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Sim Lab 3 > ERAS and Transplant > Flashcards

ERAS and Transplant Flashcards

1
Q

What is ERAS?

A

Enhanced Recovery After Surgery

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2
Q

What is the point of ERAS?

A

Start the patient on a healthy lifestyle before surgery to help recovery

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3
Q

What do we need to think about with alcoholics?

A

Cardiomyopathies
Infections
Arrythmias (dehydration electrolyte issues)
increase post op complications

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4
Q

Smoking cessation values

A

20 mins: Decreased effects on BP and vasoconstriction
8 hours: CO levels halved
12 Hours: CO levels normalized
24 Hours: Chances of MI go down
48 Hours: Cilia muscus expusion begins
2 Weeks: Lung inflammion decreases

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5
Q

What time frame after quitting is a mucus plug more likely?

A

48 hrs to 8 weeks

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6
Q

E-Cigs contain what

A

Nicotine
Glycerol
Heavy Metals
possible social drugs

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7
Q

What is EVALI?

A

E-cig or vaping use associated lung injury

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8
Q

NPO in ERAS?

A

8 hours with ability to have carb beverage up to two hours prior

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9
Q

What does the carb drink do for the patient?

A

Increased rate of bowel return to function
reduces insulin resistant
decreases anxiety
prevent catabolic state

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10
Q

ERAS: Intraop MMA

PLONNKED-GM

A

Precedex
LA
Opioids
Non-Opioids Analgesics (Acetaminophen)
NSAIDS (Toradol)
Ketamine
Esmolol (decreased sympathetic outflow)
Decadron
Gabapentin
Magnesium Sulfate

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11
Q

What three ways does a patient feel pain?

A

Perception
Transmission
Modulation

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12
Q

What is allodynia

A

pain due to a stimulus that does not usually cause pain

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13
Q

What is hyperalgesia

A

increased pain due to a stimulus that does usually cause pain

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14
Q

OIH?

A

Opiod induced hyperalgesia
short acting narcotic exposure that causes increased pain perception

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15
Q

Opioid Tolerance

A

increased naroctic need to provide analgesia

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16
Q

What NMDA antagoist helps with OIH?

A

Ketamine

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17
Q

CTZ

A

Chemoreceptor trigger zone

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18
Q

Factors that increase PONV

A

Female
Young
Anxiety
Non-smoker
Hx of PONV, Migraine, Motion Sickness

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19
Q

What is a PONV risk with morphine?

A

Histamine release

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20
Q

What anesthetic drugs/agents increase PONV?

A

Opioids
Volatile agent
NO2
Long case

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21
Q

What surgical related factors increase PONV?

SEPSS-VV

A

Swallowed Substances
Emotional Distress
Peritoneal Irritation
Serotonin Release
Strabismus Surgery
Vestibular Stimulation
Vagal Stimulation

22
Q

Issues with Reglan (Metoclopramide)

Prokenitic (10mg)

A

Not very effective
Increase GI motility
Hypotension/Tachy
Extrapyramidal effects (parkinson like effects)

23
Q

Issues with Droperidol

D2 antagonist (0.625-1.25)

A

Increased Anxiety, Akathisia, and Dystonia
Prolonged QT (can induce torsades)
Avoid in patients with Parkinson’s

24
Q

Issues with Diphenhydramine (Benadryl)

25-50 mg

A

Profound sedative for patients with dementia
Urinary retention
Extrapyramidal symptoms

25
Q

Issues with Promethezine (Phenergan)

12.5-25mg

A

Vascular necrosis
Similar side effects to Benadryl

26
Q

Issues with Scopolamine Patch

1.5mg

A

Visual disturbances
dry mouth
sedation/dizzy
Avoid in dementia/Alzheimer’s

Great for vestibular issues of PONV (motion sicknes)

27
Q

Atropine for PONV?

0.2mg

A

Only if Neostigmine is given

28
Q

Zofran for PONV

4mg

A

More effective than dopamine antagonists
no extrapyramidal issues
does prolong QT

29
Q

What is Aprepitant?

A

Neurokinin-1 Antagonist
Better than Zofran but more expensive
Takes a long time to work
Can cause constipation, headache, fever, and itching

30
Q

Decadron?

A

Slow onset, give at beginning of case
Works on the Nucleus Tractus Solitarius (grey matter near CTZ)

31
Q

Minimize SSI?

A

Pre-incision Antibiotics

32
Q

Ancef dosing

A

Under 60kg = 1 g
Between 60 and 120 kg = 2 g
Over 120 kg = 3 gm

33
Q

Adam loves testing on Hypothermia shit. Giant list of it’s effects

LIPIDIC-APP

A

Left Shift Hemoglobin-oxygen sat curve (O2 doesn’t leave)
Increased Renal dysfunction
Platelet dysfunction
Increased infection risk
Decreased drug metabolism
Increased cortisol levels
Coagulopathy
-
Arrhythmias
Protein catabolism
Poor wound healing

34
Q

What causes hypothermia in the OR?

A

Cold IV fluids
Exposure
Anesthetic vasodilation
Hypothalamic thermoregulatory depression via anesthesia

35
Q

Two ways to measure CORE temp

A
  1. Bladder
  2. Esophgeal
36
Q

ARDS Management: 10 steps

A
  1. 4-6 mL/kg tidal volume
  2. Pleateau pressure < 27 cmH2O
  3. Driving pressure < 15 cmH2O
  4. RR < 30 per min
  5. PEEP ≤ 15 cmH2O
  6. Mechanical Power < 17 J/min
  7. Prone position 12-18 hours if PaO2/FiO2 < 150
  8. NMB if severe
  9. Recruitment maneuvers can help
  10. Consider ECMO if pt does not improve
37
Q

Lung protective maneuvers?

A

SEE ARDS STEPS!
On Adam’s slide:
TV: 4-6 mL/kg IBW
PEEP: 5-10 cmH2O
Recruitment Maneuvers (30 second breath at 30 cmH2O)
Recruitment breaths right after intubation
Minimum FiO2 to maintain SpO2 of 94%

38
Q

PPV value?

A

5-9%

39
Q

Glucose goal for surgery?

A

80-180 mg/dL

40
Q

Post op goals

A

Quick to ambulate
early PO intake
continue analgesia

41
Q

How do we treat Diabetes Insipidus?

A

desmopressin (DDAVP)

42
Q

What is not advised in Organ donation cases?

A

Phenylephrine, causes acidosis

43
Q

Organ harvesting pearls

A

Avoid pressors unless asking the surgeon
give heparin prior to retrieval
remove PAC or central line if heart and lungs are being taken
Sevo and narcs to control hemodynamics is preferred

44
Q

Living donations

A
  • Liver: only partial
  • Kidneys only one
45
Q

Hepatic transplant

One of the most involved cases for anesthesia

A

Hepatorenal syndrom
hepatopulmonary syndrome
Cirrhosis
Cardiomyopathy
Electrolyte disturbances

Prepare for:
Central Line
Art Line
Large bore IVs
TEE
Rapid infusion
Hot line
iStat
PRBC’s ready

46
Q

Hepatic transplant: Preanhepatic

A

Blood loss
hyponatermia
hyperkalemia
citrate toxicity

citrate toxicity from blood products, its the coag in the bags of blood we use

47
Q

Hepatic transplant: Anhepatic

A

+/- VV bypass
zero drug metabolism during this time

48
Q

Hepatic transplant: Neohepatic

A

Reperfusion syndrome
* cold
* acidotic
* hyperkalemia solution washout
* +/- emboli
Hepatic ischemia

49
Q

Complications to a living liver donor?

A

Post-op bleeding
portal vein thrombosis
biliary leak

50
Q

What is Antithymocyte Globulin Rabbit?

A

Anti-rejection drugs for kidney xplant

2nd line immunosuppressant

51
Q

First line immunosupressant for kidney transplant?

2 drugs

A

Solu-Medrol
Diphenhydramine

52
Q

Renal transplant intra-op

A

CVP around 15 mmHg
Mannitol
Lasix

Sim Lab 3 (6 decks)

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