Exam 1 Flashcards
1
Q
Dibucaine 20
A
Homozygous for atypical gene, paralyzed 4-8 hours after succ
2
Q
Dibucaine 60
A
Heterozygous, succinylcholine duration of action prolonged 50-100%
3
Q
Dibucaine 80
A
homozygous for typical gene, normal response
4
Q
receptor affected in malignant hyperthermia
A
Ryanodine
5
Q
Interventions for MH
A
no volatile agents, no succ, first case of day, new machine, TIVA, flush out existing agent with HF O2
6
Q
True allergy action
A
Avoid medication and determine cross sensitivities to any other medications you may use
7
Q
up to 20% of intraoperative anaphylactic reactions are attributed to
A
Latex
8
Q
High risk of latex allergy
A
chronic exposure to latex, spina bifida, repeated surgical procedures (>9), intolerance to latex based products, allergy to certain foods and tropical fruits, intraoperative anaphylaxis of unknown cause, health care professionals
9
Q
Calculate pack years
A
packs per day x years of smoking
10
Q
pack year history that increases risk of periop complications
A
20 pack years
11
Q
Second hand smoke increases risk of
A
Reactive airway disease, abnormal pulm function tests, increased resp tract infections, periop complications in kids
12
Q
When should pt stop smoking before surgery
A
At least 8 weeks before. Within 4 weeks has no reduced risk of periop resp complications
13
Q
Alcohol intake associated with:
A
Arrhythmias, infection, alcohol withdrawal syndrome. Anesthesia requirements may be increased (chronic) or exaggerated (acute).
14
Q
Functional Capacity Assessment
A
METS
1 MET - rate of energy consumed at rest
Determines if further preop testing is required
15
Q
Mallampati assesses:
A
Size of tongue in relation to the oral cavity
16
Q
Mallampati class 1
A
Soft palate
Fauces
Entire Uvula
Pillars
Palatine Tonsils
Uvula
Soft Palate
Hard Palate
17
Q
Mallampati Class 2
A
Soft Palate
Fauces
Portion of uvula
Uvula
Soft Palate
Hard Palate
18
Q
Mallampati Class 3
A
Soft palate
Base of uvula
Soft palate
Hard palate
19
Q
Mallampati Class 4
A
Hard Palate only
20
Q
Indicators of difficult mask ventilation:
A
Age >57 years old
BMI >30 kg/m2
Presence of a beard
Mallampati 3 or 4
Limited mandibular protrusion
History of snoring, increased neck circumference, face and neck deformities, RA, trisomy 21, scleroderma, cervical spine disease, previous cervical spine surgery
21
Q
Predictors of difficult tracheal intubation
A
Mallampati 3 or 4
Thyromental distance < 6-7cm
Short interincisor gap
Limited head and neck mobility
Limited mandibular protrusion
22
Q
How long to wait after MI for nonemergent cases
A
60 days
23
Q
How long to delay for drug-eluting stent
A
6 months
24
Q
How long to delay for bare metal stent
A
30 days
25
Midsystolic murmur at 2nd parasternal interspace. Crescendo-decrescendo. Radiates to carotids. Valsalva and sustained hand grip decrease intensity
Aortic stenosis
26
Holodiastolic murmur at third and fourth parasternal interspaces. Decrescendo, high pitched, blowing, radiates to carotid. Austin Flint rumble at apex. Squatting, hand grip exercise, and leaning forward increase intensity
Aortic insufficiency
27
Middiastolic murmur at the apex. Opening snap, low pitched rumble radiates to the axilla. Squatting and hand grip exercise increase intensity
Mitral Stenosis
28
Holosystolic murmur at apex. High pitched, blowing, radiates to the axilla, standing decreases intensity
Mitral Regurgitation
29
Von Willebrand disease
Can occur in pts with aortic stenosis
30
Child-Turcotte-Pugh class associated with poor outcomes
C
31
MELD score associated with poor outcomes
>14
32
Standard preop testing for ESRD/dialysis patients
Electrolytes, glucose, GFR, Ca, creat, ECG
33
Diabetic patients should have documented A1C within how many months of procedure
3 months
<7 is well controlled
34
ASA 1
A normal healthy patient.
Healthy, nonsmoking, no or minimal alcohol use
35
ASA 2
A patient with mild systemic disease Ex. mild diseases only without substantive functional limitations. Include: Current smoker, social alcohol drinker, pregnancy, obesity (BMI >30 but <40) well controlled DM/HTN, mild lung disease
36
ASA 3
A patient with severe systemic disease
Ex. Substantive functional limitations. One or more moderate to severe diseases. Include poorly controlled DM or HTN, COPD, morbid obesity (BMI >40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of EF, ESRD undergoing regular HD, premature infant, history (>3 months) of MI, CVA, TIA, or CAD/stents
37
ASA 4
A patient with severe systemic disease that is a constant threat to life
Ex. Recent (<3 monthts) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of EF, sepsis, DIC, ARDs, or ESRD not undergoing regularly scheduled dialysis
38
ASA 5
A moribund patient who is not expected to survive without the operation
Ex. ruptured abd or thoracic aneurysm, massive trauma, intracranial bleed with mass defect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
39
ASA 6
A declared brain-dead patient whose organs are being removed for donor purposes
40
Purpose of ASA classification
Designed to classify physical condition and reflect preop status - it is NOT an estimate of anesthetic risk!
41
When should herbal supplements be dc'd before surgery
2-3 weeks
42
Screening tools for alcohol use
AUDIT
CAGE (Cut down, annoyed, guilty, eye opener)
43
How long before surgery should patient quit drinking
4 or more weeks
44
PTSD effects on anesthesia
abuse and ptsd victims may experience difficulty with emergence and induction
45
concerns for hormone replacement therapy/synthetic androgens
hepatic and endocrine dysfunction
46
Example of 4 METS
climbing stairs, raking leaves, gardening
47
Example of 1 MET
eating, getting dressed
48
BMI formula
weight in kg/ height in meters^2
49
How many cm in a meter
100
50
how many cm in an inch
2.54
51
how many lbs in 1 kg
2.2
52
Ideal body weight calculation
Male: 105lb + 6lb for each inch > 5 ft
Female: 100lb + 5lb for each inch > 5 ft
53
STOP BANG
sleep apnea
Snoring, Tired, Observed, Pressure (BP)
BMI >35, Age >50, Neck circumference >40cm, Gender (male)
54
Most common reason for anesthesia related claims
Dental injuries
55
How long before surgery should routine preop labs be done
6 months
56
what is the thyromental distance
Measured along a straight line from the thyroid cartilage prominence to the lower border of the mandibular mentum
< 6-7 cm is concerning ( < 3 ordinary adult fingerbreadths)
57
what is the sternomental distance
Feeling sternal notch to the lower border of the mandibular mentum
< 12 cm is concerning
58
Inter-incisor distance
Adults should be able to open mouth at least 4 cm (allowing 2-3 fingerbreadths to be placed in between)
Distance <3 cm or gap of less than 2 fingerbreadths is nonreassuring and is a well-recognized contributor to difficult intubation
59
primary passage by which air enters the lungs
Nose
60
Supplies blood to nasal mucosa
Branches of the maxillary, ophthalmic, and facial arteries
61
Upper airway is the anatomic structures above what
Cricoid cartilage
62
Responsible for afferent nerve signals in nose
Maxillary and ophthalmic branches of the trigeminal nerve
63
Parasympathetic innervation of nose
CN 7 and pterygopalatine ganglion
64
Sympathetic innervation of nose
Superior cervical ganglion
Results in vasoconstriction and shrinkage of the nasal tissue.
Depression of SNS can cause engorgement of nasal tissue
65
Rises during eating to prevent food from passing from the mouth into the nose
Soft palate
66
Takes up most of the oral cavity
Tongue
67
Protects passageway from oral cavity into the oropharynx
Uvula
68
Landmarks of the pharynx
Base of the skull to level of the cricoid cartilage
69
Landmarks of nasopharynx
Anterior to C1. Bound superiorly by base of skull and inferiorly by soft palate
70
Landmarks of oropharynx
Lies at C2-C3. Bound superiorly by soft palate and inferiorly by epiglottis
71
Hypopharynx
Lies posterior to larynx. Bound by superior border of the epiglottis and inferior border of cricoid cartilage at C5-C6
72
What nerves innervate the muscles of the pharynx, larynx, and soft palate
Glossopharyngeal, Vagus, and Spinal accessory
73
Nerve responsible for afferent signals when pharynx is touched
Glossopharyngeal - carries signal to medulla - synapse with vagus nerve and spinal accessory
74
Nerve responsible for efferent signal aka gag reflex
Vagus nerve
75
Two branches of the vagus nerve that innervate the hypopharynx
Superior laryngeal (internal and external) and Recurrent Laryngeal
76
Nerve that provides sensory input to hypopharynx above the vocal folds, including base of tongue, epiglottis, aryepiglottic folds, and arytenoids
Internal Superior Laryngeal Nerve
77
Nerve that provides motor function to the cricothyroid muscle of the larynx
External Superior Laryngeal Nerve
78
Nerve that provides sensory innervation to the subglottic area and the trachea
Recurrent Laryngeal Nerve
79
Nerve that loops around the brachiocephalic artery
Right RLN
80
Nerve that loops around the aorta
Left RLN
81
Provides motor function to all the muscles of the larynx except the cricothyroid muscle
Recurrent Laryngeal Nerve
82
Physiology which places traction on the RLN
Dissecting aortic arch aneurysms and mitral stenosis (via dilated pulm artery)
83
Unilateral injury to RLN causes
Hoarseness but not respiratory compromise. Not an emergency
84
Acute injury to bilateral RLN causes
Unopposed tension and adduction of the vocal cords. Stridor. Severe resp distress aka emergency
85
Chronic injury to bilateral RLN causes
gruff/husky speech, but normal respiration via compensatory mechanisms
86
Injury to the SLN causes
NO respiratory distress
87
Landmarks of the larynx
Begins with epiglottis and extends to Cricoid cartilage
Contains intrinsic and extrinsic laryngeal muscles.
88
Larynx is composed of what single cartilages
3: Thyroid, Cricoid, Epiglottis
89
Larynx is composed of what paired cartilages
3: Arytenoid, corniculate, cuneiform
90
Function of the Larynx
Protection to the lower airway from aspiration.
Patency between hypopharynx and trachea.
Protective gag and cough reflexes.
Phonation
91
Function of the intrinsic muscles of the larynx
Control the tension of the vocal cords and opening and closing of the glottis
92
Function of extrinsic muscles of the larynx
Connect the larynx, hyoid bone, and neighboring anatomic structures. Primary function is to adjust the position of the larynx during phonation, breathing, and swallowing
93
Intrinsic muscles of the larynx
Posterior cricoarytenoids
Lateral cricoarytenoids
Interarytenoids (transverse and oblique)
Thyroarytenoids and vocalis
Aryepliglottic
Cricothyroids
94
Extrinsic muscles that depress the larynx
Omohyoid
Sternohyoid
Sternothyroid
95
Extrinsic muscles that elevate the larynx
Stylohyoid
Digastric
Mylohyoid
Geniohyoid
Stylopharyngeus
Thyrohyoid
96
Blood supply to larynx
Originates from External Carotid
Branches to Superior Thyroid Artery
then superior laryngeal artery
Inferior laryngeal artery is the terminal branch of thyroid artery and supplies the infraglottic region of the larynx
97
Lower respiratory tract is composed of:
Everything below Cricoid Cartilage:
Trachea and Diaphragm
98
Landmarks of the trachea
Inferior border of the cricoid cartilage and extends to carina. 10- 20 cm long
99
Only cartilage of trachea that is a complete cartilaginous ring
Cricoid Cartilage
100
Function of bronchi
Humidification and warming of inspired air
101
How many C shaped rings in trachea
16-20
102
Angle of R mainstem bronchus bifurcation and length from carina
25-30 degrees
2.5 cm
103
Angle of L mainstem bronchus bifurcation and length from carina
45 degrees
5 cm
104
Sympathetic innervation of trachea
1-5 thoracic ganglia
105
Parasympathetic innervation of trachea
Vagus nerve
106
Diaphragm arises from what 4 structures:
Septum transversum
Dorsal esophageal mesentery
Pleuroperitoneal folds
Body wall mesoderm
107
Diaphragm nerve supply
Phrenic nerve
108
Components of Preop Airway Exam
Length of upper incisors.
Relation of maxillary and mandibular incisors during normal jaw closure and during voluntary protrusion.
Interincisor distance (< 3cm difficult)
Visibility of uvula.
Shape of palate (high arched or narrow difficult).
Compliance of mandibular space
Thyromental distance
Length of neck
Thickness of neck (>43cm difficult)
Range of motion of head and neck
109
Indications of difficult bag mask ventilation
Beards, altered anatomy, NG tubes.
Obstruction of upper/lower airway.
Obesity with redundant upper airway soft tissue
Age greater than 55 (loss of upper airway elasticity)
No teeth
Stiff lungs
Sleep apnea or snoring
110
Proper bag mask ventilation
Left thumb and index finger around the collar of facemask at both mask bridge and chin curve - C
Middle and ring fingers on bony part of the mandible to help compress the mask and raise the chin
5th finger at angle on the mandible (anterior jaw thrusting maneuver)l
111
Hallmark signs of upper airway obstruction
emergency - hoarse/muffled voice, difficult swallowing, stridor, dyspnea
112
Signs of lower airway obstruction
High PAP, low TV, impaired ventilation
113
Apneic Oxygenation
Strategy to provide a patient with O2 during times of apnea. High flow rate of 15 L/min.
Sustains PO2 but does not eliminate CO2
114
Signs of inadequate ventilation during BMV
minimal or no chest movement.
Inadequate exhaled CO2.
Reduced or absent breath sounds.
Decreased o2 Sat.
115
Troubleshooting BMV
1. Reposition patient's head and neck
2. Place oral airway: tongue or airway soft tissue obstruction
3. Two hands BMV
116
Axes that should be in line for good BMV
oral axis, pharyngeal axis, laryngeal axis
117
Direct laryngoscopy
process of airway instrumentation with a laryngoscope to acquire a direct line of sight with the laryngeal opening and supporting structures
118
Video laryngoscopy
an INDIRECT procedure for viewing the laryngeal opening using an airway device with a camera linked to a video monitor
119
Tracheal intubation
Process of placing an ETT into the trachea proximal to the carina. Direct or Indirect
120
Most used airway assessments for difficult laryngoscopy and tracheal intubation
Modified Mallampati classification
Thyromental distance
Interincisor gap distance
Atlanto-occipital joint mobility and cervical range of motion
Mandibular protrusion test
Evaluation for obstruction of the upper airway
Measurement of neck circumference
121
Cormack-Lehane grading system
Objective scoring system to describe laryngoscopy difficulty. Assesses pharyngeal structures, glottic structures, and glottic opening during laryngoscopy
122
Grade 1 view
Most or full view of glottic opening
123
Grade 2 view
Only the posterior portion of the glottic opening can be visualized; anterior commissure not seen
124
Grade 3 view
Only the epiglottis can be visualized; no portion of the glottic opening can be seen
125
Grade 4 view
Epiglottis cannot be seen; only view is of the soft palate
126
Thyromental distance that indicates difficulty
<6cm and >9cm
127
Adequate interincisor gap
2-3 fingerbreadths or minimum of 4cm
128
Class A mandibular protrusion test
Lower incisors can be protruded anterior to upper incisors
129
Class B mandibular protrusion test
The lower incisors can be brought edge to edge with the upper incisors
130
Class C mandibular protrusion test
Lower incisors cannot be brought to edge with with upper incisors
131
Indicators of supraglottic airway difficulty
Restricted mouth opening
Obstruction of the upper airway
Distortion of airway anatomy preventing adequate seal
Stiff lungs (max positive airway pressure is 20)
132
complications of oral airways
trauma and airway hyperreactivity (gagging, vomiting, obstruction, laryngospams)
133
nasal airway measuring
from nostril to external auditory meatus
134
most common complication of nasal airway is
epistaxis
135
Contraindications to nasal airway
fractures, septal deviation, coagulopathy, basilar skull fractures, CSF leak, pregnancy, transsphenoidal & Caldwell luc procedures
136
What volume and pressure are face mask seals/cuffs
high volume/low pressure
137
Goal of face bag mask ventilation
Provide positive pressure gas movement through an unprotected airway. Denitrogenate and replace with oxygen
138
Signs of successful BMV
chest movement, condensation, o2 sat, etco2, pap, exhaled TV
139
Perioperative oxygen delivery methods
FM and nasal cannula, pharyngeal oxygen insufflation, noninvasive positive pressure ventilation, high flow nasal cannula
140
primary o2 source that supplies apneic ventilation during airway manipulation
NC or facemask
141
How to maximize preoxygenation for pts who are obese, elderly, extremely young, pregnant, critically ill (reduced frc, increased risk atelectasis, right to left shunt)
combine 100% o2 with NIPPV
142
DIfference between 1st and 2nd gen SGA
2nd gen has gastric drain which can hook up to suction
143
Contraindication for classic LMA
N2O use
144
1st gen LMAs
Classic and Unique (single use)
145
2nd gen LMA
Supreme (single use), ProSeal (re-usable), I-Gel (single use)
146
Where does LMA supreme form seals
with Oropharynx
Upper esophageal sphincter
147
LMA for head and neck anesthesia
LMA flexible. Protects from blood and secretions above the trachea
148
Pressure when ventilating with an LMA
<15-20 cm H2O. LES opens at pressures >20
149
Vent settings that can be used with LMA
Manual, Pressure Support, Pressure Control. NOT volume control because pressures are variable
150
Criteria for LMA removal
spontaneous respirations, adequate TV, maintaining o2 sat, appropriate etco2 (35-45)
151
Indications for LMA
Rescue device, emergent difficult airways, shorter procedures, procedures not requiring muscle relaxation
152
Contraindications of LMAs
morbidly obese
pregnant women >14 weeks
individuals at increased risk for aspiration
Patients in which PIP may exceed 20cm H2O
153
Conditions that create high risk for aspiration
Head and neck trauma, bleeding into resp tract, severe GERD, inadequate gi emptying, gi obstruction. Diabetics and glp1 agonists have delayed emptying
154
Anesthesia/surgical indications for tracheal intubation
high risk aspiration
Predicted difficult airway
Patient positioning that impedes access to airway
Ineffective o2 or ventilation with BMV or SGA
155
Surgical indications for tracheal intubation
Airway access shared with surgeon
Require paralysis by neuromuscular blocking meds
Procedure affecting ventilation and perfusion (ct surgery)
Prolonged surgical time
156
Medical indications for tracheal intubation
Inadequate airway protection or suppressed reflexes
Critical illness
Controlled management of co2 content
157
Placement of Miller blade
Underneath epiglottis to lift it directly
158
Placement of Mac blade
In vallecula, stretching the hyoepiglottic ligament which causes epiglottic elevation (indirect)
159
Purpose of the Murphy eye on ETT
provide place for air to flow in case of distal occlusion
160
Uses of armored ETT
head, neck, tracheal surgery, and positions where head must be flexed. Resistant to kinking. Does NOT revert to original shape
161
Feature of RAE tubes
manufactured, preformed bend. Used to direct connector away from surgical field
162
What should be given prior to nasal intubation
Nasal mucosal vasoconstrictor in BOTH nares: cocaine, phenylephrine, oxymetazoline
163
What is the most serious danger associated with use of lasers in OR
airway fires 2/2 ignition of ETTs
164
Purpose of Neural Integrity Monitor Electromyogram tracheal tube
Identify recurrent laryngeal nerve or vagus nerve.
Control manipulation during dissection.
Verify integrity of nerve prior to surgical closure.
Used in thyroid cases. Patient intentionally not paralyzed.
165
Indications for use of Trachlite Lighted Stylet
Small oral opening
Minimal neck manipulation needed
Failure of conventional DL
166
Use of Airway Exchange Catheters
When interchanging an ETT and/or extubating the trachea.
Capable of gas exchange via jet ventilation or o2 insufflation
167
Uses of flexible bronchoscope
Evaluate airway.
Facilitate intubation in a patient with a difficult airway.
Check ETT placement.
Change an existing ETT.
Perform postextubation evaluations
168
Indications for flexible bronchoscope
Anticipated difficult airway
Cervical spine immobilization
Anatomic abnormalities of upper airway.
Failed intubation attempt but ventilation possible with mask or SAD
169
Flexible bronchoscope limitation
Fogging
Secretions or blood
Epiglottitis, laryngotracheitis, bacterial tracheitis airway burns.
Constraints with time and skills of clinician
Patient cooperation needed if awake
