Choice of Anesthetic Technique

Question 1

Describe the presentationof responsiveness, airway, spontaneous ventilation and cardiovascular function in the minimal sedation (anxiolysis)

Answer 1

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands.

Responsiveness: Normal response to verbal stimulation

Airway: Unaffected

Spontaneous ventilation: Unaffected

Cardiovascular function: Unaffected

Question 2

Describe the presentation of responsiveness, airway, spontaneous ventilation and cardiovascular function in the moderate sedation (conscious sedation)

Answer 2

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Responsiveness: Purposefully*
response to verbal or tactile stimulation

Airway: No intervention required

Spontaneous ventilation: Adequate

Cardiovascular function: Usually maintained

• Reflex withdrawal from a painful stimulus is NOT considered a purposeful response

Question 3

Describe the presentationof responsiveness, airway, spontaneous ventilation and cardiovascular function in the Deep Sedation/Analgesia

Answer 3

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond
purposefully after repeated or painful stimulation.

Responsiveness: Purposeful
response after repeated or painful stimulation

Airway: Intervention may be
required

Spontaneous ventilation: May be inadequate

Cardiovascular function: Usually maintained

Question 4

Describe the presentationof responsiveness, airway, spontaneous ventilation and cardiovascular function in the General Anesthesia

Answer 4

General anesthesia is a drug-induced, reversible state
characterized by unconsciousness, amnesia, immobility, and control of the autonomic nervous system (ANS) responses to noxious stimulation

Responsiveness: Unarousable even with painful stimulus

Airway: Intervention often
required

Spontaneous ventilation: Frequently inadequate

Cardiovascular function: May be impaired

Question 5

Clinical Settings Appropriate for General Anesthesia

Answer 5

• Pain (nociception) of surgical procedure cannot be addressed
  with local, topical, or regional anesthesia
• Surgical procedure requires secure airway (e.g., procedure
  compromises airway integrity, oxygenation, or ventilation)
• Patient or procedure characteristics that are not suitable for regional anesthetic
• Patient or procedure characteristics that are not suitable for monitored anesthesia care (e.g., risk of airway, respiratory, or cardiovascular compromise)

Question 6

Situations in Which Regional Anesthesia May Not Be Appropriate

Answer 6

• Preferences and experience of the patient, anesthesia provider, and surgeon
• Need for an immediate postoperative neurologic examination in the anatomic area affected by the regional anesthetic
• Coagulopathy
• Preexisting neurologic disease (e.g., multiple sclerosis, neurofibromatosis)
• Infected or abnormal skin at the planned cutaneous puncture site

Specific Considerations for Neuraxial Anesthesia
- Hypovolemia increases the risk for significant hypotension
- Coagulopathy (including anticoagulant and antiplatelet
medication therapy) increases risk of epidural hematoma
- Increased intracranial pressure may result in cerebral herniation with intentional or inadvertent dural puncture

Question 7

Sequence of events in the rapid-sequence induction

Answer 7

(1) preoxygenation;

(2) intravenous administration of a hypnotic (e.g., propofol); (

3) immediate administration a of a rapidonset neuromuscular
blocking drug (e.g., succinylcholine 1.0 to 1.5 mg/kg or rocuronium 1.0 to 1.2 mg/kg);

(4) application of cricoid pressure (using a force of 30 newtons, approximately 7 pounds);

(5) avoidance of ventilation via a mask;

(6) tracheal intubation; and

(7) release of cricoid pressure after confirmation of correct endotracheal tube placement

• Though ventilation via a mask is generally avoided with RSI, the use of positive pressure less than 20 cm H2O (called modified RSI) should minimize the risk of gastric insufflation and may be needed if the patient develops
  hypoxemia before tracheal intubation
• Although RSI with cricoid pressure has been used for several decades and is a standard approach, a 2015 metaanalysis did not demonstrate a measurable impact of cricoid pressure on
  clinical outcomes during RSI

Question 8

In the context of Multimodal General Anesthesia Strategy, describe the primary* e secondary** drugs for antinociception

• Primary: drug that explicitly maintains that component of anesthesia

** Secondary: drug that “implicitly” (i.e., additionally) contributes

Answer 8

Primary drug:
- Opioids (e.g., remifentanil)
- Ketamine (NMDA antagonist)
- Dexmedetomidine (α2 agonist)
- Lidocaine (antiinflammatory, sodium channel blockade)
- NSAID (antiinflammatory)

Secondary Durg
- Propofol
- Sevofluarane

Question 9

In the context of Multimodal General Anesthesia Strategy, describe the primary e secondary drugs for unconsciousness (and amnesia)

Answer 9

Primary drug
- Propofol
- Sevoflurane (inhaled anesthetic)

Secondary drug:
- Ketamine
- Remifentanil
- Dexmedetomidine
- Magnesium (NMDA agonist)
- NMBA (decrease proprioception)

Question 10

In the context of Multimodal General Anesthesia Strategy, describe the primary e secondary drugs for immobility

Answer 10

Primary drug:
- NMBA

Secondary drig
- Magnesium (smooth muscle relaxant)
- Propofol (central muscle relaxation)
- Sevoflurane (central muscle relaxation)