Anesthesia

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
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 not 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.Pt needs emergent surgery but ate 3 hours ago, what do you do?   spinal anesthesia or popliteal, or if they are DM2 with neuropathy you don’t need anything, they have no feeling!
12.What does epinephrine do to local anesthetics?
  • shortens the onset and prolongs the effect of local anesthetic
  • also increases dosage available by prolonging the effect and lowers bleeding
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
What systolic and diastolic levels are worrisome in pre-op?
  • >180 systolic
  • >110 diastolic
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
What medication do you continue on the day of surgery?  ACE inhibitors, Beta-blockers, and Angiotensin II blockers
What medication do you discontinue for surgery?  Diuretics, Warfarin, Heparin
What laboratory testing do you obtain before surgery?
  • Complete blood count (CBC)
  • Basic Metabolic panel (BMP)
  • Coagulation test (PT/INR)
  • Chest radiograph (CXR)
  • Electrocardiogram (ECG)
  • Urinalysis
What orders do you place the night before surgery?
  • NPO after midnight
  • AM meds taken with sip of water
  • Hold oral hypoglycemia meds
  • Morning vitals
  • Begin IV 1/2NSS (normal saline solution)
  • Begin IV antibiotics (Ancef, Vancomycin if needed)
  • Consult with Anesthesia (General, MAC, etc.)

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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?
  • pain
  • temperature
  • touch
  • noxious 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 15cc
  • 1% Lido with epinephrine is 50cc
  • 2% 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 35cc
  • 0.5% 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/kg
  • with epinephrine is 7mg/kg
24.Benefits of adding epinephrine?
  1. shortens onset of anesthesia
  2. prolongs effect
  3. vasoconstriction
  4. slows 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, hallucinations
  • CNS 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-S3
  • Tibial nerve – L4,L5, S1-S3
  • Common Peroneal – L4-S2
  • Superficial Peroneal – L4-S1
  • Sahenous (L3, L4)
31.What is in an ankle block? (6 nerves)
  1. tibial n.
  2. saphenous n.
  3. deep peroneal n.
  4. medial dorsal cutaneous n.
  5. intermediate dorsal cutaneous n.
  6. sural n.
32.Mayo block?
  1. saphenous n.
  2. deep peroneal n.
  3. medial plantar n.
  4. 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

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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)
  • Warfarin
  • Heparin
  • Oral 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 maneuver
  • Bag-valve mask ventilaiton
  • removal of foreign objects
  • Oropharyngeal airways (moves tounge and soft tissue obstruction
  • cuffed endotracheal tube
  • Laryngeal mask (LMA)
  • cricothyrotomy (emergecy cut)
19.Types of sedation?
  • General Anesthesia
  • Conscious sedation
  • Monitored anesthesia care (MAC)
  • Regional anesthesia
  • Local anesthesia
20.General Anesthesia?
21.Conscious Sedation?
  1. conscious but semi-asleep
  2. able to respond to physical and verbal effects
  3. typical dose is 2mg Midazolam & 2mg Morphine
  4. used for minor procedures, combined with local anesthesia
22.Monitored anesthesia care (MAC)?
  1.  like conscious sedation but taken to deeper level of sleep
  2. not aroused easily, still feels pain
  3. anesthesia team must be present
  4. monitor oxygen, vitals, heart rate
23.Regional Anesthesia? Includes:

  • ankle,
  • MAYO,
  • popliteal, and
  • spinal 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 aneshtesia care unit (PACU)?
  1. Nausea and vomiting
  2. urinary retention
  3. Fevers or chills
  4. Pain management
  5. any digit or foot discoloration (white toes)