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Anesthesia > ECEs > Flashcards

ECEs Flashcards

1
Q

What are the components of the anesthesia exam?

A

mouth opening (3 fingers), neck flexion (chin to chest, look up), Mallampati classification, thyromental distance (next extended, bottom of chin to thyroid notch 3-4finger breadths)

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2
Q

How is the thyromental distance taken, and what should it be?

A

neck extended, distance from bottom of chin to thyroid notch; should be at least 3-4 finger breadths

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3
Q

What are the Mallampati classes?

A

Class 1: Soft palate, uvula, tonsillar pillars can be seen.
Class 2: As above except tonsillar pillars not seen.
Class 3: Only base of uvula is seen.
Class 4: Only tongue and hard palate can be seen.

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4
Q

What is normal neck ROM?

A

90-165 degrees

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5
Q

What are the pros and cons of an LMA?

A

Pros: easy to insert, bypasses supraglottic structures (eg tongue won’t block airway), frees up anesthetist’s hands; can deliver some positive pressure ventilation
Cons: still invasive; doesn’t have advantages of ET

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6
Q

What are the pros and cons of ET intubation?

A

Pros: patency of airway; minimal aspiration risk (airway protection); enables mechanical ventilation
Cons: invasive; difficult (skill + tools); risk of misplacement (in esophagus, or R bronchus); risk of damage to cord structures

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7
Q

When do you need mechanical ventilation (& thus ET tube)?

A

Surgery requires muscle relaxation (eg neurosurgery); surgery involves thoracic cavity; surgery is very long (resp muscles might fatigue)

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8
Q

How do you confirm placement of ET tube?

A

Gold standard is direct visualization of ETT between vocal cords
Normal end-tidal CO2 confirms (except in cardiac arrest)
auscultation of both lungs + epigastrium
vapour in ETT supportive but not confirmatory.

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9
Q

What identifies placement of tube in R bronchus?

A

R breath sounds and ø L breath sounds on auscultation. Excess advancement of tube (F: >20cm, M: >22cm)

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10
Q

Walk through the steps of intubation

A

pt in “sniffing position”
introduce Macintosh blade into R, sweeping tongue to L
advance tip to the space between base of tongue & epiglottis (the vallecula)
keep wrist stiff and don’t leverage blade (eg against teeth)
lift laryngoscope, exposing vocal cords & glottic opening
insert ETT under direct vision through cords

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11
Q

What size ETT should you use?

A

Size 7.0 or 7.5 ETT for adult female, size 8.0 or 8.5 for adult male

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12
Q

When you insert a supraglottic airway, where would its tip be if adequately placed?

A

Upper esophageal sphincter

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13
Q

Think of clinical situations in which supraglottic airways may be used instead of an endotracheal tube.

A

Urgent situations, or as a temporizing measure
Lower extremity orthopedic surgeries when pt want general
For surgical efficiency: eg can go to PACU without anesthetist, with LMA in
(many others)
Why NOT to use it? COVID!

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14
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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15
Q

What is malignant hyperthermia?

A

autosomal dominant variant → changes in Ca++ processing in muscle, in context of inhalational anesthetics or succinylcholine → … → CV collapse, vital organ failure, coma, death

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16
Q

What is pseudocholinesterase deficiency?

A

Genetic deficiency in pseudocholinesterase; prolongs response to succinylcholine

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17
Q

What are important questions for pre-anesthetic history?

A

Any cardiac or respiratory disease Hx. Any hepatic or renal disease Hx. Any other disease Hx.
Medications. Hx of adverse drug reactions.
Pt and F Hx with anesthesia.
Specific Qs re: malignant hyperthermia and pseudocholinesterase deficiency.
Soc Hx, incl smoking and EtOH.
If pre-op: Medications and NPO status today.

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18
Q

What are the main anatomical landmarks to visualize on intubation?

A

Epiglottis, vocal cords, artytenoids

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19
Q

How is the laryngoscopy technique different for curved vs straight blades?

A

Macintosh (curved) vs Miller (straight): Macintosh blade is inserted into the vallecula anterior to the epiglottis, whereas Miller blade is inserted posterior to the epiglottis and lifts it upwards while depressing the tongue for direct laryngoscopy.

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20
Q

How does video compare to direct laryngoscopy?

A

Video: Decreases the amount of force needed for laryngoscopy. Allows for glottic visualization when there is limited mouth opening, neck immobility/ injury, or an anterior airway. Is not reliable with airway blood or secretions.

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21
Q

Think of strategies to minimize tooth and lip damage during laryngoscopy.

A

Strategies to limit tooth damage: keep arm straight, lift up, check in, position self well … consier using video

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22
Q

What are the absolute contraindications to central anesthesia (or LP)?

A

coagulopathy, sepsis (systemic or at site of injection), increased intracranial pressure (ICP), shock

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23
Q

What are the relative contraindications to central anesthesia (or LP)?

A

evolving neurological deficit, obstructive cardiac lesion (e.g. aortic stenosis), spinal hardware

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24
Q

What are the structures that spinal needle passes through while being inserted?

A

Layers: skin, superficial fat & fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, into epidural space; if spinal, on through the dura

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25
Q

How is a spinal anesthetic different from an epidural?

A

Spinal goes intrathecally and acts on the spinal cord. Epidural goes in epidural space and acts on the nerve roots.

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26
Q

What are signs of local anesthetic toxicity?

A

tinnitus, perioral numbness, metallic taste in mouth, dizziness - might experience if catheter is in vein

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27
Q

What are the contraindications for epidural anesthesia?

A

Same as for spinal

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28
Q

What is a sign of misplacement of epidural intrathecally?

A

sensory/motor block after only small amount of local anesthetic

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29
Q

What is the pathophysiology of post dural puncture headache?

A

reduced CSF pressure due to loss of CSF in the epidural space through the dural puncture site

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30
Q

Name 3 complications of epidural anesthesia

A

Early:
incorrect catheter placement → LA toxicity, total spinal block
excessive volume of LA delivered → high block, which can → hypotension, bradycardia, resp compromise; or → block of sympathetic fibres → hypotension, bradycardia
Late:
needle & catheter insertion → nerve injury, epidural abscess or hematoma, post-dural h/a (if dura is punctured)

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31
Q

How do you calculate how many milligrams of a local anesthetic there are in one millilitre of a certain solution (i.e. lidocaine 2% or bupivacaine 025% etc)?

A

Multiply by 10 (E.g. 1% lidocaine = 0.01g/mL = 10mg/1mL)

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32
Q

What are the predictors of difficult bag-mask ventilation?

A

best predictor is previous Hx

BONES: Beard, Obese, No teeth, Elderly, Sleep apnea/snoring

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33
Q

What are some strategies to optimize BMV in case of difficulty?

A
  • Use the C-E hand position
  • Pull the jaw upwards to the meet the mask
  • Insert an oropharyngeal airway
  • Ventilate in sync with spontaneous breathing (if possible)
  • Two person BMV
34
Q

How does obesity impact airway management?

A

Both BMV and intubation may be more difficult.

35
Q

How does obesity impact ventilation?

A

More difficult: ↓ lung volumes, ↓ chest wall/diaphragm compliance (esp with Trendelenburg, pneumoperitoneum), obesity hypoventilation syndrome, OSA. Also note: can desat rapidly on induction.

36
Q

What two post-op complications are obese patients at higher risk of?

A

PONV

Post-op neuropathy (obese and cachexic pt at highest risk)

37
Q

What airway complication are obese patients at higher risk of?

A

Aspiration

38
Q

How can obesity impact the pharmacokinetics of certain anesthestic agents?

A

Lipophilic drugs may have delayed clearance

More interstitial volume, so may have to administer higher doses of meds that disperse

39
Q

List 3 comorbidities that may be more commonly seen in the obese patient

A

OSA, DM (& potentially gastroparesis), obesity hypoventilation syndrome

40
Q

According to the Canadian Anesthesiologists’ Society, which monitors must be continuously used intraoperatively?

A

Required continuously: 5 items/features
Oxygenation: Pulse oximeter
Ventilation: ETCO2 capnography; Agent-specific anesthetic gas monitor
Circulation: ECG; non-invasive BP (q3-5m) (or, invasive, eg art line)

41
Q

According to the Canadian Anesthesiologists’ Society, which monitors must be immediately available if needed?

A

Without delay: Temperature probe, Peripheral nerve stimulator, Stethoscope
Without undue delay: Spirometer for tidal volume, Manometer for ETT cuff pressure

42
Q

How do you place 3- and 5-lead ECGs (mnemonics)?

A

White on the right, smoke over fire

Snow over grass, chocolate close to the heart

43
Q

What is capnography? How does it relate numberically to PaCO2?

A

Waveform and numerical measurement of end-tidal concentration of CO2.
Note: ETCO2 is ~2-5mmHg lower than PaCO2 in healthy lungs (normal PaCO2 is 35-
45mmHg). This gradient is due to mixing with anatomic, alveolar, or mechanical dead space air; the gradient is increased in diseased lungs and in cases of poor pulmonary perfusion.

44
Q

Where is the arterial line transducer placed, and why?

A

Normally placed at level of right atrium (circle of Willis for neurosurgery).
If placed too high: underestimates P.
If placed too low: overestimates P.

45
Q

What artery is preferred for an arterial line?

A

Radial

46
Q

Why would you use an art line?

A

Gold standard BP monitoring. ABGs. Might use if continuous monitoring or hemodynamic instability anticipated, frequent ABGs needed, or inadequate BP cuff size.

47
Q

Think of reasons you might decide to place an arterial line on a patient. Why sometimes arterial lines are done prior to induction and sometimes are done after induction?

A

Why do before induction? - very unstable pt, or concerns re BP drop with induction
Why do after? it HURTS

48
Q

What changes should you make for a pt with chronic pain?

A

Consider regional or local anaesthsia, to reduce pain medication requirements post-op
Patients may need higher doses to manage acute pain
Note: Titrate opioid dose to RR when possible at the end of a case (RR 8-10) to avoid
overdosing.

49
Q

What changes should pt with chronic pain make to pain management perioperatively?

A

None: Pts should continue their usual pain medication in perioperative period.

50
Q

What does it mean to use a multimodal pain management strategy? Think of examples to minimize opioid requirements.

A

Multimodal analgesia: A combination of different classes of drugs to maximize analgesia provided by targeting different aspects of the pain pathway and minimizing adverse side effects of individual drugs.
• e.g. opioids, local anesthetics, NSAIDs, anti-depressants, cannabinoids, serotonin agonists, anti-epileptics.

51
Q

How might a patient’s hypoglycemic therapy may need to be adjusted perioperatively?

A

BG may need to be monitored more closely

may need to increase medication, or short-term admin insulin

52
Q

Why might it be important to be cautious of dexamethasone use for patients with diabetes?

A

Dexamethasone can trigger hyperglycemia

53
Q

How do neuromuscular blockers work?

A

Succinylcholine is a competitive agonist to AChR: causes depolarization → contraction; not removed by ACh-ase → muscle paralysis
Rocuronium is a competitive antagonist to AChR: blocks depolarization → paralysis

54
Q

What changes/considerations should be made for paralytic selection & use in neuromuscular disease? (dystrophy, MS, MG)

A

Duchenne/Becker’s: do not use depolarizing. Increased sensitivity to non-depolarizing.
MS: Caution with depolarizing in advanced disease.
MG: decreased sensitivity to depolarising, increased sensitivity to non-depolarizing

55
Q

In patients with advanced neuromuscular disease, how would their cardiorespiratory system be affected?

A

PARALYTICS AND NEUROMUSCULAR DISEASE
• Any cause of loss of muscle contraction can lead to increased post-junctional ACh receptors (e.g. crush/burn injury, UMN/LMN lesion, denervation, immobility, toxins).
• Adverse events of paralytics in these conditions include hyperK+, rhabdomyolysis,
prolonged paralysis, respiratory complications, and autonomic instability.

56
Q

What is bronchospasm?

A

Bronchospasm: A reversible involuntary smooth muscle contraction in the bronchi leading to narrowed airways mediated by vagal innervation.

57
Q

What are risk factors for bronchospasm?

A

Asthma, smoking, cold air, inhaled irritants, tracheal intubation/extubation.

58
Q

How can bronchospasm be prevented?

A

Pre-op prophylactic SABA/steroids, adherence to COPD/asthma therapy, topical lidocaine, ensure adequate anesthesia during intubation/extubation.

59
Q

For a patient with known COPD/asthma, think of strategies to prevent bronchospasm perioperatively.

A

Perioperative prevention: Pre-op prophylactic SABA/steroids, adherence to COPD/asthma therapy, topical lidocaine, ensure adequate anesthesia during intubation/extubation.

60
Q

How can OSA be managed intraoperatively?

A

Pre/intra-operative management: Supplemental O2 and adequate pre-oxygenation, CPAP/BiPAP therapy preoperatively (ask pt to bring their own machine), opioid-sparing multimodal/regional techniques, reverse Trendelenburg positioning, extubation when awake.

61
Q

How can OSA impact a patient’s disposition post-operatively? Think of strategies to minimize OSA related complications post-operatively.

A

Post-operative management: Careful monitoring for apnea and cardiorespiratory complications (may require continuous oximetry monitoring overnight before discharge), supplemental O2, CPAP/BiPAP therapy, semi-upright or lateral position, opioid-sparing analgesia

62
Q

Name 6 intraop respiratory emergencies

A 
Anaphylaxis
Aspiration
Bronchospasm
Laryngospasm
Status asthmaticus
Pneumothorax
CICO (Can’t intubate, can’t oxygenate)
63
Q

Why might an anesthetist delay a surgery if a patient has (or is freshly recovered from) a URTI?

A

URTI (current or recent) is a risk factor for laryngospasm; consider delaying elective surgeries to 2-3w after URTI.

64
Q

What is laryngospasm?

A

Laryngospasm: Partial/complete airway obstruction from laryngeal closure reflex (despite
inspiratory attempts) due to chemical or mechanical stimuli.

65
Q

What are the risk factors for laryngospasm?

A

Risk factors: Pediatric pts, recent URTI, cigarette smoke exposure, emergency surgery, insufficient depth of anesthesia (higher risk during induction and emergence), oropharyngeal secretions

66
Q

What strategies can be employed to prevent laryngospasm?

A

delay elective surgery to 2-3w post-URTI; apply topical lidocaine; ensure adequate anesthesia before intubation; extubate when deep or fully awake (higher risk during induction and emergence).

67
Q

If laryngospasm does occur, how would you treat it?

A

Management: Continuous positive airway pressure with 100% FiO2 with well-fitting mask and jaw thrust, suction secretions, deepen anesthetic with propofol, use paralytic (succi- nylcholine IV or IM), provide ventilatory support (consider reintubation if needed).

68
Q

What is status asthmaticus and how would you manage that intraoperatively?

A

Status asthmaticus: Extreme asthma exacerbation that is unresponsive to SABAs.
Management: 100% FiO2, IV SABAs, IV steroids, IV magnesium sulfate, ketamine or sevo/isoflurane, Heliox, monitor lytes (K+) and fluids.
Note: Intubation is often not required in status asthmaticus and irritates the airway; it is usually reserved for impending respiratory failure.

69
Q

What is a vasopressor?

A

Vasopressors increase vasoconstriction, which leads to increased systemic vascular resistance (SVR). Increasing the SVR leads to increased mean arterial pressure (MAP) and increased perfusion to organs.
Vasopressors act to increase CO and SVR through increasing contractility and HR as well inducing vasoconstriction peripherally. The three main groups are catecholamine, smooth muscle, and dopaminergic receptors.

70
Q

What are the most common vasopressors?

A

Catecholamine: phenylephrine, norepinephrine, epinephrine
Smooth muscle: vasopressin
Dopaminergic: dopamine
(Also dobutamine, milrinone)

71
Q

How do you detect intraoperative MI?

A

ST elevation/depression, unexplained ↑ HR or ↓ BP, arrhythmias, new Q waves, new LBBB.

72
Q

How do you prevent intraop MI?

A

Identify pts at risk, perform appropriate pre-op optimization, risk-stratify CVS complications, 5 or 12 lead ECG, consider invasive BP monitoring.
Consult with surgery team; consider cardiology consult, delay of surgery if appropriate.

73
Q

How do you manage intraop MI?

A

General principle is to maximize myocardial oxygen and decrease demand.
Depends on many factors (surgery, urgency, pt condition and PMHx, timing & severity; eg pre-incision vs open abdomen, elective vs trauma).

74
Q

What are the indications for RSI?

A

Increased risk of aspiration (e.g. unable to protect airway, critically-ill, pregnant, emergent surgeries, full gastric contents).

75
Q

Why can end tidal CO2 increase during laparoscopic surgery?

A

Insufflation with CO2 –> blood absorption –> increased CO2

76
Q

List 5 anesthetic considerations for laparoscopic surgery.

A

ETCO2 may be high.
Block should be higher than any manipulated tissue, not just incision area.
May need positive pressure ventilation if there is insufflation – increased intraabdominal pressure.

77
Q

If a patient’s condition raises concerns of cardiovascular instability intraoperatively, how could you adapt your technique in terms of monitoring?

A

Main way would be to use an art line

Also consider 5-lead over 3-lead EKG

78
Q

If a patient’s condition raises concerns of cardiovascular instability intraoperatively, how could you adapt your technique in terms of selection of drugs?

A

? (ask)

79
Q

Think of the potential challenges the anesthesiologist encounters when formulating an anesthetic plan for a patient coming for an emergency procedure. How can the surgical team facilitate that process?

A

? (ask)

80
Q

What are the indications for rapid sequence induction?

A

RSI Indications: Increased risk of aspiration (e.g. unable to protect airway, critically-ill, pregnant, emergent surgeries, full gastric contents).
Absolute contraindication: A known or anticipated difficult airway (must demonstrate ability to secure airway with BMV in case of failure to intubate).

81
Q

How would you determine if ventilation and oxygenation are adequate (esp with BMV)?

A

End-tidal CO2 indicator!
Also, condensation in face mask, chest rise, presence of breath sounds by ausculatation, feel of pressure & recoil (with experience can tell eg lung vs stomach)
Oxygenation is confirmed by oximetry

Anesthesia (3 decks)

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