Things to Know 2 Flashcards
1
Q
Anaphylaxis vs. Anaphylactoid
A
Anaphylaxis –> Type 1 hypersensitivity reaction, due to antigen-specific IgE antibodies, causes increased capillary permeability, peripheral vasodilation, bronchoconstriction, negative inotropy, coronary artery vasoconstriction
Anaphylactoid –> Triggered by mast cells and basophils direct interaction with certain allergens rather than interaction with IgE antibodies, dose dependent, doesn’t require prior sensitization
2
Q
How to treat anaphylactic reaction
A
1) Call for help
2) 100% O2
3) 1-2 L fluid bolus
4) EPI
5) steroids, histamine blockers (H1, benadryl), H2 blockers (ranitidine, famotidine, etc.)
6) Inhaled b2 agonist
7) Supportive care
3
Q
How does epi work for anaphylaxis?
A
alpha agonism causes vasoconstriction
beta agonism relaxas bronchial smooth muscle
increased cAMP restores vascular permeability
give IV if hypotensive and subQ if normotensive
4
Q
Risk factors for latex allergy?
A
1) Spina bifida
2) Congenital urinary tract abnormalities
3) Undergoing multiple surgeries or medical procedures
4) Working in healthcare or rubber industry
5) Allergy to certain foods such as avocados, bananas, chestnuts, kiwis and passion fruit
basically repeated exposure to healthcare setting and fruits
5
Q
Reasonable BP cut off for elective surgery
A
SBP > 180 or DBP > 110 if no end organ dysfunction
6
Q
Causes of HTN
A
CKD Renovascular disease Chronic steroid use Sleep Apnea Drugs Alcohol Abuse Obesity/metabolic syndrome Thyroid or parathyroid disease Pheo Coarctation of the aorta
7
Q
How to perform an axillary block?
A
Patient in a supine position with arm abducted and elbow flexed 90 degrees
Use US to locate the axillary artery and the nerve sheath next to it
Insert needle under US guidance into the nerve sheath and after negative aspiration inject 15-20 cc of local anesthetic
Block the musculocutaneous nerve within the coracobrachialis with additional 5 cc of local
8
Q
What does the musculocutaneous nerve do?
A
Motor to the biceps
Sensory innervation to the lateral forearm
9
Q
Differential for ACT not rising with heparinization for bypsas
A
1) AT3 deficiency
2) ACT machine broken
3) IV infiltrated
4) Insufficient dose of heparin
10
Q
Types of protamine reactions
A
1) brief hypotension
2) anaphylactic/anaphylactoid generalized reaction
3) Severe pHTN with noncardiogenic pulmonary edema with cardiopulmonary collapse
11
Q
What are the types of TEF?
A
Type A: Isolate esophageal atresia
Type B: Proximal fistula
Type C: Distal fistula
Type D: Both proximal and distal fistulas
Type E: H type, isolated fistula no atresia
12
Q
What are VACTERL deformities?
A
Vertebral Anal Cardiac TracheoEsophageal Renal and radial Limb
13
Q
What percentage of infants with TEF have cardiac defect?
A
Up to 20%, pre op echo is very important
14
Q
Airway/induction for infant with TEF?
A
Many options, but basically you are trying to reduce aspiration but also reduce positive pressure ventilation
Would plan on inhaled induction after suctioning blind pouch to reduce chance of aspiration, this leaves infant spontaneously ventilating to reduce gastric distention
15
Q
What type of TEF is most common?
A
80+% are Type C (c for common!)
Blind proximal pouch with a distal fistula
Try to position ETT past the fistula but above the carina
16
Q
FHR variability
A
Indicates intact autonomic system
Minimal is < 5 bpm
Moderate is 6-25 bpm
Market is > 25 bpm
Over 2 cycles/min
17
Q
What decreases FHR variability?
A
fetal hypoxia, sleep, prematurity, neurologic abnormalities, fetal tachycardia, betamethasone, opioids, benzos, mangesium
18
Q
Adequate fetal accelerations
A
Adequate accelerations are defined as:
<32 weeks’ : >10 BPMabove baseline for >10 seconds
>32 weeks’ : >15 BPM above baseline for > 15 seconds
Twice in a 20 minute period = reactive
19
Q
Normal FHR
A
110-160 bpm
20
Q
Normal pressure differential for raising the transducer
A
10 cm = 7.5 mm Hg
A vertical difference of 10 cm between the pressure transducer and the artery of interest results in a pressure difference of 7.5 mmHg due to hydrostatic pressure
21
Q
At what gestational age is LUD indicated?
A
18-20 weeks
22
Q
What is rhesus isosensitization?
A
When blood from an Rh+ baby gets into the circulation of an Rh- mother and she develops IgG antibodies against the Rhesus D antigen. Can cross the placenta and lead to anemia, hemolytic dz of the newborn, hydrops, etc.
Can happen 2/2 delivery, miscarriage, abortion, amnio, ectopic pregnancy, abdominal trauma etc.
Can be prevented by administering anti-Rh antibodies (RhoGAM) within 72 hrs of event, destroying fetal D+ RBCs
23
Q
Kleihauer-Betke Test
A
To detect and quantify the extent of fetomaternal hemorrhage to determine dose of RhoGAM
24
Q
When to avoid NSAIDs in a pregnant patient and why?
A
2nd half of pregnancy due to possibility of closure of the fetal ductus arteriosus
25
When does FHR variability develop?
25-27th week of gestation, suggestive of normally functioning autonomic nervous system
26
Most significant intrapartum sign of fetal compromise?
Absent or minimal FHR variability
*but remember can be affected by opioids, benzos, steroids, etc
27
Effect of maternal hyperventilation on a fetus?
Leads to reduced maternal cardiac output, decreased BP, increased uteroplacental vasoconstriction --> all can result in compromised blood flow to the baby
28
Spina bifida occults vs. cystica
Occulta: abnormal or incomplete formation of midline structures over the back without herniation of meninges or neural elements
Cystica: Failed fusion of the neural arch, associated with herniation of the meninges (meningocele) or both meninges and neural elements (myelomeningocele)
Often associated with hair or dimple on the skin, can be associated with tethered cord
29
What is an omphalocele
- Herniated abdominal viscera through the abdominal wall at the base of the umbilicus
- Occurs when gut fails to return to the abdominal cavity during gestation
- Has a membranous covering around the herniated viscera
- Normally functioning bowel
- Associated with other congenital defects such as CDH, trisomy 21, bladder exstrophy, cardiac abnormalities
30
What is gastroschisis?
- Defect in the abdominal wall with herniated viscera lateral to the umbilicus
- Exposed viscera and intestines with no covering
- Inflamed and functionally abnormal bowel
- Less likely associated with congenital abnormalities
31
What is Beckwith-Wiedemann?
- Congenital syndrome
- Macrosomia (weight & length > 90th percentile)
- Macroglossia
- Midline abdominal wall defect (omphalocele, umbilical hernia)
- Ear creases/pits
- Neonatal hypoglycemia and polycythemia
- There is a potential for difficult airway
32
What is Pierre Robin Sequence?
underdeveloped jaw, backward displacement of the tongue and upper airway obstruction. Cleft palate is also commonly present, large tongue, natal teeth
33
Carcinoid triad
Diarrhea, flushing and cardiac involvement (pulmonic stenosis or tricuspid regurgitation)
34
What is carcinoid syndrome?
Signs and symptoms when a carcinoid tumor releases excessive amounts of histamine, kallikrein and serotonin into systemic circulation
Most tumors do not result in symptoms because they enter portal circulation and are inactivated by the liver but liver mets of head/neck/lung/breast tumors can also result in symptoms
Symptoms include: flushing of the upper body, bronchoconstriction, diarrhea, right sided heart disease, hypotension and hypertension
35
How to diagnose carcinoid?
24 hour urine 5HIAA
Elevated serum chromogranin A
Also can use octreoscan, PET/CT, MRI
36
Why is left heart protected from carcinoid syndrome?
Pulmonary degradation of serotonin (except in cases of right to left intracardiac shunt)
37
How to reduce pre-op risk of carcinoid crisis?
1) Perioperative somatostatin analogue administration such as ocretotide - reduces tumor secretion of ocreotide
2) Optimize intravascular fluid status - probably depleted
3) Anxiolytic to present stress induced release of vasoactive substances
4) Alpha & beta blockers
5) H1 & H2 blockers
6) Steroids
38
When to avoid reglan pre op?
If there is a bowel obstruction
39
Vapor pressures of volatile anesthetics?
```
Sevo = 160 mm Hg
Iso = 240 mm Hg
Des = 681 mm Hg
```
40
What happens if you put iso in sevoflurane vaporizer?
Delivered concentration will be higher than expected because the vapor pressure of iso is higher than that of sevo. Danger compounded by the fact that iso is more potent than sevo.
41
Chance of crossreactivity between PCN allergy and cephalosporin allergy?
About 0.5% 1st generation
Near 0 for 2nd and 3rd generation
Also incidence of TRUE PCN allergy with reported PCN allergy is less than 10%
42
How many times faster than air does nitrous oxide diffuse into abdominal cavities?
34x
43
Tricuspid regurgitation effecto on CVP tracing?
Prominent CV wave and absent x-descent
44
Pathophysiology of aspiration pneumonitis?
Damage to surfactant producing cells and pulmonary capillary endothelium by gastric contents, causes atelectasis, pulmonary edema, bronchospasm, tachypnea, tachycardia, increased pulmonary vascular resistance 2/2 hypoxic pulmonary vasoconstriction and increased WOB
Intense inflammatory response can lead to ARDS
Then can develop pnuemonia due to transmission of bacteria into the lungs from the oropharynx
45
Abx after aspiration as prophylaxis?
No not usually recommended unless there was feculant aspiration (bowel obstruction etc)
46
Differential of a normal PT and elevated PTT
Von Willebrand's, Hemophilia A, B or C, lupus anticoagulant or low dose heparin administration
47
Hemophilias
A & B are both sex linked recessive disorders that are clinically indistinguishable
A - factor 8 deficient
B - factor 9 deficient
48
PT vs. PTT (extrinsic vs intrinsic)
PT - extrinsic & common pathway
| PTT - intrinsic
49
When to give DDAVP for hemophilia?
When patient has mild hemophilia A with Factor VIII levels > 5%
Induces release of factor VIII and vWF from endothelial cells
50
What level of factor VIII prevents surgical bleeding?
Most think 30%, but would correct to 75-100% depending on bleeding risk
51
Pros and cons of LMA for tonsillectomy
Pros: better protection of lower airway from blood, less bronchospasm, laryngospasm, bleeding and post-operative desaturation
Cons: ETT would be easier to place, occupies less space in the oropharynx and provides more reliable positive pressure ventilation
52
What are contra-indications to deep removal of LMA?
OSA, obesity, difficult airway
53
How to dose narcotics in patients undergoing tonsillectomy?
1/2 what you would normally give
There is a black box warning on codeine containing products in children undergoing tonsillectomy
54
How to dose factor VIII after a surgery?
Continue to replace for up to 2 weeks or longer for bone or joint surgery
Half life is 6-10 hrs in adults and 6 hrs in children
55
Benefits of induced hypotension in orthopedic surgery?
Decreased blood loss and operative time
56
Interscalene nerve block distribution
Indications: Shoulder and upper arm surgery, surgery of the clavicle (combined with cervical plexus nerve block)
Transducer position: Transverse on the neck, 3–4 cm superior to the clavicle, over the external jugular vein
Goal: Local anesthetic spread around superior and middle trunks of brachial plexus, between the anterior and middle scalene muscles
Local anesthetic: 7–15 mL
Commonly ulnar sparing, inferior trunk (C8-T1) is spared.
Anterior deltoid often received innervation from superficial cervical plexus so may not be blocked with interscalene
57
Bezold-Jarisch reflex
Bradycardia, apnea, hypotension in response to shoulder surgery, spinal or epidural anesthesia, after an MI etc. Thought to be a cardiac productive response (induced bradycardia to avoid ischemia)
A cardiovascular decompressor reflex involving a marked increase in vagal (parasympathetic) efferent discharge to the heart, elicited by stimulation of chemoreceptors, primarily in the left ventricle.
This causes a slowing of the heart beat (bradycardia) and dilatation of the peripheral blood vessels with resulting lowering of the blood pressure.
58
Horner's Syndrome
ptosis, miosis (constricted pupil), anhydrosis
Many causes but iatrogenic from anesthesia include cervical plexus block, stellate ganglion or interscalene block
59
Curling's ulcers
Curling's ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa
60
Cushing's ulcers
from head injury/elevated ICP
61
DPG & oxygen hemoglobin dissociation curve
Increased DPG --> right shift
| Decreased DPG --> left shift
62
Minimum UOP
0.5 ml/kg/hr
63
GCS
Scoring system used to describe the level of consciousness of a person following TBI using eye opening, motor response and verbal response
From 3-15
Below 9 = severe brain injury
9-12 = moderate
> 13 = minor
64
Definition of massive transfusion
1 blood volume in 24 hrs
| 50% blood volume in 4 hours
65
Trauma product resuscitation ratio
1:1:1
66
ARDS criteria
Acute Respiratory Distress Syndrome (ARDS)
acute onset
PaO2/FiO2 ratio < 200
bilateral infiltrates consistent with pulmonary edema
no evidence of LA hypertension
67
Ventilation strategy in ARDS
Protective lung ventilation
- low tidal volume (TV) ventilation (4-8 mL/kg)
- Maintaining plateau pressures (Pplat) <30 cmH20
- Permissive hypercapnia
- 6 mL/kg PBW (predicted body weight, not actual body weight)
68
Severity of ARDS
Mild 200 – 300
Moderate 100 – 200
Severe < 100
69
Pathophysiology of ARDS
Acute lung inflammation, increased permeability of the lung endothelial and epithelial barriers, inhibition of surfactant function, impairment of alveolar fluid clearance mechanisms and systemic inflammation
70
Pre-thoracotomy respiratory assessment
Evaluate:
1) Respiratory mechanics: FEV1, MVV, RV/TLC, FVC
2) Lung parenchymal function: DLco, PaO2, PaCO2
3) Cardiopulmonary reserve: Vo2 max, Stair climbing, 6 minute walk test, exercise SpO2
71
What if a thoracotomy/pneumonectomy patient has a ppoFEV1 < 40%?
- Order a VQ scan to assess contribution of lung to be resected
- Get an echo to eval rRV function (high risk of RV function)
72
What is pancoast's syndrome?
Malignant involvement of the structures in the superior sulcus or thoracic inlet, referred shoulder pain or pain in the ulnar distribution, ipsilateral horner's syndrome
73
Cushing's syndrome, secretion of excess ACTH causes potassium to do what
hypokalemia
74
Stair climb correlation to VO2 max
5 flights - VO2 max > 20
2 flights - VO2 max of 12
< 2 flights = high risk
75
Revised Cardiac Risk Index
History of:
- Ischemic Heart Disease
- IDDM
- Stroke or TIA
- Heart failure
- Renal insufficiency with Cr > 2
- Supra-inguinal vascular, intraperitoneal or intrathoracic surgery
0-1 predictors = low risk of MACE
> 2 = elevated risk of MACE
76
Sequence to treat pedi laryngospasm
1) Call for help
2) Suction oral secretions
3) Larson's maneuver (jaw thrust with pressure at the ascending ramus of mandible)
4) PPV using 100% oxygen
5) Deepen anesthetic & give lidocaine
77
Age cut off for caffeine halothane contracture test?
Age 7 and 20 kg
78
Starter jet ventilator settings
Pressure 5-10 psi for pedi, 15-25 psi for adult
| Inspiratory time of < 1 second
79
Extubation criteria in general terms
When the patient demonstrates adquate oxygenation and ventilation, minimal ventilatory support, normal lung compliance, stable hemodynamics. If any airway injury consider also making sure no airway edema and the presence of a cuff leak.
80
Hepatopulmonary syndrome what is it?
Hepatopulmonary syndrome (HPS) is characterized by the triad of abnormal arterial oxygenation caused by intrapulmonary vascular dilatations (IPVDs) in the setting of liver disease, portal hypertension, or congenital portosystemic shunts.
Caused by increased perfusion at the lung bases with poor ventilation there. Worst in the upright position, better with laying flat.
81
What causes ascites?
portal hypertension and renal retention of sodium and water, low oncotic protein intravascularly
82
Criteria for hepatorenal syndrome
1) Presence of advanced liver disease and portal HTN
2) low GFR (serum Cr > 1.5)
3) Absence of shock, infection, flood losses or treatment with nephrotoxic agents
4) No sustained improvement in renal function with a 1.5 L fluid challenge
5) Absence of protenuria, urinary obstruction or parenchymal renal disease
83
Pathophysiology of HRS?
Splanchnic arterial vasodilation, leads to reduction in effective blood volume sensed by juxtaglomerular apparatus which then leads to activation of RAAS and sympathetic nervous system, causes intra-renal arterial vasoconstriction
84
Types of HRS?
Type 1 - rapidly progressive renal failure ( 2 weeks or less)
2) slower onset renal failure
85
Classifications of portopulmonary hypertension
```
Mild = mean PAP of 25-35
Moderate = mean PAP of 35-45
Severe = mean PAP > 45
```
86
Aneurysm vs. dissection
Aneurysm: abnormal dilation of all 3 layers of an artery (intima, media, adventitia)
dissection: Blood has entered the arterial wall through a tear in the intima
87
Craword Aneurysms
Type 1 - originate below the left subclavian and extend only to involve the celiac and mesentary axis
Type 2 - originate below the left subclavian and extend into the infrarenal abdominal aorta
Type 3 - Originate in the lower descending thoracic aorta and involve the remainder of the aorta
Type 4 - Originate at the diaphragm and involve the abdominal aorta only
Type 5 - Originate below the 6th rib and extend only to the renal arteries
88
Perioperative concerns specific to aortic aneurysm
Aneurysm rupture, propogation of aneurysm, paraplegia 2/2 disruption of radicular arteries, hemodynamic instability, potential massive blood loss, post-op kidney dysfunction, stroke
89
CSF target pressure via lumbar drain?
8-10 mm Hg
90
Spinal cord preservation strategies
```
Passive hypothermia
Avoidance of intra-op hypotension
Maintenance of normal hematocrit & PaO2
Neuromonitoring
Avoidance of hyperglycemia
ID and preservation of blood flow to critical intercostal arteries
```
91
Types of endoleaks
Type 1: failure of seal between stent graft and aortic wall at the proximal or distal attachment site
Type 2: retrograde flow from intercostal arteries fills in the aneurysm sac
Type 3: Structural failure of the stent graft
Type 4: Stent graft too porous
Type 5: Unknown location of leak
Type 2 & 4 are benign, 1 & 3 require urgent intervention
92
How to create a hemodynamically "still" field for endograft deployment in thoracic aneurysm
1. adenosine 6-12 mg
2. rapid pacing 150-180
3. RA flow occlusion via occlusion balloon
93
Renal protection during aortic surgery
```
Adequate hydration
Minimize contrast use
Avoid nephrotoxic drugs
Renal protective drugs: statins, mannitol, loop diuretics, low-dose dopamine, fenoldopam
systemic or regional hypothermia
```
94
How does mannitol protect kidneys?
Increases renal cortical blood flow, is a free radical scavenger, increases renal prostaglandin synthesis, decreases renin secretion, reduces cellular edema
(little evidence to support this)
95
What is post-implantatoin syndrome?
Associated w/ endovascular aortic aneurysm repair, post-op complication
2/2 endothelial activation by the prosthesis
Fever, elevated inflammatory mediators, leukocytosis, usually mild and self limiting (2-10 days) and treated with NSAIDs
96
Tetrology of fallot defects
1. Overriding aorta
2. RVH
3. RVOT Obstruction (pulmonary stenosis)
4. VSD
97
Drugs that inhibit antiplatelet effect of clopidogrel and aspirin?
PPIs - don't give in patients on DAPT
98
Complication of TPN that causes difficulty with ventilator weaning?
Hypophosphatemia causing muscle weakness
| Elevated Co2 from carb delivery which might require more ventilation than patient can perform on their own
99
Treatment of cholinergic crisis
1) Intubation if necessary
2) D/c any anticholinesterase therapy
3) Give antimuscarinics (like atropine)
4) Supportive care
5) In most severe cases can consider plasmaphoresis or IVIG
100
Complications of retrobulbar blocks
1) Direct trauma to the optic nerve
2) Retrobulbar hemorrhage
3) Increased IOP 2/2 globe compression
4) Globe perforation
5) Stimulation of oculocardiac reflex
6) Intravascular or intraneural injection
7) Spread of local to the CNS causing general anesthesia & apnea
101
Pedi foreign body aspiration
Give metoclopramide & glyco
Ensure presence of ENT and rigid bronchoscope
Apply appropriate monitors
Inhalational induction and maintain spontaneous ventilation
PPV can push the foreign body further so I would not ventilate if at all possible
102
Complications of foreign body aspiration
Obviously life threatening airway obstruction but also:
1) Chemical pneumonitis
2) Bronchial stenosis
3) PNA
4) Lung abscess
5) Tissue erosion/perforation
6) Pneumomediastinum or pneumothorax
103
What is pseudotumor cerebri?
Benign intracranial hypertension
Normal CSF and absence of mass lesion
Headaches, visual disturbances, papilledema, etc
Treatment:
- Carbonic anhydrase inhibitors: acetazolamide to decrease CSF production
- Furosemide
- Steroids
- Serial LPs
- VP shunt
- Optic nerve sheath fenestration
104
Avoid sux in male children
8 years
| 2/2 risk of undiagnosed muscular dystrophies
105
FAST exam
focused assessment with sonography for trauma
Views:
- Subxiphoid (pericardium)
- RUQ (hepatorenal recess)
- LUQ (perisplenic space)
- pubic (retrovesical pouch)
However CT is better in a stable patient
106
What is abdominal compartment syndrome?
When the abdominal pressures rise above the perfusion pressure of abdominal organs (20-25mm Hg), reduced perfusion to the liver, kidneys & bowel, impaired ventilation, cardiovascular depression 2/2 decreased venous return, increased SVR 2/2 compression of the aorta, increased ICP 2/2 decreased cerebral venous outflow
107
How to diagnose abdominal compartment syndrome
```
Triad of
1) Elevated intra-abdominal pressures
2) Abdominal distension
3) End organ dysfunction
Don't need to have all but if have all 3 highly suggestive
```
Can measure pressure via NG tube with gastric pressure or intra-vesicular pressure with Foley
> 10 mm Hg can cause it but > 20-25 mm Hg are critical
108
What is PRIS?
Propofol infusion syndrome
Primarily occurs in kids & critically ill adults
Continuous infusion of high dose propofol (4-5 mg/kg/hr) for > 5-6 hrs but usually > 24-48 hrs
Leads to metabolic acidosis, bradycardia, rhabdo, lipemia, hyperkalemia, hepatomegaly, fatty liver, renal failure, cardiomyopathy
Mortality > 80%
109
Slit Ventricle Syndrome?
When excessive CSF shunting happens during brain growth, leads to irreversibly collapsed ventricles and decreased intracranial compliance
High risk of cerebral herniation
110
Significance of LBBB
- Significant association with ischemic heart disease, aortic valve disease, LVH, CHF, HTN
- hard to diagnose MI because LBB hides ST & T wave segment changes
- wide QRS can mistake SVT for VT
- Placement of PA catheter can lead to complete HB bc of transient RBB during placement
111
Contrast induced nephrology - how to diagnose
25% or 0.5 mg/dL increase in serum cr from baseline within 3 days of contrast injection, usually resolves within 7-14 days
112
What is vWD?
Most common inherited coagulation disorder, caused by qualitative and quantitative defects in vWF. vWF mediates platelet adhesion to the surface of blood vessels and also paltelet to platelet aggregation. It also acts as a carrier for factor 8.
113
vWD eval?
History: ask about bleeding, bruising, epistaxis etc.
Labs: CBC, plt, bleeding time, PT and PTT (all could be normal but severe dz has prolonged bleeding time and PTT)
114
Blood products to have available for patient with vWF?
DDAVP
cryo
FFP
humate p (preparation of f8 and vWF concentrate)
115
Which vWD type cannot get DDAVP?
Type 2B
116
DDx for AMS after crani
1) hematoma
2) tension pneumocephalus
3) cerebral edema
4) Cerebral infarction/ischemia
5) hypoxia
6) hypercarbia
7) seizure
8) obstructive hydrocephalus
117
Risk factors for peripheral nerve injury
Male, hospital stay > 14 days, hypotension, vascular dz, hx hypertension, dm, smoking, very thin or very obese
More than 1/2 regain full sensory and motor function within 1 year, most within 6-12 weeks
118
Systemic effects of chronic renal failure
- Metabolic derrangements such as hyperK, hypoNa, hypoCa, hyperMg, hyperphos, hypoalbuminemia, metabolic acidosis
- peripheral & autonomic neuropathy
- uremia with encepholopathy
- delayed gastric emptying
- insulin resistance
- cardiac arrythmias or conduction blocks
- accelerated atherosclerosis
- renal osteodystrophy from secondary hyperPTH and decreased renal vitamin D
- uremic pericarditis
- HTN
- CAD
- cerebrovascular disease
- anemia
- bleeding
- increased susceptibility to infections
119
explain pathophys of HTN in renal disease
renal retention of sodium & water and activation of the RAAS system leads to HTN
120
Hemodynamic goals in cardiac tamponade
```
tachycardia = good
full = good
```
give fluid, 100% oxygen, treat bradycardia
121
PACU discharge criteria
Postanesthesia Discharge Scoring System (PADSS) or ALdrete
Crtieria include:
1) Vital signs within 20% of baseline
2) Activity level steady gate no dizziness
3) N/V minimal and treated with PO meds
4) Pain acceptably controlled with PO meds
5) Surgical bleeding minimal no dressing changes required
OR
```
Activity
Respiration
Circulation
Consciousness
Oxygen Sat
```
need a score of 9
122
Neonatal SLE?
Maternal autoantibodies cross the placenta and bind to fetal tissue - can cause heart block, cutaneous lupus and thrombocytopenia
123
Interscalene block complications
- Diaphragmatic hemiparesis from ipsilateral phrenic nerve block (100% incidence, 25% reduction in pulmonary function)
- Pneumothorax
- Permanent neurologic injury
- Blockade of vagus, recurrent laryngeal, and cervical sympathetic nerves (Horner’s syndrome)
- Epidural or subarachnoid injection
- Vertebral artery injection
- Severe hypotension and bradycardia (Bezold-Jarisch reflex)
