AKT-24

When large amounts of Cl- are administered the body reduces or loses HCO3- to maintain neutrality. This loss of HCO3- is the cause of metabolic acidosis.

MOA of MA with 0.9% administration?

Cardiotoxicity results from magnesium acting as a calcium and potassium channel blocker

MOA of Magensium casuing cardac toxicity?

Activates guanylate cyclase, resulting in cGTP --> cGMP, resulting in smooth muscle relaxation.

MOA of N.O. on pulmonary vasculature?

potentiate the action of nitrates via prolongation of cyclic guanosine monophosphate activation? Contraindicated with nitro if taken in the past 24 hours.

Phosphodiesterase 5 inhibitors MOA?

Normal (physiologic): -V waves = NREM 1 -Sleep Spindles = low amp. waves in rapid succession = 2-4 nREM -K complexes = large amp.biphasic ,followed by sleep spindles = 2-4 nREM Pathologic: -Slow activity = < 8 mhz in an awake patient's baseline = distrubed brain -Paroxysmal discharge = pattern stands out from baseline = seizures a. Sharp wave = rapid rise b/w 70-200 ms b. Spike = steep slow < 70 mS

Physiologic and Pathologic Patterns of EEG?

excision of the glands, reversible gland ischemia, hypothermia, or release of Endothelin-1 (an acute phase reactant known to suppress PTH production.

Reasons why low PTH levels can happen s/p thyroidectomy?

There is no accrediting body that examines or mandates required procedures or equipment to be maintained by office-based procedural practices, and if often falls to the anesthesia provider to ensure the safe provision of medical care in these setting. Including ensuring ancillary staff is trained and there is a transfer policy.

17-20% of outpatient procedures are done in physician offices. Whose responsibility is it to ensure safe care?

early exudative phase-acute and chronic inflammation, interstitial edema, type II cell hyperplasia, and hyaline membrane formation. 7-10D fibroproliferative phase-esolution of pulmonary edema, squamous metaplasia, interstitial infiltration of myofibroblast-7-10D fibrotic stage=bliteration of normal lung architecture, cyst formation, and fibrosis.

3 phases of ARDS?

AFE > pulm circulation, causing an intense vasopressin leading to cardiovascular collapse. Also has a higher rate of uterine atony.

AFE pathology?

Age Pre-existing CKD

AKI with CBP risks?

Oxygenation: -oxygen analyzer with low o2 concentrations limit. -SPO2 Ventilation: -CO2: -D/c alarm. Circulation: -EKG -BP q5 minutes Temp probe

ASA recommends monitoring Oxygenation, ventilation, circulation, and temperature. How are these four primarily monitorered?

Thoracic = T2-T6 Abdominal = T6-L1

Abdominal and thoracic epidurals are covered by which levels?

MRSA coverage (clindamycin or vancomycin) as well as a third generation cephalosporin (e.g. ceftriaxone or cefotaxime) to target: Haemophilus influenza type B, Staphylococcus aureus, or group A beta-hemolytic Streptococci

Abx for Acute Epiglottis.

advanced age (greater than 65), long operative times (greater than 120 minutes), ASA grade of III or IV, obstructive sleep apnea, and vascular disease

Admissions after ambulatory surgery aren't paid for by medicare. in order to prevent this, what are some risk factors which would increase post-op admission?

Needle cricothyroidotomy cannulae require a high-pressure oxygen source and rely on a patent upper airway for ventilation/expiration. Surgical cric = they do have a larger potential for trauma during insertion, like crushing the trachea 2/2 to force. Needle cric = smaller amount of trauma with insertion, but higher chance of issues during use like ptx, hypoventilation.

Advantage of a scalpel cric over a needle cric? vise versa

-No Metabolic acidosis -hypotonic = suppression of ADH -Better splanchnic perfusion

Advantages of LR > NS in the periop setting?

1 glucose = 2 pyruvate + 4 ATP (2 consumed = 2 ATP). Without O2: 2 Pyurvate -->Lactate + 2 ATP + NAD+ (from NADH). With O2: 2 pyruvate -->|mitochondria|-->A-COA-->KREB = GTP, FADH2, and NADH, CO2-->OP = 30 ATP, NAD+, FADH+, H2O, GAS

Aerobic vs. Anaerobic glycolysis?

Thyroid storm can even occur in the postoperative phase 2/2 to prolonged half-life of T4/T3. Also, propronalol not only decreases symptoms, but decreass the conversion of T4-->T3.

After Thyroidectomy, why is it important to continue taking the beta blockers in patients with graves?

platelet

After appropriate reversal of heparin with protamine, treatment of coagulopathy after CPB should begin with

Contraility increase = downward and to the right on the ES curve of the pressure volume loop. Aftload = up and to the right

Afterload vs. Contractiltiy increase on the PV-Curve?

18.

And diastolic pressure should be less than what in the left ventricle?

Antibodies targeting the thyrotropin receptor,

Antibodies against which protein is involved in graves disease?

Hashimotos MOA of TPO = heme protein that converts MIT and DIT to T3/T4.

Antibodies targeting thyroid peroxidase

Andexanet alfa Binds apixaban or rivaroxaban as a decoy factor Xa molecule

Antidote for Apixaban and Rivaxaban? MOA?

NSR 2/2 need atrial kick, Normal HR, full preload, maintain afterload, AI: HR > 80 to decrease diastolic time, maintain contractility, minimize afterload, normal preload

Aortic Stenosis = Angina, Syncope, and SOB. However, the degree of symptoms doesn't correlate with the degree of stenosis. Aortic Regurg vs. Stenosis?

< 1 cm And critical if < 0.6 cm

Aortic Stenosis is severe if Valve Area is?

Apfel simplified risk score -Female sex* -History of PONV or motion sickness* -Nonsmoker* -Use of opioids* If >1 risk factors shown, then ppx with 2 anti-emetics is recommended.

Apfel Simplied risk score took and modified the Society of Ambulatory Anesthesia (SAA) guidelines for PONV. What is it?

5-15 = MILD 16-30 = Mdoerate >30 = severe.

Apnea score for OSA?

1.) If Cushings symptoms or > 20 mg/day for > 3 weeks = will need stress dose steroids. 2.) Type of surgery determines how much: -Minor = only daily dose needed. -Moderate like a lap chole = dose + 50 mg prior to incision, then 25 mg IV q8H for 24 hours, then back to regular dose. -Major sx: daily + 100 mg + 50 mg Q8H x 24 hours, then taper back to regular dose. May need 0.45 saline + D5% to avoid hypoglycemia.

Approach to stress-dose steroids?

-spinal nerves in the cervical region are based on the lower vertebrae such as C3 which exits between C2-3. -regions below the cervical vertebra, the names of the dermatome levels are bases on the upper vertebrae such as in L2 which exits between L2-3.

At the level of the cervical and lumbar spine, how are the spinal nerves named?

<1.5

At what INR is an epidural acceptable to remove?

At the level of the pec minor.

At what point do the cords transition into the nerves in the brachial plexus?

-Blocks the terminal branches of the brachial plexuses. -Intercostobrachial nerve must be blocked seperate for tourniqute -Median = b/w axillary artery & bicep = median nerve causes thumb opposition and finger and wrist flexion. -Ulnar = medial & superficial to axillary artery -Radial = deep and medial to the -Muscolcutanous nerve comes off lateral cord proximally=elbow flexion.

Axillary nerve block pearls and anatomy? -Nerve locations -Nerves' job?

desflurane (0.42) < nitrous oxide (0.46) < sevoflurane (0.65) < isoflurane (1.46). Generally, lower blood:gas partition coefficient means faster onset.

BG co-efficent of inhalation agents and what it means?

This is spinal stenosis. This will improved with squating and walking uphill, but will be worse with standing and walking down hill 2/2 to back extension.

Back pain improved with squating will also become worse with?

When the atrium is stretched and full , HR goes up.

Bainbridge reflex

Has similar benefits of decreased illeus, decreased pain, and decreased post-op bleeding. decreased surgical stress and post-operative pain, lower incidence of ileus, shorter hospitalizations, and improved cosmetic outcomes. However, Pediatric patients absorb more CO2 than adults due to less peritoneal fat acting as a buffer and the aforementioned thinner peritoneum.

Benefits of laparoscopy in children vs. adults?

T-10 level Allows for continous mental status monitoring 2/2 to hyponatermia from large-volume irrgation, and decreases the discomfort from constant irrgation to the bladder.

Benefits of spinal anesthesia in a TURP, to what level should it be?

-Atropine for bradycardia -Magensium -Class IB medication -Temporary pacemaker

Besides FAB what other medications can be given for dig toxicity?

Alpha receptors with little clinical importance. Beta receptors which dilate the smooth muscle, which works by stimulating the intracellular calcium back into the Sarcoplasmic Reticulum.

Besides M3 receptors, what other receptors work in bronchconstriction and dilation?

-narrow external auditory meatus, making these usually fast cases more challenging and lengthy. -may have atlantoaxial instability.

Besides a larger tongue, why is an LMA a good choice when a Downs Syndrome patient is undergoing an ear tubes procedure?

alanine, y epinephrine and cortisol. inhibited by hyperglycemia, insulin, somatostatin, and glucagon-like peptide.

Besides hypoglycemia, what else releases glucagon? Inhibited by?

Hypocalcemia and hypophosphotemia. hyponatermia In order to correct the calcium effectively, magnesium needs to be corrected as well.

Besides low mg2+, what other electrolyte is likely depleated in ETOH patients?

Mivacurium is a nondepolarizing neuromuscular blocking agent that is also degraded by pseudocholinesterase.

Besides sux, what other paralytic is degraded by pseudocholinestrases in plasma?

A 1 g/kg dose of albumin is the preferred fluid for patients with hepatorenal syndrome. Because these patients are often volume overloaded, a more concentrated 25% albumin formulation is often preferred to lower concentrations.

Best fluid for hepatorenal patients?

Milroinone

Best iniotrope for mitral regurg?

Axilla. If you listen. in the center of the chest, you can hear transmitted lung sounds.

Best place to listen to confirm bilateral lung sounds? why?

PT.

Best prognostic indicators for recovery of liver function?

Subclavian/axillary > IJ > Fem. Should be single > multilumen.

Best sites for CVC placement to run TPN to limit infection?

Posteriomedial Papillary Muscle: RCA Anteriolateral papillary Muscle: LAD & LCx. If rupture happens, the jet flow will be eccentric & move opposite of the flail segment. Example- Posterio-Medial Pap muscle rupture = anterior & eccentric jet flow.

Blood supply to the papillary muscles? If blood supply is cut off, causing rupture of the muscle which way will the blood flow go?

Haldane Effect: Tissue level Hg -->tissue -->o2 released-->Hg-CO2 and return to the lungs. BoHr Effect: at the lung level Hg-CO2 -->lung -->Hg is releases CO2.

Bohr and Haldane effect.

Cells produce CO2 at tissue levels which builds up-->Hg-O2-->o2 displaced from the Hg and given to the tissues--CO2 transported back to the lungs to undergo the haldane effect. -Causes right shift in Hg.

Bohr effect?

Des = 24 degrees Iso= 49 degrees Sevo = 59 degrees N2O = - 88 degrees

Boiling points for Des, Iso, Sevo, and N2O.

50 mcg/kg loading dose followed by 0.2-0.3 mcg/kg/min. Bolus dose can initially worsen the hypotension.

Bolus of milrinone dose?

High intramedullary pressure causes an exothermic reaction. Gets into the blood stream, leads to profound hypotension & circulatory collapse. Less than 5% of the time. Tx for it is supportive case of blood pressure, avoid nitrous oxide.

Bone Cementing embolism process is due to?

cyanide toxicity. This process works by inducing Met-Hg (Ferric-3+) which binds to CN- = cyanomethemoglobin allowing Oxidative Phos to continue. hydroxycobalamin sodium thiosulfate are other antidotes.

Both amyl nitrate and sodium nitrite are used to treat?

cardiac accelerator fibers at T1-T4 as well as activation of the Bezold-Jarisch reflex (BJR).

Bradycardia after a spinal is 2/2>

Midbrain = CN 3+4. Superior Colli = visual | inferior = auditory Pons = CN 5-8. Breathing, recticular center, locus ceruleus, facial movement. Medulla = CN 10-12. Vomiting center, swallowing reflexes.

Brain stem is consists of and brief explanation each:

Carina -->Bronchi with complete rings-->lobar bronchi-->segmental bronchi -->broncholes (lack the cartilaginous structures)

Branching of the respiratory system?

oxygen dissociation curve takes into account Pao2 (oxygen dissolved in the blood) and Hg-o2 (Sao2 = oxygen hemoglobin saturation). Sigmod curve = 2/2 to cooperative binding where P50 = 26.7 mmHg = oxygen binding further increasing the affinity for additional oxygen molecules to bind to the hemoglobin. Right shift = decrease affinity = increase po2

Break down of the sigmodal curve of hemoglobin?

A normal A-a gradient is < 10 mm Hg, and a normal a-A ratio is >0.75.

By comparing the PAO2 and the PaO2 (A-a gradient and A:a ratio), a determination of oxygenation can be made. What is a normal a-A ratio?

Contralateral-hemiparesis & sensory loss. Ipsilateral injury to CN 5, 6, 7, 8.

CN in the Pons and what how does medial pontine infract present with?

-loss of cortical neuron density = decrease in CMro2 = decrease in cerebral blood flow. -dopamine, ach, and serotonin receptors decrease.

CNS changes in the elderly?

Brain: uneven distribution of brain volume loss-PFC, neuronal cell loss, neuronal cell shrinkage, reduction in neurotransmitters, reduction in CBF, Epidural/Subdural: decreased CSF volume, smaller epidural space, larger subdural space. Spine/Nerves reduction in number and size of myelinated fibers in ventral and dorsal horns, reduction in conduction velocity of peripheral nerves, impaired blood brain barrier, preserved auto-regulation and coupling, reduced ventilatory responses to hypoxia and hypercapnia.

CNS changes in the eldery?

SV = EDV - ESV -Preload -Afterload -Contractility.

CO = SV x HR. What is SV and what effects it?

Release of Vasopressin via decreased renal blood flow & SNS stimulation resulting the release of it via the RAAS pathway activation.

CO2 abdominal insufflation leads to increase in SVR and MAP. How?

Linear between 20-80 mmhg of CO2. As Co2 goes up, there is more curve to the right, and eventually dropping. If the CO2 goes up, patients will breath more. If the co2 goes up and patient is hypoxic, they will breath even more.

CO2 response curve.

I = air leaving the tracheal dead space II = mix between tracheal and alveolar gas III = alverolar exhalation.

CO2 wave forms

Baralyme > sode lime > Weak bases such as Ba(OH)2, and Ca(OH)2 do not result in the formation of carbon monoxide

CO2 which produce CO?

Increases FRC

CPAP in the recovery room does what?

CPRS 1- no nerve injury (organic) CPRS 2-Nerve injury 2/2 to trauma or sx. Tx: PT, SNS blockade, NMDA antagonist, GABApentin, IT/Sstim blockade.

CPRS 1 vs. 2?

Decreased SVR, maintained CO due to an increase in HR.

CV effects of inhaled anesthesia

X and Y descents are related to a tricuspid valve issue: -Loss fo X = tricuspid regurg -Loss of Y = trispid valve stenosis A wave is lost in a-fib C wave is more prominent in a-fib

CVP wave form issues:

(1.34 x SaO2)—bound to Hg + (0.003 x PaO2)-dissolved in blood. Should be 20 ml/DL

CaO2 (oxygen content in the blood)

PPO DLCO = %DLCO * (# lung segments remaining / # lung segments total) PPO FEV1 = %FEV1 * (# lung segments remaining / # lung segments total)

Calculating PPO DLCO?

increased estrogens may increase the amount or sensitivity of myocardial adrenergic receptors and volume overload = atrial stretch = SVT Tx: Adenosine, while it is a class C drug, its short half-life is unlike to effect baby. Other drugs = CCB, Metoprolol.

Cardiac arrhythmias occur at an increased frequency during pregnancy MOA?

Mixed apnea is the most common type seen in clinical practice.

Central apnea occurs secondary to brainstem or peripheral chemoreceptor immaturity. Obstructive is when the infant breaths against closed structures. Which of these is most commonly seen as a reason to lead to apnea?

CPP = MAP − CVP or CPP = MAP − ICP if ICP > CVP.

Cerebral Perfusion Pressure Formula?

MAP minus ICP

Cerebral perfusion pressure is equal to

Distilled H2O = Hemolysis, Hemoglobinemia, Hemoglobinuria, hyponatermia. Glycine = Hyperammonia, hyperoxulria, visual changes Mannitol = hyperglycemia, LA, osmotic diuresis Sorbitol = Diuresis, Intravascular volume expansion.

Common TURP irrigation solution and complications?

bronchopulmonary dysplasia (BPD), hydrocephalus, seizures, and cerebral palsy, more signicant procedures, hypothermia.

Consition risk factors for pediatric post-op apnea other than PCA?

PCAs without a continuous infusion have no higher risk of respiratory depression than on-request (nurse) IV opioids (1.5%), PCAs with a continuous infusion have been shown to have a higher risk of adverse respiratory events in adult postoperative patients.

Continuous infusions are generally only utilized in opioid-tolerant or pediatric patients because?

For the same amount of volume for the heart, you generate more pressure inside the heart, shifting the ESV up and to the left.

Contractility on the pressure-volume curve will represent what?

h CO2 and KTP lasers.

Covidien laser Oral/Nasal dual cuffed tracheal tube is intended for what kind of surgery?

To remember the severe MR criteria, think of 7-6-5-4: Vena contracta greater than or equal to 0.7 cm Regurgitant volume greater than or equal to 60 mL Regurgitant fraction greater than or equal to 50% Effective regurgitant orifice greater than or equal to 0.4 cm2 Left ventricle dilation

Crieteria for severe MR?

Initial Perioperative infusion rates:20-40 mL/kg over 2-4 h using isotonic fluid in the OR. Maintenance rates in the 12 hours immediately post-operatively should be reduced to 2-1-0.5-mL/kg/hr and then only returned to 4-2-1 mL/kg/hr if the patient is not tolerating PO. In kids weighing over 20 kg.

Current periop. fluid guidelines in kids?

Admit if <45 weeks. If 45-60 weeks, should be considered for admission on institutional policy of a case-by-case basis. Part of the case-by-case basis is include apnea at home and anemia with a HCT < 30, or a full-term baby who is <4 weeks and having surgery.

Current recommendation of formely premature infants in being admitted?

Cold Ischemic time: chilling of an organ with its blood supply reduced or stopped and the time that the organ is rewarmed by having the blood supply restored Liver = 6-10 hours. Heart = 4-6 hours Kidneys = 24 (up to 72 with perfusion pump) hours. Lungs = 4-6 hours

Define Cold Ischemic Time. What are the cold ischemic times for organs? (liver, heart, kidneys, lungs)

drug elimination rate is proportional to the concentration: When the drug elimination rate is graphed logarithmically, it appears as a straight line. When graphed in regular intervals = expotential downward curve. Proportional to the level of plasma concentrations. C(t) = Ae−kt

Define First-Order Kinetics? How would it look like on a graph?

Licensing-proper training is met at a state level. Credentialing-proper training is met at an employer level. Privileging = scope of permitted activities the practitioner may engage in while at the facility. Certification = is awarded to physicians by their specialty board.

Define Licensing, Credentialing, Privileging, Certification?

nausea and/or vomiting in the postanesthesia care unit or in the first 24 hours after surgery,

Define PONV time-line?

BP 140/90 + protienuria. Or 140/90 + any of the following: -Plt count < 100k -LFT 2X normal -Creatnine > 1.1 or 2X basal. -Pulmonary Edema -Visual/Cerebral disturbance.

Define Pre-E without severe features.

.Posterior segment of the spinal cord = propoception, fine touch, and vibration. Anterior segment is supplied by the Anterior Spinal Arteries made by 6-8 radicular arteries, with the largest being the Artery of Adamkiewicz supplies T9-12 (lower thoracic to the conus medularies). Role covers: -Spinothalamic tract = pain = loss of pain and temp. -Corticospinal = motor = parapalagia -intermediolateral column (autonomic)

Define the injury obtained to the spinal cord with a throacoabdminal aneusrysm repair?

during which the voltage-dependent ion channels are inactivated while the Na+ and K+ ions return to their resting state distributions across the membrane

Define the refractory period?

One studied showed that time to desaturation in obese patients with adequate denitrogenation was only 2.7 minutes versus 6 minutes in nonobese patients

Desaturation in obese patients occurs how long?

Allodynia is the perception of an ordinarily non-noxious stimulus as being painful. It is characteristic of neuropathic pain syndromes (e.g. post-herpetic neuralgia, diabetic neuropathy, multiple sclerosis, and complex regional pain syndrome).

Describe Allodynia?

Bohr Effect: -In face of pCO2 and low pH in the tissues, there is a right-ward shift in oxygenated-Hg to release O2 from the Hg to give to the tissues nd bind CO2 to be carried back to the lungs. Haldane effect: -In face of carboxy-hemoblobin in the lungs, O2 is bumped on, CO2 is bumped off.

Describe Haldane and Bohr effect?

5th cranial nerve —>cillary ganglion ~~>gasserian ganglion ~~> cranial 10 ~~~> bracyardia.

Describe the Ocalo cardiac reflux

Similar to Codiene, oxycodone is a pro-drug which needs to be metabolized via 2 CYP enzymes: -34A = inactive compounds. -2D6 = active compounds like Oxymorphone which is 8 times potent than oxycodone.

Describe the metabolism of Oxycodone?

1.). Portal HTN with or without hepatic diease. 2.)Mean PAP of 25 mmHg at rest & 30 while exercising 3.) Mean Pulm. Occlusion pressure <15 mmHg 4.) PVR = > 3 woods units.

Diagnosis of Portopulmonary HTN is based on four criteria:

The Lad

Diagonals are branches of which are there any

Nothing, it will be a normal anion gap. Other things that cause metabolic acidosis with a normal anion gap: Diarrhea, Renal Tubla ACIDOSIS, hyperalimentation.

Diamox does what to the anion gap?

Diarrhea is associated with a celiac plexus block (T5-12),

Diarrhea can be seen after which type of truncal block?

Heart has difficulty with compliance and it is stiff. EF is normal, however, a stiff left ventricle causes high LV pressures which causes a back up of blood into the pulmonary system, preventing forward flow. Pressure volume loop shows low volume, however, elevated elevated LVEDP

Diastolic Dysfunction definition and it's MOA.

Primary: existing hx of migraines & PDPH Secondary: Medical condition + PDPH

Difference b/w primary and secondary PDPH?

Solutions of 25% albumin are manufactured to approximately the same specifications as 5% albumin except for the final albumin concentration. Albumin 25% solutions are osmotically equivalent to approximately 5 times the volume of human plasma.

Difference between 5% and 25% albumin?

An increase in CC means that airways close at a higher lung volume, possibly before end exhalation. a decrease in CC would mean that the airways start closing at a lower lung volume, likely at a volume lower than functional residual capacity (FRC).

Difference between high and low closing capacity and how it relates to lung volumes?

Hypokalemic: -sodium and calcium channel mutations, seen in an autosomal dominate fashion whenever insulin increases, resulting in hypokalemia. Causes include: stress, excerise, carb-rich meal, laxatives, steroids. Hyperkalemic: -mostly due to dysfunction in the sodium channel, autosomal dominate fashion, resulting in things that causes high potassium, inculding: pregency, rest after exercise, potassium rich meals, -Tx: HCTZ hypothermia causes paralysis in both hyper & hypo

Difference between hypo and hyperkalemic period paralysis?

Typical mature receptors have two α, one β, one γ, and one ε. -A subunit is where ach and NMB drugs bind. Immature receptors have 2 alpha, one beta, and 2 gamma- the ε is replaced by a γ subunit. When immobilized these receptors proliferate to the muscle membrane-outside of the NMJ. These are sensitive to Ach and sux and stay open 10 times longer, however they do have an increase resistence to NDMB.

Difference between immature and mature nicotinic Ach receptors?

Preload = EVD on the same curve (to the right) without a downward shift. Lusitrophy = rightward & downward shift.

Difference between increased preload and increased lusitrophy on the pressue-volume curve?

Upper airway = inspiratory stridor lower airway = expiratory stridor.

Difference between stridors in lower airway vs. upper airway obstruction?

AS = LVH 2/2 to parrel replication of sarcomeres AI = Dilation 2/2 to serial replication of sarcomeres (endt-to-end) aka eccentric hypertrophy.

Difference between the sarcomere replication in AS vs. AI?

Type 1 HRS? -Acute due to a provoking factor like GI bleed or infection. Type 2 HRS? -chronic due to worsening liver disease. MOA: -Splahnic vasodilation, decreased blood flow to the kidneys. Dx = increase creatinine and liver diease.

Difference between type I and type II hepatorenal syndrome?

The metabolite of naloxone is not an opioid receptor antagonist and thus it does not act as such. Naltrexone has a longer onset of action and duration of action. The metabolite of naltrexone, 6-beta-naltrexol is an active antagonist which lasts about a day

Differences between Narcan & Naltrexone, despite both being opioid antagonists?

HypoK

Dig toxicity is worsensed with what?

-Acromegly: associated with 20-30% difficult intubation. Subglottic narrowing, thick or paralyzed vocal cords due to RLN stretching. -DM: decreased mobility of the Atlanto-Occpital joint--associated with prayer sign. -RA: Same as DM-lateral xray in flexion can help Dx. it. -Radiation of the neck. -Pierre Robin Syndrome: small lower jaw (micrognathia ), a tongue that is placed further back than normal (glossoptosis), and blockage (obstruction) of the airways. Treacher Collins syndrome is associated with malar and mandibular hypoplasia and microstomia (not macrostomia).

Diseases associated with Difficult intubation?

Duchenne and Becker muscular dystrophy, King-Denborough disease, central core and multiminicore disease, and nemaline rod myopathy. Should be avoided in boys, can cause bradycardia in kids. Not Associated: Charcot-Marie-Tooth disease, critical illness polyneuropathy and myopathy, and chronic inflammatory demyelinating polyneuropathy.

Disorders associated with MH? What disorders aren't associated with MH?

Coronary artery that gives off the PDA. USUALLY THE RIGHT.

Dominate coronary Arturo means what?

Fluid in the alveolus -->continuous blood flow = Ventilation/Q (flow) mistmatch. Salt Water: Water in the alveoli -->draw fluid out of blood stream-->hypovolemia and hemoconcentration. Fresh Water: Hyptonic fluid -->lungs-->blood stream-->lysis and hemodilution

Drowning pathophysiology -Difference between Salt and Fresh water?

Beta Blockers. Vasodilators ACE inhibitors Neprilysin inhibitors Mineralocorticoid receptor antagonists Sodium-glucose cotransporter-2 (SGLT-2) inhibitors

Drugs for CHF?

fluconazole, metronidazole, valproic acid, and ciprofloxacin.

Drugs known to inhibit the p450?

Relative: Angina, DVT, osteoporosis, high risk pregnancy, retinal detachment. Absolute: MI, CVA, mass, Pheochromocytoma Pacemakers and normal risk pregnancy is okay.

ECT contraindications

Alpha (8-12) = awake w/ eyes closed. Beta (13-30) = awake + attentive. | REM Gamma (>30) = wide-awake + concentration Delta (01.-3) IV of NREM Theta (4-8) = 1, II nREM

EEG waves:

-PVCs -Increase PR interval -QT interval decreased -T-wave inversions and flattening -Sagging ST segment depression -AV block -Tachy

EKG findings of dig:

zero-balance" approach, in which no additional fluid is given beyond identified losses.

ERAS patients should be euvolemic prior to entering the OR. Not hyper or hypovolemic. Some advocate for zero-balance. what is zero balance?

Bohr effect and Double Bohr effect Bohr = fetus releases CO2 from its Hg to mom, resulting in an alkolosis and a left-shift in the oxygen-fetal HG curve. Double Bohr = fetal releases CO2 to mom -- acidosis in mom's block = right shift in mom's hg-dissociation curve = release of O2 to baby.

Effects and physiology which describe the txf of oxygen from mom to baby?

Anti-seziure meds = acutely will decrease release of Ach and potentiate NMBD, however, chronically will have the opposite effect and will require more NMBD because of increase glycoproteins which bind to and deactivate the NMBD and there is also a relative increase in receptors to NMBD drug ratio.

Effects of Anti-seizure meds to NMBD?

Cardiac = IT increases CO, decreases SVR= decreased BP. Bradycardia 2/2 decreased BP = Bezold . Resp = little efffevt GI = SNS block = increased PS = increases risk of asp via decreased sphincter tone and increased bowel, secretion.

Effects of epidurals on GI tract? Cardiac?

propofol is a respiratory depressant and potent bronchodilator-a result of its direct action on intracellular calcium homeostasis and attenuation of vagal mediated bronchoconstriction. Also blunts the reflex tachycardia by blocking the baroreceptors. Infusion: decrease in tidal volume and an increase in respiratory rate.

Effects of propofol via an infusion vs. bolus?

Emergence is slightly prolonged, but ED is signficantly decreased from 47% to 2%

Emergence Delirium can be reduced by how much with precedex?

sevoflurane and desflurane have the highest incidence among volatile agents. The two main risk factors for developing emergence delirium are patient age (2-6 years) and type of anesthetic,

Emergence Dilerium is likely seen with? Two main risk factors?

PAO2 = FiO2 x (PB - Ph2o) - PACO2/R PB = 760 H2O = 47 R = 0.8

Equation for Partial pressure of alveolar oxygenation.

SEM = standard deviation / square root (n), where n is the size of the population

Equation for Standard Error of the Mean?

Induction causes a decrease in CMRO2 which leads to a Decrease in ICP & Cerebral blood flow because of cerebral vessel vasoconstriction. CPP is perversed because the MAP is perserved-considering that CPP = MAP - ICP.

Etomdiate does what to the: -CMRO2 -ICP -CPP -Cerebral blood vessels?

Upper Lip Bite Test grade 3 which raises the probability of diifficult intubation from 10% to 60%

Exam with the highest Likelihood ratio of the highest chance of difficult intubation?

High = LA, DKA, ETOH, methanol, uremia, ASA, cyanide. Normal= diarrhea, RTA, Diamox

Examples of normal anion gap vs. high causes?

In order to decrease the CO2 ==>hyperventilation at higher pressures must ensue==>barotrauma. So keeping co2 A LITTLE HIGHER TO ENSURE that aggressive ventilation and platue pressures are kept to a minimum.

Explain how permissive hypercapnia leads to lung protective ventilation?

Dehydration = contraction = Na+ goes up = increase SID >40 since the Cations increase. other factors that can increase the SID is to take away anions (NG suction and loss of Cl-)

Explain how the strong ion difference goes up with dehydration? Other factors?

Big exhale to clear the lungs -->max inhale of co --max exhale of CO. ETCO is compared to the amount of CO given.

Explain the DCLO test?

1.) O2-Hg in the lungs, bumps off CO2 off the Hg molcule into the blood of the lungs. 2.) Hg also bumps off 2 H+. 3.) H + Hco2 = Carbonic Acid. 4.) Carbonic acid dissociates into H2O + CO2. 5.) CO2 leaves the blood -->Alveoli. 6.) Decrease in CO2 on the CO2 dissoication curve.

Explain the Haldane effect?

C2-C4. Start by going 2 cm, 4 cm, and 6 cm distal of the SCM. at 6 cm, its the cricoid cartilage = Chassaignac tubercle (C6 transferse process). Approach in a posterior-medial & inferior approach.

Explain the approach of a cervical plexus deep block and which nerves does it target?

Type= find out the blood type / RH +/- Screen = tests to see if there is Antibody reactions with the patient's plasma with a known reagent. Crossmatch: patients blood and donor blood mixed together.

Explain what the type/screen test and crossmatch test is?

-po2 and pCO2 are lower in a hypothermic patient because gases are more soluable in the cold and gas molecules aren't as active. -ABG sample will take the blood sample from the hypothermic patient and heat it up to 37 degrees. It'll give a higher Po2 and PCO2 to where the pt actually is. A patient would actually be hypoxic with a lower pO2.

Explain why a blood gas of a hypothermic patient would be effected if the gas sample is heated in an ABG?

Slow on/off 2/2 to pKA of 8.0 (mostly ionized+) and protein bound by 20-40% to proteins like albumin. Has active M6G when metabolized, but has poor biovavilability of 10-45%

Explain why morphine is the standard for moderate-to-severe cancer pain?

It is a spinal reflex.

Explain why movement to surgical incision is still considered brain death?

Measures the small airways and is reduced in patients with emphysema.

FEF 25-75%

FIO2 can lead to gas resorbation with a 100% oxygen

FIO2 leading to atelectasis how?

ERV + RV 35 cc/kg. Peep increases FRC, so does other conditions that increases air in the lungs after a normal exhilation.

FRC equation

1.) Fibronogen 2.) vWF 3) F8 4) F13

Factors and products provided by Cryo?

coexisting psychiatric illness, a family history of a substance use disorder, and the use of major opioids as the drug of abuse

Factors associated with relapse,

VWF, Factor 8, Factor IV, Factor 3.

Factors not made by the liver?

-decreased response to endogenous vasopressors, -vasodilatory effects of progesterone and prostaglandins -the low resistance of the uteroplacental vascular bed. SVR decreases greater than CO leading to a decrease in BP.

Factors of decreased SVR in preggos.

Supply: -Decrease HR, increase CPP by increasing diastolic pressure, decreasing LVEDP, increasing oxygen content, coronary vaso dilators. Demand: -Decrease HR, Wall tension by decreasing pre-load & afterload, contractility.

Factors of myocardia ischemia broken down into supply and oxygen demand. What are these factors?

Factors that decrease DLCO are sarcoidosis, asbestosis, berylliosis, oxygen toxicity, COPD, anemia, and pulmonary edema.

Factors that decrease DLCO?

CBF is determined by several factors such as cerebral metabolic rate, temperature, PaCO2, and PaO2.

Factors that determine CBF?

Fetus deoxygenated blood-->Umbilical arteries (paired from internal illiac)-->placenta-->blood is oxygenated-->Single Umbilical Vein back to fetus with oxygenated blood.

Fetal blood flow:

50-60 mmHg due to mixed o2 in babies and the placenta taking oxygen as well.

Fetal po2 is?

Beta Blockers such as propranlol. Beta blockers are to be avoided in acquired QT syndrome (not congenital) as they can cause bradycardia which is a cause of QT prolongation --> Torsdes.

First line medications to decrease cardiac events in congentital prolonged QT syndrome patients?

NSAIDs, opioids are second line.

First line mgt for TNS?

tricyclic antidepressants, gabapentin, pregabalin, opioids, topical capsaicin, and topical lidocaine.

First line treatment options for herpes zoster include?

The concentration of medication X is decreasing by a constant fraction (50%) per unit of time. Exponential decrease. Higher concentration, faster the elimination. Zero-order kinetics will eliminate a constant amount of drug per unit time regardless of the plasma concentration. linear decrease. No reliant on concentration.

First order kinetics defination? vs zero order?

The loss of the reflex is the first sign of symptomatic hypermagnesemia. Assess q 1-2 hours. Magnesium should be 24 hours post-partum with the therapeutic range of 5-9

First sign of symptomatic hypermagnesemia and how often should be assessed?

HF > syncope > angina.

First symptoms found with aortic stenosis?

Prostaglandin E1 (PGE1) is the first-line therapy for treating of pulmonary atresia because it maintains patent ductus arteriosus (PDA) patency,

First-line tx for Pulmonary aterisa?

-HR -RR -Tone -Irritability -Color APGAR scoring doesn't predict long term outcomes, but correlates with worse outcomes.

Five components of the APGAR score?

activity, breathing, circulation, consciousness, and oxygen saturation

Five factors of the modified Aldrete score?

Five nerves: -Posterior Tibial = sole of foot & calcenous = blocked @ medial malleous. -Deep peroneal = web of foot = lateral to the Extensor Hallolus tendon. -Superficial peroneal = posterior foot = Sub-Q injection up to the deep peroneal site. -Sural nerve = lateral ankle & foot (5th digit) = lateral malloulus. -Saphenous = medial foot and ankle.

Five nerves blocked of an ankle block

Tracheal stenosis, goiter = truncated inspiration and expiration. Variable defects = change between inspiration and expiration. -Extrathoracic defects leads to inspiration issues = vocal cord palsy. -Intrathoracic defects leads to expiration issues = bronchial tumor

Fixed defect vs. variable defects on the pressure/volume loops?

(P1 (driving pressure) - P2)/resistance. P1 -= driving pressure Increase in resistance = decrease in flow.

Flow formula is?

0.9 = 154/154 | 308 osm LR = 130/4/109/28 lactate-->bicarbonate | 274 Osm = iso-osm D5W = 5 glucose | 252 osm = hypo-osm Albumin 5% = 145 +/- 15 / K+ = 2.5 / Cl = 100 | 330 = hyper-osmolar

Fluid types and components: -0.9 -LR -D5W -Albumin

40%, SVR drops by 39% Changes persist for up to 30 minutes after delivery and return to normal values by 2-5 days post-partum.

Following vaginal, c-section, delivery how much does CO increase by? How long does it stay that way for?

Cerebral Perfusion Pressure = MAP - ICP (or CVP).

Formula for Cerebral Perfusion Pressure?

EDV-ESV/EDV

Formula for EF?

Serum lactate, SvO2, base deficit, and UOP

Four trended values as surrogate markers of end-organ perfusion to guide resuscitative efforts, in sepsis patients?

α-islet cells and β-islet cells hypoglycemia, protein/amino acid intake, endorphins, exercise, growth hormone, epinephrine, and glucocorticoids stimulates ==>Glucagon ==> Increase in cAMP ==>gluconeogensis, suppressed by somatostatin, insulin, and glucose intake or infusion = glucagon suppression.

Glucagon and insulin are both secreted by the pancreas via?

ETO2 > 90% CPAP or pressure support helps prolong the apnea time.

Gold standard to ensure pre-oxygenation? What can be done?

micrognathia, hypoplastic zygomatic arch, facial asymmetry, and facial hypoplasia. Most patients have moderate to severe congenital cardiac defects and respiratory problems. Patients are also at risk for subluxation of C1-C2.

Goldenhar syndrome anesthesia considerations.

vital capacity. ERV + TV + RV. 60 cc/kg.

Good cough and deep breathing correlates to which capacity lung volume?

Saphenous to the PDA

Grafting of the RCA is using what?

SVG to PDA.

Grafting to the RCA is usually done how?

The marginal arteries which are the circumflex branching arteries.

Grafting to the circumflex is usually done to what arteries?

SIADH-hyponatermia.

Guillain-Barré syndrome is associated with what electrolyte issue?

20-30 minutes

Half time of nicotine is?

hypoglycemia, macroglossia, and organomegaly. Organomegaly causes the hypoglycemia. +/- Omphalocele

Hallmart signs ofBeckwith-Wiedemann syndrome?

Conduction: heat transfer. Pt. lying on cold surface Convection: Beir hugger or immersed in flowing water. Radiation: heat transfer through infrared waves. Main mode of heat loss in an OR.

Heat transfer processes in an operating room?

efficiency of the liver to remove drug from the circulating blood volume. Ranges 0-1; -0 indicates that most of the drug is not eliminated during a single pass -o close to 1 indicates that most of the drug is eliminated in a single pass.

Hepatric Extraction Ratio

Factor 7 considering its half-life is 4 hours. Unlike fibrogen which has a half-life of 4 days.

Hepatric Synthetic Function can be measured how?

pulmonary stretch receptors trigger the reflex which temporarily prevents inspiration and allows expiration to occur. This prevents overinflation of the lungs.

Hering-Breuer reflex

Oxygen not used. Examples: Cyanide toxicity. Cold Left to right shunt (LA > RA > RV > PA) Cirrhosis Sepsis

High SVO2 means?

COPD, BMI > 1 Low initial FEV1 Low post-op predicted FEV1 Can't climb over 2 stairs.

High risk for thoracic surgery?

Hip flexion utilizes L1 and L2, knee extension (and the patellar reflex) utilizes L3 and L4, and knee flexion utilizes L5 to S2.

Hip flexion utrilizes which nerves Knee extension utilizes knee flexion utilizes?

1.) IV in distal arm 2.) Lift arm to take blood out of the arm. 3.) wrap the arm with an ace bandage 4.) Place double torniquiet on. 5.)inflate the more proximal cuff first 6.) Inject 0.5% lidocaine of 1-2% lidocaine without epi. (10 cc-15 cc / 30-40 cc). If torniqut pain, inflate the distal cuff, then deflate the proximal cuff.

How a Beir Block is performed?

Increasing PA = ZONE 1 of the lung = dead space.

How can PEEP increase dead space?

TPN = decreases Phosphate = decrease in 2,3 DPG which is found in RBC and allows for confirmational change between Hg-O2 molecules to release O2 into tissues = decreased tissue oxygen delivery 2/2 left shift of the Ox-hemoglobin curve. Also a decrease in Phosphate = decreased ATP = decreased delivery to muscles such the diaphragm leading to difficulty vent weaning.

How can TPN administration lead to decreased oxygenation to tissues?

Citrate is metabolized into bicarbonate and may cause metabolic alkalosis.

How can a massive transfusion protocol result in metabolic alkalosis.

absorption atelectasis

How can high FIO2 cause a atelectasis?

Lean body weight is the total body weight minus the adipose tissue. Ideal body weight (IBW) is the weight with the lowest mortality rate for a given height and sex and was originally derived by life insurance companies. height in cm − X, where X is 100 for adult men and 105 for women nonobese, nonmuscular patients, total body weight is about equivalent to IBW.

How can lean body weight be calaculated? Ideal?

produces anesthesia via the enhancement of the action of the neurotransmitter GABA on the GABAA receptor.

How do inhalation agents cause anesthesia?

Inhalational anesthetics are capable of potentiating the neuromuscular block by interacting with the postjunctional receptors directly.

How do inhalation agents impact NMB?

Directly, esp. over 1 mac with skeletal muscle reaction. Indirectly by a synergistic mechanism that aren't understood. more pronounced with roc,vec, pancuronium > nimbex. Will just increase density of action, not duration. Most potent for this is Desflurane > iso = sevo > N2O.

How do inhalation anesthestics augment neuromuscular blockade?

Use a bronchial blocker.

How do you block off a lobe with a trach?

You block it by going 2 centimeters medial And 2 cm distal to the ASIS

How do you block the lateral femoral cutaneous nerve Only

Deep transgastric view on the TEE > 40 mmHg = severe.

How do you find the peak and mean gradients of aortic valve?

0.1 units of regular insulin/kg IV and 2 ml/kg of 25% dextrose

How do you fix hyperkalemia in kids with Malginant hypthermia?

Split lung function tests such as regional perfusion or regional ventilation with radioactive tracers to evaluate the functioning tissue of the lung.

How do you identify functional areas of lung that can be calculated in the PPOFEV ?

40 cm of h2o, 7-8 seconds.

How do you properly reopen collapsed airways?

Gradual decrease in CO2

How does CO2 relate to hypothermia?

Magnesium competes with calcium inside vascular smooth muscle cells. This prevents some actin-myosin crosslinking and can decrease the force of vascular smooth muscle contraction. Additionally, magnesium acts inside endothelial cells to increase nitric oxide and prostaglandin I2, both of which have vasodilator properties.

How does Magnesium cause hypotension?

has inhibitory effects upon plasma cholinesterase, therefore it may prolong the duration of mivacurium and succinylcholine by means of reduced degradation.

How does Metoclopramide effect sux? What other paralytic does it effect?

PaCO2 is usually 5-6 mmHg higher than ETCO2.

How does PaCO2 relate to ETCO2?

circumduction of the arm across the chest or lateralization of the neck toward opposite shoulder, leading to abduction, adduction, and external rotation of the arm. Minimized by an axillary roll.

How does Suprascapular neuropathy occur in surgery?

Small ossiclations are sensed, until the one with the maximum amplitude is picked up which represents the MAP.

How does a BP cuff work?

Negative Intrathoracic pressure against the close airway ==>increase in venous return to the right heart==>pulmonary vasculature pressure increases via hydrostatic pressure resulting in transudative edema. Uusally seen within 90 minutes.

How does a laryngospasm cause fluffy infiltrates on chest-xray?

-Incision made on the left. -Robot assistance = more distant pt from the provider. -100% need to be paralyzed -Placed in Right Decub Positon -One-lung ventilation vital -If robot asistance is needed-thoracic insufflation is required. -Require placement of pulmonary artery vent (drains right heart during pump) -Require placement of endoaortic occlusion balloon clamp-replaced the aortic clamp-care taken not to block the inominate artery(can be picked up by right-sided a-line) or coronary ostia.

How does anesthesia for MIDCAB surgery differ from a regular stenotomy anesthesia?

Glucose up = insulin release = drive potassium into the cell. Autosomal Dominant 2/2 to sodium & calcium channel mutations. Other triggers = carbs, exercise, steroids, laxatives, stress, etoh

How does glucose-containing solutions result in Hypokalemic Perodic Paralysis?

Helium is less dense than nitrogen and as a result helps lower Reynolds number and increase the tendency to laminar flow.

How does heliox work?

Granulytic chemotaxis phagocytosis bactericidal activity Other symptoms=seizures, coma, impaired vent weaning Esp. <1. replete byy starting with IV and then when levels >2, start oral and continue 5-10 days

How does hypophophotemia lead to inceased risk of sepsis?

leads to a decrease in 2,3-BPG = left shift in oxygen-hg curve = tighter bond with the oxygen-hg mocule.

How does hypophosphatemia result in oxygen-hg dissociation curve changes?

When you take off blood, give LR or NS to make the patient euvolemic. Different than autologous which takes off blood without replacing the volume.

How does isovolemic hemodilution differ from autogolous?

While it is mostly a dopamine antagonist with serotonin antagonism at higher doses functions as a weak antiemetic, likely because of its antagonism of serotonin at higher doses

How does metoclopramide functions as a weak antiemetic?

measure of lipophilicity. The oil:gas coefficient is related to anesthetic potency and minimum alveolar concentration (MAC). higher the oil:gas coefficient the lower the MAC. -ISo has a high oil:gas coeff > Des (99 to 19).

How does oil:gas coefficient relate to local anesthestics?

Maintain coronary perfusion pressure by increasing diastolic blood pressure. Diastolic blood pressure is the driving force into The myocardium. Lower the LVEDP. Considering the LVEDP is considered P2 in the formula and it will now allow pressure to move epicardium to endocardium through the coronaries to apply oxygen to myocardium. Lower heart rate. At a lower heart rate will spend more time in diastole by increase the left ventricular diastolic pressure.

How does optimizing Coronary perfusion pressure work?

AC interference. Happens if an AC power cord is lying across the EKG cable or monitor.

How does the image of an EKG look like this?

When halogenated agents prone (desflurane) of CO production react with dry CO absorbants with strong bases-particular order of: (KOH > NaOH >> Ba(OH)2, and Ca(OH)2). Other factors of CO production include: dryness of the absorbent, the concentration of volatile anesthetics used, and the chemical makeup of the absorbent..

How is CO produced from halogenated agents?

selective and nonselective pulmonary vasodilators in both inhaled and IV forms

How is PA pressure HTN during lung transplant managed after PA artery clamping?

Place color on tricuspid valve. Measure regurg Jet using the formula: 4V2

How is RVSP done?

hepatic (70% via the biliary system) and the renal (30%) systems unchanged, with only a small amount degraded by the liver.

How is Rocuronium primarily excreted?

<3 = low risk for n/v >3 yo - Adolence = high risk for nausea/vomiting (even higher than adults). -prior to puberty, boys & girls = risk, but after puberty, girls have a higher risk for PONV. Other risk factors include -motion sickness. -family hx of PONV -TNA operation. -ENT sx. ->30 minutes -Neostigmine.

How is age a risk factor for PO nausea/vomiting in the peds population?

T8/T10-S2-s4. Vaginal = T10/L1. Perineum = S2-s4. Half the dose of c-section dose. General anesthesia is better for bulging membranes, because abdominal relaxation is important to prevent further bludging and rupture.

How is anesthesia for cerclage done? When is general vs spinal chosen?

Flow across the Mitral valve E:A waves.

How is diastolic dysfunction assessed on Echo?

single-optical isomer of bupivacaine. Improved safety profile with less CNS and cardiac collapse 2/2 to reduced affinity-however, the cardiac-to-CNS toxicity is still low (meaning it is toxic).

How is levobupi different from Bupi?

Functional closure occurs shortly after birth, but anatomic closure does not occur until 2 or 3 months of age. 2/2 failure of the septum primum and secundum failing to close.

How long does it take for a PFO to close?

holding ticagrelor five to seven days prior to neuraxial

How long should Ticagrelor be lead for prior to neuraxial?

1-2 days and it is usually seen in the Right lower lobe

How long should aspiration pneumonia take to be evident on chest xray?

31 spinal nerves / 30 derematomes. C1 doesn't have a dermatome. Named from the foramina which they exist.

How many dermatomes exist? Spinal nerves?

Five electrodes consist of four extremity leads (right and left arms and legs) and one precordial lead that generates seven leads (I, II, III, aVR, aVL, aVF, and one precordial lead).

How many leads do five electrodes generarate?

30 questions per quarter or a 120 per year.

How many questions need to be completed to maintain certification of Anesthesia?

40% At 25% = orthostatic hypotension.

How much blood volume is lost for the body to show symptoms of shock?

NS or 5% dextrose in water. When a 25% albumin solution is diluted to a 5% albumin solution with sterile water, its osmolarity is approximately 1/5 that of plasma = hemolysis + AKI

How should 25% albumin be diluted to 5% albumin? What can be used for dilution?

Aminocaproic acid injection contains as a preservative benzyl alcohol, which has been associated with toxicity (fatalities) in neonates

How should amicar be used cautiously in kids?

30,000-60,000 times the strength of the earth's magnetic field.

How strong is the MRI magnet compared to earth?

The phrenic nerve paralysis is a result of local anesthetic spread over the anterior scalene muscle to the phrenic nerve at the level of the injection for the interscalene block. Keep more posterior.

How to decrease hemidiaphargm paralytic symptoms of an interscalene block?

TV 6 ml/kg Airway plasure pressure <30 Subglottic scretion drainage

How to employe lung protective ventilation?

1.) Go down the bronchial lumen, pull back on the Double Lumen Tube until its in the trachea, then advance the tube into the left or right bronchus. 2.) Go down the tracheal lumen, then look to see if its in the left main stem bronchus. Breath sounds should be bilateral with tracheal cuff, and only left-sided lung sounds with a left-sided DLT.

How to properly place a double lumen tube?

Hypotensive patients will respond less to hyper-capnia than a normotensive patient would. CBF usually increases by 1-2 cc/100g/minute every 1 mmHg change in CO2 between 25-75 mmHg. This is dropped by 33% by in moderate hypotension and 70% in severe hypotension.

How will the response to PaCO2 and CBF be different between hypotensive and normotensive patients? By how much?

Awake surgical tracheostomy is the preferred method for airway control.

How would one secure an airway in a in the setting of laryngeal cartilage disruption or laryngotracheal separation?

AD 2/2 to sodium channel mutations and results in: paralysis after: Potassium-rich meals Rest after exercise Exposure to cold temperatures Fasting

Hyperkalemic Perioid Paralysis is due to what?

Increased PR, widened WRS, interventricular delay

Hypermagnesium does what to the Ekg?

Increased basal metabolic rate 2/2 to increase in Na+/K+ATPases & beta receptors.

Hyperparathyoid s/s 2/2?

ANP will relase 2/2 to atrial stretch =. decrease sodium absoprtion in the collecting ducts.

Hypervolemia releases ANP, what is the role?

decreased response to a noxious stimulus and is often associated with peripheral neuropathies such as diabetic neuropathy or postradiation neuropathy

Hypoalgesia is associated with what medical conditions?

Knocking out more dermatome levels, so the sensory block of the spinal height will result in even more heat loss.

Hypothermia is more severe with combination regional anesthesia and general anesthesia. What would result in even greater heat loss?

-Nicotinic stimulation at preganglionic sites leads to tachycardia and hypertension nicotinic acetylcholine receptor on the neuromuscular junction, fasciculations, twitching, fatigue, and flaccid paralysis.

If Sarin is an OGP which acts on Ach increasing, how can it lead to tachycardia and hypertension?

If a patient is allergic to chlorhexidine, then an iodine solution or 70% alcohol can be used, but this is not the preferred solution.

If a patient is allergic to chlorhexidine?

To stop the flow of gases. As opposed to if you do have an endotracheal tube is to remove the tube, then stop the flow to gasses.

If an airway fire occurs that says not include an endotracheal tube what is the first stop?

If arterial dilation or large-bore catheter placement occurs, it should be left in place and vascular surgery or another service trained in managing large-bore arterial access should be immediately consulted.

If arterial dilation or large-bore catheter placement occurs of the carotid artery occurs, what should happen?

Hydralazine, and nifedipine. Tx is recommended for >160/105. Esmolol can cause fetal bradycardia

If labetalol fails to achieve BP control in pregnant patient, what else can we use?

RV because RV is supplied by blood throughout systolic and diastole. LV is supplied with blood mostly during diastole.

If you increase the systolic BP more than the diastolic BP, which ventricle would get more blood flow?

L4. Corresponds with L4/L5 interspinous level.

Illiac crest is at what spinous process?

-Raising Peak Inspiratory Pressures (shouldn't do that)-is actually employed in ARDS ventilation to decrease PIP -Shouldn't lead to hypoxemia unless there is little to no ventilation occuring.

In ARDS ventilation, permissive hypercapnia shouldn't have any effect on what two factors:

In addition, hypomagnesemia and hypercalcemia can all potentiate its toxicity.

In addition to hypkalemia, what other ion abnormlaities can potentiate dig toxicity?

In ambulatory and office-based settings, the leading causes of injuries were respiratory, and the majority of injuries occurred intraoperatively.

In ambulatory and office-based settings, the leading causes of injuries?

These patients develop hypokalemic hypochloremic metabolic alkalosis. Semi-normalization of chloride may be the most important and most relevant metabolic change suggesting surgical optimization. Some data suggests that it should normal-to-high normal (106 is goal).

In an infant with Pyloric stenosis, what lab value may be most important to look at to determine optimization for surgery?

Maintain euvolemia using goal-directed therapy. Patients should not be hypovolemia-can cause AKI or hypervolemia (pulmonary edema, increased length of stay, postoperative ileus, delay in time to first enteric feeding, and both anastomotic and wound dehiscence.) Can also determine if they need pressors or not.

In context of "Enhanced Recovery" protocols, as patient complexity increases, the monitors to manage fluid response should also increase. why?

Increase in NE because the beta receptors don't respond as well, but the PNS decrease.

In elderly CO is persevere at rest, but they have limited cardiac reverse. What happens to SNS and PNS?

First, hematology consult prior to elective surgery should be done. -minor = DDAVP -Active = cryo (8 and fibrogen) -If antibodies to F8 = Porcine F8, Recombinate F8A, Recombinate F7A

In factor 8 def. What is to be used if: -Minor bleeding -Active bleeding -Has Antibodies to F8 and active bleeding?

1.) Transesophageal echocardiography (adults) or precordial Doppler ultrasound (infants/children) 2.) End-tidal capnography/end-tidal nitrogen/pulmonary artery pressure 3.)Cardiac output/central venous pressure 4.) Peripheral capillary oxygen saturation/BP/ECG changes.

In order from most to least sensitive, the following modalities can be used to detect a venous air embolism (VAE) during craniotomies:

It has to be in In parallel or less than 20°. If it is perpendicular it will show no flow.

In order to measure flow Doppler white does the ultrasound probe have to be single wise?

Temp > 32 degrees. No paralystics/sedation No shock state.

In order to pronounce brain death, what must happen prior to testing?

enzyme works via the G6PD system so symptomatic patients with congenital G6PD deficiencies can be treated with ascorbic acid (vitamin C) or exchange transfusions.

In patients who have meth-hg and are G6PD Defiecent, what other vitamin must be given before treating their Met-HG?

This is primarily due to a decrease in albumin. goes from 1.4 ratio to 0.9 ratio.

albumin/globulin ratio decreases when comparing non-pregnant females to pregnant females in the third trimester, why?

null hypothesis was incorrectly rejected aka a Type I error. Example: There is no difference between the new analgesic and the standard of care, but researches mistakenly say that there is. null hypothesis was incorrected accepted aka a type II error Example: There is a difference between the new analgesic and the standard of care, but researches mistakenly say that there isnt.

alpha error vs. Beta error

potentiate

aminoglycosides, lithium, acute phenytoin will do what to neuromuscle blockade?

may induce miosis to treat glucoma, but It may be absorbed systemically and may impair plasma cholinesterase leading to increased duration of action of succinylcholine.

echothiophate (phospholine iodide) systemic effects?

little to no clinically significant effect on pulmonary function. Small meaning decrease in VC and FEV1 2/2 to decreased ERV due to muscle weakness required during forced exhalation. Subjective DIB 2/2 to thoracic afferent sesnsation of the chest wall.

effects on the respiratory system is expected from epidural anesthesia?

ventriculostomy catheter is the most accurate and reliable method of monitoring intracranial pressure (ICP)-AKA an EVD

gold standard for ICP measurement

TRALI is now the most common cause of transfusion-related fatalities

he most common cause of transfusion-related fatalities?

The most common organ affected by ACS is the kidney, as it is the abdominal organ most susceptible to hypoperfusion leading to Acute Tuburlar Necorosis

he most common organ affected by Abdominal Compartment Syndrome?

nonsteroidal anti-inflammatory drugs (NSAID) such as aspirin or diclofenac

he most effective prophylaxis for postoperative myalgias due to succinylcholine?

Patients with diastolic dysfunction depend highly on preload and atrial kick to maintain cardiac output

lthough the resting systolic function of the heart is maintained, the diastolic function of the heart is often impaired in elderly. Pts with disastolic dysfunction rely on what the most to maintain CO?

Substance P and calcitonin gene-related peptide (CGRP) release from pancreatic vagal afferent neurons can lead to visceral pain = can cause nociceptive pain. Also, when cancer cells invade neuronal tissue, they can lead to neuropathic pain.

mechanism for pain from localized pancreatic cancer?

-Full-term, less than one month. -preterm infant -ex-preterm, less than 60 weeks post-conceptual -Poorly controlled systemtic dz. -Sickle cell -OSA -In-born errors of metabolism -Active infection-especially respiratory.

most (60%) pediatric surgeries occur in the outpatient setting. What is a contraindication to this?

Deadspace = mpaired or absent perfusion of alveoli enhancing V:Q mismatch. = decrease in cardiac output.

most common cause of a sudden increase in physiologic dead space

Atropine counters cholinergic crisis at muscarinic receptors. pralidoxime or obidoxime should be adminsitered after atropine in order to reverse the Ach effect on the nictotinic muscles effects. Oximes cleave the phosphoryl group from the active site of the inactivated acetylcholinesterase, regenerating the enzyme.

sarin gas, soman, tabun, and VX are all organophosphates which inhibit the ACH-E leading to excess Ach. Why does atropine and pralidoxime have to be administered?

glossopharyngeal nerve. which aids in the elevation of the pharynx for special functions such as speech and swallowing

stylopharyngeus muscle is innervated by which nerve?

Internal Spincter Tone -PS = relaxation = S2-S4 = inferior hypogastric -SNS = L1/L2 = contraction. Detrusor muscle -SNS = hypogastric nerve = T10-L2 = relaxation. -PS = pevlic splanchnic (S2-S4) = contractation = peeting.

sympathetic nerves originate in the thoracolumbar spine parasympathetic nerves originate from the cervical and sacral spinal cord

Rapid glucose correction of fast than a 100 mg/dL/hour can result in brain swelling. D5W balances this out.

the administration of D5W along with insulin therapy is used because?

meperidine, fentanyl, and sufentanil, which experience significant first-pass uptake and retention by the lung

which opioids experience significant first-pass uptake and retention by the lung

The incidence of difficult intubation in the general population is between 1-3%. The incidence of difficult mask ventilation ranges from 1-5% with an impossible mask ventilation incidence of 0.15%.

Incidence of difficult intubation, difficult mask, and impossible mask?

Base-line CO2 is elevated. Pattern is the same. Phase I is mildly elevated, Phase II is normal, Phase III is longer and Gradual downslopes back to zero.

Incompetent expiratory valve will show what kind of CO2? Inspiratory valve?

Closes it. Prostaglandins keeps it open.

Indomethocine does what for the PDA? Keeps it open?

coarctation of the aorta

Infantd with TEFs and esophageal anaomalies can present with what type of cardiac problem?

Intraoperative monitoring of Leads II and V4. Alone, V5 has the highest sensitivity for myocardial ischemia

Intraoperative monitoring of Leads preferred for rhythm monitoring and sensitive for mycoardial ischemia?

Common peroneal nerve-L4-S2 nerve roots. Risk factors = prolonged sx & low bmi.

Isolated foot drop is due to which nerve? risk factors? nerve roots?

Difficulty intubation 2/2 to cervical spine fusion. + have scoliosis, strabismum, and scapular defects.

Klippel-Feil syndrome has what anesthesia concern?

Some advocate maintaining the cuff pressure below 25 cm H2O.

LMA cuff pressure under what should be the goal of decreasing injury?

LMWH = AT3 + 10 UFH = ATE + 10 + 2

LMWH and UF heparin work how?

Labetalol onset is within 5 minutes while its duration of action is 3-6 hours until it is metabolized by the liver.

Labetalol onset?

Reduces it from 5 billion WBC to 5 million WBCs

Leukoreduction decreases the incidence of febrile nonhemolytic transfusion reaction.

Cartoid = medial and deep IJ = lateral and superficial EJ = even more lateral and superficial to IJ.

Location of the Cartoid, IJ, and EJ?

Anaglesia (loss to pin prick) is 2 segments cephlad to anaesthesia (loss to touch). SNS block is up to six segments above--indicated by increased in temp.

Loss to pin prick is considered what in Epidurals and what is it the meaning of it?

Anemia Increased VO2 -shivering Low SAO2 -Ards Low CO

Low SVO2?

L1-L4/S1-S4

Lumbar plexus arises from? Sacral plexuses

The lumbar plexus gives rise to the femoral nerve, obturator nerve, and lateral femoral cutaneous nerve. The sacral plexus gives rise to the posterior cutaneous nerve of the thigh and sciatic nerve.

Lumbar plexus gives rise to? Sacral plexus gives rise to?

first stage of labor. Not second stage.

Lumbar sympathetic block can you give analgesia for which stage of labor?

inspiratory reserve volume = TV + large inspiration. Vital capacity = from a large inspiration to a large expiration. Residual Volume = gas that can be expired out after the largest expiration. FRC = gas in your lung after you exhale (35ml/kg or 2.5 liters)—> if metabolic rate is 1 (250 ml/minute) = 10 minutes before using all the oxygen.

Lung Volumes.

In an individual with obesity, -RV is unchanged - the ERV is decreased. -Therefore, FRC is decreased (FRC = ERV + RV). -The TV is decreased -while the inspiratory reserve volume is slightly increased. -The TLC can be either unchanged or slightly decreased.

Lung volumes in obese patients?

DBP + (SBP-DBP)/3

MAP formula

Charles-Pugh: total bilirubin, albumin (PT)/ (INR), and the presence of ascites or hepatic encephalopathy. MELD: serum bilirubin, creatinine, INR for prothrombin time, and sodium.

MELD vs. Charles-Pugh?

Sensitive to Non-depolarizing muscle blockers (1/10th of dose). Resistent to Sux (ED95 is 2.6 x the normal amount and should have an increased dose).

MG patients and Neurmuscular blockade?

Patients with myasthenia gravis are very sensitive to nondepolarizing muscle relaxants as even small doses can produce extreme respiratory muscle weakness. On the other hand, myasthenic patients tend to be resistant to the effects of succinylcholine.

MG patients are sensitive and resistent to which muscle blockers?

-decrease sodium reabsorption in the collecting ducts. -renal afferent arteriole dilation and efferent arteriole constriction

MOA of ANP?

The local anaesthetic diffuses into the surrounding nerves.

MOA of Beir Block?

AD genetic disorder within the RYR1 gene coding for the, ryanodine, RYR1, receptor, a calcium channel. This results in an excess amount of calcium release from the SR leading to excessive muscle contractility.

MOA of Malignant Hyperthermia?

Blocks PD3E--> Increases cAMP --> Calcium increased in the SR during diastolic and systolic phase-->Shifts the Pressure-volume loop down-->decreasing the LVEDP-->increasing lusitrophy. Also is a veno+vasodilator-->to decreased afterload and preload.

MOA of Milrinone?

Anti-IgE that is a monoclonal antibody and binds to/captures IgE prevention the interaction between receptors and basophils. Used in asthma.

MOA of Omalizumab?

Organophosphates function by phosphorylating the serine hydroxyl group of acetylcholinesterase enzymes.

MOA of Organophosphates?

Loss of dopaminergic fibers with unopposed acetylcholine activity. In order to correct must give, l-dopa, anticholinergics, anti-histamines which equal a decrease in the extra-pyramids symptoms

MOA of Parkinson's

alpha-1 receptor antagonist,

MOA of Phentolamine?

Tetrodotoxin inhibits fast sodium currents in myocytes

MOA of Tetrodotoxin

Vagus = M3 receptor activation = influx of intracellular calcium = increase in myosin-light chain kinase activity = contraction of smooth muscle. Other MOA is activation smooth muscle via bronchopulmonary sensory C fibers to a minimally extent via Non-adenorgeic. non-cholinergic response. Histamine can activate the vagus nerve => M3 activation ==> constriction.

MOA of bronchconstriction:

Brown fat is more vascular w/ higher beta-sympathetic innervation so cold stress -->SNS-->NE release-->lipase activation-->hydroxlation of triglycerides-->increase in uncoupling oxidation. Inhibited by beta blockers and inhalation anesthetics.

MOA of brown fat leading to heat production?

Cardiac = contraction Vascular smooth = dilate GDP -->GTP=-->+ATP-->cAMP-->PKA+

MOA of cAMP on cardiac vs. Smooth muscle?

Digoxin binds at the same the Na+-K+ ATPase at the same site as K+. As a result, in hypokalemia, digoxin binds more easily, and its toxicity can be potentiated. hypomagnesemia and hypercalcemia can all potentiate its toxicity. However, Hyperk+ is a marker for dig toxicity considering it remains in the outside of the cell.

MOA of digoxin toxicity when it comes to hypokalemia?

SNS blockade leading to PNS being unopposed which increases gastric motility.

MOA of epidural analgesia and the benefit to decreasing ileus?

Aricept is an cholinestrase inhibitor, which also blocks pseudo cholinestrase that can cause a decreased break down of sux and prolong its effect.

MOA of how Donepezi( Aricept) can prolong Sux effect?

Heliox is a mixture of helium and oxygen that is used to improve laminar gas flow by replacing the nitrogen in the inhaled volume.

MOA of how Heliox improves laminar flow?

Oxytocin works like ADH at high doses = decrease UOP = increase H2O into the blood, regardless of fluid status = increased volume sensed by atria = ANP release = natriuresis [ elimination of sodium in the urine ] = hyponatremia.

MOA of how Oxytocin at high doses can cause naturesis?

Hyperglycemia works by hyperpolarizing-longer opening of the potassium channels 2/2 to hypokalemia-->hyperpolarizing of the beta cells halts calcium channels for opening an releasing insulin.

MOA of hyperglycemia in thiazides?

Cold = gas more soluible in liquid = a decrease in PaCO2 and PO2 as it dissolves into the liquid = increase in pH 2/2 to a decrease in pCO2.

MOA of hypothermia on blood gases?

Increases synthesis glycogen, lipid synthesis, protein synthesis, uptake of potassium into the cells, and decrease lipolysis.

MOA of insulin?

Amminoia produced by enterocytes & colonic bacteria. Lactulose acidifies the intestinal lumen = trapping of ammonia as ammonium ion. Ammonia is bad because it decreases excitatory NT glutamate by combining with it and causing glutamine synthase to produce Glutamine. Glutamine also passes into the astryocytes and result in osmotic swelling of the cells.

MOA of lactulose?

possesses both opioid analgesic and N-methyl-D-aspartic acid (NMDA) antagonist properties 2/2 to a racemic mixture. Additionally, it inhibits serotonin and norepinephrine reuptake, resulting in antinociception and mood elevation.

MOA of methadone?

Smoking, however, is actually a dose-dependent protective factor for the development of preeclampsia. This effect may be due to nicotine inhibition of thromboxane A2 synthesis or stimulation of nitric oxide release. Risk is decreased by 30-40%

MOA of nicotine being actually protective against pre-eclampsia?

mitigating the majority of radiation-induced injury to the thyroid via saturating the thyroid with iodine and preventing uptake of the radioactive I-131 isotope. Strontium lactate plays a similar role in the bone.

MOA of potassium Iodide in radation exposure?

hypotonic freshwater moves intravascular and disrupts surfactant surface tension properties causing pulmonary edema. Saltwater is thought to maintain surfactant however it is hypertonic and causes movement of fluid into alveoli via osmotic forces; this also ultimately causes pulmonary edema and impairs alveolar gas exchange.

MOA of salt water vs. fresh water drowning?

. Pulmonary surfactant increases compliance by decreasing the surface tension of water and preventing alveolar collapse.

MOA of surfactant

Surgical incision = inflammatory markers release = afferent signals to the CNS to activate the HPA & SNS: 1.)HPA = increased cortisol = protein break down --> amino acids & insulin resistance. 2.) SNS activation = release of Epinephrine, Nore-epi, glucagon. -Epi = beta-2s = glycogenlysis on liver cells, lipolysis on fat cells-->FA-->acetyl coenzyme A, and activation of gluconeogenesis in liver cells. -Glucagon = gluconeogenesis and glycogenolysis.

MOA of surgical stress?

Zone I = public area Zone II = Changing area, unscreened patients. Zone III = Screened patients Zone IV = in the MRI room itself

MRI zones

MS = less blood in the LV. Smaller than normal. MR = looks like AI, but smaller volume AS= tall peaked AR = large volume

MS MR AR AS

-< 7 = Nausea, headache, lethargy, and diminished deep tendon reflexes. -7-12 =Somnolence, bradycardia, hypotension, ECG changes (prolonged PR interval, QRS duration, and QT interval), and absent deep tendon reflexes. -> 12 =Muscle paralysis, respiratory failure, and complete heart block -> 15 =Cardiac arrest

Magnesium levels and s/s?

Whole blood also contains less plasma potassium and hemoglobin and has higher concentrations of plasma sodium and dextrose, more viable pRBC, However, the loss of 2,3-DPG is similar in both blood products.

Main advantages of whole blood to pRBC?

Results of studies have provided evidence that fentanyl is absorbed into the systemic circulation where it produces its main analgesic effect.

Main analgesia effect of fentanyl in the epidural is produced how?

Myofascial Pain Syndrome: active trigger point, which are felt as palpable taut bands which are tender and radiate when palpated or injected leading to a twitch response. fibromyalgia tender points which do not have concomitant referred pain.

Main difference between Fibromyalgia and Myofacial Pain Syndrome?

NF-1 = afé au lait spots, neurofibromas (cutaneous, neural, vascular), intracranial and spinal cord tumor, joint and back problems, NE tumors., HTN NF-2 = mostly intracranial lesions and more likely to present for Sx.

Main difference between NF-1 vs 2?

Moederate sedation = q 10 minutes Deep/General anesthesia = 5 minutes. Both require one person who is treating the patient.

Main difference in recordings in peds moderate sedation cases vs. deep?

lE = proximal MG = Extraocular. LE = autonamic dysfunction is seen Reflexes are reduced/absent in LE. | MG = no change in DTR. LE = no response to Ach-estrase. |. MG = response to Ach-estrase.

Main differences between Lambert Eaton and MG? -initial symptoms -Autonamic Dysfunction -refexes -response to cholinestrate inhibtorrs?

1.) decreased response to beta receptor stimulation = decreased response, but a down regulation of the beta, but it's just the receptor not working as well, so circulating NE goes up.. 2.) vessel stiffness. -more preload dependent and vein stiffness. -increase afterlod = stiff left ventricle. 3. Increase in SNS ramping up while PNS goes down.

Major changes in the Elderly cardiovascular system?

Bradykinnin considering it is a vasodilator.

Major hypotensive effect of Lisinipril?

Conervative management, although AITP increases risk of PPH with decrease in platelets. -steroids indicated if <30,000 before labor or <50,000 during labor. If no response to steroids, then High Dose IVIG

Management Pregnancy-related Autoimmune thrombocytopenic purpura?

Keep SVR high, HR low,LV full.

Managing HCOM?

Steroids & +/- Tocolytic therapy with something like Magnesium. The main goal of tocolytic therapy is to sustain the pregnancy for a short interval (approximately 24-48 hours) allowing administration of corticosteroids and transfer to a tertiary care center where more appropriate treatment for the neonate may be available. Otherwise, Tocolytic therapy is not advocated for routine use except to prolong pregnancy long enough to allow for corticosteroid administration.

Managing pre-term labor?

In patients with VPS, elevations in pCO2, intraabdominal pressure, and intrathoracic pressure should be avoided. Head-down positioning should be limited. VPS patency should be confirmed preoperatively. ICP monitoring may be needed.

Mangaing VP Shunts

Systolic murmur of 1-2 = safe. However, diastolic murmur and/or grade 3 or 4 systolic murmur should be evaluated for pathology. transthoracic echocardiogram is generally the first step in the diagnosis of cardiac pathology,

Many women experience a systolic murmur 2/2 to increased blood volume. When is a murmur considered safe vs. requiring further work-up?

receiving more than 10 units blood products in a 24-hour period.

Massive transfusion is defined as

3

Max of how many attempts should be done before aborting or having someone else try the intubation?

35 and 55 mg/kg; 55 mg/kg is the upper limit when lidocaine is combined with an epinephrine concentration of 1:1,000,000 (1 mg/1L)

Maximum dose of lidocaine that can be safely used in tumescent anesthesia is?

Po2, CO2, pH, co-oximeter are measured.

Measured values on ABG?

distal radius fractures, including displacement, swelling, hematoma, and improper splinting.

Median nerve injury is most commonly happen how?

Atropine Pralidoxime should be administered after administration of atropine to avoid the transient worsening of oxime-induced acetylcholinesterase inhibition. Pyridostigmine is used for prophylaxis for expected nerve gas exposure

Medications used in Organophosphate exposure?

after the administration of midazolam, propofol, clonidine, dexmedetomidine, fentanyl, or ketamine. They can also reduce ED when given pre-emptively.

Medications used to decrease Emergence Delirum?

dapsone, sulfonamides, and trimethoprim), metoclopramide, nitrates, and nitrites. Tx: methylene blue (1-2 mg/kg IV infused over 3-5 minutes) by acting an electron receptor to Meth-hg reductase and increases the enzym'es effect 5 fold.

Meds that can cause meth-hg?

Meperidine is a mu agonist. MOA of seizure activity is due to metabolite accumulation particulary seen with repeated doses or in renal patients that causes excitation of the CNS--normeperidine, which has twice the potency of the parent drug to cause seizures.

Meperidine MOA to causing seizures?

Mivacurium is metabolized by pseudocholinesterases (also known as plasma cholinesterase or butyrylcholinesterase) into inactive metabolites.

Metabolism of Mivacurium?

: Propofol is metabolized mostly by hepatic glucuronidation.

Metabolism of propofol?

interconversion of glucose and lactate in muscle and live

Metformin can inhibit the Cori cycle. What is the cori cycle

These patients require urgent MRI without contrast and neurosurgical evaluation.

Mgt of Cauda Equina Syndrome?

General > Neuraxial.

Mgt of aortic stenosis during pregnancy?

Anterior & inferior.

Midesophageal 2 chamber view looks at which walls of the LA/LV?

mild OSA as an AHI between 5 and 15, moderate between 15 and 20, and severe > 30.

Mild, moderate, and severe OSA based on the AHI scale?

Onset: 3-4 minutes, Degradation: pseudocholinestrases-similar to sux Side effects: histamine release at intubating doses.

Mivacurium Pearls -onset -degradation -side effects

irreversible inhibition of vitamin B12 (cobalamin) through oxidation = cofactor for methionine synthase = no methylation of homocysteine to methionine =methionine to S-adenosylmethionine = used in DNA. Seen in 2-6 hours with N2O use. Increased risk in pernicious anemia, malabsorption syndromes, extremes of age, malnutrition, a strictly vegetarian diet, alcoholism, and inherited deficiencies of cobalamin or tetrahydrofolate metabolism.

Moa of Megaloblastic anemia with Nitrous?

TOF Tricuspid ateria (underdeveloped RV-one ventrcule) (BT shunt-->Glenn).

Modified Blalock-Taussig Shunt used in?

TBI in trauma patients.

Mortality increases in Neuro ICU patients with what?

Physical preconditioning, preoperative carbohydrate-containing oral hydration along liberalized NPO guidelines, expansion of regional anesthetic techniques, multimodal analgesia plans, early conversion to oral feeding, early mobilization, and improving sleep hygiene. Goal directed fluid management +/-

Most ERAS protocols for on?

Chronic HTN < 20 weeks Gestational > 20 weeks. How is gestational HTN different from Pre-E: -Protienuria (>300 mg/24H, PC>0.3, or 1+ dip stick) or if presenting with severe features such as end organ damage, no protienuria is needed-epigastric pain, FGR, BP >160/110, >1.1, <100k, alt/ast X 2, H/A, Vision changes.

Most cases of gestational hypertension will occur after 37 weeks of gestation, and 25% of patients will develop preeclampsia. When does chronic HTN occur vs. gestational?

RCA due to a superior orientation when a patient is in a supine position. If this happens, must re-heprinize and return on bypass.

Most common Coronary artery to become embolized after CBP?

meconium aspiration syndrome

Most common cause of neonatal M&M.

Pulmonary-pneumonia and atelectesis

Most common complications of thoracic surgery.

VSD >. Secundum ASD > PDA > TOF

Most common congenital heart legion?

Sevoflurane.

Most common inhalation agent to cause Excited Delirium?

AS-1 or Adsol, adenine, glucose, sodium chloride, mannitol. increases 35 -->42 days.

Most common preservative solution in the united states?

ethanol, cisplatin, phenytoin, and salicylates (at high doses).

Most drugs are eliminated via first-order kinetics. which drugs are eliminated using zero order?

FFP esp if it exceeds 1 ml/kg/min = 1 unit of pRBC q 5 minutes. . CPDA (citrate-phosphate-dextrose-adenine).

Most likely to cause citrate intoxication? What does citrate contain?

Large motor> Sensory > preganglion.

Most resistent nerves?

TEE > changes in PA > co2 > CO/BP > ECG

Most sensitive monitoring techniques for air Embolus?

inhibition of striatal release of γ-aminobutyric aid and increased dopamine production within the central nervous system, similar to the pathophysiology of Parkinson's disease. Though the rigidity may resemble grand mal seizures there is no seizure activity on EEG

Muscle rigidity from rapid, large opioid administration is thought to be due to?

Myasthenic syndrome patients are sensitive to succinylcholine & NMBD, while myasthenia gravis patients are resistant to succinylcholine, but sensitive to NDMB

Myasthenic syndrome patients VS. myasthenia gravis patients to sux?

AoDP, LVEDP, heart rate, Hgb, and CVR

Myocardial oxygen supply

Pathology: AD inherited diseases at the level of the muscle caused by calcium not returning to the SR. Can be triggered by surgery, electrocaudry, shivery. -Resp: restrictive lung disease pattern. -GI: delayed gastric emptying, intestinal hypomotility, and pharyngeal muscle weakness = asp. risk. -Cardiac: MVP, conduction issues. Tx: Treatment of myotonia or myotonic crises includes phenytoin, quinine, and procainamide.

Myotonic Dystrophy pearls and prevention in anesthesia?

Anesthesia: noncompetitive inhibition of NMDA receptors Analgesia: induction of the release of endogenous opioids Anxiolytic: activation of GABA-A receptors

N2O's three effects?

-Notably, the volume is less important than the type of liquid ingested. -Alcohol not considered a clear -Clear: Juice, black coffee, clear tea, carbonated drinks. -95% of clears emptied in one hour.

NPO guidelines for: -clears

Laser targets melanin which is found in the retina and causes retinal damage. Coolant spray recommended 2/2 heat-induced injury to the skin esp in darker patients 2/2 tot he melanin.

Nd:YAG laser should have eye protection because?

90%. While only 20% of infants will be effected from neonatal MG, born to moms with mysthantheia garvis. Reoccurance rate with future kids is 75%.

Neonatal MG will decrease by how much by month two?

15-20% of babies. Usually develop symptoms within 4 days of delivery. Get better in 2-4 weeks.

Neonatal Myasthenia Gravis is likely to be seen when?

<100 = PPV --> intubate <60 = Chest compressions. 3:1 ratio If not working, start pharmcology therapy.

Neonatal resusitation.

lower density of postjunctional nicotinic acetylcholine receptors relative to adul

Neonates and infants are more sensitive to given plasma concentrations of nondepolarizing neuromuscular blocking drugs in part because of?

gadolinium-induced contrast nephropathy in MRI patients. Factors = CKD 4/5, periop liver txp, sepsis, hepatorenal syndrome.

Nephrogenic systemic fibrosis (NSF) is what?

Axillary > suprascapular nerve. Displaced fx more likely to cause fx.

Nerve most likely to be injured by a fracture of the proximal humerus?

ventral rami of C5-C7 and the supraclavicular branches of the cervical plexus (C1-C3). Spares C8-T1 = ulnar.

Nerves targeted by the Interscalene nerve block?

Prolong the second stage of labor. >3 hours in nulliparous women | >2 hours in multiparous women. Also, association of neuraxial technique with increased risk of instrumental vaginal delivery.

Neuraxial techniques do what to stage of labor?

Tumors which arise from the SNS chain-75% of the time in the abdomen, with 1/3rd of those tumors being in the adernal medulla. Pts noted to have increase catecholamines. Req. A/Beta blockers in pre-op.

Neuroblasomtas are what?

Seen in premies 2/2 to decreased surfacant = increased surface tension = decreased compliance.

Newborn respiratory distress syndrome?

Cisatracurium when combined with rocuronium has a synergistic effect upon neuromuscular blockade.

Nimbex when combined with what other paralytic has synergistic effects?

Thrombocytopenia Rebound effects if stopped Met-hg

Nitric Oxide issues

Metabolic Acidosis + increasing mixed venous. Mixed venous increased because tissues can't utilize oxygen due to cyanide toxicity by blocking oxidative phosphorylation.

Nitroprusside ABG?

C fibers = small, unmylinated A-Delta = medium, thinly mylinated fibers. Carry Noxious signals

Nociceptive afferent neurons are high-threshold neurons and require a high amount of stimulus to fire. What are these made of?

Substance P and CGRP

Nocioceptive pain in Pancreatic Cancer?

2.5 L or 35 mL/Kg. [RV + ERV]. Can't be measured because FRC = RV + ERV. RV can't be measured. Old age + COPD increases FRC.

Normal FRC? Why can't it be measured with normal spirometery?

PH: vein-7.34 / artery-7.28 PCO2: vein-30 / artery-15. PO2: vein-35 / artery-45 Bicarb: vein-22/artery-20 Base def: vein-5 / artery-7.

Normal Umbilical vein: Normal umbilical artery:

50 mL/100g/min 20 ml/100g/min = EEG slowing 2/2 to neuronal d/f 15 mL/100g/min = isoelectric eeg 10-15 = neuronal death begins 2/2 to energy depletion 6-10 = temporary reversal of neuronal death, but permenent of not reversed.

Normal cerebral blood flow?

0.5-0.6 2/2 to increased GFR.

Normal creatinine in pregnant patient?

Omissions and errors policies protect against claims due to administrative mismanagement.

Omissions and errors policies protect against?

HTN usually seen 30-60 minutes after applied. If BP is treated, can lead to hypotension after being removed, so it is typically left alone.

One of the most prominent alterations in physiology with tourniquet use is?.

Using a Nims tube which monitors for EMG. If a surgeon is dissecting near the nerve. It will stimulate it resulting in neural monitoring to be notified. Because the contraction of the vocal cords.

One of the ways to avoid injury with vocal cords in thyroid surgery is ?

One technique to avoid large intravascular injections is to divide the injections into 3 aliquots and wait 20 to 30 sec before each injection to ensure no previously discussed symptoms occur

One technique that can be used to ensure caudal anesthesia isn't intravascular?

Intranasal fentanyl, intramuscular fentanyl, rectal acetaminophen, oral acetaminophen, and intranasal dexmedetomidine are some option

Options for pain decrease in tube surgery?

0.5 mg/kg (10 times the intravenous dose) and has an onset of action of 15-30 minutes. Increase in dose is required 2/2 decreased drug bioavailability (26-52%

Oral vs. IV versed in kids is dosed?

X = Po2 in mmHg Y = Hg 0xygen dissociation. Right shift = tissue hypoxia, increase in 2,3 BPG, acidosis, hyperthermia.

Oxy-hemoglobin dissociation curve X and Y axis?

DO2 = CO x CaO2[(SaO2)(Hb x 1.34)] + (0.0031 x PaO2)

Oxygen Delivery formula =

SaO2 (Y) & PaO2 (X)

Oxygen Hemoglobin curve relates what?

In third trimester, uterus develops more oxycotin receptors, so it is best to be used as a first-line agents. -6 minute half-life -Vaconstriction of umbilical arteris/veins & coronary arteries, so can cause ischemic demand in previously healthy patients with CAD. -Should be started prophalactically regardless type of delivery

Oxytocin pearls

post-anesthesia discharge scoring system (PADSS) that must be considered if the patient is to be sent home after ambulatory surgery. Must first meet the Adlrete score. pain and nausea control, surgical hemostasis as measured by the number of dressing changes required in the PACU, as well as a requirement for the patient to ambulate and have a responsible adult escort prior to being safely discharged from ambulatory surgery.

PADSS is what?

PCAs have been shown to provide better postoperative pain control and higher patient satisfaction. However, there are also some drawbacks to PCAs. PCAs have higher rates of pruritus and are associated with overall higher consumption of opioid medication

PCA have what two pros and what two main cons compared to nurse-given drugs?

LVEDP (Left Ventricular End Diastolic Pressure)

PCWP is a surrogate for what LV pressure?

Measured at the tip of the pulmonary artery when the balloon is blown up. Measured in diastole and is a surrogate to LVEDP.

PCWP is measured how and in what phase of the cardia cycle? What is it a surrogate to?

24-48 hours. continuous murmur. Seen a higher diastolic pressure when closed with indomethoacin.

PDA closes when? Murmur? When PDA closes what do you see?

RV.

PFTs can't measure what?

MPAP (mean pulmonary artery pressure) - PCWP / CO x 80

PVR formula

Carotid bodies at the bifurcation via CN#9 to the ponto-medullary network. This has a tonic response primarily by PaO2. When PaO2 drops below 55 mmHg. This pattern is inhibited by opioids, sub-anesthestic violatile anesthesia as low as 0.1 mac.

PaO2 decrease in the blood is sensed mostly by?

SSS, Brady, prolonged QT syndrome to speed up the HR and keep it fast, low EF.

Pacemaker indications.

Vagal, Splanic, and Celiac plexus

Pancreatic pain input?

TBSA burned (%) x Weight(kg) x 4 mL/kg Using this formula can lead to over-resustication and edema. New standards = 2 mL × total body weight (kg) × percentage of the burned total body surface area.

Parkland formula. What is the disadvantage?

advancing age, male sex, the presence of hypertension, prior history of AF, obesity, chronic obstructive pulmonary disease, asthma, valvular disease, left atrial size, and left ventricular ejection fraction

Patient factors foro AF?

contraindicated in patients who are intoxicated(2/2 substances exhaled include ETOH, aceton, CO, and methane) in uncompensated diabetic states, or who are suffering from carbon monoxide poisoning.

Patient where low fresh gas flow is contraindicated?

common in pediatric patient populations, those with significant liver disease, those undergoing liver transplantation, in patients who are hyperventilated, or if a patient is cooled.

Patients where citrate toxicity is common.

The dosing in obese patients should generally be based on LBW, with exceptions for neostigmine, sugammadex, succinylcholine, dexmedetomidine, and propofol for maintenance infusion in total intravenous anesthesia (table). *Table =Commonly used anesthesia medications and which weight they should be based on in obese patients)

Patients who are obese must have certain anesthetic medications reduced because dosing based on total body weight (TBW) could lead to an overdose of the medication. What meds are these?

difficulty with the inspiratory phase of respiration = variable extrathoracic airway obstruction = presents immediately the following extubation = tx with CPAP and Rigid bronchoscope

Patients with large compressive goiters who undergo thyroidectomy may have a component of tracheomalacia following surgical excision of that goiter. How can this be treated and when does it present?

Perioperative atrial injury, ischemia, inflammation, increased catecholamines, hypovolemia, atrial stretch from volume overload, and electrolyte disturbances. Can be decreased by: ncluding pharmacologic prophylaxis (BB or amio), attention to volume status, and altering surgical methods.

Perioperative risk factors for AF

Decreasing PVR & increasing SVR: -Opioids -avoid hypoxia -avoid hypercarbia -avoid high airway pressures -Benefits of ketamine by increasing SVR

Perks of decreasing R->Left shunts of the heart with a VSD?

Increase in after load and preload

Phenylephrine does what physiologically?

The acetate is oxidized by the liver, muscle, and heart into bicarbonate, with a small percentage converted to acetoacetate. gluconate is converted to glucose, which can then be used as a substrate for glycolysis and citric acid cycle.

Point of acetate & gluconate in the plasmalyte?

Laminar flow through Unbranched tubes. -length -visocicity -radius r^4

Poisuilles law applies to what kind of flow?

prolonged immersion (> 5 minutes), delayed initiation of CPR (> 10 minutes), fixed/dilated pupils, low Glasgow Coma Scale (< 6), abnormal brain CT within 36 hours, and absence of spontaneous/purposeful movements within 48 hours. Distress: difficulty staying afloat, but without airway compromise =>Drowning: resp. impairment from being in water: -active drowning: able to maintain airway above water. -passive drowning: patient who has had LOC.

Poor prognostic indicators in drowning victims.

<6 months, malnourished kids, kids undergoing cadiac surgery, neonates. Add glucose containing solutions of 1-2.5%

Populations of peds at risk of hypoglycemia in the peri-op period?

3-5 minutes = heavy feeling in legs = then decreased motor senesation. As oppose to an epidural which take 10-20 minutes to work. If IV catheter: ->10 BPM or >SBP of 15-25 mmhG within one minute. -Tinnitus, perioral numbness, metallic taste. Multi-orficle cath tips can lead to a false negative IT.

Positive IT epidural cath is seen about how long?

ETT > LMA -use smaller tube, lower cuff pressure, topical lidocaine, and inhalation steroids.

Post op sore throat is most likely with?

Power represents the probability of observing a difference in the population if a difference exists. Related to Beta with the formula = β by the equation 1 − β Increased by: such as increasing the sample size, increasing the effect size, increasing α, or decreasing population variability.

Power is? Increased how?

1. Low PaO2 during 2 lung-esp in lateral position. 2. Right sided thoractomy 2/2 to increased size of the right lung. 3. Supine position during OLV 4. Normal FEV1 or FVC or restrictive lung disease. -Worse pre-op spirometry = between PaO2 on one lung. 5. Pre-op V/Q scan shows high perfusion or ventilation to the operative lung

Predictors of hypoxemia during one-lung ventilation include the following:

1.) TV increased 2.) MV = TV x RR = increased 3.) RR = increased 4.) Arterial O2 increased. 5.) Arterial CO2 decreased 2/2 increased RR 6.) FRC decreased 2/2 RV, ERV

Pregnancy changes in respiratory rate?

I, VII >>>>VIII, IX, X, XII, von Willebrand factor. Esp. Factor 7. Antithrombin III, protein S = decrease.

Pregnancy coagulation factors that make them pro-coaguable? Which factors decrease?

30-40% degrees in MAC 2/2 increased endorphins and enkephalins levels will have a sedative effect.

Pregnancy does what to MAC?

Decreased SVR, increased plasma volumes = increase in CO

Pregnancy results in what kind of cardiac changes?

ncreased afterload, negative intrathoracic pressure, increased pulmonary vascular resistance, and increased pulmonary blood flow. Increased IP = increased Right heart venous return = PVR 2/2 to HVP & increased in Afterload 2/2 to SNS activation.

Pressure changes from a laryngospasm that leads to NPPE?

Primary metabolic funciton of the lung is due to the endothalial cells in the pulmonary capillaries. Three main hormones that are degraded and inactivated= NE, Sertonin, and bradykinn.

Primary metabolic unit of the lung and what primary three hormones are inactivated by it?

ERV is decreased compared to RV (preserved) = a decrease in FRC. -Also decreased is FRC, TV, and TLC. IC is increased.

Primary reason to why FRC is decreased in fat people?

where hyPeR-kalemia/-calcemia/-magnesemia lead to PRolongation of the PR interval. . The opposite tends to occur with the QT interval.

Prolonged PR intervals associated with which lytes?

They act by increasing free calcium concentration in the myometrial tissue leading to increased uterine contractions

Prostoglandin MOA in decreasing uterine atony?

-85% of the patients = Alpha subunit of the Ach-receptor. -5%muscle-specific tyrosine kinase or lipoprotein-related protein 4 -5% = no detectable antiodies.

Proteins targeted by MG?

Pseudocholinesterase, also known as butyrylcholinesterase, is an enzyme produced in the liver that metabolizes common anesthetics drugs such as succinylcholine, mivacurium, and local ester anesthetics in the plasma.

Pseudocholinesterase, also known as butyrylcholinesterase, is an enzyme produced in the liver that metabolizes common anesthetics drugs such as:

full stomach (including trauma patients), symptomatic GERD, hiatal hernia, a nasogastric tube, morbid obesity, diabetic gastroparesis, or pregnancy.

Pts which should get ppx against aspiration?

PAP-wedge pressure /CO x 80 Peaked P waves in lead II > 3 mm.

Pulmonary vascular resistance formula

Carbs-1 Fats-0.7 Protein-0.8

R Qoutient of carbs, fats, etc?

Stimulators: hypotension, hypovolemia, hyponatremia, hyperkalemia. JG cells = Hypotension detection/ Macula densa cells = hypoNA+ detection. Prorenin from JG cells --> Renin = Angiosensin --> AgI in liver. AgI --> AgII in lungs. AgII = zona glomulerousa= > aldestrone release --> increase Na+, H2O retention, decrease in K+, decrease in H+

RAAS pathway explained for the 90,000th time. -Stimulators -Where -How

Decrease in BP =JG app sensing = Renin secretion = Ag -> AgI -->ACE AgI ->AgII: -Ag II = vasconstricts, increases NE release, Vasopressin release, and alsdestrone release (Na+ increase)

RAAS system?

Inability to abduct thumb or extend the MCP. Presents with a wrist as well

Radial nerve injury as seen as

VACTERL or Turner syndromes

Renal ultrasound may be indicted for what two congenital symptoms?

IV agents = speedy induction (bypasses lungs -->brain), but doesn't reach the same plasma concentration as regular patients would. Inhalation agents = slower induction (less gets to the lungs)-rise of FA/FI is lower/slowed

Right to left shunts of the heart have what effect on IV and inhalational agents?

baseline systolic blood pressure <120 mm Hg, advanced age (≥40 years), spinal puncture at or above the L2-3 interspace, concurrent general anesthesia, and sensory level block ≥T5

Risk factors affecting the degree of hypotension from spinal anesthesia?

Risks factors for IONV under spinal include peak nerve block height greater than T6, baseline heart rate (HR) 60 beats/minute or more, a history of motion sickness, and previous hypotension after spinal nerve block.

Risk factors for Intraop N/V under spinal?

-Renal impairment (estimated glomerular filtration rate <30 mL/min/1.73 m2) -Hepatic impairment -Concomitant use of certain drugs that impair kidney function or interfere with acid-base balance, such as carbonic anhydrase inhibitors -Age 65 years old or greater -Radiological study with contrast -Hypoxic or volume-depleted states (eg, acute congestive heart failure, shock) -Excessive alcohol intake

Risk factors for MALA include?

Male gender, nonemergent surgery, chronic beta-blockade, prolonged operative duration, and younger age, HR <60 to begin with.

Risk factors for neuraxial anesthesia leading to severe bradycardia

3% risk of ventilator-associated pneumonia (VAP) per day.

Risk of VAP per day while intubated and on a vent?

Aβ fibers are mechanical sensory neurons and transmit signals of non-painful stimuli.

Role of Aβ fibers ?

Citrate quenches free ions such as calcium Dextrose provides substrate for energy generation Adenine is a substrate for ATP generation Phosphate acts as a buffer`

Role of CDAP in pRBC?

Tocolytic and Neuroprection.

Role of Magnesium Sulfate in pre-term labor?

Tenser muscle. If injured can get a whispy voice.

Role of cricothyroid muscle?

SO and PV nuceli of the Hypothalmus -->infundibular stalk bound to neurophysins transport proteins-->posterior pituitary to be stored -->inferior hypophseal veins-->body

Route of Oxytocin and AVP production?

68%, 95%, and 99% for 1, 2, and 3 standard. Data above a threshold standard deviation can be calculated as SD / 2 + 50%

SD for bimodal bell curves?

SUD in physicians has a similar prevalence compared to the general population, although morbidity and mortality may be higher because of physicians' greater access to prescription drugs

SUD in physicians has a similar prevalence compared to the general population. Why is M&M higher?

Esmolol

SVT treatment drugs that may particulary cause bradycardia to the fetus in pregnancy?

SVV = (SVmax - SVmin) / [(SVmax + SVmin) / 2] SVV is a precent.

SVV formula?

antihypertensive drug that acts by inhibiting the enzyme neprilysin = decreased break down of ANP, BNP

Sacubitril MOA?

Time it takes for the oxy-hemoglobin desats < 90% Formula = (FRC × etO2) / VO2 70-kg patient with an FRC of 30 mL/kg, an etO2 of 90%, and a VO2 of 250 mL/min would be predicted to desaturate within ~7.5 min.

Safe Apnea Time

Diagonals. Branch of the LAD. Helps supply the anterior walls.

Sapphanous is usually grafted to which coronary artery?

Exp + inspiratory valve. No CO2 absorber, and elimination is dependent on the FGF.

Semi-open System components?

swelling secondary to inappropriate ADH secretion. mental status, hyponatremia, hypothermia, and pulmonary edema may also occur.

Severe myxedema in hypothyroidisim can lead to swelling and doughy seen how?

Jet Velocity-4.0 m/s Mean gradient-> 40 mmHg AVA < 1.0

Severe. AS grading.

ataxic gait disturbances, altered mental status, and oculomotor dysfunction. Usually seen in a hypoglycemic alcoholic patient when thiamine isnt given first before a bolus of glucose, causing thymine stores to be depleted.

Sign of Wernicke encephalopathy and how it should be corrected?

Radiation > Conduction = Convection > evaporation.

Signicifant mechanisms of heat loss?

polyhydramnios, immediate feeding intolerance, cyanosis (due to protective laryngospasm),

Signs and Symptoms of a TEF?

Phase I: first phase = stop anesthesia, NMB reversal, regular RR 2/2 to activation of the lower pons and medulla. Phase II: tearing, grimacing, return of 7, 9, 10, and upper medulla C8. Phase III: Responding to verbal commands and lastly eye opening.

Signs of Emergence-3 phases?

antibodies that the host has formed against human leukocyte antigens (HLAs) present on donor leukocytes

Simple febrile reactions to blood are due to?

Hips are cast in a flexed, externally rotated and abducted position. Cast ranges from midchest to calves. Because the child must be placed in a frame to it, you must watch the airway.

Spica casts reach from the? Why is it important to watch the airway during the procedure?

1st stage: Visceral pain due to the cervical pain- T10-L1. -Complete analgesia with CSE opioid alone 2nd stage of labor: S2-s4 2/2 to somatic nerve pain. -CSE best for this stage 2/2 to anesthestic solution migrating across the dural puncture site.

Stages of labor:

1.) IV 2.) Lift arm up to exguinate the arm. 3.)wrap an ace at the distal part 4.)add torniqutes-distal and proximal. 5.) Remove ace wrap 6.) inflate proximal torniquite 7.) give 0.5-1% lidocaine in a 30-40 cc or 10-15 cc. No epi allowed. 8.) wait 40-45 minutes prior to deflating -if pain torniqute pain persists, inflate the distal one and deflate the proximal one.

Steps of Bier Block?

Type/Screen -Type: Determine ABO antigens on RBC of patients blood. -Screen: combines pt. plasma + reagent RBC which have D, Kidd, Kell, SSU Rh antigens to see if a reactions happes. Cross/Match: -Doctor RBC + Pt. Plasma = 45 minutes. -Consists of three phases: immediate = 5 minutes = looks for ABO erros

Steps of blood transfusion?

-<100 BPM = PPV. -No improvement, intubate. <60 BPM = intubate + compressions. Compressions are to be a 1:3 ratio because the neonates are particulary sensitive to hypoxia.

Steps of neonatal resusitation?

Positive - negative charged molecules. SID = 40. Increase SID: (increase in positive vs. negative ions). = dehydration, contraction alkalosis, loss of anions from aggressive NG suction. ==> water dissociates to H + Cl to shift it. Decrease SID: -NACL administration = increase in Cl- = a decrease in the SID = body shifts wants more positive anions (H+) = water dissociation = hyperCl-, metabolic acidosis. -diarrhea can cause this due to loss of K+ & Na+ -lactic acidosis or DKA.

Strong Ion Difference

primarily attributed to the high concentrations of chloride in NS due to: -Dampened renal perfusion 2/2 RAAS activation -Thromboxane release -Possible direct vasoconstrictive effect.

Studies have found that NS increases the risk of AKI and the requirement for renal replacement therapy due to?

obstructing aqueous humor flow, Extraocular muscle contraction, choroidal blood volume.

Sux resulting in IOP increases?

ME long-axis view: ME short axis view

TEE Views for: -AS

phosphate-deficient TPN solution is used, hypophosphatemia may manifest as low 2,3-DPG and ATP levels causing a leftward shift. Also trace metal depletion, including zinc, copper, and magnesium = refractory anemia.

TPN can lead to oxygen-hg shift how?

Contracture Caffiene Test = most sensitive, but a highly not specific. Genetic testing should be used first-line if they have a personal hx that is suspicious of MH or a family member has been dx with MH.

Tests of MH sensivity and specificity?

direct antiglobulin (Coombs) test, repeat crossmatching, and tests for hemolysis such as serum haptoglobin and bilirubin as well as urine hemoglobin levels.

Tests to obtain when Acute hemolytic reaction is seen?

Diagnosis is clinical via provocative testing although no single maneuver is reliable. hip flexion/abduction/external rotation (FABER), the Gaenslen test, pelvic compression, and posterior superior iliac spine (PSIS) palpation.

Tests used to test SI joint pain?

Because creatinine is freely filterated at the kidney, if it increases by a 100% of the creatinine concentration inversely reflects the GFR, it would mean that GFR would decrease by 50%

The absolute value of creatinine is dependent on muscle mass, sex, and age, so baseline variations are more clinically useful than absolute cutoffs. What would be indicative of an AKI?

both alpha and beta globulin rise, however, the amount of albumin made stays the same, but concententration decreases due to plasma volume dilution.

The albumin:globulin ratio does what in pregnancy?

The gold standard for measuring core temperature is the pulmonary artery via a pulmonary artery catheter. If PA can't be measured, other sites that are reliable of core temperature = nasopharynx, distal esophagus, and tympanic membrane.

The gold standard for measuring core temperature is? If this site can't be measured, what other sites are considered a reliable alternative?

Ulnar nerve injury. Seen in males who are obese presents at day two associated with bilateral pre-op nerve issues numbness tingling. And a claw hand

The number one nerve injury according to the clothes claims cases?

not alter MAC include thyroid function (unless there are alterations in temperature), hypo- or hypercapnia, duration of anesthesia, gender, type of surgical stimulus, metabolic alkalosis, and hyperkalemia.

Things that don't change mac?

-hypokalemia -renal failure = accumulation -Verapamil, cardizem, amio -volume depletion.

Things which increase risk of toxicity from Dig?

1.) Oxidier such as O2 >21% or Nitrous (Sevoflurane is nonflammable and thus would not increase the risk of airway fire 2.)Ignition source =electrocautery 3.)Fuel = drapes

Three factors go into play for airway fires?

HCO3 = Largest form >>> Pco2 >>Carbamino Compounds

Three forms of CO2 in the blood?

-Sodium resorption at the level of the PCT -Constrction of blood vessels -release of aldestrone

Three primary actions of AGII?

Type II alveolar cells-metabolically active unlike type I cells and secrete surfactant, and pulmonary mediators. . Type I is meant for air exchange and when they're damaged, they're replenished via type II cells. These cells are suspectible to damage-highly differiented and metabolic limited. Type III cells = macrophages.

Three types of pulmonary cells? Types of alveolar cells which replace cells in the lung after damage?

CBF = Diastolic BP - LVEDP -Decrease HR to spend more time in diastole. -Increase Diastolic BP -Decrease the pressure in LV (LVEDP).

Three ways CBF?

1. Hypoxemia 2. Hypoventilaiton 3. Respiratory mechanics -VC < 15 (biggest breath you can take in and breath out)

Three ways of defining respiratory failure.

Patients with hip fracture.

Thrombembolism is heighest in which surgical patient population

Intranasal and buccal fentanyl has a peak onset of action of around 30 minutes a

Time to onset of transmucosal fentanyl?

Tip likely to be caught on the right arytenoid cartilage because the tip will come off he right side. This is done so the left side of the tube is clearly visualized in DL. When attempted over the nasal route,the epiglottis is most likely to be caught.

Tip of an ETT is most likely to be caught where in the airway during an oral fiberoptic intubation? What about nasal?

Downregulation of beta receptors.

Tolerance to b2 agonists rescue medications like albuterol is due to what?

temporal lobe epilepsy ap

Tonic-clonic siezures specifically from which area of the brain are highest risk of postictal hypoxemia.?

CaO2 = (1.34× Hgb× SaO2) + (0.003 × PaO2)

Total oxygen content formula?

reversible gland ischemia, hypothermia, or release of Endothelin-1 (an acute phase reactant known to suppress PTH production).

Total thyroidectomy for Graves disease carries the highest risk for post-op hypocalcemia. Besides excision of the Parathyroids on accident, what other factors can lead to hypocalcemia?

Total thyroidectomy for Graves disease carries the highest risk for post-op hypocalcemia.

Total thyroidectomy for Graves disease carries the highest risk of?

he tracts located in the anterior spinal cord include: - the lateral spinothalamic = pain & temp. - anterior spinothalamic = pressure & crude touch. -lateral corticospinal-voluntary movement. - anterior corticospinal tracts-voluntary movement.

Tracts in the anterior spinal cords?

Weak acids are acids that don't fully dissociate and include: -Albumin (increase = acidosis) -Phosphates (increase-like in ESRD = acidosis)

Traditional Acid-base model correlates metabolic acidosis/alkalosis with Bicarb. Physiolochemical metabolic approach links SID and weak acid concentrations to metabolic deranmegents. What are the weak acids?

mu-opioid agonism and inhibition of serotonin and norepinephrine reuptake. -The (+) enantiomer and the active metabolite O-desmethyltramadol function as agonists at the opioid recepto -e (−) enantiomer is responsible for the inhibition of serotonin and norepinephrine reuptake.

Tramadol's anagalesic effects are taken place by?

Bernoulli equation = peak pressure gradient = 4 * (peak velocity)^2 potential energy is manifested as pressure, while the kinetic energy is manifested as velocity = total energy remains the same = as blood flows through a narrow valve, the pressure decreases, but the velocity increases

Transvalvular pressure is estimated how?

anticholinesterase therapy can be used for up to 21 days after birth if necessary. Neostigmine can be given before feedings to improve weakness. Pts. with Eaton-Lambert syndrome will show no imporvement.

Treatment is largerly supportive in Neonatal Myanthesia Garvis, but what are some therapies that can help?

Beta blockers and calcium channel blockers. Instead of diuretics and Iontropes. Afib and pulmonary edema.

Treatment of HFpEr? Associated with

Increasing the heart rate increases inotropy through the Treppe (or Bowditch) effect. Increased heart rate causes a buildup of intracellular calcium, due to the inability of the Na+/K+ ATPase to keep up with the sodium influx at higher heart rates.

Treppe (or Bowditch) effect?

Sux, cold, pain, Neostigmine, Stress.

Triggers for mytonias?

Children with trisomies 8, 13, and 18 who survive beyond the first few weeks of life likely have mosaicism.

Trisomies are highly lethal, with trisomy 21 having the best prognosis

Protein binding-fetuses have a less protein binding capabilities, so there will be more of a free drug. Fetal pH.

Two important fetal considerations for drugs?

Age (2-6) Inhalation anesthestics-in-particular sevo and desflurane.

Two main risk factors for Emergence Delrium?

Drugs/Toxins stimulate Enterochromaffin cells in the gut wall to release Serotonin = activation CN X = Nucleous Tract Soli = Chemoreceptor trigger zone. Drugs/Toxins directly stimulate the chemoreceptor trigger zone located in the area postrema at the bottom of the 4th ventricle (outside of the BBB)

Two main ways PONV can happen 2/2 to drugs and toxins?

Two major causes of visual loss are central retinal artery occlusion and ischemic optic neuropath. -Central Ret. Occlusion = unilateral visual loss and is most likely from direct pressure on the globe during surgery. -ION =

Two major forms of post-op visual loss?

1) Use of supplemental oxygen by nasal cannula.2) Holding the oxygen flush on the anesthesia machine.

Two options to assist with O2 flow rates during emergency preoxygenation using the deep breathing technique are:

Phase I = 1st hour 2/2 to core->periphery loss -best stopped by using a beir hugger. -Largest drop in the OR. Phase II = After first hour: -loses mostly to radation = loss of heat to colder OR air | conduction = contact heat loss convection = loss from circulating cooler air | evaporation = Respiratory and wounds.

Two phases of heat loss in the OR:

Treatment of myotonia or myotonic crises includes phenytoin, quinine, and procainamide. by decreasing sodium influx into skeletal myocytes and delaying the return of membrane excitability following an action potential..

Tx for myotonic crisis? Why?

1.) Cuffed Tracheal tube 2.)Uncuffed tracheal tube 3.) Larygenctoma Stoma Tube: larynx removed, tracheal stoma to the anterior neck. NO CONNECTION TO MOUTH AND NOSE. Must be intubated through trachea. 4.) Tracheal T-tube: used for pts. with mangled tracheas, basically a t-piece that is soft to connect the top, bottom, to the stoma. Can be removed by pulling on the stomal piece since it is flexible and intubated from above. 5.) Fenestrated Tubes: hole that allows for air to pass through the trachea, good for talking. Not good for positive pressure or risk of aspiration.

Types of Tracheal stomal tubes:

Myelinated: A-fibers -Alpha: Propioception & muscle spindles -->brain-->alpha motor fibers. -Beta: cutenous sensations--->brain -Gamma: gamma muscle spindles -->brain -Delta: free nerve endings pain, pressure--->brain-->withdraw Moderate myelinated: B-fibers: -SNS pre-ganglions that release Ach Unmylinated: C-fibers -Thermal, chemical, mechanical = pain-->brain

Types of fibers from largest to smallest.

A UOSM : POSM ratio >1.5 is indicative of prerenal oliguria secondary to dehydration or hypovolemia. The UOSM : POSM evaluates the ability of the kidneys to concentrate urine and increase urine osmolality above normal plasma osmolality in the setting of prerenal oliguria. Tubular damage and acute renal failure, therefore, may be represented by a decreased ratio.

UOSM : POSM evaluates what?

-rate of perioperative complications for procedures performed in offices is much higher when compared to ambulatory -standards for basic monitoring should always be abided by and require a back-up power source. -Specific to office-based care, physically present during the intraoperative period" within the office and manage complications of anesthesia in the PACU -Prior to d/c, patients must be evaled by a physician.

Unique characteristics of practicing anesthesiology in an office-based setting which may differ from ambulatory or hospital-settings?

Chronatopy Dromatrophy.

Vagus nerve reduces which two functions of the heart?

HCOM, not MR.

Valsalva will increase which murmur?

Radiation. Can be decreased by beir huggers.

Vasodilation of blood vessels under general or neuraxial anesthesia leads to heat loss by?

Umbilical artery: pH: 7.18-7.38 Po2: 30 mmHg PCO2: 66 mmHg Umbilical vein: pH: 7.41 Po2: 77 pco2:44

Venous umbilical gas? Umbilical artery sample?

ME RV inflow-outflow tract.

View used to help with placing a PAC?

InhAled anesthetics have a bigger affect an HPV. Where IV anesthetics have a much smaller of fact on HPV.

What What is the systemic effects of HPV and inhaled anesthetics verse IV anesthetics?

Positioning may be difficult in patients with a narrow external auditory canal such

What about down syndrome would make it difficult to accomplish ear tubes from a surgical standpoint?

incorporates weight, cervical spine mobility, jaw mobility, degree of retrognathia, and the appearance of the incisors Score ranges 0-10.

What accounts for the Wilson Score as a predictor of difficult intubation?

A-lines are reberation and a normal finding in a aerated lung.

What are A-lines?

B-lines = fluid

What are comet tails on ultrasound of the chest?

Facet arthropathy refers to arthritic disease of the zygapophyseal joints

What are the Z-joints and how are they clinically releveant?

Positive ionotrop, negative chrono and dromotrope. Binds to Na/K atpase =sodium can't be taken out of the cell against concentration gradient = NA/Ca2+ exchanger can't use sodium = calcium stays in the cell to increase the three above.

What are the effects of dig on the heart?

Decrease in LBW, decrease in Total body water =to smaller compartments with increased serum concentrations. Also, an increase in fat = increased VD. Decreased renal and hepatic clearance. =Medications prlonged duration.

What are the effects of medications in elderly as far as duration is concerned?

Isovolumetric relaxation, rapid fillin(most), diastasis, atrial systole E&A wave = Rapid influx of blood through mitral valve. A wave = atrial systole. It is the Doppler through the mitral.

What are the four phases of diastole and what is that in the E&A wave on echo?

If the surgery is being done in the third trimester or the surgery is being done in the pelvic or abdominal region

What are the greatest risk of precipitating preterm labor and non-obstetric surgery?

-30 CC/kg bolus in first 3 h -Abx within 1 hour-continue for 7-10 d -Levo to maintain a map >65 -If ARDS, keep a 4-6 ml/kg tidal volume with platue pressures < 30.

What are the main guidelines for sepsis?

the nature of the anesthesia plan, risks, benefits, reasonable alternatives, and an assessment of the patient's understanding of these aforementioned elements.

What are the required elements for documentation of the informed consent discussion?

orthostatic hypotension, loss of heart rate variability, resting tachycardia, gastroparesis, gastroesophageal reflux, and bladder dysfunction. The distal peripheral extremities demonstrate skin, hair, and nail changes, with the loss of sweat function.

What autonamic dysfunctions seen in DM patients?

A sub-Tenon block performed by the surgeon may also decrease emergence delirium.

What block in pediatric eye surgery can decrease Emergence Delrium?

or disadvantage of a paracervical nerve block during labor is a high frequency of fetal bradycardia = oxygenation and acidosis. Supposed to help with the first stage of labor. LA used = 1.5% Chloroprocaine or 1% mepivacaine in 5-10 mL. Bupivicaine is contraindicated.

What can happen with anesthestizing Frankenhauser ganglion in a paracervical nerve block during labor?

Neuromuscular blockade is potentiated (increased), not attenuated (decreased) with hypothermia. This is demonstrated by vecuronium with a duration of action that is twice as long at temperatures two degrees celsius hypothermic.

What can hypothermia do to NMB?

Increasing PA> Pa in normal alveoli = more zone 1 = increase in dead space.

What can peep do to dead space?

V = velocity, ρ = density, D = diameter of tubing, and n = viscosity

What determines a reynolds number?

Cardiac stents, dental implants, and orthopedic implants. If an emergency happens, quenching the MRI must happen-this results in boiling helium away. Quenching will subject the patient to cold temperatures and possible hypothermia

What devices are considered safe for MRI? WHAT happens when a device does get caught between the MRi machine and the patient?

SSRIs will inhibit CYP

What do SSRIs do CYP?

Decrease hepatic blood flow.

What do beta blockers do to hepatic blood flow?

1-produce new glucose. 2-sensitized the adipose tissue to lipolysis 3-increase proteolysis

What do glucocorticoids do in the stress response?

Analgesia and Sympatholytic

What does Central Alpha 2 Agonism do to pain signals?

Chronic opioid use can lead to increased prolactin levels, and decreased testosterone, estrogen, cortisol, luteinizing hormone, and follicular stimulating hormone (FSH).

What does Chronic Opioid use do to the prolactin levels?

II, IX, and X

What does PCC have in it?

Lipogenesis and over feeding.

What does a R quotient > 1 mean?

age > 65, > 3 CAD risk factors (HTN, HLD, DM, family history of CAD, current smoker), known CAD (stenosis > 50%), ASA use in past 7 days, severe angina (> 2 episodes in 24 hours), ECG ST changes > 0.5 mm, and positive cardiac marker.

What does a TIMI score consist of?

Recent trials have demonstrated no significant impact, however, outside of ERAS has been down to decrease complications and length of hospital stay .

What does have an important intraoperative goal-directed fluid management on length of stay, postoperative ileus, or other complications when it is used within an enhanced recovery protocol?

IONM of the RLN has not been shown to decrease the risk of damage to the nerve. It has been shown to help surgeons identify the RLN. Paralytics can't be used, but gas can be at 1.0 mac without issues.

What does intraop monitoring of the RLN help with the most?

The placenta secretes gastrin, leading to increased hydrogen ion secretion and more acidic gastric fluids in pregnant wome

What does the placenta secrete which makes gastric contents of pregnant women more acidic?

postcentral gyrus where the somatosensory cortex is located for pain perception.

What does the postcentral gyrus do?

Increase of potassium by 0.5 meq/dL

What does the potassium level increase by when sux is given to a normal person.

Umbilical Artery = acid-based status of fetus Umbilica vein = acid-base status of placenta.

What does the umbical vein acid-based status represent?

primary AI is likely to reveal hypoglycemia, hyponatremia, hypercalcemia, and hyperkalemia due to the lack of glucocorticoid and mineralocorticoid activity Since mineralocorticoid production is usually intact, these patients typically only have mild electrolyte abnormalities in Secondary AI.

What electrolyte issues does someone with Primary Adrenal Insuffiency vs. secondary have?

Factor IX.

What factors will decrease in pregnancy?

Because the heart is de innervated and it has no signal from the vagus nerve. The beta receptors are up regulated.

What happened to the beta receptors on the transplanted heart?

There's an increase in permeability in dura and the elderly patient

What happened to the girl in the elderly patient?

PVR decreases

What happens to PVR in pregnancy?

ntraoperative hypothermia has been shown to decrease drug metabolism. This results in higher plasma concentrations of drugs relative to normothermic patients.. Example-30% higher plasma concentrations of propofol when 3 degrees hypothermic.

What happens to medications relative to normothermic temperatures vs. hypothermic patients?

atracurium and cisatracurium, are combined, the overall potency is additive because they're both structurally similar. No effect on total duraiton. different classes, such as cisatracurium (benzylisoquinolinium) and rocuronium (steroidal), are combined, the overall potency is synergistic.

What happens when you add two chemically similar Non-depolarizing NMB vs. two chemically different ones?

1 met = basal metabolic rate of our body = 250 ml/minute if oxygen use.

What is 1 met to oxygen ratio?

Portion of minute ventilation that participates in gas exchange and contributes to PaCO2

What is Alveolar ventilation?

painless, palpable right upper quadrant abdominal mass accompanied by jaundice. This

What is Courvoisier sign?

Histamine and Seratonin antagonist used to treat Serotonin Syndrome.

What is Cyproheptadine?

Middle point of the PFT charts in the process of expiration-above the x-axis. =When low = indicator of small airway disease.

What is FEF-25-75?

6% Hydroxyethyl starch, lytes, glucose, and lactate.

What is Hetastarch composed of?

Meralgia paresthetica is an entrapment of the lateral cutaneous nerve of the thigh (LCNT). Pain with prolonged standing and walking, and alleviation with sitting

What is Meralgia paresthetica?

Occurrence policies cover claims for the year the policy is active, no matter when the claim is made

What is Occurence Policy?

a sample mean deviates from the actual mean of a population. This can be most accurate by increasing sample size.

What is Standard Error of the Mean?

Delayed relaxation of deep tendon reflexes, also known as the Woltman sign, can be seen in hypothyroidism.

What is Woltman's sign?

Class 1 - benefit is greater than risk and recommendation should be followed Class 2a - benefit greater than risk and it is reasonable to perform therapy Class 2b - benefit is slightly better or equal to risk and treatment should be considered Class 3 - no benefit and may be harmful

What is a class 3 benefit?

the procedure should not be performed because it is not helpful

What is a class 3 recommendation?

normal perfusion pressure breakthrough (NPPB)= after AVM is fixed, the distal compensated vessels which have been dilated will get a maximal amount of sudden, abrupt blood flow. Also important, the patient with an AVM is anticoagulated for 24 hours s/p embolization to prevent thrombus.

What is a complication with brain edema s/p days after AVM ressection?

Tip of the bougie which allows to blindly insert it into the trachea and feel the tracheal rings. Helpful in Grade III/IV views when. theglottic opening isn't visualized and allows for blind insertion under the epiglottis until tracheal rings are felt.

What is a coudé tip.?

The stationary chest wall will have a superficial, linear appearance. The underlying mobile lung will appear granular like the "sand on the beach." This is a normal finding. When both the chest wall and the lung are stationary, this is indictive of a pneumothorax and is called a stratosphere or barcode sign when the image is viewed in the M mode, where the top image looks like the bottom portion of the image. Blacklines = pleura.

What is a seashore sign? stratosphere sign?

Shunt = blood that doesn't participate in oxygenation. Normal shunt fraction = 5% 2/2 to Bronchial veins draining into the PV and Theisbeian veins draining de-oxygenated blood into the heart.

What is a shunt? What is the normal shunt fraction and why?

IPV = Hight frquency/High Flow piece that connects to a face mask or ETT, it ossiclates and breaking up/clearing patient's airway. Acapella device: Is a hand-held device that osscilatates on forced exhalation loosening patient's muscus secretions. mechanical insufflator-exsufflator: positive pressure alternating with negative pressure to simulate a cough.

What is an Intrapulmonary Ventilator? How does it differ from an Acapella device? What is a A mechanical insufflator-exsufflator?

Baro receptor response in the elderly increases. Results in wider swings in hemodynamics.

What is an example of the threshold of for afferent input activation increasing?

While courts determine competency, clinicians determine capacity, which is defined as patients' ability to understand their condition and assimilate and recall the information to make a decision

What is capacity of decision?

Common after right pneumonectomy 2/2 to incomplete closure of the pericardium 24 hours after surgery-causes impared venous return

What is cardiac herniation? When is it seen?

RV is unchanged and the ERV is decreased = FRC TV decreased = IRV Total lung capacity = unchanged.

What is changed in fat people lung wise?

Both have elevated LVEDP

What is common between Systolic and Diastolic Dysfunction?

NSAIDs, acyclevor.

What is considered ineffective against PHN?

MAP of 50-65 mmHg or 20-30% below baseline. Helps decrease tension on blood vessels and lessens the bleeding. Seen in Endoscopic sinus and Aneurysm surgeries to allow for a bloodless field and decrease blood loss.

What is controlled hypotension defined as?

Jet velocity > 5 m/s. Calcification

What is looked at to refer a patient with asymptomatic AS to surgery?

EEGEMG airflow, SPO2, ekg

What is monitored in a polysomnography

narrow-angle glaucoma, which is found in patients with Down syndrome, may experience a worsening of glaucoma with atropine administration.

What is one side effect of atropine administration that can be harmful in a pediatric eye case in a patient who has down syndrome?

It is an alpha receptor antagonist

What is phentolamine

described as dyspnea and hypoxia while sitting that is relieved by lying flat 2/2 to shunts of blood through the lungs.

What is platypnea?

Specificity = chance of ruling in the disease = high = unlikely false positive = confirmatory test. Sensitivity = if high means it rarely misses a disease = screening.

What is specifcity? Sensitivity?

P x R/2T (P= pressure, R = radius, T = thickness) -Higher volume in the heart, higher of the wall tension. However conteracted by wall thickness, which increases and decreases the wall tension. Increase in radius (dilation) or LVEDP = increase in wall tension = increase in demand.

What is the Laplace?

MCA/ICA ratio to define hyperemia to the brain vs low cardio output vs MCA constriction.

What is the Lindagaurd ratio?

Two times higher M&M, due primary mechanism of injury was related to respiratory events.

What is the M&M compared to OR case, that NORA patients have?

Omphaloceles arise from the failure of return of the physiologically herniated fetal intestines into the body cavity, and these confer a higher risk of mortality. Associated with septal defects > gasterostisis

What is the MOA for Omphaloceles?

is the narrowest point of a stream such as a regurgitant jet. This area has the highest velocity and most laminar flow in a jet.

What is the Vena contracta when discussing MR?

Glucagon. It increases cyclic AMP

What is the anti-toad for beta blockers?

Linear increase of cerebral blood flow--changing 1-2 ml/100g/min for each 1 mm Hg change in PaCO2

What is the association between Cerebral blood flow with CO2 between 25-75?

Ful cross/match + type/screen >>> type/screen with type-specific blood + partial cross/match. >> type/specific non-cross-matched blood >> O- blood is administered.

What is the best blood products to have in emergenies?

Bradycardia due to some sort of injury to the left ventricle like ischemia.

What is the bezold reflex is what?

Cranial nerve number nine stimulated goes to brainstem Cn number 10 Will slow the heart down. Can be blocked by local anesthetic around the carotid sinus

What is the carotid sinus reflux

Chloride in exchange of bicarb across a cell membrane.

What is the chloride shift?

MAC decreases by 6% per decade after the age of 40.

What is the decrease of MAC by what % after the age of 40?

Metoclopramide reduces gastric volume and acidity Oral H2-receptor blockers reduce gastric acidity and volume during the perioperative period and have shown a reduction in the frequency of aspiration pneumonitis. Same benefit not seen with IV. PPIs decrease gastric acidity and volume, but studies have not shown a decrease in aspiration. Takes up 2 days to reach peak effect. Non-particulate antacids (sodium citrate, magnesium trisilicate) increase gastric pH.

What is the effect of: Reglan Oral H2 blockers PPIs Non-particulates

Old 421 rule used hypotonic saline solutions resulting in hyponatermia and an increase in ADH release, which provides a vicious cycle of futher reducing ADH.

What is the issue with the pervious 4-2-1- rule in kid compared to the new practice of 20-40 cc/kg bolus?

Na+ being the largest contributor to plasma osmolality as it is restricted to the extracellular volume. Others include glucose & urea

What is the largest factor of plasma osmolality?

null hypothesis (false positive) states that there is no association between the predictor and the outcome variable. Serves to asses clinicaly signifcance. alternative hypothesis states that there is an association between the predictor and the outcome variable. Auto if the null is rejected.

What is the null and alt. hypothesis?

heavy menstrual bleeding and short-term prevention of bleeding in hemophiliacs, such as in tooth extractions. TXA in orthopedic, liver, and cardiac surgeries is off-label use.

What is the only FDA use of TXA?

When pressure is being measured in both the aorta and the left ventricle, usually in a cath lab and there is a delay of pressure between the LV and the aorta.

What is the peak-to-peak gradient?

After the termination of the spinal cord at ~L1, the pia mater extension covering the cauda equina is called the filum terminale.

What is the pia mater extension called and where is located?

As long as there is liquid, the vapor and liquid are in equilibrium, and the pressure remains constant at 750 psi.. the liquid has gone as the vapor is consumed, the pressure begins to decrease.

What is the pressure of N20?

Primarily an increase in fibronigen in factor seven

What is the primary hypercoagulable state in pregnancy due to?

Glutamate.

What is the primary neurotransmitter mediating afferent nociceptive transmission from the dorsal root ganglia to the spinal cord?

Headaches.

What is the primary purpose of blocking the greater occpital nerve?

Colloids = 1:1 ratio-if 5% given at 100 ml, it will expand the blood by 100 ml. Crystalliods = 3:1 ratio=100 ml / 30 ml expansion. Both can lead to dilution coagulopathy.

What is the ratio of intravascular volume expansion compared between crystalloids and colliods?

Cardiomyopathy and atrioventricular conduction defects may lead to the short life-span seen in some of these patients. Presents with weakness in the proximal muscle weakness.

What is the reason limb-girdle myopathy patients die?

Block renal SGLT-2 channels to promote glucosuria and natriuresis Examples: Dapagliflozin, empagliflozin

What is the role for Sodium-glucose cotransporter-2 (SGLT-2) inhibitors in CHF?

Predicted post operative (PPO) DLCO < 40%. -Decreased DLCO can be caused directly by alveolar fibrosis, as a result of decreased lung volume, capillary bed perfusion.

What is the strongest single predictor of risk of complications and mortality following lung resection?

0.05-0.1% (0.5 mg-0.1 mg/cc) of lidocaine for a total dose of 35-55 mg/kg dose of lidocaine. Risk of toxicity is low 2/2 to most of getting suctioned out.

What is the typical dose and concentration of lidocaine used in Tumescent Anesthesia for liposuction?

Facial clefts

What kind of birth defects arises from versed?

Thyroid goiters and tracheal stenosis may cause fixed intrathoracic and extrathoracic obstruction on flow-volume loop.

What kind of flow-volume loops would goiters present with?

Hypoglycemia -failure of gluceoneogenesis, insufficent insulin degradation, depletion of glycogen stores in the liver

What kind of glucose issues seen with liver failure, and why?

Hyperglycemia

What kind of glycemic issues would present with hyperthyroidism pateitns?

Gap junctions. Reason why skeletal blockade doesn't work on cardiac cells.

What kind of junctions are in between heart cells?

peripheral neuropathies = diseases such as Guillian-Barre resulting in asending paralysis. Patients exhibit a restrictive lung disease 2/2 to phrenic and intercostal nerve involvement.

What kind of lung disease do peripheral neuropathies patients have?

Anti-muscarinics-considering the spasm is ach mediated.

What medication is best to treat bronchoscopasm secondary to instrumentation of the airway?

no individual sedating agent appears to be safer than another

What medications are most safe during pediatric sedation cases?

fascia iliaca is deep to the fascia lata and envelopes the iliacus, psoas (commonly called iliopsoas), and pectineus muscles and the femoral nerve.

What muscles does the Fascia Illica encompass?

Six of more café au lait spots at least 1.5 cm

What must be present for NF-1 to be diagnosed?

Sodium Channalopathy most likely seen in Asian decent males, that is inherited as an AD pattern.

What mutation is Brugada syndrome seen in?

Lesser occpital and greater auricular nerves. Sub-q injections just posterior to the mastoid process.

What nerves are blocked for post-op pain related to otoplasties?

First order. Take pain from mechano + thermoreceptors to DRG horn.

What order are A-Delta fibers in the Spinothalamic tract of pain transmision?

NIOSH. Standard acceptable level of inhalation agents alone= 2 ppm or 0.0002% Standard acceptable level with violatile agents & N2O mixture = keep below 0.5 ppm.

What organization regulates PPM of inhaled agents in the OR?

Hypophosphatemia Low zinc low copper low magensium

What other electrolyte issues are seen with TPN?

75% 2 posterior spinal arteries, which together provide about 25% of the blood supply

What percentage of spinal cord blood supply comes from the anterior spinal artery?

Digoxin also increases phase 4 of depolarizations and shortens the action potential. This results in a decrease in the atrioventricular (AV) node conduction velocity and prolongs the refractory period of the AV node.

What phase of the cardiac AP does dig work on?

dose of local anesthetic plays the greatest role in determining spinal nerve block duration,

What plays the greatest role in determining spinal nerve block duration?

CHF-can worsen Pulm. Edema due increasing invtravascular volume.

What population of patients is mannitol contraindicated for?

A patient with a known placenta previa has a 3%, 11%, 40%, 61%, and 67% risk of placenta accreta for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

What precent does a patient with placenta previa have after the first c-section for which diseases?

NDMB = requires increased doses. Sux = no change in dose required.

What response does hyperparathyrodism have to NDMB vs Depolarizing?

Spinal block after a failed epidural is not a risk factor for failed neuraxial anesthesia but is a risk factor for high spinal.

What risk factor dose Spinal block after a failed epidural is not a risk factor for failed neuraxial anesthesia?

Drop the FIO2, don't decompress the chamber since it can decrease exhalation ability, leading to barotrauma. Can continue the HBO therapy. Not more common in patients with seizures.

What should be done during seizures 2/2 to HBO therapy?

If the patient needed additional transfusions in the future, the patient should receive washed red blood cells which would remove the IgA from the blood.

What should be done if an IgA deficient patient recieves blood transfusions?

In asymptomatic patients, particularly those with small fragment pieces, neurosurgical consultation is not required.

What should be done in an asymptomatic patient with the blue tip fractured into the epidural space?

Carries a high mortatiltiy risk and termination is advised. Mortality is 2/2 to RV failure.

What should be done in pregnant patients with PHTN?

a test block should be performed to see how the patient reacts to neurolysis via a celiac plexus block.

What should be done prior to celiac plexus neurolysis?

Intubation to provide positive pressure ventilation and prevents bowel insufflation. Ventilator settings should be set to low TV, permissive hypercapia, and minimal supplemental oxygenation to avoid further injury to the hypoplastic lung. Kept spontanous= better FRC. -NG tube placement -Umbilical vein access. -Open > laproscopic surgery. -Keep PIP < 25, Sao2 85-95%

What should immediately be done after a congenital diapharmagitic henia?

(pulse oximeter is placed on the right upper extremity) of 60-65% by 1 minute of life and 85-95% by 10 minutes of life.

What should pulse ox of a new born be at 1 minute of life?

Testestrone

What steroidal horomone can be reduced with intrathecal morphine?

Plasmodium falciparum via blood-borne

What transmits malaria?

TIVA-since inhalational agents-particular-Sevo can prolong the QT and be arrhythmogenic.

What type of anesthestic should be used in long QT syndrome?

One-compartment model is a volume of distribution model which states that a drug introduced into the body moves through only 1 compartment encompassing the entire volume of distribution. Drugs with low volume of distribution have this model. -For example drugs that stay in plasma. Two-three compartment model states that drugs will enter a central compartment and diffuse to other compartments such as tissue or blood. -Drugs that go from plasma to fat or tissue.

What type of drugs behave using the one-compartment model?

except in cases of pseudo-tumor cerebri (idiopathic intracranial hypertension).

What type of intracranial pathology is spinal anesthesia not contraindicated for?

LAST 2/2 to a large volume block and femoral nerve palsy.

What type of palsy can happen from a TAP block? What other complication exists?

carpal tunnel release, reduction of wrist fracture, and Dupuytren's contracture release.

What types of procedures would a Bier block be adequate to cover?

ETT is placed deep, in patients with a shorter trachea (e.g. children), and with flexion of the head.

What way is an endobronchial intubation likely to happen?

venous blood with significantly low oxygen saturation entering from the coronary sinus and mixing in the right atrium.

What will Central Venous Oxygen saturation be compared to SVO2?

Barometric pressure FGF However anesthestic potency (partial pressure) will remain the same.

What will effect vaporizor output of a variable bypass vaporizor?

with an increase in pH and temperature increasing degradation

What will speed up/slow down the break down to nimbex?

addition of clonidine to lidocaine provides no measurable benefit in terms of analgesia. Dexmedetomidine, an α-2 agonist that is 8 times more selective than clonidine, has been shown to provide some benefit

What would adding clonidine to lidocaine do?

>45 degrees turned. Tried on the left side.

When does the IJ and Carotid over lap?

hypoxia, hypothermia, or high doses of GABAergic anesthetics such as propofol. ALSO can be observed when body temperatures drop below 24.4°C and can protect the brain from hypoxemic-ischemic damage in patients with circulatory arrest in cardiac surgery.

When is burst suppression achieved and when is it important to achieve it, why?

High flows which produce turbulent flow considering heliox has a similar density to air. If there are flow flows or laminar flow exists, heliox will not help considering flows are laminar, however, visocity plays a role in this situation instead. Heliox is 79% helium/21% oxygen.

When is helox indicated? What is it made of?

Hypoplastic Left Heart Syndrome

When is it important to keep the PDA open?

Around 30 mmHg.

When should a decompression of compartment syndrome happen?

if on follow-up a progressive decline of LVEF to 60% or an increase in LVESD to 40 mm is noted, interventions should be considered, because the LV may not return to full function. If EF > 60% or LVESD > 40, continue to monitor.

When should intervention of Mitral Regurg be done regardless of asymptomatic?

LVEF is > 30%

When should severe MR be replaced/repaired?

Reflected. This will be maximum when at an angle of incidence of 90 = produce sharp images and reduces artifact. If the angle is acute and less than 90 = Refraction (source of artifact that occurs when the ultrasound direction is altered)

When ultrasound reaches an interface of two tissues with different acoustic impedance (soft tissue-air or soft tissue-bone), most of the ultrasound will do what?

Patellar snap

When using nerve stimulator what do you use to know that you are in the right spot for a facia Illiaca block?

contiguous lateral left ventricular and posterobasal walls

Where are changes seen in DMD with DCM?

Posteior cerebral arteries from the Circle of Willis and are used to feed the posterior spinal cord.

Where do the posterior spinal cord arteries originate from?

For this technique, a Doppler probe is placed over or to the right of the sternum at the fourth intercostal space (nipple line). For infants in the prone position, the probe may alternatively be placed between the scapulae.

Where do we place the Doppler probe to intentify a PE?

It doesn't matter.

Where does a-line need to be zerod?

End of the T waves- Isovolumetic Relaxation-> rapid filling ->diastatis -> atrial kick. Ends at the start of the QRS.

Where does diastole start on an EKG?

Diastole starts at the end of the T-wave.

Where does diastole start on the EKG?

terminal bronchioles

Where in the airway is the resistance to least?

Usually done to the marginal branches of the circumflex.

Where is grafting Of the circumflex usually done?

Acidosis and Hypercarbia causes vasoconstriction, however and an increase in HPV response. So Alkalosis and hypocapnia will do the opposite. Drugs like nitro, CCB, and ACE inhibititors blunt hypoxic vasoconstriction.

Where is hypoxic vasoconstriction mediated, what effects it?

Cervical, lumbar, hip and shoulder joint stiffness primarily in young men. Exhibit associated with HLA-B27 antigen in 90% of patients. Tx with NSAIDS.

Which antigen and primary symptoms seen in which population does Ankylosing spondylitis present with.

Propofol stands apart from these agents, with minimal effect on hepatic blood flow and a predictable pharmacokinetic profile despite severe hepatic dysfunction.

Which drug is best used as an induction agent for hepatic encephalopathy?

C-fibers mostly.

Which fibers carry the tourniquet pain sensation?

It supplies motor innervation to the posterior cricoarytenoid muscles (the sole muscles responsible for vocal cord abduction), the lateral cricoarytenoid, thyroarytenoid, and arytenoid muscles

Which muscle allows for abduction of the vocal cords?

he tibial nerve is the most common nerve utilized when monitoring for anterior and posterior spinal cord ischemia and cerebral hypoperfusion during these procedures

Which nerve is most utilized during aortic surgery with intropmonitoring?

Lungs considering they're highly vulnerable to injury and most difficult to preserve. 15-25% of donated organs can be utilized.

Which organ is most difficult to preserve?

T4-S4 dermatomes is considered the goal of neuraxial anesthesia for cesarean delivery.

Which oscillometric direct blood pressure measurements is the LEAST accurate when compared to invasive blood pressure monitoring?

Cisatracurium (and atracurium). Important since it can cause seizures.

Which paralytics can be metabolized to is primarily metabolized (80%) to laudanosine? Importance?

more than 60% of morphine is converted to M3G. ccumulation can cause neuroexcitation = hyperalgesia or seizures.

While Morphine-3-glucuronide is an active metabolite of morphine, what are some side effects?

gastrointestinal anatomy, morbid obesity, and potential drug-drug interactions as well as concerns regarding drug regimen adherence. Check: anti-factor Xa activity and/or drug plasma concentration

While there is no monitoring required for eliquis or xaralto, in what patient population would monitoring be useful and how is monitoring done?

Hemodilution: believed to be beneficial by improving microvascular perfusion. Nimodipine-does not reduce the amount of vasospasm, but is believed to improve outcomes by reducing the amount of intracellular calcium available and preventing cell death.

While triple H therapy + Nimodipine is contrversial, what is the point of hemodilution and nimopidine when treating a SAH patinet?

Because there isn't overlap between more than 1 nerve.

Why are areas noted in the blue circle the best areas to use to assess spina/neuraxial function?

Apneic oxygenation (e.g. after initiation of rapid sequence intubation) is less effective in children with URIs, so desaturation occurs much earlier. While there is increased peri-op respiratory effects, long-term sequale isn't any different between URI and non-URI kids WHO underwent general anestheisa.

Why can desaturation occur quicker in URI kids?

Because RV + ERV = FRC. RV can't be measured using spirometery.

Why can't you measure FRC with normal spirometer?

Arterial hyperoxia can also result in cerebral and coronary vasoconstriction, decreasing perfusion of these organs while preserving their relative oxygenation due to the increased oxygen tension in the blood. Lungs can lead to tracheobronchitis, pulmonary edema, and acute respiratory distress syndrome (ARDS)

Why do most guidelines suggest targeting a SpO2 < 100% in patients with acute cardiac or neurologic injury?

Dilution of 25% to 5% -use only NS or 5% Dextrose water. -using sterile water will result in a 1/5th concentration of the plasma, causing a hypotonic solution and lysis of RBC.

Why do you not dilute 25% to 5% albumin in sterile water?

decreased PaO2 (and oxygen saturation) due to the intrapulmonary shunt from the nonventilated lung. Hypercarbia,

Why does PaO2 decrease with endobronchial intubations?

Increase in alloimmunizations can lead to a delayed hemolytic reaposne.

Why does a sickle cell disease patient need to be cautous if blood transfuions?

due to an increase in 2,3-biphosphoglycerate and tissue acidosis decreasing the pH. This favors oxygen off-loading of the hg-oxygen molecule. Other things which causes an increase in 23 DPG? -Thyroxine. -Hyper-Phosphotemia -Anemia -High altitude, -CHF -Sleep apnea, -CHF

Why does anemia cause a rightward shift of the oxygen-hemoglobin?

Bradycardia occurs due to the hypoxic stimulation of the carotid body chemoreceptors.

Why does hypoxia lead to bradycardia in kids?

readily preserve normocapnia when driving pressures are appropriately adjusted.

Why is High-frequency jet ventilation better ?

Radioactive Iodine will be taken up by mostly the thyroid gland, leading to destruction. of cells and release of the T3/T4 worsening symptoms, so it needs to be taken with propronolol or pre-treated ppx with MTX or PTU. It is contraindicated in breast-feeding mothers and pregnancy.

Why is Radioactive Iodine effective treatment in Thyrotoxicosis? Why shouldn't it be used alone? when is it contraindicated?

Stopping a high-carb TPN may lead to hypoglycemia when abruptly stopped 2/2 to TPN infusions causing high blood insulin levels. If needs to be stopped, IV glucose and glucose monitoring should happen or twitching to a lower glucose-to-lipid ratio prior to stopping.

Why is TPN recommended to be continued?

chest wall innervation and innability to clear secretions?

Why is a C6-C7 injury cause DIB?

Can dangerously increase IOP and can lead to a laryngospasm.

Why is a TENS unit not to be used around the eyes or anterior neck?

Placenta takes some oxygen Mixture of oxygenated/deoxygenated blood.

Why is fetal oxygen never higher than 50 to 60 mmHg?

In healthy patients, the kidneys reduce tubular reabsorption. Commonly 2/2 to iatrogenic, outside of this, the most common cause is renal failure. along with: hypothyroidism, lithium toxicity, severe tissue breakdown (e.g. burns, sepsis), and Addison's disease.

Why is hypermagnsemia rare outside of oB?

Increasing HR = decreasing diastole + myocardial oxygen consumption.

Why is increasing HR worse than increasing BP for myocardium?

Induced hypotension during injection of the embolization media is typically requested to slow flow through the AVM and prevent embolization of the occlusive material into the systemic circulation. AVM with larger volume (>20 mL) or high flows (>120 cm/sec),

Why is induced hypotension important in AV malformation occlusion/resection? Which AV carries the most risk?

It means you're interneural.

Why not inject if less than 0.2 mA during a regional block?

Due to gene mutions in either Alpha or Beta chains. If alpha = decrease in alpha chain, increase in beta chain. Severity is based on deletions. Iron stores are either normal or increased.

Why should iron supplementation should be avoided in thalasemias? What are these conditions?

-Reserve 100% oxygen -Ball-valve effect= nitrous goes past obstructed epiglottis, but can't get out resulting in trapping and expansion.

Why shouldn't nitrous be used on Acute Epiglotitis inductions?

Patient is not considered brain dead if an apnea exam is positive or can't be done. You will need to obtain an ancillary test or come back a day or so later and repeat the exam.

Is a patient considered brain dead if the apnea test is positive? Is so, what should be done?

Acetazolamide is used as a treatment for altitude sickness by acidifying the blood, causing metabolic acidosis, and reducing the respiratory alkalosis that occurs from hyperventilation at high elevations secondary to hypoxia.

MOA of altitude sickness tx of Acetazolamide?

Inhibits activation of plasminogen to plasmin and inhibits plasmin which causes the fibrin clot to remain stable, preventing its break down.

MOA of amicar?

Variable intrathoracic obstruction causing collapse of then airway on expiration. Inspiration has no issues because the muscle can pull the airway apart.

MOA of an intra-thoracic lesion?

When the injury is missed, the incidence of a neurologic deficit increases 10-fold.

a Glasgow coma score (GCS) between 13 to 15, cervical spine injury incidence is 1.4%, but this jumps to 10.2%. Is injury is missed what is the chance of spine injury?

Total body weight: maintenance infusion dose of propofol, succinylcholine Lean body weight: thiopental, induction dose of propofol, fentanyl Ideal body weight: rocuronium, vecuronium

Medications should be based on Total, ideal, and lean body weight?

Non-specific plasma esterases & hoffman elimination.

Metabolism of Artacurium?

OI patients have increased capillary fragility, decreased platelet retention, decreased levels of factor VIII, and deficient collagen-induced platelet aggregation--benefits from DDAVP..

Why are osteogensis imperfecta patients at increased risk of bleeding?

typically asymptomatic and have normal PaO2 levels since their metHb levels are rarely higher than 25%. Symptoms are usually seen >30%.

Why are people with congenital methemoglobinemia not symptomatic?

SSEPs) monitoring of the RLN is not performed because the placement of electrodes required to stimulate sensory tissues innervated by the RLN (e.g. larynx, esophagus) would not be practical.

Why aren't SSEPs done in RLN with thyroid surgery?

Cardiac SNS fibers are dysrupted, but vagas is still intact.

Why can a quadrapelgic patient be at risk of bradycardic episodes?

The lidocaine is lipophilic and is drawn up into the adipose tissue, which explains why there is a decrease in systemic toxicity. However, total aspirated amount should be limited to 5 L,

Why does lidocaine in Tumescent anesthesia have a decrease in systemtic toxicity?

Can stack breaths and auto-peep. Can cause baro trauma.

Why does lung transplant patients require an I:E ratio of 1:4?

Carpal spasm upon blood pressure measurement 2/2 hypocalcemia.

Trousseau Sign?

Diabgitran Xeralto Eliquis. Can be reversed with PCC + Antifibrinolytics like TXA or Amicar.

DOACs include?

micrognathia, macroglossia, and severe upper airway obstruction.

Hallmark sigsn of Pierre Robin Sequence.

Sevoflurane does degrade but does not result in the production of carbon monoxid. Vs. Desflurane = #1

Halogenated agent that is least suspectible to CO production?

reduced P-R interval, prolonged Q-T interval, and T-wave flattening and inversion. Can present with a J-wave (similar to hypothermia) aka an osborne wave.

Hypocalemia EKG changes

High opening pressure of > 20 psi via pressure monitoring = highly sensitive for intrafascicular needle tip placement.

Pressure sensitive of intrafasciular pressure?

obesity are not hypercapnic due to the increase in alveolar ventilation because their response to hypoxemia and hypercapnia remains intact.

Why are obese patients not hypercapnic?

Due to the longer dural sleeves that accompany needle branches.

Why is epidural injection more common with the deep cervical block?

CYP enzymes carries out N-dealkylation, O-dealkylation, aromatic hydroxylation, and deamination

CYP enzymes carries out?

-Worsening hyperkalemia. -Hypotension.

Calcium Channel blockers should be avoided with Dantrolene for treatment of MH because it can cause:

Advanced age. Along with low education, long operation, and major surgeries. Cognitive decline was the same with Sevo and des.

#1 predictor for post-operative cognitive dysfunction?

Symptoms: Acute DIB Sign: RR increased/Tachycardia. ETCO2 decreases 2/2 to increased dead space 2/2 to blood flow blocked, but ventilation occurs. Dx: CT/Pulmonary angiography.

#1 symptoms of PE and #1 sign of PE?

decreased ejection fractions (< 35%), those with ischemic causes of regurgitation, history of diabetes mellitus, and/or carotid endarterectomy

, left-sided regurgitant lesions are better tolerated than stenotic lesions. What would cause patients with Left-sided regurg lesions like Mitral Regurg have worse outcomes?

upper and lower motor denervation, immobilization, severe burns, prolonged use of neuromuscular blocking agents, and cerebrovascular accidents.

Factors that promote increased risk of Extrajunctional receptor proliferation.

The criteria for recognizing AFE are Acute hypotension or cardiac arrest Acute hypoxia (dyspnea, cyanosis, respiratory arrest) Coagulopathy or severe hemorrhage

The criteria for recognizing AFE are?

Pregnancy is associated with a right shift of the oxygen-hemoglobin dissociation curve. Increases to 30 from 26, secondary to increased 2,3-DPG

What happens to the Hg-oxygen curve in pregnancy?

Lipid solubility relates to the potency of local anesthetics. Low lipid solubility indicates that higher concentrations of local anesthesia must be given to obtain nerve block. high lipid solubility produces anesthesia at low concentrations. Protein binding affects the duration of action of a local anesthetic. The onset of action relates to the amount of local anesthetic available in the base form, based on pKA . Most local anesthetics follow the rule that the lower the pKa, the faster the onset of action and vice versa

1-What does lipid soluability relate to with local anesthestics? 2.) duration of block is determined by? 3.) onset speed?

Receptors are upregulated.

What happens to the beta receptors of transplanted hearts?

Electrical stimulation with a motor response < 0.2 mA only can occur with an intraneural needle tip location.

What is the mA which an intraneural tip is likely?

Linguinal branch = somatosensory and gustatory sensation to the posterior tongue, pharyngeal branch = provides sensory innervation to much of the oropharynx and gag reflex.

2 branches of CN9 and what they do?

CYP3A4 is involved in the metabolism of over 50% of clinically used drugs and is the most abundantly CYP enzyme expressed in the liver.

What is the most abdundant CYP enzyme in the body?

Helium reduces airway resistance in large and medium airways (reduced resistance in turbulent flow). I

Heliox reduced airway resistence because of its decreased density. What sized airways does it reduce the resistence in?

-patient with suspected moderate or greater degree of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been no echo in the last year -Repeat is preop echo if there is significant change to physical exam (I.E. new onset rales/crackles)

2014 ACC/AHA perioperative guidelines make a few key recommendations regarding valvular heart disease in general

Ignition source (surgical laser) Oxidizer (N20, O2) Fuel (drape).

3 components of the fire triad and example?

Carbonic Acid = 73% Hg-CO2 = 20% Dissolved CO2 = 7%

3 major forms of CO2 in the body?

metabolite of heroin. is eventually metabolized further into morphine

6-Monoacetylmorphine is an active metabolite of

Decreased in BMI > 30

BMI effects in PDPH?

When the integer value of pH increases or decreases by 1, the concentration of the hydrogen ion changes 10-fold. pH = -log[H+] 6 = -log[H+]

A urinalysis is performed, and the pH is 6. What is the concentration of hydrogen ions?

patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and professionalism(most common cause of losing medical licenses).

ABA 6 core competencies to teach anesthesia residents?

-Unrestricted license -250 CME credits w/ 125 within 5 years and must include 20 ABA approved patient safety CME credits. -30 MOCA questions every quarter -50 points of clinical practice assessment & systems-based practice. d

ABA requires what for license renewal q10 years?

1.) Look at pH: -<7.35 = acidic ->7.45 Alkalosis 2.) Ask if the CO2 can explain what is going on? -For every 10 mmHg change in CO2, there pH should change 0.08 units. -If the CO2 went up 10 mmHg, then the pH should go down 0.08 units. 3.) If the CO2 didn't change 0.08 units per 10 mmHg = mixed acid/base problem= look at the bicarb to confirm it.

ABG interp from University of Kentucky?

Hypopnea + apnea / hours.

AHI is calculated how?

Andexanet alfa = functions by binding and sequestering the direct oral factor Xa inhibitors. it ALSO inhibits the tissue factor pathway inhibitor, facilitating the generation of tissue factor-initiated thrombin generation. Dabigatran is a direct oral thrombin inhibitor = Idarucizumab

Andexanet alfa inhibits which drug, MOA? Idarucizumab reverses what?

triad of retrognathia, glossoptosis, and cleft palate. The retracted tongue causes severe airway obstruction. Prone position of the neonate may be needed during feeds to avoid worsening of the obstruction.

Anesthesia consideration for Pierre Robin?

subglottic stenosis, obstructive lung disease, and reactive airway disease, PHTN. Often dieuresed with lasix = low calcium and potassium.

BPD seen in infants is associated with?

thyroid cartilage of larynx, not the cricoid.

BURP manuver is done by pushing on which carriage?

-Propofol (as an infusion) and bupivacaine = associated with lethal arrythmias. -should have ICD -Higher risk with emergent intervention. -Avoid class I antiarryhmics and Beta blockers considering it can lead to lethal arthymias.

Anesthesia considerations for Brugada syndrome?

pain in an area that lacks sensation, often involving the face. It is a feared complication of neurolytic blocks for the treatment of trigeminal neuralgia (eg, radiofrequency rhizotomy).

Anesthesia dolorosa i

Similar complications. Propofol based deep sedation while maintaining spontaneous ventilation has been shown to be the safest option for anesthetic management.

Anesthesia for pediatric radiation therapy vs. operating room has what complications? What kind of anesthesia is used?

Inhalation with emphasis on maintaining respiratory drive. CPAP adminsitered in the upper airway obstruction allows the keep it open. Paralytic can cause complete occlusion of airway.

Anesthesia used for forgien body obstruction?

-Ketamine -etomidate -barbiturates.

Anesthetics unsafe for acute intermittent porphyria?

Avoid neck dissection, can be done by non-surgeons, can be done at beside, less stoma infections and bleeding. Infants, infection at site, severe coagulopathy, unstable spine.

Advantages of Perc Trach at besides over open trach in the OR? What is the contraindications?

SLN (primary afferent nerve) fires ==>Nuculeus tract salitrus ==>Nucleus Ambigeus ==RLN firing ==>LCA & TA activation ==>closing of the glottis opening.

Laryngospasm loop?

-anesthesia can be easily titrated, and a rapid and predictable emergence with minimal lingering effects -reduction in airway irritation -reduction of post-extubation cough -reduction of laryngospasm by 50% in peds patients. -reduction in ED (Exited delrium). -Reduction of post-op cognitive impairment.

Advantages of TIVA for general anesthesia induction?

Reported advantages of MIDCAB as compared to traditional on-pump CABG include: decreased arrhythmias, post-op wound infections, coagulation disorders, blood product transfusions, endothelial dysfunction, renal failure, stroke, hospital stay, and cost.

Advantages of a MIDCAB vs. on-pump CABG?

resulting in contraction of the lateral cricoarytenoids, thyroarytenoid, and cricothyroid muscles

Laryngospasm muscles?

lateral antebrachial cutaneous nerve is a branch of the musculocutaneous nerve. C5-6

Lateral Antebrachral Cutaneous Nerve arises from what nerve?

due to the potential link between malignant hyperthermia and hypokalemic periodic paralysis, succinylcholine should be avoided in these patients.

Why should sux Hypokalemic periodic paralysis be avoided?

Easier to identify anatomy. Easier to place for a difficult airway. No need to exchange at the end of the procedure. Isolate at the lobar level. Difficult to suction the operative lung because of a small channel for suctioning. Difficult to convert between OLV and TLV Dislodgment Increased chance of perforation.

Advantages of bronchial blockers: Disadvantages:

it can result in hemodynamic instability and an increase in the ventricular rate.

Why shouldn't adenosine be used with irregular wide-complex tachycardias?

Death. Nerve injury, permanent brain damage, and airway injuries accounted for 21%, 9%, and 6% of cases, respectively.

According to the ASA's Closed Claims Project, the most common occurrence leading to a malpractice claim is

general anesthesia occurs when a patient is no longer purposefully responding to painful stimuli. no response and nonpurposeful withdrawal to a painful stimulus would be categorized as general anesthesia

According to the ASA, when does the line between general anesthesia and deep sedation occur?

Top = Sartorius Lateral = Vastus Medalis Medial = Adductor longus or magnus. Nerve-Artery-Vein. LA is injected lateral to the femoral artery.

Anatomic boarders of the adductor canal?

-Pt has A/B antibodies to A/B antigens -Pt has antigens to minor antigens like Rh or Kidd 2/2 to previous exposure or pregnancy-more common in women previously preggo -Pt. antibodies attack donor WBC releasing cytokines. Decreased with leucoreduction. Common with plasma (up to 30%) -Donor Antibodies attack patient's WBC. Restriction of pregnant women decreased this.

Acute Hemolytic: Delayed: NHFTR: TRALI

Inferior MI due to reputure of the papillary muscle. Decreasing afterload and allowing forward flow is needed by Sodium Nitropresside.

Acute mitral regurg is likely seen s/p what kind of MI?

L3-L4 = Saphenous nerve

Adductor Canal

Gamma Globulins-plasma cells.

All plasma proteins are made in the liver with exception to?

perception of an ordinarily nonnoxious stimulus as being painful (eg, pain from the touch of clothing).

Allodynia?

Cat I = normal without intervention Cat II = Most common tracing. Indeterminate or NRFHT = late decels, variable decels, fetal brady. Cat III = urgent intervention. absent fetal heart rate variability, sinosodal patterns

American College of Obstetricians and Gynecologists (ACOG) defines cesarean sections according to 3 categories

80% of the body's weight.

Amount of body weight which verterbal bodies old?

It will result in more blood going to the right ventricle then the left.

An increase in systolic pressure without an increase in diastolic pressure will increase blood to watch bunch power mode

increases heart rate by inhibiting parasympathetic activity when stretch receptors located in the right atrial wall sense increased pressure.

Bainbridge reflex

(NA+K) - (Cl + bicarb) = 8-16 Potassium doesn't contribute much. Albumin can cause a low anion gap and lactic acidosis can be missed unless corrected for it in hypoalbuminemia.

Anion gap equation.

AG = ([Na+] - ([Cl-] + [HCO3-])

Anion gap forumla?

Acycanotic shunts.

Another name for left-to-right shunts?

Cardiac surgery VS. Prone spine. RF: prone positioning, long surgical length (5 or more hours), obesity, male sex, significant blood loss, Wilson frame use, and external ocular compression. NOT dilberate hypotension.

Anterior ION is likely to result after what type of surgery? vs Posterior ION?

Most antibiotics will tend to cause neuromuscular blockade even in the absence of NMBDs. -For example: Amioglycocides and Clinda = decrease Ach senstivity to receptor & impair release of Ach pre-synpatically. -fluoroquinolones and tetracyclines also inhibit the postsynaptic nAChR and have been shown to trigger myasthenic crises. However, PNC and celphlosporins haven't been shown to cause any effect with NMBD.

Antibiotic effects on Neuromuscular blockade?

Balance between Crystalloids and colloids maintain an intravascular volume balance. No specific transfusion threshold.

As far as fluid management is concerned for ischemic optic neuropathy what fluid is best to use?

Triggered by inspiration, used in both Pressure and Volume Controlled ventilation. Assist Control will allow the patient to set their own respiratory rate and it will initiate a breath (at at a certain pressure or volume) and delivery that set volume or pressure. Can lead to auto-peep due to breath stacking, resulting in baro trauma.

Assist Control Ventilation?

50 mmhg systolic.

At what BP does the barosinus reflex lose its capacity?

Adductors and closes the vocal cords.

Lateral cricoarytnoids.

Halothane (2.54) Iso (1.46) Sevo (0.65) Nitrous (0.47) Des (0.42)

B/G concentration of Halothane, Iso, Sevo, Nitrous, Des?

Astrocyte feet --basment membrane of endotherial cells --tight junctions b/w endotherial cells--(blood) If tight junctions are absent, it would allow sodium to move and forth freely, causing only slight changes in sodium to result in major brain swelling.

BBB layers?

contact dermatitis, a type IV delayed T-cell-mediated hypersensitivity reaction

Latex allergy contant dermatitis is what kind?

Decreased pressure = sensed by Carotid Sinus and Aortic Arch receptors which causes a decrease in stretch receptor firing = signal transmitted via CN 9 and CN 10, repectively to nucleus of the solitary tract and the nucleus ambiguus ==> CN 10 and SNS chain increase HR and Vasoconsrict.

Baroreceptor response when BP is low ?

Low BP, JVD, distant heart sounds

Becks triad

A-lines. B-lines which are hyperchoic verticle structures that are reverberation artifacts that arise from the pleura. Can be indicitive of pulmonary edema if they arise in at least 2 fields with >3 b-lines in each field.

Beneath the pleural, hyperechoic horizontal reverberation artifacts can be seen at regular distances referred to? What are other lines?

-rely on atrial kick. -keep PA pressures lower. Can develop PA htn from hypoxia, hypercarbia, resulting in CHF and right ventricular failure. -slow HR to give time to get blood across the valve.

Factors to decrease complications in mitral stenosis?

Pulmonary function tests can identify thoracic patients who are at risk for post-op M&M, benefit of bronchodilator's and patients who need post-op vent support. If patients is given a bronchodilator and a 15% improvement is noted, should be started on bronchodilator's before. Sx.

Benefits of PFTs for thoracic surgery patients?

Apex of the Fem. Triangle -----> Aductor Hiatus = 8-11 cm in length. VM = lateral. Sarotius = top/anterior AL or AM = posterior medial based on superior or inferior portion of the canal.

Boundries of the adductor canal?

Inhibits Carbonic Anhydrase at the PCT =Dumps Bicarb into the urine. Blood is acidic.

MOA of acetazolamide?

T4-S4 For adequate analgesia for stage I labor, the T10-L1 dermatomes should be covered. The second stage of labor requires additional coverage at S2-4.

C-section should cover which dermatome distributions?

Increase the dissolved oxygen by 100% o2 or hyperbaric therapy. f

C.O. posioinging takes up the Hg-CO, so inorder to increase the oxygen content in the blood, what is needed?

CBF = (AoDP - LVEDP) / CVR.

CBF calculation?

-Subclavian CVCs have lowest infection rates. -minimum number of ports inserted -replace within 48 hours if catheter placed in emergency without chance of full aseptic technique. -tegaderm replaced q7 days. -fever alone isn't indication for removing cather -administration sets replaced q7 days, unless blood products or fatty emulsions = replace q 24 hours.

CDC central line infection recommendations?

Use Dosimeter Wear lead Increase distance considering intensity = 1/distance ^2 Decrease time exposure.

CDC guidlines to monitor and minimize radation?

QT interval. Shortened: high calcium. Increased: low calcium.

Calcium works where on the EKG?

MAP = SVR x CO

Calculate MAP?

Measured: Ph, Po2, Pco2 Calculated: Base excess, bicarb

Calculated vs. measured on blood gas.

PaO2. Via cn#9.

Carotid body responds to what?

Shunts

Changes in PaO2 as the FIO2 goes up will be least seen with what?

CV: increase in SV, small increase in HR = increase in CO. Approx. 50% by 3rd trimester. SVR decreases. Central pressures of CVP and PVP should be unchanged. Blood volume: Increased plasma volume. Resp: increased MV 2/2 to increased TV and mild increase in RR. ERV and RV decreased, IRV-increased, FRC decreased by 20%-2/2 decrease in ERV & RV. TLC & VC is unchanged. O2 consumption-100% increase during labor. Rightward shift in o2-hg curve, unless there is pre-E which shifts back to the left.

Changes in Pregnancy:

SNS increases decreases response to Alpha & Beta receptors 2/2 to decreased intracellular signaling = increase catacholeamines. decreased baroreflex 2/2 limited cardiac reserve > vascular tone decrease SA nodal cells and conduction fibrosis Decreased Beta stimulation on heart = decreased maximal HR

Changes in aging?

Right shift Hg curve = increase O2 extraction = decrease SVO2. Increased CO 2/2 to decreased Viscosity = decreased SVR

Changes with anemia?

-dihydropyridine calcium channel blocker that is highly selective for vascular smooth muscle. - Decreases SVR. - Minimal reflex tachycardia. - quickly metabolized by plasma esterases - Requires infusion.

Clevidipine MOA and route?

Difficulty intubation with: -Suspected difficult mask -Increased aspiration risk -Increased risk of rapid desaturation -Likely suspected to have a difficult invasive emergency airway procedure. If failed AFIO attempt: -Cancel case, can consider abandening procedure and seeking alt., or change to an invasive airway.

Considerations to an awake fiberoptic intubation? What should you do if AFIO fails?

>2 = difficult, but doesn't mean difficult intubation: -55 yo, > 30 bmi, no teeth, male, III/IV, OSA, beard

Clinical predictors to mask valve difficulty?

The clinical presentation is in two phases, (1) severe pulmonary hypertension with right ventricular dysfunction and (2) left ventricular failure and pulmonary edema.

Clinical presentation of AFE?

Repeat nerve monitoring and stimulation, weakness is seen to decremental nerve stimulation. Ach-Ab measurements.

Clniical course of MG in neonates can be monitored how?

Blocks Ach release into the synapse: LEADING to; cranial nerve deficits) with symmetric weakness. -Infant = 72% = 2/2 spores from honey or dust, has GI symptoms. Dx = spores in stool. -Food = GI symptoms, rapid onset. -Wound = 10 day incubation period. Dx = serum mice assays, wound culture. Tx: vital capacity < 30% of predicted = intubation, Equine >1 y/o. | Human < 1 y.o

Clostridium botulinum is a gram positive bacteria. What is the MOA?

1.) Fibrinolysis is impaired. 2.) Anticoagulants like Protein S & Protein C is decreased/resistent, respectively = usually block factor 5 & 8 = coagulation. 3.)Increased D-dimer 4.) Thrombin-antithombin 5.) Decreased platelet count 2/2 dilution and consumpton.

Coagulation issues in pregnancy?

Common bacteria: Ureaplasma urealyticum (up to 50% of cases), Mycoplasma hominis (up to 30% of cases), Gardnerella vaginalis, bacteroides, group B Streptococcus, E. coli

Common bacteria that cause chorio?

AI, PVD, CPP= DBP-LVEDP

Contraindications for IABP? MOA?

pregnancy, untreated bleeding disorders (hemophilla), and active urinary tract infections (UTI).

Contraindications to Shockwave lithotripsy?

which include pregnancy, untreated bleeding disorders, and active urinary tract infections (UTI)

Contraindications to extracorporeal shock wave lithotripsy?

50-65 mmHg or 20-30% below baseline BP.

Controlled hypotension is defined as?

Of the H2 blockers, ranitidine is the least likely to reduce gastric volume and generally has no effect on volume.

H2 blocker least likely to reduce gastric volume and generally has no effect on volume.

Bronchodilator effects. Worry if vasoconstriction of the bronchioles.

H2 receptors in the lung does what? What would happen if you start an H2 blocker in a patient ?

Fluid overload in a stiff heart = increase in diastolic pressure = backing up of fluid into the lung.

MOA of action of diastolic dysfunction and HF with persevered EF?

trauma, previous surgery, work-related injuries, and female sex PT (first-line tx)-->TCAs-->gabapentin-->sympathetic blocks-->spinal cord stimulators, intrathecal medications, somatic blocks

Major risk factors of developing CPRS? Tx:

0.2-2 degree celcius. Must be 10-20 cm deep to properlymeasure it.

Nasopharnygeal temperature is off by how much? How many cm must a np temp go to accurately measure core temp?

Major drop: resume 2 lung ventilation and check position. Gradual drop: --FIO2 100%-->Check position-->ensure MAC < 1.0 -->recruitment maneuvers to ventilated lung-->5 peep to ventilated lung (except COPD)->CPAP to operative lung-->intermittent two-lung ventilation-->Block PA of operative lung.

DLT trouble shooting with Major drop in Desat vs. Gradual drop?

CaO2 x CO Should be 1000 mL of oxygen.

DO2-delivery of oxygenated blood to the tissues.

D-dimer is elevated in DIC-considering there is both coagulation & fibrinolysis. Fibrinogen degradation products or dysfunctionl fibrinogen are more elevated in ESLD.

DIC and ESLiverD both present in a similar fashion. How can you tell the difference?

in the left-lateral decub position because because the brachial plexus is anchored to the transverse processes of the cervical vertebrae in the neck and axillary fascia in the upper arm. Other injury which can arise is a common peroneal nerve injury to the dependent (down) leg which can be avoided by flexing it and putting a pulling between the legs.

Damage to the brachial plexus is common in which particular position and why?

COPD and patients reicveung opioids.

De innervation of the carotid body is particularly dangerous in which Pt group?

Dead space-ventilation without gas exchange. Shunt- perfusion to the respiratory system but no ventilation (shunt).

Dead space vs. shunt?

Ventilation without perfusion = V/Q >1 Factors that increase it: -high airway pressures -erect posture -increased age -mechnical ventilation

Dead space?

Increases anions, causing metabolic acidosis Things that does it: -NS -Free water access -Diarrhea = loss of sodium and potassium and lessens the cations. -Increase in unmeasured anions like lactate + ketones.

Decreasing SID does what?

-Flexible stainless steel ET tube. -Soak towels. -decrease fio2. Avoid N2O

Decreasing risk of airway fires?

10 units in 24 hours of product.

Define MTP?

right internal jugular > left subclavian > left internal jugular > right subclavian.

Ease of placement for a pulmonary artery catheter from easiest to most difficult is:

IT LA = decrease in SSEP

Effects of SSEPs is most effected which what neuraxial technique?

hypokalemia, hypocalcemia, and hypomagnesemia.

Electrolyte derangements which prolong QT ?

Glucose --> Pyruvate + 2 ATP (without O2) ===> Lactate + NAD+ -NAD+ is required for Glycolysis to continue. With oxygen: Pyruvate ==> Mitrochorndia ==> NADH + FAD -->Oxidative Phos = > 30 ATP.

End product of glycolysis?

significant shunt that will cause the PaCO2 to increase relative to the EtCO2.

Endobronchial intubation will do what to PaCO2 relative to ETCO2?

-porphobilinogen deaminase (PBG-D) = porphobilinogen and δ-aminolevulinic acid build up. and diagonsis in urine -autosomal dominant -triggers 2/2 to increased demand for heme synthesis. -hemin and glucose, which decreases the activity of δ-aminolevulinate synthase and heme production

Enzyme and pathophys of AIP?

OHS = increase in CO2 and a decrease in PO2, esp. during REM. Noted to have a decrease in Sao2%. DO NOT have obstructive symptoms. More prone to develop right heart strain 2/2 to a drop in Pao2 and increase in CO2. OSA patients however, tend to have an otherwise normal SaO2 unless they're apnea. Obstructive symptoms. Otherwise normal PO2/CO2 unless during pediod of apnea.

Explain the main difference between Obesity Hypoventilation Syndrome and OSA?

Progestrone = MV increases by 45% with TV > RR w/ peak at week 12 = respiratory alkalosis = alveolar ventilation by 45% = Increased PaO2 & decreased CO2 = incomplete metabolic acidosis by dumping bicarb to 20-21, pH = ~7.4. 2nd, 3rd trimester the Po2 WILL DROP from 107-->105-->103

Explain the primary MOA of respiratory changes in pregnancy?

1.) Peripheral Chemoreceptors (aortic & cartoid): -<PO2 <50 mmHg = CN9 stimulation = medulla = increased RR 2.) Central -CO2 increase ==>cross BBB == CO2 + H20 ==>H2CO3==>H+ + HCO3- ==>H+ in the CSF stimulates the Medulla to increase RR 3.) Mechanoreceptors: -Lung volume, vascular congestation, airway stretch ==>CN10==>Medulla.

Explain the three input of receptors of the respiratory drive?

Head CT has 200 mrem, chest CT has 800 mrem, and abdomen CT has 1,000 mrem; typical radiography has 0.5 to 5 mrem. Radiation exposure is inversely proportional to the square of the distance from the source.

Exposure from CT scan vs. xray is how much?

Dose matters > volume in extent of blockade in epidural

Extent of senosry block of epidural?

Muscles -->Globe -->Short cillary nerve -->cillary ganglion -->CN5 -->CN5 ganglion [Gasserion] -->main trigeminal nucleus-->viceral motor ganglion of CN10-->SA node bradycardia.

Extraocular reflex afferents and Efferents?

Increase it. CPAP does as well.

FRC effect with peep?

Pulse, pallor, parathesia, pain,

Five Ps of compartment syndrome?

autonomy. -component of automy is informed consent. beneficence-physician's obligation to do good for patients nonmaleficence-Nonmaleficence is an obligation to not inflict evil or harm onto others justice-giving to each his or her due; focuses on distribution of medical resources. (use of ideas or treatments equally in all groups of society. For example, a new treatment should be given equally across all societal groups)

Four main principles that are considered the core of medical ethics

Isovolemic relaxation Rapid filling Diastatis (slowing of the flow) Atrial kick.

Four stages of diastole.

Hyperperistalsis can be an additional cause of nausea.

GI effects of spinals?

CN 9 --> ipsilateral nucleus solitarius-->nucleus ambiguus in the rostral medulla-->CN 10 to bilateral posterior pharnygeal muscles.

Gag reflex pathway?

Normal, when not in labor.

Gastric emptying in pregnant women?

Haldane effect is the process of oxygen binding to hemoglobin and displacing carbon dioxide, which will result in a downward shift in the carbon dioxide dissociation curve. This facilitates the removal of carbon dioxide from the body. The Bohr effect is the process of carbon dioxide binding to hemoglobin causing oxygen to be displaced, which will result in a rightward shift of the oxygen-hemoglobin dissociation curve.

Haldane vs. Bohr effect?

AV dissociation

Giant A-wave is noted to be in what CVP waveform?

Afterload-keep high. Keep sinus because pre-load dependent Bradycardia

Goals for a patient undergoing surgery for Aortic Stenosis pertaining to Hemodynamics?

ECT causes an initial Parasympathetic response with bradycardia and hypotension and then a sympathetic response due to seizures resulting in tachycardia and hypertension = myocardial ischemia and CNS metabolic demand, ICP elevation.

Hemodynamic changes with ECT?

Hepatic buffer response: As PV blood flow decreases ==> adenosine builds up in the liver which causes hepatic artery vasodilation. Can increase the hepatic artery blood supply by a 100%. Other intrinsic factors = SNS, however the hepatic artery has both alpha/beta receptors where the portal vein has alpha only. Extrahepatic increase hepatic blood supply include increasing venous return such as in inspiration, increasing arterial blood flow by C.O., or increasing portal blood flow by splanchnic vasodilation.

Hepatic blood supply is regulated by both intrahepatic and extrahepatic factors. The largest determinant of intrahepatic factors for blood supply to the liver is? How about extrahepatic?

The definitive treatment is liver transplantation that resolves the hypoxemia within one year.

Hepatopulmonary syndrome is a triad composed of liver dysfunction, intrapulmonary vascular shunting/dilation, and unexplained hypoxemia. How is it treated?

Keep spontaneous to decrease the potential dynamic airway collapse using mask induction-->IV-->CPAP of 10-15. Intubate only using DL when deep anethesia--never under moderate or awake anesthesia. Once intubated, keep CPAP at 10-15 2/2 pulmonary edema from sudden relieve of obstruction.

How should a patient with epiglottis should be managed?

labetalol blocks Beta > Alha receptors in a 7:1 ratio. This can lead to a decrease HR and BP, resulting in reflexsive release of catacholamines and alpha 1 agonism = hypertension. Tx of acute hypertension for patients undergoing removal of pheochromocytoma should include: -avoid histamine-releasing -utilization of direct-acting vasodilators -Utilize α-blockers (e.g. phentolamine)-especially important during induction.

In pheochromacytoma patients, why is labetalol bad?

Usually, a loading dose is intravenously administered followed by a maintenance dose. In women with renal insufficiency, the maintenance dose should be lowered or not given.

In pts. with renal failure, what should happen to the magnesium dose?

ncidence of hypoglycemia after TPN discontinuation can be reduced by using TPN solutions with a lower Glucose-to-Lipid ratio in 70/30 or 50/50 form

In the event that TPN is stopped, what can be used to decrease hypoglycemia risk?

There is a higher incidence in pediatric patients who have received desflurane or sevoflurane anesthesia.

Incidence of emergence dilerium is seen with what agents?

Can decrease uterine perfusion.

Increase in uterovenous pressure?

SHUNTs?

Increased in PA-pa gradient associated with?

At the level of the lungs. Will be deactivated when it binds to the hemoglobin in the lungs.

Inhaled NO works out?

Previa and c-section.

Increased risk of placenta accreta?

Increasing FIO2 = dilation of the PA = blood moving to the lungs > going through the PDA-->Aorta-->coronary + systemic circulation. Also, if you increase the RR and decrease CO2 ==>PA dilation.

Increasing FIO2 in hypoplastic left heart shows a 100% SPO2, but a poor blood gas with metabolic acidosis, why? What else can cause this?

An increase in CO2 resulting in a rightward shift is known as the Bohr effect

Increasing co2 results in a rightshift in hemoglobin dissocation curve due to?

>200 cc/hour

Indication for surgical re-exploration with chest tube bleeding?

-Untreated end-stage lung disease. -Absense of major medical illness. -Substantial limitation of daily activities -Projected life expectancy less than 50% of 2 to 3 year predicted survival -New York Heart Association class 3 or 4 functional level -Rehabilitation potential -Satisfactory psychosocial profile and emotional support system -Acceptable nutritional status -Disease-specific mortality exceeding transplant-specific mortality over 1 to 2 years

Indications of Lung transplant?

-Isolation of the healthy lung. -Bronchopleural fistula. -VATs

Indications of one-lung ventilation?

T of GV Pulm. ateria Coartactation of the aorta HLHS Neonates can go apneic, hyperthermia, and hypotension with prostoglandins.

Indications of prostogandlins in congenital?

-Sympathetic Afferents =splanchnic nerves projecting from T5-T12 throughout the whole tract. -Greater: 5-9 -Least: 10-11 -Lesser: T12-L1 -2 sensory afferents: =Esophagous to the Tranverse Colon = vagal =Tranverse colon to the rectum = sacral ganglia

Innervation of the GI tract?

superior hypogastric plexus. pelvic pain secondary to cancer or other nonmalignant conditions.

Innervation of the bladder?

nasopharynx is innervated by the maxillary branch of the trigeminal nerve. oro = CN9 Larynx = SLN (Epiglottis to VC) & RLN (VC and below + motor).

Innervation of the nasopharynx, oropharynx, and larynx?

Insulin, conversely, decreases hepatic intracellular cAMP and prevents gluconeogenesis. Insulin: promotes glucose oxidation; inhibits lipolysis in adipose and skeletal muscle; and increases the rate of protein synthesis in muscle, adipose tissue, and the liver.

Insulin

Insulin = anabolic hormone (building). Def. in insulin = catabolic (break down) of proteins, fatty acids to ketones to, glycogen break-down, and gluceoneogensis from the liver.

Insulin Defiency leads to what?

Decreased-leading to hyperglycemia.

Insulin does what during stress?

intermittent positive pressure breathing is a form of non-invasive pressure support ventilation where the airway pressure is rapidly increased following initiation of a breath

Intermittent positive pressure breathing is what?

SCM =dentify the location for the ISB, is superficial and medial to the roots. Middle = lateral Anterior = middle to the plexus

Intersalene and relation to the -scm -anterior scalene -middle

Ventral rami of C5-7 + supraclavicular branches of the cervical plexus (C1-C3). to anesthestize the shoulder and upper arm.

Interscalene blocks which nerves?

>20

Intraocular pressure over what = increased?

MEPs > SSEPs-high false positive, and false negative responses. SSEPs are also slower to change with spina cord ischemia. A decrease in MEP ratio (tibial / aductor pollis nerve) >50%, latency > 10% = LIKELY spinal cord ischemia.

Intraop monitoring in aortic surgery is importan for some aortic repair surgeries, what type of monitoring is most beneifical?

No. unless severe hypoxia. Peformed through a posterior thoractomy.

Is Bypass required for lung transplant? How is it performed?

The oxygenation use of the brain. Decreased = more oxygen use of the brain. Increased = less oxygen use of the brain.

Jegular Venous oxygen is indicative of?

-Build up of PaCO2-esp. when apnea-leading to resp. acidosis and PVC/PACs -Barotrauma-->PTX

Jet Ventilation Complications:

fast oscillations in the high beta to low gamma range (25 to 32 Hz). General: blocking excitatory neurons, causing an increased power in the slow wave range of 0-4 Hz with correlates with unconcnsciness.

Ketamine EEG reactions in sedation vs. general anesthesia?

Corneal injury. Limited penetration. You need clear glasses.

Kind of injury does a CO2 laser present what? kind of glasses do we need?

Hemorrhagic stroke. Majority of which occur in the Post-Partum period. Can be seen up to 4-6 weeks after. Recommendation is to treat BP > 160 and decrease by 15-20% in order not to distrupt uterine-placental flow. Leading Maternal death in the US in non-pre-E patients = cardiac. Leading death world wide = PPH

Leading cause of maternal mortality with pre-E is? What about regular pregnancies?

Bleeding. TIC = dyfunctional platelets, endothelial injury, and Protein C activation (leads to fibrinolysis leading to further anticoagulation.

Leading cause of preventible death after injury? What is Trauma-Induced Coagulopathy?

Ventral rami of L1-4 roots. Sacral L4-S4. -gives rise to sciatic, super/inferior gluteal, prudendal nerve, posterior cutaneous nerve.

Limbo-sacral plexus rami

Beta-blockers and ICD

Long QT syndrome treatment?

M3 muscarinic receptor agonist that pupillary constriction

MOA of pilocarpine?

In semi-closed systems, CO2 canisters aren't present and FGF is used to eliminate CO2. Mapleson D, E, and F req. FGF x 2 to MV to eliminate the CO2 properly. They are more efficent for controlled ventilation > spontanous breathing (Mapleson A best for this).

MV must be 2 x FGF in which semi-closed circuit?

Hypovolemia

MVP is worsened with what volume state?

Decrease by 30-40%

Mac does what in pregnancy?

TACO = Hypertensive | TRALI =Hypotensive

Main BP differences between taco and trali?

-Increased M&M if <2-2.5 pH which is most important. -Volume of gastric acid. -Suction, trend, ETT, suction ETT. -Dont instill saline or bicarb in the ETT -Bronchoscopy. -Likely to go into the RLL.

Mgt of LMA aspiration: Things to consider? Which lobe is likely to go into?

Right Coronary cusp

Most anterior cusp of the AV valve?

lateral cricoarytenoids, thyroarytenoid, and cricothyroid muscles

Muscles in the Laryngospasm

Green filter should be used with protective eyewear with the Nd:YAG laser because this filter will block the wavelength emitted by the laser. CO2 = clear glasses Argon = orange Orange-Red

Nd:YAG laser should have what color eye protective glasses? CO2 laser Argon laser potassium-titanyl-phosphate-Nd:YAG laser

decreased drug metabolism, increased wound infections, potentiation of neuromuscular blockade, and nearly a threefold increase in morbid myocardial outcomes-2/2 increased SNS and shivering = oxygen consumption.

Negative side effects to hypothermia?

Comorbid conditions.

No evidence that age increases preop risk in a sense of wha?

ERV, FRC, and TLC decreased. Increased minute ventilation. Pulmonary HTN 2/2 to chronic hypoxemia and hypercarbia.

Obese patients have

It is a buildup of CO2 during sleep without an increase in respiration. P02 goes down particularly during REM sleep. Different from OSA since they don't have obstruction.

Obesity Hypoventilation syndrome

25-29.9 = overweight 30-34.9 = class I obesity 35-39.9 = class II obesity40-49.9 = class III obesity (morbid obesity) ≥ 50 = super morbid obese

Obesity classes?

Obesity causes a decrease in functional residual capacity, but closing capacity remains the same in a non-elderly patient.

Obesity does what to closing capacity?

obstructive lung disease: Decrease in VC, IRV, ERV. Increase in RV, FRC, RV/TLC. Needs an increase in I:E (of 1:4), can auto-peep and need more time if 1:2 = hypotension 2/2 to decrease in intravascular volume returning.

Obstructive lung disease = higher lung volumes Restrictive lung disease = lower lung volumes. RV = 2 L mark TLC = 8-7 L mark on X-axis.

Usualyl spreads to C1-3-cutaneous innervation to the upper shoulder and lower neck,

On top of C5-C7 what other nerves are blocked by the interscalene block making it ideal for shoulder surgery?

When distance from anterior part of the Atlantis to the dontoid is greater than 3 mm = anterior sublexation = cord injury esp with flexion > extension. Seen with RA.

On xray, how do you determine Atlantoaxial sublexation?

Hypercarbia

One of the earliest signs of Malignant Hypthermia?

Dynamic parameters-SVV or PPV -can be assessed via passive leg raise. Heart-lung interactions: -TV at least 8 cc/kg.

One way to asses volume Fluid Response:

Catabolism-breaking down of things. -proteilysis -lipolysis—>liver—>ketones

Overall response to the stress response is?

PAP-PAOP/CO x 80

PVR

If the patient is in Trendelenburg position after injection, the anesthetic will spread in the caudal direction and if the patient is in reverse Trendelenburg position, the anesthetic will spread cephalad after injection.

Patient position plays an important role in hypo and hyperbaric > isobaric spinal soluations. Which way will the patient need to be positioned to ensure a caudal spread of a hypobaric solution?

-LBW decreases, increase in fat. -Decrease in total water = changes in volume of distribution. Increased Vd with in fat soluble drugs. Decrease in Vd with water soluble drugs. -changes above seen in women > men. -sensitive to agents 2/2 a pharmacodynamics effects. -decrease in serum proteins = more free drug can be available.

Pharmacological changes with aging?

Phase 4 =

Phases of the sinusoidal action control?

Intrathoracic pressure increases, decreasing the amount of blood going to the right side of the heart. BP drops. Carotid baroreflex picks up on this and HR will initially increase. When released, there is a decreased in intrathoracic pressure, causing blood to rush to the right side of the heart.

Physiology of the Valsalva Manuver?

Increased abominal pressure, can result in abdominal compartment syndrome, decreased lung compliance, hypotension from pushing on IVC.

Pitfalls of Gastroschisis repair?

placenta accreta and peripartum hemorrhage.

Placenta previa and multiple c-sections puts a pregnant female at what other risks during birth?

platelets may be < 150,000/mm3, and, in the absence of other causes, this is termed gestational thrombocytopenia.

Platelets under which amount without other causes is considered gestation thrombocytopenia?

Pull apart the vocal cords (abduct).

Posterior cricoartenoid muscles roles?

Coma Absent brain-originating motor response Absent brain stem reflexes Positive apnea test If these can't be tested then anxillary confirmatory tests must be done=Cerebral angiography with no blood flow past the Carotid bifurcation or Circle of Willis, patency of the extenral cartoid circulation, and delayed filling of the superior longitudial sinus. = gold standard. Not impacted by CNS depressants or hypothermia.

Pre-reqs to clinical examination of brain death includes: -clinical evidence of brain death -No confounding medical conditions -Temp > 36 -SBP > 100 mmHg -No poisoinings of alochol intoxication The clinical criteria include? What happens if they can't be tested?

Males: PBW = 50 kg + 2.3 kg for each inch over 5 feet Females: PBW = 45.5 kg + 2.3 kg for each inch over 5 feet

Predicted body weight = ideal body weight. How is it calculated?

Considered a sodium channelopathy that is conducted by Autosomal Dominate inheritence due to variable mutations to SCNA5. Associated with sudden cardiac cath, but A-fib as well. Req. ICDs

Prevention of arrythemias with Brugada syndrome?

Be mindful of giving IC sodium Channel Blockers like flecanide, long acting sodium channel blocking LA like bupivicaine. Keep temp normal and prevent hyperkalmia

Preventive factors for patients with Brugda Syndrome?

-Prop = -Ketamine = blocks pain and neuroexcitatory pathways @ end of procedure. -Alpha-2 adrenergic receptor agonists = clonidine or precedex by decreasing NE pathway. -Fentanyl = 10 minutes before end of surgery-1 mcg/kg

Preventive perioperative analgesia measures against ED in kids?

Central apnea more common.

Primary form of apnea in premies?

Factors associated with increased survival include: Extra-abdominal location Low International Neuroblastoma Risk Group (INRG) classification score Under 18 months of age on presentation Primary tumor No metastasis Small tumor Favorable tumor biology Good surgical resectability

Primary increased survival for neuroblastomas?

Surgical blood loss should be replaced 1:1 mL of colloid (either 5% albumin or blood) or 1:1.5 mL of isotonic crystalloid.

Ratio of Blood to crystaolid or collioids replacement in neonates?

Right atria, right ventricle, left ventricle. Helps synch the heart to allow it to beat with in rhythm for patients with a low EF to increase the HR and a BBB.

Reason for biventricular pacing?

FRC decreased 2/2 to a decrease in Exp. Reserve Volume

Reason for decrease in FRC in large patients?

V/Q mismatch due to the constricted vessels opening up secondly to oxygen supplementation.

Reason for hypercarbia in COPD patients on oxygen?

Increased risk of post-op delirium 2/2 to a possible anti-cholinergic effect.

Reason why meperidine should be avoided in the elderly and what is the effect?

Increase in Butyrulcholinestrases and EC fluid volume.

Reason why obese patients need larger doses of sux?

: Corticosteroid deficiency in the intensive care unit is most likely secondary to a functional underperformance with cellular dysfunction, peripheral glucocorticoid resistance, and impaired transpor

Reason why stress dose homones are reduced in the ICU?

Beta blockers decrease the catecholamine load on the heart and a decrease in cardiac remodeling.

Reasoning for Beta Blockers in CHF?

central causes of sleep apnea, peripheral causes of sleep apnea in these patients include macroglossia, high-arched palate, choanal stenosis, and prominent mandibe.

Reasons for OSA in ahondria plagia patients?

>50% trachea compression or the tracheabronchial diameter is reduced by 50%. -regional anesthesia -maintain spontaneous ventilation with negative pressure breathing. -if general anesthesia is induced can use a rigid bronchoscope to pass it past the obstruction for ventilation. -Cardiac bypass.

Regarding a mediastinum mass, what tracheo-bronchial compression ratio is considered unsafe with general anesthesia. What should you do?

Metoclopramide has inhibitory effects upon plasma cholinesterase, therefore it may prolong the duration of mivacurium and succinylcholine

Reglan effects on sux?

-The less potent the inhaled anesthetic is, the greater this effect For example, Desflurane = least potent = most NMB. > sevo > iso.

Relationship between NMBD and potency of inhaled anesthestics?

1

Resp Q for carbs?

Compliance and DLCO decreased. FRC, RV, TLC decreased. Both FEV1 & VC decreased.

Restricted lung disease lung volumes?

Retrobulbar: -Great analegesia, quicker onset. -No eyelid akenesis, but akensis of the eye muscles. -Increased risk of hematoma. -more complications = longer needle = higher risk of SA injection, globe rupture Peribulbar: -Shorter needle with minimal angle less likely to rupture the globe or have SA injection, has reliable eyelid akenesis. -Slower onset (>5 minutes), increased risk of chemical chemosis due to LA accumulation under the conunctiva. -Inserted through the eyelid parallel to the globe.

Retrobulbar block pearls:

Diaphragm (1st 2/2 to blood flow and resistence) Laryngeal muscles Corrugator supercilii (Correlates with larynx) Abdominal muscles Orbicularis oculi (Correlates with Adductor Pollicis) Geniohyoid Adductor pollicis

Return in muscle blockade?

Brain death.

Reverberating blood flow on TCDs is a sign of?

↑ pCO2 ↑ Temperature ↑ [H+] ↑ 2,3-biphosphoglycerate ↓ pH Left-shift at the lung level, but right shift at the tissue level.

Right shifts in the hemoglobin curve?

-Dz for > 6 y. -Underlying lung dieases such as COPD -Prydostigmine dose > 750 mg/day. -VC < 2.9.

Risk factors for MG post-op pulmonary complications such as re-intubation following thymectomy?

SaO2 - VO2/1.34 X HB X CO

SVO2 formula?

Adenosine dosing should be cut in half (e.g. 3 mg IV push) if given through a central line, including a peripherally inserted central catheter (PICC).

Should adenosine dosing be adjusted if it is given central vs. peripheral?

Main stem from intubation. A-a gradient increases. Non-ventilation to the lung will cause hypoxia vasoconstriction. Zone 1 of the lung.

Shunt = perfusion without ventilation. Example? Dead space = ventilation without perfusion. Example??

1-SaO2 / 1 - SvO2

Shunt fraction Formula?

Perfusion without Ventilation. V/Q <1 = increase in PA-pa difference -Endobronchial intubation -Normal shunt (3%) 2/2 to bronchial, pleural, and thebesian veins. FIO2 will increase to Alveoli that aren't being ventilated = no oxygen to the blood = no improvement.

Shunts are? Examples of shunts? FIO2 does what?

hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, metabolic alkalosis, acute kidney injury, sulfonamide hypersensitivity, and ototoxicity

Side effects of Loop Diruetics?

hypotension (MOST COMMON), interscapular back pain, retroperitoneal hematoma, reactive pleurisy, hiccups, hematuria, transient diarrhea, abdominal aortic dissection, transient motor paralysis, and paraplegia (due to subarachnoid injection). To decrease this from happening-test dose of local anesthetic with contrast dye confirms placement, prior to injecting phenol

Side effects of the Celiac Plexus block, what do you do to ensure proper placement.

Most likely to happen during intubation or extubation, but can happen at any time. Able to be ventilated = deepen anesthetic =>albuterol. Unable to be ventilated = epi IV 1) Increase the anesthetic depth. This can be achieved by increasing delivery of volatile anesthetic or with IV agents (e.g. ketamine, propofol). 2) Increase FiO2 to 100% and consider manual ventilation. 3) Administer inhaled B2-agonist. 4) Consider IV steroids, IV magnesium. 5) IV epinephrine may be required to break bronchospasm. Titrate to effect (e.g. 10-50 mcg IV). 6) Closely monitor hemodynamics.

Steps to take for bronchospasm intraop?

Notify surgeon to stop --> D/C agent -->100% O2 at 10 L /min -->charcol filter can be used for 1 hour prior to being changed -->2.5 mg/kg of danterolene with repeat doses until ETCO2 drops and vitals normalize, can repeat up to 10 mg/kg if contractures continue-->ABG, if BE is <-8, should be given sodium bicarb -->fix hyperK with insulin, calcium chloride, -->cool patient.

Steps to take when a Malignant Hyperthermia is suspected?

high as 5% with the supraclavicular block when it is performed without ultrasound

Supraclav block PTX precentage when done without an u/s?

1.) Glycogenlysis & depletion of hepatic glycogen stores 2.) Lipolysis 3.) Protinolysis = muscle wasting and elevated glucose.

Surgical stress leads to which three main catabolic processes?

1.) Abx within 1 hour. Continue for 7-10 days. 2.) 30 mg/cc for hypovolemic patients within first 3 hours. If require a lot of fluids, can add albumin. 3.)Transfuse if Hg < 7.0 4.) Keep MAP target at 65 by using vasopressors: Levo > Vaso > Epi

Surviving Sepsis guidelines?

The increase in intragastric pressure can be offset by a priming dose of a nondepolarizing neuromuscular blocker.

Sux LES tone increase can be decreased by what?

Critical temperature, for example 36.5 for N2O. N2O exists in gas until placed in E-cylinder-->pressure-->Liquid. If temp >36.5 = turns into gas. Critical temp for O2 = -119, so even when placed in an E cylinder-->it is still gas.

Temperature above which a gas can no longer be converted to liquid form with increasing pressure alone.

he homeothermic set point for women can vary up to 0.5 ºC depending on the phase of the menstrual cycle, with the coolest period being the follicular phase, and the warmest being the luteal phase.

Temperature regulation between men and women based on period of the month?

core temperature are the skin, axilla, rectal, oropharynx, and bladder.

Temps which dont represent core temps?

Liver via phase 2 extensive metabolism in the liver via phase 2 glucuronidation, primarily resulting in the formation of the metabolite H3G. No analageic propergies, just CNS excitiory properties.

The breakdown of Dilaudid?

The first two reflexes to be lost during general anesthesia are the oculocephalic and corneal reflexes.

The first two reflexes to be lost during general anesthesia?

>20 weeks gestation 2/2 to abnormal placenta with vascular issues due to an imbalance between TXA2 & PGI2 = Uterine & Renal blood flow decreases = SVR increase, Intravascular volume decrease.

The postulated pathophysiology behind Pre-E?

α1, β1, and β2 adrenergic receptors. -α1: Positive inotropy -B1: chronotropy, dromotropy (conductivity of a nerve), lusitropy (myocardial relaxation), and inotropy -B2: Positive chronotropy > inotropy

The target sites for sympathetic cardiac innervation include

CHF Mannitol is osmotic not oncotic, leading to Temporary hyponatremia due to dilution.

The use of mannitol can potentially lead to what? What is the mechanism of action?

MAP 60-120 CVP 4-12 Na+ <155 or 135-160 Pressor goals < 1 or low pressor. PaO2/FIO2 > 300. pH = 7.25-7.5 Glucose: < 150 UOP = 0.5-3 mL/kg/H EF >50 Hg > 10

There are 10 Ideal donor management goals. What are they?

CO VO2-tissue oxygen has. CaO2-oxygen content.

Things that Affect the MVo2?

Osmotic solutes which are unmeasured in plasma. Only three solutes are measured per the formula: Na + Glucose/18 + BUN/2.8. NA+ being the largest contribubitor becasue it is restrcited to the EC space. Solutes such as ethonal, methonl, ethylene glyco, mannitol, sorbitol, ketones are unmeasured in this formula and will lead to an Osmolality gap when substrction measured - unmeasured solutes. Gap should be < 10.

What accounts to the Osmolality gap?

If aseptic technique cannot be ensured, the catheter should be replaced as soon as possible and no longer than 48 hours postinsertion. Also, > 0.5% chlorhexidine preparations with alcohol are superior to both aqueous and alcohol-based povidone-iodine Dialysis catheters are an exception for which antibiotic ointments or creams are sometimes used

To decrease infection rates, if the central line can't be inserted in a sterile fashion, when is the maximum amount of time it should be left in?

Causation=asks whether the act of care or omission of care caused the poor outcome Duty to the patient = provider's responsibility to the patient to provide care Negligence or breach of duty = standard of care in the community was not met. Damages

To establish a medical malpractice lawsuit, 4 elements must be proven:

Increase stroke volume and EDV

To maintain CO, what does the elderly patient do?

Risk factors for failed neuraxial anesthesia during cesarean delivery include increasing maternal size, late labor epidural placement, and a rapid decision-to-incision interval.

Three common risk factors for failed neuaxial anesthesia to c-section?

Tip (cutting), bevel orientation ( parrell vs. sideways), size

Three factors that effect headache complications?

TA = 1-4 ml of solution per 1 mL of fat removed: -NS -Epi: 1: 100k -Lido: 35-mg/kg

Tumelscent Anesthesia consists of?

Beta-blockers and statins should be continued in the perioperative period

Two drugs that have a class I evidiences of continuing in the periop oeriod?

Premature birth is the single most important factor for apnea although infants born at term who are less than four weeks old are also at higher risk

Two groups of infants at high risk of post-op apnea?

Class 1 (most reassuring finding) indicates the patient is able to extend their lower incisors beyond the vermillion border of the upper lip Class 2 indicates the lower incisors are able to bite the upper lip but can't extend beyond the vermillion border. Class 3 (most concerning finding) indicates the lower incisors can't bite the upper lip at all.

Upper Lip Bite Test = highest liklihood predictor of difficult intubation-especially if a grade 3. What are the different grades of the ULBT?

Used for: -Lower extremity circulatory conditions, in which these blocks transiently improve regional blood phantom pain after amputation, varicella zoster or postherpetic neuralgia, first stage of labor, CPRS -Hepatorenal syndrome.

Use for Lumbar plexsus blocks?

Tidal volume & RR set. Volume limited, time cycled. Risk of baro trauma.

Volume Control Ventilation pearls:

procainamide, ibutilide, or electrical cardioversion

WPW treatment?

A-atrial contraction. C-tricuspid valve V-atrial filing/end of systole. Normal = 0-10.

Waveforms of CVP.

a-wave: atrial contraction c-wave: tricuspid valve (TV) bulging into the right atrium (RA) during isovolumetric contraction of the right ventricle (RV) x-descent: atrial relaxation occurs with RV ejection v-wave: systolic filling of the RA against the closed TV y-descent: atrial emptying into RV through the open TV

Waves of the CVP?

renal and GI

Ways bicarb can be lost?

Prophylaxis with nonsteroidal anti-inflammatory drugs can help to reduce myalgias.

Ways to decreases myalgias with sux?

t. Volatile agents, procainamide, and quinine have been used for relaxation, and patients are often taking medications to prevent myotonias.

Ways to relax muscles in patients with myotonias?

T12 for hip, knee, and ankle sx.

What are most orthopedic procedure levels with spinal anesthesia?

Also known as the Fink Effect, diffusion hypoxia = During emergence 5-10 minutes after d/cN2O===> N2O rushes from the tissue & blood back into the alveoli resulting in a wash out of O2 and CO2 in the alveoli. ==> Hypoxemia & decreased CO2 = a decreased drive to breath. -prevented by emegenence using a 100% oxygen. How is this different from second gas effect? =N2O + other volatile agent together == N2O has rapid diffusion into the blood == increase in space for the other gas to increase concentration.

What is the MOA of diffusion hypoxia with N2O? How is this different from Second Gas Effect?

fetal hydantoin syndrome

What is the MOA of phenytonin and what kind of birth defects?

Fio2(ATM-h2o) - PaCo2/R Carbs = 1 Lipids = 0.7 Proteins = 0.8

What is the PAO2 formula?

SaO2-VO2/(1.34*Hb*CO) -SVO2 affected by: 1.) Sao2 = Hemoglobin content, Arterial oxygen content, and dissolved oxygen. 2.) VO2 = oxygen consumption 3.) CO = Oxygen delivery. SVO2 is an indirect measure of cardiac output.

What is the SVO2 formula?

ABO incompatibility >> Rh-D incompatbaility 2/2 to: -Rhogam administration to Rh-D antigen negative moms, with + Antibody at 28-30 weeks or after their previous delivery. -Blood type/screen at 1st prenatal and third trimester visit.

What is the most common cause of Hydrop Fetalis today?

Dyspesia = #1 risk of 10-20%. There is an increased risk of atrial fibrillation, development of congestive heart failure, renal toxicity, and gastrointestinal bleeding.

What is the most common risk of NSAID use in the elderly? How about other risks?

Fixed expenses account for 56-84% of operating room (OR) costs. To decrease these costs = best to match staffing to operating room scheduling and to decrease the number of per diem anesthesiologists.

What is the most cost to ORs? How can costs be decreased?

Clamp the pulmonary artery

What is the most effective way to reduce shunting during one-lung ventilation?

Intermittent or continuous intraoperative nerve monitoring using electromyography (EMG). What other alternatives include? -MEPs (transcranial nerve monitoring)

What is the most reliable way to measure recurrent laryngeal nerve (RNL) function during thyroid surgery?

Bohr effect causes an acid mother blood, Alkalosis in the baby side Due to favoring CO2 being transferred from the baby side to the mother side this results in a right shift in the maternal hemoglobin

What will the Bohr affect due to the pH of the mom's blood and the babies blood?

pH of 7.27, pCO2 of 50 mmHg, pO2 of 18 mmHg, and base excess of -2.7 mEq/L.

What will the blood-gas of an umbilical artery s/p delivery?

-R = Time for clot formation = Decreased -K = time to fibrinogen formation = Decreased -Alpha Angle = Speed of Fibrinogen --> Fibrin mesh. = decreased. =MA = platelets = decreased

What would a TEG of a pregnant chick look like?

Barotrauma-pressurized oxygen.

What would a hole in the bellows result in?

Systole = QRS complex to end of the T wave. -Volume filling = pressure increases. -MV closure-->Isovolemic contraction-->Aortic valve opens-->Ejection-->Aortic valve closure-->isovolemic relaxation Diasystole = T wave to begining of the QRS complex. -Volume ejected = pressure decreases. -Isovolemic relaxation -->Aortic valve opens-->diastole begins.

Where is systole on the EKG pressure volume?

lateral border of the sternocleidomastoid (SCM) at the level of the cricoid cartilage(C6). B/W anterior/middle scalene muscles = posterior-lateral to SCM.

Where is the Interscalene groove identified?

Anterior two-thirds of the spinal cord starting at T9-12, usually on left-side of the aorta. -Corticospinal tract = Loss of motor function. -Spinalthalamic = loss of pain and temperature 1 level below. -Decesending autonamic fibers = sexual dysfunction and urinary/fecal incotience. -Proprioception, fine touch, and vibrations remain intact 2/2 dorsal column.

Where is the artery of Adamkiewicz? Damage to it will result in what? What does remain in intact?

anterior leg

Where is the most common place for compartment syndrome to occur?

On the expiration side between peak and points zero on the rigthside of the flat line.

Where on the flow volume loop is effort independent flow and what does it mean?

A key anesthetic concern is careful placement of the endotracheal tube tip between the TEF and the carina.

Where should the ETT be placed for TEFs?

Downs Syndrome.

Which Syndrome predisposes to subglottic stenosis in kids?

penicillins and cephalosporins do not share this characteristic and do not potentiate neuromuscular blockade.

Which antibotics will not potentiate NMBD?

PDA

Which artery does the left vs. right heart dominate refer to?

Ester LAs tend to produce more allergic reactions

Which group of LA's produce more of an allergic reaction?

N2O. Also considered safe = barbituates, LA, opiods, NDMB, and benzos.

Which inhaled agent is considered safe in MH?

At a temperature of 20°C and 1 atm, all inhalational anesthetics exist in the liquid form except for nitrous oxide, which has a boiling point of −88°C

Which is the only inhalation agent that doesn't exist as liquid at 20 degree celcius?

Children under 6 years of age, in particular those under 6 months of age, are at much higher risk of adverse events during peds sedation. Despite these events being rare, the M&M of them are high. - developmental delay have a threefold risk of oxygen desaturation. -Bronchoscopy and endoscopy -MRI/CT

Which kids are at particular risk of adverse events during pediatric sedation?

Excessive proteins can also cause an increase in respiratory drive

Which kind of enteral feeds can cause an increase in respiratory drive?

Surgical drapes decrease convection heat loss.

Which kind of heat loss does surgical drapes decreases?

-No valves or canisters -"ASk for a CD." Mapleson A = most efficient with Spontaneous ventilation. In Controlled ventilation, Mapleson D is most efficient for both.

Which mapleson is best for controlled ventilation?

Vecuronium has three active metabolites, 3-desacetyl-, 17-desacetyl-, and 3,17-desacetyl vecuronium. Among these, the 3-desacetyl metabolite is the most important since it has nearly 80% of the activity of vecuronium

Which metabolite of Vec is most important and which patient population?

II, V, protein C

Which products are unchanged in pregnancy?

the FEV1. define the diagnosis

Which resp. parameter provides the most useful metric of disease progression, severity, and response to therapy?

Portal vein.

Which vessels supplying the liver isn't autoregulated?

Laudanosine decreases the seizure threshold, and thus it can induce seizures if present at sufficient threshold concentrations. a recognized metabolite of atracurium and cisatracurium

a recognized metabolite of which paralytics can cause seizures?

central line is infection, with an incidence of about 15%.

most common complication arising from a central line

CN 9 =stimulation sensory afferent CN 10 = motor efferent to the posterior pharngeal muscles.

sensory afferent limb of the gag reflex and motor efferent branch?

stagnation and heating (increased risk of thrombi), cavitation (air bubbles), and hemolysis. However, they used smaller priming volume, now gravity drainage, and ability to prolong operation. VA: blood flow rate of 100 mL/kg/min is required for pediatric patients and 60 mL/kg/min for adult patient. VV: pediatric patients need a blood flow rate of 120 mL/kg/min as compared to 60 to 80 mL/kg/min for adults

centrifugal pumps for VA/VV ecmo disadvantages. What should be they be flowed at for peds and adult patients?

Change in pH = log10([H+]2 / [H+]1)

change in pH can be calculated using the formula:

2/2 to blockade of small inhibitory neurons in the CNS -->Leading to CNS depression -->myocardial excitibility with higher levels (V-tach)

circumoral numbness, metallic taste, lightheadedness, tremors, muscle twitching, shivering, and clonic-tonic convulsions are toxic dose of LA symptoms initally seen, why?

professional liability insurance policy that covers malpractice claims reported during the year the policy is active. -If claim made in 2022, the same year as the active policy -If claim is made in 2023, the policy will not cover it-unless there is extension of the policy-tail coverage.

claims made policy? What is "tail coverage"?

preoperative anemia, cardiac disease (such as aortic stenosis, recent myocardial infarction, or uncontrolled hypertension), recent cerebral vascular accident, clinically significant renal or liver disease, and/or active infection.

contraindications to ANH?

critical pressure is the pressure required to liquefy the vapor at the critical temperature.

critical pressure is?

(mild, 32°C-35°C; moderate, 28°C-32°C; severe, <28°C).

define mild, moderate, and severe hypothermia?

Pt. antibodies directed against precipitated by re-exposure to a non-ABO red cell antigen such as KIDD

delayed hemolytic transfusion reaction MOA?

T6 dermatome corresponds to the xiphoid.

dermatome corresponds to the xiphoid?

Compensation happens for a period of time (100-120 cc) until there is a sharp increase of pressure resulting in hernation. "Volume Compensation Zone" is due to primarily by the translocation intracranial venous blood to extracranial veins and is the reason why most interventions like head-up position is used to decrease ICP. Also, like blood, the body re-distributes CSF from intracranial -->spinal to decrease ICP

describes the mechanism by which the body compensates for increases in intracranial volume in an effort to maintain normal intracranial pressure?

Magnesium toxicity

disorders such as milk-alkali syndrome can lead to which electrolyte derangement?

Platelet disorders like Von Willebrand Disorders.

epistaxis, menorrhagia, or prolonged bleeding after dental extractions is related to what type of bleeding disorder?

The rate of metabolism and/or elimination remains constant and is independent of the plasma concentration of a drug at steady state (Cp decreases linearly over time) rate of metabolism and/or elimination is directly proportional to the plasma concentration of the drug (Cp decreases exponentially over time)

ethanol, phenytoin, aspirin are eliminated by zero order kinetics. What is ZERO order? What about 1st order?

Chi-square test assess the statistical difference between the expected and observed frequencies in one or more categories

evaluating if there is a statistically significant difference between drug X and Y and if the blood pressure was decreased or not. is best tested with?

posterior divisions of the ventral rami of L2-L4

femoral nerve is derived from?

reduce the histamine release associated with atracurium

histamine release associated with which NMBD?

Perioperative transfusion may increase the risk of bacterial infection, cancer recurrence, and mortality.

host disease (GvHD) = irradiation. Washing = removes proteins to decrease alx reactions like IgA Def. and potassium for ESRD patients. Leucoduction = removed WBC to decrease TRALI transfusion reaction

because digoxin occupies the same site as K+ in the Na+-K+ ATPase. Hypokalemia makes it easier for digoxin to bind and increases the risk of toxicity. Also risk factors associated with old age and low body weight.

hypokalemia and volume depletion is most likely contributing to digoxin toxicity in what way?

ASA 3 OSA Endoscopy/bronchoscopy non-hospital anesthesia. Increase in sedation medications-particularlly > 3

increase in adverse events in pediatric sedation cases including

indications for ANH include: The likelihood of blood transfusion is >10% Preoperative hemoglobin is ≥12 g/dL No clinically significant renal, pulmonary, liver, or coronary disease No severe hypertension No infection or risk of bacteremia

indications for ANH include:

indications for cell salvage: Anticipated blood loss of ≥20% of estimated blood volume Crossmatch compatible blood is not available The patient refuses allogeneic blood transfusion but agrees to cell salvage More than one unit of packed red blood cells is expected

indications for cell salvage:

Etomidate, ketamine. Methehexital has no effect on seizure duration.

induction agent that increases the seizure duration of electroconvulsive therapy

ongoing perfusion of alveoli not participating in gas exchange.

intrapulmonary shunting,

Femoral nerve.

largest branch of lumbar plexus

Prolactinomas are the most frequent hyperfunctioning pituitary adenoma, causing-nfertility, galactorrhea, amenorrhea, loss of libido in women, and nonspecific sexual symptoms in men. respond to bromocriptine=dopamine agonist.

most frequent hyperfunctioning pituitary adenoma?

mitral stenosis and is general 2/2 to rheumatic heart diease. hemodynamic compromise and pulmonary edema immediately after delivery is a risk due to autotransfusion regardless oft he type of delivery.

most frequently acquired valvular lesion in pregnant patients?

increase of 25% or more in the T-wave amplitude on electrocardiogram. (Along with mild increased HR & BP which can be masked under GA).

most reliable positive predictor of intravascular injection while caudal anesthesia while under volatile anesthetics.

suprascapular nerve gives sensation to the acromioclavicular joint and glenohumeral joint.

nerve gives sensation to the acromioclavicular joint and glenohumeral joint

Wilcoxon-Mann-Whitney

nonparametric test designed for studies for ordinal numbers (ranking: 1st, 2nd, 3rd, etc.).

ilioinguinal/iliohypogastric (II/IH) nerve block- =U/S on ASIS in a tranverse plane to visualize the EO,IO, TA, deep circumflex vessels,and TA = needle moves in plain from lateral to medial = between the IO and TA

orchidopexy and hydrocele repair in children and hernia repair in children and adults can be painful, what type of block can be done to help?

pH Stat: corrects CO2 while on by decreasing sweep or increasing CO2 to bypass circuit, thus increasing the total CO2. Resulting in cerebral vasodilation and vessel, countering the Left shift of the oxyhemoglobin curve. Vasodilation and right-shift of the Oxy-Hg curve = improved oxygenation. Alpha-Stat: Doesn't correct the total CO2, blood based on temp. This allows for maintained cerebral autoregulation. Keeps the ox-hg curve left-ward shifted and doesn't allow for as improved oxygenation.

pH stat vs. Alpha Stat

Analysis of variance (ANOVA) example: height

parametric test that can evaluate statistical significance when comparing the means for ≥ 3 independent groups

the washout of the accumulated tissue plasminogen activator (tPA) resulting in significant fibrinolysis.. Sodium bicarbonate is often given to neutralize the acid and calcium chloride may be given tostabilize the myocardial membranes due to the elevated potassium levels. Also seen is hypothermia due to a minimally warmed graft being reperfused, hypotension as well.

patients can be especially coagulopathic after reperfusion of liver due to?

sacrococcygeal

pertaining to the sacrum and tailbone?

Norepinephrine, glucocorticoids, and thyroxine. MOA is 2/2 to uncoupling oxidative phos at the mitochondrial level resulting in heat generation >ATP and can double the metabolic rate. Brown fat is more vascular w/ higher beta-sympathetic innervation so cold stress -->SNS-->NE releas

primary trigger of nonshivering thermogenesis in infants?

DM I Lupus RA PP status Malignancy PNC Phenytonin Interferon. primarily Autoimmune antibody response that is most likely after factor 8 = aquired factor 8.

prolonged activated partial thromboplastin time (aPTT) that does not correct after a mixing study can be 2/2 to an antibody inhibitor to a coagulation factor. Which types of illnesses can happen in?

Lateral recess stenosis. For example, lateral recess stenosis of L3-4 will cause radicular pain of the L2 nerve.

radicular pain in the nerve above the spinal level is?

L1-l5 ganglia fused together. to control the sympathetic impulses to the LE. Noted to be behind the IVC on the left side and lateral-posterior of the aorta on the left side. Needle Cephlad to L3-midline. Can lead to ED

serial lumbar plexus sympathetic blocks anatomy and complications?

male sex, extremes of body habitus, prolonged hospitalization, and malnutrition.

several risk factors exist that increase the potential for nerve injury during surgery. What are they?

>1 L which could drop >10 meq/L of sodium that can show significant neurologic symptoms. -<5 meq/L difference in sodium, normal kidneys=observation. -120-130 meq = fluid restriction & lasix. -<120 = 3% saline until 120. Pontine demylination is rare 2/2 to acutity.

severity of the acute hyponatremia in TURP syndrome is related to the amount of irrigation solution retained by the patient. How much irrgation solution would be absorbed to substanially increase risk? What should be done?

Lumbar goes cephlad, Thoracic goes caudal.

spread of medication in lumbar vs. thoracic epidural?

Labetalol is also a partial β2 partial agonist contributing to arteriolar vasodilation

Effects on B2 of labetalol?

Remove ETT Stop flow of gasses Flood the field with saline. Establish ventilation Bronchoscopy.

Steps to do in an airway fire?

PA Pressure No Change | PA Blood Flow Increased (40%) | PA Vascular =Resistance Decreased

What happens to PA pressures in pregnancy?

Increase both pre-load (EDV) and stroke volume. Will not increase Stroke volume if on the flat part of the curve.

Phenylephrine does what to the Frank-Starling Curve?

Lungs via free radicals & inflammatory release markers.

Phosphgene causes damage to which organ?

Thrombocytopenia: Timing: 5-11 days after heparin. Thrombosis Exludes other causes

4T scoring to HITT?

60 mmHg = a p50 of 27 mmHg

90 mmHg SaO2 = Pao2 of?

authentication, encryption, time-stamping, and informed consent.

: Key features of HIPAA-compliant e-mail communication between providers and patients include

Neonates generate a large proportion of their heat from the work of respiration. Which can be an increased in the OR with mechanical ventilation controlling their breathing.

A large propotion of neonatal heat comes from?

The peak effect of transdermal fentanyl can take 12 to 24 hours to be fully realized due to the relative impermeability of the skin barrier to drug absorption.

How long does transdermal fentanyl take to peak?

pH/pCO2/PaO2/HCO3-/BE/SaO2/Pulse ox: Meth-Hg = 7.27/32/300/15/-10/100%/86% CO = 7.27/32/300/15/-10/100%/100% =pulse ox is falsely elevated.

ABG of Meth-Hg vs. ABG of CO?

1.) HTN @ 20 weeks + protienura [Urine dipstick >1, P/C >0.3, 24H protein >299 mg) 2.) HTN @ 20 weeks + severe symptoms-doesn't have to have proteinuria. -HTN >160/110, <Plt <100, Elevated LFTs, RUQ pain, Headaches, visual changes, Creatinine x 2 normal, PE -Differs from Gestational HTN = No proteins or severe symptoms. ACOG defines as elevated blood pressure with either proteinuria or signs and symptoms of severe symptomatology (such as persistent headache) after 20 weeks gestation

ACOG pre-E how?

supraoptic nucleus and paraventricular nucleus of the hypothalamus produce ADH -->taken via axons through the infradibular stalk to the posterior pituiatary to be stored. Released into the inferior hypophsyeal veins via: 1.) plasma osmo receptors located at the hypothalamus. 2.) Hypovolemia-atrial stretch receptors. 3.) Angieotensin II resident-hypothalamus

ADH synthesis, storage, and release?

Trigger, either medications or stress,esulting in an increase in heme demand/synthesis. PD enzyme is mutated and can't breakdown PDG and ALA, resulting in a build up with can cause the attack. Pts. should get glucose & fluids in pre-op to help decrease attacks.

AIP MOA?

Anticonvulsants: Phenytoin,Carbamazepine,Valproic acid Antimicrobials: Sulfonamides, Erythromycin, Fluconazole, Rifampin, Nitrofurantoin Miscellaneous: Calcium channel, blockers Amiodarone, Estrogens, Fasting Metabolic, stress (surgery, infection)

AIP exaggeration.

Blood pulled off the patient, replaced with crystalloids. Blood given back to the patient in a reverse order since the first unit contains more concentrated blood and plasma. Body compesates by increasing CO via increased HR 2/2 to anemia & SV 2/2 to a decreased afterload and SVR, increased preload 2/2 to blood returning to the heart. decreased blood viscosity, and increased regional blood flow.

ANH is done how?

Allows for spontanous respirations-negative pressure increases intrabdominal pressure and drives blood into the IVC, increasing return to the heart. If patient' isnt' breathing spotanously, APRV can lead to hypercarbia. APRV isn't appropriate for non-spontanously breathing patients. P-Low should be above the lower inflection point to avoid actelectesis. P-high should be below the higher inflection point to avoid volurauma.

APRV have demonstrated both improved preload delivery to the right heart and cardiac output compared to conventional ventilator modes. WHY?

-catheter site, proper patient positioning, actual needle insertion, and confirmation of needle and guidewire placement. -Place while in trend position. -no difference in outcome between angiocath or steel needle.

ASA guidelines on centralline placement?

The ASA Guidelines recommend that a back-up power source be available during delivery of an office-based anesthetic.`

ASA guidelines on power sources in outpatient ofifce-based anesthesia?

A : Complete cord injury with complete motor and sensory deficits in S4 and S5 nerve roots. B: Incomplete cord injury with sensation preserved below the level of injury; intact S4 and S5 nerve roots. C: Incomplete cord injury with motor function preserved below the level of injury; < 3 out of 5 motor strength in half of the major muscle groups D: Incomplete cord injury with motor function preserved below the level of injury; ≥3 out of 5 motor strength in half of the major muscle groups. E: No evidence of cord injury with intact motor and sensory innervation

ASIA qualitative impairment score

RCA. 10% by LCX.

AV node is supplied by which artery?

Right coronary artery

AV node it's supplied by which artery?

1.) look at pH -acidemia <7.3 -alk > 7.45 2.) PaCo2 -respiratory = change in 10 mmHg of PCO2 should change pH 0.08.

Abg interep.

Approximately 85% of cases occur with SCI above the T5 level. Autonomic hyperreflexia begins 2-3 weeks following acute injury. It may occur with stimulation below the level of spinal cord injury leading to uninhibited sympathetic stimulation

Above which level does an autonamic hyperreflexia happen and what is the time line/reason?

Short Bowel Syndrome, SBO, Active GI bleed, Pseudo-obstructive with food intolerance, High output EC fistula-unless feeding tube can be passed distal to it. Relative: -Moderate EC fistula, bowel rest like with acute GI flares, intrabdominal sepsis leading to an illeus, Chylothorax unresponsive to medium chain tiglyceride tied.

Absolute indications for TPN?

Absolute: Short bowel syndrome, Small bowel obstruction, active GI bleeding, Pseudoobstruction with complete food intolerance, High output EC fistula. Relative: moderate output EC fistula, need for bowel rest s/p IBS flare ups, intrabdominal sepsis leading to ileus/abdominal distension, chylothorax unresponsive to medium-chain triglycerides.

Absolute vs. Relative indications for TPN?

Similar to propofol at decreasing post-op nausea/vomiting early, but is also significantly more effective at preventing late PONV (24-48 hours post-operatively).

Advantage of Aprepitant?

Cryotherapy is not typically associated with neuroma formation, hyperalgesia, and deafferentation pain. MOA = disintegration of the myelin sheath leading to Wallerian nerve degeneration, without degeneration of endoneurium, perineurium, or epineuriumby pacing the probe next to the nerve and bringing the temp down to -50 degrees celcius.

Advantages of cryotherapy vs. neurolytic techniques like radiofrequency ablation and chemical neurolysis? What is the mOA of cryotherapy?

Advantages: -decreased risk of central spread of local anesthetic as it is not near the optic nerve -decrease chance of optic nerve or retrobulbar injury Disavantages: -longer onset time of 9-12 minutes - lower incidence of complete akinesia.

Advantages offered by peribulbar vs. retrobulbar blocks?

Stimuli at the eye -> ciliary ganglion -> ophthalmic division of trigeminal nerve -> Gasserian ganglion -> trigeminal nucleus -> vagus nerve -> bradycardia.

Afferent and Efferent parhway of the MOA of oculocardiac reflex.

Vasopressin consideration it decreases catecholamine requirements and tx. DI.

After brain death, patients can exhibit severe swings in BP, get DI, DIC, hyperglycemia, ad have hypothermia. What is the first-line drug used to maintain MAP for potential heart donors?

20 weeks

After how many weeks do you want left uterine Displacement?

After 20 weeks gestation. This becomes entirely pressure dependent.

After how many weeks does uterine vessel resistance decrease in parturiants?

Closing Capacity happens during expirations 2/2 to intrathoracic pressure exceeding the pressure of the airways to remain patent, collapsing them. In emphesyma patients, this occurs early in the expiration cycle. Also worse with elderly patients, esp. >65 where it exceeds FRC. Seen more in small, dependent airways as well.

Airway closure (closing capacity) happens mostly where in patients with emphesyma and during what point of the respiratory cycle?

-Aortic pressure with first half = systole and second half = diastole after the diacrotic notch. LV = coronary blood flow inhibited in systole, blood flow increases in diastole. RV = coronary blood flow happens in both cycles, but systole > diastole.

Coronary blood flow:

DBP-LVEDP(pressure inside the heart). Driving force to go from the epicardium to endocardium.

Coronary perfusion pressure

carboxyhemoglobin levels as low as 10% can cause symptoms. Binds to Hg and intracellular pigments like cytochrome a, cytochrome a3, and myoglobin.

At what CO levels can symptoms be seen?

Hx of apnea/bradycardia recommendation to proceed to elective OP sx after six months without apnea or bradycardia. If these criteria are not met, infant should be monitored 12-24 hours or local without sedation can be done.

At what age can a previous premie with a history of bradycardia or apnea have an elective outpatient surgery? h

44 years 66 years

At what age does Closing capacity and FRC cross in a supine position? Uptight?

S4-S5-which create the sacral hiatus

At what level does a caudal epidural take place?

C6

At what level does the interscalene block take place?

Fibrinogen-half-life = 4 days. > albumin (low specfificity 2/2 to other causes for hypoalbuminemia)

BesidesPT/INR,what is the next best way to measure liver function?

tight-fitting mask for >3 to 5 min of tidal volume breathing 100% oxygen at flows of 10 to 12 L/min until end-tidal oxygen reaches >90%. However something that is eqivicol to this is : 8 deep breaths over 60 sec is nearly equivalent to 3 min of tidal volume breathing. -these methods are even better than 4 vital capacity breaths in a 30 second period.

Best way to pre-oxygenate the patient to achieve maximum apnea period prior intubation?

Increase cAMP AND Counter cGMP.

Beta 2 agonists MOA

Glucagon-increases cAMP.

Beta blocker OD TX?

Increased risk of stroke and mortality but decrease the in non fatal MI.

Beta blockers to naïve patience will cause what?

decreased stretching of the ventricular mechanoreceptors leading to reflexive bradycardia to allow for more time for venous return & heart filling.

Bezold-Jarisch reflex

Blocking of T1-T4 cardiac accelator fibers = reduction in HR in response to reduced preload Low LV volume = mechanoreceptors activated ==> CNX activated ==increase vagal tone==>decrease in HR.

Bezold-Jarisch reflex (BJR).

Cryo. Other indications: -Microvascular bleeding with hypofibrinogenemia (DIC), F13 Def, PPX before sx in congenital dysfibrinognemias, PPX before surgery in VWF diease, PPX before surgery with hemophilla A.

Bleeding due to uremia that is unresponsive to DDAVP can be stopped with?

1.) RCA: ------->SA node ------->Acute marginal ------->PDA Supplies: Inferior/Inferospetal/Apex 2.) LM: --Septal -Diagnal 3.) LXc

Blood supply of the heart:

Blood:gas partition coefficient Desflurane 0.42 Nitrous oxide 0.46 Sevoflurane 0.65 Isoflurane 1.46

Blood:gas partition coefficient

Apex of the femoral triangle --> adductor hiatus = length of it. Roof = sartotus Floor = Adductor magnus Lateral = Vastus Medialis

Boundries of the adductor canal?

Pressure and Volume change when temp is held constant. P1V1 = P2V2

Boyles law

-hemitransection -ipsilateral loss of motor function contralateral loss of pain and temperature sensation 1-2 spinal levels below the level of the lesion =Lateral spinothalamic Crosses at the same level of the spine as it innervates.

Brown-Séquard syndrome

Pseudo-RBBB + ST elevation in the Antero-Septal leads V1-V3

Brugada Syndrome on EKG?

S3 The spinal cord ends at L2-3 in newborns and at L1-2 in adults.

Dural sac in infants' location? What about spinal cord?

autosomal dominant disorder of the calcium channel that results in asymmetrical muscle paralysis during hypokalemic states. increased sensitivity to non-depolarizing NMBs requiring less frequent dosing

Explain Hypokalemic periodic paralysis

Local anesthetic is deposited between the rectus abdominis muscle and posterior rectus sheath.

Explain a rectus sheath block?

a breath is cycled when the inspiratory flow drops to a certain percentage of peak inspiratory flow that is set by the user. Flow stops and exhalation begins.

Explain flow cycled ventilation?

Upper extremity = stellate ganglion block Lower = Lumbar plexsus block Meds: Alpha-Adenoergic antagonists, CCB, Memantine is an NMDA antagonist, TCA, anticonvulstants, spinal cord stimulators,

CPRS treatments?

e. Cerebral fluid sample from lumbar puncture will classically reveal an elevated white blood cell (WBC) count, increased protein, and decreased glucose.

CSF analysis of bacterial meningitis?

Cardiac effects can be reduced with pretreatment with anticholinergics

Cardiac effects of sux can be reduced how?

Systolic phase: 1.) A wave = P on EKG = End of Diastole = Atrial kick. -->blood from the atrial to the ventricular-->tricuspid valve closes-->ventricular begins to contract 2.) C wave = end of QRS on EKG = Early Systole = Tricuspid bulging into RA. -->blood goes from RV into the PA-->Tricuspid valve is closed, ventriculat contracted, the RA begins to relax. 3.)X-descent = T-wave=mid-systole=RA relaxation to get ready for next cycle -->blood goes into the RA Diastolic phase: 4.) V-wave = after the T-wave = early diastole = RA filling. -->the tricuspid valve opens--> 5.) Y decent = after the T-wave, before the P wave = triscupid valve opening and passively filling the RV.

CVP wave form

Volatile anesthetics (especially desflurane) and the strong bases in the CO2 absorbents in the setting of decreased absorbent water content and increased with: -Disiccated CO2 (decreased h20) -Increased TEMP (increased risk of fire) -Low FGF

Carbon monoxide production occurs as a result of an exothermic reaction between?

-#1 site = GI tract. -Metastatsis to the liver causes carcinoid syndrome of the heart. -Primarily right-sided, TV >> PV leading to Tricuspid Regurg and is commonly leads to dead via HF in 50% of carincoid tumor patients. -24 HR 5-HIAA > 30 mg = carcinoid syndrome tumor.

Carcinoid Tumor Pearls:

More Decreased SVR 2/2 to pregestrone and prostoglandins > Increased CO [Increased. HR & SV] = decreased MAP

Cardiac changes in pregnancy?

Pao2. If a bilateral carotid EA happens, the response will be greatly diminished and the patient will be hypercarbic.

Carotid body responds to what?

9th cranial nerve (glossopharyngeal), from the aortic arch and carotid bifurcation.

Carotid reflex is innervated by which nerve?

I-normal tracing. II-undetermined III-abnormal tracing. Predictive of poor acid-base status.

Category of tracing

Causes of rightward shifts in the oxyhemoglobin dissociation curve can be remembered by the mnemonic "CADET, Face Right!": Increases of CO2, Acidity, 2,3-DPG, Exercise, and Temperature.

Causes of rightward shifts in the oxyhemoglobin dissociation curve?

2 ganglia that sit at T12-L1-->innervate most of the stomach, spleen, intestines, adrenal glands, and half the colon. They recieve SNS fibers from Greater (T5-9), Lesser(T10-11), and least (T12) Splanic Nerves that and minor PNS input from CNX

Celiac Plexus block anatomy and physiology?

celiac plexus block (T5-12),

Celiac plexus is seen where?

The goal is to maintain the cerebral perfusion pressure (CPP) between 50-70 mm Hg CPP = MAP-ICP

Cerebral Perfusion Pressure should be what?

Cerebral vasospasm is most likely to develop between days 2-10

Cerebral vasospasm is most likely to develop between days

RCA = inferior wall LAD = septal-antero wall LCX = lateral wall.

Coronary artery anatomy and supply.

The drop in blood pressure caused by these agents is directly related to the decrease in SVR while cardiac output is relatively maintained

Compared to Halothane, how does the remainder of the inhalation agents decrease BP?

Epidural fentanyl has a quicker onset (5-15 minutes) and shorter duration of action (2-3 hours) than morphine (onset 30-60 minutes and duration up to 24 hours). fentanyl will partition in the epidural fat, resulting in lower CSF concentrations.

Compared to epidural fentanyl, how long is the onset & duration of morphine? Why?

Large stroke volume Increase in HR Decrease in SVR Decrease aferload to keep forward flow. IABP is contraindicated. Keep HR high to decrease filling.

Compensation for AI?

-0.9 = Cl = 154 = hypercholr = decrease in SID = maintain electrical neurtrality via H20 dissociation to H+ = metabolic acidosis. -LR =metabolized to bicarb = metabolic alkalosis., hyponatremia 2/2 130 na. -D5W =Hyperosmolar = bad for TBI, can preciptate hypok+ periodic paralysis.

Complications of -0.9 -LR -D5W

pneumothorax, pneumediatrium, CO2 bumps up.

Complications of Jet ventilation?

-Pt. RBC + Anti-A antibodies -Pt. RBC + Anti-B antibodies. -Pt. Plasma + Donor RBCs -Pt. Plasma + known RBCs

Components of a type & cross-match?

(Desired Concentration in % x Desired Volume ) / given concentration = answer in volume. https://www.youtube.com/watch?v=F0VEgIL9Y2A

Concentration of Local Anesesthetic dilution?

Hyperglycemia > 300, volume overload, already depleted electrolytes like phosphate, mag, zinc, copper, and potassium, Gi feeding can happen. Continous: higher risk of hepatic steosis. Cyclic: over 10-14 hours of the same volume = higher risk of hyperglycemia, volume overload, and electrolyte issues.

Contraindications to TPN? Difference between continous vs. cyclic?

-sickle cell disease-can cause sickle crisis 2/2 limb ischemia. -PVD. -Ischemia in extremity.

Contraindications to tourniquets in orthopedic surgery?

PaO2 = peripheral Central: Co2 —-> BBB—>H+ increases and is sensed by the medulla = RR increases.

Control of breathing is done how via central and peripheral chemoreceptors?

Diastolic pressure - LVEDP

Coronary Perfusion Pressure formula

DBP - LVEDP (or PCWP) Should be 60 mmHg.

Coronary Perfusion Pressure.

Spinal T10-S4 level.

Coverage for a cervical cerclage?

AS

Cresendo-Derecendo systolic murmur?

Inspiration --> increases in pressure on the RV and RA = decreased preload ==> increase in PA pressures aka an increase in RV afterload = decrease in LA preload ==> LV preload and afterload decrease = decrease in stroke volume and cardiac output.

During Positive pressure ventilation, what are the pressure differences that happen to preload an afterload?

NS = 154 meq/L of sodium + Cl- ==>increase in chloride = SID becomes less = electrical neutrality must be maintained so H20 dissociates =>H+ and O2 =>acidosis.

Explain how SID decreases with NS administration?

They result in a mutual antagonism and the dose of sux must be increased for it to work.

If a nondepolarizing neuromuscular agent is given before succinylcholine, what happens?

Decrease temp = PaCO2 drop on ABG 2/2 to CO2 being dissolved in liquid form = partial pressure of CO2 decreases. PCO2 drops 2 mmHg for every 1 degree drop.

Explain how hypothermia changes PaCO2?

1.). Decrease Alveolar surface area. -Fibrosis, COPD, lung ressection 2.) Increase in alverolar thickness -PHTN 3.) Increase in pressure gradient -removes the PA > Pa and equalizes things so O2 can't move down its oxygen gradient. -Anemia & Polycytothemia.

Factors that increase the DLCO?

1.) Decreasing Lung volume or capillary bed perfusion (make less of the CO across the aveloi to the blood). -considering decreasing area, blood, or blood flow-empheysema, pulmonary resection, low CO, PHTN, anemia(decrease in blood volume). 2.) Increasing lung volume or capillary blood flow: L-to-R shunt increase blood Polycythemia = increased Hg Increased Pulmonary blood volume = CHF/excerise Asthma = increases the surface airway 2/2 to air trapping.

DLCO decreased with: Increased with?

>1000 cc EBL RF = C-SECTION, induction of labor, big baby, prolonged labor, polyhydro, AMA, HTN/DM, tocolytic use.

Define PPH and tis risk factors?

borders of the oropharynx are the soft palate and the epiglottis (or the hyoid bone). Nasopharynx: behind the nasal cavity, boarded by the skull base and below by the soft palate Pharynx = r structure extending from the base of the skull to the cricoid cartilage, laryngopharynx or hypopharynx is located posterior to the larynx between the epiglottis (or the hyoid bone) and the cricoid cartilage,

Define Pharynx, Boarders of oropharynx, hypopharynx ?

BP >160/100 Impaired liver. Renal insufficiency > 1.1 Pulmonary edema. Cerebral disturbance.

Define Pre-E with severe features.

Atresia right ventricular outflow tract without communication between the ventricles. Because the coronary arteries are under high pressure, they come stenosed, leading to some part of the myocardium then depend on the right ventricle for perfusion in a phenomon called right ventricular-dependent coronary circulation., because the right side of the heart to the left side happens via: 1.) RV regurg --> RA -->PFO -->LA-->LV 2.) RV -->Coronary circulation Right to left shunting will not decrease CO, however, minimal oxygenation and will not improve with a 100% FIO2.

Define Pulmonary atresia with intact ventricular septum and the unique circulatory problems they face?

Hypoxemia = PaO2 <60 mmHg on an FIO2 of 60% Hypoxemia based on =PA-Pa gradient = >350 mmHg on a 100% FIO2 Hypoventilation =PaCO2 >50 mmHg Abnormal resp. Mechanics: -Breathing fast = RR>33 Or -Have a low vital capacity = <15 ml/kg or -Low NIF (<-20)

Define Respiratory Failure via three ways?

R = speed of clot formation = FFP = 5-10 minutes. K = speed of fibrinogen formation = cryo = 3-5 minutes. Alpha angle = fibrogen -> fibrin mesh = cryo = 50-70 degrees = defines the strength of the clot. MA = platelets + fibrin mesh products = 50 - 70 mm = platelets. Ly30 = the fibrin mesh =>fibronolysis = 0-8% = TXA or Amicar.

Define TEGS?

Hyperacute = 0-7 D | Acte = 7-28 D | subacute > 28D. =no prior issues with the liver, causing an increased INR, encelopathy, and rapid decline in liver function until about 80-90%. Commonly 2/2 to Tylenol OD.

Define acute liver failure? #1 cause?

Variable-vagal response to umbilical cord compression. Late-most concerning. Inadequate uteroplacental perfusion. Early-vagal reflex to head compression.

Define decels?

5% = about osmotically equal to human plasma and will expand intravascular volume 1:1 ratio of expanding plasma 25% = 5 times equal to plasma and will expand the volume 3-4 times by drawing fluid intravascullary.

Define difference between osmostic equaliviance between 5% and 25% albumin, how much will each expand plasma by?

how the contractile force of the myocardium (stroke volume or cardiac output) is dependent on the sarcomere length (diastolic filling volume or preload)

Define frank-starling.

Teritary = exgenous steroids secondary = ACTH or CRH low Primary = cortisol low

Define primary, secondary and teriary Addrenal insuffiency?

Can happen in patient receiving enteral or parenteral nutrition. -defined as a greater than 10% loss of body weight in 6 months or less. Hypophosphatemia (seen as muscle weakness) Hypomagnesemia Hypocalcemia Hypokalemia

Define refeeding Syndrome?

CO2 produced/O2 consumed 0.7 lipids 0.8 protiens 1.0 carbs overfeeding can lead to R >1.0

Define resp. qoutient?

elevation in plasma lactic acid levels >2 mmol/L, with the requirement for vasopressors to maintain the mean arterial pressure >65 mm Sepsis: ≥ 2 SIRS criteria PLUS a suspected or confirmed underlying infection Severe sepsis: sepsis PLUS dysfunction of at least one organ or system SIRS: temp > 38/<36, HR >90, RR >20, WBC > 12K/<4K/>10% bands

Define septic shock? Sepsis? Severe sepsis? SIRS?

Static compliance: airway pressure required to hold both lungs and chest wall at end inspiration. = VT / Plat-Peep Dynamic Compliance: reflects resistence to gas flow via circuit, ETT or bronchospasm. = VT/ Peak Pressure - Peep. '

Define static vs. Dynamic compliance?

When temp increases, so does VP. When VP exceeds atrmospheric pressure in an open container then boiling occurs.

Define the relationship between VP, temperature, and boiing?

Low SVR <1600, high CO (>2.5 index) within 4 post-op hours. Usually in patients taking ACE inhibitors and long CPB times. Hyperdynamic heart.

Define vasoplegia?

Paired: single, continuous variable in the same population (UOP b4/aft lasix). Unpaired: single, cont. variable in 2 different populations. Sevo vs. Remi and MAP effects. ANOVA: > 1 variable. Chi-sqaure: same as t-test but not continious (if multiple varibles = discrete)

Define: -Paired vs. Unpaired T-tests -ANOVA -Logistics regression?

Biventricular repair would be the definitive treatment for PAIVS in patients with favorable anatomy

Definite repair for pulmonary atersia with pAIVS?

Rotation to the of >30 degrees to the right. (contralateral) side. -Increased incidence of malposition (19%) -Smaller Left IJ caliber vs. Right IJ calber.

Degree of increasing arterial puncture with Left IJs? Other complications?

Failure of the RVOT results in blood not being able to get from the RV to the LV. 1st of all, PDA must remain open via using Prostaglandin E1. Blood will flow from the right to the left via: 1.) PFO RA-->RV--bound off the closed RVOT back up the RV-->RA-->PFO-->LA-->LV--->Aorta + PDA. PDA-->Lungs-->LA-->LV 2.) Fistula b/w the coronary arteries and the RV: --->RV -->Coronary arteries-->Aorta-->LV-->la

Describe the basic pathophysiology in pulmonary atresia, how does blood get from the rigtht->left side in patients with PA with intact ventricular septum?

SV increases with inspiration 2/2 to blood being pushed from the lungs to the LV = increased preload, decreased afterload. RV will see a decrease in venous return and an increase in afterload, however.

Describe the pressure/pulmonary changes which occur in the heart and related to SV?

EtCO2 is typically only 2-5 mm Hg less than PaCO2-Difference 2/2 to V/Q mismatch-seen higher with PPV > NPV 2/2 to increasing zone 1 with PPV. PPV = increased Dead Space = less CO2 in that dead space = decrease in ETCO2. PaCO2 should be higher than ETCO2. If PaCO2 is lower than ETCO2 it can be 2/2 to an expiratory valve issue or CO2 insufflation.

ETCO2 compared to PaCO2?

1.) BT shunt is temporary 2.) Glenn procedure is the second-stage: -SVC = linked to PA. Blood from head -->SVC-->PA-->Lungs-->LA--->LV-->body. -IVC--->RA-->LA-->LV-->Body. IVC blood from the body and isn't going to the lung. Saturations are usually in the 70% 3.) Fontan Completion: IVC is attached to the PA, along with the SVC | body & head blood --> IVC -->PA--> lungs-->LA--LV-->body. -driving force for blood to go to the PA is up to CVP. -Added fenestration if the venous pressures get too high, which allows blood to go from the IVC-->RA-->LA

Describe the surgical three phase process of tricuspid atresia?

Desmopressin causes the release of endothelial cell stores of factor VIII and von Willebrand factor. Used when a TEG shows a decrease MA and will increase the MA

Desmopressin causes an increase in which factor and what will it do to a TEG?

-Widespread pain index (WPI) ≥ 7 -SS at least 3 months. -R/O other disorders Tx: Physical therapy, analgesics (e.g., tramadol), antidepressants (e.g., duloxetine), and anticonvulsants (e.g., pregabalin)

Diagnostic criteria for fibromyalgia are:

LAD.

Diagonals are branches of which artery?

decreased SID 2/2 to loss of sodium & potassium.

Diarrhea will do what to the strong ion difference?

Acute AI = LVEDP goes up high and can go into pulmonary edema quickly Acute AI requires: decreasing afterload with dilators and increasing contractiltiy with something like epi, dobutamine, or milronine.

Difference between AI chronic vs acute.

Bainbridge = Receptors sensed at SVC-RA junction, PV-LA. When volume increases = CN X to the medulla==>HR increases in response to atrial strech = seen with fluid overload. Bezold = Mechanical & Chemreceptors in the LV wall decrease volume in the LV ==>CN X ==>medulla ==>Vagal stimulation = bradycardia, hypotension, and vasodilation = seen with spinals.

Difference between Bainbridge and Bezold-Jarisch reflex?

FVC-Gas a patient can get out of the lungs if you give them time to exhale. FEV1-The amount of gas you can get out of the lungs and one second. Should be over 80%

Difference between FVC and FEV1?

A grade IIa is associated with a low rate of difficult intubation, whereas a grade IIb is associated with a high rate of difficult intubation. Grade IIa: partial view of the glottis Grade IIb: view of posterior glottis or arytenoid cartilages and epiglottis

Difference between Grade IIa and IIb?

Hyper: AD, Na+ channel = hyperexcited then weakness 2/2 to potassium, cold, hunger, stress. Tx: Loop diuretic. avoid-Succs, K+ FLUIDS, ACIDOSIS. prolonged paralysis. Hypo: AD, Ca2+ channel, low K+ = muscle paralysis. increased risk of MH-avoid succs, sensitive to Roc. avoid-glucose (low K+), insulin, salt, alkalosis

Difference between Hyper K PP and Hypo K PP?

OSA is characterized as repetitive obstruction (apnea) or partial obstruction (hypopnea) of the upper airway resulting in abnormal ventilation during sleep.

Difference between OSA and Hypopnea?

Peripheral: limited to 750 osmolarity, so requires higher fluid amount. Leads to phlebitis which can be decreased by adding heparin, hydrocortisone to the solution, or nitroglycerin patch over the site. TPN centrally requires a CVC, can run a high osm. amount of fluid.

Difference between TPN perpherally vs. centrally?

18% at 1-year and 39% at 5-years. Type 1: Acute 2/2 to doubling of Cr. due to stress, sepsis or sx. Survival = 2-4 weeks. Type 2: Slower onset, 2/2 to decrease renal blood flow. Survival = 6 months. Tx: Vasoconstrictors like Midodrine, octertide, NE, vaso, albumin.

Difference between Type I and Type II HRS?

Vegetative state = has sleep/wake cycle where coma doesn't.

Difference between coma and vegetative state?

Lipophillic drugs = faster onset, faster offset. Hyphillic drugs like morphine, dilaudid, and medeperine = slower onset, slower offset.

Difference between hydrophillic and hydrophobic opioid drugs for neuraxial anesthesia?

Medical direction pays more and must be met by: -Pre-anesthestic plan, present at induction/emergence, be avaible for any emergencies, and have a post-anesthesia plan. -Make sure procedures are done by qualified people/the anesthesiologist. If these metrics arent met, then the medically directed plan will be considered medically supervised by CMS.

Difference between medical direction and supervision?

Anion-Gap acidosis = H+ Non-Anion Gap Acidosis = H & Cl together

Difference between non-anion gap acicosis?

Phase I reactions: Include reactions which hydrolysize, oxidize, and reduce the drug into a more hydrophilic form to prepare it for elmination. Phase II reactions: include adding a polar functional group in a process known as conjugation reactions to enable to drug to be even more hydrophillic and prepare it for elimination>

Difference between phase I and Phase II reactions?

Pre: ↑ Unconjugated fraction, normal LFTs Intra: (something like TPN can do this: ↑ Conjugated fraction, ↑ LFTs, Normal to slightly ↑ Alk-P. Post: ↑ Conjugated fraction, Normal to slightly ↑ LEFTs, increase in Alk-P

Difference between pre, post, and intrahepatic injuries?

Pressure-volume loops can be useful for gauging the adequacy of tidal volume delivery, while flow-volume loops provide useful information about static and dynamic respiratory compliance.

Difference between pressure-volume & flow-volume loops?

close (spontaneous) -primary if there is no underlying lung disease -secondary is there is underlying lung disease

Difference between secondary and primary closed pneumothorax?

Conus Medullaris-at level of L2, presents with sudden onset bilateral LE weakness. Early onset fecal and urinary loss. Cauda Equina-Below the level of L2, commonly caused by posterior-medial disc herniation. Gradual onset, usually unilateral. Late onset urinary retention. Saddle Anesthesia. Obtain urgent MRI without contrast.

Differences between Cauda Equina Syndrome & Conus Medullaris Syndrome?

ST-segment depressions-2/2 repolarization abnormalities. Decreased QT interval-, atrial and ventricular refractory periods are shortened Increased PR interval-increased vagal effects at the atrioventricular node. T-wave inversion or flattening-hypoK

Dig tocity on EKG?

hemorrhagic bleeding in a patient who has received multiple units of banked blood during a massive transfusion protocol with: -pRBC, NS, whole blood thats been stored longer than 24 hours-since few viable plt exist >24 hours, Whole blood stored in cold (4 degrees celius) platelets in stored blood are damaged and readily trapped in the RES shortly after transfusion. Tx: 50-75k platelets-give platelets.

Dilutional coagulopathy develops in massive transfusion because of?

hypocarbia, vasodilating drugs, infection, metabolic alkalemia, and volatile anesthetics >1 MAC. hypervolemia, vasoconstricting drugs, hypothermia, thromboembolism, and a large hypoxic lung segment.

Direct inhibitors of the HPV mechanism include: Indirect inhibitors of HPV include

Advanced in the caudad direction behind the SCM and at C6 cricoid cartiage at 1 mA = twitching of deltoid, tricep, bicep, pec --> decrease mA (If muscle twitches <0.2 withdraw the needle)-->if the mA at 0.4-0.5 mA & muscle twitches are elicited = safe to proceed.

Direction and description of an interscalene block?

There is no mortality benefit from their use, but they decrease left ventricular filling pressure

Do loop direutics decrease motratlity?

Paralytics. Heparin. Insulin. Glycoprolatte.

Drugs that don't cross the placenta in significant amounts:

amphotericin, cephalosporins, penicillins, phenytoin, procainamide, and quinidine. cimetidine, carbamazepine, hydralazine, rifampin, streptokinase, and vancomycin.

Drugs that most commonly cause a drug fever include?

LP shows increased proteins

Dx GBS?

Low SaO2 Normal Pulse ox Normal PaO2 MV unchanged 2/2 to normal PaO2-No hyperventilation. Tx: HBO therapy to pregnant patients > 15%, patients with CO > 40%. Can given PRBC as well.

Dx of CO on ABG?

and/or dysesthesia must have a duration of ≥ three months. >30%, equally in men and women. first-line treatment for PHN is a gabapentinoid > TCA > Oxycodone (Not effective for PHN) > lidocaine patches> DRG zone lesions > Epidural steroid inectjions, intrathecal steroids, PNB, Cryotherpy, botox

Dx of PHN? tx?

PPV > CVP (static)

Dynamic parameters of fluid response include what?

downsloping ST-segment depressions and bradycardia. + PVC being common Green-Yellow Visual changes (xanthopsia). Hyperkalemia = marker for dig toxicity level and mortaility. Increased intracellular calcium = pre-disposes to arrthymias. Shortens repolarization

EKG findings of Dig toxicity? Other findings?

Low voltage with lung inflation. Enlarged P wave in type II

EKG of pulmonary htn

-pseudo-right bundle branch block (BBB) pattern =widened QRS complex, a terminal R' wave in V1, and a wide or exaggerated S wave in V5-V6) -persistent ST-segment elevations in leads V1 to V3.

EKG pattern of Brugada syndrome?

> 1 = increased CBF, decreased CMRO2. Increase ICP. <1 = decreased CBF, CMRO2. N2O = increase CBF + ICP, but with propofol or other IV gents can crease CBF and ICP, but still increase the CMRO2.

Elaborate on CBF with Inhalation agents, N2O?

Hyponatremia Hypkalemia Low phosphate, caclium, magenesium.

Electrolyte issues in liver patients?

-natural frequency: determines how rapidly it oscillates after a disturbance -damping coefficient: how quickly system returns to base-line. An overdamped intra-arterial blood pressure monitoring system (ie, arterial line) leads to an artificially low systolic blood pressure. underdamped system leads to an artificially high systolic blood pressure.

Elements important determining the accuracy of the system with a-lines?.

Phase 1 is a non-synthetic reaction that allows process of oxidation, reduction, and hydrolysis. There is inactivation of the drug (most of the time) by the addition of functional groups, which allows the drug to pass to phase 2. Metabolism of drug is dep. on phase 1 rxn. Phase II reactions are synthetic reactions which add substances to the functional groups via enzymes like glucuronyl transferase, sulfotransferase, and methylases. They make the enzyme much more drug soluable.

Enzymes such as the cytochrome P450 (CYP), aldehyde dehydrogenase and alcohol dehydrogenase are considered Phase I reaction metabolisers. what is the primary role of phase I?

Little effect on pulmonary function, except the ability to cough is decreased with high dermatome level. Patient can complain of chest tightness 2/2 not feeling the chest rise.

Epidural anesthesia has what effect on respiratory system?

epidural hematoma to be 11% for a platelet count < 49,000/μL, 3% for 50,000-69,000/μL, and 0.2% for 70,000-100,000/μL.

Epidural hematoma risk is how high with platelet count < 49K?

Epidurals with opioids delays it. Pure LA epidural fluids will not.

Epidural will do what to gastric empyting?

required dial setting = (sea level v/v% x 760 mmHg) / current barometric pressure) Example (5% x760)/500 mmHg x 100 = 7.6%

Equation for dial of des?

Six criteria: -high risk surgery (intraperotneal/thoracic/vascular Sx. -HX of ischemic heart disease. -CHF -TIA -DM with insulin tx -Cr > 2.

Estimate Risk of cardiac complications after surgery

Spinal cord injury at T5 ==>bladder, bowel, surgical stimulus below the level of injury ==SNS activation below level of the legion ==>activation of the PNS via carotid sinus reflex ==>vasodilation, sweating, flushing above the level of injury 2/2 to PNS while there is a constriction. -S/S = bradycardia, HTN, headache.

Explain Autonomic Hyperreflexia?

As CMRO2 increases, more oxygen is required = increase in CBF = Cerebral blood volume. Between 50-150 mmHg, Cerebral regulation is maintained when systemic consitrction or dilation happens, the brain will do the opposite. This is shifted to the right in HTN patient. Labetatlol has no real effect on CBF and CMRO2.

Explain CBF, CMRO2 and Cerebral volume?

Sciatic Nerve branches: -Superficial peroneal: sub-q injection to dorsum of foot -Deep Peroneal: lateral to the DP pulse or extend toe and go lateral to the extensor hallucis longus tendon. -Posterior Tibial: behind the medial malleolus. -Sural: behind lateral mallelous Fem branches: -Saphaneous: Inject around great saphenous vein

Explain how to do an ankle block

lumen of the bladder using an indwelling urinary catheter -->small amount of saline instilled into empty bladder-->transducer zeroed at mix-axillary line

Explain how to provide intra-abdominal compartment syndrome monitoring?

In the lung, when there is a PAo2 of 30-60 mmHg, this is considered alveolar hypoxia. -Blood vessels in the hypoventilated alveolar units will constrict, to shunt blood to better ventilated aveoli. Factors that can inhibit HPV include -Nitro -Inhalation agents > 1.0 mac -ACE-Inhibitors -Alkalemia -Hypocarbia -hypothermia -Infection. Lung does opposite of the blood vessels in the body-when hypoxia occurs in the body = vasodilate, but in the lungs there is vasoconstriction.

Explain hypoxic vasoconstriction, what causes an increase/decrease in it?

Lactate => Pyruvate in the live via Lactate Dehydrogenase. -->Pyruvate--Acyteyl COA -->Citric acid cycle to produce carbon dioxide, water, and bicarbonate.

Explain the breakdown of LR?

Submersion --> breath holding -->aspiration of water or a reflex laryngospasm 2/2 water contacting the Lower RT -->hypoxemia-->LOC after.2 minutes -->brain death after 2-4 minutes 2/2 to release of excitotoxic neurotransmitters and free radicals that cause lipid peroxidation.

Explain the events of drowning?

Increasing contractile state = up to the left vs. decreasing = down and to the right.

Explain the frank-starling diagram?

effective dose for 95% of the population for the medication to work.

Explain what the ED95 is?

Left SVC syndrome is when the left brachiocephalic vein does not form properly, and, instead, the left arm and head and neck drain into the coronary sinus and right atrium. Retrograde pleg will just go into the left arm when given.

Explain why retrograde cardioplegia is not effective in someone with persistent Left SVC syndrome?

lateral spinothalamic tract carried temperature and pain is sensitive to neuraxial blockade.- dermatomal block can be assessed via cold or sharp object.

Explain why we use an alcohol swab or ICE to determine the blockade of neuroaxial anesthesia?

-Lipid solubility = Anesthetic potency = more lipid = more potent. =procaine is the least lipid-soluble and least potent -Time to onset/Onset of action? pKa -Duration of action=protein binding = higher protein bindings = increasing duraiton of action. -Location of injection

Factors of LA toxicity: -Lipid solubility? -Time to onset/Onset of action? -Duration of action -Location of injection

Immature pathways, fetal protein binding-less proteins = higher fetal drug levels, and fetal pH.

Factors that effect fetal drug concentration?

Reactive airway disease Prematurity Airway surgery Endotracheal intubation in patients <5 years of age Laryngeal mask insertion Presence of copious secretions and nasal congestion Secondhand smoke Should wait 4 weeks after symptoms resolve.d

Factors that increase perioperative respiratory complications in the setting of a URI include, and how long should they wait?

Dextrose & Total LA drug dose = biggest factors. Other factors: -Height -Age -CSF volume -LA volume -Site of injection -Bevel direction -Abdominal pressure -Position.

Factors which influence level of spinal block?

Therefore, video-assisted laryngoscopy techniques have not decreased the risk of injury overall by not watching the insertion of the tube and causing damage to the pharyngeal stuctures.

How have glidescopes not decreased the overall injury?

endovascular cooling. Of these, the latter can usually cool the patient the fastest, at a rate of approximately 4 °C/hr to 32-36 degrees for 12-24 hours. Slowly rewarm the patient to 37 C. Most deaths associated with rapidily warming

Fastest way to cool a patient with induced hypothermia?

macrocephaly, frontal bossing, brachydactyly, lordosis, genu varum, spinal stenosis, hypotonia, and frequent otitis media.

Features of Acondra Playgia?

posterior divisions of the ventral rami of L2-L4 and innervates the quadriceps femoris, pectineus, and sartorius.

Femoral nerve arises from?

L2-L4 Widest and most Superficial at the femoral Crease

Femoral nerve block pearls.

1.) Small, pre-ganglionic sympathetic Beta fibers (minimal mylination) 2.)C-fibers (unmylinated)-cold, temp sensation. 3.)Alpha-Delta (mylinated)-pinprick 4.)Alpha-Beta (mylinated)-touch 5.) Alpha-A fibers (mylinated)-motor. Block starts 1-5 and then fades 5-1

Fibers blocked in order with epidural anesthesia?

abnormal relaxation of the ventricle.

First thing that happens with myocardia ischemia?

Pt has one ventricle. -ventricle pumps blood to the body. -blood returns from the subclavian—>SVC & IVC —> main pulmonary artery. Pulmonary blood flow depends on CVP.

Fontan procedure?

bananas, avocados, kiwis, apple, buckwheat, carrot, celery, chestnut, melon, papaya, peach, pineapple, tomato, and white potato

Foods associated with latex allergy?

continuation of daily SBTs with inspiratory pressure support with augmentation. atients who are able to breathe spontaneously with minimal or no ventilator support for at least 30 minutes = candidates for extubation.

For a patient failing an initial SBT, what should be done?

at C6 level (SCM) muscle and the anterior scalene located medially. the middle scalene located laterally. Needle is moved from lateral to medial through the medial scalene.

For an interscalene block, define the anatomy medially vs. laterally?

For each degree Celsius < 37, CMRO2 decreases by ~6% to 7%

For each degree celsius <37 degrees, how much does the CMRO2 drop?

Most recent EKG should be with in a 4 month interval. This includes patients undergoing non-low risk (intermitent risk) surgeries who are: -CAD, A-Fib/SSS, PAD, TIA/Cerevral vascular diease. Unless the procedures are: endoscopies, ophthalmologic procedures, and superficial procedures are considered low-risk procedures,

For patients undergoing non-cardiac surgery, how long should the last EKG be? What population of patients falls under this umbella?

If the foreign body remains in the trachea, the classic triad of asthmatoid wheeze, audible slap from the foreign body against the trachea during ventilation, and a palpable thud over the trachea are characteristic.

Foreign body in trachea will present with?

Na-K+ ATPase.

How is resting membrane potential maintained at -70?

Jugular bulb venous temperature is considered to be the "gold standard" indicator of cerebral temperature. -Placed in the IJ and advanced cranially.

Gold standard of cerebral temperature?

LMWH PPX: -Hold 12 hours of lMWH prior to starting epidural. After epidural is placed, wait another 12 hours prior to restarting PPX LWMH. Once epidural is ready to be removed, hold LMWH for 12 hours prior to taking it out. Once epidural is out, wait 4 hours to restart LWMH PPX. LMWH therpautic: -24 /24 /4 /4

Guidelines for LMWH heparin and epidural placement/removal/restart?

Labataolol half life = 6 hours with an effect of 16-18 hours. Onset within 5 minutes-peak 15 minutes.

Half-life of labetaolol?

Blood taken at baseline cortisol level < 20. ACTH analong is given. -Primary. No change with ACTH analong. -Secondary. Change with ACTH x 2-3 and cortsiol levels x 2-3 times.

How is the Diagnosis of primary vs. secondary adrenal insufficency done?

Lateral to the subclavian.

How is the plexus in vicinity of the subclavian artery?

6 monhts.

How long can ECT memory deficits last for?

HbF persists in a newborn until about 2-4 months of age and is usually completely replaced by adult hemoglobin at 6 months. Fetal hemoglobin = 2-alpha / 2 gamma adult hemoglobin = 2 alpha / 2 beta

How long does fetal hemoglobin persist for? Structure?

Factor 8 c and VWF. Should not exceed 20 ml/kg in a 24 hour period.

Hetastarch leads to a reduction of which factors?

Per the PAO2 equation = FIO2 X (ATM - H20) - PaCO2/R, if CO2 increases, it would depress the PAO2 = decreased O2 to the blood (hypoxemia).

How are PAO2 and Pco2 related?

Altitude causes a decrease in PAO2 = HPV.

How can High Altitude Pulmonary Edema happen?

Virally inactivted F8 concentrate, cryo, DDAVP.

How can VWF diease be treated other than DDAVP?

Inspired TV > Expire TV PTX esp. if there is no cutaneous involvement. Req: awake intubation DLT with spontanous ventilation. Keep TV and airway pressures low. HF Jet ventilation for larger BPF.

How can bronchopulmonary fistula present when on a ventilator?

electrocautery interference can cause erroneous readings as a result of the high-frequency currents that are generated and can radiate to the sensor.

How can electrocautery interferace cause pulse ox interface?

Left-axillary artery- FYI is this is done-the A-line will only read the arterial cannula, which will be limited use for bp monitoring.

How can fem-fem artery/venous bypass occur if the fem artery is tortious or atherosclersed?

Oxygen decreases the hypoxic vasoconstriction response ===>blood flow going to alveoli that aren't ventilated well ==> increase in V/Q mismatch.

How does Co2 increase in a COPD patient who is getting oxygen?

inhibits vasopressin.

How does ETOH lead to diuresis?

Inhibits platelet agonist induced expression of Glycoprotein IIB-IIIA on platelets = can't bind to fibrinogen = platelets can't aggregate. Hextend has smaller hydroxethyl compared to Hespan = decrease platelet issues.

How does Hetastarch inhibit platelets?

Blocking NMDA receptors and thus upregulating exitatory pathways

How does Ketamine work to increase CMRO2 and Cerebral Blood Flow?

LOR w/ air > saline.

How does LOR technique relate to PDPH?

HTN = high afterload = LVH = maintained resting systolic function, but diastolic dysfunction = pre-load dependent to fill, requiring atrial kick to fill and maintain CO. Low cardiac reserve can cause profound hypotension on induction due to drop in pre-load.

How does aging effect afterload and what can result of it from an anesthestic prespective?

Anion gap equation = [Na+] - [Cl- + Hco3-] = 8-16 meq/L Albumin is negative charged and not calculated in the anion gap. If it is low, then the anion gap is also low and closer to closed. This can lead to a closed anion gap in a patient with hypoalbuminemia and lactic acidosis.

How does albumin effect the anion gap? How can it mask a anion gap metabolic acidosis?

Stop the breakdown of Cyclic AMP.

How does amniophyline work?

Diffusion

How does placenta oxygen txp happen between mom and baby?

-decreased blood viscocity -decreased SVR -->increased CO. -Decrease in Mvo2 2/2 to increased o2 extraction.

How does the body adapt to anemia from a cardiovascular standpoint?

-Increase 2,3-BPG to allow for easier o2 offloading from HG to tissue. -Hyperventilating. -With the hyperventilation, there is a respiratory alkalosis = so there is an increase in the renal elimination of bicarbonate to compensate. -Increase in number of mitochondria to increase aerobic efficiency. -Erothropoetien increases RBC

How does the body adapt to prolonged hypxoia?

Also pattern seen in neuraxial and regional anesthesia. It results 2/2 loss of thermoconstrictive measure-these measures ensure that the core are 2-4 degree warmer than the periphery. This results from: -Rapid initial decrease. -Slow, linear reduction. -Ending with a stablization and platue of core temp. Can be decreased by pre-op waring.

How does the core-to-periphery temperature gradient change?

No difference in outcomes when doing it blind vs. ultrasound.

How does ultrasound improve the technique of superficial cervical block?

42 days. Products stored close to 42 days = less efficacy because of lysis releasing potassium and hg. and increase in complications like post-op pneumonia. Oxy-hg curve is shifted to the left 2/2 a decrease in 2,3 DPG.

How long is the max shelf-life of blood products? What happens to the oxy-hg curve?

Minimum amount of time for seizure that is required is 25 sec = initial bradycardia and then tachycardia: Etomidate = prolongs seizure. No effect: Methohexital and ketmine Decreases: Versed, prop, lidocaine, volatiles

How long should an ECT siezure last for at minimum?

1 minute.

How long should pulse be checked in a hypothermic drowning patient?

Fentanyl will have an onset of action in 7 to 8 minutes following intramuscular injection and is the most route of administration that produces the most rapid clinical effect in the absence of adequate intravenous access.

How long will IM fentanyl take to have an onset of action?

9 -thyroid and cricoid cartilages, the paired arytenoid, corniculate, cuneiform cartilages, and epiglottis

How many cartilages is the larynx composed of?

15 mm Hg, but this increase is transient and lasts about 5 minutes.

How much can Sux raise intraocular pressure?

60 to 90 minutes.

How much is 3-chloroprocaine expected to prolong the duration of action for?

300 times more potent than oral morphine. Bypasses the GI and liver-avoiding first pass and decreasing symptoms of conspitation with chronic oral therapy. They're good for metastatic cancer, especially when pain can't be targeted using something like a celiac block.

How much more potent is IT morphine than oral morphine and when is it very useful?

HCO3- of 2 mmol/L for every 10 mm Hg increase in PaCO2 in an acute setting. Chronic respiratory acidosis: HCO3- of 4 mmol/L for every 10 mm Hg increase in PaCO2. normalize blood pH can be approximated with the formula: 0.2 * kg * base deficit

How much should bicarb go up during acute vs. chronic respiratory acidosis? How much sodium bicarb is required to correct it?

145 mEQ.

How much sodium does albumin have?

It occurs in 60% to 80% of patients after amputation, with 5% to 15% of patients reporting severe pain: Treated how? -TCA -Gabapentin -Pre-gabalin -ketamine -Memantine -Opioids hysical therapy, massage, transcutaneous electrical nerve stimulation, acupuncture, and biofeedback with virtual reality/mirror therapy, are essential in treating phantom pain

How often does phantom pain happen after an amputation?

low-to-normal heart rate with sinus rhythm, avoidance of decreases in preload by avoiding aortocaval compression, and maintenance of venous return along with maintaining systemic vascular resistance. Especially after the period of delivery which can result in uterus autotrasnfusing back into the body and can increase risk of Pulmonary edema and collapse.

How should pregnant patients be managed?

Air embolism. CO posoining- esp. in pregnant patients, patients with angina, AMS Cyanide Poisoning (B12, Amylnitrite, thiosulfate) Gas gangrene Therapy is at 2-3 ATM and a 100% FIO2.

Hyperbaric Oxygen Therapy indications

If patient has seizure, decrease inspired Po2. Not more common in patients with seizures hx. vs. not. 2/2 to oxygen toxcity.

Hyperbasic Oxygen and seizures tx?

hyperglycemia exacerbating lactic acidosis in the form of releasing exictory AA & release of N.O. free radicals = lipid peroxidation, denaturation of proteins, inactivtion of key enzynmes and release of intracellular calcium.

Hyperglycemia is associated with worse neurological outcomes in acute cerebral ischemia and may exacerbate ischemia. HOW?

0.75 mmHg per CM. Ex: 30 cm above the heart = 0.75 x 30 cm = 22. If BP = 147 (147-22) = 126.

If an arm is above the heart, and BP cuff is on. How much per cm above the heart should BP be calculated to?

destabilization of the red blood cell membrane and hemolytic anemia, cardiac failure through depletion of ATP stores, neurologic symptoms due to decreased ATP stores in the brain, spinal cord, and peripheral nerves, and eventually seizures and death, difficult vent weaning, and decreased ability to oxygenate 2/2 to a left-shift and decrease in 2,3 BPG.

Hypophosphatemia from TPN can result in what negative results?

Left heart side of heart is under-developed + the initial part of the asceding aorta. For blood to get to the coronary arteries and head vessels, it must go through the RA-->RV-->RVOT-->PA-->PDA-->coronary arteries and brachioscephalic/head vessels. Need to be on prastoglandins.

Hypoplastic Left Heart common features

Due to reduced glucose metabolism and endogenous insulin release, hypothermia can result in hyperglycemia.

Hypothermia does what to glucose? MOA?

Hypothermia causes diuresis, resulting in contraction of blood volume, increasing the hematocrit and blood viscosity. Increase in HCT by 2% with each degree Celsius below normal body temperature.

Hypothermia effect on hemotocrit?

-Check placement of tube. -CPAP to the non-dependent lung (operative) lung-can effect patient's view and increased risk of post-op air leaks due to distruption of the staple lines. -Peep to the dependent (non-operative lung)-can make hypoxemia better, but worse because it can distend the blood vessels and cause the blood to be redirected to the operative lung. -Two-lung ventilation. -Clamp the non-dependent pulmonary artery to decrease blood to the operative lung and decrease v/q mismatch.

Hypoxemia protocol with a DLT?

prophylaxis if they are to undergo: -Dental procedures with gum manipulation -Resp. tract procedures that involve incision/biopsy -Procedures on infected skin, skin sutures, or MSK tissue -Sx to place prosthetic heart valves or prosthestic intravascular/cardiac materia. -GU/GI ppx not recommended unless active infection.

IE guidelines not based on the risk of developing IE, but the cardiac conditions which have the highest risk of adverse outcomes from IE:

INR values in patients following donor hepatectomy return to normal between postoperative days 5-7. Peak INR is usually no greater than 2.0 and peaks 2-3 days s/p hepatectomy-despite this TEG is hypercoaguable.

INR values in patients following donor hepatectomy return to normal when?

FIO2 100% = ~8 minutes until a healthy patient desats to < 90%. FIO2 21% = 1-2 minutes until a healthy patient desats < 90% FIO2 100% with >90% ETO2 in a fat patient = time is reduced from 8 minutes to 2.7 minutes until desat < 90%

In a healthy, non-obese pt., how long do they have before saturation occurs when oxygenated with a FIO2 100% with an ETO2 > 90%? What about at 21%? What about for a fat patient with a FIO2 of 100%?

Laminal flow, noncompressible fluid, neutonian fluid like water or air, and a constant cross-sectional area. Resistence = Pressure/Flow (Q) = Resistence = 1/R^4

In order for Poiseuille's law to take place, which four factors must exist?

The order for repair of hypoplastic left heart syndrome is "Not Gonna Fly": Norwood, Glenn, Fontan.

In what order does a hypoplastic left heart take place in the three-stage procedure?

v5 & Lead II

Lead that shows the most amount of ischemic episodes?

PE.

Leading cause of maternal mortality of pregnancy?

NS infusion directly reduces the strong ion difference (SID) while promoting the renal loss of bicarbonate. As discussed, LR is instead associated with metabolic alkalosis as a result of the metabolism of lactate to bicarbonate after infusion.

MOA of LR causing Alkalosis vs NS?

Increase CBF, ICP, and decrease CMRO2 reduce the cerebral blood flow, ICP, and cerebral metabolic rate of oxygen (CMRO2)

Inhaled agents and CBF? IV agents?

-Time to unconsciences roughly 60 seconds w/ 8% -Typical skip stage 2/excitation unlike pediatric patients. -Benzos help improve the techiqnue, but opioids worsen it because they can cause apnea.

Inhaled induction in adults pearls:

a thorough physical examination and lateral radiographs of the thoracic and lumbar spine. ==> CT if xrays aren't dx

Initial testing for a suspected compresison fx?

ischemia of the abdominal wall due to the interruption of the blood supply by the omphalomesenteric artery. The Small bowel will pushed against the weak wall and usually herniate through right of the umbilicus.

MOA of Gastroschisis?

inherited hyperbilirubinemia 2/2 to AR or AD mutation in the UGT1A1 reduction of UDP-glucuronosyltransferase activity = decreased ability to conjugate billi. Usually < 3 mg/dL. Dx: PCR

MOA of Gilbert syndrome?

The ScvO2 value is typically lower than SvO2 owing to the increased oxygen consumption by the organs that drain blood into the SVC

Is ScvO2, or central venous oxygen saturation, higher or lower than SVO2? WHY?

Can be unilateral or bilateral Painless Anterior ION: Pale optic disc, edema Posterior ION: Optic disc appears normal. Recommends: Mix colliods and crystalloids, maintain intrasvascular volume, keep head at neural at level of head.

Ischemic Optic Neuropathy pearls

When is ischemic hepatitis expected to happen? -between 1-3 days peak and lasts 3-11 days. =Increased conjugated fraction, ALT/AST

Ischemic hepatitis is seen highest when?

CA elevated = inhibiting Na channels and increasing the depolarization potential = muscle weakness.

It has been shown that hyperparathyroidism causes a hypo-sensitive to ND-Neuromuscular Blockers because an increase in Ach receptors upregulation, thus requiring more. However, this is unpredictable. How can Hyper-parathyroidism actully result in muscle weakness?

1-3 yo toddlers. W/ 3 yo = highest risk. A/P x-rays with hyperinflation and atelectases in the Right main bronchus. unroasted > roasted nuts= increased inflammatory and pneumonitis. don't delay-even if stable. inhaled induction. Neuromuscular blockade distale to the carina (can obstruct with PPV if proximal)

Kids most prone for forgien body lodgements? where and dx?

quantitate the volume of blood mixed between mom and fetus and determines the administration of Rhogam to give. Rhogam works by destroying fetal RBC before they evoke a maternal response. Adminsitration is based on Rh status of dad and fetal Rh status.

Kleihauer-Betke test is?

constrictive pericarditis. During inspiration, there is increased jugular venous distension (due to venous blood backing up).

Kussmaul sign is associated with

Lamber Eaton = sensitive to both NDMB and Sux MG = sensitive to NDMB and resistent to sux.

LE and MG with paralytics?

Pre-hepatic: increase in unconjugated bili fraction. Main cause = hemolysis. No change in LFTs seen. Intrahepatic: Increase in conjugated billi, increased LFTs, prolonged PT, decrease albumin. Post-hepatic: increase in billi, and increase in Alk-P.

Lab values for liver function pre-hepatic, intra, and post-hepatic?

Labetalol is metabolized primarily via hepatic glucuronide conjugation with excretion via urine (>60%) and feces (>30%).

Labetolol metabolism?

Angle of the jaw, mastoid process, and posterior to the SCM, tranverse process of C2,C3,C4,C5. . C2 transverse process lies 1.5 cm inferior to mastoid process. Needle is advanced, medially, cadually, and slightly posterior.

Land marks of the Deep Cervical block?

S1

Largest nerve root in body?

LFCN (derived from the L2-L3 nerve roots) provides sensory innervation to the anterolateral aspect of the thigh

Lateral Femoral Cutenous Nerve is made out of which nerve roots, where does it provide sensory innernvation?

Left: effects MAP & Contractility more. Can be performed to block sympathetic activity to the heart and reduce the risk of arrythymias associated with long QT syndrome. Right: Effects on heart rate more. l

Left vs. Right Stellate Ganglion block?

Leukoreduction decreases the incidence of febrile nonhemolytic transfusion reaction. Also reduces: HLA alloimmunization, reducing the risk for viral transmission (cytomegalovirus, Epstein-Barr virus, and human T-lymphotropic virus disease), and reducing the risk of leukocyte-induced immunomodulatio

Leukoreduction is effective in decreasing which of the following complications of blood product transfusion?

Minimum = normal mentation, airway patent, breathing not changed, and no hypotension. Moderate = responds with touch/verbal, however, no airway intervention needed, breathing is adequate, CV is usually maintained. Deep = responses to repeated/painful stimulus, jaw thrust likely/may needed, respirations may be inaqeuate, no hypotension. General: not waking up, often requires airway support, irregular resp. CO may be impaired.

Levels of mild, moderate, deep, and general anesthesia?

Liquid = liquid at room air while in a compressed cylinder -propane, CO2, Nitrous -Rely on weight > gauge since liquid and gas are in equilibrium. When gas is released, it is replaced by liquid going into gas and will read full pressure gauge until 400L/1590L remain. Non-liquid gases: -Air, Helium, Nitrogen, oxygen -Pressure gauge is best.

Liquid and Non-liquid gasses?

-activate potassium channels and therefore inhibit the presynaptic release of ACh resulting in decreased neuromuscular transmission

Lithium effects on NMBD?

75% Portal Vein / 25% Hepatic Artery. Each supply a 50/50 ratio of O2 to the liver.

Liver blood supply and oxygen supply?

Halothane > Iso > Des > Sevo. No existing evidence of Nitrous being hepatotoxic.

Liver injury due to volatile agents like with?

α2 receptors in the brain and the spinal cord primarily at the locus coeruleus.

Location of MOA of precedex?

RH-D negative mom builds IgG antibodies from previous Rh-antigen baby-->second pregnancy the IgG antibodies cross the placenta and attacks an Rh-Antigen positive second baby. Rhogam should be administered at 28-30 weeks

MOA of Hydrops Fetalis? When should Rhogam be adminsitered?

Intracellular calcium ions = muscle contraction and increased metabolism = signs and symptoms. 1.) Purge the circuit using manufactuer standards-some at 10 l/min up to 1 hours. 2.) Purge for 1.5 minus at 10 L/min, then add the activated charcol filter.

MH MOA is due to? What can be done to the circuit to decrease it?

Malignant hyperthermia (MH) is associated with central core disease, King-Denborough syndrome, and multiminicore disease. The

MH is associated with what other dieases?

ADH = CT aquaporin upregulation = decreased plasma sodium + fluid overload = naturaesis in attempt to get rid fo the water = increased urine sodium > 20. (Sodium = 115 | Urine > 20) Cerebral Salt Wasting = low plasma sodium & intravascularly low. Tx with fluids and salt.

MOA and Dx OF SIADH? Cerebral Salt Wasting?

Usually happens above a T5 lesion, less likely if the lesion is at T10. -Two weeks after injury. -Represents return of spinal cord reflexes. MOA: Bladder or viscous stretch causing SNS stimulation. PS usually will come from higher areas to counter act this SNS stimulation. PS is activated until the level of the lesion. SNS uninhibited below the level of the lesion. HTN below the lesion causing Carotid Sinus activation--> increased afterload, bradycardia, vasodilation above the lesion, but SNS activation below the lesion.

MOA of Autonomic Hyperreflexia?

Carbamazepine inhibits sodium channels in neuronal cells inhibiting excitability and conduction. >> Microvascular decompression(Radiofrequency rhizotomy)>>>> SURGERY

MOA of CBZ in TGN?

The carotid and aortic bodies contain chemoreceptors that detect changes in pH and PaO2 ==> PaO2 drops below 50 mm Hg, a signal is sent to the medulla via The afferent is the nerve of Hering (CN 9) & CN X ( aortic arch) ==> increase ventilation and PSNS activation ==> decrease in heart rate and myocardial contractility.

MOA of Carotid body and aortic body reflex?

excitation of the locus ceruleus as α2-agonists can reduce the risk of emergence, exerting their effects on the locus ceruleus. Other medications which may decrease Emergence Dillerium are: Several medications may reduce the risk of emergence delirium, such as propofol, α2-agonists (clonidine), opioids, (fentanyl), and ketamine.

MOA of Clonidine decreasing Emergence Dillerium?

The cerebral ischemia is sensed by the medullary vasomotor center activating the sympathetic nervous system.

MOA of Cushings reflex?

x-lined recessive = protein dystrophin break down = integrity of muscle and sarcolemma broke = pseudohypertrophy & fat: --Fibrosis of heart = DCM = risk of ventricular arrythmias. -90% of patients have DCM and it is equal to 20% of the deaths.

MOA of DMD and BMD?

Dig = blocks Na/K-ATPASE = Increased intracellular sodium = sodium/calcium changer takes sodium out for calcium in = increased Phase 4 & 0 = decreasing HR.

MOA of Dig?

Blockstar sodium potassium pump, causing an increase in sodium in the cell. This Results in the sodium calcium exchanger to take sodium out of the cell and put calcium into the cell.

MOA of Digitalis?

A drop in EtCO2 occurs because the air in the pulmonary circulation blocks blood flow and causes reflexive pulmonary vasoconstriction, each of which increases dead space ventilation

MOA of ETCO2 dropping in an in intraop PE?

Chronic alcohol use induces cytochrome P450 2E1 which also metabolizes many of the inhalation agents, opioids, and benzodiazepines decreasing their effectiveness and requiring higher doses.

MOA of ETOH abuse causing an increase in medication req. under general anesthesia?

Beta 2 effect-glycogenolysis, glucagoneosis, glucagon release,crease insulin secretion.

MOA of Epi increasing blood sugar?

Fondaparinux was designed to mimic antithrombin III in structure., therefore directly binding to factor 10a.

MOA of Fondaparinux ?

pralidoxime or obidoxime) should be administered to regenerate acetylcholinesterase but only after administration of atropine to avoid the transient worsening of oxime-induced acetylcholinesterase inhibition. Seen in organophosphate posioning.

MOA of Pralidoximine and when should it be administered?

Dexmedetomidine acts on α2 receptors in the brain and at the locus coeruleus of the spinal cord. EEG represents NREM sleep.

MOA of Precedex and what is the response on EEG?

The pathogenesis of vasospasm is believed to be due to the lysis of blood releasing spasmogenic compounds. SAH should receive oral nimodipine, a calcium-channel blocker, within 48 hours after symptom onset for a total duration of 21 days neuroprotection by dilation of small cerebral arteries, decreased platelet aggregation, reduction of calcium-dependent excitotoxicity, and inhibition of ischemia by lysis products.

MOA of SAH vasospasm, what medication is best used for it/prevention and why?

-Low-frequency TENS therapy stimulates μ-opioid receptors -while high-frequency TENS therapy tends to affect δ receptors. -May not be as effective with patients who are getting chronic opioids.

MOA of TENS causing pain control? Which patient population isn't it very effective in?

Stimulation of Alpha-Beta fibers ==> Blocks Alpha-Delta fibers & C-fibers ==>decreases myofascial pain, neuropathic pain. TENS units can be antagoniszed with Narcan, implying that there is potential MU-receptor involement in addition to release of endogenous endrophines. Appropriate for both acute and chronic pain. TEns units can be limited by: incorrect electode placement, compliance

MOA of TENS units, use, and potential antgaonism to it?

FFP/Platelets likely to most cause it -->Antibodies/lipids in the DONOR products -->activates patient's neutrophils (granylocytes)-->releasing inflammatory products -->ncrease of vascular permeability → plasma transudation into pulmonary.

MOA of TRALI?

Lysine analog = blocks plasminogen -->plasmin = plasmin can't lyse the clot(fibrinolysis) = stablizes clot = decreasing bleeding. tPA and Atleplase do the opposite = fibrinolytic (lysis of clot) = by activating plasminogen --plaslmin = break down of clot.

MOA of TXA? TPA?

GPIIB/IIIA inhibitor = stops fibrinogen cross-links between Platelets. IV only.

MOA of Tirofiban?

Pro-drug via 2D6 to O-des-methyl-Tramdol into two enantimers: - (+) = mu receptor agonism - (-) = inhibition of serotonin & NE

MOA of Tramadol?

Wafarin indirectly effect coagulation cascade by: -->blocking vitamin K reductase -->decreasing vitamin K ---> Decreasing gama-carboxylation of glutamate residuse on II, VII, IX, and X, protein C, Protein S. PCC + Vitamin K

MOA of Warfarin. How is it reversed?

Most efficent circuit for spontanously breathing patients. CO2 elmination is FGF = to MV. FGF = bag ========APL==Pt.

MOA of a Mapleson A circuit?

TENS unit produces analagesia by increasing circulating B-endorphins and by activating inhibitory pathways. Activation of inhibitory pathways is done by: -Activating A-beta fibers (cutaneous mechoceptor response) which then inhibits C pain fibers and A-delta fibers in a term called "closing the gate".

MOA of a TENS unit for post-inicisional pain? What does closing the gate mean?

oxygen is readily absorbed from the alveoli, unlike air, which is largely composed of nitrogen, an insoluble gas, that is not absorbed from the alveoli and can splint the alveoli open.

MOA of absorption ateletecsis

Blocks the CA in the PCT = CA helps absorb Na, Cl, and Bicarb from the urine into the blood = weak diuretic effects considering fluid isn't resorbed in the PCT and decreases the pH = decrease in ICP & ocular pressures = decrease in pH = increase CO2 = increase RR

MOA of acetazolamide

Preload increase to right atria = stretching of B Stretch Mechanoreceptors = Afferent response to medulla via CN X = efferent response to block Parasympathetic activity = increase in HR. (Also stretching of atria causes SA node to fire). Bainbridge prodominates unless the patient is hypovolemic, then the baroreflex will take over.

MOA of bainbridge reflex

There is decreased responsiveness to ß-receptor stimulation. This is likely due to inadequate cellular signaling rather than to a decrease in the number of ß-receptors. This leads to a decrease maximal HR

MOA of beta receptor decreased response in older patients? How does this effect older patients?

Tissue hypoxia by blocking oxidative Phosphorylation

MOA of cyanide?

Decrease capillary leakage across membranes, considering Vasogenic edema is 2/2 BBB disruption. Can be viewed on MRI as T2 hyperintensity in white matter. Cytotoxic edema is usually seen in gray matter, 2/2 to hypoxia. Steroids not useful and can cause harm.

MOA of decadron for vasogenic edema?

increases with mild to moderate hypothermia because peripheral vasoconstriction increases the blood volume in the central compartment. Also a decrease in ADH. This effect declines in severe hypothermia 2/2 decrease CO = decreased Renal Perfusion = oliguria.

MOA of diruesis in hypothermia?

platelet aggregation inhibition, factor VIIIc and vWF reductions, decreased activity of factor VIII, and red blood cell coating by dextrans. More pronounced with LMW solutions.

MOA of dysfunction s/p colliods?

binds and inhibits the alpha2-delta subunit of the voltage-gated calcium channel. This results in a decreased release of the excitatory neurotransmitter glutamate.

MOA of gabapentin

glucagon is to increase the amount of available glucose in the blood by stimulating gluconeogenesis, glycogenolysis, and lipolysis, which produces substrates that can be used for gluconeogenesis preventing glycogenolysis preventing glucose to be used as stores.

MOA of glucogon to increase glucose?

Diffuse alveolar hypoxia produced by an acute increase in altitude = global pulmonary vasoconstriction = dramatic increase in pulmonary vascular resistance = RV strain.

MOA of high-altitude pulmonary edema (HAPE)?

2/2 to SNS activation leading to spasm of the LPS muscle, causing lid lag

MOA of lig lag in hyperparathyrdoism?

Postive pressure ventilation @ 8 ml/kg ==> intrathoracic pressure increase == squeeze vessel in the thorax ==increasing blood to the left ventricle for a short period of time =resulting in an increase in stroke volume and pulse pressure = pressure then goes down with expiration.

MOA of mechanical ventilation and PPV & SVV?

F2+ = ferrous= able to bind oxygen is oxidized to F3+ (FERRIC) which can't bind oxygen ==>FE3+ without oxygen attached goes to the tissues ==>no oxygen to the tissues when >30% of the Hemoglobin. Death >50% Only value that will change is the PO2. 7.27/32/100/15 -->7.27/32/300/15 SPO2 = 85. |. SaO2% = 100. co-oximetry directly measures the amount of MetHb present and determines the true SaO2

MOA of meta-Hg after benzocaine? What is the only value that will change after ABG?

Nitro enters the Endothelial cell from the blood ===> converted to N.O. ===>NO activates activates guanylyl cyclase == makes cyclic GMP ===>Cyclic GMP goes on to: -de-phosporlate myosin light chain -Sequester intra-calcium SR -increase relaxation. undergoes high first-pass metabolism by the liver, so best to be given SL, transdermal, or IV which doesnt go throught portal circulation.

MOA of nitroglycerin?

fifth and tenth weeks of gestation, the abdominal contents are extruded through the extraembryonic coelom, only to return to the abdominal cavity by the tenth week.

MOA of omphalocele?

pre & post-receptors of the dorsal horn. pre-synaptic-causes an inhibition of Adanylate Cyclase resulting in a decreased in cAMP production-->decrease calcium intracellullary--> and decreased release of the glutamate, substance P. At the post-synaptic site, opioid receptor activation results in increased membrane permeability to potassium and potassium flows down its gradient and out of the cell, hyperpolarizing the post-synaptic membrane and decreasing action potential transmission.

MOA of opioids

Phenyephrine eye drops causes pupilary dilation and conjuctival vessel constriction. Dilation is done by A1 receptor activation, causing contraction of the radial smooth muscle found in the iris. Usually done in conjunction with muscarinic antagonists create a state of pupillary dilation and cycloplegic can cause acute glucoma in narrow-angle glucoma.

MOA of phenylephrine on the eye and what does it do?

Can be seen in TPN when the patient is nutrition is done quickly in a patient who is malnoroushed when causes a shift in catabolic to anabolic state ==>insulin released overload ==>electrolyte issues: -Low phosphate -Low magensium -Low potassium

MOA of refeeding syndrome?

High vagal tone and decreased responsiveness of adrenergic receptors Fibrous conductive tissue and loss of SA nodal cells.

MOA of rthostatic hypotension and poor efficacy of the baroreceptor reflex are commonly seen in older patients.

binding to muscarinic receptors on the SA node. Can be tx with atropine or pre-treated with atropine if < 1 years old.

MOA of sux causing bradycardia in kids?

-t depolarizes both postsynaptic and extrajunctional receptors. It leads to membrane hyperpolarization and desensitization.

MOA of sux?

Terbutaline increases cAMP, resulting in uterine smooth muscle relaxation, via activate of Beta 2-->Gs-coupled and leads to activation of adenylyl cyclase = increase in cAMP = de-Phosphorlation of myosin light chain = smooth muscle relaxation

MOA of terbualine?

Thizides work on the NA/CL cotransporter in the DCC, to maintain electrical neutrality H+ and K+ are also dumped into the urine. Calcium is resorbed from urine into the blood. = Hyponatermia, mag2+, metabolic alkalosis, hypercalcemia.

MOA of thiazides

Response is opposite in tissues vs. pulmonary vascular systems in the face of hypoxia: -Systemic vascular tone decreases 2/2 to increased release of endothelial N.O. -Pulmonary vascular tone increases 2/2 to hypoxia causing an increase in intra-cellular calcium.

MOA of tissue hypoxia and response from vessels vs. MOA of hypoxia in the lungs and response from vessels?

Tramadol = metabolized into active O-Des-methyl-tramdol by 2D6. Also into + and - enantimoers. (+) & o-Des-methyl-tramdol work on mu receptors while (-) works on blocking serotnonin & norepi re-uptake. CYP34A primarily just produces inactive compounds of tramdol.

MOA of tramadol? What is the role of cyp34A?

Expiration has no issues and will blow open the lesion when it passes it. Inspiration-lesion will cause the trachea to collapse. Resulting in a decreased inspiration pattern.

MOA of variable Extra-thoracic lesion?

Vecuronium is partially metabolized by the liver with one byproduct that maintains 80% of the potency of the parent compound

MOA of vecuronium causing prolonged in renal patients?

difficult intubation due to pregnancy-related changes, the short duration between induction and surgical incision, and the use of lower doses of anesthetic agents due to concerns for fetal or maternal wellbeing

MOA of why c-sections are consider increaased risk of intraop awareness?

WPW has an accesory bundle that bypasses the AV nodal system and can be prone to anterograde or retrograde conduction putting them into SVT. If it does happen, tx with: procainamide, ibutilide, or electrical cardioversion rather than with AV node-blocking agents.

Main MOA of WPW? TX?

Anesthesia: noncompetitive inhibition of NMDA receptors with minimal or no effects on GABA. Analagesic effects: Release of endogenous opioids or through weak direct agonism of opioid receptors. -minimally effects hemodynamics & respirations = stimulates SNS causing increase in SVR, CO, decrease TV and increasing RR w/ overall minimally changes on MV. -Increase ICP and CBF.

Main N2O anesthestic effects? Other pearles?

SIADH is Euvolemic or hypovolemic

Main difference between SIADH compared to Cerebral salt waiting and DI?

Type 1: Absense of nerve trauma. Type 2: occurs in the setting of nerve trauma.

Main difference bw CPRS 1 &2

Cardiogenic = intracardiac = low CO high SVR Obstructive (PE) = Extracardiac = low CO, high SVR 2/2 to low RV output

Main differences between extracardiac and intracardiac shock?

Reflex = pure reflexive vagal stimulus, the bronchoconstriction tends to be in the larger airways and more central. Antigen-induced histamine response =bronchoconstriction tends to be in the more distal bronchioles in the periphery of the lung.

Main differences between reflex and histamine-mediated bronchoconstriction>

-low dose TCA -SNRI (dulextine) -pre-gabalin -Gabapentin

Main medication tx of Fibromyalgia?

A fall in PaO2 below 65 mmHg = CN9 to increase respirations

Main response to ventilation is activation of the carotid bodies how?

AICD considering they are at risk of SCD via ventricular arrythmias and are more prone to a-fib.

Main-stay prevention in Brugada syndrome patients?

pH, PO2, PCO2 = measured. Bicarb, base-excess is calculated.

Measured vs. calculated blood gas values.

Bainbridge reflex-if Atria are full, HR goes up. If atria are empty HR goes down. Venodilation causing a decrease in pre-load. Atria gets smaller. HR decreases to Bradycardia and can get to asystole.

Mechanism of cardiac arrest after anesthesia is due to what?

medications (such as caffeine or aminophylline). Caffiene can be injected shortly after induction if the risk of apnea is high.

Medications used to treat infant apneas?

Epinephrine and vasopressin -Vaso = Low dose vasopressin infusions have been shown to increase nitric oxide at endothelial cells of cerebral, renal, and pulmonary vasodilation. Constriction of mesanteric and PVR. -Epi:

Medications which increase CBF and perfusion?

Conjugation into Morphine-3-glucurinide & morphine-6-glucuronide. =M3G = little to no analegesic effect. Can however, cause neuroexcitiation-hyperanalgesia, allodynia, and sexiures, M6G = potent mu & delta receptor compared to mirphine.

Metabolism of morphine?

Minimal Sedation: normal response to verbal stimulation, airway unaffected, spontaneous ventilation. Moderate Sedation: purposeful response to verbal or tactile stimulation, no intervention maintain a patent airway, adequate spontaneous ventilation, and cardiovascular function usually maintained. Deep Sedation: purposeful response following repeated or painful stimulation, airway intervention may be required, spontaneous ventilation may be inadequate, and cardiovascular function usually maintained. General Anesthesia: unarousable even with painful stimulation, intervention on the airway often required, spontaneous ventilation is inadequate, and cardiovascular function may be impaired.

Minimal vs. General anesthesia?

After general anesthesia, it is no longer MAC-intubation not always required for general anesthesia, but is often required.

Monitored anesthesia care (MAC) is not a defined sedation level but is a spectrum from minimal to deep sedation. When is it no longer called MAC?

-Early: Strep & H. Influenzae, Staph ~48-72 hours. -Late: Pseudomonas, Acinetobacter, Staph ~72 hours Decreased risk: -Hand washing, head of bed at 30 degrees, ppx only for high risk patient, EVAC tube. PPX can reduce acid and more bacteria can grow in the stomach = increased risk.

Organisms associated with VAP? -Early onset? -Later onset?

Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, Group B streptococcus (GBS), and Listeria monocytogenes cause more than 80% of cases of bacterial meningitis

Organisms likely to cause bacterial meningitis?

Ryanadine Receptor Mutations Genetic mutations in the genes of the L-type Ca2+ Channel: (CACNA1S and STAC3). Inherited in an autosomal dominante pattern.

Origin of MH?

SVT.

Most common cardiac dysrhythmia in pregnancy?

Usually LV failure.

Most common cause do TR?

Placental abruption

Most common cause of DIC in pregnancy?

Uterine stony.

Most common cause of PPH?

VVI is ventricular demand pacing and is the most commonly used pacing mode. Downside: No atrial sensing and the ventricle will contract at the programmed rate despite the rate of atrial contraction = loss of atrioventricular synchrony = loss of cardiac output

Most common pacing mode?

Fetal bradycardia

Most common sign of Uterine rupture

Proximal esophageal atresia (EA) with a distal tracheoesophageal fistula (TEF). Will have large gastric bubble. AKA type C.

Most common type of TEF?

2/2 to operating room temperature. Conduction to the operating room table has minimal heat loss. Radiation and covection are the two biggest mechanisms of heat loss in the OR to the enviroment. Radiation: body-->enviorment via infrared rays. = major type of loss Convection: Air currents disrupts thing amount of insulating layer of air 2/2 to exchange in the OR exchanged every 15 minutes.

Most common way the patient loses heat via radiation and convection?

TEE > EKG > Hemodynamic changes

Most sensitive to least sensitive detection of coronary ischemia?

-deltoid, long head of the triceps, and teres minor -numbness to the lateral upper arm, weakness with shoulder abduction, flexion, extension, and rotation. -EMG useful to identify nerve injury

Muscles the axillary nerve innervates, s/s of injury, and how to Dx. it?

Pre-J: -CMT = peripheral nm weakness, NMBD = prolonged block. -Friedrich: AR, CHF & resp. failure, avoid NMBD(above) and Succs 2/2 deinnervation. Post-J: -DMD = x-lined, increased intracellular ca2+ 2/2 to sarcolemma perimability = increased risk for rhabdo with sux and inhalational agents. Sensitive to NMBD. Plt issues + smooth muscle issues = increased risk of bleeding. Keep heart full 2/2 to non-compliant ventricles. Proximal atrophy. Myotonias: -Mytonic dystrophy = complete relaxation, AD, restrictive lung disease, OSA, sensitive to Neuromuscular blocking drugs. conduction heart issues. monitor glucose. increased risk of aspiration 2/2 to bulbar issues.

Mytonias at the: -Pre-junctional -Post-junctional:

Blocks the femoral and saw lateral cutaneous femoral nerve. Fata lata and fascia iliaca.

Nerves blocked for Facia Iliaca block.

Provides neuroprotection by: -constriction of cerebral vasculature = decrease ICP without a decrease in MAP = Increasing Cerebral perfusion pressure [MAP - ICP] -Neuroprotective by decreasing CMRO2 = decrease oxygen demand of the brain. -neuroprotective for focal > global ischemia. -EEG signals from Low voltage, fast --> High voltage, slow -->burst -->EEG silence.

Neurologic effects of barbiturates?

Sodium = important in maintaining the osmotic pressure. Albumin= important in maintaining the oncotic pressure. and its based on the formula: 2 (NA) + Glucose/ 18 + BUN/2.8

Normal osmolality of the body is what? What is the most important to maintaining the osmotic pressure?

OCR may occur from the pressure of local anesthetic infiltration in a retrobulbar block and topical lidocaine prior to manipulation may blunt the reflex Ketamine can also blunt the oculocardiac reflex.

Oculocardiac reflex may be blunted using which block?

PHTN: when one lung is removed, it can cause the right ventricle to fail. 46 CO2: when a lung is removed, it can cause the CO2 to get higher. predicted posto Fev1 < 800 cc: can result in an being a respiratory cripple.

Old Contraindication to pneumonectomy

Propofol-based anesthesia Adequate fluid resuscitation (>30 mL/kg of crystalloid) has also been found to decrease the risk of PONV in children compared to more restrictive fluid management strategies.

One way to help decrease PONV in kids is how?

The cricoid cartilage is the only complete cartilaginous ring in the upper airway.

Only complete cartilaginous ring in the upper airway.?

T8 level

Open appe/inguinal hernia repair should cover what level wth spinal anesthesia?

fentanyl

Opioid that undergoes a large first-pass metabolism and temporary retention by the lungs?

Atropine, glucagon, narcan, Nitro.

Opioids can increase Oddi Tone, can be reversed how?

hydromorphone metabolite hydromorphone-3-glucuronide = excitory, myoclonus in renal failure patients. morphine is metabolized to morphine-6-glucuronide, Meperidine is broken down into the neuroexcitatory metabolite normeperidine; this can result in seizures, agitation, and myoclonus in renal patients.

Opioids with byproducts which can cause harm?

Type I collegen with I-IV types 2/2 to a mutation in COLA1A or COLA2A gene. Type OI is most severe. Anesthesia considersations: Increased suspectibly to MH, Cervical artery dissection, restrictive lung diease 2/2 kyphosis, big heads can lead to hydrocephalous, increased Aortic dissections,

Osteogensis Imperfecta is a Diesease of?

Coarctation is commonly associated with a bicuspid aortic valve, persistent ductus arteriosus, and/or VSD.

Other anamolies seen with Coartctation of the Aorta?

Butyrylcholinesterase is also known by other names such as plasma cholinesterase or pseudocholinesterase.

Other names for plasma cholinestrases?

CaO2 = (Hgb * 1.34 * SaO2) + (0.003 * PaO2)

Oxygen content formula?

Right shift = need the oxygen to be released to the tissues. Left shift = hangs on to oxygen and doesn't need to be released to the tissues.

Oxygen hemoglobin curve.

Bounding due to increased aortic pressures compared to right heart pressures. Indomethocin will close by blocking Prostoglandins.

PDA pulses will feel how?

Hypoxemia, hypotension, Drop in CO2-35—>18.

PE dx intraop

Decrease V/Q mismatch, recruit alveoli, increase FRC which redistributes lung water from the alverolar units to the intersitium. It doesn't reduce lung water-infact can increase lung water by impeading lympahtic drainage.

PEEPs does what to water?

Normal > lower airway obstructive defect > or rarely restrictive defects ight ventricular outflow tract obstruction and be associated with mitral valve prolapse, right-axis deviation, heart displaced to the left, and functional murmur Ravitch (open) or Nuss (less invasive) procedure. Invasive procedure can lead to cardiac perforation.

PFTs of Pectus Excavatum? What about cardaic? How is it fixed?

1.) low VC 2.) RV/VC ratio-a lot of RV to VC increase risk of issues post op. >50% 3.) Predicted Post Op FEV1 = (pre-op FEV-1% predicted x % of lung tissue which remains). Good if >40%. <30% = increased risk. 4.) Post-Op DLCO of <40% -DLCO X % of lung tissue predicted to have left. 5.) VO2 max -max oxygen consumption. >15 mL/minute low risk <10 ml/Minute is high risk. 6.) 6 minute walk test < 2000 = VO2 max < 15 ml/min or an exercise SPO2 that drops by 4%.

PFTs which increase risk for M&M in thoracic surgery patients which put them at increased risk of M&M and post-op ventilator support?

cranial and pelvic portion -3,7,9,10 and pelvic splachnic nerves of S2-S4. -Long pre-ganglionic nerves, short post-ganglionic nerves

PNS innnervation

These indications can be further simplified as: - Symptomatic sinus node disease - Symptomatic atrioventricular node disease, particularly high grade AV block - Long QT syndrome - Hypertrophic obstructive cardiomyopathy - Dilated cardiomyopathy

Pacemaker indications include?

pancuronium-also: ketamine, atropine, ephedrine, and epinephrine, 2/2 to stimulation of SNS => thyroid storming.

Paralytic which should be used with caution in hyperthyroidism?

Sux and atracurium

Paralytics associated with histamine release?

ester hydrolysis and Hofmann elimination = Succinylcholine, atracurium, and cisatracurium.

Paralytics which are elminated by hoffman elimination or ester hydrolysis?

At T1.

Paraplegia vs. Quadraplegia happens at which level?

Helper T-cells will present an antigen to the Naive B-cells, which turn them into plasma cells that release the specific antigen antibody. If an antigen is countered, immune system will attack it with antibodies and by binding, will cause a compliment casecade reaction and destruction of the pRBC. Antbodies sticking together causes agglutation and is seen on the crossmatch test as the indirect coombs test.

Pathologic process of causing agglutation of RBCs?

Endothelial damage within the placenta results in release of vasopressive substances. Increased TXA2> prostacyclins results in vasoconstriction and platelet dysfunction. Also an increase in endothelin.

Pathological reasoning of Pre-E

Hyperglycemia 2/2 insulin def = fatty acid break down to ketone bodies = increased in osmolality in the blood and Metabolic Acidosis = fluid and electrolyte shifts intracellular to extracellular = hyponatremia, hyperkalemia,and hyperphosphotemia. -Hyperkalemia + Hyperphosptemia is a misnomer and the total body depletion will actually happen of these two, especially when correction occurs with insulin pushing both back into the cells.

Pathophysiology of DKA and electrolyte shifts?

Cold/hot sensation vis c-fibers & A-delta fibers -->Lateral Spinothalamic tract -->VPL thalmus--somatosensory cortex & hypothalmus--->if temp is 0.2 off from set point will send signals for shivering or vasodilation (cold vs. hot).

Pathway of autonomic temperature regulation?

Superior sagital, straight sinus, and occipital sinus ==> confluence of sinuses ==> bilateral transverse sinuses ==>sigmoid sinus ==>IJ Straight sinus drains great cerebral veins and inferior sagittal sinus

Pathway of sinus drainage in the brian?

Antero-Lateral spinal cord = pressure, crude touch, pain, temp---> -->Alpha-delta & C-fibers---->DRG---->X-->VPL thalmus --->Post-central gyrus. Pain-->DRG = first order DRG --> thalmus = 2nd order Thalmus --> Post-central gyrus = 3rd order.

Pathway of the Spinothalamic tract?

Absent seizure s= spikes at 3 mHz grand-mal seizures = spikes with slowe-wave activity.

Pattern of seizures on an EEG?

5 categories to assess emergence delirium: awareness of the environment, eye contact, inconsolability, purposeful movement, and restlessness.

Pediatric anesthesia emergence delirium score is made out of how many parts? j

20-40 cc/kg bolus initially with isotonic fluids-->periop infusions of 20-40 ml/kg in the first 2-4 hours and then Maintenance rates in the 12 hours immediately post-op = 2-1-0.5 ml/kg and then returned to 4-2-1 ml/kg/hr if thr patient isn't tolerating food intake. Used to be the 4-2-1- rule with dextrose containing hypotonic fluids which would result in hyponatermia 2/2 to fluid excess & ADH increases.

Pediatric fluid management?

patient age (> 3 years old), duration of surgery (> 30 minutes), type of procedure (strabismus repair and adenotonsillectomy), family history. Increasing chances of PONV = 9%, 10%, 30%, 55%, and 70%

Peds PONV risk factors?

Doesn't reduce it, but will redistribute it out of the alveolar units and into the interstitial tissue. Can possible impede the lymphatics which drains the lungs and worsen pulmonary edema.

Peep effect on pulmonary edema?

After the QRS complex. Then results in Isovolumetric contraction.

Per the EKG when does closure of the Mitral valve occurred

Abnormal reactivity: -Meconium, RDS, Sepsis, maternal smoking. Abnormal or underdevelopment: -Pulmonary hypoplasia, CDH, Pulmonary atresia, Other: -Maternal NSAIDs, SSRI, PV stenosis, Down's, Polycythemia.

Persistent fetal circulation is noted to have pulmonary HTN with patent FO and PDA along with a R-to-L shunt. At bith, this pulmonary artery pressure falls. What are some conditions that result in persistent fetal circulation?

Phase 1: TOF > 70, all of them feel equal. No fade. If neostigmine given, it would prolong block. Phase II: 2/2 to repeated sux doses or an infusion, TOF < 30%, Post-tetanic potentiation, and partial reveral of block with neostigmine

Phase I vs. Phase 2 block?

Phase I: -Cytochrome P450 system. -Mixed Oxidized to a water soluble metabolite which can be excreated in the liver. -Induced by ETOH, Ketamine, barb. -Inhibited by: HIV drugs, cimetidine. Phase II: -Conjugation with Glucuronide, sulfate -Extreated into the kidney or into the billary system into the gut. -Metabolism dependent on liver to the blood. -Lidocaine, morphine.

Phase I/Phase II liver metabolism explained

Pre-Hepatic = inision -->cross-clamp. Anhepatic = cross-clamp -->unclamping & perfusion. Neohepatic = unclamping & reperfusion --->abdominal colosure.

Phases of Liver Txp?

Reduced Atmosphere pressure = decrease PAo2 = decreased O2 to tissues: -SNS activation = increase in CO & HR -Vasodilatory effects = decrease in SVR initially from hypoxia. -Initial drop in MAP, then increase in MAP.

Physiologic effects of what happens to patients who climb atltitudes and results in hypxia?

Alpha waves = awake with eyes closed = 8-12 mHz Beta waves = awake & attentive, REM sleep = 13-30 mHz Gamma waves = awake and concentrating = >30 mHz Delta waves = IV of NREM sleep = 0.1-4 mHz Theta waves = I-III NREM sleep =4-8 mHz

Physiological EEG waveforms

EDP goes up in heart and dependent on atrial kick to maintain preload and fill the LV--eventually LV fibrosis and decrease in EF --> LV dilation is a late and AI starts to happen too.

Physiology of AS

Initially = Na, K, Cl, low, H+ low = pH up-->kidney will try to increase H+ by releasing Na+/K+ into the urine. Later = Na/K+ reabsorbed from the urine, H+ dumped into the urine = acidification of urine, worsening Alkalosis = compensation by resp. acidosis.

Physiology of Pyloric Stenosis electrolyte issues?

High Intrathoracic pressure -->PA pressure increases-->hydrostatic pressure from the capillaries into the aveoli

Physiology of the Negative Pressure Pulmonary Edema?

-Shivering= works on 2AB receptors in the hypothalmus -Sedation & Anxiolysis = works on the Locus Ceorleus of the brain stem by activating Alpha 2 receptors resulting in a decreased Nore-Epi, increased GABA neuron activation in the VPL promoting the NREM sleep state. -Pain = works on dorsal rool of the spinal cord. -Braycardia: binding in the brainstem vasomotor center inhibiting the SNS

Precedex MOA on: -Shivering: -sedation -anxiety -Pain -bradycardia?

Decreased albumin/plasma proteins = higher drug within the blood, more fat = lipid binding with a longer half life, decrease metabolic capabilities,

Reasons why benzo doses should be decreased in elderly?

BBB is composed of tight junctions which limit the small ions like sodium to pass from the intracranial vessels to the paraynchema of the brain = so the primary driving osmotic forces the brain is the sodium = hence if sodium is corrected too quickly, it can cause smotic demyelination syndrome (ODS) 2/2 to repaid removal of H2O. -Rapid increase of sodium can result in cerebral shrinkage -Rapid loss of sodium can result in cerebral edema. In the extracranial blood vessels, there is no tight junctions and it allows sodium, other lytes to pass freely, so the main osmotic driving forces is proteins, not sodium.

Primary difference between the extracranial and intercranial capallries related to osmotic forces?

Injury = smooth muscle contraction = shear stress = pushes platelets to the exterior to where the injury is = platelets accumulate to the exposed collagen via platelet adhesion = platelets + VWF + collagen fibers. = leads to platelet aggregration via ADP + TxA2 release which actviates further platelets and causes vasoconstriction = platelet activation causes GPIIB/IIIa receptors to be expressed = biding to fibrogen ( factor I) to bind between two platelets which eventually gets turned into fibrin strands.

Primary hemostatsis overview

decreasing the incidence of PHN since it decreases the overall incidence of virus reactivation but also decreases the severity of disease if reactivation does occur.

Prior vaccination is the most effective means of decreasing the incidence of PHN because?

The Norwood procedure is used to correct: 1. Transposition of the great vessels. 2. Hypoplastic left heart syndrome. 3. Tetralogy of Fallot (TOF). 4. Patent ductus arteriosus (PDA). Consists of: -three stages with an atrial septectomy, bidirectional glenn, and Fontan at 18-24 months.

Procedure used to treat hypoplastic left heart, which is also used to correct:

After acetylcholine is released it is degraded into acetate and choline by cholinesterase and then the choline is recycled by being transported back into the cell by the Na+/choline transporter

Process of Ach termination.

Decrease in CBF = Decrease in CMRO2 = decrease in ICP. preservation of auto regulation & vascular regulation (unlike violatile agents that uncouple by increasing CBF and decreasing CMRO2)

Propofol TIVAs and their advantage in neurosurgery?

chronic condition following respiratory distress syndrome. Leads to Peribronchiolar fibrosis, disorganized pulmonary vasculature, airway smooth muscle hyperplasia, and enlarged alveoli MOA: oxygen toxicity, sepsis, inflammation, infection, and barotrauma.

Proposed MOA of BPD in neonates?

When opioids and local anesthetics are paired in the epidural, they act synergistically for analgesia without prolonging the motor block. Despite this, there is still a therapeutic ceiling in which increasing the dose only increases the side effects.

Pros of using opioids/local anesthestic solutions in the epidural solution?

Pros: Easy to recognize the anatomy with SL ETT vs. DL ETT, best device for difficult intubation patients, no need to replace at end of the case, block lobar > main stem only, less chance of cuff trauma on intubation. Cons: High dislodgement, tough to get secretions out, conversion from one lung to 2 lung ventilation is more difficult.

Pros/cons for the bronchial blocker?

-Lumbar puncture (HA risk = 22% | back pain = 25% | paraparesis = 1.5% -Carbonic anhydrase = decrease CSF production. -Steroids-reduces ICP -Weight loss -VP shunting.

Pseudotumor Cerebi can cause atrophy of the optic nerve leading to blindness. Visual distrubances are treated how?

Difficult intubation Obesity Chronic ETOH = 2/2 to inducing Cyto-2E1 = metabolizes Inhalation agents, Chronic opioids, and benzos (increases glutamatergic receptors expression)

Pt. related factors that lead to intraop awareness?

Patients at high risk for refeeding syndrome also have reduced levels of prealbumin (< 10 mg/dL). Leads to insulin influx when fed = shifting lytes into the cells = hypomag2+, hypo-Phosphate, Hypo-kalemia.

Pts at high risk for refeeding syndrome have what blood level that is low?

Uni = ipsi cord abduction = assume a paramedian position, as oppose to fully abducted. Bilateral = both vocal cords assume the paramedian position. This happens because the cricothyroid muscle will be unopposed resulting in adduction of the vocal cords. TEST 27 Q8

RLN injury:

tricuspid. 4x V^2 + CVP.

RV systolic pressure can be determined by measuring the jet gradient across which valve? What is the formula?

loss of at least 20% of the vertebral body's height or a 4-mm decrease in height from baseline.

Radiographic criteria for compression fractures include

GABA-B, 5-HT4, and alpha2-receptor stimulation, vasoactive intestinal peptide (VIP) and somatostatin = reduce release. M3, Beta-adenoregic, H3 = Stimulate release of serotonin.

Receptors and substances that reduce the release of serotonin? Receptors and substances that increase release?

alpha 1 and beta 1

Receptors tageted by levo?

Increase in plasma osmlality or hypotension = ADH release = operates on 4 types of receptors, VI,2,V3 and oxytocin-type receptors = V1 is for vasoconstriction of vessels, V2 is inserted in the apical surface of CD of kidney for the uptake of H2O. V3 in the pituitary and leads of ACTH, -Oxytocin-type receptors are found primarily in the myometrium, vascular smooth muscle, and vascular endothelial cells. Vasopressin acts on these receptors to increase endothelial nitric oxide synthase activity, resulting in vasodilation.

Receptors that AHD works on?

fastest to slowest: Diaphragm Laryngeal muscles Corrugator supercilii Abdominal muscles Orbicularis oculi Geniohyoid Adductor pollicis

Recovery from neuromuscular blockade of these muscle groups occurs in fastest to slowest: order?

they also typically experience a decrease in lean body mass.

Renal function commonly declines as patients age, even if they are healthy. A decrease in the number of functioning nephrons by 30-45% as well as a reduction in renal blood flow by 10% per decade after age 40 results in a progressive decline in glomerular filtration rate. Why does Createnine remain the same? What is a better marker for Renal Function?

-Lose glomular and tubals = can't concentrate as well = predisposed to AKI. -can't dilute as well, so a greater urine volume is needed to excrete a greater solute load.

Renal system in the elderly?

-RV increased (air trapping) -FRC increased -V/Q mismatch -PaO2 dropped (90--.>70) -Increased lung compliance/decreased chest compliance. -Closing capacity and tidal volume crosses over = V/Q mismatch.

Resp. Changes in the older patients?

Increased: RV = volume trapped in lung at the end of a forced exhalation. FRC (ERV + RV). CC. Compliance. -VQ mismatch = decrease in PaO2, lower surface area.

Respiratory changes in aging?

-Increase compliance = increase in FRC. -DLCO decreases. -CC increase = v/q mismatch 2/2 to an increase in A-a gradient. -increase in RV. -stiff chest wall. -impaired changes in pao2/PCO2. -left shift in the p50 decrease in elderly. -decreased response to HPV. -V/Q mismatch even more when going from a standing/sitting to a supine position.

Respiratory changes in the elderly?

Lipophillic drugs are as early as 30 minutes (fentanyl), where moprhine is a hydrophillic drug and can be seen after 24 hours.

Respiratory depression in spinal anesthesia with lipophillic vs. hydrophillic drugs?

Inital PS with bradycardia and then SNS response with HTN & tachycardia.

Response to ECT?

Needle size and type influence PDPH rate. Other risk factors include lesser body mass index (BMI), female gender, history of recurrent headaches, and previous PDPH.

Risk factors for PDPH with spinal needle is ~1%. What increases this risk factor?

general anesthesia or regional anesthesia with IV sedation, a history of prematurity, PCA < 60 weeks (especially < 42-44 weeks), a history of apnea, and anemia

Risk factors for POST-OP apnea in infants?

advancing age, lower educational level, and a history of previous cerebral vascular accident with no residual impairment.

Risk factors for Post Op cognitive dysfunction?

Hypotension, prolonged sx, large blood loss, crystalloid resuscitation, anemia, prone position, cardiac and prone spine surgeries. Pt risk factors: HTN, DM, Atheroscleosis, High BMI, Male, smoker.

Risk factors for Post-Op visual loss?p

Transient neurologic symptoms most commonly occur with lidocaine, mepivacaine, or chloroprocaine. Other risk factors include lithotomy position and knee surgery.

Risk factors for TNS?

->5 days in hospital, prior IV abx use within 90 days, septic shock at time of occurance, ARDS or CRRT prior to the occurance. Coverage against MRSA and Pseudomonas (one MRSA + 2 pseudomonal drugs>

Risk factors for VAP and current treatment?

cardiac or vascular perforation during these surgeries include the duration of the oldest lead (generally > 5 years for implantable cardiac defibrillator (ICD) leads), female gender, a BMI of less than 25 kg/m^2, and the removal of ICD leads when compared to pacemaker leads.

Risk factors for cardiac perforation during ICD/PACEMAKER removals are?

-FVC < 50% -PPO DLCO < 40% -PPO FEV 1 < 30% -VC < 2000 -VO2 < 10 ml/kg/min -ABG findings of CO2> 46 / PO2 < 60. Exercise tolerance of less than two flights of stairs is associated with an increased risk of postoperative respiratory failure.

Risk factors for post-op M&M/complications following pulmonary resection>

Age > 60 greater pain severity during acute zoster eurption. greater severity of skin lesion greater severity of prodromal pain location of eruption (ophthalmic CN V1 and brachial plexus distribution) immune suppresion.

Risk factors for postherpetic neuralgia include

Risk factors for subcutaneous emphysema include longer operative times, a greater number of ports, higher insufflation pressures or flow rates, retroperitoneal (vs. transperitoneal) laparoscopy, lower BMI, and older age.

Risk factors for subcutaneous emphysema from laproscopic surgery =

The risk of transmission after a contaminated needle stick is HIV, 0.3%; HCV, ~2%; and HBV, 23% to 62. Most likely to occur during or after needle disposal and recapping.

Risks of carrying Hep B, C, AND HIV after a needle stick is?

Hep B (5-30%) > Hep C (0.2-2%) > HIV (0.3%)

Risks such as needle depth, hollow bore, and viral load are factors when it comes to transmission seroconversion. However, which viruses have the highest to lowest rate of seroconversion via a needle stick?

Transport M3G + M6G across the liver hepatocytes -->blood (MRP3). Also transport them into bile (MRP2)-->Intestines-->Deglucuronidated-->morphine--.absorbed into enterocytes-->metabolize morphine back into M3G + M6G->blood stream.

Role of the Multidrug Resistance Transporter Proteins? How do they work in the enterohepatic cycling of morphine?

9% for each arm, 9% for the head, and 18% for each leg (9 for upper/lower), 9% upper torso, 9% upper torso, 9% upper back, 9% lower back.

Rule of 9's for adults?

cholinergic crisis (nausea, vomiting, excessive oral secretions, bradycardia, and hypotension. 2/2 to irreversible inhibition of acetylcholinesterase. Also due to excessive ach in the synaptic cleft, can present with fasciculations, muscle spasms, and, eventually, paralysis or profound weakness.

Rxn from sarin gas? sarin gas, soman, tabun, and VX

muscle rigidity, hyperthermia, tachycardia, myoclonus, hyperreflexia (distinguishing feature b/w MH. serotonergic agents (SSRI, SNRI, MAOI, and tricyclic antidepressants, methylene blue-MOAI). Tx: oral cyproheptadine, an antiserotonergic medication

S/S of Serotonin Syndrome when mixed with what meds? TX?

profound muscle weakness; respiratory failure; and cardiac abnormalities such as left ventricular diastolic dysfunction, atrial fibrillation, focal myocarditis, or AV conduction delays. Treatment includes cholinesterase inhibitors, corticosteroids, intravenous immunoglobulin, and plasmapheresis.

S/S of a myasthenic crisis?

1. Prosthetic heart valve 2. Heart repairs using prosthetic material 3. Hx of endocarditis 4. Congenital heart disease = a .unrepaired CHD with shunts presents (example in the middle of a staged procedure) b. Repaired CHD with prosthetic material (ex. VSD) within the last 6 months. c. Repaired CHD, but still has residual defects,

SBE PPX

Zero (154-154) -leads to increased potassium, decreased renal perfusion 2/2 to constriction and decreased renin secretion, hypercholremic metabolic acidsis. 2/2: -Decreasing SID -Hemodilution of bicarb

SID of 0.9%?

SID takes into account HCO3-, albumin, phosphate, and unmeasured anions. In NS, Cl- increases, Bicarb decreases. Important to acidosis happens 2/2 to dilutional acidosis 2/2 to negative SID in Net zero solutions.

SID takes into account which anions?

Help -->stop-->FIO2 100% -->Secure airway-->If no IV = IM epi 0.3-0.5 q 5-15 minutes | IF IV = 10-100 mcg q1-2 minutes-->IV fluids-->If continued hypotension start an epi 2-10 mcg/min drip.

Step-wise fashion to managing anaphyxlasis?

SIMV-minimal respiratory rate and tidal volume set. Allows the patient to breath spontanously between the set Tidal Volumes. Will not help the patient breathing if they take a breath. Pressure Support Ventilation-is ventilation which will give a set inspiratory pressure to the spantaneously breathing patients that will help them achieve a larger tidal volume. Assist Control-Tidal Volume & RR set. If patient breaths, will give a certain set pressure or volume

SIMV vs. Assist Control Ventilation? How is SIMV different from Pressure Support?

Located at Thorocolumbar at T1-L2: Cell bodies located in the lateral gray column of the spinal cord where its cells bodies-->Pre-ganglionic neurons-->ACH -->post-ganglionic release NE, Epi (adrenal medulla) and Ach (sweat glands) -Short preganglionic, long post-ganglionic.

SNS innervation:

Repositioning can be used as a tool to help differentiate.a spinal cord injury vs. potential nerve injury from prone position (AKA ventral decubitus position)

SSEPs can help decrease the potential for nerve injury in prone spine cases. What is one thing which be done to determine if there is spinal cord injury vs. plexus injury?

The safest flowmeter arrangement is one in which oxygen is downstream from other gases (rightmost position in these figures) since if there is a leak in a proximal flowmeter, oxygen will not be lost. Should be closest to the manifold outlet.

Safest flow meter set up?

C-section: T4-S4 Labor Epidural: T 10-L1 / S2-S4.

Sensory block for C-section? What about labor epidural?

Sesnory block lasts longer in ropi, bupi, and mipivicaine > motor block (lidocaine)

Sensory block lasts longest in which three LA?

SS: rigidity, hyperthermia, myoclonus, hyperreflexia, nausea, vomiting, and diarrhea. NMS: Mental status change, hyperthermia, rigidity, and dysautonomia, and does not have hyperreflexia.

Serotonin Syndrome Vs. NMS?

Hydration first to correct hypovolemia and hyperosmolality-->administration of insulin -->potassium. Monitoring should include hourly glucose mgt until stable with hyperglycemia correction not faster than 100 mg/dL/hour to decrease risk of cerebral edema. Also, BMP, Osmolality, and venous pH q2-5 hour.

Step-wise treatment of DKA?

OR-->Inhalational induction to keep spontanous + peep -->DL w/ tube size 1-2 sizes down -->press on chest to produce air bubbles. Airway should be secured in kids <6, even if not in acute distress.

Steps in managing Acute Epiglottis?

Lift arm to exagganuate blood-->wrap in ace -->two torniqutes with the distal one inflated first-->remove ace-->lidocaine of 0.5 mg which will allow 30-45 minutes of pain relief. Okay to place mercaine in the surgical incision, but in the vein.

Steps to a BEIR block

Sodium citrate is typically given before emergent procedures or spinal anesthesia in pregnant patients. The advantage of sodium citrate is that there is no pulmonary damage if it is aspirated unlike particulate antacids, which can cause significant and persistent damage.

Sodium citrate is typically given before emergent procedures or spinal anesthesia in pregnant patients. What is its advantage?

DI-urinating off free fluid. Serum sodium increase 2/2 loss of water. Low specific gravity in urine. SIADH-serum sodium diluted out. Sodium down. Cerebral salt waiting-serious sodium is down 2/2 salt being wasted. High urine output.

Sodium differences between SIADH, DI and cerebral salt waiting?

Blood: Gas: insoluable = lower number = faster onset and offset Oil: Gas: Inversely related to partial pressure of achieving 1 mac. Describes potency based on how lipid solulable and agent is. Example-Iso = potent 2/2 low PP to achieve 1 mac. high fat/blood coefficient will tend to result in a prolonged depot of anesthetic in the fat compartment that may slow emergence.

Soluabilities and what they mean?

increased intensity of motor blockade, theoretical reduction in uterine activity via uterine β-2 receptor stimulation, and decreased uterine and spinal cord blood flow via α-1 agonism.

Some disadvantages of dilute epi added to an epidural solution.

. Because of decreased surgical exposure, MIDCAB may be combined with angioplasty or stent placement for diseased vessels unable to be directly accessed. Because cardioplegia is not delivered and the heart is still beating during the anastomosis, pharmacological bradycardia with transvenous pacing and single lung ventilation may be required to help the surgeon

Some major differences between a MIDCABG and a CABG?

most common predictors of difficult mask Age >55 years, Body mass index ≥30 kg/m2, Edentulous, Male gender, Mallampati classification III or IV, Obstructive sleep apnea or history of snoring, Presence of a beard. The risk factors for difficult intubation? decreased mouth opening, reduced thyromental distance, Mallampati class III or IV, decreased neck mobility, inability to prognath, obesity, and a history of difficult intubation.

Some of the most common predictors of difficult mask ventilation? The risk factors for difficult intubation?

<40 W = HIGHEST RISK 40-50 W = sharp decline in risk 50-60 W = gradual decline of risk until it is rare for apnea. Also the gestational age of when the patient was born.

Sources on infant apnea vs. weeks of PCA?

Balance between Osmotic pressure which pulls fluid in and hydrostatic pressure which pulls fluid out of the vessel. Filtration Coeffient in the law refers to how leaky the capillary is.

Starling's law of Capillaries states

Static Compliance = periods of zero airflow = platue pressure = (platue pressure - PEEP). Dynamic Compliance = periods of air flow = Peak pressures effected = (Peak - platue pressure). Decrease in compliance = increase in pressure. Decrease Static compliance = increase in platue pressure. Decrease in dynamic compliance = increase in peak pressures.

Static and Dynamic Compliance?

Bare-metal stent: 30 days DES-stent: 365 days. But can proceed to surgery after a 180 days.

Stent and waiting.

Identify site-->flood the fluid with saline or add bone wax--->trend position(LOWER HEAD BELOW HEART = INCREASE CVP making it harder for atmospheric pressure from entering)-->compress the Internal jugular in crani or increase PEEP (increase CVP).

Steps to stop Venous Air Emboli?

Post-Export PPx (pep) immediately within the next 72 hours and continued for 4 weeks w/ 3 anti-virals==> HIV status of patient==>HIV testing in 4-6 months.

Steps to take when exposed to HIV blood?

1.) A patient taking steroids for less than three weeks that is at any does. 2.) A patient who is taking glucocorticoids in the morning that is less than 5 mg a day. 3.) A patient who is taking glucocorticoids equivalent to 10 mg a day every other day.

Steroids in patients

Straight leg raise is ~80% specific for discogenic disease, but only 50% sensitive. Meanwhile, the Slump test has > 80% sensitivity and specificity. Discogenic disease refers to a pathology of the intervertebral discs caused by catabolic activities over time and/or mechanical disruption

Straight leg raise is specific for what kind of back injury?

3,4-Methylenedioxymethamphetamine (MDMA) aka exctasy

Street drug that can cause potentially fatal serotonin syndrome that presents as hypertension, hyperthermia, and tachycardia.

Difference between cations and anions. When you're dehydrated the sodium increases which inceeasss the SID.

Strong Ion Deficit definition

T1-T4 innervates the Atrial and Ventricles with sympathetic activity. CNX innervates mostly the atria and SA node coming from the medullary cardiovascular center.

Sympathetic and parasympathetic innervate which part of the heart?

LOC, apnea, and bilateral dilated pupils (a result of parasympathetic inhibition of the Edinger-Westphal nucleus (midbrain)). Prevented by cauded needle direction.

Symptoms of an intrathecal injection with an interscalene block. How to avoid it?

The TAP block anesthetizes the anterior rami of the thoracolumbar spinal segmental nerves from T7 to L1 as they traverse between the internal oblique (IO) and the transversus abdominis (TA) muscles, blocking the subcostal, ilioinguinal, and iliohypogastric are the peripheral nerves that travel in the TAP

TAP block localization is where?

subcostal, ilioinguinal, and iliohypogastric nerves are the peripheral nerves that travel

TAP block targets anterior rami of the thoracolumbar spinal segmental nerves from T7-L1 as they traverse between the IO and TA muscles. What peripheral nerves?

Ventral rami of T7-L1 which includes in the plane between IO and TA: -Subcostal nerve -ilioinguinal -iliohypogastric

TAP block will block which nerves at which level?

A right to left shunt that causes an increase in Pulmonary vascular resistance.

TET spell in ToF is?

Performed within 6m-1year. 1..) Modified Blalock-Taussig Shunt = temporary because it can result in pulmonary HTN over time 2/2 to PA seeing systemic shunt. =Shunt between right-subclavian artery & pulmonary artery which allows blood to go from arterial--->PA-->lungs, bypassing the RVOT. 2.) Return for patch b/w VSD, expanding PA, and removal of shunt.

TOF surgical tx?

Decrease CO2, increase Pao2, Alkalaosis, vasodilators, and inhaled nitric oxide. Esmolol which can relax the an infundibular spasm (RVOT muscle spasm).

TOF ways to decrease PVR?

volatile anesthetics (eg, sevoflurane) have a vapor pressure less than 1 atmosphere at 20ºC and a boiling point above 20ºC gaseous anesthetics (eg, nitrous oxide) have a vapor pressure greater than 1 atmosphere at 20ºC and a boiling point below 20ºC.

The difference between volatile and gaseous anesthetics?

ischemia at rest, elevated biomarkers, new ST-segment depression, worsening heart failure or mitral regurgitation, low EF, VT, hemodynamic instability, recent PCI, and prior CABG, - High-risk TIMI score (> 2 points)

The following patients, per ACC/AHA guidelines, qualify for early invasive strategy:

heart rate (most important), inotropy, afterload, and preload (least important).

The main factors that increase myocardial oxygen consumption include increases in the following:

Venturi effect.

The main the main mechanism of the way jet ventilation works is based off what physics rule?

Due to a short half life of factor 7. Assess of liver dysfunction/Injury = LFTs.

Why is PT/INR a sensitive indicator for liver function? What is used to assess liver dysfunction/injury?

maternal diabetes, congenital infections, fetal anencephaly, fetal trisomies, and twin gestation with twin-to-twin transfusion syndrome. Amio fluid index >24 CM or single fluid pocket of 8 cm deep.

Things that can cause polyhydraminos.

History of preterm birth Cervical insufficiency Multiple gestation Other risk factors: non-Caucasian race, extremes of maternal age, low socioeconomic status, low pre-pregnancy BMI, inter-pregnancy interval < 6 months, abnormal uterine anatomy, trauma, abdominal surgery during pregnancy, tobacco and substance abuse, vaginal bleeding, infection, assisted reproductive technologies, and polyhydramnios.

Three highest risk factors for pre-term labor?

1.) respiratory mechanics: -postop predicted FEV1- greater than 40% 2.) cardiopulmonary reserve: What's their VO2 max: < 15 ml/kg 3.) lung parynchma: DCLO > 40% how well the lung can diffuse oxygen?

Three legged stool of assessing if the patient is healthy enough to undergo pneumonectomy.

Liver d/f, intrapulm. vascular shunting, and unexplained hypoxia 2/2 to V/P shunting = increased A-a gradient = resulting in platypnea (SOB while in sitting position) and Orthodoxia (hypoxemia that improves when lying down). Dx: PaO2 < 80 mmHg or A-a gradient > 15 mmHg on room air, pulmonary congestion as seen on TTE with contrast or dye and bubbles appear in the left side of the heart 3-6 seconds later.

Three main s/s of hepatopulmonary function and how is it diagnosed?

Hgt, Wgt, BMI

Three things that don't matter in spread of epidural?

I: histamine induced-tx by slowing down. II: Anaphyaxis/toid-tx by slowing down, epi. Seen in hx. of rxns, fish alx, vasectomy patients, pts on NPH insulin. III: Hep-protamine complex in pulm. circulation 2/2 to TXA2 activation = pHTN, RV failure. Tx by epi/milrinone, decrease infusion, and reheprinization. All reactions lead to pHTN = decreased CO, decreased LVEDP.

Three types of Protamine Rxns, MOA, treatments?

Flushing, diarrhea and cardiac involvment = Tricupsid regurg >> stenosis > pulmonic stenosis. 50% of deaths from carcinoid tumors 2/2 to cardiac failure. plaque-like deposits on the tricuspid and pulmonic valves that commonly present as tricuspid or pulmonic regurgitation, although stenosis may also be present.

Triad of Carcinoid Syndrome?

Leathal-Median suvival age = 7 days. =Microphthalmia, cleft lip, low set ears, hypotelorism (eyes close), hyplastic/absent ribs,

Trisomy 13 aka Pataue Syndrome?

Females > Males. LBW, Microagnatha, Prominent occiput, VSD, ASD, PDA, hernias, horseshoe kidney, limited hip abduction, rocker bottom feet, clenched hand with overlapping digits

Trisomy 18 aka Edwards syndrome is mostly found in what gender?

long face, wide nose, thick lower lip, and cleft palat

Trisomy 8 likely presents with?

corpus callosum agenesis and ventriculomegaly are suggestive of trisomy 8

Trisomy 8 most likely seen prenatal ultrasound exam as?

Increases potassium. Resp. Alkalosis decreases potassium (and magensium).

What does Resp. Acidosis do to potassium?

St. John's wort, rifampicin, phenytoin, barbiturates, carbamazepine, efavirenz, and nevirapine.

What does St. John wart to do to P450?

Tx by removing stimulus, deepening the anesthestic, if epidural in place use a higher concentration of % solution to achieve a denser block. Give nitro/nitroprusside. Regional/spinal anesthestic the best > epidural > general. will not be prevented with topical/local lidocaine to the urtherial surface because the propioceptors aren't blocked.

Tx and prevention of autonomic hyperreflexia?

Younger kids = bracing >2 y/o = open reduction and spica casting

Tx of congenital hip dysplagia?

Binding antibody Magnesium Dialantin.

Tx of dig toxicity?

Umbilical vein determines the status of mom/placenta. Umbilical artery determines status of baby. So looking at a mixed acidemia or metabolic acidemia of from the umbilical artery are predictive of poor fetal outcome.

Umbilical vein vs. umbilical artery acid-base status?

Ovarian (20) and Uterine arteries -->anastomosis -->spiral arteries-->intervillous space <----terminal villi on fetal side

Uterine blood supply comes from?

T10. Same as TURP

Vaginal delivery of a fetus andhip surgery spinal coverage?

Fused c-spine. Also presents with short-stiff neck, posterior hairline, associated with chiari malformations.

What about Klippel-Feil syndrome would make it difficult from an anesthesia standpoint?

fascia iliaca

What acts as a physical barrier keeping the local anesthetic around the femoral nerve rather than spreading toward the femoral artery and vein?

Peribulbar block > Retro bulbar block because the peribulbar uses a higher volume. Retrobulbar block often requires blocking the facial muscle as well at times. Unlike topical anesthesia which provides senory, but not very good muscle blockage.

What block produces a reliable block of the orbicularis oculi muscle for eye surgery?

Ace inhibitors can attenuate the hypoxic vasoconstrictive response. Attenuate equals and hit it.

What can ace inhibits do to the HPV response on OLC?

If anticoagulation is required, it can be converted to a heparin infusion and stopped before placement of an epidural and delivery.

What can be done with pregnant patients who require anticoagulation for something like a heart valve?

Fentanyl premedication may actually sensitize patients to pain postoperatively

What can fentanyl pre-medication do to patients post-operatively?

Introducers serve to prevent contamination of the CSF with small pieces of epidermis, which could lead to the formation of dermoid spinal cord tumors.

What can introducer needles serve to prevent?

Esmolol.

What can you give to slow down the HR of a heart transplant patient??

Fresh frozen plasma is not indicated for plasma volume expansion

What can't FFP be used for?

PV = alpha only. Hepatic = alpha and beta receptors. Hepatic artery can increase blood flow by as musch as a 100%

What catacholamine the PV and Hepatic artery have? How much can the hepatic artery send blood flow to the liver?

An increase in PVR. Causing a L to R shunt which is cyanotic.

What causes PDAs to be worse? What's the signs and symptoms.

elevated DLCO. (also asthma). -Anything that increases CO, lung volumes, and pulm. vasodilation tends to do this.

What do obesity do to the DLCO of the lung?

Drop in CO2. Inform surgeon -Initially flood the field with saline. -Ventilate with a 100% O2 Jugular venous pressure Place CVP at the sino-atrial junction to pull off air. Look for biphasic p-wave to look for correct placement. Lower the head

What do you do when there is a venous air emboli during a DBS case? What is seen usually?

When the foreign body lodges in and occludes the left mainstem bronchus, radiographs may show a hyperinflated left lung, flattened left hemidiaphragm, and contralaterally shifted mediastinum.

What do you see on chest xray for a patient who has a peanut stuck in their Left Main Bronchus?

Furosemide improves the symptoms of congestive heart failure (CHF) by moving patients to lower cardiac filling pressures along the same ventricular function curve

What does LASIX do to the volume/pressure curve?

Reduce hepatic flow 2/2 to decreasing venous return to the Heart and reducing the livers ability to drain via the hepatic veins. Also seen with Right Heart Failure. Inspiration increases hepatic blood flow by increasing Intrahoracic pressure and pushing blood foward to the liver.

What does Positive pressure ventilation do to hepatic flow?

R-to-L shunt will slow down induction of anesthesia of inhalational agents 2/2 to the fact that blood doesn't get to the lungs as well. However, induction with a lower blood:gas solubility will be slowed even more in a Right to Left shunt compared to a volatile anesthesia with higher coffiecent.

What does a R-to-L shunt do to the blood-gas coeffiecent?

Jugular bulb venous oxygen saturation monitoring (SjVO2) assesses the degree of cerebral oxygen extraction by measuring the mixed venous oxygen saturation in the jugular venous bulb. It represents a value between supply and demand of oxygen within the brain. Supply of oxygen the brain is dependent on: -CBF, CaO2, Hg concentration. Demand of oxygen to the brain is dependent on: -CMRO2. Mixed JV O2 should be around 55-75%

What does a jugular venous bulb mixed oxygen concentration represent?

positive LR indicates how much to increase the probability of having a particular finding/complication/disease given a positive test result)

What does a positive Liklihood Ratio mean?

-Increase CO (SV & HR) -Decrease SVR (Decrease viscocity) -R-shift of the oxy-hemoglobin dissociation curve.

What does acute blood loss anemia do the hemodynamics?

Right ward shift which allows for a decreaed oxygen binding capacity from Hg

What does anemia do to the Hg-o2 dissociation curve?

coagulation factor dysfunction, impaired platelet aggregation, and increased fibrinolysis.

What does cold do to the coag pathway?

Etomidate also decreases CMRO2, CBF, and ICP. So does propofol.

What does etomidate do to CMRO2, CBF, and ICP?

Intrathecal fentanyl, however, reduces IONV, perhaps by improving nerve block quality, decreasing supplemental opioids, or decreasing hypotension. metoclopramide (10 mg) was effective and safe for prevention of IONV and PONV in the setting of cesarean delivery under neuraxial nerve block.

What does intrathecal fentanyl do for intraop N/V under spinal? How can Intraop N/V be reduced?

Because it has low levels of 2,3 BPG. =less release of xygen to the tissues = left shift others: -fetal hg

What does large amount of blood do to the oxygen hemoglobin curve.

Leftward shifts

What does methmoglobinemia do to the oxy-hemoglobin curve?

MIDCAB specifically refers to bypassing diseased coronary arteries under "direct" visualization on a beating heart without a midline sternal incision. (LIMA) to LAD anastomosis through a left anterior thoracotomy. Because of decreased surgical exposure, MIDCAB may be combined with angioplasty or stent placement for diseased vessels unable to be directly accessed. Because cardioplegia is not delivered and the heart is still beating during the anastomosis, pharmacological bradycardia with transvenous pacing and single lung ventilation may be required to help the surgeon.

What does minimally invasive direct coronary artery bypass (MIDCAB) entail?

Post-junctional membrane has become repolarized.

What does porgressing from Phase I to phase II mean?

Dorsal group = Inspiration. Ventral Group = expiration.

What does the dorsal group of the medulla do? What about ventral root?

Increased beause there is a Vd is increased.

What does the dose of NMB need to be done?

converts the right ventricle into the main ventricle pumping blood to both the lungs and the body. The main pulmonary artery and the aorta are connected and the main pulmonary artery is cut off from the two branching pulmonary arteries that direct blood to each side of the lungs. Instead, a connection called a shunt is placed between the pulmonary arteries and the aorta to supply blood to the lungs.

What does the first stage of the norwood procedure do?

Clark electrode measures PaO2, enzymatic measures glucose, Sans measures pH, Severinghaus measures PaCO2.

What does the various electrodes of measure: -Clark -Sanz -enzymatic -Severinghaus

Higher volume of distribution requires the sux dose to be 2-2.5 mg/kg. Infants are 75% H20, while premature infants require a higher initial dose due to 85% H20.

What does there need to be a higher dose of sux in infants?

Trach and ETT deadcrease deadspace. Unless they're being mechanically ventilated through the ETT then deadspace is increased.

What does trach do to dead space? ETT?

Neural tube defects

What does vaproic acid cause during birth?

There is a prolonged block after. Also, resistant to NMBD like roc and will have to increase dose.

What happens after neostigmine is done giving and you have to get succs?

Ventilation = 0. Flow still going 2/2 to the PA supplying blood to the non-ventilated lung = a true shunt.

What happens during One Lung Ventilation regarding V/Q?

Point for biventricular pacing is to Synchronize the ventricles and atria, so if you turn it off.

What happens if a patient with biventricular pacing & an ICD has both features turned off for surgery?

The soft palate will elevate and move toward the affected side of CN X.

What happens if the CN10 withn the gag reflex is damaged?

Phase 4: Resting potential Normal cell permeability is restored. The Na-K-ATPase along the cell membrane pumps potassium into the cardiac myocyte in exchange for sodium.

What happens in phase 4 in the cardiac myocyte?

cardiac output initially increases during spinal anesthesia due to decreased afterload from a lower systemic vascular resistance, venous dilation reduces preload, and, eventually, a neutral or slight decrease in cardiac output is seen.

What happens to CO during spinal anesthesia?

Decreases in an non-linear fashion and results in CO2 platueing as MV increases to protect the patient from alkalosis.

What happens to CO2 as minute ventilation increases?

Doesn't changes. What does change is Blood volume, cardiac output, diastolic pressure drops 10-20 mmhG, Systolic pressure drops -0-15 mmhg,

What happens to CVP in pregnancy?

Ventilation-perfusion matching referred to as V/Q matching, decreases during drowning episodes. Rescue breaths are require first to provide oxygen and break a laryngospasm that may be lingering

What happens to V/Q in drowning episodes?

VC No Change | TLC Decreased (5%)| TV Increased (40%) FEV & FVC doesn't change. Airway resistence is decreased.

What happens to VC, TLC, and TV in pregnancy?

VD increases due to an increase in fat and decrease in lean muscle.

What happens to VD in eldery?

Goes down.

What happens to calcium levels with phosphate replesion?

-WBC and PLT decreases. -Overall a worsening coagulatopathic state as the patient gets colder due to pH and senstive temperature changes of enzymes to active platelets and coag factors.

What happens to coagulation during hypothermia?

Gastric emptying is only slowed during labor itself. Esophageal peristalsis and intestinal transit have been shown to be slowed during pregnancy. 2/2 to progestrone increase and decrease in motilin.

What happens to gastric emptying in pregnancy?

SVR will increase with inflation = BP increases. Deflate tourniquet = decrease SVR, decrease in core body temp, transient increase in co2.

What happens to hemodynamics when you Inflate and deflate a tourniquet?

The decrease in FRC along with the increase in minute ventilation (MV) causes the alveolar concentration of inhaled volatiles to rise at a more rapid rate.

What happens to inhalational agents in pregnancy and speed of induction?

It is increased. Also increased is the FEV1/FVC ratio.

What happens to inspiratory capacity in obese patients?

A wave = atrial pressure increased C-wave = tricuspid valve buldging back into the atria. C-wave is more prominent and A-wave is decreased because there is most blood in the atria at the end of atrial systole, so the pressure of the c-wave would go up.

What happens to the c-wave in a-fib? Why?

Increased cardiac output, tachycardia, and risk of atrial tachyarrhythmias can result from increased sympathetic output. As hypothermia worsens (<32°C), cardiac conduction begins to slow, resulting in bradycardia due to decreased spontaneous repolarization of pacemaker cells

What happens to the conduction system of the heart with hypothermia ini

Anemic patients are prone to turbulent blood flow since blood with low hemoglobin is less viscous

What happens to the flow of blood anemic patients?

Cells decrease in number in the Sa node. There is also fibrosis and fatty tissue leading to SSS, RBBB, a-fib.

What happens to the pacemaker cells in the elderly?

Goes up.

What happens to the potassium in Acidosis?

, transferrin and total iron-binding capacity rises. Despite a decrease in Iron levels.

What happens to transferrin and TIBC in pregnency?

Pulmonary artery dialates. In hypolastic left heart where a decrease in PVR can result in more blood going to the lungs, but not to the systematic circulation.

What happens with PVR in hypero2 and hyperventilating? When is this bad?

PAO2 decreased = PaO2 also Decreases =. Body senses = TV X RR increase = alkalosis = body dumps bicarb into the urine. This process eventually normalizes and to continue to hyperventilate, a dose of diamox is recommended.

What happens with altitude and what does Diamox do??

Met-hemoglobin where the F2+ -> Fe3+ Spo2 drops to 85%

What happens with benzocaine?

TPN is the strongest predictor of postoperative outcomes, and can be tracked with serum albumin levels:

What has been found to be the strongest predictor of perioperative outcomes in patients receiving TPN?

Early parenteral feeding is associated with improved intraoperative fluid management, decreased infection risk, and improved wound healing

What has been shown to improve status of omphacele and gastroschesis patients?

A decrease in PaO2 and Increase in CO2 in infants = increase in RR then a period of apnea. As oppose in adults which results in sustained increase RR 2/2 to peripheral activation of chemoreceptors.

What is 'hypoxic ventilatory depression'.?

describes how much resistance an ultrasound beam encounters as it passes through a tissue. Water and soft tissues have intermediate acoustic impedances, while bone has a high acoustic impedance and air has a low acoustic impedance (transmission).

What is Acoustic impedance?

Addisonian symptoms (e.g. orthostatic hypotension, muscle weakness, and hyperpigmentation) may also be observed due to reduced cortisol levels.

What is Addisonian Syndrome and what can cause it in chronic opioid patients?

is pain in an area that lacks sensation, often involving the face. Feared complication of neurolytic blocks like trigeminal neuralgia treatment.

What is Anesthesia Dolorsa?

Anesthesia dolorosa is pain in an area that lacks sensation, often involving the face. It is a feared complication of neurolytic blocks for the treatment of trigeminal neuralgia (e.g. radiofrequency rhizotomy).

What is Anesthesia Dolorsosa?

described as an increased pain response to noxious stimulation or pain out of proportion to physical findings Primary hyperalgesia occurs in the area of damaged tissue, while secondary hyperalgesia occurs in surrounding non-damaged tissue

What is Hyperalgesia? Primary vs. Secondary?

neurological disorder of the lateral femoral cutaneous nerve in which there is pain, paresthesia, and hypesthesia in the anterolateral thigh,

What is Meralgia paresthetica? Where does it cause the effect?

Morquio syndrome is the most commonly occurring mucopolysaccharidoses (MPS). It is also called MPS type IV. odontoid hypoplasia, significant scoliosis, short trunk dwarfism, and genu valgus. No intellectual disability. Careful with DL due to odontoid hypoplasia can be severe with marked ligamentous laxity predisposing to cord compression

What is Morquio syndrome and what is it associated with?

inferior portion of the septum and is associated with cleft formation in the anterior leaflet of the mitral valve. OS = 75% of ASDs, located @ midportion of the aterial septum where the fossa ovalis is. Associarted with MVP and MR

What is Ostium Primum ASD associated with? What about Ostium Secundum?

Neprilysin inhibitors, used in CHF. Main role is: Reduce sodium, volume retention, adverse cardiac remodeling

What is Sacubitril?

Bicab should be <30, and is a good indicator for hydration. Not potassium. Infact, potassium should be repleated after hydration.

What is a good indicator for hydration status in a pyloric stenosis patient?

Mix patient & normal plasma together = if factor defiency exists, 50% of normal coagulation factors will cause correction of the PT/PTT. If antibodies to a factor exists then the PT/PTT will not normalize after the study

What is a mixing study and what should be seen in aquired (antibody-mediated) factor 8 vs. congenital hemophilia A.

Pleural effusion

What is a sinusoid sign on ultrasound?

Width of the jet in AI to the left ventricular outflow tract. <3 mm = mild | > 6 mm = severe.

What is a vena contracta and how is it pathopneumonic?

When you give fluid to a patient and see no response in an increase in contractility of the heart per the frank starling curves.

What is a volume challenge and what will it do to someone in congestive heart failure?

16-lead, 8-channel recording of the summation of excitatory postsynaptic potentials generated in the cerebral cortex

What is an EEG?

100% of the drug is removed after it pass it through the liver. For example, drugs that are dependent on are more dependent on hepatic blood flow for the rate of elimination. Differs from Clearance which is defined as the volume of blood from which a drug can be completely removed per unit of time

What is an extraction ratio and what does it mean? How is it difference from clearence.

endoscopies, ophthalmologic procedures, and superficial procedures are considered low-risk procedures,

What is considered low risk prcoedure?

the temperature of a cylinder is raised to above the critical temperature of the gas within, all of the nitrous oxide will be converted to its gaseous state from liquid state, no matter how much pressure is applied on the tank.

What is critical temperature and what happens if the cylinder of nitrous exceeds this temperature?

Important part of the formula = Radius, since Doubling the radius will increase flow 16 fold. Q = (P*pi*r4)/(8*n*l) where Q = flow rate, P = pressure, r = radius, n = viscosity and l = length of tubing. Formula can only be applied with laminar flow.

What is in the Hagen-Poiseuille law formula? What is the most important part of the formula?

lipid solubility of opioids. higher coefficient signifying more lipid solubility Example: Fentanyl has a partition coefficient of 813, and sufentanil has a partition coefficient of 1778,

What is is measured by the octanol/H2O partition coefficient?

Radiant energy that is not effectively contained by shielding around the emitter or radiograph tube. Due to advancements this is minimal. Remnant Radiation: also called exit or transmitted radiation) is defined as the residual radiant energy that has passed through the patient without being absorbe

What is leakage radation? Remnant radation?

Right radial = pre-ductal = reflect whats going on in the head. left radial = post-ductal = reflects whats going on in the body and after the duct.

What is pre-ductal vs. post-ductal?

Needs proper platelets, fibrinogen, and temperature to work in pts.

What is required for Factor 7A supplementation to properly work?

Blood flowing through Non-Dependent lung / CO

What is shunt fraction?

Progressive MR (stage B): Vena contracta < 0.7 cm Regurgitant volume < 60 mL Regurgitant fraction < 50% Effective regurgitant orifice < 0.4 cm2 Stage D and C are forms of severe MR. -Stage D = symptomatic -Stage C = asymtomatic severe MR.

What is stage B Mitral Regurg? How does this differ from stage D or C?

which is defined as a drop of 15 bpm or more below baseline fetal heart rate for at least 120 seconds and less than 10 minutes

What is terminal decel defination?

Provided schedules of medications: I: High abuse, no medicinal purpose = Weed, LSD, MDMA II: High dependence, can be prescribed oral or typical, < 1 month = morphine, topical cocaine, oxycodone, hydrocodone NSAID III: Low-to-Moderate abused or high psychological dependence = 5 x w/in 6 months and can be called in. Ketamine, subxone, thopental, codiene NSAID IV: Limited physical or psych dependence = 5x in 6 months = benzos, phenobarb, tramadol, methohexital, sleep aids. V: cough medicine

What is the 1970s Controlled Substance Act?

Diastolic pressure - compartment pressure. Delta pressure is an indication for faciatomy.

What is the ACS delta pressure?

50 mL/100g/min with gray matter receiving 80% of the blood flow and white matter receiving the remaining 20%

What is the CBF at rest and how much goes to white vs. gray matter?

FA (Alveolar concentration ) / Fi(intake) ratio is dependent on the alveolar concentration.

What is the Fa/Fi ratio mostly dependent on?

Fisher grading scale is used to predict the likelihood of vasospasm occurring based on CT findings to predict likelihood of Cerebral Vasopasm. I- No bleed. II= < 1 mm thickness of blood. III = localized clot, verticle layer of blood. IV = Interecerbal or interventricular clot with diffuse or no SAH.

What is the Fisher grading scale?

As a general rule of thumb: Morphine: 10mg IV = 1mg Epidural = 0.1mg Intrathecal (1/10 ratio; very hydrophilic) Hydromorphone: 1mg IV = 0.2mg Epidural = 0.04 Intrathecal (1/5 ratio; intermediate) Fentanyl: 100mcg IV = 33mcg Epidural = 6-10mcg Intrathecal (between 1/3 to 1/5 ratio; very lipophilic)

What is the IV to IT dose conversion of morphine, dilaudid, and fentanyl?

Group of disorders at the muscular level 2/2 to abnormal ion channels which leads to temporary, involuntary contractions of muscle fibers. Most common = Stienert msucular destrophy, also includes Hyper PP and Hypok PP. Sux can lead to a hyperK respose 22 to muscle wasting.

What is the basis of myotonic diseases? Some common types?

42 L of body water = 0.6 x 60-70% Extracellular = 1/3rd or 33% = 25% interstitial, 8% plasma. Intracellular = 2/3rd or 66%

What is the composition of the body as far as fluid is concerned?

CBF = Diastolic BP - LVEDP (pressure inside the heart at End of Diastole). Higher the pressure in the heart, the more difficult the blood will go from the epicardium to the endocardium. Because of this, the endocardium is the highest risk of ischemia.

What is the formula for CBF?

DO2 = CaO2 x CO x 10 CaO2 = 1.34 * [Hgb] * SaO2 + (0.003 * PaO2) CO = HR x SV

What is the formula for delivery to tissue?

TENS unit produces stimulated by vibration or touch-->dorsal horn-->dorsal horn "gate" will preferentially transmit signals from the vibration or touch and block or dampen the nociceptive signa

What is the gate theory of a TENS unit?

Fix obstruction. Example-trachea stenosis or goiter.

What is the image show?

Autosomal Dominant. 2/2 to mutation os the first & second brachial arches resulting in impaired migration of neural crest cells, causing: -Microgathia -Hypozygomatic arch -Eaternal ear and canal issues = hearing loss -Coloboma of lower lit.

What is the inheritance of Treacher Collins Syndrome and what is the anesthesia concern?

CO2 builds up-6 mmHg first minute, then 3-4 mmHg for each subsequent minute. Apenic perioid shouldn't extend more than 5 minutes.

What is the main disadvantage to apenic oxygenation with broncoscopy?

he majority of CO2 is transported as bicarbonate 2/2 to the fact that RBC and endothelial cells have carbonic anhydrase which turns CO2 + H20 -->H2CO2 --->H+. + Bicarb-. Also, some of the CO2 transported as Carbamino compounds which are produced from a reaction with proteins

What is the majority of the CO2 in the blood transported as?

Metformin decreases the hepatic glucose release and peripheral glucose load. It is absorbed in the small intestines and excreted via the kidneys. Pts with renal failure are susceptible to metformin toxicity.

What is the pharmacologic elimination of metformin and how does it effect patients?

Moms BP Low urine venous pressure (IVC compression) Low vascular resistance (pre-eclampsia, high concentration of LA)

What is the urine blood pressure dependent on?

Univent endotracheal tube with a dedicated channel for the bronchial blocker. Advatange is less movement. Disadvantage is it has two lumens and they're not any smaller than an outer diameter of 7.5-8.0 mm.

What is unique about a univent?

myocardial dysfunction, catecholamine storm followed by hemodynamic instability, hypovolemia, pulmonary edema 2/2 to catecholamine storm, hyperglycemia, and polyuria.

What is usually physiologically seen in a brain dead patient?

The femoral nerve is not located within the femoral sheath. he sartorius and femoral artery and vein are located between the fascia lata and iliaca within the femoral sheat

What isn't located in within the femoral sheath.?

Type B (non-hypoxic) acidosis because = it allows pyruvate to accumulate 2/2 decreasing Pyruvate DH activity = anaerobic metabolism. Key diagnostic findings include: -Metformin levels > 5 -increased lactate:pyruvate ratio. -Lactate >5 -anion gap acidosis (without evidence of ketosis),`

What kind of acidosis does metformin lead to and how?

hypovolemic hyponatremia, and hypokalemia depending on the amount of gastrointestinal fluid lost through vomiting or diarrhea. Metabolic acidosis

What kind of electrolyte abnormalities seen with SBO?

Obesity, Pregnanny, medistinal mass, khyphoscolsis.

What kind of extrinsic lung dieases lead to striction?

Overall, first-pass uptake occurs for opioids that are lipophilic and basic but does not affect drugs that are neutral or acidic

What kind of opioids undergoes first-pass metabolism?

horseshoe headrest has been associated with an increased incidence of postoperative visual loss and for thoracic spine surgery

What kind of prone view padding is increased with post-op vision loss?

Glycocalyx

What limits colloids to stay within the intravascular space?

Hydrochlorothiazide has the potential to cause several electrolyte disturbances such as hyponatremia, hypochloremic alkalosis, hypokalemia, hypercalcemia, and hyperglycemia Increased excretion of chloride can lead to hypochloremic metabolic alkalosis and increased excretion of sodium can lead to hyponatremia.

What lytes does HCTZ mess up? Why?

major opioid use, parenteral administration of drugs, a family history of substance abuse, and a concomitant psychiatric disorder diagnosis

What makes relapse more likely?

Two things: -Inspiratory capacity = IRV + TV -Forced Residual Capacity = ERV + RV Vital capacity = TLC - RV

What makes up total lung capacity?

Aortic valve opening occurs after isovolumetric contraction, which corresponds to the c-wave on CVP and after the QRS complex on ECG.

What on the CVP waveform represents the aortic valve opening?

histamine, dopamine, and epinephrine pass unchanged through the pulmonary circulation due to a lack of active transport mechanisms for these substances within the pulmonary endothelial cells.

What three chemicals aren't broken down by the lungs?

Inotropy & decreasing SVR, B2 decrease PVR beta 2)

What two Physiologic effects of Dubutamine?

Pheocrhomcytoma 2/2 to hyperglycemia & and severe hypertension. Insulinoma 2/2 to risk of severe hypoglycemia. MOA = release from alpha cells = g-protein activation = Adenylyl cyclase activtion = increased CAMP levels = -glycogenolysis -gluceneogenesis -decrease glycogen syntheisis in the liver.

What two conditions is glucagon contraindicated in?

Fontan repair is associated with the highest prevalence of arrhythmias during pregnancy. All types, but neuraxial > general because it avoids avoids the adverse effects of myocardial depressant medications and positive-pressure ventilation

What type of anesthesia can a patient who has had a Fontan repair get and what is it associated with?

1.) A patient taking steroids for less than three weeks that is at any does. 2.) A patient who is taking glucocorticoids in the morning that is less than 5 mg a day. 3.) A patient who is taking glucocorticoids equivalent to 10 mg a day every other day.

What types of patients do not need stress those steroids?

ropivacaine may also possess some intrinsic vasoconstrictive effects that can further offset the effects of epinephrine on the duration of analgesia.

What unique property of ropivicaine gives it the ability to offset the effects of epinephrine on duration of analgesia?

PT depends on vitamin K consumption and absorption so when bile acid secretion is impaired, as in biliary obstruction, PT will be prolonged though hepatic function may be normal

What will happen to PT if bile acid secretion is impaired? What about hepatic function?

vapor pressure of an inhaled anesthetic is not affected by barometric pressure, so it will not change.

What will happen to vapor pressure of an inhaled anesthetic if it is brought up to 6000 feet above sea level?

Venus oxygen nation from the juggler ball represents a supply in demand. The supply is due to hemoglobin concentration oxygenation and CBF. The demand is due to CMRO2. Barbiturates result in a decrease in CMRO2 which results in an increase in jugular venous oxygenation

What would barbiturates due to jugular bulb Venus oxygenation?

It causes a leftward and upward shift of the Frank-Starling curve. Inotropic agents will move patients to a higher ventricular function curve resulting in greater cardiac work for a given level of ventricular filling pressure. So it will just shift directly up.

What would milrionine do to the frank-starling curve? What about levo?

De-hydration = Increased concentration of the anions = alkalosis Over hydration = dilution of the strong ions = decrease in SID = acidosis. The following strong ion changes result in the following SID changes: ↓ [Na+] → ↓ SID and acidosis ↑ [Na+] → ↑ SID and alkalosis ↑ [Cl−] → ↓ SID and acidosis ↑ organic acids → ↓ SID and acidosis

What would the hydration status of a patient do to the strong ion difference? -Dehydration vs. Over-hydration?

the diaphragm and laryngeal muscles, with response of the peripheral muscles such as adductor pollicis occurring later. This response is quicker for the central muscles due to the greater amount of blood flow and, as a result, NMBA delivery. However, the diaphragm still recovers first due to the higher density of nictonic receptors.

When Neuromuscular blockers are administered why do the central muscles like the diaphragm and laryngeal muscles get relaxed first?

Phase 2.

When QT shortens, what phase is this associated with?

it resembles non-rapid eye movement (REM) sleep-delta waves and theta waves.

When an EEG is performed in patients with precedex, what does it resemble?

Prophylaxis, therapeutic, and emergently. Emergently otesents with most risk of uterine rupture.

When are cerclages done? Contraindications: preterm labor, bleeding, fetal abnormalities, fetal death, ROM, abruption, chorio.

Glucose-containing solutions are only indicated for pediatric populations at risk of perioperative hypoglycemia including infants less than 6 months old, malnourished children, or children undergoing cardiac surgery.

When are glucose-containing solutions needed in kids?

asymptomatic, exhibit a transvaginal ultrasound without extrauterine gestation, and have a low and decreasing hCG. Managment = methotraxate in HD stable patients with a HCG < 5000 WITHOUT fetal cardiac activity.

When can an ectopic pregnancy be managed medically > surgically?

it would be important to maintain the blood bag(s) in connection with the patient's circulation to follow their religious beliefs. Meaning, the blood can be siphoned into a storage bag via the IV line then clamped and later re-infused through the same IV line.

When collecting ANH from a Jehovah's witness what should be done?

Systolic > Diastolic > MAP. Systolic BP overestimates in states of hypotension.

When comparing Non-ivasive BP monitoring to invasive BP monitoring, what is the least accurate measurement?

If metabolism of citrate is unimpaired, ionized calcium levels do not begin to decrease until infusion rate is greater than 1 unit of blood every 10 minutes.

When does calcium ion decrease with pRBC administration?

Quadriplegia occurs with injury above the first thoracic vertebra,

When does quadrplegia happen vs. Paraplegia?

-The dependent leg should be flexed to avoid stretching the lower extremity nerves dependent arm should be secured on a padded arm board perpendicular to the torso head should be in a neutral position-lateral rotation to the dependent side can result in stretching of the non-dependent brachial plexuses.

When in a laterl decub position how should the patient be positioned to avoid stretch injuries to the nerves?

. Steady-state is reached when the infusion rate matches elimination.

When is . Steady-state achieved?

Taken off ventilator, while giving oxygen insufflation. If PaCO2 >60 mmHg or 20 mmHg above baseline.

When is an apnea test declared positive?

pregnant women, obese patients, trauma patients, patients who require emergent surgery, and patients with gastroparesis due to diabetes mellitus.

When is metoclopramide most useful?

neonataltransmission is more likely during the primary infection than recurrent episodes and with use of invasive fetal monitoring.

When is neonatal viral infection of HSV2 likely to happen?

-Steroids of any dose < 3 weeks. -Morning dose < 5 mg/daily -morning dose is <10 mg every other day.

When is stress dose steroids not needed?

Testing done using short acting ACTH such as Corsypin. It is done with the patient falls in a gray area of no cushings symptoms and doesn't take >20 mg of steroids for > 3 weeks. . If normal response, then no further stress dose needed. Pit fall is that it increases total cortisol and not free cortisol which is what has action.

When is testing needed to determine stress dose steroids?

Heard during atrial kick caused by vibration of ventricular wall during this phase. Associated with diastolic dysfunction.

When is the S4 heart sound heart and what does it mean?

Employed during pandemics. It is when one ICU physician can oversee a 100 patients or so via having subordiants such as non-ICU trained physicians and CCRNs who can over see non-CCRNs.

When is the Tiered model of staffing implented and what is it?

he shingles vaccine is a live, attenuated virus and is, therefore, contraindicated in immunocompromised individuals.

When is the shingles virus contraindicated?

transduction of manometery & guidewire threads without difficulty. If there is, further ultrasound imaging is required.

When is there no need to confirm further placement of a central line?

lateral cricoarytenoid, thyroarytenoid, interarytenoid, and cricothyroid all adduct the vocal cords shut. Posterior cricoarytenoid - These are the only muscles involved in abduction.

When laryngeospasm happens, which muscles will act? What muscles will counter it?

Scattered-energy that contacts a surface and then scatters away. Mainly ones that interact with the patient but arent absorbed. Primary radation is the dominate source of exposure for most patients, but minimally exposure to clinicans.

When modern fluoroscopic equipment is used what is the dominant type of radiation to which clinical staff are exposed to? What about exposure to patients?

Low risk: no further testing. Elevated risk: >4 Mets = no further testing. Elevated risk & unable to do find out how many Mets or <4 Mets = Pharmacologic stress test.

When shoukdncardiac testing take place?

Amisulpride-5 mg IV -At induction-(selectively binds to D2/D3 receptors antagonist) Aprepitant-40 mg by mouth-Preoperative (NK1 receptor antagonsit)

When should Aprepitant be given? What about Amisulpride?

In one large observational study of in-hospital cardiac arrest with nonshockable rhythms, early administration of epinephrine (1 to 3 minutes) was associated with a higher probability of return of spontaneous circulation, survival in hospital, and neurologically intact survival. Note, this doesn't apply to shockable rhythms. Only non-shockable only. Shockable rhythms = The algorithm for shockable rhythms calls for defibrillation, then 2 min of CPR, then defibrillation again, then epinephrine. Epinepherine in the first two minutes was associated with worse outcomes.

When should Epi be given in a code, why?

- Use to correct mildly elevated INR (< 1.8) without signs of bleeding - Use to correct a vitamin K deficiency that could be corrected with vitamin K - Use as a primary volume expander (absolute contraindication) - Use to correct a factor deficiency when recombinant factor replacement is available

When should FFP not be used?

UFH = 5000 units: -Wait 4-6 hours after the last dose of heparin before starting an epidural. Once epidural is placed, can immediately restart heparin. However, must wait 4-6 hours if heparin is given prior to removing epidural. Once the epidural is removed, can immediately started heparin. High Dose PPX (15k-20k) -Hold for 12 hours prior to starting epidural. After epidural is in, wait 1 hour prior to restarting heparin. Once epidural is ready to come out, stop heparin for 12 hours prior to removing the epidural. Once epidural is out, wait 1 hour prior to restarting heparin. UFH therapeutic dose: -IF IV, hold 4-6 hours/(SQ=24 hours) prior to epidural placement Once epidural is placed, can restart IV heparin OR Sub-Q in 1 hour. When epidural is ready to come out, hold IV heparin for 4-6 h/Sub-Q 8-12 hours prior to removing epidural. Can restart both IV or Sub-Q heparin in 1 hour after removal.

When should Heparin be: -stopped before an epidural is placed? -restarted after an epidural is placed? -Last dose and catheter removed -Catheter removal to drug resrarting?

Current recommendations to proceed with an elective outpatient procedure include waiting until 44-60 weeks post-conceptual age (PCA) if the infant has never experienced apnea or bradycardia

When should an ex-premie infant have an elective outpatient procedure if they've never experience apnea or bradycardia?

beginning in the late first trimester, specifically for women with a history of preeclampsia leading to prior preterm delivery before 34 weeks' gestation, or preeclampsia in more than one prior pregnancy.

When should asa be given to women with pre-eclapmsia concerns?

Serum magnesium levels are checked if a seizure occurs during treatment, renal insufficiency is present (creatinine > 1.1 mg/dL), or there are signs of magnesium toxicity.

When should magnesium levels be checked?

Caution should be taken when providing empathy for unanticipated patient outcomes. Sharing empathy can worsening patient-physician outcomes and caution should be taken regarding admisisons of fault.

When telling a family about an unanticipated outcome, what must the physician not do?

-A-line in right radial artery helps monitor compression of inominate artery of scope -left arm a-line advantage doesn't get interrupted if compression of the inominate artery happens, but you should place the pulse ox on the right which can pick up on inominate artery compression.

Where do you put an a-line for mediastinascopy?

DBD = 80%. or Declaration of brain death. As oppose to following cardiac cath.

Where does most of the organ donations come from?

At level of the DCT and collecting duct. = Inceassed sodium resorb, increase potassium excretion, and water resorb.

Where does the aldestrone work?

AA break down via deamination(removal of nitrogen group) & transamination(amines ->ketones) ===>ammonia==> carbamoyl phosphate,=>urea cycle==>urine.

Where does urea come from?

Released from the Zona Glomerulosa of the adrenal cortex. it is a steroid hormone that causes mRNA cytoplasma transscription--->sodium channels within the cell = factilitate resorbption of sodium leading to sodium retention.

Where is Aldestrone released from and its MOA down to the cellular level?

: Inositol triphosphate-3 (IP-3) is a second messenger molecule involved in cardiac myocyte = ncrease in cytoplasmic calcium ions.

Where is IP3 used and its role?

Pecs 1: between pec major and minor Pecs 2: between minor and serratus anterior. Okay to be used on coagulation issues. Serratus anterior plane blocks, paraveterbral blocks,

Where is a PECs block done? Why is it better for some patients?

In front of the trachea & behind the aorta-behind the innominate artery (R common carotid, right subclavian). =CVA, PTX, Bleeding, braycardia 2/2 to Vagus nerve stretching

Where is a mediastinoscope usually positioned? Complications?

Axillary Petechaie,

Where is fat emboli Petechai found?

atrioventricular node is supplied by a branch of the posterior descending artery called the atrioventricular nodal artery.

Which artery supplies the AV node?

Lamber-eaton = autonomic dysfunction such as constipation, dry mouth, erectile dysfunction, and hypohidrosis.

Which auto-immune disorder is more associated with autonamic dysfunction?

Epinephrine

Which catecholamine works both as a vasodilator and vasoconstrictor?

Axillary. Particular complication = increased risk of nerve injury.

Which central line site has low risk of infection, thrombosis, and pneumothorax. What is this particular complication?

it is essential that alpha-adrenergic blockade is instituted prior to beta-adrenergic blockade given the risk of precipitating a life-threatening hypertensive crisis.

Which class of medication should be given prior to giving another class of medication in someone who has acute cocaine toxicity?

Factor 8 and VWF.

Which coagulation factors are inhibited by Hetastarch?

IL-1 from the donor WBCs = increasing PGE2 = fever.

Which cytokine is primarily released during febrile nonhemolytic transfusion reaction (FNHTR?

Sanz electrode (measures pH), Severinghaus electrode (measures PCO2), and Clark electrode (measures PO2).

Which electrodes measure pH, CO2, and PO2?

Factor five and factor two are unchanged. Factor 11 and factor 13 are decreased.

Which factors are unchanged? And which factors are decreased in pregnancy?

CN9

Which nerve provides parasympathetic activity to the partoid?

ulnar nerve

Which nerve(s) are missed with the interscalene block?

Mivacurium is a nondepolarizing neuromuscular blocking agent that is also degraded by pseudocholinesterase.

Which non-depolarizing drug has a similar degradation to sux?

Cardiothoracic surgery is associated with the highest morbidity and mortality rate in patients with preexisting liver disease. Child Turcotte Pugh class C, those with a prolonged INR, and evidence of infection or encephalopathy.

Which patients are increased risk of post-op liver complications? What surgery causes the highesr risk?

Patients with multiple clinical risk factors (3 or more) for coronary artery disease undergoing high risk surgery should be started on beta blockade. Factors include: Ischemic heart disease, CHF, CVA, DM, and CKD. If no clinical risk factors exist, Starting beta-blocker therapy on day of surgery could increase this patient's risk of stroke.

Which pts benefit from beta blockade prior in the periop. perioid?

Notably, factor VIII levels may decline as low as 40-60% of normal concentration and factor V levels may drop to 60-70% of normal.

Which two factors are prone to dropping in FFP after storage and thawing?

Zone 1 (closest to the PV, hepatic artery). Zone 2 middle Zone 3 (least oxygen rich. Closest to the hepatic veins).

Which zone of the liver lobular is most oxygen rich?

Kids <1 yo. cerebral angiography, electroencephalography, transcranial ultrasonography, and cerebral scintigraphy (Tc 99m).

While confirmatory tests for a brain death exam aren't required for adults, but are optional. When are they most recommended? What are options?

Fentanyl is lipid soluable and short-acting, as oppose to morphine/dilaudid which would cause puritis in the head/neck and be longer.

While fentanyl causes itching in the lower abdomen/legs, where would morphine cause it?

There is no increased brain sensitivity to Barbiturates, Etomidate, and NMB. Particularly, the increased response to barbiturates is 2/2 to a decreased central VD = increased serum levels from a given dose, causing the medication to linger and this is a pharmokinetic effects. NMB 2/2 to decreased ability to clear.

While in elderly, there is increased cerebral sensitivity to propofol, opioids, benzos, and volatile agents, what is the mechanism of sensitivity to Barbiturates?

Phase II block-seen 60-120 minutes after sux administration in pts with abnormal pseudocholinestrases. Neostigmine use has to be small (<0.03 mg/kg)

While most sources advise against using neostigmine to reverse sux apnea. When is this using neostigmine allowed for sux apnea?

myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy (limb-girdle), and peroneal muscular atrophy. Class I indication for pacemaker as soon as there is 2nd degree or 3rd degree block is seen.

While pacemakers aren't usually indicated in asymptomatic bradycardic patients, what class of patients are they indicated in despite being asymtomatic?

It only takes apart the global oxygen and not the focal oxygen concentrations of areas that may be deoxygenated within the brain such as and an acute stroke. It will not show any change. Global changes include things like-Anemia, sepsis due to decreased blood pressure, and barbiturates due to decreased CMRO2.

Why is Jugular venous bulb mixed oxygen Considered a global oxygen marker of the brain?

Minimally invasive thymectomy risk factor for pulmonary complications: -Bulbular movement -BMI > 28 -Hx of Mystanic crsis d -Previous lung resection. Other non-specific risk factors of post-op complicatons: >1000 cc blood loss, Anti-Ach-R titers > 100, and prounced decterment on nerve stimulation.

While risk factors of >6 ys with dz, COPD, dose 750 mg, and VC < 2.9 determine post-op pulm. complications in MG patients undergoing a median thyemectomy, what risk factors included for minimally invasive thymectomy? Other non-specific factors?

obese individuals will have a lower TBW percent than lean individuals because of the low amount of water in adipose tissue.

Who has more water obese patients or lean patients?

Lower lung volume per body size and Higher oxygen consumption per body weight 2 times as adults.

Why do infants desat with apnea so quickly?

infants and children may actually experience a greater neural response and thus more pain compared to adults 2/2 to a more robust inflammatory reaction a d lack of central inhibitory influence.

Why do kids experience more pain than adjults?

Anesthesia is determined by partial pressure which will change with altitude. Des vaporizer will continue to give the same amount independent of altitude. Depth of anesthesia is determine by the minimum alveolar partial pressure (MAPP) of the anesthetic agent which = 1 MAC 6% of 760 mmhg = a Partial Pressure of 45.6 mmHg for des. Which is the same regardless of altitude. Thus in order to continue to maintain a 45.6 mmHg aka 1 mac aka 6% at 760 mmHg, there needs to be an increase in the dial to 9% if at 500 mmHg instead of 760 mmHg. (45.6/500mmhg)

Why do you have to change the Desflurine dial at higher altitude?

At the level of T10, the splanic plexus innervation is still intact which is part of the cranial/sacaral PNS. This allows the SNS to be opposed below the level of injury. Where above the level of injury, the splanic innervation is non-existent to oppose the SNS.

Why does Autonamic Hyperreflexia happen above T5? Why doesn't it happen at T10 or below?

oral rout, no monitoring required 2/2 to reliable plasma concentrations-unless pt. has altered GI anatomy, obesity, potential drug-intractions, and non-compliance. Monitoring can be done via Anti-factor Xa or drug plasma concentration. Otherwise no monitoring required.

Why does Xarelto increase patient adhenrence? What population of patients requiring monitoring?

In order to do crirocid pressure-it requires two practitioners, supine positioning of the patient, and neck extension. It is contraindicated in vomiting patients and unstable cervical spine. . 10 neutons applied when awake, 30 neutons applied when alseep. Manuver Not very effective because it actually displaces the esophagous laterally instead of collapsing it, It can also worsening grade view on DL if more pressure is applied-prolonging time to intubation and increased risk of aspiration.

Why does adding cricoid pressure not decrease aspiration?

High fibrinogen 2/2 acute phase = platelet aggregation and decrease in platelet levels in the first week. Also, in the first 48 H = decrease intravascular volume = increased SVR = decrease CO. After 48 hours = decreased SVR and increased CO. VD increases with these patients.

Why does coagulation issues and low platelet levels happen in burn patients? What other pathologies do they have?

Because Vapor pressure of an agent has minimal changes with a decrease of barometric pressure, the partial pressure is also unchanged. Partial pressure will determine the depth of anesthesia with the iso and sevo vaporizers, despite an increase in volume concentration leaving. With Des vaporizers = is a dual gas blender, not a variable bypass vaporizer, which deliveres a constant volume concentration, not constant partial pressure of gas and because its the partial pressure that determines the anesthesia depth, at higher altitudes, partial pressure would be less and one has to account for this by increasing the dial based on the equation: required dial setting = normal setting (volume percentage × 760 mm Hg)/current barometric pressure (mm Hg).

Why does des vaporizer differ from sevo or iso vaporizer when increased to higher altitude and how is it adjusted?

It causes the placenta transfer.

Why does ephedrine cause a worse metabolic acidosis in baby?

Spinal anesthesia produces an extensive sympathetic block that causes widespread vasodilation and hypotension and this giving fluid has very little effect on it. Instead should be treated by ephedrine or phenylephrine.

Why does giving fluid not hold true during spinal anesthesia?

Higher CO to the vessel rich groups.

Why does induction of anesthesia occur faster in infants?

Normal amount = 150 cc -Trach reduces dead space because of removing hypopharynx -Spontanous breathing with ETT = decreases dead space. -Mechanical PPV with ETT = increases Alevolar pressure = increases Zone 1 of the lung = increases dead space.

Why does intubating someone and putting them on mechnical PPV increase dead space where intubating and keeping them spontanous does not?

Binding capacity, on the other hand, is a function of the quantity of blood within or passing through the lung. Therefore, factors such as elevated cardiac output, pulmonary vasodilation, polycythemia, alveolar hemorrhage, left-to-right shunting, and increased lung volumes may also increase the DLCO.

Why dos Cardiac Output increase the DLCO? What other factors do this?

Due to the decreased water content of barium hydroxide, compared with soda lime, CO production is greater with the former than the latter. Barium Hydroxide = minimal water = increased risk of Compound A, increased Fire with sevo, increased CO. Soda lime = Ca(OH)2 + H2O + NAOH(strong base). Strong base offers the CO2 absorption. = decrease A and fire issues.

Why is CO greater in barium hyoxide than soda lime?

Because CO has an exceedingly high affinity for the hemoglobin molecule, its movement into the pulmonary capillary blood is reliably diffusion limited, allowing the degree of uptake to serve as an effective surrogate marker for the diffusion of oxygen. Go to card 438 to determine why.

Why is CO used to obtain the DCLO?

since large volumes may need to be transfused and the patient will be exposed to the risks of transfusion. Instead consider: Cryo or Factor 8 concentrate, or recombinate Factor 8.

Why is FFP not recommended to treat Hemophilla A, despite containing factor 8?

Posteromedial papillary muscle rupture is more common than anterolateral papillary muscle rupture because of the single blood supply (right coronary artery or left circumflex artery) of the former and the dual blood supply (left anterior descending artery and left circumflex artery) to the latter.

Why is a Posteromedial papillary muscle rupture is more common than anterolateral papillary muscle rupture?

-Can't suction the operative lung from blood. -Not protective/isolated. -Can't Availability to pass a fiberoptic scope to asses the operative lung. -SLET requires a size down to fit in the Left main bronchus and will need to be exchanged when pulled back into the trachea since it will be too small. -mucous plugging and high resistance from the use of a smaller internal diameter

Why is a Single Lumen ETT less effective than a bronchial blocker at One-lung ventilation?

the liver produces proteins that act as anticoagulants as well as the coagulation factors.

Why is a TEG in patients with intrinsic liver disease & elevated INR hypercoable?

Termination of the dural sac is at S3, milimeters away from the puncture site. Can lead to a total spinal.

Why is a dural puncture more likely in infants getting a caudal?

It can lead to uterine artery vasoconstriction

Why is a maternal Respiratory alkalosis bad for the baby?

Because small amounts of air are injected into the patient via IV and A-lines and can be detected as baseline tone. This can help differentiate from clinical signicifant Venous Air Emboli.

Why is a precordial doppler for assessing VAE crucial to be placed prior to surgical incision?

Because the tidal volume is decreased, but dead Space remains the same. Dead space = 1 cc/kg. And the ratio of deadspace/tidal volume is 50-50.

Why is alveolar Minute ventilation decreased with inhalational agents?

the administration of antibiotics in infantile and foodborne botulism can cause lysis of intraluminal clostridium botulinum, with the potential of increasing the amount of toxin available for absorption

Why is antibotics bad for C. Botox tx?

Glyco cant cross the PBB, but neostigmine can to a certain degree, resulting in bradycardia in baby. Considering lipid-soluble tertiary amine, it easily crossed the BBB along with neostigmine (which is actually quantary)

Why is atropine perferred to reverse pregnant patients > glyco?

cardiac toxicity is due to bupivacaine's stronger affinity for both resting and inactivated sodium channels. Bupi dissociates from sodium channels during diastole at a rate slower than most LA. Potential for causing cardiac toxicity also correlates with potency for the agent. 2:1 vs. Lidocaine/Mipficaine = 7:1

Why is bupivicaine so toxic to cardiac and CNS?

Factor VIII activity is helpful in discriminating between these conditions because factor VIII is consumed in DIC and factor VIII levels are normal or elevated in liver disease. Platelets are low in both DIC and ESLD

Why is checking platelet count in an Endstage Liver Disease patient not helpful? What is most helpful?

Because kids tend to be ultrametabolizers of codiene which results in a potential toxicity or overdose.

Why is codiene put kids at an increased risk of resp. depression

shorter-acting anesthetics, which tend to be more hydrophilic and less preferentially bound to tissue proteins; these properties allow epinephrine's local vasoconstrictive effects to keep the drug concentrated in the tissue for longer periods of time.

Why is epinephrine better to prolong LA for short-acting duration?

Fentanyl has poor oral bioavailability and is not recommended for use via the enteral route.

Why is fentanyl not good for oral route?

Insulin to decrease glucose > Reducing TPN glucose because glucose utilization is high. If TPN is stopped, insulin should also be stopped and patient should be twitched to a glucose IV fluid or it can lead to hypoglycemia

Why is insulin also with TPN?

Per DSM symptoms must be present for 2 weeks. POCD cannot be diagnosed in most postoperative hospital courses because very few surgical procedures necessitate a two-week hospitalization.

Why is it Post-Op Cognitive Dysfunction difficult to dx?

Because is there is signal changes in the MEPs and SSEPs, you can't unclamp the aorta anyway, Better way to protect the spinal cord is through the Spinal Cord Perfusion Formula = MAP - ICP. Increase MAP and decrease ICP by a lumbar drain.

Why is it not practical to do IONM during TAAA? What is a better course of action?

NMDA receptor antagonist, slow off 2/2 to lipophilic. Lacks metabolites. Difficult to titrate 2/2 to sporadic half-life in varying patients. induction, inhibition, or competition (CYP3A4, CYP2D6, and CYP2B6).

Why is methadone slow off and what receptor does it target for neuropathic pain?

Etomdiate prolongs seizure duration. Methohexital doesn't prolong seizure duration.

Why is methohexital used vs. etomidate for ECT?

Neostigmine administration during a phase I block is ineffective (A,C) as the postjunctional membrane remains in a state of sustained depolarization that is completely unresponsive to ACh. In fact, neostigmine can potentiate a phase I block, see below.

Why is neostigmine for a phase 1 block bad?

-Loss of SA node cells lowers HR -High Vagal tone -decreased responsiveness of adrenergic receptors (There is decreased responsiveness to ß-receptor stimulation. This is likely due to inadequate cellular signaling rather than to a decrease in the number of ß-receptors) = contribute to a decrease in maximal heart rate and poor regulation of cardiac output

Why is orthostatic hypotension and poor efficacy of the baroreceptor reflex are commonly seen in older patients.

Baby has a Lower pH with ephedrine.

Why is phenylephrine better for material hypotension than ephedrine?

placement of a pulmonary artery catheter via the left internal jugular vein is very difficult because it would have to traverse the coronary sinus prior to entering the right side of the heart.

Why is placement of the PAC difficult in persistent Left SVC syndrome?

Carbon dioxide buildup in obesity hypoventilation syndrome. The patient doesn't wake up despite being hypoxic and hypercarbic. Overtime this will lead to pulmonary hypertension as opposed to OSA where the patient wakes up.

Why is pulmonary hypertension more likely in obesity hypoventilation syndrome than obstructive sleep apnea?

-The increase in potassium is due to a temporary shift of potassium from the intracellular space to the extracellular space, not a total body increase in potassium.

Why is sux safe to used in renal patients?

BIS combines spectrogram, bispectrum, and time-domain of burst suppression. Computation is complex and there is a lag time due to this.

Why is there a 20-30 second lag observed between the EEG and the computed BIS value?

FRC decreases 2/2 to a decrease in ERV > RV. Esp. in supine position. CC = stays the same and is unchanged in pregnancy. When supine, the FRC/CC ratio is decreased = atelectasis.

Why is there an increase in atelectasis in pregnancy, esp. in what position?

Hyperglycemia = increase insulin. Hypoglycemia when stopped due to the high insulin levels.

Why is there shifts in glucose with TPN?

oxygen toxicity, and it can lead to shunt physiology by reversing hypoxic pulmonary vasoconstriction

Why should FIO2 be titrated down in ARDS?

Because The severity of symptoms in the neonate is not directly related to the severity in the mother. Look for : poor sucking, difficulty feeding, generalized hypotonia, feeble cry, respiratory distress, and ptosis. Of note, DTR are normal in infants with MG. Symptoms seen first 24-48 hours in life.

Why should all infants be closely monitored for MG born to mothers with Mysnthesia Gravis>

High delivery will convert it into malignant arrhythmias.

Why should dig toxicity patients be shocked at a lower voltage than usual if they go into cardiac arrest?

LCFN. Go 2 cm medial and 2 cm inferior.

anterior superior iliac spine (ASIS) can be used as a cutenous landmark for which nerve?

aminoglycosides, polymixins, lincomycin, clindamycin, and tetracyclines. ACTs MOA? inhibit the presynaptic release of acetylcholine while also decreasing the postjunctional receptor's sensitivity to acetylcholine. The tetracyclines only produce postjunctional effects.

antibiotic agents have been found to potentiate the neuromuscular blockade from nondepolarizing agents.?

Idarucizumab (Praxbind) or PCC[factor 9 complex] + TXA/Amicar.

antidote for dabigatran?

Inhibition of inflammatory response-results in decreased WBC adhesion and platelet aggregation

besides smooth muscle relaxation, what other role does cGMP play in the body?

Cardiac output increases = decrease visocity = afterload decreased = SVR decreased = higher SV Decreased sheer force leads to increased flow through the microvasculature & increased venous return. increased 2,3 DPG.

body compensates for the decreased amount of oxygen delivery to the tissues by?

the required fresh gas flow (FGF) for a Mapleson A system is equal to or slightly less than the minute ventilation (MV). fresh gas enters near the breathing bag and NOT near the patient connection. This feature results in the fact that during SPONTANEOUS ventilation, the required FGF = MV

breathing systems is the most efficient user of fresh gas flow during spontaneous ventilation?

complete airway collapse occurs with no inspiratory flow during spontaneous breathing. -negative when awake. -less negative when asleep. -positive during anesthesia.

critical closing pressure of the upper airway (Pcrit)

critical temperature of a substance is the temperature at or above which a substance can no longer be liquified regardless of the pressure applied to it..

critical temperature of a substance is?

1.) Microvascular bleeding hypofibrinogenemia (fibrinogen < 80-100 mg/dL) 2) hemorrhage or massive transfusion with fibrinogen < 100-150 mg/dL, 3) prophylaxis in patients with hemophilia A and vWD

cryoprecipitate administration?

: Bilateral choanal atresia =failure of the entire posterior nasopharyngeal aperture to develop or achieve patency

cyanosis worsened by feeding and improved with crying is a sign of?

Likely the ulnar nerve.

distal humeral fractures and non-union of displaced lateral epicondyle fractures causes injury to which nerve?

drugs known to induce P450 enzymes include phenytoin, rifampin, carbamazepine, and ethanol

drugs known to induce P450 enzymes

Mytonia Congenita. =AD, global hypetrophy if muscle = no weakness, can result in severe contractions from blockade. Use Sodium channel blockers.

dysfunctional chloride channel that is hyperexcitable is seen in what non-dystrophic mytonia?

concentration effect occurs when a high concentration of anesthetic can be use Different from the second gas effect which is when N2O + Violatile agents are used together and nitrous leaves to go into the blood.

explains why nitrous oxide has a more rapid onset than desflurane?

probability, if the null hypothesis is true, that the result is from chance alone

f P > α, then the null hypothesis is accepted. If P < α, then the null hypothesis is rejected. What is P?

Esmolol. Metabolized by RBC esterases.

first-line therapy for postoperative atrial fibrillation, following the American College of Cardiology and American Heart Association guidelines?

residual blood flow through collateral circulation results in a small delivery of oxygen and glucose distal to the occlusion which isn't seen in global ischemia leading to irreversible membrane failure 2/2 to lack of o2 and ATP production. Influx of calcium and sodium 2/2 to activation of glutmate receptors results in neuronal swelling and death.

focal ischemia appears to be more well-tolerated compared with global ischemia of the brain, why?

perineal malignancies or other perineal nonmalignant chronic pain considering it gets visceral afferent fibers from the perineum, anus, distal rectum, distal urethra, vulva, and distal third of the vagina.

ganglion impar block is good for?

Nadolol i

nonselective β-antagonist and has a half-life of 20 to 24 hours.

Proporonlol

nonselective β-antagonist with a half-life of approximately four hours.

end-systolic pressure-volume relationship (ESPVR) is represented by the upper left curve. -Decrease inotropy = a downward and rightward shift of the ESPVR -Increase intropy = upward and left shift of the ESPVR. Also effected by afterload.

on the PV-look, what serves as the surrogate for Inotropy and where is it represented?

cricoid cartilage

only circular cartilaginous ring in the airway.

Propofol. However, however >1 MAC- isoflurane will reduce total hepatic blood flow in a dose-dependent manner. and Halothane depresses the cardiovascular system reducing total hepatic blood flow.

only intravenous or inhalational anesthetic that is associated with an increase in hepatic blood flow.

Vasospasm can occur as early as day three after the SAH and the peak incidence is between days 6-10. Typically the spasms resolve by day 14. Cerebral angiogram

onset, peak of cerebral vasospasms and what is the best way to diagnose them?

A venous oxygen saturation of around 65% seems to be a reasonable measure to state that there is adequate CPB pump flow as a surrogate for cardiac output. Average 1.6 to 3 L/min/m^2 Most strokes that happen on pump are 2/2 to emboli > BP control.

real-time indication of the adequacy of blood flow through the patient can be assessed how?

A biphasic shock sequence of 5 J, 10 J, 20 J, 30 J, and then 50 J is recommended for internal defibrillation.

recommended for internal defibrillation joule amount?

Carotid embolization on the left poses a greater risk as the left cerebral hemisphere is dominant in the majority of the population. Another reason is that some investigations have found a greater cardioinhibitory effect on the right side.

right-sided carotid massage is preferred over left-sided massage, why?

Positive lusitropy aka a downward and right on the PV curve.

tolerates a higher end-diastolic volume at a lower end-diastolic pressure =

two most common causes of postoperative jaundice are hemolysis and the breakdown of extravasated blood.

two most common causes of postoperative jaundice?

10 minutes. includes Heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values should be recorded

what frequency must vital signs and monitoring data must be documented during pediatric sedation?

Whenever minute ventilation (calculated as tidal volume * respiratory rate) exceeds fresh gas flow it results in rebreathing, which is what happens with the 4 breathes Q 30 seconds. if time allows, extending deep breathing to allow 8 breaths in 60 seconds or 12 breaths in 90 seconds may be equal or better than the classic 3-min tidal volume breathing technique.

when investigators found that four deep breaths over a 30-second period provided good preoxygenation, but still inferior to the classical 3-minute tidal volume breathing technique. Why?

Up to 10% of patients with epilepsy do not have epileptiform activity on EEG

while the specificity of epileptiform activity for epilepsy is 78-98%, the sensitivity is much lower at 25-56% which means?

predictably causes cerebral vasoconstriction, pH-stat management may better preserve cerebral blood flow and homogenous brain cooling. advantage comes at the expense of an increased embolic risk.

with pH-stat management involving the addition of carbon dioxide to a patient's blood to maintain a corrected PaCO2 near 40 mm Hg and a pH near 7.40 during the hypothermic phase. WHY?

inhibits tyrosine hydroxylase, the rate-limiting enzyme in catecholamine. appropriate adjunct in malignant or inoperable pheochromcytoma tumors.

α-methyl-para-tyrosine (AMPT or metyrosine) is used for?