procedure
ACTH stimulates release of steroid hormones from adrenal
Cortex
Secondary adrenal insufficiency
Decreased ACTH production in the anterior pituitary
Intrascalene nerve block for shoulder injection of local anesthetic in what vessel leads to seizure
Vertebral artery
CYP2D6
Coedine
Fixed airway obstruction
Tracheal stenosis
Treat high spinal quickly with
Epinephrine
Decreased filling pressure leads to bradycardia
Bezold Jarisxh reflex
Neonates are less sensitive to codeine compared to school age children due to less
CYP2D6 activity
Tonsillectomy and adenoidectomy don’t use
Coeidine
Epinephrine
Increase in plasma free fatty acid levels
Beta 1 leads to
Lipolysis
Beta 2 increases glycogenolysis
First line for status epilepticus
Benzodiazepines
Cornual placenta
Predisposes to breech fetal presentation
So does macrosomia, multiparty, multiple gestations
Diltiazem
Acts on both smooth muscle and cardiac muscle
Vasodilator and cardiac depressant
Hydrogen ion concentration no affect
On cerebral blood flow
Fluoxetine prolongs effect of
Midazolam
Phase 1 rxn
Oxidation reduction hydrolysis
LIM
Monitors integrity of ungrounded power source
Alarms when leakage current greater than 5 mAMps
A first fault is not a shock hazard, a second fault is a hazard to operating room personnel
Etomidate
Increases amplitude of SSEPs
Decrease cerebral blood flow
SNS from
T1-L2
Water moves
Freely across BBB
For new a fib without hemodynamic instability
Beta blocker or calcium channel blocker
Don’t give beta blocker if COPD or diabetes
Best for platelet dysfunction
Optical aggregometry
Mixed venous from
Proximal pulmonary artery
Chest wall rigidity due to
Opioids
Succ can increase
Tracheal tone
Most likely to cause fire
Polyvinyl chloride
Bupivicaine intravascular
Increase in PR interval
QRS duration increase
T wave amplitude goes up
Caudal block
Surgery below umbilicus
Hypocarbia from hyperventilation during
Venipuncture
Motor innervation from tounge is entirely from
Hypoglossal nerve
Blockade of T type channels is MOA of
Ethosuximide
Isoflurane has higher vapor pressure than Sevoflurane thus can cause
Anesthetic overdose
Most common slice of vaporizer leak
Loose filler cap
If vaporizer tips go at high flow 20 minutes with vaporizer dial set at high
Concentration
LV diastolic dysfunction goes with LV
Hypertrophy
ACC/AHA guidelines
Good cardiac guidelines
RCRI risk
Type of surgery
Creatinine etc
Life threatening surgery
You just do it
Don’t do stress echo
If st elevations
Call cardiology and do a cath
You don’t want to stress patient with echo
Age does not affect
ECG getting it
In Stent
Thrombosis
6 months for DES
Know
Lbbb vs rbbb
Only do beta blocker if patient already on it in
OR don’t just give can lead to stroke
Troponin can last
7 days
Cirrhosis doesn’t affect
Troponins
First line is benzos for
Cocaine
Not calcium channel blocker bc doesn’t get to coronaries
ANP released in
A fib - atrial dilation
Septal
V1, V2
Lateral
1, aVl
Least pruritis
Meperidine is the least
Oculocardiac
Bainbridgre
Gag reflex
Affyerent ovculocardiac goes through gasserian ganglion- efferent through vagus
Ca absorption the most
Thiazides
Loop diuretics
Hyponatremia
Cyanide CO toxicity treated with
Hyperbaric oxygen
Benzocaine prilocaine
Methemoglobinrkia
Minimum effect on PVR
Vasopressin
What causes release of intrinsic vasopressin
Hypertonicity!
Vasopressin goes down with
Chronic septic shock
Racemic epi
To treat strider
Near drowning pathophysiology
Shunt
First get reflex laryngospasm
CSF pH regulation
By C02
Know respiratory changes in pregnancy
Pregnancy
Know fetal heart tracing
In pregnant
Desflurane
At high altitude
Descending bellow
Tells you if circuit disconnect
Hyperparathyroidism
Increased dose due to Ach
MSK
Innervayre which part of arm
Big toe
L1
Big toe
Tibial nerve
Back of knee
Sciatic
Saohenous blocked in
Adductor canal block
Know visual anatomy
Of airway
First sign of liver failure
Factor 7
Oxygen determines
Hepatic artery flow
Shortest ischemia time
Heart/lungs
Know what drugs work
Post transplant
Post heart transplant patient can
Have two P waves and be normal
Know vascular of
Spinal cord
Know ECT
What drugs prolong
Know latex allergy
Foods
4-5
ECHO questions
2.5 mg/kg
Ryanoidine
Know AIONvs PION
AION usually with cardiac
Pion with spine
Can still use succ if full stomach with retinal detachment
Increased eye preesure better than getting aspiration
Lung physiology
Based on groups
Know when PCA is
Contraindicated and conversions of opioids
CVL biggest risk of
Infection
Pediatric vs adult
PONV
Duchennes vs
Myotonic dystrophy
Difference
Hypo/hyperkalemia
OR positioning
Affect
Third highest opioid abuse in
Physician
PDA
Pulmonary edema, hemorrhage,
Ductos arterisos stays open causing left to right shunt
IVH/left heart volume afterload
PDA targets prostaglabdin
Synthetase
Use ibuprofen or indimethacin affects COX
Transcatheter
PDA closure
Stops flow across PDA
Thoractomy longer hospital stay vs transcatheter
Higher opioid use increased opioid need
Venous air embolus
Increase PA RV pressure
VQ mismatch
Y tubing for blood with extension
80 ml
Learn to prime
Hot line tubing
Higher concentration of nitrous oxide needed for anesthesia contributes to
Diffusion hypoxia
Desflurane more potent than nitrous so use
Lower concentration
TRALI causes increase In
Plateau pressure
Bronchospasm from acute asthma exacerbation
Increases Peak pressure but not plateau
Esophageal monometry
Measures transpleural pressure
PAOP =
LAP
Expiratory phase of ventilation
Ventral respirartory group in medulla
Absolute contraindication to BIPAP
GCS<8
Bipap adds pressure support to
CPAP
BPAP contraindication
Cardiac or Respiratory arrest Severe agitation Hemodynamic instability Facial trauma Can’t protect airway Lots of secretions vomiting or gi bleed
Mastectomy with pacemaker
Best is to reprogram into asynchronous mode prior
Magnet can also program pacemaker to
Asynchronous mode
Transtentorial or uncal herniation
Ipsilateral hemoparesis
Oculomoter nerve palsy
Subfalcine herniation
Midline shift
Addition if humidifier can significantly increase
Dead space in Peds patients
Overdistenson of lungs in zone 1 leads to
High Vd/Vt
Apparatus like a humidifier added to patient side on the y piece
Can add to dead space
Neostigmine crosses
Placenta
Can cause fetal bradycardia
During hemorrhagic shock first line
Volume before pressors if not increased mortality
Hgb often normal even with acute blood loss
Class 4 blood loss
More than 40%
Ketamine
Can use even in unstable patients with worry of intracranial pressure increase
Sternamental distance less than 12.5 cm
= difficult intubation
Interincisor less than 3 cm predicative or difficult intubation
Skin surface warming helps prevent redistribution of heat
Increase body heat content
Heat redistributed
From core to periphery
Delta oscillations are those with lower frequency than
Theta
Beta wave
Awake
Corneal reflex
Affereht trigeminal
Efferent facial nerve
What reflex stays intact in patients under general anesthesia
Pupillary response to light
Awake pattern of low amplitude beta gamma oscillations to high amplitude slow delta with high levels of
Propofol
Active humidifiers are much more effective at humidification of gases than
Passive devices
Active includes vaporizers/nebulizers
Burns tend to increase
Insulin resistance
Give mainly crystalloid no albumin bc oncoticbpressure already high from protein peaking into instertitial space
Never bolus fluid in burn patients give hourly
Microelectrode recording with deep brain stimulator can get broken by using
Midazolam
Gray Rami carry postganglionic sympathetic divers from sympathetic ganglia to
Spinal nerves
Only sympathetic nervous system contains
Gray rami
Gray rami contain
Unmyelinated postganglionic axons
Ketamine acts indirectly on
RAS
Most drugs affect RAS directly
Pacemaker/ICD is a contraindication to an
MRI
Rivoroxaban/Apixaban
Andexant
Awake fiber optic good jd
Clinically stable patient with multiple risk factors for difficult intubation and mask ventilation
Physicians have highest suicide rate of
Any profession
Acute hemodilution of patients blood from large volume of crystalloid solution
Hypotension following initiation of CPB
Most T3 is formed by
Partial drip donation of T4
Air bubble in sample syringe
Leads to increased Pa02
Delaying abg sample analysis lowers Pa02 due to
Ongoing metabolism of red and white blood cells
Mitochondrial myopathy
Variable penetrance
Keep normpthermic
Don’t give propofol infusion as high risk for Propofol infusion syndrome
Absence of electrical activity greater than 2 uV/mm indicates
Electrocerebral silence
EEG monitoring not part of standard criteria for diagnosing
Brain death
Fetal bradycardia can happen from
Aortocaval positioning and putting patient in supine position
Technique to most reduce heat loss during phase 1 of hypothermia
Forced air warning blanket
Desflurane forms the most
Carbon monoxide
Baralyme increases compound A more than
Soda lime
Doppler us
Echocardiography to determine both direction and speed of blood flow
Blood towards transducer higher frequency than
Transmitted signal
With imperfect alignment of US
Underestimate velocity or flow
Muscular dystrophy avoid which drugs
Succinylcholine
Volatile anesthetics
Muscular dystrophy
Need EKG and ECHO prior due to risk of cardiovascular issues
Hypermagnesium causes muscle weakness which can lead to
Blurred vision
Treat hypermagnesium with
Iv calcium
The higher the pH of the solution the more a weak base will stay in
Unionized form
Acids are
Weak bases
Lower pKa means weak base will be neutralized leading to unionized
Dexamethasone anti emetic effect is at
Nucleus tractus solitarii
Airway fire risk much higher in
MAC vs GA
Cardiovascular function is usually maintained even with deep
Sedation
Neonates should be monitored overnight until 60 wks postconceptual age to
Avoid episodes of apnea/bradycardia
LFCN landmark is the
ASIS
LFCN branches from
L2-L3 nerve roots
Block by going medial and inferior to ASIS
PVR is minimal at
FRC
TCA toxicity treatment
Sodium bicarbonate
Amiodarone
Blocks potassium channels
Can’t give if heart block or preexisting bradycardia
Can cause blue grey discoloration
Hypotension
Prolong Qt
Pulmonary toxicity
Perform surgery if 6 months free of apnea or bradycardia in
Neonate
After pneumonectomy
Maximum voluntary ventilation greater than 50% of predicted value associated with good prognosis post
Pneumectomy
Increase periop mortality if spiromatory values
FVC<50% FEV1<2 L FEV1/FVC ratio less than 50% MVV<50% DLCO<50% PaC02>45 Pa02<50
Expiratory obstruction
Unilateral vocal cord obstruction
Renal medulla
High oxygen extraction ratio
Renal cortex gets most the blood flow
Vascular rings are associated with
Right sided aortic arches
Vascular rings due to embryonic structures not regressing
Mirror branching
Right side aortic arch giving rise to left braciocephalic ehh gives rise to left subclavian and carotid artery
Giving too much neostigmine leads to
Prolonged weakness
Acetylcholinesterase inhibitors like neostigmine also inhibit plasma butyrylcholinesterase
Prolongs effect of succ
Fibrinogen
Doubles in pregnancy
Protein S levels go down
Resistance to protein C
Hexamethonium
Neuronal type nicotinic antagonist
Hypoventilation
A-a gradient normal but hypoxemic
Metochlopramide
Increases LES tone
Hyperkalemic periodic paralysis
Give dextrose
Bronchiectasis
Obstructive pulmonary disease
Patients don’t need to void in order to meet criteria for
Discharge
Urine alkalinization does not help
Renal function
Chronic dantrolene get
Liver function tests
Both types 1 and 2 of diabetes are
Increasing in children
Treacher Collins
Approximately 50% of children have hearing loss
These patients can get ketamine
Isoflurane much cheaper than
Sevoflurane/desflurane
Alfentabyl fast acting opioid due to
High unionized fraction from low pKa
Don’t use which medication during ECT
Midazolam
Decreases seizure threshold
Incompetent inspiratiry valve fix with
Higher fresh gas flow
MH
Autosomal dominant with variable penetrance
Mainly RYR and calcium channel defect
Gold standard is halothane contracture test
Amilioride associated with
Hyperkalemia
With sepsis maintain MAP of
65
Concentration calibrated variable bypass vaporizer to get right percentage
Adjust splitting ratio
Paralyzed extremity train of four is
Exaggerated
Children with strabismus four times more likely to demonstrate massater muscle rigidity after getting succ
Than normal population
Rebreath more gas if fresh gas flow goes
Down
Thoracic aortic aneurysm stent
Helped by transient cardiac asystole
Avoid shear force by doing it
Adenosine can cause
Bronchoconstriction
Acute normovolemic hemodilution can be used on Jehovah’s Witness but can’t do if
Preoperative anemia
Clopidogrel
Stop seven days before spinal anesthetic
Phenelzine and meperidine can cause
Serotonin syndrome
Don’t give both together
Febrile reactions to platelets due to
Pyrogenic cytokines and intracellular contents released by donor leukocytes
Jet ventilation
Psi 15-35
Allow time for passive expiration
Seldinger technique requires large bore 16 g or bigger
Sign of difficult intubation
Can’t protrude lower jaw beyond the upper teeth
Elevated ICP is a contraindication to
Controlled hypotension.
Normal LY30 on TEG is
6%
Prolonged exposure to corticosteroids can result in
Myopathy and lead to muscle weakness
Angioedema due to
High bradykinin
Head down associated with
Increase in cardiac index
FRC =
ERV +. RV
Thermodilution graph
Temperature change y axis
Time on x axis
Most claims in Asa closed claims project for death or brain damage
Non respiratory events
Lateral cricoarytenoid
Adduction
Thyroid cardiledge forms atoms apple and is inferior to
Hyoid bone
Median nerve does
Lateral palm of hand and motor to wrist flexors
Can block medial to brachial artery in AC fossa
Most common adrenal insufficiency in icu
Functional adrenal insufficiency did
Cardiogenic shock similar to
Obstructive shock in numbers
Need to look at cause
Emergence delirium usually lasts
10 to 30 minutes
More likely with less soluble anesthetics
If patient is taking preop steroids
Continue those steroids in the perioperative period
Dexamethasone
Most potent glucocorticoid
No mineralocorticoid
Endocarditis prophylaxis not needed for cardiac transplant unless
Valvulopathy present
SSEPs are good for checking nerve injury in
Spinal cord cases
Closing capacity increases as you age
Exceeds FRC
RV goes up as does FRC
IC goes down
Epidural 2 chloroprocaine has an onset of approximately
6-12 minutes
Transpulmonary pressures are highest in patients with
Restrictive lung disease such as idiopathic pulmonary fibrosis
CI less than 2.2 is
Bad
Synthesis of catecholamines starts with
Tyrosine
Must stop plavix for
7 days prior to neuraxial
Scoliosis is not a contraindication to neuraxial
Single most important risk factor for POCD is
Increasing age
Tumescent lidocaine
No more than 5 liters
Using GA can increase complication rate
Moving vaporizer to higher altitude will increase
Output
Midazolam to pregnant patient leads to
Fetal hypotonia or floppy baby
Ketamine does not affect
APGAR score
CSF is pulsatile and produce
500 ml per day
CSF
500 ml made per day
It is pulsatile
Made by choroid plexus and lateral ventricles
As flow through Rotameter increases
Cross sectional area increases
Hyperbaric local anesthetics movement mainly based on
Baricity
Advanced age
Less CSF volume
Block onset time not affected by addition of
Epinephrine
Local anesthetic
Higher concentration lipid solubility faster
Lower pKa faster
Higher environment pH faster
Graft vs host disease higher if
Direct blood relative is used for blood donation
Irradiation helps by eliminating donor lymphocytes
TCD us monitiring
Measures blood flow velocity in major arteries usually the MCA
And atherosclerosis plaques in same vessel
Most sensitive to volatile anesthetics
Visual evoked potentials
BAEPS MOST RESISTANT
Hypermagnesium
Treatment includes calcium, dialysis, furosemide
Lack of randomized control trials for treating
Phantom limb pain
ASA 4
Severe systemic disease that is a constant threat to life such as chest pain at rest
Necrotic small bowel
ASA 5 cant live without procedure
Continue enteral feeds in
Intubated pts going into surgery
In mass casualty must identify
Severity of injuries
Albumin worsens outcomes after
SAH
Caution giving vasopressin to patients with
CAD as can lead to ischemia
Muscular stimulation leads to
Bronchial constriction
Open waste scavenging system has no
Positive or negative relief valves
Vacuum must exceed waste gas flow
Most ppl believe hemoglobin A1c should be below
8% before elective surgery
2/3 of subq insulin the night before
One half the day of surgery
C8 nerve root between
C7 and T1 vertebrae
C1 lacks a vertebral body
And spinous process
Nerve regeneration after cryoanalgesia occurs after
1-3 months
Low max amplitude on TEG what should you give
Platelets
In deep sedation
Intervention may be required of the airway
Usually cardiovascular function is maintained
Premature closure if cranial sutures is seen in
Crouzon syndrome
IABP decreases
Afterload
Stop diuretics in
Preop period such as furosemide
Terbutaline leads to
Hypokalemia
More selective for beta 2
Beta 2 stimulation leads to
Hyperglycemia
If sartorius contracts during femoral nerve block
Advance and direct needle laterally
Femoral nerve
L2-L4
Absolute indicators for one lung ventilation
Protective isolation
VATS
Unilateral lung lavage
Bronchopleural fistula
APL valve should be closed for
Circuit leak test
Open APL valve is at
0
In the setting of poor oxygen extraction such as methemoglobinemia mixed oxygen
Normal or elevated
RCA does
Inferior wall of LV
Surgery during pregnancy higher risk of
Miscarriage Abortion Low birth weight Pre-term labor Aspiration
If patient is stable after aspiration next step is to
Suction endotracheal tube
Don’t give abx if
Aspiration
Suction
Immediate intubation
Then after suctioning can do PPV
Cooling cables increases the risk of
Thermal injury
In mri
Place pulse ox is furthest as possible from patient and cables right down the center of patient
Bigger paddle size for doing defibrillation is
Better
Electrode size 8-12 cm is good
Biphasic defibrillator is better
Ok to apply force
Ok to put gel on pads
Anemia first step
Obtain peripheral smear and reticulocyte count
After aortic cross clamp
CVP increases due to increased catecholamines
Increased vasoconstriction distal to clamp drives CVP higher
Decrease oxygen extraction due to less blood to distal regions
Increases in arterial pressure above
clamp
Decreased CO is seen
Ischemic optic neuropathy
PAINLESS SUDDEN VISION LOSS
Type 1=
Alpha error
Reducing population variability(SD)
Increase statistical power
Child Pugh score does not include
Creatinine
Electromechanical pressure transducer
Invasive arterial pressure monitoring
Haldane effect
Increased ability for hemoglobin to carry carbon dioxide from tissues to the lungs for exhalation
Blood reflects
The least
Intrathoracic airway obstruction
Mediastinal Mass
Plateau wave =
Sharp increase in intracranial pressure
Modern endotracheal tubes
High volume low pressure cuff
PVC made
Ach synthesized in presynaptic terminal
Via choline acetyltransferase in the cytoplasm
No reuptake of Ach
Atelectasis associated with increased
A-a gradient
Normal Aa gradient in
Hypoventilation
Pediatric endotracheal tube size
Age/4 + 4
LMWH more selectively inhibits
Factor X when compared to unfractionated heparin
Epidural anesthesia leads to
Increased peristalsis
Neuraxial nausea treat with
Atropine
TR affects thermodilution measurement of cardiac output
All cardiac output goes through pulmonary artery
Mannitol
Increases intravascular volume and may have deleterious effect on patients with CHF
Oligohydraminos not associated with
Placental abruption
Lowering humidity lowers risk of
Static discharge
PEEP decreases atelectasis and increases
FRC
Alanine is part of
Glucose synthesis pathway
Glycogen storage occurs in
Fed state
Glycogenolysis and gluconeogenesus during stress
Claims made policy is malpractice that works for
That year
Intrascalene block
Affects phrenic and not good for patients with COPD or asthma
Hair color has never been identified as a cause of
Intraoperative recall
High dose opioid use increases risk of recall
Angiotensin 2 is a potent vasoconstrictor but mainly effects
Efferent arteriole thus maintain renal blood flow
Myocardial oxygen demand most effected by
Heart rate
Weakness of thigh adductor muscles with
Obturator block
Never just sensory
Recommended postop management of patient with double lumen endotracheal tube is to exchange with
Single lumen endotracheal tube
Generally cardio version is used for patients with a pulse and defibrillation for patients without a
Pulse
Lidocaine decreases seizure duration making it undesirable for
ECT
Metabolic alkalosis can worsen
Hypokalemia periodic paralysis
Hyperglycemia with lower
Potassium levels
Presynaptic calcium channels
Destroyed in lambert Eaton myasthenic syndrome
Myasthenia gravis autoimmune disorder involving antibodies that attack
Postsynaptic Ach receptor in neuromuscular junction
MG improves with rest
Post op respiratory failure post op in MG patients
Disease duration > 6 years
Daily pyridostigmine dose> 750 mg
FVC<2.9 liters
Other chronic lung diseases not related to MG
NIF greater than -20 in ICU is a sign of
Unsuccessful wean
Max pressure against occluded airway
RR/TV =
RSBI
Less than 105 is good
Management of aspiration put patient in
Head down or lateral position and initiate supplemental oxygen
Increased flow rate promotes
Turbulent flow
Increasing radius promotes
Turbulent flow
Hyperglycemia happens secondary to
SIRS
Low cardiac output mostly affects
Isoflurane
Heparin is not effective in
Fat embolus syndrome
Rigid fiber optic scope
For foreign body aspiration
Type 2 pneumocytes produce surfactant which helps to prevent
Atelectasis
Do not give Succ in guillan Barre disease
Guillan
Sevoflurane is safe in renal
Disease patients
Compensation for anemia
Rightward shift of oxygen hemoglobin dissociation curve
Also get increase in cardiac output
Rotation of patients head to contralateral side during ivj cannulation leads to
Greater overlap of ijv and cca if past 45 degrees
Nitroglycerin
Systemic venodilation that decreases preload
Hydralazine
Slow onset of action and lasts for multiple hours- not the best during surgery
Child at higher cognitive level will have
Higher preoperative anxiety
Use FFP if INR is above 1.5 in urgent/emergent
Cases
Also for heparin resistance
For microvascular bleeding and one above 2
If inr high and surgery in 24 hours and need to reverse give
Vitamin K
Not FFP
Post exposure prophylaxis for Hep B exposure includes
Hey B virus immune globulin
Excessive diuresis does not lead to
Respiratory alkalosis
Excessive diuresis leads to metabolic alkalosis
Respiratory alkalosis due to
Aspirin overdose Stroke Anxiety Pain Progesterone
PE leads to
Respiratory alkalosis
Resuscitation of drowning patient starts with
Rescue breaths
AV node supplied in majority of population by
RCA
Dual chamber pacemaker usually see
P wave followed by left bundle branch pattern
Severinghouse for
C02
Sanz for 02
Bronchodilator therapy shows change in
FEV1
Hyponatremia get
Plasma osmolality
Urine sodium
Fade is due to
Blockage of pre junctional receptors
At high altitudes compensate by increase in
Minute ventilation
Hypoxia stimulation of peripheral chemoceptors
Increase in PVR due to hypoxia
Leftward shift due to
Hypocarbia
Discovery
Exchange of documents and sworn statements by the defendant witnesses to event or expert witnesses
Depositions
Statements made under oath about the case
Grade 2b
Can only see posterior arytenoids
Grade 3
Only epiglottis
Grade 4 can’t see anything
Any malpractice payment made by insurer on behalf of individual physician must be
Reported to NPDB
Insurance payments on behalf of corporations are not reported
Contraindication to ECT
Increased ICP
Main cause of guillan barre
C jejuni
Ascending motor paralysis
Elevated CSF protein
Before caudal epidural you hit
Saccroxoygeal ligament
Between S4-S5
End of Dural sac in infants ends at
S3
PRIS
Acute kidney injury
Heart failure
Metabolic acidosis
Max dose of propofol infusion
4 mg/kg/hr
Cefepime
Worsening hypotension through lipopolysacharide release
Histamine release is associated with vancomycin use
Pouiselle law
Length of tubing
Pressure exerted on fluid
Viscosity of fluid
Density of fluid not important!
Most important if radius of tubing
Reducing density leads to more
Laminar flow
Hyperglycemia lowers
Potassium levels
Spirnolactone competitively inhibits
Aldosterone
Persistent expiratory flow at end expiration suggests
auto-PEEP
Longer expiratory time. And lower MV improves peak airway pressure and intrinsic PEEP
Bag inlet valve allows bag valve mask to
Reinflate
Ambu bag =
Mapleson C circuit
Best for pain management after rotator cuff repair
Continuous intrascalene block
Zofran plus metochlopramide doesn’t help with
PONV
Cortisol made from
Zona fasiculata
All catecholamines are derived from the amino acid
Tyrosine
ECG signs of hypokalemia includes
ST segment and T wave depression
Ketamine is a sch
3 drug
Cannibis LSD
Sch 1
Benzos
Sch 4
Morphine oxycodone
Sch 2
Persistent vegetative state patients can
Open eyes
Lactated ringers did not cause
Metabolic alkalosis
Potassium of 4
20 to 40 ml/kg lactated ringer
During anesthetic in infants and children
Hyperkalemia
Widening of QRS and peaking of T waves
Malignant hyperthermia
Tachycardia
Elevated end tidal c02
Acidosis
Malignant hyperthermia
Autosomal dominant variable penetrance
Xenon primarily works by
Inhibition of NMDA receptors
Carboprost can lead to
Bronchospasm
Heart rate generation in cardiac transplant is dependent on
Donor atrium
PPV
Decrease preload
Increase right ventricular afterload
Increase intrathoracic pressure increases ivc pressure
ANP
Sodium and water excretion
RAAS activation by low cardiac output
Efferent is constricted more to preserve glomerular filtration
TNF alpha and complement increase in
Sepsis
Bedside tracheostomy
Use cuffed low pressure tracheostomy tube
For airway protecting should be cuffed
Cuffed helps avoid aspiration
Can’t use nitrous with
Malignant hyperthermia
Bad dehydration in newborn
Weight loss 15%
Fontalle sunken
Urine flow 1.030
Factor 8 levels normal or elevated in
Liver disease
Down in DIC
Thrombocytopenia is found in both
DIC and ESLD
Elemental diets do not decrease
Mortality
Most pregnancy related deaths in United States due to
Cardiovascular disease
Cstatic =
Tidal volume/ Pplat-PEEP
End of pacemaker leads go into
Endocardium
Sympathetic block for
Chronic angina
PVR =
PA mean- PCWP / CO x 80
Most evaporative hear loss under general anesthesia is from
Tissue exposure
Pre warming patient externally with forced air warming blanket prevents
Initial fire temperature change caused by redistribution
Left atrial enlargement see double density sign spreads into the space of the
Right atrium
Pressure gradient aortic valve
4 x velocity squared
Fick
Gold standard for cardiac output measurement
Fat embolus don’t see
Tachycardia
Petechiae, hypoxemia, neurologic problems like seizures
Cushing reflex
High ICP
Decrease HR increase BP
Bowditch reflex
Increase in HR
Faster inhalation induction
Increased minute ventilation - most important
Increase blood flow to vessel rich organs
Decrease blood gas partition coefficient
Decrease tissue blood partition coefficient
Ace inhibitors
More bradykinin thus more arachadonic acid
Placenta previa
Higher risk of bleeding need two large bore ivs
Salicylate poisoning
Mixed respiratory alkalosis and metabolic acidosis
Contraindication to ECT
Intracranial mass lesion
Parathyroid gland is not controlled by
Pituitary
Acromegaly =
Difficult airway
Anterior mediastinal mass
Inability to lie flat as mass causes tracheal/cardiac compression
Tracheal deviation without pneumothorax
Widened mediastinum
MH
Flush with 10L of oxygen for 60 minutes
MH don’t give
Inhaled general anesthetics
Succinylcholine
CAN GIVE NITROUS OXIDE
Methemoglobin
Fe2+ to Fe3+
AHI > 30 in adult =
Severe COPD
Mild is 5-15
Least important in heat loss in or
Conduction
Enteral less infections/maintain gut integrity compared to
Parenteral feeding
VACTERL infant with TEF look for neural tube defect
Neural tube
Myasthenia gravis patient can get
Succinylcholine
Can’t give succ to
Multiple sclerosis patient
Cyanide toxicity treatment
Hydroxycobalamin
No basal rate for
Opioid naive patients
Beta 2 agonists like terbutaline
Relax uterine contractions and increase uterine blood flow
Methyelgonavine augments uterine contractions and will
Decrease uterine blood flow
Lithium prolongs
Blockade of both nondepolarizing and depolarizing muscle relaxants
Most effective to treat intraop hypothermia in pediatrics patient
Forced warm air blanket
Excess normal saline
Non anion gap hyperchloremic metabolic acidosis with decrease bicarbonate and decreased SID
Most attenuating on EMG signal
Neuromuscular blocking agents
Leftward shift of oxyhemoglobin dissociation curve is a feature of
Alpha stat ABG
Adding CO2 = pH stat
Strongest marker for perioperative outcome in patient on TPN
Albumin
Delayed transfusion reactions
Result of donor red blood cell antigens
Hyperparathyroidism
Skeletal muscle weakness
Propofol acts on
GAbAa receptor
Allows Cl- to hyperpolarize cells
Precedex much more selective for alpha 2 than
Clonidine
Baclofen
GAbAb
Oxygen pipeline pressure for oxygen nitrous oxide and air
Ranges between 50-55 psig
Visible spec vs infrared
Visible looks at less tissue with longer wavelengths of light
Increased FRC in patient who is
Prone
Larger ERV as well
Morbidly obese
Increase in lean body weight
Transfusion related immunomodulation can be stopped by
Leukocyte reduction
Morphine 3 G
No analgesic activity
May actually lead to hyperalgesia
Nausea
Pruritis
Respiratory depression due to
M6 G
MELD greater than 14
Usually can’t go in for surgical intervention
Liver transplant
Dissection
Anhepatic
Reperfusion
Most hemodynamic instability during
Reperfusion phase
Pace atria and ventricle
In ddd
Normal Pa02 in
Methemoglobinemia
You have oxygen but RBCs can’t take it
Giving oxygen won’t help
6 months for
DES
SIADH
Euvolemic or hypervolemic so CVP will be high
Ethacrynaic acid no reaction to
Sulfonamides
Nerve problems
Then need nerve block like with change in temp or pinprick
Both ventilation and perfusion are lower in
Apical alveoli
Anuria
Urine output less than 50 ml per day
Thin layer of blood<1mm
Fisher grade 2
Bioteansformation of lorazepam by
Glucoronidation
Rate of postop pulmonary complications drastically declines in smokers after stopping for
8 weeks
Heart failure at bottom of
Frank starling curve
Patient analgesia best in order
Continuous epidural > patient controlled epidural > patient controlled analgesia > prn
In event of emergency move patient out of MRI scanner
ASAP
Saphenous block
L2-L4
Adductor canal block similar pain help to femoral but lower risk of fall
Adenosine does not help with
A flutter
Adenosine blocks
AV node
Recurrent laryngeal nerve is a branch of the
Vagus nerve
Neuraxial causes
Decrease temperature where shivering will begin
Epidural increases incidence of shivering in women undergoing vaginal delivery
Furosemide
Increased venous capacitance
Periop mortality in obese main cause is
DVT
Best way to increase CO in someone with a fib is to convert to
NSR
Inhalational induction slowed by
Right to left shunt and more insoluble anesthetic
If failed intubation with fetal distress in pregnancy and difficult intubation
Mask them or lma before video til patient comes out
Rheumatoid arthritis not associated with
Bronchospastic disease
Midazolam bioavailability greatest to least
iV> Intramuscular > intranasal > rectal > oral
Epidural anesthesia ok for
Multiple sclerosis
Fetal academia requiring delivery
pH of 7.2 or lactate greater than 4.8 mmol/L
Ketamine/precedex
No pain on injection
Duchenne muscular dystrophy
Lead to hyperkalemia/rhabdomyolysis
Not MH
Drug volume affects
Epidural anesthesia but not spinal
Spinal anesthesia affected by
Drug baricity
Drug dosage
Patient position
Deadly triad
Coagulopathy
Hypothermia
Metabolic acidosis
Acute stoppage of TPN can lead to
Hypoglycemia
Old MI =
> 30 days prior
Intercostal blocks associated with
Highest blood levels of local anesthetic following completion of block
Lower density =
Less turbulent flow
Carbon monoxide poisoning with carboxyhemoglobin level> 25%
Hyperbaric oxygen therapy
Unstable angina =
ASA 4
Pa02 increases in
Pregnancy
Increased cardiac output decreases speed of
Inhalation induction
C botulism toxin works by
Impairment of Ach release from storage vesicles
Cholestasis is a complication of
Parenteral nutrition
Cyclosporine causes
Nephrotoxicity not pulmonary toxicity
FEVERFEW PROLONGS THE ACTION OF
Warfarin
Recombinant hgb
Does not require typing or crossmatching
Terbutaline
Selective beta 2 agonist
Terbutaline can lead to
Glucose intolerance
Ritodrine side effect is
Neonatal hypoglycemia
Maternal hypokalemia
Single blinded
Only patients are not aware
Elevated CPK in heavy patient from prolonged immobilization leads to
Rhabdomyolysis
Sacral spinal nerves simulates
Urethral sphincter relaxation
In pelvis sacral spinal nerves include parasympathetic nerve fibers that promote
Sexual arousal, peristalsis, defecation, urination
5 to 10 AHI per hour is
Normal
Disadvantage of autotransfusion via intraoperative blood salvage
Platelet and clotting factor deficiency
Autonomic dysreflexia starts with spinal lesions at
T6
Avoid pre term delivery by delaying pregnant surgery until
Second trimester
Myofascial pain syndrome treat with
Trigger point injection
Physical therapy
TENS
Unchanged vital capacity in
Pregnancy
Tidal volume increases
FRC decreases
Etomidate inhibits
11 beta hydroxylase
Mapleson D most efficient for
Controlled/spontaneous ventilation
Drainage of CSF fastest way to restore
Cerebral perfusion pressure
Decrease > 10 mmHg of systemic BP during inspiration for
Pulpus paradoxus not expiration
During inspiration increase in negative intrathoracic pressure increases
Venous return to right side of heart
Most jevohahs witnesses will take
Albumin
Refuse autologous blood transfusions
When a patient is anemic
Blood viscosity is decreased. Helps to improve blood flow to specific tissues thus aiding in oxygen delivery
Vital organs
Brain heart and lungs
Polycythemia
Increased blood viscosity slows blood flow and decreaeses oxygen delivery
For difficult airways due to limited neck extension do
Flexible laryngoscopy
Three drug prophylaxis in severe exposure when the patient is known to have
HIV OR AIDS
Predisposes to atelectasis
General anesthesia
Fi02 high
Obesity
Hypothermia causes
Increased mixed venous
Chronic heparin use leads to
Hypoaldosteronism and this hypokalemia
Most injured nerve during thyroid/parathyroid surgery
Superior laryngeal
Tensor of vocal cords without it the voice tires easily
Eclampsia
Seizures in woman with preeclampsia
Telling families adverse events =
Professionalism
Giving magnesium to mother can cause
Hypotonia in neonate
Lusitropy
Active myocardial relaxation
Downward shift of EDPVR slope
Bronchospasm affects
Dynamic compliance
The AMA is not involved with
Operating room safety
Hyperosmolar vs DKA
HHS has serum osmolality above 350 and BG>600
High intravesical pressure is consistent with compartment syndrome which can lead to increased
ICP
Carbamazepine overdose causes
Anticholinergic symptoms such as mydriasis
Succ disadvantages
Increase intragastric pressure Increase iop Postop myalgia Hyperkalemia Increased LES tone
6 hours npo
Tea and toast such as an English muffin
Alpha is for
Type 1 error
Alpha decreased decreases chance of type 1 error but increases type 2 error chance
Beta error lower
Less chance for type 2- falsely accepting null hypothesis
Most chylothorax post central line is on
Left side
Transcutaneous pacemakers can lead to
Muscle injury
Rhabdomyolysis
Hyperkalemia
Most direct cause if cv collapse during massive venous air embolism is
RV outflow tract obstruction from air lock phenomenon in RV
SBO requiring surgery
Put NG tube in while awake
Metochlopramide
Dopamine antagonist
Chi square good for
Categorical data
200 mcg =
0.2 mg
1 mg intrathecal morphine = 10 mg epidural morphine
1 mg EPidural morphine = 10 mg iv
I mg iv = 3 mg po morphine
Creatinine clearance best to determine
Imminent acute kidney injury
FenA determines cause of
Established kidney injury
FENA is affected by
Diuretics
Closing capacity increases as patients
Age
SIMV with pressure support
Mandatory breaths and additional PS breaths all synchronized with patient effort
Delayed hemolytic transfusion reaction
3 to 7 days post
Anaphylactic or anaphylactoid transfusion rxn
First stop transfusion
First give bolus of fluids then slow epinephrine pushes
No premedication to prevent
Allergic or febrile non hemolytic transfusion rxn
Stopping transfusion is ok
Jehovah’s Witness ok with
Acute normovolemic hemodilution
No acute normovolemic hemodilution on patient with
Cardiac abnormalities such as stable angina
Vapor pressure depends on
Temperature and specific liquid
PVC is ok with laser
Especially if aluminum covers it
Avoid nitrous and volatiles bc can lead to airway problems
First letter
Chamber paced
Position 2
Chamber sensed
Still pacing but not sensing in
Asynchronous mode with a magnet
Soda lime especially with KOH form bad
Byproducts
Intraop awareness
Higher with neuromuscular agents
So does TIVA
VATS pleurodesis for
Chronic pleural effusion
Bain circuit conserves
Moisture better
When oxygen falls below 20 to 30 psi
Fail safe valve decreases or ceases nitrous oxide delivery
Most effective noninvasive oxygen delivery device
Nonrebreathing mask
Venturi mask is not a good device
Boyle’s law hyperbaric oxygen decreases
Emboli
Max Fi02 NC
50%
Des
Highest vapor pressure
Ventilator disconnnect
Alarm
Atracurium
Histamine release
Pancuronium can worsen
Tachycardia
Rocuronium can be used on patient with liver lac
High spinal
Numbness and or tingling in hands and SOB
Tounge points towards the lesion in
Stroke
Beach chair position can lead to
Stroke
In MH RYR I’m locked state so keep getting more and more intracytoplasmic
Calcium
Sodium citrate works
Immediately to increase gastric pH
Aspiration pneumonia has CXR findings while aspiration pneumonitise
Does not
Anaphylactoid does not activate
Antigen mast cell activation
Anaphylaxis treatment first give
Fluid bolus and epinephrine
Pac02 30 to 35 for a
Crani to reduce blood flow
Pac02 etC02 difference due to
Dead space
Airway fire
Take out ETT
Intraop awareness more likely in
Cardiac
Obstetric
Trauma
Hypothermia can cause
Coagulopathy
If vital signs stable not due to massive blood loss
C02 insufflation could lead to
C02 embolus
Best strategy for fat embolus
Low tidal volume similar to ARDS
Treatment of TRALI is with
Ventilator support
Use low tidal volume with high RR and peep
Tourniquet release
Increase in HR
Increase in potassium
Slight increase in pac02
Transient metabolic acidosis
Lumbar epidural prior to
Ex lap is ok
Best predictor of postop renal injury
Preop creatinine clearance
Give naloxone if you give too much
Dilaudid
Intercostal to caudal
Intrascalene lower absorption as part of brachial plexus
Neuraxial opioids procure analgesia via
Dorsal horn opioid receptors
Morphine can go to stark when given intrathecal and can cause respiratory depression at 6 to 18 hours
PDPH is not associated with
Fever
1 liter of crystalloid or 1 pRBC lowers temp by
.25 degrees C
Hypothermia is protective against
Cerebral ischemia and hypoxia
Postop vision loss if
Prone position
Long duration of surgery
Prolonged hypotension
Significant intraop blood loss
Protect ulnar nerve with
Forearm supination
Dantrolene decreases
Release of calcium from SR
Mandibular central incisors most likely to be injured during
Intubation
Cuff of LMA can cause
Hypoglossal or lingual nerve injury
Hypoglossal goes to ipsilateral side
Positive pressure leak test will not find leak in
Vaporizer
IOP is not affected by
Etomidate
Left IJ most likely to lead to
Chylothorax
Anaphylaxis
Type 1 hypersensitivity antigen binding for IgE
Atracurium
Histamine release
Pancuronium can worsen
Tachycardia
Rocuronium can be used on patient with liver lac
High spinal
Numbness and or tingling in hands and SOB
Tounge points towards the lesion in
Stroke
Beach chair position can lead to
Stroke
In MH RYR I’m locked state so keep getting more and more intracytoplasmic
Calcium
Sodium citrate works
Immediately to increase gastric pH
Aspiration pneumonia has CXR findings while aspiration pneumonitise
Does not
Anaphylactoid does not activate
Antigen mast cell activation
Anaphylaxis treatment first give
Fluid bolus and epinephrine
Pac02 30 to 35 for a
Crani to reduce blood flow
Pac02 etC02 difference due to
Dead space
Airway fire
Take out ETT
Intraop awareness more likely in
Cardiac
Obstetric
Trauma
Hypothermia can cause
Coagulopathy
If vital signs stable not due to massive blood loss
C02 insufflation could lead to
C02 embolus
Best strategy for fat embolus
Low tidal volume similar to ARDS
Treatment of TRALI is with
Ventilator support
Use low tidal volume with high RR and peep
Tourniquet release
Increase in HR
Increase in potassium
Slight increase in pac02
Transient metabolic acidosis
Lumbar epidural prior to
Ex lap is ok
Best predictor of postop renal injury
Preop creatinine clearance
Give naloxone if you give too much
Dilaudid
Intercostal to caudal
Intrascalene lower absorption as part of brachial plexus
Neuraxial opioids procure analgesia via
Dorsal horn opioid receptors
Morphine can go to stark when given intrathecal and can cause respiratory depression at 6 to 18 hours
PDPH is not associated with
Fever
1 liter of crystalloid or 1 pRBC lowers temp by
.25 degrees C
Hypothermia is protective against
Cerebral ischemia and hypoxia
Postop vision loss if
Prone position
Long duration of surgery
Prolonged hypotension
Significant intraop blood loss
Protect ulnar nerve with
Forearm supination
Dantrolene decreases
Release of calcium from SR
Mandibular central incisors most likely to be injured during
Intubation
Cuff of LMA can cause
Hypoglossal or lingual nerve injury
Hypoglossal goes to ipsilateral side
Positive pressure leak test will not find leak in
Vaporizer
IOP is not affected by
Etomidate
Left IJ most likely to lead to
Chylothorax
Anaphylaxis
Type 1 hypersensitivity antigen binding for IgE
Rodenticide
Super warfarin
Amide local anesthetic breakdown
Plasma cholinesterase
Onset and recovery of block works fastest at
Diaphragm
Atracurium breakdown
Hoffman elimination
Block recovery after single dose of NDMR is the result of
Redistribution
Avoid which NDMB in patients with renal failure
Pancuronium
High K above 5.5 don’t use
Succ
Hypercalcemia does not enhance
Neuromuscular block
Histamine release following administration of NBMAs is most apparent after giving
Succinylcholine
Can give succ to a burn patients as long as they got it within
2 days of burn
Succ is a partial agonist of the
AchR
Binds the alpha subunit
Succ onset
Succ offset
<1 min
5 to 10 minutes
Succ much higher risk of
Allergic reaction which is IgE mediated
Succ can increase
ICP
Heart transplant patients can get
Succinylcholine
Succ binds
Alpha subunit of postsynaptic AcH receptor
Phase 1 block
Cation channel stays open leading to
Flaccid paralysis
Phase 2
TOF<50%
At very high doses of succinylcholine
Dantrolene elimination half life is
12 hours
Dantrolene inhibits calcium release from the
Sarcoplasmic reticulum
Continue dantrolene infusion in MH patients for at least
24 hours in the ICU
Increase in biliary pressure due to
Opiates
Least is from tramadol/buenorphine
Antiemetics don’t act on
Opioid receptor
TIVA = less
PONV
Can’t use in pts with Parkinson’s disease
Droperidol
Black box droperidol for
QT prolongation
Can use propofol with
Acute intermittent porphyria
Amnesia persists the longest with
Benzodiazepines
Flumazinil lasts
45 to 90 min
Give in doses of 0.2 mg up to 3 mg
Clonidine
Hypotension and bradycardia
Lorazepam
Lasts 32 hours
Etomidate
PONV and thrombophlebitis
Maintains Hypoxic pulmonary vasoconstriction
No ketamine during
Pregnancy
Reduction of methemoglobin to hemoglobin is action of
Methylene blue
Mannitol can cause
Pulmonary edema
Glucagon produced by
Pancreatic alpha cells
Glucagon causes
Positive inotropy and increased heart rate
Can treat hypoglycemia and beta blocker overdose (5 to 10mg iv)
IV beta blockers for
HTN and tachyarrhyhmias
Propranolol non selective beta blocker
Labetalol is 7 times more
Beta than alpha
Esmolol is much less
Potent than propranolol
Want to discontinue TCA and MAOis
2 weeks before surgery
Digoxin
Positive inotropy, negative chronotropy, reduced SVR
Inhibits sodium/potassium ATPase
Can give lidocaine for
V Tach
High potassium can lead to
Digoxin toxicity
Clindamycin prolongs
NDMBs
Buprenorphine 50 times more potent than
Morphine
Nalbuphine iv for
Intrathecal
Itching
Start with dose 4 mg iv
Can’t give reglan to patients with
Epilepsy
Reglan increases
LES tone
Randomization no affect on
Power of study, does balance cofounders
Type 1 error =
False positive
Mann Whitney for
Unpaired groups
Nominal variable has two or more categories such as
Gender
Patients can refuse testing for
HIV
Roe v Wade
Established women’s right to obtain a therapeutic abortion in early stages of pregnancy
Four principles of malpractice
Preexisting duty of care
Breach of duty
Injury to patient
Proximate cause
Antithymocyte globulin side effects
Leukopenia
Thrombocytopenia
Serum sickness, anaphylactic rxn
Orthodeoxia
Hepatopulmonary syndrome
Parameter of TEG measuring clot strength is
Maximum amplitude
Drug of choice for increasing heart rate in heart transplant patients
Isoproterenol
ESRD
Nprmochromic, normocytic anemia
Hyperventilation with lower tidal volumes with
Cirrhosis
Vasopressin affects SVR without big effect on
PVR
Diagnosis of rejection requires a
Liver biopsy
Reperfusion syndrome occurs during
Neohepatic phase of liver transplant when portal vein, hepatic artery, and vena cava are unclamped
Don’t use nimbex in
Rapid sequence induction
Ok to use succ if preop potassium less than
5.5 in ESRD
Usually two p waves on
Donated heart due to both donor and recipient AV nodes
Usually plt count goes up 10000
Per donor unit
Give FFP bc it gives back
All coagulation factors
Cryoprecipitate for hypofibrinogen which shouldn’t be given for bleeding before FFP
Citrate not metabolized without liver
During anhepatic phase need to watch calcium bc low amounts will lead to decreased cardia contractility
Most common cause of ARDS is
Severe sepsis
Same volume replete on overall whether using
CVP or PA cath
Delirium leads to
Increased morbidity and mortality
Expiratory wheezing not heard in
Severe asthma
ARDS damage
Capillary endothelial
Alveolar epithelial cells
Impaired surfactant levels
Pneumothorax can lead to
Impaired ventilation of unaffected lung
Transient increase in atrial pressure produced by isovolumetric contraction =
C wave
PEEP can decrease
LV afterload and thereby enhancing cardiac performance
DKA has a high
Anion gap
Sodium bicarbonate problems
No benefit in acidosis from cardiac arrest, shock, and sepsis.
Can lead to venous hypercarbia, tissue hypoxia, hypernatremia, shift of 02 dissociation curve
No ketonuria is seen with
HHS
If u had a pneumonectomy
Don’t do central line on other side bc only lung u have
Don’t do subclavian on side with
AV fistula
Trunk is
18% in burn formula
4 ml/cc/hr per
Parkland formula
Cherry red pigmentation
Only during high CO concentrations
In anaphylaxis intravascular fluid moves into tissue triggering acute tissue edema leading to rise in
Hematocrit in pts suffering from anaphylactic rxn
Intraop urine output has not been shown to be a predictor of
Postop renal dysfunction
If life threatening bleeding after giving tPA can reverse first line with
Cryoprecipitate
Transfusion of pRBCs helps BP by increasing
Preload
Most citrate toxicity would come from
FFP
Sepsis you see a low
SVR
Can you CPAP and biPAP for
Cardiogenic pulmonary edema
Nitric oxide
Potent pulmonary vasodilator that can cause plt dysfunction
Giving pRBCs shifts oxyhemoglobin curve to the
Left
In management of acute aortic dissection
Morphine first then esmolol then sodium nitroprusside
Want systolic 90-110
First signs of cyanide toxicity in patients treated with nitroprusside is
Tachyphylaxis
Tachycardia decreases
Diastole time
Cryoprecipitate contains
Fibrinogen Fibronectun VwF Factor 8 Factor 13
MABL
EBV x (pt hct-minimum tolerated hct))/Pt hct Older children EBV 75 to 80 cc/kg
Albuterol acts on
cAMP
Relax bronchial smooth muscle
Can be used in ppl with cardiovascular disorders
Spinal cord stimulator does not treat
Pancreas related pain
Tumescent lidocaine max dose
55 mg/kg during liposuction
Neuraxial morphine has an association with
Reactivating heroes simplex virus
Lidocaine speak plasma concentration occurs more than
6 hours after injection when given for tumescent lidocaine procedures
Bainbridge reflex
Increase in HR due to an increase in CVP
Stroke volume and arterial pulse pressure drop during
Expiration
Guillan barre causes
Pain
Brain dead pts more vasopressin release and most common electrolyte abnormality is
Hypernatremia
PEEP increases
FRC
Does not decrease extra vascular lung water
No enteral nutrition if patient has ileus but ok for
Pancreatitis
Do not use verapamil or other calcium channel blockers during
MH
MAC
Concentration of vapor that prevents the reaction to a standard surgical stimulus of 50% of subjects
To achieve same partial pressure at altitude need to increase
Concentration of anesthetic
Primary polycythemia higher
Plt count than secondary polycythemia
Epidural analgesia during first stage is
Fever
Ordinal data
Wilcoxon rank sum test
Milrinone
Inodilator and vasodilation
Jet ventilation reduces risk of
Airway fire
Two small groups comparing data use
Fisher exact test
More likely to cause atlantoaxial instability
Neck flexion
Dexamethasone no
Mineralocorticoid activity
Celebrex raises
Lithium levels
SD=
SE x square root of sample size
Gi/Gu
No infective endocarditis prophylaxis
Masseter muscle innervation
Trigeminal nerve
Nitric oxide
cGMP
Sensory innervation of tounge
Mandibular nerve CN V3
Nitrous oxide
NMDA receptor antagonist
Fraction of expired gases use
Infrared absorption spectrophotometry
More airway resistance with
Hyperventilating
Most common cause of normal anion gap in setting of lactic acidosis
Hypoalbuminemia
Vocal cord paralysis may result from
Prolonged over inflation of an endotracheal tube
Anaphylactoid are not
IgE mediated
Esmolol breakdown
Red cell esterases
Labetalol iv 7 to 1
Beta to alpha
Intracranial aneurysm symptoms
Severe headache
Neck stiffness
Cerebral vasospasm treatment includes
Nimodipine aka calcium channel blockers
Hyperthermia can trigger
Myasthenia gravis
In pregnancy plasma volume goes up causing albumin levels to go
Down
Coagulation factors that go up most in pregnancy
Factors 7 and fibrinogen
HFJV allows for
Passive expiration whereas HFOV does not
Flumazinil half life 1 hr not long enough for most
Benzo agonists and causes resedation
N20
1590 L and 745 psig
Furosemide
Hypochloremic metabolic alkalosis
Thiazides works at
Distal convoluted tubule
Increase in renal bicarbonate with
Acetazolamide
Acetazolamide
Hyperchloremic metabolic acidosis bc more bicarbonate in urine getting excreted
Hemoglobin curve affected by carbon dioxide and pH due to
Bohr effect
Mivacurium broken down by
Psuedocholinesterase
Meperidine resembles atropine so May cause increase in
HR
Most common cause of bradycardia in neonates is
Hypoxia
PRIS
Cardiac failure
Rhabdomyolysis
Pancreatitis
Drugs not crossing placenta
Heparin insulin glycopyrolate muscle relaxants and succ
Tourniquet release can cause
PE through dislodgement of thrombus with acute decrease in Etc02 and sp02
HTN
Bradycardia
Diaphoresis
Autonomic hyperteflexia
After spinal cord injury extra junctional receptors are highest 3 days to
9 mo after
Treat autonomic reflexia with
Short acting not long acting like phenoxybenzamine
Autonomic hyperteflexia causes
Reflex bradycardia
Ion trapping
Fetus has low pH
Gives hydrogen ion to basic drug like lidocaine trapping it by making it ionized
Great auricular artery originates from the aorta between
T9-T12
Circle of Willis is made up of
ACA, PCA, anterior communicating internal carotid
MCA is not considered part of the circle of Willis
Precedex is most selective for
Alpha 2
Propofol decreases amplitude of
SSEPs
Least resistant
BAEP
Carcinoid associated with
Tachycardia not bradycardia
Greater cornu of hyoid bone local anesthetic
Internal branch of superior laryngeal nerve
External obliques muscles contract
During forced exhalation
Cardiovascular collapse during massive venous air embolus
Air lock phenomenon in right ventricle
NMDA is an
Excitatory neurotransmitter blocked by ketamine
Double blinded is to both
Patient and investigator
Isoflurane most improved with
High minute ventilation
Expiration controls
Ventral respiratiry group in the medulla
Heat loss through breathing circuit
Evaporation
Phenelzine is an MAOi used for treatment can cause
Serotonin syndrome
Clonus hyperreflexia tachycardia also seen
No meperidine to patient on phenelzine
Uremia causes platelet dysfunction including impaired aggregation
In dialysis patients
Platelet count usually doesn’t go down
Glycine
Metabolized to ammonia
Myelingocele goes with
Hydrocephalus
Non pitting edema
Myxadema coma
Cuffed trach is necessary when
Positive pressure ventilation is required
At least 10% of transfused blood is
Hemolyzed within 24 hours of blood transfusion
Patients with Gilbert’s have a hard time dealing with increased unconjugated bilirubin load
Supraclavicular block high risk for
Pneumothorax - near subclavian artery and pleura
Intrascalene usually doesn’t affect
Ulnar where’s supraclavicular does
Corneal reflex
5 and 7
Sulfhemoglobinemia shifts oxyhemoglobin dissociation curve to the
Right
Clevidipine breakdown is by
Plasma esterases
Gabapentin binds
Alpha 2 receptors
Most sensitive lab test for acromegaly
IGF-1
Cryotherapy helps with postop pain by
Nociceptive sensitivity inhibition by slowing nerve conduction
MG and chronic renal failure do not lead to
Upregulation of nicotinic Ach receptors
Indications for hyperbaric oxygen therapy
Air embolus, carbon monoxide poisoning, ischemic ulcers
Epi
Norepinephrine
Dopamine do not cross
BBB
Mitral valve closes at the
R wave
W/o first stage regulator
Can get depletion of oxygen tank
Hyper magnesium
Iatrogenic
May result in reduced deep tendon reflexes and muscle weakness
Cerebral vasospasm most likely to develop at 2-14 days post
Sub arachnoid hemorrhage
Milrinone dose should be reduced in setting of
Renal failure
PDE inhibitor
Increases cAMP levels leading to more inotropy
Increases cardiac index without increasing myocardial oxygen demand
Reduces SVR and PVR
Inferior wall of LV is done by
RCA it is on septal side
MAOi use increases
MAC
Hypermagnesium can cause
Muscle weakness which can lead to blurred vision
Cardiac myxona most common benign cardiac tumor mainly found in
Left atrium
Activating nicotinic Ach on motor end plate requires
Two Ach or one succ molecule
Meperidine main effect is through
Kappa opioid receptors
Aorta to pulmonary artery
PDA
Urine to plasma osmolar ratio > 1.5 indicates
Prerenal oliguria
PPV in neonate if HR under
100
Chest compressions if under 60
Acute mountain sickness treat with
Acetazolamide
Dexamethasone
NSAIDS have a ceiling affect to
Analgesia
Cephalad movement of diaphragm is seen in
Pregnancy
Progesterone
Causes relaxation of bronchiolar smooth muscle during pregnancy and mitigates upper airway edema
Esmolol breakdown
Red cell esterases
Labetalol iv 7 to 1
Beta to alpha
Intracranial aneurysm symptoms
Severe headache
Neck stiffness
Cerebral vasospasm treatment includes
Nimodipine aka calcium channel blockers
Hyperthermia can trigger
Myasthenia gravis
In pregnancy plasma volume goes up causing albumin levels to go
Down
Coagulation factors that go up most in pregnancy
Factors 7 and fibrinogen
HFJV allows for
Passive expiration whereas HFOV does not
Flumazinil half life 1 hr not long enough for most
Benzo agonists and causes resedation
N20
1590 L and 745 psig
Furosemide
Hypochloremic metabolic alkalosis
Thiazides works at
Distal convoluted tubule
Increase in renal bicarbonate with
Acetazolamide
Acetazolamide
Hyperchloremic metabolic acidosis bc more bicarbonate in urine getting excreted
Hemoglobin curve affected by carbon dioxide and pH due to
Bohr effect
Mivacurium broken down by
Psuedocholinesterase
Meperidine resembles atropine so May cause increase in
HR
Most common cause of bradycardia in neonates is
Hypoxia
PRIS
Cardiac failure
Rhabdomyolysis
Pancreatitis
Drugs not crossing placenta
Heparin insulin glycopyrolate muscle relaxants and succ
Tourniquet release can cause
PE through dislodgement of thrombus with acute decrease in Etc02 and sp02
HTN
Bradycardia
Diaphoresis
Autonomic hyperteflexia
After spinal cord injury extra junctional receptors are highest 3 days to
9 mo after
Treat autonomic reflexia with
Short acting not long acting like phenoxybenzamine
Autonomic hyperteflexia causes
Reflex bradycardia
Ion trapping
Fetus has low pH
Gives hydrogen ion to basic drug like lidocaine trapping it by making it ionized
Great auricular artery originates from the aorta between
T9-T12
Circle of Willis is made up of
ACA, PCA, anterior communicating internal carotid
MCA is not considered part of the circle of Willis
Precedex is most selective for
Alpha 2
Propofol decreases amplitude of
SSEPs
Least resistant
BAEP
Carcinoid associated with
Tachycardia not bradycardia
Greater cornu of hyoid bone local anesthetic
Internal branch of superior laryngeal nerve
External obliques muscles contract
During forced exhalation
Cardiovascular collapse during massive venous air embolus
Air lock phenomenon in right ventricle
NMDA is an
Excitatory neurotransmitter blocked by ketamine
Double blinded is to both
Patient and investigator
Isoflurane most improved with
High minute ventilation
Expiration controls
Ventral respiratiry group in the medulla
Heat loss through breathing circuit
Evaporation
Phenelzine is an MAOi used for treatment can cause
Serotonin syndrome
Clonus hyperreflexia tachycardia also seen
No meperidine to patient on phenelzine
Uremia causes platelet dysfunction including impaired aggregation
In dialysis patients
Platelet count usually doesn’t go down
Glycine
Metabolized to ammonia
Myelingocele goes with
Hydrocephalus
Non pitting edema
Myxadema coma
Cuffed trach is necessary when
Positive pressure ventilation is required
At least 10% of transfused blood is
Hemolyzed within 24 hours of blood transfusion
Patients with Gilbert’s have a hard time dealing with increased unconjugated bilirubin load
Supraclavicular block high risk for
Pneumothorax - near subclavian artery and pleura
Intrascalene usually doesn’t affect
Ulnar where’s supraclavicular does
Corneal reflex
5 and 7
Sulfhemoglobinemia shifts oxyhemoglobin dissociation curve to the
Right
Clevidipine breakdown is by
Plasma esterases
Gabapentin binds
Alpha 2 receptors
Most sensitive lab test for acromegaly
IGF-1
Cryotherapy helps with postop pain by
Nociceptive sensitivity inhibition by slowing nerve conduction
MG and chronic renal failure do not lead to
Upregulation of nicotinic Ach receptors
Indications for hyperbaric oxygen therapy
Air embolus, carbon monoxide poisoning, ischemic ulcers
Epi
Norepinephrine
Dopamine do not cross
BBB
Mitral valve closes at the
R wave
W/o first stage regulator
Can get depletion of oxygen tank
Hyper magnesium
Iatrogenic
May result in reduced deep tendon reflexes and muscle weakness
Cerebral vasospasm most likely to develop at 2-14 days post
Sub arachnoid hemorrhage
Milrinone dose should be reduced in setting of
Renal failure
PDE inhibitor
Increases cAMP levels leading to more inotropy
Increases cardiac index without increasing myocardial oxygen demand
Reduces SVR and PVR
Inferior wall of LV is done by
RCA it is on septal side
MAOi use increases
MAC
Hypermagnesium can cause
Muscle weakness which can lead to blurred vision
Cardiac myxona most common benign cardiac tumor mainly found in
Left atrium
Activating nicotinic Ach on motor end plate requires
Two Ach or one succ molecule
Meperidine main effect is through
Kappa opioid receptors
Aorta to pulmonary artery
PDA
Urine to plasma osmolar ratio > 1.5 indicates
Prerenal oliguria
PPV in neonate if HR under
100
Chest compressions if under 60
Acute mountain sickness treat with
Acetazolamide
Dexamethasone
NSAIDS have a ceiling affect to
Analgesia
Cephalad movement of diaphragm is seen in
Pregnancy
Progesterone
Causes relaxation of bronchiolar smooth muscle during pregnancy and mitigates upper airway edema
Nonshivering thermogenesis
Triggered by norepinephrine glucocorticoids thyroxine
Alveolar dead space goes down during pregnancy
Due to increase in cardiac output
Mid esophageal aortic long axis view see ascending aorta at
105 degrees
To reduce PONV need metochlopramide dose
25-50 mg
Trans cranial Doppler can see elbolization in
90% of occlusions
Next to intrascalene block you have vertebral artery where if you inject local anesthetic you get immediate
Seizures
Phrenic nerve stimulators improve
Atelectasis
Vasoplegia causes bad
Vasodilation
Dixogin inhibits myocyte Na K ATPase
Leads to increased intracellular calcium and positive inotropy
Treatment of overdose is with immunotherapy
Glucagon
Acts via G protein coupled receptor independent of beta 1 receptor to cause chronotropic and inotropic effects
Milrinone
May be limited due to hypotension
Due to its arterial and venous vasodilatory effects
Sinus Brady and angina
Give amlodipine
Increased bradykinin is due to
Ace inhibitors leading to angioedema
V/Q ratio is 1 at the
Third rib in upright lungs
TLC, RV FRC all increased with
COPD
Chemoceptors sense higher pC02 and increase
Ventilation
02 content of arterial blood
1.39 x hemoglobin x O2 sat + 0.003*PaO2
Diastole is
Ventricles filling
Consists of Isovolumetric relaxation Rapid inflow Duastasis Atrial systole
SVR =
80 x (MAP-CVP)/CO
A failing ventricle leads to dilation and significantly increase
Afterload which lowers cardiac output
Hypoxia acidosis ischemia and drugs like calcium channel blockers and beta blockers decrease
Contractility
Coronary perfusion pressure
Aortic diastolic pressure - LVEDP
Fourth power of radius
Reduction in flow due to coronary lumen getting smaller
Coronary vasodilation by
Calcium channel blockers
Nitrates
Dipyridamole
Left recurrent laryngeal wraps around the
Aorta
Right recurrent laryngeal wraps around
Right subclavian artery
Apex of heart is conducted by
Left posterior fasicle
ICD for
Left bumble branch block
With QRS complex greater than 150
Atrial arrhythmias can lead to
Inappropriate ICD firing
IABP cycling is triggered by the
R wave of the ecg
Contraindications to IABP
Platelet count<50000, active stroke, severe AI, active bleeding
Amionester local anesthetic more likely allergy than
Aminoamide
Sulfites are added to local anesthetics to stabilize
Vasoconstricting agents like epi
Methylparaben preservative can lead to
Anaphylactoid rxn
Cocaine is a local anesthetic reversibly blocks the flux
Of sodium ions
Norepinephrine reuptake inhibitor
Cocaine has led to
Ruptured aortic aneurysms
Infective endocarditis
Vascular thrombosis
NSAIDs block
Cox which enhance prostaglandin production
They have a ceiling effect for pain control
Water freely moves across the
BBB
Atropine doses cross
BBB and causes sedation
Glycopyrolate does not
Can’t give which drug IM as it causes local ischemia and tissue necrosis
Norepinephrine
Phenylephrine direct alpha 1 that causes more
Venoconstriction>arterial constriction
Midazolam can interfere with placement of
Deep brain stimulator
Propofol affects MERs as well but is rapidly titratable
Lumbar plexus block spares the
Sciatic nerve which does muscles that do planterflexion at the ankle
It does block femoral obturator and lateral femoral cutaneous nerves
Newly diagnosed hyperthyroidism
See elevated thyroid hormone binding ratio
Resting LV systolic function is not affected by
Aging in most studies
Plasma catecholamines are significantly elevated
Rocuronium
25-30% renally excreted
Not affected by renal failure
Decrease in fresh gas flow
From semi closed to closed circuit
As more fresh gas is injected into the system, it causes less vaporizer gas so u rebreather less
Closed circuit causes more rebreathing of gas
C02 levels still go down with scavenging
Conus medullaris =
Terminal end of spinal cord
Ends at L3 in newborns and sural sac at S3
In adults ends at L1 and Dural sac at S1
TAP block
Intercostal, subcostal, ilioinguinal, iliohypogastric
Succ in kids causes
Bradycardia
Can give atropine before in patients<1
Monoclonal anti Ige antibody
Omalizumab
Most common periop neuropathy is
Ulnar
Keep hand and forearm supinate to prevent injury
Double peak is common in capnography who have received
Single lung transplant
Capnogram does not return to 0 during inspiration
When expiratory valve is incompetent
Discogenic low back pain
Pain increases with sitting
Morning stiffness
Ankylosis spondylitis
GBS is associated with SIADH which causes
Hyponatremia
Ileus
LP shows increased protein with normal cell count and glucose in CSF
Associated with DVT as well
Cornula placenta predisposes to
Breech fetal presentation
First order kinetics is a
Constant fraction not a constant amount per unit time
Administration of glucose containing crystalloid is not recommended in
Adult burn pts
Coma
No brainstem reflexes
Apnea for
Brain death
Static compliance is measured without
Gas flow
Inspiratory gold is an example of static compliance
Tidal volume/Pplat-PEEP
No lung sliding and no B lines think
Pneumothorax
TEE then precordial Doppler are best for looking at
Venous air embolus
Inspiration less with
Poor patient effort
Pregamglionic nerve fibers of upper extremity originate from
First four or five thoracic spinal segments
Precurization with non depolarizing blocker clearly reduces
Fasiculations before giving succinylcholine
First degree relative
Leads to more increase graft vs host disease
Latex allergy
Avocado, banana, kiwi, pineapple, mango
Tropical fruits
Spinal block can fail if
Maternal obesity
Late labor epidural placement
Moving from epidural to spinal does not cause this but can lead to high spinal
Beer measure of plt function
Optical aggretometry
Medial arch of foot is
Saphenous nerve. Passes anterior to medial malleolus
Hyperparathyroidism leads to
Skeletal muscle weakness due to hypercalcemia
Hypercalcemia often leads to hypertension
Shortens at interval
Communication between physician and attorney are almost always
Privledged
Phosgene leads to
Pulmonary damage
Gel filled mattresses for
Hypothermia can be transferred easily
Most heat loss is due to radiation and can be fixed by
Warming the room
As flow through rotameter increases so does the
Cross sectional area of the orifice around the rotameter
Neuromuscular blocking agents effect
EMG signals
Ach can affect
Post synaptic receptors at motor end plate to obliterate emg signal
Type 2 pneumocytes produce
Surfactant which helps reduce atelectasis
Carbon dioxide cylinder is
Gray
Nitrogen cylinder is
Black
Treacher Collins
50% of these patients have hearing loss
OSA common
Hard to ventilate/intubate
Oscillations in BP occur during
Deflation. Highest oscillation is the MAP
Electromechanical pressure transducer is needed for
Invasive arterial monitoring
National practitioner database reports
Any malpractice payment made by an insurer on behalf of an individual physician
Path of motor evoked potential
Lower limb capsule to internal capsule to brainstem to corticospinal tract to peripheral nerve
Prevent post op ileus with
Sympathetic activity inhibits bowel motility and the surgery itself interrupts normal basal activity, and opioids May also lead to postop Ileus
Almovopan can help with postop ileus
U2
Respiratory depression, miosis, reduced Gi motility
Precedex as low as
.15 mcg per kilo has been shown to reduce postop delirium in children
Postpartum period leads to exacerbation of
MS
Avoid succ in MS can lead to
Hyperkalemia
Pataloglossus is innervated by
Vagus nerve
Most affected dermatome from herpes zoster
Thoracic
Hypophosphatemia leads to
Dysfunction of the skeletal muscles
Lack of atp
Refeeding syndrome
All eclectrolytes are low but you get hyperglycemia
Terbutaline can cause
Hyperglycemia
Tachycardia
Hypokalemia
LV diastolic dysfunction usually goes with
LV hypertrophy
Increase LES tone to block aspiration prophylaxis with
Metochlopramide - antidopaminergic agent
Iv form usually acts within 1-3 min
Helps with gastric emptying
MLT tube leads to
Increased length of tube
Mlt tube is not safe with lasers
1.5 Mac and permissive hypercapnia leads to
Higher CBF to CMR ratio
Volatile anesthetics increase CBF and decrease CMR
Brain gets
15% of cardiac output with blood flow approx 50ml/100g/min
N20 increases
CBF and CmR
Propofol and hypothermia decrease
CMR
When a patients intrinsic HR is higher and set pacemaker with lower HR and in asynchronous mode can lead to
R on T leading to V tach or V fib
Morphine can have an analgesic duration of action of
4 hours
Alfentanyl is unionized with
Low pka
FRC and TLC you cant get from
Spirometry
Fenoldopam causes increase in
Renal perfusion
Selective dopamine 1 agonist
Obesity leads to big reduction in
Expiratory reserve volume
Angiotensinogen is made in the
Liver
ACE cleaves
Angiotensin 1 to 2 and is made in the lungs
Platelets are released from megakaryocytes which are released from the
Bone marrow
IgA blood to patient who is iga deficient
Leads to transfusion rxn
CVP is the pressure in the right atrium and does not change much in
Pregnancy
SVR decreases in a normal pregnancy by about
15%
V wave
Increased venous return and systolic return to right atrium
Normal CVP
2 to 8 mm Hg
Total spinal in neonate first step is
Intubation
Usually leads to apnea/respiratory depression
Thiazides increase reabsorption of calcium in distal convoluted tubule leading to
Worsening hypercalcemia
Bladder distention can lead to
HTB intraop
Activation of NMDA receptor increases intracellular calcium which acts as a
Signaling pathway
Carotid body chemoceptors are primarily responsive to
Reductions in arterial partial pressure of oxygen
Buffering of excess hydrogen ions is why bicarbonate is low in
High anion gap metabolic acidosis
Renal failure causes metabolic acidosis bc kidney usually excretes hydrogen ions into extracellular fluid but this mechanism
Is messed up in renal failure
If patient is stable after aspiration episode
Suction the endotracheal tube
Vascular rings are a sign of
Right sided aortic arches
Milrinone is a
PDE3 inhibitor that increases inotropy
Milrinone causes venodilation which
Decreases preload
Optimum rostrel level of sensory block for c section is at
T4-S4
Second stage of labor need to cover
S2-S4
Aspirin blocks formation of
Thromboxane A2
About 10% of platelets come back each day after
Aspirin is stopped
Eliquis
Direct factor 10a inhibition
Inhaled nitric oxide
Pulmonary vasodilator
Max recommended dose of tumescent lidocaine is
55mg/kg
0.055 mg/kg is max dose of
Epinephrine
Phantom limb pain is a type of
Neuropathic pain
Don’t give carboprost if pt has
Asthma
Increases in metabolic activity of fetus will use oxygen
And decrease amount of oxygen transferred to the fetus
Fetal hgb is
Left shifted
During acidic situations oxygen binds hemoglobin
Less tightly
A side effect of PGE1 is
Apnea
PGE1 can open a
Closed ductus arteriosus
Maternal ace inhibitor usage is associated with
Oligohydraminos
Carbon monoxide poisoning will show
Metabolic acidosis with a normal Pa02 and a falsely elevated Sa02
Hyperchloremic non anion gap acidosis due to
Diarrhea
Dobutamine is good if patient is
Hypotensive
Cardiogenic shock failure of one or both ventricles
Leads to increased preload and inadequate ejection of end diastolic volume
Dopamine can lead to
Tachyarhythmia
Dobutamine increases cardiac output and decreases afterload with minimal increase in myocardial oxygen demand so it is good for
Cardiogenic shock
Don’t use volatile anesthetics or succinylcholine in kids with
Psuedohypertrophic myscular dystrophy
Avoid volatile anesthetics in muscular dystrophy
Can lead to rhabdomyolysis
Codeine must be
Metabolized to exert its effects
Metabolized to morphine with CYP2D6
High bilirubin with normal AST goes with
Large hematoma absorption
Elevations in AST Less than 2 times normal unlikely to cause
Postop hepatic dysfunction
Pousielle law
To the fourth power
Doubling radius will increase flow 16 fold
High pressure/low viscosity and short tubing lead to
Slower flow rates
Nicardipine has a prolonged half life in
Liver disease
Nicardipine is a calcium channel blocker
Nicardipine decreases
SVR and is a good coronary and peripheral dilator
Increases cardiac contractility
Renal insuffiency has no effect on nicardipine
Lead 2 is in between
Red and white electrode
Left leg and right arm
Lead 3 is between left leg and left arm
Black and red
Nitroglycerin first line in female not anesthesized for
Retained placenta
Coiling cables very high risk for
Thermal injury
Use of nonferrous cables and fiberoptic cables lowers risk of
Injury during mri
Renin release is increased in
Cirrhotic patients
Dyspnea while sitting
Platypnea
Need to monitor patient for
4-5 hours post racemic epinephrine
A sympathetic response is seen initially with
Hypoxemia followed by bradycardia
Continued use of opioids despite adverse consequences is
Addiction
Labetalol is much more beta to alpha
7 to 1 ratio
Normal ly30 is 6%
If too high need to give txa which is an antifibrinolytic bonding plasmin effectively decreasing breakdown of fiber
DHCA
Continue bypass for 20 minutes past to make sure neural tissues are cooled
Forced elbow extension
Leads to median nerve injury
Abduction of the arm too far leads to
Stretching of axillary neurovascular bundle
Too much cycling of bp cuff leads to
Radial nerve injury
Lidocaine is a weak base
Put in a basic solution will keep liocaine mainly unionized
TPN causes
Hyperglycemia
Decreasing glucose to lipid ratio of TPN leads to
Less incidence of steatosis and hypoglycemia after stopping TPN
Need to monitor glucose levels when giving TPN
Polycystic kidney disease first get
CT angiogram to screen for intracranial aneurysms
Hypochloremic metabolic alkalosis from
Loop and thiazide diuretics
Best for synthetic function of the liver is
Prothrombin time
24 hours to giving
Intrathecal morphine
AS patients like
Increased preload
Bolus dosing for propofol
Lean body mass
Baclofen pump is used to treat
Muscle spasm
Rocuronium dosing should be based
On ideal body weight
Hypokalemic periodic paralysis is caused by a
Calcium channel defect
High glucose leads to it bc will release more insulin and lower the potassium
Infants larynx is at
C3-C4
C4-c5 in adults
Lower than expected
Fi02 if crack in o2 cylinder
Lateral cricoarytenoid for
Adduction
Thyroid cartidledge
Atoms Apple
Increases in metabolic activity of fetus will use oxygen
And decrease amount of oxygen transferred to the fetus
Fetal hgb is
Left shifted
During acidic situations oxygen binds hemoglobin
Less tightly
A side effect of PGE1 is
Apnea
PGE1 can open a
Closed ductus arteriosus
Maternal ace inhibitor usage is associated with
Oligohydraminos
Carbon monoxide poisoning will show
Metabolic acidosis with a normal Pa02 and a falsely elevated Sa02
Hyperchloremic non anion gap acidosis due to
Diarrhea
Dobutamine is good if patient is
Hypotensive
Cardiogenic shock failure of one or both ventricles
Leads to increased preload and inadequate ejection of end diastolic volume
Dopamine can lead to
Tachyarhythmia
Dobutamine increases cardiac output and decreases afterload with minimal increase in myocardial oxygen demand so it is good for
Cardiogenic shock
Don’t use volatile anesthetics or succinylcholine in kids with
Psuedohypertrophic myscular dystrophy
Avoid volatile anesthetics in muscular dystrophy
Can lead to rhabdomyolysis
Codeine must be
Metabolized to exert its effects
Metabolized to morphine with CYP2D6
High bilirubin with normal AST goes with
Large hematoma absorption
Elevations in AST Less than 2 times normal unlikely to cause
Postop hepatic dysfunction
Pousielle law
To the fourth power
Doubling radius will increase flow 16 fold
High pressure/low viscosity and short tubing lead to
Slower flow rates
Nicardipine has a prolonged half life in
Liver disease
Nicardipine is a calcium channel blocker
Nicardipine decreases
SVR and is a good coronary and peripheral dilator
Increases cardiac contractility
Renal insuffiency has no effect on nicardipine
Lead 2 is in between
Red and white electrode
Left leg and right arm
Lead 3 is between left leg and left arm
Black and red
Nitroglycerin first line in female not anesthesized for
Retained placenta
Coiling cables very high risk for
Thermal injury
Use of nonferrous cables and fiberoptic cables lowers risk of
Injury during mri
Renin release is increased in
Cirrhotic patients
Dyspnea while sitting
Platypnea
Need to monitor patient for
4-5 hours post racemic epinephrine
A sympathetic response is seen initially with
Hypoxemia followed by bradycardia
Continued use of opioids despite adverse consequences is
Addiction
Labetalol is much more beta to alpha
7 to 1 ratio
Normal ly30 is 6%
If too high need to give txa which is an antifibrinolytic bonding plasmin effectively decreasing breakdown of fiber
DHCA
Continue bypass for 20 minutes past to make sure neural tissues are cooled
Forced elbow extension
Leads to median nerve injury
Abduction of the arm too far leads to
Stretching of axillary neurovascular bundle
Too much cycling of bp cuff leads to
Radial nerve injury
Lidocaine is a weak base
Put in a basic solution will keep liocaine mainly unionized
TPN causes
Hyperglycemia
Decreasing glucose to lipid ratio of TPN leads to
Less incidence of steatosis and hypoglycemia after stopping TPN
Need to monitor glucose levels when giving TPN
Polycystic kidney disease first get
CT angiogram to screen for intracranial aneurysms
Hypochloremic metabolic alkalosis from
Loop and thiazide diuretics
Best for synthetic function of the liver is
Prothrombin time
24 hours to giving
Intrathecal morphine
AS patients like
Increased preload
Bolus dosing for propofol
Lean body mass
Baclofen pump is used to treat
Muscle spasm
Rocuronium dosing should be based
On ideal body weight
Hypokalemic periodic paralysis is caused by a
Calcium channel defect
High glucose leads to it bc will release more insulin and lower the potassium
Infants larynx is at
C3-C4
C4-c5 in adults
Lower than expected
Fi02 if crack in o2 cylinder
Lateral cricoarytenoid for
Adduction
Thyroid cartidledge
Atoms Apple
Sympathetic stimulation leads to sharper phase 4
Causing quicker depolarization
Phase 0
Calcium channel opening
Patients hypoxic ventilator drive is run by
Glossopharyngeal nerve
Carotid bodies respond to
Afferent body of CN 9 for acute hypoxia
Cerebral vascular dilation will occur when using
Sodium nitroprusside
APRV can lead to
Hypercarbia if patient not spontaneous
Variable intrathoracic airway obstruction such as mediastinal mass leads to
Plateaued expiratory flow
Mediastinal mass
Intrathoracic airway obstruction
Inspiration is
Going down on flow volume loop
Goiter
Extrathoracic airway obstruction
Cyclosporine prolongs
Neuromuscular blockade the most out of the immunosuppressants
AKI following cardiac surgery
Preop creatinine greater than 1.2
Combined valve and bypass
Emergency surgery
Preop iabp
Lumbar nerve roots exit the
Same numbered pedicle
Cervical nerve roots exit above the last vertebra. Seven vertebrae and 8 nerves
Esmolol is metabolized by
Red cell esterases
Trans pulmonary pressures highest in
Restrictive lung disease
Ester local think
Parabenzoic acid
Low sodium in blood with
Cerebral salt wasting
Lumbar sympathetic blocks for cprs
Lead to failure with ejacylation
TPN common to see
Hyperglycemia hypercarbia hypophosphatemia
Airway reflexes under ketamine are
Maintained
ASIS is palpated for accurate placement of
Lateral femoral cutaneous Block
Klippel Feil syndrome in newborn
Cervical spine fusion
Endocardial cushion defects
Trisomy 21
Glycine toxicity causes
Hyperammonia
Two days of smoking cessation
Decreased carboxyhemoglobin
Shifts oxyhemoglobin curve to the right
Tracheobronchial fistula
Inhalational induction
Volatile anesthetics
Decrease CMR even at 1 Mac
Don’t use mannitol for
Cardiogenic pulmonary edema
Cyanide toxicity give
Hydroxocobalamin
Large quantities of blood products containing sodium citrate can lead to
Metabolic alkalosis
Angiotensinogen 2 increases GFR by causing
Efferent arteriole constriction
Renin hydrolyzes angiotensinogen into
Angiotensin 1
90% stenotic lesion of PDA leads to
AV nodal blockade
Preop vital capacity less than 2.9 L correlates with post op ventilation needs in those with
Myasthenia gravis
MG
Non activating antibodies bind to post synaptic ACH receptors at the neuromuscular junction
Very sensitive to NMDB but resistant to succ
Pyloric stenosis
All electrolytes are down including
Sodium
Before pyloric stenosis case put in
Og tube and suction out stomach
Bag inlet valve is a one way valve that allows
Air as well as fresh gas to flow into bag reservoir as it Reexpands
Venous drainage provides most the blood to
Liver through portal vein 75% of Livers blood supply
Hepatic artery is made up of
Lobules. Liver metabolizes nutrients. Bile produced and goes into bile duct and all form common bile duct
Liver failure
Porto pulmonary hypertension
Hepatipulmonary syndrome
Coagulation abnormality
Renal etc
Liver sometimes doesn’t metabolize
Nitric oxide leading to pulmonary HTN
Liver patients can be
Hypo or hypercoaguable
More ammonia due to liver failure can lead to
Hepatic encephalopathy
Dissection
Anhepatic
Reperfusion
Neohepatic phases of
Liver transplant
Dissection phase
Usually elevated INR, low Hgb, low plts, other issues. Lots of hemodynamic instability
Anhepatic phase
Give steroids which increase glucose but gluconeogenesis stops
Most hemodynamic instability during
Reperfusion phase
Referring syndrome
Starting to feed after prolonged starvation
HFJV causes
Passive expiration for very short period leading to Autopeep
Need TIVA with HFJV because can’t use
Inhalational anesthetic
Wind up phenomonen is due to repetitive stimulation of
Peripheral C fibers
Leads to increased action potentials in spinal synapse
Allodynia
Painful response to nonpainful stimulus
Sural nerve is a division of the
Tibial nerve
Tibial divides into
Posterior tibial and the sural nerves
Deep peroneal nerve is blocked at
Dorsum of food. Innervates between first and second toes
Saphenous is a branch of the
Femoral nerve
PEA
Start CPR and give epi as soon as possible
Atropine is not indicated in
Cardiac arrest
Hypocarbia from hyperventilation can lead to
Hypocalcemia
Centrifugal pump flow varies depending on pump
Preload/Afterload
Rheumatoid Arthritis goes with
Mitral regurgitation
Primary hyperaldosterone
Hypokalemic metabolic alkalosis
Aldosterone is made in the
Zona glomerulosa
Etomidate is associated with
30-40% nausea and 70% incidence myoclonus
Pain on injection is common with
Etomidate
Volume control ventilation
Breath at a constant flow rate
Latex causes
Type 1 ige mediated reaction
Most significant is through mucosal exposure
Latex allergy has delayed onset of
30 minutes
Succ almost always causes
Bradycardia in pediatric patients. Pretreat with atropine
Tense ascites leads to
Restrictive lung disease
The FEV1 and FVC are both decreased both ratio is normal
FEF25-75% will be normal
Decreased beta receptor responsiveness with
Age
Amionamides cause anesthetic rxn from more likely the
Preservative than the anesthetic itself
Thiazide induced blockade of sodium entry entry enhances
Na Ca antiporter activity and increases overall resorption of calcium
Thiazides work at the
Distal convoluted tubule
Carbonic anhydrase acts on
Proximal Convoluted tubule
Digoxin toxicity is caused by hypokalemia
Hypokalemia bc digoxin competes with potassium
Stellate ganglion block seizure due to
Vertebral artery injection
Bupivicaine
Potent lipid soluble agent that easily crosses BBB and can cause CNS toxicity
SEM
SD/sqrt(n)
Medial to lateral in ac fossa
Median nerve, brachial artery, radial nerve
FFP if can’t get the
ACT high enough. Give two to three units FFP which has AT3
COPD results in flow volume loop with expiratory phase with
Quick peak followed by a much lower plateau phase
Acute MR due to
Posteromedial papillary muscle rupture
AsMR progresses increases in HR will decrease
Left Atrial distension since they reduce regurgitant volume. Avoid bradycardia
Magnesium most potentiates neuromuscular
Blockade
Phenytoin acutely potentiates
Neuromuscular blockade
No Coumadin to
Pregnant women
Anyone taking steroids preop should continue them in
Perioperative period
Spinal anesthesia has faster block onset in infants
Due to higher cardiac output and loose myelination
Lambert Eaton
Proximal muscle weakness better with movement
Antibodies to presynaptic calcium channel do less AcH release
Aging see increased
Residual volume
Doubling distance from radiation source decreases exposure to
1/4 the original
Phenelzine and meperidine lead to
Serotonin syndrome
Thyroid storm usually takes place
A few hours after surgery is done
660L for 2200 psig for
Oxygen tank
Nitrous inhibits
DNA synthesis
Hepatic arterial vasodilation in response to
Reduced portal venous flow
Liver gets
20-25% of cardiac output
Nitric oxide has no role in the
Hepatic arterial buffer response
Intercostobrachial nerve from
T2 nerve root and is not blocked by any of the brachial plexus nerve blocks
Does sensation your upper medial arm
Plasmin leads to
Removal of thrombus
Aminocaproic acid is an antifibrinolytic
And prevent plasmin binding
Prevents bleeding
Argatroban inhibits
Thrombin
In fontan venous circulation bypassed the heart to reach
The lungs
Milrinone causes smooth muscle vasodilation by increasing
Intracellular cAMP levels
Grade 3 view you see
Only epiglottis
Grade 4 you can’t see eiglottis
High protein binding of bupivicaine prevents
Placental transfer
Ionized and more protein bound drugs go
Less into the placenta
Hoffman elimination is a
PH and temp related process
Proceeds more rapidly when pH and temp are higher
Glycopyrolate causes
Pupillary dilation
Loss of fetal heart rate variability is an early sign of
Fetal hypoxia
Most cancer related pain due to
Tumor invasion and metastatic tumor formation
Preeclampsia
Elevation in thromboxane A2 levels
Decrease in prostacyclin leading to
Primarily vasoconstricted state
Full term newborn blood volume
80-90 ml/kg
Lateral ankle covered with
Sciatic nerve block
Sciatic covers posterior thigh sensation and all the leg below the knee
Doesn’t do medial strip supplied by the saphenous
Butorphanol
Mixed mu opioid receptor agonism and antagonist plus kappa receptor agonism
Methadone
Mu opioid receptor agonist and NMDA antagonist
Morphine improves coronary perfusion through
Reduction in preload and a reduction in end diastolic pressure in the ventricles
Preload is ventricular volume at end of
Diastole
Morphine reduces
Preload and afterload
PDA blood will flow preferentially to the
Lungs
Newborn experiences a mild and transient anemia at
8-12 weeks of life
Opioids staying in epidural space mainly due to
Lipophilicity. More lipophilic will stay at the level of injection
Forceps delivery a risk factor for
HIV vertical transmission
Jaw thrust maneuver affects
Genioglossus muscle
Amniotic fluid embolus leads to
Intense pulmonary vasospasm
Manual replacement of bulging membranes prior to induction is not recommend as may increase risk of
Premature rupture
Ischemia reperfusion injury during liver transplant surgery is due to
Alteration of the sodium potassium pumps to maintain ion gradients
Termination of a bolus dose of thiopental mainly due to
Redistribution of the drug from the brain to the peripheral tissues
CT scan during strike should get within
25 minutes and interpretation within 45 minutes
Refractory v fib despite multiple rounds of CPR and rounds of epi and defibrillation next consider
Amiodarone
Administration of anticholinergic medication such as
Benztropine or diphenhydramine quickly and reliably treats eps symptoms from antidopaminergics
If refractory to vasopressors with septic shock can give
IV hydrocortisone 200mg daily
Hydrocortisone inhibits nitric oxide
Synthesis
Second order neuron for pain goes with
Spinothalamic tract
Lumbar sympathetic block for
First stage of labor
Mechanism of action of midazolam
Positive allosteric modulator of GABAA receptor
Only hard palate is seen if
Mallampati 4
Increased ICP can use
Etomidate to induce
Never hyperventilate to PaC02 below
25, even with high ICP
CPP =
CBF-ICP or CVP whichever is greater
Amiodarone commonly causes
Bradycardia
Lactic acidosis most likely seen in a
Hypovolemic trauma patient getting contrast
Transfusion is for
Inadequate oxygen delivery
Citrate is anticoagulant binding
Calcium in blood
Blood stored at
1 to 6 degrees Celsius
Definition of viability of RBCs is greater than
70% to survive and function after being transfused first >24 hours
Most common blood type is
Group O
Alloantibodies are antibodies to
Foreign antigens
If you give two units o negative
Stay with O negative
Platelets are activated
To start a clot
Fibrinolysis
Remodels clot and removes thrombus
Only factor not made by liver is
8
ACT
90-120 seconds is normal
Physiologic changes to anemia
Cardiac output increases with decreased SVR increased HR
Oxygen availability increased at cellular level by increased DPG levels
Shunting of blood to core organs
Hgb mine portion of
Oxygen equation
Can’t wash cells if
Infection, urine, amniotic fluid, malignancy
10K to 50K platelets
Spontaneous bleeding likely
VwF
Due to platelet dysfunction but platelet number is good
MTP
1 plt 1 FFP 1 prbc
Citrate intoxication
Hypocalcemia
Treat with calcium
TRALI
Most common acute transfusion rxn
Most blood rxn due to
Giving wrong blood to wrong patient
Contractility compromised by
Myocardial dysfunction or acidosis
Afterload equals
Resistance against ventricular blood flow with each contraction
Oxygen hemoglobin has
4 oxygens
Tissue acidosis increases
Oxygen unloading Bohr effect
Resistance to catecholamines after
Too much shock
Hypocapnia with acidosis bc you have to
Breath more to drive off acid
Hyper dynamic system
Hypotension due to decreased SVR
Hypodynamic state due to
Decreased CO with compensation by increasing SVR
3-7 days post LAD infarct can lead to
Papillary muscle rupture
Isolated RV infarcts are
Rare
Treat with fluid and inotropy rather than pressors
Inhalation equals negative pressure and decreased intrathoracic pressure
More fluid in right heart
RA collapse with
Tamponade during systole
PE
Pleuritic chest pain Tachycardia Hypoxemia Respiratory alkalosis RV strain
Best for treating hypotension in setting of severe acidemia
Vasopressin
SV02 90% least appropriate is
Milrinone
Don’t want to decrease SVR more
Myocardial 02 consumption most work for heart is in order
HR then afterload then Preload
Secondary hyperaldosteronism
Increased renin
Spirnolactone
Potassium goes up
Antigypertebsive by blocking aldosterone
Intraop steroids needed if
Prednisone 20mg or more for greater then 3 weeks
If minor surgery just take morning dose
Major give morning dose plus 100mg hydrocortisone
Ephedrine stimulates
Catecholamine release
Carcinoid rumors release
Vasoactive substances such as serotonin/histamine
Carcinoid tumors are mainly found in
GI tract
Serotonin causes
Vasoconstriction and possible coronary artery spasm
Serotonin metabolites in
Urine for carcinoid
Pancreatic pituitary parathyroid =
MEN type 1
Elevated fasting blood glucose >126
A1C > 6.5%
Diabetes
Tachypnea
Abdominal pain
Nausea vomiting with
DKA
Due to low insulin and catabolism of free fatty acid
DKA and HHS
Fluid resuscitation insulin and potassium to treat
Carcinoid disease you should get an
ECHO
RASS system blocked when chronically taking
Corticosteroids
Fluid status and thus CVP generally stays normal
With adrenal suppression
Septic patient induced with etomidate can get
Adrenal insufficiency
Increased MAC at
High atmospheric pressure
At higher atmosphere
Reduced ambient pressure
Reduced partial pressure
Reduced gas density
High altitude PVR
Goes up
Lead V5 best for detecting
Ischemia
Arterial hypoxemia
Hypoventilation
Diffusion impairment
Shunting
Major predictor of cardiac risk
Unstable coronary syndromes
AcuteMI within last seven days or recent MI within 1 month with clinical symptoms
Decompebsated heart failure
Significant arrhythmias
Severe valvular disease like <1 cm for severe aortic stenosis
Three major determinants of myocardial oxygen demand are
Myocardial LV wall tension(preload/afterload)
Cardiac contractility
HR
Meralgia paresthetica
Mono therapy of the lateral femoral cutaneous nerve
TNS associated with
Spinal
Bilateral or unilateral pain in the buttocks radiating to the legs and resolving within one week or less
Deceased breath sounds on the right in Peds after aspirating foreign body
Aspiration
Croup mainly caused by
Parainfluenza or RSV
Congenital muscular dystrophy
Hypotonia, feeding difficulty, respiratory dysfunction
In abscence of hemorrhage can wait up
To an hour for placenta to deliver
Retained placenta is second most common cause of PPH
25% of cases
Most common is uterine atony
Mannitol containing priming solutions used in CB bypass is found to
Improve urine output
Esophageal perforations need to be treated with
Medical or surgical intervention even if vitals are stable
Hypercalcemia antagonizes NMDBS so need a
Higher dose
Category data best for
Chi square test
Shows goodness of fit if data from chance alone
Most important predictor of desaturation on one lung is
Pa02 with two lung
Laryngeal edema causes stridor
Post extubation
Laryngeal edema from pressure of endotracheal tube on the mucosa
Superior laryngeal nerve
Innervated the cricothyroid muscle
Registry studies
Describe rare events
Most likely cause of shivering during labor in a patient with a epidural is
Redistribution of core heat to the periphery
Prejunctional is nerve related
Post junctional is muscle related
More ACHrs in burn patients so need to give more
NMDBs
Glaucoma due to increased
IOP
Zofran is safe
Open globe eye injury avoid increases in IOP so don’t use
Succinylcholine
Unless difficult airway
Hepatopulmonary triad
Liver dysfunction, otherwise unexplained hypoxia, and intrapulnknary vascular dilation
Alpha 1 antitrypsin deficient affects
Lung and liver
Ketamine enhances
Motor evokes potential amplitude the most
Best indicator of liver transplant graft function is
INR
Which anesthetic potentiates neuromuscular blockade the most
Desflurane
Vital capacity
Unchanged in pregnant women
Quick propagation of electrical signal in cardiac myocyte is due to
Gap junctions
Stage one and two of labor pain can be relieved by
Caudal epidural
Intercostal nerve blocks
One of the highest rates of systemic absorption due to vascularity
Low risk of local anesthetic toxicity if blocking one level
Every patient receiving any anesthesia must have
ECG
Acute herpes zoster deratomal distribution is mainly
Thoracic
DLCO looks at
Diffusion capacity of the lung
Lowered by PE
Best for cerebral vasospasm after SAH
Cerebral angiography
Most aneurysms occur in the
ICA
Small less than 12 mm is most
If CT is negative use what to diagnose SAH
LP
Risk of bleeding after ruptured aneurysm is highest
24 hours after
Cooling of aneurysm big complications are
Hemorrhage or thrombosis
If cool malposiyioned continue anticoagulation
While IR snares the coil
Don’t premeditate before
Craniotomy
Patient at risk of aspiration
Medications to decrease gastric acidity and volume are appropriate
Must prevent rupture of aneurysm on
Induction while maintaining adequate CPP
Done need a line for
Unruptured aneurysm that needs to be coiled
MEPs for
Subcortical ischemia
CPP =
Transmural pressure
If too high aneurysm ruptured
If too low you get ischemia
Pa02 less than 60 increases
CBF
After Dural opening one of the best ways to decrease ICP is with
Hyperventilation, also helps with surgeon exposure
Trans pulmonary pressures are highest in patients with
Restrictive lung disease such as idiopathic pulmonary fibrosis
Acute mountain sickness best prophylaxis is
Acetazolamide
Preservation of laryngeal reflexes with
Ketamine
Cerebrovascular disease is not associated with
Postop AKI
TRALI within
6 hours
Non cardiogenic pulmonary edema
Heparin acts on
AT3
Heparin resistance if AT3<60% Plt count>300000 LMWH Preop heparin Age>65
Treat again with heparin AT3 or FFP
Improper canning leading to botulism
Equine serum antitoxin
Activation of Nicotinic AcH receptor on motor end plate results in
Inward flow of sodium ions
Calcium leads to release of Ach into synapse
Calcium ions do not flow through nicotinic AcH
Prolonged steroid leads to
Myopathy and can lead to muscle weakness
Controlled ventilation is not recommended for
Congenital emphysema
Etomidate given as a bolus can help identify
Seizure foci
Etomidate inhibits
11 beta hydroxylase
Albumin down in pregnancy as
Plasma volume goes up
Smoking cessation in first week leads to more
Sputum production
Smoking causes
Vasoconstriction leading to decreased blood flow to certain areas
Sodium<= 155 Map 60-120 CVP 4-13 Pa02/Fi02>300 Glucose<150 Hgb>10 Ef>50%
Goal for organ procurement after brain death
Succinylcholine induced hyperkalemia
Greater than 0.5 as a result of potassium reflux
Myasthenia gravis
Antibodies against postsynaptic ach receptors
MG usually
Thyroid issues
Progressive weakness with activity
MG postop mechanical ventilation
Duration longer than 6 hrs
Chronic respiratory disease
Pyridostigmine dose greater than or equal to 750 mg
Vital capacity less than or equal to 2.9L
Anestgesia dolorosa
Pain in a region that is deenervated with no sensation at all and is a pain referral
Closing capacity is when small airways start to close at
Certain lung volume
High CC means small airways close before FRC leading to atalectasis bc the small airways close before end exhalation
Deceased FRC leads fo
Atelectasis
Midazolam does not cause
Drug fever
Exposure to Hep B blood or bodily fluids
Get HBV hyper immune globulin
Also offer vaccination
Only 10% of acute HBV infections progress to
Chronic HBV carrier state
Valproic acid not helping for
CPRS type 2
Cprs type 2 is precipitated by a
Nerve injury
Physical therapy is first lint treatment
Hypocalcemia is expected in patients with
ESRD
Kidney can’t reabsorb calcium as well
CP patients increased incidence of GE reflux and
Esophagealdysmotility
CP can give
Succ
No big hyperkalemic response
Tachycardia is a universal funding in
Thyroid storm and malignant hyperthermia
Urine sodium is high with
Acute tubular necrosis
Albumin down in pregnancy as
Plasma volume goes up
Smoking cessation in first week leads to more
Sputum production
Smoking causes
Vasoconstriction leading to decreased blood flow to certain areas
Sodium<= 155 Map 60-120 CVP 4-13 Pa02/Fi02>300 Glucose<150 Hgb>10 Ef>50%
Goal for organ procurement after brain death
Succinylcholine induced hyperkalemia
Greater than 0.5 as a result of potassium reflux
Myasthenia gravis
Antibodies against postsynaptic ach receptors
MG usually
Thyroid issues
Progressive weakness with activity
MG postop mechanical ventilation
Duration longer than 6 hrs
Chronic respiratory disease
Pyridostigmine dose greater than or equal to 750 mg
Vital capacity less than or equal to 2.9L
Anestgesia dolorosa
Pain in a region that is deenervated with no sensation at all and is a pain referral
Closing capacity is when small airways start to close at
Certain lung volume
High CC means small airways close before FRC leading to atalectasis bc the small airways close before end exhalation
Deceased FRC leads fo
Atelectasis
Midazolam does not cause
Drug fever
Exposure to Hep B blood or bodily fluids
Get HBV hyper immune globulin
Also offer vaccination
Only 10% of acute HBV infections progress to
Chronic HBV carrier state
Valproic acid not helping for
CPRS type 2
Cprs type 2 is precipitated by a
Nerve injury
Physical therapy is first lint treatment
Hypocalcemia is expected in patients with
ESRD
Kidney can’t reabsorb calcium as well
CP patients increased incidence of GE reflux and
Esophagealdysmotility
CP can give
Succ
No big hyperkalemic response
Tachycardia is a universal funding in
Thyroid storm and malignant hyperthermia
Urine sodium is high with
Acute tubular necrosis
Propofol related infusion syndrome
No thrombocytopenia
Be careful giving vasopressin to patients with CAD as may lead to
Vasoconstriction of coronary arteries
Myssthenic syndrome patients are sensitive to
Succ
Children with strabimus are 4 times more likely to
Demonstrate masseuse muscle rigidity
P= 2T/R
For alveoli bubble
Anatomic dead space is about
2 ml/kg
Dorsal respiratory center mainly for
Inhalation
Ventral is for both
Elective case hold for
Sodium>150
Oliguria
0.5 ml/Kg/hr
Anuria
Urine output<50 ml per day
Neural tube defect should be ruled out before placing
Caudal catheter
Preeclampsia associated with an increase in
Thromboxane A2 levels
Lactated ringers lactate can make metabolic alkalosis worse as it is converted to
Bicarbonate
Tachycardia Is only a minor criteria for
Fat embolization syndrome
For diagnosis of ARDS don’t need
Wedge pressure less then 18
Phrenic nerve stimulators are utilized to improve, not worsen
Atelectasis
A child greater then 1yo blood volume
70-75 ml/kg
In line stabilization of cervical spine
One gets head and neck in neutral position
2 stabilizes the shoulders
Potassium iodide can help with
Radiation exposure
Labetalol is
7 to 1 beta over alpha
Anesthesia dolorosa
Pain in a region that is deenervated and should have no pain at all
Fat embolus does not require
Heparin
Half life of methadone
13 to 50 hours
Methadone does not need to be adjusted with
Kidney disease
Inhaled anesthetics and zofran increase
QT interval
Don’t give hydrocortisone to patient with
Septic shock responsive to fluids and vasopressors
Heparin anticoagulant effect is
90 min
Normal ACT
90 to 120
Tissue thromboplastin is added to patients plasma
PT
Micro vascular bleeding andPT/PTT exceeds 1.5 the control value
FFP should be considered
Cryo lacks factor
5
Severe aspirin toxicity
Dialysis
