PBL I: Subarachnoid Hemorrhage Flashcards
where do cerebral aneurysms usually occur?
most are anterior near bifurcation of vessels
What are symptoms of cerebral aneurysm?
"worst headache of their life" syncopal episode nausea/vomiting neck pain photophobia focal deficits
Should you defer to Vancomycin because of a mild or distant reaction?
Rash reactions do not preclude cephalopsporins perioperatively
defferment is not recommended
at 1/10 test dose is reasonable for documentation but be aware it will not always give an immediate reation
What products are used to formulate propofol? what was it originally formulated with?
Originally formulated with Creamophor- a surfactant associated with severe anaphylactic reaction
Propofol is currently formulated with egg lecithin and soybean oil.
Why is there a rather small chance of egg allergy with propofol?
The egg in propofol is phoshatide extrated from the yolk to reduce allergenicity. most egg allergic people react to albumin.
Propofol allergy is often attributed to diisopropyl sided chain or phenol group
What is the purpose of taking 81mg aspirin q day?
vascular anticoagulation. Inhibits platelet aggregation and provides a cardio-protective effect
What kind of drug is Valsartan?
Blood pressure control
Angiotensin II receptor antagonist
Is a member of the Renin-agiotensnsin system inhibitors
These are same class but different mechanism as ACE inhibitors
Should AM dose of ACE inhibitor be taken prior to surgery?
not if HTN is well controlled
What is Lorcet (Lortab, vicodin)
Pain medication consisting of Hydrocodone, a modified morphine (5-10mg) combined with Acetominiphen
Waht is the class, use and example of dose for napoxen?
NSAID
used for pain/inflammation
dose is 250mg q4dayor 500mgq2day
What is Novolin-
REcombinant engineered human insulin used to treat diabetes. supplined as 100units/ml
Waht is metformin and how does it work?
Biguanide class hypoglycemic drug. it works to decrease glucose levels. decreases hepatic glucose production increses insulin action on muscle and fat Is used primarily in Type II diabetes
What are containdications for metformin?
renal impairment
history of lactic acidosis
hepatic disease
cardiac failure
What type of drug is Nimodipine (Nimotop)? how is it used?
Calcium channel blocker used for angina, cardiac dysrythmias.
often combined with other medications for treatment of patients with heart disease and HTN
Indicated for use in patients for improvement of neurological outcome where deficits secondary to vasospasm after cerebral aneurysm rupture
Also indicated for vasospasm after cerebral aneurysm coiling
What are the effects fo calcium channel blockers?
Decrease systemic BP
Increase coronary blood flow
delaying of A-V conduction
decrease HR
What is simvastatin (Zocor) used for?
treatment of dyslipidemia
What is the indication for vicodin?
moderate to moderately severe pain
what are warning for vicodin?
REspiratory depression
increased ICP
how can vicodin lead to increased ICP?
CO2 building up for hypoventilation is a vasodilator which will increase ICP
What is colace (docusate sodium)?
anionic surfactant which lowers the surface tension of stool, allowing easier defacation
What is pepcid (famotidine) used for and how does it work?
Used to treate GERD and gastric and duodenal ulcers
It is an Histamine H2 receptor blocker
Inhibits gastric acid production
70% reduction in acid secretion
Most effective on basal acid secretion which is responsible for nocturnal acid secretion
what are other drugs in pepsids class?
tagamet (cimetidine), Zantac (Ranitidine), Axid (Nizatidine)
Surgical mortality rates in the diabetic population is __ times higher than the non-diabetic population when end organ dysfunction extists.
5
What is the pathophysiology of diabetes mellitus?
Pancreatic Beta cells either do not produce insulin or not enough
This DM is an autoimmune disease that affects young nonobese patients.
Type I
DM with low or nonmeasurable insulin levels
Type I
90% (18 million) of all diabetics are this type,
Type II
This type of DM is susceptible to keto acidosis
Type I
How is type II diabetes diagnosed?
Fasting blood glucose > 125 mg/dl
Normal plasma insulin levels or elevated but low for glucose level, A1c levesl, urine ketones
how do sulfonylureas and Repaglinide treat DM?
Stimulate insulin release
What are concerns with DM and surgical wounds?
Wound healing-Granulocytic function and collagen synthesis are suppressed with glucose levels above 200 mg/dl
Wound infection–prevelance fo vacular and renal disease in diabetics contributes to higher rate of infection
What are the goals of Perioperative management of a DM patient?
Prevent ketoacidosis (hypoglycemia) Prevent hyperglycemia
Diabetics should be the ___ case of the day
first
What is the greatest concern with diabetics. how is it treated?
Hypoglycemia
glucose <50mg/dl must be treated with 50% dextrose, starting with a 15ml bolus
What should be done before insulin infusion is started?
first 50 ml discarded
Separate IV started for insulin and glucose infusions
What are starting rates for insulin and D5W/.45NS with 20 meq of KCl?
Insulin at 1 units/hr and D5W at 100 cc/hr
When should glucose be checked in DM pt receiving infulsion?
every 1-2hours before surgery, every hour during
how is an insulin infusion titrated?
Aim for blood glucose 100-200 mg/dL by adjusting insulin infusion rate in 0.5 unit/hr
how is glucose checked intraoperatively?
Accucheck, arterial or venous
What are causes of asthma?
inhaled allergens-dust, animal dander, industrial pollutants
stress
Airway instrumentation
REcurrent pulmonary infections
What is the physiologic response of asthma?
Mast cell release fo Histamine
What is the pathology of Asthma?
Bronchoconstriction or Spasm
Aiway infllamation
What size aerosols make it to the alveolar level?
0.5um
What is the advantage of a nebulizer for use in the pediatric patient?
Does not require hand-breathing coordination like an MDI does
What is the onset and duration of short acting beta-2 agonists?
onset-1-5 min
duratine 2-6 hours
can long acting Beta 2 agonists be used for perioperative prophylaxis?
NO, also not to treat an acute attack
What is the onset and duration of Long acting beta 2 agonists? Give 2 examples.
Onset > 20 minutes
duration 12 hours
examples: salmeterol, formoterol
how do steroids work to treat asthma?
Not categorized as bronchodilators, but do have that effect by decreasing mucosal edema and preventing the release of bronchoconstricting substances
How can steroids be administered for asthma?
Oral or aerosolized
How do accolate or singulair treat asthma
leukotriene receptor antagonist
leukotriens 1000x more potent brochoconstrictors than histamine
How does Xolair treat asthma?
Anti-IgE therapy
REcombinant humanized monoclonal antibody targeting IgE receptors on mast cells, thus preventing bronchoconstriction
How does theophylline treat Asthma?
theophylline is a methylxanthine that acts as a phosphodiesterase inhibitor–prevents the breakdown of cAMP
What are anesthetic considerations for cerebral aneurism coiling?
- Immobility–general anesthesia with neuromusclular blockade
- Hemodynamic stability–Direct arterial monitoring is needed to maintain cerebral perfusiona nd prevent aneurysm rupture
- Anticoagulation-heparin
- Rapid emergence for neurologic assessment
What are possible complications of aneurysm coiling?
- Aneurysm rupture with hemorrhage
- Thromboembolism
- Vasospasm
