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N928 Basic Principles of Anesthesia > Final exam review part II- preop evaluation & airway anatomy > Flashcards

Final exam review part II- preop evaluation & airway anatomy Flashcards

1
Q

Describe the AANA standards of care.

A
  1. Patient’s Rights
  2. Preanesthesia Patient Assessment and Evaluation
  3. Plan for Anesthesia care
  4. informed consent for anesthesia care and related services
  5. documentation
  6. equipment
  7. anesthesia Plan implementation and management
  8. patient positioning
  9. monitoring, alarms
  10. transfer of care
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2
Q

What is the calculation for BMI?

A

(weight (lbs)/ height (in)^2 x 703

kg/m2

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3
Q

Essential components of the anesthesia interview include:

A 
BMI
allergies
NPO instructions
medications
Previous anesthetics/complications
family history of malignant hyperthermia
possibility of pregnancy
systems review
baseline level of cognition 
airway assessment
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4
Q

Describe the NPO guidelines.

A

Clear liquid (water, black coffee, tea, pulp-free juice, carbonated beverages)- 2 hours
breast milk- 4 hours
formula or cow’s milk, light meal- 6 hours
full meal, fried or fatty food- 8 hours

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5
Q

Emergency cases are considered to have

A

a full stomach

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6
Q

Patients with longer stomach emptying times include

A

diabetes, recent injuries, obesity, abdominal complaints, GERD, pregnant or recently delivered

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7
Q

How much force needs to be applied when doing Selleck’s maneuver?

A

3 lbs to start

progress to 6-8 lbs

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8
Q

Describe the mallampati classes.

A

Class 1: PUSH- pillars, uvula, hard and soft palate
Class 2: PUS- pillars, part of uvula, soft palate
Class 3: US- soft palate and base of uvula
Class 4: hard palate only

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9
Q

Thryomental distance is

A

the mandibular space or Patil’s test
head full extended from the mentum to the thyroid notch (upper edge of thyroid cartilage to chin)
Short TM distance implies more difficult intubation because less space for the tongue
7 cm is ideal

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10
Q

Describe the prayer sign.

A

indicative of decreased joint and cartilage mobility

positive prayer sign is limited atlanto-occipital joint motion

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11
Q

Airway assessments include:

A

Mallampati, thyromental distance, cervical range of motion, prayer sign, dentition, upper lip bite test, mouth opening, neck circumference

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12
Q

A neck circumference of ______ is indicative of a difficult intubation.

A

40 cm.

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13
Q

What needs to be assessed in female patients?

A

Female patients of child-bearing age need to be assessed for possible pregnancy

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14
Q

What medications should be taken the day of surgery?

A

beta-blockers, GERD medications, Ca+ channel blockers, bronchodilators, antiarrhythmics, steroids, diuretics (if history of CHF) antipsychotics, thyroid medications

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15
Q

What medications should be held on the day of surgery?

A

oral hypoglycemics, ACE-I, ARBs, diuretics, herbal supplements

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16
Q

The system review includes:

A

CV, respiratory, neurological, GI, endocrine, musculoskeletal, hepatic, renal, alcohol/drugs, hematologic/coagulation, autoimmune

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17
Q

Patients over age _____ need an EKG

A

50-60

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18
Q

Important cardiac considerations include

A

hypertension, angina, coronary artery disease, myocardial infarction, valvular disease, syncope, congestive heart failure, edema and/or dyspnea of cardiac origin, cardiac arrhythmias

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19
Q

Patients with angina, CAD, or hx. of MI should have

A

EKG, echo, possible cardiac cath and cardiac clearance

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20
Q

Important respiratory considerations include

A

asthma, chronic bronchitis, emphysema, recent URI, pneumonia, tuberculosis, obstructive sleep apnea, & tobacco use

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21
Q

Describe how to calculate pack years.

A

number of years smoked x packs/day

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22
Q

Neurological consideratios include:

A

stroke, TIA, HAs, seizures, neuropathy

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23
Q

With any GI diseases, there is concern for

A

aspiration

think GERD, hiatal hernia/bowel obstruction

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24
Q

What endocrine considerations are there?

A

diabetes, thyroid disease

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25
Q

Autoimmune disorders such as

A

rheumatoid arthritis can cause difficulty due to decreased cervical spine mobility

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26
Q

Musculoskeletal disorders include

A

muscular dystrophies, MS, myasthenia gravis, myopathy, fibromyalgia, myotonias, obesity, Sjogrens syndrome

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27
Q

For patients with hepatic disease, consider (studies)

A

PT/PTT, liver panel, and EKG

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28
Q

For patients with ESRD consider (studies)

A

electrolytes, CBC, PT/PTT, LFTs, and EKG

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29
Q

Describe the ASA classes.

A

Class 1- normal healthy patient
Class 2- patient with mild systemic disease
Class 3- patient with severe systemic disease
Class 4- patient with severe systemic disease that is a constant threat to life
Class 5- moribund patient not expected to survive without surgery
Class 6- declared brain-dead; anticipating organ procurement (donor)
E- emergency surgery

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30
Q

What leads detect arrhythmias and which leads detect ischemia?

A

arrhythmias- II

Ischemia- V

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31
Q

The pharynx is composed of the

A

nasopharynx, oropharynx, and hypopharynx

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32
Q

The cricoid cartilage is at the level of

A

C6

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33
Q

What is the significance of Waldeyer’s Tonsillar Ring?

A

lymphoid tissue ring in the pharynx that is at high risk for bleeding, especially with nasal intubation- highly vascular area

34
Q

The Waldeyer’s Tonsillar ring is made up of:

A 
pharyngeal tonsils (adenoids)
Palatine tonsils (located in oropharynx)
Lingual tonsils (located at base of tongue)
35
Q

Where is the larynx in adults vs. children?

A

Larynx: C3-C6 in adults

C2-C4 in infants and children

36
Q

Describe the 9 cartilages of the upper airway.

A

Single: thyroid, cricoid, epiglottic
Paired: arytenoid, corniculate, cuneiform

37
Q

Describe the significance of the epiglottis.

A

broad/leaf shaped
VASCULAR area
can be traumatized and swell incredibly
protects against aspiration by covering the glottis during swallowing

38
Q

The _____ attaches to the cords

A

arytenoids- most commonly seen paired cartilages on laryngoscopy

39
Q

The vestibular folds are known as

A

the false vocal cords; they are a narrow band of fibrous tissue on each side of the larynx

40
Q

The only complete cartilage is

A

the cricoid cartilage

it sits at C6

41
Q

The narrowest portion of an adult airway vs. a children’s airway is

A

glottic opening is the narrowest portion of an adult airway

in children, the narrowest portion of the airway lies just below the cords at the cricoid ring

42
Q

Describe the cricothyroid membrane.

A

relatively AVASCULAR

site of emergency airway

43
Q

The trachea is composed of

A

16-20 cartilaginous rings that sit anteriorly

44
Q

Describe the differences between the adult & infant/pediatric airways is:

A

Pediatrics have larynx positioned higher in the neck, tongue larger relative to mouth size, epiglottis larger, stiffer, angled more posteriorly; head and occiput larger relative to body size; short neck; narrow nares; cricoid ring is narrowest region

45
Q

The intrinsic muscles of the larynx include:

A 
posterior cricoarytenoid
lateral cricoarytenoid
arytenoids
cricothyroid
thyroarytenoid
46
Q

What adducts the vocal cords:

A

lateral cricoarytenoid

arytenoids

47
Q

What abducts the vocal cords:

A

posterior cricoarytenoid

48
Q

The cricothyroid produces

A

cord tension, closure and elongates the vocal cords

can result in laryngospasm

49
Q

The thyroarytenoids

A

shorten and relax the vocal cords

50
Q

What muscles elevate the larynx?

A

stylohyoid

mylohyoid

51
Q

What muscles draw the hyoid bone inferiorly?

A

sternohyoid, thyrohyoid

52
Q

What muscle draws the thyroid cartilage caudad?

A

sternothyroid

53
Q

What muscles draws the hyoid bone caudad?

A

omohyoid

54
Q

Describe the nerve innervation of the airway.

A

the superior laryngeal nerve innervates above the vocal cords- internal branch provides sensation above and external branch is a motor nerve (SIS & SEM)
the recurrent laryngeal nerve provides sensation below the vocal cords

55
Q

Describe the innervation of the tongue.

A

Anterior 2/3rds is cranial nerve 5

Posterior 1/3rd is cranial nerve 9

56
Q

Damage to the hypoglossal nerve can cause

A

the tongue to relax and fall back leading to an obstruction

57
Q

Innervation for all muscles of the larynx is provided by:

A

superior laryngeal nerve- external branch provides motor innervation to cricothyroid muscle
recurrent laryngeal nerve- innervates all muscles of the larynx EXCEPT for the cricothyroid

58
Q

What nerve is responsible for laryngospasm?

A

superior laryngeal nerve

-specifically external since it is motor

59
Q

Describe a unilateral vs. bilateral superior laryngeal nerve damage.

A

unilateral- minimal effects

bilateral- hoarseness, vocal tiring

60
Q

Describe a unilateral vs. bilateral recurrent laryngeal nerve damage.

A

unilateral hoarseness
bilateral- acute stridor, respiratory distress from unopposed tension of the cricothyroid muscle
chronic will cause aphonia

61
Q

A vagus nerve injury will

A

affect both the SLN and RLN

producing flaccid, malpositioned cords resulting in aphonia

62
Q

What axes are we aligning when we place the patient in ‘sniffing’ position?

A

the oral, pharyngeal, and laryngeal axis

OPL

63
Q

How do you align the different axes?

A

PiLlow- pharyngeal and laryngeal

head extension will align the oral axis

64
Q

What is the normal atlanto-occipital joint mobility?

A

35 degrees

greater than 2/3rds decrease is associated with a grade III or IV

65
Q

A short thyromental distance creates

A

difficulty in aligning pharyngeal and laryngeal axes

66
Q

Describe the different laryngoscopic view:

A

grade 1 view: full view of the glottic opening
grade 2 view: posterior portion of the glottic opening and arytenoid cartilage visible
grade 3: only tip of epiglottis is visible
grade 4: soft palate visible; no recognizable laryngeal structures

67
Q

How do we treat a laryngospasm?

A

remove the stimulus
positive pressure
deepen anesthetic
muscle relaxants

68
Q

A soft tissue obstruction is treated by

A

head-tilt, chin-lift maneuver or by jaw thrust. this moves the hyoid bone anteriorly and lifts the epiglottis to clear the obstruction

69
Q

Describe MOANS & BONEs

A

beard, BMI >25, age >55, edentulous, snores

mask seal, obesity, age, no teeth, snores

70
Q

What is the “lemon” rule?

A

look externally, evaluate the mandibular space, mallampati classification, obstructions, neck mobility

71
Q

Oral airways are not well tolerated in

A

lightly anesthetized patients- may provoke, gag reflex, cough, vomiting, laryngospasm or bronchospasm

72
Q

Describe LMA size 3

A

used for patients 30-50 kg
cuff volume test 30 cc
max cuff volume 20 cc

73
Q

Describe LMA size 4

A

used for patients 50-70 kg
cuff volume test 45
max cuff volume 30 cc

74
Q

Describe LMA size 5

A

used for patients 70-99 kg
cuff volume test 60 cc
maximum cuff volume 40 cc

75
Q

What is the maximum airway pressure when using an LMA?

A

<20cmH2O

76
Q

Describe the size and depth of insertion for ETT for men & women

A

men: 8 or 9; 24-26 cm at lip
women: 7-8; 20-22 cm at lip

77
Q

Describe the size ad depth of insertion of ETT for children

A

size 4+ age/4

depth: 12 + age/2

78
Q

The cuff pressure of the ETT should be

A

20-25 mmHg

tracheal mucosal perfusion pressure= 25-30 mmHg

79
Q

Describe how the ETT can move with head flexion, extension & rotation

A

flexion 1.9 cm down
extension 1.9 cm up
rotation 0.7 cm

80
Q

Describe the subjective criteria for “awake” extubation:

A 
follows commands
clear oropharynx
intact gag reflex
sustained head lift for 5 seconds
sustained hand grasp
adequate pain control
minimal end expiratory concentration of inhaled anesthetics
81
Q

Describe the objective criteria for “awake” extubation:

A 
vital capacity >15 mL/kg
peak voluntary negative inspiratory pressure >25 cmH20
tidal volume >6 mL/kg
sustained tetanic contraction
SPO2 >90%
RR <35
PaCO2 <45

N928 Basic Principles of Anesthesia (16 decks)

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