Anesthesia Practice 1 Flashcards
1
Q
HHealthcare Associated Infections (HAIs)
A
- 5% - 10% (approx. 2 million people) of hospitalized patients acquire 1 or more HAIs yearly
- 90,000 deaths annually
- $4.5 - $5.7 billion in excess healthcare costs annually
- 4 most prevalent cases responsible for 80% of cases: UTIs (35% and catheter related), surgical site infection (20% of cases but 1/3 of excess costs), bloodstream infections (15% majority are intravascular-catheter related) and pneumonia (usually ventilator-associated, 15% of cases, 25% of attributable mortality)
- Organisms in 70% of these infections are resistant to 1 or more antibiotics
2
Q
NIOSH vs. OSHA
A
National Institute for Occupational Safety and Health (NIOSH) - makes rules
Occupational Safety and Health Administration (OSHA) - enforces rules
3
Q
Methylmethacrylate
A
- Glue used for ortho cases
- OSHA 8 hrs avg 100 ppm (280 ppm max)
- Exposure for factory workers <8 hours
- Causes respiratory (asthma), cutaneous, genitourinary, allergic sensitizer issues
4
Q
Latex Allergy
A
- 70% rxn reported were healthcare workers
- Anesthesia sensitivity - 13-16%
- Can’t be reversed
- Caution for ppl with Spina Bifida (have severe latex allergy)
- History of Hay fever, Rhinitis, asthma, eczema
- Food allergies (avocado, kiwi, banana, chestnuts, stone fruit)
- Schedule elective surgery as first case of the day
- Post signs indicating “LATEX ALLERGY”
5
Q
Radiation Hazards
A
- Exposure: diagnostic radiographs, fluoroscopy, radiation therapy, PACU
- Lead aprons and shields
- Dosimeters - measure exposure
- Maintaining distance: E = 1/d2
- Gonads = greatest sensitivity
- You can stand behind someone w/ the lead jacket and be okay
6
Q
Laser Hazards
A
- Risks include thermal burns, eye injury, electrical hazards, fire & explosion (O2)
- Plume contains viral DNA and toxic chemicals
- Need to wear high efficiency laser mask & special glasses
- If operating around the head w/ laser, you need to decrease FiO2
7
Q
Major Reason for Error in Anesthesia Management
A
Fatigue - 64%
8
Q
Requirements for Transmission of Infectious Agents
A
- Source
- Stabile pathogen
- Adequate numbers
- Infectivity of agent
- Appropriate vector
- Portal of entry
9
Q
Respiratory Transmission
A
Aerosolization
- Flu
- Measles
- Rhinovirus
- Tuberculosis
Self Inoculation
- Rhinovirus
- Respiratory Syncital Virus
10
Q
Influenza
A
- Easily transmitted
- US 36k deaths, 200k hospitalizations
- Cells shed 5d
11
Q
Rubeola & Rubella
A
Rubeola (aka Measles)
- Transmission: Aerosol
- Highly infective
- Maculopapular rash & Koplicks spots
- Fever and 3C’s - cough, coryza (runny nose), conjunctivitis
- Complications commons: M 1:1000, 30% immunosuppressed
Rubella (German Measles)
- Causes misscarriages 1st trimester
- Birth defects or fetal defects
- Elective surgeries cancelled
12
Q
Mumps (Epidemic parotitis)
A
- Infection by airborne droplets
- Painful swelling salivary & parotid glands
- Symptoms not severe in children
- Most often children 5-9 YO
13
Q
Respiratory Syncytial Virus (RSV)
A
- Paramyxoviridae
- Most important / most common cause of lower respiratory disease in young
- 60% infants
- 100% 2-3 YO
- Infected by self-inoculation
- Prevalenet November-May
- Viable on surface for 6 hours
- Infected individual sheds virus for 7d
- Immunity not permanent
- Recurrent asthma symptoms in young kids for up to 6 mo
14
Q
Rhinovirus
A
- Most common viral infective agents in humans
- Causes common cold
- Transmission: self-inoculation and/or aerosolized particles
- Over 110 serologic virus types
15
Q
Herpes Virus
A
Varicella-zoster (VZV)
- Chickenpox and herpes zoster (shingles)
- Communicability: 1-2 days before and last 5-6 days after
- HC workers >36 YO have VZV antibodies, 6.5% younger pop susceptible
HSV 1 & 2
- Type 1: Oral herpes
Cytomegalovirus (CMV)
- Occurs during childhood
- 40-90% adults have antibodies
- Transmitted via direct contact
- Infection during pregnancy results in fetal infection 2.5%
16
Q
Hepatitis B
A
- Prevalence HBV US is 3-5%
- Seoconversion up to 30%
- 5% develop chronic hepatitis which develops into cirrhosis and ESLD
- 1% develop fulminant hepatitis (>70% mortality)
- Transmission via sexual contact, shared needles/syringes, and perinatally
- HBV vaccines primary prevention strategy
17
Q
Hepatitis C
A
- Leading cause of chronic liver disease in US
- 9K new cases/yr
- Prevalence HCV in US ~ 3%
- 60% HCV infected patients will have chronic hepatitis / cirrhosis
- Seroconversion 1.8%
18
Q
Leading cause of chronic liver disease in US
A
Hepatitis C
19
Q
HIV
A
- Seroconversion 0.3% percutaneous exposure, 0.1% mucous membrane exposure
- Increased risk associated with visible blood on device, deep injury, needle placed intravascular, terminal illness
- Since 1957, 57 documented cases of HCW acquiring HIV through exposure
20
Q
Tuberculosis
A
- Viable bacilli on airborne particles 1-5 microns
- 7-8 million become infected every year
- 8000 die each day
- Groups with high prevalence include: personal contacts with active TB, immigrants, alcoholics, homeless, IV users
- Protection: N95 mask, patient kept in neg. pressure rooms
- 3 neg. sputum acid fast bacillus smears to determine that patient is no longer infectious
- Non elective procedures done at end of day
- High efficiency filter (99.97% particles >0.3 microns)
- Filter put on expiratory port of circuit to protect machine
21
Q
What fluids are and are not considered infectious?
A
Infectious
- Blood
- CSF
- Amniotic fluid
- Pleural
- Pericardial
- Peritoneal
- Synovial
- Inflammatory exudates (pus)
Not Infectious
- Urine
22
Q
A
23
Q
Precautions for Patients with Multi-Drug Resistant Microorganisms
A
Methicillin-Resistant Staphylococcus Aureus (MRSA) - most common bug on surface of skin
Vancomycin-Resistant Enterococci (VRE)
Clostridium Difficile (cdiff)
- Hand washing (EtOH alone not effective)
- Yellow gown and gloves
24
Q
Droplet Precautions
A
Wear a mask w/in 3 feet of patients with:
- Mumps
- German measles
- Streptococcus
- Meningococcal
Spatial separation of 3 feet with other patients, keep curtains drawn
25
Disposal of Contaminated Materials
* Linen: BLUE container
* Sharps: RED
* Reusable sterile gowns: GREEN
* Paper Goods: trash can
26
Cleaning
Antiseptic
Disinfectant
Sterile
Sterilization
_Cleaning_: Removal of Foreign Material
_Antiseptic:_ chemical germicide for use on living tissue
_Disinfectant_: chemical germicide for use on non-living items
_Sterile_: completely free of all microorganisms
_Sterilization_: process that results in probability of microorganism survival on an item \<1:1,000,000
27
Disinfection Levels
High-Level Disinfection: kills fungi, viruses, and vegetative bacteria (except endospores)
Intermediate Level: kills fungi, non small or nonlipid viruses and bacteria (except endospores)
Low-Level: Kills fungi, some viruses (lipid/medium sized) and bacteria (except TB, endospores)
28
Chlorine (Hypochlorite)
Most widely used of the chlorine disinfectants. Used on tables, floors, surfaces, equipment
* 1:100 - 1:1000 effective against HIV
* 1:5 - 1:10 effective against hepatitis
* 1:10 (5.25%) for blood spills
29
Sterilization
* Steam (Autoclaving)
* Chemical (Gas, Liquid)
* Radiation
* Plasma
30
Autoclaving
* Type of steam sterilization
* Quick, cheap, effective with no residues
* Kills everything (pressure & temp)
* Minimum times:
* 15 mins @ 121 C
* 10 mins @ 126 C
* 3.5 mins @ 134 C
* Confirmed by indicator strip inside the wrapped metal trays
31
Handling Preservative-Free Medications
* Check label
* Use aseptic technique (alcohol swab) to rubber septum or neck of glass ampule
* Discard vial / ampule or syringe after use
32
Multidose Vials
* Aseptic technique (alcohol swabs)
* Uncontaminated vial may be used until manufacturer's expiration date
33
Betadine Allergy
People allergic to Betadine also often allergic to contrast dye and shellfish
34
Prevention of Intravascular Catheter-Related Infections
Catheter Selection
* Single lumen is best
* Antimicrobial or antiseptic impregnated CVC
Insertion
* Subclavian v. carries a lower risk
Barrier Precautions
Catheter Site Dressing
* Transparent, semi-permeable polyurethane dressings permit continuous visual inspection of the catheter site
35
Surgical Subspecialties: Cardiovascular Cases
CABG: Coronary Artery Bypass Graft
Valve Replacement
Aortic Arch Dissection - longitudinal tear
Aneurysms
Congenital Defects
Transplants
36
Surgical Subspecialties: CV Anesthetic Concerns
General Anesthesia
Sternotomy
Cardio-pulmonary bypass
Invasive Monitoring
ICU Transport
Chest Tube Placement
37
Surgical Subspecialties: Thoracic Cases
Tumor Resection: Lumpectomy, wedge, lobe, pneumonectomy
Lung Reduction
Transplant
Esophageal Resection
Tracheal Resection
Thoracoscopy
Bronchoscopy (put a scope down the ETT, so you have to do a TIVA)
38
Surgical Subspecialties: Thoracic Concerns
General Anesthesia
One-lung ventilation
Sternotomy
Positioning
Invasive Monitoring
ICU Transport
Chest Tube Placement
39
Surgical Subspecialties: Neurological Cases
* Intracranial (tumor, aneurysm/AVM - arteriovenous malformation, trauma/bleeding, craniectomy, VP shunt - ventricular-peritoneal
* Spinal - decompression/fusion, alteration/straightening
* Functional - DBS, Infusion pumps, generator changes
40
Surgical Subspecialties: Neurosurgery Anesthetic Concerns
* General Anesthesia vs. Local Anesthetic vs. MAC
* Invasive Monitoring
* CBF Changes/Diuretics
* Hyperventilation
* Positioning
* Head Fixation (Mayfield)
* Paralysis
* Burst Suppression (slowing down all electrical activity in the brain while they operate on it - done with high dose Propofol infusion)
41
Surgical Subspecialties: Intracranial Hypertension
* Intracranial Pressure \> 15mmHg
* Increase in tissue or fluid w/in the rigid cranial vault
* Signs and Symptoms: headache, N/V, altered consciousness
* Treatments: fix underlying cause, steroids (decadron), fluid restriction, diuretics (mannitol 0.25-0.5 g/kg), hyperventilation (ETCO2 30-35mmHg), Intraventricular drain
42
Surgical Subspecialties: Orthopedic Cases
* Joint Surgery: hip/knee/shoulder, replace vs. repair, arthroscopy
* Spine: cervical, lumbarl, thoracic
* Hand: trauma, reattachment, carpal tunnel
43
Surgical Subspecialties: Orthopedic Anesthetic Concerns
* GA vs. Regional vs. Nerve Block
* Positioning: sitting/prone/supine
* Blood Loss/Fluid Replacement
* Tourniquets
* Emboli: blood/fat/glue, polymethylmethacrylate
44
Surgical Subspecialties: Ophthalmology Cases
Retina
Lens
Refractive
Tumor
Cosmetic
Trauma
45
Surgical Subspecialties: Ophthalmology Anesthetic Concerns
* RBB (Retrobulbar Block) vs. GA vs. MAC
* Intraocular Pressure
* Oculocardiac Reflex: (reflex when lateral and medial rectus mm. pull at the same time) Ophthalmic tract trigeminal n., Vagus n.
* Gas Expansion (no nitrous on when you have a gas bubble)
46
Surgical Subspecialties: Vascular Cases & Anesthetic Concerns
* Carotid Endarterectomy
* Aneurysm
* Revascularization
* Trauma
Concerns:
* GA vs. Regional vs. Local
* Invasive Monitors - Location
* Anticoagulation
* Neuro-monitoring
* Length of Case
* Patient population
47
Surgical Subspecialties: Laparoscopic Cases & Anesthetic Concerns
* Cholecystectomy
* Kidney Donor
* Herniorrhapy
* Appendectomy
* Splenectomy
* Bowel Resection
* GERD Cessation
* Adrenalectomy
* Gastric Bypass
Concerns:
* GA
* Abdominal Insufflation
* Increased PIP
* Positioning
* ETCO2 issues
* Pneumo
48
Surgical Subspecialties: Transplant Cases & Anesthetic Concerns
* Renal - CRT vs. Living Related
* Heart
* Liver
* Lung
* Pancreas
Concerns:
* GA
* Electrolyte Imbalance
* Organ Preservation
* Coagulation Anomaly
* Pathophysiology of Patient
* Volume Status
* IV Access
49
Surgical Subspecialties: Pediatric Cases & Anesthetic Concerns
* Young: congenital, hernia, TE Fistula, pyloric stenosis
* Older: ear tubes, tonsils/adenoids, orthopedic, trauma
50
Surgical Subspecialties: Obstetric Cases & Anesthetic Concerns
* Labor
* Delivery (Vaginal, C-Section)
* Resuscitation
* Anesthesia for Pregnant Patients
Concerns:
* GA vs. Spinal vs. Epidural
* Drug Effects on Mother/Fetus
* Sensory vs. Motor Block
* Fetal Distress/Monitoring
* Positioning of Mother - aorto-caval compression
* APGAR
* Teratogenic Drugs
51
Surgical Subspecialties: Gynecologic Cases & Anesthetic Concerns
* EUA
* Hysteroscopy
* Hysterectomy
* Myomectomy
* D&C
Concerns:
* GA vs. Regional
* Monitoring
* Blood Loss
* Apprehension
* Age of Patient
52
Surgical Subspecialties: Genitourinary Cases & Anesthetic Concerns
* Cystoscopy
* TURP
* Stone Extraction
* Nephrectomy
* Prostatectomy
* Cystectomy w/ Neobladder
Concerns:
* GA vs. Regional vs. MAC
* GU Suite Location
* Positioning
* Obturator Reflex - bx or lateral wall of bladder, TURBT
* TURP Syndrome - water, electrolytes, sorbitol, mannitol
53
Surgical Subspecialties: Otorhinolaryngology Cases & Anesthetic Concerns
* Endoscopy - laryngoscopy, esophagoscopy, bronchoscopy
* Nasal/Sinus
* Head/Neck Cancer
* Cranio-facial Reconstruction
Concerns:
* GA
* Fire Protection - airway fire, laser
* Field Avoidance
* Tracheostomy
* Nasal Intubation
* Difficult Airway
* No airway!
* Muscle Relaxants
54
Emergence duration is proportionate to what factors?
* Agent Solubility (directly)
* Agent Concentration (directly)
* Duration of Anesthesia (directly)
55
Emergence of inhalational anesthesia depends chiefly on what?
Pulmonary Elimination
* Most frequent delay from inhalational GA
* Sometimes balance b/t building up CO2 and breathing gas off
56
Blood-Gas Partition Coefficients of:
* Des
* N2O
* Sevo
* Iso
* Des: 0.45
* N2O: 0.47
* Sevo: 0.65
* Iso: 1.4
Ex: There has to be 1.4x as much Iso in the blood as in the gas to equilibrate
57
Half-Life & Clearance of:
* Droperidol
* Etomidate
* Ketamine
* Midazolam
* Propofol
* Droperidol: 1.7-2.2 / 14
* Etomidate: 2.9-5.3 / 18-25
* Ketamine: 2.5-2.8 / 12-17
* Midazolam: 1.7-2.6 / 6.4-11
* Propofol: 4-7 / 20-30
58
Minimum FiO2 during hypoventilation
0.85, except severe COPD patients
59
Effects of Hypercarbia
* Stimulates sympathoadrenal system (increase HR, CO, PP, BP, SV, etc.)
* Vasodilator, except pulmonary arteries (constricts)
* Hypercarbic narcosis
* Dysrrhythmias
60
Action of Neuromuscular Blockade
* NMBD interrupt transmission of nerve impulses at NMJ of skeletal muscle
* Categories:
* Depolarizing
* Nondepolarizing
* Long \>60 mins.
* Intermediate 15-45 mins.
* Short
61
Action of Succinylcholine
* Bind to ACh and depolarizes the end-plate nicotinic receptor
* Short duration due to pseudocholinesterase metabolism --\> depolarizes the motor end plate then diffuses away and is metabolized
* Side Effects: Fasciculations, myocyte rupture, hyperkalemia, myalgias
* Sinus bradycardia - muscarinic receptor
* Malignant hyperthermia
* Dose 1-2 mg/kg
* Laryngospasm (0.1 mg/kg)
62
Action of Non-Depolarizing NMBD
* Competitively inhibit end plate nicotinic cholinergic receptors
* Do NOT bind to ACh receptors
* They bind ACh receptor sites, then as ACh continues to be released, it pushes the non-depolarizing drug off the site so it can bind again.
* Non-depolarizers are then metabolized, redistributed, diffusion, or excreted from the body
63
Peripheral Nerve Stimulator Monitoring Location
* Ulnar n.
* Adductor Pollicis
* Facial n.
* Orbicularis Oculi
* Most closely reflects block at diaphragm
* Posterior Tibial n.
* Medial malleolus - flexion of big toe
* External Peroneal n.
* Dorsiflexion
64
Which PNS monitoring site is better for induction?
Which is better for emergence?
Induction: Orbicularis Oculli
Emergence: Adductor Pollicis
65
Which muscle is most sensitive and which is most resistant to neuromuscular blockade?
Most Sensitive: Extraocular
Most Resistant: Vocal cords
\*Diaphragm is 2nd most resistant
66
Characteristics of Depolarizing and Non-depolarizing Blocks for:
* TOF
* Tetany
* Double Burst Stimulation
* Postetanic Potentiation
* TOF, Tetany & Double Burst Stimulation
* Depolarizing: Phase 1: constant but diminished, Phase 2: Fade
* Non-Depol: Fade
* Postetanic Potentiation
* Depolarizing: Phase 1: absent; Phase 2: Present
* Non-Depol: Present
67
Train of Four (TOF)
* 4 Stimulations at 2 Hz (0.5 sec)
* 4 of 4 can have 75% block
* 3 of 4 = 85% block
* 2 of 4 = 90% block
* 1 of 4 = 95% block
* 0 of 4 = 99% block
* Must have 1 twitch prior to reversal or post tetanic count \>10
68
Post Tetanic Count
* Profound NMB with no response to single twitch
* Apply 50 Hz tetany 5 seconds
* Wait 3-5 seconds
* Single twitch response 1/sec.
* Count total twitches
* \>10 twitches indicates sufficient receptors for reversal
Post –Tetanic Potentiation: do tetany at 50-100 Hz for 5-10 seconds. This will flood the junction with ACh. Follow with TOF. If you have a response from TOF, this will indicate that the muscle relaxant is being metabolized and you will be able to reverse soon. If no response, this means you have a lot of NMB left that needs to metabolize
69
Double Burst Stimulation
| (DBS)
* 3 stimulus at 50 Hz, 750ms pause, 2 stimulus at 50 Hz
70
Head lift greater than 5 sec = TOF ratio of what?
\>0.7
71
What is the action of Neostigmine?
It is an anticholinesterase, inhibits acetylcholinesterase
Causes muscarinic stimulation (PNS)
Dose: Max 0.07 mg/kg or 70 mcg/kg
NOT 5 mg!
Peak onset: 5-10 mins
72
How do you assess the adequacy of ventilation?
* Arterial Blood-Gas
* PaO2 \> 65 on FiO2 \> 0.40
* PaCO2 \< 50 torr
* ETCO2
* SpO2 \> 90%
* Tidal Volume (better than 250 cc/min but subjective)
73
NAW vs. OAW
* Nasal airway primarily used for sleep
* Consider establishing airway prior to extubation for patients believed to have obstructive issues (obesity, OSA, snoring)
74
Snoring
* Indication of obstructed upper airway
* Vibration of soft palate responsible for noise
* Incidence greatest in 1st, 5th, and 6th decades of life
* More prominent in males
* Obesity is a factor
75
Obstructive Sleep Apnea
Pathophysiology:
* Sleep fragmentation in adults affects neuropsychological and cognitive performance
* Usually results in arousal, followed by clearance of the pharyngeal airway.
* Hypoxia is the major factor in arousal SaO2 = 85%
* Arousal results in massive sympathetic discharge.
* Hypercapnia = increased PAP and afterload = right ventricular hypertrophy
76
What is the most common reason for readmittance into the hospital after surgery?
77
Surgical Sites with the Greatest Risk of PONV
* Intra-abdominal
* Laparoscopic
* Orthopedic
* Gynecological
* ENT
* Breast
* Plastic
* Neurosurgical
78
Anti-Emetics:
Serotonin 5-HT3 Receptor Antagonists
* End in -tron
* Zofran (Ondansetron)
* Anzemet (Dolasetron)
* Kytril (Granisetron)
79
Anti-Emetics:
Dopamine Antagonists
Droperidol
Don't use for Parkinsons patients
80
Anti-emetics:
Antihistamines
* Diphenhydramine
* Promethazine (Phenergan)
81
Post-op Pain Management
* Epidural Placement
* Bolus 6-8 cc agent in divided doses prior to extubation
* Verify normovolemia prior to bolus
* Be prepared for hypotension
* Parenteral Narcotics
* NSAIDs (Toradol 30mg)
* 30mg Toradol = 10mg Morphine
* Contraindications: GI Ulcers/bleeding, coagulopathies, renal impairment, bone graft
82
Equivalent of Toradol to Morphine
30mg Toradol = 10mg Morphine
83
Potency of Hydromorphone relative to Morphine?
Dosage and Duration of Hydromorphone?
8x as potent as morphine
Dosage: 1-4 mg
Duration: 4-8 hrs
84
Dosage, duration and contraindications of Morphine?
Dosage: 2-10 mg
Duration: 4 hrs
Contraindications: Renal Failure
85
Potency and duration of Fentanyl
100x as potent as morphine
Duration: 0.5-1 hr
86
Narcotics should be titrated to a respiratory rate of \_\_\_\_\_\_\_ breaths per minute
10-16 BPM
87
When is it appropriate to extubate a patient?
* A/w protective reflexes in tact
* Clinical stability
* Intact neurological function
* Adequate pulmonary function
* Normal body temp (35-37 C)
* Normal neuromuscular function
* Normal coagulation
* Head lift, grip, TOF 4/4 ST (5 sec)
* RR 5-30
* TV \> 5 cc/kg
* PaO2 \> 65 on FiO2 \< 0.40
* PaCO2 \< 50 torr
* Resting MV \< 10 L/min.
* Level of Consciousness
* Muscle Relaxant Reversed
88
What is the Purpose, Contraindications & Criteria for Deep Extubation?
* Purpose
* Minimize tracheal stimulation
* Minimize coughing/bucking - Increase IOP, ICP, BP, Dehiscence
* Contraindications
* Difficult mask airway
* Difficult Intubation
* Aspiration Risk
* Airway Edema
* Criteria
* MAC 1.3
* NMB completely reversed
* Spontaneous rhythm at regular rate/rhythm
* No a/w reflex
* 100% O2
* Lidocaine (0.5 mg/kg)
89
What should you never deep extubate a patient without?
An oral a/w in place
90
What are the steps after extubating a patient?
* Suction again
* Place mask on patient
* Keep right hand on the bag
* Test for a/w patency
* Help them breathe for a while if they are not doing an adequate job on their own
91
ASA Standards for PACU
* **Standard I**: all patients who have received general, regional or MAC shall receive appropriate post-anesthesia management
* **Standard II: ** A patient transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition.
The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient’s condition.
92
ICU Transport Equipment & Monitoring
* Equipment
* Cardiac Monitor or defibrillator
* a/w managment equipment - breathing bag, reintubation equip.
* O2 source w/ 30 min reserve
* Standard resuscitation drugs - epi, lidocaine, atropine, IV fluids
* Medication
* Monitoring
* EKG & spO2 = continuous
* BP, RR, Pulse Rate = intermittent
* Capnography, PA and/or IC pressure
93
PACU Admission Monitoring Reqmts
* Every pt: HR & rhythm, BP, airway patency, spO2, RR and pain
* Every pt continuous: pulse ox, ECG
* Capnography only necessary for ventilated pts.
94
PACU Report
* Pt name, Allergies, preop vitals
* ASA class, Medical Hx
* Procedure, Surgeon, Anesthesia
* Type Anesthesia
* Pre-meds, narcotics, paralytics, Rx
* Fluids, lines
* Orders
95
MAC Anesthesia: ASA Guidelines
* Oxygenation:
* Inspired gas (insufflation) - 100% O2 from auxillary O2 flowmeter
* O2 mask, nasal cannula, breathing circuit tubing
* Never use N2O or inhalational agents - no scavenging, potential loss of a/w
* Blood oxygenation - pulse ox, nail beds, etc.
* Ventilation:
* Chest excursion, thoracic impedance plethysmography, capnography (via nasal cannula)
* Circulation:
* ECG & HR, BP, Pulse Pleth., Auscultation of heart sounds, palpation of pulse
96
Neuraxial Anesthesia Contraindications
Absolute:
* PATIENT REFUSAL!!
* Infection at site of injection
* Coagulopathy
* Severe hypovolemia
* Increaseed ICP
* Severe aortic stenosis
* Severe mitral stenosis
Relative:
* Sepsis
* Uncooperative Patient
* Neurologic deficit
* Severe Spinal deformity
Controversial:
* Prior back surgery
* Inability to communicate
* Complicated surgery
97
Coagulopathy and Neuroaxial Anesthesia
Oral Anticoagulants:
* Coumadin (warfarin)
* Must be stopped to normal PT and INR
Antiplatelet Drugs:
* NSAIDs
* Plavix (clopidogril) - stopped 7 days prior!!!
Heparin:
* Subcutaneous, Intraoperative, Therapeutic
* Cardiopulmonary bypass
Low Molecular Weight Heparin
* Lovenox
* Lot of pts on this post-op
98
Principle Landmarks for Spinal Anesthesia
Superior aspect of iliac crest crosses body of L4 (Tuffier's Line)
99
Principle Landmark for Thoracic Epidural
T7-T8 interspace at scapula (inferior aspect of scapula)
100
Ligaments of the Spinal Column
* Ligamentum flavum - tough one right outside epidural space
* Supraspinous ligament
* Interspinous ligament
101
Where does the spinal cord end in adults and infants?
Adults: L1-L2
Infants: L3-L4
102
Indications for an Epidural vs. a Spinal
Epidural:
* Belly or lower extremity
* Supplement to GA
* Postop pain control
Spinal:
* Lower abdomen
* Perineum
* Lower extremities
103
What is the mechanism of action for epidurals and spinals?
* Site of action is the nerve root
* Somatic blockade:
* Interrupts painful stimuli
* Abolish skeletal muscle tone
* Differential blockade (symp, sensory, motor)
* Autonomic blockade:
* Sympathetic (thoracolumbar, small myelinated, T1-L2)
* Parasymp - (craniosacral, will not block vagus)
104
Spinal vs. Epidural Needles
Epidural Needles
* 17-18 ga
* Blunt
* Tuohy (curved), crawford, neiss (winged)
Spinal Needles
* 20-22 ga
* Sharp
* Quinck, whitacre, sprotte
105
What are the advantages and disadvantages of Epidurals?
Advantages:
* Decreased risk of post dural headache
* Decreased risk of hypotension
* Segmental sensory block
* Greater control over intensity of sensory block
* Motor block achieved by adjustment of local concentration
* Indwelling catheter allows titration of block and long term drug admin
Disadvantages
* Slow onset (10-20 mins)
* Block is less dense
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Test dose for epidurals
* 3mL 1.5% lidocaine with 1:200,000 epi
* an increase in HR indicates that you are in an artery or vein
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What are the advantages of spinal anesthesia?
* Less time to perform
* Less local required
* More intense sensory and motor block
* Needle placement confirmed by CSF
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What determines the level of block in spinal anesthesia?
* Baricity of the solution (hypo, hyper, isobaric)
* Position of the patient (during and immed. after)
* Drug dosage
* Site of injection
* Less common factors:
* Age
* CSF
* Curvature of spine
* Drug volume
* Needle direction
* Height
* Pregnancy
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What is baricity?
* Density of a substance relative to density of CSF
* CSF specific gravity is 1.003-1.008
* Hyperbaric = GREATER than CSF (heavier - drug will sink)
* Hypobaric = LESS than CSF (lighter - drug will rise)
* You can change baricity of the local anesthetic - glucose makes it heavier, sterile water makes it lighter
* Position of patient is CRUCIAL
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What are the complications associated with Neuraxial Anesthesia?
* High neural block
* Cardiac arrest (spinal)
* Urinary retention
* Inadequate anesthesia or analgesia
* IV injection
* total spinal anesthesia
* Subdural injection
* Drug toxicity
* Backache
* **Postdural puncture headache**
* Neurological injury
* Spinal / epidural hematoma
* Meningitis or aracnoiditis
* Epidural abscess
* Sheering of epidural catheter
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Postdural Puncture Headaches
* Any breach of dura can cause
* Needle size (larger causes headache)
* Cause: CSF leak causes decreased ICP
* Symptoms include photophobia and nausea
* Position dependent
* Onset (12 hrs - 3 days)
* Treatment:
* Conservative: caffeine, lay down in dark, hydration, ibuprofen
* Epidural Blood Patch: use blood to form a plug from hole in dura
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What is Caudal Anesthesia?
* Needle penetration of sacrococcygeal ligament covering the sacral hiatus
* Sacral hiatus created by unfused S4-5 laminae
* Most common regional technique in peds
* Common in kids for procedures below diaphragm
