Exam 1 REVIEW Flashcards
(273 cards)
1
Q
Adverse effects of Doxorubicin (CM)
A
Cardiac toxicity, myelosuppresion
2
Q
Adverse effects of Asparaginase (CHHT)
A
Coagulopathy
Hemorrhagic pancreatitis
Hepatic dysfunction
Thromboembolism
3
Q
**Adverse effects of Bleomycin (PPP-IB)
A
Pneumonitis, Pulmonary HTN, Toxicity
Interstitial pulmonary fibrosis
Bronchiolitis obliterans
4
Q
If they use Bleomycin in the past.
A
Avoid high O2 concentration if they have use bleomycin in the past.
5
Q
***Bleomycin short adverse effects
A
Pulmonary HTN
Pulmonary toxicity
6
Q
Adverse effects of Carmustine and Mitomycin (MP)
A
Myelosuppression, pulmonary toxicity
7
Q
Adverse effects of Chlorambucil (MPS)
A
Myelosuppression, pulmonary toxicity, SIADH
8
Q
Adverse effects of Busulfan and ETOPOSIDE (CMP)
A
Cardiac toxicity
Myelosuppression
Pulmonary toxicity
9
Q
**Adverse effects of Cisplastin (DMMO, PSRT) RHL
A
Dysrhythmias Magnesium wasting Mucositis, Ototoxicity Peripheral neuropathy SIADH Renal tubular necrosis Thromboembolism
Renal insufficiency
Hypomagnesemia
Large fiber neuropathy
10
Q
Adverse effects of Cyclophosphamide (EHM, 3xPPPS)
A
Encephalopathy/delirium, hemorrhagic cystitis, myelosuppression, pericarditis, pericardial
effusion, SIADH, pulmonary fibrosis
11
Q
Adverse effects of Etoposide (CMP)
A
Cardiac toxicity, myelosuppression, pulmonary toxicit
12
Q
Adverse effects of Fluorouracil (GAM-C)
A
Gastritis
Acute cerebellar ataxia
Myelosuppression
Cardiac toxicity
13
Q
Adverse effects of Ifosfamide (CHRS)
A
Cardiac toxicity
Hemorrhagic cystitis
Renal insufficiency
SIADH
14
Q
**Adverse effects of Methotrexate MEM-HPPMR
A
Mucositis Encephalopathy, Myelosuppression Hepatic dysfunction Pulmonary toxicity Platelet ,dysfunction Renal failure
15
Q
Mitomycin SE (MP)
A
Myelosuppression, pulmonary toxicity
16
Q
Mitoxantrone SE
A
Cardiac toxicity, myelosuppression
17
Q
Paclitaxel SE (AAA, PB)
A
Ataxia, Autonomic dysfunction, Arthralgias, Myelosuppression,
Peripheral neuropathy,
Bradycardia
18
Q
Vinblastine (CH PMS)
A
Cardiac toxicity Hypertension, Pulmonary toxicity Myelosuppression SIADH
19
Q
*****3 side effects of Cisplastin RHL
A
Renal insufficiency
Hypomagnesemia
Large fiber neuropathy
20
Q
Prolonged methotrexate use can cause
A
irreversible dementia
21
Q
CV:Doxorubicin exposure anesthesia consideration
A
Left ventricular dysfunction
Dysrhythmias
Engorgement of great vessels
22
Q
Pulmonary: Bleomycin, busulfan, chlorambucil exposure
anesthesia considerations OHA
A
- Obstructive/restrictive disease
- Avoid high concentrations of oxygen with
- history of bleomycin exposure
23
Q
NEURO: Cisplatin, vincristine, fluorouracil exposure
EPS PONE
A
Elevated intracranial pressure
Papilledema
Spinal cord compression due to metastases
Phrenic nerve palsy in presence of metastases
or superior vena cava syndrome
Exercise caution with peripheral nerve blocks,
Neuraxial anesthesia
24
Q
Most endocrine abnromalities with paraneoplastic syndrome
A
Most occur after the diagnosis
25
Paraneoplastic syndromes NEURO
Myasthenia Gravis
| Eaton-Lambert syndrome
26
Paraneoplastic syndromes
| ENDOCRINE
SIADH
| Hypercalcemia
27
Paraneoplastic syndromes is a
Pathophysiologic disturbances in pts with cancer
28
Paraneoplastic syndromes is most common in
▪ Most common in individuals with lung, ovarian,
| lymphatic, or breast cancer
29
Paraneoplastic syndromes May involve
endocrine, neuromuscular or musculoskeletal, cardiovascular, cutaneous, hematologic, gastrointestinal and renal systems
30
Paraneoplatic syndrome May reflect
tumor necrosis, inflammation,
release of toxic products by cancer cells
or production of endogenous pyrogens
31
Paraneoplastic syndrome Cachexia
Psychologic effects of cancer on appetite, cancer cells compete with normal tissues for nutrients and may eventually cause nutritive death of normal cells
32
Paraneoplastic syndrome Nervous System: symptoms generally develop over
days to weeks usually prior to the tumor being
| discovered
33
Nervous system symptoms of Paraneoplastic
| Neuro : Memory, speech, vision, sleep, limbs, muscle tone
Symptoms include difficulty in walking or swallowing, Loss of muscle tone, loss of fine motor coordination, Slurred speech, memory loss, vision problems, sleep
disturbances,
Dementia, seizures, sensory loss in the limbs, and vertigo or dizziness
34
Paraneoplastic syndrome: Mostly seen in
small cell lung, lymphoma, myeloma
35
Paraneoplastic syndrome Can affect both
central and peripheral nervous systems
36
Neuro abdnormalities with Paraneoplastic syndrome occurs
Majority manifest BEFORE the diagnosis of cancer
37
ENDOCRINE abdnormalities with Paraneoplastic syndrome occurs
Most occur AFTER the diagnosis of cancer
38
ENDOCRINE abdnormalities with Paraneoplastic syndrome arise from
Arise from hormone or peptide production within
| tumor cells
39
ENDOCRINE abdnormalities with Paraneoplastic syndrome Preferred management
Treatment of underlying tumor = preferred
40
ENDOCRINE abdnormalities with Paraneoplastic Syndrome
| Most common cause of hospitalized patients
▪ Hypercalcemia- cancer is the most common cause in
| hospitalized patients
41
ENDOCRINE abdnormalities with Paraneoplastic Syndrome: SIADH
▪ SIADH- mostly from small cell lung cancer
42
ENDOCRINE abdnormalities with Paraneoplastic Syndrome: CUSHING
Cushing’s Syndrome small cell lung ca & carcinoid
43
ENDOCRINE abdnormalities with Paraneoplastic Syndrome: Hypoglycemia
Hypoglycemia - islet cell
| tumors of the pancreas
44
Paraneoplastic syndrome
Hormone : ACTH
Associated cancer _________
Manifestation_______
Carcinoid, lung (small cell), thymoma, thyroid (medullary)
| Manifestations: Cushing's syndrome
45
Paraneoplastic syndrome
Hormone : ADH
Associated cancer _________
Manifestation_______
Duodenal, lung (small cell), lymphoma, pancreatic, prostate
| Manifestations : Water intoxication
46
Paraneoplastic syndrome
Hormone : Erythropoietin
Associated cancer _________
Manifestation_______
Hemangioblastoma, hepatic, renal cell uterine myofibroma
| Manifestations: Polycythemia
47
Paraneoplastic syndrome
Hormone : HCG
Associated cancer _________
Manifestation_______
Human chorionic gonadotropin Adrenal, breast, lung (large cell), ovarian, testicular
Manifestations: Gynecomastia, galactorrhea, precocious
puberty
48
Paraneoplastic syndrome
Hormone : Insulin-like substances
Associated cancer _________
Manifestation_______
Retroperitoneal tumors
| Manifestations: Hypoglycemia
49
Paraneoplastic syndrome
Hormone : Parathyroid hormone
Associated cancer _________
Manifestation_______
Lung (small cell, squamous cell), ovary,
pancreas, renal
Manifestations: Hyperparathyroidism, hypercalcemia,
hypertension, renal dysfunction, left ventricular dysfunction
50
Paraneoplastic syndrome
Hormone : Thyrotropin
Associated cancer _________
Manifestation_______
Choriocarcinoma, testicular (embryonal)
| Manifestations: Hyperthyroidism, thrombocytopenia
51
Paraneoplastic syndrome
Hormone : Thyrocalcitonin
Associated cancer _________
Manifestation_______
Thyroid (medullary)
| Manifestations: Hypocalcemia, hypotension, muscle weakness
52
Paraneoplastic syndrome Renal abnormalities
Glomerulonephritis
Membranous glomerulonephritis
Nephrotic syndrome
Amyloidosis
53
Paraneoplastic syndrome Renal abnormalities
| Glomerulonephritis common in
Glomerulonephritis common in lymphoma & leukemia
54
Paraneoplastic syndrome Dermatologic & Rheumatologic Abnormalities ▪
Appearance should initiate cancer screening
55
Paraneoplastic syndrome Hematologic Abnormalities ▪
| ▪ Eosinophilia most often seen in ____and what can it cause?
Rarely symptomatic but usually present with
advanced cancer
leukemia and lymphoma
▪ Can cause wheezing or occasionally end -organ damage resulting from eosinophilic infiltration
56
Radiation therapy adverse effects:
| Skin : Acute and Chronic
Acute: Erythema, rash, hair loss
Chronic: Fibrosis, sclerosis, telangiectasias
57
Radiation therapy adverse effects: Gastrointestinal
| Acute and Chronic
Acute: Malnutrition, mucositis, nausea, vomiting Chronic: Chronic: Adhesions, fistulas, strictures
58
Radiation therapy adverse effects: Cardiac
Acute: NONE
Chronic: Conduction defects, pericardial effusion, pericardial fibrosis, pericarditis
59
Radiation therapy adverse effects: Respiratory
Acute: NONE
Chronic: Airway fibrosis, pulmonary fibrosis, pneumonitis,
tracheal stenosis
60
Radiation therapy adverse effects: Renal
Acute: Glomerulonephritis
Chronic: Glomerulosclerosis
61
Radiation therapy adverse effects: Hepatic
ACUTE: Sinusoidal obstruction syndrome
Chronic: NONE
62
Radiation therapy adverse effects: Endocrine
Acute: NONE
| Chronic Endocrine Hypothyroidism, Panhypopituitarism
63
Radiation therapy adverse effects: Hematologic
Acute:Bone marrow suppression
Chronic: Coagulation necrosis
64
Colon cancer is one of
The most types of cancer, very treatable if caught early
65
Colon Cancer stage 0
Cancer has not grown beyond inner layer of colon wall
66
Colon Cancer stage 1
Grown to outer layer of wall
67
Colon Cancer stage 2
Tumor is through wall, not spread to lymph nodes
68
Colon Cancer stage 3
Spread to lymph nodes
69
Colon Cancer stage 4
Cancer spreads to distant sites in body, such as liver or lung
70
Colon cancer How does the tumor begins
Normal tissue forms a polyp projecting from colon wall
| Over time polyp become a tumor
71
Risk factors for colon cancer are (PAF)
Patient with a hx of Ulcerative colitis or Crohn's Disease
Age
Family Hx of colon cancer
72
Clavicle repair Position
Beach chair or supine, head turned away from
| surgical field, bump placed behind affected shoulder
73
Clavicle repair Airway
| Tube taping?
GETA or GLMAA
| • Tape tube on one side opposite of surgical field
74
Clavicle repair Unique considerations
* RSI if trauma
* ISB will NOT help cover proximal clavicular pain
* IV/cuff on nonoperative side
75
Clavicle repain pre-op
| CMS
Perform a thorough distal neuro assessment on
the affected arm both pre/post
( Circulation, sensation, motor function)
76
Clavicle repair head.
• Carefully stabilize head in beach chair position
77
Clavice repair Tube , what to do severely and why ?
* Tape the ETT or LMA SEVERELY
| * Head will be under drapes
78
Clavicle repair, important to have
Eye protection is important
| Tape eyes closed, place pads over eyes, consider goggles (DON’T)
79
Clavicle repair: Surgeon may require
SBP < 100 mm Hg to prevent bleeding
80
Clavicle Repair Complications:
brachial plexus or subclavian artery injury
81
Dye injection:
| Post op
Pt may be allergic to dye, tattooing of skin, discoloration of urine
urine emesis or stool may be blue for 24-48h
82
Isosulfran dye reaction:
| Treat with
Pruritus, localized swelling, blue hives
| Diphenhydramine 10-50mg IV, epi if BP ↓
83
Dyes and SPO2 (how much and when)
Drops SPO2 (2-5% 20-25 minutes after injection)
84
Regional for breast procedures
Regional (paravertebral, pec I & II blocks)
• Less PONV, less pain, earlier discharge,
less chronic pain
85
Breast Biopsy and Lumpectomy
Paravertebral block
• With MAC or GA
• Pectoral nerve block type II
86
Paravertebral block for mastectomy
| Levels block ? how much and meds concentration
Multilevel paravertebral blocks
• T1-T6 block required
• 4-5 mL/level
• 0.5% bupivacaine or 0.5% ropivacaine (1:400,000 epi)
87
Contraindications to regional
Contraindications: patient refusal, local
anesthetic allergy, pathology or anatomical
distortion of paravertebral space, infection at site
88
When to sedate for breast block
Sedate when performing block, best in OR
89
Medication management for breast surgery patient:preop
Midazolam
90
Medication management for breast surgery patient: Intraop
Propofol 25-100 mcg/kg/min
Fentanyl/remi and midazolam titrate effect
Remi bolus 0.5-1mcg/kg 90 second prior to initial incision with LA
91
Breast biopsy /SNL Airway
GA may mask or LMA if appropriate
92
What is Normal hepatic blood flow in
| adults?
1,500mL/min
93
% distribution of blood flow in hepatic
• 25-30% delivered via hepatic artery,
• 70-75% supplied by portal vein (normal oxygen
saturation around 85%)
94
Portal vein normal oxygen saturation around
85%
95
% of blood delivered by hepatic artery
25-30%
96
% supplied by portal vein
70-75%
97
Liver receives how much of CO?
25-30% of the cardiac output
98
The Hepatic plexus is innervated by:
1. Sympathetic nerve fibers from T6-T11
| 2. Parasympathetic fibers from right phrenic nerves and the right and left vagus
99
Laparoscopic cholecystectomy complications
• 5% of “lap choles” convert to open because inflammation obscures the anatomy
100
Laparoscopic procedures Anesthesia considerations:
➔
• Treated c/ glucagon, naloxone, or nitroglycerin
• Insufflation ➔ ↑ intra-abdominal pressure ➔interferes c/ ventilation and venous return, can result in bradycardia (glycopyrrolate vs atropine)
Immediate ↓ in venous return and cardiac output →
↑ MAP and systemic vascular resistance
101
Can help after insufflation
Reverse Trendelenburg can help c/ BP and SVR
102
During Lap Chole procedures, Opioid induced
Sphincter of Oddi spasm occurs in less than 3% of patients
103
With lap chole procedures if sphincter of oddi spasms occur what do you treat it with?
glucagon, naloxone, or nitroglycerin
104
Assessing liver damage, enzymes: ALT
cytoplasmic enzyme high specific to the liver
105
Assessing liver damage, enzymes: AST
Enzyme that exist in hepatic and extra hepatic tissues
106
When both liver enzymes are elevated
Ratio is considered
ALT/AST ratio < 1 nonalcoholic steato-hepatitis NASH
2 to 4 = alcoholic liver disease.
107
Assessment of liver function:
ALBUMIN and INR
108
Synthesized exclusively by hepatocytes
Albumin
109
Albumin is responsible for
15% of all protein synthesis in the liver
| There can be severe impairment of the synthesis capacity in the liver
110
INR is correlated with
liver dysfunction
111
Considered the reliable predictive value for survival in patients with liver disease
INR
112
INR is associated with the impairment of the
Hepatic synthetic function of coagulation factors.
113
Bilirubin is the
degradation product of hemoglobin and myoglobin.
114
•Total bilirubin concentration is normally
< 1 mg/dL
115
•Total bilirubin concentration• > 3 mg/dL =
scleral icterus
116
•Total bilirubin concentration• > 4 mg/dL =
overt jaundice
117
Sensitive marker for hepatocellular damage
• α glutathione-S-transferase ; ↑ transiently after
administration of isoflurane, desflurane, and
sevoflurane
118
MOST indicative of liver damage
ALT
119
Distinguishing Cholethiasis from ureterolithiasis and acute intermittent porphyria)
Serum bilirubin and alkaline phosphatase
| are sharply ↑
120
Hep C is the most
virulent ➔ chronic hepatitis (40%) and cirrhosis ➔ end-stage liver disease requiring liver transplantation
121
Hep B co exist with
D
122
Hep C co exist with
E
123
What is Immune-Mediated Hepatotoxicity?
Administration of volatile anesthetics (especially halothane) leads to immune-mediated hepatotoxicity (IgG)
124
In immune mediated hepatotoxicity
Microsomal proteins on the surface of hepatocytes are covalently modified by reactive oxidative trifluoroacetyl halide (TFAH) metabolites to form neoantigens (“self” is turned into“nonself”)
➔ Rare life-threatening hepatic dysfunction
125
➔ Rare life-threatening hepatic dysfunction
immune mediated hepatotoxicity
126
Fluorinated volatile anesthetics (DIE)
(enflurane, isoflurane, and desflurane) form trifluoroacetylated metabolites, which have a cross sensitivity c/ halothane
127
Fluorinated Volatile anesthetics: does NOT have this property
sevoflurane
128
Coagulopathy
Hepatocytes produce fibrinogen .,factor 5,7,9,10,12 and protein C and S and antithrombin
129
Sinusoidal endothelial cells produce
factor VII and vWF
130
Cirrhosis on pro and anticoagulants
```
↓ serum albumin
prolonged prothrombin time,
↑ serum AST/ALT,
Thrombocytopenia
↑ INR
```
131
Hepatic failure correct coagulation with
FFP (has all the clotting factors)
132
Hepatic Failure if PT/INR prolonged
Administer Vitamin K (treat thrombocytopenia)
133
The liver role with coagulation
The liver clears activated coagulation factors from circulation
134
Drug doses for Liver disease: blood
Administer blood slowly because clearance of citrate is decreased with cirrhotic liver
135
Drug doses for Liver disease: Plasma cholinesterase and SUCC
Severe liver disease may alter plasma cholinesterase activity and prolong SUCCINYLCHOLINE
136
With liver disease , Volume of distribution is
INCREASED
137
Because with liver disease Vd is increase, the initial dose of ____________however, subsequent doses should be
NDNMB needs to be larger than normal; decreased due to decrease hepatic clearance
138
Liver disease and Vecuronium doses
Elimination half life of Vecuronium is NOT INCREASED until the dose EXCEED 0.1mg/kg
139
Hepatic Failure: Critically ill patients should receive
low doses of volatiles or N2O c/ TIVA
140
Hepatic failure and protein binding
Decrease protein binding due to low albumin
| ↑ active forms of IV drugs
141
Acute alcohol; Chronic alcohol ingestion
Less anesthetics (additive effects) ; more
142
Risk stratification For liver disease
| Parameter: Bilirubin (mg/dL) Low, mod, High
<2
2-3
>3
143
Risk stratification For liver disease
| Parameter: Albumin Low, mod, High
>3.5
3-5
<3
144
Risk stratification For liver disease
| Parameter: Prothrombin time (sec) Low, mod, High
1-4
4-6
>6
145
Risk stratification For liver disease
| Parameter: Encephalopathy Low, mod, High
None
Moderate
Severe
146
Risk stratification For liver disease
| Parameter: NutritionLow, mod, High
Excellent
Good
POOR
147
Risk stratification For liver disease
| Parameter: Ascites Low, mod, High
None
Moderate
Marked
148
Risk Stratification parameters for liver disease are (BAPENA)
```
Bilirubin
Albumin
Prothrombin time
Encephalopathy
Nutrition
Ascites
```
149
```
High risk for Liver disease
Bilirubin
Albumin
Prothrombin
Encephalopathy
Nutrition
Ascities
```
```
>3
<3
>6
Severe
Poor
Marked
```
150
What is porphyria
Genetic errors of metabolism characterized by OVERPRODUCTION of porphyrins and their precursors
151
What is the most important porphyrin?
Heme (bound to proteins to form hemoproteins including hemoglobin and cytochrome P-450)
152
Porphyria and anesthesia
ONLY ACUTE PORPHYRIAS are relevant to anesthesia because they produce life-threatening reactions to certain drugs.
153
Acute intermittent porphyria is the
common acute form of porphyria, producing the most serious symptoms
154
Acute intermittent porphyria Signs and symptoms
Hypertension, Renal dysfunction and CNS symptoms and can be precipitated by the administration of certain drugs.
155
```
Acute intermittent Porphyria DRUGS TO AVOID
KEPT MAN (most important KEMT)
```
```
Ketorolac
Etomidate
Pentazocine
Thiopental and Thiamylal
Methohexital
Nifedipine
```
156
Porphyria anesthesia considerations
Carbohydrate administration can suppress porphyrin synthesis (10% glucose in saline recommended )
Minimize NPO time
Document existing muscle weakness
157
Porphyria anesthesia intra op
Avoid all barbiturates
| Keep patient warm
158
Treatment of acute Porphyria
• Remove triggering agents
• Adequate hydration and carbohydrate administration
• Treat symptoms as needed
• Benzodiazepines and propofol can help alleviate symptoms
Hematin
159
Is the only specific therapy for acute porphyric crisis
Hematin (3-4mg/kg IV over 20min)
160
Adverse events with ETT : LMA
| Clinical significant Problems
3.4: 0.9 Ratio
161
Adverse events with ETT : LMA
| Laryngeal Spasms
0.38: 0.12
162
Adverse events with ETT : LMA
| Aspiration
0.017 :0.02
163
Adverse events with ETT : LMA
| Sore throat
50:10
164
Adverse events with ETT : LMA
| Laryngeal Trauma
6.2; <1 Ratio > 6
165
Adverse events with ETT : LMA
| Coughing or emergence
60: 2 Ratio 30
166
Not much difference in occurence ETT vs LMA
Aspiration
167
Major difference in this event for ETT vs LMA
Coughing on emergence
60 ETT
2 LMA
168
Narcotic Management Fentanyl
TIVA
Controlled hypotension = SBP < 100 mm Hg, MAP 60-70 mm Hg
do NOT exceed 4 mcg/kg for total dose
169
Extra cranial Narcotic Management TIVA
| SANDWICH ANESTHETIC
c/propofol and remi and boluses of fentanyl = facilitation
of moderate-controlled hypotension, improves hemodynamic stability during most stimulating parts, and promotes smooth emergence
“Sandwich anesthetic”
170
Controlled Hypotension
Controlled hypotension = SBP < 100 mm Hg, MAP 60-70 mm Hg
171
Extracranial IV narcotics : patients
Minimize IV narcotics
| Warn patient about postoperative discomfort
172
Pain score: UPPP vs UPF
| Sinus surgery
8-10
6-10
2-3
173
UPF is _____ painful than UPPP
less
174
What is the Retrobulbar block?
Retrobulbar block involves depositing local anesthetic inside the muscle cone behind globe
175
Akinesia Requires
retrobulbar block
176
What does the retrobulbar block do?
Blocks Ciliary ganglion of CN III, IV and VI
177
A retrobulbar block does not anesthetize____ which leaves the patient able to close the eye with the ________ but not open it with the ____
cranial nerve VII (facial nerve), Orbicularis oculi VII ; levator muscle (CN III).
178
Exception of retrobulbar block
The exception of the orbicularis oculi of the eyelid
179
Oculocardiac reflex Neural pathways (2 nerves ) five and dime
The relevant neural pathways are branches of the trigeminal nerve (afferent) and vagus nerve (efferent)
180
Oculocardiac reflex Treatment of bradycardia includes
removal of stimulus
asking the surgeon to stop the stimulation
initiation of intravenous anticholinergics (eg atropine 5-10 ,20mcg/kg or glycopyrrolate 2.5-5 mcg/kg), and checking depth of anesthesia (where GA is used).
181
What is Oculocardiac reflex?
a decrease of HR by 10%, HYPOTENSION and Bradycardia due to a range of stimuli in or around the orbit, such as traction on the extraocular muscles, pressure on the globe, retrobulbar block, ocular trauma
182
Emergence after eye surgery (FEDO)
Fully revere NMB
Extubate awake, but smoothly
Decompress blood from stomach
Observe swallowing
183
Emergence if concerned about extreme edema?
Consider extubating over tube exchanger (bougie)
184
Emergence after eye surgery : Bailey maneuver
LMA substituted for the tracheal tube while patient is deeply anesthesized, inflated LMA inserted, then tracheal tube removed, LMA inflated, and patient allowed to emerge
185
Emergence Nasal airway before emergency if
NO sinus /nasal surgery
186
Emegence after eye surgery
Expect pain and HTN, treat with opioids before emergence (not too much, have a calculated number in mind!)
187
Emergence HTN can lead to
bleeding
188
Complications with emergence after eye surgery:
Airway/resp. most common
| ↑CO2, pulm edema, reintubation, broncho/laryngospasm
189
Make sure surgeon removes
throat pack at end of surgery!
190
When sedatives and/or narcotics are used in geriatric patients.
Careful, slow titration is necessary
191
OSA have
Exaggerated response to sedatives
192
Parkinsons: Deep brain stimulator placement why?
Avoid GABA agonists with deep brain stimulator placement (alter characteristic microelectrode
recordings of specific nuclei in the basal ganglia)
193
Parkison's Disease levodopa therapy
Continue levodopa therapy because acute withdrawal can results in skeletal muscle rigidity which can lead to ventilation problems
194
Anesthesia management of Parkison's Disease
Use opioids and DEXMEDETOMIDINE instead, but avoid respiratory depression because head frame limits ability to intubate
195
Avoid in Parkinson's
Hypotension
196
In parkinson's, sudden
Alteration of consciousness could indicate intracranial hemorrhage.
197
Alzheimer's Medication management Tx (TDRG)
Cholinesterase Inhibitors (Tacrine, donepezil, rivastigmine, galantamine) May PROLONG ACTIVITY of SUCCINYLCHOLINE and MAY BE RESISTANT to NDNMB
198
Subarachnoid Hemorrhage d/t Aneurysm and spasms
Intracerebral vasospasms can occur 3-15 days
| after subarachnoid hemorrhage
199
Subarachnoid Hemorrhage d/t Aneurysm and spasms If vasospasm is identified via
via transcranial doppler
200
Vasospasms triple H therapy is initiated
(Hypervolemia, Hypertension, Hemodilution)
| Colloid, crystalloid, and pressors may be used
201
Medication: helps reduce occurrence of vasospasm
Nimodipine
202
EEG waves
```
DELTA = deep •
S/THETA = sleep •
ALPHA = awake •
BETA = concentrating
```
203
A. EEG monitoring
monitor cerebral function during GETA
= Detect cerebral ischemia during CEA, cerebral
aneurysm surgery, and arteriovenous malformation
management and CABG
204
SAH d/t aneuryms limit the
risk of rupture
Avoid significant increase in BP
ICP can be left higher than normal but not abnormal >20, to tamponade aneurysm
205
CPP and vasospasms
prevent cerebral ischemia , CPP must be kept elevated during vasospasms
206
When is rupture most likely to occur
During the late stages of surgical dissection
207
EPs: Anesthesia drugs effect on EEG latency and amplitude DAIL
IV anesthetics and Volatiles
DECREASE AMPLITUDE,
INCREASE LATENCY
208
•MNEMONICS:
VEP = very sensitive
• SSEP = somewhat sensitive
• BAEP = barely sensitive
209
A-line/CVP/PAP transducer at
external auditory/acoustic meatus level (Circle of
| Willis assessment of CPP).
210
BIS 100 :
Awake
211
▪ Monitors brain wave activity; main
| application is with______
BIS: alertness
212
BIS 70-90:
Light/Moderate Sedation
213
BIS 60-70:
Deep Sedation (low probability of explicit recall)
214
BIS level with low probability of explicit recall
BIS 60-70
215
BIS level 40-60
*** GENERAL ANESTHESIA
216
BIS level 10-40
Deep Hypnotic State
217
BIS level 0-10 :
Flat line EEG
218
Assess for symptoms of increased ICP •
| AMDPMM
```
Altered consciousness
Nausea, vomiting
Decreased reactivity of pupils to light
Papilledema
Mydriasis
Midline shift > 0.5cm
```
219
High ICP Cushing’s triad •
* Bradycardia
* Systemic hypertension
* Breathing disturbances
220
Laparoscopic colon surgery regional
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TAP Block
Transthoracic Epidural (as opioids sparring techniques)
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Laparoscopic colon surgery regional: Thoracic Epidural Analgesia (TEA)
Beneficial effects of TEA require that catheter placement be targeted at the Thoracic segments innervating injured skin, muscle and bone from which nociceptive input originated.
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ERAS Preopearative
| (COPS PRIP)
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Cardiopulmonary exercise testing
Optimized diets
Preadmission education and counseling
Shortening fasting
Prophylactic ABT
Respiratory drug intervention
Intensive Pulmonary physioologic therapy
Physical exercise training
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ERAS Intraoperative PPFES
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Protective lung ventilation
Prevention of hypothermia
Fissureless surgical techniques
Epidural anesthesia/analgesia
Single chest tube placement
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ERAS POSToperative (EMSIEE)
Epidural analgesia/ nonsteroidal analgesic painkillers
Measures to promove bowel movements
Standardized chest tube management
IV fluid restriction
Early removal of epidural and urinary catheter
Early oral feeding and ambulation
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TMJ surgery
| Complications due to
Patients swallowing blood from the procedure, results in increased chance of N/V.
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TMJ surgery complications: Airway
Airway obstruction d/t retained throat packs from the surgery. Surgeon and staff must always check for throat packs if patient is showing signs of airway obstruction.
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TMJ complications: One of the most common complications is
a permanent loss in range of motion of the joint.
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TMJ complications Injury to the
Facial Nerve, CN VII, can result in partial loss of facial muscle movement or loss in sensation
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TMJ can cause Injury to the Trigeminal Nerve,
CN V, which is responsible for facial sensation and facial motor movements like chewing/biting.
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TMJ and hearing
Partial hearing loss
231
TMJ complications Frey Syndrome? what does it cause?
a rare complication due to injury of the parotid glands near the TMJ. This will cause excessive facial swelling.
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Sub-tenon Regional
Provides profound analgesia, but motor movements may still be present, done between the rectus muscles of the globe
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Most effective regional for eye
Retrobulbar
234
Retrobulbar block Procedures
Pt instructed to look up and nasally
23G needle inserted and local injected in the muscle cone
after injection, eyelid should be closed, and digital pressure applied over the grobe to the orbit. After a few moments the eyelids should be opened and the globe inspected for akinesia.
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Currently, cataract surgery most commonly performed using only
topical anesthetics (e.g., 2-4% lidocaine, 0.75% levobupivacaine, 1% ropivacaine, or 1% oxybuprocaine). Need very compliant.
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Blocks- Local anesthetics should be avoided in
patients with uncontrolled movement disorders, or inability to cooperate.
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EYE Surgery General anesthesia is very rare. Indications include
children, dementia, mental disability, severe anxiety, severe head tremor, or inability to lie flat (breathing issues)
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Coughing or bucking can
increase intraocular pressure by 40 to 60 mmHg which can lead to optic nerve ischemia
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Contraindications include
uncontrolled movement disorders, claustrophobia, chronic cough, symptomatic gastric reflux, inability to lie flat, inability to communicate or cooperate, or patient refusal.
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Epidural hematoma occurs when the
middle cerebral artery via a skull fracture
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Prognosis better in this condition than acute subdural hematoma-Looks like a lemon or eye,
Epidural
242
Most common cause for emergency neurosurgery and has the highest mortality.
Subdural hematoma
243
On CT it appears as a crescent or banana shape.
Subdural
244
****Indicate anesthetic and surgical emergency
Sustained HTN
Increased ICP
swelling indicative of aneurysm rupture
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Anesthesia management to minimize ICP
Give mannitol 20% 0.25-0.5g/kg , lasix 0.3mg/kg and dexamethasone 16mg IV
Stop N2O , ensure ISO or SEVO in use
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Induction in anesthesia management to minimize ICP
Induction with propofol 1-2mg/kg or etomidate 0.3-0.6mg/kg
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Anesthetic drugs on CBF
IV drugs such as propofol, etomidate, benzodiazepine and thiopental decreases CBF by virtue of drug induced decrease in CMRO2, and subsequent flow metabolism coupling.
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Autoregulation and PaCO2
Responsiveness remain intact with these agents vasoconstriction is caused by these meds and is the resonse for the decrease in CBF and CMRO2
249
OPIODS and CMRO2
Opiods have very little effect on CRMO2, CBF, autoregulation and PaCO2 responsiveness
250
Ketamine and CBF
It increases CBF and CMRO2 with little effect on autoregulation or PACO2 responsiveness.
251
Volatile anesthetics and CBF
Iso, sevo, and dest are direct cerebral vasodilators.
252
Complication that can occur before during and after the aneurysm has been clipped.
Arterial vasospasm
253
An aneurysm is a
focal protrusion from weakness of a vessel wall at a major bifurcation of arteries in the Circle of Willis.
254
CSF secreted by
Choroid plexus in each ventricle
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CSF absorption is at the
Arachnoid villi into the dura venous sinus
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Hydrocephalus
Dilation of the ventricular system due to obstruction of CSF flow
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Aneurysm rupture in the
Subarachnoid space
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Most of aneurysm occur in bifurcation of
Anterior communicating artery 30%
Posterior communicating artery 25%
Middle Cerebral Artery 25%
Basilar artery 2%
259
During lap surgery, if insufflation cause bradycardia
ask surgeon to deflate
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Chemotherapy drugs on CV
Dysrhythmias, get EKG possibly needs echo or cardiology clearance
261
Chemotherapy drugs on Renal
nephrotocity prehydrate and avoid nephrotoxic agents
262
Chemotherapy drugs on CISPLATIN can cause
Neuropathy
263
Chemotherapy drugs on methotrexate can cause
Irreversible dementia
264
Choriocarcinoma
Uterus
265
Interscalene bLock and clavicle repair
wont work for clavicle repair
266
Put BP cuff
Nonoperative side
267
Breast surgery tips
know lidocaine toxicity level
| serum level doesn't always transfer
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Epidural hematoma
Under the bone, between dura and skull
| Middle meningeal artery
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ICP increased induction agent
Use etomidate
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Etomidate and profopol
0.1-0.4 mcg/kg to decrease CMRO2, and CBF
271
ICP keep
glucose down
272
PVB block level
T1-T6
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Signs of Rupture
Severe HTN
Seizures
Swelling and increased ICP
