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Describe the hx you would take if someone needed quick surgery
- Last Meal
- Events leading up to presentation
Why do we want to know about a FHx of anesthesia probs?
Difference between an allergy as opposed to intolerance or side effect
Allergy is an actual immune reaction
How would you assess an airway for intubation?
- MOUTH mnemonic
- Mandible - should be three fingers
- Opening - scleroderma? small opening
- Uvula - Mallampatti classification
- Teeth - bad teeth are choking hazard
- Head - range of motion (want them in the sniffing position ideally)
Three things that can compromise a bag mask?
- no teeth (causes a sunken face)
- facial hair
- fat face
Describe the ASA classification of patients (6)
- I - no systemic illness
- II - mild systemic illness, no functional impairment
- III - Systemic illness with func impairm.
- IV - Sys. ill. that is const. threat to life
- V - patient will die within 24 hours without operation
- E - emergency operation
What red flags should cause you to cancel the procedure? (3) How long before you can re-book an elective procedure?
- can't eat or drink
- fever or lethargy
reschedule for 6 weeks
Anesthetic concerns in asthma (2)
- 1) intraoperative brochospasm can cause hypoxemia
- 2) decreased lung compliance makes it difficult to ventilate
When should you tell a patient to stop smoking before surgery?
as soon as they are ready
Why are we worried about ventilating in COPD
barotrauma: so much pressure that you actually cause a pneumothorax
How to you screen for OSA? why worry about this in anesthesia?
- Snoring loudly?
- Tired during day
- Observed apnea at night
- P -Blood Pressure high
- BMI > 35
- Age > 50
- Neck size > 40 cm
- Gender = male
These patients are highly susceptible to the resp depressent effects of sedatives, may have a difficult airway, pulm hypertens
Why are people with cardiac problems vulnerable after surgery? How long should people wait after they have had an MI for surg?
-There is a symp response after surgery causing HTN.
-inflammatory mediators will circulate an will dislodge plaques
-wait at least 4/52, ideally 6/12
what are the hemodynamic goals for someone with IHD that will avoid cardiac ischemia?
- Keep them near baseline
- -want them at normal or low contractility
- -want to minimize afterload, but need to keep diastolic pressure in order to keep heart perfused.
What should you do with patients with HTN?
- -take meds with a small sip of water in the AM of surgery
- -KEEP PATIENT AT BASELINE
What BP swings are we willing to accept intraoperatively? how low can you go?
+/- 20-30 mm Hg, can go to 50 mmHg
In aortic stenosis, what do you want to happen with the afterload?
You want to increase it. This is counterintuitive, but it helps maintain perfusion in the coronary arteries. This is why you dont want to give a spinal, it causes vasodilation below and lowers the afterload.
In a diabetic, why hold oral hypoglycemics the AM of a surgery?
They are already NPO, do not want to push them into hypoglycemia
What is of most concern to anesthesia in a type I diabetic?
During surgery, why do we like to anticoagulate with heparin rather than plavix/clopidogrel
heparin is quickly reversible. bridge them off of warfarin.
What do you use to emergently reverse heparin?
Why is important to know a patient's coagulation status when doing a spinal/epidural?
worried about a spinal epidural hematoma
Why is aspiration of solid stuff worse than liquid?
it is a perfect growth medium for bacteria
Describe prophylaxis of aspiration
- want to reduce volume and acidity.
- 1) give ranitidine
- 2) keep them on prokinetics if they are on them.
What is Rapid Sequence Induction?
Steps we take to secure the airway quickly. Give big doses of drugs rather than titrating so you get the airway quickly. Remember that this can put the patient into hypovolemic shock
Describe procedure priority
- Urgent/Ca: days-weeks
- -E3: within 24 hours of booking case
- -E2: within 8 hours of booking case
- -E1: within 1 hours of booking case
Describe NPO orders
- 2-4-6-8 rule
- Restriction on:
- -clear fluids, 2 hours
- -Breast milk, 4 hours
- -Formula, 6 hours
- -Solids, 8 hours
3 drugs a patient should not take the day of surgery, what about all the others?
- 3 drugs: anticoags, diuretics, oral hypoglycemics
- -take all others with a sip of water
4 phases of anesthesia
- Airway mgmt
What are the 5 indications for intubation?
- 5 P's
- 1) Hypoxia (PaO2 < 60mm Hg) or resp failure (PCO2 ) 55-60 mm Hg)
- 2) Protection: aspiration or burnt airway
- 3) Positive pressure ventilation needed (long procedure, etc)
- 4) Pulmonary toilet (cant clear own secretions)
- 5) Patency
How can you tell if your endotracheal tube is in place? (3)
- -equal air entry
- -measure end tidal CO2
- -look at sats, if they are 100% and not falling, you are in.
Define MAC. What is the desireable MAC in a patient?
1 MAC is the amount needed to be given for 50% of the patient population to have an effect. Usually want 1.3 MAC (95% respond)
What indirect parameters can be used to indicate awareness?
increased sym response to pain: HR, RR, BP
What are the three goals of anesthetics?
Amnesia, Analgesia, Akinesia
How do you calculate fluid deficit?
- 4-2-1 rule:
- 1st 10 kg-> 4 ml/kg/hr
- 2nd 10 kg -> 2 ml/kg/hr
- mass over 20 kg -> 1 ml/kg/hr
replace in first 1-2 hours
e.g. 70Kg adult with no water for 8 hours needs 880 ml for replacement
Why do you need to give 3x as much crystalloid as you have lost in blood?
because only 1/3 of it will stay in the vascular compartment
In a healthy person in a straightforward surgery, when should you transfuse RBC's?
usually around a hgb of 60, have a higher threshold (as high as 100) if someone is old with complications
How can you tell if an anesthetic is an amide? What can you give if someone is allergic to amides?
If there is an I in the prefix, it is an amIde (e.g. lIdocaine, bupIvacaine; but not tetracaine). You can give an ester (like tetracaine) and vice versa
Where should you not inject anesthetic with epi in a patient?
fingers, toes, nose, and ho's (end of penis). But the last one is likely the only one we care about
What is the difference between an epidural and a spinal? (5)
- 1) spinal goes through the dura, epidural sits on top
- 2) spinal is faster and stronger
- 3) can do a more local block with epidural whereas spinal is basically like a cord transection
- 4) differential blockade in epi means that motor neurons are intact and you can have a walking epidural
- 5) need a higher dose in epidural (10x higher)
What are some narcotic side effects? (5)
- Resp depression
2 common options for treating nausea
gravol and ondansetron
How would you treat acute post op surgical pain in a patient who suffers from chronic pain?
Make sure that you are taking their current medications into account. They are going to be pain killer tolerant. Need to give them more drugs ON TOP of their current regimen.