Worksheet #1 Flashcards
(118 cards)
1
Q
What are the 5 As regarding the “Requirements of General Anesthesia”?
A
Amnesia Analgesia Anxiolysis Akinesis Autonomic Control
2
Q
What’s the difference between anterograde versus retrograde amnesia?
A
Anterograde: inability to create new memories after the event (i.e preop midazolam)
Retrograde: inability to remember memories prior to the event
3
Q
What is MAC-BAR?
A
The minimum alveolar concentration that prevents sympathetic response to surgical incision in 50% of patients.
MAC-BAR is 1.7-2 x MAC (For sevo, MAC of 2.1 x 1.7 = 3.57)
4
Q
What’s MSMAID
A
Machine Suction Monitor Airway IV Drugs
5
Q
The primary goal of informed consent is to:
A
educate the patient.
a) Explain the nature and purpose of procedures and the associated risks, benefits, and alternatives.
b) Maximize the patient to make informed decisions.
6
Q
What is informed refusal?
A
When the conversation moves from informed consent to informed refusal. This usually occurs after a patient refuses a recommendation or requests an inappropriate technique.
7
Q
T/F. pre-anesthetic eval is a quality and legal standard.
A
true
8
Q
What is the BIS monitor?
A
Bispectral index monitor - monitor that attempts to measure the effects of anesthesia by processing EEG and converting it to a single number to measure state of awareness.
9
Q
What drugs have little effect on the BIS reading?
A
ketamine, N2O
10
Q
Name stress responses to surgery.
A
Increased HR, BP
Decreased GI activity
Increased sympathetic response = increased catabolism for energy, retain NaCl and H2O, maintain fluid and CV homeostasis
11
Q
Surgery is a (hypercoagulable/hypocoagulable) state.
How could you intervene?
A
hypercoagulable
Provide SCDs
12
Q
What is the first thing you want to know about a surgery?
A
Is this an emergency?
Why is the surgery being done?
13
Q
Describe Guedel’s four stages of anesthesia.
A
Analgesia
Excitement
Surgical State
Stage 4
14
Q
What stage of Guedel’s four stages of anesthesia is respiratory paralysis seen?
A
Stage 4
15
Q
What stage of Guedel’s four stages of anesthesia is eye movement not first seen?
A
Surgical stage - moderately relaxed
16
Q
During stage 2 of Guedel’s four stages, the eyes are:
A
moderate
17
Q
Propofol’s duration after induction is based on:
A
redistribution
18
Q
Why is propofol the most common induction agent?
A
short 1/2 life
19
Q
You have an 82 y/o male with a SBO. How much propofol would you use for induction?
A
Textbook answer is 2-2.5mg/kg.
With him I would use a smaller dose because of the potential for an exagerated drop in BP to a normal dose.
20
Q
What is dissociate anesthesia?
A
Functionally dissociates the thalamus from the limbic cortex. Patients may keep eyes open and maintain many reflexes.
21
Q
Sodium thiopental can produce what side effects?
A
garlic or onion taste
22
Q
T/F. Sodium thiopental is a good induction drug for patients with acute intermittent porphyria?
A
False
23
Q
T/F. Sodium thiopental should not be used in neuro patients because it increases the cerebral metabolic demand.
A
False
24
Q
Can a patient be ventilated during RSI?
A
Some say yes, others say no.
(not greater than 20cm H2O?)
25
When directing an assistant to provide cricoid pressure, when should the pressure be released?
When the anesthesia provider says so
26
A patient on NPO orders should hold off on surgery following ___ hours after drinking clear liquids and ___ hours after eating a light meal.
2, 6
27
When deciding whether to use mask ventilation, LMA, or ETT, name at least four factors for consideration.
Risk of aspiration
Need for muscle relaxation
Length of surgery
Patient positioning
28
What is the cornerstone/motto of anesthesia practice?
Vigilance: vitals, ventilation, surgical field, communication with surgical team
29
What does TIVA stand for?
Total IV anesthesia
30
Phenylephrine works on which receptors?
Alpha 1 agonist
31
Clonidine works on which receptor
Alpha 2
32
N2O is ___x times more soluble in blood than nitrogen
34
33
How do you calculate maintenance fluids of crystalloids?
0-10kg = 4ml/kg
11-20kg = 2ml/kg
21+ kg = 1ml/kg
For adults, weight + 40ml/hr
(i.e. 80kg ==> 80+40 = 120ml/hr
34
What is the typical cause of delayed emergence from general anesthesia?
Residual anesthetic medications
35
List the ASA/Physical Status classification levels.
1. a normal healthy patient
2. mild systemic disease (no functional limitations)
3. severe systemic disease (functional limitations)
4. severe systemic disease, constant threat to life
5. moribund patient who is not expected to survive without the operation
6. patient who is brain dead for organ harvest
E. emergency
**a medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health**
36
What formula would one use to calculate IBW (ideal body weight)?
Broca's formula:
Female: IBW = Ht in cm - 105
Male: IBW = Ht in cm - 100
(i.e. 68 inch female ==> 68in x 2.54cm - 105 ==> 172.72-105 = 67.72kg)
37
Adjusted body weight formula
ABW = [(Actual weight in kg - IBW) x 0.2] + IBW
I.E. If the 5'8 female weighed 220lbs, then IBW = 67.72.
ABW = [(100-67.72) x 0.2] + 67.72 = 74.176kg
38
Succinylcholine should be based off
a) lean body weight
b) adjusted body weight
c) total body weight
total body weight
39
Obesity is a BMW >/= than
30
40
The progression of anesthesia is:
```
Cortex - amnesia, cognition, vision
Sub-cortex - localize, withdraw
Brainstem - Autonomic NS
Cranial nerves - hearing
Spinal cord - akinesis, deep tendon reflex
```
41
The first step in developing an anesthesia plan is to address the:
airway
42
Epidural anesthesia infusion of local anesthetics will (increase/decrease) endocrine and metabolic responses to surgery?
Decrease. Pain sensation is stopped or delayed at the spinal cord, the brain does not receive the pain impulse and therefore cannot react to a perceived stress through a sympathetic response.
43
What is the purpose of denitrogenation?
Replace the N2 in the patients FRC, increasing the concentration of O2 in the alveoli and blood to add a factor of safety during the period of apnea when intubation is taking place.
44
What is the one single class of anesthetic that can provide all the requirements of anesthesia?
volatile agents
45
Volatile agents will do what to respiration:
increase rate, decrease tidal volume and minute ventilation
46
Opioids will do what to respiration:
decrease rate, increase tidal volume, overall decrease in minute ventilation
47
Which medication has a more narrow safety index, fentanyl or isoflurane?
Isoflurane.
48
Most common type of anesthesia uses IV and inhalational agents to provide:
balanced anesthesia
49
Regional + general anesthesia is called:
combined technique
50
Mendelson's syndrome occurs when:
clear aspirate is > 25 ml or 0.4ml/kg and pH < 2.5
51
Wood chest syndrome or chest wall rigidity occurs when:
fentanyl is pushed fast and at high doses
52
What opioid is most commonly associated with sphincter of oddi tone spasms?
morphine
53
How can succinylcholine give a patient a really bad day (aka kill them)?
Hyperkalemia
Triggers malignant hyperthermia
Renal failure secondary to rhabdomyolysis
54
Why use a defasciculating dose of a NDNMB prior to giving succinylcholine?
To prevent myalgias from fasciculations; decrease risk of rhabdomyolysis.
55
3 major phases of a general anesthetic:
preop
intraop
postop
56
What drug may precipitate if mixed with other drugs such as vecuronium?
sodium thiopental
57
What drug induces dissociate anesthesia?
Ketamine
58
T/F. Opiods shift the CO2 response curve to the right (requires more CO2 to trigger a breath)?
true
59
One needs a (higher/lower) dose of succinylcholine after giving a defasiculating dose of a NDNMB.
higher
60
What stage would be most appropriate to perform a deep extubation?
Stage 3
61
Succinylcholine should not be used on patients with spinal cord injuries ___ hours after the accident because:
24.
Loss of neural influence or activity due to a SC injury will cause an upregulation of nicotinic ACh receptors. However, many of these receptors are immature and they populate in areas outside of the NMJ. If succinylcholine is given, it will bind to these immature receptors and release more potassium (hyperkalemia).
62
Diffusion hypoxia is:
an influx of N2O into the alveolus from the blood when N2O flow is decreased from the anesthesia machine common gas outlet. The decreased N2O delivery to the patient causes diffusion of N2O from the blood into the alveoli, and since N2O is 34x more soluble than N2 it will dilute the O2 in the alveolus. This can be prevented by TURNING UP THE O2 FLOW.
63
Which stage of anesthesia is the worst, Stage 1, 2, or 3?
Stage 2. Hyperreflexia of the airway and CV, and irregular respiratory pattern.
64
What should you ask your patient regarding recall?
1. What was the last time you remember before going to sleep?
2. What is the first thing you remember waking up?
3. Do you remember anything in between going to sleep and waking up?
4. Did you dream during your procedure?
5. What was the worst thing about your operation
65
What is implicit memory?
Awareness without recall
No conscious recollection of events.
Like PTSD
66
What is explicit memory?
Awareness with recall.
| Remembers something unpleasant (pain, disparaging remarks).
67
Management of recall
Factually document the incident and continue to be a resource for the patient.
Provide appropriate consultation.
Discuss with your staff.
File a Risk management report.
68
What is MAC?
Minimum alveolar concentration of an inhaled anesthetic that prevents movement in 50% of patients in response to a standard stimulus such as a surgical incision.
69
How can one increase MAC?
Increase ventilation rate of an agent.
Increase amount of delivered agent (% of agent).
Increase flow of carrier gas (O2, air).
Decrease HR/CO.
70
Incidence of recall ranges from:
0.13 to < 2%
71
Benefits of regional anesthesia
Preemptive analgesia
Improved mental alertness
Low rate of nausea/vomiting
72
Six "absolute" contraindications to regional anesthesia:
```
Pt refusal
Uncooperative pt
Increased ICP
coagulopathy
Infection at site of needle injection
uncorrected hypovolemia
```
73
Mallampati classification
Class 1 - PUSH
(tonsilar pillars, uvula, soft palate, hard palate)
Class 4 - H (hard palate)
74
1/2 life of chloroprocaine in the blood stream?
30 seconds
75
T/F. A patient undergoing monitored anesthesia care will lose consciousness?
False
76
Name some keypoints of moderate sedation (conscious sedation):
Purposeful response to verbal or light tactile stimulation
No airway intervention is required
Adequate spontaneous ventilation
CV function usually maintained
**reflexive withdrawal from pain is NOT purposeful movement**
77
Deep sedation
The patients is:
- not easily aroused
- airway intervention may be required
- Spontaneous ventilation may be inadequate
- CV system is usually maintained
78
General anesthesia
- unarousable
- airway intervention required
- impaired CV function
79
Ideal sedation/analgesic agent will have the following:
- no untoward side effects
- quick onset/offset
- painless
- cooperative patient
- awaken promptly
- fully alert, no recollection
80
On the Ramsay sedation scale, a pt crawling all over the bed and yelling for her mother can be said to have a score of __.
1 = anxious
81
On the Ramsay sedation scale, a pt following commands appropriately has a score of __.
2 = awake, tranquil
82
On the Ramsay sedation scale, a pt who does not respond to stimuli has a score of __.
6 = asleep
83
On the Ramsay sedation scale, a patient who quickly opens their eyes to vigorous stimuli has a score of __.
4 = asleep, brisk response to tactile or loud auditory stimuli
84
On the Ramsay sedation scale, a patient opens his eyes to questions has a score of __.
3 = drowsy responds to verbal commands
85
Monitored anesthesia care
- reversible and drug induced
- depressed mentation
- NO loss of consciousness
86
Using an LMA, positive pressure ventilation should not exceed ___ cm H2O.
20
87
T/F. LMAs can be used for prone surgeries?
False, at least in the US.
88
What are some indications for tracheal intubation?
- airway protection (but the ETT is not a definite guaranteed protection against aspiration)
- Maintenance of patient airway
- Pulmonary toilet
- Application of PEEP
- Maintain adequate oxygenation
89
A priming dose of a NDNMB should be given ___ min before the intubation dose. Intubation dose is ___ times ED95.
3-5min
| 1-2 times the ED95, 2-4 times for RSI
90
TIVA
```
Total IV anesthesia: only with IV agents
- IV induction
- infusion pumps, rates easily adjusted
- boluses with pump or syringe
(usually propofol)
```
91
Disadvantage of inhalational anesthesia
- Not receptor specific
- Slower onset than IV induction agents
- No specific reversal agent
- Waste anesthetic gasses
- Increased PONV
- little postop analgesia
- narrow safety index
- can be expensive
92
Advantage of inhalational anesthesia
- Bronchodilator
- Maintain spontaneous ventilation
- Some muscle relaxation
- Simple
- Safe - self-limiting depth of anesthesia if spontaneous respiration maintained
- Does not require IV
- Single medication that can provide all requirements of anesthesia (muscle relaxant doses may decrease CV function)
93
What is MAC-BAR?
1.7-2.0 MAC, the concentration required to block autonomic reflex to nociceptive stimuli.
94
What is MAC-Awake
0.3-0.5 MAC, the concentration required to block voluntary reflexes and control perceptive awareness
95
What is MAC?
Minimum alveolar concentration, the concentration needed to prevent a motor response in 50% of subjects in response to a surgical stimulus
96
What are some medications that can be given to patients at risk for aspiration?
Non-particulate antacids
H2 receptor antagonists
Gastrokinetics
97
Which induction drug can causes adrenocortical suppression?
etomidate
98
Which induction agent will not decrease respiratory drive?
ketamine
99
What is the reasonable patient standard?
What would a reasonable patient in the same or similar situation need to know in order to make an appropriate decision regarding a proposed surgery, treatment, or procedure?
100
T/F. A peripheral nerve block is considered a neuroaxial block.
False. Epidural and spinals are neuroaxial.
101
Which Guedel stage is most associated with laryngospasm?
Excitement stage - stage 2. Avoid airway manipulation especially if ETT not in place.
102
What is meant by disinhibition? When is it seen?
Depression of inhibitory centers of cortical and subcortical producing.
Seen in Stage 2
103
Is Guedel relevant in today's practice?
Not as much because new agents are faster.
104
What IV induction agents are hemodynamically stable?
ketamine, etomidate
105
What is the typical duration of an induction agent?
5-10 min
106
What receptor does propofol work on?
GABA. Also some Na channel blockage.
107
How much can propofol decrease ABP?
25-40%
108
Ketamine provides ___ anesthesia.
dissociative.
| Pt may keep eyes open and maintain many reflexes.
109
What is the induction dose of ketamine?
1-2mg/kg IV
| 3-5mg/kg IM
110
T/F. Ketamine can be used with L&D patients to augment an ineffective epidural.
true. used in caesarian sections.
111
Ketamine's MOA is on the ___.
NMDA receptor antagonist (also opioid receptors, monoamine transporter)
112
T/F. Ketamine can cause a remarkable drop in respiration rate.
False
113
Etomidate works on the ____ receptor.
Modulator at the GABA A receptor.
114
Induction with etomidate has been associated with the following reactions:
myoclonic movement
hiccups
nausea/vomiting
pain on injection
115
The usual dose for induction with etomidate is _____.
0.2-0.3mg/kg IV
116
Injection of a barbituate into the artery will cause:
severe vasospasm
117
What is the benzodiazepine most favorably used for induction?
midazolam. 0.05-0.15mg/kg
118
Steps of RSI
```
Pre O2
Cricoid pressure
Induction of IV agent
Succinylcholine or Rocuronium at 4x ED95
Patient is/isn't ventilated
Rapidly intubated
```
