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Special Pop Exam 1 > Week 5: Part 2 > Flashcards

Week 5: Part 2 Flashcards

40-77

1
Q

T/F
Ambulatory surgery centers have access to blood banks.

A

False

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2
Q

Revised Cardiac Risk Index

A

Patients ≥45 years old (or 18-44 years old with significant cardiovascular disease) undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery.

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3
Q

T/F:
An ASA 4 pt can be scheduled outpt under the right circumstances.

A

True
Weigh the Benefits and Risks

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4
Q

T/F:
You continue to be responsible for the pt after they’re discharged from outpt sx.

A

True
up to 72 H

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5
Q

distinguish between plain Rhinitis
vs.
more significant viral/bacterial pharyngitis/laryngitis/tracheobronchitis/pneumonitis

when do we cancel the case?

A
  1. Cough (especially during your exam or if the parent states the child coughs while sleeping)
  2. Sore throat
  3. Hoarseness
  4. Fever (temperature>38 degrees C rectally with an associated URI symptom)
  5. Malaise, lethargy or increased irritability
  6. Vomiting, diarrhea or generalized rashes

4 through 6 indicate systemic infection and probably should cancel elective surgery.

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6
Q

Which of the following would be good ambulatory cases?

A. 3-month-old with a hemoglobin of 5.8
B. A 5-month-old with a family history of SIDS
C. A 2-year-old with a recent history of a URI (5 days ago) and the mom states the child hasn’t eaten much since the URI was diagnosed
D. An infant that is 42 weeks post-conceptual age

A

none are safe!

PCA = weeks of age at birth + weeks of age since birth
Example : 25 weeks at birth + 15 weeks since birth = 40 weeks PCA
Children born prematurely (before 37wks) who have a PCA < 55, may be required to stay overnight after general anesthesia. Tell the parents to be prepared to stay.

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7
Q

Guide to Determine Length of Stay for Infants after Surgery
Table 31-1

A
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8
Q

Would you proceed with this case?

An 18-month-old is scheduled to undergo inguinal hernia repair. His medical and developmental histories are unremarkable. On the day of surgery his parents said he is getting over a cold. He has mild to moderate nasal congestion and is otherwise symptom free. He is afebrile.

A

afebrile and minimal symptoms
but
be aware of hyperreactive airway

Generally Safe to Proceed if….
No fever >38.5 C
No purulent discharge
No lower respiratory tract signs
No altered behavior

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9
Q

How long are peds airways reactive after a URI?

A

typically 2-3 weeks but can be may remain hyperactive for 4-6 weeks

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10
Q

What percentage of adult patients are “unaware” that they have OSA prior to surgery?

A

80-90%

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11
Q

Which of the following tools can help identify patients with OSA?

A

Stop-bang

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12
Q

OSA and difficulty ventilating with a face mask or intubating the trachea

A

anticipate 2 hand mask, OPA

boujee, fiberoptic, additional 2-3 people

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13
Q

of OSA and uses CPAP every night
What should/could we use for pain control?

A

low dose fentanyl

ketamine, ofirmev, robaxin

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14
Q

Bariatric surgery (lap band)
increases the risk of…

A

aspiration

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15
Q

T/F:
Patients require smaller amounts of drug during infusions compared with bolus dosing, affecting both recovery time and resource utilization.

A

True
boluses will also cause more build up in tissue

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16
Q

Context-sensitive half-time

A

merely refers to the time it takes for the plasma concentration to decline by 50% after terminating an infusion.

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17
Q

Intravenous opioid administration may induce
(2)

A

skeletal muscle rigidity
chest wall rigidity

can be severe enough to make ventilation difficult when large doses are administered rapidly

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18
Q

Discharging the Ambulatory Patient

A
  • Phase I recovery – immediate Post-Op period in PACU
  • Phase II recovery – after awake, responsive
  • Ability to tolerate liquids, walk and sometimes void
  • Informing patients of anesthetic side effects
  • Where to go if they have issues
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19
Q

Informing patients of anesthetic side effects
Suxx & Spinals

A

Sux: headache, muscle aches
Spinal: inability to void

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20
Q

T/F
General anesthesia pts must always go to phase I recovery.

A

True

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21
Q

LEVELS of Postoperative Care

A
  • Phase I
  • Phase II
  • Pediatric, Inpatient, Outpatient areas
  • PACU triage
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22
Q

PACU triage
assessment based on certain factors

A
  • Clinical condition
  • length/type of procedure
  • anesthetic
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23
Q

PACU
V/S

A

vitals Q5 min x 15 minutes
then every 15 minutes

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24
Q

Table 54-1
Components of a Postanesthesia Care Unit Admission Report

A
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25
Q

Postoperative Evaluation

A
  • Respiratory
  • CV
  • Mental Status
  • Temperature
  • Pain
  • Nausea and Vomiting
  • Postop hydration
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26
Q

Two most common types of patients to encounter troubles will be the patient with ….

A

CAD & CHF

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27
Q

Patients in the PACU may not complain of angina due to

A

residual anesthetics
pain medications

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28
Q

first sign of myocardial ischemia may well be

A

hypotension

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29
Q

can cloud the picture of a patient’s cardiac disease and prevent us from catching hypoTN
(initial sign of myocardial ischemia)

A

sedation techniques using drugs like dexmedetomidine can lead to hypotension postoperatively

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30
Q

T/F:
Hypotention is the most “common sign” of myocardial ischemia.

A

False
tachycardia

The first sign of myocardial ischemia may well be hypotension

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31
Q

T/F:
Tachycardia is often a reaction to myocardial ischemia but not the cause.

A

True

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32
Q

T/F:
Many things anesthesia/surgical related can impair ventilation, oxygenation and airway maintenance.

A

True

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33
Q

Pulmonary Issues
Patient disease process

A

sleep apnea, Obesity, COPD, Smoking

34
Q

Pulmonary Issues

A
  • Drug related (opioids, NMBA)
  • Hypercarbia
  • Respiratory acidemia
  • Patients with neuromuscular abnormalities
  • Respiratory issues from blocks
35
Q

T/F:
Along with HTN and tachycardia, pain can also cause dysrhythmias.

A

True

36
Q

Increased in SNS due to pain can mask _____

A

hypovolemia

37
Q

The best measure of analgesia is

A

the patient’s perception

38
Q

“To Avoid masking signs of an unrelated condition or surgical complication….

A

ascertain that the nature and intensity of pain are appropriate for the surgical procedure”

39
Q

Pain by procedure type

A

ortho, urogenital, general
highest pain scores PACU

40
Q

The 3 most common reasons for delay in patient discharge from PACU?

A

Drowsiness
Nausea and vomiting
Pain

41
Q

Assessing a patient with delayed awakening

A
  • What was their preop status?
  • Any intraoperative events?
  • Oxygenation/Ventilation assessed (ABG)
  • Residual drug effects (TOF, flumazenil, Narcan)
  • Hypothermia
  • Labs (which ones?)
  • Send for a CT, neuro consult
42
Q

Most common cause of delayed awakening

A

Prolonged action Of anesthesia

43
Q

Prolonged action Of anesthesia

A
  • Age
  • hypothermia
  • decreased protein binding, metabolism changes
  • hypoventilation
  • NMBD
  • sedating drugs used for ERAS/opioid free anesthesia
  • Preexisting cognitive/psych issues
44
Q

delayed awakening in PACU
Metabolic issues

A

hyperglycemia, hypoglycemia, electrolyte issues, hypothyroid

45
Q

delayed awakening in PACU
Neurologic issues

A

CVA, Intracranial hemorrhage, increased ICP

46
Q

How does Hypoventilation affect awakening?

A

decreases exhalation of inhaled, increase in CO2 narcosis

47
Q

Electrolyte Imbalances that cna delay awakening

A

Hyponatremia, Hypocalcemia and Hypermagnesemia

48
Q

T/F:
Emergence delirium shares common causes with delayed emergence.

A

True

49
Q

T/F:
Propofol can contribute to emergence delirium.

A

True

along w/ versed ofc

50
Q

You are called to the PACU to eval a pt with HYPERTENSION/HYPOTENSION

A

HTN: pain? may need stat MRI if brain Sx

HypoTN: bleeding? esp if trending low over time

51
Q

Hypothermia is defined as

A

Body Temperature below 36o C

52
Q

Hypothermia
Can Cause:

A
  • Prolonged recovery, drug metabolism decreases
  • Physiologic instability (decreased oxygen, cardiac and rhythm changes)
  • Postoperative morbidity
53
Q

Hypothermia
High risk patients

A

elderly, neonates, intoxicated, general anesthetics

54
Q

What’s the most effective method of treating hypothermia?

A

forced air warmer
fluid warmer
increase Temp in room

55
Q

⭐️
review the differences in radiation, convective, conductive and evaporative heat loss

A

Most to least heat loss:
1. radiation (heat emantes from warmer to colder)
2. convection (colder air passing over warmer surface)
3. evaporation (heat loss via water vapor)
4. conduction (ie: pt touching cold OR table)

56
Q

PONV based on APFEL score

A
57
Q

Apfel’s risk assessment tool

A

Patient scored on four risk factors
(gender, smoking status, history of PONV or motion sickness, postoperative use of opioids)

58
Q

T/F:
Choice of anesthestic, patient history, and the surgery itself can contribute to PONV.

A

True

Anesthetic risks
Patient-related risks
Surgery related Risks

59
Q

Other Potential Issues to Think About

A
  • Renal
  • Metabolic issues
  • Ocular and Visual changes (due to what)
  • Hearing (from aminoglycosides)
  • Dental, Pharyngeal and Laryngeal Injuries
  • Nerve Injuries, Soft tissue injuries
60
Q

Post-discharge Nausea and vomiting
(PDNV)

A

Apfel’s risk assessment of PDNV
1. Female
1. History of motion sickness and/or PONV
1. Age less than 50 years
1. Use of postoperative opioids
1. PONV in PACU

61
Q

Post-discharge Nausea and vomiting (PDNV)
Treatments

A

same as PONV

62
Q

Scoring System for PACU discharge

A

Modified Aldrete Scoring System (Aldrete)
quantify readiness for discharge from PACU Phase 1
9/10 is required for discharge to Phase II

Postanesthetic Discharge Scoring System (PADSS)
9/10 = ready for discharge

63
Q

What is considered NORA?

Nonoperating Room Anesthesia

A
  • MRI, CT,
  • IR
  • EP labs
  • Cardiac cath
  • GI suites (interventional & screening)
64
Q

problems and challenges of anesthesia in remote areas

A
  • Non-surgical patients lack pre-testing
  • No proper preop eval
  • rushing the day of the procedure
  • delays! tardiness anywhere in the process
  • Cramped room, poor lighting, unfamiliarity with equipment/room
  • inadequate anesthesia support,
  • equipment not well maintained
65
Q

Three-Step Approach to NORA

A
66
Q
A
67
Q

Nora Procedures

A
68
Q

T/F:
A diagnostic cardiac cath is a common NORA procedure.

A

True

69
Q

NORA
what to know about the procedure

A

Position
How painful is it
When is it stimulating
How long will it take

Do you have a plan in an emergency?

70
Q

Room check for NORA

A
  • Some locations don’t have an anesthesia machine? When was it last checked?
  • suction & Ambu
  • anesthesia cart? Paperwork?
  • Do you need to bring your own drugs?
  • Code Cart? MH Cart?
  • Where can I sit?
  • Pumps for TIVA/sedation
  • Where do I hang my IV bag
  • Where’s the bathroom?
71
Q

ASA Standards for NORA

A
72
Q

The most common complications associated with NORA are?

A

Airway obstruction
&
Respiratory depression

73
Q

NORA
Minor and Major complications

A
74
Q

Top 3
MINOR
NORA complications

A

Postoperative nausea and vomiting
Inadequate postoperative pain control
Hemodynamic instability

75
Q

Patient Safety in NORA

A

Increase risk?
Respiratory depression d/t oversedation
Minor & Major complications (Table 33-4)
Radiology and Cardiology

76
Q

T/F:
Safety in anesthesia often compares to the aviation industry

A

True

77
Q

paramount to creating safe outcomes in NORA

A

Consistent human performance

78
Q

T/F:
NORA patients tend to have fewer complications overall, but the complications of NORA may be more serious and life-threatening than traditional OR room.

A

True!

79
Q

Random Case Study he included

A 75-year-old, 100-kg, ASA 2 man was scheduled for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). Monitors, including pulse oximetry, blood pressure, and ECG, were placed and the patient was turned prone for the procedure. He was given midazolam 2 mg and fentanyl 50 mcg IV, and he remained anxious.

A

Additional midazolam 2 mg and fentanyl 150 mcg IV were given, but the patient could not tolerate the endoscope insertion. Propofol 20 mg IV, followed by an infusion of 50-70 mcg/kg/min, was administered, and the procedure was begun with O2 saturations of 88-92% on 4 L/min O2 by nasal prongs.

After 20 minutes, the O2 saturation decreased to 70%, and the patient became severely bradycardic, and was treated with atropine 1 mg.

Attempts at bag-mask ventilation and placement of a laryngeal mask airway failed. Blood pressure was not obtainable, and the procedure was aborted. It took 2-3 minutes to push aside the heavy endoscopy equipment, move in a gurney, and turn the patient supine to begin CPR.

Although the patient was resuscitated after 10 minutes of CPR, he sustained severe anoxic brain damage, and life support was eventually discontinued.

Moral of the story: preventable if we inubate

80
Q

ASA closed claims project review
remote vs OR anesthesia
found that…

A

NORA has:

  • much higher claims that were preventable by better monitoring
  • more respiratory & inadequate oxygenation/ventilation claims
81
Q

CMS defintion of general anesthesia

A

loss of consciousness/reflexes for 1 second

reflex ie: gag

Special Pop Exam 1 (16 decks)

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