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For CQI, does every patient generate a CQI form?


SRNA's responsibility for CQI

Post op rounds, makes notes of post op complications, follow up with the patient's CRNA, and report to department.

Importance of CQI in Anesthesia?

Errors effect more than 18% of all hospitalizations, trend patient safety and identify problems. Anesthesia is not therapeutic, so any M&M needs to be investigated. CQI is used as staff educational mechanism


process of continually evaluating anesthesia practice to identify systematic problems and implement strategies to prevent their occurance

Critical incidents

events that cause or have the potential to cause patient injury if not noticed and corrected in a timely manner

Sentinel Event

Single, isolated events that may indicate a systemic problem. May or may not result in significant pt injury or death

Root Cause Analysis

Includes everyone involved in the are of the effected patient in reconstructing the events to identify system flaws that facilitated medical error.

Non-punitive Environment

Learning environment in which managers encourage reporting of errors by avoiding inappropriate punitive reactions to errors

Why focus on safety?

No error is acceptable, many are preventable, public knows about errors, Joint commission, and the financial implications of errors.

100,000 Lives Campaign

an initiative to engage US hospitals in a commitment to implement changes in care proven to improve patient care and prevent avoidable death. EBP, education, accountability, patient centered care

What is SEAT?

Stop, Engage, Audible, Timing. Keystone should be done after positioning but before draping.

When does the most human error occur?

During maintenance phase are the most preventable errors. We can prevent errors by reducing complexity and creating redundance.

Error reduction through CQI

Encourage documentation of all incidents, non-punitive environment, identify need for in-services or policy changes, protocols for "handling incidents" such as fire or equipment

What are other ways errors

Clinical event reviews, peer review process, making system wide changes when problems are found, M&M meetings

Monitoring on floow

has decreased arrest

Serious Clinical event?

event that resulted in an adverse patient outcome or had the potential to lead to an adverse outcome. Can be related to anesthesia, surgery, or pre existing condition. If there is death, CNS event, MI, neurological deficit, fire...then a RCA must be done

Joint Comission Sentinel Events

Must report events are wrong side surgery, transfusion reactions, suicide, infant abduction, discharge error, rape

What are some methods to prevent events?

Site and sidedness, moment of silence, final verification, audits on blood verification

What are the clinical events that are serious?

Post op aspiration pneumonitis, periop respiratory arrest, peri op CNS complication, periop peripheral neurological deficit, cardiac arrest up to 24 hrs, periop acute MI, death, pulmonary edema, perioperative thermal injury

What are high risks for awareness?

Crash trauma, bypass open heart surgery, and OB crash spinals

What are the most common causes of allergies?

Latex and muscle relaxants are most common cause of anaphylaxis and allergic reactions

Oral and Dental injuries are...

the most common complaint from surgery

Lasik surgery

You want to make sure that their eyes are lubed...

What is induction?

The initiation of anesthesia, from intact reflexes from being unconscious

What do you need prior to any induction?

Machine check, table top setup, suction on and at head of bed, patient prepared, patient assessment complete, consents completed.

What is the importance of checking the machine?

You want to make sure there are no leaks because if you need to give positive pressure for a laryngospasm and can't, you won't be able to treat it. occlude end of circuit with hand and occlude APL valve to make sure the bag blows up tight

Why do we preoxygenate?

denitrogenize the patient and buy CRNA time to safely complete induction. Normal FRC is 2500 ml. If you denitrogenate for 3 minutes you can meet the pt's metabolic demands for 8-10min.

Why has less FRC?

Obese, infants, pregnant woman. They have less FRC and less margin of safety.

What is the suggested time of preoxygenation?

Tidal breathing 100% O2 for 3-5 minutes. If the mask is lifted off face, then you need to start over!

What is Propofol?

GABA mimetic, less PONV but short lived effects, people wake up quickly with propofol, it reduces ICP and can be considered anticonvulsant, does not trigger MH, anti-itch

What is the dose of Propofol?

2mg/kg for induction. It is used for sedation and is a hypnotic. Maintenance does is 100-300mcg/kg/min, MAC is 25-75mcg/kg/min. Immediate onset and lasts 10minutes.

What are the disadvantages of Propofol?

1) Lowers BP because of negative inotropic effect,
2) Causes the largest decrease in SVR,
3) Burns on injection,
4) Expires in 6hrs,
5) Formulated from soybean, glycerol, and egg lecithin 6) Sulfite allergy to generic drug, Diprivan does not have preservsative.
7) Lactic acidosis risk

Why do kids need preservative free Propofol?

could be harmful to them?

What are the respiratory effects of Propofol?

initial brief increases followed by a decrease in minute ventilation. The reduction in minute ventilation has to do with a reduction in tidal volume. Dose dependent ventilatory depression. Propofol also has a mild bronchodilation effect.

What is sodium pentothal?

Barbituate. Dose dependent decreases in CMRO2 and cerebral blood flow. Protection for circulatory arrest because you decrease metabolic rate of brain. Dose is 4mg/kg. Sedative properties are prolonged with accumulation. GABA mimetic

What are disadvantages of sodium penothal?

1) There is a decrease in venous capacitance vessels that results in venous pooling
2) Direct inotropic effect so there is low venous return and low CO, dose dependent reductions
3) Post op drowsiness with hangover effect
4) It will precipitate other drugs.
5) dose dependent resp depression and doesn't blunt reflexes unless at high doses

What is Etomidate?

GABA mimetic, short acting hypnotic. Dose is 0.2-0.4mg/kg for induction, lasts 4-10 minutes and has onset in 30-60 seconds.

What does Etomidate cause?

Produces EEG burst supression, decreases ICP, used in patients with decreased cardiac function because it doesn't drop blood pressures, sedation & hypnosis

What are advantages to Etomidate?

1) hemodynamic stability because it doesn't have drop in inotropoic effect
2) reduces ICP, cerebral blood flow, and oxygen use in the brain

What are the disadvantages of Etomidate?

1) produces myoclonus
2) pain on injection
3) adrenal suppression for 6hrs post op
4) Increases PONV
5) decreases seizure threshold
6) dose dependent respiratory effects- minute volume decreases, but RR increases. If given with opioids it is worse.

What is Ketamine?

It is usually as an adjunct to anesthesia. Dosed 1mg/kg. LSD derivative, produces dissociative state of anesthesia. Onset is relatively slow compared to other drugs 2-5 minutes.

What are the advantages Ketamine?

1) Circulatory stimulant causes increase in HR, BP, CO, and CVP
2) Positive inotrope
3) Increases in MVO2 so not good to use with heart patients
4) Potent bronchodliaotr will dilate airway for asthmatics
5) maintains airway and respiratory reflexes
6) good to use with older people

What are the disadvantages of Ketamine?

1) produces a dissociative state
2) Increased cerebral metabolic rate, increased cerebral blood flow, and increases ICP
3) Increases salivation and respirator secretions.
4) Associated with emergence delirium, nightmare, and hallucinations
5) don't use with heart patients, neuro patients and psych patients.

What is Versed?

Versed is dosed 2mg/IV. Onset is 60 seconds and it lasts 60 minutes, subject to first pass

What are the advantages to Versed?

1) It relieves anxiety, produces mild sedation, and also has amnestic properties.
2) Less respiratory depression except in the very young, very old, or debilitated
3) Decreases cerebral blood blow and CMRO2 so it decreases blood flow to the head and decreases O2 demand by the brain

When do you us an inhalation induction?

1) Slower onset than any IV agent
2) Dose dependent decrease in BP
3) Does causes airway irritability and Sevo is less irritating

What are anesthetic indications for cardiac patients?

want smooth induction, you want to keep them stable and not have any spikes or dips in blood pressure. You want to avoid significant change in vitals

What are anesthetic indications for neurosurgical patients?

stable hemodynamics and you don't want drugs that increases ICP or cerebral blood flow

What are the anesthetic indications for pediatric patients?

Volume distribution is different because kids have more body fluid. Pediatric patients take different doses of medications

What are anesthetic considerations for geriatric patients?

Longer circulation time so more time needed for drug's action. Slower induction process with the elderly. Want the pt's vital signs to not have any major spikes or dips.

What is the preparation for an LMA case?

Head straps in place, arm boards applied and arms secured prior to induction, all monitors on, precordial on suprasternal notch, induction drugs ready, oral airway at head of bed, preoxygenate for 3-5min at 5L/min, APL open until pt is no longer breathing, tell pt they will feel drowsy, ensure good mask fit and make sure there is no leaks. SUCTION AT HEAD OF BED! check lash reflex.

What are the steps of induction?

1) Run IV wide open
2) give calculated dose of induction agent at steady rate
3) Recheck IV, make sure drug has infused
4) watch patient and observe for long deep breaths
5) assess LOC
6) Once pt is asleep, tape eyes, and gently assist ventilation. Insert oral airway if you cannot ventilate
7) If using LMA, insert once asleep
8) turn on agent of choice and overpressure them to get them deep.

What is the positive pressure limit that you don't want to exceed?

20cm H2O. When assisting ventilation make sure the patient initiates the breath and then finish it.

Why do you need the patient deep at incision?

Because they can spasm on incision. You want vital signs in range, low RR, an okay blood pressure.

How do you gauge the level of anesthesia?

The amount of tidal volume patient takes when breathing

What are the essentials for an induction for general anesthesia with planned intubation?

Peripheral nerve stimulator, laryngoscope, ETT, OPA of correct size, and SUCTION!!

What are the first steps of induction in regards to prepration?

1) make sure machine is checked
2) Adjust height of OR table
3) preoxygenate 3-5 minutes
4) administer narcotic (this blunts the airway reflexes- 2cc of fentanyl usually)
5) if using propofol give Lidocaine 20-30mg to numb vein.

Once pt is preoxygenated, what are the next steps with induction?

1) give dose of induction agent
2) assess LOC, check lash reflex, and tape eyes
3) Assess airway patency, assist and control ventilation. Insert an OPA if necessary
4) If airway is manageable say airway is good and give muscle relaxant
5) Turn on agent of choice while waiting for muscle relaxant onset.

What do you do if you can't ventilate the patient once asleep?

Wake them back up

What are the onsets of the different muscle relaxants?

Rock takes 3-5 mintues and succ takes 30-60 seconds. Floppy head and slacked jaw are indications that the pt is ready for intubation.

Once the muscle relaxant is given, what do you do next?

1) place intubating equiptment near patient's head, ETT on pts chest and scope on LEFT side of head
2) Check onset of muscle relaxant with PNS
3) Preform laryngoscopy and insert ETT
4) Remove carefully
5) Inflate cuff
6) Check intubation
7) turn on agent, put pt on ventilator, and adjust flows
8) secure ETT

How do you check intubation?

visualization of tube passing through cords, chest expansion, ETCO2, breath sounds. Listen at 2ICS on Left side.

What is the most reliable site for nerve stimulation?

Ulnar, with positive red lead closest to heart

Who is responsible to check breath sounds for the tube?

The person who intubated

When do you remove the stylet?

Right before moving the tube through the cords. Make sure the stylet is above the eye of the tube

What are special indications for a RSI?

-When patient has a full stomach
-Bowel Obstruction
-Known hiatal hernia with reflux

What is the point of RSI?

To minimize change of regurgitation and aspiration.

What is required during an RSI?

SUCTION at the head of bed, an assistant to hold cricoid pressure, and strict adherence to policy.

What happens if you have a NGT?

If you keep it in, make sure it is on suction the whole time. There is no evidence supporting leaving it in vs taking it out.

What are the steps for an RSI?

Suction at HOB and always on, preoxygenate, pretreat with subclinical dose of NDMR to avoid facculiations.
2) Give full dose of induction agent
3) Have assistant hold pressure as soon as drugs are injected
4) follow with FULL dose of succ
5) Do not ventilate
6) wait for succ to work then intubate

How do you apply cricoid pressure?

exert in an anteriorposterior direction occluding the esophagus. 5Kg of pressure.

When do you release cricoid presure?

once the ETT placement is confirmed with ETCO2 and breath sounds

When can you place an OGT?

After the ETT is secured.

What is maintenance?

Period from the end of induction to anesthetic emergence. Plans are adopted constantly and decisions are made continuously

What is the most important intraoperative maintenance?

Preoperative planning

What are the goals of intraop maintenance?

Provide protective functions of life, render the patient insensible to pain, provide optimal exposure and surgical conditions for surgeon

What are important factors of maintenance?

monitoring, oxygenation, ventilation, positioning, temperature, charting, fluids, blood loss, assuring depth, assuring amnesia, assuring analgesia, muscle relaxation, preparing for emergence, preparing for the next case

What factors determine types of monitors?

type of surgery, patient condition, length of surgery, access to extremities

What senses are used during intraop?

observation for the rise and fall of chest, nail beds,
lips are blue,
bounding pulses,
look at surgical field and also at canister, mucous membrane,
skeletal muscle tone

What are we listening for?

alarms, heart rate, SPO2, suction, listen for cues for the end of surgery

Sense of touch for intraop?

Are they cold? Are they sweating? clamminess? bounding vs weak pulse?

Non invasive monitors during intraop

pulse ox, ekg, BP, temp, BIS, salter cannula, PNS, precordial stethoscope, evoked potentials.

What are considerations for the evoked potentials?

not as much muscle relaxant because it could affect motor and not as much gas because it could affect sensory.

What can affect SPO2 reading?

methylene blue, carbon monoxide, and blood pressure on same arm

EKG during intraop

Lead II monitors arrythmias
Lead V monitos ischemia
Get strip before induction
Do a 5 lead on pts with heart history

NIBP cuff

You want set for every 3 minutes, standard is every 5 minutes, for regional you want every 1 minute. Put a regular sized cuff on forearm if they are obsese. Cuff width should equal 40% of arm circumference

When would you see NO CO2 on your ETCO2?

Kink, PE, cardiac arrest

When would you see low CO2 on ETCO2?

decreased TV, prolonged hyperventilation

When would you see increased ETCO2?

hypoventilation, MH,

What are considerations for temp?

Forehead is most widely used but least accurate, nasal temp will put pt at risk for nose bleeds

Why is controlling body temp such a big deal?

-heat loss and gain center is in the hypothalamus anterior and posterior respectively
-Redistribution of body heat and anesthetic interferes with hypothalamus 1-5 degrees during first hr
-After the first hr, the temp decreases at slower rate.

Do anesthetics inhibit central thermoregulation?

Yes, because they interfere with hypothalamic functions.

What happens when a patient is cold?

Left shift when pt is hypothermic!!
High SVR
Platelet dysfunction when cold
Stress response and catabolism
Impaired renal function
Decreased drug metabolites
Poor wound healing
Increased incidence of infection

Why do patients with spinal anesthesia lose heat?

vasodilation and altered perception of temp in the blocked dermatones

What is the purpose of BIS?

to reduce patient awareness, there are a higher incidence of recall with hearts. titrate drugs, so less drug used and a faster wake up time. Sedation is 65-85 and general anesthesia is 40-65

Why use salter?

when pt is deep with anesthesia it can be a helpful monitor. You can move it to your mouth if pt is a mouth breather.

Why use a peripheral nerve stimulator?

All pts using long acting NMRB. When you have no twitch is when it is the best time to intubate. All patients getting NMRB should be tested with a tetnus and TOF

Where are nerve stimulator placed?

Adductor pollicis for ulnar and the orbicularis oculi for facial nerve.

What should be considered when you see twitches when using the orbicularis oculi?

The orbicularis oculi recovers from neuromuscular blockade before the adductor pollicis.

What could also happen with the orbicularis oculi?

Make sure you have the electrodes over the facial nerve because it can cause the muscles to twitch

What is special about a precordial stethoscope?

earliest detection of respiratory issue because you could hear a circuit disconnections. Make sure you have on left side of patient.

What can you see on the visual screen on the anesthesia machine?

TV, CO2, inspired and expired gases, FiO2, capnography, EKG, pulse Ox, Aline, CVP, Swan

When do you place an aline?

based on a patients history, surgical procedure, expected blood loss

Urinary catheters

This is the only reliable way of monitoring urinary output. Should maintain 0.5ml/kg/hr. Longer than 2hr cases and expected fluid shifts.

What is the risk of a catheter?


Positioning for patients

Any procedure over 1hr make sure they have padding.

Table turning considerations

Think about tube connections and taping of the tube. Make sure the monitors will end up on the side the CRNA is on. CHECK BREATH SOUNDS everytime the table is turned.

What is the only continuous record of the intraop course?

Charting. It is not uniform from provider to provider but try as best you can to put down most vital information

What is the basic core information that must be documented?

patient identification, provider information, equiptment checks, minimal monitors, anesthesia techniques, medications, intake and output, procedural data, parameters measured

What fluid is required intro-operatively to replace?

basal requirements, preop deficits, third space loss, blood loss, transcellular fluid loss

An essential condition of the anesthetized state is....


How can we measure unconsciousness?

response to stimuli. If no stimulus is applied, nonresponsiveness can be induced by deep sleep, boring lecture, 2% iso.

What is the distinguishing factor for unconsciousness?

differential in stimulus that penetrates nonresponsiveness and rouses brain to conscious perception.

What is the order of loss of response?

2) Formation of implicit and explicit memories
3) Purposeful movement
4) Ventilation (loss of RR and apnea)
5) sudomotor (tearing and sweating)
6) Hemodynamics

What are the components of anesthesia?

amnesia, analgesia, LOC, muscle relaxation

Volatile anesthetics do what?

hypnosis, but have minimal analgesic effect

Opiates get rid of your hemodynamic response to noxious stimuli

before movement

Hypnotics ablate movement response to noxious stimuli before...

hemodynamic response

What increases or decreases BIS number?

increase with ketamiine and opioids lower BIS

What is associated with a BIS of less than 60?

the probability of awareness and responsiveness to surgery are very low. This is associated with general anesthesia

How do you assure amnesia?

1) premedicate patient with amnestic agent, particularly if clinical situation suggests light anesthesia might be required.
2) Measure and document ET concentration of volatile anesthetic minimally every 15 minutes.
3) ask surgeon if there has been change on their field if you see CO2 goes up.

Assuring analgesia with regional cases

1) patients typically awake enough at incision and are able to communicate pain
2) if relief is not adequate: block may need more time to work or the patient may need to be converted to deep sedation or general anesthetic

What are considerations for sedation cases?

1) keep track of local anesthetics
2) B3, Li5, R4
3) ask surgeon to give more local

What are considerations before the end of case?

have all drugs ready for emergence, have oral airway in before the patient wakes up so they don't bite tube, if they have a full stomach then do an awake extubation RSI,
for plastics do a deep extubation

When giving medication...

open the IV and then return to the maintenance rate. DO NOT INFUSE ENTIRE BAG!!

What is included in the break report?

Past medical history, anesthetic plan, surgical plan, important airway information, fluid/blood loss, complications, allergies, and ask if they need any more information

What are some intraop complications?

1) accidents during maintenance phase due to a lack of vigilance
2) human error causes most anesthesia related deaths
3) most adverse complications are respiratory

What are the common intra-op complications?

PVC's after surgical stimulation, patient moving, bronchospasm, tachycardia, bradycardia, hypotension, hypertension, bleeding, allergy, power outage.

Have a plan for every complication

1) use ambu bag if electricity goes out
2) have a plan for every complication possible
3) take care of the immediate problem
4) always label syringes

What are factors complications associated with human errors?

1) inadequate preparation
2) inadequate machine checkout
3) preop eval
4) haste in preparation
5) Inadequate experience and training
6) Environmental limitations
7) Poor communication with surgeon
8) physical and emotional factors fatigue and personal problems

Complications in the OR

1) unrecognized breathing circuit disconnection
2) mistaken drug administration
3) airway mismanagement
4) anesthesia machine misuse
5) fluid mismanagement
6) IV line disconnection

Why is O2 beneficial?

small increases can increase paO2, decrease PONV, and decrease infection

Low Flow system O2

if you are okay with pt having entrained air, it supplies less than the total inspired volume of O2 needed by the patient because it supplements it with room air

What does the FiO2 depend on?

1) reservoir for O2
2) the oxygen flow rate
3) the patient's ventilation pattern
4) O2 device must fit properly

A low flow system...

depends on effort and rate of the patient. Greater than normal tidal volume and/or more rapid respiratory rate reduces the inspired concentrations of fiO2.

You would use a low flow system if...

minute ventilation was 8-10ml/min, RR less than 20, 800cc or less, or if the patient is not in resp distress. For patients who are not profoundly

Nasal Cannula

-1-6 L/min, each L increase is an increase in FiO2 by 4%

Simple mask

not as comfortable, does not have valve, 35-60% O2 with 5-8L/min flow
-Rate should always be at least 5 L/min to avoid re-breathing
-Not as comfortable as NC and may not be as tolerated

Partial re-breathing

-Valveless system with a reservoir bag 50-60% at 10L/min
-Valves are off and air is entrained

Non rebreathing mask

-Includes unidirectional valve and reservoir bag
-Inhaled FiO2 is close to 100% when 10L/min is utilized
-Difficult to get a good enough mask fit to assure no room air.
-Increased flows can cause GI bloating and skin breakdown

Face tent

-Passive flow of O2 could be a risk and start a fire
-flow rate 4-8L/min 30-55%
-Utilized in the eye room, post nasal plastic surgery

T piece/ Trach mask

1) Similar to regular masks but bypassing of the naso & oropharynx DOES NOT allow for air entrainment
2) This can cause a decrease in FiO2 unless a sufficient reservoir is utilized

High Flow

Flow of O2 will override passive flow, these systems have a high flow rate and reservoir capacity adequate to provide the total inspired volume to the patient. Can give an exact FiO2 which can range from 24-50%. Venturi mask compare to a perfume bottle, force is high.

Why is giving high O2 to COPD patients a problem?

They breathe by hypoxic drive and should receive O2 at precise FiO2. PaO2 is 60-70 generally and SaO2 is 96%. ABG sat on blood vs sat on probe tend to make sure not getting too high on O2.

Absorption Atelectasis

Giving O2 over period of time. The air we breathe has nitorgen which keeps our alveoli open. When you get rid of N, it causes alveoli to shink. This can happen quickly

Oxygen toxicity

Takes more time for this to affect patient. 10-20hr can cause toxicity if you are giving 100%. 50-60% can cause O2 toxicity at 20-40hrs. Free radicals and cellular breakdown. O2 mediated breakdown of alveolar capillary membrane which can lead to ARDS

Broncho Pulmonary dysplasia

Causes eye injury and lung injury with high amounts of O2.

ROP retinaopathy of prematurity

O2 promotes disorganized vascular proliferation and fibrosis. This can happen when O2 is given without justification. Retinal detachment and partial blindness. PaO2 50-80, don't strive for 100

High V/Q

Air is entering but there is low perfusion.

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