2025 Lab 1 Exam 2/Final Flashcards

Question

LMA Insertion 2

Answer 1

Connect to ventilator and verify Chest Rise Bilateral Breath Sounds Absence of Gastric Sounds EtCO2 Condensation in tube Acts as a Bite Block Secure LMA

Answer 2

Our pre-operative interview is where we establish the initial level of trust and communication with our patient The information obtained in this interview can play a significant role in how we cater our anesthetic plan for each individual Depending on what questions you ask and how you ask them, the patient may reveal more pertinent history that allows for us to treat them as safely and efficiently as possible Making the patient feel comfortable/at ease before surgery will ensure the best possible outcome WE are the most powerful “drug” we can give our patients before heading back to surgery

Answer 3

Find out exactly what the patient is getting done and which surgeon is performing the procedure (each surgeon will have their own preferences – after working with them several times, we learn them and are able to more efficiently plan our anesthetic) If you are unfamiliar with the procedure, do your research! Look it up and find out any pertinent information that can help you establish your anesthetic plan Based on this information, you can have a baseline idea of your anesthetic plan (ie: GETA, TIVA, LMA, ETT, monitoring techniques required, etc) Review the patient’s chart for any relevant medical history Looking at their medication list ahead of time can give you an idea of what conditions they have If the patient has had previous surgeries, we can generally see how induction/intubation went, any issues that arose, etc Review lab results and determine if any more need to be ordered ALWAYS be sure to get a pregnancy test for woman of childbearing age Think of any pertinent questions you may need to ask them based on their medical history

Answer 4

Knock first! Ask for permission to enter Although this sounds simple, small things like this help to develop a level of respect with the patient (and may be easily forgotten if it is a busy day) Introduce yourself upon entering “Hi, I’m _____________, the student Anesthesiologist Assistant working together with Dr. ___________ (attending anesthesiologist) and ______________ (preceptor).” “Can I ask you some medical questions related to today’s procedure?” If there are people in the room with them, this gives them the opportunity to tell you if they would like privacy when discussing medical information

Answer 5

Be sure you have the correct patient in front of you! There is nothing worse than getting into an interview and realizing later that you have the wrong chart (and therefore reviewed the incorrect information ahead of time) or are in the wrong room entirely The most common identifying factors are patient’s name and DOB It is a good idea to check their wrist band if they have one on to double check their name is correct everywhere. Human errors happen all the time! Be sure to not only check your work, but the work of others in order to provide the safest possible care for each patient. Something as serious as incorrect administration of medications could start with something as simple as a registration error when the patient was admitted to the hospital! Check that the patient understands what they are having done and why (in simple terms), who their surgeon is, which side the procedure is on (if applicable), and that all of this information matches that provided on their chart/other preoperative documents such as consent forms

Answer 6

The things you want to get no matter what, get before a patient might go unconscious if emergency situation: Anesthetic History Family History with MH Allergies - Anaphylaxis or Side Effect? NPO Status

Answer 7

“Have you had any previous surgeries/anesthesia? If they have, be sure to find out if it was general or regional An easy way to do this is ask if they were knocked out for the procedure or awake Were there any issues with the anesthesia? Red flags you are looking for: high fever (possible MH), staying intubated for extended time (possible pseudocholinesterase deficiency), or nausea vomiting (PONV) “Are you aware of any family history of issues with anesthesia?” This is especially significant if the patient has never had anesthesia before, as it could be indicative of a genetic condition (ie: MH)

Answer 8

“Do you have any allergies to medications or otherwise?” Some people say they are allergic to something just because they don’t like the way they feel from it (ie: “Epinephrine makes my heart race” or “Augmentin makes me nauseous” Check for TRUE anaphylactic reactions If they are allergic to exotic fruits  think possible latex allergy If they are allergic to shellfish  think possible iodine allergy If they are allergic to Penicillin  no Ancef! If they are allergic to tape, be sure to use proper tape for eyes/tube/etc during procedure (paper tape or “pink tape”)

Answer 9

“When was the last time you had anything to eat or drink?” Sometimes patients don’t tell the whole truth or forget… Consider asking “what did you have for breakfast this morning?” This information helps us to determine their fluid deficit (hourly requirement in mL/hr) = (weight in kg) + 40 Fluid deficit = (hourly requirement) x (number of hours NPO)

Answer 10

If the patient is on beta blockers, they should take those the morning of surgery As a general rule, herbal supplements should be stopped two weeks prior to surgery... can google what ones (should be about 10) ACE/ARB/Diabetics/Diuretics should be avoided for 24 hours before surgery!! ... The GLP-1 agonists (ozempics, etc.) guidelines are constantly changing due to their newness Anticoagulants need to be stopped before surgery Xarelto  24 hours before Eliquis  48 hours before Coumadin (Warfarin)  5-7 days before (there is an INR test for therapeutic levels that could postpone the surgery) Aspirin and/or Plavix  7-10 days before

Answer 11

“Do you drink alcohol?” How much, how often, what kind? “Do you smoke cigarettes?” How many packs/cigarettes per day and for how long? “Any elicit drug use?” Assure them that this is a judgement free zone, but we need to know so we can properly care for them before, during, and after the procedure The patient may be hesitant to answer this or lie if there are others in the room The best time to ask may be when you are rolling back into the operating room or have privacy

Answer 12

It is important that we establish the patient’s overall physical activity level To do this, we determine their METS, or metabolic equivalent, which is the energy spent when the patient is sitting at rest One MET is approximately 3.5 mL of O2 consumed per kg of body weight per minute METS “Can you climb a flight or stairs without feeling shortness of breath?” “Do you do your own grocery shopping?” “Are you able to clean your house on your own?” However, each of these things could vary so much by individual A more standard question to ask would be something like… “If we were to take a walk to the entrance of the hospital together right now, could you do that with no issues?” Of course, this is all dependent on the issue patient is presenting for For example, if they have a broken leg, they may have issues walking)

Answer 13

Any deficits pre anesthesia... so know if there is a deficit post anesthesia due to procedure or not

Answer 14

Past Diabetes and Thyroid function only ask about them if see it in record

Answer 15

Heart Lungs Mouth/Airway

Answer 16

Listen to the different valve sounds on YouTube

Answer 17

Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). CHF Rhonchi. Sounds that resemble snoring. Bronchitis/COPD Stridor. Wheeze-like sound heard when a person breathes. Laryngospasm/inflammation of cords Wheezing. High-pitched sounds produced by narrowed airways. Brochospasm/asthma Listen to on YouTube and what is causing each one inspiration, expiration, etc.???

Answer 18

“Open your mouth and stick out your tongue, without saying ‘ahh’ please” Assign Mallampati score (see next slide) and document “Anything loose, chipped, cracked, or removeable?” Implants, caps, crowns, dentures, etc If they have dentures or anything removeable, it will be taken out prior to rolling back to OR Let them know they will be placed with their belongings and available for them in the recovery room Dentures are commonly lost between pre-op and PACU! Be sure to put them in the appropriate place to avoid this Document everything you see and are told in the dental exam Remember teeth numbering system (shown on next slide) It is very important to make note of all of this in case anything gets damaged or knocked out during intubation

Answer 19

“Is there anything we haven’t discussed that you think is important for me to know so I can take excellent care of you?” This is a way to cover everything you may have missed and give the patient an opportunity to bring up any issues or concerns they may have regarding their medical history

Answer 20

Select an Anesthetic Technique General Anesthesia Regional Anesthesia... Local Anesthesia Monitored Anesthesia Care A lot of times the surgeon will dictate this to you , and you then formulate the particulars of that plan for the technique based on the individual. Formulate an appropriate anesthetic plan based on the preoperative interview and the proposed surgical procedure Communicate this plan efficiently and effectively

Answer 21

Diagnostic/Laboratory Studies * CBC, BMP, Coagulation, ECG, Chest Xray, CT, Echo * Type and Screen Crossmatch * Allowable Blood Loss IV access Premedication * Anxiolysis, analgesia * Aspiration prophylaxis Increase gastric pH Reduce gastric volume * Antiemetics Positioning

Answer 22

Standard ASA Monitors Ventilation EtCO2- capnography Circulation ECG, NIBPM/IBPM Oxygenation SpO2 Temperature ADDITIONAL MONITORS BASED ON CIRCUMSTANCES OF THE OPERATION Special Monitors- ICP, PAP, CVP Warming Devices- Bair Hugger Infusion Devices Bladder Catheter OGT/NGT to suction

Answer 23

Intravenous/Inhalational Inhalational Induction- used in pediatric anesthesiology for patients who will not be able to tolerate putting in an IV preoperatively. Older children may prefer intravenous induction Deciding on what agents you want to use: * NPO status questionable, uncontrolled acid reflux (GERD), trauma, obesity, diabetes, difficult airway→ RSI with cricoid pressure and succinylcholine * When patient has taken ACEIs or ARBs, or when hypotension upon induction of anesthesia is expected and not desired: Use etomidate instead of propofol Use lower dose of propofol Use increased narcotics, benzodiazepines, and inhalational agents

Answer 24

Mask * Inhalational induction OETT * Mechanical ventilation NETT * Maxillofacial surgery, dental operations, when orotracheal is not feasible LMA * Spontaneous ventilation

Answer 25

Checklist prior to incision/procedure start: * Patient is anesthetized * Narcotized * Paralyzed (if needed) * Antibiotic is circulating Volatiles Fresh gas Muscle Relaxants Fluids * If pt > 20 kg, # kg + 40= hourly rate of fluid replacement * If pt < 20 kg use 4-2-1 rule (as get more into this, will learn this isn't/doesn't have to be applied based on the patient) * Hourly rate * # hours NPO= preop deficit * 1st hour: half of preop deficit is given along with hourly maintenance * 2nd and 3rd hour: 1⁄4 of preop deficit is given along with hourly maintenance

Answer 26

Check TOF, administer antiemetic(s) Call attending Give reversal agent (glycopyrrolate first, neostigmine second if not mixed... giving glyco first hopefully blocks bradycardic effects of neo) Begin to turn gas down slightly and decrease RR to build ETCO2 Suction Decrease VA/turn off THIS IS THE ART OF HOW YOU DID REALLY... HOW WELL THEY COME OUT IS A BIG INDICATOR OF THE INDUCTION, MAINTENCE, AND EMERGENCE Is patient ready for extubation? * Check TOF for 4/4 twitches and sustained tetany * Check to see if patient can follow commands * Adequate tidal volumes * Extubation (NEED TO BE SPONTANOUSLY BREATHING) Confirm patient stable for transport to PACU

Answer 27

RSI with cricoid pressure and succinylcholine is the induction plan 30 ml of 0.3 molar Bicitra, sodium citrate increase gastric pH Pepcid/Famotidine, 30 mg PO/IV- decreases gastric H+ ion secretion Ranitidine/Zantac, 20 mg IV- H2 receptor antagonism Omeprazole-PPI, controls the production of gastric acid

Answer 28

Risk factors: female gender, young age, history of PONV, non-smoker, laparoscopic or gyn cases Transdermal scopolamine patch Decadron, given post induction-avoid in diabetics Metoclopramide/Reglan- accelerates gastric emptying Zofran Phenergan/Promethazine- H1 antagonist Benadryl/Diphenhydramine-H1 antagonist

Answer 29

Spinal/Epidural Anesthesia and analgesia * Spinal effects may only last 4 hours; w/ epidurals you can keep redosing if the catheter is left in Considerations: is the patient a good candidate for the technique? Safe platelet count, no bleeding disorders, not on anticoagulants Complications: hypotension, nausea/vomiting

Answer 30

Patient is spontaneously breathing Administer propofol, benzodiazepines, and narcotics as necessary throughout the case Continuously assess/monitor the patient MAC CAN BE THE HARDEST TO DO BECAUSE: Airway not controlled Not Paralyzed... so have to control their movement

Answer 31

Step 1: Consider the procedure * Comes with experience/varies by hospital Step 2: What will actually change your anesthesia plan? * The details are in the preop * NPO * If not RSI * Were there problems with anesthesia/MH? * Allergies * Airway assessment * ROM/glidescope? * LMA vs ETT Step 3: Refine the plan * Now that you have a general idea of the type of anesthesia, look at the history and refine your plan * Examine every problem the patient has and consider how to optimize the anesthetic

Answer 32

Tape the ETT Patient Positioning Put on warming device Insert OG tube (if you need to suction out stomach) Put in Temp probe Surgeon enters room * Check which antibiotic and administer (Usually 1-2 g Ancef) Immediately before incision * Ask yourself, “Is the patient anesthetized, paralyzed, and narcotized?” * Increase volatile agent * Check train of four (aka “twitches”) * Give another 50-100 mcg fentanyl THIS IS ALL REALLY THE BEGINNING OF THE MAINTENANCE PHASE

Answer 33

Passive process with gradual return of consciousness, after discontinuation of anesthetics and adjuvants Most patients transition from surgical anesthetic state to awake state with intact protective reflexes (coughing, swallowing) Patients do not experience REM sleep even though "asleep"

Answer 34

Depending on type of anesthetic used (inhaled vs IV), specific timing for discontinuation must be planned BEFORE surgical procedure end, not AT END of procedure (surgeon speed, what you hear being talked about, knowledge of drugs/gases) If volatile anesthetics used, differences in blood solubility may prolong emergence (Isoflurane > Sevoflurane > Desflurane) If IV anesthetics used, bolus vs infusion affects speed of recovery (bolus relatively shorter than infusion, which also depends on how long infusion is on)

Answer 35

Inhaled concentration Fresh gas flow in breathing circuit (turning up just O2, always waking up a pt with 100% FiO2) Duration of administration (depends on solubility of agent) Minute ventilation RR x TV TV with controlled pain = normal breathing TV with over anesthetized = 3-5 breaths with normal TV 6-8 ml/kg TV with uncontrolled pain = minimal TV per Respiration Cardiac output Dependent on agent... but overall: Slow = Slow emergence High = Fast emergence

Answer 36

Liver and/or Kidney function of patient Duration of action of IV med Combination of IV meds Duration of any IV med infusions

Answer 37

Assess and reverse effects of neuromuscular blocking agents (non-depolarizing) * Assess degree of muscle relaxation * Administer reversal agents (Suggamadex and Neostigmine and Glycopyrrolate) Observe electroencephalographic evidence of consciousness return * BIS monitor * Neuromonitoring, if surgery requires it Evaluate physiologic signs of return of consciousness * Spontaneous respiration (THE BIG ONE) * Swallowing and gagging reflexes * Tearing and grimacing * Return of muscle tone: *Volitional movements *Response to verbal commands

Answer 38

Performing awake extubation * Pre-oxygenate with 100% oxygen (It's essentially just flipping to 100% Fi02) * Suction as appropriate * Bite block (rolled gauze, OPA) * Establish regular breathing (ETCO2 and TV consistent and smooth, SPO2 is adequate) * Ensure adequate minute ventilation * Wait until awake (eye opening/obeying commands) * Apply positive pressure (APL Valve 5-10), deflate cuff and remove tube * Check airway patency and continue to provide 100% oxygen * Transfer with oxygen

Answer 39

Bronchospasm due to coughing and bucking on airway Treatment * Administer opioid to minimize coughing response * Allow spontaneous respiration; less fighting with the ventilator

Answer 40

Airway obstruction * Macroglossia * Laryngeal edema * Vocal cord paralysis * Laryngeal or tracheal obstruction Treatment * If known obstructive breathing history (eg. OSA), prepare with OPA and ensure reversal of all anesthetics and narcotics * If anticipated surgically-induced obstruction (eg. Edema), may need to consider keeping patient intubated until edema resolves

Answer 41

Inadequate spontaneous ventilation and/or respiratory distress with residual NMBA, before or after extubation Treatments * Ensure NMBA have been appropriately antagonized * Old school: Neostigmine + glycopyrrolate * New school: Sugammadex * Ensure opioids are not suppressing respiratory drive * May need naloxone antagonization

Answer 42

Apnea Treatment * May need brief support with mask ventilation * Ensure all drug-related causes are addressed * If all addressed, may be neurological (eg. Stroke) or other (eg. Hypothermia, hypercapnia)

Answer 43

Laryngospasm Treatment * Remove noxious stimuli (eg removal of blood or secretions with suction) * Positive pressure ventilation * Jaw thrust with notch pressure (aka Larson’s maneuver) * If patient desaturates despite all maneuvers * IV succinylcholine 0.1mg/kg to relax cords * If still unsuccessful, emergency reintubation may be necessary

Answer 44

Negative pressure pulmonary edema, due to airway obstruction and simultaneous forceful inspiration (biting down on endotracheal tube, or breathing in while in laryngospasm) Treatment * Ounce of prevention worth a pound of cure: ensure bite block in place before extubation * Mechanism: intense negative intrathoracic pressure with inspiration against closed glottis creates fluid shift across alveolus, leading to fluid accumulation * Supportive treatment: * Oxygen * Diuretics * May need reintubation

Answer 45

Agitation Treatment * Anxiety and disinhibition * Ensure residual effects of anesthetic meds are reversed * Inadequately treated pain * Control pain * Panic caused by dyspnea and respiratory distress * Inadequate NMBA reversal * Can look like general agitation, but generally weaker looking, esp with respiratory effort * Hypoxemia or hypercarbia * Oxygenate * Ensure no obstructive breathing causing CO2 retention

Answer 46

Inability to protect the airway resulting in gastric content aspiration Treatment Turn the patient on their side, if possible Suction the pharynx Place the bed in Trendelenburg position Suction the endotracheal tube Administer 100% oxygen Treat bronchospasm with bronchodilators Consider bronchoscopy Consider intubation

Answer 47

Ensure some sort of O2 supplementation is present (NC, face mask) If possibility of obstructive breathing, ensure OPA or NPA is present Possibility of all problems during emergence is still possible in PACU Always be vigilant

Answer 48

Twitch Monitors: New verse Old ones Different Ways to Utilize it: Tetany—a sustained stimulus of 50 to 100 Hz, usually lasting 5 s Single twitch—a single pulse 0.2 ms in duration Train-of-four—a series of four twitches in 2 s (2-Hz frequency), each 0.2 ms long Double-burst stimulation (DBS)—three short (0.2 ms) high-frequency stimulations separated by a 20-ms interval (50 Hz) and followed 750 ms later by two (DBS3,2) or three (DBS3,3) additional impulses TRAIN of 4 Main Way: Train of Four (TOF) Interpretation: A presence of 4th twitch = 0-5% paralysis (but could be higher up to that 65%-75%), 3rd twitch = 65-75% paralysis, 2nd twitch = 85% paralysis (80%), 1st twitch = 95% (90%) paralysis, 0 twitch = 100% paralysis Someone with Fade is more paralyzed than someone without Fade.

Answer 49

Spontaneous Ventilation Vitals on monitor are stable

Answer 50

Deep Comes with more risks Can be LMA or ETT Typically Done If: Surgeon asks for it Procedure requires it (ENT, groin/hernia/abdominal surgeries) Contraindications: Absolute - Pts considered full stomach Uncontrolled GERD Tube was difficult to place Relative - Obesity OSA *** Positioning Airway Edema Criteria: Have to be breathing spontaneous Pt must truly be deep * Assessment The absence of coughing when you deflate the ETT cuff Did they hold their breath on ETCO2 after deflate the ETT cuff? Jaw Thrust reflex - Grimace or hold their breath Pt must be thoroughly suctioned to prevent laryngospasm Acronym No one is home (Deep) Dry as a bone (Suction) Breathing on their own Make sure have OPA in while you mask

2025 Lab 1 Exam 2/Final Flashcards

Need 2025 Lab 1 Exam1/Midterm Deck to Complete Material