1. In Adult with mediastinal mass, the greatest risk of adverse event by CT scan is pericardial effusion, not airway compression...
3. Cerebral palsy does not increase dosing of succinylcholine as it does not result in extrajunctional receptors. More nondepolarizing NMBs are required for same effect though.
5. People who are sensitive to latex: people who work in OR, people who need catheterization (spinal cord issues)
10. C5 innervates no fingers. C6 - thumb and index, C7 - index and middle, C8 - ring and pinky
11. Parturient's hearts grow, leading to increased diameter of all 4 chambers and mitral valve. This leads to lower threshold for dysrhythmias.
16. Desflurane creating CO more than other volatiles. Desiccated gas on monday morning.
18. MV changes by 3L/min per 1mmHg of increase or decrease of PaCO2. This is mediated by central chemoreceptors.
19. Succinylcholine does increase intraocular pressure but may be necessary for case so not absolute contraindication.
26. Mapleson systems spontaneous ventilation can be summarized as follows: A > DFE > CB. During controlled ventilation, DFE > BC > A
31. What increases A-a gradient. Remember that hypoxemia is due to 5 causes and A-a gradient changes in the first 3:
Shunt, VP mismatch, Poor diffusion, Altitude, Hypoventilation (hypercarbia does not change A-a gradient)
32. Multiple sclerosis avoid succinylcholine 2/2 hyperkalemia. Sensitivity to NMB. Regional vs general both can cause exacerbation though epidural is thought to be safer than spinal.
46. Noxious s timulus with cause 2 distinct sensations carried by A-delta fibers and C fibers. First is well localized, sharp and brief. 2nd is dull, not well localized. Speed of conduction is 10-20m/s for a-delta while C is 1/m/s
49. Most common symptom of uterine rupture is fetal bradycardia. Rate of rupture in low transverse c/s is 0.8-1.6 percent.
55. Babies respond to cold by vasoconstriction of skin and non-shivering thermogenesis. There is a chance that a premature neonate returns to fetal circulatory pattern 2/2 cold because there is an increase in PAP causing opening of the PFO and also increasing O2 usage may result in ypoxemia -> opening ductus arteriosus.
64. Peripartum cardiomyopathy is defined by development of EF <45% in the last month of pregnancy or 5 months after delivery without identifiable cause. Pt must not have HF for another reason before the last month.
72. Aspirin or salicylate poisoning causes a metabolic acidosis but also a respiratory alkalosis from hyperventilation 2/2 stimulating respiratory center. Give sodium bicarbonate to alkalinze urine.
73. Three-legged stool: parenchymal (DLCO <40%, PaO2 <65, PaCO2>45), functional (Vmax >15), spirometry (FEV < 2L, VC < 50%, RV/TLC > 50%)
74. If initial screening for postoperative risk s/p pneumonectomy is bad, followup testing is warranted. Split lung function testing utilizes VQ scans with radioisotopes. Predicted postoperative FEV1 <0.85L, blood flow >70% to diseased lung. Third phase of testing if split lung function is concerning is balloon occlusion to main bronchus of operative lung. Measure PAP>45, PaCO2 >60, PaO2 <45, severe dyspnea.
Thursday, February 12, 2015
Tuesday, February 10, 2015
ACE 2009 6A x
10. Mannitol should be given over 30 minutes to decrease ICP. Initial effect in 15 min, max effect in 1 hr, lasts 6 hrs. Can temporarily increase ICP with rapid administration but NOT hypertension. Serum osmolarity goal with mannitol administration should target 300-320.
18. Lithium prolongs both nondepolarizing NMB and succinylcholine.
31. Mitral regurgitation 2/2 ischemia is NOT most likely due to papillary muscle rupture. It does however portend increased risk of cardiac death as even small amount of regurg can lead to pulm HTN.
32. When you see late decels: oxygenation, left lateral decubitis, give pressors for hypotension, stop oxytocin and given terbutaline if signs of uterine overstimulation. If not successful, c/s.
33. Parturtients may be more resistant to opioid induced respiratory depression 2/2 progesterone stimulating RR.
41. Aminoglycosides can cause nephrotoxicity (ATN) with neomycin being most likely, gentimicin moderate and streptomycin weakly. Risk can be reduced with coadministration of beta-lactam, also giving calcium or calcium channel blockers. Antioxidants proven in animals but not humans. Give less total dose and less frequent dosing.
42. To distinguish between somatic (musculoskeletal) vs visceral (stretching of organs) pain, you can give intercostal blocks. Also celiac plexus blocks are not as long lasting for noncancer pancreatic pain. Pain control from celiac plexus is from afferent sensory fibers, not as much sympathetic efferent fibers.
44. Stellate ganglion is made up of inferior cervical ganglion fused with T1, located anterior to transverse process of C7 or T1. The stellate ganglion contains sympathetic nerves to the face and arm. A typical stellate block to anterior process of C6 will cause Horner's syndrome (ptosis, miosis, nasal stuffiness, scleral hyperemia) with sympathetic block of the face. Temperature rise in the arm is required to insure that the block as affected the upper extremity.
45. Correctly done stellate block results in phrenic nerve and recurrent laryngeal nerve blockage.
51. In older people, SV increases while HR and CI decreases. This makes sense because pulse pressure increases in older people and pulse pressure approximates SV.
53. Glossopharyngeal block - extraoral approach - line drawn from angle of mandible to mastoid process. Styloid process lies below midpoint of this line. Hit styloid 3cm needle and walk off posteriorly, inject. Close to IJV and ICA. Accessory nerve and vagus nerve are more posterior. LA will block all 3 nerves.
56. Remifentanil in high doses can isolate epileptogenic areas but decreasing EEG activity in normal brain and increasing single and repetitive spike burst activity in epileptogenic areas.
63. Penile block consists of ring block or dorsal penile nerve block. The latter aims to anesthesize nerves deep to the fascial plane under Scarpa's fascia. Two injections lateral to the midline inferior to the symphsis pubis is required.
66. Croup vs epiglottitis. Croup is in younger kids (1 year) who barks and has low grade fever and triangle positioning. Epiglottitis is in older children without viral prodrome with higher temperature. Also the kid is drooling, dysphagia, and distress. Usually a muffled voice.
Croup rx - cool mist doesn't benefit, give corticosteroids, racemic epinephrine, heliox,
72. SvO2 decreases with pulm embolism, pulm edema, and MI (decreased CO). It increases with cyanide, hypothermia, and shunts or AV fistulas.
77. Suboxone is combination of buprenorphine/naloxone to be used sublingually. The Suboxone has very little absorption through this route but prevents abuse by IV.
18. Lithium prolongs both nondepolarizing NMB and succinylcholine.
31. Mitral regurgitation 2/2 ischemia is NOT most likely due to papillary muscle rupture. It does however portend increased risk of cardiac death as even small amount of regurg can lead to pulm HTN.
32. When you see late decels: oxygenation, left lateral decubitis, give pressors for hypotension, stop oxytocin and given terbutaline if signs of uterine overstimulation. If not successful, c/s.
33. Parturtients may be more resistant to opioid induced respiratory depression 2/2 progesterone stimulating RR.
41. Aminoglycosides can cause nephrotoxicity (ATN) with neomycin being most likely, gentimicin moderate and streptomycin weakly. Risk can be reduced with coadministration of beta-lactam, also giving calcium or calcium channel blockers. Antioxidants proven in animals but not humans. Give less total dose and less frequent dosing.
42. To distinguish between somatic (musculoskeletal) vs visceral (stretching of organs) pain, you can give intercostal blocks. Also celiac plexus blocks are not as long lasting for noncancer pancreatic pain. Pain control from celiac plexus is from afferent sensory fibers, not as much sympathetic efferent fibers.
44. Stellate ganglion is made up of inferior cervical ganglion fused with T1, located anterior to transverse process of C7 or T1. The stellate ganglion contains sympathetic nerves to the face and arm. A typical stellate block to anterior process of C6 will cause Horner's syndrome (ptosis, miosis, nasal stuffiness, scleral hyperemia) with sympathetic block of the face. Temperature rise in the arm is required to insure that the block as affected the upper extremity.
45. Correctly done stellate block results in phrenic nerve and recurrent laryngeal nerve blockage.
51. In older people, SV increases while HR and CI decreases. This makes sense because pulse pressure increases in older people and pulse pressure approximates SV.
53. Glossopharyngeal block - extraoral approach - line drawn from angle of mandible to mastoid process. Styloid process lies below midpoint of this line. Hit styloid 3cm needle and walk off posteriorly, inject. Close to IJV and ICA. Accessory nerve and vagus nerve are more posterior. LA will block all 3 nerves.
56. Remifentanil in high doses can isolate epileptogenic areas but decreasing EEG activity in normal brain and increasing single and repetitive spike burst activity in epileptogenic areas.
63. Penile block consists of ring block or dorsal penile nerve block. The latter aims to anesthesize nerves deep to the fascial plane under Scarpa's fascia. Two injections lateral to the midline inferior to the symphsis pubis is required.
66. Croup vs epiglottitis. Croup is in younger kids (1 year) who barks and has low grade fever and triangle positioning. Epiglottitis is in older children without viral prodrome with higher temperature. Also the kid is drooling, dysphagia, and distress. Usually a muffled voice.
Croup rx - cool mist doesn't benefit, give corticosteroids, racemic epinephrine, heliox,
72. SvO2 decreases with pulm embolism, pulm edema, and MI (decreased CO). It increases with cyanide, hypothermia, and shunts or AV fistulas.
77. Suboxone is combination of buprenorphine/naloxone to be used sublingually. The Suboxone has very little absorption through this route but prevents abuse by IV.
Monday, February 2, 2015
2014 ACE 11A x
1. SSEPs test the posterior column in upper limbs but actually anterior column in the lower limbs
5. Naproxen is safer than diclofenac and ibuprofen in risk of myocardial infarction
6. Sevoflurane reduces respiratory resistance by 40% while desflurane does not reduce at all.
9. After ondansterone, diphenhydramine is good antinausea medication for parkinsons. Its antihistamine and anticholinergic. Remember compazine is antihistamine but has antidopaminergic effects.
10a. Succinylcholine induces hyperkalemia, rabhdo, possible MH in glycogen storage diseases.
b. Hyperkalemic periodic paralysis is triggered by exercise. Hypokalemic period paralysis is triggered by glucoseinsulin infusions.
c. Myotonic dystrophy does not cause hyperkalemia. It causes muscle contraction, cardiac abnormalities.
13. Postpolio syndrome is a constellation of signs that occur 15-40 years after initial polio infection. Generealized fatigue, muscle weakness, dysphagia, increased sensitivity to sedatives, OSA, respiratory weakness.
14. Hypogastric plexus blockade alleviates pelvic pain associated with cancer. Afferent fibers coming from pelvis travel with sympathetic nerves through hypogastric plexus.
Celiac plexus block relieve visceral pain in upper abdomen
Lumbar sympathetic block relieves pain in lower extremities such as claudication
Pudendal blocks result in analgesic of penis, peri-anal area, and posterior surface of scrotum
15. Asthma, left to right shunts, polycythemia, hemmorhage increase DLCO
16. Pregnant women have same tidal volume, vital capacity. Residual volume, FRC, and ERV are decreased.. Airway resistance doesn't change because prostaglandin E (bronchodilation) and prostaglandin F2a (Hemabate/carbaprost) keeps things unchanged.
In obese pts, FRC, ERV, VC are all decreased. Closing capacity is increased. Dead space is unchanged. FEV1 and FVC are decreased a great deal.
20: Heparin-induced thrombocytopenia mostly results in thrombosis and PE not bleeding. Criteria is platelets less than 50% of baseline or 100,000 after exposure to heparin. Thrombosis (75%).
21. Steeple sign = croup/laryngotracheobronchitis, thumb sign is epiglottitis
Smoking cessation - first 48-72 hrs, increased secretions and more reactive airways. Acute cessation decreases carboxyhemoglobin and increases oxygenation. Other benefits take 2-4 weeks. 4-6 weeks immune function normalize. 12 weeks improvement in mucociliary transport and small airway function.
VA study shows increased pulmonary complications within 4 weeks of smoking cessation. CABG pts may need 8 weeks.
25. Determining brain death. Exclude: metabolic, temperature, hypotension, drugs/paralysis. Cause of coma should be known and irreversible. Absence of relfex and CO2 drive. Spinal reflexes (plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks ) do not exclude brain death.
33. SVC syndrome use armored tube....
36. Graft vs host disease is fatal disease caused by T-Lymphocyte of donor proliferativing in immunocompromised recipient. More likely in elderly and in similar donors such as family (directed donor blood). Symptoms occur 2-6 weeks afterwards and appear like autoimmune hepatitis. Reduced by irradiation.
39. Methohexital has little to no effect on seizure duration, which is related to efficacy of ECT. Propofol and ketamine reduces length while etomidate increases length.
31. PCI stent surgery decision, if elective wait 12 months. If urgent a decision is made to continue which antiplatelet therapy. If risk is low/intermediate and <12 months, continue both. If risk is high than discontinue plavix and continue aspirin.
44. In upright position, 1 cm vertical distance from BP cuff to brain is approximately an increase of 0.77 mmHg in BP. This means ~30-37 mmHg from arm cuff to circle of Willis. More than 45% of adults have incomplete circle of Willis.
50. Mediastinoscopy most frequently compresses the inominate artery so put a-line in RUL
51. Lung resection risk factors "three legged stool" =
lung mechanics parenchymal function cardiopulm reserve
FEV1 < 40% DLCO <40% VO2 max >15
PaO2 >60, PaCO2 < 45 stair climb, exercise SpO2 <4%
Other factors that influence hypoxemia during OLT:
COPD increases oxygenation
Right thoracotomy decreases oxygenation
Wedge has greater hypoxemia than pneumonectomy 2/2 reduced perfusion (from central tumors)
56. Carcinoid syndrome - serotonin excretion causes flushing, diarrhea, right sided heart problems, bronchoconstriction. The syndrome is in only 20% of pts with the tumor. GHRH may result in acromegaly and intrathoracic carcinoid tumors can release ACTH or CRH resulting in Cushings. Octreotide of somatostatin treat carcinoid.
64. Moderate sedation vs minimal sedation vs deep sedation
67. Line isolation monitor provides protection against macroshocks on the order of 100-300mA, whihc can cause VF. Microshocks are at an order of 100 to 300 mA.
69. If a patient survives intracranial SAH aneurysm bleed, the greatest cause of mortality and morbidity is Delayed cerebral ischemia (DCI = vasospasm). DCI presents 3-14 days after initial hemorrhage. DCI is treated with nimodipine triple H therapy (HTN, hypervolemia, hemodilution).
71. Serotonin and norepinephrine are metabolized by the lung. MAO-A break down serotonin, norepi, epi. Both MAO-A and B breakdown dopamine, tyramine, tryptamine. Remember that MAO-A inhibitors are used for psychiatric reasons and MAO-B inhibitors are used for Alzheimer's and Parkinson's.
MAOI inhibit breakdown of dietary amines such as tyramine and pts suffer hypertensive crisis. Tyramine displaces norepinephrine from storage vesicles. Avoid foods like liver, fermented substances, alcoholic beverages, aged cheeses, broad beans. Rememeber linezolid is weak MAOI.
COMT also break down dopamine, norepi, and epi. Rememeber levodopa is broken down by COMT so entacapone (COMT inhibitor) and carbidopa (inhibitor of dopa decarboxylase) is standard triple therapy.
72. Cough reflex - superior laryngeal nerve afferent
laryngospasm reflex - superior laryngeal nerve afferent
Swallowing - glossopharyngeal nerve
74. Refeeding syndrome leads to muscle weakness and trouble with vent weaning
PEEP, I to E ratio, FiO2 may increase PaO2 as part of vent strategy
75. High altitude leads to higher MV, decreased PaCO2 and higher PaO2 in the first 30 minutes but this is not sustained. Then PaO2 drops again. After 1 week, a patient go through a slow acclimatization that leads to a sustained increase in ventilation. Remember that acetazolamide, a carbonic anhydrase inhibitor leads to secretion of bicarb in urine (alkalinization) and metabolic acidosis. Body's reponse will be hyperventilation, speeding up acclimatization.
80. Nadir of physiologic anemia of infancy newborn is 3 months Hgb of 8
84. Pyloromyotomy for pyloric stenosis is not emergent and anesthesia should correct for fluids, electrolytes. Good things to do would be anticholinergic administration, gastric decompression with OG before induction, RSI, minimal opioids, awake extubation. Succinylcholine is ok. Mask induction not ok.
5. Naproxen is safer than diclofenac and ibuprofen in risk of myocardial infarction
6. Sevoflurane reduces respiratory resistance by 40% while desflurane does not reduce at all.
9. After ondansterone, diphenhydramine is good antinausea medication for parkinsons. Its antihistamine and anticholinergic. Remember compazine is antihistamine but has antidopaminergic effects.
10a. Succinylcholine induces hyperkalemia, rabhdo, possible MH in glycogen storage diseases.
b. Hyperkalemic periodic paralysis is triggered by exercise. Hypokalemic period paralysis is triggered by glucoseinsulin infusions.
c. Myotonic dystrophy does not cause hyperkalemia. It causes muscle contraction, cardiac abnormalities.
13. Postpolio syndrome is a constellation of signs that occur 15-40 years after initial polio infection. Generealized fatigue, muscle weakness, dysphagia, increased sensitivity to sedatives, OSA, respiratory weakness.
14. Hypogastric plexus blockade alleviates pelvic pain associated with cancer. Afferent fibers coming from pelvis travel with sympathetic nerves through hypogastric plexus.
Celiac plexus block relieve visceral pain in upper abdomen
Lumbar sympathetic block relieves pain in lower extremities such as claudication
Pudendal blocks result in analgesic of penis, peri-anal area, and posterior surface of scrotum
15. Asthma, left to right shunts, polycythemia, hemmorhage increase DLCO
16. Pregnant women have same tidal volume, vital capacity. Residual volume, FRC, and ERV are decreased.. Airway resistance doesn't change because prostaglandin E (bronchodilation) and prostaglandin F2a (Hemabate/carbaprost) keeps things unchanged.
In obese pts, FRC, ERV, VC are all decreased. Closing capacity is increased. Dead space is unchanged. FEV1 and FVC are decreased a great deal.
20: Heparin-induced thrombocytopenia mostly results in thrombosis and PE not bleeding. Criteria is platelets less than 50% of baseline or 100,000 after exposure to heparin. Thrombosis (75%).
21. Steeple sign = croup/laryngotracheobronchitis, thumb sign is epiglottitis
Smoking cessation - first 48-72 hrs, increased secretions and more reactive airways. Acute cessation decreases carboxyhemoglobin and increases oxygenation. Other benefits take 2-4 weeks. 4-6 weeks immune function normalize. 12 weeks improvement in mucociliary transport and small airway function.
VA study shows increased pulmonary complications within 4 weeks of smoking cessation. CABG pts may need 8 weeks.
25. Determining brain death. Exclude: metabolic, temperature, hypotension, drugs/paralysis. Cause of coma should be known and irreversible. Absence of relfex and CO2 drive. Spinal reflexes (plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks ) do not exclude brain death.
33. SVC syndrome use armored tube....
36. Graft vs host disease is fatal disease caused by T-Lymphocyte of donor proliferativing in immunocompromised recipient. More likely in elderly and in similar donors such as family (directed donor blood). Symptoms occur 2-6 weeks afterwards and appear like autoimmune hepatitis. Reduced by irradiation.
39. Methohexital has little to no effect on seizure duration, which is related to efficacy of ECT. Propofol and ketamine reduces length while etomidate increases length.
31. PCI stent surgery decision, if elective wait 12 months. If urgent a decision is made to continue which antiplatelet therapy. If risk is low/intermediate and <12 months, continue both. If risk is high than discontinue plavix and continue aspirin.
44. In upright position, 1 cm vertical distance from BP cuff to brain is approximately an increase of 0.77 mmHg in BP. This means ~30-37 mmHg from arm cuff to circle of Willis. More than 45% of adults have incomplete circle of Willis.
50. Mediastinoscopy most frequently compresses the inominate artery so put a-line in RUL
51. Lung resection risk factors "three legged stool" =
lung mechanics parenchymal function cardiopulm reserve
FEV1 < 40% DLCO <40% VO2 max >15
PaO2 >60, PaCO2 < 45 stair climb, exercise SpO2 <4%
Other factors that influence hypoxemia during OLT:
COPD increases oxygenation
Right thoracotomy decreases oxygenation
Wedge has greater hypoxemia than pneumonectomy 2/2 reduced perfusion (from central tumors)
56. Carcinoid syndrome - serotonin excretion causes flushing, diarrhea, right sided heart problems, bronchoconstriction. The syndrome is in only 20% of pts with the tumor. GHRH may result in acromegaly and intrathoracic carcinoid tumors can release ACTH or CRH resulting in Cushings. Octreotide of somatostatin treat carcinoid.
64. Moderate sedation vs minimal sedation vs deep sedation
67. Line isolation monitor provides protection against macroshocks on the order of 100-300mA, whihc can cause VF. Microshocks are at an order of 100 to 300 mA.
69. If a patient survives intracranial SAH aneurysm bleed, the greatest cause of mortality and morbidity is Delayed cerebral ischemia (DCI = vasospasm). DCI presents 3-14 days after initial hemorrhage. DCI is treated with nimodipine triple H therapy (HTN, hypervolemia, hemodilution).
71. Serotonin and norepinephrine are metabolized by the lung. MAO-A break down serotonin, norepi, epi. Both MAO-A and B breakdown dopamine, tyramine, tryptamine. Remember that MAO-A inhibitors are used for psychiatric reasons and MAO-B inhibitors are used for Alzheimer's and Parkinson's.
MAOI inhibit breakdown of dietary amines such as tyramine and pts suffer hypertensive crisis. Tyramine displaces norepinephrine from storage vesicles. Avoid foods like liver, fermented substances, alcoholic beverages, aged cheeses, broad beans. Rememeber linezolid is weak MAOI.
COMT also break down dopamine, norepi, and epi. Rememeber levodopa is broken down by COMT so entacapone (COMT inhibitor) and carbidopa (inhibitor of dopa decarboxylase) is standard triple therapy.
72. Cough reflex - superior laryngeal nerve afferent
laryngospasm reflex - superior laryngeal nerve afferent
Swallowing - glossopharyngeal nerve
74. Refeeding syndrome leads to muscle weakness and trouble with vent weaning
PEEP, I to E ratio, FiO2 may increase PaO2 as part of vent strategy
75. High altitude leads to higher MV, decreased PaCO2 and higher PaO2 in the first 30 minutes but this is not sustained. Then PaO2 drops again. After 1 week, a patient go through a slow acclimatization that leads to a sustained increase in ventilation. Remember that acetazolamide, a carbonic anhydrase inhibitor leads to secretion of bicarb in urine (alkalinization) and metabolic acidosis. Body's reponse will be hyperventilation, speeding up acclimatization.
80. Nadir of physiologic anemia of infancy newborn is 3 months Hgb of 8
84. Pyloromyotomy for pyloric stenosis is not emergent and anesthesia should correct for fluids, electrolytes. Good things to do would be anticholinergic administration, gastric decompression with OG before induction, RSI, minimal opioids, awake extubation. Succinylcholine is ok. Mask induction not ok.
Saturday, January 10, 2015
Obstetrics
- With meconium, it is no longer recommended to do intrapartum suctioning of newborn
- The main recommendation is necessary pre- and post-op monitoring of fetus during surgery
- Lung volumes are easy. Basically TLC decreases 5% and VC doesn't change. VT increases and IRV doesn't change. So RV + ERV = FRC must decrease ~20%.
- Chlorprocaine is used because fastest onset, fastest breakdown (so less worry about toxicity). 21 secs in maternal blood and 2 min even with pseudocholinesterase deficiency.
- The most common side effect of intraspinal narcotics is pruritus. The next most common side effects are nausea and vomiting, followed by urinary retention. Respiratory depression and headache may occur, but are relatively infrequent
- Average blood loss in vaginal delivery is 600 and c/s is 1000
- NTG, nitroprusside, and nifedipine all treat HTN but are uterotonic, only labetalol is not.
- Preeclampsia becomes severe if BP 160/110, proteinuria 5 g/24 hr; elevated serum creatinine, urine output of less than 500 mL/24 hr; CNS disturbances (seizures, altered consciousness, headaches, visual disturbances); pulmonary edema; epigastric or right upper quadrant pain; hepatic rupture; impaired liver function; thrombocytopenia; or HELLP syndrome.
- WBC normally rises to 15000 postpartum day 1
- Paracervical blocks only block the first stage pain. Pudendal blocks block the somatic component during the second stage but not visceral pain of contractions.
- Tocolytics include MgSO4 and/or β-adrenergic agonists (ritodrine, terbutaline) are used. Prostaglandin-synthetase inhibitors (indomethacin, ketorolac) and calcium entry blockers (nifedipine) have recently been used in selected cases.
- Magnesium therapeutic level is 4-8 Meq/L, loss of tendon reflex at 10, and CV effects at 15
- Aortocaval compression is relevant starting at 20 weeks
- Atropine readily crosses the placenta but at low doses does not seem to cause fetal tachycardia; at high doses, it may produce tachycardia. The combination of neostigmine, which crosses the placenta slightly, and glycopyrrolate, which does not cross the placenta well, has been associated with fetal bradycardia, which is why neostigmine with atropine is preferred when reversing neuromuscular blockers if a fetus is present.
- When EDTA was used, the incidence of severe deep back pain that lasted several hours become noted. This back pain was felt to be related to calcium chelation from the EDTA in the local anesthetic solution that leaked out of the intervertebral foramen and produced hypocalcemic tetany of the paraspinal muscles. Currently, the EDTA has been removed and the chloroprocaine manufactured today is in colored vials to reduce the rate of oxidation
Wednesday, October 29, 2014
Pediatrics
PRBC 10-15cc/kg will raise Hgb 2
FFP 10-15cc/kg will raise 30%
Plts 5cc/kg will raise 30%
Cryo 1 baby unit/5kg
FFP 10-15cc/kg will raise 30%
Plts 5cc/kg will raise 30%
Cryo 1 baby unit/5kg
Neonates higher Hgb goal. Apneic if anemic.
Single ventricle goal Hct>40
Single ventricle goal Hct>40
- Post-anesthesic apnea - central and obstructive components, risks include prematurity and hx of apnea. Other risk factors include current age (usually delay elective surgery until 44wks), anemia, hypothermia, infection, neurologic disorders. For pts with known apneic spells or BPD, delay surgery until 6 months. Can give caffeine to theophylline to treat.
- Definition of post-anesthesic apnea - >15 secs, desaturation, or bradycardia within 24 hrs postop
- RDS -> BPD after 28 days
Monday, July 14, 2014
Hall Machine Physics Complete
23. splitting ratio is determined by the vapor pressure. Higher the vapor pressure, the lower the splitting ratio.
Decreasing temperature will result in decreasing vapor pressure and less output.
31. N2O dissolves in vaporizer decreasing outflow when added to admixture. When turning off N2O, all the N2O in the vaporizer now goes into the outflow, suddenly increasing volume delivered of the volatile.
37. TO figure out vapor outflow
VO = (carrier gas flow x vapor pressure) / (barometric pressure - vapor pressure)
38. At extremely low flows and extremely high flows, volume delivered of volatile is lower than you think 2/2 insufficient flow and insufficient mixing
46. Uptake of volatile in the first minute = uptake between 4th minute and 9th minute, 9th minute and 16th minute, 16th minute and 25th minute etc
53. Highest FiO2 developed by NC is 45%. 4% per liter until 6L max.
56. Minimum minishock is 100milliAmps
57. The Line Isolation Monitor or LIM sounds an alarm when grounding occurs in the OR.
Decreasing temperature will result in decreasing vapor pressure and less output.
31. N2O dissolves in vaporizer decreasing outflow when added to admixture. When turning off N2O, all the N2O in the vaporizer now goes into the outflow, suddenly increasing volume delivered of the volatile.
37. TO figure out vapor outflow
VO = (carrier gas flow x vapor pressure) / (barometric pressure - vapor pressure)
38. At extremely low flows and extremely high flows, volume delivered of volatile is lower than you think 2/2 insufficient flow and insufficient mixing
46. Uptake of volatile in the first minute = uptake between 4th minute and 9th minute, 9th minute and 16th minute, 16th minute and 25th minute etc
53. Highest FiO2 developed by NC is 45%. 4% per liter until 6L max.
56. Minimum minishock is 100milliAmps
57. The Line Isolation Monitor or LIM sounds an alarm when grounding occurs in the OR.
Sunday, July 13, 2014
ACE questions 2012 9A COMPLETE
1. #general intrathecal clonidine has bee shown to reduce hyperalgesia and reduce postsurgical pain. IT ketamine does not.
6. #Peds Infants who receive total spinal anesthesia by mistake will suffer apnea. They hemodynamics won't change much 2/2 infant's low sympathetic tone compared to adults.
12. #general Stimulating needles for regional techniques need to be cathode polarity (cathode is negative so electrons decrease positive charges on cell membrane making depolarization easier), insulated (no dispersion of current), square wave (to avoid accommodation which occurs when subthreshold stimulus inactivates Na channels before threshold is achieved).
15. #general SLE drugs: methotrexate - pulm infiltrates, azathioprine - resistance to non-depolarizing blockers, procainamide - prolongs sux
21. LEAST not MOST
23. #general Treatment of MH: stop volatiles and sux. Give 100% FiO2 and increase MV. Give 2.5mg/kg of dantrolene. Cool to below 38 then stop. Give the normal meds for hyperkalemia.
30. #general peribulbar block - larger volume behind the eye but outside the medullary cone, will block OO muscle of the eyelid, possibly less complication than retrobulbar
31. #general minimal sedation: normal response to verbal stimulus and unaffected airway and vitals
moderate sedation (conscious sedation): purposeful response to verbal or tactile, no airway intervention
Deep sedation: purposeful response for repeated or painful stimulation, airway may be required
General anesthesia: unarousable except withdrawal to pain, intervention airway required
38. #general Aspiration of nonparticular matter, give 100% FiO2, PEEP, tracheal suctioning. Bronchial lavage is discouraged 2/2 pushing material further.
47. #cards Atrial fibrillation after cardiothoracic surgery is likely in pts who are >60 yos, Male, preop tachycardia, previous afib, low CO, increased postop BNP.
50. #general critical illness myopathy vs poluneuropathy. Myopathy has normal nerve conduction studies and increased CK. Treatment is supportive and mechanical vent.
51. #general TRALI is the greatest case of mortality 2/2 blood transfusions. More likely with platelets and plasma. MOre likely with multiparous women than men.
54. #general Bezold-Jarsich reflex - bradycardia, vasodilation, hypotension w/ spinal anesthesia
Bainbridge reflex - increase in HR 2/2 increase in CVP. This is likely in autotransfusion
57. #general mannitol extravasation can cause tissue necrosis.
63. #general CO2 laser is used to burn cornea not retina. Other lasers are used to burn retina.
65. #OBGYN placental transfer of meds, all opioids and ketamine. NMB do not get through.
66. #OBGYN uterine tone with volatiles. N2O does nothing. Other volatiles decrease tone. Des<Sevo.
68. #Peds TOtal lung capacity is smaller per weight in children compared to adults. FRC and TV is same. RR and MVO2 are increased.
72. #general Static compliance = V/P, tidal volume/(Plateau P - PEEP)
Dynamic compliance = tidal volume/(PIP - PEEP)
74. #general Myotonic dystrophy contraindicates sux, etomidate, and neostigmine. Use regional if possible. Shivering and hypothermia not hyperthermia induces contractions.
81. #general blood is not tested for CMV 2/2 general prevalence. More dangerous for pregmamt women and newborns.
84. #general GBS presents with pain and peripheral muscle weakness (no tendon reflex).Fever at the time of presentation suggests GBS is unlikely
85. #general indications for intubation vital capacity less than 15ml/kg and NIF less negative than -20
86. #general treatment of GBS: plasma exchange and IVIG. Not steroids or exchange transfusion. Remember interferon 1B is useful for multiple sclerosis but not GBS. Other treatments for GBS include steroids and plasma exchange for acute attacks. Glatiramer and ineterferon 1B for chronic treatment.
98. #OBGYN for women with preeclampsia underoging cesarean delivery, neuraxial anesthesia is preferred 2/2 airway concerns and hypertension w/ laryngoscopy. Studies show that women w/ preeclampsia is less likely to develop hypotension w/ spinal or epidural. (and no difference bewteen spinal and epidural)
6. #Peds Infants who receive total spinal anesthesia by mistake will suffer apnea. They hemodynamics won't change much 2/2 infant's low sympathetic tone compared to adults.
12. #general Stimulating needles for regional techniques need to be cathode polarity (cathode is negative so electrons decrease positive charges on cell membrane making depolarization easier), insulated (no dispersion of current), square wave (to avoid accommodation which occurs when subthreshold stimulus inactivates Na channels before threshold is achieved).
15. #general SLE drugs: methotrexate - pulm infiltrates, azathioprine - resistance to non-depolarizing blockers, procainamide - prolongs sux
21. LEAST not MOST
23. #general Treatment of MH: stop volatiles and sux. Give 100% FiO2 and increase MV. Give 2.5mg/kg of dantrolene. Cool to below 38 then stop. Give the normal meds for hyperkalemia.
30. #general peribulbar block - larger volume behind the eye but outside the medullary cone, will block OO muscle of the eyelid, possibly less complication than retrobulbar
31. #general minimal sedation: normal response to verbal stimulus and unaffected airway and vitals
moderate sedation (conscious sedation): purposeful response to verbal or tactile, no airway intervention
Deep sedation: purposeful response for repeated or painful stimulation, airway may be required
General anesthesia: unarousable except withdrawal to pain, intervention airway required
38. #general Aspiration of nonparticular matter, give 100% FiO2, PEEP, tracheal suctioning. Bronchial lavage is discouraged 2/2 pushing material further.
47. #cards Atrial fibrillation after cardiothoracic surgery is likely in pts who are >60 yos, Male, preop tachycardia, previous afib, low CO, increased postop BNP.
50. #general critical illness myopathy vs poluneuropathy. Myopathy has normal nerve conduction studies and increased CK. Treatment is supportive and mechanical vent.
51. #general TRALI is the greatest case of mortality 2/2 blood transfusions. More likely with platelets and plasma. MOre likely with multiparous women than men.
54. #general Bezold-Jarsich reflex - bradycardia, vasodilation, hypotension w/ spinal anesthesia
Bainbridge reflex - increase in HR 2/2 increase in CVP. This is likely in autotransfusion
57. #general mannitol extravasation can cause tissue necrosis.
63. #general CO2 laser is used to burn cornea not retina. Other lasers are used to burn retina.
65. #OBGYN placental transfer of meds, all opioids and ketamine. NMB do not get through.
66. #OBGYN uterine tone with volatiles. N2O does nothing. Other volatiles decrease tone. Des<Sevo.
68. #Peds TOtal lung capacity is smaller per weight in children compared to adults. FRC and TV is same. RR and MVO2 are increased.
72. #general Static compliance = V/P, tidal volume/(Plateau P - PEEP)
Dynamic compliance = tidal volume/(PIP - PEEP)
74. #general Myotonic dystrophy contraindicates sux, etomidate, and neostigmine. Use regional if possible. Shivering and hypothermia not hyperthermia induces contractions.
81. #general blood is not tested for CMV 2/2 general prevalence. More dangerous for pregmamt women and newborns.
84. #general GBS presents with pain and peripheral muscle weakness (no tendon reflex).Fever at the time of presentation suggests GBS is unlikely
85. #general indications for intubation vital capacity less than 15ml/kg and NIF less negative than -20
86. #general treatment of GBS: plasma exchange and IVIG. Not steroids or exchange transfusion. Remember interferon 1B is useful for multiple sclerosis but not GBS. Other treatments for GBS include steroids and plasma exchange for acute attacks. Glatiramer and ineterferon 1B for chronic treatment.
98. #OBGYN for women with preeclampsia underoging cesarean delivery, neuraxial anesthesia is preferred 2/2 airway concerns and hypertension w/ laryngoscopy. Studies show that women w/ preeclampsia is less likely to develop hypotension w/ spinal or epidural. (and no difference bewteen spinal and epidural)
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