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Cardio Exam 3 > 45 - Introduction to Anesthesiology > Flashcards

45 - Introduction to Anesthesiology Flashcards

1
Q

What are the goals of anesthesia?

A
  • Maintain physiological homeostasis
  • Amnesia
  • Analgesia
  • Neuromuscular blockade
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2
Q

What does it mean to maintain homeostasis?

A
  • Cardiovascular function
  • Respiratory function
  • Renal function
  • Neurologic Function

This includes monitoring during perioperative and intraoperative monitoring

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3
Q

What does it mean to achieve amnesia?

A

Lack of memory of the perioperative and intraoperative period

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4
Q

What does it mean to achieve analgesia?

A

Pain control in the perioperative and intraoperative period

This can be achieved in a number of ways

  • Local anesthetics
  • NSAIDs
  • Neuromuscular blockades
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5
Q

What is the purpose of a neuromuscular blockade?

A

Block the acetylcholine receptors at the neuromuscular junctions of striated muscle to provide “relaxation” of the major muscle groups in the body

This allows patients to remain still during surgery

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6
Q

Describe what you will ask during the history before taking a patient to surgery

A
  • Detailed history of symptoms and clinical course
  • Prior surgical history
  • Any previous anesthesia?
  • Any familial history of problem with anesthesia?
  • Exercise tolerance
  • Clinical predictors (angina, coronary heart disease)
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7
Q

How will you assess the functional capacity of the patient to undergo anesthesia?

A
  • Assessment of cardiac functional status
  • Of prognostic value (patients with good functional status have lower risk of cardiac complications)
  • Expressed in metabolic equivalents
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8
Q

What is a metabolic equivalent?

A

A physiological measure expressing the energy cost of physical activities and is defined as the ratio of metabolic rate (and therefore the rate of energy consumption) during a specific physical activity to a reference metabolic rate

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9
Q

How many METs does the body demand during most normal daily living activities?

A

4 METs

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10
Q

What are some normal activities and their MET consumption?

A
  • Eating, dressing or using toilet = 1 MET
  • Walking up stairs = 4 METs
  • Heave work around the house = 4-10 METs
  • Playing basketball, swimming, etc. = >10 METs
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11
Q

How do METs relate to cardiac risk during surgery?

A

Perioperative cardiac and long-term risk is increased in patients unable to meet a 4-MET demand during most normal daily activities.

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12
Q

How can you functionally determine cardiac risk in your patients?

A

Inability to climb 2 flights of stairs or walk 4 blocks is one important indicator of poor functional status and an increased risk of postoperative cardiopulmonary complications after major non-cardiac surgery

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13
Q

How do you determine most of your cardiac risk assessment?

A

History and physical exam

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14
Q

What else can you do to determine cardiac risk if you are unsure?

A

ECG

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15
Q

Would you ever need to cancel your surgery due to potential cardiac risk?

A

YES

  • When you discover risk factors, they need to be treated
  • Unless surgery is emergent, it will be canceled
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16
Q

How does cardiac risk vary depending on whether or not your patient has had a recent MI?

A

The sooner you do surgery after an MI, their risk of re-infarction goes up

  • You need to wait to prevent re-infarction
  • Always delay elective surgery until you know there is no increased risk
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17
Q

What are major predictors of cardiac risk during anesthesia?

A
  • Decompensated heart failure
  • Significant valvular heart disease
  • Significant arrhythmias
  • Recent PCI***
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18
Q

Describe recent PCI as a predictor for cardiac risk during anesthesia

A

Recent PCI (percutaneous coronary intervention)

  • Cath lab procedure to clear coronary artery and possibly place a stent
  • There is an increased risk of both postoperative MI and death
  • This happens because the patient will be on blood thinners following the PCI and then in order to undergo the surgery, they will stop the blood thinners
  • This means their blood will be thicker AND they will be traumatized/immobilized aftersurgery
  • Huge risk for postoperative MI and death
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19
Q

What is one option for surgery if your patient has recently had a PCI and is on blood thinners?

A

If patient is anti-coagulated for their heart and you are doing something small like a toe amputation, you can leave them on anticoagulants to not increase their risk of a cardiac event

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20
Q

What are some other conditions that will warrant further workup before proceeding with surgery?

A
  • Ischemic heart disease
  • Compensated heart failure
  • Diabetes
  • Renal insufficiency
  • Cerebrovascular disease
21
Q

What are some MINOR predictors of cardiac risk during anesthesia?

A

You are going to see a lot of patients like this. They are at increased risk, they probably have a cardiologist and they will need to get their sign-off before surgery…

  • Advanced aged (70+)
  • Abnormal ECG
  • Rhythm other than sinus (AF)
  • Uncontrolled systolic hypertension

Note: presence of one or more of these can lead to high suspicion of coronary artery disease

22
Q

What risk factors exist for patients to develop post-operative pulmonary complications?

A
  • Preexisting pulmonary disease (asthma, COPD)
  • Thoracic or upper abdominal surgery
  • Smoking
  • Obesity
  • Age > 60 years
  • Prolonged general anesthesia

If you go into diabetic limb salvage, this will be every single patient

23
Q

What should your respiratory physical exam include?

A
  • BP
  • Carotid artery bruits
  • Jugular venous distention
  • Auscultation of lungs and chest
  • Examination of extremities for edema and vascular irregularities
  • ECG
24
Q

What are you looking for on a resting ECG?

A
  • Presence of Q waves
  • Significant ST segment elevation or depression

Both of these have been associated with an increased incidence of perioperative cardiac complications

This may uncover findings suspicious for heart failure or aortic stenosis, which increases perioperative cardiac risk

25
Q

What are ASA classes?

A

NEED TO KNOW

The American Society of Anesthesiologists (ASA) physical status classification

  • Class 1
  • Class 2
  • Class 3
  • Class 4
  • Class 5
  • Class 6
26
Q

Describe what ASA class 1 means ***

A

A normal healthy patient

27
Q

Describe what ASA class 2 means ***

A

Mild systemic disease

  • hypothyroidism
  • mild hypertension (on one medication)
  • smokers
28
Q

Describe what ASA class 3 means ***

A

Severe systemic disease, but not incapacitating

  • hypertension on more than one medication
  • diabetic with some end-organ damage
  • prior stroke or heart attack
29
Q

Describe what ASA class 4 means ***

A

Severe systemic disease that is a constant threat to life

  • unstable angina
  • oxygen–dependent COPD
  • terminal cancer patients
30
Q

Describe what ASA class 5 means ***

A

Moribund

- not expected to live 24 hours regardless of operation

31
Q

Describe what ASA class 6 means ***

A

Organ donor with brain death

32
Q

What are all the different types of anesthesia?

A
  • General
  • Spinal
  • Epidural
  • IV regional block
  • Local/peripheral nerve block
  • Monitored nerve block
  • IV sedation
33
Q

Describe general anesthesia

A
  • Altered physiologic state characterized by reversible loss of consciousness, analgesia of the entire body, amnesia, and some degree of muscle relaxation.
  • Divided into three distinct phases: induction, maintenance, and emergence.
34
Q

What is the most common induction agent used in the US?

A

Propofol ***

  • Short half life
  • Favorable recovery
35
Q

What is the preferred anesthetic agent for maintenance?

A
  • Sevoflurane
  • Desflurane

Due to low hepatotoxicity

36
Q

What is emergence?

A

Crucial time in which the anesthesiologist welcomes the patient back to a restored state of consciousness.

With this return of consciousness there is a short period of time in which the patient’s body is aware of the emergence without a full return to consciousness.
- They might not be awake, but they will start pulling away from pain

37
Q

Describe spinal anesthesia

A
  • Small gauge needle is inserted into a lumbar (usually L3-L4 or L4-L5) interspace until it reaches the subarachnoid space.
  • Local anesthetic is then injected to produce temporary numbness and muscle relaxation
38
Q

What procedures commonly use spinal anesthesia?

A

Used extensively in lower extremity procedures

  • Less blood loss
  • Less surgical time
  • Less need for blood transfusion
39
Q

Describe epidural anesthesia

A

Achieved with the placement of a small gauge flexible catheter into the epidural space via a needle

40
Q

How can you get repeat doses of epidural anesthesia?

A

Repeat

  • Repeat dosing of local anesthetic and adjunctive medications for prolonged intraoperative management is possible by leaving a catheter in the central neuraxial space for infusion
  • Catheter can also be left in place for post operative analgesia.
41
Q

What is a regional block or Bier block?

A

An alternative to local/peripheral nerve block for extremity surgery

42
Q

What is the technique for administering a regional block or Bier block?

A
  • 20 to 22 gauge intravenous cannula placed intravenously for administration of local anesthetic
  • Tourniquet is placed proximal and extremity is exsanguinated using Esmark bandage
  • Dilute solution of lidocaine (0.5%) is injected into the intravenous line at a rate of 3 mL/sec. The volume of local anesthetic required to achieve the block using the dilute concentration of 0.5% lidocaine is about 60 to 80 mL for the lower extremity.
43
Q

What are the four types of lower extremity peripheral nerve blocks?

A
  • Femoral block
  • Popliteal block
  • Ankle block
  • Digital block
44
Q

Describe a femoral block

A

The patient is placed in a supine position. The common femoral artery is palpated. The needle is inserted just below the inguinal ligament and 1.5 cm lateral to the artery

45
Q

Describe a popliteal block

A

Anesthetizes the sciatic nerve in the popliteal fossa prior to its division into the tibial and the common fibular nerves

46
Q

Describe an ankle block

A

Anesthetizes four branches of the sciatic nerve:

  • Superficial and deep peroneal [fibular] nerve
  • Posterior tibial nerve
  • Sural nerves

And one cutaneous branch of the femoral nerve:
- Saphenous nerve

47
Q

What is monitored anesthesia?

A
  • Includes intraoperative physiologic monitoring, provision of analgesia and anxiolysis, and further intervention and support as necessary
  • Does not involve complete loss of consciousness (you “twilight” the patient)
  • They will be very lightly sleeping and then you give a local anesthetic block
  • They start to wake the patient up after you have given them the block
  • Patient will feel pressure at the operative site but should not feel pain
48
Q

Describe conscious sedation

A
  • No anesthesia personnel in attendance – sedative and/or anesthesia is administered by surgeon and patient is communicative and conscious
  • Often used in ER setting for reduction of fractures

Cardio Exam 3 (13 decks)

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