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Paul's ITE Review/Notes
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         PAUL’S ANESTHESIOLOGY ITE REVIEW | 

Clinical Signs of General Anesthesia

  1. State of sedation → patient is calm and easily arousable, with the eyes generally closed
  2. May enter a state of paradoxical excitation → purposeless or defensive movements, incoherent speech
  3. Irregular respiratory pattern → Loss of response to oral commands + loss of skeletal muscle tone → apnea
  4. Oculocephalic, eyelash, and corneal reflexes are lost, but the pupillary eye reflex remains
  1. Phase 1: Return of spontaneous respiration
  2. Phase 2:
  1. Phase 3: Spontaneous eye opening + Response to oral commands

Succinylcholine-induced Myalgia and Fasciculation

Lateral Patient Position: Complications

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Shock Wave Lithotripsy

IV Contrast Agents

Blood Storage

Methemoglobinemia

Transient Neurologic Symptoms (TNS)

High Altitude Physiology

Pharmacokinetic Principles

Figures: Pharmacokinetics of opioids (above). Pharmacokinetics of inhaled anesthetics (below)

Fresh Frozen Plasma (FFP)

Electroconvulsive Therapy (ECT)

Fetal Heart Rate (FHR) Monitoring

  1. Baseline FHR 110-160
  2. Moderate (6-25 bpm) variability
  3. No late or variable decelerations
  4. Early decelerations may be present
  5. Accelerations may be present
  1. Sinusoidal pattern (abruption)
  2. Absent FHR variability with

Outcomes of Neuraxial Anesthesia

Neuromuscular Blockade Physiology

Smoking Cessation

EEG-based Monitors

Carcinoid Syndrome

Retrobulbar Blockade

Fenoldopam

Biostatistics: Statistical Tests

Variable type →

Discrete

Continuous

Survival (events)

Ordinal (rank)

Single Variable

Chi-Square or Fisher’s Exact (n<10)

t-test

Kaplan-Meier Analysis

Mann-Whitney U test

Multivariable

Logistic Regression

ANOVA

Cox Proportional Hazard Analysis

Kruskal-Wallis

Axillary Block

        

Crystalloids: Composition

Fluid

Na

K

Cl

Ca

Mg

HCO3

Lac

Acetate

Gluconate

Glucose

Osm

Notes

pH

Plasma

140

5

100

4.4

2

24

1

285

SID 42

7.4

NS

154

154

308

SID 0

6

D5

50

252

4.5

LR

130

4

109

3

28

273

6.5

D5LR

130

4

109

3

28

50

525

5

Plasma-Lyte

140

5

98

3

27

23

294

4-6.5

Lambert-Eaton Myasthenic Syndrome (LEMS)

MG

LEMS

Affected muscles

Extraocular, bulbar, facial

Proximal limbs (legs > arms)

Response to repetition

Worsens weakness

Improves weakness

Gender

Females > Males (autoimmune)

Males > Females

Co-existing pathology

Thymoma

Small cell lung carcinoma

Response to succinylcholine

Resistant

Sensitive

Response to nondepolarizing NMBAs

Sensitive

Sensitive

Response to anticholinesterases

Good

Poor

Bronchial Blocker

Airway Exam

Airway Innervation

Postpartum Hemorrhage

Scopolamine for PONV Prophylaxis

Neuropathic Pain

Diuretics

Pediatric PONV

Epidural: Paramedian Approach

Nitrous Oxide

Periodic Paralysis Syndromes

Cardiopulmonary Changes in Pregnancy

Hematological Changes in Pregnancy

Anesthetic Management of the Brain-Dead Organ Donor

Neuromuscular Blocking Drugs (NMBD): Drug Interactions

Near Drowning Resuscitation

Hypoxic Pulmonary Vasoconstriction (HPV)

Acromegaly

Myasthenia Gravis (MG)

Tumescent Anesthesia

Amiodarone

QT Prolongation

Laser Surgery Considerations

Mandibular Hypoplasia

Emergence Excitement

Hepatic Blood Flow Regulation

Organophosphate Poisoning

AV Node Perfusion

Porphyria

Vasopressin

Electrolyte Abnormalities: ECG Changes

Mixed Venous Oxygen Saturation (SvO2)

Note: COHb will cause ↓S⊽O2 only if CO-oximetry is used to get a true Hgb value

Pseudocholinesterase (PChE)

Substance Use Disorder (SUD) Among Anesthesiology Residents

Drugs that act at the NMDA receptor

Varying Sensitivity of Different Muscle Groups to NMBA

ACGME Core Competencies

Cricoid Pressure

Dynamic Markers of Volume Status

MRI Safety

Bronchopulmonary Dysplasia (BPD)

Laryngomalacia and Bronchomalacia

Laryngeal Musculature

NMJ AChR Upregulation

Pediatric Perioperative Fluid Management

Neuraxial Anesthesia: Gastrointestinal Effects

Herbal Medications: Perioperative Concerns

Cardiac Reflexes

Epoprostenol

Contrast-Induced Nephropathy (CIN)

Opioids: Pruritus

Preoperative Cardiac Evaluation Guideline (2014)

NIM EMG Endotracheal Tube

Note: These images are for the Medtronic NIM TriVantage ETT

Preoperative Potassium Levels

Stress Hyperglycemia

Postoperative Jaundice

Post-Cardiac Transplant Patient

PONV Guidelines (2014)

Malignant Hyperthermia (MH)

Cardiac Output Measurement: Thermodilution

Glasgow Coma Scale (GCS)

Sympathetic Cardiac Innervation

Double-Lumen Tubes

Frank-Starling Curves

  1. Pure inotrope or inotrope with vasoconstriction (e.g. norepinephrine, epinephrine)
  2. Inotrope + vasodilator (e.g. milrinone)
  3. Vasodilator (e.g. nicardipine, hydralazine)
  4. Inotrope + vasodilator + diuretic
  5. Diuretic

EEG Frequencies

Infections and Blood Transfusions

Cervical Spine Stabilization

AHA/ACC Surgery Classification

Arterial Blood Pressure Monitoring Waveforms

As you go more peripheral → increased reflected waves from branch points in the arterial tree → higher peaks in both the systolic and diastolic pressure curves

Dicrotic notch: aorta is highly elastic and recoils once the aortic valve closes → further propelling forward flow → seen as the dicrotic notch (red arrows)

Brachial artery cannulation complications:

Axillary artery cannulation

Intraoperative Radiation Exposure

  1. Total radiation exposure time → cumulative (recommended < 5000 mrem/yr)
  2. Total radiation exposure intensity → chest x-ray = 5-10 mrem; CT = 5000 mrem
  3. Distance from source → Intensity ∝ 1/distance2 ⇒ double distance → 1/4th radiation intensity

Spinal Anesthesia Spread

Uterine Defects and Rupture

NMBA in Pediatrics

Uterine Relaxation

Labor Stages

Preeclampsia

Neuraxial Anesthesia for Labor and Delivery

Sub-Ambient Pressure Alarm

APGAR score

0

1

2

Appearance

Cyanotic

Acrocyanotic (pink chest, cyanotic extremities)

Pink

Pulse

Absent

<100 bpm

>100 bpm

Grimace (reflex irritability)

No response to stimulation

Grimace and/or feeble cry when stimulated

Active, strong response to stimulation (cough/sneeze)

Activity (tone) 

Absent, limp

Some extremity flexion

Active movement

Respirations 

Absent

Weak, irregular, slow, shallow, or gasping

Strong, regular, crying

Chloroprocaine

Acute Epiglottitis - Airway Management

Flow-Volume Loops

Epinephrine in Obstetric Neuraxial Anesthesia

Neuraxial α2-agonists

Cryoprecipitate

Spinal Cord Stimulation

Robot-Assisted Gynecological/Prostate Surgery

Conn’s Syndrome

Hypoplastic Left Heart Syndrome

  1. Lungs for oxygenation
  2. Systemic/coronary circulation via PDA

Herpes and Pregnancy

Placental Abruption

Pulmonary Vascular Resistance

Lateral Femoral Cutaneous Nerve (LFCN)

Anesthesia for Cerclage Placement

Dexmedetomidine

Receptor

ɑ2A

ɑ2B

ɑ2C

Effects

Presynaptic inhibition of norepinephrine release, sedation, hypotension, anticonvulsant

Analgesia, hypertension - seen initially with bolus dose

Inhibition of adrenal catecholamine release, analgesia

Ex utero intrapartum treatment (EXIT) surgery

Alcohol

 Inhalational Agents: Neuropharmacology

Postoperative Acute Renal Failure

Aortic Stenosis

  1. Maximal aortic jet (peak) velocity: > 4 m/s
  1. Measured by continuous wave doppler (CWD) of LVOT → velocity time integral (VTI) and Bernoulli equation of spectral tracings → final value
  1. Mean aortic valve gradient: > 40 mmHg
  2. Aortic valve area: < 1.0 cm2
  1. Derived from three variables: LVOT VTI, LVOT diameter and aortic valve VT

CNS Monitoring During Carotid Endarterectomy

Pulmonary Artery Catheterization

Compartment Syndrome

PCI and Antiplatelet Therapy (2016 ACC/AHA Update)

Growth Hormone (GH)

CIED (Cardiovascular Implantable Electronic Device) and Electrocautery

Gas Cylinders

Gas

Oxygen

N2O

CO2

Air

Helium

Cylinder color

Green*

Blue

Gray

Yellow

Brown

Physical state in cylinder

Gas

Liquid and gas

Liquid and gas

Gas

Gas

Cylinder contents (L)

625

1590

1590

625

500

Cylinder weight empty (kg)

5.9

5.9

5.9

5.9

Cylinder weight full (kg)

6.76

8.8

8.9

 

Cylinder pressure full (psi)

2000

750

838

1800

1600

*USA only; Rest of the world: oxygen tank = white

Methanol Poisoning

Bier Block aka Intravenous Regional Anesthesia

  1. Tourniquet ischemia → impaired nerve conduction → provides analgesia by itself
  2. Local anesthetic → improves onset and density of tourniquet block by two mechanisms:
  1. Vascular diffusion from veins → capillaries → vasa nervosa of peripheral nerves
  2. Extravascular diffusion to nerves supplying the skin

Transfusion Therapy and Warming

Ischemic Optic Neuropathy (ION)