Basics of Anesthesia Exam 1 – Flashcards
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what to inhalation agents are not irritating to the airway
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sevoflurane and halothane
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What should BG be in ASC patients.
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<180mg/dl
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T/F -- MH patients can safely receive anesthesia in a ASC. Should prophylactic Dantrolene be given?
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True. No - dantrolene should not be given prophylactically
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What are three intraoperative goals in ambulatory surgery patients.
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1. Rapid emergence 2. Good analgesia 3. Minimal PONV
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what two gases increase the likelihood of PONV?
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Sevoflurane and Nitrous Oxide
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What 3 classes of medications can be given preoperatively to prevent/reduce pain and to reduce the amount of opioids given (which contribute to PONV)?
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1. local anesthetics 2. acetaminophen 3. NSAIDS (toradol)
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What are the 9 Discharge Criteria for ambulatory patients.
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1. A&O x3 2. VSS for 30-60min 3. ability to walk unassisted 4. tolerating PO fluids 5. able to void 6. no significant pain, bleeding, or nausea 7. has driver present to take pt home. 8. responsible adult present to stay with pt overnight. 9. pt must be d/c by both the person administering anesthesia and the surgeon.
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what 2 scoring systems are used for discharge criteria from PACU
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Aldrete scoring system and PADS (Postanesthesia discharge scoring system)
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what 5 things are considered in the Aldrete scoring system
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1. activity 2. respiration 3. circulation 4. consciousness 5. O2 saturation
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what Aldrete score is required for discharge from PACU
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> or = 9
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what is characteristic about succinycholine
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depolarizing NMB --> fasciculations
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what are the two main causes of unplanned hospital admissions post-op from ASCs
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uncontrolled pain and PONV
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What are the top 3 causes of death from ambulatory surgery cases?
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1. PE 2. Post-op medication OD 3. MI
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will fasciculations be seen when rocuronium is given
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no - it is non depolarizing
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What are some of the out of the operating room sites where anesthesia is sometimes given?
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1. GI suite 2. Cath lab 3. EP lab 4. radiology suite 5. radiation oncology suite 6. ICU
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what are the 11 ASA guidelines for non operating room anesthesia
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1. Reliable O2 source 2. suction 3. waste gas scavenging 4. safe electrical outlets 5. adequate monitoring (equipment) 6. adequate illumination (battery backup) 7. sufficient space for anesthesia, personnel, and equipment 8. Ambu bag, crash cart, defib, and drugs present 9. reliable means for 2-way communication 10. applicable facility and safety codes met 11. appropriate Post-anesthesia mgmt.
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what are some conditions that cause special care when providing anesthesia in non-OR setting
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1. pt unable to cooperate 2. GERD (severe) or gastroparesis 3. orthopnea and/or OSA 4. morbid obese 5. trauma 6. extremes of age 7. presence of URI or unexplained fever 8. known difficult intubation 9. increased ICP 10. decreased LOC 11. procedures limiting the access to the airway 12. prone position
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What percent of all surgeries are ambulatory?
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>70%
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what are some factors that explain why there is an increase in the # of ambulatory cases?
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1. new, highly titratable anesthetics 2. less invasive surgery (laparoscopy) 3. faster recoveries 4. rapid, short acting drugs (propofol) 5. cost savings
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what percentage of all outpatient procedures are performed in the office
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15-20%
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what are three benefits of outpatient surgery being performed within a hospital?
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1. access to specialists 2. ease of transfer (in case of pt decline) 3. wider range of services (labs, X-ray, etc)
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how many OBA procedures are performed annually
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1.2 million
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what are the 11 AANA standards for OBA (or any other case - since they all have same standards)
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1. Thorough preanesthetic assessment 2. obtain informed consent 3. Form a patient-specific anesthetic plan 4. implement and adjust the anesthetic care plan according to patients physiological response 5. Monitor pt's condition (VS, EKG, ETCO2, etc) 6. Accurate and timely documentation 7. Transfer responsibility of care 8. Adhere to safety precautions (minimize risk of fire, explosion, shock, and equipment malfunction) 9. minimize risk of infection 10. Assess anesthesia care assuring its quality and contribution to positive pt outcomes (pt satisfaction) 11. respect/maintain pt's rights (advocate)
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what are the minimum monitoring equipment for all general anesthetic patients.
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1. pulse ox 2. EKG 3. BP 4. O2 analyzer 5. ETCO2 6. esophageal stethoscope (temp) 7. PNS (peripheral nerve stimulator?)
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What ASA classes are acceptable for outpatient procedures
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ASA 1&2, medically stable 3, rarely 4 (CRNA/MDA and Surgeon usually make decision together)
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what drug is not recommended for GA induction in outpatients, why?
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ketamine - prolonged emergence
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why is propofol ideal for GA induction in outpatients?
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quick emergence, antiemetic, ideal with LMA
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what medications/methods are used during GA maintenance in outpatients
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1. short acting opioids 2. TIVA 3. NMB agents (still have to reverse at end of case)
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what med is not recommended during GA maintenance in outpatients
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high dose narcotics
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what are 3 advantages to regional anesthesia for outpatients
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1. less alteration in cerebral function 2. post op pain relief 3. less PONV than GA
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what are 3 disadvantages to regional anesthesia for outpatients
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1. blocks are time consuming to place (perform in pre-op) 2. discharge delays (hypotension, urinary retention, prolonged blockade) 3. failed blocks
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what are 3 advantages to MAC for outpatients
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1. IV sedation and local anesthesia - minor procedures 2. versed and propfol bolus prevent recall 3. rapid discharge
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what is one disadvantage to MAC for outpatients
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light sedation can cause agitation and disorientation
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what are some methods for postoperative pain relief
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1. IV analgesics 2. local nerve block 3. local anesthesia by surgeon 4. NSAIDS - IV/IM 5. PO pain meds
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what are 4 postoperative complications from anesthesia
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1. prolonged somnolence 2. headache (GA) 3. urinary retention 4. sore throat
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what 9 things would be included in an ideal anesthetic
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1. patient safety 2. patient satisfaction 3. excellent operating conditions for the surgeon 4. rapid recovery 5. avoidance of post-op s/e 6. low in cost 7. early transfer or d/c from the PACU 8. optimize post op pain control 9. quick turnover times
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what are the two methods of initiating GA
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1. IV drugs 2. inhalation agents (with or without N2O)
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LMA cuff pressure should not be greater than what mmHg
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44
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what practice would increase the margin of safety during periods of upper airway obstruction/apnea that accompany induction of anesthesia
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preoxygenation/denitrogenation
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what does pre oxygenation do
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denitrogenation - replaces the nitrogen in the patient's function residual capacity (2500ml of 21% O2)
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breathing 100% O2 for 3 minutes with normal tidal volume breaths is equal to how many vital capacity breaths
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8 VC breaths (over 60 seconds)
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which muscle relaxant has a slower onset time - succ or roc?
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Rocuronium
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the use of this type of drug without proper anesthetic drugs causes recall during anesthesia
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NMB agents
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what are the 11 steps of RSI
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1. equipment check 2. preoxygenation 3. cricoid pressure 4. give opioid (fentanyl) 5. give lidocaine (numb) 6. give induction agent (propofol, etomidate, or ketamine) 7. give NMB (roc/succ) 8. intubate patient 9. ventilate patient. 10. verify tube placement 11. remove cricoid pressure
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what two NMB are given for RSI, and why are these drugs appropriate for this induction
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Rocuronium and Succinylcholine - they are fast acting NMB
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what 6 things are evidence of a patent upper airway (correct tube placement)
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1. upper chest expands during inspiration 2. reservoir bag partially empties during inspiration 3. reservoir bag partial refills during expiration 4. ETCO2 waveforms are 0 during inspiration and >20mmHg during expiration 5. pulse ox > 95% 6. bilateral breath sounds present
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what population of patients typically are induced with inhalation agents
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pediatrics
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what two inhalation anesthetic is irritating to the airway
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desflurane and isoflurane
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Loss of consciousness occur within how long when breathing 8% sevoflurane
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1 minute
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the prior administration of what type of medication facilitates induction with sevo
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benzos
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the prior administration of what type of medication complicates induction with sevo
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opioids
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why is priming the circuit with sevo important for induction with inhalation agents
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allows for the first breath taken with mask on to have 8% concentration of sevo (quicker induction)
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why are opioids given just prior to RSI
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opioids blunt the SNS response (increase BP/HR) from direct laryngoscopy and intubation
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what are the 4 goals for the maintenance stage of anesthesia
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1. amnesia 2. analgesia 3. skeletal muscle relaxation 4. control of SNS responses evoked by noxious stimuli
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what is the most frequently used volatile agent
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N2O
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what is one advantage of using volatile agents
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attenuation of SNS response to noxious stimuli
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what is the purpose of substituting N2O for a portion of the dose of a volatile anesthetic
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it is an adjunct to the anesthetic effect --> won't have to give as much inhalation agent or IV agents (decreases cardiac depression)
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what three things are included in neuraxial anesthesia
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spinal, epidural, caudal
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what meningeal space is used for spinal anesthesia
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subarachnoid
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what are the three advantages to spinal anesthesia
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1. less time to perform 2. produces more rapid onset of better quality sensory and motor anesthesia 3. less pain during surgery
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what are the 4 advantages of epidural anesthesia
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1. lower risk for PDPH 2. less systemic hypotension (if epic is not added to the solution) 3. able to prolong the anesthesia through indwelling catheter 4. postoperative analgesia
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what is the only absolute contraindication to spinal or epidural anesthesia
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patient refusal and request for a different type of anesthesia
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what are the 2 disadvantages for spinal/epidural anesthesia
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1. failed of the spinal/epidural to work 2. hypotension
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what causes the hypotension post spinal/epidural
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SNS blockade from the regional anesthesia --> venodilation (made worse by hypovolemia)
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what are the steps in Bier blocks
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1. application of double tourniquet 2. exsanguination of the extremity 3. pump up BP cuffs (tourniquet) 4. administer 0.5% lidocaine
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when are bier blocks indicated
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procedures lasting between 20-90 minutes
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when are peripheral nerve blocks indicated
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for superficial operations on extremities (AV shunts)
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what are the advantages for peripheral nerve blocks
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1. maintenance of consciousness 2. continued presence of protective upper airway reflexes
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what types of patients are good candidates for peripheral nerve block
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1. chronic pulm disease 2. severe cardiac disease 3. renal failure
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what is the disadvantages for peripheral nerve blocks
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unpredictable attainment of adequate sensory/motor anesthesia needed for the surgery
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what are 6 conditions that increase the risk for spinal/epidurals
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1. hypovolemia 2. increased ICP 3. coagulopathy (thrombocytopenia) 4. sepsis 5. infection at the cutaneous puncture site 6. preexisting neurologic disease (MS) 7. aortic stenosis (SAB)
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what are 2 advantages to MAC
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1. avoidance of side effects from anesthetics (sympatholysis, respiratory depression, delayed emergence) 2. cost effective
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what is the ultimate goal of pharamcoeconomics
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obtain the best results for the patient at the most practical cost 1. low toxicity 2. rapid awakening 3. absence of nausea and vomiting
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what are the three ways to control the airway during GA
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1. oral airway 2. LMA 3. ETT
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cricoid pressure should be administered before or after loss of upper airway reflexes?
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before
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what are 11 factors that influence the choice of anesthetic technique
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1. preference (pt, MD, CRNA) 2. coexisting disease (GERD, DM, asthma) 3. site of surgery 4. position during surgery 5. elective or emergency case 6. likelihood of increased stomach contents at induction 7. suspect difficulty airway/intubation 8. duration of surgery 9. patient age 10. anticipated recovery time 11. PACU d/c
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what are some conditions that put pt's at increased risk for aspiration
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1. severe trauma 2. pregnant (12-14+ weeks) 3. hiatal hernia 4. GERD 5. DM 6. Gastroparesis 7. extremes of age 8. Increased intraabdominal pressure (Obesity, ascites) 9. GI obstruction 10. ileus 11. Difficult intubation 12. pt who does not meet NPO requirements 13. neurologic factors 14. narcotic administration
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how many hours post heavy meal is considered NPO
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>8 hours
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how many hours post light mean is considered NPO
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> 6 hours
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how many hours post clear liquid intake is considered NPO
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> 2 hours
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what are 7 neurologic factors that increase pt's risk for aspiration
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1. GCS < 8 2. Parkinsons 3. MS 4. bulbar palsy 5. Myotonia dystrophica 6. CVA 7. increased ICP
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what are two conditions that, if present, succinylcholine should not be given
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1. pseudocholinesterase deficiency 2. increased ICP
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what is amnesia
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condition when ones memory is lost
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what is analgesia
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absence of pain without loss of consciousness
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what is a major disadvantage of volatile anesthetics
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dose dependent cardiac depression
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what determines the height of the neuraxial anesthesia
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the volume of medication given
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the heigher the block is, there is more _____
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venodilation
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what determines the density of the block
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the concentration of the medication (1% vs 2% lidocaine, etc)
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how long should the tourniquet be kept of during a Bier block
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> 30 minutes
