Approach to Perioperative Problems/Situations Flashcards
(39 cards)
1
Q
Approach to the Patient in Crisis
A
“Look, Listen, Feel, Get”
DON’T FORGET TO SAY OUT LOUD THAT THIS IS AN EMERGENCY
Check Airway, Breathing, and Circulation/HD stability first
Look - assess color (cyanosis), palor, restlessness, diaphoresis, wound sites/drains, respiration (rate, depth, pattern), neck (jvd, trachea, hematoma)
Listen - to the patient’s complaints and observations of bystanders, for stridor or other breathing noises, bilaterality of breath sounds, heart sounds (muffled?, murmur?, gallop?)
Feel - pulse (rate, intensity, pattern), subcutaneous emphysema
Get - help, crash cart (and other equipment as needed), vitasl monitor, labs (ABG, CXR, E-)
2
Q
LAST
A
- My initial focus is airway and seizure management. I would ventilate the patient with 100% O2, administer midazolam, and have the nurse notify the nearest ECMO-capable hospital. If the patient’s seizure was prolonged or I was concerned about their airway, I would secure the airway with an ETT, and would avoid propofol in an unstable patient.
- If the patient developed arrhythmias, I would begin chest compressions and ACLS as appropriate, and would avoid vasopressin, CCB, and reduce the dose of epinephrine to 1mcg/kg.
- I would then administer a bolus of intralipid at 1.5mL/kg, and start an infusion at 0.25 mL/kg/min. If the patient remained unstable, I would repeat bolus and increase the infusion to 0.5 mL/kg/min and would not administer over 10mL/kg in the first 30 minutes.
- I would continue the infusion 10 minutes after reaching hemodynamic stability.
3
Q
Malignant Hyperthermia
A
- I would discontinue triggering agents, call for help and hyperventilate the patient with high-flow, 100% FiO2.
- I would then intubate the patient if they were not already.
- And then administer a bolus of dantrolene at 2.5mg/kg. I would repeat every 5 minutes until symptoms subside, and continue bolusing 1mg/kg q6h to for 24-48h to prevent relapse.
- To monitor the patient, I would order baseline ABG, electrolytes, calcium, LFTs and CK, and urinalysis. A mixed respiratory and metabolic acidosis on ABG would be expected.
- If the patient was hyperkalemic, I would hyperventilate and administer dextrose + insulin.
- I would lastly begin active cooling with ice to the groin and axilla, and monitor UOP and treat oliguria with fluid and lasix, monitoring for myoglobinuria.
4
Q
After Induction, can’t intubate but can ventilate, what do you do? After multiple attempsts, you are no longer able to ventilate, what do you do?
A
- I would continue to mask ventilate with 100% FiO2 while considering the reasons for the failed attempt my my options moving forward.
- If ventilation was adequate, my options would be to continue anesthesia by facemask or supraglottic device, reattempt intubation with a change in position, video laryngoscopy, diffferent blade, fiberoptic scope, intubating LMA, glidescope-assisted fiberoptic intubation, or a bougie.
- If at any time I was unable to ventilate, I would call for help, including a surgeon capable of placing a surgical airway if needed.
- If I could not ventilate, I would then place a supraglottic airway. If I were still unable to ventilate (emergent pathway), I would perform a surgical cricothyroidotomy, and if that was not possible, I would place a needle cricothyroidotomy with jet ventilation.
5
Q
Airway Fire
A
- I would turn off oxygen, disconnect the circuit, and remove the ETT.
- If tissue continued to burn, I would pour water down the airway.
- Once the fire was extinguished, I would reintubate and examine the airway with a fiberoptic scope.
6
Q
Seizure
A
- My differential includes [xyz]. I would first evaluate hemodynamic stability and manage the patient’s airway by mask ventiliating with 100% FiO2. If I was at all concerned about the patient’s ability to protect their airway, I would place an ETT.
- I would then treat the seizure with a benzodiazepine an the underlying causes of the seizure.
7
Q
Management of a patient in DKA?
A
- I would go to the bedside and assess the patient’s airway, breathing, circulation and mental status and would treat accordingly. If the patient showed signs of hypovolemia, I would treat with a 1L bolus NS followed by continuous infusion, and guide my rescusitation with urine output.
- For labs, I would order BG, BMP, CBC, ABG, plasma osmolality, urinalysis, and urine ketones and calculate the anion gap.
- I would use 0.45%NS if the Na was high, or continue with 0.9% if the Na was low.
- In addition to volume rescusitation, I would give the patient an insulin bolus and infusion, with frequent BG checks. I would not correct BG too rapidly to avoid cerebral edema.
- When the BG dropped below 250, I would add 5% dextrose.
- Lastly, I would add K+ to the fluids when K returned to normal and UOP was adequate
8
Q
Management of Laryngospasm
A
- I would turn the FiO2 to 100% and perform a jaw thrust with CPAP. I would then attempt to give small positive pressure breaths, and administer lidocaine IV.
- If these steps failed to break the laryngospasm, I would give small doses of propofol or SCh.
9
Q
Neonatal Rescusitation
A
- Prior to assisting in the neotate’s resuscitation, I would ensure that mom was hemodynamically stable and does not require my immediate attention. I would then have the neonate brought closer to the head of the bed and call for a colleague to watch mom, as she is my top priority.
- First, I would warm, dry, and stimulate the neonate.
- I would then position the airway and only suction if I believed there was an obstruction.
- I would use supplemental air or oxygen to maintain targeted goals.
- If the baby’s HR was < 100 or it was apneic or gasping, I would provide positive pressure ventilation and place a pulse oximeter.
- If after 30s of PPV the HR was < 60, I would intubate, start chest compressions, and establish IV access through the umbilical vein.
- If after 60s the HR was still < 60 I would give epinephrine and replace volume with normal saline.
10
Q
How would you treat intraoperative bronchospasm?
A
- I would hand ventilate with 100% FiO2, provide positive pressure ventilation, deepen the anesthetic, and administer a β2-agonist. If these measures failed, I would administer 5-10mcg epinephine IV for adults, or subQ 0.1mL/kg for children and nebulized racemic epinephrine.
- I would also rule out anaphylaxis as a cause of the bronchospasm.
11
Q
Care of the parturient after trauma?
A
The primary goal in managing the pregnant trauma patient is to resuscitate and stabilize the mother. However, to address unique concerns with a pregnant patient, I would ensure LUD positioning with in-line stabilization, prepare for difficult airway management and aspiration, monitor FHR and uterine contraction, and assess for membrane rupture, uterine rupture, or placental abruption. I would also prepare for emergent delivery of the baby.
12
Q
Management of Wide-Complex Tachycardia?
A
I would place supplemental oxygen while assessing for adequate oxygenation, hemodynamic stability, level of consciousness, and the presence of a pulse. I would also place defibrillator pads on the patient and call for necessary airway equipment.
Assuming the patient were stable, I would order a 12-lead EKG and consult cardiology. I would first have the patient perform a vagal meneuver. If this is SVT with abberency from WPW, I would administer procainamide. If this were SVT with abberancy from something else like AVNRT, I would administer adenosine and would consider verapamil. If this was monomorphic VT, or if I was unsure, I would administer amiodarone 150mg or consider synchronized cardioversion.
If at any point the patient becomes unstable (even with a pulse), I would sedate and secure the airway and perform immediate synchronized cardioversion.
13
Q
Management of pulseless VT or VFib (cardiac arrest with shockable rhythm)?
A
I would confirm true pulselessness, begin chest compressions, and defibrillate immediately after verification of a shockable rhythm.
If pulselessness persists, I would immediately resume BLS, intubate, and give 1mg epinephrine every 3-5 min. I would continue to defibrillate every 2 minutes until the rhythm changes.
I would also send an ABG and correct any metabolic or electrolyte abnormalities. I would administer bicarb if ACLS lasted greater than 10 minutes or if pH < 7
14
Q
Management immediately after aspiration
A
- First, I would place pt in Trendelenurg (drain contents from lungs)
- Apply cricoid pressure
- and suction the oropharynx
- I would then intubate
- Administer 100% FiO2
- and suction the trachea
- Apply PEEP after suctioning
- Suction stomach with OGT
- Order baseline ABG and CXR
- Monitor for 24-48hr
** NO PROPHYLACTIC STEROIDS OR ABX
15
Q
Management of TURP syndrome
A
1) Secure the airway with an ETT
2) Provide circulatory support with pressors and inotropes as indicated
3) Place an arterial line and draw ABG, BMP, glucose, Cr
4) 12-lead EKG
5) Tx hyponatremia with fluid restriction, diuretics, hypertonic saline, anticonvulsants
6) Monitor and treat DIC and anemia
16
Q
Postpartum Hemorrhage
A
- I would first assess the severity of blood loss, the patient’s hemodynamic status, and the root cause of the PPH to determine my course of action.
- If the hemorrhage was severe or the patient was unstable, I would call for the assistance of another anesthesiologist and tech, a rapid transfuser, and initiate the massive transfusion protocol.
- Next, I would get 2 large-bore IVs, begin volume expansion with crystalloid, treat hypotension with vasopressors, and start an oxytocin infusion.
- I would then place an arterial line and send an ABG, PT/INR, ACT, Fibrinogen, and cross-match.
- If the initial management were unsuccessful, I would give methergine, hemabate, misoprostol, and TXA an correct anemia and factor deficiencies with their respective products in a 1:1:1 ratio.
- If the patient became hemodynamically unstable or the volume lost was expected to be high, I would induce a GA with ETT (RSI with etomidate, aspiration ppx).
- For maintenance, I would use midazolam 2mg, N2O 50-70%, and low halogenated volatile concentration to reduce uterine atony (unless the problem was retained placenta, then I would use high-concentration to help with uterine relaxation).
17
Q
Management of Hyperkalemia
A
- I would assess for EKG signs of hyperkalemia, including peaked T waves, prolonged PR interval, sine wave (late stage) and would administer meds to stabilize the cardiac membrane potential (CaCl), promote intracellular shift of K+ and get rid of K+
- Promote intracellular K+ shift: hyperventilation, Sodium bicarbonate, insulin + dextrose (10U + D50 10-25g)
• Get ride of K+: Kayexalate, furosemide, dialysis
18
Q
Management of Asystole?
A
- I would call an overhead code blue, shut off volatiles and drips, and initiate chest compressions and give epinephrine every 3-5 minutes
- My differential includes: hemorrhage, anesthetic overdose, shock, auto-PEEP, anaphylaxis, medication error, high spinal, local anesthetic toxicity, tension pnuemothorax, vagal stimulus, PE, tamponade, myocardial ischemia, hyper/hypokalemia, hypoglycemia, acidosis, hypocalcemia
- I would draw an ABG and troponins and seek to correct any correctable abnormalities
- Every 2 minutes I would check for a change in rhythm, and if it became shockable I would immediately defibrillate.
19
Q
Management of Unstable Bradycardia?
A
- I would first check for a pulse, call for the code cart and halt surgical stimulation.
- Then I’d increast to 100% O2 and give a bolus of atropine.
- If unstable bradycardia persisted, I would start an epinephrine infusion, place arterial line.
- Lastly, I would externally pace if Rx interventions didn’t work.
20
Q
Management of PEA arrest?
A
- I would immediately call a code blue, initiate chest compressions, turn off vasodilating agents, and flows to 100% O2.
- I would additionally place an arterial line, ensure two large bore IVs or a central line, and send an ABG to evaluate electrolytes, pH, O2, and CO2.
- If the rhythm ever became shockable, I would immediately defibrillate, and give epinephrine 1mg q3-5min.
- I would find and treat common periop causes, which include:
- Hemorrhage
- Anesthetic overdose
- Shock states
- Auto-PEEP
- Anaphylaxis
- Medication error
- High Spinal
- Tension PTX
- LAST
- Vagal stimulus
- Pulmonary embolus
- Hs & Ts
- Hypoxemia
- Hypovolemia: give rapid bolus of IV fluid or pRBC
- HyperK/HypoK
- Acidosis: hyperventilate and give 1 amp bicarb
- Hypoglycemia
21
Q
Managment of Stable Narrow-Complex SVT?
A
- I would check for a pulse and call for help and a code cart.
- Next I would increase to high flow O2 at 100% and confirm adequate oxygenation and ventilation
- If stable, I would order a 12-lead and place defibrillator pads
- If still stable, I would administer 6mg adenosine and if unsuccessful, a 2nd dose with 12mg.
- If the patient does not convert, I would give esmolol 0.5mg/kg or diltiazem.
- Cardiology consult
22
Q
Management of Unstable Narrow-Complex SVT
A
- I would check for a pulse and evaluate for hemodynamic instability (sharp decrease in BP, acute ischemia, SBP < 75, altered mentation), and bring the code cart into the OR.
- After increasing to an FiO2 of 100%, decreasing volatile agents and placing defibrillator pads, I would immediately synchronized cardiovert at 100J. If unsuccessful, I would resynchronize and cardiovert at 200J.
23
Q
Management of VFib, Torsades or Pulseless VTach?
A
- I would simultaneously call for the code cart, initiate CPR, turn off volatiles, and increase flows to 100% FiO2
- After defibrillator pads are placed, I would defibrillate with 200J and resume CPR immediately
- I would repeat this every 2 minutes, and give epinephrine every 3-5minutes
- Additionally, I would place an arterial line and draw an ABG, and consider underlying causes that could have caused the arrhythmia (Hs + Ts, hypoMg)
- I would give amiodarone 300mg if pulseless, or if TdP 2mg Mg Sulfate
24
Q
Management of Amnionic Fluid Embolism (AFE)?
A
- * Consider AFE if there is a sudden onset of the following in a pregnant or postparum patient:
- Respiratory distress, decreased SpO2
- Cardiovascular collapse: Hypotension, tachycardia, arrhythmias, cardiac arrest
- Coagulopaty +/- DIC
- Seizures
- AMS
- Unexplained fetal compromise
- I would first increase flows to 100% FiO2, establish large bore IV access, and support circulation with IV fluid, vasopressors and inotropes
- Prepare for emergent intubation
- I would place an arterial line, send ABG and preare for hemorrhage and DIC
- Consider DDx for AFE
25
How to Recognize and Manage Anaphylaxis?
* If the patient suddenly develops hypoxemia, rash/hives, hypotension, tachcardia, bronchospasm, increased peak inspiratory pressures, and angio edema, anaphylaxis would be my primary DDx.
* I would first discontinue potential allergens (NMBD, latex, Abx, colloids, protamine, blood, contrast
* Next I would decrease volatile agents, give 100% Fio2, and give a large IV fluid bolus
* I would also give epinephrine, albuterol, and diphenhydramine
* After the patient is stable, I would send serum tryptase and histamine levels to confirm the diagnosis.
26
Management of Delayed Emergence?
* I would first confirmat that all anesthetic agents are off and that the patient's NMBD has been adequately reversed.
* I would then check for and correct hypoxemia, hypercarbia, hypothermia, hypoglycemia, electrolyte abnormalities, and an abnormal neuro exam.
27
Management of Oligura?
* To manage this patient's oliguria, I would first assess the patient's **hemodynamics and volume status** and look for obvious post-renal obstructions. I would also send labs including a BMP to look at [Na+], Cr and BUN, as well as a urinalysis to look at specific gravity, urine [Na], urine osmololality, and FeNa.
* **Note:** Pre-renal oliguria will show higher spec grav, low urine Na, and \< 1% FeNa
* If the patient was hypovolemic, I would give a fluid challenge and optimize hemodynamics.
* If the patient was hypervolemic (pulmonary congestion, etc), I would administer diuretics.
* If the patient was euvolemic I would consider SIADH or a renal cause of oliguria.
28
Management of Hemorrhage?
* If I suspected large or on-going hemorrhage, I would call for help, the code cart, a **rapid transfuser,** **cell-saver** and initiate the **massive transfusion protocol**.
* I would treat hypotension with IV fluid and temporize with vasopressor boluses
* I would then establish additional large-bore IV or central line access and consider **intraosseous** placement if this was difficult and place an **arterial line**
* Next I would send a type & cross and follow the patient's acid-base status with serial ABGs.
* Once blood products arrived, I would replace with a 1:1:1 fashion (RBC:FFP::Plt) (remember its really 6:6:1)
Note:
* PRBC: give for Hgb \< 7-10 (CAD? Blood loss?); each unit should raise Hgb 1g/dL
* Plt: give for \< 50,000-100,000/uL with signs of bleeding; each unit raises plt about 50,000
* FFP: give for INR or PTT \> 1.5x normal
* Cryo: give for fibrinogen \< 80-100 mg/dL; each 10 units raises fibrinogen ~50mg/dL
29
Management of intraoperative hypotension?
* I would check monitors, inspect the surgical field, and give vasoconstricor/inotrope/and fluids to temporize.
* If the hypotension continued, I would turn down the volatile agent, increase to 100% FiO2, and consider potential rapildy lethal causes of the hypotension including: **hemorrhage, vasodilators, tension pneumothorax, anaphylaxis, cardiac event, pneumoperitoneum, IVC compression**.
* I would also place an arterial line and send labs.
30
Management of intraoperative Hypoxemia?
1. I would immediately increase to 100% high flow O2 and check the gas analyzer for low FiO2 and pulse ox for proper placement.
2. After quickly assessing her vitals, ETCO2 and peak inspiratory pressures, I would **hand-ventilate** to check compliance and rule out leaks, **auscultate bilaterally,** and **check the ETT position.**
3. If the etiology was yet unclear, I would suction the ETT and call for a bronchoscope.
4. Depending on the likely diagnosis, I would consider:
* Large **recruitment breaths**
* **Bronchodilators**
* **Additional NMBD**
* **ABG**
31
Steps to wean from CPB?
WRMVP
## Footnote
• To wean from CPB, the patient needs to be normothermic with a perfusing rhythm. I would then turn on the monitors, ventilate with oxygen and volatile anesthetic, and lastly confirm that the patient is able to maintain hemodynamics without help from CPB. To this effect I would use the PA catheter to determine the patient's cardiac index and SVRI and titrate inotropes and vasopressors as needed.
32
Management of ↓ SpO2 during OLV?
1. Increase FIO2.
2. Recheck positioning of double lumen tube for correct placement using fiberoptic bronchoscope.
3. Suction both lumens of double lumen tube for secretions or mucous plugs
4. May need to notify surgeons to stop and return to two-lung ventilation. Or at least ask for periodic reinflation/recruitment maneuvers of the nondependent collapsed lung.
5. Consider CPAP (5-10 cm H2O) to the collapsed, nondependent lung. This maintains patency of the nondependent alveoli allowing gas exchange to occur and will divert blood away from the collapsed lung.
6. Consider PEEP (5-10 cm H2O) to the ventilated, dependent lung. This can increase FRC and improve gas exchange in the dependent lung. However, high levels can increase PVR and shunt blood flow to the nondependent lung.
7. Ultimately may need to ligate or clamp the ipsilateral pulmonary artery (i.e. during pneumonectomy) so that all blood flow directed to ventilated lung.
8. Last resort (as in patient undergoing a lung transplant) may need to go on cardiopulmonary bypass to improve oxygenation.
33
Treatment of Myocardial Ischemia
* I'd suspect myocardial ischemia if there was ST depression or elevation, new conduction abnormalities, or unexplained tachy/brady or hypotension, regional wall-motion abnormalities or chest pain in an awake patient
* If I suspected myocardial ischemia or infarct, I would inform the surgeon, pre-emptively call for the code cart, increase to 100% O2, **verify ischemia with a 12-lead**, and **treat hypotension or hypertension**
* I would administer a **β-blocker** if the patient were tachycardic and **NTG** so long as there was no hypotension
* I would then place an **arterial line** and send an ABG, CBC, and troponin, and treat any metabolic/electrolyte/Hgb abnormalities
* If symptoms persist, or concern for STEMI, I would consult cardiology for possible medical or interventional treatment
*
34
Management of Oxygen failure?
1. Disconnect from machine and ventilate with an Jackson-Rees circuit with an E-cylinder
2. Switch to TIVA
35
Management of Pneumothorax?
* I would suspect PTX with ↑PIP, tachycardia, hypotension, hypoxemia, asymmetric breath sounds, hyperresonance of chest to percussion, tracheal deviation (late sign), especially if **trauma patient or with COPD**
* To treat, I would first increase to 100% FiO2, call for stat CXR if stable, and once confirmed would place a 14G needle in the **mid-clavicular** **2nd intercostal space immediately followed by chest tube.**
36
Management of Total Spinal Anesthesia?
* I would suspect total spinal if after neuraxial block there was a sudden rapid rise in sensory blockade, numbness/weakness in upper extremities, dyspnea, bradycardia, hypotension, LOC, apnea, or cardiac arrest.
* I would immediately call for the code cart and check for a pulse. If pulseless, I would start CPR and **immediately administer epinephrine**
* If the patient did not suffer cardiac arrest, I would support ventilation and intubate if needed, treat bradycardia/hypotension with **epinephrine**, and give an IV fluid bolus
37
Management of Transfusion Reactions?
* I would **stop the transfusion**, **support blood pressure with IV fluids and vasoactive medication.**
* I would retain the blood product bag and notify the blood bank.
* If there is evidence of lung injury such as hypoxemia or pulmonary edema (TRALI or TACO), I would keep the patient intubated post-operatively.
* If the patient had a **hemolytic reaction**, I would maintain urine output with **IV fluids and diuretics** and monitor for signs of **DIC**
* If the patient had a **febrile reaction** I would treat with tylenol and rule out bacterial contamination
* If the patient had an **anaphylactic** reaction, I would give antihistamine, epinephrine, and bronchodilators.
38
Treatment of VAE
* I would suspect a VAE if I observed air on TEE or change in Doppler tone, ↓ETCO2, hypotension, hypoxemia
* After increasing to 100% O2, I would have the surgeon **flood the surgical field with saline**, place the surgical site **below the heart** if possible, **aspirate air** from the central line, give a **rapid fluid bolus**, support hemodynamics with **epinephrine**, and call for a TEE or TTE to assess air and RV function
39
Management of Torsades
* Mg2+ (2g), start infusion and monitor for signs of hypermagnesemia
* Discontinue contributing medications
* Follow standard ACLS algorithm but **do not give amiodarone or procainamide**
