Conditions Flashcards
1
Q
TURP Syndrome
A
- APO
- Heart failure, cardiac ischaemia
- Confusion/seizure/coma/blindness.
- low Na/osmo/glycine
- 3NS to 125 mmol/L. Up to 10 mmol/L in 24 hours (ODS)- or per hour if seizing until seizures stop
- Fluid restrict + support
2
Q
Marfan’s Syndrome
A
- High arched Palate, C1/2 laxity, TMJ laxity
- Scoliosis, pectus excavatum, RLD, pneumothorax
- pHTN, MR/AR/MVP –> HF, Aortic root dilation (SBP <120), arrhythmias
- Dural ectasia
- Lens dislocation, ret det, glaucoma
Obs: C/s if root >45 mm, no ergometrine
3
Q
Acute Leukaemia
A
Immunosuppression/infection risk
Anaemia
Thrombocytopaenia/bleed risk
Hyperleukocytosis: DIC, TLS, VTE
BMT: GVHD
Nutrition
Chemotherapy
4
Q
Tumour Lysis Syndrome
A
K- arryhtmia
Uric acid- renal failure
Hypocalcaemia- tetany, long QT, seizure
Hyperphosphataemia- arrhythmia, QT
Malignancy 4 Ms
Chemo/radiation end organ dysfunction
HDU/ICU
VOlume load
Diuresis
K treatment
Rasburicase/allopurinol
5
Q
Antiphospholipid syndrome
A
Primary vs secondary (SLE)
Thrombosis or miscarriage
Issues
- VTE/CVA(/CTEPH/pHTN)
- Valve thickening
- Anticoagulation
6
Q
G6PD Deficiency
A
BG: X lined, oxidative stress –> haemolysis
- Chronic haemolysis –> transfusion, Xmatch difficult, anaemia
-Avoid oxidative stress: oxidative drugs, infection, hypoxia, hypothermia, stress, metabolic derangement
- Avoid: methylene blue, rasburicase, sulfonylureas, FQs
- Manage haemolysis: remove trigger, transfuse prn, supportive
7
Q
Acute DIC
A
Dx
PT/aPTT/INR prolonged, low Fib, high D-dimer, thrombocytopaenia, schistocytes and helmet cells
Mx
- Haem, TEG
- Tx underlying condition
- Periop: FFP, Plt >50, Cryo
- Contraindicated: Prothrombinex, TXA
8
Q
Factor V Leiden
A
APC resistance –> thrombosis
- Anticoagulation/antiplatelets
- Increased VTE risk
9
Q
Haemophilia
A
- May have normal coags or prolonged aPTT
- Factor activity 40/5/1%
-Periop activity 80-100% depending on bleed risk - rFVIII/IX
- DDAVP
-Inhibitors –> FEIBA - TXA, Cryo (FVIII)
PBM - Chronic pain- haemophilic arthropathy
-Obs: male fetus risk. >50% activity NA ok
Tertiary centre
10
Q
Ehler’s Danlos (Vascular)
A
TMJ subluxation, AO instability. Use small ETT, care with BURP
PTx risk
Aortic dissection, vascular aneurysm, valvulopathy.
USS lines
Careful positioning
Avoid compartment syndrome
Pregnancy HIGH risk
Tertiary centre
11
Q
Heparin Induced Thrombocytopaenia
A
Thrombocytopaenia 50% drop
Timing 5 - 10 days
Thrombosis
oTher causes ruled out (sepsis, MCS, DIC)
Stop heparin
Treat with Direct thrombin inhibitor- argatroban, bivalrudin
consider IVIG/plasmapheresis
CPB
□ Patients wtih HITT 1 can receive heparin safely
□ Patients with a history of HITT II with undetectable antibodies and who have not received heparin for > 90 days can receive heparin for CPB
□ Patients with active HITT II should be anticoagulated with alternative anticoagulation- Bivalrudin
Aim to delay elective cardiac surgery until HITT antibodies are negative
12
Q
ITP
A
Acquired thrombocytopaenia- antibodies against plt antigens. Dx of exclusion
Goal to prevent significant bleed, NOT to normalise plt
Critical bleeding events Mx- Plt transfusion, dexamethasone, IVIG. Refractory cases- rituximab, TPO agonist, splenectomy
13
Q
Jehovah’s Witness
A
- Blood Components vs Fractionated products vs recombinant factors
-Autologous donation: cell salvage, pre deposit, frozen autologous blood, ANH
-Extracorporeal circuits: ECMO/CPB, dialysis, predonation
-Transplants
14
Q
Sickle Cell disease
A
-Acute chest syndrome, restrictive pulm fibrosis,
- LV hypertrophy, high output, pHTN cardiac failure, MI, Vasoocclusive crisis. Hb 100 hct 0.3
- Acute and chronic pain, CVA
-Renal failure/AKI
-Chronic transfusion/alloimmunisation
Obs- NA safe. VTE risk high.
* Aplastic crisis → Low reticulocyte count, caused by Parvovirus B19, leading to severe anemia.
* Splenic sequestration → Rapid spleen enlargement, hypovolemic shock, and high reticulocyte count.
* RUQ syndrome → Severe RUQ pain, often due to hepatic infarction or gallstones
15
Q
Acute Transfusion Reactions
A
AHTR
FNHTR
TACO
TRALI
Allergy
Bacterial sepsis
16
Q
Thalassaemia
A
Decreased A or B Hb chain Synthesis –> anaemia
- Chronic haemolysis- increase CO, jaundice
- Multiple transfusion- iron overload, CM, dysrhythmia, pHTN, hepatic fibrosis, DM, alloimmunisaiton
Beta thalassaemia major- maxillary overgrowth DA
A and B minor- mild
17
Q
Von Willebrand Disease
A
Assay 48 h prior to Sx
- Obs >50% Minor Sx >30, Major >50% ?Critical >100
- Repeat 2 hours prior to start
-TXA
- DDAVP- not 2B/3
-FVIII-vWF concentrate
-rFVIII
-Cryo
-FEIBA
18
Q
Liver Disease
A
- Cause/Tx e.g. alcohol, viral, steroid
- Aspiration risk
-Hepatic hydrothorax/pleural effusion/HPS/ascites/restrictive physiology
-Hyperdynamic circulation, cardiomyopathy, PPHTN
-Encephalopathy, cerebral oedema
-hyponatraemia, hypoglycaemia, lactatemia
-Coagulopathy, low plt
-hepatorenal syndrome
-Varices
-Altered pharmacology- VD/clearance/PB
19
Q
Abdominal Compartment Syndrome
A
IAP >20 mmHg with end organ dysfunction
- Primary- intrabadominal disease e.g. pancreatitis/trauma
-Secondary e.g. due to sepsis/burns/fluid
Aspiration risk
Restrictive ventilation
high SVR, low CO
AKI
Hepatic dysfufunction
Reperfusion syndrome!
20
Q
ARDS
A
Predisposing factor: onset in 1 week of exposure, bilateral opacities not oedema/atelectasis/other, PF <300 on PEEP 5
Plat P <30
TV 6-8
Optimise PEEP
Prone
APRV
iNO
ECMO
Restrictive fluid/steroids/low CHO/NMB
21
Q
End Of Life Care
A
Identify dying
Beneficence of procedure vs non malifencence of harm
Cultural safety
Mitigate clinical momentum
Manage limitations of medical treatment (autonomy)
22
Q
Airway Trauma immediate Mx
A
Immediate:
- Severe Hypoxia
- Airway obstruction
- Decreased LOC
- Shock/Cardiac arrest
Immediate if actual or expected deterioration
- Stridor
- Resp distress
-SC emphysema
- Expanding neck haematoma
-Inability to lie flat
23
Q
Postpartum neuro deficit
A
Anaes
Traumatic
Ischaemic
Chemical
Infective
Obs- compressive
24
Q
Hyponatraemia
A
Hypertonic: translocational glucose mannitol contrast
Isotonic: pseudohypoNa- protein/lipid. Osmo = 2Na + Glu + Ur
Hypotonic: Hypovolaemic (renal vs non renal- Urinary Na), Euvolaemic (SIADH, psychogenic, IVF, adrenal insuff, thyroid), Hypervolaemic (CHF/cirrhosis/nephrotic, preg/TURP)
25
Hypernatraemia causes
In- excess Na/K (NaHCO3, 3NS, K, Soy sauce), vs inadequate free water intake
Out- Increased GI H2O loss (D/V/stoma) vs increased renal H2O loss vs renal Na retention e.g. Conn's, exogenous steroids
Renal H2O Loss: DI (Central vs peripheral), loop diuretics, SGLT2i
26
Scoliosis
Idiopathic vs non: marfans, NF, DMD, CP)
A neck/spine difficult
RLD (Cobb >65), pHTN
Cor pulmonale (Cobb >100- severe), MV prolapse
Surgery: Cobb > 45deg
Pain
Blood loss
IONM
Prone, POVL
OLV if thoracic
VAE
27
Cocaine
CVS- vasospasm, HTN, arrhythmia, QTincr, APO
CNS- Euphoria, anxiety, myoclonus
-Hyperthermia, fasciculations, mydriasis
- Rhado, ARF, cerebral oedema, vessel dissection, SAH, ischaemic colitis
Mx
- VT: NaHCO3, lignocaine, defib, hyperventilate
- ACS- avoid BBloclers
- Hyperthermia - benzos, fluid, Roc
28
Methamphetamine
NAd, 5HT, DA. t1/2 20 hrs
Psychomotor agitation
Hyperthermia
CVS- HTN, rhythm, MI
Rhabdo, AKI, seizrue
Abruption
IABP
Remi/mag
Benzo
No sux/indirect SNSmimetics
29
Cannabis Marijuana
Long half life
ANS instability)
CVS: myocardial depression, tachycardia
CNS: intoxication/sedaiton
UAW irritable, cough
Obs: decr UPF, LBW
30
Myotomes
C5 Elbow Flex
C6 Wrist Ext
C7 Elbow Ext
C8 Finger Flex
T1 Finger abd
L2 Hip Flex
L3 Knee Ext
L4 Ankle dorsiflex
L5 Toe Ext
S1 Ankle Plantarflex
S4/5 VAC
31
Hallucinogens
LSD; 5HT syndrome
PCP: adrenergic
Appetite suppression, euphoria, memory dysfunction, behavioural
MDMA- MH/rbado, renal and heart failure
GHB: N/v/seizrues
Overall- ANS dysregulation, Cardiomyopathy adn vasospasm, CVA. Avoid indirect SNSmimetics and serotonin agents
32
Substance abuse general
Acute intoxication: physiological effects, drug interactions, Consent
Chronic use:: phsyiological, comorbidities, nutrition, psych, IV access, HIV/HepC/endocarditis, compliance
33
Le Fort Fractures
LF I: Nasomaxillary (floating Palate) no BOS#
LF II: Pyramidal Floating maxilla, may have BOS#
LF III: Craniofacial dysjunction- concomitant BOS#
34
Radiation Effects on Airway
- Mucosal necrosis/mucositis- haemorrhage, FMV
- TMJ fibrosis
- Glossitis
- Dental caries
- FOM and suprahyoid fibrosis- decreased mobility of tongue
- Mandible osteonecrosis (pain, swelling, fistulation), OM, #, micrognathia,
-Epiglottic/glottic oedema- stridor
35
Anaemia
IDA: Ferritin <30 or TSAT <20%
IDA + Fxnl element: Ferritin 30 -100 & raised CRP
FIDA: Ferritin >100 + Tsat <20 or CHr >30
Other
Normal Iron studies- B12, folate
CKD anaemia: Normal/increased Ferritin, decreased TSAT
36
Dental Abscess spread
Dental infection -> pulpitis -> periosteal perforation -> soft tissue via planes
Cervical fascia: AW obstruciton, mediastinitis, pulmonary pus aspiration
Maxillary infection -> orbital cellulitis, CVST
Wisdom teeth -> parapharnygeal abscess- minimal signs until late. Trismus
Ludiwgs angina:: Cellulitis of FOM involving SM and SL glands bilaterally. Can cause mediastinitis
37
Thyroid Storm Mx
Mx
- Treat trigger where able (infxn/pregnancy/trauma/DKA etc)
-Support: IVF, cool, paracetamol, dextrose, datrolene 1 mg/kg if intubated
Specific
- Endocrine
- Propranolol 1 mg increments
-PTU 600 mg load T4 -T3 conversion block
- Carbimazole start
- Hydrocort blocks T4 -T3
-Lugols iodine- prevents release of Thyroid hormone. Only give one hour after above drugs
38
Trisomy 21
95% extra Chromosome 21. Others- translocation/mosaic
A: large tongue,, increased airway soft tissue, subglottic stenosis, high palate, tonsillar hypertrophy. AAI/AOI
B: OSA with pHTN. Recurrent LRTI
C: AVSD, VSD, ASD, TOF, pHTN, PDA. MVP, AI
D: Developmental delay/cooperation, epilepsys, Hypotonia
E: Hypothyroid, DM, obesity, leukaemia, duodenal atresia,
39
Cerebral Palsy
Secretions/aspiration, SCh risk
RLD, recurrent chest infection
IV access difficult
Epilepsy, muscle spasms, developmental delay, pain assmessment
Contractures, difficult positioning, scoliosis
Medications: diazepam/baclofe, PPi, latex allergy
40
Facial Fractures
-Upper third: frontal/sphenoid/upper nasoorbitoethmoidal complex. Dural tears, CSF leak
-Middle Third: maxilla, zygoma, lower NOE complex. Le Fort I - III. teeth.
-Lower third: Mandible. Bilateral anterior or major displacement --> risk of AW obstruction
41
Mitral stenosis pregnancy
Issues: Fixed LV preload- unable to increase CO in vasodilation. Hypervolaemia and tachycardia cause increased gradient across MV --> LA dilation, APO, RV failure
Goals: Low normal HR, Strict SR, Normovolaemia, vasopressors > fluid for hypotension. Percutaneous balloon valvuloplasty.
42
Aortic Stenosis Pregnancy
Issues: Low SVR -> Decr coronary perfusion pressure. Relatively fixed CO. Tachycardia reduces LV filling time and perfusion
Slow titrated epidural with a. line/vasopressor. Prompt volume resus in haemorrhage. Consdier TAVI preop
43
AR/MR in pregnancy
- Generally improve: reduced regurgitant fraction with low SVR and high HR. NA good. MR a/w LA enlargement/arrhythmia. May result in APO if sudden SVR increase or ischaemia/chordae rupture
Avoid sVR increase, avoid braducardia, avoid arrhythmia.
44
Mechanical valve in pregnancy
- High thrombosis risk- valve/CVA
-LMWH vs VKA 1st trim --> VKA --> 1 week LMWH --> UFH 48 hours
Tertiary centre with CTS support
45
pHTN/RV dysfunction in pregnancy
Issues:
- Increased BV (e.g. placental autotransfusion) and VR --> can precipitate RHF (esp if incr PVR)
- Hypercoagulable- increased PE risk
- Decreased SVR -> Decreased CorBF
Mx
- Maintain RV perfusion and minimise PVR!!!!
- Regular volume status tracking +/- diuresis
- Invasive monitoring- A line, CVC, +/- TOE
-Vasopressors for NA
- Reduce PVR- milrnione/NO/prostacyclin
-Caution with oxyctocin, Ergot/carrboprost contraindicated- increase PAP
46
ASIA Classification
ASIA
A: Complete motor/sensory loss below level
B: Presered sensory, no motor
C: Preserved motor >50% muscles with power <3
D: Preserved motor >50% muscles with power ≥3
E: normal function
47
Spinal Cord Syndromes
ASA: Motor loss + loss of pain and Temp
Central Cord syndrome: Bleeding/oedema/infarction of central gray matter, usually C-spine. UMN in leg and LMN in arms with loss of pain and temp in arms. Sacral sparing.
Brown Sequard: lateral cord damage e.g. osteophyte impaction- ipsilateral motor, fine touch proprioception and vibration loss, contralateral pain and temp loss
CES: Bladder and bowel dysfuction + UMN neurology in lower limbs- injury to lumbosacral nerve roots
Posterior cord syndrome: loss of vibration and proprioception. rare
48
Spinal cord Injury acute physiological effects
If AIS- A:
- >C3: ventilator dependence
- >C3 - 5 may require long term ventilation
- >T1 Breathing entirely diaphragmatic- no intercostal Fxn. Better lying flat (increased Diaphragm excursion)
APO from catecholamine release
Inital few mins: HTN/tachycardia from massive catechol release (APO)
Then neurogenic shock. Common if above T6- hypotension +/- bradycardia if T1-4 affected.
49
Acute SCI Neuroprotection
- MAP >85 mmHg 5 days. Up to 2L fluid then vasopressors
- Therapetic hypothermia and steroids not recommended
- Brain stuff- normoxia, low normal CO2, avoid excess PEEP
- Surgery: stabilisation/reduction/decompression to relieve pressure on cord. Urgent if any deterioration in neurology
- Immobilisation: No evidence for semi-rigid collars. Spinal boards- ideally padded to prevnet comfort movement/pressure injury
50
SCI Long term
Airway
- Extrajunctional AChR
- Difficult in C spine immobilisation
Breathing
- Ventilator dependence
- Tracheostomy
- Cough/infections
CVS:
- AD weeks to months post injury
- Arrhythmia- vagal
- Anaemia
- Postural hypotension
- VTE prophylaxis: Clexane after 72 hours
Other
- Spasticity and contractures
- Gastric ulcer prophylaxis: unopposed vagal activity. PPi.
- Nutrition: gastroparesis common. EEN <24 hours
- Pressure areas
-
51
Pelvic Fractures
- Stable vs unstable fracture (tamponade)
- Bleeding- presacral veins, bone, arterial
- Bowel/GU/SC injury
- Pelvic binder as part of ATLS
- Fixation: Bleeding and pain main issues
52
Complex Regional Pain Syndrome
Post traumatic nerve disorder characterised by:
- non dermatomal severe continuous limb pain
- Associated sensory, motor, vasomotor, sudomotor, trophic changes
- Usually glove/stocking distribution, usually upper limb
CRPS II: Demonstrable nerve lesion
Pathophys: neurogenic Inflammation, central sensitisation, microvascular ischaemia, psych
-Mx
- Physio, psychology
- Meds: pain ladder no strong oipioids. Gabapentin. Bisphosphonates. Vasodilators if VC e.g. CCB. Muscle relaxants e.g. baclofen. Consider glucocorticoids, TNFa agonists, thalidomide. Topical LA and ketamine
- Invasive: SC stim, stellate ganglion or thoracolumbar SNS blocks
53
Edmonton Frailty
Eating
Dependence
Medication use
Overall health status
Numbers around clock
Overall Fxnl performance (up and go)
No bladder control
Temperament/mood
54
Stridor causes
Infective: croup, abscess, epiglottitis, bacterial tracheitis
non-infective: anaphylaxis, post extubation, trauma, tumour, HAE, laryngospasm
Congenital: laryngomalacia/clefts
55
Fat Embolism Syndrome
Triad: resp (SOB/hypoxaemia/ARDS), Neurological (confusion/drowsy/seizure/FND), Petechial rahs
Other: pyrexia, tachycardia, R heat strain, DIC, AKI
Mx- Early immobilisation, steroids controversial, Supportive
56
Rheumatoid arthritis
A: AA instability, TMJ dysfunction
B: fibrosis, RLD, scoliosis, pleural effusion
C: pHTN, valve, pericardial effusion, pericarditis
D: Chronic pain
E: positioning, nerve injury, anaemia
Medicaitons- steroid dependence, immune suppression, renal/liver fxn.
57
Hyperparathyroidism
1- Incr PTH secretion
2- Hypocalcaemia e.g. vit D deficient
3- Secondary to prolonged 2
58
Postamputation Limb Pain
DDx:
- Acute stump pain (nociceptive)
- Persistent stump pain: Noci/neuropathic pain >3/12 postop
- Phantom sensation
-Phantom Limb pain
Mx
- Simple
- Opioid: ASP and CSP
- Ketamine: ASP and PLP
-Regional- reduced PLP
-Calcitonin, ganapentinoids PLP
Non pharm- graded motor imagery, /mirror therapy, VR
-Pain specialist referral/MDT
59
GBS
-Acute autoimmune demyelinating polyneuruopathy usually following infection
- Ascending sensory, motor defect
A: bulbar weakness
B: resp weakness
C: ANS instability, long QTc
D: Neurodeficits, neuropathic pain. SCh contraindicated, increased NDNMB sesitivity
Mx
- IVIG/PLEX. No role for steroids
- Supportive- ventilation, ANS Analgesia, VTE, MDT
60
MS
Autoimmune disease characterised by CNS demyelination/damage.
- Focal demyelinating plaques
Brainstem/CNs- IIitis. Valgia, diplopia
Cerebellum
Cerebrum/spinal cord- motor/bladder/cognition
chronic: DMARDs +/- MABs
Acute: Steroids +/- PLEX
SCh/sensitive to NDNMB
Resp/ANS fxn
Normothermia/reduce stress
Steroid replacemetn
Risk of flare regardless of mode of anaesthesia
61
Porphyria
Attacks last day to weeks
Bulbar dysfunction
Resp failure (weakness)
ANS instability
Seizure, neuropathy, quadriplegia, psych, altered LOC
Hypo Na/K/Ca
Medications: steroids, Ketamine, etomidate, dexmed thio, sulfonamides, ergot, amio
Crisis:
-Eliminate trigger, hematin, ocreotide, glucose, PLEX
- Hydration/electrolytes/seizures/ANS
62
4 Bottle Drain system
63
Bronchopleural fistula Airway Management
- Normal AW, Small leak, non obese/normal pressures- RSI, IPPV PRN
- Normal Airway large leak- SV induction
- Difficult airway: awake intubation SLT BB, consider exchange after asleep look
64
Adrenal Insufficiency
Primary- Addisons (autoimmune/haemorrhage/tumour)
Secondary- GCC deficient, pituitary surgery etc
Anaesthesia
- Steroid supplementation
- Correction of fluid/electrolyte abnormalities
- May need HD support
65
Sickle cell
Inherited Hbopathy causing microvascular occlusion and crises
Normal phsyiology/minimise starvation
Vasoocclusive crisis
Acute chest syndrome
Pulmonary HTN
Pain - opioids/PMOL/ketamine/lignocaine
Transfusion
Hydroxyurea
66
G6PD deficiency
X linked disorder -RBC susceptible to oxidative stress- haemolysis
Spectrum of disease/frequency of haemolysis
Considerations: Anaemia, antibodies
Avoid oxidative stress
Metabolic disturbance e.g. DKA, stress, fasting, infection, hypoxia, hypothermia
Haemolysis- transfusion and supportive Tx
Acetaminophen
Acetylsalicylic acid
Ciprofloxacin
Dapsone
Methylene blue
Nitrofurantoin
Phenytoin
Streptomycin
Sulpha drugs
67
WPW SVT
Orthodromic- Treat as normal SVT
Antidromic- Procainamide or DCCV
AF- Procainamide or DCCV
Wider complex= greater chance of VF
68
High ICP treatment Tiers
1. I/V normal CO2, neck ties, 30 deg HOB, paralysis, CPP Mx
2. Deepen anaesthesia
3. EVD
4. Hyperosmolar therapy
5. Induced hypocarbia
6. Therapeutic hypothermia, barbiturate coma
7. DECRA
69
Failed AF ablation risk factors
Persistent AF
Structural heart disease
ongoing risk factors
70
Dementia Periop issues
Coexisting medical disease
Drug interactions- anticholinesterase/NMB
Consent
Anaesthetic sensitivity
Delirium risk
Pain assessment/management
71
Fontan
Circulation formed as part of palliative staged operations for single functional ventricle conditions
Physiology
- 1 Ventricle powers systemic and pulm circulation. Pressure = CVP - Common atrial pressure. Cavopulmonary flow = bottleneck
- PVR- PL and AL
-Single ventricle only pumps blood allowed by bottleneck
CVP AND PVR MAIN DETERMINANTS OF CO
Complications
- HF
- pHTN
- Persisting hypoxaemia/cyanosis
- Arrhythmia
- VTE
- Liver disease
- PLE
- Developmental delay
Anaesthetic Goals
- Maintain preload/CVP
-Minimise PVR
- Regional or Early extubation
- Bubble minimisation
-Consultant lead surgery.
72
Eisenmengers
- congenital lesion, surgery
- Baseline SO2
- SVR: PVR balance
- Bubbles
- Complications- HF, PPM, VTE/AC, hepatic/renal
-Continuing pHTN drugs periop
- ABx prophylaxis
73
Scleroderma
Autoimmune CT disorder characterised by fibrosis + vasculopathy
Classification:
- Local- skin only
- Systemic: Limited (CREST) vs diffuse
Microstomia, esophageal dysmotility ILD, pHTN, arrhythmia, myopericardiitis, scleroderma renal crisis, Raynauds (pressors/a. line/keep warm), VTE risk immunosuppression/steroid/DMARD/MAB, positioning
REGIONAL!
Catastrophic APLS
74
Ehlers Danlos
- Genetic connective tissue disease- Collagen mutation
- Skin hyperextensibility, joint laxity, vessel fragility
- A: TMJ/C spine
B: PTx risk -vent pressures
C: Bleeding/aortic root dilation/arrhythmia/MR/aneurysms/USS lines
Desmopressin useful
Positioning care- risk of dislocation
75
AKI KDIGO
1: Cr 1.5x or UO <0.5 12h
2. Cr 2x or UO <0.5 24 h
3. Cr 3x or dialysis or UO <0.3 24 h or anuria 12h or Cr > 350 umol/L
76
CKD KDIGO
GFR mL/min/1.73m2
1 >90
2 60 -90
3a 45 -60
3b 30 -45
4 15 - 30
5 <15
Albuminuria (ACr)
A1<3 mg/mmol
A2 3 - 30 mg/mmol
A3 >30 mg/mmol
77
OMEDDs
OMEDD= daily dose x Conversion factor
PO
- Codeine 0. 13
- Tramadol 0.2
- Tapentadol 0.3
- Oxycodone 1.5
- Hydromorphone 5
TD mcg/hr
- Buprenorphine 2
- Fentanyl 3
IV
Fentanyl 0.2
Pethidine 0.4
Oxy/morphine 3
Hydromorphone 15
78
HIV
Retrovirus destroying CD4+ T cells --> immunosuppression
Infection stages
- Acute infection (flu), latent phase (asymptomatic replication), AIDS (severe immune dysfunction)
HAART prevents AIDS
Airway- kaposi sarcoma
Resp: opportunistic infections
CVS: IHD/CM risk, pHTN
Anaemia/thrombocytopenai
Cognitive impairment
Immunocompromise/infection risk
Treatment complications: neuropathy, BM suppression, renal failure
Minimise ART interruption
ID involvement
Standard precautions, post exposure prophylaxi ASAP
Obs- myelopathy/spinal neoplasm/CNS infection/Coagulopathy could be contraindications to NA
79
Herpes
VZV- Lifetime infection risk 95%
- Primary infection = varicella = chickenpox (flulike symptom then vesicular rash). Can be complicated by bacterial superinfeciton, varicella pneumonia, encephalitis or cerebellitis
-Reactivation = herpes zoster = shingles- occurs in elderly/immunicomp. Latent in sensory ganglia- dermatomal vescicular rash.
Consider vertical transmission in obs
NA- main concern is introducing virus to CNS --> meningitis/encephalitis
NA not recommended in primary herpes infection as patient has viraemia
-consider if active varicella pneumonia
-do not pass through skin lesions
- PP Needle
80
Transplanted heart
Altered physiology of denervated heart
- PL dependent
- high resting HR, loss of vagal tone
- Delayed SNS response- circulating catechols
-Dysrhythmias- 5% PPM
Altered pharmacology
- Indirect agents ineffective
-Intact response to direct agents
Allograft fxn
- Rejection
-Rhythm
- Vasculopathy (silent)
Comorbidities
- pHTN
-HTN
- DM/renal/malignancy
Steroids
Immunosuppression- anaemia, low plt, liver/renal tox
ABx prophylaxis
81
Lung transplant
Allograft physiology
- heterogenous compliance, impaired cough, disrupted lymphatics (APO prone)
-differential lung ventilation
Extrapulmonary features of underlying disesae e.g. pHTN, RV failure
Complications
- Rejection
-vascular and bronchial anastamotic complications
Immunosuppression- stress dose and SEs
?Denervated heart
Goals
- RA/NA where able
-if ETT- consider differential lung ventilation, LPV, miniimal ETT insertion
- aspesis, ABx
82
Sarcoidosis
Multisystem disease characterised by granulomatous infiltration of organs
A: Airway granuloma (laryngotracheal)
B: Pulmonary fibrosis/lymphadenopathy, RLD
C: pHTN, Cardiac infiltration, restrictive CM, MR, conduction defects
D: Neurosarcoid, central DI, dementia, Neuropathy including CN and ANS
E: Hypercalcaemia
Hepatomegaly and liver dysfunction
Drugs: Steroids, DMARDs, MABs
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Amyloid
Multisystem disease characterised by organ deposition of amyloid fibrils
Primary: IgG light chains
Secondary: a/w other conditions e.g. RA, myeloma
A: macroglossia, TB tree involvement, stridor, aspiration risk
B: ILD RLD
C: pHTN, restrictive CM, CHB, sudden death, CAD
D: ANS/sensory/motor neuropathy
E: Nephrotic syndrome/renal failure
Dysphagia, aspiration risk
Coagulopathy. FX deficient, decr Plt fxn
Medications, steroids, MABs, cardiac
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Acute Transfusion Reaction
Suspected Transfusion reaction
1. Stop Transfusion
2. Ensure other IV access
3. Assess
a. Correct product for patient
b. Respiratory issues --> TACO/TRALI
c. Fever --> not TACO
d. Uriticaria/Bronchospasm/Angioedema/Hypotension --> anaphylaxis
e. Bleeding/jaundice/dark urine/hypotension - AHTR
f. Bag contamination
g. Consider underlying condition as cause for presentation
4. Investigations
a. FBC- haemolysis
b. UEC- renal failure, K+
c. LFTs- jaundice
d. Haemolysis screen- DAT, hapto, LDH, Retic
e. Coagulation screen ?DIC
f. Cultures patient and blood
g. BNP
h. ABG
i. CXR
5. Management
a. D/W BB/TMS
b. Supportive
i. O2
ii. Fluid vs furosemide (TACO)
iii. Pressors/tropes
iv. Adrenaline
v. Antibiotics
vi. Antipyretic
c. Consider restarting if isolated <1 deg temp rise, otherwise well
6. Post event
a. Document
b. RCA
c. Open disclosure
d. Incident reporting
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Thrombocytopenia
<150
Decr production: Liver failure, BM suppression (Drug, AA, nutrition, viral, Chemo, sepsis), ETOH, vWD2
Sequestration liver spleen
Dilution
Destruction: Autoimmune (ITP, Heparin), Extracorporeal circuit, Spesis, TMA (DIC, TTP, HUS, APLS, SLE), Pregnancy (PET, HELLP, thrombocytopenia of pregnancy)
Pseudo- clumping
Dx: Blood smear, B12/folate, liver funciton, DIC screen, ADAMTS13, PF4 (HIT), autoimmine screen, BM Bx
86
Huntington's Disease
AD neurodegenerative disease characterised by choreiform movements, depression and dementia
Bulbar dysfunction/aspiration risk
Dementia/consent
No anaesthesia contraindicaitons but consider decreased dose
Droperidol may help controlling choreiform movements
87
Neurofibromatosis
Cafe au lait spots
Neurofibromas involve sking +/- peripheral nerves, nerve roots, viscera, blood vessels
Airway- potentially difficult due to obstruction/distortoin from upper airway tumours. Macrocephaly and macroglossia. Tumours vascular
B: RLD, kyphoscoliosis, pulmonary fibrosis
C: pHTN/RV failure, medisatinal mass, HTN, dysrhtymia, cardiomyopathy, RVOTO
D: incresed ICP, seizures, decreased cognition, peripheral neuropathy, unpredictable NMB response
Difficult regional, NA contraindicated if spinal neurofibroma or high ICP. Must have imaging prior.
Endocrine: Pheo, hypoglycaemia, pituitary tumours, thyroid ca, hyper parathyroid
88
MAOi Use
MAOA and non-selective: Depression (5HT)
MAOB- PD management
Consult psychiatrist, ideally 2 week wean
Risks
- Severe HTN with: sympathomimetics (esp indirect), light GA, ketamin/panc, tyramine food
- 5HT syndrome- avoid serotonergics
Altered GA response
- Increased MAC
Exaggeraeed hypotension with NA
89
Congenital Heart Disease
- Anatomy
- Obstruction to flow (+ static vs dynamic)
- Long term consequences: CHF, pHTN, arrhythmia, residual shunt, valvulopathy
- Noncardiac: polycythemia, liver disesase, CVA, developmental abnormalities,
- Treatments: HF, antiarrhythmics, diuretics, AC, PPM/AICD
- Funcitonal status
- Endocarditis prophylaxis
- Deairing of lines
- Specific HD goals of disease in context of surgical stress and positioning
- MDT
-
90
Mitral Stenosis
High risk- especially pregnancy
HD sequelae- limited ability to increase CO
- Atrial dilation and arrhythmias
-APO/CHF
-pHTN/RVF
-Thromboembolic events
Associated conditions
- Valvulopathies
-Rheumatic heart disease
-Connective tissue disease (SLE, RA)
- Obstructive- carcinoid, atrial myxoma
Medicaitons
- AC, diuretics, antiarrhythmics
Goals
- maintain preload, low normal rate (most important), Strict SR, maintain contractility/AL, avoid precipitants of pHTN
Obs
- Early slow titrated epidural preference for NVD or caesar
- Avoid SAB
- GA- maintain goals
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MINS
MINS: Encompasses type 1 and 2 MI, including asymptomatic myocardial injury.
Dx- >1 Tn above 99th%, 20% change presumed ischaemic origin, within first 30 days postop
Management MINS- optimise supply/demand, increase monitoring, OP follow up, risk factor Mx (statin/ASA), consider Dabigatran (MANAGE trial)
92
Thyroid Storm Mx
Supportive
FiO2 1.0
Normal PaCO2- hyperventilate
Fluid- cool
ANS lability +++ short acting pressors/tropes/vasodilators
Arrhythmia Mx
CVC/A. line +/- TOE/PAC
Paracetamol, cooling cares, no NSAID
Dextrose
Dantrolene if intubated
ICU + Endocrine
Specific
- Propranolol/Esmolol inhibit T3/4 conversion + peripheral effects
- Propylthiouracil- inhibit T3/4 synthesis and conversion
- Hydrocortisone- inhibit t3/4 conversion, relative hypoadrenalism
- 1 hour after above - lugols iodine to prevent release of Thyroid hormone
- Plasmapheresis
- thyroidectomy
93
Adrenal Crisis
Sx- N/v/malaise/syncope/dizzy/abdo pain/weight loss Hypotension, bradycardia, hypothermia. Hyponatraemia, hyperkalaemia, hypoglycaemia
Causes: inadequate stress hormone replacement, adrenal haemorrhage, pitapoplex
Cortisol/ACTH levels
adrenal or pituiraty imaging
Mx
- Hydrocortisone 100 mg then 200 mg over 24 h
- IV fluid
- Vasopressors/inotropes- may be resistant
- A/ line/CVC
-Sugar
- ICU/endocrine
Cover cause e.g. ABx for sepsis
94
Adrenal hormone conversion
Dex 0.75 mg = Prednisone 5 mg = hydrocortisone 20 mg
MC activity if addisons: 20 mg hydrocort = 50 mcg fludro
95
DKA/HHS
Management
- Fluid resusciation
○ Often 5-10 L behind
○ When glucuose <15mmol/L begin a dextrose containing fluid e.g. D4S to prevent hypoglycaemia
○ Resuscitation: no evidence for NS vs balanced crystalloid
○ No difference in fluid resus for HHS and DKA (Oh's/DP)
- Insulin
○ Low dose/physiological replacement works as well as high dose
○ 0.1 U/kg/hr
○ Goals
§ Increase HCO3 by 3 mmol/L/hr
§ Decrease BSL by 3 mmol/L/h
§ Decrease BKL by 0.5 mmol/L/hr
§ Maintain normal electrolytes while doing so
○ Decrease to 0.02 - 0.05 U/kg/h once BSL <15 (same as VRII starting dose!)
- Electrolyte replacement
○ Na 10 mmol/Kg
○ K 5 mmol/Kg- begin replacement as soon as K <5 mmol/L!
○ Cl 5 mmol/Kg
○ Mg/Ca/ PO4 1 mmol/Kg
- Support
○ Intubation: some controversy- Issues
§ MV when not intubated > than can be produced by ventilator - risk of worsened acidosis
§ Haemodynamic instability +++ if intubating critically unwell patient
○ Consider IAL, CVC UO monitoring, ICU
- Mange underlying cause
○ Infection
○ Ischaemia
○ Pregnancy, Compliance
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GLP 1 agonist Mx
Do not stop preop except liraglutide (DOS)
<4 weeks- full stomach: RSI, regional only or gastric USS
Do not use extended fast time
Consider 3 mg/kg/250 mg erythromycin 1-2h before anaesthesia
97
Neuroleptic Malignant syndrome
Hyperthermia, lead pipe rigidity, encephalopathy, bradyreflexia, catatonia. Normal pupils.
Dopamine blockers or agonst deficiency. E.g. haloperidol/droperidol, atyicak antipsychotics, metaclopramide, DA agonist withdrawal
Within 1-3 days
DDx- SNS toxidrome, Anticholinergic, MH, 5HT
Mx
- Stop DA antagonists
- Bromocriptine/amantadine/restart usual agonist
- Dantrolene- severe cases
98
MH Management
CRM: Clear leader- delegate task cards, decision making, situational awareness, team work, CLC.
Stop crisis: Remove volatile/SCh, machine to 15 L/min 100% O2 +/- charcoal filters, MH box
Dantrolene: HIGHEST PRIORITY, MANPOWER 2.5 mg/kg Q10 mins until hypermetaboism resoving (Acidosis, pyrexia, rigidity)
20 mg/vial 60 mL sterile H2O
Support
-I and V, low CO2,
-Cold fluid- lots, ice
-Art/central access
- Defibrillator
- TIVA Roc
-Cooling- bladder, exposure, temp probe, ambient T
- IDC
Complication management
Frequent ABG/UEC/CK/Coags/urine Mb
-rhabdo aim 2 mL/kg/hr (3g mannitol/vial of dantrolene!)
-Hyperkalaemia Ca, Insulin dex, NaHCO3, PCO2
-Antiarrhythmics- amio/lignocaine
- Acidosis: NaHCO3 if <7.2
-DIC- TEG
Logistics
- Complete or abandon surgery
-Getting more dantrolene
-ICU
-Documentation/open disclosure/incident report
99
Rib fractures APMS5
Fixation in ≥3 fractures- lower pneumonia, tracheostomy, duration of ventilation, LOS
TEA, PVB, IC blocks are superior to IV opioids
Systemic NSAIDs + ketamine are efficacious
SAP and ESPB are supported by case series and can be considered
100
Sickle cell Pain
IV corticosteroids effective
Hydroxyurea reduces frequency of vasocclusive crises adn transufion requirements
IV opioid and PCA good
IV ketamine and lignocaine good adjuncts
NSAIDs bad- no analgesia, increased AKI
101
Herpes Zoster pain
Antivirals <72 h after onset of rash accelerate resolution of acute pain but do not reduce PHN
PVB and amitryptiline in acute Herpes Zoster reduces PHN
102
Elderly Pain issues
- Pain Assessment difficult
- Failure to report pain- may see as normal part of ageing
- Multiple comorbidities causing pain
- PK
○ Increased F for PO morphine
○ Increased fat, decreased muscle, decreased CO
○ Decr Liver/renal function
- PD
○ Biggest change
○ Increased CNS sensitivity
○ Comorbid disease- increased ADR risk
○ High POCD/delirium risk
Polypharmacy- increased interaction risk
103
Neuropathic pain Mx
1. TCAs/SNRIs, Gabapentinoids
2. Another of above
3. Tramadol- acute rescue Tx
4. Capsaicin
5. Carbamazepine (1st in trigeminal neuraligai)
6. Pain specialist- cannabis, vanlafaxina, strong opioids, AEDs
104
Envenomation
May have dry bite- still need to observe
- Cardiac arrest/hypotension
- Paralysis/respiratory failure
- Seizures
- VICC Venom induced consumptive coagulopathy
- TMA
- Rhabdo/ARF
- Spiders- muscle fasciculation, HTN, tachy, bronchorrhea
Goals
- Pressure bandage immobilisation
- Determine what has bitten
- Observation/labs over 12 h
- Determine antivenom to use
- Supportive care of above
105
Drowning issues
- ARDS
- HIE
- Hypothermia
- Atypical pneumonia
106
Electrical injury
- Airway - uncommon
- B- respiratory muscle tetany/brainstem disrupption/aspiration/AbdoCS
C- Arrhythmia- highest risk at time of injury. Telem if >1000 V, LOC, Transthoracic current, abnormal ECG. Vasospasm, thrombosis, myocardial necrosis
D: seizures, FND, SCI, coma, ANS
E. Myonecrosis/compartment, cutaneous underestimate, vascular thrombosis/aneurysm, ARF, IUFD
107
Paeds Opioids
PCA
- M: 20 mcg/kg Q5min
- F: 0.4 mcg/kg Q5 min
Infusion- Clinical bolus as per PCA dose
M: 20 mcg/kg/h
F: 0.4 mcg/kg/h
If <12 weeks old: Half dose
Naloxone 2 mcg/kg for sedation, 10 mcg/kg if life threatening
Ketamine infusion: 0.1 mg/kg/h. Avoid boluses
<1/higher dose/PCA + basal- HDU
APMS review
Q1H obs
Higher risk
-Sedationscore>2, Significantcardiorespiratoryimpairment, OSA, concurrent sedatives, SpO2 <94- continuous oximetry, Line of sight
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Paediatric epidural
Max volume per hour
<12 weeks: plain 0.2% ropi 0.2 mL/kg/hr
>12 weeks 0.2% ropi + 2 mcg/mL 0.3 mL/kg/hr
- e.g. 0.1 - 0.2 mL/kg/hr + up to 1x 0.1 mL/kg bolus
>30 kg- PCEA
109
Paediatric Spine anatomy
Termination of Spinal cord: <1yo L3 (A L1)
Termination of subarach space: < 1 yo: S3-4 (A S1-2)
110
Myasthenia Gravis obstetrics
Maternal- NA preferred, assisted second stage, Mid thoracic block may impair ventilation.
Neonatal- Neonatal MG from plaental transfer- breathing difficulty. Transient.
111
Methamphetamine
Psychosis- assessment/consent/procedures
CVS-HTN tachy, ischaemia, APO, dissection. Avoid serotonergic and indirect agents, TIVA remi a line
Seizures
hyperthermia
Rhabdo, aKI
112
Graves and Cardiac/IR
angiogram- iodine +++
Amiodarone- iodine +++, thyroiditis
- D/w endo
113
Brugada
Sodium channelopathy AD a/w Sudden cardiac death
RBBB and STE V1-3 wtih negative T wave Type 1 Coved, Type 2 saddleback
Avoid
- Vagal tone
- BB, alpha agonists, neostigmine, Na channel blockers, TIVA, SCh, droperidol
- Electrolyte abnormalities
- Fever- use cooling measures
Consider AICD
Defib pds on
Atropine, ephedrine, isoprenaline
- Iso can suppress VT storm 1mcg/min
Quinidine
114
Anti Xa levels
Rivaroxaban <30 ng/ML safe to proceed, >50 therapeutic
115
Indications for bridging (2024 AHA)
VTE < 3/12
CHADvasc ≥7
Mechanical MV, caged ball, tilting disc valve
CVA <3 mo
Active Ca a/w high VTE
LV thrombus
Severe thrombophilia e.g. APLS
116
DOAC Periop
- Minimal risk bleeding --> continue
- Low/mod bleed risk: 1/7 (2/7 dabigatran CrCL <50)
- High bleed risk 2/7 (Dabigatran 4/7 CrCL <50)
117
OHS
BMI ≥30
Awake PaCO2> 45
HCO3 >27
118
Objective Functional Capacity Assessments
6MWT
- <440m- conflicting evidence predicts <15/<11
-Weak evidence predicst 1/12mo DFS/mortality
ISWD <250 m fair prediction of major complications/30d mortality colorectal surg
BNP
raditionally, RCRI >1 or a calculated risk of MACE with any perioperative risk calculator >1% is used as a threshold to identify patients at elevated risk. §Abnormal biomarker thresholds: troponin >99th percentile URL for the assay; BNP >92 ng/L, NT-proBNP ≥300 ng/L.
Vision study NTProBNP >100!
CPET
- VO2 Peak <15/AT <11 VE/VCO2>31 predicts mortality/pulmonary complications
119
Subjective functional Capacity Assessments
Stair climbing
2 flights = 4 mets= VO2p 14- Poor consistency
Modest ability to predict postop outcomes
ADLs
does not provide an accurate estimation of METs. Furthermore, the inability to achieve 4 METs on subjectively assessed ADLs has poor predictive value for postoperative cardiac complications.
DASI
- 34 = VO2p 17.5 = 5METS
= VO2P = 0.43xDASI + 9.6
Predicts adverse outcomes
120
Long QT
- Optimal electrolytes preop
- Prevent SNS: continue BB, TIVA Remi
- Avoid QT prolonging drugs
- Disaster planning: Defib, Mg 2g/2min, lignocaine, isoprenaline, overdrive pace 110, K >4.5/Ca
- AICD Mx
121
vWD
- Plt/adhesion and FVIII t1/2
- may have normal aPTT/PT
- 1 quantitative, 2 function 3 absent
- Targets vWFLRCO >50 IU/dL, FVII:C >50, >100 if cardiac/NSx,
-TXA, desmo except 2B and 3, Biostate, Plt/FVIII/FVIIa, cell salvage
- Obs- foetal risk e.g. forceps, desmopressin in PET- fluid retention
121
Parkinsons withdrawal syndromes
Parkinson Hyperpyrexia Syndrome- similar to NMS- fever, rigidity, CVS instability, AMS
DAWS: nausea anxiety depression, orthostatic hypotension
122
Marfans
Genetic CT (fibrillin) disorder
A high arched palate, C spine instability, TMJ dislocation
B: RLD/scoliosis/PTx
C: Aortic root diameter pHTN, MR/AR/ arrhtymia
D: Dural ectasia
E: positioning/hypermobility
123
Multip pregnancy
Increased PET/HELLP/GDM
2 resuscitaires/Neonatologists
Increased congenital abnormalities.
Airway oedema greater
Greater FRC reduction
Increased Aortocaval compression
Increased PPH
124
PET/HELLP Goals
Reduce BP
Prevent Eclampsia
Facilitate delivery, CFM prior
Manage/prevent complications: APO, ICH, DIC, haemolysis, AKI, liver dysfunction
125
Hypocalcaemia
Neuromuscular excitability
Seizures
Long QTc
Corrected Ca <2.2 0.8 x (n-pt alb) + pt Ca
Parathyroid removal
Neck Radiation
Vit D deficient
High PO4
126
Hypercalcaemia
Psych disturbance, constipation, osteoporosis, nephrolithiasis, short QT, HTN, pancreatitis, muscle weakness
Causes
- PTH 1/3/ectopic
- Granulomatous
-Medications
- Thyrotoxicosis
Rehydration + furosemide
IV bispphosphonate
Hydrocortisone if sarcoid/malignancy
Dialysis if renal failure
IV Phosphate if >4.5 mmol/L
127
CTG Interpretation
Define risk
Contractions
Baseline RAte
Variability
Accelerations
Decelerations: early, variable, late
Overall impression
128
Child Pugh Score
129
VT vs SVT
Patient: Age > 35, IHD, structural heart disease, FHx WPW
ECG: Axis, concordance, capture/fusion beats, AV dissociation, QRS >160 msec, L RSR,
130
Acute ischaemic CVA Mx
- Facilitate thrombolysis/clot retrieval
- BP < 220 or 180/110 if thrombolysis
- Thrombolysis <4.5h unless bleed disorder, pregnant, prev ICH, etc
- Mechanical thrombectomy- up to 24 h NIHSS ≥6
131
Chronic spinal cord injury
A: C spine fixation- DA, SCh
B: Ventilatory support
C: AD
D: Chronic pain, psych
E:- Positioning/contractures, thermoregulation, GI/GU
Obstetrics
- PET vs ADR
- Leave epidural in post delivery
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