Special Populations Flashcards
For induction of cardiac patients, is ketamine a myocardial depressant?
Yes. It will still likely improve BP due to inhibition of NE reuptake in the vasculature, but it will make the heart a less effective pump.
Bariatric considerations for anesthesia:
- Excess tissue makes them prone to total airway collapse.
- Put in semi-fowler’s to get weight off of thorax.
- Reduced FRC = reduced apnea time.
- Ensure IVs aren’t interstitial in adipose.
- Use CPAP to recruit alveoli pre-induction and recurrent recruitment maneuvers during transport.
- Different drugs have different doses depending on IBW/LBW/TBW. Induction doses are often the same, but maintenance needs to be much higher!
- Consider esophageal balloon to monitor safe plateau pressures.
Obstetrical considerations for anesthesia:
- Fix mom first, not baby.
- Remember to wedge/shift patients uterus and to DC any hypotensive drugs like tocolytics.
- Progesterone’s effects include engorgement of airway vasculature (reduced mallampati) as well as sensitization of receptors to induction agents. Use less Rx.
- Decreased FRC/apnea time and higher risk of aspiration. Consider anti-emetics prophylactically.
- Supradiaphragmatic IV access
- NMRBs don’t cross placental barrier. Everything else does. Who cares.
Pediatric considerations for anesthesia:
- Age < 6 = big tongue, floppy epiglottis, narrow trachea.
- Atropine to reverse vagal sensitivity and dry up Orogastric secretions.
- Be prepared for laryngospasm.
- Large occiput. Use shoulder roll.
- Healthy kids need a higher mg/kg than normal.
- Check cuff pressure in flight to keep between 20-30.
- Have a variety of ETT sizes available.
- Use epi as an emergency vasopressor, not phenylephrine
What’s your surgical airway strategy for children < 8y/o?
-Catheter cricothyrotomy as a temporizing measure. Use O2 litre flow to match patient’s age with a 6:1 I:E ratio. Still utilize an SGA to facilitate getting air out of lungs and continue to work on a patent airway.
Accurate SpO2 pleth is unreliable below what reading?
86%
Signs of a crumping pediatric patient:
- Any tachycardia should be considered shock before it is considered pain or under sedation!
- Other signs include tachypnea, delayed cap refill and any kid who isn’t freaking out appropriately!
Vasopressor of choice for the failing pediatric patient:
Epinephrine
Considerations for geriatric anesthesia:
- A lot more comorbidities
- Fewer adipose stores and decreased hepatorenal function means a lot less drugs!
- Much more sensitive to narcotics, benzos and propofol. Use ketamine.
- Use same dose of NRMBs, but expect them to last much longer.
Considerations for securing ETT in burn patients:
Swelling in oropharynx will continue after intubation and potentially push ETT out of place. Insert a little deeper than normal and secure tightly.
Concerns when intubating penetrating neck trauma…
If the airway isn’t patent, you can make it worse with ETT placement. Then you’ll be ventilating the mediastinum and I’ve heard that isn’t good. Maybe wait for an ENT to scope the airway first?
State your intubation strategy for a failed right side thoracostomy. You have to intubate the left lung only…., but how?
Turn patient’s head towards the side of the failing lung and rotate the ETT towards side of the good lung. Keep the same rate, but half the tidal volume.
Cardiovascular and hemodynamic changes to the mother during pregnancy:
- Increased HR
- Decreased BP
- Increased CO by 40% at term
- Increased DBP (venous HTN)
- Increased pelvic/uterine blood flow
- No autoregulation of the placenta/fetus. Changes in FHR may be first indicator of maternal compromise.
- Increased VO2
- Supine hypotension syndromes
Hematological changes that occur in the mother during pregnancy:
- Decreased Hgb + Increased plasma/ECFV = Decreased Hct
- Decreased Plts, clotting factors and fibrinogen
- Decreased WBC function
- Decreased serum HCO3
Airway and ventilation considerations for the maternal patient:
- Reduced FRC + increased VO2 = reduced apnea time
- Increased RR and VT = Increased VE
- Consider high PEEP if BP can tolerate it
- Decreased LES tone
- Increased progesterone levels = lower Mallampati score
- Mild respiratory alkalosis is normal (PaCO2 30-32)
- Chest tubes go in higher than normal
