Medical Conditions and Anesthesia Flashcards
Risk of URI and exacerbating factors
2-10x incr risk of resp complications –> Lspasm, Bspasm, periop hypoxemia
Risk incr with kids <2yrs
Complications can occur up to 6 wks post URI
Exac Factors:
intubation, RAD, parental smoking, airway sx, copious secretions, nasal congestion
What are mediators are released during URI?
Leukotrienes, bradykinin, histamine
Incr vagal activity –> PNS flares
Decr neutral endopeptidase –> results in incr amounts of bronchoconstrictive substances –> promotes shunting/hypoxemia d/t decr diffusing capacity
Complications during Anesthesia
Bspasm, Lspasms, hypoxemia, atelectasis, stridor/subglottic edema
HME = prevents dry secretions
Lido/Opioids = decr AW reflexes
Atropine = decr brady risk, decr secretions
Suction ETT while deep = removes mucus plugs
Cool Mist in PACU = prevent dry secretions
Uncomplicated URI =
Complicated URI =
Seasonal allergies/rhinitis =
1-postpone sx 2 weeks if runny nose/congestion/non-prod cough
2-postpone sx 4-6 weeks if any lower airway involvement, wheeze/croup/poor appetite/febrile/prod cough
3-considered non-infectious, ok for sx
Req sx still? LMA if possible, deep plane for ett and 1/2 size smaller, prevent dry secretions, depress AW reflexes, sxn ett when deep p/ intubation, a/ extubation
RAD, precipitating factors for Bspams
URI, lower airway infection, irritants, cold/dry gases, allergens, emotional stress/fear/anxiety, mechanical manipulation of airway, GERD
RAD pathophys
1-inflamm cells, mast/ephils –> rls subs –> obstruction/hyperreactive tissue
2-bronchoconstriction/mucosal swelling by mediators
3-increased mucus production –> aw obstruction
Overall = wheeze, air trapping, hyperinflation, decr gas exchange, obs sm airways, v/q mismatch, hypoxia/hypercarbia, resp fatigue–>failure
RAD/asthma treatments
bronchD with Beta2 agonists
oral/inh steroids
leukotriene modifiers
anti-Ach, methylxanthines –> adenosine induced bronchial relaxation
Pre-op questions for asthmatics
Typical episode? Precip factors? Most recent attack? Oral steroids this year? Hospitalized? Intubated? Compliant w/ meds? Need pre-op optimization?
Intra-Op Mgmt of RAD
BronchoD p/ induction / ketamine/safe propofol induction
Avoid histamine rx = morphine, atracurium, thiopental (toradol), use IV lidocaine
Use LMA if possible, deep profile for ETT w/ warmed gas
Signs = changed EtCO2 waveform, incr PAP, wheeze+, decr O2 saturation
Avoid: breath stacking, air trapping, hyperinflation by prolonged exp time, lower RR, appropriate NDMR
Laryngospasm Mgmt
Lspasm: 100% FiO2, CPAP/PEEP, jaw thrust/head tilt/OA, sxn OP, deepen anesthetic, apply 10-15 secs of PPV
Rx = succs 2-3mg/kg IV, 4-5mg/kg IM + atropine 0.02mg/kg
Bronchospasm Mgmt
Bspasm: Confirm Dx, 100% FiO2, incr anesth depth, Inh albuterol, IV lido/atropine, IV corticosteroid, modify vent settings no breath stacking
Adjuncts: terbutaline 0.01ml/kg subq (max 0.25ml), IV epi 10 mcg/kg, theophylline 5mg/kg IVP (level 10-20), mag sulf 50-100mg/kg over 30m
Deep Extubation for RAD
Not OK: RSI, full stomach, diff airway, neo & young infants
OK: albuterol, suction while deep, lido1-1.5mg/kg 5 min prior, consider atropine for bronchD and anti brady
Post op give humidified O2
Anemia Pre-op
Normal Values: neo = 15-20, 3mo = 9-11, 6m-2yr = 11-15
Anemia most likely r/t poor diet
No transfusion trigger but 7g/dL is threshold for negative phsyio changes, heart compromised if < 5g/dl
1.5kg prem w/ cardiopulmo disease requires preop Hgb of 12+
Anemia Intra-op
avoid excess sedation (hypercapnia = incr CO/BP = incr O2 use), maintain PaO2, maintain intravasc volume, avoid incr CVP (increase venous oozing), no bucking/coughing, avoid high PEEP, poor positioning. Avoid shivering and L shifts of OxCurve w/ alkalsosis, hypocapnia, hypothermia.
Retinopathy of Prem
Definition: failure of retinal vasc growth. Vasc damage by hyperoxic environment –> free radical damage tissues. Pathophys: hyperoxia>hypoxia –> retinal art vasoC –> capillary endothelial swelling –> peripheral retinal tissue damage. Common pts: born <1.5kg. Post term susceptible as well. Normal PaO2 = 60-80 in neonates.
ROP and Anesthesia
Maintain sats 90-95%, attempt to maintain with FiO2 below 40%. Tx w/ photocoagulation, lasers.
Epiglottis
Characteristics: supraglottic, rapid onset (24h), 2-6 yrs, inspiratory stridor, thumbprint cxr, bacterial pathogen.
S/S: resp distress, leaning forward, drooling, high fever, cherry red/edematous epiglottis
Tx: careful intubation, Abx, hydration, keep calm, mask while sitting, gentle PPV w/ pt breathing, NO NDMR, use smaller ETT 1-2sizes, preTx w/ atropine.
Be prepared for AW emergency
LarygnoTracheoBronchitis “croup”
Characteristics: subglottic, gradual onset, 6mo-6yrs, insp & exp stridor, steeple signs cxr, viral pathogen
S&S: barking cough, low grade fever
Tx: humidified O2, racemic epi (has both beta, alpha actions), intubation for severe distress. Cool mist, humid O2, blow by 100% O2, dexamethasone 0.1-0.5 mg/kg
Subglottic Edema “Post extubation croup”
D/t mucosal irriation/swelling r/t prolonged intubation, incorrect sizing, etc. Want air leak @ 15-20 cm H2O. Most at risk = pt < 4yrs d/t size of laryngeal diameter, rept ETT attempts/mvmt, head/neck Sx. Smaller the natural airway the more compromised by edema.
S/S: stridor, retractions, cyanosis, restlessness. Usually by 3 hrs post op
Tx: humid, 100% O2, racemic epi, steroids
Foreign Body Aspiration
Most common 1-3yrs, usually w/ edibles. Usually land in right mainstem. Bronchial = mild distress, wheeze, cough, dyspnea, decr air entry/chest mvmt to affected side.
Larygno/Tracheal = stridor, cyanosis, severe distress, coughing, sob = near total/total aw obstruction
Supraglottic/glottic = stridorous / Subglottic = wheeze
Anesthesia FBA
Avoid N2O, NO NDMR, want spont ventilation. AW mgmt influenced by location and degree of obstuction. Desire calm pt, quick to OR, avoid oversedation, maintain spont resp, keep sitting upright, avoid PPV as will move foregin body into distal airways.
Meds: consider atropine, propofol for steady LOA, IV steroids for inflammation.
Good communication w/ sx for bronch, typically rigid bronch.
Spont Vent for FBA
Pre-oxy –> atropine/glyco –> Sevo/O2 induction –> LTA 1-2%lido –> intubate w/ vent bronchoscope –> deep LOA to prevent cough/bronchospasm. Small NDMR during retrieval possible. Exsufflate/sxn stomach, place ETT or mask to manage AW for emergence.
Controlled Vent for FBA
RSI w/ NDMR/prop –> LOA w/ prop/remi/NDMR –> intubated w/ vent bronchoscope –> vent w/ high pres long exp time = decr barotrauma.
Adv: rapid control of AW, no pt mvmt, decr anes req
Dis: intermittent ventilation, displaced FB
Pain Mgmt
Historically undertreated/misinterpreted by diff communication of pain signaling. Pain pathways heightened/altered by rept early exposures to nox stimuli.
Preverbal: body language, emotional distress
Physiologic: VS, diaphoresis
Behavioral: crying, grimacing, change in activity
