Exam 1 Part 3 Flashcards
Emergence characterized by
- Airway obstruction
- Agitation
- Delirium
- Hypothermia
- Shivering
- Autonomic lability
Emergence planning
- Should start as soon as you put the patient to sleep
- vapors decreased or off
- Excess muscle relaxation is reversed
- pt is breathing spontaneously
Emergence is synonymous with removal of ETT or other airway device. Coughing is an indication that the patient is awake. T or F?
False
Factors influencing emergence
- agent solubility
- agent concentration
- duration of anesthesia
Emergence of inhalational anesthesia depends chiefly on ______________
pulmonary elimination
Combination of building CO2 and breathing gas off
_____ and/or _____ ______ blunt the ventilatory responses to both hypercarbia and hypoxemia.
- IV
- inhalational anesthetics
What drives a pt to take a breath?
- central/chemical chemoreceptors
- hypercapnic ventilatory drive–the more narcotic we give, the higher the capnic threshold
- hypoxic ventilatory drive
PaCO2 where spontaneous ventilation is initiated is ______ ______.
apneic threshold
To increase PaCO2, need to:
- Adjust minute ventilation (RR x TV)
- Maintain FiO2 > 0.85 during hypoventilation
Maintain FiO2 > 0.85 during hypoventilation except in _________ ______ patients.
severe COPD because their drive to breath will go away
The following are effects of __________:
Stimulation of sympathoadrenal system
Vasodilator (except pulmonary arteries CONSTRICT)
hypercarbic narcosis
dysrhythmias
hypercarbia
Intermediate NMB is between ____ and ____ minutes
15-45 minutes
NMB depolarizes the end-plate _______ receptor.
nicotinic
Succx has short duration due to _______________ metabolism . It quickly diffuses away and is metabolized.
pseudocholinesterase
Side effects of succx:
- myocyte rupture
- hyperkalemia
- myalgia
- sinus bradycardia – muscarinic receptor
- malignant hyperthermia
Non depolarizing NMB __________ inhibit end plate nicotinic cholinergic receptor.
competitively
Non depolarizing NMBs (do/do not) bind to the Ach receptors.
do not bind
What NMBs block the Ach receptor sites, thn as the Ach continues to be released it pushes the drug off the site so it can bind once again?
non-depolarizing
Monitoring locations
- ulnar nerve
- facial nerve
- posterior tibial nerve (medial malleolus, flexes big toe)
- external peroneal nerve (dorsiflexion)
__________________ is a better monitoring location during intubation. ______ is better for emergence.
orbicularis oculi
adductor pollicis
4 out of 4 twitches, I can still have ____ % block.
3 out of 4, ____ % block.
2 out of 4, ____ % block
1 out of 4, _____ % block
0 out of 4, ______ % block
75 %
85%
90
95
99
Conditions prior to NMB reversal:
- 1 twitch or
- post-tetanic count > 10
If profound NMB with no response to single twitch, then (5):
- apply 50 Hx tetany for 5 seconds
- wait 3-5 seconds
- single twitch response (1/sec)
- count total twitches
- >10 twitches indicates sufficient receptors for reversal
NDMB reversal by ___________.
anticholinesterases … which inhibits acetylcholinesterase. Neostigmine
Neostigmine side effects causes stimulation of ______ nervous system.
parasympathetic
Neostigmine peak onset:
Dose?
5-10 minutes
Max 0.07 mg/kg NOT 5mg!!
How much glycopyrollate with Neo?
0.2 mg per 1 mg of neo
Assessing adequacy of ventilation
Arterial blood gas:
- PaO2 > 65 on FiO2 < 0.4
- PaCO2 < 50 torr
- EtCO2
- SpO2 > 90%
- Tidal volume
In obstructive sleep apnea, what is the major factor in arousal?
SaO2 = 85%
Hypercapnia = increased PAP
Increased afterload = right ventricular hypertrophy
Factors that incr ease incidence of PONV:
- Type of surgery: eye, ENT, abdominal, GI/GU
- use of volatile anesthetics
- nitrous oxide
- large does of neostigmine
- opioids
Surgical sites that have increased risk of PONV:
- intra-abdominal
- laparoscopic
- orthopedic
- gynecological
- ENT
- Breast
- Plastic
- Neuro
If 80 kg patient, how much reversal do you need to give?
8 cc: 4cc of Neo, 4cc of glycopyrrolate
Anti emetics work on the chemotaxic trigger zone:
- seratonin antagonist (Zofran)
- dopamine antagonist (Droperidol)
- antihistimine
- others (Decadron)
Post op pain magement: (3)
- epidural
- narcotics
- NSAIDS–Toradol 30mg)
NSAID Toradol 30 mg equivalent to ___ mg morphine.
Contraindications?
10
Contra: GI ulcers/bleeding, coagulopathy, renal impairment, bone grafts
Narcotics titrate to ____ to ____ breaths per minute.
10-16
No droperidol to what patients?
Parkinsons
Epidural placement is for post-op pain management.
- Bolus 6-8 cc of numbing agent in divided doses prior to extubation
- VERIFY NORMOVOLEMIA PRIOR TO BOLUS!
- be prepared for hypotension
