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Anesthesia Practice > AP 1 Final > Flashcards

AP 1 Final Flashcards

1
Q

The National Library of Medicine notes people as “elderly” if they are between what ages?

A

65-79

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2
Q

For those over the age of 80, what is the terminology used to describe the patients age?

A

AGED, 80 AND OLDER

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3
Q

How many people in the United States reach the age of 65 every day

A

10,000

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4
Q

By 2030, what percentage of the US population will be 65 or older

A

20%

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5
Q

Patients older than 65 account for what percentage of hospital stays across the country

A

43%

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6
Q

What type of neurologic problems are patients at increased risk for during the post-operative period?

A

CVA (stroke), post-op delerium, over narcotization, drug-drug interactions (particularly with anti-cholinergic side effects)

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7
Q

What is the ASA recommendation for when mental status of the patient should be assessed?

A

Periodically during emergence and recovery

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8
Q

What does NSQIP stand for

A

National Surgical Quality Improvement Project

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9
Q

What types of surgeries does NSQIP EXclude?

A

NSQIP excludes cardiac, carotid, and neurologic procedures

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10
Q

NSQIP states that for ages over __, odds ratio of a CVA is __

A

62, 3.9

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11
Q

If a perioperative stroke occurs in an eldery patient, it is associated with an _______ increase in 30 day mortality

A

8-fold

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12
Q

Patients with a history of what 2 problems are at highest risk for peri-operative CVA?

A

Prior CVA and Renal Failure

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13
Q

What is the definition of an odds ratio

A

The likeliness of an event occurring if exposed to a given variable

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14
Q

In an adjusted odds ratio when taking into account other variables, what is the greatest predictor of peri-operative stroke?

A

Age

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15
Q

What are the guidelines from the Emory Comprehensive Stroke Center regarding neurologic exams in high-risk patients?

A
  • q15min neuro exams x 4, q30min neuro exams x 2
  • USE A SCREENING TOOL: FAST (Face, Arm, Speech, Time)
  • Don’t hesitate to call an anesthesiologist/surgeon to the bedside or activate a STROKE TEAM
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16
Q

What 2 things can we as anesthesists do to monitor neurologic function in high risk patients?

A

Frequent neuro exams and control blood pressure

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17
Q

In a perioperative setting, what percentage of decline from baseline blood pressure is associated with stroke?

A

20%

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18
Q

Should we manage BP based on a percentage of the patient’s baseline or the absolute number of the patient’s baseline?

A

Percentage

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19
Q

Most BP recommendations suggest keeping within 15-20% of ____ ____ ____

A

Mean Arterial Pressure

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20
Q

In eldery patients, an episode of delirium in the hospital increases the risk of what 3 things?

A

Longer hospital stay, persistent cognitive decline, placement in nursing home

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21
Q

What is the incidence of delirium in the PACU in elderly (age > 70) patients?

A

Up to 45% of patients >70

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22
Q

What are the risk factors for post-operative delirium?

A 
Age > 70 (OR 3.4) 
Age > 80 (OR 5.2)
Psychiatric/Neurodegenerative disorders (OR 4.2)
Current alchol abuse (OR 6.5)
COPA/OSA
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23
Q

What factors associated with increased risk for post-op delirium do we have control over correcting?

A

Dehydration, abnormal electrolytes, anemia, dysglycemia

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24
Q

What are 4 anesthetic risk factors for post-op delirium?

A

Pre-op benzodiazepines, ASA III-IV, fluid fasting > 6 hrs, anticholinergic drug use

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25
Q

What are 7 surgical/OR risk factors for post-op delirium?

A

Hip replacement, abdominal aortic aneurysm repair, neurosurgical procedure, CT surgery, blood loss, intraop hypothermia, intraop hypotension

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26
Q

What is the incidence of post-op delirium in hip replacement surgeries?

A

37%

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27
Q

What are the symptoms of HYPERactive delirium?

A

Agitation, hallucinations, disorientation

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28
Q

Why is HYPOactive delirium usually missed in the PACU?

A

It is subtle, the pt could be cooperative, many pts are asleep or resting

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29
Q

What are 4 treatments of post-op delirium?

A
  • Behavioral/environment interventions
  • Dexmedetomidine
  • Haldol
  • Possibly Risperidone/Olanzapine
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30
Q

What is the dose and frequency of Haldol to treat post op delirium

A

1-2mg IV, may repeat every 15 minutes

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31
Q

When is the only time you should treat post-op delirium with a benzodiazepienes

A

In the case of suspected alcohol withdrawal

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32
Q

What are some reasons that elderly patients are at higher risk for post-op delirium and pain?

A

1) Organ changes may compromise renal or liver funtion
2) Liver mass decreases with age and can limit metabolism of drugs
3) Increased body fat causes longer time of action for lipophilic drugs like fentanyl
4) Kidney mass decreases up to 60%
5) Decreased water in the body so hydrophilic drugs have a more profound effect

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33
Q

Dose reduction of opioids while treating post-op pain is appropriate to both treat pain and still avoid unwanted effects of pain meds. What are the reduced bolus doses of morphine, fentanyl, and hydromorphone?

A

Morphine - 1-2mg IV
Fentanyl - 25mcg
Hydromorphone - 0.2mg

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34
Q

What is the dose of acetaminophen when using it is a non-narcotic adjunct to treat pain?

A

1gm IV

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35
Q

What is the max daily dose of acetaminophen?

A

4 grams

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36
Q

What is the max daily dose of Ketorolac in patients over 65?

A

60mg IV or IM

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37
Q

You should avoid Ketorolac in patients with what comorbidity?

A

Severe renal impairment

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38
Q

What must a patients CrCl value be in order to be classified as having severe renal impairment?

A

Less than 45ml/min

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39
Q

Ketorolac is contraindicated in patients with what 2 complications

A

1) Active peptic ulcer disease

2) Recent GI bleed

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40
Q

What doses of iv ibuprofen (NSAID) are used for post-op analgesia to decrease opioid requirements

A

400-800mg

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41
Q

What is the range of doses for IV Diclofenac aka Dyloject (NSAID)

A

3.75-75mg

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42
Q

What is the recommended dose for Diclofenac

A

37.5mg IV

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43
Q

What is the recommended dose for Diclofenac for elderly

A

18.75mg IV

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44
Q

What advantage does IV Diclofenac have over ketolorac or aspirin?

A

Significantly less disruption of platelet function

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45
Q

What type of drug is Tramadol

A

Weak opioid agonist with tricyclic anti-depressant properties

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46
Q

What is the onset time for oral Tramadol

A

One hour

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47
Q

What is the peak time for oral Tramadol

A

2-4 hours

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48
Q

When is Tramadol contraindicated

A

In patients with renal disease and seizure disorders

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49
Q

What is the initial dose of Tramadol

A

50-100mg

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50
Q

What channels does Gabapentin work on that creates its analgesic properties

A

Alpha2delta subunit of calcium channels

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51
Q

How is the Gabapentin excreted

A

Renally

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52
Q

What is the starting dose of Gabapentin

A

300-400mg po

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53
Q

What do patients with CAD have a risk of post-operatively?

A

Tachycardia

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54
Q

What is the percent chance for both men and women of developing CAD after age 40?

A

49% for men, 32% women

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55
Q

What is the incidence of post-op cardiac intervention in patients with stable angina

A

22%

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56
Q

What is tachycardia a significant risk for in patients with CAD?

A

Ischemia

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57
Q

What is the J point on an EKG

A

Where the QRS ends and ST segment begins

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58
Q

Where should ST elevation be measured?

A

From the upper edge of the PR segment to the upper edge of the ST segment

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59
Q

What is the most common post-operative dysrrythmia?

A

Atrial fibrillation

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60
Q

What are the 4 risk factors for atrial fibrillation?

A

1) Cardiac surgery
2) Thoracic surgery
3) Age
4) Male

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61
Q

Loss of atrial contraction can increase what

A

Pulmonary pressures and pulmonary edema

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62
Q

A-fib can lead to what 3 poor outcomes

A

1) Increased risk of stroke
2) Increased hospital length of stay by 2 days
3) Increased mortality

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63
Q

What 4 things can we do to prevent a-fib

A

1) Check and correct abnormal electrolytes
2) Treat hypotension
3) Be watchful of hypervolemia in high risk patients (dialysis, CHF)
4) Monitor respiratory status (hypercarbia/hypoxia)

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64
Q

What is the electric cardioversion treatment for unstable a-fib

A

50-100 J sync

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65
Q

What is the pharmacologic therapy for unstable a-fib

A

Amiodarone load + drop

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66
Q

What is a pharmacologic therapy for rate control with stable a-fib

A

Diltiazem IV

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67
Q

What is the target HR for stable a-fib in the immediate period

A

80-100bpm

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68
Q

What is a pharmacologic treatment for stable a-fib if the patient has CAD

A

Beta blocker

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69
Q

What 3 hemodynamic changes can decrease preload

A

1) Hypovolemia
2) Increased venous capacitance (due to regional anesthesia)
3) Increased intrathoracic/cardiac pressure

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70
Q

What 2 hemodynamic changes cause decreased cardiac function

A

1) Decreased stroke volume

2) Change in HR/rhythm

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71
Q

What 3 things can cause decreased afterload (SVR)

A

1) Sepsis
2) Anaphylaxis (also affects preload)
3) Residual medication/anesthetic effect

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72
Q

What are 6 causes of hypertension in the PACU?

A

1) Pain
2) Hypercapnia
3) Urinary retention
4) Pre-existing HTN
5) Hypervolemia
6) Increased ICP

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73
Q

Almost 90% of patients in the PACU who will become hypertensive do so within what amount of time

A

1 hour

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74
Q

50% of patients who develop HTN in the PACU will do so within what amount of time

A

15 minutes

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75
Q

What fraction of major PACU complications are respiratory

A

2/3

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76
Q

What are the 3 most common respiratory issues in the PACU

A

Hypoxia, hypercarbia, aspiration

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77
Q

All anesthetic drugs cause a dose dependent reduction in minute ventilation except which 2 drugs

A

Ketamine and N2O

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78
Q

Which part of the minute ventilation equation do opioids affect

A

Rate - they reduce rate

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79
Q

Which part of the minute ventilation equation do volatile agents

A

Volume - they reduce volume

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80
Q

Which part of the minute ventilation equation does propofol effect

A

Both rate and volume

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81
Q

What effects can hypercapnia have on heart rate, heart function, and neurologic function

A

Tachycardia, arrhythmias, htn headache, confusion, tremor, coma

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82
Q

Where are peripheral receptors that detect PaCO2 located

A

Carotid bodies

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83
Q

Where are central receptors that detect PaCO2 located

A

Medulla

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84
Q

How is ventilation affected by a rise in PaCO2

A

Linear increase in ventilation with increase in PaCO2

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85
Q

Ventilatory response to ___ is reduced by almost all anesthetics

A

CO2

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86
Q

What effect does supine positioning, laparoscopic procedures, obesity, and atelectasis have on FRC

A

Decrease

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87
Q

What happens to closing capacity of airways under anesthesia

A

Increase

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88
Q

What aspects of the lung change with age

A

Lung volumes and elasticity

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89
Q

Geriatric patients have an elevated risk of developing what 2 lung problems

A

Atelectasis

Pneumonia

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90
Q

Deep breathing has not shown to be beneficial in the post-op setting except with what population

A

Elderly populations, they are benefited with greater pulmonary recovery and prevention of pneumonia

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91
Q

What part of the airway does airway obstruction almost always occur in

A

Pharyngeal

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92
Q

Are men or women more at risk for OSA

A

Men

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93
Q

Are post-menopausal or pre-menopausal women more at risk for OSA

A

Post-menopausal

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94
Q

What jaw problems increase risk for OSA

A

Micrognathia and retrognathia

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95
Q

Patients with a neck circumference greater than __cm are at risk for OSA

A

40cm

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96
Q

What is the definition of OSA

A

Repetitive episodes of upper airway partial/complete obstruction during sleep that are accompanied by sleep disruption, changes in air flow and hypoxemia.

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97
Q

What are the 2 parts of the oropharynx

A

Palatopharynx (velopharynx) - length of soft palate to the tongue
Glossopharynx - below base of tongue

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98
Q

What is the action of the genioglossus muscle

A

Depress and protrude the tongue

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99
Q

What nerve innervates the genioglossus muscle

A

Hypoglossal (12)

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100
Q

After 60 minutes of anesthesia, you should make sure the patients respiratory rate is over

A

8 breaths/min

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101
Q

After 60 minutes of anesthesia, check for apneic episodes over __sec

A

10

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102
Q

After 60 minutes of anesthesia, check for SaO2 over ___% on room air

A

90

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103
Q

What are risk factors for residual NMB

A

Patient distress, upper airway obstruction, aspiration, hypoxemia, impaired ventilation, re-intubation

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104
Q

What was the NMB agent used in 99% of residual NMB cases

A

Rocuronium

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105
Q

What percentage of elderly patients are affected by dysphagia

A

15%

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106
Q

Why are elderly patients more at risk for dysphagia

A

Muscle mass decreases with age and swallow reflex loses strength

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107
Q

In eldery patients with concomitant neurological disease, the percentage with dysphagia rises to

A

50%

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108
Q

What are diseases/conditions that increase risk of oropharyngeal dysphagia?

A

Alzheimers, tumors, myasthenia gravis, ALS, Parkinson’s, achalasia, dementia, history of CVA

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109
Q

High risk patients should have an HOB greater than ____

A

30 degrees

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110
Q

What types of drugs should you minimize in patients at risk for dysphagia

A

Sedatives and opioids, helps limit pharyngeal motor dysfunction

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111
Q

What exam can be performed in the PACU to screen for dysphagia

A

3oz swallow challenge

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112
Q

Does the ASA recommend we monitor for urine output in all patients?

A

No, just select patients

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113
Q

What is the biggest risk factor for POUR

A

Age

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114
Q

What surgeries increase risk for POUR

A

Inguinal hernia repair, colorectal/anorectal, pelvic, hip surgeries

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115
Q

What type of drug increases risk of POUR

A

Opioids

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116
Q

Is POUR a risk factor for post op delirium?

A

Yes

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117
Q

How is hypothermia defined in Dr. Duggan’s lecture

A

Less than 36 degrees celsius

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118
Q

What are predictors of hypothermia

A

Age, duration of anesthesia, pain, risk score of CAD, CVA, insulin dependent DM, renal failure

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119
Q

A 1.9 degree drop in temperature increases risk of WI by?

A

20%

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120
Q

How does hypothermia affect the incidence of cardiac events

a. Doubles
b. Triples
c. Quadruples

A

b. Triples

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121
Q

What effect does hypothermia have on the blood

A

Impairs platelet function, decreases fibrinogen, disturbs coagulation enzymes, coagulopathy

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122
Q

Why does a 1.9 degree drop in temp increase risk of WI

A

Impairs antibody and cell-mediated defenses, decreases o2 delivery to peripheral tissues

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123
Q

Active warming reduces the time taken to achieve normothermia by how much in comparison to warming blankets

A

30 minutes

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124
Q

Active warming was found to reduce mean time taken to achieve normothermia by how much in comparison to unwarmed blankets

A

90 minutes

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125
Q

What is the difference in shivering of patients who were actively warmed vs. those who were passively warmed

A

There is no difference

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126
Q

What are the triggering agents for MH

A

Sux, volatile agents (except N2O)

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127
Q

What kind of disorder is MH

A

Pharmacogenetic

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128
Q

MH is caused by the abnormal handling of what element in skeletal muscle

A

Intracellular calcium

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129
Q

What is the mortality rate from MH using MH Hot Line in the hospital

A

7%

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130
Q

What is the mortality rate from MH using MH Hot Line outside the hospital

A

20%

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131
Q

MH is normally a defect in what receptor

A

Ryanodine

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132
Q

What is the effect of MH triggers on Ca2+ release

A

Triggers uncontrolled calcium (Ca2+) release from the sarcoplasmic reticulum (SR) through the ryanodine receptor (RYR1) causing a rapid and sustained rise in myoplasmic Ca2+. The high intracellular Ca2+ activates Ca2+ pumps at the SR and the sarcolemma to reuptake calcium into SR or to transport it into the extracellular space respectively. The energetic cost to regain cellular Ca2+ control causes a need for ATP, which in turn produces heat.

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133
Q

How does O2 consumption change with MH

A

3-5 times the normal O2 consumption

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134
Q

How does PaO2 change during MH

A

142 +/- 10 mmHg

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135
Q

How does PvO2 change during MH

A

36 +/- 4 mmHg

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136
Q

How does PaCO2 change during MH

A

54 +/- 4 mmHg

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137
Q

How does PvCO2 change during MH

A

107 +/- 10 mmHg

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138
Q

When is the onset of MH explosive?

A

During induction

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139
Q

When is the onset of MH insidious?

A

Maintenance, postop

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140
Q

Do all patients with MH outbreak have muscle rigidity?

A

No

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141
Q

What is an early sign of MH outbreak?

A

Unexplained increased etCO2

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142
Q

What is a late sign of MH outbreak?

A

Temperature

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143
Q

Does MH cause respiratory/metabolic alkalosis or acidosis?

A

Acidosis

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144
Q

Is hyperthermia an early, intermediate, or late sign of MH?

A

Late

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145
Q

Is venous cyanosis an early, intermediate, or late sign of MH?

A

Late

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146
Q

Is MMR an early, intermediate, or late sign of MH?

A

Early

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147
Q

Hyperthermia was the 1st sign of MH in what fraction of patients

A

1/3

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148
Q

What are the main causes of death within the first few hours of MH manifestation

A

Hyperkalemia, v-fib

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149
Q

What are the main causes of death within several hours of MH manifestation

A

Pulmonary edema, acid/base abnormalities, electrolyte imbalance, coagulopathy

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150
Q

A high incidence of disseminated intravascular coagulopathy occured when temperatures were above

A

41.5 degrees celcius

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151
Q

What are the main causes of death days after MH manifestation

A

Multi-organ failure, brain damage, renal decompensation

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152
Q

What 2 diseases associated with MH are due to a mutation with Ca2+ release via muscle isoform ryanodine receptor RYR 1 gene (Chromosome 12q13)

A

Central Core Disease

King-Denborough Syndrome

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153
Q

What disease associated with MH is due to a mutation with Excitation-Contraction Coupling Protein on STAC3 Gene (Chromosome 12q13.13)

A

Native American Myopathy (NAME)

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154
Q

What 2 diseases associated with MH are due to a mutation in the Ca2+ channel voltage dependent 1S subunit CACNA1S (Chromosome 1q32)

A

Hypokalemic periodic paralysis

Multiminicore Disease

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155
Q

What disease/symptom that is possibly associated with MH is caused by an RYR1 mutation

A

Exertional heat stroke

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156
Q

What disease that is possibly associate with MH is found in patients that were CHCT + and had an RYR1 mutation

A

Exercise induced rhabdomyolysis

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157
Q

What deficiency is possibly associated with MH

A

Carnitine palmitoyl transferase

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158
Q

What are some differential diagnoses associated with MH

A 
NMS
Hypoxic encephalopathy
Ionic contrast agents in CSF
Baclofen withdrawl
Amphetamine toxicity
Cocaine toxicity
ETOH withdrawal
Myopathy /rhabdomyolysis  with  Statins
Hypoxia
Iatrogenic overheating
Transfusion reaction
Thyrotoxicosis
Pheochromocytoma
Anticholinergic syndrome
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159
Q

What is the first thing you should do if you suspect MH

A

Stop all volatile agents/sux

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160
Q

After stopping volatile agents/sux, what should you do in cases with suspected MH manifestation

A
  • Call for assistance
  • Hyperventilate with 100% O2 and flows over 10L/min
  • Communication/halt procedure
  • Give dantrolene
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161
Q

Whats the dose of Dantrolene

A

2.5mg/kg

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162
Q

How should you dilute a 20mg bottle of Dantrolone

A

Dissolve with 60ml sterile water, each bottle has 3gm mannitol

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163
Q

What are some side effects of Dantrolene

A

Cardiac arrest, thrombophlebitis (pH 9), synergistic action with NMB

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164
Q

After Dantrolene, what should you begin to treat

A

Hyperkalemia, arrythmias, hyperthermia, electrolyte imbalances

165
Q

What is the endpoint of the treatment of hyperthermia

A

38 degrees celsius

166
Q

What should you keep the UOP at

A

Greater than 2cc/kg/hr

167
Q

What is the Dantrolene dosage/frequency for post-acute phase therapy

A

1) 1mg/kg IV every 4-6 hours OR 0.25mg/kg/hr - give for 24-36 hrs
2) After step 1, oral Dantrolene 1mg/kg every 6 hours for the next 24 hours

168
Q

What tests/electrolyte levels should you check to watch for signs of recrudescence, myoglobinuria, renal failure, DIC

A

ABG, CPK, K+, Ca+, urine/serum myoglobin, clotting

169
Q

How often should you check ABG/CPK/K+/Ca+/etc. for post-acute phase therapy

A

Every 6 hours until normal and stable

170
Q

How long should you observe MH patients in the ICU

A

24-48 hours

171
Q

Where should you refer patient and families for counseling

A

MHAUS

172
Q

Children less than __ years old who experience a sudden cardiac arrest after sux, in the absence of hypoxia, should be treated for what first?

A

9 years old, acute hyperkalemia

173
Q

What test is indicated with family or personal history of MH or MH-like events

A

Halothane-Caffeine Contracture Test

174
Q

What are the contraindications for the Halothane-Caffeine Contracture Test?

A

Age less than 4 years old (20kg), less than 3 months from the event

175
Q

How should you prepare the anesthesia machine for an MH susceptible patient

A
  • New fresh gas outlet hose and circle system tubing
  • Remove vaporizers
  • Flush system with >10L/min O2 for 10 min
  • Flush for 20min if fresh gas can’t be replaced
176
Q

What should you have in or near the OR when you have an MH susceptible patient

A

MH cart

177
Q

What type of temperature should be monitored in an MH susceptible patient

A

Core temp

178
Q

When should Dantrolene be given as a pre-med

A

Cases of stress-induced MH

179
Q

How often should you monitor RR, BP, HR, temp in the PACU with an MH susceptible patient

A

every 15 minutes for 1 hour

180
Q

What vitals/tests should be monitored on an MH susceptible patient in Phase II of PACU

A

Pulse ox, urine color, HR, temp, and BP every 30 min for at least 1.5 hours

181
Q

What muscle often becomes rigid during MH manifestation

A

Masseter

182
Q

What are early signs of MH outbreak

A

Increased CO2, increase HR, resp/met acidosis, venous desaturation, masseter rigidity, electrolyte imbalance

183
Q

Halstead and Hall injected what anesthetic into peripheral sites in the 1880’s

A

Cocaine

184
Q

In 1885, Corning used what device to arrest local circulation and prolong the block

A

Esmarch tourniquet

185
Q

What did Braun invent in 1903

A

Chemical tourniquet

186
Q

Who wrote the definitive text on regional anesthesia in 1920

A

Labat - Regional Anesthesia: Its Technique and Application

187
Q

What are 3 risks of regional anesthesia

A

Nerve injury, LA toxicity, site specific risks

188
Q

What are 4 contraindications of regional anesthesia

A

Uncooperative, coagulopathy, infection, LA allergy

189
Q

What are hypoechoic structures and how do they appear on an ultrasound

A

Structures through which sound passes easily, appear dark or black

190
Q

What are hyperechoic structures and how do they appear on an ultrasound

A

Structures reflecting more sound waves, appear white

191
Q

High frequency waves have ______ resolution but _____ tissue penetration when compared to low frequency waves

A

Higher resolution, poorer tissue penetration

192
Q

Low frequency sound waves have _____ resolution but _____ tissue penetration when compared to high frequency sound waves

A

Poorer resolution, better tissue penetration

193
Q

Is low frequency better for shallow or deep structures

A

Deep structures

194
Q

What type of probe is better for shallow structures

A

Linear

195
Q

When is the needle best seen with a linear probe

A

When its perpendicular to the transducer and parallel to the surface

196
Q

What probe/needle angle is best for deeper structures

A

Low resolution curvilinear probe, steeper needle angle

197
Q

What does an In Plane technique look like

A

Needle inserted from the side of the transducer

198
Q

What does an Out of Plane technique look like

A

Needle inserted at the front side of the transducer, midline

199
Q

What 4 blocks block portions of the brachial plexus

A

1) Interscalene
2) Supraclavicular
3) Intraclavicular
4) Axillary

200
Q

The cervical plexus is derived from what spinal nerves

A

C1-C4

201
Q

Cervical plexus supplies branches to what 2 muscle groups

A

Prevertebral muscles, strap muscles of the neck

202
Q

The cervical plexus supplies branches to what nerve

A

Phrenic nerve

203
Q

What are some examples of surgeries where cervical plexus blocks are useful

A

Lymph node dissections, plastic repairs, carotid endarterectomy

204
Q

Bilateral cervical plexus blocks are used for what surgeries

A

Tracheostomy, thyroidectomy

205
Q

What is an advantage of the cervical plexus block

A

The ability to monitor the awake patient’s neurologic status continuously

206
Q

What are some complications and side effects of cervical plexus blocks

A

Intravascular injection, blockage of phrenic nerve and SLN, spread of anesthetic into epidural and subarachnoid spaces

207
Q

Nerve roots of musculocutaneous nerve

A

C5-C7

208
Q

Nerve roots of axillary nerve

A

C5-C6

209
Q

Nerve roots of radial nerve

A

C5-T1

210
Q

Nerve roots of median nerve

A

C5-T1

211
Q

Nerve roots of ulnar nerve

A

C8-T1

212
Q

What cord innervates musculocutaneous nerve

A

Lateral

213
Q

What cords innervate median nerve

A

Lateral and medial

214
Q

What cord innervates ulnar narve

A

Medial

215
Q

What cord innervates radial nerve

A

Posterior

216
Q

What type of surgeries are interscalene blocks indicated for

A

Shoulder and upper arm surgeries

217
Q

What type of surgeries need an interscalene block to be supplemented with an ulnar nerve block

A

Forearm and hand surgeries

218
Q

What are some complications of interscalene blocks

A

Ipsilateral phrenic nerve block, vagus/RLN/cervical sympathetic nerves can be blocked, PTX

219
Q

What trunk levels does the interscalene block occur at

A

Superior and middle trunks

220
Q

What dermatomes is the interscalene block most intense at

A

C5-C7

221
Q

What dermatomes is the interscalene block least intense at

A

C8-T1

222
Q

What types of surgeries are supraclavicular blocks indicated for

A

Elbow, forearm, hand

223
Q

What trunk level do supraclavicular blocks occur at

A

Distal trunk-proximal division

224
Q

What are some complications of supraclavicular blocks

A

PTX, phrenic nerve block, Horners syndrome

225
Q

What are symptoms of Horners syndrome

A

Ptosis, miosis, anhydrosis

226
Q

What surgeries are infraclavicular blocks used for

A

Arm and hand

227
Q

What level do infraclavicular blocks block

A

At the level of the cords, arranged around axillary artery

228
Q

Relative to supraclavicular blocks, what do infraclavicular blocks have less of a risk for

A

Pneumothorax

229
Q

Are the shoulder and upper arm anesthesized with an infraclavicular block?

A

No

230
Q

Axillary blocks are useful for what type of surgeries

A

Forearm and hand

231
Q

What level does an axillary blockade occur at

A

Terminal nerve branches

232
Q

What are some complications of axillary blocks

A

Nerve injury, systemic toxicity, hematoma, infection

233
Q

Why are multiple injections needed for an axillary block

A

The nerves are separated by fascia

234
Q

Where is an axillary block more intense

A

C7-T1 (ulnar nerve)

235
Q

What are the 5 types of terminal nerve blocks

A

Median, ulnar, radial, musculocutaenous, digits

236
Q

What cords are blocked with a terminal nerve block of the median nerve

A

Lateral and medial cords

237
Q

What cords are blocked with a terminal nerve block of the ulnar nerve

A

Medial cord

238
Q

What cords are blocked with a terminal nerve block of the radial nerve

A

Posterior cord

239
Q

What drug do you not use with a terminal nerve block of the digits

A

Epi

240
Q

Are Bier Blocks useful for short or long procedures

A

Short

241
Q

What are the benefits of a Bier Block

A

Easy to administer, rapid onset

242
Q

What is the dose and concentration of Lidocaine needed for a Bier Block

A

25-50 ml of 0.5% Lidocaine

243
Q

What type of tourniquet is used for a Bier Block

A

Pneumatic

244
Q

What is an example of a surgery that would use a Bier Block

A

Carpal tunnel (45-60min)

245
Q

Tourniquet pain occurs after how long

A

20-30min

246
Q

The tourniquet must be up for at least 15-20 min to reduce risk of what

A

Rapid bolus of local anesthetic and systemic toxicity

247
Q

What are some complications of a Bier Block

A

Phlebitis, compartment syndrome, loss of limb

248
Q

What are the nerve roots of the femoral nerve

A

L2-L4

249
Q

What are the nerve roots of the obturator nerve

A

L2-L4

250
Q

What are the nerve roots of the lateral femoral nerve

A

L1-L3

251
Q

What are the nerve roots of the sciatic nerve

A

L4-S3

252
Q

What 3 nerves are part of the lumbar plexus

A

Femoral, obturator, lateral femoral

253
Q

The lumbar plexus lies within what muscle

A

Psoas

254
Q

The 2 nerves are continuations of the sciatic nerve

A

Common peroneal and tibial

255
Q

What type of surgeries are femoral nerve blocks useful for

A

Anterior thigh, knee, medial foot

256
Q

Why are femoral nerve blocks used for knee surgery

A

Post op pain control

257
Q

What are some examples of surgeries that call for a femoral nerve block

A

Patellar surgery, knee scopes, skin grafting

258
Q

What groups of muscles/nerves does the femoral nerve innervate

A

Hip flexors, knee extensors, sensory of hip and thigh

259
Q

Can a femoral nerve block provide surgical anesthesia by itself?

A

No

260
Q

Where is a femoral nerve block placed?

A

Below the inguinal ligament

261
Q

An obturator nerve block provides anesthesia to what region

A

Medial thigh

262
Q

An obturator nerve block provides muscle relaxation to what muscles

A

Adductor muscles of the hip

263
Q

An obturator nerve block is used in combination with what 2 blocks

A

Femoral and sciatic

264
Q

For complete anesthesia of the knee, what block do you need

A

Obturator

265
Q

A sciatic nerve block provides sensory anesthesia to which areas

A

Posterior hip, knee, and low extremity

266
Q

A sciatic nerve block provides a motor block to what muscles

A

Hamstrings and low muscles

267
Q

A sciatic nerve block is useful for what type of surgeries

A

Knee, calf, achilles tendon, foot, ankle

268
Q

A sciatic nerve block is used for post op pain control in what surgeries

A

Knee, posterior knee

269
Q

A popliteal block is useful for what surgeries

A

Foot and ankle

270
Q

What muscles are spared in a popliteal nerve block

A

Hamstrings

271
Q

What 5 nerves are involved in an ankle block

A

Superficial peroneal, deep peroneal, saphenous, tibial, sural

272
Q

What type of surgeries are ankle blocks used for

A

Foot surgeries

273
Q

What drug cannot be used with ankle blocks

A

Epi

274
Q

How many injections are required for an ankle block

A

5

275
Q

Area innervated by sural nerve

A

Posteror lateral leg below the knee

276
Q

Area innervated by saphenous nerve

A

Medial leg below the knee

277
Q

Area innervated by superficial peroneal nerve

A

Anterior lateral leg below the knee, top of foot except small region between 1st and 2nd toe

278
Q

Area innervated by deep peroneal nerve

A

Region between 1st and 2nd toe on top of foot

279
Q

What nerves does a lumbar plexus (psoas) block include

A

Lateral femoral cutaneous, femoral, obturator

280
Q

What area does the lumbar plexus block provide complete analgesia for

A

Total hip and total knee

281
Q

What type of needle is required for lumbar plexus block

A

Long needle

282
Q

What is another name for a lumbar plexus block

A

Psoas

283
Q

The saphenous nerve is a terminal extension of what nerve

A

Femoral

284
Q

Saphenous nerve block blocks sensory innervation of what area

A

Medial aspect of lower leg

285
Q

Is saphenous nerve block an isolated block?

A

No

286
Q

Saphenous block is used with what other block to achieve complete analgesia in what region

A

Sciatic, Below the knee

287
Q

Clinical activity of local anesthetics (LA) are based on what 3 physiochemical properties

A
  1. Lipid solubility
  2. Ionization
  3. Protein binding
288
Q

Lipid solubility deals what 2 aspects of LAs

A

Duration of action and potency

289
Q

How does increased lipid solubility affect duration of action and potency

A

Increased lipid solubility=increased duration and increased potency

290
Q

What 3 LAs have the highest degree of protein binding

A

Tetracaine > Bupivacaine > Ropivacaine

291
Q

What aspect of LAs does ionization affect

A

Speed of onset

292
Q

How is speed of onset affected if pH of a solution is close to the pKa

A

Speed of onset is increased

293
Q

LAs affect what channels

A

Na+ channels

294
Q

List the pKas of Mepivicaine, Lidocaine, Bupivicaine, Ropivicaine

A

7.6, 7.9, 8.1, 8.1

295
Q

How does infected tissue affect the speed of onset of LAs

A

Decreased pH in infected tissues, more LA will be in the charged, hydrophilic form and not cross to the Na+ channels - so decreased speed of onset

296
Q

Do LAs with Epi have a higher or lower pH

A

Lower, so it takes longer to cross the cell membrane and bind to Na+ channels

297
Q

What part of the LA crosses the cell membrane

A

The unbound fraction

298
Q

How does increased lipid solubility and duration of action affect protein binding

A

Increase protein binding

299
Q

What 2 proteins bind LAs

A

Albumin, alpha acid glycoprotein

300
Q

How does decreased pH affect protein binding

A

Decreased pH=decreased protein binding=more unbound LA, risk of toxicity

301
Q

Where are amides metabolized

A

Liver

302
Q

What LAs are in the amide class

A

Bupivacaine, Lidocaine, Mepivacaine, Prilocaine, Ropivacaine

303
Q

What are the longest acting amide LAs?

A

Bupivacaine, Ropivacaine (1.5-8hrs)

304
Q

Duration of Lidocaine

A

0.75-2hrs

305
Q

Duration of Mepivacaine

A

1-2hr

306
Q

Duration of Prilocaine

A

0.5-1hr

307
Q

What enzyme are esters metabolized by

A

Pseudocholinesterase

308
Q

What LAs are esters

A

Benzocaine, Chloroprocaine, Cocaine, Procaine (Novocaine), Tetracaine

309
Q

All esters have a duration of 0.5-1hr except which one?

A

Tetracaine - 1.5-6hr

310
Q

What is a complication of benzocaine

A

Methemoglobinemia - decreases ability of hemoglobin to carry o2

311
Q

What are 3 major risks of nerve blocks

A

Systemic toxicity, infection, peripheral nerve damage

312
Q

Which needles decrease the risk for peripheral nerve damage

A

B bevel needles (short bevel)

313
Q

What 6 things determine risk of LAST

A
  1. Site of injection
  2. Which LA used
  3. Dose
  4. Degree of protein binding
  5. Degree of acidosis
  6. Epinephrine?
314
Q

How does epinephrine affect local anesthetic affect

A

Slows the rate of absorption via vasoconstriction

315
Q

Peak blood concentrations of LA depend on what

A

Site of injection

316
Q

Absorption of LA is related to _______ of injection site

A

Vascularity

317
Q

List injection sites from most to least vascular

A

Tracheal > intercostal > caudal > epidural > brachial plexus > femoral/sciatic > subcutaneous

318
Q

What is the 1st stage of LAST on the CNS

A

CNS excitation

319
Q

What pathways are blocked during CNS excitation due to LAST

A

Inhibitory

320
Q

What are symptoms of LAST during CNS excitation (phase 1)

A

Dizziness, tinnitis, circumoral numbness, muscle twitches, slurred speech, seizures

321
Q

What is the 2nd stage of LAST on the CNS

A

CNS depression

322
Q

What pathways are blocked during CNS depression due to LAST

A

Inhibitory and excitatory pathways

323
Q

What are the symptoms of LAST during CNS depression (phase 2)

A

Respiratory depression, obtundation, coma

324
Q

What are cardiovascular signs of LAST

A

Depress myocardial conduction/contractility, arterial vasodilation, hypotension, bradycardia, VT or VA, AV block, PVCs, PACs

325
Q

Whats the only local anesthetic that doesn’t produce arterial vasodilation

A

Cocaine

326
Q

Which local anesthetic avidly blocks cardiac Na+ channels and has a high degree of protein binding, thus making resuscitation difficult

A

Bupivacaine

327
Q

What are some methods for prevention of LAST

A

Incremental injection, frequent aspiration, adding a marker, limiting LA dose/concentration, communicate w/ patient

328
Q

What is a good marker for preventing LAST

A

Epi - 5mcg/ml

329
Q

Patients with which 3 conditions should we proceed with caution when administering local anesthetics

A

Cardiac conduction problems, kidney/liver disease, acidosis (increases free LA)

330
Q

In what 2 ways does epinephrine improve the quality of the block

A

Increased neuronal uptake, alpha 2 adrenergic receptor

331
Q

By what percent does HR increase with epinephrine

A

20%

332
Q

Epinephrine decreases absorption/prolongs action of what types of local anesthetics

A

short acting LAs like lidocaine and mepivacaine

333
Q

What amount of epinephrine is normally added to Las

A

5mcg/ml (1:200,000), 2.5mcg/ml (1:400,000)

334
Q

What are 3 pharmacologic treatment options for seizures due to LAST

A

Midazolam, propofol, thiopental

335
Q

What are treatments for cardiac toxicity/respiratory depression due to LAST

A

Manage airway, ACLS/BLS (avoid B blockers, Ca+ blockers, lidocaine), IV lipid infusion, cardiopulmonary bypass

336
Q

What drug is used as a lipid treatment for LAST

A

20% intralipid

337
Q

What is the per kilo dose for a bolus of Intralipid

A

1.5ml/kg

338
Q

What is the per kilo dose for Intralipid after the inital bolus

A

0.25ml/kg/min for 30-60min

339
Q

How many times can a bolus of Intralipid be repeated for persistent cardiac collapse

A

1-2 times

340
Q

Infusion rate of Intralipid could be increased if what declines

A

Blood pressure

341
Q

What is used during the placement of nerve blocks to test motor response

A

Peripheral nerve stimulator

342
Q

What is used during the placement of nerve blocks to test sensory response

A

Paresthesia technique

343
Q

What are the roots of the brachial plexus

A

Ventral rami

344
Q

Where are the supraclavicular nerves

A

Cape of the neck, anteriorly to second rib, top of the scapula

345
Q

The intercostobrachial nerve is at what vertebral level

A

T2

346
Q

Which block provides analgesia for shoulder, humerus, clavicle

A

Interscalene block

347
Q

Where is an interscalene block performed

A

At the level of the roots/trunks of brachial plexus, between anterior and middle scalene muscle

348
Q

What are adverse effects and possible complications associated with interscalene blocks

A

Phrenic nerve palsy, Horner’s syndrome, cervical plexus block, RLN palsy, vertebral artery injection, pneumothorax, epidural/spinal injection

349
Q

What is caused from an inadvertant block of the recurrent laryngeal nerve

A

Hoarseness

350
Q

How many ccs of LA injected into the vertebral artery can lead to seizures

A

1-3mL

351
Q

What is the most common adverse event following an interscalene block

A

Phrenic nerve palsy

352
Q

What is referred to as the “spinal of the arm”

A

Supraclavicular block

353
Q

What block is performed at the level of the divisions of the brachial plexus

A

Supraclavicular block

354
Q

What block is indicated for surgeries of the entire arm, below the level of the shoulder

A

Supraclavicular block

355
Q

What risks associated with supraclavicular blocks

A

Pneumothorax, phrenic nerve palsy, Horner’s syndrome, RLN block, vascular puncture

356
Q

What block is indicated for surgeries involving the elbow, forearm, and hand

A

Infraclavicular

357
Q

What block deals with nerve cords situated around the axillary artery

A

Infraclavicular

358
Q

What are complications associated with infraclavicular blocks

A

Vascular puncture, pneumothorax

359
Q

What block is indicated for surgeries involving the elbow, forearm, and hand and is performed at the terminal branches of the medial, ulnar, radial, and musculocutaneous nerves?

A

Axillary

360
Q

What are complications associated with axillary blocks

A

Infection, hematoma

361
Q

The arm must be in what position for an axillary block

A

Abducted

362
Q

Since an axillary block is transarterial, what adjuncts should be used during insertion

A

Peripheral nerve stimulator, ultrasound

363
Q

Which nerve of the brachial is the most difficult to locate

A

Radial

364
Q

Blocking the ulnar nerve provides good analgesia for which finger

A

5th digit

365
Q

Bier Blocks provide anesthesia for surgeries lasting how long

A

45-60 minutes

366
Q

What block is used for short surgeries of the forearm, hand, or leg

A

Bier block

367
Q

What type of tourniquet and bandage is required for a bier block

A

Double pneumatic tourniqet, eschmark elastic bandage

368
Q

What dose/concentration of lidocaine is needed for a bier block

A

50mL 0.5% lidocaine

369
Q

The lumbar plexus is comprised of the _____ _____ of vertebral levels ___ - ___

A

ventral rami, L1-L4

370
Q

What are the 4 blocks associated with the lumbar plexus

A

Iliohypogastric/ilioinguinal
Femoral
Obturator
Lateral femoral cutaneous

371
Q

The sacral plexus is comprised of the ______ _____ of vertebral levels ____ - ____

A

ventral rami, L4-S3/S4

372
Q

The sciatic nerve branches into what 2 nerves

A

Common peroneal, tibial

373
Q

Over the last 10 years there has been an increased interest in lower extremity block for what 3 reasons

A

1) transient neurologic symptoms with spinal anesthesia
2) increased use of thromboembolic prophylaxis
3) evidence of increased early rehabilitation with CPNBs

374
Q

What nerve block is used for surgeries of the hip, anterior thigh, and knee

A

Lumbar plexus

375
Q

A lumbar plexus block covers what 3 nerves

A

Femoral, lateral femoral, obturator

376
Q

Whats the distance from skin to lumbar plexus of a deep block

A

5-10cm

377
Q

What are complications of lumbar plexus blocks

A

Renal puncture, spinal or epidural injection, hematoma, LAST

378
Q

What is the largest branch of the lumbar plexus, that arises from L2-L4

A

Femoral

379
Q

What nerve is the posterior division of the femoral nerve and most medial

A

Saphenous

380
Q

The posterior division of the femoral nerve is associated with what muscles of the leg

A

Quadriceps

381
Q

The articular branches of the femoral nerve feed what parts of the lower extremity

A

Hip and knee

382
Q

What nerve is the anterior division of the femoral nerve

A

Middle cutaneous

383
Q

What muscle is associated with the anterior division of the femoral nerve

A

Sartorius

384
Q

The femoral nerve emerges from what muscle

A

Psoas muscle

385
Q

The femoral nerve enters the leg under which ligament

A

Inguinal

386
Q

In general, femoral nerve blocks fail if the anesthetic is injected superior to what tissue layer

A

Fascia iliaca

387
Q

What types of knee surgery utilize a femoral nerve block

A

TKA, ACL reconstruction, patellar surgery

388
Q

What block is used for femoral ORIF, skin grafting, and muscle biopsy surgeries

A

Femoral

389
Q

Surgeries involving the medial aspect of the lower leg would use what block

A

Femoral

390
Q

What is the largest branch of the femoral nerve

A

Saphenous nerve

391
Q

What are the 4 main locations where we can block the saphenous nerve (BAMF)

A

Below the knee, adductor canal, medial malleolus, femoral

392
Q

For any surgery involving medial aspect of foot/ankle, what nerve must be blocked

A

Saphenous

393
Q

A saphenous block is usually used in conjunction with what other 2 blocks

A

Popliteal, sciatic

394
Q

What are the landmarks for a traditional saphenous nerve block

A

Anterior edge of medial head of gastrocnemius muscle and tibial tuberosity

395
Q

While traditional techniques all have low success rates for saphenous blocks, what approach has high success

A

Paravenous

396
Q

What 4 areas are good for imaging the sciatic nerve

A

Popliteal, mid-thigh, subgluteal, transgluteal

397
Q

Which image is hardest to visualize/access the sciatic nerve

A

Transgluteal b/c of depth

398
Q

What is the largest nerve in the human body

A

Sciatic

399
Q

What nerve provides sensory innervation to the knee, hip, and below the knee (except medial)

A

Sciatic

400
Q

The sciatic nerve blocks motor function to what area/muscles

A

Hamstrings, lower leg below the knee

401
Q

In which surgeries are sciatic nerve blocks indicated

A

TKA, foot, ankle

402
Q

What are some complications associated with sciatic nerve blocks

A

Partial block, nerve injury

403
Q

Where is the ultrasound probe placed during a popliteal approach of a sciatic block

A

Popliteal crease

404
Q

Where are incomplete sciatic blocks common due to anatomical variations

A

Popliteal fossa

405
Q

The sciatic nerve divides into which 2 nerves above the popliteal fossa

A

Tibial and peroneal

406
Q

What is the main obstable while doing a subgluteal approach to a sciatic nerve block

A

Depth of nerve

407
Q

Where is the palpable groove used in a subgluteal approach to a sciatic block

A

Just lateral to the upper portion of the biceps femoris muscle

408
Q

What block is used for foot and toe surgeries

A

Ankle

409
Q

What 5 nerves are blocked with an ankle block (DPSSS)

A

deep peroneal, posterior tibial, sural, sapheous, superfical peroneal

Anesthesia Practice (9 decks)

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