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TRUE or FALSE. Corneal Abrasion is the foremost injury after general anesthesia but it can occur after any type of anesthetic.
Name some risk factors for corneal abrasions.
Any object that can strike the eye!
- •Stethescope, ID badge, wrist watch
- •Longer surgeries, head and neck surgery, prone and lateral positioning
What is corneal exposure?
- Prolonged exposure of cornea causing damage to the epithelium
- Corneal epithelium dries out from lack of tear covering
Lagopthalmus is another risk factor for corneal abrasion. What is this?
Inability to fully close eye lid
•5% of general population
•60% of General anesthesia patients
Hyperthryoid patients may be at risk for corneal abrasion due to _______
Describe Bell’s Phenomenon.
•Protective reflex of eye
•Eye moves up and outward when blinking or threatened (try to touch cornea) or lagothalmus
•Bell’s phenomenon is abolished under general aneshesia
What are some strategies to protect eyes from injury while in the OR?
- •Tape eyes completely shut immediately after loss of lid reflex
- •Assess integrity of tape periodically throughout case and after each position change
- •Re-tape when necessary
- •Place oximeter on non-dominate hand
- Do not use index or middle finger
- (when pt wakes up wants to scratch eye, use ring ringer)
- -ointments as well (on another card)
We use opthalmic ointment if needed to protect our patients eyes in the OR. What types of cases would we do this and what types of ointments are there?
- •Longer cases (4hrs +)
- •History of corneal abrasion or eye irriation
- •Head and neck cases
- •Patients with difficulty closing eyes
- •Petroleum based (more common) versus methylcellulose (surgilube like, doesn't last as long)
What is the treatment for a corneal abrasion?
- •Local anesthetic drop to affected eye
- •If pain resolves then likely corneal abrasion
- •If not, consult opthalmology
- •Fluorescein with Wood’s lamp to visualize injury
- •Antibiotic ointment to eye for three days
- •Consider non-steroidal eye drops.
•Dental injury during the perioperatrive period accounts for ____ of all
•Incidence of damage is 1:____
1/3 and 1:2100
Whose teeth tend to get damaged during intubation?
•Preexisting or poor dentition(most susceptible)
What are some interview questions you would ask regarding dentition?
- •Do you have any loose, chipped or broken teeth?
- •Any false teeth?
- •Anything removable from your mouth?
- •Any restorative dental work?
- •What teeth are involved?
How do you number the teeth?
Start w/upper right (#1) and go around the top towards the left upper then go to the bottom left and go around to the bottom right (#32)
What teeth are most people missing (hint: wisdom teeth)
# 1, 16, 17, & 32
What should you examine and document regarding dentition?
- •Exam and document any dental work present
- •Exam and document any missing, broken or loose teeth
- •Assess risk factors for difficult intubation
- •An extremely loose tooth may be removed, prior to laryngoscopy, if it poses an aspiration risk
TRUE or FALSE. Discussion regarding dentition is part of the informed consent process.
- Discuss that damage is a possibility
- Offer alternatives:
- •Patient may obtain preoperartive dental consult
Describe the post-op exam for dentition
- •Exam and document patient’s mouth after intubation or LMA placement
- •Note atraumatic nature of intubation
- •Note if intubation was traumatic
- •Examine and document patient’s mouth after extubation or removal of any airway device
- •If any damage, document it
When should you ALWAYS insert a soft bite block?
- •On intubations
- •On LMA’s
- *Document the use of a bite block*
Where should you place the bite block?
Between the molars
Oh F***! You damaged the teeth, what do you do now?
- •Document the injury
- •Save any dislodged pieces
- •Chest X-rays if any concern about aspiration
- •Call risk management
- •Do not automatically tell patient to get an estimate
Example of obstructive lung disease
Asthma or COPD
Example of Interstitial lung disease
Example of vascular lung disease
- Pulmonary embolism
- Pulmonary HTN
Example of neuromuscular lung disease
polio or spinal cord injury
TRUE or FALSE. Sleep apnea is its own category of lung disease
TRUE (according to Judy's slide)
What are some pleural diseases?
effusion or pneumothorax
What kind of symptoms are you looking for in your respiratory exam?
- chest pain
Can a cough be caused by GERD?
Your patient has a cough, what should you ask them about?
productive vs non productive, phlegm, color, when it occurs, etc.
What type of volatile anesthetic is very pungent and makes people cough?
Tell me about dyspnea
- • subjective awareness of increased difficulty with breathing
- • pathophysiology related to gas exchange & proprioceptive factors
- • dyspnea at rest is uncommon
- • quantitate dyspnea on exertion in terms of city blocks or stairs
What is the most common cause of hemoptysis?
True or False. Hemoptysis demands extensive evaluation, including CXR’s, CT scan, bronchoscopy
For hemoptysis, we always want to quantitate the amount of blood in 24 hrs. What is massive hemoptysis?
massive hemoptysis is ≥ 600 ml in 24 hrs
Explain pleuritic pain
•Pleuritic pain is sharp and knifelike. It arises from parietal pleura. Worse with inspiration & coughing
What type of pain is associated with costochondritis?
•Chest wall pain can be reproduced by palpation and by movement of the thorax
What are the four steps for physical exam of the chest? (or any system for that matter)
What are you looking for during the inspection portion of your respiratory exam?
- •Respiratory rate, depth, and pattern
- •Respiratory rate is the most neglected vital sign! >16‐18 per minute is upper limit of normal
- •Inspiratory:Expiratory ratio 1: 2
- (also looking for use of accessory muscles, scoliosis, and clubbing/color)
What are you looking for during the palpation portion of your respiratory exam?
- •Chest expansion
- •Vocal fremitus
- – Increased over areas of consolidation
- – Decreased over pleural effusion
- •Pleural friction rub
- •Does palpation reproduce the pain?
What types of sounds are you assessing for during the percussion portion of your respiratory exam? Why do we do this?
- •Resonant – sound heard over normal lung
- •Dull – sound heard over heart, liver, consolidation, pleural effusion
- •Hyperresonant – sound heard in emphysema and COPD
- •Helps to determine the interface between aerated lung & solid structures (liver, pleural fluid, or consolidation)
- •Can be used to measure diaphragm excursion between inspiration & expiration
What are we assessing for during the auscultation portion of our respiratory exam?
- •Compare the 2 sides of chest
- •What is intensity of breath sounds?
- •What is character of breath sounds?
- •Are added sounds present?
What are bronchial breath sounds?
- •Bronchial breath sounds are equal in inspiration & expiration
- •Heard best over trachea in neck
- •Bronchial breath sounds can be heard over an area of consolidation
What are the sounds of the normal lung?
Vesicular lung sounds.
Inspiration >> expiration
Besides vesicular or bronchial sounds, what else might we hear during auscultation?
- •Wheezes ‐ musical sounds usually heard in expiration. Common in asthma & COPD
- •Crackles or rales ‐ short discontinuous sounds like rubbing hair between fingers. Common in interstitial lung disease and pulmonary edema
- •Rhonchi – coarse sounds heard during inspiration and expiration. Usually indicate airway narrowing
- •Pleural friction rub – creaking or grating sound heard in inspiration and expiration as inflamed visceral and parietal pleura rub over one another
Normal Inspiratory Reserve Volume
Normal Inspiratory capacity volume
Normal Expiratory Reserve Volume
Normal Residual Volume
Normal Function Residual Capacity Volume
Normal Vital Capacity
Normal total lung capacity
Tell me about FRC
- •Residual volume (RV) + Expiratory reserve volume (ERV)
- •Reservoir of gas on top of which tidal breathing occurs
- •The “rest position” of the respiratory system.
- •The zero vector point between inward recoil of lungs & outward recoil of chest wall
Why do obese or pregnant patients desat so rapidly?
They have no FRC
What does Spirometry measure?
•Vital capacity (VC) or forced vital capacity (FVC)
•FEV‐1 (volume exhaled in one second)
FEV‐1 / FVC ratio (> 0.7)
How do you perform Bronchodilator testing?
- •Inhaled albuterol with a spacer device
- •Look for a positive bronchodilator response:
- 12% and 0.2 L increase in either FEV1 or FVC
Tell me about the spirometry loops
- •Normal loop
- •Obstructive (e.g. asthma) before & after bronchodilator
- •Severe obstructive disease (e.g. emphysema) before & after bronchodilato
- •Restrictive lung disease (e.g. pulmonary fibrosis or obesity)
- •Fixed major airway obstruction (e.g. laryngeal obstruction).
- *Be careful, could put them asleep and obstruct the airway*
- *Think about it before giving anything that will relax the airway muscles*
When and why do we do pre-op CXRs?
- •May identify abnormalities which lead to delay or cancellation of surgery or change in anesthetic care plan
- •Routine testing in patients without risk factors can cause more harm than benefit
- •Indicated in patients with history or clinical evidence of active pulmonary disease
- •May be indicated routinely only in patients with advanced age
How long do we preoxygenate our patients?
3-5 minutes of TV breathing (if morbidly obese or pregnant, mask on tight for 5 min)
Some books say 3-4 vital capcity breaths instead of minutes of tidal volume breathing
What is the ideal end tidal O2
prior to induction??? And what does this mean?
- End tidal oxygen, shows how well you’re de-nitrogenating
How do you avoid missing or broken teeth in the OR? what do you do if this happens?
- Remove loose teeth prior; avoid using
- upper teeth as fulcrum for laryngoscope blade. CXR to check for aspiration
Your patient clenches their teeth in the OR, what could you do to stop it?
Give a paralytic medication
How can you prevent an air leak? What do you do if this happens?
Check cuff prior to beginning procedure. Inject more air or change tube over guide wire.
What things can you do to ensure proper visualization of vocal cords. What can you do during the process to manage difficult visualization?
Proper patient positioning, proper laryngoscope blade size, proper suctioning. (Always have suction on bed, turned on)
Reposition, choose a different blade, adequate suction, cricoid pressure by assistant.
How can you prevent esophageal intubation? What do you do if this happens?
Visualize the cords. Remove tube, re-oxygenate and reinsert.
How can you avoid right main stem intubation? How do you manage this problem?
Avoid excessive tube advancement. Deflate cuff, re-position, and reflate cuff
How can you prevent laryngospasm? How do you manage it?
- Spray vocal cords with 2% Lidocaine
- Sometime PPV works. Or Benzodiazepine or paralytic medication *usually succinylcholine
You fail to intubate, what do you do to manage this situation?
- Have alternative plan prepared: e.g.,
- BVM, another type of tube, cricothyrotomy.
___________ provides early warning of arterial
hypoxemia that may not be appreciated by subjective observations
intraop pulse oximetry
What factors influence the accuracy of pulse oximetry?
- •Low blood flow conditions
- •Patient movement
- •Ambient light
- •Dysfunctional HGBs (carboxyHGB, metHGB)
- •Methylene blue (dye that is used frequently
- in gynocology and urology)
- •Altered relationship between PaO2
- & SaO2 (shift in oxyHGB dissociation curve)
TRUE or FALSE. The digital readout for intraop capnography is more informative than the display of the waveform.
- FALSE! Display of waveform is more
- informative than the digital readout
After placement of ETT or LMA, proper placement confirmed by clinical assessment & sustained presence of___________
ETCO2 (> 30 mmHg)
What can cause an increase in your EtCO2?
- •Malignant hyperthermia
- •Administration of bicarbonate
- •Insufflation of CO2 during laparoscopy
- (need to increase minute ventilation, RR or volume, to decrease CO2)
What can cause a decrease in your EtCO2?
- •Lowcardiac output
- •Pulmonary embolism
- •Accidental disconnection or tracheal extubation
- •Cardiac arrest
What is the multiple gas analysis?
- •Fraction inspired
- •End tidal
- •Carbon dioxide
- •Anesthesia gases
- (Techniques include infrared absorption, mass spectrometry, & Raman spectroscopy)
Ventimeter or respirometer (usually on the exhalation limb of anesthetic breathing system) will measure ____ ____
What is the calculation for minute ventilation?
RR x TV
What is airway pressure measured by?
A gauge on the anesthesia machine
What could cause excessive airway pressures?
- •Low pulmonary compliance
- •Obstruction in anesthetic breathing system (IE, closed APL valve)
Describe the clinical monitoring of spontaneous breathing in the OR
- •Spontaneous breathing
- •Monitor pattern of breathing (frequency, depth, regularity)
- •Visual & tactile (hand on the bag!) monitoring of movements of reservoir bag
- •Observation of chest movement
- •Auscultation of chest
- •Character of respiratory movements helps assess appropriateness of anesthetic drug concentrations for current or anticipated level of stimulation (ie, MAC case prior to injection of local by surgeon)
What type of breathing do you see w/volatile agents?
rapid & shallow breathing
What type of breathing do you see w/opioids?
decreased frequency and increased TV (compared to volatiles)
Early post-op respiratory physiologic disorders includes upper airway obstruction. What are some increased risks for this?
- •Obstruction in pharynx by tongue most common
- •Laryngeal obstruction from laryngospasm or edema
- •Obesity increases risk
- •Physical exam: flaring of nares, retraction at suprasternal notch & intercostal spaces & vigorous diaphragmatic & abdominal contractions
What is the most common cause of arterial hypoxemia during the early post-op period?
•Most commonly increased right-to-left shunt (atelectasis)
What is the most common cause of hypoventilation during the early post-op period?
•Most commonly inadequate CNS stimulation to ventilation due to residual effects of inhaled &/or injected anesthetics