True or False:

The scrubbed person is only sterile from the chest down to the waist level and just above the elbows to the gloves.

True

NIOSHA recommeds no more than ______ppm exposure to volatiles and ______ppm to nitrous oxide

2; 25

What is the cellular impact of nitrous oxide exposure?

-Inhibits Vit. B12 dependent enzymes including methionine synthestase (responsible for myelin formation) and thymidylate sythetase (necessary for DNA synthesis)

-Prolonged exposure can lead to bone marrow depression

-Teratogenic

The number one reason for anesthesia related morbidity and mortality

Lack of proper airway management

The division between the upper airway and lower airway is:

cricoid cartilage

Upper airway structures

Nose

Mouth

Pharynx

Larynx

What is the function of the nasal passage?

What arteries supply the nasal mucosa?

- provides large surface area to WARM/HUMIDIFY air; turbinates FILTER air

-Maxillary (sphenopalantine branch); opthalmic and facial (septal)

What is contraindicated in a cribiform plate disruption?

Positive pressure ventilation, nasal airways, nasal intubation, NG tubes

Describe innervation of the nasal passage.

What does sympathetic innervation result in?

How does anesthesia affect sympathetic innervation?

- The trigeminal nerve supplies the nasal passage; specifically the anterior 1/3 of septum and lateral wall supplied by anterior ethmoidal nerve branch and the posterior 2/3 supplied by maxillary branch via sphenoplatine ganglion.

-vasoconstriction and tissue shrinkage

- inhibits

What is the #1 cause of airway obstruction?

What is a close second and how does it cause obstruction?

Tongue

Soft palate; falls back against nasal passage and blocks air movement

Where do the following structures lie:

Nasopharynx

Oropharynx

Cricoid cartilage

C1

C2-3

C5-6

Name the 3 paired and 3 unpaired cartilages of the larynx

What is the largest unpaired?

What is the function of the arytenoids?

Paired: arytenoids, cuneiform, corniculate

Unpaired: epiglottis, thryroid, cricoid

Thyroid

Point of attachement of vocal cords, allow open/closing of cords necessary for respiration and voice

Describe sensory and motor innervation of larynx

Sensory: internal superior laryngeal (laryngeal tissue from vocal cords up) and recurrent laryngeal (mucosa inferior to vocal cords

Motor: External superior laryngeal (cricothyroid) and recurrent laryngeal

What does the right and left recurrent nerves loop around?

Right: subclavian artery

Left: aortic arch

Name the muscle that correlates with the following vocal cord actions:

1. abduction of vocal cords, opens glottis

2. adducts glottis

3. produces tension and elongates cords

4. shortens and relaxes cords

5. closes glottis and adducts

1. posterior cricoarytenoid

2. lateral cricoarytenoid

3. cricothyroid

4. thyroarytenoid

5. arytenoids

Describe the trachea

originates at inferior border of cricoid cartilage

extends to carina

10-20cm long

cricoid is only complete ring

16-20 C shaped rings

The five predictors of a difficult mask ventilation:

OBESE

Obese

Bearded

Elderly

Snorers

Edentulous

Long upper incisiors

Overbite/underbite

visibility of uvula

shape of palate

mandibular compliance

thyromental distance

length/thickness of neck

range of motion of neck/head

what are some considerations to using face masks?

all increase deadspace

has 22mm adaptor for bag to attach

correct size is important for good seal

occular trauma is a big concern

What are advantages of ETT intubation

Patent airway

Protects against blood/aspiration

PPV

Removal of tracheal secretions

Decreases anatomical deadspace

controlled oxygen delivery

route for emergency drugs

What are advantages of a MAC blade?

less dental trauma

more room for ETT

less bruising of epiglottis

less stimulating

4 common problems with laryngoscopy

blade inserts too deep/can't see structures

tongue escapes

displacing blade tip to the right in attempt to keep tongue to left

difficulty inserting blade

How much air should be put in ETT cuff?

usually 3-6ml; most importantly, to seal

What grading system is used to describe visualizaiton of larynx?

What are the grades?

cormack & lehane

1: entire laryngeal aperture

2. posterior laryngeal aperture

3. epiglottis only

4. nothing

How much cricoid pressure should be applied?

What is objective criteria for ETT extubation?

1. VC = 10ml/kg

2. Peak NIP = -20cm H2O

3. TV = 6 ml/kg

4. sustained tetanic contraction of 5 seconds

5. T1/T4 ratio of >0.7

6. PaO2-PAO2 gradient <350 torr on 100%

What are NPO fasting guidelines?

Clears : 2h

Breast milk: 4h

Formula/non human milk: 6h

Light meal: 6h

Fatty/lg meal: 8h

Who was the first nurse to specialize in nurse anesthesia? When?

Who is the mother of nurse anesthesia? What were three achievements?

Sister Mary Bernard - 1877 - St. Vincent's Hospital

Alice Magaw - widely published, performed >14,000 anesthetics without complications, mastered open drop ether technique

Who established the first school of nurse anesthesia?  When?  Where?

Agnes McGee

1909

Portland, OR

Who founded the AANA?

When?

Agatha Hodgins

1931

Describe the outcome of Frank v. South

1. medicine cannot regulate other professions

2. Hatfield (CRNA) was NOT practicing medicine

3. recognized nurse judgment involved in practice of anesthesia

Describe the outcome of Dagmar Nelson's court case.

1. She was engaged in giving anesthesia under the license of surgeon

2. She was NOT practicing medicine

When could men enter the AANA?

1947

The first certification exam was offered in ______.

Certification exams were mandated in:

1945

1978

Name the functions of the AANA

Oversees recertification, CEUs, determine recert. criteria

Educate public

Set up practice standards, guidelines

Political action

Action alerts

Where should addendums be placed in the charting?

Added as close to the time they occured as possible

describe informed consent

the patient has the right to reasonably informed participation in decisions involving his or her health care - every adult of sound mind has the right to determine what happens with his or her own body

What was the outcome of Natanson v. Kline in regards to informed consent?

Physicians must provide:

nature/purpose of proprosed tx

potential risks/benefits

alternative tx's along with their risks/benefits

What is capacity?

A clinical term refering to the ability to make rational and reasonably well informed decisions by a particular patient in their treatment and/or life decisions

What is competency?

A legal term refering to the ability to make rational and reasonably well informed decisions by a particular person in their treatment/life decisions.

Assault is an act that creates fear of imminent battery and battery is unlawful touching

Who can sign informed consent?

-Adult >18y.

-Emanicpated minor who is legally married, in the military, in law enforcement custody, has court documents,

-Legal guardians

-Pregnant teen for procedures/tests related to unborn child/pregnancy only; or if teen with baby, only for procedures/tests for her child

If family is signing for patient, what is the order of priority?

spouse, adult child (usu. all must agree/sign), parent, adult sibling, adult relative, close friend

What is the TBW fluid distribution of:

males

females

elderly

infants

-60%

-55%

-46-52%

-70-80%

Differentiate osmolarity from osmolality

Osmolarity is the # of osmoles per liter of solvent

Osmolality is the # of osmoles per kg of solvent

Crystalloid replacement of blood loss is:

3 ml crystalloid for every 1 ml blood loss

How much crystalloid should be given before blood?  What if patient is actively bleeding?

Differenetiate insensible v. sensible fluid loss

Insensible (no solutes): water loss via skin, respiratory tract, incisions

Sensible (solutes): mucous, tears, urine, stool, sweat

What is the insensible water loss in the neonate?

40 ml/kg/day

Your patient has a temperature >37C.  What is the fluid loss related to the temperature?  Is it sensible or insensible?

- 100-150ml/h for every degree >37C

-Sensible

What is the osmolality of:

D5W?

LR?

0.9NS?

Plasma?

-253 mosmol/kg

-273

-308

-290-300

What type of patient may receive D5W in OR?

Patients prone to hypoglycemia (DM, took insulin) and neonates who have limited glycogen stores

How is lactate metabolized?

1. 70% via gluconeogenesis in the liver to create glucose

2. 30% via oxidation to create bicarbonate

What is the intravascular 1/2 life of LR?

20-30 minutes

Why should LR not be used on a diabetic patient?

The Cori Cycle causes most of the lactate in the LR to be converted to glucose and the diabetic patient will have post-op hyperglycemia

What is the formula for a fluid bolus and what general type of fluid should be used?

10-20ml/kg of isotonic fluid

What is the average intravascular volume of colloids?

How do colloids affect crystalloids?

>3-4 hours

improves the intravascular 1/2 life of crystalloids

What can large amounts of colloids cause (because they are mixed in normal saline)?

Hyperchloremic acidosis

Your patient has a low albumin level.  How does this affect your medications?

If albumin levels are low, there will be more free drug as opposed to bound drug - it is the free drug that creates the effect.

Why has albumin fallen out of favor?

-Pooled product

-2X more expensive than hespan

-10X more expensive than crystalloids

-No increased benefits

-Creutzfeldt-Jakobs disease

Describe the reaction that can occur with dextran and what can be done to prevent it?

Anaphylactoid and anaphylactic reactions.

Dextran 1 (promit) can be given to bind circulating dextran antibodies

What is the hemotological risk of dextran?

Doses greater than >20ml/kg/d can interfere with blood typing and prolong bleeding time

decreases blood viscosity

What type of surgery is dextran useful for?

microvascular

Estimate blood loss for:

fully soaked 4x4

fully soaked lap pad

dripping lap pad

10 ml

100 ml

150 ml

What parameters are used to calculate total blood volume for the following patients?

Premie

Infant

child

Adult Male

Adult Female

Obese adult

90 ml/kg

85 ml/kg

80 ml/kg

75 ml/kg

65 ml/kg

55 ml/kg

How do you determine allowable blood loss for a healthy patient who does not have a hemoglobin or hematocrit on the chart?

Estimated blood volume x 20%