Ron final (old stuff)

*What does an ideal biologic warfare agent look like? (7)*

(looks like small pox) 1. Generate mass casualties 2. Easy large-scale dissemination 3. Easy to produce 4. Inexpensive 5. Highly infectious and contagious 6. Would result in widespread morbidity and mortality 7. No natural immunity

Laboratory assessment of *transaminases*: 1. _____ is located in many tissues (heart, muscle, kidney, brain) 2. _____ is located primarily in liver

1. AST (SGOT) 2. ALT (SGPT)

1. Lasers: Wavelength effect on target tissue depends on the how much of it gets _______ and converted to heat 2. Smoke and fine particulate matter produced by vaporization of tissue

1. Absorbed 2. Laser Plume

Type of Renal Failure 1. Prerenal 2. Renal (intra-renal) 3. Post-renal

1. Acute *circulatory problems* which impair renal *perfusion* 2. Caused by primary or secondary renal disease, toxins, or pigments 3. Caused by *obstruction* of the urinary tract --> Recovers quickly once the obstruction is cleared

1. Major risk factor for peri-op mortality with orthopedic surgery? 2. The most common surgical/post-op complications in the geriatric populations involve the ______ system

1. Advanced age 2. pulmonary

1. Resp arrest d/t a spinal is rare. What could cause it to happen? 2. Tx?

1. Hypoperfusion of brainstem respiratory centers (NOT phrenic paralysis) 2. Improve CO and BP --> Give ephedrine

Using clonidine in the epidural space will cause the following: 1. (hyper/hypo)tension 2. (tachy/brady)cardia 3. (excitation/sedation)

1. Hypotension 2. Bradycardia 3. Sedation

Type I Allergic Reaction: 1. mediated by which immunoglobulin? 2. What 2 other cells are involved?

1. IgE 2. mast cells and basophils

Opioids produce their effects by interacting with receptors that are: 1. (saturable/unsaturable) 2. _____-bound 3. Non-uniformly distributed throughout the _____

1. saturable 2. membrane 3. CNS

Epidural drugs for continuous infusion: 1. We like epidural LAs that produce more (sensory/motor) block 2. Examples? (3) 3. (high/low) concentrations are best for this

1. sensory 2. bupivacaine, levobupivacaine, ropivacaine 3. low

1. Epi will significantly prolong (longer/shorter)-acting LAs 2. Examples? 3. What might you *add* to an epidural if you were in a big rush to get it working?

1. shorter 2. lidocaine, mepivicaine, and 2-chloroprocaine (but don't add it to chloroprocaine, spine flu) 3. 1 mEq NaHCO3 to 10 mL LA (more unionized = faster onset & better block density) *Especially helpful in LAs packaged with Epi since they have lower pH for shelf-stability.

Allergic Reactions and *Induction Agents*: Have occurred following first or subsequent exposures Higher risk in patients allergic to other drugs High incidence of bronchospasm

Propofol

What can be done when installing a CO2 absorbent canister to reduce channeling and improve the efficiency of CO2 absorbtion?

Shake the C02 absorbent which will eliminate preferential gas flow through channels. This increases SA for C02 absorption and creates even disbursement of gas flow

Less well understood than the other T-cells Important in regulation of the cytotoxic and helper T-cells Likely important in limiting the immune system's ability to attack the host

Suppressor T-Cells

Type IV Allergic Reaction: What causes this type of reaction?

T-cell mediated delayed hypersensitivity

List 5 characteristics of a modern anesthesia vaporizer.

TAPOFFV 1. temp compensated 2. agent specific 3. pressure compensated 4. out of circuit 5. flow compensated 6. flow over 7. variable bypass

Prolonged exposure of CO2 absorbent to flourescent light may deactivate the ethyl violet dye making the absorbent white, even though the CO2 absorbtive capacity is exhausted. A. True B. False

True- fluorescent light can do this, just a weird factoid

Type of Latex Reaction -True allergic reaction -Localized and/or systemic effects

Type I (IgE-mediated) hypersensitivity

FYI: Type of Latex Reaction: -aka Delayed type hypersensitivity -Occurs over ~ 24 hours -Cell mediated -Limited to site of contact

Type IV - Contact hypersensitivity

How can you tell the difference between an umbilical venous catheter and umbilical arterial catheter on a CXR?

UVC goes to the IVC UAC will always have a sharp bend in it

Identify the necessary steps prior to safely using a vaporizer that has been tipped.

Ultimately take out of service and take it say it was tipped. If doing it yourself, 1. purge it for 20-30 min with high FGF. 2. confirm the output is accurate with agent analyzer on machine

*Epidural drugs: LA sites of action (3)

Unclear potentially: 1. Spinal nerves 2. DRG 3. Spinal cord

Positive pressure ventilation and PEEP may: 1. (increase/decrease) RBF 2. (increase/decrease) GFR 3. (increase/decrease) Na+ Excretion 4. (increase/decrease) UOP

decrease all

FYI: Opioids in the epidural space: Mechanism behind *urinary retention* with epidurals: Spinal cord opioid receptors (increase/decrease) contraction strength of the _____ muscle

decrease; detrusor

The Link-25 and similar proportioning systems do what?

prevents hypoxic mixture by coupling oxygen and N20. N20 turning on will result in oxygen turning on as well.

GU problems related to the surgical stress response: Urinary (retention/diuresis) due to reflex (increase/decrease) in urinary bladder tone

retention decrease --> reflex inhibition of smooth muscle

Mapleson variants PIC

see image

1. Where is pseudocholinesterase made? 2. T/F: pts with liver disease cannot receive sux

1. Liver 2. False (sux doesn't last long)

GI effects of a sympathectomy: 1. (increased/decreased) secretions 2. (contraction/relaxation) of sphincters 3. (increased/decreased) peristalsis 4. (constriction/dilation) of the bowel

(unopposed PS activity) 1. increased 2. relaxation 3. increased 4. constriction (may improve surgical conditions)

*1. You want an epidural with the fastest onset. What do you give?* 2. Most common LA for epidural if you need surgical anesthesia? 3. Which LA has a long duration and will give you great sensory block with minimal motor block 4. Most important determinant of the epidural dose?

*1. 3% chloroprocaine (nesacaine)* 2. Lidocaine 3. Bupivacaine (good post-op pain epidural) 4. Injection site (If you're closer to your dermatome of interest, a lower dose/concentration may be used)

The hyper*glycine*mia from TURP syndrome may cause... (2)

*1. Transient blindness (glycine is an inhibitory transmitter in the retina)* 2. Encephalopathy and seizures (potentiation of NMDA) Tx: Mag inhibits NMDA

Risk factors for the development of halothane hepatitis? (5) Which is the big one?

*Prior exposure* to halothane (10x more frequent in those with multiple exposures) (big one) Female Obese Hispanic Adult Halothane = *F*luothane (Ron: Female, Fate, Fifty, and Fertile) and Fispanic

*Contraindications to spinal/epidural anesthesia?* (9)

-*I*nappropriate for planned surgery -*M*ovement by patient -*S*evere Hypovolemia -*I*CP increased -*R*efusal -*C*oagulopathy -*A*ortic outlet obstruction (ex: aortic stenosis) -*I*nfection at site -*N*eurologic Disease-pre existing Pnemonic : IM SIR CAIN

Precipitators of hepatic encephalopathy (6)

-*Large dietary protein load*; No Texas de Brazil -GI bleed -Constipation -Diuretics -Azotemia (High urea) -Surgery and anesthesia

Uremic syndrome Kidneys no longer able to perform their major functions of (3)

--> *Regulatory* - extracellular volume and composition --> *Excretory* - elimination of waste products --> *Secretory* - Vit D and erythropoietin

Functions of the liver (8) (Ron: Know these; important)

-Blood *Reservoir* -Bilirubin Excretion -*Protein* Synthesis -Metabolic -Endocrine -Drug *Metabolism* -Immunologic -*Coagulation*

*What would cause mild elevations in transaminases? (4)

-Fatty liver -Nonalcoholic steatohepatitis -Drug toxicity -Chronic viral hepatitis

Pulmonary dysfunction with cirrhosis (4)

-Interstitial and airway edema -Mechanical effects of ascites -Pleural effusions -Hepatopulmonary Syndrome (*traffic is backed up*)

*Complications of a spinal anesthetic? (5)*

-Postdural Puncture Headache (PDPHA) -Backache -Hearing loss -Total spinal -Neurologic injury

1. What symptoms should pts expect after an epidural blood patch? (2) 2. With what symptoms would you want the pt to return to the hospital after an epidural blood patch? (3)

1. --> *Low* grade fever --> *Mild* backache 2. --> *High* fever --> *Severe* backache --> New neuro symptoms (incontinence, numbness, worsening of headache)

Extrinsic *Humoral* Regulation 1. ______ causes intense vasoconstriction of splanchnic arterial vessels while decreasing portal venous resistance, causing a marked (increase/decrease) in portal vein blood flow 2. In high doses, ______ and ______ reduce portal HTN and esophageal variceal bleeding

1. --> *Vasopressin* --> Decrease 2. --> Vasopressin --> and octreotide

1. Management of a total spinal involves support of the ______ & _____ systems 2. T/F: A serious neuro injury with a spinal is very rare 3. Most common neuro complications with a spinal? (2)

1. --> CV (pressors, fluids, atropine) --> Resp (ventilation, oxygenation) 2. True 3. --> Limited motor weakness --> Persistent paresthesia

Cystatin C 1. Estimated GFR calculated with what? (3) 2. Advantages over eGFR from serum creatinine? (2)

1. --> Serum cystatin C level --> Age --> Gender 2. --> Unaffected by abnormal high or low muscle mass --> Equilibrates more quickly, so increased accuracy when renal function is rapidly changing

*Advantages of Spinal Needles* 1. Two basic styles of spinal needles? (give names) 2. Which has a decreased incidence of PDPHA? 3. Which one requires an introducer? 4. A smaller gauge, pencil-point needle produces (more/fewer) post-dural puncture headaches (PDPHAs) than a larger gauge, cutting type needle

1. -Cutting (e.g. Quincke) -Pencil point (e.g. Whitacre, Sprotte) 2. Pencil point 3. Pencil point 4. Fewer

Anesthesia for *Renal Transplant*: 1. Most common causes of ESRD (4) *2. A kidney can be preserved, cold and perfused, for up to _____ hours 3. How is the transplant performed?

1. -DM -Systemic HTN -Glomerulonephritis -Polycystic kidney disease 2. 48 hours 3. Donor kidney placed in lower abdomen, blood supply from iliac vessels, ureter anastomosed to bladder (it's just that easy)

1. Name 3 muscle relaxants that do not use renal excretion 2. Nice TIVA combo for a renal pt?

1. -Mivacurium -Atracurium -Cisatracurium (Benzoqinoliniums) 2. Prop + Remi + Cisatracurium (watch your Laudanosine)

1. Name 3 muscle relaxants that are excreted renally 2. Name 3 reversal agents that are excreted renally 3. Renal pts are at (higher/lower) risk of re-curaritization because the reversal is (more/less) prolonged than the relaxant

1. -Rocuronium -Vecuronium -Pancuronium (aminosteroidals) 2. -neostigmine -edrophonium -pyridostigmine 3. lower; more

1. At low to moderate doses, dopamine has what effect on the kidneys? (2) 2. At higher doses, you'll also see what effect?

1. --> *DA1* (increased RBF) --> *beta* (increased CO and renal perfusion) 2. alpha (inhibits the good effects of #1)

Renal effects of aortic cross-clamp: 1. Two major predictors of acute renal failure following aortic surgery? 2. #1 reason for oliguria during surgery?

1. --> *Pre-existing* renal dysfunction --> *Peri-op* hemodynamic instability 2. Inadequate circulating volume

1. What would cause larger (but not the largest) elevations in transaminases? (2) 2. What would cause the largest elevations in transaminases? (3)

1. --> Acute hepatitis --> Chronic hepatitis (exacerbated) 2. --> *Drug* or toxin-induced hepatocellular necrosis --> Severe *viral* hepatitis --> Ischemic hepatitis secondary to *shock*

1. *Symptoms of cirrhosis? (4) 2. Signs? (5)

1. --> Anorexia --> weakness --> N/V --> abdominal pain 1. --> Encephalopathy --> hepatosplenomegaly --> ascites --> Jaundice --> spider nevi

1. *Describe the curves of the spine when laying supine (2)* 2. *Is this more important for spinals or epidurals? Why?*

1. --> Cervical and lumbar curves are convex anteriorly --> Thoracic and sacral curves are convex posteriorly 2. Spinals, because the LA is mixing with CSF (another fluid) in the spinal space. LA will spread with gravity if hyperbaric; down the curves

1. Raising the legs of a pt when doing a spinal (increases/decreases) lumbar lordosis and (increases/decreases) block depth 2. ______ accounts for 80% of variability in (spinal/epidural) block height 3. How long is it from onset until peak block height for lidocaine and mepivacaine? 4. How long is it from the onset until peak block height for tetracaine and bupivacaine?

1. --> Decreases --> Increases 2. CSF volume; spinal 3. 10-15 minutes 4. 20+ minutes

1. What are 2 volume expanders that could cause allergic reaction? 2. #1 cause of *anaphylactoid* reactions?* 3. Life-threatening peri-op allergic reactions have been reported with most anesthetic drugs, except... (2)

1. --> Dextran --> Hespan *2. Radiocontrast media* 3. --> Benzos --> Ketamine

1. Name the vasoconstrictors that may be added to spinals, and provide doses (2) 2. Why does Tetracaine have the most pronounced increase in duration when epi is added?

1. --> Epi (0.1 - 0.2mg, max 0.5mg) --> Phenylephrine (2 - 5mg) 2. It's the most dramatic vasodilator

1. If a pt has an epidural hematoma, how quickly should it be evacuated? 2. Major risk of a spinal microcatheter?

1. ASAP --> No longer than 8 hours 2. Neurotoxic injury d/t maldistribution / pooling

1. Which coagulation factors are not produced in the liver? (3) 2. Which coagulation factors are vitamin K dependent factors? (4) 3. The liver synthesizes_____, thereby modulating platelet production

1. --> Factor III: Tissue thromboplastin --> Factor IV: Calcium --> VonWillebrand factor 2. II, VII, IX, and X 3. Thrombopoietin

1. Normal values of creatinine for male and female? 2. Why would the elderly have decreased serum creatinine? 3. Would a high or low serum Creatinine be concerning in the elderly? 4. How does creatinine reflect acute changes in GFR?

1. --> Female: 0.6 - 1.0 mg/dL --> Male: 0.8 - 1.3 mg/dL 2. d/t decreased muscle mass 3. A high normal (should be decreased secondary to above) 4. slowly --> lags behind injury or recovery by *a few days* usually

1. Old-school management of a PDPHA? (3) 2. Definitive management of a PDPHA?

1. --> Forced fluids --> Bedrest --> Caffeine (PO or IV) 2. Epidural blood patch

1. What is HELLP syndrome? (3) 2. Tx?

1. --> Hemolysis --> Elevated liver enzymes --> Low platelets 2. Expedite delivery of the baby

*1*. Name 3 surgeries that would really benefit from regional anesthesia 2. Greatest risk of death following a total hip arthroplasty? 3. Highest risk of death from a hip fracture is from a ______

1. --> Hip replacement --> C-cection --> Pelvic surgeries 2. PE 3. PE

1. 2 Types of acquired immunity? 2. To initiate acquired immunity, you've got to have ______ and _______ *3. What is responsible for transplant rejection?*

1. --> Humoral: B-cell immunity; --> Cell Mediated: T-cell immunity 2. Antigens and lymphocytes 3. *T* cell lymphocytes --> *t*ransplant

1. Spinal space aka (2) 2. Immediately after injecting a drug into the subarachnoid space, focus on... (2) 3. Primary determinant of drug seletion for spinal anesthesia?

1. --> Intrathecal --> Subarachnoid 2. --> Positioning --> Block height 3. Drug duration of action

*1. How do you put a pt in lateral decubitus position for a spinal? (3)* 2. Benefits of this position?

1. --> Knees flexed --> Shoulders rounded --> Lower back bowed out 2. Comfortable & easy to maintain (even when sedated)

1. 3 positions for spinals? 2. Which is Anderson's go-to? 3. Hyper vs hypobaric: which is more reliable per Anderson?

1. --> Lateral decubitus --> Sitting --> Prone 2. Lateral Decubitus 3. Hyperbaric

FYI: ASA task force on peri-op blindness: 1. Two big risk factors of peri-op blindness? 2. Head should be maintained in the ______ position

1. --> Long case --> Heavy bleeding 2. Neutral

Effect of anesthesia on the surgical stress response: 1. Regional anesthesia/analgesia blocks the cortisol response most significantly with what types of surgery? (2) 2. Regional anesthesia and post-op analgesia have the greatest benefit in pts with (high/low) risk of complication

1. --> Lower abdominal --> Lower extremity 2. high

1. Name two mechanisms that regulate hepatic arterial blood flow 2. In a healthy pt, ______% of hepatic blood volume can be transferred to central circulation 3. Why is PT a useful lab for detecting *acute* liver failure?

1. --> Metabolic regulation --> Hepatic buffer response 2. 80% --> 500 mL 3. Due to the short half-life of liver derived Factor VII

1. Name 2 drugs that may offer some protection when given prophylactically with radiocontrast dye 2. *Nephrotoxic insults*: Name three pigment nephropathies

1. --> N-Acetylcysteine (mucomyst) --> Fenoldopam 2. --> Rhabdomyolysis --> Hemolysis --> Jaundice

1. Why do pts with chronic renal failure get HTN? (2) 2. Excess fluid can be managed with _____ or _____ 3. RAAS can be managed with drug classes (2)

1. --> Na+/H2O retention --> RAAS activation 2. diuretics or dialysis 3. ACEi/ARBs

1. What do cytotoxic "killer" T-cells attack? (3) 2. Organ transplant rejection is primarily _____-cell mediated

1. --> Normal tissue cells with *viral* particles entrapped in them --> *Transplant*ed tissue --> *Cancer* cells 2. *T*

1. How do you differentiate between oliguric and non-oliguric renal failure? 2. Important: what type of patient is at the highest risk for ARF? 3. Big difference between pre-renal and intra-renal ARF? 4. Prolonged pre-renal is the biggest cause of what disease?

1. --> Oliguric <400 mL/day --> Non-oliguric >400 mL/day 2. Elderly with DM and baseline renal insufficiency 3. In *prerenal* the kidney maintains the ability to *concentrate urine* 4. Acute tubular necrosis

1. How many spinal arteries do you have? 2. Posterior spinal arteries supply the (ventral/dorsal), (motor/sensory) portion of cord. 3. Have extensive collateral supply from _______ and _______ arteries

1. --> One anterior --> Two posterior 2. Dorsal; Sensory 3. subclavian; intercostal

1. Name the short acting LAs used for spinals (4) 2. Name the long acting LAs used for spinals (4)

1. --> Procaine (novocaine) --> Lidocaine (xylocaine) --> Mepivacaine (carbocaine) --> Chloroprocaine (nesacaine) 2. --> Tetracaine (pontocaine) -->*Bupivacaine* (most common) (marcaine) --> Ropivacaine (naropin) --> Levobupivacaine (chirocaine)

1. *How can you decrease exposure to radiation? (3) 2. *Problems that can occur with films? (2) 3. Checking for *rotation* on a CXR: The ______ process of the (cervical/thoracic/lumbar) vertebrae should be midway between the (medial/lateral) ends of the clavicle

1. --> Shielding --> Time --> Distance 2. --> Over or under penetration --> Rotation 3. spinous, thoracic, medial

1. Name two things that make killer T-cells become less toxic 2. Definition: pre & intra-op techniques to minimize post-injury hypersensitivity

1. --> anesthesia --> surgical stress response 2. preemptive analgesia

CPB: 1. After CP bypass, what two indicators are strongly correlated with post-op renal dysfunction? 2. Which is most important? 3. Mortality rate in pts who develop _____ ______ after CP bypass is close to 2 out of 3

1. --> post-op *cardiac or* ("or"?) --> pre-op *renal dysfunction* (creatinine >1.9 mg/dL) 2. pre-op renal dysfunction 3. renal dysfunction

1. Keys to prevention of systemic toxicity with epidurals? (2) 2. Most likely spot for an IV epidural injection would be in the ______ vein

1. -->*test dose* and aspiration -->*incremental injection* of the LA 2. Epidural

1. S/S cortical blindness (2) 2. Complete blindness implies infarction of both the right and left occipital cortex, how common is this? *3. Cortical blindness is usually accompanied by signs of stroke in the _____ -_____ area* *4. ~80% of post-op cortical blindness occurs following ______ surgery*

1. -Bilateral vision loss -absence of lid reflex response to threat 2. Very rare 3. Parieto-occipital 4. *cardiothoracic*

1. Name & dose of narcotics for a spinal block (2) 2. Provides analgesia for up to ______ hrs 3. Negative s/e?

1. -Fentanyl (12.5 - 25mcg) -Morphine (0.1 - 0.5mg) 2. 24 3. delayed respiratory depression

*Opioids as the primary anesthetic with chronic renal failure: 1. Advantages (2) 2. Disadvantages (2)

1. -Less myocardial depression -Avoid concerns over hepato- and nephrotoxicity 2. -Less able to control blood pressure elevations -Not as titratable (unless they're on a Remi or alfenta infusion)

Mechanism of renal failure in *sepsis*: 1. Hypotension and endotoxins result in increased what? (5) 2. All of the factors from #1 lead to what kidney effects? (5)

1. -SNS stimulation -RAAS stimulation -TXA2 -Leukotrienes -PGF2 2. -Renal blood flow -GFR -Sodium excretion -Urine output -Further renal vasoconstriction

*Advantages of Spinal Needles* 1. Advantages of cutting needle? (3) 2. Advantages of Pencil point needles? (3)

1. -Sharper -easier to get through skin -no introducer needed unless very small needle used 2. -Decreased PDPHA -"better" tactile feel -Introducer needle is required

1. Motor vs sympathetic vs sensory block locations 2. How can you tell where your pt's sympathetic block has ended? 3. Problems with differential spinal blocks? (2)

1. -Sympathetic is 2-6 dermatomes above sensory -Motor is 2-3 below sensory 2. Run your hand up their side. Where they start sweating is where the sympathetic block has ended 3. --> Distressing (to the pt) --> Sympathectomy

*Volatiles* for maintenence in chronic renal failure: 1. Advantages (2) 2. Disadvatages (2) 3. Should sevo really be avoided?

1. -Titratable -Allows reduction in dose of muscle relaxants which might have prolonged duration 2. -High incidence of concurrent hepatic disease -Risk of depression of cardiac output 3. Probably not

*Peripheral modulation: 1. Tissue injury causes a release of (2), which directly acitvate nocioceptors 2. T/F: Other mediators of inflammation are released from damaged cells, mast cells, plasma and platelets which further *sensitize and excite nocioceptors and produce inflammation* 3. The analgesic effect of ASA, NSAIDs, and COX-2 inhibitors come from _____ ______

1. -glutamate -substance P 2. true 3. prostaglandin inhibition --> less PGE1 & PGE2 mediated sensitization of peripheral nocioceptors

Background infusion with a PCA: 1. *Summary*: A background infusion with a PCA may be useful in what two populations? 2. In opioid naive pts, a background infusion (increases/decreases) total dose of drug delivered with no improvement in analgesia or night-time sleep patterns, and may result in (increased/decreased) s/e, including resp depression 3. Opioid tolerant pts and pediatrics: Background infusion may be (more/less) advantageous, although controversy exists

1. -opioid tolerant -peds -NOT in opioid naive pts 2. increases; increased (not helpful in opioid naive pts) 3. more

1. What pain mechanisms occur in the periphery? (2) 2. What pain mechanisms occur in the CNS? 3. Peripheral opioid effect is more pronounced in tissues that are ______ ____ 4._____ analgesia using agents with _____ side-effect profiles may reduce the adverse effects of pain management

1. -primary hyperalgesia -secondary hyperalgesia 2. -*central sensitization* (windup and long-term potentiation) and -*supraspinal modulation* occur in the CNS 3. Chronically Inflammed 4. multimodal; complimentary

1. Spinal dose of bupivacaine 2. Dose should be (increased/decreased) with pregnant pts

1. *12-15 mg* 2. Decreased (no more than 12 mg)

Spinal doses of short acting local anesthetics: 1. *Lidocaine* 2. Mepivacaine 3. Chloroprocaine 4. Procaine

1. *60-70 mg* 2. 30-60 mg 3. 40-60 mg 4. 50-150 *mcg*

1. Intubation techniques you might consider with a cervical spine injury? (2) 2. What is in-line stabilization?

1. *Awake fiberoptic*: May consider positioning awake following intubation with confirmation of movement of extremities prior to induction (*best* option) 2. Pt's C-spine has been "radiologically cleared", but another provider stabilizes neck while the other intubates *Because no radiologist has ever missed anything.

Important: Controllable factors that can influence *block height* with a spinal? (4)

1. *Dose* 2. *Site* of injection along the neuraxis 3. *Baricity* of the local anesthetic solution 4. Posture and *position* of the patient

Uremic syndrome neuromuscular effects: 1. Causes what change in mental status? 2. Sensory and Motor ______ 3. _______ dysfunction

1. *Encephalopathy* 2. *polyneuropathy* 3. Autonomic

Uremic syndrome CV effects (3 that he mentioned)

1. *Heart Failure* 2. *HTN* 3. *Dysrhythmias*

1. Components of the MELD score 2. In the U.S., the MELD score is used to... Liver patient preop meds: 3. They have (increased/decreased) uptake of benzodiazipines, so consider (increased/decreased) dose 4. Consider aspiration prophylaxis with.... (3 meds)

1. *I*NR, *B*ilirubin, *C*reatinine 2. prioritize liver transplants 3. Increased; Decreased 4. H2 blocker; metoclopramide; sodium bicitrate

Renal protection during cross-clamp: 1. (mannitol/dopamine) administration during an aortic cross-clamp prevents renal injury 2. Best initial technique during aortic cross-clamp? 3. Ron: *Never* give someone a _____ to increase UOP unless you're sure they have adequate fluid on board

1. *Neither* (made a big point here) 2. maintain intravascular volume 3. diuretic (mannitol or low-dose dopamine can be counted as a diuretic here)

*Uremic syndrome endocrine-metabolic effects: 1. Abnormal bone growth? 2. What do we need to be careful of?

1. *Osteodystrophy* 2. positioning and fractures

1. What kind of space is the epidural space? 2. Explain 3. The epidural space is shallowest (anteriorly/posteriorly) 4. Deepest (anteriorly/posteriorly)

1. *Potential space* 2. It's not an actual space until you inject something in there 3. Anteriorly 4. Posteriorly

*Name two interventions to prevent or treat the hemodynamic changes seen with spinal anesthesia*

1. *Prehydration*: -Give a liter immediately before the block. -Doesn't *reliably* protect against hypotension though 2. *Vasopressors*: -Ephedrine 5-10mg boluses -α+β preferable to pure α agonist (spinal = risk for bradycardia. Pure alpha agonist could worsen the brady)

Site of action of an epidural: 1. Early on? 2. Later?

1. *Segmental spinal nerves* traversing the epidural and paravertebral spaces 2. *Subdural* locations, including within the spinal cord and nerve roots

Central Neuraxis Anesthesia with renal patients: 1. Sympathetic block of _____-_____ effectively (increases/decreases) the sympathoadrenal stress response and release of catecholamines, renin, and vasopressin (at least while the block is in place) 2. RBF and GFR remain adequate as long as ______-_____ is maintained with adequate fluid load

1. *T4* - T10; decreases 2. perfusion pressure

Supraspinal modulation: 1. Supraspinal modulation _______ nerves, preventing _____ transmission and _____ release 2. Is this via the opioid or monoamine pathway?

1. *hyperpolarizes*; action potential; NT 2. both

Nephrotoxic insults 1. Radio contrast dyes cause nephrotoxic insults via microvascular _____ and direct _____ toxicity 2. In pts with ______, ______, and ______, the risk of nephrotoxic insult from *radio contrast dyes* markedly increased. 3. The risk also increases with a secondary insult (e.g. ______) in the first ____ to____ days following radio contrast 4. T/F: It's not necessary to postpone elective surgery during this period

1. *obstruction*; *tubular* 2. CHF, Hypovolemia, and diabetic renal insufficiency 3. surgery; 3-5 days 4. false (postpone it!)

Where can modulation of nocioception occur: 1. In the _______ 2. At any _______ in the *ascending* afferent pathway 3. Via *descending* efferent _______ pathways originating at brainstem level

1. *periphery* 2. *synapse* 3. *inhibitory*

Dopamine agonists on the kidneys: 1. There is (significant/minimal) inter-patient variability present in plasma levels of dopamine 2. Bottom line with using dopamine: If you have given adequate _____ to your pt, and oliguria persists, then it may be appropriate at that point to add some dopamine

1. *significant* (30-fold) 2. volume

Innate immunity: 1. Resistance of *____* to invasion 2. Destruction of swallowed organisms by *_____ _____* and *_____ _____* 3. Chemical compounds in *______* which destroy foreign organisms or toxins 4. Phagocytosis of bacteria, etc. by WBCs and tissue *________*

1. *skin* 2. *stomach acid*;*digestive enzymes* 3. Blood 4. *macrophages*

*Definitive* diagnosis of anaphylaxis: *1. Plasma ______ enzyme concentrations measured within ____ hrs of reaction* 2. FYI: Definitive identification of the causative antigen? (3) 3. How long do we need to monitor patients with anaphylactic reactions? 4. Incidence of anaphylaxis is 1:______ - _______ anesthetics

1. *tryptase*; 2hrs 2. --> skin testing --> RAST --> ELISA 3. Severe symptoms may recur 6-8 hours later, requiring several hours of close observation 4. 3,500-13,000

IMPORTANT: 1. ANP works by dilating _____ _____ _____? *2. What is the effect of ANP on phospholipase C receptors (Gq)? (2)

1. *vascular smooth muscle* 2. --> *Competitively* blocks NE --> *Non-competitively* blocks angiotensin II

1. *Fenoldopam at doses of ________ produces a dose-related (increase/decrease) in RBF and natriuresis 2. How do prostaglandins cause vasodilation in kidney? 3. In a *hypertensive* pt, CCBs will (increase/decrease) RBF and (increase/decrease) GFR, while inducing natriuresis 4. Don't give a CCB to someone who's ______

1. 0.03-0.3 mcg/kg/min; increase 2. Prostaglandins counteract the vasoconstrictive effects of NE and angiotensin II, and maintain perfusion of the inner cortex 3. increase; increase 4. hypotensive (it will interfere with autoregulation and make things worse)

1. Bupivacaine: continuous infusion dose range for a labor epidural? (don't have to memorize the following numbers) 2. Often contains _______ mcg/mL of fentanyl 3. Infusion rates vary from ______-_____ mL/hr

1. 0.05% - 0.125% 2. 1-5 mcg/ml 3. 10 - 18 ml/hr

Best way to establish a labor epidural: 1. Establish your block with ________% of which LA? 2. Run your infusion at what rate? 3. Most people will add ______ as well

1. 0.0625% - 0.125% Bupivacaine 2. same (?) 3. narcs

Equipotent parenteral doses of the following: 1. Fentanyl 2. Morphine 3. Meperidine 4. Codeine

1. 0.1 2. 10 3. 75 4. 130

With PCAs, the optimal dose is uncertain, but for opioid naïve patients, use the following demand doses: 1. Morphine 2. Fentanyl

1. 1 mg 2. 10-20 mcg (more important to know pluses and minuses of PCAs rather than specific numbers)

1. Normal *plasma* specific gravity level? 2. A *urine* specific gravity above _______ implies adequate concentrating ability 3. What if your plasma and urine specific gravities are the same? 4. What does urine specific gravity test?

1. 1.010 (290 mOsm/kg) 2. >1.018 3. The kidney's concentrating ability is impaired 4. Assessment of the kidney's concentrating ability

The positive pressure relief valve on the scavenger is set to open at > __1__ cm H2O and would result in _________2____________.The purpose of the negative pressure relief valve is to ______________3_____________. Dysfunction of this valve would result in ________________4______________________.

1. 10 2. gas escaping into the OR/pollution 3. Meet demand of suction/ allow RA to be entrained rather than sucking from the patient

*1. "Perineal" or "Delivery" dose with an epidural? 2. Patient uncomfortable near delivery, but still needing to push, Infusion concentration: (2) 3. Surgeon planning instrumented delivery (2)

1. 10 ml of LA 2. -2% 2-chloroprocaine -1% lidocaine 3. -3% 2-chloroprocaine -2% lidocaine

LMWH timing for neuraxial anesthesia: 1. Wait ______ after usual dose before you perform a block 2. Wait ______ after larger dose before you perform a block 3. Example of a "larger dose"? 4. An epidural cath should be removed ___-____ hrs after receiving LMWH 5. After removal of an epidural catheter, wait ____-___ hrs before giving the next LMWH dose 6. Most epidural hematomas occur during (insertion/removal) of the catheter

1. 12 hrs 2. 24 hrs 3. enoxaparin 1 mg/kg 4. 8-12 hrs 5. 1-2 hrs 6. removal

1. Up to ______% of the total blood volume is stored in the liver 2. In a pt with severe liver dysfunction, you will transfuse blood (more/less) readily 3. SNS suppression by anesthetic agents attenuates the auto transfusion response of the liver and predisposes the patient to _____ decompensation 4. Severe liver disease impairs the normal vaso(dilatory/constrictive) response of the body, exacerbating hypovolemia and hypotension 5. How?

1. 15% 2. More (higher threshold for transfusion; transfuse earlier) 3. Circulatory 4. Vasoconstrictive 5. Increased circulating glucagon and other vasodilators

1. An epidural blood patch is performed by slowly injecting ______ mLs of blood into the epidural space 2. Try to go at the same interspace as previous puncture. If unable, go (higher/lower) 3. ______% effective in alleviating a PDPHA

1. 15-20 2. lower (blood spreads cephalad) 3. 90%

1. Proteinuria should normally be ≤ _____/day FYI: Causes that will exceed normal? (5)

1. 150 mg 2. --> Glomerular damage --> Failure of reabsorption --> Excessive plasma proteins --> Orthostatic proteinuria (can be benign finding in adolescents/ check first void in the morning before they stand up to check if it's a true problem) --> *Microalbuminuria (first indication of diabetic nephropathy)*

A full nitrous oxide tank contains _____1___ liters at 750 psi. When the liquid in the tank is exhausted and only gas remains, the pressure will begin to fall and approximately ___2____ liters of nitrous remains.

1. 1590 (1600) 2. ~400 Ron always thinks about 1/4 left when pressure starts to drop.

Introducer. ...Put your finger over it. 1. Gauge? 2. Length? 3. Prevents smaller spinal needle and pencil points from _____ or getting misdirected 4. Can reach the ______ space in some people.

1. 18g 2. 1.5 inches 3. Bending 4. Subarachnoid

Per OSHA, operating room levels of volatile anesthetic should not exceed __1_ ppm and nitrous oxide levels should not exceed __2_ ppm.

1. 2 PPM 2. 25 PPM

Post-procedure instructions for an epidural blood patch: 1. Bed rest; no lifting for ____ 2. Force PO fluids containing ______

1. 24 hrs 2. caffeine

1. The hepatic artery is responsible for ______% of the blood supply to the liver 2. The hepatic artery is responsible for ______% of the O2 supply to the liver 3. The portal vein is responsible for ______% of the blood supply to the liver 4. The portal vein is responsible for ______% of the O2 supply to the liver

1. 25% 2. 50% 3. 75% 4. 50%

Epidurals: 1. _____ degrees head up improves low-lumbar and sacral analgesia 2. T/F: because the head's up that high, thoracic block height will decrease

1. 30 2. false

1. How many pairs of spinal nerves are there? 2. Root types? (2) 3. Spinal nerves which extend beyond the end of the spinal cord

1. 31 2. --> Anterior *motor* root --> Posterior *sensory* root 3. Cauda equina

1. How many vertebrae are there? 2. Break it down

1. 33 (24 true and 9 false) 2. 7 cervical 12 thoracic 5 lumbar 5 sacral (fused) (S5 not fused posteriorly) 4 coccygeal (fused)

Caudal epidural block: 1. For both males and females the initial needle angle is _____ degrees and advance until you hit bone After you hit bone, pull back a little and: 2. In a male, advance at a ______ angle 3. In a female, advance at a ______ degree angle

1. 45 2. Flat 3. 15

Optimal ETT positioning: 1. About ______ (above/below) the ______ 2. At the level of the ______ ______

1. 5 cm above the carina 2. aortic arch (with the pt's head in the neutral position)

1. Vessels larger than _____ are not coagulable with laser 2. Depth is not well controlled with which laser? 3. To protect patients eyes with laser surgery, you can tape them and cover them with an opaque, _____-soaked towel or cover them with a metal shield, or goggles.

1. 5 mm 2. Nd:YAG 3. Saline

Components of PCAs: 1. Typical lockout interval is _____-_____ 2. Variation of interval within this range has (significant/minimal) effect on analgesia or side effects

1. 5-10 min 2. minimal

Where does the spinal cord end in adults? (3)

1. 60% at L1 2. 30% at L2 3. 10% at L3 (If you go in at L1/L2, and you hit the spinal cord, that's your fault. Start at L3/L4 and then work your way down if needed)

Recommendations to prevent TNS with lidocaine: 1. Limit dosage to ______ 2. Reduce concentration from 5% down to ______% or less 3. Which LA is most commonly associated with transient neurological symptoms? 4. What positions are associated with TNS? (2)

1. 70 mg (range: 60-70) 2. 2.5% 3. Lidocaine 4. --> lithotomy --> knee arthroscopy positions

Clonidine for a spinal block: 1. *Dose 2. (increases/decreases) duration of block 3. (activates/inhibits) nocioceptive afferents 4. T/F: May exacerbate hypotension

1. 75-150 mg 2. increases 3. inhibits 4. true

FYI: Incidence of urinary retention: 1. Epidural opioids 2. Systemic opioids 3. Epidural local anesthetic

1. >50% 2. 18% 3. 10-30%

Classes of the Child-Pugh score(3)

1. A is the least severe 2. B is in the middle 3. C is the most severe

1. Describe the epidural compartment in the lumbar region 2. The epidural space becomes (more/less) segmented in the thoracic area 3. Depth of space (increases/decreases) as it progresses more cephalad

1. A series of *discontinuous* compartments in the lumbar area 2. Less 3. Decreases

Tx of chronic renal failure: 1. Aggressive management of HTN, with 1st line tx being _____/_____ and 2nd line being _____ _____ 2. Aggressive management of DM; maintain glycosalated hemoglobin <______% *3. Dietary protein restriction of ≤ ______ 4. Tx of anemia with ______ 5. Ultimately dialysis or ______ 6. Note: ACEi/ARBs will slow the progression of (CV/renal) disease, while reducing morbidity/mortality of (CV/renal) disease

1. ACEi/ARBs, beta blockers 2. 7% 3. 0.6 g/kg/day 4. erythropoietin 5. transplant 6. renal; CV

*Post block positioning* 1. Position the patient immediately (before/after) a spinal 2. When should you assess the development of the block? 3. How do you modify the height of a spinal block? 4. To modify the height of a spinal block, the pt must be repositioned within the first ______

1. After 2. Within 1-2 min 3. Reposition the patient 4. 5 min --> You won't change it much after that

Inactivation of invading organisms: 1. _____: Bound together in a clump 2. _____: Antigen-antibody complex becomes too large and precipitates out 3. _____: Antibodies cover all the toxic sites of the antigenic substance 4. _____: Attack cellular membranes and rupture the cells *5. This isn't enough. Most of the actual protection happens via the...* Supplement B cell immunity

1. Agglutination 2. Precipitation 3. Neutralization 4. Lysis 5. *complement system*

Protein Synthesis: 1. ______ is the major plasma protein 2. It is the primary determinant of colloid ______ pressure and is an important transport mechanism that binds many anesthetic drugs 3. Half life of albumin? 4. T/F: albumin levels are a useful indicator for acute liver disease

1. Albumin 2. Oncotic 3. 20 days 4. False, half life to long

Name the type of alcoholic liver disease: 1. Precursor of cirrhosis 2. Up to 10-fold increase of aminotransferases, with (AST/ALT) typically being higher 3. Tx?

1. Alcoholic hepatitis 2. AST 3. Abstinence, bed rest, good nutrition

Laboratory assessment: 1. Found in many organs, primarily liver and bone in healthy people 2. May be (increased/decreased) during normal pregnancy 3. When does alkaline phosphatase suggest *bile flow obstruction*? 4. Your AST and ALT are slightly elevated, but AP is significantly elevated. What might your pt have?

1. Alkaline phosphatase 2. Increased 3. Elevation of AP disproportionate to AST and ALT levels 4. Biliary obstruction

Short-acting LA: Chloroprocaine (nesacaine) 1. Excellent _______ with little or no incidence of _____ 2. (Do/ Do not) add epi

1. Analgesia; TNS 2. Do NOT ad epi --> Flu like symptoms

1. Unexpected, abrupt CV collapse. What do you immediately suspect? *Anaphylactic reaction*: 2. There's usually a first wave of symptoms, including those caused by vaso(dilation/constriction) and a feeling of _____ ____ 3. Quickly followed by a second wave as the cascade of mediators (amplifies/dulls) the reaction

1. Anaphylaxis --> at least have it in your differential diagnosis 2. dilation; impending doom 3. amplifies

Uremic syndrome *hematologic effects*: 1. (anemia/polycythemia) 2. impaired activation & ______ of _____ 3. Uremic syndrome GI effects

1. Anemia 2. Adhesion of platelets 3. delayed gastric emptying* (may need RSI)

*What should you consider regarding the vertebral anatomy? (4) Which is most important

1. Angle of the spinous processes 2. Natural curvatures of the spine (ex: lumbar lordosis) 3. Abnormal curvatures of the spine (Scoliosis) 4. Effect of positioning on above (most important)

FYI: Treatment of a Type I latex allergy: 1. Rhinitis 2. Hives 3. Airway 4. Anaphylaxis

1. Antihistamines 2. Antihistamines, systemic steroids 3. Antihistamines, systemic steroids, bronchodilators, oxygen, intubation, epinephrine as needed 4. Anaphylactic tx

The liver produces modulators of fibrinolysis and clotting: 1. _____ _____, proteins _____ and _____, and _____ factors 2. The liver produces clotting factors and modulates their ______ 3. The half-lives of liver-derived coagulation factors are (short/long) 4. Which is the shortest?

1. Antithrombin III, proteins C and S, and fibrinolytic factors 2. Consumption 3. Short 4. Factor VII (4 hours)

Renal protection in sepsis: 1. Patients in vasodilatory shock have very low plasma levels of _____ *2. The deficiency is likely a result of excessive _____-mediated release following sustained _____ 3. Addition of vasopressin can potentially allow discontinuation or dose reduction of ______ *4. Additionally, there is an effect on vascular smooth muscle _____ channels, restoring their sensitivity to _____

1. Arginine Vasopressin (they've used it all) *2. Baroreceptor-mediated; hypotension 3. Catecholamine infusions (very beneficial) 4. KATP; Norepinephrine

Extrinsic *Humoral* Regulation: *Angiotensin* 1. Marked constriction of _____ and ______ vasculature 2. Reduced ______ outflow 3. Reduced total _______ blood flow

1. Arterial and Portal 2. Mesenteric 3. Hepatic

1. Largest anastomotic link of anterior spinal artery 2. Comes from the aorta, typically entering on the left at the ______ vertebral foramen 3. Crucial to the blood supply of the... 4. Associated with what syndrome?

1. Artery of Adamkiewicz 2. L1 3. lower 2/3 of anterior cord 4. Anterior spinal artery syndrome (be aware of cross-clamp times)

1. 5 Components of the Child-Pugh score 2. Higher score = (increased/decreased) risk of liver disease (Ron: important)

1. Ascites Albumin (decreased) Bilirubin (increased) Encephalopathy PT (increased) 2. Increased

1. *Passage of material from the oropharynx into the tracheobronchial tree 2. *The disease pattern of aspiration depends upon... (2) 3. *Where is the aspirate most likely to end up in an aspiration event?

1. Aspiration 2. Volume and acidity (lower pH is worse) 3. Right lower lobe

Describe the Stages of Chronic Renal Failure: 1. Decreased renal reserve 2. Renal insufficiency 3. End-stage renal disease (ESRD) 4. Uremic syndrome

1. Asymptomatic and often without abnormal lab 2. These pts have elevated creatinine and BUN, but nocturia may be the only noticeable symptom (variable) 3. Multiple organ dysfunction, fatal without dialysis 4. The most severe form of chronic renal failure

1. Where is a spinal anesthetic presumed to work? 2. Where is an epidural presumed to work?

1. At the nerve roots 2. Initially spinal nerves and then may migrate to nerve roots

Induction of the Renal Patient: 1. A pt with renal disease has an (augmented/attenuated) SNS 2. Two things that may predispose a renal patient to #1? *3. You may see an exaggerated drop in BP if a renal patient undergoes... (4) 4. What can cause these patients to be considered a full stomach? (3)

1. Attenuated 2. --> Antihypertensives --> Uremia 3. -->Positive pressure ventilation -->Position changes -->Blood loss -->Drug-induced myocardial depression 4. --> Usual indications --> Delayed gastric emptying due to uremia --> Diabetic gastroparesis

*Increasing concentrations of local anesthetic will produce blockade in the following sequence? (4)*

1. Autonomic *preganglionic sympathetics* (B fibers) 2. *Sensory* (pain and temp) (Small A fibers) 3. *Motor* (Large A fibers) 4. C fibers

1. The complement system amplifies __-______ mediated immunity 2. The classical pathway to the complement system uses what (3) 3. System of ~20 proteins present in plasma, many are enzyme precursors 4. Important in amplifying ______ cell immunity 5. The compliment system is normally (active/inactive), but may be activated by the ______ (2) pathway

1. B-cell 2. --> IgG --> IgM --> Plasmin 3. The compliment system 4. B 5. Inactive; --> *classical (Transfusion reaction) --> alternative pathway (anaphilactoid reaction)

Allergic Reactions and *Induction Agents*: 1. Rare, more common in atopic individuals (what med class?) 2. Allergic reactions are more common with (amide/ester) local anesthetics. Why?

1. Barbiturates 2. Esters --> d/t metabolism to PABA; preservatives are often causative

1. Where is the subarachnoid space? 2. What does it contain? 3. About ______% of CSF is in the cranial vault, and about ______% is in the spinal cord

1. Between arachnoid and pia mater 2. CSF (contiguous with cranial CSF) 3. 50/50

1. Where is the subdural space? 2. You tried for an epidural, but unknowingly injected in the subdural space, how is your block effected? 3. You tried for a SAB, but unknowingly injected into the subdural space, how is your block effected?

1. Between dura and arachnoid maters (*potential space*) 2. Your block will be much stronger than anticipated 3. Won't work very well

1. (bigger/smaller) needle size is associated with PDPHA 2. How is age associated with PDPHA? (3)

1. Bigger 2. --> Low risk in children --> Increases in puberty --> Decreases again in elderly

1. What are the symptoms of anterior spinal artery syndrome 2. There is an extensive venous plexus located primarily in the ________ ________ space 3. Where does it drain into?

1. Bilateral lower extremity motor weakness with intact sensation 2. Lateral epidural (an argument against paramedian approach) 3. Azygous vein (then vena cava)

*What causes the bradycardia with a spinal? (2)*

1. Blockade of *cardioaccelerator* fibers (T1- T4) 2. Decreased preload causes cardiac stretch receptors to reflexively slow HR (*Bezold-Jarisch* reflex) (opposite of the bainbridge reflex)

*KEY POINT* Anatomical concerns with spinal anesthesia: 1. ______ Landmarks 2. Normal ______ of the spine 3. _______ traversed during spinal and epidural anesthesia 4. Meninges 5. Distal _______ of the spinal cord

1. Bony 2. Curvatures 3. Ligaments 4. Location, nature, and function 5. Termination

1. *Hypotension with a spinal is due to (arterial/venous) dilation* 2. Which is a bigger factor? 3. Primary cause of decreased CO with a high spinal?

1. Both 2. Venous dilation 3. Decreased preload

Midline approach with a spinal: 1. Insert the needle nearer the (top/bottom) of the interspace 2. Angle? 3. Where do you anchor the introducer?

1. Bottom 2. 10-15 degrees cephalad 3. In the interspinous ligament (feels "crunchy" like sand)

1. Most common long acting spinal anesthetic? 2. It comes as a (hyper/hypo)baric _____% and _____% solution prepackaged in _____ 3. Advantage of levobupivacaine and ropivacaine over bupivacaine in spinals?

1. Bupivacaine 2. Hyperbaric 0.5 and 0.75%; dextrose 3. None --> May have protective value in epidural doses

1. Which epidural drug has a narrow margin of safety? 2. *Why*? 3. Which anesthetics were made to increase this margin of safety? 4. These may be advantageous for (spinal/epidural) anesthesia

1. Bupivicaine (cardiotoxicity) 2. d/t slower dissociation from Na channels 3. Ropivacaine and Levobupivacaine 4. epidural (no difference in safety for spinals since such a small dose and less systemic absorption)

Central sensitization neuroplasticity: 1. Windup 2. Produces changes in spinal cord processing lasting up to ______ 3. What is the process of windup known as once it repeats itself and more permanent changes occur? 4. What can this eventually lead to?

1. Bursts of APs lasting up to 60 seconds after stimulus removed 2. 3 hrs (1-3) 3. Long-term potentiation 4. Chronic pain

The most common circle system in use today is the ____________1__________ circle. The differences between these systems is determined by _____________2______________. Two answers. A. Closed B. Semi-open C. Semi closed D. Presence of a CO2 absorber E. Fresh gas flow F. The addition of PEEP

1. C-semi closed 2. E-fresh gas flows

1. Height of a sensory block at the fifth digit? 2. Significance? 3. What's significant about a block that occurs at the nipple level (T4-5)? 4. Cardioaccelerator fibers come from which spinal segments? 5. Population most prone to problems when cardioaccelerator fibers are blocked?

1. C8 2. All cardioaccelerator fibers are blocked 3. Possibility of cardioaccelerator block 4. T1 - T4 5. Young, healthy males --> Increased PNS tone

1. Hepatic encephalopathy results in global depression of ______ function Possible mechanisms: 2. (increased/decreased) availability of agonist ligands of GABA receptors (aka natural benzos) 3. What drug might improve a patient's mental status? 4. Disruption of the _____-_____ _____ 5. _____ compounds 6. (enhanced/impaired) cerebral energy metabolism

1. CNS 2. Increased 3. *Flumazenil* 4. Blood-brain barrier 5. Neurotoxic 6. Impaired

1. Which lasers produce the most smoke? 2. Where is the smoke evacuator employed? 3. T/F: viral transmission by a smoke plume has been shown

1. CO2 2. at the surgical site 3. false

Name the COX enzyme: 1. May represent a central mechanism of pain and fever reduction by acetaminophen and other antipyretics 2. Constitutive --> Platelet aggregation, hemostasis, gastric mucosal protection, modulation of intra-renal hemodynamics 3. Inducible --> Pain, inflammation, fever

1. COX-3 2. COX-1 --> good effects 3. COX-2

Non-Opioids: 1. The primary mechanism of NSAIDs is inhibition of _____, and therefore inhibition of ______ _____ 2. NSAIDs act primarily (centrally/peripherally), but also act through inhibition of _____ _____

1. COX; prostaglandin synthesis 2. peripherally; spinal COX

*1. Primary manifestation of anaphylaxis in an anesthetized patient is _____ _____ within ___-___ min of drug exposure* 2. The exception is _____, which may take ______ or longer

1. CV collapse; 5-10 min 2. Latex; 30 min

Anesthesia for *Renal Transplant*: 1. Maintenence of euvolemia and adequate perfusion pressure is critical. Measurements like _____ or _____ may be helpful 2. Release of vascular clamps results in release of ______ and _____ metabolites into circulation, causing vaso(dilation/constriction) 3. There is now an additional _____ mL of new capacity in the intravascular space 4. Hypotension due to #2 and #3 usually responds to _____ _____ 5. Osmotic diuresis with _____ facilitates urine formation by transplanted kidney without relying on renal tubular mechanisms

1. CVP; SVV 2. K+ and acid; vasodilation 3. 300 mL 4. fluid bolus 5. Mannitol

Which three organ systems experience the most frequent complications with ortho surgery?

1. Cardiac 2. Pulmonary 3. Neurologic (*delerium*)

FYI: Common surgeries that report high incidences of ischemic optic neuropathies? (4)

1. Cardiothoracic surgery 2. Instrumented spinal fusion 3. Head and neck surgery 4. Nasal and sinus surgery (face, head, neck, spine, heart)

*Types of retinal artery occlusions? (2)*

1. Central: Decreases blood supply to *entire* retina 2. Branch: Affects only a *portion* of the retina

Epidurals: 1. This LA has a rapid onset and short duration 2. Intermediate onset & duration? (2) 3. Slow onset & long duration? (3) 4. Primary barrier to the spinal cord?

1. Chloroprocaine (nesacaine) 2% and 3% 2. Lidocaine 2%, Mepivacaine 2% 3. Bupivacaine 0.5 - 0.75%, Levobupivicaine 0.5 - 0.75%, Ropivacaine 0.75 - 1% 4. Arachnoid mater

Hepatopulmonary syndrome is a triad of:

1. Chronic liver disease 2. Increased alveolar-arterial oxygen gradient 3. Intra-Pulmonary Vascular Dilatations (IPVDs)

Adjuvant drugs we can add to an epidural anesthetic? (2) --> Rarely if ever used with infusion

1. Clonidine (5-20 mcg/hr) - Acts via the descending noradrenergic pathway, may improve the quality of the block 2. Epinephrine (2-5 mcg/mL) - May improve density and duration of the block (Anderson skipped over these dosages)

1. Place an epidural needle, then use it as an introducer for a spinal is called what? 2. A _______ needle is long and skinny; it might take a bit of time for CSF to flow out

1. Combined spinal-epidural (CSE) 2. CSE --> The skinny spinal needle is the one that will have the CSF flowing through it, rather than the larger epidural needle

Why do elderly pts have increased risk of morbidity and mortality: 1. Other disease states.... 2. Limited _______ capacity (*decreased ______ reserve*) 3. Ortho surg = significant __________, ______ loss & ______ shifts 4. Difficult post-op ______ management

1. Comorbidities 2. Functional; Organ 3. Inflammation, blood, Fluid 4. Pain

*Hyponatremia d/t absorption of Na+-free irrigation results in: (6)

1. Confusion 2. Agitation 3. Seizure 4. Visual disturbance 5. Pulmonary edema 6. CV collapse

1. *If your (conjugated/unconjugated) bilirubin is >______ mg/dL, you may have renal failure accompanying your liver disease Hepatic synthetic function: 2. Decreased ______ levels indicate worsening *chronic* liver disease 3. Abnormal _______ indicate *acute* hepatocellular injury

1. Conjugated; 35 2.*albumin* --> In the absence of another cause) 3. *PT/INR* --> Takes a significant liver injury to affect this

1. Ron: If someone has an elevated (conjugated/unconjugated) bilirubin, particularly in a ______ patient, that's going to increase their risk of renal injury 2. Before surgery in a pt on digoxin therapy, make sure to get a...

1. Conjugated; septic 2. pre-op dig level

1. Perception 2. Two components of perception? 3. Ability to relate a painful experience to another event 4. Only a fixed number of afferent stimuli can reach cortical centers

1. Conscious awareness and interpretation of noxious stimuli 2. -Cognition -attention 3. Cognition 4. Attention --> think gate control theory (Biofeedback; Hypnosis)

1. What structure marks the end of the spinal cord? Where is this found? 2. What is below that? 3. What's the highest you would attempt a spinal? 4. In a term newborn, spinal cord ends at...

1. Conus medullaris (typically around L1-L2 in adults) 2. Cauda equina 3. L2-L3 --> Preferably L3-L4 or L4-L5 4. L3

1. Awake fiberoptic intubation is the best option with a c-spine injury. This option requires a ______ patient 2. T/F: C-spine clearance is 100%

1. Cooperative 2. False

Cystatin C 1. Low molecular weight ________ ________inhibitor 2. Produced by all ________ _____ 3. Describe the rate its formed at 4. ______ _____ by the kidneys 5. The serum concentration is (directly/inversely) correlated with GFR 6. Unaffected by what? (5)

1. Cysteine proteinase 2. Nucleated cells 3. Constant rate 4. Freely filtered 5. Inversely 6. --> Infection --> Inflammatory/neoplastic states --> Body mass --> Diet --> Drugs

*Afferent* sensory pathways: 1. Where is the cell body in a first-order neuron? 2. Axons project to the ______ _____, where they synapse with second order neurons 3. Where is the cell body in a second-order neuron? 4. Most second-order axons project to the (ipsi/contra)lateral hemisphere of the spinal cord and ascend the ______ tract to the _______, where they synapse with third order neurons 5. Where do third-order neurons send projections?

1. DRG (dorsal root ganglion) 2. dorsal horn 3. dorsal horn 4. contralateral; spinothalamic; thalamus 5. Sensory cortex

1. Adding epi to an epidural will significantly (increase/decrease) peripheral resistance and BP 2. How do you decide between ephedrine and phenylephrine?

1. Decrease (central B2 agonism) 2. Heart rate --> Bradycardic: use ephedrine --> Tachycardic: use phenylephrine

1. As the stages of chronic renal failure progress, ______ decreases 2. Which stage of chronic renal failure is associated with the highest incidence of peri-op renal failure?

1. GFR 2. Renal insufficiency + DM

1 Adding epi to an epidural causes... 2. Which requires more practice, epidurals or spinals? 3. Where do epidural local anesthetics work?

1. Decreased SVR & MAP (central B2 agonism from systemic absorption) 2. Epidurals 3. Initially at the *segmental* spinal nerves --> Over time may gain access to the nerve *roots*

1. What is the hepatic buffer mechanism? 2. Max response? 3. What can diminish or abolish the hepatic buffer mechanism? (3)

1. Decreased portal vein flow leads to decreased washout (increased build-up) of adenosine, which dilates the hepatic artery 2. 2x increase in hepatic artery flow in response to a 50% decrease in portal vein flow 3. --> Splanchnic *hypoperfusion* --> Endotoxemia --> To some extent an anesthetic (except Sevo, which preserves the hepatic arterial buffer response)

1. Fat content in the epidural space (increases/decreases) with age 2. What's the main reason we decrease epidural doses with the elderly?

1. Decreases 2. They have less epidural fat

1. Main goal while advancing the spinal needle is to have *absolute control* how ______ the needle is being inserted 2. When do you feel the distinct "pop" when inserting a pencil point needle?

1. Deep 2. When puncturing the dura

If an anesthetic gas pipeline crossover is suspected, what steps are necessary, and why?

1. Disconnect pipeline- machine preferentially takes gas from pipeline d/t higher pressures even if the cylinder is on. 2. Turn cylinders on "commonly forgotten in the heat of battle"

FYI: Dopamine agonists on the kidneys: 1. *What is the synthetic analog of dopamine? 2. Reduces _____-_____ & increases ______ in CHF pts

1. Dopexamine 2. *after-load*; *RBF* (doesn't look to be on the market lol)

Spinal preparation (5)

1. Drug Selection 2. Add-ons? (vasoconstrictor, narcs, a2 agonist) 3. Hyper vs. iso vs. hypobaric 4. Sedation? 5. *POSITION*

Other methods of analgesic delivery? (4)

1. EPCTA 2. Chronogesic 3. Depodur 4. *Lidocaine* 5% topical patch

Central neuraxial anesthesia: 1. With lipophylic opioid, respiratory depression tends to occur (earlier/later) 2. With hydrophilic opioid, respiratory depression tends to occur (earlier/later)

1. Early 2. Both earlier and later

1. When do we give epi during anaphylaxis? 2. Epi helps to correct _____, relaxes bronchial smooth muscle via _____ effects, and restores membrane _______ via decrease the release of vasoactive mediators 3. *Corticosteroids* during anaphylaxis enhance the effect of ____ ____drugs 4. Corticosteroids inhibit _____ _____ release and subsequent production of leukotrienes and prostaglandins 5. Corticosteroids may be particularly useful following the ______ cascade

1. Early and PRN (go straight to the epi) 2. hypotension, B2, permeability 3. beta agonist 4. arachadonic acid (blocks phospholipase A2, to prevent AA from being formed) 5. complement

1. *Initially* with TURP syndrome, excessive absorption of irrigant leads to pulmonary ______ and (hyper/hypo)tension with reflex (tachy/brady)cardia 2. *Later* on with TURP syndrome, third spacing will occur secondary to (hyper/hypo)natremia 3. (hyper/hypo)tension will result in renal compromise & CV collapse

1. Edema; hypertension; bradycardia 2. hyponatremia (main factor) (dilutional) 3. hypotension

*PDPHA* 1. A PDPHA will be felt in which location: frontal or occipital? 2. Describe the pain *3. Key feature?* 4. Time frame?

1. Either, or both 2. Dull or throbbing 3. *Postural* (gets better when laying supine, worse when sitting up/standing) 4. *12-48 hours* following puncture (start thinking of other etiologies if it occurs immediately; ex: venous air embolus)

1. What other procedure produces problems similar to TURP syndrome? 2. To prevent it, keep a close record of ___/___ 3. Etiology of TURP syndrome: As the gland is resected, ______ sinuses are opened and irrigating solution is ______

1. Endometrial ablation (when irrigant is used) 2. I/O 3. Venous; absorbed

Treatment options with anaphylaxis? (5)

1. Epi 2. Fluid resuscitation (crystalloid and/or colloid) 3. B2 agonists - Reverse bronchospasm 4. Corticosteroids 5. *Antihistamines?

*1. The sympathoadrenal axis is mediated by what two catecholamines? Effects of the sympathoadrenal axis: 2. Decreased BP sensed by baroreceptors in aortic arch/carotid sinus results in (increased/decreased) adrenergic output. 3. GPCRs in vascular smooth muscle and mesangium mediate vaso(dilation/constriction) in response to adrenergic stimulation, as well as Angiotensin II, vasopressin, leukotrienes and others 4. (Ron Summary): if pt becomes hypovolemic or hypotensive, SNS outflow will drive that back up d/t ______ mechanisms

1. Epi & NE 2. increased 3. vasoconstriction 4. baroreceptor

1. More drug is used in a(n) (spinal/epidural). Why? 2. Outermost, thickest of the meninges 3. Delicate, avascular membrane *4. Primary barrier to movement of drug from epidural space to spinal cord*

1. Epidural --> further away from the nerve roots 2. Dura mater 3. Arachnoid mater *4. Arachnoid Mater*

Hearing loss - Fairly mild 1. *Complication of an _______ _______ Patch: 2. Transient, mild decrease lasting ____-___ days 3. Incidence up to ____% 4. ____:____ Female to male predominance 5. Etiology ______

1. Epidural Blood 2. 1-3 days 3. 40% 4. 3:1 5. Unclear

1. Bupivacaine is associated with cardiotoxicity more commonly with (spinals/epidurals) 2. Why?

1. Epidurals 2. higher quantity of drug needed with epidurals

What are 6 processes, besides renal problems, that could elevate BUN?

1. GI bleed 2. Increased Catabolism 3. Steroids 4. High protein diet 5. Exercise 6. Dehydration GI SHED

1. Which is more likely to result in systemic toxicity, epidurals or spinals? 2. What are the keys to prevention of systemic toxicity? (2) 3. When placing an epidural, maintaining control of the ______ is extremely critical

1. Epidurals --> large drug volume, ICEBS 2. --> An adequate test dose --> Incremental injection 3. Needle depth

1. Most commonly used epidural adrenergic agonist? 2. T/F: You'll see vasoconstrictors added to epidurals often

1. Epinephrine 1:200,000 (5 mcg/mL) 2. False (you have a catheter in place that you can drip meds through, no point in increasing duration)

1. Give _____ to prevent the anemia associated with renal disease 2. The kidneys excrete (volatile/non-volatile) acids from the body 3. In renal insufficiency/failure, urine pH (increases/decreases) and serum pH (increases/decreases)

1. Erythropoetin 2. Non-volatile 3. --> Urine pH *increases* (more alkalotic) --> Serum pH *decreases* (more acidotic) (kidneys are not excreting acid like they should)

*Cellular mechanisms* of central sensitization neuroplasticity: 1. Afferent axons release (inhibitory/excitatory) neurotransmitters 2. Synaptic potentials of A delta and C fibers are _____ onset and _____ duration 3. Accumulation of these neurotransmitters results in _____ of these action potentials and prolonged duration

1. Excitatory (glutamate, substance P, Neurokinin A) 2. Slow; Long 3. Summation

1. Hyperalgesia 2. Allodynia 3. Peripheral modulation

1. Experiencing more pain than one should anticipate 2. Experiencing pain from something that shouldn't be painful 3. Occurs either by release of or elimination of endogenous mediators of inflammation in the vicinity of the nociceptor

*Four causes of a retinal artery occlusion*

1. External *compression* of the eye (don't let it happen) 2. Decreased arterial *supply* to the retina (caused by hypotension) 3. Impaired venous *drainage* of the retina 4. Arterial *thrombosis* (compression, thrombosis, decreased inflow/outflow)

1. *Big deal*: Most common cause of peri-op retinal artery occlusion? 2. T/F: hypotension in isolation can cause retinal ischemia

1. External Compression from poor positioning --> resulting in impaired venous drainage 2. False

1. T/F: After inflation of a tourniquet, bleeding from the site is usually d/t inadequate cuff pressure 2. Upper limit of acceptable tourniquet inflation time? 3. After this time, there should be a ______ period of perfusion, then re-exsanguination and inflation

1. False --> Usually d/t long bone intramedullary blood flow; assess carefully 2. 2 hrs 3. 5 min

1. Phasic inhibition is associated with (fast/slow) (motor/sympathetic) blocks 2. Tonic inhibition is associated with (fast/slow) (motor/sympathetic) blocks 3. What is tonic inhibition? 4. What is phasic inhibition?

1. Fast, sympathetic 2. Slow, motor 3. Time between action potentials exceeds time for dissociation of local anesthetic from the Na+ channel 4. Time between action potentials is less than (think fast action potentials) time needed for local anesthetic to dissociate from Na+ channel (block builds rapidly)

1. What is seen in almost 100% of femoral or pelvic fractures? 2. What is similar, but much less common? 3. Definition: A physiologic response to fat in the systemic circulation 4. Develops (acutely/gradually)

1. Fat emboli 2. Fat embolization syndrome (1% incidence) 3. Fat embolization syndrome 4. Could be either

1. Primary component of the epidural space? 2. What's also found in that space? 3. Epidural fat is primarily located in the (anterior/posterior/lateral) epidural space 4. T/F: fat quantity correlates with the general adiposity of the pt

1. Fat globules 2. Veins, arteries, & lymphatics 3. posterior & lateral 4.true

*Sitting Position:* 1. How do you put a pt in sitting position for a spinal? 2. This position is useful in which types of pts? (2) 3. What should you do if a higher level spinal is required and the patient is in sitting position?

1. Feet resting on stool, keep low back bowed out to minimize lumbar lordosis 2. --> low level surgery (ex: perineal, sacral) --> difficult anatomy (ex: morbidly obese Michelin Men) 3. Have them lay down supine *immediately* after injection

Dopamine agonists on the kidneys: 1. _______ is a selective DA1 receptor agonist 2. Major use is for tx of.... *3. At 0.03 - 0.3 mcg/kg/min produces a dose-related increase in ______ and ______

1. Fenoldopam (Corlopam) 2. *Renovascular HTN* 3. RBF and natriuresis

1. Compared to hydrophilic opioids, *lipophilic* opioids such as _____ or _____ are associated with the following: 2. (rapid/delayed) analgesic onset 3. (longer/shorter) analgesic duration 4. (extensive/minimal) CSF spread 5. Site of action (2) 6. (more/less) side effects (ex: N/V and pruritus) 7. (early/delayed) resp depression

1. Fentanyl, sufentanil 2. Rapid (5-10 minutes) 3. Shorter (2-4 hours) 4. Minimal 5. Spinal + systemic 6. Less 7. Early

Avoiding ETT fire: 1. Minimize _____ 2. Use air/oxygen in lowest concentration instead of ______ 3. Fill cuff with _____ and ____

1. FiO2 2. N2O (flammable) 3. saline and dye

Coagulation benefits of epidural regional anesthesia and analgesia: 1. Enhances _______ activity 2. Speeds return of _______- __ to normal levels 3. Attenuates post-op increase in ______ _______

1. Fibrinolytic 2. Antithrombin III 3. Platelet adhesiveness (*summary*: more fibrinolysis & Anti-3, less platelet stickiness)

1. Incidence of volatile agent-induced hepatitis is r/t the number of _______ metabolites produced 2. What is the only volatile that does not have any of the above metabolites? 3. The incidence and severity of halothane hepatitis are (directly/inversely) related to the dose of halothane used

1. Fluoroacetyl 2. Sevo 3. Unrelated

1. You've placed an epidural, but you're only getting a one-sided block. Where might your catheter be? 2. Tx?

1. Foraminal 2. Pull it out and start over

1. Best measure of renal function? 2. Normal GFR? 3. Potentially misleading test of renal function 4. At what level is something actually going on renally? (What is this referring to?)

1. GFR 2. 125 mL/min --> (180L/day) 3. BUN (could be high d/t a number of things) 4. >50 mg/dL --> Normal 7-20

Laboratory assessment: 1. Which enzyme is found in many tissues, but isoenzyme B specific to liver. 2. Short T1/2 (how many min?) makes it a useful marker of progression or resolution of injury. 1. Found in highest concentrations in centrolobular (zone 1/ zone 2/ zone 3) hepatocytes, which are most susceptible to ischemic injury and toxic drug metabolites

1. GST 2. 90min 3. Zone 3

Antibody classes: 1. Antibodies are either ______ ______ or ______ 2. Antibodies account for ______% of all plasma proteins 3. Each antibody is specific for a particular _____ 4. What are the 5 classes of immunoglobulins?

1. Gamma globulins or immunoglobulins 2. 20% 3. Antigen 4. --> Ig*G* --> Ig*A* --> Ig*M* --> Ig*E* --> Ig*D* *GAMED*

Tributaries of the portal vein? (4)

1. Gastric 2. Esophageal veins 3. Inferior and superior mesenteric veins 4. Splenic vein (*G*astric, *E*sophageal, *M*esenteric, *S*plenic)

1. ______ produces long-lasting *arteriolar dilation*, and antagonizes arterial constriction from other responses (like catecholamines) 2. This is an example of (intrinsic/extrinsic) (neural/humoral) regulation

1. Glucagon 2. Extrinsic humoral

1. _____-hepatitis has clinical features of allergic reaction 2. T/F: Liver injury may result from antigen-antibody interaction 3. Possibility of cross-sensitivity exists in susceptible patients but should be least likely with which volatile agent?

1. Halothane 2. True 3. Des (d/t decreased metabolism)

Rank the volatile anesthetic agents according to effect on hepatic blood flow & O2 delivery

1. Halothane (BAD) 2. Des (???) 3. Iso (GOOD) 4. Sevo (BEST)

1. Which volatile agent causes the most CV & resp depression, and the greatest reduction in hepatic arterial flow? 2. Which volatile causes a 30% reduction in hepatic blood flow, and decreases splanchnic and hepatic O2 reserves? 3. T/F: Hepatic blood flow and oxygenation are well preserved with Iso 4. Which volatile keeps the hepatic arterial buffer response intact? 5. Is N2O hepatotoxic?

1. Halothane (fluothane) 2. Des 3. True 4. Sevo (best) 5. Not certain --> It increases SNS tone and may reduce arterial and portal venous flow --> Inhibits methionine synthetase which can produce toxic effects.

1. Two methods of knowing you're in the epidural space? 2. Most common?

1. Hanging drop method (very old school) 2. Loss of resistance method (most common)

Principal goals of spinal anesthesia: 1. Adequate block _____ and _____ for the surgery 2. *Primary determinant of duration of spinal block?*

1. Height; duration 2. Drug selection

Complications of epidural analgesia? (3)

1. Hematoma 2. Infection 3. Catheter migration

*Contraindications:* 1. Coagulopathy is a contraindication to spinal anesthesia d/t increased risk of epidural ________, particularly in association with what drug? 2. Sepsis or infection at insertion site are both contraindications to spinal anesthesia d/t increased risk of _________ 3. Why is severe hypovolemia/shock a contraindication to spinal anesthesia? 4. Why is aortic outlet obstruction a contraindication to spinal anesthesia? 5. Is thrombocytopenia an indication to not do a block?

1. Hematoma; LMWH 2. Meningitis 3. Increased risk of hypotension 4. Acute reduction in afterload compromises aortic root pressure and subsequently *coronary perfusion pressure* 5. Nope. No indication that low platelets is a contraindication.

1. Most common blood-borne infection in the U.S.? 2. Which organ systems does advanced cirrhosis affect? 3. Which volatile best preserves hepatic blood flow and oxygenation? 4. Your pt is coming in for an elective surgery. The pt has acute hepatic disease. Do you delay the case?

1. Hep C --> 40% of chronic liver disease 2. All 3. Sevoflurane 4.Yes

1. The sum of all processes used by liver to eliminate a drug from the body 2. Metabolism of drug by hepatocytes into inactive, water-soluble substances for excretion in urine or bile

1. Hepatic clearance 2. Hepatic biotransformation

1. Most common blood-borne infection in the U.S. 2. Accounts for 40% of chronic liver disease 3. Main drug that causes predictable, dose-dependent liver toxicity? 4. T/F: a normal dose could cause toxicity in liver disease or a malnourished pt

1. Hepatitis C 2. Hep C 3. Acetaminophen --> Other 2 are carbon tetrachloride and amanita phalloides 4. True

1. Clearance determined by hepatic blood flow is (high/low) HER? 2. Low HER drug examples (3) 3. Most opioids are high HER drug, Exception? 4. Clearance relatively independent of hepatic blood flow is (high/low) HER?

1. High 2. --> Alfentanil --> Diazepam --> Thiopental 3. Alfentanil 4. Low --> Much more affected by increased free fraction (e.g. hypoalbuminemia) and enzymatic activity

Induction of Anesthesia 1. Propofol (high/low) HER with the elimination profile (unchanged/changed) from control 2. Etomidate (high/low) HER with clearance (unchanged/changed) in cirrhosis 3. Ketamine (high/low) HER and is avoided with liver patients because of what?

1. High, unchanged 2. High, unchanged 3. High, increased sympathetic outflow decreases blood flow to liver

1. Regional anesthesia is most beneficial in ______ surgery 2. Also beneficial in (2)

1. Hip 2. --> TKA --> Radical prostatectomy (hips, knees, & prostates)

CV effects of cirrhosis: 1. (hyper/hypo)dynamic circulation *2. (increased/decreased) peripheral vascular resistance* 3. (high/low) arterial blood pressure 4. (increased/decreased) stroke volume 5. (increased/decreased) heart rate 6. (increased/decreased) total blood volume 7. (increased/decreased) central blood volume

1. Hyperdynamic *2. Decreased (circulating vasodilators like glucagon)* 3. Low 4. Increased (decreased SVR) 5. Increased (mild) 6. Increased 7. Decreased (splanchic bed becomes hypervolemic) (looks a lot like the warm stage of sepsis)

Uremic syndrome and electrolyte imbalances 1. Potassium 2. Sodium 3. Phosphorus

1. Hyperkalemia 2. Hyponatremia 3. Hyperphosphatemia

1. *Endocrine disorders that can result from cirrhosis? (2) 2. T/F: hepatic encephalopathy is irreversible 3. Symptoms of hepatic encephalopathy range from small _____ changes or sleep disturbances to confusion, lethargy, and ______ 4. Hepatic encephalopathy is primarily caused by increased _______ levels

1. Hypoglycemia and gonadal dysfunction 2. False 3. Personality; coma 4. Ammonia

Immunoglobulins (Ig): 1. _____: Normally ~75% of all antibodies 2. _____: Especially involved in allergy, but only make up a small percentage of all antibodies 3. An invading organism may be inactivated via... (4)

1. IgG 2. IgE 3. *P*recipitation *L*ysis *A*gglutination *N*eutralization

Type II Allergic Reaction: 1. mediated by which immunoglobulins? (2) 2. One other thing involved?

1. IgG, IgM, 2. complement (mem: it takes two to complement the GM)

1. What type of reaction is anaphylaxis? 2. It involves _____-mediated release of active substances 3. End-organ effects of anaphylaxis on the skin? (1) 4. End-organ effects of anaphylaxis on the respiratory system? (2) 5.End-organ effects of anaphylaxis on the CV system (3)

1. Immediate Type I hypersensitivity reaction 2. IgE 3. Urticaria (hives) 4. --> Bronchospasm --> Upper airway edema 5. --> Vasodilation --> Changes in inotropy --> *Increased capillary permeability* (half of IV volume

Summary of Drug Clearance: 1. Hypoalbuminemia and ascites will (increase/decrease) the volume of distribution of select drugs 2. Portosystemic shunting allows orally administered drugs to partially bypass the liver, resulting in (increased/decreased) systemic effect and duration 3. Do liver function tests give a diagnosis of the specific hepatic disease? 4. Name three categories of liver dysfunction

1. Increase 2. Increased 3. No --> but they can help identify a category of dysfunction 4. Hepatocellular, Hepatobiliary, Hepatic synthesis --> Hepato-cellular, synthesis, biliary

1. Ketamine produces a dose-dependent (increase/decrease) in markers of hepatic injury 2. Out of the following, which could hurt the liver: propofol, etomidate, thiopental, ketamine 3. Non-pharmacologic causes of liver injury? (2)

1. Increase 2. Ketamine & Thiopental 3. --> Sepsis/inflammation --> *Hypoxia/ischemia*

Three measures of acute renal failure: (KNOW THESE)

1. Increase in serum creatinine >0.5 mg/dL 2. 50% decrease in creatinine clearance 3. Decreased renal function resulting in the need for dialysis

How will intra-hepatic (aka hepatocellular) dysfunction affect the following: 1. Bilirubin 2. AST/ALT 3. Alkaline phosphatase 4. Causes of intra-hepatic dysfunction? (5)

1. Increased conjugated fraction 2. Markedly increased 3. Normal to slightly increased 4. Viral/Drug induced hepatitis, sepsis, hypoxemia, cirrhosis

How will post-hepatic (cholestatic) dysfunction affect the following: 1. Bilirubin 2. AST/ALT 3. Alkaline phosphatase 4. Causes of post-hepatic dysfunction? (2)

1. Increased conjugated fraction 2. Normal to slightly increased 3. Markedly increased 4. Biliary tract stones; Sepsis

1. End-effect of secondary hyperalgesia? 2. Which lasts longer, primary or secondary hyperalgesia?

1. Increases the size of the "injured" area to include adjacent non-injured tissue 2. Primary

PCA Benefits: Circumvents issues of.... (3)

1. Interpatient variability in analgesic requirements 2. Variability in serum drug levels 3. Administrative delays

1. Vascular dilatations resulting in arteriovenous communications and hypoxia 2. Most common major complication in cirrhosis?

1. Intra-Pulmonary Vascular Dilatations (IPVDs) 2. Ascites

1. FYI: Painless visual loss, no light perception, visual field defects 2. Presents within ______ hrs or often upon ______ 3. Most post-spine surgery cases are (unilateral/bilateral) *3.* Possible contributing factors for ischemic optic neuropathy? (2)

1. Ischemic optic neuropathy 2. 48 hrs; awakening 3. bilateral (could be either though) 4. --> Prone Position --> Lengthy surgery for spinal fusion --> Blood Loss --> Hypotension --> Anemia --> Vasopressors

1. Leading cause of acute vision loss in patients >50 years old (including non-surgical patients) 2. Usually presents (spontaneously/insidiously)

1. Ischemic optic neuropathy (ION) 2. Spontaneously

Type of Immunization: 1. Dead organism, but antigenic material remains. Examples? 2. No longer toxic, but antigenic material intact. Examples? 3. Cultured in special media or passed through animals until mutated enough that won't cause disease, but still antigenic. Examples? (3) 4. Transfused T-cells or antibodies from another person or an animal. Confers immunity for hours to weeks

1. Killed --> DPT (diphtheria, pertussis, tetanus) 2. Chemically treated --> Tetanus, botulism 3. Live-attenuated --> Smallpox, polio, measles 4. Passive immunity

Immunologic function of the liver: 1. The ______ cells are tissue macrophages which filter toxins, bacteria and debris from the GI tract 2. They make up about _____% of the hepatic mass 3.An impairment in Kupffer cell function is often a precursor to _______ and ______, particularly following ______ ischemia or severe GI pathology

1. Kupffer 2. 10% 3. Sepsis and MODS; Splanchnic

Skin & SubQ analgesia before actually inserting a spinal: 1. Identify the _____ or ______ interspace 2. Starting near the (top/bottom) of the chosen interspace, create a skin wheal of _____% lidocaine with a ______ or smaller needle 3. Insert at a ____ to ____ degree angle in cephalad direction 4. Inject to a depth of _______" in direction of anticipated spinal needle travel

1. L3-4 or L4-5 (Certainly no higher than L2-3) 2. bottom; 1%; 25g 3. 10-15 degree 4. 1-2" (base depth of injection on patient's body habitus)

Fluid managment/urine output for renal patients: 1. Avoid potassium containing fluids like _____ *2. With severe renal disease (but not ESRD) consider pre-op _____, typically with (NS/half NS) 3. Most likely etiology of decreased UOP is..... 4. Intra-op UOP is (predictive/not predictive) of post-op renal function *5. With ESRD, the margin of safety for fluid challenge is (narrow/wide)

1. LR 2. Hydration; either one 3. Inadequate circulating fluid volume (likely will respond with fluid bolus, assure volume is adequate prior to using mannitol or lasix to stimulate output) 4. Not predictive *5. Narrow (tend to be more conservative with fluids)

1. What kind of IV access is needed with liver pts? 2. When providing regional anesthesia to a liver pt, make sure that they're not dry (centrally/peripherally) 3. Encephalopathy within 2 weeks of development of jaundice or within 8 weeks of initial manifestation of hepatic disease

1. Large bore IV access 2. Centrally 3. Fulminant Hepatic Failure

1. Metabolite of atracurium and cisatracurium? 2. S/E of the metabolite

1. Laudanosine 2. seizures --> Careful with laudanosine and renal failure because it is renally excreted

1. Tx for a hepatocellular carcinoma 2. Pregnancy-related liver disease occurs during which trimester? 3. Produces an increase in circulating bile salts 4. Looks like cirrhosis, but it's (more/less) severe 5. Cholestatic disease is similar to ______, but less severe

1. Liver transplant --> most don't have a resectable tumor 2. 3rd --> or immediately postpartum 3. cholestatic disease 4. Less 5. Cirrhosis

1. Mechanism of a PDPHA? 2. Which needle is more associated with PDPHA? 3. Pencil point needles have (higher/lower) incidences of PDPHA 4. This is d/t (more/less) cutting of fibers and a (more/less) significant inflammatory response

1. Loss of CSF through hole in dura causes the brain to be displaced downward, causing traction on sensitive structures (nerves) 2. Cutting needle (e.g. Quincke) 3. Lower 4. Less; more (seals the hole)

Pulmonary changes in chronic renal failure: 1. Main pulmonary change with chronic renal failure? 2. This is amenable to ______ 3. Explain what the CXR will look like with pulmonary edema from chronic renal failure

1. Low-pressure *pulmonary edema* (secondary to increased permeability of alveolar capillary membranes) (butterfly wings) 2. Hemodialysis 3. Peripheral vascular congestion appearing as a "butterfly wing" distribution

1. (segmental arteries/lymphatics) are near dural cuff 2. (segmental arteries/lymphatics) run between the aorta and the spinal cord

1. Lymphatics 2. Segmental arteries

1. ______ proteins *carry antigen* proteins degraded in antigen-presenting cells to the cell surface 2. Which is the most numerous of the T-cells? 3. Major regulator of virtually all immune function 4. Via production and secretion of ______ which act on other immune system cells and bone marrow

1. MHC --> Major Histocompatibility Complex 2. Helper T-cells (75%) 3. helper T-cells 4. lymphokines

*Contraindications:* Pre-existing neurologic disease and spinal anesthesia: 1. Potential for exacerbation of diseases like ______ 2. T/F: It's a contraindication d/t legal concerns 3. T/F: Neuro diseases precludes regional anesthesia

1. MS 2. false 3. false (but warrants a more thorough discussion with the patient, probably should document this beforehand!)

1. Where is the ligament flavum thickest? 2. You are (more/less) likely to puncture the spinal meninges at this location 3. Which epidural insertion technique is *least likely* to result in unintended meningeal puncture ("wet tap")?

1. Midline 2. Less (*midline = farthest from the meninges*) 3. Midline insertion

1. At the L3-L4 level, the ligamentum flavum is thickest at _______ 2. At the L3-L4 level, the epidural space is deepest at ______

1. Midline 2. Midline (midline is the safest epidural approach; avoids wet taps)

Post-op management of renal patients: 1. Use smaller doses of which two narcotics in a renal pt? 2. Why?

1. Morphine (M6G) & Meperidine (normeperidine --> sz) 2. Their metabolites are active and renally excreted

Nephrotoxic insults:*Pigment nephropathies* 1. Describe rhabdomyalysis 2. Hemolysis 3. Jaundice 4. What occurs when conjugated biliruben is >8mg/dl?

1. Myoglobin transformed to ferrihematin and precipitates in the proximal tubules 2. Renal damage secondary to RBC stroma deposition 3. Circulating endotoxins induce renal vasoconstriction 4. bile salt excretion ceases and portal septicemia occurs

1. Major s/e when using opioids in an epidural? 2. (hydro/lipo)philic opioids usually cause less of this side effect 3. Examples? (2)

1. N/V (20-50%) 2. Lipophilic 3. fentanyl; sufentanil

Renal protection in sepsis: 1. Patients with septic shock, hypotension, and oliguria *benefit* from administration of _____ to keep MAP above 60 mmHg *2. How will #1 effect SV, GFR, and HR? 3. Adding #1 may be particularly beneficial in pts who can be weaned off of high-dose _____ 4. It may take a lot of NE to increase BP, because they're very vasodilated from _____ release and lack of______ after prolonged hypotension

1. NE 2. -Increased SV & GFR -Decreased HR 3. Dopamine 4. NO; Vasopressin

Management of ascites (5)

1. Na+ restriction and gentle diuresis 2. Paracentesis 3. Peritoneal-venous shunt (P/J shunt) 4. TIPS(Transjugular Intrahepatic Portosystemic Shunt) 5. Transplant (*STAR* shunt, transplant, aspirate, restriction)

1. Treat opioid-induced urinary retention with low-dose _____ 2. Are complications more prevalent with spinal anesthetics or epidurals? 3. Name 2 side effects are relatively common with an epidural 4. Name 1 that is not

1. Nalaxone 2. Spinals 3. Pruritis and urinary retention 4. Resp depression

1. Which drug causes a release of nitric oxide in the spinal cord, prolonging and intensifying analgesia when added to a spinal block 2. Uncontrollable factors that can influence *block height* in a spinal?

1. Neostigmine 2. Volume & density of *CSF*

1. How can dynamic modulation neuroplasticicy be described? *Dynamic modulation neuroplasticity*: Primary or Secondary hyperalgesia 2. Describe primary hyperalgesia 3. Describe Secondary hyperalgesia

1. Neural activity-dependent plasticity 2. Peripheral nocioceptors sensitized by locally released mediators of injury/inflammation (Prostaglandins, bradykinin, K+ ions) Intensity and frequency of neural discharge increases and previously subnoxious stimuli now can generate action potentials, sending impulses to the spinal cord 3.Exaggeration of impulse conduction in first-order neurons by axonal release of Substance P produces vasodilation and mast cell degranulation (releasing histamine and serotonin)

1. Alternative to the *nitrous-narcotic* technique for the wake up test? (2) 2. Acrylic bone cement, occasionally associated with sudden hypotension

1. Volatile & remifentanil infusion 2. Methyl methacrylate

1. How serious is an epidural hematoma? 2. For best outcomes, treat within ______ hrs 3. T/F: NSAIDS increase risk of epidural hematoma 4. What should you do if you can't pull the epidural catheter out?

1. Neurosurgical emergency 2. 8 (early detection is key to good outcome) 3. False 4. Put them back into the original position that they were in when you put the epidural in

*Important:* 1. What anesthetic technique is acute angle-closure glaucoma associated with? 2. This is an emergency requiring immediate _______ consultation

1. No association with any anesthetic technique 2. opthalmologic

1. The rise in K+ levels with sux will be (augmented/diminished) in pts with renal failure 2. How much will it increase? 3. Be especially careful with what types of pts? (2) 4. T/F: Sux administration is contraindicated in pts with renal failure

1. No change 2. Still about 1 mEq/L (range: 0.5-1.0) 3. --> *Extensive neuropathy* --> High or high-normal K+ to start 4. False

1. The amount of fat in circulation has a (direct/inverse/No) correlation with the severity of symptoms in fat embolization syndrome 2. *Fat Embolizaiton Syndrome:* Mechanical obstruction of end-organ _______, which triggers a systemic ______ response *3. Major features of fat embolism syndrome *(3) 4. You need at lease ______ of the major symptoms on the previous list for diagnosis. 5. What is the most common symptom of FES?

1. No correlation 2. Capillaries; Inflammatory 3. CPR --> Cerebral Involvement --> Patechial rash --> Resp Insufficiency 4. 1 5. Hypoxemia

Hematologic changes in chronic renal failure: 1. What type of anemia develops and why? 2. Most effectively treated with synthetic _____ 3. What bleeding test is normally useless, but might be a good tool with renal patients? 4. Why aren't the other tests useful? 5. Bleeding time is useful in pts with _____ or ______

1. Normocytic, normochromic d/t decreased erythropoietin production 2. erythropoietin 3. Bleeding time (correlates best with tendency to bleed) 4. Platelet count, PT, and PTT may remain normal in a renal patient 5. HELLP; uremia

Because blood loss may be so extensive with thoracolumbar spinal surgery, what might you consider? (3)

1. Normovolemic hemo*dilution* 2. Deliberate *hypotension* 3. *Staging* of the surgery (do the procedure in two separate surgeries)

Predictors of a poor prognosis with halothane hepatitis? (3) 4. Dose and hepatitis?

1. Obesity 2. Age >40 3. Overt jaundice 4. Unrelated (Fat Old Yeller)

1. Name 2 risk factors for non-alcoholic fatty liver disease 2. Non-Alcoholic fatty liver disease (NAFLD) pts are usually (symptomatic/asymptomatic) 3. Three types of alcoholic liver disease 4. 2 most frequent etiologies of cirrhosis?

1. Obesity and DM II ('Merica) 2. Asymptomatic 3. --> Fatty liver (steatosis) --> Alcoholic hepatitis --> Cirrhosis 4. --> Hep C --> Alcohol abuse

Acute renal failure management: *IMPORTANT* 1. In general, attempts to convert _____ to _____ renal failure with _______ are unsuccessful and potentially harmful *Two Exceptions*: 2. Diuresis with ______ may be appropriate in which two types of pts?

1. Oliguric to non-oliguric; diuretics 2. Mannitol; Post-renal transplant or renal crush injury (Post-transplant ATN was decreased in patients who received mannitol *in addition to adequate hydration*) (Forced alkaline diuresis with mannitol is useful in preventing ATN following renal crush injury)

Antibiotics and Anaphylactic reactions: 1. Which abx is most closely associated with anaphylactic reactions? 2. Reactions with ______ are rare (0.02%), and increase (significantly/minimally) with a PCN allergy

1. PCN 2. Cephalosporins; *minimally*

1. What test may be a useful monitor in acute liver failure? 2. A patient is on coumadin, and Vitamin K is given. Failure of normalization of PT/INR following vitamin K indicates underlying _______ dysfunction 3. Bilirubin is the end product of ______ degradation; about _____% comes from ______ breakdown

1. PT 2. Hepatic 3. Heme; 75%; Hgb

1. Typically transient pain "shooting" into buttocks or down leg 2. Cause? 3. Should you inject into a paresthesia? 4. If your pt experiences a paresthesia, pull the needle back to subQ and redirect in the (same/opposite) direction of side which produced paresthesia

1. Paresthesias 2. You bumped up against a nerve (you're not midline or you overshot your paramedian) 3. NEVER 4. Opposite

1. ______ _____ is a diagnostic procedure for Type IV latex allergies 2. Diagnostic procedures for Type I latex allergies? 3. Which is the gold standard? 4. Relatively common (but strange) way to get a latex reaction?

1. Patch testing --> tape the offending agent onto the pt's skin and wait for a reaction 2. *Serologic* testing 3. *Skin-prick* testing (gold standard) 4. Latex inhalation

*Contraindications:* 1. What the only "absolute" contraindication to regional anesthesia? 2. Why is increased ICP a contraindication to neuraxial anesthesia? 3. What type of intracranial hypertension is not a contraindication to spinal anesthesia?

1. Patient refusal 2. Risk of *herniation* if CSF is removed --> May further increase ICP if large volumes injected into epidural space 3. Benign intracranial hypertension aka pseudotumor cerebri --> Pressure is globally elevated

1. What type of patients have an increased incidence of anaphylaxis? 2. Intolerance 3. Idiosyncratic reaction

1. Patients with an *allergy history* --> asthma, food, drugs 2. Undesirable effect at low drug dosage 3. Undesirable effect independent of dose administered --> ex: anaphylaxis

*Vasopressors* in renal disease: 1. ______ or ______ have the greatest negative impact on renal vasculature 2. _____ or _____ are preferable, but may increase myocardial irritability 3. Ideally, use a _____ ____ before going right to pressors

1. Phenylephrine or *high* dose dopamine 2. β-agonists or *moderate* dose dopamine 3. fluid bolus

How is renal osteodystrophy treated? 1. Limit dietary ______ intake 2. Administer calcium-containing ______, or calcium/_______ supplements 4. Partial _____

1. Phos 2. Antacids; Vitamin D 3. parathyroidectomy

Pathophysiology of *renal osteodystrophy*: 1. Decreased GFR leads to decreased ______ clearance, increased serum ______ leads to decreased serum ______. 2. Decreased renal ______ production leads to decreased intestinal calcium absorption, and subsequently serum calcium. 3. The decreased serum calcium (from both of the above) leads to stimulation of ______ release, which results in bone resorption (calcium release)

1. Phos; Phos; Calcium 2. vitamin D 3. PTH

1. Which mater is closely adherent to spinal cord? 2. This mater layer is connected to arachnoid mater by what? 3. This mater layer has what?

1. Pia mater 2. Trabeculae 3. Fenestrations

1. *Collection of fluid in the pleural space 2. *With a pleural effusion, fluid gathers at the _______ part of the chest, according to the pt's ______

1. Pleural effusion 2. lowest, position

1. *Hallmark of end-stage cirrhosis?* 2. T/F: Hepatic oxygenation is decreased with portal hypertension 3. Explain

1. Portal HTN 2. False 3. Maintained by the *hepatic arterial buffer response*

1. Dietary carbs arrive in the liver via the... 2. After a meal (postprandially) glucose is extracted from the ______ vein with the help of ______ 3. Excess glucose is converted to ______ 4. How much glycogen can the liver store?

1. Portal vein 2. Portal; insulin 3. Glycogen 4. 24 hours-worth --> 75 grams

What 4 pt populations are particularly susceptible to pulmonary-related problems with the surgical stress response?

1. Pre-existing pulm disease 2. Obesity 3. Elderly 4. Thoracic & upper abdominal incisions (POET)

*Pre-renal vs intra-renal* 1. Which still has the ability to concentrate urine? 2. What lab values show this? (2) 3. How do the lab values differ from these 2 test

1. Pre-renal 2. -Urine osmolarity -urine/plasma osmolarity 3. see pic

Tx for hepatic encephalopathy? (5)

1. Prevention 2. Lactulose 3. Neomycin 4. Zinc 5. Liver transplant

1. Describe serum creatinine production 2. T/F: Freely filtered at the glomerulus

1. Produced at a relatively steady rate by hepatic conversion of skeletal muscle 2. True

Prostaglandins and Kinins on the kidneys: 1. promote renal vaso(dilation/constriction) 2. maintain (pre/intra)-renal hemodynamics 3. (facilitate/inhibit) Na+ and H2O excretion *4. Kinins stimulate _____. They act as _____ enhancing the action of prostaglandins

1. Promote renal *vasodilation* 2. Maintain *intrarenal* hemodynamics 3. facilitate 4. Phospholipase A2; vasodilators

Renal protection in sepsis: 1. NSAIDS decrease synthesis of renal vasodilating _____, producing worsened renal function *2. High-dose methylprednisolone will worsen outcomes by increasing catabolism and inhibiting _____, therefore reducing production of vasodilatory prostaglandins 3. It is unclear if _____ oxygen has an advantage in sepsis. Renal DO2 and VO2 (oxygen delivery and consumption) are not tied with systemic values 4. Decreased renal DO2 (does/does not) appear to cause tubular injury

1. Prostacyclin 2. Phospholipase A2 3. Supranormal 4. Does not

Antigens: 1. _____ or large polysaccharide unique to a specific _____ or organism 2. Usually of a (low/high) molecular weight (>8,000) 3. Antigenicity requires regularly recurring molecular groups (______) on the surface Lymphocytes: 4. Most highly concentrated in ______ 5. Also found where? (4)

1. Protein; toxin 2. High 3. Epitopes 4. Lymph nodes 5. --> Spleen --> Thymus --> Bone marrow --> Submucosal tissue of GI tract

1. What do IgE antibodies react with in muscle relaxants? 2. T/F: anaphylaxis may be seen on first exposure to a muscle relaxant *3. Antibodies to muscle relaxants may also cross-react with _____ and _____ *4. _____ class of muscle relaxants may also cause histamine release from direct mast cell degranulation (non-immune mediated)

1. Quaternary or tertiary ammonium ions 2. true (the above are contained in many cosmetic and OTC drugs, so the patient had prior sensitization) 3. neostigmine and morphine 4. benzylisoquinoliniums (curare, mivacurium, atracurium)

1. On a chest film, which chamber makes up the right heart border? 2. The RV is (anterior/posterior) 3. *Accumulation of fluid in the alveoli 4. Ron: negative pressure pulmonary edema is most common in what type of pt? 5. X-ray findings will lag clinical findings by about...

1. RA 2. anterior 3. pulm edema 4. Young, muscular male 5. 1-2 hrs

Invasive monitoring in renal patients: *Arterial line* 1. Some suggest to avoid the _____ and _____ arteries due to potential need for future AV fistulas 2. Pressures and gases will be inaccurate if placed in same arm as an _____ _____ 3. Use the (dominant/non-dominant) arm for an A-line *Central line* *4. Extremely vulnerable to _____ 5. T/F: An existing portocath or temporary dialysis catheter may be used if IV access is difficult *Peripheral IVs* 6. Avoid using veins in the (dominant/non-dominant) arm

1. Radial; Ulnar 2. AV fistula 3. Dominant (save the non-dominant for a future fistula) *4. Infection (strict asepsis) 5. True (remember to remove heparin before use, and re-heparinize when finished) 6. Non-dominate

1. When used for sedation with regional anesthesia, benzos (raise/lower) sz threshold 2. Resuscitation following cardiac collapse from local anesthetic toxicity is more difficult when what medication is on board? 3. What drug class may mask early symptoms of systemic toxicity with LAs, thereby delaying needed tx?

1. Raise --> not a huge deal 2. Diazepam 3. Benzos

1. Best opioid choice for a pt with significant liver disease? 2. Decreased plasma proteins = (more/less) free drug and a (more/less) significant response to a "standard" dose

1. Remifentanil 2. More; More

Airway fire steps: (7)

1. Remove the source (ETT, packing) 2. Stop ventilation 3. If airway fire continues, flood the field 4. Direct laryngoscopy/ bronchoscopy to assess airway damage 5. Reintubation following bronchoscopy 6. Monitor for >24 hours 7. Consider steroids and antibiotics

*What is involved in the endocrine function of the liver? (3)

1. Synthesis and secretion -->IGF-1 --> Angiotensiogen --> Thrombopoieten 2. Biotransformation (conversion of T4 to T3) 3. Inactivation of "endocrine things" (hormones/steroids)

1. In patients on chronic NSAID therapy, what do you want to avoid decreases in _____ _____? 2. Why? 3. Where and why is ANP released

1. Renal perfusion 2. we've taken away the protective vasodilatory effect of the prostaglandins 3. Released from atrial myocytes in response to increased atrial volume and subsequent wall stretch

ANP inhibits the secretion/release of (3)

1. Renin 2. Aldosterone 3. AVP (negative feedback mechanism) (picture shows ATII and not AVP, BUT slide says the above)

1. The majority of retinal blood supply comes from the ______ and ______ vessels 2. What may increase IOP enough to decrease this blood supply? 3. Most patients with CRAO (central retinal artery occlusion) following prone surgery were positioned on a _____ headrest 4. T/F: retinal artery occlusion vision loss is reversible

1. Retinal and choroidal 2. External compression 3. horseshoe 4. false

*Sensory Levels* 1. Sensory level required for a hemorrhoidectomy? 2. Sensory level required for a hip surgery, TURP, or vaginal delivery? 3. Sensory level required for a lower abdominal surgery or appendectomy? 4. Sensory level required for an upper abdominal surgery or cesarean section?

1. S2-S5 2. T10 (Umbilicus) 3. T6 (Xiphoid process) 4. T4 (Nipple)

*Vertebral Landmarks* 1. Which sacral vertebrae is not fused posteriorly? 2. What vertebrae is the first prominent process? 3. Most prominent process? 4. The inferior angle of the scapula falls at which vertebrae? 5.At which vertebrae is the iliac crest? 6. Posterior superior iliac spine?

1. S5 2. C7 3. T1 4. T7 5. L4 (supracristal plane) 6. S2 (*s*uperior *s*pine)

GI-related problems with the surgical stress response: 1. Pain induces (PNS/SNS) activity, which inhibits GI function 2. T/F: may result in post-op ileus 3. Failure to resume early _____ _____ may contribute to postoperative morbidity (ex: septic complications, abnormal wound healing)

1. SNS 2. true 3. enteral feeding

1. What is more prevalent in the kidneys, SNS or PNS innervation? 2. T/F: effects of anesthesia on the neurohumoral regulation of the kidneys are significant

1. SNS --> kidneys lack PNS innervation 2. False --> Insignificant, other than hemodynamic changes

1. Most common cause of new-onset ARF in the post-op period? 2. Why? 3. Sepsis and renal dysfunction are characterized by _______ nephropathy and renal vaso(dilation/constriction) in the presence of (increased/decreased) cardiac index

1. Sepsis 2. It impairs renal autoregulation (plus, their perfusion is shot) 3. vasomotor; vasoconstriction; increased (d/t decreased SVR)

Sympathectomy is absolutely contraindicated in... (2)

1. Severe aortic stenosis 2. R to L shunt (eisenmenger's) (would cause vasodilation and decreased SVR, which increases aortic runoff and decreases aortic root pressure & coronary perfusion pressure)

Nephrotoxicity of volatile agents: 1. Compound A is produced from degradation of ______ with (high/low) flows through CO2 absorbents 2. T/F: this causes renal injury in humans 3. FDA guidelines recommend FGF of _____ L/min to inhibit compound A formation and limit its rebreathing

1. Sevoflurane; low 2. false 3. >1 L/min

*******What layers will you go through when inserting a spinal? (8)*******

1. Skin 2. SubQ tissue 3. Supraspinous ligament 4. Interspinous ligament 5. Ligamentum Flavum 6. Epidural fat / venous plexus 7. Dura 8. Arachnoid

1. Define dermatome 2. What is the dermatome area of T4? 3. What is the dermatome area of T6? 4. What is the dermatome area of T10?

1. Skin area innervated by a given spinal nerve 2. The nipple line 3. Xiphoid process 4. Umbilicus

1. Where is the interlaminar foramen? 2. What forms the base of the interlaminar foramen? 3. Back (flexion/extension) will enlarge this foramen 4. Do we want to increase or decrease lumbar lordosis?

1. Space between two spinous processes --> Triangular shape 2. Upper edge of the lower vertebra's lamina 3. Flexion (slides the articular processes upward) 4. Decrease

Extrinsic regulation - *neural* FYI: Portal venous pressure is dependent upon... (3)

1. Splanchnic arteriolar tone 2. Portal venules 3. Post-sinusoidal tone (hepatic venules)

Cirrhosis - Organ System Dysfunction: 1. Develops secondary to translocation of abacteria from the intestines to lymph noes and subsequent bacteremia 2. Spontaneous bacterial peritonitis develops secondary to translocation of bacteria from the _____ to the ______, and subsequent bacteremia 3. If ______ dysfunction develops with spontaneous bacterial peritonitis, mortality increases significantly 4. *Treatment of spontaneous bacterial peritonitis? 5. ______ dysfunction develops in 1 out of 3 cases, increasing mortality

1. Spontaneous bacterial peritonitis 2. intestines to lymph nodes 3. Renal 4. Cefotaxime + long-term antibiotic prophylaxis 5. Renal

1. Spinals and epidurals have endocrine/metabolic effects, including inhibition of the surgical _____ ______ due to blockade of (afferent/efferent), (motor/sensory) input 2. Greatest effect with (upper/lower) extremities and (upper/lower) abdominal surgery 3. Spinals: to get the hole in the right position with a pencil-type needle, go a little further after popping through the ______ mater

1. Stress response; afferent sensory 2. lower; lower 3. Arachnoid

Epidural catheter malposition - possible locations (4)

1. Subarachnoid 2. Subdural 3. Intravascular 4. Foraminal

1. Is hepatic innervation more sympathetic or parasympathetic? 2. PNS stimulation of the liver causes blood glucose to (increase/decrease) d/t increased _______ synthesis and glucose uptake

1. Sympathetic 2. --> Decreases --> Glycogen

Helper-T cell function: 1. Stimulation of growth and proliferation of cytotoxic and suppressor ______ 2. Stimulation of ______ growth, proliferation, plasma cell formation and antibody secretion 3. Accumulation and activation of ______ 4. (positive/negative) feedback stimulation of helper T-cell

1. T-cells 2. B-cell 3. Macrophages 4. Positive

1. Upon antigen exposure, the specific clone of ______-cells proliferates and is released 2. These cells recirculate throughout the body for (hours/days/months/years) 3. T-cells react to antigens only when they are bound to _____ proteins on the surface of antigen-presenting cells 4. Name 3 antigen-presenting cells

1. T-cells 2. months-years 3. MHC (Major Histocompatibility Complex) 4. --> Macrophages --> B-lymphocytes --> Dendritic cells (*most potent*)

1. What does an antigen react with? (2) 2. This reaction initiates an extremely (rapid/slow) "cloning" of that specific T or B cell 3. Name two cells that amplify the antigen reaction process 4. These cells attack and liberate antigenic matter and *secrete interleukin-1* 5. *Secrete lymphokines* to help amplify T-cells and activate B-cells

1. T-cells (surface receptor proteins) and B-cells (antibody) 2. rapid 2. Macrophages & Helper T cells 4. Macrophages 5. Helper T cells --> Helper T cells are kind. lymphoKINE

Non-Opioids: 1. NSAIDs decrease hemostasis by inhibiting _____ and causing _____ dysfunction 2. NSAIDs increase GI bleed rates via inhibition of ______ 3. T/F: Renal dysfunction is likely with NSAID use in a healthy pt 4. COX-2 increases expression during ______ 5. T/F: Selective COX-2 inhibition may produce analgesia without blocking the wanted effects of COX-1

1. TXA2; platelet 2. COX-1 (which leads to decreased production of the *prostaglandins* that protect the gastric mucosa) 3. False --> possible with high-risk patients, ex: hypovolemia, baseline renal dysfunction 4. inflammation 5. true

1. Longest acting spinal anesthetic when vasoconstrictor added and dose? 2. Packaged as ______ crystals 20mg 3. Reconstitute with ___ ml sterile water to give a ___% solution 4. Mix with equal volume ____ producing a _________ 5 mg/ml (0.5%) solution

1. Tetracaine (pontocaine) --> 12-15 mg 2. Niphanoid 3. 2ml; 1% 4. D10; Hyperbaric

1. *During anaphylaxis, antihistamines are ineffective after what? 2. Anaphylaxis and anaphylactoid reactions are clinically indistinguishable and treated the same.*Main difference*? 3. What drug is responsible for most fatal anaphylactic reactions in the general public? 4. What class of drug is the most common cause of anaphylaxis in anesthesia?

1. The release of vasoactive mediators 2. Anaphylactoid reaction is not mediated by *IgE*, and you will not see elevated *tryptase* levels 3.Penicillin 4. NMB is the most common in anesthesia

1. The benefits of reducing morbidity in thoracic and upper abdominal surgeries are seen only with (lumbar/thoracic) epidural placement 2. When considering s/e in a pt who received neuraxial anesthesia, consider the pt, not just the block. Besides the block, what could be causing hypotension? 3. Viral reactivity: Which epidural opioid is associated with reactivation of herpes simplex labialis?

1. Thoracic --> NOT lumbar 2. volume status (bleeding) 3. Morphine

Stylet: 1. _____ fitting 2. Prevents ______ of needle and carrying tissue into the epidural or _______ space

1. Tight 2. Plugging; subarachnoid

TOLERANCE OF ACQUIRED IMMUNITY 1. Recognition of "host" tissues as distinct from invading organisms *2. Tolerance of acquired immunity fails as age (increases/decreases)* 3. It also begins to fail as the destruction of body tissues releases ____-______, which may activate T-cells or antibodies 4. Failure of tolerance occurs with ______ diseases

1. Tolerance of acquired immunity 2. increases 3. "self-antigens" 4. *autoimmune* (rheumatic fever, some glomerulonephritis, myasthenia gravis, SLE)

Contact with Bone 1. What might cause you to hit bone with a spinal? (3) 2. What do you do if you need to redirect?

1. Too steep an angle; Directed caudal; Started in the wrong place; 2. Pull needle back to subQ tissue and redirect (needle might bend or won't redirect if not done)

1. TIPS stands for? 2. Goes through the IJ to _____ ______ and creates ______ from portal vein to hepatic vein. 3. High rate of shunt ______ and hepatic _______ (because you're bypassing the liver)

1. Transjugular intrahepatic portal systemic shunt - Decompression 2. Hepatic vein; shunt 3. Stenosis; encephalophathy

1. T/F: Hepatic flow regulation allows the liver to get what it needs so that it can serve its purposes for the rest of the body 2. Intrinsic hepatic blood flow regulation is based on... (2) 3. Extrinsic? (2) 4. Intrinsic regulation only occurs with the (portal venous/hepatic arterial) flow

1. True 2. Hepatic buffer response & local metabolic needs (regional microvascular) 3. Neural (sympathetic) or Humoral (epi, NE, vasopressin, etc...) 4. Hepatic arterial --> There is no intrinsic regulation of portal venous flow

1. Describe Glycosuria 2. What is the common cause? 3. Earliest sign of diabetic nephropathy? 4. Urinary sodium of _____ mEq/L reflects decreased ability of tubules to conserve sodium

1. Tubules unable to reabsorb enough glucose to compensate for an increased load and it is spilled in the urine 2. DM 3. Microalbuminuria 4. ≥40 mEq/L

Epidurals: 1. If you're leaving a catheter in, use a _____ needle 2. If you're doing a single shot technique you could use a _____ needle

1. Tuohy needle 2. Straight (Crawford) (could use a Tuohy for either though)

Central neuraxial anesthesia: 1. Site of action of lipophilic opioids? 2. Examples? 3. (faster/slower) onset and clearance from CSF limits (caudal/cephalad) spread

1. Unclear, spinal vs systemic 2. fentanyl, sufentanil 3. faster; cephalad

Amino acid metabolism: 1. In the liver, ammonia is converted to _______, which is then excreted by the kidneys 2. Pts with liver failure can't degrade ammonia properly, leading to increasing serum ammonia levels and _____ _____

1. Urea 2. Hepatic encephalopathy

1. Spinals & epidurals will cause (diuresis/urinary retention) 2. T/F: hat & mask need to be worn when doing spinal anesthesia

1. Urinary retention 2. True

1. Glucagon is a vaso(dilator/constrictor) 2. High concentrations will decrease the liver's response to ______; _______ may be a more effective way to vasoconstrict the patient 3. How much of a pt's CO goes to the liver?

1. Vasodilator 2. Catecholamines; vasopressin (non-catecholamine) 3. 25%

1. Most definitive test of an intact spine? 2. The wake-up test is most commonly used when repairing a ______ 3. Straightening (distraction) of the spine can impair blood flow to (anterior/posterior) cord 4. A wake-up test should be discussed with the patient (pre/post)-op, and requires careful planning 5. T/F: the pt will not experience recall with a wake-up test

1. Wake-up test 2. Deformity 3. Anterior 4. pre-op 5. False (unlikely, but possible)

1. What can you do if the catheter in an epidural won't advance out the end of the needle? 2. What should you do if the catheter has advanced out the end of the needle, but not far enough into the epidural space?

1. Withdraw catheter & reposition needle 2. Remove the needle and the catheter as a unit (not doing this may shave off the tip of the catheter)

1. Batson's plexus in the epidural space is an extensive network of veins (with/without) valves 2. These veins anastomose freely with ______ veins 3. The epidural venous plexus communicates with (thoracic/abdominal) veins 4. T/F: changes in thoracic or abdominal pressure are transmitted to the epidural venous system

1. Without 2. Epidural (including *Intracranial venous sinuses*, Pelvic veins, and the Azygous system) 3. Both 4. True

1. Is acute Hepatitis C likely to progress to chronic Hepatitis C? 2. Most common indication for a liver transplantation? 3. Most common cause of chronic liver disease in the U.S.?

1. Yes 2. Hepatitis C 3. Non-Alcoholic fatty liver disease (NAFLD)

Other effects of TURP syndrome? 1. Metabolic (acidosis/alkalosis) from absorption of irrigation 2. (increased/decreased) ammonia levels from deamination of glycine irrigant to glyoxylic acid and ammonia 3. the increased ammonia levels could be especially problematic in pts with _____ disease 4. (hyper/hypo)*glycine*mia

1. acidosis 2. increased 3. liver 4. hyper*glycine*mia

1. Aldosterone is released from the ______ in response to (3) 2. Effects of aldosterone? (2) *3. Aldosterone acts via mRNA transcription (in the principle cells of the connecting tubule/collecting duct) so effect is not immediate, but delayed _____ hours

1. adrenal cortex (zona glomerulosa) --> Angiotensin II --> Hyponatremia --> Hyperkalemia 2. -Active Na+ absorption -passive water absorption 3. 1-2 hours

Loss of resistance method: 1. Attach needle to a syringe containing saline and a small _____ 2. Slowly advance needle while applying a ______ pressure on plunger 3. When "loss of resistance" is encountered, inject some of the saline while ______ the bevel cephalad or caudad

1. air bubble 2. bouncing 3. turning

Positive pressure ventilation and the kidneys: 1. The negative effects of positive pressure ventilation and PEEP correlate with ______ pressure 2. Attenuated by adequate _____ load and maintenance of ______

1. airway 2. *fluid load*; CO

Renal patients & general anesthesia: 1. Which general anesthetic techniques tend to reduce GFR and UOP? *2. With general anesthesia, RBF is (increased/decreased), but ______ _____ is maintained (or likely increased) due to angiotensin II-induced efferent arteriolar constriction 3. T/F: Renal autoregulation is typically well preserved 4. If you suspect a renal ischemic event, which antihypertensive should you *not* use?

1. all (not a huge problem) 2. decreased; filtration fraction (FF = GFR/renal plasma flow) 3. true 4. CCB

A bit subjective, but what would you say are the two most important components of the anesthesia machine checkout?

1. ambu bag 2. full oxygen cylinder "ultimate backup, very important"

1. Nephrotoxic insult is directly r/t high trough levels of what drug class? 2. How can we adjust dose to reduce toxicity? 3. What type of acute renal failure is typically non-oliguric with decreased concentrating ability? 4. Prostaglandins normally help protect the kidneys. Administration of ______ inhibits that protective activity, with a subsequent (increase/decrease) in RBF and GFR

1. aminoglycosides 2. once-daily dosing --> mechanism not on the exam 3. Nephrotoxic ARF (intrarenal) --> just dumps urine out without concentrating it 4. NSAIDS; decrease

1. These run along the anterior and posterior surfaces of the vertebral bodies 2. T/F: These are penetrated during a spinal/epidural 3. Function?

1. anterior and posterior longitudinal ligaments 2. false 3. spinal cord stabilization

Cytotoxic "killer" T-cells: 1. Receptor proteins on the surface of cytotoxic "killer" T-cells bind with a specific ______ 2. ______ secreted which puncture the attacked cell 3. T/F: Cytotoxic substances released into attacked cell 4. Attacked cell (swells/crenates) and dissolves, then the cytotoxic "killer" cell moves away to circulate and later attack other cells

1. antigen 2. perforins (hole-forming proteins) 3. true 4. swells

Plasma cell antibody formation: 1. Dormant B-Lymphocyte + ______ = *Lymphoblasts* 2. Some of lymphoblasts differentiate to form ______ 3. Plasmablasts divide to form ______ Cells 4. Plasma Cells produce ______ Globulin Antibodies (2,000 molecules /second/plasma cell) 5. This process continues for days to weeks or until the plasma cell ______

1. antigen 2. plasmablasts 3. plasma 4. gamma 5. dies

*S/E of placing a central line too low: 1. Low risk of ______ 2. Even lower risk of myocardial ______, leading to rupture and pericardial tamponade 3. Optimal position of the catheter for a central line?

1. arrhythmias 2. erosion 3. SVC

Epidural blood patch: 1. Must use strict (sterile/aseptic) technique 2. Must perform a basic neuro H&P and watch for new onset of neuro symptoms indicating a...

1. aseptic (confusing, says sterile on slide 83 but aseptic on slide 84....) 2. subdural hematoma

1. Before redosing (bolus dosing) an epidural, always _______ to make sure that you're in the right place 2. Does this include a catheter with a continuous infusion running? 3. If an epidural catheter is left in place, try to time the removal in conjunction with ______ dosing 4. A patient who can't sit still is especially dangerous with _______ and _____ epidural placement

1. aspirate 2. yes 3. anticoagulant (most bleeds occur after catheter removal!) 4. thoracic and cervical

Effects of IV epidural injection on the CNS 1. Initially, you will see CNS (excitation/depression) d/t inhibition of (excitatory/inhibitory) neurons in the ______ 2. At higher concentrations you see CNS (excitation/depression) due to inhibition of the (inhibitory/excitatory) pathway

1. excitation; inhibitory; cortex (seizures) 2. depression; both

Nitrous-narcotic technique done for a wake-up test: 1. Volatile d/c'd well (before/after) the test 2. Titrate NMB to achieve ______ twitches 3. D/C _____ 4. Begin asking the patient to ______. Be patient, this may take a few minutes for them to get light enough 5. When the surgeon's satisfied, (lighten/deepen) the anesthetic, being sure another wake-up won't be needed too soon.

1. before 2. 2-3 (don't fully reverse; don't want pt moving too much and hurting themselves) 3. N2O 4. wiggle toes (follow commands) 5. deepen

1. When securing an epidural catheter, use ______ or ______ to improve adhesion 2. Always use ______ tape. Apply a sterile _______ dressing if the catheter will be in place for a while

1. benzoin or mastisol 2. silk; occlusive

LA + opioid *epidural* cocktail: 1. (better/worse) post-op analgesia 2. (faster/slower) regression of sensory block 3. (increased/decreased) required dose or concentration of LA 4. (increased/decreased) incidence of s/e

1. better 2. slower 3. decreased 4. *unclear*

1. Only way to know the specific nature of hepatic damage? 2. What's the safest way to do a liver biopsy if the pt has coagulopathies? 3. Two other ways biopsy can be done?

1. biopsy 2. transjugular (maybe because it's easily compressible?) 3. open or percutaneous

Extensive throaco-lumbar spinal surgery: 1. ________ loss may be enormous 2. T/F: Positioning and ongoing monitoring of positioning is critical 3. Give two examples of neuro monitoring techniques that may be used

1. blood 2. true 3. --> Evoked potentials --> Wake-up test

Immunologic changes with the surgical stress response: 1. Pain related stress response suppresses (cellular/humoral) immune function, resulting in lymphopenia, leukocytosis, and depression of the RES 2. Anesthetic-induced reduction in ______ of neutrophils 3. T/F: Many known mediators of the stress response are potent immunosuppressants 4. T/F: May play a role in perioperative infection *5. Reduced cytotoxicity of _____ _____ cells may be a factor following cancer resection, which causes release of tumor cells*

1. both 2. chemotaxis 3. true 4. true 5. Killer T

Management of gastroesophageal varices: 1. (Fluid resuscitation/blood replacement) 2. T/F: Airway protection needed 3. What medication is 80% effective? 4. What treatment is 90% effective? 5. ______% of cirrhotics will have gastroesophageal varices

1. both 2. true 3. Octreotide (synthetic somatostatin) 4. Endoscopic band ligation or sclerotherapy 5. 50%

Supraspinal modulation: 1. Descending efferent inhibitory pathways originate at the level of the _____ 2. They synapse in the _____ ______ of the (ventral/dorsal) horn 3. What are the two inhibitory pathways? 4. What does the opioid inhibitory pathway release? (2) 5. What does the Monoamine or α-adrenergic inhibitory pathway release?

1. brainstem 2. substantia gelatinosa; dorsal 3. -opioid -monoamine (alpha-adrenergic) 4. Endorphins and enkephalins 5. NE

1. Pts with obstructive jaundice will have elevated levels of (conjugated/unconjugated) bilirubin 2. This will lead to _______ toxicity; it's important to keep these pts hydrated

1. conjugated 2. renal

Nephrotoxic insults: 1. ______ is an immunosuppressive agent used extensively following organ transplantation 2. How does this produce renal injury 3. Concurrent tx with ________ may reduce the incidence of ATN

1. cyclosporine 2. --> Induces sympathetic hyperreactivity --> hypertension --> Renal vasoconstriction 3. CCBs (cyclosporine + CCB = good combo)

Extrinsic regulation - *neural* FYI: Stimulation of α1 receptors in the liver will: 1. (increase/decrease) blood volume 2. (increase/decrease) blood flow

1. decrease 2. decrease

General Anesthesia with renal patients: 1. Volatiles (increase/decrease) RBF 2. Volatiles (increase/decrease) GFR 3. These effects aren't a huge deal, as long as they're attenuated by adequate ______ loading

1. decrease 2. decrease 3. fluid

Cardiac-related effects of *regional* anesthesia and analgesia: 1. May (increase/decrease) myocardial work and oxygen consumption due to: 2. (increased/decreased) HR 3. (increased/decreased) BP 4. (increased/decreased) contractility

1. decrease 2. decreased 3. decreased 4. decreased

General Anesthesia with renal patients: *1. IV induction agents slightly (increase/decrease) RBF, with the exception of ________, which (increases/decreases) RBF, but (increases/decreases) UOP 2. *Ron*: IV induction agents are probably all ok, except for ______. Just try to not knock your pt's BP to the dirt.

1. decrease, Ketamine, increases, decreases (via SNS activation) (It wouldn't be your first choice, but if you need it, you can use it) 2. ketamine

Renal effects of aortic cross-clamp: 1. Supra or infrarenal cross-clamps both (increase/decrease) RBF by at least ______% 2. Which will decrease RBF more? 3. Following clamp release, what happens to RBF? 4. Clamp times longer than ______ may produce a prolonged decrease in GFR

1. decrease; 50% 2. suprarenal 3. reflex hyperemia (RBF increases to supranormal levels) 4. 50-60 minutes

Hip arthroplasty: When compared to general anesthesia, *regional* anesthesia is associated with: 1. (increased/decreased) blood loss 2. ______x less chance of a DVT 3. (increased/decreased) incidence of PE

1. decreased 2. 4 3. decreased

Cardiac effects of *thoracic* epidural anesthesia: 1. (increased/decreased) incidence of myocardial ischemia and dysrhythmias in high risk populations 2. Significant (increase/decrease) in CV morbidity following major thoracic, abdominal, or vascular surgery

1. decreased 2. decrease

Effects of regional anesthesia and analgesia on the surgical stress response: 1. (increased/decreased) intensity of impulses reaching the spinal cord 2. (increased/decreased) peri-op release of catecholamines & other hormones

1. decreased 2. decreased

Factors to consider when assessing whether or not a spinal is appropriate for the planned surgery: 1. Is the anatomic ________ amenable to a spinal anesthetic? 2. Will the _______ of the surgery exceed that of your block? 3. Does the pt's ______ status make them a candidate for regional anesthesia?

1. location 2. duration 3. mental

When a hip fracture is operated on within the first 12 hours of injury, the following are seen: 1. (increased/decreased) pain 2. (increased/decreased) hospital stay 3. (increased/decreased) peri-op complications *4.* (increased/decreased) mortality

1. decreased 2. decreased 3. decreased 4. no change (results are probably skewed, because "heathier" patients are able to get surgery quicker. "Sicker" patients get tuned up first)

Epidural analgesia is associated with: 1. (increased/decreased) morbidity and mortality 2. (early/delayed) return of GI motility following abdominal surgery, unless _____ are included 3. (preserved/deteriorated) post-op pulm function 4. (increased/decreased) incidence of pulmonary infection and complications, except if _____ are added 5. (thoracic/lumbar) epidural may decrease the incidence of postop MI

1. decreased 2. early; opioids 3. preserved 4. decreased; opioids 5. Thoracic

Effects of transdermal opioids in combination with PCA: 1. (increased/decreased) # of demand doses 2. (increased/decreased) total opioid requirements and s/e 3. How long does transdermal fentanyl take to reach peak effect?

1. decreased 2. no change 3. several hours

Side effects of NSAIDs: 1. (increased/decreased) hemostasis 2. Dysfunction of which organ? 3. T/F: Interferes with bone healing and spinal fusion 4. (increased/decreased) incidence of GI bleeding 5. (broncho/laryngo)spasm

1. decreased --> platelet dysfunction --> Inhibits TXA2 2. kidneys 3. true 4. increased --> Due to inhibition of COX-1 cytoprotective gastric mucosal prostaglandins 5. bronchospasm (could shift AA to LOX pathway)

1. Increased age = (increased/decreased) epidural dose 2. What other pt population may need a lower dose? 3. With a lumbar epidural injection site, ______ mL of LA produces a mid-thoracic block

1. decreased (decreased fat, less compliant space, decreased leakage of drug out of intervetebral foramina) 2. pregnancy 3. 20ml

How does renal dysfunction occur with cirrhosis? 1. (increased/decreased) Na+ and free water excretion leads to _____ 2. decreased renal perfusion and GFR leads to ______ syndrome

1. decreased; ascites 2. hepatorenal

1. Surgical stress (increases/decreases) hepatic perfusion via: 2. (SNS/PNS) stimulation 3. Release of ______ 4. Activation of the ______

1. decreases 2. SNS 3. vasopressin 4. RAAS

Renal effects of nipride - deliberate hypotension: 1. (increases/decreases) renal vascular resistance but shunts blood (towards/away from) the kidneys 2. This produces significant (increase/decrease) in RAAS and catecholamine release

1. decreases; away from 2. increase

1. Laparotomy (increases/decreases) hepatic and splanchnic blood flow by producing marked vaso(dilation/constriction) 2. Laparoscopy (increases/decreases) hepatic and splanchnic blood flow d/t the _______ that's created 3. *Chronic* hepatitis implies hepatic inflammation and necrosis for longer than _____ 4. How do we find the *cause* of chronic hepatitis? 5. How do we find the *grade and stage*?

1. decreases; vasoconstriction 2. decreases; pneumoperitoneum 3. 6 months 4. Serologic testing 5. Biopsy

1. Vasopressin and octreotide help with portal hypertension by (increasing/decreasing) arterial inflow and (increasing/decreasing) portal venous pressure 2. This will result in (increased/decreased) pressure on esophageal varices 3. Which one is used more often?

1. decreasing; decreasing 2. decreased 3. Octreotide (Sandostatin)

Epidurals: 1. Increased abdominal pressure or a mass compressing the vena cava (pregnancy) will (dilate/constrict) the venous plexus 2. A dilated venous plexus will (increase/decrease) the spread of LA 3. It will also (increase/decrease) the probability of puncturing a vein during epidural placement

1. dilate 2. increase (d/t decreased effective volume of epidural space) 3. increase

Brachial plexus block for *shunt placement*: Advantages: 1. Ideal surgical conditions secondary to vaso(dilation/constriction) 2. Good (pre/post)-op analgesia 3. Avoids many of the concerns with what type of anesthesia? Disadvantages: 4. T/F: Must assure that the pt can coagulate 5. Possible presence of _____ or _____ neuropathies 6. Metabolic acidosis (raises/lowers) seizure threshold following IV LA injection 7. *_____ may be inadequate

1. dilation 2. post 3. GETA 4. True 5. Diabetic; Uremic (just document old neuropathies, shouldn't deter from the block) 6. Lowers (It just makes the CNS more suseptible) 7. Duration (meh)

1. Increased abdominal pressure or a mass (pregnancy) compressing the vena cava leads to (dilation/constriction) of the epidural venous plexus. 2. This results in an increased likelihood of venous _______ during epidural (or SAB) placement. It could also cause the local anesthetic to spread d/t (increased/decreased) effective volume of the epidural space

1. dilation 2. puncture; decreased

*In lateral decubitus position:* 1. Hyperbaric: Operative side (up/down) 2. Hypobaric: Operative side (up/down)

1. down 2. up

1. Angiotensin II preferentially constricts (afferent/efferent) arterioles in *lower* concentrations 2. Result: (increased/decreased) RBF and (increased/decreased) GFR 3. *Higher* amounts of angiotensin II will constrict the (afferent/efferent) arterioles, thereby (increasing/decreasing) GFR

1. efferent 2. decreased; increased (decreases RBF but increases glomerular hydrostatic pressure) 3. afferent; decreasing

1. Laser hazards to the patient include vessel or tissue injury, venous gas ______ or an ______ fire 2. T/F: Lasers may hit the wrong target 3. Venous gas embolism associated with lasers is most common in _______ surgery

1. embolism; airway 2. true 3. hysteroscopic

Extrinsic *Humoral* Regulation: 1. Which has a greater effect: epi & NE or dopamine? 2. Hepatic arterial beds contain (α/β) adrenergic receptors 3. Portal venous beds contain (α/β) receptors

1. epi & NE (dopamine is insignificant) 2. both 3. alpha

*1. 1st pain aka* *2. 2nd pain aka* 3. Epicritic (1st) pain is mediated primarily by __-_____ fibers, while protopathic (2nd) pain is mediated primarily by _____ fibers

1. epicritic 2. protopathic 3. A-delta; C fibers

1. FYI: (excitatory/inhibitory) ion channels of peripheral nocioceptors are involved in pain sensation and hypersensitivity to noxious stimuli 2. These channels modulate pain ______ following inflammation 3. *Spinal modulation* is a result of NTs acting on the (ventral/dorsal) horn and on _____ reflexes, which convey efferent impulses *back to the peripheral nocioceptors* (spinal arch)

1. excitatory 2. hyperexcitability 3. Dorsal; Spinal

Renal protection in sepsis: 1. T/F: Low dose dopamine may help protect the kidneys in a septic pt *2. Compared to placebo, low dose dopamine shows no difference in... (4)

1. false 2. -serum creatinine -need for dialysis -ICU stay -mortality

1. T/F: creatinine is good for assessing acute GFR changes 2. Most reliable measure of GFR? 3. Calculated creatinine clearance formula 4.Normal values of creatinine clearance? 5. (increases/decreases) with age

1. false 2. Creatinine clearance 3. (140 - age) x lean body mass (kg) / plasma creatinine x 72 --> most reliable measurement of GFR 4. --> Female: 85 - 125 mL/min --> Male: 95 - 140 mL/min 5. decreases

1. T/F: bearing down will alter the height of the anesthetic block 2. Rate of injection only affects the height of the block with (hypo/hyper)baric solutions 3. Needle bevel only affects height of the spinal block with the ______ needle

1. false 2. hypobaric 3. Whitacre, sprotte (pencil tip)

1. T/F: anaphylaxis may be prevented by a test dose 2. Anaphylaxis would be better described as (intolerance/idiosyncratic reaction) 3. Name the three most common causes of anaphylaxis or anaphylactoid reactions during the perioperative period

1. false 2. idiosyncratic reaction 3. --> Muscle relaxants - 69% --> Latex - 12% --> Antibiotics - 8%

1. T/F: AST/ALT numbers are good prognostic indicators 2. This is because decreasing levels may indicate either ______ from injury or that there's only a few surviving ______ *AST/ALT ratios* 3. >2 is associated with... 4. <1 is associated with

1. false 2. recovery; hepatocytes 3. *alcohol or drug* induced liver disease 4. *viral* hepatitis

Characteristics of opioids: 1. T/F: There's an analgesic ceiling with pure opioid agonists 2. However, the analgesic effect is limited by (2)

1. false 2. tolerance & s/e (n/v, sedation, respiratory depression)

Effect of anesthesia on the surgical stress response: 1. T/F: General anesthesia effectively attenuates the neuroendocrine stress response 2. T/F: high-dose opioid techniques may inhibit some components of the stress response 3. _____ MAC of inhalationals reduces *intra-op* catecholamine release. It will decrease *post-op* catecholamine response by _____%

1. false 2. true 3. 1.5 (MAC-BAR); 0%

1. T/F: ASA and NSAIDs increase risk of developing a hematoma following neuraxial anesthesia 2. In order to perform central neuraxis anesthesia or remove an epidural catheter, a pt on ______ should have an INR of (more/less) than ______ 3. INR standardizes the ______ test

1. false 2. warfarin; less; 1.5 3. PT (international normalized ratio)

Opioids in the epidural space: 1. T/F: resp depression is common with epidural placement Risk factors include: 2. (increased/decreased) dose 3. (increased/decreased) age 4. concurrent use of systemic ______ or sedative drugs 5. more (hydro/lipo)phylic drugs

1. false (no increase compared to systemic opioids) 2. increased 3. increased 4. opioids 5. hydrophylic

Antihypertensives in renal disease: 1. T/F: beta blockers and CCBs are affected by impaired renal function 2. T/F: furosemide and thiazide diuretics are affected by impaired renal function

1. false (unaffected) 2. True

Lipid Metabolism: 1. Excess carbs, lipids, and proteins get synthesized into ______ 2. #1 then esterified to (3) 3. After this, they're packaged into ______ for transport to ______ 4. The liver is capable of synthesizing (essential/non-essential) amino acids

1. fatty acids 2. phospholipids, cholesterol, or triglycerides 3. lipoproteins; adipocytes 4. Non-essential amino acids --> Essential means we must consume in the diet

*Deliberate hypotension renal effects: 1. This drug is a good choice for *deliberate hypotension* because it preserves renal blood flow 2. Which causes a greater reduction in RBF, nitroglycerin or nipride?

1. fenoldopam 2. nipride

An anaphylactoid reaction is produced by activation of: 1. The blood coagulation and ______ systems 2. The ______-generating sequence 3. The ______ cascade

1. fibrinolytic 2. kinin 3. complement

Describe the angle that your needle will need to take in the following regions: 1. cervical 2. thoracic 3. lumbar

1. flat (15 degrees) 2. steep 3. flat

What can you do prior to the placement of methyl methacrylate to prevent hypotension? 1. Ensure adequate ______ status 2. Don't (lighten/deepen) anesthetic just before placement 3. T/F: Oxygenation should be maximized 4. Discontinue ______ before placement. Why?

1. fluid 2. deepen 3. True 4. N2O; because scraping wax off opens the possibility of *air embolism*

Glucose and fasting: 1. Initially, you're going to use _____ to break down glycogen 2. Later, you're going to get glucose via muscle & fat catabolism and _______ 3. Primary reason we have hyperglycemia in chronic liver disease? 4. Hyperglycemia is a(n) (early/late) symptom of chronic liver disease

1. glucagon 2. gluconeogenesis 3. Portosystemic shunting --> Blood coming from splanchnic circulation bypasses the liver and goes right to systemic circulation. 4. Early *Later you will see hypoglycemia r/t inability to store/make glucose

1. Pts with ______ dysfunction and/or elevated levels of circulating (conjugated/unconjugated) bilirubin are susceptible to renal issues *2. Renal dysfunction or failure may occur in up to _____ of patients following liver transplant 3. Does low-dose dopamine help hydrate preoperatively and prevent renal dysfunction?

1. hepatic; conjugated (toxic to the kidneys) 2. 2/3 3. No. (Low-dose dopamine has shown no advantage over preoperative hydration in preventing renal dysfunction in patients with obstructive jaundice)

The portion of the anesthesia machine most likely to develop a leak is the _______________1______________ and consists of the portion from the ______________2_____________________to the __________3____________. This portion is downstream from all machine safety devices except the ______________4_________________.

1. low pressure system 2. flow meters 3.CGO 4. oxygen analyzer

Latex allergy management: 1. Careful ______ to identify at-risk patients 2. Complete ______ avoidance is ideal 3. Elective surgery should be scheduled as the ______ case of the day 4. "Latex Allergy" signs posted on ______ doors 5. Preview all ______ to be used to avoid unintentional exposure 6. Latex-free ______ to accompany patient

1. history 2. latex 3. first (lowest levels of airborne latex particles) 4. O.R. 5. equipment 6. cart

Neuroendocrine effects of the surgical stress response: 1. (hyper/hypo)glycemia 2. (positive/negative) nitrogen balance 3. (increased/decreased) peripheral and pulmonary extravascular fluid 4. (increased/decreased) pain sensation

1. hyperglycemia (d/t insulin resistance, gluconeogenesis, r/t release of epinephrine, cortisol, glucagon) 2. negative (d/t protein catabolism as a substrate for gluconeogenesis) 3. increased (d/t sodium and water retention from aldosterone, cortisol, ADH) 4. increased (d/t sensitization of peripheral nociceptors from catecholamines)

N/V d/t a spinal is associated with: 1. (hyper/hypo)tension 2. Block height greater than _____ 3. Use of what med class? 4. Hx of... 5. Med to help decrease N/V

1. hypo 2. T5 3. opioids 4. motion sickness 5. Choose ephedra before zofran

*CV effects of a spinal block:* 1. (hyper/hypo)tension 2. (tachy/brady)cardia 3. These effects are caused by a blockade of ______ efferents, and are related to block ______

1. hypotension 2. bradycardia 3. sympathetic; height

Immediate treatment goals with anaphylaxis: 1. Correct ______ and ______ 2. Replace ______ ______ 3. Inhibit further ______ and release of vasoactive mediators

1. hypotension and hypoxemia 2. intravascular volume 3. degranulation

(Ron: Don't worry too much about this; probably will never do one) Prone positioning for an caudal in adults: 1. A pillow under the _______ rotates the pelvis, making it easier to enter the _______ 2. Legs should be spread slightly with toes pointed (inwards/outwards)

1. iliac crests; sacral canal 2. inwards

Time frame of anaphylaxis? 1. Typically ______ 2. May be delayed ___ -___ minutes 3. Rarely delayed up to ______ hours 4. Severe symptoms may *recur* __-___ hours later, requiring several hours of close observation 5. Timing unpredictable with what administration route?

1. immediate 2. 2-15 min 3. 2.5 hrs 4. 6-8 hours 5. oral

Hyper and Hypoglycemia in Liver Disease: 1. Primary reason we see hypoglycemia in chronic liver disease? (3) 2. Hypoglycemia is a(n) (early/late) symptom of chronic liver disease 3. Hypoglycemia is also seen with a large hepatocellular cancer d/t (increased/decreased) uptake by the tumor

1. impaired gluconeogenesis, glycogenolysis, and glycogen storage 2. late 3. increased

*Paramedian approach* 1. When is this approach valuable? 2. When do you use this approach? 3. Describe how it is done

1. in pts who are unable to reduce their lumbar lordosis --> ex: elderly males, fusion, you gave a bit too much sedation, hip fracture (pain) 2. If you cant use the median approach 3. --> Move 1 cm lateral and 1 cm caudad --> Maintain 10-15 degree angle cephalad and 10-15 degree angle toward midline

Summary of Drug Clearance: 1. Reduced hepatic blood flow will (increase/decrease) the half-life and effects of high HER drugs 2. A significant (increase/decrease) in dose may be required 3. Hypoalbuminemia results in (increased/decreased) concentration and effect of a drug 4. This would (increase/decrease) the clearance of low HER drugs

1. increase 2. decrease 3. increased 4. increase (why?) *More drug in the unbound form available to be cleared

After tourniquet release with orthopedic surgery, expect: 1. 10-15% (increase/decrease) in heart rate d/t release of _____ 2. Slight (increase/decrease) in CO2 and serum potassium 3. Potential release of ______ 4. Describe Tourniquet pain

1. increase; evil humors (not a huge deal) 2. increase (only rarely do these present a problem) 3. emboli 4. Dull, aching pain and restlessness that sometimes occurs after about 45 minutes of having the tourniquet on

Respiratory effects of regional anesthesia and analgesia: 1. (increased/decreased) postoperative diaphragmatic function 2. (increased/decreased) work of breathing 3. (increased/decreased) ability to cough 4. Facilitation of chest ______ 5. (increased/decreased) incidence of post-op pneumonia & resp failure in high-risk pts following thoracic and upper abdominal surgery

1. increased 2. decreased 3. increased 4. physiotherapy 5. *decreased*

Coagulation problems related to the surgical stress response: 1. (increased/decreased) platelet adhesiveness 2. (increased/decreased) fibrinolyisis 3. (increased/decreased) blood viscosity 4. Combined with immobility, these coag issues predispose the post-op pt to _______ events

1. increased 2. decreased 3. increased 4. thromboembolic

Neuraxial anesthesia: 1. Increased drug volume = (increased/decreased) cephalad spread of drug 2. Less spread = (more/less) resp depression 3. If I want to give opioid and have it act on a concentrated spot, don't mix it with the initial _____ block 4. Might be a good idea to give the opioid after the block has been _____

1. increased 2. less 3. LA (it'll be around 20 mL, pretty large volume) 4. established --> there will be less cephalad spread

*Metabolic regulation* of hepatic arterial blood flow: 1. Decreased portal blood pH and O2 content or increased PCO2 leads to (increased/decreased) hepatic artery blood flow 2. Metabolic regulation of hepatic arterial flow is most active in a (postprandial/fasted) state

1. increased 2. postprandial

How will pre-hepatic dysfunction affect 1-3? 1. Bilirubin 2. AST/ALT 3. Alkaline phosphatase 4. Causes of pre-hepatic dysfunction? (3)

1. increased unconjugated fraction 2. normal 3. normal 4. --> Hemolysis --> Hematoma resorption --> Bilirubin overload from blood transfusion (all r/t *blood*)

*Pressors* 1. Liver disease is associated with (increased/decreased) concentrations of vasodilatory substances such as ______, resulting in a markedly (increased/decreased) response to catecholamines 2. This means that the pt may need (increased/decreased) doses of catecholamines or the addition of a non-adrenergic vasoconstrictor like ______

1. increased; glucagon; decreased 2. increased; vaspopressin

Acute Renal Failure: 1. In pre-renal, the urine/plasma osmolality is (increased/decreased/normal). Value? 2. In renal, the urine/plasma osmolality is (increased/decreased/normal). Value?

1. normal (>1.5) 2. decreased (<1.1)

Renal effects of sympathoadrenal stimulation: 1. β-adrenergic sympathoadrenal stimulation results in (increased/decreased) RBF secondary to... 2. B1 Agonists? (2) 3. Dopaminergic sympathoadrenal stimulation results in (increased/decreased) RBF and may oppose ______-induced vasoconstriction 4. Drugs? (2)

1. increased; increased CO 2. --> Isoproterenol --> Dobutamine 3. Increased; α-adrenergic 4. --> fenoldopam --> Low-dose dopamine (don't need to know dopexamine)

Portal hypertension with cirrhosis: 1. (increased/decreased) vascular resistance to portal blood flow + (increased/decreased) portal venous inflow = (increased/decreased) portal venous pressure and subsequent development of ______ collaterals and shunting 2. Where does the increased portal venous inflow come from? 3. T/F: because of the above, the majority of portal venous blood now cannot bypass the liver 4. How is hepatic oxygenation maintained during portal HTN?

1. increased; increased; increased; portosystemic 2. from dilated splanchnic arterioles 3. false (majority now bypasses liver) 4. hepatic arterial buffer response

Effects of SNS stimulation in the liver: 1. Hepatic vascular resistance (increases/decreases) 2. Hepatic blood volume (increases/decreases) 3. Blood glucose (increases/decreases) due to increased...

1. increases 2. decreases 3. increases; gluconeogenesis and glycogenolysis

Factors that can cause the release of vasopressin: 1. (increasing/decreasing) plasma osmolality 2. (increased/decreased) intravascular volume 3. Arterial (hyper/hypo)tension 4. Which is the *most potent* stimulus for the release of vasopressin?

1. increasing 2. decreased 3. hypotension 4. *hypotension*

1. After a test dose, subsequent epidural doses should be done ________, and only after ______ 2. You'll typically give ______ mL at a time

1. incrementally; aspiration 2. 5

When compared to a continuous epidural infusion (CEI), patient-controlled epidural analgesia (*PCEA*): 1. Allows for ______ of dose 2. (increased/decreased) total drug use 3. (superior/inferior) analgesia 4. (improved/worse) patient satisfaction 5. (improved/worse) side effect profile 6. T/F: In contrast to traditional IV PCA, use of a background infusion appears to be advantageous

1. individualization 2. decreased 3. superior 4. improved 5. *same* 6. true

*Positive pressure ventilation and the kidneys: 1. Positive pressure ventilation leads to transmission of ______ pressure to the _______ space, which causes the following: 2. (increased/decreased) venous return, filling pressure, and *cardiac output* 3. decreased cardiac output leads to *baroceptor-mediated*(increase/decrease) in sympathetic tone with renal vasoconstriction and Na+/ water conservation 4. Decreased filling volume (increases/decreases) *ANP* secretion with subsequent *increases in sympathetic tone, renin activation, and AVP activity*

1. intrapleural; intravascular 2. decreased 3. increase 4. decreases

CV effects of the surgical stress response: 1. Myocardial ______ and CHF 2. Coronary vaso(dilation/constriction) 3. (hyper/hypo)coagulability 4. Why does myocardial ischemia result as part of the surgical stress response? 5.Why does congestive heart failure occur as part of the surgical stress response?

1. ischemia 2. vasoconstriction 3. hypercoagulability 4. *Increased O2 demand* d/t HTN, tachycardia & dysrhythmias 5. Na+ and H2O retention, combined with effects of catecholamines

Non-Opioids: 1. ______ is used as an adjunct in pain management due to NMDA antagonism 2. T/F: May attenuate opioid tolerance 3. Reduces (central/peripheral) sensitization 4. Avoid use in the _____ _____, as concerns of neurotoxicity exist

1. ketamine 2. true 3. central 4. central neuraxis

1. When lasers are in use, use a ______ mask 2. Change the mask if it gets ______ 3. T/F: ordinary OR masks may be sufficient when a laser is in use

1. laser 2. damp 3. false

1. May serve as a vector for viral infection 2. DNA has been detected in smoke plumes from what two nasties (2) 3. DNA has NOT been detected in smoke plumes from (1)

1. laser plume 2. --> Condyloma --> Skin warts 3. laryngeal papilloma

Renal Pre-op: 1. Most important pre-op question for a renal pt? 2. Surgery will ideally be done within _______ after dialysis 3. Easy way to assess volume status? 4. (continue/discontinue) anti-hypertensives

1. last dialysis? 2. 24 hrs 3. tilt (check for orthostatic HOTN) 4. continue

1. What increases the chance of someone suffering from chronic pain? 2. How big of an incision has to occur for changes in spinal cord processing to occur? The following describes (primary/secondary) hyperalgesia: 3. noxious stimuli at the incision site persisting for many days 4. shorter duration; involves adjacent tissues

1. leaving them in a painful state for a long time 2. minor surgical incision 3. primary 4. secondary

Low dose (20 mcg/kg/min) ketamine infusion: 1. (more/less) cognitive impairment & hallucinations 2. s/e similar to those seen in _____

1. less (maybe none) 2. opioids

Effects of a *thoracic epidural* compared to a lumbar epidural: 1. (more/less) lower extremity motor block with (early/delayed) ambulation 2. (more/fewer) neurologic complications 3. (more/less) urinary retention with (more/less) bladder catheterization & infection

1. less; early 2. no change 3. less; less

Epidural opioid drugs for continuous infusion: 1. (hydro/lipo)phylic drugs are generally preferred 2. Examples?

1. lipophylic 2. Fentanyl (2-5 mcg/mL) Sufentanyl (0.5-1 mcg/mL) (Anderson skipped over these doses)

Bilirubin excretion: End products of *heme degredation* 1. Unconjugated bilirubin is bound to albumin and transported to the _______, where albumin & bilirubin are separated 2. Bilirubin is primarily conjugated with ______ ______ 3. Conjugated bilirubin is excreted into the ______ 4. Passes into ______, converted to _______ and excreted. 5. ~10% absorbed in intestine and returns to liver via the ______ vein, where it is sent back through bile to the small intestine. What's another name for this?

1. liver 2. glucuronic acid 3. bile 4. intestines; urobilinogen 5. portal; enterohepatic circulation

ETT fires 1. Ignition of the *outside* of the ETT may produce (local/systemic) thermal injury 2. Puncture of the *______* may allow for an O2-enriched environment at the target site, producing potential for fire ignition 3. Perforation of the *tube itself* may produce a _____ type phenomenon and cause severe damage

1. local 2. cuff 3. blowtorch

Managing a motor block with an epidural catheter: 1. Use a (higher/lower) concentration of LA 2. Catheter-incision (congruent/incongruent) placement 3. Turn infusion (on/off) and assess whether or not motor function returns 4. Persistent or increasing motor block should raise suspicion of (2)

1. lower 2. congruent 3. off 4. --> hematoma --> catheter migration

Selective COX-2 inhibitors: 1. (higher/lower) incidence of GI complications 2. Produce (significant/minimal) platelet inhibition 3. COX-(1/2) inhibitors impair bone healing FYI 4. T/F: COX-2 inhibitors are associated with fewer renal complications

1. lower 2. minimal 3. COX-1 4. false

*Pneumothorax: 1. Collapse of ______ tissue 2. ______ shift 3. T/F: potential cardiopulmonary compromise 4. How do you fix a pneumo?

1. lung 2. mediastinal (possibly) 3. true 4. Needle thoracostomy (Mid clavicular line 2nd intercostal space) (Mid axillary line 4th intercostal space)

Amino acid metabolism: 1. In the liver, proteins are degraded to amino acids in hepatic ______ 2. Then they're used to produce _______ and metabolize _______ 3. They're further deaminated to (3)

1. lysosomes 2. glucose; lipids 3. keto-acids, glutamine or ammonia

The most commonly used breathing circuit for transporting patients is the _______1_____________, also known as a__________2____________ circuit.

1. mapleson F 2. Jackson-Reese should know this from here on out, will get asked somewhere

Following activation of B-lymphocytes, some of the lymphoblasts form new B-lymphocytes rather than plasma cells: 1. What are these new B-lymphocyctes called? 2. These circulate throughout the body in an (active/inactive) state until activated by the ______ antigen 3. A subsequent exposure produces a much (faster/slower), (more/less) pronounced, (sustained/short-lived) response 4. This is why ______ are done in multiple stages over a period of time

1. memory B-cells 2. inactive; same 3. faster, more, sustained 4. immunizations

1. These cells are formed in a process analogous to memory B-cell formation 2. They remain dormant until a subsequent exposure to (that specific/a different) antigen 3. Results in a (more/less) rapid and pronounced effect on subsequent exposure

1. memory T-cells 2. that specific 3. more

General Anesthesia with renal patients: 1. High dose opioid techniques have a (significant/minimal) effect on RBF and GFR 2. (more/less) effective than volatiles in suppressing the *stress response* (vasoconstricting, salt retaining effects of releasing catecholamines, angiotensin, aldosterone, AVP)

1. minimal 2. more (more effective in suppressing stress response)

1. Respiratory effects of spinal anesthesia are (significant/minimal) 2. Use caution in pts dependent on _______ _______ 3. Common s/e?

1. minimal (accessory resp muscles could be compromised by high block) 2. accessory muscles 3. *feeling of dyspnea* (lack of sensation of the chest wall moving; just reassure the pt that they're still breathing)

1. Transmucosal medications are associated with (more/less) rapid absorption compared to oral or transdermal, but require ongoing titration 2. T/F: Indicated for post-op pain

1. more 2. false

Drug Metabolism: 1. Initially, give (more/less) NDNMB to a pt with severe liver disease 2. Why? 3. Subsequent doses should be (larger/smaller) 4. Does it last shorter or longer?

1. more 2. higher Vd = more rapidly removed from central compartment (less of the drug is bound so it's ready to act, but the volume of distribution is higher so it's more rapidly removed from the central compartment) 3. smaller 4. longer (it's not in the central circulation to be cleared)

1. Compared to lipophilic opioids, *hydrophilic* opioids such as _____ or ______ are associated with the following: 2. (rapid/delayed) analgesic onset 3. (longer/shorter) analgesic duration 4. (extensive/minimal) CSF spread 5. Site of action? 6. (more/less) side effects (ex: N/V and pruritus) 7. (early/delayed) resp depression

1. morphine, hydromorphone 2. delayed (30-60 minutes) 3. longer (6-24 hours) 4. extensive 5. spinal 6. more 7. both

Pain modulation via spinal reflexes 1. What does a somatic efferent impulse cause? 2. What does a sympathetic efferent impulse cause?

1. muscle spasm and more pain 2. smooth muscle spasm, vasoconstriction and release of NE in vicinity of wound, resulting in more pain.

1. Adequate local anesthetic blood levels may reduce _______ requirements 2. Excessive LA blood levels may produce ______ effects 3. Which produces a higher blood concentration, epidural fentanyl or IV fentanyl?

1. narcotic 2. toxic 3. Equal

Tourniquet pain tx: 1. If using a regional anesthetic? (2) 2. If using a general anesthetic?

1. narcotics, hypnotics 2. deepen anesthetic

Etiologies of a neuro injury r/t spinal anesthesia: 1. direct ______ trauma 2. Spinal cord ______ 3. Inadvertent injection of neurotoxic substance or ______ 4. Epidural ______

1. needle 2. ischemia 3. bacteria 4. hematoma

Pre-op exam: liver disease 1. If they have no history or physical exam suggestive of liver disease, should a pre-op screening lab be drawn? 2. If hepatic disease is known or suspected, draw labs to... 3. Your pt's LFTs are abnormal, but H&P looks good. Delay surgery?

1. no 2. quantify degree of dysfunction 3. yes (the pt may be in the early, undiagnosed stages of liver disease)

*Clinical findings with a retinal artery occlusion:* 1. Is it painful? 2. Is there vision loss? 3. Abnormal ______ reactivity

1. no 2. yes 3. pupil

1. ______ are free afferent nerve endings of (myelinated/unmyelinated) A-delta and (myelinated/unmyelinated) C fibers 2. *They are activated by what stimuli? (3) 3. These nociceptors lie in close approximation to _____ and _____, with which they operate as a functional unit

1. nocioceptors; myelinated; unmyelinated 2. -Mechanical -chemical -thermal 3. -small blood vessels -mast cells

Tx for a pt with cerebral edema from TURP syndrome? 1. Asymptomatic? 2. Symptomatic? 3. If you treat cerebral edema (hyponatremia) too quickly, central ______ ______ may occur

1. none (as long as the pt is close to iso-osmolar) 2. 3% saline 3. pontine myelinolysis (demyelination)

What is the pathway for neutralization of CO2 in Amsorb?

C02+ H20= Carbonic acid carbonic acid + calcium hydroxide = calcium carbonate which releases H20 and heat?

*Oral* opioids in acute post-op pain: Disadvantages 1. titratable? 2. (prolonged/shortened) onset and time to peak effect 3. T/F: requires a functioning GI system 4. T/F: earlier use of long-acting oral opioids may facilitate transition to oral meds and earlier discharge from the hospital

1. not really 2. prolonged 3. true 4. true

Tx of a retinal artery occlusion: 1. _____ ______ to lower IOP 2. #1 is contraindicated if ______ can't be ruled out 3. IV ______ may increase retinal blood flow 4. Inhalation of 5% ______ in O2 5. ______ by opthalmologist 6. Localized (hypo/hyper)thermia 7. *Immediate ______ consult*

1. ocular massage 2. glaucoma 3. acetazolamide (Diamox) 4. CO2 (dilation) 5. thrombolysis 6. hypothermia 7. *ophthalmology*

Risk factors for a post-op PE/DVT: 1. (older/younger) 2. (obese/thin) 3. Previous _____/_____ 4. What disease? 5. Prolonged ______ (r/t poor pain management)

1. older 2. obese 3. PE/DVT 4. cancer 5. immobility

Risk factors for *hypotension* with a spinal: 1. Age over _______ 2. Hypovolemia or concurrent ______ anesthesia 3. Addition of ______ to local anesthetic (drops their SVR)

1. over 50 2. general 3. phenylephrine

1. While doing a spinal with a cutting needle, the needle bevel should be aligned (parallel with/perpendicular to) the long axis 2. If the pt is sitting, face the bevel towards the (ceiling/side) 3. If the pt is in the lateral position, put the bevel towards the (ceiling/side)

1. parallel with 2. side 3. ceiling

1. This fracture is usually the result of significant trauma and often associated with other injuries (chest, head, liver and spleen) 2. Pelvic fractures are serious, they have a mortality of ______% at 3 months 3. A pt with a pelvic fracture may have extensive ______ bleeding 4. T/F: this surgery may be done in combo with other procedures

1. pelvic fracture 2. 14% 3. retroperitoneal 4. true

General renal-directed goals with anesthesia: 1. Maintain renal blood flow with adequate ________ pressure 2. Suppress vaso(dilating/constricting), salt (retaining/wasting) response to surgical stimulation and ______ 3. Avoid or minimize ______ insults

1. perfusion (adequate FLUID volume) 2. vasoconstricting; salt retaining; pain 3. nephrotoxic (ex: meds, ischemia causing hypoperfusion)

Drug Metabolism: (Hepatic biotransformation) 1. Phase 1 reactions make the drug more _____. 2. Phase II reactions make the drug more ______ 3. Transferase enzymes (AST/ALT) are required for phase (I/II) reactions 4. CYP 450 enzymes are required for many phase (I/II) reactions 5. Are phase I or phase II more affected by liver disease?

1. polar 2. water-soluble 3. II (mem: 2 enzymes for phase 2) 4. I 5. Phase 1

Out of pre, intra, or post-hepatic dysfunction, which... 1. increases unconjugated bilirubin? 2. increases conjugated bilirubin? 3. increases AST/ALT? 4. increases alkaline phosphatase? 5. has a cause that is related to blood? 6. is caused by sepsis or a biliary blockage?

1. pre 2. intra & post 3. intra 4. post 5. pre 6. post

Attenuation of central sensitization and the surgical stress response: 1. Interruption and limitation of central sensitization should focus on _____ rather than _____ measures 2. *Preemptive analgesia* has the greatest impact in pts with limited physiologic ______, and those having procedures involving extensive surgical _____

1. preventative; therapeutic 2. reserve; trauma

1. What position shows increased IOP and impaires venous drainage? 2. Increased IOP exacerbated by the head (up/down) position 3. Increased IOP attenuated by the head (up/down) position

1. prone (impaired venous drainage) 2. down 3. up

Pathophys of *hepatorenal syndrome*: 1. Name three things that cause splanchnic arterial vasodilation 2. This leads to (increased/decreased) effective blood volume, activation of the ______, and (SNS/PNS) stimulation 3. End result: intense renal vaso(dilation/constriction)

1. prostacyclin, nitric oxide, and glucagon 2. decreased; RAAS, SNS 3. vasoconstriction

Traditional TURP syndrome: 1. Unipolar cautery shaves slices off the ______ gland 2. Requires use of ______ fluid to distend the bladder and wash out shavings 3. T/F: Absorption of irrigation changes intravascular fluid volume and plasma solute concentrations 4. The absorption results in _____, causing confusion and other problems 5. If the bladder is perforated, fluid may fill the peritoneal space, pushing up on the diaphragm, and causing referred pain to the _____. In order for the pt to let you know that they're feeling this pain, use a _______ anesthesia technique

1. prostate 2. irrigating 3. true 4. *hyposomolality* (more important than hyponatremia) 5. shoulder; regional (Spinal)

Embolic Phenomenon: 1. (common/rare) in most surgical procedures 2. T/F: Have been reports of paradoxical embolism from surgical site 3. *Retinal micro-emboli* common during what type of surgery?

1. rare 2. true (crosses a PFO to arterial circulation) 3. open heart

Acute renal failure management: 1. Limit further ______ damage while correcting H2O, electrolyte and acid-base imbalances 2. Correct underlying cause of ______ 3. Ensure adequate circulating _____ 4. After adequate volume has been given, which vasopressors are the most useful for acute renal failure? (2) 5. Which is better for fluid resuscitation, colloid or crystalloid? 6. If using colloid for fluid resuscitation, *do not* use ____

1. renal 2. *hypoperfusion* (hypovolemia, hypotension, sepsis) 3. volume 4. NE and Dopamine (after adequate volume, dopamine has some benefit but at higher doses may compound the problem from alpha agonism) 5. no significant difference 6. *hespan* (increases incidence of renal failure)

1. A pt with a prior renal transplant should be treated like a pt with... 2. Strict _____ with immunosuppresion *3. Consideration of _____ diseases 4. Deterioration of renal function over hours to days resulting in inability to maintain fluid and electrolyte homeostasis and inability to excrete nitrogenous wastes

1. renal disease (appropriate drug selection and maintenance of fluid volume/perfusion pressure) 2. Asepsis 3. Coexisting (DM, CAD) 4. Acute renal failure

*Types of peri-op vision loss?* 1. ______ artery occlusion 2. Ischemic ______ neuropathy 3. Cortical ______ 4. (acute/chronic) glaucoma

1. retinal (central or branch) 2. optic (anterior or posterior) 3. blindness 4. acute

Respiratory-related problems with the surgical stress response: 1. Pain-induced increase in (smooth/skeletal) muscle tension (splinting) 2. Increased (intra/extra)cellular lung water 3. Someone who has a lots of extra-cellular lung water will have increased WOB. What will it look like?

1. skeletal 2. extracellular 3. fast & shallow (looks like restrictive disease; easier than breathing slow and deep)

*Steps to take after feeling the "pop" of puncturing the dura with a spinal*: 1. Advance the needle (slightly/significantly) 2. Remove the _____ 3. CSF should flow ______ (if not, rotate the hub 90 degrees) *4. ______ the needle on patients back and attach syringe with LA* 5. Aspirate gently; ______ should swirl in your local syringe 6. Inject med, then remove needle before ________ the pt

1. slightly (1-2 mm) (particularly important with pencil point needle where hole is not at end of needle) 2. stylet 3. freely 4. *ANCHOR* 5. CSF 6. positioning

At risk of latex allergy: 1. History of multiple surgical procedures, especially congenital urinary tract anomalies or _____ _____ 2. Healthcare ______ 3. Occupational ______ 4. History of food ______ 5. History of ______, hay fever, rhinitis, asthma, or excema

1. spina bifida (myelomeningocele) (30-70% incidence) 2. providers (70% of adverse events to latex are healthcare workers) 3. exposure 4. allergies 5. atopy (tendency to develop allergic disease)

1. *When administered in the central neuraxis, hydrophilic opioids act on the what?* 2. *When administered in the central neuraxis, lipophilic opioids act on the what?* 3. Nocioception 4. Neuroplasticity

1. spinal cord 2. *spinal cord*, but may have *systemic* effects as well 3. the detection, transduction, and transmission of noxious stimuli 4. Definition: The pain pathway is plastic in nature

Central sensitization neuroplasticity: 1. Increased peripheral nerve firing produces changes in the excitability of neurons in the... 2. There is a (increased/decreased) gradient between the resting and critical threshold potential for firing 3. The response of spinal cord neurons to (afferent/efferent) impulses is altered 4. Once stimulus frequency reaches a critical threshold, these second order neurons produce ______ of APs, rather than a single AP

1. spinal cord 2. decreased 3. afferent 4. bursts (windup)

1. Block height is very dependent upon patient positioning with (spinals/epidurals) 2. Avoid extremes of positioning, such as ______, unless you want a lower block 3. Key element for success with epidurals?

1. spinals (not so much with epidurals) 2. sitting 3. Patient position

Central neuraxial anesthesia: 1. Site of action with hydrophilic opioids? 2. Examples? (2) 3. Hydrophilic opioids stay in the _____ longer. 4. They produce a (faster/delayed) onset, and (longer/shorter) duration of analgesia 5. (higher/lower) incidence of side effects due to cephalad spread within the CSF

1. spine 2. morphine, hydromorphone 3. CSF 4. delayed; longer 5. higher

*Central neuraxial analgesia considerations: 1. Location: ex: _____ 2. Drugs used: ex: _____ (3) 3. T/F: s/e should be considered 4. Risk vs _____ 5. CEI (continuous epidural infusion) vs _____

1. subarachnoid vs. epidural (epidural more common for post-op pain managment) 2. LA, opioids, adjuvants 3. true 4. benefit 5. PCEA (patient controlled epidural analgesia)

Catheter-incision *congruent* epidural catheter placement results in: 1. (superior/inferior) analgesia 2. (increased/decreased) drug dose & s/e

1. superior 2. decreased

When comparing PCAs vs "PRN" analgesic requirements, *PCAs* have: 1. (superior/inferior) analgesia 2. (increased/decreased) pt satisfaction 3. (increased/decreased) risk of pulm complications 4. (increased/decreased) total opioid dose & s/e

1. superior 2. increased 3. decreased (unless family is "helping") 4. *no increase*

1. What would happen if your epidural test dose went intravascular? 2. What about subarachnoid/subdural?

1. tachycardia (except maybe in OB) and ringing in ears 2. Significant block

Once the epidural catheter is in position, withdraw the needle and attach the hub to the catheter. 1. After aspiration, give a _____ _____ to confirm that you're not in the intravascular or subarachnoid space 2. Normal test dose for an epidural?

1. test dose 2. 3 mL 1.5% Lidocaine with epi 1:200,000

When reading flowmeters, a bobbin is read at _______1_______, and a ball is read at _________2_____. Two answers required.

1. the top 2. middle/equator

1. Benefits of reducing morbidity in thoracic and upper abdominal surgery occur only with (thoracic/lumbar) epidural placement 2. These benefits are not seen with (thoracic/lumbar) epidural placement 3. What is this an example of?

1. thoracic 2. lumbar 3. catheter congruency

*Anesthetist's responsibility* with tourniquets (important) 1. Record inflation/deflation ______ and inflation ______ 2. Notify the surgeon at ______, and at least every ______ after that 3. _______ that the surgeon has been notified

1. times; pressures 2. 60 min; 30 min 3. document

Spinal Complications: 1. A block of the entire spinal cord and possibly brainstem is called a... 2. It results in profound (hyper/hypo)tension and (tachy/brady)cardia 3. Could possibly result in a...

1. total spinal 2. hypotension & bradycardia (from sympathetic block) 3. respiratory arrest

1. T/F: In laser surgery, different lasers require different colored lenses 2. Glass or plastic eyeglasses are adequate for ______ lasers, but don't provide full coverage, so _____ should be worn 3. T/F: contact lenses provide some minimal protection

1. true 2. CO2; goggles 3. false (no protection)

Management of *post-op hepatic dysfunction*: 1. T/F: Any suspect medication should be discontinued, and potential sources of infection should be investigated 2. Consider extrahepatic ______ obstruction 3. Get labs to _____ the disease

1. true 2. biliary 3. quantify

Opioid receptors: 1. T/F: opioid receptors are present in peripheral nerves 2. Peripheral opioid effect is more profound in (acutely/chronically) inflammed tissues 3. Opioid receptors produced in the _____ appear to be transported to and activated on primary afferent neurons in response to inflammation 4. Application of opioid in the periphery (at the nerve _____) may produce long-lasting analgesia of similar potency as the _____

1. true 2. chronically 3. DRG 4. Terminal; LAs

Risk factors for respiratory depression during PCA use: 1. T/F: Use of a background infusion increases risk for resp depression 2. (increased/decreased) age 3. Concurrent administration of _____ _____ drugs 4. Coexisting _____ disease or OSA

1. true 2. increased 3. sedative hypnotic 4. pulm

Guidelines for a continuous spinal: 1. T/F: Catheter should be inserted just far enough to maintain placement 2. Use the (highest/lowest) effective local anesthetic concentration, and place a ______ on the dose 3. If maldistribution is suspected, have the pt ______ in order to spread the block 4. T/F: If well-distributed sensory anesthesia is not achieved, the technique should be abandoned

1. true 2. lowest; limit 3. move 4. true

1. T/F: Acute hepatic disease, regardless of the etiology, increases perioperative morbidity and mortality 2. T/F: If patient is known to have acute hepatic disease, elective surgery should be postponed 3. Degree of liver dysfunction and morbidity/mortality are (directly/inversely) related

1. true 2. true 3. directly (which is why it's important to quantify)

1. T/F: The physiologic effects of epidurals and spinals are essentially the same 2. Sympathectomy will be more rapid in (epidurals/spinals) 3. The effects of an epidural are primarily a function of... 4. Differences between a spinal & epidural are d/t the larger volume & doses required for (spinal/epidural) anesthesia

1. true (function of block height) 2. spinals 3. Block height --> And subsequent sympathectomy 4. Epidural

1. T/F: cortical blindness is reversible 2. Tx? 3. Acute angle-closure glaucoma following anesthesia is (common/rare) 4. Most common population is elderly (men/women) 5. s/s of Acute angle-closure glaucoma (2)

1. true (healthy pts may show significant recovery of vision, but course may be prolonged) (retinal artery occlusion is *NOT* reversible) 2. Stop stroke progression 3. Rare 4. Women 5. -Painful red eye -cloudy or blurry vision

PCAs: 1. T/F: Nocturnal hypoxemia may be reduced with the use of supplemental O2 2. Which PCA mode provides the best analgesia? 3. The (epidural/parenteral) analgesic method tends to work better

1. true (mind blown) 2. IV bolus with continuous infusion 3. epidural

Neuro symptoms with *chronic renal failure*: 1. T/F: Wide variation in symptoms 2. Describe the neuropathy. *3. Some symptoms will improve with dialysis, particularly _____ _____.

1. true (ranging from insomnia and irritability to seizures, uremic encephalopathy, and coma) 2. symmetrical, distal, sensory *and* motor neuropathy may be superimposed on diabetic neuropathy *3. Uremic encephalopathy

Nephrotoxicity of volatile agents: *1. Metabolic breakdown to free fluoride ions can produce a _____ lesion resulting in loss of _____ ability 2. Which currently used volatile agent has *high fluoride* ion production? 3. (T/F) #2 produces nephrotoxicity

1. tubular; concentrating 2. Sevoflurane 3. False

*Risk factors for bradycardia with a spinal:* 1. Age under ______ 2. ASA class? 3. Medication?

1. under 50 (younger = more PNS tone) 2. ASA I 3. beta-blockade

Compared to a Mapleson breathing system, work of breathing is increased with a circle system due to the presence of: Two answers.

1. unidirectional valves 2. presence of C02 absorber

Consequences of portosystemic shunting: 1. Esophageal ______ 2. Hepatic ______ 3. Altered drug ______ 4. (increased/decreased) susceptibility to bacterial infection 5. Ascites & ______

1. varices 2. encephalopathy 3. metabolism (particularly PO meds) 4. increased 5. splenomegaly

1. Protamine-related anaphylaxis is more common following what procedure? 2. Also more common in pts with what type of food allergy? 3. Also more common in a diabetic using protamine-containing _______ 4. Protamine may also cause direct _______ release and activate the ______ cascade

1. vasectomy 2. seafood 3. insulin 4. histamine; complement

Renal effects of sympathoadrenal stimulation: 1. α-adrenergic sympathoadrenal stimulation results in vaso(dilation/constriction) 2. Drugs? (4) 3. In a pt who's got acutely compromised renal vasculature, would you prefer an alpha or beta agonist?

1. vasoconstriction 2. --> NE --> epi --> phenylephrine --> high-dose dopamine 3. beta (after you've made sure they're fluid loaded) (not a hard and fast rule)

Hepatorenal syndrome: 1. Intense renal vaso(constriction/dilation) 2. (high/low) GFR 3. (impaired/preserved) renal tubular function 4. renal histology looks (normal/damaged)

1. vasoconstriction 2. low 3. preserved 4. normal (hepatorenal syndrome seems like a flow problem, not a structural problem)

1. Kidney neurohumoral regulation protects against *hypo*volemia and hypotension through vaso(dilation/constriction) and salt/water (retention/loss) 2. What specific factors are involved in kidney neurohormonal regulation? (3)

1. vasoconstriction; retention 2. -Sympathoadrenal axis -RAAS -Arginine Vasopressin

Effect of surgery and trauma on neurohumoral regulation of the kidneys: 1. Significant vaso(dilation/constriction) and salt/water (retention/excretion) lasting several days 2. These effects lead to post-op (poly/olig)uria and (edema/diuresis) 3. T/F: the vasoconstriction predisposes the kidney to additional injury

1. vasoconstriction; retention 2. oliguria and edema 3. true

Symptoms of Cholestatic diseases 1. Peripheral vaso(dilation/constriction) 2. (increased/decreased) CO 3. (increased/decreased) portal venous pressure 4. (increased/decreased) portal venous flow 5. Coagulaopathy secondary to ______ deficiency

1. vasodilation 2. increased 3. increased 4. decreased 5. vitamin K

1. Kidney neurohumoral regulation protects against *hyper*volemia and *hyper*tension via vaso(dilation/constriction) and salt/water (retention/excretion) 2. What specific factors are involved? (3) 3. What drug class could negatively affect this type of autoregulation?

1. vasodilation; excretion 2. --> Prostaglandins --> Bradykinins --> ANP 3. NSAIDS (by inhibiting prostaglandin synethesis)

1. Hypotension is the most potent stimulus for the release of _____ 2. Which works more quickly, aldosterone or angiotensin II?

1. vasopressin 2. Angiotensin II (works almost immediately) --> Aldosterone acts via mRNA transcription, so effect is not immediate, but *delayed* 1-2 hours.

TURP syndrome is dependent upon: 1. # of _____ ____ opened 2. Duration of procedure and pressure of the ______ solution (ideally less than ______ cm above table during initial stages and less than _____ cm during the final stages) 3. Disruption of the _____ capsule 4. _____ pressure at the irrigant-blood interface 5. What are two interventions to improve #4?

1. venous sinuses 2. irrigating; 30; 15 3. Prostatic capsule 4. Venous 5. --> Hydrate to increase CVP --> Watch how steep the trendelenburg is (raises op site above heart) Both of these will decrease the gradient

1. The anterior spinal artery originates from the ______ arteries 2. Supplies the (ventral/dorsal), (motor/sensory) portion of cord

1. vertebral 2. ventral, motor

1. Allergic reactions with opioids are very (common/rare) 2. Be especially aware of the opioid ______, because it may cause direct release of ______

1. very rare 2. morphine; *histamine*

1. Vasopressin regulates urine (2) 2. Arginine vasopressin is synthesized in the ______ 3. Stored in the ______ 4. Vasopressin maintains adequate GFR via vaso(constriction/dilation) of the efferent arterioles, and vaso(constriction/dilation) of the afferent arterioles

1. volume and osmolality 2. hypothalamus (supraoptic nucleus) 3. posterior pituitary 4. constriction; little to no effect on afferent

You can increase the spread of an *epidural* by: 1. Increasing ______ at a constant ______ OR 2. Increasing ______ at a constant ______

1. volume; dose or 2. volume and dose; concentration

List the three components of the C02 absorbent.

1. water 2. neutralizing base (calcium hydroxide in ALL absorbents) 3. catalyst ( either soda lime, lytholime, or absorb) The catalyst is what gives the absorbents their names

Spinal/Epidural prep: 1. Do a good, (thin/wide) prep with betadine or chlolohexidine 2. T/F: You may not be successful at your chosen interspace 3. Drape (before/after) you prep

1. wide 2. true (reason why #1 is necessary) 3. after (always)

Regarding pruritus and epidurals: 1. Is it more prevalent with or without an opioid? 2. Is it more prevalent with fentanyl or morpine? 3. T/F: pruritis is r/t peripheral histamine release 4. It could be r/t a ______ mechanism 5. Best treatment for opioid induced pruritis from epidural?

1. with 2. morphine 3. False 4. Central 5. Small doses of Narcan (20 mcg), benadryl is rarely effective

Non-Opioids: 1. Are NSAIDs useful when used alone? 2. Particularly valuable in a _____ approach, as NSAIDs have a different MOA than opioids or LAs 3. When used as an adjunct, NSAIDs (increase/decrease) opioid dosage and s/e 4. T/F: NSAID use provides an economic benefit to the pt and hospital

1. yes, but only for mild to moderate pain 2. multimodal 3. decreased (less opioid speeds return of GI function, reduce incidence of respiratory depression, improve patient satisfaction) 4. true

Inflation pressures with a tourniquet: 1. ______ mmHg above systolic BP for the thigh 2. ______ mmHg above systolic BP for the arm

1. ~100 2. ~50

The operating room air should be exchanged at least ____ times per hour. A. 3 B. 5 C. 8 D. 10 E. 15

15--E

Basal metabolic oxygen requirement in an anesthetized adult is approximately ________ ml/min.

150-250 ml/min believe he said he wouldn't recommend going below 250 ml/min

Fulminant Hepatic Failure: Encephalopathy within ______ weeks of development of jaundice or within ______ weeks of initial manifestation of hepatic disease

2 8

Laboratory assessment: An alkaline phosphatase specific to liver disease Used to assess whether an elevated AP is of hepatic origin

5'-Nucleotidase (5'NT)

Which of the following does NOT contribute to the production of carbon monoxide by a CO2absorbent? A. High fresh gas flows B. Dessication of the absorbent C. High inspired concentration of volatile anesthetic D. None of the above

A

Which of the following gases are delivered to the scavenging system? Check all that apply. A. Ventilator bellows drive gas B. Excess gas from the APL valve when set to "vent" C. Excess gas from the ventilator relief valve when set to "bag"

A only B- should be "bag" not "vent" C- should be "vent" not "bag"

Which of the following arrangements for a ventilator is safer? A. Ascending bellows B. Descending bellows C. No difference

A- Ascending are safer because bellows must have gas for them to rise, so if disconnect they won't rise all the way, eventually at all if the disconnect is large enough. Serves as a visual cue to the fact that there is a disconnect somewhere. DESCENDING bellows will continue to rise and fall with a disconnect d/t gravity

While on a mission trip in La Rinconada Peru (elevation 16,800'), equipped with a modern anesthesia machine and vaporizers, you are delivering 1.5 MAC of volatile anesthetic, but the patient is moving and clearly experiencing discomfort with surgical incision. The agent you are most likely using is: A. Desflurane B. Isoflurane C. Halothane D. Sevoflurane

A- desflurane Takehomes: 1. modern vaporizers are essentially compensate for ambient pressures so altitude or pressure in hyperbaric chamber don't affect gas output because they are proportioned when leaving the vaporizing chamber. 2. older vaporizers would've had a marked increase in concentration but a less significant increase in partial pressure, so at altitude they would be giving less agent than anticipated and markedly overdelivered agent in hyperbaric chamber. 3. see Barash 675-676 for more explanation but info from book WILL NOT BE ON EXAM

When using vasopressors to treat hemodynamic changes r/t spinal anesthesia, which is preferable: Pure alpha agonist or Alpha and Beta agonist?

Alpha and Beta agonist (spinal = risk for bradycardia. Pure alpha agonist could worsen the brady)

Describe the plateau effect with local anesthetics

An *uncommon* effect Having given a dose of local anesthetic, after a period of time, subsequent doses may be ineffective in raising block height

The preferred granular mesh size in CO2 absorbents is: A. 2-5 B. 4-10 C. 8-15 D. 20-32 E. None of the above

B refers to the size of the granules, means there are 4-10 spaces in 1" that gas can flow through. The smaller the area, the more SA there is for absorption of C02 but this also increased resistance to breathing and work of breathing. If mesh size is too big, not enough SA to absorb CO2

Rebreathing of gases occurs with which of the following systems. Check all that apply. A. Semi-open circle B. Semi-closed circle C. Closed circle D. Bain

B, C, D - Semi-open circles have no rebreathing, we use high FGF to prevent rebreathing - semi-closed circles has some rebreathing - closed circle has a lot of rebreathing - Bain does have rebreathing, although really high FGF can prevent rebreathing, this is not the intention *When talking about closed Vs. Open were really just talking about how much FGF there is

True statements about the Bain circuit include all except: A. Partial rebreathing of gas occurs unless very high fresh gas flows are used B. Scavenging of waste gases is not possible C. Improved warming of fresh gas versus the oher Mapleson systems D. Increased risk of unrecognized disconnect E. None of the above

B- If using very high FGF you can avoid rebreathing but normally some partial rebreathing with a Bain, it can scavenge waste gas which is an advantage, improved warming with a coaxial circuit

The alveolar concentration of volatile anesthetic can be more rapidly altered in a: A. Closed circle system B. Semi-closed circle system C. No difference

B- FGF are much higher, one of the ways we rapidly increase the concentration is to use much higher FGF

In a circle breathing system where rebreathing occurs, assuming a spontaneously breathing minute ventilation of 5 liters/min, at a fresh gas flow of 8 liters/min the reservoir bag would be unnecessary. A. True B. False

B- Flows are exceeding MV because Resp. are intermittent with times of high flow exceeding the FGF, so we need a reservoir bag to meet high demands during inspiration that exceed the 8 LPM

On Friday afternoon, while doing a long case in room 8, you noticed that your CO2 absorbent had turned purple. Since the case was nearly over you didn't change it out during the procedure and forgot to do so afterwards. On Monday morning you are in the same room and during your machine check you note that the absorbent is white again. Shortly after beginning your first case you notice a color change back to purple. The absorbent you are using is most likely: A. Amsorb B. Soda lime C. Bara lime D. Litholyme

B- dye does revert to white after time but rapidly turns back to purple when used again if it is bad/used up. -Baralime would also do this, but it is not on the market anymore -amsorb and lytholime dye does NOT revert to white

The preferred drive gas for a ventilator is: A. Air B. Oxygen C. Heliox D. Argon E. CO2

B- if there is a leak in the bellows, some of the drive gas is getting into the bellows and ultimately the patient, so its better to be oxygen to avoid a hypoxic mixture

What happens to the pia mater at the tip of the spinal cord?

Becomes the filum terminale, anchoring the cord to the sacrum

Identify the incorrect statement about the Mapleson F breathing circuit. A. In the spontaneously breathing patient, an FGF of 2.5x the minute ventilation is necessary to prevent rebreathing B. Results in minimal dead space and resistance to breathing C. May be used with a facemask, but not in an intubated patient D. The overflow valve is located on the reservoir bag, and occlusion of the valve may result in barotrauma E. None of the above

C

Name the laser: Completely absorbed by water in the first few layers of cells Results in explosive vaporization of surface tissue with little damage to underlying tissue

CO2 laser (long wavelength)

Hepatic risk factors that increase complications? (10)

Child-Pugh factors Ascites Cirrhosis Serum creatinine COPD Preop infection Preop upper GI bleed High ASA Intraop hypotension Higher surgical severity score

Catheter-incision congruent vs. incongruent

Congruent = on the same plane as the surgical incision (ex: thoracic incision paired with a thoracic epidural, rather than a lumbar epidural)

Describe the Datex-Ohmeda negative pressure leak test.

Negative pressure bulb to test for low pressure system leaks, must do it for each vaporizer @ initial check to ensure no leaks.

True statements about soda lime absorbent include all, except: A. Can result in the production of carbon monoxide B. If inhaled, alkaline dust from soda lime can produce bronchospasm C. Soda lime can degrade sevoflurane to Compound A D. Soda lime has recently been removed from the market E. None of the above

D- Baralime has been removed

List the currently available (in the United States) volatile anesthetics in order from producing the most to the least amount of carbon monoxide.

DES> ISO>> SEVO=HALOTHANE (won't see much anymore)

Stages of chronic renal failure (least to most severe) (4)

Decreased renal *reserve* Renal *insufficiency* End-stage renal disease (*ESRD*) Uremic *syndrome*

Outline the RAAS

Decreased renal perfusion or SNS stimulation causes the release of renin from JG cells of renal afferent arterioles Renin combines with angiotensinogen to form angiotensin I Angiotensin I combines with ACE to form Angiotensin II, which causes vasoconstriction and the release of aldosterone

Etiologies of a neuro injury from an epidural? (3)

Direct *needle* trauma *Vascular* injury with subsequent neural ischemic insult Epidural *hematoma*

The FDA standard for E-cylinder tank colors states that an oxygen cylinder will be: A. White B. Yellow C. Green D. Gray E. None of the above

E- no FDA standard, colors change when you leave the country, just read the label to ensure correct gas

Hepatic imaging: Endoscopic guidance of a catheter through the ampulla of Vater to inject contrast into the pancreatic duct and common bile duct. Technique of choice when choledocholithiasis is suspected because a sphincterotomy can usually be done and a stone removed

Endoscopic Retrograde Cholangio Pancreatography (ERCP)

Name the laser: Allows for extremely precise focusing of UV light Used extensively in photorefractive surgery

Excimer lasers (very short wavelength)

A positive pressure leak test of the breathing circuit assures the ability to provide positive pressure ventilation and adequate function of the unidirectional valves. A. True B. False

False- Assures PPV but unidirectional valve may be stuck and still able to provide PPV, need to massage bag and make sure the valves move freely, also put lung on switch to vent and make sure valves moving.

The fail-safe valve in an anesthesia machine shuts off, or proportionally reduces flow of other gases when the oxygen pressure falls below a certain value (typically 30 psi), thereby preventing the delivery of a hypoxic mixture. A. True B. False

False- Pipeline crossover will still give hypoxic mixture, could have downstream leak/flowmeter that results in hypoxic mixture, the point is, must have oxygen analyzer

You have exactly 21% FiO2 leaving your flowmeters. In the absence of a leak anywhere in the system, the patient will not be receiving a hypoxic mixture (i.e. less than 21%). A. True B. False

False- You have 21% leaving the flow meters but vaporizers are down stream so now additional gas such as low potency des @ 10% has been added to the 21% Fi02 diluting it to less than 21%. This is most problematic w/ low potency or increased concentrations of agents.

The pin-indexed safety system prevents attachment of the wrong type cylinder to the incorrect yoke? A. True B. False

False- it is designed to prevent this but it can be overcome with an extra washer/washers

A CO2 absorbent canister that becomes warm during use implies exhaustion of the absorbent and failure of CO2 removal. A. True B. False

False- it is supposed to get warm, if it isn't getting warm it would imply it is not working

All CO2 absorbents, if dessicated, will degrade sevoflurane to Compound A and desflurane to carbon monoxide. A. True B. False

False- only sodalime will do this, absorb and lytholime will not degrade servo to compound A & CO

Name the type of alcoholic liver disease: May develop after even a brief period of heavy alcohol intake Typically benign and resolves

Fatty liver (steatosis)

Classic presentation of halothane hepatitis?

Fever, chills, anorexia, nausea, myalgias, and rash followed by jaundice 3-6 days later (looks immunologically mediated... or like you have the flu, and then turn yellow)

What is fresh gas decoupling?

Fresh gas Flow Compensation and Fresh Gas Decoupling Found in newer anesthesia machines to prevent excessive inspiratory volume or pressure related to high fresh gas flows or use of the oxygen flush valve during inspiration. In the absence of these mechanisms, tidal volume is dependent on fresh gas flows as FGF during inspiration is added to the volume delivered from the bellows. Fresh Gas Flow Compensation Inspiratory volume is measured and acts as feedback to adjust the drive gas volume to compensate for fresh gas flow changes, leaks, etc. Fresh Gas Decoupling A decoupling valve opens during positive pressure inspiration which diverts fresh gas flow (and flow from an activated oxygen flush valve) to the breathing bag and scavenger rather than to the patient.

How often should a machine be checked?

Full check at the start of each shift and an abbreviated check before each case/when you switch machines to include PP circuit leak test to ensure a PP breath can be given, suction present and functioning, ambubag

Prophylaxis for a latex-sensitive patient (3 drugs & doses)

H1 Blocker: 1 mg/kg diphenhydramine (benadryl) H2 Blocker: 1 mg/kg ranitidine (zantac) Glucocorticoid: 125 mg methylprednisolone

Name the laser: Less absorbed by water, therefore less vaporization and more thermal coagulation occurs; *deeper* laser TURP, laryngeal papilloma, laser uvulopalatoplasty

Nd:YAG laser (intermediate wavelength)

What do you do if you see a laryngeal/vocal cord papilloma?

Notify ENT surgeon (or at least tell the pt to follow up on it)

Name the epidural space identification method: Subatmospheric pressure in epidural space will suck the drop of solution into the needle

Hanging drop method (very old school)

Drug Metabolism: Fraction of drug metabolized or "extracted" during a single pass through the liver Basis of classification of drugs as having low to high hepatic extraction ratios

Intrinsic clearance

Name the epidural space identification method: When entering the epidural space you will notice a loss of resistance on the syringe plunger; contents are easily injected

Loss of resistance method

List relative opioid potencies to morphine

Meperidine 0.1x Morphine 1x Alfentanil 10-20x Fentanyl 100x Remifentanil 100-200x Sufentanil 500-1000x

Usually in the jackknife position when surgery will require this position Allows patient to position themselves Useful for rectal, perineal procedures May require gentle aspiration on needle as CSF won't flow uphill. Also used for caudal epidural placement in adults (not jackknifed though)

Prone position

Main cause of thrombocytopenia with cirrhosis? Others? (4)

Portal hypertension-induced *splenomegaly* (sequesters 90% of circulating platelets) -Increased destruction by immune mechanisms -Low-grade DIC -Sepsis -Bone marrow suppression by ETOH use and folate deficiency

*******What is one of the most important aspects of spinal preparation that we can control?********

Position

What we need to know about Mapleson's per Ron

So, what do you need to know about the Mapleson's? Probably none of that! Here's my best guess at what's important, I think likely there are only two that matter, both of which are modifications of the Mapleson D. The Bain circuit is the coaxial modification of the Mapleson D and has the alleged advantages of warming of inspiratory gas since it is surrounded by exhaled gases. The presence of some rebreathing also helps maintain moisture. It is also easier to scavenge waste gas than some of the other designs. It takes significantly more fresh gas flow (3-4x) for spontaneous than controlled ventilation to prevent rebreathing. The Jackson-Reese (Mapleson F) is also a mod of the Mapleson D, with the pressure limiting valve moved to the end of the reservoir bag. This is the design most commonly used for a transport circuit, and sometimes in kids for brief procedures because there is minimal dead space and very little resistance in the system to overcome. It takes FGF of about 2-3x minute ventilation to avoid rebreathing. The one favor Mapleson did for us is to put them in order such that greatest rebreathing occurs with "A" and follows in sequence with A>B>C>D=F.

*Epidural hematoma incidence rates: spinals vs epidurals*

Spinals: 1/220,000 Epidurals: 1/150,000 (know these numbers)

FYI: Paramedian approach at L5-S1

Taylor approach

Type III Allergic Reaction: 1. What causes this?

Tissue damage via immune complex formation or deposition

Effective post-op ______ is essential to reducing the deleterious effects of pain on organ systems and post-op recovery

analgesia

Temperature compensation in an anesthetic vaporizer works by:

diverts more or less gas through bypass chamber according to temperature. If temp decreases more gas is diverted to the vaporizer and less through the bypass chamber. If temp increases, decreases flow to vapor chamber and increases flow through bypass chamber Temp and vapor pressure are directly related, increase one the other does as well and vice versa

1. T/F: a type IV reaction (contact sensitivity) may progress to type I 2. Treatment of a Type IV latex allergy? (2)

false --> but it's a huge risk factor 2. --> Avoidance --> Topical steroids

Degradation of sevoflurane by Amsorb and Lithlyme produce much smaller amounts of Compound A than soda lime. A. True B. False

false- they produce NO/ZERO compound A. --ZERO not smaller Make sure to read every word of the question!!

When positioning a renal pt on dialysis, position in a way that would allow you access to the ______

fistula (periodically palpate thrill to ensure patency and document)

TURP syndrome with the CNS: 1. (hyper/hypo)osmolarity of the blood will cause cerebral (edema/crenation) 2. ICP will (increase/decrease), with subsequent reflex (tachy/brady)cardia

hypo; edema increase; bradycardia

Temperature compensation in an anesthetic vaporizer accounts for changes in ambient temperature, but more importantly for ______________________.

latent heat of vaporization

Mepivacaine is slightly (longer/shorter)-acting than lidocaine, and has a lower incidence of TNS

longer

The diameter indexed safety system (DISS) serves what purpose?

not allowing connection of wrong supply hose to the machine/wall. also color coded and some have unique quick connects

Which flowmeter is most distal (closest to the patient) and why?

oxygen, it is a safety mechanism. if it is leaking it will still give adequate oxygen, if it were proximal it may cause a hypoxic mixture

On older anesthesia machines, vaporizers should be placed adjacent to each other (without a space in between them) to prevent:

prevent the use of multiple gases/more than one gas turned on at a time. Old vaporizers interlock system wouldn't work if the vaporizers were not adjacent/had a gap between them.

Pain modulation via spinal reflexes: 1. Afferent impulses directly evoke ______ and ______ efferents 2. _______ reflexes (do/do not) ascend up to the brain and (can/cannot) exacerbate pain

somatic and sympathetic spinal; do not; can

Bottom line: When administering a drug to a pt with advanced hepatic disease, careful ______ of the drug is critical

titration

You're patient is on the ventilator with a minute ventilation of 5 liters/minute and fresh gas flows of oxygen 1 liter/ minute and nitrous 2 liters/ minute. There is failure of the pipeline supply and you switch to tanks. You notice that the nirtrous tank reads 745 psi and the oxygen tank reads 500 psi. At the current settings, approximately how long will your oxygen tanks last? _______ minutes

~ 27 minutes left 500/3=167L 167L/6LPM= 27 min