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;
126 Cards in this Set
- Front
- Back
|
List the advantages of Laryngeal Mask Airways
|
Muscle relaxants required for intubation can be avoided
Coughing is less thn with tracheal intubation Anesthetic requirements are reduced Hoarsenes and sore throat are reduced cost savings |
|
|
What are the 3 most common reasons for delay in patient discharge from the PACU?
|
1. drowsiness
2. N/V 3. Pain |
|
|
What are the 2 main concerns when selecting an agent for maintenance of anesthesia?
|
speed of recovery and PONV
|
|
|
Is the need for blood transfusion a contraindication for outpatient surgery?
|
No
|
|
|
What % of surgery is outpatient?
|
90%
|
|
|
What are the contraindications for outpatient surgery?
|
1. Large amount of postop pain
2. large amount of blood loss 3. Lack of a caretaker 4. love too far from hospital |
|
|
Is obesity a contraindication for outpatient surgery?
|
no, but may want to do it in a hospital vs a surgical center (less help)
|
|
|
What are the NPO Guidelines
|
NPO for 6 hours after light meal
clear liquids up to 2 hours prior to surgery |
|
|
Main reasons (2) for using Opiods
|
Pain control/ sedation
Blunt Sympathetic response to Laryngoscopy |
|
|
What preterm infants (born prior to 37 weeks gestation) should not have outpatient surgery?
|
less than 46-50 weeks post conceptual stage
or postconceptual age less 60 weeks with a history of chronic lung, neurologic disease or anemia (Hgb <6) |
|
|
how long after a URI can a patient have outpatient surgery?
|
6 weeks
|
|
|
List the risk factors for adverse respiratory events in children with URI's
|
Use of ETT vs. LMA
Prematurity Reactive airway disease Parental smoking Surgery involving the airway copious secretions Nasal congestion |
|
|
List the risk factors for PONV
|
Pregnant women
H/o motion sickness or postenesthetic emesis surgery within 1-7 days of the menstrual cycle nonsmokers specific procedures (laparoscopy, lithotripsy, major breast surgery, ENT surgery) Inhalation agents Postoperative opiod use |
|
|
How long should patient not drive for after anesthesia?
|
24 hours
|
|
|
What are the SE of anesthesia that you should tell the patient they may experience in the 24 hour postop period?
|
HA, dizziness, drowsy, N/V, muscle aches (if Sch used)
|
|
|
What are some patient considerations when choosing regional vs. spinal anesthesia?
|
1. CV: Aortic stenosis
2. Hyopovolemia 3. Sepsis 4. Lesions in the area of regional site |
|
|
what are the 2 situations that may cause you to have to convert from regional anesthesia to GA?
|
High spinal
Inadequate spinal |
|
|
Define neuraxial block
|
result in sympathetic block, sensory analgesia, and often motor block after insertion of a drug in the plane of the centroneuraxis
|
|
|
How many vertebrea are in the vertebral column?
|
33
|
|
|
What curves of the spine are convex anteriorly?
|
Cervical and lumbar
|
|
|
what curves of the spine are concave anteriorly?
|
thoracic and sacral
|
|
|
Where is C7 Landmark found?
|
At the base of the neck
|
|
|
What landmark is in between the lower borders of the scapula?
|
T7
|
|
|
Where is S2 landmark found and what type fo anesthesia is it used for?
|
in b/t the posterior superior iliac spines
Caudal |
|
|
At what level does the dural sac end?
|
S2
lowest spot that can do anesthesia |
|
|
What is the Conus Mudularis
|
name for the lower end of the spinal cord
ends at L1 in adults and L3 in children |
|
|
where is L4 landmark found
|
In b/t the tops of the iliac crest
|
|
|
Where does the spinal cord end?
|
at L1 in most adults (L2 in 15% of population) and L3 in children
|
|
|
What is the Cauda Equina?
|
free flowing nerves in the dural sac (L1-S2); floating in CSF
|
|
|
Where is the end of the epidural space
|
Sacral Hiatus S4-S5
|
|
|
Waht are the 3 main ligaments thgh?
|
Supraspinous ligament
Interspinous ligamnet Ligamentum Flavum ("yellow") |
|
|
What is defined by "loss of Resistance"?
|
Epidural space
|
|
|
What is in the epidural space?
|
nerve roots, fat, lymphatics, and blood vessels
NO CSF |
|
|
What are the 3 membranes that surround the spinal cord?
|
Dura mater: outermost
Arachnoid mater Pia mater: highly vascular and closely attached to the spinal cord |
|
|
Where is a spinal catheter placed?
|
Subarachnoid space (SAB): in b/t the pia mater and the arachnoid mater
-there is CSF here |
|
|
What artery(s) supply the sensory portion of the spinal cord?
|
Sensory portion is dorsal
2 Posterior spinal arteries |
|
|
What artery(s) supply the motor portion of the spinal cord?
|
motor portion is ventral (anterior)
1 Anterior artery |
|
|
What puts patient at the highest risk for perioperative cardiac morbidity/mortality?
|
Recent MI
|
|
|
List the Major risk factors for perioperative cardaovascular risk
|
Unstable coronary syndromes
-recent MI -Unstable angina Decompensated CHF Significant Arrythmias -AV bliock -SAV arrythmia with uncontrolled ventricular rate Severe valvular disease |
|
|
List the Intermediate risk factors for perioperative cardiovascular risk
|
Mild Angina
Prior MI (Q waves) compensated or prior CHF DM |
|
|
List the Minor risk factors for perioperative cardiovascular risk
|
Advanced age
Abnormal EKG (left ventricular hypertrophy, left bundle branch block, ST abnormalties) Rhythm other than sinus (Afib) Low functional capacity History of stroke Uncontrolled systemic HTN |
|
|
What do you want the diastolic pressure to be below for surgery?
|
110
|
|
|
What types of surgeries put the patient at high cardiac risk?
|
Emergent major operations, esp. in elderly
Aortic and major vascular Anticipated prolonged surgical procedures ass. with large fluid shift/blood loss |
|
|
What types of surgeries put patient at intermediate cardiac risk?
|
carotid endarectomy
Head and Neck Intraperitoneal and intrathoracic orthopedic prostate |
|
|
What procedures have low cardiac risk?
|
Endoscopic
Superficial procedures cataract breast |
|
|
What is one of the most important determinants of perioperative risk and need for invasive monitoring?
|
Exercise tolerance
|
|
|
List some ways to reduce the risk of pulmonary complications in patients with pulmonary disease intraoperatively
|
limit duration of surgery < 3hours
use spinal or epidural Avoid Pancuronium use laparoscopic when possible substitute less ambitious procedure for upper abdominal or thoracic surgery whenever possible |
|
|
List way to reduce risk of pulmonary complications in pts with pulmonary disease preoperatively
|
Encourage smoking cessation for atleast 8 weeks
treat ariflow obstruction in patients with COPD or asthma administer abx or delay surgery of URI present educate about lung expansion manuevers |
|
|
Does smoking cessation for 6 weeks improve outcomes?
|
No, it is ass. with increased incidence of morbidity, probably due to decreased mucociliary clearance
|
|
|
What does the autonomic dysfunction in diabetics put them at risk for?
|
silent MI
greater hemodynaic lability during induction |
|
|
What do you worry about with hyperthyroidism?
|
Thyroid storm-- Hypermetabolic state
Enlarged thyroid-- difficult intubation |
|
|
What lab should be checked in patients with Hyperparathyroidism
|
Calcium
|
|
|
What is the best test to look for poor synthetic function (liver problems)
|
prothrombin time
|
|
|
What are the signs of Increased ICP?
|
change in MS
lethargy HA change in vision |
|
|
What are the 3 components of airway evaluation?
|
thyromental distance
ability ot flex and extend neck aperture opening |
|
|
what type of heart murmur is most concerning and why?
|
Systolic murmur that radiates to the carotids
indicative of Aortic stenosis and this is ass. with high risk of perioperative morbidity and mortality |
|
|
What is the minimal preop Hgb level acceptable in patients without systemic disease?
|
Hgb 7
|
|
|
What is the least invasive and most cost efective method for evaluating for CAD
|
exercise stress test
|
|
|
What is the best predictor of perioperative outcome after vascular surgery?
|
Poor Ejection Fraction
|
|
|
What artery is critical in supplying blood to the lower 2/3's of the spinal cord?
|
Artery of Adamkiewicz (comes off the anterior artery)
-enters vertebral canal at L1 |
|
|
What is the goal in positioning for a spinal or epidural placement?
|
reduce lumbar lordosis
|
|
|
What kind of fibers are easier to block?
|
smaller, more myelinated (sympathetic C fibers)
|
|
|
Which nerve fibers are the biggest?
|
motor
|
|
|
What does Segmental block mean?
|
with an epidural, the drug is not floating in CSF, so wherever you inject the drug is where the patient will have analgesia
|
|
|
damage to what artery can result in bilateral LE motor loss
|
Artery of Adamkeiwitz -- Anterior spinal artery syndrome
|
|
|
what type of surgery have higher risk for damage to the Artery of Adamkiewitz?
|
Aorta
|
|
|
when is patient at increased risk for "Bloody Tap"?
|
when they have epidural vascular engorgement (vein engorgement)
|
|
|
name the needle that cuts the Dura
|
Quinke
|
|
|
what are the cauda equina nerves floating in?
|
CSF
|
|
|
Name the needle that spreads the Dura
|
Whitakre
|
|
|
What is the primary site of action of neuraxial blockade
|
nerve root
|
|
|
Which does a segemtnatl block: spinal or epidural?
|
epidural
|
|
|
List the absolute contraindications to nueraxial blockade
|
Absolute:
Infection at site of injection patient refusal coagulopathy severe hypovolemia Increased ICP Severe Aortic stenosis Severe mitral stenosis |
|
|
List the relative contraindications to neuraxial blockade
|
Sepsis
Uncooperative patient preexisting neurological defect -demyelinating lesions stenotic valvular heart disease severe spinal deformity |
|
|
What type of procedure is spinal indicated for
|
TURP
|
|
|
What are the 2 most important factors affecting the level of spinal anesthesia
|
position of the patient (during and immediately after injection)
drug dosage |
|
|
Lidocaine with spinal
dosages (T10 and T4) onset duration |
must be 2.5%
Dose: T10 40-50 mg & T4 60-75 mg Onset: 2-4 min Duration: 45-75 min |
|
|
Bupivicaine with spinal
dosages onset duration |
0.5-.75%
Dose: T10 8-10 mg & T4 12-15 mg Onset: 4-6 minutes Duration: 60-120 minutes or 120-180 min. with Epi |
|
|
where do the sympathetic nerve fiber come off the spinal cord?
|
thoracic and lumbar sections of spine,
so the higher you block, the more of a sympathetic effect you have and the more hypotensive the patient gets. |
|
|
why is there high incidence of cardiac arrest in young healthy patients getting a spinal?
|
they have high vagal tone, so when block sympathetic system, especially very high spinal, so profound blockage, their vagal response is unopposed and they brady down
have all monitors on and prload with 500 cc of NS Escalate treatment: Atropine, then .5 mg Epinephrine (resusitation dose is 1 mg epi) |
|
|
where do the cardio-accelerator fibers come of spinal cord
|
T4
|
|
|
Where does the phrenic nerve come off the spinal cord?
|
C4-5
|
|
|
how long should IV heparin be off for before placing an epidural?
|
1 hour.
has to be off for 4 hours before take it out |
|
|
what do spinal/epidural do to stress response?
|
decreases it
|
|
|
what has more risk of bleeding: putting in or taking out epidural
|
both are just as risky
|
|
|
What is most important about local anesthetic solution when putting in epidural/spinal?
|
Must be preservative free
|
|
|
Where does the T4 dermatone innervate?
|
Nipple line
|
|
|
Where does the T10 dermatone innervate?
|
Umbilicus
T10 block means that the patient is unable to feel coldness of alcohol swab at the umbilicus |
|
|
when you have a T4 block, what does that mean?
|
that T4 is the highest level that the patient is blocked b/c if they cannot feel the alcohol pad, their sympathetic (easiest fibers to block -- C fibers ) are blocked
so have sensory block 2 dermatones lower (T6) and motor block at T8 |
|
|
What operations is spinal anesthesia preferred vs. GA for?
|
TURP (b/c there is lower blood loss with a spinal and you want the patient awake so van check the patient for confusion/ dlutional hyponatremia/ water intoxication)
TURB: can monitor for sudden abdominal pain-- bladder perforation |
|
|
what is TURP Syndrome and what is the first sign of it?
|
water intoxication
mental confusion |
|
|
What are reasons for using regional anesthesia in obstetrics?
|
decreased aspiration risk; difficult airways
Locals don't cross the placenta facilitate early bonding of mom and baby |
|
|
What happens with a spinal at level of T4?
|
affect accessory muscles of respirations, so regional is contraindicated
|
|
|
most important factor affecting level of spinal
|
baricity of the local anesthetic:
hyperbaric, isobaric (same baricity as CSF) |
|
|
how are local anesthetics solutions made hyperbaric
|
addition of glucose
|
|
|
which lasts longer Isobaric or hyperbaric solution block
|
Isobaric bupivicaine 0.5%: lasts longer and is a more dense block b/c it stays where you put it
|
|
|
What is added to local anesthetic solution for spinal or epidural? Why?
|
Fentanyl 25 mcg-- acts on the dorsal horn of spinal cord (sensory) and decreases noxious stimulus (pain)
|
|
|
What are 2 critical times that need to check BP frequently when giving spinal/epidural?
|
1. first 10-20 minutes (check every 2 minutes)
2. moving from OR bed to stretcher (redistribution of blood) |
|
|
What are the 2 techniques for identifying that you have reached the epidural space?
|
1. loss of resistance
2. Hanging drop |
|
|
What is dose of Lidocaine used for test dose with epidural
|
45 mg of lidocaine with Epi (1.5% in 1:200,000)
Lidocaine: this is to make sure not in spinal (pt would not be able to move legs if in spinal) Epi: If intravascular, will see 20% or greater increase in HR and BP |
|
|
how do you check to make sure epidural catheter has not moved?
|
aspirate before inject and inject small increments
|
|
|
low concentration of local give what kind of block in epidurals?
|
analgesic block
|
|
|
What is the advantage of doing epidural when the patient is awake?
|
they can say they have pain/parasthesia-- this tells you that you are hitting a nerve, *need to move the needle before inject
|
|
|
Is SC heparin a contraindication to having an epidural/spinal?
|
No
|
|
|
What factor does not increase the risk for postdural puncture headache
|
timing of ambulation
continuous spinals |
|
|
what factors increase risk for postdural puncture headache?
|
Age: younger
Gender:L females Needle size: larger Needle bevel: increased when dural fibers are cut transversely pregnancy number of dural punctures |
|
|
when injecting drug druing bier blcok, what do you wnat to ask pateitn about?
|
signs of local anesthetic toxicity
perioral numbness, metallic taste in mouth |
|
|
how much lidocaine do you inject for a bier block?
|
Lidocaine 0.5%-- 50 ml
5mg/ml = 250 mg |
|
|
How lung must torniquet stay up once drug is injected?
|
at least 20 minutes
|
|
|
List the contraindications to Bier block
|
Sickle cell
Infection Ischemic vascular disease traumatic lacerations severe pain postop pain issues extremity Fx |
|
|
List the compolications with bier blocks
|
systemic toxicity
Engorgement of extremity thrombophlebitis hematoma Inadequate block |
|
|
How fast can you inject lidocaine in beir block?
|
slowely: over 2-3 minutes
|
|
|
What are signs of CNS toxicity to look for during bier block
|
nircuoral numbness, tongue parthesia, dizziness, ringing in ears, blurred vision
Seizure |
|
|
what is more likely to happen with lidocaine in bier block CNS toxicity or CV toxicity?
|
CNS-- more likely to have a Sz-- treat wtih thiopental, propofol, benzos
|
|
|
what can be seen in Mallampati Class I view?
|
uvula, faucial pillars, soft palate,
|
|
|
what can be seen in Mallampati class II view?
|
faucial pillar, soft palate
|
|
|
what can be seen in Mallampati class III view?
|
soft and hard plate
|
|
|
what can be seen in Mallampati class IV view?
|
hard palate only
|
|
|
name the 9 cartilages of the larynx
|
thyroid, cricoid, epiglottic
Cuneiform corniculate Arytenoid |
|
|
What nerves supply sensation to the airway?
|
Cranial Nerves
|
|
|
What nerve innervates the roof of the pharynx, tonsils and the undersurface of the soft palate
|
Glossopharyngeal nerve (IX)
|
|
|
What nerve provide sensation to the airway below the epiglottis?
|
Vagus Nerve (X)
|
|
|
What muscles abduct the vocal cords?
|
Posterior cricoarytenoid muscles
|
|
|
What muscles adduct the vocal cords?
|
lateral cricoarytenoid muscles
|
|
|
Acute bilateral injury to which laryngeal nerve will result in stridor and respiratory distress?
|
Recurrent laryngeal nerve (branch of the vagus nerve)
|
|
|
What is the most important manuever to allow proper ventilation in bag-mask ventilation?
|
using little finger to thrust jaw anteriorly
|
