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University of Missouri - St. Louis
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Anesthesia agents derived from Amides should not be used in these pts b/c of the metabolism and excretion?
Liver disease or Kidney disease
Anesthetic based esters are mostly used in this profession currently?
What factors affect your ability to anesthetize an area?
diffusibility- alters onset of time
vasodilation- decreases potencey & duration
Protein binding- increases binding = increased duration
Lipophilicity- more lipophilic= more potent
How do infections alter the pH of tissue?
they make the tissue more acidic (lower pH)
What is lidocaine also used for which makes systemic effects of anesthesia unnerving?
If a pt has a hx of hypersensitivity to an amide or ester, how do you numb them?
If RXN to only 1 then use the other
or if it was an anaphylaxis RXN- pretreatment from allergist, benadryl, benzyl ETOH (injected)
What are some systemic absorption issues that are common in anesthetic agents?
CNS Toxicity-Depression or Excitement
Peripheral Vascular Action
Hypotension / HTN
List some topical anesthesia agents
TAC- Teteracaine, adrenaline, cocaine
LET- Lidocaine, Epinephrine, Tetracaine
EMLA- Eutectic Mixture of lidocaine & Prilocaine
What local anesthetic agents can be used on broken skin?
This can be used for extreme reflux, sore throats, or hand foot mouth?
Viscous Lidocaine 2%
On what procedures should you use LET or TAC?
On what procedures do you use Ice or Ethyl Chloride?
On what procedures would you use EMLA?
What are the disadvantages of local anesthetic?
-Distorts wound edge anatomy- b/c fluid causes swelling
-Over injecting- causing compartment syndrome
What type of anesthetic would you use for a toenail removal or dental pain, NERVE BLOCKS or REGIONAL blocks?
Bupivacaine- long acting (usually use w/ a short acting)
What is the max dose of anesthetic you can use for most
30 cc / mL (lidocaine)
Where should you inject the anesthetic on a wound?
In the wound- b/c the nerves are already desensitized
Through the skin
When would you
inject anesthetic into a wound?
How can you decrease the pain when injecting anesthetic?
decrease needle size
decrease pressure - use smaller syringe
Inject sub-q rather than intradermally
Buffering- dilution w/ Na bicarb 10:1
Why add epi to the anesthesia agent?
-reduces systemic absorption (allows for more to be used, but can increase volume)
When would you not want to use Epi w/ anesthetic agents?
-nose, ear, penis, digits, flap lac
-pts w/ peripheral vascular disease- HTN, Arteriosclerosis, diabetes
-predisposition to exaggerate conditions (adrenilin make cond. worse) - Addison's, hyperthyroid, myxoma
What is a field block?
wall of anesthetic solution injected across the nerve pathways crossing the operative field
What is a nerve block?
injection of anesthesia near nerve branch supplying sensation to that area
How many digital nerves are going to a finger?
What travels w/ nerves?
Arteries & Veins
List the digital blocks
-3 sided ring block- inj needle on dorsal aspect parallel to skin, perpendicular to nerve (hyperextend digit to see tendon) inj pulling out
-4 sided ring block- top and bottom just like 3 sided
-Transthecal block (goes thru flexor tend. sheath)
-Unilateral digital block
-Limited palmer or plant/dorsal
What type of block is used for nail procedures?
List the type of Facial blocks
-supraorbital- inject parallel to skin
-supratrochlear- medial to lateral canthus (eye)
-Infraorbital- thur lip
-Mental Nerve- dental block
-Inferior Alveolar- parallel to k9
-Posterior Superior Alveolar- coranoid process carotid is right behind nerve can cause seizure
Specific arm blocks
-at wrist or elbow
When do you call plastics to close a wound?
List lower extremity blocks
Superficial Peroneal Nerve
Deep Peroneal Nerve
What are the goals of general anesthesia?
Maintain physiological hemostasis
Types of anesthesia
Monitored anesthesia care (MAC)
How are necessary lab draws for a surgery determined?
AGE IS NOT A FACTOR
Most drugs have an affect on anesthesia but should be continued? T/F
ASA classifications of pts?
Healthy individual w/ no systemic problems
C2: Mild systemic dis well controlled (HTN, DM)
Poorly controlled systemic disease thatlimits daily activity (CAD, uncontrolled HTN or DM)
Severe systemic disease that is a constantthreat to life (ESRD, persistent angina, CHF)
Moribund with little chance of survival(ruptured aneurysm, hemorrhage)
Brain dead organ donor.
example ASA 3E
Pre-op Anesthesia Meds
Benzos- Anxiety, Amnesia- Versed
Anticholinerginics- decrease secretions Atropine, Reglan,Robinul
H2 Blockers- increase gastric pH- pepcid, zantac
H1 Blocker- prevent allergic RXN's Benadryl, Steroid
Antiemtic- phenergran, zofran, anzemet
list the 3 parts
keeping pt from moving during surgery
-Thiopental-don’t use as much b/c it takes a long time to metabolize
-not as big of a drop in BP as
Who is rapid induction done on?
hx of reflux
- overall shorter period of unprotected airway, risk of hypotension
What is the benefit of a slow induction?
less chance of hemodynamic change
- downside longer time w/ unprotected airway (greater risk of aspiration)
What is maintained during the maintenance portion of anesthesia?
Amnesia,analgesia, and hemodynamic stability
What is MAC and who wants to use it?
Monitored Anesthesia Care- pt is under via IV meds no airway secured only nasal canula for O2
dr's in office for Minor procedures- danger b/c no eyes on the airway
What meds are used in MAC?
When should you consider MAC?
Benefits of MAC
more hemodynamically stable
Less post op N/V
What is the difference b/t spinal and epidural anesthesia?
Spinal- bathes spinal tissue in lidocaine or marcaine- injected into spine mixing w/ CSF- feel nothing
Epidural- in epidural space not as dense a form- they can feel something like pressure
When should you use a spinal or epidural?
lower extremity procedure
How do you test a pt for Malignant Hyperthermia?
Caffeine-halothane contracture test
How can you correct a malignant hyperthermia rxn?
Ca++ CB- stop the release of Ca+= stop the release of ACh= stop the depolarization of the muscles
inherited skeletal muscle d/o precipitated by exposure to inhaled anesthetics +/- succinylcholine and decamethonium. tx is dantrolene a CCB
continuous muscle contractions
what is the mallampati classification?
relates tongue size to pharyngeal size- how many structures can you see in a pts open mouth
Class I - uvula, soft palette, fauces, & pillars showing
Class II- soft palate, fauces, & uvula
Class III- uvula, little bit soft palate
Class 4- nada showing
What info does the thyromental distance prodive?
the angle of the laryngeal axis for compared to pharyngeal axis - used for intubating
< 3 fingers breadths or < 6 cm = more difficult
List the grades of Laryngoscopic view?
I- view entire aperture
II- just posterior portion
III- only epiglottis
VI- only the soft palate
What type of ventilator is better for COPD pts?
Pressure control- same volume less pressure than volume controlled
What is PEEP and what is the benefit of it?
Positive End Expiatory Pressure
increase functional residual capacity
keeps aveoli open longer= better O2 sats
What criteria must be meet to remove an assistant airway?
normal respir. rate 12-20
pH > 7.34
SpO2 > 90% w/ FiO2 40% or < than 5cm H2O PEEP
Who is controlled mechanical ventilation used for?
pts w/ no spontaneous effort
What local anesthetics are ester based?
What local anesthetics are amide based?
How are esters excreted?
by the kidney
what type of ions are lipophilic charge or uncharged?
How does this impact what we chose to use?
most products are mixed but only the uncharged ions make it thru the tissue to impact the nerves
Systemic absorption of local anesthetic agents can cause what rxn's?
CNS toxicity- depression or excitement - seizures w/ dental blocks
Peripheral Vascular action
Hypotension or HTN
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