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
