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Surgery Review 2

SR 2: Anesthesia, Fluids and Electrolytes, Nutrition, Oncology

Which inhalational agent has the quickest onset but also a high MAC (low potency)? Nitrous oxide
Which inhalational agent can cause seizures? Enflurane
Which inhalational agent is good for neurosurgery? Isoflurane
Which inhalational agent can cause hepatitis with symptoms of fever, jaundice, increased LFTs, and eosinophilia? Halothane hepatitis
What are the side effects of sodium thiopental? Decreased cerebral blood flow and metabolic rate, decreased blood pressure
When is propofol contraindicated? Patients with egg allergy
Which induction agent is contraindicated in patients with head injury? Ketamine
What are the effects of ketamine? increases cardiac work, O2 use, secretions, and BP; no respiratory distress; hallucinations possible
Which induction agent has few hemodynamic changes and is fast acting? Etomidate
Which muscle is the last to be affected and first to recover from paralytics? Diaphragm
What is the only depolarizing agent? Succinylcholine
When is succinylcholine contraindicated? Burn patients (hyperkalemia), neurosurgery, spinal cord injury, massive trauma, open angle glaucoma
What antibiotic prolongs neuromuscular blockade? Clindamycin
What is the first sign of malignant hyperthermia Increased end-tidal CO2
What is the treatment for malignant hyperthermia Dantrolene
What is the mechanism of malignant hyperthermia? Ca release from sarcoplasmic reticulum
Which paralytic is best used in patients with renal and liver failure? Cis-atracurium
Which paralytics undergoes Hoffman degradation? Cis-atracurium
What is the upper limit of lidocaine dosing? 0.5cc/kg of 1% lidocaine
What is the mechanism of local anesthetics? Increases action potential threshold, preventing Na influx
What are contraindications to adding epinephrine to local anesthetics? arrhythmias, unstable angina, uncontrolled hypertension, poor collaterals (penis and ear), or uteroplacental insufficiency
What are the effects of local anesthetic overdose? tremors, tinnitus, seizures, and arrhythmias (CNS symptoms occur before cardiac)
Which local anesthetics are more likely to have allergic reactions? Esters > Amides secondary to PABA analogue
What other drug contraindicates narcotic use? MAOIs – can cause hyperpyrexic coma
Which benzodiazepine is contraindicated in pregnancy? Versed – crosses placenta
What is the treatment of an overdose of benzodiazepines? flumazenil (competitive inhibitor, may cause seizures or arrhythmias)
What is a potential side effect of morphine used in epidural anesthesia? respiratory depression
What is a potential side effect of lidocaine used in epidural anesthesia? Hypotension and bradycardia
What is the treatment for acute hypotension and bradycardia in a patient with an epidural? Turn down epidural, fluids, phenylephrine, atropine
What is the treatment for a spinal headache? Rest, fluids, caffeine, analgesics; blood patch if symptoms persist >24 hours
What are the biggest risk factors for post-op MI? age >70, DM, previous MI, CHF, and unstable angina
What is the most common cause of a transient rise in ETCO2 in an intubated patient undergoing surgery? alveolar hypoventilation, usually due to decreased tidal volumes and resultant atelectasis
What is the most common cause of a sudden decrease in ETCO2 in an intubated patient undergoing surgery? Disconnection from ventilator, but may be pulmonary embolism or significant hypotension
What is the distribution of total body water? 2/3 intracellular, 1/3 extracellular (75% of extracellular is interstitial, 25% is intravascular)
What determines the plasma/interstitial compartment osmotic pressure? What determines the intracellular/extracellular osmotic pressure? Plasma = proteins; intra/extracellular = sodium
What gastric contents have the highest concentration of K? Saliva (20 meq) > gastric (10 meq) > pancreatic/duodenal (5 meq)
What is the first sign of volume overload? Weight gain
What is the concentration of ions in normal saline? Na 154 and Cl 154
What is the concentration of ions in LR? Na 130, K4, Cl 109, Ca 2.7, bicarb 28 (ionic composition of plasma)
How do you calculate plasma osmolarity? (2 x Na) + (glucose / 18) + (BUN / 2.8): normal = 280-295
What is the best indicator of adequate volume replacement? urine output
What are daily insensible fluid losses? 10 cc/kg/day, 75% skin, 25% respiratory; pure water
Why should maintenance fluids include 5% dextrose? Dextrose stimulates insulin release, resulting in amino acid uptake and protein synthesis (preventing protein catabolism)
What is the treatment for hyperkalemia? Calcium gluconate, sodium bicarbonate, kayexalate, 10U insulin + 1amp 50% dextrose, dialysis if refractory
What electrolyte abnormality causes restlessness, irritability, ataxia, and seizures? Hypernatremia
What is the consequence of correctly hyponatremia too quickly? Central pontine myelinosis (no more than 1mEq/hr)
What is the most common cause of hypercalcemic crisis? malignancy (breast most common)
What two electrolyte abnormalities can cause hyperexcitability (increased reflexes, tetany)? Hypocalcemia and hypomagnesemia
What is Chvostek’s sign? Tapping on face produces twitching – hypocalcemia
What is Trousseau’s sign? carpopedal spasm after application of blood pressure cuff – hypocalcemia
How does magnesium affect calcium? Low Mg inhibits PTH, so may need to replace Mg if trouble correcting calcium
What are the causes of anion gap acidosis? MUDPILES – methanol, uremia, DKA, paraldehydes, isoniazid, lactic acidosis, ethylene glycol, salicylates
How does metabolic alkalosis from loss of GI fluids cause paradoxical aciduria? Loss of Cl and H from stomach causes alkalosis but Na/H and K/H exchangers to reabsorb lost water and K – aciduria
What is the best test for azotemia? FeNa = (urine Na/Cr) / (plasma Na/Cr)
What is the best way to avoid renal damage from contrast dyes? volume expansion with fluids, HCO3, and N-acethylcysteine drips
What electrolytes abnormalities are seen with tumor lysis syndrome? Release of purines and pyrimidines leads to increased PO4 and uric acid, and decreased Ca; this can lead to increased BUN and Cr
What is the treatment of tumor lysis syndrome? Hydratio, allopurinol, diuretics, and alkalinization of urine
Describe vitamin D synthesis Made in skin (UV sunlight), goes to liver for (25-OH), then kidney for (1-OH), then active which leads to increased intestinal calcium absorption
What is the transporter of iron? What is the storage form of iron? Transporter = transferrin storage = ferritin
What are the kcal/g for fat, proteins, carbohydrates, and dextrose? Fat 9, protein 4, oral carbs 4, dextrose 3.4
What are the nutritional requirements for an average healthy adult male? 1g/kg protein, 30% of calories as fat, rest as carbohydrates
What is the maximum glucose administration in a central line for TPN? 3g/kg/hr
What is the major fuel for the colon? short chain fatty acids – butyric acid
What is the major fuel for the small bowel? glutamine
What is the major fuel for a neoplastic cell? glutamine
What causes a decrease in glutamine in the blood stream during stress? Glutamine goes to kidney to form ammonium to help acidosis
During starvation, what does the brain use for fuel? ketones from fatty acids (instead of glutamine)
What is the half life of the following: albumin, transferrin, and prealbumin? Albumin – 20 days, transferrin – 10 days, prealbumin – 2 days
What is the respiratory quotient? Ratio of CO2 produced to O2 consumed. RQ 0.7 = fat metabolism, RQ 1.0 = carbs, RQ 0.8 = protein
What does a RQ >1 indicate? RQ < 0.7? RQ >1 indicates overfeeding/lipogenesis; < 0.7 indicates fat oxidation (starvation)
What is the simplest amino acid precursor for gluconeogenesis? alanine
Where does gluconeogenesis occur during late starvation? kidney
What are obligate glucose users? peripheral nerves, adrenal medulla, RBCs, and WBCs
What compound does the brain utilize during starvation? ketones
What electrolyte abnormalities are seen in refeeding syndrome? Decreased K, PO4, and Mg – prevented by starting at a low rate
Feeding the gut early protects against potential infection by what mechanism? Bacterial translocation from bacterial overgrowth and increased permeability of starved enterocytes
How do you calculate nitrogen balance? N balance = N in – N out = (protein / 6.25) – (24 hr urine N + 4g)
What two amino acids is the majority of skeletal muscle broken down into? glutamine and alanine
Describe fat digestion Long chain: Micelles to enterocytes to chylomicrons to lymphatics (to jxn LIJ/SCV); medium and short chain are directly absorbed into portal system with aa's and carbs
What are the fat soluble vitamins? A, D, E, K
What is responsible for clearing chylomicrons and TAGs from the blood, breaking them down to fatty acids and glycerol? Lipoprotein lipase on liver endothelium
What is the most important route of entry to dietary cholesterol? VLDL
What is the preferred source of fuel for the liver and heart? fatty acids (ketones – acetoacetate, beta-hydroxybutyrate)
What are the essential fatty acids and why are they “essential”? linolenic and linoleic – needed for prostaglandin synthesis and important for immune cells
What are the essential amino acids? Branched chain amino acids – leucine, isoleucine, and valine (“LIV”)
What vitamin deficiency causes hyperglycemia (relative diabetes), encephalopathy, and neuropathy? chromium
What vitamin deficiency causes cardiomyopathy, weakness, and hair loss? selenium
What vitamin deficiency causes pancytopenia? copper
What vitamin deficiency causes hair loss, poor healing, change in taste, and a perioral rash? zinc
What vitamin deficiency causes weakness (failure to wean off ventilator), encephalopathy, and decreased phagocytosis? Phosphate
What vitamin deficiency causes Wernicke’s encephalopathy, cardiomyopathy, and peripheral neuropathy? Thiamine (B1)
What vitamin deficiency causes sideroblastic anemia, glossitis, and peripheral neuropathy? Pyridoxine (B6)
What vitamin deficiency causes megaloblastic anemia, peripheral neuropathy, and a beefy tongue? Cobalamine (B12)
What vitamin deficiency causes megaloblastic anemia and glossitis? Folate
What vitamin deficiency causes diarrhea, dermatitis, and dementia? Niacin (this triad is called Pellegra)
What vitamin deficiency causes dermatitis, hair loss, and thrombocytopenia? Essential fatty acids
What vitamin deficiency causes night blindness? Vitamin A
What vitamin deficiency causes rickets and osteomalacia? Vitamin D
Describe the Cori cycle glucose to lactate, to the liver, to glucose
What does the sudden onset of glucose intolerance in a patient receiving TPN indicate? sepsis
What is the most common cancer in men? In women? Men = prostate, Women = breast
What is the difference in the way that T cells and natural killer cells can attack tumors? T cells need MHC complex to attack tumor whereas natural killer cells can attack tumor cells independently
Which tumor marker has the highest sensitivity? PSA
Which phase of the cell cycle is most vulnerable to XRT? M phase
What are the 3 main benefits of fractionated doses of radiation therapy? Allows REPAIR of normal cells, REOXYGENATION of tumor, and REDISTRIBUTION of tumor cells in cell cycle
Why are larger tumors less responsive to XRT? lack of oxygen in the tumor
What are the two main risks of tamoxifen? 1% risk of blood clots, 0.1% risk of endometrial cancer
How are the alkylating chemotherapy agents (cytoxan, platinum agents, isofosfamide) unique? Not cell-cycle dependent and have a linear dose response curve
What is a potential side effect of bleomycin and busulfan? Pulmonary fibrosis
What are potential side effects of cisplatin? nephroteoxic, neurotoxic, ototoxic
What is a potential side effect of carboplatin? Bone (myelo) suppression
What is a potential side effect of vincristine? peripheral neuropathy
What is a potential side effect of vinblastine? Bone (myelo) suppression
What is the mechanism of methotrexate? inhibits dihydrofolate reductase (DHFR), which inhibits purine and DNA synthesis
Which chemotherapy agent does leucovorin help reduce side effects? Which agent does it increase toxicity? Leucovorin rescue for methotrexate, increases toxicity of 5-Flourouracil (5FU)
What is the mechanism of 5-Flourouracil? inhibits thymidylate synthesis, which inhibits purine and DNA synthesis
What syndrome causes childhood sarcomas, breast CA, brain tumors, leukemia, and adrenal CA? Li-Fraumeni syndrome – defect in p53 gene
Which tumor suppressor gene is located on chromosome 13 and involved in the cell cycle? Retinoblastoma (Rb1)
Which tumor suppressor gene is located on chromosome 17 and involved in the cell cycle (abnormal gene allows unrestrained cell growth)? p53
Which tumor suppressor gene is located on chromosome 5 and is involved with cell adhesion and cytoskeleton function? APC
Which tumor suppressor gene is located on chromosome 18 and is involved in cell adhesion? DCC
What is the most common primary in a small bowel metastases? melanoma
What cancer benefits from surgical debulking? Ovarian CA – improves chemotherapy
Which solid tumors are curable with chemotherapy only? Hodgkin’s disease and non-Hodgkins lymphoma
What are T-cell lymphomas associated with? HTLV-1 (skin lesions), EBV, and mycosis fungoides (Sezary cells)
Created by: jclanton82