UBP Condensed2 Flashcards
1
Q
Mg dosing for PEC
A
4-6g bolus over 20 minutes
Infusion of 1-2 grams per hour
2
Q
Mg PEC therapeutic range
A
4-6
3
Q
Mg toxicity
A
> 10: loss of DTR
15: resp depression
20: cardiac arrest
EKG: prolonged PR, widened QRS
Tx: calcium, diuretics
4
Q
Anti-HTN in pregnancy
A
Labetalol 1st line
Hydralazine: reflex tachycardia
NG
Nitorprusside (risk of CN toxicity)
Nifedipine (cant’ use w/ Mg: risk of myocardial depression)
5
Q
HELLP
A
Hemolysis, elevated liver enzymes, low plts
Tx: Mg, delivery of baby
6
Q
Drugs that DON’T cross placenta
A
He is Going Nowhere Soon
heparin
Insulin
Glyco
Non-depolarizing NMB
Succ
7
Q
Antepartum bleeding ddx
A
Placenta Previa v placenta abruption MC!! painless previa, painful abruption
Less common: vasa previa (fetal vessels overlie internal os), uterine rupture
8
Q
Uterotonics
A
Oxytocin: in Ca and contractions -> causes hypoTN, nausea, water retention (similar to ADH)
hemabate: Prostaglandin, inc Ca -> bronchospasm
Methergine: alpha agonist on blood vessels and smooth muscle -> HTN
Misoprostol: prostaglandin -> tachycardia/fever
9
Q
Number 1 determination of fetal well being
A
FHR variability!!!
Normal 6-25 bpm variability
NORMAL: 110-160
**can use fetal scalp capillary pH
10
Q
Early decelerations
A
Fetal head compression
11
Q
Late decelerations
A
Uteroplacental insufficiency
12
Q
Variable decelerations
A
Umbilical cord compression
13
Q
Molar pregnancy concerns
A
Abnormal bleeding
CHF
Pulm insufficiency
Hyperthyroidism/thyrotoxicosis
DIC
PE
14
Q
acute resp distress in peripartum period
A
Tocolytic induced pulm edema
Steroids
PE/AFE
ARDS
15
Q
Alternatives besides neuraxial for preg pain control
A
Paracervical block: 1st stage of labor T10-L1 -> assoc w/ fetal hypoxia, uterine artery constriction, inc uterine tone
Paravertebral lumbar symp block: 1st stage of labor
Pudenedal nerve block: 2nd stage of labor S2-4
16
Q
APGAR
A
Appearance
Pulse 0: none 1: < 100, 2: >100
Grimace
Activity
REspirations
17
Q
Treatment for meconium aspiration syndrome
A
If resp depression w/ HR < 100: consider suctioning ETT
-otherwise dry and stimulate -> give exogenous surfactant!! (Meconium inactivates surfactant)
18
Q
Neonatal resuscitation NALS
A
- Stimulate, if apneic or HR < 100: clear airway and PPV 30 breaths/min
- After 30 seconds: if HR < 100: ventilation
- After 30 seconds: if HR < 60: intubate, FiO2 100%, start chest compressions at 100/min and IV/IO access
- If HR still < 60 after 30 seconds:give epi (0.01-0.03 mg/kg) and fluids
19
Q
Epi dosing for neonate
A
0.01 mg/kg
20
Q
Epi dosing for ETT
A
0.1 mg/kg
21
Q
Normal umbilical artery gas
A
PH; 7.27, pCO2: 50, pO2: 22, bicarb 22
22
Q
Normal umbilical vein gas
A
PH: 7.35, pCO2 38, pO2 29, bicarb 20
23
Q
Best time to have surgery while pregnant
A
2nd trimester
-avoid miscarriage/organogenesis in 1st
-avoid preterm labor in 3rd
24
Q
When to give ppx steroids
A
Between 24-34 weeks w/ anticipation of preterm labor
25
Ppx steroids or tocolytics in non OB Surg for pregnant patient?
Not indicated
26
Intraop considerations for pregnant pt for non OB surgery
Standard monitors
LUD
FHR! (Can monitor if > 18 weeks) and tocodynamometer! (Look for preterm contractions!)
27
Goals for laproscopic surgery w/ pregnant pt
Minimize insufflation pressures: 8-12
EtCO2 32!
28
Postop pregnant pt for non OB surgery
-monitor MINIMUM of 12 hours for preterm labor
-if preterm labor: beta agonists, Mg, betamethasone! If b/w 24-34 weeks
29
Thesis isosensitization
-Rh neg moms w/ Rh positive fathers get RhoGAM at 28 weeks and 72 hours after delivery -> antibody destroys Rh + cells before Rh - mom can form antibodies to them
-if no rhogam -> Rh neg moms make antibodies to Rh + blood from fetus -> IgG Ab will cross placenta and lead to hemolytic dx of newborn
30
Emergency c/s w/ difficult airway
FiO2 100%, LUD, treat hypoTN
-awake fiber optic if time
-if no time: RSI, difficult airway equipment and maintains sp vent w/ ketamine/inhalational
31
CT in pregnancy?
IF trauma, can do if unstable to access damage -> treating condition of mom is most effective way to maintain health of baby!
32
hypocalcemia EKG changes
prolonged QT interval on EKG
33
changes in lytes in ESRD
hypoNa, hyperK, hypoCa, metabolic acidosis
34
can you use HD catheter for ESRD case?
Yes, if last result: draw back heparin and use aseptic technique: inc risk of clots and infxn
35
RF for postop AKI
advanecd age
ASA
ACE inh (dec kidney response to dec RBF)
contrast
DM
HTN
CHF
hypoTN
36
assessing volume status in ESRD
last HD
weight to dry weight
CXR
pulm edema
peripheral edema
JVD
orthostasis
37
morphine in ESRD
6-MP metabolite is active and prolonged -> risk of resp depression
38
meperidine and ESRD
normeperidine metabolite excreted renally -> builds up and can cause seizures
39
K cutoff for kidney transplant
if > 5.5 delay for dialysis
40
if need to give blood in a kidney transplant, what kind of blood do you give?
washed (leukocyte reduced), irradiated (red GvH), CMV negative blood
41
spinal level goal for TRUP
T9-10
bladder sensation: T11-12
perineum S2-4
42
HypoTN in TURP ddx
bladder perforation (nause,a diaphoresis, bradyacardia, abd/shoulder pain)
bleeding
transient septicemia (bacteria from prostate into open venous sinuses)
43
myasthenia gravis pathophys
antibodies to post junctional nicotinic ACh receptors
44
inhaled anesthestics in MG
potentiate wekaness -> should place a n monitor even w/ no muscle relaxants
45
postop predictors of mechanical ventilation in MG
pyridostigmine dose > 750 mg daily
dx > 6 years
VC < 2.9 L
other pulm dx (COPD)
bulbar symptoms
EBL > 1L
46
AHI index
the combined average number of apneas and hypopneas that occur per hour of sleep
47
Treatment of thyrotoxicosis
-propanolol: dec conversion of T4-> T3
-methimazole, PTU (PTU works fast w/ glucocorticoids to dec conversion)
-iodine prevents release of thyroid hormones but use last!
-acetaminophen for fevers (NO ASA -> inc free T3, T4)
if everything else fails can do plasmapheresis
48
Thyrotoxicosis
a fib, inc CO2, inc O2 consumption, dec SVR, dec PVR
inv Minute ventilation
anxiety, tremors
sweating
**thyroid storm: metabolic, thermoregulatory, CV mechanisms fail -> just treat
49
treatment for thyrotoxicosis
propranolol (prevents conversion)
other beta blocks for symptoms
methimazole, PTU
PTU + glucocorticoids: work faster
iodine (prevents release)
acetaminophen for fevers
50
Hypothyroidism
low cardiac output: dec contractility, dec SV, bradycarida
pleural and pericardial effusions
hypothermia
macroglossia
SIADH
51
Myxedema coma
loss of DTRs, hypothermia, hypoventilation, hypoNa, coma
52
teratment for myxedema coma
ICU admission
correct lytes and hypovolemia
give T3 and T4
give hydrocortisone
heat pt
mechanical ventilation
53
hypothyroidism intraop complications
difficult intubation (large tongue)
hypoglycemia
anemia
hypoNa
hypothermia
hypoventilation (dec CO2 production)
hypoTN
delayed awakening
54
agents to avoid in pheo
histamines (atracurium, morphine)
droperidol
metoclopramide
pancuronium
ketamine/ephedrine/atropine
succ (fasciculations inc catecholamine release)
pain, anger, anxiety
hypoxia, hypoTN, hypercarbia
55
Diabetes insipidus treatment
DDAVP
vasopression
fluids: maintenance and 2/3 UOP
56
57
Thyrotoxicosis agents to avoid
Pancuronium
Ketamine
Glyco
Atropine
Des
Ephedrine
Epi
**anything that stimulates symp system
58
Loss of DTR, hypothermia, hypoventilation, hypoNa, somnolent
Hypothyroidism: myxedema coma
59
Diagnosis for pheo
Most sensitive: plasma metanephrines
Plasma catecholamines
Urine metanephrines
Urine Vanillylmandelic acid
60
Meds to avoid in pheo
histamine (atracurium, morphine)
Droperidol
Metochlopramide
Pancuronium
Ketamine/ephedrine/atropine
Succ (fasciculations inc catecholamines release)
Glucagon
Halo one
Pain, light anesthesia
Hypoxia/hypoTN/hypercarbia
61
HTN w/ pheo intraop
Treat w/ short acting agents: esmolol, nicardipine, clevidipine, Mg
**be careful w/ NG -> can get tachycardia
**nicardipine: selective arterial vasodilator
62
When to give steroids w/ pheo
If b/l adrenalectomies
63
Postop after pheo
Hypoglycemia (inc insulin, catecholamines inhibit insulin)
HTN: if sustained retained tumor, if present but lower, can be catecholamines from peripheral n being released
Somnolence
64
Anesthesia concerns w/ acromegaly
Difficult airway: macroglossia, large jaw, thickened pharyngeal nad laryngeal soft tissues
OSA
HTN
Glucose intol/insulin resistance
Ulnar/radial muscle myopathy: no a line in wrists, use DP
65
Dx of acromegaly
IGF-1, GH
66
treatment of acromegaly
Bromocriptine and octreotide
67
Cushing syndrome symp
(Excessive ACTH)
Moon fancies
HTN
Hyperglycemia
OSA/GERD
HyperNa, hypoK (inc sensitivity to m relaxants)
68
Diabetes Insipidus
HyperNa
Dilute urine
69
tx for diabetes Insipidus
DDAVP, vasopressin, fluid replacement (maintenance and 2/3 UOP)
70
Diarrhea, flushing, heart murmur
Carcinoid triad (pulm stenosis or TR)
71
Carcinoid tumor
Releases histamine, bradykinin, and serotonin
-if in GI -> cleared by liver, no carcinoid syndrome
72
Carcinoid syndrome
Mets to liver/pulm/breast
-flushing, diarrhea, hypoTN, HTN
R heart dx
Bronchoconstriction (bradykinin)
73
Dx of Carcinoid syndrome
24 hour urine 5_hydroxyindoacetic acid
74
Preop for carcinoid syndrome
Echo (can get R heart serotonin fibrosis -> TR)
IVF
Octreotide (Dec release of serotonin)
H1 and H2 blockers
Alpha/beta blockers
75
Carcinoid syndrome intraop
Avoid succ: fasciculations and histamine release -> HTN
-bronchospasm 2/2 manipulation of tumor -> ask surgeon to stop, give octreotide and Benadryl
**reserve epi unless needed, can worsen carcinoid**
76
DM and difficult airway
Stiff joint syndrome
-glycosylation of proteins/collagen cross linking
77
DKA diagnosis
anion gap metabolic acidosis
Urinary ketones
78
Tx DKA
IVF w/ K replacement
Insulin to lower glucose (75-100 per hour to avoid cerebral edema)
When glucose < 250 add dextrose
-monitor lytes until gap closed
79
Diagnosis of hyperosmolar hyperglycemic state
Glucose >600
Serum osm > 320
*no ketones
80
HHS hyperosmolar hyperglycemic state tx
IVF
Insulin
LMWH to prevent clots
Abx if in fxn
81
Chronic steroid implications
Impairs wound healing
Inc skin friability
Inc risk of fxn, in fxn, GI bleed, ulcers
82
When to get stress dose steroids
20mg prednisone for more than 3 weeks w/i the year
-clinical Cushing’s syndrome
83
Rheumatoid arthritis considerations
-pericarditis, valvular fibrosis, arrythmias (rheumatoid nodules in conduction system)
-pulm fibrosis, pleural effusions
84
Glaucoma
Pathological elevation of increased intraocular pressure due to outflow obstruction of aqueous humor from eye
85
Succ and globe injury
Can give if give defasiculating dose -> acknowledge succ can inc IOP
86
Ketamine and eyes
Inc IOP
87
Etomidate and IOP
Inc due to myoclonuss
88
Retrobulbar block
Injecting local anesthesia inside muscle cone
-close to optic n and opthalmic artery
-less volume
RISKS: retrobulbar hemorrhage, central retinal artery occlusion, perforation of globe, spread into CNS, OCR, optic n atrophy
89
Peribulbar block
-local anesthesia injected above and below orbit into orbicularis oculi muscle
-less risk of intraocular or intramural injxn
-less risk of direct injury
-harder to get dense block
-compl: periorbical ecchymoses, transient blindness, contra lateral eye
90
Nitrous oxide and air
Concern of gas injection in eye -> different gases have different timelines -> longest 30d, don’t use nitrous w/i 30 days of eye surgery
91
Disorders linked to MH
Central core dx
King Denborough Syndrome
-defect of ryanodine receptor -> in in Ca and muscle contraction
92
If masseter muscle rigidity, give dantrolene?
Yes due to MMR and high assoc w/ MH
93
What is EMLA cream?
Prilocaine/lidocaine: risk of Met-Hg
94
Jehovah’s Witness minor
-minor: if life threatening can give blood without appealing to court
-if parents don’t want you to give blood products -> identify which are acceptable and tell them attempt to avoid BP but if life threatining would seek approval from court to administer blood
95
Positive pregnancy test in minor
-check state emancipation laws
-tell pt, encourage to tell parents, arrange f/u
96
Risks of IO
Osteomyelitis, fat embolism, marrow embolism, compartment syndrome
97
At what age risk of apnea and bradycardia of prematurity w/ anesthesia
< 60 weeks post conceptual
98
Glucosuria in infants
< 34 weeks: normal, immature renal reabsorption
> 34 weeks: hyperglycemia
99
Prematurity time frame and risks
< 37 weeks
RDS, hypoglycemia, apnea, retinopathy of prematurity, intraventricular hemorrhage, NEC, pulm HTN of newborn
100
ETT sizes newborn
3 < 3500g
2.5 if < 1500g
101
Newborn Hct transfusion goals
>35%
Prematurity has more fetal Hg -> leftward shift of Hg O2 dissociation curve
102
How dose PDA normally close
Normal 2-4 days after birth
-Inc arterial O2 and dev PVR -> Dec PG -> closure
-if premature, have RDS/hypoxia and Dec contractility of muscular layer of PDA
103
Treatment for PDA
-indomethacin: SE thrombocytopenia, mesenteric perf, renal injury, hypoNa
-ibuprofen used in low birth weight infants
104
monitors for PDA ligation
2 pulse ox: R hand lower extremity (pre and post ductal)
-if LE O2 sat is lower -> means R to L shunting
GOAL: PaO2 50-80, SpO2 87-94%
-transfuse Hct > 40 if premature or > 25 full term
105
Resp Distress Syndrome v Bronchopulm Dysplasia, which one is first?
RDS -> BPD
106
Why do infants get respiratory distress syndrome?
Lack of surfactant
107
Timeframe for retinopathy of prematurity
< 44 weeks post gestation age
RF: low birth weight, prematurity, hyperoxia, hypoTN
108
Full term normal vitals
HR 125-135, BP 50-70/35-50, 40 breaths
109
No shivering thermogenesis
Hypothermia -> NE release -> metabolism of brown fat
110
Symptoms of TEF
Intrauterine polyhydramnios (can’t swallow amniotic fluid)
OGT coiling
Drooling cough cyanosis w/ feeding
111
TEF induction/intubation
2 IVs, a line L arm (R thoracotomy)
Avoid PPV, ketamine/inh for spontaneous ventilation until fistula ligated
-use fiber optic to look for tracheomalacia
112
Complications TEF
Anastomotic leak
Esophageal dysmotility
Reflux
Tracheomalacia
VC paresis
Post-intubation croup
113
Tetralogy of Fallot
POVR: Point of View Right?
Pulmonary atresia
Overriding Aorta
VSD
RVH
114
How to manage cyanotic spells (R to L shunt) under anesthesia
Deepen anesthetic
100% FiO2
Vasopressors or ketamine to inc SVR (switch shunt)
115
Congenital diaphragmatic hernia
Nasal flaring, sternal retractions, absent L breath sounds
-> assoc w/ aortic coarctation
116
Pulm HTN tx
Avoid hypoxia, hypercarbia, acidosis, hypothermia
USE inhaled nitric oxide
117
Down Syndrome associations
-CV: congenital heart defects (endocardial cushion defects, ASD, VSD)
-airway: macroglossia, Atlanta-axial instability, subglottic stenosis
-GI: duodenal atresia, delayed gastric emptying (RSI)
**need echo and cervical spine XR prior
-difficult airway equipment, ENT surgery on standby, fiber optic
118
Propofol infusion syndrome
-peds and ICU!
-prolonged dose -> bradycardia, metabolic acidosis, rhabdo, hyperK, liver failure, renal failure, cardiac failure
119
Nitrous oxide in omphalocele
No, can distention bowel and impaired reduction
120
Beckwith-Wiedemann Syndrome
Macrosomia
Macroglossia
Hypoglycemia
Polycythemia
121
Trauma Hs&Ts
Hypoxia
H+ acidosis
Hyper or Hypokalemia
Hyper or Hypoglycemia
Hypothermia
Toxins
Thrombosis (MI or PE)
Tamponade
Tension PTX
Trauma
122
Pyloric stenosis how to tell when rehydarated prior to surgery?
Cl 100
PH 7.3-7.5
Bicarb < 30
UOP 1-2 cc/kg/hr
**prior is a hypochloremic hypoK hypoNa metabolic alkalosis
123
Succ dose in neonates
2-3 mg/kg due to higher volume of distribution
124
Hemolysis what labs to send after blood transfusion?
Haptoglobin (decreased)
Bilirubin: unconjugated/ indirect elevated
Repeated cross matching
Direct antiglobulin test
Urine free hemoglobin
125
Hemophilia A
Factor VIII def
-if don’t respond to factor VIII, give factor VIIa (activates thrombin directly)
-prolonged PTT
-give factor 8 concentrate, DDAVP (released factor VIII and vWF from endothelium suitable fo minor hemophiliacs)
126
Meds to avoid in hemophilia A
NSAIDs
ASA
Antihistamines
Antitussives (inhibit plt aggregation)
127
Hemophilia B
Def factor IX
-normal PT, prolonged PTT
-less common than A -> can only tell apart by activity levels
128
Von Willebrands Dx
Prolonged bleeding time, normal plts, bleeding diasthesis
-vWF allows plts to be adhered to damaged endothelium and carries factor VIII
-give DDAVP -> helps endothelium release
129
Hypocalcemia
Prolonged QT
Hypotension
Myocardial depression
130
FFP need to match AB +/-
Needs to match A B (plasma will have antibodies)
But the +/- doesn’t matter -> b/c RBCs have the Rh antigen
131
What’s in cryo?
Fibrinogen
Factor VIII
VWF
Factor XIII
Fibronectin
***give if volume concerned or specific factor def [hemophilia A, vWD, low fibrinogen]
132
Universal pRBC donor
O neg
133
Universal pRBC acceptor
AB
134
Universal FFP donor
AB
135
Universal FFP acceptor
O neg
136
Massive blood transfusion: citrate?
Calcium chelation -> becomes hypoCa
When metabolized by liver -> bicarb -> alkalosis and hypoK
137
With citrate-related hypoCa, how to treat?
Check for hypoMg!! CALCIUM WON”T WORK UNLESS MG REPLETED -> give Mg and Ca chloride or gluconate
138
Absolute contraindications of cell saver
Bacterial contamination of field, cancer
Relative: SCD, pheo, contamination w/ urine, bowel contents, amniotic fluid
139
Lupus anticoagulant
Normal PT
Prolonged PTT
**Prothrombotic
140
Heparin MOA
Inc activity of ATIII -> inhibit thrombin
141
Enoxaparin MOA
Binds to AT3 which inhibits factor X -> Factor Xa (prevents conversion of prothrombin to thrombin)
142
Argatroban
Direct thrombin inhibitor
Can be used instead of heparin in pts w/ HIT
Can monitor w/ PTT or ACT
143
Acute Intermittent Porphyria
When enzyme in heme biosynthesis pathway is deficient
144
Acute Intermittent Porphyria symptoms
N/v, abd pain, autonomic instability, sz, resp failure, skeletal muscle weakness
145
Acute Intermittent Porphyria meds to AVOID
Etomidate
Keorolac
Methohexital
Nifedipine
146
Acute Intermittent Porphyria safe drugs
Safe:
Propofol
Ketamine
Nitric Oxide
Volatiles
NMB
Benzos
Opioids
Regional is safe
147
Acute Intermittent Porphyria Crisis treatment
Glucose containing IVF (carbs suppress porphyria)
Hemodynamic support
Haematin
