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CDM Exam 2024 with Questions and Answers
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CDM Exam 2024 with Questions and Answers
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CDM Exam 2024 with Questions and AnswersBolus doses of lipophilic drugs will require ______ loading doses, as their volume of
distribution will be _____ in patients with more adipose tissue
higher, higher
Is there anything special the surgeon may request due to the procedure being laparoscopic?
Orogastric/nasogastric tube (OGT / NGT)
- In order to decompress the stomach; decrease risk of gastric perforation, aspiration, and
interference of a distended stomach into the surgical field
- Insert OGT with surgilube midline
Maneuvers to troubleshoot insertion:
- Flex head, fingers in pharynx to direct midline, manipulate mandible/larynx/cricoid anteriorly
- Can DL and place directly
- OG if the plan is to remove at the end of the case, NG if the plan is for it to stay in through
postop period and recovery
How does obesity affect airway concerns?
- Decreased functional residual capacity (FRC)
- Increased oxygen consumption
- Increased gastric volume and abdominal pressure → increased aspiration risk (this is
questionable based on the literature)
- Increased incidence of OSA, Pickwickian syndrome, HTN, LVH, etc
Decreased FRC + increased O2 demand = Rapid Desaturation
- Preoxygenation becomes much more important in this population
- Airway adjunct devices (OA, NT, LMA) should be immediately available and used early
- Increased incidence of OSA also correlates with difficult mask ventilation and upper airway
obstruction
Contraindications for OGt/NGt
- Caustic ingestion or oesophageal strictures (risk of perforation)
,- Coagulopathy (epistaxis risk)
- Base of skull fracture
- Severe mid-face trauma (risk of cribriform plate disruption with NGT entering the brain!)
- Previous gastric surgery (especially if recent and anastomosis is fresh)
How far down to go with OGT/NGT:
Measure tip of nose (NGT) or corner of mouth (OGT) to ear lobe to xiphoid cartilage
VCV vs PCV obesity
- Risk of VCV in an obese pt, especially with a pneumoperitoneum, is very high PIP
- Risk of PCV is low TV at normal PIP
– start with VCV, if after abdominal insufflation if PIP is >35cmH2O, switch to PCV and see what
TV you can achieve at a reasonable (< 35cmH2O) PIP
PEEP
- Start at 5cmH2O, titrate up depending on SpO2 assuming
hemodynamics tolerate it
-What does PEEP do? Prevents atelectasis.
- What does a recruitment breath do? Opens atelectatic alveoli.
Should then turn on PEEP to prevent recurrent atelectasis.
Inspiratory to expiratory ratio, obesity
- Default is 1:2 - meaning that 1/3 of breath is inspiration,
2/3 is expiration
We can alter this ratio to either:
- Increase inspiratory time (e.g. 1:1.5), which decreases the
pressure required to achieve any given TV
- Increase expiratory time (e.g. 1:3), which allows more time
for exhalation (necessary for obstructive lung diseases)
- Although this patient has asthma, the predominant
problem will be achieving an adequate TV at a
permissible PIP; so I would start at 1:1.5
Obesity presents as a _____ Lung Disease
,Restrictive
Time of inspiratory pause as a ratio of time of inspiration TIP:TI
how long it holds the breath at the plateau pressure before
exhalation starts
- Determined by lungs themselves, INC in states of DEC pulmonary compliance, pulmonary
disease, or restrictive lung disease
- This can help keep alveoli open during inspiration, aiding in oxygenation
Plateau pressure
pressure needed to keep air in the lungs since flow goes to 0 in VCV
It is the pressure that the alveoli are actually exposed to
- Cannot directly set it in the ventilator
- It is crucially important to know that PIP is totally different from plateau pressure.
A high plateau pressure may signify
a non-compliant lung (e.g. ARDS)
EtO2 laparoscopic considerations
- Abdomen is insufflated with CO2
- This CO2 will be systemically absorbed, further
increasing PaCO2 overtime
- Ventilation will be made difficult by abdominal insufflation due to the diaphragm being
displaced cephalad into lungs, increasing pressure requirements needed to ventilate
- We sometimes need to settle for permissive
hypercapnia during the procedure
Alternatively, if CO2 increases past a reasonable amount, discuss resolutions with surgeon
including:
- Pausing procedure to ventilate
- Decreasing insufflation pressure
- Reducing amount of Trendelenburg if applicable
, - Ensuring CO2 absorber isn’t saturated
Diabetic monitoring intraoperatively
Monitor glucose!
est practice is to check BG q1-2hr
What range should glucose value be kept within intraop? What values are unsafe and why?
Target glucose levels are variable based on institution specific guidelines, but 80-180mg/dL is a
good range d/t the risk of hypoglycemia with a tighter target
- Glucose levels >180 are associated with INC risk of infection and INC risk of cardiac adverse
events
Awake vs deep extubation
Awake:
Risk
- Pt has reactive airway disease
- INC RISK of laryngospasm and/or bronchospasm
Benefit
- DEC risk of airway obstruction in a patient who likely has OSA
Deep
Risk
- Airway obstruction
- DEC risk of laryngospasm and/or bronchospasm in
a pt with reactive airway disease
Beta Blockers
Clinical concern: if dose is missed, risk of intraoperative MI
Day before surgery: take regularly scheduled doses
Morning of surgery: take regularly scheduled doses
ACEi, ARBs, direct renin inhibitors
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