System Review Flashcards
preeclampsia
neuro: AMS, H/A, visual, cerebral edema, seziure, intracranial hemorrage #1 cause death
cardiac: HTN, elevated SVR, hypovolemia
pulm: airway edema, pulm edema (increase PCWP, decreased CO, excess fluid admin)-low colloid oncotic pressure and increase vascular perm predipose
GI: capsule distention, hemorrage, rupture, HELLP
renal: oliguria (decrease GFR), proteinuria from increase glomerular perm
heme: plt activation <100K, hypocoag, increased fibrinolysis
fetal: IUGR, decreased uteroplacnetal perfusion (placental infarcts), premature, abruption
Pregnancy for non-OB surgery
Neuro: decreased MAC and increased sensitivity to LA
cards: aortocaval compression predisposing to hypotension
pulm: difficult airway, low FRC predisposing to desaturation
GI: aspiration risk
Fetal: teratogencity (postnatal changes function or form, weeks 1-6), spontaneous abortion, premature labor, fetal mortality
Heme: thromboembolism
Evaluate the nature of cardiac dz
- FocusedHistory: -known diagnosis, past evaluations/hospitalizations, tests, meds/compliance
- cardiac sx (past and current): exercise tolerance, CP, SOB, syncope, orrthopnea, palpitations - PE: signs for HF -Rhythm, murmurs, S3 gallop, crackles, edema, JVD
3: Labs: CXR EKG, echo
HTN consideration head to toe
perioperative risks,
preop assessment
potential causes
Head to toe
neuro: shift in cerebral autoregulation, stroke, retinopathy
cards: LVH, CAD/MI, arrythmia, CHF (diastolic dys)
renal: overactivity of renin angiotensin-aldosterone system
concerns : BP instability, arrythmias, MI, stroke, CHF, hypoperfusion/end organ ischemia w reduction
Preop:
History:
- cause (essential, coartation aorta, OSA/obesity renal, endocrine-pheo, hyperaldosterone, cushing, pheo, thyroid/parathyroid),
- degree of control, baseline, meds
- end organ effects
PE: signs CHF
Labs: BUN/Cr-renal involement, NA K diruetic effects
EKG for LVH, arrythmia, ischemia, strain
CXR: cardiomegaly, pulm edema
Goal: keep BP within 20% of baseline
Concerns for a aneursym repair
Anesthesia
Difficult airway-
compression (airway compression, SVC syndrome edma), DLT
Cross clamp
neuro
Paraplegia- Loss sensory and motor with intact vibration and proprioception (ASA syndrome); epidural hematoma if neuraxial performed
Stroke: emboli, hypotension
CV
Aneurysm: rupture, thrombosis, compression (SVC, AI MI, CHF
Pulm
Post op pulmonary dysfxn from manipulation of diaphragm and lungs
Damage to phrenic or RLN
Heme
Coagulopathy: activation of coagulation (aneurysm thrombogenic), DIC
dilution effects of massive transfusion,
Renal
Post op AKI
hypotension…what do you do
- 100% oxygen
- confirm adequate ventilation and oxygenation (PTX, broncospasm, anaphlaxisis)
- evaluate monitors
- EKG: look for ischemia, hyperK, hypoCa, and arrythmia
- PIP, PEEP, MV, capnography (broncospasm, anaphalaxsis) - treat with fluids blood pressors PRN
- more access/monitors
- continue to eval cause
obesity
o Anesthesia: difficult airway management, patient positioning, altered drug effects (sensitivity), sensitivity to anesthetics, BP cuff
neuro: stroke, obesity hypoventilation syndrome,
CV: difficulty eval cardipulm status 2/2 sedentary lifestyle, HTN, CAD, phtn,
Pulm: rapid desat w apnea (decreased FRC, high v02), OSA/pickwickian, post op apnea, restrictive lung dz, pHTN
GI: nonalcoholic fatty liver, GERD w abdomen pushing belly up, delayed gastric emptying
Endocrine: DM o
Heme: DVT/PE, wound infection
Types of apnea
apnea
hypoapnea
obesity hyoventilation syndrome
- apnea cessation airflow >10 sec w >4% drop sat, >5 per hr
- hypoapnea >50% cessation in airflow, >4% drop sat, >15/ hr
- OHS 2/2 obesity/OSA: BMI>30, daytime arterial hypercapnea >45 nocternal hypoxia, polycythemia
- Pickwickian: severe form OHS chronic hypovent –>pulm HTN and RVF
hypothermia
neuro: AMS, delayed awaking
Cardiac;: myocardial depression, vasoconstriction (increased epi/NE levels), shivering (increased O2 consumption,increased PVR
Heme: left shift of hgb-O2 dissociation curve, plt dysfunction, poor wound healing/infection
other: decreased drug metabolism
burns
Anesthesia:increase free fraction opioid benzos, 25-30% burns resistance to NDMB at 72 hr, increased binding to alpha 1 glycoprotein, increased fetal Ach R (resistant to NDM
Neuro: head injury
Cards: hypovolemic-leaky capillaries (Parkland)
pulm: inhalational injury–>VQ mismatch, CO posioning (cooximetry) edema
GI: curling ulcer, aspiration risk
Heme: infectionsepsis/ disrupted skin barrier
Machine check
- check for emergeny ventilation equiptment: ambu suction
- check high pressure system: cylinders (1/2 full: 1000PSIG) and pipeline pressures (50-55 PSIG)
- check low pressure system: (vaporizers filled and caps tight, flowmeters cant deliver hypoxic mixture and tested through full range, negative pressure test (bulb to common gas outlet >10 sec)
- check scaavangeing: connection of APL to scavaneging system, NPRV: apl open and O2 flow low should collapse and gausge read 0, PPRV: APL open and and flush O2, bag should distent and read no more than 10 cm H20
- check breathign system: calibrate O2 monitor to RA and 100% oxyegn, inspect ciruit and CO2 absorber, Postive pressure leak test circuit (>30 10 seconds)
- check bmanual and automated breathign system: place bag on Y piece and set paremeters for pt, check this under manual and automated ventilation
- monitors
- machine final position: APL open, vaporizer off, flow off, manual vent selected
Liver disease
o Neuro: 1. Wernicke encephalopathy (ETOH thiamine def) 2. hepatic encephalopathy (production ammonia by intestinal bacteria)
o Pulm: 1. ascites decrease FRC 2. portopulmonary HTN 3. HPS
o GI; increased risk aspiration
o Renal: hepatorenal syndrome
o Heme: 1. SBP 2. plt dysfunction 3. coagulopathy
cirrhosis
heapatic necrosis, fibrosis, and nodal regeneration/ leading to portal HTN >10mmHg. causes ETOH, hepatitis, toxins
Anesthesia:
1) paralysis: may need more larger initial dose due to larger VD, decreaed proetin binding larger free fraction may off set this, and impaired metabolism few doses may be needed
2) citrate intoxication more likely w blood
3) psueocholinesterase def
Neuro: encephalopathy AMS, asterxisis, hyperreflexa, wernicke korsakoff (more permeable BBB, ammonia broken down from blood in GI tract or transfusion)
Cards: hyperdynmaic state =high mixed venous(increased CO, low SVR, anemia, systemic shunts), systemic AV shunts
resp: decreased FRC and restrictive dz from ascites, increased AV shunts, plerual effusions, inhibition of HPV (from vasodilating substances - VIP, glucagon)–>hypoxemia, resp alkalosis
GI: Portal HTN
ascities (2/2 portal HTN, hypoalbumin, renal rentention of fluids)
varices/hemorrhids,
aspiration risk, delayed gastric emptying
renal: decrease renal perfusion, sodium retentiom. (increase in total body andvolume but decrease in effective volume, HRS (prerenal oliguria w NA retention, azotemia, and ascites
Heme: thrombocytopenia (splenic sequestration), anemia (bleeding, RBC destruction, malnutritio) SBP
Electrolytes: hyponatremia (dilutional), hypokalemia (diuresis or hyperaldosteronism), hypoalbumin, hypoglycemia
esophageal cancer
cardio: often after ETOH and smoker, high risk post op a fib
pulm: smokers often, chronic aspiration–>pulm fibrosis,
GI: nutrional status poor (increased MM), liver fxn, aspiration risk (obstruction, altered motility and spincter dysfunction
chemo: doxorubicin (cardiomyopathy, belomycin lung, radiation (pnumonitis, pericarditis
chronic alcoholic
Anesthesia: intoxiciation effect on MAC
neuro: AMS, encephalopathy, wernicke korsaoff (ataxia, confusion, occular issues; tx thiamine), withdrawl (sezizures DT)
cards: acute HTN tachy; cardiomyopathy, arrythmia
resp: smoker?
gi: ulcer, cirrhosis, aspiration risk
heme: pancytopenia
RA
CV: pericardial thickening/pericarditis//effusion, myocarditis/fibrosis, vasculitis, AR, CAD from steriods, conduction defects, vasculitis
pulm: pleural effusion, pulm nodules, pulm fibrosis
Heme: anemia, Aspirin induced plt dysfxn, thrombocytopenia,
endocrine: adrenal insufficiency (chronic steriod use), immunesuppression from steriods and antiinflammatory meds
Joint involvement/difficult intubation: cervical spine (alantoaxial subluxation, >5mm alanto odontoid distance), TMJ, cricoarytenoid joint (hoarse voice, small ETT)= difficult intubation
liver and kidney dysfunction
Ankylosing spondylosis
neuro: nerve root compression, cauda equina syndrome, uvetitis, parathesia, high block 2/2 smaller epidural space, c spine/TMJ involvement
cards: AI, condution defects,
resp: restrictive lung dz, impossible trach if stuck in neck flexion, difficult airway
gi: UC, crohns
SS head to toe
CNS: cerebral thrombosis, painful/vasoocclusive crises, deficits from stoke/seizures
Cardiac: CHFfrom chronic hypoxia, hemochromatosis, MI,
pulm: increased intrapulm shunting, ACS
GI: nonconjugated hyper bili from hemolysis, bile cholelithaisis,
renal: meduallary infarcts leading to isothenuria
Heme: splenic infarcts, aspetic necrosis, osteo, infection (asplenic), aplastic anemia(Parovovirus/folate decreased rbc production+ reduced life span (20 vs 120 days)–>profound anemia), transfusion, anemia
Endocrine: hemachromatosis-DI, hepatomegaly, adrenal insufficiency, hypothyroidism, hypopara
risks factors for aspiration
delayed gastric emptying: autonomic neuopathy, acute abdomen, pain, cirrhosis, chronic alcohol abuse,
pregnancy
bowel obstruction
GERD
DM
Neuro: peripheral neuropathy, retiniopathy
Cards: autonomic neuropathy: silent MI, resting tachycardia, lack HR varibility w respirations, orthostasis, insensitivity to atropine and propranolol, lack HR response to hypovolemia, impaired vasoconstriction (susceptible to hypothermia), lack sweating, impotence
CAD, HTN, cardiomyopathy, PVD, MI
Resp: difficult intubation stiff join syndrome (TMJ, AO, cervical spine-prayer sign)
GI: gastroparesis (early satiety)
renal: nephropathy
endocrine: hyper/hypoglycemia, DKA, NKHC
Heme: impaired phagocytosis
stridor after thyroidectomy
Post extubation airway obstruction/ stridor
Hematoma
Edema
Post intubation croup
Tracheolamacia
laryngospasmm
RLN injury-partial hoarseness, complete-aphonia, aspiration risk b/l partial laryngeal obstruction (abduction of VC)
Hypocalcemia removal of parathyroid 1-3 days later
Residual paralysis (MG common in hyperthyroid pts)
ESRD
Anesthesia:
decreased protein binding–>enhanced drug effect: barbs and benzo, etomidate:
active metabolites dependent on renal excretion: keta,ine, morphine, meperidine,
increased BBB permeability and uremic toxins, effects anesthetics may be enhanced
neuro: urremic encephalopathy, peripheral/autonomic neuropathy,
cards: accelerated CAD, fluid overload, CHF, HTN, pericarditis, arrythmias, autonomic neuropathy, conduction blockade
resp: pulm edema, pleural effusion
GI: delayed gastric empyting; bleeding,
endocrine:
- hyper: K, mAg, Po4, uric acid
hypo: na ca, hypoalbumin,
met acidosis
heme: anemia (low EPO), plt and WBC dysfunction
endocrine; insulin resistance, 2 hyperparathyroidism , high TG
delayed emergence
ABCs: hypoxia, hypercarbia, hypotensions
Drugs: opioids, paralysis, benzos
Metabolic: hypoglycemia, hyponatremia, hypermagnesium (OB), hyperosmolarity
Neurologic: stroke (embolic, thrombotic, ischemic), postictal, ongoing ischemia (ICP, vasospasm, herniation) hematoma, edema tension pneumocephalus, hydrocephalus
other: hypothermia
How to manage ICP
Eval ABCs and etiology: avoid hypoxia and hypercarbia
Increase venous drainage
elevate head 15-20 degrees if hemodynamically
ensure no venous obstruction (esp if C collar in place)
diureticsadmin mannitol: (reduces ICP by osmotically shifting fluid from brain to intravascular space, decrease production CSF, induce reflex cerebral vasoconstriction 2/2 decreasing blood viscosity(lasts 6 hr)
risktransient increase intravascular volume can increase BP & decrease ICP (increase transmural pressure): hazard to unrupture aneurysm, AVM, expanding hematoma (mod elevated ICP can serve to tamponade the lesions
elderly: rapid diuresis shrink brain and tear bridging veinssubdural hematoma
increase vascular volume poorly tolerated by HF
cerebal edema if BBB not intact
furosemide
keep in mind that in presence of hypovolemia this an lead to hypotension and worsen cerebral ischemia
hypertonic saline
admin barbiturate/propofol (reduced ICP 2/2 cerebral vasoconstriction) and CMR02
risk of hypotension when admin large doses for cerebral protection
hyperventilation to PaC02 25-30 if other methods unsuccessful and ICP elevation was so severe that there was risk of brain stem herniation
too much cerebral vasoconstriction can leadto cerebral injury
effects temporary (6-12 hrs) since Hc02 levels in CSF are adjusted for the change in PaC02
between Pac02 20-80 CBF changes 1ml/100g per 1mmHg change PaC02
If ICP severe requires immediate tx: intraventricular drainremove CSF (no more than 5cc/min).
Too much can cause brainstem herniationHTN/hypotension/bradycardia/tacycardia
if lumbar catheter can cause herniation if obstructive hydrocephalus (obstruction proximal to superior sagittal sinus
steroids if brain tumor for vasogenic edema, decrease CSF production?
if at risk for seizures implement seizure ppx to avoid increases CMR02
change agent (volatile to TIVA)
muscular dystrophy
Anesthesia: rhabdo to succ/volatiles, sensitive to resp depressants
cards: EKG ab (tachycardia, tall R waves in V1, Q waves in limb leads, inverted T waves), cardiomyopathy, arrthymias, MR
resp: ineffective cough/dimished airway refexes (aspiration, infections), macroglossia,
GI; delayed gastric emptying
Loss of neuromonitoring signals
- alert surgeon
- ensure not change in dept of anesthesia (prop, volatile, relaxant)
- correct hypoxia, ensure normocarbia, correct hypovolemia, hypotension, anemia, to optimize oxygen delivery
- surgical causes- excessive distration
- perform wake up test
Complications of tumescent lipo
max limit lido
limit LAST
fluid overload pulm edema, LAST, DVT
35-55 mg/kg
1:1,000,000 epi
dilute solution, add epi, limitsurgery to 3L of fat removal, lipid rescue kit
IV fluids+ tumscuent solution-UOP
givelasix after 2L
hypothyroid
tx
Hashimoto’s thyroiditis
anesthesia: do not give volatiles (myocardial depression), consder ketamine
Neuro: AMS, slow reflexes, myxedema coma, hypothermia
cards: CHF, pericardial effusion, blunted baroR reflexes, bradycardia (downregulation of Beta R), increased SVR (decreased PP), decreased intravascular volume
resp: drug induced resp depression, large tongue intubation, limapired hypoxia and hypercarbia drive, pleural effusion, OSA
GI: delayed gastric emptying
renal: decreased intravascular volume-leaky capillaries
Heme: anaemia, coagulopathy
Endocrine: adrenal insufficiency, electrolytes: low Na(increased ADH, impaired renal concentration ability), low glucose
myxedema coma: altered mental status, (coma or seizure), hypothermia, bradycardia, hyponatremia, heart failure, hypopnea
IV levothyroxine steriods if think adrenal insufficiency
MG
Pathophysiology: destruction nicotinic acetylcholine R at post synaptic memebrane
Sx:
bulbar weakness (diplopia, ptosis, difficulty with speech and swallow, dyspnea), muscle weakness with exertion, thyoma
cardiac: HTN, AV block, a fib, myocarditis, cardiomyopathy, dystolic dysfunction
endocrine: hyperthyroid, RA, pernicious anemia, SLE, thyoma
neonate weakness 2-4 weeks
hyperthyroidism
Lab: TSH (low), Free T4 and T3 (high)
Neuro: anxiety, agitation, tremors, insomnia, muscle weakness, sweating/heat intolerance, weightloss, fever
cards: tachycardia, HTN (increased SV and CO), decreased SVR (increased PP) arrythmia (afib), cardiomegaly, hypovolemia
GI: dirrhea
renal: activation RAAS
arrythmia, hyperdynamic circ, risk hemodynamic instability
not able to render euthyroid prior to surgery,no tx: iodide, steriods (decrease peripheral conversion, BB, cholestyramine)
canceling for a cold
perioperative respiratory complications: bbroncospasm, larngospasm, desaturation
- delay 4-6 weeks if fever >38.5, malise, productive cough, mucopurulent sputum, pulm involement (wheezing)
- mild sx delay 2-4 weeks: sneezing nasal congestion, nonproductive cough +require ETT + additional RF (exposure to smoke, underlying pulm dz (asthma), surgery of airway, age < 1 year /premature
- proceed if mild sx and do no require ETT (mask, LMA, regional)
tx for MH
- call for help.ICU 72 hrs
- admin drantrolene 2.5g/kg q5-10 min, infusion 1mg/kg q6h for 24-48 hrs
- hyperventilate pt w 100%
- active cooling: lavage-gastric bladder rectal, peritoneal lavage, CBP, ice packs over major arteries
- maintain UOP w lasix fluids, mannitol
- monitor K (dextrose insulin) calcium, ABG (acidosis-bicarb), serum CK, liver enzymes, coagulation
- monitor for DIC, myoglobinuric renal failure (ATN, obstructive nephropathy), recrudenscence
Risks of prematurity
Neuro: IVH, hypothermia, retinopathy of prematurity
Resp: post op apnea, RDS, PPHN
GI: NEC, impaired liver fxn
Renal: imapired renal fxn
Endocrine: hypoglycemia (poor glycogen stores)
Heme: anemia (transfuse 40-45 if severe cardiopul dz, 30-35 moderate, normal 20-25)
Downs
Features
Neuro: alanto axial instability: subluxation,
Cardiac: bradycardia w/ sevo, 50% endocardial cushion defects (defects involving atrial, ventricular septum, and 1 or both AV valves), VSD, ASD, PDA, TOF
Pulm: marcroglossia, micrognathia, subglottic stensosis, hypotonia and redundancy soft tissue, osa
gi: duodenal atresia
When to get Echo
There is no Class 1 recommendation, all 2a
reasonable to evaluate LV function in
- patients with dyspnea of unknown origin
- patients with known heart disease with worsening dyspnea or change in clinicsl status
- clinically stable pt with prior LV dysfunction with no eval in >12 months
RCRI and MACE
Revised Cardiac Index
Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr > 2.0, IDDM, high risk surgery
CAD: unstable angina, MI, use nitrate, , active + stress test, path q wave
0-0.4% risk of cardiac complications
1-0.9% risk of cardiac complications
2-7% risk of cardiac complications
3-11% risk of cardiac complications
Active cardiac conditions
- Unstable coronary syndroms:
unstable angina (ACS)
recent MI (30 days)
- Decompensated heart failure
- Significant arrythmia:
High grade AV block, Mobitz II AV block, 3rd degree block
Symptomatic ventricular arrythmia or sx brady
SVR with HR>100 at rest
Newly recognized ventricular tachycardia
4: Severe valvular disease:
1. Severe AS (Mean gradient >40 mmHg, aortic valve area <1 cm2, or symptomatic)
2. Symptomatic MS (DOE, exertional presyncope, or heart failure)
surgery risk
Low risk <1%: ambulatory, breast, cataracts, endoscopic, superficial
Intermediate risk: 1-5%
- carotid endarterectomy, head/neck,
- Intraperitoneal/Intrathoracic,
orthopedic, prostate
High risk: aortic/other major vascular procedures, peripheral vascular surgery >5%
HTN consideration head to toe
perioperative risks,
preop assessment
potential causes
neuro: shift in cerebral autoregulation, stroke, retinopathy
cards: LVH, CAD/MI, arrythmia, CHF (diastolic dys)
renal: overactivity of renin angiotensin-aldosterone system, CKD
concerns : BP instability, arrythmias, MI, stroke, CHF, hypoperfusion/end organ ischemia w reduction
Preop:
History:
- cause (essential, coartation aorta, OSA/obesity renal, endocrine-pheo, hyperaldosterone, cushing, thyroid/parathyroid),
- degree of control, baseline, meds
- end organ effects
PE: signs CHF
Labs: BUN/Cr-renal involement, NA K diruetic effects
EKG for LVH (S in V1 + R in V5 or V6 ≥ 35 mm), arrythmia, ischemia, strain (ST depression and T-wave inversion)
CXR: cardiomegaly, pulm edema
Goal: keep BP within 20% of baseline
Indication for central cathter or PAC, TEE, a line
CVC
- monitor CVP/fluid status
- venous access in pt w poor access, drug/hyperailmetation infusion
- pacing
- aspiration of air during venous emboli
PAC
monitor filling pressures, PAP, PCWP, CO, MV02, SVR, PVR
TEE
- eval global fxn
- RWA (Most sensitive indicator of ischemia)
- fluid status
- estimate preload (filling pressures
- judge accuracy of cardiac procedures
- assess unexplained hemodynamic disturbances
a line
- monitor BP on a continuous beat to beat basis,
- ABG freq sampling
- CPB (non pulsatile flow)
aneursym repair
Anesthesia
Difficult airway-compression (airway compression, SVC syndrome edma), DLT
Cross clamp
neuro
Paraplegia-Loss motor with intact vibration and proprioception, sensory (ASA syndrome)
epidural hematoma if neuraxial performed
Stroke: emboli, hypotension
CV
Aneurysm: rupture, thrombosis, compression (SVC, AI
MI, CHF
Pulm
Post op pulmonary dysfxn from manipulation of diaphragm and lungs
Damage to phrenic or RLN
GI: mesenteric ischemia
Heme
Coagulopathy: activation of coagulation (aneurysm thrombogenic), DIC
dilution effects of massive transfusion,
Renal
Post op AKI
minimize cord ischemia during cross clamp
-Avoid hypotension MAP>80, maintain normal Hct and
Labs:
PaO2, (monitorand maintain adeuwate MAP above and below cord)
-Avoid hyperglycemia
Monitoring:
- Lower ICP w spinal drain (15cc / 15 min max 60cc) ICP 8-10
- Monitor cord with SSEP MEP
Careful with vasodilators or high conc on inhalational agents (vasodilation increase ICP which transmitted to cord and lower distal perfusion)
Surgical: Min clamp time, use shunt, reattach segmental arteries
hypotension at start of CBP
- hemodilution: decreases SVR (depends on vascular tone and viscosity) from pump priming solution (usually transient as hypotension induced vasoconstricton and endogenous catecholamine increase BP
- arterial or venous malfunction or malposition: aortic cannula inserted into aortic wall–>dissection, inserted into inmoninate or carotid (cerebal edema/hemorrhage), venous cannula kinked or malpositioned,
- switch of venous and aortic cannula
*** aortic cannula in inmoniate would see HTN w R sided a line and hypotension w L sided a line
steps of CPB and coming off
HAD2SUE
Heparin: Always give prior to bypass.
ACT: Always check before going on bypass (450 seconds)
Drugs: Do you need anything (Non depolarizing neuromuscular blocker).
Drips: Turn off the inotropes etc.
Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture.
Urine: Account for bypass urine
Emboli: Check the Arterial cannula for bubbles.
CBP, Cool, Clamp (after Vfib starts ~28C), Cardioplegia
WARMVP:
warm,, admin midaz
Anemia/electrolytes/acidbase
Rhythmn: rate ok? need to be paced? defib at 30C
Monitors/alarms/rezero lines
Ventilation: deair, check compliance/recruit
Perfusion: pump flow, cardiac fxn on TEE, admin vasopressors and inotropes
coagulopathy after bypass
- abnormal plt fxn-activation on nonendothealil surfaces-oxygenator, filter, cartiotomy suction, hypothermia, nitro protamine
preserve function: autologous blood collection, less use of cartiotomy suction, no bubble oxygenator
- thrombocytopenia
- hemodilution of coag factors
- residual heparin:inadequate neutralizaton, heparin rebound (4-6 hrs after neutralization from dissociation of heparin), residual heparin from scavanged blood
- fibrinolysis- increase plasmin 2/2 to release of TPA (tissue plasminogen activator) from endothelium during CPB, decrease levels plasminogen activator inhibitor
- DIC
- hypothermia
AICD WORKUP
Type and model of device, Indication for placement, when placed (<3 months more likely to be dislodged during central line placement, cardiac surgery, or manipulation of intracardiac catheters)
underlying rhythm and rate, Pacer dependent, pacing threshold, recoded arrhythmic events
programmed mode, response to magnet (usually disables tachydysrythmia detection therapy), reprogramming needed,
Last checked (6 months ICD, 12 months PPM), functioning properly, battery life (should be at least 3 months),alert status on lead or generator( lead could be oversensing),
Indications for iCD
PPM
- secondary prevention VF VT
- primary prevention: MI and EF<30, HF class 2-3 w/ EF <35 (intraven conduction delay 120ms cardiac resyn), congenital long QT syndrome, brugada, HCM
- Sinus node desyfunction, AV block
lung ca considerations
Signs mass effect
Obstructive PNA
SVC syndrome
Pancoast tumor
tracheal bronchial distortion- mass induced VQ mismatch
mass compression of heart and great vessels
Tumor invasion
Hemoptysis, blood stained sputum
Cancer related meds
Bleomycin (interstitial pneumonitis, pulm fibrosis)
Cisplatin: peripheral neuropathy, renal failure
Paraneoplastic syndrome
Lambert Eaton
SIADH-hyponatremia vs loop diuretic), decreased serum osm,
Cushing syndrome-Ectopic ACTH, hypokalemia, HTN, psychosis
Parathyroid releasing hormone-hypercalemia-N/V, renal failure, weakness, arrhythmia
hypoxia during OLV
100% oxygen
Ensure adequate placement by capnography, listening to chest, fiberoptic scope for direct visualization
Check BP to ensure adequate perfusion
RL shunt from collapsed lung
Recruitment breaths
CPAP 10 Cm H20 to nondependent lung if surgically acceptable
PEEP 5-10 cm H20 to ventilated lung ( in healthy lungs this way result in pressure induced shunting blood to nondependent lung)
Reinflate non dependent lung
Discuss with surgeon about ligating pulm artery to elim shunt
Encourage hypoxic vasoconstriction (remove agents that may blunt this)-volatile, systemic vasodilators, hypocapnia (inhibit HPV nondependent lung and increased vascular resistance in dependent lung
CF
cardiac: pulm htn cor pulm
pulm: freq muscus plugging, inflammation, infection–>hypoxia (V/Q mismatch), broncospasm, PTX (bbullae), bronchiestasis, resp failure,post op resp failure, lung infections
GI/hepatic: malabs (vit K def + coaggulopathy; electrolyte abnormalities), pseudocholinesterase def
endocrine: DM (pancreatic involvement)
broncodilators, abx, chest physiotherapy
post op dyspnea
Neuro: neuro conditions-MG, pain , nerve (phrenic from blocks)
Cardiac: cardiogenic pulm edema,
Pulm: atelectasis, aspiration, bronchospasm, bleeding/compression, drugs ,airway edema/NPPE/cardiogenic pulm edema , larnygospasm, PTX, PE, obstruction (OSA)
extubation critera
Neuro: Awake and alert; following commands; return of airway reflexes; fully reversed, normothermic
Cards: Stable vital signs, hemostasis
Resp: (VC >10-15ml/kg, NIF >25-30, TV >5ml/kg)
If questionable, PS support trial w/ 5cmH2O and 5cmH2O CPAP on FiO2 0.4 x 30 min
ABG: PaO2 >80, PCO2 35-45, pH 7.35-7.45
PTH
hyper para, tx
increases Ca: bone resportion, renal tubular absoprtion, synthesis of vit D (intestinal abs Ca and P04)
anesthesia: unpredictabe response to muscle relaxants
neuro: psychosis, weakness,
cards: hypovolemia, HTN, heart block, BBB, bradycrdia
resp:
gi: PUD, constipation,
renal: kidney stones
hydration, lasix, correct hypoP04, dialysis, second line -calcitonin, steriods (tx >15)
hypervent
hypopara
neuro: seziures, cramps, depression
cards: hypotension, CHF, insensitive to B agonist, prolonged QT
resp: stridor/apnea
