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APA 1 > Complications - Quiz 3 > Flashcards

Complications - Quiz 3 Flashcards

1
Q

Current rate of anesthesia related death is ___ per _______ anesthetics. (1999-2005)

A

1 per 100,000

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2
Q

If you are an ASA 1, how many deaths per 10,000

A

0.5

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3
Q

If you are an ASA 4, how many deaths per 10,000

A

5.5

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4
Q

What increases the risk of death during anesthesia?

A

Comorbidities

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5
Q

What is morbidity?

A

Any complication other than death

Minor 18-22% incidence

Hoarseness, PONV, drug error or equipment malfunction without injury

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6
Q

Top 3 ASA closed claims

A

Death - 26%

Nerve injury - 22%

Brain damage - 9%

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7
Q

Top 3 ASA emerging claims

A

Regional anesthesia 16%

Chronic pain management 18%

Acute pain 9%

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8
Q

What percent of human error is implicated in deaths?

A

51-77%

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9
Q

What is the major human error that leads to preventable accidents? And what are some other causes?

A

1 medication error

Unrecognized breathing circuit disconnect
Airway mismanagement
fluid mismanagement

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10
Q 
What colors are our labels?
Paralytics 
Narcotics
Uppers (epherine, epi, phyenylephrine) 
Downers nitro
Local anesthetics
A 
Paralytics – orange/red
Narcotics – blue
Uppers (epherine, epi, phyenylephrine) – purple solid
Downers nitro – purple strips
Local anesthetics – grey
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11
Q

Equipment malfunctions leading to preventable anesthetic accidents:

A 
Breathing circuit (most common)
Monitoring device
Ventilator
Anesthesia machine
Laryngoscope
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12
Q

With a circuit malfunction, how do you check it?

A

Start at patient and work your way back to the machine

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13
Q

New data shows that that what population of pediatrics have increased risk for developmental delays?

A

Prolonged or multiple procedures (>MAC hours)

tonsillectomy no risk

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14
Q

What are some common airway injuries?

A 
Sore throat – most common
Dysphagia
Dental injury – most common sued
TMJ
Vocal cord paralysis
Vocal cord granuloma
Arytenoid dislocation
Esophageal perforation
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15
Q

When positioning a patient, how does hypotension lead to peripheral nerve injury?

A

less blood flow to that nerve then put pressure on and gets ischemic

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16
Q

What position is air embolism most likely to occur and how can we prevent it?

A

Sitting/prone/reverse trendelenberg

Maintain venous pressure above 0 at surgical site

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17
Q

What position is alopecia most likely to occur and how can we prevent it?

A

Supine/lithotomy/trendelenberg

Normotension, padding, head turning

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18
Q

What position is backache most likely to occur and how can we prevent it?

A

any position

lumbar support, padding, hip flexion

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19
Q

What position is compartment syndrome most likely to occur and how can we prevent it?

A

esp lithotomy

maintain perfusion pressure and avoid external compression

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20
Q

What position is corneal abrasion most likely to occur and how can we prevent it?

A

esp prone

tape and lubricate eye

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21
Q

What position is digit ampuateion most likely to occur and how can we prevent it?

A

any

check for protruding digits before moving hydrolic table

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22
Q

how to avoid a brachial plexus injury

A

avoid stretching or direct compression of the neck or axilla

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23
Q

What position is common perineal nerve injury most likely to occur and how can we prevent it?

A

lithotomy and lateral decubitus

pad lateral aspect of upper fibula

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24
Q

how to avoid radial nerve injury

A

avoid compression of lateral humorous

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25
Q

how to avoid ulnar nerve injury

A

padding at elbow, forearm supination

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26
Q

What position is retinal ischemia most likely to occur and how can we prevent it?

A

prone/sitting

avoid pressure on globe

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27
Q

What position is skin necrosis most likely to occur and how can we prevent it?

A

any position

pad bony prominences

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28
Q

Awareness during general anesthesia is what the general public are must afraid of. What percent of awareness

A

0.1 - 0.4

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29
Q

When awareness does occur, patient’s may exhibit the following symptoms:

A 
Mild anxiety
Sleep disturbances
Nightmares
Post-traumatic stress disorder
Social difficulties
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30
Q

In what cases will awareness happen most?

A

MAC cases

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31
Q

In high risk cases, awareness happens most often with

A

major trauma

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32
Q

Why does obstetrics have a higher incidence of remembering?

A

don’t get versed (because we want them to remember)

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33
Q

Risk factors for awareness

A 
Female
Age (younger adults)
Obesity
Clinician experience
Previous awareness
After normal hours of operation
Emergency procedures
Use of nondepolarizing relaxants
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34
Q

Benzodiazepines provide what type of amnesia?

A

anterograde (forget from time of medication on)

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35
Q

scopolamine provides what type of amnesia?

A

retrograde (pt will forget that something occurred before)

** has to be given IV

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36
Q

How much MAC should be enough for amnesia?

A

1/3

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37
Q

What is by far the most common and transient eye injury?

A

Corneal abrasion

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38
Q

Most common cause of post operative loss of vision.

A

Ischemic Optic Neuropathy (ION)

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39
Q

What is Ischemic Optic Neuropathy (ION)?

A

Optic nerve infarction due to decreased oxygen delivery via one or more arterioles supplying the optic nerve.

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40
Q

ION is commonly reported after:

A

Cardiopulmonary bypass
Radical neck dissection
Abdominal/hip procedures
Spinal surgeries - prone position

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41
Q

Contriribiting factors to ION?

A

HTN
DM – causes vascular changes (constricted)
CAD
Smoking

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42
Q

Surgical and anesthetic factors that contribute to ION:

A

Deliberate hypotension
anemia
prolonged surgical time in prone position, head down or compressed abd

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43
Q

When is the onset of ION?

A

onset is immediately through 12th post-op day

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44
Q

What position will enhance venous outflow to help prevent ION?

A

position pt head up

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45
Q

Intraop cardiac arrest us usually ________ not _______

A

concomitant and not causative

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46
Q

Suddent cardiac arrest is usually caused by

A

hypovolemia

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47
Q

Most common CV event after non cardiac surgery

A

MI

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48
Q

cardiopulmonary arrest was like to happen because the spinal got to high at a level of

A

T4

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49
Q

what are the cardiac accelerators?

A

T1-T4

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50
Q

The higher the spinal, the more _______ the pt will get

A

hypotensive

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51
Q

Spinal with sedation will likely lead to

A

hypercarbia

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52
Q

Dermatome
T4 -
T7 -
T10 -

A

T4 - nipple line
T7 - xiphoid process
T10 - belly button

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53
Q

S/S of cardiopulmonary arrest before it happens

A

Gradual decline in heart rate and BP (20% below baseline values)
Bradycardia
Hypotension
Cyanosis

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54
Q

medications during cardiopulmonary arrest from spinal anesthesia

A

ephedrine - alpha/beta agents “baby epi”

Atropine - increase HR

Epi - stron alpha/beta agonist - for bradycardia that is unresponsive to ephedrine and atropine

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55
Q

What is the average duration of CPR from arrest from spinal?

A

11 min, waiting for spinal to come down

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56
Q

What type of airway is an LMA?

A

supraglottic airway

Keep in mind for difficult airways!

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57
Q

When perioperative hearing loss does occur, what is it most likely from?

A

5-% after spinal anesthesia d/t CSF leaks

TXT: blood patch

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58
Q

Allergic reactions are _______ response to an antigen in previously _______ individual

A

Immunologic

sensitized

59
Q

The antigen or allergen is typically a

A

protein, a polypeptide, or smaller molecule that is covalently bound to a carrier protein.

60
Q

What is a Type 1 hypersensitivity reaction?

A

Immediate

Atopy
Urticaria - angioedema
Anaphylaxis

61
Q

What is a Type 2 hypersensitivity reaction?

A

Cytotoxic

Hemolytic transfusion reactions
Autoimmune hemolytic anemia
Heparin-induced thrombocytopenia

62
Q

What is a Type 3 hypersensitivity reaction?

A

Immune complex

RA

63
Q

What is a Type 4 hypersensitivity reaction?

A

Delayed, Cell mediated

Contact dermatitis

64
Q

What is anaphylaxis

A

Exaggerated response to an allergen that is mediated by a Type I hypersensitivity reaction.

65
Q

When will an anaphylactic reaction occur?

A

Within minutes to exposure of antigen

66
Q

Anaphylaxis characteristically presents as

A

acute respiratory distress, circulatory shock, or both

67
Q

Incidence of anaphylactic reactions during anesthesia is

A

1:5000 to 1:25,000 anesthetics

68
Q

Is anaphylaxis a systemic or local reaction

69
Q

how is response to 1st exposure to an antigen

A

allergen exposure leads to Bcells which trigger the production of IgE antibodies. IgE bonds to the cell surface of mast cells or basophils

70
Q

how is response to 2nd exposure to an antigen

A

subsequent allergen exposure leads to degranulation of mast cell/basophil which leads to a histamine release. Histamine increases permeability of capillaries (can loose up to 50% of blood volume).

71
Q

What do the mast cells release that are the mediators of anaphylaxis?

A

Histamine
Leukotrienes
BK-A
Platelet-activating factor

72
Q

Degranulation of mast cells release Leukotrinene, what is typical response in asthma is

A 
constricted bronchioles
airway obstruction (mucus buildup)
73
Q

Degranulation of mast cells release prostaglandin, what is the typical response

A

dilated blood vessels
constricted bronchioles
nerve cells = headache

74
Q

Degranulation of mast cells releases histamine, serotonin, and bradykinin - what is the response

A

excessive mucus, tears, glandular formation

increased peristalsis: V/D

Constricted bronchioles (smooth muscle) - wheezing, coughing, diff breathing

dilated blood vessels - wheal and flare run, itching

75
Q

CV clinical manifestations of anaphylaxis

A

hypotension, tachycardia, arrhythmias

76
Q

Resp clinical manifestations of anaphylaxis

A

bronchospasm, cough, dyspnea, pulmonary edema, laryngeal edema, hypoxia

77
Q

Dermatologic clinical manifestations of anaphylaxis

A

urticaria, facial edema, pruritus

78
Q

What is an anaphylactoid reaction?

A

Resembles anaphylaxis but does NOT depend on IgE antibody interaction with antigen.

79
Q

Can you tell the difference between and anaphylactic and anaphylactoid reaction?

A

NO

Although the mechanisms differ, anaphylactic and anaphylactoid reactions can be clinically indistinguishable and equally life threatening.

80
Q

Risk factors associated with hypersensitivity to anesthetics

A

Female gender (cosmetics)
Atopic history
Preexisting allergies
Previous anesthetic exposure

81
Q 
Treatment of allergic reaction
Epi
LR
Benadryl
Ranitidine 
hydrocortisone
methylprednisolone
A 
Epi 0.01-0.5mg IV/IM
LR 1-2L
Benadryl (H1) 50-75mg
Ranitidine (H2) 150mg
hydrocortisone up to 200mg
methylprednisolone 1-2mg/kg
82
Q

What os the purpose of corticosteroids in anaphylactic reactions?

A

keep plasma cell from synthesizing Ige and inhibit Tcells

83
Q

What is the purpose of antihistamines, ASA, Epi, and theophylline in anaphylactic reactions?

A

counteract the effects of cytokines on targets

84
Q

What drug class is the most common cause of anaphylaxis during anesthesia.

A

muscle relaxants (70%)

85
Q

What is the incidence of anaphylaxis from muscle relaxants?

86
Q

What is the mechanism for anaphylactic reactions when using muscle relaxants

A

IgE antibodies directed against tertiary or quaternary ion epitopes

87
Q

Previous exposure to what things could cause an allergic reaction to muscle relaxants?

A

OTC drugs, cosmetics, and food products that contain tertiary or quaternary ammonium ions may sensitize susceptible individuals.

88
Q

What are the muscle relaxants that are must likely to cause an allergic reaction. IN ORDER

A
  1. ROC
  2. Succs
  3. atracurium
89
Q

What is the rate of allergic reactions to
Pentothol
Propofol

A

Pentothal - 1 in 30,000

Propofol - 1 in 60,000

90
Q

True or False: True allergic reactions to etomidate, ketamine and benzodiazepines is extremely rare

91
Q

Do opioids tend to cause true allergic reactions?

A

No

If they do, non-immune histamine release more common (morphine)

92
Q

Reactions to LA are very rare, but when they do happen what is the response?

A

vasovagal response

LAST

93
Q

Ester reactions are _____ mediated, share a common antigenicity with _____ and cross sensitivity _______

A

Ige mediated
PABA
should be expected

94
Q

Amine reactions are extremely _____, but if they do happen ______ and ______ are causative preservatives

A

rare

paraben or methylparaben

95
Q

Do volatile anesthetics cause allergic reactions?

A

no documents reports

96
Q

What type of antibiotics cause allergic reactions?

A 
B-lactam antibiotics
          Penicillin
          Cephalosporin
Sulfonamides
Vancomycin
97
Q

If Vanco is infused too fast, what might you see?

A

red man syndrome

98
Q

What is the second most common cause of anaphylaxis during anesthesia.

A

latex exposure

99
Q

How is a latex allergy mediated?

A

Direct IgE mediated immune response to polypeptides in natural latex

100
Q

What type of sensitivity reaction is latex?

101
Q

What foods that cross react with latex

A

mango, kiwi, chestnut, avocado, passion fruit and banana

102
Q

What pre-op meds can you give to help prevent a latex exposure?

A

H1 - Benadryl
H2 - ranititdine
Steroid (controversial)

103
Q

What is treatment for angioedema from lisonopril?

104
Q

How is MH characterized?

A

acute hypermetabolic state in muscle tissue after induction of general anesthesia

105
Q

MH occurrence in
Peds
Adults

A

Pediatrics 1:15,000

Adults 1:40,000

106
Q

Can the onset of MH happen after procedure is complete?

A

Yes, has occurred >1 hr. post-operatively

107
Q

What are signs of hypermetabolism in MH?

A 
Increased carbon dioxide production
Increased oxygen consumption
Low mixed venous oxygen tension
Metabolic acidosis
Cyanosis
Mottling
108
Q

What are signs of increased sympathetic activity in MH?

A

Tachycardia
Initial hypertension
Arrhythmias

109
Q

What is the most specific initial sign of MH?

A

sudden increase in etco2

110
Q

What is the most sensitive indicator of MH?

A

tachycardia

111
Q

What are some signs of muscle damage in MH?

A 
Masseter spasm
Generalized rigidity
Elevated serum creatine kinase
Hyperkalemia
Hypernatremia
Hyperphosphatemia
Myoglobinemia
Myoglobinuria
112
Q

Hyperthermia is a late sign of MH, but when it does set in, how fast can it rise?

A

core temperature can rise as much as 1*C every 5 minutes

113
Q

MH has uncontrolled increase in intracellular _______ in skeletal muscle.

114
Q

Sudden release of calcium from sarcoplasmic reticulum removes the inhibition of _______, and causes intense __________.

A

troponin

muscle contractions

115
Q

Dramatically enhanced and sustained _____ activity results in uncontrolled increase in ______ and _______ metabolism. = ______

A

ATP
aerobic and anerobic
acidosis

116
Q

How does hyperkalemia happen in MH?

A

from efflux of potassium from muscle cells and systemic acidosis

117
Q

High is there a high potential for Vfib in MH?

A

increased sympathetic tone, acidosis, and hyperkalemia

118
Q

Sudden death may occur in as little as ___ minutes.

119
Q

What abnormal receptors are responsible for MH?

A

abnormal ryanodine Ryr1 receptors

120
Q

What drugs are responsible for triggering MH?

A 
Halogenated general anesthetics
         Ether
         Cyclopropane
          Halothane
          Methoxyflurane
          Enflurane
          Isoflurane
          Desflurane
          Sevoflurane
Depolarizing muscle relaxants
         Succinylcholine
121
Q

Does NO trigger MH?

A

No, not a volatile anesthetic

122
Q

Why do you hyperventilate MH patients?

A

to blow off CO2

123
Q

How much Bicarb do you admin to MH patients?

124
Q

How much Dantrolene do you give MH pts?

A

1-2mg/kg IV, may repeat q5min to a max of 10mg/kg

125
Q

What is the purpose of giving Na bicarb, regular insulin, and beta 2 agonists during MH?

A

pushing K back into cell

126
Q

How much dextrose and insulin are you going to give for MH?

A

25-50 g dextrose

10-20 units insulin

127
Q

How does dantrolene work?

A

Directly interferes with muscle contraction by binding Ryr1 receptor, calcium channel and inhibiting calcium ion release from sarcoplasmic reticulum.

128
Q

What else is dantrolene used to treat?

A

Hyperthermia associated with thyroid storm
Neurolept malignant syndrome
Treatment of chronic spastic disorders

129
Q

What are the most serious side effects of dantrolene after acute admin?

A

muscle weakness, respiratory insufficiency and risk of aspiration

Can cause phlebitis in small hand veins, use central line if possible.

130
Q

Define laryngospasm

A

Complete spasmodic closure of the larynx as a consequence of an outside stimulus.

131
Q

In a laryngospasm, why does closure of the glottis happen?

A

Closure of the glottis as a result of reflex constriction of the laryngeal muscles.

132
Q

What would be the signs of a complete laryngospasm?

A

silent, paradoxical movement of the chest, tracheal tug, and no ventilation

133
Q

What would be the signs of a partial laryngospasm?

A

crowing noise, with mismatch between respiratory effort and ventilatory effectiveness.

134
Q

What med do you use in attempts to break laryngospasm?

A

deepen anesthetic with IV agent - big bolus of propofol

try succs

135
Q

Define bronchospasm

A

Caused by spasmodic constriction of bronchial smooth muscle creates narrowing of airway passages and increases airway resistance.

136
Q

What are the signs of bronchospasm

A 
Prolonged expiration 
High inflation pressures
Expiratory wheezes
Decreased oxygen saturation
Increased ETCO2
Decreased TV
137
Q

What med do you use in attempts to break bronchospasm?

A

deepen anesthetic with gas! volatile anesthetics are very good bronchodilators.

138
Q

What 3 things must be present for a fire in the OR?

A

Heat, oxygen, feul

139
Q

OSHA Maximum acceptable trace concentration anesthetic gases

A

N2O <25ppm
N2O&HA <25ppm and <0.5 HA
HA only <2ppm

140
Q

What is the maximum occupational whole body exposure annually

A

5 rem/year

141
Q

how far should you stand from radiation source?

A

at least 6ft, further is better

142
Q

Define critical event

A

An event in which a complication occurred or had a potential to occur

Close call

143
Q

Define sentinal event

A

An event in which a serious complication occurred

Something actually happened

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