C2: Monitoring Anesthesia – Flashcards
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When does Stage II begin? Why is it called the excitement phase? What should we ensure during this stage? When will this stage end?
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-As the anesthetic drug starts to enter the brain -Low levels can induce unconsciousness but also exciteability (involuntary struggling and vocalization) -Do not over restrain and ensure the patient doesn't injure themselves or fall off the table -Ends when a sufficient amount of anesthetic drug enters the brain
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When is stage II is more apparent?
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If the induction agent is given too slowy
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What is the primary reason not to have owners present during induction?
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Stage II excitement
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What is an important point to remember about stage II?
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-That patients will also go through this excitement phase when recovering from the anesthetic
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At what stage is there sufficient loss of consciousness along with loss of the ___ and ______ reflex to allow for intubation in dogs? Is this plane sufficient for surgery?
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-Gag -Swallowing -Stage III Plane 1 -No
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What Stage is intubation of cats possible? Is this plane sufficient for surgery?
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Stage III Plane 2 -Yes it is sufficient for most surgical procedures
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What is considered the deepest surgical plane? What kind of procedures are performed when a patient is at the plane
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-Stage III Plane 3 -More painful procedures (orthopedic surgeries)
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When might it not be necessary to use Stage III Plane 3 for more painful surgeries?
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-When sufficient pain medication is given at the premedication period or intraoperatively
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In reality most surgical patients will move back and forth between Plane __ and Plane ____ as the level of ____ ____ increases or decreases
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-Plane 2 and Plane 3 -Surgical stimulation
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Which stage is too deep causing the patient to be close to respiratory and cardiovascular collapse?
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Stage III Plane 4
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What happens in stage IV? Is this reversible?
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-Respiration fails with cardiovascular collapse imminent -It is difficult to impossible to resuscitate the patient
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To determine your patient's depth of anesthesia, what three things will you monitor? What is the most important thing to look at?
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1. Vital signs 2. Reflexes 3. Muscle tone -Change in trends is the most important thing to look at not absolute values
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When attempting to maintain the anesthetic depth you must make adjustemtns to anesthetic ______ as necessary but avoid what? Ideally adjustments should be ...(2)
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-Concentrations -Avoid the yo-yo effect where your depth swings from too light a plane to too deep and back. -Ideally adjustments should be minor and infrequent
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What vital signs are commonly assessed periodically throughout the anesthetic period? (7)
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1. Temperature 2. Pulse rate, strength and rhythm 3. Heart rate and rhythm 4. Respiratory rate and quality 5. Mucous membrane colour 6. Capillary refill time (CRT) 7. Blood pressure
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Vital signs should be assessed and recorded on your anesthetic record/patient chart at what times? (7)
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1. Prior to administering premedications 2. Prior to administering induction agent (15-20 mins after premeds) 3. Asap after induction/intubation 4. Every five mins during maintenance 5. Until patient is in sternal on recovery 6. Two to three hours after sternal 7. At least every twenty-four hours while hospitalized
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Vital signs are only recorded every ___ minutes during anesthesia, but when are they being monitored during this time?
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-five minutes -Often continuously monitored with electronic equipment but always periodically monitored manually
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Much can happen during the five minutes between your periodic manual taking and recording of vitals, so we must do what? We should for instance glancing at the patient's _____ ____ frequently so we can respond quickly to a change and not wait for the alotted check time
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--Always be aware of changes in our patients -Reservoir bag
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We should manually palpate our patient's pulse while assessing it's _____ and _____. Patient's with cardiac distrubances (which may be induced with some _____ _____) may have ____ ______. What is the only way these can be detected? What should we feel?
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-Strength -Rhythm -Anesthetic drugs -Pulse deficits -Through palpating the pulse while simultaneously listening to heart sounds -Should feel one pulse for every two heart sounds
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Palpation of the strength of the pulse is an indication of ____ ______ and therefore tissue _______
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-blood pressure -perfusion
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What are the three arteries we usually palpate in small animals for their pulse?
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1. Femoral (between muscles on medial side of femur) 2. Lingual 3. Metatarsal or metacarpal (plantar surface of paw, proximal to main pad)
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Pulse rate, rhythm and/or strength can be assessed with the following four pieces of electronic equipment: What must we remember?
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1. Pulse oximeter 2. Doppler 3. Oscillometric blood pressure monitor 4. Direct arterial blood pressure monitor -That these only gives information on the pulse not the heartrate
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We should indicate on the medical record whether we've taken the heart rate with a ______ or through the ____
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-stethoscope -pulse
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What can the pulse tell us?
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1. How effectively the heart is pumping blood out 2. A weak pulse will indicate low blood pressure and decreased tissue perfusion 3. A pulse deficit (if taken while listening to heart sounds)
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Why is important to listen to heart sounds even if you've gotten the heart rate through the pulse?
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-Detect abnormal heart soounds like murmurs -Pulse deficit
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What is the fastest way to check for a heart beat?
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Palpation of the heart (as long as the patient's chest wall is accessible)
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What are three way to manually monitor the heart ?
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1. Palpation through chest wall 2. Stethoscope 3. Esophageal stethoscope
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What three pieces of equipment can be used to assess heart/pulse rate and rhythm?
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1. ECG 2. Pulse oximeter 3. Doppler
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The ______ the anesthetic the _____ the heart rate
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-deeper -slower
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When might the heartrate temporarily increase during anesthesia (where it is usually slower than normal)?(2)
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1. During a painful surgical moment 2. During the excitement phase (stage II)
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If you see a sudden increase in heart rate your patient may be _______, what should you do first?
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-Lightening -check all other vitals and reflexes quickly before adjusting anesthetic levels
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If you see a trend to decrease heart rate that does not level out your patient may become what?
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-Too deep if we don't intervene
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What is one of the most important parameters that we control?
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Respiratory rate and quality
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What will most patients do before they go into cardiac arrest?
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Stop breathing a few minutes before
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Why is it important that we constantly monitor respiration even though we only record the values every 5 minutes?
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Most patients stop breathing a few minutes before going into cardiac arrest; if we were only monitoring heart rate or checking every 5 minutes we might miss this important indicater and lose those important minutes where we have the best chance of averting an anesthetic death
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List seven ways we can monitor respiration. What is the best way?
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1. Rise and fall of chest wall (best way if visible) 2. Reservoir bag movement 3. Esophageal or regular stethoscope 4. Sound or movement of flutter valves 5. Fogging of clear ET tube 6. Electronic apnea monitors 7. Capnography
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As anesthetic depth deepens respiratory rate will _______. Anesthetized small animals usually maintain at __-___ breaths per minute. Generally we don't like to see respiratory rates less than ___ breaths per minute. As a patient deepens to Plane ___ and beyond, the respiratory rate often becomes _____ and _______ so often seem to _______. What must we not confuse this with? What should we do? If in doubt...
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-Decrease -8-10 -8 (12?) -4 -shallow and irregular -increase -A lightening patient -We should quickly assess other vitals and reflexes to confirm if patient is in trouble -If in doubt decrease anesthetic depth and watch for signs of lightening (better safe than deepening an already too deep patient)
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A patient that has a sudden respiratory rate increase may be responding to _____ stimulation and may be too ______. What should we do? What must we remember?
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-Surgical -Light -Quickly assess other vitals and reflexes (especially globe position, jaw tone, and palpebral) before making any changes -the increased resp rate will cause the patient to take in more inhalant and in many cases the patient deepens without changing concentration
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Increased respiratory rate is a _____ response to pain ( not a ______ response)
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-reflex -conscious
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If respiratory rate increases due to surgical pain we only increase the anesthetic concentration when? What happens if we increase the concentration needlessly?
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-When there is a return of reflexes, jaw tone or other indications that the patient is too light -The patient will become too deep from the combination of increased respiratory rate and increased concentration
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What reflexes should especially assess if a patient's respiration rate increases in response to surgical pain and we worry they are too light? (3)
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-Globe position -jaw tone -palpebral reflex
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Sometimes when a quick decision needs to be made ________ monitoring is more effective then ______ monitoring because ______ may take too long
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-Qualitative (trends) -Quantitative (actually measurement/numbers) -Quantitative
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T or F Temperature is a useful indicator of anesthetic depth
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F
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Regardless of the depth of anesthesia all patients will lose ___ ____ as time progresses, so what must we do?
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-Body heat -Provide supplemental heat
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When does the greatest amount of heat loss occur? So we must pay attention to maintaining body temperature as soon as _______
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-The first 20 minutes -Intubation
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List three things we can use to provide supplemental heat
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1. Hot water circulating pads 2. Wheat bags 3. Hot air systems
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Temperature may be monitored ______ or _______ with what three types of thermometers? To be useful information, you must take the temperature with the ____ method during surgery
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-Intermittently or continuously 1. Auricular (ear) 2. Rectal 3. Esophageal -same
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If it is necessary to switch to a new temperature taking method what should we always do?
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-Take a reading with the old and new method at the same time to compare differences due to technique
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What temperature taking method is available if there is no other method? In what kind of patients? We should make sure to compare this temperature with the patient's ____ temperature as this one will be much _____
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-Standard digital thermometer in the nose -Large patients -Rectal -Lower
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List four things to remember when monitoring for hypothermia
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1. Greatest temp loss in first 20 minutes 2. Prolonged surgery can lead to a 3 degree C temp loss (or greater) 3. Hypothermic animals require less anesthetic and have prolonged recoveries 4. Shivering markedly increases oxygen demand
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Prolonged surgery can lead to a ___ degree C temperature loss or greater
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3
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Hypothermic animals require ____ anesthetic and have _____ recoveries and increases the risk of ______
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-less -prolonged -complications
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Shivering markedly increases _____ demand. What does this mean?
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-Oxygen -The patient will get deeper if we don't lower the concentration
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What three things can assessing mucous membranes warn us of(3)?
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- -Warns us about possible 1. Blood loss 2. Pain 3. Hypothermia
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It is common for mucous membranes to become ____ as anesthesia ____ progresses. When is it abnormal?
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-paler -time -A sudden blanching of mucous membranes is abnormal and should be investigated
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List what pale mucous membranes might indicate in the order they should be investigated and possible causes of each (4)
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1. Blood loss: surgery (ask surgeon) 2. Decreased blood pressure: blood loss or effect of anesthetic 3. Pain: surgery (ask surgeon) 4. Hypothermia: prolonged anesthetic or warmers need replacing
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If we suspect pale mucous membranes to be from low blood pressure what else can we test to corroborate? (2)
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1. Capillary refill time (would be slower if low BP 2. BP monitor
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List the four ways we can record mucous membrane color as in the anesthetic record
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1. Pink (p) 2. Pale pink (pp) 3. White (w) 4. Cyanotic (c)
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Capillary refill time should be ____ seconds in our patients. What does prolonged CRT usually a result of? Does normal CRT rule out cardiac problems?
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-<2 seconds -low blood pressure -No
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What is the advantage of using an esophageal stethoscope?
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Can auscult heart and lungs in patients that are draped for surgery
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Reflexes and muscle tone allow assessment of the _____ ________. List the five commonly assessed reflexes
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-Nervous system 1. Globe position 2. Jaw tone 3. Palpebral reflex 4. Pedal reflex (withdrawal) 5. Pinna reflex (ear flick)
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What other reflexes can be assessed (other than the five most common ones)? (9)
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1. Pupillary size 2. Pupillary light reflex 3. Patellar reflex 4. Corneal reflex 5. Swallowing reflex 6. Laryngeal reflex (cough) 7. Perineal reflex 8. Salivary and lacrimal secretions 9. Heart and respiratory rate (reflex response to surgical stimulation)
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Where is the normal resting position of the globe of the eye? Depending on the induction agent used we may see _______ during induction and for a short while after. In most cases the eye will remain ____ until a patient has reached Stage III Plane ___, what will the eye do at this point? As anesthesia deepens what does the eye do?
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-Central -Nystagmus -central -2 -It will slowly drift down into a ventromedial position (anteromedial in horse) and if nystagmus was present it will be lost -As anesthesia deepens further into Plane 3 and 4 the eye will again return to central
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If the globe is central what can this mean? What do we do?
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-Either too light or too deep -Check vitals and other reflexes to determine which and if in doubt always assume too deep and trun down anesthetic levels
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When in doubt if your patient is too light or too deep we always assume too ____ and turn ____ anesthetic levels and watch for patient to _____.
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-Deep -Down -Lighten
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In some patients the globe may remain central even at the ____ plane of anesthesia and we have to rely on other reflexes
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surgical
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Muscles become more _____ the deeper the patient is
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relaxed
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How is muscle tone monitored? (2)
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1. By assessing the resistance to extending or flexing limbs 2. Attempting to open jaw
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There should be little to no muscle tone at Stage III Plane ___.
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2
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What is the most important uses for assessing muscle tone? (2)
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1. Whether intubation is possible (especially cats) which is when jaw tone is mostly or entirely gone 2. Whether limb muscles are relaxed for orthopedic surgery
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Along with jaw tone what two other reflexes are assessed in relation to readiness for intubation (and also for _____ in dogs)? Are these useful for assessing anesthetic depth as well?
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-Extubation 1. Laryngeal reflex (cough) 2. Swallowing reflex -They disappear early on so are not useful for assessing anesthetic depth
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Extubation in the cat can occur once which reflex occurs?
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Pinnal reflex (ear flick)
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What four reflexes start slowing down shortly after induction and most will be gone by plane __? Describe them
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-2 (surgical plane) 1. Palpebral: touch the medial corner of eyelid and response is to blink 2. Pinna: touch or blow on hairs inside ear and response is ear flick 3. Patellar: tap patellar tendon with reflex hammer and response is to extend leg 4. Pedal: firmly pinch at nail bed of toe and response is to withdraw limb
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The _____ reflex is not generally used for anesthetic monitor, why?
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-Corneal -because it's not lost until a patient is extremely deep Stage III plane 4
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The ____ reflex should be gone by the cough and swallow reflex
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-pedal
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If you only have access to the hind of the patient what reflex can we use?
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Perineal reflex: touch perineum and rectum will clench
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In horses we'll see a decrease in ______ product the deeper they are, but they should remain _____ if _____ they are too deep
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-Lacrimal -Moist -dry
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Pupil size and light response can only be used in the assessment of what patients?
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That are not premedicated with drugs that affect those reflexes (anticholinergics like atropine or glycopyrolate)
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In general the pupils will dilate during _____ of ______ and return to normal by what stage? What do the pupil's do after this?
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-Excitement of induction -Return to normal at Stage III Plane 1 -then they gradually dilate as the patient deepens
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Progressive dilation of pupils can be used as an indication of what? But not of what?
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-Can be used to indicate patient is deepening -Cannot be used to determine actual depth
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Fully dilated pupils are an indication of ____ ____
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brain death
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Pupillary light response follows the same pattern of decreasing as ______ ____
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-pupil size
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List four important points to remember about monitoring a patient under anesthesia
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1. Trends of change are more important than actual values 2. Compare rates to normal resting rate for patient 3. Recognize when rates are consistently falling 4. Respond to falling rates before the levels become critical
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What plane does muscle tone become relaxed?
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Stage III Plane 2
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T or F during the excitement phase all the reflexes are present
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T and possibly exaggerated
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In plane 2 what reflexes might be present?
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1. Patellar 2. Ear flick 3. Palpebral 4. Corneal (rest are absent)
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In plane three what reflexes are present?
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all are diminished or absent
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At what plane does the heart rate start decreasing?
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Plane 3
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At what heart rate should you become concerned and intervene in dogs and cats?
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Dogs: 140 bpm Cats: 200 bpm
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At what respiratory rate should you become concerned and intervene in dogs and cats?
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Dogs <8 Cats <10
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