Induction, maintenance, emergence
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| describe what happens in the holding area pre-op | 1. ID by surgeon, nursing, and anesthesia 2. check ID band - ask pt for DOB 3. paperwork must be done before pt is moved from holding area 4. pt may receive sedation for anxiolysis 5. taken to OR via stretcher
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| how is pt transfered from stretcher to OR table | do not let patient move until there is one person on each side and bed is locked; anesthesia must say "the bed is locked"; pt moves themselves to table; DOCUMENT!! Nurse places safety straps and padded arm rests (45*)
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| explain how monitors are placed before start of procedure | BP cuff; place face mask near pts face to preoxygenate; place SPO2, EKG, BP, BIS, temp
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| what airway equipment do you need set up before induction | place airway equipment at head of bed: ETT, laryngoscope handle and blade, oral airway and tongue depressor, suction
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| describe the proper order of steps for induction | inject induction agent (propofol, barb, etomidate, high dose opioid, etc.); hold mask gently, check for loss of lid reflex; tape eyes closed; mask ventilate patient
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| if you are unable to ventilate the patient what should you do | change patient head position; change arm position; place oral/nasal airway
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| after you know you can mask ventilate patient, describe the sequence of events for intubation | inject neuromuscular blocking agent; wait until effect (PNS); intubate; confirm with proper methods (listen, ETCO2, condensation in tube, airway compliance when bagging)
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| after intubation; describe the proper steps to finish | place patient on ventilator and turn vent ON; lower O2 flows, turn on VAA; secure the ETT; insert esophageal stethoscope; insert soft airway if needed; check pt final position; HIGH FIVES ALL AROUND!!!
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| an anesthetic must consist of ...(5) | 1. unconsciousness/hypnosis/sedation 2. analgesia (pain) 3. amnesia (memory) 4. hemodynamic stability 5. control of movement
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| what is general anesthesia | induction of a state of unconsciousness with the absence of pain
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| anesthesia performed under general occurs in 4 stages (Guedel stages of anesthesia) | analgesia; excitement; surgical plane; anesthetic crisis
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| describe stage 1 of guedel | analgesia: patient experiences analgesia but remains conscious and able to communicate
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| describe stage 2 of guedel | excitement: pt may go bat-shit (delirium) and become violent; BP increases and becomes irregular; RR incr; may vomit or laryngospasm; effects may be bypassed by premedication and punching him in the face; avoid noxious stimuli
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| describe stage 3 of guedel | surgical stage: in which surgery can be performed; RR is regular; constriction of pupils; stopping of involuntary movement; loss of vocalization
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| describe usual pupil size and reaction to light for each stage of guedel | 1. normal 3-4mm; moderate constriction to light (1-2 mm) 2. normal 3-4 mm; pinpoint to light 3. normal moderate constriction 1-2 mm; no change to light 4. dilated/blown; no change to light
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| stage 3 of guedel is divided into how many planes | 4
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| describe stage 3, plane 1 of guedel | light anesthesia - pt has a lid reflex; swallowing and airway reflexes intact; regular respirations and good chest movement
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| describe stage 3, plane 2 of guedel | loss of blink reflex; pupils are fixed in one position; respiratory rate is regular (comfortable for surgery)
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| describe stage 3, plane 3 of guedel | loss of chest movement, and ab muscles; shallow and assisted breathing
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| describe stage 3, plane 4 of guedel | no chest movement, and diaphragmatic breathing; deep surgical anesthesia
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| describe stage 4 of guedel | anesthetic crisis; respiratory arrest, circulatory collapse, death
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| what are the generally accepted induction dosages for the average adult in proper induction sequence | 1. versed 1-2mg 2. fentanyl 50-100 mcg 3. lidocaine 100 mg 4. propofol 150-200 mg 5. succs 160 mg or roc 50 mg
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| will you see all stages of guedel | nope - some of the stages can occur quickly and may not all be observed
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| in what guedel stage can ventilation occur (after loss of lid reflex) | stage 3, plane 2
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| what is the dose, onset and duration of rocuronium | 0.4-1.2 mg/kg, onset 45s-3m, duration 25-30m
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| what is the dose, onset and duration of vecuronium | 0.1 mg/kg, onset 1-2m, duration 45m
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| what is the dose, onset and duration of succs | 1-2 mg/kg, onset 45s, duration 3-5m
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| when is the right time to intubate? | 1. establish neuromuscular blockadge (0/4 on TOF) 2. adequate depth of anesthesia to blunt hemodynamic response 3. hemodynamic status must be maintained (BP/HR/sats) 4. BIS level ~ 60
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| what type of injuries can occur with arm positioning | ulnar nerve and bracheal plexus injuries
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| what injuries can occur with oral airways and mask ventilation | oral airway can cause pressure on mucosa; mask ventilation can cause pressure necrosis and nerve damage
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| what are the goals during maintenance phase | analgesia; unconsciousness; skeletal muscle relaxation; control o sympathetic response; balance medication while maintaining hemodynamics and vital functions
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| what are 4 considerations of fluid management during maintenance | 4-2-1 rule; hourly maintenance; blood loss; urine output
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| when preop planning of maintenance plan, what things should you consider | VAA vs. TIVA; narcotics?; NMBD?
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| when should you be planning emergence | before induction
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| what criteria must pt meet before giving reversal | at least 1 twitch present on TOF to give reversal
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| what is the dosage for neo and glyco | 0.035 - 0.07 neo 7 mcg/kg glyco usually ends up being 1cc:1cc
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| what the doses for toradal and zofran | toradal 30 mg IV/IM for pain; zofran 4 mg IV for PONV
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| what is the criteria for extubation | MACawake; adequate spontaneous respirations; Vt > 7-10 cc/kg; sats > 95%; NIFs > 20 cmH2O; follows commands - open eyes, hand grasp and release, head lift > 5 seconds
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| what are indications for RSI: | full stomach, pregnant, GERD, trauma, difficult airways, you're on call, its after 5pm, you need to poop, they just delivered the chinese food, etc.
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| when should cricoid pressure be applied during RSI | while NMBD (succs) is being injected
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| should you mask ventilate during RSI | noooooo yo
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| what are ways to maintain temperature regulation in the OR | bear hugger; foam noses on breathing circuit to maintain warmth and humidity; fluid warmer; IV line underneath bear hugger; warm the room (peds); warm blood products
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| what can be damaged in lower extremities from poor positioning | femoral, obturator and sciatic nerve injuries in lower extremities
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| what type of head rest maintains neutral position | shea head rest
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| who is ultimately responsible for positioining in the OR | YOU the anesthetist
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| what are the most common types of positioning | supine, prone, lateral, lithotomy
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| what does edentulous mean | no teeth you f'in hillbilly
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| how do you get mac ratio | mac awake / mac
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| potent anesthetics have a mac ratio of | 0.3-0.4 (des, sevo, iso)
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| weak anesthetics have a mac ratio of | 0.6 (N2O)
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| what are the most common VAAs used for inhalational induction | sevo, halo
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| when would you use mask induction (inhalational induction) | peds, newborns, special needs adults and children; developmentally normal children, adults, anxious adults
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| what are sedative hypnotic INDUCTION doses for propofol, pentothol, etomidate, ketamine, versed and fentanyl according to his screwed up ppt that doesnt match the book | propofol 1.5-2.5 mg/kg Na TPL 1-1.5 mg/kg etomidate 0.3 mg/kg ketamine 2-4 mg/kg versed 0.07-0.15 mg/kg (0.1-0.4 mg/kg in book) fentanyl 50-100 mcg/kg
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| does emergence go through guedel steps in reverse order? | si
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