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System Review Flashcards

1
Q

preeclampsia

A

neuro: AMS, H/A, visual, cerebral edema, seziure, intracranial hemorrage #1 cause death
cardiac: HTN, elevated SVR, hypovolemia
pulm: airway edema, pulm edema (increase PCWP, decreased CO, excess fluid admin)-low colloid oncotic pressure and increase vascular perm predipose

GI: capsule distention, hemorrage, rupture, HELLP

renal: oliguria (decrease GFR), proteinuria from increase glomerular perm
heme: plt activation <100K, hypocoag, increased fibrinolysis
fetal: IUGR, decreased uteroplacnetal perfusion (placental infarcts), premature, abruption

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2
Q

Pregnancy for non-OB surgery

A

Neuro: decreased MAC and increased sensitivity to LA

cards: aortocaval compression predisposing to hypotension
pulm: difficult airway, low FRC predisposing to desaturation

GI: aspiration risk

Fetal: teratogencity (postnatal changes function or form, weeks 1-6), spontaneous abortion, premature labor, fetal mortality

Heme: thromboembolism

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3
Q

Evaluate the nature of cardiac dz

A
  1. FocusedHistory: -known diagnosis, past evaluations/hospitalizations, tests, meds/compliance
    - cardiac sx (past and current): exercise tolerance, CP, SOB, syncope, orrthopnea, palpitations
  2. PE: signs for HF -Rhythm, murmurs, S3 gallop, crackles, edema, JVD
    3: Labs: CXR EKG, echo
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4
Q

HTN consideration head to toe

perioperative risks,

preop assessment

potential causes

A

Head to toe

neuro: shift in cerebral autoregulation, stroke, retinopathy
cards: LVH, CAD/MI, arrythmia, CHF (diastolic dys)
renal: overactivity of renin angiotensin-aldosterone system

concerns : BP instability, arrythmias, MI, stroke, CHF, hypoperfusion/end organ ischemia w reduction

Preop:

History:

  • cause (essential, coartation aorta, OSA/obesity renal, endocrine-pheo, hyperaldosterone, cushing, pheo, thyroid/parathyroid),
  • degree of control, baseline, meds
  • end organ effects

PE: signs CHF

Labs: BUN/Cr-renal involement, NA K diruetic effects

EKG for LVH, arrythmia, ischemia, strain

CXR: cardiomegaly, pulm edema

Goal: keep BP within 20% of baseline

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5
Q

Concerns for a aneursym repair

A

Anesthesia

Difficult airway-

compression (airway compression, SVC syndrome edma), DLT

Cross clamp

neuro

Paraplegia- Loss sensory and motor with intact vibration and proprioception (ASA syndrome); epidural hematoma if neuraxial performed

Stroke: emboli, hypotension

CV

Aneurysm: rupture, thrombosis, compression (SVC, AI MI, CHF

Pulm

Post op pulmonary dysfxn from manipulation of diaphragm and lungs

Damage to phrenic or RLN

Heme

Coagulopathy: activation of coagulation (aneurysm thrombogenic), DIC

dilution effects of massive transfusion,

Renal

Post op AKI

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6
Q

hypotension…what do you do

A
  1. 100% oxygen
  2. confirm adequate ventilation and oxygenation (PTX, broncospasm, anaphlaxisis)
  3. evaluate monitors
    - EKG: look for ischemia, hyperK, hypoCa, and arrythmia
    - PIP, PEEP, MV, capnography (broncospasm, anaphalaxsis)
  4. treat with fluids blood pressors PRN
  5. more access/monitors
  6. continue to eval cause
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7
Q

obesity

A

o Anesthesia: difficult airway management, patient positioning, altered drug effects (sensitivity), sensitivity to anesthetics, BP cuff

neuro: stroke, obesity hypoventilation syndrome,

CV: difficulty eval cardipulm status 2/2 sedentary lifestyle, HTN, CAD, phtn,

Pulm: rapid desat w apnea (decreased FRC, high v02), OSA/pickwickian, post op apnea, restrictive lung dz, pHTN

GI: nonalcoholic fatty liver, GERD w abdomen pushing belly up, delayed gastric emptying

Endocrine: DM o

Heme: DVT/PE, wound infection

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8
Q

Types of apnea

apnea

hypoapnea

obesity hyoventilation syndrome

A
  1. apnea cessation airflow >10 sec w >4% drop sat, >5 per hr
  2. hypoapnea >50% cessation in airflow, >4% drop sat, >15/ hr
  3. OHS 2/2 obesity/OSA: BMI>30, daytime arterial hypercapnea >45 nocternal hypoxia, polycythemia
  4. Pickwickian: severe form OHS chronic hypovent –>pulm HTN and RVF
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9
Q

hypothermia

A

neuro: AMS, delayed awaking

Cardiac;: myocardial depression, vasoconstriction (increased epi/NE levels), shivering (increased O2 consumption,increased PVR

Heme: left shift of hgb-O2 dissociation curve, plt dysfunction, poor wound healing/infection

other: decreased drug metabolism

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10
Q

burns

A

Anesthesia:increase free fraction opioid benzos, 25-30% burns resistance to NDMB at 72 hr, increased binding to alpha 1 glycoprotein, increased fetal Ach R (resistant to NDM

Neuro: head injury

Cards: hypovolemic-leaky capillaries (Parkland)

pulm: inhalational injury–>VQ mismatch, CO posioning (cooximetry) edema

GI: curling ulcer, aspiration risk

Heme: infectionsepsis/ disrupted skin barrier

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11
Q

Machine check

A
  1. check for emergeny ventilation equiptment: ambu suction
  2. check high pressure system: cylinders (1/2 full: 1000PSIG) and pipeline pressures (50-55 PSIG)
  3. check low pressure system: (vaporizers filled and caps tight, flowmeters cant deliver hypoxic mixture and tested through full range, negative pressure test (bulb to common gas outlet >10 sec)
  4. check scaavangeing: connection of APL to scavaneging system, NPRV: apl open and O2 flow low should collapse and gausge read 0, PPRV: APL open and and flush O2, bag should distent and read no more than 10 cm H20
  5. check breathign system: calibrate O2 monitor to RA and 100% oxyegn, inspect ciruit and CO2 absorber, Postive pressure leak test circuit (>30 10 seconds)
  6. check bmanual and automated breathign system: place bag on Y piece and set paremeters for pt, check this under manual and automated ventilation
  7. monitors
  8. machine final position: APL open, vaporizer off, flow off, manual vent selected
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12
Q

Liver disease

A

o Neuro: 1. Wernicke encephalopathy (ETOH thiamine def) 2. hepatic encephalopathy (production ammonia by intestinal bacteria)

o Pulm: 1. ascites decrease FRC 2. portopulmonary HTN 3. HPS

o GI; increased risk aspiration

o Renal: hepatorenal syndrome

o Heme: 1. SBP 2. plt dysfunction 3. coagulopathy

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13
Q

cirrhosis

A

heapatic necrosis, fibrosis, and nodal regeneration/ leading to portal HTN >10mmHg. causes ETOH, hepatitis, toxins

Anesthesia:

1) paralysis: may need more larger initial dose due to larger VD, decreaed proetin binding larger free fraction may off set this, and impaired metabolism few doses may be needed
2) citrate intoxication more likely w blood
3) psueocholinesterase def

Neuro: encephalopathy AMS, asterxisis, hyperreflexa, wernicke korsakoff (more permeable BBB, ammonia broken down from blood in GI tract or transfusion)

Cards: hyperdynmaic state =high mixed venous(increased CO, low SVR, anemia, systemic shunts), systemic AV shunts

resp: decreased FRC and restrictive dz from ascites, increased AV shunts, plerual effusions, inhibition of HPV (from vasodilating substances - VIP, glucagon)–>hypoxemia, resp alkalosis

GI: Portal HTN

ascities (2/2 portal HTN, hypoalbumin, renal rentention of fluids)

varices/hemorrhids,

aspiration risk, delayed gastric emptying

renal: decrease renal perfusion, sodium retentiom. (increase in total body andvolume but decrease in effective volume, HRS (prerenal oliguria w NA retention, azotemia, and ascites

Heme: thrombocytopenia (splenic sequestration), anemia (bleeding, RBC destruction, malnutritio) SBP

Electrolytes: hyponatremia (dilutional), hypokalemia (diuresis or hyperaldosteronism), hypoalbumin, hypoglycemia

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14
Q

esophageal cancer

A

cardio: often after ETOH and smoker, high risk post op a fib
pulm: smokers often, chronic aspiration–>pulm fibrosis,

GI: nutrional status poor (increased MM), liver fxn, aspiration risk (obstruction, altered motility and spincter dysfunction

chemo: doxorubicin (cardiomyopathy, belomycin lung, radiation (pnumonitis, pericarditis

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15
Q

chronic alcoholic

A

Anesthesia: intoxiciation effect on MAC

neuro: AMS, encephalopathy, wernicke korsaoff (ataxia, confusion, occular issues; tx thiamine), withdrawl (sezizures DT)
cards: acute HTN tachy; cardiomyopathy, arrythmia
resp: smoker?
gi: ulcer, cirrhosis, aspiration risk
heme: pancytopenia

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16
Q

RA

A

CV: pericardial thickening/pericarditis//effusion, myocarditis/fibrosis, vasculitis, AR, CAD from steriods, conduction defects, vasculitis

pulm: pleural effusion, pulm nodules, pulm fibrosis

Heme: anemia, Aspirin induced plt dysfxn, thrombocytopenia,

endocrine: adrenal insufficiency (chronic steriod use), immunesuppression from steriods and antiinflammatory meds

Joint involvement/difficult intubation: cervical spine (alantoaxial subluxation, >5mm alanto odontoid distance), TMJ, cricoarytenoid joint (hoarse voice, small ETT)= difficult intubation

liver and kidney dysfunction

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17
Q

Ankylosing spondylosis

A

neuro: nerve root compression, cauda equina syndrome, uvetitis, parathesia, high block 2/2 smaller epidural space, c spine/TMJ involvement
cards: AI, condution defects,
resp: restrictive lung dz, impossible trach if stuck in neck flexion, difficult airway
gi: UC, crohns

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18
Q

SS head to toe

A

CNS: cerebral thrombosis, painful/vasoocclusive crises, deficits from stoke/seizures

Cardiac: CHFfrom chronic hypoxia, hemochromatosis, MI,

pulm: increased intrapulm shunting, ACS

GI: nonconjugated hyper bili from hemolysis, bile cholelithaisis,

renal: meduallary infarcts leading to isothenuria

Heme: splenic infarcts, aspetic necrosis, osteo, infection (asplenic), aplastic anemia(Parovovirus/folate decreased rbc production+ reduced life span (20 vs 120 days)–>profound anemia), transfusion, anemia

Endocrine: hemachromatosis-DI, hepatomegaly, adrenal insufficiency, hypothyroidism, hypopara

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19
Q

risks factors for aspiration

A

delayed gastric emptying: autonomic neuopathy, acute abdomen, pain, cirrhosis, chronic alcohol abuse,

pregnancy

bowel obstruction

GERD

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20
Q

DM

A

Neuro: peripheral neuropathy, retiniopathy

Cards: autonomic neuropathy: silent MI, resting tachycardia, lack HR varibility w respirations, orthostasis, insensitivity to atropine and propranolol, lack HR response to hypovolemia, impaired vasoconstriction (susceptible to hypothermia), lack sweating, impotence

CAD, HTN, cardiomyopathy, PVD, MI

Resp: difficult intubation stiff join syndrome (TMJ, AO, cervical spine-prayer sign)

GI: gastroparesis (early satiety)

renal: nephropathy
endocrine: hyper/hypoglycemia, DKA, NKHC

Heme: impaired phagocytosis

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21
Q

stridor after thyroidectomy

A

Post extubation airway obstruction/ stridor

Hematoma

Edema

Post intubation croup

Tracheolamacia

laryngospasmm

RLN injury-partial hoarseness, complete-aphonia, aspiration risk b/l partial laryngeal obstruction (abduction of VC)

Hypocalcemia removal of parathyroid 1-3 days later

Residual paralysis (MG common in hyperthyroid pts)

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22
Q

ESRD

A

Anesthesia:

decreased protein binding–>enhanced drug effect: barbs and benzo, etomidate:

active metabolites dependent on renal excretion: keta,ine, morphine, meperidine,

increased BBB permeability and uremic toxins, effects anesthetics may be enhanced

neuro: urremic encephalopathy, peripheral/autonomic neuropathy,

cards: accelerated CAD, fluid overload, CHF, HTN, pericarditis, arrythmias, autonomic neuropathy, conduction blockade
resp: pulm edema, pleural effusion

GI: delayed gastric empyting; bleeding,

endocrine:

  • hyper: K, mAg, Po4, uric acid
    hypo: na ca, hypoalbumin,

met acidosis

heme: anemia (low EPO), plt and WBC dysfunction

endocrine; insulin resistance, 2 hyperparathyroidism , high TG

23
Q

delayed emergence

A

ABCs: hypoxia, hypercarbia, hypotensions

Drugs: opioids, paralysis, benzos

Metabolic: hypoglycemia, hyponatremia, hypermagnesium (OB), hyperosmolarity

Neurologic: stroke (embolic, thrombotic, ischemic), postictal, ongoing ischemia (ICP, vasospasm, herniation) hematoma, edema tension pneumocephalus, hydrocephalus

other: hypothermia

24
Q

How to manage ICP

A

Eval ABCs and etiology: avoid hypoxia and hypercarbia

Increase venous drainage

elevate head 15-20 degrees if hemodynamically

ensure no venous obstruction (esp if C collar in place)

diureticsadmin mannitol: (reduces ICP by osmotically shifting fluid from brain to intravascular space, decrease production CSF, induce reflex cerebral vasoconstriction 2/2 decreasing blood viscosity(lasts 6 hr)

risktransient increase intravascular volume can increase BP & decrease ICP (increase transmural pressure): hazard to unrupture aneurysm, AVM, expanding hematoma (mod elevated ICP can serve to tamponade the lesions

elderly: rapid diuresis shrink brain and tear bridging veinssubdural hematoma

increase vascular volume poorly tolerated by HF

cerebal edema if BBB not intact

furosemide

keep in mind that in presence of hypovolemia this an lead to hypotension and worsen cerebral ischemia

hypertonic saline

admin barbiturate/propofol (reduced ICP 2/2 cerebral vasoconstriction) and CMR02

risk of hypotension when admin large doses for cerebral protection

hyperventilation to PaC02 25-30 if other methods unsuccessful and ICP elevation was so severe that there was risk of brain stem herniation

too much cerebral vasoconstriction can leadto cerebral injury

effects temporary (6-12 hrs) since Hc02 levels in CSF are adjusted for the change in PaC02

between Pac02 20-80 CBF changes 1ml/100g per 1mmHg change PaC02

If ICP severe requires immediate tx: intraventricular drainremove CSF (no more than 5cc/min).

Too much can cause brainstem herniationHTN/hypotension/bradycardia/tacycardia

if lumbar catheter can cause herniation if obstructive hydrocephalus (obstruction proximal to superior sagittal sinus

steroids if brain tumor for vasogenic edema, decrease CSF production?

if at risk for seizures implement seizure ppx to avoid increases CMR02

change agent (volatile to TIVA)

25
Q

muscular dystrophy

A

Anesthesia: rhabdo to succ/volatiles, sensitive to resp depressants

cards: EKG ab (tachycardia, tall R waves in V1, Q waves in limb leads, inverted T waves), cardiomyopathy, arrthymias, MR
resp: ineffective cough/dimished airway refexes (aspiration, infections), macroglossia,

GI; delayed gastric emptying

26
Q

Loss of neuromonitoring signals

A
  • alert surgeon
  • ensure not change in dept of anesthesia (prop, volatile, relaxant)
  • correct hypoxia, ensure normocarbia, correct hypovolemia, hypotension, anemia, to optimize oxygen delivery
  • surgical causes- excessive distration
  • perform wake up test
27
Q

Complications of tumescent lipo

max limit lido

limit LAST

A

fluid overload pulm edema, LAST, DVT

35-55 mg/kg

1:1,000,000 epi

dilute solution, add epi, limitsurgery to 3L of fat removal, lipid rescue kit

IV fluids+ tumscuent solution-UOP

givelasix after 2L

28
Q

hypothyroid

tx

A

Hashimoto’s thyroiditis

anesthesia: do not give volatiles (myocardial depression), consder ketamine

Neuro: AMS, slow reflexes, myxedema coma, hypothermia

cards: CHF, pericardial effusion, blunted baroR reflexes, bradycardia (downregulation of Beta R), increased SVR (decreased PP), decreased intravascular volume
resp: drug induced resp depression, large tongue intubation, limapired hypoxia and hypercarbia drive, pleural effusion, OSA

GI: delayed gastric emptying

renal: decreased intravascular volume-leaky capillaries

Heme: anaemia, coagulopathy

Endocrine: adrenal insufficiency, electrolytes: low Na(increased ADH, impaired renal concentration ability), low glucose

myxedema coma: altered mental status, (coma or seizure), hypothermia, bradycardia, hyponatremia, heart failure, hypopnea

IV levothyroxine steriods if think adrenal insufficiency

29
Q

MG

A

Pathophysiology: destruction nicotinic acetylcholine R at post synaptic memebrane

Sx:

bulbar weakness (diplopia, ptosis, difficulty with speech and swallow, dyspnea), muscle weakness with exertion, thyoma

cardiac: HTN, AV block, a fib, myocarditis, cardiomyopathy, dystolic dysfunction
endocrine: hyperthyroid, RA, pernicious anemia, SLE, thyoma

neonate weakness 2-4 weeks

30
Q

hyperthyroidism

A

Lab: TSH (low), Free T4 and T3 (high)

Neuro: anxiety, agitation, tremors, insomnia, muscle weakness, sweating/heat intolerance, weightloss, fever

cards: tachycardia, HTN (increased SV and CO), decreased SVR (increased PP) arrythmia (afib), cardiomegaly, hypovolemia

GI: dirrhea

renal: activation RAAS

arrythmia, hyperdynamic circ, risk hemodynamic instability

not able to render euthyroid prior to surgery,no tx: iodide, steriods (decrease peripheral conversion, BB, cholestyramine)

31
Q

canceling for a cold

A

perioperative respiratory complications: bbroncospasm, larngospasm, desaturation

  • delay 4-6 weeks if fever >38.5, malise, productive cough, mucopurulent sputum, pulm involement (wheezing)
  • mild sx delay 2-4 weeks: sneezing nasal congestion, nonproductive cough +require ETT + additional RF (exposure to smoke, underlying pulm dz (asthma), surgery of airway, age < 1 year /premature
  • proceed if mild sx and do no require ETT (mask, LMA, regional)
32
Q

tx for MH

A
  • call for help.ICU 72 hrs
  • admin drantrolene 2.5g/kg q5-10 min, infusion 1mg/kg q6h for 24-48 hrs
  • hyperventilate pt w 100%
  • active cooling: lavage-gastric bladder rectal, peritoneal lavage, CBP, ice packs over major arteries
  • maintain UOP w lasix fluids, mannitol
  • monitor K (dextrose insulin) calcium, ABG (acidosis-bicarb), serum CK, liver enzymes, coagulation
  • monitor for DIC, myoglobinuric renal failure (ATN, obstructive nephropathy), recrudenscence
33
Q

Risks of prematurity

A

Neuro: IVH, hypothermia, retinopathy of prematurity

Resp: post op apnea, RDS, PPHN

GI: NEC, impaired liver fxn

Renal: imapired renal fxn

Endocrine: hypoglycemia (poor glycogen stores)

Heme: anemia (transfuse 40-45 if severe cardiopul dz, 30-35 moderate, normal 20-25)

34
Q

Downs

A

Features

Neuro: alanto axial instability: subluxation,

Cardiac: bradycardia w/ sevo, 50% endocardial cushion defects (defects involving atrial, ventricular septum, and 1 or both AV valves), VSD, ASD, PDA, TOF

Pulm: marcroglossia, micrognathia, subglottic stensosis, hypotonia and redundancy soft tissue, osa

gi: duodenal atresia

35
Q

When to get Echo

A

There is no Class 1 recommendation, all 2a

reasonable to evaluate LV function in

  1. patients with dyspnea of unknown origin
  2. patients with known heart disease with worsening dyspnea or change in clinicsl status
  3. clinically stable pt with prior LV dysfunction with no eval in >12 months
36
Q

RCRI and MACE

A

Revised Cardiac Index

Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr > 2.0, IDDM, high risk surgery

CAD: unstable angina, MI, use nitrate, , active + stress test, path q wave

0-0.4% risk of cardiac complications

1-0.9% risk of cardiac complications

2-7% risk of cardiac complications

3-11% risk of cardiac complications

37
Q

Active cardiac conditions

A
  1. Unstable coronary syndroms:

unstable angina (ACS)

recent MI (30 days)

  1. Decompensated heart failure
  2. Significant arrythmia:

High grade AV block, Mobitz II AV block, 3rd degree block

Symptomatic ventricular arrythmia or sx brady

SVR with HR>100 at rest

Newly recognized ventricular tachycardia

4: Severe valvular disease:
1. Severe AS (Mean gradient >40 mmHg, aortic valve area <1 cm2, or symptomatic)
2. Symptomatic MS (DOE, exertional presyncope, or heart failure)

38
Q

surgery risk

A

Low risk <1%: ambulatory, breast, cataracts, endoscopic, superficial

Intermediate risk: 1-5%

  • carotid endarterectomy, head/neck,
  • Intraperitoneal/Intrathoracic,

orthopedic, prostate

High risk: aortic/other major vascular procedures, peripheral vascular surgery >5%

39
Q

HTN consideration head to toe

perioperative risks,

preop assessment

potential causes

A

neuro: shift in cerebral autoregulation, stroke, retinopathy
cards: LVH, CAD/MI, arrythmia, CHF (diastolic dys)
renal: overactivity of renin angiotensin-aldosterone system, CKD

concerns : BP instability, arrythmias, MI, stroke, CHF, hypoperfusion/end organ ischemia w reduction

Preop:

History:

  • cause (essential, coartation aorta, OSA/obesity renal, endocrine-pheo, hyperaldosterone, cushing, thyroid/parathyroid),
  • degree of control, baseline, meds
  • end organ effects

PE: signs CHF

Labs: BUN/Cr-renal involement, NA K diruetic effects

EKG for LVH (S in V1 + R in V5 or V6 ≥ 35 mm), arrythmia, ischemia, strain (ST depression and T-wave inversion)

CXR: cardiomegaly, pulm edema

Goal: keep BP within 20% of baseline

40
Q

Indication for central cathter or PAC, TEE, a line

A

CVC

  1. monitor CVP/fluid status
  2. venous access in pt w poor access, drug/hyperailmetation infusion
  3. pacing
  4. aspiration of air during venous emboli

PAC

monitor filling pressures, PAP, PCWP, CO, MV02, SVR, PVR

TEE

  1. eval global fxn
  2. RWA (Most sensitive indicator of ischemia)
  3. fluid status
  4. estimate preload (filling pressures
  5. judge accuracy of cardiac procedures
  6. assess unexplained hemodynamic disturbances

a line

  1. monitor BP on a continuous beat to beat basis,
  2. ABG freq sampling
  3. CPB (non pulsatile flow)
41
Q

aneursym repair

A

Anesthesia

Difficult airway-compression (airway compression, SVC syndrome edma), DLT

Cross clamp

neuro

Paraplegia-Loss motor with intact vibration and proprioception, sensory (ASA syndrome)

epidural hematoma if neuraxial performed

Stroke: emboli, hypotension

CV

Aneurysm: rupture, thrombosis, compression (SVC, AI

MI, CHF

Pulm

Post op pulmonary dysfxn from manipulation of diaphragm and lungs

Damage to phrenic or RLN

GI: mesenteric ischemia

Heme

Coagulopathy: activation of coagulation (aneurysm thrombogenic), DIC

dilution effects of massive transfusion,

Renal

Post op AKI

42
Q

minimize cord ischemia during cross clamp

A

-Avoid hypotension MAP>80, maintain normal Hct and

Labs:

PaO2, (monitorand maintain adeuwate MAP above and below cord)

-Avoid hyperglycemia

Monitoring:

  • Lower ICP w spinal drain (15cc / 15 min max 60cc) ICP 8-10
  • Monitor cord with SSEP MEP

Careful with vasodilators or high conc on inhalational agents (vasodilation increase ICP which transmitted to cord and lower distal perfusion)

Surgical: Min clamp time, use shunt, reattach segmental arteries

43
Q

hypotension at start of CBP

A
  1. hemodilution: decreases SVR (depends on vascular tone and viscosity) from pump priming solution (usually transient as hypotension induced vasoconstricton and endogenous catecholamine increase BP
  2. arterial or venous malfunction or malposition: aortic cannula inserted into aortic wall–>dissection, inserted into inmoninate or carotid (cerebal edema/hemorrhage), venous cannula kinked or malpositioned,
  3. switch of venous and aortic cannula

*** aortic cannula in inmoniate would see HTN w R sided a line and hypotension w L sided a line

44
Q

steps of CPB and coming off

A

HAD2SUE
Heparin: Always give prior to bypass.
ACT: Always check before going on bypass (450 seconds)
Drugs: Do you need anything (Non depolarizing neuromuscular blocker).
Drips: Turn off the inotropes etc.
Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture.
Urine: Account for bypass urine
Emboli: Check the Arterial cannula for bubbles.

CBP, Cool, Clamp (after Vfib starts ~28C), Cardioplegia

WARMVP:

warm,, admin midaz

Anemia/electrolytes/acidbase

Rhythmn: rate ok? need to be paced? defib at 30C

Monitors/alarms/rezero lines

Ventilation: deair, check compliance/recruit

Perfusion: pump flow, cardiac fxn on TEE, admin vasopressors and inotropes

45
Q

coagulopathy after bypass

A
  1. abnormal plt fxn-activation on nonendothealil surfaces-oxygenator, filter, cartiotomy suction, hypothermia, nitro protamine

preserve function: autologous blood collection, less use of cartiotomy suction, no bubble oxygenator

  1. thrombocytopenia
  2. hemodilution of coag factors
  3. residual heparin:inadequate neutralizaton, heparin rebound (4-6 hrs after neutralization from dissociation of heparin), residual heparin from scavanged blood
  4. fibrinolysis- increase plasmin 2/2 to release of TPA (tissue plasminogen activator) from endothelium during CPB, decrease levels plasminogen activator inhibitor
  5. DIC
  6. hypothermia
46
Q

AICD WORKUP

A

Type and model of device, Indication for placement, when placed (<3 months more likely to be dislodged during central line placement, cardiac surgery, or manipulation of intracardiac catheters)

underlying rhythm and rate, Pacer dependent, pacing threshold, recoded arrhythmic events

programmed mode, response to magnet (usually disables tachydysrythmia detection therapy), reprogramming needed,

Last checked (6 months ICD, 12 months PPM), functioning properly, battery life (should be at least 3 months),alert status on lead or generator( lead could be oversensing),

47
Q

Indications for iCD

PPM

A
  • secondary prevention VF VT
  • primary prevention: MI and EF<30, HF class 2-3 w/ EF <35 (intraven conduction delay 120ms cardiac resyn), congenital long QT syndrome, brugada, HCM
  • Sinus node desyfunction, AV block
48
Q

lung ca considerations

A

Signs mass effect

Obstructive PNA

SVC syndrome

Pancoast tumor

tracheal bronchial distortion- mass induced VQ mismatch

mass compression of heart and great vessels

Tumor invasion

Hemoptysis, blood stained sputum

Cancer related meds

Bleomycin (interstitial pneumonitis, pulm fibrosis)

Cisplatin: peripheral neuropathy, renal failure

Paraneoplastic syndrome

Lambert Eaton

SIADH-hyponatremia vs loop diuretic), decreased serum osm,

Cushing syndrome-Ectopic ACTH, hypokalemia, HTN, psychosis

Parathyroid releasing hormone-hypercalemia-N/V, renal failure, weakness, arrhythmia

49
Q

hypoxia during OLV

A

100% oxygen

Ensure adequate placement by capnography, listening to chest, fiberoptic scope for direct visualization

Check BP to ensure adequate perfusion

RL shunt from collapsed lung

Recruitment breaths

CPAP 10 Cm H20 to nondependent lung if surgically acceptable

PEEP 5-10 cm H20 to ventilated lung ( in healthy lungs this way result in pressure induced shunting blood to nondependent lung)

Reinflate non dependent lung

Discuss with surgeon about ligating pulm artery to elim shunt

Encourage hypoxic vasoconstriction (remove agents that may blunt this)-volatile, systemic vasodilators, hypocapnia (inhibit HPV nondependent lung and increased vascular resistance in dependent lung

50
Q

CF

A

cardiac: pulm htn cor pulm
pulm: freq muscus plugging, inflammation, infection–>hypoxia (V/Q mismatch), broncospasm, PTX (bbullae), bronchiestasis, resp failure,post op resp failure, lung infections

GI/hepatic: malabs (vit K def + coaggulopathy; electrolyte abnormalities), pseudocholinesterase def

endocrine: DM (pancreatic involvement)

broncodilators, abx, chest physiotherapy

51
Q

post op dyspnea

A

Neuro: neuro conditions-MG, pain , nerve (phrenic from blocks)

Cardiac: cardiogenic pulm edema,

Pulm: atelectasis, aspiration, bronchospasm, bleeding/compression, drugs ,airway edema/NPPE/cardiogenic pulm edema , larnygospasm, PTX, PE, obstruction (OSA)

52
Q

extubation critera

A

Neuro: Awake and alert; following commands; return of airway reflexes; fully reversed, normothermic

Cards: Stable vital signs, hemostasis

Resp: (VC >10-15ml/kg, NIF >25-30, TV >5ml/kg)

If questionable, PS support trial w/ 5cmH2O and 5cmH2O CPAP on FiO2 0.4 x 30 min

ABG: PaO2 >80, PCO2 35-45, pH 7.35-7.45

53
Q

PTH

hyper para, tx

A

increases Ca: bone resportion, renal tubular absoprtion, synthesis of vit D (intestinal abs Ca and P04)

anesthesia: unpredictabe response to muscle relaxants
neuro: psychosis, weakness,
cards: hypovolemia, HTN, heart block, BBB, bradycrdia

resp:

gi: PUD, constipation,
renal: kidney stones

hydration, lasix, correct hypoP04, dialysis, second line -calcitonin, steriods (tx >15)

hypervent

54
Q

hypopara

A

neuro: seziures, cramps, depression
cards: hypotension, CHF, insensitive to B agonist, prolonged QT
resp: stridor/apnea

AW (15 decks)

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