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Anesthesia Oral Boards > UBP book 1 > Flashcards

UBP book 1 Flashcards

1
Q

Why inc bleeding in ESRD?

A

uremia -> impaired vWF -> impaired plt function

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2
Q

Anesthesia concrens in ESRD

A

-electrolyte abnormalities
-metabolic acidosis
-cardiac conduction blockade
-LVH/CHF
-hyperglycemia
-bleeding (uremia impairs vWF)
-altered drug clearance
-anemia
-chronic HTN

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3
Q

Risks assoc w/ laparoscopic surgery

A

-capnothorax
-trocar induced trauma to bowel or blood vessels
-pneumoperitoneum-induced hypotension
-CO2 emphysema

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4
Q

Assess volume status in ESRD

A

-hypovolemic immediately post HD
-hypervolemic prior to next sesion
-how often HD, when last one, how much fluid taken off
-s/s of fluid OL or hypovolemia: pulm edema, HTN, peripheral edema = hypervolemia
-dry mucous membranes, hypoTN, orthostasis = hypovolemic

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5
Q

Elective surgery K cutoff

A

5.5 -> inc risk of cardiac irritability and arrhythmias

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6
Q

ESRD need emergent ex lap, K 5.6, what to do?

A

-hyperK inc risk of cardiac irritability and arrhythmias
-correct any metabolic acidosis or hypoCa (assoc w/ ESRD)
-avoid succ, K containing solutions (LR)
-avoid metabolic or resp acidosis
-prepare to treat hyperK w/ Calcium, glucose/insulin, albuterol, hypervent
-defibrillator in room
-proceed w/ case while monitoring EKG and K

**if urgent/emergent -> ERSD tolerate higher K at baseline

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7
Q

ESRD K 6.2 what would you do?

A

-if case can be delayed, HD prior to surgery
-hyperK inc risk of cardiac irritability and arrhythmias
-correct any metabolic acidosis or hypoCa (assoc w/ ESRD)
-avoid succ, K containing solutions (LR)
-avoid metabolic or resp acidosis
-prepare to treat hyperK w/ Calcium, glucose/insulin, albuterol, hypervent
-defibrillator in room
-proceed w/ case while monitoring EKG and K

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8
Q

mechanism of anemia in pts with ESRD

A

-dec erythropoietin production
-dec RBC survival
-GI blood loss
-iron/vit def
-usually well tolerated b/c CKD metabolic acidosis and inc 2,3-DPG induce R shift of hg-O2 dissociation curve

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9
Q

Hg baseline 9, would you transfuse pre surgery for ESRD?

A

-assuming no significant CAD, no b/c mild anemia well tolerated
-b/w metabolic acidosis and inc 2,3-DPG, they have a R shift of Hg-oxygenation curve -> offloading of O2 from Hg
-decision depends on severity of anemia, risk of excessive blood loss during surgery,

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10
Q

blood transfusion post kidney transplant

A

avoid if at all possible b/c leukocyte antigens in the blood may lead to development of alloantibodies -> predisposing to rejection of the implanted kidney
-if you do need, give PRBCs that are washed (leukocyte reduced), irradiated (red risk of transfusion-assoc graft v host dx), and CMV negative

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11
Q

ESRD, concern for cardiac fxn?

A

-since volume overload, uremia, anemia and acidosis w/ ESRD -> HTN, dilated cardiomyopathy, CHF, CAD, conduction blocks, arrhythmias, pericarditis

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12
Q

HTN, ESRD, obesity, emergent surgery, risks of anesthesia?

A

-risk of aspiration
-risk of fluid overload requiring HD after
-risk of remaining intubated, difficult intubation
-postop bleeding
-postop infxn
-cardiac arrhythmias
-SE of meds (narcotic ind resp depression, prolonged drug effects)
-assure will take steps to minimize these risks, and delay of surgery carries more risk

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13
Q

ESRD, what preop w/u?

A

-CBC for anemia
-BMP for lytes (sp Na, Ca, K)
-EKG to look for hypertrophy, signs of ischemia or conduction distrubances
-CXR: fluid status, pulm status
-if SOB: consider ABG
-coags if regional

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14
Q

EKG stands for

A

electrocardiogram

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15
Q

ESRD, good cardiopulm status, emergent ex lap, monitors?

A

standard ASA (incl 5 lead EKG to monitor for ischemia)
-due to placement of AVF, avoid BP cuff or PIV on same arm

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16
Q

ruptured diverticulum, emergent ex lap with abd tightness w/ generalized tenderness , ESRD, induction?

A

-place NGT -> empty stomach as much as possible
-aspiration ppx (avoid metochlorpramide b/c bowel rputure -> famotidine and nonparticulate antacid sodium citrate)
-place pt in RT to improve resp mechanics, reduce passive regurge, and facilitate rapid intubation
-preoxygenate w/ 100%
-perform RSI w/ cricoid pressure, use roc to avoid inc in K w succ 0.5 mEq/L

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17
Q

Drugs to avoid in ESRD

A

-dpt on renal elimination or active metabolites that accumulate in renal failure: pancuronium, atropine, glyco, ketamine, morphine, diazepam, meperidine
-red dose of drugs that are highly protein bound: benzos

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18
Q

AFter intubation, SpO2 dec to 91% w/ FiO2 100%, ddx?

A

-inadequate ventilation
-advancement of ETT into R mainstem bronchus
-bronchospasm
-Less likely: changes in pulm compliance w/ supine position in obese pt, ateletasis, obstruction of ETT, hypoxic gas mixture

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19
Q

how can capnograph help determine causes of hypoxia

A

-helpful in identifying causes: esophageal intubation (flat), obstructive lung dx, bronchospasm (more rounded during initial phase of exhalation, upward slope w/ plateau
-EtCO2 doesn’t go back to zero: incompetent ventilatory valves (rebreathing)
-incomplete m relaxation, breathing against the vent (curare cleft)

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20
Q

ESRD, hemicolectomy, how would you manage fluid administration?

A

-keep maintanence fluids at 1-2 cc/kg/hr: to replace insensible loss and third space losses
-would replace blood loss w/ colloid or pRBCs rather than 3:1 w/ crystalloid
-w/ hyperK and glucose intol: avoid LR and glucose cont solutions

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21
Q

hypotension despite fluid replacement, what do you do?

A

-recheck BP
-ensure adequate ventilation and oxygenation
-check EKG for ischemia or arrhythmia or changes w/ hyperK
-look at surgical field
-place pt in trendelenberg
-fluid bolus, consider adminstration of vasoconstrictor

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22
Q

post ex lap w/ NGT, how to extubate?

A

assuming extubation criteria were met, ensure
-complete reversal of muscle relaxants
-adequate oxygenation, normocarbia
-hemodynamically stable
-sufficient TV w/ spontaneous ventilation
-use NGT to empty stomach
-extubate once awake, alert, and exhibiting intact airway reflexes

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22
Q

vomiting on emergence w/ ETT still in place

A

-turn pts head to the side
-put table in trendelenberg (gastric material away from airway)
-suction oropharynx
-suction ETT
-utilize NGT to empty stomach as much as possible
-treat any bronchospasm
-monitor pt for signs of hypoxia

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23
Q

hypoxia in PACU ddx

A

-aspiration
-sedation
-upper airway obstruction (esp if obese w/ OSA)
-inadequate ventilation
-atelectasis
-pulm edema
-PE

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23
Q

PACU RR 18, O2 sat 90%, auscultation lungs clear, breath sounds absent at L lung base

A

-continue to provide O2
-assess level of sedation
-head up position
-incentive spirometry, CXR, ABG
-consider c/s pulm

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23
Q

OSA obesity, ESRD on HD, ex lap with infxn, epidural?

A

Assuming appropriate abx have been started pt not actively septic, no coagulopathy yes epidural
-esp since dec pulm compl with epidural and minimize narcotics
-be sure to coordinate removal w/ HD 1 hour before heparinization or 2-4 hours after heparinization

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23
Q

epidural placement receiving unfractionated heparin?

A

wait 4-6 hrs w/ subq ppx dosing (lower dose 5000U )
wait 4-6 hours w/ IV heparin and verify normal coags
waiti 12 hours w/ sub q ppx dosing (higher dose 7500 or 10000U) and assessment of coags
-wait 24 hours for subq therapeutic dosing

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23
Q

When to stop heparin infusion to remove epidural catheter?

A

4-6 hours

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24
Q

When to restart heparin after epidural catheter removal?

A

1 hour

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24
Q

when to restart higher dose (7500 or 10000U) subq heparin after epidural catheter placement?

A

don’t do it

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25
Q

when to restart heparin 5000U subq heparin after epidural catheter placement?

A

immediately

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26
Q

when to restart IV heparin w/ epidural catheter in place

A

1 hour

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27
Q

When do you need a plt count prior to putting an epidural in w/ pt on heparin?

A

if on heparin for more than 4 days

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28
Q

enoxaparin LMWH ppx BID when to place epidural?

A

12 hours late

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29
Q

enoxaparin LMWH ppx BID when to remove epidural?

A

> 4 hours

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30
Q

enoxaparin LMWH when to restart after epidural removal?

A

> 4 hours

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31
Q

enoxaparin LMWH therapeutic, when to place epidural?

A

24 hours after administration

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32
Q

enoxaparin LMWH therapeutic, when to remove epidural?

A

24 hours after catheter placement, or 4 hours prior to first postop dose

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33
Q

enoxaparin LMWH when to restart after epidural removed?

A

24 hours after non-high risk bleeding surgery
48-72 hours after high bleeding risk surgery

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34
Q

Pt on clopidogrel, how long do you have to hold prior to spinal?

A

7 days

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35
Q

Apixaban and neuraxial blockade, how long do you hold?

A

72 hours

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36
Q

How to perform a machine check

A

-turn on machine and monitors
-verify presence of emergency ventilation equipment
-calibrate/set the capnometer, pulse ox, O2 analyzer, and pressure monitors and alarms
-check high pressure system by opening each E-cylinder to ensure adequate gas pressure (O2 at least 1000 psig = half full)
-verify central pipeline hoses connected
-confirm pipeline gauges read 50 psig
-then check low pressure system: filled vaproizers, check for leaks, test flowmeters
-check scavenging system, calibrate O2, ensure proper ventilator function, check integrity of unidirectional valves
-inspect circuit
-verify adequate CO2 absorbant
-ensure availability of airway equipment and suctioning

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37
Q

how to check for leaks in a low pressure system

A

-low-pressure leak test -> verify proper method of testing for workstation using

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38
Q

What protects against the delivery of a hypoxic mixture

A

-fail safe alarm: sounds if press ure in O2 pipeline falls below 30 psig
-O2 failure cut off valves, which dec or d/c flow of other gases when O2 pressure dec below a certain threshold
-vigilance and proper monitoring of O2 analyzer

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39
Q

Desflurane vaporizer

A

-electrically heated to create vapor pressure of 2 atm -> pure des vapor is mixed w/ FG prior to exiting vaporizer

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40
Q

Sevoflurance vaporizer

A

variable-bypass vaporizer
-variable amount of gas is directed into vaporizing chamber where it mixes w/ volatile agent before returning to mix w/ rest of carrier gas that was directed to bypass the chamber

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41
Q

Pathogenesis of SCD?

A

-mutation in chromosome 11 results in hemoglobin S
-in dec O2, Hg S -> deformation of RBC membrane into sicked shape -> hemolysis, microvascular occlusion of capillaries, ischemic injury to organs, infarcts, and hemolytic crisis

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42
Q

Comorbidities with sickle cell disease

A

-chronic anemia, hypoxia, and hemochromatosis can cause:
-cardiomegaly
-CHF
-pulm HTN
-neuro deficits
-renal insuff
-painful crisess
-acute chest syndrome
-retinopathy
-aseptic necrosis of the femoral head
-asplenia (inc risk of infxn from encapsulated organisms)

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43
Q

Exchange transfusion in SCD prior to surgery?

A

-No, growing evidence to suggest preop Hcg > 30% for mod to high risk surgeries is just as effective to dec morbidity
-exchange transfusion typically requires more transfusions inc risk of transfustion-related complications
-instead transfuse to Hct . 30% to inc O2 carrying capacity and prevent sickling

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44
Q

prevent sickling intraop

A

AVOID: hypoxemia, hypotension, hypothermia, hypercarbia, acidosis, and hypovolemia
-adequate postop pain control
-Hct 30-40%

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45
Q

treatment of sickle cell crisis

A

-pain control
-hydration
-suppl O2
-maintain adequate Hct levels
-tx infxn
-consider exchange transfusion to reduce Hg S to < 40%

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46
Q

14 YOM hx of masseter muscle spasms, what do you want to know preop

A

H&P!
-circumstances of masseter spasm, severity, how treated, type of anestehsia, result of w/u related to it
-family hx of anestheic complications (esp masseter spasm or MH)

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47
Q

14 YOM masseter spasms T&A, what type of anesthesia?

A

-TIVA fent, prop infusion
-masseter muscle rigidity following administration of a known triggering agent: succ or volatile -> indicate susceptibility to MH

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48
Q

peds succ given, uanble to open pts jaw, what to do?

A

Mask ventilate w/ 100%
-if difficult: call for help, nasal airway, attempt nasal intubation, prepare for possible surgical airway
-concerned for MH: admit to hospital, place art line, monitor EtCO2, CK, temp, acid-base status, lyte levels
-evaluate for myglobinuria, generalized rigidity
-MH cart/hotline

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49
Q

peds masseter rigidity after succ, cancel the case?

A

Yes, b/c succ-induced trismus -> MH susceptibility is high, d/c all triggering agents, cancel the case, and monitor the patient for 12-24 hours
-recommend a caffeine halothane contracture test

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50
Q

elective lap chole
thyroid nodule on PTU
BP 162/98, HR 119, Hct 29%
proceed w/ surgery?

A

No, concerned about her resting HR, HTN, and anemia
-H&P identify any signs and symptoms of thyroid dysfunction, order additional lab tests, proceed as soon as reasonable

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51
Q

signs and symptoms of thyrotoxicosis

A

-cardiac: tachycardia, arrhythmias, cardiomegaly, inc SV andn CO
-dec SVR/PVR
-neuro: anxiety, agitation, tremors, insomnia, m weakness
-sweating, heat intolerance, weakness, weight loss

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52
Q

labs for thyroid function

A

TSH, free T3, free T4
-likely elevated free T3 and T4, and low TSH

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53
Q

Prepare emergent surgery if in active thyrotoxicosis

A

-goal to minimize risk of hemodynamic instability, cardiac arrhythmias, and thyroid storm
-c/s endocrinologist, continue PTU, beta blocker (goal HR < 90)
-glucocorticoids (reduce thyroid hormone secretion and peripheral conversion of T4 to T3)
-ensure adequate hydration and a normal electrolyte balance
-consider small dose of benzos for anxiety

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54
Q

hx of CAD, start a beta blocker preop?

A

If not already taking, no -> inc risk of pulm edema, hypoTN, bradycardia, stroke, possibly bronchospasm
-acknowledge at inc risk for periop atrial arrhythmias (a fib) due to CAD -> could give diltiazem

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55
Q

RF for postop atrial arrhythmias

A

male gender
COPD
CAD
peroip theophylline use (bronchodilator)
advanced age

**consider diltiazem to pts at inc risk

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56
Q

Benefits of epidural placement

A

-facilitates early intubation
-improved postop pulm fxn
-improved GI blood flow
-dec risk of anastomotic leak (thoracic epidural)

**be careful of sympathectomy

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57
Q

What to dose an epidural with?

A

low concentration local anesthetic with hydrophilic opioid (hydromorphone) allowing to cover a wider number of dermatomes
-spread more limited w/ lipophilic opioids

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58
Q

66 YOF transthoracic esophagectomy, smoker, CAD, GERD, monitors?

A

standard ASA monitors (incl 5 lead EKG for ischemia monitoring)
foley
arterial line
central line (possible hemodynamic instability)
-limited blood supply of gastric tube -> inc risk that hypoTN leads to anastomotic leakage or dehiscence)
-cardiac arrhythmias common, vagal stimulation, compression of heart or great vessels by surgeon

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59
Q

66 YOF transthoracic esophagectomy, smoker, CAD, GERD, monitors?

A

-aspiration ppx w/ metoclopramide, famotidine, and sodium citrate
-albuterol pre induction
-place pt in RT to optimize resp mechanics and minimize passive acid regurgitation
-preoxygenate, place pre-induction arterial line using lidocaine to numb the skin prior to insertion
-fent, lido, etomidate, and succ to RSI
-apply cricoid pressure
-DL and insert ETT
-place NGT to decompress esophageal conduit and stomach
-when surgeon ready for thoracotomy -> i would evacuate the stomach and exchange for a DL ETT

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60
Q

Transthoracic esophagectomy 2 phases

A

1st: laparotomy in supine position and creation of neoesophagus w/ stomach
2nd: R sided thoracotomy (req DLT)

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61
Q

Esophageal surgery and aspiration

A

-everyone w/ esophageal surgery inc risk of aspiration
-if obstruction, good change even w/ NPO, food remains in the proximal exophagus -> bacterial grwoth -> inc risk of aspiration pneumonitis w/ aspiration
-suction proximal esophagus
-w/ chronic aspration -> pulmonary fibrosis => DOE
-if hx of esophagectmoy :inc risk of aspiration their whole lives

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62
Q

One lung ventilation settings

A

TV 4-6 cc/kg of ideal body weight
-PEEP of 5 on dependent lung
-avoid volutrauma from overdistention

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63
Q

hypoxia w/ one lung ventilation in esophagectomy v lung resection

A

higher risk of hypoxia w/ esophagectomy
-b/c V/Q mismatch limited in lung resection b/c disease lung has diminished blood flow -> bigger V/Q mismatch in esophagectomy

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64
Q

Following induction, gastric contents in oropharynx, what to do?

A

-turn pts head to the side
-put bed in trendelenberg
-cricoid pressure
-suction oropharynx
-DL and put in ETT
-suction ETT and look w/ fiberoptic prior to attaching pt to vent
-place NGT to suction remaining contents
-order CXR and ABG
-monitor pt for 24-48 hours for development of asp pneumonitis

65
Q

steroids or abx ppx for aspiration pneumonitis

A

No, lack of evidence proving to be effective -> not worth the SE from the steroids or abx
-can lead to drug resistance

66
Q

RF for aspiration

A

-obesity
-delayed gastric emptying (pain, acute abd, cirrhosis, chronic alcohol abuse, autonomic neuropathy)
-pregnancy
-neurologic dysphagia
-bowel obstruction
-dirsuption of gastroesophageal jxn
-extremes of age
-hx of GERD

67
Q

what determines risk of developing aspiration pneumonitis?

A

volume of aspirate > 25 cc
gastric fluid pH < 2.5
**gastric pH more important

68
Q

When to consider abx for aspiration pneumonitis

A

-demonstrated bacterial infxn on culture and sensitivity testing
-pts clinical course failed to improve or worsened after 2-3 days

69
Q

Cirrhosis and ascites, colon cancer surgery, w/u?

A

-CBC, BMP, Coags, T&S
-bilirubin, transaminasas, alk phos, albumin, total protein, PTT, INR, hepatitis serologies
-onset and etiology of his cirrhosis -> jaundice, bleeding d/o, ascites, asterixis, hepatic encephalopathy

70
Q

systemic effects of cirrhosis

A

resp effects: intrapulm AV shunts, reduced FRC, restrictive lung dx, pleural effusions, attenuation of HPV
-neuro: accumulation of ammonia and toxins -> encephalopathy
-hepatic: thrombocytopenia,

71
Q

51 YOM cirrhosis and ascites hemicolectomy colon cancer, how would you induce?

A

ascites and possible gastroparesis -> RSI
-asp ppx, AVOID metochlopramide in setting of bowel obstruction
-RT to reduce passive reguge and facilitate intubation
-preoxygenate
-cricoid pressure
-give lidocaine, prop, and succ -> rapidly secure airway

72
Q

51 YOM cirrhosis and ascites hemicolectomy colon cancer, muscle relaxant for maintenance?

A

Cisatracurium
-hoffman elimination not dependent on liver metabolism
-if not available, recognize possibility of prolonged action

73
Q

1L of ascites fluid removed, pt hypotensive, ddx?

A

-loss of ascitic fluid -> large fluid shifts (Most likely)
-differential also incl: surgical or GI bleeding, tension PTX, hypoxia, cardiac arrhythmia, or cardiac failure

74
Q

PDPH POD1, would you place a blood patch?

A

-consider since it is the most effective treatment option
-but recognize pt might be on anticoagulation w/ recent knee surgery -> inc risk for epidural or spinal hematoma

75
Q

Signs of PDPH

A

-frontal-occipital HA
-dec pain w/ laying flat
-N/V
-neck stiffness
-back pain
-photophobia
-diplopia (stretching on the abducens n)
-tinnitus (stretching on the vestibulocochlear n)
-can get a seizure 2/2 to cerebral vasospasm

76
Q

PDPH blood patch contraindicated, treatment options?

A

-hydration
-caffeine
-abd binder (inc intra-abd pressure)
-alternative pain control

77
Q

TKA, femoral and sciatic n block, during block placement, seizure and LOC, ddx?

A

TOP: LAST
-other factors on ddx: hypoxia, acidosis, MI, alcohol w/d, sz d/o

78
Q

signs and symptoms with LAST?

A

intial sym: metallic taste, oral paresthesias, tongue numbness, visual disturbances, tinnitus, lightheadedness, dizziness
-CNS: agitation, shivering, m twitching, tremors, sz
-resp depression, tachycardia, ventricular arrhythmias, bradycardia, hypoTN, asystole

79
Q

Advantage of ropi rather than bupi

A

cardiotoxicity assoc w/ bupivacaine
-reduced cardiotoxicity w/ ropivacaine

80
Q

Epi reduce risk of LAST?

A

Yes, reduces systemic absorption, identify unintended puncture

**to further watch, monitor pt’s vital signs, provide slow, incremental injxn, and aspirate prior to injxn

81
Q

How to identify unintended venous injection of local w/ epi

A

inc in systolic pressure > 15 or 25% dec in lead II t wave amplitude

82
Q

how to local anesthetics affect the heart?

A

-inhibition of VG Na channels causing:
-slowed cardiac conduction
-dec rate of depolarization (red availability of fast Na channels that allow for rapid depolarization)
-dose-dpt reduction in cardiac contractility
-depressed spontaneous pacemaker activity in SA node

83
Q

dosing of lipid emulsion

A

1.5 cc/kg of 20% lipid solution (~100cc in adults) with infusion of 0.25 cc/kg/min -> d/c after establishing hemodynamic stability for at least 10 minutes

84
Q

injecting local anesthesia, has a seizure, and develops monomorphic V tach, BP stable what do you do?

A

-stop giving local anesthetic
-call for help and lipid emulsion
-ensure adequate O2 and ventilation to prevent factors that worsen LAST (hypercarbia, hypoxia, acidosis)
-give benzo to treat seizure
-give succ and intubate if ventilation were inadequate
-give lipid emulsion (1.5 cc/kg) 20%, infusion 0.25 cc/kg/min
-for V tach give adenosine or amiodarone
-if BP decreases: synchronized cardioversion

((epi standard 1 mg not recommended, give smaller boluses 100 mcg)

85
Q

Can you use beta blockers, CCB with LAST?

A

No -> will worsen cardiovascular effects negative inotropic and chronotropic

86
Q

can you give prop to stop a LAST sz?

A

no b/c potential for cardiovascular instability -> could make his arrhythmias unstable
-give benzo ASAP

87
Q

would you give lipid emulsion therapy to someone who develops ringing in their ears following regional?

A

-assuming it was their only symptom, no b/c unnecessary tx of a large # of patients, with only a fraction who progress to severe toxicity
-recgonize would not want to have cardiovascular collapse -> would give if signs and symp of LAST rapidly progressing, incl sz or cardiac toxicity signs
**must monitor for at least 30 minutes

88
Q

if symp of LAST and treated, how long do you have to monitor?

A

at least 12 hours b/c can redistribute into circulation from tissues -> delayed recurrence of severe toxicity

89
Q

G6P5 112 kg woman TOLAC, jehovah’s witness, PEC, concerned about jehovah’s witness?

A

-at inc risk for complications that could cause significant blood loss
-TOLAC -> risk of uterine rupture
-adhesions/scarring from prior c/s could lengthen/complicat c/s
-PEC affects hemostasis
-inc risk of uterine atony w/ muliparity (inc as well w/ Mg)

90
Q

Prolonged motor and sensory loss after prev epidural for vaginal delivery, scared for next epidural, say what?

A

-review the chart, ask for details for motor and sensory loss
-most peripheral n palsies are OB -> due to extreme positioning of pt or instrumentation w/ vaginal delivery (compression of n as baby’s head)
-alternatives: IV narcotics, NSAIDs, Lamaze, transcutaneous electrical n stimulation -> however epidural superior analgesia, and improved BF to baby
***benefit of epidural to avoid GA esp in high risk)

91
Q

Pregnancy regional options not epidural

A

-paracervical block 1st stage of labor
-pudendal block with infiltration of perineum for 2nd stage

**paracervical not typically done due to high risk of fetal bradycardia and Dec uteroplacental perfusion (inc risk of PEC)
**pudendal block issues: intravascular injxn, retroperitoneal hematoma
**not sufficient if c/s needed

92
Q

Pt wants epidural, you’re not available, nurse wanted to ask if can give nalbuphine for discomfort, would you delay until consent obtained?

A

-consent ideal prior to pt severe pain or under influence of premedications
-would not delay, pain relief may enhance ability to provide adequate consent
-under risks of narcotics unable to understand risks and benefits
-titrate medication carefully to provide pain control while avoiding excessive administration

93
Q

PPH, loss of IV access, needs OR, can’t put in peripheral what to do?

A

-give O2, monitors on, and attempt central line
-if central line difficult/can’t do -> place intraosseous line
-call for volume expanders, prepare emergency drugs, and set up intraoperative blood salvaging

94
Q

How to place intraosseous line?

A

Tibia: 10-15 deg angulation at 1-2 cm below and 1 cm medial to tibial tuberosity
-advance until felt pop, confirm w/ aspiration of bone marrow
-ensure fluids flowed freely w/o signs of extravasating
-other option: greater tubercle of humerus

95
Q

Complications w/ intraosseous access

A

-compartment syndrome (extravasation)
-muscle necrosis (extravasation of certain meds like bicarb, calcium, dopamine)
-bacteremia
-cellulitis
-growth plate injury (peds)

96
Q

PPH OB pt arteria line?

A

Yes: risk of signficant anemia and hemodynamic instability 2/2 to visible blood loss,
-beat to beat BP aid inn intraop optimization
-however realize surgery is emergent -> proceed w/ case and place art line following induction

97
Q

OB PPH jehovah’s witness, BP 88/63, obese, PEC, RSI?

A

-concern for difficult airway given pregnancy, obesity, PEC -> induction drugs can cause further hemodynamic instability w/ anemia and hypovolemia
-at risk for aspiration -> asp ppx, and utilize neuraxial

98
Q

OB jehovah’s witness, Hg 4.8, can’t achieve surgical hemostasis, do you give blood?

A

No, unethical
-I would give 100% O2, ensure adequate volume replacement with what she is okay w/
-utilize intraop blood salvage if ok with patient

99
Q

PPH, Hg 5, neck swelling where attempt at central line was, ddx?

A

**developing coagulopathy
-fibrinolysis
-hypofibrinogenemia
-dilutional coagulopathy
-DIC
-hypothermia (large volumes of cold fluids -> plt dysfunction)

100
Q

RF for OB DIC

A

-PEC: extensive vascular endothelial damage
-uterine rupture -> exposure of vascsulature to amniotic fliud rich in procoagulant thromboplastins
hypovolemia and low BP => inc risk of amniotic fluid entering intravascular system so she can’t “wash out” the accumulation of intravascular coagulation factors

101
Q

What is DIC?

A

-pathological activation of the coagulation cascade
-consumptive coagulopathy -> creating multiple small clots throughout the vasculature -> consumption of coag factors, thrombocytopenia, hemolytic anemia, diffuse bleeding

102
Q

Labs with DIC

A

-Increased PT/ PTT
-Dec fibrinogen (< 100)
-thrombocytopenia
-dec antithrombin III
-D-dimer and presence of fibrin degradation productss

103
Q

How to treat DIC?

A

-treat the hypovolemia, low BP, hypoxia, or acidosis -> can contribute and worsen DIC
-give cryo (fibrinogen < 50), FFP, plts, and PRBCs

104
Q

You accidentally stick yourself with a needle, what to do?

A

-immediately wash with soap and water
-report to employee health
-initiate post exposure ppx and r/o HIV, HBV, HCV, and other possible blood-borne dx
-obtain pt consent to draw additional blood so she can be tested for blood-borne dx

105
Q

pulmonary edema after MTP in OB PEC pt, etiology?

A

-TACO (transfusion associated circulatory overload) -> inc risk w/ inc pulm capillary permeability w/ PEC
-TRALI: transfusion related acute lung injury
-ARDS
-transfusion-assoc dyspnea

106
Q

What is TRALI?

A

-donor leukocyte antibodies (usually FFP or plts), attack recipient leukocytes -> endothelial damage and capillary leakage
-noncardiogenic pulmonary edema 1-6 hours after transfusion
-forthy pulm secretions, fever, tachycardia, cyanosis, pulmm edema, hypoTN (can’t distinguish w/ ARDS)

107
Q

Diagnostic criteria for TRALID

A

-acute onset of hypoxia (PaO2/FiO2 < 300, SpO2 < 90%)
-pulm edema
-w/i 6 hours of transfusion
-no cardiac failure or fluid overload]
-tx: supportive (similar to ARDS)

108
Q

Distinguish b/w TRALI and TACO

A

TACO: cardiogenic pulm edema -> fluid OL (peripheral edema, S3, impaired cardiac fxn, JVD, HTN,hypervolemia, inc BNP)

TRALI: noncardiogenic pulm edema (inc capillary permability) -> hypovolemia/normovolemia, fever, leukopenia, normal cardiac fxn, normal BNP, positive leukocyte antibody testing

109
Q

TRALI treatment

A

-stop transfusion of blood products, alert the blodo bank
-support ventilation: low TV, inc PEEP, suppl O2 as needed

110
Q

TACO treatment

A

-goal: reduce pulm capillary pressures
-diuretic (correct fluid OL)
-consider pRBCs if Hct not adeaute (inc viscosity)
-if compromised ventircular fxn: consider inotrope or afterload reducing agent

111
Q

post delivery w/ epidural pt has foot drop, what caused her condition?

A

-lumbosacral trunk injury: compression of the trunk w/ prolonged labor or difficult vaginal delivery -> issues w/ toe flexion and ankle inversion

-common peroneal n injury: prolonged lithotomy, excessive knee flexion, compression of lateral knee against hard objects -> issues w/ ankle eversion

112
Q

pregnant pt issues w/ climbing stairs postop

A

femoral n palsy
-stretched 2/2 abduction, external rotation, prolonged flexion of hips duringn labor

113
Q

pregnant pt postop paresthesias of anterolateral aspect of thigh

A

meralgia paresthetica
obesity/preg: entrapment of LFCN passes under inguinal ligament

114
Q

pregnant pt sensory deficits of inner thigh, weakness of hip adduction

A

obturator n palsy
=fetal compression of n at pelvic brim

115
Q

Cobb angle

A

Measure the severity of scoliosis
-angle of perpendicular lines from upper surface of the most cephalad tilted vertebrae and lower surface of most caudad tilted vertebrae

116
Q

When to get surgery on scoliosis

A

Cobb angle > 40-50
-pulm dysfxn > 60-65 deg
-pulm HTN w/ exercsise > 70
-pulm HTN at rest > 110

117
Q

SOB Duchenne’s Muscular dystrophy, concerned?

A

Yes, abnormal dystrophin:
-cardiomyopathy, ventricular dysrhythmias, MR 2/2 replacement of mycardium w/ connective tissue
-dec pulm reserves, ineffective cough, chronic PNA 2/2 resp m weakness
-chronic asp 2/2 impaired laryngeal reflexes
-OSA: contribute to pulm HTN

118
Q

SOB w/ severe scoliosis and duchenne’s muscular dystrophy, concerned?

A

Yes
-2/2 NM scoliosis: impaired pulm development, restrictive lung dx w/ inc WOB (dec chest wall compliance)
-hypoxia, hypoxic pulm constriction -> pulm HTN
-resp m weakness, laryngeal m weakness w/ DMD
-cardiomyopathy w/ DMD

119
Q

if pt wheelchair bound w/ SOB, pulm HTN concerns, test?

A

stress echo => identify any pulm HTN, RV failure, cardiomyopathy

120
Q

airway concerns for duchenne’s muscular dystrophy

A

-macroglossia
-difficulty swallowing (diminished airway reflexes inc risk of aspiration)

121
Q

how to explain a “wake up” test to patient

A

-sometimes I would whisper his name in his ear, and ask to wiggle fingers asnd toes
-probably not remember, and if he did he would be sleepy not feel pain, and go right back to sleep

122
Q

asp ppx premeds

A

-metochlopramide (unless SBO)
-H2 receptor antagonist
-non-particulate antacid (sodium citrate)

123
Q

early decelerations

A

head compression (vagal activation)

124
Q

variable decelerations

A

umbilical cord compression

125
Q

late decelerations

A

uteroplacental insufficiency

126
Q

Methergine

A

semisynthetic ergot alkaloid

127
Q

Hemabate

A

prostagladin F2alpha analog

128
Q

Misoprostol

A

synthetic prostagladin analog

129
Q

precautions for prone positioning in DMD scoliosis case

A

-place head in neutral position, freq checks to ensure ears/eyes free
-account for contractures, limited ROM
-abd arms no more than 90 deg from trunk, minimize brachail pleux injury
-frame of bed not compressing axillary sheath
-padding to ulnar n
-minimize pressure on abd -> inc shunting of blood through vertebral venous plexus -> inc bleeding on case

130
Q

monitors for scoliosis DMD case

A

-standard ASA montiors: 5 lead EKG
-a line: freq blood draws, continuous BP monitoring
-precordial doppler (R of sternum b/w 2nd and 4th ribs to detect VAE)
-central line: fluids and tx of VAE
-neuromonitoring: SSEPs, MEPs, eMG, EEG

131
Q

risks of pulmonary artery catheter

A

arrhythmias
pulm infarction
pulm a rupture
thrombosis
infxn

132
Q

complications w/ central line

A

arterial puncture
PTX
air embolism
thrombosis
thoracic duct injury
pseudoaneurysm formation
arterial or venous hemorrhage

133
Q

What do SSEPs monitor?

A

sensory pathway from distal n up SC dorsal root ganglia and posterior columns to cortex

134
Q

MEPs monitor?

A

monitor the motor pathway (motor cortex, corticospinal tract, n root, peripheral n)
-transcranial stimulation of motor cortex and measure response

135
Q

Is EMG necessary for scoliosis surgery?

A

Not universally utilized
beneficial to avoid n root injury during pedicle screw placement
-get m contracts at lower current stimulations if malpositioned

136
Q

risks w/ wake up test

A

-accidental extubation
-intraop recall
-pain
-air embolism
-dislodge surgical instruments
-removal of lines

137
Q

Reasons to use ketamine as an induction agent

A

-preserves airway reflexes
-maintains respiratory drive
-induces bronchodilation
-inc endogenous catecholamine release

138
Q

inhalational induction in pts w/ Duchenne’s muscular dystrophy?

A

While no assoc w/ MH, sevo can cause rhabdo and hyperK (in combo w/ sevo and succ too)

139
Q

NMB duchennes muscular dystrophy

A

-no succ b/c risk of hyperK
-minimize/avoid roc: b/c inc maxinmal effect and duration of action

140
Q

how many twitches are needed for neuromonitoring EMG?

A

2/4

141
Q

Large amount of blood loss anticipated, options to minimize blood transfusions?

A

-intraop blood salvage
-antifibrinolytic therapy (TXA, aminocaproic acid)
-avoid hypothermia (affects plt dysfunction)
-proprer positioning! (in spine cases avoid pressur eon the abd -> excessive shunting of blood thorugh vertebral venous plexuses

142
Q

when to avoid hypoTN for vision loss in spine surgery?

A

-prolonged procedures
-anticipated substantial blood loss

143
Q

surgeon wants deliberate hypoTN to reduce bleeding and improve visualization in surgical field, how to produce hypoTN?

A

short acting clevidipine/nicardipine and remi
-consider risk of ischemic injury to optic n, brain, heart, and SC: ensure intravascular volume, Hg 7-8, monitor EKG, MEPs, UOP, blood gases for signs of inadequate perfusion

144
Q

spine case, dec amplitude, inc latency on SSEPs, what to do?

A

-correct any hypoxemia, hypoTN, hypovolemia, anemia, hypo/hypercarbia to opitimize O2 delivery to SC
-make sure depth of anesthesia has been stable and not interfereing
-ask surgeon to r/o surgical causes

145
Q

Reasons to use ketamine

A

-preserves airway reflexes (aspiration risk)
-maintains resp drive (difficult airway)
-induces bronchodilation (obstructive dx)
-inc endogenous catecholamines

146
Q

What is considered a significant change in SSEPs/MEPs?

A

SSEPs: inc in 10% latency, dec 50% in amplitude
MEPs: 50% dec in amplitude

147
Q

Wake up test, then dec in BP 60s/30s and dec in EtCO2 ddx

A

venous air embolism

aspiration
hemorrhage
MI
CHF
dysrhythmia
TPTX
anaphylaxis

148
Q

most sensitive for detecting VAE entrained air

A

TEE

149
Q

heart “millwheel” murmur

A

VAE

150
Q

sporadic roaring sounds from precordial doppler

A

VAE

151
Q

Sporadic roaring sounds from precordial doppler, what to do?

A

-tell surgeon to flood field with saline
-d/c nitrous if on, and go to FiO2 100%
-aspiration from CVC to get air out
-give fluids to inc CVP
-give vasoconstrictors, inotropes, and chest ocmpressions if needed
-beta 2 agonsits if bronchospasm (common w/ VAE)
-if needed put in L lateral decubitus position to shift air out of pulm outflow tract

152
Q

PEEP in VAE?

A

-no impairs venous return inn pt w/ cardiac disfunction

153
Q

FVC that predicts postop ventilatory support

A

FVC < 30-35% predicts postop vent support in order to prevent atelectasis, PNA, resp failure

154
Q

Extubation criteria-

A

-awake
-cooperative
-muscle relaxants fully reversed
-intact gag reflex
-vital capacity > 10cc/kg
-TV > 6 cc/kg
-negative inspiratory force > 20 cm H2O
-SpO2 > 90% on 40-50% FiO2 with <5 PEEP
-rapid shallow breathing index < 100 breaths/min/L

155
Q

Transport to ICU, O2 sat dec to 89%, ddx?

A

-interrupted O2 source
-hypoventilation (inadequate TV or rate)
-extubation
-mainstem intubation
-PTX
-pulm edema (fluid OL, aspiration, CHF)
-aspiration (pulm edema, bronchospasm, atelectasis) -> intrapulm shutning -> hypoxia
-PE
-hemothorax
-bronchospasm
-dec cardiac output (CHF, worsening pulm HTN)
-monitor issues

156
Q

Transport to ICU, O2 sat dec to 89%, what do you do?

A

-immediately check pulse ox and pt color to verify true hypoxia
-check circuit and O2 source to make sure delivery of 100% O2
-listen for b/l breath sounds
-check BP, CVP, pulm a catheter, EKG
-treat accordingly

157
Q

STOP BANG

A

snoring
daytime tiredness
observed apnea
pressure (HTN)

BMI > 35
Age > 50
Neck circm > 40 cm
Gender, male

> 3: high risk of OSA
5-8: mod to severe OSA

158
Q

OSA: ambulatory or in patient?

A

Considerations
-severity of OSA
-anatomical or physiological abnormalities
-presence/status of coexisting dx
-type of surgery
-type of anesthesai
-post-op opioid anticipated
-pt age
-post-d/c observation
-capabilities of outpt facility

159
Q

pt has obesity, DM, high resting HR and HTN, what are your main concerns?

A

autonomic NEUROPATHY
-undiagnosed chronic HTN

160
Q

Concern for beach chair position w/ OSA, DM, GERD, HTN?

A

-inc risk of cerebral ischemia w/ GA in beach chair
-w/ inc BP and DM -> autonomic neuropathy
-HTN -> R shift oc cerebral autoregulation curve (req higher pressures for adequate cerebral perfusion)
-impairment of normal autonomic responses by GA
-vigilant of maintaining end organ perfusion!

161
Q

stop smoking prior to surgery?

A

-48 hours: reduce carboxyhemoglobin, abolish nicotine’s stimulatory effects on cardiovascular system, improves mucous clearance (so inc mucous clearance -> possible worsening airway conditions)
-4 weeks: decrease postop pulm complications
-8 weeks: approaches nonsmokers

162
Q

difficult airway, OSA, GERD, proceed w/ block over GA?

A

yes -> still give aspiration ppx w/ GERD
-have difficult airway equipment available
-inform pt that if block were to fail, next step would be an awake fiberoptic intubation

163
Q

Bezold-Jarisch reflex

A

-activation of parasympathetic NS w/ inhibition of sympathetic NS 2/2 drugs, inhibitory cardiac receptors by stretch, or chemical substances
-causes bradycardia, vasodilation, hypoTN

**can happen in shoulder surgeries -> inc circulating epi, w/ dec preload -> activation of receptors in heart

164
Q

s/s autonomic neuropathy

A

orthostatic hypotension
sweating
constipation
gastroparesis
resting tachycardia
erectile dysfunction

165
Q

How to eval for autonomic neuropathy?

A

-hx of GERD? DM? HTN?
-resting HR? tachycardia
-exercise tolerance? SOB w movement
-early satiety, prolonged postprandial fullness, bloating
-postural hypoTN
-lack of sweating
-painless MI
-peripheral neuropathy
-dysrhythmias
-N/V
-erectile dysfxn

166
Q

What is autonomic neuropathy assoc w/?

A

GERD, DM, HTN, exercise intolerance (SOB), HTN, resting tachycardia

167
Q

Progression of autonomic neuropathy

A

-affects the parasympathetic first -> so pt gets inc baseline HR
-sympaethtic 2nd: orthostatic hypoTN

168
Q
A

Anesthesia Oral Boards (8 decks)

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