Complications - Quiz 3 Flashcards
(143 cards)
1
Q
Current rate of anesthesia related death is ___ per _______ anesthetics. (1999-2005)
A
1 per 100,000
2
Q
If you are an ASA 1, how many deaths per 10,000
A
0.5
3
Q
If you are an ASA 4, how many deaths per 10,000
A
5.5
4
Q
What increases the risk of death during anesthesia?
A
Comorbidities
5
Q
What is morbidity?
A
Any complication other than death
Minor 18-22% incidence
Hoarseness, PONV, drug error or equipment malfunction without injury
6
Q
Top 3 ASA closed claims
A
Death - 26%
Nerve injury - 22%
Brain damage - 9%
7
Q
Top 3 ASA emerging claims
A
Regional anesthesia 16%
Chronic pain management 18%
Acute pain 9%
8
Q
What percent of human error is implicated in deaths?
A
51-77%
9
Q
What is the major human error that leads to preventable accidents? And what are some other causes?
A
1 medication error
Unrecognized breathing circuit disconnect
Airway mismanagement
fluid mismanagement
10
Q
What colors are our labels? Paralytics Narcotics Uppers (epherine, epi, phyenylephrine) Downers nitro Local anesthetics
A
Paralytics – orange/red Narcotics – blue Uppers (epherine, epi, phyenylephrine) – purple solid Downers nitro – purple strips Local anesthetics – grey
11
Q
Equipment malfunctions leading to preventable anesthetic accidents:
A
Breathing circuit (most common) Monitoring device Ventilator Anesthesia machine Laryngoscope
12
Q
With a circuit malfunction, how do you check it?
A
Start at patient and work your way back to the machine
13
Q
New data shows that that what population of pediatrics have increased risk for developmental delays?
A
Prolonged or multiple procedures (>MAC hours)
tonsillectomy no risk
14
Q
What are some common airway injuries?
A
Sore throat – most common Dysphagia Dental injury – most common sued TMJ Vocal cord paralysis Vocal cord granuloma Arytenoid dislocation Esophageal perforation
15
Q
When positioning a patient, how does hypotension lead to peripheral nerve injury?
A
less blood flow to that nerve then put pressure on and gets ischemic
16
Q
What position is air embolism most likely to occur and how can we prevent it?
A
Sitting/prone/reverse trendelenberg
Maintain venous pressure above 0 at surgical site
17
Q
What position is alopecia most likely to occur and how can we prevent it?
A
Supine/lithotomy/trendelenberg
Normotension, padding, head turning
18
Q
What position is backache most likely to occur and how can we prevent it?
A
any position
lumbar support, padding, hip flexion
19
Q
What position is compartment syndrome most likely to occur and how can we prevent it?
A
esp lithotomy
maintain perfusion pressure and avoid external compression
20
Q
What position is corneal abrasion most likely to occur and how can we prevent it?
A
esp prone
tape and lubricate eye
21
Q
What position is digit ampuateion most likely to occur and how can we prevent it?
A
any
check for protruding digits before moving hydrolic table
22
Q
how to avoid a brachial plexus injury
A
avoid stretching or direct compression of the neck or axilla
23
Q
What position is common perineal nerve injury most likely to occur and how can we prevent it?
A
lithotomy and lateral decubitus
pad lateral aspect of upper fibula
24
Q
how to avoid radial nerve injury
A
avoid compression of lateral humorous
25
how to avoid ulnar nerve injury
padding at elbow, forearm supination
26
What position is retinal ischemia most likely to occur and how can we prevent it?
prone/sitting
avoid pressure on globe
27
What position is skin necrosis most likely to occur and how can we prevent it?
any position
pad bony prominences
28
Awareness during general anesthesia is what the general public are must afraid of. What percent of awareness
0.1 - 0.4
29
When awareness does occur, patient’s may exhibit the following symptoms:
```
Mild anxiety
Sleep disturbances
Nightmares
Post-traumatic stress disorder
Social difficulties
```
30
In what cases will awareness happen most?
MAC cases
31
In high risk cases, awareness happens most often with
major trauma
32
Why does obstetrics have a higher incidence of remembering?
don’t get versed (because we want them to remember)
33
Risk factors for awareness
```
Female
Age (younger adults)
Obesity
Clinician experience
Previous awareness
After normal hours of operation
Emergency procedures
Use of nondepolarizing relaxants
```
34
Benzodiazepines provide what type of amnesia?
anterograde (forget from time of medication on)
35
scopolamine provides what type of amnesia?
retrograde (pt will forget that something occurred before)
| ** has to be given IV
36
How much MAC should be enough for amnesia?
1/3
37
What is by far the most common and transient eye injury?
Corneal abrasion
38
Most common cause of post operative loss of vision.
Ischemic Optic Neuropathy (ION)
39
What is Ischemic Optic Neuropathy (ION)?
Optic nerve infarction due to decreased oxygen delivery via one or more arterioles supplying the optic nerve.
40
ION is commonly reported after:
Cardiopulmonary bypass
Radical neck dissection
Abdominal/hip procedures
Spinal surgeries - prone position
41
Contriribiting factors to ION?
HTN
DM – causes vascular changes (constricted)
CAD
Smoking
42
Surgical and anesthetic factors that contribute to ION:
Deliberate hypotension
anemia
prolonged surgical time in prone position, head down or compressed abd
43
When is the onset of ION?
onset is immediately through 12th post-op day
44
What position will enhance venous outflow to help prevent ION?
position pt head up
45
Intraop cardiac arrest us usually ________ not _______
concomitant and not causative
46
Suddent cardiac arrest is usually caused by
hypovolemia
47
Most common CV event after non cardiac surgery
MI
48
cardiopulmonary arrest was like to happen because the spinal got to high at a level of
T4
49
what are the cardiac accelerators?
T1-T4
50
The higher the spinal, the more _______ the pt will get
hypotensive
51
Spinal with sedation will likely lead to
hypercarbia
52
Dermatome
T4 -
T7 -
T10 -
T4 - nipple line
T7 - xiphoid process
T10 - belly button
53
S/S of cardiopulmonary arrest before it happens
Gradual decline in heart rate and BP (20% below baseline values)
Bradycardia
Hypotension
Cyanosis
54
medications during cardiopulmonary arrest from spinal anesthesia
ephedrine - alpha/beta agents "baby epi"
Atropine - increase HR
Epi - stron alpha/beta agonist - for bradycardia that is unresponsive to ephedrine and atropine
55
What is the average duration of CPR from arrest from spinal?
11 min, waiting for spinal to come down
56
What type of airway is an LMA?
supraglottic airway
Keep in mind for difficult airways!
57
When perioperative hearing loss does occur, what is it most likely from?
5-% after spinal anesthesia d/t CSF leaks
TXT: blood patch
58
Allergic reactions are _______ response to an antigen in previously _______ individual
Immunologic
sensitized
59
The antigen or allergen is typically a
protein, a polypeptide, or smaller molecule that is covalently bound to a carrier protein.
60
What is a Type 1 hypersensitivity reaction?
Immediate
Atopy
Urticaria - angioedema
Anaphylaxis
61
What is a Type 2 hypersensitivity reaction?
Cytotoxic
Hemolytic transfusion reactions
Autoimmune hemolytic anemia
Heparin-induced thrombocytopenia
62
What is a Type 3 hypersensitivity reaction?
Immune complex
RA
63
What is a Type 4 hypersensitivity reaction?
Delayed, Cell mediated
Contact dermatitis
64
What is anaphylaxis
Exaggerated response to an allergen that is mediated by a Type I hypersensitivity reaction.
65
When will an anaphylactic reaction occur?
Within minutes to exposure of antigen
66
Anaphylaxis characteristically presents as
acute respiratory distress, circulatory shock, or both
67
Incidence of anaphylactic reactions during anesthesia is
1:5000 to 1:25,000 anesthetics
68
Is anaphylaxis a systemic or local reaction
systemic
69
how is response to 1st exposure to an antigen
allergen exposure leads to Bcells which trigger the production of IgE antibodies. IgE bonds to the cell surface of mast cells or basophils
70
how is response to 2nd exposure to an antigen
subsequent allergen exposure leads to degranulation of mast cell/basophil which leads to a histamine release. Histamine increases permeability of capillaries (can loose up to 50% of blood volume).
71
What do the mast cells release that are the mediators of anaphylaxis?
Histamine
Leukotrienes
BK-A
Platelet-activating factor
72
Degranulation of mast cells release Leukotrinene, what is typical response in asthma is
```
constricted bronchioles
airway obstruction (mucus buildup)
```
73
Degranulation of mast cells release prostaglandin, what is the typical response
dilated blood vessels
constricted bronchioles
nerve cells = headache
74
Degranulation of mast cells releases histamine, serotonin, and bradykinin - what is the response
excessive mucus, tears, glandular formation
increased peristalsis: V/D
Constricted bronchioles (smooth muscle) - wheezing, coughing, diff breathing
dilated blood vessels - wheal and flare run, itching
75
CV clinical manifestations of anaphylaxis
hypotension, tachycardia, arrhythmias
76
Resp clinical manifestations of anaphylaxis
bronchospasm, cough, dyspnea, pulmonary edema, laryngeal edema, hypoxia
77
Dermatologic clinical manifestations of anaphylaxis
urticaria, facial edema, pruritus
78
What is an anaphylactoid reaction?
Resembles anaphylaxis but does NOT depend on IgE antibody interaction with antigen.
79
Can you tell the difference between and anaphylactic and anaphylactoid reaction?
NO
Although the mechanisms differ, anaphylactic and anaphylactoid reactions can be clinically indistinguishable and equally life threatening.
80
Risk factors associated with hypersensitivity to anesthetics
Female gender (cosmetics)
Atopic history
Preexisting allergies
Previous anesthetic exposure
81
```
Treatment of allergic reaction
Epi
LR
Benadryl
Ranitidine
hydrocortisone
methylprednisolone
```
```
Epi 0.01-0.5mg IV/IM
LR 1-2L
Benadryl (H1) 50-75mg
Ranitidine (H2) 150mg
hydrocortisone up to 200mg
methylprednisolone 1-2mg/kg
```
82
What os the purpose of corticosteroids in anaphylactic reactions?
keep plasma cell from synthesizing Ige and inhibit Tcells
83
What is the purpose of antihistamines, ASA, Epi, and theophylline in anaphylactic reactions?
counteract the effects of cytokines on targets
84
What drug class is the most common cause of anaphylaxis during anesthesia.
muscle relaxants (70%)
85
What is the incidence of anaphylaxis from muscle relaxants?
1:65,000
86
What is the mechanism for anaphylactic reactions when using muscle relaxants
IgE antibodies directed against tertiary or quaternary ion epitopes
87
Previous exposure to what things could cause an allergic reaction to muscle relaxants?
OTC drugs, cosmetics, and food products that contain tertiary or quaternary ammonium ions may sensitize susceptible individuals.
88
What are the muscle relaxants that are must likely to cause an allergic reaction. IN ORDER
1. ROC
2. Succs
3. atracurium
89
What is the rate of allergic reactions to
Pentothol
Propofol
Pentothal - 1 in 30,000
| Propofol - 1 in 60,000
90
True or False: True allergic reactions to etomidate, ketamine and benzodiazepines is extremely rare
True
91
Do opioids tend to cause true allergic reactions?
No
| If they do, non-immune histamine release more common (morphine)
92
Reactions to LA are very rare, but when they do happen what is the response?
vasovagal response
| LAST
93
Ester reactions are _____ mediated, share a common antigenicity with _____ and cross sensitivity _______
Ige mediated
PABA
should be expected
94
Amine reactions are extremely _____, but if they do happen ______ and ______ are causative preservatives
rare
paraben or methylparaben
95
Do volatile anesthetics cause allergic reactions?
no documents reports
96
What type of antibiotics cause allergic reactions?
```
B-lactam antibiotics
Penicillin
Cephalosporin
Sulfonamides
Vancomycin
```
97
If Vanco is infused too fast, what might you see?
red man syndrome
98
What is the second most common cause of anaphylaxis during anesthesia.
latex exposure
99
How is a latex allergy mediated?
Direct IgE mediated immune response to polypeptides in natural latex
100
What type of sensitivity reaction is latex?
type 4
101
What foods that cross react with latex
mango, kiwi, chestnut, avocado, passion fruit and banana
102
What pre-op meds can you give to help prevent a latex exposure?
H1 - Benadryl
H2 - ranititdine
Steroid (controversial)
103
What is treatment for angioedema from lisonopril?
FFP
104
How is MH characterized?
acute hypermetabolic state in muscle tissue after induction of general anesthesia
105
MH occurrence in
Peds
Adults
Pediatrics 1:15,000
| Adults 1:40,000
106
Can the onset of MH happen after procedure is complete?
Yes, has occurred >1 hr. post-operatively
107
What are signs of hypermetabolism in MH?
```
Increased carbon dioxide production
Increased oxygen consumption
Low mixed venous oxygen tension
Metabolic acidosis
Cyanosis
Mottling
```
108
What are signs of increased sympathetic activity in MH?
Tachycardia
Initial hypertension
Arrhythmias
109
What is the most specific initial sign of MH?
sudden increase in etco2
110
What is the most sensitive indicator of MH?
tachycardia
111
What are some signs of muscle damage in MH?
```
Masseter spasm
Generalized rigidity
Elevated serum creatine kinase
Hyperkalemia
Hypernatremia
Hyperphosphatemia
Myoglobinemia
Myoglobinuria
```
112
Hyperthermia is a late sign of MH, but when it does set in, how fast can it rise?
core temperature can rise as much as 1*C every 5 minutes
113
MH has uncontrolled increase in intracellular _______ in skeletal muscle.
calcium
114
Sudden release of calcium from sarcoplasmic reticulum removes the inhibition of _______, and causes intense __________.
troponin
muscle contractions
115
Dramatically enhanced and sustained _____ activity results in uncontrolled increase in ______ and _______ metabolism. = ______
ATP
aerobic and anerobic
acidosis
116
How does hyperkalemia happen in MH?
from efflux of potassium from muscle cells and systemic acidosis
117
High is there a high potential for Vfib in MH?
increased sympathetic tone, acidosis, and hyperkalemia
118
Sudden death may occur in as little as ___ minutes.
15
119
What abnormal receptors are responsible for MH?
abnormal ryanodine Ryr1 receptors
120
What drugs are responsible for triggering MH?
```
Halogenated general anesthetics
Ether
Cyclopropane
Halothane
Methoxyflurane
Enflurane
Isoflurane
Desflurane
Sevoflurane
Depolarizing muscle relaxants
Succinylcholine
```
121
Does NO trigger MH?
No, not a volatile anesthetic
122
Why do you hyperventilate MH patients?
to blow off CO2
123
How much Bicarb do you admin to MH patients?
1-2mEq/Kg
124
How much Dantrolene do you give MH pts?
1-2mg/kg IV, may repeat q5min to a max of 10mg/kg
125
What is the purpose of giving Na bicarb, regular insulin, and beta 2 agonists during MH?
pushing K back into cell
126
How much dextrose and insulin are you going to give for MH?
25-50 g dextrose
| 10-20 units insulin
127
How does dantrolene work?
Directly interferes with muscle contraction by binding Ryr1 receptor, calcium channel and inhibiting calcium ion release from sarcoplasmic reticulum.
128
What else is dantrolene used to treat?
Hyperthermia associated with thyroid storm
Neurolept malignant syndrome
Treatment of chronic spastic disorders
129
What are the most serious side effects of dantrolene after acute admin?
muscle weakness, respiratory insufficiency and risk of aspiration
Can cause phlebitis in small hand veins, use central line if possible.
130
Define laryngospasm
Complete spasmodic closure of the larynx as a consequence of an outside stimulus.
131
In a laryngospasm, why does closure of the glottis happen?
Closure of the glottis as a result of reflex constriction of the laryngeal muscles.
132
What would be the signs of a complete laryngospasm?
silent, paradoxical movement of the chest, tracheal tug, and no ventilation
133
What would be the signs of a partial laryngospasm?
crowing noise, with mismatch between respiratory effort and ventilatory effectiveness.
134
What med do you use in attempts to break laryngospasm?
deepen anesthetic with IV agent - big bolus of propofol
try succs
135
Define bronchospasm
Caused by spasmodic constriction of bronchial smooth muscle creates narrowing of airway passages and increases airway resistance.
136
What are the signs of bronchospasm
```
Prolonged expiration
High inflation pressures
Expiratory wheezes
Decreased oxygen saturation
Increased ETCO2
Decreased TV
```
137
What med do you use in attempts to break bronchospasm?
deepen anesthetic with gas! volatile anesthetics are very good bronchodilators.
138
What 3 things must be present for a fire in the OR?
Heat, oxygen, feul
139
OSHA Maximum acceptable trace concentration anesthetic gases
N2O <25ppm
N2O&HA <25ppm and <0.5 HA
HA only <2ppm
140
What is the maximum occupational whole body exposure annually
5 rem/year
141
how far should you stand from radiation source?
at least 6ft, further is better
142
Define critical event
An event in which a complication occurred or had a potential to occur
Close call
143
Define sentinal event
An event in which a serious complication occurred
Something actually happened
