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403 Cards in this Set

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Q: Of the various types of white blood cells (leukocytes), which is most abundant?

neutrophils (also referred to as polymorphonuclear leukocytes) are the most abundant WBCs

Q: Neutrophils comprise what percent of the total WBC(leukocyte) population? What stimulates the neutrophil count to increase?

neutrophils are 55% of the leukocyte population. Any inflammatory stimulus, including bacterial infection, increases the neutrophil count.
Q: what is the normal platelet count?
150,000 to 400,000 platelets per ml
Q: Where is erythropoietin made? What stimulate the release of erythropoietin do?
The 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.
Q: what are the steps in primary hemostasis
adhesion, activation, aggregation of plts, fibrin production
Q: plts have an avg lifespan of how many days
8-12
Q: what is the normal plt count
150,000-400,000
Q: when vascular endothelium is damaged and the subendothelium of the blood vessel is exposed what anchors the plt to the collagen layer of the subendothelium
vWF
Q: what does vWf promote
plt adhesion
Q: where is vWf made and released from
endothelial cells
Q: what is the most common inherited coagulation defect
von willebrands disease
Q: what is DDAVP
a non pressor analog of arginine vasopression
Q: what is the dose of DDAVP
.3 ug/kg IV infusion over 15-20 minutes
Q: what is a side effect in children when using DDAVP
hyponatremia
Q: what is the traditional treatment of vW disease
cryoprecipitate,or DDAVP
Q: what does cryoprecipitate consist of
VIII and I
Q: Pts who do not respond to DDAVP should receive what
cryo or factor VIII
Q: Thrombin activates the plt by combining with the thrombin receptor on the plt to release what
TXA2 and ADP
Q: what does TXA2 do
it vasoconstricts
Q: what does ADP do
attracts more plts
Q: what does TXA2 and ADP uncover
fibrinogen receptors and fibrinogen attaches to its receptors and links plts together
Q: what does TXA2 do
increases ADP release, opens fibrinogen receptors, vasoconstricts
Q: how does ASA render plts dysfunctional
the acetyl group of ASA causes acetylation of cyclooxygenase
Q: How long does ASA render plts dysfunctional
8-12 days
Q: what is the rate limiting step in the conversion of AA to TXA2
cyclooxygenase
Q: How long do NSAIDS render plts dysfunctional
24-48 hours
Q: how does ticlid work
inhibits ADP-induced fibrinogen aggregation of plt drugs
Q: How does persantine work
it increases cAMP in plts and thus prevents aggregation of plts
Q: cyclooxygenase converts AA to what initially
prostaglandin G2
Q: what is PGG2 metabolized to
PGH2
Q: what is the most common acquired blood clotting defect
inhibition of cyclooxygenase by ASA and NSAIDS
Q: What is the name of factor I, where is it made and is it Vit K dependent
fibrinogen/liver/no
Q: what is II called, where is it made and is it Vit K dependent
prothrombin/liver/yes
Q: what is III called, where is it made and is it Vit K dependent
tissue factor or thromboplastin/vascular wall and cells/release by traumatized cells/Not vit k dependent
Q: what is IV called, where is it made and is it Vit K dependent
calcium/diet/no
Q: what is V, where is it made and is it Vit K dependent
proaccelerin/liver and other tissues/no
Q: what is VII called, where is it made and is it Vit K dependent
proconvertin/liver/yes
Q: what is VIII:C called, where is it made and is it Vit K dependent
antihemophilic factor/liver/no
Q: what is VIII:vWF called, where is it made and is it Vit K dependent
Von Willebrand factor/vascular endothelial cells/no
Q: what is IX called, where is it made and is it Vit K dependent
christmas factor/liver and other tissues/yes
Q: what is X called, where is it made and is it Vit K dependent
stuart-prower factor/liver/yes
Q: what is XI called, where is it made and is it Vit K dependent
plasma thromboplastin antecedent/liver/no
Q: what is XII called, where is it made and is it Vit K dependent
hageman factor/liver/no
Q: what is XIII called, where is it made and is it Vit K dependent
fibrin stabilizing factor/liver and other tissues/no
Q: where is prekallikrein factor made and is it vit K dependent
liver/no
Q: where is high molecular weight kininogen factor made and is it Vit K dependent
liver/no
Q: what are the Vit K dependent factors
2,7,9,10
Q: what factor causes the cross-linking of fibrin strands
coag factor XIII
Q: after plts aggregate what happens
fibrin is weaved into plts and cross linked
Q: Heparin affects what pathway
intrinsic
Q: what pathway does coumadin affect
extrinsic
Q: what factors comprise the intrinsic path
12, 11, 9, 8
Q: what factors comprise the extrinsic path
3 and 7
Q: what factors comprise the common path
10, 5, 2, 1, 13
Q: Hemophilia A (factor VIII:C deficiency) is a genetic disorder, describe it
it is a sex linked genetic disorder that is carried by the female member of a kindred and effects males almost exclusively
Q: how do you treat hemophilia A
FFP and cryo, VIII in low concentration
Q: How is hemophilia B (christmas disease) treated
heat treated, concentrated preparations of factor IX are available
Q: what is the best measure of plt function
a standardized skin bleeding time
Q: what is the most common reason for coagulopathy in pts receiving massive blood transfusions is the lack of what
functioning plts
Q: Plts in stored blood are nonfunctional after how many days
1 to 2 days
Q: what is the only clinical indication for transfusion of PRBC
to increase the oxygen carrying capacity of the blood
Q: all procoagulants except what are in FFP
plts
Q: cryoprecipitate contains what
factor VIII, factor I and factor XIII
Q: what does activated antithrombin III bind to
thrombin (IIa) and factor Xa greatly and factors IX, XI, and XII to a lesser degree
Q: what disease processes are associated with antithrombin III deficiency
nephrotic syndrome and cirrhosis of liver
Q: what is adequate heparinization indicated by
ACT greater than 400
Q: what should you do if the ACT is not greater than 400 (if indicated of course)
give FFP
Q: how does protamine work
combines electrostatically with heparin (positive substance combines with negative substance) to form an inactive salt
Q: how does coumadin work
binds to Vit K receptors in the liver and competitively inhibit Vit K
Q: what is a normal bleeding time
3-10 minutes
Q: what is a normal PT
12-14 seconds
Q: what is a normal PTT
25-35 seconds
Q: what is a normal thrombin time
12 - 20 seconds
Q: what is a normal ACT
80-150 seconds
Q: how does plasminogen work
it works itself into a clot and tPA and urokinase type drugs convert it to plasmin and thus breaks down fibrin into FSP
Q: where is tPa made
in the endothelial cells
Q: what stimulates tPa release
venous stasis and thrombin
Q: where is uPa found
limites stores in blood and has little affinity for fibrin, thus activates any circulating plasminogen
Q: what produces streptokinase
beta-hemolytic streptococci and also has little affinity for fibrin
Q: how does aprotinin work
it inhibits plasmin, thus fibrin breakdown is slowed
Q: how does amicar work
by inhibiting binding of plasmin to fibrin
Q: why should you never give aprotinin twice
anaphylaxis potential
Q: what are some conditions that contribute to DIC
sepsis, hemolysis, transfusion rxn, ischemia, trauma, hypotension/hypoperfusion, OB emergencies, aneurysms, hamangiomas, allograft rejections, glomerulonephritis
Q: how does DIC present
bleeding, oozing from tubes, wounds and IV sites
Q: what are some lab abnormalities with DIC
decreased plts, decreased fibrinogen, decreased prothrombin, decreased level of V, VIII, and XIII, and increased FSP
Q: what is the most common cause of isolated high PT
liver disease
Q: what is transfused blood deficient in
plts and V & VIII
Q: what is diffuse bleeding usually caused by
thrombocytopenia
Q: What are the concerns with a noncardiac surgery pt with CHF?
IHD and CHF are historically the strongest predictors of an increased risk for periop MI and increased risk of Postop death.
Q: Your pts creatinine clearance of 18 ml/min is indicative of CRF. Which of the following drugs should you be concerned with in your pt? digoxin, quinidine, vecuronium, or atracurium?
digoxin as it most depends on renal exrection.
Q: Does concentric hypertrophy decrease wall tension?
Yes, as thickness increases tension decreases (T=Pr/2h)
Q: What three hormones are involved in rebound HTN assoc with d/c of clonidine?
increased catecholamines, increased renin, increased angiotensin II
Q: In addition to the NMDA receptor, ketamine works on what other receptors?
nicotinic, muscarinic, opioid
Q: What causes serum alkaline phos. to increase?
Biliary tract obstruction causes a 3 fold increase
Q: What valve problem may be assoc. with both a systolic and a diastolic murmur if the pt has a HR of 100 and BP of 135/45?
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)
Q: 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
Q: 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 depolarizationIt works secondarily on Phase 2 of the ventricular muscle action potential, but this is not the best answer
Q: Would administration of adenosine via an endotracheal tube be effective?
NO, it is rapidly metabolized in the plasma by adenosine deaminase.
Q: As the needle is being inserted for SAB, you feel a pop. What has occurred?
The dura has been penetrated. Penetration of the dura produces a subtle "pop" that is not most easily detected with pencil-point needles.
Q: Compared with cardiac muscle cells and junctional tissue (SA and AV nodes), how fast do purkinje fibers conduct impulses?
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
Q: What is the most potent local vasodilator substance released by cardiac cells?
adenosine
Q: What constituent of extracellular fluid determines ECF volume? Why?
Sodium, when sodium is retained water is retained to keep ECF osmolality at about 300 mOsm/liter and volume increases
Q: What is an anaphylactoid reaction?
resembles anaphylaxis but does not involve IgEDirect action on mast cell
Q: How does severe acidosis alter pulmonary vascular resistance and systemic vascular resistance?
Acidosis increases PVR and decreased SVR
Q: 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)
Q: What valve problem (AS, AR, MS, MR) may be associate with both a systolic and diastolic murmur?
AS, there is a midsystolic ejection murmur that peaks in late systole with often a faint murmur of minimal aortic regurg
Q: How much Morphine is protein bound in the adult? In the neonate?
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.
Q: How does ketamine produce dissociative anesthesia?
depresses neuronal function in parts of the cortex and thalamus while simultaneously stimulating parts of the limbic systemChemical Thalmectomy
Q: The CNS actions of ketamine appear to be primarily r/t its actions at what receptor?
NMDA
Q: Barbiturates, BDZs, propofol, and etomidate produce their CNS actions by working on what receptor?
GABA
Q: The dysphoria associated with ketamine is caused by what?
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
Q: Identify the receptors that ketamine interacts with to promote dysphoria.
Kappa agonism, muscarinic antagonism, sigma agonism
Q: By what mechanism does cocaine alter sympathetic function?
blocks reuptake of NE
Q: Describe the interactions of TCAs with five groups of drugs?
1) anticholinergics increase likelihood of postop delerium2) Sympathomimetics could exaggerate pressor responses3) PIAs increase incidence of arrythmias4) antihypertensives could have rebound HTN5)Opioid effects may be augmented
Q: Normal MMEF (FEF 25-75) is?
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.
Q: The diagnosis of DM is based on what laboratory values?
polyuria (2-15 liters per day)HypernatremiaHigh serum osmolalitydecreased urine SG (1.005 or less)
Q: 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
Q: The Dx of the syndrome of inappropriate ADH secretion (SIADH) is based upon what labs?
Na concentration 100-150 mosm/kgdecreased urine/plasma osmolality less than 270Hyponatremia
Q: N2O should be avoided in what pediatric procedures?
diaphragmatic hernia, bowel obstruction, pneumoencephalogram, tympanoplasty, congenital emphysema, lung cysts, pneumothorax, NEC, PDA and OMPHALOCELE
Q: What is the Hg concentration at 2 weeks of age? 2-3 months? 2 years?
13-19< 10-11<12.5
Q: What agent decreases a right to left shunt?
Phenylephrine, by increasing SVR
Q: Describe the newborn with meningomyelocele?
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.
Q: What are the concerns for anesthetizing the newborn with meningomyelocele?
The pt may not be able to lay supine for intubation due to possible sac disruption. The awake lateral decubitus position may be necessary
Q: 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)
Q: What nerves are blocked for repair of an inguinal hernia?
ilioinguinal and iliohypogastric
Q: 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 cautery1) intravascular volume needs to be restored and 2) full stomach precautions
Q: Give two reasons why a change in OB epidural anethesia dosing is necessary?
1) neurons are more sensitive to LA2) IVC compression increases blood flow through epidural plexuses and decreases potential volume of epidural space.
Q: When giving an epidural to a parturient, how much should you decrease the dose?
25-50% or 33% in some texts
Q: Severe HTN may occur if the pregnant pt is given a pure alpha agonist and the pt is also receiving what other med?
methergine
Q: The pregnant pt requires an appendectomy emergently. How do you premedicate?
Gastric prep with 30 cc Citra and possibly robinul for antisialagogue*Appendectomy is most common emergent surgery with pregnancy
Q: 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
Q: 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
Q: 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
Q: How common is incidental or gestational thrombocytopenia?
occurs in 7.6% of all pregnancy and does not appear to have deleterious effects on mother or fetus.
Q: Curent evidence now suggests that inhaled anesthetics work on what receptor?
GABA
Q: The pt in labor has a hx of multiple sclerosis. She becomes hypotensive. What is the agent of choice to treat this hypotension.
A specific interaction b/w multiple sclerosis and the treatment of hypertension is not discussed in textbooks. Therefore treat the hypotension as you would for the normal OB Pt.1) LUD2) IV hydration3) Vasopressors
Q: What blood products reverses the effects of warfarin therapy?
FFP
Q: What is the anion gap? What is the utility of measuring the anion gap?
AG = major measured cations - major measured anions = Na - Cl - HCO3 = 12 meq/liter(range 9-15)It is used as differential for met. acidosis as some forms have AG > 25
Q: What are causes of high anion gap metabolic acidoses?
1) acids are not excreted by kidney (CRF or uremia)2) increase in endogenous acid production (both lactic acidosis and ketoacidosis are assoc with High AG)3) exogenous acids are ingested (methanol or ethylene glycol)
Q: What are causes of normal AG metabolic acidosis?
1) GI loss of bicarb (diarrhea)2) Renal loss of bicarb (pts taking carbonic anhydrase inhibitors)3) ECF volume is expanded rapidly (large infusion of NS)4) large quantity of ammonium chloride or arginine hydrochloride is given
Q: Heat is lost from the body by conduction, convection, evaporation, and radiation. Rank these from most to least heat loss.
Radiation>convection>evaporation>conduction
Q: For each degree celsius decrease in temp, metabolism decreases by what percent?
7%
Q: During a TURP, confusion and restlessness occur, blood pressure increases to 165/105, ECG changes are noted (widened QRS and elevated ST segment), and then the pt seizes. What will happen?
These are S/S of TURP syndrome and the cause is hyponatremia. Coma and arrest will follow without treatment.
Q: What actions should be initiated if TURP syndrome develops.
1) O2 and circulatory support2) notify surgeon to stop procedure ASAP3) use invasive monitors if CV status is instable.4) send lytes, creatinine, glucose and ABG5) obtain twelve lead6) treat severe symptoms with hypertonic (3%) saline at rate <100ml/hour. (treat mild symptoms with fluid restriction and loop diuretic)
Q: Your healthy young pt is in the sitting position for an open craniotomy under GETA when suddenly ETCO2 drops, what is the probable cause?
sudden drop in ETCO2 followed by sudden rise in nitrogen is cause by VAE
Q: What actions should you take with VAE?
notify surgeon to flood field, turn off N2O, 100% O2, aspirate air from central line, irrigate op site with fluid and use bone wax, infuse fluids to increase venous pressure, give pressors, temporarily compress right and left juglular veins to increase vertebral venous pressure and slow air entrainment, and place pt in horizontal position if possible.
Q: If your initial action to treat VAE fail, what position should you place the pt.
LLD with head down (trend)
Q: When do S/S of hypocalcemia after thyroidectomy develop?
24-72 hours but may manifest 1-2 hours post surgery.
Q: Following a parathyroidectomy, your pt becomes dyspneic one day post surgery. What do you suspect and what do you do?
hypocalcemia, give 10 ml of calcium gluconate over several minutes and follow with 1-2 mg/kg/hour of elemental calcium until symptoms disappear.
Q: What are the two causes of stridor after thyroidectomy?
hypocalcemia secondary to removal of parathyroid bliateral damage to RLNs
Q: Why would a pt having undergone thyroidectomy develop laryngospasm?
hypocalcemia secondary to removal of parathyroids, laryngeal muscles are very sensitive to decreased calcium.
Q: Treatment of tetany in the hypoparathyroid pt consists of administering what?
calcium gluconate IV
Q: After a laryngospasm that was treated with succinylcholine and reintubation, what additional actions may be beneficial for the patient?
assist ventilation and sedation.
Q: Postop, your pt develops a laryngospasm which is ultimately treated successfully with succinylcholine. Pink frothy sputum is now present. What would you expect and what is your course of action?
Negative pressure pulmonary edemaincrease FiO2, CPAP, PEEPDiuretics and fluid restriction typically not required as this is usually self correcting within 24 hours.
Q: The 78 yr old female pt has a pacemaker. During the case, the ECG reveals a-fib with severe bradycardia. O2 is given and the airway is controlled, what is your next action.
Atropine 0.5 to 1.0 mg repeated up to three times.
Q: What is the major concern for noncardiac surgery pt with CHF?
increased risk for postop death
Q: Your patient had a total knee replacement under spinal with tetracaine. Several hours postop she is complaining of severe pain in both extremities. You should do what?
give pain medicine as this procedure is assoc with significant postop pain.
Q: What seven cardiac parameters are observed or estimated with 2D TEE?
Ventricular wall motion, valve motion, ejection fraction, CO, Blood flow characteristics, intracardiac air, intracardiac mass
Q: 2D TEE is a sensitive indicator of wall motion abnormalities. Furthermore, wall motion abnormalities may be more sensitive indicators of MIsch than ECG changes. List and define the four types of abnormal wall motion.
Hypokinesis - presence of less than normal ventricular motionHyperkinesis - presence of greater than normal motionAkinesis - absence of motionDyskinesis - paradoxic outward motion of ventricle
Q: Where on the capnograph tracing is found dead space plus alveolar ventilation?
throughout expiration on the tracing
Q: What evoked potential is monitored during transphenoidal surgery?
Visual (CN II)
Q: The wake up test monitors what region of the spinal cord?
ventral cord supplied by anterior spinal artery
Q: What 3 antiemetics should be avoided in the parkinson pt? What antiemetic might be used to treat postperative nausea in parkinsons's patients?
inapsine, compazine, reglanZofran is acceptable.
Q: In a pt with cirrhosis of the liver, why is it impt to maintain BP?
BP must be maintained b/c liver does not autoregulate (hepatic artery)
Q: What S/S of acute porphyria?
acute abdominal pain, neurotoxicity, sensory and other neuropathies
Q: Of the following tests, which is best for determining CAD: resting ECG, Holter monitoring, stress ECG (exercise), stress thallium ECG
stress (exercise) test/ecg
Q: What four groups of pts are at risk for intraop hypothermia?
1) pediatric2) geriatric3) hypothyroid4) those with hypothalamic lesions
Q: The gas that enters the bellows during expiration has what composition?
During the expiration phase of the ventilatory cycle, exhaled gases from the patient and fresh anesthetic gases flow into the bellows.
Q: Identify the 13 best selling herbal medicines/supplements and also give the scientific name.
ginseng - pana ginsengginkgo - ginkgo bilobagarlic - allium sativumglucosamineSt. John's wort - hypericum perforatumEchinacea - echinacea angustifolia, e. purpurae, e. pallidalecithin chondroitincreatinesaw palmetto - serenoa repensephedra - ma-huangkava kava - piper methysticumvalerian - valeriana officinalis
Q: What happens to intrapulmonary pressure during normal inspiration? Expiration? When is intrapulmonary pressure zero?
Intrapulmonary pressure becomes negative or subatmospheric during inspiration and positive (above atm pressure) during expiration. Intrapulmonary pressure is zero at end expiration and at end inspiration.
Q: If the patient with cardiac tamponade need to be induced, what agent should be selected?
Ketamine and 100% oxygen after decompression of pericardial space.
Q: What should the preop eval of the pt with DM focus on? why?
End organ complications - predictor of periop M&M
Q: How does FRC compare with CC in the morbidly obese pt in supine position?
CC exceeds FRC in morbidly obese pt in all positions.
Q: How does ERV compare with CV in the morbidly obese individual in the supine position?
Closing volume exceeds expiratory reserve volume in the standing, supine and T-burg position.
Q: Identify the opioid most likely to be administered epidurally as a bolus for postop pain control after mixing with 10ml of preservative free saline.
Fentanyl. Fentanyl is the most commonly used lipophilic agent administered as a bolus into the epidural space for analgesia. It is mixed in 10 ml of preservative free normal saline. Other lipophilic opioids are mixed in the following volumes of preservative free saline:sufenta (10-60ug) in 10-20mlDemerol (25-100ug) in 10 mlhydromorphone (.5-2 mg) in 10 ml
Q: List five adverse effects of mannitol administration.
1) pulmonary edema and cardiac decompensation owing to increased (mannitol induced) in intravascular volume2) Rebound increase in ICP if BBB is not intact3) Hypovolemia4) Hyperkalemia5) Hyponatremia
Q: A trauma patient has a fracture of T1, at the time of injury, what happens to BP and heart rate.
This is acute spinal shock, hypotension develops because the sympathetic outflow to blood vessels ceases; blood vessels dilate causing the decrease in blood pressure. Since the cardiac accelerator fibers are involved (T1-4) bradycardia occurs.
Q: Relate "convulsant activity" to the "seizure threshold". How does acidosis affect convulsant activity? How does acidosis affect seizure threshold.
Acidosis increases seizure threshold and decreases convulsant activity.
Q: The sympathetic response to spinal anesthesia occurs because LAs act on what neurons?
sympathetic PREganglionic EFFerents
Q: The anesthetic level reached after SAB is determined by what four factors?
1) baricity of solution2) concentration (increasing concentration increases spread)3) contour of spinal canal4) position of patient in the first few minutes after placement
Q: What muscles are innervated by the ulnar nerve?
in the foream - flexor carpis ulnaris, medial half of flexor digitorum profundusin the hand - palmaris brevis, three short muscles of hypothenar eminence, the adductor pollicis and 3rd & 4th lumbricals and all the interossei
Q: When performing an epidural, what should alert the anesthetist to the fact that an intrathecal injection has occurred?
A profound motor block and sensory block soon after an unintended SA injection should alert the anesthetist to the fact that an intrathecal injection has occurred. The next S/S of high spinal are 1) dyspnea caused by absence of proprioceptive input from afferent nerves of abdominal and intercostal muscles, 2) respiratory arrest if block spreads to cervical regions C3-C5, 3) High concentration of LA reaches cranium and LOC, respiratory arrest and hypotension occur.
Q: The ulnar nerve passes distally through the axilla, medial to the distal artery and the brachial artery, until the middle of the arm. Before passing to the forearm, the ulnar nerve pierces the medial intermuscular septum and descends in the groove b/w what two stuctures.
the medial epicondyle of the humerus and the olecranon process of the ulna.
Q: The median nerve innervates what muscles of the forearm.
pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis
Q: What nerve is least likely to be blocked with the axillary approach to the brachial plexus? Why?
The musculocutaneous nerve is least likely to be blocked with the axillary approach to the brachial plexus b/c within the axilla, this nerve has already left the sheath and lies within the coracobrachialis muscle.
Q: What local anesthetics are used for IVRA of the upper arm? What volume and what concentrations are administered?
40-50 ml of 0.5% lidocaine or 0.5% prilocaine are usually injected
Q: Which three of the five sensory nerves of the foot are usually blocked by the superficial infiltration.
superficial peroneal, sural, and the saphenous
Q: While performing an epidural, what signs and symptoms would lead the anesthetist to suspect that an intrathecal injections has occurred?
1) dyspnea with levels higher than T2 secondary to absence of proprioceptive input from the afferent fibers in the abdomen and intercostals2) respiratory arrest if C3-5 affected3) profound hypotension if LA passes through foramen magnum and blocks the cranial nerves, a "total spinal"
Q: Complications of epidural block differ from SAB in what way?
There is increased likelihood of intravascular injection and systemic toxicity with epidural block.
Q: What causes the backache associated with epidural anesthesia?
unclear, but could be needle trauma, local anesthetic irritation, ligamentous strain secondary to muscle relaxation
Q: What prophylactic treatments should be given in an emergency appendectomy?
1) antacid2) H2 blocker3) reglan4)RSI/C
Q: How does the intrapleural pressure fluctuate during normal tidal breathing?.
Intrapleural pressure is negative at the onset of inspiration and becomes more negative during inspiration. During expiration, intrapleural pressure becomes less negative.
Q: Which zone of the lung (1,2,3) has the greatest alveolar oxygen partial pressure and which zone has the greatest alveolar CO2 partial pressure when the patient is upright?
Zone 1 the non dependent lung has the highest PaO2 and zone 3 the dependent lung has the highest PACO2.
Q: Compare intrapleural pressure in the dependent versus nondependent lung?
Intrapleural pressure is less negative (or greater) in the dependent lung and more negative (lower) in the nondependent lung
Q: How does the alveolar partial pressures of O2 and CO2 vary from base to apex when the patient is upright?
The alveolar partial pressure of O2 (PAO2) is higher in the apex and lower in the base, and the alveolar partial pressure of CO2 (PACO2) is lower in the apex and higher in the base.
Q: Compare Pulmonary arterial blood pressur and intrapulmonary pressure in Zone 2 of the lung. Is Zone 2 perfused? What is the perfusion pressure gradient in Zone 2?
PABP is higher than alveolar pressure in Zone 2. Zone 2 is perfused. The perfusion pressure gradient in Zone 2 is PABP minus PA.
Q: Compare pulmonary arterial blood pressure and intrapulmonary pressure in Zone I. Is Zone 1 perfused? Why or Why not?
Intrapulmonary pressure exceeds pulmonary arterial blood pressure in Zone 1. Zone 1 is not perfused because pulmonary artery pressure is less than alveolar pressure. The alveolar capillaries are collapsed.
Q: How do pulmonary arterial and venous blood pressures compare to intrapulmonary pressure in Zone 3 of the lung? What is the perfusion pressure gradient in Zone 3?
Pulmonary arterial and venous pressures exceed alveolar pressure in Zone 3. The perfusion pressure gradient in Zone 3 is the difference between the pulmonary arterial blood pressure and the venous blood pressure.
Q: What is the normal venous-arterial CO2 content difference (CvCO2-CaCO2)? How many ml of CO2 are eliminated from each 100ml of blood?
The normal difference is 4mlCO2/100ml blood. Hence 4ml CO2 are eliminated per 100 ml of blood.
Q: What is the difference between physiologic and anatomic dead space?
Physiologic dead space is the sum of anatomic dead space and alveolar dead space. Physiologic dead space minus anatomic dead space is therefore alveolar dead space. Alveolar dead space is caused by unperfused or poorly perfused alveoli. Hence, the difference between physiologic dead space and anatomic dead space is unperfused or underperfused alveoli.Vd(phys) = Vd(anat) + Vd(alveolar)
Q: What intrinsic laryngeal muscle dilates the cords?
PCA (post. cricoarytenoids)
Q: Injury to what nerve will prevent the vocal cords from coming together? What intrinsic laryngeal muscles are involved?
RLN, the paralyzed cords assume a position intermediate b/w the abducted and adducted states. The lateral cricoarytenoids causes adduction of the cords.
Q: If you have a known difficult airway with an aspiration risk, what steps can be taken to minimize problems during intubation?
1) gastric prep2) robinul3) awake intubation with topicalization of airway (topical LA should be limited to above the glottis in order to maintain airway reflexes)
Q: What lab value would you order for a healthy 35 y/o male scheduled for hernia surgery?
None for healthy males less than 40 and HgB/BHCG for females less than 40.
Q: Cryoprecipitate is derived from what?
It is the fraction of plasma that precipitates when FFP is thawed at 4 degreees Celsius.
Q: What does citrate do in stored blood?
Anticoagulant by binding calcium (results in lack of ionized calcium)
Q: What volume expander expands volume for 36 hours?
Hetastarch (Hespan)
Q: Intraop the surgeon order Dextran 40. What are the indications for dextran 40, what is the appropriate dose, and what are the potential complications?
Improves blood flow through the microcirculation presumably by decreasing blood viscosity. Thereby, it is used most often to prevent thromboembolism. Max dose is 20ml/kg/day or about 58ml/hour for typical 70 kg patient. SEs - interference with blood typing, prolong bleeding time, renal failure, anaphylactoid rxn,
Q: Which local amide is most cardiotoxic? Why?
Marcaine, Fast in/ Slow out kinetics and binds avidly to sodium channels.Marcaine>etidocaine>ropivicaine
Q: What are the three most cardiotoxic LA?
Marcaine>etidocaine>ropivicaine
Q: An anticholinesterase such as neostigmine is accidently infused continously in high doses. In addition to profound parasympathetic effects what else could conceivably happen?
Depolarizing muscle blockade
Q: Of the following drugs, which increases GI tone and motility? atropine, demerol, neostigmine, epinephrine
Neostigmine (all the others depress GI tone and motility)
Q: What is accomplished when drugs undergo biotransformation reactions?
They often become more water soluble and inactive which permits excretion in the urine or bile.
Q: The cytochrome P450 system is responsible for metabolizing more than one half of all currently available drugs. List six groups of drugs metabolized by the cytochrome p450 system?
barbs, opioids, amide LA, TCAs, antihistamines, BDZs
Q: List three factors that stimulate secretion of renin.
1) decreased renal perfusion r/t hemorhagge, hypovolemia, or renal artery stenosis2) beta 1 agonism3) HYPONATREMIA
Q: Where is alkaline phosphatase normally excreted in large amounts?
In the bile, since large amounts are found in the biliary duct cells
Q: How many ml of CO2 are expired from the lungs per 100ml blood?
4mlNormally, CO2 excretion is 200ml/min, since CO is 5L/min or 5000ml/min the CO2 excretion per 100 ml of blood is 200ml CO2/5000 ml blood or 4 ml/100ml
Q: How much CO2 normally is produced and eliminated per minut? How much CO2 is produced and eliminated in ml/kg/min?
CO2 is produced and eliminated at a rate of 200ml/min or 2.4-3.2 ml/kg/min
Q: What determines mixed venous oxygen content? (MvO2)
1) oxygen delivery to tissues - CO, HgB2) oxygen consumption - MH, thyroid storm, fever, shivering
Q: What two changes can cause SaO2 to remain normal and SvO2 to decrease?
1)decrease in O2 delivery (decreased CO, decreased HgB) with resulting increased O2 extraction from blood2) an increase in O2 consumption (Fever, shivering, MH, thyroid storm)
Q: In a young, normal healthy adult, what is the difference between PaO2 an PvO2: 20, 40, 60, 80, or 100mmHg?
60 mmHgPaO2 roughly 100mmHgPvO2 roughly 40mmHg
Q: What is the principle reason blood flow to dependent lungs is greater than flow to nondependent lung?
Gravity
Q: What is the most common reason for a backache after epidural or spinal anesthesia?
It is generally accepted that backache most commonly occurs after procedures in which there is flattening of the normal lumbar curve owing to RELAXATION OF THE PARASPINOUS muscles allowing for stretch of the joint capsules and spinous ligaments.
Q: After a mediastinal resection, the patient presents with SOB, unilateral breath sound, tracheal deviation, and an increased PIP. What has occurred? What do you prepare to do?
The S/S suggest pneumonthorax, the second most common complication of mediastinoscopy (hemorhage is most common). The hallmark signs of tension pneumothorax are hypotension, hypoxemia, tachycardia, increased central venous pressure, and increased PIP. Other findings include absence of breath sounds on the affected side, asymmetric chest wall movement, tracheal shift, displacement of the cardiac impulse, hyperresonance to percussion, and extreme anxiety. Tension pneumothorax is potentionally lethal; therefore immediate treatment is essential. Chest decompression should be accomplished by placing a large bore needle through the chest wall in the second intercostal space midclavicular line. The needle should be left in place until a tube thoracotomy is performed.
Q: During resuscitation, if venous access has not or cannot be established, what route of administration can result in high peak plasma drug levels?
Intratracheal administration of resuscitative drugs through an endotracheal tube results in high peak plasma drug levels, nearly identical to IV route.
Q: What is the most reliable way to assess cerebral perfusion during a CEA?
Keeping in mind that the purpose of neurologic monitoring is to identify patients at risk for adverse neurologic outcome due to the development of cerebral ischemia, particularly during carotid cross-clamping, an awake patient represents the most sensitive and least expensive neurologic function monitor during CEA. Other monitoring techniques (SSEP, EEG, stump pressure, transcranial doppler) can identify significant decreases in cerebral perfusion. There is, however, controversy about how well these more sophisticated techniques predict outcome.
Q: In the patient with PVD, the most common complications are related to what organ: liver, heart, lungs, kidneys? explain your answer
Complications associated with surgery in the patient with PVD are r/t the heart (cardiac). CAD is the leading cause of periop mortality at the time of peripheral vascular surgery. About 5% of patients with PVD have a myocardial infarction in the periop period and 1.6% die. More than 50% of patients with atherosclerotic disease have an advanced or severe CAD while less than 10% have normal coronary arteries
Q: Your patient is having a cerebral vasospasm. What should be done first? What additional actions may be necessary?
The initial approach to the patient involves fluid and blood pressure managment. It the patient has evidence of evolving vasospasm and is not symptomatic, intravascular volume should be expanded and blood pressure should be increased to the upper extreme of the patients blood pressure.
Q: If the patient with a cerebral vasospasm develops neurologic deficits, what additional two therapies may be instituted?
1) the institution of hypertensive-hypervolemic-hemodilution thereapy may ve warranted2) the next phase of patient management involves the use of drugs aimed at lessening brain ischemia. This goal is best achieved by the use of the CCB nimodipine
Q: What is the name of the regulator that is found on cylinder tanks?
Bourdon gauge
Q: What do pressure reducing devices (regulators) do?
Pressure reducing regulators reduce the high and variable pressure in a cylinder to a lower pressure (40-48 psig). Gas flow is maintained constant without changing the supply pressure.
Q: What do second stage reducing devices (regulators) do?
Second stage regulators receive gas from either the pipeling or the cylinder reducing device (regulator) and reduce the pressure to 26 psig for nitrous and 14 psig for oxygen. The purpose of the second stage regulators is to eliminate fluctuations in pressure, so flow remains constant.
Q: What are the components of the low pressure system of the anesthesia machine?
Components found in the low pressure system include 1) flow indicators, 2) vaporizers, 3) vaporizer circuit control valves, 4) back pressure safety devices, 5) low pressure safety devices, and 6) CGO
Q: Which sleeping aid supplement can readily cross the BBB and may interact with other CNS agents, including hypnotics, sedatives, or psychotropics? What are other common uses of this supplement?
Melatonin crosses BBB and increases BDZs binding to receptors enhancing activity. In addition to being sold as a sleep aid, melatonin is also sold as a remedy for jet lag, shift work, and depressionNOTE: recent studies indicate that preop use of melatonin rivals effectiveness of versed.
Q: During an anesthetic the fail safe shuts down all non oxygen gas flow. What happened?
The oxygen pressure fell below 25-30 psi. When oxygen pressure falls below 25-30 psi (roughly 50% of normal) a fail safe valve automatically closes the nitrous oxide and other gas lines to prevent accidental delivery of a hypoxic gas mixture to the patient. A gas whistle or electric alarm sounds to alert the anesthetist to this occurrence.
Q: What are the three characteristics of the high freq jet ventilator?
1) small tidal volumes (less than dead space)2) high ventilation rate (60-3600 breaths per minute)3) low airway pressure
Q: How is transtracheal ventilation performed?
Transtracheal ventilation is performed by inserting a large catheter through the cricothyroid membrane connecting it to a source of oxygen under pressure.
Q: Describe three systems that work reliably and can easily and inexpensively assemble for TTJV
1) a jet injector (blow gun) is powered by regulated or unregulated pipeline oxygen pressure2) a jet injector is powered by an oxygen cylinder regulator3) the anesthesia machine flush valve is used.The fresh gas outlet of the anesthesia machine is connected to noncompliant tubing by standard 15mm tracheal tube connector. The other end of the tubing is connected to the transtracheal catheter. NOTE: Using the anesthesia breathing system or a self inflating resuscitation bag with a transtracheal catheter will not produce effective ventilation
Q: If the oxygen partial pressure in arterial blood increases from 50 mmHg to 350 mmHg, the amount of dissolved oxygen increases by how much?
(.003*350)-(.003*50)= 0.90ml/100ml bloodBe prepared to calculate an increase in dissolved O2 associated with an increase in PaO2
Q: How are flow and resistance related?
Flow through a tube is inversely proportional to resistance. For example, if resistance doubles, flow is halved. If resistance is halved, flow is doubled.
Q: What happens to flow and what happens to resistance when the radius of a tube increases? When radius of a tube decreases?
When the radius of a tube increases, resistance to flow decreases and flow increases. Conversely, when the radius of a tube decreases, resistance to flow increases and flow decreases.
Q: If flow through a tube is laminar (streamlined), explain how resistance and flow are changed if radius is: doubled, halved, tripled, or reduced to one-third of its original value.
According to poiseuilles law, when radius is doubled, resistand is decreased to 1/16th of its original value and flow is increased 16 fold. When radius is halved, resistance is increased 16 fold and flow is decreased to 1/16th of its original value. When radius is tripled, resistance is decreased to 1/81 of its original value and flow is increased 81 fold. When radius is decreased to 1/3rd of its original value, resistance is increased 81 fold and flow is decreased to 1/81 of its original value.
Q: Assuming laminar flow through a tube, how much does flow through a tube decrease if the radius of the tube decreases to one-third of its original value? Whose law applies?
If the radius of a tube decreases to one-third of its original size, flow will decrease to 1/81 of its original value. Flow is proportinal to the radius to the fourth power. 1/3^4=1/81Poiseuilles law applies. NOTE also that if radius is halved, flow is reduced to 1/16th of its original value. If radius is doubled, flow increases 16 fold. If radius is tripled, flow increases 81 fold.
Q: The bourdon gauge on an E cylinder of oxygen show 800psi. If you turned on the cylinder with flow at 4 liters per minute, how many hours will elapse before the tank is empty?
A full oxygen cylinder has a pressure of 2200 psi and will release approximately 660 liters of oxygen. The amount of oxygen remaining in the cylinder is 800/2200 times 660 liters = 240 liters. 240 divided by 4 l/min = 60 minutes or one hour
Q: You are running 2 liters of oxygen and 4 liters of nitrogen at an altitude where the atmospheric pressure is 630 mmHg. What is the partial pressure of oxygen going to the patient?
Total flow is 6 liters, so the flow of oxygen is 2/6th or 1/3rd of the total. The partial pressure of oxygen is 1/3 * 660 mmHg = 210 mmHg.
Q: Identify 4 CV changes that occur with aging.
1) CO decreases 1% per year (50% decrease in 80 year old)2) myocardial stiffness increases (compliance decreases)3) systemic blood pressure increases4) the baroreceptor reflex is attenuated (less effective)
Q: Elderly patients have changes in autonomic function referrred to as physiologic beta blockade. Why do elderly patients have a reduced response to beta agonists?
elderly patients, despite having higher levels of circulating norepinephrine, have reduced chronotropic and inotropic (contractility) response to beta agonists. Possible explanations for the decreases responsiveness to beta agonists include:1)a reduced number of beta receptors2) abnormal receptor affinity for beta agonists3) reduced cAMP production after activation of the beta receptor
Q: For each of the herbals give the most common uses for them.
ginseng - energy and vitalityginkgo - enhance or preserve memorygarlic - decrease cholesterol, decrease blood pressure, stimulate GI function, physical strength, and energyglucosamine - osteoarthritis and joint mobilitySt. John's Wort - depression and mood elevationEchinacea - reduce cold and flu symptoms, enhance immune functionlecithin - prevent hardening of arteries, improve brain function, treatment of chronic fatigue syndromechondroitin - osteoarthritis and joint mobility, usually in combination with glucosaminecreatine - build muscle and enhance ATP stores in muscleSaw Palmetto - treat enlargement of the prostrate (BPH) in stages 1 and 2Ephedra - stimulant and a weight loss supplementKava Kava - anxiolyticvalerian - immune function stimulant, antiinflammatory, antibacterial for urinary tract infection and upper respiratory infection
Q: Why do geriatric patients have a decreases response to beta antagonists?
In the geriatric paitent, the beta receptor has a reduced affinity for beta adrenergic receptor antagonists. Beta adrenergic receptor agonists also show a reduced affinity for the beta adrenergic receptor in the elderly.
Q: Why is the elimination of midazolam prolonged in the elderly?
decreased hepatic blood flow and possibly decreases in hepatic metabolism (decreased clearance) may cause as much as a doubling of the elimination half time in the elderly (stoelting). Recall that half time of elimination increases if clearance decreases and/or volume of distro increases. NOTE: there may be controversy on this issue. Barasch states that age has relatively little influence on the elimination half time of versed.
Q: The elimination half-life of IV anesthetics is generally increased in elderly patients for what three reasons?
1) decreased hepatic metabolism develops either b/c of decreased hepatic enzyme levels or reduced hepatic circulation2) plasma binding of drugs in the elderly is often decreased, giving rise to a larger volume of dist. and a longer half life3) there is an increase in the percentage of fat which increases the volume of distribution and prolongs the half-life of lipid soluble drugs
Q: What is the most common side-effect of administration of spinal opioids?
Pruritus
Q: You plan to give an epidural opioid as a bolus in preservative free normal saline for postop pain in the patient who has had a thoracic incision. What are some choices?
Morphine (1-5 mg) may be best because it provides greater dermatomal spread. Lipophilic opioids including fentanyl (50-100 ug), sufentanil (10-60ug), meperidine(25-100ug) and hydromorphone (0.5 - 2 mg) should generally only be used when the catheter tip is close to the incisional dermatome. Morphine for epidural bolus administration is mixed in 10 ml of preservative free normal saline. NOTE: different textbooks have slightly different dosing ranges for the opioids specified.
Q: You wish to decrease the concentration of epidural opioid to reduce systemic side effects, so you plan to mix a local anesthetic with the opioid. What local anesthetic do you choose?
Marcaine (.0625 - .125%) combined with morphine (.1mg/ml) or fentanyl (5ug/ml) provided excellent analgesia.
Q: You will give a local anesthetic and an opioid in your epidural. Your goal is to produce analgesia while permitting the patient to walk (ambulate). Which of the following combos would you use?a) 1% lido with 2ug/ml fentanyl, 1% lidocaine with 50ug/ml morphineb) .5% marcaine with 5ug/ml fentanylc) .1% ropivicaine with 25 ug/ml dilaudidd) 1.5% mepivacaine with 25 ug/ml dilaudid
c)The dose of local anesthetic should be reduced when used in combo with an opioid. For example the dose of marcaine when used with morphine .1mg/ml or fentanyl 5 ug/ml is .0625-.125%. The concentration of marcaine, lidocaine, and mepivacaine in the question equal or exceed the recommended concentrations when local anesthetic is used alone. The local anesthetic concentration that is less than the recommended concentration when given alone is ropivicaine. The dose of dilaudid may be a little low (50-100 ug/ml is appropriate when used with a local anesthetic).
Q: What local anesthetic would you use for postop or post trauma care if you goal was to provide pain relief while permitting the patient to ambulate?
Either .25% marcaine or .2% ropivicaine is recommended for sensory analgesia with little motor blockade.
Q: What local anesthetics are appropriate for providing analgesia to your obstetric patient without causing motor blockade?
0.125%-0.5% marcaine, 0.2% ropivicaine, or 1% lidocaine (with epinephrine) produce analgesia with minimal motor blockade. 1% mepivicaine also produces sensory block with minimal motor block.
Q: Describe nociceptive pain.
There are two general categories of pain, nociceptive and neuropathic. Nociceptive pain is pain associated with the stimulation of specific nociceptors (pain receptors). Nociceptive pain may be either somatic or visceral. Somatic pain refers to pain that is well localized, sharp in nature, and generally hurts in the area of stimulus. Visceral pain is diffuse, can be referred to another area, and is often discribed as dull and vague in nature. Pain originating from cutaneous nociceptors is carried by Adelta and C fibers. Nociceptive pain is "physiological" pain. Nociception is the process of transduction, transmission, perception, and modulation of pain. Main point: Nociceptive pain arises when tissue trauma stimulates somatic or visceral pain receptors called nociceptors.
Q: Descrive neuropathic pain.
There are two general categories of pain, nociceptive and neuropathic. Neuropathic pain is caused by abnormal processing of painful stimuli. Neuropathic pain may occur after injury to neural tissue secondary to systemic disease, infection, trauma, ischemia, deficiencies in metabolism or nutrition, or exposure to environment toxins or neurotoxic medications. Some common examples of neuropathic pain syndromes include diabetic neuropathy, postherpetic neuralgia, immunodeficiency syndrome (AIDS) neuropathy, phantom limb pain, and carpal tunnel syndrome. In summary, neuropathic pain is initiated or caused by a primary lesion or dysfunction in the nervous system. Neuropathic pain is "pathophysiological" pain.
Q: Transcutaneous electrical nerve stimulation (TENS) works on which of the two general types of pain, nociceptive or neuropathic?
TENS has a role in patients with neuropathic pain.
Q: By what route is most heat lost in the burn patient? How much heat is lost by this route?
Most heat is lost by evaporation. 0.58 kilocalories (580 calories) of heat is lost for each gram of H2O that evaporates.
Q: Why do burn injuries, paraplegia or upper motor neuron injuries intensify the succinylcholine-induced release of K from skeletal muscles?
Denervation for any reason results in a proliferation of extrajunctional receptors, which open in response to succinycholine. The depolarization causes the release of potassium from skeletal muscle. NOTE: extrajunctional means away from the myoneural junction, or away from the motor end-plate.
Q: Why are patients with third degree burns resistant to the actions of non depolarizing agents?
The number of cholinergic nicotinic receptors (referred to as an extrajunctional proliferation of Ach receptors) is greatly increased in these patients.
Q: What is the legal term for administration of an anesthetic to an unwilling patient?
Battery. Rendering anesthesia to a patient who does not consent constitutes assault and battery.
Q: During a general anesthetic for an elective breast biopsy, you realize that there was no anesthesia consent obtained. You can now be charged with what?
Battery. Battery is the unauthorized touching of person. This usually results in anesthesia and surgery when a procedure is performed without appropriate consent.
Q: If the anesthesiologist is independent and the CRNA is a hospital employee, who is responsible for the CRNA, the anesthesiologist or the hospital?
The borrowed servant rule pertains to situations in which an employer loans an employee to another employer. An anesthesiologist who supervises an CRNA is liable for the nurse anesthetist's negligences, even if the CRNA is an employee of the hospital.
Q: The patient with spina bifida has a known allergy to latex. The CRNA does nothing to prevent contact of the patient with latex. What is the legal problem faced by the CRNA?
Negligence, this is the failure to use reasonable care which is that level of care recognized as acceptable and appropriate given the circumstance.
Q: Informed consent should inform the patient about what?
The patient is informed of the contemplated procedure, including its reasonably anticipated risks and complications, its possible benefits, and the therapeutic alternatives. If more than one type of anesthetic is contemplated, then explain both, including risks. HINT: Informed consent does not necessarily involve a description of the treatment or management of complications.
Q: What is the goal of traditional quality assurance programs? What are the three steps in a quality assurance program?
The goal of traditional quality assurance programs identifying deviations from the norm (outliers or "bad apples"). Quality assurance programs: 1) define the norm (standard of care), 2) determine whether adverse events were caused by deviations from the norm, and 3) prevent the occurrence of adverse events. NOTE: the first step in a quality assurance program is to define the norm, or set the standards. Quality assurance has been superceded by quality improvement.
Q: In the quality improvement process, indicators are used to measure the performance of functions, processes and outcomes of an anesthesia department over time. Do incident reports provide indicators of the QI process? Are lawsuits used as indicators?
Incident reports may help provide indicators of the QI process, but law suits are not indicators
Q: Quality improvement measuring over time performance function and outcomes is what: an indicator, a goal, a criteria, a standard, and occurrence?
Measuring over time performance function and outcomes is an indicator. An indicator is a tool used to measure, over time, the performance of functions, processes, and outcomes of an organization.
Q: What are 11 complications of steep trendelenberg position?
hypotension, blood loss and hypovolemia, VAE (entrainment of air in pelvic or abdominal veins), ocular complications (retinal detachment or cerebral edema), venous thrombosis, endotracheal tube migration into brochus, atelectasis, neuropathy (brachial plexus dysfunction and several others), arthralgia, finger injuries, regurgitation.
Q: What is the most likely reason a patient who undergoes a nonophthalmic procedure develops blindness postop?
Optic nerve and retinal ischemia. The perfusion of the optic nerve and retina can be seriously compromised because of eye compression, which can occlude the central retinal artery and decrease retinal perfusion. Eye compression may occur in the down eye in the lateral or the prone position. Systemic hypotension may als contribute to postop blindness. The decrease in retinal perfusion pressure produces retinal ischemia.
Q: What two sites are to be avoided when obtaining arterial blood gases in the neonate? Why?
ABG samples are usually NOT obtained from the brachial or femoral arteries.Obtaining from brachial artery has been assoc with nerve damage.Obtaining from femoral artery assoc with femoral head necrosis and limb shortening
Q: Does hypothyroidism alter MAC?
NOHowever, recovery from anesthesia may be delayed r/t hypothermia, respiratory depression and slowed drug biotransformation
Q: Your patient is on CPB. During the rewarming phase, tha MAP increases to 90 mmHg. The bypass flow is 50ml/kg/min. How should the elevated BP be treated?
The blood pressure can be lowered by administering a vasodilator or administering an inhalational agent. Because the increased SVR is usually due to inadequate anesthesia during rewarming, a volatile agent is preferable to a vasodilator in patients with good ventricular function. In cases of poor ventricular function, inhalational agents are avoided because of the potential myocardial depression after CPB. The pump flow is not excessive (at normothermia pump flow should be between 50 and 70 ml/kg/min), so you would not try to lower blood pressure by turning down the pump flow.
Q: Give the normal values for parameters measured with dynamic spirometry.
For a healthy 70 kg male, normal dynamic spirometry values are: 1) FVC = 5.0 L, 2) FEV1 = 4.0 L, 3) FEV1/FVC = 0.75-0.85, and 4) FEF25-75% = 4.7 L/sec = 280 L/min FEF25-75% is also termed MMEF and MMFR
Q: How does amrinone work? What are two CV actions of amrinone?
Amrinone is a PDE-I. PDE is the enzyme that breaks down cAMP. By inhibiting PDE, cAMP accumulates in cardiac and vascular smooth muscle cells. Amrinone improves CO because it has a positive inotropic effect (increases contractility) and also because it is a vasodilator, and it decreases SVR
Q: List three herbal therapies that would cause concern for anemia and warrant a preop CBC or H/H?
garlic, ginseng, ginkgo. Garlic is associated with increased bleeding diathesia and gingko with unexpected spontaneous bleeding. HINT: remember the Gs for bleeding and coagulation issues.
Q: Which alternative/herbal medicine may create a syndrome of hyperaldosteronism characterized by hypernatremia, hypertension, hypokalemia, and suppression of the renin-angiotensin system?
Licorice (glycyrrhiz glabra) ingestion may create hyperaldosteronism syndrome. Glycyrrhetininic acid inhibits 11 beta-hydroxysteroid dehydrogenase leading to excess glucocorticoids which bind to mineralcorticoid receptors, producing a mineralcorticoid response. Discontinue the herbal medicine at least 2 weeks before elective surgery.
Q: Identify the herbal medicines and supplements that inhibit PLT aggregation.
Garlic, evening primrose, fish oils, and DHEA are known to inhibit platelet aggregation. Request PT, INR, PLTs, and H/H during preop eval.
Q: List the herbal medicines and supplements that may alter coagulation homeostasis and/or bleeding time.
The following herbals and supplements may alter coagulation status and/or bleeding time, especially when used concomitantly with warfarin: gingko, garlic, dong quai, danshen, feverfew, ginger, DHEA, androstenedione, and glucosamine sulfate.
Q: Which herbal medicine inhibits thromboxane synthase and thus has synergistic effects with other antiplatelet agents?
ginger inhibits TXA synthase and may potentiate other antiplatelet agents, increasing the risk of bleeding and coag disorders
Q: One herbal medicine may oppose heparin or warfarin anticoagulation therapy. Which herbal is this and what periop risks are associated with a large dose of this herbal medicine?
goldenseal (hydrastis canadensis), sold as an antidiarrhetic, an anti-inflammatory,and hemostatic agent, may oppose the anticoagulant effects of heparin and warfarin. An unusually large dose of goldenseal can cause a labile blood pressure, cardiac inotropy, CNS stimulation, muscle spasms, decreased seizure threshold, and respiratory distress
Q: State four anesthetic concerns for the patient taking ginger as an herbal supplement.
1) interaction with antiplatelet agents possibly leading to coag disorders and increased risk of bleeding2) potentiation of barbs3) prolonged sleep time4) increased GI motility, decreasing the risk of aspiration
Q: Which herbal medicines and supplements increase the risk of intraoperative hemodynamic instability? Which tests would you request as part of the preop work up?
Intraop hemodynamic instability is possible with use of garlic, ginseng, feverfew, ephedra, dandelion, licorice and saw palmetto. At minimum, request lytes and check blood pressure and HR as indicators of volume status.
Q: Identify the 2 best selling herbals that might cause hypoglycemia.
garlic - especially when taken concomitantly with chlorpropamideginseng - especially if taken with oral hypoglycemics
Q: The pt presents with hypertension, tachycardia, agitation, and restlessness. Pt history reveals current treatment with prozac and they also report taking "some herbal for depression". What syndrome does this pt exhibit and which herbal medicine has potentiated this syndrome?
A serotonin-like syndrome St. John's Wort can potentiate this syndrome
Q: What drugs should be avoided or may have altered dosing requirements in the pt taking St. Johns' Wort? List an describe 2 reasons (mechanisms) for why these drugs should be avoided or may require altered dosing.
Avoid MAO-Is and SSRIsConsider increasing the dosing of digitalis, theophylline, BDZs, beta-blockers, CCBs, cyclosporins, and warfarinThe rationale is as follows: 1) St. Johns wort inhibits serotonin, NE, and DA reuptake by neurons, thus avoid MAO-I and SSRI 2) St. John's Wort induces P450 thus decreasing bioavailability of many drugs metabolized by the P450, including those previously listed.
Q: Preop eval of a male pt reveals he is taking saw palmetto as a natural remedy for a mild case of BPH. Which class of drugs may interact with saw palmetto to cause urinary retention?
anticholinergics in combo with saw palmetto may cause urinary retention.
Q: During the preop workup, the patient states an allergy to soy and soy products. What is the anesthetic implication?
Propofol should be avoided as soybean oil is used as a component of propofol emulsion.
Q: A young, otherwise healthy patient presents for an emergency appendectomy. Preop assessment reveals that they routinely take a dietary supplement to lose weight and reduce body fat. What herbal is most likely this supplement and what are the anesthetic concerns for this pt?
Ephedra is the most common ingredient in weight loss supplements. These supplements usually include a number of ephedrine alkaloids, including pseudoephedrine, thus ephedra exerts its effects by increasing sympathetic stimulation. The anesthetic concerns are chiefly CV and neuro. Hypertension, myocarditis, myocaridal infarction, and angina are of concern with the major CV concern being lethal cardiac dysrhythmia, as ephedra may interact with PIAs to promote dysrhythmias. Severe intraop hypotension should be treated with a direct acting agent (phenylephrine) b/c of tachyphylaxis to ephedrine. Neuro concerns for the patient taking ephedra are increased risk of hemorrhagic or ischemic stroke, subarachnoid hemorrhage, and seizures.
Q: 6 herbal medications may alter the sedative and hypnotic effects of anesthetics, identify these 6 herbals and describe the sedative and hypnotic alterations each may cause.
ginger - may potentiate barb effects and prolong sleep timeginkgo - may decreased the effects of IV barbsSt. John's wort - may prolong the sedative effects of anesthesiaMelatonin - may enhance BDZ activityKava - may potentiate barbs and BDZValerian - is synergistic with barbs, narcotics, hypnotics, and BDZs, sedatives effects of narcotics are unpredictable, may decreasd MAC and may have delayed emergence with delirium.
Q: As a rule of thumb how long should most herbals be d/c prior to surgery?
2 weeksNOTE: some sources state to d/c St Johns wort and ginseng for 7 days. The exception is ephedra (24-36 hours)
Q: Identify the common herbal medicines and supplements that, at this time, have no known direct anesthetic concerns.
echinacea, saw palmetto, chondroitin sulfate, cranberry, creatineNOTE: be sure to review and understand the preop concerns for these herbals and supplements. Also, consider ABX in the patient taking cranberry as they are probably treating or trying to prevent a urinary tract infection.
Q: Rank the following routes of drug administration from greatest to least with regards to peak plasma concentration.Subcutaneous, IV, caudal, epidural, intratracheal
IV intrat>caudal epidural>subcutaneous
Q: Besides children with spina bifida, what 4 groups of people appear to be at increased risk for latex allergy?
Multiple surgical procedureshealthcare workers or others frequently exposed to latexatopic individuals with hx of allergyIndividuals with allergy to food (avocados, bananas, chestnuts, and stone fruits)
Q: What is the function of the purkinje system? How is this function accomplished?
the purkinje system synchronizes right and left ventricular contractions. This occurs b/c the fibers allow very rapid transmission of the cardiac impulses from the AV node to the ventricles.
Q: Compared with cardiac fibers conduct muscle cells and junctional tissue (SA and AV nodes), how fast do purkinje fibers conduct impulses?
Purkinje fibers are large-diameter fibers that transmit impulses at a velocity 6 times that of cardiac muscle cells and 150 times that of nodal tissue (SA and AV nodes)
Q: A pt in MH crisis has PVCs. What is the antiarrhythmic drug of choice?
Procainamide, 15mg/kg IV
Q: The pt has AIP, or variegate porphyria (south africa). Other than barbs, list ten drugs that are considered high risk for precipitating an acute attack.
Drugs other than barbs that are considered high risk and are thus unsafe for pts with AIP are:etomidate, enflurane, nifedipine, sufonamides, toradol, pentozacine, phenytoin, hydralazine, mepivicaine, and lidocaine.
Q: What is the fastest way to correct hyperkalemia?
Sodium Bicarbonate, .5 to 1.0 meq/kg IV, drives potassium into cells in approximately 5 minutes. Glucose-insulin infusion will promote SUSTAINED transfer of potassium into cells, decreasing serum potassium concentration by 1.5 to 2.5 meq/l in approximately 30-60 minutes. B2 agonists will reduce serum potassium levels by 1 meq/l within 30 minutes and its effects last up to 2 hours.
Q: What is the FIRST treatment for marked hyperkalemia with widened QRS complexes and peaked T waves? In which patients must this treatment be used cautiously?
Cardiac membrane hyperexcitability due to hyperkalemia is rapidly offset by an infusion of calcium (5-10 ml of 10% calcium gluconate or 3-5 ml of 10% calcium chloride). The effects are rapid (1-2 minutes), but short-lived (15-20 minutes) so the underlying hyperkalemia must be treated. Use calcium cautiously in the patient taking digoxin, since calcium potentiates digoxin toxicity.
Q: What antiemetic might be used to treat postop nausea in the parkinson's patient?
zofran would be the appropriate antiemetic for the patient with parkinson's disease.
Q: A heroin addict is taking methadone to help break the addiction presents for surgery, what is your anesthetic concern?
Withdrawal produced by drug cessation is a concern in the patient who is taking methadone or who is dependent on other opioids. Avoid using an opioid agonist-anagonist, such as nalbuphine or stadol, preop.
Q: What is the terminal branch of the femoral nerve?
the saphenous nerve
Q: What single nerve block is best of ACL repair?
femoral nerve block alone is sufficient for ACL repair and is an effective adjunct to general anesthesia for knee joint surgery.
Q: In addition to the femoral nerve, what three other nerves may be blocked for surgery on or above the knee?
The sciatic, lateral femoral cutaneous, and the obturator
Q: a routine antenatal ultrasound reveals polyhydramnios in the pregnant pt. What is polyhydramnios and what are the implications for the fetus?
polyhydramnios occurs when the infant fails to swallow and absorb amniotic fluid in normal amounts. The most common causes are GI obstruction and neurologic problems. Esophageal atresia, as seen in TEF is of greatest concern for the infant. If polyhydramnios is present check for TEF by passing a NGT shortly after delivery.NOTE: polyhydramnios also appears antenatally in 30% of CDH cases. If both answers appear choose TEF as best answer.
Q: Which type of shock is most frequent in pediatric pts?
Hypovolemic shock, often due to blood loss from trauma is the most common in children. Appreciate that compensatory mechanisms (vasoconstriction and tachycardia) in children are very efficient at maintaining perfusion; children may lose as much as 1/4 of their blood bolume without significant CV changes in the supine position. Hypovolemic shock due to plasma loss can be seen with burns and peritonitis, and may be a component of septic shock
Q: What is the best fluid replacement for the pediatric patient in hypovolemic shock?
Crystalloid solutions (I.E. LR) are effective in the initial treatment of hypovolemic shock in pediatric patients. Crystalloids administered early in the management of hypovolemic shock will prevent renal failure and also prevent renal collapse. If indicated blood should be transfused as soon as crossmatching has been done.
Q: What is the minimum HgB acceptable for elective surgery?
In pts without systemic disease, hemoglobin levels of 7g/dl are acceptable for proceeding with elective surgery. NOTE: this represents a departure from the traditional level of 10, and is due in large part to the concern over blood-borne infections.
Q: How many days prior to surgery should MAO-I be discontinued?
14-21 days before elective surgery. However, current clinical opinion favors continuing MAO-I therapy up to the time of surgery to avoid the risks of enduring 2-3 weeks of refractory depression. If MAO-I therapy is continued up until time of surgery, avoid drugs with substantial sympathetic effects.
Q: What lab test is the best measure of end stage hepatorenal failure?
Urine sodium concentration (UNa) < 10 meq/l is indicative of end stage hepatorenal failure.
Q: The pt has a PCWP of 18 mmHg, SBP of 85 mmHg, CI of 1.5. What is the most appropriate course of action for this patient?
PCWP is high, SBP is low, and CI is lowIn spite of low SBP the pt has an adequate blood volume, indicated by the PCWP. Therefor, an inotrope such as dobutamine, amrinone, or NE is indicated to "push the volume" forward.
Q: A neonate is undergoing a surgical procedure with the use of spinal blockade. What would indicate a high or total spinal?
Decreasing oxygen saturation is the earliest sign of a high or total spinal in the neonate. A high or total spinal, produced either with a primary spinal technique or secondary to an attempted epidural, presents as respiratory insufficiency rather than hypotension owing to the relatively immature nervous system in the neonate. With an immature sympathetic nervous system, the CV parameters are remarkably stable in the neonate with a high or total spinal.
Q: Where is the epidural space b/w the ligamentum flavum and the dura mater the largest?
largest at L2-L3, approximately 4-6mm
Q: In 1990, the food and drug administration instituted the safe medical device act. What does this act require?
It requires that hospitals report instances in which medical devices cause or contribute to death, serious illness, or serious injury. The act also requires any medical personnel who become aware of the problem to remove the equipment from patient contact and to report the problem to their supervisors.
Q: The Safe medical device act of 1990 requries reporting to whom and by when?
The incident report must be made by the hospital risk manager to the FDA within 10 days of the incident
Q: Who is primarily affected by duschenne's MD?
It is an X-linked recessive disorder, thus affecting males almost exclusively. The incidence is about 1-3 cases per 10,000 live male births and most commonly presents b/w 3-5 years of age.
Q: List the top 6 surgeries in the geriatric population, from most to least frequent.
1) orthopedic2) opthalmologic3) gastrointestinal4) urological5) vascular6) gynecologic
Q: A neonate diagnosed with pyloric stenosis presents with a Na of 120, Cl of 84, and a respiratory rate of 16. What is the course of action for this patient?
Pyloric stenosis is characterized by persistent vomiting which depletes sodium, potassium, chloride, and hydrogen ions causing hypochloremic metabolic acidosis. In this particular presentation, the disturbances are moderately severe and the patient should be given IV 5 percent dextrose in 0.45 percent normal saline with 20-40 meq/l potassium chloride administered at a rate of 10 ml/kg/hr. Avoid LR because lactate is metabolized to bicarbonate.
Q: What is thoracic outlet syndrome? What are the implications of this syndrome with regard to patient positioning?
Thoracic outlet syndrome results from compression of the brachial plexus and subclavian artery at the thoracic outlet between the first rib and the clavicle or between the anterior and middle scalene muscles. Patients usually complain of weakness, numbness, or paraesthesias in the affected upper extremity after working with the arms overhead. All patients schedules for surgery in a pronated position should be assessed for these symptoms. If the patient reports any of the symptoms of thoracic outlet syndrome, the arms should be placed along the trunk during surgery.
Q: What are possible surgical interventions for thoracic outlet syndrome? What are six complications of this procedure?
Resection of the first rib, resection of a cervical rib, partial resection of the scalene muscles, or removal of anomalous fibrous bandsComplications include: pneumothorax, brachial neuralgia, pleural effusion, temporal phrneic nerve palsy, injury to the subclavian artery, injury to the long thoracic and T1 nerve roots
Q: Why are infants more prone to airway obstruction?
Infants have a proportionately larger tongue than adults.
Q: Describe the anatomic r/t of the median, ulnar, and radial nerves to the axillary artery.
The median nerve lies anterior (superior) to the axillary artery, the ulnar nerve is medial and slightly posterior (inferior) to the artery, and the radial nerve is posterior and slightly lateral to the artery.
Q: Which nerve is most commonly blocked with at transarterial approach to an axillary block?
the radial nerve
Q: List three types of patients who are poor candidates for office based surgery.
1) recent CV event2) obese3) suffer medical conditions that would interfere with recovery
Q: Which blood component, FFP or cryo, has more fibrinogen in it?
Cryoprecipitate is a concentrated source of I, VIII, XIII, and VWF
Q: How much will one unit of PLT increase the count in a 70 kg pt?
5000-10000
Q: Which periop period is most often associated with severe HTN? What percentage of pts experienced severe hypertension during this period?
Severe HTN is most often associated with induction and endotracheal intubation. Up to 25% of patients will exhibit severe HTN during induction and endotracheal intubation
Q: What "criteria based" recovery standard is an acceptable alternative to the Aldrete score? Describe this criteria based scoring system.
The post anesthetic discharge scoring system (PADDS) has been developed base on five criteria: vital signs, activity and mental status, pain and nausea, surgical bleeding, and intake and output. As with the aldrete system, a score of 9-10 is required for discharge to home.
Q: Where are pulse oximeters placed on the neonate to monitor preductal and postductal oxygenation?
Preductal - right hand or fingerPostductal - left foot or toe
Q: What is the purpose of a preductal pulse oximeter in the neonatal patient undergoing cardiac surgery?
It is a better index of neonatal cerebral oxygenation than are those taken at a postductal location. The right to left shunt at the ductus arteriosis persists for some time after birth and this shunt may affect oxygen saturation readings, thus preductal placement of the pulse oximeter is preferred. A postductal pulse oximeter may be used in addition to the preductal pulse oximeter to quantitate the severity of the right to left shunt.
Q: Identify the best area to draw ABGs from the neonate?
Radial artery, this reflects preductal oxygenation
Q: How would you expect a pt with small cell carcinoma to respond to NDMBs and DMBs?
NDMBs - increased sensitivityDMBs - increased sensitivity
Q: What is the anesthetic concern for the pediatric pt undergoing repair of a ventricular septal defect without significant pulmHTN? With PulmHTN
Without - avoid arrhythmias, RV dysfunction, pulmonary vascular obstructive disease, and paradoxical embolus.With - the pt with unrepaired VSD and irreversible PulmHTN often displays right to left shunting through VSD (eisenmenger's physiology). Manipulations that may increase PVR can cause rapid deterioration and include hypoxia, hypercarbia, acidosis, hypothermia, atelectasis, sympathetic stimulation and polycythemia. Early closure of VSD before 1 year old results in normal ventricular function and ejection fraction.
Q: Which blood substitute can alter serum amylase levels?
Hespan (hetastarch), may cause serum macroamylasemia following transfusion. Large molecules of hespan must be broken down by serum amylase before being removed from the circulation by renal excretion and redistribution. Serum amylase levels can be increased for up to 5 days following hespan.
Q: Describe the physiological anemia of the neonate and pediatric patient. How is this altered in the preterm infant?
Normal HgB concentrations progressively falls during the 9th to 12th week to reach a minimum of 10-11 g/dl, with a Hct of 33%. After the third month (12 weeks) the Hgb levels stabilize at 11.5 - 12 g/dl until about 2 years of age. After 2 y/o the Hgb levels gradual increase to reach adult levels of 14-15.5 g/dl by puberty.In preterm infants, the decrease in Hgb levels is greater and earlier, reaching the minimum HgB of 8g/dl by 4-8 weeks. At about 1 yr old, the preterm and full term infants' Hgb leverls are comparable, and preterm infants following the same progression reachin normal adult levels at puberty.
Q: Describe the preop fasting guidelines for children.
<6months - restrict solids for 4 hours and clears for 2 hours6-36 months - solids 6 hours and clears 3 hours> 36 months - 8/3NOTE: advise restriction of clear fluids for 2 hours, breast milk for 4 hours, formula or light meals for 6 hours, and fatty solid meals for 8 hours. The pattern is to start NPO at 2 hours for clear liquids and add 2 hours for each increasingly "fatty" meal.
Q: At what age is BMR normally the highest?
peaks somewhere b/w 6-12 months old. In a full term infant, BMR rises progressively during the first 10 days of life. After the first few weeks of life, BMR decreases nearly linearly throughout life. However, if you look at caloric requirements, infants under 1 y/o require about 100 cal/kg/day, whereas older infants require 75 cal/kg/day, and adults require 35 cal/kg/day
Q: If a pregnant patient is placed on 100% oxygen, by how much will fetal O2 change?
Maternal PO2 will rise from 90 to 500 mmHg, which is an increase of about 1 mmol in arterial oxygen content. Becaus increasing FIO2 will not cause uterine blood flow to increase, uterine venous oxygen content should also increase by 1 mmol. Therefore, uterine venous PO2 will increase by about 10 mmHg (11.5 mmHg, to be exact). Since uterine venous PO2 is the primary determinant of umbilical venous PO2, the fetal PO2 will increase by about 10 mmHg.
Q: Which organ (non surgical) is of greatest preoperative concern in the geriatric patient?
The cardiovascular system is of greatest preoperative concern in the geriatric patient. Nearly one-half of the geriatric population has HTN, with or without significant CAD. Other organ systems of concern, in decreasing frequency of concern, are renal, hepatic, pulmonary, and multi-organ disease.
Q: What is the most specific test of renal failure in the geriatric patient?
Serum creatinine clearance (24 hour) is specific and reliable for assessing GFR in all patients. Because serum creatinine concentrations are dependent upon many factors (e.g. degree of skeletal muscle atrophy), creatinine clearance is a better indicator of general kidney function and GFR. Creatinine clearance decreases with age such that creatine clearance is about 70 ml/min at 70 years old.NOTE: BUN is a late and less reliable indicator of renal function
Q: Discuss 5 physiologic factors that may alter SEPs. Which factor(s) has the most effect, and which has the least effect?
Five physiologic factors which may alter sensory evoked potentials are:1) temperature2) hypotension3) hypoxia4) hypocarbia5) isovolemic hemodilutionSPECIFIC DETAILS: 1) hypothermia will increase latency and decrease amplitude of SEPs (latency increases by 1 ms for each 1 degree celsius decrease in temperature) and hyperthermia will decrease amplitude by up to 15%. Miller states that SEPs are lost at 42 degrees Celsius. 2) With a MAP less than 40 mmHg, there is a progressive decrease in amplitude of SEPs. 3) A decrease in SEP amplitude is seen with hypoxia, probably due to alterations in blood flow. 4) With an ETCO2<25 mmHg, SEP latency increases. 5) With isovolemic hemodilution, SEP latency does not increase until the Hct is less than 15%, and SEP amplitude does not decrease until the Hct is less than 7%. Determining which factors affect SEPs most and least is tricky. Based upon the data, we believe that altered temperature affects SEPs the most, whereas hemodilution affects SEPs the least (based upon the dramatic alterations necessary to cause teh alterations). NOTE: read the question carefully and hope there is an obvious answer.
Q: What laboratory value will exclude CO2 retention from a diagnosis?
Normal bicarbonate values will rule out CO2 rentention. For every 10 mmHg increase in PCO2, serum bicarb will increase by 1 mmol/L.
Q: What are 5 major anesthetic concerns for the pregnant patient scheduled for nonobstetric surgery?
1) maternal safety2) fetal well-being3)avoid or prevent PTL4) fetal and uterine monitoring5) maintaining uteroplacental perfusion
Q: What are your concerns for the fetus in or after nonobstetric surgery in the pregnant pt?
Perinatal mortality is a common complication from elective surgery in the pregnant patient and your concern for the fetus includes possible teratogenic effects of anesthetic agents, intrauterine fetal asphyxia, and PTL (rare according to Kirby). Nitrous oxide has been associated with inhibition of DNA synthesis - avoid nitrous if possible. Maternal diazepam administration is associated with cleft lip/palate - avoid BDZs if possible. There is an increased risk of SAB if elective surgery is done duringthe first or second trimester (most organogenesis occurs in the first trimester).
Q: What is the best stimulation pattern to determine fade during neuromuscular block?
DBS appears to be the best test to determine fade in neuromuscular block. In DBS 3,3 - two trains of 3 impulses at 50 hz separated by 750 ms are given. The response to DBS is easier to detect MANUALLY, correlates well with TOF, and the DBS response may reappear earlier than TOF during intense neuromuscular blockade.
Q: Discuss the tests to determine the adequacy of neuromuscular block reversal. Which test is the best indicator of neuromuscular blockade reversal?
Traditional tests to determine the adequacy of neuromuscular block reversal have included 1) TOF > .7, 2) head lift for 5 seconds, 3) adequate tidal volume and/or vital capacity, 4) NIF of -50 cm H20, and 5) hand grip strengthOf these test adequate tidal volumes and/or vital capacity are the least sensitive tests of adequate NMB reversal (70-80% receptor block remains). The other tests are considered roughly equivalent in their ability to determine reversal of NMB % receptors block). Recent research and the NEW CRITERION is TOF>0.8-0.9 to exclude clinically significant neuromuscular block.
Q: What tests of neuromuscular block correlate well with TOF > 0.8-0.9?
Two tests seem to correlate well: 1) DBS and holding a tongue blade between the teeth. DBS appears to provide a better tactile response to fade, and the DBS 3,3 pattern seems to be a more reliable assessment of muscle relaxant reversal (Duke). The ability to hold a tongue blade b/w the teeth correlates with a TOF >0.86 and thus is an excellent assessment of adequate neuromuscular block reversal. NOTE: a TOF > 0.9 cannot be determined by feel; it must be quantitated by mechano-, electro-, or acceleromyography.
Q: What is an emancipated minor?
A minor (under 18) who has been given the global rights to make their own health care decisions.
Q: What qualification may enable a minor to receive the status of emancipated minor?
Pts under 18 y/o may be awarded the status of emancipated minor if they are: 1) married, 2) are a parent, 3) in the military, and 4) economically independent.
Q: State the "major minor doctrine".
applies to a minor who has decision making capacity and is legally and ethically capable of giving informed consent in specific situations as determined by the court.
Q: What are common contaminants of medical gas lines? What contaminant is most common?
Oil, water, bacteria, particulate matter, and residual sterilizing solutions.Water is the most common
Q: State 3 anesthetic concerns for the pt with hypothyroidism.
1) susceptible to the hypotensive effects of anesthetic agents2) have significantly impaired ventilatory responses to hypoxia and hypercarbia3) are particularly susceptible to intraoperative hypothermia
Q: How would you manage intubation of a patient with an obstructive tumor in the upper airway?
The optimal decision for the safety of the patient with an upper airway tumor is to intubate with FOB before induction of a nesthesia. "If there is any doubt about the ability to intubate an anesthetized pt, awake intubatio is mandated" (Kirby). An additional concern involves the friability of the tumor. If the patient has received radiation treatment to the tumor, the obstructing mass may be stiff and friable, and furthermore, temporomandibular joint mobility may be compromised. In this case, a tracheostomy is preferable as attempts at intubation risk serious hemorrhage and edema which may lead to complete obstruction of the airway.
Q: Describe a 3 in 1 block and its utility.
It is anothor, name for a lumbar plexus block. The 3 in 1 anesthetizes the femoral, obturator, and lateral femoral cutaneous nerves. Used alone the 3 in 1 block is applicable for minor knee surgeries, and in combo with spinal anesthesia is appropriate for major knee surgery. Potential disadvantages of a 3 in 1 block include: 1) large volumes of local anesthetic solution are required to achieve adequate spread along the fascial plane of the plexus, 2) the block often MISSES the OBTURATOR nerve, and 3) quadriceps weakness may limit ambulation after the procedure.
Q: What is the major intraoperative complication during cerebral aneurysm surgery?
Hemorrhage (rupture)
Q: If a cerebral aneurysm ruptures during surgery, what is your plan?
Requires immediate, aggressive fluid resuscitation and controlled hypotension. Controlled (deliberate) hypotension may be achieved with nitroprusside, labetalol, propranolol, or esmolol. These agents are preferred because they do not affect cerebral blood flow or ICP. Use dextrose free fluids since increased neurologic defects are seen with hyperglycemia. NOTE: this is the traditional answer found in most texts. However, these same texts are now favoring the use of a temporary clip on the parent vessel to allow the surgeon to gain control of the ruptured vessel. If controlled hypotension was instituted before the temporary clip was placed, restore SBP after the clipping to improve collateral blood flow. Additionally, if the temporary clip is in place for mare than 10 minutes, STP and mild hypothermia are often implemented for cerebral protection. Normocarbia should be maintained whenever possible regardless of which protocol is used.
Q: What drugs would you administer to a PEC pt with cerebral edema prior to C/S?
Hydralazine or labetalol are the most popular drugs to reduce hypertension in the PEC pt. CBF and ICP are maintained with both of thies antihypertensives. Antihypertensive with reported adverse effects during pregnancy which may be avoided include esmolol, clonidine, nifedipine, and ACE-Is
Q: What standards of care apply during MAC?
Identical standards of care apply to monitored anesthesia care and regional or general anesthesia.
Q: What is the single greatest danger associated with MAC?
Lack of vigilance
Q: Which monitors are required during MAC of the pediatric pt?
All standard monitors to include precordial, NIBP, temp, SPO2, ECG, and ETCO2
Q: Describe the periop management of the patient with hyperparathyroidism.
Hypercalcemia (serum [] higher than 5.5 meq/L and ionized calcium [] higher than 2.5 meq/L) is a hallmark of patients with hyperparathyroidism. The periop goal is to correct intravascular volume and electrolyte abnormalities. Normal saline and a loop diuretic of (usually lasix) are administered to increase calcium excretion by means of hydration and diuresis. Periop, avoid fluids with calcium, e.g. LR. Also, increased dosing vecuronium and probably all nondepolarizing muscle relaxants will be required.
Q: Which nerves are blocked in a cervical plexus block?
The ventral rami C1-C4 form the cervical plexus. However, the first cervical nerve (C1) is a motor nerve with no sensory distribution. Thus, both deep and superficial cervical plexus blocks anesthetize C2-C4. The deep cervical plexus block is essentially a paravertebral blockof C2-C4.
Q: Describe the recent modifications to the PACU aldrete score.
The major change b/w the original and modified aldrete criteria is the change from assessing COLOR (old) to assessing OXYGENATION (new). In the old criteria, pink = 2, pale = 1, cyanotic = 0. With the new criteria, SPO2>92% on room air = 2, >90 % = 1, <90= 0. The other notable change is the circulation criteria; it is fairly simple to learn. Under the new criteria, a blood pressure within 20 mmHg of normal = 2, within 20-50 mmHg = 1, and deviating >50 mmHg from normal = 0. Under the old criteria, blood pressure within 20% of normal = 2, 20 - 50% = 1, and 50% = 0.Score of 9-10 is needed for discharge.
Q: During a total hip replacement procedure, what sign indicates methymethacrylate toxicity has occurred? What is bone cement implantation syndrome?
Sudden hypotension about 30-60 seconds after placing methylmethacrylate indicates toxicity. Occasionally the hypotension may take up to 10 minutes to manifest. Two mechanisms are probably responsible: 1) transient fat and air emboli from the bone marrow, 2) residual monomer causes vasodilation and decreased SVR, leading to hypotension. Bone implantation syndrome occurs when hypotension is accompained by hypoxia, dysrhythmias, pulmonary hypertension, and decreased CO.
Q: Identify the 5 criteria that must be met for d/c to home from office based anesthesia under the clinical discharge criteria (CDC).
1) stable VS2) patient is alert and oriented3) patient is free of nausea and/or vomiting4) steady of gain5) patient has no significant bleeding
Q: Given the following spirometry values, FVC = 3.1 L, FEV1 = 2.5 L, what is your diagnosis?
This patient has a restrictive lung disease. Both values are lower than normal, but the FEV1/FVC ratio is 0.8, which is normal. By definition, in restrictive lung disease, there is a proportional decrease in all lung volumes, but the FEV1/FVC will be normal.HINT: be certain to evaluate the lung volumes and not just the FEV1/FVC ratio.
Q: What dynamic spirometry values would place a patient in the high risk category for postop pulmonary complications? Moderate risk?
High - FEV1 < 1L, FVC <1.5L or 20 ml/kg, FEV1/FVC < 35% predicted or peak flow < 200L/minModerate- FEV1 1-2L, FVC <50% predicted, FEV1/FVC >35% but less than 50%, or FEF25-75% <50% predicted, the patient is at moderate risk for postop pulmonary complications.
Q: Define sentinel event.
A sentinel event is an unexpected occurrence or variation involving serious physical or psychological injury, or risk thereof. Sentinel means send and alarm or signal that requires immediate attention.
Q: What is a major problem in any QA program? How may this problem be avoided?
The major pitfall is inconsistent reporting of data. To avoid inconsistent reporting of data, a succinct check-off form should be used.
Q: A patient with known allergies is scheduled for a precedure involving injection of IV contrast dye. What are your anesthetic concerns? What prophylactic treatments would be appropriate?
The allergic pt is at risk for an anaphylactoid allergic reaction to the IV contrast dye (5-8% of patients will experience an allergic reaction). Appropriate prophylaxis includes both H1 - and H2 antagonists and a corticosteroid. A typical prophylactic regimen would be: benadryl, cimetidine (or ranitiding), and prednisone 16-24 hours prior to the planned procedure. Adequate hydration is also warranted, as the contrast dye usually causes substantial diuresis.
Q: What prophylactic measures can be taken to minimize the risk of methylmethacrylate toxicity? If bone cement toxicity occurs, what is your first treatment?
Strategies to minimize BCIS and toxicity include:1) increase FIO2 prior to cementing2) D/C nitrous prior to cementing3) maintaining euvolemia4) creating vent holes in the distal femur5) high pressure lavage of the femoral shaft to remove debris6) using an uncemented femoral componentIf toxicity occurs, ADEQUATE HYDRATION and INCREASED FIO2 will aid in the elimination of the methylmethacrylate and restore normal blood pressure.
Q: Where are MEPs stimulated? How are they stimulated?
MEPs are stimulated over or in the motor region of the cerebral cortex. MEPs may be stimulated by transcranial electrical stimulation (teMEP), transcranial magnetic stimulation, (meMEP) or by direct stimulation of the motor cortex with an electrode.
Q: Where may motor evoked potentials be monitored?
MEPs are recorded over or att:1) spinal cord2) peripheral nerve3) the involved muscleNOTE: neither SEPs nor MEPs can be recorded at the site of stimulation
Q: An S3 heart sound is an indicator of what condition?
An S3 heart sound (gallop rhythm) during mid-diastole is most often heard in the context of CHF.
Q: What is the postulate mechanism(s) that produces and S3 heart?
The third heart sound is thought to reflect a flacid and inelastic condition of the heart during diastole (Stoelting). Guyton says: "..a logical but unproven explanation of this sound (S3) is oscillation of blood back and forth between the walls of the ventricles initiated by inrushing blood from the atria." We favor Guyton's explanation.
Q: What is the r/t of the following parameters: preload, LVEDV, PAOP, LVEDP, and LADP?
In the absence of mitral stenosis or pulmonary hypertension, PAOP = LADP = LVEDP = LVEDV = preload. Any of the pulmonary artery catheter measurement are equivalent indirect measurements of preload, in the absence of mitral stenosis or pulmonary hypertension.
Q: States Graham's Law. Give an application of Graham's law.
Graham's law states that the rate of diffusion of a gas is inversely proportional to the square root of its molecular weight. For example, Helium will diffuse faster than oxygen , which will diffuse faster than nitrous oxide.
Q: Your patient is scheduled for bilateral total hip replacement. What is a major concern and what indicator would require postponement of the second hip replacement after the first hip has been replaced?
A major concern in THR surgery is pulmonary embolism. PAP monitoring is required in this patient. PAP monitoring reliable signals embolization by a rise in PVR (> 300 dynes*s/cm^5). A rise in PVR is usually indicated by a rise in pulmonary pressure with no change in PAOP and a decreased CO. (Increased PAP, Decreased CO, and no change in PAOP).
Q: The pregnant patient delivered baby under general anesthesia; what factors(s) correlates most with a depressed APGAR score at one minute?
The general anesthetic factors which most depress the APGAR score at one minute are low FIO2 and High N2O. Initial lower APGAR scores under general anesthesia are probably due to transient sedation rather than asphyxia. The incidence of depressed APGAR scores at one minute can be markedly reduced by techniques that include: 1)higher FIO2, 2) reduced N2O, 3) lower dose (0.5 MAC) halogenated agents, 4) continuous lateral tilt, and 5) expeditious delivery time.NOTE: the fears that high maternal PO2 may cause uterine vasoconstriction are unfounded.
Q: Which is more important to neonatal outcome: the induction of anesthesia to delivery interval or the uterine incision to delivery interval.
The UTERINE INCISION TO DELIVERY interval seems to be more important to neonatal outcome than the induction of anesthesia to delivery interval.The uterine incision to delivery interval is ideally less than 3 minutes (180 seconds).
Q: What 9 CV signs indicate fetal cocaine toxicity in the newborn of a concaine addicted mother.
1) arterial hypoxemia2) increased BP3) increased HR4) increased CBF5) reduced CO6) reduced SV7) right ventricular conduction delay8) RVH9) ST segment and T wave changes
Q: What is the most common cause of thrombocytopenia in the parturient?
PECOthers include 1) ITP, 2) gestational thrombocytopenia (up to 5% of parturients), 3) HIV positive status, 4) drug induced thrombocytopenia, including cocaine
Q: Which amino acid is the immediate precursor of nitric oxide (NO)?
Nitric Oxide is formed from L-arginine
Q: What enzyme family catalyzes the release of nitric oxide from L-arginine?
The nitric oxide synthase family of enzymes catalyzes the release of NO from L-arginine.
Q: Describe the signal transduction pathway of nitric oxide.
NO is a short-lived gas which diffuses easily across membranes. NO stimulates the production of cGMP by activating GC. cGMP activates PKG which ultimately decreases cytoplasmic calcium levels.
Q: Identify 6 metabolic or electrolyte disorders that prolong/increase nondepolarizing neuromuscular block.
1) respiratory acidosis2) metabolic acidosis3) hypothermia4) hypokalemia5) hypercalcemia6) hypermagnesemia
Q: Identify drugs and conditions associated with increased resistance to nondepolarizing neuromuscular block.
Antiepileptic drugs and patients with burns are associated with increased resistance to NDMBs.
Q: Describe the process that causes ventricular myocyte relaxation (lusitropy).
Ventricular myocyte contraction requires increased intracellular calcium. Thus, for the ventricular myocyte to relax, intracellular calcium must be reduced back to resting levels. Calcium is sequestered in the sarcoplasmic reticulum through energy dependent processes.
Q: Which biotransformation reaction (acetylation, oxidation, glucuronidation, sulfonation) are NOT MATURE in the neonate?
Acetylation, glycination, glucuronidationNOTE: sulfonation IS MATURE at birth. By one year, all reactions are mature.
Q: Why is morphine sulfate used cautiously, if at all, in the neonate?
Hepatic conjugation of morphine is reduced and renal clearance of morphine metabolites is reduced.
Q: State the numeric values for absolute deadspace and shunt.
Absolute deadspace = infinityAbsolute shunt = zero
Q: Which pathway, extrinsic or intrinsic, do the PT and INR assess?
Extrinsic
Q: What is the most common anesthesia related complication in ambulatory surgery?
PONVNOTE: others in descending order are persistent hypoxemia, unresolving conduction block, PDPH, pain, and persistent HTN
Q: Which NSAID does not alter platelet function.
Tylenol (Stoelting pg 253)
Q: What is the correct vertebral level of a properly placed CVP catheter tip?
The tip of a properly placed CVP catheter will be at the T4-T5 interspace, above the level of the 3rd rib.
Q: What anesthetic agent would you avoid during retinal detachment repair?
Avoid N2O during retinal detachment repair as the surgeon will often inject a bubble of SF6 or other perfluorocarbon.
Q: Name the most commonly encountered type of drug-induced hepatitis.
Alcohol hepatitis is probably the most commonly encountered type of drug induced hepatitis.
Q: Describe the r/t between IOP in intraocular volume. How is the r/t different if the globe is open?
Increased IOP in closed globe usually means increased volumeWith an open globe, Increased IOP decreases volume.
Q: Which electrolyte abnormality will cause MAC to increase? To Decrease?
Hypernatremia - MAC increasesHypercalcemia - MAC decreases