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VLC & General RV > Anesthesia ECEs > Flashcards

Anesthesia ECEs Flashcards

1
Q

What are the components of the anesthesia exam?

A

mouth opening (3 fingers), neck flexion (chin to chest, look up), Mallampati classification, thyromental distance (next extended, bottom of chin to thyroid notch 3-4finger breadths)

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2
Q

How is the thyromental distance taken, and what should it be?

A

neck extended, distance from bottom of chin to thyroid notch; should be at least 3-4 finger breadths

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3
Q

What are the Mallampati classes?

A

Class 1: Soft palate, uvula, tonsillar pillars can be seen.
Class 2: As above except tonsillar pillars not seen.
Class 3: Only base of uvula is seen.
Class 4: Only tongue and hard palate can be seen.

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4
Q

What is normal neck ROM?

A

90-165 degrees

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5
Q

What are the pros and cons of an LMA?

A

Pros: easy to insert, bypasses supraglottic structures (eg tongue won’t block airway), frees up anesthetist’s hands; can deliver some positive pressure ventilation
Cons: still invasive; doesn’t have advantages of ET

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6
Q

What are the pros and cons of ET intubation?

A

Pros: patency of airway; minimal aspiration risk (airway protection); enables mechanical ventilation
Cons: invasive; difficult (skill + tools); risk of misplacement (in esophagus, or R bronchus); risk of damage to cord structures

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7
Q

When do you need mechanical ventilation (& thus ET tube)?

A

Surgery requires muscle relaxation (eg neurosurgery); surgery involves thoracic cavity; surgery is very long (resp muscles might fatigue)

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8
Q

How do you confirm placement of ET tube?

A
  • Gold standard is direct visualization of ETT between vocal cords
  • Normal end-tidal CO2 confirms (except in cardiac arrest)
  • auscultation of both lungs + epigastrium
  • vapour in ETT supportive but not confirmatory.
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9
Q

What identifies placement of tube in R bronchus?

A

R breath sounds and ø L breath sounds on auscultation. Excess advancement of tube (F: >20cm, M: >22cm)

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10
Q

Walk through the steps of intubation

A

pt in “sniffing position”
introduce Macintosh blade into R, sweeping tongue to L
advance tip to the space between base of tongue & epiglottis (the vallecula)
keep wrist stiff and don’t leverage blade (eg against teeth)
lift laryngoscope, exposing vocal cords & glottic opening
insert ETT under direct vision through cords

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11
Q

What size ETT should you use?

A

Size 7.0 or 7.5 ETT for adult female, size 8.0 or 8.5 for adult male

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12
Q

What are the ASA classes?

A

1: A normal healthy patient in need of surgery for a localized condition.
2: A patient with mild to moderate systemic disease; examples include controlled hypertension, mild asthma.
3: A patient with severe systemic disease; examples include complicated diabetes, uncontrolled hypertension, stable angina.
4: A patient with life-threatening systemic disease; examples include renal failure or unstable angina.
5: A moribund patient who is not expected to survive 24 hours with or without the operation; examples include a patient with a ruptured abdominal aortic aneurysm in profound hypovolemic shock.

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13
Q

What is malignant hyperthermia?

A

autosomal dominant variant → changes in Ca++ processing in muscle, in context of inhalational anesthetics or succinylcholine → … → CV collapse, vital organ failure, coma, death

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14
Q

What is pseudocholinesterase deficiency?

A

Genetic deficiency in pseudocholinesterase; prolongs response to succinylcholine

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15
Q

What are important questions for pre-anesthetic history?

A

Any cardiac or respiratory disease Hx. Any hepatic or renal disease Hx. Any other disease Hx.
Medications. Hx of adverse drug reactions.
Pt and F Hx with anesthesia.
Specific Qs re: malignant hyperthermia and pseudocholinesterase deficiency.
Soc Hx, incl smoking and EtOH.
If pre-op: Medications and NPO status today.

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16
Q

What are the main anatomical landmarks to visualize on intubation?

A

Epiglottis, vocal cords, artytenoids

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17
Q

How is the laryngoscopy technique different for curved vs straight blades?

A

Macintosh (curved) vs Miller (straight): Macintosh blade is inserted into the vallecula anterior to the epiglottis, whereas Miller blade is inserted posterior to the epiglottis and lifts it upwards while depressing the tongue for direct laryngoscopy.

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18
Q

How does video compare to direct laryngoscopy?

A

Video: Decreases the amount of force needed for laryngoscopy. Allows for glottic visualization when there is limited mouth opening, neck immobility/ injury, or an anterior airway. Is not reliable with airway blood or secretions.

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19
Q

What are the absolute contraindications to central anesthesia (or LP)?

A

coagulopathy, sepsis (systemic or at site of injection), increased intracranial pressure (ICP), shock

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20
Q

What are the relative contraindications to central anesthesia (or LP)?

A

evolving neurological deficit, obstructive cardiac lesion (e.g. aortic stenosis), spinal hardware

21
Q

What are the structures that spinal needle passes through while being inserted?

A

Layers: skin, superficial fat & fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, into epidural space; if spinal, on through the dura

22
Q

What are signs of local anesthetic toxicity?

A

tinnitus, perioral numbness, metallic taste in mouth, dizziness - might experience if catheter is in vein

23
Q

How do you calculate how many milligrams of a local anesthetic there are in one millilitre of a certain solution (i.e. lidocaine 2% or bupivacaine 025% etc)?

A

Multiply by 10 (E.g. 1% lidocaine = 0.01g/mL = 10mg/1mL)

24
Q

What are the predictors of difficult bag-mask ventilation?

A

best predictor is previous Hx

BONES: Beard, Obese, No teeth, Elderly, Sleep apnea/snoring

25
Q

What are some strategies to optimize BMV in case of difficulty?

A
  • Use the C-E hand position
  • Pull the jaw upwards to the meet the mask
  • Insert an oropharyngeal airway
  • Ventilate in sync with spontaneous breathing (if possible)
  • Two person BMV
26
Q

How does obestiy impact airway management?

A

Both BMV and intubation may be more difficult

27
Q

How does obesity impact ventilation?

A

More difficult: ↓ lung volumes, ↓ chest wall/diaphragm compliance (esp with Trendelenburg, pneumoperitoneum), obesity hypoventilation syndrome, OSA. Also note: can desat rapidly on induction.

28
Q

Which monitors must be continuously used intraoperatively?

A

5 items/features
Oxygenation: Pulse oximeter
Ventilation: ETCO2 capnography; Agent-specific anesthetic gas monitor
Circulation: ECG; non-invasive BP (q3-5m) (or, invasive, eg art line)

29
Q

Which monitors must be immediately available if needed intraoperatively?

A

Without delay: Temperature probe, Peripheral nerve stimulator, Stethoscope
Without undue delay: Spirometer for tidal volume, Manometer for ETT cuff pressure

30
Q

What is capnography? How does it relate numberically to PaCO2?

A

Waveform and numerical measurement of end-tidal concentration of CO2.
Note: ETCO2 is ~2-5mmHg lower than PaCO2 in healthy lungs (normal PaCO2 is 35-
45mmHg). This gradient is due to mixing with anatomic, alveolar, or mechanical dead space air; the gradient is increased in diseased lungs and in cases of poor pulmonary perfusion.

31
Q

Where is the arterial line transducer placed, and why?

A

Normally placed at level of right atrium (circle of Willis for neurosurgery).
If placed too high: underestimates P.
If placed too low: overestimates P.

32
Q

What artery is preferred for an arterial line?

A

Radial

33
Q

Why would you use an art line?

A

Gold standard BP monitoring. ABGs. Might use if continuous monitoring or hemodynamic instability anticipated, frequent ABGs needed, or inadequate BP cuff size.

34
Q

What changes should you make for a pt with chronic pain?

A

Consider regional or local anaesthsia, to reduce pain medication requirements post-op
Patients may need higher doses to manage acute pain
Note: Titrate opioid dose to RR when possible at the end of a case (RR 8-10) to avoid
overdosing.

35
Q

What changes should pt with chronic pain make to pain management perioperatively?

A

None

36
Q

Why might it be important to be cautious of dexamethasone use for patients with diabetes?

A

Dexamethasone can trigger hyperglycemia

37
Q

How do neuromuscular blockers work?

A

Succinylcholine is a competitive agonist to AChR: causes depolarization → contraction; not removed by ACh-ase → muscle paralysis
Rocuronium is a competitive antagonist to AChR: blocks depolarization → paralysis

38
Q

What changes/considerations should be made for paralytic selection & use in neuromuscular disease? (dystrophy, MS, MG)

A

Duchenne/Becker’s: do not use depolarizing. Increased sensitivity to non-depolarizing.
MS: Caution with depolarizing in advanced disease.
MG: decreased sensitivity to depolarising, increased sensitivity to non-depolarizing

39
Q

What are risk factors for bronchospasm?

A

Asthma, smoking, cold air, inhaled irritants, tracheal intubation/extubation.

40
Q

How can bronchospasm be prevented?

A

Pre-op prophylactic SABA/steroids, adherence to COPD/asthma therapy, topical lidocaine, ensure adequate anesthesia during intubation/extubation.

41
Q

Name 6 intraop respiratory emergencies

A 
Anaphylaxis
Aspiration
Bronchospasm
Laryngospasm
Status asthmaticus
Pneumothorax
CICO (Can’t intubate, can’t oxygenate)
42
Q

Why might an anesthetist delay a surgery if a patient has (or is freshly recovered from) a URTI?

A

URTI (current or recent) is a risk factor for laryngospasm; consider delaying elective surgeries to 2-3w after URTI.

43
Q

What strategies can be employed to prevent laryngospasm?

A

delay elective surgery to 2-3w post-URTI; apply topical lidocaine; ensure adequate anesthesia before intubation; extubate when deep or fully awake (higher risk during induction and emergence).

44
Q

What is status asthmaticus and how would you manage that intraoperatively?

A

Status asthmaticus: Extreme asthma exacerbation that is unresponsive to SABAs.
Management: 100% FiO2, IV SABAs, IV steroids, IV magnesium sulfate, ketamine or sevo/isoflurane, Heliox, monitor lytes (K+) and fluids.
Note: Intubation is often not required in status asthmaticus and irritates the airway; it is usually reserved for impending respiratory failure.

45
Q

How do you detect intraoperative MI?

A

ST elevation/depression, unexplained ↑ HR or ↓ BP, arrhythmias, new Q waves, new LBBB.

46
Q

How do you manage intraop MI?

A

General principle is to maximize myocardial oxygen and decrease demand.
Depends on many factors (surgery, urgency, pt condition and PMHx, timing & severity; eg pre-incision vs open abdomen, elective vs trauma).

47
Q

What are the indications for RSI?

A

Increased risk of aspiration (e.g. unable to protect airway, critically-ill, pregnant, emergent surgeries, full gastric contents).

48
Q

Why can end tidal CO2 increase during laparoscopic surgery?

A

Insufflation with CO2

VLC & General RV (6 decks)

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