diseases Flashcards
chronic obstructive pulmonary disorder (COPD)
• COPD is a common, preventable, and treatable disease. It is characterized by airflow obstruction that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.
A diagnosis of COPD should be considered in patients over the age of 35, who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’, or wheeze. The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry. Airflow obstruction defined by an FEV 1 /FVC ratio of <0.7 is used to diagnose COPD.
Forced expiratory volume in one second / Force vital capacity= Is decreased in obstructive (COPD) and normal in restrictive
Patients with a diagnosis of COPD have an increased risk of perioperative pulmonary complications.
The further the procedure from the diaphragm, the lower the complication rate.
Patidiabeteents with COPD, persistent wheeze, and functional limitations, despite bronchodilators, should be treated with perioperative glucocorticoids. Ideally, these patients should be reviewed by a respiratory physician preoperatively.
If patients have severe COPD, post-operative respiratory failure is likely after abdominal or thoracic surgery. Plan for elective HDU/ICU admission.
diabetes
not enough insulin produced in the pancreas to handle the amount of glucose in the blood. Due to obesity and older. Controlled with weight loss and diet. Oral hypoglycaemic agent enhance the release of insulin you produce (metformin). Usually stopped before surgery because they will be fasted and low in blood glucose and some drugs drop glucose in blood. Maybe insulin dependant if still not enough but usually non insulin dependent.
First on list
Gestational diabetes.
Side effects
- Delayed wound healing
- Poor micro circulation (small vessels in eye and small vessels in the kidney (renal impairment), autonomic neuropathy (at risk for pressure sores)),
- diabetic keto acidosis (medical emergency) LEARN - results form inadequate insulin dose to get rid of the glucose in the blood and develop blood acids called ketones. Happens to diabetics who don’t know that they are diabetic or poorly controlled. Excessive thirst and frequent urination.
- can be more prone to ischemic heart disease
- More risk for infection (natural immune response can’t get to the infection due to poor circulation).
- Increased blood glucose increase bacteria growth which is unable to be handled with poor micro circulation and causes infection.
Dextrose and insulin infusion drops potassium. Usually potassium in IV fluid solutions is used for this infusion.
Management
Monitering blood glucose pre op, peri op, and post op. especially for insulin dependant.
First on the list to limit fasting time.
Must have a one way valve to prevent insulin from going back up the line and either not being given or accidental high concentrated bolus.
Risks and benefits of a spinal anaesthetic
Spinal blockade = vasodilatation
* Diabetic have limited autonomic function so their drop in blood pressure may be more drastic
Risk of infection is increased in diabetic.
Specific drugs for diabetics
Glipizide - stimulate the release of insulin form the pancreas
Metformin - increase peripheral uptake of glucose and decrease gluconeogenesis.
DKA diabetic keto acidosis results from a relative or absolute insulin deficiency with a concomitant increase in counter regulatory hormones such as glucagon, catecholamines, cortisol, and growth hormone. Hyperglycaemia ensues
Hyperglycaemia causes osmotic fluid shifts from intracellular to extracellular compartments. The glucose load in the glomerular tubules exceeds the renal threshold leading to glucosuria and an obligatory osmotic diuresis. This diuresis causes a loss of sodium, potassium, and phosphate along with water and glucose.
= metabolic acidosis, hypotension, hypovolemea.
causes=
An underlying infection
Missed insulin treatment
First presentation of diabetes mellitus.
Initial management should focus on: Airway protection, if required Fluid resuscitation Insulin administration Assessment of severity Identification of cause
Ketosis causes delayed gastric emptying
Patients should be anaesthetized with full monitoring, with an arterial line in situ, and in theatre to facilitate continuous blood pressure monitoring post induction. An arterial blood gas (ABG) should be obtained before induction to give an indication of the degree of acidosis, and to ensure no hyperkalaemia, as succinylcholine is often used to facilitate intubation as part of a rapid sequence induction. Because of gastric stasis, the nasogastric tube should be aspirated before induction of anaesthesia.
Patients should be intubated with a rapid sequence induction with cricoid pressure. In view of the hypovoalemic state and the acidosis, anaesthesia must be induced with a combination of drugs that promote cardiovascular stability.
Regular (minimum hourly) monitoring of ABGs and blood glucose is mandatory. Patients should be ventilated to ensure no iatrogenic respiratory acidosis. Potassium needs to be kept within the normal range, and replaced as indicated. Blood glucose needs to be kept >14 mmol litre−1 whilst the patient is being treated with the FRIII.
obesity
Right ventricular failure. The work of the heart is so hard the ventricle dilates and can’t keep up so the pressure increases
Diabetes may co-exist
Hypertension
Increased blood supply
Extra weight on the airway causing lung collapse and become hypo perfused causing atylectisis.
Higher airway pressures in mechanical ventilation
Reflux
Desaturate quicker
Blood pressure measument becomes harder cause the cuff doesn’t fit right
Use of regional or spinal if appropriate
Hover mat
Staff safety risk.
Post op = sitting up right, TED stockings for DVT prophylaxis, =/- clexane, AB’s,
Difficult bad mask ventilation (OSA, upper airway obstruction), oro and nasal airways. Extra staff for two hand. Optiflow (need to open airway)
Difficult laryngoscopy= video laryngoscope. Potential fibreoptic scope. Step for anaesthetist. Stylet.
Difficult positioning = oxford help and pillows. Sitting up slightly for optiflow
More risk of bronchospasm= salbutamol
Rapid desaturation due to decreased FRC. =adequate pre oxygenation. Optiflow when intubating.
Reflux = RSI.
Difficult extubation = sitting up right. Optiflow on. Airway adjucts. Video laryngoscope available. Make sure muscle relaxant is fully reversed. Staged extubation catheter.
PVD
Narrowing of the vessels (arteriosclerosis is most common cause) and blood flow decreases, decrease in oxygen and nutrients to tissues, plaque build up.
Signs and symptoms:
- Sore legs when walking (intermittent claudication)
- anaerobic metabolism and lactic acid build up
- ischemia
- pain
- necrosis
- gangrene
- Renal and cardiac impairment
Causes/hand in hand:
- Smoking
- Increased cholesterol
- Family history
- Increasing age
- Hypertension
- Diabetes
- Overweight
Most likely to have ischaemic heart disease, increased risk of strokes, CAD, angina, lung disease, IHD.
Drugs:
Pre existing anti coagulants
Cross clamping - heparin (protamine is used to reverse)
Peri-op implications=
Pre op - thorough pre op assessment pref in clinic. Think about history, diabetes?, CAD?, IHD?, ECG, bloods done, blood thinners??, lung disease?, DVT risk??,
Intra op - full monitoring during, blood glucose if diabetic?, on blood thinners means no spinal and monitor bleeding?? Art line?
Post op - pressure sore risk, HDU post op, DVT risk, circulation monitoring
Rheumatoid arthritis
Rheumatoid arthritis, also called RA, is an autoimmune disease that causes inflammation, pain and swelling in the joints. Your body’s immune system fights off infections. In an autoimmune disease, your immune system attacks healthy tissue instead, creating inflammation. In rheumatoid arthritis, the immune system attacks the synovium, a thin membrane that lines the joints and makes a fluid that helps them move smoothly. Inflammation thickens the synovium, resulting in swelling and pain in and around the joints. The inflammation can damage systems throughout the body, including the skin, eyes, lungs, and heart. Inflammation narrows the arteries, raising blood pressure and reducing blood flow to the heart, for instance.
Signs and symptoms:
- can be anaemic from chronic disease
- Can affect mandibular joints making intubation more difficult.
- Sniffing air position can damage the joints
- Plural effusion (fluid around lung in pleural cavity)
- Rheumatoid nodules on lungs (can limit function)
- Pericardial effusion ( fluid around the heart in the pericardial cavity)
- fragile skin and vessels,
- contractures, bent fingers and hands make positioning difficult.
Complications from drugs:
NSAI - bleeding from NSAI causing platelet dysfunction, stomach ulcers, renal failure, may limit bone healing.
Prednisone (anti inflammatory)- immuno-supressent, (infections)
Corticosteroids = Corticosteroids cause insulin resistance, hypertension, hypercholesterolaemia and hypertriglyceridaemia
Management:
- Extra careful with positioning with delicate skin and contractures.
- Difficult for spinal if unable to bend into right position.
- Difficult airway potential is high (DI trolley)
- Might need smaller tube size due to ariternoid stiffness
- Difficult iv access potential
- Soft ban under BP cuff
- Softer tape
- Steriod induced suppression of the hypothalamic pituitary adrenal axis = patients receiving long term glucocorticoids (prednisone) for RA. Secondary adrenal insufficiency can be caused by acute trauma (eg surgery). Additioinal steriod cover is needed (hydrocortisone) as well as their usual prednisone.
A thorough history of the RA including severity and duration of the disease, drug treatments and systemic complications should be taken, and meticulous assessment of the airway should be performed. Screening for the cardiovascular complications described above, especially heart failure, should be carried out.
Care should be taken when examining rheumatoid patients who are often in pain and suffer with deformities that restrict simple movements (pronation, shaking hands) and fragile skin. The anaesthetist should note which movements are particularly difficult or painful and anticipate how this may affect positioning when performing procedures peri-operatively (e.g.intravascular access and regional nerve blocks
Involvement of the joints of the wrists and fingers also has implications for the postoperative analgesic plan, as the use of standard patient-controlled analgesia (PCA) may not be a realistic option.
The extent of neck flexion and extension should be assessed and documented, with the aim of avoiding exceeding this range peri-operatively
Temporomandibular joint involvement can make direct laryngoscopy very difficult. This can be assessed pre-operatively using the Mallampati score, mouth opening and mandibular protrusion.As discussed above, cricoarytenoid arthritis is vari-able in frequency, intermittent and often unrecognised.Patients have both joint and soft tissue swelling, so that the overall effect is of stenosis
1 Using a facemask or supraglottic airway device.
2 Using the smallest internal diameter tracheal tube possible.
3 Avoiding trauma at intubation.
The morbidity RA patients suffer due to synovial pathology is further complicated by a sustained systemic inflammatory response = associated with increased long-term cardiovascular risk. If remission is not achieved or acute flares not suppressed promptly, there is a prolonged state of poorly controlled inflammation, that may lead to further organ damage.
In addition to the joints of the limbs, the axial skeleton may be involved and present particular difficulties to anaesthetists with respect to airway management and patient positioning. Patients are often asymptomatic, and so a careful and focused history is required to detect subtle signs.
Head and neck manipulation during laryngoscopy and movement during transfer of anaesthetised patients may cause neurological injury to patients with subluxation.
Heart failure is a major cause of death in RA, with twice the risk compared with a control population; it probably contributes most to the excess mortality seen in RA patients
Anaemia is common. Patients with RA are therefore more likely to require perioperative blood transfusion
There should be a low threshold for ordering respiratory investigations (e.g. chest radiographs, arterial blood gases and lung function tests with flow volume loops) due to the possibility of pulmonary involvement (fibrosis, nodules, effusions) or respiratory myopathy.
Regional anaesthesia, if feasible, should always be considered, as it minimises neck movement and avoids airway manipulation. It also provides good postoperative pain relief and reduces poly pharmacy. Regional blocks, however, may be technically difficult due to severe lumbar and thoracic spine arthritis and loss of anatomical landmarks from contractures or deformities.Furthermore, if surgery is prolonged, positioning of the patient may be uncomfortable and the operation may outlast the duration of anaesthesia.
If a general anaesthetic is indicated and considered appropriate, there are several options for managing the airway depending on the patient and the type and duration of surgery.Laryngeal mask airways (LMAs) and other supra-glottic airway devices have the advantages of requiring minimal neck manipulation for insertion and causing relatively little trauma and subsequent laryngeal oedema compared with a tracheal tube. They may, however, be difficult to insert in patients with fixed flexion deformities of the neck, in which case are inforced LMA may be more appropriate.Tracheal intubation may be indicated depending on the patient’s size, aspiration risk and the type and length of surgery. There are several reasons why a difficult intubation may be encountered and should be anticipated, as discussed above.If tracheal intubation is indicated, neck manipulation should be minimised, ideally with manual, in-line stabilisation, even if there is no overt cervical spine instability.
Fibreoptic intubation is considered the appropriate and safer option in rheumatoid patients with an anticipated difficult airway or known cervical spine instability
Appropriate thrombo prophylaxis should be prescribed, as patients with RA tend to have a slower recovery and return to mobilisation. Patients with RA, in general, are considered to be in a hyper coagulable state
Pain should be adequately controlled to avoid delayed mobilisation, venous thromboembolism and chest infections. Opioid analgesia can be used in carefully monitored doses to reduce the incidence of side effects. Patients may find it difficult or impossible to use a PCA due to joint deformity and muscle weakness. In these cases, nurse-controlled analgesia or modified devices are possible alternatives.
- Inflammation of the cricoarytenoid joint can cause stenosis, leading to airway obstruction. Outline airway management considerations that would minimise trauma and the risks of post-extubation oedema.
Consider alternative techniques like Regional?? Sedation? LMA?
Look at anaesthetic history. Previous anaesthesia
Video guided and smaller tube to minimise trauma
Parker tip tube to avoid trauma.
Warm the tubes and lube them.
Narrow airway. Restricts breathing. Difficult to re intubate. Stridor. Respiratory arrest. Staged intubation if oedema is sever. Dexamethasone to reduce swelling Adrenaline nebuliser before and/or after
- Discuss five airway complications in obese patients and relate to the equipment you would consider sourcing for maintaining a safe airway in such a patient. (5 marks)
Difficult bad mask ventilation (OSA, upper airway obstruction), oro and nasal airways. Extra staff for two hand. Optiflow (need to open airway)
Difficult laryngoscopy= video laryngoscope. Potential fibreoptic scope. Step for anaesthetist. Stylet.
Difficult positioning = oxford help and pillows. Sitting up slightly for optiflow
More risk of bronchospasm= salbutamol
Rapid desaturation due to decreased FRC. =adequate pre oxygenation. Optiflow when intubating.
Reflux = RSI.
Difficult extubation = sitting up right. Optiflow on. Airway adjucts. Video laryngoscope available. Make sure muscle relaxant is fully reversed. Staged extubation catheter.
