Dr. Martin Review
Terms in this set (100)
Glucuronidation 50-70%, cod-6-gluc
N demethylation 10-15%, norcodeine
O-demethylation 0-15%, morphine via Cyt p450 CYP2D6 (the way we activate it!)
5-10% ultra-rapid metabolizers are at increased risk of reps depression
5% will not get ANY analgesia
Alzheimer's dementia and opioids
Best opioid to give to avoid ACh s/s?
Lack of ACh
Can Tx w/ AChE inhibitors (donepazil, rivastigmine)
Get brady with Sux
Resistant to NDMBs
Most opioids have antiCh properties
What rec enhance gastric emptying?
Cancer pt can't tolerate PO meds and is allergic to fentanyl. BEST option for chronic pain?
Partial Mu agonist
(3 days to work)
Could have w/d s/s if on opioids already
IV, SL, and transdermal forms
NOT tapentadol bc it is ORAL only
Pt w/ DM2 on exenatide comes for o/p surgery. What is your concern?
Exenatide (Byetta) - incretin analog
↑Insulin sec with oral carb load
***Delays gastric emptying (AE)
Treatment of Methemoglobinemia
Helps Fe3 go back to Fe2 so it can pick up O2 in lungs and drop off in tissues effectively
chocolate brown blood
85-88% O2 sat
What else do you need with prolonged QT syndrome to result in TDP/dysrhythmia?
What common PACU drug is responsible?
Prolonged QT + dispersion of repolarization
Avoid Rx: Zofran (others: anti-5HT3, ephedrine, NE, quinidine, moxi, droperidol, emycin, sevo)
HypoK --> TDP
CAD, Bradycardia, stress
Does lithium effect MAC?
Any risk to taking meperidine with lithium?
What do you need to know about taking benzos and barbs with Lithium?
Answer: Decreased MAC of sevoflurane
Increased sensitivity to volatiles
Lithium causes weakness
Lithium blocks DA, NE, EPI in brainstem
Prolong action of DMBs & NDMBs
Increased risk of NMS & EPS in combo with droperidol or haldol
YES - you risk serotonin syndrome
Prolonged action when taken together
Relationship between proposal and hepatic blood flow?
Propofol clearance exceeds hepatic blood flow.
1st hr 10 min
Every hr after add 5 minutes
ex. 8 hrs = 10 + 35 = 45min
Clearance exceeds hepatic blood flow (bc it is metabolized in other places)
* Plasma ChE
Post-T&A pedi pt with OSA gets Tylenol#3. What is most-likely to occur?
Answer: Respiratory Depression/hypoxia
Mu-rec are up-regulated in OSA (inc sensitivity to opioids) --> risk of desat
ALSO If ultra-metabolizer, could have resp dep
How to fix: Reduce opiate dose by 50%
What are the blood:gas partition coefficient for each gas?
Which has the greatest uptake in liver?
ISO - greatest uptake in liver
slower for FA/FI to reach 1/slower onset
*Bile, only 10% renal
Pt wearing fentanyl patch for the last 2 months. How long does a fentanyl last after removal?
Toxicity associated with infusion:
Risks for TDP
**Methadone >60mg/d at risk (NMDA rec (-), SNRI)
Human ether a go go related gene
liver dz, CAD, CHF
Pt with h/o heart transplant for femur frx ORIF. What agents are most likely to cause changes in HR?
*Dobutamine works (direct)
Loss of vagal tone = slightly elevated HR
AntiCh, AntiChE = no effect
Pt with Severe AS for AVR gets induced with GA. BP goes to 70.48mmHg with HR of 65. What drug is best?
Pt on SSRI, what drug can + serotonin syndrome?
- Methylene blue
- indico carmine
- Diatrizoate (Renografin)
- Indocyanine green
Others: St. Johns wart
Drugs that don't cross the placenta?
HE Is Going Nowhere Soon
Heparin, Enoxaparin, Insulin, Glyco, NDNMB, Sux,
DON'T CROSS IF: Big, charged, not lipophilic
What metabolite causes reparatory depression?
Morphine - 6 - g
Which gas is similar to ketamine?
N2O (NMDA antagonism)
Least likely to to cause hepatic injury 2/2 to fluorinated metabolites?
(others get metal to fluoride byproducts)
Meds capable of causing burst suppression?
Opiods do not
All others do
HCTZ action site
Hepatic clearance of which drug is most influenced by hepatic blood flow?
Hepatic CL = Liver BF x extraction ration
High extraction (close to 1): Rely on hepatic BF
Propofol, opioids, lidocaine
Mid: Versed, alfent, vec
Low: Benzos, Roc
(low ERs are more effected by cirrhosis bc they are more dependent on intrinsic liver function)
Similar dosing in elderly and young pt?
Neostigmine (use same dose, avoid recurarization)
Reduce etomidate by 50%
Reduce midaz by ~75%
Reduce Fentanyl by 50%
Old people has dec TBW, inc fat, dec proteins, dec hepatic metab
Inc brain sensitivity to meds
Herbal med that interferes with PLT fxn?
Ginger(inh agg), Ginko (36hrs, inh PAF), Garlic (7 days),
Green tea (-PLT agg), Ginseng (-PLT agg)
Saw palmetto (-COX) - can inc bleeding
ASA recommends stopping all herbals 2 weeks prior
Old man gets EPS side effects s/p haldol. What drug? Benedryl not an answer.
What egg allergy is a a relative CI to propofol?
Previous anaphylactis to proposal
LR will likely effect which lab value?
Lower serum Na
Once daily lovenox dosing and an epidural. When can you remove catheter?
Best method to avoid absorption atelectasis on induction and tracheal intubation?
Using FiO2 equal to 0.50 (best method)
Encouraging coughing can increase atelectasis
What distinguishes MAC from mod sedation?
Qualifications of provider
change in behavior from prior experience
Implicit memory formation
Compared to a large volume of NS, LR would result in:
Increased serum bicarb
Lactate is --> bicarb
Normal SID ~40-42
What happens with large
- NaCl 30mg/kg/ml
Prilocaine safer than lidocaine at equipotent doses
Any tourniquet pressure cannot prevent toxicity
Don't use ropivacaine.
COPD pt in PACU gets delerious and desats
pH 7.15, PaCO2 80 mmHg, PaO2 120 mmHg
COPD pt have inc dead space
Cannot maintain work of breathing to normalize
Chronic hypoxia and hypercarbia
COPD+O2 in PACU = inc PaCO2 via 3 mechanisms:
1) Inc Dead space, supp O2 reverses HPV ==> shunt/DS
2) Haldane effect - Hb and CO2 binding
3) Reduction in hypoxic drive
Least likely assoc with POVL
What drug to avoid with MS?
Sux --> HyperK
Lady needs ORIF of fibular fracture. Which block?
WPW is at risk of what arrhythmia?
TEE Mitral Valve Prolapse on TEE (photo)
Aortic valve regurg on TEE photo
ICD & Pacer DDD (pacer dept @ 60bpm) pt going for
Answer: Off, DOO/60
(place pacer pads on pt)
Post-op device check
Lady with LVAD
absent radial a pulses
TEE photo of papillary muscle transgastric view correlates with what ECG lead
(inf leads II, III. aVF)
What does ECG show when central line is in right spot
LARGE and BIPHASIC P WAVE
What PFT is normal in ALS?
they are both decreased
Normal aging process in heart
decrease in maximal HR during exercise (decrease in B-rec responsiveness)
Flexion increases risk (tension on retinaculum)
Obesity & really skinny
Some hospitalized pts will get it (even if no surgery)
What will decrease PVR?
PVR = (MPAP-PAOP)/CO
Increase in CO will decrease PVR
Lateral arm sensory complaints. Nerve roots?
C1 nerve root comes out..
above the C1 vert
Pressure-Time Curve for a single vent cycle in mech ventilated pt in ICU. What is true about this curve?
Vasculopath pt getting shoulder surgery. BP 80 mmHg vertical distance from cuff to external auditory meatus is 36cm. Best approximation of MAP at the circle of willis?
For every 1 cm change, MAP changes 0.75 mmHg 3/4 of 36cm = 27 mmHg
Leak in sample line of capnograph
compare time required to perform tracheal intubation
pt with MVP going for la chole. HR is 90. Mangagement?
What to get a pre-op CXR?
Unstable cardac dz
Active respiratory infection
Pt presents for emergent lap apply with a h/o of uneventful posterior fossa crank the previous day. Which of the following would MOST likely be CI in this pt?
Administration of N2O
Pt likely has some pneumocephalus from prior crani
In sitting position, brain settles, CSF drainage + gravity --> negative pressure
Air entrains in nearly ALL CRANIS!!!
Takes 9 wks tfor air to absorb
Pt with SAH. BEST test (highest sensitivity & specificity)?
Cardiac troponin I -- good correlation with myocardial injury and poor outcomes in SAH when levels are high
BEST monitor for CEA for detecting regional cerebral ischemia?
EEG is Gold Standard
Using neurophysiologic monitoring for scoliosis surgery. What is most true?
The Tc-MEP is minimally affected by anesthetic agents
Most sensitive Visual> Motor>sensory
LEAST likely to cause neg pressure pulmonary edema
Re-Exansion of the collapsed lung
(need a gradient for flash plum edema to occur)
What happens to PaCO2 and etCO2 with a PE
Highest risk of venous gas embolism?
C-section (as high as 97%)
- most are asymptomatic
- cough or breathing difficulty
Central line (0.2 -15%)
Stereostatic brain biopsy
Treatment of MG crisis
Most common in acromegaly?
Clinical hypothyroidism undergoing emergency surgery. Post op cx.
glucose intolerance (usually DM2)
Pt with MG has respiratory distress and weakness. Difference bt cholinergic crisis and MG crisis.
MG gets better with edrophonium
CC gets better with atropine
Metabolic syndrome is associated with
Adult pt with myotonic dystrophy type 1.
Myotonic crisis is neostigmine is administered.
Type 1 - Steinert Dz (98% myotonic dz)
- muscle weakness, endocrine, cardiac dz, cataracts
- shivering can --> myotonic crisis (keep warm)
Which type of calcium is MOST effective in treatment of acute hyperkalemia?
If not an emergency, which is better?
Calcium gluconate (bc less risk of necrosis)
What is required for a sentinel event to occur according to the Joint Commission?
an unintended outcome
Most commonly abused drug amongst anesthesia residents/attendings?
Least likely to contribute to complications after tumescent liposuction?
Use of minimal sedation instead of GA
(GA can mask)
law for pulse ox
Answer was FFP
Tumescent ansesthesia for liposuction: How long does the LA last in system?
Clinical LA lasts up to 18hrs
Vasoconstriction with Epi
Lidocaine metabolized by CYP3A4, cause increase diazepam, sertraline, CCB, emycin
What does serotonin release assay check for?
Checks for IgG antibodies to PLT in patients with a history of HIT
-if negative then can get heparin for next surgery
- if positive then use liperudin/bivalrudin
Phantom pain syndrome
What is telescoping?
If lasts >6 months, often refractory to therapy
Can occur after mastectomy and eye enucleation
Risk of chronic pain high when pain present prior to surgical removal
- Mirror treatment
Perception of limb shortening
- Right > Left (smaller foramen ovale & rotundum --> entrapment)
- Usually V2 and V3 distribution (95%)
- Majority of pts get spontaneous resolution w/in 2 months
- 1/3 pts have single episode only
Lady with nasolabial fold pain and tooth pain.
Treatment of TGN
- metal by 3A4 - lowers its own levels
- Na-channel blocker
- Monitor ECG if
Separation anxiety starts at what age?
Describe normal neonatal apneic episodes and compare to central apnea
- occurs as result of stimulation of chemoreceptors in the fetus
- aortic arch/carotid
-delivery of hypoxic blood --> vagal stim
Post extubation croup associations
Age < 4
Recent h/o croup
Coughing on tube
6 yo brought to OR emergently following MVC. Most predictive of cardiovascular collapse?
HYPOTENSION (late finding)
OSA is associated with nocturnal enuresis. True or false.
Age >3 associated with increased risk of post-op cx from tonsillectomy in OSA kids. True or false.
28yo G1P0 36wks has HA
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