Oral Flashcards
Extrathoracic airway obstruction
Flattening of inspiratory limb
Reglan sodium citrate H2 antagonist for
Full stomach
Desflurane
Not nephrotoxic. Fast on and off
Avoid which opioids in renal disease
Morphine and meperidine
NS is associated with
Metabolic acidosis
Parkland formula
4 x bsa burned x weight in kg
1/2 in first eight hours and the rest in the next 16 hours
5 x Fi02 should be the
Pa02
Minimum urine output for burn patient is
0.5 mg/kg per hour
For burn patients no
Depolarizing and give higher doses of non depolarize muscle relaxants
Glasgow coma scale to evaluate
Level of consciousness after traumatic brain injury
GCS less then 9 goes with
Severe brain injury
Abdominal paracentesis on trauma patient who is hemodynamic unstable to
Quickly diagnose intraabdominal injury requiring an ex lap
FAST is used in trauma patient to diagnose
Hemorrhage via ultrasound
Fluid status via
Mucous membranes, skin turgor, and 2 second capillary refill
In trauma patient place
aSa monitors, foley, a line central line
For iv access for trauma patient place
Central line and multiple large bore Ivs
Check neck status with collar by asking
If neck pain present, this will show whether to do an awake rsi. Negative neck films on multiple views would help
For full stomach with normal airway preixygebate with
100% 02, remove neck collar while having assistant maintain in line stabilization and induce with etomidate and Succ while giving cricoid pressure. Have difficult airway cart in room
Hi peak pressure with low blood pressure think
Tension pneumothorax
Massive blood transfusion
One blood volume in 24 hours or greater then 50% of blood volume in 4 hours
Massive blood transfusion complications include
Thrombocytopenia,coagulation factor depletion, hypocalcemia, hyperkalemia, TRALI, ARDS
Wound infection most common serious complication of
Hypothermia
Hypothermia also reduces
Platelet function and decreases activation of coagulation cascade
Hypothermia treat with
Forced air warning device, heating blankets and heating fluids
Acute cardiac tamponade becks triad of
Hypotension, jvd, muffled heart sounds. Echo to look for pericardial fluid
PEEP can improve
V/Q matching
You find out a trauma patient has been npo for 8 hours is this useful?
No! Acute trauma victims are assumed to be full stomach bc stress response from trauma lowers parasympathetic nervous system and gi motility decreased
Decorticate is a score of
3 on gcs
Decorticate response
Abnormal flexion to painful stimuli
Epidural hematoma
Tear in mid meningeal artery
Blood collects between skull and dura
Subdural is between arachnoid and dura layers
Epidural hematoma is a lucid period
Subdural is concave on ct
Preinduction a line with those with
Cocaine abuse
Have nitroprusside and esmolol infusions in case bp goes up
Goood access
Don’t use indirect agents like ephedrine bc will get exaggerated response
Chronic alcoholism will lead to
Cardiomyopathy
Avoid neuraxial in patients with
Liver disease as PT may be elevated
Chronic alcohol needs higher
MAC and RSI due to risk for gastritis
Can’t use plain x ray to clear
Cervical spine Bc can’t see ligament damage
To clear cervical spine, age >4, no cervical tenderness, no neurologic deterioration or parasthesias, lack of distracting injuries. Will need cervical mri if any of these present
Prep and drape neck for emergent trach in
RSI patient with head injury with multiple facial injuries making intubation hard
Ketamine
Increases ICP so don’t use on neuro patients
High icp
Hyperventilate to pac02 of 30
Elevated bed 15-30 degrees
Mannitol or furosemide
If BP drops during case first make sure
Patient not hypoxic, hypercarbic, or in a malignant arrhythmia
Check position of a line transducer
Look at surgical field for hemorrhage
Open fluids wide and give vasopressor
During crani ETc02 to 0 likely for
Venous air embolus Mi PE Disconnected ett Malignant arrhythmia like v fib
Low sodium in neuro patient think
SIADH or Cerebral salt wasting
In SIADH
Urine osmlarity is high whereas in cerebral salt wasting it is low or normal
SIADH leads to decrease urine output
ALI
Is Pa02 between 200 and 300
Fi02 of 50% or less to prevent oxygen toxicity in patients with
ARDS, can use peep and diuretics
Diabetes patient
Want to know if well controlled, hemoglobin a1c, neuropathy, vasculopathy, or nephropathy
Chronic hypertension leads to
Left ventricular hypertrophy
Patient with Q waves and LVH
Prior mi. Look at old ekg
If the Q waves are new, need to get noninvasive test like stress test or echo
Laser does TURP
Penetrates prostatic tissue to appropriate depth, but also poor tissue absorption so it doesn’t damage tissue close by. Risk for fire. Proper googles for staff to filter out wavelength of the laser
TURP with LVH should have
ALine
Multiple cardiac risk factors and you see risk of massive intravascular volume absorption and thus hemodynamic instability
TURP can be done under
Spinal
Spinal for TURP
Monitor mental status in case TURP syndrome can occur
Reduced opioids post op
Don’t need to instrument airways
Can lead to intraop anxiety
High spinal need to control airway
General anesthesia can’t assess
Mental status
Systemic opioids are needed post op
Necessity of induction with associated hemodynamic fluctuations
Single shot spinal and want what level for TURP
T10
After spinal for TURP nausea and patient restless due to
Cardiac ischemia, cerebrovascular event, hypoxia, pulmonary edema, bladder perforation
Stop irrigation by surgeon
Look for hypoxia, hypercarbia, malignant arrhythmia
Great ideal irrigation
Isotonic
Electrically inert
Transparent
Nontoxic
TURP from acute volume expansion and
Dilutional hyponatremia manifesting as hypertension followed by hypotension, refractory bradycardia and then neurologic symptoms
TURP resection using
Cystoscope use continuous fluid to get rid of resected debris
Most bladder perforations are extraperitoneal so classic is
Shoulder pain from diaphragmatic irritation
Low sodium to 115 with hyponatremia
Start with 3% sodium chloride with goal of correcting Ana at a rate no greater than 0.5 mEq/hr
Once sodium level reaches 120 when correcting sodium switch
Hypertonic to normal saline
If after 3% sodium given and anesthetic off and unresponsive but vitals good scared for
Cerebral vascular event
If increased serum sodium fast can get
Central pontine myelinolysis severe demyelination of brain stem
TURP with blindness due to
Glycine as irrigating fluid
Glycine induced transient blindness treatment is supportive and gets better but still get ophthalmologist to evaluate
More glycine leads to more
Ammonia which is a by product
Normal urine output for adult is
0.5 ml/kg/hr
Post TURP high heart rate and increases bladder pressure think
Catheter obstruction
Tissue resection likely blocking urethra so flush catheter with saline and place patient on continuous bladder irrigation
Want to know if aspiration in an infant is
Witnessed
Want to know size and nature of aspirated material
Want to know if child has
Preexisting respiratory conditions such as asthma
Foreign body aspiration differential
Esophageal foreign body, croup, reactive airway disease, anaphylactic reaction
Mediastinal shift should occur toward normal side when
Foreign body aspirated
IO or spinal needle into proximal tibia two fingerbreadthd distal to tibial tuberosity and screw until
Loss of resistance obtained
For foreign body before inducing as premedication give child
Anticholinergic to dry up airway secretions and minimize Vagal response to bronchoscopy
In foreign body for induction don’t do
Rapid sequence
Inhalational induction and promote spontaneous ventilation to avoid further distal migration of foreign body which can lead to total airway obstruction
Aspiration event shortly after induction
Turn child to side, suction in trendelenberg, intubate, suction endotracheal tube, ventilate with 100% oxygen
During aspiration keep patient super deep using
Tiva
Avoid nitrous
Promote spontaneous breathing
If patient needs paralysis during aspiration to remove item
Give bolus of Propofol if that doesn’t work give small dose of rocuronium
If while grabbing item it goes into patients airway have surgeon push it into
Right mainstem bronchus, if that doesn’t work turn patient lateral or prone, last resort is CP bypass
If substance removed after foreign body aspiration is traumatic to patients airway can give
Steroid like dexamethasone, humidified oxygen, nebulized racemic epinephrine
Usually no need to intubate during
Foreign body aspiration. If you do intubate it is to check for a leak
Racemic epi mechanism of action
Stimulates alpha receptors resulting in vasoconstriction and secondary reduction in mucosal and submucosap edema
After you give racemic epinephrine wait 3 hours after last dose to move patient to
Lower level ward as secondary edema can occur
Hypoglycemia and hypovolemia can lead to
Nausea
Do not give
Phenergen to child under 2 for nausea. Black box warning due to respiratory difficulties
TEF repair
Type C has an esophageal atresia with a fistula connecting the distal esophageal pouch to the trachea
Diagnosing of TEF
At birth when NGT unable to pass 9-10 cm from mouth, increased drooling, neonate coughing, choking with first feed
Other associated abnormalities with TEF
Vertebral/skeletal anomalies Anal atresia Cardiac anomalies TEF Limb defects
Monitors for TEF repair
Standard ASA, pre and post ductal pulse oximiter, preductal aline, prechordial stereoscope
TEF want to ventilate lungs without
Ventilating through the fistula leading to abdominal distension
TEF intubation
Keep spontaneous
Want ETT distal to fistula and proximal to the carina
TEF patient desaturation
100% oxygen Reassess other vitals Precordial stehescope Send off abg Manually hand ventilate and suction ett
60 weeks post gestational age
Postop apnea much higher in child les than
After TEF repair late complications most common is
GERD
Strictures, recurrent aspiration can occur as well, pneumonia, reactive airway disease
Full MH precautions for any child that has a first degree relative with MH
MH
Pyloric stenosis
Hypokalemic hypochloremic metabolic alkalosis
Pyloric stenosis definitive diagnosis via
Abdominal ultrasound
Suspecting metabolic alkalosis don’t give
Lactated ringers as lactate is converted to bicarbonate, thus worsening acid base imbalance
Inducing pyloromyotomy
High risk for aspiration thus pretreat with atropine .02 mg/kg iv and put in og or ng tube prior to induction
Fentanyl prop lido roc for rapid sequence intubation
Newborn airway compared to adult
Large tounge, long epiglottis, funnel shaped larynx. Glottis is at level of C3-C4 whereas it is C6 in adults
Term newborn use
3.0 mm internal diameter tube
Bronchospasm
Deepen patient 100% oxygen, check ett position, albuterol, last resort is Epi
Post extubation croup is a worry post
Pyloromyotomy. Treat with increased inspired oxygen, nebulizrd epi, humidify inspired gases, avoid excess narcotics
Post pyloromyotomy give fluids sigh
Dextrose as hypoglycemia is a concern due to inadequate glycogen stores
Congenital diaphragmatic hernia
Bowel sounds heard in left chest
Least aggressive ventilation for
Congenital diaphragmatic hernia. It is not a surgical emergency
Congenital diaphragmatic hernia
Scaphoid abdomen, barrel chest, bowel sounds on chest auscultation, heart sounds displaced to right, respiratory distress
Congenital diaphragmatic hernia causes
Pulmonary hypoplasia from pressure of herniated abdominal contents resulting in decreased number of alveoli
Pulmonary hypertension leading to right to left shunt through pfo and pda
Avoid increase in pvr
Increases in PVR by hypoxia and acidosis
100% oxygen worsens
Pulmonary htn
Permissive hypercapnia in CDH
Small tidal volume with high peep, avoids volutrauma
Nitric oxide
Stimulation of guanylate cyclase which increases cyclic gmp. Cgmp activates protein kinases that cause relaxation of vascular smooth muscle
CDH place
Umbilical central line. Avoid lower central line as can cause IVC compression. Want to preserve neck veins in case need to go on ecmo
CDH induction
Inhalational, avoid positive pressure
I’m CDH no 100% oxygen
More likely retinopathy of prematurity
Worsens oxygenation and ventilation as recruits additional blood flow to less compliant lung and worsens pulmonary hypertension
Only 100% to reverse any acute periods of desaturation or hypoxia
One hour into CDH bp 40/20 sat down to 80%
Pneumothorax in contra lateral lung
Severe pulmonary HTN, acute blood loss, hypovolemia, allergic rxn to drug given, compression of great vessels by surgeon
Hypothermia causes increase in
PVR
Neonates have decreased glycogen stores and are prone to
Hypoglycemia
Skin closure after CDH blood pressure drop
Likely due to IVC compression resulting in decreased cardiac output from diminished venous return. Need to open abdominal cavity and cover defect with a patch
If patient with CDH post op doesn’t respond to 100% oxygen and hyperventilate can put on
HFOV. If this doesn’t work and pharmacological intervention I would consider ECMO
ECMO improves
Oxygenation ventilation and myocardial function
VA has ecmo circuit that oxygenated blood from ij right atrium and given through right common carotid into ascending aorta.
Disadvantages of ECMO
Need for anticoagulant, increased bleeding, intracranial hemorrhage and sepsis
Most common cause of epiglottis is
Hemophilus influenza type B
Epiglottis acute symptoms
Severe sore throat, dysphagia and muffled voice
Epiglottis
Usually in children 2 to 5 years old. Fever as high as 104 degrees. Child leans forward
Thumb print sign with acute epiglottis in
Lateral view
In Peds patient with epiglottis is don’t place iv preop
Can precipitate life threatening laryngospasm
Need secure airway for epiglottis
Surgeon can look at swelling
Controlled airway
Child not aware of what is happening
For epiglottis patient want to have
Difficult intubation cart available on standby
For epiglottis do inhalational induction
Use ETT .5-1 smaller than what you’d usually use
Give reglan on child with epiglottis prior to direct laryngoscopes to lower chance of
Aspiration
Epiglottis patient must be transferred to the
Picu post surgery
Extubation of child with epiglottis
Patient a febrile with positive leak test
Do it in the OR with ENT on standby
Visualize edema and if better can extubate
Indomethacin
Cox inhibitor that decreases prostaglandin levels
Don’t use indomethacin if patient has
IVH or PDA is too big or hyperbilirubin
PDA increases risk of NEC
PDA causes blood to flow away from systemic to pulmonary circulation and decreased abdominal organ perfusion. NEC bc gut is deprived of blood
Echocardiogram will confirm
PDA
PDA monitors
Pulse ox on right hand and lower limb to measure pre and post ductal
A line In right upper extremity bc if pda torn need to clamp left subclavian artery
Maintenance of pda
Don’t use sevo as lowers svr
Use high dose fentanyl 30-50 mck/kg
For PDA want Saturation
87 to 95 as patient at risk of retinopathy of prematurity
Always listen during traumas and look for bleeding and at
Suction canisters
Ligation of pda leads to systemic hypertension so give
Vasodilator like nitroglycerin
Postop pda closure
6 months will need spontaneous bacterial endocarditis prophylaxis
Tetralogy of fallot
Vsd, overriding aorta, rvh, pulmonic stenosis
VSD
Blood from right to left so skip pulmonary circulation
Tet spell
Hypercyanotic attack. Due to increase in right heart pressure. Promotes right to left shunting of deoxygenated blood
Tet spell
Place baby on moms shoulders with infants knees tucked up underneath
Tet spell
Endocarditis prophylaxis with 50 mg/kg iv amoxicillin
Backup is clindamycin 20 mg/kg iv
Infective endocarditis prophylaxis
Prosthetic cardiac valve
Hx infective endocarditis
Valvulppathy after cardiac transplant
Unrepaired cyanotic congenital heart disease
For TOF
Want to keep sVR low and increase pvr
TOF
Don’t want right to left shunt
Tetralogy of fallot
Preoxygenate with 100% oxygen
Ketamine, fentanyl and rocuronium
Succ use contraindicated in peds
Increases risk for malignant hyperthermia
Histamine release from succ can lower svr
TOF
Should have blood in the room
Hypothermia
Hyperglycemia
Decreases plt function
Decreases drug metabolism
Retinopathy of prematurity only up to
44 weeks gestational age
Patient desaturation
100% 02
Check ETT position send abg
Cushings triad is bad in head injury
Bradycardia HTN bradypnea
Patients with murmur look out for
ASD/VSD or shunt bc can contraindicated sitting position
When looking at SSEPs need
MAC value less then 0.5
Tight dura ways to fix
Elevate head
Hyperventilating
Check oxygenating
Give propofol, muscle relaxants and diuretics
Sudden drop in Etc02 during neuro case with hypotension and tachycardia think
Venous air embolus
Venous air embolus
Ask for help and inform surgeon Switch to 100% oxygen Irrigate operative field with saline Aspirate air from central venous catheter Provide hemodynamic support
If can’t dorsiflex post surgery assume due to sciatic nerve injury and
Order EMG and do nerve conduction studies
Most cases resolve in 6-12 weeks and can see neurologist after if needed
Cushings reflex is indicative of
Elevated ICP
Cerebral blood flow in adults is about
50ml/100mg
Increase in C02 from
40 to 80 doubles CBF
CBF remains constant between a MAP of
50-150
Hypertension shifts cerebral auto regulatory curve to the
Right
For elective intracranial aneurysm clipping type and screen
4 units of pRBCs
Don’t want blood pressure too high during
Intracranial aneurysm clipping
To not affect eeg need
0.5 Mac value or less
BP lower
20% from baseline
To decrease transmural pressure across aneurysm
Can ask surgeon to place a clip on feeding vessel of aneurysm
Post SAH surgery bigger concern is
Rebleeding and vasospasm
VATS for respiratory dependence
Disease severity, possible dependence on home oxygen, response to bronchodilation, factors making it worse or better
Hct increase and digital clubbing with
Chronic hypoxia
Clopidogrel
ADP receptor inhibitor
Aspirin doesn’t lead to increased risk of epidural hematoma
So doesn’t affect what time you do placement
Left sided dlt
Preferred
Trachea clamped but still
Bilateral breath sounds with DLT, push deeper bc ventilating through bronchial lumen
Lateral decubitus position leads to
V/Q mismatch
If one lung and sat drops quickly to 85% go back to
Two lung ventilation
When hypotensive always ask surgeon if
Active bleeding or another acute event
Fi02 x 5 should equal the
Pa02
CT and MRI are good to see size of
Mediastinal mass and any tracheal deviation
For cardiac status ask if patient has
Baseline chest pain at rest
If you take an ekg try to look at
Previous ekg
Prolonged untreated HTN can lead to
LVH
If patient has right arm weakness from previous stroke
Avoid using that extremity for lines twitch monitor, or other monitors
Disadvantages of regional for carotid endarterectomy
Awake patient can move
Complications from block
Potential need for emergency intubation
Regional anesthesia for carotid endarterectomy
Superficial and deep cervical block
For carotid endarterectomy under general anesthesia want to have
EEG available
Best way to monitor cerebral function
Awake patient
For carotid endarterectomy if doing central line do on side with more occlusion bc even if you hit
Carotid artery it doesn’t cause a problem
After ensuring you can ventilate give
Rocuronium
Always recycle BP if
BP is low
High risk of stroke in watershed area of brain if
Non clamped carotid artery can’t perfuse the brain while the other is clamped
If surgeon can’t release cross clamp and big eeg changes then tell him to
Apply a shunt
Shunts during carotid endarterectomy can lead to
Small mixroemboli going through leading to a stroke
If swelling after carotid endarterectomy
Emergency intubation and page surgeon emergently for evacuation of hematoma
Carotid sinus often malfunctions after
Carotid endarterectomy and blood pressure can be very high
High glucose atlantooccipital
Joint stiffness can make intubation difficult
Most CABG you put in a
PA catheter
You can put patient in
Trendelenberg if BP is low
Heparin dose for CABG
3-4 units/kg
Want ACT>300
If ACT inadequate you can’t go on
Bypass
Protamine dose to reverse heparin
1mg/100 units of heparin
Heparin is an acid and
Protamine is a base
SIMV is a
Weaning mode of ventilation
For AAA want to lower BP
20% from baseline
Use beta blocker on day of surgery for
AAA repair
Aortic cross clamp leads to major increase in
Afterload proximal to the clamp and a decrease in perfusion distal to the clamp
After release of aortic cross clamp BP 80/45 and HR 45
Send for transcutaneous pacer while administering atropine, epinephrine and fluids as a temporizing measure
Third trimester bleeding most likely cause
Placenta previa and placental abruption
Placenta previa presents with
Painless vaginal bleeding
Abruption is painful
Double setup
Vaginal exam where might have to immediately convert to C Section
Actively hemorrhaging patient want to do an
General anesthetic as can get sympathectomy from epidural
If urine test negative it means cocaine a user hasn’t abused for at least
3-5 days
Preeclampsia
Multi organ disorder after 20 weeks gestation and better by 48 hr after delivery
Preeclampsia labs
CBC, BMP, liver function test for Helps, Uric acid, 24 hr urine, coag study
Magnesium sulfate
Decreases release of Ach, leads to vasodilation, anticonvulsant, sedative, tocolytic(decreases uterine activity) which increases uterine blood flow
Side effects of magnesium
Diminished deep tendon reflexes, EKG changes, heart block, respiratory arrest
Platelet count above
75k is ok for epidural as long as it didn’t go down abruptly
Five minutes after spinal bp on pregnant woman drops to 60/40
Left uterine displacement, 100% oxygen, open fluids, assess level, check fetal HR, give blouses of vasoconstrictor
If spinal doesn’t work and need to convert to general anesthesia
Preoxygenate with 100% and give reglan and bicitra
Perform RSI with fentanyl, lidocaine, propofol, and succ
For vaginal bleed post c section
Large bore iv
Stat CBC
Prepare or for possible reexploration
If bleeding post c section due to uterine atony
100% oxygen and open iv fluids,
See if any bad medications were given
Give second dose of oxytocin and consider giving hemabate
Patient can develop seizure up to
24-48 hours post delivery
On pump CABG
Heparin dose is 3-4 mg/kg
Check ACT for goal of 300-400
If not achieved can give additional heparin
Protamine side effects
Hypotension, anaphylaxis, pulmonary HTN, and anaphylactoid reactions
Becks triad
Hypotension
JVD
Muffled heart sounds
For pericardial tamponade
Want to maintain cardiac output, spontaneous ventilation, and BP
Patients with HOCM
Elevated EF of 80% due to hypercontractile state of the heart
HOCM
Dynamic left ventricular outflow obstruction
Mitral regurgitation
Diastolic dysfunction
MI
Coarctation of aorta can do
Regional anesthesia
IABP
Counterpulsation device sits in aorta and deflates during systole, reducing afterload, inflated in diastole to increase perfusion to coronary arteries
Absolute contraindications to IABP
Absolute are severe aortic valve insuffiency, aortic dissection, aortoiliac disease
Always want to see if AICD has
Pacemaker component
Contact manufacturer to see if any special precautions
Want to place magnet on pacemaker if surgery is on
Upper abdomen
Have defibrillation pads on if needed
CP bypass machine
Venous reservoir where deoxygenated blood collects
Transferred to oxygenater where it gets oxygenated
Oxygenated blood through arterial filter back into arterial cannula then to patient
Membrane oxygenater is less traumatic on the
Blood versus bubble oxygenator
Aortic cross clamp protect spinal cord
Maintain adequate BP above and below clamp
Institute hypothermia
Use CSF drainage
Avoid vasodilation and inhalation agents
Can place epidural for
AAA
Less DVTs and better post op pain control
Improves GIfunction
Can also lead to hypotension through sympathectomy, be careful of giving local anesthetic periop
Congenital left to right shunt in downs patients can lead to
Pulmonary HTN
For Cystic fibrosis patient
Want coagulation studies and serum glucose levels as these ppl can’t take in fat soluble vitamins
One of the first sons of CF in newborn is
Intestinal obstruction
MS relapse very unlikely in third trimester of pregnancy
Risk may increase in the first 3 mo postpartum
Avoid spinal in MS patient as may increase risk of
Exacerbation
If pregnant woman has seizures treat with
Midazolam
Epileptic seizures can lead to fetal
Asphyxia
Labetalol and Hydralazine can be used for
Pregnancy induced HTN
LMWH should be held for
12 hours before neuraxial procedures
If high dose like enoxaparin
1 mg/kg daily need to hold for 24 giyeav
General anesthesia
16 times higher mortality rate then neuraxial
Surgery during the
First trimester most harmful as highest risk bc organogenesis is occurring
Always consider the pregnant female a
Full stomach and do RSI
Absolute contraindication to epidural
Patient refusal
Coagulopathy, severe uncorrected hypovolemia, sepsis around site of epidural
Epidural
Reduces afterload
Uterine atony associated with
Overdistension of the uterus
Uterine atony
Bimanual compression and uterine msssage first
Oxytocin first like, then intramuscular methylergonavine
VwF stabilizes
Factor 8, which promotes clotting
Can do MH susceptible case in an
Ambulatory surgery center. Don’t use triggering agents.
King Deborough disease makes you susceptible to
MH
Charge syndrome can be difficult airway
Cleft lip and palate so have difficult airway cart on standby
Need to do ECHO on what type of patient before OR
CHARGE, 75% chance of cardiac problems
Pierre robin also has
Glossoptitis
Right to left shunt leads to
Blue patient
Induce patient for pyloromyotomy
First need to decompress stomach
After preoxygenation with 100% oxygen and atropine to prevent Vagal response to laryngoscopy, perform rapid sequence induction with prop and rocuronium
Rapid sequence on child post tonsillectomy with continued bleeding
Ketamine and succ to maintain hemodynamic stability
Succ in child may precipitate MH if
Undiagnosed myopathy
Positive Babinski is a sign of
Neurologic complications
Congenital heart disease unrepaired needs
Endocarditis prophylaxis
Omphalocele is associated with multiple
Conditions while gastroschisis is not
Difficult intubation and cerebral aneurysm ruptured
Can’t do slow induction. Awake intubation with airway blocks, nebulized lidocaine, preinduction a line with esmolol drip available
Somnolence goes along with elevation in
ICP
Prevent autonomic hyperteflexia by giving
Deep anesthetic
Autonomic hyperreflexia
Stimulus below level of transection causing sympathetically mediated HTN, bradycardia, sweating and flushing above the lesion
Triple H for cerebral vasospasm
Hypertension, hypervolemia, hemodilution
During TURP
Talk to patient, limit duration, lower hydrostatic pressure by minimizing height of irrigation fluid to patient
Na 121
During TURP, reduce fluids, administer lasix, don’t correct too fasy
GH secreting tumor
Acromegaly makes airway smaller and tougher to get, might need smaller endotracheal tube size
Hold lithium
36-72 hours before procedure
Urine osmolality high in
SIADH and normal in CSW, also see hypovolemia in CSW
EMG studies and neurology after conservative treatment for
Ulnar nerve injury in or
MS don’t do spinal but can do epidural
Epidural
Allodynia
Pain towards something not normally painful
CRPS
Due to dysregulation of the cns leading to pain, burning, swelling and changes in skin color or temperature
CRPS type 2
Injury to a nerve bundle
Stellate ganglion performed at what level
C7
Anterior to transverse process C7, anterior to neck of first rib, just below subclavian artery
Stellate ganglion complications
Intravascular injection, subarachnoid injection, hematoma, pneumothorax, brachial plexus block, hoarseness due to recurrent laryngeal nerve iniury
TENS
Inhibition of pain signals at presynaptic levels
Bupivicaine induced cardiac arrest treatment
20% intralipid at 1.5 ml/kg iv over 1 minute followed by infusion at .25 ml/kg
If not improves can do bolus 1-2 times
Celiac plexus block can lead to
Paraplegia from damage of artery of adamkowitz
Transforaminal epidural for
Unilateral back symptoms
Epidural
Avoidance of intubation, fewer DVTs, quicker ambulatory
After high dose lmwh
Wait 24 hours before removing catheter
Low EF
Don’t do neuraxial
Lobectomy
Place epidural catheter at level of incision or 1-2 levels lower
Don’t give which drugs to asthmatics
NSAIDs
Medical conditions associated with latex allergies
Working in rubber industry, urogenital abnormalities like spina bifida
Hetastarch side effects
Headache, parotid gland enlargement, coagulation abnormalities like increase in pt/PTT and bleeding time
Chest X ray in fat embolus shows
Bilateral infiltrates
Magnesium overdose EKG
5 to 8 prolongs pr interval and widen qrs complex
15 leads to SA AV block and 25 cardiac arrest
Severe lung disease due to
Sarcoidosis so prefer regional
Anaphylactic vs anaphylactoid
Anaphylactic produce ige antibodies which bind mast cells. In anaphylactoid the antigen itself binds mast cells and causes degranulatipn
Acute normovolemic hemodilution
Avoid in severe cardiac or renal disease
Avoid if hemoglobin already low(below 11)
Mid way during procedure with LMA patient aspirates
Suction remove LMA put back of head up and emergently intubate
At 27 weeks start seeing fetal variability
N
Arterial line for
Constabt blood pressure
Frequent abgs
Pneymonectomy requires
Double lunen tube
Need central line for
Transvenous pacing or vasoactive medications to be given
Can place cvp
In ij
Ej subclavian
Arm veins
Right ij most dorect riute to the
Heart
Hypoxia forst
100% oxygen Hand bag to check for compliance Auscultate chest Check ett placement Check abg
Dont leave DLT tube after can lead to
Mucosal edema and tracheal stenosis
Also tough for nurses to use
Insulin might behore surgery
Reduce hypoglycemua risk
2/3 normal dose of lantus and avoid taking any diabetic meds the morning of surgery
Check glucose hourly in perioperative period
Hgba1c
Indirectly shows risk of end organ damage
Looks at numver of glycosylated hemoglobin molecules- hemoglobin binding to glucose over 3 month span
TURP better to neuraxial can show
Awake patient signs of myocardial ischemia
Bladder rupture bradycardia ahoukder or andominal pain
Turp syndrome- confusion headache, hypotension arrhythmias
Turp caregully monitor
Setum sodium level
For TURP syndrome
Need T10 level
Use bupivicaine or tetracaine wiyhiut epi lasts 90-120 minutes
At t10 can still feel andominal pain of bladder perforation
Delayed emergence
Residual narcotic Sedative drug effect Neuromusvular blockade Hypoglycemia/kyponatremia Cerebral ischemia Hypothermia Hypoxia/Hypercarbia
Dibucaine homozygous for atypical allele
32
Usually dibucaine breaks down pauedocholinesterass
Vision loss after TURP
Glycine toxicity
Ischemic optic neuropathy
Corneal abrasion
Short acting beta blocker like esmolol
For copd patients
Betavblocker start on
Vascular patients who demonstrate risk of ischemia by preoperative testing
Positive tropinins but negative CKMB
Acute Mi occured 2-3 days ago and patient has not suffered repeat MI in that time interval
Myocardial ischemia oxcurs when there is inadequate oxygen supply to meet
Metabolic demands
Atelectasis
Copd or mucus plug
Cardiogenic pulomary edema can give
Diuretics
Monitor baseline cardiac function by putting
Preinduction pulmonary artery catheter
Dont forget which monitors for CABG
BIS and foley
PA catheter allows for
Post op monitoring while TEE does not
TEE more sensitive for MI
If carotid bruit dont place
Central line on that side can risk thrombus with accidental carotid puncture
Keep heparin drip on as risk
Comprimising coronary perfusion
Hypotension
Fluids
Trendelenberg position
Decrease volatile anesthetic
Small dose of vasopressor
Big BP drop going on bypass due to
Hemodilution and sudden decrease in SVR that often occurs with injection of the dilute priming solution
Also think pump malfunction, monitor error, lack of venous flow to btpass machine, kinking of cannulas
Face blanching right side mydriasis think
Malpositioning of the arterial cannula with flows of priming solution directed toward inominate artery
High risk for cerebral injury
Cerebral edema treat with
Mannitol head up position
Treat hyperglycemia while on bypass to prevent
Cerebral ischemia
Weaning off bypass
Make sure normothermic
Get ABG and treat anemia, electrolyte imbalances, turn on all anestgetic abd monitor alarms, zero transducers, check lung compliance and initiate ventilation, make sure to deair heart, look at cardiac function via TEE, give benzo diuring rewarming to prevent awareness, have available pacing device and resuscitative drips
Collect hemodynamic data from
PA catheter
Pacing leads not capturing due to
MI, lead dislodgement, lead failure, pacemaker malfunction, hypercarbia, acidosis
Always ensure
Adequate oxygenation and ventilation
Protamine can cause
Anaphylactic reaction
Severe pulmonary HTN
Hypotension
Myocardial depression
Guide with the ACT
CPB most likely cause of coagulopathy is
Abnormal platelet function
Low mixed venous
Reflects inadequate tissue perfusion
Most likely awareness during
Rewarming as hypothermic loss of anestgesia stops
Can use bis
Asystole
No pulse with no shockable rhythm on ecg
Asystole
Start chest compressions 100-120 per minute
2 breaths per 30
Depth 5 cm
Keep etC02>30 or dbp>20
Rhythm check each 2 min
If shockable biphasic 200j monophasic 300j
Check pulse only if signs of rosc(rhythm change, sustained higher etC02)
100% oxygen 10 to 15 L
Epi iv 1mg every 3-5 minutes
Hyperkalemia
Calcium chloride 1 g
Sodium bicarb 1 amp
Indulin 10 unites and one amp dextrose
Asystole pea differential heart rate
Desufflate abdomen
Drain bladdet
Remove surgical retractir and sponge
For auto peep causing hypovolemia
Disconnect circuit
Bradycardia with pulse less then 50 inadequate perfusion
Desufflate abdomen
Drain bladder
Remove surgical retractor
Remove pressure from eyes ears
All vagal stimuli
Decrease anesthetics or analgesics, atropine .5-1 mg every 3 min up to 3 mg
If atropine not effective can give epi
Place defib pads and pacer set to 80 increase current until capture
SVT
Non compensatory tachy and pulse present
Often rate greather then 150 and sudden onset
100% oxygen
If unstable like SBP<75 acute ischemia or chest pain
Consider sedation cardiovert based on if rhythm regular and how wide qrs is
If refractory give amiodarone slow 150mg over 10 minutes
SVT stable
Get 12 lead
Arterial line abg
Consider vagal maneuver first
Push adenosine 6 mg iv push then 12 mg then give esmolol but avoid in low EF or WPW
V fib or V tach
You do shock
After 2nd shock epi 1 mg every 3-5 min
After 3rd shock amiodarone 300 mg iv push
Hypoxemia
100% 02 Check tube Auscultate Hand bag Suction ett Consider chest x ray or bronch
Anaphylaxis
Wheezing Hypotension High inspiratory pressure Angioedema Flushing Hives
Anaphylaxis treatment
100% oxygen If angioedema quick intubation IV access Give epi to prevent mast cell degranulation 10-100 mcg until clinical improvement sometimes need more then 1mg Turn off volatile and give benzo Head down and lots of fluids
Send peak serum tryptase 1-2 hours after reaction onset
Monitor for at least 6 hours
May add epi vaso norepi infusions
Can give bronchodilator
Bronchospasm
Inform team
If hypotensive may be air trapping so disconnect circuit
If hypotension tachy and rash think anaphylaxis
Bronchospasm treatment
100% 02
I E ratio 1 to 4 and minimize peep
Avoid hyperinflation
Bolus propofol and more neuromyscular blockade
Auscultate, soft suctoon ett
If severe 5-10 mcg iv epi every 3-5 min or 200mcg subq
If can ventilate give bronchodilators, consider ketamine 10-50 mg iv and hydrocotisone 100mg iv
Delayed emergence
Hypoxemia hypercarbia hypothermia hypotension acidosis
Look for high icp cushing
Opioid reversal start with 40mcg ivmay double dose every 2 min
Flumazinil .2 mg to start
Physostigmine 1mg if scop patch
Hypoglycemia
Optimize positioning
Bed height sniffing position bed elevation to 30 degree
Ensure paralysis and anesthetic depth
PE
Sudden decrewse in BP, SP02 and etC02
Incesse in CVP
Dyspnea
Happens in obstrtrics and long bonefracture
PE
Vasopressirs fluids turn off vasodilator or volatile anesthetics
Want to mintain sinus rhythm
Decrease RV afterload
Consider tPA 10 mg iv followed by infusion or thrombectomy
Air embolus
Check iv lines for air, flood surgical foekd with saline, head down, aspirate from central line
Fat embolus
Petechial rash
Urgent C section with amniotic fluid embolus
Urgent
Fire
Stop fresh gas flow Disconnect breathing circuit from anestgssia machine Clamp ett if absilavle and remove Pour saline down airway Reestaish airway after and minimize Fi02 Bronch and consider steroid
Laser surgery
ETT below vocal cords
Laser resistant ETT
Low Fi02
If non airwat fire
Stop fresh gas flow
Disconnect breathing corcuit and ventilate with ambu bag
Remove all burning materials to the floor
Elevtrical fire only use c02 fire extinguisher
Start propofol infusion
Hemorhage
Activate massive transfusion ptotocol Large bore iv access Temporize severe hypotension with pressors Head down 100% 02 Ask surgein to pack or get help Rapid infuser and cell saver Transfuse dont wait check all blood 1:1:1
Massive transfusion protocol
Warm room, use warm fluids A line Foley Actively maintain normal calcium level Give FFP if inr or ptt>1.5 normal Plt if less then 50k and bleeding Fibrinogen less then 80 give cryo each 10 units of cryo raises fibrinogen by 50 Consider txa or pcc if warfarin induced bleeding If refractory can give factor 7a
SIADH with
Lung cancer or can have hyponatremia from thiazide administration
SIADH
Normal total body sodium
Elevated urine osmolality and urine sodium
Low total body sodium with thiazides
Low sodium can put patiebt at risk for
Cerebral edema
HTN induced shifting of
Cerebral autoregulation curve to left and decreased cerebral blood flow due to compression ofinominate artery in mediastinoscopy
Mediastinoscopy place
Right arterial a line to continuously monitor downstream perfusion pressure of inominate artery to quickly figure out surgical compression
Place pulse ox on right and nibp on left arm
Inominate is compressed by the scope
Inominate supplies blood to
Right arm and head and neck
Poorly controlled hypertensives lead to
End organ ischemia
Want to lower BP to
140/90 during mediastinoscopy
HTN and carotid diseaae
Should delay the case to optimize BP and get vascular surgery consult
Mediastinoscopy you need
Type and cross as might have massive blood loss
To avoid bucking can
Spray lidocaine on on trachea
Give fentanyl and blockers to prevent exagerated response to laryngoscopy
If SVC tear during mediastinoscopy use
Lower extremity iv
Stridorous after extubation
Laryngospasm
Mass obstruction from lung cancer
Recurrent laryngeal neeve injury
Bilateral recurrent laryngeal injury
Must intubate
Tracheomalacia
Cartiledge around vocal cords is soft and collapses
Quick hypotension think
Massive hemorrhage or tamponade post op
High aoreay pressure
Increased peak airway pressure>5 cm above baseline or >35?cm H20
Can see wheezing and upsloping C02
Increased EtC02
Decreased tidal volumes
Hypotension if air trapping
High airway pressure
100% o2 10-15 L
Confirm C02
Upslope think obstruction
Curare cleft means insufficient neuromuscular blockade
Manually ventilate
Check et tub
Auscultate
Soft suction if mucus plug
Asymetric breath sounds
Pneumo
Endobronchial intubation
If wheezing but symmetric think bronchospasm or pulmonary edema if crackles
Machine or breathing circuit reasons for high peak pressure think
Circuit obstruction
Scavenger closed
Ventilator valve malfunction
High spinal
100% oxygen
epi if severe brady or hypotension
If mild bradycardia can give atropine or glycopyrolate
Give rapid iv bolus with pressure bag
Raise legs to increase preload
Maintain neutral position head down makes spinal worse!
Monitor fetal heart tones, emergent section, call ob, ensure left uterine displacement
HTN causes
Inspect surgical field Receipt epi Carotid or aortic clamping Full bladder Hypercarbia Inadequate analgesia Med error Pneumoperitoneum Prolonged tourniquet time
Rare causes of HTN
Autonomic hyperreflexia Spinal cord above T6 reflex bradycardia Ischmia Malignant hyperthermia Pheo Preeclampsia Serotonin syndrome: hyperthermia, tachycardia, rigidity
Low SVR
Shock
Transfusion reaction
Vasodilator
Neuraxial block
Low preload
Auto-peep Embolus Hypovolemia Ivc compression Pneumo Right heart failure
Hypoxemia
Check Fi02 analyzer
Pulmonart artety catheter not to put in
At risk for arrhythmias, risks of line placement, pulmonary artery rupture, benefits dont outweigh the risks
Epidural to not have huge
Hemodynamic swings
Rapid sequence induction
Pregnant is full stomach
Arterial line
For hemodynamic monitoring beforehand
IHSS
Can cause collapse of LV
Avoid tachycardia or decreased preload
Oral approach to fiberoptic
Nasal approach as the nose is friable
Nasal approach is a shorter route
Nasal approach with marked epistaxis
Oral approaxh get airway as soon as possible
Volatile anesthetic to minimize awareness and titritable and uterine relaxant
Dont use nitrous prior to child out
As want oxygen to go to fetus
Hypotension after delovery
Malignant arrhythmias
Blood loss
Amniotic fluid embolus
Bradycardia in neonate
Often due to hypoxia
Suction meconium
Meconoum aspiration
Can cause obstruction to oxygen exchange
Bradycardia below 60 in neonate after oxygenation and ventilation start
CPR
Want to decrease conteactility and increase afterload with
Ihss, dont want lv to collapse
Single sjot spinal
Can cause hypotension and lots od tachycardia due to synpathectomy
Can perform recruitment breaths on
Hypoxic patient
Consider PEEP but use caution if hypotensive
Head up position desufflate abdomem
Lung ultrasound to check for
Pneumothorax effusion consolidation or interstitial edema
LAST present with
Seizures
Altered mental status
Tinnitus
Cardiovascular collapse, hypotension, arrhythmias or bradycardia
LAST
Call for lipid emulsion 20% stat
If patient unstable call earlt for ECMO or bypass
Stop any local anesthetic
Give 100% oxygen
Bolus 100 ml iv over 2-3 min or 1.5ml/kg then infuse .25 ml/kg/hr for 20 min
Can double until patient stable up to 12 ml/kg
Once stable continue infusion for 15 minutes
Keep in pacu 2 hr if seizure, 6 hr for hemodynamic instability
If seizure
Put patient lateral and head down to prevent aspiration
Benzo to treat seizure and if it doesnt work give propofol
Give low dose epi in last
0.2-1 mcg/kg iv
Vfib vtach unresponsive to defib give 300 mg iv push amiodarone
Avoid vasopressin and lidocaine
MHyperthermia symptoms
Mixed respiratory and metabolic acidosis Increwsee etc02, HR, RR Masseter spasm Hyperthermia Muscular rigidity Myoglobinuria
MH treatment
Stop succ or volatile anesthetic Dont change machine or circuit 100% 02 Maximize minute ventilation Initial dantrolene dose is 2.5 mg/kg Repeat dantrolene 2.5 mg/kg every 5 min until hypercarbia and rigidity are resolved and temperature not increasung
Severe hyperkalemia start
Urgent dialysis
Avoid calcium channel blocjers and sodium channel blockers when treating
MH
MH
Actively cool if core temp above 38 Need a line Urine myoglobin ck coag lactate Place foley Call mh hotline
Most mh patients
Relapse so need mechanical ventilation
Need dantrolene 1mg/kg bolus every 4 hours for first 24 hours
MI consider
Heparin i fusion
Aspirin
Treat pain with fentanyl or morphine
Can ventiate with ambu bag on
Room air
Pneumo
Increased peak inspiratory pressures Tachycardia Hypotension Hyperresonance to chest percussion Increased JVD Decreased or asymetric breath sounds
Unstable and no chest tube available for pneumo
14 or 16 gauge iv catheter in 4th or 5th intercostal space between anterior and mid axillary line
Right heart failure
Dyspnea, ecg with rv strain, hypotension, TEE dilated RV, flattening of intraventricular septum
Right heart failure
Pulmonary vasodilator like nitric oxide or epoprostenol
Lower tidal volume and avoid breath stacking
Minimize peep
RV dilation and hypertrophy
Avoid hypoxemia, hypercarbia, or acidosis
Transfusion rxn
Stop transfusion and retain blood product bag
100% 02
Fluid bolus turn down anestgetic
Give epi if needed
Febrile reaction give antipyretic iv tylenol 1g iv
Anaphylactic give epi dexamethasone hydrocortisone
Complications if super obese
Difficult airway management
Difficulty evaluating cardiopulmonary status due to sedentary lifestyle and/or diabetic neuropathy
Rapid desaturation with apnea due to lower FRC
Obesity hypoventilation syndrome(pickwinian syndrome)
If low risk procedure just get
Preganvy test and serum glucose
H2 receptor agonist, reglan, non particykate for
Full stomach
Do breathing treatment prior to surgery to optimize
Asthma
Diabetic neuropathy can mask warning signs of myocardium at risk such as
Chest pain
Blood pressure cuff should encircle at least
75% of upper arm
Can do umbilical hernia repair under
Local or regional anesthesia
Doing RSI means patient isnt as deep and ashtmatic patient may go into
Bronchospasm
Put patient head up to reduce risk of
Passive regurgitation and facilitate rapid intubation
Closing capacity isnt affected by moving from upright to
Supine position
Induction dose of propofol in obese fenale due to
Ideal body weight
Nonopioid alternatives like
Ketamine or precedex
Given asthma dont give muscle relaxants with lots of histamine release such as
Atracurium or mivacurium
Expiratory wheezing and desaturation go with
Bronchospasm
Extubate under deep plane of anestgesia to avoud
Bronchospasm
Pulmonary enbolus can cause
Hypoxia and is seen more commonly in the morbidly obese
Iv respiratory depression secondaey to morphine
Put head up 100% oxygen and apply CPAP and cpnsider narcan
Do epidural without narcotic in obese with
Respiratory depression
Keep obese patient on continuous pulse ox until they can maintain
Baseline oxygen saturation
PVR is reduced after
First breath. Increased oxygen levels lead to functional closure of PDA with permanent closure over a few months
Infants who are hypoxic due to respiratory distress dont make enough bradykinin to ensure closure of pda
PDA predisposing factors
Hypoxia
Acidosis
Respiratory distress syndrome
RdS
Due to insufficient surfactant which is usually inadequate prior to 35 weeks gestation
Maternal steroid can help in survival of patients with
RDS to increase surfactant production in vivo
Indomethacin
Prostaglandin synthetase inhibitor
PDA left atrial enlargement due to
Shunting of blood from systemic to pulmonary circulation
Infant with pda preop testing
Chest/abdominal x ray Abg Urinalysis H and h Coags Electrolytes Type and cross
No premedication is generally needed for infants
Infants
Glycosuria can represent
Hyperglycemia in infant
PDA repair
Precordial stethescope to aid in cardiopulmonary monitoring
PDA repair nibp on
Right arm in case pda gets torn and need to clamp subclavian
Dont need a line or central
In premature want Pa02
50 to 70 with sat 87-95%
Risk factors fir retinopathy of prematurity
Prematurity
Low birth weight
Mechanical ventilation
Acidosis
Neonates respind to cardiovascular depression from volatilesso generally use mix of
Fentanyl plus ketamine and nitrous
Pancuronium increases HR and may be helpful
During pda dropping 02 saturation
100% oxygen and ask surgeon to relax any traction on the lung until the patient is stabilized
Neutral temperature in neonate
Ambient temperature at which oxygen consumption is minimized
34 for preterm and 28 for adult
Stops increased oxygen utilization
Heat geberation in infant number one way is
Nonshivering thermogenesis
Metabolism of brown fat
Neonatal seizure differential
Intracranial hemmorhage
Hypoxic ischemic encepalopathy
Crrebral edema
Hypoglycemia
Benzo or barbiturate to stop seizure in a
Neonat
Seizure in pregnant patient is
Eclamptic seizure until proven otherwise
Medication trauma can also cause it
Pregnant mother obtunded
Intubate to protect from aspiration and hypoventilation
Avoid succ
If really difficult aorway to maintain respirations and do slow induction with ketamine
8mg per 12 hours max amount of
Ativan for seizure
Midazolam reversal will lower seizure threshold so dont do it often
A line
Place arterial line in obtunded pregnant women to maintain adequate cerebral perfusion and prevent increased icp
Increase in icp leading to cerebral ischemia think
Cushings reflex
Dilayed and unreactive pupil think
Cn 3 compression by uncal herniation
Cushings reflex treatment
Raise head of bed 30 degrees
No venous obstruction
Stop volatile anesthetics
Hyperventilate
Mannitol reduces icp bt
Osmotically shifting fluid from intracranial to intravasvular compartment decreasing production of csf
Mannitol may worsen cerebral edema if bbb is not intact
Widened qrs due to
Elevated intracranial pressure
SAH
Magnesium toxicity
Sticking yourself with hiv needle
Immediately wash with soap and water
Report to employee healty and get post exposure prophylaxis
High mag
Draw a level
Check deep tendon reflexes
Give calcium
SOB anterior mediastinal mass
Airway or cardiac compression from mass, lanbert eaton patiebts take 3,4 diaminopyridine and lambert eaton causes SOB
Lambert eaton or myasthenic syndrome
Antibodies to prejunctional voltage gated calcium channels results in reduced release of Ach from motor end plate
Lambert eaton patients get better with more
Muscle movement
Mediasyinal mass with 50% tracheal compression
Get chest x ray
PFTs
Do chemo radiation prior or case under local due to concern of mediastinal mass
For mass mediasyinal
Get cardiac echo in upright and supine positions
For fall worry about
Cervical spine, difficult airway, increased ICP due to head trauma
Bradycarfia from sick sinus can lead to
Fall
So can mi, pacemaker failure, stroke eue to hypertension
Pacemaker want
Type of device
Wheyher patient is dependent on antibradycardia pacing function
Need for perioperative reprogramming
VVE- DDDo
Pacemaker capable of ventricular shock, ventricular antitachycarfia pacing, electrogram detection
Pacemaker want to know
Why put in Model and type Pacemaker dependent Pacing mode Behavior of device when goes to a magnet Battery life Payients underlying rate and rhythm
Cautery can lead to
Inhibiting of pacing as might think it is intrinsic heart activity
Use bipolar cautery
Have temporary pacing and defib in room
If pacemaker dependent put in asynchronous mode
If using monopolar cautery with pacemaker
Put return plate close to operstibe site and far from cied, need proper edu function, put in asynchronous mode. Limit cautery use
Aicd must be checked wothin
6 months and pacemaker within 12 months
Magnet doesnt afect
Pacing only to disable tachydysrhythmia sensing and treatment if case is urgent
Magnent is good bc if you go into v tach pr v fib you can
Take it off to shock the patient
Electrosurgical pad for upper extremity surgery
Put on posterior shoulder contralateal to where aicd is. Want it close to operative site but far from aicd
Administer narcotics and lidocaine to
Blunt the sympathetic response to laryngoscopy
Transient increase in iop
With succyncholine
Can pretreat with rocc
Rather give succ if full stomach benefit vs risk
Trendelenberg will lead to
Increased iop and decreased FRC
Reverse trendelenberg
Inhibits passive reflux of gastric material
Failure to capture with lead failure due to
Lead failure,myocardial changes that lengthen therefractory period
Patients with full stomach remain at risk
Even after extubation so make sure they are awake
Sucton out stomach when they are deep and give lidocaine and reverse
If pacemaker doesnt capture start
Transcutaneous pacing and administer atropine and epinephrine and get ready for chest compressions
If not working with transcutaneous paving
Consult cardiologist and consider transvenous pacing or placement of epicardial leads
Regular wide complex rhythm with pulse
Give aniodarone and do synchronized cardioversion if patient became unstable
Primary concern aortic dissection
Massive hemorhage, cardiac involvrmrnt, end organ ischemia due to intereuption of supplying arteries
Debajey 3
Involves only descending aorta and can be treated both medically with blood pressure and pain control
Type 1 Debakey
Ascending aorta down to abdominal aorta
Type 2 debakey starts in
Ascending aorta and dosesnt go past inominate artery
Legal intoxication occurs at blood levels
80-100 mg/dl
Acute alcohol increasses risk of
Aspiration and decreases anesthetic requirements and contributes to delayed emergence
To clear C spine
Abscense of cervical pain or tenderness
Abscense of paresthesias or neurologic deficits
Normal mental status
Greater then 4
If cant get need cross table lateral c1 to T1 film both anterior and posterior views
Aortic dissection diastolic murmur
Propogation of dissection into aortic valve leading to aortic regurgitation
Aortic regurg avoid
Bradycardia as more diastolic time leads to increased regurgitant volume and worsening cardiac function
Aorticdissevtion
First give pain control and fluid
Then start esmolol infusion to decrease intramural pressure that could lead to rupture
Dissection
Need to monitor for spinal cord ischemia and often need 1 lung ventilation
Have cell saver and rapid transfuser in room
Lumbar drain to monitor cSF pressure
Also to drain csf to facilitate spinal cord perfusion
If heparin will be used durimg left heart partisl bypass weigh risks of putting in
Lumbar drain
Prior to removal of lumbsr drain if worried about coagulopathy
Get coags and neuro checks every 2 hours
TEE needed forv dissection
Shows MI as well as aid in assessing lVEDV, valve function and extent of aneurysm
During dissection because placing aortic clamp you want
Upper and lower arterial lines
Might need to clamp subclavian so put upper in right extremity to avoid surgical interference
PAC during dissection
Fluid management, assess cardiac function, timely identification of cardiac ischemia during case and pistop period
Dont do rapid sequence on
Very difficult airway
Do slow controlled IV induction
Vtach unstable
Start chest compressions cardiovert consider amiodarone or procainamide
If HR>150 with v tach but stable still cardiovert
Under 150 and stable just give amiodarone
Do adequate hypothermia if
Decreased signals with aortic crossclamp
Aorticcross clamp
Decresed EF, cardiac output, renal blood flow and distal perfusion pressure
TEG measures
Viscoelastic properties of blood during induced clot formation
Teg can show
Platelet dysfunction, primary fibrinolysis, stage 1 and 2 dic as well as residual anticoagulants
MA on TEG shows
Platlet number and function
Aortic cross clamp and not waking up think
Ischemic, embolic, or hemorhagic stroke
After aortic dissection dont want too
High pressures in pacu can place graft anastamoses at risk
Lithium overdose signs
Ataxia Widening QRS AV nodal block Hypotension Seizures
Lithium has potential to reduce anesthetic
Requirements and prolong depolarizing and nondepolarizing blockers
Tracheal compression
Know positions where it is the worst
Onset and severity of symptoms
CT scan of the neck- can tell you degree of tracheal compression
Large thyroid masses
Flatten both inspiratory and expiratory limb
To evaluate thyroid function get
TSH
Free T3 and free T4
Need to know
Free T3 and free T4
Hyperthyroid patient where you have to go to surgery
Continue PTU which inhibits organification of iodide
Give beta blocker glucocoticoids ( to reduce thyroid hormone secretion)
Add esopageal probe to monitor
Temp to asa monitors
Thyroidectomy usually doesnt require a line but
Parathyroidectomy does
Anesthesize awake fiberoptic
Maintain spontaneous ventilation
Minimal sedation and supplemental icygen
Give nebulized lidocaine
Topicalize nose in case u need to use it
Block superior laryngeal nerves to anesthesize hypopharynx
Transtracheal can anesthetize larynx but not appropriate in patient with goiter
If patient cant do
Awake intubation keep them spontaneous with sevoflurane facemask and go forward with it
Look out for thyroid storm in patient with
Hyperthyroidism
Increase in core body temp see
Increase in MAC
Patient with tracheal compression that is fixed
Extubate very slowly making sure you can view tube with fiberoptic as you extubate. Have difficult airway equipment in room
Unilateral recurrebt laryngeal nerve injury during thyroidectomy
Hoarseness
Thyroidectomy get hypocalcemia postop by
Inadvertant taking out of parathyroid
Cvostek sign
Twotching of facial muscles when tapping facial nerve at angle of jaw
Trossaeu sign
Spasm of hand muscle with occlusion of brachial artery
Replace calcium due to hypocalcemia post thyroidectomy with
10 ml of 10% calcium gluconate over 10 minutes
Thyroid storm you dont see
Metabolic acidosis
Hypercarbia
Muscle rigidity but do see it in mh
Thyroid storm treatment
Acetominophen
Active cooling measures
Beta blocker to control tachycardia
Gove fluids and replace electrolytes
Chronic htn can lead to
Hemodynamic lability and end organ ischemia
OSA and acromegaly can lead to
Difficult airway
Parasellar extension of tumor with
Headache, blurred vision due to compression of optic chiasm, rhinorrhea)
Prolactinoma
Amenorrhea, galactorea, infertility
ADH and oxytocin from
Posterior pituitary
Oxytocin causes uterine contraction and ejection of breast milk
Bromocriptine to trwat excretion of
Prolactin and GH from functional pituitary tumors. Dopamine 2 agonist
Octreotide somatostatin analouge inhibits release of growth hormone
Acromegaly
Clinical suspicion - soft tissue connective tissue overgrowth
Serum igf1
Acromegaly worry about
Difficult airway
Hard mask fit
Emglarged epiglottos and tounge
Worry about coronary disease due to HTN cardiomegaly CHF OSA
Sitting cases
Try to do echo to rule out pfo. If pfo sitting position is relatively contraindicated
Can put precordial doppler to aid with finding
Venous air embolus
Blurred vision from brain tumor can use
Visual evoked potentials
Riskof diabetes insipidus
Place foley
Increased ICP need to find hypotension
Quickly as can lead to cerebral ischemia
Acromegaly patient placement of arterial line
Femoral or dorsalis pedis
Poor collateral blood flow to the hand
Visual evoked potentials monitor
Integrity of optic nerves to make sure they dont get injured
Cocaine injected into nose can cause total spinal or dysrhythmia when it goes in the
Nose
Massive hemorrhage during dissection if brain tumor can lead to
Hypotension
Also think venous air embolus
You listen to precordial doppler for air embolus
Sporadic roaring sounds
Venous air embolus
100% oxygen
Flood field with saline
Aspirate air through central venous catheter
Give fluid, vasoconstrictors for low BP
With air embolus dont give peep
Impaired systemic venous return in a patient with significant cardiovascular dysfunction
Blunt sympathetic response to awakening in osa patient with
Iv lidocaine
Avoid laryngospasm aspiration by extubating
Awake
OSA patient more likely apnea and
Post operative airway obstruction especially when using narcotics
Pulmonary edema atelectasis can also lead to postop hypoxia
OSA
Avoid narcotics
Central diabetes insipidus
Lack of ADH so you piss a lot
Endocrine response to burn is
Hyperglycemia
Airway edema from burn and inhalation injury can make for
Difficult airway
Third soacing can lead to airway obstruction
Third spacing of fluids and renal retention of sodium leads to hypovolemia in
Burn patients
Burns worry about
Hyperkalemia from tissue obstruction and carbon monoxide poisoning
Vasculat trauma indicated by
Pain
Pallor
Pulselessness
Paresthesia
Give burn patients fluid to prevent
Hypovolemic shock
Burn patients
Lots of fluid from intravascular to interstitial compartment
Normal mixed venous oxygen saturation
65-75%
Urine output of .5-1 ml/kg
Each leg is
18% in parkland formula
Fiberoptic scope after burn injury
Examine lower airways for edema or inhalation injury
Order blood gas, chest x ray and pfts
Awakefiberoptic on
Difficult intubation with inhalation injury due to burn
Can have vagal response to
Laryngoscopy
Bicarbonate problems
Generates additional C02
Leftward shift of oxyhemoglobin curve
Hypokalemia due to movement of K from extracellular to intracellular compartment
PH below 7.1
Give sodium bicarbonate to prevent dysrhythmia, hypotension, myocardial ischemia, and catecholamine resistance assocoated with severe acidosis
Cyanosis with normal pulse ox think
Carbon monoxide poisoning
Pulselessness due to
Vascular trauma or compartment syndrome
Get intracomparmental pressures if above 30 immediate surgery
Use BIS and keep below 60
If worried about recall in patient with shock
Post burn for 24 hiurs
Cardiac output is decreased due to circulating myocardial depressant factors, increased SVR, decreased coronary blood flow
After 24 hr with burns and volume resuscitation
Increased circulating catecholamines lead to hyperdynamic state where cardiac output is increased and SVR is reduced
Pulling tube out by accident and cant ventilate think
Laryngospasm
Burn patient keep hematocrit above
30% but take into account hemodynamic instability or any signs of tissue ischemia
Fat embolus from lomg bone
Fractures or can get bone cement implantation syndrome
Bone cement implantation due to
Hardening and expansion of bone cement increased inteamedullary pressures and embolization of bone marrow debris. Methyl malcralate can lead to decreased SVR
Bone cement implantatoo treatmnt
Supportive with 100% oxygen fluids pressors
No heparin
Rhabdo can occur in
Burn patients
Myoglobinuria due to
Skeletal muscle destruction or dark colored urine could be due to hemoglobinuria from incompatibkr blood transfusion
Myoglobiuria
Givefluids and diuresis
Canalkalinize urine to lead to excretion of myoglobin
Hypotensive oliguric patient post burns and something falling on torso with decreased cardiac output and increased peak airway pressures
Abdominal compartment syndrome
Need immediate abdominal decompression
Laparoscopy risks include
Capnothorax, c02 emphysema, pneumoperitoneum induced hypotension
Potassium above 6 perfer to
Dialyze first
If hyperkalemic look for ekg changes such as long pr, peaked t waves
Patients with chronic renal failure are prone to
Increased perioperative bleeding secondary to heparin administration during dialysis and chronic plt dysfunction
In case of transplantedkidney
Want to avoid blood if possible leukocyte antigens may lead to formation of allosntibodies predisposing to rejection of the transplanted kidney
Washed blood for
Iga
Irridiated blood to prevent
Graft vs host disease
Volume overload, uremia, anemia, acidosis of
Chronic renal failure can lead to HTN, dilated cardiomyopathy, CHF, cad and arrhythmias
Obesity puts you at risk for
Aspiration
Need coagulation studies if plannig for
Regional
Renal dialysis pt get
CXR to assess fluid overload and pulmonary status
Avoid lactated ringers in
Hyperkalemics as it contains potassium
Third spacing
Fluid intravascular goes to interstitial compartment
Aspiration usually occurs in
The right middle lobe of the lung
Catheter for epidural oyt 1 hour before
Heparinization for hemodialysis or place 2-4 hr after hemodialysis
Subq unfractionated heparin no
Contraindication to neuraxial anesthesia
More pulmonary complications associated with
Neck injury
Sepsis and hyperglycemia more likely when giving
Steroids
PFTs are needed for patient having
Neck surgery with hypoxia on room air and long history of smoking
PFTs tell me about
Type and severity of disease, baseline pulmonary function, if there is a reversible component
FEV1/FVC less then 70% goes with
Obstructive disease
Hypoxic patient
8 weeks of smoking cessation, chest physiotherapy, bronchodilator, glucocorticoid
Life threatening delirium tremens starts
72 hours after alcohol withdrawal
Benzodiazepine to prevent
Alcohol withdrawal
High glucose
More infection
Poor wound healing
Osmotic diuresis
Get ecg on diabetic due to
Potential for early atherosclerosis and silent MI
Stop smoking
Less carboxyhemoglpbin shifts curve to right
Less sputum less nicotine
SSEPs and MEPs to look for
Spinal cord ischemia in posterior spinesurgery
MEPs are important along with SSEPs be ause they are more sensitive to
Motor injury
Dont use MEPs if patient has cochlear implant or
Actuve seizures
Diabetes mellitus associated with aspiration
Aspiration
Cervical spine do
Awake fiberopitiv eith mannual in line stabilization with two operators
Always get baseline
MEP and SSEPs
SSEP affected by
Hypothermia, hypercarbia hypoxia and anestheyic suppression
If bp not going up give direct agent like
Phenylephrine
Going prone can obstruct venous return leading to hypotension
If bp not going up give direct agent like
Phenylephrine
Going prone can obstruct venous return leading to hypotension
Autonomic neuropathy due to
Wxcessive glycosylation
Autonomic neuropathy due to
Excessive glycosylation
Autonomic neuropathy due to
Wxcessive glycosylation
Part of spinal cord most vulnerable to injury
Anterior spinal cord due to limited blood supply which arises from the vertebral arteries
Anterior spinal artery supplies
Anterior 2/3 of spinal cord and recieves artery of adamkiewicz
A serum lactate to look for
Acidosis
Alcoholic ketoacidosis
Bicarbonate increases C02 and causes
Leftward shift of oxyhemoglobin dissociation curve
Hypokalemia
Patient blind post procedure
Elevate head of bed to help with venous drainage, ensure adequate BP, electrolytes, hemoglobin, urgent opthamology consult
Pion
Decreased blood supply to a part of the optic nerve
High risk for PION
Prolonged surgery greater then 6.5 hours anf 45% estimated total blood volume lost
Decreased venous return due to
Increased intrathoracic pressure with positive pressure ventilation
You can still aspirate with a trach or endotracheal tube
In place
Aspiration leads to intrapulmonary shunting which leads to
Hypoxia
If patient aspirated with tracheostomy in place
Place patient in trendelenberg, add air to tracheostomy cuff, and suction trachea and oropharynx
Not currently recommebded to give antibiotics for
Aspiration
Fresh trach requires
ICU coverage
Too small an endotracheal tube leads to
Airway resistance
Pressure controlled ventilation
Limits peak inspiratory pressures by allowing low tidal volumes
Medical practice
Negligence from the standard of care
Aortiv dissection leads to
Hemmorhage and distal or proximal propagation, and interruption of arteries arising from the aorta with resultant end organ ischemia
Aortic dissection surgery concerns
Spinal cord ischemia from anterior spinal artery syndrome
Myocardial ischemia from clamping and unclamping aorta
Renal insufficeny
Respiratory failure
CAD
Aortic stenosis
CHF
Place at risk for MI arrhythmia
Higher blood pressure
More risk for aneurysm rupture
MI
Heart failure
Be careful of hypotension in patient with
Aortic stenosis
Delay systemic heparinization for 60 minutes following placement of
Thoracic epidural
If hemodynamically unstable or surgery where hemodynamics are in question
Only give narcotics through epidural
Arrhythmia can lead to
Hypotension
Best way to provide renal protection with aortic cross clamping is
Maintain adequate intravascular volume and hemodynamic stability
Mannitol dopamine loop diuretics
Still need renal protection when aortic cross clamp is placed
Infrarenal
Increase in renal vascular resistance, decrease in renal blood flow
Clamp causing ST depression
Take it off
Put in TEE
Slowly put it back on
If patient cant tolerate higher pressures due to clamp can ask surgeon to place temporary shunt to increase distal perfusion and avoid ischemic injury
Cyanide toxicity is characterized by
Metabolic acidosis
Cyanide toxicity treatment
100% oxygen
Mechanically ventilating
Give sodium thiosulfate
Prior to release of aortic cross clamp
Discontinue vasodilators
Replace fluid deficit and blood loss
TEE to guide more volume
Treat sustained reduction in SVR with pressors
Postop renal failure mortality high after
Aortic surgery. Make sure foley isnt obstructed and give fluid bolus if oliguric
Postop renal failure after clamping think
Renal ischemia
Nephrotoxins
Air embolization
Patient cant move legs post aortic dissection procedure differential
Spinal cord ischemia
Intrathecal catheter
Epidural/spinal hematoma
Discontine epidiral get stat CT/MRI and neurosurgery consult
If worried about intrathecal
Try to aspirate csf
Anterior spinal cord
Vulnerable to hypoperfusion due to reliance on on a single anterior spinal artery for blood supply
Artery of adamkowitz arises from
T9-T12
Increase in CSF pressure when you place
Aortic clamp
Avoid hypotension, SSEP and MEPs, drain CSF, shunt or bypass to maintain distal perfusion
Always need
Emergency ventilation equipment Verify central hoses connected Check high pressure by opening each E cylinder and ensuring adequate gas pressure Inspect circuit Check scavenging
Hypoxic mixture safety measures
Fail safe alarm
Oxygen failure cut off valves
Fresh gas mixes with desflurane vapor due to its high
Vapor pressure and heat of vaporization
Sevoflurane
Variable bypass vaporizer
Sickle cell
Mutation of chromosome 11 substitution of valine for glutamic acid in beta chains of hemoglobin
Sickle cell chronic anemia hypoxia ane hemochromatosis leads to
Cardiomegaly, CHF, pulm htn, acute chest, retinopathy
For moderate to high risk surgery in sickle cell patient
Transfuse to Hematocrit of 30% to prevent sickling and increase oxygen carrying capacity
Avoid sickling by avoiding
Hypoxemia, hypotension, hypothermia, acidosis, and hypovolemia
Treating sickle cell crisis
Iv fluids, oxygen, pain control, treat infection, exchange transfusion to reduce fraction of Hgb S to less than 40%
Masseter spasm
Want to know if family history of masster spasm or MH
With masseter spasm assume patient susceptible to MH
Give non triggering anesthetic
Masseter muscle rigity
Give 100% oxygen and attempt to ventolate
If unavle place NPA
Then nasal tube fiberoptic if not surgical airway
Trend CK place a line look for myoglobinuria
Thyrotoxicosis signs
Tachycardia
Increase in CO and SV decrease in SVR and PVR
Neurologic symptoms like anxiety
Sweating, heat intolerance, weakness
Glucorticoids reduce
Thyroid hormone secretion and the peripheral conversion of T4 to T3
Risk factors for aspiration
Obesity
Pregnancy
Gerd
Aspiration pneumonitis mainly dependent on
Volume and pH of aspirate
Aspiration
Apply cricoid
Place bed in trendelenberg
100% oxygen
If hypoxic need to perform rapid sequence induction
Non particulate
Raises pH of gastric content!
Preop on cirrhotic
Jaundice, bleeding disorders, encephalopathy,
Bilirubin alkaline phosphatase, albumin
Cirrohsis
Reduced FRC, restrictive lung disease, pleaural effusion, attenuates hypoxic pulmonary vasoconstriction
Good muscle relaxant for cirrhotic
Cisatracurium
PDPH
Frontooccipatal headache
Better laying down
Nausea
Neck stiff
Conservative treatment is hydration, caffiene pain control
Anticoagulants no blood patch
Want to get coagulation profile prior to placing
Blood patch
Dont want to expand spinal/epidural hematoma
Type C TEF
Esophageal atresia with blind upper pouch and lower segment tracheal fistula
TEF goes with
VACTERL
TEF induction worry about aspiration
Gastric content through fistula
Oral secretions from upper esophageal pouch
Also worry difficult intubation, gastric distension from poor placement ett, hypotension, inadequate ventilation due to decreased pulmonary compliance due to prematurity
In TEF want tube
Distal to fistula and proximal to carina
Spinal epidurals are ok for
Pregnant patients
.physilogic changes during oregnancy
20-40% increase oxygen consumption
40-50% increase in minute ventilation
FRC decreases in
Pregnancy while vital and closing capacity dont change
Kidney transplant cant delay long
Longer cold ischemia times can lead to failed graft function
Higher BP more likely to have
Ventricular dysrhythmias, mi and blood pressure liability
Bp above
180/110 would prefer to delay elective procedures 6-8 wks
Or above 140 with other contaminant end organ damage
If BP above 180 lower to below
160 with beta blocker then sodium nitroprusside over a few hours
Maintain adequate intravascular volume for
Earlier onset of graft function in kifney transplant
Elective surgery should be cancelled for potassium greater then
5.5
Renal disease patient
More likely neuraxial hematoma
Uremic platelet dysfunction and they get heparin pre dialysis
Reguonal anestgesia can be used for
Kidney transplant but causes sympathectomy and more risk for hematoma due to uremic plt dysfunction
If doing regional
Need adequate hydration, prepare for hypotensuon, get coags, look for signs of bleeding
Unclamp iliac vessels after kidney transplant
Following graft placement
Pulmonary artery catheter
Severe CAD
Left ventrucke dysfunction, severe copd
Want to avoid hypotension or hypertension during
Laryngoscopy
Iv lidocaine to attenuate
Sympathetic response to laryngoscopy
Dont use sevoflurane for
Kidney transplant as it has a risk for renal toxicity
Sevoflurane nephroxtoxicity
Compound A from breakdown of sodium hydroxide
Sevoflurane metabolites form inorganic flouride
Dont give lactated ringers to kidney transplant as can lead to
Hyperkalemia
Heparin is given during kidney transplant prior to clamping of vessels to
Prevent clotting
Hypotension following iliac unclamping in kidney transplant
Washout of vasoactive substances from previously ischemic tissues
Acute increase in up to 300 ml to the intravascular space
Want to depress cardiac membrane excitability with
Hyperkalemia
PEEP helps in pulmonary edema by
Redistribution of alveolar fluid that are less involved with gas exchange, improves oxygenation
PEEP and positive pressure ventilation worsen cardiac function secondary to
Decreased preload
Need to maintain adequate renal blood flow post transplant
T
Uremic platelet dysfunction with
Kidney disease
Uremia in esrd patients
Decreased vWF formation and release
Increase synthesis nitric oxide which has platelet inhibitory affects
Hemodialysis best way to treat uremic thrombocytopathia
Eliminates uremic acid and quickly restores adequate plt function
Oliguria post kidney transplant
Hypovolemia, hypotension, acute graft rejection, renal vein or artery thrombosus, ATN, obstruction of the foley catheter
Gastrostomy to decresse stomach size if ventilate by accident through a
TEF
Place ETT beyond fistula
Suction upper esophageal pouch to prevent aspiration
In TEF repair
Place a line and two prechordial stegescopes
One over left axilla to monitor ventilation and heart rate
One over stomach to make sure youre not ventilating the stomach
In nenate want to minimize
Sympathetic stimulation of laryngoscopy as can lead to IVH
Gastrostony tube
Reduces risk of gastric distension
Give atropine
0.02 mg/kg to ablate sympathetic response to laryngoscopy
TEF make sure
Adequate monitoring and iv access Place in head up Suction proximal pouch and stomach Atropine .02 mg/kg Rapid sequence intubation
TEF
Advance tube into right mainstem bronchus and withdraw until only breath sounds on left axilla precirdial stethescope
Use uncuffed tubes in children under 8 to minimize
Post extubation croup
Use cuffed tube in neonates for TEF but want
Air leak at20-25 cm H20 to prevent post extubation croup
Sp02 decrease during TEF repair
Tube may get displaced into rught mainstem bronchus or proxinal to fistula causing gastric distension
Managing intraoperative fluid replacement
Maintenance fluids at 4 ml/kg/hr with dextrose containing solution
Maintenace fluids neonate
4 ml/kg/hr plus dextrose
Insensible losses replace with 6-8 ml/kg/hr
Early extubation in TEF to lower pressure on
Anastomotic suture line
TEF extubation
Want awake pt due to risk of tracheomalacia Complete reversak euronuscular blockade Gag cough reglex 5 to 7 cc tidal volume on cpap Peak inspiratory pressure less than 30 Holding sats with Fi02 40% or below
Post TEF hard to ventilate
Obstruction of tube Movement kd tube Bronchospasm Anastomotic leak Pneumo
Normal hct of full term neonate is
55#’%
Inspiratory stridor due to
Extrathoracic upper airway obstruction such as epiglottitis
Barking cough think croup
Treat with nebulized racemic epinephrine and iv dexamethasone .25-.5 mg/kg
Tracheomalavia is associated with
Expiratory stridor
Requires do require pain tontrol and can do
Epidural post TEF repair or acetominophen 10-20 mg/kg every 4 hr prn
RA
Causes vasculitis that occurs secondary to deposition of immune complexes
RA
Pulmonary and cardiac issues, peripheral neuropathy, cervical spine issues
Treatment for RA
NSAIDs for analgesia
Disease modifying antirheumatic drugs like methotrexate, corticosteroids to rapidly decrease inflammation
5 mg of prednisone per day give
Prophylactic steroids
RA
Atlantoaxial subluxation
Can lead to TMJ as well
Bilateral eye irritation and gritty sensation when blinking after case think
Keratoconjunctivitis due to impaired lacrimal gland function and subsequent inadequate tear formation
Type and cross
Mixes receipent plasma with donor RBCs to detect incompatibility
Most transfusion reactions are due to
ABO incompatibility secondary to clerical error and usualky result from binding of antiA or antiB IgM antibodies to RBC membranes
Acute porphyrias
Deficiency of one of the enzymes in the heme biosynthetic pathway, resulting in too many porphyrins and their precursors
Productionof too much
Ala synthetase can lead to AIP
When patients have higher heme requirement with anemia
Conscious sedation better known as moderate sedation
Drug induced depression of consciousness patients respond purposefully to verbak or tactile stimulation
No airway stuff needed
Non anesthesia providers need
Two forms of oxygen, appropriate monitord, emergency meds, crash cart, cpr personnel trained ppl
Late stage thrombosis risk with stent much higher if stop medications within
Time free of stent
If pt stops blood thinners with DES prior to surgery during frame its needed
Try to delay surgery or give loading dose if plavix restart aspirin and wait a few hours before surgery
Extubate when
Awake and alert Active laryngeal reflexes Effective cough Good vitals/abg Pa02 above 60 pac02 below 50 Arterial pH above 7.3
Neonate under 100 HR
PpV
If after 30 seconds under 30 intubate start chest compressions 3 to 1
After 30 seconds give epi through umbilical vein or io
If mother hypermag might go to
Child after born
Treat with calcium
Right upper extremoty for
Preductal flow
Myasthenia gravis gos with thyroid cam give succ but be careful giving
Rocuronium
Intravascular or intraneural injection can happen from
Retrobulbar block
Decreased FRC and osa
Obesity
Pregnancy and seeum glucose only on
Diabetic fat woman fir umbilical hernia surgery
Give breathing treatment to optimize
Asthma
Diabetic neuropathy can mask
Cardiac problems
Can do unbilical hernia under
Regional or local
Put patient in head up to prevent
Passive regurgitation
Give narcotics upfront to
Attain deep level of anestgesia to avoud bronchospasm
Reverse trendelenburg helps with
Respiratory mechanics
Expiratory wheezing plus desaturation=
Bronchospasm
PE happens more commonly in the
Morbidly obese
Non opioid analgesics like
Ketorolac are good
Epidural to avoid respiratory depression dont add
Narcotic
Only local
Bradykinin production closes
Ductus arteriosus
Materbal sterood administration
Increasees surfactant production in vivo
RDS infant
Tachycardia, tachypnea, intercostal retractions, bilateral rales
Need type and cross during PDA surgery
Fluid status, chest and abdominal films, abgs
Precordial stehescope on
Infants
In pda surgery since clamping of left subclavian likeky put BP cuff or a line on right
PDA dont want to lower svr so use
Nitrous and ketamine
During PDA if desaturation
100% oxygen tell surgeon to relax any traction on the lung until patient stabilized
Neutral temp
Oxygen consumption minimized
Heat production in infant by
Nonshivering thermogenesis
Neonates hypothermia induced release of norepinephrine leads to
Nonshivering thermogenesis
Seizure in neonate
Hypoglycemia
Heorhage
Cerebral edema
Secure airway on someone who cant protect airway and is obtunded
Obtunded
Slow controlled infuction using ketamine to keep
Bad airway in adult spintaneous
On pregnant lady check
Babys heart tones
Ativan reversal can lower the
Seizure threshold
Babys heart tones down first
BP good
100% oxygen
Left uterine displacement
In prescene of incressed ICP dont do spinal
Can potentially lead to brainstem herniation
Epidural or spinal anesthesia
In prescense of eclampsia thrombocytopenia makes it more likely
ART line to measure
Cerebral percusion in obtunded patienr
Mannitol shifts fluid from
Intracranial to intravascular
Magnesium toxicity cwj cause
Patient to not wake up
Airway and cardiac compression by
Anterior mediastinal mass
Chest X rays and PFTs for patient with anterior medistanl
Mass
For anterior mediastinal mass causing SOB try
Chemo and radiation first
Anterior mediastinal mass
Want echo upright and supine
Atlantoaxial instability with downs makes it
Harder intubation
Difficult airway
Give enough sedation to maintain airway reflexes and spontaneous ventilation
Anterior mediastinal mass
Put a line and iv in lower extremity
Cannulate femoral vessels before on bad anterior mediastinal mass to have
Cardiopulmonary bypass ready
Caj move patient in lateral or prone position to relieve pressure on trachea from
Anterior mediastinal mass
Cholinergic edrophonium test will show
Cholinergic vs myasthenic syndrome
Third spacing of fluid from burn can lead to
Airway edema
Hyperkalemia from
Tissue destruction from burns
Burn patients need fluid to prevent
Hypovolemic shock
Head and neck
Chest
Legs are 18%
Others are 9 including arms on parkland formula
People can have a vagal response to
Laryngoscopy
Carboxyhemoglobin higher affinity for
Hemoglobin
Shifts oxygen dissociation curve to the left
Burn pt needs
Central line
Need foley to monitor urine output and assess for rhabdomyolysis
Immediate post burn for 24 hours
Cardiac output is decreased and increased SVR
Laryngospasm
Jaw thrust and apy pressure to ascending ramus of mandible
Laryngospasm first give
Lidocaine and then succinylcholine
If obstruction passing tube
Try smaller tube or prepare for emergent tracheostomy
Listen for leak around tracheostomy if
Desaturating
Add air to trach cuff if aspiration
Suction and head down and bronch
Pressure control
Limita peak inspiratory pressures by allowing smaller tidal volumes
CDH leads to
Intrapulmonary shunting, pulmonaryvHTN, impaired gas exchange
CDK pulmonary HTN and
PDA and PFO shunt cause more hypoxia hypercarbia acidosis making Pulm HTN worse
CDH
Intubate with vety low tidal volunes, get echo and fix hypothermia, abg
Avoid positive pressure thus mask ventilation with
CDH
Difference in pre and post ductal sat is due to
Shunt
If bad shunt in neonate want to
Decrease PVR and increase SVR
Emergent chest tube for pneumothorax
22 gauge in 2nd intervostal space in neonate
Hypothermia increases oxygen demand and can result in increased
Acidosis and pvr
Hydroxyurea works by increasing amount of fetal hemoglobin which thus reduces amount of
Sickled hemoglobin
HgbS in venous blood doesnt sickle bc it is time dependent and goes to get
Oxygenated even though it has a low Pa02
Aplastic crisis from bone marrow suppression secondaey to infection
Typically parvovirus B19
Sickle cell
Temp management Volume management Renal pulmonary cardiac dosease More likely infectoion History of vasocvlusive crisis
Epidural better than spinal
Less sympathectomy, can titrate local anestgetics with fluid
Amniotic fluid enbolus
Pulmonary HTN
Seizures
Hypotension
Cardiac arrest
During wmniotic fluid embolus
Keep catheter in because dont know coagulation status
Reduce risk of sickling by giving
100% oxygen
Intravitreal air in the day is
Reabsorbed within 5 days
Sulfur hexaflouride avoid
Nitrous for 10 days
Citrate can chelste calcium during
Massive transfusion
Magnesium toxicity can cause
Hypotension
PE can also occur in pregnant pts
Calcium can help with
Magnesium toxicity
Prolonged QT from
Hypocalcemia also widened QRS complexes
Need to provide pain control to
Chronic opioid users
Acute chest
Fever cough tachypnea hypoxemia pulmonary infiltrate and chest pain
Trali
Non cardiogenic pulmonary edema
Acute chest treatment
Pain control
Supplemental oxygen
Antibiotics to cover atypicals
Correct anemia and consider exchange transfusion
Try to avoid tourniquet in pt with
Sickle cell
Need to know
Babys condition as will tell you urgency of case
For preeclampsia want to know if associated symptoms such as
Cerebral edema, renal insufficency, coagulopathy
On Ob patients exam
Airway
Coagulopathy
Heart function
Volume status
CXR shows
Pulmonary congestion and cardiomegaly
Echo
Shows wall motion abnormalities and can tell you the EF
Severe preeclampsia is an indication for
C section
C section associated with more
Blood loss
Infection
Ambulation delayed
Need level to
T4 for OB
If concern about epidural hematoma do
Hourly neuro checks after removal
Preeclamptic pt with cardiac disease
A line pac central prior to induction
Epi and atropine every 3-5 min for asystole
Asystole
Deliver baby if mother in cardiac arrest not better after
A few minutes
Decreases metabolic demand
Increases venous return
Better compressions
Severe cardiac disease maximize oxygen carrying capacity by increasing Hgb to
10
Newborn weak
Uteroplavental insufficency
Hypermag
Hypoglycemua
Meconium aspiration
Use ph stat in kids on bypass
The C02 added helps brain function
Absent x descemt with severe
Mitral regurgitation
Ischemia from HTN can lead to
Atrial fibrillation or atrial dilation from worsening mitral regurg
If patient goes into irregular rhythm
Can shock or amiodarone ot immediate go on bypass if cardiac case
Perfusionist says resevior venous is getting empty
Immediately reduce flows and add fluid to blood to prevent massive air embolus
Vigorous inflate lungs after cp bypass helps
Recruit collapsed alveoli
Move air into left heart where it can go out a vent
Deairing of heart important to prevent
End organ damage from embolisation of air into cerebral or coronary arteries
LVfailure preventing weaning from bypass
First inotropes then iabp
Tip of iabp is placed at
Junction of aortic arch and descending aorta
Central aortic pressure 30 points above
Radial during peripheral vasodilation of rewarming
Femoral artery good representation of central aortic pressures
Tamponade
Higher systolic pressure diring inspiration
IV ketamine for combative patient for
Intubation
Dint go through nose if
Basilar skull fracture
Can remove andmonitor ICP with
Intaventricular catheter
Furosemide and barbiturates can
Reduce ICP
Hyperventilation can lead to
Cerebral ischemia so use as last resort for lowering ICP
Hypothermia
Coagulopathy
Cardiac dysrthymias
Poor wound healing
Impaired renal function
Fat emboli happens with
Femur fracture
Fat embolus
Sub conjuctival petichiae and hypoxemia and pulmonary edema
Diagnosis of ARDS
Acute onset
Diffuse bilateral infiltrates on chest x ray
Pa02/Fi02<200
PaOP<18
High urinary sodium with low serum sodium think
Cerebral salt wasting
Cerebral salt waating
Hypovolemia wheras SIADH is euvolemic
SIADH do
Water restriction
CSWS dont do water restriction and diuresis as patient is hypovolemic
Pyloric stenosis
Give normal saline and after urine output established start potassium
Inhalation induction faster in
Neonate
Higher minute ventilation to FRC ratio
Increased blood flow to vessel rich organs
Extubate pyloromyotomy when
Awake
Give lidocaine prior to extubation if they bronchospasm
Less then 50% postconceptual age high risk for
Postop apnea
Monitor 24 hr postop for neonate
Less then 50 weeks age risk of postop apnea
Magnet can disable
Tachydysrhythmia and sensing
Place return plate
Close to operative site but far from AiCD
Retrobulbar block high risk
Extrusion of intraocular contents
Decreased FRC with increased intraocular pressure from
Trendelenberg position
Pacemaker not capturing due to lead failure
Chevk all monitors electrolytes start transcutaneous pacing
MI can significantly increasse the energy requirement for depolarization causing pacemaker to not
Capture
If risk of pulmonary aspiration extubate patient
Awake
Preeclamptic who develops a seizure need to
Intubate
Avoid neuraxial if
Spina bifida
Preeclampsia increased risk of epidural hematoma
Ketamine is a myocardial depressant when
Catecholamines depleted and increases icp
Gastroschisus occurs
Lateral to umbilicus
Omphalocele usually associated with
Lung hypoplasia
Omphaloecele get
ECHO- not an emergency
Need good iv accesss
Place og tube
Beckwidth Weidman
Omphalocele
Macrosomia, midline abdominal wall defect, hypoglycemia
Large blood pressure swings place
Arterial line
Omphalocele closure may get high abdominal pressures so place
Lower extremity pulse ox
Omphalocele causes
Macroglossia which may lead to difficult airway management
Can do awake intubation or rapid sequence if airway is reassuring
Omphalocele dont use nitrous
Can diffuse into intestinal tract causing significant bowel distension
Diarrhea flushing and cardiac involvement
Carcinoid triad
Look at urinary 5-HIAA
Carcinoid sybdrome
When carcinoid tumor secretes hormones like bradykinin, serotonin, histamine into systemic circulation
Carcinoid syndrome diagnosis
24 hour urine levels of 5 HIAA can be measured
Only shows after these substances bypass the portal circulation
Cardiac finding in carcinoid syndrome is
TR
Vapor pressure of isoflurane is higher than
Sevoflurane
Need CVP and foley for
Carcinoid tumor removal
Need appropriate depth of anesthesia to not get
Bronchospasm when placing ETT
Dont use succ with carcinoid tumor!
Fasiculations and potential histamine release could lead to increased realse of vasoactive substances from the carcinoid tumor
Carcinoid crisis or anaphylactic rxn
Hypotension wheezing increases in airway pressures
Elevated icp with psuedotumor
Cerebri
Elevated serotonin
Delay emergence
PFTs to look at
Severity of obstruction and response to therapy
Consult hematomogist for patient with increased
Ptt and get individual coags
After tonsillectomy bleeding
Ask surgeon to put pharyngeal pack and compress ipsilateral carotid
FFP can cause
Calcium chelation leading to hypotensoon
Chrinic treatment with exogenous steroids leads to suppression of the
Hypothalamic adrenal pituitary axis
Extubate awake to prevent larngospasm
Og tube
Position pt laterally
Suction oropharynx
Administer narcotics, beta 2 agonist, and iv lidocaine
Dont give ketorolac to patient
Already bleedung
75% of post tonsillectomy hemorrhages occur within the first
6 hours
Need chest ct for pneumonectomy
And need anterior and posterior chest x rays
Dlco and
V02? Max important in pneumonectomy
Ketamine is a myocardial depressant when
Catecholamines are depleted
Both omphalocele and gastroschisis
Ovcur more in males, allows extrusion of abdominal wall viscera
Gastroschisis less associated with
Congenital abnormalities
Neonate omphalocele
Lung hypoplasia
Need good iv access, temp, prevejt infection, decrrss stomegh with og tube
Beckwidth wedidman
Present with omphalocele and macrosomia so may be difficult airway
Esopaheal probe to monitor
Temp
Nitrous leads to
Bowel distension
If good airway do
Rapod seqjence if not awake intubation
Bmi calculation
Kg/m squared
More fat shorter higher bmi
OSA
Cessation of airway for 10 seconds 4 or more times per hour decrease in sat > 4% per hour
OSA
Higher risk for gerd
Hypertensive nephropathy
Somnolence
Pickeinisn syndrome
BMI>30 with pac02>44 at rest
Important awake intubate
First preoxygenate 100%
Give 1-2% lidocaine spray or nebulizer
Perform superior laryngeal nerve block injecting 2 ml 2% lidocaine just anterior to the Cornu of the hyoid bones
Do transtracheal recurrent laryngeal nerve block
Des insoluble in fat and has fast wake up so good for
Fat people
Have difficult airway equipment available when extubation
Difficult airway
Infection wound healing worse with
High glucose
PCEA less opioid requirement than
PCA
Mg
Autoimmune disorder antibodies to alpha subunit of nicotinic AcH receptor at neuromuscular junction leading to decreased number of receptors
Thymoma
Get flow volume loops can show extent of impairment and whether fixed or dynakic
Corticosteroids inhibit the production of
Abnormal autoantibodies to Ach receptor in myasthenia gravis
Myasthenia avoid
Muscle relaxant
If high aspiration risk I would use succ 1.5-2 mg/kg for rapid intubation
Nerve stimulators often unreliable with
Myasthenia gravis due to uneven levels fade
Succ longer If you give
Preop cholinesterase inhibitor
If respiratory insufficiency after for myasthenia gravis
I would reintubate
Consider edrophonium test
Severe bulbar or respiratory symptoms from
Myasthenia crisis
Cholinergic crisis due to
Overdose of cholinesterase inhibitors
Excessive salivation, bradycardia
Endotracheal intubation atropine and stop cholinesterase inhibitors for treatment
Avoid ester local anesthesia
They are metabolized by plasma volume straw and can worsen symptoms in myasthenia gravis
Laryngeal papilloma due to
HPV and want neck ct to see extent of papilloma
Expiratory from papilloma causing
Flattening inspiratory limb
Long standing chronic airway obstruction can develop
RVH and cor pulmoale
Want cardiac echo and ekg
Right atrial hypertrophy 2 3 avf peaked t waves
Po midazolam for teens
If Pt fearful of needles don’t place iv
Prior for laryngeal papilloma can lead to obstruction
Laryngeal papilloma
Emergency airway equipment and ent on standby for tracheostomy
Intubation not preferred for papilloma removal
Just spontaneous ventilation while under
Intubation airway fire airway bleeding airway resistance difficult intubation
C02 fire prevention
Wet towel after face neck shoulders
Protect eyes
Low fi02
If not intubated use
Tiva and remi infusion
Bronch with mild edema after airway fire
Humidified oxygen steroids racemic Epi with smaller endotracheal tube
Pneumo bronchospasm
Low bp high hr desat
Bilateral pneumo and subcu emphysema think
Tracheal tear
Anemia can precipitate a crisis in a patient with
Sickle cell disease
Target hgb in patient with sickle cell is
10
Acute chest in sickle cell
Respiratory symptoms, fever, pain hypoxia, infiltrates on cxr
No tourniquets in sickle cell if
You can
A line and central line good choice in patient with sickle cell going in for
Surgery
Prefer no opioid in sickle cell as
Hypoxia and respiratory depression can lead to sickle cell crisis
Can give after if other non opioid measures don’t work
Acute chest syndrome
Start with supportive mechanical ventilation, broad spectrum abx, simple transfusion or exchange transfusion to maintain hct 30%
Echo before liver transplant
High pulmonsry pressures above 50 mm Mercury can’t get transplant
Want to know about murmers
Liver disease ascites due to
Hypoalbumin, water retention, portal hypertension
Can’t do regional during liver
High risk due to coagulopathy
Liver transplant
10 prbc 10 FFP 10 plt and 10 cryo
Don’t do renal transplantation if
Potassium 6 or more
Renal transplant- not emergency
Can hold cadevaric kidneys 36-48 hr
Gastroparesis
From renal disease makes you full stomach
Don’t do kidney transplant
Coagulopathy secondary to urecemia leading to decreased vwf
Renal transplant gastriparesis can lead to aspiration do rapid sequence with
Fentanyl etomidate succ
Desflurane good for renal transplant bc it is not
Nephrotoxic
Clamp iliac vessels in renal transplant
Give heparin prior
Surgeon inject verapamil into graft arteries prior to revadvularization to prevent arterial vasospasm and mannitol after for diuresis
After unclamping iliacs
Hypotension due to washout of vasoactive substances from renal graft
Oliguria
Pre intra post renal
Post is obstruction or kinked foley
Increase serotonin from carcinoid tumor
Avoid stress
Delayed awakening and lowers MAC
Carcinoid slow controlled induction
Fentanyl etomidate rocuronium prevent hypotension catecholamine secretion and histamine release
Acute arrhythmia can cause
Hypotension
Hypovolemia
RV failure, anaphylaxis
Carcinoid crisis
If pt peak pressure rises with skin flushing and manipulation of carcinoid tumor by surgeon give
100 mcg of octreotide bolus
Octreotide can cause
Glucose intolerance
Post op for carcinoid
Epidural or fentanyl PCA
Taper octreotide over a week
Post op from carcinoid tumor removal
Pheo need adequate blockade
Supine blood pressure under 160/90 prior to surgery with no st segment or t. Wave changes
Cardiac status
Chest pain or SOB
Talk to cardiologist
Exercise tolerance
Look at recent ekg or echo
Detect pheo by seeing
Plasma metanephrines or urinary vma
Endocrine tumors that secrete catecholamines
Pheo
10% bilateral, 10% malignant, 10% extraadrenal
PAC or TEE can be used on cardiac patients
Patients
T8 level for pheo under
Epidural but don’t do if unfamiliar
Pheo avoid which drugs
Succ bc fasiculations can stimulate tumor cells
Also histamine releasing drugs like atracurium or morphine
Sodium nitroprusside works fast to lower BP due to a
Pheo
Perception orientation messed up with
Delirium and happens over hours
Post of cognitive dysfunction develops over days
Start 5% dextrose infusion if pt
Hypoglycemia in pacu with frequent glucose checks
Perfusion to brain is auto regulated at
MAP 50-150
AS don’t want low
Coronary perfusion pressure
AS transvalvular gradient that would necessitate correcting valvular surgery
50 mm hg
Patients auto regulatory mechanism bad with
Hypertension
Beach chair position
Venous pooling in sitting position, need pt well hydrated. Cerebral perfusion pressure may be lower than what the bp cuff measures
Induced hypotension
Decreases intraop blood loss up to 50% and shortens surgical time
Interscalene block for
Shoulder
Ropivicaine .5% for
Long lasting analgesia
Check deltoid strength to look at interscalene
Block well done
Bezold Mariah reflex during shoulder surgery
Low HR or can be due to carotid sinus hypersensitivity
Give epi and atropine
Phrenic nerve palsy can make patient sob after interscalene block
B
Difficult airway with as
Esmolol drip on standby
Awake fiberoptic
If anxious give some midazolam and more nebulized lidocaine
Bone cement can cause hypotension and gets better
With iv fluid and pressors
Irregular a fib unstable
100% oxygen, feel for carotid pulse, cal for help, code, get labs and cardiac enzymes, do synchronized cardioversion
Taking AS patient to icu use
Midazolam and fentanyl drips as more cardiac stable then Propofol which causes hypotension
High risk of infection with burns
Pass the skin barrier and can lead to full blown sepsis
Torso on rule of 9s is
18%!
Cooximeter to measure for
Carbon monoxide
CO shifts oxygen curve
Down and to left
So does hypothermia alkalosis decreased 2 3 dpg
Burn patients are at risk for
Curling ulcers so consider them full stomachs
Stridor means
Soft tissue swelling has happened
Place preinduction a line as burn patients
Intravascular depleted
Colloids don’t give to burn patients
Worsen hypovolemia by increasing oncotic pressure of extravascular space
Give LR for burn patients
Not associated with acidosis like normal saline
Don’t extubate burn patients
With inhalational injury
Wait and check for a leak good volumes without discomfort the next day
5 x Fi02 =
Pa02
Minimum urine output for burn patient
0.5 mg/kg per hour
Burn patients need
More muscle relaxant
Glasgow coma scale
Looks at level of consciousness after traumatic brain injury
Abdominal paracentesis in trauma to see
In hemodynamic unstable pt to see blood to Quickly go for ex lap
FAST exam looks at 4 views
RUQ, LUQ, subxiphiod, suprapubuc to diagnose hemorrhage using ultrasound
Trauma pt labs
CBC, bmp, coags, abg and type and cross
Don’t forget
Kinked ett or anaphylactic reaction
Massive blood transfusion definition
Greater than one blood volume in 24 hours or greater then 50% of blood volume in 4 hours
Complications massive blood transfusion
Thrombocytopenia, coagulation factor depletion, hypocalcemia, hyperkalemi, trali, ARDS
Before Extubation want
Pa02/Fi02>300
Need appropriate pH>7.25 and paco2 under 45
Hypothermia
Decreased wound healing and at risk for infection
All pressures up and cardiac index low think
Pericardial tamponade
Echo to look for
Pericardial tamponade
Tamponade treatment
Open fluids support vitals with dopamine and go to or
Pericardial window or bedside paracentesis
ARDS
Pa02/Fi02<200
Pulmonary cap wedge pressure less than 18
Peep helps with ARDS by
Prevents alveolar collapse at end expiration and increase lung volume
Acute trauma is
Full stomach
Gi motility diminished bc stress decreases parasympathetic nervous system activity
Decorticate response
Flexion to painful stimuli
Epidural hematoma from tear in
Middle meningeal artery
Cocaine abuse
Lability bp with severe HTN, acute cocaine use can lead to seizures v fib mi
Cocaine abuse needs
A line to monitor bp and 5 lead ekg
Infusions of esmolo and nitroprusside ready
Two large ivs
Only direct agent like phenylephrine, might have exaggerated response to indirect agents
Chronic alcoholism
Hepatic issues
Avoid direct myocardial depressants as may have cardiomyopathy
Need cervical mri to clear c spine
To see any ligament injury missed on x ray
Ketamine worsens bp on patient already with
Cocaine abuse
Pa02/Fi02 above
200 but under 300 is
Acute lung injury
Low Fi02 to prevent oxygen toxicity with
ARDS
Chronic HTN
LVH or nephropathy
LVH
Greater than normal myocardial demand
If new Q waves and LVH
Hey more tests like echocardiogram
Laser during turp
Protective goggles
Watch out for fire
Must penetrate prostatic tissue to appropriate depth but not normal tissue
A line for TURP
Need a line if cardiac risk factors and massive intravascular volume absorption with irrigation
Want to assess mental status so do
Spinal for turp
Less anxiety with
GA
But need to give more opiates
Single shot spinal for
T10 level for TURP
TURP syndrome stop
Irrigating immediately
Good irrigating fluid for TURP
Isotonic
Electrically inert
Transparent for proper visualization
Nontoxic
TURP syndrome
Due to acute volume expansion and dilutional hyponatremia with HTN Brady and neurologic symptoms
Induce and intubate patieht you’re worried about
TURP syndrome
Dilutional hyponatremia
If under 120 start hyperionic saline then normal saline once to 120
Hyponatremia can lead to
Cerebral vascular event or metabolic disturbance
Central pontine myelinolysis
Demyelination of the brain stem
Central pontine myelinolysis
Demyelination of the brain stem
Central pontine myelinolysis
Demyelination of the brain stem
Central pontine myelinolysis
Demyelination of the brain stem
Glycine stimulates
Inhibitory neural pathways which can lead to transient blindness
Supportive measures and usually transient
More glycine leads to mote
Ammonia
High bladder pressure and hr
Think foley obstruct use saline to pass by clot
Must know if aspiration was witnessed
And what it was
Child want to know
Respiratory status prior and asthma
Physical exam child
Look for increased work of breathing,tripod posturing nasal flaring retractions
Foreign body aspiration differential
Esophageal foreigj body
Croup
Reactive airway disease
Anaphylaxis
Auscultation chest for foreign body
Will have decreased breath sounds on that side
IO into
Proximal tibia two finger breaths distal to tibial tuberosity
Aspiration child
Anticholinergic give to dry up secretions and minimize Vagal response to bronchoscopy
Do inhalational induction and promote spontaneous ventilation to
Promote spontaneous ventilation and avoid migration of foreign body which can lead to total airway obstruction
No rapid sequence
Aspiration
Head doen lateral and suction
Intubation
Suction ett and ventilate with 100% oxygen
Nitrous Loweers oxygen
Delivered
Unable to ventilate while taking out foreign object
Tell surgeon to push it in or get it out immediately
Next put pt in lateral or prone and try to get it out
If swelling of airway after foreign body
Intubate and check for air leak at 25 to 30
If no air leak keep patient intubated
Noisy breathing in child after Extubation
Soft tissue relaxation obstruction, mucosal edema or bronchospasm
Upper airway stridor
Humidified oxygen, steroids, nebulized racemic epinephrine
Racemic epi
Watch for 3 hour can lead to rebound edema
Phenergan has
Black box warning in children for respiratory failures
Phenergan has
Black box warning in children for respiratory failures
Type C
Esophageal atresia with fistula connecting distal esophageal pouch to trachea
TEF diagnosed by
NGT can’t ng tube with drooling with choking with first feeds
VACTERL
Vertebral anomalies Anal canal defects like anal atresia Cardiac anomalies TEF Renal defects Limb defects including radial aplasia
After TEF diagnosed put baby
In head up and place og tube to suction blind ending esophagus
No gastrostomy for TEF prior to surgery
Leads to air leaving trachea instead going into stomach
Monitors for TEF
Asa monitors
Preinduxtio a line
Prechordial stereoscope
Pre and post ductal pulse ox
Avoid muscle relaxant with TEF until tube is in
Right spot
Spontaneous induction with oxygen and Sevoflurane
Place in right mainstem and pull back
TEF goals
Don’t ventilate through fistula
Avoid hemodynamic instability and aspiration and maintain normothermia
If desat during TEF
Tube may have gone mainstem or ventilate fistula or kinked tube or mucus plug
Stomach can rupture in TEF if you
Ventilate fistula. It can impair ventilation
TEF
Keep patient intubated for 5 days! Worried might mess up suture line
Also increased risk of postop apnea in infant under 60 weeks post gestational age
TEF repair early complications
Anastomotic leak and stricture
Late complication is GERD and feeding issues
Pyloric stenosis differential
Ileal atresia
Intraavdominal hernia
Meckels diverticulum
Definitive diagnosis of puloric stenosis
Abdominal ultrasound
Definitive diagnosis of puloric stenosis
Abdominal ultrasound
Definitive diagnosis of puloric stenosis
Abdominal ultrasound
Baby fluid status need to know
Quantity and frequency of recent wet diapers
Lactated ringers can cause
Metabolic alkalosis. Lactate is converted to bicarbonate
Dehydration can elevate
Hematocrit level
Standard asa monitors
Pulse ox Ekg Etc02 Bp cuff Temp probs
Before pyloromyotomy decompress stomach in
Prone lateral and supine positions
Pretreat pyloric stenosis
With atropine 0.02 mg/kg
Newborns
Large tounge
Funnel shaped larynx
Long epiglottis
Level of glottis is at C3-C4
Post Extubation croup can be seen
After pyloromyotomy as well as continued risk of aspiration and pulmonary dysfunction including apnea spells
Infants up to 60 weeks postconceptual age are at increased risk for
Postoperative apnea
Neonates need
Dextrose in fluids post op
CDH
Not a surgical emergency. Stabilize cardio respiratory status want preductal sat>90%, correct acidosis, reduce R->L shunt
CDH physical
Barrel chest
Scaphoid abdomen
Bowel sounds chest auscultation
Respiratory distress and hypoxemia
Persistent pulmonary HTN with
CDH causing increase in right to left shunting through pfo and pda
CDH right to left shunt
PHtn increased PVR causes deoxygenated blood to be shunted through pfo and pda
With pulmonary HTN don’t ventilate with
100% as it makes pulmonary HTN worst
PH in child can give
Nitric oxide
High frequency oscillatory ventilation as it improves ventilation with reduced barotrauma
CDH have neck veins available for
ECMO and place umbilical central line
Avoid positive pressure with
CDH
For CDH induction
Keep patient spontaneous and use Sevoflurane and oxygen
Cdh maintenance
Sevoflurane fentanyl and vecuronium
CDHsudden BP and SAT drop
Contralateral pneumothorax
Severe ph
Compression of great vessels
PH
Reduce pvr and increase svr
Hypothermia can increase
PVR in CDH patient
Neonates have decreased glycogen stores and prone to
Hypoglycemia
Don’t extubate after CDH repair due to
Postop pulmknary complications
Keep on muscle relaxant and fentanyl infusions
If pt desaturation post CDH repair and not improving with 100% oxygen start
HFOV then ecmo
Ecmo need anticoagulant lion and more risk for bleeding
Ecmo eliminates right to left shunt
Q
Epiglottitis
Severe sore throat, muffled voice, dysphagia
Bad fever
Epiglottis is
Emergency don’t wait for x ray which will show thumbprint sign on lateral view
Don’t place iv prior in epiglottis as can lead to
Laryngospasm
Have ENT on standby when intubating for
Epiglottis
Epiglottis induction
Sevo and oxygen inhalational
Place ig after patient is deep
Use smaller endotracheal tube
Can give reglan after you get iv in patient with
Epiglottis
Epiglottitis
Have ENT on standby for surgical airway
Usually able to extubate patient with epiglottitis in
24 to 48 hours
Extubate epiglottis when
Normal temp
Use abx
Leak around endotracheal tube
Extubate epiglottis
Do in or with the neck prepped and draped by ent, do general anesthesia to inspect edema and if good extubate
Low sat with
PDA
Worry about glucose status in
Pda and degree of pulmonary HTN
Also if on chronic steroids and infection
Indomethacin can sometimes close pda but don’t give to newborn with
IVH
Necrotizing enterocolitis much higher In PDA patient
Blood shunted from systemic to pulmonary circulation resulting in decreased abdominal organ perfusion
PDA
Bounding pulses, widened pulse pressure, CHF manifested by intercostal retractions
Echocardiogram will confirm the prescence of
PDA
PDA
Aline central line
A line right upper extremity
Upper and lower sats
For PDA maintenance want
High dose fentanyl technique
PDA sat
87 to 95%
Pa02 50 to 70
PDA
PE malignant arrhythmia
Hemorrhage secondary to tearing of the ductus
After ligate PDA
Get systemic HTN so might need vasodilator like nitroprusside
Post PDA closure
For 6 months after
Neonate should receive SBP prophylaxis for ant procedure
If bad undiagnosed cardiac condition like
Hypoplastic left heart or coarctation of aorta want to keep PDA open
TOF
Cyanotic heart defect
Pulmonic stenosis RVH Overriding aorta VSD Blood from right to left bypassing lungs
Tet spells
Hyper cyanotic attacks where increase in right sided pressures promote further right to left intracardiac shunting of deoxygenated blood
Crying exercise feeding can cause
Tet spell
More PVR or less SVR
Increase SVR by tucking child’s knees during
Tet spell
Tetralogy of fallot antibiotic prophylaxis for infective endocarditis
Amoxicillin 50mg/kg iv
Infective endocarditis antibiotic prophylaxis for
Prosthesis cardiac valve
Hx infective endocarditis
Unrepaired cyanotic congenital heart disease
Valvulopayhy after cardiac transplant
Tetralogy of fallot
Ketamine fentanyl and roc
Ketamine increases SVR and prevents TET spell
Succ can cause histamine release
Decreasing svr and allowing more blood to flow from right to left with tetrology of fallot
Right to left shunt speeds up
Iv induction as more blood is diverted to systemic circulation faster
Maintenance for TOF
Nitrous oxygen ketamine
Nitrous does increase PVR but no big effect on SVR
Hypothermia causes
Hyperglycemia due to decrease in plasma insulin
Retinopathy of prematurity is only a worry up to
44 weeks post gestational age
Brain injury first step to lower BP is to lower the
Icp
Neurosurgeon can drain CSF to lower ICP
Baseline echo needed if doing brain surgery in
Sitting position if you hear a heart murmur
Furosemide better than mannitol
Furosemide does not increase CBV or ICP
It can be used in renal and cardiac pts
Can be used if BBB is compromised
Sitting position
Better surgical exposure
Less bleeding
Less cranial nerve damage
More complete resection of lesion
CVP for brain surgery in sitting position
Fluid status and to aspirate air
Precordial Doppler us and expired c02 to monitor for VAE
Sitting position
Worried about neck hyper flexion and cervical dislocation
External pressure on eyes from head set
Cerebral ischemia
Use succ for
Difficult airway
Isoflurane
Easily titritable and May offer cerebral protection
Normal saline best for brain
Surgery
Tight dura
Elevate head to improve venous return
Hyperventilate
Check oxygenation
Give propofol/muscle relaxant
Doris flexing foot issue
Sciatic nerve
CT or MRI can show the size of
Hemorrhage
Total cerebral blood flow in adults is
50mg/100ml
CBF remains constant between map of
50-150
Hunt hess grade 2
Moderate headavje with nuchal rigidity
Eeg ssep transcraniak Doppler cerebral oximetry to look at
Brain function
SSEPs monitor
Ascending sensory pathways
MEPs look at descending motor pathways
Ask surgeon to decrease
Transmural pressure of aneurysm by clipping the feeding vessel of the aneurysm
SAH post op worry about
Rebleeding and vasospasm
For rebleeding postop
Give mannitol and drink CSF
Respiratory status COPD want to know
Disease severity
Response to bronchodilation
Needing home oxygen
Baseline exercise tolerance
Aspirin doesn’t increase risk of
Neuraxial hematoma
Plavix need off 7 days
Absolute indication for dlt
Bronchopulmonary lavage
Lung abscess
Bronchial hemorrhage
If two lung ventilation doesn’t work in VATS think about
Temporary pulmonary artery clamping
Can do regional nerve blocks or PCA postop for
Vats
Mediastinal mass svc syndrome
Confusion headache altered mental status facial cyanosis venous distension of neck or arm
Mediastinal mass can cause
Airway and cardiovascular collapse
PFTs in mediastinal mass
Flow volume loops have been shown to correlate poorly with degree of airway obstruction
Asthma patients want to know any
Recent upper airway symptoms
Pyridostigmine in MG
Increases concentration of circulating AcH thereby increasing the possibility AcH binds to its receptor
Pyridostigmine
Continue on day of surgery and may need postop ventilator support
Mediastinal mass
Need a line in right radial to evaluate I nominate artery compression during mediastinoscopy
Have rigid bronch available
During mediastinal mass induction
Mediastinal mass
Inhalational induction and awake fiberoptic. Can give ketamine due to bronchodilator affect and maintains spontaneous ventilation
Lose Etc02 during mediastinal mass after securing airway
Pass rigid bronch past the obstruction
Move pt lateral or prone
Final think is Cpulmonary bypass
Compression of great vessels by tumor in anterior mediastinum can lead to
SVC syndrome
SVC syndrome can decrease preload and severely decrease
CO
Pyridostigmine weakness after Extubation
Might be cholinergic or myasthenic crisis
Myasthenic crisis is usually
Global in nature
Cerebral ischemia from right inominate artery compression can occur
Post op renal dysfunction number 1 cause is
Preop dysfunction
Aortic dissection need two arterial lines
One proximal and one distal to the clamp
A line for dissection might need to clamp subclavian so place in
Right radial
Cross clamp increases Afterload and blood pressure
Don’t want too low as distal perfusion pressure important. Pay close attention if lowering pressure with nitroglycerin
Known side effect of nitroglycerin is
Tachycardia
Surgeon can place shunt to increase perfusion pressure distal to
Clamp
Reapply cross clamp if pressure drops a lot after
Removing it
Hyperglycemia due to decrease in plasma insulin when
Hypothermic
Previous stroke with residual symptoms
Dont give succ
Don’t use extremity with residual deficits for lines or monitors
Disadvantage of regional for carotid endarterectomy
Need for emergency intubation
Complication of cervical block
Possible patient movement during case
Regional anesthetia for carotid endarterectomy
Superficial and deep cervical block
Complications of deep and superficial plexus block
Nerve injury
Risk of bleeding
Risk of intravascular injection
Want EEG sSEp transcranial Doppler to assess
Neurologic status
Best is an awake patient
Watershed areas most likely to
Stroke from not getting enough blood from non clamped carotid
If EEG changes post cross clamp
Take it off
Place shunt if can’t take off cross clamp
During carotid endarterectomy
If airway distress with hematoma from carotid endarterectomy
Immediately intubate
High bp after carotid endarterectomy
Weeks after think carotid sinus malfunction
Coronary plaques lead to luminal narrowing of arteries
Leads to CAD from clot formation
Diabetes
Gastroparesis could be full stomach
Joint stiffness makes intubation harder
ACT over 300 needed for
Bypass
Off pump CAbG
No inflammatory response or coagulopathy platelet dysfunction from CPB machine
Increase pump flow rate if pressure down
Early in cabg
Heparin reversal with
1mg/100 units of heparin
Heparin is acid and
Protamine is a base
SIMV after
CAbG
Blood loss post CAbG in test tubes
Coagulopathy
Thrombocytopenia
DIC
Inadequate heparin reversak
Protamine
Can lead to anaphylactoid/anaphylactic reaction
Pulmonary HTN
Hypotension
AAA need coagulation profile if going to place
Epidural
AAA lower 20% from
Baseline
If patient shows signs of sedentary lifestyle and CHF or presents with undiagnosed heart murmur I would get an
Echocardiogram
AAA is a major vascular operation
Start beta blocker like metoprolol on day of surgery if not on one
For AAA
Want PAC to monitor cardiac filling pressures during aortic cross clamp
Nitroprusside
Cyanide toxicity results in impairment of oxygen utilization. Patient can develop metabolic acidosis and tachyphylaxis
Aortic cross clamp
Results in afterload proximal to the clamp and decrease in perfusion distal to the clamp
Crossclamp
Higher risk for renal failure, bowel and spinal cord ischemia
Placental abruption
Separation of placenta from decidua basalis before delivery
Definitive diagnosis of placenta previa or abruption is by
Ultrasound
Double set up
Vaginal exam in or and ready to convert to GA at any time
If OB patient actively hemorrhaging
Do GA to reduce symphatectomy caused by epidural
Cell salvage can be used in
Bleeding out OB patieht
If bleeding in OB invasive measures
Uterus packing Uterine balloon tamponade Uterine artery embolization B lynch suture Last is hysterectomy
Causes of PPH
Uterine atony
Retained product of conception
Placenta accreta
Uterine rupture
IVDA
More likely for poor iv access
Increased risk of transmitted diseases such as hepatitis and hiv
Cocaine abuse and uncontrolled HTN increases the risk of
Placental abruption
Fetus of drug abuse mother more likely
IUGR, low birth weight, iVH, congenital abnormalities
Causes of HTN in pregnant
Untreated chronic HTN, gestational HTN, hypertension from preeclampsia, HTN from abusing drugs
Cocaine users
Dilated pupils increased HR, arrhythmias
Preeclampsia multi organ disorder that presents after 20 weejs gestation with remission 48 hours after delivery
Sustained SBP 140/90 and proteinuria of 300mg over 24 hr urine collection
Preeclampsia suspected labs
CBC, BMP, liver function test to assess for HELLP, Uric acid, UA, coag, 24 hr urine protein
Magnesium
Vasodilation
Anticonvulsant
Increases sensitivity to both depolarizing and nondepolarizers
Tocolytic which increases uterine blood flow
Magnesium effect
Diminished deep tendon reflexes at 4-5
Ekg changes 4-7 pr st interval increase widened qrs
Somnolence at mg 5 to 7
If plt count low
Before doing neuraxial check bleeding risk and trend plt count
Low BP after single shot spinal
Left uterine displacement with supplemental oxygen, open fluids wide, check level, check fetal hr, give pressors
Always preoxygenate and give
Bicitra and reglan before stat C section
The risk of a preeclamptic patient developing a seizure will stay for
24-48 hours after delivery so keep patient on magnesium therapy
Heparin initial dose
3-4 mg/kg
ACT goal for CAbG
300-400
Protamine side effect
Anaphylactoid anaphylaxis pulmonary HTN, hypotension
Pericardial tamponade
Want preinduction arterial line
Goals on induction are to maintain cardiac output, spontaneous ventilation and BP
Midazolam and ketamine
Once pericardial sac is open and drained give rocuronium
HOCM patient
Higher EF due to hypercontractile state of heart
Has LVOT, mitral regurgitation, diastolic dysfunction
Coarctation of aorta
Can use spinal just don’t wqnt huge hemodynamic changes leading to aortic dissection
IABP
Counter pulsation device deflates during systole decreasing afterload
IABP contraindications
Severe AI, aortic dissection, aortoiliac disease
CBP machine
Venous reservoir takes deoxygenated blood and then transfers it to an oxygenator where it is oxygenated. Blood pumped from arterial cannula back to patient
Membrane oxygenater less traumatic to blood then a
Bubble oxygenator in CBP machine
Protecting spinal cord during Aortic cross clamp
Maintain adequate BP above and below Institute hypothermia CSF drainage Tell surgeon to place shunt across cross clamp to improve perfusion distal to clamp Avoid vasodilators that can increase ICP
Protecting spinal cord during Aortic cross clamp
Maintain adequate BP above and below Institute hypothermia CSF drainage Tell surgeon to place shunt across cross clamp to improve perfusion distal to clamp Avoid vasodilators that can increase ICP
Protecting spinal cord during Aortic cross clamp
Maintain adequate BP above and below Institute hypothermia CSF drainage Tell surgeon to place shunt across cross clamp to improve perfusion distal to clamp Avoid vasodilators that can increase ICP
Protecting spinal cord during Aortic cross clamp
Maintain adequate BP above and below Institute hypothermia CSF drainage Tell surgeon to place shunt across cross clamp to improve perfusion distal to clamp Avoid vasodilators that can increase ICP
Protecting spinal cord during Aortic cross clamp
Maintain adequate BP above and below Institute hypothermia CSF drainage Tell surgeon to place shunt across cross clamp to improve perfusion distal to clamp Avoid vasodilators that can increase ICP
Protecting spinal cord during Aortic cross clamp
Maintain adequate BP above and below Institute hypothermia CSF drainage Tell surgeon to place shunt across cross clamp to improve perfusion distal to clamp Avoid vasodilators that can increase ICP
Gi or gu procedures don’t need
Bacterial endocarditis prophylaxis
CF pregnant patient need
Glucose and coagulation studies
CF patients have poor hepatic function and unable to absorb fat soluble vitskins
CF pregnant payient fetus
Intestinal obstruction
MS relapse
Decreases during pregnancy and May increase at 3 months post partum
MS avoid spinal but can place
Epidural
Treat pregnant seizure with
Versed
Help syndrome
Hemolysis
Elevated liver enzymes
Low platelets
Eclampsia
HTN complicated by grand mal seizures
ASA and NSAIDs no risk for
Neuraxial
LMWH should be held for 12 hours prior to neuraxial procedures
ASA and NSAIDs no risk for
Neuraxial
LMWH should be held for 12 hours prior to neuraxial procedures
Absolute contraindications to epidural
Refusal
Coagulopathy
Sepsis with hemodynamic instability
Uncorrected hypovolemia with ongoing hemorrhage
Uterine atony
Initial bimanual compression and uterine massage
Oxytocin is first line and then intramuscular methylergonevine
More intravascular fluid volume in
Pregnancy
Coronary perfusion pressure
Aortic diastolic pressure - LV end diastolic pressure
VwF type 1
Lack of VWF most common and don’t stabilize factor 8
Need MH cart available at
Ambulatory surgical center
CHARGe syndrome
Pts usually have cleft lip and palate
Charge syndrome get echo prior
Prior
Treacher Collins intubation
Mixrognathic
Prep and drape neck with tracheostomy and difficult airway cart in room
Give po versed and perform sedated fiberoptic while maintaining spontaneous respiration’s
Venous blood passing lungs from right to left shunt leads to
Cyanosis
Post tonsillar bleeding induction
Rapid sequence with rocuronium and ketamine
Down syndrome
Macroglossia and subglottic stenosis makes airway tough
Duodenal atresia makes them full stomach
Obstructive airway disease
Atlantoaxial instability so don’t move neck much
Omphalocele is located within the
Umbilical cord
After putting abdomen back in during omphalocele case is child desat
Due to impaired pulmonary compliance from increased abdominal pressure
Open the wound and relieve pressure
Staged closure would be better
After putting abdomen back in during omphalocele case is child desat
Due to impaired pulmonary compliance from increased abdominal pressure
Open the wound and relieve pressure
Staged closure would be better
Can’t do slow induction with
Difficult airway
Surgeon in aneurysm case
Have nitroglycerin and esmolol drips available
Always look at ekg for signs of ischemia
Surgeon can place temporary clip on the feeding vessel to lower amount of blood entering the aneurysm
For someone with spinal cord transection
Still need deep general anesthesia for cases to prevent autonomic hyperreflexia
Post bleed can get vasospasm days
3-15
Post aneurysm clipping for a SAH worry about
Seizures so give seizure prophylaxis
Rebleeding
Hydrocephalus
Minimize TURP syndrome by
Minimize height gradient between irrigation fluid and the patient to reduce hydrostatic pressure
Limit duration of procedure
Maintain verbal contact with patient throughout procedure
Secure airway if patient during TURP becomes confused and tachycardia
Restrict fluids if sodium 121 look for ekg changes and can give lasix to get rid of excess fluid
Securing airway of patient with acromegaly
Awake fiberoptic intubation
4% nebulized lidocaine glyco small doses of benzos prior to placing the scope
For ECT lithium must be held for 36-7/ hours or May
Prolong seizure
Lithium can lead to
Diabetes insipidus
SIADH
Distal convoluted tubule and collecting duct absorb water not solute
EMG study and neurology consult order if
Conservative measures don’t treat ulnar nerve injury
Avoid increases in body temp in a patient with
MS
Tissue damage leads to
Release of inflammatory mediators which sensitize peripheral nerves
CRPS due to
Dystegulation of cns
Pain burning swelling changes in skin color and temp
CRPS type 2
Due to injury to nerve bundle
Stellate ganglion block
At level of C7 transverse process just below subclavian artery
Stellate ganglion block complications
Intravascular, subarachnoid injection m, hematoma, pneumothorax, hoarseness due to recurrent laryngeal nerve injury
Tens therapy works by
Inhibition of pain signals at presynaptic levels
Newborn of mother on methadone
Worry about neonatal abstinence syndrome
Increased sweating, nasal stuffiness, fever, irratiility
After injecting bupi patient nausea light headed
100% oxygen open fluids pressors have code cart brought in
Uterine cancer block
Superior hypogastric as pain arrives from the pelvic viscera
Transforaminal epidural injection for
Unilateral back pain
Avoid all neuraxial techniques in patient with
EF<20%
For lung cancer
Put epidural at level of operation or 1-2 levels lowrr
Coumadin blocks factors
2,7,9,10 which are vitamin k dependent coag factors
FFP in emergency to reverse
Coumadin
Patients with asthma should not get
NSAIDs like ketorolac
To epidural space pass
Supraspinous, inyerspinous, ligamentum flavum
Paranedian approach to epidural only pass
Ligamentum flavum
Spina bifida and ppl who work in rubber industry at risk for
Latex allergies
All meds can lead to
Anaphylaxis
Fat embolus
Chest x ray shows bilateral infiltrates, pa02<60, subconjuctival petechiae hr>110
Severe sarcoidosis is bad for lungs so do
Regional technique
Severe sarcoidosis is bad for lungs so do
Regional technique
Avoid acute normovolemic hemodilution
In those with severe cardiac disease and anemia
LMA with aspiration
Remove LMA
Suction to oropharynx
Put back of head up
Emergently intubate
TPN after starvation leads to
Refeeding with electrolyte damage
BMS
Need for 6 weeks
MH algorithm
Discontinue triggering agent Ventilate with 100% oxygen Stop procedure Give 2.5 mg/kg iv dantrolene Up to 30 mg/kg dantrolene Administer bicarb Cool patient Go to icu 24 hr Dantrolene 1mg/kg 4-6 hr for 24 hr Freq abg and check for myoglobinuria
For mixed venous sample draw from
PA port of swan ganz catheter
No sitting position if any septal defect
Septal defect
Aortic stenosis preload dependent
Cardiac
ICP elevated
Blurry vision diplopia somnolence CT scan
Before inducing patient with high ICP need to
Evaluate pt prior to inducing and doing things to lower the ICP
High ICP medical and surgical management
Preop evd
Or medical stuff
Heart conductivity is dependent on
Potassium leading to arrhythmias and hypotension
Central line can give potassium repletion
Fast
If the patient was high blood pressure with high ICP worry about
Cushings reflex
Ruled out is a good
Phrase
Pneumo
Carotid sinus syndrome
Phrenic nerve palsy
Central line
Call for help temporizing support
Stat chest tube 2nd intercostal space midclavicular line
CXR think
Pneumo
Differential diagnosis
Given that so and so
No nitrous if pneumothorax
If something happens during case make sure to reference it
No nitrous if pneumothorax
If something happens during case make sure to reference it
Wake up or evoked potentials monitoring for
Neuro cases
Thus not required for muscle relaxant
EEG can show how derp
Mannitol 12.5 to 25 G per neuro protocol to lower
Icp
Blood serum reaches mannitol don’t give more
Sudden drop in Etc02 in clinical beach chair
Venous air embolus
Operation above level of heart
More likely venous air embolus
Operation above level of heart
More likely venous air embolus
Decadron for days increases
Glucose
Osmotic diuresis
Calculate ins and outs
Osmotic diuresis from mannitol sucks out lots of fluids and they pee out much more
Osmotic diuresis
Calculate ins and outs
Osmotic diuresis from mannitol sucks out lots of fluids and they pee out much more
Pulse pressure variation in a line and in CVP can look at positive pressure effects on fluid shifts and checking bags to look for gap acidosis
Fluids
Don’t use amicar in DIC
Use for fibrinolytic bleeding
Don’t use amicar in DIC
Use for fibrinolytic bleeding
High oxygen can lead to further atelectasis and after 24 hours
Diffuse alveolar damage and decrease in vital capacity
Reactive oxygen intermediates from too much
Oxygen use
Reactive oxygen intermediates from too much
Oxygen use
Loss of stomach acids leads to
Metabolic alkalosis
Strabismus use
Decadron ondansetrikn
Reglan doesn’t help droperidol black box warning
Hypokalemia hypophosphatemia with
Hyperglycemia
Recurrent laryngeal nerve damage unilateral vocal cord paralysis by keeping
Ett in over 6 hours
Recurrent laryngeal nerve damage unilateral vocal cord paralysis by keeping
Ett in over 6 hours
Recurrent laryngeal nerve damage unilateral vocal cord paralysis by keeping
Ett in over 6 hours
Recurrent laryngeal nerve damage unilateral vocal cord paralysis by keeping
Ett in long time causing compression
Can use cell salvage if expecting blood loss greater then 500 ml
May lead to dilutional coagulopathy
ANH you give clotting factors to while cell salvage just give
Saline and rbcs so leads to dilutional coagulopathy so need to give clotting factors
ANH you give clotting factors to while cell salvage just give
Saline and rbcs so leads to dilutional coagulopathy so need to give clotting factors
Dka
First 10-15 ml/kg NS bolus
Then give with potassium
Once bg down to 250 add dextrose to fluids
Give 10U insulin bolus and start drip
Recheck blood glucose and electrolytes every 2 hours at beginning
Dka
First 10-15 ml/kg NS bolus
Then give with potassium
Once bg down to 250 add dextrose to fluids
Give 10U insulin bolus and start drip
Recheck blood glucose and electrolytes every 2 hours at beginning
Dka
First 10-15 ml/kg NS bolus
Then give with potassium
Once bg down to 250 add dextrose to fluids
Give 10U insulin bolus and start drip
Recheck blood glucose and electrolytes every 2 hours at beginning
Dyspnea in AS
Pulmonary congestion
Digoxin
If arrhythmia continue it
AS syncope
Inadequate cardiac output
AS need to maintain
Preload
as patient will have diastolic dysfunction and requires higher filling pressures. In absense of mitral valve disease PAOP is lvedp
Patient with AS for risk for pulmonary edema thus
Not tolerating trendelenberg position
Balanced AS
Give fentanyl to keep hemodynamics stable without tachycardia
Venous hemoglobin tells you about
Perfusion status. Worried about low cardiac output status
Usually self limited usually from hemolysis
Nif
Rsbi
Following commands
Prior to Extubation
Emergence delirium correlated with
Preop midazolam
Length of surgery
PaiN
Preop state of function
Avoid NSAIDs if pt has
Peptic ulcer disease
Cardiac thoracicratio high means
Cardiomegaly
Ace or arb hold on day of surgery worry about hypotension
Pa catheter won’t
Change management
Don’t want pa in field for carotid
Stump pressure
Pressure on other side of where they clamp to make sure there is a perfusion
Prevent a line by doing Allen’s test
Occlude radial and ulnar and release one making sure you have collateral
TIA increases risk of
Carotid endarterectomy it is symptomatic
PA catheter
Management after in icu
Poor heart failure and function and lots of blood loss
Cardiac index and mixed venous
Mixed venous low
Cardiogenic shock or more blood
Ci going down give more pressors
Want to have control of bleeding
During carotid endarterectomy in case something goes wrong like cerebral edema
Bun creatinine function of kidneys and a bmp
Specially potassium
Ropivicaine or bupi just no toxic dose
Toxic
Chole need diaphragm paralyzed
Functional status after mi can they lay
Flat
Bnp for cardiac work up and look for
Lower extremity edema jvd crackles at bases
Scopolamine
Anterograde amnesia
PA oximetry for mixed venous
Throughout
Tip of the pa catheter way more deoxygenated
Takes out so much blood
Morphine
Histamine release with active metabolites so hesitant to give renally cleared medication
Morphine
Histamine release with active metabolites so hesitant to give renally cleared medication
Morphine
Histamine release with active metabolites so hesitant to give renally cleared medication
Neuromuscular relaxant
Anaphylaxis
More anesthetic during
Perfusion
Make sure anesthetic on when
Ventilating patient coming off bypass
Make sure anesthetic on when
Ventilating patient coming off bypass
Make sure anesthetic on when
Ventilating patient coming off bypass
Abg TEG other coags prior to giving things with patient
Oozing
Platelets get sheared going through pump
Give test dose with
Protamine
Sgot 65
Go over history of drinking
Sgot 65
Go over history of drinking
Note from cardiologist
Is good
RICI looks at multiple risk factors look up!
Decrease BP
With short acting and titrable
Harrington rod
High bleeding loss and monitor volume status and maintain perfusion pressure for spinal cord for distraction
Harrington rod
High bleeding loss and monitor volume status and maintain perfusion pressure for spinal cord for distraction
Harrington rod
High bleeding loss and monitor volume status and maintain perfusion pressure for spinal cord for distraction
Harrington rod
High bleeding loss and monitor volume status and maintain perfusion pressure for spinal cord for distraction
High creatinine
Increases cardiac risk and not filtering metabolites as well
Worry about fluid clearance
Fiberoptic with in line
Stabilization
Digoxin for rate control in
A fib
Anticoagulant of a fib
For neuraxial
Lidocaine spinal
Transient neurologic symptoms
PA pressures go up
With bome cement
High blood pressure can cause reduced ef
Ef
Damage to kidneys with high
Ischemic times
Before cross clamp
Bicarb calcium lidocaine epi all that ready
Before cross clamp
Bicarb calcium lidocaine epi all that ready
Graft over subclavian during dissectionso want a line on right
Right
Diaphragm fastest onset and fastest recovery in neuromuscular blockade
Last is adductor pollicus so check there and have four twitches prior to reversal
TOF at adductor pollicus should be
.9 or more prior to reversal
TOF at adductor pollicus should be
.9 or more prior to reversal
85% of receptors are still blocked at
TOF of 2
Extubate awake
Cleft lip
As airway obstruction common after
After positive stress test need
Heart catheterization with angiography
MAP = CO x SVR
AAA with
Epidural
Spinal cord injury can affect
Diaphragm C3-C5 dermatome Vegas nerve so hard to breath
FEV1
Volume of air forcefully expired in the first second of FVC maneuver
DLCO to look at
Diffusing capacity of lung
General anesthesia increase airway resistance by reducing
FRC
Ketamine maintains
Hypoxic pulmonary construction and is a bronchodilator
Most pulmonary resection
Limit fluids and no big fluid changes thus CVP or pa catheter not needed
However CVP post op as pulmonary edema can occur
Most pulmonary resection
Limit fluids and no big fluid changes thus CVP or pa catheter not needed
Atelectasis very common post thiracyomy
IS, aerosolized bronchodilator, effective pain control, early postop ambulatory
