AP1 tests 2-3 combo
what is pseudohyperkalmeia
lysis of rbcs, wbcs or throbocytosis sample. High k+, LAB ERROR
Which blade is curved which is straight
mac is curved miller is straight
what is the reduction % of volume with a class 1 hemorrhage?
less than 15%, which would be a blood loss less than 750 mL
what is poor interincisor distance
less than 3 cm or two fingers (other place says 4cm)
the ASA task force says a transfusion should be administered in patients with what hemoglobin value?
less than 6
what would a critically low hemoglobin be?
less than 6
Thyromental distance bad sign
less than 7 cm or 3 fingers = mandibular hypoplasia >9cm can also be difficult =
what was old guideline for uncuffed ett?
less than 8 is uncuffed, no they just say neonate use uncuffed, kids can use either.
acute pancreatitis and mag
low
chewing tobacco and k+
low
hyper aldosterone and mag
low
hyperparathyroid and mag (when ca++ increases mag goes....)
low
licorice and k+
low
porphyria and mag
low
renal tubular disease and K+
low
too much adrenalcorticosteroids and k+
low
Accroding to art does high or low na+ cause cerebral edema, confusion, coma, agitation
low (book says both)
hyperaldosterone and k+? All other electrolytes and high adrenal steroids?
low (hyper adrenal steroids decrease all electrolytes but na+)
What are 3 risks of albumin (1 electrolyte)
low ca++ infection (human product) allergy reaction (human product)
Why is KCl given and not other forms of k+
low cl- causes kidneys to have a hard time retaining K+
What happens with older patients and third spacing
low protien increased third spacing
what do you worry about with low Hgb vs high
low= o2 carrying capacity high = too much clotting
Burns and K+
lower
where do you want you epidural catheter placed for labor or lower abdominal anesthesia?
L2 or L3 interspace
free water deficit equation
(na/140)-1 x tbw
What is normal number ml in epi wash
0.2ml in 1:1000l
What is Epidural dose of levobupivacaine
0.5%
which medication would you use for a beir block?
0.5% lidocaine
how long do pts lay flat after blood patch
0.5-1 hrs (i think this what to book says)
bicarb epidural
1 cc/10 ml
how much local do you inject when doing a superior laryngeal nerve block
1 ml of 2% lidocaine above the membrane and 2 ml 2% lido after advancing through the membrane
What is the usual dose of platelets?
1 unit per 10 kg of body weight
Normal dose of plts
1 unit/kg (book says one per 10kg)
pencil point needles are associated with less than a ____ % risk of PDPH and a failure rate of approximately ____ %
1% 5%
Chance of PDPH
1%, less with pencil tip than cutting
Treatment for severe mag depletion
1-2 g over 5 min then 1-2g/hour Mag Sulfate
clonidine SAB
15-30mcg
What is a normal hemoglobin for men?
17
What is a MBT pack
2 units 0 neg blood 6 units PRBCS 4 FFP 1 plt
Max hours for LMA
2-3 hours
what flow of 02 can go through fiberopitc port
2-4 L
What is volume needed if epidural catheter is at L2-L3 and you want a T11-T12 block
3 levels x both cephalad and caudad = 1.5 x 6 = 9cc
Arts normal k+ range
3-5 mEq/L
Normal value for serum ca++
8.8-10.5
What is the average blood volume for an infant?
80 ml/kg
What is the average blood volume for a full-term neonate?
85 ml/kg
How many cartilages in larynx and names
9 thyroid, cricoid, epiglottic (single) arytenoid, corniculate, and cuneiform (pairs)
How long after HES administration has RRT been reported
90 days
How long should hospitalized patients who recieved HES be monitored for renal function postop
90 days
the full range of neck flexion and extension varies from ____ to ____ degrees and decreases approximately ____% between ages 16 and 75.
90 to 165 degrees 20%
What is the average blood volume for a premature neonate?
95 ml/kg
critically low hgb and critically high
< 6hgb >18
What is the max dose of hespan/hetastarch/hextend in order to reduce anticoagulation problems
<20cc/kg although art does a lot less than this
Osmolarity level (due to high na+ ) with coma seizures death
>430
Know how fast you can give CaCl
Art said look in the book
ASA difficult airway step 1
Asses likelihood and impact of: difficult ventilation difficult intubation difficulty with pt. cooperation difficult traceostomy
what nerve fibers are not mylenated
C
Pts. considered full stomach (pregnant, DM, emergency, hiatial hernia) can use LMA?
NO!
What are things that make bag mask vent difficult concerning (box 22-2): Seal (3) Age weight oral cavity (2) Lungs History (2)
Seal - beards, altered anatomy, ng tube age= greater than 55 weight = obese oral airway = obstruction or no teeth Lungs - stiff-poor compliance History - sleep apnea or snoring
define the term transfusion trigger
a single threshold for transfusion
What is a colloid?
a solution containing osmotically active substances of high molecular weight that do not easily cross the capillary membrane and therefore draw fluid into the intravascular space and expand circulating volume.
Describe the dura matter?
a thick and tough membrane. Provides the most protection for central cord structures
How much is in a bag of whole blood?
about 500 mL
what are some common colloids?
albumin, dextran, gelatins, and hetastarch which is also known by the great Menardie as Hespan
What coagulation factors does ffp contain
all of them
what is the aggresive but definitive way to treat a PDPH?
an epidural blood patch
psych and low ca++
anxiety depression irritable confused/psychotic/dementia
If RSI do you extubate deep or awake
awake
hypopharynx (laryngopharynx) beginning and end
begins at epiglottis (level of hyoid bone and base of tongue) and ends at opening to glottis (cricoid cartilage). Includes portion above esophagus.
Headache with hypernatremia hyponatremia or both?
both (look at table 20-4 and box 20-1)
when the cartilage disappears what does the bronchi change into?
bronchioles
pulm signs of low ca++
bronchospasm laryngospasm
what locals are often used in a sciatic nerve block?
bupivacaine 0.5%, ropivacaine 0.5%, and lidocaine 1.5%
which local and concentration would you choose for a subarachnoid block for a c-section
bupivicaine 0.75%; it will last longer than 0.5% (will last 1.5 to 2 hours) and longer than lidocaine
what are facial causes of an upper airway obstruction?
burns congenital abnormalities trauma
while doing a test dose in an epidural, if you inject in to a vein and your test dose contains epi, how much should your heart rate and BP raise?
by 20% within 30 seconds
what envelopes the trunks in the brachial plexus?
by a fascial sheath, which is a closed space at the interscalene space, and is also known as the sheath of the brachial plexus
how to the vocal cords compensate in a unilateral injury of the recurrent laryngeal nerve?
by shifting the midline to the uninjured side
What is the treatment for hypocalcemia?
calcium chloride or gluconate PO calcium vitamin D
3 treatments of high mag
calcium, diuretics dialysis Lower non-depolarizing paralyitc dose
according to the ASA difficult algorithm you are in the emergency pathway, meaning you have unsuccessful intubation with inadequate ventilation. what would you do next?
call for help and attempt emergency non invasive airway ventilation
What happens to esophageal sphincter if cuff is over inflated on LMA
can cause it to open
Difference between airway exchange catheter and bougie
can jet ventilate with airway exchange cathrter or bag mask
What can happen with bougie and airway exchange catheter placement if it is too distal
can perforate lower airway or irritate it
What is mapllampati class "0"
can see epiglottis
What are the two last phases of lung development
canalicular phase - weeks 16-26 -- terminal and resp bronchioles Terminal sac phase - weeks 24-36- primitive alveoli
What are some contraindications to cell saver per art (look at table 20-16)
cancer c-section (amniotic fluid) infection including BOWEL SURG
4 main causes of hyper ca++
cancer meds granulomatous disorders (TB leprosy) Nonparathyroid endocrine disorders
What is fixed volume cardiac state?
cannot compensate for BP drop
What is charted in the graphic area of the record (4)
care given drugs/fluids vitals pt response
Most innervated part of the lower airway for sensation
carina
Which direction should needle go into trachea in retrograde intubation vs. needle cricothyrotomy
caudal in cricothyrotomy and cephalad in retrograde intubation
Steroids and fluid status
cause fluid overload and hypernatremia
the ______ of the local anesthetic generally affects the density of the block
concentration
two causes of primary hypoparathyroidism
congenital maternal hyperparathyroidism
When using a nerve stimulator in doing a brachial plexus block what is done with the amplitude as the needle approaches the sheath?
continuously decreased so that the muscle response to the stimulus is maintained
What does ASRA say about coagulopathy and CNB
contraindicated
electrical translocation devices provide a ________ of variable amplitude that is administered through a conducting device
controlled stimulating impulse
When used cricoid pressure should used until
correct placement of ett is confirmed
What is the treatment for hypernatremia?
correct underlying cause replace water deficit dialysis change slow at a rate of 10 to 20 mEq per day
The epidural space is continuous from the base of the ________ to the base of the _________ at the _________ membrane
cranium, sacrum, sacrococcygeal
which cartilage is below the thyroid carilage?
cricoid cartilage
which cartilage of the trachea is the only one that is a complete ring?
cricoid cartilage
What is laryngotracheobronchitis
croup- inflammation of airway below vocal cords
How does hyperinflation of ett cuff cause obstruction
crushes lumen of tube, need to pass stylet or airway exchange catheter.
Do arytenoids sit on cricoid cartilage or thyroid
crycoid. The cricoid is larger in posterior and rises superiorly in the posterior where the thyroid is only an anteriolateral cartilage.
When trauma surgeon says "i just cant seem to get them to stop bleeding", what should you give them
cryo
What causes pdph
csf leak causes vasodilation, pressure on vault, meninges and tentorium traction
What do you need baseline before art line
cuff pressure. Chart this
What should you be careful not to hold onto with magill forcep when advancing ett
cuff, may rupture
How is fastrach (ILMA) different
curved rigid tube guiding handle epiglottic elevating bar guiding ramp in floor of mask
what are the 2 main types of needles used for spinals?
cutting and non cutting or pencil tip
Treatment for n/v with spinal epidural (4)
decadron zofran pressors fluids
In low risk ambulatory surgeries, why are fluid bolus often given
decrease pain, nausea, dizziness, and increases street rediness
loc and high mag
decreased, drowsy (same as high ca++)
What can sepsis and hypomag do to calcium and vit D
decreases vit D and ca++
Repiratory status and high mag (at what level of high mag)
depression or arrest with 10-15
what is usually added to an anesthetic to make it hyperbaric?
dextrose
Drugs for high K+
dextrose and insulin Ca gluconate/CaCl bicarb kayexelate lasix
Arts 5 treatments for high k+
dialysis calcium insulin and glucose diuretics kayexelate
pre-oxigenation in osa and obesity
doesn't last as long and hypoxia more profound
When inserting LMAs should they be in non-dominant or dominant hand
dominant
Does FFP have to be typed and crossmatched
don't have to be but desireable
why would a total spinal happen?
due to cephalad spread of local to pons
The epidural space is a potential space outside the _________ but inside the _________
dural sac, vertebral canal
What does the brachial plexus do at the lateral border of the first rib and posterior of the clavicle?
each of the 3 trunks divides into vental and dorsal divisions
In high risk pts is it better to give fluids early or late in the case
early
What kinds of pts should difficult airway equipment be used on when student is first learning?
easy airway patients
Is proseal or fastrach used more for intubation
fastrach. Proseal and classic aren't designed well for intubating. Fastrach is what almost everyone uses if they have to intubate through it. It is an "intubating LMA"
who is more likely to get a PDPH after a spinal, a female or male?
female
How to confirm placement with double lumen tube?
fiberoptic, look for carina and then blue cuffed tube. If no blue then too deep
When should hespan be discontinued concerning kidneys
first sign of renal injury
What sympathetic/parasym nerves innervate the tracheobronchial tree
first through fifth thoracic ganglia = sympathetic vagus nerve = para
will a hypobaric solution injected into the subarachnoid space sink or float
float
what do extrinsic muscles of the larynx do? 3 main functions
for connections between larynx, hyoid, and neighboring anatomic structures -MAIN FUNCTION is the adjust the position of the trachea during phonation, breathing, and swallowing
Where does vertebral column extend
foramen magnum to tip of coccyx
If you have given the appropriate amount of crystalloid and there appears to still be too low intravascular volume, what does NH say to do
give isotonic colloid not crystalloid (pg 393). However, pg 394 says to give a bolus?
what do you do if you only have o+ and you have to give to a B- patient
give them rhogam unless this is first exposure, then they should be ok
the epiglottis rests above the ___________ where it closes the ___________ during swallowing
glottic opening glottic aperature
what would a critically high hemoglobin be?
greater than 18
what is the reduction % of volume with a class 4 hemorrhage?
greater than 40% which would be a blood loss of greater than 2000 mL
class IV mallampati
hard palate only
What are 4 relative contraindications to surgical cricothyrotomy
hematoma, abcess tumor coagulopathy etc.
What is recombinant factor VIIa used for
hemophilia A, B and other congenital coagulopathies.
Art says paresthesia with high or low k+
high
can you use a cell saver on a Jehovah Witness patient?
if the patient accepts it, then you can
When do we do a caudal block?
in kids with hernia repair, this is very rare because we usually don't do regional on kids
why use paremedian
in older or arthritis where sclerosis is common
When do we use an epidural in cervical vertebrae?
in pain management
what are some complications that can occur with intubation?
in the goose laceration of lips or gums broken teeth dislocate jaw vocal cord injury foreign bodies such as teeth knocked in the airway
where is the epidural space largest (posterior to anterior)?
in the midline of the mid-lumbar region, at 5 to 6 mm
Where is the the supraclavicular portion of the brachial plexus located?
in the posterior triangle of the neck
What is non-reassuring finding for maxillary mandibular protrusion
inability to protrude mandibular incisors
how much does albumin 5% replace?
it replaces plasma loss in a 1 to 1 ratio
What can you give if kid wont hold still or for mentally impaired before CNB
ketamine dart
How can you differentiate normal neuropathy postop after spinal vs cauda equina
lingering bladder dysfunction that lasts 2 days or more
What organs does hespan effect the most
liver and kidneys Often causes needed RRT
6 FFP indications (1 organ, 1 drug, 1 condition, 3 others)
liver disease, coumadin, high PT/INR DIC, clotting factor deficiencies, excess RBC replacement
DM and mag. Pregnancy and Mag
low
calcium and MBT
low ca++ (citrate toxicity)
how is fluid volume deficit calculated?
maintenance (1.5 times wt in kg) times hours NPO
What can be lethal consequence of esphagus perforation
mediastinitis (50% morbidity)
what lies anterior to C1 and is bound superiorly by the base of the skull and inferiorly by the soft palate?
nasopharynx
Does LMA seal the esophageal sphincter
no
Is the provider who cares for pt intraop usually responsible for care post op
no usually a nurse and may be supervised another provider. We make sure they are cared for
If pt has migraine how can you tell if they have SAB PDPH
no way of knowing
would a healthy patient with normal liver and kidney function be likely to develop citrate intoxication after 20 units of banked blood?
no, a normothermic healthy patient can metabolize the amount of citrate present in 20 units of banked blood per hour
Combo CNB good for laboring women
no?
what kind of needle may drag fewer skin contaminants into subdermal tissue
non cutting or pencil point
which kind of spinal needle pierce the dura with a clearly perceptible click or pop
non cutting or pencil point
What kind of tubing needs to be attached to needle cricothyrotomy catheter for jet vent
non-compliant
Where is spinal epid site of action
normally centrally mediated substantia gelatinsosa in dorsal horn
Herbals alone and CNB
not a contraindication
NSAIDS and CNB
not a contraindication
Most common cause of hypernatremia
not enough water intake
According to the AANA what should be documented on the anesthesia record?
patient identification provider information equipment checks minimal monitors techniques medications intake and output procedural data preanesthesia evaluation informed consent
according to the AANA what does the operating room nurse document?
patient positioning restraints safety straps padding grounding pads tourniquets warming blankets other aspects of care
What are the topical doses used for awake intubation of the following (table 22-6): phenylepherine lidocaine cetacaine benzocaine cocaine lidocaine nerve block
phenly- 1% - only used as vasoconstrictor in nasal intubation Lido - 2 or 4% cetacaine? benzo - 20% cocaine - 4% lido - 2%
what is the role of the cricothyroids?
phonation
what is the role of the lateral cricoarytenoids?
phonation
Another name for intravascular volume
plasma
How is LMA classically inserted
pointer finger at back of cuff, posterior portion of cuff on palate, lubricate and slide in along palatopharyngeal curve. Usually fully deflated
Urine production and hyper na+
polyuria or oliguria
high ca++ and renal s/s (urine amount and 3 others)
polyuria polydipsia dehydration prerenal azotemia kidney stones nephrocalcinosis
Other than suctioned blood, what else needs to be calculated as blood loss
pooled blood, towels, drapes, floor etc.
Why age >55 = difficult bmv
poor airway muscle tone
What are rigid and semi rigid fiberoptic scopes used for
poor mouth opening poor neck mobility
proper patient _______ is important to ensure successful catheter placement
positioning
What does CRNA or OR nurse document
positioning, restraints, straps, padding, grounding, tourniquets, warming blankets etc.
What should you check with positioning intraop
pressure points ulnar nerve (mostly from side of bed) arm dropping (radial nerve) arm stretch beyond 90 degrees make sure head is neutral Do ROM Message head Periorbital edema
When would a nasal awake intubation be needed
previous airway difficulty, neck fractures, halo device, small oral opening, mass, critical care
Lateral cricoarytenoid muscles
primary adductors of cords. Attach to lateral criothryoid cartilage and arytenoids
what are LMA's used for?
primary airway device during appropriate surgical procedures valuable tool in managing a difficult airway a conduit for intubation of the trachea
what three thing does the ECF do?
provides a medium for cell nutrients, electrolytes, and waste products
Art's four reasons to use cricoid pressure
reflux rapid sequence full stomach Sometimes to help view
Are pts with fixed volume cardiac state relative or absolute contraindication
relative
3 causes of hyper mag
renal failure (not losses or insufficiency) Mag administration adrenal insufficiency
Normal dose of FFP
reverse coumadin = 5-8 ml/kg all others 10-20 ml/kg
Angle of left vs right mainstem bronchus
right = 25-30 (easier to intubate) Left = 45 (harder to intubate)
what is the function of the cricoarthyroids?
shortening and increasing tension of vocal cords
will JW use albumin
some will some don't, it is human
when using a nerve stimulator for a femoral block what should the milliamps be set at?
start at 1 and have a goal of 0.2 to 0.4
when doing an interscalene block, what are the settings the nerve stimulator should be at?
start at 1 milliamp decreased to 0.5
what is usually added to an anesthetic to make it hypobaric?
sterile water
in a bier block the patient in placed _______ and several layers of a suitable ________ material are wrapped around the arm in preparation for the tourniquet
supine, padding
what are intercostal nerve blocks used for?
supplementing balanced anesthesia techniques to increase the tolerance of the surgical procedure
total body water equation
tbw = kg x 0.6
Who is responsible for insturment and gauze count
tech
what are the landmarks to use in doing a median block at the wrist?
tendon of the flexor palmaris longus, and the flexor carpi radialis
Epi wash works best with which SAB meds
tetra> lido>Bup
once your wire is in placed and clamped in a retrograde intubation what can be done next?
the ETT tube is directed over the wire and passed into the trachea. as the tube enters the larynx tension on the wire is increased
what level will you see cardiac changes in an epidural or spinal?
the T1 to T4 area contains the cardiac accelerator fibers
Which of the single cartilages of the larynx is at the top of the three
the epiglottis
what is a surgical cricothrotomy?
the establishment of an airway by surgically incising through the cricoidthyroid membrane and placing a cuffed tracheostomy tube or an ETT.
where is the ECF found?
the extracellular fluid is the fluid outside of a cell.....also referred to as plasma
which nerve is formed from the contributions of the second, third, and fourth lumbar nerve roots?
the femoral nerve
what is the bromage grip?
the needle is grasped between the thumb and index finger with the patients body acting as a firm support for the needle stabilizing hand and helps prevent advancement or withdrawal fo the needle tip form the subarachnoid space
when placing a spinal, what is the paramedian approach?
the needle is inserted 1 cm or about 1 finger breadth lateral to the caudad aspect of the interspace, then directed toward the spinal canal and angled slightly cephalad then medially about 10 to 15 degrees
what is the cauda equina and location?
the nerve pathways of the spinal cord that continue in a collection of rootlets which extend from L1 to S5
which nerve is frequently injured when patients undergo extensive pelvic surgery?
the obturator nerve
The vestibular ligaments are thickenings of what
the quadrangular ligament that attaches from epiglottis to arytenoids to thyroid cartilage.
in the brachial plexus what happens after the rami pass the lateral border of the scalene muscles?
the reorganize into trunks
in the brachial plexus what do the rami from C 5 and C 6 combine to form?
the superior or upper trunk
what is formed by the space between the epiglottis and the base of the tongue?
the superior vallecula
what are the three main types of epidural needles?
the tuohy and the hustead and the crawford
which epidural needle is the easiest ?
the tuohy because it allows for directional placement of the epidural catheter into the space and the curved blunt tip is less likely to penetrate into the subarachnoid space
although forearm and anticubital fossa i.v.'s have been used for bier blocks, what is the risk of doing so?
there is an increased possibility of a partial or complete failure of the block when the hand or wrist is the surgical target
why is a patient with a long thyromental distance of 9 cm considered a difficult airway?
there is indication for difficulty due to a large hypopharyngeal tongue, caudal larynx, and longer mandibulohyoid distance
how common are permanent nerve injuries?
they are rare, less than 1 per 10,000, which is less than 0.1%
what kind of laryngeal nerve injury could be caused by dissecting aortic arch aneurysms and mitral stenosis
they can place traction on the recurrent laryngeal nerve and cause hoarseness
If functional residual capacity is limited, how does that effect preoxygenation
they cannot tolerate apnea as long (pregnancy, obese, lung disease etc.)
What happens to narcs that are more lipid soluable in CNB additive
they go intravascular and uptake is quicker Quicker onset, shorter duration Higher plasma levels (similar to csf concentratin)
According to the AANA where should notations be documented?
they may be made in dictated or written narrative forms for inclusion in the progress notes in the patients chart
Best poisitioning for CNB
they need to turn back into halloween cat
in the brachial plexus what do the median, ulnar, and musculocutaneous nerves supply?
they predominatly supply the ventral portions of the upper extremity
Why are dermatomes important?
this is how we assess our blocks
how long should a retrograde intubation take?
this procedure is usually not an emergency and can take 5 to 7 minutes
Where is the spinous process of vertebrae more steep
thoracic is most steep, cervical also steeper than lumbar
According to M and M what are the three classes of patient that will get an ETT
those at risk for aspiration Body cavity surgery Head and neck surgery (I would add positioning to this, i.e. prone)
Who is awake fiberoptic intubation preformed on?
those with anticipated difficult airway
What is 25% albumin used for mostly
those with extensive ecf volume
What do you pass wire through for retrograde intubation
through a 18-14 gauge needle or Cook needle in cricothyroid membrane
What fingers should go on cricoid during cricoid pressure
thumb and index finger
Hand position for mask ventilating
thumb and index on mask pinky on angle of madible for jaw thrust other fingers on bony part of chin. Soft tissue pressure may cause obstruction from movement of tongue
what does the recurrent laryngeal nerve provide motor function for?
thyroartenoid lateral cricoartenoid interarytenoid posterier cricoarytenoid
which of the single cartilages is the largest?
thyroid
what are the three single cartilages of the larynx?
thyroid cricoid epiglottis
What are the 4 "times" anesthesia needs to chart
time-out OR start time surgical cut time surgical end time
in a bier block how much is the tourniquet pressure increased to after exsanguination?
to 250 mmHG or 100 mmHg above their systolic blood pressure, then the esmarch bandage can be removed
why does the posterior side of the trachea lack cartilage?
to accommodate the esophagus during the act of swallowing
what is the function of the bronchi?
to provide humidification and warming of inspired air as it passes to the alveoli
true or false? the proseal LMA was designed with a second posterior cuff that when inflated helps to separate the respiratory and GI tracts?
true
true or false? the recurrent laryngeal nerve and the superior laryngeal nerve are two branches of the vagus nerve that innervate the hypopharynx
true
true or false? the thyromental space is an available pliable compartment directly anterior to the larynx, where the tongue can be displaced during direct laryngoscopy to improve direct line of site with the glottic opening
true
true or false? the trachea originates at the inferior border of the cricoid cartilage and extends to the carina
true
true or false? the trachlite can be used in patients with a small oral opening and minimal neck manipulation?
true
true or false? the use of only herbal supplements appear not to increase the risk of spinal hematoma?
true
true or false? unless prohibitively small cutting needles are used, the incidence of PDPH is clearly reduced with the use of non cutting needles
true
true or false? we use the epiglottis when we intubate?
true
true or false? while inside the spinal canal the nerve roots are covered with dura matter?
true
about _______ of total body water is in the ICF
two thirds which is also about 28 liters
Arts 4 treatments for high na+ and how fast you should change na+ levels
tx underlying cause replace water deficit dialysis change at a rate of 10-20 mEq/day unless acute
Type and screen vs type and cross
type is ABO and Rh Blood is screen other significant antibodies Ultimate test is crossmatch where two blood types are mixed in a trial transfusion.
what are the landmarks for an ulnar block at the wrist?
ulnar styloid process, tendon of flexor carpi ulnaris, and ulnar artery (ANT)
Is cuffed or uncuffed tube more likely to cause airway fire?
uncuffed, 02 leaks into airway
what can result in a bilateral injury of the recurrent laryngeal nerve?
unopposed tension and adduction of the vocal cords resulting in stridor, which may deteriorate into severe respiratory distress and possibly death.
Epi SAB
wash 0.1-0.2mg 1:100k
When should you be careful with considering autologous blood transfusion?
when 02 carrying is poor. Open heart is often OK because on pump
When should PT or PTT be treated? What is normal PT/INR
when >1.5 times normal. Normal pt is 11-13. INR is 0.8-1.1
what are indications to use a proseal LMA?
when a classic LMA may not provide sufficiant ventilation or airway protection, and endotracheal intubation would rather be avoided
when should tracheal extubation be performed?
when the patient is in the surgical plane of anesthesia or fully awake to avoid laryngospasm
If OR start time and anesthesia start time are the same, should they be documented at the exact same time
yes
If a patient is symptomatic from blood loss do we replace blood even if allowable blood loss level hasn't been reached yet
yes
Is there increased risk of nerve injury with spinal catheter placement
yes
Should laryngoscope be used to reintubate when AEC is in place?
yes
should pts bring cpap from home
yes
you are called to place an epidural on a 22 year old who takes garlic every day. Can you place it without doing any lab work?
yes
Can pt get 1st dose of coumadin day before surg and get CNB
yes if less than 24 hours and only 1 dose
can a 16 year old pregnant patient have an epidural or spinal without parental consent?
yes, she would be emmancipated
Does cricoid pressure work if it displaces esophagus laterally
yes, the hypopharynx and cricoid cartilage function as one unit. 50% of patients have lateral esophagus and 90% with cricoid pressure. Regardless, it is still effective
when intubaing what does in the goose mean?
you are in the esophagus
What nerve can be blocked for facet pain and where is the nerve
you can block the medial branch nerves that wrap around the facet joints and innervate them. The site of injection is on the lamina of the vertebrae. If effective, this site can also be ablated for deinnervation.
Why is it important to know bronchus anatomy with DL tube placement
you can inflate cuff too deep in right (branches at 2.5 cm) and may occlude upper lobe on accident.
Why should End Tidal be charted and not what is on the dial
you can prove what was given just in case they have recall or something
why doesn't art use bicarb
you have to find preservative free and by the time he gets that all figured out, his block would have been set up anyway
What do you do with follow-up complaints
you need to follow up again or comfort them if not an issue (like recall with mac)
according to the ASA difficult algorithm you have adequate face mask ventilation following a failed intubation. what you be next to try
you would follow the non emergent pathway meaning to have alternative approaches to intubation
who is more likely to get a PDPH after a spinal, the young or the old?
young
should you transfuse your patient if their hemoglobin is between 6 and 10?
your decision should be based on specific clinical factors such as cardiopulmonary reserve, expected blood loss, o2 consumption, and the presence of atherosclerotic disease
fraction of excreted urine equation
(na urine x plasma creatinine) / (Na plasma x creatinine uriine) x 100
Induction sequence per ART (11 steps)
-100% o2 mask with strap -Then bp cuff, pulse ox, and ekg with pulse ox on opposite finger as bp cuff -Then start with fentanyl (100mcg) -Then lido IV (100mg), helps with propofol and ett -Then wait for minute then propofol (200 mg) -***Then try to ventillate until pt. is floppy, make sure you can VENTILATE BEFORE succs or roc -Then roc or succs -***tape eyes -Intubate -Hook up circuit -Look for condensation and auscultate, c02
Four surgical, anesthesia or medical indications for ett (table 22-4): Critical illness, airway shared with surgeon, inneffective oxygenation with mask or supraglottic airway (2), procedure affects ventilation or perfusion, inadequate airway protection from supressed reflex (GCS <10), paralytics, prolonged surgical time, positioning, Controlled c02 management, High aspiration risk, difficult airway
---Surgery: airway shared with surgeon requires pralysis surgery effects vent/perfusion prolonged surgical time (more than 2-3 hours) ---Anesthesia: Aspiration Difficult airway positioning Ineffective 02 with supraglottic airway ---Medical: critical illness airway reflexes down Inneffective sugraglottic airway controlled co2
Differences between classic LMA and proseal
-large deep bowl with no fenestrations (grille) makes intubation easier -larger posterior cuff (2 separate cuffs?) -gastric drainage tube and opening at tip -bite block -anterior pocket for finger during seating
3 Indications for cryo and most common
-low fibrinogen (less than 80-100mg/dL) -von willebrand disease -microvascular bleeding/DIC (Art said Microvascular bleeding is most common)
how much fluid do you need to replace due to the fluid loss from a minimal procedure such as a short superficial procedure?
0 to 2 mL/kg
what is the adjustable amplitude range on a nerve stimulator?
0 to 5 milliamps
What is a good walking epidural
0.0625% bupivicaine with 4mcg/cc fentanyl
when doing an continuous infusion approach to the brachial plexus, how much should the continuous infusion be ran at?
0.125 to .0.25 mL at a rate of 4 to 6 mL/hour
What is bupivicaine concentration for pain control and weak pn control
0.25% for post op pain control and 0.125% for weaker pain control in epidural
in the trachea the cartilaginous rings and plates continue until the bronchi reach ______ to _______ in size
0.6 to 0.8 mm
Most common drug in spinal kit
0.75% bupivicaine
3 purposes of fiberoptic suction port
02 fog removal and 02 supplement, med instillation,suction
What should be done just after extubation
02 with facemask
how many units of platelets will be provided by one bag of whole blood?
1
How many C- shaped cartilage rings in trachea
16-20
what size of the average epidural needle?
17 guage
How long can morphine give pain relief per art in CNB
18-24 hours
When was the ASA difficult airway algorithm made and updated
1991 updated 2003
how many branches does the femoral nerve have?
2
Mandibular protrusion test classes
A- lower incisors protruded beyond upper B- same level C- lower incisors cannot protrude past upper
ASA difficult airway step2
Try to deliver supplemental oxygen throughout process
what is the 3 3 2 rule?
a non scientific way to ensure that upper airway geometry is adequately assessed. it evaluates various airway proportions using finger breadths as a measurement. It is a combination of different geometric dimensions that relate mouth opening and size of mandibular space to the position of the larynx in the neck.
when using a nerve stimulator in a sciatic nerve block what should the setting be set to?
frequency of 2 Hz and an intensity of 1 milliamp until plantar flexion response then it is decreased to less than 0.5 milliamps
How to gauge choice of nasal airway?
from the nare to earlobe
What herb takes more than 24 hours to return to homeostasis?
garlic, ginko, ginsing
7 Indications of difficult facemask ventilation (include sp02 level). What other type of ventilation does this apply to?
gas leak poor chest rise absent breath sounds gastric air poor co2 return decrease o2 lower than 92% with 100% 02 necessity to use oral airway or 2 handed mask ventilation
What happens if positive pressure is too high with LMAs?
gastric inflation
what are some complications that can occur with a bracial plexus block?
hemidiaphragmatic paresis, Horner's syndrome, Recurrent laryngeal nerve involvement, verterbral artery injection, total spinal, nerve injury, LAST, hematoma, infection, pneumothorax
Thirst with hypernatremia hyponatremia or both?
hyper
What can renal insufficiency do to na+
hyper na+
if a solution has a specific gravity greater than 1.0015, what would the baricity of that solution be?
hyperbaric
According to Dr Nag, what are the 2 most likely causes of hypocalcemia?
hyperventilation and massive transfusion of citrated blood
if a solution has a specific gravity less than 0.999, what would the baricity of that solution be?
hypobaric
Addisons and sodium
hypotonic hypovolemic hyponatremia
what are the signs of Horner's Syndrome?
a triad of miosis, partial ptosis, and loss of hemifacial sweating
how far is the bifurcation to the right upper lobe from the carina?
about 2.5 cm
how much local is injected when doing an ankle block?
about 3 to 8 ml injected per nerve
is trachlight more or less succesful than conventional laryngoscopy
about the same
When do you start blocking accessory muscles in spinal?
above t4
Muscle Tone and apgar scoring
absent =0 Some flexion of extremities =1 Active and spont. movements of limbs = 2
what is a hyperbaric solution
it has a specific gravity that is greater than that of CSF. this solution would fall or sink to the lowest anatomic point
what are bronchial and alveolar causes of a lower airway obstruction
acute repiratory distress syndrome (ARDS) aspiration pneumonia asthma bronchospasm COPD pulmonary edema
what is the function of the lateral cricoarytenoids?
adduction of the vocal cords (closes)
Name 6 types of risks with blood transfusion
administration error graft vs host infection trali Trim (transfusion related immune modulation--from leukocytes in transfusion, leads to worse immunity and higher infection and cancer rates) Non-hemolytics (fever, rash chills etc)
BIL injury to vagus nerve problems
affects both superior and recurrent laryngeal nerves (near total paralysis like after giving succs) -Phonation is severely impaired (or Aphonia) -Airway control is ok
the right recurrent laryngeal nerve recurs around the ___________.
brachiocephalic artery
CV signs of low ca++ (2 ekg, bp, drug, other if really bad)
brady hypotension arrest dig insensitivity qt prolonged
CV rhythms with high k+
brady, vf, asystole
how is the nasopharynx connected to the posterior portion of the nasal cavity
by the internal nares
how is exsanguination accomplished in a bier block?
by wrapping an Esmarch bandage at close overlapping intervals tightly around the arm, starting at the finger tips and continuing up to the tourniquet.
What is the surgery art listed that can be done under spinal that effects the highest durmatome
c-section
Nasopharynx lies anterior to ______ vertebrae
c1
What can make aldosterone high
chronic low blood pressure due to chf, liver, or kidney issues or dehydration
The book 5 causes of calcium chelation. Chfaflation
citrate. hyperphosphatemia free fatty acids alkalosis fluoride poisoning
Which mallampati classification has visualization of the soft palate, fauces (archway between oral and pharengeal cavities), and uvula?
class 2
Which mallampati classification has visualization of the soft palate and base of the uvula?
class 3
which mallimpati classification is where the hard palate is only visible?
class 4
what does limiting sedation while using a nerve stimulator help with?
it helps the patient tolerate the procedure, maintain sufficient alertness to respond to the stimulus, and be coopertive
according to the ASA difficult algorithm you have inadequate face mask ventilation following a failed intubation. what you be next to try
consider and attempt an LMA. if the LMA is adequate then follow the non emergent pathway. if the LMA is not adequate follow the emergency pathway
what is Sellick's maneuver?
cricoid pressure
What size of cuff vs. uncuffed in kids
cuffed, use 0.5mm smaller tube (age +16/4 for kids, use 0.5 smaller for cuffed)
What does banked blood storage do to the following: 2,3 dpg, Cell damage (2), energy, pH, clotting (3 other than factors) clotting factors (2), RBC characteristics, electrolytes, inflammation
decreased 2,3 DPG oxidative and free radical release decreased ATP acidosis Increased endothelium adhesion, lower plt viability, microaggregates less V and VIII decreased flexibility and membrane loss proinflammatory products released hemolysis
Main categories that lower K+
decreased intake or absorption Renal GI losses Sweat and burns Alkalosis Insulin B2 agonists
Deep tendon relfexes and high mag
decreases (same as high ca++)
which of the ankle nerves innervates short extensors of the toes and sensory to skin on lateral side of hallux and medial side of second toe
deep peroneal nerve
which of the ankle nerves lies lateral to the anterior tibial artery
deep peroneal nerve
Total fluids needed intraop (potentially)
deficit + maint +evap + blood loss May also add bolus or bowel prep loss
how much will a unit of PRBC's raise an H & H?
it should raise hemoglobin 1 and hematocrit 3
What are the 3 guidelines for HES in open heart surg
discontinue at the first sign of coag problems Monitor coag status Often causes more bleeding with these pts.
how does the trachlite work?
it uses transillumination of the neck to accomplish endotracheal intubation. it has a bright light source that does not require low ambient light for optimum performance
When is surgical cut time done
it varies Some do when you cut, some with local Find out what facility wants You can also write down both times if you disagree with someone
Side effect of SAB opioids
itching
What kind of wire is used for retrograde intubation
j-wire or #2 mersilene suture
Does you have to be sensitized to have ABO reaction or Rh reaction
just Rh, ABO you do not have to be sensitized first.
Paremedian approach and ligaments entered
just flavum
What should you do if a band of innervation is lost in a few dermatomes post op after spinal or epidural
keep them in the hospital and watch them because a hematoma may be building
What should you do with care plans after the case
keep them, they might apply to other cases. Put on computer and you can print them off without having to redo them
what additive has shown to be the most effective in a bier block?
ketorolac 15 to 30 mg helps to provide a degree of post operative analgesia without increasing the risk of bleeding
What population gets caudal epidural
kids
Neuro s/s and high ca++ (walking, loc, reflex, muscle tone/strength)
lethargy and confusion fatigue and weakness ataxia coma hypotonia and deminished reflexes
What filter is on cell saver
leukocyte
With age and obesity what happens with soft palate
more movable and can block the airways during GETA
Is glidescope blade more curved or less than regular mac blade
more, to help you get to anterior airways
Mags main function in the body is to act as a _________
enzymatic cofactor of 300 rxns
Drugs of choice for brady hypotension with spinal accelarator block
ephedrine, if bad then epi and atropine. Also give fluids and position them head down if needed (not going to make them much worse if already brady)
Is caudal anesthesia suppose to be epidural or spinal
epidural
Which is slower to place, an intrathecal or epidural?
epidural
Is backache more common in spinal or epidural
epidural 30-45%
what is contained in the epidural space (5)?
epidural veins, fat, lymphatics, segmental arteries, and nerve roots.
With fixed cardiac diseases like Aortic stenosis should epiD or spinal be placed
epidural, doesn't drop pressure as much
Main structure prevents aspiration
epiglottis
what are the 5 things the internal superior laryngeal nerve provides sensory for?
epiglottis base of tongue supraglottic mucosa thyroepiglottic joint cricothyroid joint
in the Cormack and Lehane Grading system what is seen in a grade 4?
epiglottis cannot be seen; only view is of the soft palate
Where does the larynx begin and end
epiglottis to the cricoid cartilage
What happens if trachlite is put in esophagus vs trachea
esophagus is posterior and there will be a diffuse glow trachea = well defined circumscribed glow, below thyroid prominence
what does the first 3 in the 3 3 2 rule measure?
estimates oral access, or the inter-incisor gap distance
How to confirm good mask seal and preox ventilation (2)
et co2 et 02
Nose innervation other than mucous membranes
ethmoidal and nasalpalatine branches of facial nerve (VII). Also CN I olfactory
true or false. ropivicaine 2% can be used for epidural dosing?
false, it can be used in spinal but not epidural dosing
true or false? the epiglottis exists as a double leaf cartilage?
false, it exists as a single leaf cartilage
true or false? the trachlite is less stimulating than laryngoscopy, but has a higher incidence of a sore throat?
false, it has a lower incidence of a sore throat
true or false? spinal anesthesia often affects pulmonary function?
false, it is rarely affected
true or false? all headaches after a spinal are considered a PDPH?
false, not all headaches after a spinal are PDPH.
true or false? highly protein bound drugs have a shorter duration as compared to the less protein bound drugs
false, the highly protein bound drugs have a longer duration
true or false? the glidescope blade is modified to resemble a miller blade?
false. it is made to resemble a Macintosh blade with a 60 degree anterior bend and 18 mm wide
Mag level that lower extremity and patellar reflex is lost
lower DTR at 4-7 loss of patellar at 7-10
What do nephrotic syndorme and chronic renal failure do to Vit D
lower it
What do phenytoin and primidone (anticonvulsants) do to ca++
lower it
What is retrograde intubation wire retrieved with in oral or nasal airway
magill forceps
What orthopedic procedures would be an indication for cell salvage?
major spine surgery knee replacement hip replacement
Is scoliosis a contraindication for CNB (central neuraxial blockade)?
no, just means that injection will be difficult
Does trachlite require low ambient light
no, not like light wand
Do high risk patients usually get a bolus? How should they be managed
no, they do better with more restrictive fluid amounts. Best to monitor urinie output and titrate fluids to 0.5-1.0ml/kg/hr
safe to give woman of childbearing year 0+ blood when type is unknown
no, unless you give rhogam, may have Rh antibodies, but male is ok if no transfusion has ever been given
Can you store cell saver blood
no, use it right away
What unit should drugs be charted in
not in cc. Always in actual dose, volume varies by concentration
How is fastrach insertion different than normal LMA
not much different, the metal portion will be on chin at beginning of insertion and LMA goes in until resistance is met or metal handle meets the face
what is a quinkie?
not to be confused with an short intimate encounter with a twinkie, it is mostly known as a cutting needle for spinals
Does anesthesia start time include pre-op
not unless you did a block pre-op, but it might have a separate start and end time just for the block
High ca++ and GI (appetite, other related organ, BM, and 2 others)
nv anorexia pud pancreatitis constipation
Where is there c-shaped cartilage vs. o shaped
o is in cricoid cartilage c is in trachea and thyroid cartilage
What is trauma blood usually
o-
How much more accurate is crossmatching than screening
on hundredth of 1% percent (0.01%)
According to ART, Which side should person applying cricoid pressure stand?
on right side so they can and you the ett
Where is microvideo camera on video laryngoscopes
on the blade (middle of blade with glidescope)
in the brachial plexus where does the inferior trunk lie?
on the first rib, superior to the subclavian artery
in the Cormack and Lehane Grading system what is seen in a grade 3?
only the epiglottis can be visualized; no portion of the glottic opening can be seen
in the Cormack and Lehane Grading system what is seen in a grade 2?
only the posterior portion of the glottic opening can be visualized; anterior commissure not seen
Which side/s of the LMA cuff should be lubricated?
only the top side that will go against the palate
Nosopharynx and oral cavity join where?
oropharynx
what part of the pharynx lies at C2 to C3 and is bound superiorly by the soft palate and inferiorly by the epiglottis?
oropharynx
what part of the pharynx opens in the mouth anteriorly through the anterior and posterior tonsillar pillars?
oropharynx
Arts 5 symptoms of high ca++
paralytic ileus thirst (also in book with high na+ low energy low appetite weakness
What are some symptoms of hyperkalemia
parasthesia cardiac dysrhythmias including peaked T's, wide QRS's, Bradycardia, V-fib, asystole
where do sympathetic and parasympathetic innervation of nose arise from
parasympathetic is cn VII sympathetic is superior cervical ganglion
what could be some other causes of hypocalcemia?
parathyroid hormone insufficiency vitamin D insufficiency parathyroid hormone resistance states
The Book's 3 causes for hypocalcemia
parathyroid insufficiency vitamin d defecient Calcium chelation
who is albumin 25% well suited for?
patients with excessive ECF who need intravascular expansion.
Pt with BID SQ heparin, how long until it is ok to place CNB
peak is in 2 hours, must wait longer (probably 4 hrs?). Book says no contraindication with BID or less than 10,000 units/day
What are the three sizes of handles or laryngoscope
peds handle normal handle Stubby
Difference between adult and peds mask
peds mask smaller to reduce dead space
Is ett migration more profound in kids or adults
peds, their airway is shorter and there is less room for it to move.
Is croup more serious in peds or adults
peds. They have a smaller airway that if inflamed can close off
what is the role of the thyroarytenoids?
phonation
what are the three landmarks when doing a popliteal fossa approach to the sciatic nerve block
popliteal crease, the medial border of the femoris biceps muscle laterally, and the tendon of the semitendinous muscle medially
what is the most commonly discussed and managed complication of neuroaxial anesthesia? Back pain PDPHA Nausea and vomiting hypotension
post dural puncture head ache
Are arytenoid cartilages anterior or posterior
posterior
.
posterior and superior
For respiration: Larynx muscles involved, innervation, and main function
posterior cricoarytenoid muscles recurrent laryngeal nerve abduction of vocal cords
What abducts the vocal cords
posterior cricoarytenoid muscles (they are the only abductors)
What muscle opens the rima glottis (opening between vocal folds). This is the only muscle that opens the vocal folds.
posterior cricoarytenoids`
which of the ankle nerves are deep?
posterior tibial and deep peroneal
which of the ankle nerves arises from the 4th and 5th lumbar roots and the 1st, 2nd, and 3rd sacral roots?
posterior tibial nerve
which of the ankle nerves travels as a larger branch of the sciatic nerve and lies on the medial side of the achilles tendon?
posterior tibial nerve
What two things cause lordosis?
pregnancy and obesity
who is more likely to get a PDPH after a spinal, pregnant or non pregnant
pregnant
Calculate estimated blood volume for men women and infants
premies - 95 ml/kg Full term - 85 ml/kg infants 80 ml/kg Men 75 ml/kg women 67 ml/kg
If fraction of excreted urine is less than 1% what does that mean
prerenal (hypotension or hypovolemia) is the cause for high creatinine
true or false? the distance to the epidural space varies with vertebral level and is loosely correlated with patient weight
true
true or false? the fastrach LMA can be used as a conduit for intubation using a fiber-optic bronchoscope and preloaded ETT.
true
Arts resp and cv s/s with high mag (3)
resp depression brady myocardial depression
what is the role of the posterior cricoarytenoids?
respiration
What can be some causes of hypercalcemia?
results when movement of calcium from the bone to the ECF exceeds the ability of the kidney to excrete calcium primary hyperparathyroidism (most common) malignancy (second most common)
When should we tape eyes
right after induction drugs, unless they rsi. We may scratch cornea on intubation because our hands rest their
What connector is needed between face mask and breathing circuit?
right angle
The right recurrent nerve "recurs" around the ____ artery
right subclavian artery
Thyroarytenoid
role: phonation function: shortening and relaxing of vocal cords; adduction innervation: RLN
What can happen to cuff easily with double lumen ETT
rupture on teeth
the sciatic nerve is the continuation of the upper division of the ________ and is the ______ trunk in the body
sacral plexus, largest
What is SPA
salt poor albumin, comes in same 5 and 25% concentrations
What is considered isobaric
same as CSF
What is the c-trach intubation device
same as fastrach ILMA except has a video screen
What are the sizes of proseal LMA
same as regular LMA
what shape should ETT stylet have when using a video laryngoscope?
same curve as video scope blade
which of the ankle blocks is a terminal branch of the femoral nerve and travels down the lateral side of the knee
saphenous
which of the ankle nerves provides sensory innervation to the medial side of the malleolus
saphenous nerve
which of the ankle nerves are superficial?
saphenous, sural, and superficial peroneal
which block is used in conjuction with lumbar plexus, femoral or saphenous nerve block to provide complete anesthesia and postoperative analgesia for lower extremity surgery
sciatic
true or false? the nerves in the brachial plexus combine, divide, recombine and divide again as the pass between the anterior and middle scalene muscles, through the posterior triangle of the neck, and into the axilla?
true
Combitube description
two lumens, if first attempt of lower lumen is in trachea, then just ventilate. Normal position of lower lumen is in esophagues. Lower cuff is inflated in esophagus and upper cuff is inflated in pharynx. Then positive pressure can be done
how long should cricoid pressure be held for?
until correct placement of an endotracheal tube is confirmed through traditional methods
How long can 100% pre-ox keep blood oxygenated after apnea in healthy people
up to 12 min
what is the normal head extension of the atlanto-occipital joint
up to 35 degrees
What is absolute contraindication of jet vent
upper airway total obstruction (cannot exhale and will hyperinflate lungs and cause co2 retention)
what is cricopharyngeous muscle
upper esophageal shincter
What is the general guideline for CNB gauge choice
use the smallest needle you can get away with
What is a short form
used for easy short cases like dental, mac, endo, office
What kind of blade is used in glidescope and what is procedure
uses blade similar to mac use like a mac, insert into vellecula and lift ett can be inserted through the glidescope with rigid stylet in shape of glidescope or off to the side with stylet in right angle just proximal to cuff
What kinds of things can cause transient neuropathy with spinals
using high dose like 5cc of 5% lido or 4cc or 0.75% bupivicaine or using cont. cath
When is end-anethesia time usually
usually 5-10 min after they are in recovery because we are with them until then
what level to transfuse CV patients
usually 8-10 hgb due to poor 02 carrying capacity
When is combitube considered
usually after failure of LMA, bougie, or intubation
What are some symptoms of hypomagnesiumia?
usually asymptomatic weakness A-fib V-fib seizures
Once the ett is placed over the wire and is advanced to the larynx during retrograde intubation, _______ is placed on the wire
tension (to allow easier passage)
What do the intrinsic muscles of the larynx control. 2 main functions
tension of the vocal cords and opening and closing of the glottis
what three drugs are considered highly protein bound?
tetracaine, bupivacaine, and ropivacaine
When removing an LMA, should it be removed when pt. is in stage III or stage I of GETA?
stage I, you want airway reflexes to be intact when you pull an LMA. This can be assessed if they can open their mouth on command
How can you tell if patient is lightly sedated (stage II) vs. awake enough for extubation
stage II will cough and and hold breath with suciton, but no purposeful movment or eye opening like when in plane I
when should hydration be done with CNB and dose?
started 30 min prior and ending when you place. Usually 1 - 1.5 liters
oropharynx beginning and end
starts at end of soft palate posteriorly (bottom surface of soft palate and uvula) and ends at epiglottis (or base of the tongue about the level of the hyoid bone around c4) Anteriorly starts at tonsilar pillars
How can you test for sensory block
stick something sharp in both side of hip (L1-L2) and move cephalad
Pradaxa and CNB
stop 7 days before or normal TT (thrombin time or ECT (ecarin clotting time)
________ and ________ are ominous signs of severe respiratory obstruction and indicate a 50% decrease in circumfrance from normal or a diameter reduced to 4.5 mm or less
stridor and dyspnea
acute bilateral reccurrent laryngeal nerve palsy can do what
stridor and resp distress due to unapposed tension on cricothyroid muscles (unless they are not innervated either by vagus nerve damage)
what does the recurrent laryngeal nerve provide sensory for?
subglottic mucosa
What can extreme head flexion or inappropriate bite block do to airway
submandibular duct obstruction and subsequent massive tongue swelling.
What is the equation for ABL?
subtract the target hematocrit from the starting hematocrit then times that by the EBV the divide it by the starting hematocrit ((EBV x (starting hct-target hct))/starting hct)
What two things should be done prior to extubation
suction and 100% 02
According to ART, what can be done to help pts. passing through stage II after extubation to prevent laryngospasm
suction them out really well.
2 positions patients can be in for fiberoptic intubation
supine or sitting
When is whole blood given in OR
when autologously drained preop and then we give it back once they have lost volume later
When do bronchioles begin
when cartilage ceases
When should you go slow with SAB
when puncturing the dura, once you get csf you can speed up procedure again
what is done with the amplitude on a nerve stimulator as the needle approaches the nerve?
the amplitude is adjusted (usually decreased)
what does the anterior branch of the femoral nerve innervate?
the anterior surface of the thigh and the sartorious muscle
The left recurrent nerve "recurs" around the ______
the aorta
what does the left recurrent laryngeal nerve loop around?
the aorta
Define dermatome
the area of cutaneous sensation supplied by a spinal nerve that is anatomically indentified as it passes through an intervertibral foramen
What artery supplies the cricoid cartilage to thyroid cartilage and membranes in between (most of larynx)
the cricothyroid artery
What is specific gravity?
the density of a substance compared with the density of water
when is the wire removed in a retrograde intubation?
when the ET tube is advanced through the larynx and cannot pass further. once the wire is removed then the tube is advance further into the trachea
what is the Fastrach LMA also known as?
the intubating LMA
why is the amplitude lowered in a nerve stimulator as the needle approaches the nerve?
the lower amplitude decreases the discomfort experienced by the patient while enhancing the ability to accurately identify the neurovascular bundle
in the brachial plexus what does the rami from C 7 continue to form?
the middle trunk
which nerve is primarily a motor nerve that has some mixed sensory fibers to the hip, medial aspect of the femur, and the skin and soft tissue of the lower portion of the thigh?
the obturator nerve
which area are the uvula and the tonsils found?
the oropharynx
Who should always make sure the seal is good with BMV
the primary provider, the assistant can squeeze the bag or help with the seal, but the primary provider should always have at least one hand on mask
Which local anesthetic would you use in a total knee athroplasty under spinal
the procedure will last 45 mins to an hour so tetracaine with epi would be a good choice cause it lasts the longest
traction applied to the right subclavian could cause damage to which laryngeal nerve?
the right recurrent laryngeal nerve
when doing a bier block on the lower extremity what would you set the cuff pressure at when the cuff is on the lower leg?
the same as the arm, 250 mmHg or 100 mmHg above blood pressure
what can occur if ventilation is performed using postitive pressure greater than 20 cm H2O with the classic LMA
the stomach can become inflated
what are the false vocal cords
the vestiblar folds and they can get easily damaged
According to the third recommendation for infusions set forth by the AABB what is the recommendation for hospitalized, hemodynamically stable patients with the acute coronary syndrome?
there is no reccomendation
describe the difference between the hypopharynx and the laryngopharynx.
they are the same thing
how long will a transfusion of platelets raise the platelet count for?
6 to 7 days
At what high level do we always treat high K+
6.0
What is totaly body water %
60%
D02> ____ is associated with survival in high risk pts
600
Look at table 20:16
...
What is high dose lovenox
1.5mg/kg/day
what angle is the hustead needle?
15 degree less pronounced curve
what are the three criteria that defines a massive transfusion?
1. replacement of estimated blood volume within 24 hours 2. greater than or equal to 10 units of PRBC's over 24 hours 3. 50% of blood volume within 3 hours or less
what are the five things to tell a patient to do when assessing their mallampati?
1. sit upright 2. extend the neck 3. open the mouth as much as possible 4. protrude the tongue 5. avoid phonation
what is the specific gravity of CSF?
1.004 to 1.009
What is formula for epidural volume
1.5 cc per level wanted but for each level up you also go one level down
What is the maintainence fluid rate for adults
1.5 ml x kg
how do you use lipid emulsion in the treatment of LAST?
1.5 ml/kg of 20% bolus, then 0.25 ml/kg gtt
how do you determine the rate for your maintenance drip?
1.5 times kg
what are 4 complications related to improper application of cricoid pressure?
1. airway obstruction 2. difficulty in placement of the larygoscope blade 3. impeding glottic visualization 4. difficulty with tracheal intubation
How do you give deficit volume
1/2 preop 1/4 1st hour 1/4 2nd hour
at 25 psi and 1 second inspiration at RR of 20, what is TV and minute volume with jet ventilation
285 ml tidal volume 5.7 L/min
serum osmolality equation
2Na + (Bun/2.8 )+ (glucose/18)
What is the max cc to be used in a spinal
2cc
what is a good witaker size to use on a c-section patient
24 to 25 gauge (use 22 gauge on older patients)
Gas is pushed into the stomach if supraglottic devise pressure is _______cm H20 or higher
25 (except King LT is 30)
when placing a spinal for a vaginal delivery what dose of lidocaine would you use and what is the duration?
25 mg, the duration would be 15 to 25 mins without epi and 40 mins to an hour with epi
what sizes of needles are used the most for spinal blocks?
25 to 27 gauge, 3.5 inches
when placing a spinal for a anorectal surgery what dose of lidocaine would you use and what is the duration?
25 to 50 mg, the duration would be 15 to 30 mins without epi and 45 mins with epi
Demerol epidural
25-100mg
Name some benefits to CNB compared to GETA
Decrease Stress Response **** Dvt Embolus Ileus Improved resp fux compared to GETA
How long do platelet last before transfusion?
7 days culture after 4 days. If in whole blood than only last 2 days. (book says stored for max of 5 days)
According to the AABB how much is recommended to adhere to a restrictive transfusion strategy in hospitalized and/or stable patients?
7 to 8 g/dl
PRBC unit volume
300ml
what is the average blood volume for an adult man?
75 ml/kg
what is the tonicity of D5 half NS?
432, thus making it a hypertonic solution
what is the angle of the left mainstem bronchus?
45 degrees
Those at particular risk of meylinolysis are those that have been hyponatremic for more than ___ hours
48 hours
when placing a spinal for a genital or lower extremity procedure what dose of lidocaine would you use and what is the duration?
75 to 100 mg, the duration would be 45 to 60 mins without epi and 1.25 to 1.5 hours with epi
How many cervical dermatomes?
8 because there are 8 intervertebral foramen
when placing a spinal for a anorectal surgery what dose of hypobaric tetracaine would you use and what is the duration?
6 mg, the duration would be 1 hour without epi and 3 hours with epi
Desirable mag level in preganany induced htn
4.2-8.4
Normal level for mag in PIH pts
4.2-8.4
Normal ionized ca++
4.5 - 5.4 mmol/dL or 1.1-1.4 mmol/L
how much total local do you inject in an axillary block?
40 mL in increments of 5 mL
Osmolarity level (due to high na+ ) with cramps hyperreflexes twtiches and spasms
400-430
Neck circumference greater than _____ = tough intubation
43 cm
4 causes of croup
Post intubation edema around glottic and subglottic structures Multiple intubation attempts Too large of ett Excessive neck head an neck movement
what is the ratio that PRBC's should be administered?
a ratio of 1 mL for every 2 mL of blood loss
where do you look while placing an ETT with a glidescope?
at the LCD screen
When is post op follow up evaluation usually made
at the end of the day or the next morning
Is retrograde intubation wire removed at skin or in mouth
at the skin
what cervical joint allows most mobility
atlanto-occipital
Two major advantages of deep or awake extubation
Deep- no CV stim, and decreased coughing and straining Awake - Airway reflexes return (decreased aspiration) and airway maintainence
Disadvantages of deep vs awake extubation
Deep- poor airway reflexes, increased aspiration risk, airway obstruction Awake - Increased CV stim, increased cough and strain
What is arytenoepiglottic muscle
attaches from arytenoid to epiglottis and closes the epiglottis over the glottis (recurrent laryngeal nerve)
how to test for sympathetic block
cold temp
Why is ICP an absolute contraindication with CNB
CSF may keep them from herniating. or may increase ICP
What other drugs can increase duration in SAB and Epidural (other than epi or opioids)
Clonadine 75mg in epidural, 15-30 in spinal Neo 5-10mcg for spinal No decadron
what grading scale offers an objective assessment of the gottic opening during laryngoscopy using direct line of site?
Cormack and Lehane Grading system
What is anesthesia start time
Depends a little on provider Should be the time that you start anesthetic and stay with patient. This may start in the ER with a trauma
What is autologous transfusion
Donate well in advance of surgery and give day of surg
Allowable blood loss (ABL) equation
EBV x (starting hct - target hct)/ starting hct
True or false? Nausea and vomiting are not important factors to include in your post-op care plan?
False
Decadron SAB
N/A
What is best fluid for neuro cases according to ART
NS
what blood type is the universal donor?
O blood
Most significant contraindication to CNB
Pt refusal
What labs should be drawn for patients getting HES
Renal function Liver function coags
Why use quinkie?
Some older people who have tough ligaments also Elderly are not very at risk for PDPH
what does AABB stand for?
it is the American Association of Blood Banks it is also how a stuttering person starts singing the ABC's
how deep is the thoracic region of the epidural space?
it may be 3 to 5 mm deep and is narrower (lateral width).
When do we use just mask ventillation and no LMA or tube with volitile agent GETA
Very short GETA cases, especially with kids, like ear tubes (BMT) and tonsils etc. Also in code or in ER/Trauma
Why is spina bifida an absolute contraindication
open neural cord more infection and it won't work well. Also more risk of neural damage
Pradaxa and CNB and catheter
Wait 7 days for block (or check ect or TT). 24 hours post needle or 6 hours post catheter removal, whichever is later
Where do you document a follow visit?
a progress note is good, but some forms have a spot to document it
What cardiac procedures would be an indication for cell salvage?
Valve replacement redo bypass grafting
What are methylperabins?
They are addatives in locals that people may be allergic to BUT THEY AREN"T IN SPINAL AND EPIDURAL LOCALS
What are cookgas ILA and Air-Q
They are intubating LMAs. Air-q is disposable. Both have stylet for ett stabilization during LMA removal
How far past vocal cords should ett be placed. What is depth should place ett in cm?
Until proximal end of cuff is 1-2 cm past the cords. This will place the distal end of tube between carina and cords. Cuff size x 3
What is the synopsis of the article about intraop fluid restriction in major elective GI surgery
Use colloids to maintain UOP > .5ml/kg/hr Only use crystalloids for maintanence use colloids for volume to volume replacement No need to replace third space loss/diruesis Avoid deep general anesthesia Eliminate preload
What is 4-2-1 rule
Used for peds in fluid maintainence first 10kg = 4ml/kg 10-20kg = 2ml/kg after that 1 ml/kg
Arts 5 symtpoms for low mag
Usually asymptomatic weakness, a. fib vf seizures
When are follow up visits required
Usually the next day. Done on All cases JACHO requires this May not always get them.
What is OR time vs. anesthesia start time
Usually the same but not if anesthesia time started outside the OR or if before surgeon gets there or something.
Is a history of a difficult airway significant
VERY STRONG predictor of difficult airway
Can you do any SAB case with Epi-D instead?
Yes, realizing the anesthesia won't be as dense or last as long with epidural
Do we give 20-30 mg/kg bolus for most cases? Over how long
Yes, with ambulatory patients, no with high-risk pts. Usually over 30 min.
What should you do if all answers to "airway approach algorithm" are yes or some are no?
Yes= proceed with induction and paralysis No= abandon management and consider MAC or regional OR follow difficult airway algorithm/guideline
how do you know how many ml's to place in a spinal
a 5 foot person would get 1 cc, every inch above 5 feet gets an extra 0.1 cc in order to get a T8 block
how high of a block do you want for a c-section?
a T6 block
what is in the middle of the blade of a glidescope?
a camera and features an anti fog system
what is a Eldor needle?
a combined spinal epidural needle with two channels, one for the spinal needle and the other for the epidural catheter
what is mandibular hypoplasia?
a condition that does not allow the tongue to fit into the thyromental space
Who usually applies cricoid pressure, assistant or provider
assistant
vitamin A toxicity and electrolytes
causes high ca++
What does nagelhout say about large volumes of NS
causes hyperchloremic acidosis
What is ramping for
elevate the shoulders, neck, and head to improve ability to BMV. Increases FRC
What might need to be considered if pt is hoarse post op
emergent reintubation due to airway muscle or nerve damage and airway obstruciton
bronchiole purpose
humidity and warming
Four signs of right mainstem bronchus intubation
increased peak pressure asymmetric chest expansion unilateral breaths sounds hypoxemia
For sphincteric function of larynx: muscles involved, innervation, and main function
interarytenoid muscle- closing of posterior commissure of glottis Arytnoepiglottics muscle - closing of laryngeal vestibule
What causes N/V with CNB
ischemia in vomit center of medulla and gut
are hernia or bunion repair minimal moderate or severe evap loss
minimal
Do osa pts usually only need one or two practitioners for airway
often two especially for ventilation
Where is preanesthesia evaluation form often printed
on back of anesthesia record
alkalosis and k+
lower
anterior subglottic mucosa
SLN-external sensory
Base of tongue
SLN-internal sensory
Epiglottis
SLN-internal sensory
cricothyroid joint
SLN-internal sensory
supraglottic mucosa
SLN-internal sensory
thyroepiglotic joint
SLN-internal sensory
b2 agonists and k+
lower
insulin and k+
lower
Low mag treatment
replace 2-4 grams
Read the document on Canvas called "documenting the standard of care: The anesthesia record"
...
Table 20-6
...
Duramorph SAB
.25-.3mg
What is charted q 5 min
HR and BP (maybe rr although he did not say this)
what is the dermatome that coorlates with the nipple area?
T4 or T5
where do you want your epidural catheter placed for thoracic surgery?
T4 to T5
Is compressing the ETT pilot balloon a reliable indicator of cuff pressure?
no
What antibodies does Rh negative patient have
"D" antibodies ONLY IF SENSITIZED
With an unanticipated difficult airway, your first intubation attempt is ususally ________ look and the second is preformed under _______________.
"awareness" best possible conditions
What are the two mechanisms of laryngospasm
"glottis shutter closure"- intrinsic laryngeal muscles cause cord adduction causing partial obstruction "ball valve closure" extrinsic laryngeal muscles cause contraction of the false cords and supraglottic soft tissues- cause complete airway obstruction
Which version of Hetastarch has least coagulopathy issues
(HES) hydroxyethy starch aka VOLUVEN
What is normal value for plts? When should plts be transfused
100-400 Usually when less than 50 but not when more than 100 (microvascular bleeding)
how many ml's down is a patinet who had a bowel prep?
1000 ml
Three methods of nasal lido topical application
-5ml viscous in each nare -4ml 4% lido and 1ml of 1% phenyl to nebulizer (takes 20 min but is effective for subglottic structures -Atomizer - denser block, bigger droplets, same dose of lido/neo
Cell saver should be considered if expected blood loss will be > _____ml
1000ml
Name 6 advantages of airway exchange catheter concerning: ventilation (2), Abilities of lumen (4), insertion safety, depth confirmation, ett replacement.
-BMV adaptor or leur lock jet vent**** -can remove ett but still have access to airway -Lumen allows for: suction, ventilation/oxygenation, meds, ***co2 monitor** -blunt tip with perforated sides reduces airway trauma -radiopaque depth markers -Sufficient length and rigidity for ett replacement
No regional if plts less than
100K , 50k if you do serial labs
What is volume of Lap radiolucide stripes sponge if saturated
100ml
What is the tonicity of 3% NS?
1026, thus making it a hypertonic solution
What is volume of saturated raytec sponge
10ml
What 4 things can be done to decrease nose bleeds in nasal intubation or nasal airway insertion according to art (not just meds)
-Meds -cocaine, phyenylepherine, lido epi -nasal trumpet and slowly increase size until you can get ett down lumen -Soften them with warm water -lubricate
What is in the upper aiway
-Nagelhout says starts at cricoid cartilage and goes up (including the larynx)
next few flashcards will be from table 22-1
.
Hyponatremia causes, look at box 20-1
...
Look at anesthesia record and memorize where things go
...
Memorize table 20-4
...
how to place bougie. How far do you insert it?
-advanced behind where you think epiglottis is -advance into glottis and feel it bounce on tracheal ring -Advance until 25 cm mark is at the lip -place ett over bougie
Tongue general sensation
-anterior two thirds is by mandibular brand of tirgeminal (v3) aka lingual nerve -posterior third is by glossopharyngeal (CN IX)
Four anesthesia/surgical ett indications. (table 22-4)
-high aspiration risk (blood in airway or GI problems) -Predicted difficult airway -Position other than supine -Ineffective oxygenation with supralaryngeal airway
Four medical indications for ett (table 22-4)
-inadequate airway reflex (like glascow scale less than 10) -Inneffective oxygenation with supralaryngeal device -critical illness -control of co2 (like cranial surgery or copd)
ETT placement with fastrach
-inflate ett and lma cuffs to check integrity -lubricate ett and pass into central lumen -lubricate LMA and insert ***remove ett adaptor and set aside for later*** -pass ett to 15 cm where epiglottic elevating bar will push it up -use fastrach handle to lift anterior and advance ett -inflate cuff and replace ett adaptor -attempt to ventilate and confirm via etco2 and bil breath sounds -can leave fastrach LMA in if needed or remove . -IF removing LMA, remove ett adaptor and set aside -deflate ett balloon and LMA balloon -place fastrach stylet on end of ett and provide counter traction caudally as LMA is removed - once ett is visualized, hold ett and remove stylet and LMA -reconfirm correct ett placement
Two ways to directly use local on vocal cords (and dose)
-nasal or oral ett is placed close to trachea, then pt breaths in lido and coughs it onto back side of vocal cords (5ml 2%) -Same thing with video or fiberoptic scope and visualize cords
What are the six FDA reccomendations for HES products (setting, organ dysfunction, RRT, stop at first sign of (2), surgery case type)
-no use in ICU, sepsis or critically ill -no use with renal dysfunction -stop with first sign of renal injury -RRT needed up to 90 days after. Monitor renal fx for 90 days -no use in open heart. Causes coagulopathy -Discontinue at first sign of coagulopathy
What 4 things might make supraglottic airway placement or ventilation difficult (box 22-2)
-restricted mouth opening -obstruction in upper airway -distorted airway = effects seal -stuff lungs
Should you try to convice pt to get regional anesthesia
no
What are 3 risks of cricoid pressure not associated with intubation visualization
-rupture of esophagus during vomiting -decreases upper/lower esophageal sphincter tone -laryngeal discomfort can can cause vomiting
Divisions of vagus nerve in airway
-superior laryngeal branch (exterior and internal) -recurrent laryngeal nerve
where will you insert your needle when doing a femoral nerve block?
1 cm lateral to the femoral artery and 1 cm inferior to the inguinal ligament
PRBC raises Hbg and Hct how much
1 hgb and 2-3 hct
what is the maximum cuff or touraquet time for a bier block?
1 hour is most discomfort produced by the tourniquet, but a dual tourniquet system and preoperative or intraoperative administration of small doses of opiods may extend this time to 2 hours
Fluid replacement for bowel prep
1 liter low. Add that amount to deficit
when doing an interscalene block how much of a test dose should you give?
1 mL
what are some common locals to use in an ankle block?
1% lidocaine, 1% mepivavcaine, 0.25 to 0.5% bupivacaine, or 0.2 to 0.5% ropivacaine
Three main indications for supraglottic devices
1- rescue ventillation 2-alternative to ett in select patients in elective surgery 3-conduit for intubation
American association of blood banks 4 recommendations for transfusion hgb thresholds
1- restrict transfuion to 7-8 hgb for hospitalized pts 2- hospitalized cv disease pts transfuse at 8hgb or less 3- No reccomendation for hospitalized stable pts with acs 4- decision to transfuse should be influenced by hgb level and symptoms (can give blood earlier just have rational)
4 basic elements to difficult airway cart + 2 suggested extras
1- standard larynngoscopy 2- intubation by alternative means 3- tube position control 4- equipment for anesthetizing airway * also video or fiberoptic are often available*
3 Steps for using macintosh. What ligament is pulled?
1- tip in vellecula 2- tension on hyoepiglottic ligament by lifting force 3- this causes indirect elevation of epiglottis
One unit whole blood provides ___ units of plts. What are apharesis plts
1. Apharesis is where plts are taken from pt and remaining blood is returned to patient. One unit of apharesis plts = 6 whole blood plts.
Allowable blood loss for female who weighs 100 kg and has starting Hct of 30
1166ml
Age less than ____ years old you would do needle vs surgical cricothyrotomy
12
what is the hemoglobin range for children?
12 to 14.5
when placing a spinal for a hernia or pelvic procedure what dose of bupivacaine would you use and what is the duration?
12 to 15 mg, the duration would be 1.5 hours without epi and 2 hours with epi
What is a normal hemoglobin for women?
12.3 to 15.5
What are the normal values for sodium?
135 to 147 mEq/L
Arts normal sodium value
135-147
Studies show prbcs can be stored how long before they start to deteriorate
14 days
when placing a spinal for a back or spine surgery what dose of bupivacaine would you use and what is the duration?
15 to 20 mg, the duration would be 1 to 1.5 hours without epi and 1.5 to 2 hours with epi
what is the reduction % of volume with a class 2 hemorrhage?
15 to 30%, which would be a blood loss of 750 to 1500 mL
what are the 4 distinguishing features of the fastrach LMA?
1. anatomacally curved rigid airway tube 2. integrated guiding handle 3. epiglottic elevating bar 4. guiding ramp built into the floor of the mask aperture
according to the ASA difficult algorithm what are your three things to consider when your initial attempt to intubate is unsuccessful?
1. calling for help 2. returning to spontaneous ventilation 3. awakening the patient
according to the ASA difficult algorithm when failing at a noninvasive awake intubation what are your three options?
1. cancel the case 2. consider feasibility of other options 3. invasive airway access
Fent SAB
10-25 mcg
Sufent epidural
10-60mcg
what are 4 indications of a surgical cricothyrotomy?
1. failed airway 2. tramatic injury of maxillofacial, cervical spine, head or neck structures making intubation through the head or nose difficult 3. immediate relief of an upper airway obstruction 4. the need for a definitive airway for neck or facial surgery assuming intubation is not possible
according to the ASA difficult algorithm you had a successful ventilation after your emergency noninvasive airway attempt, what are your next 3 options?
1. invasive airway 2. consider feasibility of other options 3. awaken the patient
what are 5 thing unique to the proseal LMA?
1. larger deeper bowel with no grille 2. posterior extension of the mask cuff 3. gastric drainage tube running parallel to the airway tube and existing at the mask tip 4. silicone bite block 5. anterior pocket for seating an introducer or finger during insertion
what are 6 ways to tell if an airway would be difficult?
1. look externally 2. evaluate with 3 3 2 rule 3. mallampati score 4. obstruction of upper airway 5. obesity with big neck and redundant soft tissue 6. neck mobility
What is the first thing to apply to the patient when they arrive in the OR
100% 02 before any monitors or anything else. get them preoxygenating
Four treatments of laryngospasm (o2, pressure, drug, and last resort)
100% 02 positive pressure vent 10-20cmh20 Lidocaine IV, 1-1.5mg/kg If none of the above work: succs 0.2-0.5 mg/kg or 4-5mg/kg IM
how small is the cervical epidural space?
1.5 to 2 mm, thus leaving very little room for error
what medication is good to use for your test dose in an epidural?
1.5% lidoacaine with 1:200,000 epi solution. This provides45 mg of lido with 15 mcg of epi in a 3 mL dose
What are the normal values for magnesium?
1.8 to 3.0 mg/dL
Normal mag levels
1.8-3.0
Normal range for Mag
1.8-3.0mg/dl
Cell washing devices can provide a volume equivalent to _____ units of blood per hour for transfusion in cases of massive blood loss.
10
How high should head be in sniffing postition
10 cm
when placing a spinal for a cesarean delivery what dose of bupivacaine would you use and what is the duration?
10 mg, the duration would be 1 to 1.25 hours without epi and 1.5 to 2 hours with epi
how much local is injected when doing a sciatic nerve block?
10 ml in 5 ml increments although the slides say 15 to 20 ml
when placing a spinal for a hernia or pelvic procedure what dose of tetracaine would you use and what is the duration?
10 to 12 mg, the duration would be 1.5 hours without epi and 2 to 3 hours with epi
when placing a spinal for a back or spine surgery what dose of tetracaine would you use and what is the duration?
10 to 15 mg, the duration would be 1 to 1.5 hours without epi and 2 to 2.5 hours with epi
how long is the trachea in adults?
10 to 20 cm
Max cell saver rate
10 units/ hr
How long is trachea in adults
10-20cm
How often to monitor neuro status in CNB pts who are anticoagulated
2 hrs
When using a nerve stimulator in doing a brachial plexus block what is the milliamps set at after the needle has been introduced into the subcutaneous tissues?
2 milliamps
how much fluid do you need to replace due to the fluid loss from a moderate procedure such as an uncomplicated intra-abdominal or orthopedic procedure?
2 to 4 mL/kg
according to the "Smart" airway stratigies, what is considered a failed intubation and what should be done
3 attempts or unable to maintain >90% sat Call for help and go to failed airway algorithm
how much test dose should you inject into the epidural space?
3 mL of a rapid acting low toxic local with or without epi.
What is onset time of 2% lido for SAB
3-5 min
gas flow and time for 100% preoxygenation? How long does preoxygenation last in apnea most of the time?
3-5 min 5L 5-8 minutes of apnea
FFP use is discouraged if INR is less than ______ unless actively bleeding
2.0
what is the distance from the skin to the lumbar epidural space using a midline approach?
2.5 cm to 8 cm, with an average of 5 cm
When does right bronchus bifurcate
2.5 cm. Bifurcates to upper lobe
duramorph epidural
2.5-5 mg
How much resistance to breathing in nose
2/3 of total
Max positive pressure with LMA vs proseal
20 cm h20 with LMA 30 with proseal
what is the max dose of Hespan?
20 mL/kg
can trachlight be used in cannot intubate cannot ventilate?
no
Normal K+ levels
3.0-5.0 (art) book says 3.5-5.0
What are the normal values for potassium?
3.5 to 5.0 mEq/L
An ett cuff pressure above ____ mmHg can cause trachea damage
30 (suprglottic pressure above 25 causes gastric inflation)
How obese before difficult bmv
30 bmi (art said above 26)
what is the angle of the tuohy needle?
30 degrees, thus being the most pronounced curve
what is the reduction % of volume with a class 3 hemorrhage?
30 to 40 %, which would be a blood loss of 1500 to 2000 mL
What is the tonicity of NS?
308, thus making it an isotonic solution
How many L/min flow during preoxygenation? And what position should the apl valve be in during preoxygenation
5-10l/min apl open
Phenyl SAB
5-10mcg
Sufent SAB
5-10mcg
significant mortality is associated with hemoglobin values less than _______ g/dl?
5
urinary retention is common after neuraxial anesthesia with an incidence of _____ and ______%
5 and 70%
When does left bronchus bifurcate
5 cm and bifucates to left superior and inferior lobe bronchi
when placing a spinal for a vaginal delivery what dose of tetracaine would you use and what is the duration?
5 mg, the duration would be 1 to 1.5 hours without epi, and 2.5 to 3 hours with epi
how much will one unit of platelets raises the platelet count
5 to 10
how much should be injected when doing a radial block at the wrist?
5 to 7 ml under the brachioradialis muscle
what is the tonicity of D5 NS?
586, thus making it a hypertonic solution
What syringe and how much fluid for LOR with epidural
5cc syringe with 2cc water or air or both
Epi epidurals
5mcg/mL 1:200k (so in 3ml you get 15mcg)
What is concentration of 1:200k epi
5mcg/ml
the archetypal brachial plexus is formed by the rami from the ____ to the ____ cervical nerves and the ____ thoracic nerve
5th, 8th, 1st
One donor can donate ___ units of plts at once
6
When K+ gets higher then ____ then attempt to lower it
6
one bag of platelets from a donor is equivalent to approximately how many platelet concentrates?
6
Trali is defined as ALI within _______ hours of transfusion
6 hours
when placing a spinal for a anorectal surgery what dose of hyperbaric tetracaine would you use and what is the duration?
6 mg, the duration would be 1 to 1.5 hours without epi and 3 hours with epi
when placing a spinal for a genital or lower extremity procedure what dose of tetracaine would you use and what is the duration?
6 to 10 mg, the duration would be 1.5 hours without epi and 2 to 3 hours with epi
what is the average blood volume for an adult woman?
67 ml/kg
How effective is caffine in PDPH
70%
clonidine epidural
75 mcg bolus
What blood type is a person with type A B blood compatible with?
A B, A, B, & O
where do you insert the needle for an unlar nerve block?
A finger is placed in the ulnar sulcus, extending approximately 1 cm proximal to the condyle. The insertion point for the needle is between the medial condyle of the humerous and the olecranon process of the ulna
what blood type is the universal recipient?
AB
Chronic bilateral recurrent laryngeal nerve palsy can do what
Airway control problems less frequent due to atrophy of other muscles etc May have aphonia though
recurrent laryngeal nerve innervates what?
Airway sensation below vocal cords- intrinsic muscles of trachea except cricothyroid (art said supraglotic mucosa?)
What are some relative contraindications for a spinal or epidural?
Allergy. fixed volume cardiac states. hypovolemia. shock. neurologic disease or disorders. patients who don't understand. history of H/A or B/A. prior bad experience with SAB/regional
Where can an epidural be injected vs a spinal
An epidural may be given at a cervical, thoracic, or lumbar site, while a spinal must be injected below L2 to avoid piercing the spinal cord.
What times are important to document?
Anesthesia start procedure start procedure end antibiotic time any blank on the form that needs a time
what are pharyngeal and laryngeal causes of an upper airway obstruction?
Angoedema foreign bodies epiglottis hematomas hemorrage laryngospasm laryngotracheobronchitis aka croup subglottis stenosis tumors or lesions
What blood type is a person with type B blood compatible with?
B & O
What does BURP accronym stand for?
Backwards, upwards, right, pressure This moves larngyeal structures into view because we try to look on right side and move tongue to left.
What is considered hypobaric
Baricity less than 0.9999
Gold standard for ruling out cervical spine fractures
CT
Four treatments for low calcium
CaCl CaGluconate Po Ca++ Vit D
What is the difference between CaCl and calcium gluconate
CaCl is more irritating Ca Glu= less tissue damage if extravisation CaCl is more water soluable and has better bioavailability, works faster
where do you want you epidural catheter placed for chronic pain treatment or surgeries of the arms, shoulders, or upper chest?
C7 to T1
If you have dermatome involvement of the pinky finger, what does that mean with dermatome block level?
C8, your block is too high!
What is CNB combo technique
Combo - Find space after you have a loss of resistance, you get into epidural space with epidural needle and then advance a smaller needle into spinal space. Then you pull smaller needle back and then thread catheter into epidural space. This allows you to do a spinal for quick profound relief. Then you thread catheter and can give future doses in epidural space.
How to measure size of oral airway
Corner of mouth to ear lobe. It needs to go just past the tongue
After intubation what is likely to be going on if sp02 dips vs. co2?
Sp02 is usually and obstruction, lung disease, or bronchial intubation CO2 drop is usually disconnected circuit or perfusion problem like pulmonary embolism
What is the average Hgb for men and women and kids
Men = 13-17.5 Hgb Women 12.5-15.5 Hgb Kids 12-14.5
What happens if pt. bites on flexible LMA
Metal rings will get perminantly smashed
Name the following dermatome landmarks Inferior scapula zyphoid umbillicus pelvis
T4-t5 - is mid nipple Inferior scapula T6-7 T6- zyphoic T10 is umbillicus T12 - is pelvis
what is the dermatome level of the xyphoid
T6
where do you want you epidural catheter placed for upper abdominal surgery?
T8 to T10
Never withdraw a epidural catheter through
THE EPIDURAL NEEDLE!!!!
What is the treatment for hyponatremia?
Correct underlying cause infusing 3% saline at a rate of 1 to 2 mL/kg/hour sodium administration should not raise sodium levels no more than 10 to 1 mmol.L in 24 hours fluid restriction diuresis I V conivaptan oral treatment with tolvaptan
Phenyl epidural
N/A
demerol SAB
N/A
4 common hypertonic fluids
D5 1/2 NS D5LR D5NS NS 3%
How does difficult airway society differ from ASA
DAS suggests that you use LMA immediately following failed intubation and then revert to face mask if LMA fails
Difference between direct laryngoscopy and direct tracheal intubation
DL = laryngoscope to get direct line of sight DTI = process of placing ett in trachea these are usually done together
What is the intraop fluid most commonly used
NS
Is it easier to learn on Mac blade or miller
for most people mac is easier
Match the followinig as Elevators or Depressors of larynx (muscles): . Digastric thyrohyoid omohyoid stylohyoid stylophryngeus sternohyoid sternothyroid mylohyoid geniohyoid
Depressors: Omohyoid, sternohyoid, sternothyroid
ASA difficutl airway step 4
Develop primary and alternative strategies A. awake intubation B. intubation after GETA
what are the 'four dementions of difficulty' with airway management'
Difficulty to : -bag mask vent -direct laryngoscopy with tracheal intubation -supraglottic airway ventilation -invasive airway placement
What are some causes of laryngospasm
During stage II: airway manipulation stimuli from blood or fluids, mucous in pharynx stimulation of larynx
what is circ nurse responsible for regarding names
Names of everyone including reps
What do the branches of superior laryngeal nerve innervate
EXTERNAL (motor) laryngeal nerve - motor cricothyroid muscle. Sensory Anterior supraglotic mucosa . INTERNAL (sensory) laryngeal nerve- Pure sensory. Epiglottis to vocal cords (hypopharynx above vocal cords including the base of the tongue) - Also all of the cartilage joints
What should you do during preoxygenation if they are claustraphobic
Need to give them more sedatives without making them obtunded. Ask them if they can hold the mask on them.
What size of ett should be used if you have to reintubate someone with an airway exchange cath? Why?
Ett internal lumen should be very close to external diameter of AEC Reduces the chance of airway trauma
true or false? it is standard to pull back on the epidural catheter through the needle?
FAAAAAAAAALLLSSE!!!!! Never attempt to withdraw the catheter through the needle! this may cause shearing of the catheter and embed particles in the patients back
What is in cryoprecipitate (6 factors)
Factor, I, VIII, von willebrand, fibrinogen, fibronectin, XIII (book just says VWB, VIII, and firbrinogen)
True or false? the spinal cord levels correspond with the vertebral levels
False
true or false? antibiotic redosing is important on your preop plan?
False, it is important on the post op plan
true or false? debilitated, mentally impaired, and intubated patients are at a higher risk for developing hyponatremia
False, they are at risk for hypernatremia
True or false? upper airway obstuctions are not an emergency?
False, they should be concidered an emerency and managed with extreme care because of the potential to become total airway obstructions.
True or false? very rapid infusion of blood can increase the level of ionized calcium?
False. It can reduse the level of ionized calcium which is referred as citrate intoxification
True or false? the spinal cord is a rectangular structure?
False. it is a cylindrical structure
What is a murphy eye?
Fenestration at end of ett to allow more options for ventilation if one hole is plugged
What lab is needed before autologous infusion
H and H
How would you position pt right after SAB for pt getting a C-section vs. someone having foot surgery?
Foot surgery sit them up so lower spinal C-section, lay them down until you get the level desired for c-section (T6 or so)
Other than CNB what else should you get consent for at same time
GETA
hemolytic reactions may be obscured by ________ during surgery
GETA
What are some symptoms of hypokalemia?
GI impairment Neuromuscular impairment renal impairment CV impairment respiratory muscle weakness dysrhythmias
What can be some causes of hypokalemia?
GI loss Renal loss poor intake increased losses from skin Redistribution from ECF to ICF promoted by beta-adernergic stimulation, insulin, and alkalosis
Art says what 4 organs effected with low k+
GI, neruomuscular, renal, and cv impairment
How long for the following to wear off: Garlic Ginko Ginsing
Garlic: 7 days Ginko: 36 hours Ginsing: 24 hours
What needs to be considered for preop careplan?
Get weight, anxiety level, pain, set up the equipment you will use for case.
What is ARTs favorite type of oral airway and why
Guedel. This has a central lumen that you can ventilate through
According to the AABB restrictive triggers may be _________ in patients with signs and symptoms of low blood volume or other risk factors such as in patients experiencing __________ or ________
Harmful acute myocardial infarction unstable angina
What is HELLP syndrome. Is it contraindicated for epidurals and spinals
Hemolysis Elevated Liver enzymes Low Platelet count With PIH get HTN to liver that causes liver damage. NO SPINALS or epidurals!
How many pts will get Hep b, HIV or hep c with transfusion
Hep B= 1: 31-205K HIV = 1:1.5 million Hep c= 1: 2-3 million
heparin and k+? Dig relationship with K+ and Ca++? Adrenal steroids relationship with K+ and Mag+?
Heparin= higher K+; High K+ or Ca++ = dig toxicity; Inverse for adrenal steroids and K+ and Mag+ levels
What is dermatome for the following Thumb anterior forearm (2) Anterior thigh (3) Posterior thigh Clavicles Lateral arm(2) Medial Arm (2) calf (2) Dorsal hand (3) Palmar hand (3) Thumb Other fingers (2) Nipples umbilicus Inguinal groin (3) lateral lower leg (2) Medial lower leg (2) lateral foot top of foot (3) medial foot sole of foot perineum (3) Pollux Other toes(2)
Here is a great dermatome link: http://bedahunmuh.files.wordpress.com/2010/05/dermatomes.jpg
Why would you want to extubate deep rather than light?
High abd, brain, cvp, iop, and blood pressures. May dehisce or bleed. Also in reactive airways where fighting the tube may cause laryngospasm However risks have to be weighed in difficult airway/ aspiration risk
What is conservative PDPH treatment (5)
Horizontal position Caffine Iv 500; po 300mg Theophylline TIme Oral pain meds
What are the insertion angles for hustead crawford and tuohy needles ***test question****
Husted - 15 degree angle on tip - Insertion angle 15-30 Tuohy - 30 degree angle on tip (15 -30 degree insertion angle) Crawford - Straight tip (Straight edge, insertion angle (little more risky, can cut on accident) - 30-45 degree insertion angle
Nerve in nasal mucosa for smell
I (olfactory)
C and L grades
I= full view of the glottic opening II= only the posterior portion of the glottic opening. Anterior commisure not seen III= only epiglottis is visualized. No glottic opening IV = no epiglottis, only a view of the soft palate
Bougie is best suited for what cormack and lehane grades
II or III, best if you can see part of epiglottis at least.
With coumadin you can remove a CNB catheter when
INR <1.5
What is the treatment for hypomagnesiumia?
IV replacement severe hypomagnesemia can be treated with 1-2 g over 5 minutes followed by administration of 1-2 g/hour
If pt. has been on maintenance gtt before surg while npo do they have deficit?
If amount is equal to operative maintainence then they don't have a deficit
What does acidemia do to ionized ca++ and why?
Increases it. Decreases protein bound fraction of ca++.
What are 4 subglottic airway techniques
Needle cricothyrotomy with jet vent Retrograde intubation Surgical/percutaneous cricothyrotomy Tracheotomy- not done in emergency and not done by anesthesia
Arts 4 s/s of high na+
Intracranial hemmorage seizures decreased reflexes (book says hyper reflexes) agitation
What is 3-3-2 rule
Intubation evalutaion: Numbers in this order Three fingers interincisor Three thyromental two between hyoid bone and thyroid notch (chin-neck juction)
What covers conus elacticus and what is it?
It is the lateral portion of cricothyroid ligament. The thyroid cartilage covers it. It thickens and forms vocal cords superiorly
pharynx beginning and end
Just superior to glottic opening at cricoid cartilage and opening to esophagus inferiorly, to base of skull superiorly
Should dentures be removed before BMV? OGT and shave?
Keep dentures May need to remove beard or ogt
Difference between king LT and combitube
King LT only has one ventilation port. king LTS-D is disposable and allows for a OG tube. Can give positive pressure up to 30cmh20
What is nitrous documented as
L/min
What pressure should ett cuff be inflated to?
Less than 25cm H20.Usually 20-25. This will require varying volumes of air. Not to be confused with max LMA pressure of 20 (except proseal which may be 30)
What is the difference between Bupivicaine, levobupivicaine and Ropivicaine
Levobupivicaine is just the S-enantiomer of bupivicaine (the active 50% of bupivicaine) Ropivicaine is a similar structure to Bupivicaine but not the same
What are the only two hypobaric locals
Lido and Tetra, no Bupivicaine
When are longer acting narcs used?
Longer cases or post op
What do certain antibiotics do to k+ and mag
Lower it, in fact most drugs in the book that change electrolyte concentration tend to lower them
My favorite anatomy description of airway is found where
M and M chp 19
Calculate fluid deficit
Maintainence rate x hours npo
What is adult size of laryngoscope blades? Peds?
Miller 2 Mac 3 for most adults (up to miller 4 Mac 5) Miller 1 Mac 2 for most peds There is a miller 0 and mac 1 for neonates
If running epidural low dose and they are on coumadin, what should you do (3)
Minimal epidural meds Assess sensory and motor daily Hold coumadin if PT >3.0
How often should you rub head and do ROM
Minimum Q 2 hours Don't interfere with surgery
What determines when you should give autologous blood back to them
Monitor H and H and give back when it gets low
What is in PRBCs
Mostly RBC and a little of other blood cell types and platelets and plasma
Arts 2 signs of low ca++
Muscle spasm/cramps Twitching/tingline in fingers mouth
When to transfuse the patient according to ASA taskforce
Never hgb>10 Usually <6 hgb except those with 02 carrying problems
If difficult intubation, will an LMA likely be difficult too?
No, and will open up time to use other means of intubation.
Preoxygenate in rapid sequence?
No, but maybe in modified RSI might still preoxygenate in emergency even though considered full-stomach if benefits outweigh risks
With ankylosing spondylitis or RA, do you attempt to put head in sniffing position?
No, it may injure pt. Do not manipulate neck with cervical spine pathology
Will JW use PRBCs?
No, some will say yes if they are going to die.
Can you just give DDAVP to pt who has von wlllebrand and is needing a spinal?
No, you could give FFP though. DDAVP only works if you have 1/2 genes of von willebrand. If you have some but not enough factor then DDAVP will help you release more.
When is care handed off to PACU nurse? After extubation?
Not necissarily, leave when PACU nurse is comfortable. Ok to still be intubated and in pain with NV etc. You do your best to address issues and give orders etc. Also nice to give meds for pain, NV, and BP etc. so they don't have to
What blood type is a person with type O blood compatible with?
O
What is transforamenal epidural
Often do a transforamenal epidural right where nerve root comes out (go in from the side instead of the median part) and they inject steroid just proximal to the nerve root that exits the lateral intervertebral foramen [these are often for disk herniations- that causes smashed nerve roots] lasts 6-12 months.
Where is post anesthesia follow-up note often made
On a portion of the preanesthesia evaluation there is a box for post anesthesia note. Progress note can also be used.
Where are preop notes charted
On back of anesthesia form or dictation
What is suppose to be in post op evaluation (follow-up)
One place says: Recovery from anesthesia, evaluation, treatment,and follow-up of possible anesthesia-related complications. ANOTHER PLACE SAYS: 1. Time and date of visit 2. Complications, if any 3. General status a. Systems reviewed should reflect care given 4. Signature
Atrixia and CNB
Only do single needle pass and no catheter
Morgan and Mikhail questions from here on: If a patient has throbocytopenia or coagulation issues, should they get oral or nasal airway?
Oral
What are the two parts that are documented on in postanesthesia care
PACU, often done by nurse Post op evaluation/follow-up done by anesthesia provider
What is the most commonly discussed and managed complication of CNB
PDPH
What is the treatment for hypokalemia?
PO and I V replacement Rates of I V replacement have a maximum rate of 10 to 20 mEq/hour with cardiac monitoring
What blood product is the component of choice for improving oxygen carrying capacity?
PRBC's
Other than waiting with heparin before CNB what also must be done
PTT (this is really what guides you)
what is the basic information that is needed to be charted according to the AANA article
Patient identification, provider information, intake and output, equipment checks, , monitors, techniques, medications, and procedural data are all part of the basic data that is necessary for every anesthesia record. A record of any parameters monitored during the anesthetic should also be part of the basic data.
What should the following procedures dermatome block level be? per art Perianal Total hip Abdominal - C Section
Perianal - L1-L2 Total hip -T10 Abdominal - T4-T6 C Section t4-t6
What pts are Ca++ pushes used for
Poor cardiac function, in signs of pending arrest like flat p wave and wide qrs.
5 Main causes of low mag
Renal diseases and losses GI losses and poor absobtion Endocrine pregnancy Drugs
What structure extends from the base of the skull to the level of the cricoid cartlage
Pharynx (According to the Nag)
What structure extends from the posterior turbinates/base of the tongue to the opening of the glottis?
Pharynx (according to Menardies notes)
PDPH s/s
Photophobia, diplopia, pain in forehead toward occuput, pain in shoulders, worse than migraine
what are the three meninges of the spinal cord from innermost to outtermost?
Pia matter Arachnoid matter Dura matter
Flow sequence for BMV difficulty management (6 steps)
Position pt one hand vent reposition to sniffing place oral airway two hand vent consider supraglottic device or awaken patient or invasive if needed
Who needs to be signed onto the anesthesia record (3)
Provider Information 1. Primary anesthetist 2. Secondary anesthetist, if any 3. Relief provider, times of relief, credentials
If you are having a hard time ventilating, your first reaction is to do what (but shouldn't do this)?
Push reservoir bag harder. But this isn't fixing the problem and may cause gastric distention.
How often to chart vitals and comfort after spinal
Q2-5min for 15 min
EKG with k+ > 8.5
QRS is sine wave, v fib and arrest
What SAB needle poses biggest PDPH risk and how should it be inserted
Quinke of any size. To reduce PDPH it should be inserted with bevel parallel to the menineal fibers that run cephalad to caudad.
What is in a bag of whole blood?
RBC's Plasma WBC's Platelets
What is in a bag of PRBC's?
RBC's WBC's some plasma
Thyroarytenoid
RLN motor
interarytneoid (adductors)
RLN motor
lateral cricoarytenoid
RLN motor
posterior cricoarytenoid (adductor)
RLN motor
Trachea
RLN sensory
subglottic mucosa
RLN sensory
dissecting aortic arch and mitral stenosis cause strain of what nerve
RLN causes hoarseness
Does acute injury to the RLN or the superior laryngeal nerve cause respiratory distress and stridor
RLN, becuase then tension and adduction are unapposed
Main indications (2) for cricoid pressure
RSI for full stomach
what does the SHORT accronym stand for
Reasons why cricothyrotomy/tracheotomy is difficult surgery hematoma obesity radiation tumors
why pts get sleepy with CNB
Reticular activating system is depressed
5 Indications for FFP
Reversal of warfarin Correction of known coagulopathy Microvascular bleeding with long prothrombin time (PT) PTT>1.5 x normal Dilutional coagulopathy
if a persons blood is Rh negative what are they compatible with?
Rh negative
if a persons blood is Rh positive what are they compatible with?
Rh positive and Rh negative
What can be some causes of hyponatremia?
SIADH water intoxification hyperglycemia mannitol excess glycerol therapy diuretics Vomiting/diarrhea third spacing sweating ketonuria renal failure hypothyroidism drugs porphyria pain stress positive pressure ventilation CHF nephrotic syndrome cirrhosis
cricothyroid (adductor tension)
SLN-external motor
With pt supine where are the two low points in the vertebrae and where are the peak and trough of lumbar and thoracic vertebrae
Saccrum and Thorax o Apex of the lumbar curve is L3-L4 o Trough of thoracic curve is T4
What can be some causes of hyperkalemia?
Shift of potasium from ICF to ECF resulting from lysis of cells, acidemia, beta blockers increased intake impaired renal excretion
S/S of PDPH
Spinal headache - post dural puncture headache Photophobia like a migraine, N/V
If person develops spinal hematoma how ill it manifest?
Slowly, usually venous, over days and weeks will build pressure and cause nerve damage
what is the dermatome level of the umbilicus?
T10
Superior laryngeal nerve block steps
Supraglottic block 1-find greater cornu of hyoid (round structure below angle of mandible 2-walk needle off the caudal edge of cornu and it will bounce of membrane, 3-aspirate and inject 1ml of 2% lido 4-advance 2-3 mm through membrane and inject 2ml of local 5- repeat on other side
What do you report to pacu nurse
Surg diagnosis and procedure medication history allergies Procedure Medical history problems during anesthesia meds and fluids given preop and intra labs baseline VS and labs gtt rates orders like ekg, cxr Med orders vent settings especially meds toward end and reversal
Two most common causes of transfusion reaction death
TRALI and hemolytic rxns
What is duration of action of most common meds for SAB with and without epi
Tetra = 1.0-1.5hrs; 2-3 hours with epi Marc = 1.0-1.5 ; 1.5-2.0 w epi Lido is 15-60 min; 1.0-1.5 hours
Memorize table 44-6 in text. Pg. 1093
This is about epidural opioids
Describe the difference between the vestibular and vocal folds and the vestibular and vocal ligaments
The vocal ligament is a superior thickening of cricothyroid ligament. the Vestibular ligament is an inferior thickening of the quadrangular ligament. The vestibular ligament is actually superior to vocal ligament, not attached to it. The "folds" are folds of mucosa that cover the ligaments. The mucosa extends from epiglottis and the first fold is over the superior vestibular ligament and then it folds again over the vocal ligament inferiorly (vocal fold)
what happens to opioids that are water soluable in CNB additives
They are not absorbed and stay in space. Slower onset, longer duration
What are surgeon preference cards
They are often for surgeon insturment preference We can make them for anesthesia
What is unique about c6-c8
They are only on the posterior body and so they innervate the posterior arm as well
What do cricothyroid muscles do
They cause larynx and thyroid cartilage to move anterior and downward (away from cricoid cartilage) which causes tightening of vocal folds (higher pitch)
What are rae ett?
They curve sharply once they exit mouth or nose to get ett out of the way.
What is unique about C5 and T1
They lie next to each other on anterior chest and arms but are separated posteriorly by c6-c8
why are cleft palate patients hard to intubate
They often have a hole in their palate
What vascular procedures would be an indication for cell salvage?
Thoracoabdominal aortic aneurysm repair AAA repair
What is a transfusion trigger
Threshold where blood products should be given. Used to be rigidly based on labs, not it is not rigid based on clinical data
What do transverse and oblique arytenoid muscles do
Transverse are parallel between arytenoids. They bring arytenoids together and adducts the cords? The oblique runs cris-cross between arytenoids and also adducts cords. They might also continue to form aryepiglottic muscle.
what do leukocyte filters reduce the risk of
Trim and non-hemolytic
True or false? Documenting your follow up visit is required by JACHO?
True
True or false? in the epidural space compartments, occupied mostly by fat but also nerves and fibrous tissue, repeat at each segment in a metameric fashon
True
What is the most important part of blood compatibility
Type (abo and rh) Antibodies are less important thus cross match isn't nearly as important at the abo RH
What needs to be on intraop care plan
Warmth BS reasons for selection, dose, and redosing for all drugs
Do we have to document tornequet, warming blanket, restraints, straps etc. times
We can, but if someone else is timing it we don't have to
ASA difficult airway step 3
Weigh merits and feasibility of basic choices : -Awake intubation vs. attemps after GETA induction -Non-invaseive intubation vs. invasive intubation -Preservation of spont. vent vs. ablation of spont vent.
Upon insertion of an ett into a fastrach, at what point does ett push the epiglottic elevating bar up?
When ett is inserted 15 cm (look at markings on ett). There should be dark line on ett at 15 cm.
what is a glideScope?
a video laryngoscope that provides a laryngoscopic view equal to or better than that of direct laryngoscopy without manipulation of the head into sniffing position
when using a trachlite what happens as the light source enters the trachea?
a well-defined circumscribed glow is noticed below the thyroid promenance and can be readily seen on the anterior neck. oh and menardie says to turn off the lights to see the light better
what is the function of the posterior crioarytenoids?
abduction of the vocal cords (opens)
(Gag Reflex) When posterior wall of pharynx is touched, impulses are carred _________(afferently/efferently) by the ___ nerve to the ____ where they synapse with nuclei of the _____ nerve and the ______ portion of the _______ nerve. The efferent response returns through the ______ nerve resulting in a gag reflex as the muscles of the ________ elevate and _____
afferently, glossopharyngeal medulla, vagus cranial, spinal acessory vagus, pharynx constrict
When is type and cross no longer valid
after 2 units of trauma blood. May become predominant type
At what point are colloids often used rather than more crystalloids to expand volume
after 3rd liter
When are pts retransfused after normovolemic hemodilution
after bleeding has stopped
What are some symptoms of hypernatremia
agitation hyper-reflexia ICH seizures thirst weakness cerebral edema muscle twitching hypovolemia polyuria or oliguria renal insuffeciancy
how should you treat a total spinal?
airway and ventilation, CV support, trendelenburg, fluids, Epi, ephedrine
according to the ASA difficult algorithm what are your two choices with an awake intubation?
airway approched by noninvasive intubation or invasive intubation
What primarily is responsible for osmotic pressure intravascularly
albumin
What are the intrinsic muscles of the larynx innervated by? What is the exception
all by the motor portion recurrent laryngeal nerve except cricothyroid muscles which is external (motor) branch of superior laryngeal nerve
What are the purpose for check boxes on an anesthesia care plan?
although they help with speed, they help quality.
what can be used as an alternative to an Esmarch bandage while doing a bier block?
an air-inflated splint
what are trachea causes of a lower airway obstruction
angioedema aspirated foreign bodies hematoma hemorrage tuomors or lesions
Thrombin inhibitors (2 names) and CNB
angiomax and iprivask No Data, don't do it
Where is mandibular hyoid distance (MHD) measured
angle of mandible to the hyoid bone (usually via xray)
is the epiglottis anterior or posterior to the vocal cords?
anterior
what does the external superior laryngeal nerve provide sensory for?
anterior subglottic mucosa
What is unique about glidescope camera
anti fog heating element located on middle of the blade
4 indications for fiberoptic scope
anticipated difficult airway cervical spine immobilization*** anatomic abnormalities failed to intubate but can ventilate
What is the risk of too much colloid (not albumin so much)
anticoagulation (maybe renal damage)
Is blood type named according to antigen or antibody
antigen because that is what is on the cell. Thus the cell type. The antibodies are not made by RBCs obviously and thus the blood type of RBC does not come from antibody type
What are five classes of meds often considered for awake intubations
antisialagogue opioid benzo IV sedative drugs to lower aspiration risk
what should tell the patient to report during a bier block?
any symptoms of LAST
Where does oral airway move tongue
away from soft palate and posterior pharyngeal wall
the brachial plexus is a large network of nerves that extend from the neck through the _______ and innervate the ________
axilla, upper extreamity
what does BURP stand for?
backwards upwards right pressure
What are two ways to irrigate
bag with a trigger Sponge
When airway has inflammatory partial obstruction what should you do when intubating
be very careful, may cause total obstruction, especially with fiberoptic
why is the sniffing position important?
because it helps to improve laryngoscopic views by promoting displacement if the tongue by better aligning the oral, pharyngeal, and laryngeal axes
although a single tourniquet can be used on a bier block, why is a dual tourniquet recommended?
because it provides a means to extend the length of the block after the initial onset of tourniquet pain
why would high block may impair ventilatory function?
because of intraabdominal or intercostal muscle paralysis
why does epi prolong the duration of spinal anesthesia?
because of vasoconstriction, thereby delaying normal uptake of local anesthetics
According to art where is the laryngopharynx
between hyoid and glottis
Which ion is important in coagulation
ca++
which ion is mainly a secondary messanger in cells
ca++
Autologous transfusion indications (2 type of case and 3 pt specific)
cabg/high blood loss cases high antibodies rare blood type Those w hx of multiple transfusions
What is the treatment for hypermagnesiumia?
calcium (in urgent situations as an antagonist) diuretics dialysis reduce nondepolarizing paralytic dose discontinue administration of mag
the second recommendation from the AABB states to adhere to a restrictive strategy in hospitalized patients with preexisting ____________ disease and consider transfusion for patients with symptoms or a hemoglobin level of ______ g/dl or less
cardiovascular 8
what causes a post dural puncture headache?
caused by a leak of CSF that out-paces production. the medulla and brainstem drop into the foramen magnum, stretch the meningies and pull on the tentorium
What does extracellular compartement serve as a medium for
cell nutrients, electrolytes, waste products
What additives will prolong bupivacaine?
clonadine or decadron (but no decadron in CNB)
what is the function of the interarytenoid?
closing of posterior commissure of the glottis
Arts 4 neuro s/s with high mag
cns depression sedation hyporeflexia weak
according ot the "smart" airway stratigies, what are two primary airway verifications
co2, bilateral breath sounds
What should you monitor in MBT
coags and hemostasis maybe ca++
Whats in FFP?
coagulation factors
Only LA that vasoconstrics
cocaine
What was the original med for spinals
cocaine
What are the five criteria for apgar and what is normal score
color heart rate respirations Reflex/irritability response Muscle tone Normal = 8-10 moderate distress 4-7 Needs resucitation = 0-3
supraglottic tubes. Name several
combitube, king laryngeal tube, rusch easy tube, and LaryVent. all are placed blindly and can be positioned into esophagus
If a patient with an ett has been repositioned, what must be done?
confirm ett correct placement again to rule out ett migration
What are some symptoms of hyponatremia?
confusion seizures coma agitation cerebral edema nausea/vomiting cramps weakness headache
What opioids is there no spinal dose for
demerol
What happens if serum sodium is too rapidly corrected?
demylenation and seizure, coma, spasticity
What is the most common airway malpractice claim
dental trauma
What are some symptoms of hypermagnesiumia
depression of PNS and CNS sedation hyporeflexia weakness respiratory depression bradycardia myocardial depression
What is the treatment for hyperkalemia?
dialysis calcium insulin and glucose (Menardie says this is typical) diuretics (Menardie says this is slow) kayexelate (be sure this is done right before taking the patient to the PACU) sodium bicarbanate
Three treatment for high ca++
dialysis iv fluids diuretics
According to M and M a lumbar epidural can be used for any procedure below the
diaphram
What is defined as difficult airway (3)
difficulty with mask ventiation, laryngoscopy, or intubation
According to Dr Nag, in a massive blood transfusion accompanied by crystalloids and colloids will not provide coagulation factors. what can this lead to?
dilutional coagulopathy dilutional thrombocytopenia
According to Menardie what are some other risks of massive blood transfusion
dilutional coagulopathy volume overload metabolic alkalosis (late) hyperkalemia hypothermia
What are risks of MBT concerning: coagulopathy (2) volume status pH (2) Electrolytes Temp
dilutional coagulopathy and citrate coagulopathy volume overload metabolic alkalosis (late) acidosis (early) Hyperkalemia Hypothermia
risks of cell saver use (2)
dilutional coagulopathy and throbocytopenia Monitor clotting levels and plts w point of care
What is LMA supreme
disposable proseal LMA
Five things that make invasive airway difficult (box 22-2)
distortion of neck anatomy obesity or short neck trauma impediments/devices around neck Surgery causing limited access
if the first blood patch does not work what would you do?
do another blood patch
what should you do if a blood patch does not cure a PDPH?
do another one, duh!!!
What is the rule for placing a spinal in a patient on thrombolytics
do not place even after 24 hours
What questions should you ask CNB patients about bleeding risk
easy bruising or bleeding in gums or cuts? Any drugs that cause anticoagulation
when doing a retrograde intubation what 2 options do you have to insert via cricothyrotomy?
either a J wire or a number 2 Mersilene suture
Where should you grab ETT when using magill forceps in nasal intubation
either below or above cuff
Should generic or trade name be documented
either but be consistent
What is charted Q15 min
ekg, SP02, fi02, monitors like biz, gases
what patients would be good to use a paramedian approach?
elderly and arthritic
according to the ASA difficult algorithm you had an unsuccessful ventilation after your emergency noninvasive airway attempt, what is next option?
emergency invasive airway access
What does gut release due to ischemia
emetogenic substances like seratonin
Hoarseness or airway obstruction noted immediately in the post-op period is found; what should be evaluated?
evaluation for possible emergent reintubation or tracheotomy
What needs to be documented preop according to AANA article (5)
evaluation of pt review of systems and records personal communications physical assessment Informed consent obtained
NH says the bougie or exchange catheter is better
exchange catheter
where does the spinal cord begin and end?
extends from the medulla oblongota through the spinal foramen to the level of the L2 vertebra
Tongue sense of taste
facial nerve (vII anterior two thirds glossopharyngeal nerve (IX) posterior 1/3
Indications for surgical cricothyrotomy
failed airway trauma to neck face or airway immediate relief of obstruction need for definitive airway for neck or facial surgery if intubation is not possible
what is failed intubation
failure to place ett tube after several laryngoscopic attemps (Nagelhout p. 437)
True or false? The vertebral foramen is palpable on skinny people
false
True or false? you should be sure to document any threats a patient makes to you, or document anything that blames others?
false
true or false? a nerve stimulator can be used for enhancing any technique except for an ultrasound guided nerve block
false
true or false? the thyroid cartilage wraps completely around posteriorly the larynx
false
true or false? the use of NSAIDS is a contraindication to spinal and epidural anesthesia
false
where do you inject your needle while doing a traditional approach to block the brachial plexus?
firmly press your fingers into the interscalene groove and insert the needle in between fingers slightly in a caudal direction
What care plan is required to be done each day
first case of the day and biggest case of the day
What happens with nasal membranes with general anesthesia
general depresses sns which causes vasodilation in nasal passages and cause more BLEEDING and ENGORGEMENT with blood.
What should "plan B" be with CNB
general, have the stuff ready
What Neurosurgery procedures would be an indication for cell salvage?
giant baislar aneurysm
How does Dr Nag say to give calcium gluconate for treatment of hypocalcemia?
give 10 mL of 10% over 10 minutes, followed by an infusion of 0.3 to 2 mg/kg/hour of elemental calcium
Arts normal dose of plts
give 6 pack and then follow up labs
the ASA task force says a transfusion is unnecessary in patients with what hemoglobin value?
greater than or equal to 10
What is the pts sensation as a needle passes the ligamentum flavum
gritty, especially with epidural
What is eschmann stylet
gum elastic bougie
Lab to check before autolougous donation
h and h
How long do h2 blockers, gastroprokinetic agent, or sodium citrate need to be given before induction to reduce aspiration
h2 blocker is 45-60 min (ranitidine etc.) antacids is 10-20 min gastroprokinetic agent is 20-30 min (reglan)
how long should a patient be in the supine position after having an epidural blood patch in treatment for a PDPH?
half an hour to an hour
burns and crush injuries and K+
has it listed as both for burns. However, I would imagine early in burn it is high and later k+ is low. Crush is high
hct of cell saver blood
hct 55
What is sniffing position
head elevated on bed, with extension. aligns oral and trachial planes
Lithium and ca++
high
Peaked narrow T wave with high or low k+
high
adrenal insufficiency and ca++
high
TB can cause what with ca++
high ca++
Tb and electrolytes
high ca++
acromegaly and electrolytes
high ca++
being immobile and electrolytes
high ca++
berylliosis and electrolytes
high ca++
estrogens and electrolytes
high ca++
histoplasmosis and electrolytes
high ca++
hyperthyroid and electrolytes
high ca++
leprosy and electrolytes
high ca++
milk-alkali syndrome and electrolytes
high ca++
Thiazides and ca++
high.
What can be some causes of hypermagnesiumia?
iatrogenesis treatment of preeclampsia treatment of preterm labor treatment of ischemic heart disease treatment of cardiac dysrhythmias renal failure adrenal insufficiency
what are the landmarks for a sciatic nerve block?
identify the greater trochanter, posterior illiac spine, and sacral hiatus
how much local do you inject when doing an ulnar nerve block at the elbow?
if parasthesia is elicited withdraw 1 mm and inject 2 to 3 ml. If parasthesia is not elicited 3 to 5 ml
What is the storage lesion
if prbcs are stored longer than 14 days, then you have changes in blood bank blood
Where is intercristus line
iliac crest L3-L4 (tuffiers line)
What can be some causes of hypernatremia?
impaired water intake
What can be some causes of hypomagnesiumia?
increased renal or GI loss poor intake alcoholism
How does "ramping" help obsese patient's during mask ventilation
increases functional residual capacity
when doing an interscalene block how much local do you inject if there are no symptoms of toxicity?
incremental injection of 3 to 5 ml, each follwed by aspiration, for a total of 30 to 35 ml (according to nagelhout, but the slides say 15-25ml)
Always make sure suction is on and ready before ______
induction (before any indcution drugs given) because you need to suction before larygoscopy
What is the size of ETT you should use for infant, peds, adults (How deep should cuff be for adults)
infant 3.5 mm - child (Age + 16/4) Female adult 7.0-7.5 --- 24 cm (art said 21-23) deep Male - 7.5-9.0 --- 24-25 cm deep
TRALI pathogenesis
inflammation and allergic rxn cause leaking wbc in alveoli, cause lung injury and edema
the lateral cutaneous nerve passes inder the lateral border of the ________ and provides the sensory innervation to the lateral aspect of the _____.
inguinal ligament, thigh
how much do you inject when doing a glossopharyngeal block?
inject 1 to 2 ml 2% lidocaine
which of the laryngeal nerves is only sensory?
internal superior laryngeal nerve
what are the 3 main nerves innervating the larynx?
internal superior laryngeal nerve external superior laryngeal nerve recurrent laryngeal nerve
the intercostal nerves emerge from the ________ and follows the rib in the costal groove which is located on the __________ aspect of the rib
intervertebral foramen, anterioinferior
If fraction of excreted urine is > 2% what does that mean
intrinisic renal disorder is responsible for high creatinine
the _______ of the larynx control the tension of the vocal cords as well as the opening and closing of the glottis
intrinsic muscles
What is ILMA
intubating LMA or Fastrach LMA
unilateral recurrent laryngeal nerve damage does what
ipsilateral paralysis of vocal cord (hoarseness and poor quality)
What is the filum terminale
is a delicate strand of fibrous tissue, about 20 cm in length, proceeding downward from the apex of the conus medullaris.It is one of the modifications of pia mater. It gives longitudinal support to the spinal cord
what does the second 3 in the 3 3 2 rule measure?
it assesses the mandibular length from the tip of the mentum to the mandible-neck junction and gauges the ability of the tongue to displace within the submadibular space during laryngoscopy
when would a PDPH occur after a spinal?
it can occur within several hours to the first or second post op day
What kind of needle is used in needle cricothyrotomy
large bore needle or angiocath (venous or arterial) (14-18 gauge is for retrograde)
What is stubby used for
large chest, the handle gets in the way. Usually obese people
Why is lumbar CNB less risk than thoracic
larger epidural space spinal cord is not there so less risk of spinal cord damage although risk of cauda equina still exists
What are the three axis
laryngeal and pharyngeal and oral
What is cormack and lehane grading system
laryngoscopic difficulty
what are some respiratory complications during extubation?
laryngospasm airway obstruction aspiration sore throat soft tissue obstruction ventilatory depression laryngeal edema vocal cord malfunction cyanosis breath holding coughing hypercarbia hypoxemia
what structure begins with the epiglottis and extends to the thyroid cartilage?
larynx
Where does superior thyroid artery travel
lateral to the crycothryoid membrane
If you are mask ventilating with apl valve open, but the resivoir bag keeps going flat, what is probably happening?
leaky mask seal
What are the strengths of Lido, Rop and Bup for surgical block in Epidural
lido is 1-2% Rop is 0.5-0.75% Bup is 0.5
what is lido lollipop and how to use
lido ointment on tongue blade, place it on back of the tongue for 1-2 min
which would be a good choice for a 10 min prone procedure lidocaine 0.5% with epi lidocaine 2% hypobaric lidocaine 5% hyperbaric bupivicaine with epi
lidocaine 5% hypobaric
what locals are considered less protein bound
lidocaine, and mepivacaine
Where is the the infraclavicular portion of the brachial plexus located?
lies in the axilla
What are the three channels in a fiberoptic scope
light source fiberoptic lens fiberopitic Aspiration channel
what is the only way to correct error in charting
line out
What type of liver procedures would be an indication for cell salvage?
liver transplant
What two drug classes are good for reducing coughing and straining on extubation
locals opioids
what landmarks do you use when doing a superior laryngeal nerve block?
locate greater cornu of hyoid bone, beneath angle of mandible
what landmarks do you use when doing a translaryngeal/transtracheal block?
locate the cricothyroid membrane, superior to cricoid and inferior to thyroid
TPN and mag
low
What is a MBT (3 definitions)
massive blood transfusion -Replace estimated blood volume in 24 hours -10 or more units of prbcs in 24 hours -or 50% of blood volume in 3 hours or less
What is max jet vent inspiratory pressure and what is normal?
max is 50 normal is <25
Teeth most at risk during intubation
maxillary incisors
What complication happens if pt is trying to breath with an obstruction (like oral airway not working)
may get negative pressure pulm edema
What happens to co2 with leak
may not look as high
what does the 2 in the 3 3 2 rule measure?
measures the mandibulohyoid distance from the mandible-neck junction to the tip of the thyroid notch and assess the position of the larynx in relation to the base of the tongue
Arytenoid dislocation can be casued by
mechanical force of ett against it or forceful intubation
What direction should a nasal ett be inserted
medial and perpendicular to nare along floor of nose
in the brachial plexus what are the branches of the lateral and medial cords?
median, ulnar, and musculocutaneous nerves
what is the glidescope made of?
medical grade plastic
What is the difference between technique of using mac blade vs. miller
miller pulls the epiglottis back gently Mac pulls the anterior tongue back in vellecula and indirectly lifts the epiglottis
is chole, acl min, mod or sever evap loss
moderate
in the Cormack and Lehane Grading system what is seen in a grade 1?
most or full view of the glottic opening
What part of care plan is positioning
mostly intraop
If you put retraction on chest, what airway nerve do you worry about
mostly right recurrent laryngeal nerve because it goes around the subclavian
Position for thyromental distance
mouth closed and head extended
What causes high antibodies for blood transfusion rxn
multiple transfusions hx
What are some symptoms of hypocalcemia?
muscle cramps and spasms twitching or tingling especially in fingers or mouth tetany muscle weakness seizures bradycardia and hypotension broncho and laryngeal spasms
corrected sodium equation
na+ 0.016 x (glucose - 100)
Is oral et tube or nasal tube better tolerated for longer cases
nasal
what can be done during jet vent to improve exhalation
nasal or oral airway. You can also push on the chest slightly
What is the superior portion of the pharynx?
nasopharynx
What part of pharynx are adenoids
nasopharynx
what part of the pharynx is the adenoids found in?
nasopharynx
Post op care plan concerns
pain nv extubation/ventillation cxr NMBD paralytic abx Post op destination like ICU, or fast track BS
What should be documented on follow-up visits
pain vs NV When block was wearing off Recovery Recall "how was anesthesia" Satisfaction
What symptoms does spinal transient neuropathy cause
pain and paresthesia in butt and legs
intercostal nerve block can provide analgesia for post operative _________ when epidural analgesia is not desired or possible
pain control
Apgar color scoring
pale/blue= 0 pink body blue extremities =1 Pink everything =2
non-reassuring finding of normal jaw closure
overbite
Is suction or oxygen usually used through fiberoptic port
oxygen, suction is difficult because lumen is small
EKG with k+ 7.5 -8.0
p wave flat, wide qrs, nodal and escape vent rhythms
should you transfuse PRBC's for a patient with a class 3 hemorrhage?
probably nessesary
if intubation and ventilation have failed should a fiberoptic be used
probably not, it is too time consuming. Good for fail to intubate but can ventilate
Is LMA ok for those with reactive airway
probably, less irritating than ETT.
Should ideal or adjusted body weight be used for fluid calculations
probably. Most people do one or the other but no actual weight in obese
what are some indications of spinals or epidurals?
procedures of the lower extremities, perineum, and abdomen. acute and chronic pain management obstetric procedures, Labor analgesia
EKG changes when k is 6.0-7.5
prolonged PR, peaked t, short qt
what are the four functions of the larynx
protection of lower airway from aspiration -patency between hypopharynx and trachea -protective gag and cough reflexes -phonation
What 2 things should be done if endobronchial intubation is discovered
pull back ett and hyperinflate to expand atalectasis.
What should be done with kids loose tooth
pull it out before intubation. Tell fam tooth-fairy came
in a patient who has been laboring for 4 hours where the epidural seems to only be working on one side what would be a good option?
pull the catheter back a cm and re-position the patient. If it doesn't start to work place a second epidural
What if you lay down pt after spinal and you still don't get the level of block you want
put their head down (hyperbaric solution)
What is ett made of and why is this important
pvc, flammable especially with 02
What are the check boxes and grids for
quality management not speed of charting. Helps to prompt as well
What are the three names of SAB needles and the one that is cutting
quinkie is cutting sprotte and whitacre are pencil-point
in the brachial plexus what are the branches of the posterior cord?
radial and axillary nerves
What Urology procedures would be an indication for cell salvage?
radical retropubic prostatectomy Cystectomy Nephrectomy
Other than sniffing what can be done to align airway axes
raise the head of the bed in addition to applying the blankets under the head
ASA taskforce summary of transfusion guidelines (different than american association of blood banks)
rarely transfuse for hgb>10 Usually administered when hgb <6 hgb 6-10 is based on clinical factors such as cardiopulmonary function/02 levels
When using a nerve stimulator in doing a brachial plexus block what is done with the amplitude as the needle enters the sheath?
reduced to 0.5 milliamps
What does vagus nerve innervate in airway (sensation, motor, autonomic NS)
sensation below epiglottis. Parasympathetic of bronchiotracheal tree. Also intrinsic muscles of larynx.
What should be documented intraop (3)
sequence of care given, drugs/fluids, responses (vitals)
is colon resection, and aorta repair min mod or severe evap loss
severe
Main difference between complex and short forms
short has more room for wasted drugs and remarks Long form has more room for graphic vitals charting
what is the function of the thyroarytenoids?
shortening and adduction of vocal cords Art said these relax the vocal cords
What are volatile agents documented units
should be End Tidal % Some people do what is on the dial
What is black line on LMA tube for
should be near the lips if placed correctly. Same with bite block
What is McGrath video scope
similar to glidescope but portable. uses one AA battery and has 1.7 inch screen. Macintosh like disposible blade, with similar anterior angle to glidescope
What is airtraq and how is it used
similar to glidescope but uses prism. Doesn't have to have monitor. Has similar mac blade. Cheap and disposible. Antifog LED if on for 30 seconds
what risks are there in using a trachlite in a patient with an upper airway anomaly?
since it is inserted blindly there is a greater risk of injury or failure in these patients
how do you prevent a complication of nerve injury in a sciatic nerve block?
slow needle advancement, do not inject with parasthesia
how do you advance the needle of a nerve stimulator
slowly
3 types of difficult airways that trachlight is good for
small oral opening minimal neck manipulation Anterior ariway
pt. position if initial attempt at LMA placement is not successful
sniffing
In brain what is most osmotically important substance unlike the rest of the body
sodium (albumin in the rest of the body)
the nasopharynx is separated from the oropharynx by the ________.
soft palate
What is not in PRBCs
some of the clotting factors like 5 and 8
will JW use cell saver
some will some won't offer to give in continuous circuit instead of going to bag
Why is assistant often needed to insert nasal airway
someone to help advance the tube while you use laryngoscope and Magill forcept. Then once at cords, tell assistant to advance the tube through the cords.
What are variations in vertebrae anatomy
sometimes +/- 1 thoracic or lumbar vertebrae
according to the AANA where should the preanesthesia eval be documented?
sometimes it appears on a special part of the anesthesia record, usually on the back, or sometimes a separate form is used.
when placing a spinal what is a Taylor approach?
this takes advantage of the L5 interspace (the largest). 1 cm medial and 1 cm caudad to the posterior superior iliac spine point is where a needle is inserted and angled medially and cephalad at a 55 degree angle toward the 5th lumbar interspace
what are the indications for doing an intercostal block?
thoracic or upper abdominal surgeries, rib fractures, breast surgery, pain relief form herpes zoster and cancer
Who should be extubated fully awake (2)
those with risk of aspiratioin Difficult airways
What are some things to document on personal notes?
threats emotional outbursts stuff that was wrong in a case
the anterior and lateral larynx is formed by the _________.
thyroid cartilage
Does thyroid have posterior portion? Cricoid?
thyroid doesn't, cricoid does
Anteriorly, the thyroid cartilage fuses and forms the ________
thyroid notch
What test is indicitive of "anterior larynx"
thyromental distance
what are the 5 nerves of the ankle that get blocked?
tibial nerve, sural nerve, superficial nerve, deep peroneal nerve, and saphenous
what is the fastrach LMA used for?
to be used in the cannot intubate and cannot ventilate scenario as well as in situations where difficult intubation is anticipated it also allows for reasonable control of the airway through the intubation process
why do you do a test dose prior to injecting large amounts of medication into the epidural space?
to determine whether the catheter or needle has inadvertantly entered the subarachnoid spaced or possibly threaded into a vein
Arts 2 treatments for low na+ and dose
treat underlying cause 3% saline at a rate of 1-2ml/kg/hr Once stable slower to raise sodium not more than 10-15mmol/L in 24 hours
what are the landmarks to use in a TAP block?
triangle of petit is an anatomical space between the posterior attachment of the EO and anterior attachment of the latissimus dorsi muscle to the iliac crest
What 3 nerves need to be blocked in airway block
trigeminal - nasal septum and lateral wall and anterior tongue glossopharyngeal - posterior third or tongue, soft palate, oropharynx vagus- hypopharynx, larynx, trachea
What 2 nerves can be damaged by prolonged face mask use
trigeminal and facial nerves (not glossopharyngeal...)
True or false? Cell salvage should be considered in all cases where significant blood loss, greater than 1000 mL, is expected or possible?
true
True or false? monitoring coagulation factors and maintaining homeostasis is importing with a massive blood transfusion?
true
True or false? plans of sending the patient to the PACU or ICU after surgery should be part of the post op care plan?
true
True or false? platelet transfusions are indicated for a patient with a micro-vascular bleeding, continued bleeding or they have a platelet dysfunction and their count is between 50 and 100 K?
true
True or false? the ASA difficult algorithm provides guidelines for dealing with difficult facemask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation?
true
What does crna document intraop
vitals positioning meds Times Names of anesthesia providers
IF INR <2 should you use ffp or vitamin K if not bleeding?
vitamin K.
the ________ of the local anesthetic affects the spread form the needle, or catheter, to the epidural space
volume
What is the treatment for hypercalcemia?
volume expansion with NS loop diuretic to enhance calcium excretion dialysis biphosphonates, mithramycin, calcitonin, glucocorticoids, and phosphate salts also have been used in treatment
in an epidural what is dose described as?
volume multiplied by concentration
What types of patients is cryoprecipitate for
von Willebrand disease DIC probable or documented deficits in fobrinogen
REOPro and CNB
wait 1-2 days
LMWH QD (or low dose) and CNB and cath
wait 10-12 hours then do procedure or pull cath also wait 2 hrs before first dose after pulling cath
ticlopidine (Ticlid) and CNB
wait 14 days
LMWH and restarting after removal of CNB catheter
wait 2 hours after pulling
LMWH (BID or high dose) and CNB
wait 24 hours since last dose
plavix and CNB
wait 7 days
what are the 2 pencil point needles used in spinals
whitacre and sprotte
QRS with high k+
wide
Why don't we give bolus an hour before spinal epidural
will be third spaced and won't help with hypotension
What happens if you give hypobaric LA to thoracic spinal pt who is prone?
will float to cervical
CV and hypermag
with 5-10 level you can get hypotension brady, 15-20 arrest
When are false vocal cords damaged
with difficult intubation, may push hard on those vestibular folds.
how should you grip your epidural needle while applying a syringe and/or passing the catheter into the epidural space?
with the bromage grip
how should you hold your spinal needle when attaching a syringe to it?
with the bromage grip
How to fix tachyphylaxis with LA
withdraw catheter and place at different level
Are airway exchange catheters tolerated well by patients usually?
yes
Does dextran cause coagulopathy like the hetastarch/hespans
yes
Does intraop charting need to have a grid
yes
should you transfuse PRBC's for a patient with a class 4 hemorrhage?
yes it would be necessary
can you place spinal catheters
yes, but hast to be labelled REALLY WELL so that epidural dose isn't given intrathecally
Has ASA difficult airway algorithm decreased airway events
yes, even though there is no evidence to back it up
If patient has difficult time being facemask ventilated will an LMA work usually?
yes, highly sucessful
can a trachlite be used in a difficult airway?
yes, it can be used in both anticipated and the unanticipated difficult airway when laryngoscopy has failed
what can be done for awake intubation if regional block cannot be done
you can use local or use several adjunct meds in smaller doses to not cause respiratory compromise in already compromised patients
How do you calculate posterior bleeding
you can't, you don't see that blood
What is the maximum depth an airway exchange catheter can be placed
25-26 cm
How long do afrin and phenylepherine need to work in nasal airway before intubation
2-3 min
what is the tonicity of D5W?
253, thus making it a hypotonic solution
Does 5% or 25% albumin replace plasma at 1:1 ratio
5%
What are the two different concentrations of albumin?
5% and 25%
what are the two albumin [ ]
5% and 25% 5% is in 250ml 25% is in 50 ml
What percent dextrose in hyperbaric
5-10% (somewhere else says 5-8%)
1 unit of plts raises value and for how long
5-10k for 6-7 days. 6 pack from whole blood raises it 30-60k (or one apharesis unit).
LMA size for weight
1-less than 5 kg---2-4 ml cuff 1.5 = 5-10kg 2= 10-20 kg up to 10ml 2.5 = 20-30---up to 15 ml 3= 30-50 ---up to 20ml 4=50-70 --- up to 30ml 5=70-100---up to 30ml ART just does LMA 3= 40-50kg; 4 = 50-60kg; 5= 60+ (size of tube x10 +10)
what are the four endpoints in the ASA difficult airway algorithm
1-intubate awake or asleep 2-adequate or inadequate facemask ventilation or LMA 3-Approach intubation with special means 4-Emergency airway
fluid amount for epidural per ART instead of Nagelhout
1-1.5 liters for spinals and epidural over 30 min Start it when you start procedure
How quick should na+ be corrected in hypo na+ patients and dose
1-2 meq/hour 3% saline 1-2 ml/kg/hr then slowed to 10-15mmol/L in 24 hours
Which pharyngeal arches form the airway
1-4 and 6 (from arch 1 in anterior mouth to 6 in lower airway)
Four general guidelines for ASA difficult airway
1-Plan ahead and be prepared for difficult intubation 2-if you are suspicious of airway trouble, intubate awake 3-If you can still ventillate but are in trouble, wake pt. up 4-When making intubating choices, do what you do best. DAWB
Name the 7 "global criteria" for extubation
1-acceptable hemodynamics 2-normothermia 3-Able to maintain patent airway (cough, Gag and LOC) 4-Adequate muscle strength (TOF ratio >0.9 or 5 second head lift, or strong hand grip 5-Aceeptable metabolic function (electrolytes, acid-base balance) 6-Hematologic indicators (hemoglobin and oxygen delivery balance) 7-adequate anelgesia for optimal respiratory effort . HeNoStrongMain, Heme Anal is Met
3 indications of difficulty with invasive airway placement
1-bleeding 2-inability to find the right structures 3-puncture of trachea instead of crycothyroid membrane
Sequence for placing surgical cricothyrotomy over trocar
1-check tube cuff for air leaks 2- palpation of membrane and stabilization between first two fingers 3-insertion of trocar through CT membrane in caudal direction 4- aspiration of air and advancement into trachea 5-removal of trocar and inflation of tube cuff 6- securing the tube with a tracheotomy tie and confirming ventilation
3 treatments for croup and 4 for laryngospasm
1-humidified supplemental oxygen 2-racemic epi (0.5ml of 2.25% in 2.5 ml NS) 3-Dexamethasone 0.1-0.5 mg/kg Laryngospasm: 1-100 % 02 2- positive pressure 10-15cmh20 3- lidocaine 1.0-1.5 mg/kg 4- if all else fails 0.2-0.5 mg/kg succs
Where are the two points that LMA is used in ASA difficult airway
1-in anesthetized pt whose trachea cannot be intubated but pt can be ventilated with facemask 2- in cannot intubate cannot ventilate with facemask
Transtracheal block steps
1-locate cricothyroid membrane 2-use 22-24 gauge angio cath with 5ml 2% lido 3- needle is placed midline and advanced caudal 4-when air bubbles are aspirated, advance catheter and withdraw needle 5-Have pt. inspire, inject local, this will cause pt to cough and local to get on vocal cords
Four main methods to maintain airway patency
1-mask vent 2-supraglottic airway 3-tube below vocal cords 4- invasive
sequence for placing sugical cricothyrotomy via seldinger technique
1-place head in neutral position 2- insert dilator into airway catheter 3-palpate CT mem and insert introducer needle caudal 4-insert guidewire through catheter until 2 inches beyond catheter 5-incise neck with single scalpel insertion along guide wire 6-Thread catheter/dilator over the guide wire and advance ("pops") 7- advance catheter off dilator and assess for ventilation 8- secure and ventilate
2 steps for miller blade
1-place tip posterior to epiglottis and 2- apply gentle force to directly lift the epiglottis
What are indications of difficult supraglottic ventilation (3)
1-same as with face mask vent, but also leak pressure less than 10-15cmH20 2-poor expired tidal volume 3-multiple failed attempt by multiple peole
6 respiratory criteria for extubation (vital capacity, insp force, spo2, pa02, pco2, rr to tv ratio):
1-vital capacity > 15ml/kg 2-inspiratory force > 20cm H20 3-sp02>90 4-Pa02>60mmHg 5-Paco2 <50mmHg 6-RR to TV ratio less than 100 breaths/min/liter
the philosophy of the ASA difficult algorithm is based on what 4 things?
1. plan ahead and be prepared for failed attempts 2. if you suspect airway trouble intubate awake 3. if you get into trouble and can still ventilate, wake up the patient 4. when making intubation choices do what you do best
What are 2 common hypotonic fluids
1/2NS D5W
when placing a spinal for a hernia or pelvic procedure what dose of lidocaine would you use and what is the duration?
100 mg, the duration would be 45 to 60 mins without epi and 1.25 to 1.5 hours with epi
what is the normal value of platelets?
100 to 150 K
CaCl , calcium gluconante, and bicarb dose for high K+
10ml of 10% over 10 min CaCl 10ml of 10% over 3-5 min for gluconate (elsewhere in the book it says over 10 min followed by a gtt of 0.3-2 mg/kg/hr) Bicarb: 50-100 meq over 10-20 min.
What are the two sizes of airway exchange catheters for adults
11 and 14 french
What should peak pressure be kept at to reduce gastric inflation with supraglotic airways and facemasks?
15-20 cm H20 (art said max was 20) inflation often occurs at 25cmh20 (can increase this in King LT to 30)
What is onset time for marcaine 0.75% SAB
5-8 min
What is LA mixed in to make it hyperbaric
5-8% dextrose
What is the tonicity of half NS?
154 thus making it a hypotonic solution
What is max dose for spinal of marcaine usually
15mg or 2cc
how big is a typical standard epidural needle?
16 to 18 gauge and 3 inches long
how many C shaped cartilage rings are in the trachea?
16 to 20
what is epi wash
1:1000K epi. Draw it up and just inject it into garbage
what should expiration ratio be for jet vent to reduce barotrauma? What else can be done?
1:2 or 1:3 also need a in-line pressure regulator
what is the concentration of epi used in epidurals
1:200,000
How much bicarb to speed up LA onset
1cc bicarb per 10ml
Art's paremedian approach
1cm lateral and 1cm caudad 10-15 degree angle
After CNB, (not cath) no IV heparin for ____hr and can pull catheter after___hrs
1hr, 2-4 (verified in book)
Dilaudid epidural
1mg
Decadron Epidural
1mg/10cc (but art says you don't do this)
For each ____ ml of blood loss ___ml of prbcs is transfused
1ml because the hct is higher in prbcs
how much local is injected in an ulnar block at the wrist?
2 to 4 ml, then another 2 ml is injected as the needle is withdrawn from the deep fascia. 3 to 5 ml in a half ring to block the dorsal branch
how much local is injected in a median block at the wrist?
2 to 5 ml in the carpal tunnel, and another 2 to 3 ml after the needle in withdrawn from the fascia of the carpal tunnel
Whats in a MBT pack?
2 units O negative blood PRBC's times 6 FFP times 4 platelets times 1
Mepivicaine and lidocaine concentration in epidural
2% lido 1-2% mepivicaine
Airway management guidelines for number failed laryngoscipic intubations and allowed time before you try and do something different.
2-4 attempts and between 5-10 minutes of total procedure time
When pulling cath on someone with IV Hep how long should you wait to pull it and then restart heparin?
2-4 hour after D/C and then restart 1 hour after
What is a very high dose marcaine spinal
2-4ml of 0.75%
What is onset time for epidural meds
2-chloroprocaine = 10-15 Lido = 10-15 Mep = 15 Bup = 15-20 Rop = 15-20 Levo = 15-20
when doing an interscalene block how much local would you inject while doing an ultrasound approach?
20 mL after injecting 1 to 2 mL to verify placement
How long does antisiologue take to work?
20 min, may not be useful for most awake intubations
at the conclusion of a bier block the cuff may be deflated for as long as _____ minutes after injection of the local
20 minutes
how much local is injected when doing a TAP block?
20 ml
when using an ultrasound for a femoral nerve block how much local should be injected?
20 ml
What is the correct amount of cricoid pressure
20 newton (2kg) while awake 40 newton (4kg) when asleep (30-44 newtons needed for good occlusion)
when doing a femoral block what volume of local anesthetic should you give?
20 to 30 ml, but 30 ml will have best results in blocking the obturator
10 to 20 mL/kg of FFP is the guideline for administration (unless you are reversing warfarin), how much should it increase coagulation levels?
20 to 30%
Max blood person w normal kidneys, liver, and normothermic, can have per hour without citrate toxicity
20 units prbcs
What is the dose you should give for a bolus per nagelhout
20-30 ml/kg But art gives different amount for epidurals/spinals
How much does FFP increase coagulation levels
20-30%
How much does pt/inr and PTT increase with1 unit FFP
20-30%
According to ART max peak pressure with LMA
20cmH20
How does tetracaine come in spinal kit
20mg powder, usually you mix that into 2cc to get a 1% tetracaine or 4cc to get 0.5%
What is the max dose of hespan
20ml/kg or 1500 ml Art usually only goes 500 rarely 1000
Common sab needle gauge in elderly and young
22 in elderly and 25 in young
what is the range of sizes for spinal needles?
22 to 29 gauge 3.5 to 5 inches
When extension is reduced to ______ degrees visualization becomes difficult
23
how many intervertebral disks
24
how many vertebral movable joints
24
What is the tonicity of LR?
273, thus making it an isotonic solution
rough number of liters fluid intracellular
28 L
while threading the epidural catheter into the epidural space to a depth of ____ to ____ cm it is important to warn the patient that a "_________" sensation my be felt in their legs
3 to 5 cm, funny bone
how much local do you inject when doing an intercostal block?
3 to 5 ml at each desired level
How long do alveoli continue to develop after birth
3 years
Epidural chlroprocaine epidural concentration
3%
What sizes does fastrach (ILMA) come in
3,4,5
What is the onset time for 0.5-1.0% tetracaine in spinal
3-5min
What is normal test dose drug and concentration and volume for epidural
3-5ml 1.5% lido with 1:200K epi even when doing bupivicaine
How thick is legamentum flavum at L2-L3?
3-5mm (5-6mm per nagelhout; 10mm/cm)
How long do colloids last in intravascular space
3-6 hours
The spine has how many vertebrae?
33
How many vertebrae and breakdown
33 Cervical -7 thoracic-12 lumbar-5 sacrum-5 coccyx-4
how much local do you inject in a popliteal block?
35 to 40 ml
when doing a bier block on the lower extremity what would you set the cuff pressure at when the cuff is on the thigh?
350 to 400 mmHg so it can occlude the femoral artery, but it increases the occurance and intensity of tourniquet pain
Osmolarity level (due to high na+ ) with confusion restlessness agitation and HA
350-375
what is the tonicity of D5 1/4 NS?
355, thus making it an isotonic solution
Osmolarity level (due to high na+ ) with ataxia, tremors, weakness
375-400
What is the ratio of crystalloid to blood when giving blood
3:1
When are 3rd spaced fluids mobilized to intravascular space
3rd day. Careful with renal and cv disease
When does pregnancy cause problem with bmv
3rd trimester
If heparin longer than _____ days then need to check _____
4 plts (for HIT)
If hematoma is suspected, how long should you wait before asking for surgery?
4 hours
how do you calculate a maintenance drip for a pediatric patient that is 10 kg or less
4 ml/kg/hour
how much fluid do you need to replace due to the fluid loss from a severe procedure such as a prolonged highly invasive procedure?
4 to 8 mL/kg
"fast track" preox
4 vital capacity breaths in 30 seconds
What is the better formula for Peds? Can it be used for adults
4-2-1 rule (1st 10 kg =4ml/kg, 10-20 = 2ml/kg, >20kg = 1ml/kg) yes, it can be used for adults
How long does coumadin take to wear off
4-5 days
What is the safe dose of lidocaine
4-5 mg/kg or 7 if using epi
When is autologous donation done? How much time needed between donations
4-5 weeks before surg need 72 hours between donations
what is normal dose of FFP for coumadin reversal and all other purposes
5-8ml/kg 10-20ml/kg for all other purposes
when placing a spinal for a vaginal delivery what dose of bupivacaine would you use and what is the duration?
5 to 7 mg, the duration would be 1 hour without epi and 1.5 hours with epi
for the reversal of warfarin, FFP is usually administered in doses of ____ to ____ mL/kg
5 to 8
platelet transfusions are usually indicated when platelet count is less than______?
50 K
what med do you give in a bier block and how much?
50 ml of 0.5% lidocaine into the i.v. catheter
when placing a spinal for a cesarean delivery what dose of lidocaine would you use and what is the duration?
50 to 75 mg, the duration would be 30 to 45 mins without epi and 1 to 1.25 hours with epi
increasing the dose of hyperbaric bupivacaine from 10 mg to 15 mg prolongs duration of sensory block by ____ % and increases the maximum sensory level achieved
50%
What are the sizes of oral airways? Normal guedel for adult
50, 60, 70 , 80 , 90, 100. Not sure what the units are here.... art didn't say 80-100 guedel for an adult
Fent epidural
50-100mcg
dilaudid SAB
50-100mcg
What is the correct dose of epi for anaphylaxis?
50-100mcg IV push
How many ml in 1 unit whole blood
500
Minimum blood needed to run cell saver
500 small bowl 1000 if they use big bowl
Dose of dextrose and insulin with high K+
50ml D50 and 10 units of regular insulin then recheck glucose in an hour
what is the tonicity of D5 LR?
525, thus making it a hypertonic solution
when placing a spinal for a anorectal surgery what dose of bupivacaine would you use and what is the duration?
8 mg, the duration would be 1 hour without epi and 1.5 to 2 hours with epi
when placing a spinal for a cesarean delivery what dose of tetracaine would you use and what is the duration?
8 mg, the duration would be 1 to 1.5 hours without epi, and 2.5 to 3 hours with epi
when placing a spinal for a genital or lower extremity procedure what dose of bupivacaine would you use and what is the duration?
8 to 12 mg, the duration would be 1.5 hours without epi and 2 hours with epi
How long to decompress hematoma before nothing can be done
8 hours
What are the normal values for calcium?
8.8 to 10.4 mg/dL
calculate allowable blood loss for 80kg male
80 kg x 70ml / hct 39 (starting hct) = 143 ml. This means that each 143 is 1 hct Starting 39 hct how much blood can be lost to get to 25 hct 143 x 14 hct = 2002 ml (can loose 2000 ml of blood)
What blood type is a person with type A blood compatible with?
A & O
what nerve fibers are the heaviest and responsible for motor function
A Alpha
What is duration of epidural meds with and without epi
Chlor = 45-60/ 1-1.5 Lido = 1.5 -2hrs / 2-3 hrs mep = 1.5-3 hrs / 3-3.5 hrs Bup = 2.5-4 / 3+ hours Rop = 2-3 hours/ 150 min + Levo = Sam as bup
what is 02 flow documented as
L/min
where does conus medularis terminate
L1-L2
The umbilical area is directly anterior to the _____ vertebrae but recieves cutaneous innervations from ______
L3, T7 to T11
Where is tuffier's line
L4 although this is not always accurate Line drawn between two superior iliac crests
3 adjunct devises that are good for extubation in difficult airway that allow for reintubation
LMA (replace quickly after extubation) Extubate over a : fiberscope exchange cath
What are six things to include on the post anesthesia care eval when taking your patient to the PACU?
LOC Airway Pain Nausea/Vomiting Vitals Temperature
What needs to be charted in PACU? Which one does Jacho require?
LOC Airway/02 Pain NV VS Temp (Big one for JACHO- hypotherm)
What are 3 common Isotonic fluids
LR NS D5 1/4 Ns (maybe hypotonic)
What fluid not to give with ca++
LR has phos that may cause lower ca++
In non-cerebral hemorrhage what fluid does NH say to use
LR instead of NS due to acidosis
Synopsis of LR in acidosis article
LR was not superior to NS in DKA acidosis concerning normalization of pH
Per ART, what do we worry about post extubation
Laryngosapsm airway obstruction negative pressure edema cord malfuction external compression aspriation sore throat vent depression laryngeal edema Other is HTC Hec
What are the 5 rosenblatt questions in the "airway approach algorithm"
NISAA is acronym is use to remember these 1- is irway management Necessary 2- will directy laryngoscopy and Intubation be straightforward 3-can Supralayngeal ventilation be used 4- Has Aspriation risk been minimized 5-can patient tolerate Apneic period?
true or false? all of the laryngeal nerves take off from the vagus nerve?
true
Arts signs of intravascular injection
Numbness/ tingling in mouth, ringing in ears, fast heart rate is sign of intravascular
When are mature alveoli present in fetus
week 36
Too much heparin is absolute contraindication to CNB how much is this?
TID or > 10,000 units/day
What is especially important to chart in airway for future reference of airway difficulty
The laryngeal view grade. Will help future anesthesia providers judge how difficult airway will be.
What happens on repeat c-sections with uterine cut time
The time from uterus cut time to delivery is often longer and puts baby more at risk
Density of block for CNB (both) is equal to?
Total Dose! Concentration to a lesser degree. Art got this mixed up when he taught it
what is a supraglottic device?
a device that sits above or surrounds the glottis
what would a non reassuring finding be when doing a thyromental distance examination?
a finding of less than 3 ordinary finger breadths
what are some factors that can cause laryngospasm?
a number of factors can cause it such as airway manipulation, noxious stimuli in pharynx, or stimulation of the larynx with inadequate anesthetic depth
what is cell saver blood mixed with
heparinized saline that is eventually spun out
how much smaller should the epidural catheter be than the needle?
about 2 gauges smaller
What is the tonicity of the human body?
about 285, give or take
how long do colloids last in the intravascualr space?
about 3 to 6 hours
how big is a bag of PRBC's?
about 300 mL
how long is the left mainstem bronchus before it bifurcates into the left superior and inferior lobe bronchi?
about 5 cm
which vertebrae does the larynx coincide with?
about C3 or C4 to C6
is PDPH more common in epidural or spinal
about the same
Apgar Irritability/reflexs scoring and respirations scoring
absent =0 grimace or noticeable facial movements =1 Cough, sneezes or pulls away=2 absent =0 weak, irregular, gasping =1 strong, lusty cry = 2
Apgar HR scoring
absent =0 less than 100= 1 >100 = 2
what are oropharyngeal causes of an upper airway obstruction?
absesses such as peri-tonsillar Ludwigs angina sleep apnea tongue
why does trachea only have c shaped cartilage and not o shaped
accomidates swallowing
What are 4 risks of cricoid pressure when it comes to intubation difficulty
airway obstruction difficult laryngoscope placement impede glottic visualization difficulty with intubation
What are the colloids that cause anticoagulation
hespan, hetastarch 6%/hextend and dextrans
how is crioid pressure done?
an assistant places their thumb and index finger in the cricoid cartilage to compress the underlying esophagus against the cervical vertebrae
what has a blunted bevel and a gentle curve of 15 to 30 degrees at the tip?
an epidural needle
cryoprecipitate gtt rate? Filter? How quickly must it be used after thaw?
as fast as possible at least 200ml/hr, with filter within 6 hours of thawing
Normal neck flexion-extension range in degrees
anywhere from 90 to 165 degrees
what is the angle of bifurcation of the right mainstem bronchus
approximatly 25 to 30 degrees
what are the 3 paired cartilages of the larynx?
arytenoid corniculate cuniform
when is laryngospasm believed to occur?
as a result of sensory stimulation of the internal branch of the superior laryngeal nerve and afferent responces from both the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve
nasopharynx beginning and end
begins at posterior nasal cavity (chonche) extends through posterior soft palate (uvuala is in oropharynx)
Larynx begins and ends at what cervical level
begins between 3-4 and ends at 6th (cricothyroid muscle)
Where does trachea begin and end
below cricoid cartilage ends at carina
Drugs for SAB itching
benadryl 25-50mg Nubain 5-10mg
Which locals cause methemoglobinemia
benzocaine and procaine
What is considered hyperbaric
baricity > 1.0015
what are the 3 ventral and dorsal divisions of the brachial plexus clinically important?
because the ventral divisions generally supply the ventral (flexor) portion of the upper extremity and the dorsal divisions generally supply the dorsal (extensor) portions.
Early signs that preceed toxicity and first signs of toxicity of LA
before = lightheaded, tinnitus, circumoral numbness and tingling After = visual disturbance, muscle twitch, convusions
how much pressure should be applied in cricoid pressure?
between 30 and 44 newtons. it is recommended that 20 newtons be applied prior to loss of consciousness and that the pressure should be increased to 40 newtons after loss of conscoisness
Where dose blood pool commonly in c-section
between legs, need to wait until after case to count this loss
where is the superior vallecula
between the epiglottis and the base of the tongue
where is the sciatic nerve located
between the greater trochanter and ischial tuberosity. gluteal area sciatic nerve is 10 cm from midline, aka, the buttcrack
where is the inferior vallecula
between the inferior edge of the epiglottis and the true vocal cords
What is glottic opening
between vocal folds
name three drugs for use in aspiration risk reduction in awake intubation
bicitra metoclopramide H2 blocker
What to always use with fiberoptic to prevent damage
bite block
what color or pen should be used
black or blue sometimes facility specifies
Indications for MBT (3)
bleeding (hgb), symptomatic or certain diseases
How is trachlight inserted
blindly, so if there is airway anomaly then it may be difficult
Uvula purpose
block food from going from oral cavity into oropharynx (according to nagelhout... I think he might have meant nasopharynx)
Three consents obtained
blood procedure anesthesia
what is the definitive treatment for a post dural puncture head ache?
blood patch; it is 95% effective
What should your intra op care plan for a diabetic include?
blood sugar checks
Is the blue or clear cuff the bronchial cuff in double lumen ETT
blue = bronchial
Weakness with hypernatremia hyponatremia or both?
both
coma with hypernatremia hyponatremia or both?
both
cramps with hypernatremia hyponatremia or both?
both
irritability/agitation with hypernatremia hyponatremia or both?
both
cerebral edema with hypernatremia hyponatremia or both?
both (art says hypo)
confusion/disorientation with hypernatremia hyponatremia or both? What are the two unique symptoms of hyponatremia only? Hyper (5)?
both. Hyponatremia = n/v and anorexia. Hyper = Thirst, ICH, Twtich, hypovolemia and oliguria/polyuria, hyperreflexia
blood supply to larynx
branches of thyroid arteries
at the lateral border of the pectoralis minor muscle, the brachial plexus cords divide into 2 __________ that reorganize to form the _____________ of the upper extremity
branches, peripheral nerves
how is the thyroid cartilage connected to the hyoid bone?
by the thyrohypoid fascia and muscles of the larynx
what is done with the distal end of the wire once it is in place when performing a retrograde intubation?
it is secured with a clamp at the neck
oropharynx is anterior to _______ vertebrae
c2-c3
Larynx extends from c___ to c__
c3,4 to c6
Where does phrenic nerve originate from (cervical levels)
c3-c5
cricoid cartilage is at _______vertebrae
c5-c6
Which mallampati classification has visualization of the entire oropharynx including the soft palate, uvula, fauces (archway between oral and pharengeal cavities), and tonsillar pillars?
class 1
trace arterial blood supply to cricothyroid artery
cricothyroid artery, superior laryngeal artery, superior thyroid artery, external carotid
vocal ligaments are a thickening of what
cricothyroid ligament (which extends up to aretynoids and attaches to thyroid cartilage)
what does the external superior laryngeal nerve provide motor function for?
cricothyroid to do adductor tension
What kinds of things do you document in journal
emotional outbursts threats Anything that goes wrong with the case. Put names in your journal
Does anesthesia have to chart names of all present in OR
no, just the anesthesia providers involved
Do you use loss of resistance with spinal
no, look for csf
sodium deficit equation
deficit = na goal - na plasma x tbw (water)
When indications for cricothyrotomy are present the decision to place it should not be ___________
delayed
What is D02 and what is factored into it
delivered oxygen to tissues: -CI -sp02 -hgb
True or false? the use of FFP is encouraged if the INR is less than 2.0 in the absence of bleeding, and the use of vitamin K is discouraged if the patient is on warfarin?
false, FFP would be discouraged and Vitamin K would be encouraged
true or false? in daily clinical use, an LMA should not be used in place of bag mask ventilation during general anesthesia?
false, is can be used in place of bag mask ventilation
true or false? unilateral injury to the recurrent laryngeal nerve can compromise respiratory status?
false, it does not compromise respiratory status
True or false? injury to the superior laryngeal nerve will cause respiratory distress?
false, it does not usually cause respiratory distress.
true or false. a quinkie needle is often referred to as a pencil point?
false, it is a cutting needle
true or false? the anterior portion of the cricoid cartilage forms the posterior border of the larynx?
false, it is formed by the posterior border of the cricoid cartilage
true or false? the carnia has low innervation, thus making it unsensitive to sensory stimulation
false, it is richly innervated making it sensitive to sensory stimulation
True or false? in a PDPH vasoconstriction is caused by high CSF pressure
false, it vasodilation is caused by low CSF pressure
true or false? all of the approaches to the brachial plexus seem to use 30 to 35 mL of local?
false, only the interscalene, subclavian, inersternocleidomastoid and continuous catheter approaches do.
how do you do a test dose in a spinal?
you don't do a test dose in a spinal, but you can do an epi wash
true or false? visulization of the vocal cords is not possible with use of a fastrach LMA?
false, they can be seen with the aid of either a videoscope or fiberscope
true or false? epidural needles should be placed in a caudad direction
false, they should be placed cephalad
true or false? extension of less than 23 degrees of the atlanto-occipital joint means that visualization would be easy?
false, visualization would be difficult
true or false? it is standard to use an epi wash in an epidural?
false, washes are only used in spinals
True or false? the eipdural space is an air filled space physical space
false, you create a space when you inject
true or false? Cormack and Lehane grade 1 would be an easier intubation, grades 2 and 3 are difficult, and grade 4 requires a tracheotomy?
false. grades 1 and 2 are generally associated with an easier intubation, where 3 and 4 correspond with higher degrees of intubation difficulty
true or false? epidural catheter should be advanced at least 6 cm but no more than 10 cm
false. is should be only 3 to 5 cm
true or false? the use of cell salvage in combination with a leukocyte depletion filter is deemed unsafe?
false. it appears to be safe
true or false? the epidural space is a uniform column surrounding an equally uniform and tapering spinal cord?
false. it is a series of lateral, posterior, and anterior compartments existing among the vertebral body, lamina, and pedicles
true or false? when doing a bier block an 18 to 20 gauge i.v. is placed in a distal vein?
false. it is usually a small bore i.v. such as a 23 to 25 gauge and is preferred in the dorsum of the hand
true or false? the motor component of the recurrent laryngeal nerve provides motor function to all of the muscles of the larynx except for the thyroarytenoid?
false. it provides motor function to all except the cricothyroid muscle
True or false? after giving a test dose when doing an interscalene block a more pronounced twitch will be observed in the quality of the motor twitch; this indicates the needle is probably within the bracheal plexus sheath
false. you will see a fade, thus indicating the needle is probably within the bracheal plexus sheath
why is the arm raised after application of a tourniquet in a bier block?
for exsanguination
what is the purpose of cricoid pressure?
for posterior displacement of the cricoid cartilage against the cervical vertebrae with the patient in a 20 degree head up position to prevent regurgitation and possible aspiration of stomach contents during the induction of general anesthesia
how is the thyromental distance measured?
from the thyroid notch to the lower border of the mentum (at the chin) when the patients head is extended and mouth is closed
What dose palatine nerve innervate
from trigeminal nerve and sphendopalatine nerve. innervates superior and inferior surfaces of the hard and soft palate
pehochormocytoma and electrolytes
high ca++
sarcoidosis and electrolytes
high ca++
Is hypovolemia more associated with low or high na+
high na+
hallucinations with hypernatremia hyponatremia or both?
high na+
muscle twitch with hypernatremia hyponatremia or both?
high na+
Lower airway obstruction s/s
high peak pressure low tv imparied ventilation
What two things are needed for jet vent
high pressure source and a pressure regulator
Acute and chronic renal failure and K+
higher
Rhabdo and k+
higher
ace and k+
higher
addison's disease and K+
higher
cyclosporin and k+
higher
dig toxicity and K+
higher
exercise and K+
higher
nsaids and k+
higher
why do restrictive lung disease cause poor bmv
higher pressure required for ventilation needed and tighter seal needed
what is the hallmark sign of an upper airway obstruction in the unanesthetized patient?
hoarse or muffled voice, difficulty swallowing secretions, stridor and dyspnea
4 Hallmark signs of upper airway obsturction
hoarse or muffled voice, difficulty swallowing, stridor, dyspnea
what does unilateral injury to the recurrent laryngeal nerve result in?
hoarseness
bilateral denervation of of superior laryngeal nerve does what
hoarseness or tiring but airway is not jeopardized
unilateral injury to vagus nerve problems?
hoarsenss airway is protected
abciximab, eptifibatide, and tirofiban and restarting after procedures
hold 4-6 weeks
what is considered to be conservative management of a PDPH?
horizontal position, adequate hydration, oral analgesics, 500 mg I.V. caffeine benzoate, 300 mg oral caffeine or theophylline
Per ART 5 things we worry about during extubation
htn tachy cough breath hold Difficult extubation cyanosis HTC Hec
posteriorly, the thyroid carilage rises toward the _________ at the base of the tongue as the posterior _________
hyoid bone cornu
intracranial bleeding with hypernatremia hyponatremia or both?
hyper
What electrolyte disorder with any cancer of the bone or parathyroid cancer
hyper ca++
With what electrolyte imbalance should you reduce your non-depolarizeing paralytic dose
hypermag
hyper ca++ and CV s/s (BP, ekg x 4, dig)
hypertension sinus brady or av block short qt or bbb (heart is similar to high K+) vent dysrhythmias more dig toxicity
anorexia with hypernatremia hyponatremia or both?
hypo (high ca++ also according to art)
N/V with hypernatremia hyponatremia or both? What two electrolytes cause thirst? Low appetite?
hypo na+ = NV; Thirst = hypernatremia and hyper ca++, Low appetite = hyper ca++ and hyponatremia
the internal branch of the superior laryngeal nerve provides sensory input to the _________ above the vocal folds (cords).
hypopharynx
what part of the pharynx lies posterior to the larynx and is bound by the superior border of the epiglottis and the inferior border of the cricoid cartilage at the C5 to C6 level
hypopharynx
Where is epiglottis located in pharynx
hypopharynx or laryngopharynx
2 indications for 3% NS Per ART
hypovolemic resuscitation hyponatremia
Three major consequences of laryngospasm
hypoxia negative pressure pulm edema Cardiac arrythmias
what can happen if traction is applied to either the aorta or the brachiocephalic artery during thoracic surgery?
injury can occur to the recurrent laryngeal nerve thus causing hoarseness or stridor.
How to block lingual nerve
innervates anterior 2 thirds -have them anesthetize with topical on tongue first -protrude tongue -displace to one side and make gutter" -Where gutter meets the base of platoglossal arch 23-25 gauge needle is inserted 0.25-0.5 cm and is aspirated. -If air, then too deep, blood then move medial (carotid) -inject 1-2 ml lido
what does the posterior branch of the femoral nerve innervate?
innervation to the quadriceps muscles, knee joint, and its medial ligament and the origin of the saphenous nerve
While doing an axillary approach what should you tell the patient to do prior to injecting your local?
instruct them to immediately inform you if symptoms of last occur, such as, dizziness, tinnitus, metallic taste in mouth, circumorul numbness or tingling, visual disturbances, or muscle twitching
Laryngospasm is believed to be due to stimulation of the ______ nerve and afferent responses from _______nerves
internal branch of superior laryngeal nerve external branch of superior laryngeal nerve and recurrent laryngeal nerve
describe the fat in the epidural space?
it is physiologically fluid, acting as a pad and lubricant for the movement of neural structures within the canal
what do you know about a malplaced tongue that does not fit into the thyromental space?
it can obstruct the direct line of site with the glottic opening during laryngoscopy
what happens to the sciatic nerve as it is in the lower third of the thigh?
it divides into the internal and external popliteal nerves
what happens to the brachial plexus after the axilla?
it ends in the 4 terminal branches that supply the upper extreamity
where does the oropharynx lie?
it extends between the soft palate and the base of the tongue. The posterior portions connects directly with the nasopharynx
how effective is caffeine in treating PDPH?
it has been shown to eliminate headache in up to 70% of patients, but this effect may be transient
What does thyroarytenoid muscle do? How many parts to the muscles is there?
it has two parts. Vocalis attaches the thyroid to the arytenoids and causes loose vocal folds and lower pitch. Runs along lateral site of vocal ligament. The thyroepiglottic muscle attaches to epiglottis and closes it.
when doing a femoral nerve block what does the acronym NAVY mean?
it helps with the landmarks from lateral to medial, nerve, artery, vein, yin yang!!
What is cell salvage?
it involves the aspiration of blood shed into the surgical field into a specialized apparatus that concentrates the RBC's and washes the shed blood to remove debris, after which the RBC's are re-infused.
describe the posterior epidural space
it is a series of fat-filled tripodial pads, shaped like a three-sided sand dune
what angle is the crawford needle?
it is a straight tip
describe the arachnoid matter of the spinal cord
it is a thin spiderweb-like covering. this subarachnoid space is filled with CSF which help to protect the spinal cord from shock injuries
what is the intravascular portion of the ECF?
it is also referred to as plasma
how effective is an epidural blood patch in treating PDPH?
it is associated with a greater than 90% cure rate.
when would you use a taylor approach for a spinal?
it is best used for pelvic and perineal surgeries
where is the thyromental space?
it is bordered laterally by the neck, superiorly by the mentum, and inferiorly by the hyoid bone, which is semi fixed
do you need to worry about ABO combatibility with FFP?
it is desirable
Is vit K useful for coumadin or not effective
it is effective
when doing a retrograde intubation and your wire is visualized in the poserior pharynx, what is done with it next?
it is either advanced through the mouth or nose, often with magill forceps
what happens after you insert your wire or line via crcothyrotomy in a retrograde intubation?
it is passed cephalad into the oropharynx, this is done through a 14 to 18 gauge I V catheter or cook needle
where is the nerve located in the costal groove?
it is the most inferior of the neurovascular bundle
what is the interstitial compartment of the ECF?
it is the overflow reservior for the intravascular compartment
describe the pia matter
it is thin and is in direct contact with the outer surface of the spinal cord.
when would retrograde intubation be used?
it is used in a situation when intubation has failed but ventilation is possible
When is cell salvage, aka cell saver, used?
it may be used in surgical cases in which significant blood loss is likely, as well as in cases of unexpected massive blood loss.
what could happen if cricoid pressure is maintained during active vomiting?
it may result in a rupture of the esophagus
where does the sciatic nerve go?
it passes out the pelvis through the great sacrossciatic foramen, below the piriform muscle, then it descends between the major trochanter and the tuberosity of the ishium to the lower third of the thigh
what is the trans arterial technique for doing an axillary block?
it uses the intentional penetration of the axillary artery and aspiration of blood as the end point for determining that the needle is within the sheath
where will you see the femoral nerve on an ultrasound?
it will be a triangular hyperechoic structure lateral to the femoral artery
what is a hypobaric solution?
it would be less dense than CSF, and it would rise or float to the highest anatomic position
what do high airway pressures usually mean after intubation
kinked tube, low compliance, high resistance to flow
Why is surgical cricothyrotomy not suggested in kids younger than 12
larynx is small and pliable (makes procedure difficult)
when doing an interscalene block, what are the 5 landmarks to be aware of?
larynx. sternocleidomastoid. external jugular vein. cricoid cartilage, interscalene groove
what are the principal adductors of vocal cords
lateral cricoarytenoid muscles
For phonation: muscles involved, innervation, and main function
lateral cricoarytenoid muscles - adduct cords lateral thyroarytenoids- shortening and adduction of cords Medial cricoarytenoids-shortening of vocal cords Cricothyroids- shortening accoring to NH (actually lengthens) and increase cord tension INNERVATION - is all RLN except cricothyroids are external laryngeal nerve
purposes of airway exchange catheters
leave in during difficult airway extubation exhange of ett use it similar to bougie for placement
How can you test motor block
leg lift
will a patient with a high BMI take more or less of anesthetic in an epidural
less
3 advantages of tachlight vs. conventional laryngoscopy (one of them is type of difficult airway it is good for)
less affected by anterior larynx less stimulating less sore throat
The incidence rate of persistent parenthesia is:
less than 0.1%
what is commonly used to assess mouth opening, size of tongue, size of oral pharynx, and assessment of posterior oropharyngeal structures?
mallampati classification
what can cause glottis closing via epiglottis with LMA placement (2)?
malposition or overinflation
unilateral denervation of cycothyroid muscle does what
minimal effects, very subtle (exterior branch of superior laryngeal nerve)
Amount of evap loss in surgery type
minimal invasive surgery 2ml/kg/hr moderate 2-4 ml/kg/hr Severe 4-8 ml/kg/hr
What is meant by awake intubatioin
misnomer. Usually have both sedation and local and may be very drowsy, but able to cooperate and ventilate on their own
What happens during pre ox if not tight mask fit
mix nitrogen into it
what are extrapulmonary causes of a lower airway obstruction
morbid obesity=BMI greater than 30 pregnancy trauma
When is a surgical cricothyrotomy used?
most airway alogrithms and strategies recommend this procedure as a means of providing ventilation for patients who cannot be intubated or ventilated with a facemask or supraglottic device
what part of the pharynx will the auditory (eustachian) tubes be found in?
nasopharynx
where are opening to eustachian tubes and adenoids? Nasopharynx or oropharynx?
nasopharynx
what is the main reason people get nausea with a CNB?
nausea immediately after initiation of CNB is often considered a sign of significant hypotension
Name the causes of secondary hypoparathyroidismd (2 damage, 2 electrolyte, 2 illness, 3 drugs, other)
neck surg. carcinoma High or low mag sepsis pancreatitis burns Drugs (chemo, etoh, cimetidine)
in a spinal what is a strait midline approach?
needle is inserted directly midline between the spinous process and toward the umbilicus perpendicularly to all planes or at the lumbar level with a slight cephalad angle
what are some possible causes to permanent nerve injury with CNB
needle trauma to the nerves, hematoma, abscess, undiagnosed neurological disease
How far should you put in epidural catheter
needs to be 3-5cm deep. However, you may put it in deeper and the withdraw it once the needle is out of the back
Are most patients subject to low levels of ca++ from blood transfusions and citrate
no, not unless hypothermic and liver or kidneys disease. Can process 20 units/hour without low ca++.
Will you treat everyone only when they get to <6 Hgb
no, not with heart or lung disease or other 02 carrying problem, you may treat them when hgb <8
Do medial branch nerves have motor function
no, pureley sensory
With severe asthma do we always intubate?
no, we try not to if we don't have to because they have reactive airway on extubation
Thrombolytics and CNB
never
How to care for fiberoptic scope
never bend tight or kink, drop or banged protect in case
What gasses are good to use on kids other than sevo
nitrous, halothane if available
Are 'Short" items absolute contraindications for cricothyrotomy or tracheotomy?
no
Can HES be used with patients with liver disease
no
LMWH + antiplt and CNB?
no CNB
How is glidescope larygoscopy different than traditional
no direct view, must use video inserted midline rather then sweeping from right to left Must use stylet shaped the same way as 60 degree blade (most angled than normal blade)
should you transfuse PRBC's for a patient with a class 1 hemorrhage?
no it would not be necessary if there was no preexisting anemia. Their hemoglobin would be greater than or equal to 10
when placing a spinal how many ml's should you first inject for a test dose?
no more than 2 ml to avoid transient neuropathy
Epi wash with epidural?
no only with spinal
Does any supraglottic device have the same aspiration protection as and ETT
no, although some have some protection
is fastrach harder to insert than regular LMA
no, easy to adapt
Do you document things that didn't happen during your care
no, if someone aspirated after you are not with them, you don't have to chart that
Should HES be used for critically ill pts
no, including sepsis
Can you give blood patch through catheter?
no, infection risk and small catheter could get clogged plus tip of catheter is in wrong place.
Is retrograde intubation used in emergencies? How long does it take
no, it usually takes 5-7 minutes
do you need test dose with spinal?
no, just give half and wait a few min and then give the rest
when do you turn on the nerve stimulator?
not until the needle enters the skin
__________ may occur in the upper or lower airway and can severely limit the effectiveness of BMV.
obstruction
What is a six pack of plts
obtained from one donation of apharesis plts or six whole blood donations
What is trousseaus sign
occlude blood flow to arm for 3 min and your hand and finders will flex due to hyper reflexia from hypocalcemia
How should late entries be documented
often with a progress note with rough times and state it is a late entry
Spinal and epidural needle approach for scoliosis?
on the outside of the C curved spine, The vertebrae or more open here
Where should you put pulse ox if they are using retractors on chest
on the right arm. That will tell you if they have occluded subclavian artery and recurrent laryngeal nerve damage. Unlikely that you will be able to tell on the left because left is aorta. Unilateral = hoarseness
When cartilage in airway ceases
once bronchi reach 0.6-0.8 cm in size
when placing an epidural what is the hanging drop technique?
once the needle is in the interspinous ligament the hub is filled with NS. As the needle is advanced into the epidural space the drop of NS is drawn into the needle by the negative pressure
when placing an epidural what is the loss of resistance technique?
once the needle is in the interspinous ligament the stylet is removed and a syringe is placed containing 2 to 3 ml of NS or air and advanced while applying slight pressure on the syringe.once the needle is in the epidural space an immediate loss of resistance occurs
What are the two types of lights in laryngoscopes
one has fiberoptic, and one has electric connection with bulb in the blade
what is an armored ETT
one that risists being kinked but will remain permenantly kinked if pt bites too hard
about _______ of total body water is in the ECF
one third
Why would you place needle cricothyrotomy over surgical
only if anatomy is less favorable with surgical or kids
How many planes can fiberoptic scope move
only one, but you can change that plane by rotating scope
Do we chart padding of body
only upper body, but make sure someone is charting what we don't
When are late entries ok
only with vitals or in a code. Vitals aren't late because you always are looking at them
Innervation of nose mucous membranes
ophthalmic division (v1) of trigeminal nerve anteriorly (anterior ethmoidal nerve) maxillary division (v2) posteriorly (sphenopalatine nerve) SEE M & M pg. 310-311 for nerves, muscles, cartilages
What is one of the first things you should consider if bag mask vent is difficult
oral airway
Oral airway or nasal better in head trauma
oral if possible. Nasal can go to cranial vault
What length of ett should you use for oral and nasal
oral is tube size x 3. Nasal you add 2-3cm to oral.
___________ innervation in the tracha is derived from branches of the vagus nerve.
parasymphathetic
class II mallampati
part of uvula soft palate tonsil pillars
How does exhalation occur with jet vent
passively through upper airway
what are absolute contraindications for spinal or epidural?
patient refusal uncorrected coagulopathy infection at the site of the block unable to obtain informed consent increased ICP
When discussing respiratory status on your post-op care plan what are some criteria to consider?
post op ventilation and proper reversal
What part of care plan are blood gas found in
potentially all three
Is whole blood or PRBCs safer
prbc, less wbc and antibodies that cause rxns
What part of care plan are BS checks
pre, intra, and postop
What is acute normovolemic hemodilution
removal of whole blood right be fore case and then give crystalloid to dilute blood so when blood is lost it is dilute. Then after bleeding stops, you give whole blood back with higher HCT to increase amount of RBCs
During laryngoscopy sweep the tongue from
right to left
Soft palate location and purpose
rises during swallowing to prevent food in nose. posterior 1/2 to 1/3 or palate
lateral cricoarytenoids
role: phonation function: close glottis, adduct vocal cords innervation: RLN
cricothyroid
role: phonation function: elongates and increased tension of cords innervation: ELN
posterior cricoarytenoids
role: respiration function: abduct vocal cords, open glottis innervation: RLN
Internal arytenoids
role: sphincteric function function: closing of posterior commissure of glottis innervation: RLN
Other than tongue what else dose glossopharyngeal nerve innervate in the airway
roof of pharynx, tonsils, under surface of soft palate
Alternative ways to insert LMA
rotate 180 degrees, or partially/fully inflate.
If resistance is felt while inserting and ett over any catheter what can be done?
rotate about 90 degrees back and forth with gentle pressure
What are the 3 neuro/reflex/nerve signs of low ca++
seizures hyperreflex paresthesia
what is the role of the interarytenoid?
sphinicteric function
Is introducer used with epidural or spinal
spinal because the needle is small gague
where are the 2 regions that the spinal cord enlarges?
spinal segments of C4 to T1 and L2 to S3
How does test dose of spinal differ from epidural
spinal you are not worried about a huge dose going intrathecal or vascular. You can inject half of your dose, wait 3-5 min and then inject the other half
Just like normal extubated patients those with airway exchange catheters can still .....(3 items)
spontaneously breath clear secretions phonate
CNB (both) volume increases what
spread of the block
true or false? 100 mcg of fentanyl can be injected as a test dose in an epidural?
true
which of the ankle nerves becomes superficial in the middle two thirds of the lower leg and remains subcutaneous as branches
superficial peroneal nerve
which of the ankle nerves provides innervation in the dorsum (top) of the foot?
superficial peroneal nerve
superior and inferior boarders of hypophargynx according to nagelhout
superior is epiglottis inferior is cricoid cartilage and upper esophageal sphincter is at lower edge
Treatment for TRALI
supportive
trace blood supply to the supraglottic region of larynx and infraglottic region of larynx (nagelhout version of blood flow)
supra- external carotid, superior thyroid artery, superior laryngeal artery Infra - external carotid, inferior thyroid artery, inferior laryngeal artery
The inter incisor gap is especially useful for what ventilation devices
supraglottic airways like LMA
which of the ankle nerves are formed from the union of a branch of the tibial and common peroneal
sural
which of the ankle nerves provides sensory innervation to the lateral posterior portion of the sole of the foot, and portion of achilles tendon above the ankle
sural nerve
Should blood sugar management be included on the post op care plan for a patient with the sugar diabetes?
sure
What are some generally accepted contraindications to cell salvage?
surgery involving woulds contaminated by bacteria sepsis bowel contents amniotic fluid malignant cells
Is needle or surgical cricothyrotomy preferred
surgical, more secure and better ventilation
the tracheobronchial trees receive ________ innervation from the first through the fifth thoracic ganglia.
sympathetic
How much above and below a sensory block will sympathetic and motor block be
sympathetic 2-4 levels above motor is 2 below
What is chvostek's sign
tap masseter muscle and get facial twitch from hyperexcitibility due to low ca++. Chomp-stick
when placing a spinal you feel a click or a pop....what should you do next?
that means you have passed though the dura, so you should remove the stylet and wait several seconds for CSF to return through the small gauge needle
what would you consider about the ease of intubation when you measure a patients thyromental distance less than 6 cm?
that would be the same as less than 3 finger breadths so they would be considered to have a higher incidence of a difficult intubation
what is included in the infraclavicular portion of the brachial plexus?
the 3 cords and their terminal branches
What happens to the brachial plexus as its divisions enters the axilla?
the 3 posterior combine to form the posterior cord, the anterior divisions of the superior and middle trunks combine to form the lateral cord, and the anterior division of the inferior trunk continues to become the medial cord
what is included in the supraclavicular portion of the brachial plexus?
the 5 primary ventral rami and the 3 nerve trunks and their 6 divisions
how would you calculate a maintenance drip for a pediatric patient that is 10 to 20 kg
the first 10 kg gets a calculation of 4 ml/kg/hour, then any wieght over that initial 10 kg gets calculated at 2 mL/kg/hour. for example: a 20 kg child would have 40 mL/hour plus 20 mL/hour equaling 60 mL/hour
how would you calculate a maintenance drip for a pediactic patient that is over 20 kg?
the first 10 kg gets a calculation of 4 ml/kg/hour, thenext 10 kg gets calculated at 2 mL/kg/hour. the rest that is over 20 kg gets 1 mL/kg/hour for example: a 25 kg child would have 40 mL/hour plus 20 mL/hour plus 5 mL/kg.hour equaling 65 mL/kg/hour
what is formed by the space between the inferior edge of the epiglottis and the true vocal cords?
the inferior vallecula
Where is the ICF found?
the intracellular fluid is found inside the plasma membrane....this is where chemical reactions take place.
what is a laryngospasm?
the involuntary protective reflex and contraction of the laryngeal musculature
when doing a 3 3 2 measurement if the 2 is more than 2 finger breadths what does that mean?
the larynx may be positioned too far down the neck and could be difficult to visualize
when doing a 3 3 2 measurement if the 2 is less than 2 finger breadths what does that mean?
the larynx may be tucked under the base of the tongue, which would be indicitive of an anterior larynx
what nerve of the lumbar plexus is formed from the second and third lumbar nerves and is the first to leave the compartment?
the lateral femorl cutaneous
How long can you manipulate the level of block with positioning after SAB
the length of drug onset so usually 3-8 min (somewhere said maybe up to 60min)
what protects the posterior epidural space
the ligamenta flava, the lamina, and the spinous processes
The vertebrae with the widest space is:
the lumbar vertebrae
What does 7.0 ett mean? What are lines on outside?
the lumen in mm cm on outside
true or false? The higher the site of injection the higher the the level of sensory block, but this is limited by the anatomy of the spinal cord
true
when doing an airway block how much direct local is put on the cords?
the patient takes a deep breath while instilling 5 ml of 2% lido
when doing a test dose with lidocaine in an epidural how will you know if you are intravascular?
the patient will have tinnitus, a metallic taste in their mouth, circumoral numbness, or a rushing sound in the ears which will only last for less than 5 minutes
in the brachial plexus what do the radial and axillary nerves supply?
the predominatly supply the dorsal portions of the upper extremity
besides having a larger epidural space, what is another important factor to stay midline with an approaching anesthetic needle?
the presence of the epidural veins.
what are the landmarks to use when doing a radial block at the wrist?
the radial styloid process and the radial flexor muscle
in the brachial plexus what combines to form the inferior or lower trunk
the rami from C 8 and T 1
traction on aorta or brachiocephalic artery during thoracic surgery can cause damage to what nerve
the recurent laryngeal nerve (RLN) which can cause malfunction of the cricothyroid muscle and hoarseness
what does the laryingopharynx include?
the region of the pharynx lying between the hyoid bone and the glottis
what is baricity?
the resting position of two fluids with differing specific gravities when the fluids are mixed in a single container, such as CSF and an anesthetic agent in the subarachnoid space.
what landmarks used in an intercostal nerve block?
the rib is palpated posterior to the midaxillary line. the lateral border of the sacrospinal muscle which lies about 7 to 10 cm from the midline
what can occur if ventilation is performed using postitive pressure greater than 30 cm H2O with the proseal LMA
the stomach can become inflated
What part of fiberoptic scope is most likely to cause infection
the suction port. It can be hard to clean between uses.
what needs to be documented on the post anesthesia care evaluation when taking an intubated patient to the PACU?
the type of tube and vent
If you give large volumes of fluids, what should always be addressed
the underlying cause
true or false? Unilateral or bilateral vocal cord paralysis can most often be attributed to nerve or mechanical injury and may manifest as partial or complete airway obstruction?
true
what if a patient demonstrates substantial or complete immobility of the atlanto-occipital joint?
then significant laryngoscopic compromise should be anticipated
true or false? a CSE is a viable option for a person having a total knee at 7:30 in the morning?
true
true or false? a nerve stimulator should have a digital readout of the amplitude?
true
true or false? all epidural solutions should be injected at 3 to 5 cc increments every 3 mins and titrated to desired anesthetic level?
true
why does the epidural needle have a blunt bevel and a gentle curve?
to pass through the skin and ligamentum flavum and abut against the dura
clinically what is the posterior segment of the cricoid cartilage used for?
to push against the esophagus during cricoid pressure
With unilateral RLN injury the vocal cords shift______
to the uninjured side
oropharynx anterior boarder to oral cavity?
tonsilar pillars
what are some common causes of laryngotracheal edema (4)
too large of cuff High cuff pressure double lumen tube traumatic suctioning
dig and ca++
too much ca++ = dig toxic Too little ca++ = dig resistant
Which ion potentiates action of Non-depolarizing NMBDs
too much mag
the duration of a spinal anesthetic is based primarily on anesthetic choice and ________.
total dose
Difference between total spinal and high spinal
total is coma high is brady and dyspnea
What does nagelhout say the lower airway is?
trachea to alveoli (below cricoid cartilage)
what does the fourth recommendation set forth by the AABB state?
transfusion decisions should be influenced by symptoms as well as hemoglobin concentration
What is TRALI
transfusion reaction acute lung injury Lungs swell, edema, microvascular hemmorage etc
What is TNS
transient neurologic symptoms symptoms
True or false? there has been a recorded Jehovah Witnesses who survived with hemoglobin as low as 1.8?
true
True or false? when calculating fluid deficit and fluid replacement you should take bowel prep and evaporative loss into consideration?
true
true or false every incremental dose in an axillary block should be considered a test dose?
true
true or false? cricoid pressure is a mainstay of anesthetic practice, particularly during rapid sequence induction of general anesthesia in patients at high risk for gastric aspiration?
true
true or false? intercostal nerve blocks can provide analgesia during or after chest tube placement insertion to limit the patients discomfort
true
true or false? plasma proteins, such as albumin, maintain osmotic pressure to maintain volume?
true
true or false? proper atlanto-occipital mobility is required for an adequate sniffing position?
true
true or false? supraglottic airways, such as an LMA, were first introduced as a substitute for face mask ventilation as as an alternative to difficult tracheal intubation?
true
true or false? surgery, neck trauma, or neoplasms can cause injury or damage to the recurrent laryngeal nerve and the superior laryngeal nerve
true
true or false? the IVF and the ISF are parts of the ECF?
true
true or false? the cricoid has a posterior segment?
true
how much does 25% albumin expand intravascular volume?
up to 5 times the volume infused.
How far can neck move with full extension to full flexion in cm?
up to 6 cm (average of 3.8 cm)
How long can an airway exchange catheter stay in?
up to 72 hours
ULBT classes
upper lip bite test I is prtrude lower incisors past upper and bite above the vermilion boarder II-can move the lower incisors in line with the upper and can bite lip below vermilion boarder III- Lower incisors cannot move in line with upper and cannot bite upper lip
should you transfuse PRBC's for a patient with a class 2 hemorrhage?
usually not necessary, unless preexisting anemia and/or cardiopulmonary disease
What is bicitra?
usually used preop to lower stomach acid (sodium citrate). Usually oral
What 3 extra times are charted with c-section
uterine cut time. Baby is at risk once uterus is cut Birth time Apgar times (1 and 5 min)
If you have loss of sensation up to t10 and have a lot of hypotension, you probably just have _______, if you get brady and your sensation is T8-T6 then it is probably due to ____ _____ with ______ block
vasodilation high spinal sympathetic
Can "short form" be used for longer cases?
yes, just number them. One page has enough for 3.5 hours of info. Complex has enough room for 5 hours
How does high spinal effect respirations
ventilatory function (how deep they breathe) intercostal and abdominal muscle paralysis around T4? There is no phrenic nerve problem this high, just accessory.
what are the 5 parts that the brachial plexus is composed of?
ventral rami, trunks, divisions, cords, and their branches
what instructions are given to a patient when using a nerve stimulator?
verbally identify discomfort, and do not move during the advancement of the needle
Aggrastat and Integrilin (eptifibatide, and tirofiban) and CNB
wait 8 hours (allows normal plt function)
4 ways to reduce fiberoptic scope fogging
warm on pt. lip antifog liquid warm in warm saline Blow 02 through suction lumen
Cost of running cell saver
washing and infusing is $700
What is tracheomalaicia? What problem can it cause with anesthesia?
weak tracheal cartilage that can cause collapse of trachea. Bad for extubation
What are some symptoms of hypercalcemia?
weakness low energy low appetite nausea/vomiting increased thirst/dehydration paralytic ileus/constipation
2 reflex, 3 muscle signs of low ca++
weakness spasm tetany chvostek's and trousseaus sign hyperreflex
when is a primitive blood gas barrier developed in fetus
week 26
because of the tripodal, dunelike shape of the epidural space, when can an anesthesia provider expect it to narrow considerably?
when approaching laterally to the midline, and in more caudad areas of the space
When is LMA used in OB patients
when intubation has failed and face mask ventilation is difficult
When are platelet replacements indicated for levels between 50k-100k instead of <50k
when microvascular bleeding at risk for plt dysfunction continued bleeding
what is an isobaric solution?
when the baricity equals 1
When do you still need more reversal when you have 4/4 train of four twitches
when they have poor breathing
what is the cornus medullaris?
where the spinal cord tapers after the L2 area
