UBP Condensed2 Flashcards
Mg dosing for PEC
4-6g bolus over 20 minutes
Infusion of 1-2 grams per hour
Mg PEC therapeutic range
4-6
Mg toxicity
> 10: loss of DTR
15: resp depression
20: cardiac arrest
EKG: prolonged PR, widened QRS
Tx: calcium, diuretics
Anti-HTN in pregnancy
Labetalol 1st line
Hydralazine: reflex tachycardia
NG
Nitorprusside (risk of CN toxicity)
Nifedipine (cant’ use w/ Mg: risk of myocardial depression)
HELLP
Hemolysis, elevated liver enzymes, low plts
Tx: Mg, delivery of baby
Drugs that DON’T cross placenta
He is Going Nowhere Soon
heparin
Insulin
Glyco
Non-depolarizing NMB
Succ
Antepartum bleeding ddx
Placenta Previa v placenta abruption MC!! painless previa, painful abruption
Less common: vasa previa (fetal vessels overlie internal os), uterine rupture
Uterotonics
Oxytocin: in Ca and contractions -> causes hypoTN, nausea, water retention (similar to ADH)
hemabate: Prostaglandin, inc Ca -> bronchospasm
Methergine: alpha agonist on blood vessels and smooth muscle -> HTN
Misoprostol: prostaglandin -> tachycardia/fever
Number 1 determination of fetal well being
FHR variability!!!
Normal 6-25 bpm variability
NORMAL: 110-160
**can use fetal scalp capillary pH
Early decelerations
Fetal head compression
Late decelerations
Uteroplacental insufficiency
Variable decelerations
Umbilical cord compression
Molar pregnancy concerns
Abnormal bleeding
CHF
Pulm insufficiency
Hyperthyroidism/thyrotoxicosis
DIC
PE
acute resp distress in peripartum period
Tocolytic induced pulm edema
Steroids
PE/AFE
ARDS
Alternatives besides neuraxial for preg pain control
Paracervical block: 1st stage of labor T10-L1 -> assoc w/ fetal hypoxia, uterine artery constriction, inc uterine tone
Paravertebral lumbar symp block: 1st stage of labor
Pudenedal nerve block: 2nd stage of labor S2-4
APGAR
Appearance
Pulse 0: none 1: < 100, 2: >100
Grimace
Activity
REspirations
Treatment for meconium aspiration syndrome
If resp depression w/ HR < 100: consider suctioning ETT
-otherwise dry and stimulate -> give exogenous surfactant!! (Meconium inactivates surfactant)
Neonatal resuscitation NALS
- Stimulate, if apneic or HR < 100: clear airway and PPV 30 breaths/min
- After 30 seconds: if HR < 100: ventilation
- After 30 seconds: if HR < 60: intubate, FiO2 100%, start chest compressions at 100/min and IV/IO access
- If HR still < 60 after 30 seconds:give epi (0.01-0.03 mg/kg) and fluids
Epi dosing for neonate
0.01 mg/kg
Epi dosing for ETT
0.1 mg/kg
Normal umbilical artery gas
PH; 7.27, pCO2: 50, pO2: 22, bicarb 22
Normal umbilical vein gas
PH: 7.35, pCO2 38, pO2 29, bicarb 20
Best time to have surgery while pregnant
2nd trimester
-avoid miscarriage/organogenesis in 1st
-avoid preterm labor in 3rd
When to give ppx steroids
Between 24-34 weeks w/ anticipation of preterm labor
Ppx steroids or tocolytics in non OB Surg for pregnant patient?
Not indicated
Intraop considerations for pregnant pt for non OB surgery
Standard monitors
LUD
FHR! (Can monitor if > 18 weeks) and tocodynamometer! (Look for preterm contractions!)
Goals for laproscopic surgery w/ pregnant pt
Minimize insufflation pressures: 8-12
EtCO2 32!
Postop pregnant pt for non OB surgery
-monitor MINIMUM of 12 hours for preterm labor
-if preterm labor: beta agonists, Mg, betamethasone! If b/w 24-34 weeks
Thesis isosensitization
-Rh neg moms w/ Rh positive fathers get RhoGAM at 28 weeks and 72 hours after delivery -> antibody destroys Rh + cells before Rh - mom can form antibodies to them
-if no rhogam -> Rh neg moms make antibodies to Rh + blood from fetus -> IgG Ab will cross placenta and lead to hemolytic dx of newborn
Emergency c/s w/ difficult airway
FiO2 100%, LUD, treat hypoTN
-awake fiber optic if time
-if no time: RSI, difficult airway equipment and maintains sp vent w/ ketamine/inhalational
CT in pregnancy?
IF trauma, can do if unstable to access damage -> treating condition of mom is most effective way to maintain health of baby!
hypocalcemia EKG changes
prolonged QT interval on EKG
changes in lytes in ESRD
hypoNa, hyperK, hypoCa, metabolic acidosis
can you use HD catheter for ESRD case?
Yes, if last result: draw back heparin and use aseptic technique: inc risk of clots and infxn
RF for postop AKI
advanecd age
ASA
ACE inh (dec kidney response to dec RBF)
contrast
DM
HTN
CHF
hypoTN
assessing volume status in ESRD
last HD
weight to dry weight
CXR
pulm edema
peripheral edema
JVD
orthostasis
morphine in ESRD
6-MP metabolite is active and prolonged -> risk of resp depression
meperidine and ESRD
normeperidine metabolite excreted renally -> builds up and can cause seizures
K cutoff for kidney transplant
if > 5.5 delay for dialysis
if need to give blood in a kidney transplant, what kind of blood do you give?
washed (leukocyte reduced), irradiated (red GvH), CMV negative blood
spinal level goal for TRUP
T9-10
bladder sensation: T11-12
perineum S2-4
HypoTN in TURP ddx
bladder perforation (nause,a diaphoresis, bradyacardia, abd/shoulder pain)
bleeding
transient septicemia (bacteria from prostate into open venous sinuses)
myasthenia gravis pathophys
antibodies to post junctional nicotinic ACh receptors
inhaled anesthestics in MG
potentiate wekaness -> should place a n monitor even w/ no muscle relaxants
postop predictors of mechanical ventilation in MG
pyridostigmine dose > 750 mg daily
dx > 6 years
VC < 2.9 L
other pulm dx (COPD)
bulbar symptoms
EBL > 1L
AHI index
the combined average number of apneas and hypopneas that occur per hour of sleep
Treatment of thyrotoxicosis
-propanolol: dec conversion of T4-> T3
-methimazole, PTU (PTU works fast w/ glucocorticoids to dec conversion)
-iodine prevents release of thyroid hormones but use last!
-acetaminophen for fevers (NO ASA -> inc free T3, T4)
if everything else fails can do plasmapheresis
Thyrotoxicosis
a fib, inc CO2, inc O2 consumption, dec SVR, dec PVR
inv Minute ventilation
anxiety, tremors
sweating
**thyroid storm: metabolic, thermoregulatory, CV mechanisms fail -> just treat
treatment for thyrotoxicosis
propranolol (prevents conversion)
other beta blocks for symptoms
methimazole, PTU
PTU + glucocorticoids: work faster
iodine (prevents release)
acetaminophen for fevers
Hypothyroidism
low cardiac output: dec contractility, dec SV, bradycarida
pleural and pericardial effusions
hypothermia
macroglossia
SIADH
Myxedema coma
loss of DTRs, hypothermia, hypoventilation, hypoNa, coma
teratment for myxedema coma
ICU admission
correct lytes and hypovolemia
give T3 and T4
give hydrocortisone
heat pt
mechanical ventilation
hypothyroidism intraop complications
difficult intubation (large tongue)
hypoglycemia
anemia
hypoNa
hypothermia
hypoventilation (dec CO2 production)
hypoTN
delayed awakening
agents to avoid in pheo
histamines (atracurium, morphine)
droperidol
metoclopramide
pancuronium
ketamine/ephedrine/atropine
succ (fasciculations inc catecholamine release)
pain, anger, anxiety
hypoxia, hypoTN, hypercarbia
Diabetes insipidus treatment
DDAVP
vasopression
fluids: maintenance and 2/3 UOP
Thyrotoxicosis agents to avoid
Pancuronium
Ketamine
Glyco
Atropine
Des
Ephedrine
Epi
**anything that stimulates symp system
Loss of DTR, hypothermia, hypoventilation, hypoNa, somnolent
Hypothyroidism: myxedema coma
Diagnosis for pheo
Most sensitive: plasma metanephrines
Plasma catecholamines
Urine metanephrines
Urine Vanillylmandelic acid
Meds to avoid in pheo
histamine (atracurium, morphine)
Droperidol
Metochlopramide
Pancuronium
Ketamine/ephedrine/atropine
Succ (fasciculations inc catecholamines release)
Glucagon
Halo one
Pain, light anesthesia
Hypoxia/hypoTN/hypercarbia
HTN w/ pheo intraop
Treat w/ short acting agents: esmolol, nicardipine, clevidipine, Mg
**be careful w/ NG -> can get tachycardia
**nicardipine: selective arterial vasodilator
When to give steroids w/ pheo
If b/l adrenalectomies
Postop after pheo
Hypoglycemia (inc insulin, catecholamines inhibit insulin)
HTN: if sustained retained tumor, if present but lower, can be catecholamines from peripheral n being released
Somnolence
Anesthesia concerns w/ acromegaly
Difficult airway: macroglossia, large jaw, thickened pharyngeal nad laryngeal soft tissues
OSA
HTN
Glucose intol/insulin resistance
Ulnar/radial muscle myopathy: no a line in wrists, use DP
Dx of acromegaly
IGF-1, GH
treatment of acromegaly
Bromocriptine and octreotide
Cushing syndrome symp
(Excessive ACTH)
Moon fancies
HTN
Hyperglycemia
OSA/GERD
HyperNa, hypoK (inc sensitivity to m relaxants)
Diabetes Insipidus
HyperNa
Dilute urine
tx for diabetes Insipidus
DDAVP, vasopressin, fluid replacement (maintenance and 2/3 UOP)
Diarrhea, flushing, heart murmur
Carcinoid triad (pulm stenosis or TR)
Carcinoid tumor
Releases histamine, bradykinin, and serotonin
-if in GI -> cleared by liver, no carcinoid syndrome
Carcinoid syndrome
Mets to liver/pulm/breast
-flushing, diarrhea, hypoTN, HTN
R heart dx
Bronchoconstriction (bradykinin)
Dx of Carcinoid syndrome
24 hour urine 5_hydroxyindoacetic acid
Preop for carcinoid syndrome
Echo (can get R heart serotonin fibrosis -> TR)
IVF
Octreotide (Dec release of serotonin)
H1 and H2 blockers
Alpha/beta blockers
Carcinoid syndrome intraop
Avoid succ: fasciculations and histamine release -> HTN
-bronchospasm 2/2 manipulation of tumor -> ask surgeon to stop, give octreotide and Benadryl
reserve epi unless needed, can worsen carcinoid
DM and difficult airway
Stiff joint syndrome
-glycosylation of proteins/collagen cross linking
DKA diagnosis
anion gap metabolic acidosis
Urinary ketones
Tx DKA
IVF w/ K replacement
Insulin to lower glucose (75-100 per hour to avoid cerebral edema)
When glucose < 250 add dextrose
-monitor lytes until gap closed
Diagnosis of hyperosmolar hyperglycemic state
Glucose >600
Serum osm > 320
*no ketones
HHS hyperosmolar hyperglycemic state tx
IVF
Insulin
LMWH to prevent clots
Abx if in fxn
Chronic steroid implications
Impairs wound healing
Inc skin friability
Inc risk of fxn, in fxn, GI bleed, ulcers
When to get stress dose steroids
20mg prednisone for more than 3 weeks w/i the year
-clinical Cushing’s syndrome
Rheumatoid arthritis considerations
-pericarditis, valvular fibrosis, arrythmias (rheumatoid nodules in conduction system)
-pulm fibrosis, pleural effusions
Glaucoma
Pathological elevation of increased intraocular pressure due to outflow obstruction of aqueous humor from eye
Succ and globe injury
Can give if give defasiculating dose -> acknowledge succ can inc IOP
Ketamine and eyes
Inc IOP
Etomidate and IOP
Inc due to myoclonuss
Retrobulbar block
Injecting local anesthesia inside muscle cone
-close to optic n and opthalmic artery
-less volume
RISKS: retrobulbar hemorrhage, central retinal artery occlusion, perforation of globe, spread into CNS, OCR, optic n atrophy
Peribulbar block
-local anesthesia injected above and below orbit into orbicularis oculi muscle
-less risk of intraocular or intramural injxn
-less risk of direct injury
-harder to get dense block
-compl: periorbical ecchymoses, transient blindness, contra lateral eye
Nitrous oxide and air
Concern of gas injection in eye -> different gases have different timelines -> longest 30d, don’t use nitrous w/i 30 days of eye surgery
Disorders linked to MH
Central core dx
King Denborough Syndrome
-defect of ryanodine receptor -> in in Ca and muscle contraction
If masseter muscle rigidity, give dantrolene?
Yes due to MMR and high assoc w/ MH
What is EMLA cream?
Prilocaine/lidocaine: risk of Met-Hg
Jehovah’s Witness minor
-minor: if life threatening can give blood without appealing to court
-if parents don’t want you to give blood products -> identify which are acceptable and tell them attempt to avoid BP but if life threatining would seek approval from court to administer blood
Positive pregnancy test in minor
-check state emancipation laws
-tell pt, encourage to tell parents, arrange f/u
Risks of IO
Osteomyelitis, fat embolism, marrow embolism, compartment syndrome
At what age risk of apnea and bradycardia of prematurity w/ anesthesia
< 60 weeks post conceptual
Glucosuria in infants
< 34 weeks: normal, immature renal reabsorption
> 34 weeks: hyperglycemia
Prematurity time frame and risks
< 37 weeks
RDS, hypoglycemia, apnea, retinopathy of prematurity, intraventricular hemorrhage, NEC, pulm HTN of newborn
ETT sizes newborn
3 < 3500g
2.5 if < 1500g
Newborn Hct transfusion goals
> 35%
Prematurity has more fetal Hg -> leftward shift of Hg O2 dissociation curve
How dose PDA normally close
Normal 2-4 days after birth
-Inc arterial O2 and dev PVR -> Dec PG -> closure
-if premature, have RDS/hypoxia and Dec contractility of muscular layer of PDA
Treatment for PDA
-indomethacin: SE thrombocytopenia, mesenteric perf, renal injury, hypoNa
-ibuprofen used in low birth weight infants
monitors for PDA ligation
2 pulse ox: R hand lower extremity (pre and post ductal)
-if LE O2 sat is lower -> means R to L shunting
GOAL: PaO2 50-80, SpO2 87-94%
-transfuse Hct > 40 if premature or > 25 full term
Resp Distress Syndrome v Bronchopulm Dysplasia, which one is first?
RDS -> BPD
Why do infants get respiratory distress syndrome?
Lack of surfactant
Timeframe for retinopathy of prematurity
< 44 weeks post gestation age
RF: low birth weight, prematurity, hyperoxia, hypoTN
Full term normal vitals
HR 125-135, BP 50-70/35-50, 40 breaths
No shivering thermogenesis
Hypothermia -> NE release -> metabolism of brown fat
Symptoms of TEF
Intrauterine polyhydramnios (can’t swallow amniotic fluid)
OGT coiling
Drooling cough cyanosis w/ feeding
TEF induction/intubation
2 IVs, a line L arm (R thoracotomy)
Avoid PPV, ketamine/inh for spontaneous ventilation until fistula ligated
-use fiber optic to look for tracheomalacia
Complications TEF
Anastomotic leak
Esophageal dysmotility
Reflux
Tracheomalacia
VC paresis
Post-intubation croup
Tetralogy of Fallot
POVR: Point of View Right?
Pulmonary atresia
Overriding Aorta
VSD
RVH
How to manage cyanotic spells (R to L shunt) under anesthesia
Deepen anesthetic
100% FiO2
Vasopressors or ketamine to inc SVR (switch shunt)
Congenital diaphragmatic hernia
Nasal flaring, sternal retractions, absent L breath sounds
-> assoc w/ aortic coarctation
Pulm HTN tx
Avoid hypoxia, hypercarbia, acidosis, hypothermia
USE inhaled nitric oxide
Down Syndrome associations
-CV: congenital heart defects (endocardial cushion defects, ASD, VSD)
-airway: macroglossia, Atlanta-axial instability, subglottic stenosis
-GI: duodenal atresia, delayed gastric emptying (RSI)
**need echo and cervical spine XR prior
-difficult airway equipment, ENT surgery on standby, fiber optic
Propofol infusion syndrome
-peds and ICU!
-prolonged dose -> bradycardia, metabolic acidosis, rhabdo, hyperK, liver failure, renal failure, cardiac failure
Nitrous oxide in omphalocele
No, can distention bowel and impaired reduction
Beckwith-Wiedemann Syndrome
Macrosomia
Macroglossia
Hypoglycemia
Polycythemia
Trauma Hs&Ts
Hypoxia
H+ acidosis
Hyper or Hypokalemia
Hyper or Hypoglycemia
Hypothermia
Toxins
Thrombosis (MI or PE)
Tamponade
Tension PTX
Trauma
Pyloric stenosis how to tell when rehydarated prior to surgery?
Cl 100
PH 7.3-7.5
Bicarb < 30
UOP 1-2 cc/kg/hr
**prior is a hypochloremic hypoK hypoNa metabolic alkalosis
Succ dose in neonates
2-3 mg/kg due to higher volume of distribution
Hemolysis what labs to send after blood transfusion?
Haptoglobin (decreased)
Bilirubin: unconjugated/ indirect elevated
Repeated cross matching
Direct antiglobulin test
Urine free hemoglobin
Hemophilia A
Factor VIII def
-if don’t respond to factor VIII, give factor VIIa (activates thrombin directly)
-prolonged PTT
-give factor 8 concentrate, DDAVP (released factor VIII and vWF from endothelium suitable fo minor hemophiliacs)
Meds to avoid in hemophilia A
NSAIDs
ASA
Antihistamines
Antitussives (inhibit plt aggregation)
Hemophilia B
Def factor IX
-normal PT, prolonged PTT
-less common than A -> can only tell apart by activity levels
Von Willebrands Dx
Prolonged bleeding time, normal plts, bleeding diasthesis
-vWF allows plts to be adhered to damaged endothelium and carries factor VIII
-give DDAVP -> helps endothelium release
Hypocalcemia
Prolonged QT
Hypotension
Myocardial depression
FFP need to match AB +/-
Needs to match A B (plasma will have antibodies)
But the +/- doesn’t matter -> b/c RBCs have the Rh antigen
What’s in cryo?
Fibrinogen
Factor VIII
VWF
Factor XIII
Fibronectin
***give if volume concerned or specific factor def [hemophilia A, vWD, low fibrinogen]
Universal pRBC donor
O neg
Universal pRBC acceptor
AB
Universal FFP donor
AB
Universal FFP acceptor
O neg
Massive blood transfusion: citrate?
Calcium chelation -> becomes hypoCa
When metabolized by liver -> bicarb -> alkalosis and hypoK
With citrate-related hypoCa, how to treat?
Check for hypoMg!! CALCIUM WON”T WORK UNLESS MG REPLETED -> give Mg and Ca chloride or gluconate
Absolute contraindications of cell saver
Bacterial contamination of field, cancer
Relative: SCD, pheo, contamination w/ urine, bowel contents, amniotic fluid
Lupus anticoagulant
Normal PT
Prolonged PTT
**Prothrombotic
Heparin MOA
Inc activity of ATIII -> inhibit thrombin
Enoxaparin MOA
Binds to AT3 which inhibits factor X -> Factor Xa (prevents conversion of prothrombin to thrombin)
Argatroban
Direct thrombin inhibitor
Can be used instead of heparin in pts w/ HIT
Can monitor w/ PTT or ACT
Acute Intermittent Porphyria
When enzyme in heme biosynthesis pathway is deficient
Acute Intermittent Porphyria symptoms
N/v, abd pain, autonomic instability, sz, resp failure, skeletal muscle weakness
Acute Intermittent Porphyria meds to AVOID
Etomidate
Keorolac
Methohexital
Nifedipine
Acute Intermittent Porphyria safe drugs
Safe:
Propofol
Ketamine
Nitric Oxide
Volatiles
NMB
Benzos
Opioids
Regional is safe
Acute Intermittent Porphyria Crisis treatment
Glucose containing IVF (carbs suppress porphyria)
Hemodynamic support
Haematin
