What is minimal vs moderate vs deep sedation vs GA
minimal has complete control
moderate has purposeful response to stimulus, deep has some loss of airway and spontaneous ventilation
GA has inadequate ventilation and possible impairment of Cards function.
How to check for mallampati
M1: uvula completely visible, tonsils pillars and faces
M2: Uvula 2/3 is visible and soft palate
M3: <1/3 of the uvula is visible
M4: soft palate not visible
Good thyromental distance and what does it mean
3 fingers breaths or 6.5cm , it means that patient can displace tongue during DL
Way to test mandibular protrusion
Have them bite their upper lip, graded on how far they can go
BMI. too big and too small challenges, what is a large neck circumference
Too big they are more difficult to intubate, have more parapharyngeal fat, more prone to desaturation, those to skinny are more likely to be dehydrated or have hypokalemia,
normal is 18.5-25, overweight is 25-30, 30-39 is obese, 40 050 is morbidly obese
neck circumference of over 43 cm is difficult intubation
Who needs laboratory tests
The EKG for elderly over 65, history of substance abuse or eating disorder, labs on people with renal disease, liver failure, coagulopatthies,
finger stick on diabetics before and after
Good test of of capacity, how many mets under is perioperative risk,
4 mets
Name the ASA classifications
1, no functional deficiets
2. casual drinkers or mild systemic disease ( obesity 30-40) well controlled DM/HTN, mild lung disease, pregnancy
3. Severe systemic disease that limits capacity but not incapacitation, hepatitis, alcohol dependence or abuse,
implanted pacemaker, moderate reduction
of ejection fraction, ESRD undergoing reg-
ularly scheduled dialysis, history
(>3 month
4. Severe disease that is a treat to life.
For example, recent (< 3 months) MI, CVA,
–
TIA, or CAD/stents, ongoing cardiac isch-
emia or severe valve dysfunction, severe
reduction of ejection fraction, sepsis, DIC,
ARD, or ESRD not undergoing regularly
scheduled dialysis
5. Patient who is not expected to survive without operations
6. Braindead waiting for organ donor purposes
NPO Guidelines
2 clears
4 breast mild
6 light foods and formula and non human mild
8 greasy foods and heavy meals
What are the properties of propofol
what does it do, how does it do it, what systems are affected, how is it metabolized, what are the doses
Who would u be cautious using it in
Potentiates gaba depressing the reticular system. Its a sedative hypnotic
It can be used with precautions against patients with allergies to egg, soy, or peanuts
Its depresses the cardiac system, can lead to bradycardia or systole, inhibits normal baroreflex to hypotension.
Respiratory depressant, it also increase bronchodilation for bronchospasms
Fast onset due to high lipid solubility
Metabolized by the liver and excreted by the kidneys.
Reduces ICP and CBF
Anti convulsant and anti emetic
Pain in injection and muscle twitching
Caution:
elderly use less (20 percent of) and slower
Cardiac patients do not use
Allergic patients
Dose for GA:
Sedation: intermittent bolus is 20-50 mg, 25-100 mcg/kg/min for infusion
Ketamine
NMDA antagonist, it causes dissociative analgesia, has analgesia, amnesia, and hypnotic. It causes cataplexy and dissociates the limbic from the thalamic system.
It is lipid soluble, processed by the liver and out the kidneys, can have active metabolite norketamine
Increase ICP, CBF
Increase cardia output and hypertension
Doesn’t affect ventilation but is a bronchodilator.
Emergenc phenomenon is hallucinations but pretreated with benzos.
Not recommended for patients that are cardiac or with intracranial pathology
Increase in salvation, can cause laryngospasms in kids
Sedation is .2–.5mg/kg intermittent boluses
Versed
Benzodiazepine it is a sedative hypnotic
It is a GABA potentiator
has anterograde amnesia
Does not really effect the cardiac (a little decrease) or the ventilatory system, in conjunction with fentanyl it has more profound decreased response to CO2.
rapid onset,
Anticonvulsant, reduces ICP and CBP
Metabolized in the liver and excreted in the urine
Side effects is allergic reactions and hiccups
Sedation is .1-.4 mg / kg
Flumazenil
competitive antagonist at the GABA, initial dose is .2 over 15 seconds can give .2 every minute, max dose is 1 mg, will respond most likely at the .6-1 mg mark
Fentanyl
Works on the U receptor, analgesia and sedation
Fast acting without loss of consciousness
Nausea vomitting due to chemoreceptors in the medulla oblongota,
Some cardiac depression from bradycardia
Respiratory depression, decreases ventilation rate, can have laryngeal and chest wall rigidity.
Side effects:
Constipation
pruritics
Nausea vomitting
tolerance and dependence,
hypothermia
shivering
Naloxone
Competitive antagonist
.4-2mg IV initial dose, repeated at 2-3 minute intervals up to total dose of 10 mg
Peds is .01 mg/kg up to .1 mg/kg
Succinylcholine and what are the risk demographic when using it
Depolarizing non competitive agent at cholinergic receptor, fast acting in about 40 seconds last around 2-3 minutes. Used for larynx spasm about 20mg . Risk is malignant hyperthermia. Risk with kids is hyperkalemia from ducchennes muscular dystrophy. Can also have prolonged action with patients with pseudocholinesterase deficiency. normal intubation dose is .3-1.1mg/kg
Repeated doses can lead to asystole or Brady, can be countered by pretreatment with atropine
Rocuronium
Nondepolarizing cholinergic receptor blocker, similar onset speed 40secs to succ, reversed by sugammandex a cycle dextrin that is selective, 1;1 RATIO. INTUBATION DOSE IS .45-.6 MG /KG
Nasal cannula, how much is 1 l/m increase in percentage and what is the calc
4% so plus 4 to 20 for each percent, can go up to 4 L/M
how about for simple face mast
also 4% per L can take up to 35-65 percent should be 8-12 L/M
non rebreather
5 % per L can take 60 to 100 percent should be 6-15 L /m
Risk factors for bag mask ventilation difficulty
Atrophic mandible, beard, obesity, large tongue, age over 55, edentulism, history of snoring
LMA allows via PPV at pressure up to what
20
steps of a Cric, and what do for kids under 6, when to convert to teach
- Feel for the cricothyroid membrane, make a horizontal incision down to the membrane, place ETT tube a 6 or a 4 track, ventilate and inflate cuff
kids need need decompression, needs to convert to trash at 72 hours
Pediatric airway difference and what is the calculation for endotracheal tube size
age/4 + 4
10 differences:
Tongue is larger
Occiput is bigger so more likely to be tilting head, C1-3 is the fulcrum dont over extend
Cricoid is a funnel and the narrowest part and susceptible to edema so use uncured
Epiglottis is big and floppy
Pediatric airway is smaller
obligatory nose breather
shorter trachea which means dislodgment
larynx higher and more anterior at C23 not C67
Large tonsils and collapsible airway
