Week 8&9 - Dr. White

Question 1

o what is mandatory for all airway management scenarios:

Answer 1

preparation!!

Question 2

o the first step in airway management

Answer 2

Bag and mask ventilation (BMV) is

Question 3

no sign of chest rising, no end-tidal CO2 detected, no mist in the clear mask

these are signs of:

Answer 3

ineffective ventilation

Question 4

o Difficult mask ventilation is often found in patients with

Answer 4

morbid obesity,
beards,
craniofacial deformities.

Question 5

a life saving temporizing measure in patient with difficult airways (b/c they cannot be ventilated or intubated)

Answer 5

LMA

i-gel LMA is what Dr. White talked about

Question 6

Difficult airway - LEMON Trial:

Answer 6

	Look
•	Facial trauma
•	Large incisors
•	Beard
•	Large tongue
	Evaluate 3-3-2
•	Interincisor distance (3 fingers)
•	Hyoidmental distance (3 fingers)
•	Thyroid to floor of mouth (2 fingers)
	Mallampati
	Obstruction
	Neck Movement – chin to chest

Question 7

Predictors of Difficult Intubation

Answer 7

o	B – Beard
o	O– Obesity
o	N – No teeth
o	E – Elderly
o	S – Snores

Question 8

type of intubation not for an unstable neck:

Answer 8

direct laryngoscopy

Question 9

type of intubation good for an unstable neck:

Answer 9

awake blind nasal intubation

Question 10

nebulized anesthesia - 4% lidocaine blocks for how long?

Answer 10

15 mins MAX

Question 11

most important element for a successful awake fiberoptic intubation?

Answer 11

Preparation

Question 12

Surgical airway - Invasive technique required when you “can’t intubate, can’t ventilate”.

A few important things to remember:

Answer 12

• 16 or 14g IV cannula required to pass through CTM.
• jet ventilation system usually found on the back of vent
• catheter MUST BE SECURE!
• short 1s bursts of Oxygen
• Avoid barotrauma; pt may develop subcutaneous or mediastinal emphysema

**If no jet ventilation; 3ml syringe can attache to catheter with plunger removed. a 7.0mm TT connector can be inserted into the syringe to attach to breathing circuit or an ambu bag.

Question 13

• Poor functional status has been identified as a risk factor for surgical site

Answer 13

infection and postoperative complications.

Question 14

• Frailty is a perioperative risk factor for

Answer 14

complications and mortality.

Question 15

Frailty is classified as primary or secondary.

Answer 15

o Primary frailty occurs as part of the intrinsic process of aging.

o Secondary frailty is related to the end-stage of chronic illnesses and is caused by inflammation and wasting, for example heart failure, COPD, inflammation, and wasting associated with cancer.

Question 16

• By some estimates, over half of elderly patients also take over-the-counter herbal products.
o The American Society of Anesthesiologists (ASA) recommends that whenever possible, herbal products be discontinued at least

Answer 16

1–2 weeks prior to surgery.

Question 17

o Garlic extract and ginkgo biloba increase the risk of

Answer 17

perioperative bleeding.

Question 18

• IV anesthetics have more pronounced hemodynamic effects, and smaller doses are required to achieve the same anesthetic depth. Dose of an induction drug and opioids should be decreased by at least

Answer 18

25%.

Question 19

• The strongest predisposing factor for postoperative delirium is

Answer 19

preexisting dementia

Question 20

• The basic principles in ethical decision making that apply to the older adult are the same as those that apply to all patients.
o In health care the most common principles are

Answer 20

 autonomy ** most important
 beneficence
 nonmaleficence
 justice.

Question 21

Patient’s right to self-determination. defined:

Answer 21

autonomy **

Question 22

An obligation or responsibility to help the patient; “to do good”

Answer 22

beneficence

Question 23

To not intentionally harm the patient; “do no harm”

Answer 23

nonmaleficence

Question 24

To treat the patient fairly

Answer 24

justice

Question 25

What body part/ organ is especially vulnerable to laser surgery?

Answer 25

the eyes

all OR personnel should wear laser-specific eye goggles with side protectors to prevent injury.
• The eyes of a patient undergoing laser treatment must be protected by taping them shut, followed by the application of wet gauze pads and a metal shield.

Question 26

• Minimally invasive robotic surgery is associated with improved patient outcomes including :

Answer 26

decreased length of stay,

faster recovery, reduced perioperative blood loss, and reduced postoperative pain

Question 27

** Regardless of the procedure the anesthetic plan must take into consideration the following factors:

Answer 27

• prolonged surgical times
• spatial restrictions associated with use of the robot
• inability to alter patient position after docking of the robot
• physiologic changes associated with extreme positioning
• risk of postoperative visual loss (POVL)
• physiologic consequences associated with the creation of pneumoperitoneum
• implementation of Enhanced Recovery after Surgery (ERAS) protocols

Question 28

type and screen tests for

Answer 28

antibodies

Question 29

if indicated b the surgical procedure, in robotic surgery, pt should be typed and cross matched for a minimum of

Answer 29

four units of blood

Question 30

• Cardiovascular Changes seen in steep trendelenburg

Answer 30

Increased:
	Mean arterial Pressure (MAP)
	Central Venous Pressure (CVP)
	Pulmonary Capillary Wedge Pressure (PCWP)
	Systemic Vascular Resistance (SVR)

Unchanged:
 Heart rate (HR)
 Stroke Volume (SV)
 Mixed Venous Oxygen Saturation

Question 31

• Respiratory Changes seen in steep trendelenburg

Answer 31

Increased:
	Airway Resistance
	Peak pressure
	Plateau pressure
	End-tidal carbon dioxide (ETCO2)
	Upper airway edema

Decreased:
 Lung compliance
 Vital capacity (VC)
 Forced Expiratory Volume in 1 second (FEV1)

Question 32

• Cerebrovascular Changes seen in steep trendelenburg

Answer 32

Increased:
 Intracranial pressure
 Hydrostatic pressure gradient
 Cerebral vascular resistance

Decreased:
 Cerebral venous drainage

Unchanged:
 Regional cerebral oxygenation
 Cerebral perfusion pressure

Question 33

what is a rare but devastating complication following surgery (robotic):

Answer 33

Postoperative visual loss

Question 34

• The most important goal in managing the hyperthyroid patient is before surgery, if possible, make the patient

Answer 34

euthyroid

Question 35

What is best to avoid during induction of a hyperthryoid patient?

Answer 35

Ketamine

It is best to avoid using ketamine for induction, even when a patient is clinically euthyroid.

Question 36

• The complications after thyroidectomy include :

Answer 36

• recurrent laryngeal nerve (RLN) damage,
• tracheal compression secondary to hematoma or tracheomalacia, and
• hypoparathyroidism

Question 37

• Unilateral nerve injury is more common and is often

Answer 37

transient.

Question 38

• Unilateral damage to the RLN is characterized by

Answer 38

hoarseness and a paralyzed vocal cord,

whereas bilateral injury causes aphonia.

Question 39

The normal total serum calcium concentration is 8.8 to 10.4 mg/dL.

In general, an increase or decrease in albumin of 1 g/dL is associated with a parallel change in total serum Ca2+ of .

Answer 39

0.8 mg/dL.

Question 40

Hypercalcemia (in hyperparathyroid) is responsible for a broad spectrum of signs and symptoms. The most common manifestation, occurring in 60% to 70% of patients is:

Answer 40

Nephrolithiasis

Polyuria and polydipsia are also common complaints. 20-50% of patients are also HTN

Question 41

The anesthetic consideration for the hyperparathyroid/ hypercalemic patient regarding NMBD:

Answer 41

There is an increased requirement for vecuronium,

and probably all nondepolarizing muscle relaxants, during onset of neuromuscular blockade

Question 42

the duration of safe tourniquet inflation is generally considered:

Answer 42

2 hours

Question 43

Tourniquet pain can become significant over time and can be mitigated with inhalational agents, opioids and/or hypnotics. Definitive management is:

Answer 43

deflation of the tourniquet.

Question 44

Changes that can be expected with tourniquet deflation and are generally well tolerated in healthy patients (3):

Answer 44

1. ) Transient systemic metabolic acidosis,
2. ) increased arterial carbon dioxide levels,
3. ) A drop in systemic blood pressure

Question 45

The mechanical effects of peritoneal insufflation impair ventilation. Insufflation of the peritoneum displaces the diaphragm in a cephalad direction resulting in: (3)

Answer 45

1. decreases FRC,
2. decreases VC,
3. in turn induces collapse of the dependent regions of the lungs.

Question 46

Studies show that recruitment maneuvers that use the combination of PEEP 10 cm H2O and intermittent positive airway pressure (40 cm H2O) for 40 seconds was most effective in improving end-expiratory lung volumes, lung compliance, and arterial oxygenation in both healthy weight and

Answer 46

obese patients than either intervention alone.

Question 47

Postoperative nausea and vomiting is a major concern for patients undergoing

Answer 47

laparoscopic surgical procedures.

Question 48

The incidence of PONV in the laparoscopic population has been reported to be as high as 72% and is known to be associated with significant postoperative complications such as

Answer 48

surgical wound dehiscence,
aspiration, and
unanticipated hospital admission.

Question 49

the etiology of PONV is

Answer 49

multifactorial

Question 50

prior to cardioversion, what should the anesthesia provider ensure to review?

Answer 50

most recent EKG

Preop Labs

Question 51

Cardiovascular stimulation also occurs with ECT because

Answer 51

The sympathetic and parasympathetic nervous systems are stimulated sequentially.

Question 52

COPD cannot be definitively diagnosed without

Answer 52

spirometry

• Results of PFTs in COPD reveal a decrease in the FEV1:FVC ratio.
• An FEV1:FVC less than 70% of predicted that is not reversible with bronchodilators confirms the diagnosis.
• Other spirometric findings of COPD include an increased FRC and TLC.

Question 53

CT is a much more sensitive test compared to simple chest radiography at diagnosing

Answer 53

COPD

Question 54

the first step in treating COPD.

Answer 54

Smoking cessation should be

Question 55

the two important therapeutic interventions that can alter the natural history of COPD.

Answer 55

Smoking cessation and long-term oxygen administration are

Question 56

In COPD, the goal of supplemental oxygen administration is to achieve a PaO2 greater than

Answer 56

60 mm Hg

Question 57

Diuretic-induced chloride depletion may produce a hypochloremic metabolic alkalosis that depresses the ventilatory drive and may aggravate

Answer 57

chronic carbon dioxide retention.

Question 58

Strategies to Decrease Incidence of Postoperative Pulmonary Complications – Preoperative include:

Answer 58

• Encourage cessation of smoking for at least 6 weeks.**
• Treat respiratory infection with antibiotics. **
• Treat evidence of expiratory airflow obstruction.
• Initiate patient education regrading lung volume expansion maneuvers.

Question 59

Strategies to Decrease Incidence of Postoperative Pulmonary Complications – Intraoperative include:

Answer 59

• Use minimally invasive surgery (endoscopic) techniques when possible. **
• Consider regional anesthesia**
• Avoid surgical procedures likely to last longer than 3 hours. **

Question 60

• The maximum benefit of smoking cessation is not usually seen unless smoking is stopped more than

Answer 60

6 weeks prior to surgery.

Question 61

what intervention is a simple and inexpensive, and provides objective goals for and monitoring of patient performance.

Answer 61

Incentive spirometry is