BASICS Exam 3 Flashcards
airway, uro/ortho/robot, POCUS, monitoring, vents
what is the #1 reason for anesthesia related deaths/morbidity
difficult airway
what condition makes patients difficult to mask
obesity
what do you do if you cant ventilate/ cant intubate
wake up
emergent cric
what do you add to ETT for long procedures to avoid heat loss
HME, passive evaporation heat loss prevention, takes 1 hour to be effective
how much higher is resistance in nasal intubation when compared to oral intubation
2x, can be higher in deviated septum
what is the the airway space behind the nose
nasopharynx
what is the airway space behind the mouth
oropharynx
when does the nasopharynx end
soft palate
when does the oropharynx end
epiglottis
what is the name of the space from the glottis down
hypopharynx
what the area below the eipiglottis where CRNAs do alot of airway manipulation
subglottic opening
what is the purpose of the nose
warm and humidify air during oral breathing
how much moisture does the nose add to air a day
1 L to 10,000L of air per day
what is the space between tongue and epiglottis
vallecula
what innervates the anterior nose
V1 opthalmic division of Cranial nerve 5- trigeminial-
anterior ethmoidal nerve
what innervates the mid nose and hard/soft palate
V2 maxillary division of cranial nerve 5- trigeminial- sphenopalantine nerve
what innervates the anterior 2/3 anterior tongue (sensation)
V3 Mandibular division of cranial nerve 5- trigeminial- lingual nerve
what innervates the posterior 1/3 tongue, oropharynx, and soft palate
cranial nerve 9, glossopharyngeal
what innervates the glotis/subglottic space, hypopharynx and trachea above the vocal cords
cranial nerve 10- vagus- internal laryngeal nerve
what innervates the trachea below the vocal cords
cranial nerve 10- vagus- recurrent laryngeal
what innervates the nasal mucosa
opthalmic and maxillary divisions of cranial nerve 5-trigeminal
what can happen with mouth breathers/ intubated patients
mucous gets thick and dry, add humidifier
what is a passive humidifier
HME
what innervates the hard and soft palate
palantine nerves from sphenopalatine ganglion
what is the innervation of the gag reflex
glossopharyngeal,
vagus,
spinal accessory nerves
what three nerves innervate all the muscles of the pharynx, larynx, and soft palate
glossopharyngeal (9)
vagus (10)
spinal accessory (11)
what carries the gag afferently to the medulla
glossopharyngeal
what carries the gag reflex efferently from medulla
vagus nerve
what nerves have synapses with the glossopharyngeal nerve to carry the gag reflex afferently towards the medulla
vagus
spinal accessory
what are the borders of the pharynx
back of tongue to nose
what are the three divisions of the pharynx
nasopharynx, oropharynx, laryngopharynx
what separates the nasopharynx and oropharynx
soft palate
what inervates the nasopharynx
trigeminal nerve- CN5
what are the borders of the oropharynx
soft palate to superior edge of epiglottis
what innervates the oropharynx
CN 9- glossopharyngeal
what are the borders of the hypopharynx
superior border of epiglottis to inferior border of cricoid cartilage
what innervates the hypopharynx
CN 10 (vagus) through internal superior laryngeal nerve
what does the R recurrent laryngeal nerve go under
innomanite artery/ brachiocephalic artery
what does the L recurrent laryngeal nerve go under
aorta
what procedures do the recurrent laryngeal nerve get damaged in
thoracic,
mitral valve,
aortic,
tumor
the recurrent laryngeal nerve innervates all muscles of the larynx except the
cricothyroid
what are risks of recurrent laryngeal nerve damage
hoarseness,
vocal cord palsy
what does the recurrent laryngeal nerve innervate in hypopharynx
sensory innervation from vocal cords down through trachea
motor function to all muscle of larynx except cricothyroid
what does the internal superior laryngeal nerve inervate in hypopharynx
sensory innervation of hypopharynx above vocal cords, base of tongue, epiglottis, arytenoids (above glottic opening)
what does the external superior laryngeal nerve inervate in hypopharynx
motor function to cricothyroid muscle of larynx
what do you block for awake intubation
superior laryngeal nerve at bifurcation
what nerve perforates the cricothyroid membrane
external laryngeal branch of superior laryngeal nerve
when do you use airway blocks
awake intubation with fiberoptic intubation
what does unilateral damage to the superior laryngeal nerve do
minimal effects
what does bilateral damage to the superior laryngeal nerve do
hoarseness
tiring of voice
what does unilateral damage to recurrent laryngeal nerve do
hoarseness
what does bilateral acute damage to recurrent laryngeal nerve do
stridor, Resp dx
what does bilateral chronic damage to recurrent laryngeal nerve do
aphonia
what does unilateral damage to vagus nerve do
hoarseness
what does bilateral damage to vagus nerve do
aphonia
where is larynx located on cervical spine
C3-C6
what is the narrowest part of the adult airway?
vocal cords
what part of airway anatomy modulates sound
larynx
what seperates the trachea from esophagus when swallowing
larynx/epiglottis
What is the larynx composed of?
muscles
ligaments
cartilage
what is size of vocal cords in males
23mm
what is the size of vocal cords in females
17mm
what is the smallest part of pediatric airway
glottic opening
just past vocal cords
what is the range of the glottic apertrue
60-100mm
what does the posterior cricoarytenoid do?
what innervates it?
abducts (opens) the vocal cords
recurrent laryngeal nerve
what does the lateral cricoarytenoid do?
what innervates it?
adducts (closes) the arytenoids, closing the glottis
recurrent laryngeal nerve
what does the transverse arytenoid do?
what innervates it?
adducts (closes) the arytenoids
recurrent laryngeal nerve
what does the oblique arytenoid do?
what innervates it?
closes the glottis
recurrent laryngeal nerve
what does the aryepiglottic /aryearritnoid do?
what innervates it?
closes the glottis (apperture)
recurrent laryngeal nerve
what does the vocalis do?
what innervates it?
relaxes the cords
recurrent laryngeal nerve
what does the thyroarytenoid do?
what innervates it?
relaxes tension int he vocal cords
recurrent laryngeal nerve
what does the cricothyroid do?
what innervates it?
tenses and elongates the vocal cords (tone of voice)
external branch of superior laryngeal
what is the first thing you see when doing DL
epiglottis
what is the second thing you see when doing DL while lifting
arytenoid cartilage
what is the third you see when doing DL while lifting
vestibular folds (false vocal cords)
what is the fourth thing you see when doing DL while lifting
true vocal cords
where do you put MAC blade
vallecula
where do you put the Miller blade
under the epilglottis
what is doorway to the airway
epiglottis
what is the epiglottis attached to
bottom of the tongue
which arytenoid cartilages are most medial/ at the bottom of DL view
corniculate
which arytenoid cartilages are most lateral/ at the sides of DL view
cuneiform
where is trachea in relation to cervicle and thoracic vertebrae
C6-T5
where is carina on thoracic vertebrae
T5
when does trachea end
carina
what is the most cephalad cartilage of trachea
cricoid
what cartilage of trachea is a full ring
cricoid
what is the shape of most tracheal cartilage
horse shoe/ C shaped
what is the first “grade” view you see when intubating and then
Cormack-Lehane
grade 4- soft tissue
grade 3- epiglottis
grade 2- vestibular folds/arytenoids
grade 1- vocal cords, arytenoids, everything
what is visible in Cormack-Lehane grade 4
soft tissue
what is visible in Cormack-Lehane grade 3
epiglottis
what is visible in Cormack-Lehane grade 2
vestibular folds
arytenoids
+ grade 2
what is visible in Cormack-Lehane grade 1
everything
true vocal cords
arytenoids
epiglottis
can you do an airway assessment pre op
no, have to stick scope down throat
when doing airway assessment do you say “ah”
no, raises soft pallate and makes it too easy
What is Mallampati class 1
most of glottis visible
- hard palate, soft palate, uvula, fauces, tonsillar pillar
what is Mallampati class 2
hard palate,
soft palate,
uvula,
fauces (usually only base of uvula visible, non tonsilar pillars)
what is Mallampati class 3
hard and soft palate, very base of uvula
what is Mallampati class 4
hard palate only
What does the Mallampati score evaluate?
difficulty of intubation
how much room you have in mouth to displace tissue
where do we do cricothyrotomy
cricothyroid membrane, right above cricoid cartilage
what is prayer sign
if cant press palms together, have arthritis of joints, probably arthritis of neck, hard to move neck to view airway
also arthritis of arytenoids
what neck circumference leads to difficult intubation
43 cm
what neck circumference/thyromental distance (NC/TMD) is difficult intubation
> 5cm
having OSA is indicitive of difficulty ___________
masking
soft tissue flaps
what percent of pregnancy has Difficult intubation
8%
what in pregnancy leads to Diff Intubation
swelling of airway
friable airway
smaller airway
lots of edema
(lay out lots of tubes to go down in size if needed)
what are large incisors indicitive of in airway assessment
decreased room, increased injury
what is large tongue indicitive of in airway assessment
large wide tongue will get in way of ETT
will cover airway making mask ventilation difficult
what is facial hair indicitive of in airway assessment
cant seal mask
how can you get a seal with facial hair
opsite dressing
water based lube
use two hands and use machine to ventilate
why dont you use petroleum based lubricant on face with intubation
airway fire
what is small mouth opening (<3cm) indicitive of in airway assessment
difficult airway
what is decreased mobility or pain or N/T with neck flexion and extension indicitive of in airway assessment
movement- cant get good angle for intubation
N/T- cervical compression, double crush syndrome watch with how you turn head
what is the upper lip bite test
vermillion border test
bite with lower teeth as far up upper lip/gums as possible
what does upper lip bite test test for
checks for retrognathia,
basically no chin with big overbite (mandible in and overbite)
what is lemon technique?
L-look externally
E-evaluate 3,3,2
M-mallampati
O-obstruction or obesity
N- neck mobility
What is the 3-3-2 rule in airway assessment?
3 fingerbreaths between incisors
3 fingerbreaths between mentum (tip of chin) and hyoid bone (chin-neck junction)
2 fingerbreaths between hyoid bone and thyroid notch
what decreases somebodys incisor distance
TMJ
how do you get help with patient with TMJ
ask them tricks of how they open jaw, or have them open jaw then stick gaurd in
what shape of palate is a predictor of difficult airway
highly arched or narrow
what neck shape is a difficult airway
short thick neck
what neck movement predicts Diff intubate
cannot touch chin to chest OR patient cannot extend neck
what female specific thing can lead to Diff intubation
large breasts, shift up and put weight on chest/airway, cant move tissue
ramp patient up to sniffing position
what is thyromental distance
distance between mental area and thyroid cartilage
what does thyromental distance help determine
how readily laryngeal axis will fall in line with pharyngeal axis
how acute the angle will be
what should thyromental distance be
> 3 fingers or > 6 cm in adults
what is thyromental distance is less than 3 fingers or >6 cm
acute pharyngeal/laryngeal angle = Diff intubation
what is the most important airway skill
masking
What is the goal of airway management?
move air
where should mask lay on patient
bridge of nose/between pupils, lateral nasolabial folds, between lower lip and chin
what can a large mask that goes under the chin cause
leak
compression of soft tissue
how can we minimize gastric insufflation with masking
pressure under 20 cm H20
give gradual not sudden breath
what does gastric insufflation cause
vomit
what do you do if you have to use high pressure (<20 cm H20) in mask patient
OG tube and suck air out
what is the CE technique
2 fingers (thumb and index) on mask in C
2 fingers (middle and ring) on jaw bone
1 finger (pinky) performing jaw thrust on mandible
what happens if you put fingers on soft tissue while mask ventilating
compressing airway
what are techniques for difficult mask
two handed- beards or difficult seal seal
opsite dressing/lube- beards
oral/nasal airway
mask straps
where do you but fingers in two handed ventilation
thumbs on mask, middle finger under mandible jaw thrusting
why do you not want hands on patients face while falling asleep
makes patient nervous
what size of mask is for Premis
00
what size of mask is for infant
0
what size of mask is for child
1
what size of mask is for a small adult
2
what size of mask is for medium adult
3
what size of mask is for large adult
4
what size of mask is for extra large adult
5
what size mask for adult is most common
3 or 4
what hand do you hold larygoscope handle with
left
what hand do you hold ETT with
right
what is shape of miller
straight
what shape is a mac
curved
how does mac open airway
goes in valecula and indirectly lifts epiglottis
how does miller open airway
goes under epiglottis and directly lifts it
which blade do you knock out teeth more
miller
what is MAC technique for intubation
R side of mouth
displace tongue to left
what is miller technique for intubation
avoid tongue
go down back side
under epiglottis
What is a stylet used for?
rigid wire inside tube used to shape ETT
usually in indirect laryngoscopy
what is 00 miller blade for
premi
what is 0 miller blade for
infant
what is 2-3 miller blade for
most adults
what is a wisconsin blade
super straight long miller
what is pediatric size MAC
1
what increases as you go up with MAC size
length and width
what is the most used MAC size
3-4
what is Dr Rices perfect mac blade
3.5 ceramic
What is the sniffing position?
It is the optimum intubation position
35 neck flexion, 15 face plane extension
head elevated 8-10 cm
how can you lift head for intubation sniffing position
pillows
stomach
chest
where do you put pillows for sniffing posistion
shoulder blades
head
what is goal of sniffing position
align oral, pharyngeal, laryngeal axis for straight line visualization of glottis
how high should patient be for intubation
CRNAs xiphoid
what is the scissor techique
2 gloves on R hand
using R thumb and R index/middle finger on maxillary teeth to push mandible and lip away
what percent of peoples mouth are opened automatically
20%
where on patients body do you aim when lifting laryngoscope
patients left foot
how do you insert laryngoscope blade
insert blade slightly to right of tongue
sweep leftward and upward
aim for patients left foot
how does wrist move during intubation
it doesn’t, lock it in place, lift with arm tucked in to body
what is BURP manuever
manipulation of trachea to find epiglottis with cricoid pressure
Backward
Upward
Rightward
Pressure
ETT is sized according to __________ diameter
internal
what is the increment of size for ETT
0.5mm
where do lengthwise centimeter markings start at on ETT
distal end to assist in placement depth
how does ETT react to body temp
the polyvinyl chloride plastic softens with body temp
how high above carina do you want ETT
3-5 cm
why do you not want ETT on carina
cause cough reflex
where are cough receptors in lungs
carina
what is normal ETT depth at incisors for females
21 cm
what is normal ETT depth at incisors for males
23 cm
what is formula for ETT depth
(body height in cm/5) - 13 to the R mouth angle (cm)
what is method for proper ETT placement depth
intubate, inflate cuff, pull tube till meet resistance, this is right on the other side of vocal cords
what type of tube cuffs do we usually use
high volume low pressure
how many ccs can ETT hold
90ccs
what is normal cause of “cuff leak”
migration of tube up vocal cords
should you squeeze little ballon on ETT
no, doesnt tell you anything, very painful
what can you do to determine if their is a cuff leak
leak test
how do you do leak test
put air in cuff
put valve thing on
put at 40-30-20
should leak at 40 and 30
should stop and 20
if leaks at less than 20 then needs more air
what other device measures cuff pressure
sphygomometer or something, monometer
what can overfilled ETT cuff lead to
tracheal stenosis
what are methods of confirming intubation
condensation in ETT
bilateral chest rise
continuous EtCO2
direct visualization of ETT through cords
lung sounds
how many EtCO2 readings do you need before know in lungs
> 4
what makes false EtCO2 reading in esophagation
bictra anaticid
its Sodium Bicarb
how do you check for R mainstem
breath sounds
PIP
unilateral chest rise
decrease volume
decreased SpO2
what is an LMA an example of
supraglottic airway
what does LMA stand for
laryngeal mask airway
T/F you can aspirate with LMA
TRUE
Is the LMA a secure airway?
NO
what is a device that “lets us mask patient without hands”
LMA
Where does the LMA seal the airway
hypopharynx
what size LMA do you use for an infant weighing <5 kg
what is the cuff volume
1
up to 4ml
what size LMA do you use for a child weighing 5-10 kg
what is the cuff volume
1.5
up to 7ml
what size LMA do you use for a child weighing 10-20 kg
what is the cuff volume
2
up to 10 ml
what size LMA do you use for a small adult weighing 20-30 kg
what is the cuff volume
2.5
up to 14ml
what size LMA do you use for a normal adult weighing 50-70 kg
what is the cuff volume
4
up to 30
what size LMA do you use for a large adult weighing 70-100 kg
what is the cuff volume
5
up to 40
what size LMA do you use for <5kg
1
what size LMA do you use for 70-100 kg
5
what size are most adults in LMA
3-4
what does supreme LMA have
catheter to suction in esophagus
where does the tip of LMA sit
esophagus
where is opening of LMA
over glottic opening
what can fast track LMA do
ETT can slide in through LMA
can also use fiber optic bronchoscope with cook exchange catheter
what can LMA be used for
airway on its own
time before intubation
as an “introducer” for ETT/bronchoscope intubation
what is the approach for video laryngoscopy
midline approach
what can be difficult in video laryngoscopy and anterior airway
can see it, but have to hook ETT up to get airway, have to twist it
what is a benefit of video larygoscope intubation wise
more room in mouth
what do you do if you cant ventilate with mask
wake up or intubate
1) oral airway
2) nasal airway
3a) paralyze and intubate OR 3b) LMA
what do you do if initial intubation is unsuccessful
1) call for help
2) return to spontaneous respiration
3) wake the patient
4) MASK
what do you do if face mask ventilation after failed intubation is inadequate
attempt SGA (LMA)
what do you do if LMA fails after face mask ventilation after failed intubation is inadequate
emergency invasive airway (cric)
at anypoint in pathway if you cant ventilate where do you jump to
emergency airway pathway
in needle cric do you ventilate patient?
NO,
just pushing oxygen in,
too small to ventilate
if multiple failed attempts to intubate but can mask ventilate what do you do
end surgery
what does waveform on anesthesia machine mean
pressure changes, not always ventilating
how long do patients last before desat
6 min in perfect patient
how long does propofol last
2-5 min
what is a bougie for
poor view,
hard tip goes into airway and you feel hard bumps of tracheal rings
if you use a bougie and it is smooth where are you
esophagus
what are some complications of intubation
ETT malposition
laryngospasm
dental trauma
soft tissue trauma
vocal cord damage
what is common ETT malposition
R main stem
-PIP
-low volumes
-decrease sats
-lung sounds
What is a laryngospasm?
vocal cords clamp closing the airway
when does laryngospasm usually happen
stage 2 anesthesia
what are steps to treat laryngospasm
100% O2 with continuous PP
jaw thrust so air hits cords
if complete
1-2 ccs succs
-bag them till succs wears off
what is a partial laryngospasm? how does it resolve?
usually resolve on own
use 100% O2 with continous PP
what happens if you breathe against a closed glottis
negative pressure pulmonary edema
negative pressure against closed airway pulls fluid from vasculature into lungs
how do you treat negative pressure pulmonary edema
cpap/bipap 12-24 hours (push fluid back out)
possible diuretic
how long does it take to develop negative pressure edema
5-6 breaths
few minutes
what kind of risk is dental trauma in anesthesia
normal risk
how can you cause vocal cord damage with stylet
pushing stylet through vocal cords- causes vocal cords palsy
never put stylet through vocal cords
what happens if you break a tooth
have to get it out
what do you do for C-spine anesthesia
hold c-spine
log roll
hold cspine while intubaing,
use glidescope or fiber optic to keep neck in line
DOCUMENT cspine held
what do you document with Cspine
Cspine help
fiber optic
no flexion/extension
preexisting issues
anything to show you didnt cause worse symptoms
when do you use jet ventilation
airway or tracheal procedures (tracheal stents)
what is rate of jet ventilator inspiration/expiration
1-2 sec inhale
5-6 sec exhale
is jet ventilator ventilation?
no only oxygenating
what is common issue with jet ventilator
increased CO2
can you run gasses in jet ventilation case
no all IV
what psi jet ventilator do you use for adults
what is limit
start at 20 psi, increase until adequate chest rise
< 50 psi
what psi jet ventilator do you use for children
what is limit
start at 5-10 psi, increase until adequate chest rise
<30psi
what rate do you use for jet ventilator
20 bursts per minute
how do you minimize barotrauma in jet ventilation
adequate expiratory phase
what do you do if surgeon is using bovie during jet ventilator
<30% O2, us air blender
if you are using 100% O2 with jet ventilator and surgeon decides to use bovie how long do you wait for O2 to diminish
3 min
what are disadvantages of jet ventilation
does not provide protection against secretions/aspiration
incomplete control
specialized training
are jet ventilators laser safe
NO
can you accurately monitor gas exchange in jet ventilation
No
use abgs
how are pH and CO2 affected in jet ventilation
low pH
high CO2
what are complications of jet ventilation
aspiration
Gi insufflation
bleeding
pneumothorax
subcutaneous emphysema
inadequate ventilation
barotrauma
what is the most common performed urologic procedure
cystoscopy
what are indications for cystoscopy
hematuria
recurrent urinary infection
renal calculi
urinary obstruction
what are some procedures using cystoscope
bladder biopsies
retrograde pyelograms
resection of bladder tumors
extraction of lithotripsy or renal stones
placement of manipulation of ureteral stents
what are anesthesia considerations for ureteral stents
patient cannot move
NMBD- ETT
what position are most cystoscopy in
lithotomy
how do you move legs in lithotomy
move legs together, avoid dislocating hip
what are anesthetic considerations for lithotomy
deep sedation, dont want movement to prevent nerve damage
what is risk of an OR bed where the foot of the bed lowers
if arms are tucked fingers can get cut off by bed
what neves can be damaged in lithotomy
common peroneal nerve
saphenous nerve
obturator and femoral nerve
sciatic nerve
how can common peroneal nerve be damaged in lithotomy
lateral knee/calf rests on strap support
how does common peroneal nerve injury manifest
loss of dorsiflexion of foot (foot drop)
How does a saphenous nerve injury present?
numbness along medial calf (nerve runs along medial thigh)
how does obturator and femoral nerve injury occur in lithotomy
excessive flexion of thigh against groin, panus/obesity
how does the sciatic nerve get injured in lithotomy
extreme flexion at thigh can stretch sciatic
how does lithotomy position affect lungs
FRC decrease, especially in large/pregnant patients
increased peak pressures
LMA may not be a good choice cause of pressure requirements
how does lithotomy position affect heart
increased venous return from leg elevation
exacerbate CHF,
increases MAP but not CO
lowering legs can cause a drop in pressure
what are contraindications for LMA
reflux,
obese,
diabetic,
lengthy procedures,
gastroporesis,
longer than 2 hours,
laparoscopic, some lithotomy
what can prolonged use of LMA cuase
nerve damage
why do you not always use neuraxial anesthesthesia in cystoscopy
cystoscopy usually 15-20 min and spinal is multiple hours
what level do you do spinals at for cystocopy
T10
what kind of neuraxial do you use for cystoscopy usually
spinal
NMBD are usually not needed for cystocopy unless you are doing what
going in ureters
what level do you spinal at for csection/OB
T6
what is preffered anesthesia tool for elderly or high risk patients in cystoscopy
spinals
what is an elderly complication for spinals
arthritis
use larger needle
what is a TURP
transurethral resection of the prostate (BPH)
what is age of most turps
> 70 so lots of comorbidities
what type of anesthesia is preferred for TURP
neuraxial/spinal
why is spinal preferred for TURP
less neuro depression, can detect TURP syndrome better
what are common side effects of TURPs
clots,
hematuria,
UTI,
failure to void
what evaluations do you do for preop eval for elderly turp patient
cardiac- aortic stenosis (loud systolic murmur)
why are spinals bad in aortic stenosis
rely of SVR to maintain CO, if SVR is decreased by spinal vasodilation, then blood cant get to coronaries or rest of body
also increased HR makes it worse
when do you do type and screen for TURP
anemia
>40g prostate gland removal
long procedures=more bleeding
what is average blood loss for TURP
3-5ml/min
avg 200-300
how much is 1 gm of tissue loss in TURP blood wise
15cc blood loss per gram
what length and mass of removal may require transfusion of TURP
> 90 min
40grams
besides bleeding what can cause a decrease in TURP hct
hemodilution from absorption of irrigating fluid
how does TURP syndrome occur
-prostate has lots of venous sinuses, irrigant is hypotonic
-this cuases hyponatremia
when does confusion occur with hyponatremia
<120 Na
what are s/s TURP syndrome
HA,
restlessness,
confusion,
cyanosis,
dyspnea,
arrhythmias,
hypotension,
seizures due to hyponatremia,
fluid overload,
solute toxicity
how much fluid absorption is related to TURP syndrome
> 2L
what lab do you draw to check TURP syndrome
BMP (Na)
what solutions are used for turp irrigation
glycine,
sorbitol,
mannitol,
nothing with Na because it conducts electricity
what two factors increase fluid absorption in turp
bag height (irrigant pressure)
time of procedure
besides hyponatremia, what other electrolyte imbalance occurs in TURPs
hyperglycemia from absorption of solutions
what vision change can occur in TURP
temporary blindness from hyperglycinemia (from glycin)
what is treatment for TURP syndrome
-recognition-constant check neurostatus
-fluid restrictions/loop diuretics
-hyponatremia- 3% saline
-seizures- versed/prop
-intubation- prevent aspiration
how does turp affect temp? what is risk?
-hypothermia-irrigant, shivering can dislodge clots and cause bleeding
how fast do you give 3% saline
100cc/hr
how do you prevent hypothermia in TURP
bair hugger, warm blankets, fluid warmers, humidifier for circuit
what bleeding disorder can occur with TURP
DIC- r/t thrombaxane release blood cell lysis
what infection can occur with TURP
septiciemia- treat with gentamycin maybe prophylactic
besides aortic stenosis, what other condition is contraindicated for spinal in TURP
cancer with spinal metastasis
what is an ESWL procedure
extracorporeal shock wave lithotripsy
what is the first line therapy for renal and upper 2/3 of ureter stones
lithotripsy
what kind of anesthesia for ESWL procedures
general
what positioning considerations for ESWL
hole in bed, dont let them fall through
what other procedure can be done with EWSL
stents
cysto
what are contraindications for ESWL
-pregnancy
-lungs away from shcok
-aortic aneurism
-coagulopathy
-arrythmias
-ICD/pacemaker (have magnet)
-urinary obstruction below stone
what is ESWL shock timed with
HR so no shock on R wave
what medication is given to increase speed of ESWL shocks
robinol/glycopyrolate (speed up HR)
what are anesthesia considerations for ESWL
-want patient intubation (no LMA)
-time shocks during expiration so lungs arent close to wave
-bradycardia prolongs procedure
-patients with arrythmia hxs are at higher risk for dysrhythmias
what do you need to know with cancer patient
mestastasis, malignancy
what is position for prostectomy
-extreme trendelenburg with robot
-arms tucked
what are anesthesia considerations for prostectomy
-long procedure (4-6 hours)
-2 IVs
-decreased FRC, increased PP (peak pressure_
-OG to suction patient
-pressure mode for ventilator
-EBL 100-300 usual
what are preoperative considerations for radical nephrectomy
-degree of renal impairment
-size of tumor
-underlying diseases (HTN, DM)
-COPD, CAD
-most are anemic and may need preop transfusion
-cooler of blood in room
what is a well documented risk for renal tumors? what are other risk factors associated with this
smoking
emphysema
what are intraop considerations for radical nephrectomy
SEVERE BLEEDING (Type and cross, 2 large IVs, a-line, CVC)
-positioning/approach
-mannitol to preserve renal function
-use lots of narcotics
-adrenal gland= BP swings, have nitro ready
what is it called when tumor extends outside of renal capsule
thrombus
what is a level one renal tumor
into IVC below liver
what is a level 2 renal tumor
up to liver below diaphragm
what is a level 3 renal tumor
above diaphragm in to R atrium
what test can you do pre-op to check for preexisting embolization and thrombus of renal carcinoma(into diaphragm)
VQ and TEE
what lines/blood products do you use for a radical nephrectomy with tumor thrombus
invasive monitoring (swan, TLIJ)
multiple large IVs
10-15-50 units PRBC
use platelets, FFP, cryo
what is risk of swan placement with tumor thrombus of renal carcinoma
contraindicated in level 3 throbus due to potential of dislodgement of tumor
-causes stroke
what do you do if renal carcinoma tumor covers >40% of right atrium
cardio-pulmonary bypass (perfusionist)
do you use cell saver for radical nephrectomy
no, spread cancer cells
what are serious potential complications of radical nephrectomy with tumor thrombus
pulmonary embolism of a tumor piece
what are s/s PE
sudden dysrhythmias,
arterial desaturation,
profound hypotension
what does a high CVP during a radical nephrectomy with tumor thrombus point towards
venous obstruction by the thrombus
what is polymethylmethacrylate
bone cement
what kind of reaction is bone cement
exothermic, gives off heat
what is a risk of bone cement
expansion, leads to emboli, like fat (called intermedullary HTN-the force that pushes the fat out)
what is a serious side effect of bone cement
DIC
how can you prevent emboli in orthopedics
100% O2 prior to cement
drill a vent hole in bone
use non-cementing prothesis
what are some diseases/procedures that have DIC risk
amniotic fluid emboli,
bone cement
fat emboli,
bone cement emboli,
sepsis,
TURP syndrome,
crystalloids,
ARDS
what happens in DIC caused by bone cement emboli
release of tissue thromboplastin,
platelet aggregation,
microthrombus formation in lungs,
cardiovascular instability,
EtCO2 emboli pattern
what do you set pressure on tourniquet to
100mmHG over systolic BP
150mmHg over systolic BP for thigh
how does anesthesia help create a bloodless field
decrease BP
how long can you have tourniquet inflated for
2 hours
if it goes longer deflate for 20 min then can go for 2 more hours
what can deflation of tourniquet lead to
acidosis,
hyperkalemia,
myoglobinemia,
renal failure
increased EtCO2
When does tourniquet pain occur?
around 60 min
what is tranexamic acid (TXA)
inhibits fibrinolysis
plasminogen to plasmin inhibitor
what sx can you not use tourniquet in? what do you use instead
joints like hips and shoulders
use TXA
when do you give TXA periop
beginning of case and before tourniquet inflation or at closing
what are the main anesthesia issues with ortho
clots and bleeding
what are the neurological affects of tourniquet use
-30 min = decreased somatosensory evoked potentials and nerve conduction
-60 min = tourniquet pain and HTN
-2 hrs = postop neuropraxia
-nerve injury
what are the muscle changes of tourniquet use
-2 min= cellular hypoxia
- decreased cellular creatinine
-cellular acidosis
-2hrs= endothelial capillary leak
what are the systemic effects of tourniquet inflation
-increased arterial and pulmonary arterial pressure
-more severe without volatile anesthetics
what are the systemic affects of tourniquet release
-decrease in temp
-metabolic acidosis
- decrease central venous O2
-thromboxane release
-decrease in pulm and arterial pressures
-increase in eTCO2
what nerve fibers cause tourniquet pain
c fibers
what can happen anesthesia wise with tourniquet release
increase CO2 leads to spontaneous breathing
kinda wake up a bit
what nerve fibers are associated with tourniquet pain
c fibers
what kind of fractures have fat emboli
long bone fractures- nearly 100%
what is Fat embolism syndrome triad
dyspnea,
confusion,
petechia (of chest and upper extremities)
what is the differentiating symptoms of fat embolism vs amniotic fluid, VAE
petechia of chest and upper extremities
what are life threatening complications of Fat embolism syndrome
ARDS,
neurodamage via edema,
DIC
what does fat from long bone fx come from
medullary vessels
what are the two complications for beach chair position in shoulder sx
VAE,
decreased cerebral perfusion pressure
in sitting position, what is difference between BP in head and in arm
about 20mmHg
what is treatment for VAE
Position- Left lateral, trendelenburg
flood sx site with NS
central catheter to suck VAE out
DC N2O
100%O2
what are risk factors of DVT/PE
> 60 yo,
obesity,
tourniqet,
>30 min procedure,
>lower extremity fx,
>immobilized >4 days
how do you prevent DVT
pneumatic compression devices, pharmocological methods
how does neuraxial anesthesia affect thromboembolitic events
decreased them
what are anesthetic considerations for old people
-decrease doses for induction agents
-high mortality
-dehydration, malnourishment
-increased blood loss
-increased comorbidities
what bleeds more intracapsular or extracapsular hip fxs
extra
what is an anesthesia method to decrease mortality of hip fx patients
neuraxial
spinal
epidural
combo
how long does spinal last
about two hours, so if longer do combo
what is replaced in total hip
ball and socket, usually due to osteoarthritis
(longest hipp procedure so use spinal/epidural combo)
what is replaced in hemiarthroplasty
only ball (shorter procedure)
what is used in gamma nail
nail to fixate fracture
what positions are shoulder sxs done in
lateral or sitting
what is positioning considerations for lateral shoulder
head and neck in neutral position
axillary roll -protects brachial plexus
what are risks of beach chair CV wise
vasodilation,
increased HR,
BP swings (mix neo)
anesthesia considerations for shoulder sx
higher blood loss
GETA with regional block
low visualization of ETT after draping
consider a-line
what does gas insufflation do anesthesia wise
increased intrathoracic pressure
increased PP (peak pressure)
harder to breathe
absorb CO2, causes acidosis so increase MV to breathe it off
what type of anesthesia technique for laprascopic technique
general ETT anesthesia
what is pneumoperitoneum
increased pressure caused by insufflation of CO2 in laparoscopic technique
CO2 insulflation affects
what are factors leading to subcutaneous emphysema (crepitus)
-insufflation
-intraabdominal pressure >15mmHg
-multiple attempts at the abdomen entry
-needle or cannula outside peritoneal cavity
-cannula seal not snug
-use of >5 canulas
-laparoscope used as a lever
-canula acting as a flucrum
-long arm of laparoscope
-compromised tissue integrity by repetitive movements
-structural weakness caused by repetitive movements
-improper cannula placement
-soft tissue dissection and fascial extension
-procedure >3.5 hours
-etCO2>50 mmHG
how do you manage subcutaneous emphysema
-decrease intraabdominal pressure
-dc NO2
-100%fiO2
-evaluate pneumothorax
-increase MV to treat hypercarbia
-evaluate ETCO2 and PaCO2
-assess chest wall and lung compliance
-assess airway to rule out compression prior to extubation
what is celiac reflex
vagal nerve stimulation from traction or structures within peritoneal and thoracic cavities
-causes severe brady, asystole
how do you treat celiac reflex
robinol/glycopyrolate
atropine
decrease CO2 pressure in abd
what are causes of gas embolisms
trocar insertion into vessel,
open intravascular vessels with lower pressure than intraabdominal pressures
hit liver with trocar
c section
how do you treat VAE
left lateral,
100% O2,
discontinue N2O,
flood field with NS,
place CVC
what is positioning for lap cholecystectomy
trendelenburg and airplane left
what is positioning for lap appendectomy
Reverse trendelenburg and airplane left
what is positioning for robotic prostatectomy
steep trendelenburg
what are some open abdomen procedure considerations
evaporative fluid loss
heat loss
blood loss
decreased bowel function
how do you decrease bowel function issues
ERAS,
reduce opioids,
consider regional blocks,
what are some ERAS (enhanced recovery after surgery) protocol recommendations preop
PREOP
preadmin counseling
fluid and carbo loading
eliminate NPO status
no/selective bowel prep
antibiotic prophylaxis
thromboembolism prphylaxis
eliminate routine use of premedicating
what are some ERAS (enhanced recovery after surgery) protocol recommendations intraop
INTRAOP
short acting anesthetic agents
epidural use
avoid sx drains
avoid salt/water overload
maintain normothermia
what are some ERAS (enhanced recovery after surgery) protocol recommendations post-op
POSTOP
epidural anesthesia
avoid NG tubes
PONV prophylaxis
avoid salt/water overload
early ambulation
early oral nutrition (gut motility)
early catheter removal
how does gas affect evoke potentials
decrease them, so <1/2 mac
if doing muscle evoke potentials what do you do anesthesia wise
dont paralyze, use succs to intubate
how do you keep patient from moving in spinal anesthesia when you cant use NMBDs
OVERSEDATE if not paralyzed
where do you put hands and how do you roll patient for prone
log role kinda, one head on top of face on on back of head, secure tube, CRNA in charge of movement
anterior ethmoidal nerve
1
sphenopalentine nerve
2
lingual nerve
3
glossopharyngeal nerve
4
superior laryngeal nerve
5
internal laryngeal nerve
6
recurrent laryngeal nerve
7
superior laryngeal nerve
1
internal laryngeal nerve
2
external laryngeal
3
carotid artery
4
vagus
5
left recurrent laryngeal nerve
6
right recurrent laryngeal nerve
7
recurrent laryngeal nerve
8
epiglottis
1
hyoid bone
2
thyroid cartilage
3
cricothyroid membrane
4
cricoid cartilage
5
cervical sympathetic ganglion
6
inferior ganglion of vagus nerve
7
superior laryngeal nerve
8
internal laryngeal branch
9
external laryngeal branch
10
vagus nerve
11
recurrent laryngeal nerve
12
innominate artery
13
hard palate
1
soft palate
2
nasopharynx
3
oropharynx
4
hypopharynx (laryngopharynx)
5
epiglottis
6
vocal cords
7
larynx
8
trachea
9
valleculae
1
epiglottis
2
aryepiglottic folds
3
trachea rings
4
true vocal cords
5
vestibular folds
6
arytenoids (corniculates)
7
nasopharynx
1
oropharynx
2
epiglottis
3
hypopharynx
4
vocal cord
5
larynx
6
trachea
7
esophagus
8
tongue
9
epiglottis
10
vocal cords
11
trachea
12
epiglottis
1
aryepiglottic folds
2
true vocal cords
3
corniculate cartilage
4
cuneiform cartilage
5
Cormack and Lehane grade 4
soft tissue only
Cormack and Lehane grade 3
epiglottis
Cormack and Lehane grade 2
vestibular folds
arytenoids
Cormack and Lehane score grade 1
true vocal cords
Cormack and Lehane grade 4
soft tissue only
Cormack and Lehane grade 3
epiglottis
Cormack and Lehane grade 2
vestibular folds
arytenoids
Cormack and Lehane score grade 1
true vocal cords
mallampati class 4
hard pallate only
mallampati class 3
hard and soft palate
base of uvula
mallampati class 2
hard and soft palate
uvula
fauces
mallampati class 1
hard and soft palate
uvula
fauces
tonsilar pillars
what is the distance from the subclavian vein to the R atria
right 15 cm
left 25cm
what is the distance from the R IJ to the R atria
15 cm
what is the distance from the L IJ to the R atria
20 cm
what is the distance from the right Femoral vein to the R atria
40cm
what is the distance from the R median basilic vein to the R atria
40 cm
what is the distance from the L median basilic vein to the R atria
50 cm
What does CVP measure?
right atrial pressure
what is normal CVP
1-10mmHg
what does CVP estimate
preload
in a CVP waveform what does the a wave denote
atrial contraction
in a CVP waveform what does the c wave denote
tricuspid valve closure (pressure pushed against valve at closure)
in a CVP waveform what does the v wave denote
passive filling of RA (coranaries, IVC, SVC)
where does the a wave of the CVP waveform correlate to the EKG
comes after P wave
where does the c wave of the CVP waveform correlate to the EKG
during QRS
where does the v wave of the CVP waveform correlate to the EKG
t wave/ repolarization
what causes an elevated a wave in CVP waveform
(increased contractile force)
junctional rhythm (atria pushing on closed tricuspid valve)
PVCs
tricuspid stenosis
ventricular pacing
what causes an elevated C wave in CVP waveform
(pushing against tricuspid valve)
pulm htn
mitral insufficiency (regurge)
what are causes of elevated CVP
(elevated preload)
RV failure
tricuspid stenosis or regurge
cardiac tamponade
constrictive pericarditis
volume overload
pulmonary htn
LV failure (chronic)
how does hypovolemia affect CVP waveform
hides abnormalities
what causes a large V wave in CVP waveform
(increased filling pressure)
increased preload
high volume of fluid given
what happens to CVP waveform when you give alot of volume
up and plateaus
what condition causes a lack of a waves in CVP waveform
a fib
with a swan, what is the distance from the Rt IJ to the RA
15-25 cm
with a swan, what is the distance from the Rt IJ to the RV
25-35 cm
with a swan, what is the distance from the Rt IJ to the PA
35-45 cm
what is the approx normal pressure of the RA
5
(no systolic, same as CVP)
what is the approx normal pressure of the RV
25/5
(gain systolic, diastolic mimics RA)
what is the approx normal pressure of the PA
25/10
(systolic same, diastolic increase)
what does a thick line on a swan represent
50 cm
what does a thin line on a swan represent
10 cm
what is the thermistor port on a swan for
CO
CI
what color is the CVP port on a swan
blue
what color is the balloon port on a swan
red
how many ccs go in a swan balloon
1.5 ccs
what color is the PA port on a swan
yellow
what is used to introduce a swan? how big is it? where is it usually placed?
cordis
9 french
Rt IJ
when do you inflate the swan balloon during insertion
RA
what is a common dysrhythmia when inserting a swan
PVCs
if you insert swan from the L side IJ instead of the R how much distance do you add
10 cm
how can you tilt bed to help with swan insertion
R and trendelenburg
what is the A wave on a PAOP or wedge
left atrial contraction
what is the C wave on a PAOP or wedge
mitral valve closure (bulge)
what is the v wave on a PAOP or wedge
filling of L atria
what causes a large a wave on PAOP
mitral stenosis
what causes a large v wave of PAOP
mitral regurg
what causes an elevated PA pressure
LV dysfunction
mitral stenosis/insufficiency
L-R shunt
ASD/VSD
pulm htn
what causes an elevated PAOP
LV dysfunction
cardiac tamponade
constrictive pericarditis. (chronic pericarditis, mimics tamponade)
Ischemia
what three pressures are the same in a patient with cardiac tamponade
PAD
PAOP
CVP
What is the Frank-Starling law of the heart?
the more the heart fills with blood during diastole, the greater the force of contraction during systole (to a point then it fails)
when do you read a PA mean in a spontaneous breathing patient? a ventilated patient
patient peak- diastolic pressure during expiration
vent valley (or just make them apnic)
what does PAOP approximate
LVEDP
PA pressure is and indirect measurement of
ventricular function
what is normal CVP, PADP, PAOP
cvp 1-10
PADP- 5-15
PAOP- 4-12
what causes CVP, PADP, and PAOP to be low
hypovolemia, or misplaced transducer
what causes normal or high CVP, High PADP, and high PAOP
LV failure
what causes high CVP, normal or low PADP, and normal or low PAOP
RV failure
Tricuspid regurge
Tricuspid stenosis
what causes normal or high CVP, High PADP, and normal or low PAOP
PE
what causes high CVP, High PADP, and normal PAOP
Pulm HTN
what causes high CVP, High PADP, and high PAOP
tamponade,
ventricular interdependence,
transducer not at phlebostatic axis
what causes normal CVP, normal High PADP, and high PAOP
LV myocardial ischemia
MR?
what causes low CVP, High PADP, and normal PAOP
ARDS
how do you calulate CO
CO=SVxHR
what is normal CO
5-6 L/min
how do you calculate CI
CI= CO/BSA
what is normal CI
2.8-3.6 L/min
what helps us calculate CO, CI on a swan
thermodilution +/- 5-10%
how does thermodilution work
inject 10ccs ns/d5,
computer reads temp change and when it returns to normal
why is mixed venous drawn from PA
has SVC and IVC blood
what is normal mixed venous
65-77%
what does mixed venous tell us
measurement of O2 delivery, can be an indicator of low CO
what needs to be documented every 5 mins for all anesthetics
BP
HR
RR
what reading does methemoglobin give and why
85%, absorbs red and infrared light equally
if you intubate too deep, where is tube most likely to go
right lung, shorter straighter
how can temperature affect blood loss
big temp change can increase blood loss
what needs to be monitored continuously on all pediatric (<12) patients receiving general anesthesia and when indicated on other pts
body temp
what monitors are necessary
lung sounds-stethoscope
inspired o2 concentration- gas analysis
expired gas analysis
spo2
pulmonary/chest wall mechanical function
what does pulmonary chest wall mechanical function include
inspiratory pressures, respiratory volumes
what should be monitored continuously on all patients
oxygenation
what are the three ways of verify intubation listed on standard 9
auscultation,
chest excursion,
confirmation of co2 in expired gas
what should be continuously monitored during controlled or assisted ventilation with any artificial airway support
end tidal CO2
what is recommended by standard 9 for alarms
have threshold and variable pitch audible alarms
how many breaths at minimum are needed for etco2 to avoid misinterpretation
6 breaths
what prevents 93% of anesthetic mishaps
pulse oximetry and capnography
how is co2 analysis helpful in gas monitoring
assesses ventilation and detects equipment/patient problems
what co2 analysis is ph sensitive, co2 presence changes color, and used most often by ems
colorimetric co2 analysis
if you intubate and get color change after 1 breath, what could be a problem
could be co2 from stomach
what does a galvanic cell play a role in analyzing
O2 analysis
what law explains pulse oximetry
lambert beer law
what instrument uses a mathematical means of expressing how light is absorbed by matter
pulse ox
what are two main types of oximetry
fractional
functional
what kind of oximetry measures arterial oxygen saturation (Sao2)
fractional oximetry
what kind of oximetry is only measurable by arterial blood sample
fractional ox
what absorbs more red light and what is the light wavelength
deoxyhemoglobin- 660
what absorbs more infrared light and what is light wavelength
oxyhemoglobin 940
if you are seeing more red light than infrared light what is happening with oxygen
higher oxygen- more infrared light being absorbed means higher oxygen content
if you are seeing more infrared light, what is happening to oxygen
decreasing oxygen- more red light being absorbed into deoxyhemoglobin means less oxygen content
what is the formula for fractional oximetry
oxyhemoglobin/
(oxyhemoglobin+deoxyhemogobin
+methemoglobin+carboxyhemoglobin)
in 100% pulse ox, which light will you see most of
red light- infrared has been absorbed into oxyhemoglobin
what kinds of light flash hundreds of times per second in pulse ox
red and infrared light
what does a pulse ox rapidly sample from each pulse wave
peak and trough
what is a trough in pulse ox
vascular bed has arterial, capillary, venous blood, and tissue density
what is a peak in pulse ox
all of blood from trough + additional arterial blood
when is pulse ox inaccurate
methemoglobin, methylene blue, carboxyhgb messes up pulse ox- do abg for real oxygen reading
what is it called when neither red or infrared light is emitted from pulse ox
off period
what are causes of low etco2
hyperventilation,
decreased co2 production,
alveolar dead space
how does a cerebral oximeter work
does not require pulsatile flow, gets readings from vascular beds- also tries to measure arterial though
parabolic arch
below what reading is pulse ox not reliable
below 70%
what happens during off time in pulse ox
reading of ambient light is read and subtracted from sequences
where do you put pulse ox probe to detect changes faster
centrally place
peripheral=slower
what are some pulsatile vascular beds you can attach pulse ox to
finger, cheek, ear, toe, nose,
what are some pulsatile vascular bed you can attach pulse ox to on infant
palm, forefoot, wrist
when is pulse oximeter accurate to within 5%
70-100%
what happens when pulse ox is below 70%
readings are extrapolated and unreliable
what conditions affect accuracy of pulse ox
raynauds,
movement,
vasoconstriction,
poor circulation d/t low co,
improper placement,
hypothermia
what are dyes that can cause false high/low readings in pulse ox
methylene blue,
indigo carmine
exposure to what can cause false high/low pulse ox reading
smoke or fire
what causes fire/smoke to give overestimate of pulse ox
carboxyhemoglobin
what can fluorescent light cause in pulse ox reading
false high- red light isn’t getting absorbed because of same wavelength 660
what can drugs cause that makes pulse ox have false high/low reading
methemoglobinemia -doesn’t release oxygen
85% reading
name some drugs that can induce methemoglobinemia
nitrates,
locals such as prilocaine,
chlorates,
sulfas,
metochlopramide
what are two disease that can cause false high/low pulse ox reading
anemia,
sickle cell (vaso-occlusive crisis),
dyes
what kind of light can interfere with pulse ox
fluorescent light
what happens if esophageal stethoscope enters lungs
makes a leak in cuff, bellows collapse
what can inhibit passage of light through finger
nail polish- black henna or dark blue
what is placed in nasall/orally and is only used in intubated patients
esophageal stethoscope
when is esophageal stethoscope contraindicated
esophageal varices/strictures
when should temperature be carefully monitored according to standard 9
pediatric (<12), or when significant temp change is intended/anticipated/suspectd
what is a late sign of malignant hyperthermia
increased temp
what does hypothermia triple the incidences of
cardiac complications and surgical wound infections
what impact does hypothermia have on blood loss
increases it
what is heat production and how is it brought about
thermogenesis- shivering and non shivering
what is heat loss
thermolysis
what is normal range of temp
36-37.5 c
where is thermoregulation controlled
hypothalamus
what is total body heat a combination of
zone temperatures- peripheral and core zones
what is more important than maintenance of individual temps
maintenance of total body heat
what is the peripheral temp zone made up of
skeletal muscle, subcut tissue, skin
what is core temp zone made up of
trunk and head- holds more heat and releases more heat
how does body respond to cold exposure
increases heat production, reduces heat loss
how does body reduce heat loss
vasoconstriction of peripheral vessels,
increased metabolic rate,
layering w/clothes
Why do peds lose heat more quickly than an adult?
bigger core zone than peripheral zone-
is hypothermia or hyperthermia more cmmon
hypothermia- body naturally vasoconstricts to increase temp but anesthetics gases cause vasodilation
what can you give for shivering
demerol
what is shivering indirectly controlled by
catecholamines
how much heat can you lose in the first hour aka phase 1
1-1.5 degrees c
what is phase 3 of heat loss
equilibriate, plateau, produce same heat you are losing after 4 hours
what is phase 2 of heat loss
still declining but plateauing, losing more heat than you can generate for next 2-4 hrs
how can hypothermia influence ekg
increase pr/qrs/qt
increase or decrease st segment
what is the extra wave from hypothermia in ecg
j wave aka osborn wave
cricothyroid muscles
tense vocal cords
cords Tense
thyroarytenoid muscle function
relaxes vocal cords
they relax
posterior cricoarytenoid muscles
ABducts vocal cords
Please Come Apart
lateral cricoarytenoid muscles
ADDuct vocal cords
Lets Close Airway
what nerve innervates the cricothyroid muscles?
Superior Laryngeal Nerve
what muscles does the Right Laryngeal nerve innervate
vocalis
thyroarytenoid
lateral cricoarytenoid
posterior cricoarytenoid
aryepiglottic
interarytenoid
What can cause a loss of a waves or only v waves
Afib
Ventricular pacing
What causes giant a waves aka cannon a waves
Junctional rhythms
Complete AV block
PVCs
Ventricular pacing
Tricuspid/ mitral stenosis
Diastolic dysfunction
Myocardial ischemia
Ventricular hypertrophy
What can cause large V waves on cvp
Tricuspid/ mitral regurg
Acute increase in intravascular volume
What can cause elevated CVP
Rv failure
Tricuspid stenosis/regurg
Cardiac tamponade
Restrictive pericarditis
Volume overload
Pulm HTN
LV failure
What can cause elevated PAP
LV failure
Mitral stenosis/regurg
L to R shunt
ASD or VSD
Volume overload
Pulm HTN
Cather whip
What causes elevated PAOP
LV failure
Mitral stenosis/ regurg
Cardiac tamponade
Constrictive pericarditis
Volume overload
Ischemia
What can cause overestimated thermodutjln CO
Low injectate volume
Injectate too warm
Thrombus on thermistor of PAC
Partially wedged PAC
What can cause underestimates of thermodultion CO
Excessive injectate volume
Too cold injectate
After induction of general anesthesia, if initial attempts at intubation are unsuccessful, which of the following is NOT advised as a potential “next step”:
Invasive airway access
ASA guidelines suggest equipment in a portable storage unit for difficult airway management should include (Check all that apply): Select one or more
Rigid laryngoscope blades of alternate design and size
Tracheal tube guides (e.g., ventilating tube changer, light wands, forceps designed to manipulate the distal portion of the tracheal tube)
Supraglottic airways (e.g., LMA) equipment
e. Equipment suitable for emergency percutaneous or surgical airway access
Follow-up care for the patient with a difficult airway includes all of the following:
Informing the patient or responsible party of the airway difficulty that was encountered
Providing a description of the airway difficulties that were encountered
Providing a description of the various airway management techniques that were used
Evaluation and follow-up with the patient for potential complications of difficult airway management
If awake intubation is unsuccessful in a patient with a known difficult airway, the following management options are recommended, EXCEPT
A rapid sequence intubation
In the emergency situation in which the patient cannot be ventilated and cannot be intubated, which of the following is recommended
Awakening the patient
Supraglottic airway (SGA) ventilation
Jet ventilation
Percutaneous airway access
Surgical airway access
Strategies to deliver supplemental oxygen throughout the process of difficult airway management include oxygen delivery by
Nasal cannula
Face mask
Supraglottic airway (SGA) Insufflation
An airway history should be conducted, whenever feasible, before the initiation of anesthetic care and airway management in all patients. Examples of at-risk history include all but which one of the following
History of episodic, mild snoring in 10 year old child
A two-year old pediatric patient with an anticipated difficult intubation should be considered a candidate for which of the following management strategies?
Spontaneous ventilation following induction with volatile anesthetic.
Intravenous induction aiming to maintain spontaneous ventilation.
What is sniffing position
35 degree neck flexion
15 degree face plan extension
Head elevation 8-10cm
What is sniffing position
35 degree neck flexion
15 degree face plan extension
Head elevation 8-10cm
What grade view do you visualize most of glottic opening and epiglottis
Cormack-Lehane Grade 1
What view has partial view of vocal cords and full view of posterior laryngeal cartilages
Cormack-Lehane grade 2a
What view has only the posterior portion of the glottic opening can be visualized
Cormack lehane grade 2b
What view only the epiglottis can be visualized; no portion of the glottic opening can be seen
Cormack lehane grade 3
What view is epiglottis cannot be see ; only view is of the soft palate
Cormack lehane grave 4
What is the formula to get ETT depth
Body height (cm) / 5 -13
Pierre robin syndrome
Retrognathia
Micrognathia
Glossoptosis
Cleft palate
Treacher Collins syndrome
Mandibular hypoplasia
Micrognathia
Facial bone hypoplasia
Choanal atresia
Cleft palate
L in lemon
look externally
facial trauma
large incisors
beard or mustache
large tonge
e in lemon
evaluate 3-3-2
incisor distance 3 finger breadths
hyoid mental distance 3 fingers
thyroid to mouth 2 fingers
m in lemon
mallampati score
o in lemon
obstruction
epiglottitis, abscess, trauma
n in lemon
neck mobility
Goldenhar syndrome
Hemifacial microsomia,
mandibular hypoplasia;
vertebrae may be incomplete, fused, or missing
Mucopolysaccharidosis
Macroglossia,
odontoid hypoplasia,
dental anomalies,
Klippel-Feil syndrome:
Short neck,
fusion of two or more cervical vertebrae,
limited range of neck motion
Down syndrome:
Macroglossia,
flattened nose,
cervical spine abnormalities,
obstructive sleep apnea,
dental anomalies
Acquired Conditions Associated With Difficult Airway Management
*Morbid obesity: Thick neck with redundant airway tissue, obstructive sleep apnea
*Acromegaly: Macroglossia, prognathism, vocal cord swelling
*Ludwig angina: Infection at the floor of the mouth, trismus
*Abscesses (oral, retropharyngeal): Distortion or stenosis of the airway tissues, trismus
*Laryngeal papillomatosis: Viral infection causing tumors or papillomas within the larynx
*Epiglottis: infection causing swelling of the epiglottis, laryngeal edema
*Croup: infection causing laryngeal edema and subglottic edema
*Rheumatoid arthritis: Limited cervical spine range of motion, temporomandibular joint ankylosis, cricoarytenoid arthritis
*Ankylosing spondylitis: Cervical spine ankylosis, decreased chest expansion
*Tumors involving the airway: Distortion or stenosis of the airway, fibrosis with fixation from irradiation
*Trauma (airway, cervical spine): Distortion, edema, hemorrhage of the airway
what size lma for >100 kg
6 LMA classic only
up to 50ml
what LMA size and volume for 30-50 kg
3
up to 20 mL
acute inferior wall MI
afib with moderate ventricular response
early repolarization (a normal variant)
ectopic atrial rhythm, non specific T wave abnormalities
acute anterolateral MI
NSR with old inferior MI
left atrial abnormality ( left atrial enlargement)
left posterior hemiblock
left bundle branch block
-60
atrial flutter with low voltage
left ventricular hypertrophy
what is criteria used for LVH diagnosis
The R in lead I plus the S in lead III is greater than 25mm
the R wave in aVL is greater than 11 mm
Left atrial abnormality (enlargement)
left axis deviation
evidence of old anteroseptal MI
sinus rhythm, frequent PVCs, early transition
right bundle branch block with left anterior hemiblock
ST depression- consistent with ischemia
sinus rhythm, type I second degree AVB, LVH with strain
there is a normally functioning single chamber ventricular pacemaker that started competing with the sinus rhythm
pre excitation (WPW)
What nerve injuries can result from masking
Stretch facial nerve (drool, sag)-jaw thrust
CN7 compression (buccal branch)- face mask
Supraorbital nerve compression (ETT in face)
What nerve injuries can result from masking
Stretch facial nerve (drool, sag)-jaw thrust
CN7 compression (buccal branch)- face mask
Supraorbital nerve compression (ETT in face)
What degree of AO extension indicates difficulty with DL
<23 degrees
What are the 4 treatments for hereditary angioedema
C1 esterase concentrate
FFP
Ecallantide
Icatibant
Anatomical borders for LMA
Sides: pyriform sinuses
Distal end: upper esophageal sphincter
Proximal end: base of the tongue
