EXAM 1 Flashcards
(231 cards)
1
Q
When would we give stress dose steroids?
A
Pt has taken 2 wks corticosteroids (doesn’t matter the kind) within 3 months or they have been taking 20 mg/day prednisone
2
Q
What part of CNS is activated during surgery and what does it cause?
A
SNS causes hypothalmic-pituitary axis—> anterior pituitary—> releases adrenocorticotropic hormone —-> which hits adrenal cortex (release corticosteroids) and the adrenal medulla (release epi)
3
Q
Why do we give stress dose steroids?
A
Adrenal insufficiency caused by HPA suppression from use of exogenous steroids pt will not hold on to volume because they don’t have aldosterone so if we give fluids, doesn’t matter. So then we can give steroids IOP
4
Q
Which steroids and doses do we give IOP for stress dose?
A
100 mg Hydrocortisone IV for 24 hrs
10 mg dexamethasone IV after induction (tell surgeon)
125 mg solu cortef
5
Q
BMI calculation
A
weight (kg)/Height (m^2)
6
Q
Herbals: echinacea
A
Pharm: activation of cell-mediated immunity
concerns: allergic rx, decrease effects of immunosuppressants, potential for immunosuppression with long-term use
7
Q
Herbals: ephedra (ma haung)
A
Pharm: increases hr and bp
concerns: risk of mi and stroke from tachycardia and htn, vent arrhythmias with halothane, long-term use depletes endogenous catecholamines and may cause intraoperative hemodynamic instability, threatening with MAOIs
24 hrs
8
Q
Herbals; Garlic (ajo)
A
Pharm: inhibits platelet aggregation (may be reversible), increases fibrinolysis, antihypertensive activity
Concerns: increase risk of bleeding especially when combined with other antiplatelets
7 dats
9
Q
Herbals: Ginger
A
Pharm: antiemetic, antiplatelet
Concerns: increase risk of bleeding
10
Q
Herbals: Ginkgo (duck-foot tree, maidenhair tree, silver apricot)
A
Pharm: inhibits platelet activating factor
Concerns: risk of bleeding
36 hrs
11
Q
Herbals: Ginseng
A
Pharm: Lowers blood glucose, inhibits platelet aggregation (may be reversible) increased PT/PTT in animals
Concerns: Hypoglycemia, increase risk of bleeding, may decrease anticoagulant effect of warfarin
12
Q
Herbals: Green tea
A
Pharm: inhibits platelet aggregation and thromboxane A2 formation
Concerns: increase risk of bleeding, decrease anticoagulant effect of warfarin
7 days
13
Q
Herbals: Kava (awa intoxicating pepper, kawa)
A
Pharm: Sedation, anxiolysis
Concerns: May increase sedative effect of anesthetics
24 hrs
14
Q
Herbals: Saw palmetto (dwarf palm, Sabal)
A
Pharm: inibits 5alpha reductase, inhibits cyclooxygenase
Concerns: increase risk of bleeding
15
Q
Herbals: St. John’s Wart (amber, goat weed, hardhay, hypericum, kalamath weed)
A
Pharm: inhibits neurotransmitter reuptake, MAO ihibition unlikely
Concerns: Induction of cytochrome P450 enzymes; affects cyclosporine, warfarin, steroids, and protease inhibitors, may affect benzodiazepines, CCB, and many other drugs
5 days
16
Q
Herbals: Valerian (all heal, garden helitrope, vandal root)
A
Pharm: sedation
Concerns: may increase sedative effect of anesthetics, benzodiazepine-like acute w/d, may increase anesthetic requirements with long-term use
17
Q
O2 sat calculation
A
Numerator: [Total O2 -(PaO2 x 0.003)] x 100
Denominator: Heme x 1.34
18
Q
Drug interaction: ACE inhibitors
A
IOP: hypotension with or without bradycardia; intolerance to hypovolemia
Manage: hydration, moderated doses of vasopressors
DC: pt on amio possibly, multiple antihyperstensives (3+), hypotension- sensitive patients, omit am dose
19
Q
Drug interaction: Beta adrenergic blockers
A
IOP: if dc’d may increase preop cv morbidity and development of w/d symptoms( increased nervousness, tachycardia, ha, n/v, exacerbation of MI or death), give esmolol during surgery
Manage: hydration
DC: continue them if pt undergoing surgery who receive b-blockers to treat angina, symptomatic arrhythmias or htn
20
Q
Drug interaction: CCB
A
IOP: decrease SVR and bp via peripeheral vasodilation; negative inotropic effect by slowing sinus automaticity and av conductivity; negative chronotropy by slowing sa and av nodes and prolonging av nodal conduction
Manage: hydration; phenylephrine as needed to maintain atrial pressure
DC: Continue CCB preop in pt with normal or slightly impaired heart function; be careful with left vent dysfunction (ef<40%)
21
Q
Drug interaction: Diuretics
A
IOP: Hypokalemia; hypovolemia
Manage: Monitor K levels preoperatively; hydration
DC: Pt may become symptomatic if morning dose withheld; patients appreciate lack of urinary urgency while awaiting surgery; it might be desirable to continue in patients for whom diuretics are part of the treatment for chronic renal failure.
22
Q
Drug interaction: Antiarrhythmics
A
IOP: Cardiac depression; prolonged neuromuscular blockade; amiodarone-hypotension and atropine-resistant bradycardia requiring ventricular pacing
Manage: monitor serum drug levels as needed; amiodarone- large doses of vasopressors or inotropes and pacemaker capability.
DC: rarely recomended to dc because its usually prescribed for arrhythmias; amioderone impractical to dc because its half life is 58 days; withhold concurrent meds tho like ACE-i
23
Q
Drug interaction: antiplatelet drugs and NSAIDS
A
IOP: impaired platelet function; altered renal function; gi bleed
Manage: transfusion if bleeding, or anastamosis leak (leak from colorectal surgery), bone fusion issues from surgery.
DC: antiplatelet drugs (asa, clopidogrel, ticlopidine) should be dc 7-10 days prior to high risk surgery; unless surgery puts pt at risk for catastrophic bleeding or impaired renal function it is reasonable to continue NSAIDs up to morning of surgery; if desirable to dc NSAIDs preop, short-acting NSAIDs should be withheld for at least 1 day, longer-acting agents 2-3 days
24
Q
Drug interaction: anticoags (heparin, coumadin, LMWH)
A
IOP: increased hemorrhage
Manage: May reverse heparin with IV protamine; may reverse coumadin with vitamin K or ffp
DC: heparin - dc IV 6 hr before surgery and check PTT; Coumadin- dc 3-5 days (5 days if INR < 1.5 required) before surgery and check INR or PT; LMWH - dc 12 hr before surgery
25
Drug interaction: Fibrinolytic drugs (streptokinase, urokinase, tissue plasminogen activator)
IOP: Hemorrhage
Manage: Antifibrinolytic agent (aprotinin) may be indicated
DC: DC usually not an oprion when administered for treatement of life threatening conditions (acute MI, massive PE)
26
Drug interaction: Insulin
IOP: Hyperglycemia; hypoglycemia
Manage: Montior serum gluose; use insulin-supplementation protocol
DC: Morning dose either withheld or reduced and adjustments in therapy based on periodic serum glucose determinations
27
Drug interaction: Oral hypoglycemic agents
IOP: Hyperglycemia, hypoglycemia
Manage: Monitor serum glucose; avoid dehydration
DC: Withhold oral hypoglycemic agents beginning on day of surgery
28
Drug interaction: MAO-i
IOP: HTN secondary to indirect-acting sympathomimetic drugs causing release of norepinephrine; excitatory state or depressive phenomena secondary to opioid administration
Manage: Older, nonselective, irreversible MAO-i dc for 2 wk with risk of serious physchiatric consequences or provide MAO-i safe anesthesia if drugs are continued; newer, reversible inhibitors of MOA -have a shorter half life therefore dc drug on morning of surgery; consider changing irreversible MAOIs to a reversible MAOi in the weeks prior to surgery, then only dc reversible MAOi on morning of surgery
Avoid demerol, ephedrine with these patients. Demerol may increase htn, so DC day before surgery
29
Drug interaction: TCAs
IOP: alpha adrenergic blocking activity and potential to block norepinephrine reuptake may lead to cardiac arrhythmias or hypotension; lowers sz threshold
Manage: Norepinephrine should be considered the vasopressor of choice for related hypotension
DC: DC gradually over 2 wk period before surgery; obtain baseline ECG; if continued, take precautions to reduce the significance of adverse events
30
Drug interaction: Lithium
IOP: T-wave smoothing, ventricular arrhythmias myocarditis; sinus dysfunction can lead to extreme atropine-resistant sinus bradycardia; dehydration will lead to increases in lithium blood levels
Manage: hydration
DC: DC 72 hrs before surgery
31
What 10 things need to be done in preop?
```
History
Labs
EKG
Physical exam (including malinpati)
Cardiac risks
Types of anesthesia you will use
Anesthesia risks to be considered
Invasive lines
Post-Op concerns
NPO
```
32
Patient History includes?
```
HPI
exact name of surgery and preop dx
how did this condition develop?
Previous therapy
Present medical history
- DM, HTN, COPD, OSA...
Previous anesthesia complications
-spinal headache (most likey will happen agian), MH, difficulty waking up, difficult airway, awareness
```
33
Stages of HTN
Normal <120 and <80
Elevated 120-129 and <80
Stage 1 130-139 or 80-89
Stage 2 >140 or >90
Stage 3 (HTN crisis) >180 & or >120
34
Values of BP in which we cancel surgery if beta blockers do not solve
200/115
35
What value is considered uncontrolled HTN
2 readings of > 140/90
36
What conditions are considered unstable cardiac dz?
CHF, Aortic stenosis, new onset of afib, new SVT, chest pain
37
What could a murmur be indicative of?
CHF or valve prolapse
38
Bruits heard over the carotid arteries put pt at risk for?
CVA
39
What are some s/sx that you have OSA?
daytime sleepiness,
fatigue
temporary morning HA relieved after CO2 related dilation of cerebral vessels decreases
40
What does EVALI mean?
E-cigarette vaping associated lung injury
41
Things to evaluate for pulmonary
```
Sounds
Asthma, COPD
OSA
Pickwickian syndrome
recent URTI
Tobacco use
```
42
Things to evaluate for CV
Sounds
HTN
Stents
Implantable devices
43
Things to evaluate neuromuscularly
```
CVA
SZ
ETOH use
Weakness
Nerve injury
Parasthesia
```
44
Things to evaluate for Endocrine/Renal
DM
Hyperlipidemia
Renal dz
Dialysis? If so when? Could be dry if done recently
45
Things to evaluate for GI/Liver
Liver dz
coagulopathy
GERD
Hiatal hernia
46
Top 4 most common allergies
1. Muscle relaxants
2. Latex (tropical fruits)
3. ABX
4. Local anesthetics
(esters & amides with esters most common)
47
Difference between anaphylaxis and anaphylactoid reaction?
anaphylaxis: MOSF immune mediated IgE with mediators released from mast cells and basophils
anaphylactoid: non-IgE mediated with mediators released from mast cells and basophils
48
Why do NMBD have high rate of allergy?
There is a high affinity for IgE receptors
49
What are the mediators involved in NMBD anaphylactic reaction?
```
Histamine
proteases
proteoglycans
platelet activating factor
potent inflammatory leukotrienes (LTC)
prostaglandins
```
50
What is the rank of allergy causing NMBD?
Rocuronium > Sux > atricurium > vecuronium
51
What are the clinical signs of an allergic reaction?
Histamine:
Erythema, Urticaria. angioedema, tachycardia,
vasodilation , edema, arterial hypotension, Gi constriction
LTC and PGD cause bronchial constriction and increased vascular permeability
52
Treatment of NMBD allergic reaction?
Treat symptoms:
vasopressor (epi)
bronchodilator
benadryl
53
Who are the high risk groups for latex allergy?
Spinal bifida when young or any condition where long-term or frequent use of catheters exists
54
What type of reactions are caused by latex?
Type IV cell-mediated
and
Type 1 IgE - mediated hypersensitivity reactions
55
How to treat IV contrast allergy
acytelcystine (mukomyst), fluids
also can pretreat patient prior to receiving contrast
56
What is Contrast induced nephropathy (CIN)?
IV contrast causes an increase in serum creatinine by 0.5 mg/dL or 25% increase from baseline. This is considered a reaction and treat accordingly, fluids, mukomyst
57
Most common ABX allergy and cross sensitivity?
PCN with <2% cross sensitivity to cephalosporins
58
Which types of local anesthetics most likely to produce allergy?
Esters: due to para aminobenzoic acid (PABA)
Amides: very rare but usually due to methylparaben which is chemically similar to PABA
59
Which local anesthetics are esters?
Those with one i: procaine, cocaine
60
Which local anesthetics are amides?
Those with 2 i's: lidocaine, bupivicaine, ropvicaine
61
Name the portions of the model structure of local anesthetics
aromatic ring
intermediate linkage/chain (determines if ester or amide)
amine
62
Key signs of anaphylaxis under general endotracheal anesthesia (GETA)
urticaria
vasodilation (tough because we give so many drugs that cause this)
erythema or edema
bronchospasm (watch peak pressures) and upper airway edema (oral cavity swelling)
63
Formula for smoking pack-years
(cigs per day)/20 X # yrs smoked
64
What are the byproducts of tobacco?
Nicotine and Carbon Monoxide
65
What are effects of nicotine on CV?
Carotid body and aortic sinus barroreceptors affected
66
What are CNS effects of nicotine?
Increases sympathetic tone
| Adrenal stimulation
67
How does Carbon Monoxide effect the body?
200-250% greater affinity to heme than oxygen
| decreases body's oxygen carrying capacity and makes pt more hypoxic
68
What are some effects of smoking cigs?
Wound infections
Decrease macrophage function (infection)
Respiratory or airway complications (laryngospasm easier)
Sever cough (problem for pt post op) can use drugs to help
- lidocaine
- prop
- dex
69
More smoking effects
Coronary flow
HTN, ischemia
longer hospital stay
Postop ICU admission
Shift Oxygen curve to the left
70
What does smoking cessation help and how quickly can we see effects relevant to OR?
12-24 hrs reduces
- HR
- BP
- circulating catecholamone
carboxyheme levels
cyanide
low nicotine helps improve vasodilation and toxins
71
What is the CAGE questionaire and how many + responses show risk?
Alcoholism assessment and if pt has 2 + answers then @ risk
felt like should cut down on drinking?
people annoyed you by criticizing your drinking?
felt bad or guilty about your drinking?
drink in the morning to steady nerves or get rid of h-over?
72
Anesthesia implications for chronic ETOH
Aspiration (GI motility, esophageal sphincter, gastric pressure, increased HCL)
Increased MAC requirement
Increase deppressant effects of opiods and BZP
NDMB resistance
73
Anesthesia implications for chronic ETOH
Aspiration (GI motility, esophageal sphincter, gastric pressure, increased HCL)
Increased MAC requirement
Increase deppressant effects of opiods and BZP
NDMB resistance
74
Anesthesia implications for acute ETOH
Lower MAC
Synergy with other depressant drugs
75
ETOH w/d anesthesia implications
Increased requirements
- hypnotics
- opioids
- volatiles
76
ETOH w/d signs
n/v
d/t's
automatic hyperreactivity
- sweating
- tachy
- systolic htn
77
When would we cancel an elective surgery?
substance abuse causes sympathetic responses we can delay or cancel
78
What are common eye changes by 3 drug categories?
Opioids - pinpoint
Amphetamines - dilation
PCP - nystagmus
79
What is some evidence of illicit drug use?
```
Skin holes
lymphadenopathy
eye changes
dentition
nasal perforation (lubricate NG, can even use lidocaine lube for nasal intubation to decrease laryngospasm)
malnourished
```
80
What drugs can trigger intermittent acute porphyria
Barbs
| etomidate
81
BMI chart
small <18.5
normal 18.5 -24.9
Overweight 25 - 29.9
Obese class 1 30 - 34.9
Obese class 2 35 - 39.9
Obese class 3 (morbid) >40
82
What happens to oxyheme when pt is apenic during intubaton and O2 sats drop below 90%?
Their PO2 sats drop even more dramatically. Can get to 70 within moments
83
What happens to PaCO2 values during apnea?
Increase by 6 mm Hg for 1st min of apnea
then 3-4 mm HG each additional
84
When it comes to intubation what do we worry about with obese pt and O2 sat?
Their SPO2 drop faster than average so definitely denitrogenate them to close to 100% sat
85
What does denitrogenation accomplish?
-bring pt sat to as close to 100%
-denitrogenate residual capacity of lungs to make room
for oxygen
-denitrogenate and maximally oxygenate bloodstream
-replaces nitrogen volume of lung with O2 to provide a resivoir for diffusion into the alveolar capillary blood after the onset of apnea
86
Functional residual capacity of 2.5L does what for pt during intubation?
Gives pt more time for intubation. It is the amount of air left in lungs after expiration
87
How much O2 are we applying during mask ventilation?
100%
88
Quantitatiev measurements of adequate preoxygenation
1. Fogging face mask
2. Movement of reservoir bag
3. Capnography
4. Increasing O2 sats
5. Expired O2 concentration nears inspired O2 concentration (a good # is 86)
89
What does the slow technique for mask ventilating look like?
THREE MINUTES
-Tidal volume breathing for 3 min
- if flows are 5L/min lung denitrogenation is 95% after 3 min
- Most pt in clinical practice are at 100% with this slow technique
90
Vital capacity equation
Inspiratory reserve volume + Expiratory reserve volume + Tidal volume
91
Vital capacity breath define
The amount of air pt can expire after a max exhilation.
| Pt needs to be awake and alert to do this for you
92
What does the fast technique of mask ventilating look like?
Either:
- 4 vital capacity breathes at FIO2 of 100% over 30-sec
or
- modified vital capacity breathing 8 deep breathes for 60-sec period
93
What is the BImanual Larynngoscopy technique?
We us the force on the neck which is opposite the direction of the the lift by the laryngoscope
CRNA reaches around with right hand and manipulates the larynx while observing for effect of laryngeal view and the assistant takes over and maintains pressure at this location.
94
BURP technique and how much does it lower the incidence of intubation failure?
Backward upward right pressure
Posterior displacement of the larynx by putting backward pressure on the thyroid or cricoids cartilage, 2 cm cephalic direction and displaced 0.5-2.0 cm to the right.
Lowers failed intubation from 10% to 2%
95
During RSI discuss Cricoid pressure
Cricoid pressure/Sellick maneuver
- apply pressure before pt loses consciousness
- keep pressure till intubation
- pressure before LOC is 20 newtons or @ least 2 kg
- pressure after LOC is 40 newtons or @ least 4 kg
ALL to bock glottis and reduce aspiration risk
96
What are the complications of placing cricoid pressure?
- Esophageal rupture if pt actively vomiting
- Airway obstruction
- Impaired glottic visualization
- Difficult laryngoscopy
- Difficult intubation
97
How to perform Larson's maneuver and why
apply firm pressure 3-5 seconds to the laryngospasm notch located behind the earlobe to relieve active laryngospasm. If no relief wait 5-10 seconds to reapply pressure.
98
What are the goals of the Larson's Maneuver?
Displaces the mandible anteriorly to help open the airway
Breaks laryngospasm by causing the light anesthetized patient to sigh
99
What kinds of patients might we perform awake intubations on?
Pt with hx of CA or Neck issues??? LOOK AT VIDEO FOR THIS
100
What 3 meds/interventions required for awake intubation?
Premedication and sedation
Topicalization
Airway blocks (Nerve Blocks)
101
What are the Premedication and sedation for awake intubation
Antisialagogues
Nasal Mucosal vasoconstrictors
Apsiration prophylaxis agents
Sedatives/hypnotics
102
What types of drugs are Antisialogogues, which ones are they, what do they do, and when to administer?
for awake intubation
Anticholinergics
30 min prior to topicalization
Used to decrease bronchial and oral secretions
Atropine. Tachy (+++) antisial..effect (++) sedation (+)
Glycop. Tachy (++) antisial..effect (+++) sedation (0)
Scolpal. Tachy (+) antisial..effect (+++) sedation (+++)
atropine tertiary amine
glyco quartinary amine
Scolpal tertiary amine
103
Nasal Mucosal vasoconstrictors, why we use them and which ones do we use?
for awake intubation
To decrease visualization problems
To decrease laryngospasm
Blood is a foreign body
Cocaine & phenylephrine (neo)
104
Aspiration Prophylaxis during awake intubation
H2 receptor blockers to decrease gastric fluid and H+ secretion of pareital cells
PPIs rarely, not as effective as H2
Metoclopramide (Reglan) Dopamine receptor antag but can exacerbate extrapyramidal effects.
105
Sedatives/hypnotics for awake intubation
```
Benzodiazepines
Opioids
IV anesthetics
-Dex
-prop
```
106
Topicalization drugs for awake intubation
Lidocaine and cocaine
The bottom 2 can cause methemoglobinemia
Benzococaine
Cetacaine
107
What does methemoglobinemia do to oxyheme curve
| and what is the reversal?
left shift
methylene blue is reversal
108
What are the application techniques for topical drugs for awake intubation?
Atomizer
Nebulizer
"Spray-As-You-Go"
109
What are the airway blocking areas?
Nasal cavity & nasopharynx
Oropharynx
Larynx
Trachea and vocal cords
110
What are the airway blocking areas we need to know for awake intubation?
Nasal cavity & nasopharynx
Oropharynx
Larynx
Trachea and vocal cords
111
What are the 12 CN?
On occasion our trusty truck acts funny...very good vehicle any how
olfactory optic oculomotor trochlear trigeminal abduscens
facial vestibulocochlear glossopharyngeal vagus accessory hypoglossal
112
HOTSPOT
Where is the sensory innervation for the nasal cavity and nasopharynx?
SLIDE 29 AIRWAY 3S
VIDEO on this too
@ sphenopalatine ganglion (Meckel's ganglion) and teh anterior ethmoidal nerve
113
What are the 3 branches of the trigeminal nerve and which do we want to target?
VIDEO
```
V1 optic
V2 maxillary (target this one)
V3 Mandibular (this is sensory and motor)
```
114
What are the 3 branches of the trigeminal nerve and which do we want to target for awake intubation?
VIDEO
```
V1 optic
V2 maxillary (target this one)
V3 Mandibular (this is sensory and motor)
```
115
2 ways to perform Sphenopalatine nerve block for awake intubation
HOTSPOT
Slide 30 Airway 3S
#1 Use long cotton-tipped applicators soaked in either cocaine or lidocaine with epi over the muscosal surface overlying the ganglion
(common practice)
#2 Use a long plastic 20-G angiocatheter placed along the same path as #1 and squirt 4 mL of lidocain/phenelephrine rapidly and 2 min later anesthetic should take effect
116
How can we minimize gag reflex stimulation?
Pt breathe in a nonstop panting fashion
117
How can we minimize gag reflex stimulation?
Awake intubation
Pt breathe in a nonstop panting fashion
Avoid pressure on base of the tongue
Administer opioids
Perform blockade of the glossopharangeal nerve (GPN)
118
How to perform glossopharyngeal nerve block for awake intubation?
HOTSPOT SLIDE 34 Airway 3S
The classic intraoral approach to GPN block must block LA at the base of the posterior tonsillar pillar (palatopharyngeall fold). We have 2 folds so numb both
OR
Use anisthetic toothpase and create a popsicle with gauze and tongue blade and have pt suck on it
119
What is a complication of these oral and nasal blocks?
intra-arterial injection could result in headach or sz
hypopharyngeal swelling and mucosal bleeding may occur
tachycardia may also result from blockade of the afferent nerve fibers of the GPN that arise from the carotid sinus
120
What nerve do we block to block Larynx and what other anatomy within it?
Superior laryngeal nerve (SLN) blocks:
Hypopharynx
upper glottis
vallecula
epiglottis
121
What nerve do we block to block Larynx and what other anatomy within it?
Superior laryngeal nerve (SLN) blocks:
Hypopharynx
upper glottis
vallecula
epiglottis
122
What are the bones that can be palpated for SLN block?
The greater cornu of the hyoid is the most lateral aspect of the bone that can be palpated and is most common
The cornu of thyroid is the other landmark but less likely used
123
What is the SLN block technique?
Plece needle below the cornu of hyoid bone, and should feel a slight resistance through membrane
Needle is the entering the pre-epiglottic space
Aspirate and if air is aspirated then needle has gone too far and we are in pharynx, so w/d till no air can be aspirated
If blood aspirated then needlehas cannulated superior laryngeal artery or vein or carotid artery and needle should be directed more anteriorly
124
What are the complications of SLN block?
Laryngeal edema & airway obstruction from insertion of needle into thyroid cartilage and accidentally placing LA at vocal cords
Accidental IV injection into carotid should be avoid by displacing it posteriorly
125
What are CV complications of SLN block?
Hypotension and bradycardia possibly due to:
- vasovagal reaction related to painful stimulation
- digital pressure on the carotid sinus
- too much manipulation of larynx = vasovagal reaction
- accidental IV administration of LA in carotid
- direct neural stimulation of the branch of vagus nerve by needle
- USE ANTICHOLINERGICS BEFORE BLOCKING PERFORMED
126
Which nerve innervates trachea and vocal cords?
Right recurrent laryngeal nerve (RLN) which has both sensory and motor fibers
127
What is a complication of blocking RLN?
If we block the motor fiber which is on the side of the neck rather than the middle the trachea won't move and pt will have stridor
128
What is a complication of blocking RLN?
If we block the motor fiber which is on the side of the neck rather than the middle the trachea won't move and pt will have stridor
129
How to get to Translaryngeal (Transtracheal)
Positioning and landmarks
-supine with neck extension
- thyroid cartilage (Adam's apple) is palpated at midline and followed caudally until a depression and firm ring of tissue are identified
- these are the cricothyroid groove and cricoid cartilage, respectively
- Overlying the cricoid groove is the cricothyroid membraine
130
T/F pt coughing during transtracheal block is good?
True, because it will spread the anisthetic
131
What are the complications of translaryngeal (transtracheal) block
HOTSPOT side 48 Airway 3s
laryngeal trauma so tip of needle should never be aimed in a cephalad direction and to ensure spread of LA below vocal cords
cough may increase HR, MAP, ICP, and intraocular pressure so contraindicated in pt with elevated ICP or open globe and careful with pt with significant CV dz
132
What are the complications of translaryngeal (transtracheal) block
HOTSPOT side 48 Airway 3s
laryngeal trauma so tip of needle should never be aimed in a cephalad direction and to ensure spread of LA below vocal cords
cough may increase HR, MAP, ICP, and intraocular pressure so contraindicated in pt with elevated ICP or open globe and careful with pt with significant CV dz
133
T/F blood pressure regulation to decrease is positive feedback
False: negative
and it is positive feedback when working the other direction to try and increase BP
134
Explain the baroreceptor feedback loop for a elevated BP
Arterial BP is elevated, mechanoreceptors in aortic arch (vagus nerve) and carotid (glosopharyngeal but Hering's nerve within it) sense this and send sensory afferent signals to brainstem. Brain then sends efferent signals through vagus nerve (increase action potentials) and sympathetic nerves to (decrease action potentials).
Vagus nerve will decrease HR thus decreasing CO
Sympathetic nerves stimulate:
(1) Heart to decrease contractility which decreases SV &
CO
(2) Veins to vasodilate to decrease CO by decrease
venous return
(3) Arteries to decrease svr to decrease afterload
135
Premeds for Periop
```
BZP/Alpha-2 agonists
Pain control
antisialogoues
aspiration precautions
attenuation of SNS responses
ABX (SCIP says so)
```
136
Precautions or things to think about before deciding to give BZP preoperatively
Chronic users require larger doses
Decrease or omit in elderly w/OSA or those with neurological impairment (ask your CRNAs what they do)
137
What are the alpha 2 agonists and what is one of them sometimes used for?
Clonidine
| Dexmedetomidine - sometimes given preoperatively to extend the effect of regional anesthesia
138
Antisialogogue uses
decrease salivary, bronchial, and GI secretions
139
What is a one of the top 3 causes of death in anesthesia?
Aspiration
140
Aspiration percentages assoiciated with anesthesia
```
Induction 42%
Mainenance 18%
Emergence/PACU 11%
Obstetrical-related 21%
Difficult intubation 13%
Cricoid pressure 11%
History of reflux 3%
```
141
Which patients do we worry about aspiration most?
```
Pregnant
morbid obese
significant GERD
"full stomach"
diabetics with gastroparesis (type 1)
```
142
What drugs to give for aspiration precautions
H2 antagonists (rantidine, famotidine) block histamine release from parietal cells and decrease acid fluid and volume
Nonparticulate antacids sodium citrate increase pH
Prokinetics (metoclopramide) stimulate gastric emptying
143
If we think pt might aspirate what can we do if it isn't an emergency?
Perform awake intubation
144
How to attenuate SNS during laryngoscopy
```
Opiods (blunt sympathetic response)
Beta blockers (tachycardia)
```
Usually the upper 2 cause precedex expensive
Alpha-2 agonists
145
What is the name of the group that coordinates with joint commision and CMS national initiative-2003 that has 9 core measures?
SCIP (surgical care improvement project)
they say things like give abx before we cut
146
What are some things we want to alleviate post-op?
Pain control
PONV
shivering
147
How can we deal with post-op pain control
```
Epidural or intrathecal opioids
PCA
Regional anesthesia (continuous nerve block cath)
```
148
Increased risk of PONV are
(especially) Young fat menstruating females
Prior PONV or easy motion sickness
nonsmokers
149
What are the anesthetics associated with PONV and how can we decrease rates?
GA
Increased duration of anesthesia
Intraop use of opioids
Use of nitrous
To reduce risk TIVA (total IV anesthesia) which means to use propofol
150
What are the surgical characteristics that increase risk of PONV?
```
Laproscopic procedure
Gynecologic procedure
Opthalmologic procedures (strabismus - cross-eyed)
Ear and nasal procedures
Shoulder surgery
```
151
Drug prophylaxis for PONV
```
serotonin antagonists ("setron"s)
-inhibit 5-HT3 receptors in the CTZ (chemoreceptor zone)
```
anti-histamines
- inhibition of H1 receptors in the CTZ
- also produce sedation
anticholinergics (scolpalomine patch)
-inhibit M1 and H1 receptors in hypothalamus and CTZ
-also produce sedation
-1.5 mg Patch at postauricular area
SE- dry mouth, drowsy, blurred vision, sedation,
midriasis
Butyrophenones (droperidol, metoclopramide)
-droperidol blocks dopamine receptors in CTZ
-droperidol can prolong QT interval and increase sedation
-metoclopramide promotes gastric motility, blocks dopamin
receptors in the CTZ and possesses weak antagonist properties for 5-HT3
EXTRAPYRAMIDAL FOR BOTH
Phenothiazines (promethazine)
- block dopamine receptors in CTZ
- sedation and extrapyramidal
Steroids
- MOA not known, may inhibit prostaglandin or release endorphins
- most effective when administered prior to induction of anesthesia (give when pt asleep, perineal burning)
152
How to decrease post-op shivering and what meds can increase it
Warming IV meds
Meperidine
Volatile agents lower the threshold for shivering
153
What does shivering cause?
Heat production
increases O2 demand and CO2 production
Poorly tolerated in patients with marginal CV and pulmonary reserve
154
What does NPO stand for?
Nil Per Os
155
6 guidelines for NPO status
1. No solid food or nonlcears 6-8 hrs preop
2. Meds can be taken with small H2O 2 hrs preop
3. small amount of clear liquid up to 2 hrs preop
(black coffee ok)
4. In practice tell pt nothing after midnight and take
am meds preop
5. Kids:
no food 8 hrs
formula 6 hrs
breast milk 4 hrs
clears 2 hrs
6. Gum increases gastric emptying and motility and may
increase volume/acidity? Check with hospital about gum
policy some say 4 hrs some say 2 hrs
156
Examples of clear liquids
```
water
fruit juice without pulp
carbonated bevs
clear tea
black coffee
```
157
Example of light meal
dry toast and clear liquid
158
ASA fasting guidelines
Clear liquids 2 hrs
Breast milk 4 hrs
Infant formula 6 hrs
Non-human milk 6 hrs
light meal 6 hrs
159
How long before us SRNAs are considered advance airway beginners?
Upgrade from novice in a couple months
160
What anatomy is considered upper airway?
What is considered lower?
Nose
Pharynx
Larynx
Trachea
161
Hotspots Airway 1a SC
Slide 5 Nose, 6 Mouth, 7 Pharynx, 11 Bone of larynx, 12 Cartilage of larynx, 15 & 16 Epiglottis
162
What CN motorly innervates tongue?
XII hypoglossal
163
What are the tongue divisions, their innervations, and jobs
Tongue is 2/3 anterior
-pain, touch, pressure, and temp via CN V (trigeminal and
its the lingual portion of V3)
-taste via VII (facial)
1/3 posterior
- taste and general sensation via CN IX (glossopharyngeal)
- middle portion of the root is CN X
164
Where is the pharynx located?
Base of the skull to the level of the cricoid cartilage anteriorly and inferior border of C6 posteriorly
165
What are the 3 portions of pharynx and who innervates them?
Nasopharynx
-IX and small anterior portion V
Oropharynx
-IX and X (middle portion of the root of the tongue)
Larryngopharynx (hypopharynx)
-IX and X
166
What are the muscles and motor innervations of the pharynx?
Stylopharyngeus muscle CN IX
| Other pharyngeal muscles CN X
167
Describe the larynx, its location, and function
Voice box
Watchdog of the respiratory box
Protects lower airway from stomach particles
C3-C6
Last segment of the upper airway
made of bone and cartilage
168
Which part of the airway is most narrow for peds? For adults?
Peds: cricoid cartilage
Adults: true vocal cords
169
Sensory/Motor innervations of the larynx
2 branches of the vagus nerve: superior and recurrent
| laryngeal nerves
170
Describe the eipiglottis
Leaf-shaped crtilage behind the root of the tongue and the valleculae is the site of the MAC blade
171
Names for Atlanto-Occipital Joint mobilitiy
1. Head and neck mobility
2. Sniffing position
3. Magill's position
172
How to perform Sniff position check``
1. range of motion from full extension (atlanto-occipital head to neck) to full flexion (cervical moves chin towards chest)
2. Side to side neck
173
What are the 3 axis and which 2 are parallel to one another when pt correctly aligned in sniff position?
Oral axis
| parallel
Pharyngeal axis
Laryngeal axis
174
How is the sniff position performed?
Flex cervical spine over the trunk by means of a small pillow placed under the head and extending the head over the neck
175
Slides In Airway 2SC
4-8 sniff position,
176
Neck circumference, discuss
short and thick, no bueno
greater than 40 cm or 15.74 inches
BMI => 40 kg/m2
177
Tough to intubate with what kinds of teeth?
Long upper incisor/predominate overbite is really hard with mac but also hard with miller
178
Facial hair issues
Mask ventilation
| may hide physical signs of difficult airway (thyrometal distance)
179
Whats up with prayer sign?
Difficult airway is 10X higher in 30-40% type 1 DM pt 2/2 limited joint mobility (atlanto-occipital)
Glycosylation of tissue proteins occur with chronic hyperglycemia
180
What does prayer sign look like?
Pt unable to straighten interphalaneal joints of the fourth and fifth fingers
181
LEMON
also has a slide 16 and 17 on Airway 2SC
Look
-externally for facial trauma large incisors beard
moustache large tongue
Evaluate
- the 3-3-2 rule
incisor distance 3 finger breadths
hyoid-mental distance 3 finger breadths
thyroid-to-mouth distance 2 finger breadths
Mallampati
-score >3
Obstruction
-presence of anything like epiglottitis, peritonsillar abscess
trauma
-if so will need to perform awake intubation
Neck mobility
-limited
182
The Cormack-Lehane Classification
also has a slide 20 Airway 2SC
Describes laryngeal view during direct laryngoscopy
Grade 1 can see all/almost all of the glottic opening
Grade 2 see posterior region of glottic opening
-cannot see anterior commissure
Grade 3 Epiglottis only
-cannot see part of the glottic opening
Grade 4 Soft palate only
-cannot see any part of larynx
183
Which grades of Cormack-Lehane classification are easy, hard, or require alternative approach to intubation?
1 & 2 easier
3 harder
4 requires alternative approach
184
Misc patient features that make for difficult intubation
Short neck
| History of radiation
185
Acronym for difficult mask ventilation
BOOTS
```
Beard
Obese >26 BMI
Old >55
Toothless
Snoring
```
186
2 questions to ask before any airway management
1. Can I ventilate this patient?
Risk factors: BOOTS
2. Can I intubate this patient?
Risk factors: All airway assessments performed
187
2 questions to ask before any airway management
3. Can I use supraglottic airway (LMA)?
a. Risk factors for supraglottic device placement
- Limited mouth opening
- Upper airway obstruction
- Altered pharyngeal anatomy which can prevent an adequate seal for the device
- poor lung compliance requiring excessive peak inspiratory pressure
- increased airway resistance requiring excessive PIP
4. Can I place an invasive airway?
a. Risk factors for invasive airway
- Abnormal neck anatomy (tumor, hematoma, abscess, history of radiation
- Obesity (difficulty identifying cricothyroid membrane)
- Short neck (difficulty identifying cricothyroid membrane)
- Laryngeal trauma
- Limited access to cricothyroid membrane (halo, neck flexion deformity)
188
Why do we perform an airway assessment?
To prevent anesthesia disaster
Review available anesthesia records
Ask pertinent questions
assessment tools used concomitantly (together, lol)
189
What are the 9 tools or features we look for when assessing airway?
```
Mallampati
Thyromental distance
Mouth opening
Head and neck mobility
Neck circumference
Teeth
Facial hair
Prayer sign
LEMON
```
More tools you use the better you can make decisions about approach for airway
190
Number of risk factors and their corresponding incidence of difficult intubation
0 0%
1 2%
3 4%
4 or 5 17%
191
What does the Mallampati score do?
Assess relationship between tongue size and oral cavity
192
The 4 structures for Mallampati Score
PUSH
1. tonsilar Pillars
2. uvula
3. soft palate
4. hard palate
193
Is the Mallampati a great predictor of difficult airway?
Not at all, but when combined with other tools it helps
194
How to position patient for Mallampati
```
Sit upright
extend the neck
Open the mouth wide
Stick out the tongue
No phonate
```
195
What does Thyromental distance tell us?
Wether we have a good glottic opening
estimates the size of the submandiblar space
196
How do we measure thyromental distance and what do the numbers tell us?
Slide 11 airway 1bsc has pic of this
straight line from tip of mentum (chin) to thyroid-notch in neck-extended position with pt mouth closed
6 (3 finger-breadths) to 9 cm is easy intubation
197
Thyromnental distance less than 6 cm
Mandibular hypoplasia
| small mandibular space
198
Thyromental distance more than 9 cm
- Larynx assumes caudal position
- Because the tongue is fixed at the hyoid bone, the tongue moves caudally as well
- These changes shift the glottic opening beyond the line of site, increasing difficulty of laryngoscopy
199
Where does the tongue go during direct laryngoscopy?
The submandibular space to expose the glottic opening
200
What happens if the thyromental distance is no bueno?
The tongue may not be displaced during direct laryngoscopy and glottic opening will not be exposed
201
What are the borders of the submandibular space?
Superior border - Mentum (chin)
Inferior border - hyoid bone
Lateral border- either side of the neck
202
How to perform the Mandibular protrusion test and the 3 classes
AKA Upper lip bite test
Pt sublux the jaw (move lower portion forward)
Class 1: pt can move Lower insicor past upper and bite the vermilion of the lip (where lip meets the facial skin)
Class 2: Pt can move LI in line with UI
Class 3: Pt cannot move LI past UI (increases risk of difficult intubation)
203
Mouth opening test
Checking for interincisor distance with mouth fully open
if mouth opening >3 fingers/6 cm there is enough room for laryngoscope or LMA
204
What are some family history that could mess with anesthesia?
Atypical plasma cholinesterase
MH
Intermittent acute porphyria (triggers are barbs & etomidate)
205
Lab testing preoperative
1. Intermediate-risk test pt >64 or with medical comorbs
2. high-risk surgery
- CBC and chem
- type/screen or type/cross
LFT's and coags are based on co-morbidities
3. Routine pregnancy testing not required for premenopausal women but careful history regarding possible pregnancy is required and pregnancy test performed if indicated by hx
206
When are results of previous tests good to use?
within past 6 months as long as pt medical condition hasn't changed significantly (MI, CA)
207
Preoperative CXR when?
- Pt with known major respiratory condition (COPD) -------- -
- sympotms of a respiratory condition
- CHF
- malignancy
- hx of acute reps illness within the past 6 months
- pt undergoing cardiothoracic surgery
208
PFT's when?
only if pt has severe COPD, SOB, orthopnea and will be undergoing a long surgery or intrathoracic surgery
209
Urinalysis when?
Pt with sx of UTI or undergoing genitourologic procedures
OR
undergoing hip or knee surgery
Protein in urine = infection
210
EKG when?
Baseline EKG for male > 40
Female >50
younger pt clinical sx or signs of heart disease
pt having cardiothoracic surgery
211
Questions to ask pt to assess cardiac risks
"Are you able to walk up a flight of stairs? Can you carry groceries down the block?"
we ask to reduce perioperative MI
212
6 things that can be preop issues for anesthetic plan
1. Length of surgery procedure
2. Potential for blood loss/hemodynamic instability (A-line)
3. Positioning (if we are proning def intubate, no LMA)
4. Airway anatomy
5. Anticipated postsrugical pain (regional might be good)
6. Requirement for NMBD
7. Hx of PONV
213
Types of anesthesia
```
General
MAC (Monitored anesthesia care)
Regional
-spinal
-epidural
-peripheral nerve blocks
```
214
Anesthesia risks
Risks have declined over time
data from retrospective studies
ASA classification is predictor of complications of anesthe
215
ASA classification is used for?
Scoring system to assess fitness of pt who will recieve anesthesia and surgery but not intended to predict operative risks
216
(American society of anesthesiologists) ASA classification is used for?
Scoring system to assess fitness of pt who will recieve anesthesia and surgery but not intended to predict operative risks
217
7 Causes of death related to anesthesia
```
#1 Equipment fx
#2 Intubation complication
#3 Pulmonary aspiration of gastric contents
#4 Postoperative resp depression
#5 Anaphylactic shock
#6 MI
#7 Med error
```
218
What can Neostygmine cause and how can we try and ameliorate this?
Bradycardia, give atropine or glycopyrrolate
219
Common complications of anesthesia
PONV
waking up in pain
Post-operative sore throat
Confusion/Groggy upon waking (elderly esp delirium)
220
What are some invasive monitors we might place?
IV
A-line
CVP
PA catheter
221
ASA II
pt with mild systemic dz
- current smoker
- social etoh'r
- pregnant
- obese
- well controlled DM/HTN
- mild lung dz
222
ASA III
pt with severe systemic dz
- substantial functional limits
- one or more moderate to sever dz
- poor control DM, HTN, COPD, morbid obese, active hepatitis, etoh dependance or abuse, implanted pacemaker, moderate reduced EF, ESRD recieving regular dialysis, premature infant PCA <60 wk, hx (>3 mo)of MI, CVA, TIA, or CAD/stents
223
ASA IV
pt with severe systemic dz that is constant threat to life
-recent (<3 mo) MI, CVA, TIA, or CAD/Stents, ongoing cardiac ischemia, or severe valve dysfunction; severe reduction of ejection fraction; sepsis; DIC; ARD (acid reflux dz); ESRD not getting dialysis regularly
224
ASA IV
pt with severe systemic dz that is constant threat to life
-recent (<3 mo) MI, CVA, TIA, or CAD/Stents, ongoing cardiac ischemia, or severe valve dysfunction; severe reduction of ejection fraction; sepsis; DIC; ARD (acid reflux dz); ESRD not getting dialysis regularly
225
ASA V
pt that will probably die
-ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemia bowel in the face of significant cardiac pathology or multiple organ/system dysfunction.
226
ASA VI
brain dead declared whose organs are being removed for donation
227
ASA when we add an E means?
Emergency, so class IVE and so on....no such thing as class VIE tho
228
What ASA class are most of our patients going to be?
ASA II or more
229
Where is the laryngospasm notch
DRAWING SLIDE 12 in AIRWAT 3SC
1. Behind the lobule of the pinna of each ear
2. Anteriorly bounded by the ascending ramus of the mandible adjacent to the condyle
3. Posteriorly by the mastoid process
4. cephalad by the base of the skull and external auditory canal
230
Things that shift Oxyheme curve to the right
```
MOPS
Maternal Heme
Sickle cell
Opiods
P50 (increase)
```
Increase:
- 2,3 DPG
- Temp
- PCO2
Decrease pH
231
Things that shift Oxyheme cure to the left
Carboxyhemeglobin
Fetal heme
Methemoglobin
Smoking
Decrease:
- 2,3 DPG
- Temp
- PCO2
Increase pH
