DDx post-op disorientation/agitation
- Unstable vitals - hypoxia, hypotension, malignant arrhythmia
- Anesthesia causes - residual anesthetic/paralysis, narcotic overdose, medication reaction
- Delirium tremens from withdrawal
- Metabolic or endocrine causes - hypoNa, K, Ca, glycemia, thyroidism, hypothermia, hyperglycemia, hyperthermia,
- Neurological - post-ictal, cerebral edema, stroke
- Pain, anxiety
DDx for post op weakness
Residual NMB Narcotic overdose Residual inhalational anesthetic Hypothermia Hypocarbia Acidosis Hypoxia Myasthenic crisis Cholinergic crisis
DDx for desaturation and hypotension
PTX
Airway obstruction
Bronchospasm
Tracheal rupture/tear
DDx for hypotension in anhepatic phase of OLT
Assuming normal CVP and other stable vitals, blood loss usually not culprit in this phase
Rule out mechanical cause for surgical manipulation
Prolonged QT/poor contractility for hypoCa
ST segment changes from ischemia
TEE for WMA
Ddx for post-op stridor
- Laryngeal nerve injury
- Laryngospasm
- Hematoma
- Inadequate reversal
- Residual anesthetic
- Tracheomalacia
- HypoCa (post thyroid, circumoral tingling)
Ddx for hypotension
Hypoxia Dysrhythmia Dec after load - vasodilation - sepsis - anaphylaxis - high spinal or spinal shock
Dec Preload
- Hypovolemia secondary to blood loss
- PTX
- PE
- aortic cross clamp
- Tamponade
- IVC occlusion
Dec Contractility - Ischemia - RV failure/LV failure - acidosis - hypocalcemia Anesthetic overdose Carcinoid crisis Erroneous value
DDx for hypotension and inc airway pressures
- Tension PTX
- Hemothorax with trauma
- Anaphylaxis
- Mainstem ETT
- Bronchospasm
- Kinked ETT
- ETT obstruction due to mucous plug or pulmonary edema
Ddx for low etCO2
With crani = venous air embolism
Hypotension = PE, fat embolism, MI, arrhythmia
Disconnected ETT
DDX for delayed awakening
hypoxia hypercapnia hypotension Metabolic - acidosis - hypoglycemia - hyperMag - hepatic encephalopathy
residual anesthetic - scopolamine, benzos
pain medicine overdose - review chart and MAR
inadequate NMB reversal
neurologic insult
Asses oxygenation, adequate CO2 to stimulate breathing but not excessive, pulse oximeter, patient’s color, capnograph. Check twitches, pupils. Obtain ABG, glucose electrolytes, head CT
Causes of oliguria
Pre-renal
- asses volume status, HR, BP, hemodynamic cause
- hypovolemia, hypotension
- Urine Na <20
- FeNa <1%
Renal
- ischemia, toxins (contrast, abx), mechanical injury
- Urine Na >40
- FeNa >1%
Post-renal
- check foley for kinks/clots
- urethral or ureteral obstruction
Review anesthetic record, look for drug exposures, BUN, Cr, UA, FeNa
FeNa (Na clearance/CrCl)
Ddx for hypoxia
Low insp [O2] Hypoventilation/hypercarbia Shunt-V/Q mismatch - atalectasis - mucous plug - PTX - pleural effusion - pulmonary edema - PNA - endobronchial intubation - aspiration - bronchospasm - PE
Ddx for hypercarbia
Inc CO2 production
- fever
- MH
- high carbohydrate intake
- thyroid storm
- bicarbonate administration
- release of tourniquet or clamp
Hypoventilation
- large PE
- significant hypotension
- pneumonperitoneum
Rebreathing
- incompetent insp/expiratory valve
- exhausted soda lime
Check ETT, adequate ventilation, breath sounds, rhythm, BP, etCO2
DDX for wheezing
Lower airway
- kinked ETT
- mucous plug
- foreign body
- endobronchial intubation
- PTX
- bronchospasm
- PE
- anaphylaxis
- Aspiration
Upper airway
- laryngeal edema
- laryngospasm
- laryngomalacia
- foreign body
- vocal cord paralysis
- tumor
Ddx for hypertension
Hypoxia Hypercarbia Light anesthesia Pain Anxiety Inc ICP Hypovolemia Bladder distention Pheo Thyroid Storm MH Carcinoid Drug effect - cocaine, MAOI
Ddx for tachycardia
Hypoxia Hypercarbia Light anesthesia Pain Anxiety Drug withdraws - clonidine, etOH Dysrhythmia Hypovolemia/hypotension Fever MH Pheo Thyroid storm Carcinoid MI Bladder distention Drug effect - pancuronium, cocaine, epi
Ddx for bradycardia
Hypoxia Hypercarbia Anesthetic overdose Dysrhythmia - AVB, pacer malfunction MI High spinal/ spinal shock Vagal reflex - HTN (autonomic hyperreflexia) - visceral traction - insufflation - inc ICP - RA distention hypothermia Suctioning of airways Drug effects - opiates - BB, CCB - Antichoinesterase - Sux Baseline condition (athletes)
DDx for post-op tachycardia
Pain Hypoxia Hypercarbia Delirium - inadequate reversal Signs of MH - rigidity, temp, peripheral mottling, rhabdo
DDx for prolonged NMB
Pseudocholinesterase deficiency Drug error Defective nerve stim NM disease (myasthenia, LEMS, ALS, MS, DMD) Hypothermia Acidosis Hypercarbia
Vec - active metabolite in renal failure
DDX delayed emergence s/p crani
hematoma tension pneumoephalus cerebral edema cerebral ischemia hypoxia hypercarbia seizure obstructive hydrocephalus
DDX for neonatal seizure
ICH hypoxic-ischemic encephalopathy cerebral edema hypoglycemia hypoCa, Mag Benign seizures TORCH (toxoplasmosis, rubella, CMV, herpes) Sepsis
DDX unresponsive/cardiac arrest in pregnant patient
Eclamptic seizure until proven otherwise
A - Anesthetic complication, Abruption B - Bleeding C - Cerebral (bleed, stroke, tumor), Cardiovascular D - Drugs (medication, IVDU) E - Embolism (PE, AFE) + Epilepsy F - Fever G - General non-obstetric causes (H&Ts) H - Hypoglycemia, HTN
Trauma
DDX for post-op rhonchi
Pulmonary edema
- aspiration
- volume overload/cardiomopathy
- PE
Causes of Anion-gap acidosis
MUDPILES
- Methanol
- Uremia
- DKA
- Paraldehyde
- Iron
- Lactic Acid
- Ethylene Glycol
- Salicylate
Causes of Non-anion gap metabolic acidosis
GI losses
Urinary losses
Saline
