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161 Cards in this Set
- Front
- Back
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What are the 4 PROPERTIES of general anesthesia?
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A mnesia
A nalgesia H ypnosis M uscle relaxation |
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How many STAGES of anesthesia are there?
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5
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What is Level 1 anesthesia called and what are the qualities that define it?
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- LOSS OF CONSCIOUSNESS
- Unresponsive to verbal commands, responds to painful stimuli |
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What are the 4 PHASES of all types of anesthesia?
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I nduction
M aintenance E mergence T ransfer |
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What is Level 2 anesthesia called and what are the qualities that define it?
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- DEPRESSION-EXCITATION
- Irregular breathing, laryngospasms, secretions, arrythmias, hyperesthesia |
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What is Level 3 anesthesia called and what are the qualities that define it?
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- MINIMAL ANESTHESIA
- stimulation increases respirations, mild hypotension |
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What is Level 4 anesthesia called and what are the qualities that define it?
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- LIGHT ANESTHESIA
- respiratory depression but responds to maximal stimulation, hypotension unless stimulated, minimal cardiac response to stimulation |
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What is Level 5 anesthesia called and what are the qualities that define it?
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- DEEP ANESTHESIA
- apnea, no responses to stimulation (SNS or any other), arrythmias |
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What stage of anesthesia is consider the danger zone for a patient?
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Level 2 Depression-Excitation
(risk of layrngo/broncho spasms) |
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What are the three methods for providing anesthesia?
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Inhalation only
Total IV anesthesia (TIVA) Balanced (inhalation/IVA) |
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What method of anesthesia is the most common?
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Balanced anesthesia (inhalation + IVA)
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What is the PRIMARY goal of the INDUCTION phase of general anesthesia?
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Produce unconsciousness and move to Level 3 without compromising cardiovascular stability
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What are the general steps for intubation from when the patient rolls into the OR?
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1. apply monitors
2. Baseline VS 3. Align Pharyngeal/ Occipital/oral axis 4. denitrogenate @ 100% O2 5. Induce patient 6. Intubate |
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What are the 5 cardinal signs for appropriate intubation?
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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) |
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What are 2 ways that you can denitrogenate your patient?
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1. normal breathing of 100% O2 for 3-5 min
2. patient breaths 4 vital capacity breaths (maximum inhalation/exhalation) |
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What are the most common barbituates used for anesthesia induction?
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Thiopental (Pentothal)
Methohexital (Brevital) Thiamylal (Surital - not in U.S.) |
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What are the most common non-barbituates used for anesthesia induction?
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Propofol (Diprivan)
Etomidate (Amidate) Ketamine (Ketalar) |
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What sign signifies your induction drug has reached the desired effect?
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Loss of lid reflex (no reaction with eyelash stimulation)
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What type of drug is given FIRST during the induction phase?
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Adjuvant drugs (e.g. Fentanyl, Lidocaine, Esmolol)
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What drug is given SECOND during the induction phase?
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Induction agent (e.g. barbituate, non-barbituate)
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What drug is given THIRD in the induction phase?
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The NMBA (e.g. atracurium, vecuronium, succinylcholine)
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What should be administered after successful intubation?
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Volatile gas or repeat dose of opioids
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How often do you check vital signs during anesthesia?
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A minimum of q5" (but as frequent as q2")
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What are two differences differences between standard induction and Rapid Sequence Induction (RSI)?
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1. simultaneous administration of induction agent & paralytic
2. Application of cricoid pressure from induction through verification of ETT |
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What determines whether a patient must be done by RSI or standard induction?
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Any risk of a "full stomach"
- includes dz that delays gastric emptying, recent meals, excess weight, altered mental status (chemical/biological) |
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Why is Nitrous Oxide (N20) used in anesthesia? What is the effect called?
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It acts as a carrier agent for volatile gases via the second gas effect?
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What sign indicates readiness for intubation?
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Jaw relaxation
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What procedures/conditions warrant ETT placement?
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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" |
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During the first 5 min into your anesthesia case, the patient's BP drops. What are your options?
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1. Reduce volatile gas
2. Administer fluid challenge 3. Administer vasoactive drugs |
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What is the main difference between Monitored Anesthesia Care (MAC) and General Anesthesia (GA)?
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In MAC, the patient maintains their own airway and protective reflexes
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What is the toxic range for Lidocaine with and without epinephrine?
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with epi = 7 mg/kg
without epi = 4 mg/kg |
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What is the toxic range for Bupivicaine with and without epinephrine?
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with epi = 3.2 mg/kg
without epi = 2.5 mg/kg |
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What vital sign monitoring is optional in MAC anesthesia?
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Temperature
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Is oxygen required in MAC?
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Yes; you are altering their consciousness
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What three drug classes are typically used in MAC?
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1. Benzo's
2. narcotics 3. hypnotics |
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What must you always be prepared for with MAC?
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Movement to general anesthesia and intubation
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What property of anesthesia is missing with MAC?
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Muscle relaxation
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When should you stop your propofol infusion?
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2-5" before the end of the case depending on if you are using N20
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What two advantages does continuous infusion have over intermittent bolus techniques?
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1. Greater cardio-respiratory stability
2. Greater speed of recovery |
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What type of patient would you use a combination of Sevo/N20 to induce anesthesia?
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In frightened patients without IV sites
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What patients ARE candidates for LMA usage?
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Non-cavity, supine procedures, with normal, empty stomachs and no pathological airway problems
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What must be avoided with primary volatile gas induction?
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Manually ventilation; the patient should be able to breathe spontaneously
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Other than N20, what are the two least "pungent" gases for primary inhalation induction?
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1. Sevoflurane (Ultane)
2. Halothane (Fluothane) |
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What type of patient ensures a more predictable anesthetic induction phase?
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A calm, relaxed patient (SNS excitation antagonizes induction medications resulting in increased dosage requirements)
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What is the total body water of a 70 kg, adult male?
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60% or 42 L
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What are the 2 compartments of total body water?
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1. Extracellular Fluid (ECF)
2. Intracellular Fluid (ICF) |
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What are the 2 compartments that make up the ECF?
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1. interstitial fluid (ISF)
2. Plasma volume |
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What are the main cations and anions of the ICF?
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cations = K, Mg
anions = Protein, PO4 |
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What are the main cations and anions of the ECF?
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cations = Na, Ca
anions = Cl, HCO3 |
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What makes up the plasma volume?
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All intravascular fluid except the erythrocytes
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What pressure moves fluid/nutrients outside of the vascular space to the ISF area?
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Hydrostatic pressure
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Where is capillary hydrostatic pressure the greatest?
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arterial capillaries
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What causes cellular waste into the venous vascular space?
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The pressure difference between ISF and venous hydrostatic pressures
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Why does edema occur?
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The venous hydrostatic pressure is greater than ISF hydrostatic pressure and fluid does not return to the veins
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What protien is 2/3 responsible for oncotic pressure?
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Albumin
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What are the 4 Starling forces that govern fluid dynamics?
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1. capillary hydrostatic pressure
2. ISF hydrostatic pressure 3. ISF oncotic pressure 4. capillary oncotic |
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Which one of Starling's fluid dynamic forces do anesthesia influence?
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The capillary oncotic pressure (plasma osmotic pressure)
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What POD does "third spacing" resolve?
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POD #3
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What 2 different types of losses results in vascular dehydration?
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1. Absolute fluid loss (loss to outside of body system)
2. Relative fluid loss (shift of fluid to ISF) |
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What is a hallmark of H20 deficiency?
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Na > 145 mEq/L
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What is a cerebral complication with hypernatremia?
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Cerebral dehydration; Na concentration is lower in the brain and H20 leaves to where Na concentration is higher (the body)
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Can you determine a patient's hydration status by color and amount of urine?
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Generally yes, but if they have renal dz or diuretics in use, it will be unreliable.
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What are S/S of dehydration?
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- dry mucous membrane
- decreased skin turgor - increased thirst - increased BUN - tachycardia - hypotension - oliguria - respiratory fluctations in the A-line |
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What is the equation to estimate plasma osmolality?
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2Na + (Glucose/18)
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What is the normal range of serum osmolality?
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280-290 mOsm/L
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What two hormones control Na levels in the body?
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1. Aldosterone (increase Na reabsorption & excretion K)
2. ADH (water reabsorption) |
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Where is ADH produced?
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anterior pituitary
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Where is ADH secreted?
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hypothalamic posterior pituitary glands
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Where is aldosterone secreted?
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adrenal cortex
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What are some causes of hyponatremia?
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- GI loss
- wound drainage - Aldosterone/ADH abnormalities - use of hypotonic solutions |
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What are S/S of hyponatremia?
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- muscle weakness/cramping
- confusion/agitation - arrythmias (QRS widens, ST segment elevation) - pulmonary edema - coma/seizures |
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What is a cerebral complication resulting from hyponatremia?
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Cerebral edema (Na content in brain is lower than in body resulting in fluid shift across blood-brain barrier)
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At what Na concentration does cerebral edema occur?
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Na < 123 mEq/L
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What is a risk associated with rapid Na replacement in a patient hyponatremic >48H ?
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central pontine myelinolysis (leads to disorders of upper neurons, spastic quadriparesis, pseduobulbar palsy, mental disorders, or death)
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How fast should hyponatremia be corrected?
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Serum Na increases by 1-2 mEq/L/H until clinically stable, then 10-15 mmol/L over then next 24 hours
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What are some causes of hypernatremia?
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- Imbalance of H20 intake/loss
- Impaired renal function - Excessive hypertonic fluids - increased aldosterone levels - diabetes insipidus |
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What are the two different types of diabetes insipidus (DI)?
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1. Central DI = low secretion of ADH
2. Nephrogenic DI = decreased renal response to ADH |
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What are S/S of hypernatremia?
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- irratibility
- confusion - hypotension (hypovolemic) - oliguria - increased temperature |
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If serum glucose increases by 100 mg/dL, how much of a change occurs in the sodium?
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a decrease of 1.6 mEq/L
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What is the safe limit of hypernatremia for elective cases?
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Na must be <150 mEq/L
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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
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What effect does acidosis have on serum K ?
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Increases levels
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What effect does alkalosis have on serum K ?
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Decreases levels
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What NMBA is contraindicated in hyperkalemia?
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succinylcholine (a depolarizing agent)
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What are causes of hypokalemia?
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- dietary deficiency
- GI loss - insulin shock - alkalosis (resp or metabolic) - surgical stress |
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What are S/S of hypokalemia?
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- Neuromuscular weakness
- arrythmias - hypotension - flat T-wave, prolonged PRi, depressed ST, widening QRS |
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What ion is the most influential on osmotic pressure and volume in the ECF?
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Na
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What ion is the most influential on osmotic pressure and volume in the ICF?
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K
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If serum pH changes by 0.1, how much does K change?
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pH change of 0.1 = K change of 0.6 mEq/L
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If a patient is symptomatic from hypokalemia, about how low is their serum K ?
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Hypokalemia is asymptomatic unless <3 mEq/L
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How fast will serum K increase with IV medication?
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KCl IV 10 mEq = increase serum K by 0.15 mEq/L
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What medication's thearpeutic level is dependent on serum K?
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Digoxin
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What effect will hyperkalemia have on NMBAs?
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Hypersensitivity (reduce dose by 25-50%)
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What are some causes of hyperkalemia?
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- tissue trauma (burns, crush injuries, MI)
- acidosis - ECF cation deficit - rapid PRBC transfusions - PCN-G potassium - aldosterone antagonists (creates ECF cation deficit) |
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What are S/S of hyperkalemia?
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- neuromuscular weakness
- paralysis - tall, narrow, peaked T-wave - P-wave flattens - widening QRS - GI upset - rewarming after hypothermia |
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What patient populations should succinylcholine use be avoided?
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- spinal cord injuries
- Hx of large burns within 1 yr - neuromuscular dz |
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What is the upper limit for mandatory treatment of hyperkalemia?
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6 mEq/L
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What is safe limit for hyperkalemia in elective surgeries?
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5.5 mEq/L
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What are some acute treatments used in hyperkalemia >6 mEq/L?
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- 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 |
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What % of Ca is protein bound, anion bound, and free?
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protein = 40%
anion = 10% free = 50% |
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What hormone is the most influential on serum Ca regulation?
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Parathyroid hormone (PTH)- increases bone reabsorption
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What vitamin is needed to absorb Ca in the GI tract?
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Vit. D
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What hormone inhibits Ca bone reabsorption?
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Calcitonin
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What happens to Ca in alkalosis?
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Decreases due to increased Protein binding
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What happens to Ca in acidosis?
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Increases due to decreased Protein binding
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What are the top two reasons for hypercalcemia?
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1. Primary hyperparathyroidism
2. Malignancy |
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What are causes of hypocalcemia?
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- large PRBC transfusions (citrate binding)
- surgical damage of parathyroid gland - renal failure - alkalosis |
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What are S/S of hypocalcemia?
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- 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 |
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What are S/S of hypercalcemia?
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- fatigue
- GI upset - lethargy, confusion - wide QRS - prolonged PRi |
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How do you acutely treat symptomatic hypercalcemia?
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Hydration with NS along with diuresis (UOP > 200 ml/H)
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What are causes of hypomagnesemia?
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- malnutrition
- GI losses - Renal losses - Theophylline toxicity - medications |
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What are S/S of hypomagnesemia?
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- agitation/confusion
- exaggerated deep tendon reflexes (DTR) - tetany - tachycardia - prolonged PRi, wide QRS - hypocalcemia (impaired PTH secretion) - hypokalemia (renal K wasting) - hypophosphatemia |
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What are causes of hypermagnesemia?
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- renal failure
- DKA - overdosage in treatment of pregnancy-induced HTN |
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What are S/S of hypermagnesemia?
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- sedation
- decreased DTR - weakness - respiratory depression - hypotension - prolonged PRi, wide QRS (blocks Ca release) |
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How do you treat symptomatic episodes of hypermagnesemia?
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- hypotonic fluids
- Ca-gluconate |
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What are the 3 responses/systems that control body pH?
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1. buffer systems (dominant control)
2. ventilatory responses 3. renal resoponses |
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What are the major extracellular buffers?
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1. Bicarbonate 50%
2. Hgb 35% 3. Plasma Proteins 6% |
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Acids (donate/accept) H ions
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donate
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Bases (donate/accept) H ions
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accept
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What are the major intracellular buffers?
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Proteins, polypeptides
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What is the normal range of arterial pH?
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7.35-7.45
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What is the normal range of venous pH?
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7.32-7.42
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What is the enzyme responsible for conversion of C02 + H20 --> H2CO3 (carbonic acid)
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Carbonic anhydrase
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What does the renal system do to control pH?
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1. Excrete H ions
2. Form & reabsorb HCO3 |
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What is the anion gap formula? What is a normal value?
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1. Na - (Cl + HCO3)
2. Normal = 10-14 |
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What are causes of metabolic alkalosis?
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- upper GI loss
- diuresis (from Cl/K loss) - HC03 administration - hypovolemia - hyperaldosteronism (excess Na trapping which keeps HC03) |
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Which way does the oxyhemoglobin curve shift in alkalosis and how does it affect O2 affinity?
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Left shift; this means INCREASED Hgb affinity for O2 at the lungs but DECREASED delivery to tissues
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Which way does the oxyhemoglobin curve shift in acidosis and how does it affect O2 affinity?
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Righ shift; this means DECREASED Hgb affinity at the lungs for O2 but INCREASED delivery to tissues
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If a patient develops metabolic acidosis, what are the two differentiating causes that affect treatment?
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1. Normal anion gap with excess HCO3 loss
2. Increased anion gap |
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What is the main reason that a patient becomes hypotensive in an acidotic state?
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A decreased responsiveness to catecholamines (SNS response)
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What is the formula to determine the amount of NaHCO3 to give?
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1. (BE on ABG)(Wt in kg)(0.3)and give 1/2 the dose
or 2. (24-HCO3)(Wt in kg)(0.2)and give 1/2 the dose |
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What does hyperventilation do to cerebral blood flow?
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Doubling alveolar ventilation (hyperventilation) halves CBF for 8-24 hours
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What are some causes of respiratory acidosis?
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- Impaired gas exchange (e.g. resp depression, obstruction, shunting, etc.)
- hypermetabolic states (excess CO2 production) |
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A change in 0.1 pH results in how much of a change in PaCO2?
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10 mmHg
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A change in 0.1 pH results in how much of a change in HCO3?
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2 mEq/L
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What are the S/S of inadequate oxygenation?
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- restlessness
- agitation - confusion - coma - seizures - bradycardia to tachycardia - hypotension to HTN - SpO2 < 90% |
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What are the S/S of inadequate oxygenation?
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- hypercarbia
- bradypnea to tachypnea - nasal flaring - retractions - abnormal breath sounds - diaphragmatic breathing - abnormal ETCO2 - abnormal PaCO2 |
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What is the immediate priority of the patient upon arrival to PACU?
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evaluation, verification of stability and adequacy of respiratory/cardiovascular fxn
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According to AANA Standards for Nurse Anesthesia care, what does Standard VII state?
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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
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What is the most widely used scoring system in the PACU?
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Aldrette scoring system
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What does the Aldrette scoring system evaluate?
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- activity
- respiratory - circulatory - consciousness - color |
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What is the most common cause of upper airway obstruction?
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the tongue
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What are the risk factors for upper airway obstruction?
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- obesity
- large/short neck - poor muscle tone - swelling |
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What are ways to relieve upper airway obstruction?
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- stimulation
- jaw thrust/chin lift - oral/nasal airway |
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What are the S/S of incomplete airway obstruction?
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- crowing sound
- stridor |
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What is the initial intervention for laryngospasm?
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positive pressure ventilation with 100% O2
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If positive pressure ventilation ineffective in a laryngospasm, what additional steps do you take?
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- consider succinylcholine 0.1 mg/kg
- Lidocaine 1-1.5 mg/kg |
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How much of an increase in CO2 after the first minute of total obstruction to ventilation? And each following minute thereafter?
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- 6 mmHG
- 3-4 mmHg |
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What is the PaO2 if the SaO2 reads 90%?
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60 mmHg
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What kind of shunt results from atelectasis?
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a right to left shunt ("unoxygenated" blood bypasses O2 exposure)
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What drugs do you use for afterload in pulmonary edema?
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- NTG
- Nipride |
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What is Virchow's Triad and what does it increase the risk for?
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- hypercoagulability, hemostasis, BV wall abnormalities
- increases risk for PE |
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What % of PEs arise from DVTs?
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90%
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What type of aspiration is the most severe form?
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Gastric aspiration
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What is the focus of treatment for aspiration?
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- correction of hypoxia
- maintenance of hemodynamics |
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What is the most common cause of hypotension in the PACU?
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hypovolemia secondary to inadequate fluid replacement in the OR
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If a fluid challenge does not resolve hypotension in the PACU, what other causative factor must be considered?
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myocardial dysfunction (MI, tamponade, embolism, acute LV failure)
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What is the leading cause of HTN in the PACU?
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pain
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What effect does hypothermia have on cardiac conduction?
|
Prolongs the refractory period results in
- bradycardia - A-fib - Blocks - V-fib |
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What effect does halothane have on cardiac function?
|
- sensitizes heart to catecholamines (higher risk of arrythmias)
- depresses SA & AV node function |
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What is the most common cause of delayed awakening?
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Prolonged action of anesthetic agents
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