Apex Unit 12 Miscellaneous Topics Flashcards
Match each chemical bond with its definition.
Ionic bond + Complete transfer of valence electrons
Covalent + Equal sharing of valence electrons
Polar covalent + Unequal sharing of valence electrons
Which law is represented by the image? p1 + p2 + p3 =
Dalton
Henry
Graham
Charles
Dalton
Dalton’s law of partial pressures says that the total pressure is equal to the sum of the partial pressures exerted by each gas in the mixture.
P total = P1 + P2 + P3…
Click on the part of the oxygen delivery equation that exemplifies Henry’s law.
DO2 = CO x [(1.34 x Hgb x SpO2) + (PaO2 x 0.003)] x 10
Pao2 x .003
Henry’s law: At a constant temperature, the amount of gas that dissolves in solution is directly proportional to the partial pressure of that gas over the solution.
Henry’s law applied to oxygen solubility:
DO2 = CO x [(1.34 x Hgb x SpO2) + (PaO2 x 0.003)] x 10
Multiplying the PaO2 by oxygen’s solubility coefficient (0.003) allows us to calculate how much oxygen is dissolved in the blood.
Match each gas law with its equation.
Boyle’s law + P1 x V1 = P2 x V2
Charles’s law + (V1 / T1) = (V2 / T2)
Gay-Lussac’s law + (P1 / T1) = (P2 / T2)
During laminar flow, quadrupling the radius will cause flow to increase by a factor of:
256
The Poiseuille Equation describes the laminar flow of fluid through a tube, where flow equals:
(Pi x Radius ^4 x Pressure difference) / (8 x viscosity x length)
As you can see, the radius of the tube exhibits the greatest impact on flow.
R = 1^4: 1 x 1 x 1 x 1 = 1 R = 2^4: 2 x 2 x 2 x 2 = 16 R = 3^4: 3 x 3 x 3 x 3 = 81 R = 4^4: 4 x 4 x 4 x 4 = 256
Reynold’s number is the LOWEST in the:
medium-sized bronchi.
terminal bronchioles.
glottis.
carina.
Terminal bronchioles
There are 3 types of flow, and Reynold’s number helps us predict what type of flow will occur in a particular situation.
Laminar (Re < 2,000) Turbulent (Re > 4,000) Transitional (Re = 2,000 - 4,000) Gas flow through the terminal bronchioles is laminar.
Flow through the glottis, carina, and medium-sized airways is turbulent
When applied to the left ventricle, which variables are included in the law of Laplace? (Select 2.)
Diameter
Wall tension
Wall thickness
Transmural pressure
Wall tension
Wall thickness
In spheres and cylinders, the law of Laplace illustrates the relationship between the wall tension, internal pressure, and radius.
The equation is a bit different for spheres vs. cylinders.
When applied to the left ventricle, we usually want to understand wall tension. This is the equation that we use:
Wall Tension = (LV Pressure x Radius) / (LV Wall Thickness x 2)
*We use the radius (not diameter) and internal pressure (not transmural pressure).
The risk of ionizing radiation exposure to the anesthesia provider is:
directly proportional to the square of the distance of the source.
directly proportional to the cubed radius of the distance from the source.
inversely proportional to the square of the distance of the source.
inversely proportional to the cubed radius of the distance from the source.
Inversely proportional to the square of the distance from the source
Understanding the inverse square law helps us reduce our exposure to ionization radiation inside and outside of the operating room.
The risk of ionizing radiation exposure to the anesthesia provider is inversely proportional to the square of the distance from the source. It will make more sense on the next page. We promise.
The number of calories required to convert one gram of liquid to vapor without a temperature change in the liquid is called the:
critical temperature.
latent heat of vaporization.
specific heat.
boiling point.
Latent heat of vaporization
Latent heat of vaporization is the number of calories required to convert one gram of liquid to vapor without a temperature change in the liquid.
Boiling point is the temperature at which a liquid’s vapor pressure equals atmospheric pressure.
Specific heat the amount of heat required to increase the temperature of one gram of a substance by one degree C.
Critical temperature is the highest temperature where a gas can exist as a liquid. Said another way, it is the temperature above which a gas cannot be liquefied regardless of the pressure applied to it.
How many centimeters of water is equal to 1 mmHg?
(Round to the hundredths place)
1.36 ( We accepted 1.34 - 1.36)
You should understand how to convert pressure to different units, specifically mmHg to cm H2O and vice versa’
1 mmHg = 1.36 cm H2O
We believe that Nagelhout has a small error, so we accepted the calculation using the numbers in that text. It says that standard atmospheric pressure = 1020 cm H2O, however we think a better answer is 1033 cm H2O.
What is the BEST method of minimizing intraoperative heat loss?
Forced air warmer
Fluid warmer
Circulating water mattress
Warm blankets
Forced air warmer
The four mechanisms of heat transfer (in order of importance) include:
Radiation > Convection > Evaporation > Conduction
The forced air warmer is arguably the most effective single method of perioperative warming, however any combination that prevents hypothermia is acceptable.
Which temperature monitoring site offers the BEST combination of accuracy and safety over an extended period of time?
Rectal
Tympanic membrane
Esophageal
Pulmonary artery
Esophageal
Esophageal temperature monitoring provides a good estimation of core temperature with minimal risk.
Rectal temperature monitoring produces less consistent results.
Tympanic membrane temperature monitoring is reliable when used correctly, however it can’t be used for continuous monitoring and there is a risk of tympanic membrane injury.
Pulmonary artery temperature monitoring accurately reflects core temperature, however it is invasive.
Anesthetic considerations for removal of vocal cord papilloma with a carbon dioxide laser include:
adding saline instead of air to the cuff of the endotracheal tube.
reducing the FiO2 by adding nitrous oxide.
applying reflective tape to a red rubber endotracheal tube.
using amber goggles.
Adding saline to the cuff of the endotracheal tube
Adding saline to the cuff of the endotracheal tube provides two benefits: 1) It acts as a heat sink for the thermal energy produced by the laser and 2) If the laser breaks the balloon, then the surgeon will see the saline in the surgical field. Adding dye to the saline makes this more obvious.
When a laser is in use, air should be blended with oxygen to maintain an FiO2 < 30 percent. Nitrous oxide supports combustion and should be avoided.
When a CO2 laser is used, the eyes are protected by clear lenses (not amber).
While reflective tape can be used to reduce the flammability of conventional endotracheal tubes, it is best to use a laser resistant endotracheal tube.
Calculate the 24-hr fluid requirement for a 70 kg adult with a new burn that consumes 50 percent of his total body surface area.
(Enter your answer as a whole number in mL)
7,000 - 14,000 mL/24 hr period
There are 2 commonly used formulas to calculate fluid requirements for the acutely burned patient. These include the Parkland and Modified Brooke formulas. We accepted responses and everything in-between.
Modified Brooke Formula: 2 mL x % TBSA burned x kg (body weight)
Parkland Formula: 4 mL x % TBSA burned x kg (body weight)
2 mL x 70kg x 50 = 7,000 mL
4 mL x 70kg x 50 = 14,000 mL
Choose the statement that BEST describes the anesthetic considerations for the patient undergoing electroconvulsive therapy.
There is an initial increase in sympathetic tone followed by an increase in parasympathetic tone.
Pregnancy is an absolute contraindication.
Lithium shortens the duration of action of succinylcholine.
Hypocarbia increases the seizure duration.
Hypocarbia increases seizure duration
Hypocarbia increases seizure duration, making this a useful modality prior to the ECT procedure.
The seizure caused by ECT results in a profound hemodynamic response. Initially there is a surge in PNS activity, and this is followed by an increase in SNS activity (not the other way around).
Pregnancy is a relative contraindication (not absolute).
Lithium prolongs (not reduces) the duration of action of both succinylcholine AND nondepolarizing NMBs.
Match each drug-induced hyperthermic syndrome with its antidote.
Neuroleptic malignant syndrome + Bromocriptine
Serotonin syndrome + Cyproheptadine
Anticholinergic syndrome + Physostigmine
NMS is caused by dopamine depletion in the basal ganglia and hypothalamus. The DA concentration is restored with bromocriptine.
Serotonin syndrome occurs when there’s excess 5-HT activity in the CNS and PNS. Cyproheptadine is a 5-HT antagonist that reverses the effects of excess serotonin.
Anticholinergic poisoning is the result of excessive Ach blockade in the CNS and PNS. Physostigmine is the only cholinesterase inhibitor that lacks a quaternary ammonium, so it diffuses into the CNS and increases the Ach concentration.
Identify the statement that BEST represents the anesthetic considerations for ophthalmic surgery.
Intraocular perfusion pressure equals MAP - CVP.
Nitrous oxide is contraindicated for 10 days after a sulfur hexafluoride bubble is placed.
Hypocarbia increases intraocular pressure.
Aqueous humor is reabsorbed by the ciliary process.
Nitrous oxide is contraindicated for 10 days after a SF6 bubble is placed
Aqueous humor is produced (not reabsorbed) by the ciliary process. It is reabsorbed in the canal of Schlemm.
Intraocular perfusion pressure = MAP - IOP (not MAP - CVP).
Hypercarbia (not hypocarbia) increases IOP.
A transverse abdominal plane block would be useful for all of the following procedures EXCEPT:
inguinal hernia repair.
cystoscopy.
kidney transplant.
appendectomy.
Cystoscopy
The TAP block is a peripheral nerve block that targets the anterior and lateral abdominal wall. It reduces opioid requirements in patients undergoing general, GYN, and urologic surgeries involving the T9-L1 distribution.
Since the patient undergoing cystoscopy won’t receive an abdominal incision, he won’t benefit from a TAP block.
Match each term with its definition.
Algogenic + A stimulus that is normally expected to produce pain
Allodynia + Pain due to a stimulus that does not normally produce pain
Hyperalgesia + Exaggerated pain response to a painful stimulus
Neuralgia + Pain localized to a dermatome
Match each antibiotic with its drug class.
Cefazolin + Beta-lactam
Gentamycin + Aminoglycoside
Levofloxacin + Fluoroquinolone
Match each disease with the appropriate safety precautions.
Influenza + Droplet Precautions
Mycobacterium tuberculosis + Airborne Precautions
Methicillin-resistant staphylococcus aureus + Contact Precautions
Which procedure places health care workers at the HIGHEST risk of developing a positive skin TB test?
Cataract removal
Open reduction internal fixation of a femur
Video assisted thoracoscopic surgery
Bronchoscopy
Bronchoscopy
TB is transmitted via small (1-5 um) aerosolized droplets These are released into the environment when a person with TB coughs, sneezes, or even talks. Therefore, any procedure involving the airway is inherently associated with a higher risk of transmitting TB.
Bronchoscopy is associated with the highest risk of skin test conversion in health care personnel. Endotracheal intubation is the second highest risk procedure.
To reduce the risk of transmission, the infected patient and all health care workers must wear tight fitting N95 masks.
Anaphylaxis causes degranulation of: (Select 2.)
monocytes.
mast cells.
neutrophils.
basophils
Basophils
Mast cells
Degranulation is a fancy way of saying that a cell releases cytotoxic contents from its storage vesicles. These chemicals play a critical role in the immunologic response.
Basophil and mast cell degranulation can be stopped with epinephrine (beta-2 receptor stimulation). This is one of the several reasons we give epinephrine during anaphylaxis. More on this in a bit…
Match each type of hypersensitivity reaction with its BEST example.
Type I + Anaphylaxis
Type II + ABO incompatibility
Type III + Serum sickness after snake bite
Type IV + Graft-vs-host reaction
Match each chemotherapeutic agent with its unique side effect.
Cisplatin + Renal toxicity
Bleomycin + Pulmonary toxicity
Doxorubicin + Cardiac toxicity
Match each gastrointestinal hormone with its unique characteristic.
Gastrin + Associated with Zollinger-Ellison syndrome
Somatostatin + Treatment for carcinoid tumor
Cholecystokinin + Produces gallbladder pain after a fatty meal
Which agent primarily targets the chemoreceptor trigger zone?
Scopolamine
Hydroxyzine
Ondansetron
Dexamethasone
Ondansetron
Ondansetron is a 5-HT3 receptor antagonist. It treats PONV by antagonizing serotonin receptors in two places:
Chemoreceptor trigger zone (area postrema)
Peripheral receptors in the GI tract and vagus nerve
Scopolamine (M1 antagonist) and hydroxyzine (H1 antagonist) primarily target the vestibular apparatus in the inner ear.
Dexamethasone binds to intracellular steroid receptors, however its exact site of action is unknown.
Deflation of the pneumatic tourniquet during orthopedic surgery is expected to increase:
mixed venous oxygen saturation.
end-tidal carbon dioxide.
blood pH.
blood pressure.
End-tidal carbon dioxide
The pneumatic tourniquet is used to reduce blood loss during extremity surgery. Cells distal to the tourniquet shift to anaerobic metabolism, and metabolic byproducts accumulate as long as the tourniquet is inflated.
Releasing the tourniquet produces transient changes that include:
Increased EtCO2 Decreased core body temperature Decreased blood pressure Decreased SvO2 (SaO2 is usually normal) Metabolic acidosis
All of the following are associated with Samter’s triad EXCEPT:
nasal polyps.
allergic rhinitis.
bronchospasm.
hypertension.
Hypertension
Aspirin exacerbated respiratory disease (Samter’s triad) refers to the combination of asthma, allergic rhinitis, and nasal polyps. These patients can develop life threatening bronchospasm following aspirin administration.
Match each herbal medication with its unique characteristic.
Licorice + May mimic Conn's syndrome Valerian + Decreases MAC St. John's Wort + Serotonin syndrome with MAOIs Garlic + Increases bleeding
Herbal medications have perioperative implications including effects on bleeding, synergism with other agents, cardiovascular instability, and metabolic derangements. We’ll cover the essentials on the next page.
Match each regulatory agency with the standards it sets.
Food and Drug Administration + Food and drugs
United States Department of Transportation + Compressed gas cylinders
Occupational Safety and Health Administration + Acceptable occupational exposure to volatile anesthetics
American Society for Testing and Materials + Required components of the anesthesia machine
All of the following are assessed by the modified Aldrete scoring system EXCEPT:
postoperative nausea and vomiting.
level of consciousness.
oxygen saturation.
quality of respiration.
Postoperative nausea and vomiting
The modified Aldrete scoring system is used to quantify readiness for discharge from the PACU. It assesses five areas: Activity Respiration Circulation Consciousness Oxygen saturation
PONV is not assessed by the modified Aldrete scoring system.
How many calories are required to produce one gram of body fat?
4
7
9
11
Nine
Each gram of fat provides nine calories. If unused, the body will store these excess calories as adipose.
By comparison, a gram of carbohydrate provides four calories and a gram of protein provides four calories.
A patient weighs 176 pounds and stands 74 inches tall. Calculate this patient’s body mass index.
(Round your answer to the nearest hundredth)
22.59 or 22.64 kg/m2
We accepted a range to account for different ways of calculating BMI.
- Convert weight from pounds to kilograms. (Conversion = lbs / 2.2)
176 lbs / 2.2 = 80 kg - Convert height from inches to centimeters. (Conversion = in x 2.54)
74 inches x 2.54 = 187.96 cm - Convert centimeters to meters. (Conversion = cm / 100)
187.96 cm / 100 = 1.8796 m
- BMI = kg / m squared
80 kg / 1.8796 m squared = 80 / 3.53289616 = 22.64
Calculate the ideal body weight for a woman who is 5 feet 3 inches tall.
(Enter your answer in kg and round your answer to the nearest whole number)
52 – 58
The ideal body weight for this patient is 55 kg.
IBW men (kg) = Height (cm) - 100 IBW women (kg) = Height (cm) - 105
We understand there are some other formulas for the IBW calculation, so we accepted a range of answers (52 – 58).
Which factors are reduced by obesity? (Select 2.) Closing volume Vital capacity Residual volume Expiratory reserve volume
Vital capacity
Expiratory reserve volume
Obesity creates a restrictive ventilatory defect. In effect, this compresses the lungs and reduces lung volumes.
FRC decreases (ERV decreases and RV remains constant).
Closing volume is increased.
Vital capacity is decreased.
What is the optimal tidal volume for a patient with class III obesity?
6 – 8 mL/kg ideal body weight
6 – 8 mL/kg total body weight
10 – 12 mL/kg ideal body weight
10 – 12 mL/kg total body weight
6 – 8 mL/kg ideal body weight
The lungs do NOT grow in proportion to body mass, so the morbidly obese patient should receive a tidal volume 6 – 8 mL/kg of ideal body weight.
A higher respiratory rate may be required to maintain PaCO2.
Higher tidal volumes only minimally increase PaO2 and may cause shear stress on the lungs.
Considerations for the cardiovascular effects of morbid obesity include: (Select 2.)
tachycardia.
diastolic dysfunction.
increased venous return.
increased EKG voltage.
Diastolic dysfunction
Increased venous return
The expansion of intravascular blood volume is one of the key changes that lead to the cardiovascular complications of obesity.
Increased circulating volume augments venous return (preload) and consequently myocardial wall stress. The heart compensates by becoming thicker, however this occurs at the expense of myocardial relaxation. This causes diastolic dysfunction.
Heart rate is usually unchanged (not increased) in the obese patient. An increased stroke volume is responsible for the increased cardiac output.
The EKG voltage is typically reduced (not increased) because the fat mass increases the distance between the heart and the skin leads.
In the obese patient, which factors are expected to increase? (Select 2.)
Volume of distribution of hydrophilic drugs
Volume of distribution of lipophilic drugs
MAC
Circulation time
Volume of distribution of lipophilic drugs
Volume of distribution of hydrophilic drugs
This one may be a bit tricky, but it builds on several important concepts from the last question.
The Vd of lipophilic drugs is increased due to a larger fat mass.
The Vd of hydrophilic drugs is increased due to a larger muscle mass and blood volume.
A higher cardiac output hastens IV drug delivery to the site of action. This shortens circulation time.
MAC is unchanged.
Select the drug whose initial dose should be based on total body weight. (Select 2.)
Midazolam
Remifentanil
Succinylcholine
Propofol
Succinylcholine
Midazolam
The initial doses of succinylcholine and midazolam should be based on total body weight.
The initial doses of propofol and remifentanil should be based on lean body weight.
Before moving to the next page, can you think of why this is?
All of the following muscles dilate the upper airway EXCEPT the:
hyoid muscles.
tensor palatine.
genioglossus.
thyroarytenoid.
Thyroarytenoid
There are three sets of muscles that dilate the upper airway. You should know the primary function for each one.
Tensor palatine (opens nasopharynx) Genioglossus (opens oropharynx) Hyoid muscles (opens hypopharynx) The thyroarytenoid muscles relax the vocal cords.
Which apnea/hypopnea index score is consistent with mild obstructive apnea?
3
12
25
40
12
The apnea/hypopnea index helps quantify the severity of OSA. This value is derived by the number episodes of apnea and hypopnea divided by the total hours of sleep.
Mild = 5 – 15 episodes/hr Moderate = 15 – 30 episodes/hr Severe = > 30 episodes/hr
In the Charles Dickens novel “The Pickwick Papers”, the errand boy named Joe suffers from what ailment?
Virchow’s triad
Obesity hypoventilation syndrome
Metabolic syndrome
Bulimia
Obesity hypoventilation syndrome
Okay, maybe this question is unfair for those of you who don’t read classic British literature. Who has time for that?
Having said this, you should be able to deduce the answer from the title, “The Pickwick Papers.” Pickwick…Pickwickian syndrome…another name for obesity hypoventilation syndrome…you get the idea.
What is the MOST sensitive sign of an anastomotic leak following gastric bypass?
Unexplained tachycardia
Abdominal pain
Shoulder pain
Fever
Unexplained tachycardia
Unexplained tachycardia is the most sensitive sign of an anatomic leak following gastric bypass.
Abdominal pain, shoulder pain, and fever are additional signs of an anastomotic leak, however they are not the most sensitive.
Match each appetite suppressant with its drug class
Ma huang + Ephedra alkaloid
Phentermine + Norepinephrine reuptake inhibitor
Sibutramine + Norepinephrine and serotonin reuptake inhibitor
Orlistat + Lipase inhibitor
The Trendelenburg position: (Select 2.)
moves the diaphragm caudad.
increases functional residual capacity.
increases the risk of endobronchial intubation.
reduces pulmonary compliance.
Reduces pulmonary compliance
Increases the risk of endobronchial intubation
Just as gravity affects the distribution of blood volume in the anesthetized patient, it also affects the position of the abdominal viscera.
When the patient is placed into the Trendelenburg position, the abdominal viscera shift toward the thorax. This has several consequences:
The diaphragm moves cephalad (not caudad).
FRC is reduced (not increased).
Pulmonary compliance is decreased.
The risk of endobronchial intubation is increased.
The surgical team is positioning a patient for a robotic assisted laparoscopic radical prostatectomy. What is the BEST position to protect the brachial plexus?
Arms tucked at sides + non-sliding mattress
Arms tucked at sides + shoulder braces placed near the acromion.
Arms abducted 90 degrees + non-sliding mattress
Arms abducted 90 degrees + shoulder braces placed at the midpoint of the clavicle
Arms tucked at side + non-sliding mattress
Surgical positioning for robotic assisted laparoscopic radical prostatectomy requires steep Trendelenburg position.
To minimize the risk of brachial plexus injury, the arms should be tucked at the patient’s sides and he should be positioned on a non-sliding mattress.
Shoulder braces increase the risk of brachial plexus injury.
A patient is unable to abduct his fifth digit after a prolonged stay in the intensive care unit. Which nerve sustained an injury?
Median
Long thoracic
Ulnar
Radial
Ulnar
The ulnar nerve is the most commonly injured peripheral nerve. Although its anatomy renders it susceptible to compression, it’s critical to understand that this isn’t the only cause of ulnar neuropathy that develops during hospitalization.
Presentation may include:
Impaired sensation of the fourth and fifth digits
Inability to ABduct or oppose the pinky finger
Chronic injury presents with claw hand (muscular atrophy)
Which nerve is MOST likely to be injured following traumatic IV insertion in the antecubital space?
Axillary
Median
Ulnar
Radial
Median
Although median nerve injury is a rare event, it can occur as a result of traumatic IV insertion at the antecubital space.
Which nerve is MOST likely to be injured by an IV pole that presses against the dorsolateral aspect of the humerus?
Ulnar
Axillary
Median
Radial
Radial
The radial nerve passes along the spiral groove at the lateral aspect of
the humerus (about 3 fingerbreadths above the lateral epicondyle).
It can be injured by: External compression by an IV pole Excessive cycling of the NIBP cuff Upper extremity tourniquet Sheets that are too tight (if the arms are tucked)
A patient developed foot drop following vaginal hysterectomy. She was positioned in candy cane stirrups. Which nerve was injured?
Saphenous
Femoral
Common peroneal
Obturator
Common peroneal
The common peroneal nerve is highly susceptible to injury when the patient is placed in stirrups. This nerve wraps around the fibular head, and it can be compressed when the lateral aspect of the leg leans against the stirrup bar.
Presentation of common peroneal nerve injury:
Foot drop
Inability to evert the foot
Inability to extend the toes dorsally
Which complications are MOST commonly associated with the sitting position? (Select 2.)
Tracheobronchial compression
Paradoxical air embolism
Midcervical tetraplegia
Lower extremity compartment syndrome
Midcervical tetraplegia
Paradoxical air embolism
Midcervical tetraplegia is associated with hyperflexion of the neck (chin to chest). Ischemia occurs as a result of stretching and/or compression of the midcervical spinal cord (usually C5). This complication is most common in the sitting position.
Although the sitting position is most commonly associated with venous air entrainment, this complication can occur in any position that produces a pressure gradient between the atmosphere and the veins at the surgical site.
A nurse anesthetist in middle management submits written complaints to a state board about several other nurse anesthetists that are false and defamatory. Which AANA document could be applied to this situation?
Practice Standards
Position Statements
Code of Ethics
Practice Guidelines
Code of Ethics
The AANA Code of Ethics dictates the principles of conduct and professional integrity that guide the decision making and behavior of nurse anesthetists. This document speaks to the anesthetist’s responsibilities as a professional, which holds the individual CRNA accountable for his or her own actions and judgments, regardless of institutional policy or physician orders.
As a professional, the CRNA is held individually accountable for his or her “conduct in maintaining the dignity and integrity of the profession” and “does not knowingly engage in deception in any form.”
The specific act committed by the CRNA in this question is called libel.
The use of unnecessary invasive preoperative testing is most likely to put the provider in violation of the principle of:
justice.
beneficence.
respect for autonomy.
nonmaleficence.
Nonmaleficence
Nonmaleficence asserts that a provider has an obligation not to inflict hurt or harm—in other words, the Hippocratic oath primum non nocere (first do no harm). There is no distinction between intentional or unintentional harm.
The use of unnecessary preoperative testing can put the provider in violation of the principle of nonmaleficence.
Informed consent for anesthesia should include a discussion of which topics? (Select 2.)
Agreement to undergo the scheduled surgery/procedure
Description of the recommended type of anesthetic
Patient preferences, questions, and fears
Risks and benefits of each type of appropriate anesthetic
Risks and benefits of each type of appropriate anesthetic
Patient preferences, questions, and fears
Informed consent conversations should include a discussion of all available and appropriate anesthetic choices for both the particular surgery/procedure and relevant comorbidities.
The preoperative consent process should allow for open sharing of information regarding anesthetic care and focused on the patient’s concerns, needs, and questions. It is recommended that the anesthesia consent process and paperwork should be separate and apart from the surgical consent process; further, the only appropriate person to conduct the anesthesia informed consent is the anesthesia provider.
What must the anesthesia provider do to obtain informed consent for epidural placement in a parturient who just received 50 mg of meperidine?
Review the efficacy of current pain management.
Determine that the patient has sufficient capacity.
Document the patient’s dilation, effacement, and station.
Perform detailed obstetrical history and physical exam.
Determine that patient has sufficient capacity
Despite the pain and distress that may accompany active labor, research has shown that most women retain the ability to understand, assimilate information, and make decisions. However, capacity is one of the elements of consent and should be ascertained as part of the informed consent process (review the last page if this doesn’t make sense).
It should go without saying that a current H&P, labor progress, and the effectiveness of current analgesia are all important parts of the pre-anesthetic evaluation process.
A terminal cancer patient with a “do not resuscitate” order presents for a port-a-cath placement. Which standard of nurse anesthesia practice has the most immediate relevance to the anesthetist’s preoperative activities?
Standard 4 on informed consent and related anesthesia services
Standard 13 on wellness
Standard 3 on plan for anesthetic care
Standard 2 on thorough preoperative assessment and evaluation
Standard four on informed consent and related anesthesia services
Reconsideration of a pre-existing advanced directive is a critical component of the informed consent process, because some events that may occur are responses to the anesthetic and are not part of the terminal disease process. Advance directives should not be routinely suspended perioperatively, but require a detailed discussion as noted in this lesson.
Identify the standards of care that have been published by the American Association of Nurse Anesthetists. (Select 3.)
Transfer of Care Chronic Pain Management Wellness Mass Casualty Incident Preparedness Latex Allergy Management Infection Control and Prevention
Wellness
Infection Control and Prevention
Transfer of Care
Only three of the answer choices are standards published by the AANA (listed above).
These standards represent the expected behaviors that must be demonstrated in a professional practice and that “must” be adhered to. These are the standards against which the delivered care is compared in the event of a lawsuit. Failure to adhere to these standards will provide prima facie evidence of negligence.
The AANA publications on latex allergy, chronic pain, and mass casualty incident management are practice guidelines—suggestions that “should” be adhered to but that do not rise to the level of standards.
You are four hours into a complex case and are relieved by another anesthesia provider. You are late to an appointment and give only a cursory report that results in a missed repeat antibiotic dose. The patient ultimately develops sepsis intraoperatively that results in an unexpected 3-day ICU stay. Which two causes of action against you might apply to this scenario? (Select 2.)
Abandonment
Malpractice violation of the AANA standards of care
Loss of chance of survival
Vicarious liability for relieving anesthetist
Malpractice violation of the AANA standards of care
Abandonment
Standard 11 relates to the accurate reporting of a patient’s condition which is defined as, “ Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care to another qualified healthcare provider. Communicate the patient’s condition and essential information for continuity of care.”
A plaintiff attorney may also claim abandonment—the transfer of care, although to a qualified provider, was incomplete in not addressing the requirement for a repeat dose of antibiotic. Thus, the duty to the patient was abandoned.
Vicarious liability and loss of chance of survival will be defined shortly.
Which law ensures public access to emergency services regardless of their ability to pay?
Affordable Care Act
Health Information Technology for Economic and Clinical Health Act
Health Insurance Portability and Accountability Act
Emergency in Medical Treatment and Active Labor Act
Emergency in Medical Treatment and Active Labor Act
There are 6 federal laws that significantly affect health care practice in the United States. Deciphering these laws and their acronyms is the object of Parts I and II of the next lessons.
Match each drug to its schedule based on the Controlled Substances Act.
Schedule I + Heroin
Schedule II + Cocaine
Schedule III + Ketamine
Schedule IV + Tramadol
When a patient experiences a serious anesthetic complication, what information is most appropriate to offer to the patient’s relatives?
Disclose nothing until you are certain of the patient’s outcome
Describe the facts of the event while also expressing regret
Tell the family that risk management will contact them
Provide the names and roles of the party or parties at fault
Describe the facts of the event while also expressing regret
It is now generally accepted that the relationship between the anesthesia provider and the patient-family should be based on honesty and trust. Disclosure of actual events early reinforces this relationship of trust. Disclosure of facts does not pose any greater threat to the providers because the patient and family will inevitably discover them in the future.
There is evidence that the “disclosure, apology, and offer” approach to adverse events versus the “deny and defend” approach reduces claims, settlement amounts, and defense costs. All providers should ensure that they are aware of their institutional or group policies as well as state law on these matters.
“Proof” in a juried malpractice case must include which components? (Select 2.)
Absolute certainty that the provider was negligent
The highest standards of care were not followed
Evidence of duty, breach, cause, and harm
More likely than not that negligence occurred
Evidence of duty, breach, cause, and harm
More likely than not that negligence occurred
A claim of malpractice must prove that the defendant had a duty to the patient, the defendant breached their duty, a causal relationship exists between the defendant’s acts and the patients’ injury, and damages resulted from the breach.
With this in mind, absolute certainty of malpractice is NOT required. A jury may find for the plaintiff if they believe that the probability of causal injury is greater than 50%. Further, the defense need only prove an acceptable, not the highest, standard of care was provided.
Rank the causes of anesthesia-related lawsuits from most common to least common.
(1 is the most common, and 4 is the least common)
1 + Death
2 + Nerve damage
3 + Permanent brain damage
4 + Awareness
