Midterm Review Flashcards
What are (2) formulas that can be used to calculate BMI?
BMI = weight (kg) / height (m^2)
BMI = [weight (lbs) / height (in^2)] x 703
BMI class (ASA)–overweight = ___-___
25-29.9
BMI class (ASA)–obese class I = ___-___
30-34.9
BMI class (ASA)–obese class II = ___-___
35-39.9
BMI class (ASA)–obese class III/extreme obese = ___-___
40-44.9
BMI class (ASA)–obese class IV/severe obesity = > ___
> 45
What type of fat distribution is central or abdominal visceral; patients are apple shaped?
Android
What type of fat distribution is gluteal, femoral, or peripheral; patients are pear shaped?
Gynecoid
Which type of obesity (android or gynecoid) is associated with more comorbidities?
Android
Increased cardiac output of ___ L/min for each kg of fat
Increased CO of 0.1 L/min for each kg of fat
Respiratory–obese patients have ___ (increased/decreased) lung compliance; why?
Obese patients have DECREASED lung compliance; d/t pressure from abdominal, diaphragmatic, and thoracic fat
Obese patients have a ___ F/V loop pattern
Obese patients have a RESTRICTIVE F/V loop pattern
Obese patients have ___ (increased/decreased) FRC, ERV, VC, TLC; ___ (increased/decreased) dead space; ___ (increased/decreased/no change) in RV, CC, FVC, and FEV1
Obese patients have DECREASED FRC, ERV, VC, TLC; increased dead space; no change in RV, CC, FVC, and FEV1
Obese patients ___ventilate, which leads to ___carbia and ___osis
Obese patients HYPOventilate, which leads to HYPERcarbia and acidosis
What volumes/capacities are decreased in obese patients?
Decreased
- FRC
- VC
- TLC
- ERV
What volumes/capacities show no change in obese patients?
No change
- RV
- CC
- FVC
- FEV1
What is OSA defined as?
Excessive episodes of apnea (10 seconds) and hypopnea
OSA includes > ___ episodes of apnea per hour or ___ per night
OSA includes > 5 episodes of apnea per hour or 30 per night
OSA leads to ___ia, ___carbia, ___ and ___ hypertension, and cardiac ___
OSA leads to hypoxia, hypercarbia, systemic and pulmonary hypertension, and cardiac arrhythmias
What is the gold standard test for OSA?
Polysomnography (PSG)
What questionnaire can we use to evaluate patients for OSA and has up to 93% sensitivity?
STOP-BANG
What does STOP-BANG stand for?
S-Snoring (Do you snore loudly?)
T-Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)
O-Observed apnea (Has anyone observed that you stop breathing, or choke or gasp during your sleep?)
P-high blood Pressure (Do you have or are you being treated for high blood pressure?)
B-BMI (Is your body mass index more than 35 kg per m^2?)
A-Age (Are you older than 50 years?)
N-Neck circumference (Is your neck circumference greater than 40 cm [15.75 inches]?)
G-Gender (Are you male?)
What syndrome does this describe?–inappropriate and sudden somnolence, OSA, hypoxia, hypercapnia, arterial hypoxemia, cyanosis-induced polycythemia, respiratory acidosis, pulmonary hypertension, right sided heart failure
Obese hypoventilation (Pickwickian) syndrome
Obese hypoventilation (Pickwickian) syndrome can lead to what? How?
Right heart failure d/t hypoxic pulmonary vasoconstriction (AKA cor pulmonate)
Pharmacology in obese patients–___ (increased/decreased) volume of distribution; ___ (increased/decreased) blood volume; ___ (increased/decreased) total body water
increased volume of distribution; increased blood volume; decreased total body water
Pharmacokinetic changes associated with obesity–___ (increased/decreased) fat mass; ___ (increased/decreased) cardiac output; ___ (increased/decreased) blood volume; ___ (increased/decreased) lean body weight; ___ (increased/decreased) total body water; ___ (increased/decreased) renal clearance; ___ (increased/decreased) volume of distribution of lipid-soluble drugs
increased fat mass; increased cardiac output; increased blood volume; increased lean body weight; decreased total body water; increased renal clearance; increased volume of distribution of lipid-soluble drugs
Effects of general anesthesia–obese patients have __% reduction in FRC compared to ___% in non-obese patients
Obese patients have 50% reduction in FRC compared to 20% in non-obese patients
Tidal volumes in obese patients–___-___ ml/kg of ___ (IBW or TBW) for volumes
6-10 ml/kg of IBW for volumes
Volume replacement for obese patients–increased ___ volume, but proportionately decreased ___ volume
increased total body volume, but proportionately decreased estimated blood volume
EBV in obese patients–use ___-___ ml/kg
use 45-55 ml/kg
What is the first priority of anesthetic management in a burn patient?
Diagnose and treat airway injury
EARLY intubation if necessary–may be extremely difficult, consider awake/fiberoptic, surgical airway, succs?
What is the denervation-like phenomenon that occurs during the resuscitative phase of burn patients?–proliferation of ___ receptors, ___ release
Proliferation of acetylcholine receptors, K+ release
Do NOT give succs to a burn patient after ___ hours
Do NOT give succs to a burn patient after 24 hours
When is it okay to give succs to a burn patient?
When the wound is closed and the patient is gaining weight
If you are using a NDNMB in a burn patient, you have to give ___-___x the ED95 dose for proper intubating conditions
2-3x the ED95 dose
CO has ___x affinity for hemoglobin than O2
CO has 200x affinity for hemoglobin than O2
CO poisoning–tissues are unable to extract ___, leads to metabolic ___osis
CO poisoning–tissues are unable to extract O2, leads to metabolic acidosis
Labs for CO poisoning–SaO2 is ___; ABG has ___ total oxygen
SaO2 is normal; ABG has decreased total oxygen
What device is needed to show true oxygen saturation in a patient with CO poisoning?
Co-oximeter
Treatment of CO poisoning = ___
100% O2–decreases CO half-life from 4 hours to 40 mins
Fluid loss/shifts are greatest in the first ___ hours in burn patients; begin to stabilize after ___ hours
fluid loss/shifts are greatest in the first 12 hours in burn patients; begin to stabilize after 24 hours
Fluid shifts from ___ to ___
Fluid shifts from intravascular to interstitial
Result of fluid shifts in burn patients–severe depletion of ___; marked increase in ___ volume
severe depletion of plasma (hypovolemia); marked increase in extracellular volume (edema)
Parkland formula for burn patients–in the first 24 hours, give ___ ml LR/% burn/kg; give 1/2 in the first ___ hours, give 1/2 in the next ___ hours; ___ (yes/no) colloid
In the first 24 hours, give 4 ml LR/% burn/kg; give 1/2 in the first 8 hours, give 1/2 in the next 16 hours; no colloid
Parkland formula for burn patients–in the second 24 hours, ___ maintenance fluid
In the second 24 hours, D5W maintenance fluid
The hypermetabolic/hyperdynamic phase usually occurs after ___ hours
after 48 hours
Increased CO, tachycardia, lower SVR
CV changes in burn patients–immediate IV fluid loss can occur for up to ___ hours; after ___ hours, get hypermetabolic
Immediate IV fluid loss can occur for up to 36 hours (most in first 12 hours, usually stabilize after 24 hours); after 48 hours, get hyper metabolic
What is the hallmark of burn shock?
Decreased cardiac output–occurs within minutes of burn
Pulmonary function is decreased in burn patients, even without inhalation burns–T/F?
True
What (3) pulmonary things are reduced in burn patients?
- FRC
- Lung and chest wall compliance
Ventilation can increase from ___ L/min to ___ L/min in burn patients
Ventilation can increase from 6 L/min to 40 L/min in burn patients
What is the leading cause of death in burn patients?
SEPSIS
Adults–75%
Peds–near 100%
Max cold ischemic times–heart and lungs = ___-___ hours; liver = ___-___ hours; kidneys = ___ hours
Heart and lungs = 4-6 hours; liver = 12-24 hours; kidneys = 72 hours
What is donation after cardiac death?–non-___ donors; severe ___ dysfunction; have ___ activity in the brain; death is defined by cessation of ___ and ___
- Non-heart-beating donors
- Severe whole brain dysfunction
- Have electrical activity in the brain
- Death is defined by cessation of circulation and respiration
DCD donors meet the criteria for brain death–T/F?
False–DCD donors do NOT meet the complete criteria for brain death
For DCD, after the patient’s heart stops beating and the physician declares death, the transplant team waits no less than ___ minutes following pulselessness before starting organ recovery
The transplant team waits no less than 5 minutes following pulselessness before starting organ recovery
Anesthesia management ___ (is/is not) required for organ donation after brain death (DBD)
Anesthesia management IS required for organ donation after brain death
Anesthesia management ___ (is/is not) required for organ donation after cardiac death (DCD)
Anesthesia management IS NOT required for organ donation after cardiac death
Anesthesia for organ recovery–anesthesia support of donor organ systems is necessary until the ___
until the proximal aorta is clamped (after which the ventilator, IVs, and cardiac monitors may be discontinued)
Anesthesia for organ recovery–if the lungs are to be recovered for transplantation, anesthesia support ___ (will/will not) be required post cross-clamp
if the lungs are to be recovered for transplantation, anesthesia support will be required post cross-clamp
Why is anesthesia needed post cross-clamp if the lungs are to be recovered?
Anesthesia will hyperventilate the lungs to ensure that the perfusion is delivered at the cellular level
Living organ donors are frequently related to the recipient, healthy individual between ___-___
18-60
Living organ donors must have no history of what (5) things?
- HTN
- Diabetes
- Cancer
- Kidney disease
- Heart disease
Absolute contraindications to organ implantation–active uncontrolled ___; ___; inability to tolerate ___ suppression; severe ___/___ condition (pt unfit for surgery); continued ___ or ___ abuse; ___ malignancy; inability to comply with ___ regimen; lack of ___ support
active uncontrolled infection; AIDS; inability to tolerate immune suppression; severe cardiopulmonary/medical condition (pt unfit for surgery); continued drug or alcohol abuse; extrahepatic malignancy; inability to comply with medical regimen; lack of psychosocial support
What is the most frequent solid organ transplant (order from greatest to least)?
Kidney > Liver > Heart > Lung > Heart/Lung
Gastroparesis, another complication of autonomic neuropathy, increases the risk of ___ during induction of GETA
increases the risk of aspiration during induction of GETA
CRF is characterized by Hgb ___-___; Hgb of ___% or greater is needed for adequate O2 delivery to the heart and transplanted graft
CRF is characterized by Hgb 6-8%; Hgb of 8% or greater is needed for adequate O2 delivery to the heart and transplanted graft
___ evaluation is very important for patients with type 1 insulin dependent diabetes mellitus (IDDM); why?
Airway evaluation because these patients often manifest with stiff joint syndrome, characterized by a fixation of the AO joint, along with limited head extension
Pulmonary function impairment (for patients with type 1 IDDM) is characterized by a decrease in ___ reactivity, a significant restriction of lung volumes, with reduced ___ volume and forced ___ ventilation
Pulmonary function impairment (for patients with type 1 IDDM) is characterized by a decrease in cough reactivity, a significant restriction of lung volumes, with reduced tidal volume and forced expired ventilation
What gas should NOT be used for living kidney donors? Why?
Nitrous oxide–can distend the bowel which can get in surgeons way (because it is done laparoscopically)
What med(s) should be given when the clamps are released from the external iliac vein/artery?
Mannitol or lasix
Be attentive to ___tension after reperfusion of donor kidney because graft function is critically dependent on ___
Be attentive to hypotension after reperfusion of donor kidney because graft function is critically dependent on perfusion pressure
What drugs should be avoided in kidney transplant patients? Why?
Avoid alpha adrenergic drugs b/c transplanted kidney is sensitive to sympathomimetics
Alpha adrenergic drugs enhance blood flow to transplanted organs–T/F?
FALSE–alpha adrenergic drugs compromise blood flow to transplanted organs
Choice of muscle relaxant in kidney transplant patients depends on what electrolyte?
K+ level
In normokalemic patients, ___ (what muscle relaxant?) is safe
Succs– 1-1.5 mg/kg
What are (2) other muscle relaxants that can be used in kidney transplant patients?
- Cisatracurium (Hoffman elimination) (0.1 mg/kg)
- Mivacurium (0.15-0.2 mg/kg)
___ (depolarizing/nondepolarizing) muscle relaxant is preferred in patients who are at high risk of pulmonary aspiration in ESRD d/t autonomic gastropathy, obesity, or on peritoneal dialysis with significant volume of dialysate fluid left in
Depolarizing–succs
Reversal of muscle relaxants with neostigmine and robinul is safe in patients with ESRD–T/F?
True–but sugammadex is even better
If diabetic gastroparesis is a concern, what can be administered immediately prior to the induction of anesthesia to decrease the gastric acid content?
Sodium citrate/citric acid oral solution
What drug can be given to increase gastric emptying and lower esophageal sphincter tone?
Metoclopramide
What drug can be given 6-12 hours prior to induction to decrease gastric acid production?
H2 blocker
What (2) drugs should be given before unclamping vascular supply to transplanted kidney?
- Mannitol
- Loop diuretics
Reperfusion of kidney graft may be associated with ___tension; this is most often related to a reduction in the ___load as a consequence of unclamping the ___; how should you treat?
Reperfusion of kidney graft may be associated with hypotension; this is most often related to a reduction in the preload as a consequence of unclamping the iliac artery; treat with crystalloid, colloid, or low-dose dopamine
Moderate to severe ___tension may accompany emergence from anesthesia for renal transplant; treat with ___ (short/long) acting antihypertensives
hypertension; treat with short acting antihypertensives
Should long acting beta-blockers be used to treat hypertension on emergence from anesthesia for renal transplant?
NO–because they can raise K+ levels
Use short-acting antihypertensives
How is the excretion of drugs affected by a prior renal transplant?
Renal excretion of drugs is usually decreased in patients with a prior renal transplant
Patients with chronic liver dysfunction and cirrhosis have a ___ (hyper/hypo) dynamic circulation with ___ (low/high) peripheral vascular resistance and a/an ___ (increased/decreased) cardiac index
Patients with chronic liver dysfunction and cirrhosis have a hyperdynamic circulation with low peripheral vascular resistance and an increased cardiac index
What are the (3) phases of liver transplantation surgery?
- Preanhepatic phase
- Anhepatic phase
- Neohepatic phase
Preanhepatic phase involves what?
- Lysis of adhesions and exploration of abdomen
- Mobilization of liver and careful dissection of hepatic artery, common bile duct, supra and infra hepatic vena cava and portal vein
Preanhepatic phase–if portal HTN is severe to the degree that mobilizing the liver may result in significant blood loss or the patient is unstable, then what (2) things may be instituted?
- Portocaval shunt
- Venous bypass
Preanhepatic phase–non-shunting procedures are aimed at controlling ___ from ___
non-shunting procedures are aimed at controlling hemorrhage from portosystemic varices
Preanhepatic phase–shunting procedures redirect the portal venous flow into the systemic ___ circulation via a ___ conduit, thus relieving ___, decompressing ___, and at the same time relieving ___
shunting procedures redirect the portal venous flow into the systemic venous circulation via a nonvariceal conduit, thus relieving portal hypertension, decompressing varices, and at the same time relieving ascites
Anesthesia management of preanhepatic phase–hemorrhage leads to ___ instability; ___ problems occur at this stage; impaired ___ from surgical retraction and IVC clamping; ___calcemia, ___kalemia, and metabolic ___osis
hemorrhage leads to CV instability; coagulation problems occur at this stage; impaired venous return from surgical retraction and IVC clamping; hypocalcemia, hyperkalemia, and metabolic acidosis
Anhepatic phase begins with ___
clamping of hepatic blood flow
What (2) big things occur during anhepatic phase?
removal of native liver, implantation of donor liver
Bicaval clamp used during the anhepatic phase clamps what?
Clamps vena cava above and below the liver
Bicaval clamp drops ___, leading to profound ___tension and ___cardia
Bicaval clamp drops preload, leading to profound hypotension and tachycardia
Piggyback technique for anhepatic phase ___ clamps the IVC; what is the benefit of this?
Piggyback technique for anhepatic phase side clamps the IVC; benefit is that it preserves some caval flow/preload
Considerations during anhepatic phase–___, increasing ___lysis, ___pathy, ___osis, ___thermia, and decreased ___ function
hemorrhage, increasing fibrinolysis, coagulopathy, acidosis, hypothermia, and decreased renal function
Anhepatic phase–cardiac output and systemic blood pressure may need to be supported with ___ and ___
inotropes and vasopressors
Anhepatic phase–___ intoxication may occur from rapid infusion of large volumes of blood in absence of liver function
citrate intoxication
What electrolyte abnormality may occur during anhepatic phase? How should you treat?
Hypocalcemia–give calcium
Neohepatic phase begins with what?
Unclamping of the portal vein, hepatic artery, vena cava and reperfusion of the donor liver
What may occur with unclamping of portal vein?
Severe hemodynamic instability–post reperfusion syndrome
Neohepatic phase–before unclamping of portal vein, ___ should be normal, ___ should be corrected, and K+ should be ___
ionized calcium should be normal, acidosis should be corrected, and K+ should be < 4.5
What vasopressors should be used during neohepatic phase? What should be avoided?
Epi, norepi, or both
Avoid fluid overload prior to unclamping
Neohepatic phase–hemodynamics typically stabilize once ___
allograft begins to function
Reperfusion syndrome is characterized by decreased ___, ___, and ___; ___ defects (___arrhythmias, ___); ___ HTN; ___ (increased/decreased) SVR
decreased CO, HR, and BP; conduction defects (bradyarrhythmias, asystole); pulmonary HTN; decreased SVR
Reperfusion syndrome–a rapid increase in ___ can occur, ensure normal pH and electrolytes prior to unclamping
a rapid increase in K+
Reperfusion syndrome–severe coagulopathies occur d/t ___lysis, release of ___, and ___thermia
severe coagulopathies occur d/t fibrinolysis, release of heparin, and hypothermia
Initial indirect signs of a functioning graft = intraoperative ___ production; intraoperative spontaneous correction of ___; improvement in ___
intraoperative bile production; intraoperative spontaneous correction of negative base excess; improvement in coagulation
Interventional radiology–these procedures (i.e.: embolization of cerebral and dural AVMs, coiling of cerebral aneurysms, angioplasty of sclerotic lesions, thrombolysis of acute thromboembolic stroke) often require deliberate ___tension and deliberate ___capnia
often require deliberate hypotension and deliberate hypocapnia
Interventional radiology–deliberate ___tension is called for during cerebral ischemia in an attempt to maximize collateral flow
deliberate hypertension
ECT is performed ___ times a week for ___-___ treatments
ECT is performed 3 times a week for 6-12 treatments
Followed by weekly or monthly maintenance therapy to prevent relapses
MOA of ECT–ECT therapeutic effects are thought to result from the release of ___ during the electrically induced ___
ECT therapeutic effects are thought to result from the release of neurotransmitters during the electrically induced grand-mal seizure
ECT–___ and ___ levels increase immediately after; ___ levels decrease more rapidly thereafter
norepi and epi levels increase immediately after; epi levels decrease more rapidly thereafter
ECT–___ homeostasis is variably affected by ECT; improvement in control of ___ (insulin/non-insulin) dependent diabetes is generally noted, whereas hyperglycemia may be seen when the diabetes is ___ (insulin/non-insulin) dependent
glucose homeostasis is variably affected by ECT; improvement in control of non-insulin dependent diabetes is generally noted, whereas hyperglycemia may be seen when the diabetes is insulin dependent
Physiologic response to ECT–grand mal seizure with ___-___ second ___ phase; ___-___ second ___ phase
grand mal seizure with 10-15 second tonic phase; 30-60 second clonic phase
Other physiologic responses to ECT–___ (increased/decreased) CBF and ICP; CV–initial ___cardia followed by ___tension and ___cardia, ___rhythmias, myocardial ___; ___-term memory loss; muscle ___/___/___; status ___; sudden ___
increased CBF and ICP; CV–initial bradycardia followed by hypertension and tachycardia, dysrhythmias, myocardial ischemia; short-term memory loss; muscle aches/fractures/dislocations; status epilepticus; sudden death
What is one absolute contraindication to ECT?
Pheochromocytoma
Relative contraindications to ECT–increased ___ pressure; recent ___; CV ___ defects; high-risk ___; ___ and ___ aneurysms
Relative contraindications to ECT–increased intracranial pressure; recent CVA; CV conduction defects; high-risk pregnancy; aortic and cerebral aneurysms
What muscle relaxant is preferred for ECT to prevent fractures/dislocations during the seizure?
Succs–0.75-1.5 mg/kg
Preferable to the longer acting nondepolarizing agents
What medication helps reduce ECT-induced myalgia in younger patients?
Toradol 15-30 mg
What (2) medications can prevent the parasympathetic effects of ECT (i.e.: salivation, bradycardia, asystole)?
Robinul and atropine
What (2) meds lessen hemodynamic responses to ECT? Which of the two has less of an effect on seizure duration?
- Labetalol (0.3 mg/kg)
- Esmolol (1 mg/kg)
Esmolol has a lesser effect on seizure duration
What (2) meds administered before induction of anesthesia for ECT are effective in controlling BP without affecting seizure duration?
- Clonidine (1 mcg/kg over 10 mins)
- Dexmedetomidine (1 mcg/kg over 10 mins)
Complications of ECT–seizure activity causes an initial ___ discharge, manifested by ___cardia, occasional ___, premature ___, or a combo of these abnormalities; ___tension and ___ may be noted, and then ___ activity
seizure activity causes an initial parasympathetic discharge, manifested by bradycardia, occasional asystole, premature atrial or ventricular contractions, or a combo of these abnormalities; hypotension and salivation may be noted, and then sympathetic activity
What (2) ECG changes may be seen after ECT? Do these changes indication myocardial infarction?
- ST-segment depression
- T-wave inversion
Occur without any myocardial enzyme changes consistent with myocardial infarction
Arrhythmias associated with ECT, even in patients with preexisting arrhythmias, are self-limited and not in themselves a contraindication to treatment–T/F?
True
What are the most common causes of death from ECT?
MI and arrhythmia
ECT–goal is a seizure that is ___-___ seconds long
30-60 seconds long
Dental surgery for patients with Down syndrome–patients often have CV abnormalities–___ abnormalities and ___ defects; risk of ___ dislocation; airway difficulties–___glossia, ___plastic maxilla, ___ abnormalities, mandibular ___
CV abnormalities–conduction abnormalities and structural defects; risk of atlanto-occipital dislocation; airway difficulties–macroglossia, hypoplastic maxilla, palatal abnormalities, mandibular protrusion
What are the (4) stages of sedation and analgesia?
- Minimal sedation (anxiolysis)
- Moderate sedation/analgesia (“conscious sedation”)
- Deep sedation/analgesia
- General anesthesia
Minimal sedation/anxiolysis–drug-induced state during which patients respond normally to ___; although cognitive function and physical coordination may be impaired, ___ reflexes, ___ and ___ functions are unaffected
Minimal sedation/anxiolysis–drug-induced state during which patients respond normally to verbal commands; although cognitive function and physical coordination may be impaired, airway reflexes, ventilatory and cardiovascular functions are unaffected
Moderate sedation/analgesia (“conscious sedation”) is a drug-induced depression of consciousness during which patients respond ___ to verbal commands, either ___ or accompanied by ___ stimulation; interventions ___ (are/are not) required to maintain a patent airway, and spontaneous ventilation ___ (is/is not) adequate; ___ function is usually maintained
Moderate sedation/analgesia (“conscious sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation; interventions are NOT required to maintain a patent airway, and spontaneous ventilation is adequate; CV function is usually maintained
Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily ___ but respond ___ following ___ or ___ stimulation; the ability to independently maintain ventilatory function may be ___; patients may require assistance in maintaining a ___ airway, and spontaneous ventilation may be ___; CV function is usually ___
Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation; the ability to independently maintain ventilatory function may be impaired; patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate; CV function is usually maintained
General anesthesia is a drug-induced loss of consciousness during which patients ___ (are/are not) arousable, even by ___ stimulation; the ability to independently maintain ventilatory function is often ___; patients often require assistance in maintaining a ___ airway, and ___ ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of ___ function; CV function may be ___
General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation; the ability to independently maintain ventilatory function is often impaired; patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function; CV function may be impaired
Fasting protocol for sedation/analgesia for elective procedures–all categories (except for children younger than 6 months) should not have solids and nonclear liquids ___-___ hours before surgery
no solids/nonclear liquids for 6-8 hours before surgery
Fasting protocol for sedation/analgesia for elective procedures–children younger than 6 months should not have solids and nonclear liquids ___-___ hours before surgery
children younger than 6 months should not have solids/nonclear liquids 4-6 hours before surgery
Fasting protocol for sedation/analgesia for elective procedures–all categories should not have clear liquids ___-___ hours before surgery
no clear liquids 2-4 hours before surgery
Sympathetic stimulation = iris ___ (dilator/sphincter) muscle contracts, causing pupil ___ (dilation/constriction) or ___sis
Sympathetic stimulation = iris dilator muscle contracts, causing pupil dilation or mydriasis
Parasympathetic stimulation = iris ___ (dilator/sphincter) muscles contract, causing pupillary ___ (dilation/constriction) or ___sis
Parasympathetic stimulation = iris sphincter muscles contract, causing pupillary constriction or miosis
The retina ___ (does/does not) contain capillaries
The retina does NOT contain capillaries
Since the retina does not contain capillaries, what layer of the eye provides oxygen to the retina?
Choroid layer provides oxygen to the retina
Retinal detachment from the choroid compromises blood supply and is a major cause of vision loss–T/F?
True
The pars plana is a safe entry area for what procedures?
The pars plana is a safe entry area for vitrectomy procedures
What is the term used to describe a variety of arrhythmias resulting from manipulation of the eye?
Ocular cardiac reflex (OCR)
Ocular cardiac reflex (OCR) manifests as ___cardia, ___ block, ventricular ___ and ___ (rarely)
Ocular cardiac reflex (OCR) manifests as bradycardia, AV block, ventricular ectopy and asystole (rarely)
OCR can occur with any stimulation of orbital contents, including lid and periosteum–T/F?
True
OCR is seen especially with traction of what particular muscle of the eye?
Medial rectus traction
OCR is ___ (from what cranial nerves does it originate?)*** Memorize
OCR is trigeminovagal
***Memorize
___ (afferent/efferent) impulses of the OCR originate in orbital contents (via long and short ciliary nerves)***Memorize
AFFERENT impulses of the OCR originate in orbital contents (via long and short ciliary nerves)
***Memorize
Afferent impulses from the OCR travel to the ___ ganglion, to the ___ division of the ___ nerve, to the ___ (sensory/motor) nucleus of the ___ nerve near the ___ ventricle, to visceral motor nuclei of the ___ nerve***Memorize
Afferent impulses from the OCR travel to the ciliary ganglion, to the ophthalmic division of the trigeminal nerve, to the sensory nucleus of the trigeminal nerve near the fourth ventricle, to visceral motor nuclei of the vagus nerve
***Memorize
Efferent limb of the OCR is ___ nerve to the ___***Memorize
Efferent limb of the OCR is vagus nerve to the heart
***Memorize
The OCR occurs more frequently in adults than peds–T/F?***Memorize
FALSE–OCR occurs more frequently in peds than adults
***Memorize
OCR may be seen during topical and general anesthesia–T/F?
True
OCR is seen ___ (more/less) during retrobulbar blocks
OCR is seen LESS during retrobulbar blocks
~Although orbital injections can stimulate reflex
OCR response is worsened by ___emia and ___carbia
OCR response is worsened by hypoxemia and hypercarbia
What should you do FIRST if OCR occurs?
Ask the surgeon to stop manipulation of the eye
Other steps in treatment of OCR–assess adequacy of ___; ___ localization or ___ anesthetic may help; for persistent bradycardia, treat with ___
Other steps in treatment of OCR–assess adequacy of ventilation; lidocaine localization or deepening anesthetic may help; for persistent bradycardia, treat with atropine
The OCR response becomes stronger with repeated stimulations–T/F?
FALSE–OCR response fatigues with repeated stimulations
Pretreatment with what (2) medications can be effective in preventing OCR? What patient populations should you consider this for?
Pretreatment with glyco or atropine can be effective in preventing OCR; consider this in patients with conduction block or on beta blocker
Blood supply to the eye is dependent on ___ perfusion pressure
Blood supply to the eye is dependent on intraocular perfusion pressure
MAP - IOP
Volume in the globe is relatively fixed, except for ___ fluid and ___ blood volume
Volume in the globe is relatively fixed, except for aqueous fluid and choroid blood volume
Normal IOP = ___-___ mm Hg
Normal IOP = 10-22 mm Hg
IOP > ___ mm Hg is pathological
IOP > 25 mm Hg is pathological
Production of aqueous humor is facilitated by what enzyme?
Production of aqueous humor is facilitated by carbonic anhydrase
Decreased PaCO2 results in a fast ___ (rise/drop) in IOP from choroidal vaso___
Decreased PaCO2 results in a fast drop in IOP from choroidal vasoconstriction
Increased PaCO2 results in a slow ___ (increase/decrease) in IOP
Increased PaCO2 results in a slow increase in IOP
A fast respiratory rate may ___ (increase/decrease) IOP from insufficient ___ drainage
A fast respiratory rate may increase IOP from insufficient venous drainage
Metabolic acidosis ___ (increases/decreases) the choroid vessel volume and therefore ___ (increases/decreases) IOP
Metabolic acidosis decreases the choroid vessel volume and therefore decreases IOP
Metabolic alkalosis ___ (increases/decreases) the choroid vessel volume and therefore ___ (increases/decreases) IOP
Metabolic alkalosis increases the choroid vessel volume and therefore increases the IOP
Most anesthetic drugs ___ (increase/decrease) or have ___ on IOP
Most anesthetic drugs decrease or have no effect on IOP
Inhalation agents ___ (increase/decrease) IOP by ___ (increasing/decreasing) BP and thereby ___ (increasing/decreasing) choroidal volume; they ___ (relax/contract) extraocular muscles and ___ (increase/decrease) wall tension; pupil ___ (constriction/dilation) enables aqueous outflow
Inhalation agents decrease IOP by decreasing BP and thereby decreasing choroidal volume; they relax extraocular muscles and decrease wall tension; pupil constriction enables aqueous outflow
IV agents propofol and thiopental ___ (increase/decrease) IOP
IV agents propofol and thiopental decrease IOP
Ketamine may ___ (increase/decrease) IOP because it usually ___ (increases/decreases) BP and doesn’t ___ (relax/contract) extraocular muscles
Ketamine may increase IOP because it usually increases BP and doesn’t relax extraocular muscles
What IV anesthetic is associated with myoclonus and thus may not be appropriate with an open globe?
Etomidate
Opioids generally ___ (increase/decrease) IOP
Opioids generally decrease IOP
Tracheal intubation will increase IOP if depth of anesthesia is inadequate, regardless of NMB used–T/F?
True
Nondepolarizing NMB ___ (do/do not) alter IOP
Nondepolarizing NMB do NOT alter IOP
Succinylcholine ___ (does/does not) increase IOP
Succinylcholine DOES increase IOP
Succinylcholine increase in IOP starts within ___ minute; IOP increases ___-___ mm Hg for ___-___ minutes d/t prolonged contracture of extraocular muscle
Succinylcholine increase in IOP starts within 1 minute; IOP increase 5-10 mm Hg for 5-10 minutes d/t prolonged contracture of extraocular muscle
Glaucoma patients have similar IOP response to succs as people without glaucoma–T/F?
True–the increase in IOP from succs administration is not exaggerated or prolonged in patients with glaucoma
Succs can cause false measurements of IOP during exam under anesthesia for glaucoma patients–T/F?
True–measurements may be falsely elevated
Rise in IOP from succs administration can cause extrusion of eye contents through an open surgical or traumatic wound–T/F?
True
Prolonged contracture from succs administration alters forced duction test (test for extraocular muscle balance) for ___ minutes and may influence the type of strabismus surgery done
Prolonged contracture from succs administration alters forced duction test (test for extraocular muscle balance) for 20 minutes and may influence the type of strabismus surgery done
What are (2) diuretics that can be used to decrease IOP?
- Acetazolamide
- Mannitol
Acetazolamide (Diamox) decreases ___ production by inhibiting ___ (what electrolyte?) pump, which decreases IOP; chronic use depletes what (3) electrolytes?
Acetazolamide (Diamox) decreases aqueous production by inhibiting sodium pump, which decreases IOP; chronic use depletes Na, K+, and bicarb
What acid-base imbalance can result from chronic diamox use?
Metabolic acidosis
Mannitol drops IOP by increasing ___ blood volume; max effect ___-___ minutes, returns to baseline in ___-___ hours
Mannitol drops IOP by increasing circulating blood volume; max effect 30-45 minutes, returns to baseline in 5-6 hours
Echothiophate is a topical anti___ drug that maintains ___ (mydriasis/miosis) to treat ___
Echothiophate is a topical anti cholinesterase drug that maintains miosis to treat glaucoma
Systemic absorption of echothiophate leads to total inhibition of ___, resulting in prolonged ___ after succinylcholine administration
Systemic absorption of echothiophate leads to total inhibition of plasma cholinesterase, resulting in prolonged muscle paralysis after succinylcholine administration
AND MIVACURIUM bc mivacurium is metabolized by plasma cholinesterase
Echothiophate may predispose patients to ___-type (amide/ester) local toxicity
Echothiophate may predispose patients to ester-type local toxicity
Echothiophate is ___ (short/long) acting
Echothiophate is LONG acting–takes 4-6 weeks for enzyme activity (plasma cholinesterase) to return to normal
Phenylephrine is a/an ___ (alpha/beta) adrenergic agonist topically used to ___ (constrict/dilate) pupil
Phenylephrine is an alpha adrenergic agonist topically used to dilate pupil
Pilocarpine and acetylcholine are ___ drugs (what class?) used to ___ (dilate/constrict) the pupil; ___cardia and acute ___ have been reported
Pilocarpine and acetylcholine are cholinergic drugs used to constrict the pupil; bradycardia and acute bronchospasm have been reported
What is a topical beta blocker used to treat glaucoma?
Timolol
Systemic absorption of timolol can cause ___cardia, ___spasm, and ___ exacerbation
Systemic absorption of timolol can cause bradycardia, bronchospasm, and CHF exacerbation
Flomax (tamsulosin hydrochloride) has selective ___ (alpha/beta) ___ (agonistic/antagonistic) properties; it binds the iris ___ (constrictor/dilator) muscles, affecting iris ___ and complicates ___ surgery
Flomax (tamsulosin hydrochloride) has selective alpha antagonistic properties; it binds the iris dilator muscles, affecting iris dilation and complicates cataract surgery
In those taking flomax, the iris remains floppy even after ___-___ days off therapy
In those taking flomax, the iris remains floppy even after 7-28 days off therapy
Most agree that it is safe to do cataract surgery with patient on warfarin–T/F?
True
Facial nerve blocks ___ muscle
Facial nerve blocks orbicularis oculi muscle
What is a major complication of Van Lint, Atkinson, or O’Brien blocks?
Subcutaneous hemorrhage
Nadbath Rehman blocks entire trunk of facial nerve; expect lower facial droop postop for several hours; injection is close to what (2) cranial nerves?
Nadbath Rehman blocks entire trunk of facial nerve; expect lower facial droop postop for several hours; injection is close to VAGUS and GLOSSOPHARYNGEAL nerves
Nadbath Rehman block is associated with ___ paralysis, ___spasm, dys___, and ___ distress
Nadbath Rehman block is associated with vocal cord paralysis, bronchospasm, dysphasia, and respiratory distress
Retrobulbar block involves injection of local anesthetic within the ___
Retrobulbar block involves injection of local anesthetic within the muscle cone
What is added to retrobulbar block to speed tissue penetration?
Hyaluronidase (Hydase, Amphadase, Vitrase, Hylenex)
Retrobulbar block produces anesthesia of the ___, akinesia of the ___ muscle, and ___tony (drop in IOP from relaxation of ___ muscle and ___ [increased/decreased] production of aqueous humor)
Retrobulbar block produces anesthesia of the globe, akinesia of the extraocular muscle, and hypotony (drop in IOP from relaxation of extraocular muscle and decreased production of aqueous humor)
What muscle may NOT be blocked by a retrobulbar block? Why?
Superior rectus muscle because it runs outside the muscle cone
How can you tell if the superior rectus muscle was NOT blocked by a retrobulbar block?
Intorsion on downward gaze
What is the most common complication of retrobulbar block?
Retrobulbar hemorrhage–watch for OCR
What are (2) signs of retrobulbar hemorrhage?
- Proptosis (downward displacement)
- Subconjunctival ecchymosis
Monitoring of ___ is mandatory if retrobulbar hemorrhage occurs
Monitoring of IOP is mandatory if retrobulbar hemorrhage occurs
If there is no elevation in IOP from retrobulbar hemorrhage, then surgery may proceed–T/F?
True
Retrobulbar hemorrhage–bleeding outside muscle cone is seen as ___ without ___
Retrobulbar hemorrhage–bleeding outside muscle cone is seen as subconjunctival ecchymosis without proptosis
RBB–intravascular injection ___ (can/cannot) occur with negative aspiration
RBB–intravascular injection CAN occur with negative aspiration
RBB–IV injection is usually of little consequence–T/F?
True because it is such a small dose
RBB–arterial injection leads to high brain levels via retrograde flow in internal carotid artery; CNS ___ and ___ are possible, but are usually ___ d/t redistribution
RBB–arterial injection leads to high brain levels via retrograde flow in internal carotid artery; CNS excitation and seizure are possible, but are usually transient d/t redistribution
RBB complications–injection into optic nerve sheath (which is continuous with the ___ space) leads to…contralateral ___; ___ation; ___ arrest (occurs within ___ minutes, resolves within ___ hour); vascular ___ from depressant effect on the medulla (total ___)
RBB complications–injection into optic nerve sheath (which is continuous with the subarachnoid space) leads to…contralateral amaurosis (complete lack of vision), obtundation, respiratory arrest (occurs within 20 minutes, resolves within 1 hour), vascular collapse from depressant effect on the medulla (total spinal)
Other RBB complications–___ nerve damage; ocular ___ with retinal ___ and vitreous ___; postop ___ from anesthetic myotoxicity (occurs with what local?)
Other RBB complications–optic nerve damage; ocular perforation with retinal detachment and vitreous hemorrhage; postop strabismus from anesthetic myotoxicity (occurs with bupivacaine)
RBB complication–postop strabismus from anesthetic myotoxicity = vertical ___ vision that occurs day after surgery, worsening over ___ months; occurs d/t tight ___ rectus muscle
RBB complication–postop strabismus from anesthetic myotoxicity = vertical double vision that occurs day after surgery, worsening over 2 months; occurs d/t tight inferior rectus muscle
What are contraindications for RBB?–___ disorders; extreme ___; ___ eye injury
contraindications for RBB–bleeding disorders (d/t risk of RB hemorrhage); extreme myopia (longer globe is more at risk of perforation); open eye injury (b/c pressure of fluid behind eye may force intraocular contents out through wound)
Compared to RBB, peribulbar blockade involves multiple injections made around eye without entering the ___
Compared to RBB, peribulbar blockade involves multiple injections made around eye without entering the muscular cone
Peribulbar blockade has a ___ (shorter/longer) onset time compared to RBB
Peribulbar blockade has a longer onset time compared to RBB (9 to 12 minutes)
Peribulbar block offers ___ (more/less) complete akinesia
Peribulbar block offers less complete akinesis
There is a/an ___ (increased/decreased) likelihood of ecchymosis with peribulbar blocks than RBB
There is an increased likelihood of ecchymosis with peribulbar blocks than RBB
Benefits of sub-tenon’s block–local anesthetic ___ into retrobulbar space; avoid use of ___; complications ___ (more/less) than RBB and peribulbar block
Benefits of sub-tenon’s block–local anesthetic diffuses into retrobulbar space; avoid use of sharp needle; complications less than RBB and peribulbar block
What (2) local anesthetics are used topically for eye surgery?
- Tetracaine 0.5%
- Lidocaine 4%
How is the topical given?–two drops of ___ given initially, followed by ___ more doses of ___ or ___ q ___ minutes just before surgery
Two drops of tetracaine given initially, followed by 3 more doses of tetracaine or lidocaine q 5 minutes just before surgery
What is the only anesthetic option for ruptured globe?
General ETT is the only choice for ruptured globe
Should nitrous be used in vitreoretinal procedures where an air bubble is used? Why?
NO–because nitrous diffuses and causes air bubble expansion, with potential for IOP increase
N2O should be d/c’ed ___ minutes before placement of sulfur hexafluoride and avoided for ___ to ___ days after
N2O should be d/c’ed 15 minutes before placement of sulfur hexafluoride and avoided for 7 to 10 days after
Another vitreal air agent, perfluoropropane (C3F6), persists for ___
Another vitreal air agent, perfluoropropane (C3F6), persists for weeks
How long should N2O be avoided if perfluoropropane (C3F6) is instilled?
Avoid N2O for 1 month after instillation of the agent
Open globe surgeries are usually ___
Open globe surgeries are usually emergent, full stomachs
Succs can be safely used for induction of anesthesia for open globe injury–T/F?
True–no actual case reports of further eye injury when succs is used
Controversy d/t increase in IOP from succs; actual intubation would probably cause more of an increase in IOP than use of succs if patient is not adequately anesthetized
16% of all eye surgeries are related to a muscle disorder–T/F?
True
What drug should be avoided in strabismus surgery?
Succs d/t prolonged response
Eyelid surgery–usually done ___; ptosis raises suspicion for ___ disease
Eyelid surgery is usually done local; ptosis raises suspicion for neuromuscular disease
What is most important consideration for lacrimal apparatus surgery?
Suction pharynx well!!!
Defectively drained excess tears will drain back into the pharynx
What drug is usually avoided for eye surgeries? Why?
Ketamine d/t nystagmus
If gas bubble is used, ___ precautions must be used
If gas bubble is used, nitrous precautions must be used
Why is nitrous oxide good to use for BMT surgery?
Because it diffuses into middle ear and increases pressure
Increased middle ear pressure from nitrous oxide use is relieved by ___ or by ___
Increased middle ear pressure from nitrous oxide use is relieved by reabsorption of NO after it is discontinued or by Eustachian tube venting
What can happen to BMT graft as nitrous oxide is rapidly reabsorbed?
Negative pressures produced by rapid reabsorption can displace the graft
Most avoid nitrous oxide for ear surgery or limit it to < ___%
Most avoid nitrous oxide for ear surgery or limit it to < 50%
How does partial or complete neuromuscular block affect NIM?
Partial or complete neuromuscular block ABOLISHES nerve activity…so you won’t be able to reliably assess NIM
What should you do if patient is partially or completely paralyzed and you are trying to monitor the facial nerve?
Reverse the paralytic to increase reliability of NIM
What drug can be used to maintain depth of anesthesia without having to use neuromuscular relaxant during NIM?
Remifentanil
___ is very common with ear surgery
PONV is very common with ear surgery
Treatment of PONV for ear surgery–keep patient ___; prophylaxis with ___ antagonists, ___ones, ___ patch, ___one (steroid), ___ide
Treatment of PONV for ear surgery–keep patient hydrated; prophylaxis with serotonin antagonists, butyrophenones, scopolamine patch, dexamethasone, metoclopramide
Butyrophenones = D2 antagonists, antipsychotics like haldol
Nasal fractures are fixed within ___ days, after initial swelling goes down
Nasal fractures are fixed within 10 days, after initial swelling goes down
Samter’s triad = ___ sensitivity in patients with ___ and ___ polyps leading to severe ___spasm
Samter’s triad = NSAID sensitivity in patients with asthma and nasal polyps leading to severe bronchospasm
So an important consideration in patients with asthma and nasal polyps–use ___ cautiously
So an important consideration in patients with asthma and nasal polyps–use NSAIDs cautiously (b/c Samter’s triad, NSAID use can lead to bronchospasm)
What are (4) common nasal vasoconstrictors used to reduce bleeding and localize?
- Cocaine
- Epi
- Phenylephrine
- Lido with epi
Cocaine has a ___ (slow/rapid) onset, excellent vaso___ (dilator/constrictor)
Cocaine has a rapid onset, excellent vasoconstrictor
Small doses of cocaine are ___tonic, ___ (increase/decrease) HR; higher doses cause ___cardia, ___tension, ___ (what lethal arrhythmia?) and direct myocardial ___ (depression/excitation), leading to sudden ___
Small doses of cocaine are vagotonic, decrease HR; higher doses cause tachycardia, hypertension, VFib and direct myocardial depression, leading to sudden death
The CV effects of cocaine (at higher doses) result from the blockage of reuptake of ___ (what catecholamine) at the sympathetic nerve terminal; this leads to a potentiation of ___ (sympathetic/parasympathetic) activity
The CV effects of cocaine (at higher doses) result from the blockage of reuptake of EPI at the sympathetic nerve terminal; this leads to a potentiation of SYMPATHETIC activity
Cocaine should be avoided in patients with a history of what (5) things?
- CAD
- MI
- CHF
- HTN
- MAOI
Nasal surgery–flexible LMA may result in LESS lower airway blood contamination than ETT–T/F?
True
Cuffed ETT for nasal surgery may result in blood in airway up to cuff; uncuffed ETT will result in blood in airway beyond cuff–T/F?
True
Point is that LMA (when placed properly) will result in less lower airway blood contamination than a cuffed or uncuffed ETT
Before extubation after nasal surgery, oral cavity and postnasal space should be inspected for blood by standard laryngoscopy; direct visualization of the passage of a suction catheter behind the soft palate should be observed too–T/F?
True
Neck ___ encourages any clot to fall past the soft palate
Neck FLEXION encourages any clot to fall past the soft palate
___ clot is any clot left behind that can be inhaled after ETT is removed, leading to total airway obstruction and death
Coroner’s clot is any clot left behind that can be inhaled after ETT is removed, leading to total airway obstruction and death (hence the name)
Why it is important to remove throat pack, examine oral cavity/postnasal space for blood, and suction behind the soft palate before extubation
Nasal packs may be used post op which can cause partial or complete obstruction of nasal airway; if used, instruct patient to breath through ___
Nasal packs may be used post op which can cause partial or complete obstruction of nasal airway; if used, instruct patient to breathe through mouth
Nasal packs are more problematic in ___ patients
Nasal packs are more problematic in OSA patients
If respiratory depression occurs post op after removal of ETT, consider dislocation of ___ blocking airway
If respiratory depression occurs post op after removal of ETT, consider dislocation of nasal packing blocking airway
Adenoidectomy is needed ___ (more/less) as kid grows; why?
Adenoidectomy is needed LESS as kid grows
Because postnasal space enlarges in proportion to other pharyngeal structures
Adult tonsillectomy is associated with ___ (more/less) pain
Adult tonsillectomy is associated with more pain from scarring and fibrosis
OSA untreated leads to severe ___emia, ___carbia, ___ hypertension, and ___ (another name for right sided heart failure)
OSA untreated leads to severe hypoxemia, hypercarbia, pulmonary hypertension, and cor pulmonale
What can develop minutes or hours after relief of airway obstruction (after removal of enlarged tonsils/adenoids)?
Pulmonary edema
Typical PONV dose of dexamethasone (what we give) is ___ mg/kg; max dose ___ mg
Typical PONV dose of dexamethasone is 0.15 mg/kg; max dose 8 mg
ENT decadron dose is ___-___ mg/kg; max dose ___ mg
ENT decadron dose is 0.5-1 mg/kg; max dose 20 mg
Decadron given for ENT procedures is associated with less postop ___, better ___ tolerance, and reduced ___
Decadron given for ENT procedures is associated with less postop emesis, better diet tolerance, and reduced pain
Even though it is ideal to wait to do surgery on a child a full 6 weeks after a respiratory infection, a lot of times, surgery (i.e.: tonsillectomy) WILL still be done on a child who is not a full 6 weeks infection free…why?
Because you have to eliminate what is causing the infection. The kid may not be able to last a full 6 weeks of being infection free if they have tonsillitis, enlarged tonsils. Need to remove the causative agent.
Because surgery is still done on a child who is not necessarily a full 6 weeks infection free, you need to be aware that the kid will be at a higher risk of what (2) things?
Kid will be at a higher risk of laryngospasm/bronchospasm
How to prevent postextubation laryngospasm and stridor–extubate ___ or ___, avoid stage ___; IV ___ may help prevent; sub hypnotic doses of ___; ___ maneuver
How to prevent postextubation laryngospasm and stridor–extubate deep or asleep, avoid stage 2; IV lidocaine may help prevent; sub hypnotic doses of propofol; Larson’s maneuver
What is Larson’s maneuver?–gentle positive pressure with anterior pressure at the angle of ___
Larson’s maneuver–gentle positive pressure with anterior pressure at the angle of ramus
(This is basically a jaw thrust with fingers positioned at the back of the ear)
Postop bleeding incidence after T&A ___ (increases/decreases) with age; higher in ___ (peds/adults), ___ (male/female), and if there is inflammation of the throat, especially with an ___
Postop bleeding incidence after T&A increases with age; higher in adults, males, and if there is inflammation of the throat, especially with an abscess [another word for this is quinsy]
Primary bleeds after T&A occur within ___ hours, usually ___ or ___ in origin
Primary bleeds after T&A occur within 6 hours, usually venous or capillary in origin
Bleeding 7-8 days postop T&A is usually due to ___ that falls off
Bleeding 7-8 days postop T&A is usually due to scab that falls off
Postop T&A bleeding can occur up to ___ days after surgery
Postop T&A bleeding can occur up to 14 days after surgery
Suggestive S&S of bleeding tonsil include unexplained ___cardia, excessive ___, ___or, ___ness, ___ing, ___ (increased/decreased) capillary refill time
Suggestive S&S of bleeding tonsil include unexplained tachycardia, excessive swallowing, pallor, restlessness, sweating, increased capillary refill time
What is a late sign of bleeding?
Hypotension
Hypotension in a kid without anesthesia is CONCERNING!!!
Bleeding tonsil management–get experienced help; give ___; ___ resuscitate; check ___, ___, ___ (labs); ___ (how many) suctions; ___ induction, head ___ if tolerated; ___ induction with patient lateral or head down is an option for experienced provider; ___ stomach; extubate ___
Bleeding tonsil management–get experienced help; give O2; fluid resuscitate; check H&H, coags, T&C; 2 suctions; rapid sequence induction, head down if tolerated; mask induction with patient lateral or head down is an option for experienced provider; decompress stomach; extubate AWAKE
Preop assessment for vocal cord pathology–presence of stridor indicates >___% reduction in airway diameter; in adults, stridor suggests < ___-___ mm airway diameter
Presence of stridor indicates > 50% reduction in airway diameter; in adults, stridor suggests < 4-5 mm airway diameter
Stridor is a significant finding–T/F?
True
Inspiratory stridor suggests ___ (intra/extra) thoracic airway obstruction
Inspiratory stridor suggests extrathoracic airway obstruction
Expiratory stridor suggests ___ (intra/extra) thoracic airway obstruction
Expiratory stridor suggests intrathoracic airway obstruction
If a patient has stridor and then that stridor suddenly stops, what should you consider?
Total airway obstruction!!! NOT a good sign if stridor suddenly stops because it means the airway is completely blocked–there is insufficient airflow to generate enough turbulent flow for stridor
What are (3) components of airway fire? Fires need ___, ___, and ___ source
Fires need fuel, oxidant, and ignition (heat) source
Eliminate one of these factors and you will have no fire!
To avoid airway fire, you should utilize lowest O2 setting to maintain oxygenation–T/F?
True
To avoid airway fire, avoid ___, use ___, maintain FiO2 < ___%
To avoid airway fire, avoid N2O, use air, maintain FiO2 < 30%
YAG laser = ___ lens goggles
YAG laser = green lens goggles
Argon laser = ___ lens goggles
Argon laser = amber lens goggles
CO2 laser = ___ lens goggles
CO2 laser = clear lens goggles
Steps for airway fire–___ circuit; ___ and submerge tube in ___; ventilate patient with ___ and new ___; re___/bronchoscope to assess and remove debris; maintain anesthesia with ___ agents; extensive pulmonary care–high ___, ___, ___oids, anti___, racemic ___
Steps for airway fire–disconnect circuit; extubate and submerge tube in water; ventilate patient with mask and new circuit; reintubate/bronchoscope to assess and remove debris; maintain anesthesia with IV agents; extensive pulmonary care–high humidity, PEEP, steroids, antibiotics, racemic epi
You can monitor ETCO2 with supraglottic jet ventilation–T/F?
False–you CANNOT monitor ETCO2 with supraglottic jet ventilation
What must you assure with subglottic jet ventilation?–___ of air and ___ of air out of the airway
Must assure entrainment of air and egress of air out of the airway
If rigid bronchoscope is being used, observe chest rise for adequacy of ventilation as tidal volume and ETCO2 will not return via circuit–T/F?
True
Adequate oxygenation equals adequate ventilation–T/F?
FALSE–adequate oxygenation does not necessarily equal adequate ventilation
PCO2 accumulates ___-___ torr/minute of apnea
PCO2 accumulates 3-4 torr/minute of apnea
Patient undergoing fiberoptic bronch with local should remain NPO until return of ___
Patient undergoing fiberoptic bronch with local should remain NPO until return of gag reflex (to prevent aspiration)
General anesthesia for fiberoptic bronchoscopy–use adult tube size no smaller than ___-___
General anesthesia for fiberoptic bronchoscopy–use adult tube size no smaller than 8-9 mm
If there is a foreign body in the esophagus, what can occur if cricoid pressure is applied?
Perforation of the esophagus–especially if the object is sharp
Esophageal foreign body can cause ___ of trachea if it presses on the posterior tracheal wall d/t absence of ___ support
Esophageal foreign body can cause perforation of trachea if it presses on the posterior tracheal wall d/t absence of cartilage support
Inhaled foreign bodies are more common in ___-___ year olds, ___>___
Inhaled foreign bodies are more common in 1-3 year olds, males > females
Which is worse–organic or inorganic inhaled foreign body? Why?
Organic inhaled foreign body is worse because it can soften, expand, and fragment (and thus occlude more lung area)
S/S of airway foreign body–___or, ___nea, ___ing, ___ing; localized ___ and ___ing seen later in diagnosis; ___ (inspiratory/expiratory) CXR helpful–may see unilateral ___ trapping and mediastinal shift ___ (away from/toward) affected side or atelectasis ___ (away from/toward) affected side
S/S of airway foreign body–stridor, dyspnea, coughing, wheezing; localized pneumonia and wheezing seen later in diagnosis; expiratory CXR helpful–may see unilateral air trapping and mediastinal shift away from affected side or atelectasis toward affected side
Treatment of urgent foreign body removal–___% O2, ___ or ___, ___ (yes/no) preop sedation, ___ (yes/no) N2O; ___ (awake/asleep) laryngoscopy
Treatment of urgent foreign body removal–100% O2, robinul or atropine, NO preop sedation, NO N2O; awake laryngoscopy
In near complete occlusion from foreign body, pushing laryngeal/tracheal foreign body into mainstream bronchus has resulted in reducing obstruction temporarily–T/F?
True
For less urgent foreign body removal, can do ___ or ___ induction and maintain ___ respiration until foreign body is identified
For less urgent foreign body removal, can do IV or inhalation induction and maintain spontaneous respiration until foreign body is identified
If foreign body is known organic material, position patient ___ with ___ (affected/unaffected) side down to minimize fragment spread
If foreign body is known organic material, position patient lateral with affected side down to minimize fragment spread
If removal of scope is required to retrieve foreign body, brief period of ___ may be needed, otherwise spontaneous respiration is useful to identify tracheal ___
If removal of scope is required to retrieve foreign body, brief period of NMB may be needed, otherwise spontaneous respiratory is useful to identify tracheal occlusion
After foreign body removal, patient may need to be intubated until edema subsides–T/F?
True
Bacterial etiology of epiglottitis = ___ and ___
Bacterial etiology of epiglottitis = Haemophilus influenza type B (less now) and Group A strep
Viral etiology of epiglottitis = ___ virus
Viral etiology of epiglottitis = parainfluenza virus
Epiglottitis occurs typically in ___-___ year olds
Epiglottitis occurs typically in 3-5 year olds
S/S of epiglottitis (4 D’s)
- Dysphagia
- Dysphonia
- Dyspnea
- Drooling
Kids with epiglottitis have high ___, ___cardia, ___ tender to touch; ___ may be present on inspiration; ___ is not present; often sitting ___, leaning in a ___ position (___); lateral neck x-ray shows ___ sign at epiglottis
Kids with epiglottitis have high fever, tachycardia, neck tender to touch; stridor may be present on inspiration; hoarseness is not present; often sitting upright, leaning in a sniffing position (tripod); lateral neck x-ray shows thumb sign at epiglottis
Without treatment, epiglottitis can progress to life threatening airway obstruction–T/F?
True
Treatment of epiglottitis–administer ___ ASAP; induce with sevo and 100% O2 with patient in ___ position; maintain ___ respiration, add CPAP ___-___ cm H2O
Treatment of epiglottis–administer O2 ASAP; induce with sevo and 100% O2 with patient in sitting position; maintain spontaneous respiration, add CPAP 5-10 cm H2O
You must place an IV pre-induction for child with epiglottitis–T/F?
False–only start IV if it can be done without exacerbating airway compromise
Kids with epiglottitis must be intubated in the OR–T/F?
True!
What is most important thing to not do for kid with epiglottitis?
DO NOT RILE THEM UP–IT WILL MAKE AIRWAY COMPROMISE WORSE
How can you assess adequate depth of anesthesia for child?–___ signs, ___ and ___; loss of prominence of ___ breathing and conversion to quiet ___ breathing
eye signs, BP and HR (both drop); loss of prominence of intercostal breathing and conversion to quiet diaphragmatic breathing
Intubation for epiglottitis–intubate orally or nasally with tube ___-___ size smaller than usual
Intubation for epiglottitis–intubate orally or nasally with tube 0.5-1 size smaller than usual
Patient with epiglottitis normally remains intubated for ___-___ hours
Patient with epiglottitis normally remains intubated for 24-48 hours
Trach ties should not be changed for first ___ days
Trach ties should not be changed for first 7 days–because a collapse of tissue around stoma makes correct passage hard to find
If trach is dislodged in early postop period, what is indicated?
Reintubation through larynx is indicated–try a smaller size tube
If there is an emergent need to ventilate the patient with an uncuffed trach tube in place, what can you do?
Pass a small 5.5 ETT through plastic trach tube to establish positive pressure
