final exam Flashcards
true or false:
You MUST check an airway assessment on each patient; regardless of anesthetic management
true
Components of the Airway Exam
- Length of upper incisors
- Dental health
- Relationship of upper incisors to lower incisors (overbite or underbite)
- Lower mandibular sliding
- Between teeth/gum distance
- Tongue size
- Visibility of uvula
- Facial hair (not adequate mask-seal)
- Thyromental distance with neck extension
- Length of neck
- Neck thickness (the thicker, the worst)
- ROM of head/neck (backward or fixed movement is the issue, not lateral movement!)
** remember what the question is asking on the exam: difficult mask, airway, intubation!
yep!
Difficult AIRWAY conditions
craniofacial abnormalities
ortho defects (TMJ)
morbid obesity
scarring
cleft palate/high arch palate
neuro defects
pharyngeal problems (large adenoids, tongue, abscesses)
multiple genetic syndromes
laryngeal disease (papillomas, stenosis, malformation)
spinal and neck abnormalities
difficult MASK conditions
age > 55
facial hair
history of snoring/OSA
edentulous (no teeth)
large tongue, tonsils, adenoids
obesity (BMI > or equal to 26)
facial dressings
massive jaw
poor neck extension
pharyngeal pathology
facial deformities
having 2 OR MORE are indicator of at least minor difficulty for MASKING:
age > 55
BMI > or equal to 26
history of snoring/OSA
edentulous
facial hair
true or false for masking:
A COMBO of factors is usually the biggest risk!
NO SINGLE test should be used exclusively
true
Soft palate
tonsillar fauces
ALL/FULL uvula
gap above tongue
Mallampati I
Soft palate
tonsillar fauces
MOST of uvula
Mallampati II
Soft palate
BASE of uvula
Mallampati III
Soft palate not visualized, only hard palate visible
Mallampati IV
what are the 6 important things for patient with mallampati
seated upright
neutral
mouth open as widely as possible
tongue max protruded
no phonation/speaking
examiner at eye level
true or false:
do NOT use mallampati as a standalone
true
Distance between prominence of the THYROID cartilage and the bony point of the lower mandibular border
thyromental distance
thyromental distance
< less than ___ cm
< LESS THAN 7 cm
(6 or less is difficult intubation!)
Degree of mouth opening, function of TMJ mobility
Interincisor Distance/oral opening
Interincisor Distance
< less than ___ cm
< LESS THAN 4 cm between upper and lower incisors
(3 or less! difficult intubation!)
Evaluate “sniffing position” for optimal intubation
Aligns oral, pharyngeal, and laryngeal axes
atlanto-occipital function
atlanto occipital degrees
< ____ degrees is a warning sign
< 80 degrees is a warning sign
Have patient slide jaw forward, bite upper lip above vermillion border
Indicates ability to manipulate laryngoscope
MANDIBULAR mobility
Objective measurement of head extension
Distance between UPPER border of the MANUBRIUM sterni and the mental process/lower mandibular border with the head in full extension and the mouth closed
sternomental distance
sternomental distance
< less than ___ cm
< 12.5 cm
12.4 cm or less is difficult!
true or false:
ALWAYS document dental issues preoperatively & inform patient of possible dental damage risks
true
what is the MOST frequent reason for anesthesia related legal claims
dental injuries
pediatrics:
true or false:
nothing is reliable (example: mallampati)
true
What is the reason that people die
lack of oxygen
true or false
MULTIPLE factors should be used, no one factor is sufficient as a stand-alone
true
true or false
EVERYONE must have an airway assessment of some kind BEFOREHAND
true
Which factor contributes to an assessment of a likely difficult airway
Atlanto-occipital joint extension of 20 degrees
what indicates TMJ mobility
interincisor distance/oral opening
what are the 3 minimum things to do for physical exam
heart, lungs, airway
true or false:
previous anesthesia records do NOT carry over between hospitals
true
AANA standard I
perform + document a thorough
preanesthesia assessment and evaluation
AANA standard II
obtain informed consent
(otherwise, this is grounds for assault and battery)
AANA standard III
patient-specific plan for anesthesia care
when to evaluate patient:
High disease (dz) severity
BEFORE day of surgery
when to evaluate patient:
LOW dz severity + HIGH surgical acuity
BEFORE day of surgery
when to evaluate patient:
LOW dz severity + LOW to MED surgical acuity
ON or BEFORE day of surgery
in an ideal world, pre-anesthetic evaluation should occur:
before the day of surgery
true or false
during the preop interview, discuss the surgical PROCESS, not the surgical procedure
true!
true or false
Special considerations must be made for PEDS, NEURO IMPAIRED, and NON-ENGLISH
true
what are 6 examples of increased risk of latex allergy
Chronically exposed
Spina bifida hx
> 9 surgical procedures
Tropical food allergies
Hx of intra-op anaphylactic event of unknown origin
Healthcare workers (?)
↑ HR, BP, myocardial contractility & excitability, O2 consumption, PVR
↓ coronary blood flow
1/2 life: 40-60 minutes
nicotine
Binds to Hgb (250-300 times higher affinity than O2)
Altered O2 supply/demand (LEFT shift: ↓ transport to tissue d/t HGBs affinity for CO over O2)
½ life: 130-190 min
carbon monoxide
smoking patients are ___x more likely to have post-op respiratory complications
6x
how long should a SMOKER have cessation
8 weeks
decrease resp complications
and
normalize liver enzymes
how long is the MINIMUM for smoking cessation
12 hours
Chronic excessive alcohol is __-__x ↑ risk of peri-op dysrhythmias, infection, poor wound healing, bleeding and withdrawal syndrome
2-5x
how long should a person with ALCOHOL have cessation
4 weeks
what are the 4 questions for alcoholics
CAGE questions:
- Do you feel you should Cut down?
- Do others Annoy you when they criticize your drinking habits?
- Do you feel Guilty?
- Do you need an Eye-opener?
what are most frequent illicit drugs
marijuana and cocaine
Pupils abnormally constricted (________) or dilated (_________________) or nystagmus (_____)
constricted = opioids
dilated = amphetamines
nystagmus = PCP
what is the biggest alcoholic anesthesia risk
Acute abuse or withdrawal
Cancel elective procedures if suspected!
Long-term use of steroids cause __________ and ____________ dysfunction
hepatic and endocrine
with patients on anabolic steroids, preop ______ should be done
LFTs
NPO guidelines:
Meal: __-__ hours
7-8 hours
NPO guidelines:
LIGHT meal: toast, clears, non-human milk: ___ hours
6
NPO guidelines:
Breast milk: ___ hours
4 hours
NPO guidelines:
Clear liquids: __ hours
2
NPO guidelines:
Preop medications
Take with water 1 hour prior to surgery
o Up to 150ml for adults
o Up to 75 ml for children
NPO guidelines:
if you have diabetes, _____ your oral diabetes med
HOLD it
NPO guidelines:
take ____ of your insulin dose
1/2
NPO guidelines:
diabetes: drink gatorade ___ hours prior to surgery
2
BMI 25-30
overweight
BMI 30-35
moderate obesity
BMI 35-40
severe obesity
BMI >40
morbid obesity
BMI calculation
mass (kg) / height (m2)
true or false:
Pre-op testing, EKG, sleep study for obese patients may be overkill
true
Chronic anti-inflammatories for arthritis: evaluate for ______________
bleeding (coags?)
when do patients need stress dosing for steroids
> 20 mg hydrocortisone Qday in the past year
adrenal insufficiency meds
signs of increased ICP
headache
N/V
Altered mental status
HTN with decreased HR (avoid pre-op sedation)
low risk surgeries
endoscopic, GYN <1%
moderate risk surgeries
head/neck, neuro 1-5%
major risk surgeries
aortic, major vascular >5%
HTN
SBP >140
DBP >90
what 2 drugs are WITHHELD day of surgery
diuretics
and
ACE inhibitors: _______pril
cardiac consult needed (7)
Known ischemic heart disease
Hx of coronary stents
Active LEFT ventricular dysfunction
Valvular disease
Mitral valve prolapses: ask how severe (99% are skinny white women)
Dysrhythmias
Implanted Electronic Devices
___% of adults have resp disease
25%
2x more likely to have complications
true or false
Isoenzyme 5 fractions
is more specific for liver disease
true
what is the most accurate test for renal function
creatinine clearance
Insulin dependent diabetes
IDDM (Type 1)
NON Insulin dependent diabetes
NIDDM (Type 2)
what are 2 important things for patients with diabetes
insulin protocol (endocrine consult?) morning of surgery
intra-op BG monitoring
true or false
ASA physical status classification IDEALLY represents PREoperative health status
(NOT anesthetic or surgical risk)
true
healthy, NO comorbidities
ASA Physical Status 1
mild CONTROLLED systemic disease
smoker, HTN, obesity, pregnant, DM, asthma
age >65 years, < 3 months (age range varies by institution)
ASA Physical Status 2
SEVERE systemic disease; POORLY controlled disorders
hx of CAD, dysrhythmia, renal failure ON DIALYSIS
age >85 years, < 1 month
ASA Physical Status 3
severe systemic disease, constant threat to life
recent MI <3 months, unstable angina, severe CHF, severe COPD, hepatic failure/ESLD, ESRD
ASA Physical Status 4
moribund, not expected to survive without the procedure
ASA Physical Status 5
declared brain-dead, presenting for organ donation
ASA Physical Status 6
emergent procedures, added to the end
E
(example: open fracture healthy patient, 1E)
Chronic renal failure/dialysis
3
GERD
2
Hx of MI (8 mo ago)
3
Hx of MI (2 mo ago)
4
anticoagulant therapy
2
controlled IDDM
2
controlled asthma
2
healthy 60 year old
1
healthy 9 month old
1
healthy 87 year old
3
healthy 68 year old
2
healthy 2 month old
2
healthy 2 week old
3
smoker
2
obese with BMI 30-40
2
obese with BMI >40
3
chronic a fib
2
controlled epilepsy
2
appendicitis
trick question
alcoholic
3
social alcohol drinker
2
pregnancy
2
CHF with edema
3
CHF with O2, wheelchair bound
4
HIV
1! or 2
AIDS
3
hemophilia
2
poorly controlled diabetes
3
what does time out do
wrong site, wrong procedure, wrong patient
Are there “Benefits” of Routine Testing
NO
very small likelihood of finding a problem
plan altered only 0.6% of the time
true or false
Routine screening is not cost-effective or predictive and is unnecessary with no suspect patient history!
true
true or false
Utilize SELECTIVE pre-op testing (based on records, interview, PE, surgical procedure)
true
true or false
Inconclusive data to advise for regional techniques
Consider standardized protocols for regionals
true
when is UCG/HCG done
MUST be done the
day of surgery
in general, labs are acceptable up to how many months
within last 6 months is great! if no patient change in health status
What is the most common cause of anesthetic complications
Inadequate preoperative planning
Which of the following descriptions of daily activity would suggest that a patient has the most significant cardiopulmonary reserve
Swims laps regularly
what are the 7 variables for history of present illness
location
quality
quantity
timing
setting
aggravating/alleviating factor
associated manifestations
“How would you describe the sensation?” Aching, sharp, dull, etc.
quality
o Intensity
o Frequency
o Number
o Volume
o Size
0-10 range
quantity
includes onset, duration, frequency,
timing
test visual fields using what
confrontration
should GLP-1 agonists be held prior to surgery
yes
Ozempic
Trulicity
what does jugular venous distension represent
Right side of the heart (right atrium, RVEDP, CVP)
what can elevated jvp mean
acute/chronic heart failure, tricuspid stenosis, pulm HTN, SVC obstruction, cardiac tampanode, pericarditis
low frequency =
bell
high frequency =
diaphragm
orthopnea
SOB when laying supine or exerting
left heart failure, obstructive pulm disease
PMI
point of max impulse
1-2.5 cm normally
5th ICS left midclavicular
> 10 can indicate LVH, MI, HF
carotid murmur
during systole =
after systole =
during systole = systolic murmur
after systole = diastolic murmur
S3, S4, and MVP is best heard in what position
left lateral decubitus (mitral)
aortic regurg is best heard in what position
sitting up leaning forward
S1 is best heard where
apex (mitral area)
S2 is best heard where
base (aortic area)
Split S1
tricuspid valve
Split S2
pulmonic valve (varies with respiration)
2 tests for mitral regurg vs aortic stenosis
squat test (louder = aortic stenosis)
valsauver (louder = mitral regurg)
what is a thrill associated with
murmur
paradoxical pulse
> 10
drop in systolic BP with inspiration
associated with cardiac tamponade
diastolic murmur
valvular heart disease
right lung has how many lobes
3
Rovsing’s sign
press down on LLQ, pain on RLQ (opposite side)
appendicitis
Psoas sign
hand on right knee
raise the thigh against the hand
obturator
flex thigh at right hip, rotate internally
liver span
6-12 cm R midclavicular
4-8 cm R midsternal
pain that is relieved with rest
intermittent claudication
(arterial issue)
heel to toe in a straight line
tandem walking
point to point tests (3)
finger to finger
finger to nose
heel to shin
loss of vibration
peripheral neuropathy
stereogenosis
identify object
graphesthesia
identify number
tactile agnosia
inability to recognize objects by touch
flex neck, the hip and knee should stay relaxed
brudzinskis
flex the patient’s leg at both the hip and the knee, and then slowly extend the leg and straighten the knee
kernigs
tennis elbow, aka
LATERAL epicondylitis
anterior drawer sign
anterior cruciate
medial collateral ligament
valgus test
lateral collateral ligament
varus test (adduction)
mcmurray test
medial and lateral meniscus
tinels
tapping median nerve
phalens
full flexion 60 seconds
thenar atrophy
median nerve
hypothenar atrophy
ulnar nerve
nodes for OSTEOarthritis
heberden (DIP)
bouchard (PIP)
rheumatoid arthritis
DIP, MCP, wrist
what signals achilles rupture
“gun shot”
absent plantar flexion
entry point for retinal vessels
physiologic cup
darkened circular area surrounding the point of central vision
fovea
absence of a red reflex is suggestive of the following EXCEPT:
glaucoma
Vesicular lung sounds are normally heard over
most of both lungs
Broncho-vesicular lung sounds are normally
between the scapulae
Bronchial lung sounds are normally heard
large, proximal airways
when auscultating lung sounds, “ee” heard as “ay” is called
egophony
Recent studies show that S3 corresponds to
Deceleration of inflow across the MITRAL valve
Recent studies show that S4 corresponds to
Decreased compliance due to L ventricular stiffness
Which of the following accurately describes the use of “squatting” during exam of the heart
Squatting is used to help identify mitral valve prolapse and distinguish cardiomyopathy from aortic stenosis.
S1 corresponds to closure of
MITRAL
S2 corresponds to closure of
AORTIC
An abdominal bruit suggests
aortic aneurysm
The 2 phases of gait to be observed are
stance and swing
Which of the following is NOT a characteristic finding with scoliosis
Symptoms usually appear BEFORE the curvature can be seen
this is wrong!
During the finger-to-nose test, initial overshooting with eventually reaching the mark is called
dysmetria
top 3 common causes of pain in elderly
1) Musculoskeletal (back, joints, nighttime leg pain)
2) Headache, neuralgias (d/t diabetes and shingles)
3) Cancer
