Principles Ii, Exam 1- Cumulative

Front 1

What are the obstructive lung disorders?

Back 1

-asthma
-emphysema
-chronic bronchitis
-cystic fibrosis
-bronciectasis
-bronchiolitis

Front 2

Asthma is characterized by variable _____ _____ airflow obstruction and airway/bronchial ______________.

Back 2

reversible expiratory
hyper-responsivenss

Front 3

Asthma is generally allergen-induced immunologic responses by _____________.

Back 3

several chemical mediators

Front 4

Flow volume loops for obstructive disease are affected on ______. FEV1 is less than of equal to _____% of predicted.

Back 4

expiratory
60

Front 5

The degree of reversilbility, increased airway hyper-reactivity and after admin of bronchodilators you will see a 12% or greater increase in FEV1 and 200 ml increase in Peak expiratory flow rate are the things that make...?

Back 5

asthma different from chronic bronchitis

Front 6

Preop Assessment for Asthma...

Back 6

-what is your breathing baseline and how is your breathing now?
-current clinical symptoms, last exacerbation, infections?
-medication regimen
-comparison and review of PFTs
-exercise tolerance?
-sputum at baseline and what is it currently?
-last time presented to ED and last time received systemic steroids?
-benefit to stop smoking 8 wks preop
-thorough chest auscultation

Front 7

smoking cessation is beneficial to surgical pts greater than ____ weeks preop but not any sooner.

Back 7

8 weeks

Front 8

Preop laboratory studies for asthma?

Back 8

-CXR: for baseline, signs of infections, severity of dx
-FEV1 or PEFR to assess severity of dx
-Full PFTs
-Baseline ABG
-Perhaps EKG to assess right heart failure

Front 9

an additional dose of ____ and _____ ____ may be given just before induction (inhalers and systemic corticosteroids)

Back 9

ipratropium and beta agonist

Front 10

You should avoid giving an ___ ______ before anesthesia for the risk of bronchospasm. Consider using non pariculate antacid such as bictra or reglan.

Back 10

H2 blocker

Front 11

Asthma can be managed preop by Leukotriene inhibitors like ______, beta adrenergic agonists like _____-_____ or anticholinergic drugs like ______-____

Back 11

singulair
salmetrol-serevent
tiotropium-spiriva

Front 12

_____ is classified as a histamine blockers.

Back 12

chromolyn

Front 13

Chromolyn works by suppressing the secretory response of ___ ____ reaction

Back 13

IgE-Antigen

Front 14

Chromolyn is effective only in _____ ___ not basophils.

Back 14

mast cells

Front 15

How is chromolyn deliverd?

Back 15

only by inhalation

Front 16

Chromolyn can only be used ______ and is ineffective following histamine release.

Back 16

prophylactically

Front 17

Examples of inhaled corticosteriods are?

Back 17

Beclomethason (QVAR)
Tramicinolone (Azmacort)
Fluticasone (Flovent)

Front 18

The PO corticosteroid most given is _____. It can cause hypothalmic pituitary adrenal suppression so if the pt has received it in the last ____ months give Solucortef 100mg preop.

Back 18

prenisone
6

Front 19

Corticosteriods have __________ effects on the bronchial mucosa. Stabilize ____ cell membranes. Decrease airway ________. Controls chronic symptoms and prevents ______.

Back 19

-anti-inflammatory
-mast cell
-hyper-responsiveness
-exacerbations

Front 20

Cysteinyl-lekotriene (CysLT1) antagonist is a?

Back 20

leukotriene inhibitor

Front 21

Cysteinyl-lekotriene (CysLT1) competitively blocks ______ __ from binding to the receptor. Examples of this are Zafirlukast, montelukast and pranlukast.

Back 21

leukotriene D4

Front 22

Leukotriene inhibitors also inhibit the conversion of ______ acid to leukotriene A inhibiting the generation of leukotrienes. An example is Zileuton.

Back 22

arachidonic acid

Front 23

____ is a good induction choice for asthmatics because it bronchiodilates but a downfall is that it also increases secretions.

Back 23

ketamine

Front 24

both ____ and ____ are good choices for induction in an asthmatic because they bronchodilate and don't release histamine.

Back 24

etomidate and propofol

Front 25

the ____ form of propofol dose contain sulfites so this should be avoided in an asthmatic.

Back 25

generic

Front 26

the neuromuscular relaxants that release histamine and should be avoided in an asthmatic are?

Back 26

succinylcholine and atricurium-dose and speed dependent
(curare, mivacurium)

Front 27

Regarding pain management in an asthmatic; ____ should be avoided due to histamine release but fentanyl and analogues are okay to use.

Back 27

morphine

Front 28

avoid ____ and ____ in asthmatic related to prosteglandin decrease.

Back 28

ketorolac and NSAIDs

Front 29

All volatile anesthetics are potent _____ but _____ and ____ may irritate the airway.

Back 29

bronchodilators
iso and des

Front 30

reversing neuromuscular blocking agents is not a problem in the asthmatic because _____ are always given with the reversal which is an anticholinesterase.

Back 30

anticholinergic

Front 31

the most critical time intraop is?

Back 31

airway instrumentation

Front 32

Although regional anesthesia may decrease the risk of airway induced bronchospasm, a high spinal may aggravate ______ by blocking sympathetic tone (T1-T4)

Back 32

bronchoconstriction

Front 33

What are the goals of induction in the asthmatic patient?

Back 33

-achieve deep anesthesia before airway manipulation and surgical stimulation
-avoid histamine releasing drugs
-avoid bronchospasm

Front 34

Again, the agents to avoid in an asthmatic are?

Back 34

-morphine
-atracurium
-mivacurium
-meperidine
-succinylcholine (sometimes ok to use)

Front 35

administering ipratropium and a beta 2 agonist just before ____ help to reduce bronchospasms.

Back 35

induction

Front 36

1-1.5mg/kg IV of ______ can also help to reduce bronchospasm.

Back 36

lidocaine

Front 37

Some things to think about for differential diagnosis for wheezing...

Back 37

-foreign body
-partially blocked/kinked ETT
-light anesthesia
-aspiration
-endobronchial intubation
-tension pneumo
-pulm embolism
-pulm edema
-acute exacerbation of asthma
-anaphylaxis

Front 38

What is the first step of management for an OR emergency related to asthma?

Back 38

deepen your anesthetic agent and 100% FiO2

Front 39

What is the second step of management for an OR emergency related to asthma?

Back 39

-auscultate the chest
-verify the problem is bronchospasm
-check patency and position of ETT

Front 40

What is the third step of management for an OR emergency related to asthma?

Back 40

-admin medications
-b-adrenergic agnosits
-iv hydrocortison (1.5-2mg/kg
-epi (0.1mcg/kg bolus)
-aminophylline

Front 41

for emergence of an asthmatic giving 1.5-2mg/kg of ____ may help to blunt airway reflexes

Back 41

lidocaine

Front 42

_______ is the most common pulmonary disorder and it effects more men then women.

Back 42

COPD

Front 43

COPD is the loss of elastic recoil of the lung due to destruction of the lung ____. This leads to the collapse or airways during ____, leading in turn to an increase in airway ____.

Back 43

parenchyma
expiration
resistance

Front 44

the obstruction of airway outflow can lead to the enlargement of _____ distal to terminal bronchioles.

Back 44

air spaces (bullae)

Front 45

Preop treatment for COPD includes

Back 45

-supportive
-smoking cessation
-bronchodilators and glucocorticoids
-ipratropium (more effective than B2 agonists in COPD)
-treat hypoxemia carefully

Front 46

Giving oxygen to patients with COPD presents a problem because it can raise ___ in patients who already have CO2 retention.

Back 46

PaCO2

Front 47

Giving oxygen to patients with COPD presents a problem because elevating ____ can lead to respiratory failure and it can abolish ______.

Back 47

PaO2
hypoxic pulmonary vasoconstriction (HPV)

Front 48

What is the preop managements for COPD

Back 48

-thorough pulmonary eval
-cardiac eval
-cessation of smoking
-abx if warranted
-review of lung expansion procedures (spirometry)

Front 49

what is the intraop management for COPD?

Back 49

-use of minimally invasive surgery
-consider regional anesthesia
-avoid long acting neuromuscular blocking agents
-alines, central lines?
-use of PEEP
-humidified O2
-N2O?

Front 50

_____ ____ follows prolonged exposure to environmental irritants with a hyper-secretion of mucus and inflammatory changes in the bronchi. There is also a productive cough.

Back 50

chronic bronchitis

Front 51

the preop eval for COPD includes?

Back 51

-assessment of current symptoms (dyspnea, cought, sputum)
-hx of respiratory infection and exercise tolerance
-thorough chest auscultation
-consider PFTs, ABG, CXR, EKG

Front 52

Preoperatively if the COPD pt exhibits signs of respiratory infection give them ____ and possibly _____ if there is a reversible component present.

Back 52

antibiotics, bronchodilators

Front 53

Regional anesthesia may offer benefits for surgery of the extremities and lower abdomen because it is ____ or below.

Back 53

T10

Front 54

You must use ____ cautiously because you want to treat post op pain but avoid respiratory depression.

Back 54

opiods

Front 55

The advantages to N2O are that it decreases the dose of ____ ____ and it goes quick on and quick off.

Back 55

volatile anesthetics

Front 56

one disadvantage of N2) is that it can diffuse into ______ quicker than nitrogen can exit, potentially leading to bullae rupture and tension pneumo.

Back 56

airspaces

Front 57

another disadvantage of N2) is that concentrations between ___ and ___ % can limit the concentration of oxygen that can be administered while maintaining the appropriate level of anesthesia.

Back 57

50-70%

Front 58

_____ _____ occurs due to air trapping. Also called dynamic hyperinflation. Because air cannot be exhaled, pressure builds up in the lung leading to _______.

Back 58

-intrinsic PEEP
-positive end expiratory pressure (PEEP)

Front 59

in COPD there is increased ____ ___ due to airway obstruction. Meaning, all inspire4d air does participate in gas exchange and exhaled gas may not contain a normal amount of ____ measured by capnography.

Back 59

dead space
CO2

Front 60

Restrictive lung disease characteristics are?

Back 60

-decreased vital capacity
-expiratory flow rates remain normal
-FEV1 and FVC will be reduced
-FEV1/FVC is preserved at >0.7

Front 61

What are the types of intrinsic restrictive pulmonary diseases?

Back 61

-pulm edema
-ARDS
-Pneumonitis
-idiopathic fibrosis
(may also see an increased AaO2 gradient)

Front 62

What are the types of extrinsic restrictive pulmonary diseases?

Back 62

-pleural effusion
-obesity
-kyphoscolisosis
-ascites
-pregnancy

Front 63

Restrictive pulmonary disease have a decreased lung compliance due to an increase in _________.

Back 63

extravascular lung fluid

Front 64

In Restrictive pulmonary disease there should be no ____ surgery. If emergency surgery is needed, oxygenation and ventilation should be optimized

Back 64

elective

Front 65

In Restrictive pulmonary disease use _____ support as needed.

Back 65

pressor

Front 66

Sarcoidosis causes small lumps which generally heal but if they do not the tissue can remain inflamed and become _____. This can develop into pulmonary fibrosis which distorts the structures of the lungs and can interfere with _____.

Back 66

scarred
breathing

Front 67

Also, _____ can occur from sarcoidosis. This is where pockets form in the air tubes of the lungs and become sites for infections.

Back 67

bronchiectasis

Front 68

On the flow-volume loop for Restrictive pulmonary disease both ____ and ____ are affected.

Back 68

inspiration and expiration

Front 69

People with Restrictive pulmonary disease suffer from increased work of breathing because increased effort is needed to move air in and out of the lungs---less air (_____) is moved per decrease in intrapleural ____.

Back 69

volume
pressure

Front 70

Increased PaCO2 in patients with Restrictive pulmonary disease represents _____ disease. Early on these pts may be hypocarbic however late in the disease the patient will live with a higher PaCO2 in return for not working as hard to breathe.

Back 70

advanced
-hypercarbia and arterial hypoexemia cause vasocontrictive pul htn and cor pulmonale

Front 71

Regional anesthesia on patients with Restrictive pulmonary disease is similar to regional in other lung disease (safe below T10 as to not impair breathing) however, ____ may be difficult.

Back 71

positioning

Front 72

for patients with Restrictive pulmonary disease undergoing GA, _____ and increased ____ may be required.

Back 72

PEEP and Oxygen

Front 73

In pts with Restrictive pulmonary disease you can predict post op problems if FVC is less than ____ ml/kg and a preop PaCO2 higher than ___.

Back 73

15
50

Front 74

Restrictive pulmonary disease pts by definition have decreased _______. And surgery especially of the abdomen or throax decrease these further. This may make it difficult to clear ______.

Back 74

preop lung volumes
secretions

Front 75

It is important that asthma is considered _____ whereas COPD is not.

Back 75

reversible

Front 76

if you are giving a neb through an ETT you are losing half of the dose so ___ the dose.

Back 76

double

Front 77

Wet airways trigger _____ so make sure to have a dry airway.

Back 77

laryngospasm

Front 78

For a COPD patient, dont have insp pressures greater than _____ on pressure mode.

Back 78

30

Front 79

To help patients with COPD you can _____ the I:E ratio.

Back 79

increase
go from 1:2 to 1:3

Front 80

Know the COPD pts _____ baseline and make sure they are at it when waking up=drive to breathe.

Back 80

CO2

Front 81

The ___ position offers optimal access of the lungs, pleura, esophagus, great vessels, vertebrae and other mediastinal structures. It alters normal ____ ____ making the pt at risk for hypoxia. The ____ lung is less compliant.

Back 81

-lateral
-V/Q relationship
-lower

Front 82

____ effectively redirects blood flow away from hypoxic or poorly ventilated lung units by the vascular endothelium releasing potent vasocontrcitor peptides called endothelin.

Back 82

HPV

Front 83

______ >1 MAC and ____ block HPV.

Back 83

Volatile anesthetics and N2O

Front 84

when one side of the chest is opened the negative pressure is ___ and elastic recoil of the lung on that side tends to ______. This can cause progressive hypoxemia and hypercapnia. Effects are overcome by _________.

Back 84

lost
collapse it
positive pressure ventilation

Front 85

Mixing of _____ blood from the collapsed upper lung with oxygenated blood from the ventilated dependent lung widens the alveolar to arterial O2 gradient and often results in ______. Fortunately, blood flow to the non ventilated lung is decreased by ___.

Back 85

hypoxemia
HPV

Front 86

____ to _____ is poorly matched in mechanically vented pts.

Back 86

ventilation to perfusion

Front 87

______ pushes gas into apexes of lung which follows the path of least resistance.

Back 87

positive pressure ventilation

Front 88

blood perfuses primarily the ____ parts of lung due in part to the pull of gravity.

Back 88

dependent

Front 89

The result of PPV in pts in gas flow to the ____ and blood flow to the ____ resulting in ______ ____.

Back 89

apex
bases
VQ mismatch

Front 90

Poorly ventilated alveoli are prone to _____ and ____.

Back 90

atelectasis and collapse

Front 91

What are the indications for one lung ventilation (OLV)

Back 91

-lung resection
-drainage of abscess, cyst or empyema
-bronchopleural fistula
-bronchial tumors
-lung transplant
-persistent intrapulmonary bleeding (PA rupture)
-esophageal surgery
-anterior approach to the thoracic spine
-select open heart procedures
-improve pt outcomes

Front 92

OLV can improve pt outcomes by restricting _____ or ____ to one lung.

Back 92

infection or bleeding

Front 93

OLV can differentially ventilate each lung after trauma, post op or with a ______ fistula.

Back 93

bronchopleural

Front 94

Which mainstem bronchus is longer, the left or right?

Back 94

left

Front 95

the right upper lobe orifice is ____ cm from the carina and is higher than the left upper lobe orifice at ___ cm.

Back 95

2.5cm
5cm

Front 96

the adult trachea is ___-___ cm long

Back 96

11-13

Front 97

The trachea begins at the cricoid which is?

Back 97

C4-C6

Front 98

The trachea bifurcates at the carina which is?

Back 98

T4-T6

Front 99

The right mainstem diverges away at a ___ degree angle. The left mainstem diverges away at a ___ degree angle.

Back 99

25
45

Front 100

The following methods are used in OLV.

Back 100

-double lumen ETT
-single lumen ETT with a built in bronchial blocker
-single lumen ETT with an isolated bronchial blocker (wire guided)
-endobronchial intubation of a single lumen ETT

Front 101

The disadvantages of single lumen endobronchial tube are?

Back 101

-inability to ventilate or suction other lung
-if placed in right lung, cannot ventilate right upper lobe

Front 102

the bronchial blocker is placed under ____ guidance. They are beneficial to patients already ______/_____.

Back 102

fiberoptic
intubated/trached

Front 103

The appropriate size double lumen tube for females is ___-___ fr. for males it is ___-___fr.

Back 103

35-37 (usually 37)
37-39 (usually 39)

Front 104

in the awake and upright position, you have perfusion to the ____ and lower ventilation from negative pressure generated from spontaneous breaths.

Back 104

bases

Front 105

in the asleep and upright position you have perfusion to the ____ (gravity dependent) and ventilation to the ____ because of PPV=V/Q mismatch

Back 105

bases
upper

Front 106

In the asleep and lateral position, you have perfusion to the dependent side and ventilation to the ___ lobes from PPV. This is a worsened V/Q mismatch because paralysis, bean bags, open chest

Back 106

upper

Front 107

complications of double lumen tubes

Back 107

-HYPOXIA
-traumatic laryngitis
-tracheal-bronchial rupture
-ETT suturing/stapling in the bronchus
-decreased venous return

Front 108

Complications of a throacotomy

Back 108

-volume overload
-broncial disruption
-pneumonia/atelectasis
-pulm htn
-Low CO (r heart failure, decreased preload)
-bleeding
-dysrythmias

Front 109

-Managing OLV, you should avoid ____.
-To protect HPV, use ____ and narcotics (avoid IAs)
-Use muscle relaxants and atropine

Back 109

-N2O
-TIVA

Front 110

During OLV, restrict ____ because lungs are a venous reservoir.

Back 110

fluids

Front 111

During OLV you should have an ____ to monitor for decreased venous return and monitor ABG.

Back 111

Aline

Front 112

When ventilation a OLV make sure you are using ____% FiO2. Maintain a PIP < ____ by adjusting TV (avoiding major adjustments).

Back 112

100%
30

Front 113

If hypoxia develops during OLV you can compensate by?

Back 113

-PEEP to dependent lung
-CPAP to non dependent lung
-insufflation of O2 to non dependent lung

Front 114

Preop eval for common thoracic procedures include?

Back 114

-lab tests
-prescreen for underlying pulm infection
-tracheal stenosis, positional dyspnea, airway collapse, hypoxemia, anatomic narrowing?
-review abg, PFT, CXR, V/Q scan, CT/MRI, angiography
-coexisting patho

Front 115

Transfuse preop lung pt with pre op Hct less than __%

Back 115

25%
-T and C 2-4 units of blood

Front 116

lung cancer patients may have myasthenic syndrome with increased sensitivity to __________.

Back 116

non depolarizing muscle relaxants

Front 117

When is the lateral decub position the aline should be in the ____ arm. When doing a mediastinoscopy the aline should be in the ____ arm.

Back 117

dependent
right

Front 118

The central line should be in the ______side of neck. Pressure reading may be affected by open chest, lateral position and surgical manipulation.

Back 118

non dependent

Front 119

epidural anesthesia reduces volatile agents requirements but epidural anesthesia may create sympathetic blockade and ____.

Back 119

hypotension

Front 120

opening the chest produces _____.

Back 120

pneumothorax

Front 121

manipulation of the lung, heart, and major vessels may interfere with ______________________ intraop and post op.

Back 121

ventilatory exchange and cardiovascular stability

Front 122

the lateral decub position changes the distribution of blood flow and pattern of ventilation and exposes lower lung to danger of contamination by ____, ____ or ____.

Back 122

secretions, blood or fluids

Front 123

Open thorax surgery risks include...

Back 123

-dysrhythmias
-DVT
-PE
-MI
-bronchopleural fistula
-chylothorax
-subq emphysema
-phrenic nerve injury
-recurrent laryngeal nerve injury

Front 124

Small cell (oat tumors) account for ___% and non small cell tumors account for ____%.

Back 124

20%
80%

Front 125

-Often proceeded by bronchoscopy/mediastinoscopy
-lateral or posterior lateral thoracotomy incision
-lateral decub position
-double lumen tube
-time=2-3 hours
-EBL= <500ml
-post op care = ICU
-careful attention to chest tubes
-mortality= +/- 1%
-pain score= 7-8

Back 125

lung resection

Front 126

intrapulmonary hemorrhage is characterized by massive hemoptysis r/t trauma, pulm artery rupture, erosion into vessel by trach, abcess or tumor. This requires immediate _____ with ____% FiO2, suctioning the airway, lung iso if unilateral involvement. May need thoracotomy and surgical repair

Back 126

intubation, 100%

Front 127

_____ ____ and ____ can be air filled, thin walled, bronchogenic or alveolar destructive, post infective, infantile or emphysematous cysts.

Back 127

lung cysts & bullae

Front 128

_____ may rupture cysts or bullae = tension pneumo

Back 128

positive pressure

Front 129

Once cysts or bullae are removed, _____ is usually improved.

Back 129

respiration

Front 130

key points to remember with cysts and bullae are...?

Back 130

-PPV < 10cm (may need double lumen tube)
-No N2O
-Extubation-smooth and without coughing

Front 131

____________ is an autoimmune disorder with prejunctional decreased Ach release and no improvements with anticholinesterases. The peripheral muscles and pelvis are most affected.

Back 131

myasthenic syndrome-eaton lambert syndrome

Front 132

The underlying malignancy of myasthenic syndrome is?

Back 132

small cell cancer of the lung

Front 133

Symptoms improve with ____ in myasthenic syndrome

Back 133

exertion

Front 134

muscle relaxants greatly affect myasthenic syndrome patients. ____ having the most effect.

Back 134

NDMR

Front 135

what is a broncho-pleural fistula?

Back 135

abnormal communication between bronchial tree and pleural cavity with pus.

Front 136

what causes a broncho-pleural fistula?

Back 136

pulmonary resection, bronchus or bulla rupture, penetrating chest wound, lung cyst or empyema cavity.

Front 137

the risks of bronco-pleural fistula are ____ may contaminate healthy lung or cause a tension pneumo.

Back 137

PPV

Front 138

The goal with a broncho-pleural fistula is to isolate the _____ lung with a double lumen tube (DLT). Also minimal gas leak through the fistula

Back 138

affected
-lumen is to the unaffected side

Front 139

____ is indicated for stenosis, tumor or congenital defect.

Back 139

tracheal resection

Front 140

With a tracheal resection patient, you may note ____ and the flow volume loop may help you determine where the obstruction is.

Back 140

wheezing

Front 141

with tracheal surgery give minimal _____ to avoid airway obstruction.

Back 141

premedication

Front 142

for induction of tracheal surgery consider ______ induction or awake fiberoptic induction to avoid complete obstruction with loss of muscle tone. Questionable muscle relaxants.

Back 142

inhalation

Front 143

When emerging a tracheal resection, consider ____ the neck to reduce tension and reduce the risk of re-anastomosis

Back 143

flexion

Front 144

What are the three thoracoscopic procedures?

Back 144

-bronchoscopy
-mediastinoscopy
-bronchoalveolar lavage

Front 145

The complications of mediastinoscopy procedures include?

Back 145

-#1 rupture/laceration of the major vessels
-#2 pneumo (hemo) thorax
-intermittent occlusion of the innominate artery (CVA risk)
-tracheal collapse, tension pneumomediastinum, mediastinitis, chylothorax
-phrenic nerve/RLN injury

Front 146

anesthetic consideration with endoscopy are?

Back 146

-small ETT vs. DLT
-laser tube and laser precautions
-short acting hypnotic agent
-inhaled agents vs TIVA
-short acting narcotics
-short acting muscle relaxants
-local anesthesia post op

Front 147

With rigid bronchoscopy you should use _______. The risks/features of rigid include; hypercapnea, hypoxemia, air leaks, anesthesia machine vs HFJV, side arm ventilation port

Back 147

general anesthesia

Front 148

complications of endoscopy include?

Back 148

-facial, dental and laryngeal injury
-airway rupture-pneumo
-hemorrhage
-airway obstruction-blood, edema

Front 149

_______ for thymectomy, medisinal masses, bilateral pulmonary resection.

Back 149

median sternotomy/sternotomy

Front 150

the _____ is the treatment of choice for myastinia gravis patients. it can be done through sternal incision or cervical approach.

Back 150

thymectomy

Front 151

_________ is an autoimmune diease with ocular, pharyngeal, and skeletal muscle weakness. It improves with edrophonium 10mg, corticosteroids, immunosuppresants, plasmapheresis and thymectomy.

Back 151

myasthenia gravis

Front 152

for myasthenia gravis patients they should hold their anticholinesterase med on _______.

Back 152

the day of surgery

Front 153

with myasthenia gravis patients neuromuscular monitoring is indicated but results can be ______.

Back 153

misleading

Front 154

myasthenia gravis pts may need to be vented post op if?

Back 154

-duration of disease greater than 6 years
-coexisting COPD
-anticholinesterase dose greater than 750mg/day

Front 155

resection of neoplasms, anti-reflux procedures and repair of traumatic or congenital lesions are all indications for?

Back 155

esophageal surgery

Front 156

with esophageal surgery you must consider...?

Back 156

-chronic malnutrition related to cancer/swallowing difficulty
-hypovolemia related to swallowing
-aspiration risk

Front 157

during esophageal surgery use an aline, CVP and _____. DLT may be indicated and epidural analgesia can be used ____ and _____.

Back 157

foley
intraop and post op

Front 158

postoperatively pts with esophageal surgery may need to stay intubated for _________.

Back 158

aspiration precations

Front 159

When using the DLT, DL with a ____ MAC blade and advance the tube to at least the ___ cm mark.

Back 159

3
26cm

Front 160

what is the most common error associated with DLT insertion?

Back 160

advancing the tube too far in the bronchus and causing only distal lumen ventilation to one lung

Front 161

the amount of ____ is the main component of oxygenation. HPV may limit ___ unless it is blunted.

Back 161

shunt
shunting

Front 162

The greatest risk of OLV is _________. With that in mind:
TV= 8-10 ml/kg
Adjust RR to keep PaCO2= 40
No PEEP (or less than 5)
Continuous monitoring of O2 and ventilation (SpO2, ABG, ETCO2)
if pulse ox is less than 94% recheck DLT or BB

Back 162

hypoxemia

Front 163

What is the O2 management of OLV

Back 163

-minimize ventilated lung atelectasis
-D/C or avoid N2O to maintain PaO2
-check tube position and suction prn
-PEEP to vented lung (may shunt blood to non ventilated lung)
-CPAP to nonventilated lung (5-8cmH2O)
-Reinflate nonventilated lung with 100% fio2 or have surgeon clamp the PA (last resort)

Front 164

Intraop blood and fluid requirements of OLV

Back 164

-IV 2 large bore
-central line
-aline
-restrict IV fluids (1000-1500 ml NS/LR max)
-1 unit autologous blood if available
-vasopressor if hypotensive
-ephedrine 5-10mg
-phenylephrine 50-100mcg

Front 165

after positioning the patient?

Back 165

reassess breath sounds, vital signs, monitors, lines and IVs

Front 166

when the surgeon is finished lung re-exapnsion is done by _____ ventilation, stacking breaths with increasing pressure.

Back 166

hand

Front 167

filling the chest with water to determine if there is a leak in the lung is known as the?

Back 167

lung bubble test

Front 168

decrease ____ during closing to avoid injury while suturing.

Back 168

TV

Front 169

inflating the lungs to 30 cm H2O not only checks for leaks but it also reinflates areas of ____.

Back 169

atelectasis

Front 170

the surgeon will insert ______ and drain the pleural cavity and aid in lung re-expansion.

Back 170

chest tubes

Front 171

The patient is usually extubated in the OR but if they are remaining intubated, exchange....?

Back 171

the double lumen tube for a single lumen ETT

Front 172

chest tubes can be set to water seal or ____cmH2O. Except in pneumonectomy=water seal only.

Back 172

20

Front 173

the patient will be transferred to the _____ on monitors and nonrebreathing mask.

Back 173

ICU

Front 174

Things to remember...

Back 174

-watch your field
-interact with your surgeon

Front 175

A right DLT is rare but it has an extra murpheys eye to ventilate the?

Back 175

right upper lobe

Front 176

the gold standard for DLT placement is?

Back 176

fiberoptic confirmation

Front 177

When scoping down a DLT you use a ____ scope.

Back 177

peds

Front 178

with thoracic surgery it is better to give ____ for fluid replacement/drop in BP

Back 178

colloids

Front 179

when inserting an ETT for bronchoscopy, you should have the _____ tube possible.

Back 179

largest

Front 180

the blue cuff on the DLT sits in the _____ and the white cuff sits in the _____. the stylet goes through the _____ lumen because it is longer.

Back 180

bronchus
trachea
bronchial/blue

Front 181

What does obese mean?

Back 181

the amount of fat tissue is increased to such an extent that physical and mental health are affected and life expectancy is reduced

Front 182

Why do we care about obesity?

Back 182

-technical difficulties
-physiologic changes
-co-morbidities (increase M&M)
-40% of US population

Front 183

What is the formula for BMI?

Back 183

kg/m2

(lbs/ in x in )x703

*cm= in x 2.54 m= in x 0.0254

Front 184

What is the formula for IBW

Back 184

Height (cm) - X
x= 100 for adult males
x=105 for adult females

Front 185

At what BMI has morbidity and mortality been noted to increase?

Back 185

30

Front 186

if the actual body weight is greater than 30% of the calculated IBW you should calculate the ____?

Back 186

Adjusted body weight (ABW)

Front 187

What is the formula for ABW?

Back 187

IBW + 0.4(actual weight-IBW)

Front 188

BMI less than 20 is classified as?

Back 188

underweight

Front 189

BMI 20-25 is classified as?

Back 189

normal

Front 190

BMI 26-29 is classified as?

Back 190

Overweight

Front 191

A BMI of 30-39 is classified as?

Back 191

Obese

Front 192

A BMI of greater than 40 is classified as?

Back 192

Extreme obese

Front 193

A BMI greater than 50 is classified as?

Back 193

Super obese

Front 194

A BMI greater than 60 is classified as?

Back 194

Super-super obese

Front 195

Total blood volume is (increased/decreased) in the obese?

Back 195

increased
*but on a volume to weight basis, they have less blood volume...only 50ml/kg (non obese= 70ml/kg)

Front 196

most of the blood flow is disributed to the ____.

Back 196

fat
blood flow to fat = 2-3ml/100g of tissue

Front 197

What are some increases related to the cardio system and obesity?

Back 197

-Increased CO (0.1L/min to perfuse 1 kg of fat)
-increased Stroke volume
-Increased blood volume
-increased dysrhythmias

Front 198

Obese patients have ____ to ___ HR

Back 198

normal to increased

Front 199

Obese pts suffer from left ventricle _____ and cardiac _____.

Back 199

dilation, hypertrophy

Front 200

What are some cardio complications from obesity? (8)

Back 200

-HTN
_cardiomegaly
-CHF (10% of pts)
-CAD/Ischemic heart disease
-PVD
-Pulm HTN
-Thromboembolism
-Sudden death

Front 201

An obese person with HTN leads to an increase in preload and afterload which leads to _____ and _____.

Back 201

Dilation and hypertrophy

Front 202

Obese pts have poor tolerance to hypotension, hypertension, tachycardia and fluid overload secondary to ____ ___ ___.

Back 202

Limited cardiac reserve
(try to keep their BP and HR where they normally live)

Front 203

Increased CO comes from and increase in ____ secondary to LVH which is secondary to _____.

Back 203

workload, volume
*all increases metabolic demand which increases CO

Front 204

Becuase of increase pulm blood flow and HPV and obese pt can suffer from _____ ____ which leads to cor pulmonale and right sided heart failure.

Back 204

pulmonary HTN

Front 205

What are some reasons for increased rish of arrhythmias? (6)

Back 205

-hypertrophy
-hypoxemia/hypercapnia
-fatty infiltration in cardiac conduction
-diuretic (hypotension with induction)
-increased catecholamines
-sleep apnea

Front 206

Excess metabolically active adipose + increases workload on supportive muscle leads to?

Back 206

increased CO2 production (hypercarbia) and increased O2 consumption (hypoxia)

Front 207

because of increased tissue, obese patients suffer from _____ lung disease.

Back 207

restrictive

Front 208

Restrictive lung disease leads to...
____ chest wall compliance
diaphragm forced ____
____ lung volumes

Back 208

decreased
up
decreased

Front 209

The effects of restrictive lung disease are worsened by ___ and ____ positions

Back 209

supine and trandelenburg

Front 210

If FRC falls below closing capacity the _____ collapse and that leads to _____ ________.

Back 210

alveoli, V/Q MISMATCH!
*prone to atelectasis

Front 211

In PFTs, all of the following things are moderately decreased (4)

Back 211

-TV
-inspiratory reserve volume
-total lung capacity
-vital capacity

Front 212

in PFTs, all of the following things are significantly decreased (2)

Back 212

-expiratory reserve volume
-functional residual capacity

Front 213

There is an (increase/decrease) in metabolism but the ___ ____ ___ is WNL.

Back 213

increase, basal metablic rate

Front 214

the most common cause of hypoxemia in obese is from ____ ____.

Back 214

V/Q mismatch

Front 215

Pulmonary perfusion is increased secondary to increased ____ and increase ___ ___.

Back 215

CO and blood volume

Front 216

Airway closure due to decreased ____ (which is lower than closing capacity) leads to decreased _____ ventilation.

Back 216

FRC, alveolar

Front 217

Pulmonary HTN is developed secondary to ___ ___ ___

Back 217

hypoxic pulmonary vasoconstriction (HPV)

Front 218

All of the respiratory problems leading to hypoxemia are overall related to ___ ____ ____.

Back 218

Increased pulmonary shunt

Front 219

On the hemoglobin destaturation curve, obese people ____ much quicker

Back 219

desat
*the more preoxy the better!

Front 220

Obese people are at risk for spinal deformities such as?

Back 220

kyphosis and lordosis

Front 221

Obese people are at risk for an upper airway obstruction while sleeping known as?

Back 221

obstructive sleep apnea (OSA)

Front 222

OSA is dx by a period of apnea grater than ____ seconds and a desat to at least ____%

Back 222

10 seconds, 85%

Front 223

People with OSA exhibit, ____ ____, _____, _____ and _____.

Back 223

loud snoring, hypercarbia, hypoxia and somnia

Front 224

Risk factors for OSA include (7)

Back 224

-age over 65
-men
-african americans
-craniofacial anatomy
-obesity
-smoking and ETOH
-diabetics

Front 225

WIth a neck size of ____ inches for men and ___ inches for women, they are at an increased risk of OSA because of smaller upper airway and increase collapsibility of pharyngeal airway related to large neck mass.

Back 225

17, 16

Front 226

OSA can be caused by changes in neural compensatory mechanisms such as _____________.

Back 226

diminished protective reflexes
(normally maintain airway patency)

Front 227

increase waist circ contributes to OSA because of reduced ____ ____

Back 227

lung volumes which leads to caudal traction of airway

Front 228

low lung volumes are also associated with diminished ____ ____.

Back 228

oxygen stores

Front 229

There are two types of sleep apnea. In obstructive sleep apnea you have respiratory ____ but in central sleep apnea you do not.

Back 229

effort

Front 230

The apnea hypoxia index (AHI) is what is used to rate the severity of OSA. WHat is the scale?

Back 230

mild: 5-15 events/hr of sleep
moderate: 15-30 events/hr of sleep
severe: >30 events/hr of sleep

Front 231

What is the acronym for the predisposition towards OSA?

Back 231

Stop-Bang
S-Snoring
T- tired
O-Observed (apnea)
P- Pressure =treated for HTN
B- BMI>35
A- Age> 50
N- Neck circ> 17 males, 16 females
G- Gender, male
High risk = 3 or more yes
Low risk = less than 3 yes

Front 232

What are the 6 things to do to treat OSA?

Back 232

-weight loss
-avoidance of ETOH and sedatives
-CPAP
-UPPP (take out uvula)
-Trach (extreme cases)
-genioglassal advancement (jaw forward)

Front 233

Obesity hypoventilation syndrome is known as?

Back 233

Pickwickian Syndrome

Front 234

Besides hypercapnia and hypoxemia what are some other more serious effects of Pickwickian syndrome?

Back 234

-respiratory acidosis
-secondary polycythemia
-pulm htn
-right vent hypertrophy
-right heart failure
-biventricular failure if not treted
*like OSA with more heart problems!*

Front 235

Obese pts have decreased neck ____ and _____ because of numerous chins and fat pads

Back 235

flexion and extension

Front 236

Obese pts have ___ mouth opening

Back 236

decreased

Front 237

Obese pts have a shortened distance between ____ and sternal fat pads

Back 237

mandible

Front 238

The laryngeal position in obese pts is?

Back 238

high/anterior

Front 239

the obese pts airway is narrowed due to large _____, fleshy ____ and copious flaps of palatal, pharyngeal, supra-laryngeal tissue.

Back 239

tongue
cheeks

Front 240

Obese pts are at a severe risk of _____ due to: GERD, gallstones, hiatal hernia and increased abd pressure.

Back 240

aspiration

Front 241

after an 8hr fast 85-90% of obese pts have gastric volumes of greater than ___ mls and pH less than ___.

Back 241

25mls
2.5
*give 25ml Bicitra before if concern for GERD

Front 242

glucose tolerance is frequently impaired because pancreatic islet cells ______, hyperinsulineamia exists, high prevalence of ____ in obese.

Back 242

hypertrophy
DM

Front 243

Abnormal lipid profiles are associated with increased prevalence of ____ ____ ___.

Back 243

ischemic heart disease

Front 244

Metabolic Syndrome is defined as: (5)

Back 244

-decreased HDL (by >40 women, >50 men)
-HTN
-Increased fasting glucose >100
-Triglycerides > 150
-Waist circ greater than 35 in women, >40 in men

Front 245

Pharmacological considerations for the obese patient are increased...

Back 245

-adipose tissue
-lean body mass
-blood volume
-alpha 1 acid glycoprotein
-CO
-proteins and free fatty acids
-GFR

Front 246

Pharmacological considerations for the obese patient are decreased/abnormal....

Back 246

-decreased PFT
-abnormal liver fxn

Front 247

Pharmacological considerations for the obese patient that is unchanged is....

Back 247

albumin

Front 248

Obesity effects the _____, _____ and _____ of drugs.

Back 248

distribution, binding and elimination

Front 249

body composition, regional blood flow, affinity for plasma proteins and or tissue components are the main factors affecting ___ ____.

Back 249

tissue distribution

Front 250

Obese pts have a high volume of distribution (Vd) meaning that the drug goes to the tissues and is not in the _____ for it to be distributed to vital organ like the brain heart etc.

Back 250

plasma

Front 251

Increased lipid tissue, increased lean body mass, increased blood volume and CO, reduced body water, alterations in protein binding and lipophilicity of a drug all affect ___ in the obese.

Back 251

Vd

Front 252

lipophilic drugs have a ____ Vd

Back 252

increased

Front 253

For lipophilic drugs you need and ___ initial dose, there is a _____ elimination half life and maintenance dosing is _____.

Back 253

larger
longer
decreased

Front 254

Hydrophilic drugs have a ____ Vd.

Back 254

normal

Front 255

hyprophilic durgs have a ____ half life.

Back 255

normal

Front 256

Water soluble drugs are doses on ____ and lipid soluble drugs are dosed on _____.

Back 256

-IBW
-TBW

Front 257

What are some examples of lipophilc drugs?

Back 257

-propofol
-ketamine
-benzos
-fentanyl
-sufentanil
-IAs
*dose on TBW

Front 258

Towards the end of the case, you should consider giving ___ or ___ for pain control because fentanyl/sufenta will last longer in the obese pt.

Back 258

tylenol or toradol

Front 259

What is an example of a hyprdophlic drug?

Back 259

non depolarizing muscle relaxants
*dose on IBW

Front 260

There is (increased/decreased) pseudocholinesterase activity?

Back 260

increased

Front 261

Obese patients are prone to decrased liver fxn (failure) because of (increased/decreased) liver blood flow?

Back 261

increased

Front 262

Metabolism and GFR are (increased/decreased)

Back 262

increased

Front 263

Don't overdose your obese pt...

Back 263

you can always give more!

Front 264

increase cardiac output ____ induction

Back 264

slows

Front 265

increased alveolar ventilation _____ induction

Back 265

speeds

Front 266

Preop Airway Eval Includes

Back 266

-hx of prior anesthetics
-range of motion (TMJ)
-Thyromental Distance
-Mask vent issues (claustrophobic)
-Awake Intubation?

Front 267

Preop Pulm eval includes?

Back 267

-smoking hx
-OSA/OHS
-CPAP
-PFT
-Room air sats
-Baseline ABG/CXR
-Orthopnea-sit up at night?

Front 268

Preop Circ Eval includes?

Back 268

-S&S of CHF
-HTN; angina, PVD, Prior MI
-EKG
-CXR
-Exercise tolerance/chest pain
-ECHO required?
-IV access

Front 269

vascular access is challenging because fat obscures ____ _____.

Back 269

blood vessels

Front 270

Central line placement is difficult because vessels are distorted by _____.

Back 270

anatomy/adipose tissue

Front 271

Obese pts have a total body water of ____% whereas non obese have 60-65%

Back 271

40%

Front 272

EBV in obese pts is

Back 272

50ml/kg

Front 273

avoid rapid rehydration to avoid?

Back 273

cardiopulm compromise

Front 274

Replace blood loss with crystalloids at the ratio of?

Back 274

3:1

Front 275

Volume replacement should be figured out on ____ but also have adjusted body weight calculated too.

Back 275

IBW

Front 276

Obese patients have the appearance of ______.

Back 276

hypovolemia

Front 277

before inducing consider an H2 antagonist (Zantac), Reglan and Bicitra for increased risk of

Back 277

aspiration pneumonitis

Front 278

before induction avoid unnecessary respiratory ____.

Back 278

depressants

Front 279

Semi sitting or reverse trandelenberg may be the best position for ____?

Back 279

induction

Front 280

Obese pts should be treated like ____ _____ which means ____ is indicated.

Back 280

full stomachs
RSI

Front 281

Paralytic doses are based on ____?

Back 281

IBW

Front 282

It is important to align the __, ___ and ___ in obese pts, this will require significant _______ and position changes.

Back 282

OA, LA and PA
ramping

Front 283

Make slow position changes because ____ status can change precipitously.

Back 283

volume

Front 284

all agents should be ___ at the end to minimize sedation at extubation and long acting agents should be _____.

Back 284

tapered
avoided

Front 285

To ventilate the obese patient, the following things should be done (6)

Back 285

-cuffed ETT
-min 50% FIO2
-PPV
-PEEP
-minimize peak airway pressures
-prone/trandelenberg can worsen oxygenation

Front 286

Reverse trandelenburg is the best position for obese pts because it _____ pulmonary compliance and FRC and returns ____ to baseline. It is a better solution than large TV and PEEP

Back 286

increases
PaO2

Front 287

the bladder of the BP cuff should be greater than or equal to ___% of circ

Back 287

75%

Front 288

Goals for maintenance of anesthesia

Back 288

1. strict maintenance of airway
2. adequate skeletal muscle relaxation
3. optimum oxygenation
4. avoid residual effects of NDMR
5. appropriate TV
6. effective post op analgesia
7. effective volume replacement

Front 289

When extubating an obese patient, you should always reverse _____, make sure they are completely ____ and always be ready to ______.

Back 289

NDMR
awake
reintubate

Front 290

Early ___ is important for post op pain relief

Back 290

ambulation

Front 291

_____ anesthesia is sometimes best for post op pain.

Back 291

epidural

Front 292

PCAs are dosed on ____.

Back 292

IBW

Front 293

IM narcs are _____.

Back 293

unpredictable

Front 294

Things to consider in the post op period...

Back 294

1. increased M&M
2. Post-op ventilation
3. ICU for pickwickian pts
4. transport to PACU with O2
5. O2 and pulse ox monitoring (continue CPAP if app.)
6. fowlers position, avoid supine
7. increased risk for DVT, PE and infection

Front 295

For spinal anesthesia, a longer ____ may be required and the procedure can be technically difficult.

Back 295

longer

Front 296

Dose requirements may decrease by ___% for spinal anesthesia

Back 296

20

Front 297

spinal anesthesia in the obese pt makes it difficult to predict level which can _____ onset and lead to a high spinal which causes _____ ____.

Back 297

slow
respiratory compromise

Front 298

_____ spinal anesthesia may be a better option because you can give small incremental doses and assess as you dose.

Back 298

continuous

Front 299

Epidural anesthesia dose is also decreased by 20% because there is a ____ ____.

Back 299

smaller space

Front 300

The Roux-En Y procedure is the _____ _____.

Back 300

gold standard
(pouch from the upper part of the stomach, leads to protein and vitamin deficiencies)

Front 301

Complications after gastric surgery are?

Back 301

-decreased O2 up to 2 days post op
-anastomotic leaks (fever)
-risk of rhabdomylosis
-risk of thromboembolism, infection and atelectasis

Front 302

Clinical Pearls with obese patients:

Back 302

1. Induce with Des, comes off quicker
2. Use precedex for pain control
3. use pressure control vent instead of a volume control mode.

Front 303

What is the definition of aging?

Back 303

not all age-related changes are necessarily present in an older person, no 2 individuals age at the same rate

may include chronological, physiological, and clinical age

Front 304

What is chronological age?

Back 304

- most convenient measure, widely used in clinical settings and aging research
- medicare, most important mechanism for payment of health for elderly, eligible at age 65

Front 305

What subcategories are the groups of older adults divided into?

Back 305

young old 65-74
mid old 75-84
oldest old 85+

Front 306

What is physiological age?

Back 306

- biological age
- progressive changes of physiologic system w age during postmaturation period of life
- with decr physiologic reserve, older adults cannot mount an adequate compensatory response to an insult (surgery, new onset disease process, catastrophic psychosocial event)

Front 307

What are the normal signs of aging?

Back 307

loss of height
gray hair
wrinkles in skin
reduced mvmt coordination

Front 308

What is clinical age?

Back 308

emphasizes that intrinsic physiolgic aging, extrinsic factors, as well as disease processes all contribute significantly to decr physiologic reserve, reduced functional capacity, and altered homeostasis in older adults

Front 309

What are the changes in the brain associated with aging?

Back 309

- volume of cortical gray matter decreases w age
- aging incr CSF and incr ICP
- reduced NTs (dopamine, ACh, NE, 5HT3 -- glutamate not affected)
- memory declines in 40% after age 60
- CBF decr (15-20% CO) in proportion to neural tissue
- preserved cerebral autoregulation of blood flow
- hydrostatic pressure incr

Front 310

Elderly pts need a ____ dose of LAs with peripheral nerve blocks.

Back 310

lower

Front 311

The process of aging causes anatomic changes of the extradural space which constricts the vertebral canal, making it more difficult to...

Back 311

thread an epidural catheter

Front 312

Lipophilic drugs will have a _____ volume of distribution, and will last (shorter/longer).

Back 312

larger, longer

Front 313

Renal failure pts will have a ____ volume of distribution.

Back 313

higher

Front 314

Dehydrated elderly pts will have a _____ volume of distribution.

Back 314

lower

Front 315

What drugs are lipophilic and have a higher volume of distribution in the elderly?

Back 315

fentanyl, propofol -- give lower doses!

Front 316

In the elderly, hydrophilic drugs will have a ____ volume of distribution.

Back 316

lower

Front 317

The elderly have a sensitivity to centrally acting anticholinergic agents such as...

Back 317

scopolamine and atropine

Front 318

Brain sensitivity to most anesthetic agents ____ With age.

Back 318

increases

Front 319

How are benzodiazepine pharmacodynamics different in the elderly?

Back 319

- no change in benzo binding properties of GABA receptors
- ability of midazolam to MODULATE GABA receptor function (can bind but not causing a change/conveying info) varies w age
- suggests alterations in signal transduction

Front 320

In the elderly, a decr in muscle mass and an incr in percentage of body fat leads to..

Back 320

a decrease in total body water

Front 321

In the elderly, decreased volume of distribution for water-soluble drugs can lead to...

Back 321

higher plasma concentration

Front 322

In the elderly, increased volume of distribution for lipid-soluble drugs can lead to...

Back 322

lower plasma concentrations

Front 323

Thiopental is ____ soluble.

Back 323

lipid

Front 324

In the elderly, dosage for local and general anesthetic are _____.

Back 324

reduced

Front 325

In the elderly, epidural anesthetic tends to result in a more extensive ____ spread, but with a shorter ______ and _____.

Back 325

more extensive cephalad spread,
shorter duration of analgesia and motor block

Front 326

Cognitive dysfunction in the elderly postop is multi-factorial and includes...

Back 326

drug effects
pain
underlying dementia
hypoxemia
metabolic disturbances
lower levels of NTs (ACh)

Front 327

What are the age-related cardiac physiologic changes in the elderly?

Back 327

- decr arterial elasticity (incr afterload, incr SBP, LV hypertrophy)
- decr adrenergic activity (decr resting HR, decr 1 bpm per yr over 50; decr max HR, decr baroreceptor reflex)
- 20-30% decr in blood volume

Front 328

What are the common cardiac pathophysiologies in the elderly?

Back 328

- atherosclerosis
- CAD
- essential HTN
- CHF
- cardiac arrhythmias

Front 329

In the absence of disease, what CV functions are preserved in the elderly?

Back 329

- DBP (unchanged or decr)
- CO
- resting systolic cardiac function

Front 330

Diminished cardiac reserve in the elderly may manifest as ...

Back 330

exaggerated drops in BP during induction of general anesthesia

Front 331

Prolonged circulation time in the elderly delays _____ but speeds _____.

Back 331

delays onset of IV drugs,
speeds induction w IAs (IAs dont need circulation, just lung to brain transfer)

Front 332

Elderly pts have less ability to increase their HR to respond to....

Back 332

hypovolemia, hypotension, hypoxia

Front 333

What are the age-related RESPIRATORY physiologic changes?

Back 333

- decr pulmonary elasticity (decr alveolar surface area, incr RV, incr Closing capacity (leads to atelectasis), VQ mismatch, decr arterial O2 tension)
- incr chest wall rigidity
- decr muscle strength (decr cough, decr maximal breathing capacity)
- blunted response to hypercapnia/ hypoxia

Front 334

What are the common RESPIRATORY pathophysiologies of the elderly?

Back 334

emphysema, chronic bronchitis, pneumonia, lung CA

Front 335

In the elderly, mask ventilation may be _____.

Back 335

difficult (endentulous)

Front 336

The elderly have a ____ Risk of aspiration pneumonia and hypoxia.

Back 336

increased

Front 337

The elderly may experience ______ from VQ mismatch.

Back 337

shunting

Front 338

In the elderly, decr FRC and incr Closing volume leads to...

Back 338

more atelectasis

Front 339

In the elderly, post op pain and analgesics contribute to a reduction in _____ and impaired clearance of _____.

Back 339

tidal volume,
impaired clearance of secretions through normal cough mechanisms

Front 340

How is HPV shunting different in the elderly?

Back 340

response is blunted

Front 341

The elderly have a greater sensitivity to narcotic induced...

Back 341

respiratory depression

Front 342

What should the preop eval entail for elderly pts?

Back 342

- H/P
- CXR
- Spirometry
- ABG, ECG, exercise/stress test, echo, labs

Front 343

How is O2 consumption different in the elderly?

Back 343

basal and maximal O2 consumption declines

Front 344

How is heat production and loss affected with aging?

Back 344

heat production decr
heat loss incr

Front 345

What occurs in hypothalamic temperature regulating centers with aging?

Back 345

resets to a lower level

Front 346

Elderly patients have _____ insulin resistance, ____ response to beta-adrenergic agents, and _____ NE levels.

Back 346

incr insulin resistace
decr response to beta agents
incr NE levels

Front 347

How is GI function affected with aging?

Back 347

- decr liver mass
- decr hepatic blood flow
- decr hepatic function reserve
- decr biotransformation rate and albumin production
- decr plasma cholinesterase (in men)
- incr gastric pH
- prolonged gastric emptying

Front 348

What are the age-related RENAL physiological changes with aging?

Back 348

- decr RBF: decr renal plasma flow, decr GFR
- decr renal mass
- decr tubular function: impaired Na handling, decr concentrating ability, decr diluting capacity, impaired fluid capacity, decr drug excretion
- decr renin-aldosterone responsiveness (impaired K excretion)

Front 349

In the elderly, impaired renal Na handling can lead to...

Back 349

over or under excretion fo Na (And accompanying fluid)

Front 350

What are the common RENAL pathophysiologies of the elderly?

Back 350

- diabetic nephropathy
- HTN nephropathy
- prostatic obstruction
- CHF

Front 351

Why is serum Cr level unchanged w aging?

Back 351

decr in muscle mass accompanies it

Front 352

How are BUN and ability to reabsorb glucose changed in the elderly?

Back 352

incr BUN
decr ability to reabsorb glucose

Front 353

What are the musculoskeletal changes associated with aging?

Back 353

- muscle mass reduced
- NMJ thickens
- skin atrophies
- veins frail
- arthritic joints interfere w positioning and regional anesthesia

Front 354

Albumin, which tends to bind ____ Drugs, will ____ with age.

Back 354

acidic, decreases

Front 355

AAG, which binds ____ Drugs, will ____ with age.

Back 355

basic, increase

Front 356

MAC anesthesia requirements _____ with age.

Back 356

decrease -- 4% per decade over 40 yrs old

Front 357

The onset of IAs will be faster if... and delayed if....

Back 357

faster if CO is depressed

and it will be delayed if signification VQ mismatch

Front 358

With aging, the myocardial depressing effects of IAs are _____.

Back 358

exaggerated

Front 359

Isoflurane reduces ____ and ____ in the elderly.

Back 359

CO, HR

Front 360

In the elderly, recovery from IAs may be _____.

Back 360

prolonged

Front 361

How is the thiopental dose different in the elderly?

Back 361

1/2 induction dose needed for octogenarian, as compared w 20 yr old

Front 362

How is diazepam administration different in the elderly?

Back 362

VD is larger and elimination is longer

Front 363

How is lorazepam administration different in the elderly?

Back 363

elim half life remains relatively unchanged

Front 364

How is the administration of muscle relaxants different in the elderly?

Back 364

- succ and non-depol. are unaltered
- decr CO my cause up to 2-fold prolongation in onset
- non depol MRs that depend on renal excretion may be delayed
- non depol MRs that depend on hepatic excretion may have prolonged half life and duration of action

Front 365

the periop plan must take into account the ____ and ____ changes of aging as they impact surgical and anesthetic management

Back 365

psychological and physiological

Front 366

What are the common Nervous System changes related to aging?

Back 366

-decreased CBF and brain mass
-degenration of peripheral nerve cells leads to prolonged conduction velocity and muscle atrophy
-increased threshold for sensory modalities
-pain perception changes are poorly understood
-dose requirements of many anesthetic agents decrease

Front 367

make sure to allow sufficient ____ for IV drugs to circulate from the IV site to the heart to the brain before you ____ again!

Back 367

time
dose

Front 368

decrease in the neurotransmitters dopamine, acetylcholine, norepi and serotonin causes...?

Back 368

a decreased ability to respond stress

Front 369

elderly have are sensitive to centrally acting anticholinergics like ____ and ___ because of decreased neurotransmitters

Back 369

scopolamine and atropine

Front 370

delirium, dementia and depression are predictors of ____ patient outcome

Back 370

poor
(age, poor cognitive fxn, poor physical condition, alcohol abuse, AAA, non cardiac surgery, abnormal Na K or glucose)

Front 371

delirium occurs ___ to ___ % of the time after general surgery. This number increases to 28-61% after orthopedic surgery due to fatty emboli being released.

Back 371

10-15%

Front 372

the length of stay for patients with delirium increases by ___%

Back 372

60

Front 373

what are the major symptoms of delirium?

Back 373

-abrupt change in cognition and consciousness

Front 374

Do not give ____ to elderly pts because it increases their risk of delirium 2-7x that of other opioids (long acting)

Back 374

meperidine

Front 375

____ and long acting ____ also increase the risk of post op delirium

Back 375

barbituates and benzos

Front 376

when an elderly person gets a spinal anesthetic it will?

Back 376

last longer

Front 377

fibrosis of the SA node, atrophy of pathways, loss of pacemaker cells, sick sinus syndrome, hemi-blocks, BBB, SV and vent ectopy put elderly patients at risk for?

Back 377

arrhythmias

Front 378

Recent MI, uncompensated CHF, unstable ischemic heart disease and certain rhythm disorders are?

Back 378

the strongest predictors of adverse cardiac events

Front 379

unstable coronary syndrome, decompensated CHF, and severe valvular disease are all?

Back 379

major clinical predictors
*evaluate and treat prior to elective non cardiac surgery

Front 380

mild angina, prior MI, compensated CHF and DM (realatively controlled) are all?

Back 380

intermediate clinical predictors

Front 381

advancing age, abnormal EKG, rhythm other than sinus, low functional capacity, hx of CVA and uncontrolled HTN are all?

Back 381

minor clinical predictors

Front 382

functional capacity based on expenditure is measured by ____?

Back 382

METs

Front 383

eating, dressing, walking 1-2 blocks and light house work is?

Back 383

1-4 METs

Front 384

climbing stairs, walking up a hill, heavy house work, golf, bowling, tennis and dancing is?

Back 384

4-10 METs

Front 385

continuing beta blocker therapy is important because it has shown to reduce...?

Back 385

long term (6 month) mortality rates

Front 386

Antihypertensives should be continued during the periop period except?

Back 386

ACE inhibitors-hold the am of surgery

Front 387

Continue beta blocker and ____ even if the pt is NPO.

Back 387

clonidine

Front 388

Arthritis of the TMJ/C-spine makes for a?

Back 388

challenging intubation

Front 389

the lack of upper teeth can actually help with _____ of vocal cords during laryngoscopy.

Back 389

visualization

Front 390

to prevent periop hypoxia ____ FiO2 concentrations, give PEEP and provide aggressive pulmonary ____.

Back 390

increase
toileting

Front 391

pulmonary disease ____ the risk of periop complications.

Back 391

increases

Front 392

preop functional level is a reliable ____ of pulmonary complications periop

Back 392

predictor

Front 393

patients with severe preexisiting respiratory disease, following major abdominal and chest surgery should potentially?

Back 393

be left intubated after surgery

Front 394

more agressive ___ ____ should be considered for patients with existing lung conditions

Back 394

pain management
(epidurals, intercostal blocks)

Front 395

the additive effect of the supine position, general anethesia and thoracic or abd incisions leads to ____ FRC and ____ airways resistance

Because of this the elderly are predisposed to _____, _____ and infection

Back 395

decreased
increased

atelectasis
hypoxemia

Front 396

Keep elderly patients covered and ____

Back 396

warm!

Front 397

adverse effects of hypothermia include (8)

Back 397

-bleeding
-decreased immune fxn
-decreased wound strength
-impaired platelet fxn
-inhibition of clotting cascade
-decreased drug metabolism and clearance
-increased risk of infection
-increased incidence of MI

Front 398

Arthritic joints may become problematic with ____ and ____.

Back 398

positioning and regional anesthesia

Front 399

Joint mobility should be assess when?

Back 399

prior to induction

Front 400

With positioning it is important to watch for nerve _____ or over _____.

Back 400

compression
stretching

Front 401

Atlanto-occipital degeneration may make airway manipulation more difficult due to?

Back 401

cervical stenosis/spondylosis

Front 402

benzos like midazolam and diazepam can contribute to prolonged ____.

Back 402

confusion

Front 403

____ can contribute to increased secretions, bronchodilation, increased ICP and increased delirium

Back 403

ketamine

Front 404

Etomidate is less cardiac ____ than propofol

Back 404

depressing
-rapid recovery from hydrolysis to inactive metabolites
-clearance is hepatic and blood flow dependent
-high incidence of post op N&V
-depression of adrenocortical fxn

Front 405

Induction dose of propofol in the elderly is?

Back 405

1.2-1.7 mg/kg
-rapid onset
-lasts 5-10 mins
-produces dose dependent CV and resp depression

Front 406

How can hypotensive effects of propofol be minimized?

Back 406

push it slowly and titrate it to effect