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NSU AA Denver > 2025 Intro to Clinical Anesthesia Exam 1 > Flashcards

2025 Intro to Clinical Anesthesia Exam 1 Flashcards

Basic Equipment, Perioperative/Induction

1
Q

Goals of Perioperative Period

A

Ascertain risk of patient and procedure

Sort out of patient is/needs to be/can be optimized before surgery

Develop Anesthetic Plan to care for patient that respects patient wishes, surgical expectations and, your skillset.
General vs regional
Airway choice
Surgical Positioning

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2
Q

Steps for Taking a Solid Patient History

A
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3
Q

Obstacles to Talking with Patient

A

Poor Historian
Anxious or emotional
Overly Talkative
Language Barriers
Hearing/visual impairment
Angry/disruptive

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4
Q

Preoperative Period (Chart Review)

A

Chart review- Why are they here?

Chief Complaint
HPI- History of present illness
PMH- Past medical history
PSH- Past surgical history
Previous anesthetic experiences
Allergies and Medications
Physical exam

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5
Q

Chief Complaint and HPI

A

Why is the patient here today?
What’s been going on and for how long?

Can be found in surgeon’s history and physical (H&P)

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6
Q

Past Medical History (PMH) and Review of Systems

A

Pulmonary- OSA, smoking, Asthma, SOB, COPD, Home oxygen, recent URI

Cardiac- HTN, Angina, CAD, Arrythmia, orthopnea

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7
Q

ROS: Cardiovascular Review Questions

A

History of:
High BP?
Chest pain?- can be cardiac, pulmonary, or GI based
Heart ever skip a beat?
Funny noises when they listen to your heart?
Stenotic lesion vs leaky valve murmur
Heart attack?
Swollen hands/feet?
Can indicate congestive heart failure (CHF) or renal impairment
Sleep on multiple pillows?
Orthopnea can have cardiac or GI roots
Ever randomly have vision loss, limb weakness or dysphasia (trouble speaking and comprehending)?
Carotid artery disease/vasospasm

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8
Q

ROS: Coronary Artery Disease (CAD)

A

CV complications account for 25-50% of deaths following noncardiac surgery.
MI
Pulmonary edema
CHF
Thromboembolism

~10,000,000 Americans w/ CAD

750,000 w/ significant disease will undergo anesthesia/surgery for non-cardiac operations

5 to 7% will have perioperative MI
Mortality of intraoperative MI: 38-70%

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9
Q

ROS: Risk for Cardiac Event Under Anesthesia

A

Recent MI (surgery must wait 6-8 weeks)
Valvular Heart Disease
CHF
Unstable Angina (chest pain at rest)
Diabetes (associated with neuropathy can cause silent MI)

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10
Q

ROS: Metabolic Equivalent of Task (METS)

A

<4 METS associated with great increase in risk under anesthesia

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11
Q

ROS: Perioperative Cardiac Risk Management

A

Monitor for perioperative ischemia (ST Depression, cardiac markers ie troponin trending)

Repair before if able
Severe Aortic stenosis
Coronary Revascularization

Optimize CHF
Correct anemia, volume status, nutritional status, medication adjustments

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12
Q

ROS: Neurological

A

Stroke (CVA)/mini stroke (TIA)
Seizure hx
Parkinson’s
Paraplegia
Gross motor function difficulty

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13
Q

ROS: Tubes and Filters

A

Gastrointestinal (GI)
Acid Reflux
GERD
GI bleeding/Ulcerations
Hx weight loss surgery
Liver Disease- cirrhosis, hepatitis
Acute abdomen

Genitourinary (GU)
Kidney function
ESRD (dialysis schedule PD/HD)
Nephrolithiasis
BPH
Prostate Cancer
Recent UTI

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14
Q

ROS: Infections/Isolations

A

COVID
Sepsis
Methicillin resistant staph aureus (MRSA)
Clostridium difficile (C Diff)
TB

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15
Q

ROS: Musculoskeletal and Pain

A

Musculoskeletal
Implanted hardware
DJD (joint)/DDD (disk)
OA/RA
Muscular dystrophy

Pain
Acute v Chronic
Location
Daily opiate use

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16
Q

ROS: Endocrine and Hematologic

A

Endocrine
Diabetes (Type I v II)
Thyroid disease (want to worry about Hyperthyroid, Hypothyroid does not have any big complications with Anesthesia)
Chronic Steroids
Anti-inflammatory or immunosuppressive effects

Hematologic- Do you bleed or clot easy?
Hemophilia
Thrombocytopenia
Sickle Cell Disease
Anticoagulant therapy
Liver disease

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17
Q

Why Care About Periop Glucose So Much?

A

Hyperglycemia (GLU >200) is a risk factor

Postoperative sepsis- bacteria like sugar too

Endothelial disfunction- permeability and fluid shifts, NO production

Cerebral ischemia
Pro oxidation/inflammation/coagulant lead to higher lactic acid in ischemic tissues

Impaired wound healing
Poor perfusion

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18
Q

ROS: Obstetric and Gynecologic History

A

Preop HCG pregnancy test offered to all premenopausal woman

Cannot force or coerce a patient into a pregnancy test, as this violated patient autonomy

Current literature is inconclusive as to whether exposure to anesthesia causes unknown harmful effects in early pregnancy.

G: Gravity – total number of pregnancies
T: number of term pregnancies
P: number of preterm pregnancies
A: number of abortions, spontaneous or induced
L: number of living children

Generally abbreviated to G2P1
A patient that is G2P1 is pregnant and has one living child

Weeks and days gestation. 39 weeks and 4 days abbrev 39.4 weeks.
Is baby vertex or breech?
Previous C-section/hemorrhage?
Pregnancy complicated by PIH/GDM?

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19
Q

High Quantities - Recreational Drug Use and Anesthesia

A

Affect anesthetic requirements
Reactive airway d/t inhalation
Difficult IV access
Propofol cross-tolerance

If the patient was in a car accident, were they given fentanyl already… will affect how much you can give

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20
Q

Psychiatric Considerations

A

Anxiety- baseline benzodiazepine use may increase anesthetic requirements

Depression- Very small risk of serotonin syndrome

PTSD- can affect induction/emergence

Bipolar/schizophrenia- Lithium can prolong NMB and decrease anesthetic requirements

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21
Q

NPO Status

A

Commonly are told from midnight and on…

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22
Q

Family History of Anesthesia

A

Screening for Malignant hyperthermia- “Mom had a fever under anesthesia”
Can be fatal, triggering agents succinylcholine and halogenated inhalation agents (ie Deflurane, Sevoflurane,)

Screening for pseudocholinesterase deficiency- “Dad had to stay intubated longer than they planned” or “Mom wouldn’t breathe on her own”
Can’t break down muscle relaxants

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23
Q

Body Mass Index (BMI)

A

BMI = (Weight in kg)/(Height in meters)^2
Underweight < 18.5
Normal Weight 18.5-24.9
Overweight 25-29.9
Obese >30

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24
Q

Airway Evaluation

A

Smoking- copious secretions, cough, laryngospasm

Beards and facial hair- difficult mask

Nasogastric tube present- difficult to seal mask

TMJ Disease/Rheumatoid Arthirits- difficulty opening jaw (passive vs active)

Ankylosing Spondylitis- Fusion of cervical spine

Acute burn- Edema

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25
Q

Appearance Suggesting Difficult Airway

A
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26
Q

ASA Physical Status

A
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27
Q

ASA Physical Status (More Detail)

A
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28
Q

ASA Classification Emergency

A

Emergency surgical procedure where delay could mean significant increase in threat to life or body part.

Crash C-section
Open Fracture with vascular compromise
Ruptured AAA
Closed head injury with decompensation
NPO status waved

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29
Q

Should I Take My Meds

A

Beta Blockers- Continue, supplement IV if discontinued
Decreased myocardial oxygen demand, chance of arrythmias, pre & post-op M&M

CA Channel blockers- Continue

ACE Inhibitors/ARB- Discontinue unless indicated for heart failure

Continue inhalers bronchodilators- Albuterol prior to GA etc

Discontinue blood thinners per recommendations

Generally hold oral hypoglycemics, halve SQ insulin night before

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30
Q

PreOp Testing: ECG (When to Based off ASA)

A

Resting echocardiography- Not routinely offered before surgery except when

Patient has a heart murmur or new onset cardiac symptom (breathlessness, pre-syncope, syncope, chest pain)

Signs or symptoms of heart failure
Fatigue/weakness
Swelling in legs/ankles/feet
SOB with activity or laying down

Carryout resting ECG and review before delaying surgery/ordering echo

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31
Q

PreOp Testing: Chest X-Ray, Lung Function

A

Chest X-Ray- Do not routinely order preop chest X-ray
Low yield in absence of active pulmonary symptoms, exposure to radiation

Lung function tests- Do not routinely order unless
ASA 3 or 4 with known or suspected respiratory disease having major or complex surgery.
Candidate for lung resection

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32
Q

ROS: Pulmonary Risks of Anesthesia

A

Hypoventilation Atelectasis
Pneumonia
Can result in post-operative mechanical ventilation

Patient at risk
Smokers
COPD
Age>70
Thoracic or Upper Abdominal Surgery
Anesthesia > 2 hours

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33
Q

ROS: Pulmonary Risk Management

A

Smoking cessation
Bronchodilator therapy
Early treatment bronchitis
Early mobilization

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34
Q

PreOp Testing: Complete Blood Count (CBC)

A

Ordered routinely for those with suspected active bleeding
GI Bleed, fracture of pelvis/femur, trauma

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35
Q

PreOp Testing: Coagulation Testing

A

Coagulation testing (PT/PTT/INR) and Hematology

Coagulation labs not routinely ordered outside of
Those currently anticoagulated ie coronary stents, atrial fibrillation, DVT
Those with Liver disease

Transfusion therapy
Consider preop transfusion in symptomatic patients with Hb <7mg/dl
One unit of PRBC should raise Hb 1mg/ml or HCT by 3%
Consider platelet transfusion to >50,000 (generally accepted)
1 6 pack of platelets will increase count 30-60,000

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36
Q

Informed Consent

A

Anesthesia without consent in a non emergent situation could be construed as assault, so make sure to get that paper signed.

Explain anesthetic options with pros and cons

Decision-making capacity
Minors cannot sign for themselves
No benzo admin before consent
Power of Attorney signs as proxy if patient is unable to sign/make healthcare decision

Emergency consent- if surgeon deems procedure emergent and delaying would result is loss of life or limb in a patient unable to consent themselves, and without proxy- informed consent is waived

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37
Q

Premedication Goals to Anesthesia

A

Decrease anxiety

Decrease post op pain requirements/Anesthetic requirements

Prevent Post operative Nausea and Vomiting

Early Recovery After Surgery (ERAS)

… Surgery and Surgeon Specific

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38
Q

Decreasing Anxiety

A

ANXIETY BEGONE
Midazolam- Benzodiazepine, most given anxiolytic/peri procedural sedation medication. IV/PO, anterograde amnesia

RELATIVE CONTRAIDICATIONS
Newborn (<1 year )- Won’t remember anyway
Elderly (>65 years old)- May increase POCD (post operative cognitive dysfunction)
Decreased baseline consciousness
Intracranial pathology-Increased CO2 = bad
Severe pulmonary disease- increased CO2 = bad
Hypovolemia- chance of hypotension

39
Q

Decrease Post-op pain/anesthetic requirements

A

Acetaminophen-1 gram if no contraindications

Celecoxib ( Celebrex ) - oral COX-2 receptor inhibitor 200-400 mg dose
No increased bleeding risk, unlike non-specific COX meds (aspirin etc)

Gabapentin/Pregabalin-
Gabapentinoid meds 300-1200 mg Gabapentin (Neurontin).
75-150 mg Pregabalin (Lyrica)
Avoid in >65 years of age, OSA

Oxycontin- Extended-release oxycodone 5-20 mg for major surgery in the absence of regional anesthesia

40
Q

PONV Prophylaxis- combo of meds = greater efficacy

A

Most Patient will routinely receive
Dexamethasone (Decadron) 4-10 mg after induction of anesthesia
Ondansetron (Zofran) 4 mg as premed/intraop/or end of surgery

Hx of PONV
Scopolamine 1.5 mg Transdermal patch
Avoid in patients over 65- confusion, sedation, dementia
EDUCATE patient on touching the patch and washing hands

41
Q

Early Recovery After Surgery

A

Minimize narcotics when available, opt for regional or neuraxial anesthesia

Intraoperative measures to be discussed in next lecture!

42
Q

Where Does the IV Go?

A

Non-surgical side, non-dominant side

Flat-non-moving surfaces
Back of hand, forearm

What gauge IV?
20g for most outpatient surgeries
18g for surgeries with significant expected blood loss (EBL)

Tough Stick?
Even a lowly 22 is enough to induce anesthesia, vasodilation of anesthetic agents allow for larger IV post-induction
May need to consider Ultrasound in morbidly obese patients, or those with IVDA history

43
Q

Types of Anesthetics/Anesthesia… “What is the Plan?”

A

General anesthesia
Regional Anesthesia
Peripheral nerve blocks
Monitored Anesthesia Care (MAC)

44
Q

When To Use What

A

ANESTHETIC CHOICE IS BASED ON SEVERAL CRITERIA

Surgeon preference and patient safety
Surgical positioning
Patient comfort/choice
Post-operative requirements
Patient age and coexisting disease
NPO status
Procedure duration
Elective and Emergency
Airway evaluation

45
Q

When is a Tube Used?

A

Positioning- Prone and often beach chair position

Full-stomach- trauma, gastroparesis, high aspiration risk

Long surgical time, laparoscopy

Does my patient need to be paralyzed?
Open abdominal and thoracic cases, laparoscopic and robot assisted cases

Will relaxation facilitate surgical conditions, or keep patient safe?
Exposure in spine surgery, Mayfield pins for neurosurgery

46
Q

Regional or Neuraxial Anesthesia

A

Subarachnoid block (SAB or Spinal) anesthesia- common for C-section, knee and hip replacement, some urological procedure

Epidural anesthesia- laboring parturient, thoracotomy, open abdomen

Peripheral nerve blocks (PNB) and regional anesthesia- block surgical stimulus from anesthetized area

…Far more to come on all of these

47
Q

Induction - Putting them to Sleep

A

IV induction is gold standard, but peripheral IV access may be difficult, traumatic, or impossible preinduction

Kiddos, those with mental handicaps consider inhalational induction

IM Ketamine- 5mg/kg in patient that will not tolerate PIV placement or mask induction… KETAMINE DART

48
Q

Big Questions Determining Anesthesia Plan

A

What meds will be used for maintenance of anesthesia? Pain Control? Inpatient vs Outpatient

Is paralysis needed? How much/when do I reverse?

How will I maintain CV homeostasis (+/- 20% of baseline BP, HR etc)
Bolus medication vs drip

How does my patient’s history affect my plan?
Cardiac/pulmonary and reactive airway disease/kidney disease etc.

49
Q

Post-Op Considerations

A

Is patient heading home, to a hospital bed, or the ICU?

How will I meet the patient’s post-op oxygen requirements?
Nasal cannula v face mask, oral airway/nasal airway

How am I covering the patient’s pain?
Outpatient vs inpatient
How painful was the surgery?
Does patient have underlying tolerance of pain medication?
What meds are onboard?

50
Q

Monitored Anesthesia Care (MAC)

A

Sedation without ventilatory support- breathing on your own

Full monitoring (ASA monitors) and generally End tidal CO2

Response to verbal commands or more profound stimulation unless contraindicated

Rescue equipment available, supplemental oxygen

”Twilight sleep”

Common agents- versed/fentanyl/propofol/precedex/ketamine

51
Q

Preoperative Planning

A

Positioning- can determine ET vs LMA

Monitoring/lines/IV access- Is an arterial line indicated? Pre/post induction? Second IV? Central line? Neuro-monitoring, TEE

Post-op destination and care transition

Plan for intraoperative events
Hypothermia, bleeding, anticoagulation, tourniquet use, positioning, redosing antibiotics etc

52
Q

To Sleepy Town Process

A
53
Q

Preoxygenation

A

Cases where preoxygenation is particularly important:
During RSI and intubation- trauma, full stomach

If difficult airway management is predicted

In patients who are expected to desaturate quickly (Desat curve- Obese, pregnant, pediatric, hypermetaboilic)

54
Q

Goals of Preoxygenation

A

Prolong safe apnea time without desaturation- reduces time pressure to secure an airway

Oxygen storage in lungs primarily resides in
Functional Residual Capacity (FRC )

FRC = Expiratory Reserve Volume + Residual volume and is around 3L

TV usually around 500 ml

55
Q

O2 Facts

A

21% O2 in the air we breath

Alveolar gas makeup in healthy patient breathing room air
14% O2, 5% CO2, 6% H2O vapor, 75% Nitrogen

After onset of Apnea O2 consumption is ~250 ml/minute

Precipitous drop after 90% Sat

8 deep breaths with good mask seal, high flow O2
May require 3-5 minutes in case of severe lung disease

56
Q

Common Induction Medications

A

Oxygen

Fentanyl- Narcotic to blunt response to airway management

Lidocaine- Decrease pain on propofol infusion/decrease airway reflexes

Propofol – Induction agent of choice for most anesthetics

Rocuronium/Succinylcholine- Muscle relaxant to maximize conditions for intubation

57
Q

Stages of General Anesthesia

A
58
Q

Considerations When Planning for Emergence from Anesthesia

A

Timing is Everything
Analgesia
Hemodynamic Management
Destination and Transition of Care
Airway

59
Q

Cases

A

1
65 y/o male patient 5’7” 187lbs
NKDA
Home medications Aspirin, Metoprolol, Lisinopril, omeprazole
History of coronary stents x2 10 years ago, HTN, GERD
ROS- RUQ pain for 1 week with N/V
Scheduled for laparoscopic cholecystectomy estimate duration 1.5 hours
ASA? What’s your plan? Premeds? Airway choice? Perioperative concerns?

2
34 y/o woman 5’3”
Allergies listed to PCN and Sulfa
Home Meds- Mirena BC, multivitamin, albuterol PRN
ROS- L Breast mass, asthma
Scheduled for L Breast lumpectomy, exceptionally nervous in preoperative area
What’s the plan? Premeds? Airway?

3
55 y/o male here for screening colonoscopy
Home meds include fish oil, ibuprofen prn, Ambien
ROS- abdominal pain, pre-diabetic diet controlled, insomnia
GETA vs LMA vs MAC?

4
36 y/o male 205 pounds, 6’2”
NKDA Home medications: MVI
ROS- Negative except for torn Left ACL
Surgery- Left ACL reconstruction with patellar tendon graft
ASA? General with Et tube/LMA or MAC?

5
68 y/o female 5’6” 185 lbs
Allergic to bananas
ROS- History of CAD with CABG 7 years ago, smoker, HTN, anxiety and depression presenting with active stroke with right sided weakness in emergency room
Home medications include- Aspirin, Sublingual nitroglycerin, losartan, metoprolol, Lipitor, Xanax
Scheduled case- Thrombectomy
Patient aphasic in preop
ASA? Consent? Anesthetic Choice?

60
Q

Gas Supply

A

Anesthesia Machines have inlets for both E-cylinder gases and pipeline gases coming from the wall (hospital source)

Pipeline inlets
Air, Nitrous Oxide, and Oxygen
Color coded tubing
Attached using a noninterchangeable Diameter-index safety System (DISS)
Approximate pipeline pressure of the gases delivered to the anes. machine is 50pisg (pounds per square inch gauge)
O2 Flush delivers 50psig directly to the pt!!!!! Bypasses vaporizers. Fig 4-3 page 53

61
Q

Oxygen Cylinders

A
62
Q

Nitrous Oxide

A

Normal capacity is 1590L
Normal E-cylinder tank pressure is 745psig
The volume of N20 is not proportional to its cylinder pressure
The pressure in the tank will not change until the vol. is at or around 400L
Only reliable way to measure how much is by weighing the cylinder

63
Q

Anesthesia Machine Basic Components with Air

A

Flow valves and meters
Vaporizers
Common fresh gas outlet
Oxygen analyzers
Adjustable Pressure-Limiting Valve (APL)
Humidifiers
Ventilators
Waste gas scavengers

64
Q

Flow Sequences

A
65
Q

Surgical Fires/Thermal Injuries

A

Very Rare, but good to know what to do in case one happens

Prevention includes
If possible lowering the FiO2 to 30% or lower
Avoid draping that allows for the build up of O2
Using a Laser ETT if needed
Avoiding N2O use

66
Q

Airway Fire

A

First step is to DISCONTINUE THE FLOW OF OXYGEN!!!!
This can be done a couple different ways.

Next Steps include
Removing the current ETT and flushing the airway with sterile water or saline.
Re-establish a secure airway.
Exam the burnt ETT for missing pieces and possible perform a bronchoscopy on the patient.

67
Q

Anesthetic Gas Analysis

A

Very vital and essential part in the delivery of Anesthesia

Measured by infrared absorption analysis
Based on the BEER-LAMBERT law

68
Q

Beer-Lambert Law

A

Formula for measuring an unknown gas within inspired gas because the absorption of infrared light passing through a solvent (inspired or expired) is proportional to the amount of that unknown gas.

Oxygen and Nitrogen do not absorb infrared light.

69
Q

Oxygen Analysis

A

Various technologies have been used to accomplish this.
Galvanic Cell
Paramagnetic analysis (most common used)
Polarographic Electrode

In our newer machines the method used is Paramagnetic analysis.

70
Q

Paramagnetic Analysis

A

Oxygen is a nonpolar gas, but it is Paramagnetic.

When placed in a Magnetic field it will expand and it will contract when that magnet is turned off.

If you compare the resulting change in volume (or pressure or flow) to a known standard you can measure the amount of Oxygen that is being expired or Inspired

71
Q

ASA Standards for Monitoring

A

Non-Invasive Blood pressure Cuff (Circulation)
Pulse Oximetry monitoring (Oxygenation)
Electrocardiography (ECG) monitoring (Circulation)
Capnography (Ventilation)
Temperature

72
Q

BP: Non-Invasive

A

Most common method used to monitor Blood Pressure
Utilizes Oscillometry to determine SBP, DBP, and MAP

MAP = SBP + 2(DBP) /3

Different Sizes Available
Can be placed in multiple locations

Actual BP can be different depending on where the cuff is located.
1cm ( 1cm H2O) is equal to 0.74mmHg
If the cuff is on a patients forearm and that is 20cm below the patients Head then we know that the Cerebral BP is 14.7mmHg lower than what the cuff is showing
Systolic and Diastolic

73
Q

Pulse Oximetry

A

Factors that can affect your reading or give a false reading

Methemoglobinemia (rare blood disorder affecting hemoglobin)
Carboxyhemoglobin (what happens to RBC when carbon monoxide is inhaled)
Malposition of probe
Ambient light
Low perfusion to extremities
ETC,ETC

74
Q

ECG

A

Recording of the electrical potentials generated by myocardial cells
What makes up our cardiac rhythm
“P” wave is the contraction of both Atria
”QRS” complex is the Ventricular Systole
“T” wave represents the repolarization of the Heart as it awaits the next cardiac cycle.
Two most important leads to monitor
Lead 2 (best at detecting Inferior wall Ischemia)
Lead V5 ( best at detecting Anterior and Lateral wall Ischemia)

75
Q

Capnography

A
76
Q

Capnography Visuals

A
77
Q

Temperature

A
78
Q

Drawing Up Medication

A
79
Q

Medication Expiration

A
80
Q

Infusion Lines and Medication/Fluid Bags

A
81
Q

Standard Contact Precautions

A
82
Q

Enhanced Contact Precautions

A
83
Q

Multi-Drug Resistant Organisms

A

MRSA (Methicillin-resistant staphylococcus aureus)

VRE (Vancomycin-resistant enterococci)

84
Q

Enhanced Contact Precautions

A
85
Q

Droplet Precautions

A
86
Q

Airbourne Precautions

A

Wear mask at all times in hospital unless eating/drinking.

N95 for Covid/TB positive patients or those at high risk

Chickenpox (varicella)

Measles (rubella)

Disseminated zoster (shingles)

Covid 19

TB

Current personal vaccinations

87
Q

Bloodborne Pathogens

A

Hepatitis-B (HBV)
Hepatitis-C (HCV)
HIV (very low sero-conversion rate)
Practice standard precautions (gloves, hand washing, needle safety and eye protection)

88
Q

Key Concepts: Chapter 2 - Operating Room Environment

A

A pressure of 1000 pounds per square inch (psig) indicates an E-cylinder that is approximately half full and represents 330 L of oxygen.

The only reliable way to determine the residual volume of nitrous oxide is to weigh the cylinder.

To discourage incorrect cylinder attachments, cylinder manufacturers have adopted a pin index safety system.

A basic principle of radiation safety is to keep exposure “as low as reasonably practical” (ALARP). The principles of ALARP optimize protection from radiation exposure by the use of time, distance, and shielding.

The magnitude of a leakage current is normally imperceptible to touch (<1 milliampere [mA] and well below the fibrillation threshold of 100 mA). If the current bypasses the high resistance offered by skin, however, and is applied directly to the heart (microshock), current as low as 100 microamperes (μA) may be fatal. The maximum leakage allowed in operating room equipment is 10 μA.

To reduce the chance of two coexisting electrical faults, a line isolation monitor measures the potential for current flow from the isolated power supply to the ground. Basically, the line isolation monitor determines the degree of isolation
between the two power wires and the ground and predicts the amount of current that could flow if a second short circuit were to develop.

Almost all surgical fires can be prevented. Unlike medical complications, fires are a product of simple physical and chemical properties. Occurrence is guaranteed given the proper combination of factors but can be almost entirely eliminated by understanding the basic principles of fire risk.

The most common risk factor for surgical fire relates to the open delivery of oxygen.

Administration of oxygen in concentrations of greater than 30% should be guided by the clinical presentation of the patient and not by protocols or habits.

The sequence of stopping gas flow and removal of the endotracheal tube when a fire occurs in the airway is not as important as ensuring that both actions are performed immediately.

Before laser surgery is begun, the laser device should be in the operating room, warning signs should be posted on the doors, and protective eyewear should be issued. The anesthesia provider should ensure that the warning signs and eyewear match the labeling on the device because laser protection is specific to the type of laser.

89
Q

Key Concepts: Chapter 4 - The Anesthesia Workstation

A

Equipment-related adverse outcomes are rarely due to device malfunction or failure; rather, misuse of anesthesia gas delivery systems is three times more prevalent among closed claims. An operator’s lack of familiarity with the
equipment, an operator’s failure to verify machine function prior to use, or both are the most frequent causes. Such mishaps accounted for about 1% of cases in the ASA Closed Claims Project database from 1990 to 2011.

The anesthesia machine receives medical gases from a gas supply, controls the flow and reduces the pressure of desired gases to a safe level, vaporizes volatile anesthetics into the final gas mixture, and delivers the gases to a
breathing circuit that is connected to the patient’s airway. A mechanical ventilator attaches to the breathing circuit but can be excluded with a switch during spontaneous or manual (bag) ventilation.

Whereas the oxygen supply can pass directly to its flow control valve, nitrous oxide, air, and other gases must first pass through safety devices before reaching their respective flow control valves. These devices permit the flow of other gases only if there is sufficient oxygen pressure in the safety device and help prevent accidental delivery of a hypoxic mixture in the event of oxygen supply failure.

Another safety feature of anesthesia machines is a linkage of the nitrous oxide gas flow to the oxygen gas flow; this arrangement helps ensure a minimum oxygen concentration of 25%.

All modern vaporizers are agent specific and temperature corrected, capable of delivering a constant concentration of agent regardless of temperature changes or flow through the vaporizer.

A rise in airway pressure may signal worsening pulmonary compliance, an increase in tidal volume, or an obstruction in the breathing circuit, endotracheal tube, or the patient’s airway. A drop in pressure may indicate an improvement in compliance, a decrease in tidal volume, or a leak in the circuit.

Traditionally ventilators on anesthesia machines have a double-circuit system design and are pneumatically powered and electronically controlled. Newer machines also incorporate microprocessor controls and sophisticated
pressure and flow sensors. Some anesthesia machines have ventilators that use a single-circuit piston design.

The major advantage of a piston ventilator is its ability to deliver accurate tidal volumes to patients with very poor lung compliance and to very small patients.

Whenever a ventilator is used, “disconnect alarms” must be passively activated. Anesthesia workstations should have at least three disconnect alarms: low peak inspiratory pressure, low exhaled tidal volume, and low exhaled carbon dioxide.

Because the ventilator’s spill valve is closed during inspiration, fresh gas flow from the machine’s common gas outlet normally contributes to the tidal volume delivered to the patient.

Use of the oxygen flush valve during the inspiratory cycle of a ventilator must be avoided because the ventilator spill valve will be closed and the adjustable pressure-limiting (APL) valve is excluded; the surge of oxygen (600–1200 mL/s) and circuit pressure will be transferred to the patient’s lungs.

Large discrepancies between the set and actual tidal volume are often observed in the operating room during volume-controlled ventilation. Causes include breathing circuit compliance, gas compression, ventilator–fresh gas flow
coupling, a preset ventilator peak airway pressure limit, and leaks in the anesthesia machine, the breathing circuit, or the patient’s airway.

Waste-gas scavengers dispose of gases that have been vented from the breathing circuit by the APL valve and ventilator spill valve. Pollution of the operating room environment with anesthetic gases may pose a health hazard to surgical personnel.

A routine inspection of anesthesia equipment before each use increases operator familiarity and confirms proper functioning. The U.S. Food and Drug Administration has made available a generic checkout procedure for anesthesia gas machines and breathing systems.

90
Q

Key Concepts: Chapter 5 - Cardiovascular Monitoring

A

The tip of the central venous pressure catheter should not be allowed to migrate into the heart chambers.

Although the pulmonary artery (PA) catheter can be used to guide goal-directed hemodynamic therapy to ensure organ perfusion in shock states, other less invasive methods to determine hemodynamic performance are available, including transpulmonary thermodilution cardiac output (CO) measurements, pulse contour analyses of the arterial pressure waveform, and methods based on bioimpedance measurements across the chest.

Relative contraindications to PA catheterization include left bundle-branch block (because of the concern about complete heart block) and conditions associated with a greatly increased risk of arrhythmias.

Pulmonary artery pressure should be continuously monitored to detect an over wedged position indicative of catheter migration.

Accurate measurements of CO depend on rapid and smooth injection, precisely known injectant temperature and volume, correct entry of the calibration factors for the specific type of PA catheter into the CO computer, and avoidance of measurements during electrocautery.

91
Q

Key Concepts: Chapter 6 - NonCardiovascular Monitoring

A

Capnographs rapidly and reliably detect esophageal intubation—a cause of anesthetic catastrophe—but do not reliably detect mainstem bronchial intubation.

Postoperative residual paralysis remains a problem in postanesthesia care, producing potentially injurious airway and respiratory function compromise and increasing length of stay and cost in the postanesthesia care unit (PACU).

92
Q

Key Concepts: Chapter 18 - Preoperative Assessment, Premedication & Perioperative Documentation

A

The cornerstones of an effective preoperative or preprocedure evaluation are the history and physical examination, which should include a complete and up-to date listing of all medications taken by the patient in the recent past, all pertinent allergies, and responses and reactions to previous anesthetics.

The anesthesiologist should not be expected to provide the risk-versus-benefit discussion for the proposed surgery or procedure; this is the responsibility and purview of the responsible surgeon or “proceduralist.”

By convention, physicians in many countries use the American Society of Anesthesiologists’ classification to identify relative risk prior to conscious sedation and surgical anesthesia.

In general, the indications for cardiovascular investigations are the same in elective surgical patients as in any other patient with a similar medical condition.

Adequacy of long-term blood glucose control can be easily and rapidly assessed by measurement of hemoglobin A1c.

In patients deemed at high risk for thrombosis (eg, those with certain mechanical heart valve implants or with atrial fibrillation and a prior thromboembolic stroke), chronic anticoagulants should be replaced by intramuscular low molecular- weight heparins or by intravenous unfractionated heparin.

Current guidelines recommend postponing all but mandatory emergency surgery until at least 1 month after any coronary intervention and suggest that treatment
options other than a drug-eluting stent (which will require prolonged dual antiplatelet therapy) be used in patients expected to undergo a surgical procedure within 12 months after the intervention.

There are no good data to support restricting fluid intake (of any kind or any amount) more than 2 h before induction of general anesthesia in healthy patients undergoing elective procedures; moreover, there is strong evidence that
nondiabetic patients who drink fluids containing carbohydrates and protein up to 2 h before induction of anesthesia experience less perioperative nausea and dehydration than those who are fasted longer.

To be valuable, preoperative testing must discriminate: There must be an avoidable increased perioperative risk when the results are abnormal (and the risk will remain unknown if the test is not performed), and when testing fails to detect the abnormality (or it has been corrected), there must be reduced risk.

The utility of a test depends on its sensitivity and specificity. Sensitive tests have a low rate of false-negative results and rarely fail to identify an abnormality when one is present, whereas specific tests have a low rate of false-positive
results and rarely identify an abnormality when one is not present.

Premedication should be given purposefully, not as a mindless routine.

Incomplete, inaccurate, or illegible records unnecessarily complicate defending a physician against otherwise unjustified allegations of malpractice.

93
Q

Gradient Difference Between PaCO2 and ETCO2

A

normally 2-5 mmHG, reflects alveolar dead space

94
Q

Carboxyhemoglobin (COHb) and HbO2

A

NSU AA Denver (15 decks)

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