Exam 1 Flashcards
(413 cards)
1
Q
Echinacea (purple coneflower root)
A
Pharmacologic: Activation of cell mediated immunity. Periop Concerns: allergic reaction, decreased immunosuppressant effects, poss. immunosuppression with longterm use
2
Q
Ephedra (mahuang)
A
Pharmacologic: Directly/indirectly Increases heart rate and blood pressure Periop Concerns: Ischemia, Arhythmias, depleted catecholamines, interacts with MAOI D/C: 24 hours prior
3
Q
Garlic (ajo)
A
Pharmacodynamics: Inhibits platelet aggregation, increases fibrinolysis, antihypertensive activity D/C: 7 days prior
4
Q
Ginger
A
Pharmacodynamics: Anti-emetic, antiplatelet aggregation
5
Q
Ginkgo (duck-foot tree, silver apricot)
A
Pharmacodynamics: Inhibits platelet activating factor D/C: 36 hours prior
6
Q
Ginseng
A
Pharmacodynamics: Lowers blood sugar, inhibits platelet aggregation, increased PT/PTT in animals Periop Concerns: May decrease anticoagulant effect of warfarin D/C: 7 days prior
7
Q
Green tea
A
Pharmacodynamics: Inhibits platelet aggregation and thromboxane A2 formation Periop Concerns: May decrease anticoagulant effect of warfarin D/C: 7 days prior
8
Q
Kava (awa, intoxicating pepper, kawa)
A
Pharmacodynamics: sedation and anxiolysis Periop Concerns: May increase anesthetic effect, long term use increases anesthetic requirement D/C: 24 hours prior
9
Q
Saw palmetto (dwarf palm)
A
Pharmacodynamics: Inhibits 5 alpha reductase (responsible for turning testosterone into DHT) and cyclooxygenase
10
Q
St. John’s Wart (goat weed, hardhat, amber)
A
Pharmacodynamics: Inhibits neurotransmitter reuptake, MAO inhibition unlikely Periop Concerns: Decrease serum dig levels, delays emergence, induction CP450 D/C: 5 Days
11
Q
Valerian (vandal root, all heart, garden heliotrope)
A
Pharmacodynamics: Sedation Periop Concerns: Increase anesthetic effect, acute benzo-like withdrawal, long term use increases anesthetic requirements
12
Q
Anesthesia considerations for ACE inhibitors (-pril) Intraop concerns, management and D/C issues
A
Intraop Concerns: Intolerance of hypovolemia, hypotension Management: Optimize hydration and moderate doses of vasporessors D/C issues: Brief interruption tolerated well, may improve regional blood flow and oxygen delivery and preserve renal function, HOLD am dose day of surgery
13
Q
Anesthesia considerations for beta blockers (-lol) Intraop concerns, management and D/C issues
A
Intraop Concerns: D/C may increase cardiovascular morbidity and develop of withdrawal symptoms Management: Hydration D/C issues: Should be continued on day of surgery
14
Q
Anesthesia considerations for Calcium channel blockers Intraop concerns, management and D/C issues
A
Intraop concerns: Decrease. SVR and BP d/t peripheral vasodilation; Neg. into and chronotropic effects Management: Hydration and phenylephrine as needed to maintain atrial pressure D/C issues: Caution in patients with left ventricular dysfunction shown by EF <40%
15
Q
Anesthesia considerations for diuretics Intraop concerns, management and D/C issues
A
Intraop concerns: hypokalemia and hypovolemia Management: Preop potassium levels, hydration D/C issues: Pts rarely show issues with holding morning dose, might be desirable to continue if part of tx for chronic renal failure
16
Q
Anesthesia considerations for antiarrythmics Intraop concerns, management and D/C issues
A
Intraop concerns: Cardiac depression, prolonged neuromuscular blockade Management: Serum drug levels as needed, if on amio may need vasopressor, inotropes and pacemaker capability D/C issues: Rarely recommended to stop meds, withhold concurrent medications such as ACE-i
17
Q
Anesthesia considerations for NSAIDS and anti platelet drugs Intraop concerns and D/C issues
A
Intraop concerns: impaired plt function, altered renal function, GI bleed D/C issues: Antiplatlet drugs such as aspirin, clopidogrel, ticlodipine should be d/c 7-10 days prior, NSAIDS can be continued the day of unless risk of bleeding is high
18
Q
Anesthesia considerations for anticoagulants (heparin, coumadin, LMWH) Intraop concerns, management and D/C issues
A
Intraop concerns: Increased hemorrhage Management: Reverse heparin w/ protamine, revers coumadin with vitamin k or FFP D/C issues: Heparin IV 6 hours prior and check PTT, Coumadin 3-5 days prior, 5 if INR <1.5 needed, LMWH 12 hours prior to surgery
19
Q
Anesthesia considerations for fibrinolytic (streptokinase, TPA, urokinase) Intraop concerns, management and D/C issues
A
Intraop concerns: Hemorrhage Management: Antifibrinolytics (aprotinin) may be indicated D/C issues: usually not an option
20
Q
Anesthesia considerations for oral hypoglycemic agents Intraop concerns, management and D/C issues
A
Intraop concerns: Hyperglycemia/hypoglycemia Management: Avoid dehydration and monitor serum glucose D/C issues: Withhold oral agents the day of surgery
21
Q
Anesthesia considerations for MOAI’s Intraop concerns, management and D/C issues
A
Intraop concerns: Hypertension secondary to norepinephrine release; meperidine causes excitatory state or depressive phenomena secondary to opioids Management: Avoid triggering agents such as meperidine, pentazocine, dextromethorphan and indirect sympathomimetics D/C issues: Irreversible MAOI’s 2 weeks prior w/ high risk of serious psychiatric consequences, reversible can be continued up to the day of surgery
22
Q
Anesthesia considerations for TCA’s Intraop concerns, management and D/C issues
A
Intraop concerns: alpha blocking activity and potential to block norepinephrine reuptake potential for cardiac issues, lowers seizure threshold Management: norepinephrine should be considered the vasopressor of choice D/C issues: gradually over 2 weeks prior to surgery, obtain baseline ECG
23
Q
Anesthesia considerations for Lithium Intraop concerns, management and D/C issues
A
Intraop concerns: Ventricular arryhthmias, atropine-resistant sinus brady, dehydration increases lithium levels Management: Hydration D/C issues: 72 hours prior to surgery
24
Q
Neuraxial Anesthesia guidelines for LMWH (exonaparin, dalteparin, tinzaparin) When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
A
Before procedure: 24 hours, check anti factor Xa in elderly/renal insufficient Restart after procedure: 24-72 hours Before catheter removal: Should be removed before intiation of LMWH Restart after catheter removal: 4 hours prior to first post dose and at least 24 hours post neuraxial procedure Additional: Wait >24 hours after bloody tap to restart Half-life: 4-7 hours
25
Neuraxial Anesthesia guidelines for Fondaparinux (Arixtra) When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: Regional - no recommendation, Pain - 4 days (5 half lives) Avoid restarting the medication while catheter is in place Restart after catheter removal: 6 hours Additional info: Longer hold time in patients with renal impairment (CrCl \<50-30 ml/min); Contraindicated in CrCl \<30 or child-pugh C hepatic failure Half-life: 17-21 hours
26
Neuraxial Anesthesia guidelines for Factor Xa-inhibtors (edoxaban, rivaroxaban, apixaban) When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: 72 hours Restart after procedure: At least 6 hours, avoid while catheter is in place Before cather removal: 20-30 hours depending on med Restart after catheter removal: 6 hours, longer if bloody tap Additional info: same as fondaparinux Half-life: rivaroxaban: 5-9 hours, apixaban: 6-12 hours, edoxaban: 10-14 hours
27
Neuraxial Anesthesia Guidelines for argatroban, a direct thrombin inhibitor When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: avoid Restart after procedure: Avoid while catheter is in place Before catheter removal: 34-36 hours Restart after catheter removal: 2 hours Additional info: 1/2 life in hepatic impairment is 181 min Half-life: 40-50 minutes
28
Neuraxial Anesthesia Guidelines for bivalirudin (angiomax), a direct thrombin inhibitor When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: avoid Restart after procedure: while catheter is in place Before catheter removal: 34-36 hours Restart after catheter removal: 2 hours Additional info: 1/2 life with CrCL \<30ml/min is 57min Half-life: 25 min
29
Neuraxial Anesthesia guidelines for dabigatran (Pradaxa), a direct thrombin inhibitor When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: 5 days Restart after procedure: 6 hours unless catheter is in place then avoid Before catheter removal: 34-36 hours Restart after catheter removal: 6 hours, 24 hours post traumatic puncture Additional info: consider longer hold times in renal impairment Half-life: 8-17 hours
30
Neuraxial guidelines for clopidogrel (plavix) When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 5-7 days Restart after procedure: restart immediately if no loading dose, 6 hours if LD Before catheter removal: 24 hours postop Restart after catheter removal: restart immediately, 6 hours if loading dose Half life: 6 hours
31
Neuraxial guidelines for cilostazol (pletal) When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: 48 hours Restart after procedure: 6 hours unless catheter still in then avoid Before catheter removal: avoid restarting Restart after catheter removal: 6 hours Additional info: consider extending time prior to catheter placement if renal impairment Half-life: 11-13 hours
32
Neuraxial Anesthesia guidelines for Diprydamole/ASA (Aggrenox), an anti platelet drug When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 24 hours Restart after procedure: 6 hours unless catheter in place Before catheter removal: avoid Restart after catheter removal: 24 hours post, immediately post neuraxial procedure, 6 hours if loading dose Half-life: 10-12 hours
33
Neuraxial Anesthesia guidelines for prasugrel (effient), an anti platelet drug When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 7-10 days Restart after procedure: Immediately if no loading dose, avoid if catheter in place Before catheter removal: avoid Restart after catheter removal: same as after procedure Half-life: 2-15 hours
34
Neuraxial Anesthesia guidelines for ticagrelor (brilinta), an anti platelet drug When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 5-7 days Restart after procedure: immediately if no loading dose, avoid if catheter in place Before catheter removal: Avoid Restart after catheter removal: Same as after procedure Half-life: 7 hours
35
Neuraxial Anesthesia guidelines for ticlodipine (ticlid), an anti platelet drug When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 10 days Restart after procedure: Avoid while catheter in place Before catheter removal: 6 hours Restart after catheter removal: 24 hours post, immediately post neuraxial, 6 hours if loading dose Half-life: 13 hours
36
Neuraxial Anesthesia guidelines for cangrelor, an anti platelet drug When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 3 hours Restart after procedure: 8 hours Before catheter removal: Avoid Restart after catheter removal: 8 hours Half-life: 3-6 minutes
37
Neuraxial Anesthesia guidelines for fibrinolytics (streptokinase, alteplase, tenecteplase, reteplase) When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and additional info
Before procedure: 10 days, 48 hours + normal clotting studies including fibrinogen Avoid restarting the medication while catheter in place, if needed then neuro checks Q2 hours Check fibrinogen level before restarting after catheter removal (TPA has the longest half life at 24-46 hours)
38
Neuraxial Anesthesia Guidelines for abciximab (reopro), a GP 2b/3a inhibitor When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal, additional info and half-life
Before procedure: 24-48 hours Avoid restarting the medication while catheter is in place Restarting medication after catheter removal is contraindicated for 4 weeks post op Additional info: receptor bound remain for up to 2 weeks Half-life: 30 minutes
39
Neuraxial Anesthesia Guidelines for eptifibatide (integrellin), a GP 2b/3a inhibitor When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure 4-8 hours Avoid restarting medication while catheter is in place Restarting medication after catheter removal is contraindicated for 4 weeks post op Half-life: 2.5 hours
40
Neuraxial Anesthesia guidelines for tirofiban (aggrasta), a GP 2b/3a inhibitor When to hold before procedure/catheter removal, when to restart med after procedure/catheter removal and half-life
Before procedure: 4-8 hours Avoid restarting medication while catheter is in place Restarting medication after catheter removal is contraindicated for 4 weeks post op Half-life: 2 hours
41
ASA 1
A normal healthy patient Healthy, non-smoking, no/minimal alcohol use
42
ASA II
mild systemic disease without substantial functional limitations: current smoker, social alcohol drinker, preggo, obesity, controlled HTN/DM, mild lung disease
43
ASA III
severe systemic disease with 1+ of: poorly controlled DM/HTN/COPD/Morbid Obesity, active hepatitis, ETOH abuse/dependency, pacemaker, reduced EF, ESRD (regular HD), premie or age \<60 weeks \>3months of: MI, CVA, TIA, CAD/stents
44
ASA IV
severe systemic disease w/constant threat to life: \<3months: MI, CVA, TIA, CAD/stents ongoing cardiac ischemia or severe valve dysfunction severely reduced EF; sepsis/DIC/ARDS/ESRD (no regular HD)
45
ASA V
moribund patient who is not expected to survive without operation: ruptured aneurysm, massive trauma, intracranial bleed w/mass effect, ischemic bowel, MODS or significant cardiac pathology.
46
ASA VI
declared brain dead patient whose organs will be removed for donor purposes.
47
Pack-Year formula
of cigs / 20 x years smoked = PPY (there are 20 ciggies in a pack)
48
NMBD allergen tier list
Rocuronium \> Succinylcholine (anectine) \> Atracurium \> Vecuronium
49
Allergies (most common to least)
Muscle relaxants \> Latex \> Antibiotics (PCN) \> Local Anesthetics (esters \> amides)
50
Oxygen formula constants
Oxygen carrying capacity: 1 g Hgb = 1.34 ml O2 Solubility coefficient of O2 = 0.003 ml O2/100ml
51
Oxygen Saturation formula
(Oxygen combined with Hgb / Oxygen carrying capacity) x 100 1. Find Plasma O2 (PaO2 x solubility coE of O2) 2. Subtract plasma O2 from total O2 content (given) 3. Find O2 carrying capacity: Multiply Hgb (given) x 1.34 4. Divide values "2"/"3" and x100
52
BMI formula
Weight (kg) / Height (m^2) Remember to convert! 1 kg = 2.2 lb 1 cm = 2.54 in.
53
What are 3 key points associated with brachytherapy
1. Seed implantation for prostate cancer 2. Patient will be in the lithotomy position 3. If seeds not successful, patient will need a prostatectomy
54
In what area would we place invasive lines?
Preop setting
55
2 examples of things we look for when reviewing Anesthesia Records?
1. Malignant Hyperthermia 2. Laryngospasm
56
Who should we ask if there is a question about what type or where the surgery is occurring?
The surgeon
57
Other name for succinylcholine?
Anectin
58
Other name for bupivicaine?
Marcaine
59
Major risk associated with Diabetes Mellitus that is relevant to anesthesia?
Aspiration due to slower motility presents an aspiration risk during induction and extubation
60
What are 3 considerations for patients that have asthma?
1. Do they use an inhaler and what is it? 2. When was the last time they used an inhaler? 3. Should we order an inhaler to be used prior to surgery?
61
What should we be aware of with COPD patients? (2 things related to airway)
1. Laryngospasm 2. Post-op respiratory depression
62
What is Pickwickian's Syndrome?
Hypoventilation associated with obesity
63
What is a key sign of spinal headache?
Headache that gets worse with sitting up
64
Treatment for spinal headache?
Caffeine, laying down, or blood patch
65
5 Major anesthesia complications
1. Spinal headache 2. Malignant Hyperthermia 3. Difficulty waking uo 4. Difficult airway 5. Awareness
66
When considering a patients blood pressure, what should we look at?
Check patients health history to get a good idea of their baseline blood pressure as we want it to be 10-15% from that baseline during surgery
67
What reading is classified as uncontrolled hypertension?
Two or more readings greater than 140
68
If your patient shows with a SBP \>200 or DBP \> 115, what is this indicative of and what should be done in regards to the procedure?
This is indicative of malignant hypertension and the procedure should be delayed until a cardiac consult is obtained
69
4 diseases associated with unstable cardiac disease?
1. Aortic stenosis 2. New onset Afib 3. New onset SVT 4. Congestive Heart Failure
70
What would a murmur indicate?
Possible congestive heart failure or valve prolapse, delaying surgery
71
What would the presence of bruits over the carotid arteries indicate?
High risk for stroke, consider delaying surgery
72
Risk factors associated with OSA? (4)
1. Snoring (Morning headache that goes away soon after waking) 2. Daytime sleepiness 3. Hypertension 4. Obesity
73
Patients mom states that her infant has an upper respiratory tract infection, but needs their scheduled procedure done today as she cannot take off work again for awhile, what is your action as an anesthesia provider?
Delay the surgery and explain to the mom that they patient has a hyperactive airway and at high risk for laryngospasm
74
What is alcohols effect on albumin?
Alcohol lowers albumin levels, therefore allowing more free drug available in the system for protein bound drugs
75
What is metabolic syndrome associated with?
Diabetes Mellitus Type 2
76
What vasopressors do we utilize for renal patients on dialysis who may be hypovolemic?
Neo and ephedrine
77
What is a major issue with patient who have liver or gastric disorders?
They tend to bleed more
78
What are Hgb triggers?
Hgb triggers are numbers that we begin to worry about, but we look at the patient to see how they are doing (Oxygen supply depends on the amount of blood available)
79
When placing an NGT on your patient you get blood content back upon aspiration, what is a possible cause for this?
You hit a hiatal hernia
80
What is the major intra-op concern when a patient has been taking ACE-i?
Hypotension with or without bradycardia, have your vasopressors and hydration available
81
What beta blockers do we usually give intraoperatively?
metoprolol or esmolol
82
What would be considered massive bleeding?
1-2 liters of blood loss
83
What does ERAS stand for?
Enhanced recovery after surgery
84
What is the goal for ERAS?
To go home quickly
85
Which patients do we want to avoid use of NSAIDS for?
Acute or chronic kidney disease
86
With use of NSAIDs, which surgery presents a high risk of anastomotic leak?
Cholorectal surgery
87
What is are the other names for vitamin k?
phytonadione (aqua-mephyton)
88
What does chiroprecipitate replace?
Factor 1
89
What do we worry about intraoperatively with insulin users?
Hypoglycemia and infection
90
Can we give contrast media to patients taking metformin?
Yes, new research shows that it is not contraindicated
91
What is the hypertension caused by with MAOI's?
Norepinephrine release
92
Why does surgery cause the release of stress hormones?
Sympathetic nervous system activity increases
93
What are the 3 stress hormones released during surgery?
1. Glucagon 2. Epinephrine 3. Steroids (Cholesterol based)
94
Example of glucocorticosterioids
cortisols
95
Example of mineralocorticoids
aldosterone
96
Example of Androgens
testosterone
97
When does HPA (hypothalamic pituitary axis) suppression occur?
Exogenous steroid use
98
What does the adrenal cortex release?
Steroids
99
What does the adrenal medulla release?
Epinephrine
100
Why is it relevant that HPA is suppressed with exogenous steroid use?
No cortisol will be released by the body, meaning the hypotension will not resolve until steroids are administered
101
2 Risk factors for HPA suppression
1. 2 weeks of corticosteroids used within 3 months, doesn't matter what form of steroid 2. 20mg/day prednisone
102
What is the problem with herbal medications?
They are not regulated by the FDA
103
When should herbal medications be discontinued if there is no pharmacokinetic data?
1 week prior to surgery
104
What should you do before giving versed to a patient?
Make sure family members are gone
105
List the most common allergic reactions from most common to least common
1. Muscle relaxants 2. Latex 3. Antibioitics 4. Local Anesthetics (Esters being more common than Amides)
106
What is one of the first questions we ask a patient during an emergency?
What allergies do they have
107
What would be an example of an adverse side effect vs a medication reaction?
Adverse SE = Nausea and vomiting Reaction = Airway closure
108
Describe anaphylactic reactions
Involve multi organ system failure, immune mediated (IgE), mediators released from mast cells and basophils, LIFE THREATENING
109
Describe anaphylactoid reactions
non-IgE mediated, mediators released from mast cells and basophils and direct complement activation, LIFE THREATENING
110
List the allergic reactions of common NMBD in order from most common to least common
1. Roc 2. Such 3. Atracarium 4. Vecuronium
111
What causes NMBD to have a high affinity for IgE receptors?
Quartenary Ammonium Ions have the high affinity for IgE receptors
112
What is hypotension secondary to in an anaphylactic reaction?
Histamine, protease, proteoglycans and platelet activating factors; these are all inflammatory markers
113
What is pulmonary vasodilation and bronchoconstriction secondary to in an anaphylactic reaction?
Potent inflammatory leukotrienes (LTC) and prostaglandins (PGD); These cause increased reactivity of the respiratory system
114
What does pancuronium cause that is good for some cardiac patients?
Tachycardia to help with cardiac output, this med lasts a long time
115
What do LTC and PGD cause?
Bronchial constriction and increased vascular permeability (Can give montelukast to prevent action of these and open up airways)
116
What does histamine cause?
Vasodilation, erythema, edema, arterial hypotension, GI constriction, tachycardia, pruritus, urticaria, angioedema
117
If you suspect a patient is having an allergic reaction to NMBD during a procedure, what action can you take to maintain muscle relaxation?
Utilize inhalation anesthetics
118
What type of chest redness would you look for to determine if a patient who is under general anesthesia is having an allergic reaction?
Non-blanchable redness, most commonly starts on the chest area
119
Describe latex-mediated reactions
1. Irritant contact dermatitis 2. Type IV cell-mediated reactions 3. Type I IgE mediated hypersensitivity
120
What type of food allergies would indicate a true latex allergy?
Bananas, kiwi and tropical fruits
121
What patient population would be at high risk for developing a latex allergy?
Kids with spina biphida or those with long term urologic issues that exposed them to multiple foley catheter insertions
122
What is the correct way to handle rubber stoppers for medications vials with patients who have latex allergies?
Follow hospital policy
123
What inhalation agent can we use to treat symptoms associated with IV contrast allergies?
Mucomyst
124
What is NORA?
Non-OR-Anesthesia
125
What would you see that would cause you to suspect contrast induced nephropathy (CIN)?
Increased in serum creatinine of 0.5mg/dL or 25% increase from baseline
126
What is the most common antibiotic allergy?
Penicillin (Small risk of cross sensitivity, \<2%, to cephalosporin
127
What is the mediator for ester allergic reactions?
para-aminobenzoic acid (PABA)
128
What is the mediator for amide allergic reactions?
methylparaben (chemically similar to PABA)
129
How many "i" are found in the name of ester local anesthetics?
one
130
How many "i" are found in the name of amide local anesthetics?
two
131
What are 6 key signs of anaphylaxis under General Endotrachial Anesthesia?
1. Urticaria 2. Bronchospasm 3. Upper airway edema 4. Vasodilation 5. Erythema 6. Peripheral Edema
132
What would you observe that would make you suspect a patient is having bronchospasms while under GETA?
high pressures on the vent
133
What would you observe that would make you suspect a patient is having upper airway edema while under GETA?
swelling in the oral cavity
134
What type of feedback mechanism do baroreceptors utilize to regulate body functions?
negative feedback
135
What effects do you see from nicotine use?
Cardiovascular effects
136
What are the effects on the cardiovascular system seen from nicotine use?
1. Adrenal Stimulation 2. Carotid body and aortic sinus resetting of baroreceptors, mimicking increased sympathetic tone
137
What is the effect of adrenal stimulation with nicotine use?
Intraoperative tachycardia and post-op delayed wound healing
138
What is the definition of hypoxemia?
Low concentration of oxygen in the blood
139
Why is carbon monoxide dangerous to oxygenation?
Carbon monoxide has a 200-250x greater affinity for Hgb than oxygen
140
What does carbon monoxide lead to in smokers?
Reduction in oxygen transportation and an increased risk of hypoxemia in smokers Reduces availability of O2 binding sites and carrying capacity
141
What causes the increased risk of infection in smokers?
increased sympathetic tone from nicotine and have decreased macrophage function (fight infections)
142
Interventions that can be utilized in smokers for respiratory or airway complications?
Patient will have a hyperactive airway, we can give lidocaine, make sure patient is fully sedated prior to intubation, and utilize gases during induction to dilate bronchi
143
What is the worry when a patient has a severe cough and what can we do to prevent it?
Laryngospasm that can be prevented by utilizing an oral airway, lidocaine or propofol
144
By what percent can the carboxyhgb in smokers be increased from the normal 1-1.5%?
Can be as high as 5-15%
145
What type of shift does carbon monoxide cause on the oxyhemoglobin dissociation curve?
left shift due to a reduction in 2,3 DPG from inhibition of glycolysis in erythrocytes
146
4 factors that would cause a left shift on the oxyhemoglobin dissociation curve?
1. Decreased PCO2 2. Decrease temp 3. Decrease 2,3 DPH 4. Increased pH
147
What does a left shift on the oxyhemoglobin dissociation curve represent?
Hgb does not want to let go of oxygen, it is left-locked
148
4 factors that would cause a right shift on the oxyhemoglobin dissociation curve?
1. Increased PCO2 2. Increased temp 3. Increased 2,3 DPG 4. Decreased pH
149
What does a right shift on the oxyhemoglobin dissociation curve represent?
Hgb wants to get rid of oxygen to the tissues; Right released
150
What type of shift would an increase in P50 cause on the oxyhemoglobin dissociation curve?
Right
151
What type of shift would methemoglobin cause on the oxyhemoglobin dissociation curve?
Left
152
What type of shift would fetal hemoglobin cause on the oxyhemoglobin dissociation curve?
Left
153
What type of shift would maternal hemoglobin cause on the oxyhemoglobin dissociation curve?
Right
154
What type of shift would sickle cell cause on the oxyhemoglobin dissociation curve?
Right
155
What is 2,3 DPG responsible for?
RBC production
156
When do you start seeing a reduction in HR, BP and circulating catecholamines after smoking cessation?
12-24 hours
157
What does not improve post 24 hours of smoking cessation?
pulmonary function
158
When do carboxyhemoglobin and cyanide levels drop after smoking cessation?
24 hours
159
After smoking cessation, what does lower nicotine levels in the body assist in improving?
improves vasodilation and toxins
160
What test can be incorporated to asses alcohol history?
CAGE (cut, annoyed, guilty, eye) 2 positive responses mean patient is at high risk for alcoholism
161
What are 4 anesthesia implication for chronic alcohol users?
1. Aspiration d/t slowed gastric motility 2. Increased MAC requirements 3. Increase depressant effects of opioids and benzos 4. Resistance to nondepolarizers (roc, vec, cis)
162
What does 1 MAC mean?
50% of patients won't move and 50% of patients will move
163
2 Anesthesia implications for acute alcohol users?
1. Lower MAC needed b/c alcohol is already causing the relaxant effects 2. Synergy with other depressant drugs such as opioids, which effect would be doubled
164
What are the 4 reasons why aspiration risk is higher in chronic alcohol users?
1. Gastric motility slowed 2. Gastroesphageal sphincter tone is diminished 3. Increased intraabdominal pressure 4. Elevated gastric acid levels
165
What anesthesia considerations should we take when we have an elderly patient who is a chronic alcohol user?
Want to either skip giving benzos or decrease the dose given
166
Why do we see a delayed effect of medications when we give them to elderly patients?
Circulatory time in their system is not as fast as younger populations
167
When is it okay to cancel a surgery if a patient tests positive for illicit drugs?
You can cancel an elective surgery if the clinical presentation is mostly sympathetic in nature
168
Anesthesia implications for alcohol withdrawal?
Hypnotics, opioids, and gas requirements are increased
169
When do you delay a surgery for results from a urine test?
Positive pregnancy test Viable age women should be pregnancy tested unless they have had a hysterectomy. Will still be able to go to the OR, but will have to take precautions if the patient is pregnant.
170
Eye changes linked to opioid, amphetamine and PCP use
1. opioid = constriction 2. amphetamine = dilation 3. PCP = nystagmus
171
What does Intermittent Acute Porphyria effect?
Hgb (Porphyria is useful to help Hgb to bind iron)
172
Triggers for intermittent acute porphyria?
Barbiturates and etomidate
173
What do we gear laboratory and diagnostic testing towards for anesthesia?
Improved care, change in management or avoidance of problems
174
What would be considered low risk surgeries that do not require routine labs?
EGD, cataracts, D&C
175
What type of procedure would we consider getting a baseline Creatinine?
A patient receiving IV contrast
176
What patient population, receiving intermediate-risk surgeries would lab testing be indicated for?
Patients \>64 or with medical co-morbidities such as hypertension, kidney disease or diabetes
177
What should all patients going through high-risk surgeries receive?
CBC, chem panel, type and screen or type and cross
178
Within how many months would test results be acceptable as long as the patients medical condition has not changed at all?
Results within 6 months
179
When should you order a pre-op chest X-ray?
Patient undergoing cardiothoracic surgery, with a major known respiratory condition such as COPD, or presenting with symptoms of a respiratory condition, CHF, malignancy or acute respiratory illness within the past 6 months
180
When would you want a PFT?
Severe COPD, SOB, orthopnea, or undergoing CT surgery to get a baseline
181
When would you order a urinalysis prior to surgery?
Patients with symptoms or history of UTI, or undergoing knee/hip replacement
182
When should we obtain a baseline 12-lead EKG for males/females?
male \>40 female \>50
***[Or younger with active s/s (chest pain)]***
183
When should you get a baseline EKG for patients under the normal age range stipulations?
Any patient showing signs or symptoms of cardiac disease and any patient undergoing cardiothoracic surgeries
184
What question should we ask a patient to assess for cardiac risk factors?
"Are you able to walk up a flight of stairs?
185
When do you decide on the type of sedation for a specific patient?
Pre-op area
186
What type of airway should be utilized in a patient who is going to be in the prone position?
ETT
187
What 4 pre-op issues should you specifically address before going to the OR?
1. Airway anatomy, can use regional if difficult airway 2. Anticipated post surgical pain 3. Requirement for NMBD (Will need intubated) 4. Hx of PONV - give antiemetics that hit all receptors
188
What are the two types of real anesthesia?
1. General 2. Regional
189
What is MAC anesthesia?
Monitored Anesthesia Care (used to bill)
190
What two categories are included in regional anesthesia?
1. Central-neuraxial 2. Peripheral nerve blocks
191
What is a common denominator of anesthesia risk?
ASA classification
192
What is the ASA classification system?
Scoring system to asses fitness of patients subjected to anesthesia and surgery
193
What would the addition of an E to ASA 6 mean?
The addition of E indicates that it is an emergency, although the class 6E doesn't actually exit, all organ retrieval in brain-dead patients is done urgently
194
What are the 7 causes of death related to anesthesia listed in order from most common to least
1. Equipment failure 2. Intubation complications 3. Pulmonary aspiration 4. Postop respiratory depression 5. Anaphylactic Shock 6. Cardiac Arrest 7. Medication error
195
What is a major side effect of neostigmine that should be considered when administering it?
Severe bradycardia, sometimes asystole
***(glycopyrrolate administered first, then neostigmine to prevent this)***
196
Which patient population should we worry about emergence delirium?
Elderly patients
197
What is the afferent (sensory) nerve that stimulates the carotid sinus?
Cranial Nerve IX (Hering's Nerve)
198
What efferent (mechanical) nerve stimulates the aortic arch?
Cranial Nerve X
199
Where does Hering's nerve send signals to?
The medulla
200
What do you see if the medulla uses sympathetic nerve fibers to stimulate the heart?
Contractility, stroke volume and cardiac output
201
What anatomical landmarks are considered the upper airway?
1. Nose 2. Pharynx 3. Larynx
202
What anatomical landmarks are considered the lower airway?
Trachea
203
3 major anatomical parts found in the nose?
1. Nasal septum 2. Cribriform plate 3. Vascular Mucosa
204
What is the cribriform plate part of?
The ethmoid bone
205
What do we avoid placing if there is an ethmoid fracture?
Do not place an NGT!!!
206
What do we use to cause vasoconstriction of nasal vascular mucosa?
Aferin or neosynpehrine
207
What CN provides motor innervation for the tongue?
CN 12, the Hypoglossal
208
What sections is the tongue divided into?
Anterior 2/3 and Posterior 1/3
209
Sensory information such as pain, touch, pressure and temperature are innervated by which CN to the anterior portion of the tongue?
CN 5 (Trigeminal)
210
What specific branch of the Trigeminal nerve innervates the anterior portion of the tongue?
V3 branch
211
What CN innervates the anterior portion of the tongue to sense taste?
CN 7 the Facial Nerve
212
What CN supplies taste and general sensation to the posterior portion of the tongue?
CN IX, the glossopharyngeal nerve
213
What CN innervates the middle portion of the posterior portion of the tongue?
CN X the Vagus nerve
214
What are the branches of the Trigeminal Nerve?
V1: Sensory = Ophthalmic V2: Sensory = Maxillary V3: Motor and Sensory = Mandibular
215
Which branch of the Trigeminal Nerve is the lingual portion?
V3
216
What area is considered the Pharynx?
Base of the skull to the level of the cricoid cartilage anteriorly and the inferior border of C6 posteriorly
217
Starting at the base of the skull, what are the levels of the pharynx in order?
1. Nasopharynx 2. Oropharynx 3. Hypopharynx (Laryngopharynx)
218
What CNs innervate the nasopharynx?
IX (Glossopharyngeal) and small anterior portion of V (Trigeminal)
219
What CNs innervate the oropharynx?
IX (Glossopharyngeal) and X (Vagus)
220
What CNs innervate the Larryngopharynx?
IX (Glossopharyngeal) and X (Vagus)
221
What are the 2 main motor CNs that innervate the pharynx?
1. Stylophryngeus muscle IX (Glossopharyngeal) 2. Other pharyngeal muscles innervate by X (Vagus)
222
What level of the spine is the larynx found?
C3-C6
223
What is considered the "Watchbox" of the respiratory tract?
Larynx which is also called the voice box
224
What is considered the last segment of the upper airway?
Larynx
225
What does the Larynx protect?
Protects the lower airway from stomach particles
226
What is the larynx made up of?
Bone and cartilage
227
What bone is at the top of the larynx?
Hyoid bone
228
What do we consider the Adams Apple?
Cartilages of the Larynx
229
What are the 4 cartilages of the Larynx?
1. Thyroid cartilage 2. Cricoid cartilage 3. Arytenoids 4. Epiglottis
230
What is the narrowest part of the pediatric airway?
Cricoid cartilage
231
What is the narrowest part of the adult airway?
Vocal cords
232
Why do we need to know which part of the airway is the narrowest?
This determines the size of the ETT
233
What cranial nerve branches into the superior and recurrent laryngeal nerves that provide sensory/motor innervations of the larynx?
Vagus Nerve, cranial nerve 10
234
What is the site that we place the tip of a MAC blade?
Valleculae
235
Describe the epiglottis
Leaf-shaped cartilage behind the root of the tongue
236
What does the sniffing position allow for?
Allows alignment for best visualization of the airway
237
What is the other name for the sniffing position?
Magill's Position
238
What type of flexion/extension moves the chin towards the chest?
Cervical Flexion
239
What type flexion/extension moves the head on the neck?
Atlanta-occipital extension extends the head on the neck
240
What 3 Axis are basically aligned when the patient is in the optimal sniff position?
1. Oral axis 2. Pharyngeal Axis 3. Laryngeal Axis
241
What piece of equipment do we use to assist us in getting the patient into the sniff position?
A pillow
242
What patient population is contraindicated for the sniffing position?
Patient with suspected cervical spine injury
243
What type of neck signals difficult airways?
Short and thick necks
244
What neck circumference is associated with difficult intubations?
40 cm
245
What BMI is associated with difficult airways?
BMI \>= 40kg/m2
246
What type of teeth interfere with blade position during intubation?
Long upper incisors
247
Why is someone who is edentulous difficult to ventilate?
No seal
248
What physical sign of difficult airway could facial hair hide?
Thyrometal distance
249
What does facial hair interfere with?
Proper mask ventilation
250
How much more prevalent are difficult airways in diabetic patients?
10x
251
What occurs in 30-40% of insulin-dependent patients?
Limited joint mobility syndrome
252
What patient population is usually affected by prayers sign?
Diabetes Mellitus
253
Which joints are affected in Prayer's sign?
Interphalaneal joints of the fourth and fifth fingers
254
What is the 3-3-2 rule?
Incisor distances 3 finger breadths, hyoid-mental distance 3 finger breadths, thyroid to mouth distance 2 finger breadths
255
What does checking mouth opening give us a look at?
Access to airway and obtaining glottic view
256
What does check the tip of mentum to hyoid bone give us information about?
Can tongue be deflected to accommodate the laryngoscope
257
What does the acronym LEMON stand for?
L- look externally E - Evaluate the 3-3-2 rule M - Mallampati (\>3 =difficult) O - Obstruction (epiglottitis, peritonsillar abscess, trauma) N - Neck mobility (limited neck mobility)
258
What does the Cormack-Lehane Classification tell us?
Describes laryngeal view during direct laryngoscopy
259
What can you see on the Cormack-Lehane Grade 1?
Complete or nearly complete view of the glottic opening
260
What can you see on the Cormack-Lehane Grade 2?
Posterior region of the glottic opening
261
What can you see on the Cormack-Lehane Grade 3?
Epiglottis only
262
What can you see on the Cormack-Lehane Grade 4?
Soft palate only
263
What can you not see on the Cormack-Lehane Grade 2?
Anterior commissure
264
What can you not see on the Cormack-Lehane Grade 3?
Any part of the glottic opening
265
What can you not see on the Cormack-Lehane Grade 4?
Any part of the larynx
266
What Cormack-Lehane Grade is this View? Describe what you see
Grade 1 ; Complete or nearly complete view of the glottic opening
267
What Cormack-Lehane Score would this be? Describe what you can see
Grade 2; Posterior region of the glottic opening
268
What Cormack-Lehane score would this view be? Describe what you see
Grade 3; Epiglottis only
269
What Cormack-Lehane score would this view be? Describe what you see
Grade 4; Soft Palate only
270
What Cormack-Lehane score would this view be? Describe what you canbot see
Grade 1; You can see everything
271
What Cormack-Lehane score would this view be? Describe what you cannot see
Grade 2; You cannot see the anterior commissure
272
What Cormack-Lehane score would this view be? Describe what you cannot see
Grade 3; You cannot see any part of the glottic opening
273
What Cormack-Lehane score would this view be? Describe what you cannot see
Grade 4; You cannot see any part of the larynx
274
How dose a Corrmack-Lehane grade 3 correlate to intubation?
Harder intubation
275
How dose a Corrmack-Lehane grade 4 correlate to intubation?
Requires alternative approach to intubation
276
History of what type of treatment predisposes a patient to difficult airway?
Radiation d/t stiffness of the neck and not being able to open the mouth
277
What does the mneumonic BOOTS stand for and what is it used for?
Beard, Obese (BMI \>26), Old (\>55), Toothless, Snoring;
This is used to pre-determine a possible difficult airway
278
What 4 questions do we ask before any airway management?
1. Can I ventilate this patient?
2. Can I intubate this patient?
3. Can I use a supraglottic airway?
4. Can I place an invasive airway?
279
When we ask ourselves, can I use a supraglottic airway, what 5 things do we consider risk factors for LMA placement?
1. Limited mouth opening
2. Upper airway obstruction
3. Altered pharyngeal anatomy which can prevent an adequate seal of the device such as radiation theraoy
4. Poor lung compliance requiring excessive peak inspiratory pressure
5. Increased airway resistance requiring excessive PIP
280
When we ask ourselves, can I place an invasive airway, what 5 things do we consider as risk factors for ETT placement?
1. Abnormal neck anatomy (tumor, hematoma, abscess, hx of radiation)
2. Obesity
3. Short neck
4. Laryngeal Trauma
5. Limited access to cricothyroid membrane (halo, neck flexion deformity)
281
Which patent population do we decrease or omit benzos for?
Elderly patients w/ OSA or those with neurological impairment
282
Examples of Alpha 2 agonists
1. Clonidine
2. Dexmedetomidine
283
What type of anesthesia does dexmedetomidine help extend the effects of?
Regional anesthesia
284
What two effects other than anitiemetic, does scopolamine provide?
Antisialogogue and some sedation
285
Which antisialogogue provides the anti-spit effect without sedation?
glycopyrolate
286
What is Glycopyrolate used for?
To decrease salivary, bronchial and GI secretions
287
What about Glycopyrolate makes it unable to cross the blood brain barrier?
It is a quartenary amine
288
What is the most common phase of anesthesia associated with aspiration?
Induction
289
What patient populations shoud we pay particular attention to for aspiration precautions?
1. Pregnant patients
2. Morbid obesity
3. Significant GERD
4. "Full stomach" patients
5. Diabetics with gastroparesis
290
What does cricoid pressure prevent?
Prevents substances from the belly going into the upper airway to cause aspiration
291
What effect does the endotracheal tube have on risk for aspiration?
Reduces it
292
What type of extubation should we do to help prevent aspiration?
Awake extubation with airway reflexes intact
293
What patient populations would we use RSI as an aspiration precaution?
Full stomach or high risk patients
294
What is the issue with utilizing alpha 2 agonists to blunt the SNS response during laryngoscopy?
Expensive meds
295
What does SCIP stand for and how many core measures does it include?
Surgical Care Improvement Project; 9 core measures
296
3 things to consider controlling postop?
1. Pain
2. PONV
3. Postoperative shivering
297
What patient characteristics are associated with increased risk PONV?
1. Female (young and obese or menstruating)
2. Prior Hx of PONV
3. Non-smokers
298
Anesthetics associated with PONV?
1. General Anesthesia
2. Increased duration of anesthesia
3. Intraop use of opioids
4. Use of nitrous
299
What anesthesia technqiue actually decreases risk of PONV?
Total IV Anesthesia (TIVA) with propofol
300
Surgical characteristics that increase the risk of PONV?
1. Laparoscopic procedures
2. Gynecologic Procedures
3. Opthalmologic procedures (strabismus)
4. Ear and nasal procedures
5. Shoudler surgery
301
Where do 5HT3 antagonists target?
Chemoreceptor Trigger Zone (CTZ)
302
Where do H1 Antagonists target?
Chemoreceptor Trigger Zone (CTZ)
303
Why are H1 receptor antagonists not good for elderly patients who have a hard time coming out of anesthesia?
H1 receptor antagonists such as diphenhydramine or dimenhydrinate produce sedative effects
304
What are the side effects of scopolamine patches?
Dry mouth, drowsiness, blurred vision, sedation and mydriasis
305
What receptors does scopolamine patches inhibit?
M1 and H1 receptors in the hypothalamus and CTZ
306
Which drugs are considered butyrophenons?
droperidol and metoclopramide
307
What are the physiologic effects of metoclopramide?
Promotion of gastric motility, blockade of dopamine receptors in the CTZ and weak 5HT3 antagonistic properties
308
What are the side effects associated with droperidol?
Prolonged QT interval and increased sedation
309
What class of drug is promethazine considered to be?
Phenothiazines
310
What receptors does promethazine block?
Blocks H1 receptors in the CTZ
311
What side effects can promethazine produce?
EPS and sedation
312
When are steroids most effective for prophylaxis of PONV?
Prior to induction of anesthesia, goal is to give when pt is asleep d/t intense perineal itching
313
What are the physiologic effects of postop shivering?
Generation of heat and increased O2 demand and CO2 production
314
In which patient population is postop shivering not well tolerated in?
Marginal CV and pulmonary reserve patients
315
How do we treat postop shivering?
Active warming and medications such as meperidine
316
How do volatile anesthetics effect postop shivering?
They lower the threshold for shivering
317
What does NPO stand for?
nil per os
318
What are the NPO guidelines for solid foods, nonclear liquids, meds and clear liquids prior to surgery?
1. Patient should not have any solid foods or nonclear liquids for 6-8 hours prior to surgery
2. Medications may be taken with a small sip of water up to 2 hours prior to surgery
3. A small amount (few sips) or clear liquid is ok up to 2 hours prior to surgery.
319
When is coffee considered a clear liquid?
Coffee is considered a clear liquid as long as it does not have any cream or milk added
320
In the clinical setting, what do we tell patients in regard to NPO status and medications?
Patients should not eat or drink anything after midnight and take their AM meds 2 hours prior to surgery with a small sip of water
321
What are the NPO guidelines for pediatric patients?
No solid foods for 8 hours, formula is okay up to 6 hours prior, breastmilk is okay up to 4 hours prior and clear liquids are okay up to 2 hours prior to surgery
322
What effect doe chewing gum have?
Increased gastric emptying and motility
323
How fast would we see a drop in O2 saturation numbers in a a patient whos BMI is \>40?
Saturation will drop within 30 seconds
324
What does denitrogenation allow for?
A safety buffer during periods of hypoventilation and apnea
325
At what O2 sat would a patient be considered under safe apnea levels?
\<90%
326
What are the PaCO2 changes in the 1st minute of apnea and then the minutes following?
1st minute: 6mmHg increase
After 1st minute: 3-4mmHg increase per minute
327
5 goals of preoxygenation?
1. Bring patients saturation as close to 100% as possible
2. Denitrogenate the residual capacity of the lungs to max oxygen storage
3. Denitrogenate and maximally oxygenate the bloodstream
4. Practice in every case when time allows
5. Replaces nitrogen volume of the lung with O2 to provide for diffusion into the alverolar capillary blood after the onset of apnea
328
What is a necessity to preoxygenation regardless of technique?
Application of a tight fitting mask and use of 100% O2
329
5 Indicators of adequate preoxygenation?
1. Fogging on the face mask
2. Movement of the reservoir bag
3. Presence of capnopgrah waveform (3 waveforms)
4. Increasing O2 saturation
5. The expired O2 concentration nears inspired O2 concentration
330
When would we expect to see decreased O2 saturation when giving Versed?
In very sick patients
331
3 points associated with Slow preoxygenation technique
1. Tidal volume breathing for 3 minutes (normal breathing)
2. Fresh gas flow of 5L/min, lung denitrogenation is 95% complete after 3 minutes
4. Most patients are adequately preoxygenated after 3 minutes of tidal volume breahting with an inspired fraction of oxygen (FIO2) of 100%
332
2 points associated with fast preoxygenation?
1. Vital capacity breath
* 4 vital capacity breaths ate FIO2 = 100% over 30 seconds
2. Modified vital capacity breathing
* 8 deep breaths for 60 second period
333
What does the mneumonic BURP stand for?
Backward, upward (towards cephalid), rightward, pressure (can help or harm your view)
334
By what percent does proper cricoid pressure lower the incidence of failure?
10% to 2%
335
4 points of the Sellick Maneuver?
1. Apply pressure before the patients loses consciousness
2. Keep pressure
3. Pressure before decr. LOC = 2kg or 20 newtons
4. Pressure after decr. LOC = 4kg or 40 newtons
336
5 complications associated with cricoid pressure?
1. Esophageal rupture if patient actively vomiting
2. Airway obstruction
3. Impaired glottic visualization
4. Difficult with laryngoscopy
5. Difficult intubation
337
Describe Larson's maneuver
The applciation of firm pressure to the laryngospasm notch located just behind the earlobe
338
What is the proper procedure for applying pressure to the laryngospasm notch?
Apply 3-5 seconds of pressure then release for 5-10 seconds and repeat until spasm relief
339
Describe the location of the laryngospasm notch
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
340
2 goals of Larson's maneuver
1. Displaces the mandible anteriorly to help open the airway
2. Breaks laryngospasm by causing the light anesthetized patient to sigh
341
3 key points of awake intubation
1. Premedication and sedation
2. Topicalization
3. Airway blocks (Nerve blocks)
342
4 classes of meds utilized in the premedication and sedation stage of an awake intubation
1. Antisialagogues
2. Mucosal vasoconstrictors
3. Aspiration prophylaxis agents
4. Sedative/hypnotics
343
When do we administer antisialagogues for an awake intubation?
30 minutes prior
344
Why do we not give antisialagogues that cause tachycardia to patients with CAD?
slows diastolic filling time
345
Which of the three antisialagogues are tertiary amines, meaning they can cross the blood brain barrier?
Atropine and scopolamine
346
Why is bleeding considered a bad thing in the oral cavity?
1. Obscurring vision
2. Foreing body and laryngospasm as it is irritating
347
2 Nasal Mucosal Constrictors?
1. Cocaine
2. Phenylephrine
348
3 classes of drugs used for aspiration prophylaxis
1. H2 blockers (decreased secretion of acid from parietal cells)
2. PPI (not as effective as H2 blockers)
3. Metoclopramide
349
In which patient populations would we avoid giving scopolamine or metoclopramide to?
Patients exhibity CNS symptoms d/t possible exacerbation of EPS
350
4 medications used for topicalization in awake intubation?
1. Lidocaine
2. Cocaine
3. Benzocaine
4. Cetecaine
351
Of the medications utilized for topicalization in awake intubations, which are likely to cause methemoglobin? What type of change would this cause to the oxyhgb dissociation curve?
Benzocaine and Cetecaine; Would cause a left shift
352
What is the drug of choice to reverse methemoglobin?
Mehtyline Blue
353
6 locations to utilize when doing airway blocks
1. Nasal cavity
2. Nasopharynx
3. Oropharynx
4. Larynx
5. Trachea
6. Vocal cords
354
Names the cranial nerve innervating each region of the airway
1. Blue area = Trigeminal or CN 5
2. Yellow area = Glossopharyngeal or CN 9
3. Red area = Vagus or CN 10
355
What provides sensory innervation to the nasal cavity and nasopharynx?
Sphenopalatine ganglion (Meckel's ganglion) and the anterior ethmoidal nerve
356
When placing nerve blocks in the nasal cavity or nasopharynx, what are we targeting?
The V2 branch of the trigeminal nerve, which supplies the maxillary area
357
What are the three regions innervated by Cranial Nerve 5 in the nasal cavity and nasopharynx?
V1 = opthalamic
V2 = Maxillary
V3 = Mandibular
358
What location are we trying to reach when we are placing a Sphenopalatine Nerve Block?
The V2 area of the Trigeminal Nerve
359
3 key points of placing a Sphenopalatine Nerve Block?
1. 20-G angiocatheter used to reach the V2 area
2. 4mL of lidocaine/phenylephrine is rapidly injected
3. About 2 minutes should be allowed for the anesthetic to take effect
360
What cranial nerve provides sensory innervation to the oropharynx?
Cranial nerve 9, the glossopharyngeal nerve
361
In the oropharynx, where does the afferent limb of the gag reflex arise from?
Stimulation of deep pressure receptors found in the posterior third of the tongue
362
4 key points to minimizing gag reflex stimulation
1. Instruct patient to breathe in a nonstop, panting fashion
2. Avoid pressure on the base of the tongue
3. Administer opioids
4. Perform blockade of the GPN
363
Where would we inject lidocaine to perform a glossopharyngeal nerve block?
The base of the posterior tonsillar pillars (palatopharyngeal fold)
***DON'T FORGET TO PLACE LIDOCAINE ON BOTH PILLARS***
364
3 complications associated with GPN blocks
1. Intra-arterial injection, which could result in headache or seizures
2. Hypopharyngeal swelling and mucosal bleeding
3. Tachycardia d/t blockade of afferent nerve fibers of the GPN that arise from the carotid sinus
365
How does the Vagus nerve branch in the laryngeal region?
1. Superior Laryngeal Nerve
* Internal laryngeal branch
* External laryngeal branch
2. Recurrent Laryngeal Nerve (Inferior Laryngeal branch)
366
Name structures labeled 1, 2, 3 and 4
1. Superior Laryngeal Nerve
2. Recurrent Laryngeal Nerve
3. Internal Laryngeal Branch
4. External Laryngeal Branch
367
What nerve innervates the Larynx?
Superior Laryngeal Nerve
368
What regions are affected when we utilize a superior laryngeal nerve block?
1. Hypopharynx
2. Upper glottis
3. Vellecula
4. Epiglottis
369
Would these be considered above or below the trachea? Hypopharynx, Upper glottis, Vellecula, Epiglottis
Above the trachea
370
What is the most lateral aspect of the hyoid bone that can be palpated?
The greater cornu of the hyoid
371
What are the two main landmarks utilized when placing an SLN block?
1. Cornu of hyoid
2. Cornu of thyroid
372
What do we know has occured after we feel a slight resistance as the needle is advanced through the membrane when placing an SLN block?
The needle has entered the pre-epiglottic space
373
When placing an SLN block, you aspirate air, what could be the cause of this and how should you respond?
The needle has gone too deep and may have entered the pharynx. You should withdraw the needle until no air can be aspirated.
374
When placing an SLN block, you aspirate blood, what would this indicate and how should you respond?
The needle has cannulated the superior larygngeal vein or the carotid artery. The needle should be directed more anteriorly.
375
Why do we want to avoid instertion of the needle into the thyroid cartilage?
To prevent the possiblity of injecting lidocaine at the level of the vocal cords, possibly causing laryngeal edema and airway obstruction
376
How would we minimize the risk of intravascular injection when placing an SLN block?
Identify the carotid artery and displace posteriorly
377
5 possible causes of hypotension and bradycardia associated with placing an SLN block?
1. Vasovagal reaction r/t painful stimuli
2. Digital pressure on the carotid sinus
3. Excessive manipulation of the larynx causing vasovagal reaction
4. Large dose of or accidental intravascular admin of local anesthetics
5. Direct neural stimulation of the branch of the vagus nerve by the needle
378
What is recommended to be administered prior to performing an SLN block?
Anticholinergics
379
Which nerve innervates the trachea and vocal cords for both sensory and motor fibers?
Right recurrent laryngeal nerve
380
What portion of the right recurrent laryngeal nerve, if blocked will cause stridor?
Blocking the sides will cause stridor
***(We want to block the middle portion)***
381
Positioning and Landmarks associate with placing a Translaryngeal (Transtracheal) block
1. Supine position with neck extension
2. Thyroid cartilage is palpated at midline and followed caudally until a depression and a firm ring of tissue are identified
3. The identified tissue are the cricothyroid groove and cricoid cartilage
4. Overyling the cricoid groove is the cricothryoid membrane
382
What is the only procedure that we actually want the patient to cough, causing spread of the local anesthetic?
Translaryngeal Block
383
How do we avoid laryngeal trauma when placing a translaryngeal block?
Never point the tip of the needle in a cephalad direction
384
Which patients would be contraindicated for translarygneal block due to the possible increased HR, MAP, ICP and intraoccular presssure from coughing?
Elevated ICP or open globe, care should be taken in patients with severe cardiac disease
385
What type of nerve block is being demonstrated in this picture?
Glossopharyngeal Nerve Block
386
Name the structrures 1-4
1. Condyle
2. Mastoid Process
3. Pressure Point for Larson's Maneuvre
4. Base of Skull
387
Name the areas labeled 1-8
1. Inspiratory Reserve Volume
2. Tidal Volume
3. Residual Volume
4. Expiratory Reserve Volume
5. Vital Capacity
6. Inspiratory Capacity
7. Functional Residual Capacity
8. Total Lung Capacity
388
Name the Phases of Anesthesia associated with Aspiration risk 1-7
1. Induction
2. Maintenance
3. Emergence/PACU
4. Obstetrical-related
5. Difficult intubation
6. Cricoid Pressure
7. Hx of reflux
389
What head positioning is associated with these axis alignments?
Neutral Head Positioning
390
What head positioning is associated with these axis alignments?
Head is elevated but not extended
391
What head positioning is associated with these axis alignments?
Head is extended but not elevated
392
What head positioning is associated with these axis alignments?
Head is elevated and extended, this is the optimal sniff position
393
What are the structures labeled 1 and 2 in this picture?
1. The right and left true vocal cords
2. Epiglottis
394
Where in this image would we place the tip of a mac blade? The ET-Tube?
Mac-blade tip goes at #3
ET-Tybe goes at #4
395
Name the areas 1-3
1. Nasopharynx
2. Oropharynx
3. Hypopharynx (Laryngopharynx)
396
What does the PUSH mneumonic stand for?
tonsillar Pillars
Uvula
Soft palate
Hard palate
397
What does the mallampati score assess?
The relationship between tongue size and the oral cavity
398
What is the largest structre in the mouth?
The tongue
399
How do we increase predictive power when assessing a patients airway for possible difficulty?
Utilzing multiple airway exam methods
400
5 key points for the mallampati score
1. Sit upright (semi-fowlers)
2. Extend the neck
3. Open the mouth wide
4. Stick out the tongue
5. Do not phonate
401
Where must the tongue be displaced during direct laryngoscopy to expose the glottic opening?
In the submandibular space
402
What are the borders of the submandibular space?
1. Superior border - mentum (chin)
2. Inferior border - hyoid bone
3. Lateral border - either side of the neck
403
What does the thyromental distance estimate?
The size of the submandibular space
404
How many finger-breadths/cm indicates an easy intubation per the thyromental distane evaluation?
Greater than or equal to 6 cm/3 finger-breadths
405
How many cm indicates an difficult intubation per the thyromental distane evaluation?
Greater than 9cm
406
What does a thyromental distance of less than 6cm indicate?
1. Mandibular hypoplasia
2. Small mandibular space
407
What does a thyromental distance greater than 9 cm indicate?
1. Larynx assumes a caudal position
2. Tongue will move caudally
3. The glottic opening will shift beyond the line of site
408
What does the mandibular protrusion test assess?
The function of the temporomandibular joint
409
When assessing the mouth opening of a patient, how many finger-breadths/cm indicate enough room for a laryngoscope or LMA?
\>3 fingers/6cm
410
When attempting to assess mouth opening of a patient who is edentulous, what are we measuring?
The interalveolus distance
411
What class of mandibular protrustion test is indicated in this image and describe it.
Class 1; Patient can move LI past UI and bite the vermillion of the lip
412
What class of mandibular protrustion test is indicated in this image and describe it.
Class 2; Patient can move the LI in line with UI
413
What class of mandibular protrustion test is indicated in this image and describe it.
Class 3; Patient cannot move LI past UI, indicating increased risk of difficult intubation.
