Guidelines/Indications/Risk Factors Flashcards
ASA recommendations for preop EKG
Age greater than 50. Good for 1 year if 50-69. Good for 6 months if over 69
Hx of CV disease or HTN. Good for 6 weeks if significant CV disease. Mandatory if the pateint has a change in cardiac sx: SOB, CP, etc
Hx DM: EKG required if age greater than 40 or if patient has had DM greater than 10 years
Central nervous system disease: required
indicatios for an a line
1- continuous real time bp monitoring
2- planned pharm or mechanical cardiovascular maniopulation
3- repeated blood samplings (ABG, hct, glucose)
4 - failure of indirect arterial bp management
5- supplementary diagnostic information from the art waveform (art pulse contour analysis - systolic pressure variation; pulse pressure variation)
6- patient with end organ dz
7- patient w large fluid shifts
Indications for central line
cvp monitoring transvenous cardiac pacing required for insertion of PA catheters temporary hemodialysis drug admin: drugs irritating to periph veins - vasoactive drugs, hyperalimentation, cehmo, prolonged abx
rapid infusion of fluids: trauma, major surgery
major surgery with large fluid shifts
aspiration of venous air embolus
inadequate peipheral access
sampling site for repeated blood testing
PAC measurements
cardiac output cardiac index PA pressure CVP calculation of oxygen delivery assessment of cardiac work mixed venous oxygen saturation (MVO2) pulmonary capillary wedge pressure systemic vascular resistance
PAC indications
Cardiac: CHF, low EF, left sided, valvular heart disease, CABG, aortic cross clamp
Pulmonary: COPD, ARDS
Complex fluid management: shock, burns, acute renal failure
High risk OB care: ecclampsia, placental abruption
Neurological: sitting craniotomy, venous air embolus
Situations to consider intraop TEE over PA catheter
anticipated hemodynamic swings that may not be tolerated by the patient
pateints who are persistently hypotensive despite interventions that shouldve corrected the hypotension
pateints undergoing procedures where there is a significant risk for venous air emboli
any case where a cardiac abnormality is suspected and where knowledge of the abnormality would alter clinical care
Draw the Mapleson circuits
Draw them
Indications for intubation
Mechanical function: resp rate > 35, Vital capacity < 15mL/kg (10 for child), Neg insp force less than 20-25 cm H2O
Gas exchange function: PaO2 <60 on FiO2 of 50%, A-a gradient >350 on FiO2 of 100, PaCo2 >55 (unless chronically elevated CO2), Dead space ventilation/tidal volume (Vd/Vt) ratio >0.6 (normal = 0.3)
Unstable vital signs
INabilty of the patient to protect his airway 2/2 agitation, airway burns, facial trauma, neurologic injury
discharge criteria
Aldrete: activity breathing circulation (BP) consciousness o2 sat score 9 or greater for discharge
PADSS vitals (bp/hr) activity N/V pain surgical bleeding 9 or greater for discharge
deleterious effects of hypotehermia
coagulopathy
cardiac dysrhythmias
impaired renal function
poor wound healing
RCRI
history of ischemic heart dz hx compensated or prior heart failure hx cerebrovascular dz (stroke/TIA) IDDM Renal insufficiency (Cr >2) Undergoing supra-inguinal vascular, intraperitoneal, or intrathoracic surgery
0-1 = low risk of MACE
2 or more = elevated risk of MACE
stent delay guidelines
BMS 30 days
balloon angio 14 days
DES 6 months (can be 3 if weigh risks/benefits)
risks of COPD
RV dysfunction bullae formation (increased pnx risk) bronchospasm
level for spinal for TURP
T10, above T9 can bask pain from bladder perf (shoulder/abdomen) or prostatic capsule perf (lower abdomen and back)
type of case for infective endocarditis ppx
in high risk patients undergoing dental procedure that may perforate oral mucosa, manipulate gingiva or periapical region of the teeth
Infective endocarditis prophylaxis risk factors
1 - prosthetic valve or prosthetic material used in valve repair
2 - previous occurence of IE
3 - unrepaired cyanotic congenital heart disease
4 - 6 month post op period following repaired congenital heart defect using prosthetic material or a device
5 - repaired congenital heart disease with residual defects at (or adjacent to) the site of a prosthetic patch or device
6 - cardiac transplantation recipients who develop valvulopathy
common causes of afib
heart failure cardiomyopathy acute MI longstanding hypertension valvular heart disease hyper/hypothyroidism drugs (cocaine, sympathomimetics) PE hypoxemia sick sinus syndrome
risk factors for post extubation croup
oversized ETT repeated attempts at intubation itnraop changes in patient position surgery duration > 1 hour traumatic intubation age 1-4 coughing on ETT volume overload head/neck procedures coexisting respiratory tract infection previous hx croup
risk factors postop apnea peds
postconceptional age <50weeks general anesthesia hx chronic lung dz hx apnea/bradycardia multiple congenital anomalies sepsis anemia neurological abnormalities narcotic administration
how long monitor infant post op
if less than 50 weeks postconceptual age, 12-24 hours post op, if 50-60 can consider shorter period of monitoring
benefits of GA over regional
I would employ a general anesthetic because it provides a still patient and operative field, provides definitive control of the airway and ventilation, and preserves the option to utilize pharmacologic intervention fro brain protection (from a CEA stem)
Extubation criteria
awake, following commands
maintain own oxygenation and ventilation (O2 sat and ETCO2)
Able to consistently achieve tidal volume >5ml/kg IBW
Able to protect airway (cuff leak, neuro status)
No residual neuromuscular blockade
increased surgical/anesthesia risks for obstetric patient for nonobstetric surgery)
increased risk of failed intubation pulm aspiration hemorrhage infection thromboembolism
baby increased risk: preterm labor/delivery (esp abdom surg) teratogenesis fetal asphyxia intrauterine growth restriction miscarriage neurotoxicity
laparoscopic:
damage to gravid uterus
icreased risk miscarriage or preterm labor
hypercapnia-induced fetal acidosis
contraindications to ect
intracranial mass lesions vascular malformations recent MI recent stroke increased ICP from any cause pheochromocytoma
ppoFEV1 is waht
predicted postoperative FEV1
ppoFEV1 stratification
> 40% low risk
<30% high risk
ppoDLCO
<40% increased risk
VO2 max
<10 high risk pneumonectomy
