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)
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%
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