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NBCRNA BOARD PREP 6 - MISC NEW SET WITH 100% VERIFIED SOLUTIONS 100% VERIFIED!! Cholinergic Side Effects - ANSWER DUMBELLS >>increases concentration of Ach at muscarinic receptor = AchE inhibitors cause predictable parasympathetic side effects Diarrhea Urination Miosis Bradycardia Bronchoconstriction Emesis Lacrimation (increased tear production) Laxation (elimination of fecal waste) Salivation Muscarinic Antagonist Side Effects - ANSWER muscarinic antagonist = anticholinergics -increased HR = Atropine > Glyco > scopolamine -smooth muscle relaxation = atropine = glyco >scopolamine -sedation = scopolamine > atropine (glyco doesn't cross BBB) -antisialagogue = scopolamine >glyco > atropine - mydriasis + cycloplegia = scopolamine > atropine (glyco doesn't cross BBB) -prevent motion sickness = scopolamine > atropine (glyco doesn't cross BBB) -decreases gastric H secretion = atropine = scopolamine = glyco TEG - ANSWER >> provides real time visual representation of disorders of coagulation and fibrinolysis R = time to being forming clot (FFP_ K time = time until clot has achieved fixed strength (Cryo) Alpha angle = speed of fibrin accumulation (Cryo) maximum amplitude = highest vertical amplitude on the TEG (plt/DDAVP) amplitude at minutes after maximum amplitude (A60)= height of vertical amplitude 60 min after MA (TXA or aminocaproic acid) Increased R = increased initial clot formation >>> problem with coagulation factors = FFP Increased K (clot kinetics) = time until clot acheives fixed strength = clotting factors + fibrinogen = cryo increased alpha angle = speed of fibrin accumulation = problem with fibrinogen = cryo increased maximum amplitude (MA) = highest vertical amplitude of TEG = pit count, pit function, fibrinogen = platelets/DDAVP LY30 = fibrinolysis, percent lysis at 30 minutes = plasmin = TXA or aminocaproic acid order from left to right = R>>K>alpha angle>>MA>>LY30 FFP>>Cryo>>Cryo>>plt/DDAVP>>> TXA/Aminocaproic acid Negligence - ANSWER 4 things that must be proved: 1. Duty = anesthesia provider had a duty to the patient 2. breach of duty = the provider failed to fulfill their duty 3. causation = a close causal relationship existed between the provider's acts and patient's injury 4. damages = actual damage was the result of a breach in the standard of care assault vs. battery - ANSWER - these are torts (civil wrongdoings) Battery - physical act of touching another person without either expressed or implied consent assault - making a person feel or percceive that battery is imminent AANA Code of Ethics - ANSWER >> dictates principles of conduct and professional integrity that GUIDE decision-making and behavior of nurse anesthetists >>the CRNA is held individually accountable for his or her “conduct in maintaining the dignity and integrity of the profession" and "does not knowingly engage in deception in any form" Practice Standards - ANSWER >>authoritative statements that describe minimum rules and responsibilities for which anesthetists are held accountable >>muSt be adhered to often used in the context of inappropriate diagnostic testing Beneficence - ANSWER providers should act for the benefit of others includes preventing harm and actively helping their patients Justice - ANSWER principle that people under similar circumstances and conditions should be treated alike (known as distributive justice) informed consent - ANSWER 6 elements: - competence - pt has legal authority to consent -decision-making capacity - ability to decide -disclosure of information - at minimum = nature and purpose of proposed anesthesia technique, risks benefits and side effects of proposed technique, alternatives and their risks benefits and side effects, risks of not receiving anesthesia care -understanding of disclosed information - must demonstrate understanding -voluntary consent - absence of coercion or duress -documentation - medical record Types and subsets of Law - ANSWER Criminal Law Civil Law = contract law and tort law tort law = intentional, strict liability, and negligence intentional = assault, battery, intentional infliction of emotional distress strict liability = defective products negligence = action was unreasonably unsafe, res ipsa loquitur Res Ipsa Loquitur - ANSWER "the thing speaks for itself" can shift the burden of proof from the plaintiff to the defendant this can happen if 4 conditions are established: - if the injury would not have occurred in the absence of negligence - the injury was caused by something under the complete control of the defendent - the patient did not contribute in any way to the injury - the evidence for the explanation of events is solely under the control of the provider slander - ANSWER defamation in verbal form libel - ANSWER defamation in written form respondeat superior - ANSWER "let the master answer" damages - ANSWER general damages = directly result from an injury (pain, suffering, emotional distress) special damages = actual damages from an injury (medical expenses, lost income) punitive damages = rare, punishment for reckless or malicious behavior Affordable Care Act - ANSWER >>it required all individuals to carry health insurance >>it launched health care exchanges to assist people with finding insurance >>it prevented insurance carriers from denying coverage or charging higher premiums to patients with pre-existing conditions >>established new standards and requirements for health insurance policies failure to provide proof of insurance will trigger individual shared responsibility payment Emergency in Medical Treatment and Active Labor Act (EMTALA) - ANSWER >>ensure public access to emergency services regardless of their ability to pay >>"anti-patient dumping” Controlled Substances Act - ANSWER Schedule 1 - no currently accepted medical use with high potential for abuse >>> LSD, heroin, marijuana, MDMA, ecstasy Schedule 2 - high potential for abuse potentially leading to dependence >>> barbituates, cocaine, methadone, hydromorphone, fentanyl, oxycodone, phencyclidine (PCP) Schedule 3 - moderate to low potential for abuse and dependence >>> tylenol w/codeine, buprenorphine, ketamine, anabolic steroids, testosterone Schedule 4 - low potential for abuse and dependence >>> alprazolam, valium, ativan, ambien, tramadol, phenobarbital Schedule 5 - lower potential abuse than 4, limited quantities of certain narcotics >>> robitussin AC, pregabalin **propofol is not a scheduled drug** quality assurance (QA) program - ANSWER typically designed for analysis when performance falls below acceptable levels example: peer review systems or m&ms continuous quality improvement program - ANSWER identifies opportunities for improvement sentinel event - ANSWER any unexpected occurrence involving death or serious physical injury or risk thereof root cause analysis - ANSWER all sentinel evens should undergo RCA the underlying causes of an incident must be identified, and this information informs the most effective solutions outcome = a change in. health status after the delivery of care process = the planning and coordination of care activities structure = the setting in which care is provided Thermoregulation: mechanisms of heat transfer - ANSWER hypothermia = less than 36°C >> patients at extremes of age are at greatest risk of developing perioperative hypothermia >>body regulates between 36.7-37.1° >>reflex with afferent limb (thermoreceptors = skin, deep tissue, spinal cord), Control center (hypothalamus-preoptic region, brainstem), efferent response (too cold = vasoconstriction, piloerection, shivering, nonshivering thermogenesis, too hot = vasodilation, diaphoresis) 1. Radiation (60%) - infrared >> #1 source >> heat follows temperature gradient >> most heat lost through skin >> covering patient reduces radiant heat loss 2. Convection ~ air (15-30%) >> #2 source of heat loss >> transfer of heat by the movement of air >> "wind chill" >>> air movement whisks away the heat that has radiated from the body >> LAMINAR FLOW INCREASES THE AMOUNT OF HEAT LOST TO CONVECTION 3. Evaporation ~ water loss (20%) >> significant amount of energy to vaporize water (latent heat of vaporization) >> respiration, wounds, exposure of internal organs during surgery 4. Conduction ~ Contact (<5%) >>heat loss when patient comes in direct contact with a cooler object 3 phases of intraoperative heat transfer - ANSWER Phase 1 = Heat REDISTRIBUTION from core to periphery >>with general, spinal or epidural anesthesia there is a redistribution of heat from the central compartment to peripheral compartment >> anesthetic agents impair the thermoregulatory response in the hypothalamus = prevent shivering, cause vasodilation >>nominal heat loss phase 2 = heat transfer > Heat production >>hour 1-5 in OR Phase 3 = heat transfer ~ heat production >>>equilibrium between heat lost and heat production Consequences of Perioperative Hypothermia - ANSWER Cardiovascular = > SNS stimulation >>> MI + dysrhythmias >>> shifts oxyhgb curve to LEFT >>> decreased O2 available to tissues >>> vasoconstriction + decreased tissue PO2 >>> surgical site infection >>> coagulopathy + pit dysfunction >>> increased blood loss >>> sickling of hgb = risk of sickle cell crisis pharmacologic = slowed drug metabolism, increased solubility of volatile agents shivering = increased O2 consumption by up to 400-500% >> increased MI risk pharmacologic treatment = meperidine, clonidine, dexmedetomidine benefits = oxygen consumption reduced by 5-7% for every 1° reduction in body temperature >>useful during = cerebral ischemia, cerebral aneurysm clipping, TBI, CPB, cardiac arrest, aortic cross-clamping, carotid endarterectomy Airway Fires - ANSWER 3 ingredients required = >> ignition source (electrosurgical cautery, laser) >> fuel (endotracheal tube, drapes, surgical supplies) >>oxidizer (oxygen, nitrous oxide) >>1st degree = superficial, spontaneous healing, epidermis only, stinking, tender, and sore >>2nd degree superficial = epidermis to upper dermis = spontaneous healing >>2nd degree deep = epidermis to lower dermis = skin graft = very painful 3rd degree - full thickness - complete destruction of epidermis + dermis >>> no sensation because nerve endings are obliterated >>> skin graft 4th degree = full thickness - extends to muscle and bone = no sensation >>> skin graft >>>up-regulation of extrajunctional receptors begins after 24 hours so succ is safe within the first 24 hours >>dose of nondepolarizing NMB should be increased 2-3 times because there are more receptors ketamine good choice patients become hypermetabolic >>> increases catabolism, oxygen consumption, HR, RR Rule of 9's adult - ANSWER head = 9 arms - 9 each torso front = 18 torso back = 18 legs = 18 each genitals = 1 rule of 9 (pediatric) - ANSWER arms - 9.5% each head - 19% torso = 16 each front and back legs = 15% each Burns fluid resuscitation - ANSWER >> immediately after a burn, microvascular permeability increases, and this creates capillary leak >> fluid shifts and edema formation are greates in the first 12 hours and begin to stabilize by 24 hours >> avoid albumin in first 24 hours First 24 hours = parkland = 4 mi LR x % TBSA burned x kg >>1/2 in first 8 hours, 1/8 in next 16 hours modified brooke = 2 ml x % TBSA burned x kg second 24 hours= >D5W maintenance rate, colloid administration = 0.5 ml x TBSA x kg clinical end points of burn resuscitation = >>urine output = adult (> 0.5 ml/kg/hr), child < 30 kg (> 1 mi/kg/hr), electrical injury (> 1.5 ml/kg/hr d/t myoglobin toxicity) >>BP = adult (MAP > 60), infant (MAP > 60), child (MAP 70-90 + (2 x age)) >>HR = 80-140 age dependent >>base deficit <2 oxygen delivery index = 600 mixed venous O02 = 35-40 abdominal compartment syndrome - ANSWER intraabdominal pressure > 20 mmHg (transduction of bladder pressure) AND evidence of organ dysfunction (hemodynamic instability, oliguria, increased PIP) Carbon Monoxide Poisoning - ANSWER CO binds to hgb with an affinity 200 times that of 02 shifts oxyhgb curve to the left which impairs offloading to the tissues oxidative phosphorylation is also impaired inadequate O2 delivery >>> METABOLIC ACIDOSIS treatment = 100% O2 + hyperbaric oxygen Electroconvulsive Therapy - ANSWER >> treatment of medication resistant depression, mania, catatonia, suicidal ideation, some types of schizophrenia physiologic response = >>initial increased PNS activity during tonic phase (~15 seconds) >> decreased HR, decreased BP, increased oral secretions, increased gastric secretions >>secondary response = increased SNS activity during clonic phase (several minutes)>> increased HR + BP + intragastric pressure + CBF + ICP + lOP contraindication = absolute = recent MI (<4-6 months), recent intracranial surgery (<3 months), recent stroke (<3 months), brain tumor, unstable cervical spine, pheochromocytoma relative = pregnancy, pacemaker, ICD, CHF, glaucoma, retinal detachment, severe pulmonary disease key features: >> hypotension, decreased LOC/coma, polymorphic VT, NO MUSCLE RIGIDITY treatment: >>magnesium, serum alkalization Serotonin Syndrome - ANSWER onset: >> up to 12 hours causes: >>SSRIs: fluoxetine, paraoxetine, sertraline, citalopram >>SNRIs: venlafaxine, duloxetine, milnacipran >>MAOIls: phenizine, tranylcypromine, selegiline >>MCMA (ecstacy) >> these drugs + other serotoninergic drugs can cause serotonin syndrome (methylene blue, meperidine, fentanyl) key features: >>akathisia, mydriasis, tremor, AMS, clonus, MUSCLE RIGIDITY treatment: >>cyproheptadine (oral 5-HT2A antagonist), chlorpromazine (IV), supportive care anticholinergic syndrome - ANSWER onset: >> up to 12 hours causes: >>centrally acting anticholinergics (atropine, scopalomine) key features: >>red, hot, dry skin, mydriasis, delirium, no muscle rigidity treatment: >>physostigmine, supportive care Neuroleptic Malignant Syndrome - ANSWER onset: >> up to 24-72 hours causes: >>dopamine depletion in the basal ganglia and hypothalamus >>dopamine antagonists = reglan, haloperidol, chlorpromazine, risperidone >>withdrawal from dopamine agonists key features: >>bradykinesia, decreaased LOC/coma, rhabdo, myoglobinuria, acidosis, ANS instability, normal pupils, MUSCLE RIGIDITY treatment: >>bromocriptine, dantrolene, supportive care, ECT, succinylcholine is safe eye physiology - ANSWER >>globe is relatively noncompliant >>normal IOP = 10-20 >>factors that increase IOP = HYPERCARBIA, hypoxemia, increased CVP, increased MPA, laryngoscopy, trendelenburg Allodynia - ANSWER pain due to a stimulus that does not normally produce pain example: fibromyalgia Algogenic - ANSWER a stimulus that is normally expected to produce pain example: surgical incision analgesia - ANSWER no pain is sensed in response to a stimulus that produces pain example: opioid analgesics relieve kidney stone pain dysesthesia - ANSWER abnormal and unpleasant sense of touch example: burning sensation from diabetic neuropathy Hyperalgesia - ANSWER exaggerated pain response to a painful stimulus ex: opioid induced hyperalgesia neuralgia - ANSWER pain localized to a dermatome ex: herpes zoster neuropathy - ANSWER impaired nerve function ex: silent myocardial ischemia from diabetic neuropathy paresthesia - ANSWER abnormal sensation described as pins and needles ex: nerve stimulation during regional anesthesia chronic pain - ANSWER pain modulation occurs in the spinal cord Airborne = >transmission = airborne >>> organism smaller than droplet particles >prevention = gown + gloves, N95, negative pressure room >organisms = COVID, tuberculosis Mycobaterium Tuberculosis - ANSWER >bacillus >targets anterior, apical segments of lungs but also brain, kidney, joints, spine, GI tract diagnosis = > Mantoux test (skin test) >> if positive, get CXR treatment = >isoniazid is first line agent (pyridoxine can be added to reduce the incidence of liver damage) >rifampin causes thrombocytopenia, leukopenia, anemia, kidney failure White Blood Cells - ANSWER can be divided into granulocytes (neutrophils, basophils, eosinophils) and agranulocytes (monocytes, lymphocytes) >neutrophils = immune defense (fight bacterial and fungal infection) and make up 60% of all WBC >basophils = allergic reactions, release histamine, leukotrienes, prostaglandins (mast cells do same thing), epi prevents degranulation by binding to the beta-2 receptors on the cell membrane >eosinophils = against parasites >monocytes = fight bacterial, viral, and fungal (phagocytosis), release cytokines, present pieces of pathogens to T-lymphocytes >lymphocytes = >>B-lymphocytes = humoral immunity, produce antibodies >>T-lymphocytes = cell-mediated immunity (does not produce antibodies) >>natural killer cells = limit the spread of a tumor and microbial cells and their functio is reduced by opioids hypersensitivity reactions - ANSWER **Anaphylaxis = requires prior sensitization or cross-reactivity **anaphylactoid reaction = no prior exposure needed >>mast cell + basophil >> Histamine + Arachidonic acid metabolites Histamine = >H1 receptor = vasodilation, increased vascular permeability, snooth muscle contraction >H2 receptor = cardiac stimulation (tachycardia), gastric acid secretion Arachidonic acid metabolites = >Leukotrienes = bronchoconstriction + vasodilation >prostaglandins = bronchosconstriction + vasodilation Cardiovascular = > hypotension, tachycardia, arrhythmia, cardiac arrest Respiratory = >Bronchospasm (decreased ETCO2, decreased SaO2, increased PIP), laryngeal edema, increased mucus production >skin = flushing, uticaria (hives), erythemia, pruritis >GI = abdominal cramping, N/V, diarrhead TYPE 1 = immediate hypersensitivity >> antigen + antibody interaction in a patient who has been previously sensitized to the antigen >> IgE mediated reaction >> tryptase is released from mast cells during allergic reaction >> its the best lab test to determine if an allergic response has occurred >>examples: anaphylaxis, extrinsic asthma TYPE 2 = antibody-mediated >> IgG + IgM antibodies bind to cell surfaces or extracellular regions >> the reaction activates the complement cascade >> examples: ABO incompatibility, HITT TYPE 3 = immune complex mediated >>an immune complex is formed and deposited into the patient's tissue (normally these complexes are cleared from the body) >>example: snake venom reaction TYPE 4 = delayed >>allergic reaction is delayed at least 12 hours following exposure >>example: contact dermatitis, graft v host reaction, tissue rejection anaphylaxis treatment - ANSWER - d/c offending agent -increase FiO2 + provide airway support -epi = 5-10 mcg for hypotension, 0.1 mg IV for CV collapse -liberal fluids >>> 10-25 ml/kg crystalloid, 10 ml/kg colloid - H1 receptor antagonist = benadryl 0.5-1 mg/kg -H2 receptor antagonist = ranitidine or pepcid -hydrocortisone 250 mg IV -albuterol for bronchospasm -vasopressin for refractory hypotension epi = prevents degranulation, provides CV support, dilates airways somatostatin >>> universal "off" switch for digestion >site of production =D cells (pancreatic islet), stomach, small intestine >stimulus = food in gut, gastrin, CCK >function = decrease all GI function **Gastrin increased in Zollinger-Ellison syndrome (gastrin secreting tumor > increase stomach acid > gastric ulceration) **Gallbladder pain after fatty meal is caused by increased CCK release *“somatostatin is treatment for carcinoid tumors Gastric barrier pressure - ANSWER >>the likelihood of GERD is determined by barrier pressure > the higher the pressure, the lower the likelihood of reflux >> barrier pressure is reduced by things that reduce LES tone or increase intragastric pressure things that decrease barrier pressure = >> anticholinergics (decrease LES tone) >> cricoid pressure (decrease LES tone) >> pregnancy (decrease tone and increase intragastric pressure) things that increase barrier pressure = > reglan (increase LES tone) things that don't affect barrier pressure = >>succinylcholine (increased LES tone + increased intragastric pressure = 0 net change) PONV patho - ANSWER vomiting center = NUCLEUS TRACTUS SOLITARIUS (medulla) >>sensory arises from chemoreceptor trigger zone, GI tract, vestibular system Gl tract >> Vagus Nerve >> 5-HT3 + NK-1 >>>Vomiting Center Chemoreceptor trigger zone (area postrema) >> 5-HT3 + NK-1 + DA - 2 + Noxious chemicals >> Vomiting Center Vestibular apparatus >> H1 + M1 >> vomiting center PONV risk factors - ANSWER Patient risk factors = >Female > NONsmoker > hx of motion sickness > previous PONV > youth > elderly Surgical risk factors = >>41hr > GYN procedures > Laparoscopy > Breast > Plastics > Peds = strabismus, orchiopexy, T+A Anesthetic risk factors > Halogenated anesthetics > Nitrous oxide > Opioids > Etomidate > Neostigmine **Key Points** > TIVA or regional reduces risk > BBB is poorly developed at the CTZ >> why its stimulated by noxious chemicals > H/A + diarrhea most common SE of ondansetron > dopamine antagonists can cause extrapyramidal symptoms = contraindicated in Parkinson's disease Bone Cement Implantation Syndrome - ANSWER >> Methyl methacrylate (bone cement) >> increase intramedullary pressure up to 500 mgHg >> Microemboli (fat, bone marrow, cement) >> lungs >> V/Q mismatch (increase deadspace) >> RHF >>residual cement >> blood stream >> bradycardia, dysrhythmias, hypotension (decreased SVR), pulmonary htn (increased PVR), hypoxia, cardiac arrest >> hip arthroplasty = highest risk >> in awake pt, first signs are typically AMS + dyspnea >> under anesthesia first sign = decreased EtCO2 >>treatment = 100% FiO2, IV hydration, phenylephrine Fat embolism syndrome - ANSWER long bone trauma (within 72 hours of injury) risk factors = pelvic fx, femoral fx., instrumentation of femoral medullary canal 
