2025 Lab 1 Exam 2/Final Flashcards
Need 2025 Lab 1 Exam1/Midterm Deck to Complete Material
Nasal Cannula
For every 1L/min of O2 = 4% Increase in O2%
FiO2 of 24-44%
Anesthesia (Monitored Anesthesia Care)
Need a gas sampling line to monitor for spontaneous respirations
2 Variations Essentially
Nasal Cannula without CO2 monitoring
Nasal Cannula sampling line (CO2 monitoring)
Used when patient under anesthesia is asleep, common would be during MAC, make sure they are breathing
A lot of providers will just jump to mask if have to go more than 4 L/min in fear of drying out patients nose
Face Masks
Simple
FiO2 35-60% (6-10L/min)
Partial rebreathing
FiO2 60-90% (6-10L/min)
Non rebreathing
FiO2 Almost 100% (10-15L/min)
Venturi Mask
24-50% (Variable)
Simple Mask
FiO2 35-60% (6-10L/min)
Some providers prefer to use a simple mask post surgery when delivering patient to PACU… can see the fog to know they are breathing
Partial Rebreathing Mask
FiO2 60-90% (6-10L/min)
Nonrebreathing Mask
FiO2 Almost 100% (10-15L/min)
Rebreather Mask Function
Rebreather Mask Diagram
High Flow Devices
Have flow rates and reservoirs large enough to provide the total inspired gases reliably
Flows in excess of 30-40 L/min (or 4x minute volume)
Venturi masks, aerosol masks, and T-pieces powered by air-entrainment nebulizers or air oxygen blenders
Ability to deliver predictable, consistent, and measurably high and low FiO2s despite ventilatory pattern
Venturi Mask
24-50% (Variable)
Provides predictable and reliable FIO2 values of 24-50% (independent of patient’s respiratory pattern)
Air entrainment based on Bernoulli principle
Rapid velocity of gas moving through a restricted orifice
Fixed FiO2 model (color coded)
OR
Variable FiO2 model (graded adjustment)
Venturi Effect
Nasal Airways
Nasal airways
Nasal trumpet
Oral Airways
Oral airways
Berman
Side channels to facilitate air passage
Guedel
Tubular center channel allows air to pass
LMA Description
Specially designed airway that seats over the larynx to allow ventilation in normal patients. The LMA may be a useful adjunct in patients who are inadequately ventilated by mask.
The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support
It consists of an inflatable silicone mask and rubber connecting tube
It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation
All parts are latex-free
Construction
Silicone
30o between airway tube
and body of mask
Basic components
15 mm connector
Airway tube
Cuff
Inflation system
Valve
Pilot balloon
Pilot tube
When to Use LMA
The Laryngeal Mask Airway is an appropriate airway choice when:
Mask ventilation can be used
(except in the Difficult Airway Algorithm) … can take the place of Mask Ventilation
Endotracheal intubation is not necessary (when they do not have to be paralyzed is a big indicator)
MAC procedures are good with LMA
LMA Function
Establishes airway
with supraglottic seal
(above the vocal cords)
LMA Indications
Indications
Administration of general anesthesia
Establish unsecured airway emergently
Facilitate endotracheal intubation
Adjunct to FOB airway management
Decadron is a drug to be used to help with swelling and bleeding in the airway
LMA Advantages
Advantages:
Allows rapid access
Does not require laryngoscope
Does not require neuromuscular blockade for placement or maintenance
(just need Propofol, and some lidocaine for the sting of the Propofol)
Provides airway for spontaneous or controlled ventilation (can be used PPV, but not a first choice)
Tolerated at lighter anesthetic planes
Advantages (compared to):
Less stimulating during use (ETT)
Less ↑ in intrathoracic and intraabdominal pressures during emergence (ETT)
Less cardiovascular response (ETT)
Less ↑ in IOP (ETT)
Frees practitioner’s hands (mask)
Provides seal for PPV (OAW or NAW)
LMA Disadvantages
Does not protect against aspiration in the non-fasted patient
Standard LMA not recommended for use with ventilator… though it is used all the time
Requires re-sterilization if Original LMA
Learning curve for insertion
Over-estimated ease of use
(can be harder to correctly insert and seat compared to an ETT)
Not a Secure Airway
LMA Contraindications
Non-fasted patients
(the only true absolute contraindications)
Risks of aspiration (GERD, not NPO, hiatal hernia, obesity, pregnancy, bowel obstruction, acute pancreatitis, ….)
Morbidly obese patients
Obstructive or abnormal lesions of the oropharynx
Maxillofacial Trauma
Respiratory disease with low compliance and/or high resistance
Patient position or surgery limiting airway access
Upper airway pathology (infection, hematoma, cyst, ….)
LMA Insertion Problems
Jam into vallecula (pull out start over)
Push epiglottis down over glottic opening (pull out start over)
Get caught on glottic opening (adjust with little pull back, might have to pull out and start over)
LMA: ProSeal
Special Features:
Suction gastric contents
Basic components
Cuff
Drainage system
External drain tube with connector
Internal drain tube
Drain tube orifice
Integral bite block
Introducer strap
LMA: Fast-trach LMA
Special Features:
May be used as a rescue airway and fiberoptic conduit when intubation is difficult, hazardous or unsuccessful
It can be used for bronchoscopy in the awake or asleep patient
LMA Head Positioning
LMA Insertion 1
LMA Insertion 2
LMA Insertion 3
LMA Insertion 4
Verify LMA Placement
Connect to ventilator and verify
Chest Rise
Bilateral Breath Sounds
Absence of Gastric Sounds
EtCO2
Condensation in tube
Acts as a Bite Block
Secure LMA
Preoperative Assessment Importance
Our pre-operative interview is where we establish the initial level of trust and communication with our patient
The information obtained in this interview can play a significant role in how we cater our anesthetic plan for each individual
Depending on what questions you ask and how you ask them, the patient may reveal more pertinent history that allows for us to treat them as safely and efficiently as possible
Making the patient feel comfortable/at ease before surgery will ensure the best possible outcome
WE are the most powerful “drug” we can give our patients before heading back to surgery
PreOp Assessment - Before Entering Patient’s Room
Find out exactly what the patient is getting done and which surgeon is performing the procedure (each surgeon will have their own preferences – after working with them several times, we learn them and are able to more efficiently plan our anesthetic)
If you are unfamiliar with the procedure, do your research! Look it up and find out any pertinent information that can help you establish your anesthetic plan
Based on this information, you can have a baseline idea of your anesthetic plan (ie: GETA, TIVA, LMA, ETT, monitoring techniques required, etc)
Review the patient’s chart for any relevant medical history
Looking at their medication list ahead of time can give you an idea of what conditions they have
If the patient has had previous surgeries, we can generally see how induction/intubation went, any issues that arose, etc
Review lab results and determine if any more need to be ordered
ALWAYS be sure to get a pregnancy test for woman of childbearing age
Think of any pertinent questions you may need to ask them based on their medical history
PreOp - Entering Room
Knock first! Ask for permission to enter
Although this sounds simple, small things like this help to develop a level of respect with the patient (and may be easily forgotten if it is a busy day)
Introduce yourself upon entering
“Hi, I’m _____________, the student Anesthesiologist Assistant working together with Dr. ___________ (attending anesthesiologist) and ______________ (preceptor).”
“Can I ask you some medical questions related to today’s procedure?”
If there are people in the room with them, this gives them the opportunity to tell you if they would like privacy when discussing medical information
Identify the Patient
Be sure you have the correct patient in front of you! There is nothing worse than getting into an interview and realizing later that you have the wrong chart (and therefore reviewed the incorrect information ahead of time) or are in the wrong room entirely
The most common identifying factors are patient’s name and DOB
It is a good idea to check their wrist band if they have one on to double check their name is correct everywhere.
Human errors happen all the time! Be sure to not only check your work, but the work of others in order to provide the safest possible care for each patient. Something as serious as incorrect administration of medications could start with something as simple as a registration error when the patient was admitted to the hospital!
Check that the patient understands what they are having done and why (in simple terms), who their surgeon is, which side the procedure is on (if applicable), and that all of this information matches that provided on their chart/other preoperative documents such as consent forms
The Big Four
The things you want to get no matter what, get before a patient might go unconscious if emergency situation:
Anesthetic History
Family History with MH
Allergies - Anaphylaxis or Side Effect?
NPO Status
PreOp Assessment - Anesthetic History
“Have you had any previous surgeries/anesthesia?
If they have, be sure to find out if it was general or regional
An easy way to do this is ask if they were knocked out for the procedure or awake
Were there any issues with the anesthesia?
Red flags you are looking for: high fever (possible MH), staying intubated for extended time (possible pseudocholinesterase deficiency), or nausea vomiting (PONV)
“Are you aware of any family history of issues with anesthesia?”
This is especially significant if the patient has never had anesthesia before, as it could be indicative of a genetic condition (ie: MH)
PreOp Assessment - Allergies
“Do you have any allergies to medications or otherwise?”
Some people say they are allergic to something just because they don’t like the way they feel from it (ie: “Epinephrine makes my heart race” or “Augmentin makes me nauseous”
Check for TRUE anaphylactic reactions
If they are allergic to exotic fruits think possible latex allergy
If they are allergic to shellfish think possible iodine allergy
If they are allergic to Penicillin no Ancef!
If they are allergic to tape, be sure to use proper tape for eyes/tube/etc during procedure (paper tape or “pink tape”)
NPO Status
“When was the last time you had anything to eat or drink?”
Sometimes patients don’t tell the whole truth or forget…
Consider asking “what did you have for breakfast this morning?”
This information helps us to determine their fluid deficit
(hourly requirement in mL/hr) = (weight in kg) + 40
Fluid deficit = (hourly requirement) x (number of hours NPO)
PreOp Assessment - Medications
If the patient is on beta blockers, they should take those the morning of surgery
As a general rule, herbal supplements should be stopped two weeks prior to surgery… can google what ones (should be about 10)
ACE/ARB/Diabetics/Diuretics should be avoided for 24 hours before surgery!!
… The GLP-1 agonists (ozempics, etc.) guidelines are constantly changing due to their newness
Anticoagulants need to be stopped before surgery
Xarelto 24 hours before
Eliquis 48 hours before
Coumadin (Warfarin) 5-7 days before (there is an INR test for therapeutic levels that could postpone the surgery)
Aspirin and/or Plavix 7-10 days before
PreOp Assessment - Social History
“Do you drink alcohol?”
How much, how often, what kind?
“Do you smoke cigarettes?”
How many packs/cigarettes per day and for how long?
“Any elicit drug use?”
Assure them that this is a judgement free zone, but we need to know so we can properly care for them before, during, and after the procedure
The patient may be hesitant to answer this or lie if there are others in the room
The best time to ask may be when you are rolling back into the operating room or have privacy
PreOp Assessment - Measuring Physical Activity
It is important that we establish the patient’s overall physical activity level
To do this, we determine their METS, or metabolic equivalent, which is the energy spent when the patient is sitting at rest
One MET is approximately 3.5 mL of O2 consumed per kg of body weight per minute
METS
“Can you climb a flight or stairs without feeling shortness of breath?”
“Do you do your own grocery shopping?”
“Are you able to clean your house on your own?”
However, each of these things could vary so much by individual
A more standard question to ask would be something like…
“If we were to take a walk to the entrance of the hospital together right now, could you do that with no issues?”
Of course, this is all dependent on the issue patient is presenting for
For example, if they have a broken leg, they may have issues walking)
PreOp Assessment - Review of Systems
PreOp - ROS: Neurological
Any deficits pre anesthesia… so know if there is a deficit post anesthesia due to procedure or not
PreOp - ROS: Endocrine
Past Diabetes and Thyroid function only ask about them if see it in record
PreOp - ROS: Respiratory
PreOp - ROS: Cardiovascular
PreOp - ROS: Gastrointestinal
PreOp - ROS: Urinary, Reproductive, Hepatic, Renal
PreOp - ROS: Musculoskeletal
PreOp - Physical Exam
Heart
Lungs
Mouth/Airway
PreOp - Physical Exam: Heart Sounds
Listen to the different valve sounds on YouTube
PreOp - Physical Exam: Lung Sounds
Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales).
CHF
Rhonchi. Sounds that resemble snoring.
Bronchitis/COPD
Stridor. Wheeze-like sound heard when a person breathes.
Laryngospasm/inflammation of cords
Wheezing. High-pitched sounds produced by narrowed airways.
Brochospasm/asthma
Listen to on YouTube and what is causing each one inspiration, expiration, etc.???
PreOp - Physical Exam: Dental/Mallampati
“Open your mouth and stick out your tongue, without saying ‘ahh’ please”
Assign Mallampati score (see next slide) and document
“Anything loose, chipped, cracked, or removeable?”
Implants, caps, crowns, dentures, etc
If they have dentures or anything removeable, it will be taken out prior to rolling back to OR
Let them know they will be placed with their belongings and available for them in the recovery room
Dentures are commonly lost between pre-op and PACU! Be sure to put them in the appropriate place to avoid this
Document everything you see and are told in the dental exam
Remember teeth numbering system (shown on next slide)
It is very important to make note of all of this in case anything gets damaged or knocked out during intubation
PreOp - Physical Exam: Range of Motion
PreOp - Explain What Will Happen Next
PreOp - Others…
“Is there anything we haven’t discussed that you think is important for me to know so I can take excellent care of you?”
This is a way to cover everything you may have missed and give the patient an opportunity to bring up any issues or concerns they may have regarding their medical history
