Week 1: Basics and assessment Flashcards
(106 cards)
1
Q
Basics to Anesthesia Set UP
A
SOAP: Suction, Airway, Pharm
2
Q
Suction (in SOAP)
A
Make sure suction is on and accessible
3
Q
Oxygen (SOAP)
A
Have oxygen setup and ambubag
Check gas machine
4
Q
Airway (SOAP)
A
-ETT w/ or w/o stylet
-LMA
-Oral airway
-Esophageal stethoscope or temp probe
-Oral Airway
5
Q
Pharm (SOAP)
A
Meds LABLED:
-Strength
-Date and time
-Initials
6
Q
MS MAIDS (OR setup)
A
Machine
Suction
Monitor
Airway equipment
IV poles
Drugs
Special equipment
7
Q
MS MAID
(Machine)
A
Machine check and backup supplies (Ambu!)
8
Q
MS MAIDS
(Suction)
A
Suction is on and working, at head of bead for easy access
9
Q
MS MAIDS
(Monitor)
A
Have all monitors for appropriate case
-BP
-Tele
-O2
-ETCO2
10
Q
MS MAIDS
(airway equipment)
A
Tubes, blades, various airways:
-ETT w/ or w/o stylet
-Oral airway
-LMA
11
Q
MS MAIDS
(Drugs)
A
table top and case specific drugs ready
labeled if drawn up
12
Q
MS MAIDS
(Special equipment)
A
Two drape clips, bair hugger, fluid warmer, OG tube, IV pumps, swa ganz/CVP monitor, shoulder roll, pillows
13
Q
Anesthesia Stages
A
- Pre- induction
- induction
- Maintenance
- Emergence
14
Q
Induction stage, must
A
Ensure adequate oxygenation and airexchange with bag valve mask
15
Q
Maintenance stage
A
Sustain surgical anesthesia
16
Q
Emergence Stage
A
Discontinuation of anesthesia–>return to consciousness and protective physiologic reflexes are regained
reversals for muscle relaxants are given
17
Q
Depth of Anesthesia
A
Degree to which CNS is depressed
Useful parameter for individualizing anesthesia
18
Q
Stage 1 depth of anesthesia
A
Analgesia - amnesia and reduced awareness
Pt progresses to drowsy, poor coordination
VS and pupils UNCHANGED
19
Q
Stage II depth of anesthesia
A
Increased SNS activity = Excitement - delirium and possibly combative behavior
Larygospasm can occur
Pupils are dilated
20
Q
Stage III anesthesia depth
A
Adequately anesthetized for procedure
eventual loss of spontaneous movement
Eyelid reflex disappears
gag reflex is obtunded
21
Q
Stage IV anesthesia depth
A
Medullary paralysis
Too much, overdose, arrest
22
Q
Pain is
A
Conscious perception of noxious stimuli
NOT absence of movement
23
Q
Prys-Roberts theory
A
Anesthesia is a state which patient does not perceive or recall noxious stimuli
24
Q
Modern thoughts on anesthesia depths
A
Drug-induced non response to stimulation
CALIBRATED
against strength of surgical stimulus and diffiiculty of suppressing the response
Depth depends on what is happing in procedure
(i.e. Toe bunion vs open heart surgery)
25
Theory of General Anesthesia
Loss of response and perception of all external stimuli
26
Where in CNS to anesthetics work?
Spinal chord to inhibit movement
Hippocampus and amygdala to cause amnesia
27
Most relevant site of anesthetic action
Synapse
28
Basic anesthetic MOA
Presynaptic inhibition of neurotransmitter release --> enhancement of inhibitory neurotransmitter effects-->inhibition of excitatory neurotransmitter effect
29
Anesthetics modulate:
Ligand-gated ion channels
30
Ligand-gated ion channel mediate
fast excitatory and inhibitory neurotransmission
31
3 Ligand activated ion channels in anesthetics and basic ligand function
5-HT3
Glycine
Nicotonic
Ligand channel activation inhibits fast excitatory synaptic transmission and/or facilitates fast inhibitory synaptic transmission
32
Anesthetics and Glycine
Anesthetics increase affinity of receptor for glycine (potentiate glycine activated currents)
possibly contributes to action of volatile and some parenteral anesthetics
33
5HT3 channels are affected by
Volatiles but NOT propofol
possible responsible for PONV
34
Nicotinic receptors and anesthesia
Inhibited
may contribute to amnesia
35
Why are ligand gated ion channels a logical target for anesthetics?
Selective effects on these channels could either
INHIBIT fast excitatory synaptic transmission and/or FACILITATE fast inhibitory synaptic transmission
36
Most important inhibitory neurotransmitter in CNS
GABA
37
GABA
inhibitory neurotransmitter
38
GABA receptor location
abundantly in CNS
39
GABA nuerotranmitter type
ligand gated Cl - channel
40
GABAa and anesthetics
Potentiated by many anesthetics
Probably target molecular target of anesthetics
41
Glutamate
Major excitatory neurotransmitter in CNS
42
Glutamate -activated ion channels
nonselective, involved in fast excitatory synaptic transmission
43
Categories of glutamate activated ion channel
-NMDA
-AMPA
-Kainate
44
NMDA receptors and anesthesia
Volatile anesthetics may inhibit NMDA-activated currents
45
NMDA - type glutamate receptors and ketamine
Ketamine is a potent and selective inhibitor of NMDA activated currents
46
NMDA type glutamate receptors are
inhibited by Ketamine and N2o2 and xenon
47
MAC
Minimum alveolar concentration
48
One MAC =
alveolar partial pressure of a gas at which 50% of humans do not respond to surgical incision
ie.e sero 2% (2% is the MAC)
49
MAC-awake
Min alveolar concentration of anesthetic that inhibits response to COMMAND in 505 OF PATIENTS
1/3 of MAC
i.e. sero 2%, MAC awake is 0.6%
50
MAC-BAR
Min alveolar concentration of anesthetic that blunts autonomic response
1.6 x higher than MAC
i.e Sero 2%
MAC-BAR is 3.2%
51
Disadvantages of MAC
Highly dependent on anesthetic end point (i.e. different stimuli require different MAC values)
52
Factors that reduce MAC (need less)
-older age
-hypothermia
-Depressant meds
-A2 agonist
-Acute ethanol consumption
-Hypoxemia
-anemia (less than 3.4)
-Hypotension
-Pregnancy
-N2O, Ketamine, lidocaine, clonidne, alpha-methyldopa, reserpine, chronic amphetamine use, lithium
53
Factors that increase MAC (need more)
any hypermetabolic state
-young age
-hyperthermia
-hypermetabolism
-chronic ETOH consumption
-Acute administration of amphetamine
-redheaded females
54
Factors with no effect on MAC
Anesthesia duration
gender
hyper/hypocapnia
metabolic alkalosis
HTN
Neuromuscular blocking agents (muscle relaxants)
Hypyer/hypothyroidism
55
Nitrous Oxide effects on body
Increase HR
Increases SVR
no significant BP change
56
Isoflurane effects on body
respiratory irritant
mild Increases heart rate
Significant BP drop
Decreases SVR
57
Desoflurane effects on body
Respiratory irritant
moderate Increase HR
Decrease BP
Decrease SVR
58
Sevoflurane effects on body
Seizure activity
No HR change
decrease BP
Decrease SVR
59
Gas with highest metabolism by liver
Sevo (5-8%)
59
N20 Advantage
reduces MAC
60
N20 disadvantages
expansion of closed air spaces
diffusion hypoxia
61
Isoflurane disadvantage
Trigger for MH
62
Diasdvantage of sevoflurane
Trigger for MH
63
Thipental is a/an______ and contraindicated in _____
IV induction agent
patients with porphyria
64
ASA clasification system purpose
Asses and communicate patients comorbidities for anesthesia planning and risk assessment
65
ASA class 1
Normal, healthy patient
nonsmoking, minimal ETOH
66
ASA class II
Mild systemic disease w/o substantial function limitations
i.e. smoker, social ETOH, pregnancy, obesity, well controlled DM/HTN/Lung disease
67
ASA III
Severe systemic disease and substantial limitations
poorly controlled DM, HTN COPD, morbid obesity, ETOH dependence, pacemaker, moderately reduced EF, ESRD,
Greater than 3 months from stent/MI/Stroke/CAD
68
ASA IV
Severe systemic disease CONSTANT THREAT TO LIFE
less than 3 motnhs MI, CVA, stents, CAD
ongoing cardiac ischemia or valve dyfxn
Severe EF reduction
Sepsis/DIC/ARDS/ESRD
69
ASA V
Moribound, not expected to survive without procedure
i.e. ruptured aneurysm, massive trauma, intracranial bleed with mass effects, ischemic bowel with organ dysfunction
70
ASA VI
Brain dead, organs to be removed for donation
71
ASA E
Emergency operation
72
Benefits of beta blockers
-Restores oxygen supply/demand mismatch
-reduces perioperative ischemia
-Redistribute coronary blood flow to the sub endocardium
-stabilizes plaques
-increases ventricular fibrillation threshold
73
Medications affecting perianesthesia
-ACE inhibiitors
-Beta blockers
-Calcium channel blockers
-Diuretics
-Antiarrythmics
74
Airway assessment components
1. Mallampati Classifcation
2. Jaw protrusion
3. Range of neck movement
4. 3-3-2
75
3-3-2
Mouth opening 3 fingers between incisors
Thyromental distance 3 fingers (distance from tip of mandible to anterior neck
Mentohyoid distance 2 fingers - between base of mandible and thyroid notch
76
TM distance ratings
Good >7.5 cm
Moderate 6-7.5
Poor: <6cm
77
Mouth opening score
Good >4cm
moderate: 3-4 cm
poor: <3cm
78
Mallampati classes and general indication
Stage II-IV = 50% of people difficult to intubate
79
Cormack and Lehane Grade
view of vocal chords
80
Mandibular mobility test
jaw thrust forward
81
Herbal supplement use key points
FDA does not regulate! Should be d/c'd 2 weeks prior if possible
82
4 herbal Gs that increase bleeding
Garlic
Ginger
GInkgo
Ginseng
83
BMI calculation
Weight in Kg
-----------------
height squared (m)
84
Action of metabolic equivalents
Measures functional capacity (cardiovascular assessment)
85
METS and proceeding to surgery
>4 METs can proceed even with risk factors if managed with statins and beta blockers
<4 METs should be further assessed to identify cardiac risk
86
Cardiac risk assessment question (beyond history)
1. Are you able to walk 2 blocks without stopping (regardless of limiting symptoms)
2. Are you able to climb 2 flights of stairs without stopping (regardless of limiting symptoms)?
87
one MET is defined as
The amount of oxygen consumed while sitting at rest
88
One met is equal to
35 mL O2 per kg/min or 250 mL 02/min
89
MET calculation
VO2 = oxygen consumtion
VO2 x 3.5 mLO2/kg/min
90
Highest risk of perioperative MI
Unstable angina- surgery should be canceled until patient is stabilized
91
CV symptoms to assess for
Syncope
Fatigue
Chest pain
Dyspnea
92
If patient has BMS (bare mental state)
delay elective surgery for 30 days
93
If patient has drug eluding stents
delay surgery for 6-12 months or more
94
Thiopental
-Barbiturate
-contraindicated in patients with porphyria
-gaba-a agonist
-histamine release (no asthma)
95
Propofol
DIRECT gaba-a agonist: inhibits neuronal cell excitation
antiemetic effect pain
on injection
96
Etomidate
Gaba-a agonist
-suppresses adrenocortical function
-triggering agent for porphyria
-increases PONV
-minimal effects on CV system
97
Ketamine
NMDA receptor ANtagonist
-increases ICP, cerebral blood flow, cerebral metabolic rate
-Bronchodilator
-Preserves airway reflexes
-increases secretions
-dissociatic anesthesia
-trigger to patient with porphyria
-Increases BP and pulse
-caution in pts with HTN, angina, CHF, psychiatric diseases, airway issues (silent aspiration)
98
Benzodiasapine
gaba-agonist
Midazolam, lorazepam, diazapam
anterograde amnesia
Little effect on CV system unless hypovolemic
Causes cerebral vasoconstriction (decrease CBF and ICP)
99
Dexmedetomidine (precedex)
Alpha-2 receptor agonist (prevents central sympathetic response)
-Bradycardia and hypotension
-does not cause resp depression
100
Methohexital
Barbituate
-triggering for porphyria
-Gold standard for ECT
101
unconciousness
reticular activating system
102
amnesia
hippocampus and amygdala
103
analgesia
spinothalmic tract
104
immobility
ventral horn
105
