NBCRNA Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

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NBCRNA Exam Questions with 100% Correct Answers | Verified | Updated 2024 Muscle that tenses vocal cords - Correct Answer-Cricothyroid Muscle that relaxes vocal cords - Correct Answer-Thyroarytenoid Muscle that abducts vocal cords - Correct Answer-Posterior cricoarytenoid Muscle that adducts vocal cords - Correct Answer-Lateral cricoarytenoid Sensory innervation of upper airway - Correct Answer-Trigeminal nerve: V1 (ophthalmic) - nares + anterior 1/3 septum V2 (maxillary) - turbinates + septum V3 (mandibular) - anterior 2/4 tongue Glossopharyngeal nerve: Posterior 1/3 tongue/soft palate/oropharynx Vallecula, anterior epiglottis Vagus nerve: SLN (internal branch): posterior epiglottis to vocal cords RLN: below vocal cords to trachea Superior laryngeal nerve external branch - Correct Answer-Motor to cricothyroid muscle Superior laryngeal nerve internal branch - Correct Answer-Sensory posterior epiglottis to vocal cords Recurrent laryngeal nerve - Correct Answer-Sensation below vocal cords to trachea Motor: all intrinsic Laryngeal muscles except cricothyroid Recurrent laryngeal nerve injury - Correct Answer-Bilateral acute: respiratory distress due to unopposed action of cricothyroid muscles Bilateral chronic and unilateral = no respiratory distress Superior laryngeal nerve injury - Correct Answer-No respiratory distress but possible voice changes /hoarseness Glossopharyngeal nerve block location - Correct Answer-Anterior tonsilar pillar Superior laryngeal nerve block location - Correct Answer-Greater corneu of hyoid bone Transtracheal nerve block location - Correct Answer-Cricothyroid membrane 3 paired cartilages of larynx - Correct Answer-Corniculate Arytenoid Cuneiform 3 unpaired cartilages of the larynx - Correct Answer-Epiglottis Thyroid Cricoid Adult larynx spinal levels - Correct Answer-C3-C6 Where do vocal cords attach? - Correct Answer-Anteriorly: thyroid cartilage Posteriorly: arytenoids Laryngospasm risk factors - Correct Answer-Recent URI Infants/young children Asthma Smoking ASA 4, prematurity, GERD, OSA Airway procedures (T&A) Muscles of inspiration - Correct Answer-Diaphragm, external intercostals Accessory muscle of inspiration - Correct Answer-Sternocleidomastoid Scalene Muscles of active expiration - Correct Answer-Transverse abdominis Internal obliques Rectus abdominis External obliques (I let the air out of my "tire"s) V/Q ratio > 1 - Correct Answer-Dead space V/Q ratio < 1 - Correct Answer-Shunt Normal minute ventilation - Correct Answer-4 L/min Normal cardiac output - Correct Answer-5 L/min Normal V/Q ratio - Correct Answer-0.8 Narrowest part of airway in adults - Correct Answer-Vocal cords Narrowest part of pediatric airway - Correct Answer-Cricoid (fixed) Vocal cords (dynamic) Conditions when intrapleural pressure is positive - Correct Answer-Forced exhalation Pneumothorax Normal amount of dead pace - Correct Answer-2 mL/kg Factors that cause increased dead space - Correct Answer-Face mask HME Positive pressure ventilation Anticholinergics (bronchodilation) Old age Neck extension Decreased CO/hypotension COPD PE Sitting upright Factors that cause decreased dead space - Correct Answer-ETT LMA Tracheostomy Neck flexion Supine Head down position venous admixture - Correct Answer-Another term for shunt Diaphragm innervation - Correct Answer-Phrenic nerves which arise from C3-C5 Conditions that reduce FRC - Correct Answer-Anything that reduced outward lung expansion or reduces lung compliance Ex) obesity pregnancy, supine position, anesthetic induction, NMBs, surgical displacement Conditions that increase FRC - Correct Answer-COPD or any condition that causes air trapping Bohr vs Haldane effect - Correct Answer-Bohr: describes O2 carriage: increased CO2 and decreased pH causes erythrocyte to release CO2 Haldane: describes CO2 carriage: more O2 bound to hemoglobin = CO2 release from erythrocytes (occurs in lungs) aka deoxygenated hemoglobin can carry more CO2 (occurs in venous blood) 4 areas of respiratory center - Correct Answer-Medulla: 1) Dorsal respiratory center: active during inspiration (respiratory pacemaker) 2) ventral respiratory center: active during expiration Pons: 1) pneumotaxic center: inhibits DRC 2) apneustic center: stimulates DRC Dorsal respiratory center - Correct Answer-Located in the medulla Respiratory pacemaker Active during inspiration Ventral respiratory center - Correct Answer-Located in medulla Active during expiration Pneumotaxic center - Correct Answer-Located in pons Inhibits DRG Apneustic center - Correct Answer-Located in pons Stimulates DRC Central vs peripheral chemoreceptors - Correct Answer-Central: located in medulla, responds to H+ concentration in CSF Peripheral: located in carotid bodies and aortic arch, responds to decreased O2, increased CO2, and increased H+ Herings nerve - Correct Answer-Aka carotid sinus nerve Branch of Glossopharyngeal nerve (CN IX) Peripheral chemoreceptors location/innervation - Correct Answer-Carotid bodies: herings nerve (carotid sinus nerve -> Glossopharyngeal nerve) Aortic arch: vagus nerve Respond to: decreased O2, increased CO2, and increased H+ Hering-Breuer reflex - Correct Answer--prevents over inflation of lungs - stimulus = inflation > 1.5 L -afferent = vagus -efferent = phrenic nerve Things that inhibit hypoxic pulmonary vasoconstriction - Correct Answer--Halogenated anesthetics> 1-1.5 MAC (IV anesthetics do not affect) - phosphodiesterase inhibitors - dobutamine - vasodilators Hypoxic pulmonary vasoconstriction (HPV) - Correct Answer--combats shunt by reducing blood flow to poorly ventilated areas (atelectasis or one lung ventilation) -low alveolar PO2 (not arterial pO2) is the trigger for HPV FRC - Correct Answer-functional residual capacity RV + ERV Normal FRC - Correct Answer-35 mL/kg or 2,300 mL (ERV 1,100 + RV 1,200) Fick's Law - Correct Answer-The rate of diffusion of a gas into a liquid is: Directly proportional to: the partial pressure of the gas above the liquid and the surface area available for gas exchange Inversely proportional to: the molecular weight of the molecules and the thickness of the membrane Normal DLCO - Correct Answer-17-25 mL/CO/min/mmHg DLCO - Correct Answer-Diffusing capacity of the lung for carbon monoxide Used to asses how well the lung can exchange gas Factors that reduce DLCO - Correct Answer-Anything that reduces alveolar surface area (emphysema) Or increases thickness (pulmonary fibrosis, pulmonary edema) How is tobacco smoke harmful? - Correct Answer-Increased SNS tone, sputum production, carboxyhemoglobin concentration, and risk of infection How long after quitting smoking does pulmonary function return to normal? - Correct Answer-At least 6 weeks Risk factors for postop pulmonary complications - Correct Answer-Age > 60 ASA 3-5 CHF COPD Smoking -aminophylline (phosohodiesterase inhibitor) Definitive treatment for alpha 1 antitrypsin deficiency - Correct Answer-Liver transplant Alpha 1 antitrypsin disease - Correct Answer--Abnormal alpha antitrypsin enzyme produced in liver, accumulates and causes cirrhosis -deficiency in normal alpha antitrypsin enzyme causes emphysema due to relative greater alveolar elastase activity Examples of restrictive lung diseases - Correct Answer-Acute intrinsic: pulmonary edema, aspiration Chronic intrinsic: sarcoidosis, drug induced pulmonary fibrosis Mediastinum/chest wall: kyphosis, flail chest, ankylosis spondylitis, pleural effusion, neuromuscular disorders Other: pregnancy, obesity, ascites Mendelsons syndrome - Correct Answer-Chemical aspiration pneumonitis Mendelsons syndrome risk factors - Correct Answer-Gastric pH < 2.5 Gastric volume > 25 mL Aspiration risk factors - Correct Answer-Trauma Emergency surgery Pregnancy GI obstruction GERD Peptic ulcer disease Hiatal hernia Ascites Cricoid pressure Impaired airway reflexes Head injury Seizures Residual neuromuscular blockade Aspiration treatment - Correct Answer-Tilt head downward/to side (first action) Upper airway suction Secure airway to support oxygenation PEEP to reduce shunt Bronchodilators to reduce wheezing Lidocaine to reduce neutrophil response Steroids probably don't help Antibiotics only indicated if patient develops a fever or increased WBC count greater than 48 hours Flail chest/treatment - Correct Answer--multiple rib fractures d/t blunt force trauma resulting in paradoxical chest wall movement -treatment = intercostal nerve blocks or epidural for pain, some patients need mech ventilation or surgical fixation Order of monitor sensitivity for VAE - Correct Answer-TEE Doppler PAP/EtCO2 CO/CVP BP/EKG/stethoscope Signs/symptoms of VAE - Correct Answer-Air observed on TEE Milk wheel murmur Decreased EtCO2 Increased PAP Increased EtN2 Hypotension Dysrhythmias Pulmonary edema Hypoxia Cyanosis Pulmonary hypertension definition - Correct Answer-Mean PAP > 25 mmHg PVR calculation and normal values - Correct Answer- Factors that increase PVR - Correct Answer-Drugs: ketamine, nitrous, desflurane Hypoxemia Hypercarbia Acidosis SNS stimulation/pain Hypothermia Increased intrathoracic pressure (PEEP, atelectasis, mech ventilation) Drugs that decrease PVR - Correct Answer-Nitric oxide Nitroglycerin Phosphodiesterase inhibitors (sildenafil) Prostaglandins (PGE1 + PGE12) Calcium channel blockers ACE inhibitors Factors that decrease PVR - Correct Answer-Increased PaO2 Hypocarbia Alkalosis Decreased intrathoracic pressure (prevent coughing/straining) Normal lung volumes Spontaneous ventilation High frequency jet ventilation Drugs you can give via ETT - Correct Answer-"NAVEL" Narcan Atropine Vasopressin Epinephrine Lidocaine CO poisoning treatment - Correct Answer-100% FiO2 until COHgB is <5% or for 6 hours Hyperbaric oxygen if COHgB is > 25% or the patient is symptomatic Pathophysiology of CO poisoning - Correct Answer-CO causes left shift of oxyhemoglobin dissociation curve CO has 200x affinity for HgB than oxygen Result is metabolic acidosis Patients take on cherry red appearance Pulse ox does not read accurately Problem with desiccated soda lime - Correct Answer-CO production: des > iso > sevo Compound A production with sevo (fire risk) Absolute indications for OLV - Correct Answer-Isolation of one lung to avoid contamination (infection) Control of distribution of ventilation (broncho-pleural fistula, surgical opening of major airway, large unilateral cyst or Bullae, life threatening hypoxemia r/t lung disease) Unilateral bronchopulmonary lavage Relative indications for OLV - Correct Answer-Surgical exposure high priority: thoracic AAA, pneumonectomy, upper lobectomy, mediastinal exposure Surgical exposure low priority: middle/lower lobectomy, esophageal resection Pulmonary edema s/p CABG Severe hypoxemia r/t lung disease OLV sizing - Correct Answer-Men: 39-41 Reduced cervical mobility 6 risk factors for difficult LMA placement - Correct Answer-Limited mouth opening Upper airway obstruction Lower airway obstruction Poor lung compliance (requires increased PIP) Increased airway resistance (requires increase PIp) Altered pharyngeal anatomy 5 risk factors for difficult invasive airway placement - Correct Answer-Abnormal neck anatomy Obesity Short neck Laryngeal trauma Limited access to cricothyroid membrane (halo, neck flexion deformity) 3 causes of angioedema - Correct Answer-Anaphylaxis ACE inhibitors Hereditary angioedema (C1 esterase deficiency) Angioedema - Correct Answer-The result of increased vascular permeability that can lead to the swelling of the face, tongue, and upper airway Treatment for hereditary angioedema (C1 esterase deficiency) - Correct Answer-C1 esterase cocnentrate or FFP (not epi, antihistamines, or steroids) Ecallantide Icatibant Patients should receive prophylaxis prior to stimulating procedures (FFP or danazol) Icatibant - Correct Answer-Bradykinin receptor antagonist Treatment for C2 esterase deficiency Ecallantide - Correct Answer-Plasma kallikrein inhibitor (stops conversion of kininogen to bradykinin) Treatment for c1 esterase deficiency Ludwigs Angina - Correct Answer-A bacterial infection characterized by rapidly progressing cellulitis in the floor of the mouth Can cause posterior displacement of the tongue and complete airway obstruction Best way to secure airway is with the patient awake (nasal or tracheostomy) Retrograde intubation is contraindicated with an infection above the level of the trachea NPO guidelines - Correct Answer-Clears: 2 hours Breast milk: 4 hours Non human milk/solids/formula: 6 hours Fried/fatty foods: 8 hours Syndromes associated with large tongue - Correct Answer-"Big tongue" Beckwith syndrome Trisomy 21 (Down syndrome) Syndromes associated with small/underdeveloped mandible - Correct Answer-Pierre robin Goldenhar Treacher Collins Cri du chat Syndromes associated with cervical spine abnormality - Correct Answer-"Kids try gold" Klippel-feil Trisomy 21 Goldenhar The sniffing position - Correct Answer-Cervical flexion Alanto-occipital extension (Head elevated and extended) Types of oral airways that can be used for fiber optic intubation - Correct Answer- Williams Ovassapian Best time to use an Eschmann Introducer - Correct Answer-Aka bougie or intubating Stylet Best used with grade III view Next best used with grade IIB Don't use with a grade IV Contraindications to nasal airways - Correct Answer-Cribiform plate injury: le fort II or III fracture Coagulopathy Previous transphenoidal hypophysectomy Previous caldwell-luc procedure Nasal fracture 3 types of Le Fort fractures - Correct Answer- Recommended cuff pressure for ETT - Correct Answer-< 25 cm H20 Recommended cuff pressure for LMA - Correct Answer-< 60 cm H20 Max peak Inspiratory pressures for LMA- unique - Correct Answer-< 20 cm H20 Max peak Inspiratory pressure for LMA- proseal - Correct Answer-<30 cm H20 Max peak Inspiratory pressure for LMA supreme - Correct Answer-< 30 cm H20 LMA Classic - Correct Answer-First generation reusable LMA LMA unique - Correct Answer-Single use version of classic LMA LMA proseal - Correct Answer-Adaptation of classic LMA Double lumen LMA Has gastric drain tube Larger mask Bite block Max PIP < 30 LMA supreme - Correct Answer-Disposable version of LMA proseal LMA fast trach - Correct Answer-Intubating LMA LMA size 1 patient weight - Correct Answer-< 5 kg LMA size 1.5 patient weight - Correct Answer-5-10 kg LMA size 2 patient weight - Correct Answer-10-20 kg LMA size 2.5 patient weight - Correct Answer-20-30 kg LMA size 3 patient weight - Correct Answer-30-50 kg LMA size 4 patient weight - Correct Answer-50-70 kg LMA size 5 - Correct Answer-70-100 kg LMA size 5 cuff inflation - Correct Answer-40 mL LMA size 4 cuff inflation - Correct Answer-30 mL Best used when intubation has failed but ventilation is still possible since takes around 5-7 min for experienced practitioners Contraindications for retrograde intubation - Correct Answer-Poor anatomy (goiter, obesity, neck flexion) Laryngotracheal disease (stenosis below puncture site) Coagulopathy Infection (pre tracheal abscess) Best time to use airway exchange catheter - Correct Answer-To manage extubation of difficult airway (remains in place after extubation) What can you do with an airway exchange catheter? - Correct Answer-EtCO2 measurement Jet ventilation (leuer lock adapter) Oxygen insufflation (15 mm adapter) Contraindications to trans tracheal jet ventilation - Correct Answer-Upper airway obstruction Laryngeal injury Contraindications to cricothyrotomy - Correct Answer-Children < 6 Neoplasm Laryngeal fracture Receptors that use Gq second messenger system - Correct Answer-Alpha 1 Muscarinic 1,3,5 Histamine 1 Vasopressin 1 (vascular) Describe the Gq second messenger system - Correct Answer-Effector: phospholipase C Second messengers: IP3, DAG, calcium Receptors that use Gq: alpha 1, histamine 1, muscarinic 1,3,5, vasopressin 1 (vascular) What receptors used the Gi second messenger system? - Correct Answer-Alpha 2 Muscarinic 2,4 Dopamine 2 (presynaptic) Describe the Gi second messenger system - Correct Answer-Effector: decreased adenylate cyclase Second messenger: decreased cAMP Receptors that use system: alpha 2, Muscarinic 2,4, dopamine 2 (presynaptic) What receptors use the Gs second messenger system? - Correct Answer-Beta 1, 2 Dopamine 1 (postsynaptic) Histamine 2 Vasopressin 2 (renal) Describe the Gs second messenger system - Correct Answer-Effector: increased adenylate cyclase Second messenger: cAMP Receptors that use this system: beta 1,2, dopamine 1 (postsynaptic), histamine 2, vasopressin 2 (renal) Describe autonomic innervation of heart - Correct Answer-SNS: cardioacceleratory fibers T1-T4 B1 receptors: increased HR, contractility PNS: vagus nerve M2 receptors: decreased HR, contractility Describe the autonomic innervation of the vasculature - Correct Answer-Arteries: alpha 1 > alpha 2 (vasoconstriction) Veins: alpha 2 > alpha 1 (vasoconstriction) Myocardium: beta 2 (vasodilation) Skeletal muscle: beta 2 (vasodilation) Renal: dopamine (vasodilation) Mesenteric: dopamine (vasodilation) No parasympathetic Cardioacceleratory fibers location - Correct Answer-T1-T4 Autonomic innervation of bronchial tree - Correct Answer-M2: bronchoconstriction B2: bronchodilation (no direct innervation, respond to circulating catecholamines) Describe autonomic innervation of kidney - Correct Answer-B1: increased renin release A2: ADH inhibition (diuresis) Autonomic innervation of the eye - Correct Answer-Sphincter muscle (iris): M - contraction (miosis) Radial muscle (iris)- alpha 1 - contraction (mydriasis) Ciliary muscle: B2 (relaxation, far vision), M (contraction, near vision) Autonomic innervation of GI tract - Correct Answer-Sphincters: alpha 1 (contract) M (relax) Motility/tone: a 1,2 b 1,2 (decrease) M (increase) Salivary glands: alpha 2 (decrease) M (increase) Gallbladder & ducts: beta 2 (relax) M (contract) Autonomic innervation of the liver - Correct Answer-Alpha 1 & beta 2: increase serum glucose Autonomic innervation of uterus - Correct Answer-Alpha 1: uterine contraction Beta 2: uterine relaxation Autonomic innervation of bladder - Correct Answer-Sphincter: alpha 1 (constrict) M (relax) Detrusor: beta 2 (relax) M (contract) Autonomic innervation of sweat glands - Correct Answer-Alpha 1: increased secretion M: increased secretion Rate limiting step of Norepi synthesis - Correct Answer-Conversion of tyrosine to DOPA (Enzyme = tyrosine hydroxylase) Steps of norepi synthesis - Correct Answer-Tyrosine DOPA Dopamine Norepinephrine Enzyme that converts norepi to epi - Correct Answer-Phenylethanolamine-N- methylyransferase (In adrenal medulla most of norepi is converted to epi and secretes about 80% epi and 20% norepi) 3 ways norepi is removed from synaptic cleft - Correct Answer-1. Reuptake into presynaptic neuron (80%) 2. Diffusion away from cleft 3. Reuptake by extraneural tissue What enzymes metabolize epi and NE? - Correct Answer-MAO COMT What is the final byproduct of epi and NE metabolism? - Correct Answer- Vanillylmandelic acid (VMA) (Elevated levels in tribe help diagnosis pheochromocytoma) 3 types of cholinergic receptors and location - Correct Answer-Nicotinic type M (muscle): neuromuscular junction Nicotinic type N (nerve): autonomic ganglia SNS and PNS, central nervous system -grow in neuroendocrine tissue that are in close proximity to carotid artery, aorta, Glossopharyngeal nerve, and middle ear -can release several vasoactive substances that can lead to exaggerated hyper or hypotension (NE, 5-HT, histamine, bradykinin) Anesthetic considerations for glomus tumor - Correct Answer--can release several vasoactive substances that can lead to exaggerated hyper or hypo tension - carcinoid like symptoms can be used to treat carcinoid like symptoms -cranial nerve dysfunction can cause swallowing impairment, aspiration, and airway obstruction - surgical dissection of glomus tumor that has invaded the IJ can increase risk of VAE Multiple system atrophy - Correct Answer-Degeneration of locus coerulus (where cell bodies of SNS lie) Results in autonomic dysfunction Anesthetic considerations multiple system atrophy - Correct Answer--Autonomic dysfunction (orthostatic hypotension) -Treat hypotension with volume and direct acting sympathomimetics -exaggerated hypertensive response to ephedrine and possibly ketamine Low vs medium vs high dose epi - Correct Answer-Low (0.01-0.03 mcg/kg/min): non selective beta effects predominate. Beta 1 stimulation results in increased HR and contractility, and beta 2 stimulation causes skeletal muscle vasodilation l. Net effect = increased CO and reduction in SVR. Medium (0.03-0.15 mcg/kg/min): mixed alpha and beta effects High (> 0.15 mcg/kg/min): alpha effects prevail and BP rises. SVT common at these doses (limits usefulness) Cardiovascular effects of isoproteronol - Correct Answer--synthetic catecholamine that stimulates B1 and B2 receptors -increased HR, contractility, and myocardial oxygen demand -decreases SVR, diastolic pressure, and may decrease coronary perfusion pressure -causes severe dysrhythmias and tachycardia -vasodilates non essential vascular beds (do not use in septic shock) 4 clinical indications for isoproteronol - Correct Answer-1) chemical pacemaker for bradycardia unresponsive to atropine 2) heart transplant 3) bronchoconstriction 4) cor pulmonale Situations where ephedrine should not be used to treat hypotension - Correct Answer-- when neuronal catecholamine stores are depleted (sepsis) or absent (heart transplant) -risk of hypertensive crisis in patients on MAOi's -conditions where increased HR or contractility are detrimental to hemodynamics Vasopressin mechanism of action - Correct Answer-V1 receptor stimulation: vasoconstriction V2 receptor stimulation: synthesis and insertion of aquaporins into collecting ducts- results in increased water reabsorption and lower serum osmolarity Best treatment for vasoplegic syndrome - Correct Answer--aka refractory hypotension that does no respond to conventional therapies -best treatment = vasopressin 0.5-1 units bolus followed by 0.03 units/min infusion -next best choice = methylene blue 6 selective B1 antagonists - Correct Answer-Esmolol Metoprolol Atenolol Acebutolol Betaxolol Bisoprolol 6 non selective B antagonists - Correct Answer-Carvedilol Labetalol Nadolol Pindolol Propanolol Timolol Which beta blocker is eliminated by kidneys and should be avoided in renal failure? - Correct Answer-Atenolol How is esmolol metabolized? - Correct Answer-RBC esterases (not pseudocholinesterase) Primary site of metabolism for beta blockers? - Correct Answer-Liver (Except esmolol and atenolol) Which beta blockers have local anesthetic properties? - Correct Answer-Propanolol Acebutolol (Membrane stabilizing properties that reduce the rate of rise of cardiac action potential) Which beta blockers are partial agonists/have intrinsic sympathomimetic properties? - Correct Answer-Labetalol Pindolol Phenoxybenzamine MOA - Correct Answer-Long acting, nonselective, noncompetitive alpha 1 and alpha 2 antagonist Phentolamine MOA - Correct Answer-Short acting, non selective, competitive antagonist of the alpha 1 and alpha 2 receptor Prazosin MOA - Correct Answer-Selective alpha 1 antagonist 3 locations of alpha 2 receptor - Correct Answer-Presynaptic: NE releasing neurons in CNS & PNS, negative feedback reduces NE release Postsynaptic: smooth muscle (arteries, veins, GI), renal tubules, salivary glands, pancreatic islet cells Nonsynaptic: platelets (increase platelet aggregation) White ramus - Correct Answer-Where preganglionic sympathetic fibers enter the sympathetic chain ganglia Stellate ganglion - Correct Answer--sympathetic ganglion outside the sympathetic chain ganglia -provide sympathetic innervation to the ipsilateral extremity and part of the head/neck Consequences of stellate ganglion block - Correct Answer-"Horner's syndrome" Ptosis, anhidrosis,miosis, enopthalmos Vasodilation Bezold-Jarisch reflex symptom triad - Correct Answer-Bradycardia Hypotension Coronary artery dilation Celiac reflex - Correct Answer-Initiated by reaction to mesentery or other abdominal organs Mediated by vagus nerve, causes bradycardia and hypotension Cushing's triad - Correct Answer-Sign of intracranial hypertension Hypertension, bradycardia, irregular respirations Symptoms of multiple system atrophy - Correct Answer-Aka shy drager syndrome Orthostatic hypotension Describe the Frank Starling relationship - Correct Answer-The relationship between preload and cardiac output. Increased preload increase cardiac output to an extent by increasing myocardial stretch Factors that increase contractility - Correct Answer-SNS stimulation/catecholamines Calcium Digitalis Phosphodiesterase inhibitors Factors that decrease contractility - Correct Answer-MI Severe hypoxia Acidosis Hypercapnia Hyperkalemia Hypocalcemia Volatile anesthetics Propofol Beta blockers Calcium channel blockers Explain excitation-contraction coupling in the cardiac myocyte - Correct Answer-- myocardial cell membrane depolarizes -calcium enters the cardiac myocyte via Ltype calcium channels -calcium influx turns on the ryanodine-2 receptor which release calcium from the sarcoplasmic reticulum (calcium induced calcium release) -calcium binds to Troponin C (contraction) -calcium unbinds from Troponin C (relaxation) -most of calcium is returned to SR vis SERCA2 pump Explain the Law of Laplace and how it relates to ventricular afterload - Correct Answer- Wall stress = (intraventricular pressure x radius) / ventricular thickness 3 conditions that set afterload proximal to the systemic circulation - Correct Answer- Aortic stenosis Hypertrophic cardiomyopathy Coarctation of the aorta Review the Wiggers diagram (see fill in the blank diagram) - Correct Answer- Draw a normal cardiac pressure volume loop - Correct Answer- Explain how beta stimulation effects cardiac excitation contraction coupling - Correct Answer- Best TEE view to diagnose myocardial ischemia - Correct Answer-Short axis view, mid papillary muscle level Inferior EKG leads - Correct Answer-II, III, aVF Lateral EKG leads - Correct Answer-I, aVL, V5, V6 Anterior/septal EKG leads - Correct Answer-V1 V2 (septum) V3 V4 (anterior) Coronary perfusion pressure equation - Correct Answer-Coronary perfusion pressure = aortic DBP - LVEDP (LVEDP can be estimated by PAOP and PA diastolic) CPP can be improved by increasing aortic DBP or decreasing PAOP Which region of heart is most susceptible to myocardial ischemia and why? - Correct Answer-LV subendocardium Best perfused during diastole (as aortic pressure increases, LV tissue compresses it's own blood supply) Explain autonomic influence on coronary artery constriction/vasodilation - Correct Answer- Which 2 factors both decrease myocardial Oxygen supply and increase demand? - Correct Answer-Tachycardia (decreases supply by decreasing diastolic filling time, increases demand by increasing oxygen consumption) Increased preload (decreases supply by decreasing CPP, increases demand by increasing wall stress) What are the 3 pathways in regulating vascular smooth muscle tone? - Correct Answer- Explain the B2/cAMP vascular smooth muscle pathway - Correct Answer- Explain the NO/cGMP vascular smooth muscle pathway - Correct Answer- Explain the phospholipase C vascular smooth muscle pathway - Correct Answer- Explain 3rd heart sound - Correct Answer--heard after S2 -"gallop rhythm" -may suggest systolic dysfunction -normal in kids and athletes Explain 4th heart sound - Correct Answer-Heard before S1 May suggest diastolic dysfunction Where to ascultate for aortic valve - Correct Answer- Where to ascultate for pulmonic valve - Correct Answer- Where to ascultate for tricuspid valve - Correct Answer- Where to ascultate for tricuspid valve - Correct Answer- What does "sarcomeres added in parallel" mean - Correct Answer-Concentric hypertrophy (respond to pressure overload) What does "sarcomeres added in series" mean? - Correct Answer- Draw aortic stenosis pressure volume loop - Correct Answer- Draw mitral stenosis pressure volume loop - Correct Answer- Draw chronic and acute mitral regurgitation pressure volume loops - Correct Answer- Draw acute and chronic aortic insufficiency pressure volume loops - Correct Answer- Mitral stenosis hemodynamic goals - Correct Answer-HR: slow normal Preload: maintain Contractility: maintain SVR: maintain PVR: avoid increase Aortic stenosis hemodynamic goals - Correct Answer-HR: slow normal Preload: increase Contractility: maintain SVR: maintain or increase PVR: normal Mitral regurgitation hemodynamic goals - Correct Answer-HR: increased Preload: maintain or increase Contractility: maintain SVR: decrease PVR: avoid increase Aortic insufficiency hemodynamic goals - Correct Answer-HR: increased Preload: maintain or increase Contractility: maintain Pathophysiology of constrictive pericarditis - Correct Answer--caused by fibrosis or any condition where the pericardium become thicker -during diastole, the ventricles can't fully relax which reduces compliance and diastolic filling -ventricular pressure increased which creates a back pressure to the peripheral circulation -ventricles adapt by increasing myocardial mass but over time this impairs systolic function Beck's triad - Correct Answer-Hypotension JVD Muffled heart tones (Occurs in the patient with acute cardiac tamponade) pulsus paradoxus - Correct Answer-Decreased SBP > 10 mmHg during inspiration Kussmaul's sign - Correct Answer-Increased CVP and JVD during inspiration 2 conditions associated with kussmauls sign - Correct Answer-Constrictive pericarditis Pericardial tamponade 2 conditions associated with pulsus paradoxus - Correct Answer-Constrictive pericarditis Pericardial tamponade Preferred anesthetic technique for patient with acute tamponade undergoing pericardiocentesis - Correct Answer-Local anesthesia Drugs that are safe to us with cardiac tamponade - Correct Answer-Ketamine (best choice) Nitrous oxide Benzos Opioids Primary anesthetic goals with cardiac tamponade - Correct Answer-Preserve myocardial function Avoid drugs that depress the myocardium or reduce afterload Factors that increase ventricular compliance - Correct Answer-Any condition that dilates the heart (chronic aortic insufficiency or dilated cardiomyopathy for example) Symptoms of Conns syndrome - Correct Answer-(Hyperaldosteronism) Hypertension Hypokalemia Alkalosis Fatigue/weakness Parasthesia Nocturnal polyuria/polydipsia 3 main symptoms of pheochromocytoma - Correct Answer-Headache Palpitations Diaphoresis Clonidine mechanism of action - Correct Answer-Alpha 2 agonist (like precedex) Used to treat hypertension Loop diuretic mechanism of action - Correct Answer-Inhibit Na-K-2Cl transporter in the thick ascending loop of henle Examples: furosemide, bumetanide, ethacrynic acid Thiazide diuretic mechanism of action - Correct Answer-Inhibit NaCl transporter in distal convoluted tubule Examples: HCTZ, metolazone, indapamide, chlorthalidone Spironolactone mechanism of action - Correct Answer-Aldosterone antagonist Inhibits K excretion and sodium reabsorption in the collecting ducts Potassium sparing diuretics mechanism of action - Correct Answer-Inhibit K+ excretion and sodium absorption in collecting ducts (independently of aldosterone) Examples) triamterine, amiloride Only calcium channel blocker proven to reduce M&M from cerebral vasospasm - Correct Answer-Nimodipine Which reduces EF more: verapamil or diltiazem? - Correct Answer-Verapamil > diltiazem Acute pericarditis Pathophysiology - Correct Answer-Usually the result of inflammation Does not impair diastolic filling unless inflammation leads to constrictive pericarditis or tamponade Most common cause of acute pericarditis - Correct Answer-Infection Dressler's syndrome - Correct Answer-Inflammation from necrotic myocardium s/p MI Symptoms of constrictive pericarditis - Correct Answer--Kussmauls sign -Pulsus paradoxus Increased venous pressure: distended neck veins, hepatomegaly, ascites, peripheral edema -pericardial knock -atrial dysrhthmias d/t atrial distension Symptoms of acute pericarditis - Correct Answer-Acute chest pain with pleural component (increased pain with inspiration and relieved by leaning forward or supine) Pericardial friction rub ST elevation with normal enzymes Fever Draw pressure volume loop of cardiac tamponade - Correct Answer- Cardiac tamponade symptoms - Correct Answer-Beck triad: hypotension, JVD, muffled heart tones Pulsus paradoxus Kussmauls sign Reduced EKG voltage Compression of heart,lungs,trachea, esophagus 7 patient factors that require antibiotic prophylaxis against infective endocarditis - Correct Answer-(Not required for CABG, stents, Unrepaired valve disease or repaired congestion risk disease > 6 months) 3 surgical procedures that warrant antibiotic prophylaxis against infective endocarditis - Correct Answer--dental procedures involving gingival manipulation and or damage to mucosal lining -respiratory procedure that perforate the mucosal lining with incision or biopsy -biopsy of infective lesions on the skin or muscle Factors that narrow LVOT (worsen CO) in patients with obstructive hypertrophic cardiomyopathy - Correct Answer-- decreased systolic volume (decreased preload or increased HR) - increased contractility - decreased aortic pressure Factors/drugs that help with obstructive hypertrophic cardiomyopathy - Correct Answer- Beta blockers and calcium channel blockers (help decrease HR and contractility) Which law predicts aortic aneurysm rupture? - Correct Answer-Law of Laplace Explain effects of aortic cross clamp and removal - Correct Answer- Artery of adamkiewicz - Correct Answer-Radicular artery that perfused anterior spinal cord in thoracolumbar region Most commonly originates on left side between T11/T12 Spinal cord protection strategies during aortic surgery - Correct Answer-Moderate hypothermia CSF drainage Proximal HTN during cross clamp (MAP ~100) Avoidance of hyperglycemia SSEP and MEP monitoring Partial CPB (LA to FA) Drugs: corticosteroids, CCBs, mannitol Cross clamp time > 30 min = significant risk for spinal cord ischemia Cerebral oximetry - Correct Answer-Uses near infrared spectroscopy to monitor cerebral oxygen saturation in the frontal lobe Cerebral perfusion is at risk when rSO2 is reduced > 25% from baseline Transcranial Doppler - Correct Answer-Assessment of continuous blood flow velocity in middle cerebral artery (where most emboli lodge) May indicate when a shunt should be placed 5 factors that reduce albumin concentration - Correct Answer-Liver disease Kidney disease Old age Malnutrition Pregnancy 3 key plasma proteins - Correct Answer-Albumin: primarily binds acidic drugs Alpha 1 acid glycoprotein: primarily binds basic drugs Beta globulin: primarily binds basic drugs How to calculate volume of distribution - Correct Answer-Vd= amount of drug/ desired plasma concentration How to calculate loading dose of a medication - Correct Answer-Loading dose = (Vd x desired plasma concentration) / bioavailability (Bioavailability of IV medication = 1) Conditions that increase alpha 1 acid glycoprotein concentration - Correct Answer- Surgical stress Myocardial infarction Chronic pain Rheumatoid arthritis Advanced age Conditions that decrease alpha 1 acid glycoprotein - Correct Answer-Neonates Pregnancy Context sensitive half time - Correct Answer-The time it takes for the plasma concentration to decline by 50% after discontinuing the drug First order kinetics - Correct Answer-Type of drug elimination where a constant FRACTION of drug is eliminated per unit time Zero order kinetics - Correct Answer-Drug elimination where a constant AMOUNT of drug is eliminated per unit time (aka elimination is independent of plasma drug concentration) Ex) alcohol, aspirin, phenytoin, warfarin, heparin, theophylline 6 drugs that follow zero order kinetics - Correct Answer-Aspirin Phenytoin Warfarin Heparin Theophylline Alcohol Phase 1 reactions - Correct Answer--oxidation, reduction, hydrolysis -make molecules more water soluble and prepares them for phase 2 reactions -most are carried out by P450 system Phase 2 reactions - Correct Answer--conjugation -adds on a highly polar/water soluble substrate to the molecule -makes molecule biologically inactive and ready for excretion -example of substrates: glucuronic acid, glycine, acetic acid, sulfuric acid, or a methyl group Example of a drug that undergoes enterohepatic circulation - Correct Answer-Diazepam Enterohepatic circulation - Correct Answer-Some conjugated drugs are excreted in bile and then reactivated in the intestine and reabsorbed into systemic circulation Ex) diazepam Extraction ratio - Correct Answer-A measure of how much drug is delivered to a clearing organ vs how much drug is removed by that organ Flow limited elimination - Correct Answer-For drugs with a high hepatic extraction ration (>0.7), clearance is dependent on liver blood flow Capacity limited elimination - Correct Answer-For drugs with a low extraction ratio (<0.3), clearance is dependent on the ability of the liver to extract drugs from the blood Changes in enzyme activity or protein binding have a profound effect on clearance of these drugs Drugs with low hepatic extraction ratio - Correct Answer-Rocuronium Diazepam Lorazepam Methadone Thiopental Theophylline Phenytoin Drugs with high hepatic extraction ratio - Correct Answer-Fentanyl Sufentanil Morphine Meperidine Naloxone Ketamine Propofol Lidocaine Bupivacaine Metoprolol Propranolol Diltiazem Verapamil Enzyme inducers (6) - Correct Answer-Tobacco smoke Barbiturates Ethanol Phenytoin Rifampin Carbamezapine Enzyme inhibitors (7) - Correct Answer-Grapefruit juice Omeprazole 12 hours infusion Preservatives in brand vs generic propofol - Correct Answer-Diprivan: preservative = EDTA (no problems) Generic: metabisulfide (bronchospasm jn asthmatics), benzyl alcohol (avoid in infants) Metabisulfide - Correct Answer-Preservative in generic propofol that can precipitate bronchospasm in asthmatics EDTA (ethylenediaminetetraacetic acid) - Correct Answer-Preservative in brand name propofol (diprivan) No problems with any patient population in contrast to generic Antipruritic dose of propofol - Correct Answer-10 mg IV can reduce itching caused by spinal opioids and cholestasis Propofol dose for antiemetic - Correct Answer-10-20 mg IV can treat PONV or infusion of 10 mcg/kg/min Alkaline phosphatase - Correct Answer-Enzyme that converts fospropofol to propofol Fospropofol onset and duration - Correct Answer-Onset: 5-13 min Duration: 15-45 min Bolus dose of fospropofol - Correct Answer-6.5 mg/kg Side effects of fospropofol - Correct Answer-Genital and anal itching Benefits to fospropofol - Correct Answer-Aqueous solution (no preservative required, doesn't promote microbial growth) Prevents burning on injection Propofol chemical structure - Correct Answer- Ketamine mechanism of action - Correct Answer-NMDA antagonist (antagonizes glutamate) Dissociates thalamus (sensory) from limbic system (awareness) IV dose ketamine (induction, analgesia) - Correct Answer-Induction: 1-2 mg/kg Analgesia: 0.1-0.5 mg/kg IM dose ketamine - Correct Answer-4-8 mg/kg Ketamine clearance - Correct Answer-Liver (P450s) Produces an active metabolite: norketamine (1/3-1/5 the potency of ketamine) Duration of action ketamine - Correct Answer-10-20 min (may require 60-90 minutes to return to full orientation) Ketamine cardiovascular effects - Correct Answer-Increased SNS tone (increased CO, HR, SVR, PVR) (not activated at subhypnotic doses <0.5 mg/kg) Myocardial depressant (SNS effects require intact SNS - myocardial depressant effect may happen in catecholamine depleted patients) Respiratory effects of ketamine - Correct Answer-Bronchodilation Preserved airway reflexes and respiratory drive Increased secretions Ketamine CNS effects - Correct Answer--Increased CBF, CMRO2, EEG activity (caution in seizure hx), ICP, IOP -Nystagmus -emergence delirium Risk factors for emergence delirium with ketamine - Correct Answer-Female Age > 15 Dose > 2 mg/kg Hx of personality disorder Most effective way to prevent ketamine emergence delirium - Correct Answer-Benzos (midaz) Etomidate induction dose - Correct Answer-0.2-0.4 mg/kg Etomidate clearance - Correct Answer-Hepatic P450s + plasma esterases Etomidate CV effects - Correct Answer--minimal change in HR, CO -SVR is decreased, small reduction in BP -does not block SNS response to laryngoscopy Etomidate respiratory effects - Correct Answer-Mild respiratory depression Etomidate CNS effects - Correct Answer-Decreased: CBF, CMRO2, ICP No analgesia Misc Etomidate side effects - Correct Answer--myoclonus -adrenocortical suppression How long does a dose of etomidate suppress adrenocortical function - Correct Answer- 5-8 hours (some books says up to 24 hours) Which enzyme does etomidate suppress? - Correct Answer-11-beta hydroxylase (located in adrenal medulla) (some texts add 17 alpha hydroxylase) -cortisol and aldosterone synthesis are dependent on this enzyme 11-beta hydroxylase - Correct Answer--enzyme inhibited by etomidate -cortisol and aldosterone synthesis are dependent on this enzyme -located in adrenal medulla Which induction agent is most likely to cause PONV? - Correct Answer-Etomidate 2 classes of barbiturates - Correct Answer-Thiobarbiturates: sulfur molecule in second position that increases lipid solubility and potency (thiopental, thiamylal) Oxybarbiturates: oxygen molecule in second position (methohexitol, pentobarbital) Mechanism of action thiopental - Correct Answer-GABA (A) agonist (depresses reticular activating system in brain stem) Low/normal dose: increases affinity of GABA for its receptor High dose: directly stimulates receptor Thiopental dose - Correct Answer-Adult: 2.5-5 mg/kg Children: 5-6 mg/kg Thiopental onset/duration - Correct Answer-Onset: 30-60 seconds Duration: 5-10 minutes Thiopental clearance - Correct Answer-Liver (P450s) CV effects thiopental - Correct Answer--hypotension due to venodilation and decreased preload as well as myocardial depression (less hypotension than propofol) -histamine release -baroreceptor reflex preserved (tachycardia helps restore cardiac output) Respiratory effects thiopental - Correct Answer-Respiratory depression (shift CO2 response curve to the right) Histamine release can cause bronchoconstriction (caution with asthma) CNS effects thiopental - Correct Answer-Decreased: CMRO2, CBF, ICP, EEG activity (neuroprotective) How does precedex produce analgesia - Correct Answer-Alpha 2 stimulation in dorsal horn of spinal cord (decreased substance P and glutamate release) Nasal/buccal dose of precedex - Correct Answer-3-4 mcg/kg 1 hour prior to surgery Useful for preop sedation in children Precedex drug class - Correct Answer-Imidazole Precedex chemical structure - Correct Answer- Midazolam chemical structure - Correct Answer- Onset/duration midazolam - Correct Answer-Onset: 30-60 seconds Duration: 20-60 minutes IV sedation dose midazolam - Correct Answer-0.01-0.1 mg/kg IV induction dose of midazolam - Correct Answer-0.1-0.4 mg/kg Midaz PO sedation in children dosing - Correct Answer-0.5 - 1 mg/kg Midazolam clearance - Correct Answer-P450s in liver and intestines Active metabolite: 1hydroxymidazolam has half the potency of midaz, renal failure prolongs its effect Midazolam mechanism of action - Correct Answer-GABA-A agonist: increased FREQUENCY (not duration) of channel opening Results in neuronal hyperpolarization PO bioavailability of midazolam - Correct Answer-50% due to significant first pass metabolism Which induction agents have an active metabolite? - Correct Answer-Midazolam Ketamine Fospropofol CNS effects of midazolam - Correct Answer--innduction dose: decreased CMRO2, CBF -Cannot produce isoelectric EEG (propofol and barbiturates can) -anterograde amnesia -anticonvulsant -anxiolysis -muscle relaxation/antispasmodic -no analgesia Flumazenil MOA - Correct Answer-competitive antagonist at GABA receptor Flumazenil dosing - Correct Answer-Initial dose 0.2 mg IV Tito rates in 0.1 mg increments q 1 min Flumazenil duration of action - Correct Answer-30-60 minutes Side effects of flumazenil - Correct Answer--no increase in SNS tone like narcan -can cause benzo withdrawal including seizures in benzo-dependent patients Rank potency of 3 main benzos highest to lowest - Correct Answer-Most potent: lorazepam Midazolam Least potent: diazepam Significance of imidazole ring in midaz - Correct Answer-Water soluble in vial (open ring) Lipid soluble in blood stream (closed ring) How do you tell the difference between the chemical structures between the halogenated agents? - Correct Answer-Iso: 5 fluorines + 1 chlorine atom Desflurane: 6 fluorine atoms Sevoflurane: 7 fluorine atoms How does fluorination affect physical characteristics of halogenated agents? - Correct Answer-Tends to reduce potency (Sevo is more potent than des despite more fluorine a due to bulky propyl side chain Relationship between vapor pressure, boiling point, and molecular weight - Correct Answer-Higher vapor pressure/lower molecular weight = lower boiling point Desflurane vapor pressure - Correct Answer-669 mmHg Isoflurane vapor pressure - Correct Answer-238 mmHg Sevoflurane vapor pressure - Correct Answer-157 mmHg Nitrous vapor pressure - Correct Answer-38,770 mmHg Nitrous boiling point - Correct Answer--88 C Desflurane boiling point - Correct Answer-22 C Sevoflurane boiling point - Correct Answer-59 C Isoflurane boiling point - Correct Answer-49 C Order of vapor pressures of anesthetic gases - Correct Answer- Order of boiling points of anesthetic gases - Correct Answer- 1 atm - Correct Answer-760 mmHg Blood:gas coefficient - Correct Answer-Relative solubility of an inhalational anesthetic in the blood vs. alveolar gas Lower blood:gas solubility = faster onset of induction Sevo blood gas coeffient - Correct Answer-0.65 Des blood gas coefficient - Correct Answer-0.42 Iso blood gas coefficient - Correct Answer-1.46 Nitrous blood gas coefficient - Correct Answer-0.46 % hepatic biotransformation of anesthetic gases - Correct Answer- Vessel rich group - Correct Answer-Heart, brain, kidneys, liver, endocrine glands 75% cardiac output 10% body mass Muscle group - Correct Answer-Majority of tissue uptake of anesthetic agents after vessel rich group 20% cardiac output 50% body mass Fat group - Correct Answer-5% CO 20% body mass Additional uptake of anesthetic gases after vessel rich and muscle groups Metabolites of des and iso - Correct Answer-Inorganic fluoride ions Trifluoroacetic acid (TFA) (cause of halothane hepatitis) Metabolite of sevo - Correct Answer-Inorganic fluoride ions (no TFA) Theoretical concern of high output renal failure Desiccated soda lime and anesthetic agents - Correct Answer-Sevo: compound A Des + iso: carbon monoxide Ephedrine Levodopa Hypernatremia Age: increased in infants 1-6 months (sevo same for neonates and infants) Hyperthermia Red hair Factors that decrease MAC - Correct Answer-Drugs: Acute etoh IV anesthetics Nitrous Opioids Alpha 2 agonists Lithium Hydroxyzine Hyponatremia Age: old age (decrease 6% per decade after 40), prematurity Hypothermia Etc: hypotension, hypoxia, anemia, CPB, metabolic acidosis, hypo osmolarity, pregnancy- postpartum (24-72 hours), PaCO2 > 95 Factors that do not affect MAC - Correct Answer-Hyper/hypokalemia Hyper/hypomagnesemia Hyper/hypothyroidism Gender Hypertension PaCO2 15-95 How does hypo/hyperthyroidism affect MAC? - Correct Answer-Does NOT directly affect MAC but changes in cardiac output can affect anesthetic uptake:onset of action Meyer-Overton rule - Correct Answer-Lipid solubility is directly proportional to the potency of and inhaled anesthetic Theory implies that depth of anesthesia is determined by the number of anesthetic molecules that are dissolved in the brain Unitary hypothesis - Correct Answer-All anesthetics share a similar mechanism of action, all though each may work at a different site Main receptor/MOA/most important site of action of halogenated agents in the brain? - Correct Answer-GABA A receptor (ligand gated chloride channel) Stimulation of receptor increases chloride influx (hyper polarized neurons) Volatile agents most likely increase the duration that the chloride channels remains open Where do halogenated agents produce immobility? - Correct Answer-Ventral horn of spinal cord Which cerebral receptors are stimulated by nitrous oxide? - Correct Answer-NMDA antagonism Potassium 2P channel stimulation (Not GABA A receptor) 3 areas of brain where halogenated agents produce unconsciousness - Correct Answer- Cerebral cortex Thalamus RAAs Which regions of the brain do halogenated agents produce autonomic modulation? - Correct Answer-Pons Medulla How do halogenated agents reduce blood pressure? - Correct Answer- Halogenated agents and heart rate - Correct Answer-Decrease in dose dependent fashion But des and iso can sometimes increase HR 5-10% from baseline due to resp irritation/SNS stim Which halogenated agent is the most potent coronary artery vasodilator ? - Correct Answer-Isoflurane (potential for coronary steal phenomenon) Nitrous oxide effect on hemodynamics - Correct Answer--activates SNS which can increase SVR/MAP -also a myocardial depressant but SNS stimulation overrides this (myocardial depression more likely when given in combo with opioids) Halogenated agents and ventilation - Correct Answer--dose dependent depression of central chemoreceptors and respiratory muscles -impaired response to CO2 (shifts curve down and right) - decreased tidal volume and compensatory increased RR (decrease minute ventilation and increased dead space ventilation) Halogenated agents and CMRO2 - Correct Answer-Decrease CMRO2 until brain is isoelectric (1.5-2 MAC) Volatile agents vs nitrous effects on CBF - Correct Answer-Volatile agents: "uncouple" CMRO2 and CBF (increase CMRO2 and decrease CBF) Nitrous: increase CMRO2 and increase CBF Halogenated agents and nitrous effect on evoked potentials - Correct Answer- Halogenated:Decrease amplitude, increase latency Nitrous + halogenated can lead to a more profound amplitude reduction Rank type of evoked potentials from most to least sensitive to volatile anesthetics - Correct Answer-Most sensitive: visual evoked potentials SSEPs/motors in between Least sensitive: brain stem evoked potentials N20 and bone marrow suppression - Correct Answer-Inhibits methionine synthase and folate metabolism which can cause megaloblastic anemia Best scenarios for retrograde intubation - Correct Answer-Best used when ventilation is possible Great for unstable cervical spine Often performed on patient with known difficult airway in a controlled setting before induction of anesthesia When during a lap case is air embolism most likely to occur? - Correct Answer-Initial insufflation What places a child MOST at risk for laryngospasm? - Correct Answer-Upper respiratory infection Contraindications to retrograde intubation - Correct Answer-Goiter Neck flexion deformity Coagulopathy Afferent pathway of oculo cardiac reflex - Correct Answer-Long/short ciliary nerves Most common side effect of MAOis - Correct Answer-Orthostatic hypotension How to convert inches to cm - Correct Answer-Inches x 2.54 Rank top 3 most common causes of intraop allergic reactions - Correct Answer-Muscle relaxants (50-60%) Latex (15%) Antibiotics (10-15%) A alpha fiber function - Correct Answer-Skeletal muscle motor Proprioception Nerve fibers order of block onset first to last - Correct Answer-1st B: preganglionic SNS 2nd C: slow pain, temperature, touch + postganglionic SNS 3rd: A gamma (skeletal muscle tone) and A delta (fast pain, temperature, touch) Last: A alpha (skeletal muscle motor, proprioception) and A beta (touch, pressure) A beta fiber function - Correct Answer-Touch Pressure A gamma fiber function - Correct Answer-Skeletal muscle tone A delta fiber function - Correct Answer-Fast pain Temperature Touch B fiber function - Correct Answer-Preganglionic SNS C fiber function - Correct Answer-Slow pain Temperature Touch Post ganglionic SNS Which nerve fibers aren't myelinated? - Correct Answer-C fibers Minimum effective concentration (Cm) - Correct Answer-The concentration of local anesthetic that is required to block conduction Fibers that are more easily blocked have a lower Cm Analogous to ED50 or MAC What 2 configurations of the sodium channel do local anesthetics bind to - Correct Answer-Active (open) state Inactive (closed refractory state) Do NOT bind to sodium channels in their resting states What causes repolarization during nerve action potential - Correct Answer-Potassium leaving cell SSEPs - Correct Answer-Monitor integrity of the dorsal column (medial lemniscus) Perfused by posterior spinal arteries MEPs - Correct Answer-Monitor integrity of corticospinal tract (perfused by anterior spinal artery) Methyl isopropyl ether - Correct Answer-Sevo Methyl ethyl ether - Correct Answer-Des Iso Oil:gas partition coefficient - Correct Answer-Higher number = more lipid solubile Nitrous: 1.4 Des: 19 Sevo: 47 Iso: 91 Desflurane boiling point - Correct Answer-24 C Nitrous boiling point - Correct Answer--88C Mechanism of action local anesthetics - Correct Answer-Bind to alpha subunit inside voltage gated sodium channels when they are in their active or inactive state and prevents cell from depolarizing Does not affect threshold or resting membrane potential What portion of local anesthetic binds to sodium channel - Correct Answer-Ionized, conjugate acid 3 components of local anesthetics and function - Correct Answer-Benzene ring: lipid solubility Intermediate chain: class ester vs amide Tertiary amine: hydrophilic, makes molecule a weak base Ester local anesthetic metabolism - Correct Answer-Pseudocholinesterase (Exception = cocaine, metabolized by both pseudocholinesterase AND liver) Amide local anesthetic metabolism - Correct Answer-Liver/P450s Cocaine metabolism - Correct Answer-Both pseudocholinesterase esterase and liver PABA - Correct Answer-Molecule within ester type local anesthetics that can cause allergic reaction Which class of local anesthetics is more likely to cause an allergic response? - Correct Answer-Esters (d/t PABA) What determines local anesthetic onset of action? - Correct Answer-PKa Lower pka (closer to pH) = faster onset of action Why does chloroprocaine have a fast onset of action despite its high pKa? - Correct Answer-Not very potent so it must be given in higher concentrations What determines local anesthetic potency? - Correct Answer-Lipid solubility (primary) Intrinsic vasodilating effect (secondary- more vasodilating less potent) What factors determine local anesthetic duration of action? - Correct Answer-Protein binding (primary) Secondary: lipid solubility & intrinsic vasodilating effect (More vasodilating = shorter duration of action) Which local anesthetic causes vasoconstriction? - Correct Answer-Cocaine Rank amide local anesthetics according to pKa - Correct Answer-Bupivacaine 8.1 Ropivacaine 8.1 Lidocaine 7.9 Prilocaine 7.9 Mepivacaine 7.6 Which local anesthetic does not bind to plasma proteins - Correct Answer- Chloroprocaine Rank ester local anesthetics according to pKa - Correct Answer-Procaine 8.9 Chloroprocaine 8.7 Tetracaine 8.5 Amio agent of choice for VT Avoid vasopressin, lidocaine, and procainamide Lipid emulsion dosing LAST - Correct Answer-Bolus: 1.5 mL/kg (LBW) 20% lipid emulsion over 1 minute Infusion 0.25 mL/kg/min Can repeat bolus twice and increase infusion to 0.5 mL/kg/min if symptoms slow to resolve Factors that increase risk of bupivacaine toxicity - Correct Answer-Beta blockers Pregnancy Calcium channel blockers Digitalis Cocaine max dosing - Correct Answer-1.5-3 mg/kg 200 mg Best drug to treat cocaine toxicity - Correct Answer-Nitroglycerin Max dose of lidocaine for tumescent anesthesia - Correct Answer-55 mg/kg Potential complications of large volume tumescent anesthesia - Correct Answer-LAST Fluid overload/pulmonary edema When does Cp peak for tumescent anesthesia - Correct Answer-Cp peaks at 12 hours Eliminated by 36 hours Order local anesthetics (4) from risk of cardiac toxicity - Correct Answer-Bupi (highest) Levobupivacaine Ropivacaine Lidocaine Which 2 local anesthetics can cause methemoglobinemia - Correct Answer-Prilocaine (EMLA) Benzocaine (cetacaine) Common drugs that can cause methemoglobinemia - Correct Answer-Benzocaine (cetacaine) Prilocaine (EMLA) Nitroprusside Nitroglycerin Phenytoin Sumfonamides Methemoglobinemia treatment - Correct Answer-Methylene blue 1-2 mg/kg over 5 minutes Pathophysiology methemoglobinemia - Correct Answer-Iron molecule on heme oxidized to its ferric (Fe3+) form Shift oxyhemoglobin Dissociation curve to the left Components of 5% EMLA cream - Correct Answer-2.5% lidocaine 2.5% prilocaine How long does it take for EMLA cream to take effect - Correct Answer-Analgesia in 1 hour Max effect 2-3 hours Hallmark sign of methemoglobinemia - Correct Answer-Cyanosis with normal paO2 2 patient populations at higher risk for methemoglobinemia - Correct Answer-Patients with glucose 6 reductase deficiency Neonates 3 additives to local anesthesia that provide supplemental analgesia - Correct Answer- Clonidine Epinephrine Opioids (except chloroprocaine reduces the effect of opioids in the epidural space) Max dose EMLA cream <5 kg - Correct Answer-1g 10 cm2 Max dose EMLA cream 5-10 kg - Correct Answer-2 g 20 cm2 Max dose EMLA cream 10-20 kg - Correct Answer-10 g 100 cm 2 Max dose EMLA cream > 20 kg - Correct Answer-20 g 200 cm2 Local anesthetic that is not ionized at physiologic pH - Correct Answer-Benzocaine (pka = 3.5) Which local anesthetic can't be given for spinal anesthesia - Correct Answer- Chloroprocaine (associated with neurotoxicity) Local anesthetic with highest degree of protein binding? - Correct Answer- Levobupivacaine)98%) What happens when Ach activates the post synaptic nicotinic receptor at the neuromuscular junction - Correct Answer-Ach binds to the 2 alpha subunits Channel opens Sodium and calcium enter, potassium exits This activates voltage gated sodium channels ->AP What conditions cause extra junctional nicotinic receptors? - Correct Answer-Upper/lower motor neuron injury SCI Burns Skeletal muscle trauma CVA Tetanus Severe sepsis Muscular dystrophy Prolonged chemical denervation (mag, long term NMB infusion How much can sux raise K+ levels with extrajunctional receptors - Correct Answer-0.5-1 mEq/L up to 10-15 minutes How does the presence of extra junctional receptors affect nondepolarizers? - Correct Answer-Resistant to nondepolarizers (potency reduced) Phase 1 vs Phase 2 block - Correct Answer-Phase I: no fade Phase II: fade How can you get phase 2 block with sux? - Correct Answer-IV infusion Dose > 7-10 mg/kg Max % receptors occupied tidal volume > 5 mL/kg - Correct Answer-80% Max % receptors occupied TOF no fade - Correct Answer-70% Max % receptors occupied vital capacity > 20 mL/kg - Correct Answer-70% Max % receptors with sustained tetanus - Correct Answer-60% Max % receptors with double burst stimulation - Correct Answer-60% Tests that = 50% max number of receptors occupied - Correct Answer-Insp force > -40 cmH20 Head lift > 5s Which neuromuscular blocker has a vagolytic effect? - Correct Answer-Pancuronium Which neuromuscular blocker most commonly causes anaphylaxis? - Correct Answer- Succinylcholine Non competitive inhibitors of acetylcholinesterase - Correct Answer-Organophosphates (sarin/nerve agents) Echothiophate Best anticholinergic pairing with edrophonium - Correct Answer-Atropine Best anticholinergic pairing with pyridostigmine - Correct Answer-Glycopyrrolate Edrophonium dose - Correct Answer-0.5 - 1 mg/kg Edrophonium duration of action - Correct Answer-30-60 minutes (shorter than neostigmine and why atropine is a better pairing) What happens if sux is given after neostigmine? - Correct Answer-Prolonged effect (neostigmine also inhibits pseudocholinesterase) Which acetylcholinesterase inhibitor crosses the blood brain barrier? - Correct Answer- Physiostigmine Pyridostigmine dose - Correct Answer-0.1-0.3 mg/kg Side effects of acetylchonisterase inhibitors - Correct Answer-"DUMB BELLS" (parasymp side effects) Diarrhea Urination Miosis Bradycardia Bronchoconstriction Emesis Lacrimation Laxation Salivation Which anticholinergics cross the BBB? - Correct Answer-Atropine Scopolamine What nerve fibers transmit pain? - Correct Answer-A delta - fast pain C fibers- dull pain Descending inhibitory pain pathway - Correct Answer-Begins in periaqueductal gray and rostroventral medulla and projects to substantia geletanosa (rexed lamina I and II) Descending pain pathways release NE, 5-HT, and endorphins Opioid mechanism of action - Correct Answer-Bind to G protein Inhibit adenylate cyclase Decrease cAMP Decrease calcium influx (decreased NT release) Increase potassium efflux (hyperpolarize membrane) Mu receptor endogenous ligand - Correct Answer-Endorphin Kappa receptor endogenous ligand - Correct Answer-Dynorphin Delta receptor endogenous ligand - Correct Answer-Enkephalin Which opioid receptor causes anti shivering - Correct Answer-Kappa Which opioid receptors cause pruritis - Correct Answer-Mu Delta Which opioid receptors cause urinary retention - Correct Answer-Mu Delta Which opioid receptor causes bradycardia - Correct Answer-Mu Which opioid receptors cause miosis - Correct Answer-Mu Kappa Which opioid receptor causes N/V and constipation? - Correct Answer-Mu Effects of kappa stimulation - Correct Answer-Antishivering Miosis Diuresis Dysphoria/delirium/hallucinations Effects of delta stimulation - Correct Answer-Urinary retention Pruritis Effects of mu stimulation - Correct Answer-Bradycardia Sedation/euphoria/prolactin release/mild hypothermia Miosis Urinary retention N/V, constipation, increased biliary pressure Pruritis Opioid CV effects - Correct Answer-Bradycardia (mu stimulation) Minimal effect of BP in healthy patients Contractility not affected (unless combined with nitrous) *Demerol can increase HR (similar structure to atropine)* Immunologic effects of opioids - Correct Answer-Histamine release (morphine, meperidine, codeine) Inhibition of cellular and humoral immune function Suppression of natural killer cell function Thermoregulagory effects of opioids - Correct Answer-Resets hypothalamic temperature set point: decreased core body temp Which opioids release histamine - Correct Answer-morphine, meperidine, codeine Rank opioids from most to least potent - Correct Answer-Sufent Fentanyl = remi Alfent Dilaudid Morphine Demerol Compare IV opioids dose relative to morphine - Correct Answer-Meperidine 0.1 Morphine 1 Dilaudid 7x Alfentanil 10x Fentanyl 100x Sufentanil 1000x Which opioids have active metabolites and what are their effects? - Correct Answer- Morphine (can build up in patient with kidney problems and cause resp depression) Meperidine (can build up in patient with kidney problems and cause seizures) Examples of MAOIs - Correct Answer-Phenelzine Isocarboxazid Tranylcypromine Methylnaltrexone key points - Correct Answer-Opioid antagonist Does not cross BBB so does not reverse respiratory depression Useful for mitigating side effects of opioids such as constipation Nalmefine key point - Correct Answer-Opioid antagonist Similar action to naloxone but longer duration of action (10 hours) Can be used for opioid abusers Naltrexone key points - Correct Answer-Opioid antagonist Longest duration of action (24 hours) Can be used for etOh and opioid abusers No significant first pass metabolism (unlike naloxone) Does naloxone cross the placenta? - Correct Answer-Yes Can precipitate withdrawal in the neonate Pregnancy affect on minute ventilation - Correct Answer-Increase (up to 50%) Mostly by increasing tidal volume (40%) Small increase in RR (10%) Progesterone = respiratory stimulant Pregnancy and maternal ABG - Correct Answer-Compensated respiratory alkalosis with mild increase in PaO2 d/t reduction in physiologic shunt pH: no change PaO2: increase 104-108 mmHg PaCO2: decrease 28-32 mmHg HCO3-: decrease 20 mmHg Normal p50 - Correct Answer-26.7 mmHg Pregnancy effect on lung volumes/capacities - Correct Answer-Decrease in FRC (ERV decreases more than RV) = fast onset of hypoxemia paired with increased oxygen consumption Slight decrease in TLC No change in closing capacity Cardiac output in pregnancy - Correct Answer-Increases by 40% Stroke volume increase more than HR How much cardiac output does the pregnant uterus receive? - Correct Answer-10% Cardiac output during labor - Correct Answer-1st stage: increase 20% 2nd stage: increase 50% 3rd stage: increase 80% Returns to pre-labor values in 24-48 hours Returns to pre-pregnancy values in 2 weeks Pregnancy and MAP/SVR - Correct Answer-Decrease SVR but no change in MAP due to increased blood volume SVR: decrease PVR: decrease MAP: no change SBP: no change DBP: decrease 15% Fluids changes during pregnancy - Correct Answer-Increased intravascular volume by 35% (plasma volume increase 45%, erythrocytes volume increase 20%) Prepares mom for hemorrhage during labor Creates dilutional anemia Pregnancy and clotting system - Correct Answer-Pregnancy = hypercoaguable state Mom makes more clot but also breaks it down faster Increase clotting factors Decrease anticoagulants Increase fibrinolytic system Pregnancy effect on MAC - Correct Answer-MAC decreased 30-40% due to increased progesterone Pregnancy effect on gastric volume and pH - Correct Answer-Increased gastric volume and decreased pH Pregnancy effect of gastric emptying - Correct Answer-No change during pregnancy Slowed during onset of labor Uterine blood flow at term - Correct Answer-500-700 mL/min (10% CO) Conditions that decrease uterine blood flow - Correct Answer-Uterine blood flow does not autoregulate Causes of decreased uterine blood flow: -decreased perfusion: hypotension/hemorrhage/aortacaval compression -increased resistance: uterine contraction/hypertensive conditions that increase UVR Which law determines which drugs will pass through the placenta - Correct Answer-Fick principle Which stage of labor does pain in the perineum begin? - Correct Answer-Stage 2 (full cervical dilation to delivery of the fetus) Stage 1 of labor - Correct Answer-Onset of regular contractions to full cervical dilation Divided into latent and active stage Stage 2 of labor - Correct Answer-Full cervical dilation to delivery of fetus Stage 3 of labor - Correct Answer-Delivery of placenta How does uncontrolled labor pain affect fetus? - Correct Answer-↑ maternal catechol → HTN → *↓ UBF* maternal hyperventilation → L shift of oxyhgb curve → *↓ O2 delivery to fetus* Drugs that do not cross the placenta (anesthesia related) - Correct Answer-NMBs Glyco Heparin Insulin 1st vs 2nd stage labor pain - Correct Answer- Pain management techniques 1st vs 2nd stage of labor - Correct Answer-1st: neuraxial, paraverrebral lumbar sympathetic, para cervical 2nd: neuraxial, pudendal Bupivacaine vs ropivacaine for labor - Correct Answer-Bupi: low placental transfer, cardiac toxicity more common, greater sensory than motor block Mild vs severe preeclampsia - Correct Answer-Severe disease: SBP > 160 and end organ signs (headache, visual impairment, decreased platelet count, HELLP syndrome, epi gastric pain) Antihypertensives for preeclampsia - Correct Answer-Labetalol Nitroglycerin Anesthetic considerations preeclampsia - Correct Answer-BP control: labetalol, nitro Mag for seizure prophylaxis (will relax uterus and increase risk of hemorrhage) Neuraxial anesthesia helps with BP (rule out thrombocytopenia first) Exaggerated response to sympathomimetics Seizure prophylaxis mag dose - Correct Answer-4 g IV loading dose over 10 minutes 1-2 g/hr infusion HELLP syndrome - Correct Answer-hemolysis, elevated liver enzymes, low platelets How does placenta previa present? - Correct Answer-Painless vaginal bleeding Placenta previa risk factors - Correct Answer-Previous c section Multiple births Risk factors for placenta accreta - Correct Answer-Previous c section Placenta previa Placental abruption presentation - Correct Answer-Painful vaginal bleeding that can break through epidural Risk factors for uterine atony - Correct Answer-Multiparity Multiple gestations Polyhydramnios Prolonged oxytocin infusion prior to surgery Components of apgar scoring system - Correct Answer-HR Respiratory effort Muscle tone Reflex irritability Color Normal apgar score - Correct Answer-8-10 Neonatal epi dose - Correct Answer-10-30 mcg/kg IV Normal newborn vital signs - Correct Answer-BP 70/40 HR 140 RR 40-60 Neonate - Correct Answer-First month of life Infant - Correct Answer-one month to one year Primary determinant of cardiac output and blood pressure in neonate - Correct Answer- HR (Neonate can't significantly adjust contractility or stroke volume due to non compliant ventricle) Autonomic influence on newborn heart - Correct Answer-SNS less mature than PNS Stressful situations can cause bradycardia Baroreceptor reflex poorly developed Do infants preferentially breathe out of their mouth or nose? - Correct Answer- Preferential nose breather up to 5 months of age Adult vs infant epiglottis shape - Correct Answer-Adult: C shape, shorter, floppier Infant: U (omega) shaped, stiffer, longer Larynx position adult vs infant - Correct Answer-Adult C5-C6 Infant C3-C4 (larynx more cephalad but not anterior) Vocal cords have more anterior slant in infants Same as adult at age 5 to 6 Narrowest part of airway adult vs infant - Correct Answer-Adult: glottis Infant: cricoid or glottis (glottis in paralyzed infant) Adult vs child right mainstem take off - Correct Answer-Adult: R take off 25 degrees (more vertical) Infant: both take off 55 degrees (Less vertical) Optimal intubating position for infants - Correct Answer-NOT sniffing position Head on bed with shoulder roll Infant fast vs slow twitch muscle fibers - Correct Answer-Less type 1 (slow twitch) muscle fibers in diaphragm and intercostals which explains why neonates fatigue more easily with breathing Treatment of choice for postop apnea of newborn - Correct Answer-Prophylactics caffeine (10 mg/kg IV) Newborn (first 10 minutes) ABG - Correct Answer-pH: 7.20 PaCO2: 50 PaO2: 50 Newborn is hypoxic, acidotic, and retains CO2 Stimulation for newborn to breathe - Correct Answer-Clamping of umbilical cord and acute rise in PaO2 (Hypoxemia causes apnea) Fetal P50 - Correct Answer-19 mmHg How does hypoxemia affect ventilation in the newborn? - Correct Answer-Respiratory control doesn't mature until 42-44 weeks Before maturation: hypoxemia depresses ventilation After maturation: hypoxemia stimulates ventilation Why does fetal hemoglobin have a higher affinity for oxygen? - Correct Answer-Fetal hemoglobin: 2 alpha and 2 gamma chains instead of 2 alpha and 2 beta chains Does not bind to 2,3 DPG so able to bind more oxygen When is fetal hemoglobin completely replaced by adult hemoglobin? - Correct Answer-6 months PRBC transfusion dose in neonate - Correct Answer-10 mL/kg (Will raise HgB by 1-2 g/dL) FFP dose for neonate - Correct Answer-10 mL/kg Platelet dose neonate - Correct Answer-5 mL/kg (apheresis) Neonatal H&H at birth, 3 months, and 6-12 months - Correct Answer-Birth: higher (14- 20) 3 months: physiologic anemia (10-14) 6-12 months: 11-15 Estimated blood volume preemie, neonate, child > 1 - Correct Answer-Preemie: 90mL/kg -more common in males Metabolic/electrolyte abnormalities with pyloric stenosis - Correct Answer-Hyponatremia Hypokalemic Hypochkoremic Metabolic alkalosis Risk factors for necrotizing enterocolitis - Correct Answer-Prematurity Low birth weight (<1500 g) Risk factors for retinopathy of prematurity - Correct Answer-Prematurity Low birth weight Hyperoxia SpO2 goals to prevent retinopathy of prematurity - Correct Answer-Keep SpO2 85-93% until retinal maturation is complete (up to 44 weeks post conception) Anesthetic agents not implicated in apoptosis - Correct Answer-Opioids Precedex What enzyme metabolizes bilirubin - Correct Answer-Glucuronyl transferase (Not mature at birth, can result in hyperbilirubinemia) Ductus venosus function/location - Correct Answer-Function: allows umbilical blood to bypass liver Location: umbilical vein to IVC Foramen ovale function/location - Correct Answer-Function: shunts blood from RA to LA to bypass lungs Ductus arteriosus function/location - Correct Answer-Function: shunts blood from pulmonary trunk to aorta to perfuse the lower body Location: pulmonary artery to descending aorta Ligamentum venosus - Correct Answer-Adult remnant of ductus venosus Fossa ovalis - Correct Answer-Adult remnant of foramen ovale Liamentum ateriosum - Correct Answer-Adult remnant of ductus arteriosus When does ductus venosus close? - Correct Answer-After clamping of umbilical cord When does foramen ovale close? - Correct Answer-3 days after birth When does ductus arteriosus close? - Correct Answer-Several weeks after birth What drug is used to open the ductus arteriosus - Correct Answer-Prostaglandin E1 Drug that is used to close the ductus arteriosus - Correct Answer-Indomethacin 5 examples of right to left shunt - Correct Answer-5 Ts: Tetralogy of fallot Transposition of great arteries Tricuspid valve abnormality (Ebsteins anomaly) Truncus arteriosus Total anomalous pulmonary venous connection Most common left to right shunt - Correct Answer-VSD 4 types of left to right shunts - Correct Answer-ASD VSD Patent ductus arteriosus Coarctation of aorta Intracardiac shunts and inhalation induction - Correct Answer-Right to left: slower induction Left to right: no effect Intracardiac shunts and IV induction - Correct Answer-Right to left: faster Left to right: slower Eisenmenger syndrome - Correct Answer-What a patient with a left to right shunt develops pulmonary hypertension and this reverse flow through the shunt which causes a right to left shunt, hypoxia, and cyanosis 4 defects of tetralogy of fallot - Correct Answer-RVOT obstruction RV hypertrophy VSD Overriding aorta "Tet" spell presentation - Correct Answer-Hypoxemia Cyanosis Squatting during activity: kinks arteries in groin and increases SVR to reduce left to right shunt Treatment for perioperative tet spell - Correct Answer-FiO2 100% Intravascular volume expansion Increase SVR with phenylephrine Reduce SNS stimulation (deepen anesthesia, esmolol) Avoid excessive airway pressure Place infant in knee chest position Hemodynamic goals for tetralogy of fallot - Correct Answer-Increase SVR Decrease PVR Avoid increased contractility Increase preload Best induction agent for tetralogy of fallot - Correct Answer-Ketamine Syndrome associated with coarctation of aorta - Correct Answer-Turner syndrome How is blood pressure affected in coarctation of the aorta? - Correct Answer-SBP elevated in upper extremities SBP reduced in lower extremities Most common congenital defect of the tricuspid valve - Correct Answer-Ebstein's anomaly Anesthetic management of patient with Fontan completion - Correct Answer--patient has single ventricle that pumps blood to the entire circulation -blood flow to pulmonary circulation dependent on negative intrathoracic pressure during spoantnepus breathing -avoid positive pressure ventilation -patients are preload dependent: don't let them get dry Epiglottitis vs croup - Correct Answer-Epiglottitis: bacterial, 2-6 years, rapid (<24 hours) onset, swollen epiglottis (thumb sign) Croup: viral, <2, 24-72 hours onset, sub glottis narrowing (steeple sign) Lateral chest x ray sign croup - Correct Answer-Steeple sign (sub glottic narrowing) Lateral chest X-ray sign epiglottitis - Correct Answer-Thumb sign (swollen epiglottis) Epiglottitis clinical presentation - Correct Answer-High fever Tripod position 4Ds: drooling, dysphonia, dyspnea, dysphagia Epiglottitis treatment - Correct Answer-O2 Urgent airway management (intubated or trach) Antibiotics Induction with spontaneous ventilation ENT surgeon must be present Postop ICU care C - cleft palate H - hypocalcemia (due to hypoparathyroidism) 22 - 22 q deletion (cause of syndrome) Anesthetic considerations for digeorge syndrome - Correct Answer-Hypocalcemia High risk for infection if thymus is absent How to make racemic epi - Correct Answer-0.5 mL of 2.25% solution diluted into 2.5 mL of NS Pierre robin - Correct Answer-Micrognathia Glossoptosis Cleft palate Neonate often requires intubation Treacher Collins - Correct Answer-Small mouth Micrognathia Choanal atresia Ocular and auricular abnormalities Klippel-Feil Syndrome - Correct Answer-Congenital fusion of cervical vertebrae Golden har syndrome - Correct Answer-Micrognathia Cervical spine abnormality Cri du chat - Correct Answer-Laryngomalacia Strider Micrognathia Lowest post cenceptual age appropriate for same day surgery - Correct Answer-60 weeks Most common cause of liver transplant before 2 years of age - Correct Answer-Biliary atresia Best indicators of full muscle relaxant reversal in neonate - Correct Answer-Flexion of knees to chest Max Inspiratory force > -25 cm h20 Activities that = 1 MET - Correct Answer-Self care activities Working at a computer Walking 2 blocks slowly Activities that = 4 METs - Correct Answer-Climbing a flight of stairs without stopping Walking up a hill 1-2 blocks Light housework Raking leaves Gardening Activities that = 10 METs - Correct Answer-Strenuous sports: running, swimming, basketball Minute ventilation changes in elderly - Correct Answer-Minute ventilation increases to compensate for increased dead space Lung elasticity changes in elderly and it's consequences - Correct Answer-Decreased lung elasticity results in: Increased dead space V/Q mismatch Increased A-a gradient Decreased PaO2 Chest wall compliance in elderly - Correct Answer-Decreased chest wall compliance At what age is closing capacity > FRC in supine position - Correct Answer-45 At what age is closing capacity > FRC when standing? - Correct Answer-65 Residual volume in elderly - Correct Answer-Residua volume and FRC increase due to reduced elastic recoil of the lungs Arterial compliance changes in elderly - Correct Answer-Arterial compliance decreased which results in increased SVR/BP and pulse pressure Myocardial compliance changes in elderly - Correct Answer-Myocardial compliance decreased Impaired relaxation may cause diastolic dysfunction Atrial kick becomes more important for maintenance of cardiac output and to prime no compliant ventricle HR/SV/CO changes in elderly - Correct Answer-All decrease Systolic and diastolic function in elderly - Correct Answer-No change in systolic function Decrease in diastolic function MAC change in elderly - Correct Answer-6% per decade decrease after 40 Dose adjustment for spinal/epidural anesthesia in elderly - Correct Answer-Decrease dose since CSF volume and volume of epidural space is reduced so there is greater spread of local anesthetic GFR changes in elderly - Correct Answer-GFR decrease 1mL/min/year after age 40 Creatinine change in elderly - Correct Answer-DOES NOT change (even though GFR decreases, muscle mass also decreases) Creatinine clearance does decrease Changes in production of plasma proteins in elderly - Correct Answer-Albumin and pseudocholinesterase production decreases Alpha 1 acid glycoprotein increases (larger reservoir for basic drugs) One MET oxygen consumption - Correct Answer-3.5 mL/kg/min Drugs that exacerbate Parkinson's symptoms - Correct Answer-Reglan Droperidol Chlorpromazine Samter syndrome - Correct Answer-Triad of nasal polyps, allergy to aspirin, and asthma These patients have an increased risk for intraoperative bronchospasm Batsons plexus - Correct Answer-Epidural veins that drain venous blood from the spinal cord Obesity and pregnancy increase intra abdominal pressure admins can cause engorgement of the plexus (increase risk of needle injury) Plica mediana dorsalis - Correct Answer--existence is controversial -band of connective tissue between ligamentum flavum and dura mater -could impact spread within epidural space (unit lateral epidurals or difficult catheter insertion) Sacrococcygeal ligament - Correct Answer-Ligament that covers the sacral hiatus and what is punctured during the caudal approach to the epidural space Thumb spinal nerve root - Correct Answer-C6 2nd/3rd digit spinal nerve root - Correct Answer-C7 4th/5th digits spinal nerve root - Correct Answer-C8 Delayed onset Longer duration of action Delayed respiratory depression Higher incidence N/V and pruritis Characteristics of lipophilic neuraxial opioids - Correct Answer-(Fentanyl, sufentanil) Systemic and spinal cord sites of action Less rostral spread Faster onset, shorter duration Early respiratory depression Less N/V and pruritis Most common side effect of neuraxial opioids - Correct Answer-Pruritis 4 side effects of neuraxial opioids - Correct Answer-Pruritis (most common) Respiratory depression (higher risk with more hydrophilic - greater rostral spread) Urinary retention N/V Which local anesthetic reduced the efficacy of epidural opioids - Correct Answer-2- chloroprocaine Which neuraxial opioid can deactivate herpes simplex labialis? - Correct Answer- Epidural morphine Risk factors for PDPH - Correct Answer-Younger age Female Pregnant Cutting point needle Larger needle Using air for LOR Needle perpendicular to long axis of meninges Treatment for PDPH - Correct Answer-Bed rest Hydration NSAIDs Caffeine Epidural blood patch (Opioids DO NOT help) Success rate of epidural blood patch - Correct Answer-90% Most common side effects of epidural blood patch - Correct Answer-Back ache and radicular pain Epidural hematoma presentation - Correct Answer-Lower extremity weakness Numbness Low back pain Bowel and bladder dysfunction NSAIDs/aspirin and neuraxial - Correct Answer-Okay to proceed with neuraxial Clopidogrel and neuraxial - Correct Answer-Hold 7 days before block placement Ticlodipine and neuraxial - Correct Answer-Hold 14 days before block placement Sub Q heparin and neuraxial - Correct Answer-Okay for neuraxial IV heparin and neuraxial - Correct Answer-Hold 2-4 hours before block placement Hold 1 hour after block placement Hold 2-4 hours after catheter has been removed LMW heparin and neuraxial - Correct Answer-Hold 12 hours before block placement for prophylactic dosing and 24 hours before block placement for therapeutic dosing Hold 12 hours before removing catheter Hold 2 hours after catheter removed Warfarin and neuraxial - Correct Answer-Hold 5 days before placement Can remove catheter if INR < 1.5 Vitamin K dependent clotting factors - Correct Answer-2, 7, 9, 10 Conus medullaris and dural sac adult vs infant - Correct Answer-Conus medularis: adult L2, infant L3 Dural sac: adult S2, infant S3 Cause of cauda equina syndrome - Correct Answer-Neurotoxicity due to exposure to high concentrations of local anesthetic Factors that increase risk of cauda equina syndrome - Correct Answer-5% lidocaine and spinal microcatheters. Presentation and treatment of cauda equina syndrome - Correct Answer-Bowel and bladder dysfunction, sensory deficits, weakness, and/or paralysis Treatment is supportive Cause of transient neurologic symptoms - Correct Answer-Patient positioning Stretch of sciatic nerve Myofascial strain Muscle spasm (NOT neurotoxicity) Risk factors for transient neurologic symptoms - Correct Answer-Lidocaine Lithotomy position Ambulatory surgery Knee arthroscopy Transient neurologic symptoms and treatment - Correct Answer-Severe back and butt pain that radiates to both legs, develops within 6-36 hours and persists for 1-7 days Treatment: NSAIDs, opioids, trigger point injections Most common organism responsible for post spinal bacterial meningitis - Correct Answer-Streptococcus viridians (most commonly found in mouth and why it is important to wear a mask) Best way to prep skin prior to neuraxial - Correct Answer-Chlorhexidine and isopropyl alcohol Where does the intercostobrachial nerve arise from? - Correct Answer-T2 Surgical procedure best suited for interscalene block - Correct Answer-Shoulder and upper extremity Not good for procedures below the elbow Which upper extremity block is most likely to cause phrenic nerve paralysis - Correct Answer-Interscalene (almost 100%) Upper extremity block most likely to cause horner's syndrome - Correct Answer- Interscalene Location of stellate ganglion - Correct Answer-C7 Tourniquet inflation pressure for bier block - Correct Answer-250 mmHg or at least 100 mmHg over SBP 6 terminal branches of lumbar plexus - Correct Answer-Iliohypogastric