EXAM 3 REVIEW Flashcards
(519 cards)
1
Q
C5
A
ELBOW FLEXORS
2
Q
C6
A
WRIST EXTENSORS
3
Q
C7
A
ELBOW EXTENSORS
4
Q
C8
A
FINGER FLEXORS
5
Q
T1
A
FINGER ABDUCTORS (LITTLE FINGER)
6
Q
L2
A
HIP FLEXORS
7
Q
L3
A
KNEE EXTENSORS
8
Q
L4
A
ANKLE DORSIFLEXORS
9
Q
L5
A
LONG TOE EXTENSORS
10
Q
S1
A
ANKLE PLANTAR FLEXORS
11
Q
How long does spinal shock last (hemodynamic disturbances)
A
1-3 weeks
12
Q
Reduction in BP after acute spinal cord injury due to
A
Loss of sympathetic tone and decreased SVR
Bradycardia from loss of T1-T4 innervation of the heart
13
Q
Complications 2 years after INJURY in order of from most incidence to least incidence (USCD A-SHPRP)
A
UTI (59%) Skeletal muscle spasticity (38%) Chills and fever (19%) Decubitus ulcer (16%) Autonomic hyperreflexia (8%) Skeletal muscle contractures (6%) Heterotopic ossicification(3%) PNA (3%) Renal dysfunction (2%) Postop wound infection (2%)
14
Q
Complications 30 years after INJURY in order of from most incidence to least incidence (DSGC UI-VUMR)
A
Decubitus ulcer (17%) Skeletal muscle or joint pain (16%) GI dysfunction (14%) CV dysfunction (14%) UTI (14%) ID or Cancer (11%) Visual or hearing disorders (10%) Urinary retention (8%) Male GU dysfunction (7%) Renal Calculi (6%)
15
Q
Several weeks after acute spinal cord injury, spinal cord reflexes
A
gradually return, and patients enter a chronic stage
16
Q
After several weeks after Acute SCI patient enters a chronic stage characterized by
A
characterized by overactivity of the sympathetic nervous system and involuntary skeletal muscle spasms
17
Q
Injury at or above C5 =
A
apnea due to denervation of the diaphragm
18
Q
Succinylcholine is likely to provoke hyperkalemia
within the
A
first 6 months after injury (Avoid it after 24 hours of injury)
19
Q
When does Autonomic hyperreflexia appear?
A
Appears AFTER spinal shock in association with
return of spinal cord reflexes
20
Q
Autonomic Hyperreflexia Can be initiated by
A
cutaneous or visceral stimulation below the level of spinal injury
21
Q
Autonomic hyperreflexia common stimuli
A
Surgery or distention of hollow viscus (bladder, rectum) are common stimuli
22
Q
Autonomic hyperreflexia Stimulation does what? then end result is ?
A
initiates afferent impulses that enter the spine, this elicits an increase in sympathetic nervous system activity along the splanchnic outflow tract (in normal patients, this is inhibited by higher centers of the CNS) . End result is a Generalized systemic vasoconstriction occurs BELOW the level of the spinal cord injury
23
Q
Generalized systemic vasoconstriction occur
A
BELOW the level of the spinal cord injury
24
Q
Autonomic hyperreflexia patho
A
- Stimulus below level of spinal cord transection
- Activation of preganglionic sympathetic nerves
- Vasoconstriction
- Hypertension
- Carotid sinus
- Vasodilation /Bradycardia
- Activation of pre-ganglionic sympathetic nerves
25
What is the hallmark of autonomic hyperreflexia?
Hypertension and REFLEX BRADYCARIDIA (carotid sinus stimulation)
26
When there is reflex cutaneous vasodilation ?
Reflex cutaneous vasodilation ABOVE the level of spinal injury (nasal stuffiness)
27
Autonomic Hyperreflexia Neuro symptoms
Headache, blurred vision = severe hypertension (can lead to LV failure)
28
Who experienced and DO not experience autonomic hyperreflexia?
85% of patients with lesions above T6 exhibit this reflex, unlikely to be associated below T10
29
Splanchnic nerve and innervations: GREATER SPLANCHNIC NERVE
T5-T9
30
Splanchnic nerve and innervations: LESSER SPLANCHNIC NERVE
T10-T11
31
Splanchnic nerve and innervations: LEAST SPLANCHNIC NERVE
T12
32
Loss of input from higher centers to these nerves
| increase risk of exaggerated autonomic reflexes
T5-T12
33
***Management for exaggerated autonomic reflexes
prevent it! Have vasodilators available (SNP, hydralazine), can occur in PACU when drugs begin to wear off
34
Loss of input from higher centers to nerve T5-T9, T10-T11 and T12 leads to
Increase risk of exaggerated autonomic reflexes
35
what happens to the parts of the body ABOVE the level of the spinal cord lesion
VASODILATATION
36
When GA is selected, avoid
Succinylcholine 24 hours after injury due to risk of hyperkalemia. use NDNMB agents
37
Autonomic Hyperreflexia occurs in patients with spinal cord injury what level
Above T6
38
CREST Syndrome
Calcinosis: Calcium deposits in the skin
Raynaud’s Phenomenon: Spasm of blood vessels with
cold or stress.
Esophageal dysfunction: Acid reflux and decrease
esophageal motility.
Sclerodactyly: Thickening and tightening of the skin on
fingers and hands.
Telangiectasias: Dilation of capillaries causing red
marks on skin surface
39
3 main problems with MARFAN (HPK)
High Arched palare
Pectus excavatum (spoon chest)
Kyphoscoliosis
40
Marfan's syndrome most deaths caused by
Cardiovascular
41
Most common cause of
Mitral Prolapse
| Mitral Regurgitation
42
Mitral stenosis
Snap
43
MVP
Mid systolic click late systolic murmur
44
Aortic issue with Marfan
Aortic dilation
| Aortic dissection or rupture
45
Issue with Marfan and CT
Defective CT in aorta and heart valves.
46
Cardiac Conduction abnormality with Marfan is
BBB common
47
Respiratory with Marfan 2 common developments
Early development of emphysema
| High incidence of spontaneous pneumothorax
48
Marfan's Syndrome Anesthesia Considerations
| Mainly focus on ?
CV Focus on cardiopulmonary abnormalities
49
Marfan's syndrome patients and AIRWAY
Susceptible to temporomandibular joint dislocation
| →caution with jaw thrusting
50
Marfan syndrome and BP considerations
AVOID any sustained increase in systemic blood pressure r/t increased risk of aortic dissection
51
Marfan and monitoring
Invasive monitoring including TEE consideration in selected patients
52
High risk for the development of pneumothorax
| What kind of patients -->
Marfan's syndrome
53
FORMAL DIAGNOSIS of ARF
• INCREASED SERUM CREATININE MORE THAN 0.5 MG/DL OF BASELINE
• 50% DECREASE IN CREATININE CLEARANCE
• A CHANGE IN SERUM CREATININE OF GREATER THAN 0.3 MG/DL WITHIN 48 HOURS OF
ACUTE INSULT
54
RENAL BLOOD FLOW (RBF) (AUTOREGULATED @
50 TO 150 MMHG
55
Most susceptible cause ➔
RENAL TUBULE ISCHEMIA (MOST SUSCEPTIBLE) ➔ PROLONGED ➔ IRREVERSIBLE CORTICAL NECROSIS.
56
Chronic Renal Failure
HYPERKALEMIA, HYPERMAGNESEMIA, HYPERPHOSPHATEMIA, HYPOCALCEMIA
57
CRF METABOLIC ACIDOSIS -ANEMIA
INCREASED CO, RIGHT SHIFT OF OXYHEMOGLOBIN DISSOCIATION CURVE
58
Lumbar lordosis/kyphoscoliosis and neuraxial
⇧neuraxial technical difficulty and positioning concerns
59
EHLERS – DANLOS SYNDROME and neuraxial
Bleeding: Avoid IM injections; excessive instrumentation of nose or esophagus; laryngoscopy; A line or CVP (hematoma);
no regional anesthesia (too much bleeding)
60
Achondroplasia Dwarfism, Small epidural space =
difficult to introduce epidural catheter
Osteophytes, prolapsed intervertebral discs, or deformed vertebral bodies also contribute to difficulties with neuraxial blockade
61
Duschenne Muscular Dystrophy and Regional anesthesia
avoids the unique risks of general anesthesia in Duschenne Muscular Dystrophy.
62
Nemaline Rod Muscular dystrophy Regional anesthesia
high motor block could = respiratory compromise
63
Myotonic dystrophy:
GA, regional and NMB do NOT prevent/relieve contraction
64
High concentrations of VA may
decrease contractions but will also cause myocardial depression
65
What is Nemaline Rod Muscular Dystrophy is a
Slowly progressive symmetrical dystrophy of skeletal and smooth muscles.
66
Nemaline Rod Muscular Dystrophy and motor
Delayed motor development; muscle weakness; hypotonia, abnormal gait, and loss of deep tendon reflexes
67
Nemaline Rod Muscular Dystrophy Facial
Micrognathia, dental malocclusion
68
Nemaline Rod Muscular Dystrophy Skeletal abnormalities
Kyphoscoliosis and pectus excavatum
69
Heart and Nemaline Rod Muscular Dystrophy
Dilated cardiomyopathy ➔ cardiac failure.
70
Nemaline Rod Muscular Dystrophy NEURO
Normal mentation
71
Nemaline Rod Muscular Dystrophy Anesthesia Consideration : INTUBATION
* Difficult tracheal intubation due to micrognathia and high arched palate
* Awake fiberoptic endotracheal intubation may be needed
72
Nemaline Rod Anesthesia Consideration Respiratory
Respiratory depressant effects of drugs may be exaggerated d/t respiratory muscle weakness and chest wall abnormalities
73
Nemaline Rod Anesthesia Considerations: Ventilation
V/Q mismatch increased; ventilatory response to CO2 may be blunted
74
Nemaline Rod Anesthesia Considerations: MUSCLE RELAXANTS
Sux and NDNMB response is unpredictable
75
Not been reported with Nemaline Rod
MH
76
What is Periodic Paralysis?
Intermittent acute attacks to skeletal muscle ➔ weakness or paralysis
77
Causes of Periodic Paralysis
hypo or hyperkalemia
78
Anesthesia Considerations for PERIODIC PARALYSIS 2 meds
1. Acetazolamide
| 2. Mannitol
79
Monitor this and AVOID 2 meds in Periodic Paralysis
Frequent K+ monitoring
Avoid potassium solutions
Avoid succinylcholine
80
Treatment for Periodic Paralysis
Administer glucose containing solutions if treating hyperK c/insulin
81
Clinical Features of Familial Periodic Paralysis Type: HYPOKALEMIA K value
<3.0
82
Clinical Features of Familial Periodic Paralysis Type: HYPOKALEMIA : PRECIPITATING FACTORS
PAMGHHSS- CE
```
Pregnancy
Anesthesia
Menstruation
Glucose infusion
HIgh Carb meal
Hypothermia
Strenuous Exercise
Stress
```
Cardiac Dysrhythmias
ECG signs of Hypokalemia
83
Clinical Features of Familial Periodic Paralysis Type: HYPERKALEMIA K value
>5.5
84
Clinical Features of Familial Periodic Paralysis Type: HYPERKALEMIA : PRECIPITATING FACTORS
PHEM
Potassium Infusion
Hypothermia
Exercise
Metabolic Acidosis
85
Clinical Features of Familial Periodic Paralysis Type: HYPERKALEMIA: OTHER FEATURES
Skeletal muscle weakness may be localized to tongue and eyelids
86
MYASTHENIA GRAVIS - What is MG
Chronic autoimmune disorder caused by a decrease in functional acetylcholine receptors (AchR) at the NMJ resulting from destruction or inactivation by circulating antibodies
87
ACH receptor and MG
Down regulation of AchR
88
2/3 of patient with MG have
Thymic hyperplasia is present in two thirds of patients with myasthenia gravis, and 10% to 15% of these patients have thymomas
89
What is the Hallmark of MG:
weakness and rapid exhaustion of voluntary muscles with repetitive use
Partial recovery with rest; muscle strength is normal when well rested
90
MG Initial symptoms:
ptosis, diplopia, and dysphagia
91
MG and Aspiration
High aspiration risk (Weak pharyngeal, laryngeal muscles = dysphagia, dysarthria and difficulty handling saliva
92
MG and heart
Myocarditis can result in atrial fib, heart block, or cardiomyopathy
93
Other autoimmune diseases that may precipitate MG
| HPRS
Hyperthyroidism
Pernicious anemia
Rheumatoid arthritis
Systemic lupus erythematosus
94
What are meds that can aggravate muscle weakness
Antibiotics, especially aminoglycosides, can aggravate muscle weakness
95
May precipitate or exacerbate muscle weakness in Myasthenia Gravis (PIESE)
```
Pregnancy
Infection
Electrolyte abnormalities,
Surgery
Emotional stress
```
96
Treatment of Myasthenia Gravis PIP-T
Pyridostigmine
Immunosuppressive Therapy
Plasmapheresis
Thymectomy
97
Anesthesia Considerations of Myasthenia GRAVIS
| MUSCLE RELAXANTS
⇧ sensitivity to NDNMB; decrease dose by ½ to 2/3 Or just avoid it completely
Resistance to succinylcholine Need 2.6 X the ED95
98
MG and Volatile agents
VA have MS relaxation properties
| Postpone extubation and ventilator support postop.
99
MYASTHENIC SYNDROME AKA Eaton-Lambert Syndrome
| What is it?
Resembles Myasthenia Gravis IgG antibodies attack Ca2+ channels
100
Treatment of Myasthenic Syndrome
3,4 Diaminopyridine
| • IgG (6 to 8 weeks).
101
Myasthenia syndrome Anesthesia Considerations
Sensitive to depolarizing and non-depolarizing NMB
| Antagonism of NM-Blockade with anticholinesterase drugs may be inadequate.
102
The potential presence of myasthenic syndrome and the need to decrease doses of muscle relaxants should be
Considered when?
considered in patients undergoing bronchoscopy, mediastinoscopy, or thoracoscopy***for suspected lung cancer
103
Epidermolysis Bullosa Despite
dystrophic skeletal muscle, no increased risk of a hyperkalemic response when treated with succinylcholine
104
Scleroderma Musculoskeletal system:
myopathy- weak, mostly proximal skeletal muscle groups
105
EHLER”S DANLOS SYNDROME Musculoskeletal: Joint
hypermobility, musculoskeletal discomfort, susceptibility to osteoarthritis.
106
DERMATOMYOSIS
Abnormal immune responses ➔ Slow, progressive skeletal muscle damage
107
S/ S of Dermatomyosis S
keletal muscle weakness (e.g., difficulty climbing stairs) d/t skeletal muscle destruction ➔ increased serum creatine kinase levels.Neuromuscular junction is not affected
108
Neuromuscular junction is not affected
Dermatomyosis
109
Marfan’s Syndrome Additional skeletal abnormalities
| PKHH
Pectus excavatum
Kyphoscoliosis
Hyperextensibility of the joints
High-arched palate
110
Duschenne Muscular dystrophy Group of
hereditary diseases characterized by painless degeneration and atrophy of skeletal muscles
111
Duschenne Muscular Dystrophy
Progressive, symmetrical skeletal muscle weakness and wasting but no evidence of skeletal muscle denervation
112
Initial symptoms of Duschenne Muscular Dystrophy
waddling gait, frequent falling, difficulty climbing stairs, and these reflect involvement of the proximal skeletal muscle groups of the pelvic girdle
Affected muscles become larger as a result of fatty infiltration
113
Duschenne Muscular dystrophy and ambulation
| Predispose to ?
Typically confined to a wheelchair by age 8 to 10
| Skeletal muscle atrophy can predispose to long bone fractures
114
PRADER WILLI SYNDROME and skeletal
Weak skeletal musculature = poor cough and ⇧pneumonia
115
Systemic Lupus Erythematous *(SLE) is a
Multisystem chronic inflammatory disease characterized by antinuclear antibody production
116
SLE exacerbated by
Exacerbated by infection, pregnancy, surgery
117
SLE Onset can be drug induced: PHIDA
```
Procainamide
hydralazine
Isoniazide,
D - penicillamine
ALpha - methyldopa
```
118
Treatment of SLE (CIB)
Corticosteroids
Immunosuppressive treatment
Bone marrow transplant
119
Anesthesia Considerations for SLE
| CRML
Laryngeal involvement
Mucosal ulceration
Cricoarytenoid arthritis
Recurrent laryngeal nerve palsy, may be present in as many as 1/3 patients
120
Periodic Paralysis: Avoid
Potassium solutions
121
Periodic Paralysis: CAUSES
HYPO and HYPERKALEMIA
122
Epidermolysis Bullosa and K+ and SUCC
NO INCREASED OF HYPERKALEMIC RESPONSE WITH SUX
123
Duschenne Muscular dystrophy Succinylcholine
contraindicated d/t risk of rhabdomyolysis, hyperkalemia, and/or cardiac arrest -
124
Duschenne Muscular dystrophy: VA
Rhabdomyolysis, with or without cardiac arrest, observed with administration of VOLATILE anesthetics to these patients even in the absence of succinylcholine
125
What is Mastocytosis
Rare; disorder of mast cell proliferation; degranulation of mast cells
126
Mastocytosis Urticaria pigmentosa is usually
benign and asymptomatic
| Children are most often affected → resolves by adulthood
127
Systemic mastocytosis : What happens
mast cells proliferate in all organs (especially bone, liver, and spleen, but not in the CNS).
128
Signs and Symptoms of Mastocytosis
Histamine release from mast cells and prostaglandins are involved➔ anaphylactoid responses characterized by pruritus, urticaria, and flushing with hypotension (life threatening) and tachycardia
129
Mastocytosis and bronchospasm,
Low risk of bronchospasm Bleeding unusual, even though mast cells contain heparin!
130
Anesthetics Management for MASTOCYTOSIS Influenced by
the possibility of intraoperative mast cell degranulation and anaphylactoid reaction
-Have epinephrine readily available
131
Mastocytosis : Contrast dye
has caused profound hypotension- pretreat with H1,H2 blockers and glucocorticoid
132
Mastocytosis and Cromolyn-
inhibits mast cell degranulation, i.e. release of histamine (also used to treat asthma) -
133
Mastocytosis Safe: VVPF
Volatile anesthetics,
Vecuronium.
Propofol
Fentanyl
134
Mastocytosis Avoid:
Succinylcholine and Meperidine may cause mast cell degranulation
135
Upper cervical spine most at risk
(C1-C3)
136
Morbidity and mortality for cervical injuries include
alveolar hypoventilation with inability to clear bronchial secretions, plus the risk of aspiration of gastric contents, pneumonia, and pulmonary embolism (slide 5)
137
Lateral protrusion of a cervical disk usually occurs at
C5-6 or C6-7 intervertebral spaces
| Symptoms can be exaggerated by coughing
138
CERVICAL INJURY Management of anesthesia: primary concern is
airway approach, direct laryngoscopy should only be done if no significant worsening of symptoms occur with neck movement (especially extension)
139
Management of anesthesia: cervical spine procedures via the anterior approach
involves retraction of the airway structures and may result in injury to the ipsilateral recurrent laryngeal nerve and can manifest as hoarseness, stridor, or frank airway compromise
140
MANAGEMENT OF CERVICAL SPINE PROCEDURES Compression of
Recurrent laryngeal nerve fibers can be caused by the endotracheal tube or the inflated cuff. It is common practice to decrease the cuff completely and reinflate it until a leak is no longer heard
141
Cervical spondylosis =
neck pain and radicular pain in the arms and shoulders accompanied by sensory loss and skeletal muscle wasting. Later, sensory and motor signs may appear in the legs producing an unsteady gait
142
UNSTABLE C-NECK
| Sensitivity of plain radiographs for detecting cervical spine _____THEREFORE
injury is < 100%, treat all acute cervical spine injuries as potentially unstable
143
Immediate immobilization to limit
neck flexion/extension
| Manual in-line stabilization during laryngoscopy
144
CERVICAL SPINE movement tend to
Movement tends to occur in the occipito-atlanto-axial area even with stabilization
145
Neck hyperextension can further
damage the spinal cord
146
Anesthetic implications for old spinal injury. Chronic spinal cord injuries lead to ICACAA
```
Impaired alveolar ventilation
Cardiovascular instability
Autonomic hyperreflexia),
Chronic pulmonary and genitourinary tract infections, Anemia
Altered thermoregulation
```
147
Chronic spinal cord injuries and renal
Renal failure can occur
148
Anesthetic implications for old spinal injury.Immobility leads to
osteoporosis, skeletal muscle atrophy, DVT/VTE, pathologic fractures
149
Several weeks after acute spinal cord injury,
spinal cord reflexes gradually return, and patients enter a chronic stage characterized by overactivity of the sympathetic nervous system and involuntary skeletal muscle spasms
150
Spasm with spinal cord injury Medication to help and how it works
Baclofen
| potentiates GABA) is useful to treat spasticity (abrupt withdrawal = seizures
151
Chronic Spinal Cord Injury
| Injury at or above C5 there is ______Due to
apnea due to denervation of the diaphragm
Even when the diaphragm is intact, coughing and the ability to clear secretions from airway may be impaired due to denervation of intercostal and abdominal muscles
152
Injury at or above C5 RESPIRATORY CHANGES
| What does anesthetist need to do? What can occur?
Marked decreased vital capacity, arterial hypoxemia Need to preoxygenate before suctioning (bradycardia or cardiac arrest can occur)
153
Chronic Spinal Cord Injury Management of Anesthesia
Prevent autonomic hyperreflexia
154
Chronic Spinal Cord Injury Management of Anesthesia; Muscle Relaxant
Use NDNMB to prevent reflex skeletal muscle spasms in response to surgical stimulation
155
Chronic Spinal Cord Injury Management of Anesthesia: SUCC
Succinylcholine is likely to provoke hyperkalemia within the first 6 months after injury (Avoid it after 24 hours of injury)
156
Chronic Spinal Cord Injury Management of Anesthesia: ANTICIPATE what? What medication not to stop ?
Anticipate altered hemodynamics
| Continue Baclofen and benzodiazepines perioperatively
157
What is Amyotrophic Lateral Sclerosis (ALS)
Degenerative disease involving the lower motor neurons in the anterior horn gray matter of the spinal cord and the corticospinal tracts (primary descending upper motor neurons)
158
ALS produces
Produces both upper and lower motor neuron degeneration
159
Most common affected with ALS
Most commonly affects men 40-60 years of age
160
ALS: Primary lateral sclerosis
= limited to the motor cortex of the brain
161
ALS Pseudobulbar palsy =
limitation to the brainstem nuclei
162
Amyotrophic Lateral Sclerosis Symptoms reflect and resemble what?
upper and lower motor neuron dysfunction (resembles myasthenia gravis)
163
ALS Begins with
Skeletal muscle atrophy
Weakness
Fasciculations in the hands
Eventually includes all skeletal muscles including the tongue, pharynx, larynx, and chest TPLC
164
ALS Bulbar involvement includes
fasciculations of the tongue plus dysphagia, which leads to pulmonary aspiration
165
With ALS Autonomic nervous system dysfunction can be manifested as
Orthostatic hypotension and resting tachycardia
166
Muscles Spared with ALS
Ocular muscles are spared
167
Amyotrophic Lateral Sclerosis Anesthesia considerations: RESPIRATORY
Exaggerated respiratory depression
168
Amyotrophic Lateral Sclerosis Anesthesia considerations
| Vulnerable to
Vulnerable to hyperkalemia following succinylcholine administration
169
Amyotrophic Lateral Sclerosis Anesthesia considerations NDNMB
Prolonged responses to NDNMBA
170
What predisposes ALS patients to aspiration
Bulbar involvement predisposes to pulmonary aspiration
171
Syringomyelia (syrinx) is a disorder where there is
cystic cavitation of the spinal cord
172
Syringomyelia (syrinx) What is called syringobulbia?
Rostral extension into the brainstem
173
Syringomyelia (syrinx) - Communicating syringomyelia =
Either only dilation of the central canal of the cord (hydromyelia) or there is communication between the abnormal cystic lesions in the spinal cord proper and the CSF spaces
174
Syringomyelia - What is communicating syringomyelia associated with?
Associated with basilar arachnoiditis or Chiari’s malformation
175
Syringomyelia- Noncommunicating syringomyelia =
presence of cysts that have no connection to the CSF spaces
176
Syringomyelia Symptoms:
sensory impairment involving pain and temperature sensation in the upper extremities (destruction of neuronal pathways), as cavitation progresses, destruction of lower motor neurons ensues causing skeletal muscle weakness and wasting and loss of reflexes
177
Syringomyelia Thoracic scoliosis why?
Thoracic scoliosis can result from weakness of paravertebral muscles
178
Syringobulbia
paralysis of the palate, tongue, and vocal cords
179
Syringomyelia Management of anesthesia:
| TEAT
Thoracic scoliosis can cause V/Q mismatching
Avoid succinylcholine due to lower motor neuron disease
Exaggerated responses to nondepolarizing muscle relaxants
Thermal regulation may be impaired
180
GFR
best measure of renal function • normal: > 90 ml/min
181
Creatinine clearance •
Most reliable measure of GFR
182
Normal CrCL
110-140ml/min
183
Serum creatinine
Normal: 0.6 to 1.3 mg/dl
184
Blood urea nitrogen (bun) • normal:
10 to 20 mg/dl
185
Function of Renal system
Sodium and water removal
Waste removal
Hormone production
186
Kidney Filter the plasma volume every
22 minutes
187
3 things kidney regulate OVP
2. Regulation of plasma osmolarity
3. Regulaiton of plasma volume
4. Regulation of arterial pH (acid-base)
188
3 things kidney regulate OVP
Regulation of plasma osmolarity
Regulaiton of plasma volume
Regulation of arterial pH (acid-base)
189
Kidney Removal of
metabolic water and foreign substances (urea and drugs)
190
Kidney produces and activation of
Production of erythropoietin and renin
| Actionvation of Vitamin D 3
191
Fluid overload problems in kidneys
Elevated wastes products (Urea, creatinine, potassium)
192
Changes in hormone control in the kidney (BUM)
Blood pressure
Making RBCs
Uptake of calcium
193
Filtration is
movement of fluid from glomerulus to Bowman's capsule
194
Tubular Reabsorption is
Movement from Bowman's capsule to Peritubular capillaries
195
Tubular Secretion is
Movement from Peritubular capillaries to Bowman's capsule
196
Proximal tubule NaGluKAHPPUH
```
reabsorption of
NaCL
Glucose
K
Amino Acids
HCO3
PO4
Protein
Ureak
H2O ( ADH not required)
```
197
Tonicity of fluid (within ducts) Proximal
Isotonic
198
Tonicity of fluid (within ducts) Loop of Henle
Isotonic, Hypertonic, Hypotonic
199
Tonicity of fluid (within ducts) Distal
Isotonic or Hypotonic
200
Tonicity of fluid (within ducts) Collecting duct
Final Concentration
201
Proximal tubule Secretion of (HFOI)
H+
Foreign Substances
Organic Anions, Catiion
Isotonic
202
Where is ADH not required
Proximal
203
LOOP of HENLE (CADU)
Concentration of urine (countercurrent mechanism)
Ascending loop Na+ Reabsorbed (active transport, water stays in)
Descending loop WATER Reabsorbed Nacl diffuses in
Urea secretion in thin segment
204
Distal Tubule NHH
| KUHNS
```
Reabsorption of NaCL, H2O (ADH required) HCO3
Secretion of KUHNS
K+
Urea
H+
NH3+
Some drugs
```
205
Distal Tubule NHH KUHNSI
```
Reabsorption of NaCL, H2O (ADH required) HCO3
Secretion of KUHNSI
K+
Urea
H+
NH3+
Some drugs
Iso or Hypo
```
206
Connecting Tubule Reabsorption of
H2O (ADH required)
207
COLLECTING Reabsoprtion OR secretion of NaKHN
Na+
K+
H+
NH3+
208
COLLECTING DUCT urea secretion in
Medulla
209
Major sites of exchange within the nephron: Reabsorption in Proximal (NHG)
Na+
H2O
Glucose
210
Major sites of exchange within the nephron: Reabsorption in Distal Tubule ()
H2O and K+
| Secretion NH3
211
Major sites of exchange within the nephron: Secretion in Distal tubule
NH3
| H+
212
ACUTE RENAL FAILURE (ARF)
• PERIOPERATIVE ANESTHESIA CONSIDERATIONS
Fluids
1. NS VS. LR
| • NS ➔ HYPERCHLOREMIC METABOLIC ACIDOSIS ➔ SECONDARY HYPERKALEMIA.
213
Acure Renal Failure, action of ALPHA 1 AGONIST VS. VASOPRESSIN
increased systemic pressure is accompanied by reduced renal sympathetic tone and vasodilation
214
ARF Alpha 1 agonist vs vasopressin
Alpha 1 agonist: ARF r/t sepsis with renal vasoconstriction ➔ exacerbate tubular injury. • • alpha 1 agonist: arf r/t sepsis with renal vasoconstriction ➔ exacerbate tubular injury. • vasopressin: selectively constrict renal efferent arterioles ➔ preserve gfr and uop.
215
Vasopression is better than alpha 1 agonist why?
vasopressin: selectively constrict renal efferent arterioles ➔ preserve GFR and Urine OUTPUT
216
CRF perioperative anesthesia considerations IV access:
use temporary hemodialysis catheter (not encouraged) ➔ must be accessed aseptically. • a line: not in same extremity as patent fistula ➔inaccurate arterial pressure and abg concentrations.
217
CRF induction ➔
hypovolemia ➔ impaired peripheral vasoconstriction. • give 250ml of 5% albumin via direct ivp using a 60ml syringe before induction.
218
In CRF, Giving Albumin, How does it help?
this “somewhat” corrects hypoalbuminemia, giving protein bound drugs something to bind to. it also acts as a volume expander helping to decrease hypotension’
219
RENAL TRANSPLANTATION
| • ANESTHESIA CONSIDERATIONS: Fluid and volume
A high-normal systemic blood pressure and euvolemia are required to maintain adequate urine output
220
RENAL TRANSPLANTATION
| • ANESTHESIA CONSIDERATIONS: VENTILATION
surgical retraction in the area of the diaphragm ➔ respiratory mechanics impaired ➔ *** controlled mechanical ventilation preferred •
221
Renal transplant: Old kidney vs new kidney clearance
A newly transplanted kidney can clear neuromuscular blockers and anticholinesterase drugs at the same rate as a healthy native kidneys
222
Monitoring and Meds after kidney transplant
Cvp monitoring should be used to guide volume infusion
| Mannitol is administered to facilitate urine formation in the new kidney and decrease the risk of acute tubular necrosis
223
RENAL TRANSPLANTATION
| • RELEASE OF VASCULAR CLAMPS ➔
➔ venous drainage from the legs and preservative solutions from the transplanted kidneys are released into circulation ➔ cardiac arrest can occur during this time due to hyperkalemia (potassium-rich preservative solutions)
224
2 reasons Why Hypotension after unclamping during renal transplantation?
➔ hypotension can follow unclamping because
1. there is a 300 ml increase to the intravascular capacity
2. previously ischemic tissues release vasodilating metabolic byproducts.
225
Anesthesia considerations for someone who has had a kidney transplant: • immunosuppressant drugs have multiple side-effects What are they (SLAT)
Systemic hypertension
Lowered seizure thresholds
Anemia
Thrombocytopenia
226
Anesthesia considerations for someone who has had a kidney transplant GFR and RBF.
GFR and renal blood flow likely to be lower, activity of drugs excreted by the kidneys may be prolonged •
227
Anesthesia considerations for someone who has had a kidney transplant Minimize
minimize drugs that depend on renal clearance, avoid nephrotoxins
228
When should diuretics be administered for someone who has had a kidney transplant
diuretics should only be administered after careful evaluation of intravascular volume status • decreases in renal blood flow should be minimized
229
Nephrotic syndrome • definition:
daily urinary protein excretion exceeding 3.5 g
230
Nephrotic syndrome associated with (SHIT)
Sodium retention
Hyperlipidemia,
Infectious complications
Thromboembolic
231
Nephrotic syndrome most common cause:
diabetic nephropathy •
232
Nephrotic syndrome signs and symptoms • revolve around
Sodium retention and decreased plasma oncotic pressure leading to intravascular hypovolemia and edema
233
Signs of Nephrotic syndrome (VOPT)
Vasoconstriction
Orthostatic hypotension
Peripheral
Tachycardia,
234
To correct hypovolemia with Nephrotic Syndrome
Infusion of albumin to correct hypovolemia,
235
Loop diuretics and Nephrotic syndrome
Loop diuretics to offset sodium retention (careful to avoid hemoconcentration because patients are at risk for thromboembolic events)
236
How does hypoalbuminemia affect nephrotic syndrome?
hypoalbuminemia decreases available binding sites for drugs and increases circulating levels of unbound drugs
237
NEPHROLITHIASIS Assessment: • stones in the renal pelvis are
are painless unless complicated by infection or obstruction
238
NEPHROLITHIASIS what happens
a stone passage through the ureters produces flank pain radiating to the groin with nausea and vomiting •
239
NEPHROLITHIASIS: What can be seen with passage
hematuria can be seen with ureteral passage
240
NEPHROLITHIASIS: Treatment
Treat underlying disorder • maintain daily uop > 2-3l/day
241
TURP Hypervolemia can result from ________ leading to HBP
absorption of irrigants→
| htn, bradycardia, pulmonary edema
242
TURP hyponatremia can result from _______ leading to
| CAP-CS
absorption of na free irrigants→
Confusion, Agitation, pulmonary edema,
CV collapse, Seizures
243
2 issues that may occur with TURP
Hypervolemia
| Hyponatremia
244
TURP Ace inhibitors →
increased risk of intraoperative hypotension
245
ANESTHESIA AND RENAL DISEASE
| Volatile anesthetics →
decreased RBF GFR, and UOP by causing a drop in
| BP and CO (transient)
246
ARF official diagnosis Criteria
FORMAL DIAGNOSIS:
• INCREASED SERUM CREATININE MORE THAN 0.5 MG/DL OF BASELINE
• 50% DECREASE IN CREATININE CLEARANCE
• A CHANGE IN SERUM CREATININE OF GREATER THAN 0.3 MG/DL WITHIN 48 HOURS OF
ACUTE INSULT
247
ANESTHESIA AND RENAL DISEASE: Painful stimuli
Painful stimuli → increased ADH secretion
248
ANESTHESIA AND RENAL DISEASE- How PPV impact
Positive pressure ventilation→ decreased ANP secretion → oliguria
249
Renal transplantation: Kidney from a cadaver
a kidney from a cadaver can be preserved by perfusion at low temperatures for up to 48 hours •
250
Renal Transplantation what must be matched?
HLA antigens and ABO blood groups must be matched •
251
Renal transplantation , donor kidney ?
donor kidney is placed in the lower abdomen and receives its vascular supply from the iliac vessels •
252
Renal Transplantation , when is immunosuppresion therapy started?
immunosuppression therapy is started perioperatively
253
Long-term immunosuppression results in _____And frequency of _______
opportunistic infections
| frequency of cancer is 30 to 100 times higher
254
Treatment of acute immunologic rejection
Removal of the transplanted kidney, especially if accompanied by DIC
255
What are the delayed signs of graft rejection (FLD)
Fever
Local tenderness
Decreased UOP
256
Meds and therapy for Treatment of acute immunologic rejection (CAH)
Corticosteroids
Antilymphocyte globulin
Hemodialysis
257
ESRD and its effect on oxygen dissociation
| CRF Signs and symptoms 1. Electrolyte imbalances:
hyperkalemia, hypermagnesemia, hyperphosphatemia, hypocalcemia
258
ESRD and its effect on oxygen dissociation
| CRF Signs and symptoms 2. Metabolic acidosis. Anemia
a. Anemia • increased co, right shift of oxyhemoglobin dissociation curve
259
ESRD and its effect on oxygen dissociation Bartter syndrome = What is it?
Ccongenital hypokalemic alkalosis)- autosomal recessive
260
How oxygen dissociation is affected with Bartter syndrome? KPL-VI
- k+ follows H+
- pH and O2 dissociation curve→ less O2 available to tissues
- volume depletion from Na+ wasting
- increased Prostaglandins → activate renin/angiotensin/aldosterone axis (RAAS)
261
Bartter Syndrome move the O2 dissociation curve to the
LEFT
262
Sevoflurane is metabolized to
Fluorine (F-)
263
Sevoflurane leads to
transient tubular dysfunction (concentrating ability, increased β-n-acetylglucosaminidase) •
264
Effect of renal disease on anesthesia drugs Sevoflurane, is there changes in BUN or Cr? What about compound A?
no change in cr- or bun • Compound A- questionable significance •
265
Effect of renal disease on anesthesia drugs: ACE
Increased risk of intraoperative hypotension
266
Effect of renal disease on anesthesia drugs disrupted bbb and less protein binding →
increased bioavailability of induction drugs
267
Effect of renal disease on anesthesia drugs " gastric
Delayed Gastric emptying
268
K release after succ is how much ? Does defasciculation change K+ release?
• k+ release after sux (0.5 to 1.0 meq/l) de-fasiculation does not change k+ release
269
CHRONIC RENAL FAILURE • Perioperative anesthesia considerations AVOID ➔
NSAIDS
270
Why do we avoid NSAIDS with CRF? HPI
Exacerbate →
HYPERTENSION
PRECIPITATE EDEMA, AND
INCREASE THE RISK OF CV COMPLICATIONS WITH ESRD.
271
Chronic renal Failure and Opioids
USE PARENTERAL OPIOIDS JUDICIOUSLY.
272
Acute Renal FAILURE: Give at lower dose based on GFR: CoFeKeMMM
```
CODEINE
FENTANYL
KETOROLAC,
MEPERIDINE
METHADONE
MORPHINE.
```
273
Acute Renal FAILURE Do not require dosage adjustments→ ARS
Alfentanil
Remifentanyl
Sufentanyl
274
Acute Renal FAILURE avoid further renal insults
hypovolemia, hypoxia, nephrotoxins
275
ARF Perioperative anesthesia considerations dialysis
within 24 hours of elective surgery.
276
CHRONIC RENAL FAILURE
• PERIOPERATIVE ANESTHESIA CONSIDERATIONS
13 Drugs that rely heavily on renal elimination: (VENGA- HAMCCPSV)
```
VECURONIUM
EDROPHONIUM
NEOSTIGMINE,
GLYCOPYRROLATE,
ATROPINE,
HYDRALAZINE,
AMINOGLYCOSIDES
MILRINONE,
CEPHALOSPORINS,
CODEINE
PENICILLINS
SULFONAMIDES
VANCOMYCIN,
```
277
Chronic Renal Failure Drugs that have active metabolite and its implications.? MMH
Meperidine, Morphine, and Hydromorphone with active metabolites ➔ accumulate in ESRD
278
Chronic Renal Failure Best paralytics ? What may be delayed?
Atracurium and cisatracurium (best choice paralytics), but LAUDANOSINE clearance maybe delayed.
279
CRF and serum potassium
serum potassium should not exceed 5.5 meq/L
280
LR and CRF
LR has 4 meq/L of potassium
281
Reno-protective pharmacological agents Perioperative anesthesia considerations→low dose fenoldopam
➔ renal vasodilation
282
Reno-protective pharmacological agents
| Perioperative anesthesia considerations mannitol ➔
renal prostaglandins produced ➔ renal vasodilation
283
Reno-protective pharmacological agents Perioperative anesthesia considerations N-acetylcysteine ➔
free radical scavenger ➔ protect against radiographic dye-induced nephropathy
284
Hemodialysis: mainstay of treatment d/t .
volume overload, hyperkalemia, severe metabolic acidosis, symptomatic uremia, and overdose with a dialyzable drug
285
Reno-protective pharmacological agents best choice and why?
Selectively constrict renal efferent arterioles ➔ preserve gfr and uop_
286
Reno-protective pharmacological agents best choice and why?
Selectively constrict renal efferent arterioles ➔ preserve GFR and UOP
287
2 main things that mannitol doses
Scavenges Free radicals
| Release prostaglandins, causing vasodilation
288
Herbal Supplements that Decrease Platelet Aggregation
| BB D FFF GGGGS
* Bilberry
* Bromelain
* Dong Quoi
* Feverfew
* Fish oil
* Flax seed oil
* Garlic
* Ginger
* Gingko biloba
* Grape seed extract
* Saw palmetto
289
Herbal Supplements that Inhibit Clotting
| DDHCC
* Dandelion root
* Dong Quoi
* Chamomile
* Curcumin
* Horse chestnut
290
Hemodynamic effects of prone position
| Do not administer excessive
crystalloid volume to promote urine output.
291
Hemodynamic effects of prone position Urine output is
often less than expected when patients are positioned prone
292
Prone CPR and SBP
Increase in systolic BP
293
Prone CPR and circulation
good circulatory and respiratory support, easy to perform
294
Prone and GFR
Increased intra-abdominal pressure may decrease GFR.
295
Prone , Pressure transmitted to
epidural veins, increased bleeding.
296
Prone : In the absence of cord compression,
modest decrease in BP may be helpful, when extensive surgery is anticipated
This can be accomplished with anesthetics and opioids or by the use of beta blockers and SNP
297
BP approximately
20% below patient lowest recorded BP when awake
298
PRONE: MAP
>60 mm Hg in youg patients and
| MAP> 80 mm Hg in elderly pts
299
Prone and ↓ BP may be due to
abdominal compression and decreased venous return
300
Prone and ↑ Blood loss
2º to epidural vein engorgement abdominal compression or vascular injury
301
Acute ↓ BP may be due to a
vascular injury either obvious or occult until proven otherwise.
302
Prone: If ↓ BP persists despite vigorous blood and fluid administration, what would you suspect?
RETROPERITONEAL BLEEDING
303
Risk Factors for POVL (MOHP)
Male
Obese
Hypertension and Peripheral Vascular disease
Prolonged procedures, Substantial bloodloss or Both
304
Recommendations to prevent POVL
| Blood pressure management
• Assess the patient’s baseline blood pressure.
• Continually monitor systemic blood pressure in high risk patients.
Treat prolonged significant decreases in blood pressure.
305
Recommendations to prevent POVL : Determine
| and discuss
• Determine on a case-by case basis whether deliberate hypotension should be used in high-risk patients.▪ Discuss with the surgeon whether deliberate hypotension is necessary.
306
Recommendations to prevent POVL Management of Blood Loss and Administration of Fluids Periodically monitor
hemoglobin or hematocrit values during surgery in high-risk patients who experience substantial blood loss.
307
Recommendations to prevent POVL : Continual monitoring of
▪ Continual monitoring of hydration levels to avoid overhydration
▪ Fluid replacement limitation.
308
Recommendations to prevent POVL
| Use of Vasopressors
Adrenergic agonists may be used on a case-by-case basis when it is necessary to correct for hypotension
309
Recommendations to prevent POVL Patient and Head Positioning Devices
Positioning the patient so that the head is level with
| or higher than the heart
310
Recommendations to prevent POVL eyes
Avoidance of direct pressure on the globe of
| the eye
311
Recommendations to prevent POVL Maintaining of face in a
neutral forward position(e.g., without significant neck flexion or extension, lateral flexion, or rotation)
312
Recommendations to prevent POVL Staging of Surgical Procedures
Use of staged procedures for spine surgery when
| anticipated length is greater than 6 h
313
Rheumatoid arthritis: What is it?
it is a autoimmune condition, immune mediated joint destruction with chronic and progressive inflammation of synovial membranes
314
RA patients implications
these are the really involved and difficult patients,
| affects multiple organ systems
315
RA and Cardiovascular – PMCCVA
```
Pericardial thickening and effusion
Myocarditis
Coronary arteritis
Conduction deficits,
Vasculitis and cardiac valve fibrosis
Aortic regurgitation)
```
316
RA and stress test Arthritis
limits exercise probably cant get treadmill ECHO, so dobutamine ECHO may be needed
317
RA → HTN / cardiovascular disease and c
Conduction defects common in elderly leads to dysrhythmias leads to falls then Hip fracture
318
If patient has RA, at a minimum get
get EKG at minimum , if tamponade or severe CV disease suspected - ECHO
319
RA and respiratory what is common, and what is rare, and if rare presents, what are the symptoms (CDS) Get these tests___
Pulmonary effusions common, rare to have Pulmonary fibrosis, if present will have cough, dyspnea, SOB-
PFTs,
320
RA and airway derangements
Cricoarytenoid joints
| Glottic narrowing
321
Arthritis and TMJ
Arthritis of TMJ – limited mouth opening
322
Arthritis of TMJ implications? What is needed.?
making direct laryngoscopy difficult and may need fiberoptic if intubating
323
RA have cricoarytenoid joings, glottic narrowing, anesthesia considerations?
– Use smaller ETT – presenting sign hoarseness, worry about post extubation stridor even with smaller ETT
324
Neurological and RA
Check for Full ROM –
| nerve root compression and cerebral ischemia from vertebral artery compression
325
RA : Position and Musculoskeletal
Pain and arthritis make positioning and regional uncomfortable and more difficult
326
RA and small joints and implications
Affect small joints causing deformity like in hand, wrist and feet - Difficult to place arterial line or IV
327
Hematologic and RA
Anemia from NSAID gastritis and renal toxicity
| Eosinophilia
328
RA HGB if less than 12
HGB if less than 12 consider autologous blood donation as Hip fracture has the potential for large volume loss +1 L
329
RA has PLT dysfunction why?
from aspirin therapy and thrombocytopenia
330
RA and Endocrine
adrenal insufficiency ( from glucocorticoid therapy and impaired immune system
331
RA and Dermatological
Thin and atrophic skin from the disease and immunosuppressive drugs so just make sure pressure points are padded well so don’t get skin breakdown
332
RA –If pt has severe RA: Means patient is on
steroids, immune therapy or methotrexate
333
RA patient get xrays ? which type and why?
Especially lateral views of neck
Atlantoaxial subluxation instability, which is diagnosed by an x-ray, can compromise vertebral blood flow and compress spinal cord and brainstem,
334
RA patients with Xray showing Atlantoaxial subluxation instability, What do you do?
Intubate one of these patients - do so using fiberoptic laryngoscope.
335
PTS W/RHEUMATOID ARTHRITIS MAYBE ON
ORAL CORTICOSTEROIDS AND SUPPLEMENTAL PERIOPERATIVE STEROIDS
336
RA and Adrenal insufficiency
Adrenal insufficiency from steroids therapy, supplemental intraoperative steroids
337
AC and Regional Warfarin
Hold for 4-5 days prior to block
| Removed catheter with INR < 1.5, INR >3 hold dose
338
AC and Regional→ ASA
NO CONTRAINDICATIONS
339
AC and Regional→Clopidogrel
stop 7 days prior, if neuraxial considered between 5-7 days,restoration of platelet function should be confirmed.
340
AC and Regional→ Prasugrel ,
stop 7-10 days, wait 9 hours after neuraxial block or catheter removal before administration of drugs
341
AC and Regional → Ticagrelor
stop 5-7 days prior to neuraxial ,wait 10 hours after neuraxial block or catheter remove before administration of drug
342
AC and Regional→ Ticlopidine
Stop 14 days prior to neuraxial block
343
AC and Regional→ LMWH : Preop
wait 10-12 hours after prophylactic dose, 24 hours after tx dose
344
AC and Regional→ LMWH Post op
catheters removed at least 2 hours prior to initiation of dose of 2x daily
345
AC and Regional→ For single daily dose of LMWH ,
catheters can be maintained but should only be removed 10-12 hours after last dose
346
AC and Regional →Heparin SC < 10000 units per day
NO contraindications
347
AC and Regional→ Heparin SC >10000 Units per day
use caution- Check platelet if on heparin > 4 days
348
AC and Regional→ Dabigatran
stop 5 days prior to neuraxial block, wait 6 hours after neuraxial block or catheter removal before adminis ofdrugs
349
AC and Regional→ Apixaban,
Stop 3 days prior to neuraxial block, wait 7 hours after neuraxial block or catheter removal
350
AC and Regional→ Rivaroxaban
stop 3 days prior to neuraxial block, wait 8 hours after neuraxial block or catheter removal
351
AC and Regional Thrombolytics/Fibrinolytics, thrombin inhibitors:
CONTRAINDICATED
352
Regional contraindicated
TPA contraindicated
353
Bone Cement Implantation syndrome. Methymethacrylate (MMA): Cause is not completely known. Some speculate it
from micro emboli forming during cementing, others believe its from histamine release, complement activation, and vasodilation.
354
In BCIS, Intense
exothermic reaction causes heat and results in intramedullary hypertension which can cause fat, bone marrow, cement and air embolization into venous circulation.
355
MMA is not usually used in
younger patients and those physically active, just press fit which means just forcibly seated with mallet into femur opening.
356
BCIS Etiology
not completely understood
357
BCIS Most common with
hip arthroplasty, but also can occur with knee cementing and vertebroplasty.
358
BCIS Occurs in
2-17% of cementing surgeries
359
BCIS Risk factors – PPAD
preexisting CV disease
preexisting Pulm. HTN,
ASA 3 or greater,
depends on type of fracture and surgical technique
360
S/S of BCIS : HIHAP-D
```
Hypoxia
Increased pulmonary shunt)
Hypotension
Arrhythmias (including heart block and sinus arrest), Pulmonary hypertension (increased pulmonary vascular resistance)
Decreased cardiac output.
```
361
BCIS Treatment: Cementing time
should be recorded in chart and communication at cementing time is crucial as prior to cementing,
362
BCIS Treatment BP needs to be
optimized, FiO2 100% and pressure bags for fluids if needed.
363
BCIS Treatment If hypotension occurs use
Alpha agonist – phenylephrine for hypotension and aggressive fluid resuscitation
364
DVT Venous Thromboembolism /PET
| Without prophylaxis – DVT in
40-80% of orthopedic pts.
365
Multimodal prophylaxis protocol for THA in one study had DVT and PE rates of
2.5% and 0.6% which much lower than the numbers above.
366
DVT Risk factors include OPAULI
```
Obesity
Procedures lasting more than 30 min
Age greater than 60 years
Use of a tourniquet
Lower extremity fracture
Immobilization for more than 4 days.
```
367
Patients at greatest risk for DVT include those undergoing
hip surgery and knee replacement or major operations for lower extremity trauma
368
DVT and Preventative:
America College of Chest Physicians guideline recommend a minimum 14 days of pharmacologic thromboprophylaxis and / or SCD device to decrease risk
369
DVT and regional anesthesia
The use of neuraxial anesthesia, which causes vasodilation in the lower extremities, reduces the incidence of DVT by 50% in comparison to general anesthesia.
370
Complications: BLEEDING: Deliberate Hypotension
Deliberate hypotension using neuraxial anesthesia during hip surgery decreases blood loss and intraoperative transfusion needs when compared to general anesthesia
371
Tranexamic acid (TXA) can be
given intravenously or topically in the perioperative setting to decrease blood loss and transfusion requirements
372
What can improve intraoperative coagulation?
Maintaining normothermia improves intraoperative coagulation
373
Orthopedic syndrome Fat embolism syndrome classically presents
within 72 h following long-bone or pelvic fracture,
374
TRIAD of PE (PCD)
Petechiae
Confusion
Dyspnea
375
Fat embolism Petechia location (ACU)
Axilla, Chest, UE
376
FAT embolism signs w/ GETA –P
decline in ETCO2
| decline arterial oxygen saturation and rise in PA
377
FAT embolism mortality
10-20% mortality
378
FAT embolism Treatment: SOPR
Stabilization and surgery on fracture,
Oxygen therapy especially CPAP to prevent hypoxia, Pressors in hypotension and vasodilators may help
Pulmonary HTN
Respiratory support
379
FAT embolism useless and controversial
steroids are controversial and heparin is not effective
380
What is Venous Air embolism ?
Potential hazard whenever the operative site is above the level of the heart such as a shoulder surgery in beach chair position, or hip replacement when pt. is on their side.
381
VAE: Most sensitive monitor
TEE
382
VAE of S/S: (SIRI)
Sudden decrease in ETCO2
Increase in PAP, RV
Decrease in CO and BP
Increased dead space
383
Treatment of VAE (IFLAT) TAGS
Inform surgeon
Flood area with saline
Lower preoperative sites
Apply occlusive dressing to all bone edges if possible Try to identify air entry, if possible
Try aspiration thru right atrial catheter
Avoid PEEP
Give O2
Stop nitrous if on
384
VAE treatment Support hemodynamics with
Pressors and fluids
385
Lateral position and air exchange
Pulmonary shunting involved in lateral position
386
Positioning and how it affects MAP in different organs
Decreased CI, CVP, PCWP, and increased SVR
387
MAP and SITTING UP
Increases SVR
| Postural DECREASE IN BP
388
45 degree head up and hemodynamics
(minimal hemodynamic changes)
389
90 degree head up and hemodynamics
CO decrease by 20% due to venous pooling of blood in legs
390
Excessive flexion of neck can
impede arterial and venous blood flow and cause hypoperfusion and inadequate drainage of the brain
391
Kinked tube due to neck flexion,
risk of tube pressure on tongue leading to macroglossia. Keep two fingerbreadths between chin and sternum
392
The sitting position interferes
the least with ventilation and has less influence on lung volumes
393
With flexion of the hips and elevation of the legs
abdominal contents may shift caudally and limit the diaphragm, which will decrease FRC
394
Arm support to prevent stretching
of brachial plexus
395
Leg support/flexion of knees to prevent
stretching of sciatic nerve
396
Venous pooling in lower extremities
| VPQP
Venous Air Embolism (VAE),
Pneumocephalus
Quadriplegia
Peripheral nerve injuries
397
Conversion factor: 1 cm rise =
0.75 mmHg drop in MAP
| MAP 5020 cm rise = 15mmHg DROP in MAP = 65mmHG
398
Patients in the deck chair position are prone to .
hypotension, mainly due to venous pooling in the extremities and lack of surgical stimulation with an effective block.
399
The angle of elevation from the waist should be
increased slowly in the compromised patient, thus allowing time for haemodynamic equilibration
400
Intra-operative cerebral ischemia has been reported, probably through changes in
cerebral blood flow from a combination of postural hypotension and excessive head and neck manipulation
401
MAP increases or decreases by
0.75mmHg for each cm change in height between heart and a body region.
402
MAP increases or decreases by 0.75mmHg for each cm change in height between heart and a body region. Therefore region
elevated above the heart in the sitting, head-up or lithotomy position may be at risk for hypoperfusion and ischemia, especially with hypotension.
403
Try to elevate torso in increments
giving the body time to adjust.
404
Often used to support head using straps or tape to secure head to the headrest - note risk of brachial plexus injury with manipulation of limbs/head
Horse shoe head rest
405
TURP and Spinal
Spinal is considered the anesthetic of choice
406
Why is spinal better for TURP?
Early signs and symptoms of TURP syndrome, hypervolemia, and bladder perforation can be easily detected in a responsive patient.
407
Other benefits of SPINAL In TURP (LDE)
Less blood loss
Decreased incidence of postoperative venous thrombus
Embolus
408
Spinal anesthesia level for TURP
T10 sensory level is a must for adequate anesthesia
409
Incidence of PDPH
very low in this age group
410
Spinal for TURP Medication:
0.75% bupivacaine, 12 mg in 7.5% dextrose solution (1.6 mL)
411
The nerve supply to the prostate originates from the
inferior hypogastric plexus and carries both sympathetic fibers from T11 to L2 and parasympathetic fibers from S2 to S4.
412
Pain signal from bladder distension travels along with
T11 to L2 sympathetic fibers.
413
Considering this innervation, height of regional block up to
T10 is sufficient for TURP
414
Jaffe recommends T9 level, but Higher level of block may
mask the pain if perforation of the prostatic capsule should occur.
415
TURP Spinal meds commonly included with LA.
Intrathecal opioids (fentanyl or sufentanil)
416
TURP and Continuous lumbar epidural anesthesia
has no advantage during TURP-procedure relatively short and supplemental dose usually not necessary
417
TURP and Fluids
Cautious fluid loading may be used to minimize spinal anesthesia-induced hypotension, but if patients cant tolerate this or need pulmonary support perform GA
418
TURP Advantage of Regional anesthesia- In the awake patient-classic Triad of symptoms- TURP syndrome
increase in both systolic and diastolic pressures (increase in PP), bradycardia, and mental status changes.
419
Advantage of Regional for TURP
| GAPU
Good post op analgesia
Allows to monitor level of consciousness and detect early signs of TURP syndrome
Possible reduced blood loss
Useful in patient with significant respiratory disease
420
Regional advantage with perforation
Earlier recognition of bladder perforation or CAPSULAR TEAR
421
Disadvantage of Regional
Does not prevent penile erection which can interfere with surgery.
422
High Prevalence of BPH is in which zone
transitional ZONE
423
MOST BLOOD
Dorsal VENOUS COMPLEX-
424
Anesthetic approach to TURP
| Respiratory
COPD common-if patient has a > 50 pack-year history, or any respiratory symptoms-consider PFTs, ABG, or CXR
425
Anesthetic approach to TURPCardiovascular
CAD, CHF-exercise tolerance needs to be assessed-
426
TURP and Cardiac patient should be able to
Climb a flight of stairs without difficulty or SOB, EKG, check history of pacemaker.
427
TURP Neurologic
CVD or Alzheimer’s common-assess baseline mental status to guide evaluation of any intraop or postop changes.
428
TURP and Renal
Renal impairment should be anticipated secondary to chronic obstruction. Check BUN, Cr, Cr clearance, and electrolyte values.
429
Hematologic and TURP
| Moderate blood loss should be expected with l
Larger glands and T and C is indicated.
430
TURP, when is Type and cross NOT NECESSARY
If gland < 80 g, not necessary. Check CBC/coags
431
TURP premedication CV : Continue those medications DiNB and which medication for anxiety
Continue commonly used drugs (digitalis, BB, NTG) to prevent CV problems.
Midazolam 1-2 mg IV prn for anxiety.
432
TURP preop evaluation goal
Surgical population generally elderly may have preexisting medical problems-preop evaluation should be directed toward detection and treatment of these conditions.
433
TURP and Pacemaker-must be
converted to a fixed rate unless they are designed to operate in presence of applied currents.
434
TURP Induction:
Can use LMA, but lithotomy position with head down tilt decreases FRC and has increased risk for aspiration.
435
TURP and Maintenance-muscle relaxation a
not mandatory,
436
TURP, what must be avoided and why?
patient movement during procedure must be avoided-can lead to perforation or injury to the external sphincter-postop incontinence.
437
TURP and The obturator
The obturator nerve passes in close proximity to the inferolateral bladder wall, bladder neck and lateral prostatic urethra.
438
During TUPR resection in these areas may result in
stimulation of the obturator nerve, causing adductor contraction (obturator reflex) and possible inadvertent bladder perforation.
439
Shortcoming with subarachnoid block with TURP is
sparing of this nerve (Obturator nerve)
440
To successfully prevent this injury to Obturator nerve
Ultrasound guided obturator nerve block or injecting a local anesthetic into the sensitive area through a special needle passed through the resectoscope
441
TURP If using GA consider
succinylcholine or rocuronium-can be rapidly reversed using Sugammadex (4-8mg/kg).
442
With TURP Want to give minimal amounts of IV fluids why?
Minimize fluid overload due to possible irrigation absorption.
443
TURP Anticipate decrease BP
when legs are repositioned from lithotomy position.
444
TURP Avoid stress on lumbar spine by
Slowly and simultaneously bringing legs together and returning to supine position
445
With TURP Solutions should
not be hung higher than 30 cm above the operating table at the beginning of the procedure and higher than 15 cm during the final stages-decreases fluid absorption.
446
TURP Should
not exceed 2 hrs-Uptake of 1 L of irrigant into the circulation within 1 hour can decrease the serum sodium 5-8 mEq/L-limiting resection time to 1 hours is ideal.
447
TURP, May want to avoid this position and why ?
Tredenlenburg; promotes fluid absorption
448
Questions to consider with TURP
1. What is the irrigation fluid?
2. What is the bag height over the prostate?
3. What is the size of the prostate?
4. What is the expected duration of procedure?
5. What is the surgical operating position?
449
Systemic absorption of the irrigation fluid directly through
the prostatic venous plexus, or more slowly through the retroperitoneal and perivesical spaces.
450
TURP and fluid reabsorption Average of
10-30 mL of fluid can be absorbed per minute of resection time, and 6-8 L can be absorbed in cases that last up to 2 hours.
451
TURP Complications of absorption: HDVCRT
Hypoosmolality
Dilutional hyponatremia
Volume overload with pulmonary edema,
Cardiac effects
Retinal toxic effects (with glycine), and
Transient hyperglycemia/hypokalemia with glucose
irrigation solutions.
452
TURP signs and Symtpoms
| General Anesthesia-CNS symptoms
are hidden under general anesthesia.
453
TURP SYNDROME Can see (ABC-VA)
```
Arrhythmias
Bradycardia
Cyanosis,
Vagal response
And unexplained hypotension or hypertension
```
454
TURP Intravascular Volume Expansion
Systemic HTN and reflex bradycardia-pulmonary edema
455
TURP and Intravascular Volume Loss
H20 flux along osmotic and hydrostatic pressure gradients out of the intravascular space and into lungs-pulmonary edema and hypovolemic shock
456
TURP and Dilutional Hyponatremia
Osmotic shift of fluid->cerebral edema, increase in ICP, and CNS symptoms.
457
TURP and Hypoosmolality
BBB freely permeable to water->cerebral edema, increased ICP->bradycardia and HTN
458
TURP Hyperammonemia
Oxidative deamination of glycine to glyoxylic acid and ammonia
459
TURP and Hyperglycinemia
Deterioration of vision-transient blindness.
460
Robotic surgery Positioning
| Different positioning
increases risk for nerve injury
| Improved nerve sparing
461
Robotic surgery Positioning
| Different positioning Taped or strapped to bed frame to
prevent movement in steep Trendelenburg, increased risk for pressure points/nerve damage
462
Robotic surgery Positioning Trocars ? what is crucial
are fixed and can cause injury if patient moves-NMB crucial
| Increased risk of aspiration
463
Robotic surgery Trendenlenburg Respiratory stress –
patients with significant hx of lung disease cannot tolerate
464
Robotic surgery Trendelenburg position -
CO decreased by 10-30%, pts with preexisting HD can lead to ischemia/dysrhythmias
465
Robotic surgery Pneumoperitoneum can cause
extreme brady or asystole
466
Robotic surgery Trendelenburg RBF and GFR
decreased/ADH and aldosterone increased
467
Lithotomy with stirrups/boots (Less extreme than Trendelenburg)
CC300
Compartmentsyndrome/thrombus/Sciatic/obturator/femoral/peroneal/saphenous
Cephalad movement of diaphragm/ck ETT
300 ml auto return
468
Steep Trendelenburg
(more extreme changes from Lithotomy)
469
Lithotomy with stirrups/boots
(Less extreme than Trendelenburg)
470
Steep Trendelenburg advantage
Optimizes organ visualization
471
Steep Trendelenburg Hemodynamic changes CARDIAC (LSV)
Left ventricular filling pressure and CO decrease
Systemic vascular resistance and MAP increase
VQ mismatch
472
Steep Trendelenburg Hemodynamic changes RESPIRATORY D-CLF LVUPR
Decreased compliance
Decreased lung volume
Decreased FRC
```
Limited diaphragm movement
VQ mismatch
upper airway edema
pulmonary edema
Regurgitation – place OGT
```
473
Steep Trendelenburg CNS
Increased intracranial/Brain edema and intraocular pressure
474
Steep Trendelenburg- 3 extra interventions with arms (BBP)
Bilateral arms tucked at sides
Beware of fingers/table down
Padded arms/ulnar nerve/eyes (also taped)
475
Steep Trendelenburg/Pneumoperitoneum/Respiratory compromise Intervention: (PDI)
Pressure control
Decreased tidal volume,
Increased RR to maintain ETCO2
After intervention,
***watch for decrease in insufflation or
change from Trendelenburg to flat -> decrease pressure!***
476
Facial and airway swelling (Steep Tren) -
confirm airway movement BEFORE extubating
477
What happens with Spondylothesis
Anterior Subluxation
478
Epidermolysis BULLOSA which anesthesia preferred
Regional Anesthesia
479
Myotonic Dystrophy
General anesthesia doesn't stop contraction
480
Clinical Features of Familial Periodic Paralysis : Factor with Both HYPOKALEMIA and HYPERKALEMIA
Hypothermia
481
Good response to anticholinesterase (MG vs MS)
MG
482
Sensitive to both succ and NDNMB (MG vs MS)
Myasthenia Syndrome
483
How does kyphoscoliosis affect ?
Anterior + Lateral flexed spinal column
484
```
Manifestations of Myasthenic Syndrome
ProLA
ES
MC
RAD
```
Proximal limb weakness (Legs more than arms)
Exercise Improves stength
Muscle pain common
Reflexes absent or decreased
485
```
Manifestations of Myasthenia Gravis
FOB
EF
MU
RN
```
Extraocular,bulbar and facial muscle weakness
Exercise causes fatigue
Muscle pain uncommon
Reflexes normal
486
Myasthenic syndrome Gender more affected M/F
Affect males more often than females
487
Myasthenia Gravis more affected M/F
Affect females more often than males
488
Myasthenic syndrome Co-Existing Pathologic conditions
Small cell lung cancer
489
Myasthenia Gravis Co-Existing Pathologic conditions
Thymoma
490
Myasthenic Syndrome RESPONSE to muscle relaxants
Sensitive to succ and NDNMB
491
Myasthenic Syndrome RESPONSE to Anticholinesterases
POOR
492
Myasthenia GRAVIS RESPONSE to muscle relaxants
Resistant to Succ, Sensitive to NDNMB
493
Myasthenia GRAVIS RESPONSE to Anticholinesterases
GOOD
494
H2 Blockers
Cimetidine, famotidine, -tidine
495
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS and ANGIOTENSIN RECEPTOR
BLOCKERS (ARB) ➔
MPROVE INTRARENAL HEMODYNAMICS and HAVE RENOPROTECTIVE QUALITIES.
496
During a renal transplant which vessel supply the new graft?
Iliac artery
497
Where in the nephron is most of the blood reabsorbed?
PCT
498
What is spondylolisthesis?
Anterior subluxation of vertebrae
499
A patient with CREST syndrome is at risk for what during anesthesia?
Aspiration
500
What is a clinical feature of Myasthenia Gravis
Bulbar muscle weakness
501
CURCUMIN effects
```
Increase (Prolonged) aPTT, PT significantly
Inhibit thrombin (II) and Factor Xa
```
502
Complications of Prone position with Airway
ETT kinking, dislodgment
| Upper airway edema.
503
Complications of Prone position with NECK
Hyperextension or hyperflexion.
| -Cervical rotation: compromised blood flow to brain
504
Complications of Prone position with EYES
-Orbital pressure->central retinal artery occlusion,
supraorbital nerve.
-Corneal abrasion
505
Complications of Prone position with ABDOMEN
Pressure transmitted to epidural veins, increased bleeding.
506
Complications of Prone position with UE
Brachial plexus stretch. -Ulnar nerve compression.
507
Complications of Prone Position with LE
Flexion of hips: occlusion of femoral vein, DVT, kinking of vascular grafts
--Pressure lateral to fibula: peroneal nerve palsy
Pressure on iliac crest—lateral femoral cutaneous nerve.
508
In Prone position , Flexion of hips lead to (KOD)
Kinking of Vascular grafts
Occlusion of femoral vein
DVT
509
In Prone position, Pressure lateral to fibula leads to
peroneal nerve palsy
510
In Prone Position, Pressure on Illiac Crest leads to
Lateral femoral cutaneous nerve damage
511
TURP Important to determine
Size of the enlarged prostate or adenoma must be carefully assessed before the surgery, usually with cystoscopy, to determine if the procedure can be completed within two hours (ideally 1 hr or less). If unable, open prostatectomy should be performed to prevent TURP syndrome
512
```
ROBOTIC SURGERY ADVANTAGE
BIS
Improved nerve sparing
Blood loss
Hospital time
______continence
Improved ________rate
Incisions? Scaring
post op pain?
infection?
omplications?
```
```
Improved nerve sparing
< Blood loss
< Hospital time
Enhanced continence
Improved impotency rate
Small incisions/Less Scarring
Less post op pain
Decreased infection
Fewer complications
```
513
Ascending permeable to _____and not to _______
NaCL not to H2O
514
Region permeable to Water?
PCT and descending
515
Water and% absorption in each section
PCT 60-70% and NaCL
Loop 25% and NaCL
DCT 5% influenced by ADH
Collecting Variable influenced by ADH
516
3 most common complications of Prone
Post Operative vision loss
Cardiovascular compromise
Venous Air Embolism
517
Myasthenic Syndrome suspected for lung cancer patients undergoing, bronchoscopy, thoracoscopy and mediastinoscopy and WHAT ELSE SHOULD BE CONSIDERED> ?
Need to decrease doses of muscle relaxants should be
518
T10 for TURP why
T10 level, because the stretch receptors in the distended bladder cause pain higher than the coverage needed for bladder surgery.
519
Na replacement for TURP syndrome
100ml/hr of 3% hypertonic saline
| D/C when Na>120
