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161 Cards in this Set

  • Front
  • Back
What are the 4 PROPERTIES of general anesthesia?
A mnesia
A nalgesia
H ypnosis
M uscle relaxation
How many STAGES of anesthesia are there?
What is Level 1 anesthesia called and what are the qualities that define it?
- Unresponsive to verbal commands, responds to painful stimuli
What are the 4 PHASES of all types of anesthesia?
I nduction
M aintenance
E mergence
T ransfer
What is Level 2 anesthesia called and what are the qualities that define it?
- Irregular breathing, laryngospasms, secretions, arrythmias, hyperesthesia
What is Level 3 anesthesia called and what are the qualities that define it?
- stimulation increases respirations, mild hypotension
What is Level 4 anesthesia called and what are the qualities that define it?
- respiratory depression but responds to maximal stimulation, hypotension unless stimulated, minimal cardiac response to stimulation
What is Level 5 anesthesia called and what are the qualities that define it?
- apnea, no responses to stimulation (SNS or any other), arrythmias
What stage of anesthesia is consider the danger zone for a patient?
Level 2 Depression-Excitation
(risk of layrngo/broncho spasms)
What are the three methods for providing anesthesia?
Inhalation only
Total IV anesthesia (TIVA)
Balanced (inhalation/IVA)
What method of anesthesia is the most common?
Balanced anesthesia (inhalation + IVA)
What is the PRIMARY goal of the INDUCTION phase of general anesthesia?
Produce unconsciousness and move to Level 3 without compromising cardiovascular stability
What are the general steps for intubation from when the patient rolls into the OR?
1. apply monitors
2. Baseline VS
3. Align Pharyngeal/ Occipital/oral axis
4. denitrogenate @ 100% O2
5. Induce patient
6. Intubate
What are the 5 cardinal signs for appropriate intubation?
1. Visualize ETT passing through vocal cords
2. Condensation in the ETT
3. sustained ETCO2 confirmation
4. Bilateral breath sounds ausculated
5. No borborygmi (air in the stomach)
What are 2 ways that you can denitrogenate your patient?
1. normal breathing of 100% O2 for 3-5 min
2. patient breaths 4 vital capacity breaths (maximum inhalation/exhalation)
What are the most common barbituates used for anesthesia induction?
Thiopental (Pentothal)
Methohexital (Brevital)
Thiamylal (Surital - not in U.S.)
What are the most common non-barbituates used for anesthesia induction?
Propofol (Diprivan)
Etomidate (Amidate)
Ketamine (Ketalar)
What sign signifies your induction drug has reached the desired effect?
Loss of lid reflex (no reaction with eyelash stimulation)
What type of drug is given FIRST during the induction phase?
Adjuvant drugs (e.g. Fentanyl, Lidocaine, Esmolol)
What drug is given SECOND during the induction phase?
Induction agent (e.g. barbituate, non-barbituate)
What drug is given THIRD in the induction phase?
The NMBA (e.g. atracurium, vecuronium, succinylcholine)
What should be administered after successful intubation?
Volatile gas or repeat dose of opioids
How often do you check vital signs during anesthesia?
A minimum of q5" (but as frequent as q2")
What are two differences differences between standard induction and Rapid Sequence Induction (RSI)?
1. simultaneous administration of induction agent & paralytic
2. Application of cricoid pressure from induction through verification of ETT
What determines whether a patient must be done by RSI or standard induction?
Any risk of a "full stomach"
- includes dz that delays gastric emptying, recent meals, excess weight, altered mental status (chemical/biological)
Why is Nitrous Oxide (N20) used in anesthesia? What is the effect called?
It acts as a carrier agent for volatile gases via the second gas effect?
What sign indicates readiness for intubation?
Jaw relaxation
What procedures/conditions warrant ETT placement?
1. Intracavity surgical procedures
2. Any position other than supine
3. Any position that inhibits direct view of the airway
4. Any condition that places the patient at risk for a "full stomach"
During the first 5 min into your anesthesia case, the patient's BP drops. What are your options?
1. Reduce volatile gas
2. Administer fluid challenge
3. Administer vasoactive drugs
What is the main difference between Monitored Anesthesia Care (MAC) and General Anesthesia (GA)?
In MAC, the patient maintains their own airway and protective reflexes
What is the toxic range for Lidocaine with and without epinephrine?
with epi = 7 mg/kg
without epi = 4 mg/kg
What is the toxic range for Bupivicaine with and without epinephrine?
with epi = 3.2 mg/kg
without epi = 2.5 mg/kg
What vital sign monitoring is optional in MAC anesthesia?
Is oxygen required in MAC?
Yes; you are altering their consciousness
What three drug classes are typically used in MAC?
1. Benzo's
2. narcotics
3. hypnotics
What must you always be prepared for with MAC?
Movement to general anesthesia and intubation
What property of anesthesia is missing with MAC?
Muscle relaxation
When should you stop your propofol infusion?
2-5" before the end of the case depending on if you are using N20
What two advantages does continuous infusion have over intermittent bolus techniques?
1. Greater cardio-respiratory stability
2. Greater speed of recovery
What type of patient would you use a combination of Sevo/N20 to induce anesthesia?
In frightened patients without IV sites
What patients ARE candidates for LMA usage?
Non-cavity, supine procedures, with normal, empty stomachs and no pathological airway problems
What must be avoided with primary volatile gas induction?
Manually ventilation; the patient should be able to breathe spontaneously
Other than N20, what are the two least "pungent" gases for primary inhalation induction?
1. Sevoflurane (Ultane)
2. Halothane (Fluothane)
What type of patient ensures a more predictable anesthetic induction phase?
A calm, relaxed patient (SNS excitation antagonizes induction medications resulting in increased dosage requirements)
What is the total body water of a 70 kg, adult male?
60% or 42 L
What are the 2 compartments of total body water?
1. Extracellular Fluid (ECF)
2. Intracellular Fluid (ICF)
What are the 2 compartments that make up the ECF?
1. interstitial fluid (ISF)
2. Plasma volume
What are the main cations and anions of the ICF?
cations = K, Mg
anions = Protein, PO4
What are the main cations and anions of the ECF?
cations = Na, Ca
anions = Cl, HCO3
What makes up the plasma volume?
All intravascular fluid except the erythrocytes
What pressure moves fluid/nutrients outside of the vascular space to the ISF area?
Hydrostatic pressure
Where is capillary hydrostatic pressure the greatest?
arterial capillaries
What causes cellular waste into the venous vascular space?
The pressure difference between ISF and venous hydrostatic pressures
Why does edema occur?
The venous hydrostatic pressure is greater than ISF hydrostatic pressure and fluid does not return to the veins
What protien is 2/3 responsible for oncotic pressure?
What are the 4 Starling forces that govern fluid dynamics?
1. capillary hydrostatic pressure
2. ISF hydrostatic pressure
3. ISF oncotic pressure
4. capillary oncotic
Which one of Starling's fluid dynamic forces do anesthesia influence?
The capillary oncotic pressure (plasma osmotic pressure)
What POD does "third spacing" resolve?
POD #3
What 2 different types of losses results in vascular dehydration?
1. Absolute fluid loss (loss to outside of body system)
2. Relative fluid loss (shift of fluid to ISF)
What is a hallmark of H20 deficiency?
Na > 145 mEq/L
What is a cerebral complication with hypernatremia?
Cerebral dehydration; Na concentration is lower in the brain and H20 leaves to where Na concentration is higher (the body)
Can you determine a patient's hydration status by color and amount of urine?
Generally yes, but if they have renal dz or diuretics in use, it will be unreliable.
What are S/S of dehydration?
- dry mucous membrane
- decreased skin turgor
- increased thirst
- increased BUN
- tachycardia
- hypotension
- oliguria
- respiratory fluctations in the A-line
What is the equation to estimate plasma osmolality?
2Na + (Glucose/18)
What is the normal range of serum osmolality?
280-290 mOsm/L
What two hormones control Na levels in the body?
1. Aldosterone (increase Na reabsorption & excretion K)
2. ADH (water reabsorption)
Where is ADH produced?
anterior pituitary
Where is ADH secreted?
hypothalamic posterior pituitary glands
Where is aldosterone secreted?
adrenal cortex
What are some causes of hyponatremia?
- GI loss
- wound drainage
- Aldosterone/ADH abnormalities
- use of hypotonic solutions
What are S/S of hyponatremia?
- muscle weakness/cramping
- confusion/agitation
- arrythmias (QRS widens, ST segment elevation)
- pulmonary edema
- coma/seizures
What is a cerebral complication resulting from hyponatremia?
Cerebral edema (Na content in brain is lower than in body resulting in fluid shift across blood-brain barrier)
At what Na concentration does cerebral edema occur?
Na < 123 mEq/L
What is a risk associated with rapid Na replacement in a patient hyponatremic >48H ?
central pontine myelinolysis (leads to disorders of upper neurons, spastic quadriparesis, pseduobulbar palsy, mental disorders, or death)
How fast should hyponatremia be corrected?
Serum Na increases by 1-2 mEq/L/H until clinically stable, then 10-15 mmol/L over then next 24 hours
What are some causes of hypernatremia?
- Imbalance of H20 intake/loss
- Impaired renal function
- Excessive hypertonic fluids
- increased aldosterone levels
- diabetes insipidus
What are the two different types of diabetes insipidus (DI)?
1. Central DI = low secretion of ADH
2. Nephrogenic DI = decreased renal response to ADH
What are S/S of hypernatremia?
- irratibility
- confusion
- hypotension (hypovolemic)
- oliguria
- increased temperature
If serum glucose increases by 100 mg/dL, how much of a change occurs in the sodium?
a decrease of 1.6 mEq/L
What is the safe limit of hypernatremia for elective cases?
Na must be <150 mEq/L
If a patient is hypovolemic and hypernatremic, what type of solution should be used:
Hypo-, Iso-, or Hyper- tonic solutions?
Isotonic to correct hypovolemia first, then hypotonic solutions to decrease Na
What effect does acidosis have on serum K ?
Increases levels
What effect does alkalosis have on serum K ?
Decreases levels
What NMBA is contraindicated in hyperkalemia?
succinylcholine (a depolarizing agent)
What are causes of hypokalemia?
- dietary deficiency
- GI loss
- insulin shock
- alkalosis (resp or metabolic)
- surgical stress
What are S/S of hypokalemia?
- Neuromuscular weakness
- arrythmias
- hypotension
- flat T-wave, prolonged PRi, depressed ST, widening QRS
What ion is the most influential on osmotic pressure and volume in the ECF?
What ion is the most influential on osmotic pressure and volume in the ICF?
If serum pH changes by 0.1, how much does K change?
pH change of 0.1 = K change of 0.6 mEq/L
If a patient is symptomatic from hypokalemia, about how low is their serum K ?
Hypokalemia is asymptomatic unless <3 mEq/L
How fast will serum K increase with IV medication?
KCl IV 10 mEq = increase serum K by 0.15 mEq/L
What medication's thearpeutic level is dependent on serum K?
What effect will hyperkalemia have on NMBAs?
Hypersensitivity (reduce dose by 25-50%)
What are some causes of hyperkalemia?
- tissue trauma (burns, crush injuries, MI)
- acidosis
- ECF cation deficit
- rapid PRBC transfusions
- PCN-G potassium
- aldosterone antagonists (creates ECF cation deficit)
What are S/S of hyperkalemia?
- neuromuscular weakness
- paralysis
- tall, narrow, peaked T-wave
- P-wave flattens
- widening QRS
- GI upset
- rewarming after hypothermia
What patient populations should succinylcholine use be avoided?
- spinal cord injuries
- Hx of large burns within 1 yr
- neuromuscular dz
What is the upper limit for mandatory treatment of hyperkalemia?
6 mEq/L
What is safe limit for hyperkalemia in elective surgeries?
5.5 mEq/L
What are some acute treatments used in hyperkalemia >6 mEq/L?
- Calcium Gluconate (except if taking digoxin as it worsen toxicity)
- NaHCO3
- Beta-2 agonists (Epi-increases activity of Na-K pump)
- Hyperventilation
- Humulin R 10 units IV + D50 1 amp IV
What % of Ca is protein bound, anion bound, and free?
protein = 40%
anion = 10%
free = 50%
What hormone is the most influential on serum Ca regulation?
Parathyroid hormone (PTH)- increases bone reabsorption
What vitamin is needed to absorb Ca in the GI tract?
Vit. D
What hormone inhibits Ca bone reabsorption?
What happens to Ca in alkalosis?
Decreases due to increased Protein binding
What happens to Ca in acidosis?
Increases due to decreased Protein binding
What are the top two reasons for hypercalcemia?
1. Primary hyperparathyroidism
2. Malignancy
What are causes of hypocalcemia?
- large PRBC transfusions (citrate binding)
- surgical damage of parathyroid gland
- renal failure
- alkalosis
What are S/S of hypocalcemia?
- circumoral numbness
- muscle weakness
- tetany (low Ca = high Na permeability)
- seizures
- hypotension
- pathological fractures
- Chvostek's sign (facial twitching with facial nerve stimulation)
- Trousseau's sign (vasoconstriction of arm causes carpal spasms)
- laryngo/broncho spasms
What are S/S of hypercalcemia?
- fatigue
- GI upset
- lethargy, confusion
- wide QRS
- prolonged PRi
How do you acutely treat symptomatic hypercalcemia?
Hydration with NS along with diuresis (UOP > 200 ml/H)
What are causes of hypomagnesemia?
- malnutrition
- GI losses
- Renal losses
- Theophylline toxicity
- medications
What are S/S of hypomagnesemia?
- agitation/confusion
- exaggerated deep tendon reflexes (DTR)
- tetany
- tachycardia
- prolonged PRi, wide QRS
- hypocalcemia (impaired PTH secretion)
- hypokalemia (renal K wasting)
- hypophosphatemia
What are causes of hypermagnesemia?
- renal failure
- overdosage in treatment of pregnancy-induced HTN
What are S/S of hypermagnesemia?
- sedation
- decreased DTR
- weakness
- respiratory depression
- hypotension
- prolonged PRi, wide QRS (blocks Ca release)
How do you treat symptomatic episodes of hypermagnesemia?
- hypotonic fluids
- Ca-gluconate
What are the 3 responses/systems that control body pH?
1. buffer systems (dominant control)
2. ventilatory responses
3. renal resoponses
What are the major extracellular buffers?
1. Bicarbonate 50%
2. Hgb 35%
3. Plasma Proteins 6%
Acids (donate/accept) H ions
Bases (donate/accept) H ions
What are the major intracellular buffers?
Proteins, polypeptides
What is the normal range of arterial pH?
What is the normal range of venous pH?
What is the enzyme responsible for conversion of C02 + H20 --> H2CO3 (carbonic acid)
Carbonic anhydrase
What does the renal system do to control pH?
1. Excrete H ions
2. Form & reabsorb HCO3
What is the anion gap formula? What is a normal value?
1. Na - (Cl + HCO3)
2. Normal = 10-14
What are causes of metabolic alkalosis?
- upper GI loss
- diuresis (from Cl/K loss)
- HC03 administration
- hypovolemia
- hyperaldosteronism (excess Na trapping which keeps HC03)
Which way does the oxyhemoglobin curve shift in alkalosis and how does it affect O2 affinity?
Left shift; this means INCREASED Hgb affinity for O2 at the lungs but DECREASED delivery to tissues
Which way does the oxyhemoglobin curve shift in acidosis and how does it affect O2 affinity?
Righ shift; this means DECREASED Hgb affinity at the lungs for O2 but INCREASED delivery to tissues
If a patient develops metabolic acidosis, what are the two differentiating causes that affect treatment?
1. Normal anion gap with excess HCO3 loss
2. Increased anion gap
What is the main reason that a patient becomes hypotensive in an acidotic state?
A decreased responsiveness to catecholamines (SNS response)
What is the formula to determine the amount of NaHCO3 to give?
1. (BE on ABG)(Wt in kg)(0.3)and give 1/2 the dose
2. (24-HCO3)(Wt in kg)(0.2)and give 1/2 the dose
What does hyperventilation do to cerebral blood flow?
Doubling alveolar ventilation (hyperventilation) halves CBF for 8-24 hours
What are some causes of respiratory acidosis?
- Impaired gas exchange (e.g. resp depression, obstruction, shunting, etc.)
- hypermetabolic states (excess CO2 production)
A change in 0.1 pH results in how much of a change in PaCO2?
10 mmHg
A change in 0.1 pH results in how much of a change in HCO3?
2 mEq/L
What are the S/S of inadequate oxygenation?
- restlessness
- agitation
- confusion
- coma
- seizures
- bradycardia to tachycardia
- hypotension to HTN
- SpO2 < 90%
What are the S/S of inadequate oxygenation?
- hypercarbia
- bradypnea to tachypnea
- nasal flaring
- retractions
- abnormal breath sounds
- diaphragmatic breathing
- abnormal ETCO2
- abnormal PaCO2
What is the immediate priority of the patient upon arrival to PACU?
evaluation, verification of stability and adequacy of respiratory/cardiovascular fxn
According to AANA Standards for Nurse Anesthesia care, what does Standard VII state?
The responsibility for the care of the patient shall be transferred to other qualified providers in a manner which assures continuity of care and patient safety
What is the most widely used scoring system in the PACU?
Aldrette scoring system
What does the Aldrette scoring system evaluate?
- activity
- respiratory
- circulatory
- consciousness
- color
What is the most common cause of upper airway obstruction?
the tongue
What are the risk factors for upper airway obstruction?
- obesity
- large/short neck
- poor muscle tone
- swelling
What are ways to relieve upper airway obstruction?
- stimulation
- jaw thrust/chin lift
- oral/nasal airway
What are the S/S of incomplete airway obstruction?
- crowing sound
- stridor
What is the initial intervention for laryngospasm?
positive pressure ventilation with 100% O2
If positive pressure ventilation ineffective in a laryngospasm, what additional steps do you take?
- consider succinylcholine 0.1 mg/kg
- Lidocaine 1-1.5 mg/kg
How much of an increase in CO2 after the first minute of total obstruction to ventilation? And each following minute thereafter?
- 6 mmHG
- 3-4 mmHg
What is the PaO2 if the SaO2 reads 90%?
60 mmHg
What kind of shunt results from atelectasis?
a right to left shunt ("unoxygenated" blood bypasses O2 exposure)
What drugs do you use for afterload in pulmonary edema?
- Nipride
What is Virchow's Triad and what does it increase the risk for?
- hypercoagulability, hemostasis, BV wall abnormalities
- increases risk for PE
What % of PEs arise from DVTs?
What type of aspiration is the most severe form?
Gastric aspiration
What is the focus of treatment for aspiration?
- correction of hypoxia
- maintenance of hemodynamics
What is the most common cause of hypotension in the PACU?
hypovolemia secondary to inadequate fluid replacement in the OR
If a fluid challenge does not resolve hypotension in the PACU, what other causative factor must be considered?
myocardial dysfunction (MI, tamponade, embolism, acute LV failure)
What is the leading cause of HTN in the PACU?
What effect does hypothermia have on cardiac conduction?
Prolongs the refractory period results in
- bradycardia
- A-fib
- Blocks
- V-fib
What effect does halothane have on cardiac function?
- sensitizes heart to catecholamines (higher risk of arrythmias)
- depresses SA & AV node function
What is the most common cause of delayed awakening?
Prolonged action of anesthetic agents