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N928 Basic Principles of Anesthesia > Final Exam review part III- taxonomy, MAC, Positioning, & Monitoring > Flashcards

Final Exam review part III- taxonomy, MAC, Positioning, & Monitoring Flashcards

1
Q

What are the components that make up anesthesia?

A

amnesia, analgesia, unconsciousness, immobility, and arreflexia

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2
Q

Describe the stages of anesthesia

A

Stage 3 plane 2 is where we perform general anesthesia

patients in stage 2 should not be touched because they are hyperreactive

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3
Q

Describe the types of anesthesia

A

MAC- monitored anesthesia care- sedation case where patient protects their own airway
General- inhalational or intravenous induction- patient has assisted breathing
Regional- local area block

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4
Q

Describe how medication syringes should be labeled.

A

Medication name
medication concentration
Date, time
initials

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5
Q

What does DAMMITTTS stand for?

A 
Drugs
Airway
Machine,
Mask
monitors
IV
Temperature
Tube 
Tape
Suction
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6
Q

What does MSMAIDs stand for?

A

machine, suction, monitor, airway, IV, drugs

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7
Q

Reasons why your patient may fail to emerge include:

A

residual NMBD
excessive opioid or benzodiazepine administration
intraoperative CVA
electrolyte abnormalities
acidosis
hypothermia
Pre-existing pathophysiologic conditions such as CNS disorders, hepatic insufficiency, ETOH ingestion

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8
Q

A loss of lash reflex means

A

a loss of airway protective reflexes

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9
Q

What monitors are required for a MAC case?

A

blood pressure, end tidal, EKG, pulse oximetry, assess ventilation adequacy, presence of a qualified anesthesia provider

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10
Q

The medication amounts for a MAC case

A

are highly variable as they depend on surgeon experience, patient’s medical history, and surgical stimulus
typical medications given include versed, propofol, fentanyl or remifentanil and local anesthetic

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11
Q

Inappropriate cases for MAC include:

A 
the use of muscle relaxation
potentially difficult airway access
pediatric patients
patients with psychiatric disorders
any uncooperative patient
patient that refuses MAC anesthesia
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12
Q

What standard relates to positioning?

A

standard 8

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13
Q

What is the most common positioning injury?

A

ulnar nerve injury

and then brachial plexus

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14
Q

Goals for positioning include:

A

patient safety, optimize surgical exposure preserve patient dignity, maintain hemodynamic stability, maintain cardiorespiratory function, no ischemia injury or compression, prevent pressure related injuries

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15
Q

Mechanisms associated with nerve injury include:

A

compression, transection, stretch and traction

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16
Q

Risk factors for skin issues include

A

age: elderly; diabetes, PVD, surgical time, chronic hypotension, increased body temperature, body habitus

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17
Q

Pressure injury sites related to the supine position:

A

occiput, scalpulae, thoracic vertebrae, sacrum, coccyx, elbows, heels, calves

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18
Q

Positioning in the supine position:

A

arms should be secured on arm board with padding
if arms are lateral or abducted they need to be <90 degrees, supinated forearm, avoid brachial plexus injury (stretch), pronation of the forearm can lead to ulnar curve compression
legs should be flat, uncrossed with heels padded, small lumbar support

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19
Q

Respiratory and CV implications of supine positioning.

A

CV: BP stability, compensatory mechanisms (ANS) are intact
Respiratory: reduced TLC and FRC, diaphragm shifts cephalad, general anesthesia and NMBs can enhance this

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20
Q

Prone positioning implications

A

intubated
head & neck should be neutral
arms <90 degrees
body/trunk supported

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21
Q

What types of surgical cases use the prone position?

A 
spine
buttocks
rectum or peri-rectal
ankle
intracranial
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22
Q

Areas that need to be kept free of pressure in prone positioning include:

A

eyes, breast, genitalia, nose, face, lower legs

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23
Q

What are the CV and respiratory considerations for prone positioning?

A

CV: pooling of blood (lower extremities/abdomen), compression of inferior vena cava, epidural engorgement
respiratory: decreased compliance if chest is not freely hanging, increased FRC (improved posterior lung ventilation may increase oxygenation

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24
Q

Discuss postoperative vision loss prevention:

A

surgical duration < 6 hours
10-15 degree head up (reduce orbital edema)
BP 20% of preoperative baseline
maintain HCT >25

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25
Q

Postoperative vision loss can be due to:

A 
prolonged surgical time spine surgeries (prone)
central retinal artery occlusion
central retinal vein occlusion 
ischemic optic neuropathy (89% of POVL)
cortical blindness
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26
Q

Ischemic optic neuropathy is associated with:

A 
extended surgical time & extensive blood loss
obesity
gender--> male
Wilson frame
Ocular perfusion pressure
It is NOT associated with globe pressure
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27
Q

Describe central retinal artery occulsion.

A

“eye stroke”

sudden profound vision loss, painless, monocular

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28
Q

What is the etiology of central retinal artery occlusion:

A

embolism, vasculitis, vasospasm, sickle cell, trauma, or glaucoma

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29
Q

How is central retinal artery occlusion diagnosed?

A

retinal pallor, macular cherry red spot, +/- afferent pupillary defect

30
Q

What is central retinal vein occlusion?

A

“eye DVT”

variable- blurred vision to sudden vision loss, painless, monocular

31
Q

What are the risk factors for central retinal vein occlusion?

A

typical stroke risk factors, hypercoagulable states

glaucoma, compression of the vein in thyroid or orbital tumors

32
Q

How is central retinal vein occlusion diagnosed?

A

optic disk edema, diffuse retinal hemorrhages

33
Q

Describe considerations with the lithotomy position.

A

legs abducted, elevated
fingers free–> footboard
legs free–> peroneal nerve injury
hip flexion- sciatic/obturator stretch, femoral nerve palsy

34
Q

Lithotomy position facilitates access to:

A

perineal structures
gynecological
urology

35
Q

Describe the CV and respiratory considerations of the lithotomy position.

A

20% reduced FRC, reduced VC, hypoventilation when breathing spontaneously
CV- autotransfusion of 250-300 mL/leg when raised
increased (shifted) central blood volume

36
Q

Describe considerations with the lateral position.

A

head neutral, supported
pressure free of the eyes/ears/face
dependent arm on padded arm board, perpendicular to torso <90 degrees
axillary roll under the dependent side of thorax- should be slightly caudad, not directly in axilla

37
Q

Lateral positioning is used for the following surgical procedures.

A

kidney, shoulder, orthopedic (THA; hip)

Thorax

38
Q

What are the CV and respiratory considerations with lateral positioning?

A

CV: with euvolemia we have minimal changes
when the kidney rest is elevated: must do so slowly under ilia crest, great vessels compressed, decreased venous return
Resp: V/Q mismatch possible
the dependent lung lower than left atrium is prone to atelectasis and fluid accumulation
FRC: increased in nondependent lung (top), decreased in dependent lung (bottom)

39
Q

The sitting position can be used for

A

cervical spine surgery, should surgery, posterior fossa, and breast reconstruction

40
Q

Considerations with the sitting position include:

A

HOB 30-90 degrees above horizontal plane
Head secured with 2 finger breadths between the neck and mandible
head can be dislodge from headrest with vigorous surgical manipulation

41
Q

Potential complications with the sitting position include:

A

venous are embolism- negative pressure gradient
pneumocephalus- neuro procedures, often benign
quadriplegia- spinal cord stretch when head flexed + loss of autoregulation with general anesthesia; limit strain at C5 vertebra level

42
Q

CV & respiratory considerations with the sitting position

A

CV: reduced SV & CO, decreased MAP & CVP, lower extremity venous pooling, decreased cerebral perfusion
resp: increased FRC, increased compliance

43
Q

Trendelenburg positioning leads to

A

increased ICP, IOP, CV
dependent edema
Brachial plexus stretch or compression

44
Q

Reverse Trendelenburg positioning leads to

A

increased pulmonary compliance & FRC

decreased ICP, IOP, CPP, & BP

45
Q

Injuries to the brachial plexus in supine and lateral decubitus positioning:

A

supine: arms abducted >90 degrees
humeral head rotated
lateral decubitus: stretch/traction/tension, chest- dependent compression

46
Q

For all anesthetics ________ needs to be documented at least every 5 minutes.

A

Blood pressure, heart rate, and respiration

oxygenation must be continuously monitored

47
Q

Pulse oximetry requires

A

a pulsatile arterial bed
works via Lambert-Beer law
HbO2 absorbs more infrared at 960 nm
reduced Hb absorbs more red at 660 nm

48
Q

Factors that affect the accuracy of pulse oximetry include:

A

high intensity light, patient movement, electrocautery, peripheral vasoconstriction, hypothermia, cardiopulmonary bypass, presence of other hemoglobin (carboxyhemoglobin leads to false increased reading) methemoglobin can be positive or negative
IV injected dyes such as methylene blue or hemoglobin <5

49
Q

Discuss the estimates of the oxyhemoglobin curve.

A

PaO2:30, SaO2: 60
PaO2: 40, SaO2: 75
PaO2: 60, SaO2: 90

50
Q

The precordial stethoscope is placed at

A

suprasternal notch or the apex of the left lung

51
Q

The precordial stethoscope

A

easily detects changes in breath sounds or heart sounds including airway/circuit disconnect, endobronchial intubation, anesthetic depth/increased heart rate, contractility

52
Q

An abnormal PACo2-PaCO2 gradient can be due to

A

gas sampling errors, prolonged expiratory phase, V/Q mismatch, airway obstruction, embolic states, COPD, hypoperfusion

53
Q

Describe the phases of a capnograph.

A

Phase 1- corresponds to inspiration (should be zero unless rebreathing is present)
Phase II- early exhalation/steep upstroke (mixing of deadspace with alveolar gas)- prolonged upstroke can be due to COPD, bronchospasm
Phase III- mild upslope; end of 3 is where we read CO2
Phase IV- inspiration & return to baseline

54
Q

What lead measures arrhythmias and what lead measures ischemia?

A 
lead II- arrhythmias
Lead V (any of the V leads)- ischemia
55
Q

Describe where you place the lead that reads lead II

A

lead II is placed on the right side, 2nd intercostal space, mid-clavicular line

56
Q

An anterior MI is detected via

A

V3 & V4

57
Q

A septal MI is detected via

A

V1 & V2

58
Q

An inferior MI is detected via

A

II, III, and aVF

59
Q

A lateral MI is detected via leads

A

aVL, V5, and V6

60
Q

For patients with atherosclerosis and HTN, the BP cuff will read:

A

systolic low
diastolic high
as compared with invasive arterial pressure

61
Q

Concerns with using the femoral artery for arterial line site selection:

A

pseudoaneurysm & atheroma formation

62
Q

Concerns with using the axillary artery for arterial line insertion:

A

potential for plexus/nerve damage from hematoma or traumatic cannulation

63
Q

The most common form of heat loss in the OR is:

A

radiation>convection>conduction>evaporation

64
Q

Patients at risk for hypothermia include:

A

extremes of age, patients with spinal cord injuries, burn patients

65
Q

The temperature sites that most reflect core temperature include

A

Blood (via PA catheter)
Tympanic membrane (risk of perforation
esophagus and bladder are also good at detecting core temperature

66
Q

The greatest effect on maintaining body heat is

A

ambient temperature

67
Q

When monitoring the ulnar nerve with paralytics, we are looking at

A

the adductor pollicis muscle
it will adduct the thumb
best for recovery

68
Q

When using neuromuscular monitoring on the face, we are looking to monitor

A

the facial nerve
looking at the obicularis oculi muscle which closes the eyelid
Best for onset

69
Q

Most reliable clinical signs of recovery from neuromuscular block include

A

sustained headlift x 5 seconds
sustained leg lift x 5 seconds
sustained handgrip x 5 seconds
Max inspiratory pressure >40-50 cm H2O

70
Q

Unreliable signs of recovery from neuromuscular block include

A 
sustained eye opening
tongue protrusion
arm lift to opposite shoulder
normal TV
normal or near normal vital capacity
max inspiratory pressure <40-5o cmH2O
71
Q

The BIS score for general anesthesia is

A

40-60

>70 is associated with greater recall risk

72
Q

Describe your blood pressure if the cuff is too small or too large.

A

Too large it will have a low reading

too small it will have a high reading

N928 Basic Principles of Anesthesia (16 decks)

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