Pre-Op Flashcards
(75 cards)
1
Q
Learning Objectives
A
- State the key components of the Perianesthesia evaluation and how it fosters a safe surgical procedure
- Discuss the prime essential elements of the preoperative interview
- Define the ASA Physical Status Classification and its use
- Identify advantages and disadvantages of general anesthesia
- List the indications for regional block administration
- Locate the dermatome levels anatomically
- Describe various care principles such as preop testing and NPO guidelines
2
Q
What is the purpose of the Preop Assessment?
A
- To reduce morbidity and mortality asctd w surgery to prevent longer hospitalization and unnecessary cancellations*
- TO OPTIMIZE PATIENTS*
3
Q
Purpose of Preoperative Assessment
- Prepares patient ph_____ and m_____ for surgical procedure
- Obtain d______ tests and con_____ as needed
- Decreases potential de____ and can______ the day of surgery
- Identify and addresses potential pr_____ before the day of surgery
- Great time for preoperative patient t_____
A
- Prepares patient physically and mentally for surgical procedure
- Obtain diagnostic tests and consultation as needed
- Decreases potential delays and cancellations the day of surgery
- Identify and addresses potential problems before the day of surgery
- Great time for preoperative patient teaching
4
Q
Preanesthesia Evaluation and Goals
- Informs patient of the r___, b_____, and al_____ so that an informed con____ can be obtained
- Educates the patient regarding the plan of an______ care as well as perioperative events
- Assess if the patient is clinically op______ for planned surgical procedure
A
- Informs patient of the risk, benefit, and alternatives so that an informed consent can be obtained
- Educates the patient regarding the plan of anesthesia care as well as perioperative events
- Assess if the patient is clinically optimized for planned surgical procedure
5
Q
Types of Preoperative Assessments
(3)
A
- Surgicenter/Hospital face to face interviews
- Telephone interview
- Web based survey questionnaires
- however cannot do PE and labs with telephone interview
- however elderly, non-tech savy may be difficult to do web based preop assessment
6
Q
Preop Physical Assessment
- A__ - Linear increase in surgical risk resulting from increase comorbidities
- H_____/Actual W_____/V___ signs (for baseline)
- Em____ support to patient and family
- Assess patients und______ of preoperative instructions and teachings-opportunity for questions
- Discuss advance d______
- Identify essential ____ work or diagnostic work up
- Serum or Urine H_ _
A
- Age - Linear increase in surgical risk resulting from increase comorbidities
- Height/Actual Weight/Vital signs (for baseline)
- Actual weight* (not what they want to it to be) important to calc med dosages
- Emotional support to patient and family
- Assess patients understanding of preoperative instructions and teachings-opportunity for questions
- Discuss advance directives
- Identify essential lab work or diagnostic work up
- Serum or Urine H _ _
- Not all pts need preop labs, labs will be reviewed by PCP, anesthesia, and surgeon
7
Q
Preoperative Physical Assessment
- Medication history (pr_____ and O__/H_____)
- Nut_____ status
- Cog_____ assessment
- Lan____ barriers
- Cul_____/Soc____ assessment Complete ROS-documenting and reporting abnormal findings
A
- Medication history (prescribed and OTC/Herbal)
- Nutritional status
- Cognitive assessment
- Language barriers
- Cultural/Social assessment Complete ROS-documenting and reporting abnormal findings
- Herbal meds like “The G’s” - ginkgo, ginger, garlic*
- Check albumin for nutritional status (many drugs attach to albumin)*
8
Q
Herbal Medications
- Ephedra = (2)
- Garlic, Fish Oil, Alfalfa, Ginger =
- St. Johns Wort =
- Kava Kava =
- Valerian =
- Gingko =
- Viagra =
- All these meds should be held how long before surgery?*
- How about viagra, cialis?*
A
- Ephedra = arrhythmias, HTN
- Garlic, Fish Oil, Alfalfa, Ginger = Increased bleeding
- St. Johns Wort = Prolonged anesthesia effects
- Kava Kava = Potentiates benzodiazepines
- Valerian = Decreases symptoms of Benzos
- Gingko = May enhance bleeding
- Viagra = Releases Nitric Oxide
- All these meds should be held 7 days before surgery*
- Viagra stop 24hrs before surgery, Cialis stop 48hrs before*
9
Q
Previous response to Anesthetics
- A____ reactions (include l____)
- Delayed aw_____, Prolonged muscle par_____
- Nausea and Vomiting (ONFM)* =
- H____ness, My____
- Developed high f____ during surgery
- Adverse response in rel_____
A
- Allergies/Allergic reactions (include latex)
- Delayed awakening, Prolonged muscle paralysis
- Nausea and Vomiting (ONFM)* = Opioids, Nonsmoker, Female, Motion Sickness Hx
- Hoarseness, Myalgia
- Developed high fever during surgery
- Adverse response in relatives
10
Q
Previous Adverse Response to Anesthetics Notes
Important to ask about allergies bc (2) abx often used in OR
ONFM risk associated with each factor?
Treatment of PONV?
A
Cefazolin and Ancef often used in OR
Opioids, Nonsmoker, Female, Motion sickness Hx
- Each letter = 20% chance of post op NV
- Ex) Female nonsmoker who takes opioids = 80% of post op N/V
Triple Therapy Tx = ie scopolamine patch (muscarinic) before surgery, decadron during, zofran (5HT3 receptor)
11
Q
What is the most common post-op complication affecting ⅓ of the surgical population?
A
Post Op Nausea Vomiting (PONV)
12
Q
Food Allergy Correlation and Hypersensitivity to Latex
- B
- A
- K
- Ch
- Pl
- P
- Ch
- P
- T
- Po
- F
- Ap
A
- Banana
- Avocado
- Kiwi
- Chestnut
- Plum
- Peach
- Cherry
- Papaya
- Tomato
- Potato
- Figs
- Apricots
13
Q
Essential Areas Requiring Attention in Preop Interview
Which body systems (10)
A
- CNS
- CV
- Pulmonary
- Hepatic
- Renal
- Endocrine
- Heme/Coags
- Skeletal Muscle
- Reproductive
- Dentition
14
Q
CNS
- Cerebrovascular insufficiency (2)
- S_____
- If on meds- make sure _____ lvls
A
- Cerebrovascular insufficiency (CVA/TIA)
- Seizures
- If on anti-seizure meds- make sure therapeutic lvls
15
Q
CV
- Ex_____ tolerance
- An____ or chest pain
- Hx MI = what is the rule?
- H___ (treated and compliant), val___ disease
- Tachydys_____/AICD =
- Recent drug abuse?? =
A
- Exercise tolerance
- Angina or chest pain
- Hx MI = If past MI in last 3m → usually wait about 6m before any procedure to reduce risk of CV complications post-op
- HTN (treated and compliant), valvular disease
- Tachydysrhythmias/AICD (automated implantable cardiac defibrillator)
- Recent drug abuse?? = If recent drug abuse - won’t get surgery bc lots of street drugs interact with anesthesia drugs (lots of CI literature that says if you should cancel or not)
16
Q
Pulmonary
- (2)nea
- Cough with s_____ production
- As____/C____ - what to do?
- Pn_____
- Sm_____ history
- Sleep _____
- Recent URI- treated? do you have to hold surgery?
A
- Dyspnea or orthopnea
- Cough with sputum production
- Asthma/COPD
- Asthma/COPD = do we have a recept PFT if they’ve had a recent exacerbation (will also need referral to pulm)
- Pneumonia
- Smoking history
- Sleep Apnea
- Recent URI- treated?
We don’t cancel procedures anymore for URI (not lower just upper congestion, afebrile, runny nose)
17
Q
Hepatic and Renal
Hepatic
- J_______
- Consuption of E_____
- Hepa____
Renal
- D______, Renal in_____
- Dialysis pts = make sure __ and __ in optimal range
A
Hepatic
- Jaundice
- Consuption of ETOH
- Hepatitis
Renal
- Dialysis, Renal insufficiency
- Dialysis pts = make sure K and Na in optimal range
18
Q
Endocrine
- D_
- Th_____ pathology
- Ad____ gland dysfunction
A
- DM
- Thyroid pathology
- Adrenal gland dysfunction
19
Q
Coagulation disorders/Hematologic
- Coagulo_______ or in family
- Br_____/bl____ easily
A
- Coagulopathies or in family
- Bruises/bleeds easily
20
Q
Skeletal Muscle
- A_____, osteo_____
- W____ness
A
- Arthritis, osteoporosis
- Weakness
21
Q
Reproductive
- Ch____ bearing age, men____ history
- Pr_____
A
- Child bearing age, menstrual history
- Pregnancy
22
Q
Dentition
Why is dentition important?
- M______, L_____, Pr______ Teeth
- C___, Ven_____, Br____, Den____
- Anything r_____able
- Fangs, canines (if present…___)
A
Dentition is a biggie bc anything removable or protruding bc when using instrumentation - if knocks tooth into bronchus can cause embolus
- Missing, Loose, Protruding Teeth
- Caps, Veneers, Bridges, Dentures
- Anything removable
- Fangs, canines (if present…run)
23
Q
What is the most #1 risk factor before going into surgery?
Elective patients should be?
A
History of Myocardial Infarction
Delay 6 months POST MI to reduce perioperative morbidity
24
Q
Testing in Perioperative Setting
What labs/diagnostic tests to collect?
(5)
A
CBC
Coags
BMP
EKG
Chest Radiography
PFTs
25
CBC: Hemoglobin/HCT
* What level should surgical patient's Hgb be?
* Patients with (2) may need to be cleared by hematology
* Cardiac surgery patients should have a hemoglobin level \>7g/dL to reduce cardiac complications as a result of surgery. Transfuse for Hgb of 7 or less
* Patients with anemia or thrombocytopenia prior to major surgery may need to be seen and cleared by hematology
26
Platelet Count
* \> ____ for most surgical cases
* \> ____ for neurosurgery and ocular procedures
* \> ____ for epidural anesthesia
* \>50k for most surgical cases
* \>100k for neurosurgery and ocular procedures
* \>80k for epidural anesthesia *bc we don’t want them to develop a hematoma in spinal cord that causes compression*
* *Book says 50k but we like 90k*
27
Coagulation Studies
Do you always need coag studies?
No, only perform if clinically indicated by H&P exam
28
Basic Metabolic Profile (BMP)
When should you get a BMP?
Especially (2)
Recommend to obtain for routine screening on patients with coexisting disease
Especially Diabetics and renal patients
29
EKG
Should we get an EKG on everyone?
Routine screening asymptomatic patients undergoing low risk surgery is not recommended
30
Chest Xray
Should we get a Cxray on everyone?
Warranted based on scheduled surgical procedure
31
Pulmonary Function Tests
Do we get PFTs for everyone?
Not routine screening
May be required for lung surgery or pt has underlying history of COPD or surgery is dependent on lung volume measurements
32
Airway Assessment
=
Will usually check airways by looking in the mouth preop for everyone incase they need to be intubated
33
Medications to be held 7 days before surgery
(5)
1. Clopidogrel (Plavix)
2. Herbal supplements
3. Aspirin
4. Garlic tablets
5. Vitamins
*Must consult with cardiologist for important meds such as plavix before dc’ing*
34
Medications to hold 5 days before surgery?
(1)
Coumadin (Warfarin)
35
Medications to hold 3 days before surgery?
(1)
NSAID's
36
Medications to hold 1 days before surgery?
(2)
Lovenox
ASA (however can be continued for most surgical procedures)
37
Medications to hold the day of surgery?
(3)
* Diuretics *(Hold diuretic bc don’t want them to pee during surgery and get a UTI)*
* Oral hypoglycemic agents
* MAO Inhibitors (*Effects many anesthesia drugs)*
38
Medications to take with a _SIP_ of H20
* Anti\_\_\_\_\_\_\_\_ (2)\*
* (1) Blockers (SCIP!)
* (1) Blockers
* S\_\_\_\_\_\_
* Anti\_\_\_\_\_\_\_
* Chronic _____ medications\*
* Drugs to treat \_\_\_\_\_\_\* (inform anesthesia team)
* Antihypertensives (ACES & ARBS)\*
* Beta Blockers (SCIP!)
* Calcium channel blockers
* Statins
* Anticonvulsants
* Chronic pain medications\*
* Drugs to treat addiction\* (inform anesthesia team)
39
NPO Guidelines
Usual instruction? To get a minimum of how many hours after a light meal?
* ASA Fasting Recommendations:
* Clear liquids =
* Breast milk =
* Infant formula
* Nonhuman milk =
* Light meal =
* Regular meal =
Usual instruction- NPO after midnight, or a minimum of 6 hours after a light meal
* ASA Fasting Recommendations:
* Clear liquids 2h
* Breast milk 4h
* Infant formula
* Nonhuman milk 6h
* Light meal 6h
* Regular meal 8h
*Dt aspiration precautions bc when they are unconscious will lose protective reflex*
40
Fluid Considerations
* Patients may be *Nil Per Os* (NPO) for up to __ hours before surgery
* **Inpatient =** ______ containing fluids should be started when NPO to prevent (1)
* **Outpatient =**
* Patients may be *Nil Per Os* (NPO) for up to 12 hours before surgery
* **Inpatient =** Dextrose containing fluids should be started when NPO to prevent lean muscle catabolism
* **Outpatient =** Fluid status should be assessed and IV fluid administered accordingly
41
What about piercings?
**Have patient move all piercings, no matter how cute they look!**
42
ASA Physical Status Classification
_List each description into ASA Classes 1-6_
A patient with mild systemic disease with no functional limitations
A moribund patient who is not expected to survive without operation
A healthy patient
Brain dead whose organs are being harvested
A patient with severe systemic disease that is a constant threat to life
A patient with severe systemic disease resulting in functional limitations
1. A healthy patient
2. A patient with mild systemic disease with no functional limitations
3. A patient with severe systemic disease resulting in functional limitations
4. A patient with severe systemic disease that is a constant threat to life
5. A moribund patient who is not expected to survive without operation
6. Brain dead whose organs are being harvested
* *\>65yo automatically at least a 2*
* *Stage 4 = ESRD with dialysis patients*
43
Considerations Influencing the Choice of Anesthetic Technique
## Footnote
**✔** Coexisting d\_\_\_\_ that may or may not relate to the reason for surgery (GERD, asthma, recent MI)
**✔** Surgical s\_\_\_\_ being operated on
**✔** P\_\_\_\_\_ of the patient during surgery
**✔** A\_\_\_/maturity of the patient
**✔** Patient pr\_\_\_\_\_\_
**✔** Em\_\_\_\_\_\_\_ or el\_\_\_\_\_
**✔** L\_\_\_\_\_\_\_ of planned surgical procedure
**✔** Coexisting disease that may or may not relate to the reason for surgery (GERD, asthma, recent MI)
**✔** Surgical site being operated on
**✔** Position of the patient during surgery
**✔** Age/maturity of the patient
**✔** Patient preference
**✔** Emergency or elective
**✔** Length of planned surgical procedure
44
Types of Anesthetics
1. **Minimal Sedation/Anesthesia:** Appropriate response to \_\_\_\_l\_ stimuli
2. **Moderate Sedation/Analgesia (Conscious sedation):** Purposeful response to \_\_\_\_\_/\_\_\_\_\_ stimulation
3. **Deep Sedation/Analgesia (MAC):** Purposeful response to re\_\_\_\_\_ or n\_\_\_\_\_\_ stimulation
1. **Minimal Sedation/Anesthesia:** Appropriate response to verbal stimuli
2. **Moderate Sedation/Analgesia** (Conscious sedation): Purposeful response to verbal/tactile stimulation
3. **Deep Sedation/Analgesia (MAC):** Purposeful response to repeated or noxious stimulation *(**surgeon will likely give the local anesthesia to the site.)*
45
General Anesthesia Involves
1. Complete loss of C\_\_\_\_\_ness
2. Complete loss of S\_\_\_\_\_\_
3. Complete loss of P\_\_\_\_\_
4. Complete loss of A\_\_\_\_\_ness
1. Complete loss of consciousness
2. Complete loss of sensation
3. Complete loss of pain
4. Complete loss of awareness
46
Peripheral Nerve Blocks
Why are peripheral nerve blocks increasing in frequency?
What is one of the advances of using a peripheral nerve block?
Are there serious complications with peripheral nerve blocks?
Peripheral nerve blocks are increasing in frequency due to recent **advances in ultrasound technology**
PNB’s have may advances including **decreased narcotic requirements** and increased patient satisfaction
Serious complications are rare but do occur
(Choosing to perform PNB requires consideration of each patient and surgical procedure, as well as individual surgeon preferences)
47
Indications for regional block
* O\_\_\_\_\_\_\_-sparing population
* Sleep ______ Patients
* Ob\_\_\_\_\_
* Co\_\_\_\_\_\_
* Ad\_\_\_\_\_ General Anesthesia sequelae
* Opioid-sparing population
* Sleep Apnea Patients
* Obesity
* Comorbidities
* Adverse General Anesthesia sequelae
48
Contraindications to Nerve Block
* Needle ph\_\_\_\_\_ or otherwise unc\_\_\_\_\_
* Excessive sedation (adults)
* In\_\_\_\_\_\_ (local and untreated systemic)
* Antic\_\_\_\_\_\_\_?
* Pre-existing n\_\_\_\_\_ injury?
* Surgery specific (e.g. motor block and post-op neuro exam)
* Block specific (e.g pulmonary disease and interscalene block)
* Needle phobia or otherwise uncooperative
* Excessive sedation (adults)
* Infection (local and untreated systemic)
* Anticoagulation?
* Pre-existing nerve injury?
* Surgery specific (e.g. motor block and post-op neuro exam)
* Block specific (e.g pulmonary disease and interscalene block)
49
Advantages of Regional Blocks
(2)
Avoidance of general anesthesia
Post operative pain control
50
Avoidance of General Anesthesia (PNB)
* Decreased Post op (1)
* Decreased sore th\_\_\_\_
* Decreased post op de\_\_\_\_\_
* No airway ob\_\_\_\_\_ and respiratory dep\_\_\_\_\_
* ________ time to discharge from PACU
* Increased patient sat\_\_\_\_\_\_\_
* Decreased PONV
* Decreased sore throat
* Decreased post op delirium
* No airway obstruction and respiratory depression
* Decreased time to discharge from PACU
* Increased patient satisfaction
51
Post Operative Pain Control (PNB)
* Decreased n\_\_\_\_\_\_ requirements and associated adverse side effects (e.g. nausea, pruritis, sedation, confusion, respiratory depression)
* Earlier recovery of b\_\_\_\_\_ function
* Improved tolerance of ph\_\_\_\_\_ therapy
* Improved p\_\_\_\_ scores, but not always in PACU
* Increased patient s\_\_\_\_\_\_
* Decreased narcotic requirements and associated adverse side effects (e.g. nausea, pruritis, sedation, confusion, respiratory depression)
* Earlier recovery of bowel function
* Improved tolerance of physical therapy
* Improved pain scores, but not always in PACU
* Increased patient satisfaction
52
Disadvantages of PNB
Are few but include
* Infra\_\_\_\_\_\_\_ requirements and potential for surgeon de\_\_\_\_
* F\_\_\_\_\_ blocks
* Intraoperative a\_\_\_\_ness and non-operative discomfort (e.g. po\_\_\_\_\_)
* M\_\_\_\_ block
* Variable d\_\_\_\_\_\_ (~4-40 hours)
* Rare serious complications (e.g. local anesthetic t\_\_\_\_\_, nerve in\_\_\_\_)
* Infrastructure requirements and potential for surgeon delays
* Failed blocks
* Intraoperative awareness and non-operative discomfort (e.g. positioning)
* Motor block
* Variable duration (~4-40 hours)
* Rare serious complications (e.g. local anesthetic toxicity, nerve injury)
53
Common Peripheral Nerve Blocks
* (1): Trigeminal, Retrobulbar
* (1): Cervical Plexus, Laryngeal nerve block
* (1): Brachial plexus, Interscalene, Bier Block
* (1): Femoral, sciatic, ankle
* Face: Trigeminal, Retrobulbar
* Neck: Cervical Plexus, Laryngeal nerve block
* Upper extremity: Brachial plexus, Interscalene, Bier Block
* Lower Extremity: Femoral, sciatic, ankle
54
Spinal Block (SAB)
Spread of local anesthetic agent into the tissues of the CNS within the CSF is determined by:
1. D\_\_\_\_ injected (ml administered)
2. L\_\_\_\_\_ solubility
3. Local bl\_\_\_ flow
4. Surface _____ exposed
1. Dose injected (ml administered)
2. Lipid solubility
3. Local blood flow
4. Surface area exposed
55
MH is a Crisis
What is the best way to prevent MH?
Best prevented by healthcare providers is being **educated and prepared**
56
**A rare inherited disorder of skeletal muscle metabolism that is triggered in susceptible individuals resulting in hyperthermia, skeletal muscle damage, a hypermetabolic state, and death if not recognized or left untreated.**
Malignant Hyperthermia
57
Triggering Agents for Malignant Hyperthermia
* (5) -flurane
* (1) - thane
* (1) - choline
* Desflurane
* Enflurane
* Isoflurane
* Methoxyflurane
* Sevoflurane
* Halothane
* Succinylcholine
58
Physiologic Mechanism of Malignant Hyperthermia
* A bio\_\_\_\_\_\_\_ chain reaction
* Abnormal handling of intracellular **(1)** levels caused by the inability of the **(1)** to regulate Calcium
* A hy\_\_\_\_metabolic crisis is seen as manifested by respiratory and metabolic \_\_\_\_osis, \_\_\_\_cardia, cardiac \_\_\_\_\_\_, skeletal muscle r\_\_\_\_\_\_, and rh\_\_\_\_\_\_\_\_.
* A biochemical chain reaction
* Abnormal handling of intracellular Calcium levels caused by the inability of the muscles to regulate Calcium
* A hypermetabolic crisis is seen as manifested by respiratory and metabolic acidosis, tachycardia, cardiac dysrhythmias, skeletal muscle rigidity, and rhabdomyolysis.
59
Malignant Hyperthermia Pathophysiology
1. Triggering agent binds to (1) R\_\_\_\_\_ receptor
2. Ca channel stays _____ resulting in high Ca levels
3. High levels of Ca causes muscles to \_\_\_\_\_\_
4. The \_\_\_\_\_\_metabolic state sets up a dangerous positive-feedback cycle
1. Triggering agent binds to (Ca Gatekeeper) Ryanodine receptor
2. Ca channel stays open resultting in high Ca levels
3. High levels of Ca causes muscles to contract
4. The hypermetabolic state sets up a dangerous positive-feedback cycle
60
Clinical Manifestations of Malignant Hyperthermia
Resulting from the increased myoplasmic calcium concentration.
**\*First Sign**\* =
**\*\*Masseter Muscle Spasm…Generalized Muscle Rigidity\*\*\***
61
Hypermetabolism Results in MH
* \_\_\_\_\_capnia
* \_\_\_\_xemia
* \_\_\_\_\_cardia
* \_\_\_\_osis (Respiratory/Metabolic)
* _\_\_\_\_\_ PRODUCTION: Elevated T\_\_\_\_ (late sign)_ *late sign is like 3min, can get as high as 110F*
* Hypercapnia
* Hypoxemia
* Tachycardia
* Acidosis (Respiratory/Metabolic)
* _HEAT PRODUCTION: Elevated TEMP (late sign)_ *late sign is like 3min, can get as high as 110F*
62
Resulting from rhabdomyolysis
* Increased C\_\_ and __ concentrations
* Cardiac (1)
* (1) uria
* Renal \_\_\_\_\_
* Increased CK and K concentrations
* Cardiac arrhythmias
* Myoglobinuria
* Renal failure
63
Genetics and MH
Over __ genetic defects have been associated with MH
**MH Susceptible Individuals**
* CCD (1) and MmD (1)
* BMD (1)
* Myo\_\_\_\_
* DMD (1)
Over 80 genetic defects have been associated with MH
* Those who carry the gene may be completely unaware of the risk unless they have a family member or they themselves have developed an MH reaction.
(50%/50% from parents, 25% chance to children)
**MH Susceptible Individuals**
* CCD (Central Core Disease) and MmD (Multiminicore Disease)
* Becker’s Muscular Dystrophy (BMD)
* Myotonias
* Duchenne’s Muscular Dystrophy (DMD)
64
Incidence of MH
1 in 10,000 ______ , 1 in 50,000 \_\_\_\_\_
High incidence areas in the United States include:
* W\_\_\_\_\_
* N\_\_\_\_\_\_
* West V\_\_\_\_
* M\_\_\_\_\_
_\*\*_ **_(1)_** _Population has a high incidence of MH.\*\*\*_
1 in 10,000 Children, 1 in 50,000 Adults
High incidence areas in the United States include:
* Wisconsin
* Nebraska
* West Virginia
* Michigan
_\*\*_ **_Swedish_** _Population has a high incidence of MH.\*\*\*_
65
Current treatment of MH
**(2)**
**Dantrolene\***
**Ryandex**\*
66
Dantrolene
**MOA**
**Dose**
With every ___ minutes of delay between crisis recognition and administration of dantrolene sodium, there is a \_\_\_% increase in complications, including death
**Works on the ryanodine receptor preventing the release of calcium**
**2.5mg/kd in sterile distilled water q5 min until symptoms resolve**
* Eg. 85kg \* 2.5mg= 212mgs
* Each vial contains only 20mg
* Dissolve 20mg bottle in 60 ml of sterile preservative free water
**With every 20 minutes of delay between crisis recognition and administration of dantrolene sodium, there is a 30% increase in complications, including death**
67
Ryanodex
Indicated for tx of MH in conjunction with appropriate supportive measures and for prevention of MH patients at high risk
How to reconstitute?
* Use 5ml of sterile water to reconstitute a vial
* Should take less than 10 seconds
* In most cases, 1 vial is required to meet the patients loading dose and can be prepared and administered in 1 minute
68
Ryanodex Treatment Dose
For pediatric and adult patients, administered via **(1) route** at a minimum dose of **\_\_\_mg/kg**. If the physiologic and metabolic abnormalities of MH continue, administer additional IV boluses up to a maximum cumulative dose of **\_\_mg/kg**
For pediatric and adult patients, administered via **IVP route** at a minimum dose of **1mg/kg**. If the physiologic and metabolic abnormalities of MH continue, administer additional IV boluses up to a maximum cumulative dose of **10mg/kg**
69
Ryanodex Prophylactic Dose
**\_\_\_\_mg/kg IV** over **\_\_ minute __ minutes** prior to surgery
**2.5mg/kg IV** over **1 minute 75 minutes** prior to surgery
70
Diagnostic Tests for MH
(2)
1. **Genetic Testing (Ryanodine Receptor RYR1 gene sequencing)**
2. **Caffeine-Halothane contracture test (CHCT)**
71
Genetic Testing (Ryanodine Receptor RYR1 gene sequencing)
## Footnote
Presence of causative mutation in (1) gene is diagnostic for MH susceptibility
Do all patients who get MH have this gene?
What is the sensitivity of this genetic test?
Presence of causative mutation in RYR1 gene is diagnostic for MH susceptibility
Not all proven MHS individuals have been found to harbor a causative mutation.
Sensitivity of the genetic test depends upon factors including the population selected and the methodology of the test.
72
Gold Standard for MH Diagnosis
=
**Caffeine-Halothane contracture test (CHCT)** **muscle contracture test**
73
Muscle Contracture Test
How is the test done?
What is the sensitivity?
Biopsy of skeletal muscle is sampled from the thigh to assess muscle contracting properties when exposed to ryanodine receptor agonist (eg. caffeine, halothane)
Abnormally high levels of contractile force indicated MH susceptibility
Close to 100% sensitivity (false negatives are rare)
74
MH Treatment Protocol
1. *\_\_\_\_\_\_ triggering agent*. CALL FOR \_\_\_\_.
2. (1) with *high flow \_\_\_% O2*
3. Administer (1) 1-2 meq/kg IV
4. Mix (1) with 60ml sterile distilled water at \_\_\_mg/kg IV STAT
5. Apply (1) (blanket, lavage, cool irrigations, IV fluids)
6. Administer (1) doses of dantrolene- up to \_\_mg/kg
7. Treat *hyper\_\_\_\_/ ventricular \_\_\_\_\_*
8. Consider *invasive m\_\_\_\_\_\_*
9. Contact (1) at 1-800-644-9737
1. *Discontinue triggering agent*. CALL FOR HELP.
2. Hyperventilate with *high flow 100% O2*
3. Administer NaHCO3 1-2 meq/kg IV
4. Mix *dantrolene sodium* with 60ml sterile distilled water at 2.5mg/kg IV STAT
5. Apply *cooling measures* (blanket, lavage, cool irrigations, IV fluids)
6. Administer additional doses of dantrolene- up to 10mg/kg
7. Treat *hyperkalemia/ ventricular dysrhythmias*
8. Consider *invasive monitoring*
9. Contact MHAUS at 1-800-644-9737
75
Post Crisis Intervention
1. Administer *dantrolene* \_\_mg/kg every **\_***-*\_ hours for \_\_**-**\_\_ hours or a continuous infusion of \_\_\_\_mg/kg/hr for the next __ hours
2. Monitor for (1) for 24 hours- rate is \_\_%
3. Monitor *el\_\_\_\_\_, blood g\_\_\_, C\_\_, core t\_\_\_\_\_, _____ output and color, co\_\_\_\_\_ studies*
4. Monitor for signs of (1)
1. Administer *dantrolene* 1mg/kg every 4-6 hours for 24-48 hours or a continuous infusion of 0.25mg/kg/hr for the next 24 hours
2. Monitor for *reoccurrence* for 24 hours- rate is 25%
3. Monitor *electrolytes, blood gases, CK, core temperature, urine output and color, coagulation studies*
4. Monitor for signs of *rhabdo*
