Induction and emergence Flashcards
1
Q
what is visible in mallampati class 1
A
pillars, uvula, soft palate, hard palate
2
Q
what is visible in mallampati class 2
A
uvula, soft palate, hard palate
3
Q
what is visible in mallampati class 3
A
soft palate, hard palate
4
Q
what is visible in mallampati class 4
A
hard palate
5
Q
what is an ASA of 1-2
A
healthy, young, no negative health factors
6
Q
what is ASA of 3
A
1 or more comorbitities that affect life (DM)
7
Q
what is ASA 4
A
illnesses that affect day to day life (ESRD, CHF, Angina)
8
Q
what is ASA 5
A
they will die whether or not you do surgery
9
Q
what is ASA 6
A
Brain-dead organ donor.
10
Q
What is ASA E?
A
Emergency operations
-Place by any of the ASA numbers
11
Q
what do you do before going back to OR
A
consent
check with surgeon
check with circulator
preop anxiolytics
abx
12
Q
what are the steps for before induction
A
lock stretcher
move patient to table
attach monitors
preoxygenate
13
Q
how long do you preoxygenate
A
3-4 minutes tidal volumes
8vital capacity breaths
14
Q
what is a normal FRC
A
2L
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
16
Q
what causes decreased FRC
A
obesity
pregnancy
smoking
positioning
medication
17
Q
when do we use RSI
A
aspiration
DM
full stomach
gastroporesis
trauma
18
Q
what are steps to RSI
A
prepare patient in room
preoxygenate
MEDS
cricoid pressure
intubate immediately
check breath sounds/etCO2
19
Q
how much force is used for cricoid pressure
A
2.2kg
20
Q
what meds do we use for RSI
A
Fentanyl
Lidocaine
Propofol
Roc (defasiculate)
Sux
21
Q
how does a defasciculating dose of roc affect sux
A
decreases sux onset
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
23
Q
if patient is opioid free what can we give to decrease stimulation with intubation
A
esmolol 10-20 mg
24
Q
what is onset of ROC 0.6 mg/kg
A
2-3 min
25
what is onset of 1.2 mg/kg ROC
90 seconds
26
how can you check onset of ROC
TOF
27
what does 1 MAC mean
1 MAC = 50% of patients will move
28
what dose MAC do we use to ensure no movement
1.2 MAC
29
how much recall occurs in 0.5 MAC
50% will have recall
30
what do you do after successful intubation
turn on volatiles/ infusion of TIVA
31
what do we >1 MAC do to prepare for incision
- >1 MAC anesthesia or narcotics/paralytics
-re-dose paralytics
-drapes
-time out
32
what is a maintenance dose of TIVA
prop infusion 100-200
33
what is the maintenance dose of volatiles
1 MAC
34
when do we redose abx
4 hrs
35
when do we redose vanco
6 hrs
36
how often do you check arms/face
q5-15 min depending on position
37
what do you do during maintenance
-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
38
when do you plan for emergence
pre op
39
where do you TOF for induction
Orbicular Occuli
40
where do you TOF for emergence? why
Adductor Pollicus (correlates closer to diaphragm)
41
what are the two ways to check depth of NMBs
TOF
subjectively (timing of last dose, resp effort, head lift, hand squeeze etc)
42
1 twitch = ____% block
95
43
2 twitch = ____% block
90-95
44
3 twitch = ____% block
80-85
45
4 twitch = ____% block
75-80
46
what does one twitch under train of 4 represent
95% blockade and no free drug
47
when can we use reversals
post tetanic stimulation and return of 1 twitch
10 mins
48
what does spontaneous resp effort tell us
less than 100% blockade
49
what are examples of anti-cholinesterase inhibitors
neostigmine, edrophonium
50
when does neostigmine peak
10 min
51
what is the effect of anti-cholinesterase inhibitor
increase ACH everywhere
52
how do we counteract cholinergic symptoms
anticholinergics like glyco and atropine
53
how much atropine do we give with 3 mg neostigmine
0.6mg atropine
1.5 cc
*.2mg for every 1 mg neostigmine*
54
what affects the speed of reversals
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
55
what abx medication increase the length of block
gentamycin
56
what are signs of cholinergic crisis
wet, bronchospasms, paralysis, bradycardia
57
what are signs of anti-cholinergic crisis
dry, hyperthermia, urinary retention, tachycardia, delayed emergence
58
what anticholinergic do we give with edrophonium
atropine
59
what anticholinergic do we give with neostigmine
glycopyrolate
60
which anticholinergic crosses the BBB
atropine
61
what are neuro effects of atropine
hallucinations, sedation
62
which has a faster onset atropine or glycopyrolate
atropine
63
which causes more tachycardia atropine or glycopyrrolate
atropine
64
which is a better antisialogue atropine or glycopyrrolate
robinol
65
what is the structure of glyco
quaternary
66
what property of inhaled anesthetics affects DOA
lipid solubility
67
what affects the offset of inhaled anesthetics
ventilation, fresh gas flow, concentration gradient
68
low flow and hypoventilation makes inhaled offset
slow
69
high flow and hyperventilation makes inhaled offset
fast
70
what does IV offest depend on
beta half life
length of infusion
71
what is gold standard TOF ratio
0.7-0.9
72
sustained tetanus from 50-100 mhs>5s indicates what blockade
50%
73
four TOF twitches tell us what percent blockade
75%
74
T/F spontaneous breathing and adequate tidal volume is a reliable sign of recovery
false
75
what are subjective signs of anesthesia recovery
5 second head lift
tongue protrusion
forced handgrip
76
what is our goal RR for narcotic dosing
8-10 with deep TV
77
what do we do for post-op analgesia
short acting narcotics
awake dosages
APAP
Toradol
regional blocks
78
how do avoid PONV
opioids
narcotics
anti-cholinesterase inhibitors
79
when do we give decadron
4 mg pre-incision
80
when do we give zofran
4 mg pre induction OR 30 min prior to emergence
81
when do we give propofol for PONV
20 mg close to emergence
82
what is a good rescue PONV drug
propofol 20 mg
83
what is taken into consideration for deep extubation
patient selection
must be recovered from NMBs
>1 mac
rr <15
clear secretions
always prepare for laryngospasms and reintubation
PACU cooperations
risk> benefits
84
what is lawsons maneuver
jaw thrust
85
what stage must patient be out of before leavin OR
stage 2
86
T/F extubate peds deep
F only awake
87
T/F you can extubate a RSI patient deep
false
must be awake
88
if doing awake extubation what criteria must patient meet
-follows commands
-protects airway
-appropriate cough/gag
-no edema
-difficult intubation?
-strong resp function
-SpO2> 93% on FiO2 <0.5
-stable hemodynamics
89
what signs do we look for for patient waking up
-hemodynamic changes
-increased HR
-increased BP
-return of reflexes (swallowing, lid reflex, Glabellar tap)
-call first name if reflexes have returned
90
what is bucking
a reflex response to a noxious stimulus
91
what attenuates a bucking response
narcotics,
LTA or lidocaine
hyperventilation
hypocarbia
92
what medication can make patient forget to breathe
narcotics (sufentanil)
93
what is the traditional wake up method
reverse NMBs
lighten anesthetics
increase EtCO2
return to spontaneous
titrate narcs to RR
extubate when patient is awake and following comands
94
what are pros of traditional wake up
smooth, adequate anesthesia, comforting
95
what are cons of traditional wake up
slow, hypoventilation decreases elimination of anesthetic
96
what is the Fast off method
reverse NMBs
titrate down inhaled anesthetics
high FGF and High RR
dose narcs
extubate when patient awake and following commands
97
how do we increase EtCO2
decrease RR, hold breathe
98
how long does holding breath for 1 minute increase EtCO2? 2 minutes?
10, 11
99
what are pros of fast wake up
fast, smooth when timed correctly
100
what are cons of fast wake up
may not have adequate pain control
over/under dosing narcotics
101
what is the crash wake up
full reverse
high FGF, high RR
narcan
shock em, pinch em, jaw thrust,
extubate when awake
102
what is pros of crash wake up
fast emergence
103
what is cons of crash wake up
not smooth
104
what do you do if patient is too light and surgeon needs a little longer
push something: prop, lidocaine
push nothing: increased inhaled (N20 50%)
105
if patient goes apnic what do you need to rule out
laryngospasm vs apnea
106
what do you do for apnea
ventilate off gas and stimulate
Narcan
107
what is sign of residual NMB
poor work of breathing
108
what is treatment of laryngospasm
PPV,
sux,
prepare to intubate
109
how much sux do you give for laryngospasm
1-2 ccs
110
what can sustained laryngospasm lead to
Negative pressure pulm edema
111
when patient has delayed emergence how do you respond
RULE OUT: hypercarbia, hypoxia, hypotension
intoxication
inadequate reversal or prolonged paralysis
hyper/hyponatremia
hyper/hypoglycemia
neuro/stroke
112
bucking is better than anoxic brain injury
yep
113
what are five considerations before you roll back to the OR
consent
surgeon (consent/ readiness)
check with room/circulator
preop anxiolytics
abx
114
what are the steps for rsi
preoxygenated
Meds: fent, lido prop, roc/succ
cricoid pressure (before sedation)
intubate immediately
check breath sounds/etco2
let go cricoid pressure
115
when can circulator/rn let go of cricoid pressure
after you have checked lung sounds/etco2
116
when does criculator/rn need to start holding cricoid pressure
As prop is being pushed
117
what are the steps for standard induction
preoxygenate
meds: fent/esmolol, lidocaine, propofol
tape eyes
ventilate
nmb
ventilate
intubate
check breath sounds/etco2
118
when does awareness under anesthesia usually occur
between propofol and 1/2 mac
119
you have just checked breath sounds after successfully placing ett during standard intubation, what is your next step
turn on volatile gas/infusion if TIVA
120
after you have intubated and turned on the gas, what are your next steps
tape tube,
position arms/head,
put on temp probe
121
at what mac should patient be at before incision
1.2 MAC
122
what should you check every 5-15 minutes during the surgery/operation
position- arms, face depending on position
123
when should you start planning for emergence
before induction
124
what nerve should you be testing nmb blockade depth with when patient is first getting paralyzed
orbicularis occuli- (facial nerve-7)
125
what muscle should you be testing nmb blockade depth when patient is waking up from nmb
adductor pollicus (ulnar nerve)
126
why do you test adductor pollicus response before waking up
better correlated with diaphragm
127
what are the five factors for how fast reversal doses for nmb's work
depth of block
type of anticholinesterase
dose of anticholinesterase
spontaneous reversal/metabolism of nmb
concentration of anesthetic gas
128
what are the side effects of over reversal from nmb
cholinergic crisis
129
what are the sx of cholinergic crisis (with neostigmine)
wet(vomit/diarrhea)
bronchospasm
paralysis
bradycardia
130
what are the sx of anti cholinergic crisis (glycopyrolate)
dry
hyperthermia
urinary retention
tachycardia
delayed emergence
131
what can atropine cause since it cross the bbb
hallucinations, sedation
132
which volatile is the fastest to wear off and why
desflurane- low lipid solubility
133
what are variables that influence how quickly an anesthetic wears off
ventilation
fresh gas flow
concentration gradient
blood/gas/lipid solubility
134
what does low flow and hypoventilation lead to with anesthetic wearing off
slower to come off
135
what does high flow and hyperventilation lead to with anesthetic wearing off
faster to come off
136
what does iv anesthesia wearing off depend on
beta half life
length of infusion
patient
level of stimulation
137
what is the gold standard for verifying reversal
tofr of 0.7-0.9
138
what does sustained tetanus of >5 seconds at 50-100 mhz without fade indicate
50% blockade
139
what are some subjective ways to verify reversal
5 second head lift
tongue protrusion
forced handgrip
140
t or f- spontaneous breathing with adequate tidal volume is a reliable way to verify reversal
f- diaphragm is most resistant to nmb
141
how can you prevent patient form waking up in pain
timing of narcotics
adjuncts
regionals
142
how should you dose shorting acting narcotics
titrate to rr- use awake dosages
143
what meds can you try to avoid so that ponv is minimized
opioids/narcotics
cholinesterase inhibitors
tiva instead of volatiles
144
what are some meds you can give to prevent ponv
-zofran 4mg pre induction/30 minutes before emergence
-decadron 4mg pre incision
-prop 20mg close to emergence
-scopolamine patch pre op
145
when should you give zofran for ponv prevention
4mg pre induction or 30 mins before emergence
146
when should decadron be given for ponv prevention
4 mg pre incision
147
when should propofol be given for ponv prevention
20mg close to emergence
148
what should you alway prepare for during extubation
laryngospasm and reintubation
149
your patient laryngospasms on your way to pacu, what is your first action
larson maneuver
150
what are the steps for traditional wake up
reverse nmb
lighten anesthetic/increase etco2
return to spontaneous breathing
titrae narcotics to resp rate
activate when pt is awake
151
what are some pros of traditional wake up
smooth, adequate analgesia, comforting
152
what are cons of traditional wake up
slow
hypoventilation decreases elim of anesthetic
153
what is the fast off way for waking someone up
reverse nmb
titrae down inhaled anesthetics
high fgf/rr
extubate when awake and following commands
154
what are cons of fast off
may not have adequate pain control
under/overdose narcotics
155
what are the steps for crash wake up
full reverse
high fgf/high rr
narcan
jaw thrust, shock, pinch
extubate when awake
156
what can you do when patient is too light and student is closing
push a little something- propofol
increase n2o/inhaled concentration
157
what should be ruled out before diagnosing emergence delirium
hypercarbia
hypoxia
hypotension
inadequate nmb reversal
neurologic problems- stroke
hypoglycemia
158
what can cause emergence delirium
waking up too fast
inadequate pain control
159
what stage of anesthesia is emergence delirium most common
stage 2
160
what is the management process for emergence delirium
don't extubate
restart- push prop/fent/precedex
--avoid benzos
161
what med class should be avoided to treat emergence delirium
benzos
162
what can happen with a large dose of narcan
catecholamine surge
flash pulmonary edema
163
what can prolonged laryngospasm lead to besides poor oxygenation
negative pressure pulmonary edema
164
you believe your patient has laryngospasmed on the way to pacu, what are some next steps
sustained ppv
prepare succ/reintubation
165
you think your patient is apneic on way to pacu, what are some next steps
ventilate off gas
stimulate
narcan
-could be residual nmb
166
what can you use to decrease bucking response
narcotics
lta or lidocaine to numb cords
167
during preop exam, where do you get most of information from
patient history
-other: labs, exam
168
what kind of past anesthesia complications do you want to ask patient abou
intubated for long time post op- cholinesterase deficiency
high fever- MH
severe PONV
169
what kinds of disease would prompt crna to use rsi technique
acid reflux everyday
dm- gastroparesis
full stomach-emergency
170
how long does bicitra last and when do you want to give it
20 mins, give right before rolling back
-neutralizes acid in stomach
171
why do you want to make stomach less acidic before anesthesia
decrease risk of aspiration pneumonitis
172
what is mendelson's criteria
ph <2.5
volume >30 cc
173
if patients has a low ph and high volume in their stomach, what are they more at risk for
aspiration pneumonitis
174
your patient has taken their ace inhibitor the morning of surgery. what will this cause and how do you treat it
refractory hypotension
-vasopressin or phenylephrine
175
a patient comes to their surgery have not taken their beta blocker in 24 hours. It is ok to proceed as usual with surgery
no- give patient beta blocker to avoid rebound tachycardia/htn
176
what does MET score need to be to have surgery
>4
177
what does met score stand for and why is it used
metabolic equivalent testing
-predicts cardiac function
178
what does asa 2 mean
1-2 comorbidities
htn, osteoarthritis
smokers, social drinkers
179
what does asa 3 mean
>1 comorbidity that alters life
-chf uncontrolled, dm, copd
morbid obesity
pts with severe systemic disease or substantive function limitations
180
what does asa 4 man
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
what does asa 5 mean
iminent death with/without surgery
182
what does asa 6 mean
organ procurement
183
what are risks/benefits do you have to talk about with patient to get consent
heart attack
death
stroke
dysrhythmias
breathing tube insertion
ponv
numbness/back pain/sore throat
184
after preop is done, what should you do
go back to room to make sure room is set up for patient and their comorbidities
185
how long should you preoxygenate patient for
3-4 mins or 4 vital capacity breaths
186
what is a normal frc
2L
187
what is normal minute ventilation
200cc/min
188
how do you calculate minute ventilation
tidal volume x rr
189
if your end tidal o2 is reading 90%, what does this mean
it means at a normal frc of 2L, 90% of it is oxygenated (so 1800ml)
190
if your end tidal o2 is reading 90%, how many minutes can be patient be apneic before desaturating
90% of 2L frc= 1800 mL of oxygen
1800 ml/200 ml minute ventilation=
9 minutes
191
what are some things that increase o2 consumption
hyperthermia
pregnancy
infection
192
what are some things that decrease frc
copd
pregnancy
positioning
abdominal obesity
193
what threshold do you want to hit on feo2 before intubation
90%
194
when giving a defasiculating dose of roc, how does this affect succ
slows onset time
195
what do you give to decrease sns stimulationg during DL
fent or 1 cc esmolol
196
what mac needs to be reached to ensure there isn't recall
1/2 mac, ideally 0.8 mac
197
what does 1/2 mac mean
1/2 of patient's won't have recall
198
what does 1 mac mean
1/2 of patient's won't move on incision
199
if your surgery is going to last 1 hour, how much roc or vec should you push
30-50 mg of roc
5mg of vec
200
what is a prop infusion dose
125-150 mcg/kg/hr
201
how often do you re dose ancef
q4 hours
vanc q6h
202
how much does succ increase potassium
0.5 transiently
203
you are performing a post tetanic stimulation. You have 1 twitch post tetany. When can you reverse
10 min
204
how can you tell on monitors that neostigmine is having increased affect
increasing tidal volume
205
what are reasons for giving glyco or atropine with cholinesterase inhibitor
help to isolate nicotinic receptors
prevents muscarinic effects such as decrease HR, intestinal spasm, hypotension, bronchoconstriction
206
what med can simulate phase 2 block if given too much
neostigmine
207
what volatile lasts the longest
isoflurane
208
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
post op residual paralysis
-suggamadex
209
when should you extubate patient that you did rsi- deep or awake
awake
210
when should you extubate someone if you are worried about laryngospasm- deep or awake
awake
211
what is rr requirement for deep extubation
<15
212
what is mac requirement for deep extubation
>1 mac
213
what are some requirements for deep extubation
>1 mac
<15 rr
clear secretions
pacu cooperation
214
what are requirements for awake extubation
follows commands
cough/gag reflex
no edema
spo2>93% or fio2 <0.5
stable hemodynamics
215
what reflexes are you looking for return of
swallowing
lid reflex
glabellar tap
cough
216
you take patient off ventilator for 2 minutes to increase their etco2 so they start sponatenously breathing. How much will etco2 raise
10 meq/L 1 for every minute after
217
what ways can you increase etco2 and why would you want to do that
decrease rr, take off vent
-spontaneously breath
218
at what etco2 will patient start breathing again
50 meq/L
219
what are some causes of air not moving post extubation
obstruction- jaw thrust
narcotic od- narcan 0.4mg
220
your patient is retracting but air is not moving with jaw thrust, what is cause
laryngospasm
221
when preoxygenating patient, what setting should apl valve be on
open
222
when preoxygenating patient, what should o2 flow be
>5L/min
223
t or f- tape eyes shut before bagging patient during induction sequence
true
224
what is standard roc dose for standard intubation
0.6 mg/kg or 50mg
225
which hand should you double glove when intubating
right hand- it gets in patient's mouth
