2025 Lab 1 Exam 1/Midterm Flashcards
OR Orientation, ASA Monitors, Patient Positioning/Transport
Proper OR Etiquette
OR Attire
Hospital supplied scrubs
No long-sleeved undershirts
Hospital photo ID badge worn on upper body not waistline
Hat or hood
Shoe covers (Optional PPE)
Mask
Eye protection (Required PPE)
N95, gloves, and disposable gown for all COVID or suspected COVID patients
Time Out Procedure
OR Timeline
Patient transport from stretcher to OR table 1-5 min
Placing ASA Monitors on patient 2-5 min
Induction of anesthesia 5-10 min
Maintenance of anesthesia 30min-12+ hours
Emergence from anesthesia 5-20 min
Transport to PACU 5-10 min
OR Room Equipment
Sterile Table
Anesthesia Machine
C-Arm
OR Table
Boom
Ultrasound
Suction
Pyxis
Tourniquets
Tanks/Wall Outlets Gas and Air
Gas and Air
Tanks/Wall outlets
Blue (nitrous)
Yellow (air)
Green (oxygen)
Gray (CO2)
Purple/gray (vacuum)
OR Supplies
IV
Central Lines
Laryngoscope/ETT/LMA/OPA/NPA
Neuraxial (Epidural and Spinal)
Regional Blocks
IV Sizes
Central Line Use
Used for access when other IVs are unsuccessful, for massive transfusion, trauma, and to give vasopressor and cardiac stimulating medications directly to the heart.
Most Commonly placed in the R Internal Jugular vein but can also be placed in the femoral veins, subclavian veins and L IJ vein
Tip should be just before entrance to the R atrium/on a chest x-ray at the level of the carina
Requires a sterile and full sterile gown and gloves technique due to a high infection rate
Central Lines must be exchanged or replaced every 5-7 days
Regional Blocks Use
Referred to as “blocks”
Local anesthetic injections using ultrasound to target specific nerves that supply an area of the body being operated on.
Regional anesthesia can lead to quicker discharge from the hospital and less opioid requirements
Hospital Staff
Physician (MD, DO)
Charge Nurse (be extra polite)
OR Nurse (can make your life easy or hard be respectful)
PACU Nurse (expects a concise yet detailed case report)
Preop Nurse
ICU Nurse
Anesthesia Tech
Respiratory Therapist
PA, NP, CRNA, CAA
Administrators (ensure proper PPE is on/badge is viewable)
CEO, CMO, CNO (any C suite members be extra nice)
OR Staff/Areas of Hospital
Attending Physician – graduate physician, person in charge, board certified
…Resident (physician) – medical school graduate, in specialty training
Scrub nurse or technician – person who is in charge of the sterile instruments
Circulating nurse – catch all for the room, in charge of paperwork, gathering supplies needed for the sterile procedure, patient identification and correct surgical procedure, nurse in charge of the single OR
Orderlies (bed techs, OR aides) – clean-up crew and setting up the room, assisting with lifting and transporting the patient
Anesthetists (CRNA or AA) – the person staying in the room to deliver the anesthesia care
Pre-op (pre-op holding) – location where patient awaits surgery (where we will see the patient)
Pre-op nurse – nurse in charge of getting the patient ready for surgery (undressing, surgical site, IV insertion)
PACU – post anesthesia care unit, recovery room for patients, low nurse to patient ration (1:2), an ICU specifically for patients emerging from anesthesia
PACU nurse – nurse in charge of recovering the patient after surgery and either discharges to outpatient center, home, floor or ICU
Floor – regular patient hospital room, patient ratio (1:8)
ICU – Intensive care unit, patient ratio (1:2)
Hospital Locations to Know
Post operative anesthesia care unit (PACU)
Operating Room (OR)
Interventional Radiology (IR, CT, MRI)
Intensive care unit (ICU)
Critical Care Unit (CCU)
Pharmacy
Blood Bank
Lab
Burn Unit
OR Safety
Proper PPE
If you see something say something
If anything happens, do not be afraid to tell someone
If a needle stick or eye contamination occurs tell your attending immediately
Proper eye wear is required
Ensure hair is fully in scrub cap
Stay out of sterile field
If the case seems difficult to the surgeon refrain from asking questions and ask your attending
Be polite, respectful, and attentive and you will have an amazing clinical rotation
-It is true. You truly get what you give.
OR Case Types
OB/GYN
GENERAL
RENAL
HEPATIC
THORACIC
CARDIAC
PODIATRY
GASTROENTEROLOGY
NEUROLOGIC
VASCULAR
IR
ORTHOPEDICS
SPINE
PLASTICS
ASA Monitors
The term “standard ASA monitors” is often used to refer tothe basic physiologic monitors recommended by the American Society of Anesthesiologists.
During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated.
Inspired gas: During every administration of general anesthesia using an anesthesia machine, the concentration of oxygen in the patient breathing system shall be measured by an oxygen analyzer with a low oxygen concentration limit alarm in use.
During all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry shall be employed.
When the pulse oximeter is utilized, the variable pitch pulse tone and the low threshold alarm shall be audible to the anesthesiologist, or the anesthesia care team personnel.
Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful. Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment. Quantitative monitoring of the volume of expired gas is strongly encouraged.
To ensure the adequacy of the patient’s circulatory function during all anesthetics.
To aid in the maintenance of appropriate body temperature during all anesthetics
Parts of ASA Monitors
Pulse oximetry
Blood pressure (invasive or noninvasive)
Temperature
Capnography (CO2)
EKG
Pulse Oximetry
Measures Oxygenation (different from ventilation)
Normal range 95-100%
Requires perfusion for accurate reading
Delay in actual reading by 20-30 seconds due to Cardiac output
Locations for readings:
Fingertips, Toes, earlobes, nose, forehead
Measures in wavelengths
Red 660nm (Deoxygenated)
Infrared 960nm (Oxygenated)
Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through. Based on the amount of infrared and red light that is absorbed through the two points determines the final oxygenation saturation percentage.
The reverse is true for deoxygenated hemoglobin.
Errors in Readings:
Hypoperfusion (vasoconstriction, cold, decreased cardiac output, hypotension)
Fingernail polish especially blue, black, and red
Obesity
Motion/ambient light from overhead lights
Iv dyes
Carbon monoxide poisoning (hemoglobin has a higher affinity (20 times that of oxygen) for carbon monoxide than for oxygen so while the hemoglobin all appear to be oxygenated on a pulse oximeter the patient is hypoxic.
Treatment 100% oxygen nonrebreather 4-5 hrs, but if unconscious intubation with 100% oxygen.
Methemoglobinemia (usually genetic or caused by a medication) causes reading ~85%. It is hemoglobin being converted from iron Fe+2 (ferrous) to Fe+3 (ferric)
Treatment methylene blue (considered an electron acceptor to form Fe+3 to Fe+2)
Cyanide poisoning (high reading because cyanide reduces oxygen extraction from arterial blood)
Treatment nitrates
Anemia does not cause erroneous readings
Oxyhemoglobin Dissociation Curve
When shifted left Hgb binds oxygen more tightly
When shifted right Hgb releases oxygen to tissues more easily.
Normal PaO2 is 75-100mmHg
PaO2 is the partial pressure of oxygen in blood
Partial pressure = the pressure that an individual gas exerts in a mixture
You can think of it as the amount of oxygen in the blood and the saturation is the percentage of that bound to hemoglobin
Notice the steep drop around 80% but the gradual drop from 100-90%
Therefore preoxygenation is important
Oxyhemoglobin Dissociation Curve: 2,3 DPG
2,3-diphosphoglycerate (just call it 2,3 DPG)
Binds with a greater affinity to deoxygenated blood and decreases the affinity of hemoglobin to oxygen to promote the release of remaining oxygen supplies. (Read that twice or ten times)
1 hemoglobin binds 4 oxygen molecules
Example of why this is important:
During an ischemic stroke, a clot is usually cutting off blood flow to areas of the brain. 2,3 DPG would promote the deoxygenated blood behind that clot to release all its oxygen stores to the dying tissue to increase the time to cellular death.
Perfusion: Blood Pressure (Non-Invasive)
Non invasive BP
Measures Mean arterial Pressure directly (only method to do so)
Mean arterial Pressure (MAP)=DP + 1/3(SP – DP)or MAP = DP + 1/3(PP)
Pulse Pressure (PP)= SP-DP
Cuff sizing= length 80% of circumference of arm/width 40% circumference
Cuff to large falsely low BP’s
Cuff to small falsely high BP’s
For every 1cm change above or below the BP area there is a 0.75 drop or increase in MAP
In the beach chair position that means the brain is seeing a 15mmHg drop in MAP compared to the heart, which can lead to hypoperfusion and stroke.
Perfusion: Arterial Line (Invasive)
Invasive
Transducer must be at the level of the heart.
Ensure there is no air in the line!!!!
Inflate bag to 250-300mmHg
Sites:
Radial (Most Common)
Axillary
Femoral (Highest Risk of Infection)
Ulnar
Brachial
Dorsalis Pedis (Artery on top of mid foot)
Cannulation for invasive pressure and sites of BP can change readings due to resistance changes in the vasculature.
As you move more distal:
Systolic increases
Diastolic decreases
Pulse pressure increases
Mean arterial pressure stays the same
Ex. Upper arm Bp 120/80, Bp at the lower calf or foot would read 135/72 (same MAP)
Temperature
Normal Temperature is 37 degrees Celsius
Central sites are Esophageal, Central Line
Intermediate sites are Oral, Nasopharyngeal, Rectal, Bladder
Peripheral sites are axilla and skin
A core temp of 32 degrees Celsius or lower can cause atrial or ventricular fibrillation
A temperature of 41 degrees Celcius can cause denaturing of certain proteins
ONLY ONE THAT IS DEPENDENT ON TIME OF PROCEDURE
Why is Temperature Important
Why temperature is important in anesthesia:
Temperature is expected to drop within first 15mins induction of general anesthesia due to vasodilation and redistribution
Malignant hyperthermia is inherited in an autosomal dominant fashion
MH is a lethal scenario seen as a drastic increase in temperature and CO2
Treatment is Dantrolene (muscle relaxer but not a paralytic) initial dose is 2.5mg/kg
Triggered by anesthetic gases and succinylcholine
N2O does not trigger MH
Hypothermia and the body:
Cardiac- depression of pacemaker cells, bradycardia, arrythmias
Respiratory- decreased lung compliance, reduced response to elevated CO2 or hypoxia, acidosis commonly occurs
Coagulation- reduced platelet function and count, reduction in synthesis of clotting factors,
Wound Healing- vasoconstriction occurs and reduces blood flow to injured areas
CNS- reduced EEG activity and a reduction in oxygen demand (helpful in certain neuro cases where intracranial pressure can be of concern. Less oxygen demand=less blood flow, which leaves more space for tumors and intracranial hemorrhage reducing ICP).
Drug Metabolism- therapeutic index (range of doses at which a medication is effective without unacceptable adverse events) narrowed, clearance of drugs dependent on cytochrome P450 reduced
Capnography
Normal CO2 35-45mmHg
Normal Respiratory Rate is 12-16/min
Reading is normally 5-6mmHg off compared to the PaCO2 due to dilution with dead space in the airway during exhalation
The more perfusion that is happening the more CO2 that can be exhaled so a dramatic drop in CO2 can sometimes mean a drop in perfusion (Blood pressure).
ECG
Precordial leads: V1-V6 look at the frontal plane of the heart
Limb Leads I, II, III, aVL, aVR and aVF look at a complete 360 degrees of the heart but only the edges of the frontal plane
To get a complete picture of the heart a 12 lead ekg is required (10 electrodes)
Green or Left? (Shouldn’t it be Right?) lower leg is considered the ground lead. We need a ground lead because the earth is negative, and positive charges are attracted to that. The ground lead gives these charges a safe place to go without causing artifact or shock to the patient.
Capnography Problem Indicators
ECG: 3 Lead
ECG: 5 Lead
ECG: 12 Lead
12-lead Precordial lead placement
V1: 4th intercostal space (ICS), RIGHT margin of the sternum
V2: 4th ICS along the LEFT margin of the sternum
V4: 5th ICS, mid-clavicular line
V3: midway between V2 and V4
V5: 5th ICS, anterior axillary line (same level as V4)
V6: 5th ICS, mid-axillary line (same level as V4)
ECG: Potential Lethal Rhythms
Potentially lethal rhythms: ventricular fibrillation, ventricular tachycardia, asystole, ST depression/elevation, atrial fibrillation/flutter, complete heart block, and pulseless electrical activity.
ECG: ST Depression and Elevation
ST depression is the result of myocardial ischemia
Hypotension, blood clot, hypoxia, arrythmias
ST elevation myocardial infarction (STEMI) is seen at the time or right after a myocardial infarction occurs
Actual cell death due to inadequate oxygen supply the result of the above complications if not resolved
Case Study 1
A male 135kg 65 year old patient is recovering from anesthesia. You notice his nasal cannula is on 3 liters of oxygen his saturation is 96% and his CO2 is barely visible on his expiration. What is likely the issue?
Sleep apnea. While the oxygenation of this patient is adequate (determined from the pulse ox) the ventilation is low as determined by the lack of CO2 on his waveform. Hypercapnia (retaining CO2) can lead to prolonged emergence from anesthesia due to CO2 narcosis.
Case Study 2
During a R shoulder repair in the sitting position the surgeon requests to anesthesia she would like us to lower the BP from 100/56 to a systolic in the 90s due to visualization issues from bleeding tissues. The anesthesia provider declines. Why would they go against the surgeons wishes?
The mean of 110/70 is 71mmHg with the head being roughly 20 cm from the blood pressure cuff that would be a mean perfusion pressure to the brain to be 51 mmHg, which is too low to guarantee adequate perfusion to the brain.
Case Study 3
During a Case a CAA notices a sudden drop in end title CO2 from 36 to 21 mmHg and immediately cycles the BP cuff. Why did they do this?
A sudden drop in CO2 is usually due to hypoperfusion (low BP).
Positioning and Anesthesia
Normal response to positioning are blunted under anesthesia
In normal state move from upright to supine state MAP is maintained in a narrow range with interactions through complex interactions in parasympathetic and sympathetic nervous system
Under anesthesia positioning is going to cause wider physiologic swings… taking away ANS (para and sym) typical responses
Reclining from Upright to Supine
When a person reclines from an upright to a supine position, venous return to the heart increases and this increases preload, stroke volume, and cardiac output. These changes cause a brief increase in arterial blood pressure, which in turn activates afferent baroreceptors from the aorta (via the vagus nerve) and within the walls of the carotid sinuses (via the glossopharyngeal nerve) to decrease sympathetic outflow and to increase parasympathetic impulses to the sinoatrial node and myocardium. This parasympathetic outflow counters the increase in arterial blood pressure from increased preload and as a result systemic arterial blood pressure is maintained within a narrow range during postural changes in the nonanesthetized setting.
General Positioning
Surgical Positions should be ones patients can tolerate while awake!
Perioperative team effort
Maintain spine and extremity neutrality
Proper padding – focus on tissues overlying bony prominences
Securing the patient
Before Placing Patient on OR Table
Be aware of the equipment
Lock Bed
Assemble all attachments
Fittings and attachment properly tightened
Staff moving the patient are properly protected
Know how the operating table raises, lowers, tilts, if there are any loose parts or any previous damage to the bed
Bed locked and if necessary have someone standing on opposite side to allow for no movement
Make sure that anything necessary for the positioning of the patient that must be attached to the equipment is already attached before the arrival and placement of the patient on the OR table. Patients restraints should be secured in place so once patient is on the OR table they can easily and gently be strapped in to ensure safety
Don’t want to have to readjust linens or anything else once the patient is in the proper position
Protection via surgical caps, eyewear, coats and also proper moving techniques are used
Common Surgical Positions
Supine… on back
Prone… on stomach
Lateral… on side
Lithotomy… on back, feet in air
Supine
Most common position
Laid on back
Extremities
Padding
Protective measures
Surgical procedures associated
Easy to place, least amount of harm is done to the patient
Back should not be compromised, spine should be straight and parallel to the OR bed, head should be aligned with body and hips parallel to spine
Legs are extended out with knees relaxed, arms are either extended outward with palms up using an arm board with padding and can be secured by arm straps or they may be tucked against the body
If surgery is long enough the patient might have a padded foot board placed at feet to prevent the feet from dropping and/or moving
Padding placed under every part of body and there is a usually a pillow placed under the patient’s head… under knees as well
Sequential Compression Devices (SCDs) on lower legs to keep perfusion
Protective measures include strapping of the legs just above the knees so they do not move and sometimes even eye padding is included in the surgery so there is no harm to the eyes, if the patient is slightly on their side they should use a doughnut or special headrest to protect the ear
Many surgeries are associated with this position such as: eye, ear, chest (any kind of cardio or pulmonary surgery), abdomen, extremities etc.
Supine: Considerations
Airway obstruction
Circulation
Backache
Limit Arm Abduction to > 90 degrees to protect Brachial Plexus
Ulnar nerve damage with compression on medial aspect of elbow
Airway obstruction is the main concern with supine positioning, there can also be seen a decrease in tidal volumes
Hypotension is a possibility due to compression of inferior vena cava because of vertebral bodies pressure, usually only seen in obese or pregnant women
Central redistribution of blood that may lead to volume overload in a failing heart
If the patient is improperly placed, for instance their arm is extended greater than 90 degrees, this can stretch the arm too far creating difficulties with the brachial plexus
Ulnar nerve compression most common in supine position. More common in men than in women because of the coronoid process is 1.5 times larger in men than women and less adipose tissue over the medial aspect of the elbow
Prone
Patient anesthetized in supine position
Jackson table
Entire team needs to help
Head in line with rest of body
Extremities (checking with surgeon important)
Monitors
Roll placement
Head (C-Spine Neutral Important)
Padding (most important position to pad properly)… specifically on the orbital bone, NOT Eyes… also want to pad shoulders
Spinal procedures and intracranial procedures
Almost always will put a ETT in during Prone position
Arms placed and tucked at patient’s sides or can be supported along the head, legs extended outward, arm supported so no movement
A roll is a form of padding that allows the patient less pressure to particular areas leading to less of a chance of damage.
Chest rolls can be placed to allow less pressure on abdomen and chest
Iliac or pelvic rolls can be placed to allow less pressure on the abdomen, pelvic and upper leg area
Prone: Considerations
Challenge with obese patients
Maintain neck neutral position
Avoid direction pressure on the eyes
Pulmonary compliance improves in prone position
Mindful of arms abducted less than 90 degrees
If arms abducted less than 90 degrees at shoulders then it can cause stretch and damage to brachial plexus
Forearm pads need to be placed to avoid ulnar nerve damage via compression and indirect compression of axillary neurovascular bundle
Arm board can be too low causes
Lateral
Patient anesthetized in supine position
Placed on opposite side of intended surgical access
Extremities
Padding
Head aligned with spine
Protective measures
Can use an LMA
Right Lateral means right side is down
Left Lateral means left side is down
Extremities, knee joint flexed and upper leg stays straight, arms in arm board and secured by arm straps
Padding should be placed under lower legs and to arms
Head aligned can see vertebrae and feel to make sure line
Dependent ear not bent
(the one you are depending on)
left lateral decubitus vs. right lateral decubitus… use pillow with hear hole
Protective measures include placement of axillary roll on downside arm, not in armpit just below so no pressure, if put hand in fist and put in armpit and should have space, placed more caudad to axilla to prevent direct pressure on brachial plexus, large enough to relieve any pressure from mattress on lower shoulder
Pillow placed under neck and head area, and pillow placed between legs and between arms
Safety straps can be placed at various points of the body (hip area, above knee) to ensure patient doesn’t move
Used for surgery on either lung, kidneys or the small bladder, hips potentially, SPECIFIC SURGERIES
Lateral: Considerations
Greatest number of ocular complications
Hypoxemia
Venous hypertension
Spinal misalignment
Neck, Head, Ear aches
Nerve damage
Primarily corneal abrasions, equal frequency in both dependent and non-dependent eyes
Venous hypertension almost inevitable in dependent arm because outflow obstruction
Increased risk of spinal misalignment due to position
Improper placement of padding or rolls can lead to postoperative aches, and we want to ensure the ear is not bent
Brachial plexus at risk if no lateral head and neck support
If axillary roll incorrectly placed may have neurovascular bundle compression
Lack of padding can damage both peroneal and saphenous nerve
Lithotomy
Supine position, legs raised
Extremities
Padding
Protective measures
Surgeries associated
Placed in supine position and first intubated, then moved to position
Leg holder can be in standard, low or high lithotomy position, depending on procedure
Arms can rest at side, over abdomen or on arm boards
Padding should be placed as with supine, all over underside of body
Protective measures include eye padding, and strapping of arms or thorax area sometimes
Used for perineal, small bowel (low anterior section remove lower colon go in from bottom and remove what is left colon resections), rectal and vaginal surgeries
Lithotomy: Considerations
Legs placed at same time
Pooling of lower limb blood
Cephalad movement of endotracheal tube
Airway pressures increase
Decreased oxygenation
Decreased CO2 exhaled
Arm crushing
Nerve damage
Calf compression
Can cause hip dislocation and back strain if legs are not placed at same time
Pooling can lead to volume overload in a failing heart
Though usually an easy fix, sometimes movement of endotracheal tube cephalad and has to be properly placed again
Can sometimes lead to bronchospasm
Particular attention should be given to placement of arms because when the leg section of table is replaced in original position digits and/or arms can be injured, crushed, or even amputated , arms tucked or out
Nerve damage can occur from extreme flexion of hip joints, sciatic and obturator nerves are associated with this damage
Compression of femoral nerve and distally, peroneal nerve and saphenous nerve
Calf compression occurs frequently, can lead to venous thromboembolism and compartment syndrome
Compartment syndrome Is when there is not a good amount of blood to supply muscles and nerves with oxygen because of an increase in pressure to the compartment (i.e. arm, leg, etc)
Trendelenburg
Patient in supine position, head down
Extremities
Padding
Supine position, downward tilt of head usually about 35-45 degrees, more commonly 45 degrees
Head is lower than pelvis
Pads even on shoulders so no overextension of head, however this should be avoided to prevent pressure on the shoulder area which could lead to compression of peripheral neuropathy
Pads on bottom of bed down and legs up in stirrups (bladder removal, prostate or hysterectomy and robot goes between legs in stirrups) RESEARCH
New studies show no pads on shoulder in Trendelenburg
Legs in neutral position and arms are either tucked in at sides or on arm boards
Padding must be placed beneath body of patient
Surgical tape may be used to insure no slippage of padding
Protective measures includes velcro adhesive, it MUST be checked prior to placement on OR table, eye padding, straps
Used for surgery in lower abdomen and pelvic organs, better exposure to pelvic area because the abdominal viscera is moved away from the area, robotic assisted hysterectomies (for lower bowel) , easier access to uterus, may be in association with lithotomy position
Trendelenburg: Considerations
Pulmonary and hemodynamic concerns
Autotransfusion of 9% from blood collected in the legs
Decrease in pulmonary compliance as abdominal contents displaced towards the diaphragm
Patient sliding off OR bed
Surgical brace damage
Slowly taken out of position
Could cause airway swelling
Do not use excessive fluids, can exacerbate the problem
Ventilator will max out, might have to increase 02 Concentration
A little more extreme with Trendelenburg than supine
Ventilation-perfusion mismatched, raised ICP, raised IOP and regurgitation
Increase PIP, have to switch to pressure controlled vs volume controlled in supine, pulmonary fibrosis would worsen in this position
Decrease in respiratory exchange can be due to the movement of viscera creating a pressure against the diaphragm and a pooling of blood in the upper torso of the patient
Surgical braces can lead to damage in brachial plexus
Allow patient a slow transition back to normal positioning in order to give the patient’s body time to readjust itself to change in blood volume
Reverse Trendelenburg
Head higher than feet in supine position
Extremities
Padding
Protective measures
Benefits (decreased pressure on pulmonary)
Risks (hypotension)
Literally opposite of Trendelenburg
Padded footboard used to prevent sliding of patient off of OR table
Surgeries are usually head and neck procedures, usually thyroid or parathyroid surgery
Helps breathing and decreases blood supply to surgical area
Decrease in ICP and IOP
Less likely to regurgitate
Hypotension main concern and an increase risk in venous air embolism
Unless arterial line then blood pressure lower in brain than arm, with NIBP less mmHg than normal because brain is above arm
If pressure below 90 mmHg, and measuring 90 at arm so you know head is less so can bump them a bit vs. in Trendelenburg would be higher because head below arm
Reverse Trendelenburg: Considerations
Hypotension from venous pooling
Falling off the bed
Often used on upper abdominal procedures where pneumothorax can be caused by surgeon
Key Points to Remember with Patient Positioning and Transport
We work as a team!
Initial assessment is essential
Procedure length
Padding and protective equipment checked and available
Previous injury
DOCUMENTATION!!!!!!
End of the day position injuries will fall on Anesthesia (if surgeon changes anything, make note of it for legal considerations)
Assessment including weight, type of surgery, surgeons preference
Procedure length includes assessment of repositioning, schedule times to move patient so whole team is available
MSMAID and NEALSIVMAN
NEALSIVMAN
Dilution of Neo and Ephedrine
Neo
How to make 100 mcg/ml
10 mg/ml = “10,000 mcg/ml” standard concentration
100 ml bag… add your vial (~100 mcg/ml)
250 ml bag… add your vial (40mcg/ml), 2 vials (80 mcg/ml)
10 cc syringe… draw 9 ccs fluid and add vial (1,000 mcg/ml), take another 10 cc syringe and add 9 ccs of fluid - take this syringe and draw 1 cc from original 10 cc syringe (100 mcg/ml)
Ephedrine
Common concentration 50mg/ml
Common dose application
5 mg (1cc) or 10 mg (2cc)
How to make for this common dose application
10 cc syringe, draw 9 ccs fluid and add vial 1cc (5 mg/ml)
Other NEALSIVMAN drugs need to knows…
Atropine
Color green
Prevents parasympathetic
Use 3cc syringe
Lidocaine
2% (100mg) verse 1% (50 mg)… use 5 cc syringe
Succinylcholine
Typical comes in premade with red cap
10 cc syringe
Propofol (not controlled universal, facility dependent)
20 ml…
Versed (controlled, special for waste process)
2cc vial
Rocuronium
5 ccs
Antibiotics
Ansef typically always stocked. Comes as powder, 1 g/ vial, have to constiute
Under 60kg = 1 gram
60-120 = 2 grams
120+ = 3 grams
Narcotic
Fentanyl typical (controlled, special for waste process)
Could see amps 250mg/5ml
IV Tubing Parts
Primary tubing
Drip chamber
O2 filter
Lure lock port
Roller clamp
Lure lock port
Port to iv access
10, 15, gtts/ml
20 gtts/ml… not listed on slides
Micro Dripper
Micro dripper
Little wedge in drip chamber to slow down
60 gtts/ml
Secondary Tubing
lack o2 filter
lack ports
typical for antibiotics
Y-Tubing
y-tubing (for blood)
normal saline typical
when priming, put drip chamber up side down to fill to not over fill
albumin doesn’t need y-tubing, do need the extra needle (like socm propofol)
Airway Equipment on Table
Appropriately sized and functional laryngoscope blade and handle
One appropriately sized ETT with cuff checked for patency (10 mL syringe)
- a stylet inserted into ETT
- two ETTs (one size below and one size
above the chosen size) in the top drawer of
the anesthesia machine (What about ped. OETT sizes?)
A tongue depressor
Two appropriately sized oral airways
Additional Equipment on Tabletop
Tape / Gloves / Alcohol wipes
Extra towels / Pillows
4 x 4 gauze pads
Lacri-Lube eye ointment
Temperature probe (skin or esophageal)
KY jelly or lubricant
Bair Hugger blanket (upper or lower body)
Airway Table Top Set Up
Unless otherwise specified, tabletop setup must be present for ALL cases:
Laryngoscope (x2 Appropriate Laryngoscope Blades)
ETT (x2 appropriate sized ETTs)
Tongue depressor
Oral airway(s)
Choose appropriate OPA size for patient
Early setup: estimate 2 sizes for upcoming patient
Final placement: confirm appropriate size
Nasal airway(s)
Choose appropriate size NPA for patient
Early setup: Estimate 2 sizes for upcoming patient
Final placement: confirm appropriate size
Tape
4x4s
Drugs on Table
Drawing Up Drug Vials
Drawing from Ampule
O2 Delivery Devices Overview
Why do we use supplemental oxygen?
Preoxygenation before intubation
Avoidance of intubation or other invasive airway measures
Patients prone to hypoxia/hypoxemia
Respiratory, cardiac disease
Shock
Drug related respiratory depression
Oxygen - Green cylinder
Pressure: 2000 psi
Capacity: 625 L
O2 Delivery Devices for Patient
Nasal Cannula
Commonly used in MAC procedures
Use NC with CO2 sample line for MACs
Up to 6L/min O2
Turbulent flow, pt discomfort limit maximum L/min O2
Every 1 L/min increase in O2 increases FiO2 by 0.04
High Flow Nasal Cannula
Up to 40 L/min O2
Humidify and warm delivered gas
Possible CPAP effect from the high flows
Face Masks
Circuit Face Mask
Tight seal can be created around pt nose and mouth
Deliver up to 100% FiO2, air, and/or nitrous or anesthetic gases
Simple Face Mask
6-10 L/min O2
>6L/min O2 decreases rebreathing of CO2
40-60% oxygen, 5L = 40% FiO2
Nonrebreather Face Mask
10-15 L/min O2
Delivers >75% FiO2 between
High flow delivery devices
BiPAP (Bilevel positive airway pressure)
Spontaneous ventilation
CPAP (Continuous positive airway pressure)
Spontaneous ventilation
Venturi Mask
FiO2 range 24-50%, 3-15 L/min O2
Rate depicted by multi-colored orifice adaptors
Intubation
Indications
Prevent aspiration
Unusual operative position
Facilitate PPV
Difficult mask
Upper airway surgical site
Provides a patent airway
Sniffing position
Aligns the oral, pharyngeal, and laryngeal axes for optimal direct visualization from lips to the glottis
Elevate head 8-10 cm (adults)
Extend head at the atlanto-occipital joint
BURP
Backward, upward, rightward pressure
Sellick’s Maneuver (cricoid pressure)
Exert downward pressure using thumb and index finger on cricoid cartilage
3kg or 30 newtons, recommended force of downward external pressure
Intubation: DL
Sniffing Position
Scissor mouth open
Carefully insert blade
Angle handle ~45 degrees (aim for the corner where ceiling meets the wall)
Watch teeth and lips!
Carefully place ett
Carefully remove blade
Inflate cuff
Confirm placement
Laryngeal Mask Airway
Classic
Unique
iGel
Intubating
Supreme
ProSeal
Choose appropriate size
Lubricate posterior cuff
Sniffing position
Guide cuff along hard palate until resistance is met
Inflate cuff, if needed
Ventilate with PIP <20 cmH2O
Proper placement
Cuff is bordered by the base of the tongue (superior border), the pyriform sinuses (lateral borders), and the upper ES (inferior border)
LMA opening faces larynx
Epiglottis is not folded over, rests on anterior cuff
Pharynx supports lower cuff
What happens to anesthetic gas when you O2 Flush the Anesthesia Machine?
Dilute mixture, so reduce it
What is the PSI when you O2 flush an anesthesia machine?
45-50 PSI (could be considered 45-60 PSI as well)
Which is the full reduced pressure wall amount
Where does a Epidural and Spinal go
Epidural - Epidural Space (another name peridural space)
Spinal - Subarachnoid Space (another name is intrathecal space and leptomeningeal space)