Other Flashcards
FeNa
FeNa < 1% = pre-renal pathology
- hypovolemia
- hypotension
- renal artery stenosis/injury
FeNa > 1% = intrarenal pathology
- ATN
- AIN
- Glomerulonephritis
- Rhabdomyolysis
LAST
- Stop injection of local anesthetic and call for help
- Manage ABCs - Bag mask ventilation or intubation
- Administer propofol or benzos to stop seizure
- Treat hemodynamic instabilities with vasopressor/inotropic support (down dose epinephrine)
- Administer 1.5 mL/kg 20% lipid emulsion followed by infusion
- Prepare for CPB if needed
Extracorporeal Shock Wave Lithotripsy
Vaporization of water by energy sources generates a pressure wave which travels easily through tissue and water. Once it reaches something of a different density (stone) compressive energy released and destroys stone
Minimal damage if shock wave travelling through water/tissue but if it hits an air/tissue interface it can cause tissue damage
OK to use with AICDs/PMs
- small risk of shock wave induced arrythmias
- small risk it can damage the generator but not usually when they are located in the chest
CRPS
Type 1: unknown injury or minor limb injury - pain does not follow a dermatomal distribution pattern
Type 2: pain after known or major peripheral nerve injury. May or may not have dermatomal distribution
Central - wide dynamic range neuron changes in the dorsal horn
Dx: myriad of sensory, vasomotor, sudomotor/edema, motor/trophic symptoms contribute to diagnosis
CRPS Treatment
Physical therapy/occupational therapy
NSAIDS
Opioids - early disease
Steroids (early)
SSRIs, TCAs
AEDs: Gabapentin, Carbamazepine
Clonidine
Ketamine
Sympathetic Blocks: stellate ganglion, lumbar sympathetic block, celiac plexus blocks
TENS
Spinal cord stimulator
intrathecal drug pumps
Malignant Hyperthermia Symptoms
Early Sx: Tachycardia, increased CO2, tachypnea, mixed acidosis, masseter muscle spasm
Late Sx: Hyperthermia, muscle rigidity, myoglobinuria, arrythmias/cardiac arrest
Malignant Hyperthermia Treatment
Call for help, get MH cart
Discontinue triggering agents - volatiles, succinylcholine
Increase FGF to 10 L/min at 100% FiO2
Increase Minute ventilation
Administer Ryanodex (2.5mg/kg) rapidly, can repeat up to 10 mg/kg
Treat acidosis with bicarb
Cool patient
Treat hyperkalemia
Avoid calcium channel blockers
Labs: ABG, lactate, Chemistry, CK, urine myoglobin coags
Malignant Hyperthermia Susceptibility
AD form - inherited familial disease
Muliminicore Disease
King Denborough Disease
Central Core Disease
Other myopathies can have MH-like reactions
Anaphylaxis
Call for help and discontinue offending agent
Increase FiO2 to 100%
Turn off anesthetics worsening hypotension
Epinephrine - 10-100 mcg/dose
Start epinephrine +/- vaso/norep infusion
Albuterol
Secondary:
Antihistamine, steroids (hydrocortisone)
Local Anesthetic Systemic Toxicity
Call for help, discontinue LA use
Support airway, breathing, circulation as necessary
Treat seizures with benzos
Call for intralipid - 1.5 cc/kg bolus x 3 + infusion 0.25 cc/kg/min
Reduce dose of epinephrine
Buprenorphine
Partial mu agonist/kappa antagonist properties
Start after ‘washout’ - can illicit withdrawal if patients are physically dependent.
Suboxone
Combination of buprenorphine and naloxone - taken sublingual and very little naloxone is absorbed
Discourages misuse because if crushed/injected - naloxone precipitates withdrawal
Naltrexone
Opioid antagonist - treats alcohol and opioid use d/o
reduces cravings, no abuse potential
Wait until off opioids 7-10 days
Ketamine MOA
Dexmedetomidine MOA
Propofol MOA
NMDA Antagonist
a2 receptor agonist
GABA agonist
Sickle Cell Disease
Chromosome 6 - beta globin gene - glutamic acid instead of valine
Hypoxia, acidosis, stress –> RBC sickling –> VOD
Associated Comorbidities - CVA, chronic pulmonary disease (acute chest), cardiomyopathy, chronic kidney disease, pHTN, femoral head necrosis, chronic pain
Mod/severe risk surgery - optimize by simple transfusion or exchange - goal Hct ~ 30
Agressive pulmonary toilet, early mobility, early/effective analgesia, supplemental O2
Porphyria
Enzyme deficiency in heme pathway –> accumulation of porphyrins
Drugs to Avoid: Ketorolac, Etomidate, Nifedipine, Methohexitol, Thiopental
Abdominal pain, nausea, autonomic instability, electrolyte changes
Tx: hematin - suppresses the heme pathway
Methemoglobinemia
Path: Hemoglobin oxidized into methemoglobin which doesn’t release O2
Drugs: benzocaine, dapsone
Sx: Cyanosis, chocolate-brown blood
Tx: Methylene blue, O2
Blood Gas: PaO2 normal-high, SaO2 ~85%
Cyanide Poisioning
Smoke inhalation, poisoning
Path: inhibits electron transport chain, can’t use O2
ABG: lactic metabolic acidosis, normal PaO2 and SaO2,
Tx: Hydroxycobalamin, Sodium thiosulfate
Carbon Monoxide Poisoning
Smoke inhalation - exhaust, enclosed fires
CO binds to Hgb with much higher affinity than O2 –> poor O2 delivery to tissues
PaO2 normal, SaO2 normal, Co-Oximeter - high CO, metabolic acidosis
Supplemental O2, Hyperbaric O2
