SAQ 2025.1.1 Flashcards
Describe the mechanisms underlying postoperative shivering and outline the perioperative management strategies to prevent and treat this condition.
Postoperative shivering is primarily caused by hypothermia, pain, and the effects of anesthesia. Management strategies include maintaining normothermia, using warming devices, and administering medications like meperidine.
Example sentence: ‘To prevent postoperative shivering, it is crucial to monitor the patient’s temperature closely during surgery.’
Describe the challenges and anaesthetic considerations in managing a 25-year-old patient with cystic fibrosis undergoing elective sinus surgery.
Challenges include managing respiratory function, potential for difficult intubation, and the need for postoperative respiratory support. Anaesthetic considerations involve ensuring optimal lung function and minimizing airway irritation.
Outline the perioperative risk assessment and optimisation strategies for a patient with cirrhosis undergoing major abdominal surgery.
Risk assessment includes evaluating liver function, coagulopathy, and portal hypertension. Optimization strategies involve correcting coagulopathy, managing fluid status, and considering liver transplant evaluation.
Outline the perioperative risk factors and strategies for optimisation in a 70-year-old patient with ischaemic heart disease undergoing elective total hip arthroplasty.
Risk factors include age, cardiac history, and comorbidities. Optimization strategies involve cardiac evaluation, medication management, and careful monitoring during anesthesia.
Explain the pathophysiology of intraoperative venous air embolism and justify your approach to prevention and management.
Intraoperative venous air embolism occurs when air enters the venous system, leading to potential cardiovascular collapse. Prevention includes proper positioning and avoiding open veins. Management involves immediate aspiration and supportive measures.
Outline the perioperative considerations for using trans nasal humidified rapid insufflation ventilatory exchange (THRIVE) in managing a difficult airway.
Considerations include ensuring proper equipment availability, monitoring for adequate ventilation, and being prepared for rapid sequence intubation if necessary.
Outline the principles of anaesthesia for awake craniotomy and discuss how patient selection affects outcomes.
Principles include maintaining consciousness for neurological monitoring while providing adequate analgesia and sedation. Patient selection is critical, as cognitive function and cooperation influence outcomes.
List the clinical features of preeclampsia and describe the perioperative management of a 32-week pregnant patient with severe preeclampsia and pulmonary oedema requiring emergency caesarean delivery.
Clinical features include hypertension, proteinuria, and edema. Management involves stabilizing the mother, controlling blood pressure, and preparing for rapid delivery, often with regional anesthesia.
Discuss the perioperative challenges in managing a Jehovah’s Witness patient requiring major abdominal surgery.
Challenges include managing the patient’s refusal of blood products. Strategies involve meticulous surgical technique, minimizing blood loss, and using alternatives like cell salvage.
Managing a Jehovah’s Witness patient requiring major abdominal surgery presents significant perioperative challenges due to their refusal of blood transfusions. This refusal stems from deeply held religious beliefs and requires a comprehensive, multidisciplinary approach to ensure patient safety while respecting their autonomy.
Preoperative Considerations
Patient Assessment and Optimization
A thorough preoperative evaluation is crucial for Jehovah’s Witness patients. This includes:
- Detailed medical history review
- Assessment of bleeding risk factors
- Evaluation of current medications, especially anticoagulants
- Laboratory testing (hemoglobin, hematocrit, platelet count, coagulation profile)[2]
Optimizing the patient’s condition before surgery is essential:
- Treating preexisting anemia with iron supplements, vitamin B12, and folic acid
- Administering erythropoiesis-stimulating agents like recombinant human erythropoietin (rhEPO) to boost red blood cell production[1][2]
- Implementing prehabilitation protocols to improve functional capacity[4]
Informed Consent and Ethical Considerations
Obtaining informed consent is particularly important for Jehovah’s Witness patients:
- Discuss the risks associated with refusing blood transfusions
- Review the patient’s advance directive and acceptable blood products or alternatives
- Address potential ethical dilemmas and legal implications[1][2]
Intraoperative Management
Blood Conservation Techniques
Several strategies can be employed to minimize blood loss during surgery:
- Meticulous surgical technique and use of hemostatic devices (electrocautery, ultrasonic scalpel)
- Application of topical hemostatic agents (fibrin glue, thrombin gel)
- Proper patient positioning and use of tourniquets when applicable[2]
Anesthetic Considerations
Anesthetic management plays a crucial role in blood conservation:
- Maintain low central venous pressure to reduce bleeding
- Use controlled hypotension techniques when appropriate
- Employ cell salvage techniques if accepted by the patient
- Implement normovolemic hemodilution if permitted[4]
Fluid Management
Careful fluid management is essential:
- Restrict intravenous fluids to avoid dilutional coagulopathy
- Use crystalloid or colloid solutions to maintain normovolemia
- Consider the use of albumin or synthetic volume expanders if accepted by the patient[4]
Postoperative Care
Monitoring and Management
Close postoperative monitoring is crucial:
- Vigilant surveillance for signs of bleeding
- Restricted phlebotomy to minimize iatrogenic blood loss
- Continuation of erythropoietic agents and iron supplementation[2]
Complication Management
In case of postoperative complications:
- Conservative management of minor bleeding episodes
- Use of pharmacological agents to promote hemostasis
- Careful consideration of anticoagulant use for thromboprophylaxis[4]
Conclusion
Managing Jehovah’s Witness patients undergoing major abdominal surgery requires a delicate balance between respecting religious beliefs and ensuring optimal medical care. Success depends on meticulous planning, a multidisciplinary approach, and the use of blood conservation techniques throughout the perioperative period. While challenging, many centers have demonstrated that major surgeries can be performed safely in this patient population with careful preparation and management[1][4].
Sources
[1] Major abdominal surgery for Jehovah’s Witnesses - PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC10748892/
[2] Preanesthetic Assessment of the Jehovah’s Witness Patient - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC3307508/
[3] Preoperative considerations for Jehovah’s Witness patients - PubMed https://pubmed.ncbi.nlm.nih.gov/32371641/
[4] [PDF] Perioperative challenges in the management of a Jehovah’s Witness … https://www.apicareonline.com/index.php/APIC/article/download/1870/2738/
[5] Jehovah’s Witnesses: The Surgical/Ethical Challenge - JAMA Network https://jamanetwork.com/journals/jama/article-abstract/364809
[6] Anaesthesia and peri-operative care for Jehovah’s Witnesses and … https://anaesthetists.org/Home/Resources-publications/Guidelines/Anaesthesia-and-peri-operative-care-for-Jehovahs-Witnesses-and-patients-who-refuse-blood
[7] Perioperative Jehovah’s Witnesses: a review | BJA - Oxford Academic https://academic.oup.com/bja/article/115/5/676/230337
[8] The challenges of treating Jehovah’s witnesses https://www.medicalprotection.org/southafrica/casebook/casebook-may-2014/the-challenges-of-treating-jehovahs-witnesses
[9] Outcomes of perioperative management in Jehovah’s Witness … http://www.embse.org/journal/view.html?pn=lastest&vmd=Full
[10] Major abdominal surgery in Jehovah’s Witnesses https://search.lib.uts.edu.au/discovery/fulldisplay?docid=cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_5392872&context=PC&vid=61UTS_INST%3A61UTS&lang=en&search_scope=MyInst_and_CI&adaptor=Primo+Central&query=null%2C%2C1%2CAND&facet=citedby%2Cexact%2Ccdi_FETCH-LOGICAL-c525t-3436b009e53ab7cfd9a245e4082087a90262f741dd99c41bb9da7a2b92f4c1343&offset=20
[11] [PDF] Caring for patients who refuse blood - Royal College of Surgeons https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/caring-for-patients-who-refuse-blood–a-guide-to-good-practice.pdf
[12] Major abdominal surgery for Jehovah’s Witnesses - Sage Journals https://journals.sagepub.com/doi/abs/10.1177/2050313X231220836
[13] [PDF] Ethical perspectives on Jehovah’s Witnesses’ refusal of blood https://www.ccjm.org/content/ccjom/64/9/475.full.pdf
[14] Major abdominal surgery in Jehovah’s Witnesses - ResearchGate https://www.researchgate.net/publication/305336542_Major_abdominal_surgery_in_Jehovah’s_Witnesses
[15] Major abdominal surgery for Jehovah’s Witnesses: Challenge while … https://journals.scholarsportal.info/details/2050313x/v11inone/nfp_masfjwmiamic.xml&sub=all
[16] anaesthesia and peri‐operative care for Jehovah’s Witnesses and … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14441
[17] Major abdominal surgery in Jehovah’s Witnesses - RCSEng https://publishing.rcseng.ac.uk/doi/abs/10.1308/rcsann.2016.0210
Discuss the impact of multimodal analgesia on opioid consumption and postoperative recovery in elective colorectal surgery.
Multimodal analgesia reduces opioid consumption, minimizes side effects, and enhances postoperative recovery by addressing pain through various mechanisms.
Describe the factors influencing extubation strategies in a patient with cervical spine instability following trauma.
Factors include neurological status, airway protection, and the risk of respiratory compromise. Strategies may involve awake extubation and careful monitoring.
Extubation strategies for patients with cervical spine instability following trauma require careful consideration of several key factors:
Patient-Specific Factors
Neurological Status
The severity and level of cervical spinal cord injury significantly impact extubation outcomes[1][3]. Patients with complete high cervical spinal cord injuries (C1-C4) are at higher risk of respiratory failure and may require prolonged mechanical ventilation[2].
Respiratory Function
Diaphragm function is crucial for successful extubation. Monitoring diaphragm electrical activity (EAdi) can help predict extubation outcomes[1]. A higher increase in EAdi during a maximal inspiratory effort is associated with successful extubation.
Airway Edema
Postoperative airway swelling is a major concern, especially after anterior cervical spine surgeries[3]. The cuff leak test (CLT) is commonly used to assess airway edema and predict extubation success.
Surgical Factors
Extent of Surgery
More extensive surgeries, particularly multi-level anterior-posterior fusions, are associated with a higher risk of airway complications and may require delayed extubation[3][6].
Postoperative Imaging
Lateral neck radiographs can help assess prevertebral soft tissue swelling. Significant increases in swelling at C2 (>250%) or C5 (>150%) may indicate the need for prolonged intubation[6].
Extubation Protocol
Timing
Many centers advocate for overnight intubation following complex cervical spine surgeries, with reassessment for extubation readiness the following morning[6].
Cuff Leak Test
A quantitative CLT >200 mL is often used as a criterion for safe extubation[3][6]. However, this should be combined with other clinical factors.
Staged Approach
Some protocols use a staged approach, with repeated assessments of airway edema and cuff leak over several days if initial extubation criteria are not met[6].
Airway Management Strategies
Difficult Airway Preparation
Given the potential for difficult reintubation, equipment for difficult airway management should be immediately available during extubation[9].
Airway Exchange Catheters
Pediatric airway exchange catheters (PAEC) can be considered for patients at high risk of extubation failure, as they facilitate reintubation if needed[6].
Tracheostomy
Early tracheostomy may be considered for patients requiring prolonged ventilation or those failing multiple extubation attempts[2][3].
Post-Extubation Care
Respiratory Support
High-flow nasal oxygen or non-invasive ventilation may be used post-extubation to support respiratory function and reduce the risk of reintubation[2].
Monitoring
Close monitoring for signs of respiratory distress, including work of breathing, oxygen saturation, and arterial blood gases, is essential in the immediate post-extubation period[9].
By carefully considering these factors and implementing a structured extubation protocol, clinicians can optimize outcomes and minimize complications in patients with cervical spine instability following trauma. The decision to extubate should be made collaboratively between the intensive care, neurosurgery, and anesthesia teams to ensure the safest possible approach for each individual patient[3][6].
Sources
[1] Predicting extubation in patients with traumatic cervical spinal cord … https://pmc.ncbi.nlm.nih.gov/articles/PMC10700269/
[2] A Fast-Track Respiratory Protocol for High Cervical Spine Injury https://pmc.ncbi.nlm.nih.gov/articles/PMC10681283/
[3] Analysis and Temporal Evolution of Extubation Parameters for … https://pmc.ncbi.nlm.nih.gov/articles/PMC7538349/
[4] Analysis and Temporal Evolution of Extubation Parameters for … https://www.e-neurospine.org/journal/view.php?number=959
[5] [PDF] Emergency airway management in the trauma patient https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/195165/NSW-Health-ITIM-Emergency-airway-management-trauma-patient.pdf
[6] Management and treatment algorithm of airway complications after … https://jss.amegroups.org/article/view/6570/html
[7] Cervical spine injury – Emergency management in children https://www.childrens.health.qld.gov.au/for-health-professionals/queensland-paediatric-emergency-care-qpec/queensland-paediatric-clinical-guidelines/cervical-spine-injury
[8] [PDF] BEST PRACTICES GUIDELINES SPINE INJURY https://www.facs.org/media/k45gikqv/spine_injury_guidelines.pdf
[9] [EPUB] Tracheal Extubation of Patients With Cervical Spine Injury https://journals.lww.com/aacr/Fulltext/2017/01150/Tracheal_Extubation_of_Patients_With_Cervical.1.aspx?generateEpub=Article%7Caacr%3A2017%3A01150%3A00001%7C10.1213%2Fxaa.0000000000000410%7C
[10] Airway management in cervical spine injury - PMC - PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC3982371/
[11] Management of acute cervical spinal cord injury in the non … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16198
[12] Airway management in patients with suspected or confirmed cervical … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16290
[13] Acute cervical spinal cord injury and extubation failure - ResearchGate https://www.researchgate.net/publication/331689747_Acute_cervical_spinal_cord_injury_and_extubation_failure_A_systematic_review_and_meta-analysis
[14] Clinical Practice Guidelines : Cervical spine assessment https://www.rch.org.au/clinicalguide/guideline_index/Cervical_spine_injury/
[15] Tracheal Extubation of Patients With Cervical Spine Injury https://www.researchgate.net/publication/309828264_Tracheal_Extubation_of_Patients_With_Cervical_Spine_Injury_A_Case_Report_and_Review_of_Literature
[16] [PDF] Guideline: Cervical Spine (suspected) Innjury: Patient Management https://resources.schn.health.nsw.gov.au/policies/policies/pdf/2012-8014.pdf
[17] Acute cervical spinal cord injury and extubation failure - PubMed https://pubmed.ncbi.nlm.nih.gov/30876697/
[18] Airway management in patients with suspected or confirmed … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15807
Outline the physiological changes and anaesthetic management considerations for laparoscopic surgery in a morbidly obese patient.
Physiological changes include altered respiratory mechanics and increased cardiovascular strain. Management considerations involve optimizing positioning, ventilation strategies, and monitoring for complications.
Laparoscopic surgery in morbidly obese patients presents unique physiological challenges and requires careful anaesthetic management. Here’s an outline of the key considerations:
Physiological Changes
Respiratory System
- Decreased functional residual capacity (FRC) and lung compliance[4][5]
- Increased closing capacity approaching FRC, leading to airway closure and V/Q mismatch[4]
- Rapid arterial oxygen desaturation with apnea[4]
- Increased oxygen consumption due to excess adipose tissue[4]
Cardiovascular System
- Increased cardiac output and blood volume[4]
- Hypertension and increased risk of coronary artery disease[4]
- Altered venous return due to pneumoperitoneum[6]
Gastrointestinal System
- Increased risk of aspiration due to higher intra-abdominal pressure and gastroesophageal reflux[4]
- Faster gastric emptying but larger residual volume after NPO period[4]
Metabolic Changes
- Altered drug pharmacokinetics due to increased adipose tissue[4]
- Insulin resistance and impaired glucose tolerance[4]
Anaesthetic Management Considerations
Preoperative Assessment
- Thorough evaluation of comorbidities, especially cardiopulmonary status[9]
- Airway assessment and planning for potential difficult intubation[4]
- Consider sleep studies to evaluate for obstructive sleep apnea[4]
Induction and Airway Management
- Position patient in head-elevated laryngoscopy position (HELP)[4]
- Consider awake fiberoptic intubation for difficult airways[4]
- Use of video laryngoscopy may improve first-attempt success rate[9]
Ventilation Strategies
- Pressure-controlled ventilation with higher instantaneous flow peaks[7]
- Use of PEEP to minimize alveolar de-recruitment[7]
- Lung-protective ventilation with limited tidal volumes[3]
Pneumoperitoneum Management
- Limit intra-abdominal pressure to 15 mmHg or less if possible[11]
- Monitor for hemodynamic changes and adjust anaesthesia accordingly[11]
- Be prepared for increased peak airway pressures[6]
Fluid Management
- Judicious fluid administration due to altered cardiovascular physiology[4]
- Consider goal-directed fluid therapy[9]
Analgesia
- Multimodal approach including regional techniques when possible[4]
- Cautious use of opioids due to increased risk of respiratory depression[4]
- Consider thoracic epidural for major open abdominal procedures[19]
Emergence and Extubation
- Ensure full reversal of neuromuscular blockade[9]
- Consider extubation in semi-upright position[9]
- Be prepared for potential reintubation[4]
Postoperative Care
- Close monitoring in PACU with head-up positioning[19]
- Early mobilization to reduce risk of thromboembolism[4]
- Consider CPAP or non-invasive ventilation for patients with OSA[19]
By addressing these physiological changes and implementing appropriate anaesthetic management strategies, the risks associated with laparoscopic surgery in morbidly obese patients can be minimized, leading to improved outcomes.
Sources
[1] Obesity: physiologic changes and challenges during laparoscopy https://pubmed.ncbi.nlm.nih.gov/15343262/
[2] Obesity in laparoscopic surgery - PubMed https://pubmed.ncbi.nlm.nih.gov/25770750/
[3] Anesthetic management of a morbidly obese patient with … https://pmc.ncbi.nlm.nih.gov/articles/PMC8021672/
[4] Anesthetic Implications of Obesity in the Surgical Patient - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC3311489/
[5] Should Laparoscopy be Performed in the Morbidly Obese? An … https://gocm.bmj.com/content/4/3/e000049
[6] Effects of obesity, pneumoperitoneum, and body position on … https://journals.physiology.org/doi/full/10.1152/japplphysiol.00551.2022
[7] Anaesthesia for laparoscopic surgery | BJA Education https://academic.oup.com/bjaed/article/11/5/177/282908
[8] [PDF] Physiological changes in obesity and patient preparation for … https://jag.journalagent.com/less/pdfs/LESS-33042-REVIEW-SAHIN.pdf
[9] Anesthetic Management of Laparoscopic Surgery in Obese Patients https://www.researchgate.net/publication/312383814Anesthetic_Management_of_Laparoscopic_Surgery_in_Obese_Patients
[10] Laparoscopy in the morbidly obese: physiologic considerations and … https://pubmed.ncbi.nlm.nih.gov/24100146/
[11] Cardiovascular and Ventilatory Consequences of Laparoscopic … https://www.ahajournals.org/doi/10.1161/circulationaha.116.023262
[12] Obesity: physiologic changes and challenges during laparoscopy https://www.ajog.org/article/S0002-9378(04)00563-0/abstract
[13] Physiological changes during laparoscopy (Chapter 7) https://www.cambridge.org/core/books/morbid-obesity/physiological-changes-during-laparoscopy/EAFD830EF5210E29102F37A5D8563759
[14] Physiology of Laparoscopy in the Morbidly Obese | Management of M https://www.taylorfrancis.com/chapters/physiology-laparoscopy-morbidly-obese-david-magner-ninh-nguyen/e/10.3109/9780203025758-11
[15] [PDF] Anaesthesia: non bariatric surgery in obese patients https://www.health.qld.gov.au/__data/assets/pdf_file/0019/147430/qh-gdl-395.pdf
[16] Peri‐operative management of the obese surgical patient 2015 https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13101
[17] Perioperative Management of Morbidly Obese Patients during Major … https://www.e-acnm.org/journal/view.php?doi=10.15747%2FACNM.2021.13.2.26
[18] Should Laparoscopy be Performed in the Morbidly Obese? An … https://gocm.bmj.com/content/gocm/4/3/e000049.full.pdf
[19] [PDF] Laparoscopic surgery in the high risk patient - Anaesthetics https://anaesthetics.ukzn.ac.za/Libraries/Londiwes_uploads/FMM_PERI-OPERATIVE_MANAGEMENT_OF_THE_OBESE_SURGICAL_PATIENT-_ANDISHA_29_September_2017.pdf
[20] Anaesthesia and morbid obesity | BJA Education - Oxford Academic https://academic.oup.com/bjaed/article/8/5/151/268305?login=false
[21] A review on the anesthetic management of obese patients … https://pmc.ncbi.nlm.nih.gov/articles/PMC8985303/
Discuss the perioperative anticoagulation management in a patient with atrial fibrillation and a mechanical aortic valve undergoing major abdominal surgery for bowel resection.
Management involves balancing the risk of thromboembolism with bleeding. Strategies include bridging therapy with low molecular weight heparin and careful timing of anticoagulant resumption.
Perioperative anticoagulation management for a patient with atrial fibrillation and a mechanical aortic valve undergoing major abdominal surgery requires careful consideration of both thromboembolic and bleeding risks. This patient would be considered at high risk for thromboembolism due to the mechanical valve and atrial fibrillation.
Preoperative Management
- Discontinue warfarin 5 days before surgery to allow the INR to normalize[1][3].
- Start bridging anticoagulation with therapeutic-dose low molecular weight heparin (LMWH) or unfractionated heparin (UFH) when the INR falls below 2.0, typically 2-3 days before surgery[1][3].
- Administer the last dose of LMWH 24 hours before surgery or stop UFH 4-6 hours preoperatively[3].
Intraoperative Management
Monitor for bleeding and be prepared to reverse anticoagulation if necessary. Avoid neuraxial anesthesia due to the recent use of therapeutic anticoagulation.
Postoperative Management
- Resume warfarin 12-24 hours after surgery if there are no bleeding complications and the patient can tolerate oral medications[3].
- Restart bridging anticoagulation with LMWH or UFH 48-72 hours after surgery, once hemostasis is achieved[3][15].
- Continue bridging until the INR reaches the therapeutic range (typically 2.5-3.5 for a mechanical aortic valve)[2][5].
- Consider a lower target INR of 2.0-3.0 if using a newer generation mechanical valve like On-X, as recent evidence suggests this may be sufficient[6][20].
- Resume aspirin 75-100 mg daily in addition to warfarin, as dual therapy is recommended for patients with mechanical valves[2].
Additional Considerations
- The CHA2DS2-VASc score should be calculated to assess stroke risk from atrial fibrillation, though anticoagulation is required regardless due to the mechanical valve[14].
- Closely monitor for signs of bleeding or thromboembolism in the postoperative period.
- Consider involving a multidisciplinary team, including the surgeon, anesthesiologist, and cardiologist, in perioperative management decisions[5].
- Direct oral anticoagulants (DOACs) are not recommended for patients with mechanical heart valves, as trials have shown increased risk of thromboembolism compared to warfarin[22].
This approach balances the need for continued anticoagulation to prevent valve thrombosis and cardioembolic events with the increased bleeding risk associated with major abdominal surgery. Close monitoring and individualized management are essential for optimal outcomes in this high-risk patient population.
Sources
[1] [PDF] The perioperative management of anticoagulation https://www.nps.org.au/assets/9bf65e3bdcbf0fe0-ac62d69f22ee-c0d8a6fa7795b1097b2afb4eab5437f708fbaaa4536a31d33e077815d2ee.pdf
[2] Anticoagulation for Valvular Heart Disease https://www.acc.org/latest-in-cardiology/articles/2015/05/18/09/58/anticoagulation-for-valvular-heart-disease
[3] Perioperative Anticoagulation Management - StatPearls - NCBI https://www.ncbi.nlm.nih.gov/books/NBK557590/
[4] New oral anticoagulants and perioperative management … - RACGP https://www.racgp.org.au/afp/2014/december/new-oral-anticoagulants-and-perioperative-manageme
[5] 2020 ACC/AHA Guideline for the Management of Patients With … https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923
[6] DOACs in the Anticoagulation of Mechanical Valves - PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC10419922/
[7] How I treat anticoagulated patients undergoing an elective … https://ashpublications.org/blood/article/120/15/2954/30631/How-I-treat-anticoagulated-patients-undergoing-an
[8] Perioperative management of patients on chronic antithrombotic … https://pmc.ncbi.nlm.nih.gov/articles/PMC3653565/
[9] How to bridge? Management of anticoagulation in patients with … https://www.jtcvs.org/article/S0022-5223(18)31859-2/fulltext
[10] Advances in Neurocardiology: Focus on Anticoagulation for Valvular … https://www.ahajournals.org/doi/10.1161/STROKEAHA.122.039310
[11] [PDF] Guidelines on Perioperative Management of Anticoagulant and … https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/458988/Guidelines-on-perioperative-management-of-anticoagulant-and-antiplatelet-agents.pdf
[12] How to bridge? Management of anticoagulation in patients with … https://www.jtcvs.org/article/S0022-5223(18)31859-2/pdf
[13] Perioperative Anticoagulation Management - StatPearls - NCBI https://www.ncbi.nlm.nih.gov/books/NBK557590/
[14] Atrial fibrillation: an update on management - Australian Prescriber https://australianprescriber.tg.org.au/articles/atrial-fibrillation-an-update-on-management.html
[15] [PDF] Perioperative Management of Antithrombotic Therapy https://acforum-excellence.org/Resource-Center/resource_files/-2023-10-23-113234.pdf
[16] [PDF] Anticoagulant Guideline for Hospitalised Adult Patients https://www.health.qld.gov.au/__data/assets/pdf_file/0015/1152213/statewide-anticoagulant-guideline.pdf
[17] Perioperative Management of Antithrombotic Therapy - CHEST https://journal.chestnet.org/article/S0012-3692(22)01359-9/fulltext
[18] New oral anticoagulants and perioperative management … - RACGP https://www.racgp.org.au/afp/2014/december/new-oral-anticoagulants-and-perioperative-manageme
[19] Perioperative Anticoagulation in Patients with Mechanical Heart … https://pmc.ncbi.nlm.nih.gov/articles/PMC2823059/
[20] Antithrombotic therapies in patients with prosthetic heart valves https://pmc.ncbi.nlm.nih.gov/articles/PMC3699194/
[21] How to manage anticoagulated patients undergoing elective surgery … https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-7/How-to-manage-anticoagulated-patients-undergoing-elective-surgery-or-invasive-pr
[22] There is still no alternative to warfarin for mechanical valves https://www.jtcvs.org/article/S0022-5223(24)00610-X/pdf
[23] 2020 ACC/AHA Guideline for the Management of Patients With … https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923
[24] Prosthetic heart valves: Part 2 - Antithrombotic management https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-20/prosthetic-heart-valves-part-2-antithrombotic-management
Discuss the anaesthetic considerations and perioperative management strategies for a 70-year-old with multiple comorbidities, including COPD and pulmonary hypertension, scheduled for elective lobectomy.
Considerations include optimizing pulmonary function, assessing cardiac risk, and planning for postoperative care. Regional anesthesia may be beneficial to reduce respiratory complications.
Anaesthetic Considerations and Perioperative Management for a 70-Year-Old with Comorbidities Undergoing Elective Lobectomy
Managing a 70-year-old patient with multiple comorbidities, particularly Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension, presents unique challenges during the perioperative period. This requires a comprehensive approach that encompasses preoperative assessment, intraoperative management, and postoperative care to optimize outcomes.
Preoperative Assessment
Risk Stratification
- Comorbidities: Assess the severity of COPD and pulmonary hypertension. Utilize tools such as the American Society of Anesthesiologists (ASA) physical status classification and functional capacity evaluations (e.g., six-minute walk test).
- Pulmonary Function Tests: Evaluate lung function through spirometry, focusing on FEV1 and FVC. A FEV1 < 70% indicates increased risk for postoperative pulmonary complications (PPCs) [6][10].
- Cardiac Evaluation: Given the patient’s age and comorbidities, a thorough cardiac assessment is crucial, including echocardiography to evaluate right heart function due to pulmonary hypertension [12][13].
- Prehabilitation: Implement prehabilitation strategies to enhance the patient’s functional capacity. This may include pulmonary rehabilitation, nutritional support, and smoking cessation if applicable [10][11].
Intraoperative Management
Anaesthetic Technique
- Induction: General anesthesia is typically preferred. Use agents like etomidate or propofol cautiously due to their cardiovascular effects. Pre-oxygenation with 100% oxygen is essential to improve oxygen reserves [1][5].
-
Ventilation Strategies: Employ lung-protective ventilation strategies:
- Use low tidal volumes (6–8 mL/kg) to prevent over-distension of alveoli.
- Maintain peak airway pressures below 30 mmHg.
- Avoid one-lung ventilation when possible to minimize hypoxic pulmonary vasoconstriction [1][14].
- Monitoring: Continuous hemodynamic monitoring is critical. Be prepared to manage potential arrhythmias or hypotension, which are common in patients with pulmonary hypertension [5][12].
Pain Management
- Analgesia: Utilize multimodal analgesia strategies to minimize opioid use. Consider epidural or paravertebral blocks for effective pain control while preserving respiratory function [3][10].
Postoperative Care
Monitoring and Recovery
- Intensive Monitoring: Postoperatively, patients should be monitored in an intensive care or high-dependency unit due to their comorbidities. Focus on respiratory function, hemodynamics, and pain control [3][8].
- Respiratory Management: Implement early mobilization and respiratory physiotherapy to reduce the risk of atelectasis and pneumonia. Use incentive spirometry to encourage deep breathing exercises [4][16].
- Fluid Management: Maintain euvolemia with careful fluid management to avoid fluid overload, which can exacerbate pulmonary hypertension [10][11].
Complication Prevention
- Preventing PPCs: Engage in strategies such as early extubation if feasible, minimizing sedation, and employing non-invasive ventilation if respiratory distress occurs postoperatively [18].
- Nausea and Vomiting Prophylaxis: Use a multimodal approach for preventing postoperative nausea and vomiting (PONV), which can complicate recovery in older patients [11][12].
Conclusion
The perioperative management of a 70-year-old patient with COPD and pulmonary hypertension undergoing elective lobectomy requires careful planning and execution. By addressing the unique challenges posed by these comorbidities through comprehensive preoperative assessment, tailored intraoperative strategies, and vigilant postoperative care, it is possible to minimize risks and enhance recovery outcomes.
Sources
[1] Anesthesia for Patients With Pulmonary Hypertension or Right Heart … https://www.ncbi.nlm.nih.gov/books/NBK572071/
[2] [PDF] Perioperative Pulmonary Complications in the Elderly - BINASSS https://www.binasss.sa.cr/bibliotecas/bhm/set23/8.pdf
[3] Perioperative management in thoracic surgery - Medicina Intensiva https://www.medintensiva.org/en-perioperative-management-in-thoracic-surgery-articulo-S2173572720300424
[4] Postoperative Respiratory Exercises Reduce the Risk of Developing … https://www.archbronconeumol.org/en-postoperative-respiratory-exercises-reduce-risk-articulo-S1579212916000653
[5] Anesthetic Considerations in the Geriatric Population - NCBI https://www.ncbi.nlm.nih.gov/books/NBK572137/
[6] Chronic obstructive pulmonary disease and anaesthesia https://academic.oup.com/bjaed/article/14/1/1/336087
[7] Clinical guidelines on perioperative management strategies for … https://pmc.ncbi.nlm.nih.gov/articles/PMC6976358/
[8] Lobectomy: Procedure Details & Recovery - Cleveland Clinic https://my.clevelandclinic.org/health/treatments/17608-lobectomy
[9] [PDF] Anesthesia for patients with severe chronic obstructive pulmonary … https://anaesthetics.ukzn.ac.za/Libraries/Resp/Anaes_for_COPD-Curr_opin.pdf
[10] [PDF] Anesthetic Management for Pulmonary Resection - BINASSS https://www.binasss.sa.cr/novi/55.pdf
[11] Guidelines for enhanced recovery after lung surgery https://academic.oup.com/ejcts/article/55/1/91/5124324?login=false
[12] Perioperative management of patients with pulmonary hypertension … https://www.jhltonline.org/article/S1053-2498(22)01992-1/abstract
[13] Evaluation and Management of Pulmonary Hypertension in … https://www.ahajournals.org/doi/10.1161/CIR.0000000000001136
[14] Mechanical ventilation guidelines in lung lobectomy surgery and the … https://pmc.ncbi.nlm.nih.gov/articles/PMC6344724/
[15] Anesthetic considerations for lung resection - PubMed Central https://pmc.ncbi.nlm.nih.gov/articles/PMC6712248/
[16] Lobectomies: Before & After Care - Lung Foundation Australia https://lungfoundation.com.au/blog/lobectomies-before-after-care/
[17] Perioperative interventions for prevention of postoperative … https://www.bmj.com/content/368/bmj.m540
[18] clinical practice guidelines for mechanical ventilation management … https://jtd.amegroups.org/article/view/15690/html
[19] Sleeve lobectomy or pneumonectomy: optimal management … https://www.annalsthoracicsurgery.org/article/S0003-4975(03)01243-8/fulltext
[20] Lobectomy | Johns Hopkins Medicine https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lobectomy
[21] Clinical Observation of General Anesthesia Combined with Spinal … https://pmc.ncbi.nlm.nih.gov/articles/PMC9420591/
[22] Pulmonary hypertension and its management in patients … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.12831
[23] Postoperative chest tube management for patients undergoing … https://jtd.amegroups.org/article/view/24659/html
Justify the use of sugammadex in the reversal of neuromuscular blockade instead of traditional reversal with glycopyrrolate and neostigmine.
Sugammadex provides rapid and effective reversal of neuromuscular blockade without the side effects associated with traditional agents, improving patient recovery times and safety.
The use of sugammadex for reversing neuromuscular blockade offers several significant advantages over traditional reversal with glycopyrrolate and neostigmine:
Faster and More Predictable Reversal
Sugammadex provides a substantially faster and more predictable reversal of neuromuscular blockade compared to neostigmine/glycopyrrolate:
- Studies consistently show that sugammadex produces more rapid recovery from moderate and profound neuromuscular blockade than neostigmine/glycopyrrolate[1][11].
- Sugammadex can reverse deep neuromuscular blockade faster than neostigmine can reverse even moderate blockade[4].
- The reversal with sugammadex is more predictable, with 98% of patients achieving a train-of-four ratio of 0.9 within 5 minutes, compared to only 11% with neostigmine[6].
Improved Safety Profile
Sugammadex offers a better safety profile and reduces risks associated with residual neuromuscular blockade:
- It greatly reduces the risk of residual neuromuscular paralysis compared to neostigmine[4].
- Sugammadex is associated with a lower incidence of postoperative nausea and vomiting (PONV) during the first 24 hours after surgery[8].
- Unlike neostigmine, sugammadex does not require co-administration of an antimuscarinic drug, avoiding potential side effects like bradycardia[4].
Efficacy in Special Populations
Sugammadex demonstrates clinical advantages in patients with certain conditions:
- It is particularly beneficial for patients with pulmonary disease, cardiac disease, hepatic dysfunction, myasthenia gravis, and/or morbid obesity[10].
- Sugammadex can be used effectively in pediatric patients for rapid and safe reversal of rocuronium-induced neuromuscular blockade[1].
Potential for Improved Operational Efficiency
While cost considerations exist, sugammadex may offer operational benefits:
- Faster reversal times could potentially lead to improved operating room efficiency and reduced recovery room times[3][13].
- Some studies suggest that the time savings associated with sugammadex use could offset its higher acquisition cost, particularly if the time saved is in the operating theater[5].
Unique Capabilities
Sugammadex offers unique reversal capabilities not possible with neostigmine:
- It can rapidly reverse deep levels of neuromuscular blockade, which is not achievable with neostigmine[10].
- Sugammadex can be used as a rescue therapy in ‘can’t intubate, can’t oxygenate’ situations[10].
While sugammadex offers these significant advantages, its use should be carefully considered due to its higher cost compared to neostigmine/glycopyrrolate. However, in situations where rapid, predictable, and complete reversal of neuromuscular blockade is crucial, particularly in high-risk patients or emergency situations, the benefits of sugammadex may outweigh its cost.
Sources
[1] The efficacy and safety of sugammadex for reversing postoperative … https://www.nature.com/articles/s41598-017-06159-2
[2] Impact of Sugammadex Versus Neostigmine Reversal on… https://journals.lww.com/anesthesia-analgesia/fulltext/9900/impact_of_sugammadex_versus_neostigmine_reversal.835.aspx
[3] Impact of Sugammadex Versus Neostigmine/Glycopyrrolate on … https://www.dovepress.com/impact-of-sugammadex-versus-neostigmineglycopyrrolate-on-perioperative-peer-reviewed-fulltext-article-CEOR
[4] Sugammadex - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK470263/
[5] Sugammadex compared with neostigmine/glycopyrrolate for routine … https://pmc.ncbi.nlm.nih.gov/articles/PMC2955536/
[6] Sugammadex versus neostigmine for neuromuscular blockade … https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2022.1072711/full
[7] Neuromuscular Blockade Agents Reversal with Sugammadex … https://pmc.ncbi.nlm.nih.gov/articles/PMC7084040/
[8] Effects of sugammadex versus neostigmine on postoperative … https://www.nature.com/articles/s41598-023-32730-1
[9] A systematic review of sugammadex vs neostigmine for reversal of … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13277
[10] [PDF] Sugammadex injection 200 mg in 2mL and 500 mg in 5mL https://www.health.qld.gov.au/__data/assets/pdf_file/0033/638835/qh-gdl-442.pdf
[11] Sugammadex compared with neostigmine/glycopyrrolate for routine … https://academic.oup.com/bja/article/105/5/558/234565
[12] Reversal of neuromuscular blockade with sugammadex during … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14897
[13] Impact of Sugammadex Versus Neostigmine/Glycopyrrolate on … https://www.tandfonline.com/doi/full/10.2147/CEOR.S221308
[14] Full article: Safety of sugammadex for reversal of neuromuscular block https://www.tandfonline.com/doi/full/10.1080/14740338.2019.1649393
[15] Recovery characteristics of patients receiving either sugammadex or … https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14174
[16] [PDF] Sugammadex vs Neostigmine, a Comparison in Reversing … - Cureus https://www.cureus.com/articles/273169-sugammadex-vs-neostigmine-a-comparison-in-reversing-neuromuscular-blockade-a-narrative-review.pdf
