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Basic Principles of Anesthesia > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Dibucaine 20

A

Homozygous for atypical gene, paralyzed 4-8 hours after succ

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2
Q

Dibucaine 60

A

Heterozygous, succinylcholine duration of action prolonged 50-100%

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3
Q

Dibucaine 80

A

homozygous for typical gene, normal response

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4
Q

receptor affected in malignant hyperthermia

A

Ryanodine

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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

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6
Q

True allergy action

A

Avoid medication and determine cross sensitivities to any other medications you may use

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7
Q

up to 20% of intraoperative anaphylactic reactions are attributed to

A

Latex

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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

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9
Q

Calculate pack years

A

packs per day x years of smoking

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10
Q

pack year history that increases risk of periop complications

A

20 pack years

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11
Q

Second hand smoke increases risk of

A

Reactive airway disease, abnormal pulm function tests, increased resp tract infections, periop complications in kids

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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

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13
Q

Alcohol intake associated with:

A

Arrhythmias, infection, alcohol withdrawal syndrome. Anesthesia requirements may be increased (chronic) or exaggerated (acute).

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14
Q

Functional Capacity Assessment

A

METS
1 MET - rate of energy consumed at rest
Determines if further preop testing is required

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15
Q

Mallampati assesses:

A

Size of tongue in relation to the oral cavity

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16
Q

Mallampati class 1

A

Soft palate
Fauces
Entire Uvula
Pillars

Palatine Tonsils
Uvula
Soft Palate
Hard Palate

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17
Q

Mallampati Class 2

A

Soft Palate
Fauces
Portion of uvula

Uvula
Soft Palate
Hard Palate

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18
Q

Mallampati Class 3

A

Soft palate
Base of uvula

Soft palate
Hard palate

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19
Q

Mallampati Class 4

A

Hard Palate only

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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

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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

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22
Q

How long to wait after MI for nonemergent cases

A

60 days

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23
Q

How long to delay for drug-eluting stent

A

6 months

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24
Q

How long to delay for bare metal stent

A

30 days

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25
Q

Midsystolic murmur at 2nd parasternal interspace. Crescendo-decrescendo. Radiates to carotids. Valsalva and sustained hand grip decrease intensity

A

Aortic stenosis

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26
Q

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

A

Aortic insufficiency

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27
Q

Middiastolic murmur at the apex. Opening snap, low pitched rumble radiates to the axilla. Squatting and hand grip exercise increase intensity

A

Mitral Stenosis

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28
Q

Holosystolic murmur at apex. High pitched, blowing, radiates to the axilla, standing decreases intensity

A

Mitral Regurgitation

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29
Q

Von Willebrand disease

A

Can occur in pts with aortic stenosis

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30
Q

Child-Turcotte-Pugh class associated with poor outcomes

A

C

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31
Q

MELD score associated with poor outcomes

A

> 14

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32
Q

Standard preop testing for ESRD/dialysis patients

A

Electrolytes, glucose, GFR, Ca, creat, ECG

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33
Q

Diabetic patients should have documented A1C within how many months of procedure

A

3 months
<7 is well controlled

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34
Q

ASA 1

A

A normal healthy patient.
Healthy, nonsmoking, no or minimal alcohol use

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35
Q

ASA 2

A

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

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36
Q

ASA 3

A

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

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37
Q

ASA 4

A

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

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38
Q

ASA 5

A

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

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39
Q

ASA 6

A

A declared brain-dead patient whose organs are being removed for donor purposes

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40
Q

Purpose of ASA classification

A

Designed to classify physical condition and reflect preop status - it is NOT an estimate of anesthetic risk!

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41
Q

When should herbal supplements be dc’d before surgery

A

2-3 weeks

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42
Q

Screening tools for alcohol use

A

AUDIT
CAGE (Cut down, annoyed, guilty, eye opener)

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43
Q

How long before surgery should patient quit drinking

A

4 or more weeks

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44
Q

PTSD effects on anesthesia

A

abuse and ptsd victims may experience difficulty with emergence and induction

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45
Q

concerns for hormone replacement therapy/synthetic androgens

A

hepatic and endocrine dysfunction

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46
Q

Example of 4 METS

A

climbing stairs, raking leaves, gardening

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47
Q

Example of 1 MET

A

eating, getting dressed

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48
Q

BMI formula

A

weight in kg/ height in meters^2

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49
Q

How many cm in a meter

A

100

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50
Q

how many cm in an inch

A

2.54

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51
Q

how many lbs in 1 kg

A

2.2

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52
Q

Ideal body weight calculation

A

Male: 105lb + 6lb for each inch > 5 ft
Female: 100lb + 5lb for each inch > 5 ft

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53
Q

STOP BANG

A

sleep apnea
Snoring, Tired, Observed, Pressure (BP)
BMI >35, Age >50, Neck circumference >40cm, Gender (male)

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54
Q

Most common reason for anesthesia related claims

A

Dental injuries

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55
Q

How long before surgery should routine preop labs be done

A

6 months

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56
Q

what is the thyromental distance

A

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)

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57
Q

what is the sternomental distance

A

Feeling sternal notch to the lower border of the mandibular mentum
< 12 cm is concerning

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58
Q

Inter-incisor distance

A

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

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59
Q

primary passage by which air enters the lungs

A

Nose

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60
Q

Supplies blood to nasal mucosa

A

Branches of the maxillary, ophthalmic, and facial arteries

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61
Q

Upper airway is the anatomic structures above what

A

Cricoid cartilage

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62
Q

Responsible for afferent nerve signals in nose

A

Maxillary and ophthalmic branches of the trigeminal nerve

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63
Q

Parasympathetic innervation of nose

A

CN 7 and pterygopalatine ganglion

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64
Q

Sympathetic innervation of nose

A

Superior cervical ganglion
Results in vasoconstriction and shrinkage of the nasal tissue.
Depression of SNS can cause engorgement of nasal tissue

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65
Q

Rises during eating to prevent food from passing from the mouth into the nose

A

Soft palate

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66
Q

Takes up most of the oral cavity

A

Tongue

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67
Q

Protects passageway from oral cavity into the oropharynx

A

Uvula

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68
Q

Landmarks of the pharynx

A

Base of the skull to level of the cricoid cartilage

69
Q

Landmarks of nasopharynx

A

Anterior to C1. Bound superiorly by base of skull and inferiorly by soft palate

70
Q

Landmarks of oropharynx

A

Lies at C2-C3. Bound superiorly by soft palate and inferiorly by epiglottis

71
Q

Hypopharynx

A

Lies posterior to larynx. Bound by superior border of the epiglottis and inferior border of cricoid cartilage at C5-C6

72
Q

What nerves innervate the muscles of the pharynx, larynx, and soft palate

A

Glossopharyngeal, Vagus, and Spinal accessory

73
Q

Nerve responsible for afferent signals when pharynx is touched

A

Glossopharyngeal - carries signal to medulla - synapse with vagus nerve and spinal accessory

74
Q

Nerve responsible for efferent signal aka gag reflex

A

Vagus nerve

75
Q

Two branches of the vagus nerve that innervate the hypopharynx

A

Superior laryngeal (internal and external) and Recurrent Laryngeal

76
Q

Nerve that provides sensory input to hypopharynx above the vocal folds, including base of tongue, epiglottis, aryepiglottic folds, and arytenoids

A

Internal Superior Laryngeal Nerve

77
Q

Nerve that provides motor function to the cricothyroid muscle of the larynx

A

External Superior Laryngeal Nerve

78
Q

Nerve that provides sensory innervation to the subglottic area and the trachea

A

Recurrent Laryngeal Nerve

79
Q

Nerve that loops around the brachiocephalic artery

A

Right RLN

80
Q

Nerve that loops around the aorta

A

Left RLN

81
Q

Provides motor function to all the muscles of the larynx except the cricothyroid muscle

A

Recurrent Laryngeal Nerve

82
Q

Physiology which places traction on the RLN

A

Dissecting aortic arch aneurysms and mitral stenosis (via dilated pulm artery)

83
Q

Unilateral injury to RLN causes

A

Hoarseness but not respiratory compromise. Not an emergency

84
Q

Acute injury to bilateral RLN causes

A

Unopposed tension and adduction of the vocal cords. Stridor. Severe resp distress aka emergency

85
Q

Chronic injury to bilateral RLN causes

A

gruff/husky speech, but normal respiration via compensatory mechanisms

86
Q

Injury to the SLN causes

A

NO respiratory distress

87
Q

Landmarks of the larynx

A

Begins with epiglottis and extends to Cricoid cartilage
Contains intrinsic and extrinsic laryngeal muscles.

88
Q

Larynx is composed of what single cartilages

A

3: Thyroid, Cricoid, Epiglottis

89
Q

Larynx is composed of what paired cartilages

A

3: Arytenoid, corniculate, cuneiform

90
Q

Function of the Larynx

A

Protection to the lower airway from aspiration.
Patency between hypopharynx and trachea.
Protective gag and cough reflexes.
Phonation

91
Q

Function of the intrinsic muscles of the larynx

A

Control the tension of the vocal cords and opening and closing of the glottis

92
Q

Function of extrinsic muscles of the larynx

A

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
Q

Intrinsic muscles of the larynx

A

Posterior cricoarytenoids
Lateral cricoarytenoids
Interarytenoids (transverse and oblique)
Thyroarytenoids and vocalis
Aryepliglottic
Cricothyroids

94
Q

Extrinsic muscles that depress the larynx

A

Omohyoid
Sternohyoid
Sternothyroid

95
Q

Extrinsic muscles that elevate the larynx

A

Stylohyoid
Digastric
Mylohyoid
Geniohyoid
Stylopharyngeus
Thyrohyoid

96
Q

Blood supply to larynx

A

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
Q

Lower respiratory tract is composed of:

A

Everything below Cricoid Cartilage:
Trachea and Diaphragm

98
Q

Landmarks of the trachea

A

Inferior border of the cricoid cartilage and extends to carina. 10- 20 cm long

99
Q

Only cartilage of trachea that is a complete cartilaginous ring

A

Cricoid Cartilage

100
Q

Function of bronchi

A

Humidification and warming of inspired air

101
Q

How many C shaped rings in trachea

A

16-20

102
Q

Angle of R mainstem bronchus bifurcation and length from carina

A

25-30 degrees
2.5 cm

103
Q

Angle of L mainstem bronchus bifurcation and length from carina

A

45 degrees
5 cm

104
Q

Sympathetic innervation of trachea

A

1-5 thoracic ganglia

105
Q

Parasympathetic innervation of trachea

A

Vagus nerve

106
Q

Diaphragm arises from what 4 structures:

A

Septum transversum
Dorsal esophageal mesentery
Pleuroperitoneal folds
Body wall mesoderm

107
Q

Diaphragm nerve supply

A

Phrenic nerve

108
Q

Components of Preop Airway Exam

A

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
Q

Indications of difficult bag mask ventilation

A

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
Q

Proper bag mask ventilation

A

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
Q

Hallmark signs of upper airway obstruction

A

emergency - hoarse/muffled voice, difficult swallowing, stridor, dyspnea

112
Q

Signs of lower airway obstruction

A

High PAP, low TV, impaired ventilation

113
Q

Apneic Oxygenation

A

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
Q

Signs of inadequate ventilation during BMV

A

minimal or no chest movement.
Inadequate exhaled CO2.
Reduced or absent breath sounds.
Decreased o2 Sat.

115
Q

Troubleshooting BMV

A
  1. Reposition patient’s head and neck
  2. Place oral airway: tongue or airway soft tissue obstruction
  3. Two hands BMV
116
Q

Axes that should be in line for good BMV

A

oral axis, pharyngeal axis, laryngeal axis

117
Q

Direct laryngoscopy

A

process of airway instrumentation with a laryngoscope to acquire a direct line of sight with the laryngeal opening and supporting structures

118
Q

Video laryngoscopy

A

an INDIRECT procedure for viewing the laryngeal opening using an airway device with a camera linked to a video monitor

119
Q

Tracheal intubation

A

Process of placing an ETT into the trachea proximal to the carina. Direct or Indirect

120
Q

Most used airway assessments for difficult laryngoscopy and tracheal intubation

A

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
Q

Cormack-Lehane grading system

A

Objective scoring system to describe laryngoscopy difficulty. Assesses pharyngeal structures, glottic structures, and glottic opening during laryngoscopy

122
Q

Grade 1 view

A

Most or full view of glottic opening

123
Q

Grade 2 view

A

Only the posterior portion of the glottic opening can be visualized; anterior commissure not seen

124
Q

Grade 3 view

A

Only the epiglottis can be visualized; no portion of the glottic opening can be seen

125
Q

Grade 4 view

A

Epiglottis cannot be seen; only view is of the soft palate

126
Q

Thyromental distance that indicates difficulty

A

<6cm and >9cm

127
Q

Adequate interincisor gap

A

2-3 fingerbreadths or minimum of 4cm

128
Q

Class A mandibular protrusion test

A

Lower incisors can be protruded anterior to upper incisors

129
Q

Class B mandibular protrusion test

A

The lower incisors can be brought edge to edge with the upper incisors

130
Q

Class C mandibular protrusion test

A

Lower incisors cannot be brought to edge with with upper incisors

131
Q

Indicators of supraglottic airway difficulty

A

Restricted mouth opening
Obstruction of the upper airway
Distortion of airway anatomy preventing adequate seal
Stiff lungs (max positive airway pressure is 20)

132
Q

complications of oral airways

A

trauma and airway hyperreactivity (gagging, vomiting, obstruction, laryngospams)

133
Q

nasal airway measuring

A

from nostril to external auditory meatus

134
Q

most common complication of nasal airway is

A

epistaxis

135
Q

Contraindications to nasal airway

A

fractures, septal deviation, coagulopathy, basilar skull fractures, CSF leak, pregnancy, transsphenoidal & Caldwell luc procedures

136
Q

What volume and pressure are face mask seals/cuffs

A

high volume/low pressure

137
Q

Goal of face bag mask ventilation

A

Provide positive pressure gas movement through an unprotected airway. Denitrogenate and replace with oxygen

138
Q

Signs of successful BMV

A

chest movement, condensation, o2 sat, etco2, pap, exhaled TV

139
Q

Perioperative oxygen delivery methods

A

FM and nasal cannula, pharyngeal oxygen insufflation, noninvasive positive pressure ventilation, high flow nasal cannula

140
Q

primary o2 source that supplies apneic ventilation during airway manipulation

A

NC or facemask

141
Q

How to maximize preoxygenation for pts who are obese, elderly, extremely young, pregnant, critically ill (reduced frc, increased risk atelectasis, right to left shunt)

A

combine 100% o2 with NIPPV

142
Q

DIfference between 1st and 2nd gen SGA

A

2nd gen has gastric drain which can hook up to suction

143
Q

Contraindication for classic LMA

A

N2O use

144
Q

1st gen LMAs

A

Classic and Unique (single use)

145
Q

2nd gen LMA

A

Supreme (single use), ProSeal (re-usable), I-Gel (single use)

146
Q

Where does LMA supreme form seals

A

with Oropharynx
Upper esophageal sphincter

147
Q

LMA for head and neck anesthesia

A

LMA flexible. Protects from blood and secretions above the trachea

148
Q

Pressure when ventilating with an LMA

A

<15-20 cm H2O. LES opens at pressures >20

149
Q

Vent settings that can be used with LMA

A

Manual, Pressure Support, Pressure Control. NOT volume control because pressures are variable

150
Q

Criteria for LMA removal

A

spontaneous respirations, adequate TV, maintaining o2 sat, appropriate etco2 (35-45)

151
Q

Indications for LMA

A

Rescue device, emergent difficult airways, shorter procedures, procedures not requiring muscle relaxation

152
Q

Contraindications of LMAs

A

morbidly obese
pregnant women >14 weeks
individuals at increased risk for aspiration
Patients in which PIP may exceed 20cm H2O

153
Q

Conditions that create high risk for aspiration

A

Head and neck trauma, bleeding into resp tract, severe GERD, inadequate gi emptying, gi obstruction. Diabetics and glp1 agonists have delayed emptying

154
Q

Anesthesia/surgical indications for tracheal intubation

A

high risk aspiration
Predicted difficult airway
Patient positioning that impedes access to airway
Ineffective o2 or ventilation with BMV or SGA

155
Q

Surgical indications for tracheal intubation

A

Airway access shared with surgeon
Require paralysis by neuromuscular blocking meds
Procedure affecting ventilation and perfusion (ct surgery)
Prolonged surgical time

156
Q

Medical indications for tracheal intubation

A

Inadequate airway protection or suppressed reflexes
Critical illness
Controlled management of co2 content

157
Q

Placement of Miller blade

A

Underneath epiglottis to lift it directly

158
Q

Placement of Mac blade

A

In vallecula, stretching the hyoepiglottic ligament which causes epiglottic elevation (indirect)

159
Q

Purpose of the Murphy eye on ETT

A

provide place for air to flow in case of distal occlusion

160
Q

Uses of armored ETT

A

head, neck, tracheal surgery, and positions where head must be flexed. Resistant to kinking. Does NOT revert to original shape

161
Q

Feature of RAE tubes

A

manufactured, preformed bend. Used to direct connector away from surgical field

162
Q

What should be given prior to nasal intubation

A

Nasal mucosal vasoconstrictor in BOTH nares: cocaine, phenylephrine, oxymetazoline

163
Q

What is the most serious danger associated with use of lasers in OR

A

airway fires 2/2 ignition of ETTs

164
Q

Purpose of Neural Integrity Monitor Electromyogram tracheal tube

A

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
Q

Indications for use of Trachlite Lighted Stylet

A

Small oral opening
Minimal neck manipulation needed
Failure of conventional DL

166
Q

Use of Airway Exchange Catheters

A

When interchanging an ETT and/or extubating the trachea.
Capable of gas exchange via jet ventilation or o2 insufflation

167
Q

Uses of flexible bronchoscope

A

Evaluate airway.
Facilitate intubation in a patient with a difficult airway.
Check ETT placement.
Change an existing ETT.
Perform postextubation evaluations

168
Q

Indications for flexible bronchoscope

A

Anticipated difficult airway
Cervical spine immobilization
Anatomic abnormalities of upper airway.
Failed intubation attempt but ventilation possible with mask or SAD

169
Q

Flexible bronchoscope limitation

A

Fogging
Secretions or blood
Epiglottitis, laryngotracheitis, bacterial tracheitis airway burns.
Constraints with time and skills of clinician
Patient cooperation needed if awake

Basic Principles of Anesthesia (3 decks)

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