Prep for anesthesia Flashcards
People that have what are at greater risk of anesthesia related complications?
liver disease
People who have liver disease are at increased risk of what?
bleeding
Why are patients who have liver disease at greater risk of bleeding?
Because you make vitamin K in your liver, which helps synthesize factor 2, 7, and 10.
What is the most important factor for surgery? why?
Factor 7, it is the only clotting factor that is on the extrinsic clotting pathway external to patient (scapel to skin)
What are 5 things that are associated with addiction that can cause issues with surgery?
- liver changes
- esophageal varices
- pancreatitis
- malnutrition - low albumin levels
- withdrawal
What is important to remember with esophageal varices?
be careful with NG’s because they can burst esophageal varices
What does alcohol withdrawal look like?
palpitations, tremors, nausea and vomiting, clammy skin (SPEED)
What do you want to do with latex allergies?
latex risk assessment
Who are at a great risk for latex allergy?
people who are consistently exposed to latex (like healthcare workers)
What is ideal for case lineup for a patient with latex allergy?
first case of the day
What are examples of things with latex?
boufant caps, elastic tape, ace bandages, egg crate (pink or yellow, not purple)
Do not remove what from medications for latex allergies?
rubber stoppers
Can increased ICP cause issues with anesthesia?
yes
Too much fluid can increase what in related to ICP?
increase ICP further
Too little fluid decreases what in relation to ICP?
decreases BP and perfusion to brain
Renal dialysis patients can have no what on their AV fistula arm?
no BP cuffs or IVs
What kind of imbalances are common with renal dialysis patients?
fluid and electrolyte imbalances
1/3 of patients on induction are going to what?
vasodilate
Medications that are metabolized in the kidneys for a patient that is on dialysis should be what?
avoided
What are burn patients prone to what?
hypothermia
What kind of imbalances are common in burn patients?
fluid and electrolyte imbalances
What can be a challenge with diabetics?
glucose control
What are diabetics are more prone to?
high blood pressure and GERD
Diabetics have delayed what?
wound healing
What do we want to keep in the room for diabetics?
glucometer in room
What is diabetes insipidus
injury around the pituatary and hypothalamus and there is an interruption in ADH, which causes excessive diuresis (1 liter of output of urine an hour)
What can happen very quickly with diabetes insipidus patient?
dehydration
What do we want to be mindful of with diabetes insipidus patients?
be mindful in surgeries involving the pituitary or hypothalamus or head trauma
How do we want to treat diabetes insipidus?
treat with fluid cc/cc of urine ouput
What kind of line do patients need to have with diabetes insipidus?
central line
What do we want to give to patients with diabetes inspidius?
vasopressin
What does vasopressin do?
stiffens up blood vessels and holds onto volume.
What is the downside of vasopressin?
increases BP which is something we might not need with diabetes insipidus
What might we give instead of vasopressin? why?
DDAVP, because it will hold onto volume but not stiffen blood vessels
How long does ciliary function return to normal for smokers?
7-8 weeks
What do you need ciliary function for with smokers?
to move the gunk up out of their bronchials into their bronchi and trachea to cough it out
What do we want to tell smokers?
stop smoking ASAP before surgery
Nicotine is a powerful what? why is that important?
Vasoconstrictor. Constricts blood vessels at the periphery which decreases blood flow, decrease oxygenation to periphery or wound. Anaerobic bacteria get a foothold which increases chances of infection!!
any blood pressure that is over textbook 120/80, and the patient is symptomatic, the physician can do what?
order BP meds and insurance will pay for it
Our goal for BP during surgery is?
steady BP on the low side of baseline to minimize bleeding
What is hemophilia?
Factor VIII deficiency
What do we want to give throughout surgery for hemophilia patients?
synthetic factor VIII replacement throughout surgery
What do we want to remember with pregnancy?
to check for pregnancy on all females of childbearing age
What is considered childbearing age
first menses - last menses plus 1 year without breakthrough bleeding.
What happens if a female has breakthrough bleeding?
If they have to do breakthrough bleeding then they have to have repeat pregnancy test
If patient is pregnant, always position off what?
vena cava
What does positioning off vena cava look like?
putting bump under the right or tilting the table to the left to get as close to left lateral as possible
What happens if mom is laying on back during surgery?
weight of baby compresses vena cava it decreases mom’s CO, which decreases fetal blood flow
Hormonal changes that come with pregnancy do what? which can cause what?
stiffens blood vessels to make them less easy to collapse which can increase BP
What happens to BP for pregnant women during surgery under anesthesia?
the hormonal changes that stiffen up blood vessels are eliminated which means they will vasodilate big time
What is an intervention for for pregnant women prior to getting anesthesia?
loading up with liter of fluid before surgery
Maintain what for fetal perfusion?
maintain BP
Have what kind of device in the OR with pregnancy if they are at least 20 weeks gestation?
fetal heart monitor
What are the most common surgeries that are done on pregnant women that are not related to pregnancy?
cholecystectomy and appendectomy
What do pregnant patients wake up with after getting cholecystectomy and appendectomy?
braxton hicks contractions bc to retract the uterus to get to the gallbladder or appendix, that physical manipulation is going to irritate the uterine wall.
What are we looking for with real contractions?
- increase in severity and regularity of contractions
- lose mucus plug
If patient is less than 20 weeks gestation where will they have fetal heart monitor?
in recovery
CHF patients are prone to what?
fluid overload
What does anesthesia not want for patients with CHF to take?
for them to not take their diuretic
What do CHF patients have an exaggerated response to?
vasodilation
Under anesthesia what do CHF patients do? they need what?
dilate and need fluid
What is morbid obesity?
BMI greater than 40
What is obesity
greater than 30
What is overweight?
greater than 25
What is compromised in morbid obesity patients?
wound healing (increased adipose tissue, decrease in vasculature)
What 2 things are difficult in morbid obesity patients?
- intubation
- ventilation
What is the most difficult position for ventilation?
exaggerated lithotomy or high lithotomy
What decreases in exaggerated lithotomy? What increases?
tidal volume, because ability to take a nice easy breath is going to decrease. work of breathing increases
What do we want to have asthmatics bring with them? why?
their inhalers for taking puffs in preop because they have a reactive airway so the ET tube can
What is important to consider with intubation for patients with asthma?
deeper sedation for intubation so they don’t react
Patients with COPD have to live in a state of what to maintain respirations?
hypoxia
Where do we want the sats for a patient who has COPD?
88-92
In patients with COPD what stimulates breathing, not what?
low O2 stimulates breathing not high CO2
What do need for COPD patients?
low concentration O2, means 30% or less.
In order to get to low concentration of O2 you need what?
nasal cannula
What is top limit of nasal cannula that will get 30% O2?
2 Liters
What are the 2 requirements for post op ventilator?
- Vt lower than 500 mL in an adult
- PCO2 > 45
What kind of positioning do you have with RA?
creative positioning
If you have any patient who has a diagnosis that makes you think they may not have a normal ROM (MS, cerebral palsy, musclar dystrophy), what do you do
positioning when they are awake, so that they can tell us if they are uncomfortable?
RA causes what?
anemia
What is really important preop for RA?
H and H
What puts RA patients at risk for impaired stress response?
steroid coverage
What is an impaired stress response?
hypo-adrenal crisis
Because RA patients always have steroid coverage what is their body not doing?
adrenal glands are not producing corticosteroids to support you through stress
What does hypoadrenal crisis look like?
circulatory collapse and shock
What do RA patients get in the preop area?
stress dose of steroid (hydocortisone)
Steroid coverage is an anti-inflammatory, which suppresses what? which causes?
first phase of wound healing, which increases likelihood of infection
Sickle cell anemia cells do not carry what well?
oxygen
What do sickle cell patients end up with?
ischemic tissue
Ischemic tissue makes what?
lactic acid
What are the 5 triggers of sickle cell crisis?
- hypothermia - hot line and bair hugger (most effective) warming room (not as effective - just maintains)
- hypotension - nerve blocks and TIVA blocks are preferred, AVOID general and spinal/epidurals
- hypovolemia
- hypoglycemia
- hypoxia
What can we do with temperature of room according to AORN if we have at-risk procedure/patient?
allow us to surpass 75 degree upper limit for one at risk patient/procedure for the duration of patient, so sickle patients need to have higher degree room
What has anesthesia body recommended for patients with sickle cell in order to avoid hypoglycemia?
clear liquids with calories up to 2 hours prior to surgery. Like gatorade or pedialyte
What triggers gastric emptying?
drinking the carbohydrate drink
Drinking a carb drink for sickle cell patient puts them in a what? which decreases what and increases what
anabolic fed state which decreases PONV, helps increase metabolization of medications in the kidneys.
What is considered infant?
up to 18 months
How do we soothe infants?
with pacifier, holding, and rocking
What is age range for toddler?
18 to 30 months
What do toddlers have?
separation anxiety
Communicate to toddlers with what?
simple sentences
We want to sooth toddlers with what?
distraction and familiar objects
What is age range for preschooler?
2 1/2 to 5 years
What do preschoolers believe?
may believe they are in the hospital because they are in trouble
What do preschoolers fear?
- pain and mutilation
- abandonment
Provide what to preschoolers when possible?
independence
Communicate using what with preschoolers?
compound sentences
Be careful of what word with preschoolers?
BETTER. because better is associated with behavior
You want a preop what with preschoolers?
pre-op tour, showing the waiting room
Don’t what with preschoolers? Just what?
don’t ask, just do
Consider what for induction with preschoolers?
parental involvement.
If you have parental involvement with induction and preschoolers?
make sure to educate the parents what induction looks like
What is school age?
6 years - 11 years
Give what to school age children?
HONEST gentle information
School age children are able to be what?
more cooperative
Give what to school age children for cooperative behavior?
positive reinforcement
Watch for what with school age children?
loose teeth
Adolescent is what age?
12 years to 18 years
What do adolescents have a fear of?
loss of privacy
What is important to adolescents?
body image
Adolescents are hypersensitive to what?
the opposite sex as caregivers
Give what to adolescents?
give honest information
Young infants have short what?
tracheas
Maintain what in intubated infants?
maintain neutral neck alignment
Why do we need to maintain neutral neck alignment in intubated children?
chin to chest - extubate. If they look up they are down the right main stem
What do we weigh for peds?
sponges to keep accurate count of blood loss in small infants
Infants are very sensitive to what?
heat loss.
Don’t leave young infants what?
ALONE
Newborns have what 3 things?
- immature vasomotor control - that is why they are red, they can’t clamp down if they are cold so they just lose heat
- no shiver response
- low muscle mass
What 3 things do elderly have?
- poor peripheral vasomotor control
- low muscle mass
- ineffective shiver response
In sequence, who is most at risk for hypothermia?
- newborn
- elderly
- toddler
Respiratory rate drives what in pediatric populations?
heart rate
Kids decomponsate more what?
suddenly
Kids recover more what?
quickly
Why do babies have faster heat loss?
immature vasomotor control
Infants do have mature what?
pain receptors
What is the best post-op position for pediatric patients?
lateral, because the tongue does not fall into the airway
What is the best post-op position for pedicatric patients who have gotten oral procedure done?
semi-prone (lateral but leaning forward)
What can you do for an infant to maintain position and comfort?
swaddle
What should you use to maintain tubes and drains in pediatric populations?
safety restraints
What is an important question to ask for positioning?
How will the patient tolerate the planned position? think about it
Positioning devices should be what?
in clean and in proper working order
Move unconscious patients using what?
assistive devices
Monitor the patient’s what when moving unconscious patients?
body alignment and tissue integrity
What is severe on braden scale?
<10
What is braden scale
Scoring system to assess for the susceptibility of skin breakdown
The lower the score the higher the risk of skin breakdown
What is a perfect score on braden scale?
24
What is considered high risk on braden scale?
10-12
What is considered moderate on braden scale?
13-14
What is considered mild on braden scale?
15-18
What are the risk factors for braden scale?
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction/shear
You are scored a what through a what on braden scale risk factors?
1-4
HINT: question on the exam. Who is most likely to have skin breakdown? the answer with braden scale score is the one to choose
Before transfer or transport who do we check with?
anesthesia 1st
If patient weighs greater than 72 kg, you need how many people to transfer?
4 people
If patient weighs less than 72 kg, you need how many people to transfer?
3 people
if patient weights less than 20 kg, you need how many people to transfer?
2 people
Where does a foley go on a stretcher?
on the frame (not laying in bed with patient. not on side rail)
We lock what when moving patients?
bed and stretcher
What do we remove from patient prior to transfer?
restraints
What nerve can be damaged during lithotomy?
obturator nerve
What is the closest nerve to the surface of the groin?
obturator nerve
What procedure really stretches the obturator nerve?
vaginal hysterectomies
If there is damage to the obturator nerve, what does it feeling?
- burning in the groin, down the inside of the thigh
- pain and numbness of the inner thigh
The obturator nerve innervates what muscle groups?
adductor muscles
How long does it take to recover from obturator nerve damage?
year
What is the popliteal nerve?
This nerve is a part of the sciatic nerve, found in the popliteal fossa (behind the knee) and branches into the tibial nerve and the common peroneal nerve, providing sensation and motor function to the lower leg.
The popliteal nerve is part of the what?
sciatic nerve
Where do we pay special attention for the popliteal nerve?
boot stirrups
When placing a patient in boot stirrups where is the weight?
weight of leg on thigh and knee
How long is recovery for popliteal nerve?
1 to 4 months
What nerve is prone to reinjury?
popliteal nerve
What nerve are we dealing with when there is external rotation of the hips?
sciatic nerve
What 2 other places do we have to worry about the sciatic nerve?
- lithotomy
- herniated disc
What is the percentage of patients where sciatic nerve recovers?
80-90%
Peroneal nerve runs how?
laterally
What 3 things can cause peroneal nerve damage?
- long leg casts
- lateral hip and total knee procedures
- positioning
What is peroneal nerve damage also called?
peroneal nerve palsy?
How do we assess for peroneal nerve palsy?
we assess for this by dorsiflexing. If patient can point big toe to forhead then you are ok
What is common injury with peroneal nerve damage?
foot drop
Saphenous nerve is what?
medial
The saphenous nerve is close to the what?
saphenous vein
IF you are doing saphenous vein harvest or vein stripping procedures what do you have to separate?
the saphenous vein and saphenous nerve
What do you want to maintain to prevent brachial plexus nerve injury?
brachial plexus
Support what arm on arm board by abduction less than what to prevent brachial plexus injury?
90 degrees
Brachial plexus injury occurs when extremity is doing what 3 things?
- forcefully pulled or stretched
- ROM exceeded for extended time
- risk increases when head is turned to the side
Some brachial plexus injuries what, and some have what?
some recover, some have permanent disability
What are the pressure points
- occiput
- scapula
- olecranon process
- sacrum/coccyx
- heels
Where do you see the most brachial plexus injury?
robotic procedures with severe reverse trendelenburg
What are 3 safety precautions with positioning in supine?
- spinal alignement
- pad the head/elbows
- float the heels
How do we maintain spinal alignment in supine?
- legs parallel
- ankles uncrossed
What are nerve precautions in supine?
- brachial plexus
- ulnar
- radial
- median
If you are palms down in supine what injury do you risk?
ulnar nerve injury
Reverse trendelnberg is head what?
head up
What 3 procedures are good for reverse trendelenberg?
- craniotomy
- breast reconstruction
- neck procedures
- lap chole
Trendelenburg is head what?
down
Trendelenburg helps with what?
difficult insertion of neck lines
What surgery is good in trendelenburg?
pelvic surgery
What is an added benefit of trendelenburg?
easier to stick in veres needle
What is a indication for lithotomy?
perineal surgery (i.e. hemorrhoidectomy
What is a variation of lithotomy?
frog leg
Why might we do a frog leg?
CABG for saphenous vein access
What are 7 safety precautions for lithotomy?
- stirrups should be even
- buttocks to edge of bed
- elevate legs together
- lower legs together
- minimal external rotation of hips
- place arms on abdomen or on arm boards at <90 degrees
- protect hands
What are the 2 indications for lateral?
- thoracic
- kidney
Kidney rest (center part of bed) goes on what rib?
the 12th rib
What are 4 safety precautions for lateral?
- flex lower leg, top leg straight
- pillow between knees
- be careful of pressure points
- support head and upper arm with appropriate positioning equipment - you can compress brachial plexus nerve
What are the pressure points in lateral?
- ear
- acromion process
- iliac crest
- greater trochanter of femur
- dependent knee
- malleolus
What are 2 indications for prone?
- spine surgery
- arms tucked for cervical spine procedures
What should you not do with arms tucked in cervical procedures?
DO NOT tie down because ischemic injury is reported every year
What are 5 safety precautions for prone?
- arm boards should be lower than table
- chest rool from clavicle to iliac crest improves chest expansion
- pressure points
- cervical alignment
- protect fact
What are 2 indications for sitting?
- craniotomies
- shoulder
What are safety precautions for sitting?
- pressure points
- secure hands on lap
- foot board maintains dorsiflexion
What are the 3 pressure points in sitting?
- scapula
- ischial tuberosities
- heels
what are 3 common types of hemodynamic monitoring?
- central venous pressure
- swan-ganz catheter
- aterial line
Why do hemodynamic monitoring?
- heart disease
- respiratory disease
- high risk/type of surgery
- shock
What is the main reason for hemodynamic monitoring?
blood pressure
CVP is pressure in the what?
right atrium
What is a normal CVP?
4-8 mmHg
What does low CVP mean?
- hemorrhage
- dehydration
- venous pooling
What does high CVP mean?
- pulmonary hypertension
- pulmonary edema
- right ventricular failure
What is swan-ganz catheter also known as?
intrajugular or subclavian
Intrajugular or subclavian is usually on the?
right side
What 5 things does swan-ganz cather measure?
- CO
- RA
- PA pressures
- wedge pressure
- core temp
What is the risk of swan-ganz catheter?
micro shock
What is normal CO?
4-8 liters/min
What is normal RA? or CVP
4-8 mmHg
What is normal PA pressures
1/3 systemic pressure
What is normal wedge pressure?
4-12 mmHg
How do we protect from micro shock?
we are checking PM stickers on machine/bovie pad
What is arterial line for?
- for continuous monitoring of blood pressure
- for frequent blood test
What is art line required for?
infusion of nipride or other hemodynamic drugs requiring tight control
What is most commonly used for arterial line?
radial artery
What test should be done before arterial line?
allen test
