1.Patient has an emergency surgery to be performed, he ate 3 hours ago, what type of anesthesia do you do? | Spinal, because under general anesthesia they will have aspiration pneumonia. Or if they are DM2 with neuropathy you don’t need anything, they have no feeling! |
2.What anesthesia causes arrhythmia? | succinylcholines |
3.Why do we add epinephrine to local anesthesia? | 1)prolongs duration, 2)it shortens onset, 3)decreases toxicity |
4.Which gas anesthesia CAN be used with a patient with hx of malignant hyperthermia? | Nitrous oxide |
5. What is the reverse drug for a benzodiazepine? | Flumazenil |
6.Patient has asthma what ASA classification does he fall under? | ASA II – mild systemic disease under control such as DM, HTN, smoker, and asthma |
7. What is an ASA III include? | CHF, CKD, and uncontrolled mild diseases |
8.What dose of Epinephrine do you give for anaphylatic shock | 0.25cc |
9.How far away do you need to be for sterile field? | 12 inches |
10.Which anesthetic most likely causes an allergic reaction? | Procaine, it is an ester drug type* |
11.Which gas anesthesia CANNOT be used with a patient with hx of malignant hyperthermia? | Isoflurane, Sevoflurane, Halothane, Succinylcholine |
12.What does epinephrine do to local anesthetics? |
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13.Patient with hypertension which med continue the day of surgery? | beta blockers (atenolol) |
14.Patient has rheumatoid arthritis, having surgery tomorrow, what medications do you need to continue day of? | Prednisone |
15.What are spinal anesthesia complications? | Difficulty urinating, nerve damage, hypotension, headache, hematoma |
16.Which one of these is a benzodiazepine? | Chlorodiazepoxide, Clonazepate, and anything ending in -am |
17.What level of spinal anesthetic is placed? | L3-4, L4-5 |
18. RA patient forgot to take her corticosteroid the morning of surgery, what can occur to her? | Hypotensive crisis |
20.In a 3rd interspace mayo block, which 3 nerves are blocked? | Medial plantar nerve, Lateral plantar nerve, and Intermediate dorsal cutaneous nerve |
21.What structure do you pierce in spinal? | Dura Mater |
22.What anesthetic causes hallucinations? | Ketamine, aka special K |
23.During the start of surgery the patient experiences increase in temperature, and heart rate, he is having Malingnant hyperthermia, what do you do? | administer Dantrolene |
24.What is the dose of epinephrine for anaphilaxsis? | 0.3-0.5 at 1:1,000 |
25.What is the toxic dose of bupivacaine | 175 mg/dl |
26.True or False: hypertension increases the risk of stroke during surgery? | True |
27.A patient presents post op day #3 with a fever of 101.1F, what is the most likley cause? | Wound infection. Remember wind,water,walk, wound, wonder-drug. |
28.In a 65 year old Male what study do you want to get? | Chest x ray and EKG especially after 55 years of age |
29.Patient has Addison’s disease taking 35mg of prednisone, what instructions do you tell them the day of surgery? | Take normal dose; it should be continued both during and after surgery. At <30mg your surgeon will give you additional doses at the start of your procedure. This is because long-term steroid therapy suppresses the adrenal gland, which manufactures the steroids your body needs. Inadequate steroid levels during surgery can lead to hypotension or low blood pressure |
30.What systolic and diastolic levels are worrisome in pre-op? |
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31.Pre-op doing physical exam but Right upper sternal border has weird sounds during systolic. You want to know whether the sound occurs in systolic vs diastolic so you check to see if the sound occurs at the same type as the BP pulse in the patient’s wrist (systolic) but it does not, it occurs on a separate time interval. In addition the murmur can be heard across the heart and radiates down. What is diagnosis? | Aortic regurgitation |
32.What medication do you continue on the day of surgery? | ACE inhibitors, Beta-blockers, and Angiotensin II blockers |
33.What medication do you discontinue for surgery? | Diuretics, Warfarin, Heparin |
34.What laboratory testing do you obtain before surgery? |
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35.What orders do you place the night before surgery? |
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Local Anesthesia
1.Name the nerve fiber types. | A fibers (large/myelinated)B fibers (medium/myelinated)C fibers (small/unmyelinated)delta fibers |
2.What are A fibers? | both large and myelinated, allow rapid conduction of motor ans sensory. |
3.What fibers most vulnerable to injury? | A fibers, from pressure or lack of oxygen from tourniquet |
4.What are B fibers? | slower conduction and smaller diameter, compared to A fibers |
5.Which fibers provide autonomic function? | B fibers (unique) |
6.What are C fibers? | the slowest pain and autonomic function, unmyelinated and small diameter. Transmit chronic pain |
7.What are delta fibers? | unmyelinated that signal sharp acute pain |
8.What is the spinothalamic tract signal? | paintemperaturetouchnoxious stimuli |
9.What will happen at a brain stem lesion? | pain sensor deficit on contralateral side |
10.What will happen at a spinal cord lesion? | ipsilateral proprioception and touch deficit |
11.What is a nerve impulse mechanism of action? | a cell reaches threshold, depolarizing by Na/K ATP pump. Sodium enters and potassium exits reaching -55mV. When depolarized a signal is transmitted and returns to -70mV |
12.How does local anesthesia function? | inhibits depolarization of nerve by mostly blocking Na influx, and some potassium current. |
13.How does the anesthesia enter cell? | it is a weak base, the unpronated form diffuses across a cell membrane. The lower pH inside cell makes the anesthesia be pronated and causing it to stay inside the cell. |
14.Why do you NOT place local anesthesia near a wound infection? | It won’t work. The infection creased a low pH, the anesthesia is pronated outside cell and cannot diffuse in to cell to work. The acidity level makes it ineffective. |
15.Where do you inject if a patient has a wound infection? | Instead add local anesthesia proximal to nerve fibers. |
16.Max dose of Lidocaine? | 1% Lidocaine plain is 30 mL (30cc)2% Lido plain is 15cc1% Lido with epinephrine is 50cc2% Lido with epinephrine is 25cc |
17.Max dose of Carbocaine? | 1% carbocaine is 30cc (30 mL)2% carbocaine is 15cc |
18.Max dose of Marcaine? | 0.5% Marcaine plain is 35cc0.5% Marcaine with epinephrine is 45cc |
19.How are esters metabolized? | Hydrolysis by plasma pseudocholinesterase. Esters have a higher chance of allergy reaction than amides* |
20.Amides metabolized? | By liver and excreted in renal |
21.What is the half-life of Lidocaine? | 1.5 – 2 hours |
22.Bupivacaine (marcaine) half-life? | 3.5 – 4 hours |
23.Dose per kilogram of lidocaine? | plain is 4mg/kgwith epinephrine is 7mg/kg |
24.Benefits of adding epinephrine? | shortens onset of anesthesiaprolongs effectvasoconstrictionslows rate of absorption |
25.Most common side effect of epinephrine? | tachycardia |
26.Max dose of epinephrine? | 1mg or 100mL of a :100,000 |
27.Systemic effects of central nervous system? | CNS excitation: tingling around mouth, tremor, dizziness, seizures, hallucinationsCNS depression: (with higher exposure of Lidocaine) causes lethargy, slurred speech, respiration depression |
28.Systemic effects of cardiovascular system? | Lidocaine is an antiarrhythmic agent- slows conduction, causes bradycardia, coma, or death |
29.What is side effect of prilocaine? | *Methomoglobinemia, reduction of hemoglobin for oxygen transport |
30.What nerves are in sciatic, tibial, common peroneal, superficial peroneal, and saphenous nerve block? | Sciatic nerve – L4,L5,S1-S3Tibial nerve – L4,L5, S1-S3Common Peroneal – L4-S2Superficial Peroneal – L4-S1Sahenous (L3, L4) |
31.What is in an ankle block? (6 nerves) | tibial n.saphenous n.deep peroneal n.medial dorsal cutaneous n.intermediate dorsal cutaneous n.sural n. |
32.Mayo block? | saphenous n.deep peroneal n.medial plantar n.medial dorsal cutaneous n. |
33.What is the order of nerve functions affected after local anesthesia? | Pain> Temperature> Touch> proprioception |
34.What is a hematoma block? | Used in ER for ankle fractures. Aspirate blood in ankle joint, then insert local anesthesia. Once numb close reduce ankle |
General anesthesia
1.What is hypertension? | blood pressure greater than 140/90 mmHg in (2) consecutive times. |
2.When do we stop surgery for severe hypertension? | BP > 200 mmHG. Antihypertension medication is taken up to day of surgery |
3.What medications are not taken on day of surgery? | Diuretics (causes electrolyte imbalance)ACE inhibitors (causes hypotension)WarfarinHeparinOral hypoglycemic (Metformin) |
4.What is Malignant hyperthermia? | Rare complication caused by anesthesia that causes muscle rigidity, increase carbon dioxide production, tachycardia, an increase temperature. Dantrolene Sodium and cold cover sheets are supportive treatment therapy. |
5.What medications are used in general anesthesia? | Benzodiasepines (Valium, Versed)Propofol (Diprivan)Opioids (fentanyl)inhaled nesthetics |
6.What is mechanism of action (MOA) of benzodiasepines? | Inhibit gamma aminobutyric acid (GABA). Has hypnotic, sedative, anticonvulstand, and muscle relaxing effects. raid onset of 30 seconds |
7.True or False: Does Diazepam (Valium) produce analgesia? | FALSE, the benzodiasepines do NOT! Its a short lasting drug class to decrease anxiety |
8.What is the adult dose of Midazolam (Versed)? what is reversal drug? | 1 to 2 mg IV. Reversed with flumazenil |
9.What is MOA of propofol (Diprivan)? | Affects GABA ad NMDA receptors. Most common IV for General aneshtesia, has hypnotic effects. It is popular because it is predictable, since tested to much. |
10.Dosage of propofol? Side effects? | Adult dose 2mg/kg IV push. Must watch for respiratory depression. Has 1% purified egg phospholipid (think egg allergy) |
11.What is Ketamine? | Class of propofol, short acting hypnotic agents, produces unconsciousness and analgesia. Onset 10-15 seconds. |
12.Side effects of Ketamine? | Increases heart rate, BP and known to cause vivid dreams/ illusions (think Special K). Good to give to pediatric patients! |
13.Etomidate acting effects? | Short acting hypnotic, no analgesic effects. Causes nausea and vomiting. Has adrenal suppression, causing deaths in ICU! |
14.Name (3) opioids: | Morphine,fentanyl, sufentanil, alfentanil |
15.What is most common opioid? | Fentanyl, has good stability with no respiratory depression. has 100x more potent than morphine |
16.What drug is reversal for opioids? | Naloxone |
17.What are some Inhaled anesthetics? | Fluorinate, isoflurane, deslfurane. Effects are loss of conscious, amnesia, an decrease reflexes. |
18.Airway management? | head-tilt/chin-lift maneuverBag-valve mask ventilaitonremoval of foreign objectsOropharyngeal airways (moves tounge and soft tissue obstructioncuffed endotracheal tubeLaryngeal mask (LMA)cricothyrotomy (emergecy cut) |
19.Types of sedation? | General AnesthesiaConscious sedationMonitored anesthesia care (MAC)Regional anesthesiaLocal anesthesia |
20.General Anesthesia? | |
21.Conscious Sedation? | conscious but semi-asleepable to respond to physical and verbal effectstypical dose is 2mg Midazolam & 2mg Morphineused for minor procedures, combined with local anesthesia |
22.Monitored anesthesia care (MAC)? | like conscious sedation but taken to deeper level of sleepnot aroused easily, still feels painanesthesia team must be presentmonitor oxygen, vitals, heart rate |
23.Regional Anesthesia? | Includes:ankle,MAYO,popliteal, andspinal blocks |
24.How do you achieve spinal anesthesia? | it is a subarachnoid block, by inserting anesthesia in subarachnoid space |
25.What spinal do you insert at? | L3-L4 or L4-L5, below the distal spinal cord |
26.What most common medication used in spinal block? | Bupivacaine |
27.What is the potential space in spinal block? | the epidural space where the ligamentum flavum but not deep to dura mater |
28.In spinal block do you insert needle deep to dura mater? | NO, do not insert deep to dura mater only to subarachnoid space! |
29.What are side effects of spinal block? | urinary retention, hypotension, infection in spinal fluid! |
30.A patient just ate 1 hour ago but need an emergency forefoot amputation, what can you do? | Spinal block, or if he is DM type 2 with neuropathy you could do TMA with no anesthesia, he doesn’t feel anything remember! |
31.After surgery, what do you check in Post anesthesia care unit (PACU)? | Nausea and vomiting, urinary retention, Fevers or chills. Pain management, any digit or foot discoloration (white toes) |