question

Median n stimulation

answer

Wrist flex Thumb opposition Flexion of radial half of digits Forearm protonation

question

Drugs administered via ETT

answer

Lidocaine Atropine Naloxone Epi LANE

question

02 content equation

answer

1.39 * Hemoglobin * saturation) + .003 * Pa02

question

2 equations to calculate GFR

answer

Cockcroft-Gault: (140-age)*weight (kg)/72*Cr Modification of Diet in Renal Disease 175*(Cr)-1.154*age-0.203*(.742 if female)*(1.212 if african american)

question

Von Bezold Jarisch Reflex

answer

Noxious stimuli to either ventricle a/w myocardial ischemisa, hypovolemia, coronary reperfusion, AS, neuraxial anesthesia results in decreased BP, coronary vasodilation, and inibition of sympathetic outlfow

question

Bainbridge atrial reflex

answer

Increased vagal tone and distention of right atrium or central veins results bradycardia, hypotension, decreased SVR

question

Gestational age that aortocaval compression begins

answer

20 weeks gestation

question

Average blood volumes

answer

Premature - 95 Full Term - 85 Infant- 80 Adult men - 75 Adult women - 65

question

Morphine equivalent dose

answer

Intrathecal duramorph is 10 times for IV dose and 100 times for PO dose

question

Changes in mixed venous oxygen saturation

answer

Increase - sepsis Decrease - Anemia, hypoxemia, low CO, Increased 02 consumption

question

Spinal cords ends and dural sac ends in adults and peds

answer

Spinal cord Adult - L1-L2 Peds - L3-L4 Dural Sac Adult - S2-S3 Peds - S3-S4

question

Uterine blood flow at term

answer

700 - 900 mL/min and is not autoregualted

question

Superficial peroneal nerve innervation

answer

Dorsum of foot

question

Posterior tibial nerve

answer

Plantar surface of food

question

Deep peroneal nerve

answer

Web space between the first and second toe

question

Sural nerve

answer

Posterolateral foot

question

Saphenous nerve

answer

anteromedial side of food

question

Landmark for superior hypogastric plexus block

answer

Plexus extends from L5-S1

question

Landmark for lumbar sympathetic block

answer

L3

question

Landmark for celiac plexus block

answer

L1

question

Afferent and efferent limbs of laryngospasm reflex

answer

Afferent - Internal branch of superior larygneal nerve Efferent - Reccurent laryngeal nerve

question

Number needed to harm

answer

1/ARI ARI = experiment event rate - control event rate

question

Infraclavicular blocks brachial plexus at what level?

answer

Cords

question

Foot drop

answer

Anterior tibial n or peroneal n

question

Weakness below the knee and dcreased sensation of all of the foot with exception of innter arch

answer

Sciatic

question

Loss of knee extensiion and hip flexion

answer

Femoral

question

Inability to abduct leg

answer

Obturator

question

Pierre Robin Syndrome abnormalities

answer

micrognathia - MC others - glossoptosis, cleft palate, laryngomalacia, and hearing loss

question

Total body bicarbonate deficit equation

answer

Weight kg * Deviation of [HCO3-] from 24 * 0.3

question

MAP equation

answer

(SBP + 2* DBP)/3

question

Cerebral perfusion pressuire

answer

MAP - CVP/ICP

question

Oculocardiac reflex

answer

Results in decreased HR with compresion of eyeball Afferent: ophthalmic bracnh (Trigeminal) Efferent: Vagus

question

Equation for vaporizer output of bubble through

answer

Output = Carrier gas flow* saturated vapor pressure of agent/Barometric pressure- saturated vapor pressure of agent

question

Pulmonary fucntion changes in patients with Acites

answer

Decreased - FEV1, DLCO, FVC, IRC

question

NNT

answer

1/ARR ARR - control event rate - experimental event rate

question

Interaction of muscle relaxants with antibiotics, lithium, antiepileptics, magnesium, volatiles

answer

Antibiotics (aminoclycosides, polymixins, lincomycin, clinda) - potentiate Antiepileptics - Resistance ot NDNMBs, Potentiate Succ Lithium - Potentiation of NDNMBs and Succ Mag - Potentiates NDNMBs and no effect on succ Volatiles - Potentiate - Des > Sevo>Iso>Hal>NO

question

Coronary artery perfusion pressure equation

answer

MAP-PAWP

question

Artery of Adamkiewitz

answer

T9-T12

question

Spinal cord perfusion pressure

answer

MAP- CSF pressure

question

SVR

answer

(MAP-CVP)*80/CO

question

PVR

answer

(PAMP-PAWP)*80/CO

question

Dextran SE

answer

Decrease platlet agreation, Anaphylaxes

question

Hetastarch SE

answer

Anticoagulatent effects - decrease F7, vWF, Fibringogen, decrease plately aggreation Pruitic crisis

question

Treatment of ventricular fibrillation in adults and peds

answer

Defibrillate at 2 J/kg followed by subsequent shocks at 4 J/kg

question

Fail safe valve

answer

Prevents delivery of hypoxic mixture to patient due to failure of 02 supply Pressure of 02 below which this valve with decrease or prevent flow of N20 = 25 psi

question

Stimulation of nerve will induce extension of the digits, wirst, and elbow as well as forearm supination

answer

Radial nerve

question

Lung parameter most affected with scoliosis curvature > 65 degrees

answer

Vital Capacity

question

Lung changes during pregnancy

answer

TV and Ispiratory reserve capacity increase Vital capacity remains the saem All other decrease

question

Filling SEVO vaporizer with Des

answer

HIgher output concentration

question

Exagerated pain in response to nonciceptive stimuli

answer

Hyperathia

question

Increased sensitivity to pain

answer

Hyperalgesia

question

Abnormal sensation without an apparent stimulus

answer

Paraesthesia

question

Pain in the distribution of nerve fiber or bundle

answer

Neuralgia

question

Perception on nonnoxious stimuli as painful

answer

Allodynia

question

Conditions a/w with low DLCO

answer

COPD CHF Anemia Sarcoidosis Asbestosis TB

question

Condtions a/w increase DLCO

answer

Asthma Polycythemia Left to right intracardiac shunt Exercise Pulmonary Hemorrhage

question

TAP Block

answer

Useful for procedures invovling lower abdomen Subcostal T12, Ilioinguinal L1, iliohypogastric (L1), genitofemoral nerves targeted Nerves travel in plan of internal obliquie, and transversus abdominal msucle

question

Predictors of operative risk for thoracotmy

answer

FEV1<40 DLCO<40 VO2<10

question

Intracranial hypertension exists when ICP is greater than...

answer

15

question

GAG Relfex

answer

Afferent - Glossopharyngeal n Efferent - Superior and recurrent laryngeal n

question

Cerebral blood flow

answer

Normal = 50 Slowing EEG = < 20 Isoelectric EEG = 15 Irreversibel brain damage = < 10

question

Signs of dehydration

answer

Mild - UOP < 2 Moderate (10% weight loss) - sunken fontanels, decreased skin turgur, and decreased mucous membraens Severe (15% weight loss) - reduced BP

question

Herbal drug interaction

answer

CV - Ephedra Bleeding - Garlic, ginko, ginsing, green tea, saw palmeta Hepatotoxic - echinacea, kava Changes drug metabolism - St johns wart Changes glucose metabolism - ginsing Immunosuppresant - echinacea

question

Popliteal nerve block - structures noted within popliteal fossa

answer

Sciatic, n,Tibeal n, Common peronial nerve, Popliteal A/V

question

Aphonia, and respiratory distress imeediately after thyroidectomy

answer

BL recurrent laryngeal nerve injury = VC close due to unoposed constriction of cricthyroid msuclle (intervated by external branch of recurrent larngeal n)

question

Afferent and efferent branches of laryngoaspm refelx

answer

Affferent - superior larngeal nerve

question

Bloow volume lost for ever 1% of the body surface area excised during burn repair

answer

3.5-5% Note - volume of tissue excised should exceed 10-15% of total body serface area at one procedure

question

Ventilation/Perfusion throughout the lung

answer

V & Q both increase from the apex to the base, but base of the lung recieves more ventilation than the apex Base recieves the greatest amount of perfusion At apex of the lung there is less blood becasue gravity pulls it odwn and relatively high ventilation, so V/Q highest at apex and lowest at base

question

Blood loss of standard vaginal delivery

answer

500 C section - 1000

question

Myocardial oxygen consumption - normally, @ 22 degrees c, and after cardioplegia

answer

10 mL/100g/min - normal 5.5 mL/100 g/min - @ 22 degrees C 0.3 mL/100 g/min - cardioplegia

question

Most important mechanism of heat loss in OR following redistribution in first 30 mins

answer

Radiation - heat loss from skin to cold surroundings in OR

question

Paravertebral thoracic block

answer

Indications - thoracic procedures, masectomy Complications - pnumothroax (major), hypotesnion Thoracic paravertebral space - Posterior - costotransverse ligament Anterior - pleura of lung Medial - vertebrae/intervertebral foramina Inferior - Rib Superior - Rib

question

Neuromuscular blockers excretion

answer

Pancuronium - renal (avoid in renal failure) Vec/Roc - hepatic metbasolim and biliary excretion with slight renal excretion Mivacurioum - pseudocholinesterase Cisatracurium - hoffamn degradtion

question

Transtracheal block which nerve

answer

Recurrent laryngeal nerve Superior larngeal n - greater cornu of the hyoid

question

INcrease ventialtion increase FA/FI of which type of agents the most?

answer

Soluble agents

question

Side effects of terbutaline

answer

tachycardia hypotesnion MI Pulm edema inhibiition of hypoxic pulmnary vasoconstriciton Hyperglycemia Metabolic acidosis Hypoklaemia Axiety/nervousness

question

Reynolds Equation for gas flow

answer

Re = 2*radius*velocity*diameter/viscocity Re>4000- turbulent Re<2000- laminar Low numbers (e.g lminar ) - low gas density, low velocity, small radius of tube high numbers - (turblent) - low viscoity

question

Superior hypogastric pleux block

answer

Inidication - pelvis pain unresponsive to lumbar or caudal epidural blocks - cancer of the cervix, uterus, bladder, prostate, rectum Contains - postganglionic lumbar sympathetic fibers, viceral sensory fibers from cervi, uterus, bladder, and rectum, preganglionic parasympathetic fibers from S2-S4 Landmark - L5 Complications - Common illiac artery puncture

question

Stimulation of musculocutanous nerve

answer

Elbow felxion

question

forwarm supination

answer

radial nerve

question

forearm pronation

answer

median nerve

question

wrist flexion

answer

ulnar nerve

question

Intralipid dosing

answer

Bolus 1.5 ml/kg over one minute with a continuous infussion of 0.25 ml/kg/min conitniuning for at least 10 mins after cardiac stability is obtained Repeat bolous once or twice for persistent CV collpase Infusion rate can be doubled to 0.5 mL/kg/min if BP is low

question

Sensation to tongue

answer

General sensory - trigeminal (anterior two thirds) and glosspharyngeal (posterior one third) Tase - facial (anerior 2/3) and glosspharngeal (posterior 1/3)

question

Metbaolism of atracurium

answer

HOffman and nonspecific esterases A/W histamine release

question

Effect of transfudcer of a line blood pressure

answer

If transducer is placed lower than the set zero reference , the blood pressure reading will tend to overestmate IF the transfucer is placed high tahn the set zero, the blood pressure reading will tend to underestmate BP

question

Sevo put into a iso vaporizer

answer

Sevo VP 162, is filled in an iso cannister with a vapor pressure of 239, then it will deliver a lower concentration than expected IF sevo was filled in a cannister that has lower vapor pressure than 162, it would result in a high than expected concentration

question

Neonatal circulation

answer

Oxygeanted blood from placenta travels via the inferior vena cava to right heart Venous oxygenated blood bypasses nonfunctional pulmonary system through the foramen ovale and the ductus arteriosus @ birth expansion of lungs with air decreases PVR

question

Initial fluid replacement for pyloric stensosis

answer

NS - add K once urine out put increased

question

Treatment of cyanide toxicity

answer

Discontinue infusion, adminster 100% O2 Administer amyl-nitrate (inhaler) or IV sodium nitrite and thiosulfate, except in those pateints with abnormal renal function, for whom hydroxocobalamin is recommended

question

Bohr effect vs Haldane effect

answer

Bohr - CO2/H are affecting the affinity of Hb for 02 Haldane - 02 is affecting the affivinty of Hb for CO2/H+

question

Cholindergic crissi

answer

DUMBELS Diaphrosies.Diarrhea Urination Miosis Bronchospasm/Bradicardioa Emesis Lacrimation Salivation

question

Most common nerve damaged during aortic arch repair

answer

Left recurrent laryngeal nerve - branches of left vagus in the chest vs right recurrent laryngeal nerve that branches off vegas lower in the neck Left recurrent largneal nerve injury - post op hoarseness a/w adducted left vocal cord and an abducted right vocal cord

question

Muscle relaxants associated with histamine release

answer

Succ Atracurium and tubocurare

question

Risk factors for PDPH

answer

Yougner age Feamel

question

Which patient not candate for tramadol?

answer

Alcoholic - Increased risk of seizure

question

Carotid Body chemoreceptors

answer

Located near bifurcation the internal carotids Afferent: glosspharygneal Senses: hypoxemia, Hypercapnia, , decreased pH, PO2<80 most potent stimulus leads to ventilator stimulation

question

Factors a/w with risk of ischemic optic neuropathy

answer

Spinal surgery, Cardiopulmonary bypass Males Prone position Intraoperative hypotesnion Massive fluid replacement Hx of diabets, HTN, vascular disease Long duration of surgery Obestiy Wilson frame use Massive blood loss

question

Stages of labor

answer

Latent - contractions become more regualr Active - Cervix dilates from 4 to 8 cm and contractions get more intesnse, about 3 minutes aprt, lasting aobut 45 seconds Transition - Cervix dilates from 8 to 10 cm, contractions are 2 to 3 minutes apart and last about 1 minute Fetal decent - Babys head more toward the pelvis Second stage - Cervix fully dialted @ 10 cm, followed by crowing of baby head Delivery Third stage - Begins after the baby is born and ends when the placenta seperates from uterus

question

Alveolar Ventilation

answer

TV - Dead space * RR

question

1 mac of N20

answer

500 mL/min

question

Vascualr suseceptibel to IV injection

answer

ICE Beyond Slight Freezing I=intercostal C= cuadal E=Epidrual B=Brachial plexus S=sciatic F=femoral

question

pH change for patients with chronic respiratory acodsis for incrase in PaCO2

answer

pH will change 0.03 units for every 10 mmHg change in PaCO2

question

Normal CBF

answer

45-55 mL/100g/min 75-80 gray matter 20- white matter

question

Boyles Law

answer

T=PV -at constant temperature th eprodcut of the pressure and volume is constant

question

PaPlaces Law

answer

T = P*R, T = suraface tension, P = intraalveorl pressure, R - radius of alvesuls

question

Normal mitral valve and aortic valve area

answer

Mitral - 4-6 cm2 Aortic - 2-4

question

Autoregulation range of the kideny

answer

60 - 160 thus GFR and RBF only begin to decrease at MAPS below 60 or above 160

question

Fast conducting fibers, responsible for intesnse sharp pain and paraesthesias

answer

A delta

question

Sensation of pressure, light touch, propioception and fine hair moment

answer

A-Beta

question

Delayed burning sensation after noxius stimuli

answer

Unmylinated C -fibers

question

Muscle spindles

answer

Gamma motor neurons

question

Shock dose for synchronized cardioversion for a flutter

answer

50 - 100 J

question

MAC by age for SEVO

answer

Neonates and infants 1 year - 2 %

question

Indications for cardiac pacemaker

answer

Symptomatic sinus or AV nod disease Long QT Hypertrophic obstructive cardiomyopathy Dialted cardiomyopathy Congestive heartfailure Severe bradyarrhytmia Afib

question

Lung volumes unchaged during obesity

answer

Unchanged - forced expiratory volume, forced vital capacity, peak expieratory flows Reduced - RV, Expieratory lung volume, Functional residual capacity, total lung capcity

question

Anesthetic changes for elderly

answer

MAC declines from young adulthood by 30% Dose of opoids decreases ED50 of NMB is increased Creatine increased Volume of LA recued

question

Autonomic hyperreflexia

answer

Chornic spinal cord injury above T5-T6 Symptoms: Vasodialtion above the leshion HTN below the leshion others sweating nasal congestion HA blurred vision bradycardia heartblock ventricular dysrhythmias

question

How much does PaCO2 increase during apena in first minute

answer

6 mmHg and then rises 3-4 mmHg each subsequent minute of apnea

question

Pre eclampsia risk factors

answer

Nulliparity (not having bared children) age>40 black family history chronic reanl disease chronic hypertension

question

4 distinct plans of stage 3 (surgical plane)

answer

1 - ocular movement 2 - decreased tidal voumes, low risk of larygnospasm 3 - respirations by diaphragm, ETT can be saefely placed 4 - flacid muscle tone

question

Characteristic of difficult mask ventilation

answer

Facial hair, edentia, over/under bite, facial deformity, enlarged tongue/tonsils

question

How many days after MI should surgery be delayed?

answer

30 days

question

Factor that demonstrates direct correlation with delayed gastric empyting in diabetic patient?

answer

Presence of autonomic nueropaty Features - Orthostatic hypotension, elevated resting heart rate, sexual disfunction, etc

question

Medications that decrease LES tone?

answer

IV anesthetics - propofol, thiopental, opoids, anticholinergics Volatiles B - agonists TCAs Antichoinergics - glyco

question

Medications that increase LES tone?

answer

Antacids Metoclopramide Cholinergics Succ A adrenergic agonists Metoprolol

question

Medications that done alter LES tone

answer

H2 antagonists NDNMBs

question

Sensitivity

answer

TP/TP+FN

question

Specificity

answer

TN/TN + FP

question

EEG changes with anesthesisa

answer

EEG in the awake pt - irregular rapid activty of low amplitude with a dominant frequent of 13 Hz EEG w/ anesthesia Beta type rapid oscillations increase in amplitude 13-20 Hz EEG w/deeper anesthesia a/w global slowing of theta, then delta (0-4 Hz) which becomes regular before disappearing into isoelectric EEG with very deep anesthesia (Burst suppression) Sevo A/W beta wave activity

question

Reccurent laryngeal nerve

answer

Branch of vagus Sensory - VC, and trachea Motor - all larynx muscles except cricothyroid Anesthesized by trastrachial block

question

Glosspharyngeal nerve

answer

Sensory - oropharynx, soft palate, psoterior third of tongue, tonsils, vallecula, and anterior surface of epiglotis Blocking this nerve blocks the gag reflex

question

Internal branch of the superior larygneal nerve

answer

Sensroy - base of tongue, posteror surface of epiglottis, aryepiglottic fold, and arytenoids

question

Diameter Index safety system

answer

noninterchangeable gas specific connections to the pipeline Note - if wrong gas connected e.g nitrous connected to oxygen site then hypoxic gas mixture could be delivered to patatient

question

Pin index safety system

answer

connects E cylinder tanks to the machine

question

Fail safe valve

answer

located in the intermediate pressure circuite - if pressure of oxygen drops below 28 psi it will stop the flow of nitrous oxide to the patient

question

Pressure regulator

answer

reduces cylinder pressure to 45 psi, which is lower than normal pipeline pressure of 50 psi malfunctioning regulator results in release of cylinder gas at high pressure and depletion of e cylinder

question

Lambert- Eaton syndrome

answer

Suseptible to NDNMBs

question

Conditions a/w difficult intubation

answer

Pierre Robin syndrome Treacher Collins Downs Acromegally

question

Check valve

answer

Present in the distal end of the low pressure circut - downstream from the vaporizers but upstream from oxygen flush valve Prevents pressure from the flush valve, ventilator or reservoir bag from renturing into the low pressure circuit Note - prevents positive pressure test from finding leak in low pressure circuit, need to use negative pressure test

question

Oxygen pressure failure alarm will be activated if the pipeline pressure drops below?

answer

30 psig

question

Laryngospasm

answer

Involuntary contraction of the cords Caused by stimulation of sensory paths of recurrent and supperior laryngeal nerves (branches of vagus) Triggered via secretions, blood, or debris Rx - 100 oxygen, jaw thrust, IV anesthesitcs or succ

question

BL recurrent laryngeal nerve injury (e.g after total thyroid removal)

answer

Stridor - unopposed adduction of vocal cords Note UL injury - hoarsness

question

BL superior laryngeal nerve injury

answer

Increased risk of aspiration as the vocal cords remain open and unable to protect the airwawy

question

Color code different gases?

answer

CO2 - grey NO - Blue Air - Yellow Nitrogen - Black 02 - Green

question

Low, Intermediate, and High pressure circuit contents

answer

Low - vaporizers, begins with flow meters Intermediate - begins at wall gas supply and the first stage regulators for the e cylinders and ends at the flow meters HIgh - contains just e cylinders and ffirst tage pressure regualtors

question

Gas flows - laminar vs turbulent

answer

Low flows - laminar - viscocity High flows - turbulent - density

question

Expiratory valve stuck in open position

answer

capnograph tracing failing to return to baseline

question

Expiratory vavle stuck in closed

answer

Breath stacking, volumtrauma and barotrauma Hyperinflation of the lungs could result in hypotesnsion 2/2 decreased venous return

question

Inspiratory and expiratory valve stuck in open position

answer

incrase in end tital c02

question

Coponents of soda lime

answer

75 % Calcium hydroxide 20% water 3% soium hydroxide 1% potassium hydroize Sodoum hydroixe, potassisum hydorixide are strong alkalis and implicated in the formation of CO, Compound A

question

Maximum pressure ETT cough should be inflated

answer

25-30 cm H20

question

3 rules to prevent rebreathing in a circle system

answer

Unidirectional gas flow Fresh gas flow does not enter circuit between patient and expiratory valve APL valve not located between inspiratory valve and patient

question

CO production

answer

Produced when volatiles passed through desiccated absorbents containg strong alkali (barium, potassium or sodium hydroxide) Des>en>iso>sevo

question

Contraindications to LMA use

answer

Aspiration risk - full stomach, hiatal hernia, GERD, intestinal obstruciton, delayed gastric emplyting Obestiy ok as long as no refulx present Not advised if postive pressure ventilation, peritoneal insufflation, or trendelenberg anticipated

question

Factors a/w Compound A formation

answer

Alkali absorbents - barium, sodium, and potassium hydroxide Higher concentration of Sevo Longer anesthetic Dessication

question

Alveolar concentration of a volatile that represents the ED 95?

answer

1.3 MAC

question

MAC that alows eye opening

answer

1/3 - 1/4 MAC

question

MAC BAR

answer

1.7-2.o MAC

question

ED 50 of dose response curve of volatile

answer

1 MAC

question

VP of DES

answer

669

question

Effect of volatiles on cerebral blood flow

answer

Increase CBF, especially N20 and HAL

question

Efffect of volatiles CMR02?

answer

Decrease, except N20 which increases

question

Effect of N20 on vascular resistance

answer

Decrease

question

Volume of distribution

answer

Apparent volume into which a drug is diluted Concentation = Dose/Volume Volume exceeds patient volume for fat soluble and highly protein bound drugs

question

Compare and contrast fentanyl and morphine during spinal injection

answer

Morphine - hydrophilic, leading to long duration of effect, slow onset, slow absorption into system ciruculation Fentanyl - lipophilic, quickly bind lumbosacral nerve roots

question

Conetext sensitive half life

answer

Concept that half life increases over time, especially for lipid soluble drugs

question

Effect of NDNMBs on MG?

answer

Exaggerated response

question

First order vs zero order kinetics

answer

First order -rate of the elimination is proportional to the concentration of the drug -exponential decay process Zero order -elimination is fized regardless of drug concentration

question

Drug potency function of...

answer

Drugs receptor and the receptor response to drug binding Drugs with higher potency have lower ED 50

question

Effect of Des at elevated altitude

answer

The des vaporizer delivers the correct dialed in percentage of desflurane at any altitude That dieled in percentage of DES at high altitudes results in a lower delivered partial pressure of DES, however, so one would need to use a DES vaproizer

question

Factors that increase and decrease MAC

answer

Increaese -Hypernatremia -Hyperthyroid -Alcoholism -Acute administraton of dextroamphetamine -Cocaine (acute) -Ephedrine -Younge age Decreases -Hypoxemia - Pa02 < 40 -Hyponatremia -Anemia - HC<10% Metabloic acid base status, hypercapnia, hypocapnia have no effect

question

Myasthenic vs Cholinergic crisis

answer

Myasthenic -an exacerbation of the myathenic symptoms caused by UNDERMEDICATION with anticholinesterases -priority to maintain adequate respiratory function -Tensilon test will help improve muscle tone Cholinergic Crisis -acute exacerbation of muscle weakness caused by overmedication with cholinergic anticholinesterase drugs -muscle twitching to the point of respiratory comprmise -symptoms improve with anticholinergic medis (atropine)

question

MAC value by age

answer

Peaks at age 1-6 months Lower in neonates, and decreases even further in premature infants in proportion to their prematurity Gradually decrease from age 1-6 months through the rest of ones life

question

Law of mass action

answer

Predicts that if you give larger mass of drug, the onset will be quicker

question

How does right to left shunt affect rise of Fa

answer

Repeate dilatuion of pulmonary blood affects lease soluble agents the most

question

Principle advantage of remifentanl

answer

Fast emergence - Metablized by plasma esterase and by hoffamn elimation - conext sensitive half life 2 to 3 minutes, no matter how long it has been infused

question

Primary disadvantage to remifentanl

answer

Acute opoid tolerence

question

Sufentanil

answer

Very lipophilic with large volume of distribution 2.48 L/kg

question

Drugs with zero order kinetics?

answer

ETOH Heparin Pheytoin Warfarin ASA

question

Ciatracurium

answer

Larger molecular weight and is highly polar - low volume of distribution

question

Diazepam

answer

Metabolized in the liver to active metabolites that prolong diazepams sedative effects

question

Propofol

answer

Total body clearance exceeds hepatic blood flow Anti- emetic Promotes bacterial growth - ampual must be used within six hour of opening Children require higher induction dose of propofol per kg 2/2 larger central distribution volume Decreases BP

question

Ketamine

answer

Induces sympathetic nervous system - increased BP, and HR

question

Etomidate

answer

Hemodynamically neutral

question

How does ESLD, PNA, increased age, and pregnancy affect albumin and alpha glycoprotein levels?

answer

Increased albumim Decreased albumin - ESLD, Increased age, Pregnancy Increased glycoprotein - PNA Decreased glycopretoin - Pregnancy

question

Factors that alow drugs to pass membranes

answer

low molecular weight lipophilic low degree of ionization large concentration gradient

question

Propol binds which receptor

answer

GABA A

question

MOA of ketamine

answer

NMDA antagonist

question

MOA of dexmetatomidine and clonidine

answer

alpha 2 adrenergic agonists

question

MOA of droperidol

answer

Dopamine receptor antagnoist

question

Metabolite of midazolam

answer

Hydroxymidazolam, may lead to progloned sedation in renal failure

question

pKa deffiniton?

answer

pKA of a drug is defined as pH at which half the drug is in the its ionized form and half is in its unionized form

question

How to decrease pain a/w propofol injection into small vein?

answer

larger veins Prior lidocaine, thiopental, or fent/remi Diluting the formulation with additional solevent - intralipid Sodium metabisulfite as antimicrobial agent Note ampofol has more pain with injection

question

Sulfite containing medicaitons that increase indicence of bronchospasm

answer

Generic propofol Epineprhine Dexamethasone/Hydrocortisone

question

Effect of benzos of CO2 reponse curve?

answer

Shift it down

question

Effect of PNA on lidocaine bioavailability?

answer

PNA increases alpha glycoprotein which binds more lidocaine decreasing the bioavailability

question

IV anesthetic effect on respirations?

answer

Propofol - apnea Thiopental - apnea Ketamine/etomidate - preservation

question

Alpha 2 subunit of GABA - A responsible for?

answer

anxiolysis, and muscle releaxation

question

Alpha 1 subunit of GABA A receptor responsible for?

answer

sedation, anticonvulsant, and amnesia

question

Of the IV anesthetics which is not chiral?

answer

Propofol Chiral ones include - Thiopental, etomidate, Ketamine

question

Characteristic of Tetralogy of Fallow

answer

VSD Right ventricular outflow tract obstruction Over riding aorta Right ventricular hypertrophy

question

pKA that produces drugs with smallest amount of its molecules ionized, hence the largerst percentage in neutral form?

answer

pKA closest to blood stream pH, e.g the lowest pKa

question

Active metabolites of diazepam?

answer

Oxazapam Desmethyldiazepam Both prlong clinical effect Note enterohepatic circulation produces secondary peak in diazepam after 6-12 hours

question

Propofol infusion syndrome

answer

Critically ill children and adults on long term infusion in ICU Sx - lactic acidosis, lipemic serum, cardiac dysfunction, heart failure, V- fib, tachycardia, heart block, rhabdo, hyperkalemia, renal failure, fatty liver Mechanism - inhibition of fatty acid oxidation and mitochondrial ETC RFs - TBI, airway infection, peds, total cumulative dose, high catecholamine levels, criticall illness, inborn errors of metabolism

question

How should induction dose of propofol be calculated?

answer

Lean body weight

question

Treatment of propofol infusion syndrome?

answer

Hemodyalsis

question

How should propofol infusion be dosed?

answer

Total body weight

question

Metabolite of meperdine

answer

Normemperdine, in renal failure can cause irritability, tremors, muscle twitching, myoclonus and even seizure

question

Opoid a/w prlonging QT interval?

answer

Methadone

question

Tolerance

answer

reduction in effect of drug over time a/w repeated delivery of agonist, or increase in dose required to yield an equivalent response

question

Propylene glycol toxicity a/w what drug and symptoms?

answer

Parenteral - Lorazepam Sx- metabolic acidosis, and AKI, ELEVATED osmolar gap (>12)

question

Phase 1 vs phase 2 block?

answer

Phase 1 -TOF >0.7 -Sustained tetanus Phase 2 block -antagonized by anticholiesterase -Fade on TOF -Post tetanic facilitaton -TOF <0.3

question

Buprenorphiene mechanism

answer

Partial Mu receptor opoid agonist

question

Nalbuphine

answer

Mixed agonist antagonist with agonist at K receptors and antagonist a Mu recpeotr Releaves pruritis without reversing analgesia

question

Methylnatrexone mechnasim of reversing opoid induced constipation?

answer

Peripherally acting opoid Mu rec antagonist

question

Homozygote butrylcholinesterase number

answer

20 -30, duration of suc inuced paralsysis of 4-8 hourss

question

Heterozygote dibucaine number

answer

50-60,

question

Dose required for phase 2 block with suc?

answer

>5 mg/kg for over 60 minutes

question

Level of GABA - A receptor ccoupancy that will lead to amnesia, anxiolysis, sedation, and unconsciousness?

answer

Amnesia, Axiolysis - 20% Sedation 30-50% Unconsciousness - > 60%

question

List the endogenous opoid ligands

answer

Endorphins Enkepalins - delta rec Dynorphins - kappa rec Endomorphins - Mu rec Nociceptin or orphanin - don't bind opoid receptors, may be involved in opoid induced hyperalgesia

question

T1/2 of plasma cholinesterase?

answer

8-16 hours

question

Most important side effect of Benzos

answer

Respiratory depression, but apnea uncommon at sedative doses

question

M2 receptor

answer

respirtaroy depression

question

Mu 1 receptor

answer

Analgesia

question

Kappa opoid receptor

answer

dysphoria, diuretic effects (negative regulation of ADH)

question

Delta opoid rec?

answer

Modulate Mu recptor activity

question

Cirrhosis effect on plasma cholinesterase?

answer

Decreases it

question

2nd dose of Succ likely to...

answer

Cause bradycardia, especially in children

question

Echthiphate

answer

Prolongs succ

question

Antibiotic should be used with caution in patient receiving benzos?

answer

Macrolides - erythromycin - inhibits p450 3A4, leading to increased level of midazolam and prolonged sedation

question

Opoids most likely to cause skeletal fidgety?

answer

Sufenta + Fent

question

Muscle relaxants most effect by renal failure?

answer

Pancuronium - T1/2 increased 97 % with prolonged duration of action

question

Muscle relaxants a/w histamine release?

answer

Atracirum

question

Muscarinic side effects?

answer

Bradycardia Bronchospasm INcreased secretions Diarrhea Urination Miosis Lacrimation

question

Muscle relaxant a/w tachycardia

answer

Pancuronium - atropine like effect

question

Muscle relaxant metabolized by plasma cholinesterase and terminated by hoffman elimination?

answer

Atracurium

question

Muscle relaxant metabolized by plasma cholinesterase alone?

answer

Mivacurium

question

Muscle relaxant whose metabolite with 80% of the activity of the primary drug?

answer

Vec - 3 OH compound Note 30-40% of ven excreted unchanged in bile 25% excreted unchanged in urine

question

Aminosteroid muscle relaxant with least renal clearance?

answer

Roc - cleared over 90% by the liver

question

Class of muscle relaxants most likely to cause histamine release?

answer

Benzylisoquinolinium NDMRs - Mivacurium, cisatracurium, atracurium However atracurium most likely to cause histamine release

question

Muscle relaxant that is prolonged in renal failure?

answer

Pancurionium - excreted largely unchanged by the kidneys

question

Muscle relaxant a/w laudanosine metabolite?

answer

atraciurym - lowers seizure threshold

question

Myasthenia graves response to muscle relaxants?

answer

Sensitive to non depolarizes (requires less) Resistant to such (requiring more)

question

Metoclopramide effect on NDMRs?

answer

Has plasma cholinesterase inhibition activity - prolonging NDMRs metabolized by them - mica curium, atracurium, cisaracium, and suc

question

Effect of carbamazepine on NDMR function?

answer

Increased plasma clearance of vec, panc, and roc however atracurium, and mivacurium not affected Note phenytoin can enhance the function of NDMRS

question

What is sugammadex incompatible with?

answer

verapamil, ranitidine, and odansetron

question

How is sugamedex eliminated/

answer

unchanged in the urine

question

Volatile with most reduction on hepatic blood flow?

answer

Hal

question

Volatile most likely to cause renal failure after 12 hours of use?

answer

Enflurane

question

Order in which volatiles depressed hypoxic ventilatory response?

answer

Hal;En;Iso;Sevo;Des;;NO

question

Antihypertesnives that potentiate myocardial depressant effects of volatiles?

answer

beta antagonists, calcium channel blockers, or hypoglycemia (e.g high dose insulin)

question

ED 95 of Roc and effect of Des?

answer

ED 95 (average dose producing 95% twitch suppression) is 0.6 mg/kg However Des at 1 MAC nearly doubles potency of roc, so dose of 0.3 mg/kg would acomplish same goal

question

NO a/w with what deficiency?

answer

B12 def - Magloblastic anemia - presents with paresthesias in hands and feet, anorexia, fatigue, glossitis

question

How does bilateral carotid endarterectomies affect hypoxemia response?

answer

Pt with BL CEA - likely have decency of their peripheral chemoreceptors located in the carotid bodies which are sensitive to changes in arterial oxygen tension

question

Effect of volatiles on cortical evoked potentials?

answer

Decrease amplitude, and increase latency

question

Effect of volatiles of hemodynamics

answer

Increases Heart rate Decreases SVR Presereved CO Decreased MAP

question

How do muscle relaxants contribute to muscle relaxation and imobilzation

answer

Desensitize the Act receptor spinal NMDA type glutamate rec and glycine rec contribute to mobilization

question

In the presence of apnea how long does it take for CO2 to increase

answer

Increase 5 mmhg in first minute, and 3 mmHg every minute thereafter

question

Snydrome associated with cardiac arrest with volatiles on induction?

answer

Williams syndrome - higher percentage of these patients have prolonged QT intervals

question

Effect of N20 on hemodynamics?

answer

Sympathomimetic effect - under most clinical circumstances maintains CO, heart rate, and BP however does have tendency to increase heart rate and BP if given alone

question

What agents to avoid in atrial and ventricular arrhythmia ablation procedures?

answer

Volatiles - suppress atrail and ventricular arryhtmias Note propofol - only suppreses atrial arryhmias, but not ventricular

question

Inhibition of movement by volatiles mediated by?

answer

Resides in spinal cord and NMDA and glycine receptors appear to be involved Note: GABA - loss of consciousness mediated at supratentorial level Acetycholine recptors - muscle relaxation

question

Volatile that causes greatest decrease in hepatic blood flow?

answer

Halthane

question

myocardium supplied by circumflex

answer

lateral wall

question

Air embolus mostly likely to go where in heart?

answer

Right ostium - leading to RCA infarction - supplied posterior wall and posterior septum

question

CRH

answer

Produced in hypothalamus, stimulates anterior pit to release ACTH - which subsequently stimulates the adrenal cortex to release cortisol

question

Lowest PO2 value of blood?

answer

Coronary sinus - heart maximally extracts 02

question

LAD supplies

answer

Anterior LV, apex, anterior septum

question

Treatment of negative pressure pulmonary edema?

answer

Constant positive airway pressure

question

S4

answer

Aortic stenosis - concentric LV hypertrophy Atrial contraction against non compliant ventricle

question

Law of Laplace?

answer

Wall stress is equal to the product of intracavitary pressure and the radius of the chamber divided by the thicken of the cavity or P*r/2T

question

S3

answer

Heart failure

question

AV node supplied by?

answer

RCA - if included results in complete heart block with slow, wide complex, ventricular escape rhythm

question

Management of patient with hypertrophic cardiomyopathy

answer

Obstruction worse with decrease preload, or after load or increases contractility or heart rate thus... Ensuring adequate preload wihtvolume Maintenance of after load Avoid increases in HOUR and contravitly

question

Muscarinc receptor most prominent in myocardium?

answer

m2

question

Best vasopressor hypertrophic obstructive cardiomyopathy?

answer

Phenelephrine - increases after load and lowers heart which both decrease left ventricular outlet obstruction

question

Oculocardiac reflex

answer

Afferent - Trigenminal CN 5 Efferent - Vagus CN 10

question

New S3 during pregnancy?

answer

Benin - due to increase circulating volume

question

Best echo view to visualize stenotic aortic valve as well as determination of gradients across the left ventricular outflow tract and the aortic valve

answer

Deep transgastric long axis view

question

SA node location and intervention?

answer

Supplied by RCA and located at junction of the RA and SVC

question

Primary determinants of myocardial oxygen demand?

answer

Wall tension, contractility, and HOUR

question

Hyperventilation effect on PVR?

answer

Decreases resistance

question

Most important determinat of cardiac output?

answer

Venous return

question

Factor controling venous return?

answer

Mean systemic filling pressure, right atrial pressure, and blood flow resistance between the peripheral veins and the right atrium VR=Mean systemic filling pressure - right atrail pressure/resistance to venous return

question

Flow equation (Poiseulles law)

answer

Pie *r^4/8*nL

question

Nor - epi effect

answer

Increases SVR

question

Dobutamine

answer

Inodilator - increase CO, and decrease SVR

question

Milrinone

answer

PUlmonary vasdodilation and decrease PVR and SVR while increase CO and contractility

question

Acute aortic insufficiency

answer

Decrease dialtolic pressure HR and contractility will increase - wawter hammer pulse - maintains CO

question

Diuretics that cause hyperkalemia

answer

triamterene amiloride spironolactone

question

Pulmonary edema associated with which diuretic?

answer

Mannitol

question

Fenoldopam

answer

Selective dopamine rec 1 agonist Increase renal blood flow and sdoium excretion while decreaseing afterload SE - tachycardia 2/2 baroreceptor response to decrease bp

question

Spironolactone

answer

competes with aldo sterone receptor SE - gyncomasatia, hirsutism, and mestral irregulatires

question

Urine electrolytes associated with intrinsic renal failure?

answer

Urine Na ; 40, Urine osms ; 400

question

Urine electrolytes associated pre - renal cauase?

answer

Urine Na 400

question

Mechanism reponsible for rewakening on ketamine?

answer

Redistribution

question

Effect of ketamine of IOP?

answer

Increase - avoid in open eye procedures

question

Diuretics to avoid in chronic renal failure?

answer

Potassium sparing because they increase K - e.g spironolactone

question

DIfference between PO and IV ketamine?

answer

PO about 20% of IV bioavailability, so peak effect similar but oral would result in a slower onset and loger duration of action

question

Recptors affected by ketamine?

answer

Mu agonist - analgesia Inhibits NMDA Muscarinic Ach antagonist NMDA antagonist

question

Excitaory NMDA agonists?

answer

Glutamic acid, aspartic acid, and glycine

question

EEG waves seen with ketamine?

answer

Theta waves

question

Mecahnism of oliguria during laparoscopic surgery?

answer

Decreased renal blood flow 2/2 decreased CO, and increased SVR Increased levels of renin, ADH, and aldosterone Increased renal vein pressures

question

Which opoid receptor does ketamine bind?

answer

MU

question

Electrolytes abnormalies a/w PVCs

answer

Hypomag and hypokalemia

question

Diuretics that increase serum glucose?

answer

Loops - furosemide, torsemide HCTZ Triamterene

question

Changes the kidney undergoes during pregnancy?

answer

Kidneys and ureters increase in size Increase plasma flow Increase in GFR Decreased BUN Glucosuria

question

RFs for prolonged weaning from vent?

answer

Advanced age COPD Plueral effusions Pulmonary Hypertension Delerium Metabolic alkalosis

question

Acute changes after rapid bolus of manitol

answer

Increase in intravascular volume leading to increaed ICP, CVP, BP, CO

question

Prostaglandin E2 effect on kidney?

answer

renal vasodilation

question

Tase and sensation to the tongue?

answer

Anterior - facial nerve (taste), trigeminal (sensation) Posterior - glospharngeal for tase and sensation

question

Nerve injury associated with vocal cord paralysis and haorsness?

answer

Recurrent laryngeal nerve

question

Determines when ventilator assisten inspiration terminates in pressure support?

answer

pressure support breaths terminated when inspiratory flow decrease to a certeain percentage (typically 25%)

question

SIMV

answer

Combines assist control ventilation (either pressure or volume) and on breats above the set rate, will alow for pressure support ventilation Used for weaning

question

High freq oscillatory ventilation

answer

Pressure and volume are both variable and affected by lung mechanics, time (inspiratory and expiratory) is sthe only controled variable

question

Pressure regulated volume control

answer

Each breath is pressure controlled and has a variable or decelerating flow cruve however the clinician enters a target folume for each breath Every several breaths, the computer calcualets the driving pressure needed to achieve that volume Compliance can can change and high pressure alrms must be set

question

Presure support ventialtion

answer

RR is set by the patient When patient achieves a triger, a pressure is then generated by the vent Flow are meastured throughout the breath When the flow rate achieves approxmately 1/3 the intial flow rate, the pressure support is ended and the vent will await the next triger THe mode is pressure controlled, flow triggered (by patient) and flow cycled Differes from assist control pressure since inspiration is determied by time in that mode

question

Surfae landmark of trachea?

answer

extends from C6-T4/5

question

Costodiphragmatic recess

answer

Extends from eighth to tenth ribs along mid axialy lines

question

Volume control ventilaton

answer

Desired TV, flow rates, and inspirtaory time are set by clinician A decrease in compliance with the same delivered tidal volume results in an increase in peak inspirtory pressure

question

Pharynx

answer

Tube extending from base of skull to cricoid cartilage

question

Sternal angle

answer

T4/T5

question

Anatomic relation between neurvascular structures in costal grove

answer

Vein (superior), Artery (midle), and nerve (inferior)

question

Angle of the scapula

answer

T7

question

Xiphoid process

answer

T6

question

Umbilicus

answer

T10

question

Increased peak airway pressure, no change in plateau?

answer

Increased airway resitance

question

Increased peak airway pressure, increased plateau presssure

answer

Decreased lung compliance

question

RIse in PaCo2 in ashmatic?

answer

implies impending airway obsturction

question

High peak inspiratory pressure, normal plateau DDX

answer

HIgh resistance to air flow mucous plug foreign body bronchospasm kinged endotracheal tube compression of the external vent circuit

question

Extrahoric obsutruction

answer

Normal epiration, but inhalation is decreased

question

Fixed intra or extra thoracic obstruction

answer

Both inhalation and expiration are affected

question

Unilateral recurrent largngeal nerve injruy

answer

Hoarseness and paralyized ovcal cords that assume intermediate position

question

Bilateraly recurrent largnyeal nerve injury

answer

Aphonia, and paralyzed VC that flap together producing obstruction

question

Cricoid cartilage

answer

C6

question

Carina

answer

T5

question

Diaphgram acounts for what percentae of the inhaled tidal volume in normal adults?

answer

70%

question

Pulse oximeter - X and Y axis?

answer

X - time Y - absoprtion

question

Vagus nerve trajectory

answer

Runs posterolateral to the distal (intrathoraic) trachea and typically position in grove between the trachea and esophagus

question

Elecated peak airway pressure, normal plateau pressure

answer

Bronchoaspm - adminster inhaled beta agonist

question

Increased peak and plateau pressure?

answer

Migraation of ETT into right mainstem

question

Red:IR Modulation Ratio in pulse ox

answer

R = (Ared,AC/Ared,DC)/(Air,AC/Air,DC) R is a double ratio of the pulsatile and non - ppulsatile components of red light absoprtion to IR absorption

question

Beer Lamberts Law

answer

Intensity of transmitted ligh is inversly proportional to the concentration of the substance thourhg which the lighth passes

question

Pulse ox reports?

answer

Functional saturation

question

Co oximeters report

answer

Fractional saturatiion

question

Gass exchange occurs.....

answer

Respiratory bronchiole Alveolar ducts Alveolar sacks

question

Pleural pressure gradient

answer

Difference between intrapleural and intra alveolar pressure

question

Venturi effect

answer

Reduction in fluid pressure that results whne a fluid flows through a contricted section of pipe Pnumotachometers mreasures the flow rate of gases by detecting pressure differences across a fine mesh

question

Airleak in ETT for peds?

answer

Air leak below 25

question

Resistance proportion too?

answer

R^4 for laminar flow R^5 for turbulent flow

question

Effect of moving blood pressure cuff from proximal (e.g arm) to distal (e.g ankle)

answer

BP reading will increase

question

IV agent with imidazole structure?

answer

Etomidate

question

Etomidate physologic effects?

answer

Slightly decresases SVR CO unchanged IOP, CMR2, and ICP all decrease RR increases, and TV decreases

question

BP measurement technqiues that only provide systolic measurement

answer

Doppler and palpation Note asuculation - Systolic and diastolic

question

Etomidate acts at what recepotr?

answer

GABA A agonist

question

Oscillometric NIBP directly measures?

answer

MAP Systolic and diastolic calculated

question

How to calculate actual blood pressure if cuff is below level of the heart?

answer

Falsly elevated due to hydrostatic effect of blood Multiply height in cm of cuff below the heart * 0.7 then subtract that product from the falsly elevated measured pressure

question

what percentage of etomidate is protein bound?

answer

75%

question

Effect of etomidate on EEG

answer

Biphasic - low concentrations, activation occurs and at high concentrations inhibition occurs

question

HIccups at induction a/w what IV anesthetic?

answer

Etomidate

question

How is etomidate eliminated and metabolized?

answer

Metabolised by plasma esterases and hepatic enzymes and elimated in urine

question

Side effects of Etomidate

answer

Thrombophlebitis 20% Myoclonus 30-60%

question

MAP

answer

DBP + 1/3 pulse pressure

question

Effect of etomidate of auditory eoked potentials?

answer

Decreased amplitude, and increased latency In contrast to SSEPs which the amplitude is increased

question

Hyponatremia sighs

answer

confusion, malaise, lethardy

question

Digoxin toxicity a/w

answer

Hypokalemia

question

Hypernatremia signs

answer

irritability, spacticity, tremor

question

Fluid associated with reduction in factor 8 and vWF

answer

Hetastarch

question

Fluid a/w decreased platlet aggregation and prolonged bleeding time?

answer

Dextran

question

Colloid a/w allergic reaction

answer

Dextran has been a/w allergic reactions, interference with blood typing and renal failure

question

Fluid assoicated with pruritis

answer

Hetastarch

question

Recomended dural antiplatelet therapy after DES, baremetal, and baloon angiolasty?

answer

DES - 365 day BM - 4-6 weeks BA - 14 days

question

Tolerance Dependence

answer

Tolerance - escalating dose required for same effect Dependence - withdrawl

question

Cross tolerance

answer

Occurs between etoh and hypnotics/sedative requiring larger dose to achieve same effect

question

Addiction

answer

compulsive suse of a substance and seeing to aquire a substance to the exclusion of other activites, despite evidence of harm

question

Tachyphylaxis

answer

Rapid devlopment of tolerance to a drug after large, repeated doses or infusion

question

TBW

answer

Females 50% and males 60% of body weight

question

Crystaloid that does not contain potassium?

answer

NS

question

Mechansim responsible for long term tolerance with chronic opoid use?

answer

NMDA activation Ketamine and methadone, both antagongist at the NMDA receptor have been show to slow the onset of tolerance

question

Clincal risk factors predtive of periopertive CV complications (Revised cardiac risk indiex)?

answer

Ischmeic heart disease Heart failure Stroke or TIA Insuilin dependent DM Renal impartiment Cr;2

question

Two things that do not delop tolerance while on opoids?

answer

Miosis, Constipation

question

Blood loss to crystaoloid replacement

answer

1:1.3 to 1:1.6

question

Symptoms of cyanide toxicity from nitroprusside?

answer

Tachyphlaxis Metabolic acidosis Elevated mixed venous Pa02

question

Meperidine CI in patients taking what due to increased risk of serotonin syndrome

answer

MAO inhibitors - Selegiline

question

Fluid replacement on top of maintence for fever?

answer

2.5 mL/kg over 24 hours

question

Nicardipine

answer

DHP calcium channel blocker Used to decrease SVR and MAP after cardiac surg Bolus 0.5-1 mg, followed by infusion 2.5-10 mg/hr

question

Diltiazem

answer

Non DHP calcium channel blocker Rate control for Afib Bolus, followed by infusion 1-15 mg/hr

question

Antibiotifcs a/w renal dysfunction?

answer

Gentamycin (5-10%) Levofloxacin (1%)

question

Best antbiotic for lower GI procedures?

answer

Cefoxitin

question

Antiotiotic that increases QT interval?

answer

Macrolide -Erythromycin Levofloxacin can also increase QT but association less common

question

Dobutamine effects

answer

Increases CO with SVR Se - itachyarrhymias and PVC's

question

Ionotrope associated with decreased platlet count?

answer

Amrinone

question

Common EKG finding in digoxin tocity

answer

Atrial tachycardia with variable degree of heart block

question

Ionotrope that is Beta 1 selective?

answer

Dobutamine - B1 agonist and increases cAMP increasing intra celluar calcium concentration

question

Effects of ACE inhibitor

answer

Block ACE on Ang1 in the kidney blunting Ang 11 production and subsequent effects on vasocontriction, aldo synthesis, and ADH release Increase bradykinin levels 2/2 inhibition of ace

question

Compounds responsible for vasopressin release?

answer

Ach Histamine Nicotine Prostagandins

question

Hydralazine associated with?

answer

Lupus like syndrome

question

HR, SV, SVR, Mv02 all increased

answer

High dose epineprhine - >.1 mcg/kg/min

question

Increase HR, Increaed SV, Decrease SVR, increase Mv02?

answer

Dobutamine

question

Increased HR, Inreased SV, Increased SVR, INcreased Mv02

answer

Dopamine @ >10 mcg/kg/min - predominately alpha effects Dopamine stimulates D1, alpha, and B receptors, so its expected to increase HR and SV (B1), increase SVR (alpha), and increase Mv02 (B1)

question

Antibotics that potentiate neuromuscular blockade?

answer

Gentamicin, neomycin, tobramycin, amikacin Doxy, tetracycline Clinda

question

CI to MB andministration?

answer

Renal failure

question

Vasodilators associated with blunting hypoxic pulmonary vasoconstriction?

answer

Nitroglycerin and Nitroprusside

question

Hypoxic pulmonary vasocontriction

answer

Local hypoxia causes vasocontriction in pulmonary arteries, redirecting blood flow away from hypoix areas to areas with better oxygenation

question

Coronary vasospsm RX

answer

Diltiazem

question

Desmopressin (DDAVP)

answer

V2 specicic

question

Nicardipine

answer

INcrease HR, Decrease SVR, CO no change, Decrease contracility Coronary vasodilator

question

High risk patients for infective endocarditis?

answer

Prosthetic valve History of EC Unreparied cynatotic congenital heart disease Cogenital defect with prosthetic material reparied within last 6 months Cardiac transplant patient with vlave defects

question

Nesiritide

answer

Decreases vascular resitsance while having minimal effect on contractility and oxygen demane

question

PDE 2 inhibitors - milrinone and amrinone

answer

Only inotropic class that decreases Mv02 Inodilator, Increaes SV and CO and decreases SVR and PVr

question

Prolongs effects of calcium channel blockers and thus dose needs to be reduced?

answer

Liver failure

question

Location of V1a receptors?

answer

Vascular smooth muscle mainly resulting in vasocontriction other locations platelets, liver, adrenal glad, myometrium, brain and kidneys

question

Adverse effects of vasopressin

answer

Decreased CO Angina Myocardial ischemia Metbolic acisosis Ventricular dyshyhmia

question

Vasopressin use

answer

Control GI bleeding 2/2 decreased splanchnic blod flow

question

Nesiritide

answer

Binds to the A and B natriuretic peptide receptors, incrasing cGMP resulting in relaxation of smooth muscle, resulting in decrease preload, afterload and PVR

question

Nrepinephrine

answer

A, B agonist with predominatley alpha 1 effects Commonnly adminstered with milrinone after CPB

question

Acidosis effect on vasocontrictors

answer

Catecholamines less potent in setting of metabolic acisosis, so epi, phenylephrine and dopamine will not help Vasopressin and desmopressin work in acidotic enviroemnts however desmopressin tends to decrease BP (V2 selective) whereas vasopressin increases it (nonselective, V1a)

question

Procaineamide

answer

Sodium channel blocker, proloing duration of action potential and repolarization Bradycardia and prolong QT interval - Torsodes A/W lupus like syndrome

question

Hypophosphatemia

answer

Muscle weakness (poor tidal volumes), seizure, confusion, and peripheral neurpathy Increased sensitivity to NMBs

question

Diagnosis - head trauma causing LOC, with lucid period followed by rapid deterioration

answer

Epidrual hematoma - middle meningeal artery injury

question

Spinothalamic pathway

answer

Spinal cord - VPL nuc of thalamus - synapse - posterior limb of internal capsule - postcentral gyrus of the cortex Conveys temp, pain and touch sensation

question

EKG changes in hypercalcemia?

answer

Short QT, prolonged PR

question

Basal ganglia structures

answer

Corpus stratum: caudate, putamen and accumbens

question

Adenosine

answer

AV node blocker Used to stop reentrant circuit AV nodal reentrant tachycardia

question

EKG changes of hypokalemia

answer

Increaed ampltide and width of the P wave Prolongation of PR interval T wave faltening and inversion ST depression Prominant U wave Long QT due to fusion of teh T and U waves

question

EKG changes of hyperkalemia

answer

Peaked Ts Prolonged PR Wide QRS Decrease P wave amplitude/p wave disappearence Short ST V-fib/asystole

question

First treatment for ischemic head injury?

answer

Dexamethasone

question

Antiarryhmic assocaited with Torasades?

answer

Quinidine but procaineamide too

question

Mechanism of parkinsons?

answer

Neuronal depletion in the substantia nigra leads to a decrease in dopamine stores in the striatum

question

Class 3 antiarrhymthmics

answer

Potassium channel blocking class Amiodarone Sotalol Ibutilide Dofetilide Bretylium All lengthen the rate of cardiac depolarization, the APD, and ERP

question

Class 1B antiarrhymtic

answer

Shorten the APD, and the ERP Lidocaine Mexilitiine Tocainide Phenytoin

question

Class 1 A antiarrhymthic

answer

Lengthen the APD adn ERD, OTC A/W Torsades Quinidine Dispyramide Procainamide

question

Class 1 C antiarrhythmic

answer

Decreases rate of phase 0 AP and increase APD Prodyshythmic Metabolized in liver Propafenone, and Flecainide

question

Cerebral steal syndrome

answer

Redistribution of blood from ischemic areas of brain to vasodilated non ischemic areas

question

For each degree Celsius decrease in body temp, by how much will CMR02 be reduced?

answer

6%

question

During hyperventilation how much would you expect blood flow to reduced to brain

answer

CBF changes by 1-2 mL/100g/min per mmHg change in PaC02

question

Carotid Cavernous Fistula

answer

Presents - headache, pulsating exophthalmos, and extraocular nerve palsies Communication between internal jugular with venous outflow and resulting back pressure on the oculomotor, trochlear, and abducens nerves

question

HA prior to LOC, LOC followed by N/V, generalized headache and neck stiffnes

answer

Ruptured cerebral aneurysm

question

Head trauma

answer

Subdural hematoma - rupture of a bridging vein

question

Cerebral venous sinus thrombosis DDX

answer

Sickle cell Pregnacny Nephrotic syndrome Hormone replacement Dehydration Thrombophilia Inflamatory disease Polycthemia Meningitis Direct injury Head/neck procedures Homocystinuria

question

How long can a patient be in deep hypothermic circulatory arrest ?

answer

40 mins

question

Autoregulatory range at which cerebral blood flow is normally kept constant under autoregualtion?

answer

MAP 70-150

question

Where is serotonin release from?

answer

Raphe nuc

question

Where does NE synthesis occur?

answer

Locus coeruleus

question

Cerebral blood flows a/w EEG slowing and Flat EEG?

answer

Slowing - 20 mL/100g/min Flat - 10-12 mL/100g/min Irreversible damage - 6-10 mL/100g/min

question

Volatile agent that best preserved autoregulation?

answer

Sevo

question

How to calculate blood pressure in sitting postion?

answer

multiply the number of centimeters between cuff and external auditory meatus X .74 and then subtract this number from the blood pressure

question

Comparison of CSF components to blood?

answer

Higher - sodium, chloride, mag Lower protein, glucose, calcium, potassium

question

Genetic predisposition to Post operative cognitive dysfunction?

answer

E4 allele

question

Post operative delerium pre op RFs and periop risk factors?

answer

advanced age pre op cognitive impariment etoh abuse hip fracture surgery decreased functional status vison or hearing impariment cognitive imparment BUN:Cr>18 Use of physical restraints >3 medications added 24-48 hours prior to the onset of delerium Periopertive -Greater blood loss, pain, blood transfussions, post op hct<30%

question

Is there a difference between GA and RA in terms of indicidence of post opertive cognitive dysfunction

answer

NO

question

Emergence delerium

answer

Seen during or immediately after emerging Directly correlates with duration of anesthesia Peak incidence is children 2-4 years Frequent assicated with rapid emergence from sevo or des

question

Does on pump vs off pump cabg effect incidence of POCD?

answer

NO

question

Oxygen uptake across the alveolar membrane determined by?

answer

Diffusion capability -surface area of alveolus, thickness of membra,e, pulmonary capilary blood volume (similar to CO) and hemoglobin concentration

question

Mechanism of increasing ventilation

answer

Ventilation determined by CO2, wihch crosses blood brain barrier and alters the pH in the central medually chemorecptors. Thus increase in CO2 results in an increase in minute ventilation

question

Effects of hypercarbia

answer

Increased CBF Splanchnic and hepatic vasocontriction Decreased MAC Compesatory metabolic alkalsois Acidosis decreases th affinity of hemoglobin for oxygen, as decribed by the bohr effect

question

Oxygen consumption formula (Ficks principle)

answer

CO * C(a-v)O2 Ca/v02=hemogobin*1.34*Sa/vO2/100 + Pa/vO2*.003

question

Oxygen delivery formula (D02)

answer

CO * Ca02 (note Ca02 in mL02/dL blood) CO out usually given in liters/minute so you need to converte it to dL/min so times it by 10

question

Adult, and fetal hemoglobin p50

answer

p50 - 27 p50 - 18 (decreased 2,3 DPG)

question

Transient neurologic symptoms

answer

Pain and dysethesia 12 to 24 hours after spinal raidiating to ass Lidocaine A/W outpatient surgery, lithomy, positioning for arthroscopic proceudres Rx. NSAIDS

question

ortho toluidine metabolite of what and what does it cause

answer

Metabolite of prilocaine and can cause methemoglobinemia

question

Why add epi to local anesthetics?

answer

INcrease duration of the block

question

Factors that increase diffusion of across the epidural space?

answer

Larger drug dose Volume Lipid solubilty

question

What determines the spread of spinal?

answer

Dose volume baricity Patient position

question

What determiens duration of a spinal anethetic?

answer

Amoutn of drug adminstered Lipid solubulity

question

Difference between epidural and spinal?

answer

Epidural -slower onset and less predictable -increased volume needed -additional time for LA to cross dura to subarachnoid space Spinal -Faster, more reliable -Less durg is needed but both are dpeendent on dose to ryield optimal results

question

Lipophilic intrathecal opoids

answer

Faster onset Shorter duration Respiratory depressant effects usually occur in the first 2 hours of administration

question

Effect of adding lipophilic fentanyl to LA spinal?

answer

LA anesthetic alone results in N/V Adding fentanyl works synergistcally with LA to block visceral pain stimulating, leading to less intraopertive N/V compared to the same dose of LA alone

question

Bohr effect

answer

Describes the small impact of pH and PaCO2 on the position of the oxyhemoglobin disssociation curve

question

Right shift of oxy hemoglobin curve

answer

Sicke cell thalassemia acidosis (bohr) Hypercarbia (bohr) hyperthermia increased 2,3 DPG volatiles Pregnancy Hypophosphatemia

question

What is 2,3 DPG

answer

Allosteric inhibitor of oxygening binding to hemoglobin Byproduct of anarobic metabolism INcreaed in states of chronic hypoxia

question

Leftward shift of oxy hemoglbin curve

answer

INcreaesd pH Decreased PaCo2 Decreaed 2,3 DPG Hypothermia Fetal MEthemoglobinemia Sulfhemoglobinemia Carboxyhemogobinemia

question

Effect of Oxygen and hyperbaric oxygen therapy on carboxyhemoglobin levels

answer

Therapy with Fi02 1 decreases the half life of CO-Hb from 4-6 hours to 1 hour Hyperbaric oxygen therapy with Fi02 1 at 3 ATM redusced the T1/2 to 15 - 30 mins

question

Predicting post operative complication in lung resection

answer

VO2 max - 6 minute walk test of 2000 ft or 612 meters is equivlant of V02 max of 15 mL/kg/min and predicts low post operative risk VO2 max best predictor in patients with normal lung parenchma e.g no COPD while the DLco better predictor in pateints with lung disease

question

How much pressure is needed to expand atelectatic lung?

answer

40 cmH20

question

Hypoxic ventilatory response

answer

Type 1 glomus cells of carotid body sense partial pressure of Pa02 slight below 100 but substantial increase in ventilaton does noto occur until Pa02 falls below 70 mmHg. Ventilatory response does not maxmize until Pa02 falls below 60

question

Location of generation vs rhythm of respiration

answer

Generation - medualla - dorsal respiratory group Modulation of respiratroy rhythem - Pons via apneutic center and pnumotaxic center

question

How does pKa effect LA

answer

Onset of action for local anesthetics determied by pKa Lower the pKA, the fasater the onset Exception chlorprocaine with pKa of 9.1 can give greater concentration

question

Differenec between ester and amide anesthetics?

answer

Ester local anesthics - hydrolyis via pseudochoinesterase Amide - hepatic metabolism via p450

question

EMLA

answer

2.5% lidocaine and 2.5 % prilocaine Effective in penitrating skin Requires dosing 30-60 minutes prior to procedure

question

RFs for local anesthetic toxicity from amides

answer

Very young or old Cardiac disease Hepatic dyyfucntion

question

ECG cahnges associated with inravenous injection to test dose

answer

increaed amplitude of t waves on ecg increased or a decreased heart rate increased blood pressure

question

PABA

answer

Para aminobenzoic acid Allergic reactions Metabolite of preservitive methylparaben

question

Bupivicaine cardiac toxicty RX

answer

bolus 1.5 mL/kg of intralipid

question

Cauda equina syndrome

answer

Caused by lidocaine toxicty Order an MRI Sx inculude bowel and bladder incontience and perineal sesory loss (Note no sensory changes or incontenence in TNS)

question

Inflamation effects on LA

answer

Inflamation leads to acidosis, or decreased pH which lowers the unionized fraction of LA and creates unfavorable absorption because only the unionized lipophilic portion of the drug is able to penitrate

question

Haldane effect

answer

Decribes the fact that the oxygenation state of hemoglobin affects the positon and slope of CO2 reposne cruve Deoxyhemoglobin better able to bind CO2 and H+ facilitating greater CO2 clearence from tissues When 100% of hemoglobin exits as doxyhemoglobin the blood conceration of CO2 (y axis) is high for a give pCO2, as proportion of oxyhemoglobin increased, the total blood carbon dioxide concenrtaiton dorps

question

Dynamic lung volumes and capacities

answer

TV Inspiratory reserve volume Expiratory reserve volume Inspiratory capacity Vital capacity

question

How can dynamic lung volumes and capcities be measured?

answer

Simple spirometry

question

Lymphangioleiomyomatosis managment

answer

Smooth muscle proliferation lungs casue sever obstructive pattern After initation of ventilaton patients become high risk for auto peep (refractory hypotension 2/2 decreased venous return) Disconect patient from vent Vent stratagies - slow RR, prolonged I:E ratio HIgh risk for pneumothorax

question

Reduction in FRC

answer

Changing from standing to supine (30-40%) Sitting Induction of general anestheisa (20%) Lower abdominal surgery (30%)

question

Afferent branch of aortic body chemorecptors

answer

Vagus nerve

question

Afferent branches of lung mechanorecptors and activaiton?

answer

Vagus and spinal nerves Activation of these recptors occurs via maximal inspiration, irritant stimuli (secretions, gastric contents, and foregin bodies) Resulting in cough

question

Complication of bilateral carotid endarterectomies

answer

Patient loose the carotid body chemorecptors, and hypoxemia does not generate increase in ventilation Hypercapneic ventilatory drive also blunted

question

CO2 response curve

answer

Opoids - shift curve to the right (slope may change at high dose) Benzos/Roc - decrease slope (lessen response) wihtout affect the intercept or apenic threshold Propofol: decreases the slope of ventilaatory response curve Hypoxemia: at less than 65 mmHg pa02, the CO2 response curve is left shifted Volatiels: decrease the response (slow and right shift) to CO2 (although low doses - .1 MAC controversal)

question

LA that cause methemoglobinemia

answer

Prilocaine Benzocaine

question

Channels in the heart affected by local anesthetics?

answer

sodium, potassium, and calcium affecting depolarization, repolarization and contractility

question

Assesory muscle of breathing

answer

Scalene, sternocledomastoid, alae nasi

question

How much does 1 mmHGg increase in CO2 increase minute ventilatoon?

answer

2-3 liters/min/mmHg

question

Sequence of LA absorption from fastest to slowest

answer

IV>Tracheal>intercostal>caudal>paracervical>epidural>brachial>sciatic>SQ

question

Bupivicaine cardio toxicity risk factors

answer

Pregnant patients - due to effects of progesterone on myocardium Hypoxemia Respiratory acidosis Hyperkalemia

question

Inferior tip of scapula?

answer

T7

question

Postive test dose?

answer

INtraosseous or intravasucalr injecction positve when there is increase in heart rate of more than 15 beats per minute and increase in T wave amplitude of 25%

question

Superior aspect of illiac crest corrosposponds to waht level?

answer

L4-L5

question

Dural sac extends to what level in new borns?

answer

S3 -4 by 1 year of age its S1-S2 spinal ends at L1 by one year of age

question

Nipple line corrosponds to what level?

answer

T4

question

5th finger corresponds to what level?

answer

C8

question

DDx of SOB after spinal?

answer

Diaphgramatic weakness - C3-C5 Intercostal nerve - T1-T12 - all of these nerve typically affected in spinal for c - section

question

Anestheitc concern in RA patients

answer

Periopertive cervical flexion extension radigraphs should be obtained in RA pateints with limted neck movement and neuro symptoms On lateral flexion view, a distance >3 mm from the anterior arch of the atlas to the odontoid process indicates atlantoaxial subluxation Aneiro subluxation of C1 to C2 most common form of sublaxation and may occur in 40% of RA patients

question

CI to neuraxial blockade?

answer

Tethered cord syndrome

question

Epidural hematoma assocaited with rupture of what structure

answer

Middle menigeal arter Briding veins = sub dural hematoma

question

Structures transversed in midline epidural placement?

answer

SKin, supraspinous, interspinous, ligamentum flavm Ligamentum flavum you hear a "pop"

question

Subarachnoid space

answer

Filled with CSF Continous space with brain Bounded by pia matter and the arachnoid matter

question

Timming of epidural abscess after spinal?

answer

2 to 3 days More common if catheter has been in place for 3-5 days Epidraul hematomas usually occur within hours of cathiter placement or removal

question

Meralgia paraesthetica

answer

Mononeuropathy of the lateral femoral cutanous nerve presseting with loss of senation limited to the aterolateral thigh

question

Speed of onset of LA

answer

Determined by how many molecules are in the non ionized form LA with pKa closest to physiologic pH 7.4 have molecules in the non ionized form verse LA with high pKa

question

Duration of LA

answer

Dependent on the amount of protein binding

question

Structures transversed during paramedian approach epidural

answer

SKin, superficial and deep fascia, paraspinous msucles and ligamentum flavum

question

Layer of menignes repsponse for most of the resistance to durg movement from epdural space to the intrathecal space?

answer

Arachnoid matter 2/2 tight junctions

question

Ebtifibatide

answer

Glycoprotein 2 B/3 A inhibiotor REgional techniques avoided for 8 days

question

Monitor heparin?

answer

PTT

question

Warfarin interfesres with the snytehsis of waht factors?

answer

2, 7, 9, 10 and Protein C, S

question

How long to wait for neuraxial injection after clopidogrel and ticlopidine?

answer

Cloidogrel 7 days Ticlopidine 10 to 14 days

question

How does midazolam exert its effects?

answer

Water solbule durg that is converted into a lipid soluble form on exposure to the bloods pH, which can readly cross BBB and exert its effects

question

How much shoudl the most common test dose increase heart rate?

answer

MC test done 3 mL of 1.5 % Lido containg 5 mcg/mL epi (1:200,000) typically raises heart rate 20-30 beats/minute

question

What does a 1:200,000 epi mixture mean?

answer

1:200,000 - 1000 mg/200,000cc 1g=1000 mg=1,000,000 micrograms

question

Which needle types are most likely to laed to PDPH?

answer

Cutting needles (quinke) have higher incidence of PDPH than pencit point needles Also larger bore needles (smaller gauge) will increase PDPH

question

Risk factors for post dural puncture headache?

answer

Smaller guage and cutting needles (quinke) Younger age Female Pregnancy

question

Cardaic accelerator fibers?

answer

T2-T4

question

How long should you wait to perform a spinal for patients on lovanox?

answer

Full dose - 24 hours Prophylactic - 12 hours

question

Spinal epidural space

answer

Extends from the foramen magnum to sacral hiatus

question

Most significant factors that affect spread of LA in epdural space?

answer

Level of injection and volume/dose of LA Baricty of LA more significant with spinal anesthesia

question

Absolute contraindication to epidural ?

answer

Infection at enry site

question

Final anatomic sturcutre traversed by the needle prior to entering the caudal epidural space?

answer

Sacrococcygeal membrane

question

1ml/kg volume of LA will provide reliable sensory block up to what level if injected in the caudal space?

answer

T10

question

Stucture not covered during caudal block?

answer

Manipulation of teh testicle will pull on the upper peritoneal fibers not covered by the T10 level of caudal block

question

CI to caudal block

answer

Septicemia

question

Most sensitve sighn of intravascular injection of LA

answer

Peaked T waves

question

At this gestational age there is minimal risk for teratogencity but peak risk for fetal loss during anesthesia and surgery?

answer

Surgery during the first 2 weeks of gestation may increase change of fetal loss Mild cellur damage is generally fully recoverable during the first 2 weeks without teraogency By third trimester, the risk of preterm labor is increased

question

Heart other other vital organs deveop within which period making them susceptible to structural defects

answer

3-9 weeks

question

Predicts pulmonary complications during thoracotomy?

answer

PpoFEV1% = preoper FEV1% * (1-% functional lung tissue removed/100) if >40% low risk If <30% high risk for pulmonary complications

question

Times after smoking

answer

12-24 hr - decrease carboxyhemoglobin, right shift of hemoglobin dissociation curve 1-2 weeks - decreased sputum 12 weeks - improvement in small airway function

question

Muscle relaxants a/w histamine release?

answer

Atracurium and mivacurium

question

A/w skeletal abnormalities during first trimester?

answer

N20

question

During what trimester is a fetus at highest risk for dead associated with anesthesia and surgery?

answer

1st trimester

question

Maximal volatile concenetration allowablle?

answer

Alone - 2 ppm Volatile + N20 = 0.5 ppm

question

Or personell exposure to volatiles puts patietn at risk for stucturel abnormaliees in fetus - True or false

answer

No data has proven increaed risk to fetus from personnel expsoed chronically to trace anestheitc agents However association have been made with spontaneous abortion

question

Hoarse voice after intubation associated with wht neve?

answer

Unilateral vocal cord paralysis - pasly prevents abduction of ispilateral cord thus it becomes stuck in the adduction positon

question

Lingual nerve pasly

answer

Tongue numbness due to compression with oral airway, laryngeal mask or intubation Brnch of trigeminal V3 Somatic snsation to anetior 2/3 of tongue and gingiva along the lingual side of the mandibular teeth

question

Ischmeic optic neuopathy

answer

Number one diagnosis for non periopertive acute visual loss in pateints over the age of 50 Arteritic form - temporal arteritis, involing the anterior portion of optic nerve Rx. steroids

question

Posterior ischemic optic neuropathy

answer

Most common cause of POVL in spinal surgeries, more common when spinal fusion or instrumentation is involved Imeddiate post bilateral vision loss Fundo exam: optic disc pallor over weeks to months

question

Anterior ischemic optic neuropathy

answer

Most commonly reported after CABG, but also associated with bilateral neck, spine orthopedic procudres Vison loss dealyed up to one week post op Fundo: optic disc edema and pallor Afferent pupilalry defect

question

Common perionail nerve injury

answer

Lithotomy postion impared ankle dorsiflexion or foot drop

question

Ulnar nerve injury

answer

Most common peripheral neuropthy in supine patient Men>women, thinner Weakness of lumbrical in 4th, 5th digits with loss of flexion at MCP join and loss of extension at the IP joints, or "claw hand"

question

Conduction

answer

Transfer of heat betwen two adjacent srufaces

question

Convection

answer

Transfer of heat via air currents

question

Mechanism of negative pressure pulmonary edema?

answer

Negative intrahtoracic pressure 50 to 100 cmH20 rsults in sudden increase in venous return of blood to heart, which increase preload and an increase in both end diastolic and end systolic ventricular volumes

question

Patient biting down on tube, what dose of succ to give?

answer

0.1-0.2 mg/kg

question

Mechanisms for development of increase interstial lung fluid?

answer

Increased hydrostaric pressure in pulm cap bed Decreased interstitial space pressure Decreased osmotic pressure of plasma Increased permiability of membrane Decreased return of fluid to the circulation via lympathic

question

Particulate antaacids

answer

Sodium bicarbonate Magnesium hydroxide Calcium carbonate Aluminnim hydoxide

question

Non particulate antiacids

answer

Sodium citrate Sodium citrate + citric acid Sodium citrate + citric acid + potassium citrate

question

Pink frothy sputum diagnositic for waht?

answer

Negative pressure pulmonary edema

question

How long to avoid nitrous oxide following intravitreal injection of a gas bubble (ie Sulfur hexafluoride)?

answer

10days

question

Cotton wool exudates on the retina

answer

Retinal bleeding that orginates from the arterial circulation is often assicated with head trauma other event - severe chest or abdominal truama, acute pancreatitis, fat or amnotic fluid embolus

question

RF's for posterior iscemic optic neuropathy?

answer

Most common cause of post op visual loss Most commonly a/w spinal fusion procedures in prone position Other RFs - hemodilation, large volume of crystaloid, hypotension, prolonged surgical time, vasocontriction or pressure support, male, EBL;1000 mL, facial edema Patients typically report visual symptoms within 24 hours, most often while still in recovery room Fundo exam reveals - normal appearing optic disc, that begin to look pale over weeks to months Leshion: Retrobulbar portion of optic nerve

question

Normal optic disc and intact pupilary reflex?

answer

Cortical blindness note pupilary light reflex normaly absent in AION, PION, Central retinal artery occlusion

question

RF's for ION?

answer

Spinal fushion Male Obesity Wilson fram Longer anesthetic duration - This is by far the most significant factor and surgergy with >6 hours as an apparent inflection point Greater EBL Lowe amonts of colloid anministration Recomendations: Avoidi wilson head frame If using prone position put reverse t berg Staging long complex procedures

question

Nuropathy from retractor injury druing open abominal hysterectomy?

answer

Lumbar pleux or proximal femoral nerve resulting in loss of leg extension

question

Neuropathies: neuropraxia, axonotmesis, neurotmesis

answer

Neuropraxia -No disruption of anatomical nerual elements -Resolved in a few weeks Axonotmesis -Axons are disrupted, but nerve sheats remain intact -Wallerian degeneration, but axon regeneration results in recovery of funtion over weeks to months Neurotmesis -trasection of axons and myelin sheats -prevents regeneration and recovery

question

Most common periop neuropathies?

answer

Ulnar 25% Brachial plexus 19%

question

Weak leg abduction

answer

Obturator

question

Loss of sensation over the anterolateral thigh?

answer

Meralgia paresthetica - injury to lateral femoral cutanous nerve MOst common neuropathy related to child birth

question

Volume and pH necessary for developement of aspiration PNA?

answer

Gastric volume >0.3 mL per kg of body weight (20-25 mL adults) with a pH<2.5

question

Concentration effect

answer

Comprises concentrating effect and augmented tracheal inflow Desribes teh effect that a high concentration of N20 has on its own uptake and is independent of the other gases that are administered

question

Second gas effect

answer

requires borht nitrous oxide and a volatile agent

question

Which nail polish has greatest effect on accuracy of pulse ox?

answer

Blue nail polish -similar absorbance as deoxygenated hemoglobin - near 660

question

Augmented tracheal inflow

answer

Component of the concentration effect that involves gas from more proximal areas of the airway and lung replacing the alveolar gas that has rapidly diffused across the alveolar memebarane Requires a high FiN20 and the abiity to augment tidal volume Becasue volume control ventilation delivers fixed tidal volume prevents augmenation of tracheal inflow, note airway obstruction would have the same effect

question

Dry skin indiactor of what

answer

Indicatior of prolonged or severe hyperthermia Sweating decreases to conserve body fluids

question

Wavelength of light used in pulse ox?

answer

660 nm (red) 940 nm (infared)

question

Consequences of intraoperative hypothermia..

answer

Post op myocardial ishcemia wouund infection Impared coagulation Decreased drug metabolism

question

What increases partial pressure of agent?

answer

Increased input to the alveoli -Inspired anesthetic partial pressure -minute ventilation -Inspired gas flow Decreased uptake from the alveoli -Solubility -CO -Alveolar to venous partial pressure difference

question

Effect of right to left intracardiac shunt on N2O

answer

Decrease uptake of N20 Note a left to right shunt would have minimal effect

question

Vapor pressure is a function of...

answer

Temperaure VP increases in a non linear fashion as temperature incresaes

question

Safety features on modern anesthesia vaporizer

answer

Agent specifc keyed filling ports that prevent fill its rervoir using a bottle keyed for a different agent Low filling port with a fill line to provide a visual indicator and prevent overfilling INterlocks that prevent administration of more than one volatile at a time Cocentration dial taht increases out when rotated counter clockwise

question

VP of des

answer

681 - high est of all voaltiles

question

Filling a vaporizers calibrated for an agent with lower VP with one with a higher VP results?

answer

Patients higher than the amount being deliverd VP sevo - 157 VP hal - 243

question

How mcuh oxygen flow into the vaporizing chamber calculation

answer

Basically use the splitting ratio: e.g 12:1 Divide the fresh gas flow by 13 this nymber is the amount of fresh gas flow that flows into the vaporizer

question

What do the number on the dial of a vaporizer represent?

answer

Indicates volume precent, which is partial pressure of anesthetic vapor, as a percentage of total ambient pressure, calculated at sea level Vol % = (partial pressure due to vapor/total ambient pressure) * 100%

question

Relative humidity

answer

Partial pressure of water vapor in the air divided by the partial pressure of the water vapor when the air is saturated with water vapor at the same temperature, expressed as a percentage RH=Pwater/Psasturated water

question

Contraindications to N20 use?

answer

Pnumothorax INtravitreal gas injection Typnaoplasty Open crani as it could increase volume of gas embolus Acute intestinal obstruction

question

What increases when a variable bypass vaporizer, calibrated at sea level, experiences a decrease in barometric pressure (increase in altitude)?

answer

Partial pressre of anesthetic in the vaporzing chamber is unaffected by change in ambient pressure to the output in clincal temrs (MAC units of partial pressure) remains constant THe vaprizer output in % increases with decrease in barometric pressure

question

Critical temperature

answer

Temp above which a gas cannot be liquefied no matter how much pressure is applied

question

Ideal gas law

answer

One mole of an ideal gas will ocupy 22.4 liters at standard temp (273.15 K or o C) and pressure 101.325 PV=nRT

question

Daltons Law

answer

Mixture of gases in a volume, each gas exerts the partial pressure in the mixture that it would exert if it occupied the volume alone

question

Albumin

answer

Increased risk of mortality in patients with TBI

question

Cryoprecipitate

answer

Contains F8, vWF, fibrinogen Check fibrinogen level before replacement

question

Hetastarch

answer

Associated with acute renal failure Coagulopathy at larage doses

question

Platlets

answer

Stored at room temp which increases risk of bacterial infection

question

Symptoms of citrate intoxication?

answer

Hypotension Narrow pulse presure Increased intraventricular end diastolic pressure Lengthening of the QTc interval

question

Which stage of liver transpalnt are patients most susecptible to citrate intoxication?

answer

Anhepatic phase - portal vein cross clamped and patient unable to metabolize citrate from transfused blood products

question

Universal recipient blood type?

answer

AB postive - becasuse all antigens are present they do not make any antibodies

question

Blood Cold Chain to RBCs

answer

After fractionation, RBCs sotred between 2-6 C and 2-10 C for transportation until the point of use The 30 minute rulel states that RBC units should not be kept outside this temperature range for any period exceeding 30 minutes RBCs may travel back to blood bank in approved container capable of maintiang temps of 2 -10 C for up to 24 hours

question

Blood cold chain

answer

Specifies appropriate storage conditions for all blood components dervied from human volunteers from the time of harvest until the point of use - applied to all blood derived components, regardless of optimal temp and storage conditions This includes -Platlets - stored at 20-24 C Albumin -Whole blood/RBCs - Refridgerated @ 2-6 degrees -Cryopercipitate/FFP - frozen at temp below -20 C Recominant factors are not regualted under the blood cold chain e.g rF7

question

Monitors capable of measuring oxygen?

answer

Mass specctrometry Ramen Spectrometry

question

Bivalirudin

answer

Direct thrombin inhibitor Substitute for heparin in patients with heparin allergy orheparin induced thrombocytopenia

question

What is the only paramagnetic gas used in anestheisa?

answer

Oxygen -

question

Electrolyte abnomralities assoicated with transfusion?

answer

Potassium increase Hypocalcemia Hypomagnesium Sodium unaffected

question

What temperature should platlets be sotred at?

answer

Sotred at room temp 20-24 C,

question

Infared spectrometers detect what gases?

answer

CO2, N20, and volatiles They cannot measure symetic molecules ie 02, N2

question

Albuterol effect on monitoring volatile anesthetic agents?

answer

Albuterol contains halogenated propellants that absorb infared light in the range of volatile anesthetics. After treating with bronchodialtor, the machine may alrm "mixed agents" and show halothane as a detected gas

question

Lethal triad of trauma patients?

answer

Hypotension, Hypothermia, and acidosis

question

RBC changes with storage?

answer

Decreased 2,3 DPG Cells become more spherical with surface projections (spheroechinocytosis) Increased K outside of cells and increase Na within cells

question

Methods that can be used to measure volatiles?

answer

Infrared Piezoelectric Refractometry

question

Abnormalies that contribute most importantly to coagulopathy during massive transfusion?

answer

Dilution thrombocytopenia and hypofibrinogenemia

question

Platelet storage leshion

answer

When platlets are cooled their surface proteins change that trigger the rapid elimination from circulation by hepatic macropahges

question

What is leading cause of death related to transfusion?

answer

TRALI

question

Transfusion filters?

answer

170 micrometer - leukoreduced blood 40 mm - cell saver, massive transfuion

question

Adverse effects of sodium bicarbonate

answer

Hyperosmolarity Paradoxical CSF acdiosis Hyernatremia Hypercarbia

question

When is dextran indicated?

answer

a/w strong anticoagulant properties and would not be indicated in most operations It may sometimes be indicated in vascular or plastic surgeries where improving perfusion and avoiding thrombosis is desirable such as a musclar free flap

question

Diagnostic criteria for TRALI

answer

ALI -acute onset -hypoxemia Pa02/Fi02<300 -Bilaeral opacities -No left atrail hypertension PAOP <18 + the following: -Onset of signs <6 hours after administration -ALI not present before transfusion -NO temporal relationship to an alternative risk factor for ALI

question

Bronchial aspirate findings in TRALI

answer

Increased permiablitly of pulmonary capillaries results in exudative pulmonary edema Asspirate would contain: -High protein -High specific gravity >1.020 -Pleural fluid protein/serum protein >0.5 -Pleural fluid LDH/serum LDH>0.6

question

Mechanism of urticarial reaction following blood transfuion

answer

Reaction to donor plasma proteins

question

Mechanism of febrile hemolytic reaction?

answer

Reaction to donor leukocytes

question

What has been shown to reduce incidence of TRALI?

answer

Avoidng blood products from multiparous women and using male dominat plasma pool

question

RFs for TACO

answer

extremes of age CHF Renal impairment Hypoalbumin Fluid overload

question

Mechanism febrile non hemolytic transfusion reactions?

answer

Result cytokines and intracelluar contents released by donor leukocytes Reaction minimized with leiukoreduced blood

question

Type of pulmonary edema seen in TACO?

answer

Transudative pulmonary edema

question

When are irradiated RBCs useful?

answer

Preventing graft vs host disease

question

What is the first sign of ABO incompatibility in anestheized patient?

answer

Hemoglobinuria followed by hypotension and DIC

question

What inteventions have shown no use in TRALI?

answer

Diuretics, antibiotics, and steroids Note maintaing oxygenation (intubation) and pressor support only things that help

question

Treatment of TACO?

answer

Mild (cough, dypnea) - stop transfusion, supplemental O2 Severe (cyanosis, frothy fluid in ETT) - diuretic

question

Purpose of irradiating blood products to prevent graft vs host disease

answer

Irradiating blood renders T-cells incapable of repilicating and attacking host

question

What is the second most common cause of mortality realted to blood transfuison?

answer

TACO

question

What increases risk of graft vs host disease?

answer

Transfusion of RBCs from first or second degree relatives because they share HLA haplotypes, the recipients immune system cannot recognize and destory the donor T cells that can cause GVHD

question

What differentiates a dealyed hemolytic transfusion reaction from an immediate one?

answer

DIC does not occur in delayed type

question

RFs for TRALI

answer

Sepsis Liver Disease ETOH abuse Mechanical ventialtion

question

Pathophysiology of TRALI

answer

MOst cases due to antibodies from donor May require two hit immune mechanism Final common path involves neutrophil activation, endothelial injury, and capilalary leak May require pressure support

question

heterophil antibody negative, and prsents with enalrged lymph nodes in neck

answer

CMV

question

What carries highest risk of transfusion transmitted infection?

answer

Hep B 1:205,000

question

1:2,135,000

answer

HIV risk in blood

question

1:2,993,000

answer

Risk of HTLV 2 in blood

question

1:1,935,00

answer

Risk of hep c in blood

question

What is not tested for in blood?

answer

Hep A

question

Bacterial infections associated with blood products stored at room temp vs frozen

answer

Platlets stored at room temp have high risk of gram + infection e.g staph, and bacillus RBCs stored at 4 C increases liklihood of contamination with gram - bacteria such as Yersinia and psudomonas

question

What disqualifies a person from donating blood prodcut?

answer

One year band on donors who recenetly traveled to malaria edemeic countries Men who have had sex with men in the last year Sex with prostiute or injected drugs in last year

question

Massive transfusion definition?

answer

Replacement of a patients blood total blood volume -Greater than 10 units of PRBCs over a 24 hour period or Replacment of half a patients blodo volume within 3-4 hours -Greater than 4 units of PRBCs in 1 hour with a foreseeable ongoing need

question

Hyperkalmeic arrest

answer

In setting of massive transfuion and rapid infsuion rates, hyperkalemia can cause wide complex tachycardia potassium level in a unit of PRBCs - 77 meq/L and infusion rates of 100-150 mL/min can cause hyperkalemic arrest

question

Symptoms of citrate toxicty

answer

Tetany (lower calcium) Prolonged QT Decreased myocardial contracitliy Hypotesnion (Lower SVR) Narrow pulse pressure Eleavated CVP Pulseless electrical activity Ventricular fibrilation

question

What treatment is a JW most likely to accept in the circumstance of large blood loss?

answer

Intraoperative autotransfusion

question

Universal donor and recipient of blood?

answer

Donor: O negative Recipient: AB

question

Universal donor and recipeint for plasma?

answer

Type 0 patients can receive any type of plasma, because their RBCs lack antigen to attack either A or B antibodies AB type patients, as in this case shoudl only receive AB plasma

question

Monitoring heparin

answer

Low dose - pTT High dose - ACT

question

Anticoagulants to avoid in patients with renal disease?

answer

Dabigatran Rivaroxaban LMWH

question

Treatment of HIT

answer

Parenteral anti 10 a agents -Fondaparinux Parenteral Direct Thrombin inhibitors -Lepirudin -Argatroban -Bivalirudin

question

LMWH briding dose for pateint taking warfarin?

answer

D/C warfarin 5 days before procedure Start LMWH 1.5 mg/kg s.c. qd or 1 mg s.c. bid Therapeutic doses should be stopped 24 hours prior to neuraxial procedure and normal INR should be documented prior to neuraxial block

question

Drugs that decrease warfarin effect?

answer

barbiturates carbamazepine cholestyramine nafcillin phenobarbital phenytoin rifampin

question

Drugs that increase warfarin effect

answer

Levofloxacin Omeprazole Amidoarone

question

How long does it take for dabigitran to clear your system and coagulation normalize?

answer

Dabigatran should be stopped 1-2 days before surgery for CrCL>50 mL/min and 3-5 days before surgery for CrCl<50 mL/min

question

Natural course of HIT

answer

Antibody disappears over time, usally within 3-6 months Upon re exposure to heparin it reappears typically within 1-3 days There should be a 12 -24 hours period in which its safe to use unfractionated heparin

question

How long does intramuscular vitamin K take to nomralize INR

answer

12-24 hours no appropraite for emergent reversal of warfarin

question

Side effect of protamine?

answer

IgG or complement driven reaction resulting in severe pulmonary hypertension and right ventricular failure MOre common in patietns with fish allergy, previous vasectomy, or prior exposure to protamine or NPH insulin

question

Drugs most likely to cause fevers and anaphylaxis?

answer

Monocloncal antibodes and globulin prodcuts

question

What drug increases immunosuppresent levels and results in additive QT prlongation?

answer

Amiodarone

question

Gentamicin effect on immunosuppresnts?

answer

INcreases risk of nephrtoxicity

question

Amphotericin effect on immunosuppresnats

answer

Increases risk of nephrotoxicity

question

Rifampin effect on tacrolimus?

answer

decreases concentration

question

Effect of levofloxacin on immusppresants?

answer

Increases concentration

question

Side effect from adding tacrolimus to voriconazole or fluconazole?

answer

QTc prolongation

question

Effect of cyclosporin on benzo levels?

answer

Casues moderate increase in benzo concentration

question

Effect on immunosuppresent levels BBs CCB Amidarone DIgoxin

answer

BBs- no signficnat interactions CCB - increase concentration Amiodarone - increase immunosuppresnt concentrations and worsen QT Dogoxin - involved in the p glycoprotein pathway and can have interactions

question

Stimulus for vasopressin release?

answer

Released from posterior pituitary when the hypothalamus senses hyper osmolality (not hypo osmolality) or the carotid or aortic baroreceptors are not stimulated (as in hypotension)

question

Water compartments in body (%)

answer

TBW 60% of total body weight Intravascular 5 Intracellar 60 Interstitial 35

question

Rivaroxiban

answer

Oral factor 10 a inhibitor

question

Bivalirudin

answer

Direct thrombin inhibitor

question

Unfractionated heparin

answer

Indirectly inhibits factos 2 a (thrombin) and 10 a' Reuires antithrombin as cofactor

question

WIth decreasing temperature, gas solubility?

answer

Increase

question

With increasing temperature, pH...

answer

Decreases

question

A hypothermic pateints blood gas is heated to 37 C. The PCO2.... in the same sample when compared to the patients much colder blood?

answer

Increases

question

Combitube

answer

2 lumen decidce that contains latex used to secure airwawy in patints with facial trauma or vomitting

question

Rusch Easy tube

answer

Similar to combitube but contains no latex

question

Gag relfex

answer

Glossopharygneal

question

Must be anestized to provide tracheostomy?

answer

Recurrent laryngeal nerve

question

Touch sensation to anterior 2/3 tongue

answer

CN V - trigeminal

question

Benzocaine

answer

Methemoglobinemia

question

How mcuh does pH change for every degree C chnage?

answer

pH will change by 0.015 E.g Patients with ABG measures pH of 7.33 at temp of 37. What would the temperature corrected PH be if the patietns bladder temp is 20? pH will be higher as the patient cools and lower as the patient warms up 7.33 + (37-32)(0.015) =7.585

question

How much does bicarbonate rise for an acute respiratory acidosis?

answer

Bicarb rises 1 mEq/L for every 10 mmHg rise in pC02

question

You are cooling patient down to 17 C . You are following pH stat strategy. Th blood gas is 7.20. What do you do?

answer

First solve for corrected pH -Cooling patient down, so pH is gonna be increased... -7.20 + (37-17)(0.015)=7.5 Pt is alkalotic according to pH stat managment which strives to keep pateints pH at 7.4 There you would adise perfusionist to increase the patients C)2

question

Clark electrode

answer

Used to measure Oxygen - note falsly low 02 may result from build up of protein on semipermable membrae

question

How does laryngeal tube differ from combitube?

answer

Basically the same thing but LT does not contain latex

question

How does clark exlectrode work?

answer

Oxygen diffuses across the membrane, and undergo reduction at the cathode. The voltage difference betwewen the cathode and anode is directly proptional to the amount of oxygen in the same

question

What happens when yoy manage patient with pH stat?

answer

Increases cerebral blood flow

question

Total bicarbonate deficit

answer

base deficit * 0.3 * bodyweight (kg)+ deficit in meq

question

Which nerve affected if patient has low pitch voice?

answer

Sup Larygenal Nerve - external branh resposible for producting high pitch phonation

question

Acute respiratory compensation for metabolic acdisois?

answer

PaCO2 = 1.5 (HCO3) + 8

question

INferior boarder of scapula

answer

T7

question

Ach binding to 1. nicotinic and 2 msucarinic receptors result in what?

answer

1. sodium channels opening 2. Activation of G protein

question

Dermatomes needed to be covered for lower abdominal surgery e.g insciion from umbilcus to pubus?

answer

Sensory block extending cephlatad to T6-T8

question

Common legnth of gudie wire of retrograde wire intubation?

answer

100 cm

question

Cause of urinary retention during spinal?

answer

Inhibition of sacaral parasympathetic outflow

question

M2 receptor

answer

Located in heart - slows heart down

question

M1 receptor

answer

exocrine galnds and CNS

question

M3 receptor

answer

smooth muscles of the blood, as well as the lungs M3 receptors are G coupled and mediates increases in intracellar calcium resulting in contraction of smooth muscle such as bronchocontriction however withrespect to vasculature, M3 activation on vascular cells increases NO resulting in vasodilation

question

M4

answer

CNS, inhibition

question

CI to cricothyroidectomy

answer

Patients less than 5 years old due to larnygeal collapse

question

dermatome needed for c section

answer

T4 - nipples

question

A. of Adam kiewicz

answer

T8-L1

question

Oculocardiac reflex

answer

AFrrent - CN V, X Efferent - CN X

question

In supine spinal where would you expect densest block to be achieved?

answer

T5-T7 - most dependent area

question

What intervatioes small intestines and and trnsverse colon

answer

vagus nerve

question

What inetervates decending colon, sigmoid, and rectum

answer

Sacral portion S2-S4

question

Contraindaciton to jet ventilation

answer

Upper aireway obstruction - barotrauma

question

Cook exchange cathiters

answer

Usufel for bridege to extubation esepcially if known difficlut airway

question

Escherman vs Frova introducers

answer

Scenario may present a patient with tiny portion of aretnoids showing and needs intubation -Eschmann and Frova introducers coudl both be used in this situiation becasue they have angualted tips diesinged to hook uner epiglotis in Grade 3 or worse views -However Eschemann is lower cost and but cannot not deliver oxygen so in the scenario that you dotn need to deliver oxyggen this is the better option+ its more widely available

question

Arndt airway exchange catheter

answer

placed through an LMA using fiberoptic scope using gudie wire to exchamge LMA for ETT

question

Parasmypathiic nervous syem orgin?

answer

Cell bodies orignate form cranil nerves 3, 7, and 10 of the midbrain and medulla Sacral fibers orinate from the 2, 3, and 4th sacral semgement

question

SSEPS monitor?

answer

dorsla column function

question

MEPs meaure what pathwyay?

answer

lateral corticospinal tract and and anterior corticospinal tract

question

Where does the sympathetic NS originate from?

answer

T1-L2

question

Effect of volatiles, narcoitics, NO, and ketamine on SSEPS

answer

Volatiels - attenuation N20 - decreases amplitude IV agents/narcotics - incnrease latency, decrease amplitude Etomidate - increase latecny, increase amplitude Ketamine prodcues increase in amplitdue but no effect on latency

question

MEPS indication of what blood suppy?

answer

anterior spinal artery

question

Stellate ganglion comprsied of what structures?

answer

inferior cervical and first thoracic ganglion LOcated at the level of the 7th cervical vertebrae, anetior to the transverse process of C7

question

Most important sign of sucessful stellate ganglion block?

answer

2 degree temeprature increase in affected limb 2/2 to sympathetic block aide and vavsodilation Horners - side effect of stellate gagnlion block but does not confirm it

question

What neruo monitoring is most suseptible to volatiles?

answer

MEP BAEPs are the most insenstive agents and SSEPs are intermediate

question

When inducting patient with pheo what agents shoudl typically be avoided?

answer

Drugs casuing histamine realease (morphine) or increased catecholamines e.g ketamine, pancuronium

question

Explain increased temperature in upper extremity after stellate ganglion block but no decrease in pain

answer

Nerve of Kuntz -interostal nerve carrying sympathetic innervation to upper extremity that bypasses stellagte gangion -Location T1-T4

question

Procedures EMG is useful for monitoring nerve roots?

answer

urethral and rectal sphinters during a relase of tethered cord Identifying cortical bone breeches during pedicle screw placement and monitoring nerve root function anterior cerivcal disectomy and fushsion

question

Autonomic hyperrlexia

answer

Stimulation below level of leasion results in unopposed vasocontrisction below the level of the leashion - occurs becasue there is loss decending inhibition in th espinal cord THe carotid sinus senses this elevation in pressure and triggers vasodilation above the leshion

question

Wind up

answer

sensitizatioon of second order neurons where repeated high intesnistiy nociceptive inputs leads to a cellular such that the neruons become more easily activated

question

First site of nocicpetive sensory processing occurs?

answer

Second order neruons in nociceptive pathways are located in the doral horn of the spinal cord

question

M1

answer

analgesia

question

M2

answer

hypoventialtion, bradycardia and physical dependence

question

Kappa opoid receptors

answer

sedation, dysphoria, DIURESIS

question

Periaqueductal gray area of midbrain function

answer

Reponsible for descending inhibition at the level of the doral horn of the spinal cord where it inhibits afferent nociceptive transmition Mu agonism removes the inhibitory tone at PAG allowing it to inhibit transduction at spinal cord

question

Buprenorphine

answer

partial agonist of mu opoid receptor with high potency at low doses Ceiling affect where increased doses does not result in increased effect High afficnty but low intrinsic activatiy at mu recptors Displaces morphine, methadone and full opoid agonists from recpetor rsulting in increased opoid requirments in order to provide analgesia

question

Allodynia

answer

Pain to a stimulus that normally does not provoke pain

question

Anesthesia dolorosa

answer

Pain in an area without sensation

question

Hyperalgesia

answer

Increaeed pain assocaited with a normally painful stimulus

question

Dysesthesia

answer

spontaneously prodcued painful sensation

question

Superior hypogastric plexus recieves affernt pain fibers from where?

answer

Bladder, urethra, uterus, vagina, vulva, perineum, prostae, penis , testes, rectum, and decesing collon

question

Celiac plexus tranmits what information

answer

visceral pain from liver, pancreas, and biliary tree

question

Ganglion impar transmits what information

answer

recieves afferent pain fibers from the perninium, distal rectum, anus, distal urethra, vulva, and distal third of vaigina

question

Complex regional pain syndorme divided into type 1 and type 2 baed on what?

answer

Type 2 associated with specific nerve injury

question

Contraindicaiton to celiac plexus block?

answer

Bowel obstruction - unopposed parasymapthic stimulation with increased owel motility can result in perforation

question

How does sympathetic block reduce pain in CRPS?

answer

Reduces pain by disrupting sympatheic efferent pathway to the affected extremity THe amount of circulating catechoolamines in that extremity is reduced rsutling in decreased adrengergic recptor stimulation of the nociceptive afferent fibers

question

How does TENS unit relieve pain?

answer

Gate control theory of pain proposed as the potential mechanism Stimulation of large myelinated non nociceptieve (A-beta fibers interfers with the ability of small nociceptive fibers to transmit pain signals to secondary neurson at the level of the dorsal horn,

question

NSAID associated with reductions in GI side effects?

answer

COX 2 selective - Celecoxibib

question

Prilocaine

answer

Methemoglobinemia

question

Lidocaine a/w

answer

TNS

question

Best opoiod for renal failure?

answer

Fentanl - no active metabolites

question

Opoids associated with post histamine release?

answer

Morphine, meperdine, and codeine

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