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Anesthesia Techniques > Induction and emergence > Flashcards

Induction and emergence Flashcards

1
Q

what is visible in mallampati class 1

A

pillars, uvula, soft palate, hard palate

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2
Q

what is visible in mallampati class 2

A

uvula, soft palate, hard palate

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3
Q

what is visible in mallampati class 3

A

soft palate, hard palate

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4
Q

what is visible in mallampati class 4

A

hard palate

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5
Q

what is an ASA of 1-2

A

healthy, young, no negative health factors

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6
Q

what is ASA of 3

A

1 or more comorbitities that affect life (DM)

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7
Q

what is ASA 4

A

illnesses that affect day to day life (ESRD, CHF, Angina)

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8
Q

what is ASA 5

A

they will die whether or not you do surgery

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9
Q

what is ASA 6

A

Brain-dead organ donor.

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10
Q

What is ASA E?

A

Emergency operations
-Place by any of the ASA numbers

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11
Q

what do you do before going back to OR

A

consent
check with surgeon
check with circulator
preop anxiolytics
abx

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12
Q

what are the steps for before induction

A

lock stretcher
move patient to table
attach monitors
preoxygenate

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13
Q

how long do you preoxygenate

A

3-4 minutes tidal volumes
8vital capacity breaths

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14
Q

what is a normal FRC

A

2L

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15
Q

if a patient is at if you want a patient with 2L VC to have 90% SpO2, how many ccs of O2 must they have?
what is a normal MV?
using this math how long will it take to preoxygenate

A

1800ccs
200-250ccs
8-9 minutes

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16
Q

what causes decreased FRC

A

obesity
pregnancy
smoking
positioning
medication

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17
Q

when do we use RSI

A

aspiration
DM
full stomach
gastroporesis
trauma

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18
Q

what are steps to RSI

A

prepare patient in room
preoxygenate
MEDS
cricoid pressure
intubate immediately
check breath sounds/etCO2

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19
Q

how much force is used for cricoid pressure

A

2.2kg

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20
Q

what meds do we use for RSI

A

Fentanyl
Lidocaine
Propofol
Roc (defasiculate)
Sux

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21
Q

how does a defasciculating dose of roc affect sux

A

decreases sux onset

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22
Q

what are steps of standard induction

A

prepare patient and room
preoxygenate
fent/lido/prop
tape eyes
ventilate
NMB
ventilate
intubate
check breath sounds
etCO2

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23
Q

if patient is opioid free what can we give to decrease stimulation with intubation

A

esmolol 10-20 mg

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24
Q

what is onset of ROC 0.6 mg/kg

A

2-3 min

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25
Q

what is onset of 1.2 mg/kg ROC

A

90 seconds

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26
Q

how can you check onset of ROC

A

TOF

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27
Q

what does 1 MAC mean

A

1 MAC = 50% of patients will move

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28
Q

what dose MAC do we use to ensure no movement

A

1.2 MAC

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29
Q

how much recall occurs in 0.5 MAC

A

50% will have recall

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30
Q

what do you do after successful intubation

A

turn on volatiles/ infusion of TIVA

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31
Q

what do we >1 MAC do to prepare for incision

A
  • > 1 MAC anesthesia or narcotics/paralytics
    -re-dose paralytics
    -drapes
    -time out
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32
Q

what is a maintenance dose of TIVA

A

prop infusion 100-200

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33
Q

what is the maintenance dose of volatiles

A

1 MAC

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34
Q

when do we redose abx

A

4 hrs

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35
Q

when do we redose vanco

A

6 hrs

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36
Q

how often do you check arms/face

A

q5-15 min depending on position

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37
Q

what do you do during maintenance

A

-TIVA or Volatiles dosage
-scan environment of pulse ox, volatiles, monitors, surgeon, patient
-check arms/face q5-15
-monitor EBL, evaporative loss
-listen to surgeon
-redose paralytics, narcotics, abx
-plan emergence

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38
Q

when do you plan for emergence

A

pre op

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39
Q

where do you TOF for induction

A

Orbicular Occuli

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40
Q

where do you TOF for emergence? why

A

Adductor Pollicus (correlates closer to diaphragm)

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41
Q

what are the two ways to check depth of NMBs

A

TOF
subjectively (timing of last dose, resp effort, head lift, hand squeeze etc)

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42
Q

1 twitch = ____% block

A

95

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43
Q

2 twitch = ____% block

A

90-95

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44
Q

3 twitch = ____% block

A

80-85

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45
Q

4 twitch = ____% block

A

75-80

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46
Q

what does one twitch under train of 4 represent

A

95% blockade and no free drug

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47
Q

when can we use reversals

A

post tetanic stimulation and return of 1 twitch
10 mins

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48
Q

what does spontaneous resp effort tell us

A

less than 100% blockade

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49
Q

what are examples of anti-cholinesterase inhibitors

A

neostigmine, edrophonium

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50
Q

when does neostigmine peak

A

10 min

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51
Q

what is the effect of anti-cholinesterase inhibitor

A

increase ACH everywhere

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52
Q

how do we counteract cholinergic symptoms

A

anticholinergics like glyco and atropine

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53
Q

how much atropine do we give with 3 mg neostigmine

A

0.6mg atropine
1.5 cc

.2mg for every 1 mg neostigmine

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54
Q

what affects the speed of reversals

A
  1. depth of block
  2. type of anti-cholinesterase
  3. dose of anti-cholinesterase
  4. spontaneous reversal and metabolism of neuromuscular blocking agent
  5. concentration of anesthetic gas
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55
Q

what abx medication increase the length of block

A

gentamycin

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56
Q

what are signs of cholinergic crisis

A

wet, bronchospasms, paralysis, bradycardia

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57
Q

what are signs of anti-cholinergic crisis

A

dry, hyperthermia, urinary retention, tachycardia, delayed emergence

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58
Q

what anticholinergic do we give with edrophonium

A

atropine

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59
Q

what anticholinergic do we give with neostigmine

A

glycopyrolate

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60
Q

which anticholinergic crosses the BBB

A

atropine

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61
Q

what are neuro effects of atropine

A

hallucinations, sedation

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62
Q

which has a faster onset atropine or glycopyrolate

A

atropine

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63
Q

which causes more tachycardia atropine or glycopyrrolate

A

atropine

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64
Q

which is a better antisialogue atropine or glycopyrrolate

A

robinol

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65
Q

what is the structure of glyco

A

quaternary

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66
Q

what property of inhaled anesthetics affects DOA

A

lipid solubility

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67
Q

what affects the offset of inhaled anesthetics

A

ventilation, fresh gas flow, concentration gradient

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68
Q

low flow and hypoventilation makes inhaled offset

A

slow

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69
Q

high flow and hyperventilation makes inhaled offset

A

fast

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70
Q

what does IV offest depend on

A

beta half life
length of infusion

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71
Q

what is gold standard TOF ratio

A

0.7-0.9

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72
Q

sustained tetanus from 50-100 mhs>5s indicates what blockade

A

50%

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73
Q

four TOF twitches tell us what percent blockade

A

75%

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74
Q

T/F spontaneous breathing and adequate tidal volume is a reliable sign of recovery

A

false

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75
Q

what are subjective signs of anesthesia recovery

A

5 second head lift
tongue protrusion
forced handgrip

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76
Q

what is our goal RR for narcotic dosing

A

8-10 with deep TV

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77
Q

what do we do for post-op analgesia

A

short acting narcotics
awake dosages
APAP
Toradol
regional blocks

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78
Q

how do avoid PONV

A

opioids
narcotics
anti-cholinesterase inhibitors

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79
Q

when do we give decadron

A

4 mg pre-incision

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80
Q

when do we give zofran

A

4 mg pre induction OR 30 min prior to emergence

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81
Q

when do we give propofol for PONV

A

20 mg close to emergence

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82
Q

what is a good rescue PONV drug

A

propofol 20 mg

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83
Q

what is taken into consideration for deep extubation

A

patient selection
must be recovered from NMBs
>1 mac
rr <15
clear secretions
always prepare for laryngospasms and reintubation
PACU cooperations
risk> benefits

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84
Q

what is lawsons maneuver

A

jaw thrust

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85
Q

what stage must patient be out of before leavin OR

A

stage 2

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86
Q

T/F extubate peds deep

A

F only awake

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87
Q

T/F you can extubate a RSI patient deep

A

false
must be awake

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88
Q

if doing awake extubation what criteria must patient meet

A

-follows commands
-protects airway
-appropriate cough/gag
-no edema
-difficult intubation?
-strong resp function
-SpO2> 93% on FiO2 <0.5
-stable hemodynamics

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89
Q

what signs do we look for for patient waking up

A

-hemodynamic changes
-increased HR
-increased BP
-return of reflexes (swallowing, lid reflex, Glabellar tap)
-call first name if reflexes have returned

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90
Q

what is bucking

A

a reflex response to a noxious stimulus

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91
Q

what attenuates a bucking response

A

narcotics,
LTA or lidocaine
hyperventilation
hypocarbia

92
Q

what medication can make patient forget to breathe

A

narcotics (sufentanil)

93
Q

what is the traditional wake up method

A

reverse NMBs
lighten anesthetics
increase EtCO2
return to spontaneous
titrate narcs to RR
extubate when patient is awake and following comands

94
Q

what are pros of traditional wake up

A

smooth, adequate anesthesia, comforting

95
Q

what are cons of traditional wake up

A

slow, hypoventilation decreases elimination of anesthetic

96
Q

what is the Fast off method

A

reverse NMBs
titrate down inhaled anesthetics
high FGF and High RR
dose narcs
extubate when patient awake and following commands

97
Q

how do we increase EtCO2

A

decrease RR, hold breathe

98
Q

how long does holding breath for 1 minute increase EtCO2? 2 minutes?

A

10, 11

99
Q

what are pros of fast wake up

A

fast, smooth when timed correctly

100
Q

what are cons of fast wake up

A

may not have adequate pain control
over/under dosing narcotics

101
Q

what is the crash wake up

A

full reverse
high FGF, high RR
narcan
shock em, pinch em, jaw thrust,
extubate when awake

102
Q

what is pros of crash wake up

A

fast emergence

103
Q

what is cons of crash wake up

A

not smooth

104
Q

what do you do if patient is too light and surgeon needs a little longer

A

push something: prop, lidocaine
push nothing: increased inhaled (N20 50%)

105
Q

if patient goes apnic what do you need to rule out

A

laryngospasm vs apnea

106
Q

what do you do for apnea

A

ventilate off gas and stimulate
Narcan

107
Q

what is sign of residual NMB

A

poor work of breathing

108
Q

what is treatment of laryngospasm

A

PPV,
sux,
prepare to intubate

109
Q

how much sux do you give for laryngospasm

A

1-2 ccs

110
Q

what can sustained laryngospasm lead to

A

Negative pressure pulm edema

111
Q

when patient has delayed emergence how do you respond

A

RULE OUT: hypercarbia, hypoxia, hypotension
intoxication
inadequate reversal or prolonged paralysis
hyper/hyponatremia
hyper/hypoglycemia
neuro/stroke

112
Q

bucking is better than anoxic brain injury

A

yep

113
Q

what are five considerations before you roll back to the OR

A

consent
surgeon (consent/ readiness)
check with room/circulator
preop anxiolytics
abx

114
Q

what are the steps for rsi

A

preoxygenated
Meds: fent, lido prop, roc/succ
cricoid pressure (before sedation)
intubate immediately
check breath sounds/etco2
let go cricoid pressure

115
Q

when can circulator/rn let go of cricoid pressure

A

after you have checked lung sounds/etco2

116
Q

when does criculator/rn need to start holding cricoid pressure

A

As prop is being pushed

117
Q

what are the steps for standard induction

A

preoxygenate
meds: fent/esmolol, lidocaine, propofol
tape eyes
ventilate
nmb
ventilate
intubate
check breath sounds/etco2

118
Q

when does awareness under anesthesia usually occur

A

between propofol and 1/2 mac

119
Q

you have just checked breath sounds after successfully placing ett during standard intubation, what is your next step

A

turn on volatile gas/infusion if TIVA

120
Q

after you have intubated and turned on the gas, what are your next steps

A

tape tube,
position arms/head,
put on temp probe

121
Q

at what mac should patient be at before incision

A

1.2 MAC

122
Q

what should you check every 5-15 minutes during the surgery/operation

A

position- arms, face depending on position

123
Q

when should you start planning for emergence

A

before induction

124
Q

what nerve should you be testing nmb blockade depth with when patient is first getting paralyzed

A

orbicularis occuli- (facial nerve-7)

125
Q

what muscle should you be testing nmb blockade depth when patient is waking up from nmb

A

adductor pollicus (ulnar nerve)

126
Q

why do you test adductor pollicus response before waking up

A

better correlated with diaphragm

127
Q

what are the five factors for how fast reversal doses for nmb’s work

A

depth of block
type of anticholinesterase
dose of anticholinesterase
spontaneous reversal/metabolism of nmb
concentration of anesthetic gas

128
Q

what are the side effects of over reversal from nmb

A

cholinergic crisis

129
Q

what are the sx of cholinergic crisis (with neostigmine)

A

wet(vomit/diarrhea)
bronchospasm
paralysis
bradycardia

130
Q

what are the sx of anti cholinergic crisis (glycopyrolate)

A

dry
hyperthermia
urinary retention
tachycardia
delayed emergence

131
Q

what can atropine cause since it cross the bbb

A

hallucinations, sedation

132
Q

which volatile is the fastest to wear off and why

A

desflurane- low lipid solubility

133
Q

what are variables that influence how quickly an anesthetic wears off

A

ventilation
fresh gas flow
concentration gradient
blood/gas/lipid solubility

134
Q

what does low flow and hypoventilation lead to with anesthetic wearing off

A

slower to come off

135
Q

what does high flow and hyperventilation lead to with anesthetic wearing off

A

faster to come off

136
Q

what does iv anesthesia wearing off depend on

A

beta half life
length of infusion
patient
level of stimulation

137
Q

what is the gold standard for verifying reversal

A

tofr of 0.7-0.9

138
Q

what does sustained tetanus of >5 seconds at 50-100 mhz without fade indicate

A

50% blockade

139
Q

what are some subjective ways to verify reversal

A

5 second head lift
tongue protrusion
forced handgrip

140
Q

t or f- spontaneous breathing with adequate tidal volume is a reliable way to verify reversal

A

f- diaphragm is most resistant to nmb

141
Q

how can you prevent patient form waking up in pain

A

timing of narcotics
adjuncts
regionals

142
Q

how should you dose shorting acting narcotics

A

titrate to rr- use awake dosages

143
Q

what meds can you try to avoid so that ponv is minimized

A

opioids/narcotics
cholinesterase inhibitors
tiva instead of volatiles

144
Q

what are some meds you can give to prevent ponv

A

-zofran 4mg pre induction/30 minutes before emergence
-decadron 4mg pre incision
-prop 20mg close to emergence
-scopolamine patch pre op

145
Q

when should you give zofran for ponv prevention

A

4mg pre induction or 30 mins before emergence

146
Q

when should decadron be given for ponv prevention

A

4 mg pre incision

147
Q

when should propofol be given for ponv prevention

A

20mg close to emergence

148
Q

what should you alway prepare for during extubation

A

laryngospasm and reintubation

149
Q

your patient laryngospasms on your way to pacu, what is your first action

A

larson maneuver

150
Q

what are the steps for traditional wake up

A

reverse nmb
lighten anesthetic/increase etco2
return to spontaneous breathing
titrae narcotics to resp rate
activate when pt is awake

151
Q

what are some pros of traditional wake up

A

smooth, adequate analgesia, comforting

152
Q

what are cons of traditional wake up

A

slow
hypoventilation decreases elim of anesthetic

153
Q

what is the fast off way for waking someone up

A

reverse nmb
titrae down inhaled anesthetics
high fgf/rr
extubate when awake and following commands

154
Q

what are cons of fast off

A

may not have adequate pain control
under/overdose narcotics

155
Q

what are the steps for crash wake up

A

full reverse
high fgf/high rr
narcan
jaw thrust, shock, pinch
extubate when awake

156
Q

what can you do when patient is too light and student is closing

A

push a little something- propofol
increase n2o/inhaled concentration

157
Q

what should be ruled out before diagnosing emergence delirium

A

hypercarbia
hypoxia
hypotension
inadequate nmb reversal
neurologic problems- stroke
hypoglycemia

158
Q

what can cause emergence delirium

A

waking up too fast
inadequate pain control

159
Q

what stage of anesthesia is emergence delirium most common

A

stage 2

160
Q

what is the management process for emergence delirium

A

don’t extubate
restart- push prop/fent/precedex
–avoid benzos

161
Q

what med class should be avoided to treat emergence delirium

A

benzos

162
Q

what can happen with a large dose of narcan

A

catecholamine surge
flash pulmonary edema

163
Q

what can prolonged laryngospasm lead to besides poor oxygenation

A

negative pressure pulmonary edema

164
Q

you believe your patient has laryngospasmed on the way to pacu, what are some next steps

A

sustained ppv
prepare succ/reintubation

165
Q

you think your patient is apneic on way to pacu, what are some next steps

A

ventilate off gas
stimulate
narcan
-could be residual nmb

166
Q

what can you use to decrease bucking response

A

narcotics
lta or lidocaine to numb cords

167
Q

during preop exam, where do you get most of information from

A

patient history
-other: labs, exam

168
Q

what kind of past anesthesia complications do you want to ask patient abou

A

intubated for long time post op- cholinesterase deficiency
high fever- MH
severe PONV

169
Q

what kinds of disease would prompt crna to use rsi technique

A

acid reflux everyday
dm- gastroparesis
full stomach-emergency

170
Q

how long does bicitra last and when do you want to give it

A

20 mins, give right before rolling back
-neutralizes acid in stomach

171
Q

why do you want to make stomach less acidic before anesthesia

A

decrease risk of aspiration pneumonitis

172
Q

what is mendelson’s criteria

A

ph <2.5
volume >30 cc

173
Q

if patients has a low ph and high volume in their stomach, what are they more at risk for

A

aspiration pneumonitis

174
Q

your patient has taken their ace inhibitor the morning of surgery. what will this cause and how do you treat it

A

refractory hypotension
-vasopressin or phenylephrine

175
Q

a patient comes to their surgery have not taken their beta blocker in 24 hours. It is ok to proceed as usual with surgery

A

no- give patient beta blocker to avoid rebound tachycardia/htn

176
Q

what does MET score need to be to have surgery

A

> 4

177
Q

what does met score stand for and why is it used

A

metabolic equivalent testing
-predicts cardiac function

178
Q

what does asa 2 mean

A

1-2 comorbidities
htn, osteoarthritis

smokers, social drinkers

179
Q

what does asa 3 mean

A

> 1 comorbidity that alters life
-chf uncontrolled, dm, copd

morbid obesity

pts with severe systemic disease or substantive function limitations

180
Q

what does asa 4 man

A

pts with severe systemic disease that is constant threat to life
<3months MI CVA TIA or CAD stents, low EF, sepsis, severe valve dysfunction

impairs day to day living
-esrd, angina

181
Q

what does asa 5 mean

A

iminent death with/without surgery

182
Q

what does asa 6 mean

A

organ procurement

183
Q

what are risks/benefits do you have to talk about with patient to get consent

A

heart attack
death
stroke
dysrhythmias
breathing tube insertion
ponv
numbness/back pain/sore throat

184
Q

after preop is done, what should you do

A

go back to room to make sure room is set up for patient and their comorbidities

185
Q

how long should you preoxygenate patient for

A

3-4 mins or 4 vital capacity breaths

186
Q

what is a normal frc

A

2L

187
Q

what is normal minute ventilation

A

200cc/min

188
Q

how do you calculate minute ventilation

A

tidal volume x rr

189
Q

if your end tidal o2 is reading 90%, what does this mean

A

it means at a normal frc of 2L, 90% of it is oxygenated (so 1800ml)

190
Q

if your end tidal o2 is reading 90%, how many minutes can be patient be apneic before desaturating

A

90% of 2L frc= 1800 mL of oxygen
1800 ml/200 ml minute ventilation=
9 minutes

191
Q

what are some things that increase o2 consumption

A

hyperthermia
pregnancy
infection

192
Q

what are some things that decrease frc

A

copd
pregnancy
positioning
abdominal obesity

193
Q

what threshold do you want to hit on feo2 before intubation

A

90%

194
Q

when giving a defasiculating dose of roc, how does this affect succ

A

slows onset time

195
Q

what do you give to decrease sns stimulationg during DL

A

fent or 1 cc esmolol

196
Q

what mac needs to be reached to ensure there isn’t recall

A

1/2 mac, ideally 0.8 mac

197
Q

what does 1/2 mac mean

A

1/2 of patient’s won’t have recall

198
Q

what does 1 mac mean

A

1/2 of patient’s won’t move on incision

199
Q

if your surgery is going to last 1 hour, how much roc or vec should you push

A

30-50 mg of roc
5mg of vec

200
Q

what is a prop infusion dose

A

125-150 mcg/kg/hr

201
Q

how often do you re dose ancef

A

q4 hours
vanc q6h

202
Q

how much does succ increase potassium

A

0.5 transiently

203
Q

you are performing a post tetanic stimulation. You have 1 twitch post tetany. When can you reverse

A

10 min

204
Q

how can you tell on monitors that neostigmine is having increased affect

A

increasing tidal volume

205
Q

what are reasons for giving glyco or atropine with cholinesterase inhibitor

A

help to isolate nicotinic receptors
prevents muscarinic effects such as decrease HR, intestinal spasm, hypotension, bronchoconstriction

206
Q

what med can simulate phase 2 block if given too much

A

neostigmine

207
Q

what volatile lasts the longest

A

isoflurane

208
Q

you drop your patient off at pacu and before you leave the nurse says the patient looks floppy. what is the likely problem and what can you do about it

A

post op residual paralysis
-suggamadex

209
Q

when should you extubate patient that you did rsi- deep or awake

A

awake

210
Q

when should you extubate someone if you are worried about laryngospasm- deep or awake

A

awake

211
Q

what is rr requirement for deep extubation

A

<15

212
Q

what is mac requirement for deep extubation

A

> 1 mac

213
Q

what are some requirements for deep extubation

A

> 1 mac
<15 rr
clear secretions
pacu cooperation

214
Q

what are requirements for awake extubation

A

follows commands
cough/gag reflex
no edema
spo2>93% or fio2 <0.5
stable hemodynamics

215
Q

what reflexes are you looking for return of

A

swallowing
lid reflex
glabellar tap
cough

216
Q

you take patient off ventilator for 2 minutes to increase their etco2 so they start sponatenously breathing. How much will etco2 raise

A

10 meq/L 1 for every minute after

217
Q

what ways can you increase etco2 and why would you want to do that

A

decrease rr, take off vent
-spontaneously breath

218
Q

at what etco2 will patient start breathing again

A

50 meq/L

219
Q

what are some causes of air not moving post extubation

A

obstruction- jaw thrust
narcotic od- narcan 0.4mg

220
Q

your patient is retracting but air is not moving with jaw thrust, what is cause

A

laryngospasm

221
Q

when preoxygenating patient, what setting should apl valve be on

A

open

222
Q

when preoxygenating patient, what should o2 flow be

A

> 5L/min

223
Q

t or f- tape eyes shut before bagging patient during induction sequence

A

true

224
Q

what is standard roc dose for standard intubation

A

0.6 mg/kg or 50mg

225
Q

which hand should you double glove when intubating

A

right hand- it gets in patient’s mouth

Anesthesia Techniques (11 decks)

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