Oral Boards SOE Flashcards
Left uterine displacement
When 18 weeks…1.5 trimester
RhoGam MOA
Stop mom from forming antibodies to attack Rh+ cells
Therapeutic mag in preeclampia
Therapeuatic mag: 4-7
Respiratory paralysis: 13-15
*Give calcium if sufficiently concerned for mag tox in mom (PEA arrest) or baby
*May see wide QRS on EKG
5Hs, 5Ts
-Hypoxia
-Hypothermia
-Hacidosis
-Hypo/hyperklaemia
-Hypovolemia
Tamponade
Tension PTX
Toxin
PE
MI
Are you concerned about a neonate airway…
Yes, you can do an awake fiberoptic
Beckwith-Widemann
Big baby with big tongue…anticipate difficult airway
Retinopathy of prematurity…until when
44 weeks gestation…O2 sat 90-95% is fine
Foot pulse ox reading lower…ddx
-R to L shunt
-Aortic coaractation
-Increased intraabdominal pressure
Duchenne muscular dystrophy
(anesthesia considerations)
-Cardiac Issues
-Lung issues including pulm HTN
No volatile or succinylcholine…risk of life-threatening hyperkalemia/rhabdo
Cobb Angle
-A measure of scoliosis severity
-Greater 60 degrees: think restrictive lung disease/pulm HTN
Aspiration cocktail
Famotidine + Reglan + Bicitra (non-particulate antacid)
Prone positioning…precautions
-Head neutral
-Eyes and ears free of presure
-Arms not abducted more than 90 degrees (to avoid brachial plexus injury)
-Ulnar nerve padding
EMG
Should do to monitor for peripheral nerve injury
Child with cough…delay the nonemergent case?
Yes
2-4 weeks if mild sxs
4-6 weeks if more severe sxs
LMA vs ETT
LMA: cannot paralyze, not protected airway, less effective in delivering positive pressure, may unseat
MMR (muscle masseter rigidity)
-Cancel case
-Monitor for s/s MH (hyperthermia, elevated PaCO2, electrolyte deranagements, rhabdo)
MH precautions
-Disengage vaporizers/remove succincylcholine
-Change out circuit and CO2 absorbent
-Flush the machine with O2
-Dantrolene avaiable
MH management
-Dantrolene (2.5mg/kg q5-10 min per sxs)
-Cool the patient
-Electrolyte management
…
Must cont IV dantrolene for 24-48 hrs to prevent relapse
How does dantrolene work? blocks the release of calcium from muscle
Cervical spine injury..can’t move/can’t breathe
Injury above C6….
How many PVC/min is concerning
> 6 PVC/min
Spinal shock
-Typical lasts for 1-3 weeks after injury
-Expect paralysis, bowel/bladder dysfxn below the level of injury
Elective noncardiac surgery after intervention..
Balloon: 14 days
BMS: 1 months
DES: 6 months, maybe 3 months
Autonomic hyperreflexia
Lesion above T7
S/s: Hypertension, reflex bradycardia
COPD: PFTs
-FEV1/FVC <70% is diagnostic
<50% is severe
Smoking cessation: ideal timing
8 weeks
-Improves airway hyperreactivity and sputum production
Issues with giving unnecessary bicarb…
-sodium load
-hypokalemia
-shift oxy-hemoglobin curve left
Most common cause of post-op vision loss
PION (posterior ischemic optic neuropathy) …painless vision loss within 24-48 hrs
Down syndrome considerations
Airway: cranio-cervical instability, subglottic stenosis, macroglossia
Cardiac: defects
Pulm: OSA (think big tongue)
Can you dart the patient…
IM ketamine (5mg/kg)
or IM precedex (2mcg/kg)
or IM midazolam (0.1mg/kg)
WPW…stable…
Orthodromic:
Esmolol/amio is fine
(looks like SVT)
Antidromic:
Or Orthodromic with AFfib
*Procanimide only
(looks like VT)
Elevated PTT ddx
VWD, Hemophilia
Hemophilia A vs B
A: factor 8 deficiency…85% cases
B: factor 9 deficiency…14% cases
DDAVP…txt for
Hemophilia A and VWD….increases VWF and Factor 8
Who not to deep extubate…
Obesity/OSA
Difficult airway
Bloody secretions in airway…
Full stomach
Stress dose steroids…
Hydrocort 100mg, then Hydrocort 50 q6hr
Burn and inhalational injury
Signs of inhalational injury: burns to lip/mouth, sooth in the mouth, stridor….
If there is any sign of inhalational injury OR major burns in general…intubate urgently
Otherwise should do serial airway exams for 24 hrs with fiberoptic scope
Burns rule of 9
Each arm: 9%
Torso: 36%
Each leg: 18%
Head: 9%
***
In kids, HEADS are bigger (18%), legs are smaller.(9%)..
Burn shock
Basically, severe hypovolemic shock
Parkland formula
4 x kg x BSA
-Half in the first 8hrs after injury
-The rest in the following 16 hrs hrs after injury
*
In kids, 3 x kg x BSA
Inhalation injury…
Have to think about carbon monoxide poisoning, cyanide poisoning
Carbon Monoxide Posioning Txt
-100% FiO2
-Hyperbaric oxygen if CO-hg level >25%
Pulse ox and PaO2 will be nl
O2 sat on ABG will not (since less heme binding sites will be bound by oxygen)
Where to monitor temp
Esophagus, nasopharynx, bladder
Jet ventilator
Can jet ventilate through cook catheter (don’t advance cook catheter too far), or supraglottic
Risk of supraglottic: gastric distension, aspiration, rupture
Risk in general: PTX (avoid in severe COPD), inadequate gas excahgne (hypoxia, hypercarbia)
MH, distinsiguish features
-Extreme rigidity
-Hypercarbia
(vs NMS vs SSS)
Cola-colored urine ddx
Rhabdo…
Acute hemolytic trf rxn (from ABO incompatibility)
TAAA repair…features
-OLV to facilitiate surgical access by left thoracotomy
-Sometimes LHB for distal aortic perfusion
-Hypothermia for spinal cord protection
-Lumbar drain
-Epidural
**
Med managment:
-Strict HR and BP control
PFTs suggesting need for postop ventilation
-FEV1 <2L
-MMEFR (maximal mid expiratory flow rate)<50%
TAAA monitors
Right radial Aline
Femoral Aline (+/-)…LHB
TEE
Belmont
Lumbar drain
*some add SSEP/MEP (but then need 0.5 MAC gas)
Cross-clamp applied..signals decreased
-Release cross-clamp
-Check ABG
-Drain from lumbar drain
-Fluid load, vasopressor….maintain euvolemia
-LHB (increase flows), create shunt, reimplant arteries to perfuse vital organs
-Hypothermia
Spinal cord blood supply
-Anterior spinal artery, single supply of anterior spinal cord
-2 posterior spinal arteries suplying posterior spinal cord (sensory)
Hypotension after cross-clamp release
/-Reapply clamp, release more slowly next time
-Fluid load, pressor
-TEE/PA cahteter to guide…r/o ischemia
-Send ABG
-Decrease anesthesia depth
Parameters for Extubation
TV>6cc/kg
VC>10cc/kg
NIF>20
RR<30
O2sat>90%, on FiO2 50%, PEEP 5-8
Neg cuff leak
Leg weakness post-TAAA ddx
-Is this epidural hematoma, spinal cord ischemia, inadvertent intrathecal infusion
*
Get imaging, drive up BP, drain CSF
How does cross-clamp drive spinal cord ischemia
-Drop blood flow to spinal cord
-May increase CSF pressure
DeBakey classification of TAAA
Type 1: ascending aorta and beyond
Type 2: ascending aorta only
Type 3: distal to left subclavian…
*Type 1 and 2 are surgical emergencies
*Type 3 is medical
HD changes with cross-clamp
Pre: increased afterload, decrease CO, increase filling pressures
Post: decreased preload
-Try to maintain MAP>100 above, MAP>50 below (only applies if you are doing LHB)
EVAR vs Open Aneurysm Repair Outcomes
EVAR outcomes better in short-term, likely worse in the long-term
EVAR vs open repair….difrences
-No cross-clamp
-No epidural
-No one-lung ventilation
-1 A-line (ideally in RUE…may manipulate left subclavian)
*
Yes, consider lumbar drain
What is aneurysm vs dissection
Aneurysm: involves dilation of all 3 layers of aorta
Dissection: involves tear in intima, resulting in false tract of blood flow
EVAR complications
Same as open procedure
+Endoleak (blood leaks through stent graft into the aneurysmal sac)
Aortic Dissection: Goal BP/HR
HR<65
SBP<110
Sodium Nitroprusside toxicity
Think: cyanide toxicity (prevent cells from using O2)…give Vitamin B12
Cross-clamp and renal protection for OPEN REPAIR
-Ideally, cross-clamp should be infrarenal, minimize cross-clamp time…but infrafrenal cross-clamp is no guarantee against AKI
-Mannitol, lasix before cross-clamp
-Shunt blood to distal aorta
-Reimplant arteries
EVAR spinal cord protection strategies
-SSEP/MEPs (0.5 MAC of gas)
-Lumbar drain
-Reimplanting critical intercostal arteries
Why might you give adenosine during EVAR…
To create a hemodynamically still field for stent/graft deployment
Cross-clamp is about to be released…what do you do
-Come down on gas
-Fluid bolus
-Vasopressor
-Use PA cathter and TEE to ensure euvolemia
-Reapply clamp and gradually release
Airway exam
Mouth opening
Mallampati
Jaw protrusion
ROM
Large tongue
Short neck, thick neck?
Cerebral Aneurysm Monitors
Aline
SSEP, EEG
Hunt and Hess
Grades severity of non-traumatic SAH
Before clip placement for cerebral aneurysm….
Surgeron may request deliberate hypotension..
With temporary clip placement, may request hypertension to support collateral blood flow…may also request burst suppression
Brain relaxation techniques
-HOB up
-Low PEEP
-Hyperventilate
-Steroid
-Lasix/mannitol/hypertonic saline
-TIVA
-Lumbar drain
Which is higher, PaCO2 or EtCO2…
ALWAYS PaCO2, 2/2 dead space ventilation
How to treat cerebral vasospasm?
-Supportive care
-Normovolemia
-Drive up pressure
-Intraarterial CCB
SAH complications
First 24 hrs: rebleed
Next 2-14 days: vasospasm watch
Causes of low sodium in NSG
-SIADH vs cerebral salt wasting
Neonatal TEF patient…in respiratory distress…what to do
-Stop mask ventilation…you are insufflating the stomach
-Cuffed ETT (distal to fistula, proximal to the carina)
-G tube
-Maybe fogarty catheter to seal off fistula
Types of TEF fistulas…
Type A: estophageal atresia, no fistula
Type B: esophageal atresia, proximal fistula
Type C: esophageal atresia, distal fistula (most common)
Type D: esophageal atresia, both proximal and distal fistula
Type E: no atresia, single esophagus, single fistula
Prematurity Neonate Concerns (ie before 37 weeeks)
Neuro: IVH, reintopathy of the newborn
Cardiac: defects
Pulm: insufficiency (RDS)
GI: necrotizing enterocolitis
GU: reduced renal fxn
MSK: susceptibel to hypothermia
Preop optimization for TEF
Think VACTERL
-Spinal films (for caudal anesthesia
-ECHO for cardiac anomalies
-Renal u/s for renal anomalies
Other:
Fluids given likely poor PO intake
Continous suctioning of esophagus to minimize aspiration risk
What TEF monitors?
-Aline (anywhere)
-Precordial stethoscope (listen over left chest, stomach)
-Consider central line for CVP monitoring
Other:
**-Plan for caudal anesthesia for post-op pain
How to induce and intubate
RSI..continous suctioning beforehand…bronchoscope to guide placement
or awake intubation (however may be difficult, risk of sympathetic response and IVH)
Inhalation induction without paralytic…risk of aspiration…however, spontaneous ventilation minimizes gastric distension
What size ETT for TEF…
3.0 cuffed…
How to place ETT tube? Bronchoscope, vs right mainstem and pull back
TEF patient desats
Check ETT with bronchoscopy…
Is G tube venting?
–
Could also be surgical compression of heart/great vessels…PTX/atelectasis
Intraop neonatal fluid managment
4-2-1 for maintainance: D51/2 NS
Bolus with isotonic
HCT>35
Would you extubate TEF patient?
No, high-risk for reintubation, protect suture lines, avoid aspiration
Neonatal extubation critiera
TV 6cc/kg
RR 30-40
O2 sat 90%, 50% FiO2, PEEP 5
Awake, reflexes intact
AVOID RETINOPATHY
Neonatal vent settings
-O2 sat >90% (no hyperoxia)
-RR 30-40
-PIP <25
TEF complications
-GERD
-Anastaomotic leak
-Tracheomalacia
-Recurrence
Neonatal vitals
HR: 120-160
BP: 80 and 60/30
O2 sat: 95% in newborn, 90% in premies
RR: 40-60
Fetal circulation
Ductus venosus (bypasses liver)
Foramen ovale (RA to LA)
Ductus arteriosus (Pulmonary Artery to aorta)
With first breath of life, PVR drops, facilitating closure of DA
Tetralogy of Fallot…4 features
Goal O2 sat
-RVH
-Pulmonary stenosis
-VSD
-Overriding aorta
Pre surgery: 75-80%
Post surgery: 90%
Tetralogy of Fallot…how to induce
Slow controlled IV induction…less control with mask induction (could overly reduce SVR)
Nitrous oxide and kids
-Can increased ICP
-Can increase PVR (bad in RTL shunt)
*
Why do we use? It is fast and odorless
CDH
Diaphragram fails to form…
Causing pulmonary hypoplasia and pulm HTN…assume RTL shunt until proven otherwise
Med management CDH
Intubate early on to control ventilation…
-Lung protective ventilation
-Permissive hypercapnia
*
Ventilatory goals:
**-Goal O2 sat, preductal 85%
**-PIP <25
-pH>7.25
How to intubate CDH…
RSI vs awake fiberoptic…do not want to insufflate stomach and worsen gastric distension
If still hypoxic…gotta think RTL shunt from pulm HTN…correct the usual/increase afterload (vasopressin)/pulm vasodilators…ECMO
CDH monitors
-Central line (umbilical vein, in case need ECMO…for fluid shift management)
-R Aline
-Preductal and postductal O2 sat (R arm and L foot)
-Precordial stethoscope over R chest
CDH: cause of hypoxia
-R to L shuting worse
-Atelectasis
-Pulmonary hypoplasia
**
What is HFOV:
Lung-protective ventilation involving high frequency, low TVs…risk
**
These patient may need ECMO, consider placing umbilival central line
Would you extubate CDH patient?
No…high risk for cardio-pulm complications, shunting, PTX, etc….
ACLS for pregnant patient
The same except:
-Maintain left uterine displacement
-stop magnesium infusion, give calcium to reverse
-If no ROSC after 4 minutes, proceed with C section
OB considerations
-Decreased FRC
-Lower MAC requirement
-Opioids and benzos ok
-Never NSAIDS…NO TORADOL
-Reverse with sugammadex, otherwise neostigmine and atropine (glyco does not cross)
-Maintain left uterine displacement (starting 2nd trimester)
-Full stomach
-If viable…have OB and neonatal team available
-if pre-viable, check uterine contraction/FHR before and after
Drugs that do not cross the placenta
Heparin
Insulin
Nondepolarizing
Glycopyrrolate
Succinylcholine
(HE IS NOT GOING SOON)
When to monitor uterine contractions and FHR intratop?
At viability (24 weeks)
Pneumoperitoneum complications…
-RIght mainsteam intubation
-PTX
-Capnothorax (CO2 hemothorax)->EtCO2 elevated
ECT physiology/contraindications
Physiology: parasympathatetic followed by sympathetic surge
Absoluate contraindications:
Recent MI/stroke, Elevated ICP, intracranial mass
Anesthesia for ECT
-Induce (prop/etomidate/methohexital)
-Paralyze to minimize harm of seizure
-Hyperventilate to prolong seizure
Thoracic preanesthetic assessment…
Must review imaging studies, lookg for possible mass effect
Thoracic PFTs…predictors of badness
FEV1<30%
DLCO<40%
VO2 max <10cc/kg/min
***
Consider leaving intubated with any of these
Thoracic primer: complications
-Cardiac herniation
-PTX
-Broncho-pleural fistula
-RHF (2/2 chronic hypoxia, pHTN)
-Post-op afib (from stress of surgery, fluids, manipulation of the heart)
L-sided DLT for Left Lung surgery…can you do?
Discuss with surgeon…
-Could injure bronchial stump following closure with inadvertent advancement of DLT
-Significant left bronchial involvement may preclude L DLT placement….would need to place R-side DLT or bronchial blocker
OLV desaturation
-100% FiO2
-Confirm placement
-PEEP to dependent lung
-CPAP or blow-by O2 to the non-dependent
-Pulmonary artery clamping to non-dependent lung
-Switch back to 2-lung ventilation
Thoracic case, maintenance plan
Either gas or TIVA is fine…but MAC>1 inhibits hypoxic pulm vasoconstriction
After thoracic surgery, blood pressure drops…don’t miss…?
Cardiac herniation
**Immediate txt: shift the patient such that non-operative side is down…can help return heart into pericardial sac…must ultimately reopen chest…put heart back into pericardium…close the defect…
50% mortality rate 2/2 incomplete closure of pericardium…sxs appear within 24 hrs..right-sided defect presents with obstruction of venous return….left-sided with MI and arrhythmias…
4 Absolute indications for OLV
-To prevent contamination of a healthy lung
-To control ventilation distribution (bp fistula)
-For VATS surgery
-To facilitate single lung lavage (cystic fibrosis)
-
Relative indications:
TAAA
Esophagectomy
Pneumonectomy
DLT, do you switch to SLT at the end of the case
Yes
Less bulky->less edema and risk of mucosal ischemia
Throacic pain plan: best…
1: EPIDURAL
Paravertebral block
Advantage of DLT over bronchial blocker
-Less likely to dislodge
-Able to suction operative lung
Transplant heart…spinal or epidural?
Would do epidural…
Transplanted heart is preload-dependent…may not tolerate abrupt drop in preload with rapid sympathectomy
Hence, for pregnant patient…would slowly raise level with epidural
Transplanted heart…tell me about drugs…
Parasympathetic denervation…hence, less minimal response to glyco, atropine…also less response to indirect actors of sympthateic nervous system (including ephedrine)
*
Should I give glyco with neostigmine…yes, there is some cardiac reinnervation over time….also want to reverse the other muscarinic effects
Why 3-6 months for DAPT for DES vs BMS?
The drugs inhibit endothelialization…this means less restenosis in the long run…however in short-run there is risk of rethrombosis
How to long to wash out Aspirin? Plavix?
Aspirin 10 days
Plavix 7 days
*In general, should continue aspirin…exception: neurosurgery….bleeding into brain/spine could be catastrophic
Laparoscopic surgery and hypotension…ddx
-Vagal response
-Tension PTX
-Capnothorax
-Mainstem intubation
-CO2 embolus
Anaphylaxis vs Anaphylactoid rxn
Anaphylaxis: IgE mediated…requires prior exposure to antigen
Anaphylactoid rxn: non-IgE mediated…mast cell degranulates 2/2 direct interaction….
Anaphylaxis txt
-Fluid
-Pressor
-Epinephrine, mag, albuterol (think bronchospasm)
-Steroid, H2 bloker
Esophagectomy…pain control plan…even for minimally invasive eophagectomy…
EPIDURAL
Esophagectomy: unique risks
Blunt dissection is blind…
Injury to heart, lungs, airway, great vessels
*Must protect newly constructed gastric tube:
avoid hypotension, fluids over pressor per some
OLV is often required for esophagectomy via thoracic approach…What are your OLV ventilation goals?
4-6 cc/kg TVs
PEEP 5-10
PPlt <25
T&S vs T&C
T&S…blood is selected based on screening for antibodies
T&C…blood actually selected for patient is screened for final confirmation of compatibility…
Cell saver in cancer patient…
Many say no…risk of metatsis of tumor cells…maybe even after washing…
Cell Saver…complications
This is just pRBC…can result in coagulopathy
CRPS Type 1 vs Type 2
Type 1: negative for definite nerve injury…90% of cases
ESOPHAGECTOMY: 1- thoraic epidural 2- OLV
May have more issues with ventilation/oxygention with OLV compared to lung resection cases…
*The diseased lung requiring lung resection usually has baseline diminished blood flow…so less V/Q mismatch to start
High risk aspiration concent
Low pH, high volume
Myasthenia gravis
-Etiology?
-Edrophonium?
-What condition?
-What drugs to avoid?
-Etiology: autoimmune destruction of postsynaptic ACh receptors
-Edrophonium..rapid-acting but works like pyridostigmine…if myasthenic crisis, will fix quickly…if cholinergic crisis…will worsen
-Thymoma
-Avoid glyco/atropine (anticholinergic effect not ideal)
-Other: “RS”…use half dose of rocuronium
Protamine rxn
Type 1: Hypotension (histamine-related) from rapid administration
Type 2: Anaphylaxis (IgE mediated)
Type 3: Pulm HTN crisis (IgG/complement)…supposedly dose-dependent, maybe less risk with lower dose of protamine
Protamine: Type 3 rxn
Supportive care
Epinephrine
Pulm vasodilator
Reheparinize, go back on bypasss
How to prevent airway fire?
-Laser-resistant ETT
-Inflate cuff with saline
-Low FiO2
OSA vs Obesity Hypoventilation Syndrome
OSA: hypoventilation during sleep, but will often hyperventilate between apnea episodes..often obesity related, not always
Obesity hypoventilation syndrome: hypoventilate including during the day…often don’t hyperventilate…always obesity related
Crichothyrotomy
-Incision through cricothyroid membrane
Respiratory distress syndrome of the newborn
In premies (before 37 weeks)
2/2 undeveloped lungs
Txt: maternal steroids while in utero, exogenous surfactant
Is PDA LTR or RTL shunt, normally
*Murmur
LTR
*Continuous murmur
Premie considerations
Neuro: IVH, retinopathy of prematuirty
Cards: cardiac anomalies,
Pulm: respiratory insufficency, RDS, postop apnea
GI: necrotizing enterocolitis
GU: AKI
MSK: hypothermia
Endocrine: Hypoglycemia
Ligation of PDA complications…
Bleeding
Nerve injury (vagus, recurrent laryngeal nerve)
Fluid shifts, left heart failure, pulm hypertensive crisis
Ligation of PDA-monitors
R Radial A line
Central line
Precordial stethoscope
Pre and postductal O2 sat
*
Goal O2 sat: 90%
Ligation of PDA…how to maintain anesthesia…
Low dose gas (0.2-0.3 MAC gas), remi gtt, some fentanyl/dilaudid at end of case
When to maintain PDA?
Ductal dependent lesions (eg hypoplastic left heart syndrome)
Sick premie goal HCT…
HCT>35…
Why? (Fetal Hgb causes leftward shift of oxygen-hemoglobin dissociation curve)
How do infants maintain temperature?
Nonshivering thermogenesis via brown fat metabolism….
Neonates have mimimal brown fat stores…must take care to warm them
Pheochromocytoma: anesthesia plan
-Get them deep with induction..consider remi gtt
-Have antihypertensivies: nicardipine gtt, nitroglycerin…
-Have uppers as well, including vaso
-Avoid morphine (may cause histamine release)
-Magnesium is great…may decrease catecholamien release
Pheochromocytoma: med optimiziation
Alpha blockade 10 days prior
Then add beta blocker
(Avoid unopposed alpha receptor stimulation)
Robotic surgery precautions…
-Keep paralyzed…don’t want patient to injure themselves while instruments are in the boody
-Pad the patient, to protect from robotic arms
Hypercarbia from pneumoperitoneum…ddx
-May be normal…CO2 being absorbed into the bloodstream->increase ventilation
-But must rule out CO2 capnothoroax
Subcutaneous emphyema with abdominal insufflation…
-Must rule out capnothorax/pneumothorax
-Surgeon should use lower insufflation pressure
-Raises concern for laryngeal edema->delay extubation until hypercapnia resolves, +cuff leak
CKD…which drugs to be careful with
Morphine, meperidine, **benzos (use lower dose) **
How to treat HyperKalemia
Insulin, Calcium
Sniffing position
Aligns the tragus of the ear with the sternal notch
*consider placing shoulder roll, head rest
Resusciation, colloids vs crystalloid
Crystalloid 3:1, Colloid 1:1
What does VWF do?
Mediates platelet aggregation, stabilized Factor 8
VWD disease…most common type
Type 1: mild
Management of undifferentiated VWF
Prepare for bleeding…
Plan to give DDAVP (stimulates release of VWF), FFP, cryoprecipitate, HUMATE P (vWF-Factor 8 concentrate)
DDAVP and VWD
DDAVP stimulates the release of vWF…
Side effect: hyponatremia
MAC gas and CBF
MAC >1, increased CBF
MAC <1, no effect on CBF
*
Inhaled gas always reduces CMRO2
Sitting crani…exclusion criteria
MUST get ECHO to rule out PFO…
Infective endocarditis ppx
Think: oral and respiratory procedures
*Amoxicillin is abx of chocie
Sitting crani…monitors
A line (transducer at the level of tragus)
Central line
TEE
Precordial Doppler
EEG, SSEP, MEP, EMG
Induction for elevated ICP
RSI is the preferred method:
Etomidate, roc, lidocaine, high-dose fent
Neuro patient…deep extubate?
Never
Wide awake, following commands, confirm no new neuro deficit
Tension pneumocephalus…what is it
Air accumulates, causing mass effect
Hence, never use nitrous
Posterior fossa crani…
Specific concern: post-op swelling causing impingement on cardiac/respiratory centers
Sitting position precautions…
-Neutral neck
-Avoid hip flexion greater than 90 degrees
-Pad pressure points
Laryngeal papillomatosis…remember they use a laser
*they use a laser for debulking/surgical excision
Laryngospasm management
-Jaw thrust +Larson’s maneuver (firm pressure behind the earlobes)
-Positive pressure
-Deepen anesthetic + lV idocaine
-paralyze
MH inheritance
Autosomal dominant…
Caffeine Halothane Test
Kid must be older than 7…if they can’t be tested, can test family member
Laryngeal papillomatosis airway management
-ETT (oral vs nasal)
-Intermittent apnea (mask up, surgeon works quickly, TIVA)
-Jet ventilation
Desaturation with jet ventilation…ddx
-Inappropriately aligned
-Inadequate ventilation (increase jet pressure)
SCD: why take hydroxyurea
Increases the amount of Fetal Hgb, thereby decreasing the amount of HgbS sickling
SCD: types of Hemoglobin
80-90%, HgbS
Normal people have HgbA
Preop eval of SCD patient
Any recent vaso-occlusive crises…MI / renal infarct/ stroke /acute chest syndrome
What is it? Vaso-occlusive crisis of the pulmonary vasculature
Abx (superimposed PNA), simple transfusion to correct anemia, exchange transfusion …
Goal of exchange transfusion is to refuse Hgb S to 30-40% (from 80-90%)
Hgb goal for major surgery in SCD
Goal of ~30
Def Type &C blood given difficulty of obtaining compatible blood
Precipitants of sickle cell crisis
-Hypoxia
-Hypotension
-Hypothermia
-Acidosis
-Pain/anxiety
Sympathetectomy in preeclamptic patient
They are intravascularly deplete…may not tolerate super well…fluid replete before attempting
OB patient..mom is seizing post delivery…ddx
-Eclampic seizure
-AFE (hypoxia, hypotension/RVF failure, AMS, DIC)
-LAST from epidural
SCD post-op pain after OB
High risk for pain…need to treat to avoid vaso-occlusive crisis…low threshold to split epidural, start PCA
Lung Mass H&P
Must consider:
-Airway compression
-Compression of the heart and great vessels (if SVC compression, must get LE IV acecess)
-SVC compression may lead to airway edema, may be best to attempt AFOI
Lambert Eaton
Associated with lung cancer
Sensitive to both roc and sux
May develop respiratory failure after anesthesia
Mediastinoscopy Complications
-Brachiocephalic compression (consider R brain stroke)
-Recurrent laryngeal nerve injury->would need to be bilateral for airway obstruction
-PTX
-Hemorrhage->would need DLT for thoracotomy, or just sternotomy
Contraindications to mediastinoscopy
Absolute: prior mediastinoscopy
Relative: thoracic aorta aneurysm
Mediastinoscopy monitors
RUE pulse ox (to monitor for brachial compression)
L UE A-line or femoral A line
Patient is HYPERTENSIVE…elective procedure
Ok to delay for 6-8 weeks
Meds to hold before surgery
Day before: ace, arb, lasix
3 days before: SGLT inhibitors (can cause euglycemic ketoacidosis)
SVC Syndrome: anesthesia consideration
-Airway: edema (consider awake fiberoptic)
-Consider lower extremity IV access
Cystic Fibrosis…Organ involvement
Respiratory: Obstructive lung disease (bronchiectasis) (obstructive lung disease), PTX
GI: Diabetes and Vitamin K deficiency (pancreas involvement)
Heme: Coagulopathy
*
Newborn may develop meconium ileus
Obstructive vs Restrictive Lung Disease: PFTs
Obstructive: FEV/FVC reduced, TLC increased
Restrictive: FEV/FVC nl to increased, TLC decreased
Cystic pathophysiology
-Autosomal recessive
-Defect in ion channel regulating movement of Na and Cl->results in thick secretions (pulmonary, pancreas, GI)
Cystic Fibrosis Txt
Pulm: Chest PT, mucolytic, abx
GI: insulin, Vitamin K supplementation
Cystic fibrosis, appendectomy…do this under regional?
Advantage: avoid airway manipulation
Disadantage: with preexist lung dysfxn, may not tolerate given the high level of neuraxial level blockade required
Cystic Fibrosis: high airway pressures…ddx
-mucus plugging
-PTX (ruptured bullae)
Emergence Delirium
Appears in kids 1-5 yo
Inconsolable, unable to recognize surroundings
Txt: precedex, prop, midaz
Acute dystonic. rxn from reglan…txt
-Diphenhydramine, benztropine
Carotid Endarterectomy: Major Concern
Stroke, MI
Carotid Endarectomy…anesthetic approach
Ideally, done under regional…would allow for the continuous neuro assessment of an awake patient
*speech, consciousness, contrallateral hand grip
Carotid Endarterectomy: what type of regional anesthesia?
Risks:
Superficial and deep cervical block
***
Risks of deep cervical block:
-phrenic nerve paralysis, recurrent laryngeal nerve block
-Intravascular injection (vertebral arteries)
-Epidural or intrathecal injection
-Horner’s syndrome (miosis, ptosis, anhyidrosis)
May shunt blood away to well-perfused areas due to vasodilation of non-ischemci vasculature
Carotid endarterectomy: Monitors
Aline
If asleep: EEG, SSEP, cerebral oximeter
If sick cardiac patient, consider femoral central line, to avoid obstructing venous return from brain
Carotid endarterectomy: if asleep….for maintainance
Consider a remifentanil gtt for smooth wake up
Carotid endarterectomy:
Carotid sinus
vs Carotid Body
Carotid Sinus: regulates BP/HR…can see reflex brady 2/2 surgical manipulation
Carotid body: regulates respiration (response to hypoxia, hypercarbia)
Carotid Endarterectomy: EEG changes…
Ask surgeon to release clamp
Consider driving up MAP (not more than 20%)
Correct anemia, hypocarbia, etc
Carotid Endarterectomy, post-op complications
-Neck hematoma
-HD lability 2/2 carotid sinus manipulation
-Impaired ventilatory response 2/2 carotid body manipulation
-Cerebral hyperperfusion syndrome (vasculature has lost ability to autoregulate blood flow, increased blood flow following stenosis reveresal results in edema/bleeding)…txt: avoid HTN!
Can you use a temporary dilaysis catheter in a pinch for pressors/etc…
Yes
Aspirate before use, re-heparing the line after
What type of block for AV fistula?
Supraclav block (for distal humerus and beyond)
*Don’t forget to check CBC/coags before attempt block
Risks:
PTX
Phrenic nerve paralysis
When to give neosigmine, how many twitches
Ideally 4 twitches, but can after give after 2 twitches
Acromegaly, anesthesia considerations
Difficult mask, Difficult intubation
-Large tongue, tracheal stenosis
-Cardiomyopathy, HF
-OSA
PDPH, sign and symptoms
Positional headache (worse sitting up)
Photophobia
N/V
Etiology:
Loss of CSF, causes loss of bouyant support of the brain
SLE and seizure in pregnant woman
Is this embolic stroke? Eclampsia?
SLE is ofen associated with hypercoaguable state (both venous and arterial thrombosis)
Autonomic hyperreflexia…
What is it?
Management?
-Occurs with spinal cord lesions T7 and above
-Noxious stimuli results in sympathetic discharge (cannot be inhibited by higher CNS center) with hypertension and bradycardia
Management:
-Stop surgical stimulus, empty bladder
-Deepen sedation
-Antihypertensives
FHR monitoring
What is nl HR?
What is nl variability?
What is early decels?
-Nl HR: 120-160
-Nl variability: 6-25 bpm..less could be a sign of fetal distress/acidosis/hypxoia
-Early decels…decel coincides with uterine contraction…benign
Porphyria
What is it?
Why you care?
Txt?
-Accumulation of prophyrins 2/2 deficiency in heme synthesis pathway
-CP: abd pain, n/v
-Think: muscle weakness, respiratory failure
-Txt: fluids, oxygenate, hematin (inhibits porphyrin synthesis)
Common tocolytic
Terbutaline, Ritodrine…both Beta-2 agonists
Laryngectomy…
How to achieve airway prior to surgery?
What happens if trach comes out postop?
-Maybe AFOI (may be challening to achieve good airway topicalization…also, could injure vascular friable tumor)
-Otherwise, surgical airway under local anesthesia….
*
Try to reinsert with fiberoptic scope
Otherwise mask ventilate over stoma, place LMA through stoma
(Obvi can’t intubate or mask ventilate from above)
Dyspnea in a 2yo…ddx (4)
-Foreign body aspiration
-Asthma
-URI (croup, epiglottitis)
-Anaphylaxis
Foreign body aspiration, induction plan
Plan 1:
Inhaled induction…maintain spontaneous ventilation…ENT to place rigid bronchoscope (can ventilate through it)
(of course risk of laryngospasm/aspiration etc)
->would need TIVA for maintenance
Plan 2:
RSI…risk of pushing the foreign body distally, complicating retrieval…
Foreign body aspiration…now cannot ventilate during retrieval…WTD?
-Either quickly remove or push past carina
-Modify patient position
-V-V ECMO
Ischemic cardiomyopathy and pregnancy…vaginal delivery or C-section
Vaginal delivery whenever possible…less fluid shifts, blood loss, HD changes…with each uterine contraction, auto-tranfusion of 300-500cc of blood back into the circulation
When to favor C-section: aortic aneurysm, cerebral aneurysm, dissection
Ischemic cardiomyopathy and epidural…tell more
Gentle sympathectomy…slowly raise the level of epidural to T4…no epinephine (or ketamine)
Platelet cutoff for epidural
Per SOAP, >70k….with reassuring trend
Reversible causes of arrest…
5Hs:
-Hypoxia
-Hypovolemia
-Hyperkalemia/Hypokalemia
-Hacidosis
-Hypothermia
5Ts:
-Toxin
-Tension PTx
-Tamponade
-MI
-PE
Cardiac Arrest in OB patient..ddx
AFE, LAST
Stable monomorphic VT….med management
Adenosine, lidocaine, amio, mag
Newborn SOB, ddx
-Transient tachypnea of newborn (retain fluid, benign)
-Meconium Aspiration
-Respiratory Distress Syndrome (premie, immature lungs)
Other:
-Mag tox
-Acute uteroplacental deficiency
-Hypoglcyemia
-Undiagnosed congential anomaly
Patient has blurry vision, headache, rhinorrhea…ddx
Elevated ICP vs pituitary compression on the optic chiasm
Pituitary adenoma…meds
Bromocriptine/octreodtide for acromegaly->inhibits GH
Bromocripine for prolactinoma->inhibits prolactin
Diagnosis of Acromegaly
Serum IGF-1
Oral glucose load challenge
Trasphenoid Pituitary Approach: monitors
-Aline (in close proximity to the interal carotid artery…risk of massive hemorrhage)
-Consider VEPs (if optic nerve compression, need TIVA)
**
Anytime surgical field is elevated above level of the heart…VAE risk
Transphenoidal approach: unique anesthesia considerations
-No PPV (risk of pneumocephalus)…CSF leak especially increases risk
-No coughing/bucking
*
-TIVA wake up, lidocaine down the tube
-Surgeon can suture nasal trumpets to help with OSA
Treatment of VAE
-Flood the field with saline
-Lower surgical field to level of the heart
-Maybe left lateral decubitus position
Treatment of LAST
-20% Lipid emulsion (1.5cc/kg bolus, followed by infusion)…if CV instability persists, re-bolus and double infusion
-Benzos for seizure
-Lower dose epi (1mcg/kg to start)
Transphenoidal Pituitary Surgery…unique post-op considerations
Refractory hypotension->2/2 decreased ACTH and cortisol
Diabetes insipidus->2/2 decreased ADH…treatment DDAVP
JW what are they ok with…
Many are ok with derivatives…
Albumin
Factor concentrate (K centra)
Intraop cell saver
DDAVP, TXA
Prolonged motor/sensory loss after epidural…
If beyond 24hrs,
unlikely to be anesthesia related…more likely obstetric in origin (positioning, nerve compression as the baby is delivered)
Alternative to epidural anesthesia
-PCA: fentanyl, dilaudid, remifenantil
-Nitrous oxide
-Paracervical block in 1st stage (high risk for fetal bradycardia)
-Pudendal block in 2nd stage (pushing)
Where can you place IO
Proximal tibia
Proximal humerus
What is TRALI?
How to manage?
-Pulmonary edema developing within 1-6 hrs following blood transfusion (2/2 FFP, platelets
-Donor abs activaite recipient lung neutrophils, causing lung injury
How to manage?
-Notify blood bank: no more blood from that donor
-Supportive
STOP-BANG
-Snoring
-Tired
-Observed apnea
-Blood pressure
**
-BMI
-Age
-Neck circumference
-Gender
Obesity: FRC and closing capacity
-Decreased FRC (hence, rapid desaturation with apnea)
-Increased closing capacity (hence, more atelectasis/shunting)
–
Consider inducing with reverse trendelenburg to improve respiratory mechanics
> 4 METS
-can climb a flight of stairs
-can walk on level ground at 4mph
Propofol vs rocuronium (TBW vs IBW)
-Prop: induce per IBW, maintain per TBW
-Rocuronium: per TBW, maintain per TBW
C-spine clearance
May need CT (first-line) and possibly MRI….MRI is more sensitive at detecting ligamentous injury
FAST EXAM…looking for
-Tamponade
-Morrison pouch (liver-kidney)
-Perisplenic bleeding (Spleen and diaphgram)
-Suprapubic bleeding
Abdominal compartment syndrome physiology
Decreases preload, lung compliance
Increase afterload (pressures are transmitted across the diaphgram)
*
Hence, with laparotomy, don’t be surprised by marked reduction in afterload
Why is ok to give Rh+ blood to a man (who has not received a prior transfusion) rather than woman…
The risk of Rh sensitization in a man (eg delayed transfuion rxn) is much less than in a child-bearing female (hemolytic disease of the newborn, stillbirth)
Do platelets and FFP have to be ABO compatible?
Yes, suspend in plasma, will have anti-A and anti-B abs
Hypocalcemia, (citrate-tox), EKG
Look for prolonged QT on EKG
PRIS (propofol-related infusion syndrome)
A life-thretening complication associated with rhabdo, cardiac collapse, death
Carcinoid Syndrome
*diagnosis
*s/s
S/s: flushing, diarrhea, bronchospasm, hypotension
Diagnosis: Urine 5-HIAA, a serotonin metabolite
Tumor mostly releases serotonin, but also histamine
Triggers of carcinoid crisis
-Hypovolemia, hypoxia
-Tumor manipulation
-Succinylcholine (possible histamine release)
-Adrenergic agents (epipnephrine, ephdrine)
*favor phenyl, vasopressin
Treatment of carcinoid crisis:
-Ocreotide bolus, followed by infusion
-Bendaryl (H1 block) 25-50mg IV
-Fluid
Carcinoid syndrome: most common heart lesion
-Tricuspid regrugitation
(pulmonary circulation degrade serotonin, left heart is relatively protected)
Preop optimization for carcinoid syndrome
-Octreotide 2 days prior to surgery and continue a week out
-Fluids
-Albuterol nebulizer
-Minimize pain and anxiety
Carcinoid crisis vs anaphylaxis
May present similarly…hypotension/bronchospasm
Who care? Epinephrine would worsen carcinoid crisis
Nitrous oxide and bowel surgery
Avoid…will increase bowel distension (ischemia/perforation/n/v), could complicate closure
Osteogenesis Imperfecta..workup
-Cervical spine imaging…or just assume instability
-TTE to r/o cardiac abrnoamlities
*
A collagen defect…results in brittle bones, teeth, blue sclerae
*
Consider intubating awake to minimize trauma vs RSI
*
Epidural placement is laboring woman is more high-risk
Pyloric stenosis: electrolyte abnormalities
-Nonbilious projectile vomiting
-Hypochloremic, hypokalemic, hyponatremia metabolic alkalosis
Preop management for Pyloric Stenosis
*When to proceed with surgery?
Fluid resuscitate with NS until euvolemic
Have dextrose-containing fluid running in the background for maintenance (also replete lytes)
*
This is a med emergency, not surgical one
Why NS? LR has lactate-can be converted to bicarbonate
When to proceed with surgery?
Appears euvolemic, pH 7.3-7.5, Bicarb <30
Induction plan for Pyloric Stenosis
-RSI vs AFOI
-Must suction out stomach with baby in multiple positions
Pyloric Stenosis Post-Op Conerns
-Postop apnea (possibly 2/2 persistent CSF alkalosis)
*newborns <60 weeks postconceptual age are at increased risk of postop anea
Management of post-extubation stridor
-Steroids
-Humidified air
-Racemic epinephrine
Circle Anesthetic System (what we use)
Advantage: preserves humidity, heat, volatile anesthetic…less dead space
Disadvtange: can rebreathe CO2 if failure of CO2 absorbent system
Multiple Sclerosis: epidural and spinal
-Epidural and spinal should be ok…possibly slightly increased risk of MS flare with spinal
*
Def no succinylcholine
Multiple Sclerosis Flares
Less common in pregnancy
Elevated risk post-partum, also post-op
SEVERE AS…diagnosis
-Valve area under 1.0, transvalvular gradient >40 (subject to LV fxn, hemodynamics)
Severe AS and OB
-Epidural is fine…slowly raise the level…
*no epinephrine or ketamine (don’t want tachycardia)
-Def no spinal (would not tolerate rapid drop in afterload/preload)
Epidural and therapeutic enoxaparin (LWMH), also prophylactic enoxaparin
-Must wait 24hrs (12 hrs for prophlactic)
-What about therapeutic heparin…also need to wait 24hrs (12 hrs for prophlactic)
*Def check platelets
*No can’t try to reverse
*Many OBs switch from enoxaprin to heparin at 36 weeks…supposedly shorter half-life
STAT C section in AS
-General is best bet
-Unlikely to be able to safely raise level with epidural in time
-Etomidate, high-dose fent, roc…phenylephrine…pads on patient
*
High-dose fent may affect baby…try to dose fent/benzos after baby comes out
*
Avoid methergine…would increase myocardial oxygen demand
Boggy uterus txt
-Manual massage
-Uterotonic (oxytocin, misoprostol, methergine, hemabate)
-Uterine balloon
-Emergent hysterectom
-Uterine artery embolization
Shoulder surgery, beach chair position, monitors
-A line, transducer zeroed at the tragus
*Obvi BP cuff on arm will overestimate BP to the brain
-Get TTE to rule out PFO…risk of paradoxical air embolus
Shoulder, beach chair position, physiology
Decreased venous return, preload…increases risk of ischemia to brain
Ok to quit smoking a day before surgery…?
-Ideally should quick 6-8 weeks beforehand
-But quitting even just before has some benefits, including decreasing CO levels in the blood, improving mucus clearance
Severe COPD and supraclav/interscale block?
Think twice! All associated with phrenic nerve paralysis
What is the Bezold-Jarish reflex?
A reflex characterized by bradycardia and hypotension 2/2 stimulation of cardiac receptors…
may explain CV collapse after spinal
Corneal abrasion…TXT
TXT: saline eye drops, abx ointment
Confirm diagnosis: blink eyes, sxs should be worse
What shifts oxyhemoglobin dissociation curve left?
-Carbon monoxide
-Methemoglobinemia
-Fetal Hemoglobin
Methemoglobinemia:
how does it cause cyanosis
how to diagnosis
how to treat
1-shift oxyhemoglobin dissociation curve left, methemoglobin does not bind O2
2-not pulse ox, but blood gas, co-oximeter
3-methylene blue…if G6PD, ascorbic acid
G6PD deficiency, anesthesia considerations
Enzyme deficiency rendering RBCs more susceptible to hemolysis
-Avoid certain meds, abx
-Avoid hypoxia, hypercarbia, acidosis, etc
Preeclampsia diagnosis
@20 weeks
140/90 +proteinuria or signs of end/organ damage
prior to 20 weeks…chronic HTN
after 20 weeks…gestational HTN
Preeclampsia physiology
-Hypovolemia
-Increased SVR
-Decrease uteroplacental perfusion…baby could come out more floppy
TTM post-cardiac arrest
Who?
How long?
Comatose patient
Avoid fever
24-72 hrs
PA catheter contraindications
Absolute:
Right-sided endocarditis
Relative:
Coagulopathy
Severe TR
LBBB
Pharmacalogic Stress Test
Adenosine is first-line….dilates coronary vessels, unmasking stenotic vessels
Diabetic: hypotension after induction…surprised?
Nah…c/w autonomic neuropathy
How to prevent contrast nephropathy?
Fluid load before
Pacemaker settings:
VV-DDDR
-Ventricular shock
-Ventricular anti-tachycardia pacing
*
AV paced
AV sensed
V-lead response to atrial sensing
Rate responsive per patient physical activity
Patient has a PPM…what to ask?
-Are they pacer depedent? ->switch to asynchronous mode
-Response to magnet?
Pacemaker management
Below umbiliculus->leave pace maker
*otherwise
Favor bipolar cautery
Place grounding pad appropriately
when surgery is done, must reprogram…otherwise, leave pads on
Rupture globe surgery…deep extubate?
-Think twice: full stomach precautions
-Can do TIVA wake up
*Remember: no succinylcholine
ACLS meds: pVT/VF
-Epi
-Amio 300/lidocaine 1.5mg/kg
-Amio 150/lidocaine 0.75mg/kg
Epi dosing for bradycardia
2-10mcg/min gtt
*for bronchospasm, would do 4mcg pushes at time
Neonatal Resuscitation
Step 1: warm, dry, stimulate
.
Step 2: suction, supplemental O2 per preductal saturation (start low and go high)
Still struggling…(HR<100, apenic, or gasping)
Step 3: PPV
If after 30 seconds, HR< 60
Step 4:
-Chest compressions (3:1, 120bpm)
-Intubate
-Venous access (umbilical vein vs proximal tibia IO)
If after 60 seconds of chest compression, HR<60
Step 5:
-GIve epi 0.01mg/kg (IV or down ETT)
*
Other considerations:
Mag tox->calcium
Hypoglycemia->glucose
Narcosis->Naloxone
Rule out PTX, hypovolemia
Where to place pulse ox? RUE (preductal)…make take 1-2 minutes for an accurate reading
Epiglottis..airway management
-Transfer to OR
-Difficult airway equipment
-In sitting position: Inhalation induction vs ketamine, maintain spontaneous ventilation, avoid paralysis,
-Slowly lower supine, gentle laryngoscopy
-Surgical airway vs perc transtracheal jet ventilation
**
Try to avoid upsetting the child and worsening distress
Epiglottitis…when to extubate
-After at least 24hrs of abx (H influenzae type B)
-Extubate in OR
-Airway exam before, cuff leak
Hyperthyroidism…which labs to send
TSH
Free T4 and Free T3
T3 is the active form
Hyperthyroidism in emergent surgery
Block thyroid hormone synthesis:
-Methimazole/propylthiouracil
Block peripheral conversion:
-Steroids
-Beta blocker
*propylthiouracil is safer in pregnancy
*no role for iodine, except in thyoird storm
MRI
-Thermal injury
-Dislogement/malfxn of implantable devices (PPM, spinal cord stimulator)
-Projectile injury from magnetic objects
-Limited access to airway
When to hold TFs for anesthesia…
Varies by hospital policy…
-If intubated, I would continue
-Otherwise, could hold for 6hrs…or attempt RSI
TPN indications
Bowel rest/bowel obstruction
TPN complications
-Cholecystitis
-Pancreatitis
-Ifxn
-Endopthalmitis
*
Can also increase CO2 production…consider increasing lipid component to TPN
TPN and difficulty weaning from the vent…
-Hypophosphatemia (refeeding syndrome)
-Increased CO2 production
Who needs stress dose steroids?
Prednisone 5mg/day for more than 3 weeks
Cervical spine bone 1 and bone 2
C1: Atlas (holds up the head)
C2: Axial bone
Rheumatoid Arthritis considerations
-Cervical spine instability
-TMJ dysfxn (limited mouth opening)
*
-Stress-dose steroids
*
Sjogren syndrome->dry eyes->corneal abrasion
Stellate Ganglion block…what is it? risks?
Stellate ganglion is a sympathetic ganglion in the neck, block may help with complex pain
Side effects:
-Nerve palsy
-Intravascular injection
-Epidural/Spinal injection
-Horner Syndrome
-Parasympathetic s/s
Stellate Ganglion Block SOB ddx
-Nerve palsy (phrenic nerve, recurrent laryngeal nerve)
-LAST
-Epidural/spinal injection
LAST sxs
1: metallic taste, ringing in ears, perioral numbness
2: CNS tox (seizures)
3: Cardiac tox
Treatment of LAST
-20% Lipid emulsion (1.5cc/kg bolus, followed by infusion)…if CV instability persists, re-bolus and double infusion
-Benzos for seizure
-Lower dose epi (1mcg/kg to start)
*
Patient should be monitored for at least 12 hrs following LAST becuase local anesthetic will continue redistributing from tissue depots, resulting in recurrence
What factors affect absorption of local anesthetic?
-Blood flow to site of injection (IV > Tracheal > Intercostal)
-Addition of epinephrine (vasoconstriction inhibits systemic absoprtion)
How to avoid LAST?
-Aspirate
-Inject a little at a time
-Stay under max recommended dosing
-Epi to minimize systemic absorption, also surveil for systemic absorption
-Awake patient
Most cardiotox local anesthetic
Bupivicaine…the cardiotox dose is only 3 times higher than the CNS tox dose
Centrifugal vs roller pump
Centrifugal:
-less damage to RBCs
-sensitive to preload and afterload
-will not entrain a significant amount of air
Alpha vs pH-stat
Alkaline drift 2/2 hypothermia…
pH stat: add CO2, to protect ped brain
Alpha stat: let it ride
Why vigorously inflate lung when coming off bypass
-Reverse atelectasis
-Shunt air into the left heart, where it can be more easily deaired…
Why can’t we come off bypass
-Graft down
-Valvulopathy
-Preload issue/bleeding
-Vasoplegia
-Heart dysfxn
-Malignant arrhythmia
-Electrolyte abnormalities
Why does radial a-line poorly correlate with central aortic pressure coming off bypass…
Peripheral vasodilation while rewarming
Cardiac Tamponade…ECHO Findings
RV diastolic collapse
Pulsus paradoxus (>10 point drop in systolic pressure with inspiration)
Equalization of diastolic pressures
ESLD vs DIC
Factor 8….
Thyroidectomy: concerns
-Difficult airway management
-?Hyperthyroid
Sick Euthyroid
Nl TSH, low T3 and T4
Thyroidectomy: Airway management
-ETT with nerve monitoring capability (to monitor recurrent laryngeal nerve…requires TIVA
-Reinforced ETT (so can paay beyond point of compression)
-Rigid bronchoscope as back up
==
AFOI->if they refuse, consider inhalation induction (maintain spontaneous breathing)
Capability for surgical airway
Thyroidectomy: How to maintain anesthesia
Do they need to be wide awake?
-Consider TIVA for smooth wake up, to avoid coughing and bucking, also for recurrent laryngeal nerve monitoring
-Yes, extubate awake, high risk for airway complications including stridor, obstruction, laryngospasm
New stridor in the PACU, s/p thyroidectomy
-Is this 2/2 inadvertent removal of PTH glands, causing hypocalcemia…txt with calcium, airway support
ALso on ddx:
-Edema (steroid, racemic epinpehrine)
-Upper airway obstruction
-Recurrent laryngeal injury (**MUST BE B/L injury)
-Hematoma
What is Chvosek’s sign?
-Facial nerve excitability 2/2 hypocalcemia
TURP (transurethral resection of the prostate)…anesthesia plan
-Regional or general is fine…
Advantage of regional:
Awake patient…allow 1) early detection of TURP syndrome->AMS 2) bladder perforation
TURP syndrome
What is the ideal irrigation solution?
AMS developing after systemic absorption of hypotonic irrigation syndrome
Distilled water->Hyponatremia
Glycine-> hyperammonia (vision changes)
Sorbitol->Hyperglycemia
The ideal irrigation solutions is electrically inert and isotonic
TURP and spinal…what level/what anesthetic
-Hyperbaric bupi
-T10 level (do not want to mask bladder perforation)
Succinylcholine…Phase I vs Phase II
Phase I: no fade (no difference in twitch amplitude)
Phase 2: yes, fade
GCS
Eyes, verbal, motor
-Decerebrate is worse
Trauma: periorbital ecchymosis and hemotympanum
Basilar skull fxr
ICP crisis numbres
ICP>20
CPP>60
*
Hypertonic saline <160
Mannitol Serum Osm<320
PaCO2 30
NSG: hyponatremia…urine sodium is high, ddx
Cerebral salt wasting
SIADH (euvolemic)
What is HELLP?
A variant of preeclampsia…RUQ pain is suggestive
Txt:
Mag for seizure ppx
BP management
OB and mag indications
-Preeclamptic/HELLP moms
-Preterm babies for neuroprotection (24-32 week gestational age)
Spinal/epidural for OB is not working…WTD
-Redose
-Reposition the patient
-Replace catheter
-General anesthesia
Mom has delivered, baby needs help…WTD
Mom is my primary patient
Will only help if she is stable
They should wheel the baby over to me
How do uterotonics work?
They increase intracellular calcium in uterine smooth muscle cells…causing contraction
Eclamptic seizure..txt
Mag bolus, midaz, low threshold to intubate
Cardiac ablation: anesthesia plan
MAC or GA…GA if this is a complex case, higher risk for complications
Cardiac ablation complications
-Arrythmia, atrial perforation, cardiac rupture, heart block
-Stroke
Stroke workup
ECHO
Holter monitor
Carotid doppler study
Syncope workup
Brain imaging (?stroke)
Holter monitor
ECHO (?AS)
Rheumatic heart disease, which valves
Mitral #1, Aortic #2…can cause stenosis or regurg
PA catheter in mitral stenosis
Would overestimate LVEDP
Antiemetics MOA
Zofran (serotonin antagonist)
Reglan (dopamine antagonist)
Aprepitant (neurokinin antagonist)
When to delay an elective case for hyperK?
K+ 5.5, although ideally under 5
Reason to avoid regional anesthesia for boards…
I think it would be hard to achieve a high enough surgical block without compromise respiratory function…would be better to have a secure airway in the event of a complication
Kidney transplant: monitors
A-line
Central line (for pressor, immunosuppressants, volume monitoring)
Pulse pressure variation cutoff for fluid responsiveness
> 12%
Fluid managment for kidney transplant
What fluid?
Usually 2-3L
Maintain euvolemia, keep kidney perfused
Consider volume loading during (iliac vein) clamp placement…for when clamp is released
Isotonic fluid is fine….maybe avoid NS since large volumes can result in acidosis and hyperK
Kidney transplant, what meds prior to iliac vein clamping
-Lasix/mannitol to increase renal blood flow
-Heparin to prevent clotting
PACU patient in respiratory distress, would you immediately intubate?
If I was concerned for imminent airway collapse
Uremic coagulopathy…
Txt?
Cause platelet dysfxn by decreasing amount of vWF
txt: platelet
Also, FFP, cryo, DDAVP (to increase vWF)
Ascites in liver disease, pathophys
HRS pathophys
2/2 portal HTN and activation of RAAS
*
2/2 renal vasoconstriction
Txt: volume loading, raise BP (midodrine)
*
Cirrhosis hemodynamics
Splanchnic vasodilation->decreased SVR->increased CO
(Hyperdynamic circulatory state)
Liver TXP…why V-V bypass
To maintain preload when completely clamping the IVC, shunts blood from the IVC to UE veins
Thanks to piggy-back technique, where this only partial occlusion of the IVC, preload is maintained
Liver txp: 3 stages
Preanhepatic (removing old liver)
Anhepatic (no liver->working on vascular anastamoses)
Reperfusion (portal vein is opened)
What is reperfusion syndrome? Liver txp
How to prevent?
The introduction of cold, hyperkalemic blood and vasoactive substances into the systemic circulation causes hypotension, arrhythmias, pulm HTN
Treat hyperkalemia, hypocalcemia, acidosis prior
What happens when bypass is initiated?
1-Heparin is administered
2-Arterial cannula placed in ascending aorta
3-Venous cannula in RA
4-Initiate blood flow
5-Aortic cross-clamp, then give cardioplegia
6-Discontinue ventilation
Nl dig level…
0.5-2.0
DIGIFab, not dialyzable
Why does the patient’s BP drop with initiation of bypass…
The dilute priming solution drops the SVR…however, always must wonder about positioning of the venous and arterial cannula
How to wean off bypass?
-Rewarm the patient (give midaz)
-Correct anemia
-Correct electrolyte derangement, give mag and calcium
-TEE to guide preload, afterload, inotropy
-Reinitiate lung ventilation
-Pacer and pads for chronotropy, arrhythmia
4Ts of Anerior Mediastinal Mass
-Teratoma
-Thymoma->myasthenia gravis (30-65% of patients)
-Thyroid
-Terrible lymphoma
Down Syndrome Considerations
Airway: Cervical instability, macroglossia, subglottic stenosis
Cardiac: Defects
*Down syndrome kids should be screened at age 3-5 for cervical spine film
How to evaluate for cervical instability?
-Review airway history
-Review imaging
-Any exremity numbness/tingling/weakness with neck mvmt->if concerned and can delay, get NSG consult
Anteior mediastinal mass: H&P
-Reviewing imaging, to determine airway compression, level of compression
-Compression of heart or great vessels
Thus, can cause airway and circulatory collapse
*
-Reviewing CT imaging, any recent fiberoptic exam findings
-ECHO in supine and upright position
Anterior Mediastinal Mass: Airway Equipment
-Armored ETT (to get back obstruction…multiple sizes, lenghts
-RIgid bronchoscope
-Surgeon with sternal saw for emergent sternotomy
-Line for V-A ECMO
Anterior Mediastinal Mass: How to approach airway
-Awake fiberoptic, that way can assess level of compression, get tube distal (may even have to advance to patent bronchus)
-If they refuse, ketamine or inhalation induction
Anterior Mediastinal Mass: Airway Attempted, running into issues…ddx
Apnea
Laryngospasm
Bronchospasm
Mass Compression
*
If apnea->try to expeditious place ETT
If laryngospasm->try to break with jaw thrust, PPV, avoid paralyzing
If mass compression->try to advance tube past obstruction, prone patient, emergent sternotomy to elevate mass, initiate ECMO
Would you extubate anterior mediastinal mass airway?
Nah, would want them to recover in ICU, would want airway hyperactivty from recent manipulation, also edema to subside
Interscalene block
Complications
Coverage: shoulder…if need forearm (block ulnar nerve separately)
Complications:
Phrenic paralysis 100% time
Intrasvascular injection
Epidural/spinal anesthesia
Horners syndrome
*Just like stellate ganglion block
5 Causes of RTL in 1st year of life
1-Persistent truncus arteriosus (pulmonary trunk and aorta fail to divide)
2-Transposition of the great vessels (Aorta off RV, PA off LV)
3-Tricuspid Atresia
4-Tetralogy of Fallot (RV hypertrophy, pulmonary stenosis, overriding aorta, VSD)
5-Total anomalous pulmonary venous return (pulmonary vein drains into right heart)
RTL shunting (inhalational vs IV induction)
Inhalational: slowed
IV: Hastened
Inhalational decreases SVR, not a good idea for RTL shunt
Tet spell, physiology
-Increased RV outflow obstruction
-Decreased SVR
*
Txt:
-increase SVR (knees to chest)
-esmolol to decrease inotropy (relieve RV outflow obstruction)
Axillary Nerve Block
Indications
Complications
Covers: distal humerus and beyond (like supraclav, infraclav)
Complication: very safe
What nerve is often missed? Musculocutaneous nerve
Cirrhosis…paralysis plan?
Cisatracurium
Undergoes hoffman degradation in the plasma, independent of kidney and liver
Extracorporeal Shock Wave Lithotripsy: anesthesia plan, considerations for PPM/ICD
Any anesthesia (MAC, GA, regional)
If ICD, turn off, put pads on, PPM put in asyncrhonous mode
*
Pregnancy is a contraindication
Liposuction…anesthesia plan, risks, dosing
Tumescent technique…inject large amount of lidocaine and epinephrine into fat
Max dose lidocaine: 55mg/kg…(fat is poorly vascularized, much of it is absorbed with the procedure)
Complications: LAST (usually 14-16 hrs after procedure), volume overload
Child declines blood products…
-I am ethically bound to provide life-saving care, does not have capacity
-I am ethically bound to take the child’s considerations into account, if surgery is elective, could defer until she is an adult and make her own decisions
Retrobulbar block: (unique) complications
Local anesthetic spread to the CNS->apnea/unconscious
SCD
Sickle cell crisis…txt
Goal HCT for big surgery…
-Consider exchange transfusion
-Goal HCT ~30
HOCM and epidural…plan
Hydrate first
Gentle sympathectomy
No epi or ketamine
*
Benefit of epidural: avoids pain, tachycardia
*
Avoid methergine: increase myocardinal oxygen demand
HOCM, hemodyanmic goals
LV hypertrophy, dynamic LVOT, and SAM
-Maintain preload
-Maintain afterload
-Avoid tachycardia
-Avoid inotropy
HOCM, pulm edema after delivery
2/2 abrupt autotransfusion of blood into the systemic circulation in the setting of diastolic dysfxn
1.
Conscious sedation
Sedation where the patient is still arousable, no airway manipulation is happening
-
Always need to have backup airway equipment available, under the supervision of someone who can convert to GA
Standard ASA monitors
-EKG
-Pulse
-BP cuff
-EtCO2 monitor
-Temp probe
Status Asthmaticus txt
-Steroids (methylprednisolone)
-Nebulizing treatment
-Mag/epinephrine infusion
Celiac plexus block
Complications
A bundle of nerve innervating the visceral organs
Bleeding, infxn, nerve injury, IV injection, paralysis, parasympathetic s/s
Txt of COPD exacerbation
-Steroids
-Abx
-Scheduled nebulizing treatment
-Vent management (low RR, increase time in expiration, 6-8cc/kg TVs)….if overbreathing the vent, sedate
**
Trouble of auto-PEEP
-decreases venous return
-increased PVR
-PTX
-Makes it harder for the patient to trigger the vent
Pediatric CPR
Big differences:
-Less depth to compressions
-Less energy for shocks
-epi dose 0.01mg/kg
Same:
Compression rate (100-120)
Stable narrow complex SVT…txt
-Vagal maneuver
-Adenosine
Anesthesia machine: how do you do a machine check
-Check monitors
-Calibrate CO2 and O2-analyzers
-Check for leaks in the high and low-pressure system
-Confirm adequate CO2 absorbent
How do you check for leaks in the low-pressure system?
-Postive pressure leak test
How to avoid delivering a hypoxic mixture?
-Alarms
-O2 analyzer
-The machine should shut off flow of other gases if O2 pressure drops too low
Sevoflurane vs Desflurane vaproizer
Sevoflurane is a variable-bypass vaporizer… a variable amount of fresh gas flow mixes with the volatile agent
Desflurane is a gas-vapor blender
Main cause of PPH
Uterine atony
4 causes of bleeding in OB women
-Tone (Uterine atony)
-Tissue (retained placenta)
-Thrombosis (DIC)
-Tear (surgical)
CF complications in newborn
Pulmonary and GI sxs…meconium ileus may be the first sign
Contraindicatons to epidural placement
-Coagulopathy
-Severe hypovolemia
-Increased ICP
**
HD changes of pregnancy
Increased cardiac output (from increase circulating volume), Decreased SVR
Open aortic dissection surgery: how many A-lines
2: RUE radial, femoral ( to monitor MAP below the clamp)
Aortic dissection, you are trying to lower the pressure above the clamp, but the pressure below the clamp is already low..wdyd
Ask the surgeon: to reimplant arteries to important organs, place shunt
CABG, starting dose of heparin
300units/kg
Goal ACT>400
CABG, BP is low on bypass
-Increase CO->can perfusionist increased pump flow rate
-Phenylephrine gtt
How to protect the spinal cord during aortic clamping?
-Maintain MAP >50
-Drain CSF
-Reimplant arteries, shunt
-Hypothermia
Anesthesia plan for pericardial window…
-Only local
-Otherwise, ketamine to maintain spotaneous ventilation, only paralyze after effusion is drained
Cooractation of aorta in pregnancy…risks
-Risk of aortic dissection with swings in BP
Newborn vs Adult Airway
-Large tongue
-Omega shaped epiglottis
-More cephald larynx (C3-C4, vs C6 in adult)
-Angled vocal cords
Size of ETT in newborn
Premie: 2.5
Newborn: 3
General rule: 1/4 age+ 4
Newborns and apnea
High risk for apnea until 60 weeks postconceptual age
ECMO risks
-Coagulopathy (bleeding/hemorrhage)
-Cannula dislodgement
-Sepsis
Neonates and hypoglycemia
They have limited glycogen stores…hence, always should have maintenance running at D51/2 NS
Premature neonate concerns
N: IVH, retinopathy of prematurity
C: Defects
P: Hypoplasia, pulm HTN
GI: necrotizing enterocolitis
Endo: Hypoglycemia
MSK: temperature
King-Denbourough Syndrome
Rare congenital myopathy
Patients are susceptible to MH
MH and nitrous
Yes, nitrous is fine
Treacher Collins syndrome/Pierre Robin syndrome
Difficult airway 2/2 mandibular hypoplasia
Beckwith-Wiedemann Syndrome
Omphalocele + large tonuge
Why are newborns prone to hypothermia
-High surface area to volume ratio
-Limited subcutaneous fat
**
Fontan/single ventricle physiology
Cardiac output is dependent on preload/PVR
*Avoid PPV
How to preoxygenate
-8 deep breaths over 1 minutes
-3 minutes of TV breathing
-ETO2 80-90%
vWF and epidural placement
-vWF and Factor 8 level should be 80%
-If needed, give DDAVP or replacement
*
If Type 1 and no signs of abnormal bleeding, don’t have to check a level necessarily
Local anesthetic allergy…
Esters 2/2 PABA metabolite
Is cardiac workup indicated…?
Poor exercise tolerance + high risk surgery
Hyperoxia complications
-Absorption atelectasis
-Inhibits hypoxic pulmonary vasoconstriction
-Free radical generation
Hemophilia A txt
-Factor 8 concetnrate
-FFP
-Cryo
TEG
Prolonged R->give FFP
Prolonged K/decreased alpha angle->give cryoprecipitate
Short MA->give platelets
Rapid loss of amplitude->give TXA
Caudal Anesthesia
-The lowest portion of the epidural space
-Passes through the sacrococcygeal ligament
Midline epidural placement
Skin->Supraspinous ligament->interspinous ligament->Ligamentum flavum…
Epidural space is between ligamentum flavum and dura mater
vs paramedian approach:
skin->muscle->ligamentum flavum
Where does the spinal cord terminate
Adults: L1-L2
Kids: L3-L4
Asymmetric epidural level
-Confirm epidural is in place
-Reposition the patient
-Give volume to raise level
-Pull catheter back, replace catheter
**
For spinal: use hyperbarci bupivicaine
Why neuraxial morphine?
Morphine is hydrophilic…sticks around, hence good for post-op pain
(tho slow onset)
Opioid speed of onset
-Lipid soluble
-Uninonized
Alfentanil is lipid soluble and unionized->hence, rapid onset
Tramadol
SNRI + partial opioid agonist
NPO guidelines
2hrs-clear liquid
4hrs-breast milk
6hrs-light meal, including milk
8hr-full meal
Peds volume resucitation
20cc/kg…maybe 10cc/kg for card patients
Caudal Anesthesia
->single-shot…for intraop as adjunct, and post-op
->might make sense to do just after induction to help with intraop pain management, may have to redose after 4hrs
->landmarks: find sacral hiatus (between 2 sacral cornu), go through sacrococcygeal ligament…
…confirm LE mvmt and urination before discharge
IM darting
IM midaz: 0.1mg/kg
IM precedex dosing: 2mcg/kg
IM Ketamine: 5mg/kg
ST changes during OR…what drug to give?
Nitroglycerin…coronary vasodilator
DIC vs dilutional coaguloapthy…
HYPERFIBRINOLYSIS…give TXA
ISCHEMIA to hand
-Elevate the hand
-Topical nitroglycerin
-Stellate ganglion block
PaCO2-EtCO2 gradient…
2/2 dead space ventilation
LINE-ISOLATION
MACRO-SHOCK
Faulty equipment vs too many pieces plugged in
For epidural steroid
Use non-particulate steroid, like dexamethasone
