Exam 1 Flashcards
overdamped transducer system tend to ___
underestimate SBP by 15-30, will have 0 oscillations after flushing
extrinsic muscles of larynx do what?
control position of larynx during phonation breathing and swallowing
risk percentages of MI and anesthesia
general risk of MI = >.3%
MI within 3-6 months and reinfarct risk = 6%
MI within 1-2 months and reinfarct risk = 19%
MI within 30 days and reinfarct risk = 33%
How long should beta blockers be given for prior to having surgery
> 45 days to assess for tolerance of the beta blocker
mallampati class 3 findings
soft palate, base of uvula
which ecg lead is where ischemia is detected the earliest and most frequently
V3
Signs of abstinence syndrome
HTN, tachy, abd cramping, diarrhea, tremors, anxiety, irritability, lacrimation, mydriasis, sweating, yawning
Combitube characteristics
placed directly into esophagus
double lumen, esophageal and tracheal
pharyngeal balloon inflated first (40-85mL)
distal balloon inflated second (5-12mL)
Conditions that make cricothyrotomy difficult
SHORT
surgery
hematoma
obesity
radiation
tumors
should NPH be given day of surgery
1/3 or 1/2 regular dose
FEV1/FVC ratios less than 80%
obstructive process
definition of AKI
increase in creat by .3 or 50% increase, or <.5mL/kg/kr urine for more than 6 hours
theta brain waves
4-8hz, occur with light sleep
thryomental distance nonideal numbers
<6cm - tongue cant be displaced easily
>9cm - anterior view, larynx assumes a more caudal position
cannabis effects
tachycardia, labile BP, headache
what echo finding is correlated with greater incidence of postop heart failure and death
EF < 35%
the dicrotic notch on arterial BP waveform displays ___
closure of aortic valve
extremity with BP cuff is above heart results in
falsely low BP
changes in latency of evoked potential
a 10% increase is suggestive of cerebral ischemia
when to stop taking vitamin E
stop 2 weeks before surgery
lb to kg
2.2lb = 1kg
cormack-lehane grade 1
full view of glottic opening including anterior commissure and posterior laryngeal cartilages
should long acting insulin be given day of surgery
yes continue DOS
blood supply to nose
maxillary artery, ophthalmic artery, facial artery
When to stop taking ephedra
24 hours before surgery
what metabolizes propofol
CYP2B6, UFTHP4, and CYP2C6
delta brain waves
0-4hz, high amplitude, deep sleep
labetalol ratio of beta to alpha
7:1 beta to alpha
anatomical levels of pharynx
base of skull to cricoid cartilage
Naso : C1
Oro: C2-C3
Hypo: C5-C6
3 elements needed for disease transmission
Reservoir of infectious agent, micro-organism, susceptible human host
Glycopyrrolate numbers
Dose: .2mg for every 1mg of neostigmine
Onset: 1-2 minutes
Duration: 2-4 hours
what value is correlated with regional and global ischemia during carotid endartectomy
a greater than 20% reduction in cerebral oxygen saturation
half life of carbon monoxide
130-190 minutes
what is ACC/AHA guidelines to wait for elective surgery if MI occurs
wait at least 60 days from MI
What causes pain on injection with etomidate
propylene glycol
PaCO2 > 45 + SpO2 < 90 =
increased postoperative pulmonary complications
labetalol numbers
Dose: .25mg/kg but usually 2.5-10mg bolus
Duration: 2-6 hours
Strategies to reduce risk of PONV
regional anesthesia, propofol for induction, hydration, avoidance of N2O, avoidance of volatile anesthetics, minimization of opioids, minimization of neostigmine
Characteristics of soft palate
posterior 1/3-1/2 of oral cavity, moves with eating, will fall back when a patient is anesthetized or paralyzed
suggested wait time if recent URI
6 weeks
when to stop taking ginger
stop 7 days before surgery
motor-evoked potentials anesthesia requirement
no paralytic
inch to cm
1 inch = 2.54cm
S.T.O.P.B.A.N.G
snoring, tired, observed apnea, high blood pressure, BMI >35, age >50, neck >40cm, male gender
induction agents effect on EEG
propofol and etomidate increase frequency and decrease amplitude of beta waves
ideal intraoperative glucose level
120-180
recurrent laryngeal nerve function
provides sensory input to subglottic area and trachea
L mainstem angle and length
45 degrees and 5cm long
single sided vs double sided injury to recurrent laryngeal nerve
single sided - hoarseness
double sided - airway emergency
when to d/c plavix before surgery
5 days
goal NIRS level during surgery
goal is 75% of baseline obtained prior to induction
in pulse oximetry, deoxygenated hgb absorbs ___ at ____
red light, 650-750nm
LMA are sized based on ____
patient’s weight
Opioids effect on EEG
produce slowing in delta range
i-gel characteristics
non-inflatable cuff
can be used as a conduit for intubation under fiberoptic guidance
gastric channel
has bite block
tip is blunt
mortality rate if reinfarction occurs during surgery
> 50%
define emergency surgery
life, limb, or organ saving
needs to be done in under 6 hours
ex. ruptured aortic aneurysm, major trauma to chest/abdomen, increase in ICP
what shifts oxyhemoglobin dissociation curve to left
low CO2, low temp, alkalosis, methemoglobin, carbon monoxide, low levels of 2,3 DPG
Nitrous Oxide (alone) effect on EEG
increase in beta wave activity through low, moderate, and high dose inhalation anesthesia
Normal RV value
15-30 over 0-8
extremity with BP cuff is below heart results in
falsely high BP
what is primary cause of hypothermia in OR
redistribution of blood from core to periphery due to vasodilation during anesthesia
define time sensitive surgery
stable but requires intervention
can be done in days to weeks
ex. tenson, nerve injury, cancer procedure
how often should BP be checked in OR
at least every 5 minutes
definition of morbid obesity
actual body weight 2x IBW
diabetes mellitus criteria
fasting BG > 126 more than once
random BG > 200 w/ symptoms of polyuria, polydipsia, or weight loss
75g glucose test with 2h value >200
HgbA1C >6.5
suggested abstinence from alcohol prior to surgery
4 weeks
risk factors of difficult mask ventilation
BONES
bears
obesity
no teeth
elderly
sleep apnea
when to stop taking gingko
stop 36 hours before surgery
X wave of CVP
produced by atrial diastole
what procedures make up 85% of surgical fires
Head, neck, and upper chest
normal CVP value
1-10
maximum cuff pressure and ventilation pressure for LMA
cuff: 60 cmH2O
ventilation: 20 cmH2O
how is MAP calculated
MAP = DP + (SP - DP)/3
AKI classifications
non-oliguric = >400mL/day
oliguric = <400mL/day
anuria = <100mL/day
polyuric = >2.5L/day with elevated BUN and creat
numbers associated with poor ventricular function
CI <2.2
LVEDP >18
EF <40%
Ephedrine numbers
Dose: 5-25mg
Onset: <1 minute
Duration: 15min - 1.5hours
Propofol numbers
Dose: 1-3mg/kg
RSI dose: 2-3mg/kg
Onset: 5-30 seconds
Duration: 5-15 minutes
what PPE is needed for contact precautions
gown and gloves
Conversions for 1gm
1gm = 1000mg = 1,000,000mcg
interincisor gap predictor of difficult intubation
<3cm
Where is beta angle in ETCO2 monitoring
between phase III and IV
half life of nicotine
40-60 minutes
BMI classifications for obesity
overweight = BMI 25-29.9
class 1 obesity = BMI 30-34.9
class 2 obesity = BMI 35-39.9
class 3 “severe” obesity = BMI >40
C wave of CVP
produced by closure of tricuspid valve
Suggested FiO2 for laser surgery
<30% FiO2 to reduce fire risk
BP cuff is too large results in
falsely low BP reading
For intubation doses, how much rocuronium is given in comparison to the effective dose (ED)?
usually 2-3x the ED95
when to stop taking ginseng
stop 7 days before surgery
% concentration
1g/100mL, ex. 2% = 2g/100mL = 20mg/mL
beta brain waves
> 13hz, normal awake consciousness, alertness, logic, and critical thinking
Succinylcholine numbers
Dose: 1-1.5mg/kg
Onset: 30-60 seconds
Duration: 5-10 minutes
Order of how to doff PPE
- remove gloves
- remove gown away from body
- exit room
- hand hygiene
- remove face shield or goggles
- remove respirator
- hand hygiene
ProSeal LMA characteristics
larger, deeper bowl with no grille
OG can be put thru it
silicone bite block
allows peak ventilation pressure of 28-30 cmH2O
Esmolol numbers
Dose: 10-20mg
Onset: 2 minutes
Duration: 10-15 minutes
treatment for laryngospasm
- remove stimulus
- administer 100% FiO2
- provide an open and clear airway
- perform a jaw thrust
- apply positive pressure ventilation
- consider deepening anesthesia
- administer small dose succinylcholine
adverse effects of hypothermia
impaired coagulation, decreased drug metabolism, increased wound infection, SNS stimulation, vasoconstriction, shift oxyhemoglobin curve to left
cricothyroid muscles action
adduction and tension of vocal cords
BP cuff is too small results in
falsely high BP reading
should anticonvulsants be given day of surgery
yes continue DOS
Meds to decrease gag and cough reflex
benzocaine 20% (risk of methemoglobinemia)
5% lido paste
4% viscous lido
mallampati class 4 findings
hard palate only
what are the contraindications for cricothyrotomy during an emergency
NONE
Vecuronium numbers
Dose: .1mg/kg
Onset: 3-4 minutes
Duration: 30-45 minutes
where should bougie be held at lip
25cm
Distance from RIJ to PA wedge
40-50
thyroarytenoid muscles action
adduction and relaxation of vocal cords
when to stop taking garlic
stop 7 days before surgery
threshold for ST depression
-.5mm in V2 V3, -.1mm in all other leads
cormack-lehane grade 2a
partial view of cords and full view of laryngeal cavities
Atropine numbers
Dose: .4-.6mg
Onset: 1-2 minutes
Duration: 4 hours
transtracheal block target
pierce cricothyroid membrane and instruct patient to take a breath then inject on inspiration
length of trachea
10-20cm
What is the most common cause of adult valvular disease
rheumatic disease
cocaine/amphetamines effect
tachy, labile BP, HTN, MI, tremors, hyperreflexia
Male IBW
105lb + (6lb per inch over 5ft)
Parts of larynx
313
3 single cartilage: thyroid, cricoid, epiglottis
1 bone: hyoid
3 paired cartilage: arytenoid, corniculate, cuneiform
lateral cricoarytenoid muscles action
adduction of vocal cords
How much time to discontinue meds before surgery
allow for metabolic clearance, 3-5 half lives
should oral hypoglycemics be given day of surgery
no, hold DOS
when to d/c xarelto before surgery
depends on Cr/Cl
Cr/Cl normal = 1 day
Cr/Cl 60-90 = 2 days
Cr/Cl 30-59 = 3 days
Cr/Cl 15-29 = 4 days
A wave of CVP
produced by contraction of RA
Cranial nerve 9 function
glossopharyngeal
provides sensory innervation from oropharynx to anterior epiglottis (gag reflex)
Main goals of pre-op assessment
optimize patient, minimize risk
active smokers are at ___ greater risk of postop pulmonary complications
4x
Mallampati class 1 findings
soft palate, fauces, entire uvula, pillars
where is alpha angle in ETCO2 monitoring
between phase II and III
Superior laryngeal nerve function
internal branch: provides sensory input above vocal cords
external branch: motor function to cricothyroid muscle of larynx
Sugammadex numbers
Dose for 2/4 twitches: 2mg/kg
Dose for 0 twitches 1-2 PTC: 4mg/kg
Dose for immediate reversal: 16mg/kg
Onset: 1-3 minutes
underdamped ABP transducer systems tend to ____
overestimate SBP by 15-30, will have several oscillations after flushing
left recurrent laryngeal nerve loops around ____
aortic arch
Neostigmine numbers
Dose: .025-.075mg/kg
Onset: 5-15 minutes
Duration: 45-90 minutes
what PPE is needed for bloodborne precautions
gloves
hypertension stages
normal BP 120/80
elevated 120-129/<80
Stage 1 130-139/80-89
Stage 2 >140/>90
Stage 3 >180/>110
mallampati class 2 findings
soft palate, fauces, portion of uvula
Cranial nerve 5 function
Trigeminal nerve
V1 (ophthalmic): nares and anterior 1/3 of nasal septum
V2 (maxillary): turbinates and 2/3 of nasal septum
V3 (mandibular): anterior 2/3 of tongue
Distance from RIJ to PA
35-45
Metoprolol numbers
Dose: 1-5mg
Onset: 2 minutes
Duration: 4 hours
when to stop taking Kava
stop 24 hours before surgery
Chronic alcohol use effects of anesthetics
patient will require higher doses of hypnotics, opioids, and inhalation agents
opioids effect
hypotension, bradycardia, constipation
T/F the hard palate is moveable
False
contraindications for trachlite
upper airway tumors, foreign bodies, polyps or soft tissue injuries
V wave of CVP
produced by filling of RA
normal PAOP value
5-15
ketamine numbers
dose: .2-.8mg/kg
Onset: 1-2 minutes
Duration: 15-30 minutes
what PPE is needed for airborne
gown, gloves, N95, eye protection, negative pressure room
when to d/c aspirin before surgery
7-10 days
electromyography anesthesia requirement
no paralytics
what is the greatest risk for noncardiac surgery
Severe aortic stenosis
Distance from RIJ to JVC/RA
15cm
documentation of airway exam
mallampati score, dentition, degree of neck mobility, neck circumference, thryomental distance, body habitus, partinent deformitites, pre-existing tooth abnormalities
Somatosensory-evoked potentials anesthesia requirements
0.5 MAC, TIVA, paralytics are okay
angina vs unstable angina
angina will resolve will rest or nitro and usually lasts less than 15 minutes, unstable angina will not resolve with rest and usually lasts longer than 30 minutes
cormack-lehane grade 4
epiglottis cant be seen
LMA supreme
fixed curve
gastric port
bite block
can have peak ventilation 26-28 cmH2O
when to d/c dabigatran before surgery
1-2 days for good kidney function, 3-4 days for decreased kidney
when to d/c eliquis before surgery
Cr/Cl > 60 = 1-2 days
Cr/Cl 50-59 = 3 days
Cr/Cl 30-49 = 5 days
alcohol based products do not work well against this type of micro-organisms
ones with spores (c-diff)
upper airway components
nose, mouth (tongue, soft palate, hard palate), pharynx (naso, oro, hypo), larynx
When to cancel surgery for hypertension
stage 2 with end organ disfunction or stage 3
intrinsic muscles of larynx do what?
control tension of vocal cords and opening/closing of glottis
BIS levels
100 = awake
40-60 = adequate general anesthesia
0 = absence of brain activity
R mainstem angle and length
25-30 degrees, 2.5cm long
changes in amplitude of evoked potential
50% decrease is suggestive of cerebral ischemia
what PPE is needed for droplet precautions
gown, gloves, mask, goggles/face shield
innervation of nose
trigeminal nerve
what is the name of midazolam’s metabolite and what is its potency
1-hydroxymidazolam, 20%
8 weeks of smoking cessation has what effects
enhanced ciliary function, decreased secretions, decreased small airway obstruction, and enhanced immune function
what medication is needed for nasal instrumentation and why
topical vasoconstrictor to decrease chance of bleeding
ex. 4% lido spray with 1% phenylephrine
posterior cricoarytenoid muscles function
abduction of vocal cords
should regular insulin be given day of surgery
no, hold DOS
Who is most at risk for latex allergy
chronic exposure, spina bifida, repeated surgical procedures, allergy to tropical fruit
when to stop taking St John wort
stop 5 days before surgery
Distance from RIJ to RA
15-25
in pulse oximetry, oxygenated hgb absorbs ___ at ____
infrared light, 900-1000nm
how to calculate F, C, and K
F = (C x 1.8) + 32
C = (F - 32) x (5/9)
K = 273 + C
BP cuff appropriate sizing
width should be 40% of circumference of extremity, length should be 80% of circumference of extremity
what is the hallmark sign of asthma
inflammation of airways
cormack-lehane grade 3
only epiglottis visualized
definition of obesity
actual body weight >20% from IBW
Which neurotransmitter does ketamine block
glutamate
Rocuronium numbers
Dose: .6-1mg/kg
RSI dose: .9-1.2mg/kg
Onset: 1.5-3 minutes
Phenylephrine
Dose: 40-100mcg
Onset: <1 minute
Duration: 5-20 minutes
Inhalation agents effect on EEG
increase in beta wave activity through low and moderate dose, diffuse delta and theta activity in high dose, burst suppression at >1.2 MAC
Lean body weight
IDW x 1.3
Distance from RIJ to RV
25-35
Midazolam numbers
Dose: .02-.04mg/kg
Onset: 1-3 minutes
Duration: 20-30 minutes
is airway resistance greater through the mouth or nose
nose, 2x greater thru nose due to turbinates
LMA fasttrach characteristics
intubating LMA
PaO2 < 60 +/- PaCO2
chronic bronchitis
Y wave of CVP
produced by opening of tricuspid valve
what defines significant stenosis of cardiac arteries
> 70% stenosis, >50% of left main
normal PA value
15-30 over 5-15
proper placement of LMA is
LMA in hypopharnx
lower airway components
trachea, bronchi, bronchioles, alveoli
cormack-lehane grade 2b
only posterior portion of glottic opening can be visualized
what to do when a patient aspirates with an LMA in
leave LMA in, place patient in trendelenburg, give 100% O2, use low FGF and tidal volumes
Female IBW
100lb + (5lb per inch over 5ft)
sternomental distance predictor for difficult intubation
SMD <12.5cm
right recurrent laryngeal nerve loops around ____
subclavian artery
define urgent surgery
conditions threaten life, limb or organ
should be done in 6-24 hours
ex. perfed bowel, compound fracture, eye injury
definition of chronic renal failure
GFR < 60 for >3months
asthma optimization
continue home meds, prophylactic B-adrenergic metered dose inhaled used morning of surgery, check theophylline levels (10-20), consider corticosteroids, anxiolytics, hydration, abx for infections
what shifts CO2 curve to right
high CO2, elevated temp, high levels of 2,3 DPG, acidosis
glossopharyngeal block target
lingual gutter
trace blood flow to larynx
external carotid -> superior thyroid -> superior laryngeal -> inferior laryngeal
when to give antibiotic prophylaxis for surgery
given with 60 minutes of incision, 120 minute for vanco
Etomidate numbers
Dose: .2-.3mg/kg
Onset: 5-30 seconds
Duration: 5-15 minutes
superior laryngeal nerve block target
displace hyoid bone then poke at inferior border of the greater cornu
Cranial nerve 10 branches important to anesthesia
Vagus nerve
Superior laryngeal & recurrent laryngeal
apneic oxygenation
15L via nasal cannula during apnea to entrain oxygen into trachea
*be mindful of hyercapnia
acute alcohol use effects on anesthetics
lowers requirement of anesthetic gas
alpha brain waves
8-13hz, occur with eyes closed during deep relaxation
suggested FiO2 for suspected burn
humidified 40-60
assess thermal trauma via ____
abg, carboxyhemoglobin levels, chest xray
