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2-General Anesthesia Exam 1 > General Anesthesia Techniques > Flashcards

General Anesthesia Techniques Flashcards

1
Q

Define GA.

A

General Anesthesia

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2
Q

Define RSI.

A

Rapid Sequence Induction

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3
Q

Define TIVA.

A

Total Intravenous (IV) Anesthesia

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4
Q

Define ERAS.

A

Enhanced Recovery after Surgery

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5
Q

What are the three gold standards of general anesthesia? (3)

A

Amnesia, Anxiolysis/Hypnosis & Analgesia

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6
Q

What is the mnemonic for anesthesia case preparation?

A

Ms. Maid

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7
Q

What does the M in Ms. Maid mean?

A

Machine

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8
Q

What does the S in Ms. Maid mean?

A

Suction

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9
Q

What does the second M in Ms. Maid mean?

A

Monitor

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10
Q

What does the A in Ms. Maid mean?

A

Airway

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11
Q

What does the I in Ms. Maid mean?

A

IV, Preop Assess

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12
Q

What does the D in Ms. Maid mean?

A

Drugs

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13
Q

What does the E in Ms. Maide mean?

A

Equipment

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14
Q

Who should you conform the anesthesia gas machine check with at clinical sites?

A

Confirm with Clinical Coordinator/colleagues/faculty AGM at new facility prior to rotation

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15
Q

What must be selected for appropriate ventilation?

A

appropriate size mask for ventilation

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16
Q

What must we ensure in functional and working?

A

ETCO2 monitor

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17
Q

What is a standard equipment check that must be in every room before the start of the case?

A

AMBU

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18
Q

What must be done to suctioning?

A

readily available and functional

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19
Q

What suction is used for intubation?

A

Yankauer

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20
Q

What is used for ETT suction?

A

Soft, flexible suction available to suction ETT

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21
Q

What is important to do about monitor set up?

A

Ensure standard monitors are organized and laid out to facilitate easy placement based on patient position

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22
Q

What are standard vital signs taking throughout surgery?

A

Pulse oximeter; NIBP; ECG; temperature

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23
Q

Where should ECG leads be set to prepare for a supine patient?

A

under pillow

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24
Q

Where should ECG leads be set to prepare for a prone patient?

A

on IV pole

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25
Q

What other equipment should you have prepared?

A
  • 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.
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26
Q

What are some other monitors that may need to be prepared for surgery?

A

BIS, cerebral oximeters, central lines (CVP/Pa Cath), Vigileo, etc.

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27
Q

What are the components of the airway setup?

A
  • 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
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28
Q

What are the components of a complete focues patient assessment?

A

PMHx, PSHx, comorbidities, planned surgical intervention, NPO status, medication regimen, etc.

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29
Q

What must be done to the patients PIVs?

A

Ensure patency of pre-existing PIV or need to place PIV

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30
Q

What should be done regarding the patients arterial line?

A

Assess viability for arterial line whether or not one is anticipated

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31
Q

Why is it important to auscultate patient prior to surgery and induction?

A

Auscultate and ensure knowledge of baseline function

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32
Q

What might have to be done based on auscultation of the patient?

A

Optimize if necessary, e.g. nebulizer

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33
Q

What should be done to your ventilator prior to the case?

A

Pre-set ventilator

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34
Q

Who should the anesthetic plan be discussed with?

A

anesthesia and surgical team

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35
Q

What is a vital part of the preparation prior to surgery?

A

Obtain informed consent

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36
Q

Why is inspiration more of a concern with BLN?

A

Negative pressure and leads to pulmonary edema

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37
Q

What are the common classification of medications used in anesthesia?

A
  • Benzodiazepine
  • Lidocaine
  • GA induction agent
  • Muscle relaxant (1-2)
  • Opioid
  • Emergency medications (Vasopressors/Anticholinergic)
  • Antiemetic(s)
  • Anticholinesterase
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38
Q

What should the pump be preset with during the prep phase of surgery?

A

Preset infusion pumps with patient information (e.g. weight)

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39
Q

What should be done if you are infusing multiple medications?

A

Ensure manifold is prepared and medications labeled at the injection port

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40
Q

What should be done regarding IV access?

A

Consider how many IV lines are necessary and location of IV based on surgical site

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41
Q

Where do you do not want to put the IV?

A

Concerns with antecubital IV’s and positioning

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42
Q

What should be done with IV’s immediately following repositioning?

A

Makes sure your IV’s run immediately after arms are tucked or positioned

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43
Q

Inhalation induction: When is the commonly used? Why?

A

Often used in pediatric patients to maintain spontaneous ventilation, To sedate before starting IV

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44
Q

Inhalation induction: What is used during inhalation induction?

A

Use of oxygen/air/nitrous oxide and a volatile anesthetic such as isoflurane, sevoflurane, or desflurane

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45
Q

Inhalation induction: What is the nervous system that is depressed?

A

Depresses the SNS, allows for instrumentation of the patient’s airway and renders the patient unconscious

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46
Q

Inhalation induction: What is the advantages?

A

Less preparation (no need to prime infusions, preset patient weight, etc.)

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47
Q

Inhalation induction: What are the disadvantages?

A

Increased risk of PONV, can be irritating to airways (especially desflurane)

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48
Q

Inhalation induction: What is a way to encourage kids to participate more readily?

A

In pediatrics, can engage the child (flavored chapstick, blowing up balloon, etc.)

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49
Q

Inhalation induction: What nervous system is stimulated? What is the result?

A

PNS= increase secretions, salvation and nasal engorgement

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50
Q

Intravenous induction: What is typical patient positioning?

A

Patient is positioned in the supine position, with UE/LE secured and all monitors on and functioning

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51
Q

Intravenous induction: What should you ensure prior to induction?

A

Ensure VS are stable

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52
Q

Intravenous induction: Do you preoxygenate the patient?

A

Yes

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53
Q

Intravenous induction: what do you need to communicate with the attending?

A

Okay to extubate or Any airway concerns that you would want another provider present for

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54
Q

Inhalation induction: What is a tell tale sign of stage 2?

A

Engage accessory muscles, excitatory phase> once they decrease then we can turn the gas down

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55
Q

Intravenous Induction: What are some adjunct medications that may be administer?

A

Administer benzodiazepine, Administer lidocaine (+/-) and general anesthesia induction agent & Administer opioid (+/-)

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56
Q

Intravenous Induction: When is the best time to administer a benzo?

A

May be given in the holding area

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57
Q

Intravenous Induction: What is done after the medications are given to the patient?

A

Test glabellar tap then patient’s lash reflex

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58
Q

Intravenous Induction: What is done after testing the patients lash reflex?

A

When reflex is obliterated, tape eyes closed and begin bag/mask ventilation

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59
Q

Is mask ventilation preformed with RSI?

A

No mask ventilation if performing RSI

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60
Q

Intravenous Induction: What is the hand technique for bag/mask ventilation?

A

One or two handed

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61
Q

Intravenous Induction: What can be added to help with bag/mask ventilation?

A

OPA or NPA (+/-)

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62
Q

Intravenous Induction: What are we monitoring to assure adequate bag/mask ventilation? (3)

A

Monitor chest rise, tidal volume and respiratory rate

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63
Q

Intravenous Induction: When do you give the muscle relaxants?

A

Once you are able to demonstrate you can successfully mask ventilate the patient, the muscle relaxant can be given

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64
Q

Intravenous Induction: What is important to do before giving muscle relaxants?

A

Don’t forget to check the time!

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65
Q

Intravenous Induction: What are you doing while you wait for the muscle relaxant to take effect?

A

Continue bag mask ventilation long enough for muscle relaxant to set up

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66
Q

Intravenous Induction: What are we looking for during laryngoscopy and placement of ETT? (2)

A
  • Verbalize view of cords

- Attach anesthesia circuit to ETT

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67
Q

Intravenous Induction: How do we ensure accurate ETT placement?

A

monitoring B/L chest rise, condensation in ETT, positive ETCO2, and auscultation of B/L breath sounds

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68
Q

Intravenous Induction: After ETT placement is confirmed what do we do next?

A

Turn on ventilator

69
Q

Intravenous Induction: After ETT placement is confirmed what do we do next?

A

Turn on ventilator

70
Q

Intravenous Induction: What do we turn on after turning on the ventilator?

A

Turn on inhalation agent or infusions if performing TIVA (TIVA infusions may be initiated at induction)

71
Q

Intravenous Induction: How do we secure airway?

A

Tape, Place soft bite block between molars in anticipation of emergence/extubation

72
Q

What is a concern if the patient has pink frothy secretions?

A

Negative pressure pulmonary edema

73
Q

When do you give the muscle relaxants during RSI?

A

after induction medications and do not touch the bag

74
Q

What is the primary difference from standard induction and rapid sequence induction?

A
  • Avoid ventilation

- Cricoid pressure administered prior to beginning induction

75
Q

When is cricoid pressure released?

A

auscultation

76
Q

What are some extra attention components of RSI to ensure?

A
  • Patient positioning
  • Quality of preoxygenation
  • Location and function of suction
  • Accessibility of materials
77
Q

When should patient positioning equipment be collected?

A

Collect all patient positioning equipment as part of OR set up, e.g. arm straps, arm boards, gel pads, etc.

78
Q

What should be consider with patient position in the prone positioning?

A

If prone, consider whether or not to remove monitors for the “flip”

79
Q

What should be consider with patient position in the lateral positioning?

A

If lateral consider where ECG leads are in relation to bean bag, surgical site, etc.

80
Q

What is important to ensure patient safe position?

A

Place appropriate padding, safety belt, etc.

81
Q

When should the bair hugger be applied?

A

Apply Bair Hugger (warming device) but do not turn on until surgical drapes are in place

82
Q

Who should be communicated with regarding OGT and NGT?

A

Surgeon and whether or not he would like it be removed or kept in after surgery

83
Q

What is the emory system’s term for a time out?

A

Call to order

84
Q

Review time out for patient safety

A

Slide 23

85
Q

What is the Standford anesthesia emergency manual?

A

cognitive aids for perioperative critical events

86
Q

What is malignant hyperthermia?

A

A condition that triggers a severe reaction to certain anesthetic medications (e.g. inhalational anesthetics, succinylcholine)

87
Q

What can happen with out treatment of malignant hyperthermia?

A

the disease is fatal

88
Q

What is most of the cause of malignant hyperthermia?

A

Genes that cause MH are autosomal dominant

89
Q

What is the typical s/s presentation for malignant hyperthermia?

A

In most cases no signs or symptoms of the condition exist until you are exposed to anesthesia

90
Q

Maintenance: ________ is the key!

A

Vigilance

91
Q

Maintenance: What should you be doing constantly in the maintenance stage?

A

Constant, purposeful sweep (right to left)

92
Q

Maintenance: What is the being reviewed in the purposeful sweep?

A

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

93
Q

Maintenance: What must be considered in the purposeful sweep?

A

Consider ergonomics

94
Q

Maintenance: Why is it important?

A

Anticipate key moments upcoming in the procedure

95
Q

Maintenance: What must we avoid?

A

Avoid distractions/temptations

96
Q

What is Guedel’s stages of anesthesia?

A

Analgesia (induction), Excitement, Surgical Anesthesia, Medullary Paralysis

97
Q

What are the components of Guedel’s analgesia stage of anesthesia?

A
  • Conscious but drowsy

- Decrease response to noxious stimuli

98
Q

What are the components of Guedel’s excitment stage of anesthesia?

A
  • Loss of consciousness
  • Non-responsive to non-noxious stimuli
  • Reflex response to noxious stimuli
99
Q

What are the components of Guedel’s Surgical Anesthesia stage of anesthesia?

A

-Movement ceases and respiration is regular

100
Q

What are the components of Guedel’s Medullary Paralysis stage of anesthesia?

A
  • Respiration and vasomotor control cease

- Death

101
Q

Pinpoint eyes means ____

A

Too much narcotics

102
Q

Dilated eyes means ____

A

Too little narcotics

103
Q

What is the response if someone is paralyzed?

A

May not have physical response but have autonomic response (increased heart rate or bp)

104
Q

What may need to be administer during maintenance phase?

A
  • Administer additional medications as needed

- Opioids, muscle relaxants, volume

105
Q

What must be used when administering volume?

A

use appropriate formula

106
Q

What type of lab work may need to be completed during the maintenance stage?

A

Type and screen, H&H, blood glucose, ABG, etc.

107
Q

What can you begin to prepare for during the maintenance stage?

A

Prepare medications and supplies for extubation

108
Q

What is the goal of emergence?

A

When the drapes comes down the patient is immediately extubated and ready for PACU

109
Q

What is a cavet to the goal of emergence?

A

Unless the patient is in a position other than supine

110
Q

Know the depth of anesthesia.

A

slide 30

111
Q

Begin weaning the anesthetic when ________

A

closing begins

112
Q

What is the foundation of emergence?

A

Remember you want the minimum amount of anesthesia necessary for the intervention

113
Q

What may be needed when patient received a non-depolarizing muscle relaxant?

A

prepare reversal agents

114
Q

When should the reversal for muscle relaxants be given?

A

Fascia closure, returning the patient to spontaneous ventilation, etc.

115
Q

What is the reversal medication for non depolarizing muscle relaxant?

A

Sugammadex

116
Q

What should be given prior to emergence?

A

antiemetics

117
Q

When is the patient ready to extubate?

A
  • Maintaining regular, adequate spontaneous ventilation

- Following commands: opens eyes, squeeze hand, show two fingers, 5 second sustained head lift

118
Q

What are the steps for extubating?

A

-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.

119
Q

What will the patient experience during extubation?

A

Patient will cough

120
Q

What needs to be assessed following extubation?

A

Assess patients’ ability to maintain airway following extubation – monitor saturation

121
Q

What should you begin to prepare you patient for after extubation?

A

Prepare patient to either move themselves or be moved by anesthesia and surgical team to stretcher/in-patient bed

122
Q

What is the last monitor to be removed?

A

Pulse oximetery

123
Q

_______ will provide you valuable information to refine your technique

A

Post-operative visits

124
Q

What are some important questions to ask the patient in a post-op visit?

A
  • 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?
125
Q

Who can you also talk to to gain insight on you patient post operatively?

A

Talk to PACU nurse to find out opioid and antiemetic requirements

126
Q

What is TIVA?

A

Use of oxygen and intravenous general anesthesia induction agent and (possibly) opioid

127
Q

What are the most common medications used for tiva? (2)

A

Most common medications are propofol and remifentanil

128
Q

What medications are used for tiva when it is an atrial fibrillation ablation (3)?

A

Propofol, remifentanil, mivacurium with HFJV

129
Q

What does TIVA depress?

A

Depresses the SNS to allow a for instrumentation of the patient’s airway and renders the patient unconscious

130
Q

What are the advantages to TIVA?

A

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

131
Q

What are the disadvantages to TIVA?

A

Depending on agents used can be expensive, may be more difficult to time wake up

132
Q

What is not present in the US right now?

A

At present no methods of measuring specific drug concentrations in real time (e.g. end tidal concentrations of inhalational agents)

133
Q

What can make infusion rates more challenging?

A

Confounders may make infusion rates more challenging: Obesity, induction of CYP systems

134
Q

TIVA: Careful consideration of ______ and _______ for access is critical

A

access and planning

135
Q

What will effect context sensitive half life?

A

a specific drug will vary depending on the length of the infusion

136
Q

What is context sensitive half life?

A

The time taken for the drug concentration to reduce by half once an infusion designed to maintain a constant plasma concentration is stopped

137
Q

During an infusion, drugs will _______ and ________ within all tissues/compartments

A

accumulate and equilibrate

138
Q

What effects accumulation of a drug?

A

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

139
Q

What are some characteristic that are important for the careful selection of a TIVA drug? (4)

A
  • Small volume of distribution
  • Rapid metabolism with no active metabolites
  • Short CSHT
  • High clearance rate
140
Q

What are some advantage populations that can benefit from TIVA? (8)

A

-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

141
Q

What is target controlled infusion?

A

An infusion system designed to aid in administering the appropriate amount of medication for TIVA goals

142
Q

What algorithm is involved in the TCI?

A

Based on algorithmic modeling-Models built on experiences/studies of healthy volunteers

143
Q

Many studies have concluded that TIVA will decrease the occurrence of what?

A

N/V and retching

144
Q

What is enhanced recovery after surgery?

A

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.”

145
Q

What are the characteristics of Enhanced recovery after anesthesia? (4)

A
  • 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
146
Q

What is a cheap carb loading alternative?

A

Gatorade

147
Q

What is integral for ERAS? (2)

A

Both the multimodal and OFA approach are integral for ERAS programs

148
Q

ERAS: Involves a __________ pathways and

________ approach

A

Multimodal perioperative care; Multidisciplinary

149
Q

How does ERAS achieve early recovery after surgical procedures? (6)

A
  • Maintaining pre-operative organ function
  • Reducing the stress response following surgery
  • Preoperative counselling
  • Optimization of nutrition
  • Standardized analgesic and anesthetic regimens
  • Early mobilization
150
Q

What is the ERAS society?

A

is todevelop perioperative care and to improve recovery through research, education, audit and implementation of evidence-based practice

151
Q

What is the multimodal approach?

A

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

152
Q

What are some examples of the multimodal approach?

A

analgesia, muscle relaxation, unconsciousness, amnesia, NV, etc.

153
Q

What is the principle of the multimodal approach?

A

using a combination of drugs allows one to use less of each agent to achieve desired effect while minimizing unwanted side effects

154
Q

What is the multimodal pain approach?

A

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.

155
Q

_______ maximizes the multimodal approach by avoiding opioids all together

A

OFA (opioid free anesthesia)

156
Q

What is OFA?

A

Anesthesia technique in which preoperative/intraoperative opioids are avoided to achieve better postoperative outcomes

157
Q

What does the OFA avoid?

A

Avoids negative side-effects of opioids

158
Q

What are negative side effects of opioids?

A

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

159
Q

What is an NMDA drug that can be used for OFA (2)?

A
  • Ketamine (NMDA) doses of 0.5 mg/kg

- Magnesium sulfate (NMDA)

160
Q

What Alpha-2 agonists could be used for OFA?

A

Alpha-2 agonists (clonidine, Dex)

161
Q

What is an anticonvulsant that can be used for OFA?

A

Gabapentin (anticonvulsant, analogue to GABA) or Pregabalin

162
Q

What is the ceiling effect of Gabapentin?

A

Analgesia ceiling effect 600 mg (oral)

163
Q

What is the ionizationation of Gabapentin?

A

Highly ionized

164
Q

What is the protein binding of gabapentin?

A

not protein bound

165
Q

What is the excretion of gabapentin?

A

Excreted unchanged in the urine- clearance follows creatine clearance.

166
Q

What is the peak effect of gabapentin?

A

Peaks 3 hrs

167
Q

What is the elimination half life of gabapentin?

A

half-life 5-7 hours

168
Q

What are some antinflammatory drugs that can be used for OFA?

A

Anti-inflammatory drugs (dexamethasone, nonsteroidals, acetaminophen, ofirmev)

169
Q

What is a regional anesthetic that can be used for OFA?

A

Intravenous lidocaine (1.5 mg/kg/hr) and regional blocks (blocks Na+ channels that suppress the nociceptive pain transmission)

2-General Anesthesia Exam 1 (7 decks)

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