Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
90 Cards in this Set
- Front
- Back
|
Anesthesia goals
|
Offset effects of surgical stimulation & functional abnomalities
-manipulation of drugs -fluids (LR, Hespan,Colliods) -Respiratory mech |
|
|
Definition of pain (IASP)
|
Unpleasant sensory and emotional experience that we associate with tissue damage or describe in terms of tissue damage
|
|
|
Definition of pain
|
Implies pain preception is linked w/ degree of tissue damage
-may be out of proportion to tissue damage -occur w/o tissue damage -severe tissue damage may occur w/o pain |
|
|
Factors that influence pain
|
-Site, nature, duration of OP
-Physio & psych makeup -serious complications -preop management -quality of post-op care (address prior to waking) |
|
|
Physiology of pain
|
-local tissue damage
-nociceptors -afferent path (A delta & C fibers |
|
|
Physiology of pain
|
Release of alogogenic subst
-subst P -Excitatory neurotrans -somatostatin, cholecystekinins enkephalins & endorphins - Noxious stim trans to thalmus (from dorsal horn -> spinothalmic tract |
|
|
Nociception involves balance
|
Excitatory process
Inhibitory process -decend path stim inhibit NT -Norepi & Serotonin (Blk subst P @ dorsal horn -prevent spread of periph nociception |
|
|
Gate theory
(Think how you will modulate pain) |
balance between A deltal & C fibers to dorsal horn determines the intensity of the stimulus that is passed to higher brain center
|
|
|
Pain causes autonomic reflex responses that lead to
|
Pulm- shallow breathing
Circ- Inc HR, BP (SNS stim) GI- Inc secretions emesis Impair muscle metab Thromboembolic process Psych & Emotional rxns |
|
|
Nociceptor Concetration
High |
Mucosal memb
Periosteum Deep Fascia Ligament jt capsules cornea |
|
|
Nociceptor Concetration
Moderate |
muscle
skeletal cardiac smooth |
|
|
Nociceptor Concetration
Minimal |
Bone
cartilage marrow |
|
|
Ideal Anesthetic
|
Sedation - hypnosis (asleep)
amnesia analgesia (free of pain) muscle relax obtund reflexes PNS, SNS Physiological stable reversible antiemtic |
|
|
Anesthetic delivery
|
regional (conduction)
IV (systemic) Inhalation (ventilatory) |
|
|
Triad of anesthesia (Must have all 3)
|
Analgesia
Amnesia Areflexia |
|
|
General Anesthesia
|
induction of a state of unconsiciousness w/ the abscence of pain sensation over the entire body through admin of anesthetic drug
-alt flow of Na+ molecules into neurons through cell memb. |
|
|
Inhalation agents
|
NO2
halothane ethrane Isoflurane Sevoflurane Desflurane |
|
|
Stages of General Anesthesia
|
Stage 1 Analgesia
2 Excitement 3 Surgical anesthesia 4 medullary paralysis |
|
|
Ideal stage 2 (excitement)
|
Too have a short stage 2 to minimize coughing, salivation, laryngospasm, movement,
|
|
|
What can be done to speed up stage 2
|
administer a narcotic or give propofol
|
|
|
MAC =
|
Minimal Alveolar Concentration
Inhaled anesthetic @ 1 ATM prevents skeletal mus move in response to noxious stim, (surg incision) in 50% of patients |
|
|
MAC represnets one point on a ____ curve
Pbr (what the brain sees) |
dose-response curve
|
|
|
Most useful index of anesthetietic equal potentcy for comparison of inhaled anesthetics
|
MAC
|
|
|
General Anesthesia
5 parts |
Preparation
Induction Maintenance Emergence Recovery |
|
|
General Anesthesia Preparation
|
Equipment Full machine check (FDA checklist)
-modified check after full check in am - Monitoring equipment (available & functional |
|
|
General Anesthesia
Airway equipment |
Laryngoscope
-Miller & Macintosh blades -two handles -location of airway cart ETT -anticipated size & size smaller - check cuff -stylet insertion Oral airway/bite blk/tongue depressor |
|
|
Induction Drugs
Hypnotics |
Propofol
pentothal etomidate (CV disease) |
|
|
Induction Drugs
Narcotics |
Fentanyl, Sufentanyl (short acting)
|
|
|
Induction Drugs
Muscle relaxants |
Succinylcholine (depolarizing short act)
Rocuronium, Vecuronium, Cisatracurium (nondepol long act) Have both ready don't draw up non depol, expensive |
|
|
Emergency drugs
|
Lidocaine 20mg/cc (halothane may cause bigeminy)
Ephedrine 5mg/cc Atropine 0.4mg/cc (1ml syrng) Phenylephrine 100mg/cc (10mg/100ml) Cardene for neuro cases (inc BP) |
|
|
Non depolarizer Reversal
Acticholinesterase |
Neostigmine 1mg/cc
Edrophonium 10mg/cc (may cause Brady) |
|
|
Non depolarizer Reversal
Anticholinergics |
Glychopyrrolate 0.2mg/cc (prevent brady)
Atropine 0.4mg/cc |
|
|
Induction sequence
Preintubation |
Check pt ID/surg procedure
Review preop eval/labs transport to OR Position Monitor application (pulse ox first) Document 1st set vitals Hypnotic +/- Narcotic ventilate muscle relaxant (depol/nondepol) |
|
|
Induction sequence
Post sedation |
Protect eyes
intubation (if indicated) verifiy ett placement (breath sounds ETCO2 3 breaths to get reading) Inhalation agent (carrier O2,Nitrous, Air) Secure ETT Surg Position Line placement Warming devices notify operative team when ready |
|
|
General Anesthesia
Maintenance |
Anesthetic
- Inhalation anethesia - TIVA (total IV anesth) -Narcotics -Muscle relxants |
|
|
General Anesthesia
Maintenance Fluid maintenance |
Crystalloid
-pt arrives in fluid def (know wt) -give for maintenance -replacement (bld loss evap) Colloid Blood |
|
|
General Anesthesia
Emergence |
Discontinue inhalation anesthetic
-Volatile agent, N2) -Reversal of nondepol (after muscle layer closed) |
|
|
General Anesthesia
Emergence Extubation |
spontaneous vent
adequate tidal vol head lift/respond to command (if long case or neck op let cuff down |
|
|
General Anesthesia
Recovery |
-Safe transfer to recovery
-oxygen -monitoring transfer -Spo2 applied first (asses vent status) -Verify BP/EKG (Hyper/hypo BP, tachy/brady) -Temp |
|
|
General Anesthesia
Recovery |
Immeadiate stabilization
-hemodynamics -airway |
|
|
General Anesthesia
Recovery Transfer report |
SBAR subject background assess, reccomendation ASA Class
-Surgery, Anesth, Vitals, fluids Complete doc of care |
|
|
Post op course
|
-Acute pain manage
narcotics Sedation for post-op vent -Chronic pain mang -Post-op anesth assess ventilation pain control post op memory (recall) |
|
|
General Surgery Cases
Minor |
breast biopsy/lymph node biopsy
Umbillical hernia repairs |
|
|
General Surgery Cases
Major |
Thyroidectomy/Para
mastectomy intarabdominal Cholecystectomy, splenectomy, bowel resect, adrenalectomy (pheochromocytomas) |
|
|
Anesthetic Requirements
General Anest |
most common
muscle relax for intraab case |
|
|
Anesthetic Requirements
Regional Anesth |
less common
lower abd-herniopathy |
|
|
Anesthetic Requirements
MAC |
soft tissue procedures
patient motivation key fact |
|
|
Minamally invasive surg
|
soft tissue cases
-lymph node biopsy -breast biopsy -excision of lipoma |
|
|
Minamally invasive surg Technique
|
Freq out pt proced
Gen or IV sedation Minimal bld loss standard monitors Inc incidence N/V |
|
|
Moderately invasive surg
|
Umbillical/Inguinal Herniorrhaphy
Breast aug/reduce Mastectomy Thyroid/parathyroid |
|
|
Maximally invasive surg
|
Open/Lap cholecy (emergence stim in open, stimulating surg in lap)
Adrenalectomy Whipple Hiatal hernia Gastric bypass |
|
|
Why monitor
Therapeutic dose of anesth cause |
Resp dep
Cardio dep Sedation Regional General |
|
|
Monitoring standards
AANA Standards Standard 1 |
preanesthetic evaluation
|
|
|
Monitoring standards
AANA Standards Standard 2 |
Obtain informed consent
|
|
|
Monitoring standards
AANA Standards Standard 3 |
Form a patient specific plan of care
|
|
|
Monitoring standards
AANA Standards Standard 4 |
Implement care plan adjusted for patient response
|
|
|
Monitoring standards
AANA Standards Standard 5 |
Monitor continous
-ventilation -oxygenation -cardio status -temp -neuromsuc funct -pt position |
|
|
Monitoring standards
AANA Standards Standard VI |
Document care
-complete -accuracte -timely |
|
|
Monitoring standards
AANA Standards Standard VII |
transfer care of pt to other qualified staff
|
|
|
Monitoring standards
AANA Standards Standard VIII |
Equipment check & doc
|
|
|
Monitoring standards
AANA Standards Standard IX |
minimize infection risk of infection to pt CRNA & others
|
|
|
Monitoring standards
AANA Standards Standard X |
quality assurance performed
|
|
|
Monitoring standards
AANA Standards Standard XI |
Respect & maintain basic rights of pts
|
|
|
Monitoring standards
at not law, fail to follow nationally published standards sets the practitioner up for |
credentialling problems, lawsuits
|
|
|
Monitoring standards
ASA Standards Standard I |
Qualified anesth provider
throughout anesth (no breaks/sleeping) |
|
|
Monitoring standards
ASA Standards Standard II |
Cardio, Resp, Temp, NMS blk monitors
|
|
|
Why do we use monitoring equip
|
senses limited
-palp of heart good for pulse not BP -Palp heart good for eratic pulse not arrhythmia Free hands Too many parameters at once |
|
|
Percordial/Esophageal stethoscope
|
simple reliable, (metal bell attached to length of tubing
Esop is more clear |
|
|
ECG
|
Rate, rhythm assess
-ST seg (ischemia) -Lead 5 detects 75% ischemia -II + 5 = 80% -II,4,5 = 98% detction |
|
|
NIBP
|
Oscillometric tech
sense oscillations as the cuff drops systolic pressure -strongest oscillations = mean Calc diast after measure syst and mean |
|
|
Pulse ox
|
measure absorption ratio
660 (red) 940 (infared) R= (AC red/DC red) AC infared/DC infared) -value of R correlate to sat% derive from human tests accurate to 1-2% |
|
|
Factors influence accuracy of pulse ox
|
low bld flow
pt movement ampient light dysfunctional hgb meth blue alt relation bet PaO2 & SaO2 |
|
|
FiO2
|
Oxygen analyzer
-confirms FiO2 -detects mistake in lines -calibrate daily - low limit alarm set |
|
|
Capnometry
side stream infared capnography |
-CO2, N2O, H20 & inhaled agents absorb infared light at diff freq
|
|
|
Capnometry
Mass spectrometry |
gas continously withdrawn
measure -measures O2, N, CO2 -expensive complicated |
|
|
Capnometry
Raman |
independent analysis of each agent
|
|
|
Colorimetric detection
|
hydration of CO2
-leads to H ion liberation & acidification of ph sens medium -color change purple -> yellow -resucitation in remote sites |
|
|
Ventilation monitors
|
ventilator disconnect
spirometers (hi/low limit alarms overpressure alarms overpressure pop-off valves |
|
|
Temperature
|
low esophageal temp most reflective of core temp
-tympanic memb temp reflective of core -skin temp misleading |
|
|
Periph Nerve Stimulator
|
Brief variable amplitude spike
-superficial motor nerve stim TO4 assess (level of non depol) Double burst stim asses (return of strength at end of case) Clinical monitoring difficult w/o Perph nerve stim |
|
|
Train of 4
|
most common, easy
stim 4 pulses low freq 2-4 hz for 2 sec at 0.5 sec interv. # of responses of TOF indicates degree of Neuromus blk |
|
|
TOF Response 4 =
0-75% blk correlates |
may move with weakness, can reverse
|
|
|
TOF Response 3 =
75% blk correlates |
may need additional drug, reversible
|
|
|
TOF Response 2 =
80% blk correlates |
suitable for short term relaxation or long term ventilation
|
|
|
TOF Response 1 =
90% blk correlates |
short term relaxation or mech vent
|
|
|
TOF Response 0 =
100% blk correlates |
conditions for intubation may lead to long term effects
|
|
|
Site of TOF
Adductor Pollicis muscle |
adductor pollicis muscle- thumb adduction
Place along ulnar nerve |
|
|
Site of TOF
Orbicularis Occuli Muscle |
Eyelib twitching
on facial nerve |
|
|
Site of TOF
Flexor Hallucis Brevis Muscle |
Flexor Hallucis Brevis muscle = plantar flexion (curl of big toe)
|
|
|
Bispectral Index (BIS)
|
Processed EEG = sedation level between 0-100
GA < 60 (gen anesth) measured from superficial scalp electrode |
