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Oral Boards Flashcards

1
Q

Benefits of Labor Epidural

A
  • Aid in BP control (preeclampsia Pts)
  • Likely no future need for laryngoscopy
  • ↑Uteroplacental blood flow
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2
Q

Causes: DIC

A
  • Sepsis
  • Amniotic/OB abruption
  • AML/tumors
  • Trauma
  • Transfusion
  • Toxin reactions
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3
Q

Code Situation

A

This is a critical event. I would

  • Notify the surgeon
  • initiate chest compressions (if pulseless)
  • Call for the code cart and hook up defibrillation pads once it arrived
  • Call for help (MD or CRNA)
  • Verify IV access and ETT is secured
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4
Q

Complications: Sickle Cell Disease

A
  • Vasocclusive crisis
  • Splenic sequestration
  • Aplastic Crisis
  • Cardiomegaly/CHF
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5
Q

Considerations: Bowel Obstruction

A
  • Distention leading to dec FRC and V/Q mismatch
  • Fluid shifts
  • Sepsis
  • Often Hypokalemic, Hypochloremic, alkalemia/acidemia
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6
Q

Considerations: Obesity

A
  • PreOp assessment for difficult airway management
  • Airway difficulty, thick neck
  • ↑CO→ ↑LVH, ↑HTN; ↑PVR→Cor Pulm
  • Cardiac: HTN, CAD, DVT/PE
  • Pulminary: Restrictive-like: ↓FRC, ↓VC, shunting, hypoxia, atelectasis, rapid desaturation, OSA
  • Gastrum: ↑Volume, ↓pH → ↑Asp risk
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7
Q

Considerations: Parturient

A
  • ↓MAC by 40%, ↓ LA req ( ↓Epidural space)
  • Airway swelling + Breasts = Difficult intubation
  • ↑CO 50% 2nd Tri, 110% at Labor; ↓SVR
  • ↑MV&O2 consum + ↓FRC→ Desaturation
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8
Q

Considerations: Rheumatoid Arthritis

A
  • Cervical spine C1-2 instability
  • TMJ Cricoarytenoid joint
  • CV Valve fibrosis, AR
  • Restrictive lung Dz
  • Peripheral neuropathies 2° nodules
  • Anemia
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9
Q

Considerations: Sickle Cell Disease

A
  • Use ↑ FiO2
  • Avoid ↓O2, dehydration, infxn, ↓Temp
  • Goal: Normocarbia/hypocarbia; avoid respiratory acidosis
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10
Q

Considerations: TEF & EA

A

TEF/EA is associated with VACTERL:

  • Vertebral defects
  • Anal atresia
  • Cardiac defects (coarctation, ASD/VSD)
  • TEF
  • Renal dysplasia
  • Limb anomalies
  • At risk for aspiration, pneumonia, cardiac/pulmonary complications
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11
Q

EKG changes with Hyper/Hypo K/Ca

A

Hypo: ↓PR/↑QT
Ca- inverted Ts
K- flattened Ts

Hyper: ↑ PR/↓QT
K&Ca- Peaked Ts

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12
Q

EKG: Hyperkalemia

A

↑ PR
Peaked T waves
ST elevations

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13
Q

Changes in Geriatric Patients

A
  • ↓CO, ↓Compliance
  • CC ↑ > FRC → shunting
  • ↓VC, TV
  • ↓GFR but Cr stays same due to ↓ muscle mass
  • GI emptying↓; ↓HBF, Albumin→ ↑ Rx Bioavailability
  • Skin ↓vascularity → necrosis
  • ↓ MAC requirements
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14
Q

Hs and Ts (Code)

A
  • Hypoxemia, Hypovolemia, Hypo/erkalemia/glycemia, H+ ions (acidosis), Hypothermia
  • Tension PTX, Tamponade, Toxins (illicits), Thrombosis (cardiac/pulm)
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15
Q

Hypoxemia: Cardiovascular Causes

A
  • CHF
  • Cardiogenic Shock
    
- MI
  • Congenital (TOF, VSD etc)

  • Eisenmeiger’s

  • Anemia 2° to blood loss, MetHgb, CO poisoning, SNP
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16
Q

Hypoxemia: Pulmonary Causes

A
  • Hypoventilation (Drugs, Resp failure)

  • Low FiO2

  • V/Q mismatch = ↓FRC, OLV, Bronchospasm, PNA/ARDs, Embolism
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17
Q

TTP vs ITP

A
  • TTP: microvasculature thrombosis due to lack of inhibition of vWF
  • ITP: PLT destruction due to anti-platelet Abs
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18
Q

Indications for Bicarb

A
  • Renal bicarb dumping
  • Enterocutaneous fistula (bicarb wasting)
  • RTA2
  • NOT for lactic acidosis→ Tx underlying cause
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19
Q

Indications for Intubation

A

Oxygenation- PaO2 <70 on FiO2 40%
A-a gradient >350 torr with 100% FiO2

Ventilation- PaCO2 >55 (exception in Pt with chronic hypercarbia)
Vd/Vt is >.6

Tachypnea (~35), VC <15cc/kg preclude extubation

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20
Q

Indications for Platelets

A

<50k for procedure
<100k w/ microvascular bleeding
<20k in nonbleeding patient

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21
Q

Larynx Innervation

A
  • Cricothyroid (Tensor) - external branch of SLN

- All others RLN

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22
Q

Malignant Hyperthermia

A

MH is a hypermetabolic state characterized by overactivity of the ryanodine receptor leading to excessive Ca2+ in the SR leading to excessive myocyte consumption of ATP resulting in production of CO2, anaerobic metabolism, elevated lactate, hypoxemia and cell ischemia

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23
Q

MOA: TXA

A

Blocks plasminogen to plasmin (and thus prevents plasmin attachment to fibrin)

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24
Q

N2O and ICP/CMRO2

A

↑ICP, ↑CMRO2

can expand air (pneumocephalus)

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25
Q

Phase II block

A
  • Usually with 2.5mg/kg SCh
  • inactivation of receptors due to prolonged stimulation phase
  • Fade with twitch and tetanus
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26
Q

Pros/Cons Albumin

A
  • Pros: Can improve microcirculatory flow (increased O2 delivery)
  • Cons: expensive, Worsened edema with non-intact endothelium (whether pulm, cerebral etc)
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27
Q

ST-segment Changes

A
  • Ischemia until proven otherwise
  • Preexisting?
  • Acute change in Demand/Tachycardia?
  • Acute MI, ischemia
  • ↑↓[K], ↑[Ca2+]
  • Hypothermia
  • C-section/Vaginal delivery
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28
Q

Sfx: Bicarbonate

A
  • Hyperosmolarity
  • Hypokalemia
  • L shift
  • Worsened intracellular acidosis
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29
Q

Sx: Airway Obstruction

A
  • Hoarseness (dysphonia)
  • Dysphagia
  • OSA
  • ↑ PAP
  • Laryngospasm
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30
Q

Sx: Fat Embolus

A
  • Bilateral pulmonary infiltrates
  • Petechial rash (conjunctiva, oral mucosa, neck folds)
  • Hypoxemia/ resp distress
  • Increased PA pressure
  • Hypotension
  • AMS
  • Usually occurs with long bone fracture
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31
Q

Sx: Moderate Dehydration (peds)

A
  • 6-9% Volume/weight loss
  • ↓skin turgor/cap refill (2-3s)
  • Deep respirations +/- tachypnea
  • UOP ≤1cc/kg/hr
  • Specific Gravity 1.020-1.030
  • Tachycardia
  • Orthostatic HoTN
  • Dry mucous membranes
  • Hearing loss
  • Sunken fontanelle
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32
Q

Sx: Pneumothorax

A
  • ETCO2 should be relatively normal due to high solubility of CO2
  • ↑PAP
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33
Q

Dx Criteria: PreE

A
  • New onset of HTN and proteinuria or the new onset of hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation
  • SBP >140 and/or DBP > 90 meets criteria
  • End organ dysfunction: SEE OTHER FLASHCARD
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34
Q

Sx: Uterine Rupture

A
  • HoTN
  • Severe pain
  • Loss of fetal heart tones
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35
Q

Type/Screen vs Type/Cross

A
  • Screen= recipient plasma mixed with commercial RBCs

- Cross= recipient plasma mixed with donor RBCs

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36
Q

Tx: ACLS for LAST

A
  • 1 mcg/kg epi
  • No vasopressin, calcium, lido
  • 1.5mg/kg Intralipid 20% emulsion
  • CPR and airway
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37
Q

Tx: Bronchospasm

A

Deepen anesthesia

  • Albuterol
  • Low dose Epi, Lidocaine
  • Mehtylprednisolone (wont help acute but prevents future)
  • Subq 1:1000 epi at 0.1 mL/kg
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38
Q

Tx: Cyanide Toxicity

A
  • Sodium nitrate (oxidizes Hgb→MetHgb→↑affinity of cyanide to MetHgb but then if O2sat↓ → give Methylene Blue)
  • Thiosulfate
  • Vit B
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39
Q

Tx: DIC

A
  • Assess field for diffuse oozing
  • CBC, INR, TEG
  • Products (PLT, Cryo, FFP) as needed
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40
Q

Tx: DKA

A
  • FLUIDS
  • Insulin
  • D5W when Glu is 250
  • K when UO returns and when K is back to normal
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41
Q

Tx: Hyperkalemia

A
  • if <6.0mEq → Diuretics, IVFs, Albuterol, Insulin, hyperventilate, Kayexalate (if time)
  • if >6/symptomatic→ 0.5g CaCl2, 1amp Bicarb, Glucose 50cc of D50 + insulin; DIALYSIS!
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42
Q

Tx: Hypotension

A
  • Treat underlying cause (PTX? EBL? Surgical compression?)
  • Confirm accuracy
  • 100% O2
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43
Q

Tx: Hypoxemia

A
  • Confirm SaO2

  • ↑FiO2 to 100%

  • Hand ventilate

  • Visualize ETT and circuit

  • Auscultate bilaterally
  • Laryngoscopy to confirm ETT placement
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44
Q

Tx: ↑ ICP

A
  • Elevate Head of bed
  • Hyperventilate to PaCO2 25-30mmHg
  • HTN control while maintaining CPP
  • Drugs: Furosemide/Mannitol, Dexamethasone, Paralysis, - Drain CSF if drain exists
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45
Q

Tx: IntraOp MI

A 
- First address anemia, hypovolemia
Then, 2 goals:
1) *↑ Myocardial O2 supply (Hgb, CPP, NTG)
2) *↓Myocardial O2 Demand (βBlockers)
- EKG/Troponins
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46
Q

Tx: Oliguria

A
  • Check Foley, obtain urine sample
  • Review volume administered
  • Draw BMP (check for changes in Cr)
  • Fluid challenge: bolus of 500cc
  • Mannitol (low dose .25mg/kg)
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47
Q

Tx: PONV

A
  • Ondansetron (5HT3 antagonist)
  • Droperidol/Metoclopramide (D2 antagonist)
  • Scopolamine (anticholinergic)
  • Promethazine (H1 Blocker)
  • Benzos/Propofol (GABA-A agonist)
  • Tigan
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48
Q

Tx: PreE

A
  • Bedrest
  • Hydralazine/BP control
  • Magnesium for seizure (goal: 4-6mEq/L)
  • Epidural if PLT ok
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49
Q

Tx: Retained placenta

A

GA, NTG

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50
Q

Tx: Uterine Atony

A
  • Uterine Massage
  • Oxytocin
  • Methylergonovine
  • PgF2a (carboprost)
  • Prostaglandin E/Misoprostol
  • Emergency hysterectomy with ligation of uterine/internal iliacs
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51
Q

Causes: VT

A
  • Ischemia
  • Hypokalemia
  • Hypomagnesemia
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52
Q

What are the Standard ASA Monitors?

A
  • “Oxygenation, Ventilation, and Circulation”
  • Qualified anesthesia personnel
  • EKG
  • BP cuff
  • Temp
  • O2 and capnograph
  • Pulse Oximeter
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53
Q

SFX: Mg++

A

VAST:

  • Vasodilation
  • Anticonvulsant
  • Sedative, skel muscle relaxant (dec sens to ACh)
  • Tocolytic
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54
Q

SFX: TURP

A
  • ↑Glycine + ↓Na→ transient blindness
  • Transient HTN then HoTN may indicate ↓↓Na
  • Cardiac (100/120mEq levels)
  • Postop SIADH
  • Ammonia toxicity (glycine): delayed awakening
  • Spinal is choice of anesthetic to monitor for AMS
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55
Q

SFX: Transfusion

A
  • Fever
  • TACO (100)
  • TRALI (10k)
  • Hemolytic/L-T Rxn
  • HBV >HCV >HIV/HTLV
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56
Q

Causes: ↑ BP/HTN

A
  • Preexisting: Essential, Renal, AH
  • Surgical, SNS
  • Hypoxemia, Hypercarbia
  • Medication
  • Volume Overload
  • ↑ICP
  • Laryngoscopy
  • Emergence
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57
Q

↑ ETCO2

A

SO much METH

  • Sepsis, Overfeeding (TPN)
  • Mainstem
  • MH
  • Exhausted soda lime, ↓FGF
  • Thyroid storm
  • ↑Temp/Fever
  • ↑airway resistance ↓elimination (COPD, CHF, PTX)
  • Laparoscopy/CO2 embolism
  • Tourniquet release
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58
Q

DDx: ↑ Peak Airway Pressures

A
  • PE
  • Bronchospasm
  • PTX
  • Pulmonary Edema
  • Pleural Effusion
  • Pulmonary aspiration
  • Intraperitoneal insufflation
  • Kinked ETT
  • Stuck expiratory valve
  • Mucous Plug
  • Chest wall rigidity (narcotic or ↓paralytic)
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59
Q

DDx: ↑ Temperatures

A
  • Iatrogenic- bair hugger
  • Infection
  • Illicits/Rx- MAOi TCA cocaine amphetamines
  • Transfusion Reaction
  • Thyroid storm
  • MH
  • NMS
  • Pheochromocytomas
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60
Q

DDx: ↑ HR/Tachycardias

A
  • Light anesthesia
  • Hypoxemia, Hypercarbia
  • Hypovolemia/Hypotension
  • Hyperthermia
  • “PAST TIME”
  • PE, Anaphylaxis, Storm, Transfusion txn, Tumors (pheo/carcinoid),Ischemia, MH, Electrolytes, Tension Pneumo
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61
Q

DDx: ↓ Temperatures

A
  • Preexisting
  • CNS/hypothalamus
  • Drugs
  • Redistribution to periphery
  • Heat loss (radiation- EM wave loss)
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62
Q

DDx: ↓ BP/Hypotension

A
  • Hypoxemia, Hypercarbia
  • ↓Preload, ↓Intravascuar volume
  • Arrhythmias
  • PEEP, AutoPEEP, Gravid Uterine, PTX
  • Sympathectomy/↑Venous capacitance/ Spinal Shock
  • Anaphylaxis
  • Sepsis, shock
  • BMP: Hypocalcemia, Hypoglycemia, Acidemia
  • Cardiogenic- shock, HOCM, AS/AR, Mitral Stenosis, Tamponade, CHF
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63
Q

DDx: HR/Bradycardia

A
  • Hypoxemia, Hypercarbia
  • Vagus- Oculocardiac reflex, Baroreceptor, ↑ICP, Pneumoperitoneum, Laryngoscopy
  • Drugs: Beta Blockers, Narcotics, Amio, Dex/Clonidine, ND-CCB
  • ↓Temperature/hypothermia
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64
Q

DDx: ↓ O2/Hypoxemia

A
  • Low FiO2
  • Hypoventilation
  • V/Q mismatch- shunt, PNA, ARDS, OLV/Mainstem, Embolism, ↓FRC
  • Circulation CHF, MI
  • Blood: Anemia, Cyanide, CO, MetHgb
  • Seizures
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65
Q

DDx: ↓ UOP/oliguria

A
  • Prerenal: CHF, HoTN/Hypovolemia, Abdominal Compartment Syndrome, Shock, Pneumoperitoneum, Aortic cross clamping
  • Renal: ATN, Nephritis
  • Postrenal: Ureter stones, Foley kink
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66
Q

CSWS vs SIADH vs DI

A
  • CSWS & SIADH ↓ serum Na and osm, ↑ urine Na
  • CSWS associated with hypovolemia
  • SIADH associated with euvolemia
  • DI = loss of free H2O, ↑ serum Na and ↓ urine osm
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67
Q

Procedure: Intraosseous Line Placement

A
  • Insert IO needle into the tibia at 10-15 degrees caudal angulation (to avoid the epiphyseal plate), located 1-2cm below and 1 cm medial to the tibial tuberosity
  • Advance needle until a “pop” or reduced resistance is felt
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68
Q

TRALI (Pathophys, Sx, Dx, Tx)

A
  • Non-cardiogenic pulmonary edema
  • Occurs 1-6hrs after administration of any blood product (most commonly plasma-containing products)
  • Pathophysiology: transmission of donor leukocyte antibodies activates neutrophils in the lungs -> factor release, endothelial damage, capillary leakage, and ALI
  • SSx: fever, chills, tachycardia, dyspnea, hypoxemia, hypotension, pulmonary edema, pink frothy pulm secretions
  • Dx: hypoxemia (P:F <300, SpO2 <90%) and pulmonary edema (b/l chest infiltrates) WITHIN 6 HRS OF TRANSFUSION in the absence of heart failure or volume overload (PAOP <19)
    Tx: stop transfusion, increase FiO2, notify the blood bank, support ventilation as necessary; diuretics and steroids are NOT indicated in TRALI
69
Q

Considerations: Duchenne Muscular Dystrophy

A
  • Cardiac: Cardiomyopathy, ventricular dysrhythmias, MR
  • Pulm: ↓ pulmonary reserves, ineffective cough, recurrent pneumonia, chronic aspiration, sleep apnea
  • Other: macroglossia, difficulty swallowing, increased bleeding (dystrophin abnormalities -> ↓ vasoconstrictor response)
70
Q

Tx: ↓ SSEP signals

A

1) correct hypoxemia, hypercarbia, hypotension, hypovolemia, anemia
2) make sure anesthetic depth is stable
3) ask surgeon to rule out surgical causes of spinal cord injury
4) (in peds) perform a wakeup test if signals remained abnormal

71
Q

Tx: Venous Air Embolism

A
  • Dx: acute hypotension and ↓ ETCO2
  • Tx:
    1) Tell surgeon to flood surgical field with saline
    2) ↑ FiO2 to 100%
    3) Attempt to aspirate air through central venous line
    4) Administer fluids
    5) Administer vasoconstrictors and inotropes (and compressions) as necessary
    6) Place in left lateral decubitus to facilitate air going to the RA and avoid outflow tract obstructions
72
Q

Extubation Criteria

A
  • Awake/cooperative
  • Airway & gag reflexes intact
  • NMBDs reversed
  • Vital capacity >10 mL/kg/breath
  • Vt > 6mL/kg/breath
  • NIF >20 cmH20
  • SpO2 > 90% on FiO2 40-50% w/ < 5 of PEEP
  • RSBI < 100 breath/min/L
73
Q

Bezold-Jarisch Reflex

A
  • Stimulation of INHIBITORY cardiac receptors (by stretch, chemicals or drugs) ➙ ↑ parasympathetic tone/ ↓ sympathetic activity ➙ bradycardia, vasodilation, hypotension
74
Q

SSx: Diabetic Autonomic Neuropathy

A
  • Cardiac: HTN, resting tachycardia, painless MI, dysrhythmias
  • GI: early satiety, prolonged postprandial fullness, nocturnal diarrhea, bloating, GERD, N/V
  • Other: peripheral neuropathy, impotence, lack of sweating
75
Q

Procedure: Needle Thoracostomy

A
  • Relief of tension pneumothorax

- 14g needle inserted into the 2nd intercostal space at the midclavicular line

76
Q

Drugs to Avoid in Pheochromocytoma

A
  1. Drugs that stimulate tumor cells - SCh, histamine-releasing drugs (morphine, atracurium)
  2. Drugs that ↑ sympathetic activity: atropine, pancuronium, ketamine, ephedrine
  3. Droperidol, metoclopromide, ephedrine
77
Q

Sx: ↑ ICP

A
  • Headache, vision changes/papilledema, altered mental status
  • Cushing’s Triad of HTN, bradycardia, change in respiratory pattern (or wide pulse pressure)
78
Q

Airway Evaluation (Difficult Airway)

A

Findings that suggest difficult airway:

  • Small mouth opening
  • Poor cervical spine mobility
  • Retrognathia
  • Large tongue
  • Prominent incisors
  • Short neck
  • ↓ Thyromental distance ( <6.5 cm)
  • Mallampati III or IV
79
Q

Hunt & Hess Classification for SAH

A
  • Grade 0 = unruptured aneurysm
  • Grade 1 = aSx or minimal HA and slight nuchal rigidity
  • Grade 2 = mod-severe HA, nuchal rigidity, no neurologic deficit other than CN palsy
  • Grade 3 = drowsiness, confusion, mild focal deficits
  • Grade 4 = stupor, mod-severe hemiparesis, early decerebration, vegetative disturbance
  • Grade 5 = deep coma, decerebrate rigidity, moribund

**Note: higher grades are associated with the presence of vasospasm, ICH, ↑ surgical mortality

80
Q

SAH-associated complications (5 major)

A
  1. ) Neurogenic pulm edema: sympathetic surge ➙ systemic/pulm vasoconstriction ➙ ↑ pulm volume/ ↓ LV compliance ➙ ↑ pulm pressures and capillary permeability
  2. ) Vasospasm: develops 3-12 days after SAH, peak days 6-7; presents with neurologic deterioration/drowsiness; dx made with angiography or TCD; treat with NIMODIPINE, HYPERTENSION, NORMOVOLEMIA (previously Triple-H)
  3. ) Re-bleed: usually within the first 24-48h, up to 2 weeks
  4. ) Dysrhythmias & EKG abnormalities: due to ↑ ↑ catecholamine release with SAH; long-QT/deep T-wave inversions; pHTN/sHTN
  5. ) E- abnormalities: hyponatremia from CSWS or SIADH
81
Q

Myocardial Ischemia Contributing Factors

A

Ischemia happens when there is an inadequate O2 supply to meet the metabolic demands

  • Causes of decreased supply: tachycardia, anemia, hypoxia, decreased CPP (hypotension, coronary vasospasm/obstruction, severe AS/AR, elevated LVEDP)
  • Causes of increased demand: tachycardia, increased wall tension, contractility, increased afterload
82
Q

Anesthetic Considerations/Concerns: Cystic Fibrosis

A
  • Pulmonary: hypoxia (VQ mismatch), bronchospasm, pneumothorax, post-op respiratory failure, pulmonary htn
  • Heart failure from pHTN and cor pulmonale
  • GI: coagulopathy (hepatic involvement and vit k malabsorption), psuedocholinesterase deficiency, diabetes, electrolyte abnormalities
83
Q

Risk factors for Post-Op Delirium (PEDS)

A

1) preoperative anxiety
2) young age (1-5yo)
3) post-op pain
4) use of less-soluble volatiles (sevo/des)
5) type of surgery
6) prolonged surgical duration

84
Q

Stent Placement and Surgery Delays

A

**GET UPDATED INFORMATION!

85
Q

TURP Syndrome: pathophysiology/SSx

A

• Large volumes of hypotonic solution absorbed through disrupted venous sinuses ➙ circulatory overload, hypo-osmolality, hyponatremia, & solute toxicity

By System:
• CV: hypertension, reflex brady, circulatory depression, pulm edema
• NEURO: confusion, restlessness, seizures, visual disturbances, coma, death
• RESP: pulm edema, hypoxia
• HEME: DIC & hemolysis (from hypotonicity)
• RENAL: renal failure
• METABOLIC: acidosis

86
Q

Tx: TURP syndrome

A

1) Secure the airway with an ETT
2) Provide circulatory support with pressors and inotropes as indicated
3) Place an arterial line and draw ABG, BMP, glucose, Cr
4) 12-lead EKG
5) Tx hyponatremia with fluid restriction, diuretics, hypertonic saline, anticonvulsants
6) Monitor and treat DIC and anemia

87
Q

Tx: Septic shock

A

1) obtain blood cultures prior to Abx
2) administer empiric broad-spectrum abx
3) control the source of infection
4) administer fluids (crystalloids first line), pressors (Norepi first line), and inotropes as necessary to maintain MAP >65, UOP >0.5mL/kg/hr, normal lactate
5) blood products as necessary
6) corticosteroid therapy when lactate is ↑ and SpO2 ↓ despite adequate resuscitation
7) administer insulin to keep BG < 180 mg/dL
8) bicarb for pH < 7.15
9) mechanical ventilation with PEEP, ↓ Vt, and Pplat < 30 cmH2O
10) minimal sedation, avoid NMB
11) DVT and stress ulcer ppx
12) daily spont ventilation trials

88
Q

TURP: other complications (non-TURP Syndrome)

A 
• Bladder or capsular perforation
• Bleeding
• Coagulopathy
• Transient bacteremia/septicemia (post-op)
• Hypothermia
• Toxicity of irrigating fluids
- Glycine tox: transient blindness
- Ammonia tox: neurologic sequelae, n/v, convulsions, coma
89
Q

How Long Should Elective Non-Cardiac Surgery be Postponed After Angioplasty, BMS, and DES placement?

A

Elective non-cardiac surgery should be delayed 14 days after balloon angioplasty, 30 days after BMS placement, and optimally 6 months after DES placement.

If noncardiac surgery is required, I would reach a consensus decision with the surgeon (and cardiologist if possible) as to the relative irks of surgery and discontinuation of DAPT.

Elective noncardiac surgery may be considered after 3 months in newer DES if the risk of postponing surgery is greater than the risk of discontinuing DAPT.

90
Q

ASRA Guidelines - Heparin

A

SQ: check platelets, no delay needed
IV: placement/removal 2-4h after discontinuation of heparin; re-start heparin 1 hour after placement of catheter

91
Q

ASRA Guidelines - LMWH/enoxaparin

A
  • Delay needle instrumentation 12 hours following low-dose LMWH and 24 hours following high-dose LMWH
92
Q

Steps to take after aspiration

A
  1. Place pt in Trendelenurg (drain contents from lungs)
  2. Apply cricoid pressure
  3. Suction oropharynx
  4. Intubate
  5. 100% oxygen
  6. Suction trachea
  7. Apply PEEP after suctioning
  8. Suction stomach with OGT
  9. Order baseline ABG and CXR
  10. Monitor for 24-48hr
    * * NO PROPHYLACTIC STEROIDS OR ABX
93
Q

Pre-op Pheochromocytoma Optimization

A
  • α-blockade for at least 7-10 days (phenoxybenzamine, phentolamine)
  • BP < 165/90
  • Restoration of intravascular volume
  • Echo, ECG, CXR to evaluate cardiac function (dilated cardiomyopathy, ectopy, ischemia)
  • B-blocker for rate control
94
Q

Pre-op Pheochromocytoma Optimization

A
  • α-blockade for at least 7-10 days (phenoxybenzamine, phentolamine)
  • BP < 165/90
  • Restoration of intravascular volume
  • Echo, ECG, CXR to evaluate cardiac function (dilated cardiomyopathy, ectopy, ischemia)
  • B-blocker for rate control
95
Q

Weaning from CP bypass

A
  • Ensure normothermia
  • Correct anemia, e- abnormalities, metabolics
  • Turn on alarms
  • Recalibrate/zero transducers
  • Check lung compliance and initiate ventilation
  • Ensure heart is de-aired
  • TEE to assess function/PA cath for numbers
  • Midazolam to prevent awareness during rewarming
96
Q

Weaning from CP bypass

A
  • Ensure normothermia
  • Correct anemia, e- abnormalities, metabolics
  • Turn on alarms
  • Recalibrate/zero transducers
  • Check lung compliance and initiate ventilation
  • Ensure heart is de-aired
  • TEE to assess function/PA cath for numbers
  • Midazolam to prevent awareness during rewarming
97
Q

Contraindications: Cell Salvage

A

Relative Contra:

1) Pre-existing Hgb-opathy
2) Contamination with drugs
3) Contamination with clotting agents
4) Contamination with urine, bone chips, amniotic
5) Pts with pheochromocytoma
6) Malignancy

Absolute Contra:

1) Microbial contamination
2) Cancer surgery with high risk of direct tumor rupture

98
Q

Extubation Criteria (ICU)

A
  • PaO2 > 60 on FiO2 <50%
  • PaCO2 < 50 mm Hg
  • pH > 7.3
  • Vital Capacity > 15 mL/kg
  • PEEP < 5
99
Q

S/Sx: AFE

A
  • Phase 1: pHTN (pulm vasospasm), hypotension (RHF), hypoxia (V/Q mismatch), seizure, cardiac arrest
  • Phase 2: LV failure, pulmonary edema, coagulopathy
100
Q

Risk Factors: Post-Extubation Croup (Peds)

A

1) Oversized ETT
2) Multiple intubation attempts
3) Intraop position changes
4) Surgery duration > 1hr
5) Traumatic intubation
6) 1-4 years old
7) Coughing
8) Volume overload
9) coexisting URI

101
Q

Causes: A-Fib

A 
Cardiac:
• Valvular disease
• LV hypertrophy
• HTN
• CAD
• Cardiomyopathy
Non-Cardiac:
• Hyperthyroidism
• PE
• Excessive EtOH
• Caffeine intake
102
Q

Causes: Pre-op HTN

A

1) CKD
2) Renovascular disease
3) Chronic steroid therapy (Cushing’s)
4) OSA
5) Drugs
6) EtOH abuse
7) Obesity/metabolic syndrome
8) Thyroid disease
9) Pheo
10) Coarctation of aorta

103
Q

Mgmt: Electrocautery use with pacer/AICD

A

1) Recommend use of bipolar electrocautery
2) Place return plate as far from pacer as possible
3) Disable tachydysrhythmia detection/therapy (shock)
4) Place defibrillator pads
5) Reprogram device to asynchronous mode (pacer)
6) Recommend surgeon does short bursts of EC if monopolar is needed

104
Q

How does a magnet affect pacemakers and AICD/Pacemakers?

A
  • Pacemaker: magnet may set to asynchronous mode
  • AICD/Pacer: will not set pacing function to asynchronous, usually disables tachydysrhythmia sensing and treatment function
105
Q

Hemodynamic Goals: AoR

A
  • Full, fast, and forward
  • Adequate preload
  • Relative tachycardia (decreases diastolic time)
  • Relative low SVR (reduce regurgitant fraction)
106
Q

SSx: AoS

A
  • Symptom triad: angina, syncope, CHF

- Severe AS: gradient > 50, AVA < 1.0

107
Q

Hemodynamic Goals: AoS

A

I want to: avoid tachycardia (or extreme bradycardia), maintain normal sinus rhythm and SVR.

108
Q

Assessment of Pulmonary Function

A

Ascertain the patient’s smoking history, use of inhalers, productive cough, worsening dyspnea, baseline symptoms.

109
Q

Tx: MH

A
  1. D/C triggering agents
  2. Call for help.
  3. 100% FiO2, high flow, hyperventilate
  4. Dantrolene 2.5 mg/kg IV q5min until sx subside
  5. Collect ABG, E-, calcium, LFT, CK
  6. Treat hyperkalemia: hyperventilate, dextrose + insulin
  7. Active cooling: ice to groin/axilla
  8. Maintain UOP >2 mL/kg/hr w fluids, lasix, mannitol
110
Q

Hemodynamic Goals: Mitral Stenosis

A

1) Avoid LA overload
- Avoid tachycardia
- Aggressively treat dysrhythmias

2) Avoid dropping LA pressures
- Fluid to maintain BP & CO

3) If pt has pHTN, avoid exacerbations
4) Maintain SVR

**Full (volume), normal HR, maintain SVR

111
Q

Tx: neonatal resuscitation

A
  • Keep warm, dry, clear airway
  • If HR < 100bpm: PPV, SpO2 monitoring
  • If HR < 60: consider intubation + epi and chest compressions
112
Q

PA Catheter: normal values

A
  • PA Pressure: 25/10 (mean ~15)
  • CO: 4-8 L/min
  • CI: 2-4 L/min
  • Mixed Venous O2 (SvO2): 60-80%
  • EF 55-70%
113
Q

Heart Chamber Normal Pressures

A 
RA: 0-5 mmHg
RV: 25/5
PA: 25/10 (diastolic step up)
LA: < 12
LV: 120/10
114
Q

Pre-Eclampsia: signs of end organ dysfunction

A
  • Severe HA, altered mental status, blurred vision
  • Pulmonary edema
  • GI: epigastric/RUQ pain, liver infarct, elevated LFTs
  • HELLP syndrome
  • Thrombocytopenia/pathia (note: coag studies are usually normal)
  • AKI (elevated Cr), oliguria
115
Q

Dx criteria for Severe Pre-E

A
  • SBP >160 or DBP > 110

- OR if pt has BP > 140/90 with signs of end organ dysfunction

116
Q

PreOp Eval: Sickle Cell Disease

A
  1. Cardiac: r/o CHF due to anemia, hypoxia
  2. Pulm: discuss h/o acute chest syndrome
  3. Neuro: assess any deficits from strokes/seizures
  4. GU: assess renal function
117
Q

Pre-Op Evaluation: Pacer/AICD

A
  1. Indication for placement
  2. Manufacturer
  3. Pacer dependent rhythm?
  4. Last time interrogated?
  5. Affect of magnet placement
  6. Reprogram pacer/disable anti-dysrhythmia if dual AICD/pacer
118
Q

Pre-Op Evaluation: Pacer/AICD

A
  1. Indication for placement
  2. Manufacturer
  3. Pacer dependent rhythm?
  4. Last time interrogated?
  5. Affect of magnet placement
  6. Reprogram pacer/disable anti-dysrhythmia if dual AICD/pacer
119
Q

Indications for Synchronized Cardioversion (low energy)

A
  • Unstable atrial fibrillation, atrial flutter, atrial tachycardia, and SVTs.
  • If medications fail in the stable patient with the before mentioned arrhythmias, synchronized cardioversion will most likely be indicated.
120
Q

Management: Wide-Complex Tachycardia

A

I would place supplemental oxygen while assessing for adequate oxygenation, ventilation, hemodynamic stability and the presence of a pulse.

Assuming the patient were stable, I would order a 12-lead EKG and consult cardiology. If this were a true monomorphic VT, I would treat with adenosine and then amiodarone (if adenosine did not work).

If at any point the patient becomes unstable (even with a pulse), I would sedate and secure the airway and perform immediate synchronized cardioversion.

121
Q

Management: pVT, VFib (cardiac arrest w/shockable rhythm)

A

I would confirm true pulselessness, begin chest compressions, and defibrillate immediately after verification of a shockable rhythm.

If pulselessness persists, I would immediately resume BLS, intubate, and give 1mg epinephrine every 3-5 min. I would continue to defibrillate every 2 minutes until the rhythm changes.

I would also send an ABG and correct any metabolic or electrolyte abnormalities. I would administer bicarb if ACLS lasted greater than 10 minutes or if pH < 7

122
Q

Management: Care of the Parturient After Trauma

A

The primary goal in managing the pregnant trauma patient is to resuscitate and stabilize the mother. However, to address unique concerns with a pregnant patient, I would ensure LUD positioning with in-line stabilization, prepare for difficult airway management and aspiration, monitor FHR and uterine contraction, and assess for membrane rupture, uterine rupture, or placental abruption. I would also prepare for emergent delivery of the baby.

123
Q

Management: Care of the Parturient After Trauma

A

The primary goal in managing the pregnant trauma patient is to resuscitate and stabilize the mother. However, to address unique concerns with a pregnant patient, I would ensure LUD positioning with in-line stabilization, prepare for difficult airway management and aspiration, monitor FHR and uterine contraction, and assess for membrane rupture, uterine rupture, or placental abruption. I would also prepare for emergent delivery of the baby.

124
Q

Carcinoid Tumor (Dx, mediators)

A
  • Tumor releases histamine, kallikrein, serotonin; symptomatic only if mets or primary outside intestine
  • Urine 5-HIAA to diagnose
125
Q

Carcinoid Syndrome

A
  • Carcinoid syndrome is a constellation of symptoms that results when excessive amounts of vasoactive hormones (histamine, kallikrein, seritonin) are secreted into the blood stream, causing upper body flushing, bronchoconstriction, diarrhea, right-sided heart disease (TR or PS), hypotension or hypertension.
  • Tricuspid regurgitation most common lesion, TS/PR/PS occur but less commonly
  • Hepatomegaly, peripheral edema, DOE suggest significant RHF from valvular lesion
126
Q

Carcinoid Syndrome: PreOp Meds

A
  • Perioperative administration of octreotide to reduce serotonin secretion from the tumor (best 2d-2w before surgery)
  • Optimize volume status, as patients are typically hypovolemic
  • Axiolysis to prevent stress-induced tumor release
  • H1 and H2 blockers to attenuate the effects of histamine
  • α and β blockers to prevent catecholamine-mediated release
  • Steroids
127
Q

Pre-Op Considerations: Lung CA

A
  1. SVC syndrome: dyspnea, headache, edema above the shoulders, chest pain, dysphagia, orthopnea, hoarsness, nasal stuffiness, pleural effusions, cough, AMS, facial cyanosis.
  2. Paraneoplastic syndromes (Humoral hypercalcemia, SIADH, LEMS, Cushings, carcinoid)
  3. Pancoast
128
Q

Paraneoplastic Syndromes

A
  1. Humoral hypercalcemia: tumor release of PTH-related peptides; presents with muscle weakness, cardiac arrhythmias, n/v, renal failure.
  2. SIADH: tumor secretion of ADH, leading to hyponatremia, decreased serum oSm, increased urine osm; euvolemic
  3. Cushing’s Syndrome: increase ACTH release, leading to hypokalemia, alkalosis, HTN, psychosis
  4. LEMS: commonly associated with small cell carcinomma
  5. Carcinoid syndrome
129
Q

Risk Factors: PPH

A

Risk factors for PPH include augmented labor, chorioamnionitis, fetal macrosomia, maternal obesity, multifetal gestation, preeclampsia, primiparity

130
Q

Tx: Postpartum Hemorrhage

A

Rx:

  1. Oxytocin
  2. Carbaprost
  3. Methergine
  4. Misoprostol
  5. TXA

Surgical:

  1. Hysterectomy
  2. Uterine aa. embolization
  3. Uterine aa. ligation
  4. Uterine balloon tamponade
131
Q

What steps would you take to resuscitate a neonate?

A

First, I would warm, dry, and stimulate the neonate. I would then position the airway and only suction if I believed there was an obstruction. I would use supplemental air or oxygen to maintain targeted goals. If the baby’s HR was < 100 or it was apneic or gasping, I would provide positive pressure ventilation and place a pulse oximeter. If after 30s of PPV the HR was < 60, I would intubate, start chest compressions, and establish IV access through the umbilical vein. If after 60s the HR was still < 60 I would give epinephrine and replace volume with normal saline.

132
Q

What steps would you take to resuscitate a neonate?

A

First, I would warm, dry, and stimulate the neonate. I would then position the airway and only suction if I believed there was an obstruction. I would use supplemental air or oxygen to maintain targeted goals. If the baby’s HR was < 100 or it was apneic or gasping, I would provide positive pressure ventilation and place a pulse oximeter. If after 30s of PPV the HR was < 60, I would intubate, start chest compressions, and establish IV access through the umbilical vein. If after 60s the HR was still < 60 I would give epinephrine and replace volume with normal saline.

133
Q

Targeted Preductal (RUE) SpO2 in neonates

A 
1 minute = 60-65%
2 minute = 65-70%
3 minute = 70-75%
4 minute = 75-80%
5 minute = 85-95%

Newborns > 35 weeks - start with room air
Newborns < 35 weeks - start with 21-30% FiO2

134
Q

What circumstances call for intubation of a neonate during resuscitation?

A
  1. Inadequate mask ventilation
  2. Chest compressions initiated / HR < 60 sustained
  3. Need for prolonged intubation
  4. Need for ETT medication
  5. Special circumstances (CDH, low birth weight)
135
Q

Causes: Postpartum Hemorrhage

A
  1. Uterine atony
  2. Retained placental parts
  3. Placental accreta
  4. Uterine rupture
  5. Coagulopathy
136
Q

Abdominal Compartment Syndrome: Effects on cardiac, vascular, pulmonary, neruo, abdominal organ systems

A
  • Excessive intraabdominal pressures > capillary filling pressure -> reduced organ perfusion (oliguria, reduced lactate metabolism, coagulopathy, translocation of intestinal bacteria)
  • Impaired ventilation secondary to cephalad displacement of the diaphragm and decreased FRC
  • Decreased venous return, increased afterload -> cardiac depression
  • Elevated ICP
  • Increased PVR
137
Q

Why is SCh contraindicated in children < 8 yrs?

A

• Risk of undiagnosed dystrophinopathy, and despite the lack of outward symptoms, the disease can still lead to a proliferation of extrajunctional AChR -> life-threatening rhabdomyolysis + hyperkalemia

138
Q

Which 4 disorders are linked to MH?

A
  1. Hypokalemic periodic paralysis
  2. Hyperkalemic periodic paralysis
  3. King Denborough Syndrome
  4. Central Core Disease
139
Q

If a patient has a suspected MH reaction, what would you do?

A
  1. Cancel the case
  2. Administer dantrolene
  3. Monitor for myoglobinuria, generalized rigidity, hypermetabolic state, electrolyte disturbances
  4. Check creatine kinase (CK)
  5. Admit the patient, work up for MH and undiagnosed muscular dystrophy
140
Q

How would you prepare an OR for a patient with known or high-risk for MH?

A
  1. Remove SCh syringes from the room
  2. Disengage vaporizers
  3. Replace circuit and CO2 absorbent
  4. Flush anesthesia machine
  5. Ensure the presence of iced solutions, monitors, and dantrolene
141
Q

What would you expect to see on ABG with MH?

A

Decreased PO2 along with a mixed metabolic and respiratory acidosis. The beginning stages of MH show a purely respiratory acidosis.

142
Q

How long do you continue dantrolene after MH event?

A

Continue dantrolene 1mg/kg every 6 hours for 24-48h to prevent relapse.

143
Q

Non-obstetric surgery for a pregnant patient: concerns

A
  • Risks to mother include failed intubation, aspiration, hemorrhage, infection, thromboembolism.
  • Risk to the fetus include preterm delivery, teratogenesis (highest risk during 1st trimester), fetal asphyxia, IUGR, miscarriage, and neurotoxicity
  • Laparoscopic surgery carries further risks, including trochar damage to the gravid uterus, hypercapnia-induced fetal acidosis
144
Q

How can Trisomy 21 complicate airway management?

A
  • Short Neck
  • Macroglossia
  • Subglottic stenosis
  • Mandibular hypoplasia
  • Atlanto-axial, atlanto-occipital instability
145
Q

Describe the three tachydysrhythmias associated with Wolff-Parkinson-White

A
  1. Orthodromic AVRT: narrow QRS (regular) because the cardiac impulse travels through the AV node and returns retrograde from the ventricle -> atrium via the accessory pathway. Treat with vagal maneuvers first, then treat with medications that slow conduction through the AVN (adenosine, BB, verapamil, amiodarone). Synchronized CV if Rx doesn’t work or pt becomes unstable.
  2. Antidromic AVRT: wide QRS (regular) because the cardiac impulse travels antegrade through the accessory pathway and returns through the AV node. Treat with procainamide or ibutilide. Rx that slow AVN conduction are CONTRAINDICATED because it increases conduction through the accessory pathway. Synchronized CV if Rx fail or pt becomes unstable.
  3. AFib with ventricular pre-excitement: wide QRS (irregular). Treat with procainamide, ibutilide, amiodarone to slow conduction from the atria -> ventricles. Synchronized CV if the patient is unstable, defibrillation may be warranted if the rate is too fast to synchronize (rates may be close to 300).
146
Q

How would you treat intraoperative bronchospasm?

A

I would hand ventilate with 100% oxygen, deepen the anesthetic, and administer bronchodilators.

147
Q

How long after angioplasty, BMS, and DES should elective non-cardiac surgery (ENCS) be postponed?

A
  • 14 days after balloon angioplasty
  • 30 days after BMS
  • Optimally 6 months after DES
  • If P2Y12i must be d/c perioperatively, ENCS after DES implantation may be considered after 3 months if the risk of further delay is greater than the expected risk of stent thrombosis
148
Q

Neuraxial Anesthesia in an anticoagulated patient: Heparin (SQ), Heparin (IV), Heparin (systemic), Heparin (Complete)

A
  • Heparin (SQ) - consider the same recommendations as IV since there can be a 10-fold variation in effect
  • Heparin (IV) - placement and removal should be delayed 2-4 hours after discontinuation of heparin. Heparin administration should be delayed 1 hour after placement. No need for cancellation after traumatic placement.
  • Heparin (systemic) - placement/removal should be delayed 2-4 hours after discontinuation of heparin. Heparin administration should be delayed 1 hour after placement. No need for cancellation after traumatic placement.
  • Heparin (CABG) - delay heparinization 1 hour after placement. Removal of catheter should be delayed 2-4 hours after discontinuation of heparin. Surgery delayed 12-24 hours after traumatic placement.
149
Q

Neuraxial Anesthesia in an anticoagulated patient: LMWH

A
  • PreOp - delay instrumentation 12h after last low-dose LMWH and 24h after last high-dose LMWH
  • PostOp - catheter removal 12 hours after last low-dose LMWH with dosing reinstated 2h after removal; catheter removal at least 2h prior to the first dose of high-dose LMWH
  • Anti-Xa monitoring not recommended as it isn’t predictive of the risk of bleeding
150
Q

Protamine Reactions

A
  1. Histamine release from rapid administration leading to venodilation, decreased SVR, reduced preload
  2. Anaphylactic/anaphylactoid reaction
  3. Catastrophic pulmonary HTN and RHF
151
Q

How to assess volume status in pediatrics?

A
  • Dry mucous membranes
  • Slow capillary refill
  • Sunken fontanelles
  • Number of wet diapers
  • Hx of vomiting/diarrhea/poor intake from parents
152
Q

Criteria for outpatient surgery discharge?

A

PADSS system: score of 9 = ready for d/c

  1. Vital signs - within 20% of baseline
  2. Activity - steady gate w/o dizziness
  3. Minimal PONV
  4. Acceptable pain control per patient with PO meds
  5. Minimal surgical bleeding
153
Q

What are the complications of an interscalene block?

A
  • Pneumothorax
  • Phrenic nerve blockade
  • Neuraxial injection
  • Intraarterial injection -> LAST and seizures
  • Horner’s syndrome
154
Q

Glasgow Coma Scale

A
  • Eye opening (EYES - 4 pts max)
  • Verbal response (MOUTH - 5 pts max)
  • Motor response (MOTORS - 6 pts max)
155
Q

Normal Values (neuro)

A

• CPP 70-85 mmHg

156
Q

Normal Values (cardiac)

A
  • Cardiac index 2.5 - 4.5
  • PCWP 2-15 mmHg
  • PA pressure 15-30/4-12
  • MVO2 = 65-75%
157
Q

Tx: ARDS

A
  • Vt < 6mL/kg
  • Static airway pressure < 30 mmHg
  • FiO2 < 50%
  • Enough PEEP to recruit small airways
158
Q

How to asses for outpatient surgery appropriateness?

A
  • Potential for unDx OSA
  • Anatomical/physiologic abnormalities
  • Extent/severity of coexisting disease, and whether medical management is optimized
  • Nature of the surgical procedure (superficial, abd)
  • Intraop anesthetic requirements (local vs GA vs sedation)
  • Capabilities of the outpt facility to handle emergency or escalated post-op requirements
  • Adequacy of patient’s post-discharge care
  • Anticipated post-op needs
159
Q

How to prevent an airway fire during laser airway surgery?

A

• 3 principles of airway fire: 1. ignition source (laser), 2. Fuel (prepping agents, drapes), 3. oxidizer (O2, N2O)

  1. Avoid N2O
  2. Use lowest FiO2 possible
  3. Use metal or laser-resistant dual cuffed ETT
  4. Cuff should contain water to extinguish fire if perforated, the extra cuff will keep high-O2 concentration to the lungs
  5. Consider jet ventilation or apneic oxygenation
160
Q

SSx: LAST

A
  • CNS symptoms before CV symptoms
  • Initial S/Sx include tinnitus, metallic taste, circumoral numbness, excitation/agitation ➙ seizures & respiratory arrest
  • Late stage includes bradycardia, ventricular arrhythmias, and cardiac arrest
161
Q

How to prevent an airway fire during laser airway surgery?

A

• 3 principles of airway fire: 1. ignition source (laser), 2. Fuel (prepping agents, drapes), 3. oxidizer (O2, N2O)

  1. Avoid N2O
  2. Use lowest FiO2 possible
  3. Use metal or laser-resistant dual cuffed ETT
  4. Cuff should contain water to extinguish fire if perforated, the extra cuff will keep high-O2 concentration to the lungs
  5. Consider jet ventilation or apneic oxygenation
162
Q

SSx: LAST

A

• CNS symptoms before CV symptoms
• Initial S/Sx include tinnitus, metallic taste, circumoral numbness, excitation/agitation ➙ seizures & respiratory arrest
•

163
Q

DIC

A
  • Consumptive coagulopathy leading to microvascular occlusion, bleeding, and organ failure
  • Lab: prolonged PT & PTT, thrombocytopenia, low fibrinogen, elevated D-Dimer
  • Treatment of the underlying cause of the DIC is the primary goal. Transfuse pRBC, FFP, cryoprecipitate, and platelets as needed.
164
Q

Causes of DIC in pregnancy

A
  • AFE
  • Placental abruption
  • Retained products of conception
165
Q

Causes/DDx: Torsades

A
  1. Drug-induced: droperidol, ondansetron, methadone
  2. Hypokalemia and hypomagnesemia

Note: PAC/PVC and R on T can lead to TdP

166
Q

Causes: PVC

A
  • Cardiac ischemia
  • Heart Failure
  • Hypoxia
  • Hypertension
  • Increased sympathetic activity (anxiety)
  • Drugs (cocaine, meth)
  • Electrolyte imbalances
  • Irritated myocardium
  • Re-entrant loop
  • Ectopic focus
  • Hyperthyroidism

*Note PVCs can lead to VTach/Fib

167
Q

Celiac Plexus Block (indications, complications)

A
  • Pain from pancreatic, liver, splenic cancer

* Complications: diarrhea, orthostatic hypotension, LAST, paraplegia, arterial/venous injury

168
Q

Ways to monitor cerebral/spinal perfusion

A
  • EEG
  • Evoked potentials (SSEP, MEP, BEP)
  • EMG
  • Stump pressure (cerebral)
  • Transcranial doppler
  • Cerebral oximetry
169
Q

Acute Transfusion Reactions

A

Mild allergic: Attributed to hypersensitivity to a foreign protein in the donor product.

Anaphylactic: Similar to a mild allergic reaction, however resulting in a more severe reaction. Sometimes this can occur in a patient with IgA deficiency who makes alloantibodies against IgA and then receives blood products containing IgA.
Febrile non-hemolytic: Generally thought to be caused by cytokines released from blood donor leukocytes (white blood cells).

Septic: Caused by bacteria or bacterial byproducts (such as endotoxin) which may contaminate blood.

Acute hemolytic transfusion reactions: Can result in intravascular or extravascular hemolysis, depending on the specific etiology (cause). Immune-mediated reactions are often a result of recipient antibodies present to blood donor antigens. Non-immune reactions are possible, and occur when red blood cells are damaged before transfusion (e.g., by heat or incorrect osmotic conditions).

Transfusion-associated circulatory overload (TACO): Occurs when the volume of the transfused component causes hypervolemia (volume overload).

Transfusion-related acute lung injury: Acute lung injury is due to antibodies in the donor product (human leukocyte antigen or human neutrophil antigen) reacting with antigens in the recipient. The recipient’s immune system responds and causes the release of mediators that lead to pulmonary edema. Possibly contributing to this are clinical conditions that predispose the patient including infection, recent surgery, or inflammation.

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