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215 Cards in this Set
- Front
- Back
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Described ASA II:
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mild systemic disease, no functional limitations
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describe ASA III:
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severe systemic disease that results in functional limitations.
example: diabetes with vascular complications |
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describe ASA IV:
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severe systemic disease that is a constant threat to life.
example: congestive heart failure |
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describe ASA V:
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moribund
not expected to survive without the operation example: AAA |
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describe ASA VI:
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organ harvest
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describe ASA E:
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emergency. Can be added to any of the other ASA classifications.
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Why are antihistamines given preoperatively?
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for their sedative and antiemetic properties
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why are anticholinergics given preoperatively?
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to produce sedative and amnesic effects
prevention of reflex bradycardia as an antisioalagogue (anti saliva.) |
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Which anticholinergic, beginning with s, is given as an antisioalagogue?
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scopolamine
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what sets scopolamine apart from other anticholinergics?
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it is three times more potent as an antisioalagogue.
it is more sedating than other anticholinergics (eight to 10 times more.) |
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Describe the contrast between scopolamine and glycopyrrolate:
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glycopyrrolate does not produce sedative or amnesic effects.
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When are antacids given before surgery?
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15 to 30 minutes before induction.
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What is the minimum fasting time for clear liquids?
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two hours
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what is the minimum fasting time for breast milk?
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four hours
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what is the minimum fasting time for infant formula?
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six hours
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was a minimum fasting time for a light meal?
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six hours
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what are the choices for anesthetic technique?
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General
regional peripheral nerve block Mac a combination of any of these |
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why would you choose short acting drugs with neurologic cases?
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because rapid neurological evaluation is needed
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what 6 things does an ideal anesthetic provide ?
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patient likes it
optimal conditions for surgeon rapid recovery no postoperative side effects cheap allow early discharge from pacu |
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what is rapid sequence induction?
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injection of a hypnotic immediately followed by injection of a rapid skeletal muscle paralytic
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what is the purpose of preoxygenation ?
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to replace nitrogen in the patient's frc
it increases the margin of safety during periods of apnea |
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what is a good drug use for rapid sequence induction if succinylcholine is contraindicated?
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rocuronium
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can you use long acting paralytic to facilitate intubation?
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yes, you just wait for them to work.
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Name one option you can use if you cannot perform rapid sequence induction?
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inhalation induction with sevoflurane
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how long does it take for the patient to go to sleep with inhalation induction of sevoflurane?
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within one minute when breathing 8% sevoflurane.
LMA can be inserted after two minutes once they are asleep, you can give a skeletal muscle relaxants to facilitate intubation (or just insert an LMA.) |
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What is the most common regimen for maintenance of anesthesia?
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a combination of drugs, may include both inhaled and injected
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how does the administration of nitrous oxide affect the action of concurrent inhaled anesthetics?
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it allows for a decrease in delivered concentration of the volatile drug, resulting in less cardiac depression despite the same total dose of anesthetic drugs
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what is the ASA definition for Mac anesthesia?
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a procedure in which an anesthesiologist is requested or required to provide anesthetic services, preop, support of vital functions, administration of sedatives/analgesics/hypnotics/anesthetic drugs
provision of services as needed to complete the procedure safely be prepared for a "unplanned" general anesthetic (in which extra care is needed in monitoring to prevent airway mishaps such as obstruction and desaturation.) |
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What are the 3 most common disorders following anesthesia in the pacu?
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nausea and vomiting
need for upper airway support systemic hypertension |
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name a couple of simple treatments for loss of pharyngeal tone in the pacu:
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jaw thrust
CPAP |
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what is the significance of obstructive sleep apnea?
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they are particularly prone to airway obstruction
they should not be excavated until they are fully awake and following commands |
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which muscles recover faster from neuromuscular blockade, diaphragm or pharyngeal?
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diaphragm. Patients sometimes have trouble supporting their airway in the pacu
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when does laryngospasm occur postoperatively?
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when the extubated patient is emerging from anesthesia
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how can we treat postoperative laryngospasm?
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jaw thrust with CPAP
.1 to 1 mg per kilogram of succinylcholine |
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what fraction of patients who received premedication still experience postoperative nausea and vomiting?
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one third
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who is high risk for postoperative nausea and vomiting?
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women
history of motion sickness non smokers the use of postoperative opioids |
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what is the percentage risk based on numbers of risk factors for postoperative nausea and vomiting, 1 to 4?
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1,10%
2, 21% 3, 39% 4, 61% |
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how much dose propofol decreased postoperative nausea and vomiting?
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19%
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how much does pre
treatment with antiemetics, steroids included, decrease postoperative nausea and vomiting? |
26%
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what is more effective with postoperative nausea and vomiting, prophylaxis or rescue?
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prophylaxis
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when should dexamethasone be given for ponv prophylaxis?
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at the start of the surgery
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when should serotonin receptor antagonists be given for prophylaxis?
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30 minutes before the end of the anesthesia
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what is the FDA warning on droperidal?
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torsades
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organ wise, why is, fluid a challenge with kids?
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liver and kidneys are immature
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what percentage water is a term baby?
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70%
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what percentage water is an adult?
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55 to 60%
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when does hyperkalemia occur with newborns?
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the first 10 days
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how much fluid to adults excrete?
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14%
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how much fluid to newborns excrete?
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33%
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name three things that put newborns at a disadvantage respiratory wise:
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1. Big tongue
2. Collapsing pressure with inspiration (compliant Airways and thorax) 3. Less alveoli |
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when do alveoli develop?
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after birth
there are 300 million at 18 months |
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what happens hemodynamically when placental circulation is cut off?
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decreases PVR (with increased pulmonary blood flow)
increased SVR |
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what causes persistent fetal circulation?
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acidosis or hypoxemia
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with PDA, we're is the whole?
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between the atria
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what two things do we monitor for when giving children a lot of fluid?
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CHF
PDA |
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which type of tracheal esophageal fistula is the most common?
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type C.
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what is the best way to intubate a child with tracheal esophageal fistula?
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awake intubation
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where does myelomeningocele occur?
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lower back.
may need to do a cesarean section |
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describe congenital diaphragmatic hernia:
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abdominal contents herniate through the diaphragm into the plural cavity
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with congenital diaphragmatic hernia, if the patient desaturate's or gets hypotensive quickly, what 2 differential diagnoses must you consider quickly?
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pneumothorax
pulmonary hypertension |
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what is it that benzoisoquinolone paralytics elicit that causes drop in blood pressure?
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histamine release
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Re: duration of action, when do we choose a nondepolarizing neuromuscular relaxants?
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when rapid paralysis is not needed
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describe how succinylcholine attaches to the receptor, and it's hydrolysis:
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it grabs on just like acetylcholine
the difference is, hydrolysis is slow. It stays there and holds the cell depolarized. |
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If a patient has incomplete jaw relaxation after receiving succinylcholine, what 2 things could it be?
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masseter muscle rigidity related to MH
spasm related to succinylcholine |
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what effect does mild hypothermia have on steroidal neuromuscular relaxants?
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it doubles the duration of action
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if potassium is low, how does this affect nondepolarizing neuromuscular blockers?
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makes them stronger
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if potassium is low, how does this affect succinylcholine?
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makes it weaker
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if potassium is high, how does this affect succinylcholine?
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makes it stronger
membrane is partially depolarized |
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if potassium is high, how does this affect nondepolarizing neuromuscular blockers?
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makes them weaker
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what will happen if you give succinylcholine to patient with Burns?
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hyperkalemia
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how do Burns affect nondepolarizing agents?
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there is resistance
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how do stroke patients react to neuromuscular blockers?
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there is resistance to the drug on the affected side
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what effect do opioids have on sodium, potassium, and cell membrane?
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there is increased potassium conductance, which leads to hyper polarization
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what can opioids cling to when given in a spinal?
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there are mu receptors in the subarachnoid space
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how do epidural opioids produce pain relief?
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they diffuse slowly across the dura toward the mu receptors in the subarachnoid space
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what is the dose of epidural opioids compared to subarachnoid opioids?
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5 to 10 times
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on the anesthesia machine, where do the flowmeters send gases to?
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either to be oxygen flush valve or the vaporizer's
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how do you turn on the vaporizer?
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first press the release button, then turned the vaporizer (lefty loosey)
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where does excess from the APL valves go?
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into the scavenging system
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what two places does the scavenging system receive waste gas from?
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either the APL valves or the ventilator relief valve (if you are on vent.)
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Where does waste gas go with an active scavenging system?
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to the suction canister
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where does the waste gas go with a passive scavenging system?
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hospital ventilation (passively)
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what are the maximum doses for Marcaine and Marcaine with Epi?
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1.5 mg per kilogram and 2.5 mg per kilogram, respectively
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what is the dose for dantroline?
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2
3 milligrams per kilogram, may repeat every 10 minutes |
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what is the formula for mean arterial pressure?
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confirm this
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what does decrease on systolic peak with arterial waveform indicate?
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dehydration
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who is most at risk for postoperative nausea and vomiting?
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female, history of motion sickness, non
smokers |
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which types of patients are at risk for wheezing with beta
blockers? |
COPD, asthma
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do we need to stop NSAIDS prior to neuraxil anesthesia?
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no
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how soon before surgery do we stop coumadin?
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4 to 5 days, then check PT
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which Pressor is preferable with MAOIs?
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Neo
Synephrine |
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which age group gets a chest xray automatically?
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75 years or older
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which 2 classis of cardiac drugs cannot be stopped abruptly?
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beta
blockers alpha 2 agonists there will be withdrawal |
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if your patient has COPD or asthma, what do we give as an alternative to a beta
blocker? |
alpha
2 agonists |
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what 2 advantages to epidurals have over spinal?
hint: location of block, dosing |
epidurals can produce segmental block
you can titrate the block with epidurals throughout the procedure and afterwards |
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in which direction is the vertebral body?
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anterior
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in which direction is the vertebral arch?
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posterior
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what are the things called sticking out of the vertebrae posteriorly and laterally?
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transverse processes (laterally)
spinous process (posteriorly) |
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how many vertebrae are there?
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24
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how many of each type of vertebrae are there?
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7
12 5 5 |
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what is the difference in position between thoracic and lumbar spinous process ?
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thoracic points downward
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what is the sacro hiatus?
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the hole between the fused lamina of the fourth and fifth sacro vertebrae.
the needles for a caudal block goes here |
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what is the bony prominence at the bottom of the neck?
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The landmark for C 7
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what is a landmark for the T7 T8 interspace?
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draw a line between the lower unit of the scapula (commonplace for thoracic epidural)
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what holds the spine together?
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anterior and posterior spinal ligaments
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name the three meninges and their location:
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dura (outer)
arachnoid pia (surrounds cord) |
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which to meninges are inherent to one another?
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dura and arachnoid
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what is the structural characteristic of the dura?
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support
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what is the structural characteristic of the arachnoid?
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it is impermeable
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if a spinal is failed, we are does the dose and up?
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in the sub dural space
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what type of spinal roots are dorsal?
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afferrant
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what type of spinal roots are ventral?
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efferent
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how many cranial nerves are there?
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31
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how many of each type of spinal nerves are there, respectively?
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8, 12, 5, 5, 1
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where are the spinal nerves located?
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in the subarachnoid space. They lie dependent in supine position
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how does epidural medication get absorbed?
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with time, it defuses into the subarachnoid space and it reaches the nerve roots and spinal cord tracts
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which nerves get blocked with a very high spinal?
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cranial nerves
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how deep does an epidural go in the mid
thorax? |
4 mm
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how deep does an epidural go at L2?
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6 mm
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what is the bleeding risk with epidurals?
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damage to the artery of adamkewicks
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what types of procedures are spinal is usually used for?
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lower abdominal
peroneal lower extremities |
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do we use epidurals and spinals with upper abdominal surgeries?
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no. There can be breathing difficulties.
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What is the difference in block between epidurals and spinals?
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epidurals are segmental in nature. Spinals get a larger area.
also, epidurals are not optimal if you want to hit lower sacro roots |
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name the four absolute contraindications to neuraxial anesthesia:
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refusal
infection at the site increased intracranial pressure bleeding issues |
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which two positions are optimal for insertion of a spinal or epidural?
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setting or lateral
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Re: choice of insertion site, in which direction do you increase the likelihood of a failed spinal?
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as you go more caudal
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what are the sizes for spinal needles?
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22 or 25
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what is the advantage with a pencil needle?
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less headache
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what is the disadvantage with a pencil needle?
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harder to insert
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in which case it is the paramedian approach best for epidurals?
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narrowing of the interspace or trouble flexing the spine
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with midline insertion of a spinal, in relation to the vertebrae, how is the spinal needle inserted?
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it goes along the top of the lower vertebrae
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where do we insert the epidural with the paramedian approach?
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1 cm lateral to midline
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what does success with the paramedian approach largely depend on?
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appreciation of anatomy encountered
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how do we confirm placement of a spinal?
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flow of CSF or blood tinged CSF
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what if we get continuous blood tinged CSF?
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try another site
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how fast do we push the spinal anesthetic through the syringe?
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3 to 5 seconds
(then drop back again to confirm your still in the subarachnoid space.) |
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Name three factors that determine where the spinal will have its affect:
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position
relation to curvature of the spine baracity of the solution |
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in which direction does recovery from a spinal go?
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from high to low
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what effect does isobaric solution have in terms of block?
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more profound motor block.
longest duration of action |
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what is the duration of action of morphine in a spinal?
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24 hours
patient needs to be admitted |
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what is the duration of action of lidocaine in a spinal?
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60 to 90 minutes
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what is the significance of chloroprocaine in practice?
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it may replace lidocaine
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which agents have a long duration of action with spinal?
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bupivacaine
tetracaine |
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describe testing onset of sympathetic block with spinal:
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use alcohol swab
do this 30 to 60 minutes after the spinal is given |
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how do you test sensory block with a spinal?
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sharpness test
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if you think you have a failed spinal, how do you proceed with a second attempt?
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choose another site, but make sure the combined dose of both attempts does not exceed the max for one dose
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which type of innervation does a spinal hit?
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sensory
motors sympathetic |
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describe how area of sympathetic block computers to area of sensory block:
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sympathetic block exceeds sensory block by 2 to 6 dermatomes
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describe patient feeling short of breath with spinal:
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there is loss of proprioception, not loss of alveolar ventilation
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describe the hemodynamics of severe hypotension with spinals:
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decreased preload
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describe the hemodynamics of mild hypotension with spinal:
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decreased after load
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how do you treat bradycardia with a spinal?
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atropine or ephedrine
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describe the pathophysiology of spinal headache:
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supporting structures are stretched
blood vessels are distended |
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how is a spinal headache relieved?
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by lying down
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how do you treat a spinal headache medically?
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fluids, bedrest, pain management, maybe a blood patch
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describe a total spinal:
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loss of consciousness
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how do you treat a total spinal?
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supportive treatment
no sitting |
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in which case we do not sedate a patient with epidural insertion?
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labor and delivery
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describe a tuhoy epidural needle:
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it has a blunt tip
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what significance does L1 have for epidural?
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it is also a site for a low epidural
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describe the steps to inserting an epidural finder:
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finder is inserted until resistance is met, local is injected
push in and out in a medial/cephalad direction until resistance disappears |
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describe loss of resistance technique:
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advance needle while assessing injection resistance with syringe. The plunger keeps springing back, until it passes through the ligamentum flavum, and into the epidural space. Here is where you give the contents of the syringe
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describe the hanging drop technique:
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small drop on the hub of a needle. Advance until the drop gets sucked in
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once you get into the epidural space, how far in does the epidural go?
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5 cm
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how do you try to rule out a wet tap with epidural insertion?
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drawback with a 3 cc syringe. If you get nothing, there is no wet tap
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what influence does baracity of the solution have with an epidural?
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it has no influence
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what role does epinephrine have with epidural and spinal solutions?
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through vasoconstriction, it limits systemic uptake and toxicity
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what is the site of action for un
epidural? |
spinal roots
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can epidurals have sympathetic block?
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yes, but it is slower
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what could we do if a massive epidural does is given into the subarachnoid space?
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consider irrigation of the subarachnoid space to dilute and prevent neurologic injury
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if paresthesia occurs on advancement, what is the significance?
|
it is almost always transient
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which needle has a back eye?
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tuhoy
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what effect does inhalation anesthesia have on hemodynamics?
|
it decreases SVR and mildly decreases cardiac contractility
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describe the risk for acidosis with massive infusions of crystalloids:
|
they have lots of chloride
there could be chloremic induced NAG acidosis |
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when should we use crystalloids containing dextrose?
|
only with diabetes.
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What is the half
life of albumin? |
16 hours
|
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which type of dextran is used to enhance perfusion in the microcirculation?
|
dextran 40
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what is given to patients to help with hypersensitivity prior to dextran?
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dextran one
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discuss bleeding issues with dextran 70 and dextran 40:
|
there can be decrease in platelet aggregation and loss of clotting factors
avoid with known coagulopathies |
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when we "type" blood, what are we checking?
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a, B, Rh
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when we "cross match" blood, what do we do?
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we take donors red blood cells and incubate them in the recipients plasma. If there is agglutination, they are incompatible
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what is type specific blood?
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only ABO and Rh is checked.
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What is the risk of hemolytic reaction with type specific blood?
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one in 1000
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what is partially cross matched blood?
|
there is visual observation for macro agglutination
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if you end up having to give type O blood in an emergency, which is better: whole blood or packed red cells?
|
packed red cells
there are less antibodies |
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what is a type and screen?
|
type and Rh are checked. Plus, common antibodies are checked.
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What is the risk for reaction with only type and screen?
|
one in 10,000
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what is the effect of moderate anemia postoperatively?
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there is no evidence of any adverse effects
|
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women how much blood loss would we consider administering packed red cells?
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1500 to 2000
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what is the reaction risk unique to platelets?
|
they have a lymphocyte antigens
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in terms of factors, what does cryo precipitate have a lot of?
|
factor VIII
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when does transfusion related acute lung injury usually occur?
|
within six hours of the transfusion
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what is the clinical picture with transfusion related acute lung injury?
|
hypoxemia
noncardiogenic pulmonary edema the pulmonary edema fluid has high protein content |
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how does transfusion affect risk for postoperative infection ?
|
there is immunomodulation with transfusion. It contributes to postoperative infection
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what effect does the storage of blood have on ability of the cells to to deliver oxygen?
|
storage of blood decreases 2,3 dpg. They say sicker patients should get blood that has not been stored for that long
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why do we give calcium to patients who have received a lot of blood?
|
because citrate binding to calcium
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what are blood warmers used for?
|
to decrease the rate of transfusion hypothermia
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when is cryo precipitate indicated ?
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fibrinogen less than 150
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what are the signs and symptoms of hemolytic reaction?
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lumbar/sternal pain, flushing, dyspnea
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describe normovolemic humoral dilution:
|
draw blood off the person
tank them with fluids so they are dilute when they lose the blood give the blood back |
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describe the pharmacokinetics of induction anesthetics:
|
they are lipophilic and go to the lipophilic areas of the body (brain, spinal cord.)
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Describe the pharmacokinetics of the termination of propofol and most intravenous anesthetics:
|
redistribution from highly vascular compartment's to less vascular compartment's
|
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dose propofol potentiate neuromuscular blockers ?
|
no
|
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describe the chemistry of theopental and methohexital:
|
high pH. Precipitates when given with low pH drugs
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what effect do barbiturates have on cerebral blood flow?
|
they decrease it
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what effect do barbiturates have on blood pressure with induction?
|
only modest effect
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in what two instances are barbiturates usually use?
|
rapid sequence induction
to decrease intracranial pressure |
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what is the classic drug combination with rapid sequence induction ?
|
theopental and succinylcholine
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why is rapid sequence induction performed?
|
so we can avoid mask ventilation and decreased aspiration risk
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how does versed terminate?
|
rapid redistribution
|
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describe the pharmacokinetics of ketamine:
|
it is highly lipid soluble
|
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describe the pharmacodynamics of ketamine:
|
no respiratory destruction
promotes bronco dilation, promotes analgesia |
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describe the respiratory and human dynamic effects with etomidate:
|
less respiratory depression than barbiturates
less decrease in cardiovascular activity |
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when can dexmetomidine be used?
|
adjunct to general anesthesia
awake fiber optic intubation in combination with spinal anesthesia |
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when inserting a needle into the spine, what will it transverse first?
|
Supra spinous ligament
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