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Choice of anesthesia Flashcards

1
Q

what are the three main points of outpatient/out of OR anesthesia

A

patient selection
type of procedure
tailored anesthetic focused on quick discharge

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2
Q

what is the definition of outpatient/ambulatory surgery

A

a surgery not requiring an overnight stay

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3
Q

what makes outpatient surgery possible

A

improved anesthetics
minimally invasive procedures

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4
Q

what are benefits of outpatient surgery

A

*Reduced surgical tissue trauma through minimally invasive techniques

*Enhanced recovery

*Minimal adverse outcomes

*More effective postop analgesia (peripheral nerve blocks)

*More efficient scheduling

*Fiscally more resourceful through eliminating overnight recovery

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5
Q

what is the benefit of a hospital outpatient surgery

A

*More cost effective from sharing of resources such as: equipment, facilities, and staff

*Flexibility in revenue generation i.e. COVID elective case cancellations can still do emergent/urgent cases

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6
Q

what is the disadvantage of hospital outpatient surgery

A

Can be inefficient due to delays and cancellations in favor of emergent inpatient procedures

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7
Q

what is the difference between hospital integrated and hospital self contained outpatient surgery centers

A

hospital self contained centers dont share an OR

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8
Q

what is the benefit of a hospital self contained vs a hospital integrated outpatient surgery centers

A

-can still share resources with hospital

More efficient than integrated due to separation from urgent/emergent inpatient surgery

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9
Q

what is the benefit of a free standing ambulatory surgery center

A

*Very efficient
*Complete separation from hospital based, inpatient surgery
-some have accommodations for overnight

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10
Q

what is the disadvantage of a free standing ambulatory surgery center

A

*Must have plan for hospital admission for additional resources if necessary
*Limited patient population in relation to acuity
-shut down during pandemic

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11
Q

what is the advantage of an office based outpatient surgery facility

A

*Rapidly expanding model
*Increased convenience for surgeon and patient
*Lower cost (facility charges lower)

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12
Q

what is the disadvantage of an office based outpatient surgery facility

A

*More limitations to patient selection and procedures
*Likely to be the sole anesthesia provider in the facility- Sometimes we need help
-no ASA 3 or higher
*Usually less and more budget minded anesthesia equipment
-must have backup plan like admission to local hospital, during covid there was very limited room

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13
Q

what factors should be considered for outpatient surgery

A

*Limited surgical trauma
*No expectation of significant blood loss, large fluid shifts, complex post-op care, or unreasonable pain (nerve blocks for ortho)
*Patient acuity. Does the risk outweigh the benefit? Will this increase the likelihood for a hospital admission? Does the facility have the resources to care for this individual?
*Social factors: Patient living arrangements/care, travel distance, somebody to drive

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14
Q

what is the goal of an anesthetic

A

safe, effective, cheap, easy to administer, no side affects

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15
Q

what is the most common type of anesthesia

A

general

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16
Q

what are the benefits of general anesthesia

A

*Complete unawareness during procedure
*Provides secure airway
*Motionless surgical field-usually

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17
Q

what are the negatives of general anesthesia

A

*Can cause post op nausea- volatile agent(iso, civo, des), N2O, narcotics
*Emergence delirium
*Propofol and volatile agents can cause dose dependent BP depression (decreased SVR)

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18
Q

what are the benefits of MAC (monitored anesthesia care)

A

*Faster recovery-usually
*No airway manipulation-usually
*Ability to bypass recovery if alert when leaving OR
*Can be combined with regional/neuraxial anesthesia

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19
Q

what are the negatives of MAC

A

*Difficult in patients with severe obstructive sleep apnea
*Difficult in patients with severe anxiety
*Difficulty providing motionless surgical field
*Unsecured airway

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20
Q

what are the benefits of regional/neuraxial anesthesia

A

-Provides intraoperative and postoperative pain control. Sometimes for several days post-op (catheters with bulbsplaced, can last 5 days)
-Speeds recovery time. Patients can leave the OR fully alert and pain free
-Ability to provide a non-narcotic anesthetic
-Can be combined with general and MAC anesthetics

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21
Q

what are the negatives of regional/neuroaxial anesthesia

A

*Can require specialized equipment like ultrasound machines
*Requires proficient training
*Sometimes requires preoperative sedation and monitoring
*Can slow down the efficiency of the facility if understaffed/undertrained
*Duration of action may not be adequate for procedure time

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22
Q

what must be included in consideration of anesthetic technique

A

*Patients consent- do they agree with the choice you recommend
-if scared of needles no blocks
-if anxious may want general over mac
*Ability of provider to administer the anesthetic in a safe, timely manner
*Equipment availability at the facility (ultrasound, nerve stimulator)
*Properly trained staff to care for the patient when anesthetic is administered
*Will the anesthetic be adequate for the procedure
*Will it provide adequate pain control for the entire length of the procedure
*Back-up plan in case the anesthetic fails, able to convert to general

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23
Q

what percentage of anesthesia is performed out of OR

A

36%

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24
Q

what is the percentage of death claim of out or OR anesthesia vs in OR

A

54% vs 29%

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25
why is out of OR anesthesia sucky
*Trending toward older, sicker patients not suitable for OR procedures *Often performed in remote locations- have to call for help which can be delayed *Anesthesia is usually an afterthought (lack of room, lack of supplies, lack of equipment) -performed under MAC so no secured airway
26
what are common examples of out of OR anesthesia
-bronchs -Cath lab -GI lab -MRI/CT -IR -TEE lab/ECho -ER to set joint or fracture -ICU
27
what are the criteria for outpatient discharge
*Be alert and oriented to time and place *Have stable vital signs *Have pain controlled by oral analgesics, liposomal bupivacaine, or peripheral nerve block *Have nausea or emesis controlled *Be able to walk without dizziness *Have no unexpected bleeding from the operative site *Be able to take oral fluids and void *Have discharge instructions and prescriptions from the surgeon and anesthesia provider *Accept readiness for discharge *Have a responsible adult escort present
28
ASA 3 patients may still have ambulatory procedures given
their diseases are well controlled benefits outway risks
29
what BMI is thought to be of great risk to ambulatory surgical centers
50 and up
30
what can be done preop to decrease cardiac complications in OSA patients
CPAP
31
what are the ASA guidlines for OSA patients in OR
-avoid resp depressants such as opiods -regional anesthetic techniques when possible -no discharge until no longer at risk for resp depression -return to baseline spO2 prior to discharge -observe resp while unstimulated -consider CPAP use peri op -prolonged post op observation
32
what should be considered when providing anesthesia to patients with stents
antiplatelet use surgeon and cardiologist to discuess perioperative use
33
what is the risk of B blocker use during anethesia
transient hypotension with induction
34
what is the targeted intraoperative BG level
less than 180 mg/dl
35
what are the two most common causes of unplanned hospital admin from ASC
PONV uncontrolled pain
36
should prophylactic dantrolene be administered for patients with history of malignant hypothermia
no
37
what are common airway complications associated with sedation and analgesia
airway obstruction aspiration regurgitation dental/soft tissue injury
38
what are common respiratory complications associated with sedation and analgesia
resp depression hypoxemia hypercarbia apnea
39
what are common cardiovascular complications associated with sedation and analgesia
hypotension arrhythmias
40
what are common neurological complications associated with sedation and analgesia
deeper level of sedation unresponsiveness
41
who does pre op eval
CRNA
42
who sees patient in PAT
seen by RN
43
what happens in PAT
med rec HH paperwork labs radiology EKG follow algorithm for HH
44
when would CRNA see patient in PAT clinic
-difficult airway -fam hx trouble waking up -abnormal EKG
45
when is preop eval
before surgery, at center or in room, seen by CRNA
46
if in medically directed state who does peop eval
Anesthesiologist and CRNA
47
what is Qk billing
medical direction
48
what does MD have to doto happen for TEFRA guidelines in Qk
preop eval prescribe plan induction emergence check-in during anesthesia
49
is TEFRA possible
no
50
what happens when TEFRA isnt met
medicare fraud
51
what do you do in preop eval
-review labs, cxr, HP -fasting status -develop anesthesia plan
52
who do you check anesthesia plan with
surgeon patient
53
what must be obtained from patient for anesthesia plan
informed consent
54
what is an example of an anxiolytic for anesthesia?
versed, also causes antegrade amnesia
55
what is an example of an analgesic for anesthesia?
fentanyl
56
what is an example of gastric motility for anesthesia?
reglan
57
what is an example medications to prevent aspiration for anesthesia?
pepcid reglan bictra
58
what is an example of a breathing treatment for anesthesia?
albuterol, zopinex
59
when do you do a breathing treatment with anesthesia?
smokers asthmatics
60
what is an example of PONV medication for anesthesia?
emend marinol zofran scopolamine patch
61
what else can you order during preop eval
EKG, CXR, ABG, other labs
62
who is responsible for preop eval
anesthesia, but work with surgeon for tests
63
what is regional anesthesia
peripheral nerve block neruaxial (spinal, epidural)
64
what do you consider for anesthesia technique
-patient preference -surgeon preference/skill -CRNA preference/skill level -coexisting diseases -surgical site -outpatient/inpatient -body position -elective vs emergent -the gastric content amount -difficult airway management -duration of surgery -patient age -anticipated recovery time -PACU discharge criteria
65
can you do spinal anesthesia for patient with aortic stenosis?
no
66
what do you consider with inpatient vs outpatient anesthesia
inpatient it is okay to give drugs that last longer, outpatient want them to go home faster
67
how doe body position effect anesthesia
if prone must be intubated so general
68
how does gastric content affect anesthesia
if full must intubate to prevent aspiration
69
what is the perfect anesthetic
-patient safety -void of side effects (PONV) -low cost -optimal operating conditions for surgery -rapid recovery and short discharge -pain free -optimal operating room efficiency -patient satisfaction (expectations) -amnesia (MAC vs general)
70
what is an informed patient
-understand procedure -understands technique -knows risks/benefits -knows alternatives -no coercion
71
what must you document for informed consent
-discussed options and risks/benefits -answered questions -provided consent
72
what do you discuss for anesthetic failure
-if spinal/MAC fails then might have to be switched to general
73
if patient says no general anesthesia can you do surgery
no
74
what is general anesthesia
loss of consciousness
75
what are the two ways to induce and maintain general anesthesia
IV inhaled
76
what are the 4 main components of general anesthesia
anesthesia: loss of consciousness amnesia: inability to recall events analgesia: pain control areflexia: motionless
77
what is the most important component of a general anesthesia
amnesia
78
when performing trauma anesthesia on a hemodynamically compromised patient what do you use
ketamine versed
79
what kind of amnesia does versed cause
antegrade (forward)
80
what kind of anesthesia does scopalamine cause
antegrade and retrograde
81
what is the first part of IV induction during general anesthesia
loss of consciousness
82
what meds do we use to IV induce
prop etomidate ketamine
83
how do we maintain control of airway during iv induction/loss of consciousness
Oral airway nasal airway mask LMA ETT after paralytic
84
do you have to loose ability to breath during IV induction?
no, general is loss of consciousness
85
how much O2 do we give before induction? for how long? what does this accomplish
100% 3 minutes normal breathing 8 deep breaths denitrogenation/preoxygenation
86
how long do people to take desat after only being on room air
20-30 sec
87
how long do people take to desat after 100% O2
6-8 min
88
how long does succs last
6-8 min
89
how does being TFTB and COPD affect preoxygenation
will desat faster
90
what is RSI
rapid sequence intubation
91
what do you use during RSI
fast acting NMB (succs) fast acting anesthetic (prop)
92
what is a trick to help intubate
cricoid pressure,
93
when do we do RSI
high chance of aspiration high gastric content
94
what position do we put patient in for intubation
sniffing position
95
what are steps of intubation
1) head in sniffing position (line of sight to VC) 2) DL after muscle3 relaxation 3) ETT tube with cuff just passed cords 4) confirm placement
96
how do we confirm proper ETT placement
ETCO2 bilat breathsounds fog in ETT Chest rise and fall
97
when do we use inhalation induction
peds elderly (they fall asleep faster)
98
adults fall asleep faster using __________ induction while peds and elderly fall asleep faster using __________ induction
IV inhalation
99
what are common inhalation induction
sevoflurane NO2
100
what are steps of inhalation induction
inhaled anesthetic IV placement IV medication intubation
101
what is stage one anesthesia
analgesia -analgesia -amnesia -euphoria
102
what is stage two anesthesia
excitement -excitement -Delerium -combative -nystagmus -irregular breathing
103
during what anesthesia stage do patients have laryngospasm
stage 2
104
what is stage 3 anesthesia
surgical anesthesia -unconscious -regular respiration -decreased eye movement
105
what is stage 4 anesthesia
medullary depression -respiratory arrest -cardiac arrest -no eye movement -basically an overdose
106
with IV induction you go from awake to stage________
3 surgical anesthesia, maybe some euphoria (stage 1)
107
when do we see a patient go through all stages of anesthesia
inhaled anesthetics
108
when do we extubate the patient?
stage 1 or stage 3
109
when do we not extubate patient
stage 2
110
how do we achieve anesthesia in maintanence
volatiles TIVA
111
how do we achieve amnesia in maintanence
volatiles TIVA versed
112
how do we achieve areflexia in maintanence
NMBs regional volatiles
113
how do we achieve analgesia in maintanence
opioids OFA (opioid free) PNB
114
how do we achieve all 4 principles in anesthesia
Balance, use multiple agents
115
what is danger of high doses of volatile anesthetics for areflexia
hypotension, cardiac depression
116
what can we use in IV anesthetics
propofol, ketamine, precedex, lidocaine, mag
117
what is TIVA
total intravenous anesthesia (no volatiles)
118
what is benefit of volatile anesthesia
high potency concentration easily controlled titrated response prompt awakening attenuate sns response
119
what is disadvantage of volatile anesthetics
cardiac depression
120
what do NMBs provide
muscle relaxation
121
What do NMBs NOT do?
amnesia analgesia anesthesia smooth muscle relaxation
122
what is risk of NMBs
awareness under anesthesia
123
what are examples of NMBs
Roc Vec Succs
124
what are examples of opioids
fent sufent remi fent
125
what do opioids accomplish
analgesia decreases sns sedation
126
what is opioid anesthesia very useful in
cardiac cases
127
what is a spinal anesthetic (intrathecal, subarachnoid)
in subarachnoid space, kind of regional anesthesia
128
what is benefit of spinal anesthesia
fast onset dense block (sensory and motor) fast to perform (less than 1-2 min)
129
what is problem of spinal anesthetic
spinal headache (CSF leak) cause hypotension (pretreat) all or nothing, titrate to affect limited duration of action no redose
130
when do we use spinal
c sec hip sx
131
what can happen if Bier block procedure lasts less than 20 min and you release tourniquet
LAST
132
when do you take tourniquet off in bier block
after you are sure there is no toxicity
133
how do you deflate tourniquet
incrementally ( deflate and inflate cuff)
134
what is important to do with regional anesthesia
-education patients -set expectations
135
what is MAC anesthesia
-CRNA monitoring patient (spectrum) -can be no meds -can be meds -can be watching patient after peripheral nerve block -not a TIVA
136
what are MAC criteria
1) diagnosis and treatment of clinical problems during the procedure* 2) support of vital functions* 3) administration of sedatives, analgesics, hypnotics, anesthetic drugs, or other medications as necessary for patient safety;* (4) psychological support and physical comfort* (5) provision of other services as needed to complete the procedure safely.
137
which is harder MAC or general
MAC
138
what is synergism
two meds combine to be stronger than drugs individual action
139
what are some additional considerations for anesthesia
nausea pain control infection mitigation
140
what do we do in PACU
emergence from anesthesia pain control airway maintenance spontaneous breath treat side effects rapid emergence treat complications

Anesthesia Techniques (11 decks)

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