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Semester 4 TxWes > Principles of Anesthesia II Unit II > Flashcards

Principles of Anesthesia II Unit II Flashcards

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1
Q

Memory decline occurs in what percentage of people over 60?

A

40%

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2
Q

Neuronal shrinkage leads a decrease in what?

A

Decrease in grey matter

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3
Q

Decrease in white matter increases what in size?

A

Ventricular size

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4
Q

Decrease in white matter causes progressive loss of what?

A

Memory, balance, mobility

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5
Q

What neurotransmitter release is significantly reduced as you age? Which is not affected?

A

Dopamine, Ach, norepi and serotonin. Glutamate is unchanged.

CRMO, CBF and EEG are generally unchanged with age

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6
Q

What neuraxial changes occur as you age?

A

Decreased epidural space

Increased permeability of dura

Decreased volume of CSF

Decreased diameter/number of myelinated fibers in dorsal and ventral nerve roots

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7
Q

What PNS changes occur as you age?

A

Inter-Schwann cell distance decreased

Conduction velocity decreased

In general, elderly are more sensitive to neuraxial and peripheral blocks

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8
Q

What cardiac changes occur as you age?

A

Myocyte number decreases

LV wall thickens

SA node cells decrease – sensitive to tachy/brady arrhythmias

Conduction velocity decrease

Thickened and calcific aortic valve

Decreased contractility, increased ventricular stiffness (higher filling pressure)

Less beta-adrenergic sensitivity (less fight/flight response, you lose the ability to increase HR and CO during stress)

many of these changes are d/t increased afterload as you age

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9
Q

What increases vascular stiffness as you age?

A

Breakdown of collagen and elastin
Less NO related vasodilation
Early wave deflection…increased afterload, diastolic dysfunction

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10
Q

What pulmonary changes occur as you age?

A

Loss of elastic recoil and loss of surfactant = increase in lung compliance and decrease in elastic recoil

Enlarged bronchioles/alveolar ducts coupled with early collapse of small airways during exhalation = increase in anatomic dead space, increased closing capacity and impaired gas exchange

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11
Q

Lost of vertebral height and calcification of vertebrae lead to what pulmonary changes?

A

Barrel chest
Diaphragmatic flattening
Chest wall stiffness….increased work of breathing

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12
Q

How do VC, CC and RV change as you age?

A

VC decreases, CC increases and RV increases

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13
Q

How much does FEV1 decrease per decade?

A

6 - 8% d/t decrease in muscle mass and increase in CC

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14
Q

What relationship has the greatest effect on the alveolar-arterial oxygen gradient?

A

The relationship between FRC and CC, as the mismatch increases shunt increases and arterial oxygenation declines

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15
Q

How much does GFR decrease each decade after 30?

A

About 10% each decade

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16
Q

Why does reduce the body’s ability to adjust fluid and e-lytes?

A

The body has a blunted response to aldosterone, vasopressin, renin

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17
Q

Metabolism of drugs requiring what types of metabolism are affected by aging? What types of drug metabolism are not affected by aging?

A

Affected by aging: Phase I metabolism = oxidation, reduction, hydrolysis. Very common in narcotics and anesthetics

Not affected by aging: Phase II metabolism, acetylation and conjugation

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18
Q

What occurs to subQ fat as you age?

A

SubQ fat things

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19
Q

How much does temperature change in the 60 - 80 year old range?

A

About 1 degree C less than infants/children/younger adults

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20
Q

What are the listed significant predictors of 6 - 12 month mortality?

A

Impaired cognition

Recent fall

Hypoalbuminemia

Anemia

Functional dependence

Comorbidities

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21
Q

Surgery and anesthesia cause peripheral inflammatory responses. In a vulnerable brain, what negative outcomes can occur because of this inflammaion?

A

Dysfunctional anti-inflammatory response leads to an exaggerated neuroinflammation and acceleration of AD pathology causing long-term cognitive decline

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22
Q

What are the neurotoxic factors that are the pathogenesis of dementia?

A

Amyloid B, Tau, calcium and neuroinflammation

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23
Q

How does amyloid B accumulate? Proposed MOA in causing neuro-degeneration?

A

It’s a fragment of synaptic origin - its released as synapses break down. The proposed MOA is the coagulate to form amyloid plaques that disrupt cell membranes over time

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24
Q

What is the relationship of temperature and Tau?

A

Decreases in temperature lead to increases in Tau

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25
Q

What is the primary MOA of Tau causing neuro-degeneration?

A

By causing neurofibrillary tangles/destabilizing microtubules

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26
Q

What is Tau?

A

Phosphorylated and aggregated T-protein

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27
Q

What biomarker increases earliest before cognitive impairment begins to show?

A

Amyloid-B accumulation (Slide 29)

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28
Q

How is calcium release affected as you age?

A

Exaggerated release from endoplasmic reticulum - Specifically ryanodine and IP3 receptors

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29
Q

What inflammatory markers contribute to cognitive decline?

A

Cytokines, IL-6 and TNFa

inflammation mitigating drugs such as dexamethasone, lidocaine and toradol may augment this

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30
Q

Why is propofol a great choice for GETA in the elderly?

A

Volatiles have a high incidence rate of cognitive decline/injury, whereas propofol has significantly less cognitive decline/injury chances

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31
Q

What risk factors appear to contribute to high chances of cognitive decline after surgery?

A

Increasing age, duration of anesthesia, lesser education, a second operation, postoperative infection and respiratory complications

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32
Q

What are the basic anesthesia strategies for the elderly?

A
  1. Using neuraxial/regional anesthesia when possible
  2. Avoid long-acting NMBD and reverse adequately
  3. Opioid sparing strategies
  4. Neutralization of stomach acid with non-particulates (Bictira)
  5. Consider using EEG based titration
  6. Avoid hypotension (Try to avoid massive drops in SVR)
  7. Pad skin and nerves
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33
Q

CO decreases as you age, how does this affect drug distribution/redistribution?

A

slower distribution to initial site of action
slower redistribution
slower distribution to metabolic organs

combined, this takes drugs longer to “kick in”

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34
Q

How does the NMJ change as you age?

A

Increased distance between the axon and motor end plate Decrease in: concentration of Ach receptors, amount of Ach in presynaptic vesicle and release of Ach upon neuronal impulse

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35
Q

T/F: anesthetic drugs that are not metabolized by the kidney/liver have little to no changes to their metabolism as we age

A

True

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36
Q

How does drug metabolism that are dependent on the kidneys/liver change as you age?

A

Drugs dependent on this route of metabolism have: a prolongation of their effect, decreased need during maintenance phase and delayed recovery phase for non-depolarizers

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37
Q

If an elderly patient needs thoracic surgery, and has a history of poor exercise tolerance, CAD, DM or CHF, what would the next appropriate step be prior to surgery?

A

Myocardial perfusion imaging. If low risk is confirmed, proceed with surgery, if increased risk is confirmed, proceed with coronary angiography

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38
Q

How man total lung subsegments are there?

A

42

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39
Q

How many lung subsegments are in each lobe of the lungs?

A

LUL = 10
LLL = 10
RUL = 6
RML = 4
RLL = 12

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40
Q

If you preop FEV1 is 80%, and take out the entire right lung, what is the predicted FEV1?

A

20/42 = 0.476
80 x (1 - 0.476 / 100) = 0.4192 or ~42% FEV1

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41
Q

At what predicted FEV1 after thoracotomy would allow for extubation in the OR?

A

40% or greater

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42
Q

At what predicted FEV1 after thoracotomy would you require a V/Q scan, DLCO and consideration of other associated diseases before extubating in the OR?

A

FEV1 of 30 - 40%

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43
Q

At what predicted FEV1 after thoracotomy would you likely not extubate in the OR and send to ICU for staged weaning from the ventilator?

A

FEV1 of less than 30%

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44
Q

If FEV1 is greater than 20% after surgery, what intervention would potentially allow you to extubate?

A

Thoracic epidural analgesia

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45
Q

How many patients develop nosocomial infections?

A

~ 1/31 patients

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46
Q

What 2 sources have the highest incidence rate of nosocomial infections?

A

SSIs and hospital acquired PNA

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47
Q

What are the most “contaminated” or dirty environments on the patients skin?

A

Inguinal, perineal and axillary areas

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48
Q

What type of bacteria is most likely to migrate from the skin into the body (assuming a route to get into the body is present)?

A

Coagulase-negative Staphylococci

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49
Q

What percentage of nosocomial infections occur in surgical patients?

A

38%

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50
Q

What type of SSI is just in the area of the incision?

A

Superficial incisional

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51
Q

What type of SSI is beneath the incision area and is in the muscle and/or tissues surrounding muscles?

A

Deep incisional

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52
Q

What type of SSI is any area other than skin and muscle and includes organs or space between organs.

A

Organ or space SSI

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53
Q

What types of bacteria are common sources of an SSI?

A

Staphylococcus
Streptococcus
Pseudomonas

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54
Q

What type of wound is not inflamed or contaminated; don’t involve internal organ

A

Clean

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55
Q

What type of wound has no evidence of infection; but does involve internal organ(s)?

A

Clean-contaminated

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56
Q

What type of wound does involve internal organ with spillage of contents from the organ?

A

Contaminated

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57
Q

What type of wound is a known infection ad the time of surgery?

A

Dirty

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58
Q

What length of surgery increases SSI risk?

A

Surgery greater than 2 hours in length

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59
Q

What 2 types of surgery increase SSI risk?

A

Emergency and abdominal surgery

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60
Q

Approximately how many SSIs are preventable?

A

About half

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61
Q

List the grading categories of evidence for SSI prevention

A

1A: strongly recommended; moderate-to high quality of evidence

1B: strong recommendation; low quality evidence

1C: strong recommendation required by state/federal regulation

II: weak recommendation;

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62
Q

What SSI strategies are 1A level of evidence?

A

Perioperative control of BG, keep BG under 200, maintain normothermia, use an alcohol based antiseptic for skin preparation, and if pulmonary function is normal increase FiO2 after extubation (this step is controversial, see slide 24)

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63
Q

What is the most common indication for a total knee arthroplasty revision?

A

Infection

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64
Q

What is MIC?

A

Minimum inhibitory concentration of ABX in the serum and tissues

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65
Q

Why should you give ancef within 30 minutes of incision and not 1 hour?

A

If you give it 1 hour before, you will likely have to redose during the surgery

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66
Q

What are the general principles when choosing an anti-biotic?

A
  1. should be active against common surgical wound pathogens
  2. proven efficacy in clinical trials
  3. must achieve MIC in the serum and tissues
  4. shortest possible course effective….ideally 1 dose
  5. newer antibiotics reserved for resistant infections
  6. if everything equal: give oldest/cheapest
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67
Q

What antibiotics should be given within 2 hours of first incision, not 15 - 60 minutes?

A

Vanco and fluoroquinolones

So they are usually given in pre-op. Also of note, on the SCIP powerpoint slide 10, Cornholio says Clindamycin (a macrolide) is another antibiotic that is given with 2 hours of incision

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68
Q

What must be done with ABX prior to tourniquet use?

A

The antibiotic must be completely infused prior to tourniquet use

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69
Q

What is the general redosing interval for ABX?

A

2 half lives or excessive blood loss. May also be redosed s/p CBP

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70
Q

What are some beta lactam ABX?

A

Penicillins
Cephalosporins
Carbapenems

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71
Q

Gentamycin is what class of antiobiotic?

A

Aminoglycoside

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72
Q

Cipro is what class of antibiotic?

A

Fluroquinolone

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73
Q

How do penicillins/beta lactams work?

A

Inhibit bacterial cell wall synthesis

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74
Q

What is the DOC for streptococci, meningococci, pneumococci?

A

Penicillins-beta lactams

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75
Q

Penicillin G, Methicillin, Nafcillin and Amoxicillin are what class of ABX?

A

Penicillins-beta lactams

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76
Q

What bacteria are commonly causative agents for skin infections, catheter infections or URIs?

A

Gram + bacteria like streptococci, meningococci, pneumococci

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77
Q

What antibiotic class is the DOC for surgical prophylaxis?

A

Cephalosporins

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78
Q

Cefepime is what generation of cephalosporin?

A

Gen 4

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79
Q

Ceftriaxone (Rocephin), Ceftazidime (Fortaz) and Cefotaxime (Claforan) are what generation of cephalosporin?

A

Gen 3

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80
Q

Cefuroxime (Zinacef), Cefoxitin (Mefoxin) and Cefotetan (Cefotan) are what generation of cephalosporin?

A

Gen 2

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81
Q

Cefazolin (Ancef) is what generation of cephalosporin?

A

Gen 1

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82
Q

What generations of cephalosporins may be able to cross the BBB?

A

Gen 3 and 4

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83
Q

Anaphylaxis to what antibiotic class increases the chances of a reaction to a cephalosporin?

A

Penicillin

84
Q

What antibiotic(s) is indicated if you have a true anaphylaxis allergy to cephalosporins?

A

Vancomycin or clindamycin

85
Q

What class of antibiotics are effective against gram - rods such as enterobacter or P aeruginosa?

A

Carbapenems

86
Q

What are our last line agents for intra-abdominal, resistant UTI’s and PNA’s?

A

Carbapenems

87
Q

T/F: Most carbapenems penetrate the BBB?

A

True

88
Q

What medication may be a contraindication to using a carbapenem?

A

Valproic acid (Depakote) as carbapenems can decrease it up to 90%

89
Q

IM formulations of carbapenems have what allergy concern?

A

LA allergies as they contain lidocaine (so amide allergy concerns)

90
Q

What type of bacteria does vancomycin work well against?

A

Gram + (vanco is too large to penetrate gram - walls). It also only works if the bacteria is actively dividing

91
Q

What infections is vancomycin particularly useful for?

A

Blood stream infections and endocarditis caused by MRSA

92
Q

What antibiotic class inhibits ribosomal proteins and causes mRNA to be misread?

A

Aminoglycosides

93
Q

What antibiotic class has a very long half life?

A

Aminoglycosides

94
Q

Aminoglycosides have a synergistic effect with what antibiotic classes?

A

Beta lactams and vancomycin (very useful in enterococcal endocarditis)

95
Q

What s/e are common to aminoglycosides?

A

Ototoxicity (very common), nephrotoxicity and a curare like effect

96
Q

What antibiotic class inhibits DNA protein synthesis?

A

Fluoroquinolones

97
Q

Fluoroquinolones are good for what kinds of organisms?

A

Gram -. Common in GU surgery, UTIs, bacterial diarrhea and bone/joint infections

98
Q

What antibiotic class can prolong the QT interval and cause cartilage damage/tendon rupture?

A

Fluoroquinolones

99
Q

What antibiotic is an Antiprotozoal /Anaerobic antibacterial?

A

Metronidazole

100
Q

What antibiotic works by forming toxic byproducts that cause unstable DNA molecules?

A

Metronidazole

101
Q

What is metronidazole generally indicated for?

A

Intra-abdominal infections
Vaginitis
C-diff

102
Q

What antibiotic can cause peripheral neuropathy and have a disulfiram-like effect with alcohol?

A

Metronidazole

103
Q

If ancef is contraindicated d/t allergy concerns for cardiac/vascular/thoracic surgery, what are the secondary antibiotic options?

A

Clindamycin or vancomycin

104
Q

What was the original goal of the SIP?

A

Decrease morbidity and mortality of SSI

105
Q

What are the performance measures of the SIP?

A

Proportion of pts who get abx started within 1 hr of incision

Proportion given abx regimen consistent with guidelines

Proportion of pts whose abx is discontinued within 24 hrs of surgery stop

106
Q

Explain the reasoning for this: For the SIP goals, we want to start ABX early/often, but stop them in a timely manner, generally within 24 hours.

A

Appropriate timing/dosing of ABX can reduce SSI incidence, but we also want to limit duration to reduce the chances of bacterial resistance

107
Q

What is the primary goal of the SCIP?

A

To reduce surgical mortality/morbidity

108
Q

In general, what timeframe do we stop antibiotics? What is the exception?

A

Within 24 hours. The exception is cardiac surgery which is within 48 hours

109
Q

What is the timeframe to restart BBs for someone on chronic BB therapy?

A

Within 24 hours

110
Q

T/F: Razors are an appropriate measure to get rid of hair from the surgical site

A

False. Clippers only.

This is because razors can cause small wounds in the skin that allow for bacterial contamination.

111
Q

If there is not a reason to keep a surgical foley, when should it be dc’d?

A

On or before POD 2

112
Q

What are the SCIP BG goals for cardiac patients?

A

Get to or less than 180 within 18 - 24 hours after anesthesia ends

113
Q

What are the SCIP DVT measures?

A

SCDs placed during surgery for all procedures >/= 1 hr

Orders for appropriate DVT prophylaxis on the postoperative admission orders (Unless documentation criteria for not administering pharmacologic and mechanical prophylaxis)

RN administration of the appropriate DVT prophylaxis within 24 hours of surgery end

114
Q

What is the goal PACU temperature after surgery?

A

Greater than 96.8 (or rather, goal temperature greater than 96.8 within 15 minutes of leaving the OR)

115
Q

What is the temperature difference from axillary vs an oral/core temperature?

A

A 0.5 - 1 degree F difference, axillary is cooler relative to oral/core

A temporal temperature is similar to the axillary temperature in that it is also 0.5 - 1 degree F lower than an oral/core

116
Q

What ingested material(s) requires a minimum 4 hour fasting period?

A

Breast milk

117
Q

What ingested material(s) requires a minimum 6 hour fasting period?

A

Infant formula, non-human milk and a light meal

118
Q

What ingested material(s) requires a minimum 8 hour fasting period?

A

Fried foods, fatty foods and meat

119
Q

What are 4 basic goals to accomplish in pre-op?

A

Perform an H/P, ensure NPO status, explain the anesthesia choice and what to expect in the OR, set expectations for post-op recovery/pain control

120
Q

What are the 2 big patient complaints from surgery?

A

Pain and N/V

121
Q

If a patient has been on bowel prep, approximately how much fluid do you add to their fluid deficit?

A

2 - 3L

122
Q

4-2-1 refresher: what is the fluid replacement rate for a 135 kg patient?

A

(4 x 10) + (2 x 10) + (1 x 115) = 175 ml/hr

123
Q

How much fluid is lost d/t insensible losses?

A

4 - 8 ml/kg/hr

124
Q

What is the ratio of fluid to replace blood loss?

A

3 ml of crystalloid per 1 ml of blood lost, or 3:1

125
Q

What class of medications act on both the spinal cord and the brain to mitigate pain?

A

Opioids and A2 agonists

126
Q

What is the standard concentration of IVP precedex?

A

4 mcg/ml

127
Q

What are the 2 primary concerns with Toradol administration?

A

Bleeding and kidney injury

128
Q

Why does NGT suction not prevent/reduce aspiration events?

A

Studies showed prophylactic NGT suction does not reduce aspiration events, furthermore, you can still aspirate because the NGT keeps the esophageal sphincter open

129
Q

PONV prophylaxis refresher: what are the risk factors for PONV?

A

Female, non-smoker, young, length of anesthesia, opioid use and history of PONV/motion sickness

130
Q

At what risk level of PONV is the use of 2 or 3 agents from different classes warranted to prevent PONV?

A

High risk for PONV

131
Q

(Because my fish brain struggles to remember acronyms) what does ERAS stand for?

A

Enhanced Recovery After Surgery

132
Q

What are the pre-op “must haves” for ERAS?

A

Pre-Operative- Formal, pre-surgical patient education and/or counseling

Risk assessment – intervention with standardized optimization

133
Q

What are the Intra-op “must haves” for ERAS?

A

Limited fasting, carbohydrate rich drink up to 2 hrs before surgery

Opioid sparing, multimodal analgesia that continues through discharge

134
Q

What are the post-op “must haves” for ERAS?

A

Ambulation w/in 8 hrs of surgery stop time

Formal discharge education that includes incision care and mobility recommendations

135
Q

Should education about a surgery vary based on the surgeon?

A

No, it should be formal patient centered and remains consistent regardless of the surgeon

you MUST document the educational process

136
Q

The STRONG for Surgery checklist mentions 4 things a patient should do to prep for surgery, what are they?

A

Eat well, quit smoking, control your BG and ensure the healthcare team knows about all medications you are taking

137
Q

What interventions may be warranted if you Hgb drops below 11.5 prior to surgery?

A

Start iron and/or EPO (erythropoietin)

138
Q

At what BMI is surgery generally avoided?

A

A BMI greater than 40

139
Q

What is required during the intra-op phase by (think newer school of thinking)?

A

Limit fasting and carb rich beverage up to 2 hours prior to surgery and use opioid sparing multimodal analgesia

140
Q

List the steps of the catabolic pathway

A

Post op lean tissue loss -> increase in IL 1 and IL 6 -> increase in cortisol, glucagon and GH -> catecholamine surge -> increase in gluconeogenesis -> decreased glucose uptake -> immunosuppression and insulin resistance

141
Q

CHO loading (carb loading with carbohydrate drinks) resulted in what post-operative events?

A

Improved insulin resistance, improved patient comfort (less thirst, hunger), no conclusions on preservation of muscle mass, no aspiration events and “probably safe”

142
Q

Based on the Penn neurosurgery ERAS multi-modal protocol, what medication is given in pre-op only?

A

Gabapentin

143
Q

What are the “suggested” post-op phase goals?

A

Early nutrition (eat in chair, not bed), post-DC call within 7 days (discuss pain, concerns, incisions and clarify post-op instructions) and a follow up clinic visit within 14 days

144
Q

What type of crystalloid should we generally avoid giving in the OR?

A

NS

145
Q

What is the Clearsight monitor?

A

A non-invasive BP cuff that sits on your finger and mimics an arterial line

146
Q

What have recent studies shown occur if a patient is not ordered a bowel prep prior to a surgery that normally uses one?

A

They have an earlier return of bowel function, shorter hospital stay with no difference in the rate of anastomotic leaks or wound infections

147
Q

Carbohydrate loading up to 2 hours prior to surgery is associated with what outcomes?

A

Rate of pulmonary aspiration has not increased
Reduced thirst, hunger, anxiety
Reduced insulin resistance
More muscle strength and lean body mass
Accelerated recovery
Shorter hospital stay

148
Q

What regional anesthesia may be helpful in thoracic surgery?

A

Erector spinae or a TAP block

149
Q

What regional anesthesia may be helpful in abdominal surgery?

A

a Quadratus lumborum or TAP block

150
Q

The multi-modal PONV prophylaxis chart says medium risk dictates use of how many interventions? High risk?

A

Medium = 1 - 2 interventions
High = 2+ interventions

151
Q

What does standard 2 of the PACU dictate that anesthesia staff must do?

A

A member of the anesthesia team who is knowledgeable about the patient’s condition must accompany the patient to PACU

152
Q

What should be done with the patient upon arrival to PACU?

A

Assess the airway, vitals, mental status, pain and PONV. If hypoxemic assess and treat. Connect to the PACU monitors

153
Q

What are some common causes/risk factors for hypoxia in the PACU?

A

Room air, Obesity, Sedation, Respiratory rate, advanced age (> 60)

154
Q

How many phases of recovery are there in the PACU?

A

2

155
Q

What phase is the immediate post-op recovery phase?

A

Phase I

156
Q

How is phase I different from phase II?

A

It is the more “intense” phase, vitals and airway patency are rigorously monitored. If intubated, neuromuscular function is also monitored.

157
Q

How frequently are VS done during phase I?

A

q5m for the first 15 minutes, then q15m throughout phase I

158
Q

What are the 3 primary scores used to determine if the patient is appropriate for d/c from phase II?

A

Standard Aldrete Score.

Modified Aldrete Score.

Postanthesia Discharge Score.

159
Q

What factors does the standard aldrete score measure?

A

Activity, respiration, circulation, consciousness and oxygen saturation

all are scored on a scale of 0 - 2, the higher the score the safer the patient is for D/C

160
Q

Determine the standard aldrete score: The patient is moving their legs, is shallowly breathing, pre-op BP was 130/80 and is currently 118/65, is arousable and is currently 94% on RA

A

7

161
Q

Determine the standard aldrete score: The patient is not moving, has a poor respiratory drive, the current BP is 102/55 and was 157/78 in pre-op, is arousable and is satting 91% on 15L NRB

A

4

The respiratory drive, though poor, is still breathing so the get a score of 1 for respiration

162
Q

What does the post-anesthesia discharges scoring system measure?

A

VS (BP/HR), activity, N/V, Pain and Bleeding

163
Q

Determine the post-anesthesia discharge score: BP and HR are 92/40 and 55, in pre-op it was 101/55 and 62, has no trouble ambulating, is nauseous but not vomiting with PO zofran, reports that the PO pain meds are not adequate and you have had to change the surgical dressing twice

A

8

164
Q

Determine the post-anesthesia discharge score: BP and HR are 127/91 and 88, pre-op they were 166/87, patient needed help to get to the bathroom, reports recurrent nausea with PO and IM medication, says pain is acceptable and has required 1 dressing change

A

6

165
Q

How does phase II differ from phase I?

A

Vitals taken every 30 - 60 minutes.
Monitor:
Airway and ventilation status.
Pain level & PONV.
Fluid balance.
Integrity of the wound.

166
Q

Per lecture, what are the 3 most common complications in the PACU (reference slide 24)?

A

N/V, upper airway support is needed and hypotension

167
Q

Other than a history of HTN, what are some common reasons for HTN in the PACU?

A

Pain and urinary retention

168
Q

What pharmacologic intervention could help resolve airway obstruction without giving a paralytic?

A

A small dose of propofol

Have a low threshold for further intervention, if you give the low dose propofol, and are even slightly uncomfortable with how the patient is breathing, continue scaling up interventions

169
Q

What are the patient related risk factors for airway complications?

A

COPD, Asthma, OSA, obesity, heart failure, Pulmonary HTN, Upper respiratory tract infection, tobacco use, & higher ASA score.

170
Q

What are the procedure related risk factors for airway complications?

A

Surgery near diaphragm, ENT procedures, severe incisional pain, IV fluids, long procedure (3 hours).

171
Q

What are the anesthetic related risk factors for airway complications?

A

General, muscle relaxers, administration of opioids.

172
Q

What are the common causes of airway obstruction? Treatment?

A

Cause = loss of pharyngeal muscle tone and paradoxical breathing (chest wall moves in on inspiration and out during expiration)

Tx: Jaw thrust, continuous positive airway pressure and an OPA/NPA

173
Q

Common causes of laryngospasms?

A

Stimulation of pharynx or vocal cords.

Secretions, blood, foreign material.

Regular extubations.

174
Q

Other than hypoxemia and loss of the airway, what is a major concern of a laryngospasm?

A

Negative pressure pulmonary edema

175
Q

What is the timeframe for negative pressure pulmonary edema to resolve?

A

Generally in 12 - 48 hours

176
Q

What is the most common cause of negative pressure pulmonary edema?

A

Laryngospasm, followed closely by breathing against a closed airway tube (think the patient trying to breath while biting on the tube)

177
Q

The stimulation of what nerve can cause exaggerated closure of the glottis?

A

The superior laryngeal nerve

178
Q

What early s/sx can indicate laryngospasm?

A

Early = faint inspiratory stridor d/t increased respiratory effort and increased diaphragmatic excursion along with flailing of the lower ribs

later sign is “fish out of water”

179
Q

What steps do you take if laryngospasm occurs?

A

Get help in the OR,
Apply the facemask on the patient with a very tight seal. 100% FiO2, close your APL valve to about 40 cm H2O. Do NOT squeze the bag - wait for them to breath.

Suction airway.

Chin lift/jaw thrust, oral or nasal airways.

Pressure on the “laryngospasm notch”.

180
Q

What is the primary risk of applying pressure to Larson’s point?

A

Jaw dislocation

Larson’s point is another name for the laryngospasm notch

181
Q

Describe how to apply pressure to Larson’s point to help treat a laryngospasm

A

Forcible jaw thrust with bilateral digital pressure resolves the spasm by clearing airway and stimulation.

Apply for 3-5 seconds, then release for 5-10 seconds, while maintaining tight seal with the facemask

182
Q

If you can’t break the laryngospasm, what are the appropriate next steps?

A

Atropine, Propofol, Succinylcholine.
Re-Intubate.

183
Q

Airway edema is generally associated with what?

A

Prolonged intubation or long surgical procedures in the prone or Trendelenburg position.

Cases with large blood loss = aggressive fluid resuscitation.

Facial and scleral edema alert the CRNA that the patient most likely has airway edema.

184
Q

If you suspect airway edema, what test should you do before extubating the patient?

A

ETT cuff leak test

185
Q

What surgeries carry the highest risk of airway hematoma?

A

Thyroid and carotid

186
Q

What physical s/sx may indicate an airway hematoma is forming?

A

Can see deviated trachea & compression of the trachea below the level of the cricoid cartilage.

187
Q

Treatment of airway hematoma?

A

Decompress the airway by releasing the clips or sutures on surgical incision, subcutaneous clot removed before attempting reintubation.

Re-intubate - have advanced airway equipment ready.

Surgical backup - tracheostomy.

Be very judicious if you release the surgical site, if you release sutures on a carotid and it opens up, you will bleed out very quickly

188
Q

Vocal cord palsy is associated with what surgeries?

A

Otolaryngologic surgery, thyroidectomy, parathyroidectomy, rigid bronchoscopy, over inflated ETT cuff

189
Q

Upon direct laryngoscopy, you notice the vocal cords appear wavy, what does this indicate?

A

There is loss of tension to the vocal cord, which indicates damage to the external branch of the superior laryngeal nerve

The cricothyroid muscle may also be paralyzed

190
Q

If bilateral recurrent laryngeal nerve damage has occurred, when are the vocal cords most likely to cause an obstruction?

A

During inspiration

191
Q

After thyroid surgery, can hypocalcemia occur?

A

24 - 48 hours post-op

192
Q

What are the 2 classic s/sx of hypocalcemia?

A

Chvostek’s sign = facial spasm
Trousseau’s sign = carpal spasm

193
Q

Per lecture, what evaluation of return of muscle function did Cornelius spend time explaining as a solid indicator of adequate reversal, though not definitive?

A

Holding up the head for 5 seconds

194
Q

What type of extubation should you avoid if a patient has a history of OSA?

A

Deep extubation - you want them as awake as possible

195
Q

What questionnaire evaluates sleep apnea?

A

STOP-BANG

196
Q

What does STOP-BANG measure (list out each part)?

A

S = snore
T = tired/sleepy during the day
O = observed a stoppage of breathing by someone else
P = pressure, HTN
B = BMI over 35
A = age over 50
N = neck circumference greater than 16 inches
G = gender, male

197
Q

What is low, medium, and high risk of OSA on the STOP-BANG?

A

Low = 0 - 2
Med = 3 - 4
High = 5 - 8

198
Q

What is the common cause of diffusion hypoxia?

A

Nitrous oxide

it dilutes alveolar gas, including oxygen which can decrease both PAO2 and PaCO2

199
Q

Why does diffusion hypoxia cause such profound hypoxia?

A

Because it dilutes oxygen (self explanatory why this is bad) but it also reduces PaCO2, which can depress the drive to breathe.

quite the double whammy

200
Q

In the absence of oxygen, how long does diffusion hypoxia generally persist?

A

5 - 10 minutes after DC of nitrous oxide

201
Q

What are some common causes of systemic HTN in PACU?

A

Emergence excitement, shivering, hypercapnia, pain, agitation, bowel distention, urinary retention

202
Q

Treatment of HTN in PACU?

A

Treat the underlying cause first (pain, agitation, full bladder etc), if you are confident there are no other underlying causes, then treat with: Labetalol, Hydralazine and/or Metoprolol

203
Q

What are the 3 most common drugs used to treat HTN in the PACU (include dosage range)? Which one can be given in consecutive doses in a short timeframe?

A

Labetalol 5 - 25 mg
Hydralazine 5 - 10 mg
Metoprolol 1 - 5 mg

Labetalol can have several doses in a short timeframe

204
Q

What type of hypotension is caused by decreased preload?

A

Hypovolemic

205
Q

What type of hypotension is caused by decreased afterload?

A

Distributive

206
Q

What type of hypotension

A

Semester 4 TxWes (2 decks)

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