Comorbidities Flashcards
Right to Left Shunts
Tetralogy of Falot (VSOR) Transposition of the Great Vessels Truncus Arteriosus Tricuspid Atresia Total Anomalous Return
Causes of HTN
CKD Renovascular disease Chronic steroid therapy OSA Drugs (cocaine, amphetamine, supplements, OCPs) EtOH abuse Obesity Metabolic syndrome Thyroid/parathyroid disease Pheochromocytoma Coarctation of the aorta
Signs of end-organ damage from HTN
LVH Angina MI CHF CAD Stroke TIA CKD Retinopathy PAD
Diabetes Insipidus
Central (no ADH) vs Nephrogenic (unresponsive to ADH)
Tests: Urine specific gravity, serum osm, serum/urine lytes
Increased serum Na and osm
Urine specific gravity is low (<1.005)
Urine osm increases with ADH administration (CDI)
Txt:
- fluid replacement (D5W, 1/2NS at maintenance plus 2/3 previous hours UOP)
- desmopressin (DDAVP)
Lithium: signs of toxicity, drugs to avoid, anesthetic effects
skeletal muscle weakness, cognitive changes (sedation), ataxia, widening QRS, AV heart block, hypotension, seizures; avoid thiazides, NSAIDS, ACEIs; administer Na containing fluids to prevent excessive renal reabsorption of lithium; reduces anesthetic requirements and prolongs depol NMBs and nondepol NMBs
Optimization of thyroid status
endocrine consult, continue PTU (inhibits organification of iodide, synthesis of thyroid hormone, and peripheral conversion of T4 to T3), give propranolol (txt hyperadrenergic state and peripheral conversion of T4 to T3), give steroid (reduce hormone release and conversion), optimize hydration, correct electrolyte abnormalities, prepare to treat HD instability, arrhythmias, and thyroid storm
RA systemic manifestations
Due to vasculitis that develops secondary to deposition of immune complexes: pericardial thickening, pericardial effusion, pericarditis, myocarditis, aortitis, cardiac valve fibrosis, myocardial ischemia, diastolic dysfunction, pulmonary hypertension, dysrhythmias, pleural effusions, pulmonary fibrosis, interstitial lung disease, peripheral neuropathy (CTS), liver dysfunction, kidney dysfunction, mild anemia, joint disease (affecting airway). Commonly associated with Sjogren syndrome (keratoconjunctivitis and xerostomia).
RA Txt
NSAIDs, steroids, DMARDs ( methotrexate, sulfasalazine, azathioprine)
Hypothermia
coagulopathy, cardiac dysrhythmias, impaired renal function, poor wound healing; dec CMRO2 by 7%/C below 36C
GCS
MoVE: 6, 5, 4
Motor (obeys, localizes, withdraws, decort, decereb, none)
Voice (oriented, confused, inappropriate, incomprehensible, none)
Eyes (spont, speech, pain, none)
3-15; 0-8 severe, 9-12 mod, 13-15 mild
ARDS
pulmonary manifestation of SIRS; injury to capillary alveolar membrane
Berlin Criteria:
1) P/F ratio <300 (mild 200-300, mod 100-200, sev <100)
2) acute onset (<7d)
3) bilateral infiltrates
4) resp failure (“not fully exp by cardiac failure or fluid overload”)
OSA
inc risk of perioperative complications: resp depression, airway obstruction, hypoxia, hypercarbia
AHI >30 severe, 16-30 mod, 5-15 mild
- require longer postop stay for monitoring (3h longer than non-OSA patients)
- keep for 7h after the last episode of airway obstruction or hypoxemia
- use CPAP/NIPPV in PACU if patient uses at home
RCRI
1) IDDM
2) Hx of MI
3) Hx of CHF
4) Hx of CVD
5) CKD (Cr >2)
6) High risk surgery (suprainguinal vascular, intraperitoneal, intrathoracic
Risk of MACE: 0=4% 1=6% 2=10% >2=15%
Preeclampsia
Mild:
1) SBP >/=140 or DBP >/=90 on 2 readings 4h apart
2) proteinuria (24h Upr >/=300 or P:C 0.3)
3) >20 WGA
Severe:
1) SBP >/= 160 or DBP >/= 110
2) renal insufficiency (Cr >1.1 or doubled)
3) CNS disturbance (HA, vision change)
4) pulmonary edema
5) liver dysfunction (ALT/AST doubles)
6) epigastric or RUQ pain
7) thrombocytopenia
methemoglobinemia
SpO2 = 85%
Causes: benzocaine, prilocaine, other oxidizers
Level >10% can lead to cyanotic appearance
<30% - no tissue hypoxia
30-50% - signs and symptoms of tissue hypoxia
>50% - coma or death possible
Txt: 100% O2 + exchange transfusion vs methylene blue (2mg/kg over 3-5 min; repeat after 30min; NOT in G6PD def)
MG vs LEMS
MG:
- Ab to post-synaptic nAChR
- ext weakness +/- bulbar symptoms (diplopia, ptosis, dysphagia, dysarthria)
- cardiac manifestations as well (HTN, AV block, Afib, myocarditis, cardiomyopathy)
- txt w/ AChE inh to inc Ach
- resistant to Sux (1.5-2mg/kg)
- sensitive to NDMR (red dose 1/2)
- associated w/ thymoma, hyperthyroidism, pernicious anemia, RA, SLE, neonatal muscle weakness
LEMS:
- Ab to pre-synaptic Ca channel preventing release of ACh
- weakness
- sensitive to depolarizing and nondepolarizing NMBs
Edrophonium (tensilon) test - diagnosis of MG and differentiate MG exacerbation from cholinergic crisis
CSW vs SIADH
CSW: hypovolemic, nml ADH, UNa >100, Uosm low or normal, polyuria
SIADH: euvolemic, inc ADH, UNA <100, Uosm high, decreased UO
Txt for CSW: fluid replacement, no diuresis
Txt for SIADH: water restriction, diuresis, demeclocycline, Na replacement
Extubation Criteria
TV >5ml/kg VC >10ml/kg SpO2 >90% on <50% FiO2 PaCO2 <50 PEEP =5 awake and cooperative intact airway reflexes
Smoking cessation
- reduced COHb
- dec nicotine effects on CV system
- improved mucous clearance/ciliary function
- 4 wks needed to dec risk of postop pulm complications
- 8 wks needed for risk to equal non-smoker
- may lead to permanent cessation
TRALI
1) acute onset of hypoxemia w/in 6h of transfusion
2) chest infiltrates w/out cardiomegaly
3) no evidence of atrial HTN (i.e. PAWP =18)
4) no preexisting ALI before transfusion
5) no other temporally related causes of ALI
- noncardiogenic pulmonary edema
- plasma containing blood products (WB, FFP, Plt, PRBCs)
- fever, chills, hypotension
- intrinsic inflammatory response w/in the lungs
DMD
-abnormal production of dystrophin
CV: cardiomyopathy, ventricular dysrhythmias, MR, pulm HTN, cor pulmonale, JVD, LE edema
RESP: wheezing, pulm edema, nocturnal desat and sleep apnea -> pulm HTN
AIRWAY: macroglossia
NEURO: possible neuro deficits, weakness
GI: delayed gastric emptying, diminished laryngeal reflexes
ENDO: chronic steroid use to inc muscle mass
**NOT considered associated with MH but administering sux to DMD patients can cause hyperkalemia and rhabdomyolysis (avoid sux in children =8yo)
Obesity
- airway management
- patient positioning
- pulmonary abnormalities (atelectasis, hypoxia, dec FRC, inc CC, rapid desat)
- OHS/OSA
- postop apnea
- metabolic syndrome (DM, HTN)
- CAD
- stroke
- DVT/PE
- OA
- NAFLD
- altered drug effects
Aortic Dissection
- massive hemorrhage
- propagation
- interruption of arteries arising from the aorta (end organ ischemia - cerebral, renal, coronary, mesenteric)
- spinal cord ischemia
- myocardial ischemia 2/2 HD effects of clamping
- renal insufficiency/failure
- respiratory failure
DeBakey:
Type I - asc aorta + thoracic or abdominal aorta
Type II - asc aorta only (not beyond the innominate)
Type IIIa - desc aorta to diaphragm
Type IIIb - desc aorta to aorto-iliac bifurcation
Stanford:
Type A - asc aorta +/- arch and desc aorta (Type I & II)
Type B - all cases where asc aorta not involved (Type III)
HTN
hemodynamic instability, CVA, MI, acute CHF, resp failure
Smoking
- inc risk of significant pulmonary disease
- bronchospasm
- hypoxia
- prolonged mechanical ventilation
- infection
- impaired wound healing
Physiological Changes of Pregnancy
RESP: FRC dec 20% TV inc 45% MV inc 45% RR no change O2 consumption inc 20-40% VC no change CC no change FEV1 no change FEV1/FVC no change Resp alkalosis (inc pH) w/ metabolic compensation (dec bicarb)
CV: CO inc 50% SV inc 30% HR inc 20% IV vol inc 45% SVR dec 20% MAP dec in mid-trimester 2/2 dec DBP
NEURO: Epidural space vol dec Epidural space pressure inc CSF volume dec LA dose req dec Sensitivity to LA inc MAC dec
Cirrhosis
CNS: encephalopathy
CV: dec PVR, inc CO, cardiomyopathy
RESP: intrapulm AV shunts, dec FRC, RLD, pleural effusion, attenuation of HPV, hepatopulmonary syndrome
GI: varices, portal HTN, dec gastric emptying, ascites
RENAL: hepatorenal syndrome
HEME: dec platelets, dec clotting factors, coagulopathy
MET EFFECTS: dilutional hypoNa, hypoK, hypoGlu, hypoAlb
Alcohol
Withdrawal:
- tremulousness w/in 6-8h
- hallucinations, seizures w/in 24-36h
- DT (confusion, agitation, autonomic instability) w/in 72h
Effects:
CNS: inc MAC, drug tolerance, cognitive impairment, cerebral atrophy, cerebellar degeneration, peripheral neuropathy
CV: cardiomyopathy
Other: cirrhosis, hypoGlu, dec plts, electrolyte abn, GI bleeding, inc aspiration risk, nutritional def
Delayed Emergence DDx
- residual anesthesia
- residual NMBs
- severe neurologic injury
- hypercarbia
- hypotension
- metabolic derangements
- hyper-/hypoGlu
- hypothermia
Liposuction
- tumescent (usually <3L fat removed)
- semi-tumescent (usually >3L and inc risk)
- laser or ultrasonic energy (safe, MAC/local usually)
Complications: fluid overload, pulm edema, LAST, systemic epi uptake, arrhythmias, pulm embolism
Max lido dose: 55mg/kg
Respiratory Distress in a Child
epiglottitis laryngotracheobronchitis (croup) FB aspiration tonsillitis pharyngitis pharyngeal abscess
Systemic Effects of GH
CV: HTN, CAD, cardiomyopathy
RESP: vocal cord palsy, OSA, glottic stenosis, difficult airway
ENDO: insulin resistance
MSK: skeletal and soft tissue overgrowth (hands, feet, nose, mandible, tongue, soft palate, tonsils, epiglottis), skeletal muscle weakness, OA
CDH - initial treatment
Delay surgery until medical stabilization; reduce pulm HTN that is causing R to L shunt through PFO and PDA; avoid PPV, est IV access, monitors, supplemental O2, intubate (RSI vs awake), NG/OG, vent w/ low TV and high RR, sedation (opioids and benzos), muscle relaxation, avoid hypothermia and metabolic acidosis; ABG, CXR, TTE/TEE; goal is preductal SpO2 of >85% w/ PIP <25; permissive hypercapnia (50) is ok.
If needed: PGE1 or NO, exogenous surfactant, high frequency oscillatory ventilation, ligation of the PDA (may result in RHF), ECMO
UV and UA cannulation and complications
2 UA + 1 UV
caudal traction to cannulate vein w/ intent to extend to cavoatrial junction; cephalad traction to cannulate artery w/ intent to extend to desc thoracic aorta
Cx: infection, sepsis, thrombosis, portal cirrhosis, endocarditis, cardiac tamponade, liver abscess, hemorrhage, subcapsular hematoma
ROP - pathophys and risk factors
Vasoproliferative retinopathy occurring in infants <44 weeks postconceptual age. Vasoconstriction and obliteration of retinal vessels leads to abnormal neovascularization.
RF: hyperoxia, prematurity, CO2 fluctuations, hypoTN, sepsis, RBC transfusions, cyanotic CHD, RDS, IVH, corticosteroid therapy, mechanical vent, hyperGlu, maternal DM, hypoxemia, fluctuations in O2, exposure to bright light, maternal antihistamine use within 2 wks of delivery
Relative contraindications to Mg therapy
ischemic cardiomyopathy (recent MI), myasthenia gravis, impaired renal function, concomitant Ca channel blocker therapy
EBV
90 - premature neonates and pregnant females 80 - full term neonates 70 - >3mo 65 - adult women 75 - adult men
Neonatal depression
May present with metabolic acidosis, persistent pulm HTN, persistent fetal circulation.
DDx: acute uteroplacental def, transient tachypnea of the newborn (retained fetal lung fluid), hypoglycemia, Mg toxicity, meconium aspiration, undiagnosed congenital anomaly
Pyloric stenosis
hypokalemic, hypochloremic, hyponatremic metabolic alkalosis; txt with volume resuscitation and correction of metabolic and electrolyte derangements then surgery (i.e. hydrated, pH 7.3-7.5, Na >130, K >3, Cl >85, Bicarb <30, UO >1); NS at first then supplement K after UO established; hydration is important bc kidneys reabsorb Na to fix dehydration which leads to bicarb reabsorption, H excretion, and worsening metabolic alkalosis
Postoperative apnea risk factors
postconceptual age <50 weeks, chronic lung disease, history of apnea and bradycardia, multiple congenital anomalies, sepsis, anemia, neurological abnormalities, narcotic administration, general anesthesia; monitor for 12-24h after GA if <50 weeks postconceptual age
Postextubation croup txt
dexamethasone (0.5mg/kg), humidified air, nebulized racemic epi, reintubation if necessary with smaller tube
STOP BANG
>2 high risk of OSA, 5-8 mod-sev OSA Snoring Tiredness Observed apnea Pressure (inc BP) BMI >35 Age >50 Neck circ >40cm Gender (male)
OSA vs OSH vs OHS vs Pickwickian syndrome
OSA: complete cessation of airflow for more than 10s, occurring 5 or more times per hr of sleep, despite continued resp effort against a closed glottis, & associated with a >4% decrease in SpO2.
OSH: 50% reduction in airflow for more than 10s, occurring 15 or more times per hr of sleep, and associated with a >4% decrease in SpO2.
OHS: condition that develops secondary to obesity or as long-term consequence of OSA; defined as obesity (BMI >30), daytime arterial hypercapnia (PaCO2 >45), nocturnal hypoxia, polycythemia (absence of known causes of hypoventilation)
Pickwickian syndrome: severe OHS where pulm HTN and RV failure develops
Factors to consider for outpatient surgery
severity of sleep apnea, anatomical and physiological abnormalities, coexisting diseases, nature of the surgery, type of anesthesia, need for postop opioids, adequacy of post-discharge observation, capabilities of the outpatient center
Circuit leak
circuit system, Y-piece, ETT connection, ETT cuff, gas flow meters, CO2 absorber, scavenging system, ventilation bellows
Causes of Afib and goals of txt
valvular disease, LVH. CAD, HTN, cardiomyopathy, SSS, pericarditis, hyperthyroidism, PE, excessive EtOH consumption, caffeine
rate, rhythm, anticoagulation
PONV risk factors & txt
Patient - female, nonsmoker, anxiety, hx of PONV or motion sickness
Anesthetic - volatile, N2O, neostigmine, intra- & postop opioids
Surgical - lap, ENT, NSGY, breast, plastics, strabismus, laparotomy
Txt: ondansetron, dexamethasone, promethazine, haloperidol
Safe discharge criteria
- stable vital signs
- controlled N & V
- absence of unexpected bleeding
- adequate pain control
- ability to walk w/out dizziness
- provision of D/C instructions and Rx
- pt acceptance of discharge
- responsible escort
Anaphylaxis vs anaphylactoid
- type 1 hypersensitivity reaction, occurs on second exposure to antigen, IgE mediated, manifests within 10min of exposure
- indistinguishable from anaphylaxis clinically, degranulation triggered by direct interaction with allergen, do not require prior sensitization, dose-dependent effects
Preop HTN in elective surgery
Delay at least 6-8 weeks to optimize BP for any patient who:
1) SBP >180 or DBP >110
2) SBP >140 or DBP >90 with end-organ damage
3) undergoing cardiac, carotid or pheo sx
End-organ damage: LVH, angina, MI, CHF, CAD, stroke, TIA, CKD, retinopathy, PAD
VEaL CHoP
Variable - Cord compression
Early - Head compression
Late - Uteroplacental insufficiency
ICD, PM
ICD - checked w/in 6mo
PM - checked w/in 12mo
indication, underlying rhythm & rate, PM dependency, type, manufacturer, programmability, functionality, behavior w/ magnet exposure, programmer device availability, alternative pacing modality, device out of path of shock/bovie/etc, continuous telemetry
Trisomy 21
Down’s syndrome
