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Surgery Review 2
SR 2: Anesthesia, Fluids and Electrolytes, Nutrition, Oncology
| Question | Answer |
|---|---|
| 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
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