2025 Intro to Clinical Anesthesia Exam 1 Flashcards

Question

Appearance Suggesting Difficult Airway

Answer 1

Emergency surgical procedure where delay could mean significant increase in threat to life or body part. Crash C-section Open Fracture with vascular compromise Ruptured AAA Closed head injury with decompensation NPO status waved

Answer 2

Beta Blockers- Continue, supplement IV if discontinued Decreased myocardial oxygen demand, chance of arrythmias, pre & post-op M&M CA Channel blockers- Continue ACE Inhibitors/ARB- Discontinue unless indicated for heart failure Continue inhalers bronchodilators- Albuterol prior to GA etc Discontinue blood thinners per recommendations Generally hold oral hypoglycemics, halve SQ insulin night before

Answer 3

Resting echocardiography- Not routinely offered before surgery except when Patient has a heart murmur or new onset cardiac symptom (breathlessness, pre-syncope, syncope, chest pain) Signs or symptoms of heart failure Fatigue/weakness Swelling in legs/ankles/feet SOB with activity or laying down Carryout resting ECG and review before delaying surgery/ordering echo

Answer 4

Chest X-Ray- Do not routinely order preop chest X-ray Low yield in absence of active pulmonary symptoms, exposure to radiation Lung function tests- Do not routinely order unless ASA 3 or 4 with known or suspected respiratory disease having major or complex surgery. Candidate for lung resection

Answer 5

Hypoventilation Atelectasis Pneumonia Can result in post-operative mechanical ventilation Patient at risk Smokers COPD Age>70 Thoracic or Upper Abdominal Surgery Anesthesia > 2 hours

Answer 6

Smoking cessation Bronchodilator therapy Early treatment bronchitis Early mobilization

Answer 7

Ordered routinely for those with suspected active bleeding GI Bleed, fracture of pelvis/femur, trauma

Answer 8

Coagulation testing (PT/PTT/INR) and Hematology Coagulation labs not routinely ordered outside of Those currently anticoagulated ie coronary stents, atrial fibrillation, DVT Those with Liver disease Transfusion therapy Consider preop transfusion in symptomatic patients with Hb <7mg/dl One unit of PRBC should raise Hb 1mg/ml or HCT by 3% Consider platelet transfusion to >50,000 (generally accepted) 1 6 pack of platelets will increase count 30-60,000

Answer 9

Anesthesia without consent in a non emergent situation could be construed as assault, so make sure to get that paper signed. Explain anesthetic options with pros and cons Decision-making capacity Minors cannot sign for themselves No benzo admin before consent Power of Attorney signs as proxy if patient is unable to sign/make healthcare decision Emergency consent- if surgeon deems procedure emergent and delaying would result is loss of life or limb in a patient unable to consent themselves, and without proxy- informed consent is waived

Answer 10

Decrease anxiety Decrease post op pain requirements/Anesthetic requirements Prevent Post operative Nausea and Vomiting Early Recovery After Surgery (ERAS) ... Surgery and Surgeon Specific

Answer 11

ANXIETY BEGONE Midazolam- Benzodiazepine, most given anxiolytic/peri procedural sedation medication. IV/PO, anterograde amnesia RELATIVE CONTRAIDICATIONS Newborn (<1 year )- Won’t remember anyway Elderly (>65 years old)- May increase POCD (post operative cognitive dysfunction) Decreased baseline consciousness Intracranial pathology-Increased CO2 = bad Severe pulmonary disease- increased CO2 = bad Hypovolemia- chance of hypotension

Answer 12

Acetaminophen-1 gram if no contraindications Celecoxib ( Celebrex ) - oral COX-2 receptor inhibitor 200-400 mg dose No increased bleeding risk, unlike non-specific COX meds (aspirin etc) Gabapentin/Pregabalin- Gabapentinoid meds 300-1200 mg Gabapentin (Neurontin). 75-150 mg Pregabalin (Lyrica) Avoid in >65 years of age, OSA Oxycontin- Extended-release oxycodone 5-20 mg for major surgery in the absence of regional anesthesia

Answer 13

Most Patient will routinely receive Dexamethasone (Decadron) 4-10 mg after induction of anesthesia Ondansetron (Zofran) 4 mg as premed/intraop/or end of surgery Hx of PONV Scopolamine 1.5 mg Transdermal patch Avoid in patients over 65- confusion, sedation, dementia EDUCATE patient on touching the patch and washing hands

Answer 14

Minimize narcotics when available, opt for regional or neuraxial anesthesia Intraoperative measures to be discussed in next lecture!

Answer 15

Non-surgical side, non-dominant side Flat-non-moving surfaces Back of hand, forearm What gauge IV? 20g for most outpatient surgeries 18g for surgeries with significant expected blood loss (EBL) Tough Stick? Even a lowly 22 is enough to induce anesthesia, vasodilation of anesthetic agents allow for larger IV post-induction May need to consider Ultrasound in morbidly obese patients, or those with IVDA history

Answer 16

General anesthesia Regional Anesthesia Peripheral nerve blocks Monitored Anesthesia Care (MAC)

Answer 17

ANESTHETIC CHOICE IS BASED ON SEVERAL CRITERIA Surgeon preference and patient safety Surgical positioning Patient comfort/choice Post-operative requirements Patient age and coexisting disease NPO status Procedure duration Elective and Emergency Airway evaluation

Answer 18

Positioning- Prone and often beach chair position Full-stomach- trauma, gastroparesis, high aspiration risk Long surgical time, laparoscopy Does my patient need to be paralyzed? Open abdominal and thoracic cases, laparoscopic and robot assisted cases Will relaxation facilitate surgical conditions, or keep patient safe? Exposure in spine surgery, Mayfield pins for neurosurgery

Answer 19

Subarachnoid block (SAB or Spinal) anesthesia- common for C-section, knee and hip replacement, some urological procedure Epidural anesthesia- laboring parturient, thoracotomy, open abdomen Peripheral nerve blocks (PNB) and regional anesthesia- block surgical stimulus from anesthetized area ...Far more to come on all of these

Answer 20

IV induction is gold standard, but peripheral IV access may be difficult, traumatic, or impossible preinduction Kiddos, those with mental handicaps consider inhalational induction IM Ketamine- 5mg/kg in patient that will not tolerate PIV placement or mask induction... KETAMINE DART

Answer 21

What meds will be used for maintenance of anesthesia? Pain Control? Inpatient vs Outpatient Is paralysis needed? How much/when do I reverse? How will I maintain CV homeostasis (+/- 20% of baseline BP, HR etc) Bolus medication vs drip How does my patient’s history affect my plan? Cardiac/pulmonary and reactive airway disease/kidney disease etc.

Answer 22

Is patient heading home, to a hospital bed, or the ICU? How will I meet the patient’s post-op oxygen requirements? Nasal cannula v face mask, oral airway/nasal airway How am I covering the patient’s pain? Outpatient vs inpatient How painful was the surgery? Does patient have underlying tolerance of pain medication? What meds are onboard?

Answer 23

Sedation without ventilatory support- breathing on your own Full monitoring (ASA monitors) and generally End tidal CO2 Response to verbal commands or more profound stimulation unless contraindicated Rescue equipment available, supplemental oxygen ”Twilight sleep” Common agents- versed/fentanyl/propofol/precedex/ketamine

Answer 24

Positioning- can determine ET vs LMA Monitoring/lines/IV access- Is an arterial line indicated? Pre/post induction? Second IV? Central line? Neuro-monitoring, TEE Post-op destination and care transition Plan for intraoperative events Hypothermia, bleeding, anticoagulation, tourniquet use, positioning, redosing antibiotics etc

Answer 25

Cases where preoxygenation is particularly important: During RSI and intubation- trauma, full stomach If difficult airway management is predicted In patients who are expected to desaturate quickly (Desat curve- Obese, pregnant, pediatric, hypermetaboilic)

Answer 26

Prolong safe apnea time without desaturation- reduces time pressure to secure an airway Oxygen storage in lungs primarily resides in Functional Residual Capacity (FRC ) FRC = Expiratory Reserve Volume + Residual volume and is around 3L TV usually around 500 ml

Answer 27

21% O2 in the air we breath Alveolar gas makeup in healthy patient breathing room air 14% O2, 5% CO2, 6% H2O vapor, 75% Nitrogen After onset of Apnea O2 consumption is ~250 ml/minute Precipitous drop after 90% Sat 8 deep breaths with good mask seal, high flow O2 May require 3-5 minutes in case of severe lung disease

Answer 28

Oxygen Fentanyl- Narcotic to blunt response to airway management Lidocaine- Decrease pain on propofol infusion/decrease airway reflexes Propofol – Induction agent of choice for most anesthetics Rocuronium/Succinylcholine- Muscle relaxant to maximize conditions for intubation

Answer 29

Timing is Everything Analgesia Hemodynamic Management Destination and Transition of Care Airway

Answer 30

1 65 y/o male patient 5’7” 187lbs NKDA Home medications Aspirin, Metoprolol, Lisinopril, omeprazole History of coronary stents x2 10 years ago, HTN, GERD ROS- RUQ pain for 1 week with N/V Scheduled for laparoscopic cholecystectomy estimate duration 1.5 hours ASA? What’s your plan? Premeds? Airway choice? Perioperative concerns? 2 34 y/o woman 5’3” Allergies listed to PCN and Sulfa Home Meds- Mirena BC, multivitamin, albuterol PRN ROS- L Breast mass, asthma Scheduled for L Breast lumpectomy, exceptionally nervous in preoperative area What’s the plan? Premeds? Airway? 3 55 y/o male here for screening colonoscopy Home meds include fish oil, ibuprofen prn, Ambien ROS- abdominal pain, pre-diabetic diet controlled, insomnia GETA vs LMA vs MAC? 4 36 y/o male 205 pounds, 6’2” NKDA Home medications: MVI ROS- Negative except for torn Left ACL Surgery- Left ACL reconstruction with patellar tendon graft ASA? General with Et tube/LMA or MAC? 5 68 y/o female 5’6” 185 lbs Allergic to bananas ROS- History of CAD with CABG 7 years ago, smoker, HTN, anxiety and depression presenting with active stroke with right sided weakness in emergency room Home medications include- Aspirin, Sublingual nitroglycerin, losartan, metoprolol, Lipitor, Xanax Scheduled case- Thrombectomy Patient aphasic in preop ASA? Consent? Anesthetic Choice?

Answer 31

Anesthesia Machines have inlets for both E-cylinder gases and pipeline gases coming from the wall (hospital source) Pipeline inlets Air, Nitrous Oxide, and Oxygen Color coded tubing Attached using a noninterchangeable Diameter-index safety System (DISS) Approximate pipeline pressure of the gases delivered to the anes. machine is 50pisg (pounds per square inch gauge) O2 Flush delivers 50psig directly to the pt!!!!! Bypasses vaporizers. Fig 4-3 page 53

Answer 32

Normal capacity is 1590L Normal E-cylinder tank pressure is 745psig The volume of N20 is not proportional to its cylinder pressure The pressure in the tank will not change until the vol. is at or around 400L Only reliable way to measure how much is by weighing the cylinder

Answer 33

Flow valves and meters Vaporizers Common fresh gas outlet Oxygen analyzers Adjustable Pressure-Limiting Valve (APL) Humidifiers Ventilators Waste gas scavengers

Answer 34

Very Rare, but good to know what to do in case one happens Prevention includes If possible lowering the FiO2 to 30% or lower Avoid draping that allows for the build up of O2 Using a Laser ETT if needed Avoiding N2O use

Answer 35

First step is to DISCONTINUE THE FLOW OF OXYGEN!!!! This can be done a couple different ways. Next Steps include Removing the current ETT and flushing the airway with sterile water or saline. Re-establish a secure airway. Exam the burnt ETT for missing pieces and possible perform a bronchoscopy on the patient.

Answer 36

Very vital and essential part in the delivery of Anesthesia Measured by infrared absorption analysis Based on the BEER-LAMBERT law

Answer 37

Formula for measuring an unknown gas within inspired gas because the absorption of infrared light passing through a solvent (inspired or expired) is proportional to the amount of that unknown gas. Oxygen and Nitrogen do not absorb infrared light.

Answer 38

Various technologies have been used to accomplish this. Galvanic Cell Paramagnetic analysis (most common used) Polarographic Electrode In our newer machines the method used is Paramagnetic analysis.

Answer 39

Oxygen is a nonpolar gas, but it is Paramagnetic. When placed in a Magnetic field it will expand and it will contract when that magnet is turned off. If you compare the resulting change in volume (or pressure or flow) to a known standard you can measure the amount of Oxygen that is being expired or Inspired

Answer 40

Non-Invasive Blood pressure Cuff (Circulation) Pulse Oximetry monitoring (Oxygenation) Electrocardiography (ECG) monitoring (Circulation) Capnography (Ventilation) Temperature

Answer 41

Most common method used to monitor Blood Pressure Utilizes Oscillometry to determine SBP, DBP, and MAP MAP = SBP + 2(DBP) /3 Different Sizes Available Can be placed in multiple locations Actual BP can be different depending on where the cuff is located. 1cm ( 1cm H2O) is equal to 0.74mmHg If the cuff is on a patients forearm and that is 20cm below the patients Head then we know that the Cerebral BP is 14.7mmHg lower than what the cuff is showing Systolic and Diastolic

Answer 42

Factors that can affect your reading or give a false reading Methemoglobinemia (rare blood disorder affecting hemoglobin) Carboxyhemoglobin (what happens to RBC when carbon monoxide is inhaled) Malposition of probe Ambient light Low perfusion to extremities ETC,ETC

Answer 43

Recording of the electrical potentials generated by myocardial cells What makes up our cardiac rhythm “P” wave is the contraction of both Atria ”QRS” complex is the Ventricular Systole “T” wave represents the repolarization of the Heart as it awaits the next cardiac cycle. Two most important leads to monitor Lead 2 (best at detecting Inferior wall Ischemia) Lead V5 ( best at detecting Anterior and Lateral wall Ischemia)

Answer 44

MRSA (Methicillin-resistant staphylococcus aureus) VRE (Vancomycin-resistant enterococci)

Answer 45

Wear mask at all times in hospital unless eating/drinking. N95 for Covid/TB positive patients or those at high risk Chickenpox (varicella) Measles (rubella) Disseminated zoster (shingles) Covid 19 TB Current personal vaccinations

Answer 46

Hepatitis-B (HBV) Hepatitis-C (HCV) HIV (very low sero-conversion rate) Practice standard precautions (gloves, hand washing, needle safety and eye protection)

Answer 47

A pressure of 1000 pounds per square inch (psig) indicates an E-cylinder that is approximately half full and represents 330 L of oxygen. The only reliable way to determine the residual volume of nitrous oxide is to weigh the cylinder. To discourage incorrect cylinder attachments, cylinder manufacturers have adopted a pin index safety system. A basic principle of radiation safety is to keep exposure “as low as reasonably practical” (ALARP). The principles of ALARP optimize protection from radiation exposure by the use of time, distance, and shielding. The magnitude of a leakage current is normally imperceptible to touch (<1 milliampere [mA] and well below the fibrillation threshold of 100 mA). If the current bypasses the high resistance offered by skin, however, and is applied directly to the heart (microshock), current as low as 100 microamperes (μA) may be fatal. The maximum leakage allowed in operating room equipment is 10 μA. To reduce the chance of two coexisting electrical faults, a line isolation monitor measures the potential for current flow from the isolated power supply to the ground. Basically, the line isolation monitor determines the degree of isolation between the two power wires and the ground and predicts the amount of current that could flow if a second short circuit were to develop. Almost all surgical fires can be prevented. Unlike medical complications, fires are a product of simple physical and chemical properties. Occurrence is guaranteed given the proper combination of factors but can be almost entirely eliminated by understanding the basic principles of fire risk. The most common risk factor for surgical fire relates to the open delivery of oxygen. Administration of oxygen in concentrations of greater than 30% should be guided by the clinical presentation of the patient and not by protocols or habits. The sequence of stopping gas flow and removal of the endotracheal tube when a fire occurs in the airway is not as important as ensuring that both actions are performed immediately. Before laser surgery is begun, the laser device should be in the operating room, warning signs should be posted on the doors, and protective eyewear should be issued. The anesthesia provider should ensure that the warning signs and eyewear match the labeling on the device because laser protection is specific to the type of laser.

Answer 48

Equipment-related adverse outcomes are rarely due to device malfunction or failure; rather, misuse of anesthesia gas delivery systems is three times more prevalent among closed claims. An operator’s lack of familiarity with the equipment, an operator’s failure to verify machine function prior to use, or both are the most frequent causes. Such mishaps accounted for about 1% of cases in the ASA Closed Claims Project database from 1990 to 2011. The anesthesia machine receives medical gases from a gas supply, controls the flow and reduces the pressure of desired gases to a safe level, vaporizes volatile anesthetics into the final gas mixture, and delivers the gases to a breathing circuit that is connected to the patient’s airway. A mechanical ventilator attaches to the breathing circuit but can be excluded with a switch during spontaneous or manual (bag) ventilation. Whereas the oxygen supply can pass directly to its flow control valve, nitrous oxide, air, and other gases must first pass through safety devices before reaching their respective flow control valves. These devices permit the flow of other gases only if there is sufficient oxygen pressure in the safety device and help prevent accidental delivery of a hypoxic mixture in the event of oxygen supply failure. Another safety feature of anesthesia machines is a linkage of the nitrous oxide gas flow to the oxygen gas flow; this arrangement helps ensure a minimum oxygen concentration of 25%. All modern vaporizers are agent specific and temperature corrected, capable of delivering a constant concentration of agent regardless of temperature changes or flow through the vaporizer. A rise in airway pressure may signal worsening pulmonary compliance, an increase in tidal volume, or an obstruction in the breathing circuit, endotracheal tube, or the patient’s airway. A drop in pressure may indicate an improvement in compliance, a decrease in tidal volume, or a leak in the circuit. Traditionally ventilators on anesthesia machines have a double-circuit system design and are pneumatically powered and electronically controlled. Newer machines also incorporate microprocessor controls and sophisticated pressure and flow sensors. Some anesthesia machines have ventilators that use a single-circuit piston design. The major advantage of a piston ventilator is its ability to deliver accurate tidal volumes to patients with very poor lung compliance and to very small patients. Whenever a ventilator is used, “disconnect alarms” must be passively activated. Anesthesia workstations should have at least three disconnect alarms: low peak inspiratory pressure, low exhaled tidal volume, and low exhaled carbon dioxide. Because the ventilator’s spill valve is closed during inspiration, fresh gas flow from the machine’s common gas outlet normally contributes to the tidal volume delivered to the patient. Use of the oxygen flush valve during the inspiratory cycle of a ventilator must be avoided because the ventilator spill valve will be closed and the adjustable pressure-limiting (APL) valve is excluded; the surge of oxygen (600–1200 mL/s) and circuit pressure will be transferred to the patient’s lungs. Large discrepancies between the set and actual tidal volume are often observed in the operating room during volume-controlled ventilation. Causes include breathing circuit compliance, gas compression, ventilator–fresh gas flow coupling, a preset ventilator peak airway pressure limit, and leaks in the anesthesia machine, the breathing circuit, or the patient’s airway. Waste-gas scavengers dispose of gases that have been vented from the breathing circuit by the APL valve and ventilator spill valve. Pollution of the operating room environment with anesthetic gases may pose a health hazard to surgical personnel. A routine inspection of anesthesia equipment before each use increases operator familiarity and confirms proper functioning. The U.S. Food and Drug Administration has made available a generic checkout procedure for anesthesia gas machines and breathing systems.

Answer 49

The tip of the central venous pressure catheter should not be allowed to migrate into the heart chambers. Although the pulmonary artery (PA) catheter can be used to guide goal-directed hemodynamic therapy to ensure organ perfusion in shock states, other less invasive methods to determine hemodynamic performance are available, including transpulmonary thermodilution cardiac output (CO) measurements, pulse contour analyses of the arterial pressure waveform, and methods based on bioimpedance measurements across the chest. Relative contraindications to PA catheterization include left bundle-branch block (because of the concern about complete heart block) and conditions associated with a greatly increased risk of arrhythmias. Pulmonary artery pressure should be continuously monitored to detect an over wedged position indicative of catheter migration. Accurate measurements of CO depend on rapid and smooth injection, precisely known injectant temperature and volume, correct entry of the calibration factors for the specific type of PA catheter into the CO computer, and avoidance of measurements during electrocautery.

Answer 50

Capnographs rapidly and reliably detect esophageal intubation—a cause of anesthetic catastrophe—but do not reliably detect mainstem bronchial intubation. Postoperative residual paralysis remains a problem in postanesthesia care, producing potentially injurious airway and respiratory function compromise and increasing length of stay and cost in the postanesthesia care unit (PACU).

Answer 51

The cornerstones of an effective preoperative or preprocedure evaluation are the history and physical examination, which should include a complete and up-to date listing of all medications taken by the patient in the recent past, all pertinent allergies, and responses and reactions to previous anesthetics. The anesthesiologist should not be expected to provide the risk-versus-benefit discussion for the proposed surgery or procedure; this is the responsibility and purview of the responsible surgeon or “proceduralist.” By convention, physicians in many countries use the American Society of Anesthesiologists’ classification to identify relative risk prior to conscious sedation and surgical anesthesia. In general, the indications for cardiovascular investigations are the same in elective surgical patients as in any other patient with a similar medical condition. Adequacy of long-term blood glucose control can be easily and rapidly assessed by measurement of hemoglobin A1c. In patients deemed at high risk for thrombosis (eg, those with certain mechanical heart valve implants or with atrial fibrillation and a prior thromboembolic stroke), chronic anticoagulants should be replaced by intramuscular low molecular- weight heparins or by intravenous unfractionated heparin. Current guidelines recommend postponing all but mandatory emergency surgery until at least 1 month after any coronary intervention and suggest that treatment options other than a drug-eluting stent (which will require prolonged dual antiplatelet therapy) be used in patients expected to undergo a surgical procedure within 12 months after the intervention. There are no good data to support restricting fluid intake (of any kind or any amount) more than 2 h before induction of general anesthesia in healthy patients undergoing elective procedures; moreover, there is strong evidence that nondiabetic patients who drink fluids containing carbohydrates and protein up to 2 h before induction of anesthesia experience less perioperative nausea and dehydration than those who are fasted longer. To be valuable, preoperative testing must discriminate: There must be an avoidable increased perioperative risk when the results are abnormal (and the risk will remain unknown if the test is not performed), and when testing fails to detect the abnormality (or it has been corrected), there must be reduced risk. The utility of a test depends on its sensitivity and specificity. Sensitive tests have a low rate of false-negative results and rarely fail to identify an abnormality when one is present, whereas specific tests have a low rate of false-positive results and rarely identify an abnormality when one is not present. Premedication should be given purposefully, not as a mindless routine. Incomplete, inaccurate, or illegible records unnecessarily complicate defending a physician against otherwise unjustified allegations of malpractice.

Answer 52

normally 2-5 mmHG, reflects alveolar dead space

Answer 53

Edentulous is not a sign of hard airway Neck radiation Pregnancy Short Neck

Answer 54

Know your drugs always for test

Answer 55

Carboxyhemoglobin - falsely elevated Pulse Ox Methemoglobinemia - falsely low Look at more!!!

Answer 56

ETCO2 will be 2-5mmHg higher than PaCO2

2025 Intro to Clinical Anesthesia Exam 1 Flashcards

Basic Equipment, Perioperative/Induction (98 cards)