Midterm Flashcards
What is the maximum amount of time a tourniquet should be used?
2 hours
Describe anesthesia management during endovascular aortic repair
can use general or regional, use A-line and carefully monitor u.o., maintain large bore IV access, may give heparin
What are anesthesia considerations for colonoscopies, EGD, and ERCP?
NPO, pre-emptive viscous lidocaine to decrease gag reflex, short acting sedatives (Versed, prop), may require glyco for upper endoscopy, possible vagal stimulation with colonoscopy
How does aging affect endocrine function?
decreased insulin secretion due to decreased beta cells, pheripheral insulin resistance, decreased hormone production
What considerations should you have with elderly and regional anesthesia?
less reliable epi test dose because of decreased end organ responsiveness
What are some congenital conditions associated with difficult airway?
Pierre Robin, Treacher Collins, Goldenhar, mucopolysaccharidosis, Klippel Feil, Down syndrome
Which lung does ventilation prefer when in lateral decubitus?
nondependent lung (perfusion favors dependent lung)
What is autonomic dysreflexia?
injury above T6, sudden sympathetic response to noxious stimuli such as a full bowel or bladder- severe HTN, sz, pulmonary edema, MI, ARI, intracranial hemorrhage
What are anesthetic management options for asthma?
assess severity pre-op and effectiveness of pharm treatment, continue antiinflammatory and bronchodilator therapy (stress dose steroids if treated with systemic steroids in last 6 months), propofol if stable, ketamine if unstable, sevo, IV or tracheal lidocaine, opioids to suppress cough, adequate hydration, extubate deep
How does aging affect the respiratory system?
decreased chest wall compliance, flattened diaphragm,, decreased elastic recoil but increased lung compliance, decreased O2 exchange, increased closing volume, decreased response to hypoxemia and hypercarbia, decreased laryngeal/pharyngeal support (airway obstruction), decreased cough/gag
What paralytic is preferred in older adults?
cisatracurium (Hoffman elimination and not organ dependent)
What is cystic fibrosis?
autosomal recessive disorder, characterized by decreased Cl (Na and H20) transport, thick secretions, scarring of glands and tissues
What are some concerns with kyphoscoliosis?
may have SC damage and respiratory dysfunction, respiratory alterations may occur when asleep, may have CV abnormalities (MVP most common), may have PH and RV hypertrophy
What does deflation of a tourniquet cause?
releases metabolic wastes into systemic circulation- metabolic acidosis, hyperkalemia, myoglobinemia, myoglobinuria, renal failure
What are some anesthetic management considerations with ARDS?
carefully manage vascular volume (avoid pulmonary edema), avoid air in vascular lines due to R to L shunt, assess for s/s of RV dysfunction, use PEEP, may prone, oscillation
What are some ways to extubate patients that are high risk for a failed airway?
extubate over FOB, extubate and follow with LMA, use AEC, leave ETT until all extubation criteria are met
What are some criteria for extubation?
optimized HD and labs, adequate muscle strength, positive reflexes, analgesia, VC at least 15 ml/kg, NIF -20, TV 4-5 ml/kg, spontaneous ventilation
What is neurogenic pulmonary edema?
massive outpour of sympathetic impulses that leads to vasoconstriction, shift of blood volume into pulmonary circulation
Describe the heat exchanger of CPB
stainless steel tubes filled with hot or cold water, blood flows around it (patient’s temp usually allowed to drop naturally but may use active cooling)
What provides sensory innervation of the airway above the vocal cords?
SLN, glossopharyngeal, trigeminal
Describe a glossopharyngeal block
blocks posterior 1/3 of tongue (lingual branch of glossopharyngeal), 2% lidocaine injected into “gutter” (posterior side under tongue), should not aspirate air or blood
What is used to monitor neuro function during aorta repair? How is the spine “protected”?
SEPs and EEGs (may not detect SC ischemia)- spinal cooling and drainage
What are some anesthesia considerations for hysteroscopy?
pretreat with NSAIDs, ensure negative pregnancy test, give pre-op anxiolytics, may do paracervical block
How does pulmonary edema look on CXR?
Kerley A lines (long, irregular lines from hila to periphery), Kerley B lines (short, horizontal lines at bases), Kerley C lines (reticular opacities at lung bases), peribronchial cuffing (doughnut densities), widened vascular pedicle
What drugs should you avoid during assisted reproductive technologies?
morphine (adverse effects), NSAIDs (inhibit prostaglandin synthesis and embryo implantation), sevo, des, droperidol, Reglan
What muscles abduct and adduct the VC?
Posterior CricoArytenoid (please come apart) Lateral CricoArytenoid (lets close airway)
What are signs of a tension pneumo?
hypotension, sub Q emphysema, unilateral breath sounds, tracheal shift, distended neck veins
What is anesthesia management like for aorta repair?
may use DLT to collapse lung for better exposure, use GA to decrease CMR, choose NMB based on renal function, use A-line and TEE, monitor u.o., may use epidural for post-op pain management, use a combination of balanced salt and colloid solutions (infused during clamp to increase volume reserve)
How do you pretreat patients with a high risk of contrast reaction?
steroids within 6 hours, benadryl
Where should the tip of your CVC be?
junction of the SVC and RA, 4 cm below the carina or 1-2 cm below the superior R heart border (tip should be slightly above the RA, NOT inside)
What are some anesthesia considerations with mediastinal masses?
extensive pre-op eval (flow volume loops, chest imaging, evaluation for compression), use FOB to check for obstruction, tumor may increase in size during anesthesia due to venous engorgement, use spontaneous ventilation whenever possible
What are airway exchange catheters? Are they capable of gas exchange?
used for interchanging ETTs or extubating; yes
What are some ABG findings you might see with asthma? What about CXR? EKG?
hypocarbia and alkalosis; hyperinflation and hilar vascular congestion; R heart strain during attack
What is ATLS Class III of shock?
blood loss 30-40%, HR >120, SBP decreased, PP decreased, RR 30-40, anxious/confused
Which population should you avoid doing a cricothyrotomy in?
young children under 12 (larynx small and pliable)
What is bronchiolitis obliterans?
disease of small airways and alveoli in childhood as result of RSV
What may happen if patients still have residual NMB? What should you give?
upper airway obstruction, hypoxemia, aspiration, muscle weakness; Sugammadex for roc and vec
What are some concerns with ankylosing spondylitis?
inflammation of spinal column and soft tissues, may have valve dysfunction, conduction delays, BBB, restrictive lung disease- may be on corticosteroids and NSAIDs
What is used to anticoagulate the patient during CPB and what are the lab parameters? How often should you check it?
heparin; should have ACT at least 400 (normal is 80-120)- check 3-5 minutes after heparin administration and q20-30 minutes after
What is pulmonary oxygen toxicity? What are predisposing factors?
prolonged use (>24 hours) of high FiO2 (>50%) causes excessive production of free O2 radicals that have toxic effect on cells and organelles- increased exposure, advanced age, radiation therapy, chemo
What is anesthesia management like for tracheal stenosis?
tracheal dilation with balloon dilators, may use helium to decrease density of gas and improve flow, may do translaryngeal endotracheal intubation
What are the 4 M’s in consideration for lung cancer patients?
mass effects, metabolic effects, metastases, meds
What drugs can cause cytotoxic drug induced pulmonary disease? What are s/s?
bleomycin, methotrexate- dyspnea, dry cough, fever, fatigue, malaise
How does aging affect the CNS?
loss of neurons and NT activity, decreased brain volume (esp gray matter and thalamus) and CSF, slower nerve conduction, increased sensitivity to anesthetic agents (increased POD), increased permeability of BBB, increased risk of neural damage with regional anesthetics
What is a risk of glossopharyngeal block?
intracarotid injection
What are indications for a cricothyrotomy?
failed airway, traumatic injuries where intubation is impossible, relief of upper airway obstruction, need for definitive airway for neck/facial surgery
Describe a SLN block
blocks supraglottic region, 2% lido injected into inferior border or greater cornu of hyoid, should not aspirate air or blood
When would you consider postponing outpatient surgery?
lack of med compliance (wide fluctuations in BP), did not fast appropriately, pregnancy, URI
Describe TRALI and its predisposing factors
acute onset of pulmonary infiltrates and hypoxemia from to blood transfusion due to neutrophils becoming trapped in pulmonary vasculature- recent surgery, malignancy, sepsis, alcoholism, liver disease
What is ATLS Class II of shock?
blood loss 15-30%, HR >100, SBP normal, PP decreased, RR 20-30, mildly anxious
What characteristics place patients at high risk for post-op delirium?
over 65/70, chronic cognitive decline, dementia, poor hearing/vision, infection, hip fracture, aortic and ortho procedures, depression, ETOH, pre-op narcotics
What are idiosyncratic reactions to contrast media?
ranges from urticaria to hypotension, laryngospasm- NOT allergic, history of asthma may predispose
Describe a transtracheal block
needle inserted through cricothyroid membrane into the tracheal lumen (SHOULD get air on aspiration), 2% lido injected on pt inspiration- pt will cough, anesthetizes cords
What is anesthesia management for bronchiectasis?
get extensive history and date of last exacerbation, delay elective procedures if active infection, may need DLT, avoid nasal intubation due to increased incidence of chronic sinusitis
What are some things you should monitor for during shoulder arthroscopy?
sub Q emphysema, tension pneumo, pneumomediastinum
What is Buerger’s and what are anesthesia considerations for it?
occlusion of small and medium vessels in extremities due to autoimmune response to tobacco- appropriate positioning and padding, keep warm, noninvasive BP monitoring, avoid using epi in LA
What are some anesthesia management considerations for cystic fibrosis?
optimize until adequate, give Vit K if hepatic function is poor, use high FiO2 and humidify it, frequent tracheal suctioning, adequate pain control for C&DB exercises
What are some ways to prevent aspiration?
NPO guidelines, pharm prophylaxis (antacids, PPIs, antiemetics), cricoid pressure, RSI if aspiration risk, ensure adequate reflexes prior to extubation
What is primary ciliary dyskinesia? What are its characteristics?
congenital impairment of ciliary activity; chronic sinusitis, recurrent respiratory infections, bronchiectasis, infertility
What is ATLS Class I of shock?
blood loss <15%, HR <100, normal SBP and PP, RR 14-20, slightly anxious
What does anesthesia look like for a PCI?
mild to deep sedation with analgesia, possible LA infiltration
What are s/s of TRALI? How is it treated?
PaO2/FiO2 <300, fever, chills, dyspnea, variable BP; supportive measures, stop transfusion, give fluids
When should you recommend smoking cessation?
minimum of 4 weeks pre-op
How do you manage autonomic dysreflexia?
remove noxious stimuli, admin nitrates, hydralazine, labetalol
What drugs can cause drug induced pulmonary edema?
opioids and cocaine
What are some considerations for the pre-bypass period?
anticoagulation, cannulation (arterial and venous), pull back PAC, TEE, supplemental meds (NMBs, anesthetics), inspect head and neck
Where should the lumens of a DLT be?
tracheal- terminates above carina
bronchial- angled to fit appropriate mainstem bronchus
What are the 5 components of CPB?
venous reservoir, main pump, oxygenator, heat exchanger, arterial filler
How do you alleviate tension pneumo?
large bore needle 2nd intercostal space midclavicular (4-5th midaxillary)
What is the treatment for bronchospasm?
100% FiO2, beta agonists, proventil inhaler, epi, steroids, aminophylline
What is a consideration with myasthenia gravis and NMBs?
resistant to succs, sensitive to nondepolarizing NMBs
What is asthma? What are its inflammatory mediators?
reversible airflow obstruction caused by bronchial hyperreactivity, constriction, and inflammation- histamine, prostaglandin D2, leukotrienes
What are some considerations about sizing and proper placement of LMAs?
black line should be near upper lip when properly placed, size is based on kg weight, intracuff pressure should not exceed 60 cmH20, avoid PIP of >20
What is considered the best imaging?
MRI
What are s/s of COPD?
DOE or DAR, chronic cough and sputum production, decreased breath sounds, expiratory wheeze, flattened diaphragm and bullae on CXR
What are some physiologic effects of CPB?
SIRS/stress response, ischemic cardiac injury, brain injury (type 1 death, type 2 declined intellectual function), atelectasis to ARDS, AKI, hypoperfusion of GI, impaired coagulation
How does aging affect body composition and thermoregulation?
decreased BMR, decreased blood volume, increased body fat, decreased TBW, impaired thermoregulation (decreased hypothalamus function, prone to hypothermia)
What are some anesthetic considerations with sarcoidosis?
give inhaled prostacyclin or sildenafil to decrease PH, anticipate difficult airway, may be on corticosteroids, methotrexate
What are risk factors for contrast induced nephropathy? What do you expect to see?
pre-existing renal insufficiency, DM, dehydration, CV disease, increased age and exposure to contrast agents within 24 hours; expect increased creat within 24 h, peaks within 4 days, returns to baseline within 7-10 days
What is atelectasis? What causes it?
collapse of pulmonary tissue that prevents alveolar exchange of O2 and CO2- compression of lung tissue, abscense of diaphragmatic induced negative pressure, impaired surfactant, absorption of O2 from N free alveoli
Where is a tracheotomy performed?
4th-6th tracheal ring
What are special considerations when doing prone spinal cases?
increased intraabdominal and thoracic pressure decreases venous return (decreased CO and increased SVR), prefer pressure control vs VC to avoid high PIP, maintain neutral head alignment
What is nuclear scintography used for?
perfusion and infarct scanning (lungs, heart, GI)
What are risk factors for POVL?
male, obesity, use of Wilson frame, anesthesia >6 hours, large blood loss, primary crystalloid replacement
How does atelectasis look on a CXR?
linear bands of opacity, focal patchy opacities, dense homogenous opacities
What is COPD?
irreversible progressive loss of alveolar tissue and progressive airflow obstruction (loss of elastic recoil)
What provides motor innervation to cricothyroid?
SLN
How do you ensure adequate perfusion to tissues distal to aortic clamp?
maintain proximal aortic pressure as high as heart can safely withstand (MAP near 100 above clamp, >50 distal)
What should you avoid using with thoracic trauma?
nitrous
What may improve V/Q when in lateral decubitus in a paralyzed patient?
PEEP
What are some ventilator considerations in a patient with pulmonary edema?
apply PEEP, low TV (6 ml/kg), RR 14-18, keep end plateau pressure <30
Where should the tip of your ETT be? How should the cuff be filled?
5-7 cm above the carina (around T2-T4); cuff should fill but not dilate trachea
What are A lines on ultrasound?
reverberation artifact from US reflection (occurs in normal aerated lung if lung sliding present, if not-pneumo)
How is endovascular treatment of carotid disease different than the open approach?
uses endovascular stenting, but CEA is considered superior and recommended
What is flail chest and how do you manage it?
multiple rib fractures with paradoxical movement at the site- provide adequate pain control with intercostal nerve block, epidural or opioids, may need intubation
What cardiac concerns should you have with somebody with PH?
R heart strain and hypertrophy, very sensitive to changes in volume and hypotension
What are the 2 different types of pumps in CPB?
roller- constant and nonpulsatile
centrifugal- more common, magnetically controlled (must use flowmeter)
What are the 6 P’s of SCI?
pain, paralysis, paresthesia, ptosis, position, priapism
What are some appropriate lab tests pre-op for outpatient surgery?
potassium within 7 days if on diuretics, glucose same day if diabetic, pregnancy test
Who should get a pregnancy test?
all females over 13 or those already menstruating and sexually active, unless last menses >1 year ago or hysterectomy/bilateral oopherectomy - urine test day of is sufficient, serum test within 1 week preferable
What are some discharge criteria for outpatient surgery?
stable VS, A&Ox3, able to ambulate, minimal/appropriate bleeding, no nausea or pain, able to void (high risk retention patients)
Describe the oxygenator of CPB
membranous with large surgace area, adds oxygen and removes CO2, can also add volatile anesthetic
How is endovascular aortic aneurysn repair different than the open approach?
reserved for elderly and those with co-existing disease, does not cause as significant physiological changes as clamping
What provides motor innervation of all larynx muscles except the cricothyroid?
RLN
How is TACO different than TRALI?
it is related to circulatory overload
What kind of monitoring should you have during thoracic surgery?
continuous EKG (V4 and 5 for ischemia), A-line in dependent arm, CVP monitoring, PAP
What should pneumatic tourniquets be inflated to?
UE- 70-90 over SBP
LE- 2x SBP
Bier block- minimum 250 unless on upper leg (2x SBP, minimum 300)
What should be included in pre-op eval before aneurysm repair?
eval for cardiac ischemia or valvular dysfunction (may need PCI or CABG), heart function stress test, spirometric testing, renal dysfunction, duplex of carotids or angio if at risk for stroke
What are clinical features of aspiration pneumonitis?
often asymptomatic unless severe- arterial hypoxemia, tachypnea, dyspnea, hypertension and tachycardia, cyanosis, bilateral infiltrates on CXR (most promiment in RLL)
What is alveolar consolidation syndrome? Difference between static and dynamic?
anything that fills alveoli with fluid, occurs in dependent areas; dynamic (air moves within bronchus with each breathing cycle) and static (obstruction of bronchus- absorptive atelectasis)
What is ultrasound used for?
guide for insertion of needle/tube insertion, evaluate conditions of lung and abdomen, cardiac and hemodynamic assessment
What are management options for pulmonary oxygen toxicity?
deliver lowest FiO2 possible, may give corticosteroids
What is HIT? What should you do if a patient has it when CPB is necessary?
an immune reaction to heparin; use bivalrudin
What are s/s of asthma?
wheeze, cough, dyspnea, chest discomfort/tightness, air hunger, eosinophilia
When does tracheal stenosis become symptomatic?
when diameter is less than 5 mm
How does ARDS look on CXR?
interstitial edema and alveolar consolidation -> coarse reticular opacities -> collagen deposition and fibrosis
What are common causes of URI?
rhinovirus, coronavirus, flu, RSV
What are some anesthesia considerations in patients with arterial insufficiency?
high risk of MI, pharm stress test vs. exercise, continue beta blockers
What arm should you monitor BP in during aneurysm repair?
right arm (repair of thoracic aorta requires clamping distal to L subclavian artery)
What is an adequate psi for transtracheal jet ventilation?
25 psi
What are some possible causes of pleural effusion? How do you treat? What diagnostic test is most sensitive?
blocked lymphatic drainage, heart failure, decreased plasma colloid osmotic P, infection/inflammation- thoracostomy, thoracentesis, pleurodesis- US
What are some indications for using FOB?
difficult airway, cervical spine immobilization, anatomic abnormalities, failed intubation but ventilation is possible
What are anesthetic management considerations in bleomycin induced pulmonary disease?
continuous O2 monitoring and ABG analysis, 100% FiO2 for 1-4 minutes before anesthesia, use lowest allowable FiO2 mid-case and post-op, consider using PEEP, caution with crystalloids (consider colloids)
What are some skeletal disorders of the chest that are usually asymptomatic unless severe?
pectus excavatum (funnel chest) and pectus carinatum
What are some anesthesia considerations for ECT?
may have parasympathetic response followed by sympathetic response, give anticholinergics to prevent asystole, use propofol or etomidate, NPO, PPV via mask, bite block, give succs for short acting m. relaxation, sz produces increase in CBF and ICP
How are aneurysms classified?
morphology (fusiform or saccular), pathological features (arteriosclerosis, cystic medical necrosis), location (DeBakey, Stanford)
What is different about intubating with a GlideScope versus normal DLI?
GlideScope does not require sniffing position and can be placed directly midline
How does aging affect renal function?
kidney atrophy, decreased blood flow, decreased GFR, sensitivity to fluid overload, decreased renin and aldosterone production (impaired sodium conservation)
What nerve fibers cause tourniquet pain?
C fibers (burning and aching) and A fibers (pinprick, tingling)
What is the recommended agent of induction for pericardial tamponade?
ketamine
When does the closing volume exceed FRC?
around 65 when sitting up and 45 when supine
What muscles tense and relax cords?
CricoThyroid (cords tense)
THyroaRytenoid (they relax)
What kind of regional anesthesia is sufficient for all procedures below the knee that do not require a tourniquet?
sciatic and femoral block
What are some anesthesia considerations when doing a cardioversion?
optimize if possible (NPO), use Versed and short acting anesthetic like propofol or etomidate- intubate and do GA if patient has not fasted
Describe the pathophysiology of ARDS and its most common causes
noxious event causes insult to alveolar capillary membrane, which increases permeability and leads to pulmonary edema- sepsis, bacterial pneumonia, trauma, aspiration pneumonitis
What are some limitations with using the FOB?
fogging, potential for damaged fiberoptic strands, limited view if copious secretions, aggressive contact with inflamed tissue can cause obstruction, requires pt cooperation
What are some considerations when using a FOB with a nasal approach?
anesthetize with lidocaine and use local vasoconstrictors (phenylephrine) to avoid bleeding
What are some other less common types of pulmonary edema?
high altitude, reexpansion (after pneumo)
What should surgery time be limited to in outpatient?
1-2 hours
Describe the arterial filler of CPB
acts as air bubble trap and filters particulate matter
What is a benefit of using regional anesthesia during carotid endarterectomy?
allows for continuous monitoring of neuro function
What do you do to optimize a patient before using a FOB?
pre-dry secretions (anticholinergic), anesthetize airway, short acting sedation (remifentanil) for stimulating portion, ketamine (helps them breath better but more secretions), precedex
What is bronchiectasis? signs and symptoms?
irreversible airway dilation with focal or diffuse lung involvement- chronic productive cough, purulent sputum, massive hemoptysis, increased susceptibility to infection, clubbing of fingers
What are some acquired conditions associated with difficult airway?
obesity, acromegaly, Ludwig angina, abscesses, laryngeal papillomatosis, epiglottitis, croup, RA, ankylosing spondylitis, tumors, trauma
What does anesthetic management for kyphoscoliosis look like?
optimize pre-op (make sure no PNA), ABG if severe, avoid nitrous (PH), may need to keep awake to evaluate nerve function, high risk for blood loss during spine correction
What are risk factors for difficult mask ventilation?
BONES (beard, obese, no teeth, elderly, snoring)
What are some signs of cardiac rupture?
hypotension, distended neck veins, muffled heart sounds
What are some appropriate meds for preemptive analgesia in outpatient surgery?
COX 2 inhibitors, tylenol, ketamine, local anesthetics
What are essential features of RSI?
preoxygenate, induction dose with succs or roc, cricoid pressure, avoid PPV until airway secured
How does aging affect hepatic function?
decreased blood flow and mass, increased half life, variable phase 1 metabolism (oxidation, reduction, hydrolysis- CP450 system), decreased serum album (binds to acidic drugs) and increased A1AG (bind to basic drugs)
What is ATLS Class IV of shock?
blood loss >40%, HR >140, SBP and PP decreased, RR >35, confused and lethargic
What drug may be given as treatment in drug induced pulmonary disease?
corticosteroids
What are some ways you can prevent atelectasis?
use lower FiO2, use PEEP and vital capacity maneuvers (lungs intermittently expanded to VC or 30 cm H20 and held in that state for 10 seconds)
What should you do if your patient has laryngospasm on extubation?
remove stimulus, 100% FiO2, oral airway, jaw thrust, apply 10-30 cmH20 PPV, deepen anesthesia if necessary or succs (0.2-2 mg/kg IV)
What are s/s of ARDS?
dyspnea, severe hypoxemia, diffuse bilateral pulmonary infiltration, stiffening and noncompliance
What drugs should you avoid in older adults to prevent POD?
benzos, sedatives, anticholinergics that cross BBB (scopalamine)
What condition should you monitor for after laryngospasm?
aspiration, negative pressure pulmonary edema
What are some complications of thoracic aorta resections?
anterior spinal artery syndrome, ischemia to SC
What provides sensory innervation below the vocal cords?
RLN
What are some methods of doing topical airway anesthesia?
viscous lidocaine, nebulizer, MAD, lidocaine lollipop
What are some age related pharm implications in the older adult?
decreased initial Vd due to lower BV (higher than expected initial concentration of drug), increased Vd of lipophilic drugs, decreased plasma protein binding, MAC decreases by 6.7% per decade after 40, prolonged onset of NMB and prolonged effect
What are risk factors for BCIS?
preexisting CV and PH, ASA III+, NYHA class 3+, pathologic fracture, intertrochanteric fracture, long stem arthroplasty
What are some advantages of outpatient surgery?
decreased costs, increased efficiency and patient satisfaction, minimal parent separation for children, better cognitive and physical capacity for elderly, uniform staffing schedules, increased availability of hospital beds
What are some concerns when using PTJV?
barotrauma (use longer expiratory times)
What is considered pulmonary hypertension?
mPAP >25 mmHg
What are risk factors for COPD?
smoking, occupational exposure, pollution, recurrent childhood respiratory infections, low birth weight, apha 2 antitrypsin deficiency
What is spinal shock?
hypotension, bradycardia, hypothermia with warm pink extremities with injury to T6 or higher- loss of sympathetic tone, cardioaccelerator fibers no long oppose vagal innervation
What is the recommended dosing for perioperative meds for older adults?
decrease propofol, etomidate, and opioids by 50%, avoid benzos if possible but decrease dose by 75% if used
What are some contraindications to LMA?
obesity, high pulmonary pressures, GERD, certain surgical positions, airway avoidance
What are some anesthesia considerations in those with Raynauds?
keep extremities warm, avoid use of epi in local anesthetics, avoid using A-line
What are some complications of beach chair positioning during arthroplasty?
risk for VAE and decreased cerebral perfusion, hypotensive bradycardic episode (Bezold Jarisch reflex)
Describe sarcoidosis
extensive tissue injury caused by intense interaction between lymphocytes and macrophages- can cause fibrosis, restrictive and obstructive lung properties, cor pulmonale, laryngeal involvement
What drug can cause noncytotoxic pulmonary disease? What are signs and symptoms?
amiodarone- new onset pulmonary symptoms, infiltrates, abnormal gallium uptake, histologic changes of lung tissue
How does a pneumothorax look on CXR?
separation of visceral pleural surface from chest wall and absence of pulmonary vessels peripheral to pleural line
What are some pharm treatments for pulmonary hypertension?
prostanoids (ex- iloprost), endothelin receptor antagonists, nitric oxide, guanylate cyclase
How does aging affect the immune system?
decreased bactericidal activity, increased cytokines and chemokines (chronic inflammation)
What is done to protect the heart during CPB?
cooling (8-10 C) and cardioplegia (hyperkalemic crystalloid solution) to decrease metabolic rate, O2 consumption, and NT release
Describe a combitube
distal balloon occludes esophagus, larger proximal balloon occludes posterior oropharynx
What are some effects of aortic cross-clamping?
increased systemic BP with no change in HR, blood flow to tissues distal to the clamp occur through collateral vessels or shunts and depend on perfusion pressure, increased ICP and PVR, hormonal factor release
What is the LV vent during CPB?
catheter placed in LV through R superior pulmonary vein to drain blood that has accumulated in the cavity from the bronchial artery and thebesian veins
When is a bronchial blocker used?
when one lung ventilation is needed but cannot place a DLT (nasal intubation, difficult airway, trach)
What are some ways to combat coagulopathy in trauma?
1:1:1 RBC plasma platelets, keep pt warm, maintain cerebral perfusion 60-70, maintain INR <1.5 and platelets >50k
What are the most common reasons for hospitalization after ambulatory surgery?
PONV and pain
What are some anesthesia considerations for hip arthroplasty?
regional or spinal block commonly used, avoid nitrous, intubate if doing prone, may administer 1-2 g TXA
When would a CXR be warranted before outpatient surgery?
new pulmonary symptoms, ESRD, decompensated HF
What are some concerns with rheumatoid arthritis?
issues with cervical spine, TMJ, larynx, pulmonary system
How does pneumonia look on CXR?
homogenous increased opacity (lobar), inflamed airways (lobular), increased linear or reticular markings with peribronchial thickening (interstitial), silhouette sign
Which sided DLT is most commonly used? The bronchial cuff should be inflated no more than?
left; 3 cc
When would you use a trachlight and how do you know it’s in the trachea?
used for small mouth opening and decreased ROM; should have bright, circumscribed glow (would be dimmer if in esophagus)
What is prime in terms of CPB?
1-2 L of isotonic electrolyte fluid used to fill the circuit, can cause dilutional anema
What are s/s of pulmonary oxygen toxicity?
substernal chest pain on inspiration, tachypnea, nonproductive cough, paresthesia, anorexia, HA, N/V
What is the pathophysiology of coagulopathy in trauma?
dilution from massive resuscitation, hypothermia and acidosis, TBI (release of TF from neurons), shock (activates protein c)
What is bone cement implantation syndrome and how do you treat it?
hypoxia, hypotension, arrhythmia, increased PVR, LOC, arrest, abrupt drop in EtCO2 with seating of prosthesis- 100% FiO2, aggressive fluids, alpha agonists
When would you use an Eschmann stylet (bougie) and what is the characteristic “feel” when you’re in the trachea?
used when glottic opening hard to see; feel “bounce” along tracheal rings
When would IV fluids be warranted for outpatient surgery?
procedures >30 min, increased risk of PONV, post-op discomfort, prolonged fasting (>15 hours), intra- and post-op bleeding, periop ABX
How long does the resolution of toxic signs take when amiodarone is discontinued? What is irreversible?
40-70 days; fibrosis
What kinds of patients are not appropriate for outpatient surgery?
acute substance abuse, premature and full term infants, physiologic elderly, ASA III+, no caregiver, poorly controlled sz, morbid obesity with comorbidities, poorly managed OSA, uncontrolled DM, current sepsis/infection, reactive airway, anticipated uncontrolled post-op pain
Describe characteristics of plain radiography
overall low sensitivity, used to identify conditions of chest of abdomen as well as device placement
What are some diagnostic data you would want to obtain before thoracic surgery?
CXR, EKG (RV hypertrophy), echo, labs (CO2, hypoalbuminemia, BUN), PFTs and response to bronchodilators, V/Q assessment, diffusion capacity, cardiopulmonary reserve
What are some renal considerations when doing aortic cross clamp?
give diuretics (mannitol) before clamping to increase cortical blood flow and GFR, surgeon may administer renal preservation fluid
What are anesthetic management considerations with URI?
increased risk of pulmonary compliations in peds (hypoxemia, laryngospasm), delay surgery 6 weeks if possible, GA can decrease mucociliary flow and bactericidal activity, PPV may spread infection lower, provide adequate hydration, may use LMA to decrease risk of laryngospasm
How does aspiration look on CXR?
depends on positioning and volume of aspirate- usually see R side involvement
What are anesthetic management considerations for COPD?
use NIPPV or intubation, use PFTs to guide optimization, eval RV function, stop smoking 8 weeks prior, optimize nutritional (albumin) status, use regional if possible except above T6, avoid respiratory depressants and desflurane, anticipate slower emergence, humidify air, avoid autoPEEP, use lung expansion maneuvers post-op, extubate to BiPAP
What are some disadvantages of outpatient surgery?
decreased privacy, possible multiple trips, need adequate home care, poor compliance, decreased observation time
What are B lines on ultrasound?
aka comet tail artifact- indicative of thickened subpleural interlobar septa or ground glass opacities- must start from pleural surface, move with lung sliding, erase A lines, and reach bottom of screen
What is the purpose of the cannulae in CPB?
remove deoxygenated blood from the heart, inserted into the vena cava
What are some anesthesia considerations for spinal shock?
use invasive monitoring, adequate fluid resuscitation, NE infusion
Where should a PAC tip be?
sits within L or R pulmonary artery, within 2 cm of hilum
Why are opioids preferred over LAs in neuraxial analgesia after aorta repair?
prevent masking of anterior spinal artery syndrome
What are some anesthesia considerations when doing a catheter ablation (RFCA)?
adults- moderate sedation and analgesia
children- general with LMA or ETT
TIVA often used b/c 25% of C.O. transiently lost when PA is occluded
What are some complications of grafts in aorta repair?
endoleaks, vascular injury, inadequate fixation, stent fracture, breakdown of material, thrombosis, SC ischemia, intra abdominal ischemia, need for re-intervention
How does aging affect the cardiovascular system?
decreased compliance, ventricular hypertrophy, prolonged ejection, diastolic dysfunction, increased circulating catecholamines but decreased organ responsiveness, calcification or conduction system, decreased baroreceptor sensitivity
What are some anesthesia considerations for carotid endarterectomy?
regional to monitor neuro function, ensure completely awake at the end if using GA, pt will likely have abnormal autoregulation, manipulation of carotid sinus may cause fluctuations in HR and BP, maintain normocarbia, use A-line, may use EEG or transcranial doppler- hyper and hypotension both common post-op
What is needle cricothyrotomy with transtracheal jet ventilation (PTJV)?
used in can’t ventilate or intubate scenarios, large bore cath inserted into cricothyroid membrane and lungs ventilated with high pressure O2
What are some special consideration cases for outpatient surgery?
sz (allow time for monitoring, continue AE), CF (degree of pulmonary involvement), MH susceptible (allow for observation), OSA (bring CPAP), sickle cell (no major organ disease, no crisis at least 1 year, close follow up)
What should you do if your patient aspirates?
suction, head down, succs 1 mg/kg, intubate (look for aspirate on cords), oxygenate, CPAP, PEEP, bronchodilators, prophylactic antibiotics IF signs of infection
How is the speed of induction affected in the elderly?
faster induction with inhalation agents but slower IV due to slower circulation
What are some methods of blood conservation during CPB?
antifibrinolytics (TXA, Amicar), blood salvage (washed, no coag factors), limiting pump prime, ultrafiltration (separates aqueous portion of blood but has coag factors)
What are some neuromuscular disorders that cause concern for ventilation?
GBS, MG, Duchenne muscular dystrophy
What should you ensure before placing a chest tube for a massive hemothorax?
adequate fluid resuscitation
How do you prepare for separation from bypass?
air clearance maneuvers, rewarming, obtain stable HR and rhythm (pacing if necessary), pump flow to maintain mixed venous O2 >70%, metabolic parameters within normal limits (K 4-5, Hct 20-25%), restart IVF, inotropes/pressors/dilators prepared
What does the venous reservoir do?
collects venous drainage from heart and the blood suctioned from the surgical field, usually vacuum assisted (around -40 mmHg)
What type of aortic dissections require emergent surgery?
ascending and arch
How does pulmonary embolism look on CXR?
cardiomegaly, PA enlargement Westermark sign, Hamptom hump (rarely use CXR to diagnose)
