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RNFA MASTER EXAM TEST QUESTIONS
AND ANSWERS UPDATED (202 5 /202 6 )
(VERIFIED ANSWERS)
DEPOLARIZING BLOCKERS - ANS ✓Succinylcholine is the only depolarizing neuromuscular blocker used clinically in the USA. succinylcholine remains popular because it is the only ultrarapid onset/ultrashort duration neuromuscular blocker available.
- Succinylcholine binds to the nicotinic receptor and acts like acetylcholine to cause depolarization of the end plate. This in turn spreads and depolarizes adjacent membranes, causing transient fasciculations, especially in chest and abdomen, though general anesthesia and prior administration of a small dose of a nondepolarizing muscle relaxant tends to attenuate them. Succinylcholine is not metabolized effectively at the synapse, therefore the membrane remains depolarized and unresponsive to additional impulses. A flaccid paralysis results. This is called Phase I block, or depolarization block. Phase I block is augmented, not reversed, by acetylcholinesterase inhibitors. - The ons et of neuromuscular blockade is very rapid, usually within 1 minute. Because of its rapid hydrolysis by plasma butyrylcholinesterase (pseudocholinesterase), duration of neuromuscular block is 5-10 minutes. - With a single large dose, repeated doses, or pro longed continued infusion of succinylcholine (30-60 minutes) the membrane repolarizes; despite this repolarization, the membrane can't be depolarized again because it is desensitized. The channels behave as if they are in a prolonged closed state. This is called phase II block or desensitization block. Phase II block may be reversed by acetylcholinesterase inhibitors.
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PHARMACOKINETICS OF NEUROMUSCULAR BLOCKERS - ANS ✓• All neuromuscular blocking agents contain one or two quaternary ammonium groups, which makes them highly polar and very poorly soluble in lipid.
- Neuromuscular blockers are inactive if given by mouth. They are always given IV or IM. They penetrate membranes very poorly and do not enter cells or cross the blood-brain barrier. NON-DEPOLARIZING BLOCKERS - ANS ✓Highly ionized. They don't cross membranes well and have limited volume of distribution of 80-140 mL/Kg - not much larger than blood volume. They have durations of action that range from 20 to 90 minutes, which can be extended by supplemental dosing. Non-depolarizing blockers can be classified into: long-, intermediate-, and short-acting. SHORT-ACTING Mivacurium INTERMEDIATE-ACTING Atracurium Rocuronium Cisatracurium Vecuronium LONG-ACTING Tubocurarine Pancuronium
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butyrylcholinesterase should be treated with continued mechanical ventilation until muscle function returns to normal. Because of the rarity of these variants, butyrylcholinesterase testing is not routine clinical procedure. ADVERSE EFFECTS - ANS ✓... NON-DEPOLARIZING BLOCKERS - ANS ✓• Some benzylisoquinolines may produce hypotension due to histamine release and ganglionic blockade.
- Some ammonio steroids may produce tachycardia due to blockade of muscarinic receptors, which may lead to arrhythmias. These drugs should be used cautiously in patients with cardiovascular disease. HISTAMINE RELEASE - ANS ✓Tubocurarine, and to a lesser extent, mivacurium and atracurium can produce hypotension as a result of histamine release. Tubocurarine is seldom used clinically at this time. Clinical signs of histamine release are erythema at the face and upper chest, a transient decrease in blood pressure, and an increase in heart rate. More severe reactions of histamine release include bronchospasm and circulatory collapse. Antihistamines can counteract responses that follow histamine release, particularly if given before the neuromuscular blocker. GANGLION BLOCKADE - ANS ✓Tubocurarine may cause some blockade of nicotinic receptors of the autonomic ganglia and the adrenal medulla; this results in a fall in blood pressure and tachycardia.
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BLOCKADE OF CARDIAC MUSCARINIC RECEPTORS - ANS ✓The ammoniosteroid pancuronium causes moderate tachycardia due to blockade of cardiac muscarinic receptors. The cardiovascular effects of pancuronium are usually not considered to be a clinically relevant problem (see table below). DEPOLARIZING BLOCKERS - ANS ✓Succinylcholine stimulates all autonomic cholinoceptors: nicotinic receptors in both sympathetic and parasympathetic ganglia and muscarinic receptors in the heart. HISTAMINE RELEASE Succinylcholine has a slight tendency to release histamine. BRADYCARDIA - ANS ✓Bradycardia may occur due to activation of muscarinic receptors. It can be prevented by thiopental, atropine, ganglionic blockers and non-depolarizing muscle relaxants. MUSCLE PAIN - ANS ✓Important postoperative complaint. Due to damage produced by the unsynchronized contractions of adjacent muscle fibers. HYPERKALEMIA - ANS ✓Due to loss of tissue potassium during depolarization. Risk of hyperkalemia is enhanced in patients with burns or muscle trauma. Hyperkalemia may lead to cardiac arrest or circulatory collapse. INCREASED INTRAOCULAR PRESSURE - ANS ✓Due to extraocular muscle contractions. Despite this effect, the use of succinylcholine for eye operations is not contraindicated unless the anterior chamber is to be opened. INCREASED INTRAGASTRIC PRESSURE - ANS ✓In some patients, the fasciculations caused by succinylcholine cause an increase in intragastric pressure. This makes emesis more likely, with the potential hazard of aspiration of gastric contents.
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- Advanced age is often associated with a prolonged duration of action from nondepolarizing relaxants, probably due to decreased clearance of drugs by liver or kidneys. - Patients with severe burns and those with upper motor neuron disease are resistant to nondepolarizing muscle relaxants. This is probably because of proliferation of extrajunctional receptors, which requires additional nondepolarizing relaxant to block a sufficient number of receptors to produce neuromuscular blockade. DEPOLARIZING BLOCKERS: CONTRAINDICATIONS - ANS ✓• Succinylcholine is contraindicated in persons with personal or familial history of malignant hyperthermia, skeletal muscle myopathies, and known hypersensitivity to the drug. - Succinylcholine is contraindicated in patients with major burns, multiple trauma, extensive denervation of skeletal muscle, or upper motor neuron injury, because succinylcholine may lead to severe hyperkalemia which may result in cardiac arrest. REVERSAL OF NONDEPOLARIZING NEUROMUSCULAR BLOCKADE - ANS ✓• The acetylcholinesterase inhibitors neostigmine, pyridostigmine and edrophonium preserve endogenous acetylcholine and also act directly on the neuromuscular junction, therefore they can be used in the treatment of overdosage with competitive blocking agents. - Similarly, upon completion of a surgical procedure many anaesthesiologists employ neostigmine or edrophonium to reverse and decrease the duration of competitive neuromuscular blockade. A muscarinic antagonist (atropine or glycopyrrolate) is used concomitantly to prevent stimulation of muscarinic receptors and thereby avoid bradycardia. USES OF NEUROMUSCULAR BLOCKERS - ANS ✓SURGICAL RELAXATION The main clinical use of the neuromuscular blockers is as adjuvants in surgical anesthesia to obtain relaxation of skeletal muscle. Neuromuscular blockers of short duration are often used to facilitate intubation with an endotracheal tube.
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CONTROL OF VENTILATION
In patients who have ventilatory failure from various causes, e.g. obstructive airway disease, it is often desirable to control ventilation to provide adequate volumes and expansion of lungs. Paralysis is sometimes induced by administration of neuromuscular blockers to eliminate chest wall resistance and ineffective spontaneous ventilation. TREATMENT OF CONVULSIONS Neuromuscular blockers are sometimes used to attenuate or eliminate the peripheral manifestations of convulsions from such causes as epilepsy or local anesthetic toxicity. PREVENTION OF TRAUMA DURING ELECTROSHOCK THERAPY ECT therapy of psychiatric disorders occasionally is complicated by trauma to the patient; the seizures induced may cause dislocations or fractures. Neuromuscular blockers and thiopental are used. Succinylcholine or mivacurium are the neuromuscular blockers most often used because of the brevity of the relaxation SPASMOLYTIC DRUGS - ANS ✓Spasticity is characterized by increase in tonic stretch reflexes and flexor muscle spasms together with muscle weakness. It is often associated with cerebral palsy, multiple sclerosis, and stroke. Drug therapy may ameliorate some of the symptoms of spasticity by modifying the stretch reflex arc or by interfering directly with skeletal muscle excitation-contraction coupling. DRUGS FOR CHRONIC SPASM - ANS ✓... A. DRUGS THAT ACT IN THE CNS - ANS ✓... DIAZEPAM - ANS ✓Benzodiazepines facilitate the action of GABA at GABAA receptors. Diazepam has useful antispastic activity. It can be used in patients with muscle spasm of almost any origin, including local muscle trauma. It produces sedation in most patients at the doses required to reduce muscle tone.
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Neuromuscular blockers. - ANS ✓Used during surgical procedures and in intensive care units to cause paralysis. NONDEPOLARIZING BLOCKERS - ANS ✓• They are competitive antagonists. In small clinical doses they act predominantly at the nicotinic receptor site by competing with acetylcholine. Their action can be overcome by increasing the concentration of acetylcholine in the synaptic cleft; this can be achieved, for example, by administration of acetylcholinesterase inhibitors such as neostigmine or edrophonium. Anaesthesiologists use this strategy to shorten the duration of the neuromuscular blockade.
- In larger doses, nondepolarizing blockers also enter the pore of the ion channel to cause a more intense motor blockade. This further weakens neuromuscular transmission and diminishes the ability of acetylcholinesterase inhibitors to antagonize the action of nondepolarizing blockers. - Nondepolarizing blockers may also block prejunctional sodium channels. As a result, they reduce the release of acetylcholine at the nerve ending. - During anesthesia, the IV admin istration of a nondepolarizing blocker first causes motor weakness; ultimately, skeletal muscles become totally flaccid and inexcitable to stimulation. Larger muscles (e.g. those of the trunk) are more resistant to block and recover more rapidly than smaller ones (e.g. muscles of the hand). PROGABIDE - ANS ✓GABAA and GABAB agonist. Reduces spasticity. GLYCINE - ANS ✓Reduces spasticity. Inhibitory amino acid neurotransmitter. It appears to be active when given orally and readily passes the blood-brain barrier.
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IDROCILAMIDE & RILUZOLE - ANS ✓New agents for the treatment of amyotrophic lateral sclerosis that appear to have spasm- reducing effects, possibly by inhibiting glutamatergic transmission in the CNS. B. DRUGS THAT ACT ON THE SKELETAL MUSCLE - ANS ✓... DANTROLENE - ANS ✓DANTROLENE Dantrolene interferes with the release of Ca2+ by binding to the ryanodine receptor in the SR of skeletal muscle. Cardiac muscle and smooth muscle are depressed only slightly. Adverse effects include generalized muscle weakness, sedation, and occasionally hepatitis. Dantrolene is also used in malignant hyperthermia. Given IV for this condition BOTULINUM TOXIN - ANS ✓Botulinum toxin, injected locally into muscles, is used to treat a form of persistent and disabling eyelid spasm (blepharospasm), as well as other types of local muscle spasm. Local injection of botulinum toxin has become popular for treatment of generalized spastic disorders, e.g., cerebral palsy. DRUGS USED FOR ACUTE LOCAL MUSCLE SPASM - ANS ✓A large number of drugs are used for relief of acute temporary muscle spasm caused by local trauma or strain. Most act as sedative or at the level of the spinal cord or brain stem. Cyclobenzaprine may be regarded as the prototype of the group. It is structurally related to the TCAs and has some properties in common with them, e.g. antimuscarinic effects. It is thought to act at the level of the brain stem. It is ineffective in muscle spasm due to cerebral palsy or spinal cord injury. It has strong antimuscarinic actions and causes significant sedation in most patients and confusion and transient visual hallucinations in some.
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retention sutures - ANS ✓large-gauge, interrupted, nonabsorbable sutures placed lateral to a primary suture line for wound reinforcement Bridges - ANS ✓plastic devices that bridge the closed incision Bolsters - ANS ✓pieces of plastic or rubber tubing threaded over the retention suture ends before the ends are tied; once tied they cover retention sutures and prevent them from cutting into the skin Buttonholes - ANS ✓holes through which tendon sutures are pulled through and tied over a button to prevent tissue damage Split lead shots - ANS ✓may be clamped onto the ends of subcuticular sutures after skin closure umbilical tape - ANS ✓used for retraction and isolation of bowel, nerves, vessels, or ducts; used moist vessel loops - ANS ✓thin strips made of silicone that can be placed around a vessel, nerve, or duct for the purposes of retracting or isolating; the loops are colored for easy identification of the retracted structures white and yellow loops - ANS ✓for nerves and ducts red loops - ANS ✓for arteries blue loops - ANS ✓for veins
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Skin closure tapes - ANS ✓adhesive-backed strips of nylon or polypropylene tapes used to reinforce a subcuticular skin closure to approximate wound edges of small incisions or superficial lacerations when sutures may not be necessary Skin adhesive - ANS ✓a sterile liquid that is applied topically; used on the surface of a wound that will not be under tension in place of adhesive skin closure tapes, staples, or suture How are Anesthesia codes grouped and where can they be found - ANS ✓Grouped anatomically, beginning with the head. To find, either use Index / Anesthesia to locate the anatomic area or turn to blue edged Anesthesia 000100 pages. Guidelines are at front of blue chapter. What is a "crosswalk" book - ANS ✓Books available to coders to assist by "crosswalking" the known surgical code to an appropriate anesthesia code. BUV - ANS ✓Base unit value. What are the 3 different types of anesthesia - ANS ✓General, Regional, and Monitored Anesthesia Care (MAC) What is general anesthesia - ANS ✓A drug-induced loss of consciousness. Where the patient is unconscious and has no control of their airway. What is regional anesthesia - ANS ✓Includes blocks, spinals, and epidurals. A loss of sensation in a region of the body such as: Spinal Anesthesia: An anesthetic agent is injected in the subarachnoid space into the cerebral spinal fluid (CFS) in the patient's spinal canal for surgeries performed below the upper abdomen. Epidural Anesthesia: An anesthetic agent is injected in the epidural space. A small catheter may be placed for a continuous epidural. An epidural can also remain in place after surgery to assist with postoperative pain.
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SRNA - ANS ✓Student Registered Nurse Anesthetist. A registered nurse who is training in an accredited nurse anesthesia program. One-Lung Ventilation - ANS ✓OVL. A term used in anesthesia related to thoracic surgery. is when the two lungs are not working together because either they are trying to protect one lung from either infection or blood. This would a be reported in the anesthesia records so it would be clear when the service is being provided. OLV occurs when one lung is ventilated and the other lung is collapsed temporarily to improve surgical access to the lung. Several anesthesia codes separately identify utilization of one-lung ventilation. Pump oxygenator - ANS ✓Is the bypass machine (cardiopulmonary bypass machine, CPB) they put patients on during cardiac procedures when they are working on the heart. When a procedure code description states, "with pump oxygenator," this is when they put the patient on that heart and lung machine which is also known as the bypass machine. Describes when a cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart or great vessel surgery. Cpb maintains the circulation of blood and the oxygen content of the body. When a CPB machine is used, the anesthesia record should describe when the patient went on and off pump. When a pump oxygenator is not used, the surgeon is operating on a "beating" heart. Intraperitoneal - ANS ✓describes organs within the peritoneum. These procedures may be performed in both the upper and lower abdomen. Intraperitoneal organs in the upper abdomen include the stomach, liver, gallbladder, spleen, jejunum, and ascending and transverse colon. Intraperitoneal organs in the lower abdomen include the appendix, cecum, ileum, and sigmoid colon. Because the cecum and ileum are part of the small intestines and originate in the upper abdomen, these may be coded as upper abdomen. Extraperitoneal or retroperitoneal - ANS ✓describes the anatomic space in the abdominal cavity behind the peritoneum. The kidneys, adrenal glands, and lower esophagus are extraperitoneal organs of the
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upper abdomen. Extraperitoneal organs in the lower abdomen include the ureter and urinary tract. Also located in the retroperitoneum are the aorta and inferior vena cava. Coding with Trocar placement during surgery - ANS ✓It doesn't matter where the trocars are placed for laparoscopic procedures, code assignment is dependent on actual procedure being done. Radical surgery - ANS ✓Is usually extensive, complex, and intendedto correct a severe health threat, such as a rapidly growing cancer. Diagnostic or Surgical Arthroscopic procedures - ANS ✓May be performed on the temporomadibular joint, shoulder, elbow, wrist, hip, knee, and ankle. Coders should assign only a diagnostic code when no surgical procedure is performed. EX: Knee arthroscopy is listed as "diagnostic" and a meniscectomy is performed, surgical arthroscopic meniscectomy code is assigned. Postoperative pain management - ANS ✓Usually the responsibility of the surgeon, and payment is bundled into the surgeon's global fee. However, it may be requested by the surgeon and billed separately by anesthesia as long as the anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique. EX: if epidural is mode of anesthesia for procedure, it cannot be reported for post operative pain management. Postoperative pain Management coding - ANS ✓Depends on what is injected, the site of injection and placement of either a single injection block or continuous block by catheter. Pay close attention to whether it is single injection or continuous infusion. CPT code reported is appended with modifier 59 to signify the service is separate and distinct from anesthesia care provided for the surgery. Ultrasound and fluoroscopic guidance utilized with pain management procedure coding - ANS ✓When utilized and appropriately documented, codes are reported with modifier 26 (professional component) unless code selected includes imaging guidance (fluoroscopy or CT).
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It is important for us to understand these values and how they are used. The values are assigned to the actual anesthesia code. relative value - ANS ✓is a numeric ranking assigned to a procedure in relation to other procedures in terms of work and cost. The relative values are also referred to as base units. These values are important because they help us determine what the anesthesia units are for a case. This is also utilized in determining how to calculate our fees for anesthesia services. It is important for us to understand these values and how they are used. The values are assigned to the actual anesthesia code. Continuous catheter codes - ANS ✓Reported for continuous administration of anesthesia for postoperative pain management. If the infusion catheter is placed for operative anesthesia, the appropriate anesthesia code plus time is reported. If the continuous infusion catheter is placed for postoperative pain management, the daily postoperative management of the catheter is included. Code 01996 Daily hospital management of epidural.... - ANS ✓Assigned for daily hospital management of epidural or subarachnoid continuous drug administration. Continuous infusion by catheter such as femoral (64448) or sciatic (64446) is not an epidural catheter; 01996 is never reported with these codes. Anesthesiologists may report an appropriate E/M service to re-evaluate postoperative pain if documentation supports the level of service reported and billed. Epidural - ANS ✓Reported when anesthesia is injected into the epidural space of the spine, including the cervical, thoracic, or lumbar area. May be either single injection or continuous catheter. Subarachnoid or spinal anesthesia - ANS ✓Reported when anesthesia, opioids, or steroids are injected into the subarachnoid or cerebrospinal fluid (CSF) space. May be either single injection or continuous catheter.
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What are the steps to help coders focus on quick and correct diagnosis code selection - ANS ✓-Identify reason for anesthesia service
- Review for other pertinent information and supporting diagnosis codes
- Check Alphabetic Index and then check the code in the Tabular List
- Locate main entry term
- Pay attention to notes listed in main terms
- Understanding coding conventions (See ICD- 9 - CM Official and Additional Conventions)
- Look for additional instructions in the tabular (numeric) section
- Make sure code is to highest level of specificity
- Assign pertinent related ICD-9 code Pain Diagnoses codes in ICD- 9 - ANS ✓Identified in 338 section. when provider is treating post-operative pain, a code from cat 338 is selected based on whether pain is acute or chronic. When the underlying condition causing the pain is treated, do no treport a code from cat 338. Instead, report code for condition causing the pain. Guidelines I.C. Add-on Codes - ANS ✓Procedures common carried out in addition to the primary procedure performed. Add-on codes may NOT be reported alone, and are identified with a + sign Anesthesiologist Assistant - ANS ✓A health professional who has completed an accreditied Anesthesia Assistant training program. Anesthesiologist - ANS ✓A physician who is licensed to practice medicineand has completed an accredited anesthesiology program. Anesthesia Time - ANS ✓Begins when the anesthesiologist ( or anesthesia provider) begins to prepare the patient for the induction of anesthesia and ends when the anesthesiologist (or anesthesia provider) is no longer in personal attendance.
