UBP book 3 Flashcards
Aortic stenosis transvalvular gradients
<25: mild
25-40: moderate
40-50: severe
> 50: critical
Aortic stenosis, valve areas
Normal 2.5 to 4
Mild 1.5 to 2
Moderate 1 to 1.5
Severe .7 to 1
Critical less than 0.7
Aortic stenosis, velocity of aortic jets in meters per second
Mild less than three
Moderate 3 to 4
Severe 4 to 4.5
Critical greater than 4.5
When do you need prophylaxis for bacterial endocarditis?
- prosthetic, cardiac valve or prosthetic material used for valve repair
-Previous occurrence of infectious endocarditis
-Unrepaired cyanotic congenital heart disease
-Six month postoperatively following repaired congenital heart defect using prosthetic material
-Repaired congenital heart disease with residual defect
-Cardiac transplant, who develops valvulopathy
Went to discontinue enoxaparin to neuraxial
24 hours
Spinal and epidural, anesthesia,
In multiple sclerosis
Can be associated with an exacerbation of MS
-More significant and spinal and epidural, using high concentrations of local anesthetic, less likely with dilute solutions for labor pain control
When do you need to start taking a platelet level with heparin?
After four days for risk of heparin induced thrombocytopenia
How long to hold subq heparin before spinal
4-6 hours or normal PTT
How long to hold subcutaneous heparin with three times a day dosing at higher doses before spinal
12 Hours and normal PTT
Can you use protamine to reverse, low molecular weight heparin?
No
Asthmatic patients way to decrease ventricular rate
Diltiazem
symptoms of PDPH
-frontal-occipital HA
-Dec pain w/ laying flat
-N/V
-neck stiffness
-photophobia
-diplopia (stretching on abducens n)
-tinnitus, hearing loss
(Sz rare from cerebral vasospasm)
Aspiration ppx in pregnancy
Metochlopramide
Famotidine
Sodium citrate
Why do we give stress dose steroids?
Suppression of hypothalamic-pituitary adrenal axis with exogenous steroids -> cannot produce adequate cortisol under stress conditions
Symptoms of Addisonian crisis
(Life-threatening low cortisol)
-fever
-abd pain
-dehydration
-N/V
-hypoglycemia (cortisol promotes gluconeogenesis)
-acidosis
-hyperK, hypoNa (Dec Aldo)
-circulatory collapse
-depressed mentation
stress dose steroids
100mg IV hydrocoritsone preop
100mg q8h on day of surgery
epidural ok for c/s in pt w/ MS?
-acknowledge risk of exacerbating MS symptoms -> however lower with short duration of action local anesthetics
-benefits of avoiding manipulating difficult airway, red risk of aspiration, superior post op analgesia
succinylcholine and MS
AVOID -> likely to have chronic skeletal muscle weakness -> run the risk of hyperK
emergent c/s needs GA, severe AS induction?
-difficult airway equipment available
-premeds: asp ppx, albuterol, fluids for AS, consider esmolol to avoid tachycardia w/ laryngoscopy
-cadioversion pads (need atrial kick and sinus) and phenylephrine
-L uterine displacement
-etomidate and narcotics -> rapidly secure airway and tell neonatal team about narcotics
-a line as soon as possible if not present yet
**assess if can get succ w/ comorbidities
ST changes in aortic stenosis after induction, what to do?
-give vasoconstrictor if concern is dec in preload or afterload causing ischemia -> need to inc coronary perfusion
-if concern is LV function and need dec in afterload -> give nicardipine (causes arterial dilation with minimal venodilation -> won’t impact preload)
large PPH, what to do?
-verify pt receiving pitocin
-FiO2 100%, ensure hemodyanimc stability -> likely req phenyleprhine
-notify blood bank and call for pRBCs
-inc oxytocin
-methergine (semisynthetic ergot alkaloid), hemabate PG F2alpha analogue), or misoprostol (PG E1 analogue)
-OB: uterine massage -> IU balloon -> compression sutures -> ligate arteries -> hysterectomy
CI for methergine
HTN
coronary artery issues (causes coronary artery vasoconstriction)
pregnant pt w/ chorio and MS and ASA, 5 hours after pulling epidural, b/l leg weakness and back pain, ddx?
-bactermia from chorio
-epidural/spinal hematoma
-residual epidural blockade
-tissue damage w/ needle instrumentation
-relapsing MS
signs/symp w/ epidural/spinal hematoma
back pain or pressure: severe and unrelenting
-bowel/bladder dysfunction (urinary retention)
-radicular pain (shoots down into legs)
-sensory deficits
sign/symp w/ MS relapse
paresthesias
-weakness
-sensory deficits
-urinary incontinence, bowel retention
-visual and gait disturbances
-autonimic dysfunction
-vision changes
post c/s MS was on AC w/ epidural catheter, urinary incontinence w/ back pain and weakness, what to do?
-likely MS relapse HOWEVER spinal/epidural hemaotoma needs to be ruled out first
-examine pt -> determine if weakness progressive or recessive -> MRI and c/s neurosurgery
-intervention needs to occur w/i 6-12 hrs to avoid irreversible SC injruy
restart therapeutic enoxaparin after c/s?
-24 hours following surgery
AND
-at least 2 hours after epidural catheter removed
*acknowledge risk of DVT/PE v bleeding from surgery or epidural/spinal hematoma
post c/s dyspneic ddx w/ MS, AS, PEC?
-pulm thromboembolism, DVT, AFE
-HF
MI
bronchospasm
TPTX (PTx after central line)
pulm edema (PEC, AS)
aspiration
MS
PE immediately postop, tx?
-100% FiO2
-give inotropes and fluids using CVP, a line, TEE monitors -> pulm vasodilators (nitric oxide, milrinone [PDE inh])
-intubate and mechanically ventilate if needed
-avoid AC due to stop -> vena-cava filter, or pulm embolectomy
how does inhaled nitric oxide work?
inc cGMP -> dec in intracellular calcium and smooth m relaxation
2 days post c/s HA, ddx?
-tension HA
-migraines
-PDPH
-lactation HA
-PNEUMOCEPHALUS (if LOR done w/ air)
-PEC?
-SAH, SDH
PDPH, tx?
hydration
caffiene
abd binder (inc intraabd pressure)
pain control
**consider epidural blood patch, but look at AC likely postop
MVA cant move extremities, SOB, ddx?
-cervical spine injury above C6
-PTX
-pulm edema (tamponade, MI, PE, neurogenic pulm edema)
-PE (fat emoblism 2/2 long bone fx)
what is neurogenic pulm edema
head injury or cervical spinen injury -?> sympathetic activation -> systemic vasoconstriction -> dec LV compliance and inc LA pressure -> pulm edema
cardioaccelerator fibers
T1-T4
cervical SC injury, concerns?
-resp dysfunction (loss of diaphragmatic fxn)
-hypoTN (loss of sympathetic vascular tone and cardioaccelerator fibers
-pulm aspriation (impaired airway reflexes)
-thermal regulation (loss of vasoconstriction and temp sensation)
-arrhythmias (autonomic dysfunction)
-end organ ischemia (inc ICP, CAD< hypoTN, acidosis, hypoxia, anemia)
-difficult airway
hyperventilate w/ SC injury or TBI?
Nope
-head trauma and SC trauma -> dec SCBF and CBF 1st 24 hours -> concernerd for ischemia
R on T phenomenon
When a QRS from a PVC lands on a T wave during the refractory period
-or a shock is delivered on a T wave
**can cause V fib or V tach
When are PVCs a problem?
-frequent: more than 3 per minute
-occur in runs of 3 or more
-R on T pneomenon
-> all lead to inc risk of V tach or V fib
**more than 5-6 per minute -> inc periop morbidity
What causes PVCs?
hypoxemia
-MI, hypoK, hypoMg
-symp acctivation
-mechanical irritation (Central line)
-d/c drugs that prolong QT
-ensure defibrilator
What to do if pt hemodynamically unstable or symptomatic w/ PVCs?
overdrive pacing
antriarrhythmic: amiodarone, a beta blocker
**if unstable -> cardiovert, stable -> amio
Spinal shock
can occur following acute SC injury
-flaccid paralysis, paralytic ileus
-loss of sensation, spinal reflexes, symp vasomotor TONE!
-no otemp regulation below injury
-can get loss of diaphragmatic function, IC and m function (can’t clear pulm secretions), loss of cardioaccelerator fibers
**can last 1-3 weeks -> risk of resp dysfxn, hemodynamic instability, aspiration, DVT/PE, hypothermia
How long for inc in extrajunctional ACh receptors after SC injury?
24-48 hours
What to do if whole bottle of volatile spills on floor
-risk of significant expsoure of OR personnel
-suction spilled volatile into plastic container -> seal and labor -> transport to appropriate waste disposal site
-verify pt secured, ensure adequate sedation and NMB -> prepare for transport into different room
SC injury to C5 w/ CAD and DES -> when can have elective surgery?
-resolution of hemodyanmic stability 2/2 spinal scord shock?
-plavix can be safely d/c ideally 6 months after DES
What level does autonomic hyperreflexia occur above?
T7
O2 supply compromised what to do?
**concern for giving hypoxic gas mixture
-switch to backup O2 cylinders
-disconnect main pipeline supply
-hand ventilate w/ low gas flows -> if pneumatically driven vent uses more O2
-ask for additional E-cylinders
Estimating O2 E-cylinder supply time
O2 cylinder pressure (psig)/ (200 x oxygen flow rate in L/min)
Autonomic hyperreflexia, what to do?
-surgeon to stop
-deepen anesthesia
-vasodilator: NG, nitroprusside
-bladder empty
-a line
-monitor for complications: cerebral, retinal, SAH, sz, MI, dysrhtyhmias, pulm edema
Pathophys of autonomic hyperreflexia
pain below level of SC injury -> reflex sympathetic d/c -> not modulated by inhibitory impuses from CNS -> unopposed symp d/c -> vasoconstriction below level of lesion, and vasodilationn above lesion where can stimulate carotid sinus receptors -> reflex bradycardia
normal closure ducturs arteriosus
ventilation -> arterial O2 levels inc and PVR dec
-dec in PVR leads to a L to R PDA shunt -> exposure to blood with higher O2 count
-decrease in PG w/ separation from placenta -> closure
reasons PDA didn’t close
hypoxia at birth (no dec in PVR)
-prematurity: poorly contractile muscular layer in ductus artioersus -> didn’t appropriately contract w/ dec PG and inc in O2)
respiratory distress syndrome of the newborn reason?
premature infants and insufficient surfactant -> widespread atelectasis -> intrapulm shuting -> hypoxemia and acidosis
sympatoms of respiratory distress syndrome of the newborn
hypoxemia
acidosis
nasal flaring
accessory muscle use while breathing
tachypnea, tachycardia
b/l rales
cyanosis
ground glass infiltrates b/l on CXR
how to minimize resp distress syndrome of newborn
maternal steroids 24-34 weeks if expect born before 35 weeks
exogenous surfactant to newborn
Indomethacin MOA
PG synthetase inhibitors -> dec PG in PDA
SE from indomethacin
thrombocytopenia
hypoNa
and reduced renal blood flow, mesenteric BF, and CBF
glucosuria in premature infants
-infants < 34 weeks have issures w/ renal tubular reabsorption of glucose
-less concerning if < 34 weeks, if > 34 weeks considerning
concerns w/ prematurity
-hypoglycemia
-retinopathy of prematurity
-intraventricular hemorrhage
-postop apnea
-hypothermia
PDA ligation complications
-RLN injury
-phrenic n injury
-thoracic duct injury
-injury to major vessels
-HTN (volume goes forward s/p ligation)
-reopening of ductus
w/ PDA closure, where to monitor BP?
R arm -> incase of rupture would need to to clamp L subclavian artery
w/ PDA closure, where to monitor pulse ox?
R upper extremity and lower extremity -> pre and post ductal readings
PaO2 goal to avoid retinopathy of prematurity
50-80
SpO2 goal 87-94%
RF for retinopathy of prematurity
-hyperoxia
-prematurity < 32 wweeks
-low birth weight < 1000g
-hypoTN
-sepsis
-RBC transfusions
-cyanotic congential heart dx
-resp distress syndrome
-intraventircular hemorrhage
-material diabetes
mechanical ventilation
maintain anesthesia for neonates
fentanyl and muscle relaxant (rocuronium)
how to monitor blood loss in neonate
weigh sponges, laps, etc. to estimate -> replace 3:1 w/ crystalloid or colloid/prbcs as indicated
average blood volume premature neonates
90-100 cc/kg
average blood volume pregnant women
90cc/kg
average blood volume full term neonates
80-90 cc/kg
average blood volume hcild 3-12 months old
70-80 cc/kg
average blood volume child > 1 yaer
70-75 cc/kg
average blood volume obese child
60-65 cc/kg
average blood volume adult man
75 cc/kg
average blood volume adult women
65 cc/kg
dissection of PDA -> O2 sat drops and HR drops, what to do?
-FiO2 100%, manually ventilate
-verify accuracy of monitors
-eval EKG, airway pressures and TV
-dissection w/ pressure on lung van inc PVR -> R to L shunting -> ask surgery to relax traction on lung
-assesss blood loss and volume status to correct
-give atropine if continued bradycardia
-adjust insp pressures and FiO2 to optimize oxygenation and ventilation
post PDA ligation neonate is hypertensive, ddx?
-ligation of PDA (BF that was prev going to lungs going systemically)
-inaccurate (wrong sized BP cuff)
-inadequate pain control
-agitation
-hypervolemia
-hypercarbia
-hypoxemia
-bladder distention
-possible inc ICP (risk of intraventricular hemorrhage)
how do infants maintain heat
nonshivering thermogenesis
-symp stimulation -> NE release -> metabolism of brown fat -> inc O2 consumption and heat production
Neonatal sz ddx?
intraventricular hemmorhage
hypoCa, hypoMg
hypoglycemia
cerebral edema
hypoxic-ischemic encephalopathy
sepsis
neonatal sz what to do?
-check ETT placement, auscultate
-review monitors and vent settings -> adequate O2 and ventilation
-check EKG and BP
-give benzos to stop
-order lytes, tell neonatologist, consider neuro c/s
SOB w/ lung cancer
mass compression of heart or great vessels
-SVC syndrome
-post-obstructive PNA
-V/Q mismatch
-cardiac or pulm dx (COPD)
-Lambert-Eaton
SOB w/ SVC syndrome
obstruction of venous draiinage -> mucosal edema and venous engorgement of airways -> dyspnea, orthopnea, and coughing
Common paraneoplastic syndromes assoc w/ cancer
-PTHrP tumor release
-SIADH
-Cushings Syndrome
-Lambert Eaton Myasthenic Syndrome (small cell lung cancer)
-Carcinoid Syndrome
Paraneoplastic PTHrP symptoms?
muscle weakness, cardiac arrhythmias, vomiting, renal failure
**HyperCalcemia
paraneoplastic cushings syndrome symptoms?
inc ACTH or CRH (corticotropin releasing hormone, adrenocorticotropic hormone)
-hypoK, alkalosis, HTN, psychosis
Lambert Eaton symptoms
proximal weakness of lower rextremities (cna progress to upper extremities)
-autonomic dysfunction: dry mouth, impotence, constipation, orthostatic hypoTN
Treatment of lambert eaton
-cancer therapy
-plasma exchange, IVIG
-prednisone
-3,4-diaminopyridine
-pyridostigmine (dec degradation of ACh)
Lab tests for SIADH
-normal total body sodium
-increase urine osmolality
-inc urinary sodium concentration
-normovolemia
Sodium level, when to delay case
Na < 130 -> assoc w/ inc risk of cerebral edema
-figure out why and treat appropriately
-discuss risks/benefits w/ surgery, acknowledge importance of timely surgery
a line and pulse ox in mediastinoscopy
R arm! b/c likely to have brachiocephalic artery compression w/ mediastinoscopy -> alert to compression
**especially important if pt has cerebral disease
Contraindictions to mediastinoscopy
-severe tracheal deviation
-cerebrovascular disease
-severe cervical spine dx w/ limited neck extension
-previous chest radiotherapy
-thoracic aortic aneurysm
Concerns for HTN intraop
BP lability
and R shift of cerebral autoregulation curve -> inc risk of cerebral ischemia
-poorly controlled HTN -> introap end organ ischemia (MI, stroke), arrhythmias, CHF, hypoTN, HTNq
HTN and elective surgery
DELAY 6-8 weeks if:
-systolic BP > 180, diastolic > 110
-HTN w/ concomitant end organ damage
-cardiac surgery, carotid surgery, or pheo resection **should be well controlled to limit postop M&M)
Causes of HTN
-CKD
-renovascsular dx
-chronic steroids (Cushings)
-OSA
-drugs (cocaine, amphetamines)
-alcohol abuse
-obesity
-thryoid/parathyroid dx
-pheo
-aortic coarctation
opacification of upper extremity collateral veins on CT, dx?
SVC syndrome
SVC syndrome symptoms
JVD
coughing/hoarseness
SOB
opacifications of upper extremity collateral vwins on CT
HA
facial/neck/upper limb edema
chest pain
dysphagia
orthopnea
visual changes
mental confusion
Intraop concerns for SVC sydnrome
-difficult intubation airway edema
-unreliable drug delibery through IV in upper extremities
-potential for massive hemorrhage if damage to vessels
-compromised cerebral perfusion (impaired drainage of cerebral veins -> inc cerebral venous pressure -> inc ICP and impaired perfusion)
-inc risk of postop resp complications (airway edema or mass compression)
SVC syndrome, what to do intraop?
-difficult airway equpiment, minimize airway manipulation
-2 large PIV catheters (1 on lower extremity)
-T&S, T&C blood
-head up position to facilitate cerebral venous drainage -> avoid inc ICP
-cautious fluids -> too much engorgement and edema, too little dec preload
-avoid coughing/bucking w/ emergence
-keep ETT and mechanical ventilation early postop unless obstruction relieved
mediastinoscopy, shortly after induction, scope advnaced when pt hypoTN ddx?
-surgical compression of brachiocephalic artery
-induction medication or inhaled anesthetics causing vasodilation
-PTX
-allergic reaction
-vagal reflex from manipulation of trachea, great vessels or vagus n
-autonomic neuropathy (LES)
-red preload w/ SVC syndrome
-MI or arrhythmia
mediastinoscopy, shortly after induction, scope advnaced when pt hypoTN, what to do?
-check a line for accurary
-check BP on L arm (difference in arms = brachiocephalic compression)
-ask surgeon regarding hemorrhage, or compression of structures
-ensure adequate O2 and ventilation
-blook at EKG to r/o arrhythmia or ischemia
-ausculate breath sounds -> dec volatile, give fluids and pressors as indicated
Main concern following mediastinoscopy
PTX!
req CXR priot to d/c
Mediastinoscopy, major bleeding, now what?
-call for help
-ensure adequate IV access on feet -> run products through here
-ask surgeon to pack
-fluids and vasopressors
-have blood brought to room -> initiate MTP
-blood warmer, call for cell saver, rapid infuser
-switch to DLT if thoracoty needed
-precordial doppler -> inc risk of venous air embolism w/ vascular injury
SOB VC not moving, midline position
b/l partial RLN injury
-reintubate -> mechanically venilate, suppl O2
-alert surgeon and ENT
-give pt sedation
Complications w/ mediastinoscopy
-tracheal compression/laceration
-cerebrovacular events (a compression)
-R U limb ischemia
-compression of aorta -> reflex bradycardia
-PTX
-RLN or phrenic n inury
-venous air embolism
-medistainal hemorrhage
-esophageal tear
post mediastinoscopy in ICU, rapid hypoTN, what to do?
-auscultate chest
-check ventilator settings
-ensure adequate oxygenation
-trendelenberg postion
-fluids, vasoconstrictors, inotrops
-ensure IV access, echo, surgeon, and possible central line placement
Cushings dx symptoms
truncal obesity
admonial straiae
HTN
hyperglycemia
function of pituitary gland
-anterior: syntehssis, storage and secretion of ACTH, TSH, LH, FSH, GH, prolactin
-posterior: stores and secretes ADH and oxytocin
Bromocriptine MOA
dopamine agonist => decrease of GH and prolactin release
Octreotide MOA
somatostatin analogue -> inh of GH from pituitary
Acromegaly blood test
Insulin like Growth Factor-1 serum (less variable throughout the day) and oral glucose tolerance test (serum GH remains high despite glucose ingestion)
Why difficult airway in acromegaly
distorted facial anatomy
macroglossia
epiglottic enlargement
overgrowth of mandiel
narrowed glottic opening
RLN paralysis
radial arterial line in acromegaly?
no -> poor collateral flow to ahnd inc ischemia -> use dorsalis pedis or femoral
pituitary surgery, sudden drop in BP ddx?
-hemorrhage
-VAE
-MI, arrhythmia
-anesethetic OD
-delayed allergic rxn
Treatment for VAE
-immediately have surgeon flood the field
-place central line and attempt to aspirate
-provide support w/ fluids, vasoconstrictor, inotropes
-treat bronchospasm w/ albuterol
-LLDQ position if needed
Plan for extubation in pituitary surgery if CSF space had been opened intraop
-still plan to maintain similar extubation criteria and wake the patient up if difficult airway
-can give lidocaine IV prior to extubate to dec risk of coughing to prevent reopening of CSF leak
OSA obtunded in PACU, ddx?
-postop airway obstruction and apnea (esp w/ narcotics)
-atelectasis (intraop hypoventilation)
-pulm edema (CHF, VAE)
-aspiration
-inadequate reversal of NMB
-hypo/hyperglycemia
-electrolyte abnormalities
-arrhythmia, MI
-stroke
post sphenoidal surgery, pt has OSA, how to manage postop
CANT USE CPAP -> risk for pneumocephalus
-maintain seated or lateral position -> supplemental O2 until able to maintain baseline on room air
-multimodal analgesia to minimize sedatives/narcotics
-continuous pulse ox -> monitor for several hours
post pituitary surgery pt starts producing copious urine, ddx?
-central diabetes insipidus (not producing enough ADH)
-diuretic administration
-hyperglycemic diuresis
How to diagnose diabetes insipidus
-dec urine specific gravity < 1.005
-hyperglycemia is ruled out
-responds to exogenous ADH
Treatment for diabetes insipidus
-replace UOP w/ 1/2 NS w/ maintanence infusion
-larger volumes: vasopressin or desmopressin (DDAVP)
post pituitary tumor removal, POD 4 pt hypotensive refractory to fluid boluses and vasopressors, ddx?
adrenal insuff 2/2 panhypopituitarism
-pituitary hemorrhage/ischemia
periop concerns dissecting anuerysm
-aneurysm rupture
-propagation of aneurysm
-MI
-periop hemodynamic instability esp w/ cross clamping and possibility of potential massive blood loss
-postop respiratory complications
-paraplegia (disruption of radicular arteries supplying SC)
-stroke
-hemorrhage
-CHF
DeBakey classification of aortic dissection
-type I: start in ascending aorta, extend to involve descending aorta
-type II: originate in ascending aorta, and do not extend beyond brachiocephalic
type III: originate beyond L subclavian and extend to diaphragm or aorto-iliac bifurcation
Type I & II: surgical III: medical management
III surgery if significant dilation, risk of rupture or end organ ischemia
Stanford aortic dissection classification
type A: ascending aorta w/ or w/o involvement of arch or descneding aorta
type B: ascending aorta not involved
Ideal time to start beta blockers prior to surgery
2-7 days
aortic repair postop resp failure
high incidence 25-45%
-have CXR, H&P
Dibucaine number
indirect measure of pseudocholinesterase activity -> when injected will inhibit butyl cholinesterase
-normal: 70-80
-hetero: 50-60
-homo recessive less than 50, will have a block for hours
Fever w/ blood transfusion ddx
-febrile nonhemolytic transfusion reaction
-acute hemolytic transfusion reaction
-TRALI
-bacterial/viral contamination
Differentiation of CSW and SIADH
SIADH: euvolemic, UNa < 100
CSW: hypovolemic, UNa > 100
Treatment SIADH
water restriction, demeclocyline (diminishes responsiveness to ADH), diuresis
Treatment cerebral salt wasting
IV fluids
What % of PPV is considered to be fluid responsive?
> 12%
-if mechanically ventilated w/ TV of at least 8 cc/kg
When can PPV not be reliable?
spontaenous ventilation
low TV
pulm HTN
dec lung compliance
open thoracic cavity
arrhythmias
inc abd pressure
What is pulse pressure variation?
Difference between systolic and diastbolic BP and it varies w/ respiration during postitive pressure ventilation -> dyanmic marker used to determine if pt is a fluid responder
-idea of where pt is on Frank-Starling curve
Pulse pressure variation equation
PPV = (PPmax -PPmin)/ PP mean x 100
