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King Fahad Medical City –Ryadh - Saudi Arabia
Page 1 of 217
He was kind enough to share them with his residents. They describe the important points-anesthetic concerns- in most common anesthesia topics, to help you prepare for the vaiva/case scenario exam.I hope that you will find them helpful in your exam as well as in your clinical works as it was for me.
A:airway. B:breathing/respiaratory system C:circulation/heart condition. D:drugs. M:metabolic concerns..lytes/glucose/ABG..etc. G:gastrointestinal system.
THA Page 2 of 217 Usually elderly Pt If a revision blood loss and it takes longer Epidural or GA Look for the cause of arthritis # due to CV disease (syncope) avascular necrosis due steroids, infarction (sickle cell disease) Spinal Vs GA less risk of PE with spinal and blood loss A, B, C look under elderly, and other co-existing diseases Consider Autologus blood donation Lab: ECG, CBC….. depend on the co-existing diseases If suspect a difficult A/W GA, due to position Intra-op: risk of PE (cement, BM, fat) consider art-line in Pt with CV disease Post-op: need to anticoagulated, pain epidural or PCA DDx of circulatory collapse intra-op: PE, MI, total spinal, anaphylaxis
Thalassemia Page 3 of 217 Ethnic: Mediterranean, African-American, middle east and Asian -thalassemia o major (homozygote) (Cooley’s anemia) severe, need treatment o intermediate (hetro) o minor (hetro) o manifest after 1st year of life, when Hb F disappears. -thalassemia o 4 genes for the -chain synthesis o 1 gene deletion silent carrier. o 2 genes deletion mild microcytic anemia. o 3 genes deletion severe hemolytic anemia. o 4 genes deletion hydrps fetalis GI absorption of iron and with multi-Tx iron overload hemochromatosis . treatment : o Tx and folate in mild form o Multi Tx and iron chelating agent in the severe form o Splenectomy
The Myotonias Page 4 of 217 delayed relaxation of skeletal muscle after voluntary contraction, myotonic contracture is not relieved by regional, NDMR, or deep GA. Relaxation may be induced by infiltration of the muscle with local anesthetic. caused by genetic abnormalities that produce defects in sodium or chloride channels or proteins which alter ion channel function in muscle cells giving drugs that Na influx into the cell and delay return of membrane excitability,like quinine, tocainide, or mexilitene, may relax myotonic contracture. Myotonic Dystrophy (Steinert's Disease) is the most common form of the myotonias and the most severe. AD inherited disorder (1 in 8000), S/S during the 2nd and 3rd decades of life. clinical features associated with myotonic dystrophy: muscle degeneration, cataracts, premature balding, DM, thyroid dysfunction, adrenal insufficiency, gonadal atrophy, cardiac conduction abnormalities. Cardiac abnormalities LV diastolic dysfunction, cardiac failure is rare. o AV block , A.fib, or flutter, ventricular dysrhythmias. o 1st -degree AV block may actually precede the onset of clinical symptoms o Sudden death may be a result of the abrupt onset of 3rd -degree AV block.
loss of expiratory volume Due to association with other injury. BPF . air leak.Thoracic trauma: Page 5 of 217 ACLS. and in addition to other injuries Heart and major vessels Chest wall flail chest > 3 ribs# need intubation with PEEP Esophageal Diaphragm initially no S/S then CXR diagnostic Lung parenchyma contusion Tracheal. bronchial injury with blunt trauma Pt may have stridor. pneumomediastinum. wheezing. and convert a pneumo to a tension pneumo Complication of chest injury empyema. dyspnea S: subQ emphysema. persistence air leak. mainly c-spine DLT is difficult to insert so consider other option If chest tube drain >1L initially or >200ml/h open When putting a C-line have it in the same side of the chest injury Always be careful with PPV which can worse the hemodynamic with tamponade. recurrent pneumo.
overriding aorta. RVH Tet spells: hypercyanotic attaches peak 2-6 m. supra) 70% have bicuspid aortic valve.TOF Page 6 of 217 Most common cyanotic CHD. crying. 10% LAD from RCA CXR: pul vascular marking. acidosis) Rt to Lt shunt S/S: clubbing. ECG: RAD. and don’t upset them Hemodynamic goals: o Preload o R/R slow and sinus o cont o SVR o PVR A N/A . F=M VSD. defecation Any thing that PVR or SVR tet spells (PO2. PCO2. by age 6y ferq & severity Initiated by feeding. valvular. cyanosis. RVH. Rt aortic arch. RVOTO(sub. polycythemia Pre-op: avoid dehydration.
or conduction abnormality after the repair So for residual defect manage as TOF hemodynamic Goals: o preload o R/R slightly maintain sinus o Cont maintain.TOF. obst Page 7 of 217 Corrected TOF. or pul outflow tract obstruction All TOF need Echo for that reason 12-ECG may have arrhythmias. may PVR Consider art-line . not risk. or slightly o Afterload maintain. avoid sudden in SVR No spinal early epidural is desirable. and no special precautions May have a residual or recur VSD.
pain. wheezing. PPV with PEEP. stridor B OSA with snoring. ARDS.Tonsillectomy and Adenoidectomy Page 8 of 217 Peds considerations Indication: recurrent tonsillitis. O2 sat. OSA. sat. chest retraction and RR C CHD need Abx prophylaxis. O2 . bleeding see other card o Pul edema due to relief of the obstruction frothy pink secretion in the ETT. diuretics o Usually subsided with in 24 hrs . aspiration o Mx supportive ETT. dehydration. RR o DDx anaphylaxis . CXR. CHF. Rt heart failure ECG. A/W obstruction wheezing . Echo D over counter meds may contain ASA Induction normal Intra-op avoid NSAID’s . give zofran and decadron Post-op: o N&V. cor pulmonale. abscess A tonsils size(0-+4(75%)). volume overload.
and Abx coverage M adrenal suppression. in addition to the side effect of immunosuppressant drugs. while some may retain afferent innervations The response to exercise in normal heart is by HR. may need stress dose steroids.Transplanted heart Page 9 of 217 High risk of infection mainly cholecystitis The efferent denervation is permanent. PCO2) by HR but it’s delayed Premature CAD. with in 3 yrs. if they have Aff pain The main symptom is dyspnea C altered response to stress. maintain preload D atropine and pancuronium No effect. in a transplanted heart it’s by SV. and drugs. mainly without angina. Norepi -effect. Adenosine effect. glucose intolerance Heme anemia. Neostgmine may slow HR. CAD. with little and delayed in HR They are preload dependent ECG may shows both donor and recipient P waves No vagal input No bradycardia But they response to stress(hypoxia. thrombocytopenia .
stabbing Burn Same rule of nines apply to pregnant Pt With inhalation injury CO poisoning the fetus has a higher affinity to CO than the mother Apply the same ATLS.Trauma in pregnancy Page 10 of 217 Blunt Closed head injury is the major cause of death Other risks: o Uterine rupture o Placenta Abruption o Fetal injury o Spleen and liver rupture Penetrating GSW. and continue FHR monitor . maintain LUD Have fetal US done.
coma. Anaphylactic reaction if CV collapse.TURP-TURB: Page 11 of 217 Distilled H2O hemolysis not used any more Sorbitol converted to fructose hyperglycemia. and mental status changes. intubate o Notify the surgeon to terminate the procedure o Consider DDx: over-sedation hypercarbia. bradycardia. also well cause osmotic diuresis and dehydration Glycine(inhibitory neurotransmitter) transit blindness ammonia encephalopathy TURP Syndrome:( water intoxication syndrome) S/S mild (restlessness. and to lactate acidosis. SOB. or CV collapse). HTN. nausea. 100% O2. diabetic coma o 12 leads ECG. Volume overload Lt heart failure pul edema CNS S/S due to both the type of irrigation and the severity of in serum Na Management: o ABC. or dizziness) to severe (seizures. CVP . and invasive monitoring art line. In the awake patient: a classic triad of symptoms in both SBP and DBP associated with an in pulse pressure. HR. hypoxia.
with best result if given 12-20h after ingestion o Roughly 150mg/kg over 15min. encephalopathy and acidosis bilirubin correlate with survival Management: o ABC o Mucomyst. RUQ pain with or without obtundation After 24h symptom disappear and Pt looks well 24-72h liver failure appear. with possible ATN. 25g fulminant hepatic failure Ingestion even a lower dose with alcohol the chance of hepatic failure Tylenol normally detoxified by conjugation to glutathione. then 50mg/kg over 4h then 100mg/kg over 16h o Look at the nomogram .Tylenol overdose Page 12 of 217 A single dose of 10-15g can produce liver injury. coaglupathy. and cardiotoxicity Poor prognosis with Phos. but with overdose glutathione depleted metabolized by P-450 to a toxic compound First few hr after N&V.
with S/S bowel obstruction RSI B possible restrictive lung disease with ank-spond C AR. perforation Page 13 of 217 . adrenal insufficiency G obstruction. K .Ulcerative Colitis A may have Ankylosing spondylitis difficult A/W. metabolic acidosis. albumin. hypovolemia D steroids (stress dose) M electrolytes imbalance.
with weakness of arm abduction . when making a fist the index and middle finger remain straight. also loss of thumb flexion Radial: If the injury at the axilla unable to extend the forearm (triceps) If in the spiral groove wrist drop MCN: Loss of arm flexion (biceps). loss of sensation over the lateral aspect of the forearm Axillary N Loss of skin sensation over the lower ½ of the deltoid muscle.Upper Ext nerve injury: Page 14 of 217 Ulnar: sensation over the 4th and 5th fingers Muscle wasting. unable to grip a paper between fingers Median: Loss of skin sensation over the lateral 3 ½ of the palm of the hand Weakness of wrist flexion.
bronchospasm. and anticipate the above problems If elective. So 2-4 wks is reasonable . the child may end up with another episode of URTI. and laryngospasm If emergency or urgent surgery proceed. LRTI postponed = = = = clear proceed to surgery How long to postponed for. and < 1yr postponed If elective. >1 yr temp postponed Elective > 1yr normal temp P/E purulent secretion. if too long.URTI Page 15 of 217 Need to distinguish from allergic rhinitis incidence of croup.
anemia Mx See abruption card Basically same management they come for stat C/S due fetal distress Page 16 of 217 .Uterine Rupture Risk see box 37-1 chestnut Mainly fetal distress and bleeding A & B onst C hypovolemic shock. hypotension Heme bleeding.
avoid sitting position Dx.VAE: Page 17 of 217 When the surgical field > 5cm above the Rt atrium. flood the surgical field with saline gauze Wax the bone edges Compress the jugular vein Head down Aspirate through the CVP D/C N2O. and PEEP which may cause paradoxical embolism . 40-50% in the sitting position.25ml of air Miller all Pt going for N.surgery in sitting position need to have CVP Mx: 100% O2 Notify the surgeon. if known PFO. By TEE the most sensitive then pericardial doppler. placed in the Rt sternal border 3rd to 6th intercostal space. which detect 0.
3ug/kg 1hr prior to surgery. N PT and PTT I (70-80%) vWF. Possible HIV + Do gentle intubation.von Willebrand's Disease Page 18 of 217 AD. II. avoid blind suctioning. avoid Regional anesthesia . DDAVP may cause fibrinolysis by releasing t-PA so consider giving TXA Cryo have vWF . IIA also function abnormal. 3types I. IIB they have thrombocytopenia which aggravated by giving DDAVP (C/I). Pregnancy vWF Rx DDAVP 0. group O blood have 20-30% less vWF Prolonged bleeding time. Hematology consult. recombinant Vwf. III(very rare).
with normal ECG and CXR mod also asymptomatic. and the lower PVR more severe symptom small asymptomatic. and PVR. with S/S depend on the size. CHF. load pansystolic murmur Lt sternal border. S/S early as 4 wks. low forward CO . Lt Rt change to Rt Lt cyanosis hemodynamic goals: o Preload o R/R N and sinus o Cont slight o Afterload o PVR Pre-op Abx prophylaxis A N/A B pul edema C shunt. with biventricular enlargement on CXR large when pul blood flow > systemic.VSD Page 19 of 217 Rare in adult . the larger.
or frozen RBCs . Patients at risk for GVHD include organ transplant recipients. platelets. and a nonproductive cough. plasma.may also develop chills. 1% of all RBC transfusions. headache.White Cell–Related Transfusion Reactions Page 20 of 217 Febrile Reactions: antibodies to the HLAs after multiple Tx. neonates who have undergone a blood-exchange Tx. It has not occurred following transfusion of FFP. respiratory distress. myalgias. and fresh. nausea. packed RBCs. anxiety. Febrile reactions can be treated with acetaminophen should be distinguished from a hemolytic transfusion reaction (direct Coombs test) Graft-versus-Host Disease (GVHD) the donor lymphocytes may become engrafted. cryoprecipitate. and the fatality rate is very high Also when a genetic relationship exists between the donor and the recipient GVHD has been reported with the transfusion of whole blood. proliferate. not frozen. granulocytes. and patients immunocompromised by many other disease processes. and establish an immune response against the recipient. the patient experiences a temp of more than 1°C within 4 hrs of a blood Tx and defervesces within 48 hours. GVHD typically progresses rapidly to pancytopenia.
low PLT. m a z e n . renin secretion D chemo R hyperaldosternism(2nd) K H severe anemia. Lytes CBC other upper body IV access Potential intra-op problem IVC obstruction CO Tumor in the IVC embolic phenomena Post-op ICU backup mazen h o m e o f f i c e . severe if both kidneys involved CHF. chemo.and central line Lab X-match. emptying RSI B lung mets.Wilms tumor Page 21 of 217 A delayed G. and radiotherapy effect C HTN. acquired vWD possible need F VIII concentrate M art.
BUN. bear hugger Monitors: standard + 5 leads ECG. art-line. ABG. Art line. Foley.AAA Elective Page 22 of 217 Long procedure. and high risk of blood loss A N/A B potential COPD C CAD. PFT. Echo if available Consider optimizing any medical condition pre-op by meds. IV worming device. with blood set Lines: Big 14G peripheral IV. modify on cardiac status Before induction have inotrops and vasodilators ready to go . Mg. CVP/PAC. Renal border line function In the pre-op evaluation: concentrate on cardiac function with detailed H/P and work up Lab: CBC-D. CXR. and further evaluation. X-match for at least 6 U of blood. Lytes. consultation. large fluid shift. creat. HTN. temp. ECG. CVP/PAC. have FFP ready Consider Epidural to do it as a combined technique Have the cell saver in the room. TEE Induction: routine.
and DIC Fetus Demise. creat. fetal monitoring . trauma. GI prophylaxis.Abruptio placenta Page 23 of 217 Risk with cocaine abuse. and can have 2500ml of blood DDx placenta previa. previous abruption. fetal hypoxia The bleeding could be concealed. BUN. PTT. CVP/PAC. Heme anemia. induction with Ketamine. uterine rupture A obst B obst C hypovolemic shock. hemoabt(PGF2). may end up need hysterectomy . age Most common cause of DIC. Lytes. large IV Synto may not work atony consider ergot. risk ante-postpartum hemorrhage. smoking. Mx: Depend on the severity. LUD Lab CBC. PT. RSI. usually partial managed conservative with bed rest ABC. hypoxia. X-match Monitor Art line. coaglupathy DIC R ARF from both shock. fibrinogen. D-dimer .
central sleep apnea Lab CXR. ECG. CT. C-spine. foramen Magnum Stenosis Avoid neck extension . OSA B Kyphoscoliosis Restrictive lung disease C Cor-pulmonale. MRI base of the skull.Achondroplasia: A potential difficult A/W. PFT. possible ICP. in addition to the regular blood work Page 24 of 217 . pul HTN CNS hydrocephalus. Echo.
adenoma effect ? pressure vision M DM. and potential post-op A/W obstruction B OSA C HTN. possible vocal cord paralysis.Acromegaly Page 25 of 217 99% from pituitary adenoma A large tongue . hyperthyroid. CXR. CHF. Cardiomegaly. Echo) D steroids for other pituitary problems N neuropathy (document). epiglottis. and subglottic stenosis smaller ETT. Position nerve compression Monitors art line . arrhythmias. cardiomyopathy. large nose difficult intubation and mask fitting Need FOI. hemodynamic instability (ECG.
SOL with ICP. know what is the program . pregnancy. even arrest o Followed by intense SNS activation with HTN. possible difficult to obtain an accurate medical history C/I: Pheo. tachycardia. consider invasive monitoring in sick Pt Pt with pacemaker or AICD not C/I have the magnet in the room. and long bone # The main effect is on the CVS: o Initial PSN effect with hypotension and bradycardia. and any problems may had happened Also review all Pt med (TCA.ACT Page 26 of 217 Mainly for depression. MAOI) avoid indirect sympathomimetics. arrhythmias and ICP and IOP Review the old anesthetic record for the dose. also be careful when direct acting drugs exaggerated response Monitors standard CAS monitors. recent CVA and MI.
exposure to toxins at work A LOC B hypoxia. drugs. V/Q mismatch D altered drug metabolism M lytes abnormalities Renal impairment CNS encephalopathy Heme coags abnormalities Avoid sedation pre-op Correct coags pre-op Intra-op avoid hypoxemia.Acute liver dysfunction Page 27 of 217 M&M Postponed if not an emergency History of alcohol. hyperventilation. and hypotension both hepatic blood flow .
with diffuse ST-elevation in ECG pericardial leads. chest exam friction rub. if suspected effusion or tamponade Normal pericardial fluid 20-30 ml. with sinus tachy. and effusion Page 28 of 217 Most common cause is viral infection Post-MI Dressler Syndrome S/S diffuse chest pain. o In chronic effusion the pericardium can accommodate up to 1000 ml. Consider Echo. without S/S of tamponade o But in acute effusion as low as 200 ml can give symptoms .Acute pericarditis.
Other: bacterial or fungal infections. surgical ablation. Secondary: anterior pituitary fails to secrete sufficient quantities of ACTH. N&V. infection.Adrenal Insufficiency (Addison disease): Page 29 of 217 Need 90% destruction of the adrenal gland to produce symptoms primary (Addison's disease) is idiopathic adrenal insufficiency due to autoimmune destruction.( less severe S/S. BP. from tumor. Hashimoto's thyroiditis in association with autoimmune adrenal insufficiency is termed Schmidt's syndrome. or radiation therapy. abd/back pain due bleeding. sepsis and hemorrhage. causes both a gluco and a mineralocorticoid deficiency. metastatic cancer. muscle weakness. hyperpigmenation in primary only Dx by ACTH stim test . aldosterone is maintained S/S Wt loss.
cardioversion. (Repair) Understand the physiology of the repair Residue. What. and the complication of the repair. and Where. use saline instead of air for epidurals. In case of pulmonary HTN have NO in the room . recent Echo. Follow up with cardiologist. In case of shunt be meticulous about air in the IV. Sequelae. When. if not ask for one Discuss the case with a college who knows more about CHD(peds cardiac anesthetist) The Need for SBE prophylaxis High risk for arrhythmia (pads on) for pacing. or shock Have inotrops support ready.Adult with repaired CHD Page 30 of 217 Type of CHD.
LUD o R/R slightly maintain sinus o Cont maintain. avoid cardiodepressant o Afterlaod Epidural is good Page 31 of 217 .AI Well tolerated in pregnancy hemodynamic Goals: o preload maintain.
minimal support if needed Assess the eye for depth (see later) The dilemma Full stomach Vs need of maintaining spontaneous Ventilation Once the eye in stage III do direct laryngoscopy Lidocaine spray May give IV bolus of propofol upon the removal of the foreign body Consider a dose of decadron . Avoid PPV. but may see atelectasis Do inhalation induction with Sevo. depend on the Severity of the symptoms and hypoxemia may consider CXR( most are radiolucent).Airway foreign body Page 32 of 217 Emergency and potential life threatening In addition to peds consideration Brief H/P AMPLE. and racemic Epi .
and ongoing fire. and fill the cuff with NS with methylene blue Avoid N2O. avoid high Fi02 initially till you make sure that there is no ongoing fire direct laryngoscope. CT The airway is shared with the surgeon close communication Eyeglasses and laser mask. cover the exposed skin with wet towels Consider glyco pre-med Use laser-metal ETT. use the lowest FiO2 possible < 40%. and steroids ICU post-op CO2 laser only 0. and metal shields. Abx. neoplasm PFT. stenosis. keep intubated. after controlling the fire asses the airway damage. covered with wet gauzes. other Jet ventilation Pt need to be completely paralyzed In case of airway fire remove ETT. reintubate with new ETT. flow volume loop. bronchoscope with possible lavage and CXR.01 mm penetration less bleeding and edema post-op With Nd-YAG laser deeper penetration. Pt eyes closed.Airway laser surgery: Page 33 of 217 Risk for both the patient and OR personal Knew what is the indication papiloma. and risk of air embolism The metal-ETT are bigger than the PVC tubes so use one size smaller . have 60 cc syringe filled with NS ready.
Equations alveolar gas equation: Page 34 of 217 Shunt equation ventilation–perfusion ratio (VQI).is determined as follows: .
LUD. obst B hypoxia. hemorrhage R ARF CNS seizure Mx: ABC. 100% O2.Amniotic fluid embolism Page 35 of 217 Catastrophic event with high mortality rate 86% A LOC. pul edema C cardiopul collapse. last thing to do CPB (case report) If Pt survive ICU . Large IV. RV failure D D/C synto Heme DIC. Lab as abruption.
tachycardia D MAC with acute intoxication. with possible arrest Ecstasy: serotonin and dopamine level C HTN arrhythmia H DIC. MSK rhabdomyolysis M+R lytes abnormality.Amphetamines For management same as cocaine A&B obst C HTN arrhythmias. anesthesia severe hypotension. while chronic MAC CNS seizure Obst risk of abruption R. ARF Fetus toxicity Mx Page 36 of 217 .
PFT/ flow volume loop. coags Monitoring: CAS. ABG. BUN. tracheal stenosis (smaller ETT) B pul edema from CHF C arrhythmias. Creat. autonomic dysfunction Renal CRF. CHF.Amyloidosis: Page 37 of 217 Extracellular deposition of amyloid type protein A macrogolssia. avoid any nephro-toxic drugs Have an ICU backup . Art-line. ECG. ECHO. restrictive myopathy. CVP/PAC. TEE Avoid Regional if coagulopathic The main goal intra-op is to maintain U/O. CXR. lytes. nephritic syndrome Heme Factor X deficiency Lab/DI: CBC.
with thyroid dysfunction Do Regional technique better If GA: Mod RSI. M abnormal glucose and Ca metabolism. reflex. ICU post-op . fasciculation and muscle atrophy A bulbar involvement Aspiration mod RSI B respiratory failure C D Sux C/I. sensitivity to NDMR.Amyotrophic Lateral Sclerosis (ALS) Page 38 of 217 Degenerative disease of the CNS with involvement of both UMN and LMN S/S Asymmetric weakness.
Hypothermia Hypoxia.Anesthesia for organ donation: Page 39 of 217 COMMON PHYSIOLOGIC DERANGEMENTS AFTER BRAIN DEATH Condition Cause Hypotension Hypovolemia (DI. Exposure Hypothermia Dysrhythmia (especially bradycardia) Intracranial injury or herniation. ischemia Avoid vasopressors may cause visceral ischemia Consider using low dose Dopamine if needed They are atropine resistance Consider use NDMR due to somatic spinal reflex No need for GA. Electrolyte abnormality Myocardial contusion. for BP consider use vasodilators . Pneumonia Gastric aspiration. hemorrhage) Neurogenic shock Hypoxemia Neurogenic pul edema. Fluid overload Hypothalamic infarction. Pul contusion.
Na losing . CV. Alzheimer A stiff neck B CC. sensitivity to narcotics and sedatives M DM. drugs clearance. risk of volume overload CNS Alzheimer. hepatic mass and blood flow Renal GFR. stiff ligament difficult epidural/spinal heme anemia Always IV wormer. CHF D Vd. arrhythmias. MAC.Anesthesia For The Geriatric Patient Page 40 of 217 physiological reserve of all organs Common diseases with aging are Sleep apnea. dementia. heat production with more prone to hypothermia GI/hep gastric empting. bear hugger. response to hypoxia and hypercarbia C diastolic dysfunction. arthritis. CAD. with both hepatic and renal clearance. Na. and consider invasive monitoring . V/Q mismatch. HTN. COPD. CAD. HTN. arrhythmias. DM.
X-match Induction as Supratentorial May need controlled hypotension. pituitary dysfunction Classic S/S: headache. DI. ECG. photophobia. SIADH. Lytes. QT. Creat. N&V. CXR.Aneurysm Page 41 of 217 F>M. LOC Lab: CBC. review CT/MRI. BUN. usually present with SAH Aneurismal SAH classification by Hunt & Hess and WFNS to estimate the surgical risk and outcome WFNS Grade GCS Scale* Motor Deficit I 15 Absent II 13–14 Absent III 13–14 Present IV 7–12 Present or absent V 3–6 Present or absent A LOC B pul edema C HTN. ECG changes ST. unless they do temporary clipping . T. U role out IHD M lytes disturbance.
difficult to perform neuraxial block by midline approach. . possible difficult intubation . with risk of C5-C7 #. TMJ involvement. lumber disc degeneration. consider PFT C: Aortitis with AI. CHF due to cardiomyopathy.o. sacroilitis A. Spines: limitation in the movement of all the spines. 20-30 y. dysrhythmias secondary to cardiac conduction system involvement. HLA-B27 is +ve in 90% of Pts S/S: back pain and stiffness improve with exercise. ? C/I if pt have peripheral neuropathy. Renal risk of RF Drugs: anti-inflammatory drugs Better to extubate awake Intervertebral ligament calcification. Cricoarytenoid involvement (rare) B: restrictive lung disease.Ankylosing spondylitis Page 42 of 217 M>F. -ve rheumatoid factor. chest wall compliance and VC.
connective tissue diseases including Reiter's syndrome and ankylosing spondylitis. mortality rate is estimated to be more than 10% per year among patients with severe AR and angina pectoris and more than 20% per year among patients with symptoms of CHF. History: chronic AR usually remain asymptomatic for years. cystic medial necrosis with or without other features of Marfan's syndrome. with later development of orthopnea and PND. with pul congestion.HR is the only comp mechanism to maintain forward CO. Early symptoms include a sensation pounding in the chest. ascending aortic aneurysm dissection Pathogenesis Chronic: LV volume overload LV dilationLVH eccentric hypertrophy LVEDV but LVEDP still normal over time LVEDP Acute: severe AR LV volume overload. Acute: infective endocarditis. and eventually symptoms of right-sided CHF with ascites and peripheral edema. Exertional dyspnea may be the first manifestation of LV decompensation. or head pounding. nonpenetrating trauma. . Prognosis worsens with the onset of symptoms. including fever with infective endocarditis. Symptoms of more advanced disease include angina pectoris. which may be nocturnal. Acute severe AR Patients typically exhibit symptoms referable to the underlying disease. hypertensive and atherosclerotic diseases. luetic (syphilitic) aortitis. palpitations.Aortic Regurgitation Page 43 of 217 Chronic: rheumatic disease. and chest or back pain with aortic dissection. LVEDP and LAP rapidly. but without time for LV dilation.
and pulmonary venous pressures. Etiology congenital (bicuspid). or severe is of lesser clinical importance. including congenital supravalvular stenosis and subvalvular membrane. mild 1. . AS is not usually of hemodynamic significance until the valve area is to 25% of normal. Syncope may be caused by peripheral vasodilation with exertion. angina pectoris. (life expectancy < 5 yrs) Dyspnea due to in LVDP. ridge or tunnel stenosis.5 cm2. Angina occurs without CAD resulting from O2 demand from LV mass and intracavitary pressures in the setting of a fixed blood supply and from coronary flow due to progressive outflow obstruction.Aortic Stenosis Page 44 of 217 Valvular AS should be distinguished from nonvalvular forms of LV outflow obstruction. With normal CO. moderate 1.0 to 1. Transvalvular gradients are affected by flow. therapeutic decisions typically are based on the presence of symptoms in the setting of significant aortic stenosis.5-3. moderate. categorization of disease as mild. rheumatic. so patients may have low gradients despite severe AS if there is LV systolic dysfunction.0 cm2.5 cm2. and syncope. History long latent period >30 yrs The three classic symptoms associated with aortic stenosis are dyspnea.0 cm2.5 to 3. or senile degenerative (calcific) in origin. with in peripheral oxygen requirement in the setting of a fixed CO. and dynamic subvalvular LV outflow obstruction in HOCM The normal AVA is 2. LA. severe AS mean transvalvular pressure gradient 50 mm Hg. severe <1.
with intravascular volume GI Vomiting. lytes. Creat. temp. art line. elderly Position lithotomy. jackknife Monitors CAS. full stomach M Lytes abnormalities. ABG Pain PCA Page 45 of 217 APR For rectal Ca. epidural . BUN. acid base disturbance Other could be septic Lab CBC-D. foley Pain PCA. with possible bowel obstruction Usually in elderly with other co morbidities With bowel prep fluid deficit hypotension upon induction A RSI (b.Appendectomy In older Pt consider other and possible catastrophic problem (AAA) A full stomach (RSI) C dehydration. obstruction) C hypovolemia.
Arnold chiari malformation Page 46 of 217 It’s one of the chiari malformation it’s type II associated with myelomeningocele present for posterior fossa decompression and repair of myelomeningocele and insertion of shunt on of the main issue is position during induction due to myelomeningocele. if big may have to the induction in lateral position then turn prone A potential difficult airway. and CN palsy position as above . resp depression due to post fossa compression C bradycardia CNS the defects. may put a donut where the defect is in the hall. due to hydrocephalus awake intubation B vocal cords paralysis trach.
avoid cardiodepressant o Afterlaod . pads on the Pt ASD: 3 types: ostium secundum @ foramen ovale . treat hypovolemia aggressively o R/R slightly maintain sinus treat arrhythmia aggressively o Cont maintain. to maintain PCWP =18 GA opioids. mix kitamine/STP Have the crash cart in the room. CVP/PAC risk of arrhythmia with insertion.AS Page 47 of 217 Mild well tolerated Mod/severe not well tolerated hemodynamic Goals: o preload maintain. avoid sudden in SVR Need are-line. LUD.
and optimize pre-op If Pt is steroids (PO) dependent asthma consider steroids coverage peri-op Pre-med -agonist. avoid STP. Anticholenergics.Asthma: Page 48 of 217 H/P: how bad is the asthma? Severity? Frequency? Any hospital or ICU admission in the past. intubate deep. wheezing Review PFT results pre-post bronchodilators. how he/she manage the asthma at home. Induction: IV Lidocaine. or need ER visit. may consider LMA Maintenance: avoid any histamine releasing drugs. Emergence: consider extubate deep. Exam: V/S. if yes when was the last one. IV Lidocaine pre-extubation Consider regional anesthesia to avoid intubation . A/E .
(RSI) B respiratory reserve and volumes. PE. pneumonia. have anti-HTN ready (Niprid) N. risk of aspiration. post-op vent (ICU) C hyperreflexia. seizure. death . assess the volume status. or too low Hyper-reflexia may happen post-op due to bladder or rectal distension. aspiration risk (FOI). 2-3 weeks after injury Stimulation below the level of transection Severe HTN with bradycardia A potential difficult A/W. orthostatic hypotension.Autonomic hyperreflexia: Page 49 of 217 Post spinal cord injury above T-7 70-75%. ECG. ABG. stroke. D (Sux C/I). stimulator show resistance N deficit Neuraxial best is a good choice but may be difficult to assess the level of the block too high. unstable C-spine. pul edema. arrhythmias. following the resolution of spinal shock. respiratory failure PFT. Sequelae CV collapse.
AVM: Page 50 of 217 M>F. ICP Pt may have (NPPB) normal perfusion pressure breakthrough cerebral hyperperfusion with normal CPP o Rx: diuretics. hypervent. Sz. LOC. SAH. mild hypothermia. 10-40yrs S/S parenchymal hemorrhage. N-low MAP. motor/sens deficit In Peds Vein of Galen AVM hydrocephalus + high output cardiac failure A LOC B aspiration during Sz C CHF CNS Sz. high dose STP The rest of management like Aneurysm High risk of bleeding blood in the room .
flow volume loop.Airway laser surgery: Page 51 of 217 Risk for both the patient and OR personal Knew what is the indication papiloma. have 60 cc syringe filled with NS ready. neoplasm PFT. other Jet ventilation Pt need to be completely paralyzed In case of airway fire remove ETT. CT The airway is shared with the surgeon close communication Eyeglasses. and metal shields Consider glyco pre-med Use laser-metal ETT. after controlling the fire asses the airway damage direct laryngoscope. Pt eyes closed. reintubate with new ETT consider ICU post-op . use the lowest FiO2 possible. stenosis. bronchoscope with possible lavage and CXR. and fill the cuff with NS with methylene blue Avoid N2O. covered with wet gauzes.
light anesthesia . metabolic encephalopathy) Theta rhythm (4–7 Hz) Sleep and anesthesia in adults. deep anesthesia.EEG FREQUENCY RANGES Page 52 of 217 Delta rhythm (0–3 Hz) Deep sleep.. or pathologic states (e. hyperventilation in awake children and young adults Alpha rhythm (8–13 Hz) Resting. predominantly seen in occipital leads Beta rhythm (>13 Hz) Mental activity.g. hypoxia. brain tumors. awake adult with eyes closed.
cramps. not more than 25 mEq/l/48 hrs Rapid correction abrupt brain dehydration central pontine myelinolysis mild (transient behavioral disturbances or seizures) to severe (including pseudobulbar palsy and quadriparesis).6x wt . coma and seizure Acute CNS S/S is due to cerebral edema What is the serum osmolality see figure Cerebral salt wasting syndrome. and infection SIADH see other card Rx < 120 with 3% NS @ 1-2 ml/kg/hr to serum Na 1-2 mEq/l/hr only for few hrs. independent of SIADH. so it’s result from excess or deficit of water total body Na regulated by aldosterone and ANP.Hyponatremia < 130 Page 53 of 217 or in serum Na & in ECV & PV. use the following equation: Current [Na+] × current TBW = desired [Na+] × desired TBW TBW= 0. areas of demyelination are apparent on MRI. tumor. where serum [Na] by ADH S/S depend on the rate and severity of of Na: loss of apatite. poor nutritional status. cerebral hemorrhage and CHF Once serum Na > 120 fluid restriction is enough . N&V. LOC. risk head trauma. SAH. weakness. mediated by BNP. burns. risk factors (alcoholism. Also treat the underlying causes To calculate the net water loss necessary to [Na+] in hyponatremia.Within 3 to 4 weeks of the clinical onset of the syndrome. liver disease. and hypokalemia) .
Unilateral lung lavage 4. Major bronchial disruption or trauma 3. Thoracic aortic aneurysm b. Esophageal surgery b. Video-assisted thoracoscopic surgery RELATIVE 1. Infection (abscess. Control of distribution of ventilation to only one lung a. Isolation of each lung to prevent contamination of a healthy lung a. Upper lobectomy 2. Unilateral cyst or bullae d. Pneumonectomy c. Massive hemorrhage 2. Surgical exposure—low priority a.INDICATIONS FOR ONE-LUNG VENTILATION ABSOLUTE 1. Bronchopleural cutaneous fistula c. Middle and lower lobectomy c. infected cyst) b. Bronchopleural fistula b. Thoracoscopy under general anesthesia Page 54 of 217 . Surgical exposure—high priority a.
Omphalocele and Gastroschisis Page 55 of 217 o Impaired blood supply to the herniated organs. B respiratory failure C CHD in 20% of infants with omphalocele. and arterial line Post-op keep intubated . and intestinal obstruction o Major intravascular fluid shift and dehydration full-strength balanced salt solution o Hypothermia and hypoglycemia A possible difficult airway Beckwith-Wiedemann syndrome consists of mental retardation. and an omphalocele. need large IV . Induction: NG aspirate gastric content then RSI . a large tongue. possible central. hypoglycemia. congenital heart disease.
ASA.fib.Stroke & TIA: Page 56 of 217 Hemorrhagic or ischemic Etiology: Atherosclerosis. CAD. arrhythmias ECG. severe HTN A LOC. A.fib. A. embolic MI. trauma. coumadin N LOC Peri-op Avoid swinging in BP. VHD. and hyperglycemia With chronic HTN the cerebral autoregulation curve shifted to the Rt . loss of A/W reflux (RSI) B hypoventilation C HTN. Echo D anti-PLT. VHD. post-op CEA.
duration and the rout of exposure are the major determine of the clinical course of intoxication Exposure to vapor gives respiratory symptoms (SOB. also carry more risk to the health care personal with direct contact All the nerve gases causes irreversible inhibition to AchE in both central and peripheral NS The key point in the management is to give the antidote ASAP.esterase inhibitor and cause a cholinergic crisis A mass casualty with both physical trauma and gas intoxication Healthy soldiers Vs civilian with different age groups and other comorbidities The amount. bronchorrhea) with rapid cardiopulmonary collapse (muscarinic effect) Where dermal exposure slow. wheezing. and gradual S/S local muscle twitches and fasciculation (nicotinic effect) then resp failure. and protect the health care personal .Bioterrorism Page 57 of 217 Use of nerve gases which are a potent Ach.
CRF. PVD. trauma. H/P standard + depend on the co-morbidities Lab also as above Options: GA Vs spinal/epidural may the incidence of phantom limb pain.BKA Page 58 of 217 For PVD. DM. tumor Most of the Pt with major co-morbidities e. nerve block. CAD. CVA. DM. but be aware of risk thrombus embolization PE Post-op pain(epidural. Sepsis. infection. COPD.g. DVT (S/C heparin). PCA). gangrene. CVA. but look for C/I monitors standard + depend on the above co-morbidities Position risk of ischemic necrosis (pads) EBL 250 ml The use of tourniquet bleeding. bleeding . MI.
and potential tension Pneumothorax In case of empyema with BPF drain the empyema under LA with chest tube under suction. and avoid N2O For non-surgical management: DLT and resting the affected lung. then may fix the BPF under GA GA options ( the main target is to avoid PPV) o Awake intubation with DLT o Gas induction and maintaining spontaneous ventilation o RSI Keep FiO2 always 1.BPF and Empyema Page 59 of 217 Causes: after pulmonary resection for carcinoma. traumatic rupture of a bronchus or bulla ( barotrauma or PEEP). or spontaneous drainage into the bronchial tree of an empyema cavity or lung cyst PPV contamination of the healthy lung. or use of HFJV Keep a high index of suspicion for tension Pneumothorax . loss of air with alveolar ventilation and CO2 retention. penetrating chest wound. then do a CXR.
Brain death Page 60 of 217 ―irreversible cessation of all function of the entire brain. including the cortex and brain stem. determined in accordance with accepted medical standards‖ CRITERIA FOR THE DIAGNOSIS OF BRAIN DEATH: LOSS OF CEREBRAL CORTICAL FUNCTION o No spontaneous movement o Unresponsive to external stimuli LOSS OF BRAIN STEM FUNCTION o Absent respiratory reflex (apnea test) o Absent cranial nerve reflexes (Gag or cough reflex to suction) o Pupillary light reflex ( no pupil constriction) o Corneal reflex ( no blinking with corneal touch) o Oculocephalic reflex ( doll’s eyes) o Oculovestibular reflex (cold caloric test) o Atropine resistance SUPPORTING STUDIES o Electroencephalography .
with CMRO2 All volatile agents and kitamine cause cerebral vasodilation.5 ml/100g/min& 5.4 ml/min. volume 100-150 ml. with production by Lasix and acetazolamide Enf production and resistance to absorption.Brain metabolism and physiology: Page 61 of 217 In adult:O2 3.5 mg/100g/min of glucose.3-0. except N2O N2O cause CBF w/out dilation.5 ml O2 the autoregulation is abolished by trauma and hypoxia CSF from the choroids plexus and absorbed by the arachnoid villi. ICP CPP. rate of production and absorption 0. peds 5. Iso 0/ resistance ICP N= 10 mmHg. and herniation All volatile agents CBF with return to baseline in 3 hrs. and no change in CMRO2 All IV drugs cause CBF and CMRO2 .
or resection of the affected segment Consider DLT to isolate the affect lung Need pre-op Abx .Bronchiectasis: Page 62 of 217 Localized irreversible dilation of bronchus May have COPD. CXR pneumonia Pt may present with hymoptysis required arterial embolization. ABG. and restrictive component And may associated with other condition so look of other underlying disease: aspergillosis. and give Abx therapy Lab: PFT. R. arthritis If Pt present to OR with active pul infection postponed Sx. HIV.
bronchospasm. endobronchial tumor obstruction C Rt side disease myocardial fibrosis TR. hypotension. and hyperglycemia A N/A. 50% appendix. diarrhea. avoid sux. consider CVP. avoid drugs that can cause histamine release octreotide 10-100 ug IV M Dehydration due to diarrhea. also from the lung. Release Serotonin. to produce the S/S of the carcinoid syndrome Could be a manifestation of MEN I. hyperglycemia Intra-op . abd pain. HTN. the hormones secreted by the hepatic metastases may have direct access to the systemic circulation. once metastases to the liver.Carcinoid Tumors Page 63 of 217 GI is the most common source. and vasoconstriction . Histamine. hormones secreted by nonmetastatic tumors reach the liver by portal vein and are usually inactivated there. Kinins Symptoms: cutaneous flushing. STP B bronchospasm. 25% in the ileum(the source of metastatic tumors). V. PR. art line sympathomimetic drugs can trigger mediator release from carcinoid tumors D Give antihistamines. Gentle induction.
o pericardial constriction of the heart (myocardial ischemia and ventricular arrhythmia) Risks: o Events that intrapleural pressure in the (ventilated) hemithorax or that intrapleural pressure in the surgical (empty) hemithorax may predispose the patient to cardiac herniation. o twisting distal trachea (wheezing). o Placing the patient with the empty hemithorax in a dependent o Use of high levels of pressure and volume during mechanical ventilation of the remaining lung can push the heart into the empty hemithorax. o twisting IVC (cardiovascular collapse).Cardiac herniation Page 64 of 217 An emergency and life threatening with mortality 50% With pneumonectomy. And coughing . o twisting pulmonary veins (pulmonary edema). in the 1st few hrs or few days later Pathophysiology: o twisting of the SVC (SVC syndrome).
Cardiac Risk* Stratification for Noncardiac Surgical Procedures Page 65 of 217 High (Reported cardiac risk often greater than 5%) · Emergent major operations, particularly in the elderly · Aortic and other major vascular surgery · Peripheral vascular surgery · Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss Intermediate (Reported cardiac risk generally less than 5%) · Carotid endarterectomy · Head and neck surgery · Intraperitoneal and intrathoracic surgery · Orthopedic surgery · Prostate surgery Low† (Reported cardiac risk generally less than 1%) · Endoscopic procedures · Superficial procedure · Cataract surgery · Breast surgery *Combined incidence of cardiac death and nonfatal myocardial infarction. †Do not generally require further preoperative cardiac testing.
CAROTID ENDARTERECTOMY Page 66 of 217 Pre-op: H/P Lab: CBC, Lytes, BUN, creat, Glucose, ECG, PFT if needed A N/A B possible smoker COPD C CAD, HTN (need to well controlled pre-op) M DM CNS neurological deficit Regional (deep, superficial cervical plexus) Vs GA same out come Induction: anticipate fluctuation of BP Maintenance: Iso neuro-protection, Keep BP 20% higher, monitor blood glucose, LA infiltration over the carotid sinus, give heparin 100u/kg Monitors: standard+ 5leads ECG, Art-line, in cardiac Pt consider TEE, Emergence: early to assess for nay neuro deficit Post-op potential problems: new neuro deficit back to OR or Angio, hemodynamic instability mainly HTN, bleeding with hematoma formation which may compromise the Airway Back to the OR, 100% O2 have difficult airway
Canadian Cardiovascular Society Functional Classification of Angina Pectoris 217 Page 67 of Class Definition Specific Activity Scale I Ordinary physical activity, (eg, walking and climbing stairs) does not cause angina; angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. Ability to ski, play basketball, light jog (5 mph), or shovel snow without angina II Slight limitation of ordinary activity; angina occurs on walking or climbing stairs rapidly; walking uphill; walking or stair climbing after meals, in cold, in wind, or under emotional stress; or only during the few hours after awakening; when walking > 2 blocks on level ground; or when climbing more than 1 flight of stairs at a normal pace and in normal conditions. Ability to garden, rake, roller skate, walk at 4 mph on level ground, and have sexual intercourse without stopping III Marked limitation of ordinary physical activity; angina occurs on walking 1 to 2 blocks on level ground or climbing 1 flight of stairs at a normal pace in normal conditions. Ability to shower or dress without stopping, walk 2.5 mph, bowl, make a bed, and play golf IV Inability to perform any physical activity without discomfort; anginal symptoms may be present at rest. Inability to perform activities requiring 2 or fewer metabolic equivalents (METs) without angina
Cesarean Section Page 68 of 217 Depend if elective/urgent Vs stat Always have the room ready: Anesthesia machine checked, A/W equipment ready, Emergency drugs ready Always ask for blood for any bleeding case Elective/urgent: Enough time to evaluate Pt, H/P as routine obstetric Hx, and anesthetic Hx with physical exam mainly the A/W, chest, edema …..+ review lab, obstetric consideration Obtain informed consent from the Pt for neuroaxial block, with risk/benefit discussion, if not C/I for the block. Pre-meds GI, other if indicated e.g. asthma, anxiety, endocarditis, steroids IV at least 1.5 -2.0 L of fluids O2, Pre-block V/S If using hyperbaric L.A lie the Pt down very quickly + LUD, repeat BP Inform the Pt that if she feel sick to tell me right way (BP) Examine the block by asking the surgeon to use a teeth forceps As soon as the baby out give synto 5 U then 20 U in the bag For spinal: 10.5 mg marcaine hyperbaric, 20 ug fentanyl, 150 ug epimorph
Cardiology consult to optimize Workup: CBC. peripheral edema Rx that proven to improve outcome: ACEI. ascites. comfortable at rest. Rt or Lt S/S: SOBOE. vasodilators Other modality: biventricular pacing. HTN. and loop diuretics Other antiarrhythmics. metabolic acidosis Could be Sys Vs Dias. and no symptom II slight limitation with normal activity.S3 gallop. orthopnea. CHD. Lytes. AICD Assess using NYHA functional capacity I no limitation with normal activity. PND. VHD. CXR. pul HTN Hallmark: CO.CHF: Page 69 of 217 Causes: IHD. anticoag. hepatosplenomegaly. les the normal activity produce symptom VI severe limitation. review Echo . JVP. symptomatic at rest Pre-op: postponed if decompensated. SVR. VEDP. 12-ECG. exercise tolerance P/E: crackles. Chem. -blocker. Cardiomyopathy. symptomatic III marked limitation with normal activity. spironlactone Rx that improve symptom: Dig.
5 Easily controlled Minimal Good 4–6 10% <3.0 2.Lab and Clinical Criteria for Estimating Hepatic Reserve (Child-Pugh 70 of 217 Page Classification) CRITERIA CLASS A CLASS B CLASS C Serum bilirubin mg/100 mL <2.0 Not easily controlled Advanced Poor >6 50% .0 >3.0–3.0 Serum albumin g/100 mL Ascites Encephalopathy Nutrition Prothrombin time (sec > control) Surgical risk mortality rate >3.0–3.5 None None Excellent 1–4 5% 3.
CVP at least . ECG: voltage of QRS. avoid sudden drop in SVR. arthritis. since limited CO o Avoid all histamine releasing drugs o Art-line.Chronic constrictive pericarditis Page 71 of 217 It resemble tamponade in impede diasolic pressure. pulsus paradoxes but less than tamponade CXR: calcification over the pericardium. kussmaul sign exaggerationin CVP with inspiration. and stroke volume Causes: idiopathic. R.fib and flutter. and post-heart S/S: arrhythmias A. CRF. radiation. PAC. avoid cardio-depressant drugs o Rate: avoid sudden HR o Afterload maintain. venous pressure. since they’re preload dependent o Cont maintain. inverted T-waves Rx surgical pericardiotomy Anesthesia Mx o Preload maintain. and avoid .
Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial217 Page 72 of Infarction. Death) Major Unstable coronary syndromes · Acute or recent myocardial infarction* with evidence of important ischemic risk by clinical symptoms or noninvasive study · Unstable or severe† angina (Canadian class III or IV)‡ Decompensated heart failure Significant arrhythmias · High-grade atrioventricular block · Symptomatic ventricular arrhythmias in the presence of underlying heart disease · Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease Intermediate Mild angina pectoris (Canadian class I or II) Previous myocardial infarction by history or pathological Q waves Compensated or prior heart failure Diabetes mellitus (particularly insulin-dependent) Renal insufficiency . Heart Failure.
CVP. avoid sudden in SVR Avoid Regional GA is better tolerated for C/S Monitors Art-line. endocarditis High mortality rate.Coarctation of the Aorta Page 73 of 217 If corrected no special precautions Arm-leg different < 20mmHg good outcome Uncorrected high risk of LV failure. and upper Vs lower BP Need Echo and 12-ECG hemodynamic Goals: o preload o R/R slightly maintain sinus o Cont maintain. avoid cardiodepressant o Afterload maintain. risk of offspring CHD Risk of having bicuspid aortic valve. aneurysm of circle of Willis Measure Rt Vs Lt side BP. Ephedrine and dopamine are the best choice since they have choronotropic effect . aortic rupture or dissection.
arrhythmias Renal ARF Heme thrombocytopenia. SAH. anemia Hepatic failure. avoid pure -blockers alone may get unopposed -effect. rupture CNS seizure.Cocaine abuse Page 74 of 217 Affect three main neurotransmitters Norepi. ICH. CVA fetus UP blood flow. pneumothorax. DIC. pneumomediasinum C MI. proteinuria A B aspiration.and ephedrine is not a good choice(not work) Neo better . bronchspasm. edema. with risk of coronary vasospasm Regional OK. So consider NTG. HTN. hydralazin with induction. be aware of severe hypotension with spinal. Serotonin and dopamine Can present like PIH with HTN. cross placenta The main problem is severe HTN with induction.
HONKC.Coma/LOC Page 75 of 217 Management: o ABC o Monitors o Give thiamine 100 mg IV. drugs(opioids.…. urine analysis.) H/P AMPLE. Dextrose 50g IV o Lab: ABG. creat. sepsis o Metabolic: hypoglycemia. chemostrip. seizure disorder. lateralization. blood/urine for toxicology and drugs level DDx: o CNS pathology: tumor. pupils. Tylenol. uremia. LFT. coagulation profile. acidosis o Respiratory: hypoxia. encephalitis. hepatic encephalopathy . hypercarbia o Overdose: EtOH. CBC-D. VS. aneurysm. trauma.. BUN. TCA. lytes. ECG. DKA. Neuro GCS. AVM o Infection: meningitis. . Cocaine.
bulbar and (arms > legs) facial muscle weakness Exercise improves with strength Fatigue with exercise Muscle pain common Muscle pain uncommon Reflexes absent or Reflexes normal Gender pathology Response to muscle relaxants Male > female Small cell carcinoma of the lung Sensitive to Sux and NDMR Female > male Thymoma Resistant to Sux Sensitive to NDMR Good response to anticholinesterases Poor response to anticholinesterases .COMPARISON OF MYASTHENIC SYNDROME ANDMYASTHENIA of 217 Page 76 GRAVIS Myasthenic Syndrome Myasthenia Gravis Manifestations Proximal limb weakness Extraocular.
with spontaneous breathing . 20% CHD Lab X-match Induction gas induction. keep suction B hypoplastic lung RDS. neonate could be on NO or ECMO.Congenital Diaphragmatic Hernia Page 77 of 217 95% Lt side neonatal and premature consideration A insert NGT . N2O is C/I. keep Airway pressure < 20-30 cmH2O. keep 100% O2 C 15% CHD R renal abnormality N neuro abnormality Congenital lobar emphysema o LUL most common o Emergency and potential life threatening A ? B resp failure. ball valve avoid PPV. and avoid lung expansion after hernia repair. 100% O2 C mediastinal shift hemodynamic instability . cyanosis. N2O C/I. risk of pneumothorax with PPV.
wheezing. cor pulmonale. hypercarbia. respiratory failure. home O2. BUN. ABG. PaCO2 > 50 H/P: smoking. JVP.COPD Page 78 of 217 A airway reactivity bronchospasm B risk of hypoxia. bronchospasm. sensitivity to resp depressant drugs Heme polycythemia Lytes PPC with: FEV1/FVC < 70%. PFT. CBC-D. steroids. cyanosis With smoking risk of CAD Lab: CXR. coughing. wheezing. consider Abx therapy Pt may need O2 supplement pre-op if PaO2<60. lytes. and PPC: atelectasis. with respiratory failure more likely if FEV1 <50%. RV failure. Hct >55 . FEF25-75 <50%. anticholenergic) . peripheral edema. ECG. bronchodilators(-agonist. pul HTN D avoid STP. pneumonia. FVC< 75%. A/E bilaterally. exercise tolerance. sputum amount and color. smoking C cor pulmonale. crackles. creat For PFT do pre and post bronchodilators Optimize the Pt pre-op: smoking cessation.
aVF Q. T Anteroseptal V1–V4 Q. V1–V4 Q. T Page 79 of 217 Coronary Artery Right Left circumflex Left LAD Electrolyte Disturbances Ca2+ Rate <100 Rhythm Regular PR interval Normal QT interval Ca2+ <100 Regular Normal/ K+ <100 Regular Normal T flat/U wave K+ <100 Regular Normal T peaked QT . ST. ST. aVL. III. T Lateral I. V5–V6 Q. ST. T Anterior I. aVL. ST.Coronary Artery Disease— Myocardial Infarction Anatomic Site Leads ECG Changes Inferior II.
large tongue. ICP A possible difficult A/W maxillary hypoplasia. PDA D Avoid ketamine and sux M lytes abnormality N ICP. bear hugger. massive blood loss. tracheomalacia. long with risk of bleeding so need art line. blood in the OR If only one suture short procedure. mental retardation Have a big IV access. Foley cath If involve below the orbit A/W swelling keep intubated post-op (ICU) till the swelling subsided .Craniosynostosis: Page 80 of 217 May associated with other syndrome Crouzon’s syndrome (MH) Main issues: difficult A/W. seizure disorder. OSA C CHD ASD. VAE. CVP. IV wormer . TOF. micrognethia Awake FOI. multi masks and blads B tracheal stenosis. if > 1 .
A prone to aspirate gastric impaired swallowing function and decreased activity of laryngeal reflexes. ionizing radiation. formalin.Jakob disease Page 81 of 217 human spongiform encephalopathies. Prions are resistant to alcohol. myoclonus. .Creutzfeldt . proteases. A prion is a small proteinaceous infectious agent. but can be inactivated by heat (autoclaving). The other two diseases in this group are kuru and Gerstmann-Straussler syndrome. these disorders are characterized by vacuolation of brain tissue and neuronal loss. Management of Anesthesia Because of the transmissibility of the disease. DBecause lower motor neuron dysfunction succinylcholine should be avoided. Pathologically. incubation time is long (years) The typical clinical characteristics include subacute dementia. C autonomic dysfunction abnormal CV responses to anesthesia and vasoactive drugs. appropriate precautions should be taken to protect other patients and health care providers. caused by an unusual infectious agent—a prion. and nucleases. and EEG changes. detergents. and extremes of pH. phenol.
fatty liver. perforation R amyloidosis Heme chronic anemia. 3rd space loss. cirrhosis. iron def. K. immunosuppressant G obstruction. albumin free fraction of drugs MSK arthritis with ROM . vit B12. folate M hypovolemia.Crohn's Disease Page 82 of 217 A RSI for S/S of bowel obstruction B N/A C hypovolemia D Steroids (stress dose).
volume overload D steroids (stress dose).antiinflammatory.1 mg·day–1 of fludrocortisone . Addison crisis MSK osteopenia. muscle wasting Immun infection Post bilateral adrenalectomy may need mineralocorticoid replacement in day 5. K. 4. give 0. psycosis M DM. met alk. 3. and glucose uptake by the cells Exogenous therapy (most common) > 21 days Bilateral adrenal hyperplasia due to ACTH from pituitary adenoma or nonendocrine tumor (lung.Na retention. avoid etomidate. and K excretion. mucosa easily traumatize B OSA C HTN. titrate NDMR N emotional.maintain BP by converting Norepi epi.hyperglycemia by gluconeogenesis.Cushing Syndrome :( Glucocorticoid Excess) Page 83 of 217 Cortisol function: 1. pancreas) A possible difficult A/W. 2. kidney.05–0.
and avoid spinal sudden SVR convert the shunt to Rt Lt o Give O2 all the time . PDA are well tolerated in pregnancy The main keys in management for anesthesia are o Avoid air bubble in the IV o For epidural insertion use saline instead of air both due to risk of paradoxical air embolism o Pain catecholamine SVR shunt RV failure o So early epidural is desirable o Slowly titrate the epidural. VSD.CV diseases in pregnancy Page 84 of 217 Lt Rt shunt e.g. ASD.
diastolic collapse . tricuspid motion toward right atrium Systolic filling of atrium Diastolic plateau Atrial relaxation.to late diastole Mid-systole y descent Early diastole Early ventricular filling. systolic collapse v wave h wave x descent Late systole Mid.CVP Waveform Components WAVEFORM a wave c wave PHASE End-diastole Early systole Page 85 of 217 MECHANICAL EVENT Atrial contraction Isovolumic ventricular contraction. descent of the base.
5 mg/kg. tachyphylaxis to SNP. SvO2.Cyanide toxicity Page 86 of 217 By preventing oxidative phosphorylation cellular hypoxia anaerobic metabolism S/S lactic acidosis. with deteriorating hemodynamics and metabolic acidosis slow IV administration of sodium nitrate. ( converts Hb to methemoglobin. which acts as an antidote by converting cyanide to cyanomethemoglobin hydroxocobalamin (vitamin B12a) which binds cyanide to form cyanocobalamin (vitamin B12) can be administered (25 mg/hour IV to a maximum of 100 mg) . Sz Management: D/C SNP 100% O2 Thiosulfate 150 mg/kg IV administered over 15 minutes (acts as a sulfur donor to convert cyanide to thiocyanate) If severe.
GI. B pneumonia. mixed obstructive/restrictive disease. GI enzyme A sinusitis avoid nasal intubation with active nasal infection.Cystic fibrosis: Page 87 of 217 A disease of the exocrine glands: salivary. PFT. pul Rx: chest physio. creat. pancreatic insufficiency. ECG. sweet. art-line Suction the airway before extubation Consider regional block for post-op pain control Encourage chest physio post-op . lytes. CXR. Abx. Echo if needed Monitors: CAS. bronchodilator. BUN. hepatic dysfunction Heme bleeding disorder Lab: CBC-D. coags. bronchiectasis C cor-pulmonale GI cholelithiasis.
AVM. and expand it if necessary. Nicardipine . if abnormal renal functionhydroxocobalamin o NTG: less potent. spine Sx. o Other: Trimethaphan. o Isoflurane: easy titration.Deliberate Hypotension: Page 88 of 217 Mainly used to blood loss: aneurysm. CVP. and rebound HTN. do not exceed 10ug/kg/min for 10 min. cyanide and thiocyanate toxicity.5mg/kg in 24hrs. hypoxia. SSEP or EEG in brain and spine Sx Choices: o SNP: rapid on/off. Esmolol and Labetalol. or 0. Rx of toxicity: IV thiosulfate. 70% of the awake MAP Monitors: Art-line. CMRO2. ICP. also it’s inhibit PLT aggregation. severe anemia. or > 1mg/kg in 2hrs. but shunt. TIA’s angina. heart failure. acidosis. Renal insuff Ass intravascular volume pre-op. major head and neck The main C/I are: uncontrolled HTN.g. Have a target MAP based on awake MAP e. risks: pul shunt. resp failure. Prostaglandin E1. no cyanide problem.
The serum sodium and plasma osmolality are measured on a regular basis. the patient with complete DI receives an iv infusion of aqueous ADH (100–200 mU·h–1) combined with administration of an isotonic crystalloid solution. management depends on the extent of the hormonal deficiency. ADH also may be given intramuscularly (as vasopressin tannate in oil). and therapeutic changes are made accordingly. During surgery. patients with a residually functioning gland usually do not need . Etiology due to destruction of the pituitary gland by intracranial trauma. hypernatremia. As a consequence of the large outpouring of ADH in response to surgical stress. infiltrating lesions. or surgery. and a high output of poorly concentrated urine.Diabetes Insipidus Page 89 of 217 from inadequate secretion of ADH (central DI) or resistance on the part of the renal tubules to ADH (nephrogenic DI) Failure to secrete adequate amounts of ADH results in polydipsia. DDAVP administered intranasally has prolonged antidiuretic activity (12– 24 hours) and is associated with a low incidence of pressor effects.
or chemosrip for glucose. difficult intubation. lytes abnormalities. hypoxia GI delayed gastric emptying. BUN. and hyperosmoalr coma . Art-line.DIABETES MELLITUS Page 90 of 217 A stiff joint syndrome ―prayer sign. PVD. frequent ABG. hyperglycemia. includes 5-leads ECG. Lytes. consider insulin/D5% infusion peri-op for long cases Document neuropathy pre-op for positioning and regional anesthesia monitoring intra-op. cardiomyopathy . FOI. mobility of the AO joint. full stomach M hypo. RSI full stomach B N/A C CAD. and in PARR unless it’s an emergency Sx. postponed DKA. creat D/C OHA in AM. silent MI. DKA. FBS. hyperosmolar coma Renal renal function CNS neuropathy (positioning). CVA Pre-op: lab: ECG. autonomic neuropathy. risk of post-op MI D metformin associated with lactic acidosis in hypotension.‖.
Diabetic Ketoacidosis Page 91 of 217 Accumulation of acetoacetate and -hydroxybutyrate ketone bodies are organic acids metabolic acidosis with an unmeasured AG. Provoked by intercurrent illness, trauma, or cessation of insulin therapy. the degree of hyperglycemia does not correlate with the severity of the acidosis. Blood sugar levels are often in the 300–500 mg·dl–1 range. leukocytosis, abdominal pain, GI ileus, and mildly amylase levels are all common in DKA, Pt may Dx as acute abdomen. Treatment Regular insulin 10 units iv bolus followed by an insulin infusion nominally at (blood glucose/150) units·h–1 Isotonic iv fluids as guided by V/S and urine OP; anticipate 4–10 l deficit When urine >0.5 ml·kg–1·h–1, give KCl 10–40 mEq·h–1 (with continuous ECG) When glucose to 250 mg·dl–1, add dextrose 5% at 100 ml·h–1 Consider sodium bicarbonate to correct pH <7.1 When glucose levels below 250 mg·dl–1, glucose should be added to the iv fluid while insulin therapy continues. K replacement is a key concern in patients with DKA, Because of the diuresis, the total body potassium stores are reduced.
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Dilated Cardiomyopathy myocardial contractility systolic dysfunction CO ventricular filling pressure Dilatation of both ventricles MR, TR. Causes: the most common is IHD and alcohol Other causes: o Direct: Toxic :Alcohol, Anthracyclines, Catecholamines, Cobalt, Phenothiazines, Radiation, Uremia, Adriamycin. Infectious:Protozoan (Chagas' disease) Viral (coxsackievirus, other enteroviruses, influenza) Metabolic :Starvation, Thiamine deficiency (beriberi) Genetic, Idiopathic o Indirect Ischemic Large-vessel coronary disease (postinfarction cardiomyopathy) Small-vessel coronary disease Global ischemia (cardiac surgery) Anemia, TTP, Hypersensitivity, Idiopathic myocarditis
Down syndrome: Page 93 of 217 Highly associated with CHD 50%, cyanotic 8%(mainly TOF) A C1-2 subluxation, subglottic stenosis, large tongue difficult intubation, avoid neck extension B C CHD, TOF, CHF, Tet spells, Rt Lt shunt ( be meticulous about air in the IV) M hypothyroidism, hypothermia CNS MR
ECT during pregnancy Obstetric consideration Risk of abortion and premature labor, also risk of bleeding Minimize the amount of drugs as much as possible Use only the drugs that are known to be safe(STP, Sux, NDMR, Opioids, Ketamine, Etomidate) Have an obstetric consultation Beyond the 1st trimester do GA with ETT, RSI, with maintaining LUD Have FHR monitor
EEG FREQUENCY RANGES Page 94 of 217 Delta rhythm (0–3 Hz) Deep sleep, deep anesthesia, or pathologic states (e.g., brain tumors, hypoxia, metabolic encephalopathy) Theta rhythm (4–7 Hz) Sleep and anesthesia in adults, hyperventilation in awake children and young adults Alpha rhythm (8–13 Hz) Resting, awake adult with eyes closed; predominantly seen in occipital leads Beta rhythm (>13 Hz) Mental activity, light anesthesia Effect of anesthesia is depend on the dose. @ low dose frequency @ moderate dose frequency and amplitude @ high dose silent compare to SEP, EEG records the spontaneous brain activity with higher amplitude, while the SEP have a smaller amplitude in response to a specific stimuli.
Avoid high airway pressure C MR. Arrhythmias. consider SBE prophylaxis Heme bleeding disorder with normal coags profile Anticipated problem bleeding Obstetric premature labor & bleeding Avoid Regional Anesthesia Page 95 of 217 . abnormal metabolism of type III collagen A avoid A/W traumatization B spontaneous Pneumothorax.Ehlers-danlos Syndrome: CTD.
with pads on the Pt Epidural have better outcome than GA careful titrate LA Page 96 of 217 . demise high rish of thromboembolic event mainly post partum Hemodynamic Goals: o preload maintain. avoid sudden in SVR o PVR avoid by hypoxia.Eisenmenger Syndrome Chronic Lt Rt shunt changes to Rt Lt Pregnancy S/S due to SVR hypoxia IUGR. acidosis. PCO2 Consider inhaled NO. avoid cardiodepressant o Afterload maintain. O2 all the time. PAC/CVP For the 1st stage single shot spinal opioids 2nd stage may consider slow titrating epidural Be aware that they could be anticoagulated For C/S crash cart in the room. avoid AC compression LUD o R/R maintain normal sinus o Cont maintain. with pulse oxi Monitors Art-line.
and other injuries o Potential burn to the face early intubation . tetanic contraction of resp muscles. and prolonged paralysis o Consider C-spine precaution. current pathway. muscle. resistance to current.Electric shock and lightning strike Page 97 of 217 Electric shock o Direct effect of the current o Conversion of electric to heat energy Factors determine the nature and severity: magnitude of energy delivered. and duration of contact o Bone and skin have a high resistance o Blood vessels. nerve have a low resistance o The skin resistance can be by moist and convert a low voltage to a life threatening shock o Alternating current is more dangerous than a direct current o Transthoracic (hand-hand) are more dangerous than vertical ones o VF more common with alternating. while asystole more with direct o Respiratory arrest due to CNS effect (medulla). type of current.
single ventricle states. or PDA (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation Physiologic. functional.Cardiac Conditions Associated With Endocarditis Page 98 of 217 Endocarditis prophylaxis recommended High-risk category Prosthetic cardiac valves. TOF) Surgically constructed systemic pulmonary shunts or conduits Moderate-risk category Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunction (eg. or innocent heart murmurs . rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets Endocarditis prophylaxis not recommended Negligible-risk category (no greater risk than the general population) Isolated secundum atrial septal defect Surgical repair of ASD. including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic CHD (eg. VSD. TGA.
and respiratory o Adult: Ampicillin 2g IV 30 min pre-op o Peds: Ampicillin 50mg/kg within 30 min of starting o Allergy to Amp Clindamycin 600 mg . oral. esophageal.Endocarditis Prophylaxis Dental.5/kg max 120mg Peds 50mg/kg & 1. Peds 20mg/kg GU/GI o High risk: Amp & Gent Adult 2g/ 1.5 kg Allergy to Amp Vanco and Gent. 1g for adult and 20mg/kg for peds o Moderate risk: Amp alone Same as above dose Allergy to Amp Vanco also the same dose Page 99 of 217 .
and avoid suctioning o skin: very fragile avoid tapes for IV and ETT. porphyria cutanea tarda.Epidermolysis Bullosa Page 100 of 217 inherited or acquired loss of intercellular bridges and separation of the skin layers intradermal fluids accumulation and bulla formation. 3 types o simplex benign o junctional rarely survive beyond early childhood o dystrophic. cardiomyopathy o CVS: cardiomyopathy and MVP o Lytes: loss of albumin hypovolemia and electrolytes imbalance o Associated diseases: D. hypercoagulation. Systemic manifestations and Anesthetic considerations: o A very fragile m. multiple myoloma . BP cuff must be pad with cotton o GI: esophageal stricture malnutrition anemia.M.m bledding & bulla formation with fixation of the tongue difficult intubation use a lot of lubricant on the ETT. avoid tourniquet.
and maintain spontaneous ventilation Use a smaller ETT. most common pathogen is H. and need to be kept intubated for 24-72h. with incidence due to vaccine The main conflict is difficult airway with risk of aspiration Other DDx is retropharyngeal abscess Rapid onset within 24h. and the kid is sitting foreword. and the difficult airway cart in the room Do a gas induction with Sevo. with toxic appearance Need to managed in the OR. keep the kid with the parents. with Abx therapy After intubation risk of pul edema NO NO NO muscle relaxant Give atropine . and do a gas induction without starting an IV. in the presence of the ENT surgeon in the room. high grade fever. and have different sizes ready After Intubation keep sedated and transfer to ICU. influenzae. inspiratory stridor. mouth opening and drooling.Epiglottitis Page 101 of 217 an emergency and life threatening condition 1-7 y.o.
avoid any drugs that may seizure threshold. bleeding). . to be taken in AM A N/A B possible frequent aspiration C tuberous sclerosis.Epilepsy: Page 102 of 217 H/P: why(pathology: head injury. CVA. enzyme induction with pentobarb. type. tumor. last aepisode. other: aplastic anemia. hepatic toxicity with carbamazepine. dose. frequency. S/S of ICP Meds: what. drugs effect (cardiotoxicity) D resistance to NDMR with phenytoin.
Epilepsy surgery Page 103 of 217 Hx type generalized. if an Art-line needed have in the same side of the lesion e. also avoid any long acting anticonvulsant . Rt temporal Rt radial art line Avoid any pre-med that may change the seizure threshold. focal. or without Aura Review all meds. and keep communication with Pt all the time In case of A/W obstruction D/C sedation gtt. with. mainly anticonvulsant metabolism of NDMR Discuss with the surgeon the anesthetic plan GA Vs sedation with LA May need awake test with speech mapping In case of sedation use a judicious amount of sedation. absence. O2 by NP. ETT In addition to the standard CAS monitoring. 100% O2 LMA.g.
Osmolality. Foley cath o ECG QT.Ethylene Glycol poisoning Page 104 of 217 Found in: detergent. Sz. pulse oxi. coma. EG level. creat. BUN. and osmolar gap S/S depend on when they present and at which stage: o Stage I (30min-12hr) CNS with hallucination. ABG. antifreeze. tachycardia. art-line. ECG o Monitors: ECG. Ca oxalate in the urine Management: o ABC o Lab: CBC-D. pul edema o III (24-72hr) Renal flank pain. Lytes. polish The toxic metabolite Glycolic acid is responsible for the metabolic acidosis with anion gap. CXR. Lytes Ca o Gastric lavage o Depend on the serum level of EG whether to give EtOH or not or to start HD . tetany o II (12-24hr) Cardioresp HTN.
evidence of myotonia as well as episodes of muscle weakness. caused by a sodium channel mutation. or hypothermia. Hyperkalemic Periodic Paralysis. acute episodes of skeletal muscle weakness. both AD inherited diseases. and hypokalemic. intermittent. infusions of KCl. Consider glucose containing solution pre-op during fasting. metabolic acidosis. Episodes of weakness lasting several hours can occur: during rest after exercise. hyperkalemia is often transient. . caused by a calcium channel mutation. occurring only at the onset of weakness. K levels measured during the episode of weakness may be N or even Treatment consists of a low-K diet and the administration of thiazide diuretics. Attach may last hours or days. More common.Familial Periodic Paralysis Page 105 of 217 Two forms: hyperkalemic. The weakness may be so severe as to produce respiratory distress. Hypokalemic Periodic Paralysis.
age (20–30 years). CRITERIA FOR DIAGNOSIS OF FAT EMBOLUS SYNDROME o MAJOR Axillary/subconjunctival petechiae Hypoxemia (PaO2 < 60 mm Hg. The incidence of FES in isolated long bone fractures is 3–4%. FIO2 < 0. rheumatoid arthritis.Fat Embolus Syndrome Page 106 of 217 associated with multiple traumatic injuries and surgery for long bone # Risk factors include:male sex. and the mortality rate ranging from 10 to 20%. intramedullary instrumentation. hypovolemic shock.4) CNS depression (disproportionate to hypoxemia) Pulmonary edema o MINOR Tachycardia (>110 beats·min–1) Hyperthermia Retinal fat emboli Urinary fat globules platelets/hematocrit (unexplained) .
Flow volume loop Page 107 of 217 .
and the rest in the nest 2 hrs Glucose requirement for neonate 4-6 mg/kg/min D10W 100mg/ml of glucose Dehydration o Based on body wt in infant 5% mild.Fluids Page 108 of 217 Blood volume o Preterm 100 ml/kg o Newborn 85 ml/kg o Up to 2y 75 ml/kg o 2-puberty 70 ml/kg Maintenance use the rule 4-2-1. 15% severe o >15 kg 3% mild. 6% mod. add the deficit using the same rule from NPO and replace it 50% in the first hr. 9% severe Clinical signs Mild mod severe Urine anuria Mucosa slight dry Dry parched Fontanel N sunken marked sunken Eye N sunken marked sunken . 10% mod.
ABG (PRN) Pre-med GI. ECG. hypothermia. Creat.anesthesia D insulin M hypoglycemia. ANS dysfunction hypotension with R. lethargy Lab: CBC-D. risk of C/S In addition to obstetric consideration A Stiff joint syndrome difficult A/W B C hypovolemia. HNKC CNS ANS dysfunction. BUN. bili. Review White classification for DM its according to the severity Page 109 of 217 .Gestationl diabetes maternal/fetal M/M. DKA. R renal dysfunction Fetus/neonate hypoglycemia. Lytes.
and do PFT In pregnancy premature labor. consider CVP. CBC. LMN involvement ? caused by viral infection GI. (K). sensitivity to NDMR GI bowel obstruction CNS demyelination Pre-op: PFT. avoid Spinal severe hypotension . ABG. stimulator in place Post-op: continue mech vent (ICU) In Pt with previous disease assess for residual neuropathy. autonomic dysfunction D NO Sux. flu A full stomach. ECG. Lytes Before induction have an art-line in place. difficult intubation if TMJ involvement B respiratory involvement C arrhythmia.Guillian barre’ Syndrome Page 110 of 217 Widespread inflammatory demyelination of peripheral and ANS It’s ascending in nature. epidural OK. unpredictable response to intubation and induction. have N. CXR.
Head and spinal cord injury Page 111 of 217 15% of CO to the brain. but PCO2 reactivity is preserved with in magnitude. avoid drugs/tech ICP.25-1g/k. adequate pain/sedation. contusion. pupils. ICP. the secondary is an exacerbation of neuronal damage from change in CBF. focal/lateralization neuro signs Lab: CT-head. use lido. toxicology screen Induction: RSI. avoid CMRO2 Exam: GCS. it’s very important to maintain SBP > 90 ICP maintain O2. sux . hypoxia. or DAI. adequate cerebral drain head up. temp . CBC. and herniation The Autorgulation of CBF is disrupted. and systemic factors e. CVP. hypothermia Anesthesia goals: o Optimize CPP. Lytes. anemia. with CBF of 50ml/100g/min Pathophysiology: TBI primary injury is due to hematoma. Coags. PCO2 30.g. art line. BP. avoid ischemia. inline stabilization. brainstem reflex. mannitol . Sz Hypotension is the most important factor poor prognosis The effect of ICP CPP. severe PCO2. temp. Monitors: routine.
0136 g-m·beat–1·m–2 Right ventricular stroke work index :RVSWI SI X (MPAP-CVP) X 0. DERIVED HEMODYNAMIC VARIABLES Name Calculation Units CI CO/BSA l·min–1·m–2 SVR (MAP-CVP/CO) X 80 dyne-cm·s–5 PVR (MPAP-PCWP/CO) X 80 dyne-cm·s–5 Stroke index SI CI/heart rate cc·beat–1·m–2 Page 112 of 217 Left ventricular stroke work index :LVSWI SI X (MAP-PCWP) X 0.0136 g-m·beat–1·m–2 .Table 25-4.
avoid Regional anesthesia . Hematology consult Rx factors concentrate VIII. direct relation between the severity of bleeding and the plasma concentration of the factors CNS bleed is the major cause of death. Hemophilia C is an AR disorder that occurs almost exclusively in Ashkenazi Jews Normal concentration of vWF. also DDAVP factors release from the endothelium With time type A may develop inhibitors to factor VIII:C . IX is 24 hrs.Hemophilia Page 113 of 217 A deficient or functionally defective Factor VIII:C. avoid blind suctioning. VIII t1/2 is 12 hrs. with N PT. Possible HIV + Do gentle intubation. and the dose of factor VIII:C need to be . IX and XI. which therefore occur almost exclusively in males. (85%) B (Christmas disease) deficiency or abnormality of Factors IX(14%) C deficiency or abnormality of Factor XI (1%) Both hemophilia A and B are sex-linked recessive disorders. may give Cryo if needed. with normal BT. Lab: PTT.
PLT. lytes. upper GI bleed CNS encephalopathy Correct coagulation pre-op (FFP. hypoglycemia. CHF D altered drug pharmacokinetics Heme anemia. Cryo. creat. PLT. Vit K) Consider paracentesis pre-op if respiratory compromise Have an ICU consult and back-up bed Lab: CBC-D. Page 114 of 217 Depends on the activity and the stage. coagulation defect M albumin. PFT. CXR. acidosis Renal hepatorenal syndrome GI portal HTN. coags(PT.C. BUN. Echo.Hepatitis B. ABG . Pul HTN C hyperdynamic circulation. restrictive lung disease. fibrinogen). ECG. ascites. B hypoxemia due to shunt. PTT. with Post-op M&M Risk of transmission to OR personal (use needle-less system) A RSI for GI bleeding. LFT. lytes abnormality.
autonomic neuropathy D drugs related side effect neuropathy. pul HTN. HBV . adrenal insufficiency CNS demyeliantion neropathy like gullian barre’ syndrome R+ Lytes CRF from sepsis. and the protease inhibitor may interact with cytochrome P-450 either by induction or inhibition which can sensitivity to BNZ GI esophagitis. heroin. pancreatitis. endocarditis. pericarditis. ARDS like. myocarditis. opioids . lactic acidosis. TB. diarrhea Heme leukopenia. side effect of antiviral drugs. and health care personal safety A N/A B PCP. anemia. dehydration. drugs Possible substance abuse cocaine. C accelerated CAD.HIV Page 115 of 217 The main considerations are the disease process. other infection HCV. ITP Endo DM. hypoxia.
treat arrhythmia aggressively o Cont . avoid sudden in SVR Neo is the drug of choice if BP Epidural very slow titration With GA risk of CHF Page 116 of 217 . LUD o R/R maintain sinus.HOCM With pregnancy HR and contractility with SVR worsen the obstruction -blockers is the treatment of choice Synto no bolus. give slowly hemodynamic Goals: o preload . avoid contractility (kitamine) o Afterload .
LVH. BUN. HTN. Rt shift of auto regulation curve Hydrate pre-induction Consider Art-line depend on Pt status and the procedure Lab ECG. PVD. Lytes. CBC. …. creat Page 117 of 217 . Postponed if DBP > 110 Continue -blockers. and 2-agonist peri-op D/C ACEI A N/A B N/A C CHF.HTN Essential or secondary. with labile BP M intravascular volume R renal impairment CNS TIA. pheo. With secondary look for the underlying cause: cushing. CVA.
or LP shunt. A impaired A/W reflex aspiration RSI B impaired resp drive ABG C Cushing reflex (brady.Hydrocephalus: Etiology: o Trauma/hemorrhage IVH o Congenital Arnold-chiari malformation o Neoplastic tumor o Post-inflammatory sbscess. meningitis Pt may come for VP. VA. HTN) D avoid ketamine and sux N ICP. LOC The rest of management as ICP card Page 118 of 217 .
One to 2 L of NS. or equivalent. by bolus or infusion. with the increased plasma viscosity producing a tendency to intravascular thrombosis. it is the combination of an impaired thirst response and mild renal insufficiency that allows the hyperglycemia to develop.Hyperosmolar Nonketotic Coma Page 119 of 217 In type II (NIDDM) elderly patient with minimal or mild diabetes may present with remarkably high blood glucose levels and profound dehydration. responds quickly to rehydration and small doses of insulin. Consider NaHCO3 if severe acidosis With rapid correction of the hyperosmolarity. and recovery of mental acuity may be delayed after the blood glucose level and circulating volume have been normalized. infused over 1–2 hrs if there are no cardiovascular contraindications. even with blood sugar concentrations of 1000 mg·dl–1. should be administered. cerebral edema is a risk. . The marked hyperosmolarity may lead to coma and seizures. Insulin. they are not in ketoacidosis. enough endogenous insulin activity to prevent ketosis.
Hyperparathyroidism Page 120 of 217 Primary benign parathyroid adenoma (90% of cases) or hyperplasia (9%) and very rarely to a parathyroid carcinoma.g.e. Secondary in parathyroid function as a result of conditions that produce hypocalcemia or hyperphosphatemia. or as part of a (MEN) syndrome. promoting fetal hypercalcemia and leading to hypoparathyroidism in the newborn. most are asymptomatic at the time of diagnosis. Surgery is the treatment of choice for the patient with symptomatic disease. malabsorption Tertiary development of hypercalcemia in a patient who has had prolonged secondary hyperparathyroidism that has caused adenomatous changes in the parathyroid gland and PTH production to become autonomous. most Pt are hypercalcemic. occurring during pregnancy is associated with a high maternal and fetal morbidity rate (50%). The placenta allows the fetus to concentrate Ca. CRF. . Pregnant women with primary hyperparathyroidism should be treated with surgery.
Hyperthyroidism Page 121 of 217 most common etiology is the multinodular diffuse goiter of Graves' disease. HTN D Avoid ketamin. to HR. and the conversion of T4 to T3 . PLT Consider giving -blockers peri-op. and pancuronium M Ca Heme anemia. between the ages of 20 and 40 years and is predominant in women A potential difficult if large goiter B N/A C hyperdynamic.
fib systemic embolism Atrial kick very important A. CHF is difficult to treat digoxin contractility obstruction. CCB is other choice.Hypertrophic Cardiomyopathy Page 122 of 217 AD. diuretics hypovolemia obstruction. Good EF due to hypercontractile state.fib not well tolerated CXR Cardiomegaly ECG LVH Treatment: -blockers 1st choice by HR and contractility outflow obstruction. Syncope. HTN is a common cause. . MR is common Could be dynamic obstruction by the anterior leaflet of the MV during systole systolic anterior motion (SAM). Arrhythmia. Peak 5th decade of life. F>M. Could associated with LVOFO or without Sport sudden death. S/S Angina.CHF A.
Within 3 to 4 weeks of the clinical onset of the syndrome. weakness. SAH. LOC. poor nutritional status. not more than 25 mEq/l/48 hrs Rapid correction abrupt brain dehydration central pontine myelinolysis mild (transient behavioral disturbances or seizures) to severe (including pseudobulbar palsy and quadriparesis). and hypokalemia) . risk head trauma.Hyponatremia < 130 Page 123 of 217 or in serum Na & in ECV & PV. where serum [Na] by ADH S/S depend on the rate and severity of of Na: loss of apatite. N&V. Also treat the underlying causes To calculate the net water loss necessary to [Na+] in hyponatremia. cerebral hemorrhage and CHF Once serum Na > 120 fluid restriction is enough .6x wt . mediated by BNP. independent of SIADH. use the following equation: Current [Na+] × current TBW = desired [Na+] × desired TBW TBW= 0. so it’s result from excess or deficit of water total body Na regulated by aldosterone and ANP. risk factors (alcoholism. cramps. burns. liver disease. areas of demyelination are apparent on MRI. and infection SIADH see other card Rx < 120 with 3% NS @ 1-2 ml/kg/hr to serum Na 1-2 mEq/l/hr only for few hrs. tumor. coma and seizure Acute CNS S/S is due to cerebral edema What is the serum osmolality see figure Cerebral salt wasting syndrome.
They are characterized by mental retardation. a short stature. Other : 131I therapy for thyroid disease. GI absorption. Pseudohypoparathyroidism is an inherited disorder in which parathyroid gland function is normal but the end-organ response to the PTH is deficient. neck trauma. Idiopathic is rare and may occur as an isolated disease or as part of an autoimmune polyglandular process (hypothyroidism. Chvostek's sign is a contracture of the facial muscle produced by tapping the facial nerve as it passes through the parotid gland. most common cause of acquired PTH deficiency is inadvertent removal of the parathyroid glands during thyroid or parathyroid surgery. or an infiltrating process (malignancy or amyloidosis).Hypoparathyroidism Page 124 of 217 underproduction of PTH or resistance of the end-organ tissues to PTH results in hypocalcemia normally: hypocalcemia PTH and 1. and renal tubule reclamation.25(OH)2D synthesis Ca2+ mobilization from bone. . granulomatous disease. and shortened metacarpals. Affected patients have hypocalcemia and hyperphosphatemia. adrenal insufficiency). obesity.
Hypotension Preload: Hypovolemia Venodilation (spinal) Tamponade Tension Pneumothorax R&R: Too fast and too slow Arrhythmias Other (may affect any component): Electrolytes imbalance Acid-base Hypoxia & hypercarbia Contractility: Ischemia Valve dysfunction CHF Drugs Page 125 of 217 Afterload: Drugs Anaphylaxis Sympathectomy Hyperthermia sepsis .
hypoparathyroidism.g. In symptomatic patients or unstable patients with cardiac ischemia. Consider adrenal insufficiency when intra-op hypotension not responding to fluids and inotrops. possible Addison’s disease postponed if severe hypothyroid Pt until at least partially treated. SLE. with possible A/W obstruction B OSA. RA. hypoventilation. response to PCO2 and PO2. pul edema C bradycardia. The management of hypothyroid patients with symptomatic CAD has been a subject of particular controversy. . hypothermia. Maintain normal body temperature. A goiter altered A/W anatomy.Hypothyroidism Page 126 of 217 Hashimoto’s thyroiditis may associated with other autoimmune disease e. sensitivity to narcotics. edema GI gastric emptying aspiration M Na. Addison’s disease. thyroid replacement should probably be delayed until after coronary revascularization. May associated with amyloidosis. CHF. heart block. hypotension. possible SIADH. DM.
head elevation 5. LOC.diuretics mannitol 0.Barbiturate 6. aspiration risk B resp failure C arrhythmias.25. artline.0 mg/kg 3. ICP.5-1. to convert to cmH2O X by 1. Lasix 0. MAP > 60.Steroids need 6-24 hrs to work 4. ICP: Page 127 of 217 Normal ICP < 10 mmHg. avoid PEEP if possible . Echo) D avoid sux N ICP. SIADH. risk of herniation M DI. MI (ECG.0 g/kg over 10 min.1. hemodynamic instability.CSF drain Avoid neck twisting obstruction of IJ. CVP Mx: 1. avoid hyperglycemia Maintain CPP.hyperventilate PaCO2 25-30 good only for 6 hrs 2.32 A LOC. cerebral salt wasting Monitors: routine.
IHD Page 128 of 217 Apart from atherosclerotic disease. other causes are: collagen vascular disease. cocaine abuse Avoid ergot. sickle cell disease. pheo. synto OK Need continues sat and ECG monitor Epidural is good prevent catecholamine and hyperventilation which PCO2 coronary vasospasm Neo is a better choice Epidural best for C/S . PIH.
rigor. diarrhea. hypotension. o 3 main objectives: Maintain BP volume. DIC. re-check blood. serotonin S/S: fever.Immediate Hemolytic Transfusion Reactions Page 129 of 217 Catastrophic and life threatening with mortality 20-60% Hemolysis of the donor RBC ARF. Kell. death Intravascular and extravascular (RES) Antibodies anti-A. inotrops Preserve renal function diuretics. direct coombs test ( for definitive diagnosis) . Kidd. chills. bleeding. maintain BP.B. Lewis. Hemoglobinuria Management: (keep index of suspicion) o Stop Tx. also complement histamine . alk the urine (NaHCO3) Prevent DIC no specific therapy. N&V. and anti-Duffy Ag-Ab complex activate Hageman factor(XII) kinin bradykinin capillary permeability. flushing. tachycardia. chest and abdominal pain Under GA most of S/S are masked only hypotension. tachy. prevent stasis o Blood sample should be collected in EDTA tubes for re-X match.
Thoracoscopy under general anesthesia Page 130 of 217 . Thoracic aortic aneurysm b. Bronchopleural cutaneous fistula c. Upper lobectomy 2. Unilateral cyst or bullae d. Surgical exposure—high priority a.INDICATIONS FOR ONE-LUNG VENTILATION ABSOLUTE 1. Pneumonectomy c. Isolation of each lung to prevent contamination of a healthy lung a. Infection (abscess. Bronchopleural fistula b. Middle and lower lobectomy c. infected cyst) b. Major bronchial disruption or trauma 3. Unilateral lung lavage 4. Video-assisted thoracoscopic surgery RELATIVE 1. Massive hemorrhage 2. Control of distribution of ventilation to only one lung a. Esophageal surgery b. Surgical exposure—low priority a.
CV instability in elderly. X. XII loss pharyngeal sensation may need to keep intubated . LOC Position sitting risk of VAE .Infratentorial Intracranial Tumors Page 131 of 217 Those tumors produce a mass effect on the brain stem. and ICP by obst hydro A CN involvement + LOC unprotected A/W RSI B Resp depression C brady. prolonged QT CNS ICP. arrhythmias ST-changes . risk SC compression Prone see other card Monitors as Supratentorial tumors Induction also the same Post-op: o need for continuous CV monitoring 24-48 hrs o HTN is a common problem post-op. need to treated aggressively other wise intracranial bleeding and edema o Manipulation of CN IX. HTN.
where major cause of mortality is intracranial bleed The main ttt is steroid.ITP Page 132 of 217 More common in young female. if not working splenectomy Consider DDx: TTP. plasmaphoresis. Connective T disease. DIC. fever. IVIG. and jaundice ttt Tx plasma. drug induced thrombocytopenia. hemolysis. HIV. other in preg PIH. renal dysfunction. steroids also the same issues as ITP regarding anesthesia . characterize by thrombocytopenia with petechiae. CNS involvement Sz. essential thrombocytopenia The main issues with Anesthesia Are o A avoid traumatize the airway o Avoid Regional o Risk of bleeding PLT Tx In Preg antibodies cress the placenta affect the fetus CNS bleed C/S TTP It’s: thrombocytopenia.
Kidney Tx Page 133 of 217 Of course for CRF A RSI for possible gastroparesis B pul edema if volume overloaded C hyper/hypovolemia. PCA . Lytes. foley. BUN. creat. ECG. X-match monitorsCAS. and diuresis with lasix. pericarditis. secondary hyperparathyroidism with Ca and phos Heme PLT dysfunction secondary to uremia Lab CBC-D. arrhythmias D altered drugs pharmacokinetics G Gastroparesis M K. CVP Goals maximize the renal perfusion at the time of graft reperfusion by maintaining a high BP. CXR. intravascular volume. pericardial effusion. and mannitol Possible problem Bleeding Post-op pain epidural. Art-line.
with no sensory deficit Femoral N: Due to pelvic Sx. external rotation during the 2nd stage of labor. with loss of ankle dorsiflexion L5 dermatome loss of sensation lateral leg In obstetric with prolonged labor and difficult vaginal delivery Obturator: Weakness of hip adduction and internal rotation Peroneal N With prolonged lithotomy position At the knee level (injury) foot drop. numbness.Lower Ext nerve inury: Page 134 of 217 Lumbosacral trunk: Foot drop. with loss of the patellar reflex Meralgia paresthetica(Lateral femoral cutaneous nerve) tingling. as well as lithotomy position Walking OK. burning sensation over the lateral thigh resolve spontaneous after giving birth . prolonged hip flexion. but unable to claim stairs. abduction.
pneumonia. involves 3 fascial spaces: submandibular. consider a reinforced and small size ETT Awake FOI. submental. pericardial effusion. pericardial effusion. difficult A/W B hypoxia. including gas-forming bacteria The infectious process may spread into the thorax. and difficulty in speaking. effusion.Ludwig's Angina Page 135 of 217 An emergency and life threatening situation generalized septic cellulitis of the submandibular region occurs after dental extraction. especially of the second or third mandibular molars it’s bilateral. inability to open the mouth. empyema C dehydration. CXR for Pneumothorax A difficult. necrotizing fasciitis Review the CT/MRI. pericarditis Have the ENT surgeon in the room. other option is inhalation induction Post-op keep intubated to ICU until swelling subsided . causing empyema. and sublingual Early S/S: chills. and pulmonary infiltrates. pericarditis. give glycopyrolate. hemolytic streptococci. aerobic and anaerobic. and the difficult airway cart in the room. drooling of saliva. scrubbed. fever. Pneumothorax. and the neck is prepped.
Lung volumes and capacities Page 136 of 217 .
Underestimation of Left Ventricular End-Diastolic Pressure of 217 CONDITION Decreased left ventricular compliance Aortic regurgitation Pulmonic regurgitation Right bundle branch block Decreased pulmonary vascular bed SITE OF DISCREPANCY Mean LAP<LVEDP LAP a wave<LVEDP PADP<LVEDP PADP<LVEDP PAWP<LVEDP CAUSE OF DISCREPANCY Increased end-diastolic a wave Mitral valve closure prior to enddiastole Bidirectional runoff for pulmonary artery flow Delayed pulmonic valve opening Obstruction of pulmonary blood flow .Page 137 TABLE 30–7.
protein-bound (30%). Na. like Ca neuronal irritability and tetany. proton pumps. and ionized (55%) Magnesium is necessary for enzymatic reactions involving DNA and protein synthesis. Hypomagnesemia clinical features of Mg. magnesium is important for the regulation of the Na–K pump. The distal tubule of the kidney is the major site of magnesium regulation. adenyl cyclase. CV coronary artery spasm. confusion. muscle spasms. lethargy. phos. and coma. and slow Ca channels. S/S: weakness.Magnesium Page 138 of 217 mainly intracellular. When severe seizures. and < 1% in the serum. and depression. 25% muscle. chelated (15%). excessive Mg losses. dysrhythmias. or failure of renal Mg conservation. GI or biliary fistulas. is associated with K. Ca-ATPase enzymes. CHF. and hypotension. 50% in bone. Excessive Mg loss is associated with prolonged nasogastric suctioning. As a primary regulator or cofactor in many enzyme systems. can aggravate digoxin toxicity and CHF. most commonly caused by inadequate GI absorption. paresthesias. Rarely resulting from inadequate dietary intake. and intestinal drains . and Ca.
gastrointestinal or biliary fistulas. give Mg Hypermagnesemia Most common cause is iatrogenic. lithium. CHF. Excessive Mg loss is associated with prolonged NGT. deep tendon areflexia Heart block. coronary artery spasm. and intestinal drains. M may associated with other electrolytes abnormality Rx stop NGT. dialysis . diuretics. A N/A B N/A C arrhythmias. other Addison’s disease. distal tubule is the major site of magnesium regulation Hypomagnesemia Rarely from inadequate dietary intake. respiratory paralysis Cardiac arrest Rx D/C Mg.Magnesium Page 139 of 217 Mainly intracellular. hypothy S/S depend on Mg level Hypotension Deep tendon hyporeflexia Somnolence Respiratory insufficiency. most commonly caused by inadequate GI absorption. or failure of renal Mg conservation. BP. excessive Mg losses. IV CaCl.
BUN. lytes. ABG. restrictive lung defect spontaneous Pneumothorax careful with PPV C cystic media necrosis. -blockers and volatiles are good. Pectus excavatum. aortic dissection. CXR pneumo. CT-chest and angio all for dissection. MVP. CBC.Marfan syndrome: Page 140 of 217 AD. need endocarditis prophylaxis Other lens dislocation. arrhythmia. AR. valve. MR. aneurysm Avoid sudden in contractility. creat. length of long bone A TMJ laxity dislocation with intubation B scoliosis. tamponade. PFT . retinal detachment Position careful Neuraxial potential difficult. may need a bigger dose and volume of LA Lab Echo. kyphoscoliosis.
Tachycardia and dysrhythmias are not infrequent. increased tone of other muscles also may be noted. anesthesia is induced by inhalation with halothane or sevo. (2) TMJ dysfunction. Repeat doses of succinylcholine do not relieve the problem. within 4–12 hours. this rigidity can be overcome with effort and usually abates within 2–3 minutes. If the anesthetic is discontinued. Muscle biopsy with caffeine–halothane contracture testing has shown that approx 50% of Pt who experience MMR are also susceptible to MH. .Masseter Muscle Rigidity Page 141 of 217 most common in children and young adults. (5) increased resting tension after succinylcholine in the presence of fever or elevated plasma epinephrine. However. the initial signs of MH appear in 20 minutes or more. the patient usually recovers uneventfully. A peripheral nerve stimulator usually reveals flaccid paralysis. DDx of MMR are: (1) myotonic syndrome. (if the anesthetic is continued with a triggering agent). peak age incidence at 8–12 yrs of age. (4) not allowing sufficient time for Sux to act before intubation. (3) underdosing with Sux. Snapping of the jaw or rigidity on opening of the jaw is seen. Characteristically. after sucx is given. However. myoglobinuria occurs and CK elevation is detected.
Maxillofacial trauma Page 142 of 217 Lower 1/3 mandible (30% in the body of the mandible) Middle 1/3 maxilla, zygomatic, orbital, nasal LeForte I, II, III Upper 1/3 frontal and cranium ( CNS) Airway 100% O2, and clear the A/W from foreign bodies, blood, # teeth (count), if there is bleeding apply pressure, nasal packing, and consider a close reduction for a # In case of tongue injury laceration edema/swelling difficult intubation In case of mid and upper facial injury avoid nasal intubation Bleeding, and possible basal skull # Laryngeal injury S/S hoarseness, stridor, sub-Q emphysema with crepitus void blind technique After intubation with direct vision bypass the injury and make sure that the cuff is beyond the injury Trismus after facial injury due to muscle spasm relived by GA
Meconium Aspiration: Page 143 of 217 Risk of PPHTN. risk with post-term pregnancy The new recommendation it does not matter thin or thick meconium If there is meconium suction the hypopharynx Apply NALS If not vigorous (HR < 100, resp depression) ETT suction, 100% O2 If vigorous no need for ETT or tracheal suctioning
MH acute crisis Page 144 of 217 Manifestations : Hypercarbia, Tachycardia, Tachypnea, Temp (1°C–2°C increase every 5 minutes), HTN, Cardiac dysrhythmias, Acidosis, Arterial hypoxemia, Hyperkalemia, Skeletal muscle activity, Myoglobinuria DDx: pheo, thyroid storm, carcinoid Management: Call for help Discontinue inhaled anesthetics and succinylcholine Hyperventilate the lungs with 100% O2 Administer dantrolene (2.5 mg/kg iv) with repeated doses (up to a maximum of 10 mg/kg iv) based on Paco2, heart rate, and body temperature (each ampule of 20 mg is mixed with 50 ml of distilled water) If Dantrolene is not available, give procainamide IV 1mg/kg up to 15mg/kg Treat persistent acidosis with sodium bicarbonate (1–2 mEq/kg iv) Control body temperature (gastric lavage, external ice packs until 38°C) Replace anesthetic circuit and canister Monitor with capnography and arterial blood gases Be prepared to treat hyperkalemia and cardiac dysrhythmias
Mineralocorticoid Physiology Page 145 of 217 Aldosterone is a major regulator of extracellular volume and K homeostasis through the resorption of Na and the secretion of K. Renal perfusion pressure+ sympathetic stimulation+ Na, and hypovolemia renin from juxtaglomerular Renin splits angiotensinogen to angiotensin I ACE in the lung Angiotensin II aldosterone. Other stimuli that aldosterone includeK and, to a limited degree, Na, PGE, and ACTH. So aldosterone K and Na and HTN, while is the opposite Mineralocorticoid Insufficiency: Common in CRF, and DM, Pt usually on fludrocortisone 0.05-0.1 mg/d C hypovolemia, heart block due to K, M K, Na, and metabolic acidosis (hyperchloremic) D Avoid Sux, and NSAID PGE Renin exacerbation
History Patients with chronic MR remain asymptomatic for an extended period. followed by more overt symptoms of CHF. including orthopnea and paroxysmal dyspnea. CTD associated with MR include SLE.Mitral Regurgitation Page 146 of 217 Chronic regurgitation caused by abnormal leaflet anatomy can be due to congenital or rheumatic disease. myxomatous degeneration(MVP). about 50% of patients with SLE have detectable MR. Almost always associated with MS. Valvular involvement in CTD is variable. acute MI with papillary muscle rupture or retraction usually from RCA. When CHF develops rapid deterioration with 5 yrs mortality rate 50% Physical Findings . ank spondylitis. Acute severe MR is caused by infective endocarditis which result in chordae tendineae. rh arthritis. CTD. Pathogenesis Long latent period 30-40 yrs. or prosthetic valve dysfunction.6 associated with severe MR. Eccentric hypertrophy of the LV. LA volume overload LV volume overload with foreword LV SV. and scleroderma. patients develop symptoms of fatigue and exertional dyspnea. PAWP giant V wave. infective endocarditis and LV hypertrophy. Regurgitation fraction > 0. In acute MR there is sudden in LAP pul edema. Later. and approximately 25% have significant regurgitation.
MS in adults is predominantly of rheumatic origin. fever. Pul arteriolar and capillary vasoconstriction protect against pul edema. and predispose to supraventricular tachyarrythemia.0 to 2. including strenuous physical exercise. PE which can lead to pul edema Stasis of the blood in the LA thrombi A fib systemic emboli. Severe gradient > 10 mmHg.0 cm2.Mitral Stenosis Page 147 of 217 normal MVA 4. and valve area < 1 cm2. emotional stress.5 cm2. Symp(exercise or tachycardia) 2. Pathogenesis Obstruction to LV inflow LA dilation and HTN and resultant pul venous HTN interstitial edema work of breathing dysponea.g. with eventual RV systolic dysfunction. . although PVR exacerbates pul arterial and RV HTN and causes RVH. Acute decompensation occur due to stress e. History Early fatigue or dyspnea precipitated by events with associated tachycardia. F>M.0 to 6. Long latent period > 20 yrs. 2 mild gradient < 5 mm Hg and VA >1. rest < 1. A fib. The MV is the most common site of rheumatic valve disease. or surgery. sepsis.5 cm . pregnancy.5 cm2. pregnancy. Pul HTN can be severe late in the course of MS.
fib with systemic embolization due to hypercoaglable state in pregnancy hemodynamic Goals: o preload maintain. avoid cardiodepressant o Afterlaod o PVR avoid pain. CVP/PAC MVP manage as MR . but if severe then art-line. avoid overload o R/R slightly maintain sinus. PCO2 If mild no need for aggressive monitoring. aggressively treat arrhythmia o Cont maintain. hypoxia.MR Page 148 of 217 Well tolerated in pregnancy risk of A. LUD.
with risk of pul edema. PAC. O2 all the time In the 2nd stage avoid explosive effort valsalva VR pul edema Avoid overzealous hydration pul edema Tachycardia -blockers hemodynamic Goals: o preload maintain.MS Page 149 of 217 Not well tolerated. over even cardioversion. and needs to treated very aggressively with -blockers. PCO2 Neo is the best choice in case of hypotension . LUD. Digoxin. hypoxia. then lasix mortality during labor/post-partum Mild is usually tolerated ok But mod/severe pregnancy worsen NYHA by 1-2 classes Need invasive hemodynamic monitoring art-line. avoid cardiodepressant o Afterlaod maintain. avoid sudden in SVR o PVR avoid by pain. avoid overhydration o R/R slow and sinus o Cont maintain. Arrhythmias are not tolerated at all.
AO instability. short neck difficult A/W B Restrictive defect C CAD. VHD. Dwarfism Routine lab + Echo. macrogolssia. odontoid hypoplasia.Mucopolysaccharoidosis: I H Hurler I H/S Hurler/Scheie I S Scheie II Hunter III Sanfilippo IV Morquio Page 150 of 217 A Coarse facial features. CXR . AR. kyphoscoliosis. Cardiomyopathy GI hepatosplenomegaly MSK joint stiffness.
Multiple Sclerosis Page 151 of 217 demyelination in the brain and spinal cord, F>M symptoms depend on the sites: visual disturbances, nystagmus, limb weakness and paresthesias, The legs are affected more than the arms. Bowel retention and urinary incontinence are frequent complaints. Involvement of the brain stem can produce diplopia, trigeminal neuralgia, cardiac dysrhythmias, and autonomic dysfunction, while alterations in ventilation can lead to hypoxemia, apnea, and respiratory failure. As is typical in many immune disorders, pregnancy is associated with an improvement in symptoms, but relapse frequently occurs in the first three postpartum months. treatment Corticosteroids, immunosuppressants (azathioprine, methotrexate, cyclophosphamide, and cyclosporine) Symptoms exacerbation with stress (emotional, surgical) temp, infections Management of Anesthesia Possible exacerbation post-op Document neurological symptoms pre-op, re-exam post-op the patient should be advised that surgery and anesthesia could produce a relapse despite a well managed anesthetic
Murmurs Page 152 of 217 Innocent murmurs: soft, systolic and not radiated, may vary with position, not characteristic of any lesions Noninnocent murmurs: all diastolic murmurs, all pansystolic, continues, late systolic and transmitted murmurs For innocent murmurs no need for surgical delay, and no need for prophylaxis Not noninnocent one’s if heard in the pre-op delay, and further investigation
Midsystolic Page 153 of 217 flow across aortic or pulmonic valve (e.g., secondary to AR or ASD) Aortic valve leaflet sclerosis (e.g., in elderly patients) Aortic or pulmonic outflow obstruction (valvular, subvalvular, supravalvular) Dilatation of aortic root or proximal pulmonary artery Papillary muscle dysfunction Holosystolic MR, TR, VSD Late Systolic MVP, Papillary muscle dysfunction Early Diastolic Aortic or pulmonic valve insufficiency Mid-Diastolic MS, TS flow across nonstenotic AV valve (e.g., secondary to MR or ASD) Presystolic MS (with sinus rhythm) Continuous Murmurs PDA
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7 main types with progressive and variable rate in losing of muscle function. The most common, and the most severe form. Due to lack of protein Dystrophin. Painless degeneration of the skeletal muscle. X-linked trait (boys) S/S 2-5 yrs old. In the wheelchair by age of 12. The affected muscle may become enlarged, due to fatty infiltration. Death by 15-25. Secondary to CHF and pneumonia. Serum CK reflect the progression of the disease, with 30-300 folds above normal, later with complete degeneration the level well . Smooth muscle involvement GI hypomotility and gastroparesis. CVS o myocardial degeneration loss of R-wave in the lateral leads o contractility dilated cardiomyopathy, and arrhythmias
Duchenne’s muscular dystrophy
Diuretics. Arrhythmias. if MR late systolic murmur A N/A unless associated with other disease B if CHF plu edema. anxious Pt may benefit from pre-op meds Hemodynamic goals Preload maintain Contractility avoid R & R sinus.g. Risk of endocarditis. Pt could be on ACEI. and ketamine CNS Stroke. ? scoliosis restrictive lung defect C CHF. anticoagulants P/E late systolic click. marfan syndrome. connective tissue disease. better . Endocarditis prophylaxis D avoid histamine releasing drugs.MVP: Page 155 of 217 More common in young female than in male May associated with other disease e. little fast Afterload avoid . arrhythmias. sudden death If associated with MR or CHF. stroke. antiarrhythmics. -blockers.
‖ Excessive doses of cholinesterase inhibitors produce abdominal cramping.Myasthenia Gravis Page 156 of 217 Osserman and Genkins classification: • Class I—ocular symptoms only • Class IA—ocular S’s with EMG evidence of peripheral muscle involvement • Class IIA—mild generalized symptoms • Class IIB—more severe and rapidly progressive symptoms • Class III—acute. to differentiate . salivation. steroids. F>M Abnormal thymus glands 75% of pts(85% show hyperplasia. vomiting. presenting in weeks to months with severe bulbar symptoms • Class IV—late in the course of the disease with severe bulbar symptoms and marked generalized weakness autoimmune disease with anti-acetylcholine receptor antibodies. cyclophosphamide. and skeletal muscle weakness that mimics the weakness of myasthenia . 15% thymoma). cyclosporine)and plasmapheresis. bradycardia. diarrhea. other immunosuppressant (azathioprine. underdosage ―myasthenic crisis‖ whereas overdosage will produce a ―cholinergic crisis. 75% of pts either go into remission or are improved post-op Medical ttt: anticholinesterase.
Pt could be on diaminopyridine Sz Keep high index of suspicion in a Pt with Lung Ca Consider Art-line .Myasthenic Syndrome (Lambert-Eaton Syndrome) Page 157 of 217 Associated with small cell ca of the lung IgG antibodies against Ca channel in the presynaptic membrane Ach release in response to nerve stimulator M>F. age 50-70 Mainly proximal muscle weakness A B rarely respiratory failure C autonomic dysfunction orthostatic hypotension D sensitive to both Sux and NDMR.
Page 158 of 217 .
the vent @ rate 40-60 min if HR > 100. and Pink ongoing care.5 sec 90:30 pre minute Chest compression using two thumbs just below a line drown between two nipples to compress the AP diameter by 1/3 to ½ Intubation can be considered at any time If Vent without ETT for > 2-3 min decompress the stomach .. give O2 not breathing or HR < 100 PPV with initial P 30-40 cmH2O for 4-5 sec to open the alveoli. tactile stimulation by rubbing the back. dry. @ 40-60 min. if HR < 60 PPV and start Chest compression for 30 sec if still HR < 60 five Epi ….NALS Page 159 of 217 Exam table goes trend for drainage and reverse trend to PO2 Avoid hypothermia VO2 metabolic acidosis Assess for choanal atersia usually cyanotic and resp depression at rest. pink when crying If Apgar score < 8 with not resp depression give O2 by ―blow by‖ So If not breathing or cyanotic suction the A/W.5:0. after the 1st breath the P 20-30 cm H2O For chest compression to vent 3:1 1. Bicarb………. flicking the soles of the foot. warmth. For vent I:E = 1:1..
respiratory failure. CO M lactic acidosis. malnutrition. renal and CV diseases Septic shock. possible under resuscitated A full stomach RSI B ARDS. lytes abnormalities R ARF CNS LOC Lab and Mx as septic shock Post-op ICU . alcoholism.Necrotizing fasciitis Page 160 of 217 Emergency and life threatening with high mortality rate Possible underlying disease: DM. pul edema C septic shock with SVR.
glucosuria H2O and lytes depletion Physiological jaundice alter drugs pharmacokinetics. rapid administration od NHCO3 Eye ROP maintain O2 sat 90-95% or PO2 50-70 . and free bili kernicterus.Neonatal Considerations: Page 161 of 217 In addition to the pediatrics considerations Metabolic risk of hypoglycemia S/S: apnea. convulsion Glucose infusion @ 4-8 mg/kg/min hyperglycemia cerebral hemorrhage. immature renal function CNS fragile cerebral vessels risk of IVH by hypoxia. low Hb. which by hypoxia. hypothermia Renal Na loss. Na. fluctuation in BP. acidosis. hypercarbia.
where. R Arthritis. reflex. and looking for any pressure demarcation Also assess for nerve or dermatomal distribution Obtain a Neurology consult for further evaluation and need for nerve conduction study. OR note for documentation of padding. Obesity. motor further evaluation . and possible MRI Sensory only F/U in 2wks. position A block done or not if yes any symptom at the time of the block pain or paresthesias with injection If the surgical procedure done in the same side ? surgical complication or prolonged use of a tourniquet. PVD. motor. motor weakness. paresthesia. smoking.Peri-op nerve injury: Page 162 of 217 History: Symptoms: pain. Drugs that may cause neuropathies chemo. alcohol. and mainly examining the affected side sensory. when did it start Presence of risk factors or conditions that may have neuropathy as a symptoms: DM. anti-virals Review anesthetic records. also BP cuff may cause injury Exam: V/S. complete neurological exam.
and catheter removal 2-4 hr after the last dose or one hr before the next dose S. but better at least 10 days before needle placement.C heparin also delay catheter placement 2-4 hrs. and may keep the catheter until next AM.g.4 is OK . NSAID are OK Pt on oral med (Warfarin) stop 5 days per-op INR= 1. give LMWH 2hrs later Anti-PLT: plavix ?? no data. vascular Sx delay IV heparin 1hr post catheter placement. if Pt receiving a higher dose 1mg/kg delay 24hr Post-op 1st dose of LMWH delay 24 hr. or delay the heparin 1 hr post catheter placement LMWH: needle placement 10-12hrs after the last dose of LMWH.Neuraxial Anesthesia and anticoagulation Page 163 of 217 IV heparin e.
possible mediastinal mass C HTN due to renovascular. with CNS vascular and skin involvement. Pheo. and short stature Could be a part of MEN IIB A difficult intubation. ECG. Lytes.5 in diameter. Echo. café-au-lait spots >6. CXR. PFT with F/V loop . interstitial lung disease. Sz disorder M diffuse endocrine disorder as well as carcinoid tumor MSK Kyphoscoliosis Regional Anesthesia could be difficult. with > 1. coarctation. meningioma (ICP). spinal cord tumor.Neurofibromatosis Page 164 of 217 AD. due to laryngeal or tracheal compression B restrictive lung defect. Avoid if there is spinal cord tumor Lab CBC. BUN. Wilm’s tumor CNS Astrocytoma. creat.
hypertension. mental changes. and psychomotor agitation Other DDx: CNS diseases meningitis. there are significant differences between the two. . acidosis.Neuroleptic Malignant Syndrome (NMS) Page 165 of 217 S/S include fever. but may be as high as 20%. Phenothiazines and haloperidol or any of the newer potent antipsychotic agents alone or in combination are usually triggering agents for NMS Sudden withdrawal of drugs used for Parkinson's disease may also trigger NMS (ECT) with Sux does not appear to trigger the syndrome. tumor. CK. tachycardia. rhabdomyolysis. agitation. Dantrolene is an effective therapeutic modality in many cases of NMS. and stupor. and myoglobinuria The mortality rate is unknown. does not seem to be inherited. muscle rigidity. rapid titration of triggering drugs. whereas NMS often occurs after longer term drug exposure. possible due to dopamine depletion in the CNS by psychoactive agents. hypoxia. bromocriptine. MH is acute. . is often useful in treatment of NMS with dehydration. a dopamine agonist. and acidosis.
Etomidate) If urgent Sx consider delay to the 2nd trimester Have an obstetric consultation For GA < 16 wks have FHM pre. for >16 wks have it intra-op for abdominal procedure consider a transvagainal monitor FHR variability present @25-27 wks Maintain normal maternal BP. and post op. acid-base status. NDMR. Sux. Oxygenation. avoid aortocaval compression For pelvic and lower limb and upper limb consider regional technique For laparoscopic procedures max peritoneal inflation pressure 8-12 mm Hg For spinal or epidural give a fluid bolus before Always give reflux prophylaxis. Opioids. and do RSI.Non-obstetrical surgery during pregnancy Page 166 of 217 Obstetric consideration Risk of abortion and premature labor Minimize the amount of drugs as much as possible Use only the drugs that are known to be safe(STP. with maintaining LUD . Ketamine.
with FRC and Pul HTN C HTN.LFT. ABG.Obesity Page 167 of 217 A difficult intubation B OSA. Lytes. CAD. ECG. pickwickian syndrome. restrictive defect. PND. gastric acidity. RV and LV dysfunction GI GERD. PFT. and RV/LV dysfunction snoring. and regional anesthesia . Creat. pul HTN with cor-pulmonale. orhtopnea. EXAM RV/LV failure LAB CBC-D. BUN. and consider Echo Difficult IV access. fatty liver with liver dysfunction M DM D calculate the drug dosage according to the lean body mass H/P evidence of OSA.
RSI B easy desat FRC. cholinesterase. VO2 C hyperdynamic state. Aortocaval compression BP. gastric empting. . UP blood flow D MAC. placental drug transfer GI/Hepatic full stomach. albumin Free F of drugs. liver enzyme . Full stomach.Obstetric considerations: Page 168 of 217 Physiological and anatomical changes A difficult A/W.
Induction: NG aspirate gastric content then RSI . hypoglycemia. and an omphalocele. possible central. a large tongue.Omphalocele and Gastroschisis Page 169 of 217 o Impaired blood supply to the herniated organs. with lytes abnormality . need large IV . congenital heart disease. B respiratory failure C CHD in 20% of infants with omphalocele. and arterial line Post-op keep intubated M intravascular volume. and intestinal obstruction o Major intravascular fluid shift and dehydration full-strength balanced salt solution o Hypothermia and hypoglycemia A possible difficult airway Beckwith-Wiedemann syndrome consists of mental retardation.
acidosis. bronchospasm C hypotension. diarrhea Page 170 of 217 . bronchorrhea. fasciculation Muscarinic: DUMBELS syndrome D diaphoresis.Organophosphate poisoning Bind to acetylcholinestrase enzyme S/S: Nicotinic: muscle weakness. dehydration GI N&V. arrhythmias. diarrhea U urination M miosis B bradycardia. bronchospasm E Emisis L lacremation S salivation A salivation. aspiration B Respiratory failure. bradycardia. QT(poor prognosis) D Avoid aminoglycosids ABx M lytes abnormalities. shock. bronchorrhea. .
vertebral # Awake FOI B kyphoscoliosis restrictive lung defect C Cor-pulmonale Heme impaired PLT function Page 171 of 217 . short stature.Osteogenesis Imperfecta: A connective tissue disorder with 4 subtypes Multiple #. blue sclera A deformity of the base of the skull.
PNC. methylene blue.Other hemolytic anemia’s: Page 172 of 217 Spherocytosis: Membrane defect abnormal shape RBC hemolysis May have a hemolytic crisis which can triggered by infection and folate deficiency May come for splenectomy G6PD Deficiency: RBC enzyme defect Can have a hemolytic crisis if exposed to some food and drugs: Fava beans. antimalarial drugs. Tyhlenol. ASA in large dose Usually happened 2-5 day after ingestion May have DIC .
003 × Pao2) DO2 = CO × Cao2 Oxygen Consumption. Oxygen delivery is a function of arterial oxygen content (Cao2) and cardiac output.Oxygen Delivery and Oxygen Consumption Page 173 of 217 Oxygen Delivery. Cao2 is expressed as the number of milliliters of oxygen contained in 100 ml of blood and is calculated as follows: Cao2 = (Hgb × 1.34 × Sao2) + (0. O2 consumption = CO x (CaO2-CvO2) Oxygen extraction Ratio ER= O2 consumption / O2 delivery ER= [ CO x (CaO2-CvO2)] / CO x CaO2 = CaO2 – CvO2/CaO2 .
chronic) Page 174 of 217 Associated with: chronic alcohol abuse. gallstone. CVP Post-op ICU. hypotension D narcotic tolerant. old blunt trauma A RSI. blunt abdominal trauma. CF.Pancreatitis:( acute. DM. pain management . acidosis. perforated PUD Lab amylase DDx cholecystitis . for GI ileus B ARDS C hypovolemia. MI. malnourished albumin free fraction of drugs careful titration M Ca. Pneumonia Chronic mainly with alcoholism. DIC Consider art-line . acute alcohol withdrawal Renal ARF due to dehydration CNS encephalopathy Heme anemia.
autonomic dysfunction. VC. shuffling gait. patients with Parkinson's disease are more susceptible to the development of mental confusion and even hallucinations.Parkinson's Disease Page 175 of 217 degenerative disease of the CNS caused by loss of dopaminergic fibers in the basal ganglia of the brain.(substantia nigra) clinical features are resting tremor. avoid Maxran. stooped posture. bradykinesia. and facial immobility. droperidol. alfenta. K one case report Post-op: In the postoperative period. cogwheel rigidity of the extremities. A laryngospasm. . COPD C arrhythmias due to L-dopa. sux may use for RSI. intravascular volume D L-dopa(sinemet) Levodopa+ a peripheral dopamine decarboxylase inhibitor carbidopa to systemic side effect give in AM t1/2 6-12. muscle rigidity before giving MR difficult vent consider RSI B frequent aspiration. Demerol.
caffeine 300mg PO q8-12hrs. tinnitus. hydration. with trismus . gentle intubation avoid rupture the abscess . possible full stomach. aggravating and relieving factors (position). and the location of the headache Exam: V/S include Temp. type and size of needle for spinal. and any other complications Review past-medical Hx neurological Hx (headache) Headache: character. meningeal signs (meningismus. sitting severe fronto-occipital headache May associated with cranial N symptoms: diplopia. do a gas induction with no muscle relaxant . associated symptoms. Neuro Exam looking for any sensory or motor deficit Rx: bed rest. and NSAID’s if not working or severe headache Epidural blood patch Peri-tonsilar abscess Emergency and potential life threatening A airway obstruction. and wet tab documentation. severity. photophobia. migraine Action: Review anesthetic Record for Neuraxial procedure. N&V DDx: meningitis. Tylenol. fever).PDPH Page 176 of 217 In a supine position very mild.
Malignant spread of highly vascular tumors in approximately 10% of cases. parathyroid hyperplasia. . pheochromocytoma. 95% in the abdomen. a small % located in thorax. may also arise in association with von Recklinghausen's neurofibromatosis or von Hippel-Lindau disease (retinal and cerebellar angiomatosis). Most (85–90%) are solitary tumors localized to a single adrenal gland. In about 5% of cases. urinary bladder.Pheochromocytoma Page 177 of 217 In normal medulla. where it is greater in a Pt with pheochromocytoma. halothane and histamine-releasing drugs. 10% of adults and 25% of children have bilateral tumors. Type IIA includes: medullary carcinoma of the thyroid. or neck. usually the right. can exacerbate the life-threatening cardiovascular effects of the catecholamines secreted by these tumors. It may be part of the polyglandular syndrome as MEN Type IIA or IIB. pheochromocytoma. neuromas of the oral mucosa. norepinephrine account for only 20% of the secretion. extra-adrenal sites (10%) along the paravertebral sympathetic chain. Type IIB consists of: medullary carcinoma of the thyroid. this tumor is inherited as a familial AD trait.
and cell membranes. Phos provide the primary energy bond in ATP and creatine phosphate. free ion (55%). Therefore. As part of 2. 10% is intracellular. complexed ion (33%).90% in bone. and a major component of nucleic acids. severe phosphate depletion results in cellular energy depletion. Phos reabsorption in the kidney is primarily regulated by PTH. Absorption occurs in the duodenum and jejunum and is largely unregulated. Control of phos concentration by altered renal excretion and redistribution within the body compartments. in the ECF. . and insulin-like growth factor.Phosphate Page 178 of 217 distributed in similar concentrations throughout intracellular and extracellular fluid. and in a protein-bound form (12%). Phos is an essential element of second-messenger systems. phos is important for off-loading oxygen from the hemoglobin molecule. phospholipids. and <1%. dietary intake. including cAMP and phosphoinositides.3-DPG.
shift of O2-Hgb curve to the Rt with P50 30mmHg C CO. minute vent.Physiological changes in pregnancy: Page 179 of 217 A venous engorgement. by PIH. cleft palate B obstruction pul edema. easy nasal bleed B FRC. shunt from 5% to 14 %. Normal BP due SVR. and O2 consumption. IRV. plasma volume Pierre Robin Syndrome: A difficult A/W due to micrognathia. URTI and fluid overload. TV. cor pulmonale. Aspiration C CHF. have ENT surgeon in the room for possible trach A/W obstruction improve with age Extubate awake only . TLC. glossoptosis. edema. ERV. pul HTN. associated CHD CNS Sz due to hypoxic brain injury Do awake FOI.
more after delivery C CHF.PIH and HELLP Page 180 of 217 In addition to the changes in pregnancy A airway edema. thrombocytopenia . albumin Heme anemia. volume. fibrinogen. headache. SNP. bleeding . fetal monitoring. BP. improve UP blood flow (if PLT are OK) Monitors: art line. ARF GI/Hepatic RUQ pain.g. could be on ASA M Mg. other meds. fibrinogen CNS LOC. hemolysis. BUN. difficult intubation difficult A/W cart in the room B pul edema. blurred vision. labetolol. consider early epidural help BP. oliguria. BT . oncotic pressure D Mg. NTG. LFT. hydralazine. seizure. Lytes. edema Renal GFR. liver rupture Rx start Mg bolus 4g then infusion @ 1-3 g/h. (ACEI are C/I due to fetal effect) Monitor Mg level avoid Mg toxicity. PTT. CVP/PAC Before giving any fluid bolus look for evidence of CHF Lab: CBC-D. consider other anti-HTN meds e. Creat. Mg. PT.
other effect hyperthyroid. usually small. lateral neck XR Critical structures internal carotid artery. Oxytocin Tumors could be non-functioning. CN palsy. N&V. then GH. stress dose steroid. CXR. Cardiomegaly. . and ICP. CVP if head-op position Lab CBC. cardiomyopathy D hormone replacement. then ACTH. and transsphenoidal approach Page 181 of 217 Ant regulated by the hypothalamus secret 7 hormones Post ADH. or pan-hypopitutarism hyper secreting could be a MEN I. CN III. ABG. or hyper secreting The non-functional mass effect headache impaired vision. lytes.Pituitary Tumors. cavernous sinuses. the most common is adenoma secreting prolactin . VI A possible difficult intubation B OSA C HTN. ECG. V. DM pituitary apoplexy due to sudden hemorrhage neuro deficit and pituitary function Mx steroids and surgical decompression May not develop DI until after starting steroids therapy Monitors routine with art-line for acromegaly. IV.
most are dilutional thrombocytopenia Mx: lab as in abruption shock as in abruption GA Vs spinal/epidural depend wither if the placenta is anterior or >1 C/S with risk of accreta GA. shock D avoid tocolytic Heme DIC rare. if posterior may consider spinal/epidural if the Pt is stable . previa Painless vaginal bleeding in the 2nd-3rd trimester Risk of abruption and IUGR Avoid vaginal exam and tocolytic therapy A and B obst C hypovolemia.Placenta previa Page 182 of 217 Risks: previous C/S.
with defect in heme synthesis Complete deficiency of enzymes is incompatible with life Deficiency of one enzyme will lead to accumulation of one or more intermediates molecules which will give the clinical manifestation of Porphyria. Inheritance is an AD pattern.Porphyrias Page 183 of 217 A group of inborn error of metabolism. but congenital erythropoietic porphyria is inherited as an AR pattern. A functional classification for the anesthesiologist is based on a division of the porphyrias into: o Inducible: acute symptoms are precipitated on drug exposure. generally manifest after puberty. The rate-limiting step in heme synthesis is the conjugation of succinyl-CoA with glycine to form D-aminolevulinic acid ALA (the enzyme is aminolevulinic acid synthetase). . which are: Acute intermittent Porphyria variegate Porphyria ( 80% photosensitive) hereditary coproporphyria o noninducible forms.
2-laryngeal edema due to volume overload or Trendelenburg position intra-op. apply CPAP. 100% O2.3. do jaw thrust. suction the A/W DDx: 1-Laryngeospasm.VC paralysis due to neck or thoracic Sx. 4. apply oral A/W. blood. and Call for help.Post-op Stridor: Page 184 of 217 Emergency.A/W foreign body (secretion. vomit . and life threatening Proceed immediately to the PARR Review the V/S. and quick AMPLE history . or residual NM blockade.
o Drugs/alcohol withdrawal o Withdrawal of anti-psychotic.Post-op Altered LOC/Agitation: Page 185 of 217 With LOC could be life threatening. agitation potential harm to him self and nurses Proceed immediately to the PARR ABC. NMB Agents. hypoglycemia o CNS: hypoperfusion. bladder distention o A/W obstruction with hypoxia and hypercarbia o Other metabolic abnormalities Na. obtain new V/S Review anesthetic chart/ talk to the anesthetist who did the case. review the old chart DDx: o Psychological response to emergence o Co-existing mental/psychological problem (post-traumatic stress) o Intra-op re-call o Residual anesthetics. Ca. seizure. Ketamine. Sz. postictal . 100% O2. CVA. Parkinson meds o Surgical pain. restrain the Pt if needed.
hypotension. AST/ALT. RF 8) Could be benign post-op intrahepatic cholestasis . retics 6) Review anesthetic and PARR records for any evidence of hypoxemia. hypovent. PE. includes intra-op use of vasopressors splanchnic vasoconstriction B flow 2) Look for source of infection 3) Blood Tx bili load in Pt with co-existing liver dysfunction 4) Look for hematoma hyperbilirubinemia 5) Role out hemolysis Hb. hypovolemia 7) Look for extra-hepatic source of liver dysfunction CHF.Post-op hepatic dysfunction Page 186 of 217 Classify as pre. resp failure. intra and post hepatic The main S/S is jaundice Need repeat measurement of bili. and ALP Most likely multifactorial One of the main factors could be intra-op hepatic hypoxemia Steps: 1) Review all meds given to the Pt without any exclusion peri-op.
resuscitate the Pt H possible bleeding disorder.Post-tonsillectomy bleeding Page 187 of 217 Emergency and potential life threatening Go immediately to see the Pt OR emerg meds . X-match . possible difficult airway use ketamine for induction. Lab CBC. airway equipment double setup X2 suction . X2 scops A full stomach. lytes. RSI B hypoxia C hemorrhagic shock. PTT. PT.
If Pt had PCA.Pre-op Cardiac evaluation: Page 188 of 217 See other card for clinical predictors See other card for stratification for noncardiac surgical procedure See the algorithm Recent MI wait 4-6 wks for elective surgery Lab evaluation o Resting LV function is not a predictor for ischemic event o 12 leads ECG o Exercise or pharma stress test for Pt with intermediate risk. wait only for one week for elective procedure. or when Pt is unreliable o Angio for Pt suspected or known CAD Pre-op therapy o CABG for high risk Pt. with possibility to improve outcome o PCA: no controlled trial for PCA vs medical therapy. with balloon dilation only. if stent 4-6 wks with minimum 2 wks. for anti-PLT therapy o Medical: -blokers Anesthetic consideration o No technique is superior .
and hyperventilation K o Lidocaine IV may prevent arrhythmia MgSO4 o See PIH for S/E. need at least 10 min D/C before giving anesthetic o S/E: hyperglycemia. hypotension. tachycardia. rebound hypoglycemia o Avoid overzealous hydration which may risk of pul edema. with possible arrhythmia. less severe than -agonist o Risk of hypotension with spinal/epidural o sensitivity to NDMR . cerebral vasospasm. myocardial ischemia.Preterm labor Page 189 of 217 Between 20-37 wks fetal M&M Pt may given tocolytic therapy if there is no C/I -agonist: Ritodrine and terbutaline o For short term only to allow time for lung maturity after steroids o The effect persist to 60-90 min after D/C. fetal tachycardia. pul edema.
iliac crest. nose. genitalia Brachial plexus injury CI. Venus return due to pressure on the abdomen vena caval pressure epidural vein engorgement . knees. TEE Pressure injury to eyes. toes. SV. CVP. breast.Prone position Page 190 of 217 Difficult access to the A/W Difficult resuscitation Difficult to add invasive monitoring art-line.
may give Antithrombin III concentrate. C IHD (MI. vit K deficiency. Peripheral vascular disease D on coumadin stop pre-op and start heparin G bowel ischemia R renal vein and artery thrombosis. angina). or Acquired due to hepatic dysfunction. TIA’s for neuraxial anesthesia look in the ASRA guidelines may give FFP to protein C level. CNS sagital sinus thrombosis stroke. Antithrombin III deficiency risk of thrombo-embolic phenomena Resistance to heparin. postpartum risk of thrombo-embolic phenomena post-op A N/A B PE.Protein C and Protein S Deficiency Page 191 of 217 Congenital AD. or FFP . post-op. with possible Pul HTN. and DIC. hemodialysis.
PCO2 O2 all the time.Pul HTN Page 192 of 217 The pulmonary vessels are more reactive compared to Eisenmenger High mortality rate Hemodynamic Goals: o preload maintain. avoid sudden in SVR o PVR Avoid any thing that PVR pain. epidural slowly titrate GA same problem as in Eisenmenger Post-op ICU . avoid cardiodepressant o Afterlaod maintain. LUD o R/R maintain normal and sinus o Cont maintain. hypoxia. Art-line. acidosis. prostacycline. Consider: NO. NTG to PVR PAC risk/benefit No spinal. CCB.
insertion of IVC filter or surgical embolectomy Also Pt may present with previous history of PE. hypercarbia o PVR. Echo . trauma. Bronchospasm o RV dysfunction and arrhythmias Pt may present to the OR for emergency surgery.Pulmonary embolism Page 193 of 217 Associated with hyper-coagulation state (protein C and S deficiency ). and now anticoagulated have a hematology consult (Q: risk/benefit of holding meds pre-op) also discuss with the surgeon regarding continuing the anticoagulation med periop Have PT. and PLT count (HIT) Better to avoid Neuraxial technique in those Pt If diagnosis is in doubt Spiral CT. V/Q scan. prolonged bed rest High M&M Pathophysiology: o Pulmonary arteries obstruction dead space ventilation hypoxemia . PTT.
better RA Have NO ready. COPD. dobutamine) SNP. Echo. PFT. ABG. with exercise > 30 Primary (idiopathic) F:M 3:1. acidosis. graham steel murmur Lab: CXR. restrictive lung disease. ASD. TEE. easy fatigue wheezing. III and aVF Options RA Vs GA. RAD. VSD o collagen vascular disease o thromboembolic disease: PE. age 20-40 Secondary: o pul disease: asthma. sickle cell S/S SOBOE.Pulmonary HTN Page 194 of 217 @ rest mean of 25. o heart disease: MS. ECG look for acute strain pattern in leads II. ECG(RVH. CVP. PCO2) . and inotropic support (milrinon. NTG Keep 100 O2 all time Avoid things PVR ( hypoxia. PAC???. NO test to if responsive or not (Viagra) Cardiology consult and ICU Monitors: CAS. art-line. cystic fibrosis. hypothermia. Rt atrial enlargement). 5 leads EGC. AS.
urine OP. Give K. K > 3. Cl>88. moist tongue. V/S Check lytes Na >132. anterior fontanel.Pyloric stenosis Page 195 of 217 M>F Not a surgical emergency. or OGT to empty the stomach (no guaranteed) and pre-oxygenate RSI with cricoid pressure Maintenance need to be paralyzed if not risk of mucosal perforation Infiltrate Marcaine with epi. dehydration Pre op assess the level hydration skin turgor. give Tylenol 15mg/kg PR for pain control . if + urine OP Induction give atropine.2. S/S appear 2-6wks With the consideration of neonate A full stomach RSI B compensated resp acidosis hypoventilation C hypovolemia shock M hypochloremic metabolic alkalosis. insert NGT.
Glycogen storage disease Impaired diastolic filling Have the same clinical picture of constrictive pericarditis Except that the LV is more affected than RV Management of anesthesia: o As Tamponade . Hemochromatosis.Restrictive Cardiomyopathy Page 196 of 217 Causes: o Toxic :Methysergide. Radiation o Infectious: viral myocarditis o Infiltration: endomyocardial fibrosis o Genetic o Idiopathic o Infiltration Sarcoid. Amyloidosis . Anorectic agents.
as low as 15ml/kg. creat. sternal deformity o Extrinsic: obesity. aspiration. myasthenia. with S/S of Rt heart failure Pre-op: determine the severity by H/P and Lab. cough. RR With severe disease Pt may have pul HTN. fibrosis due to drugs. CXR. ABG. muscular dystrophy. normal FEV1/FVC. BUN. and myasthenic syndrome o MSK scoliosis. Echo . PFT. and treat the possible acute reversible component A VC < 15ml/kg with PCO2 high risk Lab: CBC-D. and VC N 70ml/kg. pneumonia. where the acute component could be reversible Causes: o intrinsic lung disease ( edema. breathing pattern Vt. and possible hyperventilation with PCO2 Could be acute Vs chronic. ascites S/S SOBOE. exercise tolerance. Guillian barre. and plural diseases) o Neuromuscular diseases: spinal cord transection. or idiopathic. ECG. pregnancy.Restrictive lung disease Page 197 of 217 The main feature is lung compliance with TLC. ARDS. lytes.
. The degree of cord compression does not correlate well with the patient's symptoms. pulmonary nodules. horseness. Age 30-50 The hands and wrists are involved first. obstructive lung disease. and risk of postextubation stridor. particularly the metacarpophalangeal and proximal interphalangeal joints. coronary arteritis dysrhythmias secondary to development of rheumatoid nodules in the cardiac conduction system aortitis. A:C-spine: atlantoaxial subluxation. more common due to costochondral involvement Several of the antirheumatic drugs cause pulmonary dysfunction as well V/Q mismatch and hypoxia Consider PFT and possible post-op ICU bed C: Pericarditis in 30%. chronic constrictive pericarditis or pericardial tamponade myocarditis. Valve fibrosis . producing aortic root dilation and aortic insufficiency.Rheumatoid arthritis Page 198 of 217 F> M. dyspnea. B: pleural effusions. So be caution with intubation and consider Fiberoptic intubation. interstitial lung disease. and asymptomatic patients may have a high degree of spinal canal stenosis. restrictive lung disease. TMJ involvement. Cricoarytenoid arthritis which may cause pain. stridor and airway edema.
Impaired liver function or perfusion will lower the rate threshold for developing citrate intoxication.3-DPG left shift of the O2–Hgb dissociation curve Hyperkalemia with rapid Tx by acidosis.Risk of RBC Tx Page 199 of 217 Citrate Intoxication o CPDA citrateionized calcium. acidosis. coags Microaggregate Delivery . o If ECG changes are observed the transfusion should be stopped and intravenous calcium should be administered. and a widened QRS. a prolonged PR interval. VEDP. and insulin may also be appropriate according to the severity of the episode Volume Overload Hypothermia CO. o Signs hypotension. o Treatment: CaCl Acid–Base Changes ? metabolic acidosis 2. and CVP o ECG changes: prolonged Q-T interval. o Citrate is metabolized efficiently by the liver. and flattened T waves. left shift of O2-Hgb. hypovolemia. and hypothermia o ECG peaked T waves. widened QRS. o The hypocalcemia is directly related to the rate and volume of blood Tx. dextrose. Bicarbonate. narrow pulse pressure.
BUN. CXR. creat. ECG. ABG. F:M 2:1 A distorted anatomy with possible A/W obstruction difficult A/W FOI B restrictive lung disease with pulmonary fibrosis C Arrhythmias. CHF D on Steroid and immunosuppressant (stress dose) GI liver involvement CNS SOL. heart block. Sz Lab/DI CBC-D. neuropathy. Lytes.Sarcoidosis: Page 200 of 217 More common in African-American. PFT. LFT Consider ICU backup if bad PFT .
diarrhea Radiological evidence of pneumonia within 7-10 days of symptoms onset Lab: lymphopenia. other N&V. pneumococcal . pulse oxi. B. PLT. sputum for gram stain and C/S Test for other respiratory pathogens inf A. blood C/S. RSV. PTT and Liver enzymes and CK SARS serum Antibodies positive SARS CoV isolation in cell culture PCR positive for SARS CoV RNA Action: Suspected Pt should be in resp isolation room ASAP if history contact with Pt with SARS or been in an epidemic area During Pt transfer have a surgical mask over the Pt Do CXR. CBC-D.SARS: Page 201 of 217 Not contagious until Pt become symptomatic with in 4-6 days(2-10) Transmission by close contact. headache. myalgia (nonspecific) Nonproductive cough. with SOB. and in a contact with resp secretion S/S and Lab: Fever. chills.
T: Telengectesia F>M. Raynaud’s phenomenon in 70% risk of ischemia with art-line CNS: peripheral and cranial nerve neuropathy o Eye: conjunctivitis and corneal abrasion . cardiomyopathy CHF. Chronic aspiration. Diffuse lung fibrosis restrictive lung disease. motility. with systemic HTN intravascular volume hypotension . Vascular sclerosis. Age 20-40 Pregnancy the progression of the disease in 50% of the Pt. LOS tone GERD need RSI B: A major cause of M&M. diffusion capacity C: risk of IHD. E: esophageal hypomotality. S: scleroderma. Fibrosis of skin and viscera Tissue edema Some Pts have CREST syndrome.Scleroderma Page 202 of 217 Progressive systemic sclerosis:Inflammation. pericarditis effusion tamponade. fibrosis of the conductive system arrhythmia. A: flexion contracture difficult airway due to limited mouth opening. systemic and pulmonary HTN. C: calcinosis. R: Raynaud’s phenomenon.
ICU . CXR. Echo if needed OR: blood in the OR. bear hugger. so consider -blockers SSEP: if latency by 10% or amp by 60% BP. BUN.Scoliosis Sx Page 203 of 217 Need two stage Sx. Heme). and diskectomy. PFT. ABG. Lytes. ECG. the 2nd stage to posterior instrumentation The scoliosis could be secondary to muscular disease ( muscular dystrophy) A Reflux RSI B Restrictive lung disease. atelectasis) C myopathy. IV wormer Position: prone check all pressure points. X-match. with that HR will . ask the surgeon to stop Volatiles have the least effect on SSEP See SSEP card Post-op: pain. arrhythmias D avoid Sux Heme consider autologus blood donation pre-op Consult (ICU. Art-line. 1st anterior approach to release the anterior spinal artery. risk of PPC (pneumonia. and frequent checking May consider deliberate hypotension if there is no C/I. creat. talk to the Pt regarding awake test Lab:CBC-D. PPC.
SEP Any injury will cause in latency & amplitude SSEP 50% in amp to surgical maneuver significant Cortical ( SSEP. and avoid any sudden changes or a bolus doses of any drugs maintain and control other factors that may affect the SEP like temp. with 0/ effect on the VEP and no effect on BAEP at regular doses Page 204 of 217 . N2O 0/ VEP all lat/ amp BAEP alt/0 amp Effect of IV drugs: All drugs lat/ amp except ketamine and etomidate /. VEP) are more vulnerable to anesthetic drug effect brain stem/subcortical (SSEP. BP. BAEP) are more resistance key points: maintain a constant anesthetic level. PaO2 and PaCO2 Effect of inhalational agents: SSEP all lat/amp. except enf /.
ABG. Blood C/S. ACTH stim test. ECG. frequent ABG. inotrops. D Abx. Lab: CXR. ARDS. abdominal CT…. Sat. PTT. CBC-D. and urine. pul edema C low or high output failure. base deficit. LFT.. lytes disturbance. K.5ml/kg/hr. vasopressors Met lactic acidosis. creat. APC. DIC Management: ABC ECG. Art-line. CVP/PAC. adrenal insufficiency Renal ATN. TEE or TTE for ? edocarditis.g. full stomach B resp failure. ARF Heme thrombocytopenia.Septic shock: Page 205 of 217 A LOC. MAP >65. Fibrinogen. sputum. BUN. lytes. if suspecting a source of infection do further investigation e. Early goal directed therapy( CVP 8-12. D-dimer. Urine>0. steroids. SvO2>70%) Broad spectrum ABx . PT. SVR.
lethargic Crystalloid + blood Fluid (3:1 rule)‡ Crystalloid .Class I Blood loss (ml) Blood loss (%) HR (per min) Blood pressure Pulse pressure RR Urine ml/hr Mental status 750 15 <100 Normal Normal or 14–20 30 Slightly anxious Class II 750–1500 15–30 >100 Normal 20–30 20–30 Mildly anxious Crystalloid Class III 1500–2000 30–40 >120 30–40 5–15 Anxious and confused Crystalloid + blood Page Class IV 206 of 217 2000 40 140 <35 Negligible Confused.
and rotator cuff repair Use of a beach chair position VAE risk Limited access to the airway tighten the connection.Shoulder Sx: Page 207 of 217 Arthroplasy. reinforce with tap Possible eye and ears injury Avoid excessive head rotation brachial plexus injury Options GA. interscalene or combined Assess the arm before doing the block for any neurological deficit Risk of post-op neurological deficit the level of the injury is at the level of the trunk (same as interscalene) difficult to determine the cause (surgical Vs block) Neurapraxia 90% resolve within 3-4 months . and arthroscopy.
pulmonary infections. The diagnosis of the (SIADH) is one of exclusion. . Pt with severe water intoxication associated with hyponatremia and mental confusion may require more aggressive therapy. with the iv administration of a hypertonic saline solution. Clinical manifestations occur as a result of a dilutional hyponatremia. Treatment: Pt with mild/mod H2O intoxication is restriction of fluid intake to 800 ml·day– 1 . Inappropriate Secretion of Antidiuretic Hormone (SIADH) Page 208 of 217 Causes: head injuries. skeletal muscle weakness. and mental confusion or convulsions are presenting symptoms. serum osmolality. and other causes of hyponatremia must first be ruled out. Peripheral edema and hypertension are rare.intracranial tumors. and a reduced urine output with a high osmolality. Isotonic saline is substituted for hypertonic solutions once the serum Na is in a safe range. small cell carcinoma of the lung and hypothyroidism. Weight gain. This may be administered in conjunction with lasix Caution must be observed in patients with poor LV function. The prognosis is related to the underlying cause of the syndrome.
mortality with in the number of the painful crisis in adult per-year. % of Hb S o trait (mild) o < 50% is Hb S o sickling do not occur under normal physiological conditions o may happen under extreme conditions e. Ethnic background: Mediterranean and African-American. .g severe hypoxemia. but at a greater risk of sickling. o Disease (severe) o Hb S > 75% may up to 95% o Could be associated with other abnormal Hb e. position 6 glutamic acid substituted by valine 3 types of crisis o hemolytic further anemia o sickling pain & vaso-occlusive o Aplastic may cause death.g Hb C o Pt with Hb SC have a normal Hb level. Pre-op you need to knew what is the result of the Hb electrophoresis. In infancy Hb F is protective.Sickle cell anemia Page 209 of 217 The defect in -chain.
target normal PO2. ABx if suspect infection o Other consider Ventoline IV. hypercarbia. BNZ o Last volatile agent. pH. if on vent reverse ratio ventilation . and respiratory/metabolic acidosis Management: o ABC.Status asthmaticus Page 210 of 217 Emergency and life threatening Result in respiratory failure with hypoxia. PEEP 5-10. Ketamine. thiophylline. Isoprel/pei gtt. ipratrupium bromide. 100% O2 o Intubate deep/ also may consider BiPAP o Ventoline. and paralyze o Ventilation: volume control Vt 6-10ml/kg. and PCO2. leukotrine inhibitor. steroids. keep the platue pressure < 30cmH2O o If need switch to pressure control o Also may consider Heliox o Be aware of AutoPEEP disconnect the bag.
A.fib. A. post-op CEA. neuro deficit Peri-op Avoid swinging in BP. coumadin. ASA. loss of A/W reflux (RSI) B hypoventilation C HTN. arrhythmias ECG. trauma.Stroke & TIA: Page 211 of 217 Hemorrhagic or ischemic Etiology: Atherosclerosis.fib. CAD. VHD. Echo D anti-PLT. VHD. stimulator resistance N LOC. and hyperglycemia With chronic HTN the cerebral autoregulation curve shifted to the Rt . Avoid Sux. N. severe HTN A LOC. embolic MI.
papilledema. BUN. and to avoid any factor that may ICP ICP control SEE ICP card Monitoring: Standard + Art line. lytes. CVP. and consider using antihypertensive Meds(labetolol). creat. Avoid Sux Maintenance: Isoflurane. unilateral pupil dilation. No N2O Emergence: give Lidocaine IV 90 sec before extubation.Supratentorial Intracranial Tumors Page 212 of 217 Review Pt overall medical condition Focus on Neuro-evaluation: LOC. give Lidocaine IV. with other standard induction drugs. and the presence and extent of focal neurological deficit May have fluid and lytes abnormality Review CT/MRI head Lab: CBC. N&V. assess for any neurological deficit . Foley cath. for the art-line have the transducer at the level of external auditory meatus ( level of circle of Willis) Induction: may need RSI. ECG The main effect of Supratentorial masses is intracranial HTN The main anesthetic goal is to maximize the therapeutic modality to ICP. if CN involvement or LOC. S/S of ICP: headache.
anemia R common cause of M&M in patients with SLE. stroke. high correlation of pul HTN with Raynaud's phenomenon in patients with SLE. and peripheral neuropathy GI peritonitis. dementia. enalapril. clonidine. bowel ischemia. Hanti-phospholipid antibodies thromboembolic complications. ventricular function.Systemic Lupus Erythematosus Page 213 of 217 A cricoarytenoid arthritis hoarseness. noninfectious endocarditis (Libman-Sacks endocarditis) mitral insufficiency (ECG. hydralazine. ECHO) D immunosuppressants (corticosteroids) or cytotoxic drugs (cyclophosphamide. pneumonitis. PFT) C pericardial effusion. and alveolar hemorrhage. protein-losing enteropathy. methyldopa. isoniazid. azathioprine. Cardiomyopathy. psychosis. post-extubation edema B effusion. and lupoid hepatitis . tamponade. captopril. pul HTN. cyclosporine). cardiac conduction abnormalities.avoid Drug-induced lupus quinidine. stridor. and coronary arteritis. CRF CNS seizures. pancreatitis. or airway obstruction (awake intubation).(CXR.
fungal. CVP. HR. cardiac herniation ECG: diffuse ST-changes. cool extr DDx: tension Pneumo. SBP. myxedema o Radiation. pulses paradoxus Signs of systemic hypoprefusion: oliguria. CXR. Pul HTN. SV. narrow pulse pressure.Arthritis. Rt=Lt pressure Dx by keeping in mind a high index of suspicion with clinical S/S and lab Beck’s triad: hypotension. lactic acidosis. CO. RV infarction. Echo. BP. malignancy. post-heart Pathophysiology: VEDV. trauma. SLE. TB o Inflammatory disease with vasculitis: R. viral. low voltage Lab: ECG.Tamponade: Page 214 of 217 Emergency and life threatening In acute as little as 200 ml cause S/S In chronic up to 1000 ml cause S/S Causes: o Infection: bacterial. scleroderma o Metabolic: RF. distended neck veins. muffled heart sound S/S: tachypnea. CT .
So no Atropine Cardiac toxicity is the major cause of death No correlation between serum level and symptom A LOC RSI B depression. hypotension due contractility. heart block. coma. sinus tach. seizure M metabolic acidosis Management: o ABC o Gastric lavage o Activated charcoal 1g/kg with 60 ml sorbitol o Bicarb is the Key in the management 2 mEq/kg bolus then infusion 150mEq in 850 D5W to maintain pH 7. and vasodilation by -blockade.50 o For Vent arrhythmia give Lidocaine.1C are C/I o Hypotension Norepi gtt o Bradycardia Isoprel or pacing No Atropine . QT. ARDS C toxicity.45-7. wide QRS. Class 1A. arrest CNS hallucination.TCA overdose: Page 215 of 217 Gives anticholinergic syndrome.
the ligation of the fistula. metabolic acidosis Worm up the room. listen to the chest and initially intubate the Rt main bronchus. standard CAS monitors. if not stage repair. X-match with 2U peds in the room Give atropine.TEF Page 216 of 217 30% premature. with insertion of G-tube under LA. and VATER. big IV. after intubation with the bevel directed posteriorly. and reanastomosis of the esophagus A subglottic stenosis B resp distress. pneumonia C CHD. lytes. ABG. decompensation and CHF M dehydration. Echo. associated CHD. not muscle relaxant until chest open. then intubate after further mask ventilation to deepen the Pt. have different size ETT. Consider caudal epidural for post-op pain Run maintenance fluids with glucose maintenance as well . VACTREL syndromes Depend on the infant stability if stable complete repair. Inhalation induction bronch. Art-line Lab CBC-D. RDS. Cap gas or VBG. with listening to the chest withdraw the tube slowly till you here bilateral breath sound. CXR.
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