Unit 1 Flashcards
1
Q
What is NORA?
A
Non-operating room anesthesia
2
Q
Osteoporosis is related to what biologic factors increasing or decreasing?
A
Increase: Parathyroid hormone
Decrease: Vitamin D, growth hormone and insulin-like growth factors
3
Q
How does Fosamax (Alendronic acid) and Actonel (Risedronic acid) treat osteoporosis?
A
They are bisphosphonates which decreases the rate bone cells are absorbed
They can also treat Paget’s disease
4
Q
How does Boniva (Ibandronate sodium) treat osteoporosis?
A
It is also a bisphosphonate and inhibits osteoclast mediated bone resorption.
5
Q
How does Reclast (Zoleronic acid) treat osteoporosis?
A
It also inhibits osteoclast mediated bone resorption, but also induces osteoclast apoptosis
6
Q
What part of the femur is more at risk for fracture if osteoporosis is present?
A
Proximal femur
7
Q
In osteoarthritis, the loss of what causes inflammation in the joints?
A
Articular cartilage
8
Q
What is crepitance?
A
Crepitance is a grating or crackling sensation that can be felt or heard when a joint moves
9
Q
What 3 medication classes are commonly used to treat OA?
A
NSAIDS, Cox-inhibitors (usually celebrex) and opioids
10
Q
Describe the difference between Heberden and Bouchard nodes
A
Heberden = Swelling/spurring of distal interphalangeal joints
Bouchard = Swelling/spurring of proximal interphalangeal joints
11
Q
What is TENS?
A
Transcutaneous Electrical Nerve Stimulation
12
Q
What NSAID is commonly used to manage OA?
A
Meloxicam
13
Q
RA causes damage to what to cause bone erosion and cartilage destruction?
A
Joint synovial tissue and connective tissue inflammation/damage
14
Q
What joints are most commonly affected by RA?
A
The wrists and metacarpophalangeal joints
15
Q
T/F: Anorexia is commonly associated with RA
A
True
16
Q
On a lab draw, what would you expect to be elevated to diagnose RA?
A
Rheumatoid factor, Anti-immunoglobulin antibody, c-reactive protein and erythrocyte sedimentation rate
17
Q
What 3 medication classes are used to manage RA?
A
NSAIDs, opioids and Glucocorticoids (stress dose)
Glucocorticoids are drugs like Prednisone or Dexamethasone
18
Q
What are the medications listed in lecture that are commonly prescribed to RA patients?
A
Methotrexate (MTX)
Hydroxychloroquine
Sulfasalazine
Leflunomide
Infliximab (Remicade)
Etanercept (Enbrel)
19
Q
Why is RA a predictive factor for difficult intubation?
A
Limited TMJ movement
Narrowed glottic opening
Cricoarytenoid arthritis
Limited C-spine movement
20
Q
Atlantoaxial instability is common in RA, why is this a concern for anesthesia?
A
The limited/change in movement can displace the odontoid process (impinges on c-spine and the medulla) and can compress the vertebral artery
21
Q
What s/sx suggest atlantoaxial subluxation?
A
HA, neck pain, limb paresthesia with movement and bladder/bowel dysfunction
22
Q
What test can evaluate the severity of atlantoaxial subluxation?
A
C-spine flexion and extension x-rays
23
Q
If an RA patient reported N/V, dysphagia, blurred vision and transient LOC, what would be your first concern on a differential diagnosis?
A
Vertebral artery occlusion
24
Q
What is Sjogrens syndrome?
A
Dry mouth/eyes related to a chronic autoimmune process (for this unit, it’s related to RA)
25
What pulmonary concerns are common to RA?
Diffuse interstitial fibrosis and a restrictive ventilation pattern
26
What CV conditions are related to RA?
Vasculitis/vascular disease, pericarditis and cardiac tamponade
27
What is a GI and a renal concern in RA?
GI = ulcers
Renal = insufficiency
28
Orthopedic injuries are associated with what severe adverse outcomes?
Hemorrhage, shock and fat emboli. Full stomachs are a concern as well d/t emergent nature of the fixation/repair
29
What type of adverse outcome are you most concerned about affecting hemodynamics in a pelvic fracture?
Iliac artery injury causing a retroperitoneal bleed
30
What train of events from a long bone fracture can cause pulmonary collapse?
Long bone fractures -> bone marrow fat -> venous circulation -> thromboembolic hypoxic respiratory failure
31
What is the other name for cricoid pressure?
Sellick maneuver
32
What are the common induction and paralytic choices for trauma anesthesia?
Induction: Ketamine or etomidate
Paralytic: Sux or Roc
*The 2 goals are RSI and maintain CV stability here*
33
What are 3 common age-related pulmonary changes that we need to account for and may warrant further investigation in pre-op?
Progressive decreased PaO2
Increased closing volume
FEV1 decrease of 10% for each decade
34
What is the goal HR if a patient is on BBs?
Less than 80
35
What is a distinct benefit of pre-emptive analgesia?
It blocks progression of pain to chronic pain syndrome
36
What 2 fractures are commonly associated with fat emboli?
Pelvic and femoral
37
What is the triad of fat emboli?
Dyspnea, confusion and petechiae
38
What is the mortality of fat emboli?
10 - 20%
39
What lab findings would you expect with FES?
Fat macroglobulinemia, anemia, thrombocytopenia and elevated erythrocyte sedimentation rate
40
What is the normal erythrocyte sedimentation in men/women?
Male: 0 - 22 mm/hr
Female: 0 - 29 mm/hr
41
In FES, what pathology causes organ failure?
End organ capillaries obstructed by fat emboli & bone marrow particulates
42
In FES, systemic inflammatory response occurs because of what?
Inflammatory cell invasion
Cytokine release
Pulmonary endothelial injury
Pulmonary edema
ARDS (< 10% of cases)
43
What respiratory concerns are a result of FES?
Mild hypoxemia
Bilateral alveolar infiltrates
Dyspnea, edema
< 10% progress to ARDS
44
What neuro changes can occur in FES?
Drowsiness, confusion, obtundation, coma
45
In FES, where is the petechial rash most likely to occur?
Conjunctiva, oral mucosa, skin folds of the chest, neck & axilla
46
What are the "minor" features of FES?
Fever, tachycardia (generally greater than 120 bpm), jaundice and renal changes
47
What is the standard treatment of FES?
Early recognition
Stabilization of fracture
Supportive management: 100% Fi02; no N20
Aggressive and early Respiratory and Circulatory resuscitation
Minimize stress response R/T hypoxia, hypotension & decreased end-organ perfusion
Give Heparin IV
Symptoms resolve 3-7 days
48
Without appropriate prophylaxis, what is the incidence rate of DVT/PE?
40 - 80%
49
DVT/PE is of the highest risk in what 3 ortho procedures?
Hip surgery, TKA and lower extremity trauma
50
What is the primary concern with tourniquet use in ortho procedures?
Reduced limb blood flow causing venous stasis which increases DVT/PE risk
51
What is the standard timeframe to start LMWH for DVT prophylaxis?
12 hours pre-op or 12 hours post-op
52
When is it ok to perform neuraxial anesthesia if a patient is on LMWH?
10 - 12 hours after the last LMWH dose if on once daily dosing
53
If on twice daily dosing of LMWH, is use of a neuraxial catheter ok?
Generally no, if in use in the OR, you need to remove it 2+ hours before the first dose of LMWH
54
At what INR is neuraxial anesthesia ok to peform?
Less than 1.5
55
What physiologic factors decrease the DVT incidence when neuraxial anesthesia is used?
√ Increased lower extremity venous blood flow d/t sympathectomy
√ Systemic anti-inflammatory properties of local anesthetics
√ Decreased platelet reactivity
56
T/F: IV, topical and oral administration of TXA are all effective
True
57
What is the max dose of TXA?
2.5 gm
58
Dosing for TXA is variable, but what are commonly used dosages?
10, 15 and 30 mg/kg
59
How long after pneumatic tourniquet placement does pain begin to develop?
~45 minutes
60
What are the 2 primary advantages of pneumatic tourniquet use?
Decreases intraop blood loss and provides a bloodless field
61
What pressure is a tourniquet inflated to for a thigh? Arm?
Thigh = 100 mmHg or greater than SBP
Arm = 50 mmHg or greater than SBP
62
What is a common starting mmHg for upper and lower extremity tourniquet use?
Upper = 250 mmHg
Lower = 300 mmHg
63
What is the soft time limit for tourniquet use? Hard time limit?
Soft = 2 hours
Hard = 3 hours
64
What must be documented with tourniquet use?
Inflation time
Deflation time
Total inflated time
Inflation pressure & any adjustments
65
What risks do you run if tourniquet use is greater than 2 hours?
Nerve injury, ischemia, rhabdomyolysis and mechanical trauma
66
What strategy can minimize the risk of tourniquet use?
Deflate the tourniquet for 20 - 30 minutes to restore perfusion
67
Why does HR, BP and diaphoresis occur around 1 hour after pneumatic cuff inflation?
Either regression of the neuraxial block or the c-fibers are firing
68
If using a double cuff tourniquet, in what order do you inflate the cuffs?
Proximal followed by distal
69
What negative effects can occur after you deflate the cuff?
Metabolic acidosis
Hyperkalemia
Hypercarbia
Tachycardia
Hypotension
70
What disease process is the foremost medical condition leading to operations in the US?
Degenerative joint disease
71
Other than standard anesthesia pre-op assessment (vitals, airway etc), what should be assessed for prior to shoulder surgery?
Assess for pre-existing nerve conduction issues
72
What is of the utmost importance when it lateral decubitus and/or beach chair position?
Secure the head
73
What cardiac, respiratory and neuro changes would you expect with the sitting position?
Cardiac: blood pooling in the lower extremities should decrease CO, BP should decrease, and SVR/HR should increase to try and compensate
Pulm: Lung volumes and FRC increase
Neuro: CBF decreases (Keep that MAP up)
74
Venous air embolism is most common in what positions?
Sitting, prone and Rev T-burg
75
In general, the __________ is higher than the heart, there is the potential for air embolism?
The surgical site
76
How does an air embolism cause CV collapse?
It blocks the RVOT, so blood can't get into the pulmonary artery -> pulmonary edema and bronchoconstriction -> acute CV collapse
77
What is the standard VAE treatment?
Telling the surgeon so he can prevent the further entraining of air by irrigating and applying an occlusive dressing
Discontinue N20 if used.
Bilateral compression of jugular veins.
Placing the patient in a head-down position (to trap the air in the right atrial apex preventing entrance to the pulmonary artery)
Withdrawing air through a previously placed right atrial catheter (key here, a PREVIOUSLY place catheter, the evidence does NOT suggest placing a new one)
Cardiovascular collapse will need treatment with pressors
78
Where would you place a doppler ultrasound to detect a VAE?
2/3 intercostal space adjacent to the right sternum (this places you right over the right atrium)
79
What is the definitive test to detect a VAE?
TEE
80
What is the characteristic sound of a VAE?
Mill wheel murmur
81
What acute change on the monitor may indicate a VAE?
Sudden drop in ETCO2
82
Where would you level an arterial line for a shoulder case?
External meatus of the ear
83
Why is induced hypotension sometimes done for shoulder surgery?
To minimize bleeding to keep the field clear
84
How much does pressure decrease based on distance from the brain to the heart?
0.77 mmHg per cm of distance.
*if the distance is 20 cm, and BP is 120/80, then in the brain, its 105/65*
85
If the MAP is 70 in sitting position, what is the map in the head if the difference is 10 inches?
2.54 cm per inch, 10 x 2.54 = 25.4
25.4 x 0.77 = 19.5 (rounded) mmHg drop
70 - 19.5 = 51.5 mmHg
86
What is the Bezold-Jarisch reflex?
(exact MOA is murky), but common during spinal/regional anesthesia. It is a cardiac inhibitory reflex which causes marked hypotension, bradycardia, decreased preload and a hypercontractile ventricle
87
What changes in the CV system do you except in lateral decubitus?
Minimal to no changes in CO, though arterial BP may may fall as a result of decreased vascular resistance (right side > left side).
88
What pulmonary changes do you expect in lateral decubitus position?
Ventilated patients: Decreased ventilation of dependent lung (VQ mismatch); increased perfusion of dependent lung. (Further decreases in dependent lung ventilation with paralysis and open chest.)
Spontaneously breathing: Increased ventilation of dependent lung (no V/Q mismatch).
89
What strategy can you use to make sure the axillary roll does not cause a stretch/compression of the brachial plexus?
Place a pulse ox on the dependent hand and periodically check the pulse
90
How much should the tourniquet be inflated?
~100 mmHg above SBP
91
For elbow surgery using a tourniquet, what other anesthesia adjunct may be necessary?
A musculocutaneous nerve block
92
What 2 blocks may be helpful for a forearm and/or hand surgery?
Axillary block, Bier block
93
What are the advantages to neuraxial anesthesia in a hip fracture?
Decreased DVT & 1 month mortality
Shorter length of hospital stay
Lower incidence of delirium
Improved postop pain control
94
What are 3 potentially life threatening complications during total hip arthroplasty?
Bone cement implantation syndrome (BCIS)
Intra- and postoperative hemorrhage
Venous thromboembolism (VTE)
95
What are s/sx of BCIS syndrome?
Hypoxia
Hypotension
Arrhythmias
Pulmonary HTN
Decreased cardiac output
96
T/F: Paralysis is required if using GETA for a hip arthroplasty?
True
97
What cement is used for THA (total hip arthroplasty)?
PolyMethylMethAcrylate (PMMA)
98
Why is PolyMethylMethAcrylate (PMMA) useful for fixation in a hip fracture?
Results in intramedullary HTN
> 500 mmHg
Embolization of fat, bone marrow, or cement
99
What may happen if PMMA is systemically absorbed?
Vasodilation, decrease in SVR, platelet aggregation (r/t thromboplastin release) causing microthrombus and CV instability
100
BCIS syndrome treatment?
Increased FiO2
Maintain euvolemia
Manage hypotension with vasopressors
101
Most common complications of THA?
Cardiac events
PE
Pneumonia
Respiratory failure
Infection
102
Describe the positioning for hip arthroscopy
Supine, with legs spread and slightly elevated
103
What CV changes would you expect from hip arthroscopy positioning?
equalization of pressures throughout the arterial system
increased right-sided filling and cardiac output
decreased heart rate and peripheral vascular resistance (PVR
104
What respiratory changes would you expect from hip arthroscopy positioning?
Gravity increases perfusion of dependent (posterior) lung segments
abdominal viscera displace diaphragm cephalad
SV favors dependent lung segments, while CV favors independent (anterior) segments
FRC decreases (~800 mL) and may fall below CV in older patients, further exacerbated by an enlarged abdomen such as with obesity, pregnancy, or ascites.
105
What is the most common nerve injury?
Ulnar nerve d/t compression
106
What is the conscious sedation mix for hip dislocation?
Ketamine/propofol mix
*muscle relaxation with sux*
107
Standard positioning for knee arthroscopy?
Supine with knee flexed
108
What is the downside to using a spinal for knee arthroscopy?
It may delay discharge
109
What type of anesthesia is preferred for a total knee?
Neuraxial (Decreased 30-day mortality and Decreased infection rate)
110
What is the risk of using a tourniquet in a total knee?
Risk of peroneal nerve injury and significant post op pain
111
What are the 4 artificial components of a total knee?
1. Tibial component
2. Femoral component
3. Patellar component
4. Plastic spacer
112
What factors may increase the chance of wound infection in a total knee?
Poor peri-operative glucose control
Post-op hypoxia
Post-op hypothermia
113
What type of anesthesia is preferred for an ampuation?
Neuraxial
114
Describe post-op phantom pain
Onset within few days of surgery
Intermittent shooting, stabbing, squeezing, burning, throbbing pain
115
What causes phantom pain?
Remapping of circuitry
Damaged nerve endings
Scar tissue
Physical memory
Pain prior to amputation
116
Phantom pain treatment?
Biofeedback
Relaxation
Massage
TENS (transcutaneous electrical nerve stimulator) unit
117
What medications may treat phantom pain?
Neuroleptics
Antidepressants,
Sodium channel blockers
118
What are the 2 positions for an achilles repair?
Lateral or prone
119
What innervates the medial malleolus?
The Saphenous nerve
120
How many nerves are targeted in an ankle block?
5
121
What nerve is responsible for sensation to the plantar surface?
Posterior tibial nerve
122
What nerve innervates the interspace between the great and 2nd toes?
Deep peroneal nerve
123
What nerve innervates the dorsum of the foot and the 2nd - 5th toes?
Superficial peroneal nerve
124
What nerve innervates the lateral foot and lateral 5th toe?
Sural nerve
125
What does the deep peroneal nerve innervate?
The Interspace b/t great & 2nd toes
126
What does the superficial peroneal nerve innervate?
Dorsum of foot & 2nd – 5th toes
127
What does the sural nerve innervate?
Lateral foot & lateral 5th toe
128
What does the posterior tibial nerve innervate?
Sensation to the plantar surface
129
What spinal condition is most common in patients over 60?
Spinal stenosis
130
What spinal conditions are more common in patients under 60?
Degenerative spine disease & herniated disks
131
What 2 factors are classic presentations of scoliosis?
Greater than 10 degrees of lateral rotation of the spine along with vertebral rotation
132
A patient describe their pack pain is worse when walking and/or standing. What spinal condition do you suspect is the culprit?
Spinal stenosis
133
What condition describes a pinching of the nerve root?
Radiculopathy
134
What pulmonary changes would you expect with thoracic scholiosis?
Decreased chest wall compliance and restrictive lung disease/processes
*Chronic hypoxemia d/t V/Q mismatch*
135
What pulmonary vascular changes would you expect with thoracic scoliosis?
Cor pulmonale, RVH and right atrial enlargement
*Refresher, cor pulmonale is when the right side of the heart enlarges/fails d/t chronic lung disease processes*
136
Damage to what level(s) of the c-spine would cause any measure of diaphragmatic paralysis?
C3 - 5
137
What muscles are innervated by the same levels of the spine that the diaphragm is innervated by?
Deltoid
Biceps
Brachialis
Brachio-radialis
138
Spinal injury at/or above what level would cause physiologic sympathectomy?
T5 or higher
139
If a patient has hypotension, but not bradycardia after a T-spine injury, what level would you expect the spinal injury to be at?
T5
*Bradycardia occurs at injury to spinal levels of T1 - 4*
140
At what level of spinal cord injury does autonomic hyperreflexia (dysreflexia) occur?
At/above T5/6
141
What is the classic presentation of autonomic dysreflexia?
Full bladder, widespread HTN and bradycardia
142
With a T5 injury, describe the difference in SVR above/below the injury
Above = Cutaneous vasoconstriction, HTN, bradycardia and dysrhythmias
Below = cutaneous vasodilation
143
Other than spinal cord injury/insult, what are common causes of autonomic hyperreflexia?
Distended bladder/bowl or noxious stimuli
*Treatment = remove the stimulus, deepen anesthetic and use of vasodilators*
144
Respiratory failure correlates to what level of spinal cord injury?
C3 - 5
145
Impairment of abdominal/intercostal augmentation of respiration correlates to what level of spinal injury?
C5 - T7
*Likely going to have atelectasis, weak/no cough and inability to clear secretions*
146
What is the inability to maintain constant core temperature after spinal cord injury called?
Poikilothermic
147
What spinal misalignment pattern is more likely to create CV compromise?
Severe kyphoscoliosis
148
What are the 6 P's of a spinal assessment?
Pain, Pallor, Pulselessness, Paresthesia, Paralysis and Poikilothermia
149
Poikilothermia occurs to injury at what level of the spinal cord?
~T6 or above
150
Why is TIVA generally preferred in spinal surgery?
It allows for monitoring of SSEP/MEP/EMG, whereas volatiles can impair monitoring and paralytics absolutely impair monitoring of MEPs
151
Describe the basic process of inserting a dual lumen et-tube
You insert the tube with the left side of the tube (the bronchial side) along the anterior aspect of the airway, once past the cords, you rotate it 90 degrees to the left, this gets the longer left lumen into the left bronchus and the right lumen (tracheal) into the trachea, slightly above the right mainstem bronchus
*This is the simplified steps*
152
Other than peripheral injury, what is the main goal, in relation to hemodynamics, of patient positioning in spinal surgery?
Maintain low venous pressure to the surgical site
153
What device uses pins to secure the head?
Mayfield pins
154
Why is sitting an uncommon surgical position for spine surgery?
Huge risk of VAE
155
What spinal surgery generally requires a DLT? What position should they be placed in?
Anterior thoracic approach, lateral position with a bean bag
156
Describe what tube is needed, position and securing equipment needed for thoracic spinal surgery in a prone position
A single lumen ETT, a headrest/prone view and arms tucked neutral with <90 abduction
157
What extra piece of airway equipment is important for prone positioning
A corrugated adapter (this allows for connection of the circuit to the ETT, this adapter creates a 90 degree angle to allow for connection to the circuit)
158
What are the 3 common causes of POVL (Post operative vision loss)?
Ischemic optic neuropathy (ION) (most likely cause)
Retinal artery / vein occlusion
Cortical brain ischemia
159
T/F: POVL occurs because of pressure to the eyes
False
*generally occurs from disrupted blood flow and/or delivery of oxygen*
160
Risk factors for ischemic optic neuropathy?
Male gender
Obesity
Wilson frame use
Duration of surgery (> 6 hrs)
Decreased colloid use
Blood loss > 1000 mL
161
When does ischemic optic neuropathy (ION) occur?
24 - 48 hours
162
What are the symptoms of ION?
Bilateral
Painless visual loss
Nonreactive pupils
No light perception
163
Treatment of ION?
Acetazolamide
Diuretics
Corticosteroids
Increasing BP or Hgb
Hyperbaric O2
164
What strategies can help reduce the chances of POVL / ION?
Head neutral / midline
Blood transfusion or colloids
Minimize surgical hypotension/hypotensive technique
165
What position makes use of the "Superman/Surrender" arm position?
Prone
166
What is the concern of iliac crests?
The can compress the IVC and may compress the genitalia
167
Prone position increases intra-abdominal and intra-thoracic pressure, which results in what CV/Pulm changes?
Decreased FRC & pulmonary compliance
Decreased venous return
Increased bleeding from epidural veins
168
What 2 frames let the abdomen hang free?
Andrews frame and Jackson spine table
169
What frames partially compress the abdomen?
Siemens, Wilson frame and longitudinal bolster
170
What frame only has partial chest support?
Longitudinal bolster
171
What frames have full pelvis support?
Siemens and Jackson spine
*Andrews frame, Wilson and longitudinal bolster all have partial*
172
What hemodynamic changes occur in prone positioning?
Pooling of blood in extremities and compression of abdominal muscles may decrease preload, cardiac output and BP.
173
How does the prone position affect CBF?
The rotation of the head may decrease cerebral venous drainage/CBF
174
What factors increase risk of blood loss in spine surgery?
Number of levels included in surgery
Age > 50 yo
Obesity
Surgery for tumors
Increased intraabdominal pressure
Transpedicular osteotomy (cutting/shaping bone)
175
When is autologous blood donation usually considered
When anticipated EBL 500 – 1000 mL
176
What is a contraindication to autologous blood donation?
Significant cardiac disease and infection
177
What is a common standard dose of TXA, the infusion rate and max dose?
Standard dose: 10 mg/kg IV
Infusion: 2 mg/kg/hr
Max: 2.5 grams
178
What is the dose and infusion rate of Aminocaproic acid (Amicar)?
100 mg/kg IV
Infusion: 10 - 15 mg/kg/hr
179
Describe intraoperative hemodilution
Removal of ~500 ml of blood after anesthesia induction to cause permissive hypotension, BP is then maintained with crystalloid/colloids
*Huge risk of end-organ ischemia*
180
You may have to wake up patients during spine surgery to evaluate neuro function, what are the big risks/complications of waking up these patients?
Inadvertent extubation
Air embolism
Violent movements movement of instrumentation
181
What does SSEP measure/evaluate?
Dorsal column pathways of proprioception & vibration
Assesses afferent pathway
182
What does MEP measure/evaluate?
Anterior / motor portion of spinal cord
Assesses efferent pathway
183
What is used to monitor nerve root injury during pedicle screw placement & nerve decompression?
EMG (measures the efferent pathway)
184
What is a contraindication to using MEP?
Main one is seizure risk, vascular clips in the brain or cochlear implants
185
What are potential adverse effects of MEP?
Cognitive defects
Seizures
Intraop awareness
Scalp burns
Cardiac arrythmias
Bite injuries (use a soft bite block)
186
What is amplitude? Latency?
Amplitude = signal strength
Latency = time for signal to travel through the spinal cord
187
What are the confounding factors for neurophysiologic monitoring?
Hypotension
Hypothermia
Hypocarbia
188
How do volatiles affect amplitude and latency?
Decrease amplitude and increase latency
189
What gas is generally contraindicated if neurophysiologic monitoring is needed?
N2O
190
If using neurophysiologic monitoring, what is the goal MAC?
No more than 0.5
191
What neurophysiologic monitoring requires that no muscle relaxants are given after intubation?
MEPs
192
What factors may require the patient to remain ventilated after spinal surgery?
Prolonged procedures (> 4 hours -> assess for edema, Consider extubating over tube exchanger)
Thoracic cavity invasion
EBL > 30 mL/kg or > 2000 mL
Facial / laryngeal edema
193
What medication in multi-modal analgesia must be used with care s/p spinal surgery?
NSAIDs
194
What block is a good choice for analgesia s/p spinal surgery?
Erector spinae block
195
What spinal surgery has the highest risk of VAE?
Laminectomy (large amount of exposed bone and/or a surgical site above the heart)
*s/sx of VAE may include unexplained hypotension, increase in ETN2O, decrease in ETCO2*
196
What AANA standard addresses the rights to autonomy, privacy and safety?
I
197
What AANA standard addresses the pre-anesthesia evaluation?
II
198
What AANA standard addresses the patient-specific plan?
III
199
What AANA standard addresses informed consent?
IV
200
What AANA standard addresses documentation that is accurate, timely and legible?
V
201
What AANA standard addresses equipment, verifying that it works?
VI
202
What AANA standard addresses the plan/modification to it including that the primary anesthesia provider only relinquishes responsibility to another anesthesia professional?
VII
203
What AANA standard addresses patient positioning?
VIII
204
What AANA standard addresses monitors/alarms?
IX
205
What AANA standard addresses infection control policies?
X
206
What AANA standard addresses the transfer of care to an appropriate recovery area?
XI
207
List what the modified aldrete score measures
Respirations
Oxygen Saturation
Consciousness
Circulation
Activity
208
List what the post-anesthesia discharge scoring system measures
Vital Signs
Surgical Bleeding
Activity and mental status
Intake and Output
Pain/Nausea/Vomiting
209
T/F: General anesthesia can be done/classified as GA if the patient does not have an airway in place
True (slide 17), the example given during lecture, is that if the patient is on an ET-CO2 nasal cannula, then it is considered GA
210
What kind of anesthesia is recommended for a cerebral aneurysm? Drugs?
GETA: Large bore IV, volatiles, propofol drip and precedex
*An a-line may or may not be necessary*
211
What kind of anesthesia is recommended for an abdominal aneurysm? Drugs?
large bore IV, arterial line
heparin, frequent ACT’s, protamine
foley catheter
controlled mild hypotension
212
T/F: A TIPS procedure is a curative process for liver cirrhosis
False
*It does address the portal HTN to reduce the incidence of GI bleeds resistant to medical therapy, but it does NOT fix the liver*
213
What comorbidities do you expect to encounter with a patient undergoing a TIPS?
Recent GI bleed
Hepatic encephalopathy
Ascites
Pleural effusion
Alcoholic cardiomyopathy
Coagulopathy
Decreased protein binding
214
What kind of anesthesia is recommended for a TIPS?
GETA recommended
RSI
Large bore IV
Arterial line
Volume replacement??? Albumin, PRBC’s
Preop/Intraop meds???
Provider radiation protection
*Be aware of what meds are metabolized by the liver*
215
What induction drug should be avoided if a patient is get an ablation in cath lab?
Lidocaine
216
Why is a TEE a recommended prior to a cardioversion?
To rule out atrial and/or mural thrombus
217
What anticoagulant antagonizes vitamin K, and decreases factors II, VII, IX and X?
Vitamin K antagonists - Warfarin
218
What anticoagulants antagonize thrombin to prevent fibrinogen from forming fibrin?
Direct thrombin inhibitors: dabigatran (Pradaxa)
219
What anticoagulants prevent cleavage of prothrombin to thrombin?
Factor Xa inhibitors: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa)
220
How would you reverse a direct thrombin and/or a factor Xa inhibitor?
Give factors II, VII, IX, X and/or a PCC
*In general, we don't usually reverse, you stop the med prior to surgery*
221
Bivalirudin targets what?
Thrombin
222
Heparin targets what?
Thrombin and factor 10a enzyme
223
Fondaparinux targets what?
Factor 10a
224
What key piece of equipment is a necessity during an ablation?
Defibrillator - it is likely arrhythmias will be induced which may require electricity to reverse
225
What patient populations are indicated for a TAVR?
Symptomatic patients of any age with high surgical risk
Symptomatic patients with predicted post-TAVR survival of > 12 months
Symptomatic patients > 80 y/o
Younger patients with life expectancy < 10 years
226
What anesthesia considerations/equipment would you want for a TAVR?
Standard monitors, large bore IV, A-line
Defibrillator
Typed and crossed
Heparin/ACTs/protamine reversal
227
What position is common for an EGD/colonoscopy?
Lateral
228
What does ERCP stand for?
Endoscopic Retrograde Cholangiopancreatography
229
What medication should specifically be drawn up for an ERCP?
Glucagon
230
What is the common patient position for an ERCP?
Prone with head turned to the side
231
Common indications for ECT therapy?
Bipolar disease
Schizophrenia
Extreme depression
Suicidal behavior
232
What are some common physiologic responses to ECT?
Incontinence
Myalgias (may last for 2-7 days)
Headache
Emergence agitation/confusion
233
How is anesthesia generally performed for an ECT?
General anesthesia
Bag Valve Mask (Ambu) with bite block
atropine/glycopyrrolate
brevital, anectine
caffeine?
Hyperventilation
Protection of extremities
Ativan, haldol on standby
Treat HTN with short acting B-blockers
IV’s discontinued in PACU (even if in pt)
234
What nerve is at risk for injury during tourniquet use for a knee procedure?
Peroneal nerve
