Exam 2 Study Guide Flashcards
1
Q
Symptoms of ARDS
A
Arterial hypoxemia
➢ May include tachypnea, bronchospasm, and acute pulmonary hypertension
2
Q
What is ARDS?
A
Inflammatory injury to the lung that manifests clinically as acute hypoxemic respiratory failure
3
Q
Clinical disorders and risk factors associated c/ the development of ARDS include
A
events that cause direct lung injury as well as those that lead to indirect injury to the lungs in the setting of a systemic process
4
Q
Sepsis is associated c/ the
A
highest risk of progression of acute lung injury to ARDS
5
Q
DIRECT LUNG INJURY
PAPFaNI
A
- Pneumonia
- Aspiration of gastric contents
- Pulmonary contusion
- Fat emboli
- Near drowning
- Inhalational injury
6
Q
INDIRECT LUNG INJURY
STMCDA
A
- Sepsis
- Trauma associated c/ shock
- Multiple blood transfusions
- Cardiopulmonary bypass
- Drug overdose
- Acute pancreatitis
7
Q
Signs and Symptoms : First sign of ARDS
A
• Arterial hypoxemia resistant to treatment with supplemental oxygen is usually the first sign
8
Q
ARDS Death often result of
A
sepsis or multiple organ failure rather than respiratory failure
9
Q
Lung volume expansion maneuvers
A
Incentive spirometry,
10
Q
Leads to pneumonia to ARDS,
A
Intraoperative aspiration
11
Q
ARDS Radiographic signs
A
may appear before symptoms develop
12
Q
ARDS Diagnosis 2
A
- Presentation of acute refractory hypoxemia
* Diffuse infiltrates on chest radiograph consistent c/ pulmonary edema
13
Q
Resp parameters Ratio in ARDS
A
Decreased arterial PaO2/FIO2 ratio
14
Q
Decreased arterial PaO2/FIO2 ratio:
Mild ARDS:
A
Ratio is 201–300
15
Q
Decreased arterial PaO2/FIO2 ratio:
Moderate ARDS:
A
Ratio is 101–200
16
Q
Decreased arterial PaO2/FIO2 ratio:
Severe ARDS:
A
Ratio is <101
17
Q
Treatment of Acute Respiratory Distress Syndrome
POT GOD RICAN
A
Positive end-expiratory pressure
Oxygen supplementation
Tracheal intubation/Mechanical ventilation
Glucocorticoid therapy (?)
Optimization of intravascular fluid volume
Diuretic therapy
Removal of secretions
Inotropic support
Control of infection
Administration of inhaled β2 -adrenergic agonists
Nutritional support
18
Q
Anesthesia Considerations for ARDS
Battling ventilation strategies: Protective Ventilation
Vt?
A
- Protective ventilation
- Prevents ventilator-induced lung injury
- Low Vt (6 mL/kg) = 22% mortality benefit, less inflammatory mediators
19
Q
ARDS anesthesia considerations what are the 2 types of battling ventilation strategies:
A
Protective ventilation and OPEN lung ventilation
20
Q
Anesthesia Considerations for ARDS: Battling ventilation strategies: OPEN Ventilation (PSN)
A
- PEEP titrated to highest value possible while keeping plateau pressure below 28–30 cm H2O
- Significantly more ventilator-free days and organ failure–free days
- No change in mortality
21
Q
ARDS Prone positioning
A
• Exploits gravity and repositioning of heart in thorax to recruit lung units and improve ventilation/perfusion
matching
22
Q
ARDS additional treatment
A
Extracorporeal membrane oxygenation (ECMO)
23
Q
3 features of Asthma (CRB)
A
- Chronic airway inflammation
- Reversible expiratory airflow obstruction
- Bronchial hyperactivity
24
Q
What is Status Asthmaticus?
A
- Life threatening bronchospasm that persists despite treatment.
25
ASTHMA Characterized by (BHC)
Bronchoconstriction
Hyperactivity
Chronic airway inflammation.
26
Asthma PREOPERATIVE TESTS
| ACE- FA
ABG and Chest Radiography • ECG
| FEV:FVC = < 80% AUSCULTATION
27
Characteristics of Asthma to be EVALUATED preoperatively?
AAA THF CCNS
asthma
```
Age of onsent
Alllergies
Anesthetic history
Triggering events
Hospitalization of asthma
Frequency of ED visits
Need for intubation and mechanical
ventilation
Sputum characteristics
Cough
Current medications
```
28
Short acting Bronchodilators used for asthma (SABA) -- LAMP
Levalbuterol (xopenex)
Albuterol (Proventil)
Metaproterenol
Pirbuterol (Maxair)
29
MOA of short acting bronchodilators
B2 Agonist: stimulates beta 2 receptors in tracheobronchial tree
30
Adverse effects of bronchodilators
| TTD hypo
Tachycardia
Tremors
Dysrhythmias
HYPOKALEMIA
31
Long term treatment of asthma
| ILIcLMeMa
1. Inhaled Corticosteroids
2. Long-Acting Bronchodilators
3. ICS and LABA
4. Leukotriene Modifiers
5. Methylxanthines
6. Mast Cell Stabilizers
32
Asthma INTRAOPERATIVE CONSIDERATIONS INDUCTION
GETA vs LMA vs REGIONAL
2 things to know
* GETA OR LMA VS. REGIONAL
* Airway reflexes must be suppressed to avoid bronchoconstriction in response to mechanical stimulation of hyper-reactive airways
* Stimuli that do not ordinarily evoke airway responses can precipitate life-threatening bronchoconstriction in patients c/ asthma
33
GETA INDUCTION for asthma
Propofol or Ketamine
• LaryngotrachealAnesthesia (LTA) 4%Lidocaine
• Sevoflurane (BETTER) vs Desflurane
34
LMA induction for asthma
No GERD or aspiration risk
• Better method of airway management – less
instrumentation
35
```
MAINTENANCE of ASTHMA
• Opioids =
• Neuromuscular blocking agents.
• Hydration
• Ventilation:
• Slow inspiratory flow rate (at least 2 seconds)
• Sufficient exhalation time. (I:E)
• Humidification/warming of inspired gases
```
suppress cough reflex vs. histamine release and chest rigidity. Use fentanyl
36
Ketamine for asthma may cause
Increase in secretion and drooling
37
Asthmatic patient start bucking and coughin
deepen anesthesia, may get bronchospasm if not deep enough
38
2 meds help reduce cough reflex for asthma
Sevoflurane and lidocaine
39
Meds to avoid with asthma as far as NMB
Atracurium and Mivacurium because they are associated with Histamine release
40
Asthma continue bronchodilators till ______and if they take glucocorticoids?
Day of surgery ; they should receive supplementation during surgery
41
Asthma induction use
Propofol and fentanyl
42
Intraoperative bronchospasm shows as
Increase PEAK inspiratory pressure
| Delayed rise of the expiratory end tidal CO2
43
Tx of intraoperative bronchospasdm
Increase concentration of inhaled agent
Administer aerosol bronchodilator
Reduce TV
Increase expiratory time
44
I: E ratio 10 BPM
60/10 =6
| 2:4 → 1:2
45
I: E ratio 8 BPM
60/8 = 7.5 seconds/breath
| 2:5.5 -> 1:3
46
I: E ratio 6 BPM
60/6 = 10 sec/breath
Inspiration of at least 2 = Expiration 8
I:E 1:4
47
I: E ratio of 12 BPM
60/12 = 5 seconds
inspiration of at least 2 exp 3
1:1.5
48
Asthma Emergence
Deep extubation unless contraindicated.
| • IV Lidocaine (again).
49
AVOID THE FOLLOWING DRUGS PROVOKING
ASTHMA SYMPTOMS:
ABS SAN MS
1. ASPIRIN
2. BETA ANTAGONISTS (labetalol)
3. SOME NSAIDS: KETORALAC (?)
4. SULFITES
5. Atracurium
6. Neostigmine
7. Morphine
8. Succinylcholine
50
PERIOPERATIVE COMPLICATIONS
* Laryngospasm
* Bronchopasm
* Status Asthmaticus
51
Laryngospasm CXR:
*** pink frothy sputum = Negative Pressure Pulmonary
Edema
*** Coarse breath sounds
52
Treatment of Laryngospasm
in 24 hrs but mayrequire mechanical vent.___laryngeal edemaTX_ nebulized racemic epinephrineIV corticosteroids
- Increase Fi02
- CPAP/PEEP
- Reintubation
0.5-1 mg/kg Lasix IV
= will self correct c/in 24 hrs but may require mechanical vent.
53
Treatment of Laryngospasm
| ICR L
- Increase Fi02
- CPAP/PEEP
- Reintubation
0.5-1 mg/kg Lasix IV
= will self correct c/in 24 hrs but may require mechanical vent.
54
***Laryngeal edema TX
- nebulized racemic epinephrine
| - IV corticosteroids
55
TREATMENT of bronchospasm first step
R/O obstruction d/t migration of ETT, secretions, and kinking
56
Bronchospasm, Most definitive is through
fiberoptic.
57
Status asthmaticus ANESTHESIA CONSIDERATIONS
• Life-threatening bronchospasm that doesn’t resolve despite treatment
58
CO2 in status asthmaticus
Hypercarbia (PaCO2 > 50 mm Hg) requires tracheal intubation and mechanical ventilation
59
Extreme cases of status asthmaticus may need GA c/
Volatile agent to produce bronchodilation
60
For status asthmaticus Expiratory phase must be
prolonged to allow for complete exhalation and to prevent self generated or intrinsic positive end-expiratory pressure (auto-PEEP, AKA breath stacking)
61
What are the ACUTE INTRINSICE RESTRICTIVE LUNG DISEASE (PULMONARY EDEMA) AANORUCH
ARDS
Aspiration
Neurogenic Problems
Opioids Overdose
Reexpansion of collapsed lung
Upper airway obstruction (negative pressure)
CHF
High Altitude
62
What are the CHRONIC INTRINSICE RESTRICTIVE LUNG DISEASE (INTERSTITIAL LUNG DISEASE)
SHEALD
```
Sarcoidosis
Hypersensitivity pneumonitis
Eosinophillic granuloma
Alveolar proteinosis
Lymphangioleiomyoomatosis
Drug induced pulmonary fibrosis
```
63
DISORDERS OF THE CHEST WALL, PLEURA and MEDIASTINUM
| KAF PPP MMNNDD SG
```
Kyphoscoliosis
Ankylosing spondylitis
Deformities of the sternum
Deformities of the costovertebral skeletal structures
Flail chest
```
Pleural Effusion
Pneumothorax
Pneumomediastinum
```
Mediastinal mass
Muscular dystrophies
Neuromuscular disorders
Neuromuscular transmission
Spinal cord transaction
Guillain barre syndrome
```
64
Other disorders on chart
OPA
| Obesity, Pregnancy, Ascites
65
Pulmonary Edema Pathophysiology
Vigorous inspiratory efforts against an obstructed upper
airway ➔ post-extubation laryngospasm, epiglottitis,
tumors, obesity, hiccups, or obstructive sleep apnea in
spontaneously breathing patients ➔causes ↑ negative intrapleuralpressure ➔NEGATIVE PRESSURE PULMONARY EDEMA
66
Pulmonary edema Onset:
minutes to 3 hours
67
Signs/Symptoms of Pulmonary Edema
* Tachypnea
* Cough
* Failure to maintain oxygen saturation above 95% despite high FiO2
68
Treatment of Pulmonary Edema (MAO
• Maintenance of a patent upper airway
• Administration of supplemental oxygen
• Occasionally brief Mechanical
ventilation
69
Acute Intrinsic Restrictive Lung Disease
| ARDD results in LAP
• Aspiration
• Aspirated acidic gastric fluid
• Rapidly distributed throughout the lung
• Destruction of surfactant-producing cells
• Damages pulmonary capillary endothelium
Results in:
• Leakage of intravascular fluid into the lungs
• Atelectasis
• Producing capillary permeability pulmonary edema
70
Clinical picture of Acute Intrinsic Restrictive Lung
Disease is similar to that of ARDS
• Arterial hypoxemia
• May include tachypnea, bronchospasm, and acute pulmonary hypertension
71
Intraoperative aspiration and pulmonary Edema
Atelectasis➔ Leakage of intravascular fluid into the lungs➔ Producing increased capillary permeability
➔ pulmonary edema
72
Aspiration = is the
active (vomiting) or passive (regurgitation) passage of
| material from the stomach, esophagus, pharynx, mouth, or nose to the trachea
73
Aspiration AVERAGE HOSPITAL STAY IS
21 DAYS c/ ICU
74
Aspiration Complications:
bronchospasm, pneumonia to ARDS, lung abscess and
| empyema.
75
Aspiration Mortality is
5%
76
Causes of Aspiration
• Food or any foreign body
• Fluids (blood, saliva, GI contents = pH <2.5
and content >25 mls)
77
Instraoperative Aspiration Acidic Aspirates →
| AIH
alveolar-capillary breakdown
→ interstitial edema, intra-alveolar hemorrhage, increased airway resistance
→ hypoxia.
78
Instraoperative Aspiration Acidic Aspirates Non acidic fluid
→ destroys surfactant → alveolar collapse and atelectasis → hypoxia.
79
Instraoperative Aspiration Acidic Aspirates Particulate/food matter → (PAH)
physical obstruction & later inflammatoryresponse
| → alternating areas of atelectasis and hyper-expansion → hypoxia, hypercapnia.
80
S/sx of Intraoperative Aspiration and %
* Fever (90%)
* Tachypnea
* Rales in 70% of cases
* Cough, cyanosis & wheezing (30-40%)
81
INTRAOPERATIVE ASPIRATION Anesthetic considerations Prevention.Preoperative
Recognize risks in preop. (Coexisting, fasting times, preop meds
82
INTRAOPERATIVE ASPIRATION
| Anesthetic considerations DOLP
* Delay elective surgery
* Optimize cardiorespiratory function
* Large pleural effusions need to be drained
* Persistent hypoxemia may require mechanical ventilation and PEEP
83
INTRAOPERATIVE ASPIRATION
| Anesthetic considerations- INDUCTION
RSI. However, ETT does not guarantee that no aspiration will occur.
84
INTRAOPERATIVE ASPIRATION
| Anesthetic considerations- POST OP AFTER THE FACT
Supportive care
• Bronch/Suction asap.
• FiO2 x 100%
• PEEP/CPAP
85
INTRAOPERATIVE ASPIRATION: Maintenance
| Anesthetic considerations: VT use and Why?
Use low Vt (6 mL/kg), compensatory increase in ventilatory rate (14 to 18 breaths per minute) while attempting to keep the end-inspiratory plateau pressure at less than 30 cm H2O ➔ avoid BAROTRAUMA.
86
Intraoperative aspiration fluids and pulmonary
Monitor fluid and CV status
87
2 unhelpful interventions for Intraoperative aspiration
* Antibiotics and corticosteroids still controversial
| * Lavage trachea c/ sodium bicarbonate = not shown to be helpful.
88
Pulmonary lavage is done for
obstruction (not c/ aspiration).
89
INTRAOPERATIVE ASPIRATION:Rigid Bronchoscopy =
only when removing solid particles
90
COPD- Ventilator --> VENTILATION
* Controlled mechanical ventilation is useful for optimizing oxygenation
* Slow respiratory rates (6 to 10 breaths per minute) provide sufficient time for complete exhalation
91
COPD and Positive pressure ventilation (adverse effect)
Insufficient expiratory time ➔ air trapping or dynamic
| hyperinflation ➔ barotrauma
92
COPD and Tidal volumes
Tidal volumes of 6 to 8 mL/kg combined c/ slow inspiratory flow rates minimize turbulent airflow and help maintain optimal ventilation/perfusion matching
93
Ventilation strategies for Asthma (SSH)
* Slow inspiratory flow rate (at least 2 seconds)
* Sufficient exhalation time. (I:E)
* Humidification/warming of inspired gases
94
Mitral Stenosis Heart Sound
Opening snap at early diastole
95
Mitral Stenosis Auscultate At
Apex in left axilla
96
Cause of mitral stenosis
| Most common cause is
Rheumatic Heart Disease (most common)
| • Stress (tachycardia [fever & sepsis])
97
Mitral stenosis as a result leads to
➔decrease Stroke Volume, leads to Pulmonary Edema d/t high left atrial pressure
98
Mitral Stenosis complication leads to those symptoms
| DOPR
➔ dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea➔ Right sided heart failure
99
PREOPERATIVE CONSIDERATIONS for Mitral stenosis
| The normal mitral valve orifice area is
4 to 6 cm2
100
ECG changes seen with Mitral stenosis
```
Broad and notched P waves (LA enlargement)
Atrial Fibrillation (30% of patients) = thromboembolism
```
101
ECG changes seen with Mitral stenosis
Broad and notched P waves (LA enlargement)
| P-mitrale
102
Mitral stenosis arrhytmia associated with is and treatment
| BCDW , range
```
Atrial Fibrillation (30% of patients) = thromboembolism
Beta Blockers, or Calcium Channel Blockers • Digoxin, Warfarin is administered to a target INR of 2.5-3.0
```
103
Mitral stenosis Cardiac Catheterization:
| Transvalvular gradient and treatment
Transvalvular pressure Gradient is > 10 mmHg (normal < 5 mmHg) ➔increased left atrial pressures
• Diuretics
104
```
INTRAOPERATIVE CONSIDERATIONS
***goals: MITRAL STENOSIS avoid
Avoid 4 (AHHHH_
```
1. Avoid A-fib with RVR and/or tachycardia (reduces cardiac output)
2. Avoid hypotension (drug induced decreases in SVR)
3. Avoid head-down position (increase in central blood volume)
4. Avoid hypoxemia & hypercarbia (exacerbates pulmonary hypertension)
105
INTRAOPERATIVE CONSIDERATIONS
***goals: MITRAL STENOSIS avoid
Avoid 4 (AHHHH)
4Hs A
1. Avoid A-fib with RVR and/or tachycardia (reduces cardiac output)
2. Avoid hypotension (drug induced decreases in SVR)
3. Avoid head-down position (increase in central blood volume)
4. Avoid hypoxemia & hypercarbia (exacerbates pulmonary hypertension)
106
Mitral Stenosis INTRAOPERATIVE CONSIDERATIONS
| Regional Anesthesia: acceptable? which one is better?
is acceptable (Epidural > Spinal).
107
DO NOT use this induction agent for Mitral stenosis and why.
No Ketamine (tachycardia)
108
Ketamine do not use in this valvular disorder
Mitral stenosis
109
DO NOT use this volatile agent for Mitral stenosis and why.
Nitrous Oxide ➔ pulmonary hypertension
110
Mitral Stenosis : What kind of anesthesia (light or deep and why
DEEP BETTER because Light anesthesia ➔ tachycardia & HTN (pulmonary and systemic)
111
Mitral stenosis and fluid management how and why?
Slowly titrate IV fluids (fluid overload [left atrial enlargement]) ➔ pulmonary edema.
112
Mitral stenosis and hemodynamic monitoring
Invasive monitoring: A line, PAP (manipulation = rupture)
113
Mitral stenosis and paralytics
Reverse paralytics slowly
114
Mitral Stenosis POSTOPERATIVE CONSIDERATIONS
1. Avoid pain and hypoventilation (respiratory acidosis and hypoxemia) ➔ increasing HR and PVR
2. Decreased pulmonary compliance and increased
work of breathing ➔ mechanical ventilation (major
thoracic or abdominal surgery)
115
Mitral Regurgitation Heart sounds (murmur)
Pan-systolic murmur
116
Apex; radiates to the axilla
Mitral regurgitation
117
Apex; radiates to the LEFT axilla
Mitral stenosis
118
Mitral Regurgitation Causes: (RIMP)
Rupture of chordae tendinae)
Ischemic Heart Disease
Mitral annular dilation
Papillary muscle dysfunction
119
Mitral Regurgitation can cause ________
| which can be compensated or decompensated
➔Can cause decreased LV SV and CO
120
Mitral Regurgitation can cause Can cause decreased LV SV and CO : Compensated
➔Compensated: LVH & increased compliance of LA
121
Mitral Regurgitation can cause Can cause decreased LV SV and CO : DECompensated
Increased LA volume ➔ pulmonary edema AND cardiogenic shock
122
MITRAL REGURGITATION PREOPERATIVE
| CONSIDERATIONS : what is severe MR
Regurgitant fraction > 0.5
123
Auscultation: Holosystolic Apical Murmur (radiation to the axilla)
Mitral Regurgitation
124
PAOP mitral Regurgitation
Prominent V wave
125
Mitral Regurgitation Symptomatic patients:
Ace Inhibitors or Beta- Blockers (Carvedilol) & Biventricular Pacing ➔ improvement.
126
Tall v wave associated with
Mitral regurgitation
127
Mitral regurgitation and pulmonary circuit
Increase pressure in the pulmonary circuit and produce pulmonary congestion
128
Pansystolic murmur
Mitral Regurgitation
129
Mitral REGURGITATION OVERALL ANESTHESIA CONSIDERATIONS GOALS:
3 things to PREVENT (BIM)
Prevent
Bradycardia
Increases in SVR
Myocardial depression
130
Mitral Regurgitation and Volatile anesthetics good or bad? why?
Good,
Decrease in SVR
Increases heart rate
Minimal negative inotropic effects).
131
Mitral Regurgitation: Vent Settings
Sufficient expiratory time (adequate venous return).
132
Types of Anesthesia for Mitral Regurgitation and why?
```
Neuraxial Anesthesia (decrease SVR).
Invasive monitoring
```
133
For MS vs MR LV preload
Both Keep normal to increase
134
For MS vs MR : Heart rate
MS keep low
| MR keep High
135
For both MS and MR things to maintain (RCA)
Rhythm: NS
Contractility
Avoid increase in PVR
136
For mitral stenosis how should you keep SVR?
Normal
137
For mitral regurgitation how should you keep SVR?
Decreased
138
MVP as a valvular disease
• S/sx: anxiety, orthostatic symptoms,
palpitations, dyspnea, fatigue, and atypical
chest pain.
• Most common form of valvular heart disease (1%-2% of US).
139
MVP severity CIS DD
```
Benign but➔
CVA
infective endocarditis,
severe MR,
dysrhythmias (Beta blocker therapy), and death.
```
140
MVP: OVERALL ANESTHESIA CONSIDERATIONS
| Murmur (MSC LSM)
Auscultation: mid systolic click and a late systolic
| murmur
141
MVP Same anesthesia management as MR
| No BHM
```
No brady, HTN, and myocardial depression) & FAST
FORWARD FLOW (FFF)
```
142
MVP anesthesia : avoid what?
Regional Anesthesia (avoid decrease in SVR; give fluids).
143
What are the causes of Aortic Stenosis
| ABRI
1. Aging
2. Bicuspid aorticvalve (30 to 50 yo)
3. RHD
4. Infective endocarditis
144
Infective Endocarditis Causes
(Frequent Exposure to Bacteremia) DGG
1. Dental
2. GI
3. Genitourinary Tract procedures
145
Prophylaxis for Infective Endocarditis
* Maintenance of good oral health & oral hygiene (chewing, brushing, flossing, use of toothpicks, etc.) is better than prophylactic antibiotics.
146
Major changes in the updated AHA guidelines for infective endocarditis prophylaxis are these:
(1) Antibiotic prophylaxis for infective endocarditis is recommended
only under a very few conditions
147
For Infective ENDOCARDITIS (4) Antibiotic prophylaxis is NOT RECOMMENDED
genitourinary or gastrointestinal tract procedures
148
For INFECTIVE ENDOCARDITIS (3) Antibiotic prophylaxis is recommended for (Skin)
```
invasive procedures (those that involve
incision or biopsy of the respiratory tract or
infected skin, skin structures, or musculoskeletal tissue)
```
149
2) Antibiotic prophylaxis is recommended for dental procedures that involve
manipulation of gingival tissues or the
manifpulation of the periapical regions of the teeth,
or perforation of the oral mucosa
150
PREOPERATIVE ASSESSMENT
1. Normal aortic valve area is 2.5 to 3.5 cm2
151
Severe AS aortic valve area
(0.8 cm2)
152
Aortic Stenosis Cardiac Catheterization: Transvalvular
| pressure gradients
> 50 mmHg
153
Aortic Stenosis Hypertrophy type _______leading to
Concentric LVH & compression of subendocardial blood vessels ➔ (SAD) Angina Pectoris, syncope, dyspnea on exertion (CHF like).
154
Systolic murmur (radiate to neck/mimic carotid bruit).
Aortic stenosis
155
mimic carotid bruit
Aortic stenosis systolic murmur (think sad neck)
156
Majority area symptomatic.
Aortic stenosis
157
AORTIC STENOSIS
PERIOPERATIVE MANAGEMENT
Goal: Avoid (hemodynamics )
hypotension and decreasing cardiac output.
158
Rhythm to maintain for Aortic stenosis
Maintain Normal Sinus Rhythm
159
Why 2 situations do we avoid with the HR with Aortic stenosis and why?
a. Avoid Bradycardia ➔ LV overdistention
| b. Avoid Tachycardia ➔ reduced Cardiac Output (worse!
160
Aortic Stenosis SVR and why ?
Maintain or slightly ↑ SVR and Cardiac Output
| a. Optimize preload (fluids) for LV filling.
161
Aortic Stenosis when CPR is performed is it effective?
CPR is not effective.
162
Regional anesthesia is contraindicated with this valvular disorder ? and why?
Aortic Stenosis (significant hypotension)
163
Best Induction agents for Aortic stenosis
Etomidate & Benzodiazepines
164
Intraop Maintenance for aortic stenosis include
a. N20/volatile/opioids combo.
165
When a patient with Aortic Stenosis is TACHY which agent is preferred?
Phenylephrine > Ephedrine (Tachy)
166
When a patient with Aortic Stenosis has Junctional Rhythm and Bradycardia, treat with (RAE)
Robinul, Atropine, or Ephedrine
167
Patients with Aortic Stenosis with Persistent Tachycardia
Beta Blockers: Esmolol
168
Monitoring Modalities for Aortic Stenosis include :
A line, CVP, PAC, or TEE (dependent on severity of AS &
| type of surgery).
169
AORTIC REGURGITATION
| Causes: (ABRID)
```
Aortic Dissection (Immediate Surgery)
Bicuspid Aortic Valve
RHD
Infective endocarditis
Drug-Induced (Phen-Fen)
```
170
Leaflets and Aortic Regurgitation (A- DAH)
There is Aortic Leaflet Coaptation Failure leading to
➔Decreased Cardiac Output
➔Acute Volume Overload (LVH)
➔Heart Failure
171
AORTIC REGURGITATION PREOPERATIVE CONSIDERATIONS Pathophysiology
1. Angina Pectoris (reduced coronary blood flow➔ coronary ischemia
2. Pulmonary Edema (LVEDV increased➔LV failure).
3. Normal EF unless LV dysfunction: dyspnea, orthopnea, fatigue
172
Aortic Regurgitation Pulse
Widened pulse pressure
decreased diastolic pressure
Bounding pulses.
173
Aortic Regurgitation Auscultation: murmur type and where?
Diastolic Murmur (Right Sternal Border)
174
Systolic murmur with crescendo, decrescendo
Aortic Stenosis
175
Aortic Stenosis is a a SCD murmur heard best at
Right upper sternal border
176
Mitral Valve Prolapse murmur
Mid-systolic click followed by late systolic murmur
177
MVP best heard at
Apex
178
Aortic Regurgitation: INTRAOPERATIVE ANESTHETIC CONSIDERATIONS: Main 3 Goals
1. Decreasing systolic HTN and LV wall stress
2. Improving LV function (also LV failure)
3. Maintain forward LV SV (FFF): Avoid Bradycardia, Increased SVR, and Decreasing myocardial depression.
179
Aortic Regurgitation, Decreasing systolic HTN and LV wall stress how
a. Long term therapy (with good EF):
i. Nifedipine
ii. Hydralazine
180
Aortic Regurgitation: LV function (also LV failure)
| how?
a. IV infusion:
i. Dobutamine (inotropic drug)
ii. Nitroprusside (vasodilation)
181
Maintain forward LV SV (FFF): Avoid bradycardia, increased SVR, and decreasing myocardial depression What GETA? and why?
```
a. Iso/Sevo/Des:
Increases HR (HR > 80 bpm), decreases SVR, with minimal myocardial depression.
```
182
Aortic Regurgitation: Bradycardia or Junctional Rhythm, Give
IV Atropine
183
May not need invasive monitoring.
Aortic Regurgitation
184
Aortic Regurgitation High opioid anesthesia
severe LV dysfunction
185
Parameters check : AS vs AR → LV Preload
For Aortic stenosis maintain LV preload ↑
| For Aortic Regurgitation maintain LV preload NORMAL to ↑
186
Parameters check : AS vs AR → HR
For Aortic Stenosis maintain HR → normal to slow ↓
| For Aortic Regurgitation maintain HR → Modest ↑
187
Parameters check : For BOTH AS and AR
| Maintain those 3(CNP) c no problem
Maintain
| Contractility, NSR, PVR
188
Parameters check : AS vs AR → SVR
For Aortic Stenosis maintain SVR modest ↑
| For Aortic Regurgitation maintain SVR ↓
189
Keep this parameter low with Aortic Regurgitation
SVR
190
TRICUSPID STENOSIS
| How frequent and most common cause
• Rare in adults• RHD: most common cause
191
TRICUSPID STENOSIS Usually with co-existing (TRMA)
Tricuspid regurgitation and often mitral or aortic valve disease
192
Tricuspid Stenosis Pathophysiology
Increased RAP and increases the pressure gradient between the right atrium and right ventricle
193
In Tricuspid Stenosis: Right atrial dimensions
are increased, but the right ventricular dimensions are determined by the degree of volume overload from concomitant tricuspid regurgitation
194
RV dimensions in tricuspid stenosis depend onfactors
degree of volume overload from concomitant tricuspid regurgitation
195
Tricuspid stenosis Heart sound
Pre-systolic murmur
196
Best place to listen for tricuspid stenosis
Left sternal edge at 4th ICS
197
Pre-systolic murmur
Tricuspid stenosis
198
TRICUSPID REGURGITATION Causes (functional)
Functional: RV enlargement or pulmonary HTN
199
TRICUSPID REGURGITATION DISEASES Causes
| CIA RET
```
Carcinoid syndromea
Infective endocarditis (IV drug use)
AV or MV disease.
RHD
Ebstein’s anomaly
TV prolapse
```
200
Disease causing TR lead to
RA volume OVERLOAD
201
Tricuspid Regurgitation Signs and symptoms (JHAP)
1. Jugular venous distention
2. Hepatomegaly
3. Ascites
4. Peripheral Edema
202
TRICUSPID REGURGITATION PERIOPERATIVE ANESTHESIA CONSIDERATIONS
Goals: FLUIDS
Maintenance of IV fluid volume & CVP in high normal range (facilitate adequate RV preload & LV filling).
203
Avoid in Tricuspid Regurgitation Maintenance of IV fluid volume & CVP in high normal range (facilitate adequate RV preload & LV filling). by
* Avoid PPV and vasodilating drugs (reduces venous return)
| * Avoid hypoxemia and hypercarbia ➔ increased PAP
204
Tricuspid Regurgitation: venous return and vasodilation
Produce pulmonary vasodilation & maintain venous return
Avoid Nitrous Oxide
Avoid air in IV fluids (systemic air embolism)
205
Pulmonic stenosis is usually
congenital and detected and corrected in childhood
206
Pulmonic stenosis : An acquired form can be due to (PRIC)
Previous surgery or other interventions
Rheumatic fever
Infective endocarditis,
Carcinoid syndrome, or
207
Pulmonic stenosis : Significant obstruction can cause
syncope,angina, right ventricular hypertrophy, and
| right ventricular failure
208
PULMONIC VALVE REGURGITATION
| • Pulmonic valve regurgitation results from
pulmonary hypertension with annular dilatation of the pulmonic valve
209
Pulmonic valve regurgitation causes include
connective tissue diseases, carcinoid syndrome, infective endocarditis, and rheumatic heart disease
210
Pulmonary regurgitation is
rarely symptomatic
211
Pulmonic Valve Regurgitation Heart sounds (DDM)
Decrescendo diastolic murmur
212
Pulmonic Valve Regurgitation Heart sounds BEST HEARD
Left upper sternal border
213
Pulmonic Stenosis Heart sounds (CDEM)
Crescendo-decrescendo ejection murmur
214
2 murmurs HEART beast at Left upper sternal border
Tricuspid Regurgitation
| Pulmonic stenosis
215
```
Aortic Stenosis (SU)
Aortic Regurgitation (RS)
```
Right upper sternal border
| Right sternal border
216
Strove volume loss
Acute Aortic Regurgitation
217
Post CABG compllications
| CAM CVM
Cardiac Dysrhythmias: Vfib, afib a flutter, sinus block
Acute Pericarditis
Mitral Regurgitation (from inferior wall MI or complete rupture of a papillary muscle
Ventricular septal rupture (holosystolic murmur)
Cardiogenic shock
Myocardial rupture
218
What is the role of IV nitroprusside and/or intraaortic balloon pump?
Decrease LV afterload
| Increase Forward flow
219
Ischemic Heart disease Heart anesthetic management Goals
Prevent ischemia
Monitor for myocardial injury
Treat myocardial ischemia or infaction
220
Ischemic heart disease shivering on awakening
Abrupt and dramatic increases in myocardial oxygen requirements up to 500% increase
221
Sub-endocardial ischemia → Lead will show
ST segment depression
| T-wave inversion
222
Coronary Vasospasm ➔Variant angina/Prinzmetal Angina
ST segment elevation
223
Leads = simplest, most effective (80%)
• II & V5
224
Post op CABG those things can lead to increase Myocardial oxygen demand
Pain, hypoxemia, hypercarbia, sepsis, hypovolemia, hypotension, and hemorrhage
225
Six independent predictors of major cardiac complications[1] TIHCMS
- High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures)
- History of ischemic heart disease (history of myocardial infarction or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)
- History of heart failure
- History of cerebrovascular disease
- Diabetes mellitus requiring treatment with insulin
- Preoperative serum creatinine >2.0 mg/dL (177 micromol/L)
226
Six independent predictors of major cardiac complications DO NOT DO THIS
do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)
227
Lead abnormalities in ACS
ST segment elevation, depression or inverted T wave
228
Lead II, III, AVF
| Artery responsible
RCA
229
Lead II, III, AVF
| Area of myocardium that may be involved (RSIA)
RA, RV
SA node
Inferior aspect of LV
AV node
230
I,avL artery
Circumflex coronary artery
231
I,avL Area of myocardium that may be involved
Lateral aspect of LV
232
V3 , V5 Artery
LAD coronary artery
233
V3, V5 Area of myocardium that may be involved
Anterolateral aspect of LV
234
Most sensitive for coronary ischemia
TEE
235
TEE picks up on
New regional Ventricular wall abnormalities
236
Elective surgery after cardiac revascularization: Recommendation w/ DUAL antiplatelet therapy
1 PCI without STENTING
> 2 weeks
237
Elective surgery after cardiac revascularization: Recommendation w/ DUAL antiplatelet therapy
Bare Metal stent
>30 days (ideal 12 weeks)
238
Elective surgery after cardiac revascularization: Recommendation w/ DUAL antiplatelet therapy Drug-Eluting Stent
> 1 year
239
Procedure and TIME TO WAIT for ELECTIVE SURGERY :
| Angioplasy without stenting
2-4 weeks
240
Procedure and TIME TO WAIT for ELECTIVE SURGERY :Bare metal stent placement
AT least 30 days; 12 weeks preferable
241
Procedure and TIME TO WAIT for ELECTIVE SURGERY :CABG
At least 6 weeks; 12 weeks preferable
242
Procedure and TIME TO WAIT for ELECTIVE SURGERY: Drug ELUTING STENT Placement
At least 12 months
243
Evaluation and management of high cardiac risk
Recent MI < 60 days or unstable angina
Recent PCI (risk for death, MI, stent thrombosis, need for REPEAT REVASCULARIZATION
Urgent emergency surgery (EVEN if on antiplatelet therapy)
High cardiac risk surgical procedures
244
The goals of management of a patient c/ IHD includes:
1. Determining extent of IHD and any previous interventions
2. Assessing severity and stability of disease
3. Reviewing medical therapy and identifying any drugs that can increase the risk of surgical bleeding or
contraindicate a particular anesthetic technique
245
The goals of management of a patient c/ IHD includes →The need of emergency surgery
takes precedence over the need for additional workup
246
MAJOR clinical risk factors require intensive preoperative management (DUSS)
Decompensated heart failure
Unstable coronary syndrome
Significant dysrhythmias
Severe valvular heart disease
247
MINOR clinical risk factors do not independently increase cardiac risk and do not need a work up(4 HLNH)
Hypertension
Left bundle branch block
Nonspecific ST-T wave changes
History of stroke
248
Minor clinical risk factors do not
independently increase cardiac risk and do not need a work up
249
Ischemic Heart disease anesthetic management medication
Maintain adequate IV volume, Hgb concentration, heart rate, and BP (Labetalol is ok).
250
Mechanism of perioperative ACS = ischemia (rather than acute coronary or stent thrombosis) • Optimize
O2 delivery, minimize demand
251
Mechanism of perioperative ACS = ischemia (rather than acute coronary or stent thrombosis)• Hemodynamic goals:
* Low/normal HR (50-80bpm)
* Normal/high normal BP: 20% baseline, MAP 75-95 mmHg, diastolic 65-85 mm Hg
* Severe HTN increases myocardial O2 supply
252
Mechanism of perioperative ACS• Intraop HoTN defined:
SBP < 90 mmHg for > 10 min
253
Mechanism of perioperative ACS
| LVEDV level and why?
* Normal LVEDV
| * Distention = fluid overload = increase wall stress and O2 demand
254
Mechanism of perioperative ACS Arterial O2 content HGb threshold and temperature
Adequate arterial O2 content and Hgb (threshold < 9 g/dL c/recent MI or UA, otherwise < 8 g/dL)
• Normothermia = favors tissue release of O2
255
Preop med management Ischemia HD
| • Beta blockers
Maintain
• Do NOT withdraw current therapy
• Do NOT initiate new therapy
256
Preop med management Ischemia HD• Statins
Maintain
257
Preop med management Ischemia HD• Aspirin
Depends on surgery and if receiving dual antiplatelet therapy
258
Preop med management Ischemia HD• ACEI/ARB
Continued with heart failure
| • Always held with hemodynamic instability, hypovolemia, acute creatinine elevation
259
Preop med management Ischemia HD• Clonidine
• Continued if chronically administered (rebound HTN)
260
Preop med management Ischemia HD• Continue other CV meds
• CCB, digoxin, diuretics
261
Revascularization (CABG/PCI) is indicated when
optimal medical therapy fails to control Angina
Pectoris (AP) or
• Left main stenosis > 50%
• 70% or greater stenosis in a coronary artery
• CAD with EF < 40%
262
ABG is preferred over PCI in patients with
| STP
- significant left main artery disease,
- those c/ three-vessel coronary artery obstruction, and - - patients c/ diabetes who have two- or three-vessel coronary artery disease
263
ACS PATHOPHYSIOLOGY
Focal disruption of atheromatous (atherosclerotic) plaques ➔plaque rupture➔coagulation cascade is triggered➔ thrombus➔ occluded coronary artery
➔ ACS.
264
ACS characteristics
1. Angina at rest (>20 mins)
2. Chronic Angina Pectoris
3. New Onset Angina
265
NSAID lasts
(lasts platelet’s lifespan [7 days]).
| • Aspirin 81 mgs vs. 325 mgs
266
Angina Pectoris, Thienopyridines (CPT)
(lasts platelet’s lifespan) •
Clopidogrel (Plavix) •
Prasugrel (Effient)
• Ticlopidine (Ticlid)
267
Platelet Glycoprotein IIb/IIIa Inhibitors (TEA)
• Tirofiban • Eptifibatide• Abciximab
268
ANGINA PECTORIS
Metabolic O2 demand > supply• Myocardial O2
consumption > coronary blood flow➔ Angina Pectoris
➔ CHF, Cardiac Dysrhythmias, & Myocardial Infarction
269
Angina Pectoris: Stress Test
| • Negative stress test does not
exclude CAD.
270
Angina Pectoris: Exercise (Treadmill)
• 1 mm of horizontal or downsloping ST-segment depression during or c/in 4 minutes of exercise.
271
Angina Pectoris: Stress test. Nuclear (Adenosine)
• Assesses coronary perfusion & measures LVEF
272
Angina Pectoris: Chemical stress test, meds and what they assess
(Atropine or Dobutamine)
| • Assesses new ventricular wall motion abnormalities, valvular function, and EF.
273
Angina Pectoris: Gold Standard
Coronary Angiography
274
Angina Pectoris: Coronary angiography
| Significance of left main CAD
• Greater than 50% stenosis of the left main coronary artery is associated c/ a mortality rate of 15% per year•
275
Angina Pectoris: Coronary angiography →The most dangerous CAD (widow maker)
Left main coronary artery disease is the most dangerous anatomic lesion (widow maker).
276
Angina Pectoris Preop Optimization
| Lifestyle modification
Optimization prior to surgery is key, via:(e.g., smoking cessation & regular aerobic exercise)
277
Angina Pectoris Preop Optimization ↓ of risk factors
(e.g., diet, weight reduction)
278
Angina Pectoris Preop Optimization Pharmacologic management
(e.g., anti HTN, anti cholesterol, ASA)
279
Angina Pectoris Preop Optimization Identification and treatment of
diseases that can precipitate or worsen the ischemia.
280
Angina Pectoris Preop Optimization Revascularization procedure
(e.g., CABG, Percutaneous Coronary Intervention [PCI], with or without intracoronary stents).
281
Common causes of acute chest pain cardiac (RAPA)
Angina
Rest or unstable angina
Acute MI
Pericarditis
282
Common causes of acute chest pain Vascular (APA)
Aortic dissection
PE
Pulmonary HTN
283
Common causes of acute chest pain: Pulmonary (PTS)
Pleuritis/PNA
Tracheobronchitis
Spontaneous Pneumo
284
Common causes of acute chest pain:GI
Peptic ulcer
Pancreatitis
Esophageal reflux
Gallbladder disease
285
Common causes of acute chest pain: Musculoskeletal
Costochondritis
Cervical disk disease
Trauma or strain
286
Common causes of acute chest pain: Infectious/psych
Herpes zoster
| Panic disorder
287
Thrombolytic Therapy (e.g, tPA):
a. start 30-60 mins of hospital arrival, and
| b within 12 hours of symptom onset.
288
Aka Percutaneous Coronary Angioplasty (PTCA)
| • Treatment of choice for _____ and must be done
severe heart failure and/or
pulmonary edema (when tPA is contraindicated)
• Must be done 90 minutes of arrival and c/in 12 hours
of symptom onset
289
Functional capacity or exercise tolerance can be
| expressed in metabolic equivalent of the task
MET) units• O2consumption (O2) of a 70-kg, 40-year-old
| man in a resting state is 3.5 mL/kg/min = 1 MET
290
Perioperative cardiac risk is increased when a
| patient is unable to meet a
4-MET demand during normal daily activities
• Bicycling lightly, walking 3mph, calisthenics, sexual
activity, golfing
291
• Surgery-specific risk of non-cardiac procedures are
| graded as High (EAPP)
Emergency major surgery,
Aortic and other major vascular surgery
Peripheral vascular surgery, and prolonged surgery c/ large fluid shifts and/or blood loss)
292
Surgery-specific risk of non-cardiac procedures are
| graded as Medium (CHEPOI)
```
Carotid endarterectomy
Head and neck surgery
Endovascular aortic surgery
Prostate surgery)
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
```
293
Surgery-specific risk of non-cardiac procedures are
| graded as LOW
Endoscopic surgery
Superficial surgery,
Cataract surgery, Breast surgery, and Ambulatory
surgery)
294
Under-secreting thyroid tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)
High (b/c few hypothalamus receptors are bound)
High
Low
295
Over-secreting thyroid tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)
Low
Low
High
296
If problem is TSH, we don’t bother injecting TSH, we just give hormone that is lacking:
Thyroid hormone.
297
Under-secreting pituitary tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)
High
Low
Low
298
Over-secreting pituitary tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)
Low
High
High
299
Under-secreting hypothalamic tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)
Low
low
low
300
Over-secreting hypothalamic tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)
High
High
High
301
Cortisol Under-secreting adrenal gland tumor
ACTH-RH
ACTH
Cortisol
High
High
Low
302
Cortisol Over-secreting adrenal tumor
ACTH-RH
ACTH
Cortisol
Low
Low
High
303
ACTH Under-secreting pituitary tumor
ACTH-RH
ACTH
Cortisol
High
Low
Low
304
ACTH Over-secreting pituitary tumor
ACTH-RH
ACTH
Cortisol
Low
High
High
305
Under-secreting hypothalamic tumor
ACTH-RH
ACTH
Cortisol
Low
Low
Low
306
Over-secreting hypothalamic tumor
ACTH-RH
ACTH
Cortisol
High
High
High
307
So when ACTH is elevated, and body cannot make enough cortisol what happens
aldosterone will ↑, and testosterone will be made in females instead, and estrogens will be made in males. High blood glucose and high blood pressure, and
females develop facial hair while males develop
breasts.
308
ACTH Over-secreting pituitary tumor CUSHING
Low
High
High
309
ACTH Over-secreting adrenal tumor CUSHING
Low
Low
High
310
Cortisol Under-secreting adrenal gland tumor
High
High
Low
311
PRIMARY ADRENAL INSUFFICIENCY
(adrenal gland is problem)
312
SECONDARY ADRENAL INSUFFICIENCY
(pituitary is problem)
313
Secondary Adrenal Insufficiency Pituitary ACTH levels are____cortisol is _____ and hypothalamus ACTH-RH is
low, low,high.
314
Difference between primary and secondary
| adrenal insufficiency is
ACTH level
315
Primary Adrenal Insufficiency Pituitary ACTH levels are____cortisol is _____ and hypothalamus ACTH-RH is
High, low, High
316
Cushing’s Syndrome
(1° adrenal hyperplasia) Adrenal gland is problem
317
Thyroid hormone is
permissive for growth hormone (you need thyroid hormone in order for GH to work).
318
Not enough thyroid hormone →
stunted growth, even if enough growth hormone is
| present.
319
Hormonal Trigger
◦ Endocrine gland releases a hormone that stimulates another endocrine gland to release its hormone.
320
◦ Hypothalamus releases a hormone that causes pituitary gland to
release TSH, which causes thyroid gland to release thyroid hormone.
321
Thyroglobin T4 is
| ◦ T3 gets used first by body cells.
most abundant form, but it is inert (inactive).
322
T3 has
robust activity in cell.
323
◦ T4 takes longer
to be ready; one iodine has to drop off.
324
As T3 is used up, T4 is being converted by
iodinase to more T3.
325
To make thyroid hormone, you need
iodine in your body. Iodized salt has enough to meet this need.
326
Iodine is brought into
follicular cells, gene expression occurs, thyroglobulin is made.
Without enough iodine in diet, thyroid hormone cannot be made, no matter how much TSH is present.
327
Thyroid Gland role in synthesis
Building block of TH = chemically attaching Ito tyrosine.
| In plasma, TH needs a “carrier molecule” or it will be cleared from body
328
Diabetes insipidus main issue
◦ Not enough ADH (anti-diuretic hormone; a diuretic takes out excess fluid from body)
◦ Because they lack ADH, person urinates frequently (polyuria), so they are thirsty and drink a lot of water (polydipsia). Their blood glucose is normal.
329
Synthetic form of ADH is
vasopressin
330
• Hypersecretion of GH in children
◦ Gigantism (overall growth)
331
• Hypersecretion of GH in adults
◦ Acromegaly: enlarged hands and feet, and big chin, nose, and forehead
332
Hyposecretion of GH
◦ Pituitary dwarfism
| ◦ Proportions are normal, overall size is small
333
GH needs thyroid hormone (TH) to be present.
| GH stimulates all cells to
↑ protein synthesis,
| fat utilization, and gluconeogenesis.
334
Gigantism vs acromegaly
result of excess GH during pre-puberty and acromegaly is result of excess GH after growth plates closed.
335
Acromegaly Anesthesia Considerations
```
Distorted face = hard to mask ventilate
Enlarged tongue/epiglottis
Overgrowth of mandible
Edematous vocal cords = smaller glottic
opening
◦ Assess for hoarseness/stridor
Skeletal changes associated with acromegaly
may make use of regional anesthesia
technically difficult or unreliable
```
336
Syndrome of Inappropriate Antidiuretic Hormone
| Secretion (SIADH)
Too much ADH → hyponatremia from dilution
◦ Water reabsorbed by renal tubules
◦ Ectopic = small cell lung carcinoma, carcinoid tumors
337
SIADH Can result from
CNS trauma, infections, medications, hypothyroidism, major surgery
338
S/S of SIADH
N/V, weakness, lethargy, confusion, depressed mental status, seizures
339
SIADH diagnosis (RHIN)
Reduced serum osmolality (<270 mOsm/L
Hyponatremia (<130 mEq/L),
Inappropriately increased urine osmolality (hypertonic relative to plasma).
Normal or increased urine Na excretion (>20 mEq/L), and
340
SIADH Fluid restriction
(< 1L/day)
341
Democlocydine action
Demeclocycline inhibits action of ADH @ distal tubule
342
Conivaptan is a ______used in the treatment of
vasopressin-2 receptor antagonist, may be effective; SIADH
343
SIADH Severe hyponatremia
(<115 mEq/L) may require 3% hypertonic saline
344
NA Rate of correction should be
0.5mEq/L/h until Na+ 125 mEq/L Then proceed more slowly to prevent central
pontine myelinolysis
345
SIADH Anesthesia management:
◦ Careful monitoring and administration of fluids and
electrolytes
◦ Can have delayed awakening from anesthesia
◦ Can wake up confused after anesthesia
346
Flluid resuscitation of SIADH
◦ Fluid resuscitation should be done with 0.9%NS
347
Thyroid hormones All cells respond to thyroid hormone,
| increasing their
metabolic rate (heart speeds up, beats c/ greater force, more nutrients are used, etc).
348
Too much thyroid hormone is hyperthyroidism; these ppl are
people are thin and active.
349
When levels of TH are too low, it is called
| hypothyroidism; these people are
overweight, move slowly, have no energy.
350
When there is too much TH, they get
muscles tremors and ↑ blood glucose levels (hyperglycemia).
351
W/ not enough TH, they lose interest, become
sluggish, they get low blood glucose levels
| hypoglycemia
352
Major stimulus for release of thyroid
| hormone is
hormonal (TSH from pituitary tells thyroid gland that it needs to make more thyroid hormone).
353
What happens when TSH is released?
Every step in process of making TH is ↑: Follicular
cells become larger, metabolism ↑: ↑ in O2 use (especially in mitochondria), heat is generated.
TSH causes stimulation of sympathetic (beta)
receptors in heart, causing ↑ force of contraction and ↑ heart rate
354
Since thyroid hormone is partly made of
| iodine, if a person doesn’t eat enough iodine,can't make thyroid hormone. how does hypothalamus response
can’t make thyroid hormone.
Hypothalamus responds by putting out more
TSH-RH.
Pituitary will respond by releasing TSH. But thyroid can’t respond by releasing TH if it does not have iodine to make hormone, so it size of follicle grows → gland grows → GOITER.
355
Hyperthyroidism Anesthesia Management for elective cases
Euvolemia for elective cases
356
Dexamethasone action
2mg IV q6h ↓hormone release and T4→T3 conversion
357
Hyperthyroidism Anesthesia Management
Consider airway difficulties
Will need more anesthesia to control SNS response
Protect eyes
358
Hyperthyrodisim Medications to
Avoid things that stimulate SNS (ketamine, pancuronium, atropine, ephedrine, epinephrine)
359
Vasopressors to use with hyperthyroidism
Use direct acting vasopressors
| ◦ Indirect can result in an exaggerated response
360
Hypothyroidism Anesthesia Management
| Airway issues:
swollen oral cavity, edematous vocal cords, goiter
361
Hypothyroidism and Aspiration
↓Gastric emptying = regurgitation/aspiration
362
Hypothyroidism and CV
Normally have↓ CO, SV, HR, baroreceptor reflex
363
↓vent response to hypoxia/hypercarbia (enhanced with
| anesthesia)
hypothyroidism
364
Hypoventilate in general, so mechanically ventilate
Hypothyroidism
365
Hypothermia common with
Hypothyrodism
366
Hematologic complications with Hypothyroidism
anemia, dysfunctional plt/coag factors (esp. factor VIII), electrolyte imbalances (hyponatremia), hypoglycemia
367
Hypothyroidism narcotics
Very sensitive to narcotics and anesthetics in general
| ◦ Can have significant hypotension
368
Hypotension with hypothyroidism
◦ BEST treated with ephedrine, dopamine, or epi NOT
phenylephrine (opposite of hyperthyroidism)
◦ If unresponsive, give steroids
369
Hypothyroidism ◦ Beta receptors may be
less numerous and less sensitive
| ◦ Use phosphodiesterase inhibitor
370
People c/ hyperthyroidism can take a drug
| called______which does what?
PTU (Propylthiouracil), which inhibits TH production by blocking peroxidase enzyme that joins iodine to tyrosine
→results in lower thyroid hormone levels.
371
HYPERTHYROIDISM
| (Most commonly caused by
Graves Disease, which is an autoimmune disease)
372
Signs include HYPERTHYROIDISM (GRAVE"S)
thinness, eyes that stick out like a bug (exophthalmoses).
| ◦ Leads to nervousness, weight loss, sweating, and rapid heart rate.
373
Hyperthyroidism
| ◦ Graves’ Disease is when
hyperthyroidism is caused by an autoimmune disorder.
374
You can have thyroid oblated (killed off) by drinking
| radioactive iodine
◦ Kills just thyroid tissue.
◦ As metabolic rate slows, gains weight again.
◦ Can’t be around people for 5 days, and they set
off Geiger counters for months afterwards.
◦ Then start on artificial thyroxin, need to figure
out what their set point is for normal.
375
Another way is to have thyroid gland surgically
| removed.
◦ Parathyroid glands are often damaged or removed
during this surgery.
◦ Often intentionally leave some thyroid tissue
behind, in hopes of leaving enough parathyroid
glands there.
◦ If too many of parathyroid glands are removed,
calcium levels go down, can go into cardiac arrest.
◦ Now patient has to have two hormones
replaced.
376
Hypothyroidism This can be caused by
Hashimoto’s thyroiditis (autoimmune)
Iodine deficiency
Tumor
Defective enzyme in thyroid.
377
– Hashimoto’s Thyroiditis - adult hypothyroidism
◦ Antibodies attack and destroy thyroid tissue
◦ Low metabolic rate and weight gain are
common symptom
378
◦ Myxedema:
non-pitting edema associated c/ hypothyroidism
379
Cretinism –
Hypothyroidism in children
Short, disproportionate body, thick tongue and
mental retardation
380
Cretinism (diminished mental ability)
This term describes babies whose MOTHER had lack of iodine.
Baby now cannot get iodine, and baby will have reduced growth and intellectual ability.
Once it is born and gets a healthy diet, it still
won’t go back to normal because TH is necessary for proper myelination and synaptic formation.
381
Congenital hypothyroidism is term for a
baby
◦ Problem is only
whose thyroid gland is not working correctly (not secreting enough TH). c/ baby, not c/ mom.
382
Congenital hypothyroidism and cretin babies
| have similar symptoms.
◦ Child will stay tiny because GH does not work
| c/out TH.
383
Parathyroid hormone is released by a
Humoral mechanism.
◦ If blood calcium levels are low, parathyroid
hormone is released.
◦ If blood calcium levels are high, parathyroid
hormone stops being released.
384
Hyperparathyroidism
◦ Hypercalcemia
◦
◦ Skeletal muscle weakness, polyuria, ↓GFR, ↑PR interval,
↓ QT interval, HTN, decreased pain sensation
◦
385
NMB unpredictable
Hypercalcemia
386
Hypoparathyroidism
| ◦ Hypocalcemia
Neuronal irritability, skeletal muscle spasms, tetany, and
| possibly seizures
387
◦ Acidosis and calcium
increases serum calcium
388
Alkalosis and serum calcium.
Decreases serum calcium
389
Acute hypocalcemia can present with
stridor and apnea
390
◦ Congestive heart failure, hypotension, and decreased
| responsiveness to β-agonists may occur
Hypocalcemia
391
◦ Prolonged QT interval
Hypocalcemia
392
Cushing’s syndrome/Disease
```
◦ Hypersecretion of cortisol
◦ High blood glucose
◦ High blood pressure
◦ Features of opposite sex
◦ Round “moon” face and “buffalo hump”
```
393
Addison’s disease
◦ Hyposecretion of cortisol
◦ Low blood glucose
◦ Low blood pressure results
◦ Also get hyperpigmentation
394
In Cushing’s Syndrome, all adrenal cortical
| hormones (
cortisol, androgens, and
aldosterone) are elevated, but ACTH-RH and
ACTH levels are lo
395
Cushing’s Disease- pituitary tumor
| Cushing’s Syndrome
(excess ACTH)
396
•Ectopic Cushing ACTH producing tumor
(lungs)
397
•Iatrogenic Cushing
(side-effect of some medical treatment)
398
Cushing is a
primary hyperadrenalism
| •Over-secreting adrenal tumor-, all adrenocortical hormones elevated
399
Cushing Signs/symptoms:
buffalo hump, moon face, muscle loss/weakness, thin skin c/ striae, hyperglycemia, immune suppression
400
Cushing Perioperative management of HTN,
hyperglycemia, intravascular fluid volume (usually elevated), and electrolytes (hypokalemia is common) necessary Pneumothorax is possible during adrenal
surgery
401
Cushing Preoperative diuresis with
spironolactone is helpful
402
Cushing When bilateral adrenalectomy is performed,
fludrocortisone will be necessary in the postoperative period
403
Congenital adrenal hyperplasia (CAH) in a
female fetus causes
These babies have a _______________
some enzyme is not expressed which is
required to convert________
Boys are not affected; girls need__________
If presence of ACTH is driving pathway, and
it is blocked at this enzyme, ACTH can only
be used to make androgens
```
clitoris to enlarge and
labia majora fuse into a scrotal sac.
mutation in a gene,
cholesterol into corticosteroids, so cholesterol is shunted to pathway that is not compromised: androgen
production
a surgery
and cortisol for life, will be fine..
```
404
Leads to overstimulation of adrenal androgen pathways.
Congenital Adrenal Hyperplasia (CAH)
405
Addison's disease Also called
Primary Adrenal Insufficiency and
hypoadrenalism; low glucose, low blood
pressure, and hyperpigmentation in hands,
fingers, and gums.
406
Addison’s disease may be caused by anything
| that
disturbs production of adrenal hormones (e.g., Tuberculosis).
407
In Addison’s disease, adrenal cortex
does not respond to pituitary orders. Cortisol levels are low, but pituitary ACTH and
hypothalamus ACTH-RH hormones are high.
408
Secondary adrenal insufficiency deficiency
◦ Deficiency of ACTH
409
Primary Adrenal Insufficiency: Addison’s Disease
| ◦ Primary hypoadrenalism;
entire adrenal gland is destroyed due to atrophy or autoimmunedisorder
◦ Tuberculosis –disease attacks adrenal gland
◦ ACTH is ↑
410
Adrenal Gland deficiencies Signs/symptoms:
Water/salt imbalance,
plasma volume depletion, low blood glucose,
pigmentation, Addisonian crisis (low blood
pressure, low blood glucose, need to go to
hospital)
411
Addison’s Disease Anesthesia Considerations
Treat cause, give _______
replace _________________________
Administer glucocorticoids,
| water/Na+ deficits (can be up to 3L)
412
Addisons' electrolyte imbalance
Metabolic acidosis and hyperkalemia usually
| resolve with fluid and steroid administration
413
Addison's and Etomidate
Etomidate transiently inhibits Cortisol synthesis and should be avoided in this patient population
414
Addison and Anesthetics
Minimal doses of anesthetic agents and drugs are recommended, since myocardial
depression and skeletal muscle weakness are
frequently part of the clinical presentation.
415
Conn’s syndrome (hyperaldosteronism)
Too much aldosterone is secreted.
Too much salt and water is reabsorbed, person
develops high blood pressure.
Cortisone levels are not effected, so they do not
have elevated blood glucose.
416
High incidence of ischemic heart disease
Conn's syndrome
417
Anesthesia considerations Conn's syndrome:
Anesthesia considerations:
◦ Preoperative restoration of intravascular
volume, electrolyte levels (K+ supplementation), renal function, and control of hypertension
◦ Na+ restrictions
◦ Spironolactone
◦ Preop echo if hx chronic HTN
418
DIABETES INSIPIDUS
◦ Pituitary gland does not secrete antidiuretic hormone, or kidney does not respond to hormone.
◦ It can be caused by damage to pituitary or kidney
419
DIABETES MELLITUS
| ◦ Hereditary lack of
insulin secretion in pancreas, or resistance to insulin by body’s cells.
420
◦ Type I diabetes(insulin dependent, develops in children)
◦ Destruction of pancreatic islets by autoimmune
disorders.
◦ Need insulin injections daily throughout life.
421
◦ Type II diabetes (not insulin dependent, develops in
| adults)
◦ Consequence of obesity: cells are less sensitive to insulin.
◦ Initially treated c/ diet and exercise.
◦ Oral medicines or injected insulin may be need
422
DI Goal: plasma
osmolality is less than 290 mOsm/L◦ Isotonic fluids should be used for volume resuscitation.
423
DI Anesthesia management Preoperative dose of
| DDAVP
desmopressin intranasally or an IV bolus of 100 mU (0.1 unit) of aqueous vasopressin followed by a continuous infusion of 100–200 mU/h (0.1–0.2 units/h)
424
DI ◦ If plasma osmolality exceeds 290 mOsm/L,
hypotonic fluid should be used for resuscitation
and the vasopressin infusion should be
increased above 200 mU/h.
425
DI tx since Since vasopressin causes
vasoconstriction of arteriolar beds, close monitoring for myocardial ischemia is recommended
426
DM
needs to be worked up (silent)________
◦ Gastroparesis = at risk for 2 things
◦ MI
aspiration
Autonomic neuropathy → dysrhythmias, hypotension
427
DM Anesthesia Insulin
◦ Night before surgery, 1/3 NPH dose
428
DM Pump rate decreased by
30% overnight, can run basal rate during surgery
429
Oral hypoglycemics =
hold 24-48 hrs
430
DM Avoid in entire periop period ; why?
Sulfonylureas block myocardial ATP channels responsible forischemia/anesthesia-induced preconditioning
431
Intraoperative glycemic control
120- 180 mg/dL
432
BG > 200 =
glycosuria, dehydration, inhibited wound healing
433
1 unit of insulin
↓ glucose approximately 25- 30 mg/dL
434
BG Best sample =
venous, cap + art come out 7% higher, and whole blood is 15% lower than serum values
435
• Hypoglycemia treatment
treat c/50 mL 50% dextrose in water
| • ↑BG 100mg/dL or 2mg/dL/mL
436
Postop control
* Critically ill = 140-180 mg/dL
| * Initiate insulin therapy if > 180 mg/dL
437
Rigid bronchoscopy
To examine the lung airways
| Diagnostic, therapeutic, interventional
438
Flex vs rigid Thinner and longer
| Diagnostic and therapeutic procedures
Flexible
439
Flex vs rigid Access to lower airways such as third order bronchioles
Flexible
440
Disadvantage: Foreign object or thick mucus cannot be removed through the lumen
Flexible
441
Flex vs rigid Topical anesthesia and/or sedation
Flexible
442
Flex vs rigid Proximal airways
| Interventional procedures
Rigid and larger
443
General Anesthesia
Rigid
444
Flex vs rigid
| Disadvantage Potential soft tissue damage & inability to visualize deeper bronchioles
Rigid
445
Instruments of choice for Bronchoscopy: RIGID
| FEMVS
```
Foreign bodies
Massive Hemoptysis
Vascular tumors
Small children
Enbobronchial resections
```
446
Fiberoptic Flexible
```
Mechanical problem of neck
Upper lobe and peripheral lesions
Limited hemoptysis
PNA for culture
DLT posiion
Difficult intubation
checking position of ET
bronchial blockade
```
447
Anesthesia for Flexible bronchoscopy Local Anesthesia/MAC
| For patient who is awake, cooperative, and breathing spontaneously
Glycopyrrolate 0.2mg to 0.3 mg IV 15-20 minutes prior
Sedatives for patient comfort
Lidocaine & Tetracaine – commonly used
Nebulizer spray – oropharynx and base of the tongue
448
Anesthesia for Flexible bronchoscopy Block Superior Laryngeal Nerve Internal Branch
Tongue held forward, pledgets in each piriform fossa using Krause forceps
449
Transtracheal Anesthesia by
Transtracheal injection of local anesthetics
| Spraying vocal cords and trachea under direct vision with laryngoscope
450
Anesthesia for Flexible bronchoscopy Alternative to depress gag reflex
Superior laryngeal nerve block by external approach
Glossopharyngeal block
These blocks depresses airway reflexes, patient to remain NPO for several hours
451
Anesthesia for Flexible bronchoscopy Transnasal Approach
4% Cocaine topically applied to nasal mucosa or viscous lidocaine
Phenylephrine or Afrin spray can be mixed with lidocaine for vasoconstriction
452
Most widely used mode of ventilation for rigid bronchoscopy
Jet ventilator
453
Rigid Bronchoscope
Place
Suction
Reverse with
Patient may cough violently to clear secretions and blood
_______________ decrease airway reactivity
Place ETT or LMA
Suction
Reverse with Neostigmine and Glycopyrrolate and fully before extubation
Patient may cough violently to clear secretions and blood
Lidocaine 1mg/kg to decrease airway reactivity
Wake up from remifentanil tends to be smoother
Postop O2 supplementation preferably humidified
454
Rigid Bronchoscope Wake up from tends to be smoother
remifentanil
455
Rigid Bronchoscope Post op O2 supplementation preferably
humidified
456
POST OP RIGID BRONCHOSCOPOY
CXR – in PACU to check for atelectasis, pneumothorax, and mediastinal emphysema
457
Rigid Bronchoscope Induction
| Maintenance
Preoxygenate well
Consider short-acting paralytics
Succinylcholine 1mg/kg or rocuronium 0.3-0.6 mg/kg
Minimal Opioids use, consider remifentanil 1mcg/kg to avoid postop respiratory depressiong
458
Rigid Bronchoscope Maintenance
```
Sevoflurane or Isoflurane and 100% O2
TIVA alternative – (no gas leaks)
Propofol 50-150 mcg/kg/min
Remifentanil 0.1-0.3 mcg/kg/min
Paralytics
Short acting NDNMB (atracurium or rocuronium)
```
459
Rigid bronchoscope Jet Ventilation –
allows for uninterrupted ventilation and may shorten the length of the procedure (fewer interruptions)
Variable FiO2 secondary to entrainment of air
No EtCO2 available – difficult to determine adequacy of ventilation
Intermittent ABG for prolonged procedure or use of transcutaneous CO2 monitor
Restrict IV fluids to avoid fluid overload
460
Rigid Bronchoscope complications
```
Mechanical trauma to the teeth
Hemorrhage
Bronchospasm
Bronchial or tracheal perforation
Subglottic edema
Barotrauma
Airway obstruction
Pneumothorax
*Note: To avoid some of these complications, it is advised to intubate with an ETT after bronchoscopy under general anesthesia
```
461
Rigid Bronchoscope *Note: To avoid some of these complications, it is advised to
intubate with an ETT after bronchoscopy under general anesthesia
462
Advantages of Bronchial Blockers
| Disadvantages:
Can be dislodge and become life threatening
May be difficult to place
Cost more than double lumen tubes
463
Double Lumen Tubes
Allows a single lumen tube to be placed
Ideal for long cases because of no tube exchange post-operatively, and expected post-operative mechanical ventilation
Can be used to isolate individual lobes
464
Post op care rigid
A single chest tube usually is placed at the end of case and connected to a sealed drainage unit for postop chest drainage
Pain management:
IV, IM, continuous IV, PCA
Epidural, intercostal blocks, NSAID
465
When the surgeon says to reinflate the operative lung,
unclamp the lumen and manually ventilate until the lung is inflated. Then change the ventilator settings back to the original, 2 lung ventilation settings to a PRESSURE control setting, be sure to limit peak pressures to < 40 cm H20. When using a smaller Tv, a higher rate will be needed.
466
Blocks for Bronchoscope
Epidural, Intercostal block, paraveterbral block and/or intrapleural local anesthetic intercostal nerve blocks are performed when other regional techniques are contraindicated
467
Coming off Post-bypass low cardiac output
| Low pulmonary artery pressure:
give volume, increase preload
468
Coming off Post-bypass low cardiac output
| Low ejection fraction:
increase contractility with inotropes
469
Coming off Post-bypass High afterload (SVR > 1200):
decrease afterload, can use sodium nitroprusside
470
Coming off Post-bypass Low heart rate:
increase heart rate, program pacemaker
471
Coming off Post-bypass Arrythmias
Atrial/ventricular pacing, intra-aortic balloon pump set at 1:1
472
Coming off Bypass Post-bypass hypotension : assess
Assess LV volume and function
| Check CVP, PAD, CO/CI, and TEE for wall movement abnormalities
473
Coming off Post-bypass HYPOTENSION Treat with
volume, calcium, vasopressors, or inotropes as needed
Alpha agonists may be needed
A ventricular assist device may be needed for the right or left ventricle, or both ventricles
474
Coming off BYPASS Post-bypass hypertension
Assess if the anesthesia level is deep enough
Treat with narcotics and volatile agents as necessary
Some patients may need vasodilators
475
Off pump CABG
| What should be available?
Coronary artery bypass grafting may be done without cardiopulmonary bypass
Patient should be prepped and draped to go on bypass at any time
476
Best candidate for OFF PUMP BYPASS
Best for hemodynamically stable patients with coronary arteries that can be stabilized on the anterior wall of the heart
Promoted in patients at increased risk for stroke, severe lung disease, severe vascular disease, and renal dysfunction
477
POST BYPASS PERIOD Protamine
1.3-1.5 mg/100 units of heparin given can be administered once
Hemostasis is controlled
The aortic and vena cava cannulas have been removed
Hemodynamic stability is achieved
Give protamine slowly to prevent hypotension or pulmonary hypertension
478
POST BYPASS PERIOD ACT
Check ACT 3 minutes after giving protamine – it should be the same or less than baseline
479
POST BYPASS Anaphylaxis risk
is increased for patients with diabetes who have received NPH insulin and/or vasectomized males
Epinephrine 10 mcg/ml to treat reactions
480
POST BYPASS Uncontrolled bleeding may be caused by
```
Inadequate surgical control of bleeding
Inadequate heparin reversal
Thrombocytopenia
Platelet dysfunction
Hypothermia if the patient's body temperature is < 35 c
Newly acquired coagulopathy
```
481
Treatment of Post BYPASS BLEEDING
```
More protamine
FFP
Platelets
DDAVP
Factor VII
```
482
POST bypass bleeding Do this before cell saver?
Finish giving protamine before starting to give cell-saver blood, then give blood products
483
Total neck dissection Thyroidectomy pre-op
Hypertension must be controlled pre-op • Extra risk of exaggerated hemodynamic responses post -op d/t dissection near carotid body and vagus nerve
484
Intraop total neck dissection BP control
| • Gases should be humidified to avoid mucus plugs in this population
Deliberative relative hypotension is desirable for these
surgeries, with aggressive treatment of increased BP
• MAP of 60–70 mmHg, use of remifentanyl
• Laryngeal edema may occur
485
Total neck dissection intraop important to Avoid administering _____why?
paralytics until after large mandibular nerve and CN XI have been identified
486
Total neck dissection why do you get bradycardia •
transient bradycardia
487
Neck dissection Decrease in HR and BP treatment:
stop surgery, lidocaine infiltration of carotid sinus by surgeon, atropine
488
POST op BP and HR
| • Facial nerve injury: facial droop • Recurrent laryngeal nerve injury
Increased Secondary to carotid sinus
| denervation • Aggressive pharmacological intervention
489
Thyroidectomy Thyroid Storm = life threatening!
| •
* Hyperthermia
* Tachycardia
* Widened pulse pressure
* Anxiety
* Neuro changes
490
• Tx thyroid storm :
• ↑FiO2, fluids, e- replacement, cooling blanket, etc.
491
Thryroid storm CAN BE MISTAKEN FOR
MALIGNANT HYPERTHERMIA!
• When in doubt --> dantrolene
• Can be beneficial for bot
492
Thyroidectomy – Anesthesia Considerations
| • Local anesthetic
with epinephrine injection into neck
| • Monitor EKG changes (increased HR, ST-segment changes)
493
• May want to avoid LA with epi in those patients
hyperthyroid patients
494
• If hyperthyroidism, have these available
ave beta blockers available
| • HTN, tachycardia, or SNS response
495
Thyroidectomy - Indications
Performed to correct either a benign or malignant process affecting the thyroid gland
• Hyperthyroidism (Graves disease, goiter, toxic adenoma)
• Thyroid cancerDissection near carotid body and vagus nerve may result in
• Noncancerous enlargement of thyroid (goiter)
• Benign or suspicious
nodules
496
Hyperthyroidism Cause: May be commonly secondary to
Graves' disease, toxic multinodular goiter, thyroid
| adenomas, TSH-secreting tumor (rare), or overdose of thyroid hormone
497
Hyperthyroidism Common sx:
• Hypermetabolism & SNS overstimulation
• Fatigue, sweating, intolerance to heat, weight
loss or gain
• Thyroid goiter, exophthalmos
• Increased appetite, HR, BP, pulse pressure,
and temperature
• Tremor, anxiety, nervousness
498
• CHF and Atrial Fibrillation are common in these
| patients
Hyperthyroidism
499
Untreated hyperthyroidism leads to
Thyroid storm
500
Review
- Hypothyroid
• Cause:
iatrogenic or autoimmune thyroiditis
501
Common sx Hypothyroidism
| Cold, metabolism, cardiac resp function, HR, CO, DTR
Intolerance to cold • Decreased metabolism • Depressed cardiac and respiratoryfunction
• Bradycardia, decreased CO, pulse pressure, temp, mental reflexes, and DTR
• Lethargy, anorexia, weight gain or loss, constipation
502
• Decreased ventilatory response to hypoxia and hypercarbia
hypothyroidism
503
These patients are dehydrated
| • need volume repletion
• Hyperthyroid:
| hypermetabolism, sweating, diarrhea
504
• Hypothyroid:
adrenal insufficiency (untreated)
505
Thyroidectomy – Anesthetic Concerns
| Hyperthyroid
* Increased:
* HR
* Atrial fibrillation
* Palpitations
* CHF
* Caution using beta blockers
506
Hypothyroid CV CHAnge
* Bradydysrhythmias,
* Diastolic HTN or dysfunction
* Pericardial effusions
* ECG changes
* ST and QT changes, TdP
507
• Caution w/ volume expansion with LV dysfunction
Hypothyroidism
508
Complications of Thyroidectomy• Injury to recurrent laryngeal nerves (RLN) • Bilateral: • Unilateral:
- Will require reintubation
| - experience hoarseness.
509
Thyroidectomy – Anesthesia
| • Check with surgeon if needing:
• Muscle relaxant
510
Thyroidectomy – Anesthesia Avoid
histamine releasing paralytics
| Atracurium , Mivacurium
511
IONM Line up electrodes to
vocal cords
512
IONM vocal cords aligned with The electrodes, connected to a monitor, sense
EMG (electromyographic) activity from the thyroarytenoid
| muscles
513
Thyroidecomty no _______ why?
• NO muscle relaxants or topical laryngeal
anesthesia!
• to obtain appropriate signals during surgery
514
Increasing your body weight by 10% causes how much of an increase in OSA risk?
10%
515
Pickwickian syndrome is named after a character in what famous author’s book?
Charles Dickens
516
Which of the following is not an adverse effect of Albuterol
Hyponatremia
517
If you are ventilating at rate of 10, what should your I:E be?
1:2
518
If you are ventilating at rate of 8, what should be your I:E be?
1:3
519
If you are ventilating at rate of 6, what should be your I:E be?
1:4
520
Which commonly used anesthetic agent can exacerbate asthma?
Neostigmine
521
Which intervention may help with negative pressure pulmonary edema?
Add 8cm H2O PEEP
522
Which lung volume is not significantly affected by breathing irregularities?
Tidal volume
523
What is an average hospital stay for patient who aspirate?
21 days
524
What is the gold standard for assessing angina related to CAD?
Coronary angiography
525
What type of medication is abciximab?
Glycoproteins IIb/IIIa inhibitor
526
What might you hear with CHF?
S3 sound
527
When does thrombolytic therapy need to be administered by for ACS?
12 hours
528
Which papillary muscle of the mitral valve has the highest chance of rupturing?
Posteromedial
529
When is CABG preferred over a PCI?
Three vessel coronary artery obstruction
530
How much heparin would you give for a CABG about to go on bypass?
400units/kg
531
Upon arriving to the hospital, how long do you have to do a PCI?
90 min
532
What is the O2 consumption at 2 METS?
7ml/kg/min (3.5ml/kg/min at 1 METS)
533
What is the highest level serum glucose can rise to during cardiac surgery?
180mg/dL
534
After a radial neck dissection, a patient is restless in PACU. What might be occurring?
Hypercarbia
535
Which hormone is released via a neuronal trigger?
ADH
536
The release of thyroid hormone is a result of what kind of trigger?
Hormonal
537
What is the highest pressure you can deliver during jet ventilation via cricothyrotomy?
50PSI
538
Which hormone is released via humoral trigger?
Glucagon
539
Growth hormone requires which other hormone to function?
Thyroid hormone
540
Excessive testosterone production in the adrenal cortex will has what affect on males?
Nothing
541
How long can a keep a cricothyrotomy in for?
5 days
542
What hormone is released from the neurohypophysis?
ADH
543
What is necessary to diagnose SIADH?
Concentrated Urine
544
When should you initiate 3% NS in a patient with SIADH? 115mEq/L (when will you hold surgery?
Less than 125)
545
What enzyme facilitates iodination of tyrosine?
Peroxidase
546
What breakdowns T4 to T3
Iodinase
547
Subglottic stenosis may result from what surgical procedure?
Cricothyrotomy
548
What medication can decrease the conversion of T4 to T3?
Dexamethasone
549
What is the largest pure endocrine gland?
Thyroid
550
If you have an over-secreting pituitary tumor, which body part will reduce its signaling?
Hypothalamus
551
Decreased TSH-RH, decreased TSH, and increased TH indicates what?
Over-secretion by thyroid
552
Which childhood disease is a result of hypothyroidism when in the womb?
Cretinism
553
What antagonizes calcitonin?
Parathyroid hormone
554
Where is aldosterone produced?
Zona Glomerulosa
555
Humoral Trigger
Blood is being monitored. When level of substance is too low, it stimulates release of hormone.
556
Neuronal Trigger
A neuron directly stimulates gland to cause secretion of hormone.
557
Hormonal Trigger
Endocrine gland releases a hormone that stimulates another endocrinegland to release its hormone.
558
Humoral triggers Examples are
```
Parathyroid
Insulin,
Glucagon
Aldosterone
Hormone
```
559
ACS AVOID
tachycardia, systolic hypertension, sympathetic nervous system stimulation, arterial hypoxemia, and hypotension (c/in 20% of the normal awake patient)
560
SAD-P
Syndrome Adrenal
| Disease Pituitary
561
Valvular associated with PVC
MVP
562
P mitrale is associated with
Mitral stenosis
563
High Peak pressure
May be needed to deliver TV of bronchospasm
564
Fiberoptic bronchoscopy
| • Principal contraindication to pleural biopsy is
coagulopathy
565
Maintenance volatile for CABG , gas and MAC
Iso, Sevo or des, titrated to 0.5 MAC
| Avoid nitrous oxide
566
Fentanyl and bypass
May be given throughout the case
50 -100mcg if good EF
<50 if bad EF
567
CABG induction agent if CO is less than 35%
Etomidate 0.2-0.3mg/kg
568
CABG induction agent if CO is MORE than 35%
Sodium thiopental 2-4mg/kg
569
Induction meds
Succ , give roc defasciculating dose
| Midazolam
570
COPd and volume
RV gets larger closing capacity
571
Add peep
For negative pulmonary edema
572
OPCAB can be used
To Perform multi-vessel bypass
To Carry out redo CABG
In patients with Aortic disease when cannulation of the aorta poses significant embolic risk
573
OPCABG is best for patients where the side effects of cardiopulmonary bypass are
especially undesirable
574
OPCABG The major difficulties for this surgery include
hemodynamic alterations with cardiac manipulation and tilting and intraoperative myocardial ischemia.
575
Off pump better for
| ASLVR
- hemodynamically stable patients with coronary arteries that can be stabilized on the anterior wall of the heart
Promoted in patients at increased risk for stroke, severe lung disease, severe vascular disease, and renal dysfunction (SLVR)
576
Bad for regurgitation
Hypercarbia
577
Status asthmaticus give
8% sevo
Decrease TV
Lidocaine
PPV
578
• EKG and MVP change
PVCs, repolarization abnormalities, and prolonged QT interval.
579
S/sx of MVP:
```
Palpitation
Anxiety
Dyspnea
Atypical chest pain.
Fatigue,
Orthostatic symptoms
```
580
Regurgitant valve wanted hemodynamics
AB-DA-IPNIC
581
Stenotic valves wanted hemodynamics
MS-AT-IA-NIP-NIC-minpU
582
Holodiastolic descrecendo murmur
Mitral stenosis
