DUKE'S Anesthesia 100 secrets Summary Flashcards
What is the Purpose of the preop visit ?
Choice of premedication depends on
Provides psychological preparation and calm the patient's fears and anxiety. Choice of preMedication depends on : PHYSICAL and MENTAL STATUS Inpatient or outpatient Elective or emergent, Hx of PONV
Wheezes: All wheezes
All wheezes is not asthma
CHF, PE, mechanical airway obstruction, allergic reaction,
aspiration, ENDOBRONCHIAL intubation.
Periinduction hypotension responds best to _________. Estimating volume status requires gathering________
Replace intra-operaitve fluid losses with
Responds best to IV fluids
As much clinical information as possible, single variable may be misleading.
Replace intraoperative fluids losses with isontonic fluids.
What is of paramount importance? what does is prevent?
Thorough airway examination
Identification of patient with potential difficult airway
Prevent difficult to ventilate, difficult to intubate situation
For the elective case, fasting guidelines Clear liquids Nonclear liquids Light meal or snack Full meal
2 hours
4 hours
6 hours
8 hours
4 factors to speed onset of Volatile anesthetics (DAFU)
Increase – Delivered concentration of anesthetics – Alveolar ventilation – Fresh gas flow – Use non-lipid soluble anesthetics
Obese patients consideration
May be difficult to ventilate and intubate, have back up strategies readily available
Infants airway, comment on larynx, tongues and epiglottis.
What is the narrowest part of the airway for an infant?
larynx is anterior
large tongues
Floppy epiglottis
The narrowest part of the airway is BELOW THE VOCAL CORDS at the cricoid Cartilage
Most common circuit use in anesthesia ?
What are the components of it(6)?
Semi CLOSED circuit of a circle system
Components: Insp and exp limbs, unidirectional valves, CO2 absorber, a reservoir bag, POP off Valve on EXPIRATORY limb
Advantages of a circle system (3)
Disadvantage (2)
Conservation of heat and moisture
Low flow of fresh gas
Ability to scavenge the system
Dis : Multiple sites for disconnection, high compliance
2 types of Local anesthetics
how do they differ ?
AminoAmides
AminoEsters’
Differ in allergic potential and method of biotransformation
Termination of effect of IV anesthetics is by
Redistribution not biotransformation or breakdown
Benzo and IV inducation agents have synergistic effects., requiring adjustments in dosing
Neuropathic pain and response to opioids
Neuropathic pain less responsive to opioids compared to pain originating from Nociceptors
What are the most common complications of epidural analgesia?
What are the less common but potentially detrimental complications?
Hypotension, Inadequate analgesia requiring replacement and manipulation.; Pruritus, N/V
Post Dural Puncture Headace (PDPH); High total spinal, Intrathecal or IV catheter placement, Systemic toxicity and nerve injury
What is the definitive treatment of pre-eclampsia? Mainstay of management is ?
Immediate delivery
Blood pressure control with Beta Blocker and seizure prophylaxis with magnesium sulfate
High risk for postpartum hemorrhage or uterine atony
Prepare accordingly
Type and cross and have blood to transfuse readily available.
Elective thoracic surgical procedures in adults in one lung ventilation (OLV) using _______
Harder to place are the ____and ______
What is the main action of initiation of OLV?
Left double lumen ET tube
– Right double lumen tubes and BRONCHIAL BLOCKERS are more difficult to place and more likely to move during surgery and needs to be placed with a Fiberoptic Bronchoscope (FOB).
– It stops all ventilation to one lung, which would create a 50% right to left shunt and relative hypoxemia if perfusion were unchanged
Consideration for somatosensory-evoked potentials (SSEPs) are monitored
During spine surgery, avoid exceeding 1 MAC of volatile anesthetics, to maximize the effectiveness of signal acquisition.
Prolonged spine surgery in the prone position consideration? avoid what?
Use a combination of COLLOID and CRYSTALLOID for fluid replacement to help avoid ISCHEMIC OPTIC NEUROPATHY
If the patients on Beta Blockers when should they take the dose? Why? Beta blockers are _____initiated day of surgery. Medication such as______ should be continued
–Day of surgery and continue periop
Because the receptors are UPREGULATED, withdrawal may be precipitate, HTN, tachycardia and Myocardial ischemia
– Clonidine
Hypothermia effect on patient outcome
What increases 3 folds?
Increase rate of wound infection
Delay wound healing
Increase blood loss
Increase cardiac morbidity three folds
What is the UNIVERSAL DONOR for PRBCs? What about for PLASMA?
O negative blood
AB positive
T/F Not all elderly patients need an extensive preop workup.
Some patient that gets more confused with preop meds
True: just tailor to their underlying illness and invasiveness of the surgery
Alzheimer’s patients
Basal function of most organ systems is relatively _______by the aging process per se, but the functional reserve and ability to compensate for physiological stress are ______Anesthetics requirement in the elderly are _______; Increase potential for a variety of _______. what is the most common complication ?
Unchanged; reduced; decreased; postop complications;
Post op cognitive dysfunction
Pregnant women and airway
Pregnant women can pose airway management problems because of airway edema, large breasts that make laryngoscopy difficult, FULL stomach rendering them prone to ASPIRATION and RAPID O2 desaturation due to DECREASED of functional residual capacity
Normal saline in large quantity
Lead to Hyperchloremic Metabolic acidosis; associated base deficit may lead the provider to conclude incorrectly that the patient continue to be hypovolemic
Is there a set hemoglobin/hematocrit for transfusion
There is no set hemoglobin/hematocrit level at which transfusion is required. The decision should be individualized to the clinical situation, taking into consideration the patient’s health status. If blood is needed, type O- PRBCs or type specific unit may be used.
What is the most COMMON INTRAOPERATIVE BLEEDING diathesis (meaning unusual susceptibility to bleeding)
Dilutional thrombocytopenia. Not seen until significant blood loss has occurred and has been replaced with IV crystalloid and blood products that do not contain platelets.
What is thromboelastography?
Dynamic POC testing that can help distinguish between surgical and non-surgical bleeding. It can identify specific deficiencies of coagulation factors, fibrinogen and platelet and can detect plasmin dysregulation and abnormal clot breakdown
What is the primary treatment of DIC
Treat the underlying medical condition
What are the most clinical helpful indices obtained from spirometry?
Forced Vital Capacity (FVC)
Forced Expiratory Volume in 1 sec (FEV1)
FEV1/ FVC ratio
Flow between 25-75% of the FVC (mean maximal flow)
Common opioid side effect include
Nausea Pruritus Bradycardia Urinary retention Resp depression
Appropriate IV dosing of IV anesthetics requires considering
Intravascular volume status
comorbidities
age
Chronic medications
What is the best induction agetn for patients with hypovolemic trauma as long as there is no risk for increased ICP; Also used for patients with Bronchoplastic disease?
Ketamine
Ketamine
What is the least likely agent of all induction agents to result in Nausea and vomiting and the terminating effects of IV anesthetics is by________ and not by _____or ______
Propofol; redistribution , not biotransformation and breakdown
– Metabolism of relaxants is _____Important that pharmacological reversal for termination of relaxant effect. –Train of four assessment __________ and has been demonstrated to underestimate residual NMB. It may be a best practice to administer reversal agent to all patients receiving non-depolarizing agents.
–What do you do to a clinically weak patient?
–More
–HIGHLY selective
–Leave clinical weak patients intubated and support respirations until the patient can demonstrate return of strength
What determines potency of local anesthetics?
What determines onset of local anesthetics?
What determines duration of action of local anesthetics
–lipid solubility
–pKa
–protein binding
What does vasopressin has a role in ?
Vasopressin has a role in BP maintenance in septic shock
Cardiogenic shock and other shock states
Is low dose dopamine effective for prevention and treatment of ARF and for protection of the gut?
Is DOPAMINE effective at treating septic shock?
What is the best way to maintain renal function during surgery ?
–NO
–NO
–ensure an adequate intravascular volume, maintain cardiac output, avoid drugs known to decrease renal perfusion
Rate the risk of clinically significant aspiration pneumonitis in healthy patients? is routine use of pharmacologic agents to alter the volume of pH or gastric contents necessary?
Very low; many patients require low or no premedication.
- NO
What is the gold standard for preop cardiac assessment? However, the most important component of the pre-anesthetic evaluation is a _______
– American College of Cardiology / AHA
– thorough, accurate, and focused history and physical examination.
What are the four cardiac conditions that will likely result in cancellation to assess cardiac evaluation and treatment?
– Unstable coronary syndrome
– Decompensated Heart failure
– Significant cardiac arrhythmias
– Severe Valvular disease
What is increasing in frequency as far as the eyes, what can be done to prevent it?
Postop blindness is increasing in frequency . During lengthy spine procedures in the prone position, maintain intravascular volume, hematocrit, and perfusion pressure.
What is the most common post op nerve injury? Who is it most common is ? presentation ?
ULNAR NEUROPATHY
Older than 50 years, is not invariably prevented by padding, and is multifactorial in origin
2 separate respiratory processes? what does not assess adequacy of ventilation?
Oxygenation and ventilation
Pulse ox does not assess adequacy of ventilation
treat the patient not the symptom
Isolated value vs trends
Trends better than isolated values
Should always be evaluated in the context of the patient
Systolic BP in radial artery
It may be as much as 20-50 mmHg higher than the pressure in the central aorta.
Awareness is most likely in what cases?
Cases where minimal anesthetic is administered such as with CPB , hemodynamic instability, trauma and fetal delivery
Symptoms of awareness can be
nonspecific , and the use of NMB increases the risk of unrecognized awareness
Even mild hypothermia has a negative influence on patient outcome, increasing ________ rates, increasing________ delaying _______ increasing Blood _______ , and increasing __________ as well as ______morbidity. What is the best method to treat hypothermia
wound infection nitrogen loss Blood loss Hospitalization Cardiac morbidity.
– forced-air warming blankets
Warm all fluids and and blood products
