[SPEAKER_01]: Hello, and welcome back to Act Greg. [SPEAKER_01]: I'm Jed Wolpa, and I am back with the one and only Dr. Tim Kais Torah for another ABA key word episode. [SPEAKER_01]: This time we're going to tackle a kind of a grab bag, I guess, that they're calling common complications in anesthesia, which really, I guess, summer common summer not, but as we just said, talking offline, this is kind of highly tested complications from anesthesia.
[SPEAKER_01]: So you need to know it, some of them you may see some of them you may never see, but we're going to go over [SPEAKER_00]: Thanks so much for having me as always, and just like last time, we're going to kick off today with a little bit of space repetition and we've used some questions from previous keyword episodes in no particular order of jet question number one.
[SPEAKER_00]: At 59 year old female with obesity, obstructive sleep apnea, high blood pressure and diabetes presents to an ambulatory surgery center for a distal toe amputation. [SPEAKER_00]: The patient refuses regional anesthesia and you proceed with general anesthesia. [SPEAKER_00]: which of the patient's risk factors is most likely to result in an unplanned post-operative hospital admission. [SPEAKER_00]: A, obstructive sleep apnea, B, high blood pressure, or C obesity.
[SPEAKER_01]: Yeah, you know, I think this is a little tricky obviously if you remember when we talked about the last time it wouldn't be but because these things all seem they're all our risk factors I think maybe one way to think about this just from a test taking perspective is which is the least common right well be sitting in high blood pressure are so common that it seems unlikely they give you something that so many people have
[SPEAKER_01]: You know, we see a lot of patients who can't pass a room air trial. [SPEAKER_01]: They can't get out of the pack you because they can't saturate, okay, on room air because they're destructive sleep apnea. [SPEAKER_01]: So that's certainly what we see clinically. [SPEAKER_01]: And I think from a test-taking perspective is the most likely as well. [SPEAKER_01]: So I'd go with A of destructive sleep apnea. [SPEAKER_00]: Right, I think that's a great approach.
[SPEAKER_00]: And certainly there are BMI cutoffs had ambulatory surgery centers, but it's not just the presence of obesity, high blood pressure, it's not a country indication, but if you're working in a hospital setting, certainly you've taken care of a patient that at first, you look at and say, why is this being done in a hospital setting? [SPEAKER_00]: And it's often the bad obstructive sleep apnea or something like that that is brought them to you.
[SPEAKER_00]: Question number two, you are performing in a wake fiber optic nasal intubation and have injected local anesthetic via the trans trachial approach. [SPEAKER_00]: This action most likely affects the A, lossal for rindgial nerves, B recurrent laryngeal nerves, or C, the internal branch of the superior laryngeal nerves.
[SPEAKER_01]: Yeah, so, you know, this is one of those things, I think, tracheal, nerve anatomy that you do just have to kind of remember of sure people may have some namanics and things to remember it. [SPEAKER_01]: But the way I think about this is that the trans tracheal block is getting all of the cords, the subcord area and the cords themselves. [SPEAKER_01]: That's kind of the, well, I think it was the most important part of it.
[SPEAKER_01]: important area, if you've ever done in a way contamination, when you get to the cords, if they're not adequately anesthetized, that's what causes people to cough and gag like crazy, not gag with choke, cough and choke like crazy. [SPEAKER_01]: And so, recurrent low-ringed yield nerves or what to innovate that is the most important nerve for in a way, contab Asian. [SPEAKER_01]: And so, I think about the trans-tracheablec is being very effective for this.
[SPEAKER_01]: And that is what it is that recurrent low-ringed yield nerves is what you get from your trans-tracheablec. [SPEAKER_00]: Absolutely. [SPEAKER_00]: And thinking anatomically, those are vendors that are sort of running, have looped down, recurred, and are now coming back up, so they're coming up through that space as they go to their way to the vocal cords.
[SPEAKER_00]: Question number three, soon after emergency an exhibition from General anesthesia for a lower extremity orthopedic procedure, a patient becomes hypoxic. [SPEAKER_00]: Their breathing becomes rapid, which is most likely mediated by activity of which area, [SPEAKER_01]: Yeah, this is, I think we talked about some demonic for this last time. [SPEAKER_01]: So what I think of is, I think CBC, paraded body's chemo receptors, paraded sinus, like sinus pressure.
[SPEAKER_01]: So the paraded sinuses are pressure, like you get sinus pressure when you have a sinus cold. [SPEAKER_01]: And then the heornic bodies are less important, but also ABC are also chemo receptors, but they're less important. [SPEAKER_01]: They play less of a role, interestingly, that's specific to humans. [SPEAKER_01]: They play more roles of animals, but in humans, play less of a role.
[SPEAKER_01]: And so here, what we're talking about is hypoxia, which is a chemical, it's a PAO to chemical response. [SPEAKER_01]: It's not about the blood pressure, it's about the partial pressure of oxygen. [SPEAKER_01]: And so it's going to be the chemo receptor of the carotid body, CBC, carotid body, chemo receptor is going to be a right answer here. [SPEAKER_01]: If it had been about hypotension, it would be the carotid sinuses.
[SPEAKER_01]: And if I don't even know how they'd ask about the aortic body, something that if they maybe didn't give you carotid bodies as an example, and it was a chemo receptor response. [SPEAKER_00]: Right. [SPEAKER_00]: And even then though, so you're right that the aerotic bodies are a little, you can call it a little less important, but specifically, they just don't drive their hyperventilatory response. [SPEAKER_00]: They ship some of these same other things that the carotid bodies do.
[SPEAKER_00]: To remember that distinction, remember that the carotid bodies are closer to the bridge than where the ventilatory systems are, so that's the one that drives that hyperventilatory response. [SPEAKER_00]: Question number four, you induce anesthesia for a patient undergoing ECT treatment for major depression. [SPEAKER_00]: What is the most common autonomic nervous system response following seizure onset? [SPEAKER_00]: A initial Brady Cardia followed by TAC Cardia and hypertension.
[SPEAKER_00]: B initial TAC Cardia followed by Brady Cardia and hypotension. [SPEAKER_00]: C initial Brady Cardia would have returned to baseline. [SPEAKER_01]: Yeah, so if you, I mean, obviously if you've done these, you've seen it, if not, then you kind of have to memorize this. [SPEAKER_01]: It's going to be a initial break of cardio followed by technical cardio and hypertension. [SPEAKER_01]: I don't personally have a great pneumonic or anything to remember that, Tim, do you?
[SPEAKER_00]: I don't. [SPEAKER_00]: But what it's testing here is just do you remember that it's a parasympathetic response followed by a sympathetic response. [SPEAKER_00]: That's sort of what you need to know. [SPEAKER_00]: Yeah. [SPEAKER_00]: All right, great. [SPEAKER_00]: So with that warm-up under our belt, we'll move on to today's main topic, which is pulled from the basic outline.
[SPEAKER_00]: So this sits in basic topics in anesthesiology under clinical science, anesthesia procedures, methods, and techniques. [SPEAKER_00]: It's number six in that list, common complications. [SPEAKER_00]: And as you said, it's a strange list. [SPEAKER_00]: They're not all particularly common. [SPEAKER_00]: Some of them are perioperative. [SPEAKER_00]: Some of them are directly related to anesthesia.
[SPEAKER_00]: The subcategories, [SPEAKER_00]: There are eight trauma, and they have upper airway, larynx and eyes, and vascular neurological and burns in there. [SPEAKER_00]: B is chronic environmental exposure and scavenging. [SPEAKER_00]: C is temperature, both hypothermia and non-milignant hypothermia. [SPEAKER_00]: D is bronchospasm, E is latexology, F is larynxospasm, G is post-substructive pulmonary edema, H is aspiration of gastric contents, and I is malignant hypothermia.
[SPEAKER_00]: And we need to get some case, some of the same copies, out of the way as always. [SPEAKER_00]: These episodes are aimed at preparation for board examination. [SPEAKER_00]: So we'll be focusing on the highly tested topics. [SPEAKER_00]: I still have a lot of different test materials, including previously released exams, to see what comes up most frequently. [SPEAKER_00]: And whenever possible, see what textbooks cover.
[SPEAKER_00]: Since question writers have to ultimately cite sources like that, coming up with these test items. [SPEAKER_00]: So, [SPEAKER_00]: Uh, what we will see below is just what I think is tested the most and this may change over time, but the ABA does want you to know everything in that list. [SPEAKER_00]: So if there's something we didn't cover that you're unfamiliar with, you will have to brush up on it. [SPEAKER_00]: Um, the first section we'll cover is, uh, trauma.
[SPEAKER_00]: The ABA group is a broad set of mechanical injuries under trauma from dental damage dream to patient, peripheral nerve injuries from positioning, which gets tested consistently comes to a few high yield patterns. [SPEAKER_00]: When goes wrong with the airway during and after intubation, what causes perioperative visual loss and which nerves are most vulnerable under an anesthesia.
[SPEAKER_00]: are key concept one, the most common complication of direct-altern microscopy is dental trauma. [SPEAKER_00]: If a tooth is dislodged and can't be found, you need to get chest and abdominal x-rays to roll out aspiration and figure out where it went. [SPEAKER_00]: And then once the tube is in, the most common in situ complication is endobricial incubation.
[SPEAKER_00]: and as a reminder, it's next flexion, not extension that pushes the tube deeper by shifting the crine and stuff lad. [SPEAKER_00]: And I'll be honest, that that's just something that I still need to force myself to understand it's fact, it's still anatomically does not make complete sense to me. [SPEAKER_00]: And then delayed excavation complications, include Lorenzo ulceration, tracostinosis, vocal cord paralysis, and arrhythmic dislocation.
[SPEAKER_00]: Key concept two, cordial abrasions are the most common perioperative eye injury and can be prevented by taping or protecting the eyes, which is why we always stress that. [SPEAKER_00]: And then perioperative visual loss is a relatively rare but can be catastrophic. [SPEAKER_00]: It's most commonly caused by a skinic optic neuropathy followed by retinal artery occlusion. [SPEAKER_00]: Risk factors for eye awareness, skinic optic neuropathy.
[SPEAKER_00]: include prone positioning with large blood loss, that's sort of the most commonly tested one, as well as male sex obesity use of Wilson Frating in the amount of perioperative IV fluids. [SPEAKER_00]: The more in dealing with you cause the higher of a risk of possible ION, and there's no proven treatment once it occurs.
[SPEAKER_00]: If you have any concern for any type of vision loss, don't blame it on residual anesthesia and anything like that just get the ophthalmology consult right away. [SPEAKER_00]: Key concept 3, the owner nerve is the most commonly injured peripheral nerve under general anesthesia. [SPEAKER_00]: It's vulnerable at the medial epicondile where it can be compressed against the table edge.
[SPEAKER_00]: The medial nerve would injured, which is most commonly from IV fluid ex-travisation at the end cubital fascia, causes sensory and motor deficits in the first three digits. [SPEAKER_00]: The common perineal nerve is at risk at the fibular head in the anatomy position. [SPEAKER_00]: And it's significant portion of nerve injury is occurred despite appropriate positioning, which suggests that it's keeping your place real independent of padding.
[SPEAKER_00]: This is also, I think, commonly tested because these injuries show up very commonly in our close claiming databases. [SPEAKER_01]: Yeah, two quick things, Tim. [SPEAKER_01]: One, you know, the way I think about it is when you think about what you've said about you, you don't have a great way to remember which, with a flexion or extension of the neck can cause the tube to get right mainstream. [SPEAKER_01]: The way I think of it is if you extend your neck, you make your neck longer.
[SPEAKER_01]: And so the tube is going to be less deep because now it's a longer neck. [SPEAKER_01]: And when you flex the neck, I think that of the neck becoming shorter and therefore the tube is now deeper because there's less neck. [SPEAKER_01]: right. [SPEAKER_01]: So that may or not make sense, but that's how I think about it. [SPEAKER_00]: Yeah, that's certainly quick. [SPEAKER_00]: And you said two things. [SPEAKER_00]: Let's see other things.
[SPEAKER_00]: Yeah. [SPEAKER_01]: The other thing is that I don't think we're covering it because obviously we can't cover everything, but the one thing that I think does come up that we didn't mention here, but that you did list in your list of things is burns, and I will say the most common way that I think burns get tested and I've seen it on my
[SPEAKER_01]: The simple fact of the give you a scenario with a airway fire and what do you do first and you've got to get that to about right just pull the two out That may seem counterintuitive because you think what it will now I don't have an airway, but you have to realize the airway has become a blowtorch and you have to get it out It's no longer a functioning airway and won't be so that's the key thing to know I think about airway fires
[SPEAKER_00]: Yeah, yeah, this is an interesting list because this is a common complication. [SPEAKER_00]: It doesn't hit a lot of the operating room emergency. [SPEAKER_00]: So there's no oxygen failure, power failure, airway fire, anything like that here. [SPEAKER_00]: But that's a good point. [SPEAKER_00]: And when those are tested, they should never, and I hope they never do, ask you to choose between turning off the oxygen. [SPEAKER_00]: getting the tube out.
[SPEAKER_00]: Those things have to happen in tandem. [SPEAKER_00]: You need the oxygen off because otherwise as you're pulling it, it's just like a flammable torch that you're burning the airway as you come out. [SPEAKER_00]: So in my head always, you want the oxygen off in tube out, but do it as quickly as possible. [SPEAKER_00]: Okay, awesome, a question one. [SPEAKER_00]: A 47-year-old morbidly obese male undergoes a six-hour, three-segment, lumbar lemmonectomy in the prone position.
[SPEAKER_00]: Matt is maintained at 50 to 60 millimeters of mercury, and he receives six units of packed red blood cells. [SPEAKER_00]: Post-operatively, he has bilateral vision loss, which structure is most likely responsible. [SPEAKER_00]: A, the central retinal artery, B, the optic nerve, or C, the cerebral cortex. [SPEAKER_01]: Yeah, so they're giving you a lot of risk factors for a scheme of optic neuropathy here. [SPEAKER_01]: It's a prone case.
[SPEAKER_01]: He's male, he's obese, he's hypotensive, and he got a lot of fluid, so kind of everything. [SPEAKER_01]: And so it's probably a scheme of optic neuropathy, so the optic nerve is gonna be your right answer. [SPEAKER_00]: Perfect. [SPEAKER_00]: Question number two, a 32-year-old man undergoes an eight-hour exploratory laparotomy. [SPEAKER_00]: Post-operatively, he cannot oppose his left thumb to his little finger, which nerve was most likely injured.
[SPEAKER_00]: A, the radio nerve, B, the owner nerve, or C, the median nerve. [SPEAKER_01]: Yeah, so the key here is try to do it, right? [SPEAKER_01]: So when you try to oppose those, you're not moving your pinky very much. [SPEAKER_01]: It's your thumb that is moving, right? [SPEAKER_01]: Try to leave your thumb where it is and get your pinky over to it, you can't do it.
[SPEAKER_01]: So if you were thinking, well, oh, if it's the pinky, it's one thing, if it's the thumb, it's another, you'd be right, but it's the thumb. [SPEAKER_01]: The thumb is what allows you to get these two fingers opposed. [SPEAKER_01]: And so as you said, the thumb and the next two fingers are covered by the median nerve.
[SPEAKER_01]: So that's going to be a median nerve [SPEAKER_00]: Yeah, and so a little bit of a tricky question, because it doesn't tell you anything else about mechanism, right? [SPEAKER_00]: So if you thought about just the most common thing, you'd go with the owner-nerve, but in terms of what they're telling you, doesn't function, it's got to be the median-nerve.
[SPEAKER_00]: Question three, which of a following is the most common peripheral in-nerve injury associated with general anesthesia? [SPEAKER_00]: If the owner-nerve be the median-nerve or see the common perennial-nerve, [SPEAKER_01]: So this is where you have to know that the owner of the little tricky because the common per ordeal nervous of commonly tested nerve that gets injured because of the autonomy position.
[SPEAKER_01]: But overall, as you said in your intro, it's the owner of this the most common. [SPEAKER_00]: Perfect. [SPEAKER_00]: The ABA also lists several vast fewer complications under trauma, including arterial and venous thrombosis, armbalism and pulmonary artery rupture, again, not common things. [SPEAKER_00]: But of these venous armbalism is by far the most tested topic. [SPEAKER_00]: So key concepts for concerns that.
[SPEAKER_00]: Venus, Air and Belison, more VA occurs when air enters the Venus system, potentially causing right-heart flow obstruction via an airlocked mechanism. [SPEAKER_00]: It is most common during neural surgical procedures in the sitting position, but if it occur any time there is an open vein above the level of the heart. [SPEAKER_00]: The most sensitive bedside monitor, other NTE, if you have one, it is the pre-cordial Doppler, which detects air before hemodynamic changes occur.
[SPEAKER_00]: And if you don't have either of those end titles, CO2 decreases as dead-space increases from venous air embolism, and this may be the most recognizable monitoring change in most operating room cases. [SPEAKER_00]: Treatment is with less lateral deacubedist or chandelembert position of possible attempting to aspirate the air via a central line. [SPEAKER_00]: These are special central lines with multiple lumens that can pull out air.
[SPEAKER_00]: Stopping nitrous oxide if you're using it, which can expand air bubbles and hemodynamic support. [SPEAKER_00]: Anything to add or any questions about that? [SPEAKER_01]: No, I think, you know, we feel like we use less nitrous than we used to, but that is a huge one because if you look at the graphs of how quickly an error embellists, same with a new with thorax, expand when you're using nitrous oxide, it is unbelievable how much faster it is than if you're not using nitric oxide.
[SPEAKER_01]: So nitrous oxide, so you gotta get that off if you think you have an error embellist and you're using nitrous. [SPEAKER_00]: Perfect. [SPEAKER_00]: Ah, four. [SPEAKER_00]: During a sitting training out of me, the pre-cordial Doppler detects a sudden high pitch sound and the patient becomes hypotensive. [SPEAKER_00]: What would be expected on entitled gas monitoring?
[SPEAKER_00]: A, increase in entitlement nitrogen, B, increase in entitlement carbon dioxide, or C, decrease in entitlement carbon dioxide. [SPEAKER_01]: Yeah, so what you see is a decrease in entitled CO2 and that is because you have a blockage, right? [SPEAKER_01]: So you can't get the blood that has the CO2 in it to the lung for it to get into the alveoli for you to have entitled CO2.
[SPEAKER_01]: So the trick thing here is that your PCO2 will go up in your blood, but your entitled CO2 will go down. [SPEAKER_00]: Yeah, partially just due to the same drop and entitle, we see whenever we see a drop and a cardiac output as well. [SPEAKER_00]: Though there is debt space in the lungs, that's also contributing to it. [SPEAKER_00]: What do you think about the increase in entitle nitrogen as a distractor? [SPEAKER_01]: Yeah, I mean, that's interesting.
[SPEAKER_01]: I don't, well, first of all, we don't measure it, so, you know, I'm not sure how we would even know that, and I think, yeah, I guess I don't have a better option than that. [SPEAKER_01]: We don't measure it, so I don't have to even think through what happens to antidal nitrogen right there's, yeah. [SPEAKER_00]: I think it's not, it depends what's being inhaled because if you're on air, then there wouldn't be any change.
[SPEAKER_00]: If you're on a pure oxygen and you start getting in an oxygen, you could theoretically have an increase in it, but it wouldn't be the most reliable or sensitive. [SPEAKER_00]: So I'm not sure that it's the best wrong answer, but it comes up sometimes and it's definitely not what you should be looking for for a venous area. [SPEAKER_01]: Right. [SPEAKER_01]: I mean, there is no nitrogen.
[SPEAKER_01]: in the blood right so so if if you when when there is uh... when there is entitled nitrogen it is just because nitrogen went in and came right back out without getting absorbed right blood so uh... yeah i don't think that in the case of an animal side don't think there's any change that it because it was whatever you put in is what you're gonna get back out yeah [SPEAKER_00]: Perfect. [SPEAKER_00]: Next we'll talk about temperature.
[SPEAKER_00]: We'll hit milk in thermia hyperthermia last where it sits in the outline. [SPEAKER_00]: So for now, we'll just cover hypothermia. [SPEAKER_00]: If a non-milicum in hypothermia is that high yield, except as they're tested against milk in the hyperthermia, which again we'll hit at the end. [SPEAKER_00]: Hypothermia is nearly universal in OR without active prevention. [SPEAKER_00]: In some applications extend well into the postoperative period.
[SPEAKER_00]: He concepted five, perioperative heat loss occurs by radiation, convection, conduction, and evaporation, with radiation and convection together accounting for approximately 75% of the heat loss. [SPEAKER_00]: The initial drop in temperature after induction is driven by a core to periphery redistribution, not environment to loss, and then the plateau is mostly at the environmental loss.
[SPEAKER_00]: In consequences of hypothermia, including prolonged drug metabolism, coaglopathy, and wound infection. [SPEAKER_00]: be concept 6. [SPEAKER_00]: Shivering increases oxygen consumption by up to 200% and can occur even in no more thermic patients for soparatively. [SPEAKER_00]: The best thermo-cological treatment is mepheriting, one of the few remaining clinical niches for that drugs. [SPEAKER_00]: Other options include quantity, magnesium, and chamodal.
[SPEAKER_00]: And when cooling a patient actively, like during MH,
[SPEAKER_01]: uh... stop at thirty eight degrees celsius to avoid at your genetic hypothermia so you want to sort of let that last little bit drift down uh... passively without active court anything to add for hypothermia i'll just say that i've even seen quotes uh... up to five hundred percent for how much shiver and quick increase action function and that's really key because especially if you have a for example or board stem or something where they're giving you uh... patient who's cold and maybe also as corner guard of disease
[SPEAKER_01]: This is a big deal, right? [SPEAKER_01]: So there is a major reason you don't want to excavate a patient whose cold is because if they shiver and that oxygen demand goes up by 2 to 500 percent, that's a big deal for someone who may be on that a little bit of an edge in terms of their oxygen supply and demand balance. [SPEAKER_00]: That's a really good point. [SPEAKER_00]: Question five, a patient is shivering vigorously in the packu after a 3-hour abdominal case.
[SPEAKER_00]: Her temperature is 35.2 degrees, which of a following is true. [SPEAKER_00]: A, shivering only occurs in a setting of hypothermia. [SPEAKER_00]: B, shivering increases oxygen consumption by up to 50% or c, shivering can be treated with an apparent impact.
[SPEAKER_01]: Great, so you can shiver without being high votes or I make, obviously, you can shiver from, you can have tigers, for example, from a fever, right, the opposite, as well as some various drug effects and things, and so that's not the answer. [SPEAKER_01]: We just talked about the fact that shivering increases actually consumption, not by 50% but by 200 to 500%.
[SPEAKER_01]: So that's an incorrect answer, so it's going to be, as you mentioned before, that it can be traded with my parity. [SPEAKER_00]: Right, and you mentioned some of the other causes of shivering, but yet transfusion reactions, pain, residual anesthetic, and all compounding that. [SPEAKER_01]: Okay, folks, I just want to take a second to shout out our Rockstar Returning Sponsor, True Learn Smart Banks.
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[SPEAKER_01]: We rely on tru Learn for our test prep, and I recommend you do the same tru Learn.com and use Code Acrack. [SPEAKER_01]: Okay, and we're back. [SPEAKER_00]: question six, which mechanism accounts for the greatest proportion of intraoperative heat loss in an adult? [SPEAKER_00]: A, conduction to the OR table, B, radiation and convection combined, or C, evaporation from the surgical site?
[SPEAKER_01]: Yeah, so you mentioned this in your overview, but it's definitely radiation and convection combined. [SPEAKER_01]: And, you know, I think that, [SPEAKER_01]: When I think about it, I think, okay, you're not really touching the OR table very much, right? [SPEAKER_01]: We don't put people on a bare OR table, and even if you are, it's just, you know, kind of your backside, right? [SPEAKER_01]: It's not your whole body, whereas your whole body can radiate and experience convection.
[SPEAKER_01]: And then evaporates from the surgical site, obviously, can't have an effect with that's also just the surgical site. [SPEAKER_01]: It's not your whole body. [SPEAKER_01]: So the thing that your whole body experiences is radiation and convection. [SPEAKER_00]: Yeah, and I don't think I got through my board exams.
[SPEAKER_00]: I think this came up on every IT and basically I said, I'm not sure if I had it on my advanced exam, but they for some reason just really want you to know that. [SPEAKER_00]: Yeah. [SPEAKER_00]: Moving on to Broncos Bazim, Key Concept 7. [SPEAKER_00]: Interoperative Broncos Bazim presents with Weasing Elevated Peak Pressures and Sharkfin Capnography Wave Forum.
[SPEAKER_00]: The differential for a high peak in our way pressures also includes a no bronchial activation pneumothorax, kink tendo, trachial tube, and mucous plug-in, so just because you see the high peak pressure doesn't mean it's bronchospasm.
[SPEAKER_00]: The first line treatment, if it is bronchospasm, is deepening the anaesthetic, and both photos and profile are bronchodilators, so that's the reason you're deepening the anaesthetic, and giving inhaled beta to agnus, and then other bronchodilating [SPEAKER_00]: nephrine, magnesium, ketamine, and corticosterolids do work, but they take hours to work and give it early if it's really severe, bronchospasm, but don't expect that to change the course in the OR.
[SPEAKER_00]: Anything to add there, Jed. [SPEAKER_01]: Nope, I think you covered it. [SPEAKER_00]: All right, then let's test your knowledge with question seven, patient with a history of asthma is intubated for an appendectomy. [SPEAKER_00]: Peak airway pressures rise to 45 centimeters of water with bilateral expatory weasings. [SPEAKER_00]: You deepen the volatile anesthetic and give all. [SPEAKER_00]: Buderal, which of the following would not be useful in the secured setting.
[SPEAKER_00]: A, inhaled cromoline sodium, B, intravenous magnesium sulfate or C subcutaneous epinephrine. [SPEAKER_01]: So as you talked about, both magnesium and epinephrine are good helpful treatments, especially in severe bronchospasm, in hell, chromal and sodium was not something you listed. [SPEAKER_01]: And so that we know is the answer, though it's certainly not a drug that I don't think I've ever used. [SPEAKER_00]: Yeah, so it's one of the mass cell stabilizer.
[SPEAKER_00]: So it has a role in preventing bronchlorous spasm. [SPEAKER_00]: If you think you're really high risk for bronchlorous spasm in a patient, which is bronchospasm, every single tad in there, and they're all not reasonable to give it. [SPEAKER_00]: It's just not going to do anything once those mass cells have degraded and you're in the middle of a bronchlorous spasm. [SPEAKER_00]: And then we need to touch on the surprisingly often tested latex allergy.
[SPEAKER_00]: Key concept 8. [SPEAKER_00]: Latex allergy is an IGE mediated. [SPEAKER_00]: It's a type 1 hypersensitivity that characteristic represents more than 30 minutes after exposure. [SPEAKER_00]: This is later than drug reactions, which typically occur within 5-10 minutes or even a short time frame.
[SPEAKER_00]: High-risk groups are patients who are fine at Bifida, usually from repeated capitalizations and exposure to latex, early in their lives, and healthcare workers who are also exposed to latex. [SPEAKER_00]: Latex accounts for approximately 15% of perioperative allergic reactions under anesthesia, but note that neuromuscular blocking agents and antibiotics are at the most common cause of perioperative antiflexus overall, [SPEAKER_00]: or your muscle vacates and antibiotics.
[SPEAKER_00]: Anything to add to key concept eight? [SPEAKER_01]: No, it's interesting. [SPEAKER_01]: You know, I think it's less common because we've moved away from latex a lot, but you're right, it still gets tested and so I think you have to know it. [SPEAKER_00]: Yeah, and something that just gets still called out at every time now. [SPEAKER_01]: Stay with us, we'll be right back. [SPEAKER_01]: All right, and we're back.
[SPEAKER_00]: Question 8, 28-year-old woman was spying a bit for the developed high-pricotention tachycardia in Ultricarya 40 minutes after induction of propofol, pentamil, and rakyronium, of a following which is the most likely cause. [SPEAKER_00]: A propofol allergy, B, latex allergy, or C, rakyronium allergy. [SPEAKER_01]: So tricky because you may know that rachuronium is one of the most common causes of antiflaxis in the OR. [SPEAKER_01]: But the key here are two things.
[SPEAKER_01]: One of the patients find a bifida which already should get your antenna up about possibly latex allergy. [SPEAKER_01]: And then also this happened specifically telling you 40 minutes after induction. [SPEAKER_01]: And while not impossible for that to be from something used in induction.
[SPEAKER_01]: The fact that they're giving you an after 30 minutes makes it a little more likely that it's a type 1, high percentage of it reaction, as you mentioned, that tend to be more than 30 minutes after exposure, and so latex is probably your most likely answer here.
[SPEAKER_00]: Yeah, I think it's the best test answer question and as you were describing in a you know I started thinking of it like what happened is 40 minutes after an induction and it's usually Insicision you've usually given a little bit more paralytic so I could this be a rocky Roney and absolutely you might have redost it and you know sensitized the first time Don't add things to the stem. [SPEAKER_00]: That's not there. [SPEAKER_00]: This is a latex allergy as written.
[SPEAKER_00]: Yep [SPEAKER_00]: Um, and I don't know why Broncos Pasm and Lorinkos Pasm are split up by latex allergy in the outline, but then we move next time to Lorinkos Pasm and post-substructive pulmonary edema.
[SPEAKER_00]: So staying true to the list the way they gave it to us, key concept nine is going to be Lorinkos Pasm, which along with aspiration or to the most serious extubation complications, [SPEAKER_00]: Learning goes phasim is most likely when the patient is in a light plane between anesthesia and full weightfulness.
[SPEAKER_00]: Treatment should include jaw thrust with positive pressure mass ventilation with 100% or 2. [SPEAKER_00]: Larson's maneuver which is different than a jaw thrust and suctioning to remove any secretions causing the learning goes phasim and if you need it, sectional calling to relax those cords quickly.
[SPEAKER_00]: Key concept 10, post-op, post-abstructive, negative pressure, pulmonary endema, occurs when forceful inspiration against an obstructed glottis, generates extremely negative intracuracic pressure, driving fluid into the LVOI.
[SPEAKER_00]: It presents within minutes to an hour after the insult of bilateral infiltrates and throthy pink secretions, treatment is supportive with oxygen, CPAP people or intubation of necessary and die-resist to get that fluid off, in most cases self-resolve within about [SPEAKER_01]: Yeah, sounds good. [SPEAKER_00]: Question number nine, a healthy patient who underwent a lapar's phopic appendectomy is estimated to develop strider with paradoxical chest movement.
[SPEAKER_00]: Jothrost and positive pressure ventilation with 100% O2 are applied, but the obstruction does not break. [SPEAKER_00]: What is the next most appropriate step? [SPEAKER_00]: A, reincipate immediately with a video learning scope. [SPEAKER_00]: B, administers, succional calling, or C, administer rocky learning. [SPEAKER_01]: Yeah, so the reason A is not correct is because you have probably larynxbasm here, so you're not going to be able to anticipate.
[SPEAKER_01]: And even if it's not 100% complete larynxbasm, you're going to have to jam a tube through mostly closed cords, and you could really cause damage to the cord. [SPEAKER_01]: So you need to use a paralytic first. [SPEAKER_01]: Now, if they had given you, you know, larceness maneuver, while the SAT is still 100%. [SPEAKER_01]: You know, could you do some other things? [SPEAKER_01]: Could you give some profile, for example, [SPEAKER_01]: yeah, but they didn't give you those options.
[SPEAKER_01]: So it's going to be either B or C. And honestly, rock your own team is fine, except presumably you just reversed your prior rock your own. [SPEAKER_01]: And so, you know, they don't give you that, but you have to think probably I reversed it. [SPEAKER_01]: And so there's still some sugema dex or, you know, statement or whatever you gave floating around, it may not be the most successful to give rock your own.
[SPEAKER_01]: And I have a better option here of [SPEAKER_01]: I think they want you to go for sucks and I'll call in here. [SPEAKER_00]: Yeah, and then I think, you know, when I tell you a healthy patient too, there's sort of letting you know if you're starting worrying about what we're about, potassium, what about you shouldn't worry about it with a healthy patient.
[SPEAKER_00]: In question number 10, following your laparoscopic appendectomy, and patient develops clinical spasm and extcipation secondary to aspiration of gastric contents. [SPEAKER_00]: Phenomenclator, he is hypoxic with bilateral infiltrates and throthy secretions in the endocrate U.T. [SPEAKER_00]: after re-intubation. [SPEAKER_00]: What is the most likely diagnosis? [SPEAKER_00]: A, aspiration humanitis, B, pulmonary embolism, or C, negative pressure pulmonary edema.
[SPEAKER_01]: Yeah, so there's no reason to say, Polymer animal is a mirror, but they're giving you aspiration to deny this as your major distractor. [SPEAKER_01]: So you've got this patient who has luring a spasm, and they're telling you they aspirated gastric contests. [SPEAKER_01]: So it's going to be worth tempting to say aspiration to deny this, except that this is very quick.
[SPEAKER_01]: This is 20 minutes later, and he's already got bilateral infiltrates, frothy secretions in the ET2, so they're really describing pulmonary edema much more than they're describing aspirational pneumonitis, and in a patient who has luringospasm, from whatever cause, whether it's from aspirational or from anything else, [SPEAKER_01]: If they then try to take a brass and their chords are closed that can cause negative pressure pulmonary edema.
[SPEAKER_01]: So this is really a picture of negative pressure pulmonary edema, but that aspiration pneumonitis is a tricky distractor. [SPEAKER_00]: And speaking of gastric contents, key concept 11, aspiration severity depends on the pH, less than 2.5 is a risk factor, and volume, greater than 0.4 ml per kilogram is a risk factor of aspirated miniaturial. [SPEAKER_00]: Three syndromes exist, mechanical who obstruction from the particulate matter.
[SPEAKER_00]: Acid pneumonia, etisromental syndrome, which was a distractor in the previous answer, and then bacterial pneumonia. [SPEAKER_00]: Initial treatment is supportive, sailing in the virus may be necessary during broadcasts, keep people from mechanical obstruction. [SPEAKER_00]: If they really got a lot of constructs, content is down, but it can worsen high-boxymia, so it's generally not recommended.
[SPEAKER_00]: If there's a little aspiration, you don't have to bronch in use sailing in the virus. [SPEAKER_00]: And then prophylactic antibiotics and steroids do not improve outcomes, and they increase the risk of secondary infection. [SPEAKER_00]: So they're also not recommended. [SPEAKER_00]: Great.
[SPEAKER_00]: Anything to add about key concepts you love in, [SPEAKER_01]: I think that [SPEAKER_01]: You know, one of the really key things is you may be asked somehow about, you know, aspiration pneumonia versus sprint pneumonitis. [SPEAKER_01]: And aspiration pneumonia just doesn't happen right away, right? [SPEAKER_01]: It takes time. [SPEAKER_01]: And so any aspiration can become aspiration pneumonia, but you don't know right away.
[SPEAKER_01]: And you don't assume that it will, maybe there could be some exceptions with extremely immunocompromised patients or something, but with your everyday patient, you're, you know, [SPEAKER_01]: If there's a reaction that involves hypoxia, it's probably an infiltration x-ray. [SPEAKER_01]: It's probably aspiration pneumonitis. [SPEAKER_01]: And if it doesn't resolve in a day or two, then it may be developing a task ration to money.
[SPEAKER_00]: A question 11, a patient aspirates gastric contents to an exhibition and develops bilateral infiltrates with worsening hypoxemia in the pack you, which intervention is most likely to be beneficial. [SPEAKER_00]: A one-protective ventilation with low tidal volumes and keep, B prophylactic broad spectrum antibiotics or C intravenous methylprednislo. [SPEAKER_01]: Okay, so here, again, we now have a description of pretty immediate infiltrates and hop-axemia after an aspiration.
[SPEAKER_01]: So this is aspiration pneumonitis until proven otherwise. [SPEAKER_01]: you, as you went over to antibiotics and steroids do not help, and so what we want to do is protect those lungs from further damage. [SPEAKER_01]: They are inflamed, they were just burned.
[SPEAKER_01]: They just essentially got a burn, so we want to be careful and gentle with them, and so low tide of volume ventilation is going to, and lowering driving pressure, which is optimizing people as well, is what's going to protect the lungs. [SPEAKER_00]: Yeah, and I'll be honest. [SPEAKER_00]: I don't think you're wrong about the diagnosis here. [SPEAKER_00]: It could be aspirational humanitis.
[SPEAKER_00]: I don't know if this isn't also a description of negative pressure, pulmonary, and demon, right? [SPEAKER_00]: They don't give you the pink-throw-piece secretions, but it's bilateral infiltrates with five-boxemia. [SPEAKER_00]: If you're a luringospasm, it could be the same thing. [SPEAKER_00]: Both of those, if you're a high-poxymic, one-protective ventilation of low-title volume, some people is the correct answer. [SPEAKER_01]: Great.
[SPEAKER_00]: Um, and lastly, we'll move on to Millionaire Hyperthermia, which is heavily tested across genetics, pathophysiology, clinical presentation and management, um, expect multiple angles on your board examinations, uh, key concepts of 12. [SPEAKER_00]: Malignant hyperthermia is an aerosomal dominant parmaocode genetic disorder triggered by volatile anesthetics and sexinocolein.
[SPEAKER_00]: In 50 to 80% susceptible patients, a co-oprit is a mutation in the rea and Indian receptor gene RYR1, which controls calcium release from the sarcoplasmic reticulum. [SPEAKER_00]: More than two hundred ten mutations exist in a negative cardiac, a negative genetic test does not eliminate susceptibility. [SPEAKER_00]: Prior to an eventful anesthetics, which are also not reassuring, because 50% of patients have developed a major head to a more private trigger exposure.
[SPEAKER_00]: Deconcept guilty, triggering agents, cause uncontrolled calcium release from the sarcoplasmic reticulum, producing a massive hypermoda ballic state. [SPEAKER_00]: So you have writing and rising entitled carbon dioxide. [SPEAKER_00]: That's the earliest and most sensitive sign followed by tech cardio, rigidity, acidosis, rubbed with myolysis, and hyperclimia. [SPEAKER_00]: Fever is a late finding, despite being in the name.
[SPEAKER_00]: In mortality used to be around 70% before dentially [SPEAKER_00]: Key concept 14 in our last one for the day, denture lean blocks calcium release from the cycloplasmic reticulum, so it's our treatment of choice. [SPEAKER_00]: The dose is 2.5 milligrams per kilogram I feed, and you repeat it every five minutes until the patient responds, so lower and tidal cupboard they ask. [SPEAKER_00]: side, decreased rigidity, lowering of the heart rate.
[SPEAKER_00]: An additional treatment for a millionth hypothermia includes active cooling, reversal of acid doses, addressing hypercolineum if it's present, and diariesing to greater than 1 ml per kilogram per hour to protect the kidneys from the raptile myelisus. [SPEAKER_00]: And don't forget, if you're in the middle of the MH crisis, we're concerned about it. [SPEAKER_00]: There's always the M House hotline that you can call for help with diagnosis or treatment.
[SPEAKER_00]: In recall, there are a couple of mimics, neural-optic melancholy, and similar to the key mimic. [SPEAKER_00]: That's dopamine antagonist-induced develops over 24 to 72 hours. [SPEAKER_00]: It's non-herited and not triggered by flexional cooling or volatiles. [SPEAKER_00]: And then the other one is serotonin storm, which has hyper-reflexia, clonus, and shivering, compared to the lead-pipe rigidity of a [SPEAKER_00]: neurologic malignant syndrome.
[SPEAKER_00]: And then for neurolaptic versus MH, think about the time frame, MH is pretty immediate, neurolaptic malignant syndrome, kind of lags 20, 4 to 72 hours. [SPEAKER_00]: Ready for questions? [SPEAKER_01]: Let's do it. [SPEAKER_00]: All right, last set of questions, Jed, home stretch. [SPEAKER_00]: Question 12, a 23-year-old male undergoes an open appendectomy with seval fluorine and sexinocoline.
[SPEAKER_00]: One hour in, entitled Comber and Dioxide Riders' to 78 millimeters of mercury, despite serial increases in manipulation on the ventilator. [SPEAKER_00]: His jaw was difficult to open on induction and his temperature is now 38.1 degrees Celsius. [SPEAKER_00]: What is it, earliest and most sensitive indicator of MHC in this case? [SPEAKER_00]: A, temperature elevation, B, most of which are today or C, rising in title, covered in accent. [SPEAKER_01]: Yes, a little tricky.
[SPEAKER_01]: So, as you said, the first indicator is going to be rising in title CO2, but it's tricky in this question because they tell you that on induction his job is difficult to open. [SPEAKER_01]: And so it seems like that came first, but remember many, many jaws are difficult to open on induction. [SPEAKER_01]: Right? [SPEAKER_01]: That's why we give the paralytic and wait for the paralytic to kick in.
[SPEAKER_01]: And so that, it's too early for that to have been the issue plus at that point he hasn't [SPEAKER_01]: been given the Seval Floring, and maybe just got the sucks at all calling, so too early for that job would do to beat from the Millign Hyperthermia, so it's going to be the rising entitles you'll do. [SPEAKER_00]: Yeah, I think it would give you master's pass-in as the phrase for a strong, difficult to open. [SPEAKER_00]: You might have a reason to choose that.
[SPEAKER_00]: If I was to answer, but I think the most rigidity sort of reflects the whole body state, not just the master's pass-in. [SPEAKER_00]: And just know, like we said in the keywords, the rising entitle CO2 is the earliest, most sensitive sign of milk in the hyperthermia. [SPEAKER_00]: Question 13, which of a following correctly described Stancholine's mechanism of action in the Lincoln Hyperthermia Treatment?
[SPEAKER_00]: Eight, it blocks the Sino-Coline release at the neuromuscular junction. [SPEAKER_00]: Be it inhibits calcium release from the Starkopossic reticulum, or see it competitively and technizes volatile anesthetic except the ryanidine receptor. [SPEAKER_01]: And as you just have to know, as you went over to him that it inhibits calcium release from the Starkopossic reticulum. [SPEAKER_00]: Yeah, and it's a straightforward question that you just need to know.
[SPEAKER_00]: I just love it for how many phrases they stuck in there that if you don't know it, sounds kind of right and isn't the right answer. [SPEAKER_00]: Question 14, in 19-year-old, of the family history of malignant hyperthermia, is scheduled for a laparoscopic call of suspected me under Tiva. [SPEAKER_00]: She tests the negative for our wire mutation. [SPEAKER_00]: One mutation, which statement is most accurate?
[SPEAKER_00]: A, she can safely receive volatile anesthetics given her negative genetic test. [SPEAKER_00]: Beep, she is not at risk if her parents tolerated prior general anesthetics without incident, or seek an negative genetic test does not eliminate her risk of developing milk and hyperceramium. [SPEAKER_01]: So, as you said, she is not able to eliminate her risk by having a negative genetic test. [SPEAKER_01]: There are other mutations that are tested for that could be the cause.
[SPEAKER_01]: So, see as your correct answer that a negative genetic test does not eliminate her risk of developing image. [SPEAKER_00]: Yeah, she might have at 211 for whatever number we're up to at this point. [SPEAKER_00]: Question 15, you are treating a patient for full movement in the Lincoln Hyperthermia. [SPEAKER_00]: Given dentially in the begun active cooling, the core temperature is now 38 degrees, but should you do?
[SPEAKER_00]: A, stop active cooling, B, continue cooling to 37 degrees Celsius, or C, continue cooling until rigidity resolves. [SPEAKER_01]: Yeah, and as you went over, you want to stop active cooling at 38 degrees so that you don't overshoot and cause height both, or me, so you're going to stop active fully. [SPEAKER_00]: Yeah, and regenerative resolving is when you would consider stopping giving repeated doses of dantraline, not cooling.
[SPEAKER_00]: In the last question, question 16, a patient on how a parodal and, uh, circulating develops fever, rigidity and autonomic instability, 24 hours post-operatively following an anti-precedure during which they received succinyl cooling, which over following is the most likely diagnosis. [SPEAKER_00]: A, serotonin stored, B, neurolaptic malignant syndrome, or C, malignant hypothermia. [SPEAKER_01]: Yeah, so this is tricky. [SPEAKER_01]: These come up and they just are tricky.
[SPEAKER_01]: You went over this. [SPEAKER_01]: And so you know it's not serotonin storm because that has hyper-reflexia and cloness and shivering, but not fever and rigidity. [SPEAKER_01]: And so you're deciding between NMS and MH. [SPEAKER_01]: And, [SPEAKER_01]: I think what just really comes down to is the time period. [SPEAKER_01]: So this is 24 hours post-op. [SPEAKER_01]: And they also were giving you, of course, these, and I don't have them in urgent medications.
[SPEAKER_01]: So ultimately, it is going to come down to that time period. [SPEAKER_01]: If they had said this happened, you know, in the OR, I think that would be much trickier. [SPEAKER_01]: But here, because it's 24 hours after, I think it's more likely to be neuroleptic malignant syndrome. [SPEAKER_00]: Yeah, these things run together a little bit and can be hard to tease apart.
[SPEAKER_00]: I think if they gave you like lead pipe rigidity, you know, that would be slam dunk one for one sort of keyword. [SPEAKER_00]: If you see that, that's neurologic malignant syndrome. [SPEAKER_00]: If they talked about more of a spastic picture, maybe that would be serotonin storm, but neural optic malignant syndrome, on this time frame, and this stem is the best thing.
[SPEAKER_01]: And I should say to him, I said, medicines, but it's just the one answer, the Halloparent all that's the answer I do to me, then they give you the surgery, which is the SSRI. [SPEAKER_01]: So it's quite tricky, because they're giving you the serotonin and the dopamine to you really have to think about each of those and what their symptoms are. [SPEAKER_00]: Perfect. [SPEAKER_00]: That's all I'm talking about. [SPEAKER_01]: Fabulous.
[SPEAKER_01]: All right, a lot of great stuff here. [SPEAKER_01]: Let's turn to the part of our show where we make random recommendations. [SPEAKER_01]: What do you have to recommend that the audience check out for fun? [SPEAKER_00]: I'm going to a classic and one of my favorites go outside. [SPEAKER_00]: I can't recommend it enough. [SPEAKER_00]: There's fresh air. [SPEAKER_00]: There are these green things plants. [SPEAKER_00]: They make oxygen. [SPEAKER_00]: It's so good to breathe.
[SPEAKER_00]: There's yellow orb in the sky. [SPEAKER_00]: It heats you up and warms you. [SPEAKER_00]: Sometimes water comes from the sky. [SPEAKER_00]: They call it rain. [SPEAKER_00]: It's absolutely magical. [SPEAKER_00]: Just go outside. [SPEAKER_01]: love it. [SPEAKER_01]: Yeah, it is amazing.
[SPEAKER_01]: Especially, you know, we get so busy and it's easy just to forget about that, but the other day I was walking to some event at my daughter's school, and it was just a gorgeous day, and I was out walking, and I just realized, man, I haven't haven't, like, just gone for a walk in a while, and it is really, it's beautiful. [SPEAKER_01]: It's nice, it's a way to just relax a little bit, breathe, take a break from the work you're doing.
[SPEAKER_01]: So I couldn't [SPEAKER_01]: I'm going to recommend for when you're not outside, I'll show my wife and I found recently called Slow Horses. [SPEAKER_01]: It's on Apple TV+, and it's really, it's great, but we finish the first season. [SPEAKER_01]: We're on to the second. [SPEAKER_01]: It's really entertaining. [SPEAKER_01]: Well done.
[SPEAKER_01]: It's about a group of kind of misfit British spies who end up taking on some important cases and really well done [SPEAKER_01]: very well acted as well. [SPEAKER_01]: So I highly recommend it slow horses on Apple TV plus. [SPEAKER_00]: It's not a spoiler. [SPEAKER_00]: What in the world is the name from? [SPEAKER_00]: Yeah, I guess that's what it's about.
[SPEAKER_01]: I'm sure people in England know this, but my understanding from the show is that a slow horse is like a underperforming person, at least at least an unperforming spy. [SPEAKER_01]: So they are called slow horses because they're [SPEAKER_01]: Not that they aren't with it there.
[SPEAKER_01]: That's how they're labeled and then they the name and the show the name of the Location where they work is called Slaw House and it sounds like slow house and so I think that's part of it All right, thanks so much Tim. [SPEAKER_01]: We'll see you next time [SPEAKER_01]: Of course, thank you. [SPEAKER_01]: All right. [SPEAKER_01]: Hopefully you got as much out of that as I did. [SPEAKER_01]: That was really fantastic. [SPEAKER_01]: Let us know what you thought.
[SPEAKER_01]: Go to the website, acrack.com, where you can leave a comment. [SPEAKER_01]: Others can learn from what you have to say. [SPEAKER_01]: If you are a fan of the show, you can follow us. [SPEAKER_01]: We're on Twitter. [SPEAKER_01]: We are on Facebook. [SPEAKER_01]: We are on Reddit. [SPEAKER_01]: And we are on Instagram. [SPEAKER_01]: I'm AdJ Wolpa on Twitter. [SPEAKER_01]: And we're at Acrack Podcast. [SPEAKER_01]: And you can find us on all those other platforms as well.
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[SPEAKER_01]: Sonia Aminat is our tech lead, Taylor Duggen, William Mao, and Rachel Furman are our production assistants and social media managers. [SPEAKER_01]: Thanks so much for all you do. [SPEAKER_01]: Our original ACRAG music is by Dr. Dennis Quow. [SPEAKER_01]: You can check out his website at studymusicproject.com. [SPEAKER_01]: All right, that is it for today. [SPEAKER_01]: For the ACRAG podcast, I'm Jed Wolpa. [SPEAKER_01]: Thanks for listening.
[SPEAKER_00]: Remember what you're doing out there every day is really important and valued.