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Intro To AA > Emergence From Anesthesia > Flashcards

Emergence From Anesthesia Flashcards

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1
Q

What three things are considered smooth emergence?

A

Free of coughing, straining, or HTN

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2
Q

What is causes a dehiscence of an abdominal or inguinal incision?

A

Coughing

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3
Q

4 things to consider before induction:

A
  1. Pt maturity and personality
  2. Ability to metabolize drugs
  3. Pre-op/post-op pain level
  4. Post-op airway maintenance, analgesic, hemodynamics
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4
Q

When do you start to prepare for emergence?

A

Prior to induction of anesthesia

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5
Q

Where do you place the train of four?

A

Adductor pollicis or orbicularis oculi

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6
Q 
0 twitches 
1 twitch 
2 twitches 
3 twitches 
4 twitches
A 
>90%
90%
80%
75%
<75%
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7
Q

Subjectively depth of NMB

A

Timing and amount of last dose

Spontaneous respiratory effort

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8
Q

Objectively when to reverse with Neostigmine?

A
  • post-tetanic stimulation and return of 1 twitch = 10min

- at least 1 twitch represents 90% blockade and no free drug

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9
Q

Subjectively to reverse with Neostigmine?

A
  • spontaneous respiratory effort

- less than 100% blockade

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10
Q

6 factors that affect how fast Neostigmine works

A
  1. Depth of block
  2. Dose of anti cholinesterase
  3. How much spontaneous reversal
  4. Metabolism
  5. Coexisting disease
  6. Concentration of anesthetic gas
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11
Q

What can too much anti cholinesterase cause?

A

Depolarizing blockade

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12
Q

Is atropine or glycopyrrolate quicker onset?

A

Atropine

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13
Q

What would you give to children, atropine or glycopyrrolate?

A

Atropine because children can’t handle a drop in CO

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14
Q

What would you give to elders, atropine or glycopyrrolate?

A

Glycopyrrolate because can’t handle increase in HR

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15
Q

MOA for Sugammadex

A

Encapsulation of rocuronium and vecuronium causing reversal

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16
Q

Why can’t Sugammadex bind with mivacurium and atracurium?

A

Size of the cavity is too small to accommodate the bulky molecules

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17
Q

What can be used in a rocuronium induced anaphylactic reaction?

A

Sugammadex

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18
Q

Recurrence of NMB may occur with Neostigmine where the reversal effects wear off before a muscle relaxant is completely eliminated?

A

Recurarization

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19
Q

7 special considerations with sugammadex:

A
  1. Renal impairment
  2. Hepatic impairment
  3. Obese pts
  4. Elderly
  5. Peds pts
  6. Pregnancy and lactation
  7. Contraceptive steroids
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20
Q

3 assessments to satisfy recovery of sugammadex

A
  1. Skeletal muscle tone
  2. Respiratory measurements
  3. Response to peripheral nerve stimulation
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21
Q

How much sugammadex with no twitches under roc and vec?

A

4mg/kg

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22
Q

How much sugammadex with 2 twitches under roc and vec?

A

2mg/kg

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23
Q

How much sugammadex to reverse roc soon after administration?

A

16mg/kg

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24
Q

5min waiting time to admin how much NMBA and dose?

A

1.2 mg/kg of roc

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25
4hrs waiting time to admin how much NMBA and dose?
- .6mg/kg of roc | - .1mg/kg of vec
26
Objective fully reversed pt
- TOF of 4 twitches - sustained tetanus 50-100Hz >5sec - TOF ratio >.7-.9
27
Subjective fully reversed pt
- 5sec head lift - tongue protrusion - forced hand grip - spontaneous breathing with adequate tidal volumes
28
Threshold of TOF needs to be at least what to minimize risk of post-op complications
.9
29
4th twitch is 90% as strong as 1st twitch
<70% blockade of receptors
30
4 things to prevent waking up in pain?
- timing of narcotics - use longer acting narcotics early - titrate shorter acting narcotics to respiratory rate - use doses appropriate for ‘awake’ pts
31
Avoiding nauseating anesthetics to prevent puking from pt:
Opioid Nitrous oxide Anti cholinesterase inhibitors
32
Using antiemetic appropriately to prevent pt from puking (3)
- dexamethasone 4mg pre-incision - ondansetron 4mg pre-induction or 30min prior to emergence - propofol 20-30mg close to emergence
33
When to pull the tube with respiratory mechanics
Strong | -SpO2 >93% on FiO2
34
Primitive reflex of elicited by repetitive tapping on the forehead and pt blinks in response to 1st several taps
Glabellar tap (glabellar tap sign)
35
Traditional wake up method with Neostigmine:
1. Reverse NMB (10min early) 2. “Lighten” anesthetic (decrease volatile, low flow if early and high flow if late) 3. Decrease min vent to increase EtCO2 4. Return to spontaneous breathing (adequate VT and titrate narcotics to RR) 5. Extubation when pt is awake and following commands
36
Traditional wake up with sugammadex:
1. “Lighten” anesthetic (decrease volatile, low flow if early and high flow if late) 2. Decrease min vent to increase EtCO2 3. Reverse NMB 4. Return to spontaneous breathing (adequate VT and titrate narcotics to RR) 5. Extubate when pt awake and following commands
37
Advantages of traditional wake up
Smooth Adequate analgesia Comforting
38
Disadvantages to traditional wake up
Requires breathing pt Hypoventilation slows elimination of anesthetic gas Increase side effects of narcotics
39
Rapid emergence:
1. Reverse NMB 2. Hyperventilate out volatile anesthetic (10L FGF and 10-15 RR) 3. Dose narcotics appropriately 4. Extubate when pt is awake and following commands
40
Advantages to rapid emergence:
Fast | Smooth when timed correctly
41
Disadvantages to rapid emergence
Frequently not smooth | May not adequately ensure post-op analgesia (overdose or under dose)
42
What to push if pt is too tight
1. Propofol 20-50mg 2. Lidocaine 1-1.5mg/kg 3. Sux 20-30mg 4. ED95 of muscle relaxant is ~1/3intubating dose
43
What to do when pt is just too tight:
Hyperventilate Increase inhaled volatile concentration N2O
44
When can emergence delirium happen (3)
1. Wake up too fast 2. Inadequate pain control 3. Tube is still in and no LTA
45
What to rule out when pt is waking up crazy (4)
1. Hypercarbia 2. Hypoxia 3. Hypotension 4. Stage II anesthesia
46
What to do if pt is waking up crazy (5)
1. Don’t pull ETT 2. Lido 3. Propofol 4. Fentanyl 5. Avoid benzos
47
increasing doses of Sux where continuous activation of ACh receptors leads to ongoing shifts of Na into cell and K out of cell
Mechanism of Phase II block
48
Diagnosis of Phase II block
Non-depolarizing block (fade is seen with tetanic and TOF stimulation; post-tetanic potentialtion)
49
8 bad things about sux
1. Fasciculations hurt 2. Hyperkalemia 3. Cardiac arrest 4. Profound bradycardia 5. MH trigger 6. Pseudocholinesterase deficiency 7. Not give 24-72hrs after burns, trauma, or enervation 8. Can cause arrest in kids with undiagnosed muscular dystrophy
50
Ultrashort-acting nondepolarizing NMB agent | -alternative to sux
Gantacurium chloride
51
How long does administration of Neostigmine take to peak?
10min
52
CO2 <35
Narcotics
53
CO2 >50
NOT narcotics
54
CO2 35-50
Titrate to effect
55
Step that need to be taken to put tube back in:
1. Positive pressure 2. Jaw thrust 3. Lidocaine/propofol 4. Sux
56
If all else fails, what to do to provide emergency oxygenation
Emergency cricothyrotomy
57
2 reasons why colloids are good
1. Hyperproteinemia | 2. Malbourished pts who need plasma volume expansion
58
When to use colloid (3)
Renal failure Large trauma Microsurgical
59
Why to use colloid
Expand intravascular volume by plugging leaking capillaries and increasing the colloid oncotic pressure
60
What percent does blood volume increase with colloid
20%
61
When should crystalloid fluids be used?
In pts with dehydration (loss of both interstitial and intravascular fluid)
62
Primitive reflex where elicited by repetitive tapping on the forehead and pt blinks in response
Glabellar tap
63
what to avoid if pt is waking up all crazy?
Benzos (versed)
64
Rapidly diminishing response to successive doses of a drug, rendering it less effective (common with drugs acting on the nervous system)
Tachyphylaxis
65
What 2 drugs can sugammadex reverse?
Rocuronium | Vecuronium
66
How much sugammadex to give with shallow/medium blockade?
2mg/kg
67
How much sugammadex to give with deep blockade?
4mg/kg
68
How much sugammadex to give 3 min after administration of max 1.2mg/kg Roc?
16mg/kg
69
For TOF, is black lead distal or proximal?
Distal

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