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