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Anesthesia Practice 1 > Exam 1 > Flashcards

Exam 1 Flashcards

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2
Q

HHealthcare Associated Infections (HAIs)

A

5% - 10% (approx. 2 million people) of hospitalized patients acquire 1 or more HAIs yearly 90,000 deaths annually $4.5 - $5.7 billion in excess healthcare costs annually 4 most prevalent cases responsible for 80% of cases: UTIs (35% and catheter related), surgical site infection (20% of cases but 1/3 of excess costs), bloodstream infections (15% majority are intravascular-catheter related) and pneumonia (usually ventilator-associated, 15% of cases, 25% of attributable mortality) Organisms in 70% of these infections are resistant to 1 or more antibiotics

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3
Q

NIOSH vs. OSHA

A

National Institute for Occupational Safety and Health (NIOSH) - makes rules Occupational Safety and Health Administration (OSHA) - enforces rules

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4
Q

Methylmethacrylate

A

Glue used for ortho cases OSHA 8 hrs avg 100 ppm (280 ppm max) Exposure for factory workers Causes respiratory (asthma), cutaneous, genitourinary, allergic sensitizer issues

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5
Q

Latex Allergy

A

70% rxn reported were healthcare workers Anesthesia sensitivity - 13-16% Can’t be reversed Caution for ppl with Spina Bifida (have severe latex allergy) History of Hay fever, Rhinitis, asthma, eczema Food allergies (avocado, kiwi, banana, chestnuts, stone fruit) Schedule elective surgery as first case of the day Post signs indicating “LATEX ALLERGY”

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6
Q

Radiation Hazards

A

Exposure: diagnostic radiographs, fluoroscopy, radiation therapy, PACU Lead aprons and shields Dosimeters - measure exposure Maintaining distance: E = 1/d2 Gonads = greatest sensitivity You can stand behind someone w/ the lead jacket and be okay

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7
Q

Laser Hazards

A

Risks include thermal burns, eye injury, electrical hazards, fire & explosion (O2) Plume contains viral DNA and toxic chemicals Need to wear high efficiency laser mask & special glasses If operating around the head w/ laser, you need to decrease FiO2

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8
Q

Major Reason for Error in Anesthesia Management

A

Fatigue - 64%

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9
Q

Requirements forTransmission of Infectious Agents

A

Source Stabile pathogen Adequate numbers Infectivity of agent Appropriate vector Portal of entry

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10
Q

Respiratory Transmission

A

Aerosolization Flu Measles Rhinovirus Tuberculosis Self Inoculation Rhinovirus Respiratory Syncital Virus

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11
Q

Influenza

A

Easily transmitted US 36k deaths, 200k hospitalizations Cells shed 5d

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12
Q

Rubeola & Rubella

A

Rubeola (aka Measles) Transmission: Aerosol Highly infective Maculopapular rash & Koplicks spots Fever and 3C’s - cough, coryza (runny nose), conjunctivitis Complications commons: M 1:1000, 30% immunosuppressed Rubella (German Measles) Causes misscarriages 1st trimester Birth defects or fetal defects Elective surgeries cancelled

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13
Q

Mumps (Epidemic parotitis)

A

Infection by airborne droplets Painful swelling salivary & parotid glands Symptoms not severe in children Most often children 5-9 YO

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14
Q

Respiratory Syncytial Virus (RSV)

A

Paramyxoviridae Most important / most common cause of lower respiratory disease in young 60% infants 100% 2-3 YO Infected by self-inoculation Prevalenet November-May Viable on surface for 6 hours Infected individual sheds virus for 7d Immunity not permanent Recurrent asthma symptoms in young kids for up to 6 mo

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15
Q

Rhinovirus

A

Most common viral infective agents in humans Causes common cold Transmission: self-inoculation and/or aerosolized particles Over 110 serologic virus types

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16
Q

Herpes Virus

A

Varicella-zoster (VZV) Chickenpox and herpes zoster (shingles) Communicability: 1-2 days before and last 5-6 days after HC workers >36 YO have VZV antibodies, 6.5% younger pop susceptible HSV 1 & 2 Type 1: Oral herpes Cytomegalovirus (CMV) Occurs during childhood 40-90% adults have antibodies Transmitted via direct contact Infection during pregnancy results in fetal infection 2.5%

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17
Q

Hepatitis B

A
  • Prevalence HBV US is 3-5%
  • Seoconversion up to 30%
  • 5% develop chronic hepatitis which develops into cirrhosis and ESLD
  • 1% develop fulminant hepatitis (>70% mortality)
  • Transmission via sexual contact, shared needles/syringes, and perinatally
  • HBV vaccines primary prevention strategy
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18
Q

Hepatitis C

A

Leading cause of chronic liver disease in US 9K new cases/yr Prevalence HCV in US ~ 3% 60% HCV infected patients will have chronic hepatitis / cirrhosis Seroconversion 1.8%

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19
Q

Leading cause of chronic liver disease in US

A

Hepatitis C

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20
Q

HIV

A

Seroconversion 0.3% percutaneous exposure, 0.1% mucous membrane exposure Increased risk associated with visible blood on device, deep injury, needle placed intravascular, terminal illness Since 1957, 57 documented cases of HCW acquiring HIV through exposure

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21
Q

Tuberculosis

A

Viable bacilli on airborne particles 1-5 microns 7-8 million become infected every year 8000 die each day Groups with high prevalence include: personal contacts with active TB, immigrants, alcoholics, homeless, IV users Protection: N95 mask, patient kept in neg. pressure rooms 3 neg. sputum acid fast bacillus smears to determine that patient is no longer infectious Non elective procedures done at end of day High efficiency filter (99.97% particles >0.3 microns) Filter put on expiratory port of circuit to protect machine

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22
Q

What fluids are and are not considered infectious?

A

Infectious Blood CSF Amniotic fluid Pleural Pericardial Peritoneal Synovial Inflammatory exudates (pus) Not Infectious Urine

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23
Q
A
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23
Q

Precautions for Patients with Multi-Drug Resistant Microorganisms

A

Methicillin-Resistant Staphylococcus Aureus (MRSA) - most common bug on surface of skin Vancomycin-Resistant Enterococci (VRE) Clostridium Difficile (cdiff) Hand washing (EtOH alone not effective) Yellow gown and gloves

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24
Q

Droplet Precautions

A

Wear a mask w/in 3 feet of patients with: Mumps German measles Streptococcus Meningococcal Spatial separation of 3 feet with other patients, keep curtains drawn

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25
Disposal of Contaminated Materials
Linen:  BLUE container Sharps:  RED Reusable sterile gowns:  GREEN Paper Goods:  trash can
26
Cleaning Antiseptic Disinfectant Sterile Sterilization
Cleaning:  Removal of Foreign Material Antiseptic:  chemical germicide for use on living tissue Disinfectant:  chemical germicide for use on non-living items Sterile:  completely free of all microorganisms Sterilization:  process that results in probability of microorganism survival on an item
27
Disinfection Levels
High-Level Disinfection:  kills fungi, viruses, and vegetative bacteria (except endospores) Intermediate Level:  kills fungi, non small or nonlipid viruses and bacteria (except endospores) Low-Level:  Kills fungi, some viruses (lipid/medium sized) and bacteria (except TB, endospores)
28
Chlorine (Hypochlorite)  
Most widely used of the chlorine disinfectants. Used on tables, floors, surfaces, equipment 1:100 - 1:1000 effective against HIV 1:5 - 1:10 effective against hepatitis 1:10 (5.25%) for blood spills
29
Sterilization
Steam (Autoclaving) Chemical (Gas, Liquid) Radiation Plasma
30
Autoclaving
Type of steam sterilization Quick, cheap, effective with no residues Kills everything (pressure & temp) Minimum times:  15 mins @ 121 C 10 mins @ 126 C 3.5 mins @ 134 C Confirmed by indicator strip inside the wrapped metal trays
31
Handling Preservative-Free Medications
Check label Use aseptic technique (alcohol swab) to rubber septum or neck of glass ampule Discard vial / ampule or syringe after use
32
Multidose Vials
Aseptic technique (alcohol swabs) Uncontaminated vial may be used until manufacturer's expiration date
33
Betadine Allergy
People allergic to Betadine also often allergic to contrast dye and shellfish
34
Prevention of Intravascular Catheter-Related Infections
Catheter Selection Single lumen is best Antimicrobial or antiseptic impregnated CVC Insertion Subclavian v. carries a lower risk Barrier Precautions Catheter Site Dressing Transparent, semi-permeable polyurethane dressings permit continuous visual inspection of the catheter site
35
Surgical Subspecialties:  Cardiovascular Cases
CABG:  Coronary Artery Bypass Graft Valve Replacement Aortic Arch Dissection - longitudinal tear Aneurysms Congenital Defects Transplants
36
Surgical Subspecialties: CV Anesthetic Concerns
General Anesthesia Sternotomy Cardio-pulmonary bypass Invasive Monitoring ICU Transport Chest Tube Placement
37
Surgical Subspecialties:  Thoracic Cases
Tumor Resection:  Lumpectomy, wedge, lobe, pneumonectomy Lung Reduction Transplant Esophageal Resection Tracheal Resection Thoracoscopy Bronchoscopy (put a scope down the ETT, so you have to do a TIVA)
38
Surgical Subspecialties:  Thoracic Concerns
General Anesthesia One-lung ventilation Sternotomy Positioning Invasive Monitoring ICU Transport Chest Tube Placement
39
Surgical Subspecialties: Neurological Cases
Intracranial (tumor, aneurysm/AVM - arteriovenous malformation, trauma/bleeding, craniectomy, VP shunt - ventricular-peritoneal Spinal - decompression/fusion, alteration/straightening Functional - DBS, Infusion pumps, generator changes
40
Surgical Subspecialties:  Neurosurgery Anesthetic Concerns
General Anesthesia vs. Local Anesthetic vs. MAC Invasive Monitoring CBF Changes/Diuretics Hyperventilation Positioning Head Fixation (Mayfield) Paralysis Burst Suppression (slowing down all electrical activity in the brain while they operate on it - done with high dose Propofol infusion)
41
Surgical Subspecialties:  Intracranial Hypertension
Intracranial Pressure > 15mmHg Increase in tissue or fluid w/in the rigid cranial vault Signs and Symptoms:  headache, N/V, altered consciousness Treatments:  fix underlying cause, steroids (decadron), fluid restriction, diuretics (mannitol 0.25-0.5 g/kg), hyperventilation (ETCO2 30-35mmHg), Intraventricular drain
42
Surgical Subspecialties:  Orthopedic Cases
Joint Surgery:  hip/knee/shoulder, replace vs. repair, arthroscopy Spine:  cervical, lumbarl, thoracic Hand:  trauma, reattachment, carpal tunnel
43
Surgical Subspecialties:  Orthopedic Anesthetic Concerns
GA vs. Regional vs. Nerve Block Positioning:  sitting/prone/supine Blood Loss/Fluid Replacement Tourniquets Emboli:  blood/fat/glue, polymethylmethacrylate
44
Surgical Subspecialties:  Ophthalmology Cases
Retina Lens Refractive Tumor Cosmetic  Trauma
45
Surgical Subspecialties: Ophthalmology Anesthetic Concerns
RBB (Retrobulbar Block) vs. GA vs. MAC Intraocular Pressure Oculocardiac Reflex: (reflex when lateral and medial rectus mm. pull at the same time) Ophthalmic tract trigeminal n., Vagus n. Gas Expansion (no nitrous on when you have a gas bubble)
46
Surgical Subspecialties:  Vascular Cases & Anesthetic Concerns
Carotid Endarterectomy Aneurysm Revascularization Trauma   Concerns:  GA vs. Regional vs. Local Invasive Monitors - Location Anticoagulation Neuro-monitoring Length of Case Patient population  
47
Surgical Subspecialties:  Laparoscopic Cases & Anesthetic Concerns
Cholecystectomy Kidney Donor Herniorrhapy Appendectomy Splenectomy Bowel Resection GERD Cessation Adrenalectomy Gastric Bypass Concerns: GA Abdominal Insufflation Increased PIP Positioning ETCO2 issues Pneumo
48
Surgical Subspecialties:  Transplant Cases & Anesthetic Concerns
Renal - CRT vs. Living Related Heart Liver Lung Pancreas Concerns: GA Electrolyte Imbalance Organ Preservation Coagulation Anomaly Pathophysiology of Patient Volume Status IV Access
49
Surgical Subspecialties:  Pediatric Cases & Anesthetic Concerns
Young:  congenital, hernia, TE Fistula, pyloric stenosis Older:  ear tubes, tonsils/adenoids, orthopedic, trauma
50
Surgical Subspecialties:  Obstetric Cases & Anesthetic Concerns
Labor Delivery (Vaginal, C-Section) Resuscitation Anesthesia for Pregnant Patients Concerns: GA vs. Spinal vs. Epidural Drug Effects on Mother/Fetus Sensory vs. Motor Block Fetal Distress/Monitoring Positioning of Mother - aorto-caval compression APGAR Teratogenic Drugs
51
Surgical Subspecialties: Gynecologic Cases & Anesthetic Concerns
EUA Hysteroscopy Hysterectomy Myomectomy D&C Concerns: GA vs. Regional Monitoring Blood Loss Apprehension Age of Patient
52
Surgical Subspecialties:  Genitourinary Cases & Anesthetic Concerns
Cystoscopy TURP Stone Extraction Nephrectomy Prostatectomy Cystectomy w/ Neobladder Concerns: GA vs. Regional vs. MAC GU Suite Location Positioning Obturator Reflex - bx or lateral wall of bladder, TURBT TURP Syndrome - water, electrolytes, sorbitol, mannitol
53
Surgical Subspecialties:  Otorhinolaryngology Cases & Anesthetic Concerns
Endoscopy - laryngoscopy, esophagoscopy, bronchoscopy Nasal/Sinus Head/Neck Cancer Cranio-facial Reconstruction Concerns: GA Fire Protection - airway fire, laser Field Avoidance Tracheostomy Nasal Intubation Difficult Airway No airway! Muscle Relaxants
54
Emergence duration is proportionate to what factors?
Agent Solubility (directly) Agent Concentration (directly) Duration of Anesthesia (directly)
55
Emergence of inhalational anesthesia depends chiefly on what?
Pulmonary Elimination Most frequent delay from inhalational GA Sometimes balance b/t building up CO2 and breathing gas off
56
Blood-Gas Partition Coefficients of: Des N2O Sevo Iso
Des:  0.45 N2O:  0.47 Sevo:  0.65 Iso:  1.4 Ex:  There has to be 1.4x as much Iso in the blood as in the gas to equilibrate
57
Half-Life & Clearance of: Droperidol Etomidate Ketamine Midazolam Propofol
Droperidol:  1.7-2.2 / 14 Etomidate:  2.9-5.3 / 18-25 Ketamine:  2.5-2.8 / 12-17 Midazolam:  1.7-2.6 / 6.4-11 Propofol:  4-7 / 20-30
58
Minimum FiO2 during hypoventilation
0.85, except severe COPD patients
59
Effects of Hypercarbia
Stimulates sympathoadrenal system (increase HR, CO, PP, BP, SV, etc.) Vasodilator, except pulmonary arteries (constricts) Hypercarbic narcosis Dysrrhythmias
60
Action of Neuromuscular Blockade
NMBD interrupt transmission of nerve impulses at NMJ of skeletal muscle Categories: Depolarizing Nondepolarizing Long >60 mins. Intermediate 15-45 mins. Short
61
Action of Succinylcholine
Bind to ACh and depolarizes the end-plate nicotinic receptor  Short duration due to pseudocholinesterase metabolism --> depolarizes the motor end plate then diffuses away and is metabolized Side Effects:  Fasciculations, myocyte rupture, hyperkalemia, myalgias Sinus bradycardia - muscarinic receptor Malignant hyperthermia Dose 1-2 mg/kg Laryngospasm (0.1 mg/kg)
62
Action of Non-Depolarizing NMBD
Competitively inhibit end plate nicotinic cholinergic receptors Do NOT bind to ACh receptors They bind ACh receptor sites, then as ACh continues to be released, it pushes the non-depolarizing drug off the site so it can bind again. Non-depolarizers are then metabolized, redistributed, diffusion, or excreted from the body
63
Peripheral Nerve Stimulator Monitoring Location
Ulnar n. Adductor Pollicis Facial n. Orbicularis Oculi  Most closely reflects block at diaphragm Posterior Tibial n. Medial malleolus - flexion of big toe External Peroneal n. Dorsiflexion
64
Which PNS monitoring site is better for induction?  Which is better for emergence?
Induction:  Orbicularis Oculli Emergence:  Adductor Pollicis
65
Which muscle is most sensitive and which is most resistant to neuromuscular blockade?
Most Sensitive: Extraocular Most Resistant:  Vocal cords  *Diaphragm is 2nd most resistant
66
Characteristics of Depolarizing and Non-depolarizing Blocks for:  TOF Tetany Double Burst Stimulation Postetanic Potentiation
TOF, Tetany & Double Burst Stimulation Depolarizing: Phase 1: constant but diminished, Phase 2: Fade Non-Depol: Fade   Postetanic Potentiation Depolarizing: Phase 1: absent;  Phase 2: Present Non-Depol: Present
67
Train of Four (TOF)
4 Stimulations at 2 Hz (0.5 sec) 4 of 4 can have 75% block 3 of 4 = 85% block 2 of 4 = 90% block 1 of 4 = 95% block 0 of 4 = 99% block   Must have 1 twitch prior to reversal or post tetanic count >10
68
Post Tetanic Count
Profound NMB with no response to single twitch Apply 50 Hz tetany 5 seconds Wait 3-5 seconds Single twitch response 1/sec. Count total twitches >10 twitches indicates sufficient receptors for reversal Post –Tetanic Potentiation: do tetany at 50-100 Hz for 5-10 seconds. This will flood the junction with ACh. Follow with TOF. If you have a response from TOF, this will indicate that the muscle relaxant is being metabolized and you will be able to reverse soon. If no response, this means you have a lot of NMB left that needs to metabolize
69
Double Burst Stimulation  (DBS)
3 stimulus at 50 Hz, 750ms pause, 2 stimulus at 50 Hz
70
Head lift greater than 5 sec = TOF ratio of what?
>0.7
71
What is the action of Neostigmine?
It is an anticholinesterase, inhibits acetylcholinesterase Causes muscarinic stimulation (PNS)   Dose: Max 0.07 mg/kg or 70 mcg/kg NOT 5 mg! Peak onset: 5-10 mins
72
How do you assess the adequacy of ventilation?
Arterial Blood-Gas PaO2 > 65 on FiO2 > 0.40 PaCO2 < 50 torr ETCO2 SpO2 > 90%  Tidal Volume (better than 250 cc/min but subjective)
73
NAW vs. OAW
Nasal airway primarily used for sleep Consider establishing airway prior to extubation for patients believed to have obstructive issues (obesity, OSA, snoring)  
74
Snoring
Indication of obstructed upper airway Vibration of soft palate responsible for noise Incidence greatest in 1st, 5th, and 6th decades of life More prominent in males Obesity is a factor
75
Obstructive Sleep Apnea
Pathophysiology: Sleep fragmentation in adults affects neuropsychological and cognitive performance Usually results in arousal, followed by clearance of the pharyngeal airway. Hypoxia is the major factor in arousal SaO2 = 85% Arousal results in massive sympathetic discharge. Hypercapnia = increased PAP and afterload = right ventricular hypertrophy
77
What is the most common reason for readmittance into the hospital after surgery?
78
Surgical Sites with the Greatest Risk of PONV
Intra-abdominal Laparoscopic Orthopedic Gynecological ENT Breast Plastic Neurosurgical
79
Anti-Emetics: Serotonin 5-HT3 Receptor Antagonists
End in -tron Zofran (Ondansetron) Anzemet (Dolasetron) Kytril (Granisetron)
80
Anti-Emetics: Dopamine Antagonists
Droperidol Don't use for Parkinsons patients
81
Anti-emetics:  Antihistamines
Diphenhydramine Promethazine (Phenergan)
82
Post-op Pain Management  
Epidural Placement Bolus 6-8 cc agent in divided doses prior to extubation Verify normovolemia prior to bolus Be prepared for hypotension Parenteral Narcotics NSAIDs (Toradol 30mg) 30mg Toradol = 10mg Morphine Contraindications:  GI Ulcers/bleeding, coagulopathies, renal impairment, bone graft
83
Equivalent of Toradol to Morphine
30mg Toradol = 10mg Morphine
84
Potency of Hydromorphone relative to Morphine? Dosage and Duration of Hydromorphone?
8x as potent as morphine Dosage: 1-4 mg Duration: 4-8 hrs
85
Dosage, duration and contraindications of Morphine?
Dosage: 2-10 mg Duration: 4 hrs Contraindications: Renal Failure
86
Potency and duration of Fentanyl
100x as potent as morphine Duration: 0.5-1 hr
87
Narcotics should be titrated to a respiratory rate of  _______ breaths per minute
10-16 BPM
88
When is it appropriate to extubate a patient?
A/w protective reflexes in tact Clinical stability Intact neurological function Adequate pulmonary function Normal body temp (35-37 C) Normal neuromuscular function Normal coagulation Head lift, grip, TOF 4/4 ST (5 sec) RR 5-30 TV > 5 cc/kg PaO2 > 65 on FiO2 < 0.40 PaCO2 < 50 torr Resting MV < 10 L/min. Level of Consciousness Muscle Relaxant Reversed
89
What is the Purpose, Contraindications & Criteria for Deep Extubation?
Purpose Minimize tracheal stimulation Minimize coughing/bucking - Increase IOP, ICP, BP, Dehiscence Contraindications Difficult mask airway Difficult Intubation Aspiration Risk Airway Edema Criteria MAC 1.3 NMB completely reversed Spontaneous rhythm at regular rate/rhythm No a/w reflex 100% O2 Lidocaine (0.5 mg/kg)
90
What should you never deep extubate a patient without?
An oral a/w in place
91
What are the steps after extubating a patient?
Suction again Place mask on patient Keep right hand on the bag Test for a/w patency Help them breathe for a while if they are not doing an adequate job on their own
92
ASA Standards for PACU
Standard I:  all patients who have received general, regional or MAC shall receive appropriate post-anesthesia management   Standard II:  A patient transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition. The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient’s condition. 
93
ICU Transport Equipment & Monitoring
Equipment Cardiac Monitor or defibrillator a/w managment equipment - breathing bag, reintubation equip. O2 source w/ 30 min reserve Standard resuscitation drugs - epi, lidocaine, atropine, IV fluids Medication Monitoring EKG & spO2 = continuous BP, RR, Pulse Rate = intermittent Capnography, PA and/or IC pressure
94
PACU Admission Monitoring Reqmts
Every pt:  HR & rhythm, BP, airway patency, spO2, RR and pain Every pt continuous: pulse ox, ECG Capnography only necessary for ventilated pts.
95
PACU Report
Pt name, Allergies, preop vitals ASA class, Medical Hx Procedure, Surgeon, Anesthesia Type Anesthesia Pre-meds, narcotics, paralytics, Rx Fluids, lines Orders    
96
MAC Anesthesia:  ASA Guidelines
Oxygenation: Inspired gas (insufflation) - 100% O2 from auxillary O2 flowmeter O2 mask, nasal cannula, breathing circuit tubing Never use N2O or inhalational agents - no scavenging, potential loss of a/w Blood oxygenation - pulse ox, nail beds, etc. Ventilation: Chest excursion, thoracic impedance plethysmography, capnography (via nasal cannula) Circulation: ECG & HR, BP, Pulse Pleth., Auscultation of heart sounds, palpation of pulse
97
Neuraxial Anesthesia Contraindications
Absolute: * PATIENT REFUSAL!! * Infection at site of injection * Coagulopathy * Severe hypovolemia * Increaseed ICP * Severe aortic stenosis * Severe mitral stenosis Relative: * Sepsis * Uncooperative Patient * Neurologic deficit * Severe Spinal deformity Controversial: * Prior back surgery * Inability to communicate * Complicated surgery
98
Coagulopathy and Neuroaxial Anesthesia
Oral Anticoagulants: Coumadin (warfarin) Must be stopped to normal PT and INR Antiplatelet Drugs: NSAIDs Plavix (clopidogril) - stopped 7 days prior!!! Heparin: Subcutaneous, Intraoperative, Therapeutic Cardiopulmonary bypass Low Molecular Weight Heparin Lovenox Lot of pts on this post-op
99
Principle Landmarks for Spinal Anesthesia
Superior aspect of iliac crest crosses body of L4 (Tuffier's Line)
100
Principle Landmark for Thoracic Epidural
T7-T8 interspace at scapula (inferior aspect of scapula)
101
Ligaments of the Spinal Column
Ligamentum flavum - tough one right outside epidural space Supraspinous ligament Interspinous ligament
102
Where does the spinal cord end in adults and infants?
Adults:  L1-L2 Infants: L3-L4
103

Anesthesia Practice 1 (2 decks)

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