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NA 1 > GA: Induction - Exam 2 > Flashcards

GA: Induction - Exam 2 Flashcards

1
Q

GA produces states of:

A

-hypnosis
-amnesia
-analgesia
-akinesia
-autonomic and sensory block

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2
Q

AGM check must happen Q _ hrs

A

24

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3
Q

Circuit on AGM must be checked Q

A

case
-before the case!

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4
Q

Circuit check steps:

A

1.take mask off and occlude circuit
2. press O2 flush to inflate bag
3.squeeze bag watching for increased pressure in circuit
-this helps ensure no holes/leaks if +pressure is needed

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5
Q

Suction should be:

A

-at HOB
-ON!

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6
Q

T/F Preox reduces alveolar N2O

A

false,
reduces alveolar N2

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7
Q

During preox should I be concerned if SpO2 isn’t at 100%?

A

no
-also SpO2 100% doesn’t mean their alveolar conc is >90%*

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8
Q

Normal CMRO2

A

250 mL/min

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9
Q

Normal FRC

A

2500mL
-<500mL of it is O2 when on RA, so pt desats after 1-2min
- ~2000mL+ is O2 after preox, so pt can last ~8min no desat
-N2 normally takes up ~95% of this on RA

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10
Q

Goal of preox:

A

-EtO2 of 90%+ means >2000mL is O2 in FRC
-EtN2 is ~5%

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11
Q

FRC formula

A

FRC=ERV+RV
expiratory reserve volume + residual volume

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12
Q

VC formula

A

VC=Vt + IRV + ERV
tidal vol + inspiratory reserve volume + expiratory reserve volume

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13
Q

Preox methods

A

-best is 3-5min at 5+L =PaO2~392
can also do 8 VC breaths at 10+L = PaO2~370
or 4 VC breaths at 20L gets close

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14
Q

Pts with reduced FRC:

A

obese
pregnant
infants

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15
Q

Most likely reason for not achieving proper PaO2 during preox?

A

loose mask

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16
Q

Ppl who are hard to get good seal for BMV:

A

beards
no teeth
sunken cheek
NGT
wrong size

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17
Q

How to tell you have good mask seal?

A

-good EtCO2 waveform
-reservoir bag moves

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18
Q

Pts who may need LESS induction med

A

-old
-liver/renal fail
-hypovolemic
-shock
-adjuvant drugs

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19
Q

DOC for induction

A

Prop

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20
Q

Propofol is a sterically _ _

A

hindered phenol?
-water insoluble so formulated w lipid emulsion of soybean oil, glycerOL, and egg lecithin

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21
Q

Prop MOA

A

GABA mimetic, NMDA antagonist

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22
Q

Pros Propofol

A

-fast on, fast off
-ANTIPRURETIC
-BRONCHODILATOR (reduces airway RESISTANCE)
-ANTICONVULSANT (reduces CMRO2)
-ANTIEMETIC PROPERTIES -less PONV

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23
Q

Cons Propofol

A

-greatest negative inotropic effect
-largest decrease in SVR
-burns
-give within 6hr drawing up
-generic form causes allergies from sulfites

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24
Q

Etomidate indications

A

-CV instability
-frail
-trauma

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25
Q

Pros Eomidate

A

-CV stability, slight dec in SVR
-fast on and off
-REDUCES ICP, CBF, AND CMRO2; anticonvulsant
-minimal resp depress

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26
Q

Cons Etomidate

A

-myoclonus in 50-80%(can give benzo/opioid to help but if they need etom maybe shouldn’t have those)
-burns
-INCREASES PONV
-cortical adrenal suppression (don’t redose if needing more)

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27
Q

Ketamine indications:

A

-hypotensive
-likely to be hypotensive (hypovolemic, septic, CV compromise, hemorrhage)
-severe asthmatics

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28
Q

MOA Ketamine

A

NMDA receptor antagonist
-effect on areas centrally and preipherally

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29
Q

Pts who should avoid Ketamine:

A

-HTN, angina, CHF, Pulm HTN, ICP increased, increased IOP, psych dx, PHEOCHROMOCYTOMA

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30
Q

Pros Ketamine

A

-dissociative state + nystagmus often
-no vasodilation (decreases nitric oxide)
-+inotrope
-increased <3 demand of O2
-BRONCHODILATOR
-MAINTAIN AIRWAY /RESP REFLEXES
-many routes

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31
Q

Cons Ketamine

A

-dissoaciative state-hallucinations, emerge delirium
- increases CMRO2, CBF, ICP
-increases HTN (ischemia, R sd HF -pulm HTN)
-secretions
-messes w/ BIS monitor

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32
Q

Versed for induction tidbits:

A

-BP doesnt change much
-less resp depress
-decreases CMRO2 and CBF

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33
Q

Versed induction dose:

A

-0.2-0.25mg/kg

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34
Q

Should I give more propofol to old pt after 1.5 min if nothing has happened?

A

no, their circulation time is longer usually

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35
Q

Prep for induction:

A

-monitors, precordial, PNS if necessary, NIBP auto
-equipment (LMA, mask, ETT, laryngoscope, stylet, syringe, tongue blade etc) + extra + OPA at HOB
-drugs at HOB
-SUCTION ON at HOB
-armboard -brach plexus injury poss if not
-metal circuit fingers at HOB
-table at elbow ht
-preox
-APL OPEN until pt apneic
-MASK FIT +HEADSTRAP

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36
Q

BMV Induction steps:

A

-IV open wide
- give drug over 15 sec
-recheck IV, slow fluids
-watch pt -look for long deep breaths (prop yawn)
-check LOC (are you warm/lash reflex)
-bag pt, tape eyes
-insert device if needed
-turn on agent

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37
Q

When bagging avoid PIP over _cmH20 for risk of insufflation

A

20cmH2O

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38
Q

When BMV and pt is breathing a little what can I do?

A

-let them initiate breath, then assist w bag

39
Q

Can gauge level of anesthesia when masking by:

A

-amount of Vt pt takes on own

40
Q

ETT Induction steps:

A

-narcotic(blunts SNS response to tube)
-prop (give lido 20-30mg 1st or mixed in)
-induction drug
-check LOC
-be able to bag pt for 12 breaths, tape eyes(feel bag move, EtCo2 wave)
-give muscle relaxant and turn on agent of choice while waiting
-check onset of relaxant with pns (pt flaccid)
-laryngoscope + tube
-laryngoscope in basin, GLOVE OFF, inflate cuff
-attach pt to circuit
-ensure ETT placement (chest rise, EtCO2, BS)
-turn on agent, adjust vent, tape ETT

41
Q

Inhalation induction steps:

A

-often w peds
-turn up Sevo conc quickly(like 8%) or go up slowly if airway reactive
-breathe pt down
-IV in
-continue with IA or give IV induction drugs
-control breathing
-intubate

42
Q

Indications for RSI due to high risk regurg:

A

-full stomach
-obese
-pregnant
-some DM
-bowel obstruction*
-appendectomy*
-hiatal hernia + reflux
-concurrent opioids*
-trauma
-ASA IV or V
-pain /stress
-decreased LOC

43
Q

3 goals of RSI

A

-prevent hypoxia
-minimize time in stage 2 (risk of laryngospasm, pain, CV instability, combative, aspiration)**
-use methods to decrease risk of aspiration

44
Q

Most often times for pt to aspirate

A

-INDUCTION
-laryngoscopy
-during/after emergence

45
Q

Sellick Maneuver

A

-cricoid pressure against C6 area of cartilage
-20N before pt asleep
-30N after loss of consciousness

46
Q

Sellick Maneuver complications:

A

-cartilage fx
-airway obstruction
-esoph RUPTURE (from fetching if 30N on awake pt)
-C spine/ laryngeal injury (if 40N)
-decrease LES tone

47
Q

What is the primary barrier to the gastroesophageal reflex?

A

LES
-2-5cm long
-traverses diaphragm

48
Q

If the angle of a pt’s stomach is _ they will have less reflux than if the angle was _(seen in pregnant or obese pts)

A

higher
smaller

49
Q

Name the intrinsic reflexes the body has to protect against aspiration?

A

-LARYNGOSPASM
-apnea
-spasmodic panting
-cough
-expiration

50
Q

LES pressure is normally _ than the gastric pressure

A

greater than

51
Q

LES pressure - gastric pressure =

A

barrier pressure

52
Q

GERD happens when barrier pressure _.

A

decreases

53
Q

Reflux happens when either LES pressure _ or gastric pressure _

A

decreases
increases

54
Q

The diaphragmic crura is a protective mechanism that _ at the lower esophagus to prevent reflux

A

tightens

55
Q

Mendelson syndrome is a form of chemical pneumonitis that can occur after gastric contents with pH < _and volumes >_mL /kg (25mL in adults) is aspirated

A

pH<2.5
volumes > 0.4mL/kg (25mL)

56
Q

Pt is aspirating what can be done?

A

-turn head to sd
-trend bed to more easily suction contents/keep away from lower airway
-O2, CPAP 12-14 mmHG or intubate + vent
-Beta 2 agonist inhaler to treat following bronchospasm
-no irrigation, steroids, or abx

57
Q

Signs of significant aspiration happen w/in 2hrs and include:

A

-bronchospasm
-10% drop in baseline SpO2*
-A-A gradient 300mmHg on 100% O2*
-CXR shows infiltrates/atelectasis (RLL usually)
-if pt on vent >24hr after this happens likely will get ARDS
-damage to lungs can cause alveolar+interstitial edema and hyaline membrane scarring*

58
Q

NGT what do we do?

A

-keep in and must keep hooked to suction
-suction and remove to prevent LES from being propped open
-suction and pull back to midesophageal level(30cm from nare) to allow LES tone to increase and prevent pressure during induction

59
Q

Meds that can be given to prevent aspiration

A

-metoglopramide
-cimetidine/ranitidine
-Bicitra
-PPI
-Glycopyrolate and Atropine

60
Q

Metoclopramide:

A

-a procainamide derivative
-takes 20-30 mins before volume is reduced*
-increases LES tone in 1-3 min via IV*
-CI in bowel obstruction/appendectomy and PD or depression (EPS)**-dopamine antagonist
-opioids blunt this bc they delay gastric emptying*

61
Q

Cimetidine/Ranitidine:

A

-competitive H2 blocker
-lowers basal acid secretion
-takes 20-30 mins to work

62
Q

Sodium Citrate/Bicitra

A

-nonparticulate antacid
-increases pH on contact
-good bc if aspirated won’t cause chem pneumonitis unlike particulate alkalis
-INCREASES LES tone and INCREASES barrier pressure

63
Q

Preventing Regurg/Aspiration
-PPI

A

-block H+ and K+/ATP enzyme systems on secretory surface of parietal cells

-decreases stomach acid volume and increases pH

-takes 1 day to work, effective for 3 days

64
Q

Glycoprolate + Atropine

A

-anticholinergics
-inhibit vagally mediated acid production, increasing pH
-Glyco decreases LES tone, atropine doesn’t

65
Q

If GERD happens with sellick maneuver, regurgitation into the pharynx _ happen.

A

won’t

66
Q

NPO supine pt maximum intragastric pressure is _mmHg

A

25

67
Q

Gastric distention with 750mL can cause intragastric pressure to be _mmHg

A

35

68
Q

_N of cricoid pressure can prevent regurg from _N of gastric pressure

A

30N
40N

69
Q

20N of pressure can let regurg still happen but _ will not

A

rupture

70
Q

Sellick maneuver cons

A

-makes visualizing harder by displacing larynx laterally
-can occlude airway
-can decrease LES tone
-can promote gastric reflux

71
Q

T/F sellick maneuver required for RSI

A

true

72
Q

Drugs that increase LES tone and barrier pressure

A

-alpha agonists, antacids, antiemetics, cholinergics, edrophonium, histamine, metoclopramide, metoprolol, neostigmine, pancurium, sux(raisesGASTRIC pressure)

73
Q

Drugs that decrease LES tone and barrier pressure

A

-Beta agonists, dopamine, glycopyrolate, IA, NTG, opioids, nipride, thiopental

74
Q

Drugs that don’t affect LES tone

A

cimetidine, ranitidine, propranolol, vecuronium

75
Q

Which drugs has no effect on barrier pressure but lowers both esophageal and gastric pressure?

A

prop

76
Q

If pt can’t have sux for RSI, give _ at _ its dose

A

rocuronium
DOUBLE

77
Q

Reasons to not give sux for RSI

A

-burn
-crush injury
-hyperK+

78
Q

T/F Pt with hx of diff airway or airway looks diff should have RSI

A

HELL NAW
-do an awake intubation with FIS for diff airway
-if BMV diff but intubation doesnt seem to be,go for RSI

79
Q

T/F If a cuffed ETT is in place, pt is safe from aspiration

A

false
-microaspiration can happen

80
Q

_mL is considered a severe pulmonary aspiration

A

50mL

81
Q

_mL/kg is considered the avg lethal dose of gastric fluid

A

1

82
Q

Pts at risk for increased gastric volume, pressure, and acidity

A

-<6hr NPO
-gastric insufflation (mask vented pt)
-acid hypersecretion (hypoglycemia, etoh, increased gastrin)

83
Q

Pts with delayed gastric emptying

A

-intestinal obstruction
-drugs (opioids, anticholinergics)
-preg
-obese
-DM (gastroparesis), PUD, trauma
-SNS stim (pain, stress, anxiety)

84
Q

Pts with decreased LES tone

A

-preg
-GERD
-hiatal hernia
-laryngoscopy
-cric pressure

85
Q

Pt risk factors for decreased UES tone + loss of protective reflexes

A

-GA+sedation
-AMS or head trauma
-CNS depressants
-CVA/TIA
-neuro diseases (MS, GBS, cerebral palsy, PD)
-NM diseases (MD, MG)

86
Q

My pt aspirated and is on a vent, now what?

A

-use PEEP to improve FRC and improve VQ mismatch
-low FiO2 as possible to keep PaO2>60-70
-if that isn’t good enough, treat like ARDS (low Vt -6mL/kg and permissive hypercapnia)

-ADD PEEP
-LOW FiO2 - want PaO2 ~60-70

87
Q

RSI steps:

A

-suction ON at HOB**
-preox**
-have someone start sellick maneuver(if vomiting occurs, release to pvn rupture)
-pretreat with subclinical dose of NDMR **
-give full calc dose of prop or agent of choice**
-give full dose of sux (1.5mg/kg)**
-DO NOT VENTILATE**
-give sux 60 sec then laryngoscopy and intubate**
-inflate cuff THEN confirm placement**
-release cric pressure AFTER placement confirmed**
-secure ETT, place OGT

88
Q

T/F should aim for moderate doses for RSI

A

HELL NAW CRANK DAT SHIT
-high end

89
Q

Why pretreat RSI with NDMR?

A

-usually sux is given with RSI!!!
-BUUTTTTTT sux causes fasciculations that increase gastric pressure and aspiration risk, this helps prevent that

90
Q

T/F For RSI give muscle relaxants then perform sellick maneuver

A

false, sellick 1st, MR next

91
Q

T/F no oxygenation without ventilation

A

false,
can pass nasopharyngeal cath into airway and give O2 that way
-works bc there is a 240mL/min negative pressure gradient caused by difference in O2 diffusion in and CO2 diffusion out

92
Q

RSI dose of Rocif can’t use sux

A

1.0-1.2mg/kg

93
Q

RSI dose for Vec

A

0.3mg/kg

94
Q
A

NA 1 (31 decks)

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