Week 2- OR Safety & Opioids Flashcards
1
Q
The synthesis of heroin in 1874 was based on the empirical finding that boiling _________ caused the replacement of the two groups: __________ by __________
A
Morphine; -OH by -OCOH3
2
Q
7 uses of opioids
A
- preoperative meds
- anesthesia
- Induction
- intraop pain control
- post op pain control
- spinal/epidural anesthesia
- OB
3
Q
Normal fentanyl dose
A
50-100 mcg
4
Q
Common opioid added to epidurals and spinal
A
Duramorph
5
Q
Name the piperidines
A
-fentanyl
-sufentanil
-alfentanil
- remifentanil
6
Q
Piperidine opioids are
A
Synthetic
7
Q
Synthetic opioid commonly used for eye blocks due to its fast on/off onset/DOA
A
Alfentanil
8
Q
What side effect may be seen after intraoperative morphine use in the postoperative area
A
Itching
9
Q
Dilaudid:
Acts on _________ and is an __________
Comes in a ____________ vial
Typically it is ____________
Common name for Dilaudid is _________
A
Mu, agonist
10 mg/cc
Diluted
Hydromorphone hydrochloride
10
Q
What type of agonist/antagonist is Ketamine and on what receptor does it act
A
NMDA receptor antagonist, also works on opioid receptors
11
Q
Clinical effects of acting on mu-1
A
- supraspinal analgesia
- bradycardia
- Sedation
- pruritis
- N/V
12
Q
Examples of mu-1 agonists
A
Morphine and meperidine
13
Q
Clincal effects of acting on mu-2
A
- respiratory depression
- euphoria
- physical dependence
- pruritis
- constipation
14
Q
Clincial effects of acting on the K (kappa) receptor
A
- Spinal analgesia
- respiratory depression
- sedation
- miosis
15
Q
Clinical effects of acting on the delta receptor
A
- spinal analgesia
- respiratory depression
16
Q
Example agonists of the mu-2 receptors
A
Morphine and meperidine
17
Q
Example agonists of the kappa receptors
A
Fentanyl, morphine, and nalbuphine
18
Q
Example agonists of delta receptors
A
Oxycodone, B-endorphine, Leu-enkaphalin
19
Q
Are piperidines lipophilic or lipophobic
A
Lipophilic
20
Q
Where are fentanyl, alfentanil, and sufentanil metabolized and what enzyme catalyzes these breakdowns
A
Liver; cytochrome P450 enzyme system
21
Q
How much more potent is fentanyl than morphine
A
~ 100 x more potent
22
Q
Why is fentanyl typically used in anesthesia
A
To decrease CV response to noxious stimuli from laryngoscopy, intubation, skin incisions, and surgical stress
23
Q
Administering fentanyl can decrease inhalational anesthetic requirements by 50% by administered _________________ IV fentanyl
A
1.5-3 mcg/kg
24
Q
The two most pain provoking things that occur in surgery
A
Intubation and skin incision
25
T or F: Fentanyl is considered an “additive drug”
T
26
Sufentanil is a ___________derivative of fentanyl and is _________ more potent than fentanyl
Thienyl; 10 X
27
What meds lipophilicity is 2x greater than fentanyl’s
Sufentanil
28
Is sufentanil metabolized to inactive or active compounds
Both
29
Where is sufentanil metabolized
Liver
30
Metabolizes remifentanil
Blood and tissue nonspecific esterases
31
What type of chemical side chain on remifentanil affects its metabolization
Methyl ester
32
CSHL of remifentanil
2 minutes
33
Most rapidly acting opioid available
Remifentanil
34
Clearance of remifentanil
3-5 L/min
35
Is remifentanil metabolized in liver? Why or why not
No. It’s clearance exceeds liver blood flow affirming its extrahepatic clearance
36
Why is remifentanil usually a continuous infusion
It’s plasma level decreases by 50% in ~ 40 seconds
37
Active metabolite of ________ can cause seizures
Meperidine
38
Does morphine cross BBB quickly or slowly? Why?
Slowly due to low lipophilicity
39
Goal for patient in preoperative timeframe
To RELAX then not to sedate them…. Yet
40
How long to the onset of action for dilaudid
10- 15 mins
41
Who tends to have higher effects from narcotics?
Neonates, elderly, patient with OSA
42
What causes an increase in biliary pressure
Contraction of the sphincter of Oddi as a result of opioid use
43
Can you reverse the contraction of of the sphincter of Oddi?
Yes with naloxone or glucagon
44
How do opioids cause N/V
- Stimulates the chemoreceptor trigger zone in the postrema of the brain stem.
- direct effects on the GI tract,
- increased sensitivity of the vestibular system
45
What can be given to descrease incidence of coughing during an EGD and why
Fentanyl … acts on medullary cough centers
46
What is wooden chest syndrome
After giving narcotics, you can’t ventilate
47
Risk factors for wooden (rigid) chest syndrome
- high cumulative doses
- extremes of age
- concamitant use of meds that modify dopamine levels
- rapid IV admin
- critical illness
- lipophilic opioids
48
The duration of effect of narcan is
15-45 minutes
49
Administration of narcan
40 mcg every 1-2 minutes until good RR/ventilation
50
How to dilute narcan
4 mg per vial, 1 vial diluted in 9 cc NS = 40 mcg/cc
51
Adverse effects of reversing the effects of narcotics with naloxone
- sudden pain
- pulm edema
- cardiac arrhthymias
- HTN
- Seizures
- cardiac arrest
52
What type of receptor family are opioids acting on
G-protein coupled receptor family
53
When opioid receptors are signaled, what happens to the channels
K+ and Ca2+ activation
54
In reference to the function of an opioid receptor, what is the cascade of the signaling pathway
1. Inhibit adenyl cyclase & decrease cyclic AMP
2. Activation of Ca2+ and K+ channels
3. Activation of mitogen activated protein kinase/extra cellular signal/regulates kinase, protein kinase C, and P13 KK/Akt
55
What two things can antagonism of NMDA receptors lead to
-reduce opioid tolerance
- reduce opioid induced hyperalgesia and hypersensitivity (in chronic disease states)
56
What does NMDA stand for
N-methyl-D-Aspartate
57
Explain the receptors ketamine works on
NMDA antagonist causing anesthetic properties and analgesic effects due to MOR activation
58
What is nociception
Neural process of encoding and processing of noxious stimuli that can cause tissue damage
59
3 examples of analgesia driven by endogenous opioid system
1. Stress induced
2. Placebo induced
3. Condition pain modulation (CPM)
60
What is conditioned pain modulation (CPM)
Pain from noxious stimuli applied to one part of body is decreased by application of second remote noxious stimuli
61
What causes CPM
Activation of descending inhibitory pathways by higher brain centers
62
Opioids are involved in peripheral analgesia in what ways
Act directly on sensory neurons (A and C fibers) to inhibit pain transmission
63
opioid receptors found in (name 2)
Neurons & immune cells (leukocytes)
64
OIH activation mechanisms (name 3)
1. Central glutaminergic systems
2. Central nitric oxide production
3. Facilitation of descending pronociceptive systems
65
Postoperative patients who received _________ during surgery may have higher incidence of OIH. How can you prevent it
Remifentanil
- administer morphine (0.1-0.25 mg/kg) 45-60 minutes before surgery ends OR can add low dose ketamine (10-30 mg/hr)
66
Semisynthetic exogenous opioids
Dilaudid
Buprenorphine
Oxycodone
Codeine
67
Full opioid agonist of the MOR
Morphine, piperidines, and methadone
68
Opioids that are partial agonist
Buprenorphine
69
Opioid antagonists
Naloxone and naltrexone
70
Explain opioid metabolism that may occur in GI, brain, kidney
Extraction of parent drug/metabolites via kidney and/or biliary tract into the gut where some opioids reuptake the compound in the blood stream. Examples are morphine and buprenorphine
71
Enzyme metabolizing morphine in phase II reaction
UGT2B7
72
Active metabolite of morphine? What percentage is converted to active form? What should you be cautious of?
M6G
5-10%
Patient with decreased renal function
73
Transport protein that moves M3G and M6G to bloodstream? To bile ducts?
MRP3 bloodstream
MRP2 bile duct
74
Opioids that readily cross BBB
Pipieridines
75
The most important metabolic pathway of naloxone is via ________ and the metabolite is ________
Glucuronidation
Inactive naloxone-3-glucuronide
76
The opioid affect sites for analgesia, sedation, constipation, and respiratory depression
CNS- analgesia, sedation, respiratory depression
GI- constipation
77
Explain how opioids affect respiratory rate
Reduced TV due to decreases input to brain stem
If given slowly, respiratory neuron depression coincides with increased arterial CO2 accumulation which stiulates peripheral ad central chemoreceptors which offsets decrease in tidal volume and reduced RR
Opioids can increase collapsibility of upper airways d/t suppression of neurons in brain stem or from loss of muscle tone related to sedation
78
Naloxone onset
6.5 minutes
79
Special considerations when administering naloxone to reverse buprenorphine
Consider naloxone infusion d/t long actin buprenorphine and short acting naloxone
80
What area is triggered that could cause PONV following opioids
Chemoreceptor trigger zone (CTZ) which is near vagal nerve, and vestibular organs
81
Treatment for PONV from opioids
Dopamine antagonist (droperidol)
5HT-antagonist (Zofran)
Corticosteroids
82
What do opioids do to GI tract
- Inhibit intestinal and pancreatic secretion,
- increase bowel tone,
- decrease intestinal propulsive activity
83
How to treat opioid induced bladder dysfunction
Opioid antagonist
84
Remifentanil PCA for labor pain
- used when epidural contrainidcated
- bolus dose 30 mcg with a 3 minute lockout
85
WHO surgical checklist only applies to what people in the OR
it applies to the WHOLE OR
86
when are surgical checklists performed
- prior to induction of ANE
- pre-op
- prior to skin incision
- before pt leaves OR
87
rate of anesthetic drug errors
1 in 133
88
3 most common meds involved in medication errors
-opiates
- muscle relaxants
- antibiotics
89
from who's study did the WHO surgical checklist originate and when
2009- Dr. Gawande and his group from Harvard
90
in summary: why are we learning the entirety of the ANE machine
the study where they created 5 leaks in the machine
- ave number faults found= 2.2
- 7.3% found no faults
- only 3.4% found all five
greater emphasis on fundamentals of ANE machine
91
Causes of failure to deliver O2 to the alveoli- Upstream from workstation (6)
- liquid O2 reservoir empty or filled with hypoxic gas (nitrogen)
- crossed hospital pipelines
- crossed hoses or adapters in OR
- closed pipeline valves
- disconnected O2 hose
- failure to back up hospital O2 reserve
92
Causes of failure to deliver O2 to the alveoli- within the machine or circuit (12)
- cylinder filled with hypoxic gas
- empty O2 cylinder
- incorrect cylinder on O2 yoke
- crossed pipes with machine
- closed O2 cylinder valve
- O2 flowmeter off
- failure of the proportioning system
- O2 leak within the machine or flowmeter
- incompetent or absent circuit unidirectional valves
- breathing circuit leak
- closed system ANE w/ inadequate fresh O2 supply
- inadequate ventilation
93
3 complications of failure to deliver O2 to alveoli
- hypoxia
- hypocarbia
- hypercarbia
94
what would cause you to suspect the substance being delivered isn't actually O2 and what should you do
the oxygen analyzer alarm
disconnect pipeline and open O2 tank on back of machine for O2 delivery
95
normal OR temperature
68-73 degrees
96
in what situations should the OR be kept warmer
- burns
- large surface area exposed
- pediatric patients
- trauma
97
usual humidity level of OR
&
ideal humidity level of OR
30-60%
50-55%
98
what happens if the OR humidity is too high
damp or moist supplies increase the incidence of contamination
99
what happens if the OR humidity is too low
- facilitate airborne motility of particulate matter, vector for infection
- increase incidence of static changes
100
what does WHO stand for
World Health Organization
101
what does NIOSH stand for
National Institute for Occupational Safety and Health
102
what does NIOSH do
ensure employees work in safe and healthy environment
103
what are NIOSH recommended exposure limits (REM) for halogenated agents
2 ppm for halogenated agents
104
what are NIOSH recommended exposure limits (REM) for halogenated agents when used in combination with N2O
0.5 ppm for halogentaed and 25 ppm for N2O when used in combination
105
what are NIOSH recommended exposure limits (REM) for nitrous oxide alone
25 ppm for N2O alone
106
potential leak sources of anesthesia machine
- tank valves
- high/low pressure machine connections
- connection in breathing circuit
- defects in rubber and plastic tubing, hoses, reservoir bags, vet bellows, and y-connector
107
potential OR contamination sources
- spills while filling vaporizers, flushing circuits
- loose fitting masks
- uncuffed ETT
- malfunction/leak in the scavenging system
- cryosurgery, CV bypass units, PACU
108
what can decrease contamination of the surgical site and how is it done
high rate of OR airflow
blend 80% recirculated air with fresh air
109
T or F: ventilation systems in OR are not suitable for WAGD
True
110
is OR pressure + or - and why
slightly +
** drive away gases that escape scavenging
** Fresh Air flow moves/enters from the ceiling to the floor
111
what does NFPA stand for
National Fire Protection Agency
112
NFPA recommendation for air exchange and why
25 air volume exchanges/ hour from OUTSIDE.. not from hospital air
decrease the risk of stagnation and bacterial growth
113
why halogenated lights in OR
less fatiguing on the eyes
- light is given off as brightness rather than heat to protects delicate tissues
114
normal OR noise levels
70-80 decibels (dB) with frequent sound peaks
114
why is anesthesia compared to flying a plane
pre-flight planning= pre-anesthetic assessment and plan
take-off= induction
autopilot= maintenance
landing= extubation
taxi to terminal= PACU
115
7 principles of crew resource management
1. Communication
2. Assertiveness
3. Situational awareness
4. Analysis
5. leadership
6. adaptability/flexibility
7. decision making
Acronym: Crew Resource Management wants a C.A. SALAD
116
patient safety concerns of anesthesia practitioners
1. distractions
2. production pressures
3. communication (handoffs)
4. med safety
5. postop respiratory and NMB monitoring
117
the triad necessary for OR fire and examples of each
O- oxidizer (oxygen, nitrous oxide)
F- fuel (ETT, drapes, surgical supplies)
I- ignition source (cautery, laser)
118
O2 content < than _______% decreases fire risk
30
119
T or F: a major cause of fire in the OR is failing to allow the alcohol-based skin prep to dry for 90 seconds
F- 3 minutes!
120
steps to perform if you have an airway fire
1. pull tube
2. turn off all gas
3. pour fluid down airway
121
steps to avoid airway/OR fire
- prevent triad
- O2 < 30%
- wet gauze around area
- decrease O2 during cauterization
- turning down the O2 2-3 minutes before the surgeon need cautery
- let alcohol-based solutions dry
- communicate
122
estimated # of surgical fires per year in US
600
123
T or F: all surgeries have a risk of fire
T
124
surgeries to what body area account for 65% of surgical fires
head, face, neck, and upper chest
125
examples (3) of cases where you may need to use O2 with an awake patient
- cartoid artery surgery
- neurosurgery
- some pacemaker implantations
126
what does APSF stand for
anesthesia patient safety foundation
127
what is Ohm's law
E (electromotive forces)= I (Current) X R (Resistance)
128
what are the units for E= I X R
E= volts
I= amperes
R= ohms
129
in Ohms law E= I X R, what is the current representing
flow of electrons
130
what is Ohms law related to in the body
BP!
BP = CO X SVR
BP ~ voltage, CO = current and SVR = resistence
131
two types of defibrillators
DC - direct current (Monophasic)
AC- alternating current (Biphasic)
132
any substance that permits flow of electrons
conductor
133
opposes flow of electrons
insulator
134
electron flow is always in the same direction
direct current
135
electron flow that reverses directions at regular interncval
alternating current
136
sum of forces that opposes electron movement in an AC current
impedene
137
is Ohms law usually applied to AC or DC currents?
DC
138
3 ways electricity can cause morbidity/mortality
1. electrocution
2. burns
3. ignition of flammable material, causing a fire or explosion
139
electrocution effects depend on what 4 factors
1. the amount/current of electricity
2. where the current flows and its density
3. type of current
4. current durations
140
what voltage and Hz do utility companies supply to house
120 V
Frequency of 60 Hz
141
typical power cords has two conductors
- one hot that carries current to the impedance
- one neutral and returns current to the source
142
is a house a grounded or ungrounded system
Grounded to EaRtH
143
when does electric shock occur
when a person becomes part of/completes the circuit
144
how does electrical injury occur (name 2)
1. release of thermal energy= burns
2. disruption of nervous, muscular, and cardiac function (Vfib)
145
the extent of injury following electrical shock is a function of the __________ and _________
current (amperes) and duration of current flow
146
maximum harmless current intensity
(Macroshock)
5 mA
147
"Let-go" current above which sustained muscle contraction occurs
(Macroshock)
10-20 mA
148
current at which vfib will start but respiratory center remains intact
100-300 mA
149
current at which there is sustained myocardial contraction, followed by normal heart rhythm; temporary respiratory paralysis, burns if current density is high
6000 mA or 6 A
150
define macroshock
a large amount of current applied to the external surface of the body which can cause harm or death
151
define microshock
relatively small current applied directly to the myocardium in susceptible patients
152
recommended maximum leakage current vs VFIB current for microshock in pacemakers
10 uA (0.01 mA) vs 100 uA (0.1mA)
153
most common cause of macroshock
faulty or damaged wires in electrical equipment
154
which is more common... microshock or macroshock
macroshock
155
describe the grounding of equipment in the OR
electrical power is ungrounded BUT the equipment is grounded
156
Electricity entering the OR is NOT grounded, it is electrically ____________
isolated
157
what is an isolation transformer
isolates the OR power supply from ground
158
where does the line isolation monitor (LIM) take effect
with the first fault, sets off the LIM and OR becomes grounded. after the second fault, the circuit is complete and electrical shock occurs
159
features of the isolated power system
- provide protection from macroshock
- faulty equipment will not usually trip circuit breakers (life support systems)
160
will an individual contacting one side of the isolated power system and standing on the ground be shocked
no
161
what does a line isolation monitor do
continuously monitors the integrity of an isolated power system
162
when is a line isolation monitor alarm activated
2-5 mA
** Alarm is activated if an unacceptably high current flow to ground becomes possible
163
T or F: line isolation monitor does not provide complete protection from electrocution
T
164
what does 2 mA or 3 mA on a LIM tell you
indicates how much current WOULD flow in the event of a second fault
** the reading on the LIM meter does not mean that the current is actually flowing; rather indicates how much would flow in the event of a second fault.
165
LIM is triggered.... what are the next steps (5 of them)
1. check the gauge to see if a real alarm
2. if gauge > 5 mA, there is likely faulty equipment
3. identify faulty equipment by unplugging each piece of equipment (start with the once connected last).
4. if the faulty piece is not needed, then remove it
5. if the faulty piece is needed, can be used, but do NOT plug in new additional equipment
166
what is longest piece of plug and why
the ground portion to prevent electrocutionnnnn
* first to enter the receptacle
167
why would ground fault circuit interrupters be bad in the OR
it would interrupt life-saving monitors without warning.
168
what are electrosurgical units (ESU) used for
to cut or coagulate tissue using high radiofrequency electrical energy
169
ESU can cause electrical interference with what?
your equipment like ECG, CO, Pulse OX
170
what type of ESU system has electricty that travels from the probe thru the patient and then exits vie the return pad to complete the circuit and requires a return pad
monopolar ESU
171
what type of ESU system has electricity travel from the active electrode, through the local tissue, and then exits the patient thru the return electrode
bipolar ESU
172
when would you typically see bipolar ESU
surgery you dont need a lot of energy-- eye, neuro
173
the use of what type of ESU may cause electrical interference in an AICD
unipolar ESU
**AICD could interpret it as V.Tach and trigger defibrillation.
174
T or F: MAcroshock occurs when a current as small as 1 uA flows through a person
F
175
radiation-sensitive organs
eyes, thyroid, gonads, blood, bone marrow, and the fetus
176
what radiation level should be monitored
Above >40 REM
** will need film badge
177
the basic principle of radiation safety
ALARP= As Low As Reasonably Possible
178
T/F: Anesthesia has their own scavenging system and the OR has their own scavenging system.
True
179
A _______ rate of the operating room airflow ________ contamination of the surgical site
High ; decreases
** OR doesn’t like stagnant air
180
Air return in the OR is handled at or near the ______ level.
Floor
181
Human ear drum breaks instantly when exposed to sounds louder than:
160 decibel (dB).
182
Cases that involve stripping of the pleural or resection of the pulmonary blobs, or tracheobronchopleural fistula, can easily result in high concentrations of __________ in the thoracic cavity when the lung is reinflated due to gas leakage.
Oxygen
**fire hazard
183
If surgeon needs the lung inflated, then applying ________ with air instead of oxygen will greatly reduced the risk of a fire.
CPAP
184
Two major ignition sources for OR fires are the:
ESU & the laser
185
Instead of an electronic scalpel, a _______ or __________ scalpel should be used to prevent fires.
Bipolar/Harmonic
186
Safe during external and internal exposure for fires on the patient in the OR
Readily dissipates, nontoxic, least likely to cause thermal injury
CO2 fire-extinguisher
** use it if fire in OR w/ patient
187
This extinguisher contains water but can be a problem around electrical equipment.
“ A” rated extinguisher
188
Water mist are good but requires time, enough volume with multiple mist attempts.
“AC” rated extinguisher
189
In Ohm’s law. Voltage is:
The driving force
190
In Ohms law. Impedance is :
Resistance
191
Electrical power (P) is measured in
Watts (W)
192
Energy produced by a defibrillator is measured in
watt-seconds or joules.
193
An insulator has ________ impedance to electron flow.
A conductor has _______ impedance to electron flow.
High
Low
194
T/F it takes as much as 3X DC as to AC to cause V.fib
True
195
Refers to LARGE amounts of current flowing through a person, which can cause harm or death
Macroshock
196
Refers to very small amounts of current and applies ONLY to the electrically susceptible patient
Microshock
(Ex. Individual w/external conduit that is in DIRECT CONTACT w/ the heart - pacing wire, CVC and PA cath).
197
Biggest difference between macroshock and microshock
LOCATION.
198
The severity of an electrical shock is determined by the amount of _________and the duration of the flow. NOT ________.
Current
**NOT VOLTAGE.
199
Electric shock is produced by _________, not _______.
Current ; voltage
200
What color?
Hot wire =
Neutral wire =
Ground wire=
Black
White
Green
201
For a shock, contact with the electrical circuit at two points with a _________ source that causes the current to flow through a person
VOLTAGE
202
Threshold of perception
(Macroshock)
1 mA
203
Pain, possible fainting, mechanical injury;
( heart and respiratory functions continue)
Macroshock
50 mA
204
Line isolation system contains:
- a line isolation transformer
- and line isolation monitor
205
T/F: LIM alarm does not necessarily mean that there is hazardous situation, but rather that the system is no longer totally isolated from ground
True
206
Ground fault circuit interrupter:
Monitors for equality of current flow
* can detect currents at 5 mA.
*Interrupts current flow before shock occurs
207
When GFCIs are used in an OR, only ______ outlet is protected by each GFCI. The should never be __________, so that one GFCI protects multiple outlets.
ONE ; “daisy-chaine”
208
It is essential that the return plate has the appropriate amount of ________ and an intact _______.
Conductive gel ; return wire
** pad to no be placed over bony prominences or metal
209
What is Methyl methacrylate
Blue cement used in total hips/ total knees
***Causes headaches, N/V, congenital defects.
210
#1 occupational hazard in anesthesia
Substance Abuse
211
Radiation induces ________
Cataracts
