Outpatient Anesthesia Flashcards
Describe Minimal, moderate, deep sedation and general anesthesia.
-Minimal sedation: Drug induced state of anxiolysis where patients respond normally to commands
-Moderate sedation: Drug induced depression of consciousness where patients respond purposefully to verbal commands or light stimulation. Airway maintained
-Deep sedation: Drug induced depression of consciousness where patients respond to repeated or painful stimulation. Patient may require assistance with ventilation
-General anesthesia: Drug induced loss of consciousness. Patients are not arousable by painful stimulation. Require assistance with airway, CV decreased
Describe your airway assessment.
-Overall physical examination of extra-oral appearance, body habitus, extra-oral features, BMI
-Dental exam
-Mallampati score
-MIO
-Thyromental distance
-Mandibular protrusion/upper lip bite test
-Neck Circumference
Describe Mallampati Score.
-Modified Mallampati score. Scores 3-4 predictor of difficult intubation
-Class I: Soft palate, uvula, tonsillar pillars and fauces are visible
-Class II: Superior 2/3 of uvula and soft palate visible
-Class III: <1/3 of uvula and soft palate visualized
-Class IV: Soft palate not visible
What is thyromental distance?
-Distance between top of thyroid cartilage and the menton of mandible
-Indicator of the ability to displace the tongue during DL
-3FB normal
When is an EKG warranted for sedation?
-Adults over 65
-HTN, cardiac disease, substance abuse, eating disorder
What is a MET?
-Metabolic equivalent tasks
-Physiological measure that expresses the energy cost of performing various physical activities
-Ratio of metabolic rate during a physical activity over the reference metabolic rate of a 40-year-old 70 kg man
-METS>4. Climbing flight of stairs, bicycling, walking over 4 mph
Describe the ASA classifications
-ASA I: Healthy patient
-ASA II: Mild systemic disease (smoker, social alcohol, BMI >30, well controlled disease)
-ASA III: Severe systemic disease (poorly controlled DM, HTN, BMI >40, hepatitis, alcohol/drug abuse, pacemaker, dialysis, h/o MI, CVA, TID, CAD/stents)
-Class IV: Severe systemic disease, constant threat to life (<3 months MI, CVA, CAD/stents), ESRD, sepsis
-Class V: Moribund patient not expected to survive without operation
-Class VI: Brain dead, organ donor
-Addition of E denotes emergency surgery
Describe your NPO guidelines.
-2 hours: Clear liquid (not alcohol)
-4 hours: Breas milk
-6 hours: Infant formula, non-human milk
-6 hours: Light meals, non-clear liquid
-8 hours: Heavy, fried/fatty foods
What FiO2 is delivered with nasal canula, simple facemask, non-rebreather and mask ventilation?
-Nasal canula at 4 L/min: 36%
-Simple Facemask 8-12 L/min: 35-65%
-Non-rebreather 6-15 L/min: 60-100%
-Mask ventilation: Up to 100%
What are the risk factors for difficult mask ventilation?
-Age greater than 55
-BMI >26
-Edentulism
-Beard
-Snoring
How are OPAs and NPAs measured?
-OPA: Corner of mouth to angle of jaw (not for conscious patients)
-NPA: Nose to angle of jaw, can check intraorally
Describe the technique for a cricothyrotomy.
-Extend head and neck
-Identify cricothyroid membrane
-Make horizontal stab incision through skin and cricothyroid membrane, keep blade in place
-Use a tracheal hook to apply caudal and outward traction on the cricoid cartilage, remove blade
-Insert ETT, inflate cuff
-Ventilate with low pressure
-Confirm ventilation (listen to lungs)
-Convert to trach within 72h
Cannot do on children less than 12 years of age (narrowest point of airway)
How is an emergent airway handled in children 12 and under?
-Transtracheal needle ventilation
-Extend neck and identify cricothyroid membrane (2-3 cm below laryngeal prominance)
-Puncture cricothyroid membrane with saline filled syringe with 14 gauge catheter for adults or 18 gauge for children, Draw back until air enters syringe
-Advance catheter off caudally 30-45 degree angle
-Attach syringe to 100% oxygen at 5-10 PSI for children or positive pressure through a connector
What are pediatric airway considerations?
-Pediatric airway is smaller
-Large tongue, small mouth
-Large occiput
-Obligatory nose breather
-Large tonsils
-Larynx higher and more anterior
-Epiglottis is floppy and projects posteriorly
-Cricoid ring is narrowest point in the airway
-Small length of trachea
-C-spine at risk of injury
How is endotracheal tube size calculated in the pediatric population?
-Age/4 +4 (uncuffed), decrease 1/2 for cuffed
