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NORA Flashcards

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1
Q

Define MAC

A

Greater than MODERATE depth

Requires same preop and intraop care

Patient must retain consciousness and the ability to respond purposefully-not what actually happens

ALWAYadministered by anesthesia provider

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2
Q

Main differences between 4 levels of sedation

A

Minimal
Moderate- no airway intervention
Deep- airway intervention may be required
General-intervention often required

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3
Q

Expectations during MAC

A

Psychological support
And everything else that is required during general

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4
Q

Good MAC candidates

A

Can remain motionless

Can follow directions

Can tolerate conversion to general

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5
Q

MAC main complication

A

Respiratory compromise from excessive sedation

NOT less risky than generak

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6
Q

Risk of MAC vs General

A

MAC is not less risky than GA in terms of permanent brain injury or death

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7
Q

Problems with MAC med titration

A

There is significant variability in individuals response to medications- we are all snowflakes

Goal is consistent plasma concentrations and avoiding oversedation/airway compromise

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8
Q

Elimination half-life

A

Time necessary for the plasma concentration of a drug to be reduced by half

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9
Q

Context sensitive halftime

A

Time for plasma concentration of a medication to be reduced by half after cessation of an infusion of a certain duration

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10
Q

Half time equilibration constant?

A

Used to assess the time to effect after a bolus and removal of drug from effect site after cessation of infusion

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11
Q

A drug with short t1/2 Keo will demonstrate what?

A

Keo=equilibrium constant

Rapid equilibrium between plasma and brain and will have a shorter delay in onset

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12
Q

CPss50

A

Plasma concentration required to abolish purposeful movement at skin incision

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13
Q

Two qualities we love about propofol

A

Amnestic and hypnotic

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14
Q

Ketamine considerations in MAC

A

Minimal resp and card depression

Hallucinations

Oral secretions can cause laryngospasm-glyco

Good adjunct for propofol but only use low dose in outpatient setting

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15
Q

Dexmedetomidine

A

Central presynaptic alpha-2 agonist

Increases vagal tone=hypotension and bradycardia

Slow onset-sticks around

Potentiates analgesia of opioids

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16
Q

Why are MAC patients at risk of airway fire? -

A

Uncontrolled airway and an open oxygen source

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17
Q

What is the fire triad?

A

Ignition source

Fuel source- alcohol prep

Combustible gas- O2

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18
Q

What are our flammable gasses?

A

Oxygen and Nitrous

NOT the halogenated anesthetics

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19
Q

Preventing OR fires

A

Flushing under the drapes with AIR

Use air/oxygen blender

Keep drapes off patients face

Use harmonic scalpel or bipolarelectrosugery NOT cautery

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20
Q

First thing in airway fire?

A

Turn off O2

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21
Q

2nd and 3rd step in airway fire

A

Pull out burning material

Replace ETT

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22
Q

What can increase chances of LAST?

A

Cardiovascular depression= reduced hepatic flow and buildup of local

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23
Q

What potentiates cardiovascular toxicity of LAST?

A

Hypercarbia
Acidosis
Hypoxia

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24
Q

Signs of last

A

Sedation
Numbness of the tongue/circumoral tissues
Metallic taste
Restlessness, vertigo, tinnitis, inability to focus
Slurred speech, skeletal muscle twitching
Tonic-clonic seizures
Cardiovascular toxicity

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25
Treating LAST
Ventilate with 100% O2 Benzodiazepines elevate seizure threshold Avoid propofol Initiate ACLS protocols as needed Avoid vasopressin, Ca++ channel blockers, beta blockers or local anesthetics LA cardiotoxicity may be treated with Lipid Emulsion (20%) Therapy -Bolus 1.5mg/kg (may repeat 1-2 times) -Infuse 0.25-0.5 mL/kg/min
26
ASC killers
Pain Drowsiness PONV -unplanned hospital admissions
27
URI wait times
Adults 6 weeks Peds-2-4 weeks
28
Why do we care about hyperglycemia
Dehydration Fluids shifts Electrolyte abnormalities Impaired wound healing
29
Outpatient diabetes recommendations for blood sugar
A1C<7 Preprandial 90-130 Post Prandial<180
30
Ballpark a1C average glucose table
31
Why don’t we just lower BS before surgery for non optimized patients?
Artificial reduction may increase periop mobility and mortality -oxidative stress and organ impairment Chronic hyperglycemia alters hormonal counterregulatory control
32
1500 dosing rule for insulin
1500/total daily insulin =expected decrease in blood glucose with 1 unit of insulin
33
Patient takes 10 units lantus plus 10 units of regular at every meal How much will 1 unit drop their blood glucose?
10+10+10+10=40 1500/40=37.5
34
What do OSA patients have higher rates of?
Diabetes HTN MI Stroke MI CHF
35
Presumptive OSA
3 criteria on Stop bang
36
Stop bang criteria
Snoring Tiredness Observed apnea Pressure HTN BMI >35 Age >50 Neck circumference >40 Gender MALE
37
Who is unfit for ASC??
Those unwilling to use their cpap
38
What do we know about the OSA outpatient population?
-no increased need for ventilatory assistance or reintubation (exclusionary criteria) Higher incidence of post op hypoxemia
39
BMI cutoff for ambulatory surgery
Psych there isn’t one if they’re medically optimized Deal with it
40
Increased m&m in obesity- bmi and problems
>50- super obese Wound infections Sepsis Increased 30-day mortality
41
PONV risk factors
Female History PONV Non smoking Young <50 General vs regional Volatiles Post op opioids Duration of surgery Surgery type (laparoscopic, gyn)
42
Apfel score
Points 0-4 Female Non smoker History PONV Opioids
43
2 surprise ways to decrease PONV
Preop carbohydrate beverage Sugammadex instead of neo
44
What are we treating vital signs with intraop instead of opioids?
Esmolol
45
Adult PONV management flow chart
46
Main takeaway from PONV management
Combo therapy is more important than monotherapy Unless its reglan which doesn’t work regardless
47
Which surgery type should be under general?
Laparoscopic T1 spinal is a bad idea
48
What local do we not use for spinals?
Lidocaine Increased risk transient neurological symptoms
49
Which type of block is epidural?
Caudal…
50
What does epidural lower the risk of vs spinal?
PDPH
51
How do you handle an uncooperative/disinhibited patient under MAC?
Pick a lane Either sleepy time or wake them up so they are more appropriate
52
Recommendations for ASC
Use propofol for induction Minimize opioids/volatile No N2O Address PONV Use LMAs, avoid NMBD, consider BIS
53
Soap ME for NORA or OBA
Suction Oxygen source Airway equipment Pharmaceutical, epi, atropine, succ Monitoring equipment Equipment (special) -syringe pump, lead
54
What should we be prepared for in MRI?
ANAPHYLAXIS
55
Yearly radiation limit
50 millisieverts
56
IV contrast considerations
Maintain hydration Stop metformin preop-increased risk lactic acidosis Sodium bicarbonate may help improve contrast elimination
57
Cocktail for ECT
Every patient will likely have a different set of meds they typically get listed in their chart-follow it
58
Occulocardiac or “five and dime”
Bradycardia/asystole associated with v and X manipulation Trigeminal and vagal
59
Statistics on office based closed claims
50% respiratory- bronchospasm, esophageal intubation, inadequate ventilation 25% drug related- MH, wrong dose
60
Difference between OBA and ASC
OBA have no accrediting body
61
OBA vs ASC injuries
OBA 64% were permanent or led to death ASC 21% were permanent or led to death
62
Type of anesthesia for ENT surgery
Regional, general, or mac + local (fire risk)

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