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Semester 3 TxWes > Principles of Anesthesia Practice I Unit III > Flashcards

Principles of Anesthesia Practice I Unit III Flashcards

1
Q

What quick method of cylinder identification is required for gas cylinders?

A

Standard color identification

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2
Q

What are the non-liquified gases?

A

Oxygen, air and helium

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3
Q

What are the liquified gases?

A

Nitrous oxide and CO2

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4
Q

What is the definition of a liquified gas?

A

A gas that becomes liquid to a large extent in containers at ambient temperature and at pressures from 25-1500psi

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5
Q

What is the definition of a non-liquified gas?

A

Non-liquified gas: A gas that does not liquefy at ordinary ambient temperatures regardless of the pressure applied

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6
Q

What does the FDA, DOT and OSHA concern themselves with when it comes to gas cylinders?

A

FDA = purity, only so much detritus is allowed in each cylinder
DOT = marking, labeling, storage, handling
OSHA = employee safety

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7
Q

What components make up the body of the cylinder?

A

Steel, steel carbon fiber or aluminum body, flat or concave base and a neck with screw threads

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8
Q

What is the purpose of the check valve? What is it commonly made out of?

A

Attached to the neck, is made of bronze or brass and allows for refilling and discharge of gas

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9
Q

What is the purpose of the cylinder handle?

A

Opens/closes the cylinder

It is a requirement that a handle should be attached/close to every cylinder

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10
Q

What is the pressure relief device (safety relief)?

A

A vent that allows the cylinder contents to be released to atmosphere if pressure increases to dangerous levels

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11
Q

What are some examples of pressure relief devices?

A

A disc that bursts, a fusible plug that melts or a valve that opens

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12
Q

Describe how the pin index safety system works

A

Each cylinder has an arrangement of pins that only allow connections to the appropriate points. Such as oxygen have pins at positions 2 and 5, and N2O having pins at 3 and 5

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13
Q

What is the relationship of cylinder lettering to size?

A

A is the smallest and increases with subsequent letters, so A < B < C and so on

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14
Q

What are D cylinders commonly used for? E?

A

D = transport, E = commonly used on anesthesia machines

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15
Q

What happens to the pressure in a cylinder as the volume of a non-liquefied gas decreases?

A

Direct relationship; as the volume of a non-liquified gas decreases pressure will decrease (so as volume goes down, PSI goes down)

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16
Q

What happens to the pressure in a cylinder as the volume of a liquefied gas decreases?

A

There is a mix of liquid and gas in the cylinder. As you release gas, some of the gas will move from the liquid state to the gaseous state. PSI in the cylinder will NOT begin to drop until all the liquid gas is gone

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17
Q

What are the DOT requirements for gas cylinder quality/safety standards?

A

Service pressure
Test date
Diamond shaped label indicating hazard of gas…danger, warning, or caution
Name and address of manufacturer
Expiration date of contents

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18
Q

What are the basic cylinder standards?

A

Valves, regulators, gauges never come into contact with oils, greases, lubricants
Never subject to temps above 54 C (130F)
Connections always tight
Never cross use hoses, regulators, gauges
Markings, labels must not be altered
Cannot be dropped, drug, slid
Valve kept closed at all times
Properly secured to prevent fall

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19
Q

What are the basic requirements for storage rooms that house gas cylinders?

A

Adequate ventilation
Signs “no smoking” “no combustibles”
Not exposed to corrosive chemicals, fumes
Stored upright in bins
Full separated from empty
Wrapping, drapes undesirable

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20
Q

What steps should be taken before/during use of a gas cylinder?

A

Label, pin index holes, regulator, valve outlet inspected
Check if the tamper seal has been removed
Washer in place
Open valve before bringing cylinder to pt
Face valve outlet away from people
Open slowly
Check service pressure
Correct leaks if any

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21
Q

Describe how gas is delivered throughout the hospital (there are 3 primary points)?

A

Starts at central supply, when then sends it through piping at around 50 PSI which then arrives to the terminal units also at around 50 PSI

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22
Q

What is the basic location of a central supply for gas?

A

It is either outdoors in an enclosure or indoors in a secure area.

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23
Q

What are the requirements for a gas bank?

A

Must have 2 day supply and have a primary and secondary bank

the reserve supply may be in a secondary location

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24
Q

What size cylinders is gas supply generally stored in?

A

G or H cylinders that are refilled on site

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25
Q

Why is liquid supply of a gas generally more favorable to use?

A

Less expensive and more convenient to store, it is refilled from supply trucks and has no interruption to service in the hospital

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26
Q

What are the classes of piping?

A

Main lines: connect gas source to risers

Risers: vertical pipes connecting main line with branch lines on each level of the facility

Branch: sections supplying a room or group of rooms on one level of the facility

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27
Q

What are the requirements for area alarm systems?

A

Found in critical life support
areas
Alarms if pressure increases/decreases 20% from normal line pressure
Must be audible and visible
Must be labeled for gas and area
Must alarm in at least 2 places, usually Maintenance/engineering, and the affected unit

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28
Q

What are the terminal units?

A

The point in piped gas distribution where user connects/disconnects by hose

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29
Q

What system is used to make sure the terminal units are connected to the appropriate hoses?

A

The diameter index safety system (DISS) or quick connects (this is what you likely commonly used in the ICU)

this system works because the nipple and nut vary in bore/diameter of each individual connection for each gas

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30
Q

What is the advantage/disadvantage of quick connectors?

A

Pro = Quick connection with one or both hands without tools
Con = Leaks more

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31
Q

What are the 2 basic functions of a vaporizer?

A

To change a liquid anesthetic to a vapor and to add a controlled amount of that vapor to a fresh gas flow in the breathing system

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32
Q

Most modern volatiles exist in the liquid state at what temperature?

A

Below 68 F (20 C)

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33
Q

What creates vapor pressure?

A

The molecules of the gas colliding with the container walls

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34
Q

What is saturated vapor pressure?

A

When equilibrium is achieved from the liquid/gas phases of the volatile. The pressure comes from the vapor colliding with the walls of the container

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35
Q

What factors can changed the saturated vapor pressure?

A

The characteristics of the liquid and the temperature of the liquid

These factors are independent of atmospheric pressure

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36
Q

What are the definitions of partial pressure and volumes percent

A

PP = the pressure of a singular gas in a mixture of several gases
VP = is similar to above, but its the concentration of a gas in a mixture expressed as a percentage

VP = partial pressure / total pressure x 100%

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37
Q

What is the vapor pressure of Halothane (Fluothane)?

A

243

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38
Q

What is the vapor pressure of Isoflurane (Forane)?

A

238

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39
Q

What is the vapor pressure of Desflurane (Suprane)?

A

669

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40
Q

What is the vapor pressure of Sevoflurane (Ultane)?

A

157

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41
Q

What is the heat of vaporization?

A

The number of calories needed to convert 1 gram of liquid into vapor

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42
Q

What happens to the liquid as the equilibrium shifts to move more molecules into the gaseous state from the liquid state as gas is allowed to leave?

A

The liquid temperature drops causing vapor pressure to drop and the output of vapor decreases

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43
Q

What is specific heat?

A

The number of calories needed to raise the temperature of 1 gram of something by 1 degree C

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44
Q

What is the relationship of specific heat to the amount of heat absorbed?

A

The higher the specific heat, the more heat required to raise the temperature of the substance

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45
Q

What is the specific heat of water?

A

1 cal per gram

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46
Q

Why are materials with higher specific heat’s generally used when making the container to house a vaporizer?

A

Materials with higher specific heat minimize temperature variations

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47
Q

What is thermal conductivity?

A

The speed at which heat flows through a substance

The higher the thermal conductivity, the better the substance conducts heat, so a metal has high thermal conductivity

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48
Q

What metals, per lecture, have high thermal conductivity and therefore minimize temperature swings during vaporization?

A

Copper and aluminum

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49
Q

What is the most common vaporizer?

A

Concentration calibrated variable bypass

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50
Q

Where should the vaporizer be located?

A

Between the flow meter and common gas outlet

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51
Q

Why should the vaporizer not be downstream of the common gas outlet?

A

They are not calibrated for high flows of oxygen flush

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52
Q

How do you adjust how much anesthetic is delivered with variable bypass?

A

By adjusting the splitting ratio (the more you turn the knob from 0 to higher numbers you increase the splitting ratio)

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53
Q

How does a vaporizer compensate for temperature fluctuations as liquid anesthetic is converted into vapor?

A

As you lose liquid, the change in temperature causes the temperature compensating valve to move, this automatically changes the splitting ratio to compensate for the decrease in volatile being delivered by increasing the splitting ratio

as temperature decreases, vapor pressure decreases and less volatile gets delivered. The automatic increase in splitting ratio compensates

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54
Q

What color identifies Isoflurane, Sevoflurane and Desflurane?

A

Sevo = yellow
Iso = purple
Des = blue

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55
Q

It is highly unlikely to have the incorrect agent in a vaporizer, but what safety measure would indicate that this has occurred?

A

You would see 2 different vapor pressures on the monitor

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56
Q

What do you do to the vaporizer if the incorrect agent has been added to it?

A

It must be completely discarded/drained. Then run FGF until there is no vapor detected

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57
Q

What is the ideal FGF rate for variable bypass?

A

250 ml/min to 10 L/min

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58
Q

What happens with low flow rates in the vaporizer? High rates?

A

Low = The high density of volatile prevents upward movement of molecules
High = failure to saturate carrier gas

In both cases, lower levels of volatiles are delivered to the patient than what is dialed on the vaporizer

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59
Q

The pumping effect causes intermittent back pressure in the circuit. What 2 phenomena can cause this?

A

Positive pressure ventilation and the oxygen flush valve

more pronounced with low FGF, low dial settings and low levels of liquid in the vaporizing chamber

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60
Q

What measure helps attenuate the pumping effect?

A

Smaller vaporizing chambers, baffle systems, longer tube for the inlet of vaporizing chamber and the addition of a check valve

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61
Q

Throughout anesthesia, when is little to no rebreathing desired? When is rebreathing desirable?

A

No rebreathing = emergence
Rebreathing = induction

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62
Q

What is the relationship of FGF to inspired concentration?

A

High FGF - inspired concentration = the vaporizer setting
Low FGF - the inspired concentration is different than the vaporizer setting

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63
Q

What is the relationship of vapor pressure to barometric pressure?

A

They are independent of each other (because the vaporizer is generally calibrated to it’s anticipated altitude)

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64
Q

When is tipping most likely to occur?

A

When the vaporizer is incorrectly removed, transported or replaced

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65
Q

What occurs when tipping happens?

A

Excess liquid enters the bypass chamber which causes a very high output of volatile = the patient can get an overdose of volatile

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66
Q

Why is overfilling highly unlikely to occur in modern vaporizers?

A

Modern vaporizers have an overflow hole to allow excess volatile to drain

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67
Q

Common cause of vaporizer leaks?

A

Loose filler caps, drain valves or vaporizer/mounting bracket interface

when this occurs, there is usually an odor to the cause you can smell

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68
Q

What happens to the Fi if there is a vaporizer leak?

A

Fi is the inhaled concentration or fraction of the gas, if there is a leak, less gas gets to the patient and can result in patient awareness

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69
Q

What are the basic vaporizer standards?

A

Average concentrations +/- 20% of setting
Gas may not pass through more than 1 vaporizer
Vaporizer interlock
Output of vaporizer <0.05% in OFF
All control knobs move counterclockwise
Filling levels displayed

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70
Q

What are the mounting standards for vaporizers?

A

Detachable - Standard on most machines and the weight of vaporizer and “O” ring create seal

Locking lever on back (front for cannisters)

Easily removed and replaced (esp. for MH)

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71
Q

What device prevents more than 1 vaporizer from being turned on at one time?

A

The interlock device

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72
Q

Where would you find the holes for the pin index safety system?

A

On the cylinder valve positioned in an arc below the outlet port

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73
Q

What vaporizers include a transport dial to isolate the vaporizer and bypass chamber?

A

Some Drager vaporizers

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74
Q

When were the first anesthesia machine standards implemented? Last update?

A

1979 and last update was in 2005

American society for testing and materials oversees this

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75
Q

What are the basic functions of the anesthesia machine?

A

Provide accurate and safe gas delivery

Provide a means for ventilating patients

Provide electrical outlets

Provide a housing for monitoring devices

Provide storage/shelving

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76
Q

What functions are activated when the master switch is on?

A

Pneumatic and electrical functions
Activates alarms and safety features
Power-up protocol can be bypassed

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77
Q

What functions are not disabled when the master switch is turned off?

A

The battery charger, electrical outlets, oxygen flush valve and the auxiliary oxygen flow meter will all still function

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78
Q

What are the basic requirements of the power failure indicator? Recommendations for safe practice?

A

The alarm must be visual and/or audible. For safe practice, keep the machine plugged in with the battery backup fully charged

Duration of backup depends on power usage, such as are we manually ventilating or automatically ventilating

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79
Q

What is the primary purpose of the electrical outlets on the anesthesia machine?

A

To power anesthesia monitors. Any other appliances should be plugged into the main hospital outlets

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80
Q

What occurs if electrical requirements/demands exceed the anesthesia outlet?

A

Circuit breaker activates and the machine will turn off

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81
Q

What are the 3 pneumatic systems?

A

High pressure, intermediate pressure and low pressure

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82
Q

Where does the high pressure system receive gas and at what pressure?

A

From the cylinders at high variable pressure, around 2200 PSI

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83
Q

How does the high pressure system convert high pressure gas to a more manageable PSI?

A

Using the pressure regulator (1st stage regulator) to reduce it to a lower more constant pressure of ~45 PSI

Without the regulator, our flow would constantly be changing

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84
Q

We are required to have yokes for what gas cylinders?

A

Oxygen and nitrous

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85
Q

What are the basic functions of the hanger yoke?

A

Orients and supports cylinder

Provides a gas-tight seal

Ensures a unidirectional flow

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86
Q

What parts make up the hanger yoke?

A

Body - principal framework
Retaining screw - tightens cylinder (clamp)
Nipple - thru which gas enters machine
Index pins- prevents attaching an incorrect cylinder
Washer - forms seal between cylinder and yoke
Check valve assembly - ensures unidirectional flow

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87
Q

What is the purpose of the check valve assembly?

A

To prevent gas from exiting the machine when there is no cylinder in the yoke. It also prevents gas moving from a cylinder with higher pressure to one with lower pressure

The prevention of gas movement between cylinders only occurs if both cylinders have a yoke and are on

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88
Q

What is a monitoring requirement for each gas being supplied by the cylinders?

A

Each must have a cylinder pressure indicator

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89
Q

What is the mechanism that enables analogue pressure devices to monitor pressure?

A

Bourdon tubes - as pressure changes, it increases/decreases the curve of the tube. This change in curvature is transmitted to the gauge to give us a pressure reading

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90
Q

What are the 2 units of measurement that a pressure gauge may be calibrated to?

A

kPa - kilopascals
PSI - pounds per square inch

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91
Q

What areas of the anesthesia machine make up the intermediate pressure system?

A

Pneumatic part of master switch
Pipeline inlet connections and indicators
Piping
Oxygen pressure failure devices
Oxygen flush valve
Flow control valves

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92
Q

What is the PSI in the 1st stage regulator? In the pipeline?

A

1st = PSI of 45
Pipeline = PSI of 50 - 55

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93
Q

What is the intermediate pressure if the master switch is off?

A

Zero

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94
Q

What are 2 basic requirements for pipeline pressure indicators?

A

Indicator required for each gas monitored

Usually found on front of anesthesia machine

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95
Q

Why must the pipeline pressure indicator be upstream of the cylinder valve?

A

If both are open, and the indicator is downstream, you would get an adequate pressure reading until the cylinder is empty, meaning both the pipeline and the cylinder are empty and you have no backup

if the indicator is appropriately upstream, then as soon as you lose pipeline pressure you would see the alarm, start gas from the cylinder, then take the appropriate steps to fix the problem

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96
Q

How much pressure should the anesthesia machine piping be able to withstand?

A

4x the intended pressure

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97
Q

What is the acceptable leak rate inside the machine?

A

no more than 25 ml/min

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98
Q

At what PSI is the oxygen failure safety device tripped?

A

At PSI less than 30

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99
Q

What occurs if oxygen pressure drops below 30 PSI?

A

Nitrous use is decreased or stopped (if nitrous is running), 19% oxygen concentration is maintained, the alarm sounds within 5 seconds and continues until oxygen flow ceases

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100
Q

What are the basic requirements for the oxygen flush?

A

Operable with 1 hand
Single purpose
Self-closing
Designed to minimize accidental use
Have flow between 35-75 L/min

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101
Q

What are the risks of the oxygen flush valve?

A

Barotrauma and surgical awareness (the high flow rate dilutes the anesthetic)

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102
Q

What are the basic requirements for the oxygen flow knob?

A

It must be larger and fluted so that it looks and feels different from the other knobs

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103
Q

What regulates the flow of oxygen, air and other gases?

A

Flow adjustment control mechanisms - think knobs for the flowmeters

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104
Q

What components make up the low pressure system?

A

Everything downstream of flow control devices:
Flowmeters
Hypoxia prevention devices
Unidirectional valves
Pressure relief devices
Common gas outlet

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105
Q

What is the pressure in the low pressure system?

A

Variable, though should be slightly above atmospheric

Depends on flow from flowmeters and backpressure from breathing circuit

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106
Q

What tube is used in flowmeters?

A

A Thorpe tube

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107
Q

What makes up a Thorpe tube?

A

Smallest diameter at bottom
Free floating indicator
A stop at top of tube
A flow scale

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108
Q

What safety measures must be in place on a flow meter?

A

Marked with the appropriate color and chemical symbol

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109
Q

What pressure does the 2nd stage regulator maintain?

A

14 - 30 PSI (remember, 1st stage is about 45 PSI)
Smallest diameter at bottom
Free floating indicator
A stop at top of tube
A flow scale

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110
Q

Describe the general trend of gas movement in the anesthesia machine

A

It goes from bottom to top, and from left to right

this basic setup means that flowmeters should be placed on the right side

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111
Q

Why does flowmeter sequence matter?

A

Gas should flow from left to right; if a leak occurs in the gas to the far right, all gases behind it will fail/leak as well. So if oxygen is on the far left, and a leak occurs to the right, the patient may get a hypoxic gas mixture. If the oxygen is to the far right, and a leak occurs to the left, oxygen should remain unaffected

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112
Q

What is the mandatory minimum oxygen flow for the flow meter?

A

50 - 250 ml/min

only when the master switch is on

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113
Q

When does the minimum oxygen ratio activate when using oxygen and nitrous?

A

When the oxygen concentration drops below 25%

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114
Q

Where are the unidirectional valves located?

A

Between the vaporizer and the common gas outlet, upstream from the oxygen flush valve

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115
Q

In terms of unwanted pressure, what is the function of the unidirectional valves?

A

Lessens back pressure from flush or breathing circuit

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116
Q

Where would you find the pressure relief devices?

A

Near the common gas outlet.

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117
Q

What is the function of the pressure relief devices?

A

Opens to atmosphere and vents if preset pressure is exceeded

Limits ability of machine to provide adequate pressure for jet ventilation

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118
Q

What is the basic function of the common gas outlet?

A

Receives all gases from machine and delivers mixture circuit

should not be used for supplemental oxygen and should also be made difficult to disconnect

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119
Q

What is the definition of a ventilator?

A

Automatic device designed to provide/augment ventilation and oxygenation

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120
Q

What does the ventilator replace or override on anesthesia workstations?

A

The reservoir bag

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121
Q

What was the primary method of ventilation on older ventilators? What are its drawbacks?

A

Controlled mandatory ventilation (CMV)

It couldn’t provide high enough inspiratory pressure, couldn’t provide PEEP and offered only volume control ventilation

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122
Q

What type of ventilation has a decrease in Vt if the compliance of the breathing system decreases?

A

Volume control

volume is used to expand system, and if it takes more volume to overcome a less compliant system, you would lose volume

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123
Q

How do modern vents account for changes in volume delivered related to changes in system compliance?

A

By using pressure controlled ventilation

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124
Q

What is peak pressure?

A

maximum pressure during the inspiratory phase time

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125
Q

What is the relationship of FGF to Vt on older vents?

A

As FGF increases, Vt increased

newer vents divert excess FGF during inspiration

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126
Q

What is the time during which lungs are held inflated at a fixed volume/pressure?

A

The inspiratory pause time

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127
Q

What is the normal and inverse I/E ratios?

A

Normal = 1:2, inverse = 2:1

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128
Q

What allows excess gas to be sent to the scavenger during exhalation?

A

The spill valve

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129
Q

What allows the driving gas to exit the bellows housing?

A

Exhaust valve

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130
Q

What are the 2 primary factors that affect ventilation?

A

Compliance of the system and of the patient

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131
Q

Why does a leak decrease Vt?

A

The vent cannot compensate for a leak

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132
Q

What type of bellows is most common? Why?

A

Ascending; it’s harder to detect problems with descending (gravity will always pull it down), whereas if there is a problem with ascending you can clearly see the fail to rise

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133
Q

Describe when the bellows ascend/descend for ascending (standing) or descending (hanging) bellows

A

Ascending: rise on expiration, descend on inspiration
Descending: rise on inspiration, descend on expiration

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134
Q

What physiologic problems may occur if there is a hole in the bellows?

A

Alveolar hyperinflation/barotrauma

135
Q

What happens to the gas if the scavenging system is closed?

A

Waste gas is vented to the room

136
Q

What system uses 2 circuits in the ventilator? Which uses 1?

A

2 circuits = bellows
1 circuit = piston

137
Q

What are some of the basic characteristics of piston ventilators?

A

Mechanically driver motor, no driving gas, uses dramatically less gas and doesn’t alter Vt based on compliance (small piston chamber, accurate Vt, hidden on machine and very quiet)

138
Q

What are the primary problems with piston ventilators?

A

Refills even with disconnection and can entrain room air during leaks (which dilutes oxygen/volatiles)

139
Q

What is the most commonly used ventilator mode?

A

VC or volume control

140
Q

Describe VC ventilation

A

you use a set Vt, RR and I:2 ratio, and additional breaths are of the programmed Vt

141
Q

Describe PC ventilation

A

You use a set PIP, RR and I:E and the Vt changes with each breath d/t changes in resistance and compliance

can cause atelectasis and hypoventilation

142
Q

Describe how volume guarantee pressure control works

A

It’s a hybrid of VC and PC; it maintains Vt by adjusting PIP over several breaths, this prevents sudden changes to Vt d/t changes in compliance

143
Q

Describe AC ventilation

A

A determined negative pressure from the patient triggers each breath to a set Vt

144
Q

Describe intermittent mandatory ventilation

A

A mandatory number of breaths are set, but additional native breaths at a variable Vt are permitted. This can lead to breath stacking

145
Q

Describe SIMV

A

Synchronizes ventilator driven breaths with spontaneous breaths, acts as a backup to weaning the ventilator

146
Q

Describe pressure support

A

PIP and inspiratory time are set, but Vt is entirely reliant on native effort, so an apnea alarm is required

147
Q

What material are MRI compatible breathing systems generally made out of?

A

Aluminum

148
Q

What are some common reasons for ventilatory failure?

A

Disconnection from power supply
Extremely high FGF
Fluid in electronic circuitry
Leaking bellows housing

149
Q

2 common causes for loss of breathing system gas?

A

Failure to occlude spill valve or a leak in the system

150
Q

What are some common causes for incorrect settings on the vent?

A

Inadvertent bumping

Not adjusted for new case

Not adjusted for position/pressure changes

Ventilator turned off for xrays

151
Q

Pros/cons of the ventilator?

A

Pros: anesthesia can be lazy! In all seriousness, it allows anesthesia to focus on other tasks, decreases fatigue and produces a more regular rate/rhythm and Vt

Cons: loss of “feel”, older vents may lack desired mode, components are hard to clean/fix, not user friendly, noisy or too quiet, may require driving gas (expensive)

152
Q

What ppm would 100% oxygen be? 1%?

A

100% = 1,000,000 ppm
1% = 10,000 ppm

153
Q

What areas tend to have higher levels of trace gas concentrations?

A

Pediatric anesthesia, dental surgery and poorly ventilated PACUs

154
Q

What is the maximum concentration of trace nitrous oxide allowed in an OR? Dental facility?

A

OR = 25 ppm
Dental = 50 ppm

155
Q

Common causes of operating room contamination?

A

Failure to turn off vaporizer

Poorly fitting masks

Flushing circuit into room

Filling vaporizers…spills

Use of uncuffed ETT

Scavenging system leaks

156
Q

What are some of the health concerns related to exposure to trace anesthetic gases?

A

Spontaneous abortions
Spontaneous abortion in spouses
Infertility
Birth defects
Impaired performance
Cancer/mortality
Liver disease
Cardiac disease

157
Q

Describe a passive ventilation system

A

Attached to room ventilation system and as air flows it filters/gets rid of anesthetic gas from disposal tubing going from the anesthesia machine to the exhaust grill. While economic, it is less common than active ventilation

158
Q

Describe an active ventilation system

A

Attached to a central vacuum, it must be able to provide high volume of 30 L/min suction and needs plenty of suction outlets that are close to the anesthesia machine

159
Q

What work practices can help minimize trace gas contamination?

A

Ensure proper mask fit

Turn off gas flow (not vaporizer) during intubation

100% wash out at end of case

Prevent liquid spills

Place anesthesia machine as close to exhaust grill (passive system) as possible (and if present)

160
Q

What are some causes of hypoxic inspired gas mixture?

A

Incorrect gas in the pipeline
Incorrectly installed outlets
Oxygen tubing or hoses attached to incorrect flow meter
Incorrect cylinder attached to yoke
Incorrect cylinder - minimized from color standardization
Flow control malfunction
Leak in oxygen flow meter

161
Q

What are some causes of hypoventilation?

A

Insufficient gas (pipeline failure or cylinder being empty)
Obstruction
Leaks
Main machine power off
Breathing system leaks (from absorbent, connectors, gas sampling or general disconnect)

162
Q

What occurrence can block the inspiratory/expiratory paths?

A

Plastic from the mask or absorbent wrapping causing an occlusion

the example from lecture, is a common method of signaling the current circuit is clean is stuff some of the plastic that wrapped the mask into the mask itself. Some of that plastic can get into the circuit and partially block it

163
Q

Common hypercapnia causes related to the vent?

A

Hypoventilation
Absorbent failure
Excessive dead space
Defect coaxial system

164
Q

Common causes of anesthetic agent overdose?

A

Tipped vaporizer
Vaporizer accidentally on
Incorrect agent in vaporizer
Interlock system failure
Overfilled vaporizer

165
Q

When can inadvertent exposure to volatiles occur?

A

Change breathing system hoses and bag
Change fresh gas supply hose
Change absorbent
Use very high oxygen flows to flush machine
Remove vaporizers
Use axillary flowmeter for supplemental oxygen

166
Q

What type of vaporizer does not have a splitting ratio?

A

Bubble-through

167
Q

Why does CO2 insufflation of the belly cause an increase in BP?

A

It stimulates the release of catecholamines and vasopressin along with compression of the arterial vasculature

168
Q

What is the IAP goal?

A

Less than 20 mmHg, though ideally you want it closer to 12-15 to minimize side effects

169
Q

What are pulmonary effects of CO2 insufflation?

A

Increased PaCO2, decreased compliance by 30 - 50%, increased PIP, decreased FRC and development of atelectasis

170
Q

How does CO2 insufflation increase PaCO2?

A

Some of the gas gets absorbed by the body which then increases PaCO2. This increase plateaus in 10 - 15 minutes

171
Q

What is the difference in treatment of elevated PaCO2 d/t CO2 insufflation in the early vs late stage of a case?

A

Early = treat, such as by increasing minute volume
Late = you may elect to not treat it because you’ll be waking up soon and that elevated CO2 could help stimulate the drive to breathe

172
Q

What position should you get the patient into if a gas embolism is suspected?

A

Trendelenburg with left lateral tilt

173
Q

What steps need to be taken if subQ emphysema occurs?

A

In general, just monitor ventilation/oxygenation. The emphysema should be transient and resolve in 30 - 60 minutes

174
Q

Describe the gas lock phenomena

A

This is when the gas in the blood stream creates a barrier in the vena cava which decreases venous return

175
Q

What s/sx and clinical findings may support the diagnosis of gas embolism?

A

Tachycardia
Cardiac dysrhythmias
Hypotension with increased CVP
Millwheel murmur
Hypoxemia
Decreased ETCO2

176
Q

Treatment of a gas embolism?

A

Cessation of insufflation/release of pneumoperitoneum
Trendelenburg (with left lateral tilt), fluid bolus, 100% O2
Aspiration of air (requires a central line)
Vasopressor support

177
Q

At what IAP do hemodynamic effects begin to occur?

A

Greater than 10 mmHg

178
Q

What are some hemodynamic effects of elevated IAP? Treatment?

A

Decreased CO proportional to the IAP, increased arterial pressure and increased SVR/PVR

Tx = increase vapor, nitro, cardene or remifentanil

these CV effects are generally short lived and should not need drug intervention. If intervention is warranted, dose with care d/t the short lived nature of the CV effects

179
Q

Which of the following can affect cardiac arrhythmias: increased PaCO2, peritoneal stretch, electrocautery/stretch of the fallopian tubes

A

Peritoneal stretch and electrocautery/stretch of the fallopian tubes. You can treat the elevated HR with glycopyrrolate and try to limit insufflation pressure

180
Q

What is the common cause of a brachial plexus injury?

A

Overextension of the arm

181
Q

Most commonly injured nerve in lithotomy position?

A

Peroneal nerve

compartment syndrome is also a concern

182
Q

Why has laparoscopy become the first choice rather than laparotomy?

A

It has more rapid recovery, better maintenance of hemostasis, less risk, less pain, less PONV and less pulmonary dysfunction

183
Q

What is the most common injury from laparoscopy?

A

Intestinal injury (perforations, CBD injury). Other injuries: vascular injury, burns and infection

184
Q

Contraindications to laparoscopy?

A

Increased ICP, tumor, trauma, hydrocephalus

185
Q

Is LMA or GETA more common in laparoscopy?

A

GETA

186
Q

Is an OGT or NGT more common in laparoscopy?

A

OGT is more common

NGT can be warranted if needed post-op or if it is suspected it may take several days for the bowel to wake up/heal

187
Q

What are the SCIP goals mentioned in lecture?

A

Antibiotics within 1 hour of first incision, beta blockers within 24 hours (only if the patient is taking beta blockers), keep temp above 36 C and time out prior to incision

188
Q

List the breast surgeries from least to most invasive

A

Biopsy, lumpectomy/partial mastectomy, simple mastectomy, modified radical and radical mastectomy

189
Q

What type of breast surgery involves an excision of a breast lesion with margins?

A

Biopsy

190
Q

What type of breast surgery involves a partial mastectomy?

A

Lumpectomy

191
Q

At what lesion size is a partial mastectomy generally indicated?

A

2.5 - 5.0 cm

192
Q

What type of breast surgery involves the breast/nipple?

A

Simple mastectomy

generally indicated when there is no lymph node involvement or patient is a poor surgical candidate

193
Q

What type of breast surgery involves the breast, nipple, axillary lymph nodes and may or may not involved reconstruction?

A

Modified radical mastectomy

194
Q

What type of breast surgery involves the entire breast, lymph nodes and pectoralis muscle?

A

Radical mastectomy

195
Q

Why should a thorough evaluation of CV and pulm status be done prior to cancer-related breast procedures?

A

Because radiation/chemo can have negative impact on both systems.

pregnancy test is generally recommended as well

196
Q

What dyes can be used for SLN (sentinel lymph node) mapping?

A

Methylene blue (avoid in renal insufficiency)
Indigo carmine (avoid in sulfa allergy patients)
Lymphazurin (the preferred agent)

197
Q

What breast reconstruction is done below the scapula, involves muscle/skin and cut away as a pedicle graft and tunneled through the axilla?

A

Latissimus dorsi myocutaneous (LDM) or Lat flap

198
Q

What breast reconstruction is done with abdominal muscle, sub-q tissue/skin, remains attached to native blood supply with a mesh prosthesis to the abdomen?

A

Transverse rectus abdominus myocutaneous (TRAM) or Tram flap

199
Q

What breast reconstruction has skin and fat removed from the abdomen (without muscle) that denervates the abdomen?

A

Deep inferior epigastric perforators (DIEP)

200
Q

Primary indication for Nissen fundoplication?

A

To increase LES pressure related to complications from GERD

201
Q

Pre-op steps for Nissen fundoplication?

A

Identify which PPI they are on, whether or not they are on prokinetics and identify if there is documented history of esophageal hypderacidity

202
Q

Position for Nissen fundoplication?

A

Supine, low lithotomy or R T-burg

203
Q

Intraoperative concerns for Nissen fundoplication?

A

GETA via RSI, place an OGT, ensure appropriate pre-op meds given, SCIP antibiotics and ensure esophageal dilator is available

204
Q

What structures make up the triangle of Calot?

A

The cystic duct, the common hepatic duct and the inferior surface of the liver

important because the is the safest area for the surgeon to access the gallbladder

205
Q

What are the 5 F’s of cholecystectomy?

A

female, forty, fair, flatulent, fat

206
Q

Many cholecystectomy surgeries are emergent and therefore treated as what by anesthesia?

A

They are treated as if they are full stomach patients. Give prokinetics, Bictira can also help

207
Q

Positions for a cholecystectomy?

A

Supine, R T-burg with left tilt

208
Q

What is IOC in a cholecystectomy?

A

Intraoperative cholangiography

209
Q

IOC (Intraoperative cholangiography) may cause what as a side effect?

A

Sphincter of Oddi spasm - treat with glucagon

210
Q

ERCP may be required for what condition?

A

Choledocholithiasis

211
Q

Common reasons for a spleenectomy?

A

ITP (Immune thrombocytopenic purpura)

Lymphoma

Hemolytic anemia

Trauma

212
Q

What steps should be taken before a spleenectomy?

A

Ensure the patient has had pneumococcal, meningococcal, and H influenza vaccinations 1 week preop. Evaluate for the presence of LLL atelectasis (if this is present, it is a sign that the spleen is larger than anticipated)

213
Q

Position for a spleenectomy?

A

45 degree right lateral decubitus
Kidney rest, table flexed

214
Q

Common indications for a bowel resection?

A

Ulcerative colitis

Crohn’s disease

Diverticular disease

Cancers

Ischemic bowel

215
Q

What mu-opioid antagonist may be helpful in bowel surgery?

A

Entereg (Alvimopan)

In order to take advantage of this drug, it MUST be given before any other narcotic is administered. If appropriately given, this drug can decreased the GI related effects of narcotics

216
Q

What are the ERAS (early recover after surgery) goals of bowel resesction?

A

Pre-op warming, multi-modal pain/PONV control (Gabapentin, acetaminophen, scopolamine) and liquid carbohydrate drinks before surgery like Gatorade can help

217
Q

Position for bowel resesction?

A

Supine or low lithotomy

218
Q

What post-operative pain intervention can be helpful with bowel resection that also can avoid narcotic usage to minimize bowel “down” time?

A

A lumbar epidural

219
Q

Dehydration d/t fever and or N/V in appendicitis may result in what lab value changes?

A

Hemoconcentration and elevated BUN with a normal creatinine

220
Q

Position for an appendectomy ?

A

Supine with left arm tucked or T-Burg

221
Q

GETA concerns for an appendectomy?

A

Always consider full stomach/aspiration risk

222
Q

What bariatric surgery has slow weight loss? Fast?

A

Slow = Lap banding
Fast = Sleeve and bypass

223
Q

What bariatric surgery does not affect nutrients? Which does?

A

Does not = Lap banding and sleeve
Does = Bypass

224
Q

What bariatric surgery is easily removed/reversed? Not easily removed/reversed?

A

Easy = Lap banding
Not easy = Sleeve and bypass

225
Q

What bariatric surgery have suture lines?

A

Sleeve and bypass

226
Q

What are the indications for bariatric surgery?

A

BMI greater than 40, or BMI greater than 35 with comorbidities (HTN, DM, OSA, asthma among others)

227
Q

What pre-operative intervention, per lecture, is critically important in obese patients?

A

Ensure appropriate VTE prophylaxis

228
Q

Bariatric surgery position?

A

R T-burg with HOB elevated 30 degrees

229
Q

What type of induction is preferred in bariatric surgery?

A

GETA with RSI - obese patients do not tolerate supine position well and can easily become hypoxic

230
Q

When should the OGT be dc’d in bariatric surgery?

A

Before the stomach is stapled

231
Q

Common long term problems with bariatric surgery?

A

Diarrhea, dysphagia, protein malabsorption and vitamin malabsorption

232
Q

What vitamins/minerals are bariatric surgery patients at risk of being deficient in?

A

A, D, E, K, B12, calcium

233
Q

What factors can convert a minimally invasive abdominal surgery to full laparotomy?

A

Obesity

Adhesions

Bleeding

Unclear anatomy

Staple misfire

Inability to ventilate

234
Q

Indications for ex-lap?

A

Trauma
Abdominal catastrophes
Staging (staging of cancer)

235
Q

What are some of the primary intraoperative concerns during an ex-lap?

A

You need profound muscle relaxation and must keep them warm. An epidural placement may be very beneficial for pain control

236
Q

PONV risk factors in relation to gynecological surgery?

A

Female, Laparoscopy vs Laparotomy, opioids and volatiles

237
Q

What is the purpose of a D&C?

A

To remove the endometrial lining of the uterus. It may also diagnose/treat bleeding from uterus/cervix

238
Q

Position for D&C?

A

Lithotomy

239
Q

Intra-op concerns for a D&C?

A

GETA, no SCIP antibiotics, may be combined with other procedures (hysteroscopy or conization), may require Pitocin and may have bradycardia

240
Q

What is a D & E surgery?

A

Dilation and evacuation - aka abortion

241
Q

What are some of the variable factors for each state that can influence whether or not a D & E can be done?

A

Wait time, 20 - 24 weeks, may require counseling/waiting period and may require parental involvement.

242
Q

Where is Pitocin secreted from?

A

Neuro-hypophysis

243
Q

What other compound does Pitocin mimic?

A

Vasopressin (ADH) - both increase water reabsorption

244
Q

What can you use to inflate the uterus during hysteroscopy?

A

NS, LRS or sorbitol

the concern with sorbitol is it can cause sugar excess and may also cause a seizure

245
Q

The 2 primary anesthesia modalities for hysteroscopy?

A

Paracervical block or GETA

246
Q

Position for hysteroscopy?

A

Lithotomy

247
Q

What patient populations are urethral slings commonly performed on?

A

Older women who had numerous children or college athletes

248
Q

What is inserted during a sling procedure?

A

A prolene mesh

249
Q

Sling procedure patient position?

A

Lithotomy

250
Q

Patient position for condyloma?

A

Lithotomy

251
Q

What safety step must be taken for a condyloma?

A

Laser evacuation - so laser masks and ensure appropriate smoke evacuation

252
Q

What are the 3 types of vaginal prolapses?

A

Cystocele - anterior prolapse of the bladder into the vagina
Rectocele - posterior prolapse of the rectum into the vagina

Enterocele is also on the slide. That is a small bowel prolapse

253
Q

Intra-op considerations for vaginal repair procedures?

A

Lithotomy position, GA via ET or LMA, SCIP and a foley

254
Q

What are some of the considerations to robotic surgery?

A

Allows for 3-dimensional vision, improved dexterity but increased cost and longer operating time

255
Q

What are 3 important steps/safety measures for robotic surgery?

A

Keep the patient in the original position, good muscle relaxation and fluid restriction

256
Q

What are the pressures in the high, intermediate, and low pressure systems?

A

High = Starts at 2200 then via the 1st stage regulator PSI drops in the intermediate system

Intermediate = 1st stage regulator drops PSI to 45, or 50 - 55 PSI in the pipeline

Low = 2nd stage regulator maintains it at 14 - 30 PSI
(pressure in the low pressure system should be slightly above atmospheric and is variable)

257
Q

What type of anesthesia machines uses this flowmeter sequence?

A

Drager

258
Q

What type of anesthesia machines uses this flowmeter sequence?

A

Ohmeda

259
Q

What gases can act as driving gases for the bellows?

A

Air, oxygen or a mix

260
Q

What is the purpose of the pressure-limiting mechanism?

A

To limit inspiratory pressure, the general set-point is 10 cm H2O above peak pressure with desired Vt

261
Q

What breast reconstruction procedures keep the native vessels intact?

A

Lat flap (not on slide but mentioned in lecture) and Tram flap

262
Q

What puts you at risk for a weakened pelvic floor?

A

Delivery with a postponed repair, aging or prior pelvic surgery

263
Q

What are the 3 types of hysterectomy access?

A

Abdominal: via midline or Pfannenstiel incision
Vaginal
LAVH - laparoscopically assisted vaginal hysterectomy

264
Q

What is the basic difference between a Tram flap and a Diep flap?

A

A tram flap involves abdominal muscle, the Diep spares the abdominal muscle

265
Q

What is the TWA maximum concentration for halogenated agents in conjunction with other gases? When it is a halogenated agent alone?

A

Combined = 0.5 ppm
Halogenated agent alone = 2 ppm

266
Q

At what point does a decrease in GFR become symptomatic?

A

50% decrease

267
Q

What are the s/sx of moderate vs severe renal insufficiency?

A

Mod = increased Bun/Creat; anemia; decreased energy
Severe = profound uremia; acidemia; volume overload

268
Q

Normal Bun/Cr?

A

Bun: 8 - 18 mg/dL
Cr: 0.8 - 1.2 mg/dL

269
Q

What factors can elevate Bun even if the kidneys are healthy? When does kidney disease elevated Bun?

A

Exercise, steroids, dehydration. Bun is affected when GFR is 75% of normal or a 25% decrease in function

270
Q

What type of anemia is generally attributed to renal dysfunction?

A

Normochromic (normal color) normocytic (normal size) iron deficient anemia

271
Q

What causes HTN with renal disease?

A

Usually d/t the RAAS in over-drive

272
Q

What types of drugs are metabolized in the liver? Kidneys?

A

Lipid soluble and non-ionized = liver
Ionized and excreted unchanged = renal

273
Q

What drugs are listed as commonly being renally excreted?

A

Muscle relaxants (Pancuronium), H2 blockers, Cholinesterase inhibitors, thiazides, digoxin, many anti-biotics and drugs with metabolites (morphine/meperidine/ketamine/midazolam)

274
Q

What conditions paired with renal disease are of particular concern in regards to surgical mortality?

A

Cardiac/valve surgery, sepsis, crush injuries, toxins and NSAIDs

mortality rate can reach as high as 50%

275
Q

What protective steps are used for renal protection in high risk cases?

A

Maintain adequate fluid volume status, maintain RBF. Use of Mannitol, low-dose dopamine, fenoldopam, loop diuretics, bicarbonate drips can help maintain urine flow

276
Q

What drug can be used to help preserve renal function if exposed to a high dose of radiopaque dye?

A

N-acetylcysteine

277
Q

Indications for urological surgery?

A

Direct visualization of urethra, bladder, ureter and kidney

can help with biopsies/evaluate bleeding, retrograde pyelography, laser/retrieve stones, remove/treat stricture and resect masses

278
Q

Common position for urologic surgery?

A

Lithotomy position

watch for peroneal and femoral nerve injury. Watch fingers closely as well

279
Q

What is the name of the procedures that use a scope to evaluate the urethra, bladder or ureteral orifice?

A

Through urethra (urethroscopy)
Through bladder (cystoscopy)
Through ureteral orifice (ureteroscopy)

280
Q

Common indications for urethroscopy/cystoscopy?

A

Visualize the urethra and/or bladder d/t urinary symptoms (Pain, burning, hematuria, difficult urination)

Diagnosis: lesions, strictures (Dilate stricture, treat cystitis, stent placement, resect tumors)

281
Q

What is the procedure of choice for mid/distal ureter or bilateral stones?

A

Ureteroscopy

may incorporate laser technology

282
Q

How likely are men/women to develop kidney stones? reoccurrence rate?

A

Men = 10%, women = 5%. 50% chance of stones coming back

complication rate is low, perforation occurs 5% of the time, stricture formation less than 2%

283
Q

What is the MET (medical expulsion therapy) for kidney stones?

A

NSAIDs, aggressive fluids and calcium channel/alpha blockers

284
Q

What are the 3 choices of surgery to address kidney stones?

A

Stone basket/laser, SWL (shock wave lithotripsy) or percutaneous nephrolithotomy

285
Q

What type of stones does SWL work best on?

A

Best suited for small/medium intranephric stones

there is risk of kidney injury or sub-capsular hematoma

286
Q

What advantages does newer SWL have over the older?

A

Less pain and significantly less heat loss

287
Q

What are the absolute and relative contraindications to SWL?

A

Once again, I’m too lazy to type it all out

288
Q

What are some pre-op steps to consider before SWL?

A

Single IV, anxiolytic, SCIP antibiotics, be aware of an iodine allergy

289
Q

Intra-op strategy for SWL?

A

Can be local or GA, can be LMA vs ETT, minimal narcotics with newer SWL (almost no pain), may need an anti-emetic, eye covering for lasers and lead for providers

290
Q

When is percutaneous nephrolithotomy generally indicated?

A

For large intranephric stones

generally requires initial placement of ureteral stents and uses larger amounts of fluoroscopy. TUR syndrome a concern

291
Q

Pre-op and intra-op considerations for percutaneous nephrolithotomy?

A

Pre = single IV, anxiolytic and SCIP antibiotics
Intra = GETA, short NMBDs, lateral position, lead aprons and eye protection for lasers

292
Q

Describe an Orchiectomy

A

Almost always bilateral; spermatic cord is clamped, cut, and sutured (common with metastatic prostate cancer)

293
Q

Describe a hydrocelectomy

A

Wall of hydrocele excised and edges sutured to prevent recurrence

294
Q

Describe testicular torsion

A

Spermatic cord becomes twisted. Considered a medical emergency. Must be performed within 6 hours to prevent irreversible ischemic damage.

295
Q

Indications for circumcision?

A

Phimosis (can’t retract the foreskin) and to reduce penile/prostate cancer risk

296
Q

Describe a hypospadias repair

A

A surgery to correct a defect in the opening of the penis that is present at birth

297
Q

Describe a penectomy

A

Removal of tissue, usually cancerous in nature and may include inguinal lymph node biopsy

commonly a squamous cell carcinoma

298
Q

Common disease processes that can evetually cause indications for placement of a penile prosthesis?

A

DM or spinal cord injury

per lecture, take great care to be as sterile as possible with the implant

299
Q

Anesthesia considerations for penile operations?

A

Give anxiolytics, can be GETA or LMA, supine, a penile block can be used (pudendal nerve S2 - S4), SCIP - maintain sterility and manipulation of genitals can cause bradycardia

300
Q

What must be done after a radical cystectomy?

A

Either place an ileal conduit or a bladder substitution

301
Q

What would you want to know in pre-op before a cystectomy?

A

Know risk factors such as CAD or pulmonary disease. Get an EKG. Are they on anti-coagulants?

302
Q

Intra-op considerations for cystectomy?

A

GETA/SAB/Epidural, supine, SCIP.
Complications: blood loss up to 3L, have 2 IVs and type/crossmatch. 3rd space loss common as well as hypothermia

303
Q

Gold standard for BPH treatment?

A

Medical management, TURP if MM fails

304
Q

Most common population for TURP?

A

Males in 50s/60s, common comorbidities include obesity, HTN, CAD, and familial history of enlarged prostate is fairly common

305
Q

Pre-op/intra-op considerations for a TURP?

A

Pre-op: manage comorbidities, anti-coagulants and ensure a large bore IV
Intra-op: General/SAB, lithotomy position, be ready to transfuse blood and watch for TUR syndrome

306
Q

What is TUR syndrome?

A

Hypervolemic hyponatremia from irrigation fluid during a TURP/open resection of the prostate

307
Q

At what sodium levels do s/sx of TUR syndrome begin to develop?

A
308
Q

What are the types of irrigant used in TURP?

A

Saline (watch for volume overload and dispersion of current d/t the sodium)
Glycine - metabolized in liver, avoid in liver patients
Water - causes intravascular hemolysis
Sorbital - metabolized to CO2 and fructose. Can elevate BG and has seizure concerns

309
Q

At what rates does TUR syndrome become at risk to develop?

A

Irrigation rates of 300 ml/min
Absorption of 20 ml/min - 200 ml/min
Greater than 2L of absorption is usually required for TUR syndrome to develop

310
Q

What steps can you use to prevent TUR?

A

Limit resection to 1 hour, suspend the irrigating fluid to less than 30 cm above the table and treat hypotension from SAB with vasopressors

311
Q

Treatment of TUR syndrome?

A

ABCs, terminate procedure ASAP, consider invasive lines

312
Q

At what Na level does mild vs severe symptoms occur? Treatment of each?

A

Mild s/sx of Na of greater than 120, Tx = fluid restriction and loop diuretics

Severe s/sx of Na less than 120, Tx = 3% IV saline

313
Q

What are some basic steps to use for safety during a robotic prostatectomy?

A

Insert an arterial line, keep a neo drip on standby/ready and limit IV fluids (they are in very steep trendelenburg)

314
Q

Nephrectomy has a complication rate of about 20%, what are the common complications?

A

Peritonitis, acute renal failure, hernia, visceral injury, hemorrhage, pneumothorax

315
Q

What are the 3 types of nephrectomy?

A

Simple - (irreversible non-malignant disease, trauma or congenital disease)

Radical - includes the adrenal glands, common in renal cell carcinoma

Donor

316
Q

What conditions are commonly associated with contributing to the need for a nephrectomy?

A

CAD, ESRD and HTN

317
Q

Pre-op considerations for a nephrectomy?

A

Anxiolytics, SCIP, type/screen or cross and 2 large bore IVs

318
Q

Intra-op considerations for a nephrectomy?

A

GETA, consider arterial line and/or central line (ipsilateral side), epidural or other regional anesthesia to mitigate pain and have a variety of fluid resuscitation measures and diuretics available to keep the kidney(s) making urine (colloid, blood, rapid transfusion set up, mannitol, furosemide)

319
Q

What kidney is prefered for transplant? Where is it inserted?

A

The left kidney, and inferior to the native kidneys close to the iliac vasculature

left kidney preferred because it has more/longer vasculature to work with

320
Q

Why is a living kidney donor so advantageous?

A

It avoids the physiologic alterations from DBD or DCD, less to no waiting time and decreases ischemic time

321
Q

What does the anesthesia for the living donor encompass?

A

Starts a few hours prior to the recipients surgery (left kidney preferred), aggressive isotonic hydration (10 - 20 mlg/kg/hr) low level protamine reversal (you anti-coagulate prior to removing the kidney) and diuresis with lasix or mannitol to maintain 2 ml/kg/hr of urine flow

322
Q

What is Cushing’s sign?

A

HTN, bradycardia and widened pulse pressure

323
Q

What are the DBD physiologic alterations?

A

Neurologic instability (Cushings, ICP elevation)
CV instability - massive release of catecholamine, acute MI common and CV collapse
Pulm instability - neurogenic pulmonary edema and SIRS
Metabolic instability - dysfunction of hypothalamus/pituitary systems (thermoregulation, hormones, insulin, e-lytes and DIC are all concerns)

324
Q

In general, what type of drugs do you want to use for a cadaver donor when managing the CV system?

A

Drugs with a short half life

325
Q

In a cadaver donor with refractory bradycardia not responsive to anti-cholinergics, what would be the next DOC?

A

Isuprel (Isoproterenol)

326
Q

Other than hemodynamic management, what are some management strategies for anesthesia for cadaver donors?

A

Fluid resuscitate, avoid glucose containing solutions, PEEP/lung protective ventilation (6-8 ml/kg of IBW, 5-10 PEEP) and steroids to attenuate immune response

327
Q

What are the donor management goals?

A

Short version, is try to maintain everything as close to physiologically normal as possible

328
Q
A
329
Q

What is the ischemic time for a properly stored kidney?

A

48 - 72 hours (try to minimize because during ischemia the kidneys lack O2, deplete ATP/glycogen, the Na/K pump fails and intracellular Na increases causing intracellular edema)

330
Q

What conditions are very common in a patient getting a kidney transplant?

A

CAD and HTN (check for an EKG and/or hearth cath), DM is also very common. If they are on HD, check for their last date of HD

331
Q

Ideal NMBD for renal transplant?

A

Cisatracurium (nimbex)

ideal because its fairly short acting and metabolized by plasma cholinesterases

332
Q

What is the order to anastomose the renal vessels/ureters to the recipient?

A

Vein -> artery -> ureter

333
Q

What is an anti-thymocyte and what is it’s role in kidney transplant?

A

It’s an infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection

can cause cytokine release syndrome. No treatment, just manage symptoms of fever, chills and rigors

334
Q

Treatment of cytokine release syndrome related to infusion of anti-thymocytes?

A

Steroids (usually methylprednisolone), diphenhydramine and acetaminophen

Semester 3 TxWes (8 decks)

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