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135 Cards in this Set
- Front
- Back
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Of the various types of white blood cells (leukocytes), which is most abundant?
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Neutrophils (also referred to as polymorphonuclear leukocytes) are the most abundant WBC.
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Neutrophils comprise what percent of the total WBC (leukocyte) population. What simulates neutrophil count to increase?
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Neutrophils are 55% of the leukocyte population.
Any inflammatory stimulus, including bacterial infection, increases the neutrophil count. |
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What is the normal platelet count?
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150,000 to 400,000 platelets per ml
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Where is erythropoietin made?
What stimulates the release of erythropoietin and what does it do? |
Kidneys make 90% of the erythropoietin and the liver 10%.
Erythropoietin is released in response to hypoxia. Erythropoietin stimulates bone marrow to produce and release red blood cells. |
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What are the steps in primary hemostasis?
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Adhesion
Activation Aggregation of platelets Fibrin production |
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Platelets have an average lifespan of how many days?
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8-12
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What is the normal platelet count?
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150,000-400,000
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When vascular endothelium is damaged and the subendothelium of the blood vessel is exposed what anchors the platelet to the collagen layer of the subendothelium?
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vWF
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What does vWF promote?
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platelet adhesion
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Where is vWf made and released from?
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Endothelial cells
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What is the most common inherited coagulation defect?
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von willebrands disease
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What is DDAVP?
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a non pressor analog of arginine vasopressin
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What is the dose of DDAVP?
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0.3 mcg/kg IV infusion over 15-20 minutes
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What is a side effect in children using DDAVP?
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hyponatremia
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What is the traditional treatment of vW disease?
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cryoprecipitate, or DDAVP
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What does cryoprecipitate consist of?
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VIII and I
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Patients who do not respond to DDAVP should receive what?
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Cryo or Factor VIII
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Thrombin activates the plt by combining with the thrombin receptoron the platelet to release what?
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TXA2 and ADP
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What does TXA2 do?
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Vasoconstricts
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What does ADP do?
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attracts more platelets
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What does TXA2 and ADP uncover?
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Fibrinogen receptors and fibrinogen attaches to its receptors and links platelets together.
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What does TXA2 do?
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Increases ADP release,
opens fibrinogen receptors, vasoconstricts |
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How does ASA render plts dysfunctional?
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The acetyl group of ASA causes acetylation of cyclooxygenase
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How long does ASA render plts dysfunctional
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8-12 days
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What is the rate limiting step in the conversion of AA to TXA2?
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cyclooxygenase
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How long do NSAIDS render plts dysfunctional?
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24-48 hours
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How does ticlid work?
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Inhibits ADP-induced fibrinogen aggregation of plt drugs
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How does persantine work?
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It increases cAMP in plts and thus prevents aggregation of plts.
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Cyclooxygenase converts AA to what initially?
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prostaglandin G2
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What is PGG2 metabolized to?
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PGH2
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What is the most common acquired blood clotting defect?
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Inhibition of cyclooxygenase by ASA and NSAIDS
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What is the name of factor 1, where is it made,
is it Vit K dependent? |
Fibrinogen
Liver No |
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What is Factor II called
where is it made is it Vit K dependent? |
Prothrombin
Liver Yes |
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What is Factor III called
where is it made is it Vit K dependent? |
tissue factor or thromboplastin
Vascular wall and cells release by traumatized cells Not Vitamin K dependent |
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What is Factor IV called
where is it made is it Vit K dependent? |
Calcium
Diet No |
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What is Factor V
where is it made is it Vit K dependent? |
Proaccelerin
Liver and other tissues Not Vit K dependent |
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what is Factor VII called
where is it made is it Vit K dependent? |
Proconvertin
Liver Yes |
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What is Factor VIII called
Where is it made is it Vit K dependent? |
Antihemophilic factor
Liver Not Vit K dependent |
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What is Factor VIII;vWF called
Where is it made Is it Vit K dependent? |
Von Wilebrand factor
Vascular endothelial cells Not Vit K dependent |
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What is Factor IX called
where is it made Is it Vit K dependent? |
Christmas Factor
Liver and other tissues Yes- it is Vit K dependent |
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What is Factor X called
where is it made Is it Vit K dependent? |
Stuart-power factor
Liver Yes it IS Vit K dependent |
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What is Factor XI called
where is it made is it Vit K dependent? |
Plasma thromboplastin antecedent
Liver No |
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What is Factor XII called
where is it made is it Vit K dependent? |
Hageman Factor
Liver No |
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What is Factor XIII called
where is it made is it vit K dependent? |
Fibrin stabilizing factor
Liver and other tissues No |
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where is prekallikrein factor made
is it Vitamin K dependent? |
Liver
No |
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Where is high molecular weight kininogen factor made
is it Vit K dependent? |
Liver
No |
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What are the Vitamin K dependent factors
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2,7,9,10
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What factor causes the cross-linking of fibrin strands?
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Coagulation factor XIII
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After platelets aggregate what happens?
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Fibrin is weaved into plts and cross linked
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Heparin affects what pathway?
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Intrinsic
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What pathway does coumadin affect
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Extrinsic
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What factors comprise the intrinsic pathway?
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12,11,9,8
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What factors comprise the extrinsic pathway?
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3 and 7
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What factors comprise the common pathway?
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10,5,
2,1 13 |
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Hemophilia A (Factor VIII: C deficiency) is a genetic disorder, describe it.
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A: it is a sex linked genetic disorder that is carried by the female member of a kindred and effects males
almost exclusively |
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Q: how do you treat hemophilia A
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A: FFP and cryo, VIII in low concentrations
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How is hemophilia B (christmas disease) treated
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heat treated, concentrated preparations of factor IX are available
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what is the best (although not great) measure of plt function
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a standardized skin bleeding time
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what is the most common reason for coagulopathy in pts receiving massive blood transfusions is the
lack of what |
functioning plts
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Plts in stored blood are nonfunctional after how many days
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1 to 2 days:õ<Ô
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what is the only clinical indication for transfusion of PRBC
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A: to increase the oxygen carrying capacity of the blood
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all procoagulants except what are in FFP
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plts
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Cryoprecipitate contains what factors?
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Factor VIII
Factor I Factor XIII |
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What does activated antithrombin III bind to?
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Thrombin (IIa) and Factor Xa greatly and factors IX, XI, and XII to a lesser degree
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What disease processes are associated with antithrombin III deficiency?
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Nephrotic syndrome and cirrhosis of liver
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What is adequate heparinization indicated by
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ACT greater than 400
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What should you do if the ACT is not greater than 400 (if indicated of course)?
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give FFP
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How does protamine work?
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Combines electrostatically with heparin (positive substance combines with negative substance) to form an inactive salt
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How does coumadin work?
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Binds to Vit K receptors in the liver and competitively inhibits Vit K
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What is normal bleeding time?
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3-10 minutes
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What is a normal PT?
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12-14 seconds
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What is a normal PTT?
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25-35 seconds
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What is a normal thrombin time?
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12-20 seconds
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What is a normal ACT?
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80-150 seconds
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How does plasminogen work?
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It works itself into a clot and tPA and urokinase type drugs convert it to plasmin and thus breaks down fibrin into FSP.
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Where is tPa made?
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In endothelial cells
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What stimulates tPa release?
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venous stasis and thrombin
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Where is uPa found?
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Limited stores in blood and has little affinity for fibrin, thus activates any circulating plasminogen
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What produces streptokinase?
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Beta-hemolytic streptococci and also has little affinity for fibrin
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How does aprotinin work?
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It inhibits plasmin thus fibrin breakdown is slowed
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How does amicar work?
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By inhibiting binding of plasmin to fibrin
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Why should you never give aprotinin twice?
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anaphylaxis potential
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What are some conditions that contribute to DIC?
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sepsis
hemolysis transfusion reaction ischemia trauma hypotension/hypoperfusion OB emergency aneurysms hamangiomas allograft rejections glomerulonephritis |
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How does DIC present?
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bleeding
oozing from tubes, wounds, and IV sites |
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What are some lab abnormalities with DIC?
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decreased plts
decreased fibrinogen decreased prothrombin decreased level of V, VIII, and XIII increased FSP |
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what is the most common cause of isolated high PT?
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liver disease
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What is transfused blood deficient in?
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platelets
factor V Factor VIII |
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What is diffuse bleeding usually caused by?
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thrombocytopenia
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What are the concerns of a noncardiac surgery pt with CHF?
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IHD and CHF are historically the strongest predictors of an increased risk for periop MI and increased risk of postop death
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Your patients creatinine clearance of 18 ml/min is indicative of CRF. Which of the following drugs should you be concerned with in your patient?
Digoxin Quinidine Vecuronium Atracurium |
Digoxin which most depends on renal excretion
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Does concentric hypertrophy decrease wall tension?
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Yes
as thickness increases tension decreases (T=Pr/2h) |
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What 3 hormones are involved in rebound HTN assoc with d/c of clonidine?
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Increased catecholamines
increased renin increased angiotensin II |
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In addition to the NMDA receptor, ketamine works on what other receptors?
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nicotinic
muscarinic opioid |
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What causes serum alkaline phos to increase?
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Biliary tract obstruction causes a 3 fold increase
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What valve problem may be associated with both a systolic and a diastolic murmur if the patient has a HR 100 and BP of 135/45?
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AR, the very low DBP and wide PP suggest AR as primary problem. With severe and prolonged AR the
dilation of the ventricle (eccentric hypertrophy) may be associated with a secondary MR. Hence there is a diastolic murmur (AR) and a systolic murmur (MR) |
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How does hydralazine affect ABP, arterial and venous smooth muscle tone, heart rate, stroke volume
and CO? |
Decreased BP
relaxation of Vascular smooth muscle (preferentially arterial over venous), Increased HR Increased SV Increased CO |
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On what tissue of the heart does verapamil work: atrial muscle, ventricular muscle, nodal tissue,
purkinje network? |
For therapeutic effects verapamil works on nodal tissue where it slow phase 4 depolarization
It works secondarily on Phase 2 of the ventricular muscle action potential, but this is not the best answer |
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Would administration of adenosine via an endotracheal tube be effective?
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NO, it is rapidly metabolized in the plasma by adenosine deaminase.
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As the needle is being inserted for SAB, you feel a pop. What has occurred?
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The dura has been penetrated. Penetration of the dura produces a subtle "pop" that is not most
easily detected with pencil-point needles.r |
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Compared with cardiac muscle cells and junctional tissue (SA and AV nodes), how fast do purkinje fibers conduct impulses?
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Purkinje fiber are very large fibers that transmit impulses at a velocity of 6 times that of cardiac
muscle cells and 300 times that of fibers of the SA and AV nodes |
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What is the most potent local vasodilator substance released by cardiac cells?
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adenosine
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What constituent of extracellular fluid determines ECF volume? Why?
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Sodium, when sodium is retained water is retained to keep ECF osmolality at about 300 mOsm/liter
and volume increases |
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What is an anaphylactoid reaction?
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resembles anaphylaxis but does not involve IgE Direct action on mast cell
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How does severe acidosis alter pulmonary vascular resistance and systemic vascular resistance?
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Acidosis increases PVR and decreased SVR
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It is well known that rebound HTN occurs when clonidine is abruptly discontinued in patients taking
long term clonidine therapy. What is the mechanism of this rebound HTN. |
Increased plasma catacholamines (Stoelting)
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What valve problem (AS, AR, MS, MR) may be associate with both a systolic and diastolic murmur?
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AS, there is a midsystolic ejection murmur that peaks in late systole with often a faint murmur of
minimal aortic regurg |
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How much Morphine is protein bound in the adult? In the neonate?
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26-36% in the adult, in the neonate it is less because MSO4 is a weak base and generally binds to
alpha1 acid glycoprotein and neonates have less of that |
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How does ketamine produce dissociative anesthesia?
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depresses neuronal function in parts of the cortex and thalamus while simultaneously stimulating
parts of the limbic system Chemical Thalmectomy |
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The CNS actions of ketamine appear to be primarily r/t its actions at what receptor?
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NMDA
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Barbiturates, BDZs, propofol, and etomidate produce their CNS actions by working on what receptor?
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GABA
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The dysphoria associated with ketamine is caused by what?
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secondary to ketamine induced depression of auditory and visual relay nuclei (inferior colliculus and
medial geniculate nucleus) leading to misperception and/or misinterpretation of auditory and visual stimuli |
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Identify the receptors that ketamine interacts with to promote dysphoria.
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Kappa agonism, muscarinic antagonism, sigma agonism
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By what mechanism does cocaine alter sympathetic function?
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blocks reuptake of NE
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Describe the interactions of TCAs with five groups of drugs?
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1) anticholinergics increase likelihood of postop delerium 2) Sympathomimetics could exaggerate pressor responses
3) PIAs increase incidence of arrythmias 4) antihypertensives could have rebound HTN 5)Opioid effects may be augmented |
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Normal MMEF (FEF 25-75) is?
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4.7 L/sec, or 280 L/min. This makes physiologic sense if you consider normal FEV1 and FVC values; a
healthy individual will have a normal FEV1 of around 4.0 L, so flow rates between 2.5-5.0 L/sec are entirely reasonable |
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The diagnosis of DM is based on what laboratory values?
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polyuria (2-15 liters per day) Hypernatremia High serum osmolality decreased urine SG (1.005 or
less) |
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A pt with head trauma has a urine output of 4ml/min and the following lab values: Na 150, osmolality
300, urine osm 100. What is causing this? |
Diabetes insipidus
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The Dx of the syndrome of inappropriate ADH secretion (SIADH) is based upon what labs?
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Na concentration 100-150 mosm/kg decreased urine/plasma osmolality less than 270 Hyponatremia
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N2O should be avoided in what pediatric procedures?
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diaphragmatic hernia, bowel obstruction, pneumoencephalogram, tympanoplasty, congenital
emphysema, lung cysts, pneumothorax, NEC, PDA and OMPHALOCELE |
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What is the Hg concentration at 2 weeks of age? 2-3 months? 2 years?
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13-19 < 10-11 <12.5dd/60
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What agent decreases a right to left shunt?
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Phenylephrine, by increasing SVR
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Describe the newborn with meningomyelocele?
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Hydrocephalus occurs in 80% of patients with stenosis of the aqueduct of sylvius and Arnold-Chiari
malformation. There is also a great risk of infection to the sac. The infant may also have motor and sensory deficits, club foot, loss of anal and urethral sphincter tone, dislocated hips, and congenital cardiac defects. |
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What are the concerns for anesthetizing the newborn with meningomyelocele?
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The pt may not be able to lay supine for intubation due to possible sac disruption. The awake lateral
decubitus position may be necessary |
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A seven yr old patient with spina bifida comes to the OR for a ventricular-peritoneal shunt. What is
the primary concern? |
High probability of latex allergy (18-34% of this population at risk for latex allergy)
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What nerves are blocked for repair of an inguinal hernia?
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ilioinguinal and iliohypogastric
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What actions are taken if the tonsillectomy pt begins to bleed? What are the major considerations if
the patient needs to be taken back to the OR? |
Pharyngeal packs and cautery 1) intravascular volume needs to be restored and 2) full stomach precautions
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Give two reasons why a change in OB epidural anethesia dosing is necessary?
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1) neurons are more sensitive to LA 2) IVC compression increases blood flow through epidural
plexuses and decreases potential volume of epidural space. |
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When giving an epidural to a parturient, how much should you decrease the dose?
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25-50% or 33% in some texts
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Severe HTN may occur if the pregnant pt is given a pure alpha agonist and the pt is also receiving
what other med? |
Methergine
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The pregnant pt requires an appendectomy emergently. How do you premedicate?
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Gastric prep with 30 cc Citra and possibly robinul for antisialagogue *Appendectomy is most
common emergent surgery with pregnancy |
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The pregnant pt has been given a subarachnoid block with opioids only and no LA, What conditions
may have necessitated this technique? |
In pts who could not tolerate a sympathectomy. I.E. significant CV disease (hypovolemia, AS, Tet of
Fallot, Eisenmengers) or pulmonary HTN |
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An epidural or intrathecal opioid instead of an epidural or intrathecal LA should be given to the
parturient with what valve problem? |
AS, In pts who could not tolerate a sympathectomy. I.E. significant CV disease (hypovolemia, AS, Tet
of Fallot, Eisenmengers) or pulmonary HTN |
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A pregnant pt presents with thrombocytopenia, what are the likely reasons for the
thrombocytopenia? |
Of ALL pregnant pts who present with PLTs less than 150,000 74% have incidental or gestational
21% have HELLP 4 % have Idiopathic thrombocytopenia |
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How common is incidental or gestational thrombocytopenia?
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occurs in 7.6% of all pregnancy and does not appear to have deleterious effects
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Curent evidence now suggests that inhaled anesthetics work on what receptor?
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GABA
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