question

Vertebral arteries arise from the _______ ?

answer

The vertebral arteries arise from the subclavian arteries

question

The subclavian arises from the __________ ?

answer

aortic arch

question

The carotids arise from the ________ ?

answer

The carotids arise from the aortic arch

question

The vessels that can be most easily compressed during mediastinoscopy are the _______ ?

answer

The vessels that can be most easily compressed during mediastinoscopy are the innominate, right brachiocephalic and right common carotid.

question

Mediastinoscopy - Where is incision site?

answer

Mediastinoscopy This procedure can either be done via a transverse incision just above the suprasternal notch or in the second or third rib interspace. The mediastinoscope is inserted between the rib cage and the lungs.

question

Most common complication for Mediastinoscopy is _________ ? Name two other complications.

answer

Most common complication is hemorrhage and second is pneumothorax (primarily on right side). • May have air embolism if spontaneously breathing (Trendelenburg position) • May have vagal response due to stretching of vagal nerve or trachea

question

Mediastinoscopy is most useful for _______ ?

answer

Most useful for right lung tumors

question

If spontaneously breathing (Trendelenburg position) during Mediastinoscopy, what complication may happen?

answer

May have air embolism if spontaneously breathing (Trendelenburg position)

question

Mediastinoscopy what should you look for in these patients?

answer

• Myasthenic syndrome • Tracheal deviation • Thoracic inlet obstruction (lymph) • Type and cross for blood

question

What nerves should you be aware of during Mediastinoscopy?

answer

Left recurrent laryngeal nerve and phrenic nerve are around aortic arch

question

What anesthestic considerations for Mediastinoscopy?

answer

Anesthesia Application • Arterial line in right radial artery to monitor compression of innominate and right brachiocephalic arteries. • Monitor blood pressure in left arm. • Should pulse oximeter be placed on right or left hand? opposite art line • Large venous tear may mandate starting IV in leg. • Endotracheal intubation • Muscle paralysis • Positive pressure ventilation (decrease likelihood of air embolism)

question

Contraindications of Mediastinoscopy?

answer

Contraindications • Previous mediastinoscopy (scarring) • Superior vena cava obstruction • Tracheal deviation • Aneurysm of thoracic aorta

question

Complications of Mediastinoscopy?

answer

Complications: • Hemorrhage • Air embolus • Nerve injury • Pneumothorax • Esophageal injury • Thoracic duct injury • Tracheal compression

question

Where do you place art line in mediastinoscopy and why?

answer

Arterial line in right radial artery to monitor compression of innominate and right brachiocephalic arteries.

question

A body mass index greater than _______ are obese. Pts. who weigh _______ % more than their ideal body weight are obese .

answer

Anesthesia for Morbid Obesity Patients who weigh 20% above their ideal body weight or have a body mass index greater than 28 are obese.

question

Morbid obesity occurs when the patient's body weight is more than ________ above ideal body weight or when weightor his or her body mass index (BMI) exceeds ______.

answer

Morbid obesity occurs when the patient's body weight is more than 45 kg above ideal body weight, or his or her body mass index (BMI) exceeds 35 .

question

Respiratory changes in obesity (resembles ________ disease):

answer

Respiratory changes (resemble restrictive disease): O Basal metabolic rate (unchanged) O Chest wall compliance decreased O Expiratory reserve volume decreased O Inspiratory capacity decreased O Vital capacity decreased O Functional residual capacity decreased O Diaphragm is elevated O Work of breathing increased O Diaphragm breather O Pa02 decreased (arterial hypoxemia) O PaC02 normal O Restrictive ventilation defect O Sleep apnea O Be careful with the head down position.

question

Chest wall compliance decreased or increased in obesity?

answer

Chest wall compliance decreased

question

Functional residual capacity decreased or increased in obesity?

answer

Functional residual capacity decreased

question

Diaphragm is elevated or depressed in the obese?

answer

Diaphragm is elevated

question

How are Pa02 and PaC02 in the obese?

answer

Pa02 decreased (arterial hypoxemia) PaC02 normal

question

Cardiovascular changes in obesity:

answer

Cardiovascular changes O Cardiac output is increased O Congestive heart failure may occur O Pulmonary and systemic hyperperfusion O Blood volume increased (50 ml/kg) O Hypercholesterolemia O Hypertriglyceridemia O Diabetes mellitus O Ischemic heart disease O Cardiomegaly O Pulmonary hypertension

question

Cardiac output is increased or decreased in obesity?

answer

Cardiac output is increased

question

Blood volume increased or decreased?

answer

Blood volume increased: (50 ml/kg)

question

Anesthesia concerns:

answer

Anesthesia concerns: O Use caution for aspiration (rapid sequence induction, RSI) O Be aware that halothane hepatitis is a possibility due to increased fatty infiltrates in the liver O Assess your airway O Calculate drug dose on ideal rather than actual body weight O Regional anesthesia may be difficult due to obscured bony landmarks-osteoarthritis O Monitor ABGs O Mechanical ventilation with high tidal volumes O Prone to nerve stretch injuries due to difficulty in positioning; watch brachial plexus O Need to wake up quickly; extubate awake - sleep apnea

question

Anesthesia concerns: postop

answer

Postoperative O Semi-sitting position O Oxygen per mask for 2-3 days O Need early ambulation to decrease risk of deep vein thrombosis and pulmonary emboli O Use narcotics with caution due to respiratory depression O Use correct size blood pressure cuff

question

In the obese, Calculate drug dose on ideal or actual body weight?

answer

Calculate drug dose on ideal rather than actual body weight

question

Management of ventilation in the obese:

answer

Management of ventilation ■ Large tidal volume ■ Prone and head-down position may further decrease Pa02 O

question

Compared with a nonobese person, what happens to functional residual capacity (FRC) in the morbidly obese patient while upright (standing or sitting)

answer

Compared with a nonobese person, what happens to functional residual capacity (FRC) in the morbidly obese patient while upright (standing or sitting), supine, or prone? In the upright position, FRC is decreased compared with that of the nonobese person. Tidal ventilation may fall within the closing capac¬ity (CC) (see figure). In the supine position, FRC falls further and tidal breathing continues to occur with some airways closed (within the range of closing capacity). If the patient is positioned so that the abdomen hangs free, FRC is decreased less in the prone than in either the supine or the lateral positions, so events in the morbidly obese, prone patient would be between the obese upright and obese supine positions

question

Compared with a nonobese person, what happens to functional residual capacity (FRC) in the morbidly obese patient while upright (standing or sitting)

answer

Effects of position on lung volumes (Labeled left to right: Nonobese; obese upright; obese supine; obese trendelenburg) In the upright position, FRC is decreased compared with that of the nonobese person. Tidal ventilation may fall within the closing capac¬ity (CC) (see figure).

question

Compared with a nonobese person, what happens to functional residual capacity (FRC) in the morbidly obese patient while supine?

answer

Effects of position on lung volumes (Labeled left to right: Nonobese; obese upright; obese supine; obese trendelenburg) In the supine position, FRC falls further and tidal breathing continues to occur with some airways closed (within the range of closing capacity).

question

What happens to functional residual capacity (FRC) in the morbidly obese patient while prone?

answer

Effects of position on lung volumes (Labeled left to right: Nonobese; obese upright; obese supine; obese trendelenburg) If the patient is positioned so that the abdomen hangs free, FRC is decreased less in the prone than in either the supine or the lateral positions, so events in the morbidly obese, prone patient would be between the obese upright and obese supine positions

question

Pheochromocytoma :

answer

It is a tumor of the adrenal medullary or chromaffin tissue of the paravertebral sympathetic chain that has excessive catecholamine secretion (usually norepinephrine).

question

Where does Pheochromocytoma originate and where is it found?

answer

A tumor of the adrenal medullary or chromaffin tissue of the paravertebral sympathetic chain that has excessive catecholamine secretion (usually norepinephrine). It is found in the abdominal cavity most of the time (95%) and originates in the adrenal medulla about 90% of the time.

question

The diagnostic triad for Pheochromocytoma is:

answer

The diagnostic triad is: O Diaphoresis O Tachycardia O Headaches

question

Symptoms of Pheochromocytoma are:

answer

paroxysmal hypertension, sweating, tremulousness, tachycardia headache, palpitations, orthostatic hypotension. The diagnostic triad is: O Diaphoresis O Tachycardia O Headaches

question

Causes of death in pts with Pheochromocytoma are:

answer

When not diagnosed and treated in a timely manner, the patient may die from: O Congestive heart failure O Myocardial infarction O Intracerebral hemorrhage

question

Treatment (pre-operative) preparation) in pts with Pheochromocytoma are:

answer

• Alpha adrenergic blockade O Phenoxybenzamine: start with 20-30 mg/day and increase to 60-250 mg/day in order to control the blood pressure. O Prazosin • Beta block O Primarily for treatment of tachycardia • Patient will need fluid status assessed and hypovolemia will be corrected (may use Neosynephrine)

question

Treatment (intra-operative) care) in pts with Pheochromocytoma are:

answer

Anesthesia • Do not stimulate the sympathetic nervous system. Use caution and sedate during line placement, induction, laryngoscopy, and skin incision. You must have anesthesia in place before any stimulation occurs. • Continue pre-operative therapy, invasive monitors, opioids and Forane/Ethrane • Control tachycardia with esmolol, labetalol and propranolol.

question

Absolute and relative indications for one Lung Anesthesia-Ventilation

answer

Absolute indications: O Prevent contamination of healthy lung O Control distribution of ventilation Relative indications: O Surgical exposure

question

What kind of tubes should be used for one Lung Anesthesia-Ventilation?

answer

O Carlens tube is a left-sided double lumen tube with a carinal hook O White tube is a right-sided Carlens tube O Robert Shaw is a double lumen tube available in right or left clear plastic that does not have a carinal hook

question

How to Place the Robert Shaw tube in one Lung Anesthesia-Ventilation?

answer

Placing the Robert Shaw tube: • Concave curve of tube is anterior (12:00 noon) • After the tip of the tube passes the cords the tube is turned 90 degrees to the left (9 o'clock) and advanced until resistance is met.

question

How to verifying placement of Robert Shaw tube in one Lung Anesthesia-Ventilation :

answer

Verifying placement of Robert Shaw tube: • Inflate tracheal cuff and confirm bilateral and equal breath sounds • Inflate bronchial cuff (how much air?) and confirm bilateral and equal breath sounds • Confirm one lung ventilation by clamping each lumen

question

The goal of one lung ventilation is

answer

The goal of one lung ventilation is to optimize arterial oxygenation.

question

ASA Class 1

answer

Healthy patient, no organic, physiologic, bio¬chemical, or psychiatric disturbance

question

ASA Class 2

answer

Patient with mild systemic disease (disturbance) that may or may not be related to the reason for surgery

question

ASA Class 2 examples:

answer

Essential hypertension, heart disease that only slightly limits activity, diabetes, anemia, extremes of age, morbid obesity, and chronic bronchitis

question

ASA Class 3

answer

Patient with severe systemic disease (disturbance) that limits activity but is not incapacitating and may or may not be related to surgery

question

ASA Class 3 examples

answer

Heart disease that limits activity, poorly controlled essential hypertension, diabetes with vascular complications, chronic pulmonary disease that limits activity, history of prior myocardial infarction and angina pectoris

question

ASA Class 4

answer

Patient with an incapacitating systemic disease that is a constant threat to life with or without surgery

question

ASA Class 4 examples

answer

Congestive heart failure (CHF), persistent angina pectoris, any advanced kidney, liver or pulmonary disease

question

ASA Class 5

answer

Moribund patient not expected to live 24 hours with or without surgery. Submitted to surgery as resuscitative effort

question

ASA Class 5 examples:

answer

Pulmonary embolus, cerebral trauma or ruptured AAA (uncontrolled)

question

ASA Class 6

answer

A brain-dead patient whose organs are being harvested

question

ASA Class 6 examples

answer

Organ donation

question

Emergency Operation (E)

answer

Any patient requiring emergency (not elective) surgery

question

Emergency Operation (E) examples:

answer

appendicitis, dilation and curettage for bleeding, or any surgery required on a non-elective basis

question

Muscular Dystrophy:

answer

Painless degeneration and atrophy of skeletal muscles (associated with mental retardation)

question

Most common and most severe Muscular Dystrophy:

answer

Duchenne's muscular dystrophy

question

Duchenne's muscular dystrophy

answer

• X-linked recessive (boys) • Early childhood • Early childhood • Kyphoscoliosis and hip and knee contracture are common

question

What ECG changes do you see with Duchenne's muscular dystrophy?

answer

• ECG changes include prolonged PR and QRS interval, ST segment abnormalities, bundle branch block, Q waves, tall R waves

question

How are total lung capacity and residual volume affected with Duchenne's muscular dystrophy?

answer

• Total lung capacity and residual volume are reduced

question

Anesthetic considerations with Duchenne's muscular dystrophy:

answer

• Recurrent pulmonary infections • Increased incidence of malignant hyperthermia, so avoid succinylcholine • Neuromuscular monitoring is mandatory

question

The most significant anesthesia concern with Duchenne's muscular dystrophy:

answer

• Increased incidence of malignant hyperthermia, so avoid succinylcholine

question

Pseudohypertrophic muscular dystrophy:

answer

Pseudohypertrophic muscular dystrophy ■ Congestive heart failure ■ Recurrent pneumonia ■ Kyphoscoliosis ■ Hyperkalemia with succinylcholine ■ May be susceptible to malignant hyperthermia

question

Limb-girdle muscular dystrophy:

answer

(relatively benign disease)

question

Facioscapulohumeral muscular dystrophy :

answer

(heart not involved)

question

Nemaline rod muscular dystrophy:

answer

■ Micrognathia ■ Bulbar palsy

question

Multiple Sclerosis

answer

Characterized by random and multiple sites of demyelination of corticospinal tract neurons in the brain and spinal cord, exclusive of the peripheral neurons.

question

Multiple Sclerosis signs and symptoms:

answer

O Visual disturbances 0 Ataxia O limb paresthesia and weakness O Spastic paresis of skeletal muscles O Exacerbations and remission

question

How to diagnose Multiple Sclerosis:

answer

Diagnosis O Somatosensory evoked responses O Computed tomography O Immersion in hot water O Examination of CSF

question

Treatment (palliative) of Multiple Sclerosis:

answer

Treatment (palliative): O Corticosteroids O Avoid stress O Avoid marked temperature changes O Dantrolene O Carbamazepine

question

Management of anesthesia for Multiple Sclerosis:

answer

O Exacerbation of symptoms may occur, SUBARACHNOID BLOCK IS A QUESTIONABLE SELECTION. O Hyperkalemia in response to succinylcholine O Prevent increased body temperature post-operatively.

question

Myasthenia Gravis:

answer

A chronic autoimmune disease involving the neuromuscular junction. It is characterized by weakness and rapid exhaustion of skeletal muscles with repetitive use; there is some recovery with rest.

question

Signs and Symptoms of Myasthenia Gravis:

answer

O Ptosis and diplopia - most common initial symptoms O Weakness of pharyngeal and laryngeal muscles - aspiration risk O Asymmetric extremity skeletal muscle weakness - atrophy absent O Cardiomyopathy O Hypothyroidism

question

Most common initial symptoms of Myasthenia Gravis:

answer

O Ptosis and diplopia - most common initial symptoms

question

Anesthesia concern with Myasthenia Gravis:

answer

O Weakness of pharyngeal and laryngeal muscles - aspiration risk

question

Treatment of Myasthenia Gravis:

answer

Treatment O Anticholinesterase drugs (Neostigmine Edrophonium) O Corticosteroids O Cyclosporine ***O Plasmapheresis O Thymectomy - most likely elective operation

question

Anesthesia for Myasthenia Gravis:

answer

O Preoperative preparation ■ Avoid opioids ■ Inform patient of possible mechanism ventilation postoperative O Muscle relaxants NDMB - very sensitive; DMB unpredictable. ■ Expect altered response O Induction ■ Short acting IV drug ■ Tracheal intubation without muscle relaxants O Maintenance ■ Volatile drugs ■ Short or intermediate-acting muscle relaxants O Postoperative ■ Skeletal muscle strength may decrease abruptly

question

Avoid muscle relaxants in Myasthenia Gravis. T or F

answer

True Tracheal intubation without muscle relaxants if possible Short or intermediate-acting muscle relaxants

question

Parkinson's Disease

answer

Parkinson's Disease • Degenerative disease of the CNS characterized by loss of dopaminergic fibers in the basal ganglia of the brain. Dopamine is an inhibitory neurotransmitter acting on the extrapyramidal motor system.

question

Parkinson's Disease Signs and symptoms:

answer

O Signs and symptoms ■ Skeletal muscle rigidity ■ Resting tremor ■ Diaphragmatic spasms ■ Mental depression

question

Parkinson's Disease Treatment:

answer

Treatment (increase concentration of dopamine) ■ Levodopa - combines with decarboxylase inhibitor; side effects reflect dopamine effects on the CNS, heart and GI tract ■ Anticholinergic drugs ■ Antihistamine drugs - Benadryl.

question

Management of anesthesia with Parkinson's Disease:

answer

Management of anesthesia O Continue levodopa therapy O Labile blood pressure and cardiac dysrhythmias possible ***O Avoid drugs with antidopaminergic effects (droperidol, possibly opioids, and Reglan)

question

What drugs should you avoid with Parkinson's Disease? Why?

answer

Avoid drugs with antidopaminergic effects (droperidol, possibly opioids, and Reglan) Degenerative disease of the CNS characterized by Joss of dopaminergic fibers in the basal ganglia of the brain.

question

RHEUMATOID ARTHRITIS:

answer

Chronic inflammatory disease characterized by symmetric polyarthropathy and significant systemic involvement. • Has cervical vertebral involvement but no sacroiliac involvement. • Most common in females 30-50 years old. What following cardiac changes:

question

What cardiac changes do you see in RHEUMATOID ARTHRITIS?

answer

O May see the following cardiac changes: ■ Pericardial effusion ■ Aortic regurgitation ■ Cardiac conduction abnormalities ■ Cardiac valve fibrosis ■ Coronary artery arteritis

question

Airway evaluation in RHEUMATOID ARTHRITIS?

answer

Airway evaluation (restrictive disease) O Head movement and position O Hoarseness or stridor - cricoarytenoid joint involvement (May present already with hoarseness) O May need fiberoptic intubation O Pulmonary function studies and ABGs O Postoperative ventilation

question

Keratoconjunctivitis sicca: What condition do you see this in?

answer

(a condition marked by hyperemia of the conjunctiva, lacrimal deficiency, thickening of the corneal epithelium, itching and bruising of the eye, and often reduced visual acuity)

question

RHEUMATOID ARTHRITIS pulmonary concern?

answer

Pulmonary fibrosis, pleural effusion

question

RHEUMATOID ARTHRITIS symptoms :

answer

Consider multiple organ involvement Cardiac changes Anemia Rheumatoid factor is positive Keratoconjunctivitis sicca Pulmonary fibrosis, pleural effusion Cricoarytenoid involvement

question

Treatment for RHEUMATOID ARTHRITIS:

answer

■ Aspirin ■ Gold ■ Surgery ■ Corticosteroids (stress dose)

question

Osteoarthritis: .

answer

• Degenerative process that affects the articular cartilage and differs from rheumatoid arthritis due to lack of (or minimal) inflammatory reaction. • Degenerative changes are primarily in the middle to lower cervical spine and in the lower lumbar area.

question

Osteoarthritis:

answer

Treatment O Aspirin O Reconstructive joint surgery O No corticosteroids (because not inflamatory chronically)

question

SCOLIOSIS:

answer

• Lateral curvature of spine • Idiopathic scoliosis is most common type • Restrictive pattern of breathing with thoracic scoliosis • Chest wall deformity

question

SCOLIOSIS lung changes:

answer

Vital capacity (60-80% of predicted), total lung capacity decrease inspiratory volume decrease functional residual capacity decrease inspiratory capacity decrease expiratory reserve volume decrease. Residual volume may be normal. FEV₁/FVC is normal. ***(Because it is restrictive) Chest wall deformity

question

What would you see with ABGs and SCOLIOSIS:

answer

O Thoracic scoliosis associated with arterial desaturation, but PaC02 and pH are normal. O Arterial hypoxemia O Alveolar ventilation is normal

question

SCOLIOSIS and cardiovascular system:

answer

May develop elevated pulmonary vascular resistance and pulmonary hypertension leading to right heart failure. Mitral valve prolapse is most common abnormality.

question

Anesthetic technique with SCOLIOSIS:

answer

Preoperative medication: O Avoid heavy premedication O Antisialagogue Avoid succinylcholine (muscle disease) Author favors nitrous oxide - narcotic infusion - relaxant technique O Prepare for blood loss (15-25 ml/kg): Patients with neuromuscular scoliosis may lose 75 ml/kg. O Deliberate hypotension—do not want to compromise spinal cord blood flow (MAP 60-65 mm Hg)

question

Parameters for extubation for pt with SCOLIOSIS:

answer

Need to be breathing well Vital capacity > 10 ml/kg ***Tidal volume >3ml/kg Spontaneous respiration rate -30 cm H20.

question

Complications seen with SCOLIOSIS: .

answer

Complications: O Pneumothorax O Atelectasis O Pleural effusion O Hemothorax O Neurologic injury

question

What is most common abnormality with scoliosis? .

answer

Mitral valve prolapse is most common abnormality.

question

What type blood loss can you see with SCOLIOSIS?

answer

Prepare for blood loss (15-25 ml/kg): in patients with neuromuscular scoliosis may lose 75 ml/kg.

question

What type vital capacity will you see with scoliosis?

answer

Vital capacity (60-80% of predicted), Total lung capacity decreased.

question

What type of breathing pattern is seen with with thoracic scoliosis?

answer

Restrictive pattern of breathing with thoracic scoliosis

question

_________ scoliosis is most common type. .

answer

Idiopathic scoliosis is most common type.

question

Number 1 and 2 complications seen with mediastinoscopy. .

answer

1. Hemorrhage 2. Pneumothorax

question

Inominate gives rise to .

answer

Inominate gives rise to RCA and RVC .

question

ASA 3 or ASA 4 :

answer

Look for the word incapacitating.

question

Muscular Dystrophy

answer

Psdohypertrophy especially of calves due to fatty infiltration of muscles

question

Multiple Sclerosis and central blocks

answer

No central blocks; No spinals; epidurals are controversial.

question

Duchenne's muscular dystrophy and Succ: .

answer

Hyper K with Succ.

question

Eaton Lambert

answer

Myasthemic syndrome associated with carcinoma.

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