General Anesthesia Techniques Flashcards
(169 cards)
1
Q
Define GA.
A
General Anesthesia
2
Q
Define RSI.
A
Rapid Sequence Induction
3
Q
Define TIVA.
A
Total Intravenous (IV) Anesthesia
4
Q
Define ERAS.
A
Enhanced Recovery after Surgery
5
Q
What are the three gold standards of general anesthesia? (3)
A
Amnesia, Anxiolysis/Hypnosis & Analgesia
6
Q
What is the mnemonic for anesthesia case preparation?
A
Ms. Maid
7
Q
What does the M in Ms. Maid mean?
A
Machine
8
Q
What does the S in Ms. Maid mean?
A
Suction
9
Q
What does the second M in Ms. Maid mean?
A
Monitor
10
Q
What does the A in Ms. Maid mean?
A
Airway
11
Q
What does the I in Ms. Maid mean?
A
IV, Preop Assess
12
Q
What does the D in Ms. Maid mean?
A
Drugs
13
Q
What does the E in Ms. Maide mean?
A
Equipment
14
Q
Who should you conform the anesthesia gas machine check with at clinical sites?
A
Confirm with Clinical Coordinator/colleagues/faculty AGM at new facility prior to rotation
15
Q
What must be selected for appropriate ventilation?
A
appropriate size mask for ventilation
16
Q
What must we ensure in functional and working?
A
ETCO2 monitor
17
Q
What is a standard equipment check that must be in every room before the start of the case?
A
AMBU
18
Q
What must be done to suctioning?
A
readily available and functional
19
Q
What suction is used for intubation?
A
Yankauer
20
Q
What is used for ETT suction?
A
Soft, flexible suction available to suction ETT
21
Q
What is important to do about monitor set up?
A
Ensure standard monitors are organized and laid out to facilitate easy placement based on patient position
22
Q
What are standard vital signs taking throughout surgery?
A
Pulse oximeter; NIBP; ECG; temperature
23
Q
Where should ECG leads be set to prepare for a supine patient?
A
under pillow
24
Q
Where should ECG leads be set to prepare for a prone patient?
A
on IV pole
25
What other equipment should you have prepared?
- Arterial line (armboard, lidocaine, cleaning solution, sterile gloves/towels, 20g PIV/Arrow Catheter, u/s, wet set, transducer, etc.)
- Correct cables - communicating with monitor?
- Bair hugger blanket
- Fluid warmer, Belmont/Level 1, etc.
26
What are some other monitors that may need to be prepared for surgery?
BIS, cerebral oximeters, central lines (CVP/Pa Cath), Vigileo, etc.
27
What are the components of the airway setup?
- Laryngoscope blade(s) & handle
- Airway adjuncts (Glidescope, LMA, bougie)
- Tongue blade, soft bite block, OPA/NPA, lubricant
- Endotracheal tubes (Multiple sizes readily available)
- Stylet
- 10cc syringe
- Tape
- Plan A, B, C
28
What are the components of a complete focues patient assessment?
PMHx, PSHx, comorbidities, planned surgical intervention, NPO status, medication regimen, etc.
29
What must be done to the patients PIVs?
Ensure patency of pre-existing PIV or need to place PIV
30
What should be done regarding the patients arterial line?
Assess viability for arterial line whether or not one is anticipated
31
Why is it important to auscultate patient prior to surgery and induction?
Auscultate and ensure knowledge of baseline function
32
What might have to be done based on auscultation of the patient?
Optimize if necessary, e.g. nebulizer
33
What should be done to your ventilator prior to the case?
Pre-set ventilator
34
Who should the anesthetic plan be discussed with?
anesthesia and surgical team
35
What is a vital part of the preparation prior to surgery?
Obtain informed consent
36
Why is inspiration more of a concern with BLN?
Negative pressure and leads to pulmonary edema
37
What are the common classification of medications used in anesthesia?
- Benzodiazepine
- Lidocaine
- GA induction agent
- Muscle relaxant (1-2)
- Opioid
- Emergency medications (Vasopressors/Anticholinergic)
- Antiemetic(s)
- Anticholinesterase
38
What should the pump be preset with during the prep phase of surgery?
Preset infusion pumps with patient information (e.g. weight)
39
What should be done if you are infusing multiple medications?
Ensure manifold is prepared and medications labeled at the injection port
40
What should be done regarding IV access?
Consider how many IV lines are necessary and location of IV based on surgical site
41
Where do you do not want to put the IV?
Concerns with antecubital IV’s and positioning
42
What should be done with IV's immediately following repositioning?
Makes sure your IV’s run immediately after arms are tucked or positioned
43
Inhalation induction: When is the commonly used? Why?
Often used in pediatric patients to maintain spontaneous ventilation, To sedate before starting IV
44
Inhalation induction: What is used during inhalation induction?
Use of oxygen/air/nitrous oxide and a volatile anesthetic such as isoflurane, sevoflurane, or desflurane
45
Inhalation induction: What is the nervous system that is depressed?
Depresses the SNS, allows for instrumentation of the patient’s airway and renders the patient unconscious
46
Inhalation induction: What is the advantages?
Less preparation (no need to prime infusions, preset patient weight, etc.)
47
Inhalation induction: What are the disadvantages?
Increased risk of PONV, can be irritating to airways (especially desflurane)
48
Inhalation induction: What is a way to encourage kids to participate more readily?
In pediatrics, can engage the child (flavored chapstick, blowing up balloon, etc.)
49
Inhalation induction: What nervous system is stimulated? What is the result?
PNS= increase secretions, salvation and nasal engorgement
50
Intravenous induction: What is typical patient positioning?
Patient is positioned in the supine position, with UE/LE secured and all monitors on and functioning
51
Intravenous induction: What should you ensure prior to induction?
Ensure VS are stable
52
Intravenous induction: Do you preoxygenate the patient?
Yes
53
Intravenous induction: what do you need to communicate with the attending?
Okay to extubate or Any airway concerns that you would want another provider present for
54
Inhalation induction: What is a tell tale sign of stage 2?
Engage accessory muscles, excitatory phase> once they decrease then we can turn the gas down
55
Intravenous Induction: What are some adjunct medications that may be administer?
Administer benzodiazepine, Administer lidocaine (+/-) and general anesthesia induction agent & Administer opioid (+/-)
56
Intravenous Induction: When is the best time to administer a benzo?
May be given in the holding area
57
Intravenous Induction: What is done after the medications are given to the patient?
Test glabellar tap then patient’s lash reflex
58
Intravenous Induction: What is done after testing the patients lash reflex?
When reflex is obliterated, tape eyes closed and begin bag/mask ventilation
59
Is mask ventilation preformed with RSI?
No mask ventilation if performing RSI
60
Intravenous Induction: What is the hand technique for bag/mask ventilation?
One or two handed
61
Intravenous Induction: What can be added to help with bag/mask ventilation?
OPA or NPA (+/-)
62
Intravenous Induction: What are we monitoring to assure adequate bag/mask ventilation? (3)
Monitor chest rise, tidal volume and respiratory rate
63
Intravenous Induction: When do you give the muscle relaxants?
Once you are able to demonstrate you can successfully mask ventilate the patient, the muscle relaxant can be given
64
Intravenous Induction: What is important to do before giving muscle relaxants?
Don’t forget to check the time!
65
Intravenous Induction: What are you doing while you wait for the muscle relaxant to take effect?
Continue bag mask ventilation long enough for muscle relaxant to set up
66
Intravenous Induction: What are we looking for during laryngoscopy and placement of ETT? (2)
- Verbalize view of cords
| - Attach anesthesia circuit to ETT
67
Intravenous Induction: How do we ensure accurate ETT placement?
monitoring B/L chest rise, condensation in ETT, positive ETCO2, and auscultation of B/L breath sounds
68
Intravenous Induction: After ETT placement is confirmed what do we do next?
Turn on ventilator
69
Intravenous Induction: After ETT placement is confirmed what do we do next?
Turn on ventilator
70
Intravenous Induction: What do we turn on after turning on the ventilator?
Turn on inhalation agent or infusions if performing TIVA (TIVA infusions may be initiated at induction)
71
Intravenous Induction: How do we secure airway?
Tape, Place soft bite block between molars in anticipation of emergence/extubation
72
What is a concern if the patient has pink frothy secretions?
Negative pressure pulmonary edema
73
When do you give the muscle relaxants during RSI?
after induction medications and do not touch the bag
74
What is the primary difference from standard induction and rapid sequence induction?
- Avoid ventilation
| - Cricoid pressure administered prior to beginning induction
75
When is cricoid pressure released?
auscultation
76
What are some extra attention components of RSI to ensure?
- Patient positioning
- Quality of preoxygenation
- Location and function of suction
- Accessibility of materials
77
When should patient positioning equipment be collected?
Collect all patient positioning equipment as part of OR set up, e.g. arm straps, arm boards, gel pads, etc.
78
What should be consider with patient position in the prone positioning?
If prone, consider whether or not to remove monitors for the “flip”
79
What should be consider with patient position in the lateral positioning?
If lateral consider where ECG leads are in relation to bean bag, surgical site, etc.
80
What is important to ensure patient safe position?
Place appropriate padding, safety belt, etc.
81
When should the bair hugger be applied?
Apply Bair Hugger (warming device) but do not turn on until surgical drapes are in place
82
Who should be communicated with regarding OGT and NGT?
Surgeon and whether or not he would like it be removed or kept in after surgery
83
What is the emory system's term for a time out?
Call to order
84
Review time out for patient safety
Slide 23
85
What is the Standford anesthesia emergency manual?
cognitive aids for perioperative critical events
86
What is malignant hyperthermia?
A condition that triggers a severe reaction to certain anesthetic medications (e.g. inhalational anesthetics, succinylcholine)
87
What can happen with out treatment of malignant hyperthermia?
the disease is fatal
88
What is most of the cause of malignant hyperthermia?
Genes that cause MH are autosomal dominant
89
What is the typical s/s presentation for malignant hyperthermia?
In most cases no signs or symptoms of the condition exist until you are exposed to anesthesia
90
Maintenance: ________ is the key!
Vigilance
91
Maintenance: What should you be doing constantly in the maintenance stage?
Constant, purposeful sweep (right to left)
92
Maintenance: What is the being reviewed in the purposeful sweep?
Review monitor for VS, ETCO2, respiratory measures, CO2 absorbent, IV fluids, patient position (arms, face, etc.), ETT/airway, urine output, EBL, stage of the procedure
93
Maintenance: What must be considered in the purposeful sweep?
Consider ergonomics
94
Maintenance: Why is it important?
Anticipate key moments upcoming in the procedure
95
Maintenance: What must we avoid?
Avoid distractions/temptations
96
What is Guedel’s stages of anesthesia?
Analgesia (induction), Excitement, Surgical Anesthesia, Medullary Paralysis
97
What are the components of Guedel’s analgesia stage of anesthesia?
- Conscious but drowsy
| - Decrease response to noxious stimuli
98
What are the components of Guedel’s excitment stage of anesthesia?
- Loss of consciousness
- Non-responsive to non-noxious stimuli
- Reflex response to noxious stimuli
99
What are the components of Guedel’s Surgical Anesthesia stage of anesthesia?
-Movement ceases and respiration is regular
100
What are the components of Guedel’s Medullary Paralysis stage of anesthesia?
- Respiration and vasomotor control cease
| - Death
101
Pinpoint eyes means ____
Too much narcotics
102
Dilated eyes means ____
Too little narcotics
103
What is the response if someone is paralyzed?
May not have physical response but have autonomic response (increased heart rate or bp)
104
What may need to be administer during maintenance phase?
- Administer additional medications as needed
| - Opioids, muscle relaxants, volume
105
What must be used when administering volume?
use appropriate formula
106
What type of lab work may need to be completed during the maintenance stage?
Type and screen, H&H, blood glucose, ABG, etc.
107
What can you begin to prepare for during the maintenance stage?
Prepare medications and supplies for extubation
108
What is the goal of emergence?
When the drapes comes down the patient is immediately extubated and ready for PACU
109
What is a cavet to the goal of emergence?
Unless the patient is in a position other than supine
110
Know the depth of anesthesia.
slide 30
111
Begin weaning the anesthetic when ________
closing begins
112
What is the foundation of emergence?
Remember you want the minimum amount of anesthesia necessary for the intervention
113
What may be needed when patient received a non-depolarizing muscle relaxant?
prepare reversal agents
114
When should the reversal for muscle relaxants be given?
Fascia closure, returning the patient to spontaneous ventilation, etc.
115
What is the reversal medication for non depolarizing muscle relaxant?
Sugammadex
116
What should be given prior to emergence?
antiemetics
117
When is the patient ready to extubate?
- Maintaining regular, adequate spontaneous ventilation
| - Following commands: opens eyes, squeeze hand, show two fingers, 5 second sustained head lift
118
What are the steps for extubating?
-To extubate, loosen tape, and place syringe on pilot balloon. -When ready, close pop-off valve on anesthesia gas machine to create positive pressure and extubate patient with that positive pressure.
119
What will the patient experience during extubation?
Patient will cough
120
What needs to be assessed following extubation?
Assess patients' ability to maintain airway following extubation – monitor saturation
121
What should you begin to prepare you patient for after extubation?
Prepare patient to either move themselves or be moved by anesthesia and surgical team to stretcher/in-patient bed
122
What is the last monitor to be removed?
Pulse oximetery
123
_______ will provide you valuable information to refine your technique
Post-operative visits
124
What are some important questions to ask the patient in a post-op visit?
- What is the last thing you remember?
- What was the first thing you remember when you woke up?
- Were you in pain after surgery?
- What worked to alleviate the pain?
- How long did your block last?
125
Who can you also talk to to gain insight on you patient post operatively?
Talk to PACU nurse to find out opioid and antiemetic requirements
126
What is TIVA?
Use of oxygen and intravenous general anesthesia induction agent and (possibly) opioid
127
What are the most common medications used for tiva? (2)
Most common medications are propofol and remifentanil
128
What medications are used for tiva when it is an atrial fibrillation ablation (3)?
Propofol, remifentanil, mivacurium with HFJV
129
What does TIVA depress?
Depresses the SNS to allow a for instrumentation of the patient’s airway and renders the patient unconscious
130
What are the advantages to TIVA?
Decreases the risk of PONV, allows for more reliable “wake up test”, less noxious to airway so decreased coughing upon waking and decreased risk of bronchospasm with induction
131
What are the disadvantages to TIVA?
Depending on agents used can be expensive, may be more difficult to time wake up
132
What is not present in the US right now?
At present no methods of measuring specific drug concentrations in real time (e.g. end tidal concentrations of inhalational agents)
133
What can make infusion rates more challenging?
Confounders may make infusion rates more challenging: Obesity, induction of CYP systems
134
TIVA: Careful consideration of ______ and _______ for access is critical
access and planning
135
What will effect context sensitive half life?
a specific drug will vary depending on the length of the infusion
136
What is context sensitive half life?
The time taken for the drug concentration to reduce by half once an infusion designed to maintain a constant plasma concentration is stopped
137
During an infusion, drugs will _______ and ________ within all tissues/compartments
accumulate and equilibrate
138
What effects accumulation of a drug?
The longer the duration of the infusion the higher the degree of accumulation which will maintain plasma levels of the drug beyond the discontinuation of the medication
139
What are some characteristic that are important for the careful selection of a TIVA drug? (4)
- Small volume of distribution
- Rapid metabolism with no active metabolites
- Short CSHT
- High clearance rate
140
What are some advantage populations that can benefit from TIVA? (8)
-Pediatrics
-MH (or suspicion of MH)
-Spine surgery / Motor evoke potentials (MEPs)
-Severe PONV
-Long QT syndrome
ENT or thoracic surgery where ETT is variable
-Neurosurgery
-Myasthenia gravis/Neuromuscular disorders
-Cases performed outside of the operating room
141
What is target controlled infusion?
An infusion system designed to aid in administering the appropriate amount of medication for TIVA goals
142
What algorithm is involved in the TCI?
Based on algorithmic modeling-Models built on experiences/studies of healthy volunteers
143
Many studies have concluded that TIVA will decrease the occurrence of what?
N/V and retching
144
What is enhanced recovery after surgery?
Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining pre-operative organ function and reducing the profound stress response following surgery.”
145
What are the characteristics of Enhanced recovery after anesthesia? (4)
- Using an evidenced-base approach
- Preoperative counseling
- Avoidance of perioperative fasting with carbohydrate loading up to 2 hrs preop
- Standardized anesthetic and analgesic regimens to include regional anesthesia and non-opioid anesthesia, and early ambulation after surgery
146
What is a cheap carb loading alternative?
Gatorade
147
What is integral for ERAS? (2)
Both the multimodal and OFA approach are integral for ERAS programs
148
ERAS: Involves a __________ pathways and
| ________ approach
Multimodal perioperative care; Multidisciplinary
149
How does ERAS achieve early recovery after surgical procedures? (6)
- Maintaining pre-operative organ function
- Reducing the stress response following surgery
- Preoperative counselling
- Optimization of nutrition
- Standardized analgesic and anesthetic regimens
- Early mobilization
150
What is the ERAS society?
is to develop perioperative care and to improve recovery through research, education, audit and implementation of evidence-based practice
151
What is the multimodal approach?
Builds on a balanced anesthesia approach (what is commonly done today) that uses a combination of drugs is used to achieve their individual desired effect
152
What are some examples of the multimodal approach?
analgesia, muscle relaxation, unconsciousness, amnesia, NV, etc.
153
What is the principle of the multimodal approach?
using a combination of drugs allows one to use less of each agent to achieve desired effect while minimizing unwanted side effects
154
What is the multimodal pain approach?
uses a combination of drugs to decrease overall opioid use (opioid-sparing) by targeting other receptors involved in the nociceptive response of surgery: GABA, NMDA, alpha-2, COX inhibitors, local anesthetics, etc.
155
_______ maximizes the multimodal approach by avoiding opioids all together
OFA (opioid free anesthesia)
156
What is OFA?
Anesthesia technique in which preoperative/intraoperative opioids are avoided to achieve better postoperative outcomes
157
What does the OFA avoid?
Avoids negative side-effects of opioids
158
What are negative side effects of opioids?
Respiratory depression, opioid induced hyperalgesia, post-operative nausea and vomiting, addiction, hallucinations, cognitive dysfunction, sleep disturbance, impaired wound healing, cancer reoccurrence, and increased hospital stay or recovery from surgery
159
What is an NMDA drug that can be used for OFA (2)?
- Ketamine (NMDA) doses of 0.5 mg/kg
| - Magnesium sulfate (NMDA)
160
What Alpha-2 agonists could be used for OFA?
Alpha-2 agonists (clonidine, Dex)
161
What is an anticonvulsant that can be used for OFA?
Gabapentin (anticonvulsant, analogue to GABA) or Pregabalin
162
What is the ceiling effect of Gabapentin?
Analgesia ceiling effect 600 mg (oral)
163
What is the ionizationation of Gabapentin?
Highly ionized
164
What is the protein binding of gabapentin?
not protein bound
165
What is the excretion of gabapentin?
Excreted unchanged in the urine- clearance follows creatine clearance.
166
What is the peak effect of gabapentin?
Peaks 3 hrs
167
What is the elimination half life of gabapentin?
half-life 5-7 hours
168
What are some antinflammatory drugs that can be used for OFA?
Anti-inflammatory drugs (dexamethasone, nonsteroidals, acetaminophen, ofirmev)
169
What is a regional anesthetic that can be used for OFA?
Intravenous lidocaine (1.5 mg/kg/hr) and regional blocks (blocks Na+ channels that suppress the nociceptive pain transmission)
