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UBP condescened Flashcards

1
Q

Extubation criteria

A

-Adequate oxygenation: SpO2 > 92%, PaO2 > 60 on FiO2 40%
-Adequate ventilation: TV > 5 cc/kg, RR > 7, EtCO2, < 50, PaCO2 < 60
-hemodynamically stable
-reversal of NMB
-neurologically intact
-normal acid/base/lytes/normothermia
-negative inspiratory pressure > 20
-Rapid shallow breathing index < 105

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2
Q

Rapid Shallow Breathing Index

A

RR/TV in L

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3
Q

Cricoid pressure

A

-pushes esophagus to side, does not effectively compress the esophagus
-interferes w/ mask ventilation and intubation
-has not been proven to prevent aspiration -> lowers LES tone and may promote aspiration
-proper application of force (30N) is difficult to apply
-if pt begins to vomit -> release cricoid pressure to prevent esophageal rupture

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4
Q

Airway fire protection

A

-laser tube
-FiO2 30% or less
-avoid nitrous oxide
-inflate cuff with saline
-minimize laser time

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5
Q

Treatment airway fire

A

-disconnect/turn off O2
-remove ETT
-flood field w/ saline
-mask ventilate with 100% O2
-use rigid bronchoscopy to inspect for airway debris and damage, possible bronchial lavage
-re-intubate
-leave intubated for 24 hours
- steroids
-pulmonary consult
-serial CXR

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6
Q

Contraindications to jet ventilation

A

severe COPD/respiratory disease that does not allow for proper exhalation

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7
Q

Complications to jet ventilation

A

PTX
pneumomediastinum
airway fire
gastric distention
aspiration

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8
Q

Airway innervation

A

posterior oropharynx to epiglottis: glossopharyngeal n
epiglottis to VC: superior laryngeal nerve (internal branch)
VC and below: Recurrent laryngeal n

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9
Q

Airway motor innervation

A

recurrent laryngeal n: abduction
external branch of superior laryngeal n: cricothyroid m (adduction)

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10
Q

CEA indications:

A

TIA w/ angiographic evidence of stenosis
reversible ischemic deficits w/ > 70% stenosis
unstable neuro status despite anticoagulation

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11
Q

CEA regional v general

A

regional: awake for serial neuro exams, requires cooperation, dec CV depression, may not get adequate coverage if extends into territory of CN
general: controlled airway, ventilation, cooperative patient

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12
Q

COPD and CEA pretesting

A

CXR and room air ABG -> assess pt’s baseline PaCO2 -> if baseline hypercarbic don’t want to fix rapidly in the OR -> cerebral vasoconstriction and ischemia

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13
Q

How to do regional for CEA

A

-awake pt is best neuro monitor esp if concern of possible plaque rupture
-superficial and deep cervical plexus block.
-superficial cervical plexus block: 10cc along posterior border of SCM
-deep cervical plexus block (C2-C4): draw line from mastoid to anterior transverse process of C6 => at level of cricoid cartilage is C2 -> inject 10cc of local anesthetic at transverse processes of C2, C3, C4

**usually can be done under superficial cervical plexus block alone

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14
Q

How to do a deep cervical plexus block

A

(C2-C4): draw line from mastoid to anterior transverse process of C6 => at level of cricoid cartilage is C2 -> inject 10cc of local anesthetic at transverse processes of C2, C3, C4
-risks: phrenic n block, epidural, subarachnoid, vertebral artery injection, Horner’s, RLN injury

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15
Q

General plan for CEA

A

-TIVA (w/ SSEPs)
-if you use volatiles: reverse steel phenomenon (improved cerebral protection and myocardial priming)

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16
Q

Neuromonitoring EEG

A

-correlates w/ cerebral ischemia, but cannot detect subcortical ischemia
-processed EEG: can detect severe cerebral ischemia, but not focal

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17
Q

Neuromonitoring SSEP

A

-detects deep brain structure injury, sensitive to anesthetics, hypothermia, hypoTN

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18
Q

Neuromonitoring transcranial doppler

A

-can detect cross clamp hypoperfusion and shunt malfunction and emboli
-placed at ipsilateral MCA -> detects BF and embolic events
**hard to place

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19
Q

Neuromonitoring cerebral oximetry

A

simple, but low sensitivty and specificity
-detects regional ischemia, but includes all tissue beds (approximates venous saturation, since mostly venous blood)
-decrease > 20% suggests cerebral ischemia

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20
Q

Neuromonitoring carotid stump pressure

A

-helps guide need of shunting, no guideline of pressure that shunt should be placed
- < 50 indicates hypoperfusion
*goes in ICA above clamp and measures pressure from collateral flow

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21
Q

CEA reperfusion injury

A

cerebral hemorrhage or edema after cross clamp removed
-vessels distal to obstruction are maximally dilated -> lost ability to autoregulate -> renewed BF and perfusion is too high
**important to maintain strict BP control

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22
Q

Bradycardia in CEA

A

surgical manipulation of baroreceptors in carotid sinus
-infiltrate w/ local to prevent recurrence

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23
Q

CEA neuromonitoring change

A

FiO2 100%
ensure adequate MAP
ask surgeon to release clamp, consider shunt placement
ensure normocarbia
pharmacologic brain protection -> dec CMRO2

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24
Q

CEA Postop delayed awakening

A

-Residual anesthesia (opioids, volatiles, benzos)
-cardiac failure: hypoperfusion
-metabolic/hypo/hyperglycemia
-hypothermia
-neuro deficits (stroke) -> hematoma compressing artery, stenosis postop (doppler)

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25
CEA postop HTN
-control due to risk of bleeding, MI, arrhythmia, intracerebral hemorrhage, cerebral edema
26
Causes of postop HTN CEA
hypoxemia hypercarbia pain full bladder carotid baroreceptor blunting (carotid sinus dysfxn after surgery)
27
postop HTN CEA tx
correct hypercarbia/hypoxia, tx pain, give hydralazine, NG, beta blocker to lower SBP < 160 or w/i 20% baseline
28
CEA chemoreceptor dysfunction
Up to 10 months to recover -loss of response to hypoxia and hypercarbia -give supp O2, cautious w/ opioids **esp concerned if b/l CEA in past
29
CEA cerebral hyperperfusion syndrome
-previously hypoperfused lost ability to autoregulate -> inc systolic pressure and CBF -> focal neuro deficits, edema, HA, sz
30
CEA neck hematoma, what to do?
apply pressure, call surgeon, transport to OR, have difficult airway equipment ready
31
Sitting position for posterior fossa surgery: risks
-brain stem ischemia: quadraplegia due to obstruction of carotid or vertebral arteries -macroglossia/facial edema -venous air embolism
32
Oliguria
prerenal: hypovolemia, hypotension, hypoperfusion, renal v or artery thrombosis intra: ATN (ischemia, toxin, abx, myoglobin, hemoglobin), intrinsic dx (vascular, glomerula, thromboembolism, interstitial nephritis) post: obstructed catheter, urethral or ureteral obstruction
33
When should sitting position be avoided for crani surgery?
known intracardiac shut: PFO, ASD/VSD -> inc risk of stroke w/ air embolism
34
Venous air embolism causes
-inc in pulm a pressure, dec cardiac output, inc deadspace -> mediators released cause inc in PVR
35
Ways to detect venous air embolism
TEE: most sensitive, but difficult to manipulate under drapes -precordial doppler: R sternal border b/w 2-4 intercostal -DECREASED EtCO2, inc in CVP
36
Treatment for venous air embolism
have surgeon flood the field, apply bone wax, control open blood vessels -FiO2 100%, d/c nitrous oxide -Use CVP in RA to aspirate air, manual occlusion of jugular veins -left lateral decubitus position (keeps air in RA, prevents entry into RV and obstruction of RVOT) -head below heart -hemodynamic support: inotropes, fluids
37
Normal ICP
15
38
What's inc ICP
20-25 should be treated
39
Symptoms of inc ICP
papillema, nausea/vomiting, confusion, Cushings triad (bradycardia, HTN, irregular breathing)
40
Normal cerebral perfusion pressure
80-100
41
What cerebral perfusion pressure is considered to be ischemia
< 50
42
Ideal cerebral perfusion pressure for head injury
60-70
43
Increased ICP, needs central line, where to place?
subclavian or femoral to avoid head down positioning -> inc ICP
44
succ and ICP
fasciculations can cause transient inc in ICP -> but hypoxia and hypercarbia w/ difficult airway cause higher inc in ICP
45
Treatment of inc ICP
-ventriculostomy -HOB position 30 degrees -analgesia: blunt pain/symp resp -avoid hypoxemia -avoid hypothermia: shivering inc ICP -osmotic therapy: mannitol, furosemide, hypertonic saline
46
Hypothermia effects
-inc O2 demand w/ shivering -inc ICP w/ shivering -poor wound healing -coagulopathy -arrhythmia
47
glucose and neurosurg
avoid hyperglycemia -> inc brain swelling -no dextrose containing fliuds -> causes edema w/ injured blood brain barrier
48
Neurogenic pulm edema
s/p head injury or intracranial bleed -symp response -> systemic vasoconstriction -> dec LV compliance and inc LA pressure -> pulm edema -w/ catecholamine surg, inc pulm capillary permeability -tx: supportive, lung protective
49
Pseudotumor cerebri
elevated ICP (> 20) w/ normal CSF, normal mentation, no mass lesion
50
Pseudotumor cerebri treatment
Acetazolamide (dec CSF production) Furosemide steroids lumbar puncture/CSF drain VP shunt **no LP before CT head, r/o space occupying lesion
51
nitrous oxide and ICP
inc CBF, inc CMRO2
52
Benzos ICP
no change CBF, dec CMRO2
53
Why ischemia w/ dec PaCO2
cerebral vasoconstriction, left shift of O2-Hgb curve
54
PaO2 and CBF
Dec PaO2 (<60) -> inc in CBF
55
Cerebral autoregulation
b/w CPP of 50-150, shifted to the right in HTN **when MAP above this, or tumor abolishes cerebral autoregulation -> CBF is dpt on MAP
56
Inc ICP treatment
-HOB up 30 degrees -avoid hypoxemia -inc SBP to maintain CPP -analgesia: blunt pain/symp resp -avoid hypothermia (shivering inc ICP) -mannitol, furosemide, hypertonic saline -avoid hyperglycemia
57
Etomidate CBF, CMRO2
dec both
58
N2O and CBF, CMRO2
inc CBF, in CMRO2
59
Benzos CBF, CMRO2
no change CBF, dec CMRO2
60
Electrolyte disturbances from SAH
SIADH CSW hypoK/hypoCa/HypoMg from diuretics
61
Preop eval SAH
-neuro deficits/coma -cardiac dysrhythmias 2/2 catecholamine release -electrolyte disturbances: SIADH, CWS, hypoK/hypoCa/hypoMg from diuretics -labs: CBC, T&C
62
Intraop goals for SAH
-avoid aneurysm rupture: maintain transmural pressure (MAP - ICP) -maintain CPP -brain relaxation: hyperventilation (PaCO2 30-25), mannitol, furosemide, CSF drain, avoid hypercarbia, hypoxemia, and nitrous -blunt symp resp, no succ, no hypoTN -No dextrose (BG < 180)
63
cerebral protection during aneurysm clipping
-prop, etomidate, thiopental (dec CBG and CMRO2) -mild hypothermia (32-34) -inc MAP (collateral flow) -minimze occlusion time -monitor brain function (EEG, SSEP) -brain relaxation (CSF drainage, mannitol, hyperventilation)
64
SAH intraop rupture
-control bleeding but maintain CPP -bleeding control: temp clip or compression ipsilateral carotid artery -cerebral protection: avoid hyperthermia, hypoxemia, hyperglycemia
65
Hypothermia complications
-delayed emergence -HTN if hypothermic w/ emergence -MI -wound infxn -coagulopathy -dysrhtyhmias -prolonged anesthetics and muscle relaxants
66
Post SAH rebleeding timeframe
Usually w/i first 24 hours
67
Vasospasm post SAH
Starts days 3-12, peak 1 week after -dx: cerebral angio (gold), transcranial doppler (>200 cm/s) -cerebral auto regulation impaired -tx: Nimodipine, angio w/ intra-arterial verapamil
68
tx for neurogenic pulm edema
Treat CNS cause, lung protective ventilation, diuretics, Hgb > 10, PEEP
69
SIADH tx
Tx underlying cause, water restriction, hypertonic saline, diuretics DEMECLOCYLINE (kidneys not sensitive to ADH)
70
Treatment for SIADH
Treat underlying cause, water restriction, hypertonic saline, diuretics DEMECLOCYCLINE
71
Pathophys SIADH
Excessive ADH -> water retention -> hypoNa, normal total body Na, euvolemia, U Na < 100
72
Cerebral salt wasting
Excessive renal sodium excretion centrally mediated process -> hypoNa -dehydrated and hypovolemic
73
Treatment for cerebral salt wasting syndrome
Fluids, salt tabs, mineralocorticoids (fludrocortisone)
74
Diabetes Insipidus
Inability to concentrate urine due to renal resistance or decreased secretion of ADH -large volume of dilute urine -> hyperNa
75
Diabetes Insipidus treatment
Central: desmopressin/DDAVP and hydration Nephrotoxic: diuretic, hydration, indomethacin
76
What causes central pontine myelinolysis
Rapid correction of hyponatremia -locked in syndrome: quadraparesis, dysphagia, dysarthria, diplopia, LOC -don’t correct faster than 12 mmol/L/day
77
What are SSEPs measuring?
Ascending sensory pathway (dorsal column pathway)
78
SSEPs and epidural
-if epidural in place, only give narcotics -> local anesthesia will interfere
79
MEPs measure what?
Descending motor pathway (lateral corticospinal tract) **more sensitive to volatiles than SSEP
80
Contraindications for MEP
Seizure history Skull fracture Implanted metal devices Clips in brain
81
MEPs and epidural
Only give narcotics through epidural, local anesthesia will interfere
82
Brain death: how to confirm
-Objective findings of severe insult: documentation, neuro imaging (SAH, infarct, herniation) -irreversible damage -no confounding factors: sedation, hypothermia, acid/base, endocrine disturbance -no cortical response (sternal rub) -no brainstem function (corneal or gag reflex) -apnea test
83
ECT contraindications
-intracranial mass/vascular malformation -recent SAH, evolving stroke ( <1 month) -severe cardiac dx: MI < 1 mo, diminished ventricular function -severe pulm dx -ASA 4-5 -pheochromocytoma
84
ECT hemodynamic changes
Parasympathetic then sympathetic!
85
Multiple sclerosis epidural v spinal
epidural is okay, spinal more likely to cause exacerbation
86
low back pain, saddle anesthesia, LE weakness, bowel/bladder dysfxn
cauda equina syndrome -get MRI and emergent neurosug c/s
87
what happens if ventricular drain dropped to floor whole open
inc drainage of CSF and dec in ICP -> ventricular collapse and tearing of cortical veins
88
neuraxail w/ spina bifida
AVOID unless MRI shows no tethered cord
89
which volatile is most cardiac stable?
sevo -causes the least tachycardia, does cause dose dpt myocardial depression and dec vascular resistance
90
Normal cardiac index
2.6-4.2
91
Normal PCWP
2-15
92
Normal pulm artery pressure
15-30/4-12
93
normal mixed venous
75%
94
Hs and Ts PEA
hypoxia, hypoTN/hypovolemia, hypoK/hyperK, hypoglycemia, hypothermia, H+ acidosis tamponade, tension PTX, toxins, thrombosis (PE/MI), trauma
95
sinus bradycardia ddx
hypoxia/hypercarbia beta blocker succ anticholinesterase inhibitors acute inferior MI vagal stimulation high sympathetic block acidosis inc ICP reflex bradycardia
96
atropine dose for sinus brady
0.5 mg
97
SVT ddx
WPW thyrotoxicosis digoxin toxcitiy PE preganncy drug effect intravascular volume shifts -heart disease
98
SVT treatment
-vagal maneuvers -adenosine (6mg then 12) -verapamil -amiodarone -synchronized cardioversion if unstable
99
a flutter tx
Diltiazem or esmolol
100
with a fib, prior to cardioversion?
must r/o thrombi if > 48 hours
101
Junctional rhythm
HR 40-60 -ectoptic activity inferior to AV node -> abnormal P waves -> normal QRS -if hypotnesive: atropine/ephedrine/ amio: inc activity of SA node
102
Causes of PVC/bigeminy
electrolyte imbalances acidosis hypoxia drug intereactions
103
treatment of PVC/bigeminy
Lidocaine 1.5 mg/kg bolus -esmolol -procainamide -verapamil -overdrive pacing
104
treat PVCs
> 5 per min
105
Vtach w/ a pulse treatment
amiodarone 150 mg over 10 minutes OR lidocaine 1.5 mg/kg >3 PVCs, wide QRS, no p waves
106
Unstable V tach
unsychronized cardioversion 200J
107
V fib causes
MI, hypoxia, hypothermia, electrolyte imbalance
108
V fib tx
CPR, O2, unsynchronized debrillation, consider amiodarone 300mg IIV, lidocaine 1.5 mg/kg
109
LBBB and stress tests
cannot do exercise stress test: assoc w/ low specificity, must do chemical MPI stress
110
why a fib poorly tolerated w/ aoritc stenosis
inc myocardial O2 demand -dec time in diastole/dec LV filling time -dec CPP -no atrial kick
111
severe AS transvalvular gradient
> 40 mmhg
112
mid systolic ejection murmur 2nd right IC space
aortic stenosis
113
decrescendo diastolic murmur L sternal border
aortic insufficiency
114
induction w/ Mitral stenosis
be careful w/ dec in afterload -> can't compensate w/ inc in SV b/c of stenosis to maintain cardiac output -> minimize dec in SVR
115
what to be careful for after fixing mitral regurge
LV failure -> now has to work harder to pump entire volume against afterload -> was previously splitting b/w
116
blowing systolic murmur
mitral regurge
117
causes of Tricuspid regurge
pulm HTN carcinoid syndrome ebsteins anomaly infective endocarditis
118
HOCM goals
maintain SVR preload adequate low HR avoid PPV if possible
119
Things that worsen HOCM
tachycardia hypovolemia sympathectomy/dec SVR dysrhythmias excess PEEP/PPV inc myocardial contractility Valsalva
120
OB and HOCM
-ensure adequate L uterine displacement to maintain preload -avoid spinal, epidural ok (don't want a massive dec in SVR) -can get pulm edema after delivery due to autotransfusion
121
oxytocin and HOCM
avoid! dec SVR and inc HR!!
122
Determinants of myocardial O2 consumption
HR contractility wall tension
123
Normal QRS
< 0.12 ms
124
when to avoid pulm a catheters
when pt has a LBBB -> can cause a RBBB
125
how to measure cardiac output
10cc room temp or cold saline (whatever programed to) through PAC x3 -> if w/i 10% of each other, accurate -greater temp change: low CO, less temp change: higher CO
126
when is pulm artery catheter put in?
poor LV fxn (CVP doesn't correlate w/ PWCP), pulm HTN, coronary stenosis with valvular lesions, poor RV function, ascending aorta/aortic arch procedure
127
PCWP v TEE intraop ischemia
TEE is better at assessing regionanl wall motion abnormalities
128
complications of PAC placement
arrhythmias PA rupture VAE PTX hemothorax RBBB infection PE valve injury
129
treatment for benzo OD
flumazenil
130
treatment for beta blocker OD
glucagon
131
HD indications
Acidosis Electrolytes (hyperK) Intoxication (ASA, methanol) Overload of fluids and heart failure Uremia (encephalopathy, pericarditiis, issues w/ clotting(
132
Parkland formula
4 x % BSA burned x kg -half in first 8 hours, 2nd half in 16 hours after
133
Normal mixed venous
70-75%
134
what causes high mixed venous
sepsis, high CO states (burns), dec O2 consumption, CO poisoning, cyanide toxicity, L to R shunts, inotropes
135
what causes low mixed venous
low cardica output, anemia, hypoxemia, high O2 consumption
136
CI to TEE
esophagectomy active GI bleed or recent surgery oropharyngeal trauma esophageal pathology: stricture, TEF, mallory-weiss tear, scleroderma
137
stress test indications
-active cardiac conditions -3 or more RF w/ < 4 METs having high risk surgery and will change management -pts w/ 1-2 RF w/ < 4 METs undergoing intermediate risk surgery -1-2 RF > 4 METs w/ high risk surgery
138
Normal digoxin level
0.5-2
139
cardiac output and heart transplant
if dec in SVR -> can't increase HR to compensate to inc CO -> need to inc stroke volume -> dpt on preload
140
nasal intubation in heart transplant
AVOID: inc risk of infxn w/ nasal flora w/ immunocompromised
141
NSAIDs and heart transplant
inc risk of toxicity w/ cyclosprine and inc risk of gastritis w/ steroids AVOID
142
MAP equation
MAP = SVR x CO
143
CO equation
CO = SV x HR
144
roller pumps how works CABG
2 rollers partially compress tubing to promote forward flow
145
centrifugal pumps how work CAGB
rotational force creates forward flow
146
heparin dose for bypass
100 U/kg
147
ACT goal
> 480
148
glucose goal in bypass
< 150: hyperglycemia causes worse neuro outcomes
149
hypoTN w/ bypass initiation
hemodilution/dec SVR due to priming solution -inadequate venous return to reservoir: hypovolemia, caval obstruction, table too low
150
Getting ready to come off bypass
-Labs normal: pH, pCO2, pO2, Hct 20-24, K 4-4.5, Ca 1.1-1.2, mVO2 > 70% -anesthesia machine one, benzos to prevent awareness -EKg stable rhythm/rate -warmed air removed from heart -support drugs available
151
post bypass coagulopathy
MCC abnormal plt function -ACT, PT/INR/PTT, CBC, TEG
152
low mixed venous after off bypass
inadequate tissue oxygenation, needs inc FiO2
153
pacing post bypass
A pacing preferred -> improved cardiac output w/ preserved atrial kick -V if complete heart block
154
Failure to capture w/ pacemaker ddx
MI/conduction abnormalities lead dislodged electrolyte abnormalities acid-base disturbances -abnormal antiarrhythmic drug levels
155
difficulty coming off bypass ddx
air in RCA or other coronaries graft is down long time on pump MI arrhythmias hypothermia acidosis perivalvular leak
156
type A aortic dissection by Standford
ascending aorta, emergent surgical repair
157
type B aortic dissection by Stanford
descending aorta, managed medically
158
AAA complicatiosn
aortic root dilation ruputure tamponade hemothorax hoarseness (RLN compression) SOB (trachea/bronchial tree compression) SVC syndrome
159
spinal cord blood supply
anterior 2/3: anterior spinal artery, lower by radicular arteries and artery of adamkiewicz posterior 1/3: posterior spinal arteries
160
CSF pressure goal w/ drain
8-10
161
AAA repair, bair hugger?
don't put warming on clamped lower extremities -> inc acidosis
162
EVAR complications
endoleak: failure toe separate aneurysm from arterail blood flow AKI paraplegia post implantation syndrome
163
Post implantation syndrome
EVAR -> endothelial activation due to graft ->< fever, elevate dinflammatory mediators, leukocytosis **self limited, 2-10 days, give NSAIDs if no renal issues
164
when to use R sided DLT
distorted anatomy of L main bronchus compression of L main bronchus by TAA L pneumonectomy L lung transplant
165
pneumonectomy poor outcomes predictors
-ABG: PaCO2 > 45, PaO2 < 50 -FEV1 < 2L -FEV1/FVC < 50% -PAP > 40 -FEV1 < 800 cc
166
FOr a pneumonectomy, who is considered to be high risk
PaCO2 > 45 PaO2 < 60 ppFEV1 < 40% DLCO < 40% VO2 max < 15 cc/kg/min
167
Meds for ECT
-methohexital ideal: rapid onset and recovery, minimal anticonvulsant effects -prop: Dec sz duration -Etomidate: may prolong sz
168
for a pneumonectomy, predicted postop FEV1 < 40%, next steps?
V/Q scan to look for contribution of lung that will be resected and get a TTE (risk of RV failure)
169
Mediastinoscopy CI
carotid artery dx CVA due to compression of R brachiocephalic artery tracheal deviation c spine disease TAA
170
where to put a line in mediastinoscopy
R side to monitor for compression of brachiocephalic artery
171
mediastinoscopy, what do you need prior to d/c?
CXR to r/o PTX
172

Anesthesia Oral Boards (8 decks)

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