question

EKG leads corresponding to RCA territory? The RCA supplies which part of the heart?

answer

II, III, aVF RA, the entire RV except for the APEX, posterior/inferior LV, posterior 1/3rd of interventricular septum, SA (50%) & AV (90%) node, posteromedial pappillary muscle

question

EKG leads corresponding to LAD territory The LAD supplies which part of the heart?

answer

V1, V2, V3, V4 LAD supplies anterior LV, anterior 2/3rds of IV septum, Bundles

question

EKG leads corresponding to Circumflex territory The LCx supplies which part of the heart?

answer

I, V5, V6 LCx provides for posterior and lateral LV wall, and anterolateral papillary muscle

question

Nerve supply for Cricothyroid Muscle

answer

External Branch of Superior Laryngeal Nerve

question

Nerve supply for everything but Cricothyroid Muscle

answer

Recurrent Laryngeal Nerve

question

Postoperative Complications of Thyroid Surgery

answer

1) Airway obstruction due to laryngeal edema (PACU) 2) Airway obstruction due to hematoma (can present in PACU if arterial or within 24 hours if venous - this is the most common cause of airway obstruction) 3) Airway obstruction due to bilateral damage to RLN (results in laryngospasm immediately post extubation) 4) Hypoparathyroidism (24-96 hours later) - laryngeal stridor leading to laryngospasm

question

Posterior Pituitary produces which hormones

answer

Vasopressin and Oxytocin

question

MELD Score

answer

INR, Bilirubin, Creatinine, Sodium; Determines who has the highest priority to receive a liver transplant. The higher the number, the more elevated the risk. "CRIB NA"

question

Child Pugh Score

answer

INR, Bilirubin, Albumin, Ascites, Encephalopathy; Useful to determine prognosis in patients with cirrhosis. Class A (5-6 points) low risk, Class C (10-15) high risk. "HI ABA"

question

Glascow Coma Scale

answer

Eye response (4), Verbal (5), Motor (6); Extra value Meal costs $4.56

question

APGAR

answer

Appearance, Pulse, Grimace, Activity, Respiration

question

CVP waveform

answer

ACXVY a wave = atrial contraction c wave = ventricular contraction x descent = pulmonic valve opening v wave = venous return of flow with tricuspid closed y descent = TV opens, atrium empties into the ventricle (diastasis)

question

Innervation of Larynx (sensory)

answer

Anterior Tongue --> Vallecula (includes soft palate and oropharynx): CN IX Vallecula/Hypopharynx --> Vocal cords: Internal Branch of SLN Vocal cords --> Trachea --> RLN

question

Innervation of Larynx (motor)

answer

Cricothyroid Muscle: External Branch of SLN Everything else: RLN

question

Regional Anesthesia for FOI (3 blocks)

answer

1) Anterior Tonsillar Pillar - Glossopharyngeal 2) Inferior Aspect of Greater Cornu of Hyoid - Internal Branch of SLN 3) Transtracheal - RLN

question

Atracurium metabolite

answer

Laudanosine (excreted renally). Can cause seizures and hypotension in patients with renal failure. Side effect of atracurium: can cause histamine release (transient flushing, hypotension, tachycardia) Metabolism: Eliminated via Hoffman Elimination and Ester Hydrolysis

question

Morphine active metabolite

answer

Morphine-6 Glucuronide - accumulates in patients with kidney failure causing respiratory depression. THERE ARE 6 LETTERS IN THE WORD 'ACTIVE'

question

Meperidine active metabolite

answer

Normeperidine (excreted renally) - accumulates in patients with renal failure causing seizures

question

Hydromorphone active metabolite

answer

Hydromorphone 3 Glucuronide (excreted renally) - accumulates in patients with renal failure causing cognitive dysfunction and myoclonus

question

Free Water Deficit equation **corrected**

answer

(0.6 x Kg) x (Serum Na/140 - 1)

question

Diabetes Insipidus vs Cerebral Salt Wasting vs SIADH

answer

Tx of Central DI - Desmopressin Tx of Nephrogenic DI - HCTZ (counterintuitive) Tx of SIADH - fluid restriction + demeclocycline (interferes with the action of ADH) Tx of Cerebral Salt wasting - replacing urinary loses of sodium + free water with fluids **Do not correct hypernatremia too fast (no more than 0.5mEq/L/hr)

question

Plavix Mechanism of Action

answer

Blocks ADP receptor (Activation of ADP leads to surface expression of IIb/IIIa receptor on platelets - where fibrinogen and vWF binds). It is non competitive and irreversible.

question

Warfarin Mechanism of Action

answer

Blocks Vit K epoxide reductase. Leads to depletion of clotting factors II, VII, IX, X, protein C and protein S. Factor VII will be depleted first

question

Argatroban Mechanism of Action

answer

Direct Thrombin Inhibitor. Hepatic clearance. t1/2: 40-50mins

question

Bivalrudin Mechanism of Action

answer

Direct Thrombin Inhibitor. Cleared by plasma proteases - can be used in patients undergoing CPB who cannot be given heparin; it is monitored by ACT levels

question

Hirudin Mechanism of Action

answer

Direct Thrombin Inhibitor. Renal elimination.

question

Fondaparinux Mechanism of Action

answer

Factor Xa inhibitor. Renal elimination.

question

Dabigatran mechanism of action?

answer

Direct thrombin inhibitor; renally cleared

question

Rivaroxiban (xarelto) mechanism of action?

answer

Direct Xa inhibitor, use with caution in hepatic and renal insufficiency

question

DDAVP

answer

Antagonizes V2 receptor. Regulates water reabsorption and can cause a release of vWF. Indicated in DI and vWD and mild hemophilia A.

question

TXA and Aminocaproic Acid Mechanism of Action

answer

Binds to plasminogen and blocks the activation of plasmin (pro-thrombotic)

question

HIT Type I vs Type II

answer

Type 1: Non immune mediated. Seen after 1st day of exposure. Transient and insignificant Type 2: Immune mediated. IgG binds to PF4, activates platelets and causes aggregation. Seen 5-10 days after exposure. Management: switch to direct thrombin inhibitors (bivalrudin, argatroban, fondaparinux

question

vWD Type 1 vs Type 2 vs Type 3

answer

Type 1: Quantitative decrease in vWF. AD. Tx: Desmopressin Type 2: Qualitative abnormality in vWF. AD Type 3: Rare, undetectable levels of vWF. Body does not produce it.

question

Lambert Eaton Syndrome sensitive/resistant to Succinylcholine/NMBDs?

answer

Sensitive to both Succinylcholine and NMBDs.

question

Myasthenia Gravis sensitive/resistant to Succinylcholine/NMBDs?

answer

Resistant to Succinylcholine but sensitive to NMBDs.

question

How to tell the difference between Myasthenic Crisis vs Cholinergic Crisis?

answer

Give Edrophonium --> Increased weakness points to cholinergic crisis; Improvement or Decreased weakness points to Myasthenic crisis

question

Tx of Myasthenia Gravis

answer

Anticholinesterase inhibitors - Pyridostigmine

question

Malignant Hyperthermia Diagnosis

answer

Gold standard - Halothane-caffeine Test

question

Treacher Collins Syndrome

answer

Difficult airways, autosomal dominant, genetic mutation, 1:50,000 live births - Mandibular/Maxillary Hypoplasia (micrognathia, absent cheekbones) - Cleft or Arched Palate - Macrostomia - Fish like facies - Choanal Atresia - Cor Pulmonale - OSA - Conductive hearing loss, malformed ears

question

Pierre Robin Sequence

answer

Triad (Disappears after 2 years of age): 1) Hypoplastic Mandible 2) Glossoptosis - posterior displacement of the base of the tongue over epiglottis 3) Cleft palate Associated with Cor pulmonale, OSA Can be seen in Stickler syndrome, Velocardiofacial syndrome, Treacher-Collin syndrome

question

1cm elevation = what change of mmHg?

answer

0.74mmHg; Example 10cm elevation = reading will be 7.5mmHg higher than baseline

question

Types of Heat Loss? #1 cause of intraop heat loss?

answer

Convection, Conduction, Evaporation, Radiation. Radiation is the #1 cause of heat loss intraoperatively

question

Anterior/Posterior Ischemic Optic Neuropathy Associations

answer

Associated with: Prone surgeries Spine cases Cardiopulmonary Bypass cases Males Hypotension Anemia, >6hr Surgery, Increased Venous/Eyeball pressure Less Colloids

question

Vessel Rich Organs vs Vessel Poor Organs

answer

Rich = Brain, Kidney, Heart, Liver, Adrenals (does NOT include lungs because normally the lungs receive 100% of CO) Med = Muscle, Skin Poor = Bone, Cartilage, Ligaments

question

Meperidine Facts

answer

- Meperidine is a strong anticholinergic, causes tachycardia - Causes Histamine Release - Metabolite Normeperidine - accumulates in renal patients potentially causing seizures - MAO inhibitor + Meperidine can lead to serotonin syndrome (confusion, hyperthermia, shivering, myoclonus, and hyperreflexia) - Kappa receptor agonism to oppose shivering - Potency 0.1 compared to Morphine

question

Baclofen binds to which receptor

answer

GABA-B. Benzodiazepines bind to GABA-A.

question

Opioid Receptors

answer

Mu1: analgesia, skeletal muscle rigidity Mu2: respiratory depression Kappa: sedation, dysphoria, miosis. Antagonizes shivering

question

Venous systems that bypass the R Heart

answer

Thesbian, bronchiolar and pleural veins

question

Full term newborn's Total Blood Volume Premature neonate's Total blood volume

answer

Fullterm: 90cc/kg Premature: 100cc/kg

question

Neonatal Airway Differences The Larynx is positioned at ____ level. The epiglottis is long/short? The tongue is smaller/larger? The narrowest part of the airway is the ____. Occiput is larger/smaller?

answer

- C3-C4 in children. C5-C6 in adiults - Longer, floppy, omega/u shaped - Larger - Cricoid cartilage; it is conically shaped. The narrowest part in adults is the glottis - Larger occiput - may benefit from shoulder roll

question

Neonates are more likely to drop temperature intraop due to:

answer

Increased surface to body ratio

question

When does the Foramen Ovale close? Ductus Arteriosus? Ductus Venosus?

answer

Functionally: FO: Immediately, DA: 1 day, DV: 1 week Anatomically: FO: 3 months, DA: 1 month, DV: 1-3 weeks Note: Foramen Ovale remains patent in 25% of population

question

Adult SPINAL CORD ends at what level? Infant spinal cord ends at what level?

answer

Adult spinal cord ends at L1-2 Infant (<12 months) spinal cord ends at L3-4. After 12 months it is similar to that of an adult.

question

Adult DURAL SAC ends at what level? Infant dural sac ends at what level?

answer

Adult dural sac ends at S2 Infant dural sac ends at S4

question

Where would you place a pulse oximeter in a newborn?

answer

The R Hand is the only preductal choice and it is recommended to place it on the R hand to monitor lung function.

question

Delay ambulatory/elective surgery in infants after what age?

answer

Post conceptual age >50weeks. Delay surgery because of increased risk of post anesthesia apnea. Risk of apnea can be decreased with IV caffeine or aminophylline.

question

Apnea of Prematurity

answer

- Defined as >10s of apnea or 15s of apnea with desaturations or bradycardia - Risk factors: 1) Prematurity (<37 week gestation) 2) HCT < 30% 3) GA 4) Preoperative apnea - Tx Caffeine 10mg/kg IV

question

Omphalocele vs Gastroschesis

answer

Omphalocele - Midline defect - Covered in membranous sac - More likely to be associated with other defects (75% of time - VSDs [most common], Trisomy 21, Beckwith Wiedmann syndrome Gastroschisis - Off midline defect - Usually not associated with anything besides prematurity - Not covered by membranous sac - If surgeon cant close, consider leaving abdomen open with silo

question

Tracheoesophageal Fistula

answer

- Most common type is Type C - Associations: 1. Prematurity 2. CHD 3. GI abnormalities 4. VACTERL 5. Renal/GU Abnormalities - Intraop management 1. Rapid sequence or awake intubation 2. Avoid N2O 3. Spontaneous breathing until fistula is ligated 4. Murphy's eye facing anteriorly

question

How much ml/kg of pRBC can raise a patient's Hgb by 1?

answer

4mL/kg

question

Do muscle relaxants cross the placenta?

answer

No, both succinylcholine and NMBDs do not cross the placenta because they are charged particles.

question

Anesthesia Dolorosa

answer

Pain in an area that lacks sensation

question

Chassiaignac's Tubercle

answer

C6

question

A successful Stellate Ganglion Block should cause what?

answer

- Ipsilateral Horner's Syndrome (anhidrosis, miosis, ptosis, nasal stuffiness) - Increased temperature of ipsilateral arm - Hyperemia of ipsilateral arm

question

Celiac Ganglion Block at what level?

answer

L1

question

1st Stage of Labor (Latent and Active) is covered at what dermatome?

answer

Covered by T10-L1. Latent Stage = 2-3cm dilated Active stage = 3cm-complete dilation

question

2nd Stage of Labor is covered by what?

answer

Covered by S2-S4. It is due to distention of the pelvic floor. Covered by Epidural, Spinal, Caudal and Pudendal nerve blocks

question

Why would you need avoid NSAIDS in the pregnant population?

answer

It can cause closure of the Ductus Arteriosus in the fetus which can be fatal.

question

Acute Intermittent Porphyria can be triggered by?

answer

Avoid barbiturates, BZDs, glucocorticoids, etomidate, toradol, alcohol, stress/dehydration. AIP can be exacerbated by inducers of the CYP450 system Present with confusion, anxiety, autonomic instability, abdominal pain and emesis. Porphyria cutanea tarda is not affected by anesthetic medications.

question

Fetal Heart Monitoring: Early, Variable and Late Decels?

answer

Early could be due to head compression due to uterine contractions (reassuring) Variable could be due to uteroplacental cord compression (reversible) Late due to uteroplacental insufficiency (not resassuring, needs OB evaluation). Deceleration >30secs after contraction LATE DECELs "The onset and nadir of late fetal heart rate (FHR) decelerations occur after the onset and peak of the associated uterine contraction. Late decelerations are caused by delivery of deoxygenated blood to the chemoreceptors in the fetus. Activation of chemoreceptors in the aortic arch and in the carotid sinus due to hypoxia activates the vagal response. The circulation time from placenta to chemoreceptors appears to delay the onset of the deceleration, so it is referred to as "late" deceleration. Deoxygenated blood from the placenta also depresses the fetal heart. Therefore, it is suggested that both activation of chemoreceptor reflex as well as direct myocardial depression are responsible for late FHR decelerations. Late decelerations, when accompanied by decreased or absent FHR variability, are indicative of fetal hypoxia, and steps to initiate emergent delivery of the baby should be considered."

question

Mild Preeclampsia? Severe Preeclampsia? Ecclampsia?

answer

Mild preeclampsia: BP >140/90, proteinuria (>300mg/day), edema (Management: IF TERM, INDUCE; IF NOT, BEDREST) Severe preeclampsia: BP >160/110, proteinuria, edema, HA, blurry vision, RUQ pain, hyperactive reflexes, HELLP syndrome (Management: DELIVER IMMEDIATELY) Ecclampsia: Severe preeclampsia + SIEZURES

question

Magnesium Toxicity

answer

Loss of DTRs, Resp depression, complete heart block, VASODILATION (Tx: Calcium gluconate, lasix + isotonic fluids, dsialysis). Additional info for reference: - Normal serum Mg concentration is 1.5-2.5. - Therapeutic levels for preeclampsia is 5-9. - DTRs are reduced >5, lost at >12. Skeletal muscle weakness begins at 7-10. Respiratory muscle/diaphragm weakness can start to occur >15. - Cardiac symptoms can be seen >5 (prolonged PR and widened QRS) with asystole at >25. **Remember that magnesium potentiates NMBDs and LA and can prolong succinylcholine.

question

Define Placenta Accreta, Increta and Percreta What conveys the highest risk of abnormal placentation?

answer

Accreta — chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis. Increta — chorionic villi invade into the myometrium. Percreta — chorionic villi invade through the PERImetrium, sometimes invading the bladder or rectum Risk factors include advanced maternal age, prior CS, and placenta previa. Placenta previa carries the highest risk.

question

Placenta Previa

answer

Positioning of the placenta at or near the cervical os. Causes painless bright red bleeding. If it is non-obstructing, trial of labor can be allowed

question

Abruptio Placenta

answer

Separation of the placenta from the uterus. Causes mild to severe pain with dark red blood (venous bleeding). Risk factors: chronic HTN, cocaine, preeclampsia, multiparity, smoking, trauma.

question

Calculating depth of ETT?

answer

3 x Diameter of ETT

question

Croup aka laryngotracheobronchitis

answer

- MCC Parainfluenza, RSV, Influenza A/B - Well looking patient - Slow onset - Mild-moderate stridor - Barking Cough - Able to swallow - Hoarse voice - "Steeple sign" on XR - Treatment: Racemic epinephrine, no intubation needed

question

Epiglotitis

answer

- MCC H. Influenzae, Staph, Strep - Toxic and unwell apperance - Abrupt onset - High fever - Moderate-severe stridor - Unable to speak - Unable to swallow - "Thumb print sign" on XR - Treatment: Intubate in the OR with ENT available, no time for XR or any imaging, Give ABx. Do not give racemic epi (its contraindicated)

question

Racemic Epinephrine

answer

Helpful in Croup, Bronchiolitis or post intubation croup in the PACU

question

Flow volume Loops

answer

EXPiratory Blunting is due to INTRAthroacic Obstruction (i.e. Mediastinal mass, lower tracheomalacia, lower tracheal mass) INSPiratory Blunting is due to EXTRAthoracic Obstruction (i.e. Vocal cord paralsis, thyroid mass, laryngomalacia, epiglotitis) INSP- & EXPiratory Blunting is due to a FIXED lesion (i.e. Tracheal stenosis or choanal atresia)

question

DiGeorge Syndrome

answer

CATCH-22 Cardiac disease (TOF) Abnormal Facies Thymic Atresia Cleft Palate Hypocalcemia Due to Deletion of Chromosome 22

question

Rigidity associated with Neuroleptic Malignant Syndrome OR Malignant Hyperthermia resolves after administration of muscle relaxant?

answer

NMS

question

Where do you perform a needle thoracotomy?

answer

Second intercostal space, midclavicular line (below 2nd rib)

question

True or False? Factor 7 administration can overcome a relative deficiency of factors in the intrinsic pathway?

answer

True. Factor 7 couples with tissue factor to activate the common pathway (10--5-->2-->1--->Fibrin clot). The main job of the intrinsic pathway is to synergistically support the continued formation of thrombin once the extrinsic pathway is started.

question

Vitamin K is needed for production of which factors?

answer

Factors 2, 7, 9, 10, protein C and protein S

question

Fat Embolism Syndrome presents how and when?

answer

SOB, respiratory failure, RHF, mental status changes, coagulopathic changes, petchiae (pathognomic). It usually occurs 1-3 days postop. Diagnosis of exclusion but BAL can show fat droplets in macrophages.

question

Oculocardiac Reflex Pathway?

answer

Afferent: Ciliary nerves/Trigeminal Nerve - Ophthalmic division (through ciliary ganglion and gasserian ganglion) Efferent: Vagus Nerve

question

Following administration of Sulfur hexafluoride, what anesthetic should you avoid intraoperatively and for how many days after should this be avoided?

answer

Nitrous oxide; Lasts 10 - 28 days! But avoid for 4-6 weeks after use (per UK anesthesia)

question

Carbon Monoxide Poisoning Affect on Pulse oximetry? Tx?

answer

COHgb will overestimate SpO2 showing slightly low to normal oxygen levels. Diagnosis to be made with ABG co-oximetry. Treatment with 100% oxygen.

question

Methemoglobinemia affect on Pulse oximetry/ABG? Tx?

answer

MetHgb will overestimate SpO2 showing O2 levels in the 80%s. ABG will show normal PaO2 levels but the patient will be cyanotic (highly suggestive of MetHgbemia). Definitive diagnosis is to be made with co-oximetry. Treatment with Methylene Blue.

question

Functional Residual Capacity = what?

answer

ERV + RV

question

What factors decrease FRC?

answer

Restrictive lung disease, obesity, pregnancy, posture (FRC greatest to least: standing > sitting > prone > supine > trendelenberg) Not obstructive lung disease

question

Laminar flow is directly related to ____ where as turbulent flow is directly related to ____.

answer

Viscosity; Density "Las Vegas is Too Dense"

question

Laminar flow is seen in the ____ airways whereas turbulent flow is seen in the ____ airways.

answer

Distal; proximal/larger

question

A high Reynolds number (>2000) is more consistent with turbulent or laminar flow?

answer

Turbulent Flow R = (Velocity x Diameter x Density) / Viscosity

question

Heliox will reduce work of breathing how?

answer

Helium has decreased density compared to air so it will decrease the resistance caused by turbulent flow.

question

Ventilation and perfusion are maximal at what part of the lungs?

answer

Both are maximal at the base of the lungs. Perfusion is higher than ventilation at the base. Ventilation is higher than perfusion at the apex.

question

What is the Alveolar gas equation?

answer

Palv = FiO2 (Patm - Ph2o) - PaCO2/RQ. This equation can explain why elevated PaCO2 can cause hypoxemia.

question

Cushing's Triad?

answer

Response to elevated intracranial pressures which involves: 1) Elevated BP 2) Bradycardia 3) Irregular respirations (slow and irregular)

question

What EKG changes would you see during a massive pulmonary embolism?

answer

You would see ischemic changes in the anterior leads, esp V1 and V2 indicating R heart strain. RBBB could also be seen with V1-V2 RR' complexes. The classic finding is S1Q3T3 (S wave in lead I, Q wave in lead III, and inverted T wave in lead III) but is rarely seen.

question

Absolute Contraindications to Extracorporeal Lithotripsy?

answer

Absolute: 1) Pregnancy 2) Coagulation disorder/Anticoagulation 3) Distal Obstruction of Renal Calculi Relative Contraindication: 1) Large Calcified Aorta 2) UTI 3) Pacemaker/AICD 4) Morbid obesity 5) Intraabdominal aortic Aneurysm

question

What is Autonomic Dysreflexia?

answer

In a patient with spinal cord injury (usually T6 or above), noxious stimulus below the level of injury causing an amplified sympathetic response below the level. There will be a strong parasympathetic response to follow. The patient will be hypertensive and bradycardic. You will see flushing above the lesion and pale, white skin due to vasoconstriction below. It can be caused by surgical stimulation, bladder distension, or fecal impaction. Consider spinal anesthesia, arterial line and sodium nitroprusside available.

question

Dabigatrin reversal?

answer

Idarucizumab

question

Major side effect of CYCLOSPORINE

answer

Nephrotoxicity

question

Cryoprecipitate contains what?

answer

Factor VIII vWF Factor XIII Fibrinogen Fibronectin FFP contains all the plasma proteins that is found in whole blood including all factors. Cryoprecipitate is prepared by thawing FFP and allowing the larger molecules to precipitate which is the centrifuged and frozen.

question

Major side effect of CISPLATIN

answer

Nephrotoxicity

question

Major side effect of DOXORUBICIN

answer

Cardiotoxicity

question

Major side effect of VINCRISTINE

answer

Neurotoxcity

question

Major side effect of BLEOMYCIN

answer

Pulmonary fibrosis

question

Type 1 Error

answer

False Positive

question

Type 2 Error

answer

False Negative

question

To measure ICP the correct level to place the transducer is the _____.

answer

External auditory meatus

question

TV = ___mL/kg

answer

7mL/kg

question

FRC = ___mL/kg

answer

30mL/kg

question

Vital Capacity = ___mL/kg

answer

60mL/kg

question

Total lung capacity = ___ mL/kg

answer

90mL/kg

question

At what % of CO would you give supplemental oxygen?

answer

>10%; 10% or less is normal for smokers

question

Which antibiotic has the potential to prolong neuromuscular blockade?

answer

Aminoglycosides (i.e. gentamycin, amikacin, tobramycin, stretomycin, neomycin). NOT erythromycin, PCN or cephalosporins.

question

The carotid sinus Function? Location? Manipulation can cause what? Afferent limb? Injecting local anesthetic at the sinus can cause what?

answer

It is a baroreceptor that is located at the base of the internal carotid artery that functions as a baroreceptor. Manipulation of the carotid sinus can lead to profound bradycardia and hypotension that is ameliorated during a carotid artery surgery by injecting local anesthetic at the carotid bifurcation. The afferent limb of this reflex is mediated by the Glossopharyngeal nerve. Injecting local anesthetic can actually cause significant hypertension intra- and postoperatively.

question

The carotid body Function? Location? Afferent limb? Inhibited by? Bilateral CEA would cause what?

answer

Chemoreceptor cells that are located at the bifurcation of the ECA and ICA. They function mainly to respond to decreases in O2 tension <60mmHg by increasing ventilation. Afferent impulses are sent via the glossopharyngeal nerve (CN IX). It is inhibited by volatile anesthetics, BZDs or opioids. Note that a bilateral carotid endarterectomy would result in significant impairment of the hypoxic drive.

question

What would you see on an ABG in a third trimester pregnant woman?

answer

Mild, chronically compensated respiratory alkalosis. They would have elevated ventilatory rates due to an elevation in progesterone. PaCO2 would be around 30mmHg

question

Normal ABG values? Normal Cl?

answer

pH: 7.35-7.45 PaO2: 80-100mmHg PaCO2: 35-45 (45 respiratory acidosis) HCO3: 22-28 (28 metabolic alkalosis) Cl: 96-106

question

Methadone Mechanism of action? Major side effect?

answer

NMDA recepter antagonist and NE+Serotonin Reuptake inhibitor QTc prolongation, can lead to Torsades de point High doses of methadone (>60mg daily) can put you at increased risk for Torsades

question

Transplanted Heart Patient What medications act directly on a transplanted heart? What are some examples of medications that do not? Baseline heartrate?

answer

- Any medication that acts on B receptors directly such as Dobutamine, Isoprotenernol, Epinephrine, Norepinephrine. However, the heart rate response may be exaggerated because there is no parasympathetic innervation to counter the increased heart rate - Indirect drugs that affect rate will not be effective (antimuscarinics, anticholinesterases, pancuronium, digoxin). Use direct acting agents (isoproterenol, epinephrine). - Lack of vagal tone will result in baseline rate of 90-100. About 25% of patients will develop a bradycardia that will require implantation of a permanent pacemaker.

question

How does laryngoscopy affect a patient with a transplanted heart?

answer

You will not see a vagal response to laryngoscopy. Vagal bradycardic reflexes will also be absent due to denervation of parasympathetics (laryngoscopy, hypertension, carotid sinus massage).

question

Pacemaker Settings What is position 1? what is position 2? What is Position 3? What is asynchronous mode?

answer

Position 1 = Chamber paced (A, V, Dual or O[None]) Position 2 = Chamber sensed (A, V, Dual or O [None]) Position 3 = what the device does in response to the sensing (Inhibited, Triggered, Dual [both] or O [None]) Asynchronous mode = AOO, VOO or DOO

question

Two ways of stopping the heart during EVAR?

answer

Adenosine and rapid right ventricular pacing.

question

Phantom pain Occurrence following amputation? Definition Difference between phantom pain and stump pain?

answer

Occurs in 90% of patients in the first 6 months following amputation surgery Defined as unpleasant or painful sensation in the missing body part. It is usually intermittent with intervals between 1 day - several weeks. Phantom pain that lasts > 6 months is usually refractory to treatment. Stump pain is different from phantom pain in that stump pain is usually due to local processes such as soft tissue infection, skin lesions or provoked by traction or pressure on the remaining body part.

question

Keys for treating LVAD patient?

answer

Maintain preload, reducing afterload and preserving R heart function. This means: Avoid hypovolemia. Recommend MAPs between 60 and 80mmHg. Preserve R heart function by avoiding elevations in pulmonary artery pressures (avoid hypercapnia)

question

Trigeminal Neuralgia (tic dolereaux) R or L side affected more? Men or women more?

answer

R >> L side Women >> Men Pain is self limited Treatment: Anticonvulsants are first line. Baclofen and Neurontin can help as well. Surigcal treatments are available for patients who have failed medical management. Microvascular decompression (MVD), nerve lesion techniques and motor cortex stimulation are available. Question sample: A woman presents with recurrent flashes of severe pain at the junction of her R upper lip and the nasolabial fold despite normal facial appearance and neurologic exam. Brushing her upper molars triggers these attacks. Most likely diagnosis? Classical Trigeminal Neuralgia

question

What is allodynia?

answer

It is he triggering of a pain response from stimuli which do not normally provoke pain.

question

What is the difference between CRPS Type 1 vs Type 2?

answer

CRPS Type 1 (RSD) is a syndrome where chronic pain (normally in an extremity) appears to be associated with sympathetic nervous system dysfunction. It can be the result of a trivial injury (ie burn, ankle sprain, cut) on that extremity CRPS Type 2 (Causalgia) is a syndrome where chronic pain is the result of prior nerve injury. Management: Step 1: physical therapy Step 2: medical management with TCA, gabapentin, mild opioid if needed for physical therapy Step 3: diagnostic sympathetic block Step 4: somatic block of sympathetic block Step 5: spinal cord stimulator / intrathecal medications

question

What are some things that cause R shift on the Oxyhemoglobin dissociation curve?

answer

Increase in Temp, PaCO2, BPG, H ions Decrease in pH

question

What causes a L shift on the oxyhemoglobin dissociation curve?

answer

Decrease in Temp, PaCO2, BPG, H ions Increase in pH Increase in CO Increase in MetHgb Increase in HbF

question

Explain the sensory nerve distribution of the foot/ankle.

answer

The POSTERIOR TIBIAL NERVE covers the heel and plantar surface of the foot. The medial ankle is covered by the Saphenous (femoral nerve) and the lateral surface is covered by the Sural Nerve. The superior portion of the foot is covered by the common peroneal nerve. Only thing to note is that the webbing between the 1st and 2nd toe is covered by the deep peroneal nerve while the rest is covered by the superficial peroneal nerve.

question

What metabolizes codeine, oxycodone and hydrocodone?

answer

CYP2D6 Codeine is active and undergoes O-demethylation by CYP2D6 to create morphine.

question

Alfentanil has a higher or lower volume of distribution?

answer

It has a lower volume of distribution which means that it has a shorter duration of action. It also has a lower pKA so it has the fastest onset and crosses the BBB quickly. It has a brief duration of action due to redistribution.

question

Naloxone Onset? Dose? Half life?

answer

Onset 1-2 mins Dose 0.01-0.1mg/kg; 0.04mg q 3-6 mins and then infuse 4-5mcg/kg/hr t1/2 = 30-60mins

question

What is the reason for the hypercoagulable state in pregnant women?

answer

Increased fibrinogen and factor VII levels and decreased anticlotting factors.

question

Non ionized = lipophilic or hydrophilic?

answer

Lipophilic (lipid soluble).

question

pKa definition

answer

pH at which a compound exists as 50% ionized and 50% unionized The lower the pKA, the more the nonionized form (the more lipid soluble and therefore the faster the onset)

question

Explain ion trapping.

answer

If there is a pH gradient, ionized substances are trapped on the side that the pH favors ionization. For weak bases, the drug will accumulate on the acidic side of the membrane. For example, the nonionized fraction of a local anesthetic agent (weak base) crosses the placenta, where it is changed to the ionized form in the relatively acidic fetus. The ionized form cannot leave the placenta. Further, the nonionized drug continues to enter fetal circulation.

question

A patient on enoxaparin for DVT ppx, when is it appropriate to remove or place an epidural? What about in a patient receiving "treatment" dosing of lovenox?

answer

12 hours for DVT ppx 24 hours for "Treatment"

question

A patient who is receiving subQ heparin for DVT ppx, when is it appropriate to perform neuraxial anesthesia? What about a patient receiving IV heparin?

answer

There are no contraindications if the daily dose is <10,000units. IV heparin - delay needle/catheter placement 4 hours after last dose and document a normal aPTT. Restart after 1 hour.

question

Tumescent Liposuction Lidocaine dose? Epinephrine dose? Toxic range of lidocaine? Why is it so high compared to IV toxic range? Peak levels of lidocaine occurs when?

answer

- Lidocaine 0.05%, - Epinephrine 1:1,000,000 - Dose range: 35- 55 mg/kg of lidocaine injected. - The range is higher because the adipose tissue acts as a resevoir (lidocaine is highly lipophilic). Also the epinephrine vasoconstricts. - 12-14 hours after

question

Specificity = ? Sensitivity = ?

answer

Specificity = TN / TN + FP Sensitivity = TP / TP + FN

question

FA/FI Ratio notes

answer

FA = Alveolar end tidal concentration FI = Inspired concentration The larger blood:gas partition coefficient means a lower FA/FI ration (due to increased uptake). The lower the FA/FI ratio the slower the onset.

question

Onset of anesthesia is faster in volatile agents with lower/higher blood:gas coefficients?

answer

Lower. Desflurane 0.42 N2O 0.47 Sevo 0.63 Iso 1.4 The more soluble the gas, the higher the blood:gas coefficient, and the slower the onset

question

How do the following affect FA/FI? Ventilation? Cardiac output? Children vs Adults?

answer

Increased ventilation, increases FA/FI Decreased CO, increasees FA/FI Children have a more rapid

question

Surgical emergency: Aortic dissection type A or type B?

answer

Type A - involves the ascending aorta and possibly the AV Type B - can be managed medically with combined a and B blockers. SBP goal < 110mmHg

question

Why is there a resistance to NMDBs in burn patients?

answer

It is attributed to the proliferation of extrajunctional receptors.

question

When is it unsafe to use succinylcholine in burn patients?

answer

After 24 hours, for up to one year afterwards. It can result in fatal hyperkalemia.

question

Treatment of Transient Neurologic Symptoms? Increased risk of TNS with what? How is this different from neuraxial hematoma or cauda equina syndrome?

answer

NSAIDS Increased risk of TNS include: - Lidocaine OR Mepivacaine spinal anesthesia (7 fold increase compared to other LAs) - Lithotomy position - Outpatient surgery - Knee arthroscopy - Obesity **LA concentration, baricity, w/ or w/o epinephrine, and technique do not contribute to TNS*** It's different from an epidural hematoma and CE in that the patient will not have bowel or bladder dysfunction. There will only be back pain with possible radiation to the legs.

question

Myotonic Dystrophy

answer

- Patient presents with persistent muscle contraction after voluntary contraction ie unable to let go of a handshake - Autosomal dominant - Likely due to intracelluar ATP system that fails to return Ca to SR. - Contractions are not relieved by NMBDs or deep anesthesia - Avoid succinylchoine - can be severe enough to impair ventilation Coexisting disease: - Cardiac abnormalities - conduction defects and CMP - Respiratory - restrictive lung disease and OSA Triggers: - Succinylcholine - Shivering - Excessive stimulation - Hypothermia

question

In hypothermic patients, the MAC increases/decreases?

answer

Decreases

question

Lithotomy position is associated with which nerve injury, most commonly? How would the patient present

answer

Common peroneal. Loss of the ability to dorsiflex (footdrop) and evert the ankle.

question

Cardiac Tamponade

answer

Equalization of the DIASTOLIC pressure in all 4 chambers of the heart with the pressure inside the pericardium. You would see pulsus paradoxus - abnormally large decrease in SBP on inspiration. During inspiration there is increased R sided filling which causes the interventricular septum to shift to the left causing a decrease in BP. You would also see electrical alterans. Clinically you would see dyspnea, hypotension, tachycardia, distant heart sounds, orthopnea, and JVD. "FAST FULL AND TIGHT" FAST CO is HR dependent FULL SV is dependent on adequate preload TIGHT vascular tone should be tight

question

Cerebral blood flow is influenced by what?

answer

MAP, PaCO2, PaO2, and local brain metabolic activity.

question

HERBAL SUPPLEMENTS SIDE EFFECTS :( Ginger? Garlic? Ginko? Ginseng? Green Tea? Saw Palmetto? Fish Oil?? Kava? Ephedra? St. Johns Wart?

answer

- Ginger - inhibits thromboxane synthetase. - Garlic - Inhibits platelet aggregation. Discontinue for 7d prior - Ginko - inhibits platelet aggregation. Discontinue 36h prior - Ginseng - inhibits platelet aggregation and decreases blood sugar. Discontinue 24h prior - Green tea - inhibits platelet aggregation. Discontinue 7d prior - Saw Palmetto - can cause increased bleeding intraop - Fish Oil - can cause increased bleeding intraop - Kava - anxiolytic, causes sedation, decreases MAC, can cause HEPATOTOXICITY - Valerian - causes sedation, decreases MAC. - Ephedra - HTN , tachycardia, seizures - St. Johns Wart - SNRI inhibitor; also EZYME INDUCER of cytochrome P450 systems

question

Chronic opioid use can lead to increase or decrease of cortisol levels, testosterone/estrogen/LH/FSH levels?

answer

Decrease.

question

NMDA Receptor is blocked by what 5 medications?

answer

Ketamine, N2O, Methadone, Xenon and Magnesium

question

Fenoldopam mechanism of action?

answer

Antihypertensive. Selective D1 agonist. Direct renal vasodilator. Causes naturesis and diuresis. Effective in hypertensive crisis

question

Effect on MAC: Hyponatremia? Hypercarbia? Hypothermia? a2 agonists? Acute EtOH? Chronic EtOH? Red hair? Pregnancy?

answer

HypoNa - decreases MAC Hypercarbia - decreases MAC Hypothermia - decreases MAC Lithium - decreases MAC a2 agonists - decreases MAC Acute EtOH - decreases MAC Chronic EtOH - increases MAC Red hair - increases MAC Pregnancy - decreases MAC

question

Intraoperative awareness vs Dreaming vs Explicit Memory vs Implicit Memory

answer

Intraoperative awareness - postoperative recall of events while under general anesthesia Dreaming - experiences that patients are able to remember postoperatively that they believe to be dreaming and that they think occurred during general anesthesia Explicit Memory - conscious recollection of prior experiences Implicit Memory - unconscious memory of an experience that produces a change in performance or behavior. It can usually be accessed by hints or using a word stem

question

How long must you wait for elective surgery after a bare metal stent? After a drug eluding stent? After a CABG? Are you allowed to take care of a patient with a new stent in the surgery center?

answer

BMS - 4-6 weeks DES - 12 months CABG - 30 days PCI/Balloon angioplasty - 2 weeks If out of the window, continue dual antiplatelet medications PERIoperatively unless the elective procedure is with a high risk of bleeding. Then d/c plavix 5 days prior and reload postop. Alphabetical order: Balloon angio (2 wks) ; BMS (4-6 wks) ; DES (12 mo) NO; send to a facility that has cardiology service

question

Dantrolene will increase or decrease MAC?

answer

Decrease

question

Sentinel Event is defined as?

answer

Any event that is unanticipated or with an unintended outcome that has the potential to cause patient harm. A near miss can qualify as a sentinel event. A patient complaint or an error in judgement cannot be considered a sentinel event.

question

Some indications of Hyperbaric Oxygen? Absolute Contraindication of HBO?

answer

- Carbon Monoxide Levels ; 25% - Air or Gas embolism - Soft tissue necrosis - Decompression sickness - Diabetic Wound treatment Absolute contraindication = untreated Pneumothorax

question

Dobutamine affect on PVR, SVR and MAP? What about HR and Cardiac output? Receptors?

answer

Dobutamine decreases SVR, MAP and PVR because of its affect on B2 receptors. It increases HR and CO because of its affect on B1. B1: +++ B2: +

question

Milrinone affect on SVR and PVR? What about CO? Mechanism?

answer

Milrinone causes decrease in SVR and PVR. It causes increase in CO. Mechanism of Action: PDE III Inhibitor (decreased cAMP breakdown --> increased Ca breakdown in myocardium)

question

Aortic Stenosis Anesthetic plan in a patient with Aortic stenosis? Normal valve area? Classic symptoms?

answer

- Maintain HR 60-90. Bradycardia can be devastating as they are HR dependent. Maintain afterload by avoiding hypotension. Treat hypotension with small doses of phenylephrine. - Normal valve area 2.5-3.5cm2; Symptomatic stenosis occurs at 0.8-0.9cm2 and critical AS when valve area ;0.7cm2 - Angina, syncope, and angina. 50% mortality at 5, 3 and 2 years respectively.

question

Aortic Dissection Risk factors?

answer

Predisposing conditions include - male sex - age greater than 60 years - HTN - Marfan syndrome or other connective tissue disease - congenital heart disease, including coarctation of the aorta and bicuspid aortic valve - pregnancy

question

What is likely being compressed during a medistinoscopy and what side should you monitor SpO2 and BP?

answer

The inominate artery. You should put the Aline and SpO2 on the R side so that you dont have undetected hypotension.

question

TEG

answer

Thromboelastogram components shown in Figure 2 include: Reaction time (R) measures the time to initial clot formation. R can be prolonged when clotting factors are deficient or in the presence of heparin, low molecular weight heparin, direct thrombin inhibitors, warfarin, etc. Kinetics (K) represents the rate at which fibrin strands form and begin to cross-link to form the fibrin meshwork. Angle (?) represents the rate of clot formation and reflects fibrinogen activity. Maximum amplitude (MA) represents whole clot strength and reflects many aspects of clot formation, including platelet number and function as well as the fibrin contribution to clot strength. G is derived from the MA and is also a measure of overall clot strength. The G value is used to discuss platelet function and clot strength. Estimated percent lysis (EPL) represents clot breakdown as seen in patients with disseminated intravascular coagulation or hyperfibrinolysis.

question

Sodium Nitroprusside Mechanism? Toxicity?

answer

Mechanism of Action: Increases cGMP Toxicity: 1) Thiocyanate 2) Cyanide 3) Methemoglobinemia

question

SSEP Usually measure which nerves (which correlate to which cerebral distribution?) What qualifies as a significant change? False positives can be caused by what? Do NMDBs block SSEPs?

answer

- Posterior tibial nerve (ACA) and Median nerve (MCA) - Significant changes: 50% drop in amplitude and 10% increase in latency - False positives can be due to anesthetics, hypothermia, hypotension, and anemia - Volatile anesthetics and N2O are most suppressive - NMDBs do not affect SSEPs.

question

What part of the spinal cord do SSEPs test and what is the spinal blood supply for these territories?

answer

- SSEPs for the upper extremity test the dorsal column which is supplied by the Posterior Spinal Artery. For the lower extremity, it will test the dorsal lateral funiculus which is supplied by the Anterior Spinal Artery.

question

Medications that undergo ester hydrolysis?

answer

- Succinylcholine (Plasma cholinesterase) - Remifentanil (non specific esterases) - Esmolol (nonspecific esterases) - Mivacurium - Atracurium - Cisatricurium - All ester local anesthetics i.e. 2-Chloroprocaine, Procaine, Cocaine

question

Parkinson's Disease Due to a deficiency in what neurotransmitter? This causes excessive amounts of ____? What medications should you avoid? What medications are ok to use?

answer

- Dopamine (due to loss of substantia nigra) - Acetylcholine - Avoid dopamine blocking medications such as: 1) Droperidol 2) Metaclopromide 3) Antipsychotics (haldol, chlropromazine, etc) - OK to use: 1) Ondansetron 2) Antihistamines 3) Cannabinoids (Dronabinol)

question

Familial Hypokalemic Periodic Parlysis

answer

- HypoK+ periodic paralysis is a disorder characterized by episodes of weakness when serum K drops - Lasts anywhere from hours to days - Spares muscles of respirations - Avoid glucose containing solutions, hypothermia, or any medications that cause intracellular shifts of K+ (such as B blockers) - Remember, insulin causes K to move into the cells - Muscle relaxants (including succinylcholine) are OK Triggers: - Exercise followed by rest, high carbohydrate meals, high sodium meals, sudden changes in temperatures - Low dose acetazolamide may prevent attacks

question

Familial Hyperkalemic Periodic Paralysis

answer

Management: - Give glucose and insulin - Give Calcium - Give diuretics - Avoid succinylcholine

question

Innervation of the abdominal viscera?

answer

Distal esophagus to the Transverse colon is supplied by the CELIAC PLEXUS Descending colon to the rectum is supplied by the SUPERIOR HYPOGASTRIC PLEXUS (which also covers GU and perineum)

question

Conditions that will increase DLCO? Conditions that will decrease DLCO?

answer

Conditions that increase DLCO: - Asthma - Exercise - Polycythemia - L-->R shunt Conditions that decrease DL CO will be anything that impairs gas exchange across the alveolar membrane. - COPD - Heart failure - Anemia - TB, Asbestos, Sarcoid

question

In a patient who is in her third trimester, are you expected to find an increase or decrease in the following: Minute ventilation (due to what hormone?) Tidal volume Respiratory rate Vital Capacity FEV1 FRC ERV RV

answer

Minute ventilation - increased due to progesterone Tidal volume - increased Respiratory rate - more or less the same Vital Capacity - more or less the same FEV1 - more or less the same FRC - decreased ERV - decreased RV - decreased

question

Cytochrome P450 inducers or inhibitors?

answer

Carbamazepine - inducer St. Johns Wort - inducer Omeprazole - inducer Phenytoin - inducer Phenobarbital - inducer "OCPPS" Nicardipine - inhibitor Grapefruit - inhibitor Isoniazid - inhibitor Cimetidine - inhibitor Erythromycine - inhibitor "NICE-G"

question

Diseases linked to MH?

answer

Central core disease, King-Denborough syndrome, and Evans myopathy are clearly linked to MH.

question

Best preoperative tests prior to thoracotomy to assess LUNG PARENCHYMAL FUNCTION? To assess CARDIOPULMONARY RESERVE? To assess RESPIRATORY MECHANICS? (include minimum values that would result in pulmonary complications)

answer

Lung Parenchymal Function: DLCO (ppo >40%) Cardiopulmonary Reserve: VO2max (>15mL/kg/min) Respiratory Mechanics: FEV1 (ppo >40%)

question

What are some examples of medications that cause uterine smooth muscle relaxation?

answer

Terbutaline, magnesium sulfate, nitroglycerine, and inhaled inhalation anesthetics relaxes uterine smooth muscle.

question

What are some medications that cause uterine smooth muscle contraction?

answer

Oxytocin, Carboprost (Hemabate), Methergine, Cytotec Oxytocin - causes hypotension Hemabate - avoid in asthmatics Methergine - avoid in hypertensives and CAD/CVA pts

question

What is Hepatopulmonary Syndrome?

answer

Hepatopulmonary syndrome (HPS) is defined by the presence of liver dysfunction, unexplained hypoxemia, and abnormal vasodilation of intrapulmonary vessels. There is also a phenomena called orthodeoxia which is manifested by hypoxia when standing that improves when lying supine. This resolves following liver transplantation.

question

Opioid Induced Pruritis treatment?

answer

Zofran Propofol Nalbuphine (Nubain) Butorphanol (Stadol)

question

Opioids other effects? Immune Effects?

answer

Opioids suppress resistance to infection by modulation of immune cellular activity (T Cells, macrophages, NK cells)

question

Which medications do you dose using Ideal Body Weight? Total Body Weight? Lean Body Weight?

answer

Ideal Body Weight: NMDBs Total Body Weight: Succinylcholine and Propofol (infusion) Lean Body Weight: Opioids and Propofol (induction)

question

E Cylinder Volume Pressure O2 ?? ?? Air ?? ?? N2O ?? ??

answer

E Cylinder Volume Pressure O2 625L 2000psi Air 625L 2000psi N2O 1590L 750psi N20 will only start to drop in pressure at ~400L. Only way to reliably estimate the volume is to weight the cylinder PSI / (200x flow) x 60

question

Most common serious adverse event following a celiac plexus block?

answer

Paraplegia

question

Maternal Physiologic Changes Hematologic: Blood volume? Plasma volume? RBCs? Hgb? Hct? Factor VII and Fibrinogen?

answer

Blood volume? Up Plasma volume? Up RBCs? Up Hgb? Down Hct? Down Factor VII and Fibrinogen? Up vWF Up

question

Maternal Physiologic Changes Electrolytes: RBF/GFR? Serum Cr/BUN? HCO3? Na? K? Cl?

answer

RBF/GFR? Up Serum Cr/BUN? Down HCO3? Down to compensate for resp alk Na? Down K? Down Cl? Down

question

Maternal Physiologic Changes Respiratory: Rate? Tidal volume? ERV? FRC?

answer

Rate? No change Tidal volume? Up by 50% (due to progesterone) ERV? Down by 25% RV? Down by 15% FRC? Down by 20-80% TLC, VC, CC unchanged

question

Maternal Physiologic Changes Cardiac: Rate? SV? CO? SVR/MAP?

answer

Rate? Up SV? Up CO? Up (up 40% to meet metabolic demands of mom and baby) SVR/MAP? Down CVP? No change

question

What neuromonitoring technique is most affected by volatile anesthetics?

answer

MEP > SSEP > VEP > BAER They are not altered by narcotics. EMG and nerve stimulation are not affected by volatiles but avoid NMBDs

question

Subq Fentanyl Patch Time to therapeutic onset? Systemic effects after removal?

answer

Type to therapeutic onset? 12 hours Time after removal? 16 hours - 3 days

question

Weight change side effects: TOPAMAX LYRICA NEURONTIN

answer

TOPAMAX = weight loss LYRICA, NEURONTIN = weight gain

question

Bainbridge Reflex

answer

Increase in heart rate in response to increase venous return. The reflex is mediated by stretch receptors in the walls of the atria. Stimulation of sympathetic fibers and inhibition of vagal outflow from the medulla is thought to be the primary efferent pathway in the Bainbridge reflex to produce an increase in heart rate.

question

Reverse Bainbridge Reflex

answer

Decrease in venous return results in bradycardia, occurs during spinal anesthesia. Otherwise known as Bezold Jarisch Refelx

question

Of the IV anesthetics, the only medications to cause BURST SUPPRESSION are what?

answer

Etomidate, Propofol and Barbiturates. Inhaled anesthetics also can induce burst suppression

question

Critical Illness Myopathy

answer

Distal weakness and muscles of respiration first. Depressed DTRs and slightly elevated CKs. More prevalent in patients who are receiving NMBDs + steroids in the ICU

question

Amitryptiline Mechanism of action with what side effects.

answer

TCA with anticholiergic effect.

question

Postpartum Foot drop due to

answer

Lumbosacral Nerve Injury

question

NPO Guidelines for the following?

answer

Clear liquid 2h Breast milk 4h Formula 6h Non human milk 6h Light non fatty food 6h Fried food 8h

question

Bupivicaine Toxicity in Infants

answer

2.6

question

Urinary specific gravity for a patient who is hypovolemic/dehydrated?

answer

>1.010 = dehydration/hypovolemia

question

Strong ion difference =

answer

SID= [Na + K + Ca + Mg]-[Cl+Lactate] Disturbances that increase SID increase the blood pH causing alkalosis; also dehydration can cause increase in SID Disturbances that lower SID cause acidosis Normal SID = 40

question

Hyperkalemia - diagnosis and treatment?

answer

Classic EKG changes include peaked T waves, shortened QT intervals, long PR Severe - most rapidly treated by hemodialysis Mild/moderate: 1) insulin/glucose to facilitate intracellular transfer of potassium 2) Calcium to stabilize the cardiac membrane 3) Kayexelate and loop diuretics to eliminate potassium 4) B agonists

question

Are peribulbar blocks safer than retrobulbar blocks? Why?

answer

Peribulbar blocks are generally safer because the needle transverses a shallower path without directly advancing the needle towards the optic nerve or the central retinal artery

question

Aldosterone effects on sodium and potassium? How would a Conns syndrome patient present? What medicine would directly counter aldosterone?

answer

Aldosterone is released following activation of renin angiotensin pathway in response to hypovolemia or renal hypoperfusion. Aldosterone works on the distal tubules and collecting ducts to upregulate Na/K pumps. It promotes the reabsorption of Na and excretion of K. Supraphysiologic aldosterone secretion leads to HTN and hypokalemia. Spirinolactone is an aldosterone receptor antagonis.

question

Sodium deficit formula? ***skip

answer

(140 - serum sodium) x (kg x 0.6) Typically, 50% of the Na deficit should be corrected in the first 24hrs and the rate of hypertonic saline should never be higher than 100mL/hr.

question

Magnesium toxicity levels and symptoms Treatment of toxicity?

answer

5-6: Hypotension and bradycardia 6-12: Prolonged PR 12: DTR loss, weakness, can progress to respiratory depression 18: SA/AV node block 20-25: Asystole Tx of Toxicity with IV Calcium

question

Celiac plexus block

answer

Innervates the stomach, small bowel, proximal large bowel, spleen, gallbladder, pancreas, kidneys, and adrenal glands T12-L1 Complications include orthostatic hypotension (MOST COMMON), back pain, retroperitoneal hematoma, hiccups, diarrhea, abdominal aortic dissection, paraplegia (due to subarachnoid injection).

question

In a patient receiving heparin for 5 days or more, what study should be done prior to neuraxial anesthesia?

answer

Platelet count in case of HIT.

question

Differences between aortic and radial arterial waveforms?

answer

A radial waveform will have: 1) a higher systolic pressure 2) a wider pulse pressure 3) a more pronounced diastolic wave 4) a more delayed and slurred dicrotic notch

question

What is meralgia paresthetica?

answer

Entrapment of the lateral femoral cutaneous nerve.

question

VACTERL stands for?

answer

Vertebral defects Anal atresia Cardiac defects TEF Renal anomalies Limb abdmormailties Typically infants undergo repair of TEF first. Then, if there are cardiac abnormalities they will be repaired next. Imporforate anus is repaired next. Prior to considering a caudal for this procedure, consider a lumbosacral MRI to evaluate for neural tube defects (the v in vacterl). These defects are contraindications for caudal anesthesia. CHD are the most common defect associated with TEF, occurring in up to 75%

question

Hyperalimentation is commonly associated with what lab abnormalities?

answer

Hypophosphatemia Hypo-/hyper glycemia Acute liver injury/elevated PTT - usually requiring vitamin K supplementation

question

Pregnancy effects on coagulation? Which factors increase? Which factors decrease?

answer

Factors that increase include I (fibrinogen), VII, VIII, IX, X, XII and vWF. Factors that decrease include XI, XIII, antithrombin III, tPA and protein S Factors that develop resistance = Protein C Dilutional thrombocytopenia usually results in a decrease in platelets by 10%.

question

The first presenting sign of an intrathecal injection in an infant is what?

answer

Apnea. Not hypotension because infants' have a relatively underdeveloped sympathetic nervous system. You would not see bradycardia until late hypoxemia.

question

Confirmatory tests for brain death

answer

Positive apnea test, EEGs (2 isoelectric tests 24 hrs apart) and determination of the absence of blood flow (via cerebral angio, MRI/MRA, transcranial Doppler). All reversible tests must be ruled out. Note: Brain death is a clinical diagnosis and confirmatory testing is not mandatory

question

List neuromonitoring that is least to most sensitive to volatile anesthetics

answer

Least to most sensitive to anesthesia: BAEP ; SSEP ; MEP ; VEP (BAEP = BArely affected, SSEP = Somewhat affected, MEP = Mostly affected, VEP = VEry affected

question

Changes in physiology in response to altitude? Acute changes? Chronic changes?

answer

The most important immediate adaptation is increased HR and then hyperventilation and thus increase in minute ventilation due to the decrease in PaO2, this via stimulation of the peripheral chemoreceptors (central chemoreceptors are not sensitive to falls in PaO2). This results in a respiratory alkalosis. This would normally suppress ventilation but in the next 48-96 hours, the pH of the CSF compensates via bicarbonate loss and bicarbonate is further excreted by the kidneys to return blood to normal pH. In the first 12-24 hours also note that there is a right shift in the OH curve caused by an increase in 2-3 DPG. Over 1-3 weeks, the body further compensates by increasing EPO secretion causing an increase in hematocrit. The increased minute ventilation remains increased as long as the person remains at a higher altitude

question

Peripheral chemoreceptors (carotid and aortic bodies) sense/respond to ____ while central chemoreceptors (medullary) sense/respond to _____.

answer

Peripheral receptors respond to hypoxemia and hypercarbia. Body needs oxygen and makes co2 Central receptors respond to hypercarbia.

question

What do you do for hypoxemia during OLV?

answer

First give CPAP to the nondependent (nonventilated) lung to allow ventilation to the down lung. Second, you can give PEEP to the dependent (ventilated) lung or increasing FiO2. If still hypoxemic consider unclamping the down lung. If this is not possible at the time, clamping of the branch PA on the non-dependent side to decrease intrapulmonary shunting. If absolutely necessary, institution of CPB would be the final option.

question

ACA stroke would present how? MCA stroke would present how?

answer

MCA - upper extremity and facial weakness ACA - lower extremity weakness

question

Conn's syndrome/Hyperaldosteronism affect on: Sodium? Potassium? H ions?

answer

Hyperaldosteronism causes hyernatremia, hypokalemia, metabolic alkalosis. Aldosterone causes sodium reabsorption in exchange for potassium and hydrogen ions. It's net effect is an expansion in ECF volume caused by fluid retention. It is stimulated by RAS. They should be on spirinolactone.

question

What is the most common congenital heart defect?

answer

Perimembranous VSDs - VSDs are the most common and perimembranous VSDs represent 70% of all VSDs

question

What is Ebstein's Anomaly?

answer

It is a rare congenital anomaly characterized by downward displacement of the tricuspid valve. It is basically atrialization of a portion of the R ventricle causing a larger RA and a hypoplastic RV. The baby would present with cyanosis. It is associated with Wolff-Parkinson White syndrome.

question

How to differentiate between DIC and Liver disease?

answer

Factor VIII because VIII will be normal in cirrhotics.

question

Acute Epiglottitis management?

answer

Transport to the OR immediately and perform an inhaled induction. It is crucial to maintain spontaneous ventilation with PPV. Avoid N2O because of the potential for air trapping in the lungs via a ball-valve effect (meaning that air can go in but not out)

question

Surfactant is produced when and by what cells?

answer

It is made primarily after 32 weeks gestation. It is produced by type II pneumocytes. Infants born prematurely are at risk for RDS because of surfactant deficiency. Treatment with exogenous surfactant may reduce intrapulmonary shunting in RDS and hypoxemia.

question

Absolute contraindications for TEE? Relative contraindications for TEE?

answer

ABSOLUTE: Esophageal webs/rings Esophageal tumor Esophageal trauma Scleroderma Mallory Weiss Tear Zenker Diverticulum Active/Recent Variceal Bleed Esophagectomy Recent GI surgery RELATIVE: AAJ instability Symptomatic Hiatal Hernia Hx of Varices Hx of GI surgery PUD Coagulopathy

question

Tourniquets - how much do you inflate them?

answer

Upper extremity: 50mmHg above SBP Lower extremity: 100mmHg above SBP

question

B2 agonists (ritodrine and terbutaline) affect on uterine muscle?

answer

B2 agonists are tocolytics and relax uterine contractions and increase uterine blood flow. Other uterine relaxants: magnesium sulfate, nitroglycerine, and inhaled inhalation anesthetics

question

Treatment for uterine atony?

answer

(Don't need to know doses) Pitocin/Oxytocin: 10-20 U infusion over 10 mins - causes hypotension Methergine/Methylergonovine: 0.2 mg IM, contraindicated in preeclampsia, avoid in HTNives Hemabate/Carboprost (Prostaglandin F2?): 0.25 mg IM, may increase airway resistance so avoid in asthmatics. HEMAbate - Omar has Asthma, likes CARs Cytotec/Misoprostol (prostaglandin E1 analog) - avoid in maternal fever

question

Treatment for Cyanide toxicity?

answer

Hydroxocobalamin (first line) ; Amyl nitrate Elevated cyanide levels can be seen with smoke inhalation from residential or industrial fires. Elevated cyanide and thiosulfate levels can also be seen with administration of sodium nitroprusside. Thiosulfate is seen in long term administration of SNP, especially in pts with renal insufficiency. You would see elevated SvO2 and metabolic acidosis (cyanide will decrease utilization of O2 for ATP production and decrease VO2 thus increasing SvO2)

question

ARDS Severity

answer

P/F = PaO2/FiO2 ratio Mild: P/F ratio 200-300 Moderate: P/F ratio 100-200 Severe: P/F ratio 60mmHg with adequate Hgb 2) PEEP (up to 20mmHg) 3) Minimize FiO2 (;50%) 4) Minimize tidal volumes (6mL/kg)

question

Does atropine cross the placenta?

answer

Yes. It is a tertiary amine and is used if fetal bradycardia is a concern. It is usually given with neostigmine in the pregnant population.

question

Pacemakers placement is indicated in which AV node blocks?

answer

Second degree, Mobitz Type II ; Third degree block First degree = prolonged PR Second Degree, Mobitz Type 1 (Wenkebach) = progressive lengthening of PR interval with eventual dropped beat Second Degree, Mobitz Type 2 = intermittent nonconducted P wave not proceeded by PR lengthening (see picture) - the P waves will march at the same length Third degree = "two rhythms at the same time"; the P-P intervals are constant and the R-R intervals are constant irrespective of each other

question

Simple HR determination

answer

300, 150, 100, 75, 60, 50 etc

question

Median Nerve

answer

- C5-C7 - Motor: flexors of the wrist except for flexor carpi ulnaris - Sensory: palmar side of thumb, index, middle finger, and half of ring finger - Rescue block at the elbow - medial to the brachial artery in the AC fossa - It runs through the carpal tunnel and compression causes CTS

question

Use of Fetal Heart Rate Monitoring is feasible at the earliest when?

answer

The soonest you can do FHR monitoring is at 18-20 weeks gestation. Prior to this, the fetus is too small to monitor.

question

Treatment of stable SVT in patients with WPW?

answer

Procainamide is the drug of choice for patients with AVRT. Patients with AVNRT can be treated with adenosine, verapamil, B blockers, Diltiazem

question

Alkalosis does what to potassium? Insulin does what to potassium?

answer

Alkalosis drives potassium into cells. So less hydrogen ions = less potassium ions Insulin drives potassium into cells.

question

Neuraxial Block ASRA guidelines? - For the patient on ASA? - For the patient on Plavix? - For the patient on Heparin subQ? - For the patient on Unfractioned Heparin IV? - For the patient on prophylactic Lovenox? - For the patient on therapeutic Lovenox? - For the patient on Coumadin?

answer

- ASA? No contraindications - Plavix? Should be discontinued 7 days - Heparin SQ? No contraindications if dose is ;10,000 units - Unfractioned Heparin IV? Heparin gtt must be stopped 2-4 hours before needle placement with aPTT documented to be normal, can be restarted 1 hour after procedure - Lovenox ppx? Delay procedure for 12 hours from last prophylactic dose - Therapeutic Lovenox? Delay procedure for 24 hours, removal should be 12 hours after last dose - Coumadin? Should be discontinued for 4-5 days and check an INR

question

Lidocaine with epi toxic dose?

answer

7mg/kg of lidocaine with epi

question

TEG What do you give for the following: Prolonged R? Prolonged K? Decreased MA? "Teardrop" configuration?

answer

Prolonged R = FFP Prolonged K = Cryo Decreased MA = platelets Teardrop = Antifibrinolytics ie TXA, eproetin

question

HOCM intraop strategy?

answer

1) Maintain preload 2) Optimize diastolic time by decreasing heartrate (beta blockers) 3) Maintain afterload (phenylephrine)

question

Alveolar gas equation? Which energy substrate is most effective for a ventilator wean?

answer

PAO2 = FiO2 x (Patm - PH2O) - CO2/RQ RQ = 0.8 Carbs = 1.0 Protein = 0.8 Lipids = 0.7 Lipids result in the lowest increase in CO2 production. So they would be most ideal for ventilator weaning by reducing the amount of CO2 that needs to be removed by ventilation.

question

Mixed Venous Oxygen (SvO2) - what causes an increase in SvO2? What causes a decrease?

answer

SvO2 is a measure of global oxygen delivery. Increase: - Increasing Hgb concentration - Increased SaO2 (via increased FiO2) - Increased CO (eg Sepsis) - Decreased VO2 (eg cyanide, sepsis, CO, MetHgb, Hypothermia) Decrease: - Increased O2 Consumption (eg hyperthermia, shivering, pain) - Decreased CO (eg MI, hypovolemia) - Decreased Hgb - Decreased SaO2

question

Causes of Metabolic Acidosis GAP metabolic acidosis? NONGAP metabolic acidosis?

answer

Normal Anion gap = 8-12 GAP: "MUDPILES" Methanol, Uremia, DKA, Propylene glycol, INH/Infection, Lactic acidosis, Ethanol/Ethylene glycol, Salicylates NONGAP: "FUSEDCARS" Fistula, Uretero-enterostomy, Saline admin, Endocrine (hyperPTH), Diarrhea, Carbonic anhydrase inhibitors, Ammonium chloride, RTA, Spirinolactone There are three major etiologies of nongap acidosis: 1) Chloride containing solutions (NS or TPN) 2) Increased HCO3 loss (diarrhea, ostomy output, GI fistula) 3) Decreased acid excretion (ie hypoaldosteronism, ARF/CRF

question

Afferent vs Efferent

answer

Afferent is the nerve arriving to the spinal cord, efferent is the nerve exiting the spinal cord. Afferent ARRIVES, Efferent EXITS.

question

In a patient with muscular dystrophy who receives succinylcholine, why would they have hyperkalemic cardiac arrest?

answer

Not because of extrajunctional receptors but because of rhabdomyolysis. Patients with Duchenne or Becker would present with muscle weakness, pseudohypertrophy of calves, and elevated CK. They might also have dilated CMP. They are not more susceptible to MH.

question

Tumescent Liposuction dose/kg of lidocaine?

answer

35-55mg/kg is allowed because the majority is aspirated during the procedure, because it is not absorbed, and because it is given with Epi. Concentrations peak at 12 hours. 0.05% Lidocaine with Epi 1:1,000,000

question

ABGs are generally run at ___ degrees C. To correct for colder patients

answer

37 degrees C For each degree Celcius temperature decrease, the pH of the blood increases by 0.02. For example, a sample on a patient who was at 32 degrees came back with a pH of 7.20, what would the corrected pH be? 7.30

question

Reflexes: What is the Bezold Jarisch Reflex? What is the Bainbridge Reflex? What is the normal Baroreceptor Reflex?

answer

Bezold Jarisch - hypotension sensed in the LV leads to bradycardia and further hypotension Bainbridge - paridoxical tachycardia in response to fluid bolus Baroreceptor - stretch receptors in the carotid results in decreased HR and decreased BP

question

Risk factors for Post Dural Puncture Headaches (PDPH)?

answer

Age ; 40 Prior PDPH BMI ; 30 Hx of Air Travel Multiple Attempts The use of Cutting Needles (Quincke, Pitkin, Rovenstine) Puncture with a large bore needle

question

Inhaled Nitric Oxide can cause what?

answer

Methemoglobinemia and a left shift on the oxygen disassociation curve. It will improve VQ mismatch by decreasing PVR, thus increased PaO2 NO is endogenously secreted by the vascular epithelium to inhibit platelet aggregation.

question

ECT Autonomic Effects?

answer

Initially following seizure activity, there is an increase in parasympathetic stimulation which can manifest as increased secretions, bradicardia and sometimes transient asystole. The increased parasympathetic stimulation is quickly followed by an increase in sympathetic stimulation which will present as hypertension and tachycardia. You can sometimes see ST changes which is usually transient.

question

B2 agonism effect on: Glucose? Potassium?

answer

B2 agonists causes HYPERglycemia and HYPOkalemia. It also is used off label as a tocolytic/uterine relaxation. "B SWEET" Also, remember that B agonists are a treatment for hyperkalemia

question

Goals for Aortic and Mitral Insufficiency?

answer

Decrease afterload Augment contractility Avoid bradycardia - any medication that would decrease heart rate is not recommended because it will allow for more time for regurgitant flow. A mnemonic for Aortic Insufficiency and Mitral Insufficiency is "fast, full and forward" - avoid bradycardia, optimize preload, and minimizing afterload. Can use nitroprusside to decrease afterload

question

Goals for Aortic Stenosis?

answer

Avoid hypotension Maintain sinus rhythm avoiding both bradycardia and tachycardia Optimize intraventricular filling Avoid sudden increases or decrases in SVR

question

Goals for MV Stenosis?

answer

Avoid sinus tachycardia or Afib with RVR Avoid marked increases in CVP Avoid drug induced decreases in systemic vascular resistance Avoid hypoxemia or hypoventilation which might precipitate increases to PVR and eventual right sided failure

question

Goals for HOCM?

answer

1) Ensuring adequate preload and CO, 2) Reduce contractility - halothane used in the past but no longer because of arrhythmogenicity 3) Maintain SVR Etomidate is a good choice for induction because of its ability to maintain SVR.

question

Neonatal Fluid management - Things to Keep in Mind

answer

1) Neonates have reduced GFR and are prone to fluid overload because their nephrons are immature and underdeveloped. 2) Neonates are sodium wasters because they do not respond as strongly to aldosterone. 3) TBW is highest in preterms and lowest in adults. 4) A high body surface area:body weight ratio pre disposes neonates to increased evaporative losses. 5) Immature sympathetic nervous system and baroreceptors are the reason for a reduced response to low BP 6) Infants and neonates have a higher volume of distribution. 7) Infants and neonates have a LOW plasma protein content which means that they have increased plasma concentration of unbound/active molecules/hormones/medications. 8) Enzyme immaturity leads to slower metabolism but remember that they have a higher volume of distribution

question

The best medicine to improve CPP?

answer

Vasopressin is actually better at improving CPP compared to phenylephrine or NE. Not only does vasopressin increase MAPs but it also reduces ICP. CPP = MAP - ICP

question

Coronary Perfusion pressure = ?

answer

Coronary Perfusion Pressure = Aortic DBP - LVEDP

question

What factors increase in pregnancy?

answer

1, 7-10, 12 and vwf 11, 13 and at3 decrease

question

Substrates that are metabolized by butrylcholinesterase

answer

Heroin Cocaine Other ester local anesthetics ASA Mivacurium Succinylcholine **Remifentanil and esmolol are not metabolized by butylcholinesterase

question

Malignant Hyperthermia Pathophys? Earliest signs? Triggers? Associated with? Confirmation test?

answer

Caused by mutation in the ryanodine receptor (normally responsible for release of calcium into muscle cell) that causes prolonged release of calcium. Earliest signs are masseter muscle rigidity, tachycardia and hypercarbia. Hyperthermia and myoglobinuria is a late sign. Triggers: Volatile anesthetics only (NOT nitrous) and succinylcholine Clear associations with Central Core Disease, Multi-minicore myopathy and King Denborough syndrome. Confirmation test: Muscle biopsy - caffeine-halothane contracture test (10-20% false positive rate but near 0% false negative rate - it is 100% sensitive)

question

Malignant Hyperthermia Intraoperative management?

answer

Call for help 1) Stop triggering agent 2) 100% O2 - high flows 3) Dantrolene 2.5mg/kg - give early and ok to give rapidly 4) Change circuit tubing, soda lime 5) Get Arterial access for lab draws - ABG q5 mins, check BMP and clotting studies 6) Bicarbonate 1-2mEq/kg 7) Treat symptoms - cool if necessary, antiarrhythmics (procainamide), diuretics (furosemide 1mg/kg or mannitol 0.25mg/kg) Dantrolene + CCBs are contraindicated because myocardial depression has been demonstrated in animal studies

question

What is the earliest most sensitive sign for MH? What is the earliest most specific sign for MH?

answer

Earliest most sensitive: Hypercarbia Earliest most specific: Muscle rigidity

question

Known Triggers for post op OSA in Pediatric Population

answer

Severe OSA on Polysomnography Age ; 3 years old Hx of prematurity Neuromuscular disorders URI in the past 4 weeks Nasal pathology Systemic HTN Obstruction during Inhaled Induction Hx of Snoring, Frequent awakenings, Daytime restlessness Cor Pulmonale

question

Do hyper-/hypothyroidism affect MAC?

answer

NO

question

Pheochromocytoma Management? What to expect in the PACU?

answer

Alpha blockade first followed by beta blockade. If you do beta blockade first, you will get unopposed alpha causing hypertension. Treat first with phenoxybenzamine (irreversable alpha blocker) or phentolamine or prazosin (alpha 1 blocker). Combination of phenoxybenzamine, prazosin, beta blocker, ACEi, CCBs, and magnesium sulfate to attain HD stability. In the PACU, they will be hypotensive, sedated, hypertensive (if part of the tumor persists), and hypoglycemic. Not hyperglycemic.

question

Smoking Cessation

answer

12-24 hours to decrease CO levels and decrease sympathetic outflow caused by nicotine (t1/2 of 1-2hrs) 1-2 weeks to decrease sputum production, normalization of mucociliary function 3-4 weeks to decrease wound healing complications ;4 weeks to decrease respiratory complications (ie bronchospasm or pneumonia)

question

Hepatic Blood Flow is derived from?

answer

The portal vein provides about 75% of total hepatic flow and the hepatic artery only provides about 25%.

question

In obesity, what changes would you see in lung mechanics?

answer

Decreased FRC (due to decreased ERV) Decreased VC Decreased TLC RV and closing capacity are unchanged FEV 1 and FVC are usually normal.

question

Which lung volumes remain constant from infancy to adulthood?

answer

FRC (30mL/kg) and Tidal volume (7mL/kg)

question

Pierre Robin vs Apert Syndrome vs Klippel-Feil syndrome vs Beckwith-Wiedeman syndrome vs Hurler syndrome

answer

Pierre Robin: Micrognathia/mandibular hypoplasia, glossoptosis and cleft palate Apert: MAXillary hypoplasia and choanal stenosis = mouth breathers but not a difficult airway Klippel-Feil: limited neck extension due to fused cervical vertibrae Beckwith-Wiedeman: macroglossia; associated with CHD and omphalocele Hurler: airway difficulty due to infiltration of mucopolysaccharide into pharyngeal and laryngeal soft tissue

question

Tet Spell Management

answer

Knee-chest position (increases SVR) Phenylephrine (increases SVR) Fluid bolus (increases preload) Morphine (decrease agitation and decrease RVOT obstruction) B blocker (decreases RVOT obstruction)

question

Uptake of volatile agents is faster in infants why?

answer

Because they have a higher alveolar ventilation:FRC ratio. Infants also have a larger proportion of vessel rich tissues such as brain, liver and heart which also contributes to a more rapid uptake. This explains why an inhaled induction is faster in infants, compared to adults.

question

Umbilical Vein Blood Gas Umbilical Artery Blood Gas

answer

7.35 / 40 / 30 7.20-7.30 / 50-55 / 18-25

question

Estimated Allowable Blood Loss equation?

answer

EABL = EBV (Hcti-Hctf/Hcti) EBV = 80mL/kg infants, 70mL/kg adults

question

Risk factors for developing Preeclampsia?

answer

Advanced maternal age African Americans Nulliparity Family history of Preeclampsia Placental Abruption Obesity Diabetes Renal disease Vascular disease HTN NOT CIGARETTES or TABACCO

question

How does magnesium affect the NMB and the NM junction?

answer

It inhibits the release of ACh at the NMJ It decreases sensitivity at the NMJ to ACh It depresses the excitability of the muscle fiber membrane It increases potency and duration of NMDBs

question

Meds that do/do not cross the placenta

answer

Do not: Heparin, glycopyrrolate, muscle relaxants (minimal placental transfer) Do: Atropine, scopalamine, thiopental (highly lipid soluble), opiates (morphine the most, fentanyl the least), volatile anesthetics, local anesthetics (depend on pKA, maternal/fetal pH, degree of protein binding) - mainly lidocaine will cross, bupi and ropi have high protein binding and chlorprocaine is metabolized quickly.

question

P50 of neonates? P50 of 10 month old? P50 of adult Hgb?

answer

neonate - 20mmHg, left shift because of decreased interaction between HbF and 2,3 DPG 10mo - 30mmHg, the P50 decreases to adult values at about 10-12yo adult - 27mmHg

question

Beginning at what week gestation should you start to implement left uterine displacement? When can you start monitoring fetal heart tones?

answer

18-20 weeks for both

question

Up to what month can you use NSAIDs during pregnancy?

answer

Up to the end of the 2nd trimester

question

Avoid elective surgery when during pregnancy? When is the optimal time for elective surgery?

answer

Avoid it in the 1st trimester because of organogenesis (occurs between days 30-70). The second trimester is the optimal time to perform surgery

question

t-test vs ANOVA?

answer

t-test is used for comparing continuous outcomes in 2 groups. ANOVA is used to compare more than 2 groups

question

What is the leading cause of mortality in pregnant women?

answer

Pulmonary embolism - due to an increase in factor I, 7-10, 12 and vWF and a decrease in protein S (mainly hypercoagulable state is due to increased VII and fibrinogen) Risk of venous thromboembolism in pregnancy increases with the following additional risk factors: obesity, smoking, multiple gestations, advanced maternal age, increased parity, cesarean section, as well as the presence of a concomitant thrombophila.

question

Preservatives in LA solutions possible toxicity? Sulfites? EDTA? Methylparabens?

answer

Sulfites - added to 2-chloroprocaine is associated with arachnoiditis or anaphylaxis. Pts who have had accidental large intrathecal volume injection can develop bilateral lower extremity paralysis EDTA - added as a chelating agent that can cause back pain at the injection site Methylparaben - bacteriostatic agent that has a chemical structure similar to PABA and can cause anaphylaxis.

question

Absorption of LA from greatest to least?

answer

IV, Tracheal, Intercostal, Caudal, Epidural, Brachial plexus, Sciatic, SubQ "IT ICE BS"

question

Lidocaine max dose?

answer

4-5mg/kg without epi 7mg/kg with epi

question

Bupivicaine/Ropivicaine max dose?

answer

3mg/kg

question

Cocaine mechanism of action?

answer

1) Na channel blocker 2) NE reuptake inhibitor 3) Stimulates presynaptic NE + dopamine release Metabolized by butrylcholinesterase

question

Interscalene Block What part of the brachial plexus? Surgical applications? What side effects or complications?

answer

Upper and middle trunks mainly, the lower trunk is often spared Blocks the entire brachial plexus with occasional ulnar sparing Good for shoulder or proximal - mid humerus surgery Phrenic nerve paresis in 100% of patients, unsuitable for COPDs or elderly who cannot tolerate 25% reduction in pulmonary function

question

Supraclavicular Block What part of the brachial plexus? Surgical applications? What side effects or complications?

answer

Trunks/divisions Blocks the Radial, ulnar, median, musculocutaneous and axillary nerves so good for surgeries of the mid humerus, elbow, forearm and hands Risk of PTX requires caution. Phrenic nerve paresis in 30%

question

Infraclavicular Block

answer

Blocks at the level of the cords

question

Axillary Block What part of the brachial plexus? Surgical applications? What side effects or complications?

answer

Terminal branches/peripheral nerves Blocks the radial, ulnar, median and musculocutaneous (unreliably blocked) Good for operations of the forearm and hand Supplimental intercostobrachial nerve block needed for TNQT pain

question

The intercostobrachial nerve is responsible for what nerve distribution?

answer

The medial surface of the arm in the axilla

question

What formation of Bupivicaine is the most cardiotoxic? R+, S- or Racemic?

answer

R+ isomer is 7 times more potent than S- Levobupivicaine is the same as S-

question

Why do you get decreased HR in a high neuraxial block?

answer

1) you could have blockage of the cardioaccelerator fibers (T1-T4) 2) unoposed vagal tone from high sympathectomy 3) Reverse bainbridge reflex/Bezold Jarisch reflex (decresaed HR due to decreased intracardiac stretch receptors)

question

What effects on lung mechanics do you get from neuraxial anesthesia?

answer

TV is not impaired as long as C3-C5 are not blocked VC is decreased due to decreased ERV from abdominal muscle weakness Apnea during spinal is due to medullary ischemia from hypotension rather than motor block of the phrenic

question

In cases of MRI equipment malfunction, the liquid helium (which is used to cool the superconducting materials) can boil off in what is known as a _____. If the helium does not escape through the safety valve, the large amount of helium can pose a risk for_____.

answer

Quench Asphyxiation to personal and patients due to displacement of O2 in the room.

question

WPW - what are the two types of tachyarrhythmia? What are the pathways of the two types? What are the treatments of the two types?

answer

AVNRT is the most common tachyarrhythmia seen in pts with WPW. AVNRT is classified as either ORTHODROMIC or ANTIDROMIC. Orthodromic is more common and has a narrow QRS - the impulse is conducted from atrium to AV node to His to Purkinje and then return from ventricle to atria using an accessory pathway. Treatment should begin with vagal maneuver. If unsuccessful give B blockers, verapamil, adenosine or amio. Antidromic has a wide QRS - impulse is conducted from the atrium to the ventricle through the accessory pathway and returns from the ventricles to the atria via the normal AV node. Treatment with PROCAINAMIDE. Meds that slow AV node conduction such as adenosine, CCBs, B blockers, lidocaine and digoxin can actually increase conduction through the accessory pathway and are contraindicated. Cardiovert if unstable

question

Treatment of Long QT syndrome

answer

B-blockers, potassium supplementation, Mexilitine, ICD placement

question

Neurolysis for cancer pain: what are the two methods?

answer

1) Alcohol - burns on injection 2) Phenol - does not burn

question

Celiac plexus block is used for what?

answer

Cancer of organs from the distal esophagus to the transverse colon

question

Superior Hypogastric Plexus is used for what?

answer

Bladder ca, cervical Ca, prostate Ca

question

What is the caudal block dose in infants?

answer

0.5-1mL/kg of 0.25% bupi or ropi with or without epi 0.5mL/kg covers sacral dermatomes 1mL/kg covers low thoracic dermatomes 1.25mL/kg covers mid thoracic dermatomes

question

Signs of Uterine rupture?

answer

Atypical abdominal pain, shoulder pain, vaginal bleeding, uterine tenderness, hypotension, tachycardia, shock.

question

What type of nerve fibers are the most susceptible to LA blockade?

answer

Small myelinated B fibers

question

What is the anesthetic site of action for lipophilic opioid epidural infusions? Lipophilic epidural bolus?

answer

Opiate epidural infusions site of action = systemic Opiate epidural bolus site of action = spinal

question

Neuraxial hydrophilic opioids move cephalad or caudad?

answer

Hydrophilic opioids (ie morphine dilaudid) meds move more cephalad compared to fentanyl

question

Lidocaine Bier Block dose?

answer

3mg/kg of 0.5% Lidocaine will provide anesthesia for up to 90 mins

question

Most common cause of transfusion related mortality?

answer

TRALI - caused by recipient antibodies to donor HLA causing an influx of neutrophils into the lungs with subsequent activation causing inflammatory response and increased pulmonary microvascular permeability

question

Hemophilia A is a deficiency in ___? Hemophilia B is a deficiency in ___?

answer

A = factor eight B = factor nine A8, B9

question

In regards to local anesthetics: Lipid solubility is the determinant of what? pKA is a determinant of what? Protein binding is a determinant of what?

answer

Lipid solubility is the primary determinant of intrinsic local anesthetic potency (increased lipid solubility indicates increased potency) Speed of onset is related to the pKa (lower pKA indicates shorter onset of action) Protein binding is implicated in the duration of action (high protein binding indicates longer duration of action)

question

CEA Normal regional cerebral blood flow? Ischemia seen with what cerebral blood flow? EEG changes seen with what cerebral blood flow? Cerebral tissue death is seen with what CBF?

answer

Normal 50mL/min/100g Ischemia 20mL/min/100g EEG changes 15-20mL/min/100g Cell death 10mL/min/100g 16 lead EEG is the gold standard

question

Paired t-test Unpaired t-test Chi-Square Fisher-test

answer

Paired t-test: compare study subjects means at 2 different times Unpaired t-test: compares means of two different subjects Fisher test: compares 2 proportions Chi-square: compares ;2 proportions

question

SVR formula? PVR formula?

answer

SVR = 80 * (MAP-CVP) / CO PVR = 80 * (mPAP - PCWP) / CO

question

Abdominal compartment syndrome: When do you see it? What bladder pressures would you see?

answer

- Can be the result of major abdominal surgery or following massive fluid resuscitation for massive trauma or burns. This is because of massive intra-abdominal edema secondary to shock induced inflammatory mediators or surgical manipulation - ;20-25mmHg

question

Alpha stat vs pH stat

answer

During pH stat the patient's pH is maintained my managing the pH at the current temperature. ***pH stat infuses extra CO2 into the blood causing improved CBF*** During alpha stat the patient's pH management is not temperature corrected. Just remember that in a cold patient, the patient's PaCO2 will be LOWER than what is seen on the alpha stat.

question

In the prone head/neck case, patient wakes up with unilateral blindness, proptosis and retinal exam shows a cherry red spot, what is the diagnosis?

answer

Central retinal artery occlusion "Prone case with pressure on the eyeball" This is different from Posterior/Anterior IOP in that the optic disc is normal.

question

Extracorporeal Membrane Oxygenation VA ECMO VV ECMO AV ECMO

answer

VA ECMO = can provide near full support of heart and lungs VV ECMO = gas exchange of 80% of cardiac output, does not provide any cardiovascular support AV ECMO = gas exchange is driven by arterial flow through extracorporeal membrane

question

Vaporizer output at alitutde

answer

Modern conventional vaporizers are temperature compensated variable bypass vaporizers. This means that these vaporizers divert a certain amount of FGF through the liquid volatile anesthetic. Therefore the amount of volatile exiting the vaporizer is subject to change based on the atmospheric pressure. They automatically compensate for changes in altitude. However, the desflurane vaporizer is different in that it is heated to 39 degrees C. No FGF flows through a desflurane sump, rather a certain volume of desflurane is released into the circuit based on the percentage set on the control dial. Therefore, the output of desflurane from the anesthesia circuit will be the SAME weather at sea or at altitude. An example of a question: If a machine is set at 6% in two operating rooms. One machine is set at sea level (Patm 760mmHg) and the other is set at 8000ft above sea level (Patm 570mmHg), what would be the expected anesthetic depth of the patient at 8000 feet? Deeper? Lighter? The same? Answer: Relatively lighter because the partial pressure of desflurane in the sea level pt would be 760 x 0.06 = 45.6mmHg and the partial pressure of the desflurane in the 8000ft pt would be 570 x 0.06 = 34.2mmHg. So the 8000ft pt would be getting less desflurane.

question

For a sciatic nerve block, what three anatomical landmarks are required?

answer

1) Greater trochanter of the femur 2) PSIS 3) Sacral Hiatus

question

What is the most common congenital cardiac anomaly?

answer

Bicuspid aortic valve

question

Cirrhosis: increased or decreased? Intravascular volume? ECF? Total body water? Intracellular volume? Cardiac output? SVR? SvO2?

answer

Intravascular volume decreased ECF increased Total body water increased Intracellular volume unchanged CO increased - cirrhosis causes a hyperdynamic state SVR decreased SvO2 increased

question

Amniotic Fluid Embolism risk factors?

answer

Multiparity Placenta previa Abruptio placenta Uterine rupture Cervical laceration

question

GI changes in 3rd trimester: increased or decreased? - Gastric pH? - Gastric emptying? - Gastric volume? - LES tone

answer

Gastric pH down due to increased gastrin Gastric emptying decreases in active labor Gastric volume up due to increased gastrin LES tone decreases due to progestin & upward displacement of the stomach

question

Neonatal resuscitation

answer

Not breathing or crying? Dry, warm, stimulate, clear airway secretions HR <100, gasping or apneic? PPV HR < 60 after 30 seconds of PPV? Continue PPV - intubate, start chest compressions HR still < 60 after 60 secs? GIVE EPI 10-30mcg/kg IV, IT, or via umbilical artery For meconium: If adequate RR, HR and activity, do NOT intubate, just suction If not adequate HR, irregular RR, poor tone - intubate and suction

question

Conditions associated with Meconium

answer

Postmaturity (>42 weeks) Uteroplacental insufficiency IUGR Maternal conditions (ie HTN, Placenta previa, PHTN, Abruptio placenta)

question

Arrhythmia associated with SAH? Also, in the setting of SAH an echo might show what?

answer

QT prolongation Global LV hypokinesis

question

What period of the cardiac cycle is most shortened in sinus tachycadia? When does most of the LV filling occur?

answer

Diastasis (slow filling prior to atrial contraction, the y descent) Early diastole upon opening of the mitral valve. Atrial systole is responsible for 15% of LV filling

question

How does hetastarch affect anticoagulation?

answer

It binds to Factor VIII and vWF.

question

Aspirin Toxicity Laboratory findings? Clinical presentation? Treatment?

answer

First you will get direct stimulation of respiratory centers leading to respiratory alkalosis due to hyperventilation Metabolic acidosis to follow with an increased anion gap acidosis due to accumulation of lactate and excretion of bicarb (the kidneys have been wasting bicarb to compensate for resp alkalosis) Clinically, TINNITIS, tachypnea, hyperthermia, nausea/vomiting, seizures, CV collapse Tx: Activated charcoal within 1-2 hours, gastric lavage, bowel irrigation; sodium bicarb, HD, IV fluids

question

Congenital Long QT syndrome Medications to avoid? Acute management of torsades? Chronic management of LQTS?

answer

Avoid quinidines, procainamide, amio, macrolides, TCAs, SSRIs, ondansetron, methadone, volatile anesthetics Acute management: Magnesium, correct electrolytes Chronic management: B blocker and possibly a pacemaker

question

Separation anxiety does not begin until what age?

answer

6 months

question

What ETTs are the most flammable?

answer

PVC > silicone > red rubber

question

If a patient presents with MI and is found to have severe mitral regurg, what happened?

answer

There was likely posteromedial papillary muscle rupture due to RCA infarction.

question

Renal failure electrolytes?

answer

Elevated Electrolytes: potassium, phosphate, and magnesium Decreased Electrolytes: sodium, calcium Other Increases: urea, creatinine, uric acid, sulfate, phosphorus, lipids, cholesterol Other Decreases: albumin Acid/Base: anion gap metabolic acidosis

question

IE prophylaxis

answer

Previous IE Prosthetic valve CHD Heart transplant pts with valve issues

question

Most likely cause of intraop anaphylaxis?

answer

NMBDs

question

Elderly PFTs/Age related changes Closing pressure Residual volume Elasticity Gas exchange Dead space Chest wall rigidity Response to hypercapnia/hypoxia MAC CO Volume of distribution Hepatic function Recovery from anesthesia Levels of catecholamines Sensitivity to B receptor

answer

Closing pressure increased Residual volume increased Elasticity decreased Gas exchange decreased due to collapse of smaller airways and decreased alveolar surface area Dead space increased Chest wall rigidity increased Response to hypercapnia/hypoxia blunted MAC decreased CO decreased Volume of distribution increased Hepatic function decreased Recovery from anesthesia due to increased Vd and decreased hepatic function There is increased levels of catecholamines but decreased sensitivity to B receptor

question

Amiodarone Affect on SVR? Affect on HR?

answer

Decreases SVR and HR.

question

Tetanus toxin mechanism?

answer

Tetanus - travels retrograde up the motor neuron to the spinal cord where it enters the inhibitory interneurons and blocks the release of glycine.

question

Botulism toxin mechanism?

answer

Botulism inhibits the release of ACh at the NMJ by cleaving SNARE proteins - this stops the fusion of vesicular ACh.

question

FENa values

answer

1% = intrinsic (ATN or AIN) >4% = post renal

question

Acetazolamide

answer

Wastes sodium and HCO3 Cl reabsorption Clinical use: Acute mountain sickness (to compensate for resp alkalosis), glaucoma, urinary alkalinization Can in hyperchloremic metabolic acidosis

question

Etomidate/Ketamine affect on evoked potentials?

answer

Increased amplitude

question

Cyanide toxicity

answer

Hydroxocobalamin: combines with cyanide, forming cyanocobalamin (vitamin B12), which is renally excreted; few side effects, well-tolerated by critically ill Amyl nitrite: inhaled formulation, rapidly enters circulation generating methemoglobin which has higher affinity for CN than cytochrome oxidase Sodium Nitrite: slower onset, longer lasting nitrite, as above frees up cytochrome oxidase to resume aerobic metabolism Sodium Thiosulfate: regenerates sulfur-dependant rhodanese activity; this enzyme converts CN to thiocyanate, which is renally excreted; recommended co-administration with hydroxocobalamin or nitrites, especially in prolonged exposures

question

Fibromyalgia Diagnosis? Treatment?

answer

1) WPI score >7 OR SS scale score of >5 OR WPI 3-6 + SS scale of >9 2) Symptoms >3 months 3) No other explanation of pain Treatment CBT, sleep hygeine, strength training, meds - fda approved meds = Cymbalta, Lyrica or Savella

question

Facet arthropathy Nerve supply? Presentation?

answer

Each facet joint is innervated by the MEDIAL BRANCH of the posterior rami of the spinal nerves above and below Pain may be near midline and can radiate to gluteal region, thigh and knee. Worse with hyperextension and lateral rotation of spine Diagnostic medial branch block Tx Medial branch rhizotomy

question

Herniated Disc What level? Worse with? Better with? Associated symptoms? Initial tx?

answer

90% of the time it is L4-L5 or L5-S1. Occurs from flexion injuries or heavy lifting Aggravated by bending, lifting, sitting. Relieved by lying down +/- numbness or weakness or DTRs L4-L5 = weakness in dorsiflexion L5-S1 = weakness in plantar flexion Acute back pain tx: NSAIDs and APAP

question

Spinal stenosis

answer

Progressive narrowing of neural foramina and spinal canal. It is improved with flexion of the spine (squatting) and worsened with extension of the spine (walking up a hill)

question

Sciatic nerve is derived from what?

answer

L4-S3

question

Obesity

answer

Decrease in TLC Decrease in FRC (due to loss of ERV)

question

CHARGE syndrome

answer

Coloboma Heart defects Atresia, choanal Retardation of growth or development Genital abnormalities Ear abnormalities/deafness

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