1
Q
NORA =
A
Non operating room anesthesia
2
Q
AANA standards of care: I
A
Patient’s rights: Autonomy, privacy, safety
3
Q
AANA standards of care: II
A
Pre-anesthesia assessment/evaluation
Also includes:
-K (BMP)
-Coags
-EKG
-METS
4
Q
AANA standards of care: III
A
Patient specific plan
(Complete anesthetic plan
-Legal representation
-Healthcare team
-PACU/ICU?)
5
Q
AANA standards of care: IV
A
Informed consent
(Needs to happen before the case/anesthesia unless pt unable to consent AND delaying care would endanger life/limb (emergency))
6
Q
AANA standards of care: V
A
Documentation
Accurate, timely, legible
7
Q
AANA standards of care: VI
A
Equipment
(Verify it is actually there and functioning properly)
8
Q
AANA standards of care: VII
A
Plan/modification of plan
9
Q
AANA standards of care: VIII
A
Patient positioning
(includes the entire surgical team)
10
Q
AANA standards of care: IX
A
Monitoring/alarms
(oxygenation, ventilation, CV status, thermal regulation, neuromuscular response should always be audible)
11
Q
AANA standards of care: X
A
Infection control policies
(one syringe, one needle, one patient, one time)
12
Q
AANA standards of care: XI
A
Transfer of care
(general anesthesia needs appropriate recovery)
13
Q
MET =
A
Metabolic equivalents of Task
14
Q
What is the equivalent of 1 MET?
A
O2 consumption at rest which is approximately 3.5 ml O2/Kg/Min
15
Q
T/F: the CRNA provides anesthesia care until the responsibility has been accepted by another anesthesia professional
A
T
16
Q
What is the max silence for alarms according to AANA standards of care?
A
2 minutes
17
Q
What are the 2 Post anesthesia recovery scoring systems? What are they used for? How many components does each have and how many points are they worth? What are the relevance of these points?
A
- Modified Aldrete scoring system: d/c from phase 1 to phase 2 PACU
- Post anesthesia discharge scoring system: d/c from phase 2 to home
They each have 5 components that are worth 2 points each
You need a score of 9 or higher to be discharged
18
Q
What are the components of the Modified Aldrete scoring system? (5)
A
- Respirations
- Oxygen saturation
- Consciousness
- Circulation
- Activity
19
Q
What are the ASA guidelines for NORA patients? (12)
A
- Reliable O2 & back up supply
- Suction
- Scavenging system if gases are used
- Resuscitation bag capable of FI02 of 0.90 (Abu bag)
- Adequate drugs, supplies, equipment
- Adequate monitoring equipment for a basic anesthesia
- Electrical outlets, isolated electric power/circuits with ground fault interruptions with access to emergency power
- Sufficient space
- Emergency cart with defibrillator, drugs, etc
- Reliable two-way communication
- Observation of all applicable building/safety codes and facility standards
- Post anesthesia management (PACU)
20
Q
What are the components of the postanesthesia discharge scoring system? (5)
A
- Vital signs
- Surgical bleeding
- Activity and mental status
- Intake and output
- Pain/nausea/vomiting
21
Q
What’s the difference between conscious sedation and GA?
A
Consciousness:
Responsiveness: purposeful response
Airway: no intervention
Spontaneous ventilation: adequate
CV function: maintained
GA:
Responsiveness: unarousable
Airway: intervention often require required
Spontaneous ventilation: frequently inadequate
CV function: may be impaired
22
Q
MAC =
A
Minimum anesthetic care
23
Q
Levels of sedation: minimum (2)
A
- Responsive to verbal commands
- Anxiolytic
24
Q
levels of sedation: moderate (2)
A
- Response to verbal/tactile stimulation
- Depressed level of consciousness
25
Levels of sedation: deep (2)
1. Response to painful stimulation
2. Independent ventilation may be impaired
26
Describe general anesthesia
The loss of consciousness and the loss of the how many ability to respond purposefully
**AN ETT IS NOT REQUIRED FOR IT TO BE GA**
27
What are patient factors that might require anesthesia what procedures outside of the OR? (10)
1. Anxiety/panic disorders
2. Cerebral palsy
3. Seizure disorders
4. Pain
5. Acute trauma
6. Increased in a cranial pressure
7. Significant comorbidities
8. Extreme ages (children/elderly)
9. Drugs/alcohol additions
10. Emergent or routine procedures outside of the OR
28
What are common procedures in radiology/IR? (6)
1. Endovascular tx
2. Radiofrequency ablations
3. TIPS: transjugular intrahepatic portosystemic shut
4. Angiograms
5. MRI
6. CT scan guided biopsies
29
What position is TIPS performed in?
Prone (sometimes)
30
What procedures are considered endovascular? Where are they performed?
1. Cerebral aneurysms
2. Abdominal aneurysms
3. Transjugular intrahepatic portosystemic shunt (TIPS)
They are performed in radiology/IR
31
Cerebral aneurysm repairs are _______ invasive procedures. What do they do in the procedure?
Minimally
In endovascular catheter is advanced through the femoral or radial artery to the cerebral circulation --> aneurysm filled with a detachable platinum coil to close it off and prevent bleeding or rupturing by clotting/scarring to prevent aneurysm rupture.
32
What are the anesthesia recommendations for cerebral aneurysms? (4)
1. GETA
2. Large bore IV
3. VA/propofol/precedex (based on patient)
4. A-line (may need to manipulate BP/ETCO2)
33
What are the complications for cerebral aneurysms? (3)
1. Aneurysm rupture/dissection
2. Contrast hypersensitivity --> anaphylaxis
3. Groin hematoma
34
Describe the procedure for an abdominal aneurysm repair (3)
Minimally invasive
Uses a catheter through a vessel to insert a synthetic graft placed over catheter wire to prevent bleeding or rupture of the aneurysm
Provides non aneurysmal lumen to prevent aneurysm rupture
35
What are the anesthesia recommendations for an abdominal aneurysm? (6)
1. GETA
2. Large bore IV
3. A line
4. Heparin, ACCTS, protamine
5. Foley
6. Controlled mild hypotension
36
What are the complications of an abdominal aneurysm? (2)
1. Rupture/dissection of the aneurysm
2. Contrast sensitivity --> anaphylaxis
37
What are the 3 concepts for provider radiation exposure? Which is most important?
1. **Distance** <-- most important
2. Shielding
3. Time
38
TIPS or ___________ is decompression of _______ circulation in patients with ___________ (2) who has failed medical therapy.
Transjugular intrahepatic Portosystemic shunt
Portal
1. Portal hypertension
Or
2. G.I. bleeds
39
T/F: TIPS can correct existing liver damage
F
It cannot correct existing liver damage but can prevent further portal HTN
40
Where is the catheter/stent placed with the TIPS procedure?
Through the **internal jugular vein**
41
What are the comorbidities seen with patients getting the TIPS procedure? (7)
1. Recent G.I. bleed
2. Hepatic encephalopathy (confused)
3. Ascities
4. Pleural effusion
5. Alcoholic cardiomyopathy
6. Coagulopathy
7. Decreased protein binding
42
What are the anesthesia recommendations for the TIPS procedure? (7)
1. GETA
2. RSI (dt full stomach & ascities)
3. Large bore IV
4. A line
5. Volume replacement - albumin, PRBCs
-need type & cross
6. Try to avoid drugs metabolism by liver
7. Provider radiation protection
43
Interventional cardiology is also considered ______
Cath lab
44
What are common Cath Lab procedures? (4)
1. Electrophysiologic procedures
2. Cardioversions
3. TEE
4. TAVR
45
EPS/EPA =
Electrophysiology study/ablation
46
What is an Electrophysiology study/ablation used for?
Identification/ablation of dysrhythmias caused by aberrant conduction pathways
47
What are the pros of ablations? (2) Cons? (3)
Pro:
1. Minimally invasive
2. 60–85% curative on 1st attempt
Cons:
1. Lengthy procedure (2-6 hrs)
2. Uncomfortable
3. May induce Vtach/Vfib intraop
48
What are the anesthesia recommendations we should have for electrophysiology studies/ablations? (7)
1. Consider if you want/need sedation vs GA
-Gas suppresses myocardial conduction
-Propofol has minimal intererence
2. **External defibrillation pads are a must**
3. Non-magnetic equipment
4. **Anti-arrhythmic held**
5. Specific catheter concerns:
They will puncture through the R to L atria -- ensure normal hemodynamics
6. Foley (dt duration of procedure)
7. XR protection
49
T/F: TEE can only be done with cardioversion
F
Can be done w/ or w/o cardioversion
50
What do you use a TEE/cardioversion for? (2) What pathologies are commonly associated with this?
To convert someone from:
1. Afib
2. Aflutter
And to make sure they dont have clots in the atria before the cardioversion
Pathologies:
1. HTN
2. CHF
3. Valvular dz
4. Cardiothoracic sx
51
When are TEEs/Cardioversions most successful?
With Afib/flutter < 7 days duration
52
What medication must we not give with cardioversion? Why?
Lidocaine (or any Na channel blocker)
The heart may not start/restart after cardioversion
53
What is the amount of Jules for cardioversion for an adult?
200 J
54
Anticoagulation therapy: Vitamin K antagonists
Action:
Laboratory monitoring:
Food interaction:
Reversal agent:
Action: Antagonizes: vitamin K & decreases factors II, VII, IX, X
Laboratory monitoring: INR required frequently
Food interaction: Cabbage, cauliflower, leafy
Reversal agent: Vitamin K; FFP
55
Anticoagulation therapy: Direct thrombin inhibitors: Dabigatran (Pradaxa)
Action:
Laboratory monitoring:
Food interaction:
Reversal agent:
Action: Antagonizes thrombin to prevent fibrinogen from forming fibrin
Laboratory monitoring: dTT
-Last dose of drug?
Food interaction: None
Reversal agent: d/c
- II, IX, X
- II, VII, IX, X
- prothrombin complex (PCC)
56
Anticoagulation therapy: Factor Xa inhibitors:
Rivaroxban (Xarelto), Apixaban (Eliquis), Edoxaban (Savaysa)
Action:
Laboratory monitoring:
Food interaction:
Reversal agent:
Action: Prevents cleavage of prothrombin to thrombin
Laboratory monitoring: specific anti–X assays
-last dose of drug?
Food interaction: none
Reversal agent: D/C
-II, IX, X
-II, VII, IX, X
-prothrombin complex (PCC)
57
What are anesthesia considerations for TEE/cardioversion? (5)
1. Nasal cannula usually sufficient
2. Bite block (prevent biting on TEE)
3. Propofol to loss of gag/reflex (want them to keep breathing on own)
-Versed/ketamine an alternative
4. No lidocaine or Na channel blockers
5. Be prepared for multiple attempts with cardioversion
58
TAVR =
Transcatheter aortic valve replacement
59
TAVR is an option for what type of patient?
Option to surgical aortic valve replacement for patient with aortic stenosis
60
Who is a candidate for transcatheter aortic valve replacement (TAVR)? (4)
1. Symptomatic
-any age
-high surgical risk
2. Symptomatic
-predicted post–TAVR survival of > 12 months
3. Symptomatic
- greater than 80 yo
4. Younger
-Life expectancy < 10 yrs
61
What are anesthesia recommendations for transcatheter aortic valve replacement? (8)
1. GA
2. Can have TEE usage
3. Muscle relaxant
4. Large bore IV
5. A line
6. Defibrillator
7. Type & crossed
8. Heparin, ACT, protamine
62
What are common endoscopy procedures? (3)
1. Esophagogastroduodenoscopy (EGD)
2. Colonoscopy
3. Endoscopic retrograde cholangiopancreatography (ERCP)
63
What are indications for an EGD/colonoscopy? (7)
1. Biopsy
2. Foreign body retrieval
3. Esophageal varices
4. Feeding tubes
5. Removal of polyps
6. Dx of cancer
7. Dx of G.I. bleed
64
What is the position for EGD/Colonoscopies?
Lateral
65
What are the anesthesia considerations for EGD/Colonoscopies? (2)
1. Biflow nasal cannula usually sufficient
2. Typically sedation but exceptions are:
-Foreign object/esophageal obstruction
-active bleeding/vomiting
**use GETA** dt full stomach
66
ERCP which means ___________ is used to Dx/Tx __________ (2) disorders. What pathology are common in these patient populations? (3)
Endoscopic retrograde cholangiopancreatography
1. Biliary
2. Pancreatic
Pathologies:
1. Biliary stenosis
2. Jaundice
3. Common duct stones
67
What is the position for ERCP?
Prone with head turned to the side
68
What are anesthesia considerations for ERCP? (4)
1. Pts have extreme comorbidities
2. **GETA**
3. Medication selection:
-glucagon
-no/minimal narcotics
-antipyretics
4. Appropriate PACU
69
Sphincter of Oddi Medications & dosages (5)
1. Glucagon 2mg
2. Naloxone 40 mcg
3. Atropine 0.2 mg
4. Nalbuphine 10 mg
5. NTG 50 mcg
70
ECT =
electroconvulsive therapy
71
What are indications for ECT? (4)
1. Bipolar disease
2. Schizophrenia
3. Extreme depression
4. Suicidal behavior
72
Electroconvulsive therapy induces _________ & causes a release of ________. What is the treatment regiment for this?
Tonic chronic seizures
Neurotransmitters
Tx:
3x a week for 12 weeks then weaned
73
What are the physiological responses that you will see from ECT? (6)
1. Initial parasympathetic activity -->
2. Followed by 10-20 mins of sympathetic stimulation
3. Incontinence
4. Myalgia (2-7 days)
5. HA
6. Emergence agitation/confusion
74
T/F: you cannot be pregnant and do ECT
T
75
What are the anesthesia considerations for ECT? (11)
1. **GA** (can be intubated or not)
2. Need ambu bag
3. **Bite block**
4. **Atropine/Glyco** (initial PNS response)
5. Anectine (Sux) & Propofol
6. Caffeine
7. Hyperventilate (help avoid seizures)
8. Protect extremities (dt seizures)
9. Have Ativan, Haldol on standby (in case pt go manic)
10. Tx HTN w/ short acting BB (esmolol)
11. D/C IV in PACU (psych risk)
76
T/F: dental office and clinics anesthesia has the same standards but you mostly bring your own equipment
T
