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.
Monday, July 14, 2014
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)
ITE review
ITE Review
Volatiles Anesthetics
- How does left-to-right vs right-to-left affect FA/FI and induction time? Right to left slows induction time (transpulmonary shunt, mainsteam etc.). Left to right speeds up induction.
- Blood/gas partition coefficient is the ratio of a volatile anesthetic at equilibrium between blood and gas. For example, desflurane coefficient is .42 so blood has 42% of alveolar desflurane. The higher the coefficient, the slower the induction.
When comparing desflurane to isoflurane, what gets affected more by alveolar ventilation? CO? shunt? Dead space?
- alveolar ventilation would “refill” the alveoli of gas that was removed by blood, therefore, it increases rate of induction of isoflurane more than desflurane.
- higher CO “empties” the alveolar concentration of isoflurane more than desflurane, so isoflurane’s rate of induction would slow more than desflurane’s.
- for right-to-left shunts, soluble volatiles like isoflurane is less affected because they are more reliant on solubility rather to reach target concentration than desflurane.
- Dead space does not affect insoluble agents much. So the opposite of shunts.
Are induction and elimination both sped up or slowed down by changing gas flow? CO? minute ventilation?
- They will always reaction similarly. Though increasing cardiac output would slow induction and elimination.
What determines potency in volatiles? What determines rate of induction in volatiles?
- Lipid solubility determines potency. Blood/gas coefficient for second (though remember desflurane has lower coefficient but is slower than NO2 because of concentration effect).
- Lipid solubility also determines potency in local anesthetics. IV drugs use pKa to determine rate of induction.
-MAC decreases 6% per decade. The highest MACs are found in infants at 6-12 months of age and decrease with both increasing age and prematurity. For every Celsius degree drop in body temperature, MAC decreases approximately 2-5%. Hyponatremia, calcium channel blockers, hypoxia, hypercarbia, and pregnancy decrease MAC. Hyperthermia increase MAC. Factors that do not affect MAC include gender, thyroid function, and hyperkalemia.
- Remember most volatiles do not decrease CO unless at high MAC. They do decrease MAP by decreasing SVR. They mostly do not change SV or HR. Halothane and N2O are exceptions.
- Volatiles blunt the hypoxic and hypercarbia responses. They decrease lung volumes and FRC. They increase PaCO2. N2O has limit effects on minute ventilation and apneic thresholds. N2O does increase PVR like volatiles though.
- N2O causes diffusion of gas-containing cavities, inactivates B12 which affects DNA synthesis by inhibition methionine synthetase (don’t use in pregnancy), increase PONV, has effects hematologically.
- When FGF changes from 100 O2 to 40% O2 and 60% N2O, the PP of volatiles do not change but concentration decreases because of decreased solubility of volatiles in N2O
- Depending on calibration of variable bypass vaporizers, high attitude increases delivered concentration (volume percent) but keeps partial pressure the same. Since partial pressure correlates with potency, there is really no effect. However, with desflurane vaporizer that keeps the chamber pressurized to 2 atm w/o compensation for ambient pressure, the heated vaporizer will maintain delivered concentration and therefore underdose partial pressure.
- Speed of induction seems to be inversely related to uptake = λQ(PA − PV)/BP. So, higher barometric pressure decreases uptake and increases rate of induction. Likewise, high CO increases uptake and decreases rate of induction.
- Also remember that blood gas coefficient λ is reduced by anemia and hypoalbuminemia from renal diseases which speeds up induction.
Machine
Low barometric pressure means rotameters will underestimate flows at high gas flows but be accurate at low gas flows.
Changing the I:E ratio (1:3 -> 1:2) decreases peak pressures w/o changing alveolar ventilation
Vapor pressure per ml of volatile is around 200 ml gas/ml liquid. Most vaporizers hold 150cc of liquid. Therefore, most vaporizers contain 300,000 ml gas of volatile.
Since sevo and enflurane has vapor pressure around 160 and halothane/isoflurane has vapor pressure around 240, sevo and enflurane would be underdosed if put into halothane vaporizer. By how much? 1% halothane would deliver around 0.6% sevoflurane (160/240)
Tipping the variable bypass vaporizer may cause overdelivery of agent. Run at high flows and low concentration around 20-30 mins until ouput shows no excess of agent. Aladin cassettes cannot tip.
Scavenger system:
Waste gas -> APL/Pressure Relief Valve -> Tubing -> Reservoir (open/closed) -> Evacuation (active/passive). Incompetent pressure relief valve can result in hypoventilation as the bellows will have a direct opening to the scavenger system (the scavenger bag may inflate during inspiration as a sign). Active evacuation systems must have negative valve as well as positive valve to prevent negative pressure from building in the reservoir.
BP cuff width should be 40% of circumference of the patient’s arm
So higher barometeric pressure results in same PP of volatile given but higher concentration. Since MAC is directly related to concentration, you are delivering a higher MAC to the patient at high elevations.
SSEP measure amplitude and latency of dorsal columns of spinal cord by placing stimulating electrodes in limbs and recording electrodes in scalp. Changes in SSEP may reflect hypoperfusion, neural ischemia, temperature changes, or drug effects. Volatiles up to .7 MAC minimally affect SSEP. NMBs do not affect SSEP but do affect MEP.
Helium is not read through the mass spectrometer if it is included as part of gas flow. Therefore if 50% O2 and 50% He is given with 2% sevo. The machine would read 100 O2 and 4% sevo.
Variable Bypass Vaporizers deliver slightly less than set concentration at very low or very high flow rates. Low 2/2 inability to pick up the volatiles, high 2/2 inability to mix properly.
Extension not flexion inserts the ETT further into the trachea, perhaps causing endobronchial intubation.
For capnograms images showing what can go wrong click:
NIOSH minimal concentrations of N2O is 25ppm. Of volatiles alone is 2ppm, of volatiles when N2O is used in combination is 0.5ppm
IV Drugs
Ketamine and thiopental does not hurt with injection
TCA cause increased response to ephedrine, increases MAC, and has anticholinergic effects.
Milrinone works by PDEIII-inhibition.
Typical antipsychotics such as chlorpromazine enhances sedative effects, lowers seizure threshold, and prolongs QT.
Intra-arterial injection of thiopental causes intense vasoconstriction and pain treated with heparin/lidocaine/papverine/blocks
Cimetidine prolongs metabolism of midazolam and diazepam but not oxazepam and lorazepam
Dibucaine number higher means more inhibition means more normality (30 min block with hetero, 3 hour block with homo)
Etomidate causes PONV, sometimes 40%
Respiratory
Flow volume curves
Remember expiration is positive y-axis. Remember that extrathoracic obstruction is worse on inspiration 2/2 venturi effect while intrathoracic obstruction is worse on expiration because positive pressure can lead to the intrathoracic mass pushing on large airways.
In lateral decubitus position when awake, the lung-down receives more ventilation and perfusion. (Perfusion is 2/2 gravity, ventilation is 2/2 West zones I in upper lung means little tidal volume)
In lateral decubitus when anesthesized, the lung-down still receives more perfusion, but ventilation is decreased. (This is because each lung loses FRC and falls down the flow volume curve so that the lung-up now is more compliant.)
In lateral decubitus when anesthesized and chest wall is opened, the lung-up becomes even more compliant and receives even more ventilation through perfused is still low. Indeed, paralysis of this patient can induce even more V/Q mismatch as a paralyzed pt has further collapse of the non-dependent diaphragm.
Predicted poor tolerance of pneumonectomy include: PaCO2 > 45, PaO2 <50 on RA, FEV1<2L, FEV1/FVC <50%, max VO2 <10ml/kg/min
After pneumonectomy, wheezing, high CVP, and low CO could mean herniation of heart.
Mediastinoscopy can cause compression of the large vessels and cause strokes. Make sure to monitor both sides of the body ie. a-line on left and pulse on right.
What to do in aspiration: Most important is PEEP and high FiO2. Suctioning and bronchoscopic removal is suggested but lavage is contraindicated. Steroids and abx have not been shown to improve outcomes.
Respiratory - pulm edema from CHF, COPD exacerbation, postop abd and thoracic surgery, immunosuppression?
Liver/GI/Renal
In pts with severe liver dz, remember they have greater 3rd spacing so hydrophilic drugs such as non-depolarizing neuromuscular blockers need higher initial doses for same effect.
Obstetrics
Remember CO increases in pregnancy 2/2 both increases in SV and HR. Prelabor increase is 40-50% and during labor, CO can increase another 40%. The highest CO is right after delivery (80%). CO decreases to prelabor levels within 24 hours and pre-pregnancy levels within 2 weeks.
Remember MV increases by 35% in pregnancy 2/2 increases in mostly TV but also some RR. Pregnant women have lower FRC, lower RV, and lower ERV thus are more prone to hypoxia when apneic and increased rate of induction. Increased MV means normal ABG for pregnant woman is 7.45/100/30/20.
Remember hematologically, uterine artery brings nutrient rich blood to the placenta where it is transferred to umbilical vein. Old blood from the fetus is brought to the placenta by 2 umbilical arteries and transferred to the mother by the uterine vein. Uterine blood flow does not autoregulate and is directly correlated with MAP. It is often decreased by either reduced preload (aortocaval compression) or increased venous pressure (uterine contraction).
The normal hemoglobin in a pregnant woman is right-shifted 2/2 increased in 2,3-DPG. The fetal hemoglobin is very left shifted (lower P50 from 26) to improve transfer of O2. Normal umbilical vein ABG shows 7.35/30/40/20. That is, PO2 starts out as 30 and in the umbilical artery, decreases to 20 (7.27/20/50/23).
Remember fetal pH is lower than maternal so weak bases (opioids, local anesthetics) are often trapped in fetal circulation 2/2 ionization. This does not happen with ropi/marcaine/chlorprocaine.
Remember for epidural block, the first stage of labor (cervical dilatation) is pain in T10-11. For second stage of labor (pushing), pain is in the S2-4. You might have to increase epidural rate or give higher concentration bupivicaine to cover those sacral branches from a lumbar block.
Don’t give N2O >50% before delivery in c-section as it can cause diffusion hypoxia in the baby. Do give some N2O after delivery so that you can reduce volatile MAC and allow the uterus to contract.
Early fetal heart rate decelerations is usually 2/2 head compression from contraction and is benign. Variable decels are 2/2 umbilical cord compression and is a natural reaction from the sympathetic response of the fetus. Late decels are 2/2 uteroplacental insufficiency and lack of variability makes this one dangerous. Many medications including opioids, mag, benzos, lidocaine can all decrease variability but not actually endanger the fetus.
Fetal scalp pH is fine >7.25 and bad <7.2
Pathophys of preeclampsia:
Trophoblasts that are genetically fetus do not invade the spiral arteries of the uterus appropriately. They do not induce “adrenergic denervation”, which usually restricts the spiral arteries’ ability to constrict. Thus, the blood flow to placenta is constricted, high resistance, and low flow. This causes endothelial dysfunction! Decrease in vasodilating NO and PGI2! Increase in thromboxane A2 and endothelin-!. Also leads to platelet dysfunction+thrombocytopenia, capillary permeability (pulm edema), proteinuria. The systemic imbalance of vasoconstrictors vs vasodilators causes HTN, low CO, Na retention, LV failure, cerebral hemorrhage.
Amnotic Fluid Embolism is an anaphylactoid reaction that will present with combinations of PE (hypoxia/tachycardia/resp distress), anaphylaxis (hypotension), and coagulopathy (associated with DIC). Treatment is supportive and 50% die within 1 hr.
Pregnant women with severe mitral stenosis often run into trouble with spinals as it causes a sympathectomy that decreases LA pressures, which is necessary to keep preload.
Pregnant pts have increased risk of aspiration and difficult airways from 13 weeks to 6 weeks post-delivery
N2O is NOT associated with congenital abnormalities or spontaneous abortions in pts receiving the gas. It is a class C drug and chronic exposure (ie. to anesthesiologists) may cause rate of miscarriage!
Neuro:
CMRO2 is 3.5ml/100g/min
CBF is 50ml/100g/min
CBF shows EKG changes at 15ml/100g/min
CBF is related to pCO2 and pO2, not pH, as H+ from the bloodstream does not cross BBB, only CO2.
BBB is disrupted by infection, tumors, HTN, trauma, seizures but also extreme hypoxia and hypercarbia. It is not disrupted by hyperglycemia as osmotically active proteins are upregulated to absorb glucose as it accumulates. This mechanism explains why cerebral edema occurs after rapid correction of hyperglycemia.
CSF naturally is excreted slower and eliminated faster when ICP is increased.
Steroids decrease CSF production and absorption.
In pts with focal ischemic injury, hyperventilating the pt or giving propofol may cause Robin Hood phenomenon or reverse steal where normal brain is vasoconstricted and ischemic brain is unaffected resulting in more blood to ischemic areas.
How to treat VAE
- turn off nitrous, give fluids, applying positive pressure or apply pressure to the jugular to decrease gradient, attempt aspiration through central line, change position to left lateral + trendelenberg. Do not give PEEP?
Central line placement using intravascular EKG, advance until biphasic p wave as that means mid atrial position and then pull back 1 centimeter.
DO NOT give ICP lowering medications such as mannitol in an un-ruptured aneurysm until the cranial vault is open. This is because transmural pressure = MAP - ICP and decreasing ICP will increase chance of rupture.
Hunt and Hess scores SAH by clinical condition. 1 is asymptomatic, 2 is headache and nuchal rigidity, 3 is confusion or mild neuro deficit, 4 is stupor or hemiparesis or posturing, 5 is comatose and decerebrate
Triple H therapy is used to prevent vasospasm. Hypoervolemia = CVP >8, Hypertension = SBP >160, Hemodilution = Hgb ~10
Autonomic hyperreflexia is T10 and above. Neurogenic pulm edema is actually mostly caused by intracerebral trauma/bleed/seizure
Regional:
Babies who receive intrathecal caudal blocks do not have changes in BP or HR actually. They mostly become apneic and immobile.
With regards to the needle. It uses square wave function to decrease accommodation. Neural accommodation is the phenomenon that ramping depolarization can deactivate sodium channels while sudden depolarization will cause action potential. This is 2/2 the fact that sodium channels start deactivating once they are activated so if a slow depolarization happens, a significant portion of the sodium channels will be deactivated. This can happen if a needle approaches a nerve.
The polarity of the needle should be cathode as it causes depolarization.
The threshold required to cause action potential is the square of the distance between nerve and needle.
Regional is not contraindicated from asymptomatic spina bifida but insertion should be at unaffected site. Block may be discontinuous or patchy. Higher risk of dural puncture.
Thoracic epidurals compared to systemic opioids decrease ileus, decrease pulm complications, increase pt satisfaction, decrease ICU stay. They decrease morbidity in trauma pts with multiple rib fractures.
Heme/Onc:
Dipyridamole works by inhibit uptake of adenosine into plts
Peds
Down’s syndrome kids have subglottic stenosis/large tongues. Higher incidence of VSD and ASD. Higher incidence of altanto-axial instability. Higher incidence of hypothyroidism.
NPO status: 2 hour clears, 4 hour mother’s milk, 6 hours formula, 8 hours cow’s milk
Postop apnea: most important determinant is postconceptual age. Also of importance is anemia and preterm. Low-weight babies are at LOWER risk. It is not affected by anesthetic drugs or hx of ARDS/dysplasia.
Practice of Anesthesia
Deep sedation vs general vs moderate sedation
Moderate sedation does not require airway manipulation and pt has pursepoful response to verbal stimuli. Deep sedation is similar to general except that pts have purposeful movements with painful stimuli. Withdrawing does not count.
- rememeber that haldane is not in the lungs like halothane. It reflects increase in CO2 binding as Hemoglobin becomes unoxygenated. Bohr effect relates to increasing pH in the lung's blood will allow hemoglobin to have higher O2 affinity.
Bacterial Endocarditis Prophylaxis
2007 AHA guidelines
Who:
All dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
Procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa.
Procedures in patients with ongoing GI or GU tract infection.
Procedures on infected skin, skin structure, or musculoskeletal tissue.
Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials.
What:
Amoxicillin 2gm 30-60min before procedure. If allergic, given cephalexin or clinda or azithromycin.
Who:
- Prosthetic heart valves, including bioprosthetic and homograft valves.
- A prior history of IE.
- Congenital heart disease unless repaired successfully without residual defects and without prosthetic material.
- Cardiac valvulopathy in a transplanted heart.
What:
Amoxicillin 2gm 30-60min before procedure. If allergic, given cephalexin or clinda or azithromycin.
Saturday, July 12, 2014
7/12 Ace 2011 8A x
4. #thoracic After surgery for fixture of bronchopleural fistula, extubate to lower airway pressures and facilitate healing
13. #OBGYN sensory block necessary for C-section goes from T4 to S4.
15. #OBGYN epidural in laboring women may increase temp but its hard to isolate whether this is a direct effect or difficult labors require epidurals. This increase in temp is not associated with neonatal sepsis.
22. #OBGYN #Cards Obstetric hemorrhage secondary to uterine atony may be treated with 15-methylprostaglandin F2alpha (Hemabate). Administration can result in an acute increase in pulmonary artery pressure and is contraindicated in patients with pulmonary hypertension.
35. #Regional Axillary block: Median superior, ulnar inferior, radial posterior
44. #Peds Physiologic anemia in newborns. Polycythemia at birth 2/2 hypoxemia stimulating erythropoiesis. Decreased production of new RBC and shortened RBC survival (80-100d compared to 120d) causes Hgb of 8-9 during 8-12 weeks.The hemoglobin concentration at the nadir in premature infants is lower than in those born at full term. This anemia, sometimes termed the anemia of prematurity, occurs as a result of the decreased EPO levels present in infants,coupled with an even shorter red blood cell survival (60–80 days) and iatrogenic blood loss from recurring phlebotomy. Interestingly, transfusion of a premature neonate has been demonstrated to result in a lower hemoglobin concentration at the nadir. This has been attributed to increasing the percentage of HbA, which results in a right-shifted oxyhemoglobin dissociation curve.
47. #general In cirrhotic pts, maintain hepatic blood flow with volatiles, which maintain or increase hepatic blood flow. Propofol, neuraxial techniques do not work by decreasing preload.
48. #cards crawford classification for TAAA:
I - all thoracic aorta and top abdominal aorta
II - all descending aorta and all of abdominal aorta
III: lower portion of descending thoracic aorta and all of abomdinal
IV: only abdominal
53. #OBGYN air embolism presents with hemodynamic collapse. Supportive care plus clotting factors 2/2 coagulopathy develops from AFE.
55. #general Vision loss
cardiac surgery, swollen optic disc: anterior ischemic optic neuropathy
neck and head surgery, normal fundoscoptic exam: posterior ischemic optic neuropathy
Temporal arteritis, a form of arteritic ION, is characterized by painful visual loss in the setting of inflammation and thrombosis. Treatment with high-dose corticosteroids is recommended.
59. #neuro Remember that myasthenia gravis has fatiguability to repetitive test while LES has increased muscle activity. MG is resistant to sux but sensitive to NMB. LES is sensitive to both.
60. #general baclofen is GABAB agonist while benzos are GABAA agonists.
71. #general Treat TCA toxicity (dysrhythmias, VTs) with sodium bicarbonate which increases the gradient of sodium into the cell, to overcome the Na blocking caused by TCAs.
73.#general Treatment of C1 esterase deficiency or angioedema.
Dental/simple procedures
Attenuated androgens 2 days before surgery
C1 esterase inhibitors 24 hours before surgery
Fresh frozen plasma 6–12 hours before surgery
Tracheal intubation:
daily administration of an anabolic steroid (eg, danazol) 5–7 days before surgery
administration of fresh frozen plasma on the day of surgery
administration of the C1 esterase inhibitor Berinert P on the morning of surgery
76. #general circumcision in children, no difference in rescue meds or PONV for caudal vs dorsal penile block vs parenteral meds. There is less motor block in dorsal penile block
77. #general
L2-3 lumbar radiculopathy - back, butt, lateral thigh, groin pain. Does not extend past knee. Epidural shot may be helpful after NSAIDs.
L2 especially goes to groin by teh genitofemoral nerve.
Entrapment of thelateral femoral cutaneous nerve (a purely sensory nerve) will not result in upper buttock pain, weakness, muscle wasting, or groin symptoms. Therefore, a steroid injection at the
anterior superior iliac spine would not produce pain relief.
Compression of the L4 nerve root will usually refer symptoms below the knee in the distribution of the saphenous nerve.
79. #general CRPS can cause tremors and other motor dysfunction. Sympathetic dysfunction is key inclduing sudomotor (sweating), pilomotor (goosebumps), and vasomotor.
82. #OBGYN: pregnant women have higher tidal volume. Vital capacity and TLC is generally unchanged. CC is unchanged as well. FRC and ERV are decreased.
90. #Neuro: After intubation a patient who has blunt head trauma causing neurogenic pulmonary edema, what to do next to treat NPE? Lower ICP!
92. #General In carcinoid syndrome, avoid medications that release serotonin such as mivacurium, atracurium, sux, thiopental. Also many of the catecholamines like epi, norepi, dopa. Ondansteron has been used to treat the diarrhea in carcinoid syndrome.
99. #OBGYN
Trial of labor after c-section
1 c-section should be considered for TOLAC. Epidurals can be used. Misoprostol should not be used for women w/ previus c-section or previous uterine surgery.
Even twins or 2 previous c-sections can still undergo TOLAC. Spontaneous labor and previous successful VBAC increases chances of success.
In terms of outcomes. TOLAC vs elective c-section show:
decreased mortality from TOLAC and same hysterectomy risk and transfusion risk. Duration of hospitalization is lower for TOLAC. It will lower risks of previa, accreta in future pregnanies. There is an increased risk of uterine rupture and infections though. Surgical risks are similar.
13. #OBGYN sensory block necessary for C-section goes from T4 to S4.
15. #OBGYN epidural in laboring women may increase temp but its hard to isolate whether this is a direct effect or difficult labors require epidurals. This increase in temp is not associated with neonatal sepsis.
22. #OBGYN #Cards Obstetric hemorrhage secondary to uterine atony may be treated with 15-methylprostaglandin F2alpha (Hemabate). Administration can result in an acute increase in pulmonary artery pressure and is contraindicated in patients with pulmonary hypertension.
35. #Regional Axillary block: Median superior, ulnar inferior, radial posterior
44. #Peds Physiologic anemia in newborns. Polycythemia at birth 2/2 hypoxemia stimulating erythropoiesis. Decreased production of new RBC and shortened RBC survival (80-100d compared to 120d) causes Hgb of 8-9 during 8-12 weeks.The hemoglobin concentration at the nadir in premature infants is lower than in those born at full term. This anemia, sometimes termed the anemia of prematurity, occurs as a result of the decreased EPO levels present in infants,coupled with an even shorter red blood cell survival (60–80 days) and iatrogenic blood loss from recurring phlebotomy. Interestingly, transfusion of a premature neonate has been demonstrated to result in a lower hemoglobin concentration at the nadir. This has been attributed to increasing the percentage of HbA, which results in a right-shifted oxyhemoglobin dissociation curve.
47. #general In cirrhotic pts, maintain hepatic blood flow with volatiles, which maintain or increase hepatic blood flow. Propofol, neuraxial techniques do not work by decreasing preload.
48. #cards crawford classification for TAAA:
I - all thoracic aorta and top abdominal aorta
II - all descending aorta and all of abdominal aorta
III: lower portion of descending thoracic aorta and all of abomdinal
IV: only abdominal
53. #OBGYN air embolism presents with hemodynamic collapse. Supportive care plus clotting factors 2/2 coagulopathy develops from AFE.
55. #general Vision loss
cardiac surgery, swollen optic disc: anterior ischemic optic neuropathy
neck and head surgery, normal fundoscoptic exam: posterior ischemic optic neuropathy
Temporal arteritis, a form of arteritic ION, is characterized by painful visual loss in the setting of inflammation and thrombosis. Treatment with high-dose corticosteroids is recommended.
59. #neuro Remember that myasthenia gravis has fatiguability to repetitive test while LES has increased muscle activity. MG is resistant to sux but sensitive to NMB. LES is sensitive to both.
60. #general baclofen is GABAB agonist while benzos are GABAA agonists.
71. #general Treat TCA toxicity (dysrhythmias, VTs) with sodium bicarbonate which increases the gradient of sodium into the cell, to overcome the Na blocking caused by TCAs.
73.#general Treatment of C1 esterase deficiency or angioedema.
Dental/simple procedures
Attenuated androgens 2 days before surgery
C1 esterase inhibitors 24 hours before surgery
Fresh frozen plasma 6–12 hours before surgery
Tracheal intubation:
daily administration of an anabolic steroid (eg, danazol) 5–7 days before surgery
administration of fresh frozen plasma on the day of surgery
administration of the C1 esterase inhibitor Berinert P on the morning of surgery
76. #general circumcision in children, no difference in rescue meds or PONV for caudal vs dorsal penile block vs parenteral meds. There is less motor block in dorsal penile block
77. #general
L2-3 lumbar radiculopathy - back, butt, lateral thigh, groin pain. Does not extend past knee. Epidural shot may be helpful after NSAIDs.
L2 especially goes to groin by teh genitofemoral nerve.
Entrapment of thelateral femoral cutaneous nerve (a purely sensory nerve) will not result in upper buttock pain, weakness, muscle wasting, or groin symptoms. Therefore, a steroid injection at the
anterior superior iliac spine would not produce pain relief.
Compression of the L4 nerve root will usually refer symptoms below the knee in the distribution of the saphenous nerve.
79. #general CRPS can cause tremors and other motor dysfunction. Sympathetic dysfunction is key inclduing sudomotor (sweating), pilomotor (goosebumps), and vasomotor.
82. #OBGYN: pregnant women have higher tidal volume. Vital capacity and TLC is generally unchanged. CC is unchanged as well. FRC and ERV are decreased.
90. #Neuro: After intubation a patient who has blunt head trauma causing neurogenic pulmonary edema, what to do next to treat NPE? Lower ICP!
92. #General In carcinoid syndrome, avoid medications that release serotonin such as mivacurium, atracurium, sux, thiopental. Also many of the catecholamines like epi, norepi, dopa. Ondansteron has been used to treat the diarrhea in carcinoid syndrome.
99. #OBGYN
Trial of labor after c-section
1 c-section should be considered for TOLAC. Epidurals can be used. Misoprostol should not be used for women w/ previus c-section or previous uterine surgery.
Even twins or 2 previous c-sections can still undergo TOLAC. Spontaneous labor and previous successful VBAC increases chances of success.
In terms of outcomes. TOLAC vs elective c-section show:
decreased mortality from TOLAC and same hysterectomy risk and transfusion risk. Duration of hospitalization is lower for TOLAC. It will lower risks of previa, accreta in future pregnanies. There is an increased risk of uterine rupture and infections though. Surgical risks are similar.
Friday, July 11, 2014
7/11 ACE 2011 ??????
2. Putting magnet on PM disables antitachycardia pacing but does not change pacing to VOO. It stays teh same.
12. pt with GBS develop SIADH 50% of the time. Hypotension is also common as well as dysautonomia presenting as sinus tachycardia or bradydysrhythmias. However, treatment of tachycardia causes profound brady so don't do it unless CAD. EKG shows giant T waves, prolonged QT, U waves, ST-T wave changes.
13. Risks for PA endobronchial puncture include: female, mitral stenosis, PAH, >60 years, coagulopathy, hyperinflation of balloon and distal placement of PAC.
14. Lithotripsy, esp 1st generation machines, can cause ventricular dysrhythmias. Fire the machine during ventricular refractoriness (right after R) to avoid this.
18. Methylene blue blocks MAO so don't give it with SSRI
24. Treat cocaine induced coronary vasospasm w/ benzo, nitrates, and then aspirin.
24. FFP increase factors by 3-6%. There is 5x more citrate in FFP than pRBC. Remember that citrate also chelates Mag as well
30. Neurofibromas can be in the airway. Be very careful of anyone who complains of airway obstruction or dyspnea when lying flat. Do fiberoptiuc.
31. Zenkers pt can regurg their food and you should ask them to do so before intubation...
32: SLE take azathioprine an immunosuppressive and it increases resistance to NMB. Cyclophosphamide prolongs effect of sux. Also chronic inflammation can cause subglottic stenosis, vocal cord paralysis, and other airway problems. Use LMA if possible to avoid post-extubation airway obstruction from edema. SLE also has atlantoaxial subluxatoin
337. Hemophilia A and B increases PTT. Replace with factor VIII. Normal concentration of VIII or 100% activity is 1U/ml. Plasma volume is weight x 40ml/kg.
12. pt with GBS develop SIADH 50% of the time. Hypotension is also common as well as dysautonomia presenting as sinus tachycardia or bradydysrhythmias. However, treatment of tachycardia causes profound brady so don't do it unless CAD. EKG shows giant T waves, prolonged QT, U waves, ST-T wave changes.
13. Risks for PA endobronchial puncture include: female, mitral stenosis, PAH, >60 years, coagulopathy, hyperinflation of balloon and distal placement of PAC.
14. Lithotripsy, esp 1st generation machines, can cause ventricular dysrhythmias. Fire the machine during ventricular refractoriness (right after R) to avoid this.
18. Methylene blue blocks MAO so don't give it with SSRI
24. Treat cocaine induced coronary vasospasm w/ benzo, nitrates, and then aspirin.
24. FFP increase factors by 3-6%. There is 5x more citrate in FFP than pRBC. Remember that citrate also chelates Mag as well
30. Neurofibromas can be in the airway. Be very careful of anyone who complains of airway obstruction or dyspnea when lying flat. Do fiberoptiuc.
31. Zenkers pt can regurg their food and you should ask them to do so before intubation...
32: SLE take azathioprine an immunosuppressive and it increases resistance to NMB. Cyclophosphamide prolongs effect of sux. Also chronic inflammation can cause subglottic stenosis, vocal cord paralysis, and other airway problems. Use LMA if possible to avoid post-extubation airway obstruction from edema. SLE also has atlantoaxial subluxatoin
337. Hemophilia A and B increases PTT. Replace with factor VIII. Normal concentration of VIII or 100% activity is 1U/ml. Plasma volume is weight x 40ml/kg.
Thursday, July 10, 2014
7/10 ACE 2010 7A
Occupational exposure to ionizing radiation is mostly from x-rays scattering
Obese and Lungs:
decrease in FRC and ERV (by 60% if BMI increases by 10). Decreases in FEV1, TLC as well. Increase in work of breathing and closing capacity.
Post herpetic neuralgia - usually pain before rash. Give acyclovir class 72 hours after rash starts for reduction in rash duration and pain. Controversial data on whether acyclovir actually decreases post-herpetic neuralgia. Initial rash also treated with prednisone which decreases pain. For PHN, capsaicin is only drug approved by FDA, which depletes substance P.
WTF. Preoperative opioid consumption increase postop painbut also experienced increased respiratory depression in case-control studies.
Careful with interscalene block if pt cannot handle phrenic nerve blockade. It can also cause horner syndrome which consists of ipsilateral ptosis, hyperemia of conjunctiva, and nasal congestion. It can also block recurrent laryngeal nerve and vertebral artery injection.
Celiac block results in blockade of the sympathetic efferents (leaving unopposed parasympathetic) and pain afferents from stomach to splenic flexure of large intestine (including kidneys, adrenals). Adverse affects include diarrhea and hypotension from venous pooling in the gut.
Protamine can cause transient decrease in platelet count and function
2,3-DPG does not degrade in banked blood. It actually does not get produced by offsite branch of glycolysis. So when blood is cold, 2,3-DPG is 0. After returning to normal temp, 2.3-DPG increases back to normal levels at 48 hours. It is 50% at 7 hours in.
Magnesium is effective in overriding ventricular dysrhythmias such as torsad de pointes. Local anesthetics and NMB are potentiated by magnesium. It causes hypotension and in decrease in contractility following rapid transfusion.
Hypoxemia during OLV. Right sided thoracotomy predicts greatest amount of hypoxemia 2/2 size of 3 lobes vs the 2 lobes of the left. Obstructive dz actually improves hypoxemia 2/2 intrinsic PEEP. Pneumonectomies are usually associated with better oxygenation than wedge resections.
Autonomic dysreflexia T6 - hypertension, flushing, sweating above the transection (unopposed parasympathetic) and below the transection, cool pale vasoconstricted skin with piloerection.
- cath the pt if not cathed
- check and unkink the catheter if already in
- check fecal impaction if catheter is fine
- most commonly used antihypertensive meds are nifedipine and nitrates
- spinals and epidurals blunt AD
Metoclopramide increases gastric motility but not colonic motility. It also increases tone of lower esophageal sphincter and relaxes pylorus and duodenal bulb. It does not affect pH at all.
Pheochromocytoma is contraindication to ECT, pregnant is relative contraindication
ASD causes atrial dysrhythmias more than ventricualr ones. You get increased pulm blood flow and possibly PAH, RV overload, and CHF. Closure of ASD in a patient with severe pulm hypertension may result in acute right sided heart failure 2/2 reduction in right sided preload. This may require a heart-lung transplant to fix. Transient reversal can cause paradoxical emboli.
52. HPV is triggered by alveolar hypoxemia from 100mmHg to maximum of 30 mmHg.
Things that impair HPV:
- inhaled anesthetics and NO
- reduced/increased blood flow in OLV
- alkalosis and hypocapnia
- enhanced by hypercapnia and acidosis (as in atelectasis)
- vasodilators
Pectus excavatum is associated with RVOT obstruction and MVP and MR.
Haldane and Bohr both pretain to CO2 and its affects on hemoglobin. Haldane is in your lungs: oxy hemo loses CO2 more rapidly. Bohr is increased CO2 makes loss of O2 easy.
57. Acute herpes use narcotics, gabapentin, lidocaine patch, antivirals, glucocorticoids, but not capsaicin.
59. AFLP most likely happens in 3rd trimester. Associated with long chain 3hydroxyacyl coenzyme A dehydrogenase deficiency in the fetus. Coexists with preeclampsia and HELLP. Jaundice, malaise, n/v, abd pain, and fever w/ long PTT, depressed antithrombin III and high LFTs. Hhpoglycemia, DIC, renal failure, and liver failure are all possible. Treat with supportive care and expeditious delivery.
64. Hemophilia A is deficiency of factor VIII. It ranges from mild (6-30%) to severe (<1% activity). In normal situations, pts should receive recombinant factor VIII to reach activity level of >3%. For surgery, recommended perioperative 100% activity before proceeding with surgery. Continue for 10-14 days.
You can give neuraxial if activity greater than 50%.
If pt has antibodies vs factor VIII, you can give factor VIIa.
Argatroban has HL of 45 min
70.
Early goal directed therapy for treatment of septic shock
CVP 8-12
Hgb > 10
MAP of 65-90
SvO2 >70%
Obese and Lungs:
decrease in FRC and ERV (by 60% if BMI increases by 10). Decreases in FEV1, TLC as well. Increase in work of breathing and closing capacity.
Post herpetic neuralgia - usually pain before rash. Give acyclovir class 72 hours after rash starts for reduction in rash duration and pain. Controversial data on whether acyclovir actually decreases post-herpetic neuralgia. Initial rash also treated with prednisone which decreases pain. For PHN, capsaicin is only drug approved by FDA, which depletes substance P.
WTF. Preoperative opioid consumption increase postop painbut also experienced increased respiratory depression in case-control studies.
Careful with interscalene block if pt cannot handle phrenic nerve blockade. It can also cause horner syndrome which consists of ipsilateral ptosis, hyperemia of conjunctiva, and nasal congestion. It can also block recurrent laryngeal nerve and vertebral artery injection.
Celiac block results in blockade of the sympathetic efferents (leaving unopposed parasympathetic) and pain afferents from stomach to splenic flexure of large intestine (including kidneys, adrenals). Adverse affects include diarrhea and hypotension from venous pooling in the gut.
Protamine can cause transient decrease in platelet count and function
2,3-DPG does not degrade in banked blood. It actually does not get produced by offsite branch of glycolysis. So when blood is cold, 2,3-DPG is 0. After returning to normal temp, 2.3-DPG increases back to normal levels at 48 hours. It is 50% at 7 hours in.
Magnesium is effective in overriding ventricular dysrhythmias such as torsad de pointes. Local anesthetics and NMB are potentiated by magnesium. It causes hypotension and in decrease in contractility following rapid transfusion.
Hypoxemia during OLV. Right sided thoracotomy predicts greatest amount of hypoxemia 2/2 size of 3 lobes vs the 2 lobes of the left. Obstructive dz actually improves hypoxemia 2/2 intrinsic PEEP. Pneumonectomies are usually associated with better oxygenation than wedge resections.
Autonomic dysreflexia T6 - hypertension, flushing, sweating above the transection (unopposed parasympathetic) and below the transection, cool pale vasoconstricted skin with piloerection.
- cath the pt if not cathed
- check and unkink the catheter if already in
- check fecal impaction if catheter is fine
- most commonly used antihypertensive meds are nifedipine and nitrates
- spinals and epidurals blunt AD
Metoclopramide increases gastric motility but not colonic motility. It also increases tone of lower esophageal sphincter and relaxes pylorus and duodenal bulb. It does not affect pH at all.
Pheochromocytoma is contraindication to ECT, pregnant is relative contraindication
ASD causes atrial dysrhythmias more than ventricualr ones. You get increased pulm blood flow and possibly PAH, RV overload, and CHF. Closure of ASD in a patient with severe pulm hypertension may result in acute right sided heart failure 2/2 reduction in right sided preload. This may require a heart-lung transplant to fix. Transient reversal can cause paradoxical emboli.
52. HPV is triggered by alveolar hypoxemia from 100mmHg to maximum of 30 mmHg.
Things that impair HPV:
- inhaled anesthetics and NO
- reduced/increased blood flow in OLV
- alkalosis and hypocapnia
- enhanced by hypercapnia and acidosis (as in atelectasis)
- vasodilators
Pectus excavatum is associated with RVOT obstruction and MVP and MR.
Haldane and Bohr both pretain to CO2 and its affects on hemoglobin. Haldane is in your lungs: oxy hemo loses CO2 more rapidly. Bohr is increased CO2 makes loss of O2 easy.
57. Acute herpes use narcotics, gabapentin, lidocaine patch, antivirals, glucocorticoids, but not capsaicin.
59. AFLP most likely happens in 3rd trimester. Associated with long chain 3hydroxyacyl coenzyme A dehydrogenase deficiency in the fetus. Coexists with preeclampsia and HELLP. Jaundice, malaise, n/v, abd pain, and fever w/ long PTT, depressed antithrombin III and high LFTs. Hhpoglycemia, DIC, renal failure, and liver failure are all possible. Treat with supportive care and expeditious delivery.
64. Hemophilia A is deficiency of factor VIII. It ranges from mild (6-30%) to severe (<1% activity). In normal situations, pts should receive recombinant factor VIII to reach activity level of >3%. For surgery, recommended perioperative 100% activity before proceeding with surgery. Continue for 10-14 days.
You can give neuraxial if activity greater than 50%.
If pt has antibodies vs factor VIII, you can give factor VIIa.
Argatroban has HL of 45 min
70.
Early goal directed therapy for treatment of septic shock
CVP 8-12
Hgb > 10
MAP of 65-90
SvO2 >70%
Monday, July 7, 2014
7/5 ACE 2013 10B
4. Aldrete vs PADSS (Post anesthesia discharge scoring system)
Aldrete - Consciousness, BP, SPO2, Respiration, Activity (>9)
PADSS - N/V, pain, bleeding, activity, circulation, voiding? (>9)
7. Compazine or prochlorperazine is a dopamine blocker like metoclompramide
Phenergan or promethazine is a histamine blocker with dopamine antagonist effects
41. Even though neuraxial to high thoracic does not affect C3-5 of the phrenic nerve, it does affect expiratory effort. Thus, expect that tidal volume, RR, MV does not change. However, expiratory reserve volume, peak expiratory flow, and vital capacity are decreased.
45: Respiratory factors in pregnancy: lower FRC from uterus. Progesterone has opposite effects than opioids in terms of CO2 response and ventilatory drive so women breath deeper. Progesterone is also a bronchodilator so dead space increases by 45%.
46: Foot drop after partuition is often 2/2 lumbosacral stretching from lithotomy position. Injury of the lateral femoral cutaneous nerve results in meralgia paresthetica and presents with sensory deficits in the anterolateral thigh. Obturator injury means no adduction of leg and decreased sensation to medial side of leg.
54: Umbilical arterial blood goes from fetal->mother so it reflects fetal respiration. Average values
PaO2 20-30, PaCO2 50-55, pH 7.2-7.3, bicarb 22-25. pH below 7.0 and base deficit of 12 should be considered definitive evidence of intrapartum asphyxia.
fetal scalp blood pH of more than 7.25 is normal, <7.2 means emergent c-section.
55. Stable monomorphic regular VT can be treated with adenosine now!
67. Laryngoscopy w/ intubation requries higher MAC than surgical incision
Extubation criteria
RR <35
Vital capacity > 10ml/kg
NIF > -20
Tidal Volume > 5ml/kg
MV < 10L/,min
Thoracic compliance > 25ml/cmH20
Diaphragm is the most resistant to paralyzation, reason unclear.
Orbicularis oculi approximates pharyngeal muscle blockade
Distal extremities (adductor pollicis) /abd muscles recovered the slowest from blockade
Aldrete - Consciousness, BP, SPO2, Respiration, Activity (>9)
PADSS - N/V, pain, bleeding, activity, circulation, voiding? (>9)
7. Compazine or prochlorperazine is a dopamine blocker like metoclompramide
Phenergan or promethazine is a histamine blocker with dopamine antagonist effects
41. Even though neuraxial to high thoracic does not affect C3-5 of the phrenic nerve, it does affect expiratory effort. Thus, expect that tidal volume, RR, MV does not change. However, expiratory reserve volume, peak expiratory flow, and vital capacity are decreased.
45: Respiratory factors in pregnancy: lower FRC from uterus. Progesterone has opposite effects than opioids in terms of CO2 response and ventilatory drive so women breath deeper. Progesterone is also a bronchodilator so dead space increases by 45%.
46: Foot drop after partuition is often 2/2 lumbosacral stretching from lithotomy position. Injury of the lateral femoral cutaneous nerve results in meralgia paresthetica and presents with sensory deficits in the anterolateral thigh. Obturator injury means no adduction of leg and decreased sensation to medial side of leg.
54: Umbilical arterial blood goes from fetal->mother so it reflects fetal respiration. Average values
PaO2 20-30, PaCO2 50-55, pH 7.2-7.3, bicarb 22-25. pH below 7.0 and base deficit of 12 should be considered definitive evidence of intrapartum asphyxia.
fetal scalp blood pH of more than 7.25 is normal, <7.2 means emergent c-section.
55. Stable monomorphic regular VT can be treated with adenosine now!
67. Laryngoscopy w/ intubation requries higher MAC than surgical incision
Extubation criteria
RR <35
Vital capacity > 10ml/kg
NIF > -20
Tidal Volume > 5ml/kg
MV < 10L/,min
Thoracic compliance > 25ml/cmH20
Diaphragm is the most resistant to paralyzation, reason unclear.
Orbicularis oculi approximates pharyngeal muscle blockade
Distal extremities (adductor pollicis) /abd muscles recovered the slowest from blockade
Sunday, July 6, 2014
7/6 ACE 2011 8B x
9. Delayed clamping of umbilical cord in preterm babies decreases risk of intraventicular hemorrhage. Sequelae IVH can result in life-long neurological deficits, specifically cerebral palsy, developmental delay, and seizures. PVH-IVH is diagnosed primarily through the use of brain imaging studies, usually cranial ultrasonography. Two major factors that contribute to the development of PVH-IVH are loss of cerebral autoregulation and abrupt alterations in cerebral blood flow and pressure. Incidence of PVH-IVH in infants of very low birth weight (< 1500 g) or infants of less than 35 weeks' gestation has been reported to be as high as 50%. most hemorrhages occur when the neonate is younger than 72 hours, with 50% of hemorrhages occurring on the first day of life. Presents with A sudden unexplained drop in hematocrit levels, Possible physical findings related to anemia (eg, pallor, poor perfusion) or hemorrhagic shock, A sudden and significant deterioration associated with anemia, metabolic acidosis, glucose instability, respiratory acidosis, apnea, hypotonia, and stupor is present. Treatment include Correction of anemia, acidosis, and hypotension, as well as ventilatory support, might be required in those neonates who present with acute deterioration. Serial lumbar puncture, although once used to prevent progressive hydrocephalus, is not indicated. Because most patients with hydrocephalus following PVH-IVH demonstrate spontaneous resolution within weeks of onset, surgical intervention is usually unnecessary. Ventriculoperitoneal and ventriculosubgaleal shunting remain the definitive treatments for posthemorrhagic hydrocephalus requiring surgical intervention.
12. Signs of bladder perf after TURB: hypotension, bradycardia, dilution of plasma from irrigation, restlessness, diaphoresis, hiccups. Spinal should be T9-10 as below may be uncomfortable and above may mask signs.
13. Newborn HR is 120. 1 month gold HR is 160. By 12 months, BP should be 90/60
Leukocyte reduction reduces alloimmunization, CMV infections, platelet transfusion refractoriness, nonhemolytic febrile reduction.
23. CO2 absorbers problems
Compound A - sevoflurane degrades in CO2 absorber (not liver) with baralyme rather than soda lime, low flow rather than high flow, higher temperature and fresher absorbent. Not shown to have clinical affect in humans.
CO is formed with degradation of all volatiles in CO2 absorber. Desflurane > en > iso >> sevo = halothane. More than dry baralyme in higher temp and lower gas flows. Happens mondays.
Fires with sevoflurane more likely with dry baralyme and soda lyme, first case of the day.
25. The statins inhibit p450, which can affect degradation of lidocaine. Also tumescent liposuction is due with SQ injection of very dilute lidocaine (.1%) up to 35-55mg/kg. Peak levels at 8 hrs.
26. Misoprostol associated with high risk of uterine rupture during VBAC
38. SIADH vs cerebral salt wasting:
SIADH
Serum [Na+] (mmol/L): 128
Serum Osmolality (mOsm): 270
Urine [Na+] (mmol/L): 40
Central Venous Pressure (mm Hg): 12
CSW (volume contraction)
Serum [Na+] (mmol/L): 128
Serum Osmolality (mOsm): 270
Urine [Na+] (mmol/L): 40
Central Venous Pressure (mm Hg): 4
44. Neonates have high chest wall compliance so they have increased work of breathing to push and pull their chest wall.
51. 2,3-DPG is decreased in preserved blood products
52. Refeeding syndrome causes hypokalemia, hypophos, hypoglycemia, hypomagnesemia
55. femoral nerve block vs PCA for knee arthroplasty - reduces morphine consumption, reduces pain scores with activity but not at rest. Does not reduce urinary retention.
63. Superficial cervical block for entarterectomy is better in all ways to deep cervical block except higher chance of Horner syndrome.
64. After aspiration, suction intubate and then bronch
76. Insulin requirements in pregnancy decrease in first trimester and increase in 2nd and 3rd. Mother experience great decrease in requirements after giving birth. Diabetics have bigger babies, more premature babies, more birth defects. Neonates are at risk for hypoglycemia.
Myotonic dystrophy causes muscle rigidity with succinylcholine. In advanced cases, it can cause hyperkalemia.
80. Burn victims have increased metabolic demand, third spacing, vascular permeability throughout their body and low output renal failure from prerenal. However they have decrease CO! Also keep body temp at 38.5!
81. Parkland formula is 4ml*kg*%burned.
82. LSD: include elevated temperature, hypertension, tachycardia, mydriasis, agitation, anxiety, increased production of saliva, hyperreflexia, hyperglycemia, and increased wakefulness.
85. Pulm HTN: Prevent and aggressively treat hypotension, Phenylephrine, vasopressin, and norepinephrine are recommended to treat hypotension, Maintain adequate preload and cardiac contractility, Prevent hypoxia, hypercapnia, acidosis.
continue drug therapy directed at decreasing PAP: prostacyclin (epoprostenol, treprostinil, iloprost), endothelin receptor antagonists (bosentan), phosphodiesterase-5 (sildenafil). Give CCB in pts response to vasodilators. Consider nitric oxide.
88. Acute Liver Failure mortality major cause is cerebral edema and increase in ICP. Pt do not have time to develop varices, hepatopulnonary syndrome. Tylenol causes metabolic acidosis. Possible renal failure and ARDS.
89. During the reperfusion phase of liver transplant, ICP can have fatal elevations. Dysrhythmias and hypotension can lead to cardiac arrest. Pulm HTN may worsen.
90. Inhalers: need to increase albuterol dose when intubated because it ahdheres to tracheal tubes. LMA decreases airway resistance than tracheal intubation. Propofol with metabisulfite causes increase in airway resistance than calcium edetate.
95. Airway laser/fire. All plastic tubes including red rubber and silicone are flammable. PVC is most, silicone is least. Cuff needs to be filled with water and double cuffed and metal tubes are better. Jet venitlation is most effective way to prevent airway fire as it avoids tracheal tube which is flmmable material. Risks of jet ventilation: barotrauma, pneumothorax, subcutaneous emphysema, and gastric distention.
12. Signs of bladder perf after TURB: hypotension, bradycardia, dilution of plasma from irrigation, restlessness, diaphoresis, hiccups. Spinal should be T9-10 as below may be uncomfortable and above may mask signs.
13. Newborn HR is 120. 1 month gold HR is 160. By 12 months, BP should be 90/60
Leukocyte reduction reduces alloimmunization, CMV infections, platelet transfusion refractoriness, nonhemolytic febrile reduction.
23. CO2 absorbers problems
Compound A - sevoflurane degrades in CO2 absorber (not liver) with baralyme rather than soda lime, low flow rather than high flow, higher temperature and fresher absorbent. Not shown to have clinical affect in humans.
CO is formed with degradation of all volatiles in CO2 absorber. Desflurane > en > iso >> sevo = halothane. More than dry baralyme in higher temp and lower gas flows. Happens mondays.
Fires with sevoflurane more likely with dry baralyme and soda lyme, first case of the day.
25. The statins inhibit p450, which can affect degradation of lidocaine. Also tumescent liposuction is due with SQ injection of very dilute lidocaine (.1%) up to 35-55mg/kg. Peak levels at 8 hrs.
26. Misoprostol associated with high risk of uterine rupture during VBAC
38. SIADH vs cerebral salt wasting:
SIADH
Serum [Na+] (mmol/L): 128
Serum Osmolality (mOsm): 270
Urine [Na+] (mmol/L): 40
Central Venous Pressure (mm Hg): 12
CSW (volume contraction)
Serum [Na+] (mmol/L): 128
Serum Osmolality (mOsm): 270
Urine [Na+] (mmol/L): 40
Central Venous Pressure (mm Hg): 4
44. Neonates have high chest wall compliance so they have increased work of breathing to push and pull their chest wall.
51. 2,3-DPG is decreased in preserved blood products
52. Refeeding syndrome causes hypokalemia, hypophos, hypoglycemia, hypomagnesemia
55. femoral nerve block vs PCA for knee arthroplasty - reduces morphine consumption, reduces pain scores with activity but not at rest. Does not reduce urinary retention.
63. Superficial cervical block for entarterectomy is better in all ways to deep cervical block except higher chance of Horner syndrome.
64. After aspiration, suction intubate and then bronch
76. Insulin requirements in pregnancy decrease in first trimester and increase in 2nd and 3rd. Mother experience great decrease in requirements after giving birth. Diabetics have bigger babies, more premature babies, more birth defects. Neonates are at risk for hypoglycemia.
Myotonic dystrophy causes muscle rigidity with succinylcholine. In advanced cases, it can cause hyperkalemia.
80. Burn victims have increased metabolic demand, third spacing, vascular permeability throughout their body and low output renal failure from prerenal. However they have decrease CO! Also keep body temp at 38.5!
81. Parkland formula is 4ml*kg*%burned.
82. LSD: include elevated temperature, hypertension, tachycardia, mydriasis, agitation, anxiety, increased production of saliva, hyperreflexia, hyperglycemia, and increased wakefulness.
85. Pulm HTN: Prevent and aggressively treat hypotension, Phenylephrine, vasopressin, and norepinephrine are recommended to treat hypotension, Maintain adequate preload and cardiac contractility, Prevent hypoxia, hypercapnia, acidosis.
continue drug therapy directed at decreasing PAP: prostacyclin (epoprostenol, treprostinil, iloprost), endothelin receptor antagonists (bosentan), phosphodiesterase-5 (sildenafil). Give CCB in pts response to vasodilators. Consider nitric oxide.
88. Acute Liver Failure mortality major cause is cerebral edema and increase in ICP. Pt do not have time to develop varices, hepatopulnonary syndrome. Tylenol causes metabolic acidosis. Possible renal failure and ARDS.
89. During the reperfusion phase of liver transplant, ICP can have fatal elevations. Dysrhythmias and hypotension can lead to cardiac arrest. Pulm HTN may worsen.
90. Inhalers: need to increase albuterol dose when intubated because it ahdheres to tracheal tubes. LMA decreases airway resistance than tracheal intubation. Propofol with metabisulfite causes increase in airway resistance than calcium edetate.
95. Airway laser/fire. All plastic tubes including red rubber and silicone are flammable. PVC is most, silicone is least. Cuff needs to be filled with water and double cuffed and metal tubes are better. Jet venitlation is most effective way to prevent airway fire as it avoids tracheal tube which is flmmable material. Risks of jet ventilation: barotrauma, pneumothorax, subcutaneous emphysema, and gastric distention.
Saturday, July 5, 2014
7/3 ACE 2008 5A bx
If you can ventilate but cannot intubate a pregnant woman who is going for emergent c-section and the fetal VS are bad, then just continue mask ventilation while maintaining cricoid pressure. Do not do nasal intubation as pregnant women have friable nasal mucosa and may bleed. LMA or combitube is tempting but may cause aspiration in this event.
Mallampati score increases with pregnant and correlates with difficulty of intubation in pregnant women.
Ketorolac is relative contraindication to asthma.
Allergies in OR: 1. NMS, 2. Latex, 3. Abx
Corneal abrasion is NOT treated w/ patching. There is little to no evidence for abx or mydriatic drugs. There is great evidence for treatment of pain with NSAIDS.
Mallampati score increases with pregnant and correlates with difficulty of intubation in pregnant women.
Ketorolac is relative contraindication to asthma.
Allergies in OR: 1. NMS, 2. Latex, 3. Abx
Corneal abrasion is NOT treated w/ patching. There is little to no evidence for abx or mydriatic drugs. There is great evidence for treatment of pain with NSAIDS.
Tuesday, July 1, 2014
7/1/14 - ACE questions 2008 5A bx
Helium has low density, which does 2 things. One, it lowers the reynold's number is more air travels laminar instead of turbulent. Two, it increases turbulent flow but doesn't work in the small airways where laminar flow predominates. It also decreases the work of breathing.
APGAR - appearance, pulse, grimace, activity, respiration
Myotonic dystrophy - muscles still contract after NMB and regional technique. Exaggerated responses to sux. Causes AV conduction problems.
Cerebral vasospasm after SAH - most common 1 week after SAH not 3 days. More likely with severity of SAH. Nimodipine not nifedipine is drug of choice. HHH therapy should be started after cerebral vasospasm occurs.
Apnea in neonates
Risk factors: decreased postconceptional age, decreased gestational age, hx of apnea, presence of anemia
Management: regional, avoiding opioids, longer term monitoring
Postop management: stimulate the baby, metylxanthine (caffieine, theophylline), CPAP, correction of underlying metabolic diorders, PPV
Avoid: Prostaglandin E1 which is used in ductal-dependent CHD but is associated with development of apnea
Herbal Medication
Garlic, ginseng, and ginkgo biloba inhibits platets (3G)
Ginseng also associated with hypoglycemia
St. John's wort is a MAOI, p450 inducer, decrease cyclosporin levels
Kava, Valerian are both GABA agonists and potentiate sedative medication
Antibiotic prophylaxis for
- prosthetic valve, prior IE, heart transplant w/ valvulopathy, partially fixed CHD
- for dental procedures, bronch biopsies, infected skin or tissue
- not for colonoscopy, bronch w/o biopsy, vaginal delivery, hysterectomy.
give ampicillin or ancef not gent or vanc
APGAR - appearance, pulse, grimace, activity, respiration
Myotonic dystrophy - muscles still contract after NMB and regional technique. Exaggerated responses to sux. Causes AV conduction problems.
Cerebral vasospasm after SAH - most common 1 week after SAH not 3 days. More likely with severity of SAH. Nimodipine not nifedipine is drug of choice. HHH therapy should be started after cerebral vasospasm occurs.
Apnea in neonates
Risk factors: decreased postconceptional age, decreased gestational age, hx of apnea, presence of anemia
Management: regional, avoiding opioids, longer term monitoring
Postop management: stimulate the baby, metylxanthine (caffieine, theophylline), CPAP, correction of underlying metabolic diorders, PPV
Avoid: Prostaglandin E1 which is used in ductal-dependent CHD but is associated with development of apnea
Herbal Medication
Garlic, ginseng, and ginkgo biloba inhibits platets (3G)
Ginseng also associated with hypoglycemia
St. John's wort is a MAOI, p450 inducer, decrease cyclosporin levels
Kava, Valerian are both GABA agonists and potentiate sedative medication
Antibiotic prophylaxis for
- prosthetic valve, prior IE, heart transplant w/ valvulopathy, partially fixed CHD
- for dental procedures, bronch biopsies, infected skin or tissue
- not for colonoscopy, bronch w/o biopsy, vaginal delivery, hysterectomy.
give ampicillin or ancef not gent or vanc
One lung ventilation
Open pneumothorax
Lateral decubitus
One-lung ventilation
- Awake
- Paradoxical respirations and mediastinal shift as air enters the pleural cavity
- Anesthetized
- PP ventilation reverses the above 2 effects
Lateral decubitus
- Awake
- Ventilation is matched to perfusion because the lower hemidiaphragm is more efficient in contraction + lower lung is more compliant
- Anesthetized
- VQ mismatch as the reduction in FRC moves lower lung lower down the compliance curve
One-lung ventilation
- Intrapulmonary shunt is decreased by HPV
- HPV is inhibited by abnormal PA pressures, abnormal venous pO2, hypocapnia, PNA, drugs: vasodilators, beta blockers, PDE-I, CCB, volatiles
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