2 - Anesthesia Flashcards by E *

Normal pH of local anesthetics:

5.5 - 6.0
Doesn’t work well w/ infected tissue (more acidic)
Can add bicarb to buffer

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How do most local anesthetics work?

Block Na channels and impair propagation of AP

Thinner myelinated nerve fibers are more easily BLK

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Advantages of epi in locals

Vasoconstrictor
Increased duration of action
Decreased bleeding and volume needed to anesthesia

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Disadvantages of epi in locals

Increased myocardial activity

Tachycardia
HTN
Dysrhythmias

Avoid pts w/ known CV dz, HTN, DM, thyroidtoxicosis

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Describe the ideal anesthetic

Short latency
Superior penetration
Non-addictive
Completely reversible
Low toxicity
Stable and water soluble
Non-irritating
Inexpensive

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MC adverse effects of local anesthetic

Urticaria
Erythema
Edema
Dermatitis

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Toxicity from locals - prodromal sxs

Cicrumoral numbness
Tinnitus
Lightheaded / dizzy
Tingling Metallic taste in mouth

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Toxicity from locals - CV problems

HTN then HOTN
Tachy or brady
V-fib - CV collapse

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Toxicity from locals - severe CNS:

Tonic-clonic activity

ALOC -> unconsciousness

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What do you do prior to injecting to avoid intravascular injection?

Aspirate first

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Bupivicaine not recommended for:

Kids under 12yrs

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Method for injecting local

Large coverage with one puncture (longer, small gauge needle

Bent 45 degrees, hub the needle, inject as you withdraw

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Sequence of clinical anesthesia

Vasodilation - loss of symp tone

Loss of

Pain/temp sensation
Pressure sensation
Motor fx

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Peripheral nerve blocks - common sites?

Digit blocks - (Common w/ rib blocks as well)
Plantar aspect of foot
Palmar aspect of hand

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Max dose Bupivicaine?

2mg/kg up to 100mg

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Where is epidural anesthesia injected?

Into the epidural space, NOT the CSF

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Describe epidurals

Skin taped Cath - Req continuous inf of LRG anesthetic volume

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Acute complications of nerve blocks

HOTN (neurogenic shock) - txt w/ IVF/pressors (v-con)

High spinal - brady-c, HOTN, arm tingling, and respiratory distress (txt-ventilate)(diaphragm C3-C5)

Cauda equina - bladder/bowel dysfx, m/s alts in legs

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Dermatomes - Clavicles, nipples, umbilicus

Diaphragm innervation

Diaphragm inervation C3-C5
Clavicles - C5
Nipples - T4
Umbilicus - T10

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Conscious sedation provides

Analgesia and anxiolysis

Minimally depressed LOC

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Usual combo for conscious sedation?

Benzo + narcotic
OR
Propofol + narcotic

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Intubation in conscious sedation?

Nope - patient maintains their own airway

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Nice perks of conscious sedation?

Still follows commands (verbal stimuli)

Doesn’t remember any of it later (antegrade amnesia)

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Examples of procedures in which conscious sedation is used

Bronchoscopy
EGD/colonoscopy 
Thoracostomy 
Closed reduction of fx’s
Procedures in kids

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What does propofol provide (and not provide)?

It’s a sedative-hypnotic So... anxiolysis, muscle relaxant, anticonvulsant BUT NO DIRECT ANALGESIC EFFECT

Patient safety during conscious sedation

Req crash cart 1. Follow SOP’s 2. NPO prior 3. ASA class I and II patients 4. Dedicated staff

Crash cart:

``` O2 Airway adjuncts ACLS drugs Defibrillator Suction Narcan - (narc rev) Flumazenil - (Benzo rev) ```

PACU

Home w/ chaperone once goals are met: (ADMIT if not) - stable - out of bed for 30mins/amulatory/vitals - A/O x3 - pain / nausea controlled - voids

Goals of general anesthesia

Pain control Amnesia Muscle relaxation

General anesthesia - airway/breathing mangement

Intubate/ventilate Laryngoscope or Glidescope

Concerns about eyes w/ general anesthesia

Protect eyes (lubricate and tape close)

Complications of general anesthesia

Hypoxemia CV events Aspiration Nerve injury

TXT of MC adverse effects of local anesthetic

Txt - O2, Epinephrine, fluids, antihistamine, steroids

Lidocaine dosing w/out EPI?

4mg/kg up to 300mg

Lidocaine dosing WITH Epi

7mg/kg up to 300mg

1% Lidocaine conc?

10mg/mL

2% Lidocaine conc?

20mg/mL

Lidocaine onset?

2-5m

Lidocaine duration?

0.5-2hrs

Management of CNS toxicity

Hypercarbia - Hyperventilate | Seizures - Benzo

Management of CV toxicity

HOTN - IVF | Arrythmias - Wide = Shock and Narrow = Rx

Management of Malignant hyperthermia toxicity

TXT - Cool rapidly, Bicarb, Dantroline

Malignant hyperthermia pathophys

Hypermetabolism > Fever, Tetany, Hyperkalemia

Malignant hyperthermia etiology?

Rare inherited condition (MC) from colatile agents and succinylcholine

How to prevent toxicity

Administer locals in combinations of SML volumes of different agents (Do not max out one thing)

Bupivicaine onset?

5-10m

Bupivicaine duration?

2-4hrs

Purpose of local anesthetic?

Minor surgery/laceration repair

What to ensure prior to PNB?

Eval neurovascular status prior to injection

What procedures is a spinal (subarachnoid) block generally for?

GYN GU Low ABD LE

Where is a spinal (subarachnoid) block injected?

Into the sub-arachnoid space (the CSF)

Describe spinal (subarachnoid) block Rx attributes?

Anesthetic and Narcotic +/- Epi

What does a spinal (subarachnoid) block do to the nervous system?

Blocks - Sympathetic, Sensory, and Motor fx (everything)

Epidurals block?

Blocks sensory but not necessarily motor function

Rib fracture preferred anesthesia?

Epidurals

Late complications of CNB

MC - urinary retention Spinal HA 2/2 CSF leaking out of the dura - ICP decreases with postural changes Epidural hematoma - compresses spinal cord - suspect if pt is anticoagulated

MC late complication of a CNB?

Urinary retention - | Monitor UOP post-op (cath w/ foley even w/ BPH)

Late CNB complication of Spinal HA TXT

txt with IV fluids, caffeine, blood patch (autotransfuse blood into epidural space)

Late CNB complication of Epidural hematoma primary concern? And 2nd line anesthesia?

Anticoagulanted patient = anesthesia will likely be avoided in these patients (Endotracheal anesthesia)

How does a epidural hematoma usually present?

Compressed spinal cord causes Loss of neuro fx below infusion site (bladder/legs)

Narcotics reversal

Narcan

Benzo reversal

Flumazenil

General anesthesia prevention

``` Protect eyes (lube/tape) Pressure points (pad) PVT hypothermia Do not hyperextend joints ```

Mitigating aspiration complications during general surgery

NPO prior Antacids Cricoid pressure during intubation (Sellick maneuver)

Sellick maneuver is?

A way of reducing aspiration by putting pressure onto the cricoid during intubation.