CHAPTER 5: General Considerations of Anesthesia and Management of the Difficult Airway

Question 1

Goal of airway management

Answer 1

Provide the most expeditious form of management that has the lowest potential for injury and the greatest potential for control of the airway

Question 2

Fasting recommendation for clear liquids

Answer 2

2 hours

Question 3

Fasting recommendation for breast milk

Answer 3

4 hours

Question 4

Fasting recommendation for other food or beverages (infant formula and milk)

Answer 4

6 hours

Question 5

Pharmacologic agents administered preoperatively may reduce the risk of aspiration

Answer 5

1. Clear antacids (30 ml of Na citrate)
2. Anticholinergic agents (atropine or glycopyrrolate)
3. Metoclopramide (to stimulate gastric emptying and increase lower esophageal sphincter tone)
4. H2- receptor antagonists (cimetidine or ranitidine) to decrease secretion of HCl

Question 6

Most common used IV anesthetic agent

Answer 6

Propofol

Question 7

TRUE or FALSE

Propofol will cause a 25% to 40% drop in BP with 15% to 20% drop in cardiac output

Answer 7

TRUE

Question 8

TRUE or FALSE

Induction doses of propofol cause central apnea

Answer 8

TRUE

Question 9

TRUE or FALSE

Propofol has inherent bronchodilating effects that favor its use is asthmatic patients

Answer 9

TRUE

Question 10

TRUE OR FALSE

Propofol has antiemetic properties

Answer 10

TRUE

Question 11

A dissociative anesthetic that produces unconsciousness without ablating spontaneous respiration, swallowing, eye movement, or airway protective reflexes

Answer 11

Ketamine

Question 12

Most commonly used benzodiazepine in the preoperative setting because its onset of activity is within 2 to 4 minutes

Answer 12

Midazolam

Question 13

Most commonly used benzodiazepine in the preoperative setting because its onset of activity is within 2-4 minutes

Answer 13

Midazolam

Question 14

3 main task of anesthesiology team

Answer 14

1. Keep the patient safe
2. Keep the patient comfortable
3. Provide for optimal conditions during the preoperative, intraoperative, and immediate postoperative periods

Question 15

The component qualities of a general anesthetic are

Answer 15

1. Loss of consciousness
2. Amnesia
3. Analgesia
4. Muscle relaxation/paralysis

Question 16

These standards include continual evaluation of the patient’s oxygenation, ventilation, circulation, and temperature during all administered anesthetic

Answer 16

Standards for Basic Anesthetic Monitoring

Question 17

Basic anesthetic monitoring should include

Answer 17

1. Continuous oxygen analysis of the anesthetic circuit
2. Pulse oximetry
3. Continuous waveform capnography
4. Tidal volume measurement
5. ECG
6. Temperature measurement
7. Intermittent measurement of arterial BP and HR

Question 18

To assess the degree of muscle paralysis and the return of muscle strength after pharmacologic reversal of paralyzing agents

Answer 18

Twitch monitor

Question 19

True or False
Ketamine can increase a patient’s BP, HR and cardiac output through sympathomimetic effects and release of stored catecholamines

Answer 19

True

Question 20

Other unique properties of ketamine

Answer 20

1. Can administered IM
2. Analgesic properties
3. Increase salivary production

Question 21

True or False

Etomidate has neutral effects on BP and cardiac output

Question 22

True or False

Etomidate will also suppress the patient’s adrenal glands

Answer 22

True

Question 23

Given preoperatively for their sedative, anxiolytic and amnestic effects

Answer 23

Benzodiazepines

Question 24

True or False

Benzodiazepines will produce anterograde amnesia

Answer 24

True

Question 25

True or False | In sedative doses, benzodiazepines produce mild respiratory depression

Answer 25

True

Question 26

True or False | Coadministration of benzodiazepines with opiods can synergistically produce profound respiratory depression

Answer 26

True

Question 27

Used intraoperatively to provide analgesia and balanced anesthesia

Answer 27

Opiods

Question 28

The most commonly used opiods are

Answer 28

1. Fentanyl 2. Remifentanil 3. Sufentanil 4. Morphine 5. Hydromorphone

Question 29

Antagonist of opiods

Answer 29

Naloxone (u-receptor)

Question 30

True or False | Doses of lidocaine kept to 1 to 1.5 mg/kg to avoid potential toxicity

Answer 30

True

Question 31

True or False Lidocaine can also be administered prophylactically into the same IV line as propofol to reduce propofol-induced venous irritation and patient discomfort

Answer 31

True

Question 32

A newer anesthetic agent that works as an a-2 agonist to reduce sympathetic nervous system outflow and produce a sedative effect that more nearly mimics normal sleep

Answer 32

Dexmedetomidine

Question 33

Been used for sleep endoscopy to pinpoint the area of pharyngeal obstruction prior to uvulopalatopharyngoplasty

Answer 33

Dexmedetomidine

Question 34

The most commonly seen hemodynamic effect of Dexmedetomidine

Answer 34

Bradycardia

Question 35

The most potent but slowest and longest acting of the currently available volatile anesthetics

Answer 35

Isoflurane

Question 36

Contraindicated during middle ear surgery because it can expand in a closed air space

Answer 36

Nitrous oxide

Question 37

It impairs methionine synthase, which may cause an increased rate of surgical wound infections

Answer 37

Nitrous oxide

Question 38

True or False The volatile anesthetic agents are not often used for induction of general anesthesia in adults, but they are the most commonly used agents for maintenance of GA

Answer 38

True

Question 39

Characterized by uncontrolled skeletal muscle metabolism that leads to hyperthermia, acidosis, rhabdomyolysis, and sometimes death

Answer 39

Malignant hyperthermia

Question 40

The most commonly agent for TIV

Answer 40

Propofol | -mixes of ketamine and propofol may also be used to balance the hemodynamic effects

Question 41

Commonly used during suspension laryngoscopy

Answer 41

Remifentanil

Question 42

Two classes of paralytic agents:

Answer 42

1. Depolarizing agents | 2. Nondepolarizing neuromuscular blockers

Question 43

Only depolarizing paralytic agent

Answer 43

Succinylcholine

Question 44

Acts on acetylcholine receptors in the neuromuscular junction, activating the receptors but then occupying them, thereby prolonging the refractory period before the muscle can contract again

Answer 44

Succinylcholine

Question 45

Major advantage of succinylcholine

Answer 45

Very fast onset of action

Question 46

Succinylcholine: | Paralysis sufficient for endotracheal intubation can be reliably produced within

Answer 46

45-60 seconds

Question 47

Succinylcholine is metabolized and deactivated by

Answer 47

Pseudocholinesterase

Question 48

Clinical paralysis of succinylcholine usually dissipates within

Answer 48

5-8 minutes

Question 49

Most common muscle relaxant trigger for MH

Answer 49

Succinylcholine

Question 50

Primary contraindications to the use of succinylcholine:

Answer 50

1. Known or suspected MH 2. Increased ICP 3. Increased IOP 4. Elevated serum K

Question 51

Nondepolarizing agent of choice for RSI in whom succinylcholine use is contraindicated

Answer 51

Rocuronium | * onset action between 60 and 75 seconds

Question 52

Marked disadvantage of Rocuronium

Answer 52

Given in doses sufficient for intubation, persists for 40-40 minutes

Question 53

A newly available reversal agent that binds Rocuronium and Vecuronium, thus removing neuromuscular bloackade

Answer 53

Sugammadex

Question 54

In CNS, it prevents reuptake of neurotranmitters, including dopamine and NE

Answer 54

Cocaine

Question 55

Most commonly used anesthetics for local infiltration or nerve blocks

Answer 55

Lidocaine and Bupivacaine

Question 56

True or False Local anesthetic toxicity manifests initially as CNS depression and seizures followed by cardiovascular dysrhythmias with the potential for ventricular fibrillation

Answer 56

True

Question 57

True or False The maximum dose of lidocaine (5mg/kg) may be increased (to 7mg/kg) if epinephrine is used in the solution to slow uptake from the subcutaneous tissues into the general circulation

Answer 57

True

Question 58

The maximum dose of Bupivacaine + Epinephrien solution

Answer 58

2-3 mg/kg

Question 59

True or False | Local anesthetics can produce toxic effects at much lower doses if they are administered directly into the circulation

Answer 59

True

Question 60

Most commonly used drugs for intraoperative control of hypertension and tachycardia related to airway management

Answer 60

1. Beta blockers esmolol and metoprolol | 2. Mixed alpha and beta-blocker labetalol

Question 61

“ A clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both”—ASA

Answer 61

Difficult airway

Question 62

System of 3 classes to predict a difficult airway based on the position and visibility of certain anatomic structures (Mallampati)

Answer 62

1. Uvula 2. Fauces 3. Soft palate

Question 63

System of four grades to predict a difficult airway based on the position and visibility of certain anatomic structures (Modified Mallampati/Cormack an d Lehane)

Answer 63

1. Glottic aperture 2. Posterior arytenoids 3. Epiglottis

Question 64

Other physical predictors of anticipated difficulty with conventional direct laryngoscopy include

Answer 64

1. Prominent overbite 2. Receding chin 3. Large tongue 4. Narrow mouth opening (interincisor distance or gap) 5. Short neck 6. Limited neck flexibility 7. Obesity

Question 65

Other ways to predict a difficult airway use a measurement of the

Answer 65

Thyromental distance or the sternomental distance

Question 66

LMA

Answer 66

Laryngeal mask airway