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S5 - Anesthesia Pharm II - Test 3 > Awareness and Anesthesia > Flashcards

Awareness and Anesthesia Flashcards

1
Q

Components of awareness under anesthesia

A
  • Hearing
  • Weakness or paralysis
  • Feelings of helplessness, anxiety, panic, and impending death
  • Dreaming (incidence report 7%)
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2
Q

Definition of anesthesia awarenuss from AANA position statement

A

Postoperative recall of events experienced under general anesthesia

Unintended- not part of the anesthesia care plan

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3
Q

What is not included in awareness?

A

The phenomenon of dreaming

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4
Q

Surgeries where awareness has higher incidence

A
  • Cardiac
  • Obstetric (0.4%)
  • Major trauma (11-43%)
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5
Q

General incidence of awareness in non obstetric, non cardiac cases?

Pediatric incidence of awareness?

A

0.1-0.2%

20,000-30,000 per year

Pediatric 0.6-2.7%

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6
Q

Why is awareness more common in obstetric surgery?

A

Increased CO causes rapid redistribution

Also less agents used to prevent neonatal depression

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7
Q

Why is incidence of awareness greater in major trauma surgery?

A

HD instability require reduction of anesthetic

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8
Q

What type of memory involves information consciously remembered by patient?

Is pain involved?

A

Explicit memory

With or without pain

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9
Q

Examples of explicit memory

A

Vivid OR conversations or vague unpleasant sensation or dreams

(but i thought dreams dont count?)

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10
Q

Which type of memory is more sensitive to anesthesia?

A

Explicit memory

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11
Q

Which type of memory involves memory stored but not recalled but leads to changes in behavior or performance?

A

Implicity memory

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12
Q

How can you test implicit memory?

A

Hypnosis or behavioral suggestion

Recall may occur during dreaming

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13
Q

What medical problems may awareness lead to?

A
  • Traumatic neurosis (10%)
  • PTSD (71%)
  • Fear of dying, nightmares, hallucinations, inability to sleep
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14
Q

Are there legal consequences to awareness?

A

Duh

Costs of lawsuits from %1,000 to $1.7 million with average cost $195,327

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15
Q

What percent of malpractice claims are associated with awareness?

A

2%

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16
Q

Where is the “storage sight” for memory?

A

Temporal lobes of the cerebral cortex

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17
Q

How is short term memory made?

A

Reverberating circuits, or post-tetanic potentiation causes increased excitability of the synapse or decreased resting membrane potential after prolonged period of excitation

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18
Q

What does long-term memory require?

A
  • Physical or chemical change of the size and conductiveness of the dendrites
  • Changes reuire about 1 hour to maximally consolidate
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19
Q

Which S/S of light anesthesia occur first: hemodynamic or motor?

A

Motor

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20
Q

What may block motor signs of light anesthesia?

A

NMB

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21
Q

Motor signs of light anesthesia (6)

A
  • Eyelid or eye movement
  • Swallowing
  • Coughing
  • Grimacing
  • Movement of extremities or head
  • Increased respiratory effort- intercostal and abdominal muscles
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22
Q

Are hemodynamic S/S of light anesthesia reliable?

A

Nope

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23
Q

Why causes hemodynamic S/S of light anesthesia?

What may modify these S/S?

A

Caused by sympathetic stimulation

Modified by anesthetic agents

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24
Q

Hemodynamic S/S of light anesthesia

A
  • Hypertension
  • Tachycardia
  • Mydriasis
  • Tearing
  • Sweating
  • Salivation
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25
Q

What is the last sense suppressed by anesthesia?

Why?

A

Hearing (auditory pathways)

Becuase it is most metabolically actice part of brain

26
Q

What drugs may make hearing more acute?

A

NMB

27
Q

How can conversation in the OR affect the patient post-op?

A

May have implicit memories of hearing convo

28
Q

What may proivde a glimpse into anesthetic depth based off hearing?

A

Auditory evoked potentials

29
Q

What is the best monitor for anesthetic depth?

A

No single monitor

Use multiple

30
Q

How do you assess analgesia, areflexia, and hypnosis?

A
  • Analgesia- vital signs
  • Areflexia- patient movement or nerve stimulation
  • Hypnosis- processed EEG (BIS) monitor tires to give quantitative measurement
31
Q

How does BIS monitor meausure anesthetic depth?

A

It doesn’t necessarily

Based upon the cortical EEG, they measure the relative hypontic effect of the anesthetic

32
Q

Recommended BIS level to achieve appropriate anesthetic depth

A

50-60

33
Q

Is BIS valuable in predicting awareness?

A

Questionable….

34
Q

Beach chair position effect on BIS

A

Lowers

35
Q

Trendelberg position effect on BIS

A

Raises

36
Q

Ketamine and nitrous oxide effect on BIS

A

Increases

37
Q

What drugs/substances are associated with higher incidence of awareness?

A

Heavy alcohol intake

Chronic benzos, opioids, requiring treatment or both

38
Q

What patient conditions/ features are associated with higher incidence of awareness?

A
  • Impaired CV status
  • Severe end-stage lung disease
  • ASA Physical Status 3,4 and 5
  • Anticipated difficult intubation
  • History of awareness
39
Q

What procedure/ times in procedure are more associated with awareness?

A

Acute trauma with hypovolemia

Cardiac surgery, including off-pump

C-section under GA

Bronchoscopy, laryngoscopy, or both

Expected intra-op hypotension requiring treatment

40
Q

Preventable causes of awareness under anesthesia

A
  • Light anesthesia
  • Equipment malfunction
  • Increased anesthetic requirements
  • Herbal
41
Q

What may cause awak paralysis?

A

Syringe swap

Mislabeled succinylcholine drips

😱

42
Q

Why are difficult intubations high risk for awareness?

A

Redistribution of induction agent

Requires redosing

43
Q

What equipment malfunctions may result in awareness?

these cards are stupidddddd sry

A

Vaporizers not turned or not filled

Pump malfunction

Empty nitrous tank

Disconnected delivery tubing/circuit

44
Q

What factors cause increased anesthetic requirements?

A
  • Multiple general anesthetics (cause long term tolerance)
  • Chronic alcoholism
  • Hypernatremia
  • Hyperthemia
  • Drugs that increase CNS catecholamines (MAOIs, TCAs, cocaine, amphetamines)
45
Q

What herbal supplement places pt at risk for awareness?

A

St. John’s wort

46
Q

What drugs are associated with increased risk of awareness?

I feel like there are 18 cards that say this but it says it 18 times in our notes slightly different ways

A
  • Muscle relaxants
  • Nitrous with opioids
  • Opioid based (in cardiac anesthetic)
47
Q

why is TIVA associated with increased risk of awareness?

A

Due to variability of dosage requirements and variation in elimination

48
Q

TC says idk why you would do this but….

If using inhalational agents alone, what MAC would you use to prevent awareness?

A

At least 0.8-1 MAC

49
Q

What MAC of inhalational agents do you use to prevent awareness in combo with nitrous and opioids?

A

End Tidal 0.6 MAC (potent agent)

50
Q

Name some drugs that lower the concentration needed to prevent recall

A
  • Benzodiazepines
  • Scopoloamine
  • IV anesthetics
  • Ketamine
51
Q

What should you use on patients at high risk for recall?

A

Amnestics

52
Q

What important step in you anesthesia setup can help prevent awareness?

A

Machine check

  • Check vaporizers
  • Check delivery system
53
Q

Steps to take if you know your anesthetic is going to have to be on the light side

A
  • Inform patient of possibility for awareness
  • Use “auditory masking”
  • Do not use disparaging remarks (duh)
54
Q

S/S of PTSD

A
  • Flashbacks or nightmares
  • Avoidance behaviors
  • Emotional numbing
  • Preoccupation with death
  • Hyperarrousal
55
Q

Do patients usually spontaneously complain of recall?

A

No

After direct questioning, may complain of fear, anger, sadness, or “just not right”

56
Q

What things may patient describe recalling?

A
  • Conversations
  • Pain
  • Weakness or paralysis
  • Intubation
57
Q

What is PTSD usually associated with?

A

Recall of pain

58
Q

Things to ask patient experiencing recall

A
  • Obtain details to determine validity
  • Assess timing to confirm they are not confused about post-op pain
59
Q

Techniques and assurances to use when patient experiences recall

A
  • Question with empathy and compassion
  • Honest and sincere explanation of what happened and the possible reasons
  • Reassure patient that future anesthetic should not result in the same
60
Q

What should you document about patient’s recall experience?

Who do you notify?

What referrals need to be made?

A

Document interview

Notify risk managment

Refer promptly to psychologist or psychiatirst trained in PTSD treatment

S5 - Anesthesia Pharm II - Test 3 (4 decks)

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