UBP book 1 Flashcards
Why inc bleeding in ESRD?
uremia -> impaired vWF -> impaired plt function
Anesthesia concrens in ESRD
-electrolyte abnormalities
-metabolic acidosis
-cardiac conduction blockade
-LVH/CHF
-hyperglycemia
-bleeding (uremia impairs vWF)
-altered drug clearance
-anemia
-chronic HTN
Risks assoc w/ laparoscopic surgery
-capnothorax
-trocar induced trauma to bowel or blood vessels
-pneumoperitoneum-induced hypotension
-CO2 emphysema
Assess volume status in ESRD
-hypovolemic immediately post HD
-hypervolemic prior to next sesion
-how often HD, when last one, how much fluid taken off
-s/s of fluid OL or hypovolemia: pulm edema, HTN, peripheral edema = hypervolemia
-dry mucous membranes, hypoTN, orthostasis = hypovolemic
Elective surgery K cutoff
5.5 -> inc risk of cardiac irritability and arrhythmias
ESRD need emergent ex lap, K 5.6, what to do?
-hyperK inc risk of cardiac irritability and arrhythmias
-correct any metabolic acidosis or hypoCa (assoc w/ ESRD)
-avoid succ, K containing solutions (LR)
-avoid metabolic or resp acidosis
-prepare to treat hyperK w/ Calcium, glucose/insulin, albuterol, hypervent
-defibrillator in room
-proceed w/ case while monitoring EKG and K
**if urgent/emergent -> ERSD tolerate higher K at baseline
ESRD K 6.2 what would you do?
-if case can be delayed, HD prior to surgery
-hyperK inc risk of cardiac irritability and arrhythmias
-correct any metabolic acidosis or hypoCa (assoc w/ ESRD)
-avoid succ, K containing solutions (LR)
-avoid metabolic or resp acidosis
-prepare to treat hyperK w/ Calcium, glucose/insulin, albuterol, hypervent
-defibrillator in room
-proceed w/ case while monitoring EKG and K
mechanism of anemia in pts with ESRD
-dec erythropoietin production
-dec RBC survival
-GI blood loss
-iron/vit def
-usually well tolerated b/c CKD metabolic acidosis and inc 2,3-DPG induce R shift of hg-O2 dissociation curve
Hg baseline 9, would you transfuse pre surgery for ESRD?
-assuming no significant CAD, no b/c mild anemia well tolerated
-b/w metabolic acidosis and inc 2,3-DPG, they have a R shift of Hg-oxygenation curve -> offloading of O2 from Hg
-decision depends on severity of anemia, risk of excessive blood loss during surgery,
blood transfusion post kidney transplant
avoid if at all possible b/c leukocyte antigens in the blood may lead to development of alloantibodies -> predisposing to rejection of the implanted kidney
-if you do need, give PRBCs that are washed (leukocyte reduced), irradiated (red risk of transfusion-assoc graft v host dx), and CMV negative
ESRD, concern for cardiac fxn?
-since volume overload, uremia, anemia and acidosis w/ ESRD -> HTN, dilated cardiomyopathy, CHF, CAD, conduction blocks, arrhythmias, pericarditis
HTN, ESRD, obesity, emergent surgery, risks of anesthesia?
-risk of aspiration
-risk of fluid overload requiring HD after
-risk of remaining intubated, difficult intubation
-postop bleeding
-postop infxn
-cardiac arrhythmias
-SE of meds (narcotic ind resp depression, prolonged drug effects)
-assure will take steps to minimize these risks, and delay of surgery carries more risk
ESRD, what preop w/u?
-CBC for anemia
-BMP for lytes (sp Na, Ca, K)
-EKG to look for hypertrophy, signs of ischemia or conduction distrubances
-CXR: fluid status, pulm status
-if SOB: consider ABG
-coags if regional
EKG stands for
electrocardiogram
ESRD, good cardiopulm status, emergent ex lap, monitors?
standard ASA (incl 5 lead EKG to monitor for ischemia)
-due to placement of AVF, avoid BP cuff or PIV on same arm
ruptured diverticulum, emergent ex lap with abd tightness w/ generalized tenderness , ESRD, induction?
-place NGT -> empty stomach as much as possible
-aspiration ppx (avoid metochlorpramide b/c bowel rputure -> famotidine and nonparticulate antacid sodium citrate)
-place pt in RT to improve resp mechanics, reduce passive regurge, and facilitate rapid intubation
-preoxygenate w/ 100%
-perform RSI w/ cricoid pressure, use roc to avoid inc in K w succ 0.5 mEq/L
Drugs to avoid in ESRD
-dpt on renal elimination or active metabolites that accumulate in renal failure: pancuronium, atropine, glyco, ketamine, morphine, diazepam, meperidine
-red dose of drugs that are highly protein bound: benzos
AFter intubation, SpO2 dec to 91% w/ FiO2 100%, ddx?
-inadequate ventilation
-advancement of ETT into R mainstem bronchus
-bronchospasm
-Less likely: changes in pulm compliance w/ supine position in obese pt, ateletasis, obstruction of ETT, hypoxic gas mixture
how can capnograph help determine causes of hypoxia
-helpful in identifying causes: esophageal intubation (flat), obstructive lung dx, bronchospasm (more rounded during initial phase of exhalation, upward slope w/ plateau
-EtCO2 doesn’t go back to zero: incompetent ventilatory valves (rebreathing)
-incomplete m relaxation, breathing against the vent (curare cleft)
ESRD, hemicolectomy, how would you manage fluid administration?
-keep maintanence fluids at 1-2 cc/kg/hr: to replace insensible loss and third space losses
-would replace blood loss w/ colloid or pRBCs rather than 3:1 w/ crystalloid
-w/ hyperK and glucose intol: avoid LR and glucose cont solutions
hypotension despite fluid replacement, what do you do?
-recheck BP
-ensure adequate ventilation and oxygenation
-check EKG for ischemia or arrhythmia or changes w/ hyperK
-look at surgical field
-place pt in trendelenberg
-fluid bolus, consider adminstration of vasoconstrictor
post ex lap w/ NGT, how to extubate?
assuming extubation criteria were met, ensure
-complete reversal of muscle relaxants
-adequate oxygenation, normocarbia
-hemodynamically stable
-sufficient TV w/ spontaneous ventilation
-use NGT to empty stomach
-extubate once awake, alert, and exhibiting intact airway reflexes
vomiting on emergence w/ ETT still in place
-turn pts head to the side
-put table in trendelenberg (gastric material away from airway)
-suction oropharynx
-suction ETT
-utilize NGT to empty stomach as much as possible
-treat any bronchospasm
-monitor pt for signs of hypoxia
hypoxia in PACU ddx
-aspiration
-sedation
-upper airway obstruction (esp if obese w/ OSA)
-inadequate ventilation
-atelectasis
-pulm edema
-PE
PACU RR 18, O2 sat 90%, auscultation lungs clear, breath sounds absent at L lung base
-continue to provide O2
-assess level of sedation
-head up position
-incentive spirometry, CXR, ABG
-consider c/s pulm
OSA obesity, ESRD on HD, ex lap with infxn, epidural?
Assuming appropriate abx have been started pt not actively septic, no coagulopathy yes epidural
-esp since dec pulm compl with epidural and minimize narcotics
-be sure to coordinate removal w/ HD 1 hour before heparinization or 2-4 hours after heparinization
epidural placement receiving unfractionated heparin?
wait 4-6 hrs w/ subq ppx dosing (lower dose 5000U )
wait 4-6 hours w/ IV heparin and verify normal coags
waiti 12 hours w/ sub q ppx dosing (higher dose 7500 or 10000U) and assessment of coags
-wait 24 hours for subq therapeutic dosing
When to stop heparin infusion to remove epidural catheter?
4-6 hours
When to restart heparin after epidural catheter removal?
1 hour
when to restart higher dose (7500 or 10000U) subq heparin after epidural catheter placement?
don’t do it
when to restart heparin 5000U subq heparin after epidural catheter placement?
immediately
when to restart IV heparin w/ epidural catheter in place
1 hour
When do you need a plt count prior to putting an epidural in w/ pt on heparin?
if on heparin for more than 4 days
enoxaparin LMWH ppx BID when to place epidural?
12 hours late
enoxaparin LMWH ppx BID when to remove epidural?
> 4 hours
enoxaparin LMWH when to restart after epidural removal?
> 4 hours
enoxaparin LMWH therapeutic, when to place epidural?
24 hours after administration
enoxaparin LMWH therapeutic, when to remove epidural?
24 hours after catheter placement, or 4 hours prior to first postop dose
enoxaparin LMWH when to restart after epidural removed?
24 hours after non-high risk bleeding surgery
48-72 hours after high bleeding risk surgery
Pt on clopidogrel, how long do you have to hold prior to spinal?
7 days
Apixaban and neuraxial blockade, how long do you hold?
72 hours
How to perform a machine check
-turn on machine and monitors
-verify presence of emergency ventilation equipment
-calibrate/set the capnometer, pulse ox, O2 analyzer, and pressure monitors and alarms
-check high pressure system by opening each E-cylinder to ensure adequate gas pressure (O2 at least 1000 psig = half full)
-verify central pipeline hoses connected
-confirm pipeline gauges read 50 psig
-then check low pressure system: filled vaproizers, check for leaks, test flowmeters
-check scavenging system, calibrate O2, ensure proper ventilator function, check integrity of unidirectional valves
-inspect circuit
-verify adequate CO2 absorbant
-ensure availability of airway equipment and suctioning
how to check for leaks in a low pressure system
-low-pressure leak test -> verify proper method of testing for workstation using
What protects against the delivery of a hypoxic mixture
-fail safe alarm: sounds if press ure in O2 pipeline falls below 30 psig
-O2 failure cut off valves, which dec or d/c flow of other gases when O2 pressure dec below a certain threshold
-vigilance and proper monitoring of O2 analyzer
Desflurane vaporizer
-electrically heated to create vapor pressure of 2 atm -> pure des vapor is mixed w/ FG prior to exiting vaporizer
Sevoflurance vaporizer
variable-bypass vaporizer
-variable amount of gas is directed into vaporizing chamber where it mixes w/ volatile agent before returning to mix w/ rest of carrier gas that was directed to bypass the chamber
Pathogenesis of SCD?
-mutation in chromosome 11 results in hemoglobin S
-in dec O2, Hg S -> deformation of RBC membrane into sicked shape -> hemolysis, microvascular occlusion of capillaries, ischemic injury to organs, infarcts, and hemolytic crisis
Comorbidities with sickle cell disease
-chronic anemia, hypoxia, and hemochromatosis can cause:
-cardiomegaly
-CHF
-pulm HTN
-neuro deficits
-renal insuff
-painful crisess
-acute chest syndrome
-retinopathy
-aseptic necrosis of the femoral head
-asplenia (inc risk of infxn from encapsulated organisms)
Exchange transfusion in SCD prior to surgery?
-No, growing evidence to suggest preop Hcg > 30% for mod to high risk surgeries is just as effective to dec morbidity
-exchange transfusion typically requires more transfusions inc risk of transfustion-related complications
-instead transfuse to Hct . 30% to inc O2 carrying capacity and prevent sickling
prevent sickling intraop
AVOID: hypoxemia, hypotension, hypothermia, hypercarbia, acidosis, and hypovolemia
-adequate postop pain control
-Hct 30-40%
treatment of sickle cell crisis
-pain control
-hydration
-suppl O2
-maintain adequate Hct levels
-tx infxn
-consider exchange transfusion to reduce Hg S to < 40%
14 YOM hx of masseter muscle spasms, what do you want to know preop
H&P!
-circumstances of masseter spasm, severity, how treated, type of anestehsia, result of w/u related to it
-family hx of anestheic complications (esp masseter spasm or MH)
14 YOM masseter spasms T&A, what type of anesthesia?
-TIVA fent, prop infusion
-masseter muscle rigidity following administration of a known triggering agent: succ or volatile -> indicate susceptibility to MH
peds succ given, uanble to open pts jaw, what to do?
Mask ventilate w/ 100%
-if difficult: call for help, nasal airway, attempt nasal intubation, prepare for possible surgical airway
-concerned for MH: admit to hospital, place art line, monitor EtCO2, CK, temp, acid-base status, lyte levels
-evaluate for myglobinuria, generalized rigidity
-MH cart/hotline
peds masseter rigidity after succ, cancel the case?
Yes, b/c succ-induced trismus -> MH susceptibility is high, d/c all triggering agents, cancel the case, and monitor the patient for 12-24 hours
-recommend a caffeine halothane contracture test
elective lap chole
thyroid nodule on PTU
BP 162/98, HR 119, Hct 29%
proceed w/ surgery?
No, concerned about her resting HR, HTN, and anemia
-H&P identify any signs and symptoms of thyroid dysfunction, order additional lab tests, proceed as soon as reasonable
signs and symptoms of thyrotoxicosis
-cardiac: tachycardia, arrhythmias, cardiomegaly, inc SV andn CO
-dec SVR/PVR
-neuro: anxiety, agitation, tremors, insomnia, m weakness
-sweating, heat intolerance, weakness, weight loss
labs for thyroid function
TSH, free T3, free T4
-likely elevated free T3 and T4, and low TSH
Prepare emergent surgery if in active thyrotoxicosis
-goal to minimize risk of hemodynamic instability, cardiac arrhythmias, and thyroid storm
-c/s endocrinologist, continue PTU, beta blocker (goal HR < 90)
-glucocorticoids (reduce thyroid hormone secretion and peripheral conversion of T4 to T3)
-ensure adequate hydration and a normal electrolyte balance
-consider small dose of benzos for anxiety
hx of CAD, start a beta blocker preop?
If not already taking, no -> inc risk of pulm edema, hypoTN, bradycardia, stroke, possibly bronchospasm
-acknowledge at inc risk for periop atrial arrhythmias (a fib) due to CAD -> could give diltiazem
RF for postop atrial arrhythmias
male gender
COPD
CAD
peroip theophylline use (bronchodilator)
advanced age
**consider diltiazem to pts at inc risk
Benefits of epidural placement
-facilitates early intubation
-improved postop pulm fxn
-improved GI blood flow
-dec risk of anastomotic leak (thoracic epidural)
**be careful of sympathectomy
What to dose an epidural with?
low concentration local anesthetic with hydrophilic opioid (hydromorphone) allowing to cover a wider number of dermatomes
-spread more limited w/ lipophilic opioids
66 YOF transthoracic esophagectomy, smoker, CAD, GERD, monitors?
standard ASA monitors (incl 5 lead EKG for ischemia monitoring)
foley
arterial line
central line (possible hemodynamic instability)
-limited blood supply of gastric tube -> inc risk that hypoTN leads to anastomotic leakage or dehiscence)
-cardiac arrhythmias common, vagal stimulation, compression of heart or great vessels by surgeon
66 YOF transthoracic esophagectomy, smoker, CAD, GERD, monitors?
-aspiration ppx w/ metoclopramide, famotidine, and sodium citrate
-albuterol pre induction
-place pt in RT to optimize resp mechanics and minimize passive acid regurgitation
-preoxygenate, place pre-induction arterial line using lidocaine to numb the skin prior to insertion
-fent, lido, etomidate, and succ to RSI
-apply cricoid pressure
-DL and insert ETT
-place NGT to decompress esophageal conduit and stomach
-when surgeon ready for thoracotomy -> i would evacuate the stomach and exchange for a DL ETT
Transthoracic esophagectomy 2 phases
1st: laparotomy in supine position and creation of neoesophagus w/ stomach
2nd: R sided thoracotomy (req DLT)
Esophageal surgery and aspiration
-everyone w/ esophageal surgery inc risk of aspiration
-if obstruction, good change even w/ NPO, food remains in the proximal exophagus -> bacterial grwoth -> inc risk of aspiration pneumonitis w/ aspiration
-suction proximal esophagus
-w/ chronic aspration -> pulmonary fibrosis => DOE
-if hx of esophagectmoy :inc risk of aspiration their whole lives
One lung ventilation settings
TV 4-6 cc/kg of ideal body weight
-PEEP of 5 on dependent lung
-avoid volutrauma from overdistention
hypoxia w/ one lung ventilation in esophagectomy v lung resection
higher risk of hypoxia w/ esophagectomy
-b/c V/Q mismatch limited in lung resection b/c disease lung has diminished blood flow -> bigger V/Q mismatch in esophagectomy
Following induction, gastric contents in oropharynx, what to do?
-turn pts head to the side
-put bed in trendelenberg
-cricoid pressure
-suction oropharynx
-DL and put in ETT
-suction ETT and look w/ fiberoptic prior to attaching pt to vent
-place NGT to suction remaining contents
-order CXR and ABG
-monitor pt for 24-48 hours for development of asp pneumonitis
steroids or abx ppx for aspiration pneumonitis
No, lack of evidence proving to be effective -> not worth the SE from the steroids or abx
-can lead to drug resistance
RF for aspiration
-obesity
-delayed gastric emptying (pain, acute abd, cirrhosis, chronic alcohol abuse, autonomic neuropathy)
-pregnancy
-neurologic dysphagia
-bowel obstruction
-dirsuption of gastroesophageal jxn
-extremes of age
-hx of GERD
what determines risk of developing aspiration pneumonitis?
volume of aspirate > 25 cc
gastric fluid pH < 2.5
**gastric pH more important
When to consider abx for aspiration pneumonitis
-demonstrated bacterial infxn on culture and sensitivity testing
-pts clinical course failed to improve or worsened after 2-3 days
Cirrhosis and ascites, colon cancer surgery, w/u?
-CBC, BMP, Coags, T&S
-bilirubin, transaminasas, alk phos, albumin, total protein, PTT, INR, hepatitis serologies
-onset and etiology of his cirrhosis -> jaundice, bleeding d/o, ascites, asterixis, hepatic encephalopathy
systemic effects of cirrhosis
resp effects: intrapulm AV shunts, reduced FRC, restrictive lung dx, pleural effusions, attenuation of HPV
-neuro: accumulation of ammonia and toxins -> encephalopathy
-hepatic: thrombocytopenia,
51 YOM cirrhosis and ascites hemicolectomy colon cancer, how would you induce?
ascites and possible gastroparesis -> RSI
-asp ppx, AVOID metochlopramide in setting of bowel obstruction
-RT to reduce passive reguge and facilitate intubation
-preoxygenate
-cricoid pressure
-give lidocaine, prop, and succ -> rapidly secure airway
51 YOM cirrhosis and ascites hemicolectomy colon cancer, muscle relaxant for maintenance?
Cisatracurium
-hoffman elimination not dependent on liver metabolism
-if not available, recognize possibility of prolonged action
1L of ascites fluid removed, pt hypotensive, ddx?
-loss of ascitic fluid -> large fluid shifts (Most likely)
-differential also incl: surgical or GI bleeding, tension PTX, hypoxia, cardiac arrhythmia, or cardiac failure
PDPH POD1, would you place a blood patch?
-consider since it is the most effective treatment option
-but recognize pt might be on anticoagulation w/ recent knee surgery -> inc risk for epidural or spinal hematoma
Signs of PDPH
-frontal-occipital HA
-dec pain w/ laying flat
-N/V
-neck stiffness
-back pain
-photophobia
-diplopia (stretching on the abducens n)
-tinnitus (stretching on the vestibulocochlear n)
-can get a seizure 2/2 to cerebral vasospasm
PDPH blood patch contraindicated, treatment options?
-hydration
-caffeine
-abd binder (inc intra-abd pressure)
-alternative pain control
TKA, femoral and sciatic n block, during block placement, seizure and LOC, ddx?
TOP: LAST
-other factors on ddx: hypoxia, acidosis, MI, alcohol w/d, sz d/o
signs and symptoms with LAST?
intial sym: metallic taste, oral paresthesias, tongue numbness, visual disturbances, tinnitus, lightheadedness, dizziness
-CNS: agitation, shivering, m twitching, tremors, sz
-resp depression, tachycardia, ventricular arrhythmias, bradycardia, hypoTN, asystole
Advantage of ropi rather than bupi
cardiotoxicity assoc w/ bupivacaine
-reduced cardiotoxicity w/ ropivacaine
Epi reduce risk of LAST?
Yes, reduces systemic absorption, identify unintended puncture
**to further watch, monitor pt’s vital signs, provide slow, incremental injxn, and aspirate prior to injxn
How to identify unintended venous injection of local w/ epi
inc in systolic pressure > 15 or 25% dec in lead II t wave amplitude
how to local anesthetics affect the heart?
-inhibition of VG Na channels causing:
-slowed cardiac conduction
-dec rate of depolarization (red availability of fast Na channels that allow for rapid depolarization)
-dose-dpt reduction in cardiac contractility
-depressed spontaneous pacemaker activity in SA node
dosing of lipid emulsion
1.5 cc/kg of 20% lipid solution (~100cc in adults) with infusion of 0.25 cc/kg/min -> d/c after establishing hemodynamic stability for at least 10 minutes
injecting local anesthesia, has a seizure, and develops monomorphic V tach, BP stable what do you do?
-stop giving local anesthetic
-call for help and lipid emulsion
-ensure adequate O2 and ventilation to prevent factors that worsen LAST (hypercarbia, hypoxia, acidosis)
-give benzo to treat seizure
-give succ and intubate if ventilation were inadequate
-give lipid emulsion (1.5 cc/kg) 20%, infusion 0.25 cc/kg/min
-for V tach give adenosine or amiodarone
-if BP decreases: synchronized cardioversion
((epi standard 1 mg not recommended, give smaller boluses 100 mcg)
Can you use beta blockers, CCB with LAST?
No -> will worsen cardiovascular effects negative inotropic and chronotropic
can you give prop to stop a LAST sz?
no b/c potential for cardiovascular instability -> could make his arrhythmias unstable
-give benzo ASAP
would you give lipid emulsion therapy to someone who develops ringing in their ears following regional?
-assuming it was their only symptom, no b/c unnecessary tx of a large # of patients, with only a fraction who progress to severe toxicity
-recgonize would not want to have cardiovascular collapse -> would give if signs and symp of LAST rapidly progressing, incl sz or cardiac toxicity signs
**must monitor for at least 30 minutes
if symp of LAST and treated, how long do you have to monitor?
at least 12 hours b/c can redistribute into circulation from tissues -> delayed recurrence of severe toxicity
G6P5 112 kg woman TOLAC, jehovah’s witness, PEC, concerned about jehovah’s witness?
-at inc risk for complications that could cause significant blood loss
-TOLAC -> risk of uterine rupture
-adhesions/scarring from prior c/s could lengthen/complicat c/s
-PEC affects hemostasis
-inc risk of uterine atony w/ muliparity (inc as well w/ Mg)
Prolonged motor and sensory loss after prev epidural for vaginal delivery, scared for next epidural, say what?
-review the chart, ask for details for motor and sensory loss
-most peripheral n palsies are OB -> due to extreme positioning of pt or instrumentation w/ vaginal delivery (compression of n as baby’s head)
-alternatives: IV narcotics, NSAIDs, Lamaze, transcutaneous electrical n stimulation -> however epidural superior analgesia, and improved BF to baby
***benefit of epidural to avoid GA esp in high risk)
Pregnancy regional options not epidural
-paracervical block 1st stage of labor
-pudendal block with infiltration of perineum for 2nd stage
**paracervical not typically done due to high risk of fetal bradycardia and Dec uteroplacental perfusion (inc risk of PEC)
**pudendal block issues: intravascular injxn, retroperitoneal hematoma
**not sufficient if c/s needed
Pt wants epidural, you’re not available, nurse wanted to ask if can give nalbuphine for discomfort, would you delay until consent obtained?
-consent ideal prior to pt severe pain or under influence of premedications
-would not delay, pain relief may enhance ability to provide adequate consent
-under risks of narcotics unable to understand risks and benefits
-titrate medication carefully to provide pain control while avoiding excessive administration
PPH, loss of IV access, needs OR, can’t put in peripheral what to do?
-give O2, monitors on, and attempt central line
-if central line difficult/can’t do -> place intraosseous line
-call for volume expanders, prepare emergency drugs, and set up intraoperative blood salvaging
How to place intraosseous line?
Tibia: 10-15 deg angulation at 1-2 cm below and 1 cm medial to tibial tuberosity
-advance until felt pop, confirm w/ aspiration of bone marrow
-ensure fluids flowed freely w/o signs of extravasating
-other option: greater tubercle of humerus
Complications w/ intraosseous access
-compartment syndrome (extravasation)
-muscle necrosis (extravasation of certain meds like bicarb, calcium, dopamine)
-bacteremia
-cellulitis
-growth plate injury (peds)
PPH OB pt arteria line?
Yes: risk of signficant anemia and hemodynamic instability 2/2 to visible blood loss,
-beat to beat BP aid inn intraop optimization
-however realize surgery is emergent -> proceed w/ case and place art line following induction
OB PPH jehovah’s witness, BP 88/63, obese, PEC, RSI?
-concern for difficult airway given pregnancy, obesity, PEC -> induction drugs can cause further hemodynamic instability w/ anemia and hypovolemia
-at risk for aspiration -> asp ppx, and utilize neuraxial
OB jehovah’s witness, Hg 4.8, can’t achieve surgical hemostasis, do you give blood?
No, unethical
-I would give 100% O2, ensure adequate volume replacement with what she is okay w/
-utilize intraop blood salvage if ok with patient
PPH, Hg 5, neck swelling where attempt at central line was, ddx?
**developing coagulopathy
-fibrinolysis
-hypofibrinogenemia
-dilutional coagulopathy
-DIC
-hypothermia (large volumes of cold fluids -> plt dysfunction)
RF for OB DIC
-PEC: extensive vascular endothelial damage
-uterine rupture -> exposure of vascsulature to amniotic fliud rich in procoagulant thromboplastins
hypovolemia and low BP => inc risk of amniotic fluid entering intravascular system so she can’t “wash out” the accumulation of intravascular coagulation factors
What is DIC?
-pathological activation of the coagulation cascade
-consumptive coagulopathy -> creating multiple small clots throughout the vasculature -> consumption of coag factors, thrombocytopenia, hemolytic anemia, diffuse bleeding
Labs with DIC
-Increased PT/ PTT
-Dec fibrinogen (< 100)
-thrombocytopenia
-dec antithrombin III
-D-dimer and presence of fibrin degradation productss
How to treat DIC?
-treat the hypovolemia, low BP, hypoxia, or acidosis -> can contribute and worsen DIC
-give cryo (fibrinogen < 50), FFP, plts, and PRBCs
You accidentally stick yourself with a needle, what to do?
-immediately wash with soap and water
-report to employee health
-initiate post exposure ppx and r/o HIV, HBV, HCV, and other possible blood-borne dx
-obtain pt consent to draw additional blood so she can be tested for blood-borne dx
pulmonary edema after MTP in OB PEC pt, etiology?
-TACO (transfusion associated circulatory overload) -> inc risk w/ inc pulm capillary permeability w/ PEC
-TRALI: transfusion related acute lung injury
-ARDS
-transfusion-assoc dyspnea
What is TRALI?
-donor leukocyte antibodies (usually FFP or plts), attack recipient leukocytes -> endothelial damage and capillary leakage
-noncardiogenic pulmonary edema 1-6 hours after transfusion
-forthy pulm secretions, fever, tachycardia, cyanosis, pulmm edema, hypoTN (can’t distinguish w/ ARDS)
Diagnostic criteria for TRALID
-acute onset of hypoxia (PaO2/FiO2 < 300, SpO2 < 90%)
-pulm edema
-w/i 6 hours of transfusion
-no cardiac failure or fluid overload]
-tx: supportive (similar to ARDS)
Distinguish b/w TRALI and TACO
TACO: cardiogenic pulm edema -> fluid OL (peripheral edema, S3, impaired cardiac fxn, JVD, HTN,hypervolemia, inc BNP)
TRALI: noncardiogenic pulm edema (inc capillary permability) -> hypovolemia/normovolemia, fever, leukopenia, normal cardiac fxn, normal BNP, positive leukocyte antibody testing
TRALI treatment
-stop transfusion of blood products, alert the blodo bank
-support ventilation: low TV, inc PEEP, suppl O2 as needed
TACO treatment
-goal: reduce pulm capillary pressures
-diuretic (correct fluid OL)
-consider pRBCs if Hct not adeaute (inc viscosity)
-if compromised ventircular fxn: consider inotrope or afterload reducing agent
post delivery w/ epidural pt has foot drop, what caused her condition?
-lumbosacral trunk injury: compression of the trunk w/ prolonged labor or difficult vaginal delivery -> issues w/ toe flexion and ankle inversion
-common peroneal n injury: prolonged lithotomy, excessive knee flexion, compression of lateral knee against hard objects -> issues w/ ankle eversion
pregnant pt issues w/ climbing stairs postop
femoral n palsy
-stretched 2/2 abduction, external rotation, prolonged flexion of hips duringn labor
pregnant pt postop paresthesias of anterolateral aspect of thigh
meralgia paresthetica
obesity/preg: entrapment of LFCN passes under inguinal ligament
pregnant pt sensory deficits of inner thigh, weakness of hip adduction
obturator n palsy
=fetal compression of n at pelvic brim
Cobb angle
Measure the severity of scoliosis
-angle of perpendicular lines from upper surface of the most cephalad tilted vertebrae and lower surface of most caudad tilted vertebrae
When to get surgery on scoliosis
Cobb angle > 40-50
-pulm dysfxn > 60-65 deg
-pulm HTN w/ exercsise > 70
-pulm HTN at rest > 110
SOB Duchenne’s Muscular dystrophy, concerned?
Yes, abnormal dystrophin:
-cardiomyopathy, ventricular dysrhythmias, MR 2/2 replacement of mycardium w/ connective tissue
-dec pulm reserves, ineffective cough, chronic PNA 2/2 resp m weakness
-chronic asp 2/2 impaired laryngeal reflexes
-OSA: contribute to pulm HTN
SOB w/ severe scoliosis and duchenne’s muscular dystrophy, concerned?
Yes
-2/2 NM scoliosis: impaired pulm development, restrictive lung dx w/ inc WOB (dec chest wall compliance)
-hypoxia, hypoxic pulm constriction -> pulm HTN
-resp m weakness, laryngeal m weakness w/ DMD
-cardiomyopathy w/ DMD
if pt wheelchair bound w/ SOB, pulm HTN concerns, test?
stress echo => identify any pulm HTN, RV failure, cardiomyopathy
airway concerns for duchenne’s muscular dystrophy
-macroglossia
-difficulty swallowing (diminished airway reflexes inc risk of aspiration)
how to explain a “wake up” test to patient
-sometimes I would whisper his name in his ear, and ask to wiggle fingers asnd toes
-probably not remember, and if he did he would be sleepy not feel pain, and go right back to sleep
asp ppx premeds
-metochlopramide (unless SBO)
-H2 receptor antagonist
-non-particulate antacid (sodium citrate)
early decelerations
head compression (vagal activation)
variable decelerations
umbilical cord compression
late decelerations
uteroplacental insufficiency
Methergine
semisynthetic ergot alkaloid
Hemabate
prostagladin F2alpha analog
Misoprostol
synthetic prostagladin analog
precautions for prone positioning in DMD scoliosis case
-place head in neutral position, freq checks to ensure ears/eyes free
-account for contractures, limited ROM
-abd arms no more than 90 deg from trunk, minimize brachail pleux injury
-frame of bed not compressing axillary sheath
-padding to ulnar n
-minimize pressure on abd -> inc shunting of blood through vertebral venous plexus -> inc bleeding on case
monitors for scoliosis DMD case
-standard ASA montiors: 5 lead EKG
-a line: freq blood draws, continuous BP monitoring
-precordial doppler (R of sternum b/w 2nd and 4th ribs to detect VAE)
-central line: fluids and tx of VAE
-neuromonitoring: SSEPs, MEPs, eMG, EEG
risks of pulmonary artery catheter
arrhythmias
pulm infarction
pulm a rupture
thrombosis
infxn
complications w/ central line
arterial puncture
PTX
air embolism
thrombosis
thoracic duct injury
pseudoaneurysm formation
arterial or venous hemorrhage
What do SSEPs monitor?
sensory pathway from distal n up SC dorsal root ganglia and posterior columns to cortex
MEPs monitor?
monitor the motor pathway (motor cortex, corticospinal tract, n root, peripheral n)
-transcranial stimulation of motor cortex and measure response
Is EMG necessary for scoliosis surgery?
Not universally utilized
beneficial to avoid n root injury during pedicle screw placement
-get m contracts at lower current stimulations if malpositioned
risks w/ wake up test
-accidental extubation
-intraop recall
-pain
-air embolism
-dislodge surgical instruments
-removal of lines
Reasons to use ketamine as an induction agent
-preserves airway reflexes
-maintains respiratory drive
-induces bronchodilation
-inc endogenous catecholamine release
inhalational induction in pts w/ Duchenne’s muscular dystrophy?
While no assoc w/ MH, sevo can cause rhabdo and hyperK (in combo w/ sevo and succ too)
NMB duchennes muscular dystrophy
-no succ b/c risk of hyperK
-minimize/avoid roc: b/c inc maxinmal effect and duration of action
how many twitches are needed for neuromonitoring EMG?
2/4
Large amount of blood loss anticipated, options to minimize blood transfusions?
-intraop blood salvage
-antifibrinolytic therapy (TXA, aminocaproic acid)
-avoid hypothermia (affects plt dysfunction)
-proprer positioning! (in spine cases avoid pressur eon the abd -> excessive shunting of blood thorugh vertebral venous plexuses
when to avoid hypoTN for vision loss in spine surgery?
-prolonged procedures
-anticipated substantial blood loss
surgeon wants deliberate hypoTN to reduce bleeding and improve visualization in surgical field, how to produce hypoTN?
short acting clevidipine/nicardipine and remi
-consider risk of ischemic injury to optic n, brain, heart, and SC: ensure intravascular volume, Hg 7-8, monitor EKG, MEPs, UOP, blood gases for signs of inadequate perfusion
spine case, dec amplitude, inc latency on SSEPs, what to do?
-correct any hypoxemia, hypoTN, hypovolemia, anemia, hypo/hypercarbia to opitimize O2 delivery to SC
-make sure depth of anesthesia has been stable and not interfereing
-ask surgeon to r/o surgical causes
Reasons to use ketamine
-preserves airway reflexes (aspiration risk)
-maintains resp drive (difficult airway)
-induces bronchodilation (obstructive dx)
-inc endogenous catecholamines
What is considered a significant change in SSEPs/MEPs?
SSEPs: inc in 10% latency, dec 50% in amplitude
MEPs: 50% dec in amplitude
Wake up test, then dec in BP 60s/30s and dec in EtCO2 ddx
venous air embolism
aspiration
hemorrhage
MI
CHF
dysrhythmia
TPTX
anaphylaxis
most sensitive for detecting VAE entrained air
TEE
heart “millwheel” murmur
VAE
sporadic roaring sounds from precordial doppler
VAE
Sporadic roaring sounds from precordial doppler, what to do?
-tell surgeon to flood field with saline
-d/c nitrous if on, and go to FiO2 100%
-aspiration from CVC to get air out
-give fluids to inc CVP
-give vasoconstrictors, inotropes, and chest ocmpressions if needed
-beta 2 agonsits if bronchospasm (common w/ VAE)
-if needed put in L lateral decubitus position to shift air out of pulm outflow tract
PEEP in VAE?
-no impairs venous return inn pt w/ cardiac disfunction
FVC that predicts postop ventilatory support
FVC < 30-35% predicts postop vent support in order to prevent atelectasis, PNA, resp failure
Extubation criteria-
-awake
-cooperative
-muscle relaxants fully reversed
-intact gag reflex
-vital capacity > 10cc/kg
-TV > 6 cc/kg
-negative inspiratory force > 20 cm H2O
-SpO2 > 90% on 40-50% FiO2 with <5 PEEP
-rapid shallow breathing index < 100 breaths/min/L
Transport to ICU, O2 sat dec to 89%, ddx?
-interrupted O2 source
-hypoventilation (inadequate TV or rate)
-extubation
-mainstem intubation
-PTX
-pulm edema (fluid OL, aspiration, CHF)
-aspiration (pulm edema, bronchospasm, atelectasis) -> intrapulm shutning -> hypoxia
-PE
-hemothorax
-bronchospasm
-dec cardiac output (CHF, worsening pulm HTN)
-monitor issues
Transport to ICU, O2 sat dec to 89%, what do you do?
-immediately check pulse ox and pt color to verify true hypoxia
-check circuit and O2 source to make sure delivery of 100% O2
-listen for b/l breath sounds
-check BP, CVP, pulm a catheter, EKG
-treat accordingly
STOP BANG
snoring
daytime tiredness
observed apnea
pressure (HTN)
BMI > 35
Age > 50
Neck circm > 40 cm
Gender, male
> 3: high risk of OSA
5-8: mod to severe OSA
OSA: ambulatory or in patient?
Considerations
-severity of OSA
-anatomical or physiological abnormalities
-presence/status of coexisting dx
-type of surgery
-type of anesthesai
-post-op opioid anticipated
-pt age
-post-d/c observation
-capabilities of outpt facility
pt has obesity, DM, high resting HR and HTN, what are your main concerns?
autonomic NEUROPATHY
-undiagnosed chronic HTN
Concern for beach chair position w/ OSA, DM, GERD, HTN?
-inc risk of cerebral ischemia w/ GA in beach chair
-w/ inc BP and DM -> autonomic neuropathy
-HTN -> R shift oc cerebral autoregulation curve (req higher pressures for adequate cerebral perfusion)
-impairment of normal autonomic responses by GA
-vigilant of maintaining end organ perfusion!
stop smoking prior to surgery?
-48 hours: reduce carboxyhemoglobin, abolish nicotine’s stimulatory effects on cardiovascular system, improves mucous clearance (so inc mucous clearance -> possible worsening airway conditions)
-4 weeks: decrease postop pulm complications
-8 weeks: approaches nonsmokers
difficult airway, OSA, GERD, proceed w/ block over GA?
yes -> still give aspiration ppx w/ GERD
-have difficult airway equipment available
-inform pt that if block were to fail, next step would be an awake fiberoptic intubation
Bezold-Jarisch reflex
-activation of parasympathetic NS w/ inhibition of sympathetic NS 2/2 drugs, inhibitory cardiac receptors by stretch, or chemical substances
-causes bradycardia, vasodilation, hypoTN
**can happen in shoulder surgeries -> inc circulating epi, w/ dec preload -> activation of receptors in heart
s/s autonomic neuropathy
orthostatic hypotension
sweating
constipation
gastroparesis
resting tachycardia
erectile dysfunction
How to eval for autonomic neuropathy?
-hx of GERD? DM? HTN?
-resting HR? tachycardia
-exercise tolerance? SOB w movement
-early satiety, prolonged postprandial fullness, bloating
-postural hypoTN
-lack of sweating
-painless MI
-peripheral neuropathy
-dysrhythmias
-N/V
-erectile dysfxn
What is autonomic neuropathy assoc w/?
GERD, DM, HTN, exercise intolerance (SOB), HTN, resting tachycardia
Progression of autonomic neuropathy
-affects the parasympathetic first -> so pt gets inc baseline HR
-sympaethtic 2nd: orthostatic hypoTN
