Term
| What are signs of upper airway obstruction? How do you manage? |
|
Definition
1) Flaring of nostrils, retractions, vigorous abdominal contractions, difficult to mask ventilate.
2) Jaw thrust and or nasa/oral airway |
|
|
Term
| What are the important elements to an anesthesia history? |
|
Definition
1) Surgery/Procedure
2) Prior medical conditions by system
3) Functional capacity
4) Meds, social and allergies
5) Past operations
6) Personal/FH of reactions to anesthesia
7) PE (Malampati classification, tongue, teeth, cervical ROM, thryomental distance, facial hair). |
|
|
Term
What conditions would make you delay surgery?
1) Cardiac
2) HTN
3) Renal |
|
Definition
1) USA, recent MI, decompensated CHF, arrhythmia, severe valvular disease
2) >190 or >110 (if chronic, lower slowly)
3) Must dialyze within 24h of surgery |
|
|
Term
| What drugs should be discontinued on the day of surgery? |
|
Definition
1) Intermittent short-acting insulin
2) Sulfonylureas
3) Herbs/supplements
4) NSAIDS (2d before)
4) Estrogen for HRT/osteoporosis |
|
|
Term
What should you add prior to anesthesia in the following conditions?
1) Severe PONV
2) Pulmonary aspiration risk
3) PMH of substantial allergy |
|
Definition
1) Scopolamine patch 2-4h pre-op
2) H2 blocker, PPI, antacid, metaclopramide
3) Diphenhydramine and cimetidine (totally block histamine) |
|
|
Term
| Why are beta blockers and clonidine useful in some patients for pre-operative treatment? |
|
Definition
1) Beta blockers
- reduce baroreeptor-mediated increases in HR after vasodilation
- relieve angina and mortality post-MI
- decrease myocardial oxygen demand
2) Clonidine (A2 agonist)
- reduces cardiac risks and decreases needed anesthetic dose |
|
|
Term
| Describe the guidelines for food/fluid intake before elective surgery |
|
Definition
1) Up to 8h: food, fluids
2) Up to 6h: light meal
3) Up to 4h: breast milk
4) Up to 2h: clear liquids
5) 2h: NPO |
|
|
Term
| Which patients need prophylactic antibiotics? |
|
Definition
1) High risk cardiac conditions
- Prior IBE
- Mechanical valve
- Cyanotic cong heart disease
2) High risk procedure
- dental procedures
- procedures in respiratory tract, infected skin, MSK tissue
Give cephalosporins (Cefazolin for skin, Ceftazidime for gram negatives) |
|
|
Term
| What is on the differential for hypoxia and how is it defined? |
|
Definition
PaO2 < 60 or saturation <90
1) Atalectasis: R to L shunt
2) Decreased FRC
3) Decreased CO
4) Hypoventilation
5) PE
6) PTX
7) Increased consumption
8) POst-hyperventilation hypoxia |
|
|
Term
| How do you treat a relative shunt vs. an absolute shunt? |
|
Definition
1) Relative means only some alveoli are in trouble- increase O2 inspired
2) Absolute: PEEP/CPAP to re-inflate |
|
|
Term
| How do you treat a relative shunt vs. an absolute shunt? |
|
Definition
1) Relative means only some alveoli are in trouble- increase O2 inspired
2) Absolute: PEEP/CPAP to re-inflate |
|
|
Term
| What are the 3 major causes of hypercarbia and how can they be managed? |
|
Definition
PaCO2 > 45
1) Hypoventilation
- anesthetics are often culprit, which can be potentiated by hypothermia, aminoglycocydes and acidosis
Treat by reversing drug or allowing spontaneous emergence
2) Reduced ability to take breath
- Incentive spirometry, chest PT and deep breathing
3) Co-existing COPD |
|
|
Term
| What are the major differences between a pediatric and adult airway? |
|
Definition
Peds vs. Adults
1) Higher larynx, which is funnel shaped
2) Larger tongue
3) Larger epiglottic (more posterior)
4) Larger head relative to body size
5) Short neck |
|
|
Term
List 5 predictors of difficult bag mask ventilation
List 5 predictors of difficult intubation |
|
Definition
1) Bag mask
- Older
- Facial hair
- BMI >26
- Lack of teeth
- Male gender
2) Intubation
- Mallampati class > II
- Facial hair
- Thyromental distance <6-7cm
- Short neck
- limited cervical ROM |
|
|
Term
| Describe malampatti scoring system |
|
Definition
1) Soft palate, Uvula, fauces and tonsillar pillars visible
2) Soft palate Uvula and fauces visible
3) Soft palate, Base of uvula visible
4) Only hard palate visible |
|
|
Term
| List the indications/contraindications for LMA placement |
|
Definition
1) Indications
- Difficult intubation
- Conduit to pass tactual tube
- Patient not paralyzed
2) Contraindications
- Full stomach |
|
|
Term
| How can you verify the correct position of an ET tube |
|
Definition
1) Bilateral, symmetric chest rise
2) Breath sounds
3) Capnography
4) Condensation |
|
|
Term
| Describe the steps involved in a typical awake extubation |
|
Definition
1) Evaluate protection of airway (conjugate gaze, purposeful movements, following commands)
2) Turn down vent (create hypercapnic drive)
3) Establish spontaneous breathing w/ 100% O2
4) Reverse NMJ blocking drugs
5) Suction oropharynx
6) Deflate ET tube and rapidly remove tube |
|
|
Term
| Who is likely to suffer from laryngospasm and how do you deal with it? |
|
Definition
1) Lightly anesthetized patient at time of extubation
2) Treat with O2 (positive pressure via face mask), Jaw thrust, Succinylcholine
**In kids treat subglottic edema with epinephrine** |
|
|
Term
| What is the anesthesia machine checklist? |
|
Definition
MS MAIDS
1) Machine
2) Suction
3) Monitors)
4) Airway supplies
5) IV supplies
6) Drugs
7) Special items |
|
|
Term
| What are the 2 most common nerve injuries due to positioning? |
|
Definition
1) Ulnar nerve (claw hand)
2) Brachial plexus (painless motor deficit in dist of radial, median nerves) |
|
|
Term
| Why might you place a patient in the trendelenburg position? |
|
Definition
Hypotension (will increase VR and improve exposure during abd surgery)
- Increase CVP, ICP and intraocular pressure
- risk of upper airway obstruction
- will decrease FRC and pulmonary compliance |
|
|
Term
| What is the preferred location for a central line placement? |
|
Definition
| Right Jugular (vs. left subclavian) |
|
|
Term
| Describe the different elements of capnographic wave form |
|
Definition
A-B: Exhalation of anatomic dead space (no CO2)
B-C-D: Exhalation of alveolar gas (BC slope gradual? think obstruction or plum disease)
D- End tidal CO2 concentration
D-E- Inspiration |
|
|
Term
| How can core temperature be monitored during surgery? |
|
Definition
1) Pulmonary artery catheter
2) TM
3) Bladder |
|
|
Term
| What are 4 implications of hypothermia |
|
Definition
1) 1-3 degrees protects against cerebral ischemia
2) Delayed recovery from anesthesia
3) Increased Ox utilization- increase systemic BP/HR- myocardial ischemia
4) Impaired coag times, wound healing |
|
|
Term
| What are the 4 primary elements of anesthesia |
|
Definition
1) Unconsciousness
2) Analgesia
3) Amnesia
4) Muscle relaxation |
|
|
Term
| Describe the basic sequence of induction for general anesthesia |
|
Definition
1) Place monitors
2) Pre-oxygenate (valve open)
3) IV amnesia and anxiolysis (Midazolam)
4) IV analgesia (Fentanyl)
5) IV Induce sleep
6) Bag ventilate (valve closed)
7) Muscle relaxation
8) Stabilize BP (give phenylephrine if BP drops)
9) Intubate
10) Start inhaled maintenance as mix of O2 and N20 |
|
|
Term
What are typical settings for ventilation in terms of the following
1) Tidal volume
2) Respiratory Rate
3) End tidal CO2 |
|
Definition
1) 6-8 ml/kG
2) 8-16 bpm
3) 35 mmHg |
|
|
Term
| What are the defining differences between regular and rapid-sequence inductions? |
|
Definition
For rapid sequence
1) Begin with NG placement
2) Do not induce unconsciousness with propofol or bag-mask, instead go straight to roc/succ
3) Stabilize BP after intubation as opposed to before. |
|
|
Term
| Describe the usual pre-oxygenation required to achieve optimal status |
|
Definition
| - 8 deep (Vital Capacity) breaths of 100% over 1 min or 3 minutes of total volume breaths |
|
|
Term
| What factors increase MAC, decrease MAC and don't affect MAC? |
|
Definition
1) Increase (raise threshold)
- drugs (amphetamines, chronic eTOH, age, hyperthermia, hypernatremia, high CO)
2) Decrease (lower threshold)
- Drugs (chronic amphetamine, acute Ethanol)
- Hypothermia
- Hyponatremia
- Pregnancy
- Low CO
3) Don't affect
- Gender
- Duration of surgery, anesthesia |
|
|
Term
| What is MAC? How does it relate to drug partial pressure? |
|
Definition
min conc to prevent skeletal muscle movement in response to noxious stimuli in 50% of patients (spinal rather than central phenomenon).
- Represents partial pressure at site of action
- 2 drugs at 0.5 MAC= 1 drug at 1 MAC |
|
|
Term
Describe the effects of the following inhaled anesthetics on respiratory rate, tidal volume, PaCO2, ventilary response to hypoxemia, MAP, HR, rhythm and coronary vascular resistance.
1) Desflurane
2) Sevoflurane
3) Isoflurane |
|
Definition
** Volatiles actually provide protective effect against coronary ischemia**
1) Desflurane
- Increases RR, decreases Vt, increases PaCO2, decreases ventilatory response to CO2, decreases MAP (decreases SVR), increases HR (can attenuate with esmolol or fentanyl), prolong QT and decrease coronary vascular resistance
2) Sevolurance
- Same |
|
|
Term
What is the effect of volatile anesthetics on the following?
1) Cerebral metabolic rate
2) ICP
3) NMG blockers
4) Liver function
5) RR
6) Vt
7) HR |
|
Definition
1) Decreases
2) Increases
3) Enhance (esp rocuronium)
4) Can cause hepatic injury (prior exposure required)
5) Increase
6) Decrease (Minute ventilation preserved, but dead space increases)
7) Increased (can control with fentanyl/esmolol) |
|
|
Term
What are the effects of NO on the following spaces?
1) Air-filled cavities
2) Brain
3) Sympathetic NS
4) Those with B12 deficiency |
|
Definition
1) Increase in pressure and volume (exchanged for nitrogen in blood). Can decrease MAC of other anesthetics
2) Increase cerebral vasodilation, CBF
3) Increased sympathetic tone (unless given with opioids)
- Body temp, mydriasis, diaphoresis
4) Can worsen neurologic or hematologic sequele (deactivates methionine synthase and activated homocysteine levels) |
|
|
Term
| Differentiate between alpha and beta half lives |
|
Definition
1) Alpha is half life for Redistribution within blood (steep negative slope)
**Propofol has short alpha T 1/2- quickly goes from brain to body tissue**
2) Beta is for Elimination (less steep negative slope) |
|
|
Term
| Name the primary mechanism of action, advantages and disadvantages of Propofol |
|
Definition
1) Mechanism
- Slows dissociation of GABA from receptor
2) Advantages
- Rapid onset/offset with minimal residual effect
- Lowers PONV
- Cleared well in liver disease
3) Disadvantages
- Decrease HR and BP
- Egg and Soy allergens
- Pain with injection |
|
|
Term
| Name the primary mechanism of action, advantages and disadvantages of Etomidate |
|
Definition
1) Mechanism
- Potentiates GABA effect
2) Advantages
- CV stability (still decreases SVR though)
- Less respiratory depression
- Faster awakening (except for Propofol)
3) Disadvantages
- Slow onset
- PONV
- Adrenocortical suppression (4-8h)
- Seizures, Myoclonus |
|
|
Term
| Name the primary mechanism of action, advantages and disadvantages of Thiopental |
|
Definition
1) Mechanism
- Directly activates GABA receptor
2) Advantages
- Rapid onset/moderate offset
- Good for Rapid-sequence induction
- Less BP/HR effects compared to proposal
3) Disadvantages
- Decrease BP and increase HR
- Long recovery time
- Infusion in acidosis precipitates crystals in veins (DVT) |
|
|
Term
| Name the primary mechanism of action, advantages and disadvantages of Ketamine |
|
Definition
1) Mechanism
- Interacts with non-GABA receptors
2) Advantages
- IM dosing
- Sympathetic stimulant
- Not transfered to Fetus (pregnancy)
3) Disadvantages
- Dissociation with open eyes can fool you
- Hepatic metabolism
- Cerebral vasodilation and increased ICP
- Delirium
- Blocked with BZDs |
|
|
Term
| What are the major effects of Propofol on the CNS, CV and Respiratory Systems? |
|
Definition
Decreased dissociation of GABA from receptor
1) CNS
- Sedation without Analgesia
- Decreased CBF, CMR, CPP
- Decreased ICP
- Burst suppression in EEG (good for NSX patients)
2) CV
- Decreased HR
- Decreased BP (lowered SVR)
3) Respiratory
- Apnea (low RR, low Vt, low minute ventilation)
- Decreases upper airway reflexes |
|
|
Term
| How do BDZ drugs work? When are they used and what are the major side effects? |
|
Definition
1) Enhance GABA chloride channel opening
- Terminated with Flumazenil
2) Used pre-op for anxiolysis and amnesia
- Laso for sedation, suppression of seizure activity, EtOH withdrawal
3) Side effects
- Decreased CBF and CMR
- Peripheral vasodilation (low BP)
- Minimal respiratory depression |
|
|
Term
How do Opioid analgesics work?
When are they used and what are the major side effects? |
|
Definition
1) Bind opioid receptors (GPCR), facilitate inhibitory activity, inhibit substance P releases from primary sensory neurons in dorsal horn
- Also act on forebrain structures
**reversed by Naloxone**
2) Uses
- Pain relief (less effective against first pain compared to second pain)
- Better at unmyelinated C fibers compared to unmyelinated A-delta fibers.
- Drowsiness, sleep, suppression of cough reflex (ET tube)
**Best as pre-emptive analgesia**
3) Side effects
- Respiratory depression
- NV
- pupillary constriction, urinary retention
- Muscle rigidity, tonic contraction of GI smooth muscle (delayed emptying)
- Reduce MAC of volatile anesthetics |
|
|
Term
True or False
Spinal/intradural opioids do not cause sympathetic side effects, weakness or loss of proprioception |
|
Definition
|
|
Term
What is MAC and why might it be used in the OR?
What are the major complications and indications to convert to GA? |
|
Definition
1) Monitored Anesthesia Care
- Usually in combination with local/regional block
- Drugs given by continuous infusion
- Same drugs as GA but in lower doses
2) Complications
- Apnea
- CV instability
- Be ready to convert! |
|
|
Term
Provide an example of an Amide and an Ester Local anesthetic.
How do their mechanisms differ and what is the probability of allergic reactions? What about metabolism, maximum single dose required, onset and duration? |
|
Definition
1) Amide: Lidocaine, Bupivicaine
- Stabilize Na nerve channels and block conduction
- Low likelihood of allergy
- Metabolized in liver
- Lower dose required
- Slower (except lidocaine) and last longer
2) Ester: Procaine
- Same mechanism
- Can cause allergy (PABA cross-reacts with common preservatives)
- Metabolized to PABA by local Cholinesterase's
- Higher dose required
- Rapid and shorter action |
|
|
Term
| How many nodes of Ranvier must be blocked with a local anesthetic to block a myelinated fiber (A or B)? Which type of myelinated fiber is easier to block? |
|
Definition
- 3 nodes necessasry
- B fibers are easiest
**remember, locals work faster on unmyelinated, but myelinated are more sensitive** |
|
|
Term
| What are the major complications of using local anesthetics and how can they be treated? |
|
Definition
1) CNS: Agitation, restlessness, tremor, convusions, vertigo, tinnitus
2) CV: Angina, SOB, Dysrythmias
3) Resp: Methemoglobinemia (linked especially to the Amide Prilocaine)
4) Treatment
- Can give with Epinephrine to prevent complications caused by LA entering blood) EXCEPT in HTN, dysrythmias, placental insufficiency |
|
|
Term
How would you treat each of the following complications of LA administration?
1) Seizure
2) Hypotension
3) AV block
4) Methemoglobinemia
5) Transient radicular irritation
6) CE syndrome
7) Allergy |
|
Definition
1) Diazepam and Hyperventilation
2) Risk high with Bupivacaine- avoid with Lidocaine which is less lipid soluble
3) Again use lidocaine
4) IV methylene blue (risk with Prilocaine)
5) Resolves within 7 days without treatment
6) Don't use small catheters in SA space
7) Chance with Ester (Procaine) because of PABA intermediate |
|
|
Term
| What is the maximum safe dose for Lidocaine with and without Epinephrine? |
|
Definition
1) Without: 4.5 mg/kg (not to exceed 300)
2) With: 7 mg/kg (vasoconstriction decreases absorption and increases duration of action) |
|
|
Term
| How do the mechanisms of Succinylcholine and Non-depolarizing NM blockers differ? |
|
Definition
1) Succinylcholine (Depolarizing)
- Keep AChR open
- Phase 1 (depolarizing) then Phase 2 (desensitization)
2) Non-depolarizing
- Competitive Antagonist of ACh at muscle nAChR |
|
|
Term
| Distinguish between the onset/duration and metabolism of succinylcholine compared to rocuronium |
|
Definition
1) Succinycholine
- Rapid onset (30s) and short DOA (5-10m)
- Metabolized slowly by AChE (compared to ACh)
- Metabolized Rapidly by plasma cholinesterase (pseudocholinesterase)
2) Rocuronium
- Onset 1-2m and duration 20-35m
- Effects decreased under conditions of high calcium, corticosteroids, anticonvulsants (Phenytoin), burn injury |
|
|
Term
| What are the major adverse side effects of Succinylcholine and Non-depolarizing blockers? |
|
Definition
1) Succinylcholine
- Dysrythmias
- Fasciculations
- Hyperkalemia (renal failure patients protected)
- Myalgias
- Myoglobinuria
- Trismus
2) Non-depolarizing
- Dysrythmias
- Increased HR and SVR (However, not with Vecuronium) |
|
|
Term
| Which patients should NOT get succinylcholine? |
|
Definition
1) 24 after major burn, trauma, SCL with muscle denervation
- Kids should not (hyperkalemia)
- ICU patients
- Narrow-angle glaucoma
- Malignant hyperthermia (history)
- Plasma pseudocholiensterase deficiency. |
|
|
Term
| How can the depth of muscle relaxation be judged in an emerging patient? |
|
Definition
1) Superficial electrodes over facial nerve (orbicularis oculi) or Ulnar nerve (Adductor pollicis)
- Deliver supramaximal stimulation and evaluate responses
1a) Single twitch: depth of NM blockage= height of twitch/predicted x100%
- 0/4 is 100% excessive and cannot be reversed
- 1/4 is 90%, which is adequate for intubation and is reversible
- 2/4 if 80%
- 3/4 is 75% suppression and adequate for surgery with inhalation agents
- 4/4 is 25% suppression and decreased vital capacity
1b) Train of 4 (TOF at 2hz): # out of 4 and TOF ratio of 4th compared to 1st)
- For non-depolarizing, TOF ratio <0.7 indicated blockage
- For Succinylcholine, TOF ratio of 1 indicates phase 1 (all twitches down) and TOF <0.3 indicates phase 2 |
|
|
Term
How are non-depolarizing NM blockers reversed and what are the side effects of these drugs?
How/when should they be administered? |
|
Definition
1) AChE increases ACh at receptors (selective action peripherally)
- Neostigmine (strong), Edrophonium (short-acting)
2) Side effects: bradycardia, hypotension, increased GI motility, sweating, urinary retention
3) Administration
- TOF <4/4- give Neostigmine with glycopyrrolate (both 5-7 min, longer-acting)
- TOF 4/4- Give edrophonium and atropine (both rapid onset)
- TOF 0/4- Don't unblock, you don't know where you are in blockage sequence. |
|
|
Term
What are the implications of "incomplete reversal" of a non-depolarizing NM blocker
How can you confirm adequacy? |
|
Definition
1) Weak pharyngeal muscles= airway risk
2) Decreased ventilatory response to hypoxia
3) Confirmation
- TOF >0.9
- Sustained response to tetanus
- Skeletal muscle strength (head/leg lift)
- Grip strength, conjugate gaze, messeter strength |
|
|
Term
What are the basic needs for water, Na and K per day?
How should fluid losses be replaced for minor and major surgery, respectively? |
|
Definition
1) 2500 ml/day, Na 30 and K 20 mEQ/L
2) 4 ml/kg/hr for minor surgery (about 280/h)
3) 8 ml/kg/hr for major (about 560/h) |
|
|
Term
| What are the primary determinants of oxygen delivery to tissues? |
|
Definition
1) Oxygen carrying capacity of blood
2) Oxygen in blood
3) Circulating volume
4) Contractility
5) Constriction/Dilation of vessels |
|
|
Term
| How do Crystalloids and Colloids differ in their use? |
|
Definition
1) Crystalloid: Does not stay intravascular (1/3 stays)
- NS (slightly hypertonic), LR (slightly hypotonic), D5W (iso-osmotic, functions as free water).
2) Colloid
- Kept within intravascular space (good for rapid expansion)
- Albumin (5% translates to 20 mmHg colloid pressure)
- Dextran (Degrades to glucose and prevents platelet adhesion)
- Hydroxyethyl start (HES) |
|
|
Term
What type of crystalloid is preferred for each of the following situations
1) Hypernatremia
2) Hyponatremia
3) Hypochloremic MA
4) Hyperkalemia in renal failure |
|
Definition
|
|
Term
| What are the major complications of blood transfusion? |
|
Definition
1) Viral infection: Hep C (1/1.6 million), HIV (1/1.8 million)
2) Reaction (Debrile, allergic, hemolytic)
3) Acute lung injury (ARDS)
4) Immunosuppression (cell-mediated)
5) Citrate intoxication (high H+ in blood) with acidosis- use HCO3
6) Hypothemia (use warmers)
7) Coagulopathy: dilution TP, DIC |
|
|
Term
What are the indications for transfusion of the following
1) Platelets
2) FFP
3) Cryoppt |
|
Definition
1) <50k
- 1U increases 5-10k 1hr post-transfusion
2) Coag factors without platelets
- PT/PTT 1.5x longer than normal
- Reversal of warfarin therapy
- Correction of coat factor deficits
3) Clotting factors (especially VIII)
- Good for hemophilia and hypofibrinogenemia |
|
|
Term
| What are the major advantages of regional anesthesia over GA? What about the disadvantages? |
|
Definition
1) Advantages of regional
- No loss of consciousness, sore throat or laryngeal spasm
- Epidural > spinal b/c of HA, hypotension and post-op cath
- Spinal > epidural bc easier and more intense
2) Disadvantages of regional
- Inadequate sensory block
- Patient is aware
- |
|
|
Term
| Describe tissue layers a needle would pass through from skin to SA space |
|
Definition
| Skin..superficial fascia...supraspinous ligament....interspinous ligament.....ligamentum flavum...epidural space....dura mater (pop)...arachnoid space...SA space (with CSF) |
|
|
Term
| What are the major complications of spinal anesthesia? |
|
Definition
1) Neurologic
2) Hypotension (can lower head and give phenylephrine)
3) Bradycardia/asystole (give atropine)
4) Post-dural puncture headache (most common)
5) Difficulty breathing/apnea
6) Nausea, urinary retention, root irritation |
|
|
Term
| What are the major complications of Epidural anesthesia? |
|
Definition
Same as spinal PLUS
1) Hematoma, abscess
2) Dural puncture
3) Systemic absorption
4) Hypotension
5) Nerve injury (If not mid lien) |
|
|
Term
| Describe the basic organization of the autonomic NS and the order of fibers affected by regional anesthesia |
|
Definition
1) Thoracolumbar is sympathetic pregang, Wheras craniosacral is parasympathetic pre gang
2) Sympathetic, Sensory (test with alcohol rub) then Motor |
|
|
Term
Why would you use each of the following sympathomimetics/sympatholytics?
1) Dopamine
2) NE
3) Epi
4) Isoproterenol
5) Dobutamine
6) Ephedrine
7) Phenylephrine |
|
Definition
1) a (high dose), b (medium dose), d receptors (low dose). - Give for low CO, low SBP, high LVEDP, oliguria
2) a1, b1 and minimal b2 receptor action.
- Refractory hypotension
3) a1, b1 and b2
- Decreases contractility, for allergy, for refractory bradycardia
4) B1 and B2 (no alpha so lower resistance)
- Post heart transplant
- Complete heart block
- Valvular heart disease
5) B1 only
- Give for hypotension and oliguria (infuse with dopamine)
6) Indirect B1 (NE releasing agent)
- Give for hypotension
7) A1 only
- Hypotension in pregnant patients, nasal congestion |
|
|
Term
| What is glycopyrollate and why might you give it during anesthesia? |
|
Definition
1) Anticholinergic (preferred over atropine b/c does not cross BBB) that is given to prevent too much anticholinergic effects (or Succinylcholine).
** Often given with neostigmine during reversal of NM blocker to prevent over-cholinergic effects**
2) Reversed with Physiolostigmine |
|
|
Term
| How does the result of NO differ from N2O? |
|
Definition
| NO relaxes pulmonary vasculature (anti-hypertensive) whereas N2O constricts it |
|
|
Term
| How should hypertension in the PACU of unknown etiology be treated? |
|
Definition
| IV nitroprusside (monitor arterial pH to look out for cyanide which can cause M acidosis) |
|
|
Term
Who would you treat the following hemodynamically significant conditions in the PACU?
1) Tachycardia
2) Bradycardia
3) PVCs |
|
Definition
1) Verapamil
2) Atropine
3) Lidocaine |
|
|
Term
| How is a patient's readiness for discharge from the PACU scored? |
|
Definition
Each gets 0-2 points under Aldrete scoring system
**Does not need UOP or tolerating fluids**
1) Activity
2) Breathing
3) Sys BP
4) LOC
5) Oxygenation |
|
|
Term
| What are the risk factors and treatment for PONV? |
|
Definition
1) h/x of PONV, female, nonsmoker, use of post-op opioids, anesthesia
2) Ondansetron, metaclopramide, scopolamine
*** better to give pre-op or before awakening |
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Term
| What special considerations are appropriate for anesthesia in an asthmatic? |
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Definition
1) Blunt bronchospams
- Give IV lidocaine for intubation and extubation
- Rapid sequence intubation
2) PEEP is not idea (impaired exhalation)
3) Anticholinergics (used to reverse non-depol NMBD)
4) Ventilation: slow RR and high inspiratory P with long exp times
5) Extubate early to take advantage of suppressed airway reflexes |
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Term
| What special considerations are appropriate for anesthesia in a patient with Emphysema and Chronic Bronchitis? |
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Definition
1) Avoid N2O (can enlarge and rupture bullae)
2) Caution with opioids
3) Don't correct hypercarbia
4) Vent: slow RR, small Vt, high inspiratory flow rate
5) Extubate LATE (after all function is back)
- use double-lumen ET-tube |
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Term
What are the typical signs/symptoms of bronchospasm?
How can you treat it? |
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Definition
1) Wheezing, increased peak inspiratory pressure with decreased Vt, Slower phase II upslope of capnogram
2)
- Kinked tube? mucous plug?
- Augment anesthesia: IV propofol, give inhaled anesthetics, albuterol (NMB doesn't help because smooth muscle!) |
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Term
| What special pre-operative and intraopertiave management applies to a patient with COPD? |
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Definition
1) Pre-op PFTs, ABGs
2) Intraoperative
- LMA has less airway resistance
- Epidural to decrease airway reflexes and avoid hyper reactivity
- Propofol, sevlo/iso
- Avoid NO (bullae rupture)
- Humidify
- Crystalloid to decrease viscosity of secretions |
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Term
| What are the clinical predictors for preoperative cardiac risk? |
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Definition
1) USA, Decompensated HF, Significant aryth, Valvular disease
- Postopone until stabilized or corrected
2) If low risk surgery, or Mets >4, proceed. |
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Term
| What special considerations should be made for anesthesia in a patient with CAD/ischemia? |
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Definition
1) Induction
- Keep catecholamines low
- Give lidocaine prior to intubating
- place arterial line
- TEE and PA cath are reasonable
- Avoid ketamine and pancuronium (raise HR)
2) Maintenance
- Deso and Sevo are good
- Aggressive with fluids
Post-op
- Avoid hypothermia and pain to prevent O2 demand |
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Term
| What special considerations should be made for anesthesia in a patient with valvular heart disease? |
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Definition
| Keep HR high, limit fluids (except in mitral prolapse) |
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Term
| What special considerations should be made for anesthesia in a patient with CHF? |
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Definition
Give inotropes and avoid volatiles (BP and HR effects)
Use Ketamine and Opioids |
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Term
| When should a patient get preoperative beta blockers? |
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Definition
CAD, PVD, 2 RF
Atenolol is good. |
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Term
| What are the determinants of myocardial oxygen supply and demand? |
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Definition
1) Supply
- Pa O2, coronary flow (diastolic BP and HR)
2) Demand
- HR, Contractility, SBP, Preload |
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Term
| What are the major anesthetic implications of OSA? |
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Definition
Apnea= 10s of no airflow
1) Difficult to intubate- may need awake intubation
2) Do not extubate until full block is worn off
3) CNS depression (lower pre-op sedation)
4) Prefer regional/local anesthesia instead of opioid b/c respiratory depression. |
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Term
| What are the adverse physiologic effects of acute pain (hint: PaGE the ICU) |
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Definition
1) Pulmonary: low lung volumes
2) GI: ileus
3) Endocrine: hyperglycemia (catecholamine), Na and water retention, protein catabolism
4) Immune: impaired function
5) Cardio/coag (hypercoagulable)
6) Urinary: urinary retention |
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Term
| Why might NSAIDs be preferable to Opioids in the preoperative period? |
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Definition
| Ketorolac or Piroxicam- avoids N/V/resp depression |
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Term
| How should IV opioids medications be transferred to PO versions? |
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Definition
| 3-6 times higher dose because of first-pass hepatic and lung metabolism |
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Term
| What is the use of naloxone? When is it indicated? |
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Definition
1) Reverse opioid-induced analgesia and respiratory depression
- reversal is abrupt with sudden perception of pain
2) Indications
- Somnolent patient with RR<8 and pinpoint pupils
- Give as 2-3 boluses separated by few minutes (acts for 30 minutes) |
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Term
| Describe how volume, rate and pressure support are determined in mechanical ventilation. |
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Definition
1) Volume
- Pressure
- Volume
- Time
2) Rate
- Assisted: triggered by patient
- Controlled: machine takes control
- Intermittent mandatory ventilation (patient can breathe on own over)
- Assist-control: patient until they fall behind
3) Pressure Support
- CPAP: positive pressure during both inspiration and expiration
- PEEP: Holds airways open |
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