Module 6- Emergence Flashcards
What Liter of O2 is required to facilitate wash out
10L
Use 100% O2
What is MAC awake
At which 50% of people respond to commands
MAC Bar is
The MAC necessary to block SNS response to skin incision, which is about 1.6-2x MAC
What is useful to analyzing anesthetic depth
BIS
Lidocaine as an adjunct can cause
Delayed emergence due to excess plasma concentrations (infusion)
When should Ketamine be stopped
15-30 min prior
When should Sufentanil be stopped
30-60min prior
When should remifentanil be stopped?
10-15 min prior
When should Precedex be stopped
30 min before due to its long half life
When should propofol be stopped?
Until the end
What is helpful with breakthrough pain
Short acting opioids like fentanyl
What is beneficial for post-op pain
long-acting opioids, but don’t give them at end of the case
What should be considered for a patient taking chronic pain meds?
Add home dose plus what is needed for surgery
What is the dose of Ketorolac?
10-30mg IV (check with surgeon)
Post-op bleeding risk
What percentage of patients will develop PONV
One third
Anticholinergic that acts as an antiemetic
Scopolamine
What is a NK-1 receptor antagonist
Aprepitant
Corticosteroid that acts as an antiemetic
Dexamethasone
Antihistamines given for N/V
Hydroxyzine
Benadryl
What Phenothiazine is given for N/V
Promethazine
Prochlorperazine
What Butyrophenones are given for N/V
Droperidol
Haloperidol
What Prokinetic is given for N/V
Reglan
What Serotonin receptor antagonist is given for N/V
Ondansetron
What vasopressor helps with N/V
Ephedrine
A patient with no risk factors has what % of PONV risk
10%
A patient with 1 risk factor has what % of PONV risk
20%
A patient with 2 risk factors has what % of PONV risk
40%
A patient with 3 risk factors has what % of PONV risk
60%
A patient with 4 risk factors has what % of PONV risk
80%
Sufficient recovery of a NMB is confirmed by
An adductor pollicis ToF ratio of at least 0.90
What is the only method of assessing whether a safe level of recovery of muscular function has occurred
Quantitative
About what percent of patients can have TOF ratios less than 0.90 following surgery
30-50%, which is a real risk
Incomplete reversal is associated with an increased risk for
Hypoxemic events
Airway obstruction
Postop pulmonary complications
Prolonged PACU times
A profound count of <3 can receive how much Sugammadex (posttetanic)
4-16mg/kg
A deep block with 0 twitches can receive how much Sugammadex (postttetanic)
4-16mg/kg
TOF count 1-4 can receive how much sugammadex
2-4mg/kg
With fade, what is the dose of Sugammadex
2mg/kg
With no fade, what is the dose of Sugammadex
1mg/kg
TOF ratio of 0-0.8 should receive how much Sugammadex
2mg/kg
TOF ratio of >0.9 should receive how much Sugammadex
No reversal
What is required (vent settings) prior to extubation?
PSV 5/5
What are the characteristics of stage 2
Disinhibition
Delirium
Uncontrolled movements
HTN
Tachycardia
Are airway reflexes intact during stage 2
Yes & are hypersensitive to stimulation
Avoid airway manipulation during this stage
There is a high risk of what during stage 2
Laryngospasm
What can compromise the patient’s airway
Spastic movements
Vomiting
Rapid & irregular respirations
What can help reduce the time in stage 2
Fast acting agents
The brain wakes up in what order
Reverse order of evolution
Which reflexes come back first
Deep, which is why you see swallowing, gagging & coughing
What reflex comes back last
Purposeful movement, which is following commands
Why is awake extubation preferred?
For those who are at a high risk for aspiration & are a difficult intubation
Ensures they can protect their airway & breathe spontaneously
What are the disadvantages of an awake extubation
CV stimulation
Discomfort
More coughing & Straining
What is deep extubation?
When patient is in the 3rd stage of anesthesia
Minimizes the complications of laryngospasm
What is the MAC of deep anesthesia/extubation
Over 1 MAC (1-1.3 MAC)
What are the advantages of deep extubation
Reduced risk of gagging, coughing & discomfort
What are the disadvantages of deep extubation
Respiratory depression
Delayed awakening
Difficulty assessing airway reflexes
Longer PACU time
Avoiding prolonged intubation can reduce the risk of
Infections such as ventilator-associated PNA
What causes airway obstruction?
Swelling, bleeding
What is a laryngospasm
Reflex contraction of the vocal cords preventing airflow
What are the complications associated with extubation
Respiratory depression
Aspiration
CV instability
What are the extubating criteria
Confirm adequate reversal
Assess Recovery
Monitor VS
Normothermia
Pain management
What are things that can be performed to help with adequate emergence/extubating the patient
Pre-oxygenate the patient
Recruitment maneuvers
Suctioning
Remove throat packs
Use bite block
What can happen if the patient bites on the tube?
Negative Pressure Pulmonary edema
Recruitment maneuvers are essential for what patient population
Asthmatics
COPD
Procedures where insufflation was used
If high pressures with mask ventilation were used, what can you do?
Place OG to suction to decrease risk of aspiration & improve ventilation
What position is best for Obese patients when extubating
Head up position
(good for those at risk for hypoventilation
What is the lateral decubitus position good for?
Those at high risk for pulmonary aspiration
Weak pharyngeal muscles can cause
A compromise in airway patency
Why do we inspect the balloon cuff?
To avoid cord injury or arytenoid dislocation
Applying positive pressure right before cuff deflation will
Help expel secretions that have collected above the vocal cords
Reduced muscle strength can
impair adequate ventilation & risk of aspiration
The ability to respond to low oxygen levels
Is diminished
How do we objectively assess degree of NMB
tof
What are the complications of a laryngospasm
Bradycardia due to vagal response
Pulmonary edema
Pulmonary aspiration
Desat/Hypoxemia
What causes a laryngospasm
Sensory stimulation of the vagus nerve- the internal branch of SLN, leading to reflexive spasms
What muscle contracts during laryngospasm?
cricothyroid muscle 9stimulated by SLN) tense the vocal cords, while the thyoarytenoid & lateral cricoarytenoid muscles (stimulated by the RLN) cause adduction of the cords
What type of pressure can you apply to break laryngospasm
Positive pressure
What airway maneuvers break laryngospasm
Jaw thrust
Chin lift
Lawson maneuver
What medications can be given t obreak a laryngospasm?
Lidocainie
Muscle relaxant
