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Anesthesia > E-Modules Second Pass > Flashcards

E-Modules Second Pass Flashcards

1
Q

What are the “special patient groups” for which you should know specific things?

A

Pediatric, geriatric, obstetric

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2
Q

Why do pre-op assessment?

A

Establish the safest plan for the pt

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3
Q

What are the goals of the pre-op assessment?

A
  • RV med Hx
  • Assess airway, cardioresp, other systems
  • Make a plan to optimize
  • Determine post-op disposition (where pt will recover)
  • Alleviate anxiety and build rapport
  • Delay the surgery if necessary
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4
Q

What are the components of the pre-anesthesia exam?

A
  • Prepare
  • Hx
  • Physical exam
  • Review the plan
  • Any questions?
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5
Q

What things must you (and the surgeon) make sure are correct?

A

Correct patient, procedure, and side

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6
Q

What details do you want to know about a pt PMHx?

A

Ask PMHx, but also Qs to get a sense of severity and level of control. Eg if OSA, on CPAP? Using? Effective? If DM, ask about A1C, meds, micro and macrovascular complications

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7
Q

What details do you want to know about a pt PSHx?

A

what kinds of anesthetics have they had
Hx of post-op N&V
Specifically about malignant hyperthermia and pseudocholinesterase deficiency

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8
Q

What features of MH might a pt know or think of, if not familiar with the name?

A

“tense muscles”, “a severe fever”

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9
Q

What features of pseudocholinersterase deficiency might a pt know or think of, if not familiar with the name?

A

“muscle relaxant took a long time to wear off”

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10
Q

What should you do if you suspect MH or PD?

A

Inform staff immediately

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11
Q

What FHx should you ask about?

A

malignant hyperthermia and pseudocholinesterase deficiency

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12
Q

What should you ask about in the med Hx?

A

What meds, and also what day they last took each

Periop plan should be in Anesthesia or other (eg Thrombosis) consult

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13
Q

Why should a pt not smoke the day of the surgery?

A

Hb higher affinity for CO than O2, so pt will be more prone to desaturation

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14
Q

What smoking Hx should you ask?

A

Standard ever-smoked & pack-years; also, when they quit if so, and if a current smoker when last cigarette was.

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15
Q

What social Hx should be inquired about/

A

Substance use, esp chronic use (might affect sensitivity to meds) or IVDU (poor venous access)

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16
Q

What is one question you have to remember to ask day-of-procedure, and what should you do if you’re not sure pt is being honest?

A

NPO status!

Tell pt how serious it is – they could die – and they usually take it seriously.

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17
Q

What are the CAS guidelines for preop fasting?

A

Clear liquids up to 2h beforehand
HBM (infants): up to 4h beforehand
Infant formula, light meal, non-human milk: up to 6h beforehand
Large meal, fried foods, fatty foods, meat: up to 8h beforehand

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18
Q

What are the ASA classes?

A

1: A normal healthy patient in need of surgery for a localized condition.
2: A patient with mild to moderate systemic disease; examples include controlled hypertension, mild asthma.
3: A patient with severe systemic disease; examples include complicated diabetes, uncontrolled hypertension, stable angina.
4: A patient with life-threatening systemic disease; examples include renal failure or unstable angina.
5: A moribund patient who is not expected to survive 24 hours with or without the operation; examples include a patient with a ruptured abdominal aortic aneurysm in profound hypovolemic shock.

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19
Q

What does the E mean in ASA classes?

A

Emergency surgery

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20
Q

Why should you obtain baseline vitals?

A

Get a sense of how far off you are from pt normal during surgery

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21
Q

What is the average risk of dental damage with intubation?

A

1 in 500 on average

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22
Q

What are the required parts of the pre-op anesthesia exam?

A

Airway exam, discuss dental damage, CV and Resp, Venous and Arterial exam (eg Allen test), spine exam

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23
Q

Why would you consider a neuro exam as an additional component of the pre-op anesthesia assessment?

A
  • positioning: risk of injury
  • blocks: want to know how well the affected area functions normally
  • risk of stroke: assess baseline so you can assess if there is worsening
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24
Q

What are the physiologic changes in a pregnant pt in the CV system?

A

Increased CO (SV & HR)
Progesterone induced vasodilation
Compression of the uterus in supine position

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25
Q

What is supine hypotensive syndrome, and how is it addressed?

A

Uterus compresses VC, decreased venous return, decreases preload, leads to hypoperfusion
Look out for drop in BP, pallor, tachycardia
Tilt pt to L lateral to lift fetus off IVC

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26
Q

What are the implications of the physiologic changes in a pregnant pt in the CV system?

A

More strain on heart (issue if pt has heart trouble)
Hypotension
Supine hypotensive syndrome

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27
Q

What are the physiologic changes in a pregnant pt in the respiratory system?

A

More edematous and vascular
Increased adipose tissue
Decreased Functional Residual Capacity (cephalad displacement of diaphragm)

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28
Q

How do you prepare pregnancy women immediately before surgery that is different?

A

Pre-oxygenation (due to decreased FRC)

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29
Q

What are the physiologic changes in a pregnant pt in the GI system and what are the risks because of them?

A

Decreased tone in LES
Decreased gastric emptying
Increased gastric acidity
Increased intra-abdo and gastric pressure
–> heartburn, reflux, aspiration, and more severe damage (due to pH)

30
Q

How do anesthetists manage pregnant pt differently from a GI perspective?

A

Treat as recently-eaten, & give intraop PPI

31
Q

What are the physiologic changes in a pregnant pt in the CNS and what are the risks because of them?

A

Increased minute ventilation
Decreased min alveolar concentration due to hormonal changes
So:
- increased sensitivity to anesthetic agents
- faster onset of inh agents
- faster induction and emergence
Ie, they require dosage adjustments.

32
Q

What are the takeaway points of physiological differences of pregnant pt and the implications for anesthesia?

A
  • incr sensitivity to anesthetic agents
  • more diff intubation
  • potential for gastric reflux and aspiration
  • increased susceptibility to hypoxemia
  • supine hypotensive syndrome
33
Q

Where is pain felt in stage 1 of labour?

A

Paracervical nerves: T10-L1

34
Q

Where is pain felt in stage 2 of labour?

A

Paracervical nerves: T10-L1
and
Pudendal nerves: S1-4

35
Q

Where is the epidural injected? How do you know if you’ve gone too far?

A

Epidural space – just OUTSIDE the dura

If CSF comes out you’ve gone too far!

36
Q

Why do epidurals work?

A

Nerve roots pass through the epidural space as they exit the spinal cord. Anesthetic there numbs the roots.

37
Q

Why are epidurals preferred for labour?

A

Pt remains awake
Superior pain relief
No direct effect on fetus
Good for more complicated procedures – eg C-sections, forceps
Indicated for hypertension: prevents catecholamine surge from pain, vasodilates

38
Q

What are the downsides of epidurals?

A 
Labour *may* take longer (being contested)
Hypotension
Muscle weakness (may affect motor nerves)
39
Q

What is done to avoid negative effects of epidurals?

A

Fluid boluses, vasopressors, pt positioning

40
Q

Which takes more time, spinal or epidural?

A

Epidural

Spinal can be done if not enough time for epidural, eg urgent C section or planned elective C section

41
Q

When would you use a pudendal block, and how is it done?

A

Pt has advanced far into labour without anesthesia but now need vacuum or forceps
Usually done by attending OB, not anesthesia
Done through vaginal wall

42
Q

When would you use GA?

A

Urgent procedure

Contraindication to regional technique

43
Q

What size cuffed ETT does CPS recommend?

A

up to 1 y: 3.0mm
1-2y: 3.5mm
>2y: (age in years / 4) + 3.5mm

44
Q

What is the sizing difference between cuffed and uncuffed ETT?

A

add 0.5mm

so formula for uncuffed tubes is tube size = age/4 + 4mm

45
Q

What SSHADESS history should you make sure to ask a child, separate from an adult?

A

Tobacco, alcohol, other substance use, contraception & pregnancy

46
Q

What anatomical differences between kids and adults are particularly important to note?

A
  • relatively bigger heads, particularly occiput, making angles diff for intubation (put rolled towel under scapulae, enabling “sniffing position)
  • epiglottis shape, size, and compliance is different (straight laryngoscope more often used to lift the epiglottis, instead of curved into vallecula)
  • larynx more cephalad (C4, as opposed to C8)
47
Q

What is Poiseuille’s law?

A

resistance is inversely proportional to the radius of the tube to the 4th power
(radius, not diameter)

48
Q

What is different about cardiac output changes for kids generally?

A

Hearts are less compliant, so SV changes less: CO mostly modified with HR

49
Q

What is different about vagal tone in kids?

A

Increased, so more likely to get bradycardic with laryngoscopy or hypoxia

50
Q

What is different about kids’ pulmonary tissue, and how does that affect anesthesia?

A

Tissues are more compliant, so they are less likely to keep negative intrathoracic pressure, so hypoxia happens faster

51
Q

What is different about the BBB in infants?

A

More permeable than in adults: meds can cause central effects, eg apneas

52
Q

What physiologic differences in the liver might change dosing requirements in infants?

A

At birth, hald of CYP450 non-functional, so active metabolites build up more
Phase 2 conjugation reactions, which make metabolites more water-soluble, not functional in infants: decreases excretion of active drug metabolites

53
Q

What physiologic differences in the kidney might change dosing requirements in infants?

A

Infants can’t process high solute load or high amounts of free water; might lead to decreased excretion of medications, leading to long half-life
Glomerular filtration matures by age 2

54
Q

What fluid bolus is usually given at the start of peds cases, and why?

A

10-20 mL/kg bolus usually given at start of case

Intraop fluid req may be increased due to blood loss, insensible losses, volume deficits from pre-op

55
Q

How is body temperature managed differently with young kids?

A

Body surface area relatively larger, so increased risk of hypothermia: warming blankets & avoiding exposure is more common.

56
Q

How do you calculate maintenance fluids for kids?

A

4-2-1 rule

57
Q

What is physiologic pain?

A

Response to a known stimulus, and promotes a protective function
Acute: recent onset, short duration, disappears with healing/disease resolution

58
Q

What are nociceptors?

A

Primary afferent neurons
A-delta and C fibres
Innervate peripheral tissues (skin, muscle, joints, viscera)

59
Q

What role do inflammatory mediators play in pain?

A

Activate peripheral nocioceptors

60
Q

What are the 4 stages of pain response?

A

Transduction, Transmission, Modulation, Perception

61
Q

What is modulation?

A

Process which determines how nociceptive info will be transmitted in the CNS
Modified in periphery, in dorsal horn and in descending pathways

62
Q

How does peripheral sensitization work in pain?

A

Inflammatory mediators sensitize functional receptors and activate dormant ones
(–> easier activation, more firing)

63
Q

What may happen if the acute pain response is not interrupted?

A

May progress to chronic/pathologic pain: approach pain aggressively!

64
Q

What is the neuro-endocrine stress response to pain?

A
  • increased sympathetic tone
  • increased catecholamine and catabolic hormone secretion
  • decreased secretion of anabolic hormones
  • enhancement of coagulation
65
Q

What is the result of the neuro-endocrine stress response to pain?

A
  • sodium and water retention
  • catabolic and hypermetabolic state with increased oxygen consumption
  • hypergoaculability, immunosuppression, hyperglycemia, poor wound healing, risk of myocardial ischemia, decreased GI activity
66
Q

What are the treatment options for management of post-op pain?

A

Systemic: opioid & non-opioid; oral/IV/IV-Patient controlled analgesia (PCA)
Regional: Neuraxial (spinal, continuous epidural, pt-controlled epidural); periperal (nerve blocks, intra-articular injections, etc)

67
Q

What is chronic pain?

A

Persistent or recurrent pain, lasting beyond course of acute illness or injury

  • low levels of identifiable pathology
  • not assoc w/ adaptive or protective response
  • pathologic
68
Q

What is the IASP definition of pathological pain/chronic pain?

A

Pain without apparent biological value that has persisted beyond the normal tissue healing time usually taken to be 3 months

69
Q

What does malignant chronic pain relate to?

A

pertains to cancer and its treatment

70
Q

What does nonmalignant chronic pain deal with?

A

neuropathic, MSK, inflammatory

Anesthesia (3 decks)

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