Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NU 568
Exam 2 - Induction, Maintenance, and Emergence from Anesthesia
| Question | Answer |
|---|---|
| A successful anesthetic consists of what four characteristics? | Anesthesia, analgesia, akinesis, hemodynamic stability |
| Why were the 4 stages of Guedel developed? | To provide a better understanding of anesthesia for paraprofessionals during WWI |
| General anesthesia occurs in what 4 stages? | Analgesia, excitement, surgical plan, anesthetic crisis |
| In Stage I of anesthesia, the patient (does/does not) experience pain and (can/cannot) communicate. | does not, can |
| Stage II of anesthesia is called _________. | Excitement |
| The patient in Stage II of anesthesia may experience ________ or become ________. | Delirium, violent |
| What physiologic parameters are increased in Stage II? | BP and RR |
| What are two dangers of Stage II anesthesia? | Emesis, laryngospasm |
| How can the dangers of Stage II anesthesia be avoided? | Premedication |
| What should be avoided in the Excitement stage of anesthesia? | Noxious stimuli |
| Stimulation of the ____________ may break a laryngospasm. | Larson's notch or laryngospasm notch |
| Which stage of anesthesia is referred to as the Stage of Disorientation? | Stage I |
| What are the 3 planes of stage I anesthesia, as described by Artusio in 1954? | 1)No amnesia or analgesia 2)complete amnesia, partial analgesia 3)complete amnesia and analgesia |
| What stage of anesthesia is characterized by irregular breathing and breath-holding? | Stage II |
| What are two other names for Stage II anesthesia? | Stage of Excitement or Stage of Delirium |
| Stage II of anesthesia occurs from ___________ to ___________. | loss of consciousness, onset of automatic breathing |
| The 3rd stage of anesthesia is characterized by how many planes? | 4 |
| Which reflexes are present in the 1st plane of Stage 3 anesthesia? | Lid, swallowing, airway |
| What is the state of respirations and chest movement in the 1st plane of Stage 3 anesthesia? | Regular respirations w/good chest movement |
| Which reflexes are lost in the 2nd plane of Stage 3 anesthesia? | Eyelid, laryngeal |
| Characterize the pupils and respiratory rate for the 2nd plane of Stage 3 anesthesia. | Fixed pupils, regular RR |
| It is safe to begin surgery in what stage of Guedel's levels of anesthesia? | Plane 2 of Stage 3 |
| How is breathing affected in the 3rd plane of Stage 3 anesthesia? | Shallow assisted breathing w/loss of chest and abdominal movement |
| What is the deepest plane of the 3rd stage of anesthesia and what is it characterized by? | 4th plane is the deepest surgical anesthetic stage, characterized by apnea (no chest mvt., no diaphragmatic breathing) |
| In which stage of anesthesia does anesthetic crisis occur and what is it characterized by? | Stage 4 - will see respiratory arrest and circulatory collapse |
| What is the most common means of induction in adults? Children? | Adults=IV, children=inhalation |
| The anesthetic plan is influenced by what 3 factors? | PMH, surgery, preference |
| When does preoxygenation and de-nitrogenation begin? | Upon entering the OR |
| T/F: All stages of Guedel will be clearly identified as a patient progresses from one stage to the next. | F - some may be brief, may not see some at all |
| What audible sound characterizes the Excitement stage of anesthesia? | squeaky breathing or crowing |
| What are two different devices used to monitor heart and lung sounds during a case? | esophageal and precordial stethoscopes |
| What two things must be done prior to giving any medications for induction? | Preoxygenation and VS |
| Which reflex is lost in Stage II of anesthesia? | Eyelash |
| When are manual ventilations assumed? | After loss of lid reflex in Plane 2 of Stage 3 anesthesia |
| What are 3 NMBDs that are commonly used for induction? | Succinylcholine, rocuronium, vecuronium |
| What is the dose, onset, and duration of succinylcholine? | 1-1.5mg/kg, 45s, 3-5min |
| What is the dose, onset, and duration of rocuronium? | 0.4-1.5mg/kg, 45s-3min, 25-30min |
| What is the dose, onset, and duration of vecuronium? | 0.08-0.3mg/kg, 1-2min, 45min |
| What is scientific evidence of the readiness for intubation? | TOF 0/4 |
| After intubation, where should the anesthetist auscultate besides over the lungs? | epigastrum |
| Who has ultimate responsibility for patient positioning? | Anesthetist |
| What are the 4 common surgical positions for patients? | Prone, supine, lateral, lithotomy |
| What position does the Shea headrest place the patient in? | Sniffing position |
| When are the patient's eyes taped? | Prior to masking |
| What are the most common nerve injuries related to patient positioning? | Brachial, ulnar |
| What are lower body nerve injuries associated w/positioning in anesthesia? | femoral, obturator, sciatic |
| What is more stimulating, intubation or incision? | intubation |
| The maintenance plan for anesthesia should involve the consideration of what 4 types of medications? | volatile anesthetics, IV anesthetics, narcotics, NMBDs |
| What is the 4-2-1 rule? | Calculation for maintenance rate of IVF: 4cc for the 1st 10kg, 2cc for the next 10kg, 1cc for the remaining kg of bodyweight |
| Fluid loss could be encountered from either ________ or ________. | blood, urine |
| What are two different anticholinergics given in anesthesia and what are their doses? | Atropine 0.4mg, glycopyrrolate 0.2mg |
| What are the dose ranges for ephedrine and phenylephrine when given in anesthesia? | ephedrine 5-10mg, phenylephrine 100-200mcg |
| What are the dose ranges for esmolol and labetalol when given in anesthesia? | esmolol 5-10mg, labetalol 2.5-5mg |
| What is the purpose of a "foam nose"? | Placed on the breathing circuit to maintain warmth and humidity |
| What are 5 methods to regulate body warmth in patients? | Bair hugger, foam noses, fluid warmer, IV line placement under Bair hugger, heating the room |
| How many twitches in the TOF are required before the anesthetist is able to administer a NMB reversal agent? | 1/4 |
| What is the dose of neostigmine used for reversal of NMB? | 0.035-0.07 mg/kg |
| What is the dose of glycopyrrolate that is used in conjunction with neostigmine? | 7mcg/kg |
| THe ratio of neostigmine:glycopyrrolate usually ends up being ___________. | 1:1 |
| Identify two other adjunct medications in anesthesia and what are their respective dosages? | Toradol 30mg IV/IM, zofran 4mg IV |
| What are 6 criteria for extubation? | 1)Mac-Awake 2)adequate spontaneous ventilations 3)TV 7-10cc/kg 4)Sat >95% 5)NIF -20cmH20 6)follows commands |
| What are the 3 Commands criteria for extubation? Which one has the highest sensitivity for successful extubation? | opens eyes, sustained head raise >5 sec, hand grasp and release; sustained head raise |
| What returns first upon emergence: diaphragmatic or peripheral function? | diaphragmatic |
| Patients under anesthesia are most likely to become aware with exposure to what two types of statements? | states of emotion and passion |
| Brachioplexus strain occurs at an angle above ________ degrees. | 90 |
| Upon transfer into the OR, when is a patient allowed to move to the operating table? | when there is one person on each side and the bed is locked (confirmed verbally by anesthesia) |
| Airway equipment should be placed at __________. | The head of the bed |
| Induction agents are given while the patient is (awake/asleep). | Awake |
| The loss of lid reflex is checked (before/after) induction meds are given. | after |
| The patient's eyes are taped closed (before/after) the loss of lid reflex. | after |
| When is mask ventilation initiated? | upon loss of lid reflex with eyes taped |
| What are three measures to improve suboptimal manual ventilations? | 1)reposition patient's head 2)adjust operator arm position 3)place OPA/NPA |
| When is the NMBD injected? | Once optimal manual ventilations have been achieved, along with appropriate preoxygenation/denitrogenation |
| What are signs that indicate readiness for intubation? | 0/4 TOF, loss of eyelid reflex, fasciculations have ended (only w/succinylcholine) |
| What are two changes the anesthetist should make on the anesthesia machine after intubation? | Lower FGF and turn on inhaled anesthetic |
| RSI is indicated in what 5 scenarios? | Full stomach, pregnant, GERD, trauma, difficult airways |
| Succinylcholine is given (before/with/after) application of cricoid. | with (applied simultaneously) |
| RSI (does/does not) include mask ventilation. | does not |
| The different characteristics between barbiturates is related to differences in the carbons located at what two positions in the benzene ring? | 2 and 5 |
| How do barbiturates exert their effect? | Interacting with the inhibitory GABA system |
| What is the primary inhibitory neurotransmitter in the CNS? | GABA |
| Which channels do barbiturates affect and what do they cause? | Affect chloride channels by causing increased duration of opening |
| What does the barbiturate effect on chloride channelse create and what does this result in? | hyperpolarization, which results in inhibition of action potential |
| The keystone barbiturate is __________. | sodium thiopental |
| Barbituric acid by itself (does/does not) have CNS effects. | does not |
| How does barbituric obtain its sedative hypnotic effects? | With changes to the number 2 and 5 carbons in its molecular structure |
| Which induction agent is a carboxylated imidazole containing compound? | etomidate |
| What is unique about the solubility of etomidate? | initially water soluble w/acidic pH, then has enhanced lipid solubility with molecular rearrangement to closed ring structure after injection |
| Etomidate is highly (ionized/non-ionized) at physiologic pH | non-ionized |
| What percent of etomidate is non-ionized at physiologic pH? | 99% |
| Etomidate has a (high/low) level of lipid solubility. | high |
| Etomidate has a (high/low) level of protein binding. | high |
| What is the cause for the initial and rapid awakening effect of etomidate? | redistribution of active drug outside the CNS |
| What is the cause of prompt and full recovery from etomidate? | rapid metabolism by hydrolysis |
| What are the enzymes responsible for etomidate metabolism? | CYP and plasma esterase |
| What is the molecular portion of etomidate that undergoes metabolism and what is the byproduct? | ethyl side chain; carboxylic acid |
| Which anesthetic agent is injected as an active drug? | etomidate |
| Why does etomidate have a lower cumulative effect? | not sequestered in adipose compartment |
| What is the dose for etomidate? | 0.3mg/kg IV |
| What is the negative drawback to the use of etomidate? | adrenocortical hypofunction |
| How does the use of opioids influence the side effects of etomidate? | prevents hyperdynamic swings with DL |
| Are are post-op complications associated w/etomidate? | PONV |
| T/F: Etomidate injection is not painful. | False |
| Which induction agent has a significant relationship to PONV? | etomidate |
| When does adrenal suppression due to etomidate take effect? How long can this effect last? | 30min after injection; may last up to 24hr |
| Etomidate use may result in reduced levels of what two hormones? | cortisol, aldosterone |
| How does etomidate inhibit steroidogenesis? | blocks conversion of cholesterol to cortisol via hydroxylase inhibition |
| What is the trade name for etomidate? | Amidate |
| The adrenal system is responsible for the ___________ response in sick patients (i.e. sepsis). | stress |
| The use of etomidate may warrant supplementation with a __________. | steroid |
| In what scenario will etomidate cause profound hypotension? | hypovolemia |
| T/F: Intrarterial injection of etomidate has profound negative consequences. | False |
| How does etomidate affect histamine response and renal/hepatic blood flow? | It has no effect on histamine response and blood flow to the renal/hepatic systems |
| What physiologic function does etomidate suppress? How long does it take to recover from this? | ventilation; 3-5min |
| How does etomidate influence CBF? To what percentage does it have this effect and what does it ultimately reduce? | Decreases CBF by 35%, which decreases ICP |
| What effect does etomidate have on CMRO2? To what percentage does it have this effect? | Decreases CMRO2 by 45% |
| What does etomidate increase in the CNS? | Beta wave activity |
| Besides patients with sepsis, what other population should etomidate be used with caution in? | patients w/focal epilepsy |
| How does etomidate affect patients w/non-focal epilepsy? | capable of terminating status epilepticus |
| Which agent originally intended to be a mono-anesthetic agent? | ketamine |
| Ketamine's dysphoric effects are least common with which patients? | extremes of age |
| What are the different dosages for ketamine in mg/kg for each route of administration? | Nasal 6-10, oral 6-10, IM 3-10, IV 0.5-2, rectal 10 |
| What is the IV dose and onset for ketamine? | 2mg/kg, onset=1min |
| What is the IM dose and onset for ketamine? | 4mg/kg, onset=5min |
| The analgesic effects of ketamine mimics which narcotic? | fentanyl |
| What are 4 physiologic effects of ketamine? | amnesia, analgesia, immobility, CV upregulation |
| The molecular structure of ketamine contains a _________________ with two _______________. | cyclohexanone ring, optical isomers |
| What are the two enantiomers in ketamine? | (S-) left/(D+) right |
| What is the left enantiomer of ketamine and what are its effects? | S-; intense analgesia, more rapid recovery, less emergence reactions |
| Which induction agent is prepared as a racemic mixture? | ketamine |
| Ketamine is chemically similar to _________. | PCP or phenylcyclidine |
| Describe ketamine's lipid and protein binding qualities. | highly lipid soluble, low protein binding |
| Ketamine has brain concentrations _______ times greater than plasma concentrations. | 5 |
| Initial awakening from ketamine is related to _______________. | redistribution to non-CNS compartments |
| What type of state does ketamine produce? | dissociative state or cataleptic |
| Ketamine produces a dissociative state between what regions in the CNS? | thalamus is dissociated from the cortex and limbic systems |
| Patients who have received ketamine appear to be ____________ but are _________ of their environment. | awake, unaware |
| How does ketamine affect the eyes, corneal and light reflexes? | eyes=open, corneal and light reflexes intact |
| Presence of a nystagmic gaze indicates that a patient (is/is not) ready for discharge home. | is not |
| What are the skeletal muscle influences of ketamine prior to rendering akinesis? | hypertonus w/involuntary movement |
| What does ketamine inhibit and where does this occur? | glutamate at NMDA sites |
| What types of receptors does ketamine bind to? | muscarinic and nicotinic cholinergic receptors, opioid receptors |
| What types of ion channels interact with ketamine? | Na and Ca voltage dependent ion channels |
| Ketamine stimulates the (sympathetic/parasympathetic) nervous system. | Sympathetic |
| What effect does ketamine have on HR and BP? | increases both |
| What is ketamine's effect on oral and bronchial secretions? | Causes excessive amounts of both types of secretions |
| Ketamine is metabolized by _________ enzymes to by the process of __________. | CYP450, demethylation |
| What does the demethylation of ketamine yield? | norketamine |
| Norketamine is an (active/inactive) metabolite. | active |
| What is the level of potency of norketamine? | 1/4 that of ketamine |
| Ketamine is believed to have an agonistic effect on what type of opioid receptors? | mu |
| Norketamine is excreted in the (bile/urine). | urine |
| How does ketamine influence CBF and ICP in vented patients? | increases CBF w/o significant effect on ICP |
| What is ketamine's influence on CMRO2? | no increase |
| Which anesthetic agent plays a neuroprotective role in cerebral ischemic situations? | ketamine |
| Ketamine is a (positive/negative) inotrope. | negative |
| How is the negative inotropic effect of ketamine mitigated? | By its direct stimulation of the SNS |
| What are the CV effects of ketamine? | Increased: HR, CO, myocardial oxygen demand, BP |
| What can be used to blunt the hyperdynamic responses to ketamine? | Preadministration of sevoflurane, or periop use of short-acting betablocker |
| Ketamine may reverse dysrhythmias induced by what medication? | digitalis |
| What is the effect on the HR when ketamine is used in conjuction with local anesthetics containing epi? | dysrhythmias |
| What are the effects that ketamine has on the airway? | upper airway reflexes remain intact; induces oral+bronchial secretions, bronchodilation; increased pulmonary vascular resistance w/subsequent increase in RV workload |
| Which anesthetic agent has been successfully used in status asthmaticus due to its potent bronchodilatory effects? | ketamine |
| What medication should be given prior to admininstration of ketamine and why? | glycopyrrolate in order to offset the cholinergic effects of ketamine |
| How does ketamine affect platelets? | Causes reversible inhibition of platelet aggreation--similar to ASA |
| How does ketamine enhance muscle relaxation? | interferes with calcium ion binding |
| Ketamine (inhibits/induces) plasma cholinesterase activity. | inhibits |
| Aminophylline and theophylline are both ___________. | bronchodilators |
| Patients who receive ketamine and are simultaneously taking aminophylline or theophylline are at increased risk for ___________ and _____________. | Dysrhythmias, seizures |
| Ketamine reduces the the seizure and dysrhythmia thresholds for patients taking what two medications? | aminophylline or theophylline |
| What is the incidence of psychogenic effects of ketamine? | 5-30% |
| Psychogenic effects are most commonly seen by (women/men). | women |
| How can the psychogenic effects of ketamine be reduced? | Pre-administration of benzodiazepines or propofol |
| What is the classification of propofol? | non-barbiturate sedative hypnotic anesthetic |
| Propofol's effects are primarily exerted on what receptors? | GABA |
| The hyperpolarization of cells, as a result of propofol administration, occurs at the (pre/post) synaptic membrane. | post |
| The metabolites of propofol are mostly (active/inactive). | inactive |
| The metabolites of propofol are _______ soluble. | water |
| What is suggestive about propofol's rate of clearance? | Clearance exceeds hepatic blood flow, suggesting extra-hepatic sites of metabolism |
| What is the postulated extra-hepatic site of metabolism for propofol? | pulmonary |
| A patient is rendered unconscious at what dose of propofol? | 2mg/kg |
| Rapid and complete awakening from propofol occurs as a result of what mechanism? | Redistribution away from the brain to less perfuse tissues |
| Propofol administration experiences a significant degree of what metabolic effect? | 1st pass pulmonary uptake |
| Why is there a possible delay in the initial onset of effects for propofol? | delay d/t 1st pass pulmonary uptake |
| Propofol (does/does not) cross into fetal circulation and is (slowly/rapidly) cleared in the neonate. | does, rapidly |
| What are three reasons why propofol is the IV drug of choice for induction in anesthesia? | Rapid: induction, emergence, return of neurologic function |
| Why do pediatric patients require a larger dose of propofol? | Larger Vd, rapidly cleared |
| Propofol is found in colostrum for up to ____________ hours after admininstration. | 8 |
| How much should the dose of propofol be reduced in geriatric patients and why is it reduced? | 25-50% due to smaller Vd and reduced clearance |
| Propofol may cause a significant degree of (hypotension/hypertension). | hypotension |
| Patients in what CV state should not receive propofol for induction? | hypotension, decreased CO, hypovolemia, shock |
| ___________ and ___________ may greatly enhance the CV effects of propofol. | Benzodiazepines, opioids |
| What is the dose of propofol for sedation? | 25-100mcg/kg/min |
| What is the dose of propofol for TIVA? | 100-300mcg/kg/min |
| High dosages and long-term use of propofol may lead to __________. | propofol infusion syndrome |
| What are 5 signs of propofol infusion syndrome? | Unexplained tachycardia, metabolic acidosis, myocardial dysfunction, possibly rhabdomyolysis, possibly green urine (crystallization) |
| T/F: Propofol infusion syndrome occurs only with prolonged use. | False - Has been documented in short cases |
| Lab tests in a patient with propofol infusion syndrome may exhibit or indicate alterations in what 4 areas? | blood pH (metabolic acidosis), lactate, rhabdomyolysis, renal function |
| Which anesthetic agent has been shown to have anti-emetic properties? | propofol |
| How does propofol achieve its anti-emetic effects? | directly depresses the emetic center in the medulla oblongata |
| Subtherapeutic doses of ___________ have been successful for the treatment of PONV in the PACU. | propofol |
| In addition to anti-emetic properties, what other beneficial qualities does propofol possess? | anti-convulsant |
| Which ion channels are inhibited by propofol? | chloride ion channels |
| How does propofol affect CBF, ICP and CMRO2? | decreases CBF, ICP, CMRO2 |
| T/F: Propofol has no effect on CPP. | Large doses may decrease MAP enough to alter CPP |
| Somatosensory evoked potentials (are/are not) significantly altered by propofol. | are not |
| The use of propofol requires pre-administration of _______________ for at-risk patients. | adequate volume |
| Which reflex is depressed by propofol? | baroreceptor |
| Bradycardia and asystole associated with propofol possibly occurs due to ____________ and ___________. | sympathetic attenuation, parasympathetic dominance |
| Propofol induced patients are (more/less) responsive to atropine. | less |
| What beta agonist may need to be started to stabilize the patient induced with propofol? | Isuprel |
| What is the generic name for Isuprel? | isopreterenol |
| BONUS: Isopreterenol is structurally similar to what hormone? | adrenaline |
| What effect does propofol have on vascular smooth muscle and why? | Relaxes vascular smooth muscle d/t inhibition of SNS |
| Propofol causes decreased intracellular levels of _____________. | Calcium |
| Propofol has (positive/negative) inotropic effects. | negative |
| Propofol administered to the patient with __________ or __________ may result in a CV disaster. | LV dysfunction, hypovolemia |
| What is the incidence of apnea in patients who receive propofol? | 25-35% |
| Even without a bolus, propofol can blunt physiologic response to __________ and ________. | Hypoxia, hypercarbia |
| What should always be administered in conjunction with propofol? | O2 |
| BONUS: Why do the lungs the exhibit pulmonary vasoconstriction in hypoxic states? | To shunt blood flow to better-ventilated areas of the lungs |
| Hypoxic pulmonary vasoconstriction is (altered/intact) with propofol administration. | intact |
| T/F: It is okay to safely use 1 vial of propofol between multiple patients as long as the rubber stopper is disinfected with isopropyl alcohol. | False - vials are single patient use only |
| Unused portions of propofol should be discarded within _________ hours after opening. | 6 |
| How often should propofol tubing be replaced? | Q12h |
| It is safest to follow (departmental/manufacturer) guidelines concerning propofol administration and outdating. | departmental |
Created by:
philip.truong
Popular Nursing sets