DIP Episode 385 - Anesthetic Complications and The USMLEs (Ultra HY for Step 2CK and Step 3)

All right welcome my name is divine this is episode 385 of the divine intervention podcast and this podcast I'm going to discuss in a very important topic. It's a topic that has had increased emphasis on the current USMLE exams so I figured I would cut out the high old points and discuss them during the podcast and the topic is really really going to be on anesthesia complications and the USML Es. Okay the thing is with these November 2020 changes so for those of you that are just listed as podcasts for the first time the November 2020 changes are the changes that happened that like new things in the end game is started testing in November of 2020 on healthcare systems professionalism communications some weird kind of ethics quality improvement and safety and things of that nature but the thing is over time there are some other unique weird things that they have studied coming after with those topics that people are like what is this what are what exactly are we trying to discuss here and one big area in recent times have been an anesthesia complications so I'm going to discuss it it should be a relatively short podcast as a reminder if you're taking step two seek your step three anytime within the next one month complex level two and three I do offer one of two school two courses that may be maybe what you're looking for so the first series first starts with an NV Me testing and strategy scores that's going to be taking place this Friday from five to seven thirty p.m.

Pacific standard time we're going to be discussing some very high level things like many like just common problems people face right like how to read questions correctly to get the most important information from them how to pick the right answer when you narrow things down to like two choices how to pick the right answer when you don't even know the attestin in the question right we're going to talk about like even how to answer ethics questions we'll talk about many of these high level strategies again there's many people that have used these tips and techniques and they've done extremely well on the exams and then I have a 20 hour review course that's going to be taking place right after that it's going to be on this Saturday the 23rd of April and next Saturday the 30th of April it's going to be 10 hours each day we're going to be covering internal medicine psychiatry, peds, surgery, OB-GYN, neuro, multi-system processes and disorders, bio statistics and ethics we're going to be using tons and tons of things we're going to cover more than a thousand scenarios again many people don't these courses don't extremely well and then I have a 70 the second you know second series of courses I'm offering it's going to be the first two weeks in May it's going to be a 75 hours step two ck school obviously it also applies to step three and complex level two and three and the school will feature like 60 hours of deep review it's going to be extremely comprehensive like really this school is born out of many years of research and investigation and constant updates it's going to be 60 hours of very deep review it's going to be 10 hours of something I call adaptive learning where we just use like a multi-modal approach to reviewing information and then we're going to have an expanded test against strategy's course it's going to be five hours five hours long so it's going to be 75 h

ours total and again it's going to be seven and a half hours each day from May 2nd to May 13th if you're interested in and the 75 hour school has limited attendance I can't admit to many people because I want to invest very deeply in every single person that attend so if you're interested in that just shoot me an email through the website and I can give you some more information all these courses are going to be held over so okay so let's jump right into the material so the first thing that I would say you want to keep in mind for person on the green any kind of surgery you always want to optimize their comorbidities as well as as humanly possible right usually the people that need comorbidity optimization are people that for example have diabetes people that have really bad hypertension people that have a history of MI or the Afcorn area or disease people that smoke people that have institutional disease people have bad liver people have obstructive sleep apnea these are people you typically want to try to optimize before they go for surgery and then what if our friends at the MBM Es you know they'll give this long complicated question about a person that is going to the OR and then they'll talk about how you know a patient death was recorded as a result of anesthesia you know during the case blah blah blah blah and then they say what's the most likely cause of this anesthetic error I want you to pick the answer choice that says human error the most common cause of anesthetic complications for the most part you know in most circumstances is human error right and how do some of these human errors arise well you know using the wrong medication doses right using the wrong medications right because anesthesia you're literally like a human pharmacy right so you can already begin to see how you can mess things up in one way or the other right so using the wrong medication d

oses using the wrong medications you know or putting the right wrong gas in a patient right all those things can cause a problems that's why you really say if you're a person that's interested in anesthesia make sure you're present as a detail oriented you can be like a Lucy go see person with details and succeeding anesthesia that can literally be the difference between a patient living and patient dying right so you kind of need to be careful there so how can you deal with some of these problems again the mb is a very good on asking you for solutions well very high you to know that you want to use color coded syringes right and then you know you can on institute training you at your organization about okay syringe coded with this color means this the syringe with orange means opioid this syringe coated with blue means anti-hypertensive right using color coded syringes is really helpful in reducing human air in anesthesia and also using bar codes from a lot of the agents you administer so you tell the the physicians before you administer an agent just current this bar code it's almost like another self-check mechanism so that you make sure you administer in the correct medication and then what if they give you a question about a patient they tell you that this patient you know just on the went into patient and the central line was placed and then this the ventilator monitor monitors are going off more right the patient is becoming harder and harder to into beat right and then they tell you that huh there's like a you know they when chest exam is done an emergent chest exam is done you cannot hear birth sounds on one side of the patient's chest if you think about it right this patient has attention in orthodox right many times they'll be hypotensive they'll be hemodynamically unstable right what happened so as you were placing a central line or something you punctured

a part of the lung president and person got in trouble obviously for pressing has attention in orthodox the first thing you want to do is a needle decompression right remember another name for needle decompression on exams is needle thorough costum right that will convert the tension in orthodox and open your orthodox and then after that you can place a chest tube right again another name for chest tube is tube thorough costum now it's very high yield to remember that if they give you attention in orthodox question where you don't see a needle decompression or needle thorough costumy answer and all they put is chest tube or tube thorough costum pick chest tube right there'll be a good thing to do that's absolutely fine now one thing that you want to remember is they can give you a question about a person that has had a chest tube placed right and then they tell you that you notice that there's a persistent early right when you notice that there's a persistent early that means there's another conduit that has rupture usually is going to be like the rupture of an airway like a broncos for example that's causing those things again remember borrow trauma especially when you're administering anesthesia to people and you're doing it at high FIO2 so that can absolutely cause problems in those people right now what if they give you a question about a 47-year-old male they tell you that you know he's in the hospital for uh uh you know herniary pair an elective herniary pair but they tell you that 30 minutes into the procedure um the patient is uh less flexible right they tell you that the patient is becoming hotter and hotter to ventilate they tell you that his temperature is 105 degrees Fahrenheit and they tell you that you know he um that the you know they obtained an intra-op CBC and his white count is 20,000 if you see that what should you be thinking about i'll really ho

pe you're saying or divine this person is going to have a legal hypothermia right remember malignal hypothermia is something that you get open exposure to anesthesia especially does uh depolarizing your musculos blocking agents right um like succino calling for example or you know just the regular anesthetic agents being held anesthetics right those things can absolutely cause issues now remember malignal hypothermia is an orzo-more dominant disorder it's associated with mutations in either the dihydroperidine receptor or the rayanodine receptor right uh the more common one is probably the rayanodine receptor in exams remember the rayanodine receptor is a calcium channel so when it's mutated it can cause you to release more calcium from the sacroplasmine critique olem of morsel you're gonna have a hyper contractile muscles so in metabolic rate it's gonna go through the roof right um so you know your temperatures are gonna go up right your white count is gonna go up just because of the chaos that's happening in the person's body right because it is a massive metabolic stress on the body when you have a lot of stress you're gonna make a ton of cortisol that cortisol is gonna make your white count go up right because it's gonna increase your de-marginated pool of neutrophils just very high you know it increases your de-marginated pool of neutrophils i'll just say something here right now the people that are taking step 2 ck step 3 i will encourage you for some of these common medical things that you learn for step 2 ck step 3 try to understand the basic science pathofysiology behind them that's one advantage that i feel listening to my podcasts provides for you right you see most times i don't just give you stuff right i actually try to explain like the reasoning behind that stuff you see many people they just think oh you know i just need to know the know the word know

the buzzword no the thing is many times these days the buzzword answers you're looking for you're not gonna see them on exams right there's all these things i call derivative answers where it's a physiological or a pathophysiological description of the process that is the answer choice right so just something you want to keep keep in mind as you're preparing for these exams i'm telling you this the end game is they recognize that step one is now pass fail right so some of those weird things from step one just in terms of again physiological and pathophysiological understanding the beginning to bring them to step 2 ck and step 3 they're not going crazy but it's definitely there so that's just something you want to keep in mind as you prepare right so if a person has malignant hyperthermia right they can ask you what was the most likely electrolyte anomaly that may be found in this person i really hope you're picking the answer that says hypercalemia right because again as those muscle cells are dying and exploding they are releasing the intracellular ions into the circulation right that can cause hypercalemia and also remember the mild globing goes touches the kidneys causes an intra-inatal acute kidney injury or i guess you can call it acute tubular necrosis from ruptomyeluses that can cause renophidia that can cause the potassium to rise right that's something you want to keep at the back of your mind on the exam so how do we treat malignant hyperthermia remember we're going to give these people we're going to give these people dantrullin right dantrullin is a rionidine receptor antagonist but again what is the smart thing our friends at the mbimis can do instead of putting dantrullin as an answer they just put calcium channel blockers as an answer because guess what dantrullin is a calcium channel blocker because the rionidine receptor is a calcium channel right so

those are like slide ways our friends at the mbimis can give you a question where they integrate some step one into it you know you don't even realize that step one is what is being integrated right so again just all things you want to keep at the back of your mind as you study for these exams and obviously they give you malignant hyperthermia question what are the other answer choices you're going to be expecting you're going to be expecting an answer on serotonin syndrome which will be wrong you're going to be expected an answer on your elliptic malignant syndrome which will be wrong because typically they don't like give you an anti-psychotics in your pre new wrong you know except for some very weird bizarre reasons now remember another common complication of anesthesia right especially in people that have obstructive sleep apnea is a difficult airway right difficult airway the thing is there is a difficult airway algorithm that is deployed in anesthesia or that is well beyond the scope of the usml so we're going to skip that right now so let's maybe take a small detour and just talk about OSA obstructive sleep apnea or you know B3 hypodentilation syndrome in the context of anesthesia so what are some classic things our friends at the mbimis can ask you here they can ask you a few things like oh how can these people be screened for symptoms of OSA in like anesthesia pre up you want to pick the answer that says to use the stop bang questionnaire I will encourage you to because I don't have much time in this podcast I'll encourage you to go and look that up but it's the stop bang questionnaire deals with things like color size and things things of that nature do you snorre blah blah blah blah right so use the stop bang questionnaire as a screening tool right because again people that have obstructive sleep apnea they have a very high risk of difficulty in to patients

and for these people it is extremely high yield they can ask you what are some measures that can be taken in an OSA patient to reduce the risk of anesthesia related complications I know some of you may be like there is no way they could test any of this I wish you all the best but the thing you want to keep in mind is these people is very high you to know that while they're in the hospital especially when they are not intubated you want to try to use their CPAP or by-pap as much as is possible remember another name our friends at the mbn isca is for CPAP or by-pap is non-invasive positive pressure of ventilation and for these people as much as is possible if you can avoid general anesthesia avoid general anesthesia because these people they already predispose to respiratory depression at baseline so if possible instead of using general anesthesia try to use regional anesthesia in these people try to use local anesthesia in these people that's a smart thing to do on exams and also on exams you want to try to limit the use of opioids for pain control in these people because again they already have respiratory depression what is this feared complication with the use of opioids surprise surprise respiratory depression so that's very high yields to keep in mind on exams and then what if they give you a question about a 35-year-old female they tell you that she just had a hysterectomy and she's very somnolent after the surgery has been completed she's very somnolent she's very difficult to orals they tell you that her respiratory rate is 5 and then they ask what's your next best step in the as first for your diagnosis your diagnosis on exams is going to be opiate induced respiratory depression I'll say that again your diagnosis on exams keep this word in mind for your test opiate induced respiratory depression and you'll ask what is the next best step in management and the

y'll give you some kakamami answer about reintubate no give danloxone first give danloxone first it can rapidly reverse the opioids they're used in anesthesia now what is one thing you can use to assess a patient's level of some no names of consciousness I guess when there are opioids remember on exams the scale the thing is again with these healthcare systems questions they introduce you to all these weird annoying scales on the exams the key thing I want to keep in mind is use the rass scale the r-a-s-s scale remember it's the rich-monde agitation and sedation scale the rich-monde agitation and sedation scale and they can even ask you in this person who opioid induced respiratory depression what do you find on AB Gs on a terrible lot of gases remember the apau 3 is going to be low right the apau 3 is going to be high right the apau 3 is going to be high because they are accumulating CO2 because they are not breathing at an acceptable rate and then you'll have a respiratory acidosis right so the apau 3 should be low for the most part their bicarb should be roughly normal adjust the literally elevated because remember it's an acute event it takes the kidneys are fairly tremendous amount of time you know the order of hours maybe a few days to appropriately compensate and then another weird question you may see although this is probably going to be a lot rare is the concept of fire in the operating room remember there are some key risk factors most times on for these kinds of concepts one thing point in terms of risk factors risk factors for fires in the operating room are going to be things like using alcohol-based cleaning solutions especially when you're having emergent surgeries or crushed surgeries where you have to intervene immediately then when you clean the prescience skin with ethanol you're not waiting for it to dry that ethanol is very good for causing fires and

also just surgeries where you're using more oxygen than is normal that can also cause fires and also if you're doing surgery that involves the use of electrocordory right those things that are almost like bovis right you know what I'm talking about right electrocord surgeries that involve electrocordory also have a very high risk of fires in your operating room I mean some people literally have fires in the endotracheal tubes obviously that's that's not a good outcome for the patient and then remember if you're doing I'm just going to mention a few grab back things I'm going to wrap up here if you're doing nerve block surgeries right or if you're doing nerve blocks you can get nerve injuries from from having nerve blocks and remember they can give you a question about a patient detail that the patient just had a placement of some rods or whatever they had some kind of spine surgery and then you're having trouble with visual problems after surgery if you think about that you want to think about a rise in the intracurricular pressures causing those problems so remember when people have surgeries when they have to be in the prone position that can cause issues especially for example the eyes at the lower level than the heart right the eyes that are lower level than the heart and that's not a good thing because that can cause a very rapid rise in trocular pressures that can cause visual loss so how can you reduce the risk of something like this well when we reduce that risk is to use a position on exams called the reverse trendellanberg position the reverse trendellanberg position basically your head should be higher than your feet and that pretty much almost in a sense eliminates this this risk although is certainly still exists and then remember for any exams it's very high to memorize the things that can give you more than form it a BOLIC equivalent again my apologies

if I'm kind of rushing a little bit at the end here I have a lot of engagements today so but I really want to get this podcast out because I don't want another person to take the exam without having listened to those podcasts but basically if a person has more than form it a BOLIC equivalent for most surgeries you don't need to take though you don't need to have some significant cardiac evaluation for those people they're going to be fine you know many times the things that bioforemities are like you can do like physical activity like moderate physical activity for like 30 minutes or thereabouts or you can climb the certain number of sets of stairs those are all things that will tell you that you know what this person has a very low risk of a major adverse cardiac event but again our friends at the endgame is they can ask you what are some risk factors for major adverse cardiac events with surgeries again if you have pre-op ischemic heart disease so let's say you have like angina or you have a histral coronary artery disease and things like that or you have like heart failure you have diabetes chronic kidney disease or if you're over the age of 65 those are all things that can increase your risk now one thing our friends at the endgame is love to test especially in heart failure patients is they can say what are you supposed to do with beta blockers and their and surgery let's say they're getting surgery so here's the rule you're supposed to apply on your exams if a person has always been on beta blockers then continue your beta blockers while they're in the hospital continue your beta blockers not a big deal however if a person is having surgery and you've never been on beta blockers and then you're like hmm let's start these beta blockers denouville let's start it like two days before surgery that's an awful idea right so the thing is if you start beta blockers newl

y in the period period that increases morbidity and that increases mortality and the thing is beta blockers and anemia of bad bad bad mix bad bad bad mix anemia is an additive risk for a person having really bad outcomes if you're taking beta blockers because remember anemia already places a lot of metabolic stress on the heart because if you think about it when you are anemic the oxygen-carrying capacity of your blood is decreased so your heart responds by raising the cardiac output so that the block can make more passes through your tissues that's very high you'll to understand so these people already have hearts that are not doing well right so anemia and beta blockers not a good mix at all that's something one of people to recognize for exams and then don't forget is a classic question you should never get it wrong but as much as is possible your patient should quit smoking before surgery you want them to quit smoking at least eight weeks before the surgery and then remember for a person who's just had an mi and they want to get some kind of elective surgery you want to try to hold off on that surgery for at least 60 days two months after the mi before you let those people have a elective surgery so I think I'm going to go ahead and pause here again this podcast it's a weird podcast it's a bizarre podcast but a lot of what I've described here today is exceedingly high yield for you exams so as I do at the end of every podcast I'll throw one or one two during full the USML exams step one to step three complex level one two and three the key thing is just booking with me ahead of time because my schedule books week weeks in advance I do the first conference of thesis and then I tutor for shelf exams I tutor for preclinical med school exams and I do this thing called longitudinal tutoring where I work with people for a year let's say you're a fresh 30 years student I

work with you for your shelf exams and then I work with you for your step to seek exam many of the people that I've done that with they've ended up doing extremely well on their on their tests and then I offer help with ERAS applications and advice in I've said that in many podcasts before so I'm going to keep keep moving here and then I offer these review courses for step to seek is step three and complex level two and three and also I have this podcast on Apple podcasts on Google podcasts and on Spotify so if you go on those podcasts apps just look for the Divine Intervention podcasts you'll find the most recent 150 podcasts if you want everything from episode one to episode three eighty five you have to actually go to the website divineinterventionpodcasts.com if you actually subscribe with your Word Press accounts you get an email notification whenever I make a new podcast and then I also have a You Tube channel called the Divine Intervention US Mly Podcasts and videos that's where I post the videos that I make and then I also have another website that I started a few months ago it's called it's literally divineinterventionlifelessens.com many people have emailed me have gotten I know you've annoyed some people when I talk about life lessons at the end of this podcast but I've also got in an overwhelming number of messages from people that are divine I absolutely love your life lessons so many of you listen to this podcast on a Christian so I started a life lessons website so it's short podcasts on just Bible based teaching that addresses common problems that are faced in humanity these days I have about I believe 74 or maybe 75 podcasts I post about two a week and you can actually find the podcasts on Apple podcasts if you just look for it's called the Divine Intervention Life Lessons Podcasts so you know and you can also subscribe to that website you get an email

notification whenever I send a make a new podcast so thank you for listening to me I really hope you find this podcast to be helpful have a wonderful rest of your day and all the best as you study for your tests God bless you thank you

Human error (e.g., using wrong doses, wrong medications).

Needle decompression (or needle thoracostomy).

The STOP-BANG questionnaire.

Use CPAP/BiPAP when possible, and avoid general anesthesia if regional or local techniques suffice.

Naloxone.

The Ryanodine Receptor (RyR1).

Alcohol-based cleaning solutions, high $\text{FiO}_2$, and electrocautery.

Hyperkalemia (release of intracellular ions).

Reverse Trendelenburg position (head higher than feet).

Regional or local anesthesia techniques.

High $\text{PaCO}_2$ and low pH (with normal/slightly elevated $\text{HCO}_3^-$).

Dantrolene.

Alcohol-based cleaning solutions, high $\text{FiO}_2$, and electrocautery.

Hyperkalemia (release of intracellular ions).

Reverse Trendelenburg position (head higher than feet).

Regional or local anesthesia techniques.

High $\text{PaCO}_2$ and low pH (with normal/slightly elevated $\text{HCO}_3^-$).

Dantrolene.