Anesthesia Flashcards
1
Q
What is the ideal thyromental distance in airway evaluation?
A
Greater than 6 cm
2
Q
What are the preoperative NPO guidelines
A
3
Q
ASA Classifications system
A
4
Q
Common sources of error for pulse oximetry
(10 pts)
A
-Shivering
-Fingernail Polish
-Corboxyhemoglobin
-Methemoglobin
-Methylene Blue
-Hypothermia
-Hypotension
-Hypovolemia
-Hypoxia
-Ambient light
5
Q
What are the most sensitive EKg monitors to ischemia
A
Leads II and V5
6
Q
EKG helps determines
A
Ischemia, disarrhythmias, and pacemaker function
7
Q
When is invasive BP indicated
A
-In major surgeries
-Hemodynamic instability
-Vasocactive meds
-Frequent blood draws.
8
Q
Too large of a BP cuff?
A
falsely low BP
9
Q
Too small of a BP cuff?
A
Falsely elevated bP
10
Q
CO2 monitoring allows for measurement of:
A
-Assessment of ventilation
-Assessment of ciculation
-Identification of intubation
-Identification of anesthetic circuit malfunction (leaks, disconnection)
11
Q
Bispectral index
A
Yes EEG data via scalp electrodes to record the depth of anesthesia via IV or inhalation
12
Q
Levels of consciousness
A
13
Q
Responsivness for minimal, moderate, deep, general
A
14
Q
Airway, spontaneous ventilation, cardiovascular function
for minimal moderate, deep, general
A
15
Q
T/F: LMA’s can be used for airway emergencies when intubation has failed.
A
True, it is a suprglottic airway and does not protect the airway though.
16
Q
what does oral RAE stand for?
A
Ring-Adair-Elwyn
17
Q
When is a cricothyrotomy used?
A
It is used during airway emergencies when other nonsurgical attempts at securing the airway have failed.
18
Q
Volume of distribution
A
Dose of drug administered/concentration of drug in plasma
-Decreased by high protein binding affinity, ionization, decreased lipid solubility.
19
Q
What is drug clearance?
A
The volume of plasma cleared of drug in mL per minute as a result of renal elimination and metabolism (liver and other tissues: kidney, lung, gastrointestinal tract)
20
Q
How is renal elimination improved
A
It is improved with increased water solubility and inhibited by protein binding and lipid solubility
21
Q
Elimination half time:
A
Time required to decrease drug concentration by 50% _5 half times required for total elimination.
22
Q
Redistribution
A
Drugs preferentially distribute to highly perfused tissues (eg brain, heart, kidneys)
Eventually a gradient is reached that allows perfusion to the less perfused tissues (fat, skeletal muscle)
23
Q
First-pass hepatic effect
A
Oral drugs are absorbed by the GI tract and pass through the liver via the portal circulation before entering the systemic circulation
Drugs are metabolized in this process
24
Q
PAP
A
Pulmonary artery pressure-the partial pressure of volatile agent in the brain is in equilibrium with the blood and alveoli
25
MAC
Minimum alveolar concentration is the concentration (partial pressure) of volatile anesthetic (at 1 atm and measured during steady state) that prevents movement in 50% of patients during surgical stimulus.
The higher the MAC, the less the potency
26
MAC of Sevo
2.1
27
What are the advantages and disadvantages of Sevo?
Advantages-Rapid induction/recovery
Minimal airway irritation
Disadvantages-Potential renal concerns ( compound A)
28
What are the advantages and disadvantages of Iso?
Advantages-Relatively slower onset of action, Pungent odor
Disadvantages-Coronary steal effect
29
MAC of Iso
1.15
30
What are the advantages and disadvantages of Des?
Advantages-Rapid induction/recovery
Disadvantages-Airway irritation
31
MAC of des
6.0
32
What are the advantages (4) and disadvantages (6) of Nitrous Oxide?
Advantages-
-Analgesia,
-second gas effect,
-safe in malignant hypothermia susceptible patients,
-rapid induction/recovery
Disadvantages-Expansion of air-filled spaces, higher combustion risk, PONV, megaloblastic anemia, Chronic use may result in peripheral neuropathy, possible teratogen
33
MAC of Nitrous Oxide
105
34
True/FalseBlood pressure reduces from halothane, isoflurane, desflurane, sevoflurane
True, only NO seems to cause it to rise
35
When does HR increase on iso, des, sevo
Only if MAC is greater than 1.5
36
Cardiac contractility
All volatile agents cause a decrease in contractility
37
Volatile anesthetics impact on respiratory rate, TV, MV, and CO2 level
Most volatile anesthetics (except isoflurane)
1-Increased respiratory rate
2-Decreased tidal volume
3-Decreased minute ventilation
4-Produce a high carbon dioxide level
38
Which opioids are included in the Morphine group?
(10 meds)
Morphine
-Codeine
-Hydrocodone
-Oxycodone
-Oxymorphone
-Hydromorphone
-Nalbuphine
-Butorphanol
-Levophanol
-Pentazocine
39
Which opioids are included in the phenylpiperidine group?
-Meperidine
-Fentanyl
-Sufentanil
-Remfentanil
40
What is the mechanism of action of opioids?
-Agonist at various endogenous opioid receptors (Mu1, Mu2, delta, kappa, sigma) within the nociceptive pathways.
-Involves decreased presynaptic release of acetylcholine and substance P
41
What are the effects of opioids on the:
CNS
CV
Respiratory
GI
GU
42
What concerns do you have with opioids?
-Tolerance and dependence
-Chest Wall rigidity
-Crosses placenta
-Histamine release with morphine and meperidine
43
How do you reverse opioids?
Naloxone
-Adult dose is 0.04 to 0.4 mg IV; repeat dose or increase dose to 2 mg if no response.
-Pediatric dose: 0.001 to 0.005 mg/kg IV
44
Pseudoallergy of opioids
Minor symptoms of flushing, hives, diaphoresis, dysphagia, facial/airway swelling,
45
IV Meds-Bartbituates include
Pentobarbital, methohexital
46
What is the mechanism of action of barbiturates?
GABA potentiation, direction action on GABA, receptor chloride channels, some action on calcium ion channels
47
What is the induction/sedation dosage of barbituates
Induction: 1 to 1.5 mg/kg
Sedation: 0.75 to 1 mg/kg followed by 0.5 mg/kg every 2-5 minutes
48
Ketamine-MOA
(5 receptors)
Various receptors (NMDA agonist, opioid, monoaminergic, muscarinic, calcium ion channels)
49
What are the pharmacokinetics of Ketamine?
-High lipid solubility: Crosses blood-brain barrier easily
-Hepatic metabolism
50
What is the dosage of Ketamine
Induction: 1 to 4.5 mg/kg IV
Sedation (IV): 1 to 2 mg/kg IV followed by 0.25 to 0.5 mg/kg IV very 5 to 10 min
Sedation IM: 2 to 5 mg/kg IM
51
Indications for Ketamine
(3 pts)
-Dissociative anesthetic with analgesic properties
-Induction agent
-Sedation
52
Effects of Ketamine
CNS
CV
Respiratory
53
T/F: Ketamine contraindicated in head trauma
True, because it increased CBF and ICP
54
What can help mitigate the hallucinatory issues of Ketamine?
Benzodiazpines
55
T/F: Ketamine depresses respiratory rate significantly
False
56
T/F: Ketamine decreases secretions
False, it increases and so sometimes people pretreat with hypersalivation
57
Is Ketamine a bronchodilator or bronchoconstrictor
It is a bronchodilator
58
Benzodiapeines
Midazolam-Versed
Diazepam-Vallium
Lorazepam-Ativan
Alprazolam-Xanax
59
MOA of benzos
mediated by GABA
60
Are benzodiazepines anticonvulsants?
Yes, they are
61
Effects of Benzodiazepines
CNS
CV
Respiratory
62
Which drug decreases metabolism of Benzodiazpines
Erythromycin
63
What is the reversal agent for Benzos?
Flumazenil: Competitive Antagonist
Adult dose: 0.2 mg IV; repeated doses may be given at 1 minute intervals to a maximum of 3 mg
Pediatric Dose: 0.01 mg/kg may be repeated at 1 - minute intervals to a maximum dose of 1 mg
64
What is the danger of flumazenil?
the half life is less then benzodiazepines so the resection is possible of recurring.
65
Benzodiapines doses...What is the duration for Midazolam (Versed), Diazepam (Vallium), and Lorazepam (Ativan)
66
What is dexmedetomidine used for?
Sedation in short term in intubated patients?
67
MOA of dexmedetomidine?
alpha 2 adrenoceptor agonist
68
What are the effects of alpha, beta receptors.
69
Effects of dexmedetomidine
CNS
CV
Respiratory
70
What are the nueromuscular blockers used for?
Skeletal muscle relaxation during intubation, ventilation or during treatment of laryngospams refractory to positive pressure.
71
What are the depolarizing agents?
Succinylcholine
72
What are the non depolarizing agents
Rocuronium, Vecuronium, Cisatracurium
73
What is the reversal agent for neuromuscular blockers?
It is Neostigmine (Anticholinesterase, but this is only for nondepolarzing agents only)
74
What is neostigmine's MOA
It inhibits acetyl cholinesterase, leading to a build up of acetylcholine within the neuromuscular junction (NMJ)
75
Dosage for Neostigmine
0.03 to 0.07 mg/kg over 1 minute
76
What are the side effects of neostigmine?
Bradycardia (that is why atropine or glycopyrollate are also given)
77
What drugs are given in with neostigmine to fight the effects of bradycardia?
Glycopyrollate and atropine?
78
MOA of Succinylcholine
Competitive agonist at ACh receptor
-Produces a sustained depolarization of the post junctional mebrane of the NMJ
78
MOA of Succinylcholine
Competitive agonist at ACh receptor
-Produces a sustained depolarization of the post junctional mebrane of the NMJ
79
What are the pharmocokinetics of succinylcholine?
Hydrolyzed by plasma cholinesterase
80
Onset of Succinylcholine?
30 to 60 seconds
81
What is the adult dosage of succinylcholine for induction?
0.6 mg/kg IV
82
What is the dosage of Succinylcholine for treating a larygospasm?
0.1 to 0.5 mg/kg IV or 4 to 6 mg/kg IM
83
Side effects of Succinylcholine
-Fasiculations (body aches)
-Hyperkalemia
-Cardiac dysrhythmias
-Malignant hyperthermia
84
Contraindications of Succinylcholine
85
Name 5 non-depolarizing agents?
vecuronium, rocuronium, pancuronium, cisatraciruium, atracurium
86
What is the MOA non-depolarizing agents
Competitive altoists of EACh at post junctional membrane
87
Which non-depolarizing agents can be used in renal or hepatic failure patients?
Cisatracurium because it is degraded via Hoffman elimination
Hofmann elimination and ester hydrolysis occur from both central and peripheral compartments
an elimination reaction of an amine to form alkenes
88
Dosage of non depolarizing agents
89
Local anesthetics-Amides
How are they metabolized?
Metabolized by the liver microsomal enzymes, incidence of allergic reaction is lower than with esters and is likely related to the preservative
90
Local anesthetics-Esters
How are they metabolized?
Esters: Metabolized by plasma psudocholinesterase (consider if severe liver disease); p aminobenzoic acid is a metabolite and may be associated with allergy in some patients.
91
Patient's with self allergies may have a higher incidence of allergy to.....
esters
92
MOA of local anesthetics
Inhibits depolarization and impulse propagation of nerve cells through blockade of sodium ion channels in the inactivated state.
93
Amide anesthetics
lidocaine, bupivacaine (marcaine), ropivacaine, mepivacaine (carboacinae), articaine
94
Anesthetic duration of action, maximum dosage
for Lidocaine, Mepivcaine, Prilocaine, articaine, and Bupivacaine
95
High doses of anesthetics
CNS
CV
Respiratory
96
SIMV stands for
Synchronizd intermittent mandatory ventilation
97
What is SIMV?
Patients can take additional spontaneous breaths that are not supported by the ventilator
Indications: Facilitating from full ventilatory support to partial support
98
What ar the advantages of SIMV?
-Maintains respiratory muscle strength by avoiding muscle atrophy
-Decreases mean airway pressure
-Facilitates ventilatory discontinuation, weaning
99
What is a complication of SIMV (stacking?
Mechanical rate and spontaneous rate may be asynchronous and cause stacking (incomplete expiration resulting in residual air adding to volume of next inspiration."
-This may cause barotrauma
100
CPAP
Continuous postive airway pressure
-Positiv pressure provided continuously throughout inspiration and expiration.
101
BiPAP
Bilevel positive airway pressure
-Inspiratory and expiratory positive airway pressure in preset
-The difference between the two pressures determines the total volume
102
PEEP
Positive end expiratory pressure
-Positive pressure only applied during the expiratory phase
-Helps prevent early airway closure and alveolar collapse at the end of expiratory by increasing and normalizing the functional residual capacity (FRC) of the lungs
103
For extubation, what should be your RSBI, NIF, and FiO2 score?
NIF should be -30
FiO2 should be <60%
RSBI should be l<105
104
Causes of HTN-Perioperative
HTN, hypoxia, drug errors, pain,
105
Uncommon causes of HTN
MH, pheochromocytoma, Hyperthyroidism, fluid overload
106
What options should you consider pharmacologically for HTN
Esmolol (short acting)
Labetalol
-Calcium channel blockers
-Hydralazine
-Nitroprusside
-Nitroglycerine
107
How to treat HTN with bradycardia
Hydralzine 2.5 to 5.0 mg IV every 10 minutes to a max dose of 24 mg
Nitroglycerine sublingual tablet 0.4 mg every 5 minutes
108
How to Treat HTN with tachycardia?
Esmolol (5 to 10 mg) every 3 minutes up to a max dose of 100 to 300 mg or labetalol (5 to 10 mg) every 10 minutes to a max dose of 300 mg
109
Hypotension-etiology perioperative?
Hypovolemia
-administered medications/depth of anesthesia,
-cardiogenic (dysrhythmia)
-myocardial infarction
-pulmonary ( PE, Pneumothorax)
-Anaphylaxis
110
Which patient's are more likely to experience hypotension?
Those taking a diuretic and angiotensin-converting enzyme (ACE inhibitor ) or angiotensin receptor blockers (ARB) inhibitor are more prone to experience hypotension.
111
First line of action for hypotension
-Intravenous fluid bolus should be the first line of treatment ->250 mL of LR or normal saline solution
112
Treating hypotension with bradycardia?
Atropine 0.5 mg every 3 to 5 minutes up to a maximum dose of 3.0 mg
113
Hypotension with tachycardia
Phenylephrine 1% (alpha agonist with reflex bradycardia effect) 100 ug per dose every 5 minutes
114
Hypotension with normal heart rate
Ephedrine (alpha and beta agonist 5 mg every 5 to 10 minutes
115
Hypotension related with anaphylactic reaction
Epinephrine IM 0.3 mg of 1:1000 (mild case), epinephrine IV 10 to 20 ug 1:10,000 (severe case
116
Tachycardia
1-Determine if sinus tachycardia, obtain ECG
2-Common causes of sinus tachycardia preoperatively include pain, anxiety; other causes include fluid depletion, hypoxia, pulmonary embolism, residual effects of anesthetics/medications, hyperparathyroidism, acute coronary syndrome, chronic obstructive pulmonary disease
3-If tacharrythmia (vagal maneuvers, adenosine if paroxysmal supraventriclar tachycardia), refer to ACLS guidlines
117
How to manage perioprative bradycardia?
118
Angina-how to manage
119
Syncope-How to manage?
120
How to manage a laryngospasm
121
How to manage a bronchospasm
122
What is malignant hyperthermia
Hypercatabolilc state that develops in genetically susceptible individuals as a response to a variety of inhalation anesthetics such as sevofluroane, desflurane, isoflurane, as well as succinylcholine
123
What is the pathogenesis of MH?
Mediated by calcium release form the sarcoplasmic reticulum in skeletal muscle
124
What are the early signs of MH
Hypercapnia, tachycardia, muscle ridgidity
125
What are the later signs of MH
ECG changes 2ndary to hyperkalemia, rhabdomyolysis (elevated plasma creatine kinase and urine myoglobin--dark urine), and hyperthermia.
126
What is the most common cause of death in MH
Hyperkalemia and.coagulopathy from hyperthermia
127
What is the treatment of MH?
128
What is the 4 2 1 rule
129
Why is albumin a colloid?
It contains large molecular weigh substances with less membrane permeability to allow for increased intravascular osmotic pressure (albumin, hetastarch)
130
Why is albumin a colloid?
It contains large molecular weigh substances with less membrane permeability to allow for increased intravascular osmotic pressure (albumin, hetastarch)
131
How to calculate NPO deficit
Number of hrs NPO x maintenance requriement
132
What does each unit of RBC's increase hematocrit and hemoblogin by?
Hematocrit by 3% and Hemoglobin by 1%
133
What is the ratio of crystalloid used to restore blood loss?
3 cc of crystalloid are used for every 1 cc of blood lost.
134
If using RBCs or colloid to restore volume,what restoration ratio can be used?
1:1
135
What are the risks of transfusion
1-Hemolytic/nonhemolytic immune reactions
2-Infection (viral/bacterial/parasitic)
3-Coagulopathy disorders (eg, disseminated intravascular coagulation)
Administer product using normal saline (avoid using LR solution)
136
Platelets increase the count of platelets by?
1 unit will increase 5,000-10,000
137
In general, what platelet count minimum is needed for surgery?
50,000/mm3
138
What does FFP have?
It contains all the coagulation factors; may be used for several of warfarin as well as replacement of deficient factors?
139
What is cryoprecipitate?
Enriched with fibrinogen as well as von Willebrand factor, Factor VIII-C and factor XII
140
What is the name of the Post-Op anesthesia recovery discharge criteria?
Modified Aldrete
141
What 5 things are taken into consideration for the Modified Aldrete discharge score?
1-Respiration
2-Oxygen Saturdation
3-Consciousness
4-Circulation
5-Activity
142
What score must there Aldrete score be above for discharge?
>8
143
What are your serotonin antagonists for PONV?
Odansetron
Dolasetron
144
What works against Histamine for PONV?
Promethazine
145
What targets the dopamine receptors for PONV
Droperidol
Metoclopramide
146
What PONV med works gains ts the muscarine receptor?
scopalamine
147
What are the causes of delayed awakening?
1-Overdose
2-Hypothermia
3-Hypercarbia
4-Hypoxia
5-CVA
148
What can you do to troubleshoot delayed awakening?
1-Rule out stroke
2-Vitals signs assessment
3-electrolyte and glucose level eval
149
What meds can you give someone with delayed awakening?
1-Flumazenil
2-Naloxone for opiates
3-Physostigmine for reversal of anticholinergics?
150
Emergency doses for Naloxone, Atropine, Vasopressin, Epinephrine and Lidocaine given down the endotracheal tube
151
What are the main anatomical differences between pediatric and adult airways?
1-Tongue is larger
2-Epiglottis is floppy and omega shaped
3-Larynx if funnel shaped
4-Narrowest point of the airway is in the subglottic region.
152
How do you determine the size of an endotracheal tube for a pediatric patient?
Age /4 + 4
153
True or False, pediatric airways are more reliant on the diaphragm?
true
154
True/False: Cardiac output in pediatrics is mostly driven by HR
True
155
T/F: Elderly patients have decreased MAC
True, decreased minimal alveolar concentrations (increased sensitivity to inhalation agents)
156
T/F: Elderly patients are more likely to be HTN
True, because of decreased vessel compliance, decreased cardiac output and HR
157
T/F: Elderly patients have an increased V/Q mismatch
True
158
BMI
stands for body mass index in kg/m2
159
What are BMI ranges?
Overweight > 25 BMI
Obese - BMI >30
Severe/morbid obesity BMI>40
160
What is the single biggest predictor of a probelmeatic intubation in obese patients?
Neck circumference 40-60 cm neck circumferences mean probelematic intubations
161
What is Pickwickian syndrome?
Obesity hypoventilation syndrome
162
Obesity & Physiological differences with respiratory function?
1-Decreased chest wall compliance
2-Decreased function residual capacity; adequate pre-oxygenation is necessary prior to intubation
163
Obese patients have a high GFR? T/F
True, with quicker renal clearance except for lipophilic drugs
164
Preoperative risks for diabetic patients?
8 come to mind
1-Dehydration (osmotic diuresis with hyperglycemia)
2-Autonomic dysfunction (postural hypotension)
3-Gastroparesis/increased aspiration risk
4-Wound healing
5-Infection
6-Stiff joints
7-Diabetic ketoacidosis risk (type 1 DM)
8-Hypoglycemia
165
Management of diabetic patients
1-Schedule type 1 DM in early morning
2-Obtain glucose level on arrival
3-Consider halfing the daily dose
166
What can occur with hyperglycemic patient's and what symptoms can they present with?
DKA for type 1 DM, or hyperglycemic hypoerosmolar nonketotic state (type II DM)
1-Tachypnea, tachycardia, abdominal pain, temp alteration
2-Ketone breath in type 1 DM
167
In office, how do you manage DKA
1-Regular insulin infusion 0.1 units/kg/h
2-Normal saline 5 to 10 mg/kg/h, you can add 5% glucose if blood glucose is less than 250
3-REplenish potassium 03. to 0.5 mEg/Kg/h
168
What is diaphoresis
Diaphoresis refers to excessive sweating, commonly associated with an underlying medical condition that alters hormone levels in the body.
169
What are the symptoms of hypoglycemia?
1-Mental status change
2-Diaphoresis
3-Tachycardia
4-Possible seizure disorder
170
How to manage hypoglycemic patients?
1-oral glucose
2-1 to 2 mg of IM glucagon
3-10 - 25 grams of glucose with IV access
171
What symptoms may occurs with hyperthyroidism?
1-Hyperpyrexia (extreme body temp)
2-Tachycardia
3-HF
4-CNS changes
5-GI disturbances
172
What can cause hyperthyroidism?
1-Infection
2-Trauma
3-Surgical sTress
4-Withdrawl/medicine compliance
173
In neurological trauma patients, what fluids?
Isotonic fluids only to prevent intracranial fluid shifts
174
Which med do you avoid in Neurologic trauma patients?
Ketamine!
175
Which meds should you be careful of with Myasthenia gravis patients?
Ester anesthetics especially if patient is receiving anti cholinesterase therapy.
176
What med do Myasthenia Gravis patient's have decreased metabolism for?
Succinylcholine
177
What therapy are Myasthenia Gravis patients on?
antichoinesterase therapy
178
What is the treatment of myasthenia gravis?
Anticholinesterases
Thymectomy
Immunosuppression
Plasma exchange
IV immune noglobulin
179
What symptoms can present with a myasthenia crisis
1-Muscle weakness
2-Bronchospams
3-Wheezing
4-Respiratory failure
5-Diaphoresis
6-Cyanosis
180
What is the preferred method of airway treatment for asthematics
Laryngeal airway over ET tube
181
Which. meds inhibit bronchoconstriciton for asthmatics
1-Propofol
2-Ketamine
182
Which paralytics should be avoided for asthmatics
Atracurium and mivacurium because they induce histamine release
183
Whare are the main treaters of bronchoconstriction
Beta 2 agonists
184
Spastic CP vs Dyskinetic CP
1-Spastic CP-injury to the cerebral motor cortex
2-Dyskinetic-Inure to the basal gangliay
185
Cerebral Palsy
A nonprogressive movement disorder that results form injury to the developing brain
186
Ataxic CP
injury to the cerebellum
Characterized by tremor, loss of balance, and difficulty with speach
187
Preop eval of cerebral palsy patients
1-Degree of spacicity and limb contracture
2-Evaluate hx of seizure episodes
3-Evaluate severity of GI reflux and impaired pharyngeal function with pooling of oral secretions
4-Evaluate respiratory function, airway tone, restrictive pulmonary disease
188
Cerebral Palsy patients and nondepolarizing skeletal muscle realxants
CP patients may need higher dosage due to drug resistance
