ANES 660 exam 1

how much oxygen is in the air

21% oxygen

what is our hemoglobin saturation

\~100%

what happens when we induce unconsciousness or give sedatives/opioids

our  patients are more likely to hypoventilate or obstruct, resulting in  desaturation

what happens when we provide supplemental oxygen

•we can achieve an FiO2 >21%, and decrease the risk of desaturation

what is FiO2

fraction of inspired oxygen; 0.21 or 21% @ room air, up to  100% if all the “air” breathed by pt is pure oxygen \[no nitrogen or  nitrous oxide\])

I’m giving you 50% oxygen and 50% nitrous oxide. What’s your FiO2?

To calculate the FiO2, we need to convert the percentages into decimal values and sum the fractions of oxygen. The percentage of oxygen is divided by 100 to convert it to a decimal value:



Oxygen fraction = 50% / 100 = 0.5



Since the nitrous oxide is not contributing to the FiO2 (it does not contain oxygen), we can ignore it for this calculation.



Therefore, the FiO2 in a gas mixture of 50% oxygen and 50% nitrous oxide would be 0.5 or 50%.

what are the two main ways we deliver oxygen in the OR

•Invasively and non-invasively

what devices would you use to deliver oxygen invasively

•Invasively, via an endotracheal tube or an LMA

when would we use an endotracheal tube or an LMA

We use these devices when a patient is under general anesthesia

what is general anesthesia

•**General anesthesia** is when a patient is unconscious, has a loss of protective reflexes  including the ability to maintain their airway and respond purposefully to noxious stimuli or  verbal commands

If I push 2mg/kg propofol. You have a 70kg patient. How many milligrams is that for 2 mg/kg?

140mg

To calculate the dosage of propofol for a 70kg patient at a rate of 2mg/kg, you would multiply the patient's weight by the dosage rate:

2 mg/kg \* 70 kg = 140 mg

how many CCs is that for propofol?

14cc

For a 10 mg/ml concentration: Volume (in cc) = Dosage (in mg) / Concentration (in mg/ml) = 140 mg / 10 mg/ml = 14 cc

how do we deliver O2 to patients non-invasively

•Non-invasively - via a nasal cannula, simple face mask, or non-  rebreathing facemask

when are non-invasive devices used

•**These devices are used when a patient is able to maintain their airway**

•Usually utilized during **MAC procedures**, after extubation of advanced (invasive)  airways, or by patients with pulmonary diseases (e.g. COPD) who need higher FiO2 @  baseline

what is MAC

•MAC = monitored anesthesia care; colloquially known as “twilight” anesthesia;  lighter sedation \*without\* complete loss of consciousness and airway

How does oxygen get delivered to these  devices?

•We place invasive airways (ETT/LMA) in the OR

•We connect these devices to our anesthesia circuit, which is  connected to our anesthesia machine

•The FiO2 can then be chosen and changed throughout the  procedure

How would you change the FiO2?

why are we able to choose the FiO2 with LMAs and ETTs

the gas is delivered in a “closed” system

for non-invasive airway, is the system open or closed?

•With non-invasive airway, the system is “open” to atmosphere to  varying degrees, meaning the FiO2 is more variable, depending on the  device and the ”flows”

what are flowmeters

connected to the wall supply (as in PACU),  from an oxygen tank, or on the side of our anesthesia  machine (AKA auxiliary oxygen)

what is Spontaneous

•patient is breathing on their own; negative  pressure ventilation

what is Airway obstruction

•the patient’s upper airway “collapsed” or  obstructed resulting in decreased or absent ventilation, despite  patient trying to breathe spontaneously

•Think snoring

what is Positive pressure ventilation

•breathing provided by generating  positive pressure to expand the lungs

•This is how the ventilator on our anesthesia machine works

what is apneic

not breathing

what is one way to fix a patient who has gone apneic

Bag-mask-ventilation (BMV)

what is Bag-mask-ventilation (BMV)

•A way to provide non-invasive positive pressure ventilation

when do you use Bag-mask-ventilation (BMV)

When to use it?

•It’s most commonly used between induction and intubation

•But it can also be used if a patient is obstructing with a non-invasive  airway device (e.g. during a MAC procedure)

•Also during CPRwithout a “secured airway”

how do you do a Bag-mask-ventilation

•It is important to seal the mask to the face to avoid leaks

•This way, all of the pressure you generate when squeezing the  reservoir bag will be delivered to the pt’s airway

•It is also important to avoid upper airway obstructions

•This will allow all of the pressure generated to go to the pt’s lungs, not  their stomach

•We do this with the “C and E” grip

•Thumb and index finger make the C, holding the mask in place

•Middle, ring and pinky fingers make the E, pulling up on the  mandible

Bag-masking technique

•Rest the top of the mask over the bridge of the nose

•The bottom of the mask should sit below the lower lip but above the  chin – if not, you may need a different sized mask

•Especially important in peds

proper finger placement during BVM ventilation

is this the proper technique?

This is incorrect. The 3 fingers are on the soft tissue

true or false

it is uncommon for the upper airway to become obstructed

false.

•It is very common for the upper airway to become  obstructed

when can the upper airway become obstructed

•This can happen while we are trying to bag-mask or when  the patient is spontaneously ventilating through a non-  invasive device (e.g. SFM)

true or false

•There are maneuvers and airway adjuncts we can  use to try to ”un-obstruct” our patients

true

what are some ways to correct upper airway obstructions

Chin-lift / Head-tilt

Jaw Thrust

Two-hand bag-mask technique

Sit the patient up

Sniffing position

describe Chin-lift /Head-tilt

•By tilting the head back and lifting  the chin up towards the ceiling, the  soft tissue of the upper airway can  be brought off of the posterior wall  of the pharynx

•You can also attempt to un-obstruct  the upper airway by turning the  head to one side or the other

describe jaw thrust

•Fingers behind the angle of the  mandible



•Lift up to bring the lower incisors  anterior to upper incisors



•(this can be paired with a two-hand  masking technique)

describe Two-hand bag-mask technique

•One practitioner holds the mask/face with both hands while a  second provider squeezes the bag

•Two techniques for holding the mask:

•Double C/E hold

Thumbs/heels of hand on mask, 4 fingers pulling up on the mandible

describe sit the patient up

•This will get explored further when we discuss intubation axes, etc.



•The upper airway is more likely to become obstructed in the  obtunded patient when they are completely supine



•By sitting them up to some degree (Fowler’s position), we can help  un-obstruct their upper airway

describe the sniffing position

•This is especially useful for direct laryngoscopy  (intubation)



•But it demonstrates how the airway can become un-  obstructed in the sniffing position

how are nasal trumpets placed

•Placed using surgilube or  lidocaine jelly

which nostril are nasal trumpets places

•Typically in R naris

how would you put in a nasal trumpet

•Place with tip perpendicular  to pt’s face

how would you determine the right size of a nasal trumpet

•Size by length, distance between naris and external  auditory meatus

what is the function of a nasal trumpet

•Provides a conduit for patent  airflow behind the collapsible  soft tissue of the pharynx

what is the function of oral airways

•Placed (often using tongue  depressor) over tongue and  into pharynx to provide patent  conduit for ventilation

how would you determine the right size of an oral airway

•Sized from side of mouth to  angle of the mandible

how much does the five most common hospital-acquired infections (HAIs) cost the US

$9.8 billion annually

what is the most important aspect of reducing hospital acquired  (nosocomial) infections

hand hygiene

when should you practice hand hygiene

**before and after** patient contact

elaborate on the last slide

•This simply means washing your hands before patient contact,  wearing gloves when indicated (next slide), and washing hands again  after patient contact

•So even when you’re meeting your patient in preop, you should wash your  hands when you walk up to the pt (sanitizer is ok), shake hands etc., then  wash your hands again after leaving the pt’s bedside

when should we wear sterile gloves

any surgical procedure; vaginal delivery; invasive radiological procedures; performing vascular access and procedures (central lines); preparing total parental nutrition and chemotherapeutic agent

when should we wear examination gloves

potential for touching blood, body fluids, secretions, excretions and items visibly soilded by body fluids

DIRECT PATIENT EXPOSURE: contact with blood; contact with mucous membrane and with non-intact skin; potential presence of highly infectious and dangerous organism; epidemic or emergency situations; IV insertion and removal; drawing blood; discontinuation of venous line; pelvic and vaginal examination; suctioning non-closed sysrems of endotrcheal tubes

INDIRECT PATIENT EXPOSURE: emptying emesis basins; handling/cleaning instruments; handling waste; cleaning up spills of body fluids

when do you not have to wear gloves

no potential for exposure to blood or body fluid, or contaminated environment

DIRECT PATIENT EXPOSURE: taking blood pressure, temperature and pulse; performing SC and IM injections; bathing and dressing the patient; transporting patient; caring for eyes and ears (without secretions); any vascular line manipulation in absence of blood leakage

INDIRECT PATIENT EXPOSURE: using the telephone; writing in the patient chart; giving oral medications; distributing or collecting patient dietary trays; removing and replacing linen for patient bed; placing non-invasive ventilation equipment and oxygen cannula; moving patient furniture

what the difference between Hand sanitizer and hand washing

•Hand washing is indicated whenever your hands are visibly soiled

•Hand sanitizer is not effective against norovirus, c. diff., and  cryptosporidium

according to the WHO, when should you wash your hands

1. before touching a patient
2. before clean/aseptic procedure
3. aftern body fluid exposure risk
4. after touching a patient
5. after touching patient surroundings

why should you wash your hands before touching a patient

to protect the patient against colonization and, in some cases against exogenous infection, by harmful germs carried on your hands

why should you wash your hands before a clean/aseptic procedure

to protect the patient against infection with harmful germs, including his/her own germs entering his/her body

why should you wash your hands after body fluid exposure risk

to protect you from colonizationg or infection with patient’s harmful germs and to protect the health-care environment from germ spread

why should wash your hands after touching a patient

to protect you from colonization or infection with patient’s harmful germs and to protect the health-care environment from germ spread

why should you wash your hands after touching patient surroundings

to protect you from colonization with patient germs that may be present on surfaces/objects in patient surroundings and to protect the health-care environment against germ spread

what are standard precautions

•constitutes the primary strategy for the  prevention of healthcare-associated transmission of infectious agents  among patients and healthcare personnel

what are Transmission based precautions

used when a patient is infected  with an epidemiologically significant microorganism or an  uncontained and transmittable infection

when do we use standard precautions

•In practice, we use standard precautions with all of our patients in the  perioperative period

what contains transmissible infectious agents

•all blood, body fluids, secretions,  excretions except sweat, nonintact skin, and mucous membranes may  contain transmissible infectious agents

due to standard precautions, what should you wear

•Includes hand hygiene and the use of gloves, gown, mask, eye  protection, or face shield, **depending on the anticipated exposure**

according to JCAHO, when should you wear eye protection

•JCAHO dictates eye protection for us in the OR, specifically when intubating or  at any point that we are risk of being splashed from the field

what are the 3 types of transmission based precautions

contact precautions

droplet precautions

airborne precautions

what are contact precautions used for

used for multi-drug resistant organisms spread either directly or indirectly from the pt’s environment

what kinds of virsuses do contact precautions include

•Includes MRSA, VRE, c. diff.

what kind of PPE should we wear under contact precautions

•PPE should include at least gown and gloves

what are droplet precautions used for

used for dz spread through close respiratory or mucous membrane contact with respiratory secretions

what kinds of virsuses do droplet precautions include

Includes *B. pertussis*, influenza virus, adenovirus, rhinovirus, *N. meningitides*, and group A streptococcus

what kind of PPE should you wear under droplet precautions

•PPE should include a mask; pt should wear a mask when possible as well

what do airborne precautions prevent

•prevents transmission of infectious agents that  remain infectious over long distances when suspended in the air

what kinds of virsuses do airborne precautions include

•Includes measles, chickenpox, tuberculosis, and SARS-CoV

if a patient is under airborne precautions, what kind of environment should they be in

•Pt should be in room with ventilation resulting in 12 room air exchanges per  hour venting through HEPA filter directly outside

what kind of PPE should you wear under airborne precautions

•PPE should include mask or respirator (N95)

when should healthcare provided get TB testing

annually

review: when should you use sterile gloves

•Arterial line placement, central line placement, neuraxial (spinal/epidural  placement), floating PACs, accessing medports

when should you wear exam gloves

•Everything else

•Placing IVs, manipulating the airway, any contact w/ blood, mucus membranes, etc.

•I wear gloves almost any time I have any physical contact with patients

when should you wear no gloves

•Handshakes and high fives

what kind of containers do we use in the OR

•**Purple bin**

•**Red sharps bin**

•**Rx Destroyer**

•**Trash**

* red bio-hazard bag

what should you put in the red bio-hazard bag

you put things that are really bloody or soaked in urine/feces in the red bio-hazard bag

what do we put in purple-top bins

non-regulated waste ***ONLY***

where are purple-top bins located

•These bins are located on anesthesia carts or trollies for  vials & containers that are **full, partially full, or contain  residual non-hazardous drugs/waste.**

what are some examples of Non Hazardous Drugs/Waste

•Local Anesthetics

•Non-controlled Drugs/Medications (Things like atropine or metoprolol)

what kinds of things should you put in the sharps bin

•Empty syringes with/without needles

•Unused syringes

•Broken vials/ampules/bottles  containing small amounts of liquid.

•Blades

•Scalpels

•Scissors

•Objects that can puncture or cut a  plastic bag or cut skin – including  empty glass vials.

true or false

you can put full syringes into the sharps bin

false.

We don’t put full syringes in the red sharps bin because full syringes are expensive to waste, so we squirt the drug somewhere else and then put the empty syringe in the red sharps bin

**Empty the contents of sharps and syringes  containing controlled substances into the Rx  Destroyer**

what should you put in the Rx destroyer

•Disposal of controlled substances

•Disposal of drugs that are at risk  for diversion

•Pills, tablets, injections, solutions,  patches, creams, lozenges

what are some examples of controlled substances

Fentanyl, propofol, morphine, ketamine

what should NOT go in the Rx destroyer

__**Do not**__ **put syringes, vials, packaging, or solids in these containers.**

where should you put empty IV bogs and tubing

These items can be defaced of patient information and disposed of in the  normal trash!

__DO NOT__ place empty IV bags and tubing into the  purple top or sharps bins.

what can go in the trash

•Empty pharmaceutical IV bags & tubing  (defaced PHI).

•PPE (gloves, gowns & masks) used to  administer non-hazardous  pharmaceuticals.

•Disposable items that are not grossly  contaminated with blood:

•Flecked, spotted, or smeared with blood

•Non broken glass bottles

what should you put int the blus soiled linen bags

•Throw all linen from the OR into these  bags

•If it is completely saturated with blood,  throw away into the red biohazard bag

true or false

you can eat in patient contact areas

false

•No eating or drinking in these areas

•For your own protection against contamination

•To prevent spills attracting pests

true or false

to cap a needle stick, you should use both hands

false. Do not use both hands to cap a needle

what is the proper needle recapping technique

what is the seroconversion rate for Hep C

\~0.5-1.8%

what is the seroconversion rate for Hep B if non-immunized

\~30%