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Basics > BASICS Exam 3 > Flashcards

BASICS Exam 3 Flashcards

airway, uro/ortho/robot, POCUS, monitoring, vents

1
Q

what is the #1 reason for anesthesia related deaths/morbidity

A

difficult airway

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2
Q

what condition makes patients difficult to mask

A

obesity

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3
Q

what do you do if you cant ventilate/ cant intubate

A

wake up
emergent cric

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4
Q

what do you add to ETT for long procedures to avoid heat loss

A

HME, passive evaporation heat loss prevention, takes 1 hour to be effective

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5
Q

how much higher is resistance in nasal intubation when compared to oral intubation

A

2x, can be higher in deviated septum

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6
Q

what is the the airway space behind the nose

A

nasopharynx

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7
Q

what is the airway space behind the mouth

A

oropharynx

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8
Q

when does the nasopharynx end

A

soft palate

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9
Q

when does the oropharynx end

A

epiglottis

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10
Q

what is the name of the space from the glottis down

A

hypopharynx

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11
Q

what the area below the eipiglottis where CRNAs do alot of airway manipulation

A

subglottic opening

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12
Q

what is the purpose of the nose

A

warm and humidify air during oral breathing

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13
Q

how much moisture does the nose add to air a day

A

1 L to 10,000L of air per day

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14
Q

what is the space between tongue and epiglottis

A

vallecula

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15
Q

what innervates the anterior nose

A

V1 opthalmic division of Cranial nerve 5- trigeminial-
anterior ethmoidal nerve

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16
Q

what innervates the mid nose and hard/soft palate

A

V2 maxillary division of cranial nerve 5- trigeminial- sphenopalantine nerve

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17
Q

what innervates the anterior 2/3 anterior tongue (sensation)

A

V3 Mandibular division of cranial nerve 5- trigeminial- lingual nerve

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18
Q

what innervates the posterior 1/3 tongue, oropharynx, and soft palate

A

cranial nerve 9, glossopharyngeal

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19
Q

what innervates the glotis/subglottic space, hypopharynx and trachea above the vocal cords

A

cranial nerve 10- vagus- internal laryngeal nerve

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20
Q

what innervates the trachea below the vocal cords

A

cranial nerve 10- vagus- recurrent laryngeal

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21
Q

what innervates the nasal mucosa

A

opthalmic and maxillary divisions of cranial nerve 5-trigeminal

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22
Q

what can happen with mouth breathers/ intubated patients

A

mucous gets thick and dry, add humidifier

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23
Q

what is a passive humidifier

A

HME

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24
Q

what innervates the hard and soft palate

A

palantine nerves from sphenopalatine ganglion

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25
Q

what is the innervation of the gag reflex

A

glossopharyngeal,
vagus,
spinal accessory nerves

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26
Q

what three nerves innervate all the muscles of the pharynx, larynx, and soft palate

A

glossopharyngeal (9)
vagus (10)
spinal accessory (11)

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27
Q

what carries the gag afferently to the medulla

A

glossopharyngeal

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28
Q

what carries the gag reflex efferently from medulla

A

vagus nerve

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29
Q

what nerves have synapses with the glossopharyngeal nerve to carry the gag reflex afferently towards the medulla

A

vagus
spinal accessory

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30
Q

what are the borders of the pharynx

A

back of tongue to nose

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31
Q

what are the three divisions of the pharynx

A

nasopharynx, oropharynx, laryngopharynx

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32
Q

what separates the nasopharynx and oropharynx

A

soft palate

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33
Q

what inervates the nasopharynx

A

trigeminal nerve- CN5

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34
Q

what are the borders of the oropharynx

A

soft palate to superior edge of epiglottis

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35
Q

what innervates the oropharynx

A

CN 9- glossopharyngeal

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36
Q

what are the borders of the hypopharynx

A

superior border of epiglottis to inferior border of cricoid cartilage

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37
Q

what innervates the hypopharynx

A

CN 10 (vagus) through internal superior laryngeal nerve

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38
Q

what does the R recurrent laryngeal nerve go under

A

innomanite artery/ brachiocephalic artery

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39
Q

what does the L recurrent laryngeal nerve go under

A

aorta

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40
Q

what procedures do the recurrent laryngeal nerve get damaged in

A

thoracic,
mitral valve,
aortic,
tumor

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41
Q

the recurrent laryngeal nerve innervates all muscles of the larynx except the

A

cricothyroid

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42
Q

what are risks of recurrent laryngeal nerve damage

A

hoarseness,
vocal cord palsy

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43
Q

what does the recurrent laryngeal nerve innervate in hypopharynx

A

sensory innervation from vocal cords down through trachea
motor function to all muscle of larynx except cricothyroid

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44
Q

what does the internal superior laryngeal nerve inervate in hypopharynx

A

sensory innervation of hypopharynx above vocal cords, base of tongue, epiglottis, arytenoids (above glottic opening)

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45
Q

what does the external superior laryngeal nerve inervate in hypopharynx

A

motor function to cricothyroid muscle of larynx

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46
Q

what do you block for awake intubation

A

superior laryngeal nerve at bifurcation

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47
Q

what nerve perforates the cricothyroid membrane

A

external laryngeal branch of superior laryngeal nerve

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48
Q

when do you use airway blocks

A

awake intubation with fiberoptic intubation

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49
Q

what does unilateral damage to the superior laryngeal nerve do

A

minimal effects

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50
Q

what does bilateral damage to the superior laryngeal nerve do

A

hoarseness
tiring of voice

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51
Q

what does unilateral damage to recurrent laryngeal nerve do

A

hoarseness

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52
Q

what does bilateral acute damage to recurrent laryngeal nerve do

A

stridor, Resp dx

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53
Q

what does bilateral chronic damage to recurrent laryngeal nerve do

A

aphonia

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54
Q

what does unilateral damage to vagus nerve do

A

hoarseness

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55
Q

what does bilateral damage to vagus nerve do

A

aphonia

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56
Q

where is larynx located on cervical spine

A

C3-C6

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57
Q

what is the narrowest part of the adult airway?

A

vocal cords

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58
Q

what part of airway anatomy modulates sound

A

larynx

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59
Q

what seperates the trachea from esophagus when swallowing

A

larynx/epiglottis

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60
Q

What is the larynx composed of?

A

muscles
ligaments
cartilage

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61
Q

what is size of vocal cords in males

A

23mm

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62
Q

what is the size of vocal cords in females

A

17mm

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63
Q

what is the smallest part of pediatric airway

A

glottic opening
just past vocal cords

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64
Q

what is the range of the glottic apertrue

A

60-100mm

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65
Q

what does the posterior cricoarytenoid do?
what innervates it?

A

abducts (opens) the vocal cords
recurrent laryngeal nerve

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66
Q

what does the lateral cricoarytenoid do?
what innervates it?

A

adducts (closes) the arytenoids, closing the glottis
recurrent laryngeal nerve

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67
Q

what does the transverse arytenoid do?
what innervates it?

A

adducts (closes) the arytenoids
recurrent laryngeal nerve

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68
Q

what does the oblique arytenoid do?
what innervates it?

A

closes the glottis
recurrent laryngeal nerve

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69
Q

what does the aryepiglottic /aryearritnoid do?
what innervates it?

A

closes the glottis (apperture)
recurrent laryngeal nerve

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70
Q

what does the vocalis do?
what innervates it?

A

relaxes the cords
recurrent laryngeal nerve

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71
Q

what does the thyroarytenoid do?
what innervates it?

A

relaxes tension int he vocal cords
recurrent laryngeal nerve

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72
Q

what does the cricothyroid do?
what innervates it?

A

tenses and elongates the vocal cords (tone of voice)
external branch of superior laryngeal

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73
Q

what is the first thing you see when doing DL

A

epiglottis

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74
Q

what is the second thing you see when doing DL while lifting

A

arytenoid cartilage

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75
Q

what is the third you see when doing DL while lifting

A

vestibular folds (false vocal cords)

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76
Q

what is the fourth thing you see when doing DL while lifting

A

true vocal cords

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77
Q

where do you put MAC blade

A

vallecula

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78
Q

where do you put the Miller blade

A

under the epilglottis

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79
Q

what is doorway to the airway

A

epiglottis

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80
Q

what is the epiglottis attached to

A

bottom of the tongue

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81
Q

which arytenoid cartilages are most medial/ at the bottom of DL view

A

corniculate

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82
Q

which arytenoid cartilages are most lateral/ at the sides of DL view

A

cuneiform

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83
Q

where is trachea in relation to cervicle and thoracic vertebrae

A

C6-T5

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84
Q

where is carina on thoracic vertebrae

A

T5

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85
Q

when does trachea end

A

carina

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86
Q

what is the most cephalad cartilage of trachea

A

cricoid

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87
Q

what cartilage of trachea is a full ring

A

cricoid

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88
Q

what is the shape of most tracheal cartilage

A

horse shoe/ C shaped

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89
Q

what is the first “grade” view you see when intubating and then

A

Cormack-Lehane
grade 4- soft tissue
grade 3- epiglottis
grade 2- vestibular folds/arytenoids
grade 1- vocal cords, arytenoids, everything

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90
Q

what is visible in Cormack-Lehane grade 4

A

soft tissue

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91
Q

what is visible in Cormack-Lehane grade 3

A

epiglottis

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92
Q

what is visible in Cormack-Lehane grade 2

A

vestibular folds
arytenoids
+ grade 2

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93
Q

what is visible in Cormack-Lehane grade 1

A

everything
true vocal cords
arytenoids
epiglottis

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94
Q

can you do an airway assessment pre op

A

no, have to stick scope down throat

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95
Q

when doing airway assessment do you say “ah”

A

no, raises soft pallate and makes it too easy

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96
Q

What is Mallampati class 1

A

most of glottis visible
- hard palate, soft palate, uvula, fauces, tonsillar pillar

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97
Q

what is Mallampati class 2

A

hard palate,
soft palate,
uvula,
fauces (usually only base of uvula visible, non tonsilar pillars)

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98
Q

what is Mallampati class 3

A

hard and soft palate, very base of uvula

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99
Q

what is Mallampati class 4

A

hard palate only

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100
Q

What does the Mallampati score evaluate?

A

difficulty of intubation
how much room you have in mouth to displace tissue

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101
Q

where do we do cricothyrotomy

A

cricothyroid membrane, right above cricoid cartilage

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102
Q

what is prayer sign

A

if cant press palms together, have arthritis of joints, probably arthritis of neck, hard to move neck to view airway
also arthritis of arytenoids

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103
Q

what neck circumference leads to difficult intubation

A

43 cm

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104
Q

what neck circumference/thyromental distance (NC/TMD) is difficult intubation

A

> 5cm

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105
Q

having OSA is indicitive of difficulty ___________

A

masking

soft tissue flaps

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106
Q

what percent of pregnancy has Difficult intubation

A

8%

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107
Q

what in pregnancy leads to Diff Intubation

A

swelling of airway
friable airway
smaller airway
lots of edema
(lay out lots of tubes to go down in size if needed)

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108
Q

what are large incisors indicitive of in airway assessment

A

decreased room, increased injury

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109
Q

what is large tongue indicitive of in airway assessment

A

large wide tongue will get in way of ETT
will cover airway making mask ventilation difficult

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110
Q

what is facial hair indicitive of in airway assessment

A

cant seal mask

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111
Q

how can you get a seal with facial hair

A

opsite dressing
water based lube
use two hands and use machine to ventilate

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112
Q

why dont you use petroleum based lubricant on face with intubation

A

airway fire

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113
Q

what is small mouth opening (<3cm) indicitive of in airway assessment

A

difficult airway

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114
Q

what is decreased mobility or pain or N/T with neck flexion and extension indicitive of in airway assessment

A

movement- cant get good angle for intubation
N/T- cervical compression, double crush syndrome watch with how you turn head

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115
Q

what is the upper lip bite test

A

vermillion border test
bite with lower teeth as far up upper lip/gums as possible

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116
Q

what does upper lip bite test test for

A

checks for retrognathia,
basically no chin with big overbite (mandible in and overbite)

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117
Q

what is lemon technique?

A

L-look externally
E-evaluate 3,3,2
M-mallampati
O-obstruction or obesity
N- neck mobility

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118
Q

What is the 3-3-2 rule in airway assessment?

A

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

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119
Q

what decreases somebodys incisor distance

A

TMJ

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120
Q

how do you get help with patient with TMJ

A

ask them tricks of how they open jaw, or have them open jaw then stick gaurd in

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121
Q

what shape of palate is a predictor of difficult airway

A

highly arched or narrow

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122
Q

what neck shape is a difficult airway

A

short thick neck

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123
Q

what neck movement predicts Diff intubate

A

cannot touch chin to chest OR patient cannot extend neck

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124
Q

what female specific thing can lead to Diff intubation

A

large breasts, shift up and put weight on chest/airway, cant move tissue
ramp patient up to sniffing position

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125
Q

what is thyromental distance

A

distance between mental area and thyroid cartilage

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126
Q

what does thyromental distance help determine

A

how readily laryngeal axis will fall in line with pharyngeal axis
how acute the angle will be

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127
Q

what should thyromental distance be

A

> 3 fingers or > 6 cm in adults

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128
Q

what is thyromental distance is less than 3 fingers or >6 cm

A

acute pharyngeal/laryngeal angle = Diff intubation

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129
Q

what is the most important airway skill

A

masking

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130
Q

What is the goal of airway management?

A

move air

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131
Q

where should mask lay on patient

A

bridge of nose/between pupils, lateral nasolabial folds, between lower lip and chin

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132
Q

what can a large mask that goes under the chin cause

A

leak
compression of soft tissue

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133
Q

how can we minimize gastric insufflation with masking

A

pressure under 20 cm H20
give gradual not sudden breath

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134
Q

what does gastric insufflation cause

A

vomit

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135
Q

what do you do if you have to use high pressure (<20 cm H20) in mask patient

A

OG tube and suck air out

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136
Q

what is the CE technique

A

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

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137
Q

what happens if you put fingers on soft tissue while mask ventilating

A

compressing airway

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138
Q

what are techniques for difficult mask

A

two handed- beards or difficult seal seal
opsite dressing/lube- beards
oral/nasal airway
mask straps

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139
Q

where do you but fingers in two handed ventilation

A

thumbs on mask, middle finger under mandible jaw thrusting

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140
Q

why do you not want hands on patients face while falling asleep

A

makes patient nervous

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141
Q

what size of mask is for Premis

A

00

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142
Q

what size of mask is for infant

A

0

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143
Q

what size of mask is for child

A

1

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144
Q

what size of mask is for a small adult

A

2

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145
Q

what size of mask is for medium adult

A

3

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146
Q

what size of mask is for large adult

A

4

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147
Q

what size of mask is for extra large adult

A

5

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148
Q

what size mask for adult is most common

A

3 or 4

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149
Q

what hand do you hold larygoscope handle with

A

left

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150
Q

what hand do you hold ETT with

A

right

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151
Q

what is shape of miller

A

straight

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152
Q

what shape is a mac

A

curved

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153
Q

how does mac open airway

A

goes in valecula and indirectly lifts epiglottis

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154
Q

how does miller open airway

A

goes under epiglottis and directly lifts it

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155
Q

which blade do you knock out teeth more

A

miller

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156
Q

what is MAC technique for intubation

A

R side of mouth
displace tongue to left

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157
Q

what is miller technique for intubation

A

avoid tongue
go down back side
under epiglottis

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158
Q

What is a stylet used for?

A

rigid wire inside tube used to shape ETT
usually in indirect laryngoscopy

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159
Q

what is 00 miller blade for

A

premi

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160
Q

what is 0 miller blade for

A

infant

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161
Q

what is 2-3 miller blade for

A

most adults

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162
Q

what is a wisconsin blade

A

super straight long miller

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163
Q

what is pediatric size MAC

A

1

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164
Q

what increases as you go up with MAC size

A

length and width

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165
Q

what is the most used MAC size

A

3-4

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166
Q

what is Dr Rices perfect mac blade

A

3.5 ceramic

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167
Q

What is the sniffing position?

A

It is the optimum intubation position
35 neck flexion, 15 face plane extension
head elevated 8-10 cm

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168
Q

how can you lift head for intubation sniffing position

A

pillows
stomach
chest

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169
Q

where do you put pillows for sniffing posistion

A

shoulder blades
head

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170
Q

what is goal of sniffing position

A

align oral, pharyngeal, laryngeal axis for straight line visualization of glottis

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171
Q

how high should patient be for intubation

A

CRNAs xiphoid

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172
Q

what is the scissor techique

A

2 gloves on R hand
using R thumb and R index/middle finger on maxillary teeth to push mandible and lip away

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173
Q

what percent of peoples mouth are opened automatically

A

20%

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174
Q

where on patients body do you aim when lifting laryngoscope

A

patients left foot

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175
Q

how do you insert laryngoscope blade

A

insert blade slightly to right of tongue
sweep leftward and upward
aim for patients left foot

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176
Q

how does wrist move during intubation

A

it doesn’t, lock it in place, lift with arm tucked in to body

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177
Q

what is BURP manuever

A

manipulation of trachea to find epiglottis with cricoid pressure
Backward
Upward
Rightward
Pressure

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178
Q

ETT is sized according to __________ diameter

A

internal

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179
Q

what is the increment of size for ETT

A

0.5mm

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180
Q

where do lengthwise centimeter markings start at on ETT

A

distal end to assist in placement depth

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181
Q

how does ETT react to body temp

A

the polyvinyl chloride plastic softens with body temp

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182
Q

how high above carina do you want ETT

A

3-5 cm

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183
Q

why do you not want ETT on carina

A

cause cough reflex

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184
Q

where are cough receptors in lungs

A

carina

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185
Q

what is normal ETT depth at incisors for females

A

21 cm

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186
Q

what is normal ETT depth at incisors for males

A

23 cm

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187
Q

what is formula for ETT depth

A

(body height in cm/5) - 13 to the R mouth angle (cm)

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188
Q

what is method for proper ETT placement depth

A

intubate, inflate cuff, pull tube till meet resistance, this is right on the other side of vocal cords

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189
Q

what type of tube cuffs do we usually use

A

high volume low pressure

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190
Q

how many ccs can ETT hold

A

90ccs

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191
Q

what is normal cause of “cuff leak”

A

migration of tube up vocal cords

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192
Q

should you squeeze little ballon on ETT

A

no, doesnt tell you anything, very painful

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193
Q

what can you do to determine if their is a cuff leak

A

leak test

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194
Q

how do you do leak test

A

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

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195
Q

what other device measures cuff pressure

A

sphygomometer or something, monometer

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196
Q

what can overfilled ETT cuff lead to

A

tracheal stenosis

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197
Q

what are methods of confirming intubation

A

condensation in ETT
bilateral chest rise
continuous EtCO2
direct visualization of ETT through cords
lung sounds

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198
Q

how many EtCO2 readings do you need before know in lungs

A

> 4

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199
Q

what makes false EtCO2 reading in esophagation

A

bictra anaticid
its Sodium Bicarb

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200
Q

how do you check for R mainstem

A

breath sounds
PIP
unilateral chest rise
decrease volume
decreased SpO2

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201
Q

what is an LMA an example of

A

supraglottic airway

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202
Q

what does LMA stand for

A

laryngeal mask airway

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203
Q

T/F you can aspirate with LMA

A

TRUE

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204
Q

Is the LMA a secure airway?

A

NO

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205
Q

what is a device that “lets us mask patient without hands”

A

LMA

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206
Q

Where does the LMA seal the airway

A

hypopharynx

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207
Q

what size LMA do you use for an infant weighing <5 kg
what is the cuff volume

A

1
up to 4ml

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208
Q

what size LMA do you use for a child weighing 5-10 kg
what is the cuff volume

A

1.5
up to 7ml

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209
Q

what size LMA do you use for a child weighing 10-20 kg
what is the cuff volume

A

2
up to 10 ml

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210
Q

what size LMA do you use for a small adult weighing 20-30 kg
what is the cuff volume

A

2.5
up to 14ml

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211
Q

what size LMA do you use for a normal adult weighing 50-70 kg
what is the cuff volume

A

4
up to 30

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212
Q

what size LMA do you use for a large adult weighing 70-100 kg
what is the cuff volume

A

5
up to 40

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213
Q

what size LMA do you use for <5kg

A

1

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214
Q

what size LMA do you use for 70-100 kg

A

5

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215
Q

what size are most adults in LMA

A

3-4

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216
Q

what does supreme LMA have

A

catheter to suction in esophagus

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217
Q

where does the tip of LMA sit

A

esophagus

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218
Q

where is opening of LMA

A

over glottic opening

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219
Q

what can fast track LMA do

A

ETT can slide in through LMA
can also use fiber optic bronchoscope with cook exchange catheter

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220
Q

what can LMA be used for

A

airway on its own
time before intubation
as an “introducer” for ETT/bronchoscope intubation

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221
Q

what is the approach for video laryngoscopy

A

midline approach

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222
Q

what can be difficult in video laryngoscopy and anterior airway

A

can see it, but have to hook ETT up to get airway, have to twist it

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223
Q

what is a benefit of video larygoscope intubation wise

A

more room in mouth

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224
Q

what do you do if you cant ventilate with mask

A

wake up or intubate
1) oral airway
2) nasal airway
3a) paralyze and intubate OR 3b) LMA

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225
Q

what do you do if initial intubation is unsuccessful

A

1) call for help
2) return to spontaneous respiration
3) wake the patient
4) MASK

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226
Q

what do you do if face mask ventilation after failed intubation is inadequate

A

attempt SGA (LMA)

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227
Q

what do you do if LMA fails after face mask ventilation after failed intubation is inadequate

A

emergency invasive airway (cric)

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228
Q

at anypoint in pathway if you cant ventilate where do you jump to

A

emergency airway pathway

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229
Q

in needle cric do you ventilate patient?

A

NO,
just pushing oxygen in,
too small to ventilate

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230
Q

if multiple failed attempts to intubate but can mask ventilate what do you do

A

end surgery

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231
Q

what does waveform on anesthesia machine mean

A

pressure changes, not always ventilating

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232
Q

how long do patients last before desat

A

6 min in perfect patient

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233
Q

how long does propofol last

A

2-5 min

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234
Q

what is a bougie for

A

poor view,
hard tip goes into airway and you feel hard bumps of tracheal rings

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235
Q

if you use a bougie and it is smooth where are you

A

esophagus

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236
Q

what are some complications of intubation

A

ETT malposition
laryngospasm
dental trauma
soft tissue trauma
vocal cord damage

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237
Q

what is common ETT malposition

A

R main stem
-PIP
-low volumes
-decrease sats
-lung sounds

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238
Q

What is a laryngospasm?

A

vocal cords clamp closing the airway

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239
Q

when does laryngospasm usually happen

A

stage 2 anesthesia

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240
Q

what are steps to treat laryngospasm

A

100% O2 with continuous PP
jaw thrust so air hits cords
if complete
1-2 ccs succs
-bag them till succs wears off

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241
Q

what is a partial laryngospasm? how does it resolve?

A

usually resolve on own
use 100% O2 with continous PP

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242
Q

what happens if you breathe against a closed glottis

A

negative pressure pulmonary edema

negative pressure against closed airway pulls fluid from vasculature into lungs

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243
Q

how do you treat negative pressure pulmonary edema

A

cpap/bipap 12-24 hours (push fluid back out)
possible diuretic

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244
Q

how long does it take to develop negative pressure edema

A

5-6 breaths
few minutes

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245
Q

what kind of risk is dental trauma in anesthesia

A

normal risk

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246
Q

how can you cause vocal cord damage with stylet

A

pushing stylet through vocal cords- causes vocal cords palsy
never put stylet through vocal cords

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247
Q

what happens if you break a tooth

A

have to get it out

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248
Q

what do you do for C-spine anesthesia

A

hold c-spine
log roll
hold cspine while intubaing,
use glidescope or fiber optic to keep neck in line
DOCUMENT cspine held

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249
Q

what do you document with Cspine

A

Cspine help
fiber optic
no flexion/extension
preexisting issues
anything to show you didnt cause worse symptoms

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250
Q

when do you use jet ventilation

A

airway or tracheal procedures (tracheal stents)

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251
Q

what is rate of jet ventilator inspiration/expiration

A

1-2 sec inhale
5-6 sec exhale

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252
Q

is jet ventilator ventilation?

A

no only oxygenating

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253
Q

what is common issue with jet ventilator

A

increased CO2

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254
Q

can you run gasses in jet ventilation case

A

no all IV

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255
Q

what psi jet ventilator do you use for adults
what is limit

A

start at 20 psi, increase until adequate chest rise
< 50 psi

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256
Q

what psi jet ventilator do you use for children
what is limit

A

start at 5-10 psi, increase until adequate chest rise
<30psi

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257
Q

what rate do you use for jet ventilator

A

20 bursts per minute

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258
Q

how do you minimize barotrauma in jet ventilation

A

adequate expiratory phase

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259
Q

what do you do if surgeon is using bovie during jet ventilator

A

<30% O2, us air blender

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260
Q

if you are using 100% O2 with jet ventilator and surgeon decides to use bovie how long do you wait for O2 to diminish

A

3 min

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261
Q

what are disadvantages of jet ventilation

A

does not provide protection against secretions/aspiration
incomplete control
specialized training

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262
Q

are jet ventilators laser safe

A

NO

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263
Q

can you accurately monitor gas exchange in jet ventilation

A

No
use abgs

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264
Q

how are pH and CO2 affected in jet ventilation

A

low pH
high CO2

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265
Q

what are complications of jet ventilation

A

aspiration
Gi insufflation
bleeding
pneumothorax
subcutaneous emphysema
inadequate ventilation
barotrauma

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266
Q

what is the most common performed urologic procedure

A

cystoscopy

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267
Q

what are indications for cystoscopy

A

hematuria
recurrent urinary infection
renal calculi
urinary obstruction

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268
Q

what are some procedures using cystoscope

A

bladder biopsies
retrograde pyelograms
resection of bladder tumors
extraction of lithotripsy or renal stones
placement of manipulation of ureteral stents

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269
Q

what are anesthesia considerations for ureteral stents

A

patient cannot move
NMBD- ETT

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270
Q

what position are most cystoscopy in

A

lithotomy

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271
Q

how do you move legs in lithotomy

A

move legs together, avoid dislocating hip

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272
Q

what are anesthetic considerations for lithotomy

A

deep sedation, dont want movement to prevent nerve damage

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273
Q

what is risk of an OR bed where the foot of the bed lowers

A

if arms are tucked fingers can get cut off by bed

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274
Q

what neves can be damaged in lithotomy

A

common peroneal nerve
saphenous nerve
obturator and femoral nerve
sciatic nerve

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275
Q

how can common peroneal nerve be damaged in lithotomy

A

lateral knee/calf rests on strap support

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276
Q

how does common peroneal nerve injury manifest

A

loss of dorsiflexion of foot (foot drop)

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277
Q

How does a saphenous nerve injury present?

A

numbness along medial calf (nerve runs along medial thigh)

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278
Q

how does obturator and femoral nerve injury occur in lithotomy

A

excessive flexion of thigh against groin, panus/obesity

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279
Q

how does the sciatic nerve get injured in lithotomy

A

extreme flexion at thigh can stretch sciatic

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280
Q

how does lithotomy position affect lungs

A

FRC decrease, especially in large/pregnant patients
increased peak pressures
LMA may not be a good choice cause of pressure requirements

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281
Q

how does lithotomy position affect heart

A

increased venous return from leg elevation
exacerbate CHF,
increases MAP but not CO
lowering legs can cause a drop in pressure

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282
Q

what are contraindications for LMA

A

reflux,
obese,
diabetic,
lengthy procedures,
gastroporesis,
longer than 2 hours,
laparoscopic, some lithotomy

283
Q

what can prolonged use of LMA cuase

A

nerve damage

284
Q

why do you not always use neuraxial anesthesthesia in cystoscopy

A

cystoscopy usually 15-20 min and spinal is multiple hours

285
Q

what level do you do spinals at for cystocopy

A

T10

286
Q

what kind of neuraxial do you use for cystoscopy usually

A

spinal

287
Q

NMBD are usually not needed for cystocopy unless you are doing what

A

going in ureters

288
Q

what level do you spinal at for csection/OB

A

T6

289
Q

what is preffered anesthesia tool for elderly or high risk patients in cystoscopy

A

spinals

290
Q

what is an elderly complication for spinals

A

arthritis

use larger needle

291
Q

what is a TURP

A

transurethral resection of the prostate (BPH)

292
Q

what is age of most turps

A

> 70 so lots of comorbidities

293
Q

what type of anesthesia is preferred for TURP

A

neuraxial/spinal

294
Q

why is spinal preferred for TURP

A

less neuro depression, can detect TURP syndrome better

295
Q

what are common side effects of TURPs

A

clots,
hematuria,
UTI,
failure to void

296
Q

what evaluations do you do for preop eval for elderly turp patient

A

cardiac- aortic stenosis (loud systolic murmur)

297
Q

why are spinals bad in aortic stenosis

A

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

298
Q

when do you do type and screen for TURP

A

anemia
>40g prostate gland removal
long procedures=more bleeding

299
Q

what is average blood loss for TURP

A

3-5ml/min
avg 200-300

300
Q

how much is 1 gm of tissue loss in TURP blood wise

A

15cc blood loss per gram

301
Q

what length and mass of removal may require transfusion of TURP

A

> 90 min
40grams

302
Q

besides bleeding what can cause a decrease in TURP hct

A

hemodilution from absorption of irrigating fluid

303
Q

how does TURP syndrome occur

A

-prostate has lots of venous sinuses, irrigant is hypotonic
-this cuases hyponatremia

304
Q

when does confusion occur with hyponatremia

A

<120 Na

305
Q

what are s/s TURP syndrome

A

HA,
restlessness,
confusion,
cyanosis,
dyspnea,
arrhythmias,
hypotension,
seizures due to hyponatremia,
fluid overload,
solute toxicity

306
Q

how much fluid absorption is related to TURP syndrome

A

> 2L

307
Q

what lab do you draw to check TURP syndrome

A

BMP (Na)

308
Q

what solutions are used for turp irrigation

A

glycine,
sorbitol,
mannitol,
nothing with Na because it conducts electricity

309
Q

what two factors increase fluid absorption in turp

A

bag height (irrigant pressure)
time of procedure

310
Q

besides hyponatremia, what other electrolyte imbalance occurs in TURPs

A

hyperglycemia from absorption of solutions

311
Q

what vision change can occur in TURP

A

temporary blindness from hyperglycinemia (from glycin)

312
Q

what is treatment for TURP syndrome

A

-recognition-constant check neurostatus
-fluid restrictions/loop diuretics
-hyponatremia- 3% saline
-seizures- versed/prop
-intubation- prevent aspiration

313
Q

how does turp affect temp? what is risk?

A

-hypothermia-irrigant, shivering can dislodge clots and cause bleeding

314
Q

how fast do you give 3% saline

A

100cc/hr

315
Q

how do you prevent hypothermia in TURP

A

bair hugger, warm blankets, fluid warmers, humidifier for circuit

316
Q

what bleeding disorder can occur with TURP

A

DIC- r/t thrombaxane release blood cell lysis

317
Q

what infection can occur with TURP

A

septiciemia- treat with gentamycin maybe prophylactic

318
Q

besides aortic stenosis, what other condition is contraindicated for spinal in TURP

A

cancer with spinal metastasis

319
Q

what is an ESWL procedure

A

extracorporeal shock wave lithotripsy

320
Q

what is the first line therapy for renal and upper 2/3 of ureter stones

A

lithotripsy

321
Q

what kind of anesthesia for ESWL procedures

A

general

322
Q

what positioning considerations for ESWL

A

hole in bed, dont let them fall through

323
Q

what other procedure can be done with EWSL

A

stents
cysto

324
Q

what are contraindications for ESWL

A

-pregnancy
-lungs away from shcok
-aortic aneurism
-coagulopathy
-arrythmias
-ICD/pacemaker (have magnet)
-urinary obstruction below stone

325
Q

what is ESWL shock timed with

A

HR so no shock on R wave

326
Q

what medication is given to increase speed of ESWL shocks

A

robinol/glycopyrolate (speed up HR)

327
Q

what are anesthesia considerations for ESWL

A

-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

328
Q

what do you need to know with cancer patient

A

mestastasis, malignancy

329
Q

what is position for prostectomy

A

-extreme trendelenburg with robot
-arms tucked

330
Q

what are anesthesia considerations for prostectomy

A

-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

331
Q

what are preoperative considerations for radical nephrectomy

A

-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

332
Q

what is a well documented risk for renal tumors? what are other risk factors associated with this

A

smoking
emphysema

333
Q

what are intraop considerations for radical nephrectomy

A

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

334
Q

what is it called when tumor extends outside of renal capsule

A

thrombus

335
Q

what is a level one renal tumor

A

into IVC below liver

336
Q

what is a level 2 renal tumor

A

up to liver below diaphragm

337
Q

what is a level 3 renal tumor

A

above diaphragm in to R atrium

338
Q

what test can you do pre-op to check for preexisting embolization and thrombus of renal carcinoma(into diaphragm)

A

VQ and TEE

339
Q

what lines/blood products do you use for a radical nephrectomy with tumor thrombus

A

invasive monitoring (swan, TLIJ)
multiple large IVs
10-15-50 units PRBC
use platelets, FFP, cryo

340
Q

what is risk of swan placement with tumor thrombus of renal carcinoma

A

contraindicated in level 3 throbus due to potential of dislodgement of tumor
-causes stroke

341
Q

what do you do if renal carcinoma tumor covers >40% of right atrium

A

cardio-pulmonary bypass (perfusionist)

342
Q

do you use cell saver for radical nephrectomy

A

no, spread cancer cells

343
Q

what are serious potential complications of radical nephrectomy with tumor thrombus

A

pulmonary embolism of a tumor piece

344
Q

what are s/s PE

A

sudden dysrhythmias,
arterial desaturation,
profound hypotension

345
Q

what does a high CVP during a radical nephrectomy with tumor thrombus point towards

A

venous obstruction by the thrombus

346
Q

what is polymethylmethacrylate

A

bone cement

347
Q

what kind of reaction is bone cement

A

exothermic, gives off heat

348
Q

what is a risk of bone cement

A

expansion, leads to emboli, like fat (called intermedullary HTN-the force that pushes the fat out)

349
Q

what is a serious side effect of bone cement

A

DIC

350
Q

how can you prevent emboli in orthopedics

A

100% O2 prior to cement
drill a vent hole in bone
use non-cementing prothesis

351
Q

what are some diseases/procedures that have DIC risk

A

amniotic fluid emboli,
bone cement
fat emboli,
bone cement emboli,
sepsis,
TURP syndrome,
crystalloids,
ARDS

352
Q

what happens in DIC caused by bone cement emboli

A

release of tissue thromboplastin,
platelet aggregation,
microthrombus formation in lungs,
cardiovascular instability,
EtCO2 emboli pattern

353
Q

what do you set pressure on tourniquet to

A

100mmHG over systolic BP
150mmHg over systolic BP for thigh

354
Q

how does anesthesia help create a bloodless field

A

decrease BP

355
Q

how long can you have tourniquet inflated for

A

2 hours
if it goes longer deflate for 20 min then can go for 2 more hours

356
Q

what can deflation of tourniquet lead to

A

acidosis,
hyperkalemia,
myoglobinemia,
renal failure
increased EtCO2

357
Q

When does tourniquet pain occur?

A

around 60 min

358
Q

what is tranexamic acid (TXA)

A

inhibits fibrinolysis
plasminogen to plasmin inhibitor

359
Q

what sx can you not use tourniquet in? what do you use instead

A

joints like hips and shoulders
use TXA

360
Q

when do you give TXA periop

A

beginning of case and before tourniquet inflation or at closing

361
Q

what are the main anesthesia issues with ortho

A

clots and bleeding

362
Q

what are the neurological affects of tourniquet use

A

-30 min = decreased somatosensory evoked potentials and nerve conduction
-60 min = tourniquet pain and HTN
-2 hrs = postop neuropraxia
-nerve injury

363
Q

what are the muscle changes of tourniquet use

A

-2 min= cellular hypoxia
- decreased cellular creatinine
-cellular acidosis
-2hrs= endothelial capillary leak

364
Q

what are the systemic effects of tourniquet inflation

A

-increased arterial and pulmonary arterial pressure
-more severe without volatile anesthetics

365
Q

what are the systemic affects of tourniquet release

A

-decrease in temp
-metabolic acidosis
- decrease central venous O2
-thromboxane release
-decrease in pulm and arterial pressures
-increase in eTCO2

366
Q

what nerve fibers cause tourniquet pain

A

c fibers

367
Q

what can happen anesthesia wise with tourniquet release

A

increase CO2 leads to spontaneous breathing
kinda wake up a bit

368
Q

what nerve fibers are associated with tourniquet pain

A

c fibers

369
Q

what kind of fractures have fat emboli

A

long bone fractures- nearly 100%

370
Q

what is Fat embolism syndrome triad

A

dyspnea,
confusion,
petechia (of chest and upper extremities)

371
Q

what is the differentiating symptoms of fat embolism vs amniotic fluid, VAE

A

petechia of chest and upper extremities

372
Q

what are life threatening complications of Fat embolism syndrome

A

ARDS,
neurodamage via edema,
DIC

373
Q

what does fat from long bone fx come from

A

medullary vessels

374
Q

what are the two complications for beach chair position in shoulder sx

A

VAE,
decreased cerebral perfusion pressure

375
Q

in sitting position, what is difference between BP in head and in arm

A

about 20mmHg

376
Q

what is treatment for VAE

A

Position- Left lateral, trendelenburg
flood sx site with NS
central catheter to suck VAE out
DC N2O
100%O2

377
Q

what are risk factors of DVT/PE

A

> 60 yo,
obesity,
tourniqet,
>30 min procedure,
>lower extremity fx,
>immobilized >4 days

378
Q

how do you prevent DVT

A

pneumatic compression devices, pharmocological methods

379
Q

how does neuraxial anesthesia affect thromboembolitic events

A

decreased them

380
Q

what are anesthetic considerations for old people

A

-decrease doses for induction agents
-high mortality
-dehydration, malnourishment
-increased blood loss
-increased comorbidities

381
Q

what bleeds more intracapsular or extracapsular hip fxs

A

extra

382
Q

what is an anesthesia method to decrease mortality of hip fx patients

A

neuraxial
spinal
epidural
combo

383
Q

how long does spinal last

A

about two hours, so if longer do combo

384
Q

what is replaced in total hip

A

ball and socket, usually due to osteoarthritis
(longest hipp procedure so use spinal/epidural combo)

385
Q

what is replaced in hemiarthroplasty

A

only ball (shorter procedure)

386
Q

what is used in gamma nail

A

nail to fixate fracture

387
Q

what positions are shoulder sxs done in

A

lateral or sitting

388
Q

what is positioning considerations for lateral shoulder

A

head and neck in neutral position
axillary roll -protects brachial plexus

389
Q

what are risks of beach chair CV wise

A

vasodilation,
increased HR,
BP swings (mix neo)

390
Q

anesthesia considerations for shoulder sx

A

higher blood loss
GETA with regional block
low visualization of ETT after draping
consider a-line

391
Q

what does gas insufflation do anesthesia wise

A

increased intrathoracic pressure
increased PP (peak pressure)
harder to breathe
absorb CO2, causes acidosis so increase MV to breathe it off

392
Q

what type of anesthesia technique for laprascopic technique

A

general ETT anesthesia

393
Q

what is pneumoperitoneum

A

increased pressure caused by insufflation of CO2 in laparoscopic technique

394
Q

CO2 insulflation affects

A
395
Q

what are factors leading to subcutaneous emphysema (crepitus)

A

-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

396
Q

how do you manage subcutaneous emphysema

A

-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

397
Q

what is celiac reflex

A

vagal nerve stimulation from traction or structures within peritoneal and thoracic cavities
-causes severe brady, asystole

398
Q

how do you treat celiac reflex

A

robinol/glycopyrolate
atropine
decrease CO2 pressure in abd

399
Q

what are causes of gas embolisms

A

trocar insertion into vessel,
open intravascular vessels with lower pressure than intraabdominal pressures
hit liver with trocar
c section

400
Q

how do you treat VAE

A

left lateral,
100% O2,
discontinue N2O,
flood field with NS,
place CVC

401
Q

what is positioning for lap cholecystectomy

A

trendelenburg and airplane left

402
Q

what is positioning for lap appendectomy

A

Reverse trendelenburg and airplane left

403
Q

what is positioning for robotic prostatectomy

A

steep trendelenburg

404
Q

what are some open abdomen procedure considerations

A

evaporative fluid loss
heat loss
blood loss
decreased bowel function

405
Q

how do you decrease bowel function issues

A

ERAS,
reduce opioids,
consider regional blocks,

406
Q

what are some ERAS (enhanced recovery after surgery) protocol recommendations preop

A

PREOP
preadmin counseling

fluid and carbo loading

eliminate NPO status

no/selective bowel prep

antibiotic prophylaxis

thromboembolism prphylaxis

eliminate routine use of premedicating

407
Q

what are some ERAS (enhanced recovery after surgery) protocol recommendations intraop

A

INTRAOP
short acting anesthetic agents

epidural use

avoid sx drains

avoid salt/water overload

maintain normothermia

408
Q

what are some ERAS (enhanced recovery after surgery) protocol recommendations post-op

A

POSTOP
epidural anesthesia

avoid NG tubes

PONV prophylaxis

avoid salt/water overload

early ambulation

early oral nutrition (gut motility)

early catheter removal

409
Q

how does gas affect evoke potentials

A

decrease them, so <1/2 mac

410
Q

if doing muscle evoke potentials what do you do anesthesia wise

A

dont paralyze, use succs to intubate

411
Q

how do you keep patient from moving in spinal anesthesia when you cant use NMBDs

A

OVERSEDATE if not paralyzed

412
Q

where do you put hands and how do you roll patient for prone

A

log role kinda, one head on top of face on on back of head, secure tube, CRNA in charge of movement

413
Q

anterior ethmoidal nerve

A

1

414
Q

sphenopalentine nerve

A

2

415
Q

lingual nerve

A

3

416
Q

glossopharyngeal nerve

A

4

417
Q

superior laryngeal nerve

A

5

418
Q

internal laryngeal nerve

A

6

419
Q

recurrent laryngeal nerve

A

7

420
Q

superior laryngeal nerve

A

1

421
Q

internal laryngeal nerve

A

2

422
Q

external laryngeal

A

3

423
Q

carotid artery

A

4

424
Q

vagus

A

5

425
Q

left recurrent laryngeal nerve

A

6

426
Q

right recurrent laryngeal nerve

A

7

427
Q

recurrent laryngeal nerve

A

8

428
Q

epiglottis

A

1

429
Q

hyoid bone

A

2

430
Q

thyroid cartilage

A

3

431
Q

cricothyroid membrane

A

4

432
Q

cricoid cartilage

A

5

433
Q

cervical sympathetic ganglion

A

6

434
Q

inferior ganglion of vagus nerve

A

7

435
Q

superior laryngeal nerve

A

8

436
Q

internal laryngeal branch

A

9

437
Q

external laryngeal branch

A

10

438
Q

vagus nerve

A

11

439
Q

recurrent laryngeal nerve

A

12

440
Q

innominate artery

A

13

441
Q

hard palate

A

1

442
Q

soft palate

A

2

443
Q

nasopharynx

A

3

444
Q

oropharynx

A

4

445
Q

hypopharynx (laryngopharynx)

A

5

446
Q

epiglottis

A

6

447
Q

vocal cords

A

7

448
Q

larynx

A

8

449
Q

trachea

A

9

450
Q

valleculae

A

1

451
Q

epiglottis

A

2

452
Q

aryepiglottic folds

A

3

453
Q

trachea rings

A

4

454
Q

true vocal cords

A

5

455
Q

vestibular folds

A

6

456
Q

arytenoids (corniculates)

A

7

457
Q

nasopharynx

A

1

458
Q

oropharynx

A

2

459
Q

epiglottis

A

3

460
Q

hypopharynx

A

4

461
Q

vocal cord

A

5

462
Q

larynx

A

6

463
Q

trachea

A

7

464
Q

esophagus

A

8

465
Q

tongue

A

9

466
Q

epiglottis

A

10

467
Q

vocal cords

A

11

468
Q

trachea

A

12

469
Q

epiglottis

A

1

470
Q

aryepiglottic folds

A

2

471
Q

true vocal cords

A

3

472
Q

corniculate cartilage

A

4

473
Q

cuneiform cartilage

A

5

474
Q
A

Cormack and Lehane grade 4
soft tissue only

475
Q
A

Cormack and Lehane grade 3
epiglottis

476
Q
A

Cormack and Lehane grade 2
vestibular folds
arytenoids

477
Q
A

Cormack and Lehane score grade 1
true vocal cords

478
Q
A

Cormack and Lehane grade 4
soft tissue only

479
Q
A

Cormack and Lehane grade 3
epiglottis

480
Q
A

Cormack and Lehane grade 2
vestibular folds
arytenoids

481
Q
A

Cormack and Lehane score grade 1
true vocal cords

482
Q
A

mallampati class 4
hard pallate only

483
Q
A

mallampati class 3
hard and soft palate
base of uvula

484
Q
A

mallampati class 2
hard and soft palate
uvula
fauces

485
Q
A

mallampati class 1
hard and soft palate
uvula
fauces
tonsilar pillars

486
Q

what is the distance from the subclavian vein to the R atria

A

right 15 cm

left 25cm

487
Q

what is the distance from the R IJ to the R atria

A

15 cm

488
Q

what is the distance from the L IJ to the R atria

A

20 cm

489
Q

what is the distance from the right Femoral vein to the R atria

A

40cm

490
Q

what is the distance from the R median basilic vein to the R atria

A

40 cm

491
Q

what is the distance from the L median basilic vein to the R atria

A

50 cm

492
Q

What does CVP measure?

A

right atrial pressure

493
Q

what is normal CVP

A

1-10mmHg

494
Q

what does CVP estimate

A

preload

495
Q

in a CVP waveform what does the a wave denote

A

atrial contraction

496
Q

in a CVP waveform what does the c wave denote

A

tricuspid valve closure (pressure pushed against valve at closure)

497
Q

in a CVP waveform what does the v wave denote

A

passive filling of RA (coranaries, IVC, SVC)

498
Q

where does the a wave of the CVP waveform correlate to the EKG

A

comes after P wave

499
Q

where does the c wave of the CVP waveform correlate to the EKG

A

during QRS

500
Q

where does the v wave of the CVP waveform correlate to the EKG

A

t wave/ repolarization

501
Q

what causes an elevated a wave in CVP waveform

A

(increased contractile force)
junctional rhythm (atria pushing on closed tricuspid valve)
PVCs
tricuspid stenosis
ventricular pacing

502
Q

what causes an elevated C wave in CVP waveform

A

(pushing against tricuspid valve)
pulm htn
mitral insufficiency (regurge)

503
Q

what are causes of elevated CVP

A

(elevated preload)
RV failure
tricuspid stenosis or regurge
cardiac tamponade
constrictive pericarditis
volume overload
pulmonary htn
LV failure (chronic)

504
Q

how does hypovolemia affect CVP waveform

A

hides abnormalities

505
Q

what causes a large V wave in CVP waveform

A

(increased filling pressure)
increased preload
high volume of fluid given

506
Q

what happens to CVP waveform when you give alot of volume

A

up and plateaus

507
Q

what condition causes a lack of a waves in CVP waveform

A

a fib

508
Q

with a swan, what is the distance from the Rt IJ to the RA

A

15-25 cm

509
Q

with a swan, what is the distance from the Rt IJ to the RV

A

25-35 cm

510
Q

with a swan, what is the distance from the Rt IJ to the PA

A

35-45 cm

511
Q

what is the approx normal pressure of the RA

A

5
(no systolic, same as CVP)

512
Q

what is the approx normal pressure of the RV

A

25/5
(gain systolic, diastolic mimics RA)

513
Q

what is the approx normal pressure of the PA

A

25/10
(systolic same, diastolic increase)

514
Q

what does a thick line on a swan represent

A

50 cm

515
Q

what does a thin line on a swan represent

A

10 cm

516
Q

what is the thermistor port on a swan for

A

CO
CI

517
Q

what color is the CVP port on a swan

A

blue

518
Q

what color is the balloon port on a swan

A

red

519
Q

how many ccs go in a swan balloon

A

1.5 ccs

520
Q

what color is the PA port on a swan

A

yellow

521
Q

what is used to introduce a swan? how big is it? where is it usually placed?

A

cordis
9 french
Rt IJ

522
Q

when do you inflate the swan balloon during insertion

A

RA

523
Q

what is a common dysrhythmia when inserting a swan

A

PVCs

524
Q

if you insert swan from the L side IJ instead of the R how much distance do you add

A

10 cm

525
Q

how can you tilt bed to help with swan insertion

A

R and trendelenburg

526
Q

what is the A wave on a PAOP or wedge

A

left atrial contraction

527
Q

what is the C wave on a PAOP or wedge

A

mitral valve closure (bulge)

528
Q

what is the v wave on a PAOP or wedge

A

filling of L atria

529
Q

what causes a large a wave on PAOP

A

mitral stenosis

530
Q

what causes a large v wave of PAOP

A

mitral regurg

531
Q

what causes an elevated PA pressure

A

LV dysfunction
mitral stenosis/insufficiency
L-R shunt
ASD/VSD
pulm htn

532
Q

what causes an elevated PAOP

A

LV dysfunction
cardiac tamponade
constrictive pericarditis. (chronic pericarditis, mimics tamponade)
Ischemia

533
Q

what three pressures are the same in a patient with cardiac tamponade

A

PAD
PAOP
CVP

534
Q

What is the Frank-Starling law of the heart?

A

the more the heart fills with blood during diastole, the greater the force of contraction during systole (to a point then it fails)

535
Q

when do you read a PA mean in a spontaneous breathing patient? a ventilated patient

A

patient peak- diastolic pressure during expiration
vent valley (or just make them apnic)

536
Q

what does PAOP approximate

A

LVEDP

537
Q

PA pressure is and indirect measurement of

A

ventricular function

538
Q

what is normal CVP, PADP, PAOP

A

cvp 1-10
PADP- 5-15
PAOP- 4-12

539
Q

what causes CVP, PADP, and PAOP to be low

A

hypovolemia, or misplaced transducer

540
Q

what causes normal or high CVP, High PADP, and high PAOP

A

LV failure

541
Q

what causes high CVP, normal or low PADP, and normal or low PAOP

A

RV failure
Tricuspid regurge
Tricuspid stenosis

542
Q

what causes normal or high CVP, High PADP, and normal or low PAOP

A

PE

543
Q

what causes high CVP, High PADP, and normal PAOP

A

Pulm HTN

544
Q

what causes high CVP, High PADP, and high PAOP

A

tamponade,
ventricular interdependence,
transducer not at phlebostatic axis

545
Q

what causes normal CVP, normal High PADP, and high PAOP

A

LV myocardial ischemia
MR?

546
Q

what causes low CVP, High PADP, and normal PAOP

A

ARDS

547
Q

how do you calulate CO

A

CO=SVxHR

548
Q

what is normal CO

A

5-6 L/min

549
Q

how do you calculate CI

A

CI= CO/BSA

550
Q

what is normal CI

A

2.8-3.6 L/min

551
Q

what helps us calculate CO, CI on a swan

A

thermodilution +/- 5-10%

552
Q

how does thermodilution work

A

inject 10ccs ns/d5,
computer reads temp change and when it returns to normal

553
Q

why is mixed venous drawn from PA

A

has SVC and IVC blood

554
Q

what is normal mixed venous

A

65-77%

555
Q

what does mixed venous tell us

A

measurement of O2 delivery, can be an indicator of low CO

556
Q

what needs to be documented every 5 mins for all anesthetics

A

BP
HR
RR

557
Q

what reading does methemoglobin give and why

A

85%, absorbs red and infrared light equally

558
Q

if you intubate too deep, where is tube most likely to go

A

right lung, shorter straighter

559
Q

how can temperature affect blood loss

A

big temp change can increase blood loss

560
Q

what needs to be monitored continuously on all pediatric (<12) patients receiving general anesthesia and when indicated on other pts

A

body temp

561
Q

what monitors are necessary

A

lung sounds-stethoscope
inspired o2 concentration- gas analysis
expired gas analysis
spo2
pulmonary/chest wall mechanical function

562
Q

what does pulmonary chest wall mechanical function include

A

inspiratory pressures, respiratory volumes

563
Q

what should be monitored continuously on all patients

A

oxygenation

564
Q

what are the three ways of verify intubation listed on standard 9

A

auscultation,
chest excursion,
confirmation of co2 in expired gas

565
Q

what should be continuously monitored during controlled or assisted ventilation with any artificial airway support

A

end tidal CO2

566
Q

what is recommended by standard 9 for alarms

A

have threshold and variable pitch audible alarms

567
Q

how many breaths at minimum are needed for etco2 to avoid misinterpretation

A

6 breaths

568
Q

what prevents 93% of anesthetic mishaps

A

pulse oximetry and capnography

569
Q

how is co2 analysis helpful in gas monitoring

A

assesses ventilation and detects equipment/patient problems

570
Q

what co2 analysis is ph sensitive, co2 presence changes color, and used most often by ems

A

colorimetric co2 analysis

571
Q

if you intubate and get color change after 1 breath, what could be a problem

A

could be co2 from stomach

572
Q

what does a galvanic cell play a role in analyzing

A

O2 analysis

573
Q

what law explains pulse oximetry

A

lambert beer law

574
Q

what instrument uses a mathematical means of expressing how light is absorbed by matter

A

pulse ox

575
Q

what are two main types of oximetry

A

fractional
functional

576
Q

what kind of oximetry measures arterial oxygen saturation (Sao2)

A

fractional oximetry

577
Q

what kind of oximetry is only measurable by arterial blood sample

A

fractional ox

578
Q

what absorbs more red light and what is the light wavelength

A

deoxyhemoglobin- 660

579
Q

what absorbs more infrared light and what is light wavelength

A

oxyhemoglobin 940

580
Q

if you are seeing more red light than infrared light what is happening with oxygen

A

higher oxygen- more infrared light being absorbed means higher oxygen content

581
Q

if you are seeing more infrared light, what is happening to oxygen

A

decreasing oxygen- more red light being absorbed into deoxyhemoglobin means less oxygen content

582
Q

what is the formula for fractional oximetry

A

oxyhemoglobin/
(oxyhemoglobin+deoxyhemogobin
+methemoglobin+carboxyhemoglobin)

583
Q

in 100% pulse ox, which light will you see most of

A

red light- infrared has been absorbed into oxyhemoglobin

584
Q

what kinds of light flash hundreds of times per second in pulse ox

A

red and infrared light

585
Q

what does a pulse ox rapidly sample from each pulse wave

A

peak and trough

586
Q

what is a trough in pulse ox

A

vascular bed has arterial, capillary, venous blood, and tissue density

587
Q

what is a peak in pulse ox

A

all of blood from trough + additional arterial blood

588
Q

when is pulse ox inaccurate

A

methemoglobin, methylene blue, carboxyhgb messes up pulse ox- do abg for real oxygen reading

589
Q

what is it called when neither red or infrared light is emitted from pulse ox

A

off period

590
Q

what are causes of low etco2

A

hyperventilation,
decreased co2 production,
alveolar dead space

591
Q

how does a cerebral oximeter work

A

does not require pulsatile flow, gets readings from vascular beds- also tries to measure arterial though
parabolic arch

592
Q

below what reading is pulse ox not reliable

A

below 70%

593
Q

what happens during off time in pulse ox

A

reading of ambient light is read and subtracted from sequences

594
Q

where do you put pulse ox probe to detect changes faster

A

centrally place
peripheral=slower

595
Q

what are some pulsatile vascular beds you can attach pulse ox to

A

finger, cheek, ear, toe, nose,

596
Q

what are some pulsatile vascular bed you can attach pulse ox to on infant

A

palm, forefoot, wrist

597
Q

when is pulse oximeter accurate to within 5%

A

70-100%

598
Q

what happens when pulse ox is below 70%

A

readings are extrapolated and unreliable

599
Q

what conditions affect accuracy of pulse ox

A

raynauds,
movement,
vasoconstriction,
poor circulation d/t low co,
improper placement,
hypothermia

600
Q

what are dyes that can cause false high/low readings in pulse ox

A

methylene blue,
indigo carmine

601
Q

exposure to what can cause false high/low pulse ox reading

A

smoke or fire

602
Q

what causes fire/smoke to give overestimate of pulse ox

A

carboxyhemoglobin

603
Q

what can fluorescent light cause in pulse ox reading

A

false high- red light isn’t getting absorbed because of same wavelength 660

604
Q

what can drugs cause that makes pulse ox have false high/low reading

A

methemoglobinemia -doesn’t release oxygen
85% reading

605
Q

name some drugs that can induce methemoglobinemia

A

nitrates,
locals such as prilocaine,
chlorates,
sulfas,
metochlopramide

606
Q

what are two disease that can cause false high/low pulse ox reading

A

anemia,
sickle cell (vaso-occlusive crisis),
dyes

607
Q

what kind of light can interfere with pulse ox

A

fluorescent light

608
Q

what happens if esophageal stethoscope enters lungs

A

makes a leak in cuff, bellows collapse

609
Q

what can inhibit passage of light through finger

A

nail polish- black henna or dark blue

610
Q

what is placed in nasall/orally and is only used in intubated patients

A

esophageal stethoscope

611
Q

when is esophageal stethoscope contraindicated

A

esophageal varices/strictures

612
Q

when should temperature be carefully monitored according to standard 9

A

pediatric (<12), or when significant temp change is intended/anticipated/suspectd

613
Q

what is a late sign of malignant hyperthermia

A

increased temp

614
Q

what does hypothermia triple the incidences of

A

cardiac complications and surgical wound infections

615
Q

what impact does hypothermia have on blood loss

A

increases it

616
Q

what is heat production and how is it brought about

A

thermogenesis- shivering and non shivering

617
Q

what is heat loss

A

thermolysis

618
Q

what is normal range of temp

A

36-37.5 c

619
Q

where is thermoregulation controlled

A

hypothalamus

620
Q

what is total body heat a combination of

A

zone temperatures- peripheral and core zones

621
Q

what is more important than maintenance of individual temps

A

maintenance of total body heat

622
Q

what is the peripheral temp zone made up of

A

skeletal muscle, subcut tissue, skin

623
Q

what is core temp zone made up of

A

trunk and head- holds more heat and releases more heat

624
Q

how does body respond to cold exposure

A

increases heat production, reduces heat loss

625
Q

how does body reduce heat loss

A

vasoconstriction of peripheral vessels,
increased metabolic rate,
layering w/clothes

626
Q

Why do peds lose heat more quickly than an adult?

A

bigger core zone than peripheral zone-

627
Q

is hypothermia or hyperthermia more cmmon

A

hypothermia- body naturally vasoconstricts to increase temp but anesthetics gases cause vasodilation

628
Q

what can you give for shivering

A

demerol

629
Q

what is shivering indirectly controlled by

A

catecholamines

630
Q

how much heat can you lose in the first hour aka phase 1

A

1-1.5 degrees c

631
Q

what is phase 3 of heat loss

A

equilibriate, plateau, produce same heat you are losing after 4 hours

632
Q

what is phase 2 of heat loss

A

still declining but plateauing, losing more heat than you can generate for next 2-4 hrs

633
Q

how can hypothermia influence ekg

A

increase pr/qrs/qt
increase or decrease st segment

634
Q

what is the extra wave from hypothermia in ecg

A

j wave aka osborn wave

635
Q

cricothyroid muscles

A

tense vocal cords
cords Tense

636
Q

thyroarytenoid muscle function

A

relaxes vocal cords
they relax

637
Q

posterior cricoarytenoid muscles

A

ABducts vocal cords
Please Come Apart

638
Q

lateral cricoarytenoid muscles

A

ADDuct vocal cords
Lets Close Airway

639
Q

what nerve innervates the cricothyroid muscles?

A

Superior Laryngeal Nerve

640
Q

what muscles does the Right Laryngeal nerve innervate

A

vocalis
thyroarytenoid
lateral cricoarytenoid
posterior cricoarytenoid
aryepiglottic
interarytenoid

641
Q
A
642
Q

What can cause a loss of a waves or only v waves

A

Afib
Ventricular pacing

643
Q

What causes giant a waves aka cannon a waves

A

Junctional rhythms
Complete AV block
PVCs
Ventricular pacing
Tricuspid/ mitral stenosis
Diastolic dysfunction
Myocardial ischemia
Ventricular hypertrophy

644
Q

What can cause large V waves on cvp

A

Tricuspid/ mitral regurg
Acute increase in intravascular volume

645
Q

What can cause elevated CVP

A

Rv failure
Tricuspid stenosis/regurg
Cardiac tamponade
Restrictive pericarditis
Volume overload
Pulm HTN
LV failure

646
Q

What can cause elevated PAP

A

LV failure
Mitral stenosis/regurg
L to R shunt
ASD or VSD
Volume overload
Pulm HTN
Cather whip

647
Q

What causes elevated PAOP

A

LV failure
Mitral stenosis/ regurg
Cardiac tamponade
Constrictive pericarditis
Volume overload
Ischemia

648
Q

What can cause overestimated thermodutjln CO

A

Low injectate volume
Injectate too warm
Thrombus on thermistor of PAC
Partially wedged PAC

649
Q

What can cause underestimates of thermodultion CO

A

Excessive injectate volume
Too cold injectate

650
Q

After induction of general anesthesia, if initial attempts at intubation are unsuccessful, which of the following is NOT advised as a potential “next step”:

A

Invasive airway access

651
Q

ASA guidelines suggest equipment in a portable storage unit for difficult airway management should include (Check all that apply): Select one or more

A

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

652
Q

Follow-up care for the patient with a difficult airway includes all of the following:

A

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

653
Q

If awake intubation is unsuccessful in a patient with a known difficult airway, the following management options are recommended, EXCEPT

A

A rapid sequence intubation

654
Q

In the emergency situation in which the patient cannot be ventilated and cannot be intubated, which of the following is recommended

A

Awakening the patient

Supraglottic airway (SGA) ventilation

Jet ventilation

Percutaneous airway access

Surgical airway access

655
Q

Strategies to deliver supplemental oxygen throughout the process of difficult airway management include oxygen delivery by

A

Nasal cannula
Face mask
Supraglottic airway (SGA) Insufflation

656
Q

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

A

History of episodic, mild snoring in 10 year old child

657
Q

A two-year old pediatric patient with an anticipated difficult intubation should be considered a candidate for which of the following management strategies?

A

Spontaneous ventilation following induction with volatile anesthetic.

Intravenous induction aiming to maintain spontaneous ventilation.

658
Q

What is sniffing position

A

35 degree neck flexion
15 degree face plan extension
Head elevation 8-10cm

659
Q

What is sniffing position

A

35 degree neck flexion
15 degree face plan extension
Head elevation 8-10cm

660
Q

What grade view do you visualize most of glottic opening and epiglottis

A

Cormack-Lehane Grade 1

661
Q

What view has partial view of vocal cords and full view of posterior laryngeal cartilages

A

Cormack-Lehane grade 2a

662
Q

What view has only the posterior portion of the glottic opening can be visualized

A

Cormack lehane grade 2b

663
Q

What view only the epiglottis can be visualized; no portion of the glottic opening can be seen

A

Cormack lehane grade 3

664
Q

What view is epiglottis cannot be see ; only view is of the soft palate

A

Cormack lehane grave 4

665
Q

What is the formula to get ETT depth

A

Body height (cm) / 5 -13

666
Q

Pierre robin syndrome

A

Retrognathia
Micrognathia
Glossoptosis
Cleft palate

667
Q

Treacher Collins syndrome

A

Mandibular hypoplasia
Micrognathia
Facial bone hypoplasia
Choanal atresia
Cleft palate

668
Q

L in lemon

A

look externally

facial trauma
large incisors
beard or mustache
large tonge

669
Q

e in lemon

A

evaluate 3-3-2

incisor distance 3 finger breadths
hyoid mental distance 3 fingers
thyroid to mouth 2 fingers

670
Q

m in lemon

A

mallampati score

671
Q

o in lemon

A

obstruction

epiglottitis, abscess, trauma

672
Q

n in lemon

A

neck mobility

673
Q

Goldenhar syndrome

A

Hemifacial microsomia,
mandibular hypoplasia;
vertebrae may be incomplete, fused, or missing

674
Q

Mucopolysaccharidosis

A

Macroglossia,
odontoid hypoplasia,
dental anomalies,

675
Q

Klippel-Feil syndrome:

A

Short neck,
fusion of two or more cervical vertebrae,
limited range of neck motion

676
Q

Down syndrome:

A

Macroglossia,
flattened nose,
cervical spine abnormalities,
obstructive sleep apnea,
dental anomalies

677
Q

Acquired Conditions Associated With Difficult Airway Management

A

*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

678
Q

what size lma for >100 kg

A

6 LMA classic only

up to 50ml

679
Q

what LMA size and volume for 30-50 kg

A

3
up to 20 mL

680
Q
A

acute inferior wall MI

681
Q
A

afib with moderate ventricular response

682
Q
A

early repolarization (a normal variant)

683
Q
A

ectopic atrial rhythm, non specific T wave abnormalities

684
Q
A

acute anterolateral MI

685
Q
A

NSR with old inferior MI

686
Q
A

left atrial abnormality ( left atrial enlargement)

687
Q
A

left posterior hemiblock

688
Q
A

left bundle branch block

689
Q
A

-60

690
Q
A

atrial flutter with low voltage

691
Q
A

left ventricular hypertrophy

692
Q

what is criteria used for LVH diagnosis

A

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

693
Q
A

evidence of old anteroseptal MI

694
Q
A

sinus rhythm, frequent PVCs, early transition

695
Q
A

right bundle branch block with left anterior hemiblock

696
Q
A

ST depression- consistent with ischemia

697
Q
A

sinus rhythm, type I second degree AVB, LVH with strain

698
Q
A

there is a normally functioning single chamber ventricular pacemaker that started competing with the sinus rhythm

699
Q
A

pre excitation (WPW)

700
Q

What nerve injuries can result from masking

A

Stretch facial nerve (drool, sag)-jaw thrust

CN7 compression (buccal branch)- face mask

Supraorbital nerve compression (ETT in face)

701
Q

What nerve injuries can result from masking

A

Stretch facial nerve (drool, sag)-jaw thrust

CN7 compression (buccal branch)- face mask

Supraorbital nerve compression (ETT in face)

702
Q

What degree of AO extension indicates difficulty with DL

A

<23 degrees

703
Q

What are the 4 treatments for hereditary angioedema

A

C1 esterase concentrate
FFP
Ecallantide
Icatibant

704
Q

Anatomical borders for LMA

A

Sides: pyriform sinuses

Distal end: upper esophageal sphincter

Proximal end: base of the tongue

Basics (7 decks)

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