Anesthesia: Tips, Techniques and Drugs Flashcards
What should the blood pressure be regulated to while under anesthesia
+/- 20% of baseline
What drugs are commonly used to induce anesthesia
- Remifentanyl
- Lidocaine
- Propofol (Etomidate is more cardiac stable)
Zemeron
Rocuronium
What is rocuronium
A short acting muscle relaxant
when is succinylcholine indicated
during difficult intubations
When is succinylcholine contraindicated
with crush injuries
What helps sevoflurane to be better tolerated.
Start the patient on sevoflurane and then switch them desflurane
What is the ballpark End Tidal desflurane needed to wake a patient
0.5 - 0.6
When is neostigmine indicated
A nondepolarizing neuromuscular blockade reversal.
Add 0.2 Robinul per 1mg of neostigmine
What is the lead placement for anesthesia monitoring
Patients Right
- Snow over Grass (White over Green)
Patients Left
- Smoke over fire (Black over brown)
Midline
- Brown
What is a key thing to remember when using rocuronium
Ventilate the patient first for about a minute
What is the train of four (TOF)
Measures the effectiveness of a Neuromuscular blockade (rocuronium/succinylcholine)
Four consecutive stimuli are delivered along the path of a nerve, and the response of the muscle is measured in order to evaluate stimuli that are blocked versus those that are delivered. Four equal muscle contractions will result if there is no neuromuscular blockade, but, if nondepolarizing blockade is present, there will be a loss of twitch height and number, which will indicate the degree of blockade.
Toradol
Ketorolac (NSAID)
While the patient is recovering from anesthesia, what is physical indication of their level of pain
Number of respirations. If their respirations are 25 give 0.25mg Dilaudid
After intubation be sure to check for 3 things
- Breath sounds (R - L - R)
- Look for condensation of the tube
- Check for high End Tidal CO2
What should be given to the patient of the Heart rate decreases rapidly
Atropine
What can be given to the patient if the heart rate is decreasing slowly
glycopyrolate
Zemeron
Rocuronium
Robinul
Glycopyrolate
Describe the ocular cardiac reflex
HR will decrease when the eye muscles are pulled. Can lead to asystole
What size tube should you generally start with when intubating a patient
Women: 7.0
Men: 8.0
What options should you consider when a PTs blood pressure drops
Decrease Remifentanyl
Decrease Desflurane
Giving phenylephrine
Trandate
Labetalol
What is a bis-monitor
Bispectral index
- used to monitor the depth of anesthesia
- Generally speaking, look for 40-60
What additional medications should be given towards the end of an anesthesia case
- Zantac
- Dexadron (do not use with DM pt’s)
- Zofran
zantac
Ranitidine
Zofran
ondansetron
Dexadron
dexamethasone
Pepcid
Famotidine
When ventilating a patient, generally what is the max Tidal volume and Tidal pressure you want to see
Max tidal volume: 750
Max tidal pressure: 35
What may happen if you use PEEP on a pt with COPD
may rupture a bleb
What is the mechanism of Ketamine
NMDA receptor antagonist
Provides a dissociative amnesia
What are the cardiovascular effects associated with ketamine
Increase in HR and BP
Neosynephrine
Phenylephrine
What is the mechanism of phenylephrine
a1 adrenergic receptro agonist
- Should not increase HR
When is phenylephrine indicated in anesthesia
Used to increase the BP when the HR is greater than 70
What is the preoperative dosage of ancef
< 80 kg - 1gm
>80 kg - 2 gm
What is a good technique to intubate a kiddo that does not like needles
- N20 - 8.0 max
- O2 - 4.0
- Add sevoflurane at 8.0 for a few minutes and take away the N2O so that you can start the IV
What can happen during a laproscopic inflation of the abdomen
Can cause a cardiac reflex leading to asystole
What should you consider when you see a pt’s End Tidal CO2 rise and body temperature Increase
Malignant hyperthermia
What is TIVA
Total IV anesthesia
When should you use TIVA
Use with patients that have a h/o malignant hyperthermia
What is soda lime used for
to remove CO2 from the lines
What is in the SODA cannister
Calcium hydroxide
Water
Sodium hydroxide
Potassium hydroxide
What is the inspiratory to expiratory time ratio
1: 2 for normal patients
1. 25 for patients with COPD
If a patient starts to wake up during anesthesia, what should you consider doing
Increase desflurane and remifentanyl while increasing the O2 flow.
Higher O2 flow decrease the onset time of the Desflurane
When is toradol contraindicated
Patients with a creatinine clearance greater than 1.2
Less than 1.2 you can use 30mg toradol
What is the mechanism of glycopyrrolate
anticholinergic
What are the indications for glycopyrrolate
Preoperative: reduces secretions and blocks intubation/drug-induced cardiac vagal reflexes
Intraoperative use: Blocks procedure/drug induced cardiac vagal reflexes and associated arrhythmias
Nueromuscular blockade reversal: Blocks peripheral muscarinic effects of cholinergic agents
When is it a good idea to use pressure control while ventilating
Low Tidal Volume and Increased peak pressure
Especially when abdominal pressure is increased.
What is MAC
Monitored Anesthesia Care
what is typically used for MAC
Propofol and Ketamine
What are the NPO Guidelines for a typically healthy patient
2 hours: No clear liquids
4 hours: No breast milk
6 hours: No Infant formula or light meal or non human milk
8 hours: No Solid foods (fatty/fried/meat)
Normal medications can be taken with a minimal amount of water
Chewing gum may increase gastric volumes and is treated as clear fluids
Low pH and particulates make matters worse
What are the ways to control the epidural
- Choice of Agent
- Spinal catheter
- Add epinephrine
Why is morphine not frequently used
it has a delayed respiratory suppression
What should be considered when conducting a parotidectomy
minimize the regional anesthetic and NMB so that the nerve can be stimulated and avoid severing the CN VII through out the procedure
What types of surgeries do you not want to use a paralytic
Parotidectomy
Thyroidectomy
Total masectomy
What are some causes for bradycardia or asystole
Carotid pressure ICP (cushings triad) Occular cardiac reflex Increased abdominal pressure Vagal response Hypoxia Cardiac issues (MI, conduction blocks etc)
What should you always suspect in children that are brady
hypoxia until proven otherwise
What do you do when you notice the patient is Brady during anesthesia
- Undo what you did to get into the situation
- Drugs:
a. Glycopyrrolate (does not cross BBB)
b. Atropine (quicker onset)
If a patient has had a heart transplant, how does this effect the response to brady during anesthesia
The heart will not respond to the parasympathetic (atropine) will need to consider Epi (I think)
What are the problems with over breathing for a patient when you are bagging them
- Left shift of the hemoglobin dissociation curve (hard to off load O2)
- Increased intrathoracic pressure ( increase PVR, Decrease Preload, decrease CO)
How can you minimize the possibility of over breathing for a patient during CPR
- Maintain breathing at a rate of 5-6 seconds between breaths
- Continuous, rapid and deep chest compression
What joules should be used for a patient should you need to defibrilate them
MAX
When should you try to chemical cardiovert a patient during ACLS for a shockable rhythm
after 3 failed shock attempts
- Use a 300 bolus for VFIB
- Use 150 bolus for pulseless V Tach
What are the H’s and T’s for ACLS
H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyper-/hypokalemia, Hypoglycemia, Hypothermia.
T’s: Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary), and Trauma.
What should you do to correct hyperkalemia
Use bicarb to drive K+ back into the cells.
Use Calcium chloride to stabilize the cardiac membrane
If using insulin, give 10 units of insulin with an amp of D50 (25 grams in a 50 ml solution - like syrup)
