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**2 most common causes of hypoxemia in the PACU?  which is the most common?
hypoventilation
*decreased FRC: intrpulmonary right ot left shunting (loss of lung volume most likely due to micoatelectasis): most common
**3 problems that may delay awakening from anesthesia
  • prolonged action of drugs
  • metabolic causes: hypo/hyperglycemia, sodium, potassium, calcium disturbances
  • neurologic injury
**2 most common reasons for delayed discharge from ambulatory or office-based surgery facility?
excessive postop pain
n/v
what Aldrete score is required for discharge from PACU
8,9,10
5 cirteria: activity, circulation, respoiration, consciousness, and oxygenation
absolute contraindicaiton to mediastinoscopy?
previous mediastinoscopy
if right radial aline pressure is lost during a medistinoscopy, what is happening?
compression of right subclavian, inonimate, or brachiocephalic artery
where should BP cuff go during a mediastinoscopy?  why?
left arm, to detect hemmorhage (most common complication)
3 most common complications of mediastinoscopy
  • hemorrhage
  • pnuemothorax
  • recurrent laryngeal nerve damage
2 greatest risk factors predictive of morbidity in pt undergoing carotid endarterectomy
smoking
HTN
hyperglycemia is least tolerated with which of the following conditions: chronic renal insufficiency, malignant hyperthermia, thoracic aneurysm, carotid occlusion
carotid occlusion.  elevated blood glucose levels cause more severe lactic acidosis to develop and worsen ischemic brain injury
what is stump pressure
pressure measure in th ecarotid artery distal to the clamp during carotid endarterectomy.  reflects pressure through the circle of willis
signifies adequate (>60) or inadequate (<60mmHg) perfusion
where should PaCO2 be kept during a carotid endarterectomy
normocarbia (35-45); avoid hypocapnia induced vasoconstriction
during carotid endarterctomy, pt becomes bradycardic with labile BP?  what should you do?
probably due to durgical baroreceptor stimulation; surgeon can anesthetize these recetpors with lidocaine
what is first choice in treating hypertension during a carotid endarterectomy?
nitroprusside
also, labetalol or hydralazine
**in preparation for aortic or carotid cross-clamping, how much heparin should be given?
5000unite IV
list 3 causes of postop respiratory depression after carotid endarterectomy
  • bilateral laryngeal nerve injruy
  • massive hematoma
  • deficient carotid body function: this will prevent the pt from increaseing ventilation in response to a decresae in PaO2
following abdominal cross clamping, what CV changes are seen above the clamp
↑SVR, EDV, ESV, MAP
↓EF and CO
what are the CV issues when the cross-clamp is released?
"washout" of local tissue mediators and metaboic products (esp. lactate), decreased SVR and Decreased venous return
significant hypotension is possible
what things can be done prior to unclamping to prevent hypotension
decrease volatiles
stop vasodilators
adequate fluid management
communicate with surgical team
whne the clamp is removed after AAA repair, would you increase or decresae minute ventilation
incerase minute ventilation: hypocarbia will cause vasocinstriction causing blood to be diverted to tissues close to the clamp (ischemic areas); Robin Hood effect
A pt is undergoing surgery that involves clamping of the thoracic aorta.  what is the major complication of clamping the thoracic aorta?
spinal cord ischemia and paraplegia
classic defecit is anterior spinal artery syndrome: loss of motor function and pinpick sensation, rectal or urinary incontinence, and loss of temperature sensation but preservation of proprioception and vibration
where does the artery of adamkiewitz originate?
enters the vertebral canal from the left side of the lower throacic region (it is not bilateral)
major blood supply to lower two thirds of spinal cord
Describe the 3 types of Debakey's aortic dissections
type I: originates in ascending aorta and extends forward or backward(70% are this type)
Type II: orignate in ascending aorta dn is confined to ascending arota
type III: originate in descedning aorta
during posterior fossa surgery, bradycardia and hypertension suddenly occur.  why
trigeminal nerve is being stimulated: Cushing's reflex
during posterior fossa surgery, bradycardia and hypotension suddenly occur.  why?
glossopharyngeal or vagus nerve are stimulated
what is the concern if the pt is having a resection of a posterior fossa tumor located in the floor of the fourth ventricle?
damage to the respiratory centers could necessitate mechanical ventilation postop
also, manipulation in this area can cause slow wake up, swallow and gag reflexes may be impaired
common complication after a transphenoidal or transcranial removal of tumor
diabetes insipidus
what is the standard regimen for treating cerebral vasopspasm
triple H therapy: hypertension, hemodilution, hypervolemia
nimodipine (ca channel blocker)
what agents are BEST for inducing  a pt with an intracranial aneurysm
barbiturates, benzos, etomidate, propofol, and a nondepolarizing NMB
anesthetic goals for intracranial anuerysm
  • "slack" brain
  • maintain cerebral perfusion pressure; transmural perssure = MAP-ICP
  • avoid aneurysm rupture
**what is the most important anesthetic goal in intracranial anuerysm?
maintain or decrease prefusion pressure and transmural aneurysm pressure
transmural pressure=MAP-ICP, so a ↑in MAP or a ↓in ICP will increase transmural pressure and cause rupture of aneurysm
which volatiel is favored for deliberate hypotesion
Isoflurane: enhances the effects fo hypotensive agents, blunts stress-response evoked by deliberate hypotension, and does not increse pulmonary shunting
what 2 neurosurgical procedures might require use deliberate hypotension
aneurysm repair and brain tumor resection
is decreasing cerebral perfusion pressure during neurosurgery an effective way of reducing CBF and "slacking" the brain?
No, b/c CBF remains constant when map is 50-150 mmHg
hyperventiliation is much more effective
when using deliberate hypotension what happens to the blood flow to ischemic and nonischemic regions fo the brain?
this decrease in blood pressure cause cerebral blood vessels to vasodilate (decrease blood flow to the ischemic area).  ths is intracerebral steal syndrome/luxury perfusion
list 5 pulmonary function changes associated with a pneumoperitoneum
  • decreased FRC
  • Decreased vital capacity
  • increased Peak inspirtaory pressures
  • increased intrapleural pressure
  • decreased respiratory system compliance
what electrolyte disturbances are expecte duringa whipple?
hypokalemia, hypocalcemia, hypomagnesemia, hypochloremia
metabolic alkalosis
what organs are involved in a whipple
pancreas, liver, jejunum, duodenum, ans stomach
what phase of a lap chole is the pt at highest risk for a serious complication?
during the initial establishment of penumoperitoneum (insufflation)
risk for CO2 embolism and hemorrhage
how would a CO2 embolus during laparoscopic surgery produce a decrease in end tidal CO2
decreases CO and increase physiologic dead space
there is an initial increase in ETCO2 from pulmonary excretion of absorbed CO2, then will decrease due to reasons above
7 signs of TURP syndrome
  • respiratory distress
  • cyanosis
  • hypertension
  • hypotension
  • widened QRS
  • dysrhythmias
  • bradycardia
**what is central pontine myelinolysis (CPM)
potential complication of TURP, orthoptic liver transpantation and head injury
it results form too rapid treatment of hyponatremia
Hyponatremia should be corrected gradually
demyelinating lesions develop at the base of the pons: locked in syndrome results and quadriplegia
**65 yo pt having TURP with a spinal suddenly develops n/v and abdominal pain.  what happened
perforated bladder
**what is cause of coagulopathies developed during TURP
  • dilutional thrompcytopenia from large volume of irrigation fluid
  • DIC: caused by relese of tissue thromboplastin or urokinase plsminogen activator form the prostate
**7Hematologi/renal signs TURP syndrome
  • hemolysis
  • acute renal failure
  • hyponatremia
  • hypoosmolarity
  • hyperglycinemia
  • hyperammonemia
  • coma
**what is strabismus?
misalignment of visual axes
most frequent eye condition requireing surgical repair
Esophoric:one eye is turned inward
Exophoric: one eye is turned outward
Esotropic: both eyes turned inward
**4 anesthetic concerns in pt undergoing strabismus repair
  • malignant hyperthermia: pt may have myopathy and be prone to MH (avoid succs)
  • CV affects of ocular meds
  • oculocardiac reflex (CN V and X)
  • PONV is very common (avoid opioids)
3 ECG manifestations of the oculocardiac reflex
  • bradycardia
  • junctional rhythm
  • PVCs
** what are the 3 desired efect of a retrobulbar block
3A's
Akinesia of the eyes (absence of eye movement)
Abolish the oculocardiac reflex (although it can stimulate of block it)
Anesthesia of the eye
can a pt recieve a total spinal from a retrobulbar block?
yes, accidental access to the CSF via perforation of the meningeal sheaths that surround the optic nerve
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