Date: September 20, 2016 Andrew Teich, CRNA Valley .
Date:September 20, 2016From:Scott S. SchausAndrew Teich, CRNAValley Anesthesia, Inc.Subject: 2016 Mixed Review and QuestionnaireDear SRNA Friend and Soon-To-Be CRNA:It is our expectation that you have put a great deal of energy into your preparations for theNational Certification Examination (NCE). The enclosed content updates and supplements yourreview materials. Some of the items are updates and revisions of content we have dealt withpreviously. You should work hard to master this material as well as the information already inyour hands. Specifically, we remind you that mastering both the MemoryMaster and the CourseManual content along with the Mixed Reviews helps ensure your success on the NCE. Furtherstudy in your “go-to” anesthesia text—the text that speaks to you—is strongly recommended aswell. A former Valley attendee best summarized the approach to success: “It is not enough toknow the material front-to-back, up-and-down, and inside-out; you must also know itsideways!!” There are no shortcuts—work hard and stay focused!We suspect that some of the issues in the enclosed review & update packet will be new toyou. You undoubtedly will be familiar with some of the items. We have worked long hoursputting this information packet together and have made every attempt to document the answersto the questions accurately. If you think any of the items are incorrect, controversial, or containgrammatical errors, we would appreciate hearing from you. Please send Scott an email with yourcomments and suggestions.After you take the Certification Examination and have received your results, we ask a favor:please complete and return the enclosed questionnaire and send it to us. Your response, inputand feedback are particularly important to us.Thank you very much for your attendance and participation in Valley Anesthesia’s ReviewCourse and best wishes for success on the NCE. Stay focused & Never Give Up!!Sincerely yours,Scott and Andrewscott@valleyanesthesia.com andrew@valleyanesthesia.com
PLEASE COMPLETE THE FOLLOWING QUESTIONNAIRE AND RETURN TO:Valley Anesthesia5 Penn Plaza, Suite 2375New York, NY 10001customer-service@valleyanesthesia.comI took the Certification Exam in / (month/year).I took the Valley Review Course at (site) in (year).I passed the Certification Exam:Yes!!No @#*&%! LGive Valley Anesthesia a call at 855-845-7277 ore-mail us at customer-service@valleyanesthesia.com.We will help you with your plan for success.In what ways did Valley Anesthesia help you prepare for the examination (attach a sheetif you need more area for comments):How might Valley Anesthesia improve the way it prepares SRNAs for the CertificationExamination (attach a sheet if you need more area for comments):
MIXED REVIEW 60September 20161. Describe intermittent mandatory ventilation (IMV).Intermittent mandatory ventilation (IMV) allows a patient to breath spontaneously around abaseline pressure (PEEP) in between mandatory breaths. IMV circuits provide a continuoussupply of fresh gas flow for the spontaneous breaths between mechanical breaths. Note: withIMV the patient is breathing above the set minute ventilation. {Replaces IIA05:Q21.}[Sandberg W, Urman R, Ehrenfeld J. The MGH Textbook of Anesthetic Equipment, 2011:57;Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013: 1593; ButterworthJF, Mackey DC, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology, 5e, 2013: 1291.]2. What precaution should be taken when switching from synchronized intermittent mandatoryventilation (SIMV) to volume-controlled ventilation (VCV)?When switching from synchronized intermittent mandatory ventilation (SIMV) to a volumecontrolled ventilation (VCV), the I:E ratio does not automatically reset, therefore check andadjust the I:E ratio after switching to VCV. [Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e;2013:275.]3. When is intermittent mandatory ventilation (IMV) typically used?Intermittent mandatory ventilation is often used to wean a patient from mechanical ventilation. NB: Barash makes the point that “weaning from mechanical ventilation” is bettertermed “liberation” or “separation” from mechanical ventilation. {Updates IIA05:Q5.}[Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:317; Sandberg W,Urman R, Ehrenfeld J. The MGH Textbook of Anesthetic Equipment, 2011:57; Barash PG,Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:1594.]4. Describe synchronized intermittent mandatory ventilation (SIMV).Synchronized intermittent mandatory ventilation (SIMV) is a refinement of intermittentmandatory ventilation (IMV) in which the intermittent mandatory breaths are delivered insynchrony with, and triggered by, the patient’s spontaneous efforts. SIMV can be used forfull to partial support of ventilation and helps to prevent “fighting the ventilator” and “breathstacking.” [Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e; 2013:274; Butterworth JF,Mackey DC, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology, 5e, 2013:75; DorschJA, Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:318.]5. Is synchronized intermittent mandatory ventilation (SIMV) used in pressure or volumemode? What aspect of ventilation is detected to trigger synchronization with the patient’sventilatory effort?Synchronized intermittent mandatory ventilation (SIMV) may be used in either pressure- orvolume-cycled mode. A trigger window controls the amount of time during each expiratorycycle that the ventilator is sensitive to spontaneous breaths, by sensing negative (subatmospheric) pressure generated by the patient’s diaphragm. [Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e; 2013:274; [Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e;2015: 3065; Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:318.]6. Describe assist/control ventilation. (Note: assist/control is often stated as assist-control.)In assist/control (AC) ventilation, the patient is allowed to set the respiratory rate by activating the inspiratory trigger function. In volume assist/control mode, each patient effort of sufficient magnitude will trigger the set tidal volume. In pressure assist/control, the patient againsets the frequency and the upper limit of pressure—the tidal volume varies, and consistencyis sacrificed to prevent barotrauma by high pressures. As a safety measure, if no spontaneouseffort occurs, the ventilator will deliver controlled breaths at a preselected backup rate. Thevariable used by the ventilator to cycle off the breath is time. {Revises IIA05:Q6.} [Miller 2016Page 1 of 20www.valleyanesthesia.com
MIXED REVIEW 60September 2016RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:3065; Hagberg C. Benumof& Hagberg’s Airway Management, 3e, 2012:985.]7. Identify nine (9) disadvantages of a closed circle system.The major disadvantages of a closed circle system stem from the complex design. Since thereare ten or more connections, the circle system is prone to: (1) disconnects; (2) obstructions;(3) leaks; and, (4) malfunction of unidirectional valves. The larger size of a circle system(5) limits portability. Other shortcomings of a closed circle system are: (6) increased deadspace; (7) complications due to use of an absorbent; (8) difficulty predicting inspired gasconcentration during low fresh gas flow; and, (9) some components are difficult to clean.{Revises and updates IIA07:Q3.} [Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:674; Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e; 2013:268b; Dorsch JA,Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:274; Butterworth JF, MackeyDC, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology, 5e, 2013:40]8. Into what shape should a lighted intubation stylet (“lightwand”, Trachlight) be molded?What approximate angle is the bend of this shape?To facilitate oral intubation, an anterior “J” or “hockey stick” bend of approximately 75- to90-degrees just proximal to the cuff is recommended. Sandberg recommends bending aTrachlight to an “L” shape. Care should be taken not to bend the stylet at the point at whichthe bulb meets the shaft. NB: the range of the bend for adult oral intubation is 75- to 120degrees in the texts. {Updates IIBQ15.} [Hagberg, Benumof & Hagberg’s Airway Management, 3e, 2012:434; Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e;2013:1195; Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1667,1675; Sandberg W, Urman R, Ehrenfeld J. The MGH Textbook of Anesthetic Equipment,2011:107.]9. What advantage does CO2 monitoring have over pulse oximetry or vital sign monitoring?Carbon dioxide monitoring detects acute, complete airway obstruction and extubation morerapidly than pulse oximetry or vital sign monitoring. {New into IID03a.} [Dorsch JA,Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:705.]10. Interpret the b (beta) angle of the CO2 waveform.The angle between the end of phase III (alveolar plateau) and the descending (inspiratory)limb is called the b angle. The beta angle is normally 90 degrees. [Dorsch JA, Dorsch SE.Understanding Anesthesia Equipment. 5e; 2008:712; Ehrenwerth, et al. Anesthesia Equipment: Principals and Applications, 2e, 2013:248.] 2016Page 2 of 20www.valleyanesthesia.com
MIXED REVIEW 60September 201611. What issues may increase the b angle of the CO2 waveform? Decrease the b angle?The b angle of the CO2 waveform is increased with rebreathing, malfunctioning inspiratoryvalves, and with prolonged response time compared to respiratory cycle time, especially inchildren. The beta angle will be decreased if the slope of phase III is decreased. [Dorsch JA,Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:712; Ehrenwerth, et al. Anesthesia Equipment: Principals and Applications, 2e, 2013:248.]12. The capnogram baseline is elevated in the intubated patient who received a volatileagent/N2O/narcotic anesthetic. Ventilation is adequate. What are the most likely causes ofthe elevated CO2 baseline and what do you do?An elevated CO2 waveform baseline indicates the patient is rebreathing, most likely due toa CO2 absorbent issue or a malfunctioning unidirectional valve. Increasing fresh gas flowwill lower the CO2 in the circle system. {Updates IID03a:Q7.} [Dorsch JA, Dorsch SE.Understanding Anesthesia Equipment. 5e; 2008:414.]13. Explain how a pulse oximeter works.Two different wavelengths of light are used: one is visible red light (l 660 nm) and theother infrared ((l 940 nm). Infrared light (940 nm) is absorbed by oxyhemoglobin whereasvisible red light (660 nm) is absorbed by deoxyhemoglobin. The ratio of pulsatile to nonpulsatile light absorption at each frequency is calculated. The ratio is then correlated to SpO2through internal calibration. Note: a number of different infrared frequencies have been usedin pulse oximeters over the years; the most common currently-used infrared wavelength is940 nm. {Updates IID03b:Q1.} [Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1545; Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:702; Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5e; 2008:777f.]14. Why might low or poor perfusion states interfere with accurate pulse oximeter readings?Pulse oximeters require adequate pulsations to distinguish light absorbed from arterial bloodfrom venous blood and tissue light—this process is called plethysmographic analysis. Therefore, pulse oximeter readings may be unreliable or unavailable if there is loss or diminutionof peripheral pulse. [Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5e;2008:789; Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:702;Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1545; Nagelhout JJ,Plaus KL. Nurse Anesthesia. 5e; 2013:318.]15. List 12 examples of poor perfusion states that limit pulse oximeter accuracy.Examples of poor perfusion states that may result in unreliable or unavailable pulse oximeterreadings are: (1) proximal blood pressure cuff inflation; (2) external pressure; (3) improperpositioning; (4) hypotension; (5) hypothermia; (6) Raynaud’s phenomenon; (7) cardiopulmonary bypass; (8) low cardiac output; (9) hypovolemia; (10) peripheral vascular disease;(11) Valsalva maneuver, such as in laboring patient; and, (12) infusion of vasoactive drugs.{Revises IID03B:Q7.} [Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5e;2008:789.]16. List ten (10) factors other than poor perfusion that lead to falsely low pulse oximeter readings(SpO2 SaO2).Ten factors that may lead to falsely low pulse oximeter readings are: (1) altered versions ofhemoglobin, namely methemoglobin when the true SaO2 85%, and HbK; (2) intravenousdyes, i.e., methylene blue, indigo carmine, isosulfan blue, indocynanine green, and nitrobenzene; (3) motion artifacts from shivering or evoked potentials, for example; (4) anemia, especially if the hematocrit is 25%; (5) low saturation (SaO2 80%); (6) optical interference 2016Page 3 of 20www.valleyanesthesia.com
MIXED REVIEW 60September 2016from flickering or strong LED lights; (7) electromagnetic interference—electrocautery, cellphones, surgical stereotactic positioning systems; (8) henna (temporary body art dye); (9)nail polish, especially black, purple, or dark blue; and, (10) burns or pressure sores, pressurenecrosis from LED of pulse oximeter (Note: the pulse oximeter LED generates heat). {Revises IID03b:Q8.} [Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment. 5e;2008:789-794; Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e;2015:1547t; Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e; 2013:319-320; Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:703; Sandberg W, Urman R, Ehrenfeld J. The MGH Textbook of Anesthetic Equipment, 2011:133t.]17. List two factors that lead to falsely high pulse oximeter readings (SPO2 SaO2).Carboxyhemoglobin (CO poisoning) and methemoglobin—when the true SaO2 85%—leadto falsely high pulse oximeter readings. {New Q IID03B.} [Nagelhout JJ, Plaus KL.Nurse Anesthesia. 5e; 2013:320; Pino RM, et al. Clinical Anesthesia Procedures of the Massachusetts General Hospital, 9e, 2015:149; Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:702.]18. Explain how the presence of methemoglobin can lead to both falsely high and falsely lowpulse oximeter readings.Methemoglobin absorbs a significant amount of light at both 660 and 940 nm and thus thepulse oximeter detects equal amount of oxy- and deoxyhemoglobin which results in a readingof 80% to 85%. In other words, in the presence of significant methemoglobinemia the pulseoximeter reading is essentially “fixed” at 80% to 85%. Therefore, when the true SaO2 is lessthan 85%, the reading is falsely high and the obverse is true as well. [Miller RD, Cohen NH,Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1547.]19. List 5 factors the generally have no significant effect on pulse oximeter readings (SPO2 SaO2).The following 5 factors have generally no significant effect on the pulse oximeter reading:(1) polycythemia; (2) skin pigmentation; (3) alternate hemoglobins, specifically HbF, HbS,HbH, and sulfHb; (4) red henna dye; and, (5) jaundice. {New Q IID03B.} [Miller RD,Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1547.]20. When performing an epidural anesthetic, what should alert you to the fact an intrathecal(subarachnoid) injection has occurred?A profound motor and sensory block (numbness in legs and hands, for example) soon afteran epidural injection should alert you that an unintended subarachnoid injection has occurred.A rapid onset of the triad of (1) severe hypotension, (2) bradycardia, and (3) respiratoryinsufficiency secondary to complete sympathetic block ensues. Apnea may result fromprolonged hypotension (reduced perfusion of respiratory control centers in the brainstem).Nausea and loss of consciousness may proceed cardiovascular arrest. {Updates IIIH02:Q53.}[Barash PG, Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:927; ButterworthJF, Mackey DC, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology, 5e, 2013:967; Pino RM, et al. Clinical Anesthesia Procedures of the Massachusetts General Hospital, 9e,2015:532; Hadzic A. Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-GuidedRegional Anesthesia, 2e, 2012:262; Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e;2013:1149.] 2016Page 4 of 20www.valleyanesthesia.com
MIXED REVIEW 60September 201621. During an epidural block the patient’s blood pressure drops precipitously to 80/35, the heartrate falls to 50 bpm, and SaO2 falls to 85%. What has probably happened?Severe hypotension, bradycardia, and respiratory insufficiency during an epidural blockare signs and symptoms of subdural injection of the anesthetic agent. You have noticed thatthese are the same signs and symptoms of a “high spinal,” that is, sympathetic block withunopposed parasympathetic effects. The key factor is timing: with a subdural injection, thesigns and symptoms are delayed by 15-30 seconds, in contrast to immediate onset followinga total spinal. Other possible signs and symptoms of a subdural injection include patchy andmarkedly asymmetric extensive spread of analgesia. {Updates IIIH02:Q54.} [Miller RD,Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1715; Nagelhout JJ, Plaus KL.Nurse Anesthesia. 5e; 2013:1149; Pino RM, et al. Clinical Anesthesia Procedures of theMassachusetts General Hospital, 9e, 2015:248-249.]22. For epidural anesthesia, clinically useful doses of local anesthetics are based on volumes thatpermit an even filling of the anterior and posterior epidural spaces at the level of insertion.What is the suggested volume per spinal nerve segment at cervical and thoracic levels to provide epidural blockade?The suggested volume of local anesthetic for epidural anesthesia at cervical and thoracic level is 0.7-1 mL per spinal segment to be anesthetized. {New Q IIIH03 prior to Q11.}[Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5e; 2013:1091.]23. What is the suggested volume per spinal nerve segment at lumbar levels to provide epiduralblockade?The suggested volume of local anesthetic for epidural anesthesia at lumbar levels is 1-2 mLper spinal segment to be anesthetized. Note: Nagelhout & Plaus state 1.25-1.50 mL per segment for epidural block. {Revises IIIH03:Q11.} [Nagelhout JJ, Plaus KL. Nurse Anesthesia.5e; 2013:1091; Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1703;Butterworth JF, Mackey DC, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology, 5e,2013:962-963; Hadzic, Textbook of Regional Anesthesia and Acute Pain Management (NYSORA), 2007:245, 257.]24. List the local anesthetics and concentrations that produce minimal motor blockade whenadministered epidurally.Bupivacaine (0.25%), ropivacaine (0.5%), and levobupivacaine (0.25%) provide satisfactoryanalgesia for acute pain with minimal to no motor block when administered epidurally.{Revises IIIH03:Q13 [Cousins MJ, Carr DB, Horlacker TT, et al. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine. 4e; 2008:255; MillerRD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 8e; 2015:1704t; Butterworth JF,Mackey DC, Wasnick J. Morgan & Mikhail’s Clinical Anesthesiology, 5e, 2013:963t.]25. Which four local anesthetics (and concentration) provide potent sensory analgesia andminimal motor block when administered epidurally?Bupivacaine (0.5%), ropivacaine (0.5%), levobupivacaine (0.5%), and plain lidocaine (2%)provide potent sensory analgesia and minimal motor blockade when administered epidurally.{New Q IIIH03:Q14.} [Cousins MJ, Carr DB, Horlacker TT, et al. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine. 4e; 2008:255; MillerRD, Cohen NH, Eriksson LI,
Manual content along with the Mixed Reviews helps ensure your success on the NCE. Further . Cullen BF, Stoelting RK, et al. Clinical Anesthesia. 7e; 2013:1594.] 4. Describe synchronized intermittent mandatory ventilation (SIMV). Synchronized intermittent mandatory ventilation (SIMV) is a refinement of intermittent
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