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
