APA 2 Final Exam Review (From Outpatient Anesthesia On) Flashcards
60-70% of all procedures in the United States are performed on a/an ___ basis
Outpatient
Outpatient anesthesia has a/an ___ (increased/decreased) need for the anesthetist and ___ (short/long) acting anesthetics
Increased need for the anesthetist and short-acting anesthestics
___% of outpatients are less than the age of 12
30%
___% of all outpatients are greater than 60 years of age
10%
There is no age limit to outpatient surgery, with the exception of premature babies—T/F?
True
Outpatient surgery is usually less than ___ hours and rare to exceed ___ hours
Usually less than 2 hours and rare to exceed 4 hours
Most common outpatient procedures are ___
Opthalmologic
Second most common outpatient procedures are ___ surgeries
Gynecological
Substance abuse and outpatient surgery—acute abuse/intoxication has no effect on surgery—T/F?
False—surgery should be cancelled
Substance abuse and outpatient surgery—consider ___ (general/regional) technique with use of ___ to alleviate need for narcotics
Consider regional technique with use of NSAIDs to alleviate need for narcotics
Premature infant = ___ weeks or earlier gestation
37 weeks or earlier gestation
Unacceptable premature infant candidates for outpatient surgery—___mia; underdeveloped ___ reflex; immature ___ control; ___nea
Anemia; underdeveloped gag reflex; immature temperature control; apnea
Unacceptable premature infant candidates for outpatient surgery—anemia—normal drop to ___-___g/100ml 1 to 3 months after birth; < ___% hematocrit warrants further evaluation
Normal drop to 7-8g/100ml 1 to 3 months after birth; < 30% hematocrit warrants further evaluation
Unacceptable premature infant candidates for outpatient surgery—anemia—increased incidence of ___ episodes
Apnea
Unacceptable premature infant candidates for outpatient surgery—anemia—consider ___ therapy for anemic premature infants and re-evaluation before outpatient surgery
Consider iron therapy and re-evaluation
Apnea in premature infant—short = ___-___ seconds
6-15 seconds
Apnea in premature infant—prolonged = greater than ___ seconds
15 seconds
Apnea in premature infant—periodic breathing = ___ or more periods of apnea of ___-___ seconds separated by < ___ seconds of normal breathing
3 or more periods of apnea of 3-15 seconds separated by < 20 seconds of normal breathing
Apnea in premature infant—all episodes can lead to ___emia and ___cardia
Hypoxemia and bradycardia
Apnea in premature infant can develop as late as ___ hours post-op
12 hours
Postconceptual age = ___ age + ___ age
Gestational age + postnatal age
Healthy former premature infants should be greater than ___-___ weeks postconceptual age
Greater than 50-60 weeks
Premature infant—infants displaying bronchopulmonary ___ should NOT be considered for surgery
Bronchopulmonary dysplasia
Premature infants are at ___ (increased/decreased) risk of SIDS—particularly, children with history of ___nea/___cardic events; siblings with ___ (4-5x greater risk)
Premature infants are at increased risk of SIDS—particularly, children with history of apnea/bradycardic events; siblings with SIDS (4-5x greater risk)
Premature infants should not be considered for outpatient surgery until ___ months to ___ year of age
6 months to 1 year of age
Children with prior history of apnea/bradycardic events should be free of apnea/bradycardia for ___ months prior to surgery
6 months prior to surgery
Healthy full-term infant is greater than ___ weeks gestation
37 weeks
Healthy full-term infants may be candidates for outpatient surgery if they do not exhibit any respiratory, failure to thrive, feeding, or apneic problems—T/F?
True
If healthy full-term infant is free of any complications, they can be considered for outpatient surgery case by case at ___ to ___ weeks of age
2 to 4 weeks of age
Geriatric patients are those greater than ___ years of age
65
Geriatric patients—you should consider their physiologic age, not their chronologic age—T/F?
True
Geriatric patients—those aged ___ years or greater are at greater risk for hospital admission and death within the week following surgery
85 years or greater
Geriatric patients must have their existing comorbidities evaluated, adequate home care and transportation in order to be candidates for outpatient surgery—T/F?
True
Patients with convulsive disorders—schedule procedures very ___ (early/late) in the day to provide for optimal observation; should have minimum of ___ to ___ hours of postoperative evaluation
Schedule procedures very early in the day to provide for optimal observation; should have minimum of 4 to 8 hours of postoperative evaluation
Patients with convulsive disorders—ensure proper delivery of anticonvulsant medications; uncontrolled seizure activity is not acceptable in the outpatient setting—T/F?
True
Patients with cystic fibrosis—___ function is the primary predictor of candidacy for outpatient surgery
Pulmonary
Patients with cystic fibrosis—need to consider ability to manage respiratory distress and hydration in the outpatient setting with these patients—T/F?
True
Malignant hyperthermia susceptibility—must have at least 1 of the following criteria: 1) previous ___ episode; 2) ___ rigidity with previous anesthesia; 3) relative (___ degree) with previous MH episode or positive muscle biopsy
1) previous MH episode
2) masseter rigidity with previous anesthesia
3) relative (1st degree) with previous MH episode or positive muscle biopsy
Patients with MH susceptibility—trigger free anesthesia must be provided (that means no depolarizing muscle relaxant succs and no volatile agents used for anesthesia) with at least a ___ hour post-op observation
4 hour post-op observation
Preparation for outpatient surgery in MH susceptible patients—have adequate monitoring available; at minimum, ___ vials of dantrolene; schedule patient ___ (early/late) in the day to allow for a minimum of 4 hours of observation
At minimum, 36 vials of dantrolene; schedule patient early in the day to allow for a minimum of 4 hours of observation
Outpatient surgery in MH susceptible patients—overnight observation in the 23 hour outpatient has been advocated—T/F?
True
Morbid obesity and outpatient surgery—acceptable candidates are ASA class ___ and ___
1 and 2
Morbid obesity and outpatient surgery—patients with comorbidities such as cardiac, endocrine, hepatic, renal, or pulmonary should be done inpatient—T/F?
True
Morbid obesity and outpatient surgery—___ (increased/decreased) risk of difficult airway and sleep apnea; need to do thorough ___ evaluation pre-op; have __ available if patient uses at home
Increased risk of difficult airway and sleep apnea; need to do thorough airway evaluation pre-op; have CPAP available if patient uses at home
Morbid obesity and outpatient surgery—prepare for short PACU admission—T/F?
False—prepare for prolonged PACU admission
Reactive airway disease and outpatient surgery—___ status and ___ of disease should be determined prior to admission
Baseline status and severity of disease should be determined prior to admission
Reactive airway disease and outpatient surgery—patient should not experience acute symptoms, should continue routine medications until time of surgery, and should expect possible admission—T/F?
True
Reactive airway disease and outpatient surgery—two tests that can be performed prior to surgery = ___ x-ray and ___
Chest x-ray and ABG
Sickle cell disease—crisis may occur if patient is subject to ___ia, ___osis, or ___
Hypoxia, acidosis, or dehydration
Sickle cell disease—criteria for outpatient surgery—no major ___ disease (as a result of sickle cell); no sickle crisis for a minimum of ___ year; compliant medical care; schedule ___ (early/late) appointment for optimum observation post-op
No major organ disease; no sickle crisis for a minimum of 1 year; compliant medical care; schedule early appointment for optimum observation post-op
Sickle cell disease should be considered in every African American patient—T/F?
True
Those with sickle cell trait are not susceptible to sickle cell crisis if they are hypoxic—T/F?
False—those with sickle cell trait are still susceptible to sickle cell crisis if they are hypoxic
Patients with sickle cell anemia will usually have surgery done inpatient rather than outpatient—T/F?
True
Unacceptable patient conditions for SDS—ASA ___ or ___ (unstable conditions); ___ (current/previous) substance/ETOH abuse; ___ problems; ___ seizures; newly diagnosed or untreated ___; uncontrolled ___; ___ necessary (sepsis or infectious disease); post-op pain not controlled with ___ meds
ASA 3 or 4; current substance/ETOH abuse; psychosocial problems; uncontrolled seizures; newly diagnosed or untreated OSA; uncontrolled diabetes; isolation necessary (sepsis or infectious disease); post-op pain not controlled with oral meds
History and physical for outpatient surgery—for stable patient, should be within ___ days; within ___ hours for the high risk patient
For stable patient, should be within 30 days; with 72 hours for the high risk patient
Preop lab testing for outpatient surgery has not been found to reduce morbidity—T/F?
True
Lab values good within ___ days of surgery if patient status is stable
60 days
Potassium level should be obtained within ___ days for patients on diuretics/digitalis
7 days
Glucose should be taken ___ of surgery
Morning of surgery
Chest x-ray indications—previous ___ film; history of malignancy with ___; severe ___, ___, ___ or ___ disease; intra___ tumors; history of congenital ___ disease; history of prematurity with residual broncho-pulmonary ___; severe ___ (? cardiomegaly); ___ syndrome (asymptomatic subluxation of atlantoaxial junction); ___ infection
Previous abnormal film; history of malignancy with metastasis; severe asthma, COPD, pulmonary or CV disease; intrathoracic tumors; history of congenital heart disease; history of prematurity with residual broncho-pulmonary dysplasia; severe OSA (? cardiomegaly); Down syndrome; pulmonary infection
Indications for EKG—CV disease—___tension; renal disease; circulatory disease; ___ disease; ___ (40 years or older); significant ___ disease; history of unevaluated pathological-sounding ___ or ___; family history of prolonged ___ syndrome; history of moderate to severe ___; chronic anatomic airway ___ (Pierre Robin Syndrome) at risk for ___-sided heart strain
Hypertension; renal disease; circulatory disease; thyroid disease; diabetes (40 years or older); significant pulmonary disease; history of unevaluated pathological-sounding murmur or palpitation; family history of prolonged QT syndrome; history of moderate to severe OSA; chronic anatomic airway obstruction (Pierre Robin Syndrome) at risk for right-sided heart strain
All cardiopulmonary medication should be taken on the morning of surgery—T/F?
True
Coumadin—if held, should be minimum of ___-___ days
4-5 days
Coumadin—PT should be drawn ___ of surgery
Morning of
Coumadin—restart within ___-___ days post-op
1-7 days post-op
Diabetes and outpatient surgery—patient should be ___ controlled or considered for ___ only
Patient should be well controlled or considered for inpatient only
Diabetes and outpatient surgery—schedule ___ (early/late); NPO after midnight; monitor serum glucose closely ___-, ___-, and ___-op; consider giving ___ of insulin dose day of surgery
Schedule early; NPO after midnight; monitor serum glucose closely pre-, intra-, and post-op; consider giving 1/2 of insulin dose day of surgery
Rhinorrhea—20-30% of children have on/off rhinorrhea most of the year—T/F?
True
Rhinorrhea—children 2 years and younger have 5-10 respiratory infections annually—T/F?
True
Recently acquired rhinorrhea 12-24 hours prior to surgery or chronic rhinorrhea ___ (is/is not) contraindicated for outpatient surgery in an otherwise healthy child
Is not
May consider postponing outpatient surgery ___-___ weeks in a locally infected child
1-2 weeks
Symptoms of URTI—WBCs > ___-___k; muco___ nasal secretions; ___/___ mucosa; ___ (positive/negative) chest findings; temperature ___ C or >; tonsillitis; ___ ulcers in oropharynx; conjunctivitis; ___ (productive/nonproductive) coughing; fatigue; itching; laryngitis; malaise/myalgias; sneezing; ___ throat; ___/___ cultures
WBCs > 12-15k; mucopurulent nasal secretions; inflamed/reddened mucosa; positive chest findings; temperature 38 C or >; tonsillitis; viral ulcers in oropharynx; conjunctivitis; nonproductive coughing; fatigue; itching; laryngitis; malaise/myalgias; sneezing; sore throat; throat/nasal cultures
Performing surgery for questionable URTI—symptomatic should be rescheduled at least ___ weeks later
At least 4 weeks later
Performing surgery for questionable URTI—asymptomatic can be done if the following are met—child older than ___ year, otherwise healthy and surgery is not on ___ or ___; ___ is not planned
Child older than 1 year, otherwise healthy and surgery is not on thorax or abdomen; ETT intubation is not planned
There is an 11-fold increased risk of adverse respiratory complications if surgery requires ETT intubation and child has a URTI—T/F?
True
Anesthesia increases respiratory complications 2-7 fold—T/F?
True
Kids with URTI are more prone to ___-holding, ___spasm, coughing, ___emia, ___ (increased/decreased) secretions, ___spasm, ___onia, ___asis, croup, stridor
Breath-holding, bronchospasm, coughing, hypoxemia, increased secretions, laryngospasm, pneumonia, atelectasis, croup, stridor
Risk factors for respiratory complications during surgery in kids = ___ tube; < ___ years; history of ___; history of ___ airway disease; ___ smoke; ___ secretions; ___ congestion; ___ surgery
ETT; < 5 years; history of prematurity; history of reactive airway disease; second-hand smoke; copious secretions; nasal congestion; ENT surgery
Pulmonary aspiration prophylaxis is indicated in patients who are at high risk for ___
Aspiration
Pulmonary aspiration prophylaxis is not indicated in patients not at risk—T/F?
True
Pulmonary aspiration prophylaxis—this class of drugs reduces gastric volume (example = ___)
Gastrokinetics—reglan
Pulmonary aspiration prophylaxis—this class of drugs blocks H+ ion release from cells, but does not alter pH of gastric fluid that is already present (examples = Tagamet, Pepcid, Zantac)
H2 receptor antagonists
Pulmonary aspiration prophylaxis—this class of drugs inhibits gastric acid secretion without affecting volume; longer duration than H2 blockers (example = Prilosec)
Proton pump inhibitors
Pulmonary aspiration prophylaxis—Prevacid, aciphex, and protonix (all are proton pump inhibitors) are successful in ___ (increasing/decreasing) pH and ___ (increasing/decreasing) gastric volume
Successful in increasing pH and decreasing gastric volume
Goals of outpatient anesthesia—___ physiologic changes; provide fast, smooth onset of anesthetic action; promote intra-op ___/___; afford suitable operating circumstances; minimize perioperative anesthetic ___ effects; allow rapid offset of anesthesia while maintaining patient ___
Minimize physiologic changes; provide fast, smooth onset of anesthetic action; promote intra-op amnesia/analgesia; afford suitable operating circumstances; minimize perioperative anesthetic side effects; allow rapid offset of anesthesia while maintaining patient comfort
Choice of anesthetic is based on—___ requirements; skill of ___; skill of ___; patient ___; patient ___; ___ status; level of care available to the patient upon ___
Surgical requirements; skill of surgeon; skill of anesthesia provider; patient preference; patient age; ASA status; level of care available to the patient upon discharge
___ anesthesia is the most used technique in SDS
General
General anesthesia for SDS—use of ___, ___ (short/long) acting, ___ (slow/fast) onset and offset agents
Use of potent, short-acting, rapid onset and offset agents
Airway management for outpatient surgery—___ has many advantages if no contraindications exist—___ (more/less) coughing/sore throat, ___ (more/less) analgesic needed
LMA has many advantages if no contraindications exist—less coughing/sore throat, less analgesic needed
Airway management for outpatient surgery—ETT has ___ (increased/decreased) incidence of post-extubation croup, sore throat; delayed ability to resume ___ intake; utilize ___ (small/large) tubes
ETT has increased incidence of post-extubation croup, sore throat; delayed ability to resume PO intake; utilize small tubes
Selection of regional anesthesia for outpatient surgery—should use the ___- (shortest/longest) acting agent capable of providing adequate blockade without prolonging discharge with neuraxial blockade
Shortest-acting agent
Advantages of regional anesthesia—___ (shorter/longer) recovery times; inpatient admission is ___ (increased/decreased); ___ (immediate/delayed) post-op pain relief; GA side effects are ___ (minimized/maximized); patient with fear of GA/loss of control has an alternative
Shorter recovery times; inpatient admission is decreased; immediate post-op pain relief; GA side effects are minimized; patient with fear of GA/loss of control has an alternative
Disadvantages of regional anesthesia—___ of patient and surgeon are required; may require ___ (more/less) time than GA; inherent problems to regional anesthesia—sympathetic block associated with spinal and epidural may complicate discharge with orthostatic ___tension, inability to empty ___, ___ headache, ___ neurologic symptoms
Cooperation of patient and surgeon are required; may require more time than GA; inherent problems—orthostatic hypotension, inability to empty bladder, PDP (spinal) headache, transient neurologic symptoms
Top 2 postoperative complications after outpatient surgery/reason for inpatient admission = ___ and ___
Nausea/vomiting and excessive pain
Major postoperative morbidities—myocardial infarction, stroke, PE, respiratory failure…most common time for these to occur is within first ___ hours postoperatively
Within first 48 hours postoperatively
In the geriatric patient, greatest risk for postoperative mortality is ___ week
1
Contributors to PONV—___lation; postural ___tension; uncontrolled ___; post-op ___ meds; ___ intake; ___ (low/high) inspired O2 concentration; ___ agents
Ambulation; postural hypotension; uncontrolled pain; post-op pain meds; oral intake; low inspired O2 concentration; reversal agents
Who is at risk for PONV?—patients with history of prolonged ___; procedures associated with increased nausea—i.e.:, ___ surgery (wired jaw); procedures where ___ could jeopardize the surgical result (i.e.: ___/___ surgery)
Patients with history of prolonged PONV; procedures associated with increased nausea—i.e.: mandibular surgery (wired jaw); procedures where retching could jeopardize the surgical result (i.e.: plastics/eye surgeries)
PONV treatment options—corticosteroids (i.e.: ___)—the earlier received, the better the outcome
Decadron
PONV treatment options—butyrophenone/dopamine receptor antagonist (i.e.: ___); give in small doses 20 mcg/kg immediately following induction or 5-10 mg orally
Droperidol
PONV treatment options—indirect-acting sympathomimetic (i.e.: ___); 0.5 mg/kg given IM immediately at end of surgery or 10-25 mg IV
Ephedrine
PONV treatment options—gastric suctioning is ___
Controversial—no confirmed benefit
PONV treatment options—reglan 0.15 mg/kg IV post-op; advantage is that it causes no ___; disadvantage is ___ side effects
Advantage is that it causes no sedation; disadvantage is extrapyramidal side effects
PONV treatment options—selective serotonin type 3 receptor antagonist (i.e.: ___); 0.15 mg/kg IV
Zofran
PONV treatment options—phenothiazine/dopamine receptor antagonist (i.e.: ___); 0.5 mg/kg IV/IM—potential for delayed discharge secondary to ___ effects
Phenergan; potential for delayed discharge secondary to sedative effects
Postoperative pain requirements are ___ (increased/decreased) with regional, opioid/non-opioid, non-steroidal anti-inflammatories, wound infiltration with local anesthetic
Decreased
Postoperative pain—control immediate post-op pain with a ___ (short/long) acting analgesic; once controlled and patient is taking PO, give ___ analgesic intended for discharge—use this to evaluate patient comfort and ability to manage pain post-op
Short-acting analgesic; give oral analgesic intended for discharge
Phase 1 of anesthesia recovery—___ VS; no ___ impairment; protective ___ reflexes, ___ present; patient oriented to ___ level; parameters are assumed to not change
Stable VS; no respiratory impairment; protective airway reflexes, cough present; patient oriented to preoperative level; parameters are assumed to not change
Phase 2 of anesthesia recovery—___ assistance and capable caregiver; no ___ distress; bleeding ___; pain ___; PONV ___; ___ intake; ___ing (bathroom); responsible ___ present
Ambulation assistance and capable caregiver; no respiratory distress; bleeding minimal; pain controlled; PONV minimal; oral intake; voiding (bathroom); responsible caregiver present
MAC sedation = ___
Monitored anesthesia care sedation
MAC sedation—patient must be able to protect own ___; patient must be ___ independently without loss of ___
Patient must be able to protect own airway; patient must be breathing independently without loss of consciousness
MAC anesthesia—a gentle jaw thrust with initial insult is OK, but prolonged airway management is a ___ anesthetic
General
Incidence of brain damage or death are both ___ (higher/lower) in MAC anesthesia over general/regional anesthesia
Higher in MAC anesthesia over general/regional anesthesia
26% of adverse outcomes with MAC sedation are ___ related
Respiratory
10% of adverse outcomes with MAC sedation are ___ related
Cardiac
Deep sedation—patient ___ (is/is not) easily aroused; responds appropriately to ___ stimuli; may need assistance with maintaining ___ airway; CV function is usually unaltered
Patient is not easily aroused; responds appropriately to painful stimuli; may need assistance with maintaining patent airway; CV function is usually unaltered
Minimal sedation (anxiolysis)—cognitive function may be impaired, but patient can respond ___; respiratory/CV function are ___ (changed/unchanged)
Cognitive function may be impaired, but patient can respond verbally; respiratory/CV function are unchanged
Conscious sedation is an obsolete term and has been replaced by “moderate sedation”—T/F?
True
What type of sedation is this?—patient can be directed by physician performing the procedure; depth does not allow loss of protective reflexes
Moderate sedation
What type of sedation is this?—similar to moderate sedation but must have anesthesia personnel that can change to general anesthesia
MAC—monitored anesthesia care sedation
Types of sedation (in order of least to greatest depth):
1) Minimal sedation (anxiolysis)—patient can respond verbally
2) Moderate sedation—protective reflexes intact
3) MAC sedation—can protect airway and breathe independently (only jaw thrust with initial induction)
4) Deep sedation (responds to pain, needs assistance maintaining patent airway)
5) General anesthetic (comatose)
Causes of hypotension post-op—___ is most common cause; ___thermia causing veno___; ___ ventricular dysfunction may occur in sepsis, hypoxemia, or acidosis and cause hypotension
Hypovolemia is most common cause; hypothermia causing venoconstriction; left ventricular dysfunction may occur in sepsis, hypoxemia, or acidosis and cause hypotension
PAC/PVC causes—___magnesemia; ___kalemia; ___ (increased/decreased) sympathetic tone; myocardial ___ (least common cause)
Hypomagnesemia; hypokalemia; increased sympathetic tone; myocardial ischemia (least common cause)
Postoperative laryngospasm—first line treatment is ___; if unresponsive, give ___ ___ mg/kg IV
First line treatment is positive pressure; if unresponsive, give succs 0.1 mg/kg IV
Avoid droperidol (antipsychotic/antiemetic) in patients with pre-existing ___ abnormalities; recommend ___-___ hours monitoring and 12-lead ECG following administration
Pre-existing ECG abnormalities; recommend 2-3 hours monitoring and 12-lead ECG following administration
Least effective pain medication routes = ___ or ___ injections
Subcutaneous or IM injections—erratic absorption compared to other routes
Preferred route of pain medication administration = ___
IV
Secondary routes of pain medication administration = ___, ___
Sublingual, rectal
What ambulatory surgical procedure is this?—removal of endometrial lining and any polyps or myomas; used to complete a missed or incomplete spontaneous abortion; treatment of cervical stenosis; diagnose and treat bleeding; less extent, this procedure can be done to terminate pregnancy
D&C—dilation and curettage
Positioning for D&C = ___; less than ___ degree abduction is recommended
Dorsal lithotomy; less than 40 degree abduction is recommended
Blood loss management for D&C—___ 0.2 mg IM; ___ 10-20 units IV, causes contraction of uterus, found in the ___
Methergine 0.2 mg IM; oxytocin (pitocin) 10-20 units IV, causes contraction of uterus, found in the refrigerator
This procedure allows examination of the endometrial cavity; useful in diagnosis of uterine bleeding; common causes of uterine bleeding such as polyps and myomas are often able to be removed through hysteroscope
Hysteroscopy
How is hysteroscopy performed?—___ position
Lithotomy
Risks with CO2 distention during hysteroscopy—minimize risks with flow less than ___ml/min; intrauterine pressure should be less than ___ mm Hg—reduces risk of cardiac ___; may expect increased risk of ___ pain with insufflation
Minimize risks with flow less than 1200 ml/min; intrauterine pressure should be less than 200 mm Hg—reduces risk of cardiac arrhythmias; may expect increased risk of shoulder pain with insufflation
Neuraxial anesthesia for hysteroscopy—risk of ___ headache, increased risk with ___ (young/old) age; use of pencil point needle ___ (increases/decreases) risk of this because it separates fibers of the spinal canal rather than cutting them
Risk of spinal headache (PDPH), increased with young age; use of pencil point needle decreases risk of this because it separates fibers of spinal canal rather than cutting them
What is an adequate block level for a hysteroscopy?
T10
Risk for ___ damage with lithotomy position
Nerve
TMJ arthroscopy complications—___ and ___ nerve damage; partial ___ loss; ___go; ear ___; ___age
Facial and trigeminal nerve damage; partial hearing loss; vertigo; ear fullness; hemorrhage
Muscle relaxation and GA always improve mouth opening in TMJ patients—T/F?
False—do not always improve mouth opening in TMJ patients
Who needs GA for orthodontic/dental procedures?—mentally ___; young ___; patients with oral ___; patients with poorly controlled ___ disorders; patients presenting for ___ procedures
Mentally retarded; young children; patients with oral sepsis; patients with poorly controlled seizure disorders; patients presenting for TMJ procedures
ETT for dental surgeries—___ (endotracheal/nasotracheal) tube is preferred placement in dental surgeries
Nasotracheal
Nerve damage from dental surgeries—damage to ___ nerve during surgical tooth extraction = numbness of tongue
Lingual nerve
Nerve damage from dental surgeries—damage to the ___ alveolar nerve during surgical tooth extraction = lip numbness
Inferior alveolar nerve
Rheumatoid arthritis considerations for dental surgeries—instability/immobility of ___ spine; immobility of the ___ joint
Instability/immobility of cervical spine; immobility of the cricoarytenoid joint
Shoulder arthroscopy—preferred anesthetic technique is ___/___ technique
Regional/general technique
Positioning for shoulder arthroscopy = semi-___, beach ___ position
Semi-sitting, beach chair position
Semi-sitting/beach chair position for shoulder arthroscopy = increased risk of venous ___; postural ___tension can be severe—ease into position to lessen, proper ___ and ___ stockings recommended; maintain adequate BP, MAP < ___, epi 1mg/3ml)
Increased risk of venous air embolism; postural hypotension can be severe—ease into position to lessen, proper hydration and antiembolism stockings recommended; maintain adequate BP, MAP < 80, epi 1mg/3ml)
You should use nasal airways for difficult mask ventilation during tonsillectomy/adenoidectomy—T/F?
False—nasal airways can increase the risk of bleeding d/t trauma or hypertrophied adenoid tissue
Tonsillectomy/adenoidectomy—patients who do not need premedication are those with ___ and upper airway ___
OSA and upper airway obstruction
Adult patient arrives for T&A that has fever, nasal secretions, purulent sputum. Should you proceed with the surgery?
No—patient exhibits signs of URI; advise postponement of surgery and reschedule when symptoms subside
ETT for tonsillectomy/adenoidectomy—proper securement of ETT is ___ to lower ___
Midline to lower lip
How do you know if your patient is still bleeding after T&A?—frequent ___; ensure a maximally protected airway with an ___ intubation
Frequent swallowing; ensure a maximally protected airway with an awake intubation
Avoid ___capnia during emergence after T&A because this increases vaso___, which can increase bleeding
Avoid hypercapnia during emergence after T&A because this increases vasodilation, which can increase bleeding
Post-op positioning for T&A = ___, head ___ position (tonsillar position)
Lateral, head down position
Positioning for T&A—___ with elevation of shoulders using shoulder roll; arms ___ (beware of fingers); slight ___ may be requested
Supine with elevation of shoulders using shoulder roll; arms tucked (beware of fingers); slight reverse trendelenberg may be requested
T&A postoperative complications—___spasm; ___ing; retained ___ that can cause upper airway ___; postobstructive pulmonary ___
Laryngospasm; bleeding; retained throat pack that can cause upper airway obstruction; postobstructive pulmonary edema
What is the most common arthroscopic procedure performed?
Knee arthroscopy—to diagnose and treat intra-articulation disorders of the knee
Most common complication of knee arthroscopy = ___arthrosis
Hemarthrosis
Anesthesia for knee arthroscopy = ___ anesthesia; combination of ___ and ___ anesthesia
Regional anesthesia; combination of regional and general anesthesia
Goal of sterile technique for central line placement is to prevent ___
Infection
Site preparation with chlorhexidine—___ second friction rub, must allow to air dry for ___ minutes
30 second friction rub, must allow to air dry for 2 minutes
For children < 2 months old, ___ may be used instead of chlorhexidine gluconate prep for central line insertion
Povidone iodine
What is the most common/preferred site for CVC placement?
Right internal jugular
Risks of RIJ central line placement—___ damage; venous ___ embolism; carotid ___ puncture
Nerve damage; venous embolism; carotid artery puncture
LIJ risks—___thorax (leakage of lymphatic fluid from thoracic duct into pleural space); ___ effusion; carotid ___ puncture; ___ damage; venous ___ embolism
Chylothorax; pleural effusion; carotid artery puncture; nerve damage; venous air embolism
Subclavian—lower ___ rate; higher risk of ___
Lower infection rate; higher risk of pneumothorax
External jugular—___ make it difficult to thread the catheter; risks = kinking/migration, phlebitis, arterial puncture
Valves
Femoral is commonly used for CVC insertion—T/F?
False—it is used only when unable to insert CVC elsewhere
Femoral has high incidence of CVC-related ___
Sepsis
Right internal jugular vein catheterization has ___ (lower/higher) incidence of pneumothorax compared to left due to lower dome of pleura on right side
Lower incidence
Right IJ is ___ (more/less) likely to become contaminated due to respiratory secretions
More likely
Ultrasound for CVC insertion—internal jugular vein [compared to the carotid artery] should be more ___ (superficial/deep), ___ (smaller/larger), ___-shaped (oval/round), and ___ (compressible/not compressible)
More superficial, larger, oval-shaped, and compressible
If you can’t visualize the internal jugular vein on ultrasound, it might be compressed, so try using lighter pressure with the ultrasound probe. If you still can’t see it, the patient just might be severely hypovolemic.—T/F?
True
CVC insertion—blood should not flow higher than the cm of central venous pressure expected—T/F?
True
CVC insertion—if shunting is present, venous blood may appear darker than normal—T/F?
False—blood may appear brighter than normal
CVC insertion—in certain conditions (i.e.: tricuspid regurgitation and atrial fibrillation), the central venous pressure may appear to be pulsatile—T/F?
True
If the patient develops an unstable rhythm as you are passing the guidewire, you should ___ the wire immediately
Withdraw
For right IJ CVC, the catheter should be secured at around ___ cm, depending on the patient’s height (height/10 cm)
16 cm
For right subclavian CVC, the catheter should be secured at around ___ cm, depending on the patient’s height ([height/10 cm]-2 cm)
15 cm
For left IJ, the catheter should be secured at around ___ cm, depending on the patient’s height ([height/10 cm]+4 cm)
20 cm
For left subclavian, the catheter should be secured at around ___ cm, depending on the patient’s height ([height/10 cm]+2 cm)
19 cm
If removal of CVC is planned, place the patient in ___ position, ask the patient to ___ (inhale/exhale) as catheter is removed to prevent ___; apply pressure over the site for 1-2 minutes until hemostasis is achieved
Trendelenberg position, ask the patient to exhale as catheter is removed to prevent air embolism
Risk for arterial puncture is greatest with ___ CVC
Femoral > IJ > subclavian
Risk for infection is greatest with ___ CVC
Femoral > IJ > subclavian
Risk for pneumothorax is greatest with ___ CVC
Subclavian
Three areas of anesthesia with highest incidence of recall = ___, ___, and ___
CV, OB, trauma
5 criteria for potential cervical spine injury: 1) ___ pain; 2) severe ___ pain; 3) any ___ signs and symptoms; 4) ___cation; 5) loss of ___ at the scene
1) neck pain; 2) severe distracting pain; 3) any neurological signs and symptoms; 4) intoxication; 5) loss of consciousness at the scene
To intubate a patient with a cervical spine injury, the best way is ___ (MILS); can be used with glide scope
Manual inline stabilization (MILS)
Avoid ___ (what inhalation agent?) in trauma patients with a pneumothorax, pneumocephalus, or pneumoperitoneum
Nitrous oxide (N2O)
Succinylcholine can increase serum potassium levels if administered ___ hours after a burn, spinal cord, or crush injury
24 hours
Postop after massive transfusions, patients get metabolic ___osis
Alkalosis
If transfusion rate exceeds 1 unit every 5 minutes, you can see cardiac ___ caused by ___calcemia
Cardiac depression caused by hypocalcemia
In an anesthetized patient, hemolytic reactions are recognized by ___thermia, ___cardia, ___tension, ___globinuria, and ___ at the field
Hyperthermia, tachycardia, hypotension, hemoglobinuria, and oozing at the field
(From last semester)—hypotension and hemoglobinuria will NOT be masked by anesthesia during a true hemolytic reaction
Want to give ___ (warm/cold) fluids to trauma patients
Warm!…hypothermia worsens acid/base balance, causes coagulopathies, and risks myocardial function
Common cause of bleeding after massive transfusions is ___
Dilutional thrombocytopenia
Crystalloids have a half-life of ___-___ minutes
20-30 minutes
Colloids have a half-life of ___-___ hours
3-6 hours
Fluid resuscitation for trauma—___ is less likely to cause hyperkalemic acidosis than ___
LR is less likely to cause hyperkalemic acidosis than NS
Fluid resuscitation—___ in LR makes it incompatible with blood transfusions (why we hang NS, not LR, with blood transfusions)
Calcium
Fluid resuscitation—___ solutions are contraindicated in trauma because they may exacerbate ischemic brain damage
Dextrose
Fluid resuscitation—LR is slightly ___tonic; giving large volumes can aggravate ___ edema
LR is slightly hypotonic; giving large volumes can aggravate cerebral edema
___ (crystalloids/colloids) are effective in rapidly restoring intravascular volumes
Colloids (i.e.: albumin)
Dextran and hetastarch may cause ___
Coagulopathy
Type ___ blood can be released to the moribund trauma patient requiring immediate blood transfusion that has not been typed and crossed
O negative blood
Factor VIII can decrease by ___% after two days in storage; for this reason, dilutional ___ quickly develops when a patient is massively transfused
50%; for this reason, dilutional thrombocytopenia quickly develops when a patient is massively transfused
Use ___ (more/less) anesthetic in the hypovolemic patient
Less
Alveolar concentration is ___ (increased/decreased) in shock patients d/t a ___ (increase/decrease) in CO and ___ (increased/decreased) ventilation
Alveolar concentration is increased in shock patients d/t a decrease in CO and increased ventilation
Decrease in CO = train is not coming through as frequently; concentration of inhaled anesthetics builds up in alveoli; as patient breathes more frequently, more gas is taken up more quickly…moral of the story: LESS GAS is needed in trauma patients!
Trauma patients have ___ (more/less) intravascular volume, so intravenous anesthetics are exaggerated when given
Less intravascular volume
Induction agents of choice for the hypovolemic trauma patient—___ and ___
Ketamine and etomidate
Trauma patients are always at risk for ___; always assume a ___
Aspiration; always assume a full stomach
___ = circulatory failure leading to inadequate organ perfusion and oxygen delivery
Shock
Consider a ___ injury in any trauma patient with an altered level of consciousness
Brain injury
Cushing’s Triad—nervous system’s response to increased ___; ___tension, ___cardia, irregular ___
Nervous system’s response to increased ICP; hypertension, bradycardia, irregular respirations
Cushing’s triad is early signs of brain injury—T/F?
False—LATE signs that are preceded by brain herniation
Brain injuries—no sedatives or analgesics should be given if neuro exam is to be conducted—T/F?
True
Anticholinergic meds cause pupillary ___ (i.e.: robinol, spiriva, atrovent)
Dilation
Beck’s Triad = signs of pericardial ___, which is d/t an excessive accumulation of fluid within the ___; ___ distention, ___tension, ___ heart tones
Signs of pericardial effusion, which is d/t an excessive accumulation of fluid within the pericardial sac; neck vein distention, hypotension, muffled heart tones
Pulsus paradoxus = ___ mm Hg ___ (increase/decrease) in BP during spontaneous ventilation
10 mm Hg decrease in BP during spontaneous ventilation
Abdominal traumas usually need an ___
Exploratory laparotomy
Abdominal trauma—___tension occurs when abdomen is opened
Hypotension—air and/or fluid that was sitting in the abdomen leaks out of body (path of least resistance), so pressure drops
Abdominal traumas require ___ IV and ___…___ is key!
Large bore IV and blood…fluid resuscitation is key!
Remember, massive transfusions are associated with ___kalemia
Hyperkalemia
Pelvic fractures can lead to ___volemic shock
Hypovolemic shock
___ can occur with fractures
Fat embolism
Fat embolism—labs—elevation of serum ___; ___ in urine; thrombo___
Elevation of serum lipase; fat in urine; thrombocytopenia
Extremity reattachment—in general, keep patients ___ and avoid ___ on emergence to help reperfusion
Keep patients warm and avoid shivering on emergence to help reperfusion
LeFort ___ fractures are associated with increased risk with intubation—ETT may go through the fracture and right into the brain, instead of through the trachea
III
Intracranial hypertension is controlled by ___ restrictions, ___, ___capnia (PaCO2 goal ___-___ mm Hg)
Fluid restrictions, diuretics (mannitol), hypocapnia (PaCO2 goal 26-30 mm Hg)
Hypertension/tachycardia during intubation can be treated with ___ and/or ___
Lidocaine and/or fentanyl
Avoid ___ in patients with increased ICP because it increases ICP
Ketamine
Spinal cord injuries—injury to C___-C___ can cause apnea
C3-C5 (C3,C4,C5 phrenic nerve, keeps the diaphragm alive)
Spinal cord injuries—T___-T___ = cardiac accelerators
T1-T4
With a high spinal cord injury, you may see spinal shock—loss of ___ (sympathetic/parasympathetic) tone—___tension, ___ to the touch, ___cardia, ___reflexia, and ___ atony
Spinal shock = loss of sympathetic tone—hypotension, warm to the touch, bradycardia, areflexia, and GI atony
Autonomic hyperreflexia usually doesn’t occur in the first ___ hours after spinal cord injury
48 hours
Autonomic hyperreflexia is a reaction of the ___ (somatic/autonomic) nervous system in response to ___ (over/under) stimulation; this reaction may include ___tension (can be extreme), change in ___ rate, ___ color changes, and excessive ___
Autonomic hyperreflexia is a reaction of the autonomic nervous system in response to overstimulation; this reaction may include hypertension (can be extreme), change in heart rate, skin color changes (paleness, redness, blue-grey skin color), and excessive sweating
What type of pneumothorax is this?—air in the parietal and visceral pleura; lung collapse causes V/Q mismatch and hypoxia
Simple pneumothorax
Treatment of simple pneumothorax—chest tube ___ or ___ intercostal space
4th or 5th
What type of pneumothorax is this?—air in pleural space is trapped and increases with inspiration but cannot escape with expiration; will see tracheal deviation
Tension pneumothorax
Treatment of tension pneumothorax—14 gauge needle at ___ intercostal space, mid-___ line; then place chest tube
14 gauge needle at second intercostal space, mid-clavicular line
Acute respiratory distress syndrome (ARDS)—___ (acute/delayed) lung response to trauma
Delayed
ARDS mortality = ___%
50%
When caring for the trauma patient, priority should be ___ and ___ efforts first and foremost…then you can turn on gas/give other drugs
Airway and resuscitative efforts
Geriatric = patients over the age of ___
65
Geriatric CV changes—___ (increase/decrease) in elasticity of arteries; ___ (increased/decreased) afterload; ___ (increased/decreased) systolic pressures; left ventricular ___trophy; adrenergic [sympathetic] activity ___ (increases/decreases); ___ (increased/decreased) heart rate both rest and max; ___ (increased/decreased) baroreceptor response
Decrease in elasticity of arteries; increased afterload; increased systolic pressures; left ventricular hypertrophy; adrenergic activity decreases; decreased heart rate both rest and max; decreased baroreceptor response
Heart rate declines ___ beat per minute per year over the age of 50
1 beat per minute per year over the age of 50
Conduction system fibrosis and loss of SA node cells ___ (increases/decreases) chances of arrhythmias
Increases
Atrial enlargement in geriatric patients puts them at risk for ___ and most commonly, atrial ___
SVT and most commonly, atrial fibrillation
Geriatrics—left ventricular wall ___ (thins/thickens) by decreasing the cavity; as a result, SV and CO ___ (increase/decrease)
Left ventricular wall thickens by decreasing the cavity; as a result, SV and CO decrease
What type of hypertrophy is this?—ventricular dilation while maintaining normal sarcomere lengths—the heart can expand to receive a greater volume of blood; the wall thickness normally increases in proportion to the increase in chamber radius
Eccentric hypertrophy
What type of hypertrophy is this?—in the case of chronic pressure overload (as through anaerobic exercise, which increases resistance to blood flow by compressing arteries), the chamber radius may not change; however, the wall thickness greatly increases as new sarcomeres are added in-parallel to existing sarcomeres
Concentric hypertrophy
Geriatrics—decrease in CV system causes ___ (spikes/drops) in BP during induction; autonomic responses that maintain homeostasis progressively ___ (improve/decline)
Drops in BP during induction; progressively decline
Geriatrics—circulation time will ___ (slow/speed up) IV drugs but ___ (slows/speeds) induction with inhalation agents
Slow IV drugs but speeds induction with inhalation agents
Two CV responses that are altered d/t blunted beta-receptor response—decreased maximal ___ rate and decreased peak ___ fraction
Decreased maximal heart rate and decreased peak ejection fraction
The elderly patient is more dependent on an increase in end-___ (systolic/diastolic) volume than an increase in ___ to produce an increase in CO; this makes the geriatric patient more prone to ___ heart failure when large volumes of IV fluids are administered in the presence of anesthetic-induced myocardial depression and hypotension
Increase in end-diastolic volume than an increase in heart rate to produce an increase in CO; this makes the geriatric patient more prone to congestive heart failure when large volumes of IV fluids are administered in the presence of anesthetic-induced myocardial depression and hypotension
Geriatric respiratory changes—___ (increase/decrease) in elasticity of lungs; ___ (increase/decrease) in alveolar surface area; ___ (increased/decreased) residual volume; ventilation/perfusion ___ (match/mismatch); ___ (increased/decreased) chest wall rigidity; ___ (increased/decreased) cough; blunted response to ___capnia and ___ia; ___ (increased/decreased) max breathing capacity; ___ (increased/decreased) closing capacity and closing volume
Decrease in elasticity of lungs; decrease in alveolar surface area; increased residual volume; ventilation/perfusion mismatch; increased chest wall rigidity; decreased cough; blunted response to hypercapnia and hypoxia; decreased max breathing capacity; increased closing capacity and closing volume
Geriatrics—will see an ___ (over/under) distention of alveoli; ___ of small airways
Over distention of alveoli; collapse of small airways
Edentulous patients are difficult to ___
Mask ventilate—cheeks suck in so the mask does not fit as well
Geriatric patients are at ___ (increased/decreased) risk of aspiration d/t ___ (increase/decrease) in airway reflexes
Increased risk of aspiration d/t decrease in airway reflexes
Geriatrics respiratory—FRC ___ (increases/decreases) slightly; vital capacity significantly ___ (increases/decreases); residual volume ___ (increases/decreases) with age; total lung capacity ___ (increases/decreases) with age; elderly have signs of both ___ and ___ disease; dead space ___ (increases/decreases)
FRC increases slightly; vital capacity significantly decreases; residual volume increases with age; total lung capacity decreases with age; elderly have signs of both restrictive and obstructive disease; dead space increases
Vital capacity in geriatric patients significantly ___ (increases/decreases) with age—___ ml per year starting at age 20
Significantly decreases with age—25 ml per year starting at age 20
Vd/Vt ratio ___ (increases/decreases) with age
Increases with age
Dead space increases, tidal volume decreases
Vd/Vt will increase with age because dead space increases with age
Geriatrics GI—gastric pH ___ (increases/decreases); gastric emptying ___ (speeds up/slows); some elderly patients have ___ (smaller/larger) stomach volumes than younger patients
Gastric pH increases; gastric emptying slows; some elderly patients have smaller stomach volumes than younger patients
Geriatrics temperature—heat production ___ (increases/decreases); heat loss ___ (increases/decreases); ___ (increased/decreased) metabolic rate; ___ (sufficient/deficient) thermostat control
Heat production decreases; heat loss increases; decreased metabolic rate; deficient thermostat control
Geriatric renal changes—___ (increased/decreased) renal blood flow; ___ (increased/decreased) GFR; ___ (increased/decreased) renal mass; impaired ___ (what electrolyte?) handling; ___ (increased/decreased) concentration/dilution; ___ (increased/decreased) drug excretion; ___ (increased/decreased) renin-aldosterone response; impaired ___ (what electrolyte?) excretion
Decreased renal blood flow; decreased GFR; decreased renal mass; impaired sodium handling; decreased concentration/dilution; decreased drug excretion; decreased renin-aldosterone response; impaired potassium excretion
Renal cortex in geriatric patients is replaced with fat and fibrotic tissue—T/F?
True
Serum creatinine is ___ r/t decrease in muscle mass and decreased production of creatinine
The same
Geriatrics—BUN gradually ___ (increases/decreases) 0.2% mg/dL per year
Decreases
Geriatrics are predisposed to ___ as well as fluid ___ r/t sodium, dilution, and concentration management changes
Dehydration as well as fluid overload r/t sodium, dilution, and concentration management changes
Geriatrics—inability to reabsorb glucose ___ (increases/decreases)
Decreases
So more glucose is reabsorbed
Geriatrics—decreased blood flow to the kidney increases the risk of acute renal ___
Failure
The most specific test of renal failure is ___ (___ hours) to assess ___
Serum creatinine clearance (25 hours) to assess GFR
Geriatrics nervous system—cerebral blood flow and brain mass ___ (increase/decrease); neurotransmitters and their receptors ___ (increase/decrease)
Decrease; decrease
Physical activity has proven to preserve cognitive function—T/F?
True
Geriatrics have ___ (increased/decreased) thresholds to touch, temperature, and pain; ___ (increased/decreased) thresholds to proprioception, hearing, and vision
Increased thresholds…so they are slower to respond to tactile, temperature, and painful stimulation
Increased thresholds to proprioception, hearing, and vision
Geriatrics—dosages for local and general anesthetics are ___ (increased/decreased)
Decreased
Geriatrics—epidural tends to have a more ___ (cephalad/caudal) spread
Cephalad
Geriatric patients need more time to recover cognitively from general anesthetics—T/F?
True
Pharmacokinetics-relationship between drug dose and ___ concentrations
Plasma
Pharmacodynamic-relationship between plasma concentrations and ___ effect
Clinical
Geriatrics—___ (increase/decrease) in muscle mass and ___ (increase/decrease) in body fat
Decrease in muscle mass and increase in body fat
Geriatrics—___ (increased/decreased) total body water can lead to ___ (lower/higher) plasma concentrations of water-soluble drugs
Decreased total body water can lead to higher plasma concentrations of water-soluble drugs
Geriatrics—___ (increased/decreased) volume of distribution; this can ___ (increase/decrease) plasma concentrations of fat-soluble drugs
Increased volume of distribution; this can decrease plasma concentrations of fat-soluble drugs
Geriatrics—many drugs have ___ (shortened/prolonged) effects d/t renal and hepatic function ___ (improving/declining)
Many drugs have prolonged effects d/t renal and hepatic function declining
Geriatrics—MAC for inhalation agents decreases by ___% per decade after age ___
Decreases by 4% per decade after age 40
Onset of inhalation agents is more ___ (slow/rapid) if cardiac output is decreased
Rapid
Geriatrics—lower doses of barbiturates, opioid agonists, and benzos can be given—T/F?
True
Lower doses of muscle relaxants should be given to geriatric patients—T/F?
False—no change in muscle relaxant effects in geriatrics…just be cautious in renal patients d/t prolonged excretion
Most plasma proteins are unchanged in geriatric patients; albumin levels are slightly ___ (increased/decreased); alpha-1 glycoprotein (AAG) ___ (increases/decreases)—this protein binds with local anesthetics and opioids
Albumin levels are slightly decreased; alpha-1 glycoprotein (AAG) increases—this protein binds with local anesthetics and opioids
___ is aka Hutchinson-Gilford syndrome; premature aging
Progeria
Anesthesia considerations for progeria—patients will have ___ heart disease, ___ tension, cerebrovascular disease, ___arthritis, and diabetes mellitus; mandibular ___plasia; ___gnathia; ___ (narrow/wide) glottic opening—have to use ETT 1-2 sizes ___ (smaller/larger)
Patients will have ischemic heart disease, hypertension, cerebrovascular disease, osteoarthritis, and diabetes mellitus; mandibular hypoplasia; micrognathia; narrow glottic opening—have to use ETT 1-2 sizes smaller
Who is responsible for proper patient position on OR table?
Anesthesia
Bone cement hardens by an ___ (endothermic/exothermic) reaction
Exothermic reaction
Bone cement—residual MMA monomer produces vaso___, ___ (increase/decrease) in SVR
Vasodilation, decrease in SVR
Bone cement—tissue thromboplastin release may cause platelet ___, micro___ (to the lungs), and CV ___ (stability/instability)
Platelet aggregation, microthrombus (to the lungs) and CV instability
Bone cement implantation syndrome—___ia (from increased pulmonary shunt); ___tension; dysrhythmias—heart ___ and sinus ___; pulmonary ___tension—___ (increased/decreased) PVR; ___ (increased/decreased) cardiac output; embolization occurs most frequently during prosthetic ___
Hypoxia (from increased pulmonary shunt); hypertension; dysrhythmias—heart block and sinus arrest; pulmonary hypertension—increased PVR; decreased cardiac output; embolization occurs most frequently during prosthetic insertion
Strategies to minimize effects of MMA—___ (increase/decrease) inspired O2 prior to use of MMA; maintain ___volemia; administer vaso___ as needed; surgical methods—___ distal femur, ___ (low/high) pressure lavage of femoral shaft
Increase inspired O2 prior to use of MMA; maintain ESU volemia; administer vasopressors as needed; surgical methods—venting distal femur, high pressure lavage of femoral shaft
Pneumatic tourniquets are used on upper/lower extremities to create a bloodless field—T/F?
True
Tourniquet problems—hemodynamic and metabolic ___; pain; arterial ___ and pulmonary ___; muscle and nerve ___; limb ___ (warming/cooling)
Hemodynamic and metabolic changes; pain; arterial thromboembolism and pulmonary embolism; muscle and nerve injury; limb cooling
Hemodynamic changes with pneumatic tourniquets—exsanguination of a limb shifts blood volume into ___ (central/peripheral) circulation; prolonged cuff time 45-60 min is associated with ___tension, ___cardia, and ___ (sympathetic/parasympathetic) stimulation [sweating]; cuff deflation ___ (increases/decreases) CVP, MAP, and pain; HR ___ (increases/decreases), core temp ___ (increases/decreases)
Exsanguination of a limb shifts blood volume into central circulation; prolonged cuff time 45-60 min is associated with hypertension, tachycardia, and sympathetic stimulation [sweating]; cuff deflation decreases CVP, MAP, and pain; HR increases, core temp decreases
Tourniquet pain—occurs when cuff pressure is ___ tor/mm Hg above systolic pressure; severe aching and burning after several minutes; involves ___ (myelinated/unmyelinated), ___ (slow/fast) conduction ___ (A/B/C) fibers; ___ (more/less) common in regional anesthesia vs. general
Occurs when cuff pressure is 100 torr/mm Hg above systolic pressure; severe aching and burning after several minutes; involves unmyelinated, slow conduction C fibers; less common in regional anesthesia vs. general
Tourniquet pain requires supplemental analgesia—T/F?
True
Metabolic changes caused by tourniquets—metabolic waste products accumulate in tissue; cuff deflation causes a rapid wash out of the metabolic waste products—PaCO2, ETCO2, serum lactate and potassium ___ (increase/decrease); PaO2 and pH ___ (increase/decrease)
PaCO2, ETCO2, serum lactate and potassium increase; PaO2 and pH decrease
Metabolic changes caused by tourniquets—see ___ (increase/decrease) in minute volume in spontaneously breathing patients and possibly dysrhythmias
See increase in minute volume in spontaneously breathing patients
Metabolic changes caused by tourniquets—___ injuries can occur from free radical formation
Reperfusion injuries
Tourniquet ischemia, especially in a ___ (upper/lower) extremity, leads to deep venous ___
Especially in a lower extremity, leads to deep venous thrombosis
Pulmonary emboli have been reported with leg exsanguination, tourniquet inflation and deflation—T/F?
True
Tourniquets are contraindicated in ___ arteries
Calcified arteries
Prolonged tourniquet inflation is > ___ hours; can cause transient muscular injury, permanent nerve injury, and rhabdomyolysis
> 2 hours
It is important for the CRNA to monitor ___ time and inform the surgeon
Tourniquet time
Some degree of fat embolism occurs in all long bone fractures—T/F?
True
Fat embolism syndrome (FES) is ___ (more/less) frequent and ___ (more/less) fatal than fat embolism
Less frequent and more fatal (10-20% fatality) than fat embolism
Fat embolism syndrome onset is within ___ hours of long bone or pelvic fracture
72 hours
Symptoms of fat embolism syndrome—triad of ___nea, ___, and ___
Dyspnea, confusion, and petechiae
FES is also seen with ___, ___suction, and IV ___
CPR, liposuction, and IV lipids
Pathogenesis of FES—___ globules are released by disrupted fat cells in fractured bone and they enter the ___ through ___ in medullary vessels; ___ (increased/decreased) fatty acid levels are toxic to the capillary-alveolar membrane and release vasoactive ___ and ___
Fat globules are released by disrupted fat cells in fractured bone and they enter the circulation through tears in medullary vessels; increased fatty acid levels are toxic to the capillary-alveolar membrane and release vasoactive amines and prostaglandins
FES can result in ___ syndrome, ___ capillary damage, ___
ARDS, cerebral capillary damage, edema
FES diagnosis—petechiae of ___, ___ extremities, ___, and ___
Chest, upper extremities, axillae, and conjunctiva
FES diagnosis—fat globules in ___, ___, ___
Fat globules in retina, urine, sputum
FES diagnosis—coagulation abnormalities—___penia, ___ (shortened/prolonged) clotting time sometimes seen
Thrombocytopenia, prolonged clotting time sometimes seen
FES—progressive ___ involvement—clinically, can go from mild ___ and a clear ___ to ___
Progressive pulmonary involvement—clinically, can go from mild hypoxia and a clear CXR to ARDS
FES under GETA—will see a/an ___ (increase/decrease) in ETCO2 and SPO2 and ___ (increase/decrease) in PAP
Will see a decrease in ETCO2 and SPO2 and increase in PAP
Treatment for FES is ___
Supportive
DVT and PE are major sources of mortality and morbidity post ___ and ___ extremity surgery
Pelvic and lower extremity surgery
Risk factors for DVT and PE—age > ___ years; ___ity; ___ use; procedures > ___ min; ___ extremity fracture; immobilization > ___ days
Age > 60 years; obesity; tourniquet use; procedures > 30 min; lower extremity fracture; immobilization > 4 days
Highest risk procedures for DVT/PE = ___ and ___ replacements
Knee and hip replacements
DVT and PE pathogenesis—___ stasis and ___coagulability from inflammation
Venous stasis and hypercoagulability from inflammation
DVT and PE—prophylactic anti___ and pneumatic ___ compression significantly reduces incidence
Prophylactic anticoagulation and pneumatic leg compression significantly reduces incidence
DVT and PE—highest incidence still in those over ___ years of age
70
DVT and PE—the role of neuraxial anesthesia—note reduction in events via: sympathectomy-induced ___ (increases/decreases) in venous blood flow; anti-___ effects of local anesthesia; ___ (increased/decreased) platelet activity; ___ (increased/decreased) rise in factor VIII and von Willebrand factor; ___ (more/less) fall in antithrombin III; ___ (more/less) stress hormone release
Sympathectomy-induced increases in venous blood flow; anti-inflammatory effects of local anesthesia; decreased platelet activity; decreased rise in factor VIII and von Willebrand factor; less fall in antithrombin III; less stress hormone release
Neuraxial anesthesia and prophylactic anticoagulation—risk of spinal or epidural ___ formation following neuraxial anesthesia with the use of mini dose heparin or LMWH
Hematoma
Neuraxial anesthesia and prophylactic anticoagulation—placement/removal of epidural needle or catheter should not be performed within ___-___ hours of a SQ dose of heparin or within ___-___ hours of LMWH administration
6-8 hours of a SQ dose of heparin or within 12-24 hours of LMWH administration
Neuraxial anesthesia and prophylactic anticoagulation—___ (epidural/spinal) anesthesia is associated with lower risk
Spinal anesthesia is associated with lower risk
An epidural needle/catheter can be placed or removed in a fully anticoagulated patient—T/F?
False—cannot be placed or removed in a fully anticoagulated patient
Neuraxial anesthesia and prophylactic anticoagulation—antiplatelet drugs ___ (increase/decrease) the risk of spinal hematoma
Increase the risk of spinal hematoma
Neuraxial anesthesia and prophylactic anticoagulation—hallmarks of hematoma are ___ pain and ___ extremity weakness
Back pain and lower extremity weakness
Joint manipulation under anesthesia (MUA)—scars and adhesions that limit ROM of a joint may require anesthesia for manipulation to occur; procedures = ___ or ___ manipulation; ___ of dislocation
Procedures = shoulder or knee manipulation; reduction of dislocation
Anesthetic management of joint manipulation—IV agents with ___ (short/long) duration; ___ is preferred to ___—___ ventilation/___/___
IV agents with short duration (i.e.: propofol); general is preferred to regional—mask ventilation/LMA/GETA
Anesthetic management of joint manipulation—profound ___ allows surgeon to distinguish anatomical limitations from patient ___
Profound relaxation allows surgeon to distinguish anatomical limitations from patient guarding (can use succinylcholine or rocuronium)
Management of closed reduction—usually ___, but may become ___
Brief, but may become lengthy
Considerations: percutaneous pins; x-ray/fluoro; casting/splinting
Selection of anesthesia for closed reduction—regional can be used for patients with multiple ___ problems, patients with ___ stomach; general may need ___ induction; if injury is remote, ___ ventilation or ___ may be okay for a general anesthetic
Regional can be used for patients with multiple medical problems, patients with full stomach; general may need rapid sequence induction; if injury is remote, mask ventilation or LMA may be okay for a general anesthetic
Hip fractures usually involve what specific patient population?
Geriatrics
Hip fracture mortality rates—___% during initial hospitalization and ___% in the first year
10% during initial hospitalization and 25% in the first year
Immediate surgery is required for hip fractures—T/F?
False—immediate surgery is usually NOT required, but should be done within 48 hours of injury
Reasons to delay hip repair—___pathy, uncompensated ___ failure
Coagulopathy, uncompensated heart failure
Predictors of perioperative mortality for hip fracture repair—age > ___ years; history of ___; pre-op alteration in ___ status; post-op ___ infection; post-op ___ infection
Age > 85 years; history of cancer; pre-op alteration in neuro status; post-op chest infection; post-op wound infection
Regional vs. general for hip fracture repair—advantages of regional—___baric (hypo/hyper) technique can be utilized to keep patient off fracture; ___ (increased/decreased) blood loss; ___ (increased/decreased) incidence of DVT/PE; ___ (slower/faster) return to baseline neuro status
Hypobaric technique can be utilized to keep patient off fracture; decreased blood loss; decreased incidence of DVT/PE; faster return to baseline neuro status
Will lose the benefit of regional anesthesia for hip fracture repair if the patient is ___ or patient becomes ___
Oversedated or patient becomes hypoxic
Hip surgery—regional vs. general—after ___ months, there is no difference in mortality for regional vs. general
2
Blood loss from hip fracture is related to the ___ of the fracture
Location
Hip capsule ___ (restricts/enhances) blood supply by acting as a ___
Restricts blood supply by acting as a tourniquet
Level of blood loss from hip fracture in order of ___ (least/greatest) amount of blood loss to ___ (least/greatest): subtrochanteric; intertrochanteric; base of femoral neck; transcervical; subcapital
In order of greatest amount of blood loss to least
Subtrochanteric hip fracture = greatest amount of blood loss
Subcapital hip fracture = least amount of blood loss
Hip fracture—general anesthesia—bigger fracture should consider ___ line and large bore IV for ___ and ___ monitoring
Arterial line and large bore IV for transfusion and hemodynamic monitoring
GA for hip fracture—use ___ (short/long) acting drugs; use ___ (lower/higher) solubility agents; minimize postop ___ impairment—minimize use of ___ in older patients; maintain ___; maintain ___; maintain ___capnea
Use short acting drugs; use lower solubility agents; minimize postop cognitive impairment—minimize use of versed in older patients; maintain oxygenation; maintain hemoglobin; maintain normocapnea
Arthroscopy is a procedure done to examine the interior of a ___ with an ___; goal is to obtain a definitive ___
Interior of a joint with an endoscope; goal is to obtain a definitive diagnosis
Benefits of arthroscopy: less blood ___; less post-op ___; less ___ time
Less blood loss; less post-op pain; less rehabilitation time
General, neuraxial (spinal/epidural), or regional are acceptable anesthetic options for arthroscopy—T/F?
True
Airway management for knee/wrist arthroscopy—generally will use ___
LMA
Airway management for shoulder arthroscopy—___ or ___
LMA or ETT
Airway management for elbow arthroscopy—depends on patient ___
Position
Pain control for arthroscopy—intraarticular injection of ___ and ___ provide adequate pain relief for early mobility; can also give ___ (if OK with surgeon) and/or IV ___
Bupivacaine and duramorph provide adequate pain relief for early mobility; can also give ketorolac (if OK with surgeon) and/or IV Tylenol
Total hip arthroplasty/replacement (THA/THR)—arthroplasty = surgical replacement of all ___ components to achieve the return of natural ___ and ___ of the joint
Surgical replacement of all joint components to achieve the return of natural motion and function of the joint
Goals of arthroplasty = ___ relief; deformity ___; stability of joint ___
Pain relief; deformity correction; stability of joint motion
THA indications = ___arthritis; ___ arthritis; vascular ___
Osteoarthritis; rheumatoid arthritis; vascular necrosis
THA intraoperative management—patient position = ___
Lateral decubitus
THA—embolic event occurs most frequently during insertion of the ___ component
Insertion of the femoral component
THA intraoperative management—+/- use of ___; prophylaxis of ___/___; blood loss—___-___ ml, up to ___ ml for revisions; ___ loss; perioperative ___; postoperative ___ control
+/- use of MMA; prophylaxis of DVT/PE; blood loss—400-1500 ml, up to 2000 ml for revisions; heat loss; perioperative infection; postoperative pain control
Total knee arthroplasty (TKA)—___ position, ___ (shorter/longer) duration than hip
Supine position, shorter duration than hip
TKA—___ (more/less) intraoperative blood loss than THA—___-___ ml—due to ___ (most blood loss occurs postop in first ___ hours)
Less intraoperative blood loss than THA—100-200 ml—due to tourniquet (most blood loss occurs postop in first 24 hours)
TKA—___ (more/less) bone cement syndrome than THA, but release of emboli with tourniquet deflation may increase ___tension; check ___ after tourniquet goes down
Less bone cement syndrome than THA, but release of emboli with tourniquet deflation may increase hypotension; check BP after tourniquet goes down
TKA has the highest rate of ___ out of all ortho procedures
DVT
Partial knee replacements (unicondylar) are ___ (more/less) invasive but not always ___ in duration
Less invasive but not always shorter in duration
TKA—early ___ and ___ relief are key!
Early mobilization and pain relief are key!
Upper extremity surgery (shoulders)—performed ___ or ___
Opened or arthroscopically
Shoulder surgery position is ___ or ___
Sitting (beach chair) or lateral decubitus
Shoulder surgery—important to maintain ___, especially in beach chair position
Maintain MAP
Shoulder surgery—consider ___ block of ___ plexus
Interscalene block of brachial plexus
Anesthesia considerations for upper extremity arthroplasty—surgical ___; no tourniquet = potential for large ___ loss; potential for pneumo___; potential injury to ___ veins; potential inadvertent ___; potential for ___-spine injury; potential for ___ adverse event; ___ or ___ embolism; effects of ___
Surgical position; no tourniquet = potential for large blood loss; potential for pneumothorax; potential injury to subclavian veins; potential inadvertent extubation; potential for C-spine injury; potential for vaccine adverse event; fat or bone embolism; effects of MMA
Anesthesia considerations for forearm/hand surgery—___ anesthesia (i.e.: ___ block, ___ block); ___ anesthesia is the best option for lengthy procedures (can use ___ or ___)
Regional anesthesia (i.e.: Bier block, axillary block); general anesthesia is the best option for lengthy procedures (can use LMA or ETT)
Anesthesia considerations for foot and ankle surgery—excellent candidates for ___ anesthesia; another common choice = ___ anesthesia with ___ + ___ injection for postop pain control
Excellent candidates for regional anesthesia (nerve blocks with IV sedation); another common choice = general anesthesia with LMA + local injection for postop pain control
Anesthesia considerations for amputations—___ trauma and ___ pain
Psychological trauma and phantom limb pain
Anesthesia considerations for re-implantations—pay careful attention to ___; maintain body ___; regulation of ___; maintenance of ___ flow—optimal Hct ___-___%; keep patient ___; avoid vaso___; ___ or ___ infusion intraop
Pay careful attention to positioning; maintain body temperature; regulation of fluids; maintenance of blood flow—optimal Hct 28-80%; keep patient warm; avoid vasoconstrictors; dextran or heparin infusion intraop
Dextran/heparin infusion is used to improve microcirculation after reimplantation* Heparin is usually preferred because dextran has been associated with post-op renal failure
Peripheral nerve blocks for ortho procedures—what should you do when you get a regression of block, i.e.: movement, tingling?
Medicate the patient for pain! Do NOT wait for onset of pain, otherwise you will be far behind
Upper extremity blocks—inter___ block; ___clavicular block; ___clavicular block; ___ block
Interscalene block; supraclavicular block; infraclavicular block; axillary block
Interscalene block targets brachial plexus ___
Trunks—upper arm and shoulder
Interscalene block should be avoided in patient with compromised ___ status
Respiratory
Risks with interscalene block—pneumo___ can occur hours later; ___, ___, or ___ injection; 100% ___ nerve block on ipsilateral (same) side; ___ syndrome; ___ness from RLN injection; decreased ___ sensation
Pneumothorax can occur hours later; epidural, spinal, or arterial injection; 100% phrenic nerve block on ipsilateral (same) side; Horner’s syndrome; hoarseness; decreased chest wall sensation
Supraclavicular block targets brachial plexus ___
Divisions—upper and lower arm
Supraclavicular block risks—pneumo___ and ___ palsy; 50% ___ nerve block
Pneumothorax and vocal cord palsy; 50% phrenic nerve block
Infraclavicular block—targets brachial plexus ___
Cords
Infraclavicular block is useful for surgery of the ___ and ___ hand
Elbow and distal hand
Infraclavicular block risks—___ in 1% of patients
Pneumothorax
Axillary block blocks the ___, ___, and ___ nerves
Medial, ulnar, and radial nerves
Axillary block misses the ___ nerve and ___ nerve
Axillary nerve and musculocutaneous nerve
Risks of axillary block = ___ and ___ injection
Hematoma and vascular injection
Lower extremity blocks—___, ___, and ___
Femoral, sciatic, and popliteal/sciatic nerve block
Femoral nerve block causes loss of ___ function, making these patients ___ risks
Loss of quad function, making these patients fall risks
Femoral nerve block—patients should have indwelling catheters in place for < ___ hours to avoid infection
< 48 hours
Patients who receive single shot femoral nerve block are not at risk for falls—T/F?
False—still at risk for falls
This nerve block blocks the hip, thigh, knee, lower leg, and foot
Sciatic nerve block
This nerve block is useful for foot and ankle surgery; it spares the hamstring and knee, allowing flexion, which makes ambulation easier
Popliteal/sciatic nerve block
