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90 Cards in this Set

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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