question

SAIL

answer

S = Septal V1 V2 : A = Anterior V3 V4 : LAD I = Inferior II III AvF : RCA L = Lateral I V5 V6 AvL : Circumflex

question

Lead II

answer

Best lead for P wave monitoring Best for determining arrhythmias Inferior wall ischemia

question

Pulse Oximeter

answer

Contains 2 LEDs Red (660nm) deoxy hemoglobin Infrared (940nm) oxyhgb Ratio of red to infrared light absorption during arterial pulsations estimates SaO2 by an empirical algorithm from healthy volunteers Accuracy is within 2-4% Accurate from 70% - 100% Ear pulse ox will show you the change the quickest

question

Pulse Ox spurious readings

answer

Methylene blue will decrease the SpO2 - by interfering with the wave length and effecting the algorithm

question

MetHgb

answer

From prilocaine or benzicaine Causes a falsely low saturation reading SpO2 is actually greater than 85% and a falsely high reading if SpO2 is actually less than 85% Tx give methylene blue

question

CarboxyHgb

answer

From stroke, carbon monoxide Will decrease SpO2 overtime but the Pulse ox reading is false reads higher than actual PaO2 This cause by a shift left hgb holding onto O2 and not releasing it to the tissue

question

Left Shift

answer

Hypothermia, Decreased 23 DPG, Increased PH --> Hypoactive

question

Right Shift

answer

Hyperthermic, Decreased PH, Increased 23DPG --> Hyperactive (hyper metabolic)

question

Capnography

answer

Indirect assessment of PaCO2 Gradient of 5-8 torr between the ETCO2 and the PaCO2 Due to alveolar dead space ETCO2 will always be lower than PCO2 (i.e. ETCO2 = 30 and PCO2 = 40 Normal sampling volume is 250ml/min from side stream

question

SALT

answer

Suction Airway Laryngoscope (bright light: different blades) Tube (2 tubes: stylet: CHECK CUFF)

question

V5

answer

A^2 or AA 5th intercostal space Most sensitive monitor for detection of anterior or lateral ischemia

question

Based on Beer-Lambert's Law

answer

Pulse ox measurements are based on this principle Oxygenation and Deoxygenated hgb differ in absorption of red and in fared light

question

Limitations of the Pulse Ox

answer

Requires pulsating arterial bed Low perfusion states does not work Cold (vasoconstriction) Dyes (methylene blue or Indigo carmine) = as soon as circulated pulse ox will give a false low reading lasts about 3m Electrocautery/motion Intense light Requires Hgb (severe anemia) Requires nonpulsitile venous bed

question

Malignant hypothermia

answer

More common in children Hyermetabolic state with a high production of CO2 = ETCO2 will climb quick and fast (Increased temp is a late sign) TX: with dantrolene Stop triggers: Succs or inhalation agent

question

Capnography waveform: Phase 1

answer

Flat Should be at zero Inspiration Devoid of CO2 Anatomic deadspace Apparatus deadspace

question

Capnography waveform: Phase II

answer

Early point of exhalation Sharp upstroke = normally near vertical Represents appearance of expired CO2 Signifies the mixing of deadspace gas with alveolar gas

question

Capnography waveform: Phase III

answer

Plateau capnography normally horizontal may have slight incline Represents CO2 rich alveolar air Most Physiology Airway resistance End plateau point is the ETCO2 Best clinical reflection of alveolar CO2 tension

question

Capnography waveform: Phase 4

answer

Rapid downstroke Corresponds to fresh gas sampled with inspiration Travels back to baseline Should be zero Unless rebreathing has occurred

question

Abnormalities: Phase 1

answer

Above baseline CO2 in inspired gas (rebreathing) Very small and rapid tidal volume Expiratory value incompetent CO2 absorber used up, low gas flow (dial flows up to decrease rebreathing)

question

Abnormalities: Phase 2

answer

Slanted upstroke Partial obstruction Slow sampling rate Slow respond time

question

Abnormalities: Phase 3

answer

Slanted upstroke Airway resistance Low resistance first then high resistance Biphasic waveform

question

Abnormalities: Phase 4

answer

Oscillations in down slope = diaphragm moving after NMB Incompetent inspiratory valve reverse flow alarm Cuff Leak

question

Increased ETCO2

answer

Hypoventilation Increased metabolic states MH, Sepsis, thyrotoxicity Rebreathing Tourniquet release (transient: lactic acid build up = a drop in BP as the limb refills = inc ETCO2) Administration BiCarb Insufflation during laparoscopy: blow belly up with CO2 (decrease TV inc rate) Exhausted soda lime

question

Decreased ETCO2

answer

Hypothermia = dec CO2 production Decreased CO2 = decrease delivery to the lungs Hyperventilation Pulmonary embolus Leak in system

question

Agent Analyzer

answer

Monitor various gases: N2, N2O, O2 and anesthetic agents Assessment of anesthetic delivered = detection of toxic concentrations O2 consumption = difference between inspired to expired O2

question

Hypothermic Effects

answer

Ventricular arrhythmias <28 - 30 C Increased peripheral vascular resistance Left shift of Hgb-oxygen saturation curve (hgb holds O2 and does not release to tissue) Decreased drug metab

question

Postoperative effects of low temperature

answer

Shivering Increases O2 consumption 300-400% Decreases SpO2 Increases risk of MI Protein catabolism/stress response Altered mental status Impaired renal function Poor wound healing

question

Nerve Stimulators

answer

Place electrodes over course of nerve not the muscle Ulnar nerve stimulation (adductor pollicis muscle) = more accurate Facial nerve stimulator (orbicular is oculi muscle) = comes back quicker

question

TOF

answer

4 successive twitches in 2 seconds Twitches fade as relaxation increases 3 or 4 twitches = 75% blockade 2 twitches = 80% blockade 1 twitches = 90% blockade (must have at least 1 twitch to reverse) 0 twitches = 100% blockade (cannot reverse)

question

Best Test for Recovery

answer

Head lift 5 secs: laryngeal muscles and pt cooperation and understanding Hand grasp 30-50 % what they were previously

question

BIS

answer

Computer processed EEG : uses scalp electrodes Reflects anesthetic effects on the CNS : good for the correct titration of anesthetic agents 0: death 45-60: surgical anesthetic ( bis is good here) want pt at 60 80-95: sedated 100: fully conscious

question

Monitored Anesthesia Care

answer

Sedation with no loss of consciousness or protective reflexes Pre-anesthesia evaluation Prescription of anesthetic care Administration of medication Post-op anesthesia care

question

MAC for Which Procedure

answer

Any procedure in which local infiltration is likely to provide adequate surgical anesthesia Cystoscopy Suction D&C = as long as they are <10wks Eye Procedures Thrombectomy/AV GraftBreast Biopsy

question

Lidocaine

answer

Plain: 4mg/kg With Epi: 7mg/kg Total: 300 mg

question

Bupivicaine (Marcaine)

answer

Plain: 3 mg/kg With Epi: mg/kg Total: 175 mg

question

Addition of Epi to Local

answer

Not recommended with: Unstable angina Arrhythmias Ureteroplacental insufficiency Uncontrolled HTN IV regional anesthetic Areas that may lack collateral flow Penis Digits Ear lobes/Nose

question

Local Anesthetic Toxicity

answer

Dysphoric feeling Ringing or roaring in the ears Metallic taste in mouth Circumoral numbness Slurred speech Drowsiness Small muscle twitching (face/hands) Arrhythmias Seizures Hypotension Cardiac arrest Make sure pt has on O2 = increases seizure threshold

question

Pre-seizure CNS symptoms

answer

50-100mg Sodiumthyopentathol Increases seizure threshold Seizures CAll for help Oxygenate, Hyperventilate Decreasing PaCO2 decreases cerebral blood flow and thus decreases delivery of local to the brain Check BP, Pulse Succs = stops peripheral manifestations of seizure

question

Our Job

answer

Provide "Twilight Sleep" With pt 100% of the time Monitor VS, oxygenation Consider some form of CO2 monitor Either nasal prongs with CO2 port or CO2 tubing held down by mask Make them very sleepy for LA injection: after they may doze off and on If we can't get pt comfortable we induce general anesthesia *Normal MAC sleeping but arousable*

question

Midazolam (Versed)

answer

...

question

Fentanyl

answer

...

question

STP or Brevital

answer

...

question

Propofol

answer

...

question

Obstruction

answer

Rocking motion of the chest wall Attempt to move air, but posterior wall of pharynx is obstructed by tongue or epiglottis (head tilt/chin lift) Usually occurs after anesthetic induced relaxation of pharyngeal-laryngeal muscles Exaggerated in edentulous pt #1 Stimulate #2 Chin lift/jaw thrust #3 Nasal airway

question

Nasal Airway

answer

For semiconscious For lightly sedated anesthetized pt Must be lubricated Avoid in children or anti coagulated patients (prominent adenoids could cause bleeding)

question

Oral Airway

answer

Used to maintain potency of pharynx in unconscious patients Correct length = distance from the tip of the nose to the ear lobe

question

Laryngospasm

answer

Spasm of the laryngeal musculature (upper airway) Results in the closure of vocal cords and inability to ventilate Caused by: Secretions Noxious stimulation during light plane of anesthesia Treatment Call for help 100% O2 Apply 15-20cmH2O continuous airway pressure If persistent spasms and hypoxia develops give SUCCS = 20mg up to full dose

question

Negative pressure pulmonary edema

answer

YOUNG STRONG MEN = they try to breath hard against a closed glottis = they will have a low O2 sat and extra secretions

question

Bronchospasm

answer

Lower airway obstruction Manifested by involuntary contraction of the bronchial portion of respiratory tree May have wheezing Treatment: Deepen anesthesia Beta agonist Proventil inhaler (albuterol) Epi (SQ/IV) Steroids Aminophylline

question

Mallampati Class 1

answer

Full visibility of tonsils, uvula and soft palate

question

Mallampati Class 2

answer

Visibility of hard and soft palate, upper portion of tonsils and uvula

question

Mallampati Class 3

answer

Soft and hard palate and base of the uvula are visible

question

Mallampati Class 4

answer

Only Hard Palate visible

question

NPO Status

answer

Clears - 2 hours Breast milk - 4 hours Formula/milk - 6 hours Light meal - 6 hours

question

Cardiovascular

answer

Operative hx (CABG, CEA, etc) Medical hx: s/p MI, CAD , HTN, CHF, rheumatic fever, MVP, murmur/valve problem = medications often provide clues Symptoms: chest pain/pressure, arrhytmias, DOE, PND; progression of symptoms Exercise tolerance: stairs, walking/shopping, etc PVD history and symptoms

question

Pulmonary

answer

COPD, asthma: cause frequency last time in ER? Previous chest surgery SOB: progression of symptoms, wheezing, stridor, sleeping position? Medications Recent URI: any current symptoms, differentiate between head cold/chest congestion

question

Renal

answer

Especially important with DM CRI/CRF: dialysis, how long? When was last HD? Post - transplant S/P Nephrectomy

question

Hepatic/GI

answer

Jaundice, cirrhosis Hepatitis history: when? cause? look at LFT PUD, chronic heartburn Reflux symptoms Hiatal hernia: Symptomatic? Can they sleep flat? Meds? Recent N/V?

question

Neurological

answer

History of HA Syncope/seizure TIA's, visual disturbances CVA history: existing parasthesia, paralysis? Other focal neuro signs IMPORTANT AREA TO FOCUS ON FOR REGIONAL ANESTHETIC

question

Endocrine/Metabolic

answer

DM (IDDM vs NIDM): duration? brittle? Medication: give 1/2 insulin dose after IV started: Hold ORAL HYPOGLYCEMICS Other endo problems: Thyroid/parathyroid, pituitary, adrenal/PHEO, morbid obesity

question

Musculoskeletal

answer

MS Hemiparesis Arthritis Whiplash Hx Broken bones Lower back pain

question

Psychiatric

answer

Dep/anx Schizophrenia Alzheimer's Dementia Meds : Prozac/SSRIs, MAOI, Trcyclics, Lithium

question

Hematalogical

answer

Chronic anemia? Bleeding problems: bruise easily, hemophilia Sickle cell: trait or disease

question

ASA Physical Status

answer

Classification based on physical condition Independent of the planned surgery Six classes (1-6) Emergency (E)

question

ASA -1

answer

no health disturbances

question

ASA -2

answer

Mild - mod systemic disease: HTN, DM, Obesity, Bronchitis, Smoking

question

ASA -3

answer

Severe activity limiting systemic disturbances: cardiac pulmonary, angina previous MI, Brittle DM

question

ASA - 4

answer

Severe systemic disturbance that is a constant threat to life: CHF, persistent angina, CRF

question

ASA - 5

answer

Moribund patient not expected to survive 24 hours with/without surgery

question

ASA - 6

answer

Brain dead pt for organ retrieval

question

Crystalloids

answer

Polyionic and nearly isotonic: NS, LR (dextrose solutions generally not used) For fluid deficits replacement of up to 15% blood loss Inexpensive with little risk of allergy

question

Colloids

answer

Protein or starch solutions (some pt have allergies) Pull fluid into the vascular space by increasing osmotic pressure Hetastarch, albumin Expensive and increased risk of allergic reaction

question

Lactated Ringers

answer

NA 130 meq K 4 meq Ca 3 meq Cl 109 meq Lactate 28 meq Most common used fluid in anesthesia *never mix with Blood*

question

0.9%

answer

Na 154 meq Cl 154 meq This is the ONLY solution to be used for PRBC to reduce viscosity and facilitate rapid infusion

question

Colloid Solution

answer

Rapidly increase intravascular volume: pulls from extravascualr space May help reduce/avoid need for bld transfusion May increase tendency to bleed Dilution of clotting FX can occur with large infusion of colloids: avoid giving MORE THAN 20 ml/kg May stabilize pt while awaiting type and X-match

question

Antiemetics

answer

Droperidol 0.625 - 2.5mg Butryrophenone r/t haloperidol Inhibits dopamenergic receptors in CTZ Cause sedation, dysphoria, extrpyramidal reactions, tar dive dyskinesia Ondansetron (Zofran) 2-4 mg SLOWLY Selective 5-HT3 receptor antagonist Works better prophylactically

question

Benzodiazepines

answer

Produce anterograde amnesia Minimal respiratory depression Act on GABA, Limbic system, Thalamus, and Hypothalamus Anxiolytic, hypnotic, anticonvulsant, and muscle relaxant effect ROMAZICON = reversal

question

Valium (Diazepam)

answer

Preop, standard for comparison, 1/2 life 21-37 hours: CONTRAINDICATION = glaucoma and burning with injection

question

Midazolam (Versed)

answer

Water soluble - more rapid onset and shorter duration: greater amnesia 3-4x sedative potency: IV, PO, rectally, intranasally

question

Lorazepam (Ativan)

answer

6-10 hour duration- Pre CABG/ventilation management

question

Gastric antacids

answer

Neutralize/remove acid from gastric content Contains aluminum, calcium, magnesium salts

question

Particulate antacids

answer

Maalox, Mylanta, Tums etc = may cause aspiration pna

question

Non Particulate antacids

answer

Clear - Na Citrate, Bictra, Polycitra less likely to cause pneumonitis = unpleasant taste 15-30ml PO

question

Metoclopromide (Reglan)

answer

10mg over 1-2 minutes Pre med with versed can make ppl feel nervous Derivative of procainamide (no LA affects) Stimulates gastric emptying Acts as an antiemetic Increases LES tone by 10-20cm H2O Effects Nervousness Does not alter gastric secretion Minimal sedation Rare extrapyramidal reactions H-2 antagonists Prophylaxis for aspiration

question

Ranitidine (Zantac)

answer

Blocks histamine, pentagastrin, and acetylcholine induced secretions No significant effects on emptying time or volume Hepatic excretion

question

Famotidine (Pepcid)

answer

Renal excretion

question

Cimetidine (Tagamet)

answer

Many interactions and SE Renal/hepatic elimination Interferes with CP-450

question

Replacement of hourly requirements

answer

First 10 kg = 4cc/kg/hr Next 10-20 kg = 2cc/kg/hr Each kg >20 = 1cc/kg/hr or 1.5cc/kg/hr adult 3cc/kg/hr child 6ml/kg/hr infant (up to 1 year) *CHEAT +40 will work for anything above 20kg

question

Deficit Replacement

answer

Multiply maintenance rate by the NPO hours Infusion of fluid deficit 1/2 total deficit in 1st hour 1/4 total deficit in 2nd hr 1/4 in 3rd hour Try to preload 10-12ml/kg prior to induction of GA and major conduction block - helps restore deficit and prevent hypotension

question

Third spacing from wound exposure

answer

Minor = 0-4cc/kg/hr: hernia, plastics Moderate = 4-6cc/kg/hr: appy, open choly Severe = 8-10cc/kg/hr: TKH, bowel resect, radical mastectomy

question

Estimating Blood Loss: Visual

answer

4x4 sponges = roughly 10cc Lap pads = 150 cc Subjective - prone to error

question

Estimating Blood Loss

answer

Changes in VS BP, HR, CVP, filling pressures, UO Analysis of Hgb/Hct Clinical appraisal : tachy, hypotension, oliguria, poor skin turgor, collapsed veins, mild/mod hypothermia, furrowed tongue, dry mucous membrane

question

Morphine Sulfate

answer

Dose related respiratory depression Biliary tract spasm N/V, histamine release, pruritis

question

Merperidine (Demerol)

answer

50 - 100 mg IM or 1-3 mgkg IV Treat SHIVERING in PACU 1/10 the potency of morphine Mild vagolytic and antispasmodic

question

Fentanyl (Sublimaze)

answer

Potent analgesic = 100x as potent as morphine 50mcg/cc Rapid onset - short duration - resp depression may outlast analgesia Combined with Droperidol (Innovar) - Neuroleptanalgesia Cause chest wall rigidity

question

Nasopharynx

answer

From bottom of nose to the end of the soft palate (connects the back of the nose to the back of the mouth)

question

Oropharynx

answer

Opening of the mouth into the back of the throat (just behind the mouth that connects the mouth to the top of the throat)

question

Hypopharnyx (Laryngopharynx)

answer

Sits behind on either side of the larynx (LMA - laryngeal mask airway: mask sits on the glottic opening)

question

Larynx

answer

Connects from vocal cords down into the trachea that lvl is around C4 C5 and C6 Composed of nine cartlidges

question

Unpaired cartilages

answer

Epiglottis Prevents aspiration by covering the glottis (opening of the larynx) during swallowing Thyroid Cricoid (The only complete circle, all the others are open towards the spine)

question

Paired cartlidges

answer

Arytenoid Corniculate Cuneiform

question

Sensory Nerves Supplying the Upper Airway

answer

Cranial nerve V: Trigeminal Crainial nerve IX: Glossopharyngeal Cranial nerve X: Vagus

question

Division of Trigeminal Nerve

answer

V1: Opthalmic division (anterior ethmoidal) V2: Maxillary division (sphenopalatine) V3: Mandibular division (lingual nerve) NO INNERVATION AT THE BACK OF THE THROAT Anterior (part of tongue) think trigeminal

question

IX Glossopharyngeal Nerve

answer

Posterior 3rd of the tongue Where the gag is located Posterior part of the throat

question

X Vagus Nerve

answer

Sensory innervation of the larynx Parasympathetic nerve: vast innervation from eye, to neck, to uterus, to heart, to bones, to peritoneal cavity, to stomach, to carotids, etc.

question

Superior laryngeal nerve (above the larynx)

answer

Internal branch (sensory): External branch (motor): Innervates cricothyroid muscle : dmg = unilat palsy/ paralysis = not clinically significant

question

Recurrent laryngeal nerve

answer

Iinnervates all muscles of the airway except the cricothyroid: DMG = hoarseness and weak pronation = if damaged then vocal cords become floppy and will collapse on each other *DO NOT WANT TO DAMAGE THIS RECURRENT*

question

Cricothyroid Muscle

answer

Innervated by the Superior Larynegeal Muscle: External branch The Cric muscle creates tension and elongation of the vocal folds

question

Distance from Mentum to Hyoid bone

answer

With pts neck extended, measure the distance from the mentum to the hyoid bone If less than 3 fingers or 6 cm, it signals the potential for a difficult intubation Pt should be able to open mouth 6cm or 3 finger breadths

question

Connection to circuit

answer

22 mm Outside Diameter (15 mm Inside Diameter) orifice connects to breathing circuit with right angle connector

question

Components of an ETT

answer

The patient end of the tube is beveled to aid visualization and insertion through the vocal cords Murphy's tubes have a hole to lessen the risk of complete tube occlusion

question

Intubating can be commonly associated with

answer

Increased heart rate, Increased BP, Increased CVP, Increased ICP, Increased intraoccular pressure

question

Proper position for intubation

answer

Success often depends on correct positioning Texts suggest pt head should be level with anesthetist xiphoid process to prevent backstrain SNIFFING position = moderate head elevation and extension of atlanto-occipital joint Neutral with slight chin up

question

Preparation for Induction and Intubation

answer

Routine pre-oxygenation 100% O2 3-5 min Several deep breaths Maybe okay to omit on pts who object who are free from respiratory disease and have no full stomach

question

Grade 1

answer

A full view of the glottic opening

question

Grade 2

answer

Posterior portion of glottic opening is visible

question

Grade 3

answer

Only tip of epiglottis is visualized

question

Grade 4

answer

Only soft palate visible

question

Tube Placement

answer

Take ETT in right hand, pass tip through abducted vocal cords The tube cuff should lie in the upper trachea (mid tracheal) beyond the larynx Stylet is removed after cuff passes through cord The tube maybe advanced a little further The laryngoscope is carefully withdrawn Check the cuff against the clavicular notch

question

MOV

answer

3-4cc Feeling the pilot balloon is not a reliable method of determining adequacy of cuff pressure Even MOV (usually at least 20mmHg) will reduce tracheal blood flow by 75% at the cuff site Further cuff inflation on induced hypotension can totally eliminate mucosal blood flow After the cuff is inflated, connected to circuit

question

Endobronchial intubation

answer

ETT goes into right main stem bronchus d/t its less acute angle Unilateral breath sounds Unexpected hypoxia with pulse ox Inability to palpate ETT cuff in the sternal notch during cuff inflation Poor breathing bag compliance (high peak inspiratory pressure) Increaseed peak inspiratory pressure and a difference in the quality of breath sounds between the left and right lungs

question

Phenylephrine nose drops (0.5% or 0.25%)

answer

Vasoconstrict vessels and shrink mucous membranes if not contraindicated (hypertension)

question

Nasal Intubation

answer

If pt awake: Local anesthetic nose drops and nerve blocks can also be utilized Lubricate ETT with water soluble jelly Insert tube along the floor of the nose at an angle perpendicular to the face Gradually advance tube Perform the laryngoscopy, advance until its tip can be visualized in the oropharnyx Visualize the tube passing through cords

question

Extubation Considerations

answer

Extubating awake pts usually associated with coughing and bucking on the ETT: Increased HR, CVP, BP, ICP, causes wound dehiscence and bleeding, often triggers bronchospasms in asthmatic patients NEVER EXTUBATE IN STAGE 2: IF EYE NOT MIDLINE (if deviate down or to side) DO NOT EXTUBATE

question

Too Shallow Insertion

answer

Will position the cuff in the larynx Predisposes the pt to laryngeal trauma Minimal testing should include (chest auscultation, Cuff palpation, Routine capnography)

question

Flexion

answer

Tube too far in

question

Extension

answer

Tube too far out

question

Postintubation croup

answer

Caused by glottic laryngeal or tracheal edema - particularly in children

question

Vocal cord paralysis

answer

From cuff compression or other trauma Results in hoarseness and increases the risk of aspiration

question

NEGATIVE PRESSURE PULMONARY EDEMA

answer

Large negative intrthoracic pressure generated by the struggling pt in laryngospasm can result in the development of pulmonary edema

question

Anesthesia

answer

Total or partial loss of sensation, especially tactile, induced by disease, injury, acupuncture, or an anesthetic: The process of blocking the perception pain and other sensations

question

Goals of anesthesia

answer

Amnesia, Analgesia, and Abolition of reflexes

question

Pharmacokinetics

answer

What the body does to the drug (absorption, distribution, metabolism, excretion)

question

Pharmacodynamics

answer

Study of what the drug does to the body (Effects on organs, body, and side effects)

question

William Morton

answer

First to successfully demonstrate the use of Diethyl Ether as an anesthetic at Mass Gen

question

Horace Wells

answer

Mass gen demonstration unsuccessful with Diethyl Ether First to think to use Diethyl Ether as an anesthetic

question

John Snow

answer

Popularized Chloroform Many consider him the first anesthesiologist

question

Alice McGraw

answer

The mother of anesthesia

question

Agitha Hodgkins

answer

AANA: American Association of Nurse Anesthetists

question

Spinal Ligaments

answer

Skin Supraspinous Interspinous Ligamentum flavum Dura Arachnoid Pia mater SILDA

question

Supraspinous

answer

Connects tips of spinous process

question

Interspinous

answer

Connects spinous process' horizontal surface

question

Ligamentum Flavum

answer

Tough yellow ligament: Crunchy, scratchy sound when pierced, IMMEDIATELY BEFORE DURA

question

Spinal cord

answer

Ends at L-1 or L2

question

Dura Mater

answer

Tough & fibroelastic Two parts Cranial Spinal theca Ends at S2

question

Arachnoid Mater

answer

Thin and delicate Covers brain & spinal cord Almost adherent to dura Ends at S2 Potential space Between dura and arachnoid

question

Pia Mater

answer

Delicate Highly Vascular Clings to surface of cord and brain In subarachnoid space with CSF

question

Dermatomes

answer

Specific region of the skin supplied by a single spinal nerve Sensory level of block

question

C3,4,5

answer

Keep the diaphragm alive

question

C6

answer

thumb

question

C7

answer

middle finger

question

C8

answer

pinkie finger

question

T4

answer

nipple line

question

T6

answer

xiphoid

question

T8

answer

lower costal margin

question

T10

answer

umbilicus

question

L1

answer

immediately above genitals

question

S1

answer

outer foot

question

Cardiac accelerators

answer

Sympathetic Efferent T 1-4 High blockade -->unopposed vagal response (brady, hypotension) Prolonged brady Cardiac arrest Epinephrine

question

Ventilatory Changes

answer

Phrenic nerve C3-5 (diaphragm) Concentration too low to block Alpha A fibers The curvature of the back helps prevent going up the neck and to the head

question

Onset of SAB

answer

Autonomic (1st thing to go) Beta Temperature/sharp pain Alpha - delta Pain (dull) C Touch Alpha - y Pressure Alpha - Beta Motor Alpha - a Vibration Beta Proprioception Alpha - y

question

Absolute Contraindications for Spinal

answer

Sepsis/Bacteremia Infection at puncture site Shock/severe hypovolemia Coaguopathy Therapeutic anticoagulation Increased ICP Patient refusal

question

Hyperbaric

answer

Addition of glucose (dextrose) Usually in equal amount of LA Changes density above CSF (heavier) Settles to most dependent part of Determine by position of the patient T5-6 supine/saddle block Most commonly used Easily spread/good for abdominal surgeries

question

Isobaric

answer

Diluting LA with preservative free NS or CSF in equal volumes In theory stays where injected regardless of pt position Good for surgery below L1 (hips)

question

Hypobaric

answer

Addition of 6-8ml sterile water - makes density less than that of CSF (lighter) Floats to surgical area depending on patient position Good for rectal cases in jackknife position: hip cases in lateral position Rarely used b/c of unpredictability

question

Lidocaine/Xylocaine

answer

Onset 3-5 minutes Duration 60-90 minutes Packaged 5% with 7.5% dextrose (hyperbaric) Little effect with epinephrine

question

Bupivicaine/Sensorcaine

answer

Dose 10-15 mg Onset 5-8 minutes Duration 90 -110 minutes Packaged as 0.75% with 8.5% dextrose (hyperbaric) Little effect with epinephrine Greater sensory block than motor block

question

Tetracaine/Pontocaine

answer

Dose 10-15mg Onset 3-6 minutes Duration 214-240 minutes Packaged 1% plain Isobaric Need to add dextrose Most flexible Most affected by epi

question

1772

answer

N2O prepared

question

Verius Cordus

answer

First used ether in 1540

question

William Morton

answer

1846 First successful anesthetic

question

John Snow

answer

First anestesiologist

question

Sister Mary Bernard

answer

First Nurse Anesthetist

question

Alice McGraw

answer

Mother of anesthesia 1st to publish

question

Agatha Hodgins

answer

Founder of AANA Lakeside, Cleveland

question

MAC

answer

Should not have loss of conciousness with loss of protective reflexes

question

Spinals

answer

Puncture dura CSF obtained In between the Arachnoid and the pia mater

question

Caudal

answer

Anextenion of a spinal in the sacral region

question

Peripheral nerve blocks

answer

Brachial, Cervical plexus

question

Individual nerve block

answer

Sciatic, intercostal

question

Minimum alveolar concentration

answer

Decrease with hypothermia Decreases with age and is maximal at 6 months

question

Minimum alveolar concentration

answer

Alveolar concentration of gas at which 50% of humans will not respond to noxious stimulus

question

GABA

answer

NT associated with CNS depression

question

GABA

answer

Sites of action are Cerebral cortex, Brain stem, Peripheral nerves, and Spinal cord

question

Pharmikokinetics

answer

Study of what body does to the drug

question

ETT

answer

Protects from aspiration LMA does not

question

Local anesthetic

answer

Works by blocking passage of Na ions through Na channels in nerve membrane

question

Amide = 2iis

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Lidocaine Bupivicaine

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Esters

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Cocaine Procaine

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Department of transportation

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Regulates medical gas cylinders

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Oxygen analyzer

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Best way to prevent hypoxic mixture delivery Calibrate at 21% and test at 100% with the O2 flush valve

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Units of pressure conversion

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1atm = 1bar = 14.7psi = 101Kpa = 1033cmH2O = 760torr = 760mmHg

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O2 tank

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Max pressure 2000psi Min pressure 1000psi

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N2O

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PSI = 750 if less than 750 can measure if greater than 750 have to weigh canister to get contents 1590L

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O2 flush valve

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Supplies O2 @ 35-50L/min @ 40-50 psi (whatever pipeline is)

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Check valve

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Prevents backflow to the machine

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Pressure sensor outlet shutoff valve

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N2O cannot be delivered if O2 psi <25 = cannot control if crossover of gases poccurs

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2nd stage regulator

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Reduces pressure to 12-16psi - prevents variatibilty of pipeline pressure OHMEDA

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Oxygen ratio control monitor

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Prevents flow meters from delivering hypoxic mixtures

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DISS

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Safety system of the pipeline central supply

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PISS

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Saftey system for the hanger yoke

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O2 pin indexes

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2, 5

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CO2 pin Indexes

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3, 5

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Air

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Yellow

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O2

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Green

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N2O

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Blue

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Different sounding alarms

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NOT safety mechanisms

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Barotrauma

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APL Obstruction Scavenging obstruction Low outflow

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Pre-op evaluation

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Collection of info Optimization of status Care plan Decrease anxiety

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ASA 2

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No health history

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Lactated ringers

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4meq of K

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Lacted ringers

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Most common IV fluid used in OR

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NS 0.9%

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154 Na 154 Cl

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Sccpolamine

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Anticholinergic that helps most with motion sickness

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Benzos

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Work on GABA receptor

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Best antacid for aspiration?

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Bictra

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Valium

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Longest 1/2 life 21-37 hrs

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Tagamet (Cimetidine)

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Many interactions with anesthesia drugs

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Abbreviated check out

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Check bag Check leaks Check suction

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Why do we monitor?

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Improve patient safety

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Best monitor

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Pulse OX

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A2

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V5 lead Anterior Axillary Line 5th ICS LAD

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Lead II

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Best for P-wave monitoring Inferior wall ischemia

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SpO2 = 90, 80, 70

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PaO2 = 60, 50, 40

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ETCO2

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Gold standard for ETT placement 3-5 breaths

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Which one measures oxyHgb?

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Infared 940 nm

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Phase III

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Most physiology Best clinical reflection of alveolar CO2 tension

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Increased ETCO2

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Hypoventillation Increased metabolic states Rebreathing Tourniquet release Administration of bicarb Exhausted soda lime

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Decreased ETCO2

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Hypothermia Hyperventilation PE Leak in system

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Sharp upstroke in phase III

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Airway resistance

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Capnography

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Does not measure oxygenation Does measure ventilation, CO2, and resistance

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Agent analyzer

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Tell you inspired agent compared to expired agent

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Which temp is not used for core temp?

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Skin

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Esophageal stethescope can

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Atrial pace Hear heart sounds and breath sounds Temp

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V-fib

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Occurs when body temp 28-30 C

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Hypothermia

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Arrhythmias Increased PVR Left shift of oxyHgb curve Decrease drug metabolism

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General anesthesia

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Inhibits thalamic thermoregulation

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Peripheral nerve stimulator

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Used to assess blockade

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Tetany

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Sensitive test for Neurmuscular function Do no use on a non anesthetised pt

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BIS 45-60

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Surgical anesthesia

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Intubation

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ETCO2 wave forms that start high and slowly decrease

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Slant in Phase II

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Obstruction (COPD, ASTHMA)

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HCFA definition of MAC

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Intra-op monitoring, ancipate need for GA, adverse rxn to surgery,

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Cardiorespiritory depression

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#1 cause of death in MAC

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When can MAC be used?

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In any procedure when a local is likely to provide adequate anesthesia

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Lidocaine

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4 mg/kg plain 7 mg/kg with epi

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Local toxicity

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Tinnitus

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Pre-seizure CNS symptoms

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50-100 mg STP

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Mask conncetion

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22mm OD 15mm ID

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Bagging pressure

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<20 mmH2O

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Murphy's eye

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Decreases the risk of total occlusion of the ETT

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ETT placement

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Mid tracheal beyond the larynx at least 2cm above the crycoid

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Nasal intubation prep

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Affin/Pheynl dops

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Flexion

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Pushes ETT in farther

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Extension

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ETT comes out

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Surgical Airway

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Last step in ASA difficult airway management

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3 paired cartiladges

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Arytenoid Cuneiform Corniculate

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MAC Blade

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Into valiculla

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Miller blade

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Over epiglottis

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Glossopharyngeal

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Posterior 1/3 of tongue

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Dermatome

answer

Specific region of the skin supplied by a spinal nerve

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