Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
181 Cards in this Set
- Front
- Back
|
Problems with ACE inhibitors |
Hypotension on induction |
|
|
ACE inhibitors should be witheld |
Morning of surgery |
|
|
Witholding ACE inhibitors can cause (2) |
rebound hypertension increased risk of a fib |
|
|
Adverse effects of beta blockers |
hypotension bradycardia |
|
|
Beta blockers should be ______ the day of surgery |
continued |
|
|
Risks of discontinuing betablockers |
increased cardiovascular morbidity |
|
|
Calcium channel blockers can cause |
Decreased SVR Hypotension Negative inotropy -slowed sinus rate -slowed AV conduction |
|
|
Calcium channel blockers should be used with caution if ______ |
EF < 40 % |
|
|
Adverse effects of diuretics |
Hypokalemia Hypovolemia |
|
|
What should be done for patient on diuretics |
Monitor potassium levels Urinary catheter for longer cases |
|
|
Adverse effects of antiarrythmics |
Cardiac depression Prolonged neuromuscular blockade |
|
|
Is discontinuation of antiarrythmic medication recommended? |
No Usually not prescribed for benign arrythmias |
|
|
Amiodarone can cause |
Hypotension Atropine-resistant bradycardia |
|
|
Intra-operative considerations for patients on amiodarone |
Monitor serum drug levels May require large doses of vasopressors Pacemaker capibility |
|
|
NSAIDs should be discontinued |
1-3 days before surgery |
|
|
Clopidogrel should be discontinued ____ |
5-7 days before surgery |
|
|
Ticlopidine should be discontinued |
7-10 days before surgery |
|
|
Should ASA be discontinued before surgery? |
Not usually |
|
|
When do patients on antiplatelet drugs requrie a cardiology consult? |
If stent is < 1 year old |
|
|
When should IV heparin be discontinued? |
6 hours before surgery Check ore-op PTT |
|
|
When should lovenox be stopped |
12 hours before surgery |
|
|
When should coumadin be stopped |
3-5 days before surgery |
|
|
Adverse effects of MAOI drugs (i.e. phenelzine/Nardil, selegiline) |
Hypertension secondary to inderect acting sympathomimetics |
|
|
What cautions should be taken with patients on MAOIs |
Avoid triggering agents such as demerol and ephedrine |
|
|
How long should MAOIs be held prior to surgery? |
Older drugs 1-2 weeks Newer drugs day of surgery |
|
|
Adverse tricyclic antidepressants |
Alpha adrenergic blocking Potentiation of ephedrine |
|
|
_______ is the vasopressor of choice in patients on tricyclics |
norepinephrine |
|
|
Adverse effects of lithium include: |
T wave smoothing Ventricular dysrhtyhmias Myocarditis Extreme atropine-resistant bradycardia |
|
|
Dehydration can cause _____ lithium levels |
toxic |
|
|
What antiparkinson drugs should be held before surgery? |
Selegliline (MAOI) - hold 2 weeks prior Carbidopa/levodopa - hold morning of surgery |
|
|
Carbon monoxide binds to hbg with ____ times the affinity of O2 |
250-300x |
|
|
What is the half life of carbon monoxide in room air? |
130-190 minutes |
|
|
What is the half life of nicotine? |
40-60 minutes |
|
|
Adverse effects of nicotine? |
Increased HR, BP, MVO2 Impaired coronary blood flow Adverse O2 supply/demand ratio |
|
|
Smokers have ____ times the rate of postoperative pulmonary complications |
6x |
|
|
____ or more of smoking cessation reduces postoperative pulmonary complications |
8 or more weeks |
|
|
Adverse effects of ecinachea |
INCREASED -allergic sensitivity DECREASED -efficacy of immunosupressive drugs INHIBIT -hepatic microsomal enzymes -can cause phenytoin, phenobarb, rifampin toxicity |
|
|
Adverse effects of Ephedra |
Increased HR and BP Increased risk of MI/Stroke Interaction with MAOIs |
|
|
Ephedra should be discontinued |
24 hours before surgery |
|
|
Adverse effects of garlic |
decreased platelet function |
|
|
Garlic should be discontinued____ |
7 days before surgery |
|
|
Adverse effects of gingko |
decreased platelet function |
|
|
Gingko should be witheld |
36 hours before surgery |
|
|
Adverse effects of ginseng |
Inhibit platelet agregation |
|
|
Ginseng should be held |
7 days before surgery |
|
|
Adverse effects of Kava |
Sedation/anxiolysis Increased effect of sedatives |
|
|
Adverse effects of St Johns wort |
CYP450 induction Increased metabolism of: -cyclosporine, steroids, warfarin, benzos, ccbs, digoxin |
|
|
St Johns wort should be held |
5 days before surgery |
|
|
Mallampati I |
Pillars Uvula Soft Palate Hard Palate |
|
|
Mallampati II |
Uvula Soft Palate Hard Palate |
|
|
Mallampati III |
Soft palate Hard palate (only base of uvula) |
|
|
Mallampati IV |
Hard palate only |
|
|
Formula for Ideal body weight |
male 105 lbs + 6 lb/inch > 5 ft female 100 lbs + 5 lbs/inch > 5 ft |
|
|
1 inch = ___ cm |
2.54 |
|
|
1 m = ____ ft |
3.28 ft |
|
|
1 lb = ____ kg |
2.2 kg |
|
|
Formula for BMI |
(weight in kg)/(height meters)sq |
|
|
In adults, a thyromental distance less than _____ is associated with a difficult intubation |
7 cm (3 fingerbreathts) |
|
|
BMI for overweight |
25-29 |
|
|
BMI for moderate obesity |
30-34 |
|
|
BMI for severe obesity |
35-39 |
|
|
BMI for morbid obesity |
40+ |
|
|
_____ percent pf bariatric patients have OSA |
70 |
|
|
_____ is the gold standard for diagnosis of OSA |
polysomnography |
|
|
Stress dose of steroids for minor surgery |
25 mg hydrocortosone + pre-op dose |
|
|
Stress dose of steroids for moderate surgery |
50-75 mg hydrocortosone + pre op dose |
|
|
Stress dose of steroids for major surgery |
100-150 mg hydrocortosone = pre op dose |
|
|
At what concentrations does hydrocortosone have mineralcorticoid activity? |
> 100 mg |
|
|
What should be used in place of high dose hydrocortosone? |
Methylpredisolone 4 mg = 20 mg IV hydrocortosone |
|
|
Conditions that require a cardiology consult (6) |
unstable angina recent MI (30 days) high grade AV block symptomatic ventricular dysrhythmia supraventricular dysrhythmia (HR > 100) severe aortic stenosis -valve < 1 cm2 -gradient > 40 mmHg |
|
|
poor functional capacity = ___ MET |
1 MET |
|
|
good functional capacity = ___ MET |
4 MET |
|
|
excellent functional capacity = ____ MET |
> 10 MET |
|
|
Overall intraoperative MI risk = |
0.3% |
|
|
Intra-op MI risk if previous MI > 6 months |
6% |
|
|
Intra op MI risk if MI within 3-6 months |
15% |
|
|
Intraop MI risk if MI within 3 months |
30% |
|
|
Mortality rate from re-infarction = |
50% |
|
|
How long should someone wait after MI before elective surgery? |
4-6 weeks |
|
|
Stage 1 hypertension |
SBP > 140, DBP >90 |
|
|
Stage III hypertension |
SBP > 180, DBP > 110 |
|
|
How long should surgery be delayed with a bare metal stent |
6 weeks |
|
|
How long should surgery be delayed with drug elluting stent? |
12 months |
|
|
When should Dual Antiplatelet Therapy be continued |
only if surgery carries low bleeding risk |
|
|
When should plavix be witheld? |
Intermediate/high bleeding risk |
|
|
Stress ECG indicative of coronary disease |
0.2 mV ST depression early st depression hypotension |
|
|
Echocardiography indicatators of poor ventricular fuction |
EF < 40% CI < 2.2 L/min LVEDP < 18 mmHg |
|
|
Areas of akinesis on echo represent |
nonviable tissue |
|
|
Areas of hypokinesis on echo represent |
Ischemic but viable tissue |
|
|
When is cardiac catheterization before surgery indicated? |
Class III-IV heart failure undergoing high risk procedure |
|
|
Significant stenosis of coronary arteries is defined as: |
any vessel with 70% or more stenosis 50% or more left main stenosis |
|
|
Cardiac risk factors when considering pre-op pharmacotherapy |
Angina Prior MI Heart failure Stroke/tia Renal disease DM requiring insulin Moderate-poor functional capacity |
|
|
> 2 cardiac risk factors require what type of pharmacotherapy |
statin + beta blocker |
|
|
Preop statins should be started |
30 days pre-op (at least 1 wk) |
|
|
Pre op beta blocker should be started |
30 days pre-op (at least 1 week) |
|
|
Beta blockers should be titrated to resting heart rate ______ and BP ____ |
Resting heart rate of 60 and SBP > 100 |
|
|
Patients with COPD are ____ as likely to have pulmonary complications |
twice as likely |
|
|
What is the greatest risk factor for postoperative pulmonary complications |
surgical site (abdominal/thoracic) |
|
|
What are indications for canceling surgery in patient with COPD |
severe dyspnea , wheezing, or pulmonary congestion hypercarbia with PaCO2 > 50 mmHg |
|
|
Systolic left ventricular dysfunction is defined as________ |
EF < 50% |
|
|
Severe aortic stenosis (area < 1 cm2) is associated with a ______ greater incidence of perioperative sudden death |
14 fold |
|
|
Low PaO2 (<60 mmHg) is indicative of: |
chronic bronchitis |
|
|
Chest radiograph findings consistent with emphysema include: |
Diphragmatic flattening Bullae Vertical cardiac sillhouette |
|
|
Chronic bronchitis is ____recognized on chest radiograph |
rarely |
|
|
FEV1/FVC ratio indicative of an obstructive process |
< 80% |
|
|
All patients scheduled to undergo lung resection should have which type of pulmonary exam |
spirometry to estimate postoperative FEV1 ad suitability for resection |
|
|
Precipitating factors for asthma exacerbation include: |
Allergens Exercise URI Emotional stress |
|
|
Triggers for canceling elective surgery in asthmatics |
persistent cough, dyspnea, wheezing, tachypnea |
|
|
Normal peak expiratory flow |
80-100 percent of baseline |
|
|
Peak expiratory flow indicative of moderate asthma exacerbation |
50-80% of baseline |
|
|
Peak expiratory flow indicative of severe asthma exacerbation |
less than 50% of baseline |
|
|
If spirometry is below baseline in asthmatics, what dose of prednisone should be started |
0.5 mg/kg x 5 days |
|
|
Preoperative inhaled corticosteroid dose |
320 mcg/day x 1 week |
|
|
Preoperative IV steroid dose for asthmatic on steroids |
100 mg IV Q8H until stable |
|
|
Theraputic theophylline levels in an asthmatic |
10-20 mcg/mL |
|
|
Five preoperative questions to ask asthmatic |
Frequency of exacerbation Time since last exacerbation Recent hospitilization/ED visit Increased use of B agonist Current/past steroid use |
|
|
Children with URI have increased risk of respiratory related risk. Examples includ: |
bronchospasm laryngospasm hypoxemia atelectasis croup stridor |
|
|
Productive cough/lower respiratory tract infection is an indication to postpone surgery for _____ weeks |
6 weeks |
|
|
Infective nasopharyngitis is an indication to postpone surgery for ____ weeks |
2 weeks |
|
|
Clotting factors synthesized by the liver include |
I (finrinogen), II (Prothrombin), V, VII, IX, X |
|
|
Anesthetic implications of liver failure |
Decreased albumin -increased free fraction of drug Need for Vit K, FFP, fibrinogen |
|
|
Clinical evidence of renal insuficiency is not evident until _________ |
70% of nephrons are nonfunctional |
|
|
Most accurate measure of renal reserve is : |
creatinine clearance (GFR) |
|
|
Formula for GFR |
U x V / P U = urinary creatinine V = volume of urine (mL/min) P = plasma creatinine |
|
|
What GFR is indicative of mild renal dysfunction |
50-80 mL/min |
|
|
What GFR is indicative of renal failure |
<10 mL/min |
|
|
What are indications for canceling surgery in a patient with renal failure |
K > 5.5 + CHF |
|
|
Normal A1C values |
<5.7 |
|
|
Borderline A1C values |
5.7-6.4 |
|
|
Diabetic A1C values |
>6.5 |
|
|
Recommendations for preoperative insulin |
Continue basal insulin noc. before (2/3 dose) Withold short acting inulin (unless BG >200) Continue basal insuin on pump (W/D5) |
|
|
Recommendations for preop. PO antihyperglycemic meds |
Hold long acting (glyburide, glimepiride, glipizide) 48 hours
Withold metformin if IV contrast or renal compromise |
|
|
Preoperative preparation to render euthyroid. |
6-8 weeks methimazole, propylthiouracil 7-14 days iodine Beta agonist |
|
|
IV rate for esmolol |
100-300 mcg/kg/min |
|
|
Goal heart rate for hyperthyroid on beta blockers |
< 90 BPM |
|
|
Signs of cushing syndrome |
buffal hump moon face osteoporosis easy bruising hirsuitism |
|
|
Signs of hyperaldoseteronism |
Hypokalemia Water/sodium retention Metabolic alkalosis |
|
|
Patients who require a stress dose of steroids |
20 mg prednisone 5+ days Steroids for 1+ month |
|
|
Steroid induced adrenal insuficiency can persist for________ |
6-12 months |
|
|
Preoperative pregnancy testing is required in: |
all women of childbearing age unless surgical sterilization |
|
|
Who requires a preoperative ECG |
Age > 65 Cardiac history |
|
|
Who requires a CBC |
hematologic disorders vascular procedure patients on chemo sickle cell disease |
|
|
Who requires Hbg/hct |
Age < 6 months Procedure with moderate to high blood loss |
|
|
Who requries blood glucose level |
Diabetic Patient on steroids Adrenal disease |
|
|
Who requires serum chemistry |
Renal disease Adrenal/thyroid disease Fluid shifts (dehydration/bowel prep) |
|
|
Who requires a postssium level |
Diruetics Digoxin ACE inhibitors ARB |
|
|
Who requires a creat/BUN |
Cardiovascular disease renal disease HTN diabetics diuretics digoxin IV contrast |
|
|
Who requires coags? |
Leukemia Bleeding disorder liver disease anticoagulants |
|
|
PO meds can be taken up to ___ hour preop |
1 horu |
|
|
clear liquids can be taken up to ____ |
2 hours preop |
|
|
Breastmilk can be taken up to ____ hours preop |
4 hours |
|
|
formula can be taken up to ____ |
6 hours |
|
|
How do muscle relaxants affect venous return |
decrease -abolish muscle return |
|
|
What positions cause greatest decrease in BP and CO |
sitting prone flexed lateral |
|
|
The lithotomy position causes an autotransfusion of _____ mL of blood per leg |
100-250 |
|
|
MAP increases/decreases by ____ mmHg per inch above/below the heart |
2 mmHg |
|
|
What position has the greatest risk for hypoperfusion/ischemia? |
Sitting/heat up |
|
|
Cardiac output decreases by ____percent with the head up 90 degerees |
20 percent |
|
|
If cerebral perfusion is a concern, the arterial line should be placed at the level of ______ |
circle of willis |
|
|
Steep trendelenberg can cause volume overload in what type of patient? |
Cardiovascular disease/CHF |
|
|
Methods for atenuating position changes |
Light anesthesia/nitrous-narcotic technique Slow position changes Volume loading |
|
|
Why does the V/Q ratio improve in the prone postion? |
More lung volume is posterior |
|
|
In the awake patient, ventilation favors the ____ lung |
dependent |
|
|
In the lateIral decubitus position, abdominal contents move _____ in the anesthetized patient |
cephelad |
|
|
With the addition of anesthesia, muscle relaxation, and positive pressure ventilation, ventilation is favored in the ______ lung |
nondependent |
|
|
In the nondependent lung, under anesthesia, the diaphragm moves ______ |
caudad |
|
|
Under anesthesia, the lung compliance is _____ in the nondependent lung |
increased |
|
|
Hypoxic Pulmonary Vasoconstriction in the nonventilated lung can ______ V/Q mismatch |
improve |
|
|
Why can atelectasis occur in the lateral decubitous position? |
Because closing volumes are higher than FRC, with closing occuring earlier in the dependent lung |
|
|
Four strategies for improving oxygenation during 1 lung ventialtion |
Ventilate with low volumes and higher rates Application of PEEP to dependent lung 2-4 L/min passive oxygenation to nondependent lung 5-10 cm H2O CPAP to nondependent lung |
|
|
Four mechanisms of nerve injury |
Compression Stretch Kinking Transection |
|
|
Example of compressin |
Nerve forced against bony prominance/hard surface -armboard -weight of superior leg against dependent extremity in lateral position |
|
|
Example of stretch injury |
Nerves with long course (sciatic/brachial plexus) |
|
|
How does stretch injury injure axons? |
Causes conduction changes Axon disruption Interrupts vascular supply |
|
|
Example of a kinking injury |
Nerve pinched between two immovable structures -femoral nerve kinked under inguinal ligament when thighs flexed in the lithotomy posotion |
|
|
_________ is a common component to all nerve injures |
Ischemia |
|
|
The fiberous sheath surrounding an entire nerve is the ________ |
epineurium |
|
|
The sheath surrounding individual fascicles is the ______ |
perineurium |
|
|
The sheath surrounding individual fibers is the _____
|
endoneurium |
|
|
The neruolemma surrounds ______ and is composed of _______ |
axons schwann cells |
|
|
Three factors contributing to nerve injury |
Positioning devices Length of procedure Anesthetic technique |
