Cer.A.T.T. cheat sheet

High-pressure leak test: with the cylinder valve open and the yoke closed, the cylinder pressure gauge should hold steady; a falling gauge indicates a leak at the yoke, valve, or regulator.

Oxygen E-cylinder at 2000 psi holds roughly 660 L; because gas volume is proportional to gauge pressure, 1000 psi represents approximately 330 L remaining.

Nitrous oxide cylinder pressure remains near 745 psi at room temperature as long as liquid phase is present, so pressure is not a measure of remaining contents.

Pipeline oxygen and nitrous oxide are supplied at approximately 50 to 55 psi; DISS connectors are gas-specific and prevent cross-connection of hoses.

The Pin Index Safety System gives each gas a unique two-pin pattern on the yoke; an oxygen E-cylinder uses pins 2 and 5.

The oxygen failure safety device sounds a whistle alarm and shuts off nitrous oxide when oxygen supply pressure falls below approximately 30 psi.

Vaporizer interlock prevents two vaporizers on the same manifold from being turned on simultaneously, avoiding delivery of an unintended combined concentration.

Low-pressure leak test: with the machine off, confirm the system from flowmeters to common gas outlet holds pressure (for example, a fully deflated test bulb stays deflated for at least 10 seconds).

NIOSH recommends limiting occupational exposure to 25 ppm nitrous oxide and 2 ppm halogenated agents as an 8-hour time-weighted average; scavenging must be connected and functioning.

Normal end-tidal CO2 in a healthy adult is 35 to 45 mmHg; an abrupt fall to zero suggests disconnection, extubation, or esophageal intubation.

A gradual rise in end-tidal CO2 accompanied by rising temperature and heart rate should prompt evaluation for increased metabolism, including malignant hyperthermia.

Pulse oximetry is degraded by poor perfusion, motion artifact, and abnormal hemoglobins; carboxyhemoglobin reads falsely high and methemoglobin reads falsely low.

Oxyhemoglobin dissociation curve: SpO2 of 90% corresponds to a PaO2 of about 60 mmHg; P50 is approximately 27 mmHg and shifts right with acidosis, hypercapnia, and hyperthermia.

Noninvasive blood pressure cuff bladder width should be about 40% of arm circumference and length about 80%; a cuff that is too small falsely elevates the reading.

Level arterial and central venous transducers at the phlebostatic axis (fourth intercostal space, midaxillary line); each 1 cm of vertical offset changes the reading by about 0.74 mmHg.

Train-of-four ratio greater than 0.9 at the adductor pollicis indicates adequate recovery from nondepolarizing neuromuscular blockade; a ratio below 0.7 predicts residual weakness.

Mean arterial pressure = (systolic + 2 x diastolic) / 3; a MAP below 65 mmHg is commonly used as the threshold for inadequate organ perfusion.

Adult MAC values in oxygen: sevoflurane approximately 2.0%, isoflurane approximately 1.15%, desflurane approximately 6%, nitrous oxide approximately 105%, so nitrous oxide alone cannot achieve 1 MAC at 1 atmosphere.

Succinylcholine 1 to 1.5 mg/kg IV produces paralysis in 45 to 60 seconds lasting 5 to 10 minutes; prolonged block suggests pseudocholinesterase deficiency.

Rocuronium 0.6 to 1.2 mg/kg; sugammadex dosing is 2 mg/kg at a train-of-four count of 2, 4 mg/kg at post-tetanic count 1 to 2, and 16 mg/kg for immediate reversal.

Neostigmine 0.03 to 0.07 mg/kg (maximum 5 mg) is paired with glycopyrrolate 0.2 mg per 1 mg of neostigmine to blunt bradycardia and secretions.

Adult cardiac arrest epinephrine dose is 1 mg IV/IO of the 1:10,000 concentration every 3 to 5 minutes.

Local anesthetic maximum doses: lidocaine 4.5 mg/kg plain and 7 mg/kg with epinephrine; bupivacaine 2.5 mg/kg plain and 3 mg/kg with epinephrine.

Local anesthetic systemic toxicity: stop injection, secure airway with 100% oxygen, treat seizures with benzodiazepines, and give 20% lipid emulsion 1.5 mL/kg bolus then 0.25 mL/kg/min.

Common IV induction doses: propofol 1.5 to 2.5 mg/kg, ketamine 1 to 2 mg/kg, etomidate 0.2 to 0.3 mg/kg.

Controlled substance records must reconcile amount removed, amount administered, and amount wasted, with a second licensed witness signature on the waste.

Adult endotracheal tube internal diameter is typically 7.5 to 8.5 mm for males and 7.0 to 7.5 mm for females; oral depth at the incisors in cm is approximately 3 times the tube internal diameter.

Pediatric uncuffed tube internal diameter in mm is estimated as (age in years / 4) + 4; a cuffed tube is chosen one half size smaller.

Continuous waveform capnography is the gold standard for confirming and continuously monitoring endotracheal tube position.

Preoxygenation with 3 to 5 minutes of 100% oxygen or 8 vital-capacity breaths denitrogenates the lungs; an end-tidal oxygen above 90% indicates an adequate reservoir.

Mallampati class I to II predicts an easier laryngoscopic view; class III to IV correlates with difficult laryngoscopy and warrants a stated backup plan.

Difficult mask ventilation predictors follow the MOANS mnemonic; difficult intubation predictors follow LEMON (Look, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility).

Supraglottic airway cuffs should be inflated only to the manufacturer-recommended volume and pressure; pressures above about 60 cm H2O risk mucosal ischemia and nerve injury.

Cricoid pressure (Sellick maneuver) applies approximately 20 to 30 N during rapid sequence induction and should be released if it impedes ventilation or intubation.

WHO 5 moments for hand hygiene: before patient contact, before an aseptic task, after body fluid exposure risk, after patient contact, and after touching patient surroundings.

Alcohol-based hand rub requires 20 to 30 seconds; soap and water requires 40 to 60 seconds and is required when hands are visibly soiled or after exposure to Clostridioides difficile spores.

Spaulding classification: critical items entering sterile tissue require sterilization; semicritical items contacting mucosa, such as laryngoscope blades, require high-level disinfection.

Chlorhexidine-alcohol is preferred for surgical site skin preparation; it must dry completely both for antimicrobial effect and to prevent ignition of pooled alcohol by electrosurgery.

The sterile field border is approximately 1 inch (2.5 cm) around the drape edge; items below table level or outside the border are considered contaminated.

Hydrophobic bacterial-viral filters with 0.2 micron pores placed at the airway reduce circuit contamination and are changed when wet, soiled, or per manufacturer interval.

Known or suspected pulmonary tuberculosis requires an N95 respirator and a negative-pressure room; standard precautions alone are insufficient.

After a contaminated needlestick, wash the site with soap and water without squeezing or scrubbing, report immediately, and obtain source testing and post-exposure prophylaxis evaluation.

ASA physical status: I healthy; II mild systemic disease; III severe systemic disease; IV constant threat to life; V moribund; VI brain-dead organ donor; suffix E denotes emergency.

A sentinel event is an unexpected occurrence involving death or serious harm; it triggers a root cause analysis and reporting under Joint Commission requirements.

Universal Protocol has three elements: preprocedure verification, marking of the procedure site, and a time-out with the full team immediately before starting.

Malignant hyperthermia management: stop triggers, 100% oxygen at high flow, dantrolene 2.5 mg/kg repeated to 10 mg/kg, active cooling, and treatment of hyperkalemia and acidosis.

NFPA 99 requires oxygen cylinders to be separated from flammable gas cylinders by at least 20 feet or a noncombustible barrier at least 5 feet high with a 1-hour fire rating.

The OSHA Bloodborne Pathogens Standard requires an exposure control plan, offered hepatitis B vaccination, personal protective equipment, and sharps disposal in puncture-resistant containers.

Anesthesia gas scavenging systems are designed to keep nitrous oxide below 25 ppm and halogenated agents below 2 ppm over an 8-hour time-weighted average.

Closed-claims analyses consistently identify respiratory events, including inadequate ventilation and esophageal intubation, among the leading causes of anesthesia-related injury.

The anesthesia record documents preanesthetic evaluation, informed consent, drugs and doses, vital signs at defined intervals, monitors used, airway management, and postanesthesia condition.

SBAR structures handoff communication into Situation, Background, Assessment, and Recommendation to reduce omissions during transitions of care.

HIPAA permits disclosure of protected health information for treatment, payment, and operations, subject to the minimum necessary standard.

Valid informed consent requires patient capacity, disclosure of risks, benefits, and alternatives, and voluntariness; the anesthesia provider confirms and documents consent before sedation.

Escalation through the chain of command is indicated when a patient safety concern is not resolved at the immediate supervisory level.

Controlled substance documentation must record amount removed, administered, and wasted, with a witness signature for any waste.

Just culture distinguishes human error, at-risk behavior, and reckless behavior, encouraging error reporting while still addressing reckless conduct.

Delegated tasks must fall within state law, facility policy, and certification scope; the supervising anesthesia professional retains overall responsibility for patient care.

Adult cardiac arrest: compressions at 100 to 120 per minute with a depth of 5 to 6 cm, minimize interruptions, epinephrine 1 mg every 3 to 5 minutes, and rhythm checks every 2 minutes.

Perioperative anaphylaxis: stop the trigger, give epinephrine 0.3 to 0.5 mg IM of 1:1000 or 20 to 50 mcg IV boluses, provide 100% oxygen and rapid crystalloid, and use antihistamines only as adjuncts.

Malignant hyperthermia cart contents include dantrolene, sterile water for reconstitution, cooling equipment, sodium bicarbonate, calcium chloride, and antiarrhythmics; avoid calcium channel blockers with dantrolene.

Airway fire response: stop gas flow, remove the tracheal tube, extinguish burning material with saline, ventilate with air, and assess the airway for thermal injury.

RACE (Rescue, Alarm, Contain, Extinguish or Evacuate) guides general fire response; PASS (Pull, Aim, Squeeze, Sweep) guides extinguisher use.

Loss of pipeline oxygen: switch to E-cylinders, disconnect the pipeline supply, and calculate available time from cylinder volume and current flow rate.

Local anesthetic systemic toxicity: stop injection, secure the airway with 100% oxygen, control seizures, give lipid emulsion, and consider extracorporeal support for refractory collapse.

Power failure: the anesthesia ventilator may stop, so ventilate with a self-inflating bag, switch monitors to battery power, and keep a flashlight immediately available.