leersnyder day 2 Flashcards
most reliable source of info about your patient
the patient
three vanderbilt computer interfaces
vpims, vpimsweb, starpanel
if a preop was templated and has the physical exam filled out, is it complete?
no
What is the name of the diagnosis and procedure codes in the US?
icd9, icd10, CPT
Also the codes for the dx must match between anesthesia and surgery or no reimbursement.
which of the following is NOT a redflag for preops?
- aicd/pacer
- OSA
- mild pulm htn
- new stents
- mild pulm HTN
state risks associated with REGIONAL anesthesia and their incidence
prolonged numbness/weakness, post-dural headache, failure of technique
state at risk populations
extremes of age, redheads, drugs and alcohol, chronic pain patients, enzyme induced patients, genetic variances (MH)
Watch out for the old drunk redhead who goes to the methadone clinic and has a genetic predisposition to malignant hyperthermia.
state strategies to minimize risk
avoid full stomachs, emergency surgery, cardiac problems, emergency c-section (high risk of general anesthesia, high risk of loss of airway and aspiration), light anesthesia = recall (risk of PTSD, use a BIS), maintain anesthesia equipment and competency.
Don’t do an EMERGENT C-SECTION on the patient who just ate 14 KRYSTALS and has new onset A-FIB if your BIS monitor and anesthesia MACHINE aren’t working.
sore throat
50%
hoarseness
15-50%
post op N/V
10-80%
drowsiness/confusion - emergence delirium vs. POCD (postop cognitive dysfunction)
age dependent
operative awareness
less than 1%
neuromuscular blocker MOST OFTEN associated with anaphylactic reaction
succs
states with HIGHEST INCIDENCE of malignant hyperthermia
Wisconsin, Nebraska, West Virginia, Michigan
Willy Nelson wears virgin Miche
visual loss
less than 0.056%
1/20th of 1%
aspiration incidence
highest in pregnancy
drug reactions
1:13,000
number 1 drug reaction in US
antibiotics
death
1:10,000
in surveys patients are most concerned about
post op pain, N/V, not waking up, drains and needles
triple low phenomena
low MAC, low MAP, low BIS
4x greater mortality over 30 days
infection incidence post regional
3:65,000
You have a 1:22,000 chance
persistent numbness / weakness
1:4,343
seizures post regional
0.022%
Like if you accidentally shot yourself in with a tenth of a .22 pistol, you wouldn’t die you’d just have a seizure
overall cardiac arrest rate overall vs anesthesia related
3/100 vs 1/1,000
overall critical events vs anesthesia related
964/10,000 vs 64/10,000
Minus 900 critical events
overall mortality rate vs anesthesia related
463/10,000 vs 4/10,000
Minus 460 deaths
_____ was mainly responsible for CRITICAL EVENTS in patients with GOOD physical status, but _____ diseases were mainly responsible in those with POOR physical status
anesthetic management
coexisting diseases
we kill the ASA __ and __, the __ and __ kill themselves
1, 2, 3, 4
____ fold increase in critical events for ASA 4’s non-emergency vs. emergency surgery
four (148:10,000 compared to 592:10,000)
anesthesia related deaths due to ADVERSE EFFECTS OF ANESTHETICS
42.4%
WHO MOST COMMONLY DIES DURING SURGERY?
MALES (80%), age 25-54 (55%), lowest death rate (5-14 years), highest death rate (age 85 or older)
In the USA between 1999-2005, 1,030 people died of anesthesia related complications to what?
overdose of anesthetic
In Japan study emergency surgery for an ASA4 patient increases the risk of anesthesia complications by what factor?
four times the risk
In Japan what was the leading cause of CRITICAL EVENTS of people with good physical status?
anesthetic management
In Japan what was the leading cause of critical events in those with poor physical status?
coexisting diseases
HPI
history of present illness
In the US mortality due to anesthesia is higher in what gender?
males
percentage of deaths caused by adverse effects?
percentage of deaths caused by anesthetic overdose?
- 4% adverse effects
46. 5% anesthetic overdose
what are some red flags in preop?
MI within last 6 mo’s, chest pain, stents, new EKG changes
what is the fastest growing surgical specialty?
interventional radiology for neuro
a basic neuro exam should include…
oriented x4, deficits do not impair communication or comprehension, eyesight, pupils, visual fields, motor or sensory impairment
what is the NIHSS stroke score
42 point scale to identify deficits, 0 = no deficit, 42 = worst deficit, score defines 30 day mortality rate
what is hunt and hess scoring?
grading scale for subarachnoid hemorrhage
grade 1 - minimal headache
grade 2 - mod to severe HA, nuchal rigidity, cranial nerve palsy
grade 3 - drowsy
grade 4 - stuporous, mod to severe hemiparesis
grade 5 - deep coma, decerebrate rigidity
three interventional radiology treatments for a clot
penumbra, solitaire, trevo pro
three interventional radiology treatments for an aneurysm
glue, coil, clip
fourth leading cause of death and first leading cause of disability
stroke
three drugs that dissolve a clot
integrillin, TPA, reopro
EBUS stands for __
endobronchial ultrasound
american cancer society rates lung cancer the ____ cancer in the US
2
two possible airway effects of the asthmatic in the OR
bronchospasm, laryngospasm
best anesthetic gas for reactive airway?
sevo
s3 murmur
heart failure
most feared respiratory complication in anesthesia?
aspiration pneumonia
what is the PCI goal for STEMI
90 minutes
6 p’s of arterial insufficiency
pain, pallor, pulselessness, parasthesia, paralysis, perishing cold
what percentage of non cardiac surgical patients suffer a cardiac morbidity
1-5%
what does the first heart sound represent
closure of mitral and tricuspid valve
Most common cause of acute liver failure
tylenol OD
what is the gold standard test for cardiac function
treadmill stress test
most common complication of cirrhosis?
fatigue
most common drug induced hepatitis?
tylenol
liver disease is reflected by what labs
increased total bili, increased ast, alt, decreased albumin, increased PT
major cause of m and m in the pt with cirrhosis
bleeding from esophageal varices
what two labs best evaluate liver dz
serum albumin and PT
surgical risk is greater in a patient with the following 5 factors
high bili (>3g/dL), severe ascites, coma, poor nutritions, low albumin <3g/dL
concerns with morbidly obese patients
iv access, airway obstruction, metabolization of drugs, solubility of drugs
a low albumin (half life 20 days) reflects acute or chronic liver dz?
chronic
what is your primary concern with a tooth abscess?
airway
which class of drugs should you avoid in a patient with a history of ulcers?
nsaids
what should you check in a patient with GI symptoms?
frequency, recent EGD, how many pillows, treatment and efficacy, hemoptysis
what is a whipple?
resection of antrum of stomach, duodenum, gall bladder, and head of pancreas
name four issues with morbid obesity?
IV access, drug metabolism, difficult airway, use insoluble gas (des), loss of functional reserve capacity
what is a major risk factor of a patient with a bowel obstruction?
vomiting
leading cause of kidney disease in the US?
diabetes
how much kidney function can you lose before symptoms begin
you can lose 80%
which of the following electrolytes are affected by CRF?
hyperK, hyperMAG, hyperPHOS, hypoCALC
why are chronic renal patients anemic?
healthy kidneys secrete erythropoetin, anephric patients do not,
also reduced iron intake from dialysis diet leads to ironn-deficiency anemia
in order to differentiate pre renal (decreased renal perfusion) from acute renal failure (tubular damage) what test might you order?
fractional excretion of filtered sodium, if 1% = obstructive renal failure (ATN)
coagulopathy in CRF leads to what four sites of bleeding?
GI ulcers, epistaxis (nose bleeds), subdural hematoma, hemorrhagic pericarditis
Features of a child’s airway vs. adults are
funnel-shaped larynx
number one cancer in kids
leukemia
t/f it is important to discuss risks of anesthesia in front of children?
false
Most common cancer in children
leukemia
recent studies have shown that infants have___ (more/less) sensitivity to pain
increased sensitivity to pain
oxygen consumption of an infant is ___ that of an adult?
twice
what is the fastest growing endocrine disease in the US?
diabetes
almost all pediatric codes are due to
respiratory distress
what needs replaced after a parathyroidectomy?
calcium
what does MEN syndrome stand for?
MEN- multiple endocrine neoplasm
nerve damage / paralysis post regional
0.2 - 0.4 %
Box 19-12 surg risk estimates
HIGH >5% cardiac risk
Aortic
Major vascular
Peripheral vascular
Box 19-11 active cardiac conditions that require further eval before non-cardiac surgery
Unstable or severe angina MI within 30 days High grade block Symptomatic ventricular arrhythmia SVT >100 bpm Symptomatic bradycardia New v-tach Aortic stenosis (pressure >40, area 2mg/dl
Box 19-12 surg risk estimates
LOW <1% cardiac risk
Breast Dental Endo Endo Superficial Cataracts Gyn Reconstructive MinOrtho MinUro
Box 19-12 surg risk estimates
INTERMEDIATE 1-5% cardiac risk
Intra peritoneal / thoracic Transplant Carotid Peripheral arterial angioplasty Endovasc aneurysm repair Head and neck Major neuro / ortho / uro
S/s cocaine and amphetamines
Tachycardia, labile BP, HTN, MI, arrhythmia, pulm edema, excitement, delirium, hallucination, psychosis, euphoria, hyperreflexia, tremors, convulsions, mydriasis, sweat, fever, exhaustion, coma
S/s of marijuana
Tachycardia, labile BP, headache, euphoric, dysphoric, depressed, poor memory and decreased motivation, rare anxiety panic or psychosis.
S/s of opiod abuse
Resp depression, hypotension, bradycardia, constipation, euphoria, pinpoint pupils, coma.
S/s hallucinogens: LSD, PCP
Sympathomimetic, weak analgesia, altered perception and judgement, dissociative anesthesia with increasing doses.
Most common female adult cancer
Skin, breast is second
Most common male adult cancer
Skin, Prostate is 2nd
Leading cause of cancer DEATH in both male and female
Lung
what gland is often removed in pediatric congenital heart surgery?
thymus
what are the symptoms of thyroid storm?
increased heart rate, temp, and basal metabolic rate
Patients with cancer have a __ fold increase in VTE, but __ if treated with chemo
4 fold cancer alone, 7 fold if treated with chemo
Cancer is the __ most common cause of death in US
2nd
Japanese study- leading causes of mortality in patients with GOOD physical status
Procedures and massive hemorrhage
Japanese study- mortality attributed to anesthesia
7/10,000
Five major differences between peds and adults
Larynx more cephaladad Relatively large tongue Angled vocal cords Long stiff U shaped epiglottis Funnel shaped larynx narrowest at cricoid cartilage
Oxygen consumption of infant is __ that of an adult per kg/min
Twice
OB- leading cause of maternal mortality in US
Thromboembolic events / PE
OB- RSI only after __ weeks
12
What is a normal change of pregnancy
Increase in cardiac output
In the US how many pregnant women have surgery not related to delivery?
1 in 50
What is a red flag related to pregnancy?
Proteinuria and elevated LFTs
According to the AANA guidelines the primary responsibility of the CRNA is to the NEONATE post delivery?
False
How many people for a log roll
4
most common heart murmur
mitral regurge
most serious heart murmur
aortic stenosis
s3 murmur indicative of
heart failure
which is not a redflag for preops
mild pulm hypertension
murmur best heart in the 2nd right intercostal space with transmission into the neck
aortic stenosis
critical aortic stenosis
less than 0.6 cm squared
sudden death in young athletes
hypertrophic cardiomyopathy
diagnostic gold standard for pulmonary HTN
right heart cath
treatment for pulm hypertension
flolan
gold standard for coronary artery disease
coronary angiography
bare metal stents recommendation for elective surgery
6 weeks
drug eluting stents recommendation for elective surgery
one year
how long after MI before having non-cardiac elective surgery
6 months
What drug killed Michael Jackson
Jackson Juice
most common cancer in US males after skin cancer
prostate
most common cancer US females after skin cancer
breast
chemo agent associated with pulmonary fibrosis
bleomycin
chemo increases risk of PE by __ fold
7 fold
ABCDE
airway and c spine breathing and ventilation circulation and hemorrhage control disability and neuro assessment exposure and environment
goal of surgeon during level one operation
get in, get out
how to perform a log roll
4 people
HELLP
hemolysis, elevated liver ‘zymes, low platelets
first stage of labor, pain neurons enter cord at level
T10-L1
second stage of labor, pain through neurons enter cord at level
pudendal nerve, S2-S4
most common cause of maternal morbidity
thromboembolic events / PE
INR >2
cancel surgery
what does a pheochromocytoma secrete?
catecholamines
what gland is resected through the nose?
pituitary
beck’s triad associated with cardiac tamponade
low BP, JVD, muffled heart sounds
pulsus paradoxus
associated with cardiac tamponade
Mendelson syndrome
chemical pneumonitis caused by aspiration during anaesthesia, especially during pregnancy.
