TrueLearn Anesthesia

A patient has failed medical mgt (steroids, TCA, opioids, gabapentin) for complex regional pain syndrome. What is next step in mgt:

*Diagnostic sympathetic block i.e lumbar sympathetic block which temporarily anesthetizes nerves (helps determine if pain has sympathetic mediated component. Temperature will rise on side of block if effective). If effective: can do a Lumbar neurolytic block (chemical (alcohol), cryoablation (freezing), radiofreq (heat) or surgery. Can be permanent or temporary depending on whether the nerve allowed to regenerate Spinal cord stimulator is the last resort in CRPS

Signs and symptoms of MH include:

*Muscle Rigidity, hypertonia/ataxia, temperature >38˚ +inducible clonus, tachycardia* spontaneous clonus, , tachycardia, hyperpeyrexia, diaphoresis, ataxia, confusion, elevated etCO2 Decreased SVO2 <20 d/t incr metabolism consuming O2

What pathological states decrease V/Q ratio?

*decr V and/or Increased Q* -decreased ventilation to normally perfused parts of lung ex: Chronic bronchitis, asthma, pulmonary edema or Increased perfusion to non-ventilated areas Ex: Hepatopulm. syndrome

Define oliguria and polyuria. Which of these is a characteristic of diabetes?

- OLIGURIA - - urine output < 500mL/day or - < 0.5 ml/kg/hr Polyuria (Diabetes) d/t incr Glucose in urine >3L/day

A patient is getting an ICD lead removed. What are some RFs for cardiac/vascular perforation during these surgeries:

-BMI<25 -Female Gender ->5 years of ICD -the removal of the ICD leads

mechanisms to decrease ICP

-Head elevation -Barbiturate Coma -NM blockage -Decompressive craniectomy Avoid high dose glucocorticoids for TBI as they incr mortality

Meperidine is an________ for treatment of _______ and when combined with ________ can cause _______

-Opioid -post op shivering -MAOI, Phenelzine -Serotonin Syndrome

PONV in Peds RFs:

-age>3 -prolonged sx> 30min -H/o PONV in pt, parent, -sibling -strabismus sx

MOA of Hypovolemic Shock: difference bw it and cardiogenic shock

-reduced intravascular vol (reduced preload) leads to reduced CO Cardiogenic and obstructive will have elevated CVP, PAP

LA for Bier Block

0.5% to 1% lidocaine

Spinal cord's blood supply:

1 anterior spinal artery supplies blood to anterior cord = motor tracts) supplies 75% of blood 2 posterior spinal arteries (dorsal cord = sensory) supplies 25% of blood

What are the main frequencies of intraoperative EEG that are captured? and what does it monitor?

1 to 30 Hz EEG is used to monitor Cerebral Oxygenation

Factors that effect level after spinal anesthesia —Injection in subarachnoid space (Intrathecal)

1. Dose (vol x concentration) 2. Site of injection 3. Baricity of local anesthetic 4. Patient posture 5. Volume of CSF 6. Density of CSF

Refeeding syndrome can result in the following:

1. Hypo PO4, Hypokalemia, hypercapnea and decreased gastric motility 2. CV collapse 3. Rhabdomyolysis 4. Confusion 5. Seizures

4 types of Heat Loss from patient to cold environment in OR

1. Radiation #1 reason (heat loss through infrared rays-heat transfer w/o physical contact. how sun transfers heat to earth) 2. Convection (losing heat to air movement across skin) 3. Conduction (physical contact/losing heat to material laying on. warm butt on cold chair heats chair) 4. Evaporation (sweating) first heat is redistributed from core to periphery then it it lost via these methods! openanesthesia

RFs that predicts increased likelihood of PO mechanical ventilation in MG pts:

1. disease >72mo 2. H/o asthma, COPD 3. Pyridostigmine dose >750mg/day 4. Vital capacity <2.9 L avoid NMD in MG

Sites relating to Core Temperature

1. distal 1/3 of esophagus (behind the heart, reflects blood in heart temp) 2. Tympanic 3. Pulm Artery 4 N/P when urine flow is Low, bladder temp will not be accurate

2 mechanisms of hypothermia in the OR

1. impaired thermoregulation 2/2 anesthesia ---MOA: redistributes heat from core to periphery-decreasing mean body temp 2. low ambient temp of OR

Hypothermia pathological effects

1. incr RF bacterial infections (d/t vasoconstriction, decr blood flow (less WBC and O2) and post op wound infection 2. impairment of platelet function 3. Incr Vasoconstriction 4. if severe <33 leads to organ damage/failure

If surgeon asks for room air FiO2, what is air to FiO2 set to on vent?

100% air and zero FiO2 (since room air FiO2 is .21 or 21%) you will want FiO2 set to zero. This eliminates chance of fire

If you have machine on .5 air and .5 FiO2 what do you expect TV to be

1L (.5 +.5) - 300 dead space = 700 TV (would be maximum TV) This is why you need minimum of 350 TV to surpass dead space

Perioperative fluid management for children:

20-40ml/kg over course of surgery/anesthetic And maintenance following surgery: 2, 1, :5 2ml/kg for 1st 10kg 1ml/kg for 2nd 10kg .5/kg for >20kg

Smoking cessation at 24h: 2w >4w

24h: decr carbon monoxide/nicotine levels/cyanide and R shift of O2Hbg curve *initially an incr in sputum production* 2 weeks (14d) reduce sputum 4-8 weeks (30d) decreased airway activity, increased ciliary motility, enhanced mucus clearance, reduce PO respiratory complications

STOP Bang score which indicates high risk for OSA?

3 or more is High Risk <3 is low risk Used for OSA - Snoring - Tired - Observed apnea - Pressure (BP) is elevated - BMI >35 - Age >50 years - Neck circumference > 40 in - Gender = male

Onset of Sux and How metabolized: Quickest onset via

30-60seconds Cleared by plasma cholinesterase (butyrylcholinesterase) just like chloroprocaine Can give IM with lingual injection having the quickest onset

Oxygen is running at 10L/min. Oxygen Ecylinder pressure gauge reads 500 psig How much time left before cylinder is depleted?

500/1900 =26% 26% of 660L is 171L left 171L/10L/min=17min before depleted

A full oxygen Ecylinder contains how many L of oxygen and psig? If you have 165L at 10L/min of Oxygen, how many min left?

660 L of oxygen and 1900 psig 165L/10L= 16.5 min

How many L of o2 in a oxygen cylinder?

660 L oxygen at 1900 psig

Define Oliguria What should the UOP be in a 70kg pt in 12h? What is Anuria?

<0.5 ml/kg/hr 35ml/hr x 12h= 420ml Anuria: <50ml in 12 h

RFs for PONV in children

<6YO Strabismus surgery Duration of surgery >30min H/o PONV in parent/sibling/patient

Test 28:

A

Acute Respiratory alkalosis A: Acute Respiratory Acidosis: B Metabolic Acidosis: C pH/paCO2/HCO3

A: pH: 7.56, CO2: 24, HCO3: 21 B: 7.28, 55, 25 C: 7.32 30, 15

what % of CO does liver get? A What percentage of blood flow is from Portal Vein What percentage of blood flow if from Hepatic Artery? What percentage of oxygen does each (PV/HA) supply to liver?

A: 25% B: 75% C 25% D each delivers 50% of O2 supply to liver even though PV delivers 75 vs. 25% of blood flow, each supplies 50% of oxygen to liver

Stellate Gangilion Block aka: cervicothoracic sympathetic block -mc used for: -s/e: Where is it?

A: Complex Regional Pain Syndrome, refractory angina, phantom limb pain and vascular insufficiency (such as Raynaud's or frostbite), hyperhydrosis herpes zoster of head, neck UE/ upper chest, S/e: Horners: PAM is horney hoarse voice dysphagia seizures (d/t injection in vertebral or cartoid artery) Located at fusion of inferior cervical and first thoracic ganglions at level of C7 transverse process Anatomy: Inferior cervical + T1 sympathetic ganglia @ C7. Lays under the SCM/carotid, above the lung Side Effects: Horner's (intentional), hoarseness (RLN), eleveated hemidiaphragm (phrenic) Complications: hematoma, brachial plexus injury, pneumothorax, esophageal perforation, intrathecal/epidural/intravascular injection

Verbal/Tactile Responsiveness and Airway/Ventilation in: Minimal sedation (anxiolysis): A: Moderate B Deep: C General Anesthesia D:

A: Normal response to VS with no ventilation intervention B: Purposeful response to VS and TS -Protects own airway, no intervention required C: Purposeful response after repeated or painful stimulation w/ *possible airway intervention* D: Not responsive w/ventilation intervention needed

What should not be given as sole management of thyrotoxicosis?

Ablation by Radioactive Idiodine (destroys thyroid gland but in doing so causes release of thyroid hormone) worsening sxs —pretreat with PTU or mehimazole and propranolol

What does prolonged use of Neuromuscular blocking agent result in:

Acetylcholine receptor upregulation

Which conditions have increased RF atlantoaxial instability:

Achondroplasia Down's Syndrome Rheumatoid Arthritis SLE ---flexion/extension can compress/injury the spinal cord Use manual in line stabilization and/or fiberoptic intubation

Phenytoin on nondepolarizing NMBD Acute and Chronic effects:

Acute: Potentiates Blockade (enhances NMBD) Chronic: Decreases duration of block and Increased resistance to Block (ED95 increases) also incr DOA of Sux

Afferent limbs of laryngospasm reflex Efferent limbs of laryngospasm reflex Efferents to intrinsic mu

Afferent/Sensory: Internal SLN mediates laryngospasm Efferent/motor limb: ESLN +RLN to all other intrinsic ESLN to cricothyroid-adductor/VC tensor RLN all other intrinsic-adductors + posterior cricoarytenoid: only abductor keeping vc open

Hepatorenal syndrome fluid management: bolus of 25% albumin 1g/kg or bolus 4% albumin 500ml

Albumin 1g/kg of 25% --give higher percentage/concentration to avoid having to give a larger volume of albumin to avoid volume overload

Markers of hepatic synthetic function

Albumin, Platelets PT/INR (clotting factors: II, VII, IX, X)

How does each of the following affect K+ Aldosterone Cortisol Insulin Thyroid ADH

Aldos/Cortisol/Thyroid/Insulin all decrease K. Aldosterone and Cortisol (acts like mineralcorticoid): promotes K secretion Insulin, Thyroid enhance Cell uptake ADH/Vasopressin only influences Na/Water absorption (not K)

Angiotensin II effect on inotropy, chronotropy, catecholamine release Aldosterone levels, ADH levels Cardiac remodeling

All are increased with Ang II ---this is why ACE-i is protective of myocardium

What is associated with: Garlic, Ginkgo, Ginger Ginseng, Vit E

All inhibit platelet aggregation, incr RF bleeding ---Ginseng also Hypoglycemia

What is an opioid that can be given to a patient with PO ileus?

Alvimopan -potent mu receptor antagonist that doesn't cross BBB used to help w/ PO ileus in patients taking opioids so patient still has effect of opioid w/o constipaton

A patient is taking opioids for PO Pain and has Ileus. What drug can be given to prevent PO Ileus while allowing continuation of opioids?

Alvimopan: a potent Mu receptor Antagonist that doesn't cross BBB so get same analgesic affects w/o the constipation effects

Reversal to TPA

Amicar Aminocaproic acid binds reversibly *plasminogen* to incr *plasmin*.

What is the MOA of Encephalopathy (hepatic or other) and which agent is most responsible GABA or Glutamine? Does acute or hyperacute liver failure have higher mortality?

Ammonia gets metabolized to Glutamine which acts as osmotic agent pulling water into astrocytes causing cerebral edema-->HE Tx: decrease Ammonia (lactulose)->incr stools, poop out ammonia Acute liver failure (8-28 days following liver injury) has greatest mortality: 93% compared to hyper acute <7d of 35%

Where is the internal branch of SLN located What is it a branch of and what innerv does it provide? What is this block helpful for?

Anterior and Caudal to the Greater Cornu of hyoid bone Branch of Vagus n and provides sensory innerv to base of tongue, epiglottis, aryepiglottic folds, arytenoids Awake intubation: all of the following can be blocked for it: ((Glossopharyngeal (soft palate + oropharynx: sensory to posterior 1/3 tongue, vallecula, ant surface of epiglottis, pharynx, tonsils-via palatoglossal folds) and internal br of RLN-vocal folds/trachea via transtracheal technique through cricothyroid membrane))

Category of glycopyrrolate and atropine: S/efx

Anticholinergic -antiSLUDGE-Mi: Salivation, Lacrimation, Urination, Diarrhea, GI upset/emesis, Miosis, antiparasympathetic Stops saliva, lacrimation Tachycardia bronchodilation decreased gastric motility/constipation urinary retention Mydriasis (dilation)

Which types of malpractice payments must be reported to Nat'l practitioner data bank?

Any malpractice payment made on behalf of physician Must be reported -no need to report payments from personal funds or behalf of corporation

Most accurate way of assessing volume status

Arterial Pressure variation (includes Pulse Pressure and Stroke Volume Variation) >13% suggests fluid responsiveness

What leads to depolarization of muscle leading to contraction?

At Presynaptic Terminal: action potential travels along presyn. neuron which leads to intracellular calcium Influx, causing ACh release across synaptic cleft (efflux of K rapidly restores memories potential) Postsynaptic Membrane -ACh binds to Receptors on Post-S membrane resulting in depolarization which Opens up Na Channels to generate AP -Influx of Na into motor endplate--->action Potential generated

RLN damage causes SLN damage causes:

At time of Extubation: —immediate stridor and difficult with phonation, Hoarseness —Change in pitch of voice (cricothyroid mu)

Alpha waves are associated with Beta: Delta/Theta

BAT Drink, as Frequency Decreases, Amplitude Increases: Beta: Concentrating patient --Freq>14Hz, low amplitude Alpha: Awake, Fast Waves: a relaxed but awake state: resting with eyes closed --8-13, High amplitude Slow Waves: Theta: Sleep and Sedation/GA --7-4Hz, High amplitude Slowest: Delta: Deep sleep, GA, Coma/encephalopathy, Hypoxia *<4Hz, maximum amplitude*

Becker vs. Duchenne muscular dystrophy facts:

Becker: less severe/milder course, decreased dystrophin (vs. no dystrophin) -cardiac involvement higher than in DMD -assoc w/epilepsy, MAcroglossia, color blindness,

Other bronchodilators?

Beta Agonists: Albuterol, salbutamol, Musc Antagonists: ipratropium, trot Magnesium Ketamine Theophylline Nitric Oxide

Markers of biliary dysfunction:

Bilirubin and GGT

Is MG sensitive or resistent to NMBD Sux?

Both MG and LE are sensitive to NMBD MG is Resistant to Sux LE is Sensitive to Sux LSS MGRS

Anaphylaxis vs Anaphylactoid rxn

Both are Histamine mediated --cannot be differentiated clinically -- both urticaria, bronchospasm, hypotension, angioedema, flushing Anaphylaxis: Hypersen Type I, IgE mediated triggers: NMBD, Latex, Abx Anaphylactoid: Redman Syndrome (Vanc), Amniotic Fluid Emboli Direct from Uncontrolled histamine release *not IgE mediated* triggers: Protamine, IV contrast, Opioids, Amniotic fluid

MC s/e of sux in children:

Bradycardia d/t ACH/M-R on SA Node

Isobaric agents (compared to CSF) spinal local anesthetics:

Bupivacaine and Ropivacaine --as dense as CSF and remain at level at which they are injected hypobaric to CSF, made by add'n of sterile water --less dense than CSF, rise against gravity Hyperbaric to CSF, made by add'n of glucose/dex --more dense than CSF and follow gravity

its high potency, lipid solubility can cause CNS toxicity at lower doses than many other LA

Bupivicane:

Right Shift of oxyhemoglobin curve

CO2 Incr Acidosis/Anemia 2-3DPG (phosphate) Elevation Temp (high)

Color of Gases Carbon Dioxide CO2: OxyGen: Air: Helium Nitrous Oxide N20: Nitrogen:

CO2: Gray OxyGen: Green Air: Yellow Helium: Brown N2O: Blue Nitrogen: Black

What does phosphate bind to?

Calcium (decreases iCa)

Which medication CI for management of acute Malignant hyperthermia being treated with dantrolene?

Calcium Channel blockers: Diltiazem, Verapamil , nefidipine --exact mechanism for interaction w/dantrolene unknown but are synergistic and decr release of Ca from SR

What causes each shock: Cardiogenic: Distributive Hypovolemic Obstructive

Cardio: ADHF, Valve Rupture, MI, Arrhythmia Distributive: adrenal crisis, anaphylaxis, sepsis, spinal cord trauma, toxic shock Hypovolemic: hemorrhage, volume depletion (vomiting, diarrhea, dehydration) Obstructive: cardiac tamponade, constrictive pericarditis, PE, Tension Pnthx

Indication for use of an intra-aortic balloon pump?

Cardiogenic shock, acute MV insufficient and unstable angina A -placed in femoral artery

What is the CO, HR, SVR (afterload), PCWP(preload), O2 Sat, cold or warm for each of the following types of Shock: Cardiogenic/ADHF/Valve rupture/MI and Obstructive/PE/TnPnthx Hypovolemic/hemorrhage/volume depletion Distributive/Septic/Anyphylaxis/Adrenal crisis or CNS injury

Cardiogenic: Decr CO, Incr HR, Incr SVR, Incr PCWP (cardiogenic d/t reduced lV output) and Decr PCWP (obstructive d/t reduced RV output), Dec O2 sat, cold/clammy Tx: diuresis, inotropes or relieve obstruction Hypovolemic: Decr CO, Incr HR, Incr SVR, Decr PCWP/CVP, Decr O2 Sat, cold clammy Tx: fluids Distributive: Incr CO, Incr HR, Decr SVR, Decr PCWP, Incr O2, warm dry Tx: fluids, Pressors --CNS injury is Decr CO

Where does spinal cord end in children vs. adults and where does the dural sac end in adults?

Children: L3 Adults: L1 and dural sac S1

What binds with calcium to decrease iCa:

Citrate in Blood Phosphate Albumin in high pH, binds with Ca, decr iCal (in acidic environment) H+ binds Albumin increases iCa

What is HPV (hypoxic pulmonary vasoconstriction)

Common with one lung ventilation: nondependent lung (non ventilated) is vasoconstricted d/t low O2 and incr CO2 resulting in VQ mismatch d/t perfusion w/o oxygenation. Blood is shunted from area of low O2 to area of high O2 (dependent/ventilated lung) to optimize O2 exchange

Function of Renin?

Converts angiotensinogen to angiotensin I -- increases blood pressure, leading to restoration of perfusion pressure in the kidneys ACE converst Angio I to Angio II

A patient with a head injury results in Deterioration in mental status with BP 194/111 and HR 41bpm. What is the pathophysiology? What part of brain is this process mediated?

Cushing Reflex —HTN and Bradycardia and resp depression mediated by sympathetic activation via medullary vasomotor center ICP—>pushes on medulla, causes ischemia->vasomotor center w/in medulla activates sympathetic n.->HTN->reflex Brady mediated by baroreceptors

Hyperventilation effect on Cerebral blood flow: What effect does hyperventilation have on a patient with da thromboembolic occlusion of a cerebral artery?

Decr CO2 Vasoconstriction vasoconstriction will divert blood flow from healthy areas of brain to poorly perfused areas "inverse steal"

What is the expected V/Q ratio in Hepatopulmonary syndrome?

Decreased VQ ratio ---vent remains constant but perfusion elevated 2/2 pulmonary dilation

ACE-i affect on vasopressin and potassium What is main function of ACE-I?

Decreases Vasopressin (ADH) and Aldosterone so you get Hyperkalemia Main fxn: Decrease remodeling of heart- decr cardiomyocyte proliferation and fibroblast activity

What EEG waveforms are seen with deep sleep or general anesthesia

Delta Waves (D=deep Sleep and Drugs!) Theta waves: Sleep, GA

A person is experiencing hypoxia and inadequate delivery to the brain is expected. What wave is most common in this situation?

Delta waves (the slowest of all waveforms) are expected as ischemia causes "slowing" w/decr in fast waves: alpha/beta and increased theta (slow) and even slower waves (delta) as brain progresses to burst suppression (suppression of brain activity/complete silence of activity)

Muscles with fastest recovery after dose of paralytics: Which mu is delayed most?

Diaphragm Laryngeal Mu Orbicularis Oculi Masseter Rectus Abdominis Adductor Pollicis

Which is an effect of Midazolam? Decr HR, Decr Ventilation Rate

Dose dep decr in Ventilation —greater in COPD It actually causes hypotension with increased HR

Zero order kinetics

Drug elimination with a constant amount metabolized regardless of drug concentration —-depends on actions of enzymes/transporters but when they become saturated the elimination becomes constant limited to maximum amount per unit time-—-levels can become dangerously high w/unmonitored admin (ASA, Ethanol, Phenytoin)

What increases risk for post op complications in patients with Myasthenia Gravis?

Duration of sxs >72 months (6 years) Pyridostigmine dose >750mg/day Respiratory disease (COPD, Asthma, Fibrosis, etc) Vital capacity <2.9

Dx and Mgt of MH:

Dx: Caffeine/Halothane Muscle Biopsy contracture test --caffeine and halothane are ryanodine mu R agonists. + test is definitive diagnosis (High Specificity) 2.5mg/kg Dantrolene Lasix and mannitol to reduce/prevent renal damage by decr UOP NaHCO3 to correct profound metabolic acidosis

pt has anorexia, n/v, cutaneous mucosal hyperpigmentation, hypovolemia, hyperkalemia, fatigue/weakness. Disease what is most likely to occur during Gen Anesthesia?

Dz: Addisons: Hyperkalemia/Met Acidosis; hypoglycemia, hypotension, vol depletion Hypotension is most likelly to ocur Tx: Electrolyte resuscition, steroids (100mg IV Hydrocortisone q6h x24h)

Echinacea Kava Saw Palmettos St John Wart Valerian Root

E: cell immunity, immunosupression K: Sedation Saw Palmetto: COX Inhib-bleeding St John: CYP450 Induction, delayed emergence Valerian Root: Sedation, incr MAC requirement

What local anesthetic class is Mc to result in hypersensitivity reactions

ESTERS 2/2 PABA metabolite ---one I in name Procaine (amides: 2 i's bupivacaine) although hypersensitive rxns are rare

Cell type indicating early arteriosclerotic lesion? Cell type indicating Late " "

Early: Foam cell:lipid ladenmacs Late: Platelets following plaque rupture leading to thrombosis

ED95

Effective Dose required to achieve effect in 95% of pop -specifically for NMDs- the amount of NMBD required to reduce twitch height by 95%

Best induction agent to use in a patient with intracranial hemorrhage with high ICP:

Etomidate ----other options: Prop, Benzo, Barbs avoid ketamine

Respiratory mechanics of pregnant: Which component remains unchanged?

Expiratory Reserve Vol and FRV and Residual Vol decreases IC increases (TV and IRV increases) FRV decreases (worse in supine) Incr CO2 Incr Minute ventilation VC remains unchanged

Blood vol of: Females Males Kid Infant Premature

F: 60-65 ml/kg M: 65-70 ml/kg Kids: 1-12yo 70-75ml/kg Infant: 3mo-1yo 80ml/kg Newborn: 90ml/kg Premature: 100ml/kg

T/F You should use hydrocortisone for tx of sepsis responsive to vasopressors?

False -give only if not response to fluids or pressers

Left shift of O2-Hbg

Fetal Hbg COHbg Meth-Hbg Cold temp Alkalosis Decr 2,3 DPG Hypocarbia

How are most drugs eliminated from the body?

First Order Process -95% are eliminated this way In the Urine, after being metabolized

Function of cricothyroid mu: innervated by:

Fxn: Vocal cord tensor, raises pitch of sound produced) inner by EXTERNAL SLN

Why do patients usually shiver with gen aneshesia:

Gen anesth inhibits Hypothalamus/thermoregulatory center to thermoregulate the body temp. hypothalamus cant regulate temperature correctly Tx meperedine

jaw-thrust maneuver muscle to relieve upper airway obstruction:

Genioglossus muscle

soft palate and oropharynx innervation location of LA injection:

Glossopharyngeal nerve: IX Inject at anterior tonsillar pillars

Glucagon cells: —stimulated by Insulin cells:

Glucagon are alpha (each has A) Stimulated by epinephrine Gluconeogenesis and glucogenolysis Thx for BB overdose (glucagon incr G protein-cAMP to increase inotropy/Contractility) and Thx of insulinomas to counter hypoglycemia Insulin cells are beta cells Stimulated by hyperglycemia

Beta agonists cause bronchodilation w/what MOA?

Gprotein—>Incr cAMP

What is the Trauma Triad of Death? and what is it a complication from?

HAC is a complication of Massive Transfusion Hypothermia Acidosis Coagulopathy Patient will be cold <35 with oozing at IV lines with low pH

Cushing's triad

HTN Bradycardia Respiratory depression Mgt: Urgent Endotracheal intubation in setting of severe head injuries to prevent hypoxia, aspiration, and allow for hyperventilation and aid in imaging or invasive procedures

MC electrolyte disturbances in refeeding syndrome:'

HYPO Kalemia and phosphatemia and magnesium d/t increased glucose from TPN causing increased Insulin which pushes Phos/Potassium into the cells

Shift of Carbon dioxide dissociate curve is due to what process -Bohr effect -Boyle law -Haldane effect

Haldane effect: describes percent of CO2 in blood -when O2 binds to Hbg and displaces CO2, facilitates removal of CO2 from body Bohr effect is opposite: -When CO2 increases in blood and causes O2 to be displaces from Hbg, rightward shift on O2Hbg dissociation curve —then CO2 transported to lung for removal (CADET face right)

Difference b/w Haldane and Bohr effect

Haldane is the decrease in CO2 affinity of Hbg from increased O2 --occurs in Lungs --Describes release of CO2 --Effective under high pH --Caused by uptake of O2 in lungs --Facilitates the binding of O2 to Hbg Bohr is the decrease in O2 affinity of Hbg in response to incr CO2 --occurs in Tissue --describes released of O2 --Effective under low pH (high Co2) 00caused by uptake of CO2 at tissue --Facilitates release of O2 at tissue

Drugs that don't cross placenta

He Is Going Nowhere Soon Heparin Insulin Glycopyrrolate Non-Depolarizing Muscle Sux

Drowning in freshwater affect on blood

Hemolysis -decr osmolarity w/ systemic hypoxemia

Why does a patient with cirrhosis have vasodilation in lungs and kidney?

Hepatic failure causes increased NO which leads to vasodilation in lungs and kidneys causing Heptopulm and Heptorenal syndromes ---this is not hepatic buffer response. the hepatic buffer response is hepatic artery VD d/t adenosine in response to decr portal venous flow

Is CSF higher or lower in children?

Higher in children -this is why they have lower rates of postural puncture headache compared to adults Infant CSF vol: 4ml/kg child CSF vol: 3ml/kg Adults CSF vol: 1.5-2ml/kg

What does high CO2 and Low O2 do to brain vs lungs/body

Hypercapnia and Hypoxia cause VC in lungs/Body and VD in brain Hypocapnea and high O2 cause VD in lungs/body and VC in brain

Normal saline metabolic acidosis or alkalosis

Hyperchloremic Metabolic Acidosis

What are sequelae of MH?

Hypermetabolic state: increased etCO2, Lactate, heat production which can progress to muscle cell breakdown-->hyperkalemia, rhabdomyolysis, EOD, arrhythmias, death

Factors the INCREASE anesthetic requirements

Hyperthermia (high T) Hypernatremia (high Na) HyperADD Drugs: Acute Amphet/Cocaine Hyperthyroidsism Infancy/peaks at 6mo Chronic Alcoholic Red Hair Drugs which raise central catecholamines raise MAC: acute amphetamine intoxication ephedrine MAO inhibitors

Pt develops stridor 24-96h after thyroidectomy, MCC:

Hypocalcemia

MC cause of sudden strider 24-96h post thyroidectomy:

Hypocalcemia -d/t destruction of parathyroid glands -trousseau, Chvostek signs —Airway edema seen in PACU assoc w/ surgical site hematoma

Rapid administration of bicarb leads to:

Hypokalemia (alkalosis: H out/K in; also decr iCa) ---incr in pH means less H bound to albumin and more Ca bound to Albumin (decr iCa) (acidosis: H in/Kout; also incr iCa) --More H bound to Albumin, less Ca bound to albumin (incr iCa)

TPN common manifestation

Hypophos HypoK HypoMag Hypercarbia (increased carbs/aerobic breakdown to CO2) Hyperglycemia, hyper insulin Hepatitic steatosis Thrombophlebitis

Hypophosphatemia manifestations:

Hypoxia d/t Decr 2,3 diphosphoglycerate (2,3 DPG) causing left shift Mu Weakness/Low Cardiac Contractility->arrhythmia: no ATP AMS, Seizures

Components of MELD score

I Crush Several Beers Daily INR Creatinine Sodium Bilirubin Dialysis

Hepatopulmonary syndrome Characteristics

Incr NO->Intra Pulmonary Dilations->incr perfusion relative to ventilation->V/Q mismatch INcr A-a oxygen gradient Hypoxia improved when laying flat (platypnea) Worse when standing ( orthodeoia)

States that increase V/Q ratio (dead space ventilation)

Incr V or Decr Q Decr Q/Blood flow: Pulm Embolism, systemic Hypotension, emphysema (obliterated areas of lung not able to be perfused but are well ventilated)

A patient has essential hypertension, what alterations do you see with: SVR Sympathetic Tone Cerebral Autoregulation range Cardiac Output

Increased SVR, Sympathetic tone and higher cerebral resting pressures NORMAL CO

What would CVP, PAP and PCWP be in a person with obstructive shock?

Increased CVP >8 Increased PAP >20 Decr PCWP/Preload (normal 4-12) d/t reduced RV output if cardiogenic would have Incr PCWP d/t LV output failure

Why does elderly small airways collapse more easily?

Increased Closing Capacity d/t decreased elasticity (keeps lungs patent) and increased compliance (rubber band )

What do you expect to see with Sux and Morbidly obese patients?

Increased butyrylcholinesterase (aka pseudocholinesterase) and increased Extracellular volume means you need MORE Sux for incr DOA in obese -need to use TBW not IBW at 1mg/kg

What is an anesthetic concern of ALS (amyotrophic lateral sclerosis)?

Increased risk of Aspiration and pulmonary complications d/t respiratory mu weakness (worse w/opioids, Sux, non-dep mu relaxants d/t exaggerated/ prolonged effects)

Does hypercapnia increase or decrease pulmonary vasoconstriction:

Increases

Glucagon MOA

Increases Glucose by: Glycogenolysis Gluconeogenesis Lipolysis (produces substrates for gluconeogenesis: glycerol and free fatty acids) Glycolysis is Inhibited so substrates can be used for gluconeogenesis Glucagon also has inotropic and chronotropic effects

A pt has hypokalemic periodic paralysis, what should be avoided in this pt?

Infusions of glucose, insulin Na rich foods Strenuous exercise (increased thyroid/catecholamines-d/t incr pain, moves K into cell) all will decr Potassium

A patient w/ischemic stroke has developed hemorrhagic conversion after given tPA. Mgt:

Inhibition of Plasminogen and Plasmin with anti fibrinolytics: TXA or Aminocaproic Acid —they bind to plasminogen/Plasmin and prevent further breakdown of fibrin

If you have extravasation (leakage of fluid into subq tissue) by a vasoconstrictor what is mgt?

Injecting Phentolamine (alpha blocker) or hyaluronidase (hyaluronic acid) into subcutaneous tissue which causes tissue to become more permeable by vasodilation Mgt: Keep IV in place initially. -Aspirate 5ml of blood 3. Elevate limb to promote drainage proximally 4. apply warm compress for vasoconstrictions (cold for most other drugs) 5. Gault Technique: washout causes: infiltrated IV causing damage to limb/necrosis

Nerves blocks for awake intubation

Internal SLN (Ant/Caudal greater hyoid bone) Glossopharyngeal (in mouth at tonsillar pillars/palatoglossal folds) RLN (b/w thyroid/cricoid cartilage in cricothyoid membrane

What is congenital Myasthenia Gravis?

It's 2/2 genetic mutation of proteins and not d/t antibodies (like MG/LE) Can be either AD or AR Occurs early, never past adolescence No tx for this form

What to keep in mind in patient taking amiodarone?

Keep on lowest FiO2 possible b/c it is assoc w/pulmonary fibrosis and pneumonitis assoc w/ higher O2

Right mainstem intubation sxs

L to R Shunt: no vent to L stem, same perfusion Hypoxemia Elevated Peak airway pressures unilateral breaths

At what level does spinal cord/conus medullaris and dural sac end in Child vs. Adult Iliac crest is landmark for L____ and is called

L3/S3 in child L1/S1 in adult L4 interspace, tuffier's line --do spinal anesthesia in L3/L4 or L4/L5

Proximal muscular weakness upon awakening which alleviates with movment: Disease and MOA

Lambert Eaton Myasthenic Syndrome MOA: Antibodies to VGCC on Presynaptic nerve terminals

Fasest onset/offset muscles with paralytics:

Laryngeal Muscles Orbicularis Oculi Diaphragm Masseter d/t high arts of blood flow

Mcc of Stridor in PACU post extubation Mgt

Laryngeal edema Mgt 100%Fio2, nebulized racemic epinephrine, Heliox, reintubation -stridor 24-96h after surgery d/t hypocalemia after thyroid removal d/t hypocalemia -hematoma would be noticeable under incision

Fetal Hbg shifts curve to

Left

Large molecular weight drugs eliminated by: Most drugs are eliminated By-what do they need to be:

Liver/Bile Most drugs eliminated by kidneys —But first lipid soluble drugs need to be metabolized to polar, water soluble forms in the liver to interact with kidneys

Drug that is dangerous to fetus in distress

Local anesthetics Lidocaine crosses placenta and exhibits ion trapping bye to its basic structure in the distresses fetus (acidic environment)

Which diuretics cause Hypochloremic metabolic alkalosis?

Loop and Thiazide diuretics other causes: laxatives, vomiting, excessivegastric acid loss (NG tube), Tx: Normal saline (since acidic and has Cl) and mgt of hypokalemia to prevent further alkalosis

difference b/w stellate and lumbar sympathetic blocks

Lumbar sympathetic and stellate ganglion blocks are the same with the exception of the injection site and the region of the body targeted.

Metabolites of Morphine and complications if accumulated in renal failure pts?

M6G morphine 6 glucuronide (active)= significant resp depression M3G (inactive metabolite) neurotoxicity: myoclonus, allodynia,

MAC vs. non-anesthesia sedation (aka conscious sedation)

MAC is a spectrum from mild to deep sedation with possible conversion to GA when necessary-provider must anticipate, diagnose, treat any problems that occur monitors are same as GA: BP, ECG, etCO2, Pulse Ox MAC req's 2 providers: procedurals and anesthesiologist non anesthesia: sedation and procedure provided by provider or by a nurse working w/provider

Phenelzine is what type of medication?

MAOI -increases serotonin in synaptic clefts -if given with Meperidine (opioid) can cause Serotonin syndrome

Normal values of: MAP CO: Central Venous Pressure Pulmonary Capillary Wedge Pressure aka: pulmonary artery occlusion pressure Pulm Artery Pressure RA Pressure

MAP: 70-100 CO: 4-8 CVP: 4-12 PCWP: 4-12 PAP: D: 4-12, S:15-25 RA: 2-7

What's released from Adrenal Medulla:

MEN: Medulla-epinephrine/NE -stress hormones derived from neural crest cells and released in response to sympathetic stimulation

Difference in deep tendon reflexes between myasthenia graves and myasthenia syndrome (aka LE)

MG has normal Deep tendon reflexes, usu no muscle pain and ocular weakness which worsens with exercise LE: has decreased deep tendon reflexes, muscle pain is common and improves with exercise. includes Autonomic dysfunction

Venous Air Emboli aka pulmonary air embolism MOA SXS

MOA: when air enters systemic vasculature, travels to RV then to lungs --incr risk when pt is in sitting position -20ml of air or 5ml/kg is fatal -RV strain, decr pulmonary venous return, decr CO, circul collapse, cardiac arrest Sxs: Decr etCO2, decr SpO2, Rise CVP, tachy/Brady, hypotn, tachypnea SOB, respiratory distress, cough if pt is awake Most sensitive invasive: TEE MS noninvasive: pericardial US/doppler Mgt: Call for help, 100% FiO2, place surgical site below heart, left lat decub flood surgical field w/N/S, turn off volatile Anesth, Give epineph 10mcg to maintain CO,

What conditions interefere with supraglottic airway devices?

Masses of the Posterior Pharynx or the Upper Esophagus Vascular anterior pharyngeal lesions T

From medial to lateral what is the correct structure order of antecubital fossa: brachial artery, Median and radial nerves?

Medial to lateral: median n. elbow brachial a. radial a. (thumb)

MetHb and CO affect on PaO2 and pulse Ox when O2 is given:

MetHb --PaO2 increases and pulse Ox remains 85-90% CO --PaO2 increases and pulse Ox increases to 100% (falsely elevated) since CarboxyHb resembles OxHb on pulse Ox

Normal PaO2 and SaO2 of MetHb and CO

MetHb: PaO2: falsely elevated: reflects amount of O2 available in blood despite MHbg cannot bind to it SaO2: <90% CO: PaO2: normal to high (amount of O2 is normal, CO has >affinity for Hbg so O2 is not bound SaO2: Normal Left shift->decr release of O2 to tissue

Lactate Ringers metabolic acidosis or alkalosis

Metabolic Alkalosis d/t metabolism of lactate which produces bicarb

What direction does Methemoglobin shift O2-Hbg curve? What direction does CO shift curve? CO2? Sulfhemoglobinemia?

Methemoglobin and CO shift curve to left CO2 to right Sulfhemoglobinemia to right

2 Immunosuppressants for renal transplant Possible S/e

Methylprednisolone Thymoglobulin Rapid admin can result in: PULM EDEMA, CP collapse d/t acute phase rxn: fever, chills, malaise, analphylaxis, noncardio Pulm Edema, CP collapse Tx: slow down infusion +/- vasopressor

Which of the following has LEAST effect on heat loss during regional or general anesthesia? Volatile Anesth Midazolam Bupivacaine Morphine Propofol

Midazolam Regional anesthetics, Volatile anesthetics, propofol, morphine all promote heat loss thru vasodilation and alter thermoregulation --opioids also decr sympathetic outflow

Patient has increased Urea levels, what med requires decr dosage? Desfluane, Esmolol, Midazolam, Remifentanil

Midazolam -Uremia causes lower protein binding and higher concentration of Midaz

What med should you avoid in prego? -Etomidate, Midaz, Prop or Roc

Midazolam esp in early prego: cleft lip and floppy baby

What does an EEG of a person under general anesthesia look

Mimics sleep with: Slow/low frequency and Large Amplitude and minimal motor activity on EMG Awake (alpha waves) Fast/high Freq/High Amplitude and enhanced motor activity on EMG As Frequency Decreases, Amplitude Increases BAT Drink Beta>14Hz, low Amplitude, concentrating or under sedation Alpha 8-13, High Amplitude, awake/resting Theta 4-7 High Amplitude, asleep/GA Delta 0.5-4Hz Maxiumum Amplitude asleep/GA

Hormones responsible for potassium homeostasis

Mineralcorticoids: Aldosterone Cortisol: acts like aldosterone insulin thyroid Vasopressin/ADH does not affect K. Only affects Na

A pt has both Obesity hypoventilation syndrome and has been vomiting all day. What would you expect pH/CO2/HCO3

Mixed chronic respiratory acidosis and acute metabolic alkalosis 7.4 paCO2: 60 (chronic retention) increased HCO3: 36 to compensate

Safe measures during laser airway procedures

Moistened sponges/gauze Metal ETT (laser resistant TT) Use of jet ventilator (when laser not used) Lowest FiO2 or Air use (Do not use N2O) Avoidance of paper drapes

Hydrophilic opioids

Morphine Hydromorphone (dilauded) Oxycodone

Antibody test most sensitive for HIT? Heparin Induced Thrombocytopenia

Most sensitive is Platelet factor 4 Most Specific is Serotonin release assay

External br of SLN function

Motor innerv to Cricothyroid mu To Tense the Cords

bulbar symptomatology: Facial droop, ptosis, possible dysphagia with weakness that worsens with activity Disease and MOA

Myasthenia Gravis MOA: Antibodies to ACh-R on post synaptic nerve terminal

Why should you avoid SUx in Myotonic Dystrophy

Myotonic Dystrophy doesn't up regulate NAChR but will have severe contractions induced by sux

What inhaled anesthetics inhibits DNA synthesis?

N2O ---prevents DNA synthesis by irreversibly inactivating B12

Pt has an anterior mediastinal mass, what drug should be limited?

NMBD --only give if absolutely necessary --most feared complication is airway obstruction and inability to maintain gas exchange during induction. try to keep pulm/CV system at baseline to maintain spontaneous ventilation

Principle extracellular cation -which hormone mediates it total body content

Na Aldosterone

What is the most accurate measure of core body temperature?

Nasopharynx Distal Esophagus Tympanic Membrane Pulmonary Artery Least accurate: Bladder

The nasopharynx is b/w The oropharynx is b/w The hypopharynx and larynx

Nasopharynx: base of skull and soft palate Oropharynx: Soft palate and Epiglottis Hypopharynx and Larynx: extend from epiglottis to cricoid cartilage and is contiguous w/esophagus

In prego, what happens to fetus if you give neo /glyco to reverse

Neo Xs placenta but glyco doesn't so baby will have bradycardia. Better to give atropine with neo

What neurotransmitter, receptor and membrane response occurs in response of parasympathetic stimulation:

Neurotransmitter: ACH Receptor: Muscarinic Response: Hyper-polarization (more neg) d/t efflux of K

Should Sux be given to Guillan Barre patient?

No. not for any patients with peripheral polyneuropathy d/t risk of catastrophic hyperkalmic response --also avoid prolonged paralysis w/ NMBA to prevent prolonged mu weakness

Which shock results in Increased CO What is Normal CO:

Normal CO: 4.5L/min Distributive (Septic) shock—>VasoDilation->INcreased CO in early stages and decreased Central Venous Pressure Vs. Cardiogenic (MI-cardiac pump failure), Hypovolemic (bleeding, reduced preload), Obstrucive shock PE, pulm all lead to decreased CO and increased central venous pressures and and pulmonary artery pressures

What is active metabolite of Meperidine and what can this cause in patient with renal dysfunction:

Normeperidine-a neurotoxic that can cause Seizures in renal failure pts d/t accumulation

Elevated Central Venous and Pulmonary Artery Pressures and reduced Pulmonary capilliary wedge pressure means what type of shock?

Obstructive d/t elevated pulmonary vascular resistance —extra cardiac conditions that lead to poor RV output -Tension Pntx, Pericardial Tamponade, constrictive pericarditis, PE, restrictively cardiomyopathy

Shock d/t pulmonary emboli is a form of ______ shock and what will show on TTE

Obstructive shock and TTE will show R ventricle distention and dysfunction

What is more common in near drowning event in ocean vs. fresh water?

Ocean Water: Hypernatremia d/t hypertonic ocean water->pulm edema and systemic hypovolemia Sea water->hypertonic-> draws water out of cell->pulm edema/VQ mismatch/ARDS Fresh Water: Hypotonic->draws water into RBC->Swelling/rupture->intravascular HEMOLYSIS Fresh water: hypotonic—>systemic circulation->hypervolemia->Pulm Edema/VQ mismatch

A patient with long standing poorly controlled diabetes will have which? -Hyperhydrosis -Orthostatic Hypotn -Stress incontinence -Bradycardia

Orthostatic Hypotension 2/2 -neuropathy and -autonomic dysfunction (resting tachycardia) -overflow incontinence -gastroparesis -neurogenic bladder -anhidrosis and dry skin

Common S/e of celiac plexus neurolytic block:

Orthostatic Hypotension d/t splanchnic vasodilation

Tests of synthetic function in liver

PT/INR platelets Albumin

Paraneoplasitic condition associated with Sq Cell Car and possible physical manifestation:

Parathyroid related peptide secreation causing increased Calcium --hypercal induced muscular weakness

COCL2 is what? And what does it cause?

Phosgene chemical warfare causing severe pulmonary damage resulting in morbidity and mortality

Antibody test with highest sensitivity for HIT:

Platelet factor 4 HIT is ab to PF4

When is oxygenation improved in patient with hepatopulmonary syndrome? worsened when?

Playpnea (lays flat) and worsened when standing (orhodeoxia)

MOA of benzodiazepines:

Positive allosteric modulator of GABA- don't directly bind to receptors site and so are not an agonist

What is MCC of death in drowning victims:

Post Hypoxic Encephalopathy

What are the only ABDUCTOR laryngeal muscles:

Posterior Cricoarytenoid Muscle are only mu that open true VC (Lateral cricoarytenoid adduct)

Oculocardiac reflex What nerve? W

Pressure on globe results in bradycardia and hypotension Trigeminal n. V1 → primary sensory nucleus of V → motor nucleus of vagus → parasympathetic stimulation of heart

Primary vs. Secondary adrenal insufficiency:

Primary/Addisons: adrenal cortex dysfxn Secondary: Decreased ACTH released from Ant. Pituitary

hyPeR calcemia, kalmia, magnesemia and PR interval --prolonged or shortened?

Prolonged --mneumonic (PRj

Hyperparathyroidism causes Hypercalcemia. what do you expect to see re: QT interval, PR interval hyPeR....

Prolonged PR Shortened QT QT is always opposite of PR

Does Propofol increase or decrease ICP?

Propofol decreases CMRO2, Cerebral oxygen consumption and ICP

PPx antibiotics for what heart conditions:

Prosthetic valves or prosthetic material H/o Infx endocarditis H/o unrepaired congenital disease H/o Regurg valvular lesion

Acetacholinesterase Inhibitor used to treat MG

Pyridostigmine

What medication is given for organophosphate (chemical warfare) poisoning PPx and Post exposure Mgt:

Pyridostigmine Post exposure: Atropine (crosses BBB) so better than Pralidoxime which doesn't cross BBB

Efferent limb of laryngospasm

RLN LATERAL Cricoarytnoid and transverse and oblique arytnoid (all are adductors) of VC responsible for laryngospasm. Posterior cricoarytenoid is resp for abduction/opening vc. + SLN: cricothyroid mu., also adductor

BL RLN Injury vs BL SLN injury Hypocalcemia

RLN-aphonia, stridor, dyspnea after extubation, complete obstruction --unilateral damage: transient hoarseness SLN-pitch/tiring of voice but no airway compromise Hypocalcemia-24-96h p surg

What should not be given to a Graves patient with thyrotoxicosis?

Radioactive Iodine alone -worsens dz Tx: Methimazole, PTU w/Propranolol

What is the most common etiology of hypothermia in the 1st hour of induction of anesthesia?

Redistribution of body heat from core to periphery *not d/t heat loss but just redistribution -usu 1.5 degrees celsius -after redistribution then the heat is lost to the environment through radiation, convection, conduction and evaporation

What is MOA of hepatic arterial buffer response? What is the key player?

Reduced Portal venous flow leads to hepatic arterial vasodilation to maintain constant hepatic flow -if PV blood flow incr, hepatic arterial flow VC-> decr flow *hepatic arterial blood flow does not induce reciprocal changes in portal venous system Key player: Adenosine->VD

Causes of hypocalcemia include:

Renal Failure --no Ca reabsorbed Hypomagnesemia (magnesium stimulates parathyroid to incr Ca, with low Mg, parathyroid not stimulated which means low ca) Vit D Deficiency: low vit D means less Ca absorbed Citrate: chelates Ca (decr)

What procedure is indicated in pt with severe aortic insufficiency?

Retrograde cardioplegia

Muscular Dystrophy possible effect from General Anesthesia or Succcinylcholine:

Rhabdomyolysis and/or Cardiac Arrest

IBW vs. TBW Roc should be dosed according to Sux should be dosed according to

Roc: IBW Sux: TBW

MOA of hyponatremia in SAH:

SIADH -correct slowly to avoid central pontine myelinolysis (osmotic demyelinating syndrome)

Difference between Malignant H. NMS and SS?

SS has hyperreflexia/clonus and MH and NMS have rigidity

Hormones released from Adrenal Cortex If primary adrenal insufficiency, what symptoms would you see?

Salt->Sugar->Sex Aldosterone: -low amounts: hyponatremia, hyperkalemia, metabolic acidosis, hypovolemia, hypotension --stimulated by RENIN Glucocorticoid: weakness, hypoglycemia, hypotn, fatigue, wt loss --stimulated by ACTH Androgens/sex hormones

Carotid sinus baroreceptor fxn Location Aortic arch baroreceptor fxn Which is more sensitive

Senses high BP/stretch and responds by lowering SVR, by VD and reducing HR and contractility or Senses low BP to medulla and sympathetic response to VC, inr HR -located in carotid sinus at bifurcation of int/Ext carotid signals go to medulla and efferents via CN IX Aortic arch fxn does same as above-transmits signals to medulla to incr/decr BP via vagus CN X Carotid are more sensitive than aortic arch baroreceptors -decr arterial pressure ->hypervent -incr art pressure->hypovent

Difference b/w Septic shock and cardiogenic or obstructive shock:

Septic Shock has High CO and MI, PE will cause decreased CO and PCWP incr in CS and decr in Septic Shock

A patient has DM, what is associated with perioperative hyperglycemia?

Serum Glucose >180-200 Delayed gastric emptying Stimulation of Sym patho-adrenergic activity, Osmotic Diuresis (hypovol) Immunosuppression (decr WBC fxn) —delayed wound healing, reduced skin graft success PO Cognitive dysfunction *in cardiac surgery* — (incr brain, spinal cord, renal damage by ischemia) increased mortality

Typical drugs used for renal transplant:

Sevoflurane (despite Compound A does not effect graft) Cisatricurium (Hoffman) Furosemide and Mannitol to promote graft diuresis Chemo meds: methylprednisolone, thymoglobulin

Characteristics of Drugs that cross placenta

Small MW <500 Daltons Lipid soluble (fentanyl, atropine) Non-ionized Low Protein bound drugs (high Protein bound drugs bind more closely to mothers plasma proteins) High maternal drug concentration

What ion is involved in first step of generating an action potential in a POSTsynaptic NM juction?

Sodium presynaptic terminal gets depolarized by AP, ca channels open, influx of ca triggers ACh release. Ach travels across cleft, binds to Ach-R on POST synatic membrane which depolarizes endplate and opens Sodium channels Ca is first in Presynaptic terminal Na is first in postynaptic terminal

Does solubility of CO2 increase or decrease with hypothermia? What would you see on pCO2 vs. ABG:

Solubility of CO2 increases as temp decreases resulting in respiratory alkalosis PCO2 is decr (more dissolved in serum) Incr pH and ABG is normal

As CSF volume decreases, what do you expect the spinal block to be higher or lower?

Spinal block likey to be higher

What disease states up regulate nicotinic NAChR What is the implication if these pts are given NMBD?

Spinal cord inj Burns Prolonged immob Stoke NM Disorders: GB, MS, ALS *Myotonic Dystrophy doesn't up regulate but will have severe contractions induced by sux exaggerated response/sensitivity to NMBD and potential for life threatening hyperkalemia to Sux

What conditions have Upregulation of Nicotinic Acetylcholine receptors? Do these pt's have more or less response to NMBD?

Spinal cord injuries >24h Burns Prolonged immobilization Stroke NM disorders: GB, MS They have an exaggerated response to NMBD (need less) and potential for life threatening hyperkalemia with Sux

Most potent trigger for AVP-arginine vasopressin (aka ADH, vasopressin) release?

Systemic Arterial Hypotension mediated by aortic/carotid baroreceptors

Most to least sensitive modalities of venous air embolism:

TEE>Pericordial Doppler>Pulm Art. Catheter>etCO2>ECG

What lung volumes are decreased in Elderly? What is increased in elderly :

TLC, VC (TLC-R) and Inspiratory Capacity FRC, RV, Closing Capacity,

next 32

Test: 32

Does Myasthenia Gravis and Lambert Eaton up regulate NAChR?

They don't upregulate Both are SENSITIVe to NDMB MG is RESISTANT to Sux LE is sensitive to Sux

Gold standard for pain control in patient having thoracotomy

Thoracic Epidural: Decr respiratory complications compared to paravetebral blocks Allows for full breaths/ventilation preserved

TPN MC associated with what 2 conditions?

Thrombophlebitis and Infections Decr phosphate, potassium

Complications of Brachial artery or Brachial vein catheter placement

Thrombosis, infxn and Median Nerve Injury

5 T's of HIT:

Timing (4-10d p heparin) Thromobcytopenia (drops by 50%) Type of Heparin Thrombosis (DVT, arterial thrombosis, hypercoaguable) Type of patient: surgical>medical

Which thyroid hormone mc exerts direct effects on myocardium (thyrotoxic cardiomyopathy)

Triiodothyronine T3 is the active hormone Thyroxine (T4) does not

Calcium binds to what to initiate muscle contraction:

Troponin C —Ca is released from SR and binds to Trop C —tropomyosin changes conformation for actin/myosin to bind shortening muscle contraction

RLN and SLN are branches of what nerve? Int SLN and RLN provides sensation to what area?

Vagus nerve X Int SLN provides sensation to entire larynx above glottis (inferior epiglottis to VC) RLN provides sensation to larynx from glottis and below

when going from supine to standing -effect on SVR -effect on CO and SV

Vasoconstriction ->*Incr SVR* ->*decr Preload* ->*Decr CO and SV* ->then baroreceptor kicks in and *HR increases* to allow CO to recover

(acidosis) H+/CO2 effect on pulmonary vessels?

Vasoconstriction of lungs Vasodilation of brain vessels Remember: Hypercapnia and Hypoxia cause VC in lungs/Body and VD in brain Hypocapnea and high O2 cause VD in lungs/body and VC in brain

Malignant Hyperthermia is 2/2 to what meds_______ s/sxs and Tx:

Volatile anesthetics and Succinylcholine --Hyperthermia is late sign of MH Tx: 2.5mg/kg Dantrolene

Should you avoid NDNMB in patients with MG or LE?

Yes. Neuromuscular disease is a strong relative CI to NM blockade. If have to use it, use Roc and reverse with Sugammedex as Neostigimine can worsen muscle

Carotid body chemoreceptors respond to what?

a fall of O2 Rise of CO2 PH changes

Which pt will LEAST likely have pronounced up regulation of nicotinic AchE Receptors a. 31 yo with acute severe spinal cord injury 10 hours ago b. Female intubated in ICU for 18 days c. female undergoing skin grafting for 3rd degree burns 1 week prior d. female with long term MS

a. upregulaiton occurs >24h and peaks at 7-10 days post injury date

What does celiac plexus innervate and MC side effect

abd viscera: stomach, liver, spleen, pancreas, intestines up to transverse colon, adrenal glands, kidney MC SE: orthostatic hypotension 2/2 splanchnic vasodilation caused by sympatholysis

Lipophilic opioids

all the Fentanyls fentanyl, alfentanil, sufentanil, and remifentanil

Associations to latex allergy

allergies to: Avocado, banana, kiwi, other tropical fruits Being a HC worker d/t repeated exposure Having Spina Bifida d/t exposure to latex foley cath Not related to cosmetic allergies

What s/e would you expect with antiemetics: metoclopromine or prochlorperazine? Tx:

anti-dopinerigics cause extrapyramidal EPS s/efx: abnl movements, akathisia (restless), TD Tx: Anticholinergics: benztropine or atropine or diphenhydramine

Neuroleptic Malignant Syndrome d/t:

antipsychotic medication -muscle rigidity and altered consciousness' Tx: Dantrolene (inhibits Ca release from SR) or bromocriptine (Dopamine agonist)

Damage to SLN:

change in pitch of voice d/t cricothyroid muscle usu occurs right after surgery

A patient has hypothyroidism, what metabolic abnormality is common?

decr CO but unable to respond with incr SVR resulting in HYPOTENSION (depresses metabolic mechanisms) - CNS depression (thus decr MAC) - INcr sensitivity to anesthesia - hypothermia - Decr HR and contractility - decr gluconeogenesis (hypoglycemic)

For Pulm Embolism, what will V/Q scan show?

decreased blood flow to normally ventilated portion of lung so Increased V/Q scan

Monitored Anesthesia Care defined:

diagnosis and tx by anesthesiologist supports vital functions psychological and physical support administers sedatives, analgesics, hypnotics, anesthetic agents

MC complication of inter scalene block:

diaphragmatic hemiparesis 2/2 ipsilateral phrenic nerve block blocks shoulder and Upper arm -block b/w anterior and middle scalene muscles at cricoid cartilage or C6 vertebrae

Hepatopulmonary syndrome

dyspnea in the setting of chronic liver disease The hypoxemia results from pulmonary vascular dilatation with intrapulmonary shunt and V-P mismatch.=, *which may worsen when person is in upright posture* Orthodeoxia - fall in partial pressure of oxygen with upright posture Platypnea - dyspnea worse when sitting upright

Damage to RLN sxs:

early stridor, hoarseness and difficulty w/phonation usu right after surgery. Paramedian position. Can progress to respiratory distress

How to tell there is an air leak in ventilator:

etCO2 will be lower (underrepresented) d/t to loss of CO2 to environ on expiration TV will be lower b/c on inspiration, some volume lost to environment

function foramen ovale closes w/i:

first few hours of birth ->functional a few hours Anatomical foramen ovale closes w/i 1 year

possible complication of high dose bupiv injection into subarachnoid space can result in:

high spinal resulting in respiratory depression, blunting of sympathetic response (hypotn) -possible unconsciousness

Thiazide and loop diuretics cause what type of metabolic disturbance

hypochloremic metabolic alkalosis

Perioperative hyperglycemia (>180-200) is associated with:

immunosuppression d/t decr WBC fxn -incr Infxs -Sympathetic/adrenergic activity -delayed gastric emptying -osmotic diuresis -reduced skin graft success -worsened Neuro outcomes

Anesthesia mg of bronchospasm:

in order of mgt: Jaw thrust Hand assist ventilation 100%FiO2 Deepen anesth-volatiles, IV Ketamine, propofol Beta 2 agonist--->Paralytics IV Epi High Dose Steroids MgSulfate 1-2g Heliox (helium/ox)

Why are larger doses of Sux needed in obese?

incr butyrylcholinesterase (aka pseudocholinesterase) activity and incr Extracellular fluid -need to calculate with TBW not IBW

What lung volume increases with aging? What lung volume decreases with aging?

incr: Residual Volume and Functional Residual Capacity TLC, VC

LAST sxs:

lightheadedness, tinnitus, numbness of tongue and CNS toxicity (seizures) and CV toxicity at higher doses

Organophasphates are like what drugs. MOA:

like neostigmine: inhibits breakdown of ACh by inhibiting AChE. ACh then builds up and acts on M/N R

Meraligia Paresthetica is due to...

mononeuropathy d/t compression of the lateral femoral cutaneous nerve -frequently assoc w/pregnancy and delivery from increased intraab pressure or retractors used during pelvic surgery

What are some things that patients become hypothermic from?

neurological factors impairing thermoregulation anesthesia affecting thermoregulation OR is cold Rapid crystalloid, colloid, RBC transfusions

When does upregulation of nicotinic acetylcholine receptors disease states ( spinal cord injuries, burns, prolonged immobilization, stroke, neuromuscular disorders: GB,MS) occur?

peaks at 7-10 days ---won't see any changes for >24h

SIADH can result from Hallmark:

physiological stress (surgery), major trauma, severe pain, use of opioids, sepsis, nausea. Euvolemic Hypotonic Plasma (d/t incr free water retention from ADH) Hypertonic Urine ur Osm>100 High Urine Na >20

What is MOA of Distributive/Septic Shock

severe peripheral vasodilation with high CO shock:

Ddx of hypoxemia in OR:

start from machine to patient: -obstructed ETT, inappropriate FiO2, bronchospasm, pulm edema, atelectasis, pneumotx, anaphylaxis Tx: needle thoracotomy for pnthx, epi for anaphyl, w/dr ETT 2-3cm

Thyroid storm:

tachyarrythmia >140, hypo/HTN, Fever, onset usually takes hours after completion of surgery Tx: control adrenergic s/sxs with BB: propranolol

First order elimination

the amount of drug eliminated is proportional to serum drug concentration; a constant % (fraction) of drug is eliminated per unit time Kinda L shaped curve vs. Straight line for zero order

How much does Sux increase K?

transient increase in K of 0.5 to 1 mEq/L that lasts 15-20min