Action steps Flashcards
Intraop actue hypoxia actions
- check the color of the patient
- check for a pulse
- Check all vital signs
- check for ETCO2
- Take the patient off the ventilator and hand bag with 100% O2
- Call for help
- check the o2 monitor, peak airway pressure, and capnograph waveform
- listen to the chest for bilateral breath souds. note chest rise (unilateral breath sounds: ETT is too deep, PNX, or tension PNX)
- evaluate the ett. rule out kinking, mucus plug, herniated cuff. Pass the suction catheter or fiber optic scope. Check fro proper placement and position
- listen to the chest for wheezing. give aerosolized albuterol for wheezing
- if you thnk that the patient has bronchospasm, deepen the anesthetic
- if deepening the anesthetic does not treat the bronchospasm, give IV epinephrine
- order a chest x-ray
Approach to reading EKGs
Rhythm: sinus or non-sinus
Regularity: regular or irregular
P wave: generated by atrial depolarization, best in lead 2 and V2, should be 2.5mm long and 2.5mm high
PR interval: generated by conduction fo the elctrical impulse through the atria and the AV node. should not be longer than 0.2 sec (5mm). 2nd degree type 2 and 3rd degree heart block require pacing
Q wave: should not be longer than 0.03 sec (could be sign of prior transmural infarction
QRS complex: ventricular depolarization and contraction: normal duration up to 0.12 seconds. Longer duration sign of hemi-block in the His bundles.
ST segment should be isoelectric. If depressed there is myocardial ischemia. If elevated there is myocardial necrosis. This is measured by the computer on the monitors and we need to take them seriously. Most sensitive lead for diagnosis of ischemia is V5. Next most sensitive lead is V4.
T wave: ventricular repolarization: should not be longer than 0.2 seconds. Should be concordant with total amplitude of QRS complex.
Axis: normal values range between -30 and +110 degrees. Look at the total amplitude of lead 1 and lead aVf. The vector of these 2 leads is where the axis lies.
Anticipate massive blood loss
Large bore IV access
Large bore central introducer
Rapid transfuser and blood warming devices in room
10-15 units RBCs and 5 units FFP in room with additional in blood bank
Plan for intraop cell salvage
Discuss further possible interventions with surgeon: acute normovolemic hemodilution, administration of antifibrinolytic, such as aminocaproic acid or tranexemic acid.
QI Steps
-Measure current outcomes and benchmarks if appropriate
• Devise change in practice in collaboration with stakeholders if appropriate
• Educate and train clinicians regarding change in practice as appropriate
• Implement change in practice
• Measure outcomes after change in practice
Hypernatremia action steps
H&P: current meds, mental/neuro exam, determine volume status and water intake, signs and symptoms: thirst, diaphoresis, sweating, vomiting, polyuria
Measure urine osmolality, sodium concentration, integrity of ADH-renal system: urine osmolality should be 700-800 and additional ADH should not increase it.
Causes of hypernatremia with Uosm 700-800: unreplaced insensible loss: urine sodium concentratin should be less than 25 mEq/L, GI losses: urine sodium concentration should be less than 25 mEq/L, sodium overload: urine sodium concentration above 100mEq/L, defect in thirst: rare
If urine osmolality (Uosm less than 300 mOsm/L) is lower than plasma osmolality: consider diabetes insipidus
Administer ADH to distinguish between nephrogenic and central diabetes insipidus: give 10 mcg nasal synthetic desmopressin (DDAVP) or 5 units vasopressin subcutanesously.
Nephrogenic: little or no response to ADH
Central: appropriate increase in Uosm by greater than 50%
Consultation with nephrologist, endocrinologist, or neurologist to aid in diagnosis of diabetes insipidus
Measure urine solute concentration to confirm osmotic diuresis: gulcose and urea
PSVT treatment
vagal maneuvers
adenosine 6mg rapid, followed by second and third dose if needed at 12-18mg per bolus
verapamil 2.5-10mg IV
Amiodarone 150mg infusion over 10 min
esmolol 1mg/kg volus IV and 50-200 mg/kg/min infusino
edrophonium 5-10mg IV bolus
give phenylephrine 100mcg IV if the patient is hypotensive
digoxin 0.5-1.0 mg IV
rapid overt pacing ina n attempt to capture the ectopic focus
Synchronized cardioversion in incremental doses of 50, 100, 200, 300, 360 joules; this shol dbe done immediately if the patient is hemodynamically unstable.
treatment hypernatremia
determine volume status:
hypervolemia: diuretics and hemodialysis may be necessary
Free H2O deficit (in L of H2O) = {(plasma Na/140)-1} x kg x 0.6 in males (0.5 in females)
Goal less than or equal to 145
Replace half the deficit in first 24 hours, then other half over 2-3 days
Use 5% dextrose in water or 0.45% NaCl to correct the deficit
Monitor serum sodium every 1-2 hours to ensure a gradual correction (should not exceed 0.5 mEq/L per hour)
treatment of diabetes insipidus
DDAVP
IV dosing 2-4 mcg, 1-2 times per day
Nasal spray 10-40mcg 1-2 times per day
Titrate to urine output, serum sodium, osmolality
Low Na diet
Low-dose thiazide diuretic
Carbamazepine: enhances vasopressin secretion
NSAIDS: impair renal prostglandin syntehsis, potentiate ADH action resulting in incrased urine osmolality and decreased urine volume.
How would you awake intubate and induce this patient
I would
- optimize asthmatic condition with inhaled b-agonist
- provide aspiration ppx
- administer antisialogogue
- ensure adequate IV access, presence of fluids, emergency medications, difficult airway cart
- surgeon in room?
- place patient in position most comfortable (supine if no anterior mass etc)
- cannulate the femoral arteries with CPB on stand by
- provide adequate airway analgesia
- administer ketamine or dexmedetomidine
- eval airway with fiberoptic scope
- intubate with fiberoptic scope
- perform inhalational induction
laryngospasm action steps
I would: suction the airway apply positive pressure mask ventilation deepen anesthetic by... administer IV propofol (lido if spont resp) forceful jaw thrust call for help succinylcholine if no contraindication attempt to pass ETT through closed vocal cords
how will you induce cabg patient
assuming his airway were reassuring i would
place appropriate monitors
position in reverse t to improve resp mechanics, faciliate rapid intubation and reduce risk of passive regurg
note bseline cardiac function
preox with 100% fio2 and tight mask seal
provide aspiration ppx and apply cricoid pressure
induce with x meds and high dose of narcotics to avoid cv depression
intubate the patient
goals to provide a sufficient level of anesthesia to blunt the sympathetic response to intubation, while matinaining hemodynamic stability and safely securing the airway
acute hypotension after induction action steps
i would 100% o2 ensure adequate vent and oxyg auscultate the chest verify the BP check the ekg confirm ETT position obtain filling pressure and CO from PA cath check electrolytes
decrease volatile
fluid bolus
tburg
small dose direct acting vasopressor
treat conservatvely if concern from tachycardia/htn
how prepare to wean off cpb
ensure normothermia
correct any anemia, electrolte abnormalities/metabolic disturbances
turn on and check alarms and monitors
recalibrate and zero transducers
check lung compliance and initiate ventilation
snure the heart is de-aired
ensure adequate cardiac function using TEE and other hemodynamic data
administer benzos to preven awareness during reqarming
ensure availability of pacing device and resusciation drugs
during warming closely onitor cardiac fxn and administer inotrops and vasoactive drugs as necessary
manage intraop malignant hyperthermia
I would:
call for help
call the MH hotline
discontinue all triggering agents
change to a clean circuit (new machine or O2 tank with ambu bag)
hyperventilate with 100% o2
start IV dantrolene 2-2 mg/kg IV bolus q5min up to 10 mg/kg, then start an infusion of 1-2 mg/kg/hr
monitor and treat acidosis with sodium bicarbonate
cool the patient aggressively with cooling blankets, cold IV NS, cold body cavity lavage, ice bags to the body (goal temp 38-39)
closely monitor urine output with a foley catheter. Maintain goal UOP greater than 1-2 ml/kg/hr using fluids, furosemide (1mg/kg IV) and amnnitol (0.25gm/kg IV) and watch for signs of myoglobinuria
send off frequent labs, ABG/VBG, electrolytes, hepatic fxn, coag panel, CBC, CK, serum glucose, urine myoglobin (follow closely for 24-48 hours)
treat hyperkalemia with combo of 0.1-0.2 U/kg of regular insulin and 500mg/kg of dextrose IV, calcium or bicarb
treat any arrhythmias that develop using amiodarone, lidocaine, adenosine, procainamide, or any other drugs indicated according tot he ACLS protocol. Dysrhythmias usually subside with resolution of the hypermetabolic phase (DO NOT use calcium channel blockers to treat them bc can worsen hyperkalemia)
correct metabolic acidosis with 1-2 mEq/kg IV of sodium bicarb based on arterial pH
have the surgeon stop the surgery as soon as possible; expedite or abort
consider a-line and central line
manage post-op MH
alkalinize the urine and diurese, monitor for acute renal failure
follow CK levels to track the severity of the rhabdo
follow all labs and vital signs closely (watch out for hypothermia, hyperkalemia, hypokalemia, hypervolemic overshoot)
watch for signs of DIC, including thrombocytopnenia, hemolysis, abnormal bleeding
elevated liver fxns often in 12-36hrs post MH crisis
follow CNS serially
continue dantrolene 1mg/kg IV q4-6 hrs for up to 72 hrs after episode
submit forms to MH registry
continue to monitor the patient for upt o 72 hours in the SICU. measurements should include urine output, arterial blood gases, pH, serum electrolyte concentrations.
difficult airway algorithm
optimize oxygenation throughout
limit attempts
call for help
if can mask:
limit attempts and consider awakening the patient
consider alternative intubation approaches, invasive access, or feasibility of other options
if can’t mask -> LMA
if LMA fails, limit attempts and consider invasive access, call for help
alternative approaches as prepare for invasive airway
in peds consider ecmo
triggers for awake intubation
suspected difficult DL
suspected difficult ventilation with face mask/SGA
significant increased risk of aspiration
increased risk of rapid desaturation
suspected difficult emergency invasive airway
determine cause of elevated creatinine
review meds and history
check urine na levels, urine osmolality, urine-to-plasma Cr ratio, urinary sediment level
Fluid challenge: if improve then pre-renal
If urine Na >10 and granular casts then its ATN
Hepatorenal syndrome has no improvement with fluid challenge, no proteinuris, low urinary Na conc, serum sodium <130
Care for patient with hepatic encephalopathy
rule out other causes of mild confusion (drugs, wernicke’s for alcoholic)
treat inciting factors (bleeding varices, infection, hypovolemia, anemia)
eval for elevated ICP
avoid hypokalemia (increases ammonia production)
maintain normal art pH (alkalemia inc diffusion of mamonia accros blood brain barrier)
correct hypovolemia/anemia (optimize liver metabolisim of circulating toxins
cautious with psychoactive drugs (benzos)
induce with aspiration risk
assuming reassuring airway, hemodynamic stability, appropriate monitors
administer metoclopramide H2 blocker sodium citrate reverse trendelenburg pre-oxygenate 100% for 5 min cricoid pressure lidocaine/fentanyl propofol paralytic rapidly secure the airway
treat hyperkalemia
calcium chloride or gluconate
ensure access to defibrillator and prepare to treat dysrhythmias
correct contributing factors (acidosis, hyponatremia, hypocalcemia)
administer insulin and glucose, b2 adrenergics (albuterol), sodium bicarb
hyperventilate the patient to promote alkalosis
consider hemodialysis
neonatal resuscitation
warm, clear airway prn, dry/stimulate/reposition
evaluate respirations, HR, color
if apnea, HR < 100, or persistent cyanosis, then positive pressure ventilation
then if HR > 100, post-resus care
but,
if HR <60, chest compressions,
then epi (0.01mg/kg IV or 0.1mg/kg ETT) and/or volume (10 ml/kg o-neg blood, NS, or LR; albumin icnr mortality)
drugs in neonatal resuscitation
bicarb - 4.2%, only if prolonged resuscitation and documented acidosis, 2 mEq/kg via umbilical catheter
naloxone - 0.01 mg/kg IV/IM/SQ/ETT but not if opioid addicted mother cuz could withdraw
epi - (0.01mg/kg IV or 0.1mg/kg ETT) for asystole or persistent bradycardia despine 30 sec of effective ventilation and chest compressions. can repeat q 3-5 min
atropine - 0.02mg/kg IV or 0.03 mg/kg ETT for bradycardia
calcium gluconate - 100mg/kg over 5-10 min for low CO IF FROM MAGNESIUM TOXICITY (mom on Mg infusion); keep on continuous EKG
fluids - o-neg or maternally cross-matched blood 10 ml/kg; or NS/LR 10 ml/kg; def not albumin (increased mortality)
HELLP tx
mg
control bp (SBP<160 and DBP<105)
correct coagulopathy
corticosteroids for fetal lung maturity as time permits
How to diagnose a PE
gold standard in pulmonary angiogram
Lab not typically used
Imaging: V/Q scan for patients with renal failure, CT scan is faster though, CT angiogram combined with CT venography has a higher sensitivity for VTE but does not rule out PE if negative
Actions to reduce ICP
make sure no venous obstruction
elevate head 15-30 degrees
mannitol (only if BBB intact)
furosemide (unless hypovolemic)
barbiturate (reduce ICP and CMRO2)
