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Anesthesia > Peri-operative > Flashcards

Peri-operative Flashcards

1
Q

Discuss the general anesthetic procedure

A

Pre-oxygenate patient using oxygen mask -> administer IV induction medication -> brief-bag-mask ventilation -> endotracheal intubation

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2
Q

Discuss the indications for endotracheal intubation

A

5 Ps

  • Patent airway
  • Protect against aspiration
  • Positive pressure ventilation
  • Pulmonary toilet (suction)
  • Pharmacologic administration
  • Hemodynamic Instability
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3
Q

Discuss the airway management equipment

A

STABLES

  • Suction
  • Tape
  • Airway for bag-mask ventilation
  • Bag mask and oxygen
  • Laryngoscope
  • Endotracheal tube with stylet (7-8 men, 6-7 women, age/4+4 for children)
  • Syringes for medication
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4
Q

Discuss the procedure for bag-mask ventilation

A 
- most important airway management tool
Indications
- hypoventilation
- severe hypoxia
Contraindications
- prolonged or high pressure BMV contraindicated for patient with full stomach
Procedure
- sniffing position: cervical flexion with atlanto-occipital extension
- C to secure mask on face
- E to secure and lift jaw
Troubleshooting
- suction
- chin lift and jaw thrust
- oral or nasal airway
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5
Q

Discuss the procedure for endotracheal intubation

A 
Preparation
- prepare all equipment
- ensure O2 source and monitors available
- apply monitoring
- position in sniffing position
- pre-oxygenate
- administer induction medication
Intubate
- introduce laryngoscope to sweep tongue and insert posterior to vallecula
- raise handle to visualize cords
- place tube 1-2cm below cords and inflate cuff
Confirm Placement
- tube visualized
- detection of CO2 on end tidal CO2 between 30-35
- auscultation of lungs
- Observed chest rise
- Condensation on ET tube
- refilling resevoir on bag
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6
Q

Discuss laryngeal mask airway

A

Indication
- when general anesthesia required but ETT is not
- rescue when intubation and bag-mask fail
- assistive device
Absolute Contraindications
- ventilation requiring high pressure (>20) [obesity, lung disease]
- high risk for aspiration
Relative Contraindications
- patient with mass in airway
- patient position for surgery is not supine
- surgery lasting >2-3hrs

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7
Q

Discuss the procedure for general anesthesia

A
  • Pre-oxygenate with oxygen mask until expire oxygen >80%
  • IV infusion of induction agent (propofol 1mg/kg) plus muscle relaxant and pain medication
  • Wait until patient is under anesthesia (unresponsive, no reflexes/no blink reflex)
  • Bag mask ventilate and administer muscle relaxant (rocurronium 1mg/kg - takes 90sec)
  • Intubate and attach ETT to ventilator
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8
Q

Discuss the difficult airway algorithm

A

Known Difficulty Airway
- awake intubation
- if fail cancel case or use supra-glottic device (LMA) or regional anesthesia if possible
Unknown Difficult Airway and Fail
- bag mask valve
- if BMV successful then can attempt different airway (video-assisted, supra-glottic, fiberoptic)
- if fail second way then wait for anesthetic to wear off and cancel case
- if BMV unsuccessful then call for help, attempt supra-glottic airway, or emergency airway

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9
Q

Discuss the exam and investigations for hypovolemia

A 
History
- poor intake
- excessive diuretic use
- GI or blood loss
Exam
- tachycardia
- Orthostatic hypotension
- low JVP
- dry mucous membrane
- decreased skin tugor
- low urine output (<0.5mL/kg/hr)
Investigations
- high urea to creatinine (10:1)
- urine sodium <20mmol/L and fractional excretion Na <1%
- fractional excretion urea <35%
- increased urine osmolality
- increased hematocrit
- metabolic alkalosis in mild and metabolic acidosis in severe
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10
Q

Discuss the goals of IV fluid administration in anesthesia

A
  • optimize pre-operative volume status
  • compensate for losses
  • normalize electrolyte status
  • treat critical illness/events
    Ways to Increase Speed
  • short IV catheter
  • larger bore IV catheter
  • high bag height
  • pressurized device
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11
Q

Discuss types of IV crystalloids and replacement

A 
Normal Saline: 0.9% normal saline
D5W: 50g/L dextrose in water
2/3-1/3: 2/3 D5W and 1/3 NS
- 33g/L glucose and 50mEq Na and Cl/L
Ringer's Lactate: 130mEq Na, 109mEq Cl, plus small K, Ca and lactate
Replacement
- RL best for resuscitation 
- as 2/3 interstitial and 1/3 intravascular require 3:1 for replacement of blood loss
- D5W goes 2/3 ICF and 1/3 ECF
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12
Q

Discuss general indications for specific IV fluids

A 
Hypovolemia
- NS or RL
- D5W least effective as majority goes into intracellular fluid
Cirrhosis with hypovolemia
- albumin
Dehydration (hypovolemia with hyponatremia)
- hypotonic saline (0.2NS or 0.45NS)
- D5W
- done to move fluid into intracellular space
Maintenace
- 0.45NS, D5W 
- 2/3-1/3
- 0.45NS plus 20mEq/L of KCl added to replinish water and electrolytes
Blood loss
- NS or RL
- pRBC
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13
Q

Discuss massive transfusion protocol

A
  • Occurs when patient has lost entire blood volume within 24hrs
  • Require 4units pRBC for each volume blood lost
    • Give 1 FFP for every 2u
  • Require frequent monitoring of CBC, electrolytes (Ca included), INR and fibrinogen
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14
Q

Discuss Complications following blood transfusion

A

Infection
- viral most common
Hemolysis
- Immediate reaction due to ABO incompatibility
- fever, chills, chest, or flank pain, hypoxemia, hypotension, ARF and FIC
- delayed reaction at 7-21d due to trace antibodies
Non-Hemolytic Febrile Reaction
- reaction to donor leukocyte antigens and antibodies
- fever, chills, N/V, headache, myalgia
Allergy
- react to proteins in blood
Immune System
- more commonly in immunocompromised individuals
Coagulopathy
- Dilution of coagulation factors and platelets when massive transfusion of pRBC
Transfusion Associated Circulatory Overload (TACO)
- congestive heart failure and acute pulmonary edema
Transfusion Related Acute Lung Injury
- result in Acute respiratory distress syndrome (hypoxemia, dyspnea, hypotension)
Hyperkalemia
- increase K concentration in blood
- peaked T waves, wide QRS, loss of p wave
Hypocalcemia
- citrate binds to calcium
- decreased myocardial contractility, hypotension, widened QRS and bleeding
Acid-Base Abnormalities
- metabolic acidosis: citric acid and lactic acid in stored blood
- metabolic alkalosis: hepatic metabolism of citric acid into bicarbonate

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15
Q

Discuss type, screen and crossmatch for blood products

A

Type
- confirms ABO and Rh blood groups
Screen
- takes 5-10 minutes which screen for presence of antibodies
Crossmatch
- taks 45 minutes and mixes blood together to determine if reaction occurs

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16
Q

Discuss the indications for blood products

A
  • 1 unit is 280mL which should raise Hgb 10g/L
    Patient Consent
    Anemia: Acute or Chronic
  • acute anemia require transfusion
    Trajectory of Active Uncontrolled Bleeding
    Presence of CAD or CVD
  • limited compensatory mechanism so require Hgb >100
    Evidence of Ischemia or Coagulopathy
    Blood loss Exceed Estimated Acceptable Blood Loss
  • Acceptable blood loss = EBV (75mL/kg male, 65mL/kg female *kg) * [Pre-op Hgb - Transfusion Trigger Hgb]/Pre-op Hgb]
  • usually <70 require transfusion
17
Q

Discuss the indications for fresh frozen plasma, platelets, and cryoprecipitate

A

Fresh Frozen Plasma
- Factors 2/5/7/8/9/10/11 protein C/S, fibrinogen, anti-thrombin 3
- pre-op for those with coagulation disorders
- massive transfusion
- reversal of warfarin
Platelets
- Severe thrombocytopenia <10 in non-bleeding
- Mild 20-50 in bleeding
- Surgery with >500mL of bleeding and platelets <50
- patients with head injury or prior to neurosurgical procedure with platelets <100
- large volume pRBC (>6)
Cryoprecipitate
- factor 2/8/13, fibrinogen, von Willebrand Factor
- DIC
- Massive bleed with fibrinogen <1

18
Q

Discuss the calculation for deficit losses

A

Estimate Hypovolemia
- Mild 3% (dry axilla and mucous membrane
- Moderate 6% (oliguria, othostatic hypotension, cool peripheries)
- Severe 9% (profound oliguria, CNS dysfunction)
Estimate Total Body Water
- Male 60% body weight
- Female 50% body weight
- Elderly 45% body weight
Calculation
- kgEstimate Total Body WaterEstimate Hypovolemia
- Replace first half in first 8hrs and second half in next 16hrs

19
Q

Discuss volume control as a mode of ventilation

A

Indication
- used for patients with normal and constant lung volumes
Constant Features
- RR (end tidal CO2 to 35-45)
- Positive end-expiratory pressure (PEEP, >0)
- positive pressure in airway at end of expiration
- Tidal volume (VT =7mL/kg)
- volume of air moved in one breath
Advantage
- as VT is set ensures adequate ventilation and maintains PaCO2 and pH
Risk
- pressure needed to maintain VT may change leading to barotrauma

20
Q

Discuss pressure control as a mode of ventilation

A

Indication
- abnormal lung compliances or where lung compliance may change (position)
Constant Features
- RR
- PEEP
- Peak Inspiratory Pressure (PIP) which is proportional to tidal volume/lung compliance and set to ideal tidal volume of 7mL/kg
- pressure in airway during inspiration
Advantage
- set pressure control preventing barotrauma
Disadvantage
- tidal volume may change per breath leading to either volume trauma or inadequate ventilation

21
Q

Discuss synchronized intermittent mandatory control as a mode of ventilation

A

Indication
- weaning from volume control ventilation
Constant Features
- minimum tidal volume
- RR
- pressure support
Advantage
- if patient breaths on their own then machine delivers supporting pressure to help
- if do not breath machine will provide breath of minimum tidal volume

22
Q

Discuss pressure support ventilation as a mode of ventilation

A 
Indication
- weaning patient off pressure control ventilation
Constant Features
- Minimum PIP
- Minimum RR
- Pressure support
Advantages
- if do not breath machine provides minimum inspired pressure
23
Q

Discuss the criteria for extubation

A
  • Underlying cause for initial intubation addressed
  • No anticipated future need of intubation
  • Hemodynamically stable
  • Well oxygenated
  • Respiratory effort based on end tidal CO2, visible chest rise
  • Adequate level of consciousness (gagging, obeying command, moving limbs)
  • Adequate muscle tone (squeeze hand, ability to lift head)

Anesthesia (4 decks)

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