Week 8&9 - Dr. White Flashcards
Anesthesia considerations for Laser, Thyroid trach, Difficult Airway, Geriatrics, COPD
o what is mandatory for all airway management scenarios:
preparation!!
o the first step in airway management
Bag and mask ventilation (BMV) is
no sign of chest rising, no end-tidal CO2 detected, no mist in the clear mask
these are signs of:
ineffective ventilation
o Difficult mask ventilation is often found in patients with
morbid obesity,
beards,
craniofacial deformities.
a life saving temporizing measure in patient with difficult airways (b/c they cannot be ventilated or intubated)
LMA
i-gel LMA is what Dr. White talked about
Difficult airway - LEMON Trial:
Look • Facial trauma • Large incisors • Beard • Large tongue Evaluate 3-3-2 • Interincisor distance (3 fingers) • Hyoidmental distance (3 fingers) • Thyroid to floor of mouth (2 fingers) Mallampati Obstruction Neck Movement – chin to chest
Predictors of Difficult Intubation
o B – Beard o O– Obesity o N – No teeth o E – Elderly o S – Snores
type of intubation not for an unstable neck:
direct laryngoscopy
type of intubation good for an unstable neck:
awake blind nasal intubation
nebulized anesthesia - 4% lidocaine blocks for how long?
15 mins MAX
most important element for a successful awake fiberoptic intubation?
Preparation
Surgical airway - Invasive technique required when you “can’t intubate, can’t ventilate”.
A few important things to remember:
- 16 or 14g IV cannula required to pass through CTM.
- jet ventilation system usually found on the back of vent
- catheter MUST BE SECURE!
- short 1s bursts of Oxygen
- Avoid barotrauma; pt may develop subcutaneous or mediastinal emphysema
**If no jet ventilation; 3ml syringe can attache to catheter with plunger removed. a 7.0mm TT connector can be inserted into the syringe to attach to breathing circuit or an ambu bag.
• Poor functional status has been identified as a risk factor for surgical site
infection and postoperative complications.
• Frailty is a perioperative risk factor for
complications and mortality.
Frailty is classified as primary or secondary.
o Primary frailty occurs as part of the intrinsic process of aging.
o Secondary frailty is related to the end-stage of chronic illnesses and is caused by inflammation and wasting, for example heart failure, COPD, inflammation, and wasting associated with cancer.
• By some estimates, over half of elderly patients also take over-the-counter herbal products.
o The American Society of Anesthesiologists (ASA) recommends that whenever possible, herbal products be discontinued at least
1–2 weeks prior to surgery.
o Garlic extract and ginkgo biloba increase the risk of
perioperative bleeding.
• IV anesthetics have more pronounced hemodynamic effects, and smaller doses are required to achieve the same anesthetic depth. Dose of an induction drug and opioids should be decreased by at least
25%.
• The strongest predisposing factor for postoperative delirium is
preexisting dementia
• The basic principles in ethical decision making that apply to the older adult are the same as those that apply to all patients.
o In health care the most common principles are
autonomy ** most important
beneficence
nonmaleficence
justice.
Patient’s right to self-determination. defined:
autonomy **
An obligation or responsibility to help the patient; “to do good”
beneficence
To not intentionally harm the patient; “do no harm”
nonmaleficence
To treat the patient fairly
justice
What body part/ organ is especially vulnerable to laser surgery?
the eyes
all OR personnel should wear laser-specific eye goggles with side protectors to prevent injury.
• The eyes of a patient undergoing laser treatment must be protected by taping them shut, followed by the application of wet gauze pads and a metal shield.
• Minimally invasive robotic surgery is associated with improved patient outcomes including :
decreased length of stay,
faster recovery, reduced perioperative blood loss, and reduced postoperative pain
** Regardless of the procedure the anesthetic plan must take into consideration the following factors:
- prolonged surgical times
- spatial restrictions associated with use of the robot
- inability to alter patient position after docking of the robot
- physiologic changes associated with extreme positioning
- risk of postoperative visual loss (POVL)
- physiologic consequences associated with the creation of pneumoperitoneum
- implementation of Enhanced Recovery after Surgery (ERAS) protocols
type and screen tests for
antibodies
if indicated b the surgical procedure, in robotic surgery, pt should be typed and cross matched for a minimum of
four units of blood
• Cardiovascular Changes seen in steep trendelenburg
Increased: Mean arterial Pressure (MAP) Central Venous Pressure (CVP) Pulmonary Capillary Wedge Pressure (PCWP) Systemic Vascular Resistance (SVR)
Unchanged:
Heart rate (HR)
Stroke Volume (SV)
Mixed Venous Oxygen Saturation
• Respiratory Changes seen in steep trendelenburg
Increased: Airway Resistance Peak pressure Plateau pressure End-tidal carbon dioxide (ETCO2) Upper airway edema
Decreased:
Lung compliance
Vital capacity (VC)
Forced Expiratory Volume in 1 second (FEV1)
• Cerebrovascular Changes seen in steep trendelenburg
Increased:
Intracranial pressure
Hydrostatic pressure gradient
Cerebral vascular resistance
Decreased:
Cerebral venous drainage
Unchanged:
Regional cerebral oxygenation
Cerebral perfusion pressure
what is a rare but devastating complication following surgery (robotic):
Postoperative visual loss
• The most important goal in managing the hyperthyroid patient is before surgery, if possible, make the patient
euthyroid
What is best to avoid during induction of a hyperthryoid patient?
Ketamine
It is best to avoid using ketamine for induction, even when a patient is clinically euthyroid.
• The complications after thyroidectomy include :
- recurrent laryngeal nerve (RLN) damage,
- tracheal compression secondary to hematoma or tracheomalacia, and
- hypoparathyroidism
• Unilateral nerve injury is more common and is often
transient.
• Unilateral damage to the RLN is characterized by
hoarseness and a paralyzed vocal cord,
whereas bilateral injury causes aphonia.
The normal total serum calcium concentration is 8.8 to 10.4 mg/dL.
In general, an increase or decrease in albumin of 1 g/dL is associated with a parallel change in total serum Ca2+ of .
0.8 mg/dL.
Hypercalcemia (in hyperparathyroid) is responsible for a broad spectrum of signs and symptoms. The most common manifestation, occurring in 60% to 70% of patients is:
Nephrolithiasis
Polyuria and polydipsia are also common complaints. 20-50% of patients are also HTN
The anesthetic consideration for the hyperparathyroid/ hypercalemic patient regarding NMBD:
There is an increased requirement for vecuronium,
and probably all nondepolarizing muscle relaxants, during onset of neuromuscular blockade
the duration of safe tourniquet inflation is generally considered:
2 hours
Tourniquet pain can become significant over time and can be mitigated with inhalational agents, opioids and/or hypnotics. Definitive management is:
deflation of the tourniquet.
Changes that can be expected with tourniquet deflation and are generally well tolerated in healthy patients (3):
- ) Transient systemic metabolic acidosis,
- ) increased arterial carbon dioxide levels,
- ) A drop in systemic blood pressure
The mechanical effects of peritoneal insufflation impair ventilation. Insufflation of the peritoneum displaces the diaphragm in a cephalad direction resulting in: (3)
- decreases FRC,
- decreases VC,
- in turn induces collapse of the dependent regions of the lungs.
Studies show that recruitment maneuvers that use the combination of PEEP 10 cm H2O and intermittent positive airway pressure (40 cm H2O) for 40 seconds was most effective in improving end-expiratory lung volumes, lung compliance, and arterial oxygenation in both healthy weight and
obese patients than either intervention alone.
Postoperative nausea and vomiting is a major concern for patients undergoing
laparoscopic surgical procedures.
The incidence of PONV in the laparoscopic population has been reported to be as high as 72% and is known to be associated with significant postoperative complications such as
surgical wound dehiscence,
aspiration, and
unanticipated hospital admission.
the etiology of PONV is
multifactorial
prior to cardioversion, what should the anesthesia provider ensure to review?
most recent EKG
Preop Labs
Cardiovascular stimulation also occurs with ECT because
The sympathetic and parasympathetic nervous systems are stimulated sequentially.
COPD cannot be definitively diagnosed without
spirometry
- Results of PFTs in COPD reveal a decrease in the FEV1:FVC ratio.
- An FEV1:FVC less than 70% of predicted that is not reversible with bronchodilators confirms the diagnosis.
- Other spirometric findings of COPD include an increased FRC and TLC.
CT is a much more sensitive test compared to simple chest radiography at diagnosing
COPD
the first step in treating COPD.
Smoking cessation should be
the two important therapeutic interventions that can alter the natural history of COPD.
Smoking cessation and long-term oxygen administration are
In COPD, the goal of supplemental oxygen administration is to achieve a PaO2 greater than
60 mm Hg
Diuretic-induced chloride depletion may produce a hypochloremic metabolic alkalosis that depresses the ventilatory drive and may aggravate
chronic carbon dioxide retention.
Strategies to Decrease Incidence of Postoperative Pulmonary Complications – Preoperative include:
- Encourage cessation of smoking for at least 6 weeks.**
- Treat respiratory infection with antibiotics. **
- Treat evidence of expiratory airflow obstruction.
- Initiate patient education regrading lung volume expansion maneuvers.
Strategies to Decrease Incidence of Postoperative Pulmonary Complications – Intraoperative include:
- Use minimally invasive surgery (endoscopic) techniques when possible. **
- Consider regional anesthesia**
- Avoid surgical procedures likely to last longer than 3 hours. **
• The maximum benefit of smoking cessation is not usually seen unless smoking is stopped more than
6 weeks prior to surgery.
what intervention is a simple and inexpensive, and provides objective goals for and monitoring of patient performance.
Incentive spirometry is
