What is a Heller myotomy for?
To correct achalasia, or, difficulty swallowing The muscular ring of the LES does not relax properly and may result in esophageal dilation. Incisions are made to the muscular ring.
What causes the LES failure to relax?
possibly the loss or damage of ganglion cells in the myenteric plexus
What procedure may also be performed with the Heller myotomy?
Toupet fundiplication to prevent reflux but is most oftentimes not performed because it may cause an obstruction to swallowing. However, some cases require this.
What is Reglan?
GI prokinetic dopamine antagonist promotes gastric motility
When is Reglan contraindicated?
Parkinson's pts GI obstruction
*What does Reglan do to lower esophageal tone?*
Increases lower esophageal tone to further decrease risk of aspiration
What are some side effects of giving Reglan?
Dry mouth Abdominal cramping Extrapyramidal effects Prolactin associated effects such as enlarged breasts, irreg. menstrual cycles
Does Reglan cross to the placenta?
Yes but it usually doesn't have an effect on the baby
How can you treat sphincter of oddi spasm resulting from narcotic administration? (5)
Glucagon 2 mg Atropine Narcan Nitroglycerin Calcium channel blockers
*During general anesthesia for a laparoscopic cholecystectomy, the following data are obtained. What lab findings are abnormal?* PeCO2: 48 mmHg PaO2 = 84 mmHg SaHbO2 = 0.2% SaHbMet = 0.2% SaHbCO2 = 2% PaCO2 = 2% paCO2 = 64 mmHg pH = 7.28
Increased alveolar deadspace ventilation
When is aspiration pneumonitis a high risk? (2)
Volume > 25 cc pH < 2.5
*What are the fasting recommendations for: Clear liquids Breast milk Non-human milk and light meals*
Clear liquids: 2 Breast milk: 4 Non-human milk and light meals: 6
What can easily increase the aspiration risk in a healthy pt?
Chewing gum It increases the gastric volume and decreases gastric pH through vagal stimulation.
Toradol is as effective for post-op pain. True or false?
Toradol is not effective for pain in what area of the body?
How much insulin is a pt instructed to take in the AM of surgery?
1/2 of intermediate insulin
How much does 1 unit of insulin decrease blood sugar levels (in mg/dL)?
How do you determine the rate of an insulin infusion?
What is propylthiouracil used for?
decreases thyroid hormone synthesis
What does propylthiouracil decrease the synthesis of specifically? What does it not do?
T3 It does not decrease the T3 already circulating in blood
What is thyroxine?
T4 which is converted to T3 (triiodothyronine)
What drug is effective for preventing thyroid storm?
What is the most serious threat in hyperthyroid pts?
What are clinical manifestations of thyroid storm? (4)
hyperpyrexia tachycardia hypotension altered consciousness
How do you treat thyrotoxicosis?
hydration and cooling esmolol infusion or propanolol (0.5 mg until HR < 100) propylthiouracil (250-500mg q 6 hrs orally or NG)
What should you also give concomitantly with propylthiouracil?
Cortisol 100 mg to prevent complications with coexisting adrenal suppression
*What position are the vocal cords after a RLN INTERRUPTION?*
paramedian position to DAMAGE of the recurrent laryngeal
What may occur after RLN interruption? (2)
"If bilateral recurrent laryngeal nerve INJURY occurs during thyroidectomy, what are he most probable inermediate and long-term outcomes of the pt?"
Adduction of vocal cords --> acute airway obstruction --> trach
What is Addison's Disease?
glucocorticoid deficiency due to destruction of the adrenal gland leading to both glucocorticoid and minerocorticoid deficiencies.
What is deficient in Addison's Disease?
What are clinical manifestations of Addison's Disease? (6)
Hypotension Hyponatremia Hypovolemia Hyperkalemia Weakness Fatigue
What drug suppresses adrenal function and can lead to significant glucocorticoid deficiency if used long term?
What is secondary adrenal insufficiency?
Inadequate ACTH is secreted by the pituitary
*What is the management to prevent hypotension during surgical removal of a pheochromocytoma?*
Fluid replacement because they suffer from chronic hypovolemia
*What plan should be incorporated into the anesthetic management of a pt who has just completed a round or oral steroids to treat an exacerbation of steroids?*
Give glucocorticoids in pre-op (hydrocortisone, decadron) Decadron in awake pt may cause perianal itching
*In the renin-angiotensin-aldosterone system, what organ produces renin?*
*What is the pharmacologic treatment choices for severe hypotension associated with carcinoid syndrome when somatostatin fails?*
Vasopressin Somatostatin is growth hormone inhibitor
*What type of metastases bypass the portal circulation therefore causing systemic effects from carcinoid tumors?*
Hepatic Ovarian Pulmonary Since these do no release into the portal circulation, they are not destroyed by the liver thus causing systemic effects.
Why does carcinoid syndrome cause hypotension?
Tumors release too much serotonin and well as histamines causing blood vessels to dilate.
How do you pharmaceutically manage carcinoid syndrome?
Block histamine and serotonin --> Benzos Avoid histamine releasing drugs --> Morphine, Sux Fluid resuscitation Octreotide --> kills cancer cells
What can commonly occur after transphenoidal hypophysectomy?
What is diabetes insipidus characterized by after a TPH? (3)
hypernatremia serum hyperosmolality urine hypoosmmolality
How do you treat diabetes insipidus following TPH? (3)
0,45% NS with dextrose 5% vasopressin to decrease amount of water excreted in urine desmopressin
Hypoparathyroidism secondary to the inadverent surgical resection of the parathyroid glands typically results in hypocalcemia how many hours post-op?
24 - 72 hours post op or 1 - 3 days
15 yo, 65 kg pt with Cushing's disease is to undergo a TPH to remove a pituitary adenoma. GA is induced with propofol and roc. Anesthesia is maintained with iso, N2O, O2. Mannitol 1 g/kg is administed IV to reduce ICP. At the end of the operation, the pt is extubated and taken to the ICU. Over the next 6 hours, he pt has UOP of 8.3L, serum Na is 154 meq/L, K is 4.8 mEq/L, and glucose is 160. Urine specific gravity is 1.002 and urine osmolality is 125 mOsm.L. The most likely cause of large UOP is:
central diabetes insipidus
Each of the following post-op complications of thyroid surgery can result in upper airway obstruction EXCEPT: tracheomalacia tetany cervical hematoma bilateral RLN injury bilateral SLN injury
bilateral SLN injury --extrinsic branches innervate cricothyroid muscle, intrinsic branches are sensory to vocal cords and pharynx tracheomalacia tetany--secondary to hypocalcemia --> stridor --> spasm cervical hematoma bilateral RLN injury --> adduction of VC
A 54 yo is undergoing a total thyroidectomy under GA. The patient is awakened in the OR, the mouth and the pharynx are suctioned, and after intact laryngeal reflexes, the ETT is removed. 2 days later the pt has severe stridor and upper airway obstruction. The most likely cause is: Damage to RLN Damage to SLN Tracheomalacia Hypocalcemia Hematoma
Hypocalcemia usually develop within 24 - 96 hours After the airway is established, the pt should be treated with IV calcium
A 24 yo obese F is scheduled to have foot surgery under GA. She underwen a subtotal thyroidectomy years ago and take synthroid. Which of the lab tests would be most useful on whether this pt is euthyroid? Total plasma thyroxine (T4) Total plasma triiodothyronine (T3) Thyroid stimulating hormone Resin T3 uptake Radioactive iodine uptake
TSH because the circulating T4 and T3 regulate TSH release from the anterior pituitary by negative feedback, a normal TSH confirms a euthyroid state.
What is the muscle relaxant of choice during resection of pheochromocytoma?
Vec, roc, or cisatricurium Avoid histamine releasing drugs such as atracurium, pancuronium
The most sensitive test for detecting primary hypothyroidism in the preop eval in whom hypothyroidism is suspected is:
TSH or thyroid stimulating hormone
Which of the following treatments should not be used in the treatment of thyrotoxicosis? Aspirin Cold crystalloid Cholestyramine Propyluracil Sodium iodine Propanolol Dexamethasone Esmolol
Aspirin is contraindicated because it displaces thyroid hormone from thyroglobin
What can potentially occur after the removal of ascitic fluid from the abdomen?
hypovolemia and severe hypotension Build up of fluid in the peritoneum compresses the abdominal viscera. The decompression of fluid allows the the expansion of a very large venous reservoir
What is the preferred treatment of ascites?
Spironolactone --aldosterone antagonist Aldosterone increases Na and water retention --> increased blood pressure Do not exceed diuresis > 1 liter/day
How do you manage ascites fluid removal?
You should administer IV fluids, usually colloids to prevent or minimize hypotension Also have good IV access too in case rapid resuscitation is needed
*What is most likely cause of hypotension when a pool sucker is used through a small incision to remove several liters of ascites in the initial phases of an ex-lap of a cirrhotic pt?*
*How can hypotension be prevented during removal of fluid of from an ascites filled cirrhotic pt?
Fluid load patient in preop and throughout induction
What are the hemodynamic changes in the pt with hepatic failure and portal hypertension? (3)
hyperdynamic low SVR high CO
The back pressure in the portal system causes ________ and is partly responsible for accumulation of ascites in the abdomen.
What is an incredible risk to patients with portal hypertension?
enormous GI bleeding leading to death
Name the 2 major blood suppliers to the liver and the % of blood each supplies.
Hepatic artery, 20-30% Portal vein, 70%
How much CO does the liver account for?
25% of CO
How much CO do the kidneys account for?
20% of CO with both kidneys total
*A 52 yo M wih ESRD was hemodialyzed on the day prior to transplantation. What would the best IV fluid management be for the early portion of the CRT (cadaveric renal tranplantation) surgery be? Administer IV fluids are indicated by systemic BP and HR Administer IV fluids at max infusion rate until the transplanted kidney begins to function Administer IV fluids to increase his CVP Replace insensible and 3rd space losses only Volume restric all IV fluids until the transplanted kidney begins to function
Administer IV fluids to increase his CVP
Toradol is contraindicated for what type of patients?
Renal toxicity Creatinine needs to be < 1.2
What is the pediatric dose of Toradol?
0.5 mg/kg q 6 hours
What effects can lateral decubitus positioning for nephrectomy cause to cardiac output? Explain the process
Compression of the IVC can lead to decreased venous return to the heart --> decreased preload --> decreased CO However, CO is usually unchanged unless the venous return is obstructed
What are the changes in V/Q mismatch in an awake pt? An anesthetized pt?
None Increased V/Q mismatch
What is a risk involved in the kidney rest position?
Pt movement caudad which further restricts ventilation of the dependent lung
What irrigating solutions are normally used for TURPs?
Slightly hypotonic Glycine 1.5% or Sorbital 2.7% with Mannitol 0.54%
What causes water absorption of irrigating fluid even though it is hypotonic?
high irrigation pressure
What could the ideal irrigating solution for TURP surgery? (5)
isotonic non-hemolytic nontoxic transparent cheap
What ill effects can sorbitol cause?
What ill effects can mannitol cause?
acute volume expansion
What is TURP syndrome caused by?
Absorption of fluid > 2L
What are the symptoms of TURP?
hyponatremia --mental confusion, cyanosis, dyspnea, restlessness, seizures hypotension tachycardia
What is the treatment for TURP?
fluid restriction loop diuretic seizures should be treated with hypertonic saline
*What clinical findings will provide early recognition of TURP syndrome in a pt receiving GA?*
cardiac instability dysrhythmias tachycardia hypotension fluid overload --> CHF, pulmonary edema
*What visual disturbances during TURP syndrome may occur during spinal aneshesia?*
transient blindness caused by use of glycine 1.5% glycine is known to be a neurological inhibitor in the CNS Early signs: burning sensation in the face, headache, restlessness tachypnea
*What dermatome level is needed for ESWL for renal calculi?*
T6 level needed
What is the anesthetic plan for a retropubic prostatectomy?
Need arterial line for associated significant blood loss Controlled hypotension may be needed Regional requires T6 level sensory block, but awake pts need to be heavily sedated due to hyperextended supine position Consider fluids given b/c will be in t-berg for a long time --> airway edema
What anesthetic techniques can be implemented for retropubic prostatectomy?
regional, GA, or combined regional may reduce blood loss, reduce DVTs, faster return of bowel function however, disadvantage of positioning
A 68 yo 100 kg pt is undergoing TURP under GA. In PACU the pt is restless and confused. Serum Na is 110 meq/L. How many meq of sodium needed to raise Na to 120 meq/L
(TBW * 0.6) * change in sodium desired = 600 meq
An 85 yo male with no significant PMH is undergoing a TURP under spinal. 20 minutes later, the pt becomes restless. Over the next 20 min. the BP increases from 110/70 to 140/90 and his HR slows from 90 o 50. The pt has difficulty breathing. What is the most likely cause?
A 55 yo male is to undergo TURP under GA. The pt has a 40 pack/year smoking history and a history of CHF. He receives reglan and scopalamine in preop. GA induced with ketamine and undergoes procedure uneventfully. However he complains in PACU about not being able to see objects "up close". Which is the most likely cause this complaint?
Scopalamine patch, produces mydriasis (pupil dilation) and paralysis of ciliary muscle resulting in loss of accomodation ability.
Pts undergoing ESWL are at increased risk for: venous air embolism pneumothorax peripheral neuropathies postdural puncture after spinal hypotension with regional anesthesia at procedure end
hypotension with regional anesthesia at procedure end warm water causes vasodilation peripheral vasculature become compressed due to hydrostatic pressure resulting in increased preload removal from water has opposite effect
What type of nerve injury is common with candy cane stirrups?
saphenous nerve injury (medial calf) peroneal nerve injury (lateral calf) obdurator nerve (excessive thigh flexion) femoral nerve sciatic nerve brachial plexus
How do you manage pruritis in pts receiving epidural infusions of bupivicaine and hydromorphone?
nalbuphine (mixed opioid) benadryl hydroxyzine propofol has antihistamine properties (10 mg)
What is the EKG rhythm?
What is the EKG rhythm?
1st degree heart block
What is the EKG rhythm?
sinus tachycardia with PACs
*If during IV induction of GA prior to electtive surgery, a combative pt removes his IV during injection of propofol, what is the next most appropriate step?*
Proceed with induction with inhalational agent then start new IV
Wha is Nissen fundiplication for?
What is abdominal insufflation pressure during laparoscopic surgery?
12 - 15 mmHg