106 terms

Anesthesia

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Anesthesia is a combo of what 3 things?
amnesia, analgesia, neuromuscular blockade
Members of the anesthesia care team
Anesthesiologists, CRNA, CAA
lack of memory of the intraoperative and preoperative period
amnesia
Rate of recall in all surgeries
0.0068%
Surgeries that have a higher risk of recall
obstetric, trauma/emergency, or cardiac surgeries
Patient factor that increases chance of recall in surgery
depression
5 general categories of analgesia
Local anesthetics
parenteral narcotics
NSAIDs
Neuraxial blockade with epidural or spinal anesthetics
regional nerve blockade
Analgesia selection depends on? (4)
type of procedure
underlying medical conditions
risk associated with the method
patient preference
using multiple types of analgesia to improve pain control and decrease side effects is called?
multimodal or balanced analgesia
keeps the patient still during surgery
neuromuscular blockade
MOA of neuromuscular blocking agents
block Ach receptors at the NMJ of striated muscle
Neuromuscular blockade doesn't affect what type of muscle?
smooth or cardiac
in is important to have _______ around when using neuromuscular blockades
reversal agents
how can immobility be obtained without neuromuscular blockade?
combo of volatile anesthetics, analgesics, benzos
3 phases of general anesthesia
1. induction
2. maintenance
3. emergence
Most often drug used for induction of general anesthesia
propofol
Benefits of propofol for induction
short half life
less nausea, antiemetic
risks of propofol
reduces BP and CO (dose dependent)
People we should be worried about using propofol in?
elderly
HF
CKD
CAD
Propofol causes this side effect in 16% of patients
hypotension
When using propofol, it is advised to keep BP within _____% of the patients normal
20
Etomidate is used for?
induction of general surgery
Adverse effects of Etomidate
causes a burning sensation
increased nausea post-op
inhibits cortisol synthesis
What induction drug should we be careful about in people with Addison's or people on chronic steroids?
etomidate
Benefits of etomidate
DOES NOT cause CV effects
In a patient with hypotension/HF/CAD we might consider using what drug for induction?
etomidate
In a patient with asthma or other lung disease, we might consider using this induction agent
Ketamine
Ketamine should be avoided in patients with?
CAD
Adverse effects of ketamine
increases BP, HR, CO
can cause hallucinations, vivid dreams, delirium
Benefits of ketamine for induction
provides significant analgesia
preserves respiratory drive and causes bronchodilation
What can we add to ketamine to reduce CV and mental side effects
benzodiazepines or propofol
Depolarizing neuromuscular blocking agent
succinylcholine
Non-depolarizing neuromuscular blocking agent
Rocuronium and pancuronium
Onset of Depolarizing neuromuscular blocking agent
30 seconds
Onset of Non-depolarizing neuromuscular blocking agent
2-5 minutes
Duration of Non-depolarizing neuromuscular blocking agent
20-60 minutes
Which lasts longer, succinylcholine or Rocuronium?
Rocuronium
We should avoid using what drug in patients with malignant hyperthermia or pseudocholinesterase deficiency
succinylcholine
avoid using succinylcholine in who?
patients with malignant hyperthermia or pseudocholinesterase deficiency
crush/burn injuries
drug that causes muscle fasciculations prior to muscle paralysis
succinylcholine
succinylcholine can cause a transient rise in?
potassium
avoid this med in patients with crush/burn injuries
succinylcholine
due to transient rise in K
duration of succinylcholine
5-10 minutes
#1 cause of anaphylaxis in the OR
neuromuscular blockers
#2 cause of anaphylaxis in the OR
abx
#3 cause of anaphylaxis in the OR
latex exposure
Maintenance of general anesthesia is generally achieved with?
volatile or IV anesthetics
Volatile inhalation anesthetic agents
Sevoflurane, Desflurane, Isoflurane
Sevoflurane, Desflurane, Isoflurane
Volatile inhalation anesthetic agents
Volatile inhalation anesthetic agents are used for?
maintenance of general surgery
Volatile inhalation anesthetic agents are used with what in general surgery?
IV analgesics like fentanyl
Risks of Volatile inhalation anesthetic agents
dose-dependent decrease in MAP due to decrease in SVR
QT prolongation
decrease TV, increase PaCO2
Hepatotoxicity
Benefits of Volatile inhalation anesthetic agents
ease of delivery, reliable recovery, overall excellent safety, modest cost
this is used in combo with Volatile inhalation anesthetic agents
nitrous oxide
nitrous oxide is used in combo with?
Volatile inhalation anesthetic agents for maintenance stage
Advantages of nitrous oxide
quick and reliable recovery, less myocardial depression than volatile agents
disadvantages of nitrous oxide
increased risk of n/v, emergence hypoxia, rupture of blebs
inactivate vit B12
This anesthetic drug may cause significant neurodegeneration in a patient that is vitamin B12 deficient
nitrous oxide
Be careful using nitrous oxide in who?
someone vitamin b12 deficient
IV anesthetic agents used in maintenance general anesthesia
propofol and remifentanil
propofol and remifentanil
IV anesthetic agents used in maintenance general anesthesia
Benefits of IV anesthetic agents used in maintenance general anesthesia
significantly less nausea than volatile anesthetics
which has more nausea? sevoflurane or IV remifentanil
sevoflurane
Risks of IV anesthetic agents used in maintenance general anesthesia
increases time to extubation
increases time to cognitive function
higher cost
T or F? IV anesthetic agents used in maintenance general anesthesia as opposed to volatile inhalation anesthetics result in an increased time until discharge and MMSE
False
Side effects of emergence
autonomic hyper-responsiveness
HTN, tachycardia, bronchospasm, laryngospasm
How to manage autonomic hyper-responsiveness from emergence
short acting narcotics, BBs, lidocaine
Neuraxial anesthesia includes?
spinal or epidural anesthesia
Neuraxial anesthesias are usually used for what type of surgeries?
abdominal or lower extremity surgeries
Insertion of spinal anesthesia
lower lumbar into the subarachnoid space
spinal anesthesia can be used in combo with what?
general anesthesia to decrease surgical time and blood loss
insertion point of epidural anesthesia
epidural space with a catheter
T or F? you can leave in epidural anesthesia post op
true
most common complication of Neuraxial anesthesia
post-dural puncture headache
Which type of Neuraxial anesthesia has an increased risk of post-dural puncture headache
epidural anesthesia
Complications of Neuraxial anesthesia
post-dural puncture HA
spinal hematoma
epidural abscess
What is done to decrease risk of spinal hematoma from Neuraxial anesthesia
stop anti platelets and anticoags
Peripheral nerves block are most commonly used when?
procedures of the extremities
Types of peripheral nerve blocks
brachial plexus
sciatic nerve
femoral nerve group
Benefits of peripheral nerve block
anesthesia without the hemodynamic instability associated with general anesthesia or neuraxial blockade
Risks of peripheral nerve block
local inflammation
local infection
vascular puncture
Bier Block is another name for?
intravenous regional block
Bier block is usually used for?
hand or forearm surgery
bier block
lidocaine is infused
Complications of bier block
systemic lidocaine reaction>incoherence, seizures, cardiac arrest
skin discoloration or petechiae
thrombophlebitis
compartment syndrome
nerve damage
MAC
monitored anesthesia care
Does MAC involve complete loss of consciousness?
no
Components of MAC
analgesia and anxiolytics
which is usually considered deeper sedation, MAC or conscious sedation
MAC
Examples of conscious sedation
EGD/colonscopy with versed and fentanyl
ability of patient in conscious sedation
maintains respiratory drive and consciousness, can follow commands and maybe respond
conscious sedation is a type of?
MAC
Endotracheal intubation is more difficult when?
obese, small jaw or mouth opening, limited extension of cervical spine, limited mandibular flexibility
Adverse effects/risks of endotracheal intubation
sore throat
aspiration of gastric contents
damage to teeth or trachea
In endotracheal intubation the tongue blade is often inserted where?
vallecula
Laryngeal mask airway placement (LMA)
supraglottic airway
LMA stands for?
laryngeal mask airway
Side effects/risks of LMA
sore throat
oropharyngeal trauma
aspiration of gastric contents more likelikey than endotracheal
LMA is general avoided in who?
people likely to aspirate gastric contents
obesity, large hiatal hernia
Brain monitoring during anesthesia is used for?
monitor depth of anesthesia to ensure patient doesn't recall
Complications of peripheral IV catheter placement
thrombophlebitis
extravasation
catheter infection
how long can we leave in a peripheral IV catheter
3-4 days
central venous Cather is placed where
subclavian or jugular vein
when is central venous catheter used?
monitor volume status
administer vasoactive medications or irritating meds of periphery
Purpose of arterial catheter insertion
continuous arterial blood pressure
evaluate ABGs
Uses for pulmonary artery cath
measures CO, pulmonary artery pressure, pulmonary vascular resistance, and artery occlusion pressure