NORA Flashcards
Define MAC
Greater than MODERATE depth
Requires same preop and intraop care
Patient must retain consciousness and the ability to respond purposefully-not what actually happens
ALWAYadministered by anesthesia provider
Main differences between 4 levels of sedation
Minimal
Moderate- no airway intervention
Deep- airway intervention may be required
General-intervention often required
Expectations during MAC
Psychological support
And everything else that is required during general
Good MAC candidates
Can remain motionless
Can follow directions
Can tolerate conversion to general
MAC main complication
Respiratory compromise from excessive sedation
NOT less risky than generak
Risk of MAC vs General
MAC is not less risky than GA in terms of permanent brain injury or death
Problems with MAC med titration
There is significant variability in individuals response to medications- we are all snowflakes
Goal is consistent plasma concentrations and avoiding oversedation/airway compromise
Elimination half-life
Time necessary for the plasma concentration of a drug to be reduced by half
Context sensitive halftime
Time for plasma concentration of a medication to be reduced by half after cessation of an infusion of a certain duration
Half time equilibration constant?
Used to assess the time to effect after a bolus and removal of drug from effect site after cessation of infusion
A drug with short t1/2 Keo will demonstrate what?
Keo=equilibrium constant
Rapid equilibrium between plasma and brain and will have a shorter delay in onset
CPss50
Plasma concentration required to abolish purposeful movement at skin incision
Two qualities we love about propofol
Amnestic and hypnotic
Ketamine considerations in MAC
Minimal resp and card depression
Hallucinations
Oral secretions can cause laryngospasm-glyco
Good adjunct for propofol but only use low dose in outpatient setting
Dexmedetomidine
Central presynaptic alpha-2 agonist
Increases vagal tone=hypotension and bradycardia
Slow onset-sticks around
Potentiates analgesia of opioids
Why are MAC patients at risk of airway fire? -
Uncontrolled airway and an open oxygen source
What is the fire triad?
Ignition source
Fuel source- alcohol prep
Combustible gas- O2
What are our flammable gasses?
Oxygen and Nitrous
NOT the halogenated anesthetics
Preventing OR fires
Flushing under the drapes with AIR
Use air/oxygen blender
Keep drapes off patients face
Use harmonic scalpel or bipolarelectrosugery NOT cautery
First thing in airway fire?
Turn off O2
2nd and 3rd step in airway fire
Pull out burning material
Replace ETT
What can increase chances of LAST?
Cardiovascular depression= reduced hepatic flow and buildup of local
What potentiates cardiovascular toxicity of LAST?
Hypercarbia
Acidosis
Hypoxia
Signs of last
Sedation
Numbness of the tongue/circumoral tissues
Metallic taste
Restlessness, vertigo, tinnitis, inability to focus
Slurred speech, skeletal muscle twitching
Tonic-clonic seizures
Cardiovascular toxicity
Treating LAST
Ventilate with 100% O2
Benzodiazepines elevate seizure threshold
Avoid propofol
Initiate ACLS protocols as needed
Avoid vasopressin, Ca++ channel blockers, beta blockers or local anesthetics
LA cardiotoxicity may be treated with Lipid Emulsion (20%) Therapy
-Bolus 1.5mg/kg (may repeat 1-2 times)
-Infuse 0.25-0.5 mL/kg/min
ASC killers
Pain
Drowsiness
PONV
-unplanned hospital admissions
URI wait times
Adults 6 weeks
Peds-2-4 weeks
Why do we care about hyperglycemia
Dehydration
Fluids shifts
Electrolyte abnormalities
Impaired wound healing
Outpatient diabetes recommendations for blood sugar
A1C<7
Preprandial 90-130
Post Prandial<180
Ballpark a1C average glucose table
Why don’t we just lower BS before surgery for non optimized patients?
Artificial reduction may increase periop mobility and mortality
-oxidative stress and organ impairment
Chronic hyperglycemia alters hormonal counterregulatory control
1500 dosing rule for insulin
1500/total daily insulin
=expected decrease in blood glucose with 1 unit of insulin
Patient takes 10 units lantus plus 10 units of regular at every meal
How much will 1 unit drop their blood glucose?
10+10+10+10=40
1500/40=37.5
What do OSA patients have higher rates of?
Diabetes
HTN
MI
Stroke
MI
CHF
Presumptive OSA
3 criteria on Stop bang
Stop bang criteria
Snoring
Tiredness
Observed apnea
Pressure HTN
BMI >35
Age >50
Neck circumference >40
Gender MALE
Who is unfit for ASC??
Those unwilling to use their cpap
What do we know about the OSA outpatient population?
-no increased need for ventilatory assistance or reintubation (exclusionary criteria)
Higher incidence of post op hypoxemia
BMI cutoff for ambulatory surgery
Psych there isn’t one if they’re medically optimized
Deal with it
Increased m&m in obesity- bmi and problems
> 50- super obese
Wound infections
Sepsis
Increased 30-day mortality
PONV risk factors
Female
History PONV
Non smoking
Young <50
General vs regional
Volatiles
Post op opioids
Duration of surgery
Surgery type (laparoscopic, gyn)
Apfel score
Points 0-4
Female
Non smoker
History PONV
Opioids
2 surprise ways to decrease PONV
Preop carbohydrate beverage
Sugammadex instead of neo
What are we treating vital signs with intraop instead of opioids?
Esmolol
Adult PONV management flow chart
Main takeaway from PONV management
Combo therapy is more important than monotherapy
Unless its reglan which doesn’t work regardless
Which surgery type should be under general?
Laparoscopic
T1 spinal is a bad idea
What local do we not use for spinals?
Lidocaine
Increased risk transient neurological symptoms
Which type of block is epidural?
Caudal…
What does epidural lower the risk of vs spinal?
PDPH
How do you handle an uncooperative/disinhibited patient under MAC?
Pick a lane
Either sleepy time or wake them up so they are more appropriate
Recommendations for ASC
Use propofol for induction
Minimize opioids/volatile
No N2O
Address PONV
Use LMAs, avoid NMBD, consider BIS
Soap ME for NORA or OBA
Suction
Oxygen source
Airway equipment
Pharmaceutical, epi, atropine, succ
Monitoring equipment
Equipment (special) -syringe pump, lead
What should we be prepared for in MRI?
ANAPHYLAXIS
Yearly radiation limit
50 millisieverts
IV contrast considerations
Maintain hydration
Stop metformin preop-increased risk lactic acidosis
Sodium bicarbonate may help improve contrast elimination
Cocktail for ECT
Every patient will likely have a different set of meds they typically get listed in their chart-follow it
Occulocardiac or “five and dime”
Bradycardia/asystole associated with v and X manipulation
Trigeminal and vagal
Statistics on office based closed claims
50% respiratory- bronchospasm, esophageal intubation, inadequate ventilation
25% drug related- MH, wrong dose
Difference between OBA and ASC
OBA have no accrediting body
OBA vs ASC injuries
OBA 64% were permanent or led to death
ASC 21% were permanent or led to death
Type of anesthesia for ENT surgery
Regional, general, or mac + local (fire risk)
