Oral Exam Final 2

Front 1

41. What are the characteristic shapes of a flow/volume loop in restrictive disease?

Back 1

With restrictive disease the flow curve is short and skinny. The flow is usally normal but the volume is less and quicker on inspiration and expiration.

Front 2

42. What are the ASA Standards for Monitoring?

Back 2

Standard 1: Qualified anesthesia personnel shall be present in the room throughout GA, regional anesthesia, and monitored anesthesia care.
Standard 2: During all anesthetics, the patient’s oxygenation (pulse ox, O2 analyzer w/low oxygen alarm), ventilation (cont eval of breath sounds, ETCO2, ETT positioning, capnography, audible alarms), circulation (cont ECG, BP & HR q5min) and temperature (when significant changes are anticipated or suspected) shall be continually monitored

Front 3

43. How does an oscillometric blood pressure device work?

Back 3

A microprocessor derives systolic, mean, and diastolic pressres by using an algorithm. Arterial pulsations cause oscillations in the cuff pressure. These are small when cuff inflated above systolic and when pressure decreases to systolic the pulsations are transmitted to entire cuff and oscillations are increased. Maximal oscillation occur at MAP after which they decrease. Electronically measure pressures at which oscillation amplitudes change.

Front 4

44. What variables can contribute to inaccuracy in non-invasive blood pressure monitoring?

Back 4

Proper cuff size (rubber bladder ½ way around arm): too smallfalsely high, too big  falsely low
Positioning (line up arrow on artery): surgeon leaning on arm, lateral position, arm up in air or hanging dwon, tucking
HR: tachycardia, bradycardia, a-fib or flutter

Front 5

45. How does a transducer work?

Back 5

A pressure transducer is a miniaturized, disposable that has a diaphragm that is distorted by an arterial pressure wave. This mechanical energy is converted to an electrical signal and is based on the strain gauge principle which is were stretching a wire or silicone crystal changes its electrical reistance. The sensing elements are arranged as a Wheatstone bridge circuit so that the voltage ouput is proportionate to the pressure applied to the diaphragm.

Front 6

46. What variables can contribute to inaccuracy in invasive blood pressure monitoring?

Back 6

Extra tubing, stopcocks, air bubbles, improper zeroing or leveling; Over-dampened waveform underestimates, under-dampened waveform underestimated ABP.

Front 7

47. Explain the difference between ‘damping’ and ‘overshoot’

Back 7

Over-dampened waveform underestimates SBP and the frequency is too low- this can be from adding stopcocks, adding tubing or having air in the line.
Under-dampened waveform overestimates ABP and leads to overshoot, can use a smaller cathether to help correct

Front 8

48. How does a pulse oximeter work?

Back 8

It utilizes Beer-Lambert law of spectrophotometry which relates solute concentration to the intensity of light transmitted through the solution. Two wavelengths of light are passed through a vascular bed and are used to differentiate hemoglobin with O2 attached and hemoglobin(940 nm infrared) w/o O2(red 660nm). Has 2-3 light emitting diodes and a light dectector.

Front 9

49. What variables can contribute to inaccuracy in pulse oximetry monitoring?

Back 9

Poor perfusion sites, motion electrocautery, OR lights, nail polish, synthetic nails, IV dye, irregular rhythm, darkly pigmented skin. Also carboxyhemoglobin will give use falsely elevated reading and methemoglobin with give you a reading around 85% whether pt is above or below that.

Front 10

50. What actions would you take if your patient became hypoxic?

Back 10

Investigate cause, turn O2 up, draw blood gas, if not resolving with increased O2 take patient off machine and bag.

Front 11

51. What actions would you take if your patient became hypercarbic?

Back 11

Investigate vent settings, may need to increase rate to blow off CO2, investigate canisters to see if exhausted and also check expiratory check valve.

Front 12

52. What are the characteristic ECG changes associated with ischemia?

Back 12

ST elevation over 1mm, also ST depression

Front 13

53. What variables can contribute to inaccuracy in ECG monitoring?

Back 13

60 second interfact, problems with artifact with patient or lead-wire movement, electrocautery units mimic VF, faulty electrodes.

Front 14

54. What is the definition of hypothermia?

Back 14

body temp <36 C

Front 15

55. How can you prevent hypothermia?

Back 15

Expect patient will get cooler so use beer blankets, fluid warmers, warm blankets, warm and humidify gases, and have a warm room

Front 16

56. Which patient populations are at a greater risk for awareness?

Back 16

Obstetric, major trauma, Bypass, elderly , multiple comorbidities, alcohol, drug abusers.

Front 17

57. What steps can be taken to reduce the risk of awareness?

Back 17

Premedicate with amenestic drugs, give more than sleep dose of induction agents followed immediately by tracheal intubation, avoid muscle relaxants unless absolutely necessary, conduct periodic maintenance of anesthesia machine and vaporizers, meticulously check machine and ventilator prior to use.

Front 18

58. Explain reasons why the BIS monitor may not be reliable.

Back 18

B/c first tested and based on young healthy adults.

Front 19

60. When a patient exhibits 4 out of 4 twitches, what percentage of block can they still have?

Back 19

60%

Front 20

61. When a patient exhibits 3 out of 4 twitches, what percentage of block can they still have?

Back 20

75%

Front 21

62. When a patient exhibits 2 out of 4 twitches, what percentage of block can they still have

Back 21

80%

Front 22

63. When a patient exhibits 1 out of 4 twitches, what percentage of block can they still have?

Back 22

90%

Front 23

64. When is post-tetanic facilitation useful?

Back 23

PTF: 5 seconds of 50Hz tetany, wait 3 seconds, then single 1Hz twitches 1 second apart.
There is an immediate increase in available ACh at the end of tetany (stores are “revved up”) enhancing subsequent twitches. So if no response to single twitch or TOF, the number of post-tetanictwitches is related to the return of TOF.
Uses: To be sure of 100% total paralysis and to tell when patient will begin to get twitches back. For example, with an intermediate acting NMBA, PTC of 8 signals TOF will return soon.

Front 24

Why is double burst suppression considered more accurate than TOF?

Back 24

Double burst gives 3 (50Hz) short stimulations followed 750 ms later by 2 or 3 additional impulses. Easier to feel fade with double burst compared to TOF where the middle two twitches interfere with feeling the difference between the first and last twitch of 4 smaller twitches

Front 25

66. Explain the most common scenarios for an electrical injury in the operating room?

Back 25

Surgeries using electrocautery. If not properly grounded, the current will find another way to exit.
Cardiac pacing wires or PA catheter could provide microshock with stray current as low as 10 micro-Amps causing v-fib.
Electrical shock can result from body contact with 2 conductive materials at 2 different voltage potentials resulting in a completed circuit.

Front 26

67. What is the line isolation monitor?

Back 26

? Device that monitors integrity of isolation power system and sounds an alarm when isolated power is no longer isolated from group. Warms of existence of single fault, but two faults are required for shock to occur.

Front 27

68. What should you do when the line isolation monitor alarms?

Back 27

Unplug equipment one at a time, beginning w/the last piece of equipment that was plugged in, until alarm stops. When found, this piece of equipment should be removed until repaired. If absolutely necessary to patient care, the piece of equipment will continue to work and can be used but must services after the case. Staff must be made aware of the loss of isolation and the hazards of a newly grounded circuit. (If a 2nd piece of faulty equipment is added, shock could result.)

Front 28

Where are the gas shut-offs and fire extinguishers located in the operating room?

Back 28

Gas shutoff outside each center room in the sterile core. Outer room shut-offs are located outside the door in main hall. Fire extinguishers

Front 29

70. What types of cases have a higher risk of a fire?

Back 29

Airway fire most common, intestinal fire.

Front 30

71. If a fire occurs in the airway, what should you do?

Back 30

Disconnect breathing circuit from ETT, remove ETT, extinguish fire, remove any smoldering segments or pieces in airway. Evaluate (by surgeon) airway and re-intubate. Ventilate/bag with 21% RA until certain fire is out, then 100%. Treat damage accordingly: vent support, monitoring, antibiotics, steroids. Save materials for investigation.

Front 31

72. If a fire occurs in the abdomen, what should you do?

Back 31

Switch gases and O2 to RA (maintain with TIVA). Remove burning material, extinguish w/wet towel or blanket. Use saline-filled syringe for small areas. If fire under drape, pull drape off pt. If electrical equipment involved, disconnect power supply before using water or use CO2 or dry chemical extinguisher. Evaluate damage and treat accordingly.

Front 32

73. Your patient has SARS, what steps should you take in delivering an anesthetic?

Back 32

Use N95 mask, glasses, double gown, double glove, shoe covers, avoid touching before washing hands. Use disposable larynogoscope, circuit, bacterial filter, airway products. If reusable disinfect properly

Front 33

74. Your patient has TB, what steps should you take in delivering an anesthetic?

Back 33

Isolation so do later in the day, wear properly fitting mask with high efficiency filtration, use gown, gloves, shoe covers, face shields. Use disposable larynogoscope, circuit, bacterial filter, airway products. If reusable disinfect properly Use standard disinfection and sterilization procedure.

Front 34

75. Your patient has HIV, what steps should you take in delivering an anesthetic?

Back 34

Contact precautions use standard disinfection and sterilization procedures.

Front 35

76. Your patient has Hepatitis, what steps should you take in delivering an anesthetic?

Back 35

Contact precautions use standard disinfection and sterilization procedures

Front 36

77. Your patient has Creutzfeld-Jacob Disease (Mad Cow Disease), what steps should you take in delivering an anesthetic?

Back 36

Need steam sterilization between cases b/c resistant to normal decontamination methods. Use N95 mask, glasses, double gown, double glove, shoe covers, avoid touching before washing hands. Use disposable laryngoscope, circuit, bacterial filter, airway products.

Front 37

78. Your patient has MRSA, VRE, impetigo, conjunctivitis, or herpes simplex, what steps should you take in delivering an anesthetic?

Back 37

? Utilize contact precautions and clean machine before using on another patient.

Front 38

79. Explain the process of risk management in the anesthesia department as well as your responsibilities with regard to personal risk management

Back 38

Goal: A detection system designed to predict failures and ensure that precautions to prevent pt harm are taken.
Dept: Quality assurance programs and Wed meetings.
Individual: preop assessments, post op rounds, high standards of care and follow standards of care, vigilance, peer review, continuing ed, commitment to high quality pt care

Front 39

80. Explain the process of quality assurance in the anesthesia department as well as your responsibilities with regard to quality assurance. see above

Back 39

Goal: A detection system designed to predict failures and ensure that precautions to prevent pt harm are taken.
Dept: Quality assurance programs and Wed meetings.
Individual: preop assessments, post op rounds, high standards of care and follow standards of care, vigilance, peer review, continuing ed, commitment to high quality pt care

Front 40

cylinder pressures

Back 40

Cylinder supply:
Full O2 cylinder: 1900 psig, 660L
Full air cylinder: 1900 psig, 625L
Full N2O cylinder: 745 psig, 1590L or <744 psig, 300L