Outpatient shoulder surgery OSA, difficult airway, T1DM Flashcards
considerations when deciding btwn inpt and outpt surgery for safety of ASC
1) severity of OSA
2) presence of anatomical or physiological abnormalities
3) presence and status of coexisting disease
4) nature of the surgery
5) type of anesthesia required
6) anticipated post op opioids requirements
7) pt age
8) adequacy of post discharge observations
9) capabilities of outpt center
would you do this case in ASC
only if believe her risk for OSA was low or the facility had appropriate resources if she had OSA
STOP-BANG criteria and scoring ranges
1) snoring
2) tired during day
3) observed apena
4) Pressure- HTN
5) BMI >35
6) Age over 50
7) Neck circumference over 40 cm
8) Gender male
<3 is low risk
3 or more = high risk
5-8 likely mod to severe
why is beach chair concerning in pt with HTN, DM and autonomic neuropathy
rightward shift cerebral autoregulation curve
impairment of normal autonomic responses by GA and having diabetic autonomic neuropathy
would you recommend patient to stop smoking 2 days prior to surgery
yes, helps reduce CO levels, can lead to long term cessation, help with wound healing, abolish nicotine stimulatory effects on the CV system, improve mucus clearance
see that some may argue against this because risk of post op pulm complications does not decrease until 4 weeks of cessation and only approaches that of non smokers with 8 weeks of cessation
could argue increased mucus clearance in first few days could cause more airway problems
what is the bezold-Jarisch reflex
stimulation of inhibitory cardiac receptors by stretch, chemical substances, or drugs–> increased parasympathetic activity and decreased sympathetic activity = bradycardia, vasodilation, hypotension
the Bezold-Jarisch reflex in surgery
postulated that epi used with local and decreased venous return from beach chair position can lead to this causing asystole potentially
anesthetic concerns in patient with autonomic neuropathy
increased risk aspiration 2/2 gastroparesis
increased risk significant hypotension 2/2 impaired peripheral vasoconstriction
high incidence of silent ischemia
increased risk intraop hypothermia
impaired ventilatory response to hypercapnia and hypoxia leading to increased risk drug induced respiratory depression post op
risk of sudden cardiorespiratory arrest 2/2 to anesthetic or analgesic induced interference with respiration or sinus automaticity
what would you do to mitigate risk in a patient with autonomic neuropathy
act like they have a full stomach
maintain measures to keep them warm
utilize etomidate for induction (idk about that)
continue continuous cardiac and resp monitoring for 24-72 hours post op
how would you evaluate for presence of autonomic neuropathy
she has DM, resting tachycardia, HTN, GERD, exercise intolerance
See if she has early satiety, prolonged postprandial fullness, bloating, postural hypotension, lack of sweating, painless MI, peripheral neuropathy, dysrhythmias, nocturnal diarrhea, nausea, vomiting, epigastric pain
would you start BB therapy on this patient with HTN
no not acutely
increases risk bradycardia, hypotension, stroke, total mortality (although CV morbidity and mortality is reduced)
risk of stroke even higher in this patient with surgery and autonomic neuropathy and HTN
reasonable to start periop BB therapy in what patients
3 or more risk factors identified using RCI or intermediate or high risk MI identified by preop risk stratification tests
2-7 days before surgery preferred
Bezold Jarisch reflex memory tool
BJ, in Vegas is going to cause vasodilation, bradycardia, stop the simping
BP cuff is on leg, how do you account for the actual pressure at the circle of willis
subtract 0.77 mm hg for every cm difference from BP spot to circle of willis
what cerebral perfusion pressure is appropriate in this patient
usually 70-80 MAP is adequate, may want to push to 80 MAP on this patient
