Oberhansley Test 1

Front 1

MAC- 3 types
Minimum

Moderate

Deep

Back 1

Minimum sedation• Drug induced state• Anxiolysis• Normal response to commands• Moderate• Axiolysis + Analgesia• Depression of consciousness (Conscious Sedation)• Airway and CV maintained

•Deep • Cannot be easily aroused but respond to painful stimulation• Airway and CV may need support

Front 2

Who are not candidates for conscious sedation or MAC?

Back 2

Emergency

• Full stomach

• Difficult airway

• ASA ≥III

• High dose narcotics required

Front 3

2 types of Local anesthesia

Back 3

surface/topical

Infiltration or field block

Front 4

3 types of Regional Blocks

Back 4

Peripheral nerve blocks

..Plexus blocks

IV/ Bier Blocks (use tourniquet)

Front 5

3 types of Central/ Neuraxial Blocks

Back 5

• Spinal

• Epidural

• Caudal

Front 6

Stage I of Anesthesia

Back 6

Conscious

• Perception of pain is diminished

Front 7

Stage II

Back 7

Unconscious

-Delirium

• Reflexes absent– Body responds

• reflexive and irrationally – Breath holding, pupils dilated

• Muscle tone intact

Front 8

Stage III

Plane I

Plane II

Plane III

Plane IV

Back 8

• Plane I – Regular breathing, cessation of

eyeball movement

• Plane II – Beginning of ICM paralysis

• Plane III – Pupils dilated, light reflex lost.

Progressive ICM paralysis, lost of response to inc

• Plane IV – Diaphragmatic paralysis

Front 9

Stage IV

Back 9

Depression of cardiovascular and respiratory centers

• Overdose

Front 10

Who is the "Father of Anesthesia"

Back 10

John Snow
-Ether Chamber

Front 11

ASA I

Back 11

A normal healthy patient

•Healthy•Non-smoking

•No clinical co morbidity , no significant past or present medical or surgical history

Front 12

ASA II

Back 12

A patient with mild systemic disease

•Mild diseases only without substantive functional limitations.

•Current smoker

•Social alcohol drinker•Obesity (30 < BM < 40)•Well controlled DM/HTN

•Mild lung disease-Asthma

•*Pregnancy*

Front 13

ASA III

Back 13

A patient with severe systemic disease or substantive functional limitations

•Moderate to severe diseases

•Poorly controlled DM or HTN•COPD

•Morbid obesity (BMI ≥40)•Active hepatitis•Alcohol dependence or abuse•Implanted pacemaker•Moderate reduction of ejection fraction•ESRD undergoing regularly scheduled dialysis•Premature infant PCA < 60 weeks•History (>3 months) of MI, CVA, TIA, or CAD/stents

Front 14

ASA IV

Back 14

A patient with severe systemic disease that is a constant threat to life

•Recent ( < 3 months) MI, CVA, TIA, or CAD/stents•Ongoing cardiac ischemia•Severe valve dysfunction•Severe reduction of ejection fraction•ARD

•ESRD not undergoing regularly scheduled dialysis•Sepsis•DIC

Front 15

ASA V

Back 15

A moribund patient who is not expected to survive without the operation

•Ruptured abdominal/thoracic aneurysm,•Massive trauma,•Intracranial bleed with mass effect,

•Ischemic bowel in the face of significant cardiac pathology

•Multiple organ/system dysfunction

Front 16

ASA VI

Back 16

•A declared brain-dead patient whose organs are being removed for donor purposes

Front 17

What does the "E" mean after ASA status?

Back 17

emergency surgery

Front 18

Is age a factor for ASA status?

Back 18

Age is NOT taken into account

Front 19

What is the ASA status for a ruptured AAA?

Back 19

ASA VE or 5E

Front 20

What about the ASA code for a healthy child with a BMI of 29 and for surgery on a broken finger?

Back 20

ASA 1E

Front 21

What is the ASA status for a scheduled surgery for a 47 year old who has no significant medical history other than obstructive sleep apnea with BMI of 41?

Back 21

ASA III

Front 22

Is acute hypertension (d/t pain) an indication for increasing ASA status?

Eg Healthy pt with tib/fib fixation, BP 210/100

Back 22

No

ASA 1E

Front 23

How much cooler are peripheral tissues than a core temp?

Back 23

2-4 degrees celcius

Front 24

What types of afferent receptors detect most cold?

Back 24

A delta and C fibers --Increased firing in response to cold.

Front 25

Where are the central temperature sensors?

Back 25

Anterior hypothalamus

-pre-optic area and other areas

-increase rate of firing as temperature increases

Front 26

Afferent sources of cold (5)
-20% of cold perception each

Back 26

-Hypothalamus

– Other parts of brain

– Spinal cord

– Deep abdominal/thoracic tissues

– Skin

Front 27

Central Core Center for Temperature

Back 27

Posterior hypothalamus
-integrates afferent and efferent activity

Front 28

What drug or drugs may increase temperature through reduced sweating?

Back 28

Atropine, anticholinergics

Front 29

Do newborns shiver when they are cold?

Back 29

No

Front 30

Normal shivering threshold

Back 30

35.5 degrees celcius

Front 31

Treatment of shivering

Back 31

Warm blankets to head/face

Meperidine-alpha 2b and kappa agonist

Clonidine-alpha 2b agonist

dexmedetomidine

others-Physostigmine, ketanserin, tramadol, MgSO4

Front 32

Each degree above 37C increases oxygen consuptiom by how much?

Back 32

13%

Front 33

What can cause hyperthermia?

Back 33

• Watch the Bair Hugger!

• Too many tourniquets….

• Atropine

• Allergy

• Blood transfusion reaction

• Infection

• Blood in the fourth ventricle of brain

Front 34

Heat stroke

Back 34

temp >106
Body starts to malfunction

parynchymal damage to organs

Front 35

Effect of Humidity on body for heat stroke

Back 35

Humidity of 0% - up to 150 degrees OK– Humidity of 100% - body temperature willrise w/ambient temperature >94 degrees

Front 36

Causes of incidental hypthermia

Back 36

Unconscious patient -don't cover self

• Cool environment

• Wet skin prep

• High air exchange rate in OR

• Paralysis• General anesthesia

• Regional anesthesia

• Dry/unheated inhaled gases

• High flow gas flow rates• IV fluids/blood products

Front 37

How much temperature drop after give IV induction agents?

Back 37

about 1 degree C

Front 38

Drugs that alter thermoregulation

Back 38

All depressants of CNS–

Inhalational anesthetics – dose dependent– Barbituates – central decreased heat production– Aspirin – resets set point–

Phenothiazines – central action/increased heat loss–

Atropine – prevents sweating–

Muscle relaxants – prevents shivering

Front 39

Where do we get core temps for surgery?

Back 39

Lower 1/3 esophagus–

Tympanic membrane–

Pulmonary artery- rarely used

Front 40

Other places for core

Back 40

Skin- may read lower

Muscle

Rectum

Bladder

Front 41

Who is at most risk for hypothermia?

Back 41

• Infants– High body surface area:mass– Very effective radiators!

• Elderly– Decreased sensitivity of TRS– Decreased cardiovascular reserve

• Spinal cord injured patients

• Burn victims

• Prolonged surgery

Front 42

What do tourniquets do to patient temp?

Back 42

Increase temp

Front 43

Cardiovascular effects of hypothermia

Back 43

Decreased response to catecholamines

Increased cardiac afterload/SVR

<32 susceptible to afib

<30 susceptible to vfib

Front 44

Effect of hypothermia on the blood?

Back 44

hemoconcentration

diuresis

Fluid shift to extracellular

diuresis because of lessened effect of ADH

Front 45

What does a decrease in temp do to the oxyhemoglobin disassociation curve?

Back 45

Shift to the left (tighter oxygen binding to hemoglobin and less tissue delivery)

Higher SaO2(Sats) but lower PaO2 (tissue availability)

Front 46

Effect of hypothermia on metabolism

Back 46

Metabolism decreases 5-7% per degree Cfall in temperature–

Decreased O2 consumption– Decreased CO2 production–

If ventilation remains constant, relativehyperventilation results – resp alkalosis Metabolism of anesthetic agents andmuscle relaxants is slowed

Front 47

Hormonal effect of hypothermia

Back 47

Decreased insulin,

increased catecholamines

Increased cotisterone and TSH

Impaired leukocyte

Impaired local platelet function

Front 48

Top 3 risks of hypothermia?

Back 48

Increased risk of transfusion

Increased length of stay

Infection

Front 49

Shift errors 8h days vs 12h?

Back 49

12 days 3x more likely to make errors

Front 50

Error Fixation

Back 50

Focusing on one task or error, so miss another

Front 51

SBAR

Back 51

Reduces verbal communication error

Front 52

Where do we report near misses?

Back 52

Anesthesia.mayo.edu, near miss page

Front 53

4 top causes of errors

Back 53

•Inadequate experience

•Equipment/devices

•Communication

•Inattention

Front 54

Ways to reduce iatrogenic harm

Back 54

Knowledge,

experience,

vigilance,

health,

communication.

Front 55

Does the use of glove replace or supplement hand hygiene?

Back 55

No, gloves are not indicated when there is no potential for body fluid contamination/exposure

Front 56

Do you need gloves for any of these tasks?

Direct patient exposure: taking a BP, temperature and pulse, performing injections, transporting patients, any vascular line manipulation in absence of blood leakage, placing non invasive ventilation equipment and oxygen cannula

Back 56

No, just proper hand hygiene

Front 57

What is Point of Care and what is it used for?

Back 57

Point of Care is where three elements come together

•Patient

•Healthcare worker

•Care/treatment involving contact with the patient or surroundings

Front 58

3 Critical hand hygiene times for anesthesia

Back 58

•IV or line placement

•Tracheal intubation or NG placement

•Regional anesthesia

Front 59

How long should a hub be cleaned?

Back 59

It should be scrubbed not swiped for 15 seconds

Front 60

how long can do disinfectant caps have to be on before they are effective?

Back 60

5 minutes, and cannot be reused.

Front 61

why is it important to wear a mask during lumbar puncture?

Back 61

can transmit bacterial meningitis via oral droplets

Front 62

how often does equipment need to be cleaned?

How often does equipment need to be terminally cleaned?

Back 62

for each new patient

daily

Front 63

Prewarming time

Back 63

30-60 minutes prior to induction

Front 64

What does the staff wear for TB patient?

What does the patient wear for transport?

Back 64

0.3 micron N95

Regular face mask, keep OR room closed for 60 minutes after procedure

Front 65

What restrictions are there for NORA ?

Back 65

None, we can do anything in the field

Front 66

Which types of sedation do RNs perform?

What about CRNAs and MDAs?

Back 66

1. Minimal Sedation and conscious sedation (controversial to use propofol)

2. Deep sedation and general anesthesia

Front 67

What are the ASA guidelines for NORA?

Back 67

Source of OxygenBackup supply full E-cylinderSuctionScavenging systemSelf-inflating bagAdequate drugsAdequate monitors per ASA standardsAnesthesia machineElectrical outletsAdequate illuminationSufficient spaceEquipment for ACLS2-way means of communicationPACU and safe transport

Front 68

How do anesthesia death rates compare in NORA to OR?

Back 68

Double

Front 69

what is the best way to improve outcomes with NORA? Patients are sicker, older, more emergent than OR

Back 69

Closer monitoring (on test)

ASA added ETCO2 to standard for NORA

Front 70

Do ASA standards differ for NORA vs OR?

Back 70

SAME!

OXYGENATION

VENTILATION

CIRCULATION

TEMPERATURE

These standards may be adapted to needs of patient, procedure or equipmentDocumentation

Front 71

Challenge of External radiation therapy

Back 71

Use video monitor and cannot directly view the patient or manipulate airway

Front 72

optimal IR anestetic delivery is optimal on...

Back 72

communication between Interventionist and anesthesia

Front 73

Chemotoxic reaction

Back 73

dependent on dose and concentration of toxin

Front 74

Anaphylactic reaction

Back 74

Not dependent on dose of drug

Front 75

How do we reduce ionizing ratiation exposure?

Back 75

Increase Distance

- Decreases exposure by square of distance (1/d2)

Wear Lead

- Decreases exposure by factor of 10Transparent shield

Front 76

When using an LVAD and encounter hypotension, should you increase pump speed?

Back 76

No, treat with vasoactive drugs like phenylephrine

Front 77

Order of Muscle paralysis

Back 77

Vocal Cords Die Out After Adding Muscle Paralysis Externally

Front 78

Thumb muscle

Nerve?

Back 78

Adductor Pollicis

Ulnar

Front 79

Goal of Nerve Stimulation

Back 79

Evaluate the muscular response to supramaximal stimulation of a peripheral motor nerve•At least 50mA across 1000ohm… or•20-25% above max response

Front 80

Black and red elecrode placement

Back 80

Black goes over most superficial part of nerve,

Red goes proximal or towards the heart.

Front 81

Nerve stimulated on face?

Muscle?

Back 81

Temporal branch of facial nerve,

Orbicularus Oculi (wink)

Front 82

Posterior tibial nerve

Back 82

Flexor Hallus

Front 83

how far apart should electrodes be?

Back 83

2 inches

Front 84

Single Nerve Twitch

Back 84

•Single supramaximal stimulus from 1.0 to 0.1Hz (1-10sec)•Helpful for monitoring onset of muscle relaxant•Assess level for intubation•Nerve blocks•Not a good indicator of DEPTH

Front 85

Train of Four speed

How to calculate

Back 85

1 twitch every half second or 2 Hz

4th twitch divided by 1st

Front 86

1 Twitch

2 Twitches

3 Twitches

4 Twitches

Back 86

95% blocked

90% Blocked

80% blocked

<75% blocked

Front 87

Tetany

Back 87

Very rapid (30, 50, 100-Hz) electrical stimulation•Normal neuromuscular function & depolarizing NMB•5 sec tetany is sustained•NDMR and phase II block•5 sec tetany not sustained

Front 88

Post tetanic count

Back 88

50hz for 5 seconds followed by 3 second 1Hz twitch

Front 89

Double burst suppression

Back 89

More accurate but not used

Front 90

Nerve stim for peripheral blocks

Back 90

Nerve stimulators capable of Macroshock•Up to 75mA•Close to threshold of 80mA to cause cardiac arrhythmias•Current density higher in children, threshold is lower

Front 91

When (TOF ratio) is it possible to reverse a patient NDMB?

Back 91

> 0.30 or clinically has one twitch

Front 92

What else is important in Extubation/Recovery after reversing a patient?

Back 92

•Sustained (≥5 s) head lift•Ability to generate an inspiratory pressure of at least −25 cm H2O•Forceful hand grip

Mindful of ---•Postoperative residual curarization (PORC)

Front 93

Negligence is..

example:

Back 93

Failure to use reasonable care

Using latex gloves with a person with latex allergy

Front 94

Tort

Back 94

-civil wrong eg negligence or breach of confidentiality

-person has breached their contract or responsibility

Front 95

Factors in Medical Negligence

Back 95

DutyPatient/Provider relationship exists

Reasonable careBreach of DutyFailure to meet Standard of CareDamageInjury sufferedCauseDamage was caused by actions of defendantDeviation from standard of care

Proximate cause

Forseeable before event

When viewed in retrospect not thought of as extraordinary

Front 96

Res Ipsa Loquotir

and example...

Back 96

Res Ipsa Loquitur – “the thing speaks for itself”Commonly used in negligence cases

Elements that must be provenWould not occur in absence of negligence

Exclusive control of defendant

Not due to any voluntary action by plaintiff

eg. ulnar nerve injury

Front 97

Informed consent protects from

Back 97

Protects from charges of battery and negligent failure to warn

Assault – threat of action

Battery – constraint or physical violence

Front 98

Must informed consent be obtained under all circumstances?

Back 98

Yes, can be written, verbal or implied

Front 99

If a patient positioned themself for a spinal without speaking, is this informed consent?

Back 99

No, because they are capable of speaking

Front 100

What happens if informed consent is not obtained and anesthetics are administered?

Back 100

A. The anesthetist can be held liable under the principle of “res ipsa loquitor”

B. The anesthetist can be charged with an intentional tort

C. The anesthetist can be charged with battery and/or negligent failure to warn

D. Nothing, informed consent is not mandatoryE. Both B&C

Front 101

Statue of Limitations

Back 101

Discovery rule

Time begins from time of injury or time of discovery of injury

Two exceptions:DisabilityInability to discover injury caused by negligence

Front 102

Surgery DNR order:

A. The DNR order should be rescinded and patient should be made a full code for surgical procedure.

B. Course of action is dependent on institutional policies.

C. DNR order must be clarified with the patient and patient’s family.

D. Both B&C

Back 102

D

Front 103

Items not to document

Back 103

Sentinel event report, discussions with legal

Front 104

Correcting and Error

Back 104

Draw single line through and initial

Front 105

Spoilation of evidence

Back 105

Destruction, criminal charges can be filed

Front 106

Top cause of Malpractice claims

What types of hospitals have the highest claim rates?

Back 106

Tooth damage

Rural

Front 107

Next 3 causes after for malpractice claims

What is the biggest factor?

Back 107

Death

Nerve damage – ulnar most common

Brain or other organ damage

OBESITY is the biggest factor

Front 108

What legislative Act requires the employer to provide reasonable accommodation for the chemically dependent CRNA?

Back 108

1. Americans with Disabilities Act

Front 109

Respondeat Superior

Back 109

Legal principle of vicarious liabilityThe employer or another supervisor is responsible for the actions of a CRNA

Front 110

You have been served a complaint and summons, what has formally occurred?

Back 110

B. A lawsuit has been filed.

Front 111

A lawsuit has been filed, what is the first action the CRNA should take?

Back 111

Notify insurance carrier first!

Front 112

Best way to reduce lawsuits

Back 112

Establish patient rapport and be honest about events

Front 113

Class 3 Lasers

Back 113

Direct viewing and specular reflection of Class 3b lasers may cause permanent eye damage.

Front 114

Class 4

Back 114

Diffuse reflection may cause permanent eye injury or ignite fire. Protective equipment required.

Front 115

Type sof lasers

Back 115

Thermal

Mechanical

Photochemical

Front 116

What determines the effect of light?

Back 116

Wavelength of light and medium

Front 117

Direct exposure to light

Back 117

Causes harm in 3A

Front 118

Specular Reflection

Back 118

Causes harm in 3b

Front 119

Diffuse Reflection

Back 119

spot on wall can cause harm

Class 4

Front 120

Co2 Lasers cause

Back 120

Corneal Burns

Front 121

Wavelength of Visible lasers

(cause retinal damage)

Back 121

400-750nm

Front 122

CO2

Back 122

3rd degree burns

Front 123

Maximum Permissible Exposure

What is the space of MPE called?

Back 123

maximum power a person can be exposure a person can have without harm

Nominal Hazard Zone(OR)

Front 124

What eyewear do you use?

Back 124

specific wavelength

Front 125

What does nM mean for lasers

What does OD mean?

Back 125

nm is Wavelength

OD of 5 nm

Front 126

What is the primary way to evacuate laser plume?

Back 126

Using a local evacuation system

Front 127

Scope of practice...

Back 127

Establishes the boundaries of Anesthesia

Front 128

AANA Standard I

Back 128

Preop assessment

Front 129

3 MAC objectives

Back 129

Comfort

Safety

Satisfaction

Front 130

Agatha Hodgkins

Dagmar Nelson

Back 130

Hodgkins- AANA founder

Nelson - Sued in Cali for practicing medicine, gave nurses the right to practice anesthesia within scope of practice