Things to Review for the Final
100 questions @ 1.5 min per question
1. Know the drug doses
2. Which induction causes more hypotension
a. Precedex
b. Propofol
3. Major contraindications to induction drugs
a. Etomidate causes seizures
b. Ketamine causes HTN, tachycardia, increased ICP
c. Versed in AIDS patients on _____________ drugs
d. Propofol allergy to eggs or soy
e. Pt refusal
4. Which causes more hypotension – a huge dose will always supersede things
5. Remember fluid and blood transfusion – review Morgan and Mckail
a. Estimated blood volume = weight x type
i. Preemie 95
ii. Baby 85
iii. Children 80
iv. Male 75
v. Female65 ml/kg
b. Allowable blood loss = EBV x (Preop Hct – Acceptable Hct)
 Preop Hct
c. Adult Hourly Rate = weight in kg + 40 (for people above 20kg)
d. Baby Hourly Rate = (first 10 kg x 4) + (second 10 kg x 2) + ( 1cc/kg/hr for remaining
weight)
e. Surgery Replacement
i. Small incision/minimal Trauma = 2-4cc/kg/hr
ii. Moderate Incision/Moderate Trauma = 4-6 cc/kg/hr
iii. Large Incision/Severe Trauma = 6-8cc/kg/hr
iv. Major Vascular/Extreme Trauma = 10 cc/kg/hr
6. Mapleson systems
a. All Open Systems
b. For controlled ventilation systems
i. Dead Bodies Cannot Argue (D>B>C>A)
c. For Spontaneous Ventilation efficiency
i. All Dogs Can Bite (A>D>C>B)
d. Prevent Recreating of CO2 by increasing the FGF (there is no soda lime)
7. Anesthesia machine flowmeters (Thorpe tube)
a. Left side is the ml side
b. Right side is measured in L
c. Knobs for the air, O2 and No2 all feel different
d. Oxygen is always downstream and closest to the manifold, on the right
8.
9.
10.
11.
e. O2 is pneumatically or mechanically linked to other gasses so it cannot be set below
25%
Calculations for understanding how much O2 is left in an O2 cylinder
a.
Calculate amount needed for a trip based on minute vent if mechanically vented
a. Time to exhaustion = Remaining O2 volume
 Rate of Oxygen consumption
b. Remaining Volume in the O2 cylinder = amt in psig
x 660 L
 2200 psig
c. O2 consumption in mech vent = flowmeter rate + minute vent (answer in L)
d. When calculating the flowmeter rate, if given that the pt is on 2L total per minute, with
that being made up of 0.5 L/min O2 and 1.5L/min NO2, do NOT count the NO2 in the
flowmeter rate – it is there to confuse you
How much nitrous is left in a tank – you cannot tell is the answer. The tank will read 745 psig
until greater than 75% is gone
OR humidity – 50-60% decrease static electricity, dust, & microbial growth
12. Contents of Soda Lime
Soda Lime
Mesh size: a compromise
4-8
between absorptive capacity and
resistance to airflow
Method of hardness
Silica added
-minimize dust formation
Contents
Sodium Hydroxide 4%
Potassium Hydroxide 1%
Baralyme
4-8
Bound water of crystalization
Calcium Hydroxide 80%
Barium Hydroxide 20%
Calcium Hydroxide 95%
Indicator Dye
Ethyl Violet
Ethyl Violet
Absorptive Capacty
14-23
9-18
(L of CO2/100g granules)
13. What does Reglan do – increase motility, does not change gastric ph, decreases upward
pressure on the esophageal sphincter
14. Know your major things about herbal meds – ie bleeding, blood sugars
a. Garlic – inhibits platelet aggregation
b. Ginkgo (Ginkgo Bioloba) – inhibits platelet activation factor
c. Echinacea – prolongs bleeding time
d. Ginseng – inhibits platelet aggregation factor& can cause hypoglycemia in diabetics
e. Saw Palmetto – inhibition of cyclooxygenase leading to increased risk of bleeding
f. Vitamin E – may increase bleeding
15. Doses for local anesthetics with and without epic
a. Esters
Esters
Novocaine/
procaine
Nesacaine/
Chloroprocaine
Pontocaine/
tetracaine
Cocaine
Max dose
12 mg/kg
Duration
30-60 min
Max dose c Epi
Duration c Epi
30-90
12 mg/kg
30-60 min
14 mg/kg
30-90
3mg/kg
90min – 6hrs
3 mg/kg
30-60 min
b. Amide
Amide
Lidocaine/
xylocaine
Mepivicaine/
carbocaine
Ropivicaine
Bupivicaine/
marcaine
Etidocaine/
duranest 1%
Max dose
4 mg/kg
Duration
30-120 min
Max dose c Epi
7mg/kg
Duration c Epi
120-360
4 mg/kg
45-90 min
7mg/kg
120-360
3 mg/kg
2.5 mg/kg
90-240 min
120-240 min
3.2 mg/kg
180-420
6mg/kg
120-180 min
8mg/kg
180-420
16. Know pka
a. pKa is defined as the pH at which the specific drug is 50% ionized and 50% unionized
b. The lower the pKa the faster it works (it is more unionized)
17. MH – most earliest most sensitive sign – increased end title CO2
18. Dibucaine numbers – numbers and definitions
a. Dibucaine is a local anesthetic that will inhibit normal plasma cholinesterase by 80%
b. What the percent inhibited is the number (ie 40% = 40)
c. Numbers mean
i. 80 is normal
ii. 40-60 is heterozygous atypical enzyme – prolonged block
iii. 20 – homozygous atypical enzyme – really long block
19. Benzolisoquilinies – characteristics
a. D-tubo curare, Mivacurium, & Atricurium
b. Cause histamine release
20. Steroid derivates – characteristics
a. Pancuronium, pipcuroniun, Rocuronium, Vecuronium
b. Vagolytic – cause increased HR,
21. NMB – non depolizers & depolizers
a. Depolarizer – Six
b. Non depolarizers are Benzolisoquilines and Steroid Derivates
22. CVP tracing
a. Normal waveform consists of three peaks (a, c, v waves) and two descents (x, y)
b. A wave: R atrial contraction: occurs just after the P wave on the ECG.
i. Absent in afib; may be exaggerated with junctional rhythms
c. C wave: occurs due to isovolumic ventricular contraction forcing the tricuspid valve to
bulge upward into the right atrium.
d. V wave: reflects venous return against closed tricuspid valve: large v waves with
tricuspid regurgitation
23. High, intermediate, low pressures in machine – where are they – ONLY high pressure is from the
hanger yoke valve and cylinder – intermediate is from everything in between 16-75 includes O2
flush valve, Low is valve on inside of flow meter to the common gas outlet
24. What happens if you fill the high vapor pressure container with a liquid with a lower vapor
pressure?
a. LHL, HLH, low out of high is low
b. High out of low is high
25. Vapor pressures – know them
a. Des 681
b. Halo 243
c. Iso 240
d. Sevo 160
26. Fa, Fi look at graph in inhaled anesthetic factor
a. Fa is the amount in your lungs
b. Fi is the amount in the circuit
c. Increased ventilation accelerates Fa/Fi
d. Increased cardiac output slows Fa/Fi
e. A high blood gas solubility slows Fa/Fi
27. Blood gas solubility coefficients
a. Des 0.45
b. No2 0.47
c. Sevo 0.65
d. Iso 1.4
e. Enflurane 1.8
f. Halo 2.5
28. ASTM (American Society for Testing and Materials) – mandates the minimum safe anesthesia
machine checks
29. Allen test before A-line
30. Evoked Potentials – know them
a. SSEP’s: somatosensory evoked potentials (dorsal)
i. Stimulate peripheral nerve
ii. Record evoked potential over spinal cord or brain
b. TAA’s, A/P fusions, Harrington rods, complex back surgeries
c. BAEP’s: Brainstem auditory EP’s:
i. Reflect impulses along auditory pathway
ii. MOST RESISTANT to effects of anesthesia
iii. Posterior fossa crani’s; acoustic neuromas; CN VIII
d. VEP’s: Visual EP’s:
i. Measure cerebral response to flashing light
ii. Surgery near optic nerve; pituitary tumor resections
e. MEP’s: motor evoked potentials (ventral)
i. Detect motor function of spinal cord
ii. MOST SENSITIVE to effects of anesthesia
iii. TAA; spinal surgeries
f. Volatile anesthetics effect all EP’s by decreasing amplitude and prolonging latency
31. No pulse ox info, how it works, what effects it
a. Light emitting diodes with 2 wavelengths of light transmitted through tissue
b. Infrared light OxyHgb
c. Red light DeoxyHgb
d. MethHgb (~85%) – absorbs both wave lengths the same
e. CarboxyHgb (false high elevated) - absorbs more infrared light
f. Beer-Lamberts Law and principles of spectrophotometry
i. relates the concentration of a solute to the intensity of light transmitted
through a solution.
32. Level of blockade with spinal or epidural
a. STPTPMVP
i. Sympathetic
ii. Temp
iii. Pain
iv. Touch
v. Pressure
vi. Motor
vii. Vibration
viii. Proprioception
b. Motor is two below Sensory block
c. Sympathetic is two above Sensory block
33. Major contraindication to regional anesthesia
34.
35.
36.
37.
38.
39.
40.
41.
42.
a. When you really need a genera
b. Refusal
c. bleeding to death
d. Atrial Stenosis
Calc for ETT for kid
a. (Age/4) + 4 for over the age of two
b. Newborns: 3 - 3.5
c. Newborn to 12 months: 3.5 – 4.0
d. 12 to 18 months: 4.0
Blood types
a. Type A has A antigens on cell and B antibodies in the plasma
b. Type B has B antigens on cell and A antibodies
c. Type AB has A & B antigens and no antibodies
d. Type O has no antigens and A&B antibodies
Upper pressure limit for providing positive pressure vent for non intubated (20-25)
Where does MAC blade go – Vallecula – base of tongue and glottis opening
Where do you provide cricoid pressure – on the cricoid – why the cricoid – it is the only
complete ring
What are the signs of a difficult airway –
a. short neck
b. short thyromental distance
c. hx of difficult intubation
d. AO extension problem <35 degrees
e. bad teeth
f. big tongue
g. small chin
h. Mallampati score
Simple EKG questions – a few, different parts of the heart, the leads
a. II, III, AVF look at the inferior part of the heart & RCA
b. V1-V4 look at the left anterior & LAD
c. V1 &v2 look at the septal
d. I, AVL, V5, V6 (lateral leads) look at the lateral part of the heart and the LCA
e. Can see reciprocical changes in I & AVL if problems with the Right Coronary, Posterior
Artery or Circumflex
With a chronic HTN pt, do not give a drug to lower BP – bottom line is that the body are used to
a high perfusion pressure and even more so if uncontrolled, typical pressure is 50-150, when
htn, auto regulation curve is shifted to the right – therefore the lower level of what the body is
used to is higher 80-180 – if you drop below that you will compromise the blood flow to vital
organs – worse with uncontrolled very sensitive and will fluctuate both ways. Looking for
something that will be gentle to them (maybe Ettomidate) – ideally cancel the case and
medically manage the pt Shift to the RIGHT & used to a higher MEAN PRESSURE
Do not pretreat a MH pt with Dantrolene
43. Venous air embolism S&S
a. Caused by open venous system above level of the heart
b. Atmospheric pressure > venous pressure and vein sucks air in
c. Air>pulm clearance^pulm pressuresdecr CO r/t increased right ventricular afterload
d. Detection by listening to heart sounds with doppler at R 2nd intercostal space
e. A sudden decrease in CO2, decr. Sats, arrhytmias, decr. BP and a millwheel murmur
f. It is more common in a pt breathing on their own
44. Anticholinergic syndrome
a. Develops in response to high doses of atropine and scopolamine
b. S/S
i. CNS:
1. Restlessness, shivering, mania, hallucinations, delirium, drowsiness,
agitation, disorientation
ii. Peripheral:
1. Blurred vision, dry mouth, tachycardia, dry flushed skin, hypotension,
rash on face, neck and upper chest
45. Cholinergic crisis S&S
a. Excessive use of cholinesterase inhibitors or organic insecticides
i. Excessive acetylcholine peripherally and or centrally
b. Signs/Symptoms
i. Miosis, salivation, bronchoconstriction, bradycardia, abd. Cramping
ii. Weakness
c. CNS: dysphoria, confusion, seizures, coma
46. Hypothermia is bad!!
47. Trigger agents for MH – volatile inhale agents and suxx
48. Sensory blockade is the one you can most subjectively test
49. T6 is the most subjected to sensory test – sympathetic is at T4 (2 above) Motor is T8 (2below)
50. Opoiod receptor – know these
a. Mu one
i. Urinary retention
ii. Miosis
iii. Euphoria
iv. supraspinal, spinal, brain analgesia
b. Mu 2
i. Resp depression
ii. Spinal analgesia
iii. Physical dependence
iv. Constipation
v. Bradycardia
c. Kappa
i. Analgesia of spinal and supraspinal
ii. Sedation
51.
52.
53.
54.
55.
56.
57.
58.
iii. dysphoria
d. Delta
i. Spinal mostly and supraspinal analgesia
ii. Some Resp depression
iii. Physical dependence
Anterior posterior structures you go through for a spinal – skin, sub q, supraspinous, intra
spiunus, ligimentam flavum, epidural space, DAP (post – anterior)
Furthest you want to go is the arachnoid space (post to arachnoid anterior to pia)
Mallampati classifications
a. I – Can see everything (Cam’s dream girl)
b. II – Cannot see all of the uvula
c. III – stops at the stop pallet
d. IV – hard palate only
Characteristics of the local anesthetics – lipid solubility, protein binding
a. Higher lipid solubility leads to quicker onset
b. Unionized crosses faster than ionized
c. Protein binding correlates with duration of action – more protein bound longer the
duration of action
d. Locals anesthetics bind to A1A glycoprotein’s
Which leads can have a physiologic q wave – 1, AVL, V6 (normal q wave)
Contraindication to suxx
a. Dibucaine below 80
b. Hx of MH
c. High K
d. Traumas
e. Burns after the first 24 hrs
f. Stroke, MS, GB (proliferation of neuroreceptors)
Nerve stimulator characteristic - what is normal or not for a depolizer or non depolizer
a. Will NOT See a post titanic facilitation with Suxx
b. Which has a post tetanic facilitation – nondepolarizer
c. Gold standard is a double burst
d. 4/4 is a 75% block
e. ¼ is a 90% block
f. Diaphragm can move with a 95% block
g. No fade with depolizer
h. Fade with non depolizer
Physiologic effects of spinal anesthesia – what is expected – separate from a complication,
expect a drop in BP (why preload with fluid), nausea caused by low BP, see tachycardia first –
are reflex response to vasodilatation, will see bradycardia if cardiac fibers are numbed above T1.
Do NOT expect to see cardiac arrest, post puncture headache, infection, paralysis – loose
preload from loss of venous tone, venodilation causing decreased BP, arteries will maintain
more tone then veins
59. Know anatomy of vertebrae
a. Cervical 7 vertebre & 8 dermatomes
b. Thoracic 12
c. Lumbar 5
d. Sacral 5
e. Coccygeal 4
60. Local anesthetics are weak bases
61. Capnogram waveform
a. Evaluates CO2
i. Pulmonary and metabolic status of pt.
b. Capnometry - The measure of CO2
c. Capnogram - Plotting of CO2 over time
d. Capnometer - Instrument used to measure
e. 4 phases
f. I - Inspiration (no CO2; breathing in O2)
g. II - Expiratory upstroke (beginning to exhale)
h. III - Expiratory plateau (static period; no air movement)
i. IV - Inspiratory downstroke (fresh gas entrained; CO2 washed away)
j. If shape leaned over
i. Having trouble blowing out CO2
ii. COPD; kink, foreign body obstruction, emphysema
k. Stair stepping” form
i. Cardiac oscillations; changes with each heartbeat
l. V-form in middle of wave
i. “Curare cleft” rebreathing
m. Gradual downstroke
i. Inspiratory problem
ii. Kinked ETT obstruction
n. Waveform small and gradually decr. to zero
i. Esophageal intubation
o. A-B: A near zero baseline—Exhalation of CO2-free gas contained in dead space.
B-C: Rapid, sharp rise—Exhalation of mixed dead space and alveolar gas.
C-D: Alveolar plateau—Exhalation of mostly alveolar gas.
D: End-tidal value— Peak CO2 concentration—normally at the end of exhalation.
D-E: Rapid, sharp downstroke—Inhalation
p.
62. What is the normal lab work for diabetic pre op –
a. blood sugar
b. BUN and creatine
c. EKG
d. K+
e. Hgb A1C
63. What is esmolol – short acting Beta 1 blocker (metabolized by tissue esterase)
64. Questions from preop lecture – direct from the slides