Basic exam

Smoking cessation should occur how long before surgery to decrease post-op issues?

1-2 months.

Which two electolyte channels have ectopic firing in the sensory channels leading to chronic pain signals?

1.) Calcium 2.) Sodium

Anemia adaptations on CV system

1.) Decreased SVR (2/2 decrease blood viscocity) . 2.) increased CO & increase Stroke Volume

1.) AD transmission presenting as paralysis, hypokalemia, and proximal muscle & respiratory weakness. 2.) Subtypes include Type I = calcium channel & type 2 = sodium channel. 3.) Triggers: acute illness, sepsis, fasting, alcohol ingestion, lack of sleep, dehydration, menstruation, and pregnancy 4.) Tx with potassium.

1.) Explain Hypokalemic Periodic Paralysis, 2.) subtypes & 3.) triggers

What are the two most common complications of Celiac Plexus Blockade?

1.) Hypotension (50% of patients) 2.) Diarrhea

Diagonstic Pressures of the P.A. in Pulmonary HTN?

1.) Mean PA pressure > 25 at rest or >30 with exercise. and 2.) Pulmonary Artery Wedge Pressure (LA Pressure) < 15. and 3.) Pulmonary Vascular Resistance >240.

Splanchnic blood supply is controlled by what three factors?

1.) Systemic BP 2.) C.O. 3.) Sympathetic Tone

How is rebreathing prevented in a Mapleson Circuit?

1.) total fresh gas flow (most important) 2.) APL valve venting.

What three things are needed to prevent rebreathing in a semi-circle system:

1.) valve between pt, expiratory limb and inspiratory limb. 2.) Fresh gas flow can't come into the system between the patient & expiratory valve. 3.)APL can't be between the patient and inspiratory limb.

When should Beta Blockers be started?

2-7 days prior to surgery. Not day of surgery.

5 % = 1:1 osmolality to plasma. 25% = x5 osmolility to plasma.

25% albumin vs. 5% albumin?

Drug dosage (milligrams of drug delivered), baricity, and patient position are the most important factors determining the level of spinal blockade.

3 important factors that determine a spinal spread?

3 lead = monitors P wave and R wave well, but poor at monitoring ST-segment changes or complex ventricular arrythemias. V1 is good at detecting arrythmias. Second best to lead II to detecting artial arrythmias. V4 + V5 = good at detecting ischemia.

3 lead vs. 5 lead EKG pros?

Renin released by decreased NA+, decreased BP, B1 receptor activation. -->Ag-->Ag I -->AgII: MOA of AG II: -AT1 receptors to cause smooth muscle vasoconstriction. -Block NE reuptake at the nerve terminal -Increase NE from the medulla. -Increase aldestrone -Cause cardiac hypotrophy via remodeling via AT1 receptors.

3 modalities of renin release? MOA of AGII?

1) Esophageal 2) Tympanic 3) Pulmonary artery 4) Nasopharyngeal

4 Sites Correlating With Core Temperature:

1.) Thrombocytopenia 2.) Timing of Platelet count decrease in relation to initiation of heparin [4-10 days] 3.) Abcense of thrombosis

4T Score of HITT?

1-Death 2-Respiratory events: =Give less medications and mandatory to use ETCO2. 3.) Cardiac and equipement failure.

#1 reason for malpractice claims in MAC anesthesia and what can be done to prevent it?

What coags does Protein C degrade to decrease clotting?

8 and 5.

1.) Fetal HG 2.) Cold 3.) Alkalosis. 4.) Carboxy-HG. 5.) Decrease in 2,3 DPG 6.) Blood transfusion 7.) Hypophosphatemia 8.) Low CO2

8 factors that cause left-shift on Hemoglobin dissociation curve.

1.) Methylgobinemia. 2.) Anemia. 3.) CHF 4.) Pregnancy 5.) Hyperthermia. 6.) Acidosis 7.) Increased 2,3 DBG. 8.) Increased CO2 (Bohr)

8 factors that causes right-shift on the hemoglobin dissociation curve?

What is the level of glucose that patients should be kept below which will significantly reduce their peri-operative Morbidity and Mortatility?

<180-200. | <150 for cardiac & neurosurgery

prophylactic dosing of LMWH (once or twice daily), wait 4 hours after catheter removal. therapeutic dosing of LMWH, wait 4 hours or 24 hours after initial placement, whichever is longer.

A patient had a neuraxial catheter which was removed, how soon can I start/restart LMWH after catheter removal?

Increased metabolic demands & progestrone= increased MV by increasing TV > RR. CO2-ventilatory curve is shifted left ward = respiratory alkalosis, PaCO2 drops from 40 to 30 mmgh. PH is normal due to metabolic acidosis compensated for by respiratory status. ABG: pH: 7.40 |. PaCO2: 30. | PaO2: 107 | Bicarb: 20. | Base excess decreases.

ABG changes in pregnancy?

Diarrhea causes a non-gap hyperchloremic metabolic acidosis and hypokalemia.

ABG of a diarrhea will present what?

COX 1 Inhibitor in an irriverible fashion = decreased production of TxA2. TXA2 = vasoconstrictor. Plavix = blocking ADP receptor in an irrersible fashion corrisponds to 7 days.

ASA MOA? Plavix?

-RR elevated due to medullary stimulation--->>respiratory alkalosis. & Metabolic Acidosis. (Decreased Ph, decreased Bicarb).

ASA OD presentation on Blood Gas?

-Anesthesia personnel must stay with patient who is under anestheisa. -Monitoring of ventilation, temperature, oxygenation, and circulation. Machine checks not part of the list.

ASA guidelines of monitoring patients?

1- Correct PT (>1.5 x normal), PTT (>2x times normal), and INR (>2). 2-correction in coag defiencies. 3-urgent reversal of warfarin (emergent use pcc) 4-correct coag defiencies. 5-Heparin resistance-has AT3.

ASA reasons why FFP should be used?

IIa-IIIb inhibition -->preventing platelet aggregation & thrombus formation.

Abciximab, eptifibatide, and tirofiban's MOA?

Pneumothrorax.

Absent lung sliding would suggest what?

-Pheochromacytoma -MI within in the past 4-6 weeks. -Intracranial brain mass: =cerebral blood flow increases 100-400% in ECT. -CVA within the past 3 months. -Unstable cervical spine. Relative contraindications: -Angina -CHF -AICD -Glucoma -Severe COPD -Retinal detachment -Pregnancy: intubation recommended during 3rd trimester to reduce aspiration. -Major bone fracture

Absolute Contraindications of ECT?

Pregnancy, UTI, triple AAA near the stone, obstruction distal to the stone, and couagulation.

Absolutely contradictory to lithotripsy?

Prolong Non-Depolarizing Blockade: -Aminoglycosides, polymyxins, lincomycin, and clindamycin primarily inhibit the prejunctional release of acetylcholine and also depress postjunctional nAChR sensitivity to acetylcholine - Antiarrhythmics (e.g. calcium channel blockers) - Dantrolene - Ketamine - Local anesthetics (high doses only) - Lithium - Magnesium - Volatile anesthetic agents-(desflurane > sevoflurane > isoflurane.)

Abx that will prolong NMB?

The high-risk factors are: 1) Prosthetic heart valves 2) Prior history of infective endocarditis 3) Unrepaired cyanotic congenital heart disease 4) Completely repaired congenital heart defect (the first six months after procedure) 5) Repaired congenital heart disease with residual defect6) Valvular disease in a transplanted heart High risk procedures: 1.) Dental 2.) Respiratory 3.) Skin/MSk-infected sutures. Doesn't include: -GI/GU -Vaginal/C-section. Tx: Amocillin/ampicillin 2g given 1 hour prior to procedure. If alx, give clinda 600 mg.

According to the AHA guidelines, which patients and procedures require ppx for Infective Endocarditis?

Alpha subunit. Both must be bound to be activated.

Ach binds to which subunit of the Ach receptor?

Hypochloremic Metabolic Alkalosis

Acid base disturbance of Loop diuretics & Thiazides is what?

Inhibit Bicarbonate anhydrase in the PCT causing the patient to pee out bicarbonate. Loss of bicarbonate, sodium, and potassium leading to metabolic acidosis.

Acteoazmide work where in the kidney and what are the electrolyte issues?

1.) Unstable Coronary Syndromes: -Active MI within past 7 days. -Recent MI within 8-30 days. -Unstable angina. 2.)Decompensated HF: -New onset or worsening signs. -NYHS IV. 3.)Arrythmias: - High-grade atrioventricular block - Symptomatic ventricular arrhythmias - Uncontrolled supraventricular tachycardia including atrial fibrillation - Symptomatic bradycardia - New ventricular tachycardia 4.) Severe valvular disease: - Severe aortic stenosis - Symptomatic mitral stenosis 5.) Clinical risk factors: History of ischemic heart disease History of heart failure History of cerebrovascular diseaseInsulin-dependent diabetes mellitus Renal insufficiency (creatinine > 2.0 mg/dL)

Active cardiac conditions and risk factors that warrant further investigation prior to proceeding to elective surgery?

Acute: -Usually > 10.5. -Fluids and then diuretics. Non-acute: -Bisphosphonates. Takes 24-48 hours to work by blocking Osteoclasts.

Acute treatment of Hypercalcemia vs. Non-acute?

Vastus medialis muscle weakness is anticipated with a successful adductor canal block

Adductor canal causes weakness primarily to which muscle?

The Mapleson systems are beneficial because they result in a decreased resistance to breathing because they lack valves and canisters.

Advantages of a Mapleson Circuits over Circle Systems?

Advantages of PCA compared with intermittent nurse-administered dosing of opioids are: decreased time spent by nursing, higher patient satisfaction, and superior analgesia. Disadvantages are increased opioid consumption and increased cost.

Advantages vs. Disadvantages of PCAs?

Under normal circumstances, the brain exclusively utilizes glucose for energy. During periods of fasting, exercise, or starvation, the brain also uses ketone bodies for energy. After 1 month, the brain will utilize 2/3rd ketone bodies as energy and 1/3rd glucose.

After how long of starvation will the brain use mostly ketone bodies as primary energy source?

RV, FRC, and closing capacity increase with age. And lung compliance.

Airway & lung volumes that increase with age

Decreases

Alkalosis has what effect on calcium and potassium?

Pheochromocytoma treatment

Alpha then Beta blockade. If Beta then Alpha ==>hypertensive emergency.

PAO2 = FiO2 (Pbar - ph2o) - (paCo2/R) PAO2 = oxygen in the alveoli itself. R = molcules of co2 produced vs. consumed. Average 0.8. If mainly carbohydrate diet = 1.0.

Alveolar Gas equation

Amioesters > amino-amides 2/2 to PABA derievtives. -Alx to amino-amides like lidocaine can happen to the prevestivie-methylparaben-which is usually seen in multi-dose lidocaine vials.

Alx to Local Anesthestics is most common with which group?

Iso = 99 Des = 19.

An oil:gas coeffient of iso? Des?

1.) Difficult intubation & mask 2.) Increased risk of epidural hematoma due to multiple attempts. RF negative, associated with HLA-B27.

Anesthesia concerns with Ankylosing spondylitis?

AT1 receptors. Increases catecholamine secretion, aldestrone, vasoconstrictor, and ADH.

Angiotensin II acts on which receptors and what does it cause an increase in?

Na+ - [cl + hco3] = 8-16. albumin can effect the gap because it is an unmeasured negative protein. Low albumin = low anion gap. Can mask an anion gap.

Anion Gap

Clindamycin, polymxy.

Antibiotics that decrease ach release?

Coronary Perfusion Pressure (CPP)

Aortic DIastolic Oeessure - LVEDP

atrial kick

Aortic Stenosis patients require what to fill the LV?

40%.

Aortic Stenosis patients' atria give how much of blood to the ventricle?

The gauge pressure will continue to read 745 psig ("full") until approximately 16% or 253 liters of the nitrous oxide remains.

Approximately how much of a nitrous oxide cylinder must be left in percent until there pressure gauge falls?

Treatment of SIADH in Asymptomatic vs. Symptomatic Pt?

Asymptomatic = free fluid restriction. Symptomatic = Hypotonic plasma ==>give hypertonic fluids. Can given lasix if urine is 2 x as osmotic as serum.

Altitude increase = atmospheric pressure drops = partial pressure of the inhalation decrease via dalton's law. Dial up required with higher atlitudes. % percent desired x 760/new atm.

At higher altitude, what happens to the ATM and how does this effect the partial pressure? which gas law?

Low ATM pressure ==> low PAO2 => decreased PaO2 ==>hyperventilation ==>alkolosis ==>dump renal bicarb.

At higher altitude, what happens to the respiratory system?

<15 cc/min

At what Cr.CR should methodone be renally dosed?

27 mmHg= p50.

At what PO2 is the hemoglobin molecule 50% saturated?

Organ dysfunction can be seen in susceptible patients with pressures as low as 10 mm Hg. However, organ dysfunction is generally not seen till pressures are above 20 mm Hg.

At what abdominal pressures does organ dysfunction usually occur?

12-14. Usually over 14 is severe and can be treated with fluids and lasix.

At what levels of calcium can potentially show signs and symptoms of hyper calcium?

functional residual capacity

At what lung volume is Pulmonary Vascular Resistance lowest?

Dexoy-Hg absorbs at 660 nm-red light. Oxy-Hg absorbs at 940 nm-infrad light. Blue-green dyes also absorb at 660 nm and give a falsely low reading of Hemoglobin saturation.

At what wavelength does deoxy hg absorb at on the SPO2? What about oxy-hg?

Which Anticholinergic can cross the BBB?

Atropine.

Hand, forearm, and wrist. Potential elbow. At level of terminal branches. Surrounded by Median nerve, ulnar, and radial nerve.

Axillary block indications?

Blocks from the elbow down--forearm, wrist, and hand. Done for wrist surgery by blocking at the axilla at the terminal branches. -May need Musculocutanous nerve supplementation as well to block the later forearm.

Axillary nerve block is covers what?

What is the consequence of BB being started on day of surgery?

BBs started on the day of surgery decrease nonfatal MI but increase risks of stroke, death, hypotension, and bradycardia

Orthostatic Hypotension defination?

BP drops in 20 mmHg or Diastolic blood pressure drop by 10 mmHg with a change in position.

The most common contaminants include skin flora (e.g. Staphylococcus epidermidis, Streptococcus species), Salmonella species, and Escherichia coli.

Bacteria associated with platelet transfusion sepsis?

They stimulate the ALA enzyme.

Barbiturates are contraindicated in porphyria why?

Why should Sux be avoided in Organophosphate posioned patients?

Because it is degraded by plasma choleinoestrases and without them (or being blocked), it can lead to a prolonged block.

Treating cocaine toxicity?

Benzos and nitroglycerin

Magnesium & phenytonin

Besides Digitals ANtibody, what other treatments are used for digitalis?

Isoprotenonlol = Beta agonist medication.

Besides Epi, what other medication is used to increase HR of de-innervated heart?

PCC-more appropriate in emergency settings.

Besides FFP, what else can reverse warfarin?

NMDA receptor

Besides MU which receptor is mediated in hyper-analgesia and opioid tolerance ?

ultrasound is highly sensitive (85-95%) and specific (100%) for detection of pneumothorax. Typical findings include absences of lung sliding or of comet-tail artifact.

Besides absent lung sliding, what else is seen on chest ultrasound of a pneumothorax?

most critical adverse effect of sugammadex is anaphylaxis or hypersensitivity reactions

Besides bradycardia what is another notable side effect?

Mast Cell Stabilizer.

Besides improving SVR and CO due to alpha and beta agonism, what third feature makes epinephrine first-line for anaphyalyxsis?

Cystic Fibrosis, laxative abuse, recurrent vomiting, excessive gastric acid loss (such as with prolonged nasogastric tube suctioning), and post-hypercapnic metabolic alkalosis. Usually dehydrated.

Besides loop and thiazide diuretics, what other factors can cause hypochloremic Metabolic Alkalosis? And how do the patients present?

Anemia, BP, oxygenation, hypocapnia, hypothermia, hypoglycemia, electrolytes (mostly magnesium & sodium).

Besides medications, what other factors can cause evoked potential response?

Extracellular fluid volume.

Besides plasma ACH-E, what other factor determines duration of sux?

Reflex withdrawal to painful stimuli is not considered purposeful movement and can still occur in patients under general anesthesia.

Besides the pupillary reflex, what other reflex is intact under general anesthesia?

Zofran

Best drug for PONV prevention in kids?

Nitro

Best first-line agent for uterine relaxation in patients without hemorrhage & awake?

GFR >creatinine clearance

Best overall estimate of kidney function?

Phenylephrine because you don't want to make someone with a stenotic lesion tachycardia.

Best vasopressor for someone with mitral stenosis?

Where is Insulin produced & where is it metabolized?

Beta Cells. Metabolized in Kidneys & Liver.

Positive lusitrophy

Beta agonists do what to lusitrophy?

intravenous > Sub-Q > intramuscular > intranasal > rectal > oral Also, dose dependent. Higher doses can be given rectally which can increase the bioavailability

Bioavailability of Versed via routes from greatest to least bioavailability change?

TCAs work to decrease non-cancer pain by which MOA?

Blocking serotonin reuptake.

Intercostal block

Blood levels of LA is highest after which type of block?

Inferior thyroid and bronchial arteries.

Blood supply of the trachea?

c5-t8 & T1 ventral rami.

Brachial plexus is composed of?

perineum stretch leading to a hyper-vagal response.

Bradycardia & asystole during insufflation is likely to?

Stimulates CN 8 -->cochlear nucleus-->rostral brainstorm --> inferior colliculus -> auditory cortex. During posterior brain surgery.

Brain Stem EPs stimulates which nerve? When is it used?

Anemia re-distirbutes blood towards what organs?

Brain and heart

Hoffman elimination (not cholinestrase).

Break down of nimbex?

6 weeks.

Bronchial Hyperreactivity can occur how long following URI?

How does epinepherine increase the intensity of the epidural block?

By Alpha-2 agonism, seen similar to clonidine as well

Temp-for every 1 degree change in temp = CMRO2 change by 6%. PaCO2 = CBF changes by 3% for every 1 mmhg of CO2 change. PaO2 = less effect on CBF. Significant change seen if <PaO2 50. MAP = auto-regulation between 50-150 mmHg.

CBF and CMRO2 are coupled together. Changes in CMRO2 will be reflective with CBF. How does: -Temp effect CBF? -PaCO2? -PaO2? -MAP?

Stroke Volume x HR

CO

Carbon monoxide causes a leftward shift of the hemoglobin curve, changing it from sigmoidal to hyperbolic

CO reaction to the hg. dissociation curve?

Peep and CPAP can increase FRC, however, increase intrathoracic pressures which can reduce venous return and pre-load to the area. Also, PEEP can increase dead space by increasing PA > pa (zone 1).

CPAP and PEEP will do what to FRC? What are complications?

1.) A wave = right atrial contraction. 2.)C wave = right ventricular contraction against the closed AV valve. 3.)X-descent= emptying of the right ventricle

CVP Wave Forms:

1.) Type of Surgery 2.) Hx of ischemic Heart disease. 3.) Hx of CHF 4.) Previous TIA/Stroke 5.) DM with Insulin 6.) Renal failure/CR > 2.

Cardiac Risk Index is based off what six things of the revised risk index?

Right ganglion has more effect on heart rate. Left ganglion has more effect on MAP & contracility. -left stellate ganglion block can reduce the risk of arrythmias associated with Long QT syndrome.

Cardiac fibers from T1-T4 branch to stellate ganglions. There is a left and right ganglion. What does the right do more of vs. the left ganglion?

PaO2 < 60-65 mmhg.

Carotid body is responsive to which blood marker?

<50

Cerebral blood flow will vasodilate after which PaO2?

C1-C4

Cervical Plexus block is what levels of roots?

Compared to the proximal aorta, arterial waveforms measured at more distal sites have the following characteristics: -higher systolic peak, -steeper systolic upstroke, -lower diastolic peak - blunted dicrotic notch -delayed dicrotic notch -slightly lower MAP.

Charatistics of arterial wave forms as they move further away from the aorta?

1.) ADP 2.) TXA2 ==> Vasoconstricts & positive activation of further plalets

Chemical messangers used in platelet activation after platelets bound to VWF?

1. Doxorubicin- causes single strand DNA breaks or cross-links by causing the formation of free radicals in proximity to DNA 2. Cyclophosphamide-an alkylating drug 3. Fluorouracil- antimetabolite 4. Docetaxol

Chemo medications capable of causing cardiomyopathy?

calcium and magnesium.

Citrate supplied in FFP and plasma (minor in pRBC) can lead to a decrease in which two electrolytes?

ADP receptor inhibtor = impair ADP-dependant activation of IIa-IIIb

Clopidogrel, prasugrel, ticagrelor, and ticlopidine MOA?

Spinal anesthesia is associated with an incidence of PDPH as high as 25%. Other common complications or side effects include increased gastrointestinal secretions and mobility, increased ventilatory response to hypercapnia, hypothermia from peripheral vasodilation, and a transient decrease in hearing ability.

Common Side effects of spinal anesthesia.

trauma, achondroplasia, rheumatoid arthritis, and Down syndrome. Although rare, systemic lupus erythematosus can cause atlantoaxial instability due to joint laxity.

Common causes of atlantoaxial instability?

Common bacterial species involved are the streptococci, staphylococci, and enterococci.

Common species of Infective Endocarditis?

MELD: I(INR) C(Cr.) rush S(sodium)everal B(billibuin)eers D(dialysis)aily Child-Pugh: P(PT)our A(ascitis)nother B(billirubin)eer a(albimin)t E(encelopathy)leven

Comparing MELD to Charles-Puge, What do they look at?

What is the most appropriate use of the T-test?

Comparing Means between two groups.

Epi has Beta-1 properties which vasporessin doesn't. Vasopressin can result in an increase MAP via increase afterload-->decrease CO-->can result in an decrease in CPP compared to epi. Epi has beta-1 which will keep CO output up with an increase in afterload. So that's why epi is better for cardiovascular fialure.

Comparing Vasopressin to epinephrine, which one is better for cardiovascular failure?

Stomach & small intestines remain intact, causing lower risk of malabsorption.

Comparing weight loss surgery, how is gastric banding superior to gastric bypass?

Why are pregnant females in respiratory alkalosis?

Compensatory for metabolic acidosis

Phrenic nerve block in 50% of patients. Pneumothorax Intravascular injections

Complications of supraclav?

Skin color, HR(100 bmp), Reflex, muscle tone, breathing Each gets a 0-2 score.

Components of APGAR score?

MELD score is entirely objective as oppose to the child-pugh score which can be subjective. Pts with acute liver failure are given priority over a high MELD score for liver transplant. Meld Score includes: 1.) Creatinine 2.) Billirubin 3.) INR 4.) Sodium

Components of the MELD score include? Why is it better than the Child-Pugh Score?

1.) Respiratory effort 2.) Activity 3.) circulation 4.) LOC 5.) Pulse ox If >9 = d/c from phase I pacu.

Criteria to discharging patients from Phase I of PACU?

Cryoprecipitate contains approximately 200 mg/unit of fibrinogen.

Cryo contains how much fibrinogen per unit?

factor VIII:C, factor VIII:vWF, fibrinogen, factor XIII, and fibronectin.

Cryoprecipitate contains

Dead space is increased in the upright position and decreased in the supine position

Dead space is increased in what position?

Hand washing, head of bed angled up 30 degrees or greater, PPI for high risk patients, EVAC ETT.

Decrease risk of ventilator Associated Pneumonia

Can be related to: -Decreased Hg -Increased VO2: fever, shivering -Low SaO2: Blood has a lower saturating leaving the aorta going to the tissues-ARDS -Low Cardiac Output: MI, CHF, hypovolemia.

Decreased SVO2

16 times. 2^4.

Decreasing radius by a half will increase radius by how much?

1.) Hypoxemia--<60 on PaO2 while on FIO2 of 60% 2.) Hypoventilation--PaCO2 > 50. 3.) Abnormal respiratory mechanics: -VC < 15 ml/kg (biggest breath you can take in and breath out) -NIF <-20

Define Acute Respiratory Failure via three terms?

CIN is defined as impairment of renal function measured as either a 25% increase in serum creatinine from baseline or a 0.5 mg/dL increase in the absolute value within 48 to 72 hours of contrast administration.

Define Contrast Induced Nephropathy.

Efficacy-Maximum effect of a drug, and not related to the dose. Potency-Dose of a drug that must be given to product an effect. Is related to receptor affinity.

Define Efficacy vs. Potency?

1.) Heart Failure in last month or within 5 months of pregnancy. 2.) No prior hx. 3.) Objective findings on 2D echo.

Define Peri-Partum Cardiomyopathy

When repeated or large dose of Sux is given, there is blocking of pre-junctional receptors = leading to decrease in Ach transmission = decrease competition with the post-junctional Sux. A phase 2 block occurs after prolonged continuous administration of succinylcholine, or a single dose in excess of 4 mg/kg.

Define Phase II block?

1.) Systolic BP >140/90 2.) Protienuria of > 300 mg in 24 hours. OR 1.) HTN + one of the following: -Platelet count < 100k -LFTs 2x normal. -Serum Cr. > 1.1 or 2 x baseline -pulm. edema -Visusal changes.

Define Pre-eclampsia?

Radiation: Patient will radiate heat to surrounding environment. Heat is transferred from the core to the subcutaneous vessels, then lost to the environment via infrared rays. This is likely the major type of loss. Convection: The thin layer of air adjacent to the skin acts as an insulator and when air currents disrupt this layer the insulating properties are lost. Since the room air in the operating room typically is exchanged every 15 minutes, this can result in serious loss of the insulator. Conduction: Transmission of body heat through conducting medium without perceptible motion of the medium. In general, this is small because the patient is only in contact with the foam mattress of the operating room table (which is often insulated).

Define Radiation, convection, and conduction?

Ventilation/Perfusion = <1 aka, perfused lung tissue without ventilation to tissue. Increase in A-a difference. -Right main stem.--patient in trend position. FIO2 increases don't improve pao2 with shunts.

Define V/Q shunt? Examples

Residual neuromuscular blockade is defined as a train-of-four (TOF) ratio < 0.9 measured at the adductor pollicis muscle.

Define residual blockade?

Brain stem suppression

Define stage 4 anesthesia.

Hyperbaric--sinks by adding glucose. Hypobaric--goes against gravity by adding water. Isobaric-stays at the level of site of injection.

Define the meaning of baracity in a spinal?

Normal SA node atrial firing, broken AV node. Ectopic ventricular response. Seen especially after AVR

Define third degree heart block. Likely seen after which type of cardiac surgery?

Obstructive sleep apnea is defined as complete apnea for 10 seconds, five times per hour, associated with a 4% decrease in SaO2 (while sleeping).

Definition of OSA?

endomyocardial biopsy. Heart failure due to Doxubicin can occur up to several months after termination of therapy.

Definitive diagnosis of doxorubicin-induced cardiotoxicity may be obtained through?

Do2 = C.O. x Cao2 x 10: CO = HR x SV (preload & contractility, decrease in afterload) Cao2 = [(1.34 x Hg x Sao2-sat of hg with oxygen) + (0.003 x PaO2)}

Delivery of Oxygen to Tissues formula (Do2)? What does it rely on?

Drug is eliminated at the same amount no matter how much of it you've taken. Example-ethanol.

Describe zero order kinetics.

Rocuronium is up to 30% renally excreted. Metabolism of the drug does not produce active metabolites, unlike vecuronium and pancuronium.

Despite rocuronium being 30% excreted by the kidney, why is that it is not very prolonged in ESRD, but pancuronium and vec are?

What is Neonatal myasthenia gravis? How long does it last for?

Develops 48-96 s/p birth due to maternal IgG AB crossing the placental membrane to baby. Usually lasts around a month after birth when these Ab are degraded.

Fractional excretion of sodium less than 1%, BUN/Cr ratio of greater than 20:1, increased serum creatinine, elevated urine osmolality/specific gravity with a concentrated urine

Diagnostic Criteria for Pre-renal failure?

Maintenance of atrial kick, diastolic time (e.g. lower heart rate), and preload are essential to maintaining adequate oxygen delivery in these patients

Diastolic dysfunction patients require what to keep up with oxygen delivery to thickened muscle?

Acromegly DM -decreased mobility to the atlanto-occpital joint. -Prayer sign shows likely increased joint immobility. RA -atlantloaxial subaxtion -Dx by lateral xray of the neck in flexition. -restricted PFT patern.

Dieases associated with difficult airway

Mu-1 = analgesia. Mu-2 = resp. Depression

Difference between MU 1 and 2?

Potency: compares two drugs to one another to determine which drug will have an effect at a certain dose. Example, fentanyl to morphine. Efficacy: intrinsic to the drug. Determined by the Y axis on the graph. Higher the Effifacy, the better the drug.

Difference between Potency and Efficacy?

Type I is acute, usually secondary to provoking factors such as infection or surgery and usually resolves after the event has passed. Type II is gradual and is usually seen over several months/years. Usually only treatment is a liver transplant.

Difference between Type I and Type II Hepatorenal Syndrome?

Unpaired T-test -Looks at parameters between two groups. -There is a control group and an experimental group. -Measures means and compares the two. Paired T-test: -Only one group of patients. -Severe as both the control and the experimental group. -For example, you take a BP prior to treatment and then measure the mean BP after treatment in the same group of patients. ANOVA: -Looks at 3 or more groups. Parameteric data = mean.

Difference between Unpaired T-test and Paired T-test? Vs. ANOVA?

Botulinum toxin acts inside the axon terminal at the neuromuscular junction. Tetanus toxin travels via retrograde axonal transport to the CNS where it acts.

Difference between botox and tetnus toxin as far as their points of action?

Carotid body = chemoreceptor Carotid sinus = baroreceptor (sinus pressure)

Difference between carotid body and carotid sinus?

Deep: Purposeful movements to repeated painful stimulation and may require airway intervention to maintain. Moderate: purposeful movements to tactile/verbal stimulation, usually doesn't require airway intervention to maintain airway. purposeful doesn't include withdrawl from pain.

Difference between deep and moderate anesthesia?

Infants have a larger occiput, are obligate nose breathers despite having smaller nasal passages, have relatively larger tongues, longer epiglottis, shorter trachea, and a more cephalad larynx (C4) than adults (C6).

Differences in infants vs. adult respiratory systems?

Curved ST segment depression. Short QT. Flat/inverted T waves. Magnesium & potassium increases toxicity.

Dig effects on EKG. Seen with which elecolytes?

PDE inhibitor and adenosine reuptake inhibitor. Platelets are unable to aggregate properly when intracellular levels of cAMP are high (due to thromboxane A2 inhibition). Since PDE breaks down cAMP, its inhibition will lead to increased cAMP levels.

Dipyridamole MOA

Can lead to blocking of the ACH receptors, requiring a slower onset of sux to work. Doesn't effect the intraocular pressure or potassium of sux. Increase dose of sux 0.5 to 1.5 mg/kg.

Disadvantage of giving a Precurarization of roc?

aramedian approach is more painful and requires more local anesthetic due to the needle traversing sensitive structures such as the paraspinous muscles.

Disavantage of paramedian approach of epidurals?

Bolus 100 cc of interlipid which is 20% over 2-3 minutes and then run 200-300 ml over 10-15 minutes.

Dose for interlipid for patient who is 70 kg or greater?

2 mg/kg-used when 2/4 twitches. Takes 1-2 minutes with roc. 4 mg/kg-0/4 switched with 1-2 post-tetanic twitches. 3 minutes with roc. 16 mg/kg--immediate reversal with an RSI dose of 1.2 mg/kg of roc. 1.5 minutes with roc.

Doses of sugammadex?

Ideal Body Weight.

Dosing of Vec and Roc should be at?

ketamine, magnesium sulfate, nitrous oxide, and certain opioids including methadone and tramadol.

Drugs and electolytes that block the NMDA receptor?

antibiotics such as aminoglycosides, phenytoin, furosemide, non-steroidal anti-inflammatory drugs, and IV contrast dye.

Drugs associated with intrinsic AKI?

dextromethorphan, ketamine, memantine, methadone, nitrous oxide, and tramadol.

Drugs that block the NMDA receptor besides ketamine?

prilocaine, benzocaine, quinine, metoclopramide, sulfonamides, dapsone, and chloral hydrate

Drugs that can cause meth-hg?

induce: phenytoin, rifampin, carbamazepine, and ethanol Inhibit: fluconazole, metronidazole, valproic acid, and ciprofloxacin.

Drugs that induce and inhibitp450 system?

1. NMBD 2.) Heptain 3.) Insulin

Drugs which don't cross the placenta?

1.) If emergency surgery is required, then proceed. 2.) If surgery is needed within 14 days of finding out patient had CAD==>do balloon angioplasty. 3.) If completely elective surgery: -DAPT for six months for DES, can d/c after three months increased risk of bleeding. -Bare metal stent with dapt for 1 month, then do ASA around the periop period.

Dual Anti-plalelet Therapy Guidelines for Non-ischemic, non-acute stent placement & Surgery:

sacrococcygeal ligament, which is located anterior to the sacral hiatus. Sacral hiatus is superior to the coxyx.

During a caudal epidural placement, what should the needle pass prior to entering the epidural space?

greater and lesser palatine nerves and the anterior ethmoidal nerve (all derived from CN [cranial nerve] V)

During a nasal intubation, which nerve innervates the nasal cavity and should be anesthetized?

FRC

During apnea, oxygen is solely dependent on what lung capacity?

uterine blood vessels are maximally dilated and uterine blood flow is entirely pressure dependent.

During pregnancy how is uterine blood flow regulated?

AKI can be diagnosed if any one of the following is present:- -Increase in Serum Cr by ≥ 0.3 mg/dL (≥ 26.5 μmol/L) within 48 hours; or - Increase in Serum Cr to ≥ 1.5 times baseline, within the prior 7 days; or - Urine volume < 0.5 mL/kg/h for 6 hours Risk factors: advanced age, preexisting renal insufficiency, sepsis, shock, high-risk surgical procedures (renal vascularization, aortic cross-clamping, cardiopulmonary bypass, trauma, urologic surgery), and use of nephrotoxins.

Dx of AKI.

Thyroid hormonoe binding ratio is a test that determines the Free T4 that is circulating and can depedend on the TBG. Normally it is 25-35%, however, in hyperthyroidism, it is elevated. Hyperthyoidism also has: Increased T3,T4, low/normal TSH. T4 can be converted to t3 by ionidiation in the liver.

Dx of Hyperthyrodisim in respect to the Thyroid Hormone binding Ratio?

Dynamic compliance is movement of air into the lung and reflective of Peak pressures. Static compliance is reflective of the actual lung and is reflective of platue pressures.

Dynamic vs. Static compliance?

Hypercalcemia: -QT shortened. Hypocalcemia: -QT Lengthened. Hyperkalemia: -peaked T waves. Hypokalemia: -flat T waves. u wave. Hyper magnesium: -increased PR, WIde QRS -tx with calcium.

EKG changes with electrolytes: -calcium

ETCO2 = PACO2 = PaCO2. Because of dead space ventilation (ventilation in abcense of perfusion), there is a difference between what PaCO2 and ETCO2 would be. PaCO2 is usually higher than ETCO2. The gradient is usually 5-10 in ventilated patients and 2-5 mmhg in a non-ventilated, healthy patient.

ETCO2 is reflective of which pulmonary value?

2/2 a vagal response from head compression.

Early decel MOA?

right internal jugular > left subclavian > left internal jugular > right subclavian.

Ease of placement for a pulmonary artery catheter from easiest to most difficult is

Echinacea will decrease CYP450 enzyme activity, causing wafarin to stay around longer leading to increased bleeding.

Echinacea is an herbal supplement taken for ppx of colds. What effect does it have on wafarin?

Since benzodiazepines are protein-bound, severe liver disease can increase the free fraction of available benzodiazepines in the blood.

Effect of benzos in the setting of liver failure?

Metoclopramide decreases gastric volume by its prokinetic effect, increases lower esophageal sphincter tone, but has no effect on gastric pH.

Effect of reglan on stomach Ph and fluid?

Glucagon causes dose-dependent hepatic arterial vasodilation. Angiotensin II causes vasoconstriction of hepatic arterial and portal venous systems. Vasopressin increases splanchnic vasoconstriction while decreasing resistance to portal venous flow.

Effects of glucagon, Angiotensin II, and Vasopressin on hepatic artery and portal vein?

• 48-72 hours: increased secretions and a more reactive airway • 2-4 weeks: decreased secretions and less reactive airway • 4-6 weeks: immune system and metabolism normalize • 8-12 weeks: improved mucociliary transport and small airway function Recommended to stop smoking 8 weeks before surgery.

Effects of smoking cessation?

-Hypomagnesemia. -Immediately after TPN is turned off, there is a reactive increase in insulin which leads to: -Hypoglycemia. -Hypokalemia -Hypophosphate.

Electrolyte Changes with TPN?

Cytochrome P450 2C19 (CYP2C19)

Enzyme responsible for the metabolism of proton pump inhibitors, such as omeprazole, and antidepressants

Cytochrome P450 2D6 (CYP2D6)

Enzyme that metabolizes codeine, beta-blockers, some antiarrhythmics, diltiazem, and tramadol.

Cytochrome P450 2C9 (CYP2C9)

Enzyme that metabolizes phenytoin, warfarin, and ibuprofen

Increase mom's temperature.

Epidurals can do what to moment's temperature?

First stage of labor has no effect, but second stage of labor can show an average of 15 minute in prolongation.

Epidurals effect on first and second stage of labor time?

Very little effect, except for the decreased ability to cough with high dermatomal levels.

Epidurals have what effect on pulmonary function?

Minutes until hypoxemia = [ FRC / O2 consumption ] x o2% in FRC Example: 70 kg adult after breathing a 100% oxygen 30 x 70 = 2100 FRC. & 3 cc x 70 = 210 100% for 10 minutes. [ 2100 / 210 ]. x 100% = 10 minutes

Equation for minutes until hypoxemia upon after apnea?

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

Equation for oxygen content in the blood

LA allergic reactions are more likely with?

Esters because they're metabolized to PABA. Can have allergy to metabolites like methylparaben or metasulfide with amides.

1.) Blood transfusion. 2.)Post-intestinal bypass status. 3.)Medications 4.) TPN

Etiologies of Delayed (>3 week) post-op jaundice

decreases cerebral metabolic oxygen demand, cerebral blood flow, and intracranial pressure (ICP), but maintains cerebral perfusion pressure.

Etomidate action on cerebral metabolic demand, CBF, ICP, and Cerebral Perfusion?

Amplitude goes up.

Etomidate and ketamine do what to amplitude of SSEP?

Increased PONV, pain on injection.

Etomidate side effects

SIADH presentation

Euvolemic, plasma = low sodium | urine = high sodium (>20) + hypertonic (>100 sodium osmolality).

F8 and F5 will be depleated the most during storage and thawing of the FFP. Large volumes would have to be given to replenish F8 and it can lead to exposing the patient to issues. Cryo has higher levels of F8 and should be given if Recombinate F8 isn't available.

Even though FFP contains F8 and F5, why isn't a good option to replace Hemophilla A? What should be given instead?

SSEPs

Evoked potential which stimulates a peripheral nerve?

Effects voltage-gated sodium channels at the neuromuscular junction and clinically causes a myotonic reaction in patients with relatively elevated levels of potassium. Elevated potassium should be avoided.

Explain Hyperkalemic Periodic Paralysis

Sux mimics Ach at the post-junctional receptors leading to sustained depolarization. Seen with a standard intubating dose. Little-to-no fade is seen and TOF is usually >0.7. Can be potentiated/augmented with neostigimine since it increases Ach at the NMJ and also will block plasma cholinestrases.

Explain Phase I block with Sux

Paces the ventricles regardless of electrical interference. Should be the most used when coming off of pump.

Explain V.O.O. mode of a pacer? When should it be used in cardiac surgery?

Will pace the ventricles unless there is an underlying beat detected, then it will inhibit the pacemaker from firing and allow the heart to beat natrually. reduced R-T phemnon.

Explain V.V.I

Seen with increased doses of Sux (>3 mg/kg) or prolonged sux drips, leading to a response which resembles a NDMB where the patient has a TOF < 0.3 and significant tectanic fade is shown. Ach-E ihhibitor can actually antagonize phase II block like what would be seen with NDMB and addition of NDMB can potentiate it.

Explain a phase II block

Previously exposed recipient of the RBC has AB against the donor RBC, resulting in hemolysis of the donated RBCs. This is due to antibodies building back up again and lysis can be seen 2-3 weeks s/p transfusion. Leading to symptoms of fever, jaundice, low hg, increased indirect bilirubin.

Explain delayed hemolytic reaction?

Spirometery can't determine which two lung capacities?

FRC & RV

Going from 60 degrees to totally supine. Going from supine to trend position of >-30 degrees. Not a lot of change seen when: -Going from upright to supine (10% decrease) -trend position <-30 degrees.

FRC maximum decreases?

Notable factors that do 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.

Factors that don't influence mac?

Concentration in mom, molecular weight of drug, protein binding (only unbound will cross the placenta), lipid solubility, and lower degree of ionization.

Factors that effect drug transfer to baby?

Factors that can result in variable ACT include: hemodilution, hypothermia, platelet counts below 30-50 k/mL, and concomitant administration of other medications which affect platelets (e.g. prostacyclin, aspirin, glycoprotein IIb/IIIa inhibitors).

Factors that effect the ACT?

-hyperthermia, -hypernatremia, -chronic ethanol abuse, -Increased central neurotransmitter levels (e.g., as caused by MAOIs, acute amphetamine use, cocaine, ephedrine, and levodopa).

Factors that increase MAC?

Factors that increase CC are age, COPD, heart failure, smoking, and ongoing surgery.

Factors that increase closing capacity?

1.) Oxygen 2.) low dose neostigmine 3.) music therapy 4.) gastric decompression 5.) cannaboids--only useful to prevent nausea in chemotherapy patients.

Factors which have been debunked at reducing PONV?

Peds population 2/2 decreased metabolism-esp. neonates. FFP Liver failure. Decrease temp due to decreased metabolism of citate Hyperventilation => decrease calcium, leading to even more decreased calcium. Toxicity is seen when 1 unit of blood products given q 10 minutes.

Factors which increase the risk of citrate toxicity?

Which is longer acting H2 antagonist? Famotidine or Cimetidine?

Famotidine.

It is the only muscle relaxant that can be reliably used by intramuscular (IM) injection, with the quickest IM absorption via lingual injection.

Fastest onset site of IM sux?

4 hours prior to surgery. Breast milk is cleared faster in the body than cow milk (six hours). Important to wait since breast milk can cause worsening pneumititis than soymilk or cow milk.

Fasting time for breast milk prior to surgery and why?

8 hours.

Fatty foods should be stopped how long prior to surgery?

Features of the modern endotracheal tube include: -high-volume/ low-pressure cuff, -PVC construction with a longitudinal radio-opaque line -a beveled distal tip with Murphy eye -15 mm external diameter circuit adapters - and the incorporation of ultra-thin polyurethane cuffs to decrease the incidence of micro-aspiration.

Features of modern-day ETT?

Pre-ganglionic Sympathetic > Sensory C fibers > Sensory A-detla > Sensory A-Beta > Motor A-alpha. C fibers = temp sensation A-Delta-pin-prick sensation A-beta- touch Motor A-Alpha-muscle movement. Level of cold sensation via the C-fibers is 2 dermatomes higher than the level for pinprick A-delta sensation.

Fibers most sensitive to Local Anesthesia in an epidural?

Increase ISO and lead to a potential OD of violtile anesthesic due to: -ISo is more potent. -Iso has a higher VP.

Filling sevo vaporizor with iso will do what and why?

Wedge injuries > Ligamentous injuries.

Flex injuries to the neck result in what type of injury to the vertebral body?

Flexion-rotation injuries may disrupt the posterior ligamentous complex but tend to be stable

Flexion-rotation injuries results in?

avocados, bananas, chestnuts, kiwi fruit, papayas, potatoes, and tomatoes.

Foods that have a cross-reactivity with latex?

0.1 mEq/L

For each 10 meq of potassium supplementation given, will raise the serum potassium by how much?

CO x [(1.34 x Hg x Sao2) + (0.003 x Pao2)]

Formula for Oxygen Delivery to the tissues? Do2?

1-Isovolemic relaxation. 2.-Early rapid filling-when mitral opens. Contributes most blood. 3-slow filling (diastatsis). 5% blood to the LV. Mid-diastole. 4-Last rapid filling (atrial kick)-15-20%

Four phases of diastole and which phase constributes the most blood to the ventricle?

Fresh frozen plasma should not be used in the following situations:- To correct mildly elevated INR (< 1.8) without signs of bleeding- To correct a vitamin K deficiency that could be corrected with vitamin K- As a primary volume expander (absolute contraindication)- To correct a factor deficiency when recombinant factor replacement is available

Four situations when FFP should not be used.

-Molcules of >1000D, Decrease lipicity, increased protein binding, and increased cocnentration of drug into mom's blood.

Four things that make it difficult to cross the placenta?

functional closure of foramen ovale

Funtionally closes within first few hours of life. Anataomical closure within the first year of life.

Topirmate (Topamax) MOA and side effects

GABAA agonist | kidney stones, impaired heat regulation, decreased effectiveness of oral contraceptives, and increased risk of cleft lip/cleft palate in infant during first semester

Thirteen Hyperbaric Oxygen Therapy conditions

Gas-bubble diease, CO, Infections, Acute tissue ischemia, Chronic ischemia *ulcers*, Acute blood loss and unable to give blood *Jehovah's Witness*,acute burn, acute sensineural hearing loss

Nore-epi and epi. Glucagon = activate Adenylate Cyclase = increase cAMP = intropic and chronotropic HR. -contraindicated in pheochromacytoma and insulinoma.

Glucagon's effects on the heart is similar to do?

Limit colloids to staying within the blood vessel.

Glycocalyx will do what to colloids?

During hypotensive episodes in the mother, what will happen to Baby's pH?

Go into profound acidosis 2/2 no compensatory mechanism.

Fick Principle-used to calculate oxygen consumption.

Gold standard by which cardiac output is calculated?

1-Full glottic view is seen. 2.-Anterior glottis seen. 3-Epiglottis is seen 4-either epiglottis or glottis is seen. ___________________________________________________- (modified) 1-Full glottic view 2a-partial glottic view. 2b--only posterior artynoids & epiglottis seen. 3-only epiglottis seen. 4--neither glottis or epiglottis is seen

Grades of the Cormack-Lehane system?

C. botulinum has an MOA of?

Gram positive which releases toxin that stops exocytosis of the Ach leading to Cranial Neuropathies with systemic weakness.

Where are the greater, lesser and least splananic nerves located & what do they do?

Greater-T5-T9 | Least-T10-T11 | T12

Which drugs does the ASA recommend in patients with aspirations such as one who needs emergency surgery?

H2 blockers.

Famotidine MOA

H2 inhibitor = increase in gastric pH & decrease in volume in the partial cells

What is the most sensitive fetal vital sign for detecting fetal distress?

HR.

1.) Haldane: -Level of tissues -CO is produced at the level of the ttisues and oxygen off-loads to the tissues. 2.) Bohr Effect: -Level of the lung. -Hg-CO2 is able to release at the level of the lung and into the lung, then O2 is able to bind to Hg-O2.

Haldane and bohr effect?

Oral clonidine reaches peak effect within 60 to 90 minutes with a half-life of 9 to 12 hours. Rebound hypertension from acute clonidine withdrawal typically takes 12 to 60 hours after the last oral dose of clonidine Clonidine decreases mean alveolar concentration (MAC) requirements for inhalational anesthetics without prolonged emergence. Clonidine decreases anesthetic requirements (decreased MAC), is a useful co-analgesic particularly in chronic pain patients, reduces post-operative shivering, and reduces post-operative nausea.

Half-life of oral clonidine?

Vasodilation leading to core-to-peripherary heat loss. Seen especially within the first hour and then a slow linear decent until the temp stablizes. Leads to: blood loss 2/2 to platelet dysfunction, decreased drug metabolism, SSI due to vasoconstriction & decreased immune system

Heat loss in the OR is due to? Leads to?

-Hypobaric-positioning. -Hyperbaric: positioning and baricity -Iso: dose and site of injection. Positioning has no effect.

Height of spinal anesthesia is most influenced by what in: -Hypobaric, -hyperbaric -Isobaric?

Hemophilia C is a disease that results from deficiency of factor XI

Hemophilia C is a disease that results from deficiency of ?

How does Serotonin Release Assay Work?

Heparin and Platelets combine, serotonin released and detected.

Soluable > insoluble.

High cardiac output effects which agents?

Phase 2 block

High dose sux can cause what?

Aortic Stenosis--Higher SVR = higher CPP. Sinus Bradycardia = more time spent in diastole = ventricular filling & allows for better oxygenation to the thickened LV. Patients must remain in sinus to maintain atrial kick.

Higher SVR and sinus bradycardia is important in what valvular pathology?

Higher potency, higher blood solubility = slower onset.

Higher blood gas partition coefficient means

Ketamine can increase salivation, especially in children, and can potentially lead to a higher incidence of upper airway obstruction and/or laryngospasm.

How can a Ketamine induction contribute to upper airway obstruction and laryngeospasm ?

Excessice chloride loss = increase bicarb = metabolic alkalosis = decreased respiratory rate = difficulty to wean off vent.

How can nasogastic secretion cause difficulty of vent weaning in the ICU?

By decreasing the volume of capacitance or increasing Fresh gas flow. To reach 95% equlibrium, it takes 3 time constants.

How can the time constant be decreased to speed the onset of inhalation agents?

Art Line stroke volume variability with respiration in mechanically vented patients. Hypotensive patients will show a larger drop in Stroke volume during positive pressure.

How can waveform analysis determine fluid responsiveness in mechanically vented patients?

Skin temp is usually lower by 2 degrees.

How close is skin temp to core temp?

SVR >>> arterial BP > myocardial depression.

How do Des, Sevo, and Iso decrease BP?

Cardiac myocytes depend on insulin for the majority of the cells' glucose uptake.

How do cardiac cells utilize glucose?

By inhibiting sympathetic output and increasing bagel tone

How do opioids decrease heart rate and blood pressure?

Start the infusion without a bolus.

How do you decrease the hypotension and bradycardia seen with Precedex drip?

1.) Figure out the Va (volume of the anesthestic existing) =Va = (SVP x Volume of carrier gas) / 760 mmgh -SVP) 2.). Figure out % of inhalation agent delivered: % = (VA / FGF(convert to cc) + Va ) x 100.

How do you determine the percent of inhalation agent?

ACE inhibitiors = decrease in Angiotensin II. AGII usually works on AT-1 receptors located in the area to cause cardiovascular hypertrophy, proliferation, fibrosis. AT-1 receptors also found in the kidney to increase alderstrone which also works to remodel the heart. Besides angiotensin II, vaso pressin can also work on AT-1 to cause cardiac remodeling.

How does ACE inhibitors work to decrease cardiac remodeling?

Bings AT3 which increases its activity a 1000 fold. AT3 will bind to and inhibit Xa. Unfractionated heparin is longer and not only binds to AT3, but also binds to Factor II (thrombin), decreasing activity of it both.

How does Enoxaparin work?

inhibits agonist-induced expression of IIB-IIIA complex on platelets.

How does Hetastratch effect platelet aggregation?

Blocks Plasmanogen converting to Plasmin and thus fibrin can't ben broken down.

How does TXA work?

post-op delirium usually happens in patients > 50 yo and can present up to 5 days post-op. Usually in hip/bilateral knee surgery, bloody surgeries, base-line cognitive function, hx of delirium.

How does emergence delirium differ from post-op delirium?

Lower density, same viscocity.

How does helox compare to air?

Low magnesium can result less PTH release, thus leading to low calcium.

How does hypo magnesiumia effect PTH and thus magnesium?

Sympathetic cholinergic.

How does ketamine increase salavation?

Proteins produced is decreased in liver failure, so less proteins can bind. Causes an increase in the amount of free drug, resulting in potential faster metabolism.

How does liver disease have effect on protein binding of medications?

Inhibits Pseudocholinestrase = no sux break down = increased risk of post-op apnea.

How does the chemo drug cyclophosphamide interact with sux?

6-12 minutes

How fast does 2-chloroprocaine work?

15-30 minutes of oral administration. Work by increasing gastric pH, but don't work to decrease volume & may delay gastric empyting

How fast due antacids work and their primary reason of giving them prior to going back for a c-section?

CPP= DBP - LVEDP. Keeping DBP up and LVEDP down. LVEDP can be decreased by nitro and decreasing heart rate.

How is CPP kept up?

LMWH levels can be monitored via an anti-Xa assay, which is most commonly used in patients with renal failure or morbid obesity.

How is LMWH commonly monitored and in which patient population?

Metabolized through liver. Increases HR due to a SNS response > baro-receptor response. Decreases SVR & increases contraility.

How is Nicardipine metabolized? MOA of increased HR?

chylothorax is made by analyzing the suspected chylous fluid (e.g., via thoracentesis). A high fat content, specifically triglycerides, and high T-lymphocyte count are diagnostic of chyle.

How is a definitive of a chylothorax made?

Via liver into bicarb, leading to metabolic alkolosis.

How is citrate metabolized?

Renally.

How is lMWH such as enoxaparin cleared?

It is a NBMB and it is broken down via plasma Estrases

How is mivacurium broken down?

Hoffman elimination & estrases.

How is nimbex degraded?

Terminated by diffusion from the post-junction receptors. Goes back into the blood and is degraded by plasma cholinesterase Plasma cholinestrase is produced in Liver.

How is sux terminated and metabolized? Where is the enzyme produced?

SLN--Blocked by injection of LA at the horn of the hyoid bone or placing a pledget in the pyriform sinus. RLN-Transtracheal approach.

How is the SLN and RLN blocked?

About 60 minutes prior to incision or a 120 minutes of an infusion is required.

How long before incision should antibiotics be given?

After collection, FFP can be stored frozen at below -18 degrees Celsius for up to one year. Used to urgently reverse wafarin. Non-urgent reversal = vitamin K. PCC = emergent reversal of wafarin

How long can FFP be stored for at the correct temeprature?

3-4 hours vs. 9-12 hours. Onset is 30 minutes for H2 blockers.

How long does Cimetidine last compared to other H2 inhibitors? Onset?

24 hours and lasts for roughly 72 hours. After 72 hours, patch should be removed.

How long does it take for peak effects of scolopamine patch?

Uusually from 3 minutes --> 9 minutes. Prolonged due to a decrease in pseudocholinestrases.

How long is sux prolonged for in liver patients and why?

4 hours.

How long prior to surgery should scolop patches be placed?

Regardless of bare-metal or drug-eluding, should have DAPT for 12 months, unless increased risk for bleeding then 6 months.

How long should DAPT go for when he patient undergoes PCI due to a stemi/acute coronary syndrome?

wait at minimum 60 days without intervention. If patient had an MI and there was intervention, wait before an elective cardiac surgery: -14 days if balloon angioplasty at minimum. -30 days after a bare metal stent. -180 days after a DES at minimum {3 months if patients really need surgery]

How long should an elective, non-cardiac surgery be wait [ at minimum} after a patient has an MI, but doesn't have any coronary intervention? What about if intervention took place?

six hours.

How long should infant formula, non-human milk, and light meals be stopped prior to surgery?

2 hours. Considered a clear liquid.

How long should one stop orange juice prior to surgery?

Six hours before redosing zofran for it to be effective again.

How long should one wait before re-using zofran (or the same class) again for PONV?

A full E-cylinder contains 660 L oxygen at 1900 or 2200 psig

How many Liters of oxygen does an E-cylinder have and at what PSI?

2 levels above the actual insertion point. Factors affecting the height? -Position of patient -Baracity -Dose of anesthetic.

How many levels above the spinal insertion is the level blocked? Factors affecting the height of block?

1.) Oxygen consuption = 3-4 ml/kg. 2.) FRC = 30 ml/kg.

How many ml/kg is oxygen consumption in an adult? What about FRC?

NC - 25-40% FIO2 Simple mask = 35-50% FIO2 Partial rebreather mask has a resivor bag, but doesn't have one-way valves like a non-rebreather mask, allowing rebreathing and thus FIO2 is 40-70% FIO2. Non-rebreather mask has added one-way exhalation valves. Delivers FIO2 = 60-80%.

How much FIO2 does a: NC deliver? Partial breather mask? simple mask? Non-rebreather mask?

1600 L 745 PSI

How much L and PSI is in a Nitrous oxide cylinder?

1-2 cc/100g/min.

How much does the cerebral blood flow change with 1 mmhg of PaCO2?

Can get 10-30 ml of fluid absorbed in a TURP

How much fluid can a turp absorb?

urine-to-plasma osmolar ratio (UOSM : POSM) >1.5 indicates prerenal oliguria. Example--patient's plasma osmolality = 295 x 1.5. If urine osmolality is 441, then it is considered to be pre-renal.

How much higher osmolality would the urine to plasma need to be in order to be considered pre-renal oliguria?

87.5%. And is clinically equal to the drug being fully eliminated from the body.

How much of the drug is eliminated from the body after three half lives?

CO-HG has a higher affinity for Hg than oxygen, causing a left-ward shift of the Hg curve and less amount getting to the tissues. This leads to lactic acidosis. What be seen is a normal PaO2, normal Spo2%, but lactic acidosis with a decrease pH on ABG because normal two-wave pulse-ox cant tell the difference between the two. SaO2 on the ABG is also calculated. However, requires ABG with co-oximetery which can differentiate b/w Hg-O2 and Hg-CO.

How of Carboxy-Hemoglobin and what should be seen on ABG?

Within 1 year

How recent should an ECHO be prior to surgery for someone who has a high cardiac risk? ?

Short acting & regular = continue until the day of surgery as is. Intermediate acting (NPH)-usually BID-morning and night. -Night before surgery-take 75% the dose. -Morning of surgery-take 50% dose. Long acting: -Take 50% of dose.

How should patients take their short acting & regular | intermediate insulin | long acting insulin?

Inflation of an ETT cuff with 50/50 N2O/Air mixture prior to a planned anesthetic that will utilize N2O has been shown to mitigate the concern for cuff over-distension and possible tracheal injury in the setting of N2O use.

How to prevent tracheal injury from ETT cuff overinflaation using N2O?

Hydrocephalus and the presence of intraventricular blood lead to which EKG finding?

Hydrocephalus and the presence of intraventricular blood commonly lead to QTc prolongation

prolonged PR interval, peaked T waves, shortened QT interval, and wide QRS complex

HyperKalemia on an EKG?

Triggers-things that raise potassium: -exercise -potassium infusion -metabolic acidosis -hypothermia. Avoid Succs

Hyperkalemics Periodic Paralysis triggers?

Hypocalcium, hypokalima, hypophosphate,

Hypo magnesium is associated with what other electrolyte issues?

Things that cause hypokalemia such as: -stress -hypothemia -carbohydrate load -glucose solutions -beta agonist Okay to give SUX AND NDMB

Hypokalemic Periodic Paralysis triggers.

What happens to sodium in 10-30% of SAH Patients?

Hyponatermia

LA toxicity is increased by:

Hypoxia, acidosis, hypercarbia, pregnancy.

Decreases PWCP. Also decreases oxygen consumption by the heart, and peak aortic systolic pressure by promoting forward flow.

IABP do to PCWP?

Higher than expected NH4+ in the urine indicating that there is an appropriate response to trap H+ in the urine in the face of metabolic acidosis.

If Urine Anion Gap is negative (<0 ), what does it mean?

No chest tube, CO2 will be re-absorbed.

If a patient has a capnothroax, what is done about it most of the time?

The diagnostic test of choice is computed tomography scanning because it allows a higher resolution when compared with fluoroscopy and plain radiographs.

If an epidural catheter breaks, what is the imaging test of choice?

1.5 ml/kg over 2-3 minute bolus and then 0.25 ml/kg/minute based off of Ideal Body Weight.

If less than 70 kg how should interlipid be administered?

Mask the patient until the infant is delivered.

If there is a difficult airway in a pregnant female undergoing an emergent c/s, and mask ventilation is achievable, what should be done?

Potassium.

If your magnesium is low, what other electrolyte could be low?

More blood will shunt from right to left with an increase in pulmonary vascular resistance or a decrease in systemic vascular resistance. O2 not being exchanged in the lungs results in hypoxemia, despite ventilation.

In TOF what two factors make blood shunt from right to left?.

Mode is used when there is HF 2/2 conduction issues. Leads placed in the RA, RV, and coronary sinus. This allows for firing of the right heart and the coronary sinus allows for firing of the LV.

In biventricular pacing, where are the pacemaker leads placed and when is this mode used?

If the surgery is emergent--if it is, then proceed to surgery without further testing. If not emergent & patient's MACE is <1% = proceed to surgery without further testing. If MACE is >1%, ask if the patient has >4 mets. If so, then no further testing is required. If MACE is >1%, and METs can be determined or <4, consider further testing.

In cardiac risk stratification, what is the first thing that should be considered in patients before proceeding to surgery? i

For every 2 mmol/L drop in bicarb per 10 mmHg per PaCO2 drop.

In chronic or subacute respiratory alkalosis, how much does PaCO2 drop?

Platelet count can be used as an indirect measurement of portal hypertension

In liver disease patients, what can be used as an indirect value of portal hypertension?

V1 x C1 = V2 x C2

In order to dilute a concentrated drug (example: dilute 2% lidocaine to 0.5% in 30 cc.)

-Better for controlled > spontenous respirations. -If patient is spontanous breathing, FGF should be 2-3 x MV. -If patient is mechanically ventilated with D,E,F, circuits then it should be 1 -2 times more than MV.

In regards to Mapleson D,E,F systems, what is required to decrease rebrething and what are used for?

Catagorical date doesn't use looks at numbers, but more questions such as "do you have nausea & vomiting?" dichotomous (binary data)--yes/no responses , nominal (qualitative data)--what kind of surgery did you have? or ordinal (ordered, ranked, or measured without a constant scale interval)--on a scale of 1-10 how bad is your pain? Best determined by a chi-square test.

In statistics, what is the defination of catagorical data and what forms are there? Which test is best used?

musclocutaneous nerve. it provides innervation to arm flexation and also has a lateral antebrachial cutaneous nerve that provides sensation to the lateral portion of the forearm. Musculocutanous nerve can be blocked by injection LA into the coracobrachialis muscle.

Inadequate analgesia in the lateral forearm after axillary block suggests sparing of which nerve?

Increase FA/FI because uptake into the blood will decrease.

Increased Barometric Pressure has what effect on FA/FI ratio?

There is a decrease in affinity of the hemoglobin for oxygen ==> more oxygen offloading.

Increased P50 values means?

desiccated CO2 absorbents, increased temperature, strong bases within the absorbant=top factor, and low fresh gas flows, inhalation agent itself, high inhalation agent concentration, strong bases: KOH, NAOH, and barium hydroxide. Desflurane > Enflurane > Isoflurane >> Sevoflurane = Halothane

Increased likelihood of producing CO with inhalation agents?

long surgical procedures, lateral positioning, head and neck surgery, general anesthesia, and surgery on a Monday

Increased risk factors of occular injuries in the OR?

non-elective surgical procedure, light anesthesia/unexpected response to stimulation, acute or chronic GI pathology, obesity, opioid medication, neurologic disease, lithotomy position, difficult intubation, gastrointestinal reflux, and hiatal hernia.

Increased risk of aspiration?

Surgery in 3rd trimester and pelvis/abdominal surgery.

Increased risk of pre-term labor is seen when pregnant patients undergo non-OB surgery during?

Causes of Nicotinic AChR Upregulation - Nerve Injuries o Stroke o Spinal cord injury - Burns (24 hours up to 1-2 years after burn injury) - Prolonged immobility (risk greatest after 16 days) - Prolonged exposure to neuromuscular blockers - Myopathies o Duchenne muscular dystrophy - Denervation Disorders o Multiple sclerosis o Guillain-Barré syndrome o Amyotrophic lateral sclerosis

Increased risk of upregulated nicotinic receptors?

Increases power. Increasing alpha = lower chance of false negatives.

Increasing alpha does what to power?

Ionized calcium causes an exponential increase in ACH release. 2X ionized calcium release = a 16 fold release of ACH.

Increasing ionized calcium does what to the ACH?

Microvascular bleeding with hypofibrinogenemia Bleeding due to uremia that is unresponsive to DDAVP Factor XIII deficiency Prophylaxis before surgery or treatment of bleeding with congenital dysfibrinogenemias Prophylaxis before surgery or treatment of bleeding with Von Willebrand disease Prophylaxis before surgery or treatment of bleeding with hemophilia A. Use in fibrin sealant production

Indications of Cryo?

MOA of Benzos

Indirect GABAa receptor agonist = Increasing frequency of Chloride channels opening = hyperpolarization of nerve.

Decrease in frequency and increase in amplitude. From alpha, beta, to theta and delta waves.

Induction agents do what to the frequency and amplitude of the EEG?

propofol, etomidate, diazepam, methohexital, and rocuronium

Induction medications associated with pain on injection?

IABP inflates during _____ and deflates during _____.

Inflates during diastole Deflates during systole

Indications: -similar to a supraclav block, done at the level of the cords. Complication: -pneumothroax, infrathroax,

Infraclav indiction, anatomy, complications?

MV = TV x RR. RR increases, but TV decreases with inhalation agents.

Inhalation agents decrease MV how?

desflurane > sevoflurane > isoflurane > halothane > TIVA (e.g. propofol). N2O doesn't have any effect. Less potent inhalation agent, the more likely to effect the NDMB because the more potent agents are more aqeuous soluable and less likely to be present at the nACH receptor to exert their effects.

Inhalation agents most likely to cause NDMB potentation?

Fluoride ion production: methoxyflurane > sevoflurane > enflurane > isoflurane > desflurane.

Inhalation agents that produce the most floride ion.

When should Mannitol not be used?

Initial treatment in traumatic head injuries secondary to compromised BBB can cause the mannitol to cross into the brain, resulting in worsening swelling and potential herniation of the brain.

_____RLN____|(VC))|__SLN-IB____|(epiglottis)___CN 9____tongue.

Innervation of the trachea.

Which nerve is the afferent limb of the Larngospasm Reflex?

Internal Branch of the Superior Laryngeal Nerve. It provides sensation to the entire larynx above the glottis.

ipsilateral phrenic nerve blockade recurrent laryngeal nerve blockade, ulnar nerve (C8-T1) sparing, vertebral artery puncture, and Horner's syndrome

Interscalene brachial plexus block complications?

-BUN:Cr- <15 -Fena- <2% -Urine Sodium- >20% -Urine osmolality - <350

Intrinsic/ATN urine labs?

Leukoradiation doesn't eliminate Graft vs. Host. What does?

Irradiation.

Isoflurane, an isomer of enflurane

Isoflurane is an isomer of which other halogenated inhalation agent?

What happens to sputum production after stopping smoking?

It actually increases! Can result to decreased pulmonary clearance.

What happens with Protein C in HITT?

It becomes depleted, leading to increased clotting.

none

Ketamine & Etomidate has what effect on evoked potentials?

Direct myocardial suppressant.

Ketamine can cause what to sick patients' heart?

Increase ICP, cerebral blood flow, and metabolism(CMR2)

Ketamine does what to ICP and CMR2?

Direct myocardial depression - Increased cerebral metabolism, CBF, and ICP

Ketamine does what to the heart and the brain blood flow?

Ketamine-+/-, ↑, ↑

Ketamine's effect on CMRO2, CBF, and ICP?

JVD with inspiration in pericardial tamponade.

Kussmaul's sign

Bupivicaine secondary to mostly protein bound

LA with longest elimination half-time

>14 weeks pregnant.

LMAs should be contraindicated in pregnancy after how many weeks?

Binds to and activates AT-3 and more of a Xa > II a, this increasing the ratio of inactive X to II. Heparin inactives both Xa and IIa to a 1:1 ratio by acting on & activating AT-3

LMWH inactivates which enzymes?

Complete blood count, bilirubin, haptoglobin, direct antiglobulin (Coombs) test, and HLA antigen typing

Labs to Dx TRALI?

Lamber-Eaton Syndrome patients are sensitive to both depolarizing and non-depolarizing NMB.

Lamber-Eaton Syndrome are resistent and sensitive to?

Phase II block > bradycardia (seen with repeat doses within 5 minutes).

Large or prolonged doses of sux will likely lead to what side effect?

SLN-Internal branch -->RLN--->lateral cricoartenoid & transverse arythenoid to adduct vocal cords.

Laryngospasm MOA?

subendothelial layer

Later of the heart more prone to ischemia?

II-RCA V5-LAD

Lead II and V4/V5 are often used to detect ischemia in their respect fields. What Coronary artery occlusion can be detected by II and V4/V5

Pulmonary Embolis

Leading cause of maternal mortality besides cardiac?

Terminal bronchi

Least resistance is seen where in the lungs?

Minimal Sedation: normal response to verbal stimulation, the airway remains unaffected, spontaneous ventilation maintained, and cardiovascular function unaffected. Moderate Sedation: purposeful response to verbal or tactile stimulation, no intervention required to 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.

Level of Sedation:

1.) Minimal Sedation: Normal verbal conversation. 2.) Moderate: Purposeful movements to repeated tactile/verbal stimui. No airway intervention needed. 3.) Deep: purposeful movement to multiple painful stimuli. May need airway support. 4.) General: no response, needs airway support.

Levels of Sedation:

2 faults must happen to deliver a shock. Alarm goes off when one is grounded. However, line isolation monitor can only detect 2 mA, if two faults happen less than 2 mA, there could be a micro shock.

Line isolation monitors require how many faults to deliver a shock?

These complications have been associated with overinflation of a small-fitting cuff, prolonged operative times (>2-4 hours), lidocaine lubrication, difficult insertion, use of nitrous oxide, and cervical joint disease.

Linguinal nerve palsy from LMA is likely due to?

The potency of LA is determined by what?

Lipid solubility

Prolonged infusion will cause the brain and central compartment to be equal, so the drug can't redistribute back into the plasma-->fat & muscle. Termination will be determined by hepatic metabolism.

Lipophilic drugs will usually terminate via re-distribution. What is termination determined by in a prolonged infusion?

potentiates (prolongs)

Lithium does what to NDMB and DMB?

Corticalspinal & Spinothalamic tracts are damaged as they are in the anterior 2/3rds of the spinal cord leading to loss of: -Motor function. -Pain -Temperature Dorsal column is left in-tract: -Pressure -Vibration -Fine touch -Prioprioception.

Loss of functions and preserved functions of Anterior Spinal Artery blockage?

Lower lung compliance compared to adults, but their chest wall is more compliant than adults. Pliable rib case causes less effefficent gas exchange and functional airway collapse.

Lung mechanics of neonates regarding their lung compliance & chest wall compliance?

Expiratory reserve volume. Differs from the FRC which is the amount of air that remains in the lungs after a normal expiration.

Lung volume which can be forceibly expired out after a normal tidal volume?

Class Ib antiarrhythmics bind voltage-gated sodium channels and result in a decrease in the duration of the ventricular action potential. Work on activated and inactivated channels, not resting sodium channels. Example: Phenytonin and lidocaine.

MOA of 1B Antiarrythemics, what is an example?

Compliment system activation-->antibodies of patient destroys donor RBC.

MOA of ABO incompatability?

inhibits carbonic anhydrase. Inhibition of this enzyme causes an increase in renal bicarbonate. Acetazolamide may cause a mild hyperchloremic metabolic acidosis due to bicarbonate excretion.

MOA of Acetazolamide?

begins 2-3 weeks following acute injury. It may occur with stimulation below the level of spinal cord injury leading to uninhibited sympathetic stimulation. Approximately 85% of cases occur with SCI above the T5 level.

MOA of Autonomic hyperreflexia

Indirectly bind to the GABAA receptors in way of positive allosteric modulators that increase ligand binding by increasing the total conduction of chloride ions across the neuronal cell membrane when GABA is already bound to its receptor. Increasing chloride influx ==>hyperpolarizing neuon's membran potential.

MOA of Benzos

Higher affinity for hemoglobin than oxygen. This doesn't allow the remaining oxygen to be displaced from the hemoglobin to the tissue due to a left-shift in the hemoglobin curve, leading to anemic hypoxia and metabolic acidosis.

MOA of C.O. poisoning ?

BP is elevated -->stretch receptors in the carotid sinus initiate -->CN # 9 to the brain. Brain --> CN X to decrease HR. If severely hypotensive, <50 systolic, cartoid sinus can be lost and a low BP can also have low HR because cartoid sinus isn't respondering.

MOA of Carotid Sinus Reflex

CYANIDE blocks ECT by binding to cytochrome C-oxidase. No ATP can be produced and relies on aneorbic respiration. Lactic acid builds up, resulting in an anion gap. Anion gap is the most common and relaible sign. Normal PaO2, as oxygen is avaible, just not uttilized.

MOA of Cyanide toxcity?

Direct thrombin inhibitors

MOA of Dibagatran

Doxorubicin is one of several antitumor antibiotics that causes single strand DNA breaks or cross-links by causing the formation of free radicals in proximity to DNA.

MOA of Doxorubicin?

Causes a dysfunction of vWF and platelet IIa-IIIB, resulting in decreased platelet aggregation and activation. Also increase prostocyclin & nitrous oxide which both decrease platelet aggregation & function. Seen particulary with elevated uremia in missed dialysis.

MOA of ESRD has on platelet aggregation?

End-tidal CO2 (ETCO2) is measured by infrared spectrophotometry where a wavelength of infrared light is passed through a gas sample and the amount of energy detected is inversely proportional to the gas partial pressure.

MOA of EtCO2?

WBC from pRBC being attacked by recipient antibodies. This leads to lysis of WBC and cytokine release IL-1 and TNF-Alpha that cause temperature and shivering. Tx: leuocyte reduction, tylenol. Febrile transfusions reactions are relatively common in multi-transfused and multiparous patients.

MOA of Febrile, non-hemolytic reactions?

Work in an hour if given orally, will increase gastric pH and decrease volume. Only medication that doesn't decrease volume is ranitidine

MOA of H2 blockers?

HCTZ: -site of action: DCT -MOA: Increases Na+ and Chloride into the urine by activating the Na/Cl co-transporter. -Other lytes: Low potassium, low sodium, low chloride, low magnesium. . High Ca2+. Amlioride: -Site of action: Cortical collecting duct & DCT -MOA: works on EnaC transporters to increase sodium loss. -Lyte issues: Decreased H+ excretion, Elevated potassium = Prolonged PR, wide QRS, short QTc, peaked T-waves.

MOA of HCTZ vs. MOA of Amlioride?

Increases in shunt = venous ademixture 2/2: 1.) Vasodilation of blood vessels. 2.) Microatelectesis = collapse of alveoli 2/2 lower amounts of nitrogen in the alveoli to splint them open. Can be fixed with PEEP.

MOA of HPV attenuation with increased FIO2?

T cells infitrates, causing B-cell activation and production of Anti-bodies to TPO & Thyroidglobilin leading to destruction of tissue.

MOA of Hashimotos Thyroiditis?

Portal hypertension causes splachanic dilation leading to ascitis and volume loss. This decrease in intravascular volume leads to renal vasoconstriction. Increasing intrabdominal pressure has an opposite effect on renal physiology.

MOA of Hepatorenal Syndrome?

Decreased PAO2 = > vasoconstriction of vessels to area with low PAO2. Can happen with high altitude pressure and result in pulmonary edema.

MOA of Hypoxic Vasoconstriction?

NMDA receptor antagonist, Ketamine, usuaully will work on opioid receptors at higher doses to decrease pain. At lower doses, it will work on NMDA receptors to decrease pain.

MOA of Ketamine at higher doses to decrease pain?

inhibit adenylyl cyclase—> reducing cAMP—>causing a decrease in calcium influx—>decreasing release of neurotransmitters pre-synaptically. Also works post-synaptically to increase potassium exflux

MOA of MU receptor.

F2+ (ferrous) oxidized to (ferric) F3+. Can't bind oxygen, so oxygenation doesn't get transported to the tissues. fatigue, headache, cyanosis, mental status changes, shortness of breath, and can progress to coma and death at levels >50% of total Hb.

MOA of Meth-HG? Signs and Symptoms?

Blocks PDE III ==> decreased breakdown of cAMP ==>phosphorlation of Potassium and Calcium channels = increased contracility, inotropy, and cardiac output. Also will vasodilate = decrease afterload to right and left heart.

MOA of Milrinone

Phosphodiesterase III inhibitor that promotes diastolic relaxation (positive lusitropy), ventricular filling, and reduction in the myocardial wall tension muscle vasodilation by increasing intracellular cAMP levels. Excreted in urine and should be dose-adjusted in renal patients. Milrinone is unique in its ability to increase cardiac index without increasing myocardial oxygen demand. Also augments coronary circulation by its positive lusitropy

MOA of Milrinone

NAC provides cysteine for the replenishment and maintenance of hepatic glutathione stores which enhances the elimination pathway and may reduce the hepatic toxicity of acetaminophen. NAC is most effective when administered within the first 8-10 hours after an overdose.

MOA of NAC in Tylenol OD?

cGMP

MOA of Nitrous Oxide?

Nitrous oxide inhibits the vitamin B12-dependent enzymes, methionine synthetase and thymidylate synthetase. This may lead to subclinical problems in relatively healthy patients, but may cause neurologic and hematologic sequelae in critically ill and vitamin B12-deficient patients.

MOA of Nitrous Oxiide causing megaloblastic anemia?

weak dopamine antagonist

MOA of Promethazine?

deficiency of vWF-cleaving protease activity (ADAMTS13 deficiency)

MOA of TTP (Thrombotic thrombocytopenic purpura)?

donor anti-leukocyte antibodies attacking the recipient's leukocytes in the pulmonary microcirculation.

MOA of Traili

Both bind to and activates ATIII which normally binds to coagulation factors. UNF binds to & activates AT3 ==> Blocks Xa & II. LMWH binds to & activates AT3 ==>blocks Xa. If Xa or II are blocked =/= no coagulation.

MOA of UFH vs. LMWH

Hypoperfusion to the respiratory center, not the local anesthetic reaching the respiratory center.

MOA of a total spinal?

Blocks the Carbonic anhydrase in the PCT, not allowing bicarb to be re-absorbed into the body. Causes metabolic acidosis, resulting in hyperventilation and a right-ward shift of the hemoglobin curve.

MOA of acetozomide in high altitude sickness?

Decrease ACH pre-junctional release possibly due to antagonizing the calcium channel. Also, decrease sensiitivity to post-junctional receptor for ACH.

MOA of aminoglycosides causing a potentation of NMBD?

Beta agonists causes g-mediated protein production of cAMP causing calcium inside the cell to go up.

MOA of beta receptors

Bradycardia often occurs in children after they receive succinylcholine because of the activation of muscarinic receptors at the sinoatrial node, along with a high baseline vagal tone. More likely in kids due to high vagal tone. Can be prevented by pre-treating with atropine.

MOA of bradycardia in kids with sux?

Carotid sinus = controls blood pressure by increasing the SNS and decreasing the PS NS. Local anesthetic around the carotid sinus would blunt this response by blocking SNS and allowing the PS NS to work.

MOA of carotid sinus and what would happen if local anesthestic infiltrates the area?

Blocks typo II & IV leading to decreased replication of bacteria.

MOA of cipro?

Blocks calcinuerin = decrease T-cell differentiation & cytokine release. Can be cyclotoxic & T-cell differentiation decreased. Metabolized by CYP34A

MOA of cyclosporin?

Mostly seen in dental offices which patients return to breathing room air. Nitrous oxide returns from the blood into alveoli and dilutes the oxygen in the alveoli. Avoided by supplemental oxygen.

MOA of diffusion hypoxia:

O2 = vasodilation of pulmonary vasculature = decrease ability for HPV ==> blood can't be shunted from poorly ventilated alveoli & can't will be stolen from well ventilated aveoli. ==> increased dead space ==> increased PAO2 ==> increase CO2.

MOA of hypercarbia in COPD patients recieving oxygen?

Decrease in alderstrone ==> decrease in NA/K+ in the DCC + collecting ducts.

MOA of hyperkalemia in ace-inhibitors?

Increase NA-CL- cotransporter, leading to sodium into the urine. Na+/K+ ATPase ramps up, and starts to passively dump K+ into urine in attempt to uptake Na+. This leads to Hypokalemia.

MOA of hypokalemia with thizide?

Low alveolar PO2 = blood vessels constriction

MOA of hypoxic vasoconstriction?

Tyrosine-receptor kinase that is inhibited by Alpha-2. Results in: -Glycogen synthase -lipid synthesis -increase in glut-4 (fat tissue). -Blocks catabolic such as lipolysis, glycenolysis, gluconeogensis, oxidation of FA and Amio Acids.

MOA of insulin?

The NMDA receptors are a class of excitatory glutamate receptor. Ketamine does have agonist effects on the gamma-aminobutyric acid (GABA) receptor, however, this is an indirect effect via NMDA antagonism.

MOA of ketamine?

Magnesium is a calcium channel blocker. Associated with Ca2+ and potassium. Low magnesium also causes hypocalcemia and hypokalemia.

MOA of magnesium and what two electrolytes is it associated with?

Blocks vasodilatory effect of nitric oxide by inhibiting the gCMP.

MOA of methylene blue?

Person breathes against an obstructed airway which causes a negative pressure to push blood into the heart, thus increasing pre-load--->lungs There is also an increase in afterload, leading to a decrease in Cardiac output. Together, blood will immediately back up into the lungs, leading to elevated transpulmonary pressures.

MOA of negative pressure pulmonary edema.

Binds to B12 and deactivating it ==> increase in homeocystine

MOA of nitrous causing Megoblastic Anemia?

Nitrous is more soluble than nitrogen, as the blood passes by a space that is air filled (nitrogen), the nitrogen will remain in the space and not be able to leave into the blood as quickly since it isn't soluble. Nitrous will enter the airspace, so now you have nitrogen and nitrous causing the air-filled space to expand.

MOA of nitrous causing an increased size of an air-filled space?

Tugging on eye ball muscles with an afferent response of cillary nerve to cillary ganglia -->CN 5 -->gasserian ganglion with an efferent pathway of CN X to the heart. causing bradycardia.

MOA of oculocardiac reflex?

MOA: Due to uninhibited parasympathetic activity causing billary contraction. Atropine, papaverine, and naloxone can relieve opioid-induced biliary colic.

MOA of opioid-induced billary colic and which medications can be used to decrease it?

Sodium Channel Blocks. Should be given rapid IVP because it block sodium channels in the heart, causing an arrhythmia.

MOA of phenytonin and why should it be given IVP?

Alpha 2 agonist = inhibition of pre-synaptic release of NE.

MOA of precdex?

Working on the Alpha 2 receptors in the vascular smooth muscle.

MOA of precedex causing hypertension with a rapid bolus?

Prostoglandins sensitive peripheral nocioreceptors to mediators like histamine and bradykinni and increase pain transmission in the dorsal horn. Toradol will block Cox =>decrease pg ==>decrase pain.

MOA of prostoglandins in pain?

Positively charged, causing chelation of negatively charged heparin molcules.

MOA of protamine?

BP decrease sensed by the afferent arterole of the nephron --> renin released by the endothelial cells of the JG apparatus-->Angiotensigen (liver) --> Angio I -->ACE (Lungs and kidney) -->Angiotensin II. Angio II = increased SVR & efferent arterole vasoconsitrction.

MOA of renin release and increasing BP?

Renal patients unable to excrete phosphate & unable to make vitamin D resulting in an PTH to be elevated to increase calcium. Often shows elevated phosphate and decreased calcium. Takes supplements to increase calcium and phosphate binders to decrease phosphate.

MOA of secondary hyperparathyroidism?

stablization of the capillary membranes and decrease in CSF.

MOA of steroids like decadron on vasogenic cerebral edema?

Dependent on the severity of the surgery. This causes an increase in CRH & ACTH, Vasopressin, and SNS activation leading to increased catacholmines from the medulla of the adrenal gland. -NE causes inhibition of insulin release. -Peripheral insulin resistance. -Break down of fat and muscle to gain energy over than glucose. -Increased glycogenolysis.

MOA of stress response in surgery?

inhibitory neurotransmitters glycine and gamma-aminobutyric acid (GABA) across the synaptic cleft, leading to generalized muscular spasms characteristic of tetanus

MOA of tetnus toxin?

B/w bifurcation of cartoid. Responds mainly to Pao2 (oxygen tension)-->decrease in-->ventilation increases.

MOA of the Carotid Body

quaternary ammonium group is converted to a tertiary amine by cleavage of a carbon-nitrogen bond

MOA of the Hoffman Elimination.

MOA = Iontropic glumate receptor that functions as non-specific Ion. Plays role in synaptic placity, learning, memory, and pain.

MOA of the NMDA receptor and four roles it plays?

Stimuli at the eye -> ciliary ganglion -> ophthalmic division of trigeminal nerve -> Gasserian ganglion -> trigeminal nucleus -> vagus nerve -> bradycardia.

MOA of the oculocardiac reflex?

Leukocyte antibodies in the donor components activate recipient neutrophils in the recipient's pulmonary vasculature, causing damage and pulmonary capillary leak. Patients may have neutropenia or leukopenia. Leukopenia during TRALI is due to massive agglutination of the leukocytes in the pulmonary microcirculation due to the HLA antibodies in the donor transfusion.

MOA of traili?

Tramadol is a synthetic opioid analgesic which binds weakly to the opioid mu receptors. It also inhibits neuronal reuptake of norepinephrine and serotonin which is thought to mediate some of the analgesic effects.

MOA of tramadol?

Increases intrathoracic pressure --> increases CVP & decreases venous return-->CO & BP decrease -->baroreceptors fire-->reflex increase in HR. When when glottis opens-->intrathoracic pressure decreases -->venous return increases to right side-->BP and CO increase -->reflex decrease in HR.

MOA of valsalava

V1- increases IP3 and DAG leading to increased Calcium release V2 - increases pKA and CAMP

MOA of vasopressin on the vessels?

Fasting ->decrease in glucose -->decrease in insulin so the remaining glucose can stay in the blood and feed the brain. As glucose continues to decrease-->glucagon increases leading to: -Glycogenolysis -Gluconogensis -Lipolysis ---> fatty acid oxidation -->liver to produce ketones --->brain for energy. Body uses fatty acids are energy in starvation. Brain uses ketones are energy in starvation.

MOA stress response of Hypoglycemia

Decrease uterine contractions-TOCOLYTIC. increases uterine blood flow via vasodilation seizure pox in pre-ecalmpsia. 12-15--respiratory depression 15-20--resp. arrest 20-25--cardiac arrest. Potentiates NMB.

Magnesium has what use in OB?

wide QRS and prolonged PR.

Magnesium level of 5-10 causes what kind of ekg changes?

moderate sedation is able to protect their airway with no intervention whereas, in deep sedation, intervention may be required. patient with moderate sedation has adequate spontaneous ventilation whereas a patient in deep sedation, their spontaneous ventilation may be inadequate.

Main difference between moderate & deep sedation?

MAC: -trained anesthesia provider -trained to require patient from all depth of anesthesia. -trained to convert to general anesthesia -trained to intervene when airway is compromised. -Patients must go to a PACU after MAC. Concious Sedation: -physician will supervise or personally administer a sedative and/or analgesic medication. -Not expected to rescue the airway. -Expected to know when the sedation is getting too deep and to stop. -Not expected to go to the PACU after sedation. -Not trained to convert to general anesthesia. Both are physician-derived CPT codes.

Main differences between conscious sedation and MAC?

Unopposed parasympathetic (vagal) activity after sympathetic blockade causes increased peristalsis of the gastrointestinal tract, which can lead to nausea. If the goal is to treat nausea, then anti-cholinergics like glyco or atropine is better than giving the patient phenylephrine since the reason the patient is nausated isn't because they're hypotension.

Main reason for nausea in a spinal case?

-Sepsis or septic shock is a medical emergency. -ABx started within 1 H an continue for 7-10 days. -Source control ASAP. -Crystallioids given for 30 cc/kg in first 3H. If require a lot of fluids, give albumin. -Hydrostartches not recommended. -Txf <7.0 -Vasopressors = NE for map of >65. Add Vaso or Epi.

Major points of surviving sepsis campaign for fluid,pressor, and BP goals?

>59 yo BMI > 32 Chronic liver disease. COPD Emergency surgery High risk surgery Peripheral Vascular Disease.

Major risk factors of developing AKI in non-cardiac surgery?

intersitial Pneumitis. Worsened with increase FIO2 and lidocaine administration.

Major side effect of Bleomycin

1.) elevate the limb. 2.)warm compresses to promote vasodilation. 3.)gault technique--irrigation with saline through an incision. 4.)injection of phentolamine 5.)can perform a stellate ganglion block for the upper limb to promote vasodilation.

Management of Extravasation of vasopressors?

Keep BP and volume up to maintain a big heart. Keeps the anterior leaflet of the mitral valve from going forward.

Management of HCOM?

Decreasing afterload, increasing HR, and maintaining contracility. Sodium Nitroprusside does this by decreasing pre-load and after-load-->decrease in pre-load = increase in compensatory HR.

Managing Aortic Regurg?

fibronogen (factor I) is doubled in pregnancy and turned into Fibrin by factor II to form a platelet plug and eventually thrombus. -other elevated factors: 7,8,9,10,12. -Decreased factors: II, 13, proteins S. Increased resistence to Protein C. -PT/PTT decreased by 20%.

Many factors are increased in pregnancy, making the patient hypercoagulable. What is the most important factor that is increased leading to DVTs in pregnancy?

[(EBV x kg) x (Hct start - Hct Target)] / Hct start

Maximum Allowable Blood Loss formula

-Lidocaine = 5 mg/kg. |. 7 mg/kg -Marcaine = 2.5 mg/kg. | 3 mg/kg -Ropivicaine = 3 mg/kg -Chloropricaine = 12 mg/kg

Maximum allowable doses of: -Lidocaine w and without epi -Marcaine w & without epi -Ropivicaine -Cholorprocaine

MAO-I. Increased risk of serotonin syndrome since it blocks serotonin re-uptake.

Medeprine shouldn't be administered with what other drug?

Glycopyrrolate & atropine work well

Medication used to decrease nausea in spinal blockade after effective BP control?

Spironolactone should be given to patients with an ejection fraction of 35% of less.

Medications to be initiated following a myocardial infarction should be beta-blocker, ACE-I, statin, and aspirin. Spironolactone should be given to patients with what EF?

Because it is mostly renal eliminated, patients in ESRD or CKD shouldn't take their metformin within 24-48H prior to surgery, but patients who are no CKD/ESRD should take their metformin.

Metformin should be continued until the day of surgery except in which patient population?

Reducing the pyruvate dehydrenase and transport of mitochondria reducing enzymes-->results in an increase in anaerobic metabolism. Because of the Pyruvate is shunted into lactate. Worse in acute renal injury and hypovolemic patients, considering Metformin is excreted 90% unchanged by the kidneys and is less likely to cause harm in a patient with liver disease.

Metformin-associated lactic acidosis MOA

Upward and to the left.

Milronone causes what kind of shift in the frank-starling?

Soluable > insoluable agents.

Minute ventilation effects which type of agents in increasing FA/FaI?

1.) Increase Hg concentrations (blood transfusion). 2.) Increased SaO2 3.) Decreased total body oxygen consumption (VO2)- 4.) Increased Cardiac Output 5.) Left-to-right shunt. SvO2 = SaO2 - [VO2 ÷ (CO x Hgb x 1.36)]

Mixed venous oxygen saturation levels are INCREASED

50% mortability.

Mortatality rate for an aspiration event where a patient requires ventilation for >48 hours?

The most common cause of peripheral compartment syndrome is orthopedic trauma with the tibial shaft being the most common location.

Most common area for compartment syndrome to happen?

uterine abruption

Most common cause of DIC in pregnancy?

IgA deficiency is the most common human immunodeficiency.

Most common human immuniodefiency?

common peroneal nerve

Most common injured, isolated nerve?

Ulnar nerve. Mostly happens to either very thin or obese patients, males, and prolonged surgeries

Most common post-op nerve injury?

QTc prolongation (20%, very rarely clinically significant), headache (11%), transient AST/ALT increases (5%), constipation (4%), rash (1%), flushing/warmth (< 1%), and dizziness (< 1%). Zofran not recommended >16 mg IV single dose.

Most common side effects of zofran?

Fetal Bradycardia

Most common sign of uterine rupture is?

A & K varient.

Most common variant of the pseudocholinestrase defiency enzyme?

Pressure monitoring (Column monometery) is required prior to vascular dilation when placing a central venous catheter

Most reliable way to determine that the needle is in the vein during an CVC prior to dilitation is?

GGT is the most sensitive indicator of biliary tract disease,

Most sensitive indicator of billary tract disease?

1.)Age of the patient since it primarily occurs in children 2-6 y.o. other Risk Factors: 2.)Painful procedures 3.)Rapid acting inhalation agents > TIVA (TIVA decrease risk) 4.)Pre-op anxiety.

Most significant risk factor for emergence delirium AND association?

lateral cricoarytenoid muscle = main. With help from Transverse and oblique arytenoids RLN.

Muscles which Adduct (close) the vocal cords?

Sensitive to Non-depolarized blockaged. Resistant to Sux

Myanstheia Gravis patients are resistant and sensitive to which neuromuscular blockers?

Pt. has myotonic contractures leading to slow relaxation of muscles. -SUX could potentially cause worsening contraction. -Diesease is in the muscle itself, not in the nerves.

Myotonic Dystrophy and Sux?

MOA of NMDA receptor antagonists

NMDA receptor allows transfer of pain signals from the neurons to the brain. Blocking this iontropic receptor = decrease afferent pain signals.

Blue/Green (absorbs light @ 660 nm) > black > red (little absorbtion at 660)

Nail polish most likely to cause a decrease in pulse ox?

Soft Palate to base of skull

Nasopharynx starts and ends at?

Depolarized blocked due to increase Ach release.

Neostigmine in excess doses can cause what?

ESRD

Neostigmine is prolonged in which patients?

lateral femoral cutaneous nerve, Femoral nerve, and obturator nerve because they pass under the inguinal ligument and flexion at the ligement causes compression and nerve damage.

Nerves most prone to injury while in lithotomy position are? Why?

Substantia Gelatinosa (SG) of the dorsal horn. Peri aqueductal Gray Matter in the brain stem.

Neuroaxial opioids MOA is what sites?

NO ==> cGMP ==>vasodilates the pulmonary artery ==NO binds to Hemoglobin and is inactivated before it gets to the systemic vessels. Can cause re-bound pulmonary vascular resistance if stopped suddenly. Must be weaned down.

Nitric Oxide MOA on decreasing pulmonary vascular resistance?

Increase pulm vascular resistance. Increases CBF. Decrease in HPV and has diffusion hypoxia.

Nitrous will do what to the CBF and pulmonary vascularure? Respiratory system?

Acute-potentiates chronic-attenutes

Non-Depolarizing Neuromuscular block and phenytonin?

MOA of Echothiophate

Non-reversible antagonist of the Ach-E.

Organophosphates MOA

Non-reversible binding to the Ach-E

pH: 7.28 +/- 0.15 pO2: 15 +/- 10 pCO2: 45 +/- 15 biCARB: 20 +/- 4 Base Deficit: 7 +/- 4

Normal Fetal ABG from umbilical artery?

0.9% has 154 meq of sodium and chloride. Increase in cholride = hypercholremic. H2O dissociates into H+ and OH-, resulting in a excess hydrogen. Thus hypercholremic metabolic acidosis.

Normal saline in high volumes gives you what kind of ABG?

Loose filler cap.

Number one reason for leak in an anesthesia machine?

Phase II.

Obstructive pattern on ETCO2 is due to which phase?

L2-L4. provides sensory to medial thigh and motor innervation to: -adductor longus. -gracillis adductor brevis -pectineus muscles

Obturator nerve made up of which branches?

Potenancy. More soluable an inhalation agent is, most potent it is.

Olive oil solubility of a drug correlates with?

Volume remaining (L) = (gauge pressure (psig) / 745 psig) x 253 L

Once the pressure gauge shows a value below 745 psig, the volume of nitrous oxide remaining at 20 °C can be calculated without weighing the cylinder using the following formula:

Nitrous Oxide. Doesn't de-couple like other inhalation anesthestics which decrease CMRO2 with a mac >1. (less than one, CMRO2 and CBP, ICP are directly correlated)

Only violatile anesthestic that causes an increase in CMO2, CBF, and ICP?

Onset of effect takes approximately 6-8 hours following patch placement while the peak effect occurs approximately 30 hours following placement in healthy patients.

Onset and peak effect of a fentanyl patch is how long?

vertebral arteries and receives contributions from various radicular vessels that arise from intercostal arteries.

Origin of the anterior spinal artery?

Two posterior spinal arteries (PSA) stem from the vertebral or posterior inferior cerebellar arteries (PICA).

Origin of the posterior spinal arteries?

soft palate to epiglottis

Oropharanxy starts at and ends at which anataomical land marks?

DO2 = CO x CaO2 CaO2 = [(SaO2)(Hb x 1.34)] + (0.0031 x PaO2) SaO2, Hb , or PaO2 increase, CaO2 = increased oxygen delivery. Although increases in PaO2 = only produces a slight increase in Cao2

Oxygen delivery to the tissue equation is?

Cimetidine is not favorable because it inhibits which enzymes?

P-450

Oxidation, reduction, hydrolysis of a lipophillic drug.

P450 enzyme Phase I reaction does?

Part of Phase I of drug elimination and it oxidizes drugs to make them inactive.

P450 enzyme is part of which phase of drug elimination and what does it do?

CO2 is linear between 20-80 mmhg. If shifted to the right, it means it is less responsive to CO2. Apenic threshold is increased by inhaled anesthestics & opoids.

PAO2 = FiO2(PB - PH2O) - PCO2 / RQ Where: PAO2 = alveolar oxygen partial pressure FiO2 = fraction of inspired oxygen PB = barometric pressure PH2O = vapor pressure of water RQ = respiratory quotient

>6 yo.

PCAs are recommended after what age to control pain?

Increases intrathoracic pressure, resulting in an increased afterload to the right heart, but a decreased afterload to the left heart.

PEEP will do what to the right and left-sided pressures?

Skin necrosis to bony area.

Padding surgery will decrease

Propofol in particular is thought to cause pain via release of bradykinin and not due to pH or other mechanisms.

Pain associated with propofol is due to what MOA?

First stage only

Paracervical block can provide relief in what stage of labor?

Amniotic fluid in pulmonary circulation results in an inflammatory response leading to vasospasm of the pulmonary artery causing a decreased in cardiac output and right ventricular failure as well.

Pathophys of AFE?

internal capsule,brain stem,spinal cord, peripheral nerves. Requires bite block. Shouldn't be used on patients with increased ICP or cranial abnormalities

Pathway and evaluation for MEPs?

Stimulus -->Alpha-Delta & C-fibers -->dorsal horn -->spinothalamic tract -->contralateral ascend-->thalmus -->cigulate cortex (dull, poorly localized) or post-central gyrus (sharp, localized)

Pathway of Pain?

1.) Resistant to SUX 2.) sensitive to NDMB.

Patient with Multiple Scelorsis. are resistant to _______________ and sensitive to ______________

PaO2

Patient with methyl-globanemia, the only value that will significantly change on ABG after supplemental oxygen is given is?

ritically ill patients appear to be at highest risk for TRALI, especially those with: -chronic alcohol and/or tobacco abuse, -Status post liver transplantation, -being mechanically ventilated with higher peak airway pressures, -patients with positive fluid balance.

Patients increased risk of traili?

The patient at most risk is an older female receiving a large dose of ketamine Risk factors: -Adults > Peds -Females > males. -large dose of ketamine (>2mg/kg) -extrovert/spazy personality. (high Eysenck Personality Questionnaire -multiple meds. Can be decreased by : -Giving Physostigmine or benzos.

Patients most at risk of emergence dillerium with ketamine?

>6 year with diease, co-morbid issues like COPD, Pyridostigmine dose >750 mg/day, vital capacity < 2.9 L.

Patients with MG who will have increased risk of post-op ventilation

latex

Patients with food allergies to tropical fruits (e.g. avocado, kiwi, banana), chestnuts, and stone fruits are at a high risk for what allergy?

1.) Those with space-occupying lesion 2.) Those with limited cross-sectional area of the spinal cord such as spinal stenosis.

Patients with what two catagories are likely to have a neurological injury from neuroaxial anesthesia?

Exaggerated and steep, making it unreliable.

Peripheral Vascular Disease has what effect on arterial line waveform?

Decrease in plasma proteins, increase volume of distribution. Decreased platelet aggregation = thrombocytopenia & increased fibronogen.

Pharmcodynamic changes in burn patients?

1.) oxidation (p450) 2.) Reduction (not mediated by p450) 3.) Hydrolysis (also not mediated by p450) Results in the drug to become inactive.

Phase I of drug metabolism results in what three primary MOA?

Anatomical dead space with little CO2 being expired.

Phase I of the EtCO2 is due to?

a wave = atrial kick. c wave = isovolemic ventricular contraction against the tricuspid valve. x decent = during ventricular systole, the atrial relax, so there is a drop in the atria. V wave = filling of the right atrium. Y = diastolic collapse

Phases of the CVP cardiac cycle?

High. With low calcium.

Phosphate is expected to be what in renal patients?

Blood placed in a cup that occilates back/forth with a stationary pin the middle. Fibrin and platelets form between the wall of cup and the pin, causing the pin to now ossiclate as well, sending information to the computer.

Physics of a TEG?

1.) Elevated thromboxane resulting in platelet aggregation & vasoconstriction. 2.) Increased endothelin 3.) Decreased prostacyclin.

Physiology of pre-eclampsia?

Both a voltage gated and ligand gated receptor. In order to fire, two things must happen: -Glycine or glutamate must bind to its site. -receptor must be in depolarized state. If in resting, non-repolarized state, the receptor is blocked by Mg2+. After the two criteria above are met, the receptor opens, allowing Na+ and Ca2+ influx, with K+ effflux. Ca2+ will allow for activation of secondary messagers.

Physiology of the NMDA receptor

The onset of local anesthesia is related to what?

Pka + concentration

Hypothyrodism > hyperthyroidism (unless thyroid storm presents causing high output HF).

Pleural effusions is more likely seen with what thyroid issue?

Flow = Pressure x pi x R^4 / 8 x visocity x length of tube. -Density is not part of the equation. -most important factor to regulating flow is diameter. -Helium turns turns turbulent flow to laminar flow. -density more related to turbulent flow. -viscocity related to laminar flow.

Poisuelli's Law

Positive lusitropy = increased time spent in diastole and will be down and to the right on the LV volume loop. It decreased LVEDP = allows increase CPP.

Positive lusitropy is represented as what on the LV volume curve and what does it do to LVEDP?

-BUN:Cr- >15% -Fena- >4% -Urine Sodium-40% -Urine osmolality - <350

Post/renal Urine Labs?

-BUN:Cr->20 -Fena-<1 -Urine Sodium-<10 -Urine osmolality - >500

Pre-renal injury labs

Leukoradiation via pre-storage depletion has what advantage that leuokoradiation via bedside filters doesn't have?

Pre-storage avoids the accumulation of cytokines by donor WBC.

PS NS = long pre-ganglionic fibers which release Ach at nicotinic receptors with a short post-ganglionic release of Ach on muscinic receptors. SNS = short pre-ganglionic fibers that release ACH on nACH receptors. with long post-ganglionic fibers that release NE

Pre-synaptic fiber length of the parasympathetic vs. sympathetic?

none

Precedex has what effect on evoked potentials?

Beard, edentulous. Hx of snoring, BMI > 26

Predictors to a difficult mask ventilation

Vasodilation, inhibition of baroreceptor, and negative intropy. Does it the most of our induction agents.

Propofol BP decrease due to.

Lungs. 30%. Kidneys. 30%

Propofol is conjugated by the liver. What other organs help clear it?

Mivacurium, ester LA. Succs as well.

Pseudocholinestrases deficiency causes a decrease in metabolism of which other drugs?

PVR = ((MeanPAP - PAWP (wedge) ) x80 / CO

Pulmonary Vascular Resistance Formula?

MEPs

Pure injury to the anteior spinal cord can be monitored by?

Attempt to rule out Acute hemolytic reactions. If a reaction does occur, it must be reported to the FDA.

Purpose of an a positive direct antiglobulin test?

Which isomer is more potent of causing cardiac side effects of bupivicaine?

R form. More likely to cause cardio toxicity.

Efferent Branch of the laryngospasm reflex?

RLN (innervates entire larynx except cricothyroid)

1/D^2 (d= distance)

Radiation exposure

Raising the transducer (lowering the patient) = decreased blood pressure readings. Lowering the transducer (or increasing height of the bed) = increasing the blood pressure readings. Change will be 7.5 mmHg for every 10 cm.

Raising the transducer of an A-line relative to the patient or lowering it relative to the patient will do what?

Increases diameters and decreases bleeding. Only vasoconstrictor that anesthesizes the nasal passage is cocaine, otherwise no other vasoconstrictor will anesthestize the nasal passage.

Reasons that a vasoconstrictor is used in naso intubations?

-High risk & >4 mets: no further testing needed. -High risk & <4 mets or unknown mets: +pharmacologic stress testing -->cardiac cath.

Recommendations about further cardiac testing:

Sensitizes Ach receptors in the GI tract: -Increases GI emptying. -Decreases volume -No effect on Ph. -Relaxes pyloric -Contracts LES.

Reglan effects on the GI tract?

Renal plasma flow increase & GFR increases due to increase in CR. Clearance.

Renal plasma and GFR do what changes in pregnancy?

Aortic annulus or root rupture.

Repeated balloon dilation can lead to what adverse effect in a TVAR case?

1/radius^4;

Resistance formula

Decrease in tidal volume, resulting in a decrease in minute ventilation with only mild changes in respiratory rate.

Respiratory effects of versed?

TOF ratio of < 0.7: MIP > 25 cm H2O, vital capacity > 15 mL/kg, tidal volume assessment, sustained eye-opening, handgrip, and tongue protrusion.

Responses that suggest a TOF <0.6

Anemia effect on the hemoglobin-dissociation curve?

Right-shift--allows lowering of the affinity of oxygen to Hemoglobin, allowing it to release into tissues.

In the presence of a right to left shunt, inhalational induction will be slower.

Right-to-left shunts will do what to inhalation induction?

caine or benzodiazepine use or abuse, prior intraoperative awareness, history of difficult intubation or anticipated difficult intubation, chronic pain patients using high doses of opioids, ASA physical status IV or V, limited hemodynamic reserve TIVA NMB in the setting of general anesthesia.

Risk factors associated with intraop recall?

uterine rupture include a history of prior cesarean section, grand multiparity, fetal malpresentation, bicornuate uterus, prior myomectomy, and labor induction with oxytocin or prostaglandin.

Risk factors for a uterine rupture.

Both decrease in body and sinus = -Deneveration of cartoid body can increase opioid apnea sensitivity.

Risks of Bilateral Carotid Enterectomy

Proporanlol decreases RVOT obstruction.

Role of proporanlol in Tet of Fallot?

Non-specific symptoms: N/V, weakness. LTFs start to increase @ 35 H and can peak after 3-5D indicating maximum injury. Leading to coag changes, encephalopathy, and jaundice. Labs to obtain: lytes, RFP, and PT.

S/S of tylenol OD and how is it dx?

Which branch supplies sensation to the larynx above the glottis?

SLN-external branch.

-Sweat glands. They have a Musucinic ach receptor. -Chromafinn cells of the medulla--N-ach receptors.

SNS has a short pre-ganglionic and a long post-ganglionic that uses N-ACH receptors which originate from the T1-L2 ganglions. What are the only two exceptions to this?

60 mmHg.

SPO2 is 90%, what is the Pao2?

Snoring Tired during the day Observed apneas Pressure (high blood pressure) BMI > 35 Age >50 Neck size Gender (male)

STOP-BANG

Low VO2: -Cyanide Posioning -Hypothermia. High Cardiac Output: -doesn't give the tissues a chance to extract oxygen. -Sepsis, -L-to-right shunts -AV fistulas -Liver disease.

SVO2 is increased how?

1.). SVR = (MAP - CVP) x 80 / CO. 2.) SVR = (MAP - Right Atrial Pressure ) x 80 / CO. Right Atrial Pressure = CVP

SVR formula

Salt water: -hypertonic -->draws fluid out of the blood stream and into the lungs-->hypovolemia & hemoconcentration (increased hct). Fresh Water: -hypotonic-->draws to absorption into the blood stream & hemodilution, RBC lysis, and hypervolemia. CPR beings with two breaths first, then CPR in drowning patients.

Salt water vs. Fresh water drownings:

cAMP.

Secondary Messanger for insulin and glucagon on hepatocytes?

Just decrease the PaO2 or remove the patient from the Hyperbaric oxygen therapy since patient has oxygen toxicity. Benzodiazepines aren't needed.

Seizures due to hyperbaric oxygen therapy are treated how?

sympathetic blockade first, followed by pain/sensory blockade, then motor blockade last. So, the order of susceptibility to local anesthetics is small myelinated (A-delta, A-gamma) > large myelinated (A-alpha, A-beta) > unmyelinated (C).

Sensations lost of neuroaxial anesthesia first to last.

Platelet Factor 4 test Assay is specific or sensitive?

Sensitive for HITT

Myasthenia gravis response to NDMB vs. DMB?

Sensitive to NBMB | Resistent to Sux (DMB)

SIME pneumotic for SLN branches stands for?

Sensory = internal SLN. |. Motor = Extenral Larngeal Nerve

TNS: -rarely seen after epidural. -sensory pins in the buttock area and lower thights. -resolves usually within one week.

Sensory symptoms s/p spinaL?

Bag & APL on opposite side of patient. FGF closer to patient.

Set up of Mapleson D?

Shorten Non-Depolarizing Blockade: - Anticonvulsants (e.g. phenytoin, carbamazepine) - Cholinesterase inhibitors (e.g. neostigmine)

Shorten NMB time?

The plasma elimination half-life of -diazepam is 20-50 hours -alprazolam is 6-27 hours -lorazepam is 11-22 hours -temazepam is 10 hours - midazolam is 1.7-2.6 hours.

Shortest Plasma elimination Half-life of benzos?

L4-S3

Siatic nerve levels?

Battle sign, Rhinorrhea CSF, Raccoon eyes.

Signs and Symptoms of Cribriform Plate Disruption?

intercostal space > caudal > epidura > brachial plexus, and lastly femoral/sciatic

Sites of greatest to least Local Anesthetic absorption?

avoidance of general anesthesia by utilizing regional anesthesia, use of propofol for induction as well as maintenance of anesthesia, avoidance of nitrous oxide, avoidance of volatile anesthetics, minimization intra- and post-operative opioids, and adequate hydration.

Six known factors known to reduce PONV?

What is the unique physical feature of a microlaryngoscopy tube?

Smaller diameter (5 mm ID), but adult-sized length.

80% CaOh2, 15% H2O, and 4% NaOH.

Soda lime absorbs more CO2 than Barium or calcium hydroxides. What is Soda lime made of?

posterior cricoarytenoid muscle

Sole muscle that abducts (opens) the vocal cord?

halothane > isoflurane > sevoflurane > nitrous oxide > desflurane

Solubility of inhalation agents from most to least

pKa

Speed of onset of LA

1.) Decreased stroke volume. 2.) Maintained C.O. 3.) Decreased SVR.

Spinal anesthesia has what effects on cardiac?

T10-S4 level.

Spinal levels required to cover cervical cerclage?

Spread of local anesthetic within the CSF is primarily determined by the baricity of the local anesthetic solution and patient position.

Spread of Local Anesthetic is primarily determined by?

CYP 34A & CYP 2C9 resulting in ramping up the enzyme and quickly metabolism of: Alfentanil, versed, lidocaine, and nsaids.

St. John Wart specifically works on which P450 enzymes and what drugs can it effect the metabolism of?

-Increased to an FIO2 of a 100% -Deepen the anthestic -Head down patient -Suction airway. -Assess severity of aspiration using fiberoptic bronchoscopy. -Decision to leave LMA and fiber-optically intubate is up to the anesthesiologist. -Add PEEP to open the distal airways with a secured tube only.

Steps to take in an aspiration event with an LMA?

Steroids = work similar to aldestrone. => Na+/K+ pump => sodium retention, potassium into the urine. H+ into the urine ==>resulting in normal or slightly high plasma sodium, hypokalemia, and alkalosis. Results in calcium & uric acid urinary excretion as well.

Steroids result in what sort of electolyte abnormalities to Potassium, sodium, calcium, and hydrogen?

END Diastolic Pressure - End Systolic Pressure

Stroke Volume

-Male > female. - US medical school grade > FMG - Opiods are #1 abused drug. - Family and psych history increases risk of relapse. -Early performance on in-training exams is not associated with an increased risk of developing SUD -Median age is 41.

Substance Use Disorders amongst physicians?

NE, Bradykinnin (ace), ANP, PGD2, e2, F2alpha, LkT, adenosine, ATP, AMP, ADP. Usually the most basic and lipophiilic susbtances are metabolized by lungs.

Substances that tend to be metabolized by the lungs are?

PT/INR

Sugammadex increases which coagulation lab value?

ondansetron, ranitidine, and verapamil and should not be co-administered with these medications.

Sugammadex shouldn't be administered with which three medications?

Arm, elbow, forearm, wrist and hand. Blocks at level of trunks.

Supraclav covers?

ScA puncture, spread of local anesthetic to the stellate ganglion, phrenic nerve blockade (50% of procedures), and recurrent laryngeal nerve blockade. -phrenic nerve block is most common.

Supraclavicular block has the highest incidence of pneuomthorax, what other complications are there and which complication is most common?

Supraclav blocks will block: -Musclocutanous, ulnar, and median nerves. Spares the upper medial arm. -Intracostalbrachial nerve will need to be blocked to decrease the tourniqute pain by injecting local in the Sub-Q tissue of the medial axillary fossa.

Supraclavicular block will block which nerves? What other other nerve must be blocked to prevent torniqute pain?

Mixed venous oxygen (Svo2) saturation is directly related to Hgb, SaO2, and CO. Inverse to VO2.

Svo2 is directly relate to?

R-zero to initial clot formation | width = 2mm in 1-3 minutes. Coag time - speed of clot formation | fibrinogen | 2mm-20 mm. MA - measures strength of clot | platelet & fibrin | 50-60. A-angle: speed of clot formation | 45-55 degrees. fibrinogen. Teardrop configuration -> antifibrinolytics.

TEG values:

TOF ratio between 0.7 and 0.9: MIP > 50 cm H2O, head-lift test, leg-lift test, tongue depressor test, and handgrip (sustained).

TOF 0.7-0.9

TOFC = 1 : >95 percent of nicotinic acetylcholine receptors (nAChRs) blocked ●TOFC = 2 : 85 to 90 percent of nAChRs blocked ●TOFC = 3 : 80 to 85 percent of nAChRs blocked ●TOFC = 4 : 70 to 75 percent of nAChRs blocked

TOF of 1,2,3, and 4 has what percent of receptors blocked?

TOF is higher in a paralyzed vs. non-paralyzed limb. And the response becomes greater with increased NDMB. MOA: Usually >3 weeks, spacstic paralysis = >20% difference in moa 2/2 increased extra-junctional receptors. Seen to a lesser degree with <3 weeks and flaccid paralysis.

TOF response to paralyzed limb vs. non-paralyzed limb?

Antibodies in the donor blood will bind go the recipient WBC, leading to adhering to the capillary bed in pulmonary circulation, causing non-cardiogenic pulmonary edema 6 hours after transfusion.

TRALI MOA

Hyperbaric 5% lidocaine

TRansient neurological symptoms after a spinal is seen mostly with which type of lidocaine?

Increase Ca2+ in the pre-synaptic nerve results in increased ACH release, resulting in a twitch being seen when the NDMB is over-powered.

Tetanic response MOA?

What is orthodeoxia? Where is it seen?

The development of SOB upon changing position from lying down to sitting or standing - opposite of orthopnoea. It is characteristics of hepatopulmonary syndrome.

Iso -most nitrous -least

The loss of awareness and recall typically occurs at 0.4-0.5 standard MAC What agent has the most re-call blocking activity? Least?

intravenous > tracheal > intercostal > caudal/paracervical > epidural > brachial plexus > sciatic/femoral > spinal > subcutaneous.

The rate of systemic absorption of LAs from the injection site

Total pressure remains the same, but volume will be increased.

The vaporizer splits FGF into two compartments. Bypass compartment which the gas by-passes the anesthestic and the carrier compartment-which the gas carrier the anesthestic. What happens to the total pressure and volume of gas exiting?

NDMB-due to quantary ammonium ion on them.

These molecules are also found in some toothpastes, detergents, and shampoos will increase allergy to?

Hypoxia, hypercarbia, pain,

Things that can lead to a Tet Spell in children?

CO VO2-How much oxygen the tissue is using. Oxygen content present in the tissues.

Things that effect Mixed Venous Oxyen?

Things that increase mixed venous blood: means that tissues aren't utilizing the oxygen. -Cyanide toxicity-paralyzed the cytochrome C system. -Hypothermia-reduces the Vo2 of the tissues. -left to right shunt-oxygenated blood bypasses tissues. -sepsis. -cirrhosis patients.

Things that increase Mixed Venous Blood?

1.) SaO2 2.) Low Cardiac Output. -low wedge pressure = hypovolemia. -high wedge pressure = weak heart. Add an ionotrope. 3.)blood content-check hemoglobin.

Things to look for when you have a low mixed venous?

Spironalactone (Aldactone), amiloride, and trianterne.

Three Potassium Sparing Dieurtrics?

There are three elements that compose the BBB - endothelial cells, astrocyte end-feet, and pericytes

Three elements that compose the BBB?

CO, VO2, and CaO2. Should be to 68-77%

Three factors SVO2 is related to and what should it be?

lipid solubility, pKa, and the concentration of the drug.

Three factors that determines onset of an opioid?

Dissolved CO2 Carbamino compounds Bicarbonate Bicarbonate is the majority of CO2 transported in the blood.

Three forms of CO2 transported in the blood? What is the majority?

MOA: Non-gap secondary to 1:1 compensation for bicarb loss with Chloride. Pts. often have elevated chloride, decreased bicarb. Three main causes of non-gap acidosis: 1.). Increase in chloride acids in way of TPN or Normal Saline. 2.). Bicarb loss in way of GI tract or Type II RTA. 3.) Decreased acid secreation: Type I RTA.

Three main causes of non-gap metabolic acidosis? and MOA of it?

risk factors for significant carotid artery disease: age greater than 65 years, presence of a carotid bruit, and a history of cerebrovascular disease

Three major risk factors for significant carotid artery disease?

Decreases in arterial oxygen saturation, hemoglobin concentration, or cardiac output will result in a reduction in SvO2. SvO2 = SaO2 - VO2 / (1.34 * Hb * CO) Factors that lower VO2 (oxygen consumption) will also result in an increased SVO2: hypothermia, sedation, anesthesia, analgesia, and respiratory support (SvO2: mixed venous oxygen saturation in fraction, SaO2: arterial oxygen saturation in fraction, VO2: oxygen consumption [mL/min], Hb: hemoglobin [g/dL], CO: cardiac output [L/min]. 1.34 mL of oxygen is carried by each gram of hemoglobin)

Three major things that lead to a decrease in SVO2 (mixed oxygenation)?

Vagus nerve > non-adenergic, non-cholinergic neurons which release substance P and neuropeptide > and Alpha-adenergic receptors.

Three major ways which bronchoconstriction occurs?

Nicardipine, nitroglycerin, and sodium nitroprusside inhibit hypoxic pulmonary vasoconstriction.

Three medications that inhibit hypoxic pulmonary vasoconstriction.

Phase I: flat-dead space air leaving, not CO2. Phase II: upstroke-dead space + tracheal CO2. Phase III: platue-alveolar CO2.

Three phases of ETco2?

-UA = Urinary eosinophils on U/A -FeNA =pre <1%. | ATN > 2% -Fluid challange= gold standard

Three tests used to determine when pre-renal AKI has become ATN?

hypercapnia, hypoxia, and acidosis all contribute to pulmonary vasoconstriction

Three things that causes pulmonary vasoconstriction?

1.) Airway support, contact closest Cardiac bypass facility in the event that lipid should fail. 2.) Lipid emulsion should be started: -1.5 cc/kg -can repeat 2-3 times if cardiovascular collapse. + 0.25 cc/kg/min infusion for 10 minutes after stability of the patient. 3.) Avoid: Local anesthestics, beta blockers, ca+2 blockers, vasopression. Used amio are the #1 drug for tx. ventricular arrythmias.

Three things which should be done if LAST is known/suspected?

1.) Hosing-placing the hose in between patient's legs, leading to thermal injury. 2.) Reusing the upper body can lead to infection from coagulase-negative staphylococci, which is a major cause of surgical site infections. 3.) Commingling also increases the risk and involves using different manufacturer's pieces together

Three ways the bear hugger can cause patient morbidity?

First has elevated LVEDP and then later on causes dilation leading to aortic regurg.

Time line of Aortic Stenosis?

5 Ts of HITT

Timing (4-10 day), thrombocytopenia, type of heparin, type of patient (surgical > medical), and thrombosis.

1) TRALI, 2) HTRs (non-ABO > ABO), 3) Infection and TAS.

Top 3 causes of transfusion reactions in the US.

small inter-incisor distance <4.5 cm , inability to prognath mandible , limited neck movement by 80% and a history of difficult intubation are more than 95% specific in some studies.

Top predictive values of difficult intubation?

1. Cardiovascular/non-respiratory events. 2.) Respiratory events-difficult intubation, esophageal intubation etc. 3.) Equipment issues/failure.

Top three factors leading to death and law suits to anesthesiologists?

Reduce deadspace. ET increases deadspace with positive pressure ventilation because it will increase the PAo2, thus increase the PAo2 to PaO2 ratio.

Trachs do what to deadspace? ET ?

Trali: -Time: within six hours of transfusion. -MOA: Anti-HLA-antibody mediated, two-time exposure. Seen with mostly FFP & platelets. -S/S: Normal CVP, fever, chills, increased peak pressures, patchy chest x-ray. TACO: -Time: within Six hours of transfusion. -MOA: Multiple transfusions given leads to cardiomegly, increased CVP, increase BNP, and evidence of left- ventricular failure 2/2 CHF-type picture. -S/S: fluid overload. Anaphayalxisis: -Time: within an hour. -MOA: Seen in IgA defiecent patients who recieve IgA pRBC from previous exposure. Should recieve RBC that have been washed or from another IgA defient patient. -S/S: bronchospasm & DIB.

Trali Vs. Taco vs. Anaphalaxtic reaction?

Glucagon

Treating beta blocker overdose?

1.) increasing fresh gas flows 2.) decreasing altitude = decreasing atm = decreasing vapor output. -Partial pressure remains the same with increasing altittude.

Two methods to increase vapor out flow?

-Delay of sample to the lab. =Decreases PaO2 & increases PaCO2 -Air in to the sample. =Increases Pao2 & decreases PaCO2. Placing sample on ICE will decrease distorted samples.

Two most common errors of ABGs?

Shock phase: -24-48 H. -Excessive fluid loss. -increased SVR & decreased CO. Hypermetobolic Phase: -48 H. -increased O2 consumption and CO2 production, increase protein wasting. -Decreased and increased CO. Similar to sepsis patients.

Two phases of Burn Injuries and effects of CO and SVR?

Glycine and GABA

Two spinal cord inhibitory transmitters of pain?

surgeries where compression is impossible (such as intracranial neurosurgery or posterior eye chamber surgery)

Two surgeries where ASA should be stopped.

constipation& pupillary constriction

Two symptoms of opioids that have no change as tolerance increases

1.). Acidic enviroment causing the LA to become more ionized. 2.) Increased blood flow to the area due to inflammation results in washing away of the LA.

Two ways inflammed tissues influence Local Anesthetics?

Treatment of salicylate toxicity includes: 1) Supportive care (beginning with the ABC's of airway and circulatory support) 2) Activated charcoal and/or gastric lavage if recent ingestion 3) Dextrose to avoid CSF hypoglycemia4 ) IV fluids to replace losses from tachypnea and vomiting 5) Bicarbonate administration - Raises systemic pH, decreases tissue distribution of salicylate - Raises urine pH, increases the rate of renal clearance 6) Hemodialysis if severe symptoms

Tx of ASA OD?

- Calcium Chloride to stabalize myocardium unless patient is on dig. -insulin +/- glucose -Loop diuretics or dialysis > potassium binder.

Tx of Hyperkalemia

-Low dose Epi. (Less than 1 mcg) -1mg/kg lipid or a 100 cc bolus and can repeat or start a 0.25 mg/kg lipid drip.

Tx of LAST using epinephrine and lipid?

Null (saying no difference between variables) is rejected when it shouldn't have been. -Basically saying that there is a difference between variables when really there isn't. -Increase false positive. If Alpha = 5%, this means that there is a 5% chance of a type I error.

Type I Error?

Incorrectly accepts null (Ho)-stating there is no difference between variables, when it shouldn't have been accepted. -instead of alpha, uses Beta = false negatives. -Power can be calculated from beta via B-1. -Power is increased by decreasing the Beta = decreasing false negatives. -Type II error is worse in clinical practice than it is in studies.

Type II error?

Remi-non-specific esterases. Esmolol-RBC esterases. Not the same as plasma pseudocholesterases that break down six.

Type of esterases that break down remifentnil? Esmolol?

infants also have poorly developed intercostal muscles and a diaphragm with a higher percentage of type 2, fast-twitch fibers that fatigue more easily

Types of fibers found in pediatric diaphargms?

7.24 / 52 / 22 / 23 /-3 Ph /PCO2 /PO2/Bicab/Base excess. Seen because the umbilical artery is taking deoxyenated blood from the fetus to the placenta and is similar to venous blood. The umbilical vein is the blood returning from the placenta is actually close to arterial blood and used to assess the acid-base status of mom.

Typical ABG sample from an umbilical artery are?

Uncuffed = (Age/4) + 4. Go down by 1/2 size if cuffed.

Uncuffed Tube Size for Pediatrics?

PH < 7.0 an base excess of > 12.0 meq. Base excess and Bicarb are actually better predicitors of neonatal morbidity when the pH <7.0

Under what PH on umbilical ABG does ACOG express concern of fetal hypoxia?

unpaired t-test allows for comparison of two populations with respect to a single variable with continuous data. one population is the group of patients receiving remifentanil and the other population is the group receiving sevoflurane. Our single variable is the mean arterial pressure.

Unpair T-test

Max amplitude of osscilations. Systolic and diastolic BPs are less accurate. Diastolic BP is less accurate than systolic BPs.

Using NIBP what does MAP correlate to?

(Gas flow x VP) / (bariometric pressure - VP).

Vapor output in Ml formula?

Temperature and. It effected by ATM.

Vapor pressure is proportional to what?

paraventicular nucleus & supraoptic nuclei of hypothalmus travels down the hypothal tract ==> posterior pituitary to be stored in herring bodies. Responds to 1.) hyperosmolar 2.) hypotension 3.) volume loss.

Vasopression is stored and produced?

Show an elevated end-tidal nitrogen.

Venous Embolism will show an increase in which end tidal gas?

Zygous and hemiazygous veins.

Venous drain of the bronchial?

Sevo > iso > des > halothane

Violatile anesthestics that preserve hepatic blood flow?

Visocity = laminal flow. Density = turbulent flow. (dependent on grahams' law).

Visocity of gas is more assosicated with what type of flow? Density of gas is more associated with what flow?

Stimulation of the retina via a light -->optic nerve -->optic chiasm --> optic tract--> lateral geniculate nucleus -->optic cortex where the electrodes are. Very affected by anesthetic drugs.

Visual Evoked Potentials are done how? pathway?

Volatile agent blood:gas solubility in order of least to greatest is: Desflurane < N2O < Sevoflurane < Isoflurane.

Volatile agent blood:gas solubility in order of least to greatest is?.

Increase in CSF volume will decrease the spinal spread.

Volume of CSF will influence the spread of a spinal how?

LVEDP

WHat pressure is common between systolic and diastolic dysfunction?

Increase alpha = decrease false negatives. Decrease population variability Increase size make difference between conditions greater = important to decrease type II error.

Ways to increase power?

Lidocaine & Mepivacaine due to its potency and lipidicility.

What LA are more CNS toxic > cardio toxic?

In the first trimester, maternal heart rate increases and accounts for the 35-40% rise in cardiac output. During the second and third trimester, stroke volume increases.

What accounts for the increase in cardiac output during the 1st, 2nd, and 3rd trimesters?

The Hofmann elimination reaction proceeds more readily when pH and temperature are increased. Will need less redoing in patients are acidotic and cold.

What allows the hofmann elimination to proceed more rapidly?

Fospropofol has a common side effect of parathesia which are localized to the buttock and genitals. Also puritis that is localized to the genitals.

What are common side effects of fospropofol that aren't seen in propofol?

Low-tissue penetration—deeper penetration. High-tissue resolution.

What are high and low frequency used for on Ultrasound?

Grinding murmur on pericardial examination & sudden increase in CO2 before cardiovascular collapse.

What are signs and symptoms of CO2 embolus?

-LMWH should not be started in a BID ppx or a therupetuic dose. -LMWH can be started once daily, but have to wait 12 hours after the epidural cath was placed.

What are the ASRA guidelines about what to do if an epidural cath is left in place and you want to start LMWH?

Concentration of N2O and timing of N2O. At 50% N2O for 4 hours = 200% increase | 75% = 3x increase | 80% = 5x increase. MOA: N2O more soluable than nitrogen, so it diffuses into the area before nitrogen can leave.

What are the factors that lead to N2O bowel distention and how large can it get?

Diastolic then systolic RMA are first seen on TEE before EKG changes.

What are the initial changes seen on intra-op myocardial ischemia?

Ph, PaO2, and PaCO2 are measured. Bicarb & base excess = calculated.

What are the measured values on a blood gas? Calculated?

Tongue & lips go numb -->Tinnitus & blurred vision -->dizzy -->Muscle twitch --> seizures -->unconsciousness. If patient has a benzo or a barb on-board, can't tell you if tongue goes numb, so initial symptoms may be cardiovascular collapse.

What are the signs and symptoms in order in a patient with LAST?

metabolic acidosis, rhabdomyolysis, congestive heart failure, and bradycardia

What are the signs and symptoms of Propofol Infusion Syndrome?

Fentanyl & methodone.

What are two of the safest opioids in ESRD?

zona glomerulosa

What area of the medulla is aldestrone secreted from?

Caudal

What block provides good relief for first and second stage of labor?

leukoreduced blood products. It's the process of ridding WBC from blood products.

What blood sterlization technique can decrease febrile reactions, reduced levels of inflammatory mediators, and reduction of cytomegalovirus (CMV) transmission, decrease TRALI?

Verapamil. Can cause a leather hyperkalemia and myocardial depression.

What calcium channel blocker is dantrolene specifically contraindicated with?

Potentiate it since it is an anti-chol-estrase medication and can also block plasma cholenestrases.

What can Echothiophate do to sux?

Metoclopramide inhibits plasma cholinesterase and can increase the duration of action of succinylcholine.

What can Metoclopramide do to sux?

Cause worsening renal injury due to decreased renal blood flow.

What can Nore-Epi do to the kidneys in a hypovolemic sepsis patient?

Adding nasal cannula oxygen can improve pre-oxygenation before rapid sequence induction and can also provide apneic oxygenation during laryngoscopy

What can be added to improve pre-oxygenation in a RSI?

Place wires distal from the site being imaged, avoid contact with patient, keep wires in a straight line down the middle of the MRI, and do not coil. EKG leads > pulse leads to cause burns. MRI can get loud so ensure hearing protecting for patient.

What can be used to decrease risk for burns in MRI?

Deep breathing causing the MV to exceed the L/minute being delivered by the anesthesia machine. Example: Pt. breathing 4 large breaths to pre-oxygenate in 30 seconds, will breathing about 40 L/minute, which would exceed a 15 l/min FGF being delivered by the anesthesia machine.

What can cause rebreathing of CO2?

Adequate anticoagulation (ACT >250)

What can help decrease occlusion during balloon deflation and sheath removal?

SVR

What cardiac parameter decreases in pregnancy?

Decreased Mixed Venous Oxygen Concentration = <75% which means that the body is consuming more oxygen than it needs before returning to the Pulmonary Artery where SVO2 is measured and is due to: 1.) increase body energy (hyperthermia, shivering). 2.) Decreased Cardiac Output ==>decreased o2 getting to the tissue, requiring more oxygen demand. 3.) Decrease Hg concentration (anemia). 4.) Decreased Pao2 SvO2 = SaO2 - [VO2 ÷ (CO x Hgb x 1.36)]

What causes a decrease in Mixed Venous Oxygen Concentration?

Inodilator therapy results in both an increase in lusitropy and an increase in inotropy. This effect can be seen with phosphodiesterase type 3 inhibitors, such as milrinone.

What causes the this change?

Hepatocytes(glut-2), most immune cells, erythrocytes(glut-1), and brain neurons(glut-3) utilize insulin-independent glucose transporters for the majority of their glucose uptake.

What cells don't depend on insulin uptake?

Dopamine 2 receptor antgonist (same as reglan).

What class drug is droperidol?

Plasma - 11 liters. 25% of the ECF volume. 16% TBW + Intersitial fluids - 3 liters. 80% of the ECF volume. 4% TBW. = 1/3 of the body water. ___________________________________________________________________________________ Intracellular fluid = 40% TBW. 28 L. = 2/3 of the body water.

What comprises the Extracellular Fluids?

-anemia -high-altitude -hypoxia -heart failure -liver cirrhosis -sleep apnea syndrome.

What conditions increase 2,3 DPG and thus change the Oxy-hg dissociation curve to the right?

thebesian venous network., IVC, SVC, and coronary sinus

What contributes to SVO2?

Deceased PAF-3 activity, abnormal adhesion

What contributes to platelet issues in renal failure?

Lipid soluability. Less soluable opioids = longer duration of action.

What correlates to duration of action of opioids?

Lipid

What deals with potency of the LA?

Tissue protein binding

What determines the duration of LA?

Lipid

What determines the duration of neuroaxial opioids?

NMT monitor and Mechanomyography devices used to determine TOF > 75: T4:T1 height ratio of 0.75 typically guarantees (1) a sustained head lift for 5 seconds, (2) the ability to generate a vital capacity of 15-20 ml/kg, (3) an effective cough to clear secretions, and (4) a negative inspiratory force of -25 cm H2O.

What devices best determine a train of four ratio of 0.75 and what does it correlate to clinically as seen in the patient?

Posterior vision of the femoral nerve.

What division is the saphenous nerve of?

All intravenous anesthetics except ketamine cause a decrease in CMRO2 and a decrease in CBF. Fentanyl has no effect on CMRO2 or CBF.

What do IV anesthestics do to CBF and CMRO2?

Ramps it up.

What do anti-convulsants like Dilantin and Carbmazapine do to p450?

Causes resistance to medication.

What do anti-seizure medications such as Dilantin and carmazapine do to Neuromuscular agents?

Inhalational anesthetics at ≥1 MAC increase CBF and decrease CMRO2, causing an uncoupling of the flow-metabolism relationship.

What do inhalation agents due to Cerebral Blood Flow and Metabolic rate?

1.)RCA-->RA, RV, inferior LV, SA & AV node. 2.)lateral circumflex. 3.)V3-V5-

What do the leads below detect? 1.) II, III and aVF 2.)I, aVL 3.)V3-V5

Attenuate it.(reduced).

What do violate anesthetics do to Hypoxic Vasoconstriction?

Increased CVP, leading to decreased CO, decreased pre-

What does Abdominal Compartment Syndrome do to CVP?

Used for etiologies of memorizing anion-gap metabolic acidosis: 1.) M-Methonal. 2.) U-uremia. 3.) D-DKA 4.) P-propolyne glycol 5.) I-Isonizide 6.) L-Lactic acidosis 7.) E-Ethylene glycol 8.).S-Lactic acidosis

What does MUDPILES stand for?

PPV measures pre-load and fluid status. Especially if >13%. (PPmax - PPmin) / PPmean. For example, during peak inspiration, a patient's blood pressure is 120/70 (PPmin = 120-70 = 50) while at end expiration, it is 150/85 (PPmax = 150-85 = 65). Then, PPV = (65-50) / [(65+50)/2] = 0.26 or 26%.

What does PPV measure and how is it calculated?

increases it

What does SUX do to lower esophageal sphincter tone?

Static tells you more of the lung compliance. calculated via when there is no air flowing through the system. Uses VT/platue pressure - PEEP. Dynamic Respiratory Compliance is an indicator of resistance. Calculated when there is air flowing through the system. Uses VT/(peak pressure - PEEP)

What does Static resp. compliance indicate vs. Dynamic respiratory compliance?

Mildly decrease platelet concentration, but increase platelet aggregation.

What does Vasopressin do to platelet concentration and aggregation?

Decrease of albumin = more free drug avaible = requires a lower dose in the opioid and benzos which are protein-bound.

What does a decrease in albumin result in as far as dose for opioid and benzos?

They need a higher loading dose to put them to sleep. Most of the time based off of their IBW

What does a larger VD in Obease patients mean?

1 palpated twitch indicates >90% suppression. 2 palpated twitches indicate 80-90% suppression. 3 palpated twitches indicate 70-80% suppression. 4 palpated twitches indicate up to 65-75% suppression. Palpation of twitches using TOF testing cannot detect the percentage of receptors bound at < 65%.

What does a palpation of 2/4 indicate how many receptors are blocked?

Dead space remains constant, but tidal volume decreases. Ratio will go up.

What does a violative anesthesia do to the dead space to tidal volume ratio?

1.) own 2.) Decrease

What does autologous? What does attenuate mean?.1.

Cryoprecipitate is high in factors 8 and 13 as well as fibrinogen and von Willebrand factor (vWF). limited antibody concentration contained within it, so no ABO incomptability needed.

What does cryo contain? Why doesn't cryo need to be screened for ABO incompatability?

Doesn't change the concentration of the agent delivered, but decreases the partial pressure of the agent. Therefore higher elevation require the operator to manually increase desfurane concentration.

What does decreased ambient pressure ( high altitude ) do to the concentration of desfurane??

Ramps it up.

What does grape-fruit juice or anti-acids do to the cyp 450?

Sux can progress from Phase I to Phase II. In phase II, the membrane has repolarized, however not sensitive to Ach. In order to sensitive it to ach, a low dose (0.03 mg/kg) of neostigmine is recommended to only antganize the Ach-E and not the pseudocholinestrase.

What does is required to reverse a phase II block in atypical pseudochole defiency?

Things that cause a left shift means it will hemoglobin will hold on to oxygen and not oxygenate the tissues very well.

What does it mean to have a left-shift oxygen curve? What about right shift?

Preserved respiratory drive and laryngeal reflexes. Reflexes may be less protective with higher doses.

What does ketamine do to laryngeal reflexes?

Potentiate it.

What does lasix due to Neuromuscular blockade?

prolongs their action

What does lithium do the NMBD and sux?

Cause a left shift due to the F2-->F3+. Causing an increased affinity of the remaining oxygen on the hemoglobin.

What does meth-hg do to the oxygen dissociation curve?

10% of the ED95 or 0.03 mg/kg. Can lead to decrease in intraabdominal pressure = less risk for aspiration when sux is given.

What does of rocuronium will prevent faciliculations form sux? Why give it?

Oxygen dissolved in blood + oxygen bound to Hemoglobin. About 20% of oxygen per 100 cc of blood. 1 met = 250 cc of O2/min.

What does oxygen content represent?

Decreases minute ventilation by decreasing tidal volume >>> respiratory rate. Respiratory rate is increased. and results in a depressed response to breathing

What does propofol do to respiratory mechanics?

It is a GI Prokentic -->increase pylorus and deudunum activity. Decrease LES to tone. Results in decreased volume without decreased PH.

What does reglan do to the GI system?

Increase afterload, which will increase SVR and allow blood to to be shunted left to right, instead of right to left. This allows blood to go through the stenosed PA into the lungs. Abdominal pressing will cause an increase in preload and afterload.

What does squatting or pressing on a patient's abdomen with TOF do?

R time measures the level of clotting factors (the intrinsic coagulation pathway, extrinsic coagulation pathway and final common pathway)-until fibrin is formed.

What does the R-time on the TEG measure?

Stroke volume (multiple by heart = CO)

What does the area under the curve represent on an arterial wave form?

Double Peak sign from a single-lung transplant of a COPD patient. -Peak 1 = due to the healthy transplanted lung breathing -Peak 2 = due to the existing COPD lung exhaling.

What does this capnography represent?

sodium citrate

What drug is best to be given to neutralize stomach PH in pregnancy women before c-section to reduce aspiration risk?

Works mostly on short acting like lidocaine. Doesn't have much effect on bupivicaine or other long acting local anesthetics.

What duration of local anesthesia does epinephrine work to prolong?

Decreases VIII and vWF

What effect does hetastartch have on clotting factors?

Hypokalemia

What electrolyte should be fixed with dig toxicity?

If the patient is opioid naive vs. chronic pain patient since opioid naive patients can have adverse outcomes from background infusions resulting in things such respiratory depression. a background infusion in opioid-tolerant or pediatric patients may be effective.

What factors should be considered in PCA background infusion doses?

Nitrous Oxide, CO2, propane. For example, 400 L/1600 L would need to be depleated for the pressure gauge to fall from 745 PSI.

What gases are a liquid state and better to be determined via weight > pressure gauge of how much remains in the tank?

Life support machines causing the line isolation monitor to sound should not be unplugged. However, nothing else should be plugged in for the remainder of the case.

What happens if the faulty piece of equipment such as a cardiac bypass machine is connected and causes the line isolation monitor to go off?

Blood pHDecreasedIncreasedAcidemia with carbonic anhydrase inhibitors, K+ sparingAlkalemia with loop diuretics, thiazides

What happens to Blood PH with potassium sparing diuretics?

Increases with age and will surpass FRC around 60 yo.

What happens to Closing Capcity with age?

As humans age, the lung parenchyma loses its elasticity and becomes more compliant, resulting in an age-related increase in FRC

What happens to FRC over time?

-PaCO2 doesn't change as one ages. -PaO2 tends to decrease because of increasing CC to FRC and Decreased alveolar surface area.

What happens to PaCO2 and PaO2 as one ages, and MOA of their changes?

CNS: - Decreased epidural space - Decreased CSF volume - Increased permeability of dura mater. CV: - Decreased beta-receptor responsiveness - Increased sympathetic nervous system activity Resp: - Decreased vital capacity - Increased residual volume - Increased closing capacity - Increased anatomic dead space - Increased lung compliance - Increased pulmonary vascular resistance Liver: -Decreased hepatic blood flow

What happens to aging with: -CNS? -CV system? -Respiratory System? -Liver?

Decreased beta receptor and baroreceptor sensitivity-resultign in an increase in circulating NE.

What happens to beta receptors in elderly?

Infants comprised of 70-75% H2O. As one ages, the water weight decreases to 50% due to an increase in adipose tissue.

What happens to body water as one ages?

They're unchanged.

What happens to central pressures in pregnancy?

Increased

What happens to plasma volume in pregnancy?

CO decreases, resulting in Hg-OXygen curve to shift from left to right., allowing for more oxygen off-loading to the tissues.

What happens to the Oxyhemoglobin curve after smoking cessesation in as little as 48 hours?

It's blocked. Example-it you need to hyperventilate to increase oxygen, you won't.

What happens to the ventilatory response with inhaled anesthesia?

Increased free water = increase in Volume of Distribution. Water soluable drugs would need to be increased to have the same effect. Other conditions include renal failure patients.

What happens to water soluble agents such as rocurionium in liver failure or CHF?

Because ISo has a higher VP than sevo. Adding Sevo will actually decrease the vapor output.

What happens when you add Sevo to an Iso vaporizor?

Neck flexion and in a trend position.

What head position will yield an increased diameter of the IJ in CVC placement?

This autoregulation is impaired with spinal anesthesia and volatile anesthetics

What impairs the auto-regularity blood flow of hepatic circulation?

COPD Old age

What increases FRC?

Giving a second dose of sux within five minutes of the initial dose will increase risk of bradycardia in both adults and children. MOA is due to metabiltes of the initial sux dose (succinylmonocholine and choline) causing myocardial senstiization to parasympathetic effects of sucs.

What increases risk of sux and bradycardia?

More soluable agents. MOA: Blood sweeps away the alveolar concentration of the agent quickly. Increasing Minute ventilation will result in a replacement of inhalation agent into the alveoli resulting in an increase of Fa/Fi ratio. MV Effect is less for insoluable agents.

What inhalation agents are most effected by changes in minute ventilation (tidal volume x rr)?

Hyperextension injuries

What injury to the neck results in compressive forces on the posterior column with destructive forces on the anterior column.

Taking blood from the patient prior to major bleeding, diluting it down, and storing it for time of need when bleeding occurs. Causes decrease in vicocosity of blood = leading in peripheral vascular resistance = increase in CO and increase in regional blood flow. Doesn't increase oxygen content within the blood to deliver to tissues.

What is Acute Normovolemic Hemodilution?

Paradoxical bradycardia may occur during severe acute hypovolemia during anaphylaxis due to the Bezold-Jarisch reflex. -Bezold-Jarisch is due to stretch receptors in the left ventricle which are activated resulting in a vagal response and thus bradycardia.

What is Allergic Angina? MOA?

Closed circuit anesthesia is a type of low-flow technique using a circle system in which the total fresh gas flow (oxygen and inhalational anesthetic) is equal to oxygen consumption and inhalation agent metabolism. No gad is vented throught the APL into the svanaging system.

What is Closed Circuit Anesthesia?

Conduction through the heart. Decreased by vagus nerve.

What is Dromatrophy?

Eutectic mixture of local anesthetics, and it is comprised of a mixture of lidocaine and prilocaine Contraindicated in: -Allergy to Amide Anesthetics. -Pts. on class III Antiarrythmics as it can cause a synergic effect and lead to an arrythemia. -Congential methglobinemia 2/2 to the prilocaine in it causing increase methy-hg. -Infants < 12 months

What is EMLA and it's contraindications?

At end of tidal volume, the amount of air that can forcilibly be expired out until you reach RV.

What is Expiratory Reserve Volume?

Air left in the lungs at end of tidal volume. When the lung recoil and chest recoil are in equailbrium. 30 cc/kg for adults. = ERV + RV -10% less in females than males.

What is FRC?

Gas in your lungs at the end of a normal expiration. Example--push propofol, patient became apenic Use FRC.

What is FRC?

short-acting dopamine type 1 receptor agonist that causes profound peripheral vasodilation via cAMP stimulation

What is Fenoldopam?

arms are flexed quickly to the chest from the patient's side, the shoulders are adducted, and in some patients, the hands are crossed or opposed just below the chin. -seen during brain death exams usually when during the apenia test or hypotensive epsodes

What is Lazarus sign and when is it mostly seen?

Herbal supplement derived from the ephedra plant, leading to symptoms of HTN and tachycardia.

What is Ma-huang

When the jaw tenses and muscles remain flaccid. Can be an early sign of MH. Doesn't always progress to MH, but need to be monitored for 24 hours after in the event that it does proceed to MH. Can resolved within 20 minutes: Risk factors: inadequate dose of succinylcholine, inadequate time for onset, side effect of other induction medications (etomidate, high dose synthetic opioids), temporomandibular joint dysfunction, Duchenne muscular dystrophy, myotonia congenita, possibly other muscle disorders

What is Masseter muscle rigidity (MMR)

AKA lateral cutanenous nerve injury of the thigh. Purely motor 2/2 to stretch/compression. Seen in pregnancy or gyn surgery due to retractor compression.

What is Meralgia Paratherica?

Saturation of Hemoglobin in the Pulmonary Artery. It is an indirect measure of Oxygen Content in the venous system.

What is Mixed Oxygen Venous Saturation?

percentage of oxygen bound to hemoglobin in the blood returning to the right side of the heart from SVC, IVC, and coronary sinus. Best measured in the PA. Should be 75%. SvO2 = SaO2 - [VO2 ÷ (CO x Hgb x 1.36)] SvO2 = mixed venous oxygen saturation SaO2 = arterial oxygen saturation VO2 = total body oxygen consumption CO = cardiac output Hgb = hemoglobin concentration

What is Mixed Venous Oxygen Saturation (SvO2)?

pH stat = temperature adjusts the ABG sample to the patient's body temperature. Beneifical in hypothermic cooling of pediatric patients. Alpha Stat = ABG is warmed to 37 degrees and doesn't correct for what the patient's actual temperature is. Better for adults on cardiac bypass.

What is PH-Stat and Alpha-Stat ABG?

Preload in left ventricle or LVEDP

What is PWCP a surrogate of?

Law that determines the flow through a tube assumning: -Laminar flow is present -Liquid or air is compressible. -Constant cross-sectional airway Resistance = 8ηl / πr4 --> removing constants = Resistance = viscosity * length / radius^4

What is Poiseuille Law?

Higher the Reynolds number, the more turbulent flow in a tube. Reynolds number = velocity * density * diameter / viscosity. When flow rate or velocity increases, turbulent flow is more likely

What is Reynolds number?

Amount of oxygenated Hg returning to the right heart. SVO2 = Sao2 - [ VO2=oxygen consumption / CO x Hg x 1.36 ] Things that increase SVO2: -Increase Hg -Increased oxygen saturation. -decrease Oxygen consumption. -decrease CO.

What is SVO2?

It upregulates serotinin, dopamine, and nore epi to decrease depression symptoms. Pharmacological effects is that it increases metabolism of the cyp 450 in the liver, resulting in faster metabolism and decreased effect of drugs such as wafarin, lidocaine, anfentanil, cyclosporin, and versed. It should be stopped five days prior to surgery.

What is St. John Warts usually used for and what pharmacological consequences does it have?

- TPN = Feeds thru a central line or IV. - Hyperglycemia - Hyperinsulinemia - Hypercarbia - Hypophosphatemia - Hypokalemia - Hypomagnesemia - Fatty liver

What is TPN and what are some of the electrolyte derangement & side effects you may see?

Difference between cations and anions. If 0.9% NS is given, it will decrease the SID, because it has a lot of chloride. Tips the electrical neutrality, resulting in water to dissociate into H+ ions. Leading to hypercholremic metabolic acidosis.

What is a Strong Ion Difference and how does sodium chloride effect it?

Ball which is in the flow-meter. Tapered at the bottom. As flow increases, the cross-sectional area will increase as well. -Turbulent flow is considered above the bobbin. -Laminar flow is below the bobbin. -Density and viscocity of a gas is not affected.

What is a bobbin rotometer?

Compressive force to the vertebral body.

What is a burst vertebral fx?

Should be 65-70%, if less is due to increase tissue oxygen extraction due to decreased oxygen delivery to the tissue. Can be due to: 1.) Decreased Hg content. 2.) Lung disease. 3.) Decreased cardiac output 4.) Increase oxygen consumption by the tissues such as fever, exercise. 5.) C.O.

What is a decreased Mixed Oxygen Venous Content represent? What are things that lead to it?

Inner wrist acupuncture.

What is a holistic intervention that can lead to a decrease in post-op nausea, vomiting?

30. Decreased with a decrease in lung volume or capillary bed perfusion. -pneumonectomy -emphesema -pulmonary embolism -Low CO -Right to left shunt Increased DLCO? -CO high -Hg high -CHF -L to Right shunt

What is a normal DLCO?

T.E.E.-which detects RWA. These arise before ischemic changes are seen on the EKG.

What is a sensitive of detecting intra-op myocardial ischemia?

product of the density of a medium and the propagation speed of sound through that medium. Density change on ultrasound, between two mediums, results in decreased imaging in far field. impedence is Decreased by ultrasound gel.

What is acoustic impedance mismatch"

Drug volume is more important for epidural > spinal spread.

What is an important factor for epidural spread vs. spinal spread?

Patients who have an increased amount of cyp p450D that metabolizes codiene to morphine very quickly and in a high concentration.

What is an ultra rapid metabolizer patient?

Resistance is associated with laminar flow and most important determinant. In order to allow oxygen to effectively pass, there needs to be a decrease in viscocity. Heliox won't work for this, because it has a similar visocity to air and oxygen. Formula =Resistance = 8*(length)(viscosity)/(π * r^4)

What is associated with laminar flow?

-Auto-Peep: End expiration has air left in the alveoli before the next inspiration. MOA: Due to forced expiration leading to airway collapse, compliant airways leading to collapse with expiration, or simply just too much volume and not enough time to get it out before the next inspiration. Consequence: baro trauma, decrease CO d/t increasing right to left intra-thoracic pressure, Fix: by decreasing tidal volumes, RR, and increase I:E time. If emergency remove the expiratory limb of the circuit

What is auto-peep, how does it come about, consequencues, and how to fix it?

Hypotension, JVD, and distant heart sounds in cardiac tamponade.

What is becks triad?

Median is least effected by outliers and best used as a central tendency.

What is best way to determine central tendency when you have skewed data, such as outliers? For example, you have a group of patients who are adults and some who are pediatrics? Their ages range.

PAO2 and the PaO2 (A-a gradient and A:a ratio), a determination of oxygenation can be made. A normal A-a gradient is < 10 mm Hg, and a normal a-A ratio is >0.75.

What is considered a normal PAO2/Pao2?

Emergency = within six hours. Urgent = within 24 hours Time sensitive = 1-6 weeks. Elective = 1 year.

What is considered an: -Emergency case? -Urgent case? -Time sensitive case? -Elective case?

Nominal-gender, eye color, etc. Ordinal-pain score. Measured via a chi square test.

What is considered nominal data vs. ordinal data? How are they measured?

Elevated risk procedure: risk of MACE is > 1%

What is considered to be an elevated risk procedure from a cardiac standpoint?

Increased CO2 over time & decreased pulse ox, increased PIP, and absent lung sounds. Usually seen in kids d/t shortened trachea.

What is expected with Endobronchial intubation?

Post-administration volume expansion is more important than pre-procedure hydration.

What is important in patients with Contrast Induced Nephropathy?

Fibrinolysis

What is indicated by an elevated Ly 30 on a TEG?

Time it takes to get to the brain from the site which the signal was procuded. Monitor posterior sensory columns

What is latency in SSEPs? What do they monitor?

-Low TV -keep the platue pressure low. -Low FIO2 -Increased PEEP

What is lung-protective ventilation?

range

What is most influenced by outliers?

Negative lusitropy occurs with diastolic dysfunction, causes an increase in LVEDP = decrease CPP.

What is negative lusitrophy and effect on CPP?

Oxygen Diffusion is the passive movement of oxygen from areas of high oxygen to low oxygen. Seen when oxygen moves from the alveoli to the blood. During exercise, there is expansion of the lungs resulting in a less surface area of diffusion, recruitment of capillary groups, and increase in TV in way of decrease IRV.

What is oxygen diffusion and how is it increased during exercised?

Increases both SVR and pre-load.

What is phenepherine not good for CHF?

Agent's partial pressure, which can change with altitude.

What is potency of an inhalation agent dependent on?

Potency is the relative dose of two drugs. For example fat now is more potent than morphine

What is potency?

Potassium binder. Works within one hour of administration for hyperkalemic patients.

What is sodium zirconium cyclosilicate and how fast does it work?

10 mg IV morphine = 1 mg of epidural morphine = 0.1 mg IT morphine.

What is the 10 mg of morphine equal to in the epidural and intrathecal?

PAO2 = PIO2 - (PACO2/R) | V PiO2 = FiO2 * (PBar - PH2O) PBar = Barometric pressure (760 mm Hg at sea level) PH2O = Vapor pressure of water (47 mm Hg at sea level)

What is the Alveolar Gas Equation?

Seen with Spinal Anesthesia due to an acute drop in pre-load ==>parasympathetic-mediated reflex 2/2 stretch receptors in the left ventricle responding to a decrease pre-load ==>decrease HR to allow for increased filling time.

What is the Bezold-Jarisch Reflex?

Leads placed in the right atrium & right septal apex, causing an EKG pattern of a pacer spike prior to the P wave and then a LBBB-type QRS because the RV fires before the left ventricle.

What is the EKG pattern for a dual-paced pacemaker?

prevents overinflation of the lungs. When subjected to excessive stretching (e.g. during CPAP or PEEP), pulmonary stretch receptors trigger the reflex which temporarily prevents inspiration and allows expiration to occur. There is no effect on heart rate

What is the Hering-Breuer reflex?

Cross-reactivity between penicillins and cephalosporins arises from the common beta-lactam ring and common R group side chains. About 2% or less of patients with skin-proven penicillin sensitivity will have a reaction to cephalosporins.

What is the MOA of cross-reactivity between PNC and cephlosporins?

Cyanide toxicity is another example of impaired peripheral oxygen utilization where SvO2 is elevated despite evolving tissue hypoxia and lactate production.

What is the SVO2-mixed venous o2 saturation-of a patient with cyanide posioning?

Sevo-160 mmgh Elfurane-175 mmgh Iso-238 mmhg Des-669 mmgh Halothane-241 mmgh

What is the Vapor Pressure of Sevo? Elfurane? Iso?Des?Halothane?

Bolus is given -->When atrium is stretched and filled-->atrial receptors are stimulated--> heart rate increased.

What is the bainbridge reflex?

Used in SPO2 which states the concentration correlates with light absorption.

What is the beer-lambert law?

Alpha-1 constriction

What is the benefit for epi in cardiac arrest?

Tylenol. Epidural blood patch is reserved for post-dural puncture headaches, not post-spinal headaches. Post-spinal headaches usually stop after about 7 days.

What is the best initial treatment for a post-spinal headache?

V.V.I

What is the best mode after electrocaudary is no longer being used?

100 mA

What is the current of the fibrillation threshold?

-dibucaine can inhibit plasma cholinestrase. indicates the percent inhibition of enzyme activity by this agent when a serum or plasma sample is tested under standard conditions If it inhibits it by 80% = normal. -40-60% = heterozygous for plasma cholinestrase -20= homozygous loss for plasma cholinestrase

What is the dibucaine number?

How leaky the capillaries are.

What is the filitration coefficient determine?

Cerebral Perfusion Pressure = MAP - ICP or CVP. Should be maintained around 50-70

What is the formula for cerebral perfusion pressure and what should it be maintained at?

Pulse Ox.

What is the gold standard in kids to assess respiratory status?

Onset: 6-10 minutes. Half-life: 12 seconds. Blocks nerve conduction: 30-60 seconds.

What is the half-life of 2-chloroprocaine? How long dose it last? what is the onset time?

portal venous blood flow decreases, the hepatic artery vasodilates resulting in increased hepatic arterial flow. Changes in hepatic artery blood flow do not induce reciprocal changes in the portal venous system. MOA: Adenosine will accumulate as PV flow decreases. This results in vasodilation in the hepatic artery. As PV flow increases, adenosine is washed away resulting in hepatic artery vasoconstriction in a adenosine wash-out hypothesis

What is the hepatic arterial buffer response?

Relaxes the vocal cords to decrease pitch (deep voice). RLN.

What is the job of the thyroarytnoids muscle of the vocal cords?

Hyper: seen in kids, daily attacks. Hypo: late childhood-early adult. Attacks less often. Carbonic anhydrase can be used to treat both hyper and hypokalamic attacks.

What is the key differences between hyperkalemic paralysis and hypokalemic paralysis?

Plavix is a pro-drug that is activated by CYP 2C19. Prasugrel is not a prodrug.

What is the main difference between plavix and Prasugrel, another ADP receptor antagonist?

Mesure of lipid solubility in relation to potency of an inhalation agent. Mac also used as a measure of potency. Lower the mac, more soluable the agent, and more potent it is. Differs from the blood:gas coffiecent which discusses speed of onset.

What is the meyer-overton correlation?

thrombosis

What is the most common complication of Brachial Nerve placement?

Sufentil > fentanyl > alfentanil > morphine

What is the most lipid soluble opioids from greatest to least?

Halothane-Caffiene contracture test. More sensitive than genetic testing because all the genes associated with MH haven't been found yet. Not specific as it has a 20% FP.

What is the most sensitive test and gold standard to dx. Malignant Hyperthermia?

PaO2 (increase with oxygen), but pulse ox will be 86% regardless of the true SaO2%

What is the only value that will change on an ABG in patients with methglobinemia when O2 is given?

3-3.5 ml/kg

What is the oxygen consumption of an average adult?

Usually used in burns >15%: 4 cc/kg x Weight x BSA of burn% over 24 hours with 50% volume given in the first 8 hours.

What is the parkland formula?

First order. After 1 half life, you have gotten rid of 50% of the drug.

What is the pharmokentic order of most of the anesthesia drugs?

20 minutes. half-life However, duration of action is 7-10days.

What is the plasma half-life of ASA?

Levo > vasopressin.

What is the preferred drug to be used for arb/ace-I hypotension which doesn't decrease cardiac output?

-Unopposed parasympathetic activity > hypotension.

What is the primary MOA of nausea in a high spinal?

Heart rate.

What is the primary determinant of myocardial oxygen demand?

3g in healthy patients |. 2.6 g in kids & older adults | 2g for alocholics & liver disease.

What is the recommended daily dose of Tylenol?

1st stage oxygen regulator will preferribly use the wall O2 > oxygen tank. If it is faulty, it can potentially use the tank O2 which can run out.

What is the role of the first stage oxygen regulator and what happens when it is faulty?

They have a faster induction and fasted emergenance. Can also lead to faster hypoxia with hypoventilation.

What is the significance of having higher oxygen consumption in infants?

55-70 bpm. Tachycardia = decreased time spent in diastole leading to a decrease in CPP.

What is the target HR for aortic stenosis patients?

spinal space at the L5-S1 interspace. This is the largest interspace of the spine, and therefore a reliable approach. The general approach is to place the needle 1cm medial and 1cm inferior to the posterior superior iliac spine. The needle is angled about 50 degrees cephalic medial.

What is the taylor approach of starting an epidural or spinal?

universal recipient = AB Universal blood donor = O.

What is the universal recpient and who is the universal blood donor?

Happens when the stent-graft is deployed and begins to open, ejection force of the heart can push the stent-graft and cause to migrate distally. Seen in Thoracic aneurysm. Can be prevented by reducing CO: 1.) Hypotension [ 70-80's} 2.) Cause transient cardiac asysole {via adenosine} 3.) Rapid ventricular pacing {180 bp}

What is the windsock effect during aneurysm repair, when is it usually seen and how is it prevented?

Capnogram of incompetent expiratory valve. The capnograph shows a markedly elevated inspiratory segment that does not return to zero, representative of rebreathing of CO2

What is this due to?

Allogenic blood transfusions leading to pro-inflammatory and immune suppressive side effects, 2/2 to WBC in the pRBC that weren't leukoradiated. Can lead to cancer reoccurrence, CMV, and infections. Benefits include: Decreased renal rejections in patients who received pRBC that weren't leukoradiated prior to surgery beginning.

What is transfusion related immunomodulation and which population of patients benefit most from it?

Type/Screen-determines ABO-RH + screens for mot common antibodies using an indirect coombs test by mixing a known anitbody with the patient's serum. -If positive for an antibody, must determine which specific antibody. Cross-matching: donor blood + reicpient blood mixed. Meant to decrease hemolytic reactions to zero.

What is type/screen and cross match?

There are ceiling effects, particularly for respiratory depression, at high doses. Buprenorphine is a partial μ-agonist and κ-antagonist with 25-40 times the potency of morphine.

What is unique about Buprenophine at high levels? MOA? Potency?

Helox has a similar viscocity to air and oxygen, but has a lower density. Density of gas is better for turbulent flow and not laminar flow. Turbulent flow is often found in smaller airways > upper airways.

What is unique about helox and when could it be used?

-Semi-open circuit = no valves, co2 absorber, and FGF determines reabreathing of CO2. -Used best in spontanous respirations. -FGF and bag on opposite end of patient and APL valve. To prevent CO2 rebreathing, FGF = to MV.

What kind of circuit is the mapleson A circuit? When is it best used, and what should be the MV to FGF to prevent CO2 rebreathing?

Fixed upper airway obstruction such as tracheal stenosis.

What kind of pattern?

FRC (functional residual capacity)

What lung capacity is decreased in pregnancy?

Vital Capacity (VC)

What lung volume/capacity change the least during pregnancy?

High affinity for Na+ channels in an inactivated & resting state. Slow off during diastole, not allowing the sodium channel to go back to normal state following hyperpolarization. Leads to increased PR and wide QRS.

What makes Bupivicaine so cardiotoxic?

Semi-open = no inspiratory/expiratory valves, no CO2 absorber, and depends on FGF for CO2 rebreathing.

What makes a semi-open circle system different from an open circle?

Increase altitude = decrease in barometric pressure. -Iso & Sevo vaporizors are designed to automatically compensated by increasing the delivered concentration (%) because they keep partial pressure constant to what it should be at sea level. -Des heats to 39 degrees & 2 ATM. Increasing alttitude causes a drop in barometric pressure. It will keep % concentration constant, but not the partial pressure (mac) of a gas, so one has to manually increase the dial to deliver the same mac/partial pressure at seal level.

What makes des flurane vaporizor different from the remainder sevo and iso as far as altitude is concerned?

New absorbants produce less carbon monoxide because they don't have strong bases in them like old absorbants do when they react with anesthestics. Volatile anesthestics most prone to producing C.O. = Des > Iso >Sevo

What makes new generation Calcium Hydroxide , calcium chloride absorbants produce less CO?

>160 or DBP of >110 + any of the: -Platelet count < 100k -LFTs 2x normal. -Serum Cr. > 1.1 or 2 x baseline -pulm. edema -Visusal changes.

What makes pre-eclampsia with severe features different from pre-eclampsia?

Low Risk: -Steroids for < 3 weeks. -Predisone < 5 mg per day or 10 mg q every other day. Intermediate: -5-20 mg predisone > 3 weeks. -Chronic inhaled/topical steroids. High risk: -Cushings symptoms seen from daily steroid intake. ->20 mg for more than 3 weeks

What makes someone a low, intermediate, and high risk for adrenal insuffency during surgery?

Etomidate, ketamine, and methohexital are associated with myoclonus. Propofol, although less common, is also associated with myoclonic movements Versed doesn't cause myoclonus. Can also decrease myclonus induced by etomidate.

What medications cause myoclonus on induction?

Stainless Steel, alloy, nickle, titanium, and plastics. Non-ferrous or fiberoptic cables should be used, but don't completely eliminate burns.

What metals are safe for MRI?

PSV

What mode of ventiation is used during spontaneous ventilation to offload the work of respiratory muscle

posterior arytenoid muscle. Lateral arytenoid muscle.

What muscle opens up the abducts (opens) the vocal cords? Closes (addicted) vocal cords?

Magnesium

What other electolyte should be replaced along with potassium?

Pancuronium

What paralytic is prolonged in renal failure by 97%?

Peak Expiratory Pressures > Fev1 (10%) + VC. Cough decreased by 50% No change in TV. These parameters are more dependent on abdominal musculature which has a higher degree of motor blockade than thoracic musculature from a lumbar or low thoracic epidural Increases vital capacity.

What parameters are decrease with thoracic or lumbar epidural?

PTT-intrinstic PT-extrinstic-

What pathway is tested with the PTT and PT?

Patients who have had ppx heparin BID or TID for > 5 days. Prior to pulling or placing an epiudral, there should be a 4-6 H wait before the last heparin ppx dose.

What patient should have a platelet count be done in neuroaxial anesthesia?

multiple clinical risk factors (3 or more) for coronary artery disease undergoing high risk surgery should be started on beta blockade Clinical risk factors for coronary disease include:- A history of ischemic heart disease- Congestive heart failure- History of stroke- Diabetes- Chronic kidney disease.

What patient should have beta-blockers started on day of surgery, if not on them previously, according to the ACC/AHA 2014 guidelines?

90-95% is metabolized prior to getting to the motor end place. The remaining 5-10% will cause paralysis for 5-10 minutes.

What percent of sux is metabolized prior to getting to the motor end plate to perform its action?

NK-1 receptor antagonist, used for nausea/vomiting and is best to be given prior to the start of surgery.

What receptor does Aprepitant work on and what is it used for?

Buprenorphine is a partial mu opioid agonist with possible (controversial) kappa activity. Slowly dissociates from MU making reversal via narcan difficult.

What receptors does Buprenorphine work on?

Blocks Mu, activates Kappa. -Has ceiling effect in which large doses won't lead to respiratory depression. -Can result in withdrawl symptoms in opiod dependent patients. -5-10 mg used for neuroaxial itching.

What receptors does nalbuphine work on?

M1 and to a lesser extent H1 receptors in the cerebral cortex, pons, hypothalamus, and area postrema/vomiting center.

What receptors does scolp patch work on?

The management steps for loss of pipeline pressure are the same as those for pipeline crossover :1) Open the emergency oxygen cylinder fully (not just the three or four quick turns used for checking). 2) Disconnect the pipeline connection at the wall because something is wrong with the oxygen pipeline. 3) Ventilate by hand with the anesthesia breathing circuit, rather than with the mechanical ventilator (which may use cylinder oxygen for the driving gas if the pipeline is unavailable).

What should be done if a hypoxic mixture is being delivered to the patient?

Purged for 20-30 minutes at high flows.

What should be done if a vaporizer is tipped?

Placed in a prone position. Instrumentation of the airway using an OPA or NPA can lead to damage to the surgical site.

What should be done to a cleft palate/lip repair child who is obstructing?

Decreased FRC

What speeds up the alveolar rise of inhaled agents in pregnancy?

1.) Chemotactic trigger zone in medullar. -CTZ is stimulated by dopamine, setorinin, opioid, ach histamine. 2.) GI tract 3.) Pharynx 4.) Visual Centers 5.) Mediastinum.

What stimulates the vomiting center?

It works on the Beta Subinits = leading to inhibition of ACh release in hippocampus and pre-frontal cortex.

What subunits of the GABA-A receptors does propofol work on?

Lipid soluability + PKA.

What two factors are important for time of onset of opioids?

Milronine, dobutamine

What two major drugs are known as iondilators?

mydriasis (pupil dilation) and cycloplegia (paralysis of accommodation) which can place patients with glaucoma at risk for increased intraocular pressure (IOP).

What two things does scolop patches do to the eye that placed patients at increased risk of glucoma?

Lipophilic drugs with high affinity for tissue components (tissue proteins, tissue lipids) have a large volume of distribution.

What type of drugs have a high volume of distribution?

Scopolamine is particularly effective at blocking the M1 and H1 receptors activated by the vestibular system and accordingly, is highly effective at preventing motion sickness. This characteristic also applies towards preventing PONV since opioid administration increases vestibular sensitivity.

What type of nausea and vomiting is scolp patch good for?

The use of pulse pressure variation for predicting volume responsiveness is most effective in the setting of controlled ventilation with tidal volumes > 7-8 mL/kg and no positive end-expiratory pressure (PEEP). In order for PPV to most accurately predict volume response, several conditions need to be met .1) The patient is on controlled, positive pressure ventilation. 2) Tidal volume is >7-8 mL/kg (ideal body weight). 3) PEEP is not used. 4) The patient does not have cardiac arrhythmias. 5) Significant changes in chest wall or lung compliance must be avoided. For example, PPV may not be accurate in the setting of laparoscopic surgery due to abdominal insufflation or in the setting of an open chest.

What vent mode is best to assess fluid response via PPV?

Increased RV, FRC, and TLC. Decreased VC, IRV, ERV.

What volumes are increased in COPD patients? What are decreased?

Lean body weight

What weight should induction doses of propofol and fentanyl?

TBW.

What weight should maintaince infusions of propofol and sux should be dosed at?

reduction in cerebral blood flow (CBF) and cerebral metabolic rate of oxygen consumption.

What will barbiturates do to CBF and metabolic rate?

100% because CO resembles O2-HG

What will be the oxygen saturation of someone who is having an CO posioning?

nothing

What will happen to standard deviation as sample changed?

Will result in precipitation formation because the unionized state is less soluble than ionized state.

What will happen when you had sodium bicarb to speed the onset of ropivacaine or bupivacaine?

Elevation causes the Atmospheric pressure to go down. In order to achieve the same MAC, you would have to turn up your dial flow to a higher percent. Example: -1 mac of Des = 6% -At 18,000 feet which has 380 psi ATM, you would only achieve 0.5 mac. (380/760) when your dial is at 6%. -you would have to turn up the dial to 12% to achieve a mac of 1 at an atm of 380. Required dial flow to maintain formula = normal dial setting (%) x 760 mmgh/ATM given (380).

What will happen with elevation?

Double blinding is almost always required

What would need to happen in the study to consider as level 1 evidence.?

Patients continue to have an intrinsic ventricular rate and the pacer can pace on top of the R-T leading to V-fib. Decreased when the pacer is beating faster than the intrinsic heart rate.

When can R-T phemenon happen in V.O.O. mode?

1. No midline cervical tenderness 2. No focal neurological deficit 3. Normally alert 4. Not intoxicated 5. No distracting painful injury.

When can cervical spine be cleared based on the 5 criteria?

D50 can be held if blood sugar is > 250. 10 units of insulin can drop the potassium by 1 meq/L

When can d50 be held in insulin potassium correction and how much should insulin drop the potassium?

Increased risk of dislodging.

When compared to a double lumen tube, a bronchial blocker has an increased risk of?

95% twitch reduction in 50% of the population.

When discussing NDMB, what is the ED95?

2 weeks

When does CO come back to normal after pregnancy?

laryngeal cartilage disruption or laryngotracheal separation. -Awake surgical tracheostomy

When is ETT contraindicated and how should the airway be secured instead?

VwF diease & renal failure.

When is Hetastarches contraindicated?

1.) S/S of chest pain symptoms in pre-op 2.) High risk sx without chest pain. 3.) Intermediate risk surgery & at least one risk factor out of the six in the Revised Risk Index

When is an EKG in the pre-op setting indicated?

Anterior = seen in cardiac surgery, mostly related to hypotension and large fluid loss. Usually bilateral. Posterior = usually seen in long spine surgeries, mostly seen with ischemia to the optic nerve due to position. Usually one-sided and sees grey shadows.

When is an anterior ocular injury vs. posterior ocular injury in the operative settings likely?

Bladder temperature can reflect core temperature when the urine flow is normal or high

When is bladder temp considered to be close to core body temp?

Directly after birth. Can increase by 80%

When is cardiac Output highest in pregnant patients?

>5.5 cm or rate of growth is > 1 cm per year.

When is elective repair of Aneurysm indicated?

Moderate-to-Severe Aortic Regurg.

When should a balloon pump be contraindicated?

After 30 days, and then q1y or whenever the dose has been changed.

When should an EKG be done with a patient on methodone?

<2.5 if non-emergent 2.5-3.0 if elective, non-urent.

When should cases be delayed for hypokalemia?

They will only administer cephalosporins if all of the following are true :1) The reaction to penicillin occurred > 10 years ago. 2) The reaction did not include any IgE-mediated symptoms. 3) The reaction did not include any severe reactions (e.g. TENS, DRESS syndrome).

When should cephlosporins be given to a patient allergic to pnc?

An MRI should be ordered to confirm the diagnosis and immediate surgical decompression should be performed in order to preserve neurologic function.

When suspecting an epidural hematoma, what is the number one test to get?

Lidocaine can cross into the placenta and the lower pH of the baby will cause ion trapping. 3-Chloroporcaine gets metabolized quickly in mom's body before being transferred to baby that only a small amount can undergo fetal ion trapping.

When there is fetal distress why is 3-chloroprocaine a good choice > lidocaine?

When has sepsis developed to septic shock?

When vasopressors needed to keep > 65 & lactate > 2.

V1 receptors present in vascular smooth muscle-->activating G protein and phospholipase C V2 receptors present in the distal and collecting tubules of the kidney-->--cAMP -->PKA

Where V1 and V2 AVP receptors located and what are their MOA?

dural sac in adults typically ends at S1-S2. In newborns, the dural sac typically ends at S3, hence why caudal anesthesia is better for peds to decrease trauma to spinal cord as it ends around L3.

Where does the dural sac typical end in adults? What about infants?

The ligamentum flavum connects the lamina of the spine. The ligamentum flavum begins at C2 (axis) and ends at the sacrum. The ligament gets broader and thicker as it descends the spine. It is thinnest in the cervical region and thickest in the lumbar.

Where does the ligmentum flavum start and where is it thickest/thinnest?

echocardiography to assess the pressure gradient and area of mitral and aortic valves pressure (P) = 4 * (velocity of blood)^2

Where is the Bernoulli's equation most clinically relevant?

C7 level of the neck-made of the inferior cervical & 1st thoracic sympathetic chain. Chassaigniac Tubrcle- mark used in stellate ganglion block at C6 level--at level of cricoid, lateral to the trachea. Approch anteriorily until you hit the C6 tubricle and then advance medially & inferiorily--aspirate--inject. Causes Ispilateral temperture > horner syndrome.

Where is the stellate ganglion and what is it made of? How is it blocked?

The S(+) enantiomer is the more potent anesthetic agent.

Which Enantimer of ketamine is more potent?

2-Chloroprocaine

Which LA has the least transfer from mom to baby?

Bupivacaine

Which LA is most likely to cause refractory LAST syndrome?

Vecuronium's major route of excretion is also hepatobiliary, but it is secondarily cleared by the kidneys. It is increased due to the build-up of 3-desacetylvecuronium, the primary metabolite of vecuronium, which has 80% of the neuromuscular blocking function of vecuronium and is excreted by the kidneys.

Which NDMB is most likely to be effected and lead to prolonged Neuromuscular blockade in renal patients?

Pridostigmine-doesn't cross the BBB and is reversible. Protects the ach-Estrase from sarin. Not the treatment for acute toxicity like atropine, but is used in a prophylaxis.

Which anti-choleingeric is used along with atropine in sarin gas exposure?

Pyridostigmine.

Which anti-cholinergic is the Myanstheia Gravis patient usually taking?

Thalamus dissociation from the Cortical.

Which area of the brain does ketamine work on to causes dissociative symptoms?

Versed

Which benzo decrease BP the most?

Ativan

Which benzo has the highest affinity for the GABAa receptor?

Subclavian line has the lowest rate of infection.

Which central line placement has the lowest rate of infections?

Vincristine, vinblastine

Which chemo medications cause an increase in peripheral neurotoxcity?

Thiazide Dieuretics more common in patients with edematous states such as heart failure and cirrhosis.

Which diuretic is most prone to causing hyponatremia?

Procainamide or amiodrone

Which drug should be used for Wolfe-Parkinson-White?

Cytochrome P450 3A4 (CYP3A4A)

Which enzyme is responsible for the metabolism of most anesthetics, lidocaine, and dexamethasone.

MEPs & VEPS

Which evoked potentials are mostly effected by inhaled agents?

mechanical complications is similar with internal jugular (IJ) and subclavian catheterization, although subclavian has a higher risk of pneumothorax and IJ has a higher risk of arterial puncture and hematoma. Femoral CVC placement has an overall higher complication.

Which has CVC placement has a higher risk of mechanical complication compared to other sites?

Ginseng As well as issues with platelet aggregation.

Which herbal supplement can lower blood sugar levels?

Sodium preside 2/2 to cinide build up.

Which hypotensive drug is affected in severe renal disease?

Ketamine and nitrous oxide

Which inhalation agent and induction agent can increase Pulmonary vascular resistance?

Desflurane (by as much as 60%) > isoflurane & sevoflurane (as much as 40%) > then nitrous oxide (20%). MOA = due to directly causing skeletal muscle relaxation and acting synergistically with NMBDs

Which inhalation agent augments Neuromuscular blocks the most?

Halothane

Which inhalation agent primarily decrease BP by a drop of cardiac output with minimal change to SVR?

the MAC of sevoflurane is often up to 2.5-3% higher in patients 1 month to 1-year-old.

Which inhalation agent requires the most increase in MAC in a 1 year old?

Calcium. -Leads to prolonged QT.

Which ion deficit causes the following picture?

Ammonia (NH4)

Which ion in the urine serves as a buffer for excess chloride ions that is excreted?

Temporal

Which lobe of the brain does seizure foci most commonly evolve from?

A = spontanous breathing. D = for mechanical ventilation patients. F- Mapleson F system (also known as the Jackson-Rees modification) is relatively efficient at both spontaneous ventilation (FGF of 2-3 times MV) and controlled ventilation

Which mapleson circuit is best for spontanous breathing patients? How about for mechanically ventilated patients?

Epinepherine.

Which medication is the #1 medication to give during spinal cardiac arrest?

Atropine. If nausea isn't due to high spinal blockade, then use glycopyrolate to treat nausea in a spinal block.

Which medication should be used for nausea associated with a high spinal block (T5 or higher)?

Patients' sympathetic response from t1-t4 fibers and parasympathetic response has been lost. However, they continue to have an up regulation of beta receptors on the heart to compensate for it, so epinephrine would work to increase the HR > atropine.

Which medication should you use for a de-innervated heart?

etomidate, sufentanil, and alfentanil

Which medication(s) can be used to identify seizure foci during craniotomy which will activate the seizure area and prolong seizure activity?

corrugator supercilii muscle (at the eyebrow)

Which muscle highly correlates with diagrapharm and larnyx?

diaphragm > laryngeal muscles > corrugator supercilii > abdominal muscles > orbicularis oculi > geniohyoid muscle (upper airway) > adductor pollicis muscle. Hence why the APL muscle should be used to determine a TOF is >0.90 since it's the last muscle to come back from blockade.

Which muscles will recover the fastest from non-depolarizing neuromuscular motor blockade?

Sciatic nerve/ Deep perineal nerve 2/2 a lithotomy position.

Which nerve is damaged if There is a foot drop?

Median--runs medial to the brachial artery.

Which nerve is likely to be damaged in a brachial line placement?

The glossopharyngeal nerve also provides airway innervation but is involved in the gag, not the cough reflex. RLN and SLN are involved in the cough reflex.

Which nerve is not involved in the cough reflex? Which nerves are?

Facial

Which nerve will over-estimate the degree of neuromuscular blockade?

Median, ulnar, and radial. Musckoskeletal nerve is located outside of it.

Which nerves are located inside the axillary sheeth?

Afferent C-fiber.

Which neuro fibers are pain conducting fibers?

Ranatidine. Cimetidine & famotidine will increase volume and PH.

Which of the H2 inhibitors will increase PH, but not increase volume?

Heart-75-80%

Which organ extracts the most oxygen?

Sux. MOA is fasiculations can be over-sensed by the pace maker/AICD leading to stopping in pacing or thinking its a lethal arrhythmia and causing a shock.

Which paralytic can lead to malfunction of AICDs and pacemakers? MOA?

Infants have the height P50 2/2 a decreasing Hemoglobin F and an increase 2,3 DPG. Will remain at p50 of 30 mmHg for the first decade of life, then the P50 will drop to 27. Newborns have the lowest P50 > adults > infants 1 yo-12 m.

Which patient has the heighest p50?

anhepatic phase

Which phase of a liver transplant is likely to have citrate toxicity?

Endotracheal intubation requires the highest concentration of volatile anesthetic to prevent movement.

Which procedure requires the highest concentration of volatile anesthestic to prevent movement?

NMDA receptor is activated after prolonged opioid exposure.

Which receptor is important in opioid tolerance and hyperanalgesia besides the mu-receptors?

Pheochromocytoma

Which renal endocrine pathology is reglan contrinidcated in?

S2-S4

Which spinal levels mediate second stage of labor?

T10-L1

Which spinal levels mediate the first stage of labor?

Adrenaline (epinephrine), isoprenaline (isoproterenol), and dopamine undergo no metabolism in the lungs.

Which three vasoactive drugs arent metabolized by the lungs?

Oxazepam & Lorazepam

Which two bentos are good in renal failure because they don't have active metabolites?

Factor VIII and vWF, due to are produced in the endothelial cells.

Which two factors are increased in liver disease and why?

Leads II and V5

Which two leads will detect 90% of ischemia?

aortic regurgitation-tachycardia = less time in diastole = less regurg.

Which valvular dysfunction should maintain lower SVR & tachycardia?

Mitral Stenosis.

Which valvular pathology is sensitive to increase/decrease in pre-load?

Strong bases within the chemical make up can result in a reaction with dimethylfluro valotile anesthestics such as Desflurane to produce CO. Increased with KOH > NAOH > Ba(oh)2 > Ca(oh)2 Des > Eflurane > Iso.

Which violatile agents most likely to cause a CO build up when reacting with CO2 absorber?

Ginger-inhibits thromboxane synthetase Garlic-decrease platelet aggregation. Ginkgo-inhibits PAF vitamin E-decrease platelet aggregation

Which vitamin is associated with increased bleeding? What is the MAO?

Due to cardio toxicity. Use 30 cc of 0.5% lidocaine instead.

Why are bupivicaine and ropivicaine typically contrainidicated in a bier block?

Burn patients have decreased pseudocholinestrase and increase in Ach receptors requiring higher doses of particulary vec, roc, and Atracurium. Mivacurium is the only non-depolarizing agent that will not require a large increase in dose to be effective in burn patients.

Why are burn patients resistant to Non-depolarizing Neuromuscular blocking agents and need higher doses?

Thye have an increased proliferation of extrajunctional receptors.

Why are burn patients resistant to non-depolarizing neuromuscular drugs?

often favored over roller pumps due to less blood element destruction, lower line pressures, lower risk of air emboli, and elimination of tubing wear and spallation.

Why are centrifugal pumps favored over roller pumps in CBP?

Quaternary ammonium ions found in NMB are the most likely culprit for causing IgE activation. Also found in cosmetic products and some cough medicines [pholcodine]

Why are intra-op NDMB anaphyalxsis more common in women than men?

Fospropofol is a pro drug of propofol that must be metabolized into propofol via endothelial cells & hepatic alk-phasatases first--usually slower onset of about 4 minutes before sedation is what results in the safer BP and respiratory profile.

Why are the incidence of hypotension and apnea lower for fospropofol than propofol?

-When turning head >30 degrees, the left IJ will over-line the left carotid more than it does on the right. -Left IJ is smaller. -Left IJ is more torturous route to the right atrium, leading to an increased risk of mal-position of the CVC.

Why are there more complications of placing a left-sided IJ cental line than a right?

Can inactivate the pseudocholinesterase.

Why can cyclophosphamide result in prolonged action from sux?

Sodium bicarbonate can lower ionized calcium which could be deleterious in a patient at risk for malignant arrhythmias

Why can sodium bicarb potentiate malignant arrhythmias?

Calcium Channel Blockers will block L-type calcium channels. The nerve terminals have p-type calcium channels.

Why do calcium channel blockers not effect the terminal release of calcium into the nerve synapse?

They are hydrophobic and can cross the BBB from the intrathecal into the plasma (Suprathecal) leading to elevated levels of plasma fentanyl causing early resp. Depression.

Why do drugs like fentanyl and sufentil cause an increased risk of early respiratory depression?

Higher MV and low FRC than adults.

Why do infants have a faster induction than adults?

Possibly because its metabolite Chloroaminobenzoic acid which can be a mu-receptor antagonist.

Why does 2-chloroprocaine decrease efficacy of other neuroaxial opiods?

Minute Ventilation = RR x Tidal Volume. Minute ventilation is maintained due to high frequency of breaths, but smaller tidal volumes. The smaller tidal volumes results in an increased dead space, but decrease alveolar ventilation leading to hypercarbia

Why does Hypercarbia happen in Jet ventilation even though minute ventilation is maintained?

Syngergist effect if you add Roc and nimbex instead of adding roc and vec.

Why does adding two different classes of NMB agents causes a prolonged effect?

High SvO2 measurements may represent the inability of tissue to extract oxygen from Hg, such as in the setting of methemoglobinemia, carbon monoxide poisoning, or cyanide poisoning, due to less oxygen being transferred to tissues.

Why does methemoglobinemia, carbon monoxide poisoning, or cyanide poisoning have an elevated Svo2?

Because it has a higher degree of nicotinic receptors.

Why does the diaphragm recover faster in neuromuscular blockade?

Dose of sux is increased slightly because the NDMB will actually bind at the nicotinic receptors and block Sux from binding,

Why does the dose of sux have to be increased to from 1 mg/kg to 1.5 mg/kg when a defasiculating dose of NDMB has been given?

Obesity tends to be increased with pseudo cholinestrase activity and increased Extracellular fluid.

Why increase the dose of sux in Obese patients?

Alfentanil: -1-2 minute onset. -Low PKA = unionized and able to cross the lipid membranes to get to the neuons faster. -Protein bound = volume of distirbution smaller.

Why is Alfentanil the fastest onset opioid?

Facilitate burst ventricular pacing prior to valve deployment so it can eliminate flow past the aortic valve, allowing for more accurate placement of the artifical valve.

Why is a pacer used in a TVAR?

The scope can compress the right innominate artery decreasing blood flow to the right arm and INTERNAL CAROTID.

Why is a right BP cuff supposed to be used with a mediastinum scope?

Because both pro-thombotic and anti-thrombotic factors are decreased. No need to replace. Coagulation management in liver disease patients are: 1) Maintain platelet count at 50-60; in high-risk surgery, maintain >100 2) Keep fibrinogen >100 3) Transfuse to maintain Hgb > 7 4) Do not give FFP prophylactically or chase INR levels - Increased INR in these patients does not necessarily reflect risk of bleeding - If FFP is to be given, dose is 20-40 mL/kg

Why is a stable liver failure patient not at an increased risk of bleeding, despite having high INR and low platelets?

Albumin has a half-life of three weeks, so it would be a while before revealing any liver issues. Better marker for liver function = PT/INR because it changes relatively quickly given that Factor VII has a short-half life of 4 hours.

Why is albumin level not a good prognostic marker for liver function? What is a better marker and why?

When the probe is placed in the distal one-third of the esophagus it lies behind the heart and the temperature will be reflective of the blood in the heart.

Why is an esophageal probe in the distal 1/3 of the esophagus an accurate measurement of core body temp?

Because ARDS is characterized by significant intrapulmonary shunting, the hypoxemia is relatively unresponsive to oxygen therapy and therefore increasing the FiO2 is unlikely to improve gas exchange

Why is an increase in FIO2 unlike to help in patients with ARDS?

Causes an increase in LES and gastric tones. LES tone > gastric tone. Gastric tone can be decreased by pre-treating patients with NDMB 10% of ED95.

Why is aspiration minimal with sux administration? How can it be further minimized?

Because Demerol has a structure that looks similar to atropine.

Why is damn demoral The only opioid that increases heart rate?

Causes destruction of the thyroid gland, leading to elevated levels of thyroid homones in the initial days of treatment. Radioactive Iodine must be given with PTU or Methomazole & propanolol to decrease these initial symptoms of the medication.

Why is giving Radioactive Iodidne 131 as the sole medication contraindicated in thyrotoxyosis?

Neostigmine also works on plasma cholinestrase As well as achestrase at the junctional receptor, resulting in a decreased break down of sux and prolonging it's effects.

Why is giving neostigmine bad to a patient who received sux?

Sub-glottic stenosis leads to turbulent flow with a reynolds number >4000. Because heliox has a lower density than oxygen, it will decrese the turbulent flow.

Why is heliox used for sub-glottic, fixed flow?

It is hydrophilic, so it stays in the CSF and can migrate rosterol to the head, and shut down respiratory centers.

Why is intrathecal morphine at an increased risk of delayed respiratory depression?

Hypothermia triggers the hypothalamus to release Nore-epi. Nore-Epi goes to the brown fat in babies and causes an increase in lipase and triglyceride break down-->increase ketone and h2o production-->leads to increased metabolic acidosis.

Why is it dangerous for neonates to be hypothermic?

Cardiac bypass patients are cooled. ABG sample taken from the patient and sent to the lab will be heated from 30 degrees celicus to 37 degrees celcius. This results in the Pao2 and PaCO2 to be higher than they actually are, since gases are more soluable to liquid when colder. Correction would be to tell the lab to bring the temperaure down to 30 degrees instead of warming to 37 degrees. PH changes are still inverse to the CO2.

Why is it important to ensure that the ABG sample is corrected for a patient on cardiac bypass?

So patient has an elevated CPP to perfume the coronaries.

Why is it important to keep an AS patients BP elevated during induction with a phenylephrine drip?

In the vent that you have an air embolism, CO2 can diffuse while nitrogen can not, resulting in locking of the right heart. CO2 dose of lethal embolism is nearly 5 times more than other gases.

Why is it more safe to use co2 as an insufflation gas over other gases like nitrogen?

marcaine (bupivacaine) is highly protein bound and doesn't cross over from mom to baby.

Why is it safer to use marcaine in an epidural > lidocaine when it comes to an epidural and the baby is in distress?

Has MAO-I properities on top of mu agonist and NMDA antgaonist propertieis.

Why is methodone used for neuropathy?

Mixing propofol with lidocaine has been shown to decrease the stability of the propofol emulsion and may cause pulmonary embolism 2/2 lipid droplets formed more quickly and were larger with a greater amount of lidocaine. Especially > 20 mg.

Why is mixing lidocaine & propofol in the same syringe not recommended?

Only violatile anesthestic which increases CMRO2 and CBF. Other violatile anesthestics will increase CBF, but decrease CMRO2.

Why is nitrous not the preferred agent in a patient with a brain mass?

Nore-epi has potent alpha-1 vasoconstrictive properties that lead to blood vessel constriction. Pheylephrine's A-1 activation isn't as potent as Nore epi. Epi = b2 activation = less damage Ephedrine = allows NE to leak out of the vessels and doesn't technically have any direct vasoactive properites.

Why is nore-epi not safe to give IM, but phenylephrine, ephedrine, and epi okay?

1.) Risk of fetal bradycardia 2.) Highest material serum levels of local anesthetic among regional techniques.

Why is paracervical block not used in labor?

Phisostigmine crosses the blood-brain barrier unlike priostigmine. Can work on central anti-cholinergic syndrome induced by scop. Or atropine.

Why is phisostigmine unique when compared to pridostimine or neostigmine?

Closed circuit machines use low flows and have no scavanging systems. Patients who smoke or are alcoholics can rebreath acetone or C.O. resulting in nausea/vomiting post-op.

Why is post-op nausea/vomiting more common in patients who have underwent anesthesia on a closed circuit machine?

-Skips stage II. -Always spontaneous respirations and patient to control depth of anesthesia. -Patient usually doesn't salivate and is dry. -Better tolerated if benzos > opiods on board.

Why is sevo induction agent for adults good for difficult airway patients?

If angle between the ultrasound beam and blood flow is over 20 degrees, there is a decrease in accuracy in the study.

Why is the angle between the probe and velocity of blood flow important in measuring aortic stensosis?

Cooperative binding of oxygen binding to the hemoglobin. One way to measure oxygen shift is by majoring the P50-which is what the PaO2 is at 50% Sao2. Normally 27 mmHg, where a rightward shift is elevated and a leftward shift is reduced.

Why is the hemoglobin curve sigmoidal?

Exceeding the maximum dose of neostigmine by giving too much can result in elevated Acteylcholine levels in the synaptic junction, leading to a more prolonged depolarization of the sodium channel, potentially leading to something similar as a phase I block and causing weakness.

Why is the max dose of neostigmine 0.07mg/kg and should not be exceeded for NMB?

Right ventricle has lower pressures than the left ventricle which are lower than the aortic pressure. This doesn't clamp off the blood vessles which run through the myocardium unlike the left ventricle. In order for the left ventricle to be perfused, its pressure must fall below aortic pressure which happens in mid-to-late diastole.

Why is the right ventricle perfused throughout the cardiac cycle where the left ventricle is only perfused in diastole?

There is a increase in pseudocholinesterases in obese patients.

Why is there a resistance to sux in obese patients?

Ticlopidine MOA = irreversibly blocks the P2Y12 component of the ADP receptor on the surface of platelets. While elimination half-life is 12 hours, it works on irrevisibly blocking platelet aggregration for up to 14 days.,while ADP blocks like plavix work for one week.

Why should Ticlopidine be stopped two weeks prior to surgery, where other anti-platlets should be stopped 1 week prior?

Re-distribution of the blood to the periphery and warmth will cause a rapid up-take of fentanyl from the patch. After removal, it will take 24 hours to decrease by 50%

Why should a fentanyl patch be removed for longer surgerical procedures?

It will make it 1/5th the osmolility to plasma-producing a hypotonic solution that can result in lysis of RBC and renal failure.

Why should the 25% albumin not be diluated with sterile water?

Associated with worsen bronchospasm due to increased histamine release.

Why shouldn't thiopental be given to an asthmatic to deepen the level of anesthestia?

Neostigmine will cross the placenta more readily than glyco would. Fetus can become bradycardic because neostigmine has crossed, but glyco. Atorpine would counteract the fetal bradycardia

Why would atropine be more beneficial in reversing a mother under GETA via atropine & neostigimine > glyco & neostigomine?

Winter formula is used to determine the appropriate PaCO2 response for a metabolic acidosis: PaCO2 ≈ [HCO3-] * 1.5 + 8 ± 2 Therefore, an acidemic patient with a serum bicarbonate level of 14 mEq/L would be expected to increase ventilatory drive to achieve a PaCO2 of 29 ± 2 mm Hg.

Winter formula is used for?

You could potentially be interneuronal.

With a peripheral Nerve block, if you elicit a response at or less than 0.2 mA, why should you not inject local anesthetic?

Intrathoracic pressure drops, increasing blood flow to the right heart.

With exhalation, what happens to the intrathoracic pressure and blood flow to the heart?

acute hemolytic reaction

a positive direct antiglobulin test (Coombs test) is diagnostic

Volume remaining (L) = (cylinder weight (g) - 5900 g) x 0.55 L/g

calculate the volume of nitrous oxide in an E-cylinder based on weight, the following formula may be used:

Increase in R in the TEG is due to? How is it corrected?

coag factors abnormalities and heparin administration. Corrected with Fresh Frozen Plasma.

18-hydroxylase

corticosterone to aldosterone

How does stress produce hyperglycemia

cortisol.

Patients who have been receiving echothiophate eye drops are at risk for significant prolongation of succinylcholine's effects for up to 2 weeks after therapy is discontinued.

echothiophate eye drops can result in prolonged paralysis of which medication and for how long after it is discontinued?

Supine positioning will decrease functional residual capacity (FRC) but has no effect on closing capacity (CC). This results in the FRC being closer to the closing volume, resulting in the airway closure to occur earlier in expiration.

effects of placing patient in a supine position on lung volumes?

Treating C. Botulinum?

equine serum in patients > 1 year of age, and human-derived immune globulin for infants < 1 year of age.

drugs (amphetamines, cocaine, ephedrine, chronic ethanol use), electrolytes (hypernatremia), and hyperthermia.

factors that increase mac.

Which gene does Marfan Syndrome affect?

fibrillin-1 gene,

CYP2D6--can decrease metabolism of codiene, making it less effective.

fluoxetine inhibits which enzyme?

1.) ASA physical status ≥ 3, obesity, 2.) age < 3 months, 3.) undergoing airway-related procedures, 4.) sedation performed using multiple drugs

four Known risk factors for adverse effects of pediatric sedation cases?

Magnesium blocks calcium channels, resulting in a decrease in calcium influx for ACH release at the pre-synaptic junction. It also causes a decrease in sensitivity to ACH at the post-synaptic motor junction. Both of these will result in an increase sensitivity non-depolarizing and no faciculations seens with sux.

high Magnesium and neuromuscular blockage has which effect?

RIght shift. Other factors that right shift: Hyperthermia, acidosis, high pCO2, results in more oxygen off-loading.

high levels of 2,3-DPG shift does what to the Hg-curve?

Hydrocholorothiazide causes

hyponatremia, hypochloremic alkalosis, hypokalemia, hypercalcemia, and hyperglycemia

Cord level

infraclavicular blocks the brachial plexus at which level?

Decrease SVR-except halothan. Decrease MAP Decrease contracility. Maintain CO-except halothane. HR increase-except halothane.

inhalation agents and CV effects? SVR, CO, and HR?

You're too anterior

interscalene blocks stimulation means?

Root level Covers shoulder, upper arm, and elbow surgery. 100% phrenic block. Pneumothorax, can have intrathecal, epidural, and veterbral artery injection. ulnar nerve sparing. Done by: -Insert at C6-level (cricoid carriage)-->insert needle posterior to the SCM-->go medial,caudad, and posterior.

interscalene blocks the brachial plexus was which level?

Main Muscles responsible for Laryngospasm?

lateral cricoarytenoid and transverse arytenoid muscles are major adductors of the vocal cords

What is Sepsis?

life-threatening organ dysfunction caused by a dysregulated host response to infection

Core-to-Peripheral redistribution of body heat.

major initial drop in temperature under G.A. is due to?

vital capacity is comprised of the tidal volume, inspiratory reserve volume, and the expiratory reserve volume Should be 60 cc/kg.

maximal amount of air that can fill the lungs and participate in gas exchange

Glottic closure results by the involuntary contraction of the lateral cricoarytenoid, the thyroarytenoid, and the cricothyroid muscles

muscles in laryngeospasm?

Besides serotonin uptake, what other MOA do TCAs have to control pain?

noradrenergic effect (interaction with α-receptors), an opioidergic effect, blockade of the NMDA receptor complex, inhibition of the uptake of adenosine, and blockade of sodium and calcium channels

onset of action of local anesthetics is primarily a result of lipid solubility, local anesthestic concentration, percentange, and pKa

onset of L.A. is due to?

Speed of onset of an epidural block is related to?

onset of the block is related to the pH of the solution since a pH closer to the pKa of the local anesthetic will increase the proportion of un-ionized drug.

-2,3 DBG decrease. -Decrease in Ph -Increase in K.

pRBC can lead to what electrolyte and pH changes?

Stored packed red blood cells have decreased 2,3-DPG, resulting in a leftward shift.

pRBC does what to Oxy-hg dissociation curve?

cleft lip and palate

phenytoin and maternal smoking increase the incidence

pathway of fetal circulation

placenta==>Ductus Venosis==>RA==>Foramen Ovale==>LA==>LV

Lipid soluability. Protein binding pKA

potency a LA correlates with? duration of action of LA correlates with? Onset of a LA blockade correlates?

MOA of sepsis

pro-inflammatory factors --> increase oxygen demand & free radical -->high metabolism-->metabolic acidosis.

detection of opioid abuse is believed to be inversely proportional to the potency of the drug in question. Therefore, sufentanil is typically noticed within 1-6 months (its potency is 10 times that of fentanyl). Fentanyl is often detected within 6-12 months.

relationship of potency of medication and detection of abuse amongst anesthesiologists.

Oxygen decreases HPV in areas of the lung that should be constricted.

supplemental oxygen can increase CO2 in a COPD patient how?

ductus arteriosus closes in full-term infants

the first day of life. O2 = most influential mechanism of closing it.

What is Heptopulmonary Syndrome?

triad of liver dysfunction, unexplained hypoxemia, and intrapulmonary vascular dilations.

Anti-cholingeric. Used to treat EPS symptoms from anti-dopaminergic drugs.

trihexyphenidyl is what class of medication and is used to treat what?

Local anesthetic with a lower pKa will have a greater unionized fraction (and generally faster onset) at physiologic pH (7.4) than a local anesthetic with a higher pKa (greater ionized fraction at physiologic pH and generally slower onset).

why does a lower pKA of a LA will have a faster onset ?