Anesthesia Grabbag Flashcards
Aspiration on induction. WWYD?
Intubate immediately. Trendelenburg
Bronch and suction large particles
Do NOT lavage (can push down aspirate)
Sxn stomach for pH + bacteria analysis (<2.5 = pneumonitis)
No evidence for empiric abx or steroids.
4 things to do to investigate desat
Auscultate, EtCO2, PAWP, and tidal volumes
Why not extubate a patient that is cold?
1 reason: Thermal discomfort of the patient.
Also possible: altered mental status more likely from lower metabolism of the anesthetics than a direct effect of the temperature.
what causes stroke volume variation (SVV)
Increased intrathoracic pressure from ONE positive pressure breath 1st increases LV preload (and CO) while decreasing RH preload so that the 2nd beat of the left heart has less preload (and CO)
How do you measure abdomen pressures (for Abd compartment syndrome)?
Bladder pressures while patient is paralyzed. Can also measure direct pressures through belly wall or through fem vein
What are the effects of cirrhosis? (canned answer)
By system I’m worried about potential for AMS, high CO, varicesa and anemia, PPHTN, HPS, HRS, bleeding from lack of factors/platelets,
What are the systemic effects of abdominal compartment syndrome? (canned answer)
(add answer)
Normal intra-abdominal pressure?
Normal IAP in pregnant/obese/cirrhotic pts?
Normal: 0-5 mmHg
Preg/obese/cirr: 10-15 mmHg
pressure for Abd HTN? Abd Compartment Synd?
Abd hypertension is >= 12
Abd Compartment Syndrome >20 with signs of organ failure
what is hepatopulmonary syndrome? What is portopulmonary HTN
HPS: hypoxia from dilation of pulm vasculature (high CO->sheer stress–> vasodilator release–> misses crap liver–> dilates lungs)
PPHTN: pHTN in liver dz. (unclear cause but vasc smooth muscle hypertrophies and micro thromboses present)
How to treat portopulm HTN
Prostaglandins (inhaled like epoprostenol, IV like Veletri. Same as regular pHTN)
pharmacotherapy for varices
Betablocker. for acute bleeding give Octreotide
Components of MELD score
Bilirubin, INR, Creatinine
What are your concerns during the pre-anhepatic stage in liver txplnt
mostly bleeding (no factors, bad Plt, high CO), and hypotension from draining the ascites
What are your concerns during the anhepatic stage in liver txplnt
Low preload, hypothermia, hypoCa if you transfuse (because no liver to metabolize citrate)
Can give products and/or TXA to help with bleeding
What are your concerns during the neo-hepatic stage in liver txplnt
reperfusion syndrome (when clamp released): hTN, high K, acidosis
If gave TXA during anhepatic, must stop because can make pt hypercoagulable.
DDx for delayed emergence:
1) anesthetics
2) neuro (stroke, szr)
3) glucose
4) sodium/e-lytes
How do you differentiate between central and nephrogenic DI?
Administer ADH. Central will respond. Nephrogenic will not.
Na+ needs to be below __ for elective surgery?
150 mEq/L
Choice of anesthetic in a hypernatremic patient
Regional or neuraxial if possible to monitor mental status. Otherwise GA is fine.
Pt is hyperNa on presentation. What do you want to know?
Volume status. Mental status.
Rate of HypER-Na correction
No faster than 10 mEq/day.
Faster can cause cerebral edema
Rate of hypO-Na correction
Can go faster! 10 mEq every 6 hours.
Faster causes central posting myelinolysis
What is PRIS?
ACIDOSIS from propofol gtt. Rhabdo (and subsequent kidney failure), and cardiac failure. ICU not OR
What does the capnogram look like in bronchospasm
Delayed upslope. It is an obstructive process on exhale.
Dantrolene dose (loading and infusion)
Load: 2.5 mg/kg q5min up to 10 mg/kg
Infusion: 0.25 mg/kg/hr
Can continue up to 72 hrs after MH.
MH principals. What does it do?
Defect in IM Ca++ release channels
Hypermetabolism.
Acidosis, hyperK, tachy, temp. Hyper myoglobin.
Can happen minutes to hours after (including postop).
Treat numbers & symptoms. No Ca channel blockers.
Patient has masseter muscle rigidity after induction. Ddx? Concerns?
MMR 2/2 sux or volatile (correlation with MH volatile>sux)
Opioid rigidity
MH
Underdose of anesthesia/paralytic
Must observe for 12-24 hr for MH symptoms. Can continue case if mild.
How do you do a superficial cervical plexus block?
U/s transverse posterior to the SCM and halfway between the mastoid process and the C6 transverse process (Chassaignac tubercle). Needle in plane posterior to anterior. nerves are right behind the SCM
Oxyhemoglobin dissoc curve. What shifts left? Right? What does this mean?
pO2 is X, Hgb saturation is Y. So R means more O2 needed to saturate (favors tissues) left means less (favors Hgb).
Left shifts: lower CO2, H+, temp; also met-Hb, CO-hb, fetal-Hb
Right Shifts: HIGHER CO2, H+, Temp, DPG
What tests are ordered to confirm the likely presence of PHEOCHROMOCYTOMA
Urine VMA and total metanephrines (metabolites of NE and Epi respectively)
Patient presents with for pheo removal. What other conditions are you worried about?
1: Cardiomyopathy (from catecholamines). Also LVH,
#2: syndromes: MEN II (look at thyroids, parathyroids) and vonHL (eyes brain)
Also: hyperglycemia (no tmt needed), hypoMag
Are there any drugs you would avoid in this patient with renal failure
Drugs dependent on renal elimination or have active metabolites that can accumulate (atropine, glycopyrrolate, ketamine, morphine, Demerol). Also, reduce doses of drugs that are highly protein bound (BZDs)
Canned answer: what can cause hypoxia right after intubation:
1) Intubation of the esophagus
2)main stem intubation
3) inadequate ventilation
3) atelectasis
4) bstruction of the ET tube
5) delivery of a hypoxic gas mixture
You shouldn’t start BBs on DOS. For those @ high risk for aFib, what should you give?
Diltiazem (CCBs).
Those at risk are: old males with COPD and CAD.
Ddx for post incision hypotension. Always consider:
1) surgical bleeding/hypovolemia
2) tension ptx
3) hypoxia
4) arrhythmia
5) anesthesia overdose
PPeak elevated, PPlateau nml
Airway problem (bronchospasm, obstruction, etc.)
PPeak and PPlateau both elevated
Resistance! From lung, chest wall, or abd compartment.
Model for Improvement and PDSA
1) what are we trying to accomplish?
2) How do we measure change?
3) What changes can we make that will result in Improvement?
Plan, Do, Study, Act
Lean-Six Sigma (DefMAIC)
Define (goals)
Measure (Baseline, metrics)
Analyze (study current system)
Improve (implement new measures in small area and test them, educate)
Control (make new system permanent)
Standard extubation criteria
Awake, following cmds, paralytics reversed, gag reflex intact, vital capacity >10mL/kg, Vt >6mL/kg, inspiration force > 20cmH2O, SpO2 >90% on room air, RSBI <100
Steps for every vital sign crisis:
1) Verify
2) temporize
3) physical exam/machine or tube check/check surgery
4) treat
