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Surgery final (Sabiston) > 14 - Anesthesiology principles & pain management > Flashcards

14 - Anesthesiology principles & pain management Flashcards

1
Q

What are the 4 categories of drugs used in anesthesiology?

A 
inhalators (maintenance)
hypotonic IV (induction)
analgesia 
muscle relaxation (paralytica)
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2
Q

The goal of inhalator drug to to provide fast __ which is non __ and clears out quickly.

A

induction

toxic

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3
Q

Blood-gas solubility coefficient is a measure of the drug’s __ to the __.

A

uptake

blood stream

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4
Q

Less soluble inhalator drugs (__/__) lead to faster __ and __.

A

N2O/desflurane
induction
clearance

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5
Q

More soluble drugs inhalator (__) clear more __.

A

halothane

slowly

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6
Q

MAC measures the concentration needed to prevent __ due to __ in 50% of patients.

A

movement

surgical incision

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7
Q

The higher the MAC, the __ potent the drug is.

A

less

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8
Q

Examples for inhalator MAC:
Halothane-
Desflurane-
N2O-

A

0.75%
6%
104%

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9
Q

Pungency of an inhalator may lead to __.

A

respiratory irritant

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10
Q

Mention 2 low pungency drugs used for induction:

A

halothane

desflurane

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11
Q

N2O is used for fast __ when combining with another inhalator.

A

induction

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12
Q

What are the advantages of N2O?

A

minimal effect on respiratory/hemodynamic status

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13
Q

What are the disadvantages of N2O? 2

A

Not good for maintenance

increased ventilation pressure/volume

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14
Q

What are the C/I for N2O? 4

A

pneumothorax
SBO
auricle surgery
retina surgery

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15
Q

What is the most common inhalator used for induction?

A

isoflurane

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16
Q

Isoflurane is not used for __.

A

induction

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17
Q

Isoflurane is better than ___ since it decrease less __, and has __.

A

halothane
CO
minimal metabolism

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18
Q

Isoflurane is less sensitive to the __ effect of ___.

A

arrhythmogenic

catecholamines

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19
Q

What are the disadvantages of isoflurane? 3

A

tachycardia (requires monitoring)
increases ICP in high dosage
high pungency

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20
Q

Sevoflurane is an effective __ inhalator.

A

induction

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21
Q

What are the advantages of sevoflurane? 4

A

low solubility
less pungency
no CV effect

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22
Q

Which patients are likely to be inducted with sevoflurane? 4

A

children
bronchospasm
outpatients surgery
mask induction (for difficult airway)

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23
Q

Desflurane is not used for __.

A

induction

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24
Q

What are the advantages for desflurane: 2

A

fast effect

fast clearance

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25
Q

What are the disadvantages of desflurane? 3

A

high potency
tachycardia
HTN

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26
Q

What are the main hypotonic drugs used for induction? 4

A

midazolam (dormicum)
ketamine
etomidate
propofol

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27
Q

Dormicum is a __ acting __ with __ T1/2.

A

fast
benzodiazepine
short

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28
Q

Midazolam leads to __ and anti __ effect. It does not have __ effect.

A

amnesia
anxiety
analgesic

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29
Q

Since dormicum has minimal ___ effect, it is good for __ surgery.

A

cardiac

heart surgeries

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30
Q

Midazolam can cause __.

A

hypotension

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31
Q

Ketamine has a strong __ effect.

A

analgesic

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32
Q

Ketamine does not cause __ decrease, but if there is symptomatic tonus (__), it may lead to __.

A

hemodynamic
hemorrhagic shock
hypotension

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33
Q

In patients with maximal symptomatic tonus (__/__ shock) ketamine dosage should be __ by __% of normal dosage.

A

septic/hemorrhagic
decreased
20

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34
Q

Ketamine is the drug of choice for patients with __ since it does not decrease __.

A

hypovolemia

BP

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35
Q

Ketamine is the drug of choice for patients with __, since it causes __.

A

asthma

bronchodilation

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36
Q

What are the disadvantages of ketamine? 5

A 
increases symptomatic tonus (increased ICP)
tachycardia
HTN
bronchodilation
dissociative effect/delirium
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37
Q

Ketamine is not recommended for patients with __ disease, as it can cause heart __.

A

coronary

ischemia

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38
Q

What are the C/I for ketamine? 3

A

abdominal surgery
coronary disease
increased ICP

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39
Q

Etomidate is a __ agonist with __ effect and no __ effect.

A

GABA
fast
analgesic

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40
Q

What are the indications for etomidate?

A

trauma
hypovolemia (2nd line)
coronary disease (GS)

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41
Q

Why etomidate is good for trauma?

A

has minimal CV effect

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42
Q

What are the disadvantages of etomidate?

A

local pain
myoclonus
decreased ICP
adrenal inhibitor

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43
Q

Propofol is a __ agonist with __ effect and no __ effect.

A

GABA
fast
analgesic

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44
Q

Propofol is a good __ drug.

A

maintenance

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45
Q

What are the indications for propofol? 3

A 
short sedations (endoscopy)
asthma (causes bronchodilation)
no NV (nausea/vomiting)
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46
Q

What are the disadvantages of propofol?

A 
local pain (we add lidocaine)
fast hypotension due to vasodilation
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47
Q

Which patients would not be recommended propofol?

A

hypovolemic

coronary disease

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48
Q

Asthma patients should be inducted with: 2

A

ketamine

propofol

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49
Q

Renal failure patients should be inducted with: 3

A

ketamine
propofol
etomidate

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50
Q

Cardiac patients should be inducted with: 2

A

midazolam (dormicum)

etomidate

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51
Q

Remember that __ is the only induction drug that increase ICP, while the rest decrease it.

A

ketamine

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52
Q

What are the advantages of using analgesic drugs? 4

A

reducing MAC for inhalators
mask the tachycardia/HTN caused by ventilation
allow easier waking
can be used as anesthetic if used in X10-20

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53
Q

What are the disadvantages of using analgesic drugs? 3

A

hypoventilation
hypnosis
amnesia

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54
Q

What are the 4 types of analgesic drugs?

A

fentanyl
morphine
pethidine
tramadol

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55
Q

Fentanyl is a very __ drug with __ effect, lasting for - minutes.

A

potent
fast
20-30

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56
Q

Fentanyl is used as __ analgesic.

A

maintenance

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57
Q

What is the antidote for fentanyl?

A

naloxone

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58
Q

Morphine is used more for __ operative pain.

A

post

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59
Q

What is the antidote for morphine?

A

naloxone

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60
Q

Morphine starts effecting within __, and last for - hours.

A

minutes

3-4

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61
Q

Tramadol has a strong __ effect, and should be administrate in a __ together with /. Used mostly for __ pain.

A

emetic
slow drip
zofran / pramin
postoperative

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62
Q

What are the two groups of muscle relaxing drugs?

A 
depolarizing (non-competative)
non depolarizing (competitive)
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63
Q

__ is a depolarizing drug.

A

succinylcholine

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64
Q

Succinylcholine is indicated for __ intubation. The effect lasts for _ minutes.

A

fast

5

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65
Q

Before using depolarizing drugs, make sure the patient can be ventilated with a __, incase the __ fails.

A

mask

intubation

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66
Q

Which patients are more difficult to ventilate with a mask? 2

A 
obese
jaw malformation (micrognathia)
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67
Q

What are the disadvantages of succinylcholine?

A

bradycardia (more in children)
hyperkalemia (more in burn/RF/trauma/paraplegia)
malignant hyperthermia (more in myopathy/family history/children)
muscular pain

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68
Q

What are the two competitive neuromuscular blockers drugs commonly used?

A

rocuronium

vecuronium

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69
Q

What are the indications for non depolarizing drugs?

A

easy intubation

maintenance

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70
Q

What are the disadvantages of non depolarizing drugs?

A

dose adjustment in RF
can mask lack of analgesia (paralyzed but feel pain)
myopathy and neuropathy

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71
Q

What is the antidote of rocuronium? what should it given with?

A

neostigmine

atropine

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72
Q

Why do we give atropine together with neostigmine?

A

to avoid arrhythmia/asystole

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73
Q

If using rocuronium, at the end of the surgery we must give ___ (__).

A

antidote

neostigmine

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74
Q

What is TOF (train of four)?

A

quantitative measurement determining the depth of anesthesia and level of neuromuscular paralysis

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75
Q

If there are 4 TOF twitches the level of block is __ and only then it is safe to __.

A

0

extubating

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76
Q 
Describe what percentage of receptors are blocked at each twitch disappearance:
loosing the  4th -\_\_%
loosing the  3th -\_\_%
loosing the  2th -\_\_%
loosing the  1th -\_\_%
A

75%
80%
90%
100%

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77
Q

What is the TOF ratio?

A

the ratio between the intensity of the 4th twitch and the 1st

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78
Q

At what TOF ratio can you safely extubate?

A

> 0.9

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79
Q

What is percentage of oxygen saturation do we ventilate?

80
Q

When should we use arterial line to monitor BP during surgery? 5

A
  • predicted hypotension/extreme changes during surgery
  • surgeries with hemodynamic effect (hepatic/trauma)
  • a need for frequent ABG
    *
81
Q

Where would you insert an arterial line? 2

A

radial artery

axillar artery

82
Q

Which surgeries may have high hemodynamic effect on the patient- requiring arterial line BP monitoring? 6

A 
hepatic surgeries (e.g. Whipple)
trauma/MOF
cardiac morbidity
pheochromocytoma
carotid surgery 
difficult external monitoring (obesity/burn)
83
Q

Which patients are most sensitive to temperature loss during surgery? 2

A

children

burn patients

84
Q

Which disorders may occur due to hypothermia? 5

A 
coagulopathy
SSI (surgical site infection)
ischemia induced by stress
arrhythmia
apnea
85
Q

What does end tidal CO2 measure?

A

the maximum concentration of CO2 in the airway at the end of expiration

86
Q

Using EtCO2 is the GS for locating where the __ is and as a measurement of the heart __ and __.

A

tracheal intubation
perfusion
production

87
Q

What is the normal EtCO2? - mHg

88
Q

Increased EtCO2 (hypoventilation) may suggest increased:

A

BP
metabolic rate
hyperthermia (malignant hyperthermia)

89
Q

Increased EtCO2 (hypoventilation) may suggest decreased:

A

respiratory rate

tidal volume

90
Q

Increased EtCO2 (hypoventilation) may also suggest: 2

A

thyroid storm

sepsis

91
Q

Decreased EtCO2 (hyperventilation) may suggest increased: 2

A

respiratory rate

tidal volume

92
Q

Decreased EtCO2 (hyperventilation) may suggest decreased: 3

A

BP
tidal volume
metabolic rate

93
Q

Decreased EtCO2 (hyperventilation) may also suggest: 3

A

hypothermia
bronchospasm
massive PE

94
Q

How can we get a general sense of intravascular volume and renal perfusion during surgery?

A

urine catheter

95
Q

What do we use to evaluate the filling pressure of the right heart after fluid administration?

96
Q

Where would a CVP be inserted? where should it be placed?

A

above diaphragm main veins (subclavian, brachial, jugular veins)
entrance of the SVC to the right atrium

97
Q

What are the possible risks of CVP? 5

A 
pneumothorax
AV fistula
air emboli
arrhythmia
thrombosis/infection
98
Q

What are the normal CVP levels? - mmHg

99
Q

How can you evaluate the filling pressure in the left atrium?

A

PAC (pulmonary artery catheter)

100
Q

Where would a PAC be inserted? where should it be placed?

A

neck veins

pulmonary artery

101
Q

What else can be evaluated using PAC?

A

pulmonary pressure

cardiac production

102
Q

What are the possible risks of PAC? 5

A 
arrhythmia (VT...)
AV block
PE
valvular damage
bleeding
103
Q

__ is a complete C/I for PAC

104
Q

What are the normal levels of PCWP (Pulmonary wedge pressure) measured by PAC?

105
Q

ASA classification= __

A

standards for basic anesthetic monitoring

106
Q

ASA standard I= anesthetist should be present during __ and follow the __ status based on dynamic changes of the patient.

A

anesthesia

hemodynamic

107
Q

ASA standard II- continues monitoring of 4 during all stages of the anesthesia.

A

ventilation
oxygenic
circulation
temperature

108
Q

ASA standard II requires __ analyzer, pulse __, monitoring __, signs monitoring every _ minutes, __ measurement and adapting the room accordingly.

A 
oxygen
oximeter
EtCO2
5
temperature
109
Q

Name 5 reasons for instability during surgery:

A 
MI
PE
pneumothorax
anaphylaxis
malignant hyperthermia
110
Q

How would you manage a patient suffering from MI during surgery?

A

hemodynamic stable and no perfusion disorder- continue

instable patient- cease surgery and evaluate

111
Q

_% of patients going through hip surgery may suffer from __.

112
Q

What are the clinical presentation of a perioperative PE? 3

A

tachycardia
hypotension
hemodynamic collapse

113
Q

How do you diagnose perioperative PE?

114
Q

How do you treat perioperative unstable PE?

A

cease the treatment and give cardiac support/thrombolytic/embolectomy

115
Q

Pneumothorax is a common __ complication. Clinical signs include: 4

A

laparoscopy
desaturation
hypercarbia
hypotension

116
Q

How do you manage an unstable perioperative pneumothorax?

A

cease surgery -> stop inflating the abdomen ->pulmonary tube

117
Q

What are the common causes for perioperative anaphylaxis? 4

A

latex
relaxants (rocuronium, vecuronium, succinylcholine)
Abx
blood products

118
Q

How do you manage an unstable perioperative anaphylaxis? 4

A

adrenaline
H2 blockers
Hydrocortisone
fluids

119
Q

Malignant hyperthermia is usually with a __ predisposition (__/__)

A

genetic
Duchenne muscular dystrophy
other myopathies

120
Q

What is the clinical presentation of malignant hyperthermia? 8

A 
increase sympathetic activity
rapid hyperthermia
rigidity 
metabolic/respiratory acidosis
hypotension
arrhythmia
seizures
CPK/myoglobinuria
121
Q

What is the treatment for malignant hyperthermia? 6

A 
stop all suspected anesthetic
dantrolene
cooling
sodium bicarbonate (for acidosis)
treating hyperkalemia
treat arrhythmia
122
Q

When performing preoperative evaluation ask if in the past there was a delayed waking up after anesthesia as a marker for __ deficiency.

A

pseudocholine esterase

123
Q

If a patients has a pseudocholine esterase deficiency- avoid ___.

A

succinylcholine

124
Q

Mallampati score relates to the distance between the __ and __.

A

tongue

pharynx

125
Q

Mallampati class 1: ___

A

soft palate + uvula + anterior/posterior pillars

126
Q

Mallampati class 2: ___

A

soft palate +uvula

127
Q

Mallampati class 3: ___

A

soft palate + uvula base

128
Q

Mallampati class 4: ___

A

soft palate is invisible

129
Q

How wide should the mouth opening and thyromental distance be?

A

6-8 cm (3-4 fingers)

130
Q

What are the 4 criteria in Mallampati classification?

A

class
mouth opening
thyromental distance
neck extension

131
Q 
What are the death percentage for each ASA score?
1- 
2- 
3- 
4- 
5- 
6-
A 
1- 0.06-0.08%
2- 0.27%-0.4%
3- 1.8-4.3%
4- 7.8-23%
5- 9.4-51%
6- 100%
132
Q

ASA 1= ___ patient

133
Q

ASA 2= mild __ disease w/o __ limitation (eg. __).

A

systemic
functioning
balanced HTN/DM

134
Q

ASA 3= ___ systemic disease with functioning ___ (eg.__).

A

severe
limitation
COPD/MI history

135
Q

ASA 4= Severe __ disease with a __ life threat (eg. __).

A

systemic
constant
unstable angina/HF

136
Q

ASA 5= Expected __ if surgery will not be performed in the next __ hours (e.g. __).

A

death
24
aortic aneurysm/brain bleeding/MOF

137
Q

ASA 6= ___ before __.

A

brain death

organ saving

138
Q

When assessing a patient cardiovascular status pre-op check if there was a previous __. If the answer is yes- consult a cardiologist, if not- continue.

139
Q

MACE (major adverse cardiac events) >__% requires further investigation.

140
Q

METs (metabolic equivalents) > 10- ___

A

no further investigations, continue to surgery

141
Q

METs (metabolic equivalents) 4-10- ___

A

no further investigations, continue to surgery

142
Q

METs (metabolic equivalents) <4- ___

A

further investigation is needed (exertional test/heart mapping)- if not in order -> PCI

143
Q

If PCI was performed, surgery is done __ days after.

144
Q

If PCI + BMS was performed, surgery is done __ days after.

145
Q

If DES was performed, surgery is done __ months after.

146
Q

Patients with ICD require an ___ to be present in the OR.

A

external defibrillator

147
Q

What does the pulmonary pre-op check involve? 5

A 
history
physical
CXr
ABG
respiratory function
148
Q

__, __, and __ are not significant respiratory risk factors.

A

smoking
obesity
mild asthma

149
Q

Patients with OSA are in increased risk for prolonged __.

150
Q

In the case of active COPD/asthma consider to __ the surgery until respiratory __.

A

postpone

stabilization

151
Q

Patients going through dialysis should be operated - hours after their last treatment.

152
Q

Diabetic patients should __ there pump insulin treatment, keeping them in the __ values.

A

continue

basal

153
Q

At the morning of the surgery, DM patients should use a __ dose of __-__ range insulin. Stop other related drugs (__)

A

decreased
medium-long
metformin

154
Q

Pre-op fasting involves __ and __ for _ hours before.
_ hours before the surgery, patients should avoid __ completely.
Breast milk-__ hours
cow mike- __ hours
formula- __hours

A 
solids
clear fluids (water)
2
drinking
2
4
6
155
Q

Anticoagulation should be __ and bridged with __.

A

withheld

clexane

156
Q

COPD patients should be treated with ___ before surgery.

A

bronchodilators

157
Q

What is recommended for patients with risk for aspiration before starting the surgery? 2

A

pramin

PPI (a night before surgery)

158
Q

Anti anxiety, usually __ can be used. Avoid in __, __ and __.

A

benzodiazepine

pulmonary disease/OSA/elders

159
Q

What are the 3 anesthesia techniques?

A

local
regional
general

160
Q

What are the indications for RSI (rapid sequence intubation)? 3

A 
full stomach (emergency unfasted surgery)
Increased abdominal content (pregnancy/abdominal mass/ascites)
delayed gastric emptying (Bowel obstruction/opioid use/DM/pregnancy)
161
Q

When performing RSI:

1) prepare the tools
2) preoxygenate (__)
3) give both __ and __ simultaneously
4) perform __ maneuver
5) __
6) __

A 
100% oxygen for 3 minutes
hypotonic (propofol) + muscle relaxant (rocuronium)
Sellick 
intubate
nasogastric tube
162
Q

Local anesthesia mechanism is based on __ channel blockage in the neuro fibers

163
Q

In local anesthesia, the lower the pKa, the __ the effect is, the more hydrophobic the __ potent, the better it can bind to protein the __ the effect lasts for.

A

faster
more
longer

164
Q

What are the two groups of local anesthesia? 2

A 
aminoamide (lidocaine)
amino ester (chloroprocaine)
165
Q

What are the neurotoxic signs of local anesthesia? 6

A 
mouth tingling
tinnitus
visual impairment
disorientation
slurred speech
seizures (treat with diazepam/thiopental if it doesn't pass)
166
Q

What other clinical signs can be seen in local anesthesia toxicity? 2

A

arrhythmia (QRS prolongation)

metallic taste

167
Q

How can you prevent local anesthesia toxicity? 2

A

pull before push

add epinephrine

168
Q

The further away the regional anesthesia is from a __ blood vessel, the __ the absorption and __ effect.

A

large
slower
longer

169
Q

What late complication can be caused by regional anesthesia? 5

A 
headache
back pain
urinary retention
neurological complications 
SSI/meningitis
170
Q

What are the C/I for regional anesthesia? 5

A

local infection at the site
coagulation disorder/active anticoagulant
sepsis/bacteremia
hypovolemic shock
advanced neurological disease/elevated ICP

171
Q

What are the indications for spinal anesthesia? 4

A

urologic surgery
abdominal surgery
anus surgery
lower limb surgery

172
Q

Spinal anesthesia effect is __, more __, and leads to less __ pain than epidural anesthesia.

A

faster
efficient
back

173
Q

Spinal anesthesia block both __ and __ sensation under the level of the block.

A

motor

sensor

174
Q

What are the advantages of spinal anesthesia? 3

A

preventing airway/general anesthesia complications
the patients is awake (good for TURP surgery)
less delirium in elders

175
Q

What are the disadvantages of spinal anesthesia? 7

A

post-dural headache (more in young, women, large needle)
hypotension/bradycardia
neuropathy
back pain
urine retention
epidural hematoma
respiratory depression/arrhythmia if spreads cephalic

176
Q

What are the indication for epidural anesthesia?

A

abdominal surgery
chest surgery
lower limb surgery

177
Q

In epidural anesthesia the needle is inserted into the __ space between the ligamentum __ and the __ matter.

A

epidural
flavum
dura

178
Q

What are the advantages of epidural anesthesia? 4

A

better respiratory functions
better pain control
less pneumonia (same mortality)
less ileus

179
Q

What are the disadvantages of epidural anesthesia? 3

A 
epidural/spinal hematoma
epidural abscess (requires MRI)
180
Q

What are the risk factors for epidural hematoma? 2

A

coagulation disorder/anticoagulation

prophylactic clexane post surgery

181
Q

What are the clinical presentations of spinal hematoma?

A

back pain
motor/sensory disorder of the lower limbs
urinating/defecation disorder

182
Q

Stop clexane __ hours before epidural catheter insertion. Avoid clexane _ hours after the insertion.

183
Q

Stop clexane __ hours after epidural catheter clexane removal. Resume clexane __ after removal.

184
Q

In the first 24 hours post-op the patient should regain time/place orientation. In case of delirium/tough awakening - treat with __.

185
Q

What are the criteria for extubating? 3

A 
independent breathing (4-6 cc/kg TV or 30>RR>7 )
awake/responsive/protective reflexes/TOF ratio>0.9
no hypothermia/acidosis/electrolyte disorder
186
Q

In case of post anesthetic laryngospasm treat with:
positive pressure oxygen (__) ->
___
___

A

CPAP
succinylcholine
ventilation

187
Q

In case of post anesthetic vocal cord edema treat with:
__->
inhalator and IV ___ + inhalator __

A

oxygen
steroids
epinephrine

188
Q

PONV=__

A

post operative nausea & vomiting

189
Q

PONV is caused by central damage to the __. Treatment includes __ (careful from long QT) and if administrated with __ + __ can cause bradyarrhythmia.

A

brainstem
Droperidol
Ondansetron
Metoclopramide

190
Q

Using __ for maintenance reduces the frequency of PONV.

191
Q

30 minutes post op the desired body temp should be > __.

192
Q

hypothermia increases the risk for:

A

MI in CAD patients (due to shivers->oxygen demand)
drug metabolism
coagulation disorders (death triad)
SSI

193
Q

Chronic pain lasts > __ beyond the expected healing time from surgery.

194
Q

Chronic pain is describes as: 3

A

burning
stinging
shock like

195
Q

What are the risk factors for chronic pain? 5

A
  • surgery type (neck/mastectomy/thoracotomy/hernia/amputation)
  • SSI
  • nerve pain during the surgery
  • DM
  • tumor involvement (nerve entrapment)

Surgery final (Sabiston) (54 decks)

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