General Anesthesia Techniques Flashcards
Define GA.
General Anesthesia
Define RSI.
Rapid Sequence Induction
Define TIVA.
Total Intravenous (IV) Anesthesia
Define ERAS.
Enhanced Recovery after Surgery
What are the three gold standards of general anesthesia? (3)
Amnesia, Anxiolysis/Hypnosis & Analgesia
What is the mnemonic for anesthesia case preparation?
Ms. Maid
What does the M in Ms. Maid mean?
Machine
What does the S in Ms. Maid mean?
Suction
What does the second M in Ms. Maid mean?
Monitor
What does the A in Ms. Maid mean?
Airway
What does the I in Ms. Maid mean?
IV, Preop Assess
What does the D in Ms. Maid mean?
Drugs
What does the E in Ms. Maide mean?
Equipment
Who should you conform the anesthesia gas machine check with at clinical sites?
Confirm with Clinical Coordinator/colleagues/faculty AGM at new facility prior to rotation
What must be selected for appropriate ventilation?
appropriate size mask for ventilation
What must we ensure in functional and working?
ETCO2 monitor
What is a standard equipment check that must be in every room before the start of the case?
AMBU
What must be done to suctioning?
readily available and functional
What suction is used for intubation?
Yankauer
What is used for ETT suction?
Soft, flexible suction available to suction ETT
What is important to do about monitor set up?
Ensure standard monitors are organized and laid out to facilitate easy placement based on patient position
What are standard vital signs taking throughout surgery?
Pulse oximeter; NIBP; ECG; temperature
Where should ECG leads be set to prepare for a supine patient?
under pillow
Where should ECG leads be set to prepare for a prone patient?
on IV pole
What other equipment should you have prepared?
- Arterial line (armboard, lidocaine, cleaning solution, sterile gloves/towels, 20g PIV/Arrow Catheter, u/s, wet set, transducer, etc.)
- Correct cables - communicating with monitor?
- Bair hugger blanket
- Fluid warmer, Belmont/Level 1, etc.
What are some other monitors that may need to be prepared for surgery?
BIS, cerebral oximeters, central lines (CVP/Pa Cath), Vigileo, etc.
What are the components of the airway setup?
- Laryngoscope blade(s) & handle
- Airway adjuncts (Glidescope, LMA, bougie)
- Tongue blade, soft bite block, OPA/NPA, lubricant
- Endotracheal tubes (Multiple sizes readily available)
- Stylet
- 10cc syringe
- Tape
- Plan A, B, C
What are the components of a complete focues patient assessment?
PMHx, PSHx, comorbidities, planned surgical intervention, NPO status, medication regimen, etc.
What must be done to the patients PIVs?
Ensure patency of pre-existing PIV or need to place PIV
What should be done regarding the patients arterial line?
Assess viability for arterial line whether or not one is anticipated
Why is it important to auscultate patient prior to surgery and induction?
Auscultate and ensure knowledge of baseline function
What might have to be done based on auscultation of the patient?
Optimize if necessary, e.g. nebulizer
What should be done to your ventilator prior to the case?
Pre-set ventilator
Who should the anesthetic plan be discussed with?
anesthesia and surgical team
What is a vital part of the preparation prior to surgery?
Obtain informed consent
Why is inspiration more of a concern with BLN?
Negative pressure and leads to pulmonary edema
What are the common classification of medications used in anesthesia?
- Benzodiazepine
- Lidocaine
- GA induction agent
- Muscle relaxant (1-2)
- Opioid
- Emergency medications (Vasopressors/Anticholinergic)
- Antiemetic(s)
- Anticholinesterase
What should the pump be preset with during the prep phase of surgery?
Preset infusion pumps with patient information (e.g. weight)
What should be done if you are infusing multiple medications?
Ensure manifold is prepared and medications labeled at the injection port
What should be done regarding IV access?
Consider how many IV lines are necessary and location of IV based on surgical site
Where do you do not want to put the IV?
Concerns with antecubital IV’s and positioning
What should be done with IV’s immediately following repositioning?
Makes sure your IV’s run immediately after arms are tucked or positioned
Inhalation induction: When is the commonly used? Why?
Often used in pediatric patients to maintain spontaneous ventilation, To sedate before starting IV
Inhalation induction: What is used during inhalation induction?
Use of oxygen/air/nitrous oxide and a volatile anesthetic such as isoflurane, sevoflurane, or desflurane
Inhalation induction: What is the nervous system that is depressed?
Depresses the SNS, allows for instrumentation of the patient’s airway and renders the patient unconscious
Inhalation induction: What is the advantages?
Less preparation (no need to prime infusions, preset patient weight, etc.)
Inhalation induction: What are the disadvantages?
Increased risk of PONV, can be irritating to airways (especially desflurane)
Inhalation induction: What is a way to encourage kids to participate more readily?
In pediatrics, can engage the child (flavored chapstick, blowing up balloon, etc.)
Inhalation induction: What nervous system is stimulated? What is the result?
PNS= increase secretions, salvation and nasal engorgement
Intravenous induction: What is typical patient positioning?
Patient is positioned in the supine position, with UE/LE secured and all monitors on and functioning
Intravenous induction: What should you ensure prior to induction?
Ensure VS are stable
Intravenous induction: Do you preoxygenate the patient?
Yes
Intravenous induction: what do you need to communicate with the attending?
Okay to extubate or Any airway concerns that you would want another provider present for
Inhalation induction: What is a tell tale sign of stage 2?
Engage accessory muscles, excitatory phase> once they decrease then we can turn the gas down
Intravenous Induction: What are some adjunct medications that may be administer?
Administer benzodiazepine, Administer lidocaine (+/-) and general anesthesia induction agent & Administer opioid (+/-)
Intravenous Induction: When is the best time to administer a benzo?
May be given in the holding area
Intravenous Induction: What is done after the medications are given to the patient?
Test glabellar tap then patient’s lash reflex
Intravenous Induction: What is done after testing the patients lash reflex?
When reflex is obliterated, tape eyes closed and begin bag/mask ventilation
Is mask ventilation preformed with RSI?
No mask ventilation if performing RSI
Intravenous Induction: What is the hand technique for bag/mask ventilation?
One or two handed
Intravenous Induction: What can be added to help with bag/mask ventilation?
OPA or NPA (+/-)
Intravenous Induction: What are we monitoring to assure adequate bag/mask ventilation? (3)
Monitor chest rise, tidal volume and respiratory rate
Intravenous Induction: When do you give the muscle relaxants?
Once you are able to demonstrate you can successfully mask ventilate the patient, the muscle relaxant can be given
Intravenous Induction: What is important to do before giving muscle relaxants?
Don’t forget to check the time!
Intravenous Induction: What are you doing while you wait for the muscle relaxant to take effect?
Continue bag mask ventilation long enough for muscle relaxant to set up
Intravenous Induction: What are we looking for during laryngoscopy and placement of ETT? (2)
- Verbalize view of cords
- Attach anesthesia circuit to ETT
Intravenous Induction: How do we ensure accurate ETT placement?
monitoring B/L chest rise, condensation in ETT, positive ETCO2, and auscultation of B/L breath sounds
Intravenous Induction: After ETT placement is confirmed what do we do next?
Turn on ventilator
Intravenous Induction: After ETT placement is confirmed what do we do next?
Turn on ventilator
Intravenous Induction: What do we turn on after turning on the ventilator?
Turn on inhalation agent or infusions if performing TIVA (TIVA infusions may be initiated at induction)
Intravenous Induction: How do we secure airway?
Tape, Place soft bite block between molars in anticipation of emergence/extubation
What is a concern if the patient has pink frothy secretions?
Negative pressure pulmonary edema
When do you give the muscle relaxants during RSI?
after induction medications and do not touch the bag
What is the primary difference from standard induction and rapid sequence induction?
- Avoid ventilation
- Cricoid pressure administered prior to beginning induction
When is cricoid pressure released?
auscultation
What are some extra attention components of RSI to ensure?
- Patient positioning
- Quality of preoxygenation
- Location and function of suction
- Accessibility of materials
When should patient positioning equipment be collected?
Collect all patient positioning equipment as part of OR set up, e.g. arm straps, arm boards, gel pads, etc.
What should be consider with patient position in the prone positioning?
If prone, consider whether or not to remove monitors for the “flip”
What should be consider with patient position in the lateral positioning?
If lateral consider where ECG leads are in relation to bean bag, surgical site, etc.
What is important to ensure patient safe position?
Place appropriate padding, safety belt, etc.
When should the bair hugger be applied?
Apply Bair Hugger (warming device) but do not turn on until surgical drapes are in place
Who should be communicated with regarding OGT and NGT?
Surgeon and whether or not he would like it be removed or kept in after surgery
What is the emory system’s term for a time out?
Call to order
Review time out for patient safety
Slide 23
What is the Standford anesthesia emergency manual?
cognitive aids for perioperative critical events
What is malignant hyperthermia?
A condition that triggers a severe reaction to certain anesthetic medications (e.g. inhalational anesthetics, succinylcholine)
What can happen with out treatment of malignant hyperthermia?
the disease is fatal
What is most of the cause of malignant hyperthermia?
Genes that cause MH are autosomal dominant
What is the typical s/s presentation for malignant hyperthermia?
In most cases no signs or symptoms of the condition exist until you are exposed to anesthesia
Maintenance: ________ is the key!
Vigilance
Maintenance: What should you be doing constantly in the maintenance stage?
Constant, purposeful sweep (right to left)
Maintenance: What is the being reviewed in the purposeful sweep?
Review monitor for VS, ETCO2, respiratory measures, CO2 absorbent, IV fluids, patient position (arms, face, etc.), ETT/airway, urine output, EBL, stage of the procedure
Maintenance: What must be considered in the purposeful sweep?
Consider ergonomics
Maintenance: Why is it important?
Anticipate key moments upcoming in the procedure
Maintenance: What must we avoid?
Avoid distractions/temptations
What is Guedel’s stages of anesthesia?
Analgesia (induction), Excitement, Surgical Anesthesia, Medullary Paralysis
What are the components of Guedel’s analgesia stage of anesthesia?
- Conscious but drowsy
- Decrease response to noxious stimuli
What are the components of Guedel’s excitment stage of anesthesia?
- Loss of consciousness
- Non-responsive to non-noxious stimuli
- Reflex response to noxious stimuli
What are the components of Guedel’s Surgical Anesthesia stage of anesthesia?
-Movement ceases and respiration is regular
What are the components of Guedel’s Medullary Paralysis stage of anesthesia?
- Respiration and vasomotor control cease
- Death
Pinpoint eyes means ____
Too much narcotics
Dilated eyes means ____
Too little narcotics
What is the response if someone is paralyzed?
May not have physical response but have autonomic response (increased heart rate or bp)
What may need to be administer during maintenance phase?
- Administer additional medications as needed
- Opioids, muscle relaxants, volume
What must be used when administering volume?
use appropriate formula
What type of lab work may need to be completed during the maintenance stage?
Type and screen, H&H, blood glucose, ABG, etc.
What can you begin to prepare for during the maintenance stage?
Prepare medications and supplies for extubation
What is the goal of emergence?
When the drapes comes down the patient is immediately extubated and ready for PACU
What is a cavet to the goal of emergence?
Unless the patient is in a position other than supine
Know the depth of anesthesia.
slide 30
Begin weaning the anesthetic when ________
closing begins
What is the foundation of emergence?
Remember you want the minimum amount of anesthesia necessary for the intervention
What may be needed when patient received a non-depolarizing muscle relaxant?
prepare reversal agents
When should the reversal for muscle relaxants be given?
Fascia closure, returning the patient to spontaneous ventilation, etc.
What is the reversal medication for non depolarizing muscle relaxant?
Sugammadex
What should be given prior to emergence?
antiemetics
When is the patient ready to extubate?
- Maintaining regular, adequate spontaneous ventilation
- Following commands: opens eyes, squeeze hand, show two fingers, 5 second sustained head lift
What are the steps for extubating?
-To extubate, loosen tape, and place syringe on pilot balloon. -When ready, close pop-off valve on anesthesia gas machine to create positive pressure and extubate patient with that positive pressure.
What will the patient experience during extubation?
Patient will cough
What needs to be assessed following extubation?
Assess patients’ ability to maintain airway following extubation – monitor saturation
What should you begin to prepare you patient for after extubation?
Prepare patient to either move themselves or be moved by anesthesia and surgical team to stretcher/in-patient bed
What is the last monitor to be removed?
Pulse oximetery
_______ will provide you valuable information to refine your technique
Post-operative visits
What are some important questions to ask the patient in a post-op visit?
- What is the last thing you remember?
- What was the first thing you remember when you woke up?
- Were you in pain after surgery?
- What worked to alleviate the pain?
- How long did your block last?
Who can you also talk to to gain insight on you patient post operatively?
Talk to PACU nurse to find out opioid and antiemetic requirements
What is TIVA?
Use of oxygen and intravenous general anesthesia induction agent and (possibly) opioid
What are the most common medications used for tiva? (2)
Most common medications are propofol and remifentanil
What medications are used for tiva when it is an atrial fibrillation ablation (3)?
Propofol, remifentanil, mivacurium with HFJV
What does TIVA depress?
Depresses the SNS to allow a for instrumentation of the patient’s airway and renders the patient unconscious
What are the advantages to TIVA?
Decreases the risk of PONV, allows for more reliable “wake up test”, less noxious to airway so decreased coughing upon waking and decreased risk of bronchospasm with induction
What are the disadvantages to TIVA?
Depending on agents used can be expensive, may be more difficult to time wake up
What is not present in the US right now?
At present no methods of measuring specific drug concentrations in real time (e.g. end tidal concentrations of inhalational agents)
What can make infusion rates more challenging?
Confounders may make infusion rates more challenging: Obesity, induction of CYP systems
TIVA: Careful consideration of ______ and _______ for access is critical
access and planning
What will effect context sensitive half life?
a specific drug will vary depending on the length of the infusion
What is context sensitive half life?
The time taken for the drug concentration to reduce by half once an infusion designed to maintain a constant plasma concentration is stopped
During an infusion, drugs will _______ and ________ within all tissues/compartments
accumulate and equilibrate
What effects accumulation of a drug?
The longer the duration of the infusion the higher the degree of accumulation which will maintain plasma levels of the drug beyond the discontinuation of the medication
What are some characteristic that are important for the careful selection of a TIVA drug? (4)
- Small volume of distribution
- Rapid metabolism with no active metabolites
- Short CSHT
- High clearance rate
What are some advantage populations that can benefit from TIVA? (8)
-Pediatrics
-MH (or suspicion of MH)
-Spine surgery / Motor evoke potentials (MEPs)
-Severe PONV
-Long QT syndrome
ENT or thoracic surgery where ETT is variable
-Neurosurgery
-Myasthenia gravis/Neuromuscular disorders
-Cases performed outside of the operating room
What is target controlled infusion?
An infusion system designed to aid in administering the appropriate amount of medication for TIVA goals
What algorithm is involved in the TCI?
Based on algorithmic modeling-Models built on experiences/studies of healthy volunteers
Many studies have concluded that TIVA will decrease the occurrence of what?
N/V and retching
What is enhanced recovery after surgery?
Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining pre-operative organ function and reducing the profound stress response following surgery.”
What are the characteristics of Enhanced recovery after anesthesia? (4)
- Using an evidenced-base approach
- Preoperative counseling
- Avoidance of perioperative fasting with carbohydrate loading up to 2 hrs preop
- Standardized anesthetic and analgesic regimens to include regional anesthesia and non-opioid anesthesia, and early ambulation after surgery
What is a cheap carb loading alternative?
Gatorade
What is integral for ERAS? (2)
Both the multimodal and OFA approach are integral for ERAS programs
ERAS: Involves a __________ pathways and
________ approach
Multimodal perioperative care; Multidisciplinary
How does ERAS achieve early recovery after surgical procedures? (6)
- Maintaining pre-operative organ function
- Reducing the stress response following surgery
- Preoperative counselling
- Optimization of nutrition
- Standardized analgesic and anesthetic regimens
- Early mobilization
What is the ERAS society?
is todevelop perioperative care and to improve recovery through research, education, audit and implementation of evidence-based practice
What is the multimodal approach?
Builds on a balanced anesthesia approach (what is commonly done today) that uses a combination of drugs is used to achieve their individual desired effect
What are some examples of the multimodal approach?
analgesia, muscle relaxation, unconsciousness, amnesia, NV, etc.
What is the principle of the multimodal approach?
using a combination of drugs allows one to use less of each agent to achieve desired effect while minimizing unwanted side effects
What is the multimodal pain approach?
uses a combination of drugs to decrease overall opioid use (opioid-sparing) by targeting other receptors involved in the nociceptive response of surgery: GABA, NMDA, alpha-2, COX inhibitors, local anesthetics, etc.
_______ maximizes the multimodal approach by avoiding opioids all together
OFA (opioid free anesthesia)
What is OFA?
Anesthesia technique in which preoperative/intraoperative opioids are avoided to achieve better postoperative outcomes
What does the OFA avoid?
Avoids negative side-effects of opioids
What are negative side effects of opioids?
Respiratory depression, opioid induced hyperalgesia, post-operative nausea and vomiting, addiction, hallucinations, cognitive dysfunction, sleep disturbance, impaired wound healing, cancer reoccurrence, and increased hospital stay or recovery from surgery
What is an NMDA drug that can be used for OFA (2)?
- Ketamine (NMDA) doses of 0.5 mg/kg
- Magnesium sulfate (NMDA)
What Alpha-2 agonists could be used for OFA?
Alpha-2 agonists (clonidine, Dex)
What is an anticonvulsant that can be used for OFA?
Gabapentin (anticonvulsant, analogue to GABA) or Pregabalin
What is the ceiling effect of Gabapentin?
Analgesia ceiling effect 600 mg (oral)
What is the ionizationation of Gabapentin?
Highly ionized
What is the protein binding of gabapentin?
not protein bound
What is the excretion of gabapentin?
Excreted unchanged in the urine- clearance follows creatine clearance.
What is the peak effect of gabapentin?
Peaks 3 hrs
What is the elimination half life of gabapentin?
half-life 5-7 hours
What are some antinflammatory drugs that can be used for OFA?
Anti-inflammatory drugs (dexamethasone, nonsteroidals, acetaminophen, ofirmev)
What is a regional anesthetic that can be used for OFA?
Intravenous lidocaine (1.5 mg/kg/hr) and regional blocks (blocks Na+ channels that suppress the nociceptive pain transmission)
