UBP Book 2 Flashcards
What is TACO
Transfusion-associated circulatory overload
Pulmonary edema due to excess volume or circulatory overload (cardiogenic pulmonary edema).
Treat with diuretic, consider inotrope or afterload reduction.
What is TRALI?
Transfusion-associated lung injury
Pulmonary edema due to increased vascular permeability, thought to be due to donor leukocyte antibodies activating neutrophils on the pulmonary vascular endothelium.
Considerations for inpatient vs outpatient surgery
- severity of OSA
- anatomical or physiological abnormalities
- coexisting disease
- type of surgery
- type of anesthesia
- anticipated post-op opioid requirement
- patient age
- adequacy of post-op observation
- facility capabilities (emergency airway equipment, respiratory care equipment, radiology, labs)
- transfer agreement with inpatient facility
Bezold-Jarisch reflex
Vasodilation + Bradycardia + Hypotension
Stimulation of inhibitory cardiac receptors by stretch, chemical substances, or drugs lead to increased parasympathetic and inhibited sympathetic activity.
Seen in shoulder surgery performed under ISC
Autonomic neuropathy assessment
Assess cardiovagal function
- Absence of normal sinus arrhythmia: HR change <10 bpm when taking 6 slow deep breaths per min (normally changes >15 bpm)
- Lack of HR response to valsalva
Assess adrenergic function:
- Orthostatic hypotension
- HR response to sustained handgrip
Pheochromocytoma optimization
Roizen criteria:
- BP consistently <160/90 x24 hrs pre op
- orthostatic hypotension (decrease in SBP at least 15% but not <80/45)
- ECG without ST or T wave changes x2 weeks
- <5 PVCs per min
Use alpha blockers: phenoxybenzamine or phentolamine, start at least 7-10 days before surgery
Use beta blockers for HR after alpha blockade adequate
Hunt and Hess classification
Grades severity of non-traumatic SAH
0 = unruptured
1 = asymptomatic, mild HA, mild nuchal rigidity
2 = mod-severe HA, nuchal rigidity, cranial nerve palsy
3 = drowsy, confused, mild focal deficit
4 = stupor, hemiparesis, vegetative disturbances
5 = coma, moribund, deceberate
CSWS vs SIADH
CSWS: usually hypovolemic with urine Na > 100 mEq/L; treat with volume and sodium replacement
SIADH: usually euvolemic with urine Na < 100 mEq/L; treat with fluid restriction and diuresis
Risk factors for emergence delirium
Emergence delirium appears to be associated with:
- preoperative anxiety and underlying temperament
- young age (highest 1-5 years)
- post-op pain
- less-soluble volatile agents (sevo, des)
- type of surgery (eg abdominal, breast)
- prolonged surgery
Types of EPS
Dyskinesis: repetitive, involuntary, purposeless body or facial movements
Akathesia: extreme internal or external restlessness
Dystonia: very strong muscle contractions (especially the neck) often resulting in twisting of the body and pain. Most common EPS associated with metoclopramide.
Neuroleptic-induced EPS due to blockade of nigrostriatal dopamine tracts with relative increase in cholinergic activity.
Treatment for EPS: diphenhydramine or benztropine
CF pathophysiology
Systemic, autosomal recessive disease causes by defective CFTR leading to abnormal movement of sodium and chloride into and out of cells. This leads to thick, viscous secretions associated with luminal obstruction and glandular destruction in the lungs, pancreas, liver and GI tract.
How to manage patients on an insulin pump
Check for any institutional protocol
For minor survey: reduce overnight infusion by 30%. Continue basal rate if short procedure or replace with continuous insulin infusion at the same rate. Check glucose on arrival and q1-2h
For moderate/major surgery: reduce overnight infusion by 30%. Discontinue pump and start an insulin infusion and a dextrose infusion. Check glucose on arrival and q1-2h.
How long to wait after PCI before elective surgery
- DES: ideally 6 months
- bare metal stent: 30 days
- balloon angioplasty: 14 days
Solution options for TURP
Electrically inert (for M-TURP)
- Distilled water (risks: hypotonic, can lead to volume overload, hemolysis, hyponatremia)
- Glycine (risks: hyperglycinemia, hyperammonemia can cause encephalopathy, seizure, transient blindness)
- Sorbitol (risks: hyperglycemia)
- Mannitol (risks: intravascular volume expansion)
- Urea
Balanced electrolytes (for B-TURP or L-TURP)
TURP syndrome
Absorption of large amounts of hypotonic irrigation through surgically disrupted venous sinuses in prostate causing circulatory overload, hypo-osmolality, hyponatremia, and potentially solute toxicity. Presents with a classic triad of hypertension, reflex bradycardia, & mental status changes due to cerebral edema and increased ICP/solute toxicity.
Causes neurologic, respiratory (pulm edema), cardiac (circulatory depression, HTN/bradycardia), heme (DIC/hemolysis), renal (glycine metabolized to oxalate), metabolic (glycine metabolized to glycolic acid) disturbances.
Treat with fluid restriction, diuresis, careful sodium correction with hypertonic saline, prn anticonvulsants.
