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SRNA4TopicsAnesthesia > Exam 1 Reading 2 (B.Ch28) > Flashcards

Exam 1 Reading 2 (B.Ch28) Flashcards

1
Q

Which LMA allows for positioning out of the midline without affecting the hypopharyngeal position of the mask?

A

LMA Flexible

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2
Q

Placing a nasal cannula with oxygen at 6 L/min upon induction of anesthesia will delay the time it takes for the patient to desaturate via a principle known as

A

Apneic ventilation

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3
Q

What is apneic ventilation?

A

Apneic ventilation involves the entrainment of gases into the alveolar space during apnea.

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4
Q

What is the gold standard for confirming placement of an endotracheal tube?

A

Sustained detection of exhaled CO2 by capnography

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5
Q

Other methods to help confirm placement other than CAPNOGRAPHY include

A

visualization of tube placement through the vocal folds,
Chest excursion
Auscultation of breath sounds, and
Humidity in the ETT.

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6
Q

Objective criteria for routine extubation include which of the following? (4)

A
  1. A tidal volume of at least 6 mL/kg
  2. Peak Negative Inspiratory pressure of at least 20cm H20
  3. Sustained tetanic contraction for at least 5 seconds
  4. TOF ratio of at least 0.7
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7
Q

You have administered succinylcholine as part of your intravenous induction for a 55 year-old male patient undergoing a percutaneous lumbar microdiscectomy. You are able to adequately ventilate him, but are not able to perform a successful intubation via direct laryngoscopy on your first three attempts. What should your next step be?

A

Awaken the patient

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8
Q

Direct laryngoscopy in a difficult airway should be limited to

A

no more than 2-3 attempts.

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9
Q

The repeated instrumentation of the airway can incur

A

soft tissue trauma and swelling that can impair your ability to ventilate by mask or supraglottic airway.

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10
Q

One of the principle differences between a routine induction and a rapid sequence induction is that in a rapid sequence induction

A

muscle relaxants are given before mask ventilation is attempted (Muscle relaxnats are given before knowing whether or not you can mask ventilate a patient)

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11
Q

According to the difficult airway algorithm, if you are unable to ventilate an induced patient via mask or supraglottic airway, what is the next step you should take?

A

. Call for help

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12
Q

Which structure is shield-shaped and serves to protect the vocal mechanism?

A

Thyroid cartilage

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13
Q

You are preparing to induce a patient and are attempting preoxygenation by mask. The patient complains of claustrophobia and pushes the mask away. What is the best course of action to take?

A

Have the patient hold the mask

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14
Q

Which of the following is a contraindication to elective awake airway management?

A

Local anesthetic allergy

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15
Q

What are 3 Contraindications to elective awake airway management?

A

patient refusal, inability to cooperate (such as profound mental disability), and local anesthetic allergy.

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16
Q

Awake airway management: If the patient does have a history of reflux, additional measures to

A

reduce the volume or increase the pH of the gastric contents should be pursued beforehand.

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17
Q

The criteria for deep extubation include all of the following except:

A

he patient has no history of gastric reflux

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18
Q

IN what cases can a deep extubation’ be performed?

A

Cases where coughing or straining could be deleterious to the patient’s condition or surgical site, the patient may be extubated under a deep level of anesthesia

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19
Q

What are the criteria for deep extubation?

A

Easy to mask ventilate, Undergone a procedure that did not involve the airway
Have an empty stomach.

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20
Q

Reflux is not an absolute contraindication to deep extubation, but what should be assessed?

A

severity of the reflux and the associated risks should be weighed against the risks of coughing or straining for the particular situation.

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21
Q

You are performing a rapid sequence induction for an emergency case, and there is not time for extended preoxygenation. What is the next best alternative?

A

having the patient take four vital capacity breaths with 100% O2 over 30 seconds. The patient will desaturate faster than the traditional method but can still boost the arterial PaO2 to over 330 mmHg.

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22
Q

The goal of ______ is to provide a direct line of sight from the operator’s eye to the larynx.

A

direct laryngoscopy

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23
Q

Which o factors are associated with an increased risk of difficult airway?

A

Increased neck circumference
Decreased range of motion in the neck
Retrognathia

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24
Q

Individual evaluations such as

A

Dentition
thyromental distance,
jaw protrusion, increased Mallampati score, increased neck circumference, retrognathia, and mouth opening are typically aimed at predicting difficulty with a traditional direct laryngoscopy.

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25
Q

What is the maximum recommended intracuff pressure for a laryngeal mask airway?

A

60 cm H20

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26
Q

You are preparing to perform an awake intubation. Which local anesthetic would have the fastest onset and short duration when used on the oral mucosa?

A

Benzocaine

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27
Q

You are using dexemedetomidine as an intravenous sedative for an elective, awake intubation. What side effect would you expect to see?

A

Bradycardia

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28
Q

Dexemedetomidine effect on BP

A

BOth hypotension and hypertension

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29
Q

You elect to perform an awake, fiberoptic nasal intubation in a patient with a known difficult airway. You would consider the use of oxymetazoline (AFRIN) prior to the procedure because it

A

is used to vasoconstrict the nasal passages

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30
Q

After your preoperative interview, you decide to perform a rapid sequence induction on your patient. Select two CONTRAINDICATIONS for cricoid pressure.

A

Active vomiting

Cervical spine fracture

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31
Q

Cricoid pressure is contraindicated in patients with

A

cervical spine fracture, laryngeal fracture, or who exhibit active vomiting due to the risk of an esophageal rupture.

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32
Q

You are attempting to ventilate an unconscious patient and mask ventilation is not successful. According to the difficult airway algorithm, what is the next action you should take?

A

Insert a supraglottic airway

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33
Q

With the difficult airway algorithm, after attempting to insert LMA, If that is successful, then you are entering the

A

nonemergency pathway of the difficult airway algorithm, and you can consider your options for tracheal intubation.

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34
Q

You are applying local anesthetic soaked pledgets to the middle turbinates of a patient’s nasal cavity prior to a nasal intubation. What nerves are you anesthetizing?

A

Branches of the trigeminal nerve

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35
Q

The nasal cavity is innervated by the distal branches of the

A

trigeminal nerve.

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36
Q

The distal branches of the trigeminal nerve that anesthesize the nasal cavity can be anesthetized by two methods:

A
  1. applying local anesthetic soaked pledgets to the middle turbinates for 5-10 minutes OR
  2. injecting local anesthetic through the posterior-lateral aspect of the hard palate through the greater palatine foramen.
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37
Q

While obtaining a preoperative history and physical, the patient states that after his last anesthetic, he was told he has a difficult airway. What should you do next?

A

Obtain the medical record for the last anesthetic

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38
Q

Anytime a difficult airway is encountered, What should you do in the medical records?

A

a difficult airway note should be entered into the patient’s record for that case. A detailed explanation by the anesthesia provider who encountered the difficult airway provides an enormous advantage in the preparation for a difficult airway.

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39
Q

Which two laryngeal nerves innervate the larynx?

A

Superior

Recurrent

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40
Q

Confirmation of proper placement of an Eschmann (gum elastic bougie) stylet during intubation occurs when

A

The stylet passes a bumpy surface

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41
Q

During your emergence of a patient undergoing appendectomy, he begins exhibiting signs of laryngospasm. Select two interventions and management of laryngospasm.

A

Administration of a small dose of short-acting muscle relaxant
Administration of continuous, positive airway pressure

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42
Q

The primary management of laryngospasm includes

A

removing of the offending stimulus and administration of oxygen with continuous positive airway pressure. If this is unsuccessful, you may need to consider the use of a small dose of short-acting muscle relaxants.

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43
Q

What is the most common cause of suboptimal preoxygenation prior to induction of anesthesia?

A

Inadequate mask seal

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44
Q

Mrs. Frank is considered a full stomach and is scheduled for surgery. Which two agents would raise Mrs. Frank’s gastric pH?

A

Famotidine

Sodium citrate

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45
Q

How does Famotidine help>

A

Given a few hours preoperatively, famotidine increases gastric pH and reduces gastric volume.

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46
Q

Sodium citrate (15-30ml) increases

A

gastric pH to >2.5. This dose should be administered within 1 hour prior to surgery.

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47
Q

During direct laryngoscopy, the BUMP and Optimal External Laryngeal Manipulation maneuvers are performed to

A

improve the view of the glottic opening

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48
Q

A variation of the BURP maneuver procedure is known as Optimal External Laryngeal Manipulation in which the

A

thyroid, cricoid, and hyoid cartilages are pressed posteriorly in a cephalad direction.

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49
Q

According to the Vortex approach to the difficult airway, which of the following should be done between each noninvasive airway attempt?

A

Make a change in the airway visualization conditions

50
Q

VORTEX approach changes include

A

Manipulation of the position of the head, neck, or larynx, and change in device or device size, a change in the operator, implementation of airway adjuncts such as oral or nasal airways, or pharmacologic adjuncts such as muscle relaxants or reversal of muscle relaxants.

51
Q

Select two contraindications to the use of a supraglottic airway.

A

Intestinal obstruction

Poor lung compliance

52
Q

Contraindications to the use of a supraglottic airway include
FID PHD LG

A 
Full stomach
Intestinal obstruction
Delayed gastric emptying
Poor history
Hiatal hernia
Decrease lung compliance
Limited mouth opening
Glottic or subglottic airway obstruction
53
Q

When using an airway exchange catheter as part of a difficult extubation, you know that you should insert the catheter into the endotracheal tube (ETT) until

A

the depth markings match that of the ETT

54
Q

Steps to place an AIRWAY ExcHANGE CATHETER (AEC)

A

Disconnect the vent
Slide lubricated catheter through the ETT so that the depth marking on both the AEC and ETT tube match
Maintain the AEC’s position as the ETT tube is removed.
If reintubation is needed, the ETT can be pass back over the AEC to the appropriate depth and secured.

55
Q

What nerve provides sensory innervation to the base of the tongue, the posterior epiglottis, the aryepiglottic folds, and the arytenoids?

A

INTERNAL branch of the superior laryngeal nerve

56
Q

Which risk factor is the most significant predictor of a difficult mask ventilation?

A

Presence of a beard

57
Q

Predictor of difficult mask ventilation in order of importance
TB LAS

A

The presence of a beard (most significant)
Body mass index > 26,
Lack of teeth
Age > 55 years,
Snoring are independent risk factors associated with difficult mask ventilation.

58
Q

What opening is the narrowest portion of the airway in infants, children and adults.

A

The glottic opening

59
Q

The cricothyroid membrane is

A

1 to 1.5 fingerbreadths below the laryngeal prominence (thyroid notch)

60
Q

Deeply inserted endotracheal tube (ETT), tend to gain entry into the r

A

right principal bronchus due to its size and less acute angle of divergence from the midline.

61
Q

What are three clinically important neural innervations of the upper airway?

A

Glossopharyngeal nerve (CN IX)
SLN (branch of VN X)
RLN (Branch of VN X)

62
Q

RLN provide motor innervation to the ______except the _____

A

larynx ; cricothyroid

63
Q

Sensory innervation to the posterior 1/3 of the tongue

A

Glossopharyngeal

64
Q

Does the internal branch of the SLN provide motor innervation?

A

no

65
Q

This nerve provide the motor innervation to the cricothyroid

A

VAGUS nerve -EXTERNAL branch of the SUPERIOR LARYNGEAL NERVE

66
Q

This nerve provide the sensory innervation to the Epiglottis and vocal cords

A

VAGUS Nerve- INTERNAL BRANCH of the SUPERIOR LARYNGEAL NERVE

67
Q

Stretches and TENSES the vocal ligament is the ______and it is innervated by the _______

A

CRICOTHYROID ; External LN

68
Q

Relaxes vocal ligament

A

Thyroarytenoids

69
Q

Abducts (away) the Vocal folds

A

Posterior cricoarytenoids (think abducting take a child back door )

70
Q

Adducts (add together) the Vocal folds

A

Lateral cricoarytenois

71
Q

Bother Lateral and posterior cricoarytenois innervated by

A

RLN (vagus Nerve X)

72
Q

ADDUCT Arytenoid cartilatges

A

Transverse and oblique arytenoids

73
Q

Relaxes POSTERIOR VOCAL LIGAMENT while maintaining tension of anterior part

A

VOCALIS

74
Q

Vocalis innervated by

A

RLN

75
Q

2 branches of SLN

A

INternal and external branch

76
Q

Syndrome associated with difficult airway

A 
Pierre Robin sequence
Treacher collins syndrome
Down syndrome
RA
Ankylosis spondlosis(cervical spine and TMJ joint)
77
Q

Bronchospams under GA

A

Peak airway pressure increase
delayed Exhalation of capnograph
EXP Wheezing bilateral lungs

78
Q

Bronchospasm with GA, treatment step

A

Call for help
Tell the surgeon
If ventilation impossible, consider misplacement or kinking of ETT
Increase FiO2
If stable, deepen anesthetic
Administer beta 2 agonist via circuit or IV methylprednisonlone or inhaled ipratropium
MAY REQUIRE EPI for severe cases

79
Q

The positive predictive value of the Mallampati score in predicting a difficult laryngoscopy is

A

only 40%

80
Q

Mallampati grade describes

A

Relationship between mouth opening
Tongue size
and pharyngeal space.

81
Q

implication of the presence of beard?

A

Difficult mask seal

82
Q

Implication of jaw protrusion

A

Difficult tongue displacement

83
Q

Why preoxygenation?

A

several minutes of preoxygenation with 100% oxygen (O2) via a tight-fitting facemask may support ≥8 minutes of apnea before desaturation occurs.

84
Q

The most common reason for suboptimal preoxygenation is a

A

loose-fitting mask, which allows entrainment of room air.

85
Q

Appropriate positioning of the patient is paramount for

A

delivering positive pressure ventilation via facemask.

86
Q

How does the sniffing position improves mask ventilation>

A

This sniffing position improves mask ventilation by anteriorizing the base of the tongue and the epiglottis.

87
Q

Dentures left in place may

A

improve the mask seal for an edentulous patient. The advantage of this must be weighed against the risk of denture displacement or damage.

88
Q

Pressure need to inflate the lung

A

Normally, no more than 20 to 25 cm water (H2O) pressure in the anesthesia circuit (created by squeezing the reservoir bag) is needed to inflate the lungs

89
Q

How does oral and nasal airway by pass obtruction?

A

create artificial passage through the pharynx and hypopharynx.

90
Q

What is laryngospasm?

A

a local reflex closure of the vocal folds.

91
Q

4 steps to treat laryngospam

A

Remove stimulus (salive, blood, vomitus, FB)
Administer oxgyen with CONTINUOUS PAP
Deepen anesthesia
Administer rapidacting MR

92
Q

Airway devices that isolate the airway above the vocal cords are referred to as

A

supraglottic airways (SGAs)

93
Q

SGAs advantageous for

A

patients with reactive airway disease

94
Q

LMA mask has an inflatable cuff, which fills the hypopharyngeal space, creating a seal that allows positive pressure ventilation with up to

A

20 cm H2O pressure.

95
Q

For use, the LMA mask is

A

completely deflated.

96
Q

Steps to insert an LMA

A

Force is applied by the index finger in an upward direction toward the top of the patient’s head, and the mask is allowed to follow the palate into the pharynx and hypopharynx. Next, the LMA is inflated to the minimum pressure that allows ventilation to 20 cm H2O without an air leak

97
Q

LMA intracuff pressure should never exceed _______cm H2O. If not what should be done?

A

60cm H2O/ When an adequate seal cannot be obtained with 60 cm H2O cuff pressure, the LMA’s positioning or sizing should be re-evaluated. Light anesthesia and laryngospasm also may contribute to poor seal.

98
Q

Positive-pressure ventilation can be used safely with the

A

LMA (4).

99
Q

With the classic LMA, tidal volumes should be limited to_______and AIRWAY PRESSURE limited to_______

A

8 mL/kg and airway pressure to 20 cm H2O.

100
Q

If at any time regurgitated gastric contents are noted in the LMA barrel, the LMA should be_____. STEPS TO FOLLOW

A

left in place. The patient is placed in a Trendelenburg position, 100% oxygen is administered, and the LMA barrel is suctioned.

101
Q

The primary contraindication to elective use of a SGA is the

A

clinical scenario where there is an increased risk of gastric contents aspiration
Other are: High airway resistance, glottic.

102
Q

When can you remove the LMA?

A

SGAs should be removed either when the patient is deeply anesthetized or after protective reflexes have returned and the patient is able to open his or her mouth on command.

103
Q

The Macintosh (curved) blade is used to displace the

A

epiglottis out of the line of sight by placement in the vallecula and tensing of the glossoepiglottic ligament.

104
Q

The Miller (straight) blade reveals the glottis by

A

compressing the epiglottis against the base of the tongue

105
Q

Clear liquids can be administered to children and adults.

A

up to 2 and 3 hours, respectively, prior to anesthesia without increased risk for regurgitation and aspiration (10)

106
Q

The ASA recommends a fasting period of for breast milk and

A

4 hours

107
Q

The ASA recommends a fasting for nonhuman milk, infant formula, and a light solid meal.

A

6 hours

108
Q

Reduction of gastric acidity can be achieved with the aid of .

A

H2 receptor antagonists and proton pump inhibitors, which also reduce gastric volume.

109
Q

can be used to reduce gastric volume prior to anesthesia in patients at hight risk of regugitation.

A

A nasogastric tube

110
Q

The goal of RSI is to gain

A

control of the airway in the shortest amount of time after the ablation of protective airway reflexes with the induction of anesthesia

111
Q

Not performed in RSI

A

Mask ventilation

112
Q

Can you intubate with a an LMA? how?

A

Some SGAs are inserted using a similar technique to the classic LMA and other supraglottic airways. Once seated, the mask is inflated and ventilation is attempted. After adequate ventilation is achieved, an ETT, is advanced through the barrel of the LMA. Although the Fastrach LMA excels at blind intubation, a fiberscope should be used with the other varieties. Once intubation is achieved and confirmed, an intubating SGA may be removed, leaving the ETT in place.

113
Q

Extubation of the trachea criteria? Airway pressure is allowed to

A

The airway pressure is allowed to rise to 5 to 15 cm of H2O to facilitate a “passive cough,” and the ETT is removed after the cuff (if present) is deflated (4).

114
Q

There are three requirements for deep extubation:

A

(a) excellent mask fit and ventilation during induction, (b) no surgical procedure within the airway, and (c) absence of a full stomach.

115
Q

Subjective Clinical criteria for AWAKE post surgical extubation

A 
Breathing spontaneously 
Following commands
5 SECONDS sustained head lift
INTACT GAG
AIRWAY clear of debris
Adequate pain control
116
Q

Objective criteria for AWAKE EXTUBATION

A

Vital Capacity> 10ml/kg
TV > 6cc/kg
Sustained tetany 5 seconds
T1/T4 ratio >0.7

117
Q

Laryngospasm upon ETT removal may also cause

A

extubation failure and accounts for 23% of all critical postoperative respiratory events in adults

118
Q

What is the hypoxic respiratory drive?

A

When those carbon dioxide levels are high a signal is sent to speed up the drive to breathe to blow off the excess carbon dioxide. They will send send a signal to breathe when the partial pressure of oxygen begins to fall. This is referred to as the hypoxic drive but this drive has a much more minor role in breathing.

119
Q

What are the criteria for use of an emergent invasive airway?

A 
Cannot intubate
Cannot ventilate
Cannot awaken patient
SGA failed
Clinically significant hypoxia
120
Q

Common reasons for failed flexible scope intubation

A

Lack of provider experience
Failure to dry the airway
Failure to adequately anesthesize airway

121
Q

What is the highest priority in a CANNOT VENTILATE, CANNOT INTUBATE situation?

A

Call for help

122
Q

Injury to the RLN results in p

A

Paralysis of the ABDUCTOR Muscle of the vocal cords. The vocal cords will remain median or paramedian throughout the resp cycle.

SRNA4TopicsAnesthesia (47 decks)

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