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Principles of Anesthesia I > Module 3 Week 6 > Flashcards

Module 3 Week 6 Flashcards

1
Q

What is the goal of pre-operative fluid management

A

It is to provide the appropriate amount of parental fluid to maintain intravascular volume and cardiac preload, oxygen carrying capacity, coagulation status, acid-base hemostasis, and electrolyte balance.

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2
Q

What can make the pre-operative period a challenge

A

Blood loss, evaporation loss, third spacing, preoperative fluid volume status, and pre-existing disease states

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3
Q

What is the major component of all fluid compartments with in the body

A

Water

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4
Q

Total body water can be divided into two basic components ______ and _____?

A

Intracellular and extracellular

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5
Q

What are the major components of the extracellular compartment

A

Blood volume and interstitial fluid volume

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6
Q

What is the non-cellular component of the blood?

A

The plasma volume

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7
Q

What is the major difference between plasma and interstitial fluid

A

Plasma has a higher concentration of protein

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8
Q

What can influence electrolyte balance

A

Parental fluid administration

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9
Q

What can lead can happen in the perioperative period that can lead to shift in fluid balance

A

Physiologic changes

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10
Q

What is the recommended period of time for preoperative fasting from clear liquids

A

2 hours

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11
Q

Balanced salt Solutions have an electrolyte composition similar to what

A

Extracellular fluid

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12
Q

What is considered extracellular fluid and what classification of fluid do they fall in?

A

These are hypotonic solutions such as Lactated ringer‘s, Plasma-Lyte, normosol

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13
Q

In vivo ( in the body) what does lactate ringers Metabolize into

A

It becomes bicarbonate

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14
Q

What kind of solution is normal Saline

A

It is slightly hypertonic

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15
Q

Why is normal Celine preferred to dilute pack red blood cells

A

Because it is nearly isotonic

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16
Q

Osmolality of iso tonic solution’s can cause what at the point of injection

A

Hemolysis

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17
Q

Why does dextrose Function as free water

A

Because the dextrose is metabolized

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18
Q

In what circumstances is dextrose IV solution used

A

To correct hyper natremia and to prevent Hypoglycemia and diabetic patients

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19
Q

What are Colloids And why are they used

A

A colloid is albumin And it is used because it is a larger molecule in weight and remains in the intravascular space longer than a crystalloid

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20
Q

Does albumin affect coagulation?

A

A minimal effect

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21
Q

Hydroxyethyl starches (HES) interferes with what

A

With von Willebrand factor, factor VIII, And platelet function

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22
Q

Administration of what after acute blood loss may lead to more rapid improvement of filling pressures, arterial blood pressure, and heart rate

A

Colloid (albumin)

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23
Q

Postoperatively what rapidly subsides when administration of anesthetics are stopped

A

Venodilation in my cardinal depression

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24
Q

What is the fluid deficit equation

A

(Maintained fluid requirement) x (hours since last intake (Npo deficit)) + (unreplaced preoperative external and interstitial) / (third space loss(eg. vomiting, diarrhea))

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25
Q

The fluid infusion rate for normal patient should be set to whiten

A

It should be set to deliver three 24 times the maintenance rate until the Calculated deficit has been corrected

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26
Q

The onset of surgical stimulation elicits changes in what

A

Catecholamines, cortisol, and growth hormone

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27
Q

Additional approaches include replacement of Crosoli that the rate proportional to surgical incision exposure is what

A

4 to 6 mL/kg/hr for bowel resection

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28
Q

What can excessive perioperative fluid administration cause in the G.I. track

A

The Adema can contribute to an ileus

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29
Q

What is the threshold for weight gain for post operative Procedures that it would be recommended to restrict fluid’s and administer a diuretic

A

1 kg

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30
Q

What is the first clue that anesthesia providers have about their patient?

A

History and Physical – which can help identify coexisting diseases and allows CRNA to assess the patient’s anatomy to determine if difficulties with certain anesthetic techniques may arise.

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31
Q

What is the overall goal of pre-op assessment?

A

Patient safety.

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32
Q

What factors are important to consider during a pre-op assessment?

A

HCG, smoking status, illicit drug use, medications, allergies, PONV, previous surgeries, medical conditions, anesthesia problems

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33
Q

What labs are important to obtain prior to a surgery?

A

b-HCG for all child bearing aged women, CBC, glucose (for diabetics, obese, steroid treatment), electrolytes, PT/PTT/INR, CXR, echo

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34
Q

A minimum pre-anesthesia exam must include:

A

Airway, heart, lung, review of VS, oxygen saturation, Ht/Wt,

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35
Q

What is the anesthesia assessment based on?

A

The history and type of surgery the patient is having.

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36
Q

What is METS and why is it important to include in a pre-op assessment?

A

Metabolic equivalents-The ability to attain average exercise levels. 4-5 METS is the equivalent of walking two flights of stairs. If a patient scores <4 METS, they are at increased risk of perioperative complications.

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37
Q

1 MET=

A

consumption of 3.5mL of O2/mL/min/kg of body weight.

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38
Q

What are two important questions to ask a patient preoperatively about their activity level?

A

Are you able to walk four blocks without stopping regardless of limiting symptoms? Are you able to climb two flights of stairs without stopping regardless of limiting symptoms.

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39
Q

What is the mallampati exam testing?

A

Visible structures in the airway.

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40
Q

What can you see in a mallampati 1 patient?

A

The soft palate, uvula, and tonsillar pillars.

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41
Q

What can you see in a mallampati 2 patient?

A

Soft palate and uvula

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42
Q

What can you see in a mallampati 3 patient?

A

Soft palate and base of uvula seen. Very difficult airway.

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43
Q

What can you see in a mallampati 4 patient?

A

Hard palate only seen. Very difficult airway

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44
Q

What does the mallampati assessment test for?

A

Potential airway establishment difficulties. It is a predictor of difficulty.

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45
Q

What is the ASA physical status?

A

A means of communication to anesthesia staff within and among institutions about the physical status of a patient. It is NOT an estimate of anesthetic risks and should remain independent of the proposed surgical procedure. (just because someone is having a Whipple or very difficult procedure, doesn’t mean the ASA should be impacted).

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46
Q

What is ASA class 1?

A

Patient presents with no organic, physiologic, biochemical, or psychiatric disturbance. Patient is healthy.

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47
Q

What is ASA 2?

A

Patients have mild to moderate systemic disturbance. Being a smoker places you here. Well-controlled HTN of DM places you here

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48
Q

What is ASA class 3?

A

Severe systemic disturbance that limits activity. Ex: heart or chronic pulmonary disease, poorly controlled HTN, previous MI, bedridden

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49
Q

What is ASA class 4?

A

Severe systemic disturbances that is life threatening. Ex: CHF, advanced pulmonary, renal or hepatic dysfunction.

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50
Q

What is ASA class 5?

A

Moribound patient undergoing surgery as a resuscitative effort despite a minimal chance of survival. Ex: uncontrolled hemorrhage from a ruptured AAA.

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51
Q

What is an ASA class with an E added to it?

A

Indicates emergency surgery is required. Ex: if a patient cannot sign for consent.

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52
Q

What is patient centered care?

A

Basing the choice of anesthesia technique or combination of techniques on surgical and patient considerations. Most important considerations are patient safety, the ability of the surgeon to perform the procedure, and patient comfort during and after the procedure.

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53
Q

What should you always have regarding an anesthesia plan?

A

A plan A AND plan B- which is ALWAYS general anesthesia.

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54
Q

What influences choice of anesthetic technique?

A

Patient, team, and surgeon preference, coexisting disease (reflux, DM, asthma), site of surgery, body position of patient during surgery, elective or emergent surgery?, increased gastric content, suspected difficult airway, duration of procedure, patient age, anticipated recovery time, PACU discharge criteria.

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55
Q

What does the general anesthesia technique involve?

A

A loss of consciousness, induction by inhalation or IV, airway instrumented with ETT, LMA, or mask(unsecured) if procedure is short.

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56
Q

What does regional anesthesia or peripheral nerve blocks involve?

A

RA- Neuraxial anesthesia is provided by placing local anesthesia within the CSF or epidural space. It may be used as primary anesthetic or for postop pain.
Peripheral nerve blocks are provided by placing local anesthetics near peripheral nerves using a needle. Typically used for surgeries of the extremities but may be used as primary or postop analgesia when administered with other techniques like GA.

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57
Q

What does monitored anesthesia care or MAC involve?

A

Anesthetic drugs are administered to varying levels of sedation, analgesia and anxiolysis as necessary for the procedure. Must prepare to convert to GA if necessary.

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58
Q

If a patient has been rendered unconscious or losses the ability to make purposeful responses during MAC….

A

The case is now converted to GA regardless of whether or not the airway is instrumented.

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59
Q

Prescription medications can be taken up to _____ hours before anesthesia?

A

One

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60
Q

Patients are allowed how many mLs of water before surgery?

A

150mls for adults and 75mls for children.

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61
Q

What is the purpose of fasting guidelines?

A

Reduce the risk of pulmonary aspiration

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62
Q

Why are you not allowed to chew gum the night before surgery?

A

Risk of foreign body aspiration

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63
Q

Patients are allowed clear liquids up to ____ hours before surgery.

A

2

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64
Q

Children can have breast milk up until ___ hours before surgery.

A

4

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65
Q

Infant formulas and light meals must avoided ____ hours before surgery.

A

6

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66
Q

Why should you avoid fried or fatty foods 8 hours before surgery?

A

They prolong gastric emptying time and present an aspiration pneumonia risk.

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67
Q

What are the goals of a preoperative evaluation?

A

Reduce patient risk and morbidity associated with surgery and anesthesia, prepare the patient medically and psychologically, and promote efficiency and reduce costs

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68
Q

What are the components of a preoperative evaluation?

A

oReview of medical record
oHistory and physical examination
oObtaining appropriate diagnostic tests and consults
oDevelopment of anesthetic care plan
oEducate the patient about anesthesia and perioperative period
oAnswer questions and obtain consent

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69
Q

Ability to review previous anesthetic records help to…?

A

Detect presence of a difficult airway, identify a hx of malignant hyperthermia and determine an individuals response to surgical stress and specific anesthetics

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70
Q

What are the four risk factors for PONV after inhalation anesthesia (in adults)?

A

Female gender, prior hx of motions sickness or PONV, nonsmoking status, and use of postoperative opoids

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71
Q

Name the four predictors of POV in children

A

Duration of surgery longer than 30 minutes, age above 3 years old, hx of POV in patient or family, and strabismus surgery

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72
Q

What are the components of an airway evaluation?

A

Examination of oral cavity (including dentition), determination of thyromental disease, assessment of the size of pts neck and potential tracheal deviation or masses, and evaluation of their ability to flex of base of the neck and extend the head

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73
Q

In what patient populations is it critical to assess the cervical spine preoperatively?

A

Trauma, severe RA, and down syndrome patients

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74
Q

Describe the steps of intubation…

A

Flexion of the lower neck, extension of upper neck, opening the mouth to insert laryngoscope, and displacing the tongue forward and down into the submandibular space to expose glottis

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75
Q

Which laboratory biomarkers are associated with major adverse cardiac event (MACE)?

A

BNP, CRP, and N-terminal brain natriuretic peptide

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76
Q

What patient populations may present with atypical signs/symptoms of cardiovascular disease?

A

elderly, women, and diabetics

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77
Q

What clinical condition (cardiovascular) is associated with a high perioperative risk of MI?

A

Unstable angina

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78
Q

What is the best predictor of silent ischemia?

A

Autonomic neuropathy

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79
Q

What ECG pattern is suggestive of a chronic ischemic state?

A

Strain pattern

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80
Q

What is one of the most important predictors of perioperative risk for noncardiac surgery and helps define the need for further testing and invasive monitoring (the most cost effective and least invasive method for detecting ischemia)?

A

Exercise tolerance testing

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81
Q

What is the best method for defining coronary anatomy and assessing ventricular and valvular function ?

A

Coronary angiography

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82
Q

Guidelines support the delay of elective noncardiac surgery for ____ days after coronary balloon angioplasty and ____ days after bare metal stent placement

A

14; 30

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83
Q

Are preoperative PFTs and chest radiography routinely recommended for all patients?

A

No, they are not routinely recommended as they have little benefit in predicting pulmonary complications perioperatively

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84
Q

What laboratory levels appear to be associated with increased risk of perioperative pulmonary morbidity?

A

Reduced albumin level and increased BUN

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85
Q

What types of surgeries are have been associated with the highest risk for postoperative pulmonary morbidity?

A

Open aortic, thoracic, and upper abdominal surgeries

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86
Q

Name the effects of general anesthesia on the pulmonary system…

A

Decrease in functional residual capacity, reduced diaphragmatic function –> leading to ventilation/perfusion abnormalities, atelectasis, inhibition of mucociliary clearance, increased alveolar-capillary permeability, inhibition of surfactant production, increased nitric oxide synthetase, and increased sensitivity of the pulmonary vasculature to neurohumoral mediators

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87
Q

What medications should maybe be considered as prophylaxis for the severe asthmatic?

A

Steroids and bronchodilators

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88
Q

OSA patients are especially susceptible to the respiratory depressant and airway obstructive effects of what medications?

A

Sedatives, opioids, and inhaled anesthetics both intraoperatively and postoperatively

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89
Q

What is the Purpose of pre-anesthetic evaluation?

ppt

A

Tool to reduce anesthetic risk and morbidity
Promote efficiency and reduce cost
Medico-legal document
Mandated by Joint Commission for the Accreditation of Healthcare facilities
Part of the American Society of Anesthesiologists (ASA)

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90
Q

The preoperative assessment allows CRNAs to…

ppt

A

Communicate with the team
Tailor anesthetic care plan to individual needs
Identify if surgery will proceed, be delayed, or be deferred
Aids in optimization of comorbid diseases
Identify pertinent necessary preoperative testing
Educate our patients about the anesthesia process
Establish informed consent

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91
Q

What are the Goals of Preoperative Evaluation:

ppt

A
  1. Reduce patient risk
  2. Morbidity of surgery
  3. Promote efficiency and reduce costs
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92
Q

How can improve patient outcome from anesthesia?

ppt

A

History and physical examination
Laboratory tests and consultations
Anesthetic and care plan

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93
Q

What are the Standards for All Patients Receiving Anesthesia Care?
ppt

A

Review the available medical record
Interviewing and performing a focused examination of the patient to
Discuss:
Medical history, including previous anesthetic experiences and medical therapy
Assess aspects of the patient’s physical condition that might affect decisions regarding perioperative risk management.

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94
Q

Standards for All Patients Receiving Anesthesia Care (ASA 2010)
ppt

A
  • Ordering and reviewing pertinent available tests and consultations as necessary for the delivery of anesthesia care
  • Ordering appropriate preoperative medications
    Ensuring that consent has been obtained for the anesthesia care
  • Documenting in the chart that the above have been performed
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95
Q

What are the components of pre-anesthetic evaluation?

ppt

A 
1. History: 
Current &amp; past medical history 
Family history of anesthesia problems, ie, Malignant hyperthermia
Medications 
Previous Surgeries 
Anesthetics
Allergies 
NPO status
  1. Physical exam:
  2. PreopVital signs
  3. Airway
  4. Neurologic
  5. Heart
  6. Lungs
  7. Extremities
  8. Organ systems
  9. Focused areas
  10. Laboratory and diagnostic testing and evaluation
  11. ASA classification number
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96
Q

What are the most important assessors of disease and risk?

ppt

A

History and physical exam.

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97
Q

Factors to Consider for anesthesia evaluation.

A
  • Coexisting disease
  • Site of surgery
  • Position during surgery
  • Risk of aspiration
  • Age of patient
  • Patient cooperation
  • Airway management
  • Coagulation status
  • Previous response to anesthesia
  • Preference of patient
  • Elective or emergency
  • Recovery time
  • Post anesthesia discharge
98
Q

What risks are associated with anesthesia?

A

-Potential difficulty for adequate ventilation/intubation
-Induction/emergence is “stressful” Maintenance of anesthesia is associated with variable degrees of stimulation, fluid shifts, & blood loss
-Anaphylactic reactions to medications may occur
-Injuries may be incurred such as airway trauma during
laryngoscopy/neuropathy from improper patient positioning
-LIKE FLYING A PLANE, TAKE OFF AND LANDING IS THE MOST DANGEROUS

99
Q

New approaches to preoperative anesthesia evaluation?

A

-Pre-op clinics
-Decrease in same day surgical cancellations
-Improve in operating room efficiency
-Cost effective
-Computerized data accessible by all anesthesia providers prior to procedure
-Emergency procedures: hand written anesthesia
evaluation

100
Q

How to do to a healthy pre-op patient assessment.

A

-Indication for the surgical procedure
-Current Medications/Allergies
-NPO status
-Thorough history and physical
-Systems approach:
Airway, Malampatti classification
Pulmonary
Cardiovascular
Neurologic
Endocrine
Renal
Hepatic
Gastrointestinal
-Response to previous anesthetic, ie, Difficult Airway, Malignant Hyperthermia, Bleeding (watch out for Red heads)

101
Q

What is the purpose of ASA’s Fasting Recommendations

A

Reduce the risk of pulmonary aspiration

102
Q

ASA fasting recommendation what is considered as a light meal?

A

toast and clear liquids

103
Q

What is considered as a heavy meal?

A

fried and fatty foods.

104
Q

What is the recommended fasting time in hours for clear liquids

A

2 hours

105
Q

What is the recommended fasting time in hours for breast milk

A

4 hours

106
Q

What is the recommended fasting time in hours for infant formula

A

6 hours

107
Q

What is the recommended fasting time in hours for infant formula for neonates

A

4 hours

108
Q

What is the recommended fasting time in hours for non-human milk

A

6 hours

109
Q

What is the recommended fasting time in hours for light meal

A

6 hours

110
Q

What is the recommended fasting time in hours for heavy meal

A

8 hours

111
Q

What is considered as History of problems with anesthesia.

A

Malignant hyperthermia, Allergic reactions, Post-operativenausea and vomiting, Difficulty with intubation,
Unplanned/prolonged postoperative
intubation.

112
Q

category “ASA VI stands for

A

the brain-dead organ donor

113
Q

What does E” denotes for ASA category

A

Emergency surgery

114
Q

ASA Physical Status class 1

A

Normal healthy patient. No organic, physiologic, biochemical or psychiatric disturbance

115
Q

ASA Physical Status class 2

A 
Mild to moderate systemic disease that is well controlled and causes no organ dysfunction or functional limitation, that is, treated hypertension. Example, Current smoker
Social alcohol drinker
Pregnancy
Obesity
Well-controlled DM/HTN
Mild lung disease
116
Q

ASA Physical Status class 3

A

Severe systemic disease of at least one organ system that does cause functional limitation, that is, stable angina,Example
Poorly controlled DM/HTN
COPD
Morbid obesity (BMI ≥40)
Active hepatitis, alcohol dependence or abuse
Implanted pacemaker
Moderate reduction of ejection fraction
ESRD undergoing regularly scheduled dialysis
Premature infant PCA < 60 weeks
History (>3 months) of MI, CVA, TIA, or CAD/stents

117
Q

ASA Physical Status class 4

A

Severe systemic end-stage disease of at least one organ system that is life threatening with or without surgery, that is, congestive heart failure or renal failure
For example Recent (< 3 months) MI, CVA, TIA, or CAD/stents
Ongoing cardiac ischemia or severe valve dysfunction
Severe reduction of ejection fraction
EF, 30% is ASA 3
EF, 20% is ASA 4
Sepsis
DIC
ARD
End stage renal disease (ESRD) not undergoing regularly scheduled dialysis

118
Q

ASA Physical Status class 5

A

Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort) that is, ruptured aortic aneurysm
For example, Ruptured abdominal/thoracic aneurysm
Massive trauma
Intracranial bleed with mass effect
Ischemic bowel in the face of significant cardiac pathology
Multiple organ/system dysfunction

119
Q

ASA Physical Status class 6

A

A declared brain-dead patient whose organs are being removed for donor purpose. For example,

120
Q

Components of Physical examination

A

-Measurement of Preoperative Vital signs: (BP, HR, RR, T, SaO2)
-Inspection of the airway
Loose, chipped teeth
Caps
Dentures
Prominent upper incisors
TMJ
Neck ROM
-Auscultate heart and lungs
-Inspect extremities
-Brief neurologic exam

121
Q

Mallampati classification

A

Relationship between the size of the base of the tongue and the rest of the structures of the pharynx:

122
Q

Class I: Mallampati classification

A

pillars, uvula, soft & hard palate

123
Q

Class II: Mallampati classification

A

uvula, soft & hard palate

124
Q

Class III: Mallampati classification

A

: soft & hard palate visible

125
Q

Class IV: Mallampati classification

A

only hard palate visible

126
Q

Ingredients of propofol

A

Egg lecithin emulsion

10% soy bean oil, 2.25% glycerol & 1.2% egg phosphatide extracted from yolk

127
Q

Physical Examination: How to Evaluate the airway

A 
-Thyromental distance
Measure between the edge of the mandible and the cricoid cartilage: should be > 6 cm
-Neck mobility
 Flexion
 Extension
-Observation of patient, assess for:
Short neck
Obesity 
Micrognathia (restricts oral axis alignment), 
  jaw is undersized.
-Ability to open mouth
128
Q

Egg allergy-Cross-sensitivity reaction to Propofol (Diprivan)

A

Allergy usually to egg albumin in egg white!!!!!

Propofol contraindicated in patients with egg allergy

129
Q

Objective of Obtaining Anesthesia Informed Consent

A

-The subject has knowledge and comprehension of anesthesia procedures”
“-Risks and benefits have been explained”
“-Pt’s questions have been answered
-Risks,benefits,alternatives explained

130
Q

Procedure without consent :

A

Assault and Battery

131
Q

When to take two-physician emergency consent

A
  • If the patient is a Minor
  • Incompetent
  • Unconscious patient
132
Q

practice advisory for anesthesia evaluation

A

Preoperative tests should not be ordered routinely!!!

133
Q

Preoperative Testing: 12-lead EKG, Indication

A

—-Any patient with a previously undiagnosed murmur

——–Asymptomatic patients > 50 y/o or any age with one of the following:
CAD, CVA, or PVD
Creatinine >2
DM
High risk surgery or vascular surgery
Chest pain/ischemia
Prior coronary revascularization/hospitalization for cardiac causes

134
Q

Pre-op ECHO indication

A
  • Any identified EKG abnormality should be followed up by an echo
  • Patients with current or poorly controlled heart failure
  • Prior heart failure and dyspnea of unknown origin
135
Q

Stress testing,Indication

A
  • Patients with intermediate pretest probability
  • Change in clinical status of patient with suspected or proven CAD
  • Proof of ischemia prior to revascularization
  • Evaluation of adequacy of medical therapy
  • Evaluation of exercise capacity when subjective assessment unreliable
136
Q

Exercise stress test

A
  • Exercise stress test has a specificity of 69% for predicting post-op cardiac events
  • Accurate test results when patients can exercise to 85% of their target HR
  • Often used in combination with echocardiogram for patients with significant EKG abnormalities to detect wall abnormalities
137
Q

Ideal BP for surgery

A

SBP BELOW 140

DIASTOLIC BP BELOW 90

138
Q

Elective surgery should be delayed for BP

A

—if if SBP >200 mm Hg or DBP > 115 mm Hg- until BP is less than 180/110 mm Hg

139
Q

Which Anti-hypertensives should be delayed on the day of surgery

A

ACEI (Angiotensin Converting Enzyme)

ARBs (Angiotensin Receptor Blockers)

140
Q

Pharmacologic stress test

A

——-Provides the more accurate prognostic information than exercise stress test
———-Used for patients who:
Cannot exercise
Have pacemakers
Have marked bradycardia
Are on high-dose beta blockers
Can also be used in combination with echocardiogram to detect wall abnormalities

141
Q

Pre-op Testing: indication for Chest X-ray

A

–Consider in pt’s ≥ 50 y/o:
–Hx of lung disease
Asthma,
COPD
——-Active pulmonary condition
URI
Pneumonia
Pulmonary edema)
——–Having intrathoracic surgery
Smokers
Cardiac disease

142
Q

Indication for pre op Complete blood count (CBC)

A
  • Any procedure @ risk for blood loss > 500 cc
  • Extreme age (neonates, adults age ≥ 75yr)
  • Medically ill patients
  • Anticoagulant/corticosteroid use
  • Hx anemia, bleeding, hematologic disorders, infection
  • Those receiving chemotherapy/radiation treatment
143
Q

T & S AND T&C

TYPE AND SCREEN ,TYPE AND CROSS

A

T & S probability of intraop transfussion
T & C expected to require intraop transfussion
T & S (7 days)
T & C (2 days)

144
Q

Pre-op Human chorionic gonadotropin (HCG) testing

A
  • Exclusion criteria:
  • Hx of total hysterectomy
  • Menopause (1yr without menses)
  • Bilateral tubal ligation

———Usually everyone under the age of 50yo

145
Q

JMH guidelines for pre-op HCG testing

A
  • Any female patient child-bearing age who suspects pregnancy
  • Minors
  • Should be done in minors capable of conceiving (Minor patients and their guardian should be notified that a pre-operative pregnancy test is being performed, but a POSITIVE result should be reported only to the patient. -The patient should be strongly encouraged to discuss this result with her guardian.
  • Any patient undergoing a hysterectomy or gynecological procedure
  • Any childbearing woman under 50 is mandatory unless patient had a tubal ligation, hysterectomy or no menses for one year after 50.
146
Q

MEDICATIONS TO CONTINUE PRE-OP

A
  • Cardiac/BP meds (statins, BB)
  • Meds for asthma/COPD
  • GERD meds
  • Thyroid meds
  • Psychiatric meds
  • Narcotics
  • Bronchodilators/Steroids
  • Seizure meds
  • Birth control pills
147
Q

MEDICATIONS Should be held or adjust dose:pre-op

A
  • Oral hypoglycemics
  • Short acting insulin
  • ACE inhibitors
  • Diuretics (except HCTZ)
  • Viagra
148
Q

Anticoagulants dosing for pre-op

A

NSAIDs- stopped 2 days before surgery

Warfarin- stopped 5 days before surgery

149
Q

Aspirin (ASA) and surgery

A
  • Typically stopped 5 days before surgery EXCEPT:
  • In patients who have had a DES placed less than 12 months ago
  • In patients who have had bare metal placement less than a month ago
  • ASA is usually continued in patients with any type of stent placed during any given time frame
150
Q

Thienopyridines:INCLUDE Clopidogrel/ticlopidine

ppt

A

-Clopidogrel- stop 7 days before surgery
-Ticlopidine- stop 14 days before surgery
EXCEPT:
In patients who have had a DES placed less than 12 months ago
In patients who have had bare metal stent placement less than a month ago

151
Q

Ephedra HERBAL (diet aids, antitussive) can cause

A
  • Sympathetic stimulation,
  • ↑ HR, BP
  • Dysrhythmias, MI, stroke
152
Q

St. John’s wort ,HERBAL

A
  • Depression
  • Anxiety
  • Increases drug metabolism induction, cytocrome P450, decrease drug levels (ie, digoxin)
153
Q

Ginseng (stress)-HERBAL

A
  • Hypoglycemia,
  • Inhibits PLT aggregation
  • Increase bleeding
154
Q

Patients anesthetic history:

A
  • Difficult airway, examination of oral cavity and dentition
  • Malignant hyperthermia
  • Prolonged response to drugs, ie, patient states I took a long time to wake up in my last anesthetic.
  • Current medications, over the counter and herbal products
155
Q

Screening evaluation for the Pulmonary system:

A 
---------History:
Tobacco utilization
Shortness of breath
Cough
Wheezing
Stridor
Snoring or sleep apnea
Recent history of an upper respiratory tract infection
156
Q

Preoperative Predictive Pulmonary complications:

A
  • Thoracic and Upper Abdominal Surgery
  • Duration of Anesthesia
  • Chronic Cough
  • Unexplained Dyspnea
  • Exercise Tolerance
  • Wheezing/Asthma
  • Tobacco Utilization
157
Q

Guidelines for perioperative management of patients with obstructive sleep apnea

A

–ASA Guidelines
CPAP
Sensitivity to respiratory depressant effects of drugs
–Determine if noninvasive approaches for performing the surgery would reduce the need for postoperative opioids
–Discuss if it is feasible to perform the surgery under neuraxial, regional or local anesthesia to decrease the amount of anesthesia or opioids needed
–Determine if NSAIDs are acceptable for postoperative analgesia
–Discuss whether outpatient surgery is a safe option
–Determine if the patient will be able to use CPAP postoperatively
–Determine if Postop admission to ICU is needed for a first time user of CPAP

158
Q

Preoperative Evaluation of Neurologic Function:

A
  • Mental Status
  • Intracranial pressure
  • Cerebral vascular disease
  • Seizure history
  • Peripheral neuropathy
159
Q

Preoperative cardiovascular Evaluation:

A
  • Hypertension
  • Angina
  • Congestive Heart Failure
  • Auscultation (heart murmurs, carotid bruits)
  • Cardiac rhythm
  • Peripheral Pulses
160
Q

Preoperative Cardiovascular Testing:

A

—Exercise tolerance
——–Cardiovascular tests
Electrocardiography
Echocardiography
Coronary angiography

161
Q

Preoperative Evaluation of Diabetes Mellitus

A
  • Silent Angina
  • Myocardial Infarction
  • Congestive Heart Failure
  • Peripheral neuropathies
  • Autonomic Neuropathy
  • Hemodynamic instability
  • Gastroparesis
162
Q

Suboptimal glucose control

A

Hemoglobin A1C>6-8%
Electrolyte abnormalities
Ketonuria

163
Q

Ischemic Heart Disease (CAD),GOALS FOR EVALUATION

A
  • Identify heart disease risk
  • Identify severity of heart disease
  • Determine need for perioperative testing
  • Modify risk for adverse perioperative event
164
Q

With h/o steroids use how to treat patients with minor surgical risk

A

hydrocortisone 25mg iv pre-op,can restart ususal dose day after surgery

165
Q

With h/o steroids use how to treat patients with intermediate surgical risk
ppt

A

hydrocortisone 50-100 mg iv pre-op, / 25 mg iv/po qhrs x 3 doses

166
Q

With h/o steroids use how to treat patients with majorr surgical risk
ppt

A

hydrocortione 50-100 mg iv pre-op, 50 mg iv/po q8hrs and taper over 2-3 days

167
Q

What are S/S of CAD

A 
Chest pain
SOB/dyspnea
What do the labs show
What does the EKG show
Cardiac clearance
168
Q

What are Long-term CAD risk modifications

A

Statins
Aspirin
Exercise
Diet adjustment

169
Q

in cardiac pt when should elective SX be held

A
  • Those with bare metal stents placed within the last 30 days
  • Those with drug-eluting stents (DES) placed within the last 12 months
  • Premature discontinuation of dual antiplatelet therapy could result in
  • Stent thrombosis
  • MI
  • Death
170
Q

what is the goal of preoperative evaluation

A

-to identify/minimize effects of heart failure

171
Q

What do you want to evaluate in CHF pt pre operatively?

A 
Recent weight gain?
SOB/fatigue?
Orthopnea/nocturnal cou-gh?
Peripheral edema/JVD?
S3/S4?
Tachycardia?
Ascites?
172
Q

what are the stages of heart failure

A

Class I- No limitation of physical activity
Class II-Slight limitation of physical activity.
Class III-Marked limitation of physical activity
Class IV-Unable to carry out any physical activity without discomfort

173
Q

what are cardiac considerations for sx pt

A

-Angina
unstable ↑ risk perioperative MI
chronic stable not shown to ↑ risk MI
Pacemaker and/or AICD

174
Q

Clinical Predictors of Increased Perioperative Cardiovascular Risk

A
  • Unstable coronary syndromes
  • Decompensated heart failure
  • Significant arrhythmias
175
Q

what is the MET questionnaire

A

questions regarding exercise testing, exercise prescription, and evaluation

176
Q

what questions do you ask in the Metabolic Equivalent (MET) questionnaire

A

1 METs
Eat, dress, us>/= 10 METs
Strenuous sports
(swimming, singles tennis, football, basketball, skiing)
e the toilet,
walk indoors, light housework,
walk a block or two on level ground at 2 – 3 mph

4 METs
Climb a flight of stairs,
walk on level ground at 4 mph, run a short distance,
do heavy housework,
moderate recreational activities (bowling, doubles tennis, golf, dancing)

177
Q

on the Metabolic Equivalent (MET) questionnaire what number do you have to be worried about

A

Any thing under then 4

178
Q

what is the Cardiac evaluation for noncardiac surgery

A

step I - need emergency surgery
step II-active cardiac conditions
step III-low risk for sx
step IV-good function capacity

179
Q

Postoperative pulmonary complications

A 
Risk factors:
  Cigarette use current or >40 pack years
  Age 70 or >
  COPD
  BMI of 30 or 
  Mets <4
  Undergoing neck, thoracic, upper abdominal, aortic or 
  neurologic surgeries
180
Q

what can help an asthmatic prior to surgery ?

A

breathing treatment

181
Q

what are symptoms of COPD

A 
Symptoms include:
Dyspnea
Coughing
Wheezing
Changes in sputum amount, or color?
Barrel chest?
Purse-lipped breathing?
SaO2?
Chest x-ray?
182
Q

what should you postpone surgery in pt with recent Upper Respiratory Infections
 (URI)

A

Patients at risk for laryngospasm bronchospasm

183
Q

what should you assess in pt with recent Upper Respiratory Infections
 (URI)

A

Recent antibiotics?
Does patient have fever?
Does the patient have a productive cough?

184
Q

how is Pulmonary hypertension (PHTN) defined

A

as a mean pulmonary pressure >25 mm Hg or pulmonary artery occlusion pressure < 15 mm Hg

185
Q

what are Increased risk for perioperative morbidity/mortality with moderate-severe PHTN

A

Dyspnea at rest?
Hypoxemia?
Right-sided heart failure?
Split S2?

186
Q

Direct and “second-hand” exposure to tobacco increases the risk of postoperative what complications

A

Desaturation
Severe coughing
Hypertension
Ischemia

187
Q

Smokers have increased of what?

A

Sputum production,
↑ Airway reactivity,
↓Oxygenation

188
Q

why should Elective surgeries should be postponed until patient is “euthyroid” when a patient has thyroid complications

A

Surgery can precipitate myxedema coma/thyroid storm

189
Q

What are the components of intracellular fluid

A

Potassium, phosphate, magnesium

190
Q

How much of total body water is intracellular fluid (TBW)

A

2/3

191
Q

Are Na-k-ATP pump located inside or outside the cell Membrane

A

Inside the cell membrane

192
Q

How much Total body water does extracellular fluid contain

A

1/3

193
Q

How is extracellular fluid divided

A

It is divided into intravascular (plasma) and interstitial fluid

194
Q

Extracellular fluid has High concentrations of what

A

Na (cations) and cl (anions)

195
Q

Where is interstitial fluid located

A

It is fluid within the tissues

196
Q

What does intracellular fluid compartments contain

A

It is characterized by high potassium (cations), phosphate (anions), and magnesium concentration

197
Q

What are starling forces

A

Starling forces determine the motion of the fluid across capillary membrane

198
Q

What are the four forces that govern fluid dynamics

A

Capillary pressure
Isf pressure
Isf colloid osmotic pressure
Plasma colloid osmotic pressure

199
Q

Why is osmotic pressure significant

A

It pulls fluid into the cell, it is determined by plasma protein concentration and serves to maintain fluid volume within the intervascular space

200
Q

What can alter fluid and electrolyte balance of patients during the pre-operative.

A

Illness, surgery and anesthesia

201
Q

Preoperative have a bulimia and electrolyte abnormalities are at least in part an ________________ Phenomenon related to bow preparation and pre-operative

A

Iatrogenic

202
Q

Surgery can lead to ____________ And a need a replace Fluids or blood

A

Hemorrhage

203
Q

What is redistribution of fluid from intravascular space into the interstitial space

A

“Third spacing”

204
Q

Which to a lecture lights are cat ions and where are they located

A

Sodium is a major Cariant in the extracellular fluid

Potassium is a major cat ion it and intracellular fluid

205
Q

Where does protein have the highest concentration intracellular fluid or extracellular fluid

A

Intracellular (ICF)

206
Q

Where is Chloride located

A

It is in the extracellular fluid

207
Q

What is the treatment for acute hypocalcemia?

A

Treatment of acute hypocalcemia involves the infusion of calcium salts. Calcium chloride is the most bioavailable parenteral preparation of calcium & results in rapid correction of hypocalcemia.

208
Q

What is the most common cause of hypercalcemia?

A

Primary hyperparathyroidism. Malignancy being the second most common cause.

209
Q

How do we treat hypercalcemia?

A

Volume expansion with NS & loop diuretics

210
Q

What is the second most abundant intracellular cation second only to potassium?

A

Magnesium

211
Q

30% of alcoholics admitted to hospital have _____ (hyper/hypo) magnesemia?

A

hypomagnesemia

212
Q

What is the treatment for hypomagnesemia?

A

Administer 1-2 g of magnesium sulfate over 5 minutes while ECG is monitored followed by 1-2 g/hr of magnesium sulfate

213
Q

What are the clinical manifestations of hypermagnesemia?

A 
Clinical manifestation:
3-5     Flushing, N/V
4-7     Drowsiness, ▼ of deep tendon reflexes
7-10   Loss of patellar reflex
10-15 Respiratory paralysis, coma
15-20 Cardiac arrest
214
Q

What are the causative factors for hypermagnesemia?(serum magnesium >2.5 mg/dL)

A

Renal failure, excessive magnesium administration, adrenal insufficiency

215
Q

What are the three principle purposes of parenteral fluid administration?

A

Maintenance fluids, replace fluids loss as result of surgery and anesthesia (1:3 ratio for blood loss), correction of electrolyte disturbances

216
Q

Most commonly used fluid in the surgical setting with a similar concentration to ECF?

A

Crystalloids

217
Q

Crystalloid or colloid…

Which is better for volume expansion?

A

Colloid

218
Q

What is the first choice for volume resuscitation of trauma patients with head injuries?

A

Isotonic crystalloid solutions

219
Q

What is a possible adverse effect of giving NS with large volume resuscitation?

A

hyperchloremic acidosis

220
Q

What is a possible adverse effect of giving LR with large volume resuscitation?

A

metabolic alkalosis from lactate being metabolized into Bicarb

221
Q

What solutions can be given with PRBCs?

A

NS & P-Lyte

222
Q

If hypernatremia is accompanied by volume depletion, which do you treat first?

A

The volume deficit with isotonic fluids and THEN treat the hypernatremia with hypotonic fluids.

223
Q

what is the principle electrolyte in intracellular fluid?

A

Potassium, 98% of K is located in the ICF.

224
Q

K abnormalities can be the result of abnormal total body K stores and…..?

A

an imbalance between the normal ICF and ECF K concentrations.

225
Q

Which electrolyte imbalance creates disturbances with resting membrane potentials?

A

Potassium. Abnormalities cause cardiac dysrhythmias and peripheral muscular abnormalities

226
Q

Hypokalemia is defined as a serum level

A

3.5

227
Q

Maximum rate of Potassium replacement to avoid hyperkalemia is….?

A

10-20mEq/hr

228
Q

Would you most likely cancel a case as a result of hyperkalemia or hypokalemia?

A

HYPERkalemia as it is harder to treat.

229
Q

Should you replace potassium with or without chloride and with or without dextrose for treatment of hypokalemia? Why?

A

WITH chloride (to enhance the kidney’s ability to retain K) and withOUT dextrose (as insulin will draw K into the INTRAcellular compartment).

230
Q

Do anesthetic agents, such as succinylcholine, increase or decrease potassium?

A

increase

231
Q

mild hyperkalemia leads to…

A

Peak T waves and prolonged PR interval

232
Q

Moderate hyperkalemia leads to….

A

Widened ORS, loss of P wave, and ST elevation

233
Q

Severe hyperkalemia leads to……..

A

sine wave, Vfib, astystole

234
Q

How can we treat hyperkalemia by SHIFTING potassium stores instead of losing total potassium?

A

administer insulin and glucose, administer bicarb, hyperventilate, beta stimulation via albuterol,

235
Q

How can we treat hyperkalemia by decreases total K stores?

A

kayexelate and K-wasting diuretics

236
Q

Does acidosis increase or decrease serum K? Alkalosis?

A

Acidosis= increased serum K; Alkalosis= decreased serum K

237
Q

______% of Ca is found in bones

A

99%

238
Q

what faction is the most clinically significant form of Ca?

A

Ionized Ca

239
Q

What are the most likely causes of HYPOcalcemia?

A

hyperventilation and changes in pH; also caused by massive transfusions of citrated blood

240
Q

For iconic pressure it is important to have higher or lower protein

A

Higher protein is important

Principles of Anesthesia I (6 decks)

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