Exam 1 Flashcards
Equalization of pressure throughout the arterial system; increased R-handed filling and CO; decreased HR and peripheral vascular resistance
Horizontal Cardiac
Gravity increases perfusion of dependent (posterior) lung segments; abdominal viscera displace diaphragm cephalad. Spontaneous ventilation favors dependent lung segments, while controlled ventilation favors independent (anterior) segments. Functional residual capacity decreases and may fall below closing volume in older patients.
Horizontal Respiratory
Activation of baroreceptors, generally causing decreased CO, peripheral vascular resistance, HR, and BP.
Trendelenburg Cardiac
Marked decreases in lung capacities from shift of abdominal viscera; increased ventilation/perfusion mismatching and atelectasis; increased likelihood of regurgitation.
Trendelenburg Respiratory
Increase in ICP and decrease in cerebral blood flow because of cerebral venous congestion; increased intraocular pressure in patients with glaucoma.
Trendelenburg Other
Preload, CO, and arterial pressure decrease. Baroreflexes increase sympathetic tone, HR, and peripheral vascular resistance.
Reverse Trendelenburg Cardiac
Spontaneous respiration requires less work; functional residual capacity increases.
Reverse Trendelenburg Respiratory
Cerebral perfusion pressure and blood flow may decrease
Reverse Trendelenburg Other
Autotransfusion from leg vessels increases circulating blood volume and preload; lowering legs has opposite effect. Effect on BP and CO depends on volume status.
Lithotomy Cardiac
Decreases vital capacity; increases likelihood of aspiration
Lithotomy Respiratory
Pooling of blood in extremities and compression of Abdominal muscles may decrease preload, cardiac output, and blood pressure
Prone Cardiac
Compression of abdomen and thorax decreases total noncompliance and increases work of breathing
Prone Respiratory
Extreme head rotation may decrease cerebral venous drainage and cerebral blood flow
Prone Other
Cardiac output unchanged unless venous return obstructed (kidney rest). Arterial blood pressure my fall as a result of decreased vascular resistance (R side> L side)
Lateral Decubitus Cardiac
Decreased Volume of dependent lung; Increased perfusion of dependent lung. Increase ventilation of dependent long in awake patients (no mismatch); Decreased dilation of dependent long anesthetize patients (mismatch). Further decreases and dependent long ventilation with paralysis is in an open chest.
Lateral Decubitus Respiratory
Pulling blood in lower body decreases central blood volume. Cardiac output and arterial blood pressure falls bike rides and heart rate and systemic vascular resistance.
Sitting Cardiac
When the volume is in functional Residual capacity increase; work up breathing increases
Sitting Respiratory
Cerebral blood flow decreases
Sitting Other
Positions with complication of air embolism?
Sitting
Prone
Reverse Trendelenburg
Positions with complication of alopecia?
Supine
Lithotomy
Trendelenburg
Positions with complication of backache?
Any
Positions with complication of compartment syndrome?
Lithotomy
Positions with complication of corneal abrasion?
Prone
Positions with complication of digit amputation?
Any
Positions with complication of nerve palsies for brachial plexus?
Any
Positions with complication of nerve palsies for common peroneal?
Lithotomy
Lateral decubitus
Positions with complication of nerve palsies for radial?
Any
Positions with complication of nerve palsies for ulnar?
Any
Positions with complication of nerve palsies for retinal ischemia?
Prone
Sitting
Positions with complication of nerve palsies for skin necrosis?
Any
How to prevent brachial plexus?
Avoid stretching or direct compression at neck or axilla
How to prevent common peroneal?
Pad lateral aspect of upper fibula
How to prevent radial?
Avoid compression of lateral humerus
How to prevent ulnar?
Padding at elbow, forearm supination
How to prevent retinal ischemia
Avoid pressure on globe
How to prevent skin necrosis?
Padding over bony prominences
How to prevent air embolism?
Maintain venous pressure above 0 at the wound
How to prevent alopecia?
Normotension, padding, and occasional head turning
How to prevent backache?
Lumbar support, padding, and slight hip flexion
How to prevent compartment syndrome?
Maintain perfusion pressure and avoid external compression
How to prevent corneal abrasion?
Taping and/or lubricating eye
How to prevent digit amputation?
Check for protruding digits before changing table configuration
Common adverse events related to anesthesia (5):
Vomiting Nausea Sore throat Incisional site pain Emergence delirium (peds)
Physical examination of airway (5):
Mouth opening Loose or problematic dentition Limitations in neck range of motion Neck anatomy Mallampati presentations
Full visibility of tonsils, uvula, and soft palate
class 1 of mallampati
Visibility of hard and soft palate, upper portion of tonsils and uvula
Class 3 mallampati
Soft and hard palate and base of uvula are visible
Class 3 mallampati
Only hard palate visible
Class 4 mallampati
Clear liquids NPO
2 hours
Breast milk NPO
4 hours
Infant formula NPO
6 hours
Non-human milk NPO
6 hours
Light meal NPO
6 hours
Full meal NPO
8 hours
Medications to stop taking for surgery (6):
Anticoagulants Oral hypoglycemias Monoamine oxidase inhibitors Certain anti-hypertensive agents Beta blocker therapy Non-prescribed, herbal, vitamins
DAMMIS
Drugs Airway Machine Monitor IV Suction
Delays in inducing anesthesia (5):
Slow arm-brain circulation (elders) CVD Patient anxiety Recreational drug use Extravasation (leak in fluids)
Does Propofol, a non-barbiturate IV anesthetic have less postoperative nausea and vomiting and more rapid, clear-headed recovery?
Yes
Why include time of draw up on label?
Because can be a medium for rapid bacterial growth if not handled using meticulous aseptic precautions
What should be done if person, for anatomical reasons, are likely to be difficult to intubate?
Use a flexible or rigid video scope or another advanced airway tool
Indications for ETT (5):
Potential air contamination (full stomach, GERD, GI or pharyngeal bleeding)
Predictable difficulty with ETT or airway access (later or prone)
Surgery of mouth or face
Prolonged procedure
Need muscle relaxant
Succinylcholine is not degraded by AChE so it remains in NM junction to cause continuous end plate depolarization and subsequent muscle relaxation
Phase I block
How is Succinylcholine metabolized?
By plasma cholinesterase (pseudocholinesterase)
Why is there muscle flaccidity rather than tetany following fasciculations from Succinylcholine in phase I block?
Ca+ is removed from muscle cells cytoplasm independent of repolarization and as Ca+ is taken up by the sarcoplasmic reticulum, the muscle relaxes
What factors affect plasma cholinesterase? (7)
Pregnancy Liver disease Kidney failure Heart failure Thyrotoxicosis (excessive thyroid hormone) Cancer Number of other drugs
Sux’s can cause uncontrolled increase in skeletal muscle oxidative metabolism that overwhelms the body’s capacity to supply oxygen, remove CO2, and regulate body temp (leading to circulatory collapse and dead
Malignant Hyperthermia (MH)
How is MH treated?
Dantrolene sodium
What can important agents, including sevo cause?
Neurotoxic to the developing brain
-cause neurobehavioral abnormalities long term
Are FGF less than 2 L/mm recommended?
No
Minimal rest of the patient independent of the anesthesia
Little to no blood loss
Done an office setting
Category one
Minimal to moderately invasive procedure
Blood loss Less than 500 cc
Mild risk to patient
Category two
Moderately to significantly invasive procedure
Blood loss 500 to 1500Cc
Moderate risk to patient
Category three
Highly invasive procedure
Blood loss greater than 1500Cc
Major risk to patient
Category four
Highly invasive procedure
Blood loss greater than 1500Cc
Critical risk to patient
Postop ICU
Category five
A normal healthy patient
ASA 1
Patient with mild systemic disease with no functional limitations (Hypertension, tobacco, age, DM)
ASA 2
A patient with severe systemic disease that results in functional limitations (uncontrolled HTN or DM with vascular complications, MI)
ASA 3
Patient with severe systemic disease that is a constant threat of life (CHF, angina, pulmonary dysfunction, ESRD (end stage renal disease))
ASA 4
Patient who is not expected to survive without the operation (ruptured AAA, PE, head injury with ICP)
ASA 5
Organ procurement on a brain dead patient
ASA 6
Patient on whom an emergency procedure is required
E
When should stop Street/illegal drugs?
72 hours
When should stop alcohol?
48 hours
When should stop tobacco?
24 hours
Symptoms for malignant hyperthermia? (10)
Hypercarbia Tachycardia Tachypnea Hyperthermia HTN Cardiac dysrhythmias Hypoexmia Hyperkalemia Skeletal muscle rigidity Myoglobinuria
Diagnosis test for MH
Halothane-caffeine contracture test
Future - genetic testing of ryanodine receptor
What does pseudocholinesterase do?
Breaks down ACh
Ischemic Heart Disease (4)
Age (male 45 female 55)
Family history of premature CHD (male 55 female 65)
Current smoker
HTN
Your blood pressure and pulse rate drops in normal levels how long after last cigarette?
20 min
Circulation improves and lung function increases by after 30% and breathing becomes noticeably easier after how long of last cigarette?
2-12 weeks
Risk of heart disease drops half that of a current smoker after how long of last cigarette?
Within a year
Death rate from lung cancer for the average former pack a day smoker decrease by almost 50% how long after last cigarette?
5 years
Death rate from lung cancer is similar to that of a non-smoker after how long of a cigarette?
10 years
Risk of heart disease is the same as that of a non-smoker after how long of last cigarette?
15 years
No dyspnea while walking at a normal pace
Grade 0
Able to walk as far as I like provided I take my time
Grade 1
Specific Street block limitations
Grade 2
Dysnpea on mild exertion
Grade 3
Dyspnea at rest
Grade 4
4 D’s of airways evaluations
Dentition
Distortion
Disproportion
Dysmobility
Patient fully extend neck and measure distance from mandible to thyroid notch (3fingers)
Thyromental distance
3 axis of airway?
Axis of cavity of mouth (oral)
Axis of cavity of pharynx (pharyngeal)
Axis of larynx and trachea (laryngeal)
What joint is being measured when patient flex and then extension neck? (>35degrees)
Atlanto-axial joint mobility
Difficulties of mouth opening (6):
Less than 2 fingers between teeth Loose teeth Protruding upper teeth High arched palate Long narrow mouth TMJ problems
Difficult mask ventilation (OBESE+)
Obese Bearded Elderly (55) Snorers Edentulous Thick neck Sleep apnea BMI >30
<18.5 BMI
Underweight
18.5-24.9 BMI
Normal
25-29.9 BMI
Overweight
30-34.9 BMI
Obesity
35-39.9 BMI
Morbid obesity
> 40 BMI
Extreme obesity
Systolic sound heard over the carotid artery area that may occur as result of carotid artery stenosis
Carotid bruit
Testing neurological extremities:
Hand grip
Head lift
Numbness
Tingling
Normal Na level:
135-145
Normal K levels
3.6-5.2
Normal Cl levels
96-106
Normal Co2 level
23-29
Normal BUN levels
7-20
Normal Cr levels
.84-1.21
Normal Glu levels
100 after 8 hours of fasting
140 after 2 hours of fasting
Normal WBC level
4500-11000
Normal Hgb level
Men: 13.5-17.5
Women: 12-15.5
Normal Hct level
Men: 38.3-48.6
Women: 35.5-49.9
Normal PLT level
150,000-450,000
measures the integrity of the extrinsic system as well as factors common to both systems
Prothrombin Time (PT)
measures the integrity of the intrinsic system and the common components
Partial Thromboplastin Time (PTT)
calculation based on results of a PT and is used to monitor individuals who are being treated with the blood-thinning medication (anticoagulant) warfarin
international normalized ratio (INR)
makes it harder for your clots to break up
Factor 5 Leiden
fibrinogen functions in helping to form a blood clot. Measures the amount of fibrinogen in the blood
Fibrinogen level
What is anesthesia (6):
Analgesia Amnesia Immobility Unconsciousness Skeletal muscle relaxation Block autonomic responses (BP HR)
What are the 5 monitors:
BP Pulse ox EKG Temp ETCO2
3-3-2 rule
Mouth opening of 3 fingers
Mental and hyoid bone of 3 fingers
Thyroid cartilage to hyoid bone of 2 fingers
Between initial administer of induction meds and loss of consciousness: Conscious Voluntary movements Sense of unreality Increased sense of hearing
Stage 1 analgesia (induction phase)
Loss of consciousness and marked by excited and delirious activity: Uncontrolled movements Pupillary dilation Irregular respirations, HR Breath holding Vomiting Delirium Stimulation Respond violently (peds)
Stage 2 Excitement (delirium stage)
Return of regular respiration’s:
Plane 1-return of regular respiration’s to the cessation of REM
Plane 2-cessation of REM to onset of paresis of intercostal muscles
Plane 3-onset to complete paralysis of intercostal muscles
Plane 4-from paralysis of intercostal, the patient will be apneic
Stage 3 surgical (operative phase)
Toxic or danger stage: Impending death Dilated and non reactive pupils Hypotension Bradycardia Complete circulatory arrest
Stage 4 overdose (Bulbar paralysis)
Who do you RSI? (7)
No NPO Trauma victims Unknown NPO Long-standing DM Pregnant 9-12weeks (morning sickness) GERD Morbidly obese
How much pressure for cricoid pressure (selleck’s maneuver) is applied?
20-44N (2-3kg)
Less time to perform
Rapid onset
Better quality motor and sensory block
Less pain during surgery
Advantages to spinal:
Lower risk of PDPH
Slower onset of hypotension
Controlled, prolonged analgesia with indwelling catheters
Postoperative analgesia
Advantages to epidural:
Failure of block
Decrease in systemic BP
Patient awake +/-
Disadvantages to spinal/epidural
Hypovolemia Increased ICP Coagulopathy (thrombocytopenia) Sepsis Infection at cutaneous puncture site Preexisting neurological disease Patient refusal
Spinal/epidural contraindications
3 pillars of documentation:
Legibility
Consistency
Accuracy
Initial preop anesthesia assessment was done to the time the patient arrives for surgery there must be no longer than…
48 hours time limit
Repeated regularly and frequent lay in steady rapid succession
Continually
Prolonged without any interruption at any time
Continuous
Charting drugs/doses must have order:
Drug
Dose
Route (IV,IM,SubQ)
Time
2 lights to analyze hemoglobin (1 red of 650 and 1 infrared of 950)
Pulse ox
SeXy DARLing…
At SiX hundred, wavelength Deoxy hb Absorbs Red Light
BP reading too high and error can be as much as 50mmHg
Undersized BP cuff
Low BP reading because…
Too large BP cuff
MAC awake:
Volatile: .3MAC
N2O: .6MAC
MAC-BAR (blunt the autonomic response)
1.6MAC
MAC-EI (prevent laryngeal response to ETT)
1.3MAC
What is the fluids 4-2-1 rule?
100kg= 40 (bc 4x10)+20 (bc 2x10)+80 (bc 1x80)= 140cc/hr 20kg= 40 (1x10) + 20 (2x10) + 0= 60cc/hr
Pathologic state of DM affect the airway management:
May decrease mobility of atlanto-occipital joint
