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Principles of Anesthesia I > Module 2 > Flashcards

Module 2 Flashcards

1
Q

Postural changes may alter lung volumes, ventilation, and pulmonary blood flow

A

Redistribution of V/Q (Ventilation/perfusion)

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2
Q

Worsened by the majority of surgical positions

A

Anesthetic respiratory depression

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3
Q

Dependent lung (bottom) is better perfused, while independent lung (top) is better ventilated

A

V/Q mismatching

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4
Q

FRC (functional residual capacity) and TLC (total lung capacity) are decreased in this position

A

Supine position

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5
Q

Improved oxygenation, improved V/Q mismatching, and ventilation is more uniformed because abdominal organs are not pushing down on lungs in this position (commonly used to treat ARDS)

A

Prone Position

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6
Q

This position alters V/Q mismatching and can impact oxygenation

A

Lateral Position

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7
Q

This position limits diaphragmatic movement because all abdominal organs are pushing down on diaphragm and lungs causing a decreased FRC

A

Lithotomy Position

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8
Q

Nerve transection that occurs as a result of surgical maneuver or traumatic injury; Cutting the nerve.

A

Transection Nerve injury

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9
Q

What injury occurs when a nerve is forced against a bony prominence or hard surface such as an arm board or OR table

A

Compression Nerve Injury

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10
Q

Most common compressed nerve

A

Ulnar Nerve

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11
Q

What injury can cause excessive elongation of a nerve may cause conduction changes, axonal disruption, or interruption of vascular supply

A

Stretching/ Traction nerve injury

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12
Q

Muscle relaxants may contribute to this injury by allowing increase mobility of joints

A

Stretching/ Traction nerve injury

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13
Q

Most commonly affects the brachial plexus nerve

A

Stretching/ Traction nerve injury

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14
Q

This nerve root (C8-T1) injury is the second most common post op injury; most vulnerable to injury if the arm is abducted, arm board falls off, the head is rotated away from arm, and if shoulder straps are used in steep Trendelenburg because it causes stretching and compression

A

Brachial Plexus

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15
Q

Abduct arms less than 90 degrees, avoid shoulder compression, and keep head midline

A

To avoid stretching injury

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16
Q

When a peripheral nerve is pinched between two immovable structures

A

Kinking

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17
Q

Blood flow that can be interrupted by stretch, compression or transection injury

A

Nerve Injury

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18
Q

Common component of all peripheral nerve injury

A

Ischemia

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19
Q

Form of preventing injuries

A

Ensure PPP (pressure points padded)

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20
Q

Most frequently reported injury after surgery; patient will have “claw hand” and loss of abduction/adduction of fingers

A

Ulnar neuropathy

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21
Q

Use padding, place arms in supinated position (palms up), and abduct arms less than 90 degrees. Or patient’s arms tucked at side of the body in neutral position with palms facing inward. Pronation (palms down) increases pressure on ulnar nerve

A

Prevention of Ulnar neuropathy

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22
Q

Compresses neural and vascular structures and may cause compartment syndrome

A

Improper placement of axilla roll

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23
Q

Nerve injury that can occur when legs are improperly placed in candy cane stirrups

A

Peroneal nerve injury

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24
Q

Contribute to postoperative positioning complications; weight of body causes external compression of dependent tissue and states of low perfusion

A

Prolonged surgical procedures

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25
Q

Under which anesthetic technique is the patient unable to respond to painful stimuli generated by uncomfortable body positions

A

General Anesthesia

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26
Q

The brachial plexus consist of what nerve roots?

A

Primary C8 – T1

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27
Q

Name anatomical location of the brachial plexus and what happens with brachial plexus injury?

A

Fixed first rib, clavicle and humerus,compression of nerves between these locations

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28
Q

Precautions that help prevent brachial plexus injury include

A

Arm abduction <90o
Avoid shoulder braces
Maintain head midline

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29
Q

In the lateral decubitus position, injury to the brachial plexus is most commonly the result of

A

Excessive stretching

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30
Q

Causes of brachial plexus excessive stretching include

A

Abduction >90o
External rotation
Extension and lateral flexion of the head
Posterior shoulder displacement

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31
Q

What positioning device can relieve pressure of the brachial plexus

A

Axillary roll

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32
Q

To prevent brachial plexus injury during cardiac surgical procedures
what is the placement of sternal retractor and avoidance measures

A

Placement of sternal retractor is Caudad

Avoidance of prolonged asymmetric chest wall retraction.

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33
Q

The supine position is also called

A

Dorsal Decubitus

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34
Q

What position would you put the patient for surgery of abdomen, head, neck, extremities

A

Supine

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35
Q

How should the head be positioned

A

Neutral position, with small pillow or donut

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36
Q

If a patient has severe arthritis, neuropathy, and ↓ mobility of head or neck. How should Pt be positioned

A

To his or her preference prior to induction of anesthesia

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37
Q

When using an arm board it is important to use padding and place hands in what position

A

Supinated

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38
Q

Post op back pain is caused by

A

The relaxation of ligaments of the vertebral column, use pillow under knees to provide comfort
Utilize beach chair position

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39
Q

During prolonged surgery what should you do to the head

A

Reposition and massage occiput to prevent alopecia.

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40
Q

Crossing the legs during surgery can cause injury to

A

Superior peroneal nerve –dependent extremity

Sural nerve – superior extremity

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41
Q

Where is the head in trendelenberg

A

Head down position

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42
Q

Where is the head in reverse trendelenberg

A

Head up position

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43
Q

Trendelenberg position is used to increase what cardiovascular effect

A

venous return

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44
Q

This position is used to supplement the primary surgical position and improve surgical exposure

A

Trendelenberg

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45
Q

This position causes increase in central venous, intraocular and intracranial pressure,

A

Trendelenberg

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46
Q

Trendelenberg can cause _______ to face, tongue, oropharynx, and eyes.

A

Edema

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47
Q

Trendelenberg should not be used when

A

Arms are extended on arm boards

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48
Q

Avoid using this positioning device in trendelenberg

A

Shoulder brace

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49
Q

If use of steep reverse trendelenberg is necessary this positioning device should be used

A

Foot board

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50
Q

What type of position would you place your patient for laparoscopic surgery

A

Reverse Trendelenberg

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51
Q

Lithotomy position is used to access what anatomical structure

A

Perineal

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52
Q

In lithotomy position how are the legs positioned

A

Legs are in flexion and abduction above the level of the torso

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53
Q

What are the types of lithotomy positioning

A

Low, standard high, exaggerated, and hemi-lithotomy

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54
Q

When positioning for lithotomy, legs should be

A

Elevated and lowered simultaneously

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55
Q

What nerve injury can occur from incorrect positioning of lithotomy

A

Peroneal injury

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56
Q

Raising and lowering the legs separately can cause

A

Hip dislocation, spinal torsion, and post op back pain

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57
Q

Flexion of the hips more than 90o in the lithotomy position can cause

A

Stretching of the sciatic and obturator nerves

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58
Q

Use of exaggerated lithotomy can cause

A

Compression of femoral canal and stretch of the sciatic nerve

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59
Q

While using leg holders which nerves can be affected

A

Peroneal and saphenous nerve

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60
Q

Lateral Decubitus is used for surgeries involving

A

The thorax, and kidneys when the supine position cannot provide sufficient exposure

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61
Q

How should you position for a nephrectomy

A

Lateral decubitus position, with kidney rest elevated, and flexion of the table

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62
Q

Body alignment is vital, who coordinates the positioning of the patient

A

The anesthetist

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63
Q

How should the shoulders, hips, head, and legs be maintained during lateral decubitus

A

In the same plane and turned simultaneously.

64
Q

For lateral decubitus positioning, induction and intubation is performed in what position

A

Supine

65
Q

Blood pressures should be obtained in which extremity while in lateral decubitus position

A

Nondependent arm

66
Q

While in lateral decubitus position which facial areas must be free of pressure

A

Ear & Eye

67
Q

While in lateral decubitus position it is necessary to assess perfusion of dependent arm by checking

A

Capillary refill

68
Q

What medical condition has occurred due to use of lateral decubitus

A

Rhabdomyolysis

69
Q

What is the placement of an axillary roll

A

Dependent side slightly caudal to the axilla

70
Q

What is the purpose of the axillary roll

A

Relieve pressure on shoulder, axillary vessels, and brachial plexus of dependent arm

71
Q

Arm abduction position should be

A

Less than 90o

72
Q

When is the sitting position or beach chair position used?

A

Used in shoulder arthroplasty and arthroscopy

73
Q

What are some of the advantages of the sitting position?

A
  • Ventilation
  • Forced vital capacity and FRC are within normal parameters in the seated position.
  • The abdominal contents shift, causing less interference with diaphragmatic movement
  • Greater expansion of dependent lung regions.
74
Q

What are some disadvantages of the sitting position?

A
  • Pooling of blood into the lower body
  • Hypotension and hemodynamic instability.
  • Excessive cervical flexion, impedes arterial and venous blood flow causing hypoperfusion
  • Venous air embolism (VAE) is also a risk in this position.
75
Q

Sitting position complication.

A

Sitting position & interscalene block for shoulder surgery may elicit the Bezold-Jarish reflex

76
Q

What is the Bezold-Jarish Reflex?

A
  • An inhibitory reflex mediated through cardiac sensory receptors.
  • Associated with the beach- chair position.
  • Venous pooling occurs due to dependent extremities - - Subsequent increase in sympathetic tone and ultimately a low-volume, hypercontractile ventricle
  • Combination of venous pooling and paradoxical increased vagal tone results in sudden, profound bradycardia and hypotension
77
Q

What are some of the prone position advantages.

A

Provides optimal exposure for spine & orthopedic procedures.
Advocated for intracranial procedures owing to the decreased risk of VAE

78
Q

Prone position disadvantages?

A

Head, neck, shoulders & eyes must be checked preoperatively and periodically intraoperative
Maintain alignment of head and neck & provide support.
avoid pressure on the abdomen which can impede venous return
Protect the eyes from corneal abrasions & postoperative visual loss (POVL)

79
Q

What is POVL?

A
  • Postoperative vision loss (POVL) is associated with general anesthesia and prone positioning.
  • Direct pressure to the periorbital region of the eye can cause increased intraocular pressure and blindness as the result of central retinal artery occlusion.
80
Q

Mention some contributing factors for POVL.

A
  • Duration in prone position,
  • Eye compression
  • Increased IOP
  • Hypoperfusion
  • Anemia
81
Q

Name some causes of POVL.

A

Ischemic Optic Neuropathy (ION)
Central Retinal Artery Occlusion (CRAO)
Cortical blindness
Glycine toxicity

82
Q

What is Ischemic Optic Neuropathy (ION)?

A
  • Ischemia in a portion of the optic nerve.

- Majority of POVL after prone spinal procedures

83
Q

What are some of the contributing factors to ION?

A
  • Male gender
  • Presence of coexisting diseases
  • HTN
  • Vascular Dz.
  • Obesity
  • Diabetes
84
Q

What is the most common cause of ION?

A 
- Intraoperative factors
•Spinal surgery
•Prone position
•Prolonged surgical time
•Large blood loss
•Low hematocrit
•Systolic blood pressure <100 mmHg
85
Q

What is OPP?

A

ocular perfusion pressure

86
Q

How is OPP calculated?

A

OPP= MAP-IOP

87
Q

How does MAP affect OPP?

A

Intraoperative and anesthetic events that decrease MAP also decrease OPP.

88
Q

What is the formula for OPP?

A

OPP= MAP-IOP

89
Q

What are some Intraoperative events that decrease MAP and OPP?

A

Hypotension
Hemorrhage
hypovolemia
General anesthetics

90
Q

What are some positions that may affect IOP?

A

Trendelenburg

Prone

91
Q

What are other possible causes of POVL?

A
  • Infarction of the visual pathways in the parietal or occipital lobes
  • Air and particulate emboli
  • Cardiopulmonary bypass and hypoperfusion from hemorrhage or hypotension
  • Glycine toxicity
92
Q

What is the least preferred head support technique?

A

Prone position with horseshoe adapter

93
Q

What is CRAO?

A

Central retinal artery occlusion

94
Q

Location and function of the Central retinal artery.

A

Central retinal artery is one of the first branches of the internal carotid & nourishes the internal layer of the retina

95
Q

Is POVL caused by CRAO reversible?

A

•Some recovery of vision is possible if blood flow is restored within 4 hours

96
Q

What are some of the treatments for CRAO?

A
  • Thrombolytic agents
  • Carbogen inhalation
    Acetazolamide infusion
  • Ocular massage and paracentesis
  • Various vasodilators such as intravenous glyceryl trinitrate.
97
Q

What are the two optic end-arteries that leave that leave the eye susceptible to ischemia when interrupted?

A

Central Retinal Artery

Ciliary Artery

98
Q

What is the most common cause of CRAO?

A

Improper head positioning that results in external pressure on the eye.

99
Q

Hypertension, cardiovascular disease, increased BMI, Open angle glaucoma, and sickle cell anemia are risk factors in what form of POVL?

A

Central Retinal Artery Occlusion (CRAO)

100
Q

In cases involving the head and neck, what positioning device is preferred over horseshoe headrest to prevent POVL

A

Three-pin head rests

101
Q

True/False: Because three-pinned headrests avoids external ocular pressure, the risk of POVL is eliminated.

A

False, unpredictable causes of ION can still lead to POVL with the use of three-pinned headrests.

102
Q

What is the most common name for “Reperfusion injury?”

A

Compartment syndrome

103
Q

A life-threatening complication often associated with poor patient positioning and use of devices that can lead to tissue ischemia and muscle and nerve infarction

A

Compartment syndrome

104
Q

Lower extremity compartment syndrome is mostly distinguished with what type of surgical positioning.

A

Lithotomy position in surgeries of long duration

105
Q

What two surgical positions are most at-risk for compartment syndrome?

A

Lithotomy

Trendelenburg

106
Q

What 4 preoperative findings would indicate patient is at-risk for surgery-associated compartment syndrome?

A

Advanced age
Extremes of body habitus
Patient history of nerve ischemia or neuropathy
Connective tissue disease

107
Q

What are 4 intraoperative factors can put the patient at-risk for compartment syndrome?

A

Systemic hypotension
Anemia
Prolonged operative duration
Vasoconstrictive drugs

108
Q

Intrapelvic retractors can lead to what postoperative complication?

A

Compartment syndrome from vascular obstruction of the major extremity vessels

109
Q

The lithotomy position can lead to compartment syndrome from flexion of what two body parts?

A

Knee

Hip

110
Q

Why does compartment syndrome often occur in intraoperative elevated extremities?

A

External compression from poorly padded positioning devices or straps that are too tight.

111
Q

What two factors cause low flow states in the leg and are factors in the development of compartment syndrome?

A

Intraoperative hypotension

Leg elevation

112
Q

Blood pressure to the legs decrease by how much with every cm change in leg height?

A

0.75mmHg

113
Q

What is the definitive treatment for compartment syndrome?

A

Fasciotomy

114
Q

What three complications of untreated compartment syndrome can lead to amputation or death?

A

Tissue necrosis
Rhabdomyolysis
Acute renal failure

115
Q

What is the surgical complication that can occur when a negative pressure gradient forms between the right atrium and the veins at the operative site.

A

Venour Air Embolism

116
Q

What surgical complication is a well known complication of surgeries that occur in the sitting position when entrained air?

A

Venous air embolism

117
Q

What surgical complication occurs when entrained air enters the right atrium of the heart and creates a V/Q mismatch by limiting gas exchange in the lungs and displaces air in the pulmonary vasculature?

A

Venous Air Embolism

118
Q

No effect for minimal amounts of air - -
Hypotension
Arrhythmias
Cardiac arrest
death with larger volumes…
Are possible physiologic effects of what surgical complication?

A

Venous Air Embolism

119
Q

Air emboli leaving from the left ventricle can lead to what two surgical complication?

A

Myocardial infarction

Cerebrovascular accident

120
Q

The presence of Nitrogen and an increase in dead space will lead to what three assessment findings in a VAE?

A

Drop in end-tidal C02
Presence of end-tidal Nitrogen
“Mill-wheel murmur” through precordial or esophageal auscultation.

121
Q

What is the major risk-factor fo the development of ar Paradoxical Air Embolism (PAE)?

A

Patent Foramen Ovale (PFO)

122
Q

What is the gold-standard diagnostic in the evaluation of a PFO to assess the risk of PAE and VAE development?

A

Transesophageal Echocardiogram

123
Q

VAE can be aspirated from systemic circulation by what technique?

A

Aspiration from a multi-lumen CVP placed at the SVC.

124
Q

Patient who are prone during surgery should have their CVP placed in what position?

A

At the junction of the inferior vena cava to the right atrium.
Entrained air will enter via lumbar spinal and ipdural veins.

125
Q

PFO can occur in as high as ________% of the population?

A

35%

126
Q

The gold standard for the detection of a PFO is a TEE with contrast, but the cheaper, safer, alternative is the…

A

Transcranial doppler

127
Q

Act of positioning patients for surgery is a group responsibility requiring?

A

Teamwork, Timing, Communication, and Knowledge of strategies that protect patients against injury.

128
Q

What is the main goal of positioning patient accordingly?

A

To allow optimal surgical access while minimizing potential risk to patient

129
Q

Nurse anesthetist standard V related to positioning?

A

Monitor & assess patient positioning & protective measures.

130
Q

Role of anesthesia providers pertaining patient’s positioning?

A

Essential role in coordinating patient positioning & continually monitor & assess subsequent changes in patient’s physiologic status.

131
Q

Contributing factors of physiologic changes?

A

Surgical position, length of time, padding & positioning device used, type of anesthesia administered, operative procedure.

132
Q

What Physiologic changes can be seen related to positioning?

A

Cardiovascular, respiratory, and nervous system. Skin, eyes, breast and genitalia.

133
Q

Cardiovascular hemodynamic changes are usually minimal in these two positions.

A

The supine and lateral positioning.

134
Q

Cardiac output and blood pressure are often decreased in what three positions?

A

The sitting, prone & flexed lateral positions.

135
Q

Preload and strove volume are decreased by?

A

Blood pools in dependent body areas

136
Q

Pooled blood from depended body parts reduces what?

A

Blood return

137
Q

How does lateral decubitus position affect the cardiovascular system?

A

Venous return is reduced due to legs being dependent thus causing hypotension.

138
Q

In lateral decubitus position what is the kidney rest compressing?

A

The Vena Cava

139
Q

Where should the kidney rest be anatomically placed?

A

Should lie under the dependent iliac crest.

140
Q

How does lithotomy position affect the cardiovascular system?

A

Bp stays normal or higher.

141
Q

Why does lithotomy position causes hypertension?

A

Because elevated legs auto transfuse 100-250 mls of blood per lower limb.
AKA: Cephalad blood return.

142
Q

What is the patient at risk for in the head-up sitting and lithotomy position?

A

Hypo-perfusion & ischemia if hypotension occurs.

143
Q

Hemodynamic changes can be minimal if patient is placed in what position?

A

In a 45-degree head-up sitting position.

144
Q

Why is the cardiac output decreased when patient is raised to 90 degrees?

A

Because of venous blood pools in the extremities.

145
Q

GA and positioning may lower perfusion pressure but a patient’s BP should not drop more than __ percent from their normal BP.

A

20

146
Q

Though neuraxial and peripheral nerve blocks are associated with permanent and temporary nerve injuries, the majority of injuries are not related to positioning but..

A

Poor block technique, hematoma formation, and direct needle trauma.

147
Q

Patients with BMI less than___ are likely to develop ___ neuropathy.

A

Less than 22 and ulnar neuropathy

148
Q

Muscular physique patients are at an increased risk for __.

A

Compartment Syndrome

149
Q

How does obesity increase morbidity during surgery?

A

Large tissues place increased pressure on dependent body parts. Adipose tissue is poorly perfused.

150
Q

What are preexisting conditions associated with increased incidence of positioning complications?

A

HTN, DM, PVD, Peripheral neuropathies, Alcoholism, Smoking within 1 month of surgery, limited joint mobility, and liver disease

151
Q

Closed claims studies found that this nerve is the most commonly injured during surgery.

A

Ulnar

152
Q

What are complications patients encounter after damage to the ulnar nerve?

A

Claw hand (ring and little finger hyperextended). Loss of abduction & adduction of fingers & flexion

153
Q

What are contributing factors of ulnar neuropathy?

A

Surgical positioning, mechanical devices (tourniquet, BP cuff), prolonged hospital stay, sternotomy & sternal retraction. Age>50, preexisting disease, gender, Body habitus, and preexisting neuropathy.

154
Q

Ways OR staff can prevent ulnar neuropathy.

A

Pad bony prominences, supinate arms (PALMS UP) in supine position, abduct arms <90 when not tucked.

155
Q

Which way should the patients palms face when their arms are tucked?

A

Inward

156
Q

Turning the head to the side with arms abducted can cause stretching &; compression of the contralateral___.

A

Brachial plexus

157
Q

How can a CRNA relieve pressure on the brachial plexus when the patient is in a lateral position?

A

Place an axillary roll caudal to the dependent axilla to relieve pressure.

Principles of Anesthesia I (6 decks)

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