2025 Lab 1 Exam 1/Midterm Flashcards

Question

Capnography

Answer 1

Normal CO2 35-45mmHg Normal Respiratory Rate is 12-16/min Reading is normally 5-6mmHg off compared to the PaCO2 due to dilution with dead space in the airway during exhalation The more perfusion that is happening the more CO2 that can be exhaled so a dramatic drop in CO2 can sometimes mean a drop in perfusion (Blood pressure).

Answer 2

Precordial leads: V1-V6 look at the frontal plane of the heart Limb Leads I, II, III, aVL, aVR and aVF look at a complete 360 degrees of the heart but only the edges of the frontal plane To get a complete picture of the heart a 12 lead ekg is required (10 electrodes) Green or Left? (Shouldn't it be Right?) lower leg is considered the ground lead. We need a ground lead because the earth is negative, and positive charges are attracted to that. The ground lead gives these charges a safe place to go without causing artifact or shock to the patient.

Answer 3

12-lead Precordial lead placement V1: 4th intercostal space (ICS), RIGHT margin of the sternum V2: 4th ICS along the LEFT margin of the sternum V4: 5th ICS, mid-clavicular line V3: midway between V2 and V4 V5: 5th ICS, anterior axillary line (same level as V4) V6: 5th ICS, mid-axillary line (same level as V4)

Answer 4

Potentially lethal rhythms: ventricular fibrillation, ventricular tachycardia, asystole, ST depression/elevation, atrial fibrillation/flutter, complete heart block, and pulseless electrical activity.

Answer 5

ST depression is the result of myocardial ischemia Hypotension, blood clot, hypoxia, arrythmias ST elevation myocardial infarction (STEMI) is seen at the time or right after a myocardial infarction occurs Actual cell death due to inadequate oxygen supply the result of the above complications if not resolved

Answer 6

Sleep apnea. While the oxygenation of this patient is adequate (determined from the pulse ox) the ventilation is low as determined by the lack of CO2 on his waveform. Hypercapnia (retaining CO2) can lead to prolonged emergence from anesthesia due to CO2 narcosis.

Answer 7

The mean of 110/70 is 71mmHg with the head being roughly 20 cm from the blood pressure cuff that would be a mean perfusion pressure to the brain to be 51 mmHg, which is too low to guarantee adequate perfusion to the brain.

Answer 8

A sudden drop in CO2 is usually due to hypoperfusion (low BP).

Answer 9

Normal response to positioning are blunted under anesthesia In normal state move from upright to supine state MAP is maintained in a narrow range with interactions through complex interactions in parasympathetic and sympathetic nervous system Under anesthesia positioning is going to cause wider physiologic swings... taking away ANS (para and sym) typical responses

Answer 10

When a person reclines from an upright to a supine position, venous return to the heart increases and this increases preload, stroke volume, and cardiac output. These changes cause a brief increase in arterial blood pressure, which in turn activates afferent baroreceptors from the aorta (via the vagus nerve) and within the walls of the carotid sinuses (via the glossopharyngeal nerve) to decrease sympathetic outflow and to increase parasympathetic impulses to the sinoatrial node and myocardium. This parasympathetic outflow counters the increase in arterial blood pressure from increased preload and as a result systemic arterial blood pressure is maintained within a narrow range during postural changes in the nonanesthetized setting.

Answer 11

Surgical Positions should be ones patients can tolerate while awake! Perioperative team effort Maintain spine and extremity neutrality Proper padding – focus on tissues overlying bony prominences Securing the patient

Answer 12

Be aware of the equipment Lock Bed Assemble all attachments Fittings and attachment properly tightened Staff moving the patient are properly protected Know how the operating table raises, lowers, tilts, if there are any loose parts or any previous damage to the bed Bed locked and if necessary have someone standing on opposite side to allow for no movement Make sure that anything necessary for the positioning of the patient that must be attached to the equipment is already attached before the arrival and placement of the patient on the OR table. Patients restraints should be secured in place so once patient is on the OR table they can easily and gently be strapped in to ensure safety Don’t want to have to readjust linens or anything else once the patient is in the proper position Protection via surgical caps, eyewear, coats and also proper moving techniques are used

Answer 13

Supine... on back Prone... on stomach Lateral... on side Lithotomy... on back, feet in air

Answer 14

Most common position Laid on back Extremities Padding Protective measures Surgical procedures associated Easy to place, least amount of harm is done to the patient Back should not be compromised, spine should be straight and parallel to the OR bed, head should be aligned with body and hips parallel to spine Legs are extended out with knees relaxed, arms are either extended outward with palms up using an arm board with padding and can be secured by arm straps or they may be tucked against the body If surgery is long enough the patient might have a padded foot board placed at feet to prevent the feet from dropping and/or moving Padding placed under every part of body and there is a usually a pillow placed under the patient’s head... under knees as well Sequential Compression Devices (SCDs) on lower legs to keep perfusion Protective measures include strapping of the legs just above the knees so they do not move and sometimes even eye padding is included in the surgery so there is no harm to the eyes, if the patient is slightly on their side they should use a doughnut or special headrest to protect the ear Many surgeries are associated with this position such as: eye, ear, chest (any kind of cardio or pulmonary surgery), abdomen, extremities etc.

Answer 15

Airway obstruction Circulation Backache Limit Arm Abduction to > 90 degrees to protect Brachial Plexus Ulnar nerve damage with compression on medial aspect of elbow Airway obstruction is the main concern with supine positioning, there can also be seen a decrease in tidal volumes Hypotension is a possibility due to compression of inferior vena cava because of vertebral bodies pressure, usually only seen in obese or pregnant women Central redistribution of blood that may lead to volume overload in a failing heart If the patient is improperly placed, for instance their arm is extended greater than 90 degrees, this can stretch the arm too far creating difficulties with the brachial plexus Ulnar nerve compression most common in supine position. More common in men than in women because of the coronoid process is 1.5 times larger in men than women and less adipose tissue over the medial aspect of the elbow

Answer 16

Patient anesthetized in supine position Jackson table Entire team needs to help Head in line with rest of body Extremities (checking with surgeon important) Monitors Roll placement Head (C-Spine Neutral Important) Padding (most important position to pad properly)... specifically on the orbital bone, NOT Eyes... also want to pad shoulders Spinal procedures and intracranial procedures Almost always will put a ETT in during Prone position Arms placed and tucked at patient’s sides or can be supported along the head, legs extended outward, arm supported so no movement A roll is a form of padding that allows the patient less pressure to particular areas leading to less of a chance of damage. Chest rolls can be placed to allow less pressure on abdomen and chest Iliac or pelvic rolls can be placed to allow less pressure on the abdomen, pelvic and upper leg area

Answer 17

Challenge with obese patients Maintain neck neutral position Avoid direction pressure on the eyes Pulmonary compliance improves in prone position Mindful of arms abducted less than 90 degrees If arms abducted less than 90 degrees at shoulders then it can cause stretch and damage to brachial plexus Forearm pads need to be placed to avoid ulnar nerve damage via compression and indirect compression of axillary neurovascular bundle Arm board can be too low causes

Answer 18

Patient anesthetized in supine position Placed on opposite side of intended surgical access Extremities Padding Head aligned with spine Protective measures Can use an LMA Right Lateral means right side is down Left Lateral means left side is down Extremities, knee joint flexed and upper leg stays straight, arms in arm board and secured by arm straps Padding should be placed under lower legs and to arms Head aligned can see vertebrae and feel to make sure line Dependent ear not bent (the one you are depending on) left lateral decubitus vs. right lateral decubitus... use pillow with hear hole Protective measures include placement of axillary roll on downside arm, not in armpit just below so no pressure, if put hand in fist and put in armpit and should have space, placed more caudad to axilla to prevent direct pressure on brachial plexus, large enough to relieve any pressure from mattress on lower shoulder Pillow placed under neck and head area, and pillow placed between legs and between arms Safety straps can be placed at various points of the body (hip area, above knee) to ensure patient doesn’t move Used for surgery on either lung, kidneys or the small bladder, hips potentially, SPECIFIC SURGERIES

Answer 19

Greatest number of ocular complications Hypoxemia Venous hypertension Spinal misalignment Neck, Head, Ear aches Nerve damage Primarily corneal abrasions, equal frequency in both dependent and non-dependent eyes Venous hypertension almost inevitable in dependent arm because outflow obstruction Increased risk of spinal misalignment due to position Improper placement of padding or rolls can lead to postoperative aches, and we want to ensure the ear is not bent Brachial plexus at risk if no lateral head and neck support If axillary roll incorrectly placed may have neurovascular bundle compression Lack of padding can damage both peroneal and saphenous nerve

Answer 20

Supine position, legs raised Extremities Padding Protective measures Surgeries associated Placed in supine position and first intubated, then moved to position Leg holder can be in standard, low or high lithotomy position, depending on procedure Arms can rest at side, over abdomen or on arm boards Padding should be placed as with supine, all over underside of body Protective measures include eye padding, and strapping of arms or thorax area sometimes Used for perineal, small bowel (low anterior section remove lower colon go in from bottom and remove what is left colon resections), rectal and vaginal surgeries

Answer 21

Legs placed at same time Pooling of lower limb blood Cephalad movement of endotracheal tube Airway pressures increase Decreased oxygenation Decreased CO2 exhaled Arm crushing Nerve damage Calf compression Can cause hip dislocation and back strain if legs are not placed at same time Pooling can lead to volume overload in a failing heart Though usually an easy fix, sometimes movement of endotracheal tube cephalad and has to be properly placed again Can sometimes lead to bronchospasm Particular attention should be given to placement of arms because when the leg section of table is replaced in original position digits and/or arms can be injured, crushed, or even amputated , arms tucked or out Nerve damage can occur from extreme flexion of hip joints, sciatic and obturator nerves are associated with this damage Compression of femoral nerve and distally, peroneal nerve and saphenous nerve Calf compression occurs frequently, can lead to venous thromboembolism and compartment syndrome Compartment syndrome Is when there is not a good amount of blood to supply muscles and nerves with oxygen because of an increase in pressure to the compartment (i.e. arm, leg, etc)

Answer 22

Patient in supine position, head down Extremities Padding Supine position, downward tilt of head usually about 35-45 degrees, more commonly 45 degrees Head is lower than pelvis Pads even on shoulders so no overextension of head, however this should be avoided to prevent pressure on the shoulder area which could lead to compression of peripheral neuropathy Pads on bottom of bed down and legs up in stirrups (bladder removal, prostate or hysterectomy and robot goes between legs in stirrups) RESEARCH New studies show no pads on shoulder in Trendelenburg Legs in neutral position and arms are either tucked in at sides or on arm boards Padding must be placed beneath body of patient Surgical tape may be used to insure no slippage of padding Protective measures includes velcro adhesive, it MUST be checked prior to placement on OR table, eye padding, straps Used for surgery in lower abdomen and pelvic organs, better exposure to pelvic area because the abdominal viscera is moved away from the area, robotic assisted hysterectomies (for lower bowel) , easier access to uterus, may be in association with lithotomy position

Answer 23

Pulmonary and hemodynamic concerns Autotransfusion of 9% from blood collected in the legs Decrease in pulmonary compliance as abdominal contents displaced towards the diaphragm Patient sliding off OR bed Surgical brace damage Slowly taken out of position Could cause airway swelling Do not use excessive fluids, can exacerbate the problem Ventilator will max out, might have to increase 02 Concentration A little more extreme with Trendelenburg than supine Ventilation-perfusion mismatched, raised ICP, raised IOP and regurgitation Increase PIP, have to switch to pressure controlled vs volume controlled in supine, pulmonary fibrosis would worsen in this position Decrease in respiratory exchange can be due to the movement of viscera creating a pressure against the diaphragm and a pooling of blood in the upper torso of the patient Surgical braces can lead to damage in brachial plexus Allow patient a slow transition back to normal positioning in order to give the patient’s body time to readjust itself to change in blood volume

Answer 24

Head higher than feet in supine position Extremities Padding Protective measures Benefits (decreased pressure on pulmonary) Risks (hypotension) Literally opposite of Trendelenburg Padded footboard used to prevent sliding of patient off of OR table Surgeries are usually head and neck procedures, usually thyroid or parathyroid surgery Helps breathing and decreases blood supply to surgical area Decrease in ICP and IOP Less likely to regurgitate Hypotension main concern and an increase risk in venous air embolism Unless arterial line then blood pressure lower in brain than arm, with NIBP less mmHg than normal because brain is above arm If pressure below 90 mmHg, and measuring 90 at arm so you know head is less so can bump them a bit vs. in Trendelenburg would be higher because head below arm

Answer 25

Hypotension from venous pooling Falling off the bed Often used on upper abdominal procedures where pneumothorax can be caused by surgeon

Answer 26

We work as a team! Initial assessment is essential Procedure length Padding and protective equipment checked and available Previous injury DOCUMENTATION!!!!!! End of the day position injuries will fall on Anesthesia (if surgeon changes anything, make note of it for legal considerations) Assessment including weight, type of surgery, surgeons preference Procedure length includes assessment of repositioning, schedule times to move patient so whole team is available

Answer 27

Neo How to make 100 mcg/ml 10 mg/ml = “10,000 mcg/ml” standard concentration 100 ml bag… add your vial (~100 mcg/ml) 250 ml bag… add your vial (40mcg/ml), 2 vials (80 mcg/ml) 10 cc syringe... draw 9 ccs fluid and add vial (1,000 mcg/ml), take another 10 cc syringe and add 9 ccs of fluid - take this syringe and draw 1 cc from original 10 cc syringe (100 mcg/ml) Ephedrine Common concentration 50mg/ml Common dose application 5 mg (1cc) or 10 mg (2cc) How to make for this common dose application 10 cc syringe, draw 9 ccs fluid and add vial 1cc (5 mg/ml)

Answer 28

Atropine Color green Prevents parasympathetic Use 3cc syringe Lidocaine 2% (100mg) verse 1% (50 mg)… use 5 cc syringe Succinylcholine Typical comes in premade with red cap 10 cc syringe Propofol (not controlled universal, facility dependent) 20 ml… Versed (controlled, special for waste process) 2cc vial Rocuronium 5 ccs Antibiotics Ansef typically always stocked. Comes as powder, 1 g/ vial, have to constiute Under 60kg = 1 gram 60-120 = 2 grams 120+ = 3 grams Narcotic Fentanyl typical (controlled, special for waste process) Could see amps 250mg/5ml

Answer 29

Primary tubing Drip chamber O2 filter Lure lock port Roller clamp Lure lock port Port to iv access 10, 15, gtts/ml 20 gtts/ml... not listed on slides

Answer 30

Micro dripper Little wedge in drip chamber to slow down 60 gtts/ml

Answer 31

lack o2 filter lack ports typical for antibiotics

Answer 32

y-tubing (for blood) normal saline typical when priming, put drip chamber up side down to fill to not over fill albumin doesn’t need y-tubing, do need the extra needle (like socm propofol)

Answer 33

Appropriately sized and functional laryngoscope blade and handle One appropriately sized ETT with cuff checked for patency (10 mL syringe) - a stylet inserted into ETT - two ETTs (one size below and one size above the chosen size) in the top drawer of the anesthesia machine (What about ped. OETT sizes?) A tongue depressor Two appropriately sized oral airways

Answer 34

Tape / Gloves / Alcohol wipes Extra towels / Pillows 4 x 4 gauze pads Lacri-Lube eye ointment Temperature probe (skin or esophageal) KY jelly or lubricant Bair Hugger blanket (upper or lower body)

Answer 35

Unless otherwise specified, tabletop setup must be present for ALL cases: Laryngoscope (x2 Appropriate Laryngoscope Blades) ETT (x2 appropriate sized ETTs) Tongue depressor Oral airway(s) Choose appropriate OPA size for patient Early setup: estimate 2 sizes for upcoming patient Final placement: confirm appropriate size Nasal airway(s) Choose appropriate size NPA for patient Early setup: Estimate 2 sizes for upcoming patient Final placement: confirm appropriate size Tape 4x4s

Answer 36

Why do we use supplemental oxygen? Preoxygenation before intubation Avoidance of intubation or other invasive airway measures Patients prone to hypoxia/hypoxemia Respiratory, cardiac disease Shock Drug related respiratory depression Oxygen - Green cylinder Pressure: 2000 psi Capacity: 625 L

Answer 37

Nasal Cannula Commonly used in MAC procedures Use NC with CO2 sample line for MACs Up to 6L/min O2 Turbulent flow, pt discomfort limit maximum L/min O2 Every 1 L/min increase in O2 increases FiO2 by 0.04 High Flow Nasal Cannula Up to 40 L/min O2 Humidify and warm delivered gas Possible CPAP effect from the high flows Face Masks Circuit Face Mask Tight seal can be created around pt nose and mouth Deliver up to 100% FiO2, air, and/or nitrous or anesthetic gases Simple Face Mask 6-10 L/min O2 >6L/min O2 decreases rebreathing of CO2 40-60% oxygen, 5L = 40% FiO2 Nonrebreather Face Mask 10-15 L/min O2 Delivers >75% FiO2 between High flow delivery devices BiPAP (Bilevel positive airway pressure) Spontaneous ventilation CPAP (Continuous positive airway pressure) Spontaneous ventilation Venturi Mask FiO2 range 24-50%, 3-15 L/min O2 Rate depicted by multi-colored orifice adaptors

Answer 38

Indications Prevent aspiration Unusual operative position Facilitate PPV Difficult mask Upper airway surgical site Provides a patent airway Sniffing position Aligns the oral, pharyngeal, and laryngeal axes for optimal direct visualization from lips to the glottis Elevate head 8-10 cm (adults) Extend head at the atlanto-occipital joint BURP Backward, upward, rightward pressure Sellick’s Maneuver (cricoid pressure) Exert downward pressure using thumb and index finger on cricoid cartilage 3kg or 30 newtons, recommended force of downward external pressure

Answer 39

Sniffing Position Scissor mouth open Carefully insert blade Angle handle ~45 degrees (aim for the corner where ceiling meets the wall) Watch teeth and lips! Carefully place ett Carefully remove blade Inflate cuff Confirm placement

Answer 40

Classic Unique iGel Intubating Supreme ProSeal Choose appropriate size Lubricate posterior cuff Sniffing position Guide cuff along hard palate until resistance is met Inflate cuff, if needed Ventilate with PIP <20 cmH2O Proper placement Cuff is bordered by the base of the tongue (superior border), the pyriform sinuses (lateral borders), and the upper ES (inferior border) LMA opening faces larynx Epiglottis is not folded over, rests on anterior cuff Pharynx supports lower cuff

Answer 41

Dilute mixture, so reduce it

Answer 42

45-50 PSI (could be considered 45-60 PSI as well) Which is the full reduced pressure wall amount

Answer 43

Epidural - Epidural Space (another name peridural space) Spinal - Subarachnoid Space (another name is intrathecal space and leptomeningeal space)

Answer 44

Brachial Plexus Commonly caused by >90 degree abduction in prone positioning Radial nerve Results in wrist drop Ulnar nerve Results in inability to abduct pinky finger Median nerve Results in inability to oppose thumb and pinky finger Sciatic nerve Commonly caused by stretching in lithotomy position Results in weakness below the knee Common peroneal nerve (most commonly injured nerve in lower body) Commonly caused by lithotomy position Results in foot drop (loss of dorsiflexion) Obturator nerve Commonly caused by excessive flexion of thigh Results in inability to adduct leg Femoral nerve Can occur in excessive thigh angulation in lithotomy Results in loss of hip flexion/knee extension

2025 Lab 1 Exam 1/Midterm Flashcards

OR Orientation, ASA Monitors, Patient Positioning/Transport