Boards by the numbers ASA classification Anesthesia – Flashcards

The patient has no physiological, or psychiatric disturbances whatsoever, is less than 50 years old, a non-smoker, and takes no medication. Exceptions: Birth Control Pills, Estrogen Replacement Therapy, Prophylactic Salicilates (aspirin), but without any cardiac history i.e. atrial fib or stent. summary:Healthy, non-smoking, no or minimal alcohol use. Excludes very young and very old individuals (neonates and over 80)

Most patients will be in this classification therefore, requiring lab work. The patient has mild to moderate systemic disturbances caused either by the condition to be treated surgically or by other pathophysiologic processes. These disturbances do not limit activity. summary: Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well controlled DM/HTN, mild lung disease

• Current smoker • Age over 65 years or less than 3 months old will automatically require a medical consult • Asthma, well controlled on as needed basis for medication. • Hypertension well controlled with medication and/or diet; HTN requires an EKG at any age • History of heart dysrythmia (heart rhythm issue) controlled on medication • Obstructive Sleep Apnea (OSA) • Stable Angina, well controlled, not limiting activity • Mild Diabetes, well controlled on medication • Mild to moderate obesity • History of seizure disorder, controlled with medication • History of Congestive Heart Failure, controlled on medication • COPD, stable • Chronic Bronchitis • History of Hepatitis C or Cirrhosis stable, not limiting activity • Renal Insufficiency, stable Summary: Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well controlled DM/HTN, mild lung disease

Many patients are actually in this classification and require a medical consult. The patient has serious systemic disturbances or diseases, even though it may be impossible to define the degree of disability. The disease process limits activity in some way, but is not incapacitating. Appropriate specialty consultation, where deemed necessary is also required. i.e., patients with issues such as: pain management, insulin pumps, or pacemakers. summary: Severe Systemic Disease (not incapacitating) with substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ?40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA 3 months) of MI, CVA, TIA, or CAD/stents.

• Any combination of 3 or more of the disease processes listed for a Class II patient. • Any single disease process listed for a Class II patient with one or more of these criteria: • Intense severity • Poorly controlled on medication • Limits activity in some way • "Heart attack", a healed myocardial infarction (MI) of more than 6 months ago, or patients who have undergone coronary artery bypass surgery (CABG), valve replacement or angioplasty. • Pacemaker, Internal Cardiac Defibrillator (ICD), sometimes CABG patients also have these. • Diabetes with complications to vascular or other organs, i.e., retinopathy, neuropathy, etc. • Chronic Pain Management patients taking daily pain medication must have a consultation with a Valley pain management physician prior to the day of surgery for the purpose of pain management during the immediate post-op period while in the post anesthesia care unit. • Pulmonary insufficiency, including asthma, requiring the use of chronic medications and which limit activity or have uncontrolled symptoms, i.e., shortness of breath, cannot lay flat. • Any implantable electronic device (IED) i.e., for pain, insulin, deafness, etc. • Renal failure requiring Dialysis

These patients are not candidates for surgery at the Luckow Pavilion. The patient has severe systemic disease that is already life threatening. Summary:Incapacitating Systemic Disease (is a threat to life) Examples include (but not limited to): recent (<3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

Examples: • Organic heart disease with marked signs of cardiac insufficiency (i.e, NYHA class 4). • Recent myocardial infarction of less than 6 months duration. • Unstable angina. • Patients with advanced degrees of pulmonary, renal or endocrine insufficiency.

Moribund Patient (not expected to live with/without the surgery) Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

A declared brain-dead patient whose organs are being harvested for donor purposes

Phases of anesthesia: 1. Induction 2. Maintenance 3. Emergence

Stage 1: Begins with induction agent and ends with loss of consciousness. The patient can still feel pain in this stage Stage 2: Hyperexcitable state. The time where the patient looses consciousness and when they regain autonomic stability. The patient losses the ability to maintain temperature, blood pressure and may experience irregular breathing, uncontrolled movement, GI issues (vomiting). This stage last a very short amount of time.

Stage 3: This is the desirable state or Target depth of general anesthesia. patient regains autonomic stability - Plane 1: eye rolling which progresses to eyeball centrally fixed - Plane 2: loss of corneal and laryngeal reflexes - Plane 3: Pupils dilate and loss of light reflex - Plane 4: Intercostal paralysis, Short shallow abdominal respirations (diaphragmatic respiration's) Stage 4: Overdose (You have gone to far) Autonomic instability will begin to reemerge. Loss of blood pressure, decrease breathing, circulatory failure. Stage 5: Heart stops

Starts at stage 3 (surgical Anaesthesia) --->>> through Stage 2 (hyperexcitable stage) --->>> Stage 1 (conscious awake patient)

1. Reduce anxiety 2. Produce some sedation/amnesia 3. Reduce gastric PH as well as volume 4. Reduce bronchial secretion 5. Prevent nausea and vomiting

a. Diazepam (Valium): Produces sedation and amnesia. Can be given orally 1-2 hours before surgery (5-10 mg). b. Lorazepam (Ativan): Can also be given 1-2 hours before surgery (2-4 mg.) c. Midazolam (Versed): May be used as a pre-op medication and/or induction agent. Rapid onset with a relatively short duration. When given intravenously, it typically begins working within five minutes. Effects last for between one and six hours. d. Hydroxyzine (Vistaril): Used as a sedative primarily, however, it is also an anti histaminic, antiemetic and a bronchodilator. It is a good premedication for patients with asthma.

a. Atropine: Atropine is given before anaesthesia to decrease respiratory secretions. During anaesthesia and surgery, atropine is used to help keep the heart beat normal. Helps prevent bradycardia and asystole in the presence of Halothane or other vagolytic agents. b. Scopolamine: Used as a preanesthetic because it produces mild respiratory stimulation and it inhibits salivary secretion. In reversing paralysis it is used to reduce parasympathetic hyperactivity.

a. Fentanyl (Sublimaze): Short-term analgesia during anesthetic periods, premedication, induction and maintenance; and in the immediate postoperative periods as need arises. b. Morphine: Serves to alleviate perioperative pain and decreases somatic and autonomic responses to airway manipulations, improves hemodynamic stability, lowers requirements for inhaled anesthetics, and decreases anxiety. However, with the advent of newer faster and shorter acting opioids such as fentanyl, morphine, because of its slower onset and longer duration of action is no longer preferred for intraoperative analgesia and is used mainly for postoperative analgesia. c. Demerol (Meperidine): Induces amnesia and is also used for controlling post anesthetic shivering. It can cause tachycardia and therefore should be used with caution in patients with heart irregularities. Like all narcotics, adverse side effects such as nausea, vomiting, constipation occur and it is usual to see an antiemetic (such as Vistaril) used in conjunction with these strong emetic drugs.

a. Toradol (IV ketorolac): An NSAID used intraoperatively to reduce Post-Op pain. Like all NSAID's, it increases risk of bleeding. b. Acetaminophen (IV Ofirmev): Decreased risk of bleeding and nausea and safe for pediatric patients.

Nitrous oxide: Least potent and most commonly used inhalation anesthetic for sedation. However, as a general anesthetic, it is generally not used as a single agent. It may be used in combination with more potent general inhalational gases for surgical anesthesia.

1. Halothane (Fluothane): Rarely used in US and has been mostly replaced by newer agents. Side effects include an irregular heartbeat, respiratory depression, and liver problems. It is contraindicated in people with porphyria or a history of malignant hyperthermia either in themselves or their family members. 2. Isoflurane (Forane): Side effects include respiratory depression and low blood pressure. Like Halothane, It should not be used in people with a history of malignant hyperthermia either in themselves or their family members. It does not sensitize the myocardium for arrhythmias. It can, however, cause coronary artery vasodilatation that might lead to coronary artery steal syndrome (blood is diverted away from critically perfused areas because of vasodilatation in healthy parts of the heart which may lead to myocardial ischemia or infarction). It is usually used to maintain general anesthesia that has been induced with another drug, such as thiopentone or propofol. 3. Sevoflurane (Ultane): After desflurane, it is the fastest onset and offset. Unlike desflurane, it is non irritating and is therefore an excellent choice for induction and emergence. It is one of the most commonly used volatile anesthetic agents. Uthane and Surane are replacing isoflurane and halothane in modern anesthesiology. It is often administered in a mixture of nitrous oxide and oxygen. Like other drugs in this class, it causes decrease in blood pressure, respiratory depression and may trigger malignant hyperthermia. It produces a dose-dependent decrease in arterial blood pressure due to peripheral vasodilatation. It is therefore contraindicated in patients with aortic valve stenosis. It does not sensitize the heart to arrhythmias or cause coronary artery steal syndrome. 4. Desflurane (Suprane): Pretty much the same as Sevoflurane. However, it has the most rapid onset and offset of the volatile anesthetic due to its low solubility in blood. Like Sevoflurane, it produces a dose-dependent decrease in arterial blood pressure due to peripheral vasodilatation. It is therefore contraindicated in patients with aortic valve stenosis. It does not sensitize the heart to arrhythmias or cause coronary artery steal syndrome. Like all inhalation agents, it may trigger malignant hyperthermia. Due to airway irritability it is infrequently used to induce anesthesia via inhalation techniques. Drawbacks of desflurane are its low potency, its pungency and its high cost. Also, it is a liquid at room temperature and therefore requires a special heated vaporizer for delivery.

Previous myocardial infarction, of less than 6 months duration, has a perioperative rate of re-infarction that is ten times greater then if older than 6 months.

There is a high incidence of postanesthetic pulmonary complications in patients with COPD (chronic obstructive pulmonary disease) and asthmatic patients. We can reduce these complications with preoperative pulmonary function tests and preparation.

a. Discontinuance of beta-adrenergic blockers (e.g., Inderal) may produce complications related to the patients underlying disease (e.g., hypertension, angina, dysrhythmia). i. Stopping Clonidine (Catapres) may precipitate a sudden hypertensive crisis. ii. Some medications may potentiate drugs used in general anesthesia (e.g., Tolbutamide and Coumadin bind to plasma albumin which normally binds 70% of the Pentothal injected. This results in more available drug and a depressant effect.

A. In Vitro all inhalation anesthetics produce a dose related cardiac depression. However, In Vivo the effect is less clear. B. All three halogenated hydrocarbons decrease mean arterial blood pressure. C. Isoflurane depresses autoregulation the most and may cause a "coronary steal" which may cause myocardial ischemia in patients with coronary disease. D. All mu receptor opioids except Demerol decrease the heart rate via a central effect on the vagal nucleus in the medulla. The hypotension from morphine is primarily due to histamine release and can be blocked by using both histamine H1- and H2- antagonist. E. Succinylcholine can cause tachycardia, bradycardia, or cardiac dysrhythmia. F. All inhalational anesthetics reduce resistance to flow to the skin and brain.

nonflamable can be used on children inexpensive well-tolerated

linked to idiosyncratic liver disease resembles chloroform induced liver damage high potential to cause hepatotoxicity slow onset of action

great safety record unaffected y exposure to light can be used safely in pts with renal and hepatic disease can be used in animals nonflammable

slow onset of action high in cost may cause malignant hyperthermia

excellent safety record relaxes the uterus in pregnant women fast recovery from anethesia has little change in pulse and respiratory rate

cannot be used in people with epilepsy

rapid onset of action nonflammable

high cost and low potency greenhouse gas cannot be used as a starter anesthetic in children, only while the child has already loss consciousness to maintain a loss of consciousness.