Anesthesia

Capsule

Dr. Muhammad Umer

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 Contents

Topic Page No.

Part-1 Emergencies 4
Part-2 Systemic Considerations 40
Part-3 Guidelines 350

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3
 Part 1
EMERGENCIES

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 Contents

Topic Page No.

1 Airway Fire 6
2 Anaphylaxis 7
3 Bronchospasm 9
4 Delayed Emergence 11
5 Extravasation Injuries 13
6 Fat Embolism 15
7 Hypertension 16
8 Hypoglycemia 18
9 Hypotension 19
10 Hypoxemia 21
11 Increased Airway Pressure 23
12 Local Anesthetic Toxicity 25
13 Malignant Hyperthermia 27
14 Perioperative MI 29
15 Seizures 30
16 Postoperative Visual Loss 32
17 Total Spinal 34
18 Transfusion Reaction 35
19 Venous Air Embolism 38

5
 Airway Fire

Management
1. Inform team & call for help
2. Simultaneously remove the endotracheal tube (ETT) & stop
gases/disconnect circuit
3. Pour saline or water into airway
4. Remove airway foreign bodies (ie: ETT pieces, sponges)
5. When fire is extinguished: re-establish ventilation; avoid
supplemental oxygen if possible
6. Consider prompt reintubation prior to swelling & coordinated with
bronchoscopy
7. Examine entire airway (including bronchoscopy) to assess injury &
remove residual debris

Prevention
1. For high risk procedures:
o Discuss fire prevention & management with team during time-
out
o Avoid FiO2 > 0.3 & avoid N2O
2. For laser surgery of vocal cord or larynx:
o Use laser resistant ETT (single or double cuff)
o Assure ETT cuff sufficiently deep below vocal cords
o Fill proximal ETT cuff with methylene blue-tinted saline (acts as
a marker if cuff perforated by laser)
o Ensure laser in STANDBY when not in active use
o Surgeon protects ETT cuff with wet gauze
o Surgeon confirms FiO2 < 0.3 & no N2O prior to laser use (may
require several minutes to dilute FiO2 & FeO2 to
<0.3 depending on fresh gas flow & initial FiO2)
3. For non-laser surgery in oropharynx:
o Regular PVC ETT may be used
o Consider packing wet gauze around ETT to minimize O2
leakage
o Consider continuous suctioning of the operating field inside
oropharynx

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 Anaphylaxis

Signs
 Rash/hives
 Angioedema
 Hypotension
 Tachycardia
 Hypoxemia
 Bronchospasm/wheezing
 ↑ peak inspiratory pressure

Management
1. Stop offending agent
2. Inform surgeon, call for help
3. Discontinue or ↓ all anesthetic agents
4. Airway:
o 100% O2
o Secure airway
5. Administer epinephrine IV in escalating doses:
o Start at 10-100 mcg & ↑ as necessary until clinical
improvement
o Consider early epinephrine infusion (start at 2-20mcg/min)
6. Aggressive fluid resuscitation (may require several litres)
7. Bronchospasm: salbutamol PRN
8. Give secondary medications:
o H1 antagonist: diphenhydramine 25-50mg IV
o H2 antagonist: ranitidine 50mg IV
o Methylprednisolone 1-2mg/kg IV per day OR dexamethasone
20mg IV
9. Start invasive lines: arterial line, central line
10. Refractory hypotension despite epinephrine:
o Vasopressin 1-40 unit bolus, 0.01-0.04 units/min infusion
o Glucagon 1-2 mg over 5 min IV then 5-15 mcg/min IV
infusion (especially for patients taking
beta blockers; inotropic & chronotropic effects not mediated
through beta receptors)
o Methylene blue 1-2mg/kg IV (inhibits nitric oxide synthase
& guanylate cyclase)
o Consider bicarbonate (0.5-1 mEq/kg) with acidosis
o Consider transesophageal echocardiography (TEE) & entertain
other differential diagnosis

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11. Post-event care:
12. Laboratory tests to support diagnosis:
o Serum tryptase levels 15 minutes and 3 hours after onset of
symptoms
o Serum histamine levels peak 5 - 15 minutes after onset of
symptoms; return to baseline at 60 minutes
o Discharge to ICU intubated & ventilated
o Due to biphasic nature, monitor at least 24 hours
o Consult allergist

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 Bronchospam

Signs
1. Wheezing on lung auscultation
2. Slow or incomplete expiration
3. Change in EtCO2:
o Upsloping waveform
o Severe ↓ or absent waveform
4. ↓ tidal volume
5. ↓ oxygen saturation
6. ↑ peak airway pressure

Differential Diagnosis
1. ↑ resistance:
o Bronchial asthma
o COPD with reversible component
o Laryngospasm (if supraglottic airway)
o Anaphylaxis
2. ↓ compliance:
o Aspiration
o Pulmonary edema
o Pulmonary embolism/fat embolism/amniotic fluid embolism
o Pneumothorax
o Opioid-induced chest wall rigidity
o Inadequate muscle relaxation
o Circuit/machine problems
3. ETT/supraglottic airway:
o Kinked
o Malposition
o Endobronchial/esophageal/submucosal
o Herniated cuff
o Foreign body/secretions

Management
1. Adjust FiO2 as necessary, remove irritants, deepen anesthesia
2. Disconnect & hand-ventilate to assess compliance, rule out other
possibilities
3. Beta 2 agonists are first line treatment:
o Salbutamol 4-8 puffs via ETT OR 2.5-5mg via nebulizer q20min
PRN

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 o Epinephrine infusion 0.5-2mcg/min in severe, refractory cases
4. Anticholinergics: ipratropium 4-8 puffs via ETT OR 0.5 mg via
nebulizer q20min PRN
5. Steroids: methylprednisolone 125mg IV OR dexamethasone 8mg IV
6. Appropriate ventilation to avoid dynamic hyperinflation:
o Longer expiratory time (I:E 1:3-1:5)
o Low/normal respiratory rates (8-12/min)
o Permissive hypercapnia
7. Adjuncts:
o Bronchodilating anesthetics: volatiles > ketamine > propofol
o Magnesium sulfate 2g IV over 20min
o Heliox (does not reverse bronchospasm, but can be used as a
temporizing measure)
o Neuromuscular blocking drugs (may improve mechanics of
ventilation & lower peak inspiratory pressures)
o Extracorporeal membrane oxygenation (ECMO) if severe &
refractory to all other treatments

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 Delayed Emergence

Differential Diagnosis ("DIMS")

1. Drugs
o Anesthesia related:
 Sedatives & narcotics
 Residual paralysis, pseudocholinesterase deficiency
 Drug error
o Non-anesthesia related:
 Street drugs, alcohol
 Herbal medicines (valerian root, St. John's wort)
2. Infection:
o Encephalitis, meningitis
o Sepsis
3. Metabolic:
o Hypoxia
o Hypercarbia
o Electrolyte abnormalities
o Hypoglycemia or hyperglycemia (DKA or HONK)
o Hypothermia
o Uremia
o Hepatic encephalopathy
o Osmolality problems
o Myxedema coma
4. Structural:
o Stroke (ischemic or hemorrhagic)
o Hydrocephalus
o Diffuse anoxic injury
o Cerebral edema
o Seizure or post-ictal
o Pneumocephalus
o Cerebral hyperperfusion syndrome (post carotid
endarterectomy)

Management
1. Scan monitors: HR, ECG, rhythm, EtCO2, SpO2, BP, temp
2. Ensure stability of ABC's
3. Confirm reversal of paralysis
4. Review all drugs administered & syringes for drug error
5. Focused physical exam:

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 o Neurological: GCS, pupils, gag/cough, symmetric motor
movement, focal signs
o Cardiorespiratory: adequacy of perfusion
6. Blood work:
o CBC, lytes, urea, creatinine, glucometer, osmolality, ABG with
lactate & ionized calcium
o Liver enzymes, bilirubin
o Toxicology screen
o TSH, FT4
7. Consider: Neurology / ICU consultation, CT head, EEG, lumbar
puncture
8. Empiric therapy:
o Glucose: 25-50 cc of D50 or 250 cc of D10
o Thiamine 100 mg IV
o Opioid reversal: naloxone 0.04 mg IV q 2 mins, up to 2mg
o Benzodiazepine reversal: flumazenil 0.2-1 mg IV q 1 min, up to
1mg
o Physostigmine (0.5 to 1 mg IV) counteracts but does not
reverse sedation caused by inhalation anesthetics, other
sedatives, & anticholinergics

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 Extravasation Injuries

Management of Vasopressor Extravasation

1. Stop injection/infusion immediately; leave the catheter in place
2. Place immediate substitute IV access; resume vasopressors
3. Slowly aspirate as much of the drug as possible
4. Elevate the area & apply warm compresses for 48 hours
5. Consult plastic surgery & vascular surgery for opinion & ongoing
management
6. Reversal:
o First line: phentolamine subcutaneously
o Dilute phentolamine 5 mg in 10 mL 0.9% sodium chloride
o A dose of 0.1-0.2 mg/kg (up to a maximum of 10 mg) should
then be injected through the catheter & subcutaneously around
the site
o Use 25 g or smaller needle
o Additional injections may be required if blanching returns
o Systemic hypotension may occur
7. Other options:
o Topical nitroglycerin 2% 1-inch strip applied to the site of
ischemia (redose q8h PRN)
o Terbulatine subcutaneously 1mg in 10ml NS, inject locally
across symptomatic sites
o Consider sympathetic block, e.g. stellate ganglion (case reports
of success)
o Consider a saline-wash out method or liposuction:
 Saline wash out:
 Probably the most effective way of removing drug from the site of
extravasation & has been shown to reduce tissue injury
 Under sterile conditions with local or general anaesthesia, four to six
stab incisions are made around the area of extravasation
 A blunt-ended cannula is inserted through one of the incisions & a large
volume of saline flushed through the subcutanous tissues
 The saline exits through the other incisions
 Liposuction:
 Blunt-ended liposuction cannula is inserted into the area of
extravasation & used to aspirate fat & extravasated material
 Less effective than saline washout

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Prevention
1. Avoid IVs in the hand/wrist
2. Avoid unreassuring IVs
3. Perform protocolized extremity checks
4. Keep antidotes & worksheet in the room with the patient
5. 10 mg of phentolamine mesylate can be added to each liter of
solution containing norepinephrine (the vasopressor effect of
norepinephrine is not affected)

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 Fat Embolism

Signs
1. Hypoxemia (most common early sign)
2. Neurological abnormalities (majority of patients)
3. Petechial rash (only 20-50% of patients; usually on conjuctiva, oral
mucosa, skin folds of neck & axillae)

Management
1. Supportive treatment:
o Respiratory support: intubation/ventilation, treat as ARDS (lung
protective strategy)
o Hemodynamic support: fluid resuscitation, vasopressors,
invasive monitors, TEE
o Steroids: no strong evidence but consider in refractory cases
2. Reduce incidence/severity:
o Early immobilization of fractures
o Operative correction rather than traction alone
o Limitation of the intraosseus pressure during orthopedic
procedures

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 Hypertension

Differential Diagnosis
1. Hypoxemia, hypercarbia
2. Drugs:
o Vasopressors, cocaine, MAOIs, stimulants
o Drug errors
o Acute withdrawal: EtOH, benzodiazepines, opioids, clonidine,
beta-blockers
3. Pain, inadequate anesthesia:
o Laryngoscopy/intubation
o Surgical stimulation, laparoscopy
o Remote (distended bladder)
o Awareness
4. Patient factors:
o Pre-existing hypertension
o Pre-eclampsia
o High ICP (Cushing reflex)
o Autonomic dysreflexia
5. Endocrine:
o Hyperthyroidism
o Pheochromocytoma
o Carcinoid
o Malignant hyperthermia
o Serotonin syndrome
o Hyperaldosteronism
o Cushing syndrome
6. Equipment error (falsely high reading)

Management
1. Inform surgeon, request cessation of surgical stimulation
2. Cycle BP, scan monitors for HR, ECG rhythm, EtCO2, temperature
3. Provided the patient is adequately oxygenated & ventilated, deepen
anesthetic
4. Examine patient:
o Pupils (high ICP)
o Diaphoresis & flushing (carcinoid,
pheochromocytoma, hyperthyroidism)
o Rigidity (malignant hyperthermia, serotonin syndrome)
o Bladder distension

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 o Hot (thyroid storm, malignant hyperthermia, serotonin
syndrome)
5. Examine drugs & equipment:
o Potential drug error
o Possible TIVA or circuit disconnect (awareness)
o Tourniquet (pain)
o Equipment error (falsely high reading)
6. Temporize:
o Labetalol 5-20mg IV q10 min (max total 300mg)
o Esmolol 0.5mg/kg IV over 1 minute; start infusion at
50mcg/kg/min
o Hydralazine 5-20mg IV (max 30mg) slow IV push every
20 minutes
o Nitroglycerin 50-100mcg IV; start infusion at 10mcg/min
7. Treat underlying cause

Complications
 CVS: MI, arrhythmia, CHF/pulmonary edema, dissection
 CNS: intracranial hemorrhage
 ↑ surgical bleeding

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 Hypoglycemia (blood glucose <3.9 mmol/L)

Signs
1. Sympathetic system activation: diaphoresis, tremor, tachycardia,
anxiety, hunger
2. Neuroglycopenia: weakness, fatigue, altered mental status, coma

Differential diagnosis
1. Exogenous insulin
2. Critical illness/sepsis
3. Endocrine: Addison's disease, adrenal crisis, hypopituitarism
4. Insulin producing tumors
5. Fasting hypoglygemia: inherited liver/fatty acid oxidation enzyme
deficiencies, drugs (ethanol, haloperidol)
6. Reactive (postprandial) hypoglycemia: idiopathic or enzyme
deficiencies

Management
1. Confirm glucose level
2. Treat: IV dextrose (D5W 50ml IV); glucagon 1-2mg IM if no IV access
3. Seizure precautions
4. Continue to monitor & treat until glucose levels stable

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 Hypotension

Differential Diagnosis
1. ↓ preload:
o Bleeding
o Relative
2. ↓ afterload/distributive shock:
o Anaphylaxis
o Sepsis/SIRS
o Neurogenic
o Blood transfusion reaction
o Neuraxial
o Drugs: anethetic overdose/drug swap
o Endocrine: Addison's, myxedema, carcinoid
o Metabolic: hypocalcemia, hypoglycemia
3. Obstructive shock:
o Tension pneumothorax
o Tamponade
o Embolic events
o Pulmonary hypertension
4. Cardiogenic shock:
o Rate:
 Bradycardia
 Tachycardia
o Arrhythmias
o Contractility:
 Ischemia
 Drugs or toxins
o RV failure/pulmonary hypertension
o Acute valvular pathology

Management
1. Emergency situation requiring simultaneous diagnosis
& management
2. Inform the surgeon
3. Call for help
4. ↓ anesthetic & hand ventilate with 100% O2
5. Vasopressor bolus +/- IV fluid bolus:
o Phenylephrine 100 mcg IV PRN
o Ephedrine 5-10 mg IV PRN
o Epinephrine 1-10 mcg IV PRN

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6. Cycle BP & scan monitors for HR, rhythm, ST changes, SaO2,
EtCO2, PAP
7. Feel for a pulse:
o If no pulse → ACLS as per protocol
8. Ensure crash cart in room:
o If pulse present → targeted physical exam
 Urticaria, flushing, angioedema
 Tracheal deviation, jugular venous
distention, subcutaneous crepitus, bilateral air entry
 JVP (jugular venous pressure) / CVP (central venous
pressure) / PCWP (pulmonary capillary wedge pressure)
 ↑ CVP / PCWP = obstructive or cardiogenic
 ↓ CVP / PCWP = hypovolemic or distributive
 Peripheral perfusion (↑ in distributive, ↓ in others)
 Look at surgical field (blood loss, IVC compression,
pneumoperitoneum pressure)
 Check IV fluids, vasopressors, blood products
9. Reassess differential diagnosis based on findings

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 Hypoxemia

Differential Diagnosis
1. Low FiO2:
o Oxygen failure or pipeline crossover of gases
2. Hypoventilation:
o Low TV or RR
o Ventilator dyssynchrony
o Circuit leak
o Obstructed ETT
3. V/Q mismatch or shunt:
o Airway:
 Bronchospasm
 Mainstem intubation
 Mucous plug
o Alveolar:
 Pulmonary edema
 Aspiration
 Atelectasis
o Pleura:
 Pneumothorax
 Pleural effusion
4. Deadspace:
o Pulmonary embolism
o Low cardiac output state
5. ↑ metabolic O2 demand:
o Malignant hyperthermia, thyrotoxicosis, sepsis, hyperthermia,
neuroleptic malignant syndrome
6. Diffusion abnormality:
o Chronic lung disease
7. Artifacts:
o Confirm by ABG
o Poor waveform (probe malposition, cold extremity, light
interference, cautery)
o Dyes (methylene blue, indigo carmine, blue nail polish)

Management
1. ↑ FiO2 to 100%, high flow
2. Check gas analyzer to rule out low FiO2 or high N2O
3. Check other vitals, cycle NIBP, check peak inspiratory pressure, feel
for pulse

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4. Check ETCO2 (?extubated/disconnected/low BP)
5. Hand ventilate (check compliance, rule out leaks & machine factors)
6. Listen for breath sounds
7. Check position of ETT
8. Soft suction via ETT (to clear secretions & check for obstructions)
9. Consider code cart if severe
10. Depending on likely diagnosis, consider:
o Large recruitment breaths, consider PEEP
o Bronchodilators
o Additional neuromuscular blockade
o ↑ FRC (head up, desufflate abdomen)
o Fiberoptic scope to rule out mainstem intubation or ETT
obstruction
o ABG, CXR
o Consider terminating surgery for refractory hypoxemia
o Plan for post-op care

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 Increased Airway Pressure

Differential diagnosis
1. Circuit or machine problem:
o Ventilator/bag switch in wrong position
o Stuck valve (inspiratory/expiratory/APL)
o Oxygen flush valve stuck in "on" position
o Kinked/misconnected hose in circuit/scavenge limb
o Failure of check valves/regulators in machine, allowing high-
pressure gas into low-pressure circuit
o PEEP valve accidentally placed in inspiratory limb
2. ETT/supraglottic airway problem:
o Kinked tube
o Malpositioned supraglottic airway
o Endobronchial, esophageal, submucosal intubation
o Herniated cuff obstructing end of tube
o Dissection of interior surface of tube leading to airway
narrowing
3. ↓ pulmonary compliance:
o ↑ intra-abdominal pressure
o Pulmonary aspiration
o Bronchospasm
o ↓ chest wall compliance
o Pulmonary edema
o Pneumothorax
4. Drug-induced problem:
o Opioid-induced chest wall rigidity
o Inadequate muscle relaxation
o Malignant hyperthermia
5. Laryngospasm (if using supraglottic airway)

Management
1. ↑ FiO2 to 100%
2. Verify the peak inspiratory pressure
3. Switch to manually using reservoir bag; assess pulmonary & circuit
compliance
4. Disconnect circuit from ETT & squeeze bag:
o If PIP still high, obstruction in circuit; ventilate using BVM
connected to 100% FiO2
o Get help to replace/repair circuit
5. Auscultate chest & neck:

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 o Listen for symmetry (endobronchial, tension, or simple
pneumothorax) & for adventitious sounds (pulmonary edema,
bronchospasm)
o Listen for stridorous sound of laryngospasm
6. Examine trachea for deviation, check HR & BP
7. Exclude ETT obstruction:
o Pass suction catheter down ETT & apply suction to clear
secretions
o If ETT obstructed, deflate cuff & repeat
o Consider fiberoptic bronchoscopy to elucidate problem
o Remove & reintubate if necessary
8. Check for other causes of ↓ chest compliance:
o Malignant hyperthermia
o Aspiration
o Inadequate muscle relaxation
o Opiates
o Excessive surgical retraction
o Abnormal anatomy (ie: scoliosis)

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 Local Anesthetic Toxicity (LAST)

Signs & Symptoms

1. Tinnitus, metalic taste, circumoral numbess
2. Altered mental status
3. Seizures
4. Hypotension
5. Bradycardia
6. Ventricular arrhythmias
7. Cardiovascular collapse

Management
1. Stop local anesthetic injection &/or infusion
2. Call for help
3. Initial focus:
o Airway management: ensure adequate ventilation
& oxygenation; 100% FiO2, consider ETT, prevent hypoxia &
acidosis (aggravate LAST)
o Seizure suppression: benzodiazepines
preferred, avoid/minimize propofol if
hemodynamically unstable; if seizures persist, small doses of
succinylcholine to minimize acidosis & hypoxia
o Alert nearest facility having cardiopulmonary bypass capability
4. Management of cardiac arrhythmias:
o If pulseless, start CPR
o ACLS will require adjustment of medications & perhaps
prolonged effort
o Epinephrine doses <1 mcg/kg (small boluses of 10-100 mcg
IV)
o Avoid vasopressin, calcium channel blockers, beta blockers,
& local anesthetics
o If ventricular arrhythmias occur, amiodarone is preferred; avoid
lidocaine & procainamide
o If refractory to treatment, consider cardiopulmonary bypass
5. Lipid emulsion (20%) therapy:
o Rapidly administer at the first signs of LAST 1.5ml/kg bolus
(70kg = 105ml) over 1 minute, then start infusion at
0.25mL/kg/min
o Repeat bolus once or twice for persistent cardiovascular
collapse
o May ↑ infusion rate (max 0.5mL/kg/min) if BP remains low

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 o Continue infusion for at least 10 minutes after attaining
circulatory stability
o Recommended upper limit 10mL/kg over the first 30 minutes
o Propofol is not a substitute for lipid emulsion
6. Failure to respond to lipid emulsion & vasopressor therapy should
prompt institution of cardiopulmonary bypass (ECMO)

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 Malignant Hyperthermia (MH)

Signs (early)

 ↑ EtCO2
 Tachycardia
 Tachypnea
 Mixed acidosis
 Masseter spasm/trismus
 Sudden cardiac arrest due to hyperkalemia

Signs (may be later)

 Hyperthermia
 Muscle rigidity
 Myoglobinuria
 Arrhythmias
 Cardiac arrest

Differential Diagnosis
1. Neuroleptic malignant syndrome: similar presentation to MH but
associated with use of antipsychotic neuroleptic medications (also
treated with dantrolene)
2. Thyroid storm: fever, tachycardia, altered mental status
3. Anaphylaxis: cardiovascular collapse without hypermetabolic features
4. Pheochromocytoma: significant hypertension
5. Drug toxicity: consider clinical context, screen urine/plasma

Management
1. Alert surgeon & call for help
2. Stop anesthetic triggers (volatiles & succinylcholine), ↑ fresh gas flow
to 10L/min; do not change machine or circuit
3. If available, insert activated charcoal filters into the inspiratory
& expiratory limbs of the breathing circuit
4. ↑ to 100% FiO2 & ↑ minute ventilation
5. Halt surgery; if emergent, continue with non-triggering anesthetic
6. Assign several people to prepare dantrolene 2.5 mg/kg IV bolus:
o Dilute each 20 mg dantrolene vial in 60 mL preservative-free
sterile water

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 o For 70 kg person, give 175 mg (prepare 9 vials of 20 mg
dantrolene)
o Rapidly administer dantrolene & continue giving until patient
stable
o May need > 10 mg/kg
7. Cool patient: IV fluids, ice packs, gastric / peritoneal lavage
8. Treat arrhythmias:
o Usually secondary to hyperkalemia
o Treat in standard fashion, however avoid calcium channel
blockers
9. Treat metabolic acidosis:
o Sodium bicarbonate 1 to 2mEq/kg PRN for base excess
greater than -8 (max dose 50mEq)
10. Treat hyperkalemia:
o Hyperventilation
o Calcium chloride 10mg/kg (max dose 2g) or calcium gluconate
30mg/kg (max 3g)
o D50 1 amp IV (25g dextrose) + regular insulin 10 units
IV → monitor glucose
o Sodium bicarbonate 1 amp
o Furosemide 0.5-1mg/kg once
o For refractory hyperkalemia, consider beta-agonist, kayexalate,
dialysis, or ECMO if in cardiac arrest
11. Monitor temperature, electrolytes, arterial/venous blood gases,
creatine kinase, urine output, coagulation studies, lactic acid
12. Place foley catheter, monitor urine output
13. When stable, transfer to post anesthesia care unit or intensive care
unit for at least 24 hours
14. Monitor for recurrence & continue dantrolene 1 mg/kg q 4-6 hours x
24 to 48 hours
15. Refer for genetic counseling/in-vitro muscle contracture testing

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 Perioperative MI

Signs
 New ST segment or T wave changes
 New left bundle branch block
 Arrhythmias, conduction abnormalities
 Unexplained tachycardia, bradycardia, or hypotension
 Development of pathological Q waves
 Regional wall motion abnormalities or new/worse mitral regurgitation
on TEE

Management
1. Assess need for airway management & initiation of cardiopulmonary
resuscitation
2. Verify ischemia (12 lead ECG or expanded monitor view)
3. Optimize myocardial oxygen supply:
o ↑ FiO2
o Treat anemia if present
o Optimize BP (maintain coronary perfusion pressure) & HR
(avoid tachycardia)
4. ↓ coronary oxygen demand:
o Analgesia
o Nitrates (careful in hypotension)
o Beta blockers (careful in hypotension & acute heart failure)
o Optimize BP (avoid increased afterload) & HR (avoid
tachycardia)
5. Discuss aborting procedure with surgical team
6. Discuss aspirin & anticoagulation with surgical team & cardiology
team
7. Send labs: troponin, CBC, ABG
8. Initiate invasive monitoring, consider central venous access
9. Consider TTE/TEE for monitoring volume status & regional wall
motion abnormalities
10. If hemodynamically unstable, consider intra-aortic balloon pump
11. Admit to HAU/ICU/CCU

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 Seizure

Differential Diagnosis
1. Epilepsy or other primary seizure disorder
2. Drugs:
o Withdrawal syndromes (e.g. alcohol)
o Drug overdoses
o Illicit drugs (cocaine)
o Local anesthetic toxicity
3. Infection:
o Meningitis
o Encephalitis
o Sepsis
4. Metabolic:
o Hypoglycemia
o Hypoxemia/hypercarbia
o Hyponatremia/hypocalcemia/hypomagnesemia
o Toxins (uremic, hepatic encephalopathy)
o Dialysis disequilibrium syndrome
o Porphyria
5. Structural:
o Ischemic or hemorrhagic stroke
o Intracranial tumor
o Cerebral edema
6. Pregnancy:
o Eclamptic seizure
o Amniotic fluid embolism

Management
1. Inform surgical team & call for help
2. Supplemental oxygen, monitors, establish IV access
3. If needed, hand ventilate with 100% O2 - DO NOT hyperventilate (↓
seizure threshold)
4. Focused cardiorespiratory & neurological exams
5. Rapid glucometer
6. Bloodwork: CBC, electrolytes, extended electrolytes, blood glucose,
liver enzymes, kidney function tests, ABG
7. Give anticonvulsants if seizure > 2min:
o Benzodiazepines = 1st line
 Midazolam 0.05mg/kg or 1mg at a time, titrate to effect
 Diazepam 0.1-0.4mg/kg IV, 0.04-0.2 mg/kg PR

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  Lorazepam 1-2 mg at a time, titrate to effect
o Propofol 0.5mg/kg at a time, titrate to effect
o Phenytoin 20mg/kg total loading dose at a rate of 50mg/min,
watch for hypotension & arrhythmias
o Barbiturates:
 Phenobarbital 20 mg/kg infused at a rate of 50
mg/minute
 Thiopental 25-100mg dose
 Pentobarbital 10 mg/kg infused at a rate of up to 100
mg/minute
 Valproic acid IV 30mg/kg over 15 min
8. Consult neurology for further diagnosis & management
9. If ↑ ICP: institute treatment (mannitol, furosemide, hypertonic saline,
mild hyperventilation, elevate HOB, etc)
10. If eclampsia: MgSO4 4g IV bolus over 15 min, then 1-2g/hr
11. If no resolution & respiratory compromise:
o Paralyze & intubate
o Succinylcholine IM (4mg/kg) for intubation if no IV access

31
 Postoperative Visual Loss

Differential Diagnosis
 Corneal abrasion
 Ischemic optic neuropathy (ION)
 Central/branch retinal artery occlusion (CRAO, BRAO)
 Cortical blindness secondary to visual field stroke
 Transient ischemic attack (TIA)
 Acute glaucoma
 Expansion of intraocular vitrectomy gas bubble (nitrous oxide)
 TURP glycine toxicity

Risk Factors
1. External eye compression from improper patient positioning
2. Retrobulbar hemorrhage due to vascular injuries following
sinus/nasal surgery
3. Retinal microemboli associated with open-heart surgery
4. Prone positioning
5. Lengthy spinal fusion surgery, ↓ arterial pressure, ↑ blood loss,
anemia, high volume crystalloid resuscitation
6. Cardiothoracic, instrumented spinal fusion surgeries, head & neck,
nose or sinus surgeries
7. Systemic vascular risk factors: hypertension, diabetes,
atherosclerosis, hyperlipidemia, smoking, obesity, obstructive sleep
apnea & hypercoagulability

Management
1. Immediate normalization of vital signs & metabolics
2. Urgent ophthalmology consultation +/- neurology consultation
3. CRAO:
o Ocular massage to dislodge clot
o Localized hypothermia to affected eye
o Acetazolamide (500mg IV)
o Inhaled CO2 (mixture of 95% oxygen & 5% carbon dioxide)
o Anterior chamber paracentesis
o Intraarterial fibrinolysis
4. ION:
o Elevate head of bed
o Correct volume depletion & blood loss
o Restore BP to normal range
o Potential benefit from acetazolamide, mannitol, furosemide

32
 o Steroids, hyperbaric oxygen controversial
5. Surgeon to bedside for multidisciplinary debriefing with patient
& family
6. Call CMPA for counselling around disclosure & documentation

33
 Total Spinal

Signs
1. Numbness or weakness in upper extremities
2. Nausea/vomiting
3. Dyspnea/respiratory depression
4. Loss of consciousness
5. Bradycardia
6. Hypotension
7. Dilated pupils

Management
1. Supportive care:
o Assess need for intubation and/or cardiopulmonary
resuscitation
o Maintain oxyvenation/ventilation & protect against aspiration
o Support hemodynamics:
 IV fluid bolus, atropine, epinephrine (10 - 100ug IV,
increase as needed)
o If pregnant: left uterine displacement & fetal heart rate
monitoring
o Consider sedation when hemodynamically stable
2. Change position based on baricity (careful with reverse
trendelenberg & hypotension → venous pooling)
3. Support until spinal wears off

34
 Transfusion Reactions

General Management
 Stop transfusion
 Support blood pressure with IV fluids, vasoactive medications if
needed
 Notify blood bank of all possible reactions
 Determine diagnosis

Acute hemolytic reaction

 Signs:
o Awake: chills, fever, nausea, chest & flank pain
o Anesthetized: hyperthermia, tachycardia, hypotension,
hemoglobinuria, diffuse oozing in surgical field
 Management:
o Stop transfusion & notify blood bank
o Support hemodynamics
o Recheck unit against blood slip & patient’s identity bracelet
o Draw bloodwork to identify hemoglobin in plasma, repeat
compatibility testing, obtain coagulation studies & platelet count
o Insert urinary catheter & check urine for hemoglobin
o Initiate osmotic diuresis with IV fluids +/- mannitol
o Monitor for hyperkalemia, DIC

Febrile nonhemolytic reaction

 Signs:
o Fever
o No evidence of hemolysis
 Management:
o Antipyretics
o Transfusion may be continued if reaction mild
o Use leukoreduced transfusions in the future

Anaphylaxis
 Signs:
o Rash/hives
o Angioedema
o Hypotension
o Tachycardia

35
 o Hypoxemia
o Bronchospasm/wheezing
o Increased peak inspiratory pressure
 Management:
o Stop transfusion
o Epinephrine
o IV fluids
o Antihistamines, corticosteroids
o See "Anaphylaxis" page for further details

Transfusion-associated circulatory overload (TACO)

 Signs:
o Respiratory distress, hypoxia
o ↑ BP
o Acute or worsening pulmonary edema
o Positive fluid balance
 Management:
o Stop transfusion
o Supplemental oxygen
o Diuretics

Transfusion-related acute lung injury (TRALI)

 Signs:
o Acute hypoxia & noncardiac pulmonary edema within 6 hours of
transfusion (usually plasma)
o ↓ BP
 Management:
o Supplemental oxygen, endotracheal intubation / ventilation
o Similar treatment to acute respiratory distress syndrome (ARDS)
o Hemodynamic support

Urticarial reaction
 Signs:
o Erythema, hives, itching
o No fever
 Management:
o Antihistamines, steroids
o Transfusion may be continued if reaction mild

36
Complications of Massive Transfusion
 Dilutional coagulopathy
 Hypothermia
 Hyperkalemia
 Complications of citrate infusion:
o Hypocalcemia
o Metabolic acidosis or alkalosis

37
 Venous Air Embolism

Signs
1. Air on TEE or change in doppler tone if monitoring
2. ↓ ETCO2
3. ↓ BP
4. ↓ SpO2
5. ↑ CVP
6. Bronchospasm
7. Dyspnea & respiratory distress or cough in awake patient
8. Mill wheel murmur on cardiac auscultation (late sign)

Management
1. Goals: prevent further entrainment of air, hemodynamic support, treat
existing air
2. Inform surgeon
3. Flood surgical field with saline & apply bone wax
4. Supportive therapy:
o 100% oxygen, decrease or turn off volatile anesthetic
o Stop nitrous oxide
o IV fluid bolus
o Vasopressors (epinephrine, norepinephrine, dobutamine)
5. Positioning:
o Place surgical site below heart (if able)
o Lower the head position & compress the jugular veins (if
surgical site above the neck)
o Reposition the patient into left lateral decubitus, trendelenberg,
or left lateral decubitus head down position (controversial - poor
evidence & often impractical to do in the OR)
6. Definitive therapy:
o Hyperbaric oxygen therapy (especially if paradoxical air
embolism)
o Aspirate air from the central catheter if in situ
o Chest compressions
7. PEEP is of no value & increases risk of paradoxical air embolism
8. Consider TEE to assess air & RV function

38
39
 Part 2
SYSTEMIC CONSIDERATIONS

40
 Contents

Topic Page No.

1 Airway 42
2 Cardiac 53
3 Critical Care 86
4 Endocrinology 103
5 Hematology 140
6 Hepatic 159
7 Neuroanesthesia 163
8 Neuromuscular 182
9 Obstetrics 198
10 Pediatrics 225
11 Psychiatry 259
12 Rare Coexisting Disease 266
13 Renal 278
14 Respiratory & Thoracic 284
15 Skin & Musculoskeletal 313
16 Toxicities 329
17 Vascular 346

41
Airway

42
 Contents

Topic Page No.

1 Airway Abscess & Infection 44
2 Airway Trauma 45
3 Expanding Neck Hematoma 46
4 Microlaryngoscopy & Airway Laser 47
5 Penetrating Neck Injuries 49
6 Rigid Bronchoscopy 50
7 Tracheostomy 51

43
 Airway Abscess & Infection

Considerations
1. Emergency with risk of aspiration & acute airway obstruction
2. Difficult intubation & BMV with potential for complete airway
obstruction (life threatening emergency):
o Difficult topicalization
o Trismus
o Distorted anatomy, tissue edema, immobile tissue
o Copious secretions
3. Potential for airway soilage from abscess rupture
4. Shared airway
5. Possible sepsis, pneumonia, mediastinitis & need for early goal
directed therapy
6. Risk factors & co-morbidities:
o Adults: HIV, IV drug use, diabetes, head & neck malignancies,
alcohol
o Immunosuppression
o Pediatrics: upper respiratory tract infections
7. Potential for postoperative re-obstruction post extubation &
disposition to ICU/high acuity unit

Goals
1. Consider pre-op abscess draining
2. Secure airway safely & effectively, always consider awake fiberoptic
intubation (AFOI), surgical airway, ‘double set-up’
3. Manage sepsis with early goal directed therapy
4. Prevent abscess rupture & lung soilage

Conflicts
1. Uncooperative pediatric patient vs. difficult airway
2. Full stomach & need for RSI vs. difficult airway
3. Full stomach & need for RSI plus need for deep plane of
anesthesia vs. risk of hemodynamic instability (sepsis)
4. AFOI does not visualize ETT passing abscess & therefore potential
to rupture it

44
 Airway Trauma

Considerations
1. Emergency, full stomach
2. Trauma with ATLS approach
3. Difficult intubation & bag mask ventilation with possibility of complete
obstruction
o Plan for surgical airway backup
4. Co-existing injuries: unstable C-spine, traumatic brain injury,
tracheobronchial disruption, vascular injury
5. Trauma considerations

Goals
1. Safe establishment of airway (spontaneous ventilation, get tube
beyond injury)
2. Minimize C-spine movement

Conflicts
 Full stomach vs difficult airway vs need for double lumen tube
 Uncooperative or pediatric patient vs difficult airway

Airway Plan
1. Determine location of trauma: supraglottic, laryngotracheal,
infracarinal
2. Bypass area of trauma during airway management
3. Supraglottic
o Most preferred technique is tracheostomy
o Awake vs. double setup after attempting direct
laryngoscopy/video laryngoscopy/fiberoptic bronchoscopy
4. Laryngotracheal
o Use awake, spontaneous ventilation technique under direct
vision (fiberoptic bronchoscopy)
5. Infracarinal
o Injury causing bronchopleural fistula with air leak, risk of
tension pneumothorax &/or difficult ventilation during positive
pressure ventilation
o Secure airway with lung isolation: double lumen tube, bronchial
blocker, single lumen tube placed endobronchially
o Maintain spontaneous ventilation or rapid sequence
induction while avoiding positive pressure ventilation until lung
isolation

45
 Expanding Neck Hematoma

Considerations
1. Emergency situation with little or no time to optimize
2. Anatomical airway distortion & edema resulting in a difficult airway:
o Systematic & multidisciplinary approach critical, double set-up
is key!
o Release of sutures & evacuation of hematoma may be life-
saving & may eliminate the need for a crash intubation
o Unless impossible, spontaneous ventilation should be
maintained & awake fiberoptic intubation attempted in the OR
o Direct laryngoscopy (awake or anesthesized) is an option
& should be part of the management algorithm
3. Potentially full stomach & risk of aspiration in cases of delayed
hematoma formation
4. Medical & surgical control of hematoma once patient stabilized:
o Likely need for return to OR for neck exploration
o Possible need to reverse coagulopathy, thrombocytopenia,
platelet dysfunction
5. Theoretical potential for hemodynamic instability due to compression
of carotid sinus with resulting bradycardia/hypotension
6. Simultaneous management of medical comorbidities:
o E.g. coronary artery disease in carotid
endartarectomy patients

Goals
1. Immediate assessment & decisive airway plan
2. Safe airway management preserving spontaneous ventilation, upper
airway tone & patient cooperation
3. Temporize as necessary to maintain airway patency
4. Always have surgical backups prepared
5. Conservative & cautious extubation strategy

Conflicts
1. Uncooperative, agitated patient requiring an awake technique
2. Emergency airway management required in an out of OR setting

46
 Microlaryngoscopy & Airway Laser

Considerations
1. Indication for surgery, location of airway lesion, presence of
obstruction
2. Potential for dynamic airway obstruction with induction, positive
pressure ventilation & paralysis:
o Double setup with rigid bronchoscope available
3. Shared airway with need to optimize surgical conditions/safety
4. Individualized ventilation technique (communicate with surgeon):
o Closed system: laser-safe ETT
o Open system:
 Low-frequency jet ventilation
 High-frequency jet ventilation
 Spontaneous ventilation (especially pediatrics)
o Total IV anesthetic (TIVA)
o Motionless surgical field
5. Complications:
o Airway obstruction, laryngospasm
o Laser: airway fire, burns, venous air embolism with YAG laser
(deeper), pneumothorax
o Jet ventilation: barotrauma, abnormal ventilation/oxygenation
o Unprotected airway & aspiration risk

Goals
1. Optimize surgical conditions: motionless field, no risk of combustion
2. Adequate oxygenation & ventilation, secure airway
3. Depth of anesthesia sufficient to suppress hemodynamic response
4. Clear, constant communication with surgery team
5. Good postoperative care: prone to laryngeal spasm & edema

Conflicts
 Contraindication to jet ventilation & need for airway laser
 Full stomach & laser surgery: laser ETT vs jet ventilation

Airway Management Options

1. Broadly classified into
o Closed system
o Open system
2. Closed system (intubation):

47
 1.General anesthesia with ETT (microlaryngoscopy tube or laser
tube)
3. Open system (no intubation, tubeless technique):
o Topical/local anesthesia with sedation
o General anesthesia without intubation
 Apnea & intermittent intubation/bag mask ventilation
 Tubeless spontaneous ventilation technique
 Jet ventilation with Sanders technique: supraglottic vs
subglottic, via catheter/rigid scope
 High-frequency jet ventilation
4. Considerations:
o ETT/microlaryngoscopy tube: ↑ risk of airway fire & obstructs
surgeon's visualization
o Jet ventilation avoids the risk of ETT complications (kinked,
obstructed, displaced, damaged, ignited)
 Risks/complications:
 Difficulty maintaining oxygenation/ventilation in morbid
obesity, stiff thorax, restrictive/obstructive pneumopathy,
lung fibrosis, reduced alveolar-capillary diffusion capacity
(pulmonary edema)
 Risk of dynamic hyperinflation if obstructed airway with
barotrauma (subcutaneous emphysema,
pneumothorax/pneumomediastinum, tracheobronchial
injury), hypoxemia, hypercarbia/hypocarbia, gastric
distension & regurgitation due to scope malalignment,
possible vocal cord motion if supraglottic, drying of
laryngeal mucosa, distal spread of particulate matter with
potential tracheobronchial viral or tumor seeding

Safety Precautions
 Locked doors, signs on doors
 N95 mask for everyone if risk of viral particles
 Eye protection for patient & personnel
 Fire safety equipment (laser tube with methylene blue & saline into
cuff/saline for extinguishing fire)
 Difficult airway equipment
 ENT surgeon present with rigid bronchoscopy

48
 Penetrating Neck Injuries

Considerations
1. Emergency case with little or no time to optimize
2. Trauma patient & need for ATLS approach
3. Potential for serious & life threatening injuries:
o Laryngeal/tracheobronchial tree disruption
o Tension/open pneumothorax, massive hemothorax
o Major vascular disruption
o Esophageal tear
o Spinal cord injury, nerve injury
4. Difficult airway management & possible need for awake fiberoptic
bronchoscopic intubation

Goals
 ATLS resuscitation & primary survey
 Identify associated injuries
 Key principles of airway management:
o Avoid PPV & neuromuscular blockade until airway secured
distal to injury
o No cricoid pressure
o Direct visualization probably the best method of airway
management & double set-up always the safest option

Conflicts
 Full stomach/RSI vs potentially challenging airway
 Uncooperative patient vs. awake fiberoptic bronchoscopic intubation
 Securing airway vs. consequences of PPV

49
 Rigid Bronchoscopy

Considerations
1. Indication for surgery, presence of central airway obstruction & major
comorbidities:
o Risk of complete airway obstruction with an inability to ventilate
o Risk of dynamic hyperinflation with hemodynamic collapse
o Typically urgent/emergent cases in physiologically distressed
patients
2. Shared & unprotected airway:
o Aspiration risk, potentially challenging ventilation, potential loss
of airway access
o Need for GA with TIVA, neuromuscular blockade +/- depth of
anesthesia monitoring & CO2 monitoring with invasive arterial
catheter
3. Considerations for surgical technique: stenting, laser, endobronchial
electrosurgery, argon plasma coagulation, & balloon bronchoplasty
4. Procedure specific complications: hemorrhage, airway trauma,
perforation, fire, systemic gas embolism, & dissemination of
postobstructive pneumonia

Goals
 Avoidance of complete airway obstruction during induction of
anesthesia
 Avoidance of dynamic hyperinflation & cardiovascular compromise

Conflicts
 Full stomach vs. unsecured airway
 High oxygen requirements with risk of fire ignition
 Jet ventilation through obstructing stenoses with risk of air trapping
& barotrauma

50
 Tracheostomy

Considerations
1. Shared airway
2. Possible difficult airway
3. Close communication with surgeon, backup plan discussed
4. Indication for tracheostomy & concomitant injuries (traumatic brain
injury, C-spine injury)
5. Potentially critically ill patient with limited reserve, multi-organ failure
6. Potential catastrophic complications:
o Loss of airway, hemorrhage, pneumothorax,
pneumomediastinum, subcutaneous emphysema, aspiration,
false passage/tracheal disruption
o Airway fire (low FiO2, limited cautery use)

Goals & Conflicts

 Optimize underlying disease state: assessment of stability for elective
tracheostomy (high FiO2 & ventilator support, high dose
inotropes/vasopressors, raised ICP, severe volume overload,
coagulopathy/DIC)
 Surgical plan discussed along with backups & additional equipment
 Reduce risk of aspiration: NPO status, gastric suction applied
 Motionless surgical field (paralysis)
 Low FiO2 (protect against airway fire) vs. high FiO2 requirements

Considerations for the patient with a tracheostomy

1. Difficult airway:
o Difficult BMV & supraglottic device ventilation (air leak)
o Dangerous placement of ETT (direct vision preferred)
2. Indications for tracheostomy:
o Pulmonary toilet
o Respiratory failure/chronic ventilation
o Threatened airway
o Aspiration risk
3. Comorbid disease:
o ICU patient with multi-organ failure, sepsis, lung injury, etc
o Neuromuscular disorders, chronic high spinal cord injury
4. Complications of long term tracheostomy:
o Tracheoinnominate fistula, suctioning injuries, trachea/stoma
site infection/bleeding, laryngomalacia, tracheomalacia,
tracheal rupture, tracheal stenosis
5. Ensure emergency tracheostomy equipment available:
51
6. Various sizes of cuffed/uncuffed tracheostomy tubes, suction
catheters, graspers, ambubag & ties

52
Cardiac

53
 Contents

Topic Page No.

1 Adult Congenital Heart Disease 55
2 Aortic Dissection 56
3 Aortic Regurgitation 58
4 Aortic Stenosis 59
5 Atrial Fibrillation 60
6 Atrial Septal Defect 61
7 Brugada Syndrome 62
8 Cardiac Contusion 63
9 Cardiac Tamponade 64
10 Cardiomyopathies 65
11 Coronary Artery Disease 67
12 Hypertrophic Obstructive Cardiomyopathy 68
13 Infective Endocarditis Prophylaxis 70
14 Mitral Regurgitation 71
15 Mitral Stenosis 73
16 Pacemakers & ICDs 75
17 Pulmonary Hypertension 77
18 QT Prolongation 80
19 Transplanted Heart 81
20 Tricuspid Regurgitation 83
21 Wolf-Parkinson-White Syndrome 84

54
 Adult Congenital Heart Disease (CHD)

Anesthetic Considerations
1. Long term consequences of CHD:
o Cardiac: pulmonary hypertension, heart failure, arrhythmias,
residual shunts, valvular lesions
o Non-cardiac: erythrocytosis, cholelithiasis/nephrolithiasis,
developmental abnormalities, seizure disorder, CVA, chronic lung
disease
2. Endocarditis prophylaxis
3. Management of medications, especially anticoagulants
4. Lesion-specific anesthetic goals & management
5. ↑ perioperative risk requiring multidisciplinary care

Goals & Conflicts

1. Preoperative assessment of cardiac & non-cardiac complications
2. Considerations of surgical stress & positioning
3. Lesion-specific hemodynamic goals with focus on PVR, SVR, preload,
contractility, HR
4. Need for invasive monitoring including arterial line & central
line placement
5. De-airing of lines

55
 Aortic Dissection
Considerations
1. Type & urgency:
o Stanford type A: Surgical management
o Stanford type B: Medical management or stent only if organ
damage or complicated aortic dissection
2. End organ damage & ischemia
o Stanford type A associated with aortic insufficiency,
tamponade, MI, CVA
o Acute renal failure
o Spinal cord ischemia
o Ischemic gut
o Limb ischemia
o Hemorrhagic shock
o Pleural effusions
o Retroperitoneal bleeding
3. Underlying cause of aortic dissection
o Trauma
o Hypertension, atherosclerosis
o Cocaine/amphetamine use
o Pregnancy
o Collagen vascular disease (e.g. Marfan's)

Anesthetic Management
1. Medical stabilization:
 IV access, CVC, arterial line (R arm AND L arm or femoral)
 Hemodynamic goals
o Preload: maintain adequate preload; aggressive fluid
therapy may worsen dissection
o Rate: heart rate <60bpm with beta blockade
o Rhythm: maintain normal sinus rhythm
o Contractility: reduce contractility with beta blockade to
reduce sheer stress on intima
o Afterload: reduce SBP to a target of 100-120 mmHg to
reduce sheer stress on intima
o Main goal is to ↓ cardiac contractility & BP to ↓ intimal
stress
 1st line therapy is beta blockade to achieve
hemodynamic goals
 Labetalol (bolus 20-80mg then infusion 0.5-
2mg/min)

56
  Esmolol (bolus 0.5-1 mg/kg then infusion 50-200
mcg/kg/min)
 Consider diltiazem (2.5-5mg IV q15min)
& verapamil (2.5-5mg IV q15min) in patients
intolerant of beta blockers
 Consider adding sodium nitroprusside (0.25-
0.5mcg/kg/min) to achieve sBP of 100-120mmHg
 Adequate pain control
2. Things to avoid:
 Inotropes
 Hydralazine, which can cause aortic wall sheer stress
 Vasodilation before beta blockade, which can cause reflex
sympathetic activation
 Pericardiocentesis in tamponade, which can cause
exsanguination

Pregnancy Considerations
1. Aggressive alpha & beta-blockade to ↓ dP/dT as above
2. Continuous fetal heart rate monitoring (marker of end organ
perfusion)
3. Type B:
 Medical management & expedite delivery
 Use short acting agents (esmolol, labetalol, phentolamine)
 Conflicts:
o Antihypertensives vs. bleeding risk/post partum
hemorrhage (eg. nitroglycerine & ↓ uterine tone)
o Avoid fetal toxic medications (sodium nitroprusside)
o Avoid ergotamine for post partum hemorrhage
4. Type A:
 If diagnosed <28 weeks = surgical repair, then allow pregnancy
to continue
 28-32 weeks = surgical repair, cesarean section if obstetrical
indications
 >32 weeks = simultaneous repair & cesarean section

57
 Aortic Regurgitation

Considerations
1. ↑ risk of perioperative cardiovascular decompensation
2. Hemodynamic sequelae of aortic regurgitation:
 Left atrial (LA) distension/volume overload & subendothelial
ischemia
 LA dilation & eccentric hypertrophy, potential for ischemia
& arrhythmias
 CHF & pulmonary edema
 RVF & pulmonary HTN
 Acute aortic regurgitation:
o Sudden increase in LV volume, cardiogenic shock
& pulmonary edema
o ↑ sympathetic drive
3. Comorbid disease:
o Aortic arch dilation (Marfan’s, dissection, infection, ankylosing
spondilitis)
o Valvulopathy (aortic stenosis, infective endocarditis, SLE)
o Ischemic heart disease
4. Management of medical therapy (diuretics, anticoagulants)

Hemodynamic goals
1. Key is to maintain forward flow & ↓ regurgitant volume
2. Preload: normal to high to augment cardiac output
3. Rate: high normal
4. Rhythm: sinus if possible, but rate is more important
5. Contractility: maintain or augment
6. Afterload: keep afterload low to promote forward flow

Management of severe acute aortic regurgitation

1. Sudden aortic incompetence does not allow time for compensatory
LV dilation & results in acute pulmonary congestion
2. Immediate management involves afterload reduction (nitroprusside)
& augmentation of contractility & rate (dobutamine)
3. Likely needs emergency aortic valve replacement/repair
4. Intra-aortic balloon pump is CONTRAINDICATED

58
 Aortic Stenosis

Anesthetic Considerations
1. Identify severity of disease & high risk markers (angina, syncope,
CHF)
2. ↑ risk of perioperative cardiovascular complications (MI, CHF,
arrhythmias)
3. Hemodynamic consequences:
o Fixed LVOT obstruction with limited ability to ↑ cardiac output
o Hypertrophied ventricle with diastolic dysfunction
o Altered myocardial oxygen supply/demand
o Systolic dysfunction late in disease
4. Associated complications:
o Coronary artery disease (CAD): 50% of patients with angina
have concomitant CAD
o Other valvular disease
o Pulmonary hypertension
o Sudden cardiac death/malignant arrhythmia
o Potentially ineffective CPR
o Anemia/bleeding risk:
 Acquired von Willebrand syndrome
 Mucosal/GI angiodysplasias
5. Always consider valvuloplasty/cardiology & cardiac surgery consult
prior to semi-urgent/elective procedures
6. Management of medications

Anesthetic Goals
 Preload: maintain adequate intravascular volume to fill non-compliant
ventricular chamber (sensitive to volume depletion)
 Rate: low normal (maximize diastolic filling & coronary perfusion)
 Rhythm: sinus (atrial kick contributes up to 40% of total cardiac
output)
 Contractility: maintain (prone to subendocardial ischemia (↑ muscle
mass, ↓ coronary perfusion pressure)
 Afterload: maintain (coronary perfusion pressure)

Severity Scale

59
 Atrial Fibrillation

Considerations
1. ↑ risk perioperative cardiac complications
2. Etiology:
o Structural/valvular heart disease
o Other secondary causes: Alcoholism, electrolyte imbalance,
hyperthyroidism, infection, etc
3. Complications of atrial fibrillation:
o CHF, tachycardia-induced cardiomyopathy
o Embolic events & stroke risk
4. Medication management:
o Rate control & rhythm control (beta blockers, calcium channel
blockers, digoxin, amiodarone)
o Anticoagulation: Bridge for those with CHADS2≥4 in
consultation with hematology

Optimization/Goals
1. ACLS approach, cardiovert if unstable
2. Elective cases:
o if HR < 110, no CHF: proceed with OR, may need ASA
depending on CHADS2
o If CHF or HR > 110: needs optimization in consultation with
cardiology, internal medicine, or patient's GP
3. Fix underlying electrolyte abnormalities
4. Rate control in sick patients:
o Amiodarone
o Digoxin in LV dysfunction: 0.25-0.5mg IV initial dose, follow
ECGs
5. Emergency cases: ↑ risk if HR > 110 or CHF
6. Consider cardiology consult/monitored bed
7. Octaplex or FFP or Vit K for emergent INR reversal

CHADS2 Scoring System

60
 Atrial Septal Defect (ASD)

Considerations
1. Etiology & severity of ASD: Size, shunt (L→R / R→L)
2. Complications of chronic L to R shunt:
o Arrhythmias (atrial fibrillation & supraventricular tachycardias)
o Pulmonary HTN, RV dysfunction, shunt reversal (R→L with
hypoxemia)
o Tricuspid valve & pulmonic valve disease
3. ↑ perioperative risk of:
o Arrhythmia, pulmonary hypertension crisis, RV
dysfunction/failure
o R→L shunt reversal: hypoxemia, pulmonary air embolism
o Paradoxical embolism (air, CO2, septic, thrombus)
4. Comorbid disease:
o Adult congenital heart disease, Down syndrome, etc
o Previous closures
5. Medications: anticoagulation, antiarrhythmics
6. Considerations for closure of ASD:
o Out of OR considerations
o Complications (tamponade, arrhythmias, valve disruption, &
emboli)

Goals
1. Hemodynamic goals:
o Preload: maintain adequate preload
o Rate: maintain normal rate
o Rhythm: maintain normal sinus rhythm
o Contractility: maintain adequate contractility
o Afterload: avoid extremes of systemic vascular resistance; ↑
SVR may precipitate pulmonary hypertension & RV
dysfunction, ↓ SVR may cause R→L shunting & hypoxemia
2. De-air lines (risk of pulmonary air embolism)

Pregnancy Considerations
1. Pregnancy is well-tolerated if pulmonary hypertension not present
2. Control of SVR critical to limiting bidirectional shunting
3. Labour: early titrated epidural preferred
4. For epidural, do NOT use loss of resistance to air (use saline)
5. C-section: give anesthetic by titrated epidural
61
 Brugada Syndrome

Background
Brugada syndrome is a rare autosomal dominant disease & is associated
with sudden cardiac death from ventricular fibrillation or tachycardia
(VT/VF), especially in Southeast Asian males

Anesthetic Considerations
1. Potential for hemodynamic collapse due to VT & VF
2. Avoid exacerbating factors of Brugada (ST Elevation):
 Parasympathetic nervous system stimulation (increase in vagal
tone)
 Medications
 Avoid BB, alpha agonists, neostigmine
 Avoid class Ia antiarrhythmic (procainamide)
 Electrolyte abnormalities: ↑↓K, ↑Ca
 Fever
3. Considerations of AICD if in situ (only known treatment)
4. Preparations for treating Brugada Exacerbations or cardiac arrest:
 All patients without AICD need defibrillator & pads in OR
 Atropine, Ephedrine, Isoproterenol
5. Resuscitation drugs should be available

Typical ECG findings

 Characteristic findings are RBBB & ST elevation in V1-V3

62
 Cardiac Contusion

Considerations
 Trauma patient & need for ATLS approach, other occult injuries
 Potential emergency with arrhythmias, cardiogenic shock

Complications
 Early: arrhythmias, myocardial rupture, valvular damage, thrombosis
 Late: ventricular aneurysm, dilated cardiomyopathy, pericarditis,
ventricular arrhythmias

Conflicts
 Hemodynamic instability vs. rapid sequence intubation in trauma
setting
 Hemodynamic instability vs. operative management of other
significant injuries

Optimization/Goals
 Determine extent of myocardial injury (troponin, ECG, echo)
 Admit to ICU for monitoring
 Use invasive monitoring as appropriate
 Manage cardiogenic shock: invasive monitoring, fluid resuscitation,
inotropes/pressors, intra-aortic balloon pump

63
 Cardiac Tamponade

Considerations
1. Emergency with potential for cardiovascular collapse on induction
2. Pathophysiologic changes:
o Impaired diastolic filling
o Fixed stroke volume
o Rate-dependent cardiac output
3. Hemodynamic goals:
o Full, fast, maintain contractility, maintain SVR
4. Etiologies/co-existing diseases:
o Blood: post-cardiac surgery, post-MI, aortic dissection, trauma
o Other: infectious, malignant, radiation, SLE, uremia,
autoimmune, pericarditis

Goals
 If hemodynamically significant, drain prior to general anesthesia &
positive pressure ventilation (PPV)
 Spontaneous respiration & avoidance of PPV, coughing, straining
 Cardiovascular goals: fast, full and tight
o Preload: full
o Contractility: maintain, avoid myocardial depressants
o Rate: maintain, possibly ↑
o Rhythm: strict NSR
o Systemic vascular resistance: maintain or ↑

64
 Cardiomyopathies

Considerations
1. ↑ risk of perioperative hemodynamic compromise:
 CHF, dysrhythmias, emboli, myocardial ischemia
2. Type, etiology & severity of cardiomyopathy:
 Dilated, restrictive, hypertrophic, peripartum
 Presence of CHF including EF, NYHA class
 Assess volume status & sympathetic activation
3. Hemodynamic goals specific to type of cardiomyopathy:
 Restrictive (diastolic failure):
 Goals: fast, full & tight (as per tamponade)
 Contractility: maintain
 Rate & rhythm: sinus (atrial kick important), avoid
bradycardia (SV relatively fixed)
 Afterload: maintain (coronary perfusion with
↑ LVEDP)
 Preload: maintain normovolemia (but avoid
↑ LVEDP)
 Dilated (systolic failure):
 Contractility: Maintain
 Rate & rhythm: NSR
 Afterload: maintain, may benefit from ↓
 Preload: normal HR, avoid ↑ afterload
 HOCM:
 Contractility: ↓
 Rate & rhythm: strict NSR, avoid tachycardia
 Afterload: maintain
 Preload: full
 AICD/pacemaker considerations if applicable
 Comorbid disease including possible systemic implications of
etiology (eg. infiltrative disease)
 Medication management: beta blockers, ACEI, anticoagulation,
diuretics

Etiologies
 Dilated cardiomyopathy:
o Idiopathic (50%)
o Ischemic (7%)
o Valvular

65
 o Viral
o Alcoholic
o Toxic (eg. cocaine, chemo, radiation)
o Familial
o Peripartum
o Other: SLE, ESRD, hyperthyroidism, Duchenne's
 Hypertrophic cardiomyopathy:
o HOCM
o Hypertensive cardiomyopathy
o Valve lesion (e.g. AS)
 Restrictive cardiomyopathy:
o Amyloidosis
o Hemochromatosis
o Sarcoidosis
o Scleroderma
o Radiation-induced
o Idiopathic

66
 Coronary Artery Disease

Considerations
1. ↑ risk of perioperative cardiovascular complications: MI, CHF,
arrhythmias, death
2. ↓ cardiovascular reserve & need to optimize myocardial oxygen
supply & demand
3. Comorbidities: HTN, stroke, renal dysfunction, peripheral vascular
disease, diabetes, smoking
4. Management of coronary stents
5. Associated medications: antihypertensives, anticoagulants, diuretics

Goals
 Optimize myocardial oxygen supply & demand
 Preload: keep the heart small to ↓ wall tension/LVEDP & ↑ coronary
perfusion pressure gradient
 Rate & rhythm: slow, normal sinus rhythm
 Contractility: maintain
 Afterload: maintain, coronary perfusion dependent on diastolic
pressure

Potential conflicts
 Full stomach vs need for titrated induction
 Need for surgery vs antiplatelets for coronary stents

Minimum antiplatelet therapy duration

 Balloon angioplasty: 2 weeks
 Bare metal stent: 1 month
 Drug eluting stent: 1 year (but could be less; guidelines are evolving)

67
Hypertrophic Obstructive Cardiomyopathy (HOCM)

Considerations
1. Dynamic LVOT obstruction (20-30% of patients) & need to avoid
precipitants
2. Perioperative hemodynamic complications:
 Arrhythmia
 Ischemia & diastolic dysfunction
 Secondary hypertrophy
 MR
 End stage: dilated cardiomyopathy
3. Medication management:
 Beta blockers & calcium channel blockers
 Antiarrhythmics
 Anticoagulants
 Diuretics
4. Pacemaker/ AICD

Goals
 Preload: maintain preload
 Rate & rhythm: slow-normal rate; maintain sinus rhythm
 Contractility: ↓ contractility
 Afterload: maintain or ↑ afterload

Pregnancy
 Usually tolerated well
 Continue beta blockers in pregnancy
 Goals:
o Maintenance of intravascular volume & venous return
o Avoidance of aortocaval compression
o Maintenance of adequate SVR
o Maintenance of a slow heart rate in sinus rhythm
o Aggressive treatment of acute atrial fibrillation & other
tachyarrhythmias
o Prevention of increases in myocardial contractility
 Anesthetic technique:
o Likely need extra monitoring: arterial line, 5 lead ECG, possible
CVC, tertiary/cardiac centre

68
 o Spinal relatively contraindicated because of the rapid onset of a
sympathectomy
o Epidural for elective cesarean section well tolerated
o GA also well tolerated
o They tolerate 2nd stage of labor well as ↑SVR helps HOCM,
could consider assisted 2nd stage if needed
o Postpartum hemorrhage: oxytocin OK if given slowly; ergot a
great agent

Atrial Fibrillation in HOCM Patient

 Acute in OR, best measure is cardioversion
 Beta blockers also very good choice (e.g. esmolol infusion)

69
 Infective Endocarditis (IE) Prophylaxis

Indications (AHA 2007)

1. Prosthetic valve
2. Previous IE
3. Congenital heart disease, specifically:
o Unrepaired cyanotic heart disease, including palliative shunts
& conduits
o Congenital heart disease repaired within the last 6 months
o Repaired but residual defects next to prosthetic material
4. Heart transplant recipients with valvulopathy

Eligible Operative Procedures

1. Dental procedures with mucosal penetration
2. Procedures involving respiratory tract incision (including bronchial
biopsy)
3. Procedures involving infected skin/musculoskeletal tissue

Antibiotic regimens
1. One dose 30-60 min prior to the procedure
2. Recommended agent is amoxicillin
o 2g PO for adults
o 50mg/kg PO for children
3. Keflex
o 2g PO for adults
o 50mg/kg PO for children
4. Ampicillin
o 2g IV for adults
o 50mg/kg IV for children
5. Cefazolin or ceftriaxone
o 1g IV for adults
o 50mg/kg IV for children
6. Clindamycin
o 600mg IV for adults
o 20mg/kg IV for children
7. Azithromycin or clarithromycin
o 500mg PO for adults
o 15mg/kg PO for children

70
 Mitral Regurgitation (MR)

Considerations
1. ↑ risk of perioperative cardiac complications (MI/CHF)
2. Hemodynamic alterations associated with MR:
o Left atrial volume overload & ↓ forward cardiac output (CO)
o Potential for LV dysfunction (from overload)
o Potential for arrhythmias (atrial fibrillation commonly) due to LA
dilatation
o Potential for pulmonary hypertension leading to RV dysfunction
3. Acute MR: sudden LA & LV overload without compensatory
hypertrophy leading to decreased forward CO & simultaneous
pulmonary congestion
4. Comorbid disease:
o Coronary artery disease
o Atrial fibrillation
o Other valvular lesions (MS, AI)
o Connective tissue diseases (SLE, RA, Marfan’s)
o Endocarditis
5. Management of medical therapy:
o ACE inhibitors, beta-blockers, digoxin, calcium channel
blockers

Goals
1. Maintain forward flow & ↓ regurgitant fraction:
o Preload: maintain preload but avoid overload (↑ risk for CHF)
o Rate: high-normal rate (80-100bpm) & avoid bradycardia
(longer diastole = more regurgitation)
o Rhythm: sinus rhythm preferred but not as critical as stenotic
lesions
o Contractility: maintain or enhance contractility to improve
forward flow & reduce regurgitant fraction by constricting mitral
valve annulus
o Afterload: reduce afterload to enhance forward flow
2. Avoid ↑ in pulmonary vascular resistance to mitigate right heart
failure (avoid hypoxia, hypercarbia, acidosis, pain)

71
Pregnancy Considerations
1. Goals:
o Prevent an ↑ in SVR
o Maintain a normal to slightly elevated heart rate
o Maintain sinus rhythm
o Aggressively treat acute atrial fibrillation
o Avoid aortocaval compression
o Maintain venous return
o Prevent an ↑ in central vascular volume
o Avoid myocardial depression during general anesthesia
o Prevent pain, hypoxemia, hypercarbia, & acidosis (may ↑ PVR)
2. Monitoring:
o Invasive monitoring rarely required unless severe mitral
regurgitation
3. Anesthetic options:
o Epidural preferred for vaginal delivery or cesarean section
o If GA used, give attention to the maintenance of adequate
heart rate & ↓ afterload
o Acute atrial fibrillation must be treated promptly & aggressively;
hemodynamic instability warrants the immediate performance
of cardioversion

72
 Mitral Stenosis (MS)

Considerations
1. Perioperative cardiovascular decompensation:
o Severity of valvular lesion
o High risk (especially with pregnancy)
2. Hemodynamic sequelae of MS (limited ability to ↑ cardiac output)
o Atrial dilation & arrhythmias
o Pulmonary edema & CHF
o Pulmonary hypertension & RV failure
o Thrombotic events
3. Associated conditions:
o Associated valvular pathologies
o Rheumatic heart disease
o Connective tissue disease (SLE, RA)
o Obstructive (carcinoid, atrial myxoma)
4. Medications:
o Anticoagulation (often need bridging with heparin)
o Diuretics
o Antiarrhythmics

Goals
1. Preload: maintain (avoid overload)
2. Rate: low-normal (most important goal)
3. Rhythm: sinus (avoid atrial fibrillation because of ↑ HR)
4. Contractility: maintain
5. Afterload: maintain
6. Avoid precipitants of pulmonary hypertension

Severity Grading

Pregnancy Considerations
 Goals:
o Maintain a slow heart rate
o Maintain sinus rhythm

73
 o Aggressively treat acute atrial fibrillation
o Avoid aortocaval compression
o Maintain venous return
o Maintain adequate systemic vascular resistance
o Prevent pain, hypoxemia, hypercarbia, and acidosis (may
↑ pulmonary vascular resistance)
 Risk:
o Mild to moderate MS without severe pulmonary HTN is
considered low maternal or fetal risk
o Mitral stenosis with NYHA class II-IV symptoms is considered
high maternal risk
 Anesthetic options:
o Vaginal delivery
 Symptomatic patients will require invasive monitoring
 Adequate analgesia for first stage (epidural)
 Second stage should be assisted by low forceps/vacuum
o Cesarean section
 Epidural is the preferred method
 If GA required need to keep goals

74
 Pacemakers & ICDs

Considerations
 Indications for the device:
o Pacemaker: SA node disease, AV block, CRTD, MI, HOCM,
dilated cardiomyopathy
o AICD: VT, VF, cardiomyopathy with EF<35%
 Determine dependency & history of use
 Strategies to minimize risk & prepare for potential PM/AICD
interference & failure:
o Strategies to minimize EMI (electromagnetic interference):
 Bipolar cautery
 Short bursts of cautery (<5sec), distance, “cut” better than
“coag” or “blend"
 Have magnet available
o Device interrogation pre & post op:
 Reprogram to asynchronous (pacemaker) or disable anti-
tachycardia therapy (ICD)
o Alternate pacing/defibrillation strategies:
 Sympathomimetics (epinephrine, dopamine, isoproterenol)
 Transvenous/transcutaneous pacing
 External defibrillator device
 Co-existing Disease:
o Associated CAD, cardiomyopathy with low EF
o Hypertension, renal failure, diabetes
o Perioperative medication management

Goals
 Optimization of underlying cardiac status
 Knowledge of device settings & response to magnet
 Anticipate & prevent failure or interference with appropriate backups
 Avoid inappropriate inhibition (asystole) or triggering of device
(shocks) by EMI
 Prevent damage to device

Causes of Intra-operative Pacemaker Failure

 Generator failure (e.g. battery, malfunction)
 Lead failure (e.g. dislodgement)
 Failure to capture

75
  Acid-base imbalance
 Electrolyte abnormality
 Ischemia/infarction
 Antiarrhytmics (overdose or withdrawal)

Pacemaker Insertion Complications

1. Pneumothorax
2. Arterial puncture
3. Arrhythmia
4. Venous air embolism
5. Cardiac perforation/tamponade

76
 Pulmonary Hypertension

Considerations
 Potential for acute perioperative right ventricular (RV) dysfunction
& hemodynamic collapse
 Optimize pulmonary pressures & right heart function:
o Avoid hypoxia, hypercarbia, acidosis, hypothermia,
sympathetic stimulation (pain), high PEEP
o Cautious fluid administration
o Maintain RV perfusion
 Associated conditions (see table below)
 Medication management:
o Anticoagulation
o Calcium channel blockers
o Vasodilators (e.g. sildenafil)
o Prostacyclin analogs (e.g. epoprostenol/flolan)
o Endothelin antagonists (e.g. bosantan)
o Diuretics
 Need for invasive monitoring, optimized analgesia & post-op
disposition
 Potential or R → L shunt through PFO: hypoxemia & paradoxical
emboli

Goals
 Make all attempts to optimize pulmonary vascular resistance
(PVR) before surgery
 Avoid ↑ in PVR (minimize pain, sympathetic stimulation, hypoxia,
hypercarbia, acidosis, optimize airway pressures)
 RV failure management principles:
o Optimize RV rate & rhythm: sinus & normal-high rate
o Optimize RV filing
o Maintain RV perfusion & inotropy
o ↓ PVR

Conflicts
 Pulmonary hypertension & laparoscopy:
o ↑ PaCO2, sympathetic stimulation = bad
o Case is longer than open
 Ortho cases with cement, joint replacement (embolic risk)
 Hemodynamic stability vs need for RSI

77
Pregnancy Considerations
 Hemodynamic goals:
o Prevent ↑ PVR
o Maintain intravascular volume & venous return
o Avoid aortocaval compression
o Maintain adequate systemic vascular resistance
o Avoidance of myocardial depression during general
anesthesia
 Mode of delivery:
o Controversial
o Multidisciplinary meeting required
o Termination of pregnancy definitely an option as maternal
mortality is high
o Scheduled cesarean section in a controlled setting might be the
optimal route
 Monitoring:
o High acuity environment preferably in a center with cardiac
surgery expertise
o Standard CAS monitors + 5 lead ECG
o Arterial line & central line essential
o PAC a consideration but must weigh risk vs. benefits
 Anesthetic technique:
o A carefully titrated epidural likely the best option
o Avoid ↓ SVR & treat hypotension with fluids/pressors
o Single shot spinal should be avoided as it can cause severe
hemodynamic instability
o Continuous spinal has been used successfully (slow & careful
titration)
o General anesthesia has been used successfully
o Potential hazards of GA include ↑ PA pressure during
laryngoscopy/intubation, adverse effects of PPV on venous
return, & negative inotropic effects of certain anesthetic agents
o May consider a gentle narcotic-based induction/maintenance,
any fetal narcotic effects should be easily reversible
o Avoid ergotamine & carboprost; use oxytocin & misoprostol

Managing Acute Episodes/Acute RV Failure = 4 Principles

1. RV Rate & Rhythm: keep sinus & high-normal rate
2. RV perfusion & inotropy: maintain with vasopressor/inotrope combo
(e.g. norepinephrine & milrinone or epinephrine alone)
3. RV filling: optimize with CVP, PAC, TEE
4. ↓ PA pressures:

78
 o Avoid hypercarbia, hypoxemia, acidosis, hypothermia, high
airway pressures
o Use pulmonary vasodilators:
 Nitric oxide: 20-40ppm
 Inhaled flolan
 Milrinone: 0.25-0.75 mcg/kg/min; possible loading dose is
50mcg/kg over 10 min

WHO Pulmonary Hypertension Classification

79
 QT Prolongation
Considerations
 Potential for hemodynamic collapse secondary to rapid polymorphic VT
& VF
 Avoid triggers of Torsades de Pointes: sympathetic stimulation,
medications, electrolyte disturbances (↓K, ↓Mg, ↓Ca)
 Congenital long QT: may have pacemaker/AICD, perioperative β-
blockade; avoid sympathomimetics

Goals
 Avoid triggers of Torsades:
o SNS stimulation (pain, nausea, emotional stress, loud noise)
o Bradycardia, tachycardia, hypertension, hypoxemia, hypercapnia
o Electrolyte disturbances: ↓K, ↓Mg, ↓Ca
o QT prolonging medications: antiemetics, antipsychotics,
amiodarone, methadone
o Congenital long QT: avoid beta-agonists, ketamine
 Continue beta blockade for congenital long QT; ensure optimal AICD
function if applicable
 Preparations for treating Torsades: defibrillator & pads in OR, MgSO4,
resuscitation drugs

Various Definitions for Prolonged QTc

 QTc > 470 ms (males) to > 480 ms (females) (Anesthesiolgy, 2005)
 >460 ms (Stoelting Co-existing 6th Ed)
 >460 regardless of age (Cote 4th Ed)
 >470 ms (males) & >480 ms (females) (AHA/ACC Consensus
statement 2011)

Treatment of Torsades
 Defibrillation & CPR as per ACLS
 Magnesium 2g IV over 2 min (30 mg/kg), q15min x 3; pediatrics 25-
50mg/kg bolus
 Overdrive pacing to 90-110 with transvenous pacemaker
 Isoproterenol to ↑ HR 90-100
 ↑ K to 4.5
 Stop QT prolonging medications: antipsychotics,
antiemetics antibiotics, antifungals, antidysrhythmics,
antidepressants, antihistamines, antineoplastics

80
 Transplanted Heart

Considerations
1. Altered physiology of the denervated heart:
 Preload dependent
 High resting heart rate & loss of vagal tone
 Delayed sympathetic response to circulating catecholamines
 Dysrhythmias & conduction abnormalities → permanent
pacemaker in 5%
2. Altered pharmacology of the transplanted heart:
 Ineffective indirect-acting agents (e.g. ephedrine, atropine)
 Intact response to direct-acting vasoactive drugs (e.g.
epinephrine, isoproterenol)
3. Allograft function:
 Rejection
 Arrythmias
 Coronary vasculopathy (accelerated CAD): silent ischemia
secondary to denervation
4. Co-morbidities:
 Hypertension (90%)
 Diabetes
 Renal dysfunction
 Malignancy
5. Steroid therapy: will require stress dose
6. Immunosuppressive therapy:
 ↑ risk of infection & need for strict sterile technique
 Adverse effects: anemia, thrombocytopenia, hepatotoxicity,
nephrotoxicity

Goals
 Hemodynamic goals:
o Preload: maintain normal or high (CO increases by increasing
stroke volume)
o Rhythm: avoid pro-arrhythmic states
o Afterload: maintain perfusion to potentially ischemic myocardium
 Use direct-acting sympathomimetics (isoproterenol & epinephrine must
be available)
 Avoid infection: strict sterile technique & minimize catheters/invasive
devices
 Thorough review of functional capacity, investigations (echo, biopsies
for graft dysfunction)

81
 Strongly consider consultation with transplant clinic & cardiology pre-
operatively
 If valvulopathy: needs infective endocarditis prophylaxis

Pregnancy Considerations
 Same goals as above apply
 Epidural is very good technique
 Ensure adequate intravascular volume
 Extra attention to aseptic techniques

82
 Tricuspid Regurgitation (TR)

Considerations
1. ↑ risk of perioperative cardiovascular complications
2. Hemodynamic consequences:
 Mild-moderate usually well tolerated with little consequence
 Severe TR may result in RV pressure/volume overload ➝ RV
dysfunction, hepatomegaly, ascites, peripheral edema,
cardiorenal syndrome
3. Medication management
4. Management of any comorbid diseases (e.g. pulmonary
hypertension, endocarditis, carcinoid, rheumatic heart disease)

Anesthetic Goals
 Preload: normal to ↑, critical to avoid hypovolemia
 Rate: normal to high to sustain forward flow
 Rhythm: sinus
 Contractility: RV may need inotropic support if RV failure
 Afterload: maintain
 PVR: avoid any ↑ (avoid high airway pressures, hypercarbia,
hypoxemia, hypothermia, acidosis)

83
 Wolff-Parkinson-White Syndrome

Anesthetic Considerations
1. Potential for perioperative SVT or atrial fibrillation:
 Consider crash cart, defbrillator pads, invasive arterial access,
emergency drugs (procainamide, amiodarone)
 Avoid AV nodal blockers if atrial fibrillation
2. Avoid sympathetic stimulation: pain, anxiety, hypovolemia, ketamine

Goals
o Identify patients with WPW
o Minimize sympathetic stimulation & drugs (adenosine, beta blockers,
calcium channel blockers, digoxin) that could enhance anterograde
conduction of cardiac impulses through the accessory pathways
o Reduce anxiety which may precipitate tachycardia

Arrhythmia Treatments
 Acute termination of orthodromic AVRT (approach is same as the
usual patient with SVT):
o 1st line: vagal maneouvers, verapamil (5mg IV q3min up to 15mg),
adenosine (6-12mg IV bolus with flush)
o 2nd line: procainamide, beta blockers, digoxin, amiodarone
(prolongs the refractoriness of all cardiac tissues)
 Acute termination of antidromic AVRT:
o If unstable, must cardiovert
o Avoid AV nodal blocking agents
o If stable: IV drug of choice for acute treatment to terminate known
antidromic AVRT is procainamide.
 Procainamide is typically infused intravenously at 20 to
50 mg/minute given while monitoring the blood pressure
closely every 5 to 10 minutes until the arrhythmia terminates,
hypotension ensues, the QRS is prolonged by more than 50
percent, or a total of 17 mg/kg (1.2 g for a 70 kg patient) has
been given
 Acute termination of atrial fibrillation with pre-excitation:
o AV nodal blocking drugs (adenosine, verapamil, beta blockers,
& digoxin) should be avoided in patients with preexcited atrial
fibrillation since blocking the AV node will promote conduction down

84
 the accessory pathway & may sometimes directly enhance the rate
of conduction over the accessory pathway
o The goals of acute drug therapy for preexcited AF are prompt
control of the ventricular response & ideally, termination of atrial
fibrillation
o If unstable, must cardiovert
o If stable, careful trial of IV drugs (no clear 1st line drug):
 Procainamide (Class IA): 20-50mg/min until arrhythmia suppressed,
hypotension ensues, QRS prolonged by 50% of original duration or
total fo 17mg/kg has been given
 Amiodarone (Class III): first dose 150mg over 10min, then 1mg/min for
6hrs, then 0.5mg/min for 18hrs
 Ibutilide (Class III): if patient <60kg, 0.01mg/kg over 10min; if >60kg,
1mg over 10min

ECG Features
 Short PR, wide QRS, delta wave

85
Critical Care

86
 Contents

# Topic Page No.

1 Abdominal Compartment Syndrome 88
2 ARDS 90
3 Burns 92
4 Crush Injuries 94
5 Drowning 95
6 Organ Donation 97
7 Sepsis 99
8 Smoke Inhalation 101
9 Trauma 102

87
 Abdominal Compartment Syndrome (ACS)

Background
1. Definition: sustained intraabdominal pressure >20 mmHg that is
associated with new organ dysfunction
2. Patients with an intraabdominal pressure <10 mmHg generally do not
have ACS, while patients with an intraabdominal pressure >25
mmHg usually have ACS
3. Higher systemic blood pressure will be needed to perfuse abdominal
organs, keep abdominal perfusion pressure (APP) (systemic blood
pressure - intraabdominal pressure) >60mmHg
4. Etiology:
o Primary: due to injury or disease in the abdominopelvic region
(e.g., pancreatitis, abdominal trauma)
 Intervention (surgical or radiologic) of the primary
condition is often needed
o Secondary: does not originate in the abdomen or pelvis (e.g.,
fluid resuscitation, sepsis, burns)

Considerations
1. Critically ill patient with high mortality & morbidity
2. Multisystemic dysfunction:
o Airway: ↑ risk of aspiration
o CVS: ↓ cardiac output (CO) from ↓ preload & ↑ SVR
o Resp: Hypoxia secondary to restrictive ventilation
o Renal: Potential for AKI
o GI: Hepatic dysfunction (altered pharmokinetics)
3. Need to maintain APP > 60 mmHg
4. Consequences of decompression:
o Sudden ↓ in cardiac output & SVR
o Reperfusion: risk of systemic acidosis & hyperkalemia
o Possible fatal arrhythmia & arrest
o Sudden change in respiratory compliance (avoid
overventilation)

Goals/Conflicts
1. Early identification of ACS
2. Maintain APP >60mmHg

88
3. Avoid bradycardia (preload is compromised & CO may be heart
rate dependent)
4. Maintain high preload particularly once decompressed
5. Be prepared for sudden arrhythmias associated with hyperkalemia &
acidosis after decompression occurs

89
 Acute Respiratory Distress Syndrome (ARDS)

Considerations
1. Profound hypoxemic respiratory failure
2. Complications related to etiology of ARDS:
o Sepsis/SIRS
o Infection/aspiration
o Trauma
o Transfusions
o Multi-organ system failure
3. Lung protective ventilation strategies:
o Tidal volume: 6 mL/kg IBW (ideal body weight)
o PEEP & FiO2 to avoid hypoxemia: goal PaO2 ~60 mmHg
o Plateau pressure: goal < 30 cmH2O
o Permissive hypercapnea
4. Therapies for refractory hypoxemia:
o Optimize PEEP: esophageal pressure, PV curves, lung
ultrasound
o Consider paralysis
o Advanced treatments: prone position, inhaled nitric oxide, high
frequency oscillatory ventilation (HFOV), ECMO

Goals
1. Maintain oxygenation & end-organ perfusion
2. Avoid further lung injury by using lung protective ventilation strategy

Berlin Definition of ARDS (JAMA 2012): All criteria must be

present
1. Respiratory symptoms must have begun within one week of a known
clinical insult, or the patient must have new or worsening symptoms
during the past week.
2. Bilateral opacities consistent with pulmonary edema present on a
chest x-ray or CT scan. Opacities must not be fully explained by
pleural effusions, lobar collapse, lung collapse, or pulmonary
nodules.
3. The patient’s respiratory failure must not be fully explained by cardiac
failure or fluid overload. An objective assessment (e.g.,
echocardiography) to exclude hydrostatic pulmonary edema is
required if no risk factors for ARDS are present.

90
4. A moderate to severe impairment of oxygenation must be present, as
defined by the ratio of arterial oxygen tension to fraction of inspired
oxygen (PaO2/FiO2)
5. With ventilation & PEEP ≥5 cmH2O, the severity is defined as:
 Mild ARDS: PaO2/FiO2 is 200 - 300 mmHg
 Moderate ARDS: PaO2/FiO2 is 100 - 200 mmHg
 Severe ARDS: PaO2/FiO2 is ≤100 mmHg

91
 Burns

Considerations
1. Trauma patient, ATLS approach
2. Difficult/threatened airway: edema, secretions, bleeding
3. Potential inhalational injury & carbon monoxide/cyanide poisoning
4. Hypovolemia & need for goal-directed volume resuscitation (e.g.,
Parkland, see below)
5. Multisystem dysfunction:
 Acute:
 Hypovolemic/cardiogenic shock/low cardiac output state
→ septic shock/high cardiac output state
 Pulmonary edema/aspiration/restrictive lung
 Hyperkalemia/myoglobinuria/AKI
 DIC, anemia of burns
 Impaired thermal regulation
 Difficult monitoring/IV access (ECG patches, BP cuffs,
etc)
 Delayed:
 Sepsis
 DVT/PE
 Stress ulcers, adynamic ileus, hypermetabolic/catabolic
state
6. Pharmacologic changes: succinylcholine contraindication (>24 hours
to 1year)/NDMR resistance (>60 days)
7. Complications of resuscitation:
 Abdominal compartment syndrome
 Fluid creep (pulmonary edema, venous congestion, graft
dysfunction)
8. Frequent ORs (debridement/grafting):
 Blood loss
 Pain, opioid tolerance
 Possible remote location

Goals
1. ATLS approach
2. Secure definitive airway (facial/neck/inhalational or major burn)
3. Assess burn severity/extent
4. Volume resuscitation (formula driven, goal directed)
5. Measure CO levels with co-oximetry

92
 6. Prevent end-organ dysfunction (lung protective strategy if ARDS,
urine output >1ml/kg/hr)
7. Adequate analgesia (multimodal approach +/- antidepressants)

Parkland Formula
1. 4cc X %BSA X weight (kg)
o E.g. 70kg patient with 20% burn
 4cc X 20 X 70 = 5600cc
2. Total fluid for 24 hrs: 1/2 in first 8 hrs, 1/2 in next 16 hrs
3. Clinical end points:
o Urine output >0.5cc/kg/hr
o Follow HR/BP, goal MAP >60
o Follow lactate/mixed venous

93
 Crush Injuries

Considerations

1. Critically ill/trauma patient/ATLS

2. Co-existing traumatic injuries
3. Complications of rhabdomyolysis:
o Hyperkalemia, hyperphosphatemia, hypocalcemia, anion-gap
metabolic acidosis
o Myoglobinuria & renal failure
o DIC (rare, can happen with severe rhabdomyolysis)

Goals
1. ATLS resuscitation
2. Treat underlying condition
3. Prevention of hyperkalemia:
o No succinylcholine
o No potassium-containing fluids
o Monitor K closely
4. Prevention of acute tubular necrosis (ATN):
o Start with 2L bolus NS then, isotonic fluid at ~500 cc/hr for 24
hours titrated to urine output of 200-300 cc/hr
o Alkaline therapy: 3 amps of HCO3- in 1L D5W at 2x
maintainence titrated to urine pH > 6.5 (generally, a total of
200-300 mEq of bicarbonate is given on the first day)
 Must monitor:
 Serum bicarbonate/pH: do NOT allow serum pH >7.5
 Calcium: severe hypocalcemia is a side-effect
 Potassium
 Urine pH
o Mannitol 5 g/hr infusion for a total of 1-2g/kg per day maximum
o Loop diuretics if volume overload

94
 Drowning

Considerations
1. Trauma/ATLS approach:
o Possible C-spine injury
o Hemorrhage/occult injuries
o Co-ingestions
2. Hypothermia:
o Coagulopathy
o Arrhythmias
o Hypovolemia
o Rewarming technique
o Electrolyte abnormalities
3. Multi-organ system dysfunction:
o ARDS
o Hypoxic brain injury
o Electrolyte abnormalities (↑K+), cell lysis 2nd to fresh water
drowning
o Shock
o ARF
4. Etiology of drowning:
o Adults: arrhythmia (long QT syndrome), seizure, trauma,
MI, intoxication
o Children: abuse, unsupervision

Goals/Conflicts
1. Primary Resuscitation to ensure adequate oxygen exchange and
perfusion pressure
2. Prevent secondary injury: C-spine precautions
3. Aggressive rewarming
4. 100% mortality = Submersion > 25 min, Resuscitation > 25 min,
Pulseless on arrival to ED, Unconscious at scene and on arrival to
ED

Treatment
1. Treat hypoxia: restore oxygenation and ventilation
o Rescue breaths
o Endotracheal intubation
o 100% oxygen until ROSC then FiO2 to keep SpO2 > 92%

95
2. Treat cardiac arrest: may be PEA, systole, VT/VF
o Follow ACLS guidelines
o Modifications for hypothermia: active rewarming until 34ºC then
passive
o Consider 24 hours of therapeutic hypothermia (32-34ºC)
3. Cervical spine injury extremely rare (0.009%): do not place C-spine
collar unless mechanism for C-spine injury is suggested

96
 Organ Retrieval

Terminology
1. DBD: Donation after Brain Death:
o At least 2 physicians NOT involved in organ procurement must
declare brain death in accordance with the American Academy
of Neurology guidelines; the anesthesiologist is NOT involved
in this process
2. DCD: Donation after Cardiac Death:
o A DCD donor does not meet the strict criteria for brain death
but has suffered a severe non-recoverable brain insult & the
family has decided to withdraw life support
o Upon withdrawal of life support, the DCD donor’s death is
declared based on cardiopulmonary criteria
o After death is declared, 5 minutes must pass before organ
procurement begins

Considerations for DBD

1. Confirm the diagnosis of brain death & confirm wishes of patient &
family:
o Declared by 2 physicians not involved with transplant
o Minimum clinical criteria for brain death met (see guidelines)
2. Physiologic consequences of brain death:
o Hemodynamic instability (myocardial dysfunction, vasomotor
tone, hypovolemia)
o Pulmonary dysfunction with ARDS & hypoxemia (neurogenic
pulmonary edema, VAP, CHF, etc)
o Neuroendocrine dysfunction
o Diabetes insipidus (70%), hypernatremia, hypokalemia
o Hypothyroid
o Hypocortisolemia
o Hyperglycemia
o Coagulopathy/DIC (brain release of thromboplastin)
o Poikilothermia secondary to hypothalamic dysfunction
3. Etiology of brain death & secondary injuries
4. Trauma (potential for multi-organ involvement, pulmonary/cardiac
contusions)

97
Goals for DBD
1. Cardiac:
o Ensure adequate intravascular volume
o Use vasopressors to maintain adequate organ perfusion
 Vasopressin as 1st line agent as it treats BP & diabetes
insipidus (dose = 0.01-0.04 IU/min)
 Norepinehrine & dopamine also reasonable agents
 Avoid high doses of vasopressors
o Hemodynamic goals are SBP >100 mmHg, MAP >70 mmHg,
HR 60-120
2. Respiratory:
o Lung protective ventilatory strategy: TV 6-8cc/kg, PEEP 8-10,
avoid fluid overload, FiO2 <40% for lung retrieval
3. Endocrine:
o Thyroid replacement: tetraiodothyronine 20 mcg IV bolus, then
10mcg/hr infusion
o Vasopressin 1 U IV bolues, then 0.01-0.04 U/hr infusion
o Methylprednisolone 15mg/kg IV q24h
o Keep serum glucose <8 mMol/L
4. MSK: paralytics should be given during procurement to optimize
surgical conditions & stop somatic response to surgical stimulus
mediated by spinal cord reflexes
5. Hematologic:
o Keep Hgb ~100
o Platelets & FFP if clinical bleeding, do NOT simply correct
abnormal coagulation tests

98
 Sepsis

Considerations
1. Critically ill patient, high mortality
2. Emergency surgery, possible full stomach
3. Distributive shock with severe hypovolemia:
o Early goal-directed therapy & early
antibiotics/source control required
o Potential for cardiovascular collapse on induction
o Need for invasive monitoring
o Need for critical care monitoring/ICU postop
4. Multi-organ failure:
o ARDS
o AKI
o DIC

Goals
1. Follow Surviving Sepsis Guidelines:
2. Broad spectrum antibiotics within 1 hour
3. Goal directed resuscitation within 6 hours:
o MAP ≥ 65
 Fluid therapy:
 Use crystalloids as first line, avoid synthetic
colloids, consider albumin if substantial amounts of
crystalloids used
 Initial fluid bolus = 30cc/kg, use dynamic or static
variables to guide further fluid therapy
 Vasopressors/inotropes:
 Norepinehprine = 1st line
 Epinephrine can be added as second vasopressor
 Vasopressin NOT recommened alone, may be
added as second or third agent
 Dopamine not routinely recommended
 Phenylephrine can be useful if excessive arrythmia
from other vasopressor, very high cardiac output
states, or as an adjunct vasopressor
 Dobutamine as first line inotropic agent in settings
of reduced cardiac output/low mixed
venous/myocardial dysfunction
o Urine output > 0.5 mL/kg/hr
o Lactate < 2 mmol/L, clearance of lactate

99
 4. Lung protective ventilation (Tidal volumes ~6cc/kg, plateau pressure
<30cm H20, PEEP)
5. Corticosteriods:
o NOT indicated if fluids/vasopressors have restored
hemodynamics
o Consider IV hydrocortisone 200mg daily if refractory shock
6. Hemoglobin: in absence of myocardial ischemia/ischemic heart
disease, goal Hgb ≥70

*Note that routine monitoring of central venous pressure (CVP) or central venous
oxygen saturation (ScvO2) are no longer recommended

100
 Inhalational Injury

Considerations
1. Emergency/full stomach
2. Airway swelling & potential for airway obstruction
3. Tracheobronchial thermal & chemical injury resulting in pulmonary
complications:
o Alveolar collapse/atelectasis & airway plugging
o Bronchospasm
o Pneumonia
o ALI/ARDS
4. Carbon monoxide & cyanide poisoning
5. General burn considerations:
o Hypovolemic shock
o Hypo or hyperthermia
o Rhabdomyolysis
o Cardiac depression
o DIC, consumptive coagulopathy

Management
1. Secure airway early if compromised
2. Bronchoscopy to document degree of tracheobronchial injury
3. Use lung protective ventilation strategies:
o Tidal volume ≤ 6cc/kg
o Plateau pressure < 30cm H2O
o PEEP & FiO2 to achieve adequate oxygenation (PaO2 ≥55 to
80 mmHg)
4. Start burn resuscitation
5. Rule out & treat carbon monoxide & cyanide poisoning
6. ICU admission & monitoring

101
 Trauma
Considerations
1. Emergency/full stomach
2. Difficult airway due to C-spine injury/immobility
3. ATLS approach to resuscitation
4. Multiple obvious & occult injuries
5. Need for ongoing assessment & resuscitation
6. Hypovolemia, hypothermia, coagulopathy, acidosis
7. Potential toxic ingestions, uncooperative patient
8. Immediately life-threatening injuries:
o Airway obstruction
o Tension pneumothorax
o Open pneumothorax
o Cardiac tamponade
o Massive hemothorax
o Flail chest
9. Delayed/hidden injuries:
o Thoracic aortic disruption
o Tracheobronchial disruption
o Myocardial contusion
o Traumatic diaphragmatic tear
o Esophageal disruption
o Pulmonary contusion

Pregnancy Considerations
1. ↑ risk of aspiration, difficult airway
2. Altered pattern of injury: preterm labour, abruption, uterine rupture,
amniotic fluid embolism, alloimunization
3. Delayed decompensated shock secondary to physiologic changes:
hypervolemic hemodilution
4. Altered ACLS:
o IV above diaphragm
o Chest compressions higher
o Left uterine displacement
o Stat cesarean section at 4 minutes post cardiac arrest
5. 2 patients requiring:
o Fetal monitoring
o Obstetrics/pediatrics consults
o Steroids for fetal lung maturity if <34 weeks GA
o MgSO4 for fetal brain protection
6. Considerations RE: imaging (CT, X-ray)

102
Endocrinology

103
 Contents

# Topic Page No.

1 Acromegaly 105
2 Adrenocortical Insufficiency 106
3 Alcoholism 107
4 Anorexia Nervosa 109
5 Carcinoid 110
6 Cushing’s Syndrome 112
7 Diabetes Insipidus 113
8 Diabetes Mellitus 114
9 Obesity 116
10 Diabetic Ketoacidosis 118
11 Hyperaldosteronism 120
12 Hyperkalemia 121
13 Hyponatremia 123
14 Hyperparathyroidism 125
15 Hyperthyroidism / Thyroid Storm 127
16 Hypothyroidism 129
17 Perioperative Steroids 131
18 Pheochromocytoma 132
19 Porphyria 135
20 SIADH 138

104
 Acromegaly
Considerations
1. Difficult airway:
o Macroglossia & enlarged epiglottis, resulting in difficult bag-mask
ventilation & direct laryngoscopy
o Recurrent laryngeal nerve palsy, narrow glottic opening,
subglottic narrowing (stridor)
o Nasal turbinate enlargement; caution with nasal intubation &
consider smaller ETT
2. Multisystem disease:
o Cardiovascular:
 Hypertension, left ventricular hypertrophy, diastolic
dysfunction
 Arrhythmias
 Coronary artery disease, cardiomyopathy
o Respiratory:
 Obstructive sleep apnea
 Pulmonary hypertension, right ventricular dysfunction
o CNS:
 Pituitary dysfunction
 Potential for raised ICP
 Peripheral neuropathies common
o Endocrine:
 Diabetes mellitus/hyperglycemia
3. Difficult patient positioning, access, monitoring, regional anesthesia
o Radial arterial line contraindicated due to poor collateral
circulation
Goals
 Safely secure difficult airway: consider awake fiberoptic intubation
with stridor & voice changes
 Thorough cardiopulmonary examination, including volume status
assessment

Conflicts
 Avoidance of CPAP following trans-sphenoidal surgery
 Post-operative pain vs. enhanced sedation/respiratory depression

Crises
 Post-operative stridor (subglottic edema, vocal cord paralysis)
 Endocrine emergencies
o Diabetes insipidus, SIADH

105
 Adrenocortical Insufficiency (Addisonian crisis)

Background
1. Primary Addisonian crisis commonly due to autoimmune destruction
of adrenal gland; mineralocorticoid activity also lost
2. Secondary Addisonian crisis caused by ↓ ACTH production either
from hypothalamic pituitary disease or from adrenal suppression from
chronic steroids, mineralocorticoid activity usually preserved

Considerations
1. Potential life-threatening situation: shock, dehydration, hypotension
2. Physiologic abnormalities:
o Cardiovascular:
 Impaired myocardial contractility
 Arrhythmias secondary to hyperkalemia
o Volume status: dehydration can occur (2-3 L)
o Electrolyte imbalance
 Hyperkalemia
 Hyponatremia (↓ level of consciousness, seizures)
 Hypoglycemia (↓ level of consciousness, seizures)
3. Stress dosing of steroids pre-operatively:
o Hydrocortisone 100mg IV q6-8h
o Fludrocortisone if 1° adrenal insufficiency
4. Pharmacologic concerns:
o ↓ circulating catecholamines (consider vasopressin for
hypotension)
o Succinylcholine-induced hyperkalemia

Goals
1. Prevent perioperative cardiovascular collapse:
o Steroid supplementation
o Volume resuscitation
o Correction of electrolyte abnormalities

Medications
1. Hydrocortisone 100mg IV q6-8h for 24h then taper to maintenance of
15-20mg PO qAM & 5-10mg PO qPM
2. Add maintenance fludrocortisone 0.05-0.2mg PO daily if aldosterone-
deficient (1° adrenal insufficiency) when tapering hydrocortisone

106
 Alcoholism

Considerations
1. Multisystem disease:
o CNS: peripheral neuropathy, Wernicke-Korsakoff syndrome
(ocular, ataxia, confusion), cerebral atrophy/dementia
o Cardiovascular: cardiomyopathy, palpitations, arrhythmias
o GI: liver dysfunction/cirrhosis, esophagitis, gastritis,
pancreatitis, malnutrition
o Heme: pancytopenia
o Endocrine/metabolic: hypoglycemia,
hypoalbuminemia, electrolyte abnormalities (hypokalemia,
hypomagnesemia)
o MSK: myopathies, osteoporosis
o Other addictions
2. Altered pharmacology:
o Induction of liver enzymes
o ↑ MAC
3. Alcohol withdrawal syndromes & need for CIWA protocol (tremors,
autonomic hyperactivity, DTs)

Alcohol Withdrawal & Syndromes

1. Earliest & most common:
o Generalized tremors that may be accompanied by perceptual
disturbances (nightmares, hallucinations), autonomic nervous
system hyperactivity (tachycardia, hypertension, cardiac
dysrhythmias), nausea, vomiting, insomnia, & mild confusional
states with agitation
o Symptoms usually begin within 6 to 8 hours after a substantial
↓ in blood alcohol concentration & are typically most
pronounced at 24 to 36 hours
o These withdrawal symptoms can be suppressed by the
resumption of alcohol ingestion or by administration of
benzodiazepines
2. Delirium tremens:
o Occurs in ~5% of those experiencing withdrawal
o Symptoms begin 2-4 days after alcohol cessation
o Manifests as hallucinations, combativeness, hyperthermia,
tachycardia, hypertension or hypotension, & grand mal
seizures
o Treatment:

107
  First line = benzodiazepines (titrated to effect without
loss of respiration)
 Beta blockers to reduce tachycardia & hypertension
 Fix metabolic abnormalities (potassium, magnesium, &
thiamine)
 Severe cases will need ICU admission & propofol
infusion/dexmedetomidine & possible intubation
 Mortality = 10% (usually due to hypotension,
dysrhythmias, or seizures)
3. Wernicke-Korsakoff syndrome:
o Wernicke's encephalopathy:
 Loss of neurons in the cerebellum
 Acute syndrome requiring emergent treatment to prevent
death & neurologic morbidity
o Korsakoff's psychosis:
 Chronic neurologic condition
 Loss of memory resulting from the lack of thiamine
(vitamin B1), which is required for the intermediary
metabolism of carbohydrates

108
 Anorexia Nervosa

Considerations
1. ↓ gastric empyting & aspiration risk
2. Metabolic & electrolyte abnormalities:
o ↓Na, ↓K, ↓Mg, ↓PO4
o Hypoglycemia
o Osteoporosis
o Metabolic alkalosis from vomiting
3. Cardiovascular dysfunction:
o Hypovolemia
o Cardiomyopathy (LV failure)
o Mitral valve prolapse
o Arrhythmias: ↑QTc, bradycardia
o Autonomic dysfunction
4. Malnutrition:
o Anemia
o Thrombocytopenia
o Osteoporosis, fracture risk
o Risk of re-feeding syndrome
5. Coexisting psychiatric disease:
o Possibly uncooperative
o Medications

Goals/Optimization
1. Minimize aspiration risk: fasted, aspiration prophylaxis
2. Rule out cardiomyopathy & underlying arrhythmias
3. Assess functional capacity/ECG/echocardiogram
4. Fix underlying electrolyte abnormalities
5. Very careful with glucose management (risk of refeeding syndrome
& electrolyte shifts with replacement)
6. Avoid hypothermia
7. Careful positioning with osteoporosis
8. Multidisciplinary management including consultation with internal
medicine, endocrinology, psychiatry

109
 Carcinoid

Background
1. Carcinoid syndrome presents in approximately 20% of patients with
carcinoid tumours, usually with hepatic metastases
2. "Carcinoid triad":
o Carcinoid heart
o Diarrhea
o Flushing
3. Implicated malignancies: neuroendocrine tumors in GI tract (midgut),
bronchial tumors

Considerations
1. Tumor: mass effect, metabolic derangements, medications, &
metastases:
o Mass effect: hemoptysis, bowel obstruction
o Metabolic derangements: flushing, diarrhea, hemodynamic
instability, bronchospasm (serotonin-related)
o Medications: octreotide
o Metastases: liver dysfunction, raised ICP if brain metastases
2. Cardiovascular dysfunction (20-40%):
o Right-sided valvular lesions (10% present with left-sided
lesions)
o Right ventricular dysfunction
o Dysrhythmias (eg. SVT)
o Constrictive pericarditis
3. Preparation & treatment of perioperative carcinoid crisis:
o Symptoms include flushing, diarrhea, hypotension,
hyperglycemia, bronchospasm
o Carcinoid tumors can also secrete GH (acromegaly) & ACTH
(Cushing's)

Goals
1. Prevent, recognize & treat perioperative carcinoid crises
2. Triggers include:
o Histamine-releasing drugs, vasoactive drugs, succinylcholine
o Tumour manipulation
o Hypovolemia, hypoxia, hypothermia, hypercarbia
3. Treatment of perioperative bronchospasm:
o Avoid beta agonists, theophylline, epinephrine

110
 o Responds to:
 Octreotide
 Steroids
 Histamine blockade (diphenhydramine)
 Atrovent
4. Prevention & treatment of carcinoid crisis:
o Must prophylax with octreotide 300-500mcg IV
o During crisis: octreotide 100mcg IV boluses titrated to effect, or
an infusion
o H1 antagonists (diphenhydramine 25-50 mg IV)
o Refractory hypotension:
 Give fluids
 USE: octreotide, phenylephrine, vasopressin
 AVOID: epinephrine, norepinephrine, ephedrine

Conflicts
1. RSI (bowel obstruction) vs. titrated induction
2. RSI vs. need to avoid succinylcholine
3. Need for deep anesthesia vs. cardiovascular dysfunction
4. Bronchospasm vs. need to avoid adrenergic agents

111
 Cushing's syndrome

Considerations
1. Possible difficult airway: obesity, obstructive sleep apnea (OSA)
2. Cardiovascular:
o Left ventricular hypertrophy, pulmonary hypertension/right
ventricular failure, systolic & diastolic dysfunction
o Hypertension, volume overload (↑ renin & glucocorticoid
vascular reactivity)
3. Respiratory: possible OSA
4. Metabolic:
o Hypokalemic metabolic alkalosis: mineralcorticoid effect of
glucocorticoids
o Diabetes: insulin deficiency
o Osteoporosis: need for careful positioning
5. CNS: possible psychosis
6. Pharmacologic considerations:
o Perioperative steroid replacement (stress dose & post-
operative replacement)
o Sensitivity to neuromuscular blockers (due to possible muscle
weakness, hypokalemia, catecholamines)
7. Cancer considerations (mass effect, metabolic derangements,
metastases, medications) if primary Cushing's (adrenal adenoma)

112
 Diabetes Insipidus (DI)
Background
1. Central DI:
o ↓ secretion ADH
o Most often idiopathic or induced by trauma, pituitary surgery, or
hypoxic or ischemic encephalopathy
2. Nephrogenic DI:
o Normal ADH secretion but kidneys are resistant to its water-
retaining effect
3. Diagnosis:
o Dilute urine (<150 mOsm/L)
o Hypernatremia (Na>150)
o Hyper-osmolality (>290)

Considerations
1. Hypernatremia:
o Altered level of consciousness, seizures, coma, hyperreflexia
o Risk of intracranial hemorrhage with acute, severe
hypernatremia
o ↑ MAC requirements
2. Volume depletion:
o Resuscitate with normal saline initially
3. Associated conditions:
o Neurogenic (pituitary surgery, traumatic brain injury, tumor,
idiopathic)
o Nephrogenic (chronic renal failure, lithium toxicity,
hypercalcemia, hypokalemia, congenital, fluoride toxicity)
Treatment
1. Consultation with nephrology may be valuable
2. Treat hypernatremia by estimating water deficit & replacing with free
water:
o Water deficit = total body water x (Serum Na [ ]/140-1)
3. Central DI: desmopressin 1-2 mcg IV BID
4. Nephrogenic DI: hydrochlorothiazide/amiloride
5. Complications of treatment:
o Avoid rapid overcorrection if chronic hypernatremia (goal = <10
mEq/day)
o Cerebral edema, water intoxication, volume overload
Potential conflicts
 Emergency surgery vs. need for optimization of electrolytes/volume
status

113
 Diabetes Mellitus

Considerations
1. Potential difficult airway (↓TMJ mobility, obesity)
2. Aspiration risk with gastroparesis
3. End organ disease:
o Hypertension, coronary artery disease, left ventricular
hypertrophy & cardiomyopathy
o Peripheral vascular disease
o Chronic kidney disease
o Neuropathy
4. Autonomic instability
5. Chronic pain
6. Perioperative complications & management of blood glucose
& medications:
o Related to severity of disease & control of blood
glucose (hypoglycemia)
o DKA or HONK
o Hypoglycemia
o Related to end organ disease

Goals
1. Evaluate severity of end organ dysfunction
2. Perioperative management of elevated blood glucose: Canadian
Diabetes Association guidelines suggests 5-10 mmol/L
o If only on PO hypoglycemics at home: start IV insulin infusion
at 1-2 units/hr
o If on insulin at home, divide 24 hr dose by 24 & give 1/2 to 2/3
that per hour as an IV insulin infusion
o Consider bolusing a few units up front
3. Preoperatively (see SAMBA guidelines below):
o Type II diabetes, diet controlled: fast, check blood glucose
o Type II diabetes, on oral hypoglycemics: fast, hold pills morning
of surgery, check blood glucose
o Type II diabetes, on insulin: fast, insulin dose depends on type
(see below), start D5W infusion

Crises
1. Hyperglycemia (DKA, HONK)
2. Hypoglycemia

114
Special populations

 Pregnancy:
o ↑ risk of DKA, HONK, pregnancy-induced hypertension, difficult
airway, aspiration, pre-term labor, cesarean
section, polyhydramnios, postoperative infection
o For fetus:
 Macrosomia (birth trauma, shoulder dystocia, cesarean
section, postpartum hemorrhage)
 Glucose regulation (hypoglycemia)
 Congenital malformations (cardiovascular, CNS, GI)
 Respiratory distress syndrome

Insulin Management Guidelines (SAMBA Guidelines)

115
 Obesity

Definitions (WHO, NIH)

 Overweight: BMI ≥25.0 to 29.9
 Obesity: BMI ≥30
 Obesity class I: BMI of 30.0 to 34.9
 Obesity class II: BMI of 35.0 to 39.9
 Obesity class III (severe obesity, massive obesity): BMI ≥40

Considerations
1. Potentially difficult airway
2. Physiologic changes of obesity:
o ↓ FRC → fast desaturation
o ↑ cardiac demand & output with limited reserve
o ↑ gastric volume & abdominal pressure → ↑ aspiration risk
o ↑ postoperative morbidity & mortality (respiratory failure, wound
infections, thromboembolism risk)
3. Co-morbid diseases:
o Airway: OSA
o Respiratory: obesity hypoventilation syndrome (OHS),
pickwickian syndrome, pulmonary hypertension, restrictive lung
disease
o Cardiac: hypertension, coronary artery disease, left ventricular
hypertrophy, biventricular failure
o Endocrine: diabetes
o GI: reflux, non-alcoholic fatty liver disease
o Altered pharmacology:
 Implications for loading vs. steady state infusions (IBW
vs TBW)
 Sensitivity to sedatives & opioids
 ↓ neuraxial dose may be needed
4. Potential technical difficulties:
o Vascular access
o Monitoring (NIBP)
o Regional

Anesthetic Goals
1. Safe airway management; avoid hypoxemia & aspiration
2. Evaluate physiologic impact of obesity on patient
3. Establish whether regional technique is feasible

116
 4. Minimize perioperative complications:
o Minimize postoperative airway obstruction/hypoventilation
(ensure no residual anesthetic, extubate & nurse semi-
recumbent, continuous oxygen saturation monitoring
postoperatively & effective postoperative analgesia)
o Avoid thrombotic complications
o Avoid peripheral nerve injury

Potential Conflicts
1. Difficult airway vs. aspiration risk (RSI)
2. OSA vs. opioid requirements postoperatively & difficulty with regional
procedures

117
 Diabetic Ketoacidosis

Diagnosis
1. Glucose > 14
2. HCO3 < 18
3. pH < 7.3
4. + ketones in urine/blood

Considerations
1. Life threatening anion gap metabolic acidosis (ketoacidosis)
o CNS: ↓ LOC (hypovolemia, cerebral edema)
o Cardiovascular: cardiac arrythmias, congestive heart failure
o Hyperventilation (very high minute ventilation, caution
with intubation & positive pressure ventilation)
2. Hypovolemia:
o Osmotic diuresis (hyperglycemia)
o Crystalloid volume replacement
3. Electrolyte abnormalities:
o Depletion of potassium, phosphorus, magnesium
o Hyponatremia (factitious hyponatremia)
4. Consequences of therapy:
o Electrolyte abnormalities
o Hypo/hyperkalemia, hypomagnesemia, hypophosphatemia
o Hypoglycemia
o Cerebral edema, central pontine myelinolysis
5. Address underlying cause:
o Infection, trauma, intoxication (cocaine), pancreatitis, acute
coronary syndrome
o Medication noncompliance (insulin)

Conflicts
 Resuscitation vs. emergency surgery
 Severe metabolic acidosis vs. intubation/ventilation
 Hypovolemia vs. aspiration risk (RSI)

Crises
1. Electrolyte abnormalities (hyper/hypokalemia, hypomagnesemia,
hyponatremia)

118
 2. Hypoglycemia
3. Cerebral edema (glucose correction without correcting hyponatremia)
4. Central pontine myelinolysis (rapid serum sodium correction)

Management
1. Treat as per hospital protocol in consultation with endocrinology
2. For example, see BC Children's Hospital's DKA protocol:

Goals
1. Normal anion gap (AG)
2. pH > 7.2
3. Potassium > 3.5
4. Bicarbonate > 20
5. Glucose < 13
6. Urine output 1 ml/kg/hr
7. Volume replacement:
o Normal saline to correct hypovolemia (3-5L deficit)
o Then slow to maintenance (up to 500ml/hr)
o Change to D5NS when glucose < 14
o Add potassium to IV fluids once < 4.5 & urinating
8. Insulin R
o Start infusion at 0.14 u/kg/hr (10units/hr in 70kg male) OR give
0.1 u/kg bolus followed by infusion 0.1 u/kg/hr
o DO NOT start insulin if potassium <3.3
o Glucose goal 10-15 mmol/L
o When glucose <11: add D5W to solution
9. Potassium management
o If < 3.3: DO NOT start insulin, give 20-30 meq/hr of
potassium until K > 3.3
o If > 3.3 & < 5.3: give potassium 20meq/L of fluid
o If > 5.3: Do NOT give potassium
 Frequent monitoring: ABG, electrolytes (AG), BUN, creatinine,
osmolality, plasma & urinary ketones, magnesium, phosphate, lactate
 Consider sodium bicarbonate if pH < 7 & myocardial dysfunction or
vasodilation or life-threatening hyperkalemia

Complications
 Cerebral edema
 Pulmonary edema

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 Hyperaldosteronism

Considerations
1. Hypertension & end-organ dysfunction:
 Cardiomyopathy
 Cerebrovascular disease
 Chronic kidney disease
2. Fluid & electrolyte abnormalities:
o Hypokalemia (weakness, potentiates non-depolarizing muscle
relaxants)
o Metabolic alkalosis
o Volume depletion
o Hypomagnesemia
3. Associated endocrine disorders:
o Acromegaly
o Pheochromocytoma
o Primary hyperparathyroidism
o Medications such as spironolactone
4. Adrenalectomy:
o Bilateral? Need steroids
o Laparascopic vs. open (pain & disposition)

Optimization
1. Antihypertensive therapy
2. Correction of electrolyte abnormalities

120
 Hyperkalemia

Considerations
1. Emergency situation with potential for life threatening
arrhythmias, cardiac arrest
2. Etiology:
o Shift:
 Metabolic or respiratory acidosis, diabetic ketoacidosis
 Digoxin toxicity
o Total body excess:
 Rhabdomyolysis (malignant hyperthermia, crush injuries,
burns)
 Post cardiopulmonary bypass
 Iatrogenic (IV or oral)
 Hemolysis
 Tumor lysis
 Transfusion (massive transfusion, old packed red blood
cells)
 Renal failure
 Hypoaldosteronism
 Addison's
o Drugs (succinylcholine, ACE inhibitors, beta blockers,
spironolactone, NSAIDs, cyclosporin)
3. Systemic effects
o Arrhythmias
o Muscle weakness
4. Drug interactions
o Succinylcholine contraindicated
o Non-depolarizer muscle relaxants: resistance

Management
1. Stabilize myocardium:
o Calcium gluconate 100 mg/kg
2. Shift potassium intracellularly:
o Insulin 0.1 units/kg + Glucose 0.5-1 g/kg (25 g for every 10 U
insulin)
o Sodium bicarbonate 1 mEq/kg
o Ventolin 5-10 mg via nebulizer or 5 mcg/kg IV
o Hyperventilation
o Epinephrine
3. Eliminate potassium:

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 o Furosemide 20-40mg IV
o Kayexalate 30 g PR or PO
o Dialysis

ECG changes
1. Mild (5.5-6.5 mEq/L): peaked T waves, prolonged PR interval (1st
degree AV block)
2. Moderate (6.5-8 mEq/L): loss of P wave, prolonged QRS, ST
segment elevation, ectopic beats/escape rhythms
3. Severe (>8.0 mEq/L): progressive widening of QRS, bundle branch
blocks, fascicular blocks, sine wave, ventricular fibrillation, asystole

122
 Hyponatremia

Considerations
1. Acute vs. chronic hyponatremia
2. Central pontine myelinolysis from rapid overcorrection
3. Physiologic manifestations (severe = neurologic symptoms or < 120
mEq/L):
o CNS: ↓ LOC, seizures, cerebral edema, central pontine
myelinolysis
o Hyper- or hypovolemia
o Respiratory arrest
o ↓ MAC
4. Etiology:
o Hypervolemia:
 Congestive heart failure
 Hypoalbuminemia (cirrhosis, nephrotic syndrome)
 Renal failure
 TURP syndrome
o Euvolemia:
 SIADH (stress, pain, post neurosurgery)
 Psychogenic
o Hypovolemia:
 Cerebral salt wasting
 Hemorrhage
 Addison's disease
 Peritonitis
 Edema from burns
 Diarrhea
 Diuretics

Management
1. Correct severe hyponatremia before surgery
2. Restore volume deficit
o Normal saline 20mL/kg IV bolus prn
3. Restore plasma sodium concentration
o Acute:
 Generally restrict free water (500mL-1L/day) +/- diuretic
 Severe hyponatremia (< 120mEq/L or presence of
neurologic symptoms)
 Hypertonic saline 3% 1-2 ml/kg/hr until Na>125
 Loop diuretics

123
  Sodium bicarbonate (1 mEq/ml) to terminate
seizures: 0.5-1mL/kg boluses prn
o Chronic: avoid rapid overcorrection (0.5-1 mEq/hr, < 8 in mEq
in 24hrs)
4. SIADH: treat underlying cause & fluid restriction
5. Identify & treat mineralocorticoid deficiency

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 Hyperparathyroidism

Background
1. Primary hyperparathyroidism: parathyroid adenoma or carcinoma
2. Secondary hyperparathyroidism: an appropriate compensatory
response of the parathyroid glands to counteract a disease process
that produces hypocalcemia
3. Ectopic hyperparathyroidism: due to secretion of parathyroid
hormone (or a substance with similar endocrine effects) by tissues
other than the parathyroid glands

Considerations
1. Potential difficult airway:
o Mass effect (goitre)
o Osteopenic bone (pathologic fractures of mandible & vertebral
bodies)
2. Physiologic changes of hypercalcemia:
o CNS: ↓LOC, hallucinations, psychosis
o Cardiovascular: hypertension, hypovolemia, conduction
blockade
 Hypercalcemia ECG: ↑PR interval, ↓QTc
o Respiratory: potential respiratory muscle weakness, poor
clearance of secretions
o Renal: renal failure, nephrolithiasis (70%)
o GI: ↑ aspiration risk, nausea/vomiting, abdominal pain,
pancreatitis
o MSK: weakness (titrate neuromuscular blockers to effect),
pathologic fractures (careful positioning)
o Hematologic: anemia
3. Underlying etiology:
o Parathyroid tumour, PTH-producing tumour
o Chronic renal failure (usually associated with hypocalcemia,
hyperphosphatemia)
4. Considerations of cancer & associated syndromes (MEN 1):
o MEN 1: hyperparathyroid, pancreatic islet cell tumors, pituitary
hyperplasia or tumor
o MEN 2A: hyperparathyroid, medullary thyroid carcinoma,
pheochromocytoma
5. Post-op airway obstruction after parathyroidectomy:
o Hematoma, laryngospasm, hypocalcemia, recurrent laryngeal
nerve injury, tracheomalacia
o Mandibular fracture

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Optimization
1. Management of hypercalcemia:
o IV rehydration
o Furosemide after IV hydration → goal is 3-5 L urine output/day
 If severe, add:
 Bisphosphonate (etidronate 7.5mg/kg IV OD or
20mg/kg PO OD)
 Calcitonin 200 IU nasal spray/day
 IV steroids
 Phosphate repletion
o Hemodialysis if life threatening hypercalcemia or acute renal
failure
2. Monitor EKG & calcium concentrations perioperatively
3. Prevent pathological fractures (careful positioning)
4. Airway vigilance postoperatively

Conflicts
1. Hypovolemia vs. RSI (ESWL or percutaneous drainage for
nephrolithiasis)
2. Renal failure vs. succinylcholine for RSI

126
 Hyperthyroidism / Thyroid storm

Considerations
1. Potential difficult airway if goitre present (airway compression,
anterior mediastinal mass)
2. End organ effects of chronic hyperthyroidism:
o Hypermetabolic state (↑ VO2, VCO2)
o Cardiovascular: hypertension, tachycardia, myocardial
ischemia, cardiomyopathy, arrhythmias
o CNS: anxiety, psychiatric disorders
o Muscle weakness
3. Risk of thyroid storm
4. Interactions with anesthetics:
o ↑ anesthetic requirements
o Avoid sympathetic stimulants (ketamine, cocaine, epinephrine,
etc)
5. Thyroidectomy:
o Shared airway
o Airway obstruction (tracheomalacia, recurrent laryngeal
nerve injury, neck hematoma, hypocalcemia)

Optimization
1. Optimize thyroid function & limit end organ effects: heart rate <90,
normal TSH
2. Identify difficult airway or anterior mediastinal mass
3. Identify & manage thyroid storm

Conflicts
1. Difficult airway/hemodynamic instability & sympathetic stimulants
(cocaine, epinephrine, glycopyrrolate)
2. Hemodynamic instability & RSI

Thyroid storm
1. Emergency situation (mortality= 20%), consider endocrinology
consult
2. IV fluids
3. Cool (blankets, IV solution, acetaminophen)
4. Control hemodynamics:

127
 o Esmolol 0.25-0.5 mg/kg bolus or 50-200 mcg/kg/min infusion
o Propranolol 10-40 mg PO or up to 1 mg/min IV
5. Stop conversion of T4 to T3:
o PTU 200-400 mg PO/NG/PR q6h
o Hydrocortisone 100-200 mg IV q8h
6. Stop synthesis & release of new hormone:
o Potassium iodide 5 gtts PO/NG q6h or sodium iodide 0.25 g IV
q6h (1 hr after PTU)
7. Look for & treat complications:
o CVA, loss of consciousness
o Myocardial infarction, atrial fibrillation (avoid amiodarone
because of iodide content; use digoxin instead) or congestive
heart failure
o Hypoventilation & hypercarbia
o Electrolyte abnormalities
8. Consider differential diagnosis for hypermetabolic state
9. Consider last ditch treatments: plasmapheresis, dantrolene, lithium,
neuraxial blockade to T4

128
 Hypothyroidism

Considerations
1. Possible difficult airway:
o Enlarged goiter: anatomical deviation/obstruction
o Anterior mediastinal mass
o Recurrent laryngeal nerve involvement
o Prior neck radiation
2. Aspiration risk
3. Physiologic manifestations:
o Cardiovascular: congestive heart failure, ↓ CO (↓
contractility/rate), hypotension, pericardial effusion, autonomic
instability, hypovolemia
o Respiratory: hypoventilation, ↓ response to
hypoxemia/hypercarbia
o Electrolytes: hyponatremia
o Endocrine: hypoglycemia, adrenal insufficiency (cortical
atrophy)
o Hypothermia
o ↓ metabolic rate
4. Interactions with anesthetic:
o ↓ MAC
o Delayed emergence
o Sensitivity to respiratory depressents
o Perioperative endocrine supplementation (thyroid, steroids)
5. Potential for myxedema coma
6. Thyroid surgery:
o Shared airway
o Post-operative airway obstruction (recurrent laryngeal nerve
injury, tracheomalacia, hematoma, hypocalcemia)

Optimization
1. Euthyroid patient preoperatively
2. Optimize volume status, give steroids, & manage glucose & sodium

Conflicts
 Thyroid replacement & coronary artery disease (can precipitate
myocardial ischemia)

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  Potential for over-sedation vs. difficult airway (post-operative
analgesia)

Myxedema Coma
1. Life-threatening form of hypothyroidism (mortality > 50%) precipitated
by stress
2. Exaggerated features of hypothyroidism:
o ↓ LOC
o Risk of aspiration
o ↑ sensitivity to neuromuscular blockers & sedatives
o ↓ cardiac output/heart rate, congestive heart failure, pulmonary
edema
o Respiratory depression
o Hypothermia
o Metabolic: SIADH, hypoglycemia, adrenal suppression
o High risk for delayed emergence & need for post-operative
ventilation
3. Treatment:
o IV thyroxine
o IV T3 0.2mcg/kg q6h (onset 6-24 hrs)
o T4 200-300mcg IV over 5-10 mins then 100mcg IV q24
o Risk of precipitation of myocardial ischemia with IV T3/T4
supplementation in those with CAD
o Hydrocortisone 100mg IV then 25mg q6h (common association
with adrenal suppression)
o Passive rewarming with blankets
o Post-operative ventilation, fluids, pressors, inotropes
o ICU & endocrinology consult

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 Perioperative Steroids

Risk Stratification
1. Definitely suppressed hypothalamic-pituitary-adrenal (HPA) axis →
supplement
o those on prednisone > 20mg/day for >3 weeks in last year
2. Definitely non-suppressed HPA axis → no need for supplementation
o those on prednisone < 5mg/day for any duration
o those on steroids < 3weeks in last year
o inhaled/topicals rarely cause suppression (although they can)
3. Intermediate risk patients → consider HPA testing or base on patient
status
o > 5mg/day but < 20mg/day

Dosing
1. Moderate risk surgery: hydrocortisone 50mg IV q8h X 3 doses
2. High risk surgery: hydrocortisone 100mg IV q8h X 3 doses

131
 Pheochromocytoma

Considerations
1. Preoperative optimization:
o Alpha & beta blockade
o Restore intravascular volume
2. Hemodynamic lability & potential for pheochromocytoma crises:
o Hypertension, tachycardia, arrhythmia, myocardial ischemia
o Need for invasive hemodynamic monitoring
o Avoidance of sympathetic stimulation, histamine-releasing
drugs and unopposed alpha stimulation
3. End organ dyfunction:
o Relative hypovolemia
o Left ventricular hypertrophy and cardiomyopathy, ischemic
heart disease, MI, arrhythmia
o Hypertensive encephalopathy & CVA
o Renal failure
4. Associated conditions:
o MEN 2A: hyperparathyroidism, medullary thyroid carcinoma,
pheochromocytoma
o MEN 2B: medullary thyroid carcinoma, pheochromocytoma,
mucosal neuromas
o Neurofibromatosis
o Von Hippel Lindau syndrome (cerebellar hemangiomas, renal
cell carcinoma)
5. Postoperative complications:
o Hypotension
o Hypertension
o Hypoglycemia
o Hypoadrenalism

Goals
1. Adequate pre-op optimization:
o Start with alpha blockade: phenoxybenzamine used classically;
alternatively: terazosin, prazosin, doxazosin
o Once alpha blocked, may start beta blockade
o Fix hypovolemia
2. Prevent and manage pheochromocytoma crises:
o Invasive monitoring and tight hemodynamic control
o Avoid SNS surges (anxiolysis, deep induction, epidural)

132
 o Avoid histamine releasing drugs (precipitates catecholamine
release from tumour)
o Anticipate and prepare for hypotension following tumour vein
ligation (volume +/- pressors/inotropes)
3. Conflicts:
o Deep anesthesia vs. hypovolemia

Pregnancy Considerations
1. Caution with hemodynamic agents that cross placenta (esmolol,
propanolol)
2. Same optimization with alpha blockade followed by beta blockade
applies but some suggest having hemodynamic goals even lower
than Roizen criteria (e.g. upper limit 150/80mmHg but avoid
orthostatic hypotension to prevent uteroplacental malperfusion)
3. Pregnancy specific management:
o Controversial, based on case reports:
 If gestational age <24 weeks: may undergo open or
laparascopic resection of pheochromocytoma
 If gestational age >24 weeks: medical management, &
may wait until fetal maturity & do combined cesarean
section & tumor resection (the problem is that gravid
uterus >24 weeks obstructs access to tumor resection)
 Cesarean section is preferred as abdominal squeeze
during labour can precipitate a hypertensive crisis
 General anesthesia or epidural anesthesia > spinal
anesthesia
 probably best NOT TO ALLOW LABOR
4. Increased incidence of intrauterine fetal demise, growth
restriction, abruption
5. Often misdiagnosed as pre-eclampsia

Background
 Roizen criteria:
1. No in-hospital blood pressure reading higher than 165/90
mmHg should be evident for 48 hours before surgery. We often
measure arterial blood pressure every minute for 1 hour in a
stressful environment (eg. postanesthesia care unit). If no
reading is greater than 165/90mmHg, this criterion is
considered satisfied.
2. Orthostatic hypotension should be present, but blood pressure
on standing should not be lower than 80/45mmHg.

133
 3. ECG should be free of ST-T changes that are not permanent
4. No more than one PVC should occur every 5 minutes

 Anti-hypertensive agents:
o Use short acting agents only!
o Sodium nitroprusside (50mg in 250mL NS = 200mcg/mL): run
at 25-200mcg/min or 0.3-3mcg/kg/min
 prepare syringe of 100mcg/mL for bolusing
o Esmolol (10mg/mL as per ampule): run at 50-250 mcg/kg/min
o Phentolamine (10mg ampule): administer 1-2mg boluses; may
increase to 5mg/dose; onset/offset immediate
o MgSO4: 4-6g at induction over 30 minutes then 1-2g/hr

 Anti-hypotensive agents:
o Norepinephrine (4mg in 250mL NS = 16 mcg/mL): run at 1-
20mcg/min
 bolus 20-30mcg/dose
o Vasopressin: run at 0.01-0.04 U/min and boluses 4U/dose for
hypotension refractory to norepinephrine
o Consider calcium if magnesium used intraoperatively

134
 Porphyria

Considerations
1. Risk of perioperative porphyric crisis
2. The need to avoid certain anesthetic drugs, including:
o Barbiturates/etomidate
o Ropivacaine (caution in regional anesthesia), lidocaine &
bupivacaine are OK
o Ketorolac
o Anti-seizure medications: phenytoin, barbiturates
3. Acute intermittent porphyria (AIP) attacks last days to weeks & are
multi-systemic:
o Risk of aspiration (bulbar dysfunction)
o CNS: seizures, peripheral neuropathy, quadriplegia, altered
LOC
o Respiratory: respiratory failure from respiratory muscle
weakness
o Cardiovascular: autonomic instability, tachycardia,
hypertension
o Electrolyte imbalances: especially hyponatremia but also
hypomagnesemia and hypokalemia
o GI: severe abdominal pain
o Psych: anxiety, restlessness, agitation, hallucinations, hysteria,
disorientation, delirium, apathy, depression, phobias and
altered consciousness, ranging from somnolence to coma
4. Chronic effects:
o Usually symptom-free between attacks
o But, some have persistent hypertension & develop kidney
disease, chronic pain, depression/anxiety/suicidality

Goals
 Minimize risk of aspiration
 Optimization:
o Ensure consultation with hematology before procedure
o Avoid prolonged fasting
o Give pre-operative glucose load (e.g., maintain on D10NS IV
prior to surgery)
o Correct anemia
o Manage pain & anxiety
 Avoid triggers of porphyric crisis:

135
 o Drugs: sodium thiopental, etomidate, chlordiazepoxide,
ropivacaine, diazepam, steroids, ergots, ketorolac and
diclofenac, cephalosporins, sulphonamides
o Physiologic: fasting/hypoglycemia, anemia, stress, estrogen,
progesterone, infection
o Substance abuse: alcohol, smoking, marijuana, cocaine,
ecstasy, amphetamines
 Prepare to treat crisis:
o Hydration, glucose, electrolyte replacement, analgesia,
hematin, cimetidine, somatostatin, plasmapheresis
o Seizures: use midazolam, propofol

Complications
 Aspiration
 Muscle weakness, neuropathy, paraplegia:
o Postoperative ventilation requirements
o Confusion with respect to neuropraxia and complications after
regional
 Acute porphyric crisis:
o Symptoms:
 CNS: changes, seizures, sensory loss, pain,
quadriplegia, upper motor neuron signs, cranial nerve
lesions
 Cardiovascular: autonomic instability (tachycardia,
hypertension, hypotension)
 Respiratory: respiratory paralysis/failure
 GI: abdominal pain, vomiting, constipation, diarrhea
 Treatment:
o Eliminate drug/triggering factor
o Hydration
o Glucose 20g/hr infusion (D10W)
o Hematin 3-4 mg/kg IV over 20 min (specific therapy)
o Beta blockers for hypertension/tachycardia
o Octreotide
o Analgesia
o Propofol and midazolam for seizures
 Seizure attack:
o Use propofol, benzodiazepenes
o AVOID phenytoin, barbiturates

Porphyria in pregnancy
 No evidence to choose between general anesthesia vs. neuraxial
technique

136
  Epidural definitely OK
 Propofol/succinylcholine OK for RSI
 Ergotamine is CONTRAINDICATED! Use oxytocin, hemabate for
postpartum hemorrhage

Some key drugs to avoid

 Barbiturates
 Etomidate
 Ergotamine
 Antiepileptics (phenytoin)
 Corticosteroids
 Hydralazine

137
 SIADH

Considerations
1. Hyponatremia:
o Cerebral edema
o Seizures
o Coma
o Respiratory arrest
2. Associated conditions:
o Tumours (lung, pancreas, prostate, lymphoma)
o CNS insult (trauma, subarachnoid hemorrhage, tumour,
infection)
o Pulmonary (infection, cystic fibrosis, positive pressure
ventilation)
o Medications (opiates, oxytocin, chlorpropamide, vincristine)
o Postoperative ADH secretion
o Idiopathic
o Iatrogenic (hypotonic IV solutions)

Treatment
1. Free water restriction
2. Eliminate underlying cause
3. Caution with rapid correction of serum sodium (central pontine
myelinolysis)

Goals
1. Preoperative correction of serum electrolytes when possible to
target sodium >125
2. Avoid overcorrection or overly rapid correction resulting in central
pontine myelinolysis
3. Correct underlying reversible etiologies (infection, tumour,
medications, iatrogenic)

Management
1. Restore sodium concentration
2. Generally restrict free water (500mL-1L/day)
3. +/- loop diuretic
4. Acute:

138
 o Severe hyponatremia (<120mEq/L or neuro symptoms)
 Hypertonic saline 3% 1-2 ml/kg/hr until sodium >125
 Furosemide
 Sodium bicarbonate (1 mEq/ml) to terminate seizures:
0.5-1mL/kg boluses prn
5. Chronic:
o Avoid rapid overcorrection (0.5-1 mEq/hr, <8 in mEq in 24hrs)
o Demeclocycline 300-600 mg PO bid (antagonizes ADH at
collecting duct)
o Conivaptan = vasopressin receptor antagonist

139
Hematology

140
 Contents

# Topic Page No.

1 Acute Leukemia 142
2 G6PD Deficiency 143
3 Disseminated Intravascular Coagulation (DIC) 145
4 Hemophilia 146
5 Jehovah’s Witness Patients 148
6 Sickle Cell Disease 151
7 Thalassemia 155
8 Tumor Lysis Syndrome 156
9 Von Willebrand’s Disease 157

141
 Acute Leukemia

Considerations
1. Impaired immunity with ↑ risk of infections
2. Chronic anemia
3. Thrombocytopenia with risk of hemorrhage
4. Hyperleukocytosis
o Leukostasis, disseminated intravascular coagulopathy (DIC),
tumor lysis syndrome (TLS)
o Bleeding, thromboembolic events, neurologic & pulmonary
complications
o TLS: hyperuricemia, hyperkalemia, hyperphosphatemia,
hypocalcemia, acute renal failure
5. Possible bone marrow transplantation with risk of graft vs host
disease
6. Chemotherapy with end-organ dysfunction
o Doxocubicin (cardiomyopathy)

142
 G6PD Deficiency

Background
1. X-linked disorder, the most common enzymatic disorder of RBCs
2. Hemolysis is the result of the inability of the RBC to protect itself from
oxidative stress
3. Spectrum of disease: chronic hemolysis, intermittent hemolysis,
hemolysis only with triggers, no hemolysis
4. Acute insults that either precipitate or aggravate hemolysis include
infection, certain drugs, & fava beans

Considerations
1. Chronic hemolysis:
o Chronic pRBC transfusions
o Difficult crossmatch
o Anemia
2. Avoidance of oxidative stress as it precipitates acute hemolysis:
o Oxidative drugs (see list below)
o Infection, hypoxia, hypothermia, stress
o Metabolic abnormalities (e.g., diabetic ketoacidosis)
o Foods (e.g., fava beans)
3. Unable to reduce methemoglobin:
o Methemoglobinemia: oxidative stress
o Methylene blue: oxidative stress
4. Consider hematology consultation

Goals
1. Identify patients at risk
2. Avoid precipitants of oxidative stress
3. Avoid precipitants of methemoglobinemia
4. Manage hemolysis by removing trigger, pRBC transfusion as
needed, supportive management

Common Drugs to Avoid

 Acetaminophen
 Acetylsalicylic acid
 Ciprofloxacin
 Dapsone
 Methylene blue
143
 Nitrofurantoin
 Phenytoin
 Streptomycin
 Sulpha drugs

144
 Disseminated Intravascular Coagulation (DIC)

Considerations
1. Emergency: mobilize resources & delegate tasks
2. Search for & correct precipitant:
o Obstetrical hemorrhage, placental abruption, amniotic fluid
embolism, pregnancy-induced hypertension
o Trauma/burns
o Transfusion
o Sepsis
3. Aggressive treatment: potential for massive transfusion:
o Hypothermia
o Hypocalcemia
o Factor dilution
o Thrombocytopenia
o Acidosis
o Volume overload (acute respiratory distress syndrome, acute
lung injury)
4. Sequelae of bleeding & thromboembolism:
o Bleeding: intracranial, thorax, abdomen, cardiac tamponade
o Thrombus: pulmonary embolism, acute renal failure, liver
failure, stroke

Goals
1. Platelets: maintain above 50 000 (1 unit/10 kg; 0.1-0.2 units/kg)
2. Fresh frozen plasma: 10ml/kg to maintain INR < 1.5 – 2
3. Cryoprecipitate to maintain fibrinogen > 1.5 (2 units / 10 kg) (maintain
> 2.0 in pregnant patients)
4. pRBC’s to maintain organ perfusion
5. Follow coagulation profile, fibrinogen, hemoglobin & platelets at least
hourly
6. Heparin not recommended (except possibly in DIC secondary to
malignancies causing thrombosis)
7. Antifibrinolytics not recommended

145
 Hemophilia A&B

Background
1. X-linked recessive disorder characterized by a deficiency of Factor 8
(A) or 9 (B) resulting in spontaneous hemorrhage or uncontrolled
bleeding with trauma or surgery
2. Classification by factor levels:
o Mild: 5-25%
o Moderate: 1-5%
o Severe: <1%
3. ↑ PTT, normal INR

Considerations
1. High risk for perioperative bleeding
2. Sequelae of bleeding into enclosed spaces (joints, intracranium,
pericardium, thorax)
3. Potential contraindication to neuraxial anesthesia
4. Factor optimization (replacement/supplementation) & identification of
factor antibodies (e.g., inhibitors)
5. Coexisting viral infections secondary to transfusions: HIV,
hepatitis (less now with recombinant products)
6. Consider preoperative hematology consultation

Goals
 Optimize factor activity & coagulation profile in perioperative period
 Minimize perioperative blood loss; consider blood conservation
strategies

Optimization & Treatment

1. Hemophilia A
o DDAVP for mild disease
o Recombinant factor VIII (Humate P)
o Factor VIII concentrates (fresh frozen plasma contains minimal
factor VIII)
o Recombinant factor VIIa for inhibitors (approved indication)
o Cryoprecipitate if nothing else available (this is the only
standard fractionated blood product containing meaningful
amounts of factor VIII)

146
  Cryoprecipitate contains factor VIII, fibrinogen, von
Willebrand factor, fibronectin, factor XIII
2. Hemophilia B
o Recombinant factor IX
o Factor IX concentrates

Treatment Factor Levels

147
 Jehovah's Witness Patients

Background
1. Traditionally, orthodox Jehovah’s Witnesses won’t accept
homologous or autologous whole blood, pRBCs, plasma, platelets
& WBCs, even when necessary to prevent morbidity/mortality
2. Refusal is based on religious beliefs deriving from strict literal
interpretation of passages in the Bible forbidding the “eating” of blood
3. Belief that eternal life may be forfeited if they do not exactly follow
biblical commands
4. Usually refused
o Whole blood
o RBCs
o Platelets
o FFP
o Cryoprecipitated antihemophilic factor
o Granulocytes
o Fibrin glue/sealant
o Predeposited autologous blood/components
5. Usually accepted
o Normovolemic hemodilution*
o Intraoperative RBC salvage*
o Erythropoietin (albumin-free)
o Hemodialysis**
o Heart-lung equipment**
*Usually accepted if patient remains in continuous
contact with blood
**If non-blood prime used
 Individual Decision (according to the individual’s preference)
o Albumin
o Immune globulins
o Factor concentrates
o Organ & tissue transplants

Considerations
1. Need for preoperative hemoglobin optimization & perioperative blood
conservation
2. Legal issues
o A patient's legal right to refuse or consent to treatment is based
on common law & is therefore is constantly evolving as new
cases are decided

148
 o Clinicians should not administer emergency treatment without
consent if they have reason to believe that the patient would
refuse such treatment if he or she were capable
o In certain pediatric cases, the child may be made a ward of the
court in order to administer clinically necessary blood
transfusions
3. Informed consent
o Must outline risks & benefits of receiving or refusing
transfusions to the individual patient in their clinical situation
o Discuss alternatives to transfusion (may include transferring
patient to another facility with more experience)
o Determine specifically which blood products/procedures the
patient will accept & refuse
o If necessary, follow appropriate procedures to obtain court
intervention (ex pediatric patients, patients with dementia,
comatose, etc)

Conflicts
 Conflict between beneficence & autonomy, where autonomy is
generally given precedence over beneficence
 Physicians are ordinarily taught to preserve life, yet they must also
respect a competent adult patient's right to refuse treatment

Management
1. Optimize preop hemoglobin
o Enhance RBC production
 Iron supplementation if deficient
 Oral in divided doses
 IV if short time before surgery, intolerance to po
Fe, or GI absorption problems
 Folate and/or vitamin B12 supplementation if deficient
 Erythropoietin
 If anemia of renal/chronic disease
2. Minimize iatrogenic blood loss
o Avoid unnecessary testing
o Minimize test sample volume (ex pediatric tubes)
3. Minimize intraop blood loss
o Meticulous surgical technique
o Regional anesthesia
o Maintain normothermia, physiologic pH
o Intraoperative cell salvage

149
 o Normovolemic hemodilution
4. Ensure hemostasis
o Antifibrinolytic agents (tranexamic acid, aprotinin, etc)
o Fibrinogen concentrate (if acceptable to patient)
o Desmopressin
o Prothrombin complex concentrates (where appropriate)
o Recombinant Factor VIIa (controversial)
5. Maintain circulating blood volume
o Crystalloid
o Synthetic colloid

In Pregnancy
 Epidural blood patch may be acceptable if blood remains in constant
connection to patient (i.e. injecting syringe is connected to vein via
tube)

150
 Sickle Cell Disease

Considerations
1. Multisystem disease with end-organ dysfunction:
o CNS: stroke
o Cardiovascular: LV hypertrophy, high-output cardiac failure
(anemia), myocardial infarction without coronary artery
disease
o Respiratory: acute chest syndrome (ACS), restrictive lung
disease (pulmonary fibrosis), pulmonary hypertension,
RV hypertrophy, cor-pulmonale
o Renal: renal failure, renal infarction
o Spleen: sequestration, infarcts; if splenectomy → ↓ immunity
2. Potential for perioperative exacerbations of vaso-occlusive crises:
o Acute pain crisis
o Acute chest syndrome
3. Chronic hemolytic anemia:
o Chronic RBC transfusion & its complications (alloimmunization,
iron overload, viral transmission)
4. Chronic pain & potential opioid tolerance
5. Preoperative optimization: consider preoperative transfusion for goal
hematocrit: 30%, hemoglobin: 100 (see discussion in optimization)
6. Medications: immunosuppresants, antineoplastics

Goals
1. Avoid precipitants of sickle cell crisis:
o Hypoxia
o Vascular stasis
o Hypothermia
o Hypovolemia/hypotension
o Acidosis
2. Optimize perioperative pain control
3. Monitor for:
o Vaso-occlusive crisis
o Acute chest syndrome
o Aplastic crisis
o Splenic sequestration syndrome
o Right upper quadrant syndrome

Optimization (in consultation with hematology)

1. Risk factors for acute pain crises:

151
 o Age, frequency of hospitalizations &/or transfusions for
episodes of crisis, evidence of organ damage (e.g., low
baseline oxygen saturation, elevated creatinine, cardiac
dysfunction), history of central nervous system
events, concurrent infection
2. Procedural risk for complications:
o Low: minor surgery (e.g., inguinal hernia & extremity surgery)
o Intermediate: intra-abdominal operations
(e.g., cholecystectomy)
o High: intracranial & intrathoracic procedures, hip surgery
3. Hematology consult, optimize treatment:
o Hydroxyurea to ↑ fetal hemoglobin production
4. Cancel non-emergent cases if patient experiencing a crisis
5. Only low risk patients should be considered for outpatient surgery
6. IV fluid to avoid dehydration while NPO
7. Preoperative transfusion therapy:
o Controversial without good evidence
o Purpose is to correct pre-existing anemia, ↓ hemoglobin
S concentration & ↑ adult hemoglobin
o Consider target hemoglobin 100 or hematocrit 30% for
intermediate & high risk surgeries & always have blood
available for any surgery
o Exchange transfusions are not routinely recommended

Acute chest syndrome (ACS)

1. Background:
o Second most common reason for hospitalization after vaso-
occlusive crisis
o Mortality 2-12%; accounts for 25% of deaths in sickle cell
patients
o Characterized by acute respiratory symptoms concurrent with
new infiltrate on CXR
o Spectrum of pathology:
 Infection
 Infarction (especially ribs)
 Pulmonary sequestration
 Fat embolism
o Pulmonary vaso-occlusion due to sequestration of sickled cells
in small pulmonary vessels
o Infection or fat emboli may lead to vaso-occlusion &
sequestration
o Clinical picture: fever, tachypnea, pleuritic pain & cough

152
 o CXR: normal to complete opacification but usually
demonstrates a new lobar infiltrate:
 Children: upper lobe disease common
 Adults: multilobe & lower lobe disease more common
o Strong relationship between ACS & stroke
2. Treatment:
o Admit to monitored setting, may need ICU
 Hydration to euvolemia
 Oxygen, noninvasive PPV if necessary
 Bronchodilators (even if not wheezing)
 Broad spectrum antibiotics: infection is one of the most
common causes of ACS
 Transfusion: both simple & exchange transfusion:
 Simple transfusion: goal is to ↑ hematocrit to > 30%:
 Indications:
 To improve oxygenation, particularly in
patients with oxygen saturation below
92% on room air & to prevent progression to
respiratory failure
 For accentuated anemia, defined as a
hematocrit that is 10% to 20% below the
patient's usual hematocrit, or with a dropping
hematocrit during hospitalization
 Clinical or radiological progression of disease
but not impending respiratory failure
 For patients in whom exchange transfusion
will be delayed; simple transfusions may be
used to temporize the clinical situation until
the exchange transfusion can be performed
 Exchange transfusion: goal is to ↓ the level of
hemoglobin S to < 30%:
 Indications:
 Progression of ACS despite simple
transfusion
 Severe hypoxemia
 Multi-lobar disease
 Previous history of severe ACS or
cardiopulmonary disease
 Analgesia: adequate analgesia of spine, thoracic, &
abdominal pain is important to prevent hypoventilation &
atelectasis
 Possibly inhaled nitric oxide for severe cases

153
Acute pain crisis (Vaso-occlusive crisis)
1. Anesthesia may be requested to assist with analgesia (e.g., patient-
controlled analgesia)
2. Typically occurs in long bones, ribs, spine, or abdomen
3. Precipitants: infection, dehydration, hypothermia, hypoxia, stress,
alcohol intake, menstruation
4. Bone pain from ischemia & infarction of marrow or cortex
5. Abdominal pain from bowel ischemia, organ infarction, or referred
from the ribs
6. Severity of pain can range from annoying to disabling
7. Treatment: rest, warmth, reassurance, analgesia, fluid replacement:
o Oral analgesics may be sufficient for minor attacks
o Opioids (IM, SC, IV, PO):
 PCA opioids with baseline analgesia provided by
background infusion or fentanyl patch
o Acetaminophen & NSAIDs:
 NSAIDS particularly good for bone pain
o Ketamine as adjunct
o Regional blocks as appropriate, epidural use has been
reported

Pregnancy Considerations
1. Interaction with pregnancy:
o Pregnancy typically exacerbates the complications of sickle cell
anemia
o Maternal mortality is as high as 1%
o Pulmonary embolism & infection are the leading causes of
death
2. Management:
o Hemoglobin goals:
 >80 for vaginal delivery
 >100 for cesarean delivery
o Epidural strongly recommended in labor to reduce stress/pain
o Safe to use either GA or neuraxial for cesarean section
o Goals: avoid hypovolemia, hypoxemia, hypercarbia,
hypothermia, pain, stress

154
 Thalassemia

Background
 ↓ synthesis of alpha or beta chains of hemoglobin → precipitation of
unpaired chains & premature RBC destruction

Considerations
1. Chronic hemolytic anemia:
o Compensation: ↑ cardiac output, ↑ 2,3-DPG, ↑ plasma volume
o Cholilithiasis, splenomegaly
2. Sequelae of multiple transfusions/iron overload:
o Cardiomyopathy, dysrhythmias
o Pulmonary hypertension
o Hepatic fibrosis, diabetes
o Alloimmunization
3. 4 types:
o Beta thalassemia major:
 Potential difficult airway due to maxillary overgrowth
(from bone marrow stimulation)
 Hemochromatosis (deposition of hemosiderin into
cardiac muscle → dilated cardiomyopathy, heart failure,
conduction delays)
 Jaundice secondary to hemolysis
 Hemolytic anemia
 Thinning of cortical bone → potentially difficult regional
secondary to vertebral destruction
o Beta thalassemia minor:
 Mild hemolytic anemia & iron deficiency
o Alpha thalassemia major: incompatible with life
o Alpha thalassemia minor: mild anemia

Goals
 Ensure not anemic for surgery (typical goal hemoglobin > 100)
 Anticipate difficult airway in beta-thalassemia major

155
 Tumor Lysis Syndrome

Considerations
1. Severe acute life threatening condition with potential for multi-system
failure:
o Hyperkalemia & secondary arrhythmias
o Hyperuricemia & acute renal failure
o Hypocalcemia & risk of seizures, tetany
o Hyperphosphatemia & prolonged QT interval
2. Underlying hematologic malignancy:
o 4M’s (mass effects, metastases, metabolic
abnormalities, medications)
3. Chemotherapy &/or radiation with end-organ dysfunction

Treatment
1. Need for admission to high acuity setting
2. Rapidly diagnose & treat metabolic derangements
3. Prevent & support renal failure:
o Volume loading (20 mL/kg) & 1.5-2 times maintenance
o If volume overloaded → diuretics, potentially dialysis
4. Acute treatment of hyperkalemia & life threatening arrhythmias
5. Rasburicase/allopurinol for hyperuricemia

156
 Von Willebrand's Disease (vWD)

Considerations
1. High risk for perioperative bleeding
2. Sequelae of bleeding in enclosed spaces (joints, intracranial,
pericardium, thorax)
3. Potential contraindication to neuraxial anesthesia & analgesia
4. Consultation with hematology for factor optimization
(replacement/supplementation)

Goals
 Optimize factor activity & coagulation profile in perioperative period
 Techniques for minimizing perioperative blood loss

Optimization
1. Consultation with hematologist for appropriate factor management
2. Schedule OR early in the week & early in the day (ensure all
lab/blood bank/consultant resources available)
3. Assay factor levels 48h prior to OR & restore levels to 40% of normal
prior to surgery, as dictated by the surgical procedure (see tables
below). Key trough factor VIII levels:
o Obstetric > 50%
o Minor surgery > 30%
o Major surgery > 50%
4. Repeat factor assay after initial administration to confirm factor
activity (within 2 hours of expected OR start)
5. Continue to monitor factor activity level intra-operatively as dictated
by clinical situation
6. Avoid all anti-platelet medications
7. Consider antifibrinolytics during perioperative period (up to 3-5 days)

Management
1. DDAVP 0.3 mcg/kg (provides 3-5 fold increase in activity); only if
known responder:
o Maximum effect 30 min post dose but levels remain elevated
for 6-8 hours
o DDAVP works by stimulating the release of vWF from
endothelial cells
2. Factor VIII-vWF concentrates (Humate P)

157
 3. Platelet concentrates (contains vWF)
4. Recombinant factor VIII
5. Recombinant factor VIIa
6. Emergency: cryoprecipitate (contains vWF, FVIII, FXIII, fibronectin,
fibrinogen)

Pregnancy
1. Establish baseline factor VIII, vWF, ristocetin cofactor early in
pregnancy & at 34 weeks
2. During pregnancy, prophylactic treatment if factor VIII level < 25%
(typically levels increase with pregnancy)
3. Know the patient's type & factor VIII level:
o Responder: at labour onset, DDAVP 0.3mcg/kg IV q12h
o Non-responder: Humate P or cryoprecipitate
4. Labour & delivery/cesarean section: maintain levels > 50% of normal
5. Post-partum: follow levels & treat if < 25% or significant hemorrhage
6. Regional: epidural safe if factor VIII & vWF > 50%

Treatment Choices Based on Sub-types

Recommended Dosages of Factor VIII for Patients with

Severely Reduced (<10%) Factor Levels

158
Hepatic

159
 Contents

# Topic Page No.

1 End Stage Liver Disease 161

160
 End Stage Liver Disease

Considerations
1. Airway:
o Aspiration risk due to ↑ gastric volume
o Friable/edematous tissues
2. Multiorgan dysfunction:
o CNS: encephalopathy
o Cardiovascular: hyperdynamic circulation (↑ cardiac output, ↓
SVR), cardiomyopathy, portopulmonary HTN
o Pulmonary: hypoxemia (intrapulmonary AV shunting, V/Q
mismatch); restrictive lung physiology (ascites & pleural
effusions)
o GU: hepatorenal syndrome/renal failure
o GI: U/LGIB from varices & AVM’s
o Hematology: coagulopathy (↓ platelets, ↓ clotting factors, ↑
fibrinolysis) & immunodeficiency
o Endocrine: hypoglycemia, hyponatremia, lactic acidosis
3. Etiology/associated conditions:
o Viral (e.g. hepatitis)
o Drugs (e.g. alcohol, acetaminophen)
o Autoimmune (α-1-antitrypsin deficiency)
o Hemochromatosis
4. Altered drug pharmacology (↑ volume of distribution, ↓ hepatic
clearance, ↓ protein binding)
5. Altered fluid physiology:
o Total body water excess (ascites) with intravascular volume
depletion
o Low albumin state
6. Reconsider elective surgery in very high risk patients (child-pugh
class C or MELD > 20)

Goals
1. Identify & optimize multisystem complications
2. Avoid elective or non-emergent surgery in acute liver dysfunction
3. Pre-operative correction of coagulopathy & hypovolemia
4. Consider draining ascites to optimize respiratory mechanics
5. Anticipate fluid shifts & major blood loss
6. Appropriate use of hepatically-metabolized drugs
7. Universal precautions to prevent viral transmission

161
Conflicts
1. Need for regional vs. coagulopathy
2. High risk patients vs. elective surgery
3. Pulmonary hypertension vs. laparoscopy

Massive Variceal Bleed

1. Emergency situation
2. Needs emergent airway management with RSI, 2 suctions
3. Massive hemorrhage: give blood products as indicated, reverse
coagulopathy, call massive tranfusion protocol
4. Pharmacologic:
o Vasopressin 0.4 unit bolus followed by an infusion of 0.4 to 1
units/min
o Ocreotide: 50 mcg bolus, then 50 mcg/hr infusion
5. Balloon tamponade: blakemore (minnesota) tube
6. Endoscopic management of varices
7. TIPS if endoscopic management fails

162
Neuroanesthesia

163
 Contents

# Topic Page No.

1 Acute Spinal Cord Injury 165
2 Aneurysm Coiling 167
3 Arnold Chiari Malformation 168
4 Autonomic Hyperreflexia 169
5 Craniotomy 171
6 Pitutary Surgery 172
7 Posterior Fossa Surgery 174
8 Spina Bifida 175
9 Spine Surgery 177
10 Subarachnoid Hemorrhage 178
11 Traumatic Brain Injury 180

164
 Acute Spinal Cord Injury

American Spinal Injury (ASIA) Impairment Scale

 A: Complete: no motor or sensory function is preserved in the sacral
segments S4-5
 B: Sensory incomplete: sensory but not motor function is preserved
below the neurologic level & includes the sacral segments (light touch
or pin prick at S4-5 or deep anal pressure) AND no motor function is
preserved more than three levels below the motor level on either side
of the body
 C: Motor incomplete: motor function is preserved below the neurologic
level & more than half of key muscle functions below the neurologic
level of injury have a muscle grade <3 (grades 0 to 2)
 D: Motor incomplete: motor function is preserved below the neurologic
level & at least half (half or more) of key muscle functions below the
neurologic level of injury have a muscle grade ≥3
 E: Normal: sensation & motor function are graded as normal in all
segments & the patient had prior deficits

Considerations
1. Emergency trauma patient with C/T/L-spine injury:
o ATLS approach to identify multisystem life threatening & occult
injuries
o Potentially difficult airway (full stomach, C-spine, uncooperative)
o Hemodynamic instability: neurogenic +/- hypovolemic shock
o Hypothermia, coagulopathy, acidosis
o Intoxication
o Additional injuries: traumatic brain injury (TBI) with ↑ intracranial
pressure (ICP) in 25%
2. Need to prevent secondary spinal cord injury (keep MAP > 85-90)
3. C-spine precautions & airway protection
4. Potential for:
o Diaphramatic paralysis (C3-C5)
o Respiratory insufficiency with injury above T7
o Neurogenic shock (hypotension & bradycardia)
o Neurogenic pulmonary edema
o Severe autonomic nervous system abnormalities
o Hypothermia due to loss of thermoregulation
o Hyperkalemic arrest with succinylcholine after 24 hrs

165
Goals
1. Avoid secondary spinal cord injury:
o Spinal cord perfusion pressure: goal MAP > 85-90 (IV fluids,
vasopressors)
o Prevent hypoxemia, hypotension, hyperglycemia, hyperthermia
o Immobilization during airway management & positioning
2. Manage complications of acute spinal cord injuries
3. Ventilatory & hemodynamic support as needed
4. Neurogenic shock:
o Fluids/vasopressors
o If bradycardic: atropine, external pacer, pharmacologic pacing
(dopamine, isoproterenol)

Conflicts
 Unstable c-spine, difficult airway +/- TBI (↑ ICP) vs potentially
uncooperative patient
 Aspiration risk (RSI) vs hemodynamic instability

166
 Aneurysm Coiling

Considerations
1. Unfamiliar/remote environment:
o Limited help & specialized tools
o Potential prolonged patient transfers
2. Limited access to patient
3. Need for absolute immobility (muscle relaxant or
remifentanil infusion)
4. Unsecured aneurysm:
o Risk of rupture: need to avoid ↑ transmural pressure
o Need to control hemodynamics: possible need for hypotension
or sinus pause for coil placement
 place external pacing/defibrillator pads
5. Complications:
o Aneurysmal perforation/rupture
o Cerebral ischemia due to misplaced coils, clots, vasospasm,
dissection
o Seizures
o Contrast (anaphylactoid reactions, contrast-induced
nephropathy, acute kidney injury)

Anesthetic Technique
 Pre-induction arterial line is necessary
 Maintain cerebral perfusion pressure (CPP) to prevent ischemia, but
avoid ↑ transmural pressure to prevent aneurysm rupture
 Maintain on sevoflurane & remifentanil OR propofol & remifentanil
 Usually heparinized to ACT 2-3X normal

167
 Arnold Chiari Malformation

Background
 Group of disorders that are defined by anatomic anomalies of the
cerebellum, brainstem, and craniocervical junction, with downward
displacement of the cerebellum, either alone or together with the
lower medulla, into the spinal canal
 Four major types (I-IV)

Considerations
1. ↑ ICP/hydrocephalus
2. C1-2 instability, dens may impinge on brainstem
3. Association with meningomyelocele:
o Hypovolemia (fluid & blood loss from defect)
o Infection
o Heat loss
o If adult: risk with neuraxial from direct injury, herniation
4. ↑ risk of latex allergy
5. ↑ perioperative risk:
o Brainstem dysfunction: stridor, apnea, aspiration
o Autonomic instability: arrhythmias, bradycardia, labile BP
o Seizures

Goals
 Avoid ↑ ICP, maintain CPP
 Avoid brainstem herniation
 Latex-free environment
 Rapid emergence for postoperative neurological examination

168
 Autonomic Hyperreflexia

Background
1. Spinal cord injury above T6
2. Frequency variable: 20-70% of patients
3. Above lesion: reflex bradycardia & vasodilation (flushed)
4. Below lesion: unopposed sympathetic stimulation
(vasoconstriction/hypertension)
5. Common clinical manifestations:
o Headache, diaphoresis,↑ BP, bradycardia
o Flushing, piloerection, blurred vision, nasal obstruction,
anxiety, nausea
6. Consequences of event:
o Bradycardia, AV block, PACs, PVCs
o Severe headache, seizures, subarachnoid hemorrhage, ↓ level
of consciousness
o Dyspnea, LV failure, pulmonary edema
o Blurred vision
o Anxiety, agitation
o Chest pain/myocardial ischemia

Considerations
1. Potential for hypertensive emergency with end-organ damage
2. Considerations of chronic SCI
3. Need for invasive monitoring
4. Difficult to assess success of neuraxial technique

Management
1. Discussion with surgeon regarding plan for procedure
2. Remove potential triggers (e.g., full bladder, foley insertion, full
rectum, surgical stimulus)
3. General anesthetic vs neuraxial technique (if GA, consider a deep
anesthetic)
4. Management of hypertensive event:
o Consider deepening level of anesthesia if under GA
o If epidural, consider top-up
o Treat severe hypertension with fast-acting titratable agents:
 Nitroprusside 0.5-3mcg/kg/min or nitroglycerin 5-
200mcg/min
 Hydralazine 10-20mg IV prn

169
  Phentolamine 5mg IV prn
 Look for evidence of end-organ involvement & treat
accordingly

Pregnancy Considerations
1. Multidisciplinary discussion regarding plan for labor & delivery
2. Consider scheduled elective cesarean section
3. If vaginal delivery:
o Admit early to monitored bed with telemetry
o Need continuous BP monitoring with arterial line
o Remove all preventable triggers of autonomic hyperreflexia
(vaginal exams, full bladder = foley insertion)
o Start early epidural to prevent hypertensive episodes from
contractions
o Difficult to assess success of epidural:
 May need larger test dose to rule out subarachnoid
placement
 Chestnut suggests two ways to assess level of epidural
 Sensory block cephalad to level of spinal cord
lesion
 Evaluating segmental reflexes below level of the
lesion: lightly stroke each side of the abdomen
above & below the umbilicus, looking for
contraction of the abdominal muscles & deviation
of the umbilicus toward the stimulus (reflexes are
absent below the level of the block)
2. If cesarean delivery:
o Either general anesthetic or neuraxial technique:
 Must have arterial line
 Vasodilators drawn up & ready
 Succinylcholine contraindicated
 Severe respiratory insufficiency or technical difficulties
with neuraxial anesthesia may necessitate the use of
general anesthesia

170
 Craniotomy

Considerations
1. Limited airway access
2. Need to treat ↑ ICP & optimize surgical exposure
3. Maintenance of cerebral perfusion pressure (CPP):
o Retractor pressure
o Clipping/flow interruptions
4. Neuromonitoring
5. Smooth & crisp emergence for postoperative neurological
assessment
6. Complications:
o Venous air embolism
o Hemorrhage
o Arrhythmias & hemodynamic instability

Goals
1. Cerebral protection:
o Minimize ↑ ICP
o Maintain CPP
o Neuroprotection: temperature, barbiturates
2. Minimize use of long acting sedatives to facilitate post-operative
neurological evaluation
3. Facilitate intraoperative neurological monitoring

Conflicts
 Full stomach vs. ↑ ICP
 Difficult airway vs. ↑ ICP

171
 Pituitary Surgery

Considerations
1. Mass effects:
o Neurologic impairment (bitemporal hemianopsia, cranial
nerve palsies)
o Potential ↑ ICP (rare, secondary to obstructive hydrocephalus)
2. Neurohormonal effects/endocrinopathies:
o Non-functional adenomas
o Hypersecretory tumors (60%):
 Prolactin > GH > ACTH, TSH rare
 Cushing’s, acromegaly
o Endocrine deficiencies secondary to mass:
 Hormone production impaired in the following order
 GH, LH, FSH, TSH, ACTH, prolactin ("Go Look For
The Adenoma Please")
 Panhypopituitarism
3. Surgical Issues/complications:
o Shared airway
o Head up positioning:
 Poor patient & airway access
 Bleeding into pharynx (coroner's clot)
 Venous air embolism
o Systemic absorption of cocaine from
mucosa → HTN, arrhythmias
o Neurologic injury
o Massive, difficult to access hemorrhage (cavernous sinus or
carotid)
o Post-operative endocrine dysfunction
o CSF leak/meningitis risk
o Diabetes insipidus
4. Rapid smooth emergence

Goals
1. Optimize perioperative endocrine function (stress dose steroids),
consult endocrinology
2. Avoid further ↑ in ICP (if hydrocephalus)
3. Provide a still field for microscopic surgery
4. Minimize long acting sedatives (crisp emergence for neurological
evaluation)

172
5. Controlled emergence (minimize bucking/coughing/vomiting to ↓ risk
of bleeding and CSF leak)
6. Monitor for postoperative complications:
o Diabetes insipidus (~40%)
o SIADH (usually delayed)
o Adrenal insufficiency & CV collapse (steroid coverage)
o Bleeding → ↑ ICP, brainstem compression, cranial
nerve dysfunction
o CSF leak (risk of meningitis)
o Hypothalamic injury
o Cerebal ischemia
o Stroke

173
 Posterior Fossa Surgery

Background
 Posterior fossa contains: brainstem, cerebellum & cranial nerves IV to
XII
 Pathology requiring surgery usually includes: congenital lesions (e.g.
Arnold-Chiari malformation), tumours, acoustic neuromas, vascular
lesions

Considerations
 Indication for procedure & status/complications of neurological
disease (↑ ICP)
 Considerations of patient positioning & potential
complications (lateral, prone, sitting)
 Anesthetic modifications for neuromonitoring: TIVA anesthesia, no
paralysis
 Facilitation of brain relaxation: TIVA, SjvO2 for titration, mannitol,
hyperventilation
 Complications:
o Hemorrhage
o Venous air embolism (VAE)
o Hemodynamic instability from brainstem manipulation
 Limited access to patient (foresight required in planning airway,
access, monitoring)

Goals
 Maintenance of CPP
 Facilitation of neuromonitoring
 Optimal brain relaxation for surgical exposure
 Rapid & smooth emergence
 Stable hemodynamics on emergence
 Vigilance & monitoring for VAE if high risk position

174
 Spina Bifida

Background
 Failure of the developing spine to completely enclose the neural
elements in a bony canal
 May be associated with Chiari II malformation
 Spina bifida occulta:
o Failed fusion of the neural arch without herniation of the
meninges or neural elements
o Defect limited to a single vertebra (typically L5 or S1)
o Very common (5% to 36% of the population), can be
considered a normal variant
 Spina bifida cystica:
o Failed closure of the neural arch with herniation of the
meninges (i.e., meningocele) or the meninges & neural
elements (i.e., myelomeningocele) through the vertebral defect
 Myelomeningocele:
o Progressive neurologic disease that eventually produces
orthopedic, neurologic & genitourinary complications
 Occult spinal dysraphism:
o Intermediate group of conditions wherein the bony defect is
associated with one or more anomalies of the spinal cord,
including: intraspinal lipomas, dermal sinus tracts, dermoid
cysts, fibrous bands & diastematomyelia (split cord)
o These lesions are differentiated from the more benign spina
bifida occulta
o May have no neurologic symptoms or may have minor sensory,
motor & functional deficits of the lower limbs, bowel & bladder;
they also may have orthopedic issues, such as scoliosis, limb
pain & lower extremity abnormalities
o Patients with cord abnormalities have cutaneous stigmata in
50% of cases & 70% have tethered spinal cord

Considerations
 Need for neuroimaging/detailed neurological history & physical exam
prior to neuraxial anesthesia:
o Look for hair tufts, dimples, hyperpigmented lesions, cutaneous
lipomas over the spine & if present send for imaging prior to
neuraxial or do GA only
 CNS:
o Hydrocephalus & risk of ↑ ICP, many have VP shunt

175
 o Flaccid paralysis usually high lumbar/low thoracic
o Potential for autonomic hyperreflexia if lesion between T5-T8
o Bowel & bladder control dysfunction
 Respiratory:
o Scoliosis with restrictive lung disease, risk of pulmonary
hypertension/RV failure
 Cardiovascular: possible congenital heart disease
 ↑ incidence of latex allergy

Pregnancy
 Spina bifida occulta:
o Neuraxial is generally safe
o Recommend to insert needle remote from site of malformation
seen on imaging
o Patients are at higher risk of post dural puncture headache
 Meningocele & myelomeningocele:
o If spinal level involvement T11 or higher, likely will have
painless labor
o Epidural & spinal has been performed in literature, so NOT
absolute contraindication but will be difficult & may be
unreliable
 May need epidural in situ to avoid autonomic hyperreflexia during
labour

176
 Spine Surgery

Considerations
1. Surgical indication (instability, tumour, kyphoscoliosis,
decompression/fusion, infection, congenital)
2. Potential for difficult airway with C-spine disease
3. Risk of blood loss, hypovolemic shock, massive
transfusion → perioperative blood conservation strategies
4. Potential neurological deficits, spinal cord injury
5. Neuromonitoring considerations
6. Prone positioning complications:
o Venous air embolism
o Nerve injury
o Postoperative visual loss
o Airway swelling
7. Postoperative pain management
8. Patient considerations:
o Trauma, malignancy, chronic pain, spinal shock, respiratory
insufficiency
o Scoliosis (lung disease, pulmonary hypertension, RV failure)

Goals & Conflicts

1. Careful airway assessment & management
2. Perioperative blood conservation:
o Preoperative: iron, erythropoietin, preoperative autologous
donation, correction of coagulopathy
o Intraoperative: acute normovolemic hemodilution, cell saver,
anti-fibrinolytics (tranexamic acid), surgical
techniques, anesthetic techniques (patient
positioning, normothermia, controlled hypotension)
o Postoperative: transfusion targets
3. Anesthetic technique:
o Neuromonitoring (TIVA, avoid neuromuscular blocking drugs)
o Opioid sparing (ketamine, lidocaine, dexmedetomidine)
o Careful securement of ETT, lines, monitors
4. Assessment for airway swelling prior to extubation

177
 Subarachnoid Hemorrhage

Considerations
1. Emergency, full stomach
2. Unsecured aneurysm with potential for rebleeding:
o Avoid hypertension & changes in transmural pressure
o Potential massive hemorrhage
3. ↑ ICP & prevent secondary injury:
o Avoid cerebral ischemia: CPP 60-70/MAP 80-90 mmHg
o ↓ ICP
o ↓ CMRO2: barbiturate coma, burst suppression, mild
hypothermia
o Maintain euglycemia, normocapnia
4. Neurologic complications:
o Rebleed
o Cerebral vasospasm
o Obstructive hydrocephalus
o Seizures
5. Medical complications:
o Neurogenic pulmonary edema
o Myocardial dysfunction, arrhythmias
o Electrolyte imbalances (hyponatremia due to cerebral salt
wasting, SIADH)

Goals
1. Hemodynamic control & monitoring:
o Minimize transmural pressure to avoid rebleed
o Avoid acute hypertensive episodes (essential because rebleed
is often fatal)
o Keep SBP < 160 mmHg (AHA guideline 2012) & keep MAP >
85 mmHg (to prevent ischemia)
2. Facilitate surgical exposure/control ICP
3. Protect from secondary brain injury:
o CPP 60-70/MAP 80-90 mmHg
o ↓ ICP
o Normocapnia
o ↓ CMRO2: mild hypothermia, barbiturates, DHCA (deep
hypothermic circulatory arrest)
o Euglycemia: glucose < 11 mmol/L
o Prevent vasospasm (nimodipine, pravastatin)

178
Conflicts
 Aspiration risk (RSI) vs tight hemodynamic control to prevent
rebleed/cerebral ischemia (titrated induction)
 Minimize transmural pressure (deep induction to prevent rebleed)
vs maintain CPP (hemodynamic support to prevent ischemia)

Pregnancy Management of Acute Intracranial Bleed

1. Decision to proceed with surgery:
o If 3rd trimester (>32 weeks)
 Consider simultaneous procedure, or cesarean
section first followed by intracranial procedure
o If pre-term viable (24-32weeks):
 Do intracranial surgery, then wait for fetal maturity
 Deliver if fetal distress
o If pre-term non-viable (<24weeks):
 Do intracranial surgery, then wait for fetal maturity
2. Induction:
o Titrated to protect against rebleed vs secondary brain injury
o Accept aspiration risk
3. Mannitol:
o Risk of fetal dehydration
o If tight head → give
o If non urgent indication → discuss with neurosurgery, avoid if
possible
4. PaCO2 management:
o Maintain around 30 mmHg
o Consider maintaining in high 20's if tight head

179
 Traumatic Brain Injury

Considerations
1. Trauma/ATLS approach
2. Possible C-spine injury
3. Monitoring & managing ↑ ICP:
o Risk of cerebral ischemia & brain herniation
4. Prevention of secondary brain injury:
o Avoid hypoxia, hypercarbia
o Maintain adequate CPP (60-70)
o Avoid hyperglycemia, hyperthermia
5. Multisystem complications:
o CNS: herniation, seizures
o CVS: myocardial dysfunction and ST changes, arrhythmias
o Pulmonary: neurogenic pulmonary edema
o DIC (disseminated intravascular coagulopathy)
o DI (diabetes insipidus), SIADH (syndrome of inappropriate
ADH), CSW (cerebral salt wasting)

Neurosurgical Considerations
1. Limited airway access
2. Optimization of surgical exposure
3. Invasive monitoring
4. Complications:
o Venous air embolism
o Hemorrhage
o Arrhythmias and hemodynamic instability

Goals
 Assess severity of TBI
 Prevent secondary brain injury:
o Hypoxia (PaO2 > 60 mmHg)
o Hypercarbia (PaCO2 35mmHg)
o Hypotension, maintain CPP ~ 60 mmHg (MAP ~ 80)
 Avoid abrupt ↑ in BP & ICP (< 20-25mmHg)
 Avoid hyperthermia & hyperglycemia
 C-spine precautions
 Hct > 30

180
Conflicts
 Full stomach vs. ↑ ICP
 Hemorrhage/hypovolemia vs. ↑ ICP
 Difficult airway vs. ↑ ICP

Treatment of ↑ ICP
1. Elevate HOB
2. Loosen collars, ETT ties to promote venous drainage
3. Decrease intrathoracic pressures (change ventilator settings,
decrease PEEP)
4. Hyperventilation
5. Sedate
6. Analgesia
7. Paralysis
8. Barbiturate coma (1-5 mg/kg sodium thiopental then 1-3 mg/kg/hr)
9. Hypothermia (or at least normothermia)
10. Mannitol (0.5-1 g/kg)
11. Furosemide (0.25-0.5 mg/kg)
12. Hypertonic saline 6-8 ml/kg of 3% saline
13. Correct sodium and osmolality
14. CSF drainage
15. Surgical decompression (head, abdomen)

181
Neuromuscular

182
 Contents

# Topic Page No.

1 Amyotrophic Lateral Sclerosis (ALS) 184
2 Gullian-Barre Syndrome (GBS) 185
3 Multiple Sclerosis 187
4 Myasthenia Gravis 189
5 Mysthenic (Lambert-Eaton) Syndrome 192
6 Myotonic Dystrophy 193
7 Parkinson’s Disease 195
8 Polymyositis & Dermatomyositis 197

183
 Amyotrophic Lateral Sclerosis (ALS)

Background
 Progressive degenerative disease of upper & lower motor neurons
leading to denervation & atrophy of skeletal muscle with resultant
weakness & eventual death

Considerations
 Aspiration risk due to bulbar dysfunction
 Perioperative respiratory failure due to weakness & aspiration
 Autonomic dysfunction
 Altered response to neuromuscular blockers:
o Succinylcholine contraindicated due to hyperkalemia risk
o NdMR (nondepolarizing muscle relaxant) sensitivity
 Chronic pain (often girdle area)

Goals
 Minimize aspiration risk (prophylaxis, consider RSI)
 Maximize respiratory function (muscle strength, secretion & pain
management)
 Anticipate potential need for postop ventilation/ICU
 Maintain stable hemodynamics

Conflicts
 RSI vs. avoid succinylcholine/sensitive to NdMRs
 RSI vs. maintain hemodynamic stability
 Regional vs. existing neurologic deficits:
o Epidural documented in case reports but be cautious of high
block
o Peripheral nerve blocks not documented because disease so
rare but definitely a consideration given respiratory muscle
weakness
 Avoid interscalene so as to not compromise phrenic
nerve
 General anesthetic vs. respiratory depression (neuraxial is safe)

184
 Guillain-Barre Syndrome (GBS)

Background
 Acute inflammatory demyelinating peripheral polyneuropathy usually
secondary to immunologic response to viral or bacterial infection
 Ascending progressive muscle weakness, autonomic dysfunction
& areflexia
 Respiratory compromise:
o 25% will require mechanical ventilation
o Forced vital capacity < 20 mL/kg, maximum inspiratory
pressure < 30 cmH2O, or maximum expiratory pressure < 40
cmH2O → high risk of impending respiratory failure, urgent
intubation & mechanical ventilation

Considerations
1. Aspiration risk due to to bulbar dysfunction
2. Perioperative respiratory insufficiency due to muscle weakness
(anticipate need for postoperative ventilation)
3. Autonomic dysfunction with possible hemodynamic instability
& autonomic hyperreflexia type reactions:
o Arrhythmias, cardiac arrest
o Physical stimulation can precipitate
hypertension & tachycardia
4. Altered response to neuromuscular blocking drugs (NMBs):
o Succinylcholine contraindicated due to hyperkalemia risk
o NdMR (nondepolarizing muscle relaxant) sensitivity
5. ↑ risk of venous thromboembolism
6. Neuropathic pain common (40-50%)
7. Treatment includes IVIG & plasma exchange, steroids NOT
recommended

Goals
 Minimize aspiration risk (consider prophylaxis, RSI)
 Maximize respiratory function (avoid NMBs or reduced dose of NdMR
& full reversal, secretions, pain management)
 Maintain hemodynamic stability

Conflicts
 RSI vs avoid succinylcholine, hemodynamic stability
 Neurologic deficits & regional techniques

185
Pregnancy Considerations
 Controversy regarding neuraxial but probabaly safe, document pre-
existing deficits
 If general anesthetic chosen: avoid succinylchonline & avoid or use
minimal NdMR

186
 Multiple Sclerosis

Background
 Heterogenous disorder with variable clinical & pathologic features
 Inflammation, demyelination & denervation are the major pathologic
mechanisms that cause the clinical manifestations
 Cause unknown, most widely accepted theory is of an inflammatory
immune-mediated disorder

Considerations
1. Multisystem effects of demyelination:
o Aspiration risk (bulbar dysfunction)
o Respiratory failure/insufficiency (central hypoventilation &
neuromuscular weakness)
o Autonomic dysfunction with possible hemodynamic instability
2. Altered response to NMBs (neuromuscular blocking drugs):
o Succinylcholine contraindicated due to hyperkalemia
risk (denervation, misuse myopathy)
o Sensitive to NdMRs (nondepolarizing muscle relaxants), but
can also be resistant
3. Potential perioperative exacerbation of disease:
o Neuraxial technique (spinal > epidural) but very controversial &
some sources suggest regional/neuraxial acceptable
o Hyperthermia
4. Immunosuppressive medications (steroids, interferon, methotrexate)

Goals
1. Minimize aspiration risk (consider prophylaxis, RSI)
2. Maximize respiratory function (avoid paralysis, full NMB reversal,
secretions, pain management)
3. Maintain hemodynamic stability
4. Prevent postoperative exacerbations by avoiding triggers
(hyperthermia, stress, +/- neuraxial)
5. Inform patient of potential perioperative aggravation of symptoms

Conflicts
 Neuraxial technique vs. disease exacerbation:

187
 o Spinal traditionally considered contraindicated, but
controversial
o Low dose epidural most likely safe, have discussion with
patient
o Peripheral nerve block is safe, as those nerves are not
involved
 RSI vs. hemodynamic stability
 RSI vs. avoid succinylcholine

Pregnancy Considerations
 Neuraxial (both epidural/spinal) NOT contraindicated
 Discuss risk with patient that there may be post-operative/post-
delivery relapse, regardless of anesthetic technique

188
 Myasthenia Gravis

Background
 Autoimmune disorder characterized by weakness & fatigability of
skeletal muscles
 Weakness results from an antibody-mediated immunological attack
directed at acetylcholine receptors (or receptor-associated proteins)
in the postsynaptic membrane of the neuromuscular junction

Considerations
 Bulbar/skeletal muscle weakness resulting in ↑ risk of:
o Aspiration
o Perioperative respiratory failure
 Potential systemic complications:
o Thymoma & possible anterior mediastinal mass
o Myocarditis causing cardiomyopathy, atrial fibrillation, heart
block
 Altered response to NMB (neuromuscular blocking) medications:
o Very sensitive to NdMR (nondepolarizing muscle relaxants):
avoid or use 1/10 normal dose with continuous monitoring
o Resistant to succinylcholine (ED95 2.6X normal)
 Treatment: steroids, immunosuppressants, anticholinesterases
 Risk of perioperative myasthenic or cholinergic crises

Goals
 Minimize risk of aspiration (prophylaxis, RSI)
 Minimize risk of perioperative respiratory failure (judicious NMBs
& opioids) & anticipate need for post-op ventilation
 Minimize risk of myasthenic or cholinergic crisis
 Optimize neuromuscular function

Conflicts
 RSI vs altered response to neuromuscular blockers
 RSI vs cardiac involvement
 RSI vs anterior mediastinal mass
 Magnesium for pre-eclampsia in pregnancy vs contraindicated due to
muscle weakness

189
Pregnancy Considerations
 1/3 improve, 1/3 stay the same, 1/3 get worse
 Exacerbations usually in 1st trimester with improvement in 2nd & 3rd
 ~ 30% experience relapse postpartum
 ↑ abortion, preterm labor, maternal morbidity & mortality
 Cholinesterase inhibitors: minimal placental transfer but have
uterotonic effects
 Monitor for fatigue/weakness during labour (consider measuring vital
capacity)
 Magnesium is relatively contraindicated due to muscle weakness
 Generally, neuraxial anaesthesia preferred (for labour
& vaginal or cesarian delivery) unless severe bulbar or respiratory
involvement, then consider general anesthetic for cesarian delivery:
o Ester local anaesthetics may have prolonged half-life in
patients taking cholinesterase inhibitors → increased risk of
toxicity, use amide local anesthetics
o In patients with moderate respiratory compromise, the use of
BiPAP may improve the safety of neuraxial anesthesia
 Be prepared for transfer to ICU for postpartum ventilation if severe
disease
 Neonatal myasthenia in 16% due to transfer of maternal IgG
antibodies across the placenta, resolves in 3 to 4 weeks

Weakness in PACU
 Management
o Attend to patient: rule out airway obstruction, life-threatening
hypoventilation, hypoxemia, hypercarbia, or anything requiring
immediate airway management & PPV
o Examine:
 Vitals
 ? aspiration, sepsis, surgical complication
 ? myasthenic crisis (weakness improves with tensilon
test)
 ? cholinergic crisis (salivation, lacrimation, urination,
diarrhea, GI symptoms, emesis, bradycardia,
bronchoconstriction, bronchorrhea)
o Review medications given in OR, PACU
o Send ABG, electrolytes

190
Myasthenic Crisis vs Cholinergic Crisis
 Myasthenic Crisis:
o Weakness exacerbated by infections, electrolyte abnormalities,
pregnancy, surgery, emotional stress, drugs (aminoglycosides),
or interruption of immunosuppressants
o Improvement with edrophonium (tensilon test):
 Tensilon test: 1.5 mg increments of edrophonium to 10
mg total (should get better in about 2 minutes)
o Consider elective intubation if vital capacity < 20cc/kg or
maximum inspiratory force worse than -30 cmH2O
o Consider PO or IV dose of pyridostigmine:
 PO: 30-120 mg/day, onset 15-30 min, peak 2 hrs,
duration 4 hrs
 IV dose is 1/30 of PO dose
o Alternative treatment is neostigmine 0.5-2.5 mg IV/SC q1-3
hours titrated to response (max = 10mg/24hours)
o Neurology consult for management (plex, IVIG, steroids)
 Cholinergic Crisis:
o Due to excessive cholinesterase inhibitors
o Symptoms of acetylcholine excess (SLUDGE
BBB): salivation, lacrimation, urination, diarrhea, GI
symptoms,emesis, bradycardia, bronchorrhea, bronchospasm
o Distinguish by giving edrophonium (tensilon test) which
improves symptoms if myasthenic crisis & worsens symptoms
if cholinergic crisis
o Treatment includes endotracheal intubation, atropine
& cessation of cholinesterase inhibitors until the crisis is over

191
 Myasthenic (Eaton-Lambert) Syndrome

Background
 Autoantibodies are directed against presynaptic voltage-gated
calcium channels
 ↓ release of acetylcholine
 Frequently associated with cancers (paraneoplastic syndrome)

Considerations
1. Muscle weakness predisposing to respiratory failure after anesthesia;
potential need for post-op PPV
2. Associated with lung carcinoma
3. Extremely sensitive to both succinylcholine & NdMRs
(nondepolarizing muscle relaxants)
4. Autonomic dysfunction present in 30%

Optimization
1. Counsel & prepare for postop PPV/ICU
2. IVIG prep may help ↑ muscle strength

Goals
 Minimize use of neuromuscular blockers, optimize postoperative
ventilation status
 Regional anesthesia preferred to general anesthesia if possible

192
 Myotonic Dystrophy

Background
 Clinically & genetically heterogeneous disorder with two major
forms: type 1 (DM1) & type 2 (DM2)
 Multisystem disorder characterized by skeletal muscle weakness
& myotonia, cardiac conduction abnormalities, cataracts, testicular
failure, hypogammaglobulinemia, & insulin resistance

Considerations
1. Multisystem disease:
o Airway
 Bulbar dysfunction & risk of aspiration
 Central sleep apnea
o Respiratory:
 Restrictive lung disease (weak respiratory muscles)
 Possible pulmonary hypertension
 ↓ ventilatory response to hypoxia/hypercarbia
o Cardiac:
 Cardiomyopathy
 Dysrhythmias & heart blocks
o GI:
 Delayed gastric motility
o Endocrine:
 Hypothyroid, diabetes mellitus, adrenal insufficiency
2. Altered sensitivity to anesthetic agents:
o Succinylcholine contraindicated due to risks of hyperkalemia
& myotonic contractures
o Sensitivity to CNS depessants (propofol, opioids,
benzodiazepines, barbiturates)
o Anticholinergics may trigger myotonic contracture, don't use
neostigmine!
3. Risk of perioperative myotonic crisis:
o Triggers:
 Drugs (e.g., succinylcholine, neostigmine)
 Surgical manipulation, electrocautery, nerve stimulator
 Hypothermia/shivering
o Treatment:
 Phenytoin, procainamide, quinine, IM lidocaine, ↑ volatile
 Phenytoin/procainamide: 18mg/kg over 20 min
 Quinine 300-600mg IV

193
  Muscle relaxants & IV anesthetics do NOT work

Goals/Optimization
 If elective, multidisciplinary discussion regarding plans for surgery
 Prevent aspiration, administer aspiration prophylaxis
 Avoid hemodynamic instability
 Avoid precipitants of myotonic crisis & treat if required
 Arrange appropriate disposition (need for post-operative monitoring,
ventilation)

Conflicts
 Need to prevent aspiration (RSI) vs contraindication to
succinylcholine & high dose rocuronium (as reversal with
neostigmine contraindicated)

Pregnancy
 High risk pregnant patient: ↑ muscle weakness/myotonia, heart
failure, uterine atony, postpartum hemorrhage
 Neuraxial anesthesia is preferred for labor & vaginal or cesarean
delivery

194
 Parkinson's Disease

Background
 Central dopamine deficiency leading to rigidity, tremors & late
dementia

Considerations
1. Elderly with associated co-morbidities
2. Potential difficult airway (temporomandibular joint & cervical spine
rigidity)
3. ↑ risk of peri-operative complications:
o Airway: airway obstruction
o Pulmonary: aspiration (secondary to bulbar dysfunction,
esophageal dysfunction & gastroparesis) & restrictive lung
disease (secondary to chest wall rigidity)
o Cardiac: autonomic instability
o Neurologic: worsening of neurologic symptoms & risk of
postoperative delerium
4. Management of medications (see paragraph below for further
details):
o Ensure perioperative use of anti-parkinson's medications
o Avoid medications which exacerbate/precipitate parkinsonism
o Avoid meperidine in patients on selegiline

Goals
1. Safe airway management:
o Aspiration prophylaxis
o Modified RSI
2. Avoid clinical exacerbation:
o Continue anti-parkinson medications perioperatively
o Avoid anti-dopaminergic medications: droperidol,
metoclopramide, methotrimeprazine
3. Maximize respiratory function
4. Prevent delirium

Conflicts
 Aspiration risk vs autonomic instability/difficult airway
 Regional anesthesia with tremulous patient vs risks of GA

195
Medications & Parkinson's
1. Avoid drugs that precipitate or exacerbate Parkinson's disease (ie.
dopamine antagonists):
o Metoclopramide
o Butyrophenones (droperidol, haloperidol)
o Phenothiazines (chlorpromazine, methotrimeprazine)
2. Selegiline (type B MAO inhibitor):
o Used to prevent central breakdown of dopamine to improve
parkinson's symptoms
o Usually safe as is not a type A MAO inhibitor
o Avoid meperidine in patients taking selegiline (case reports of
hyperthermia, agitation, muscle rigidity & seizures)
3. Opioids:
o May have ↑ muscle rigidity with fentanyl & morphine
o Dystonic reactions associated with use of alfentanil & fentanyl

196
 Polymyositis & Dermatomyositis

Background
 Idiopathic inflammatory myopathies characterized by proximal skeletal
muscle weakness & evidence of muscle inflammation
 Dermatomyositis but not polymyositis is associated with a variety of
characteristic skin manifestations

Considerations
1. Potential difficult airway (restricted temporomandubular joint &
cervical spine mobility)
2. Aspiration risk (esophageal dysfunction)
3. Respiratory:
o Interstitial lung disease, pulmonary fibrosis
o Potential postoperative respiratory muscle failure & need for
ventilation
4. Cardiovascular:
o Myocardial fibrosis, myocarditis, conduction defects,
arrhythmias
5. Altered response to succinylcholine (theorectical hyperkalemia) &
possible sensitivity to NdMRs (nondepolarizing muscle relaxants):
o Avoid succinylcholine, consider ↓ rocuronium dose
6. Treatment: steroids, immunosuppressants, IVIG, monoclonal
antibodies

Conflicts
 RSI for aspiration risk vs. difficult intubation
 RSI for aspiration risk vs. avoid succinylcholine
 RSI for aspiration risk vs. cardiac induction

Pregnancy Considerations
 Avoid succinylcholine if RSI for general anesthesia
 Caution with neuraxial if already compromised respiratory muscles

197
Obstetrics

198
 Contents

# Topic Page No.

1 Amniotic Fluid Embolism 200
2 Antepartum Hemorrhage 202
3 Breech Presentation 203
4 Cervical Cerclage 205
5 Dyspnea in Pregnancy 207
6 External Cephalic Version 209
7 Fetal Distress 210
8 Multiple Gestation 212
9 Non Obstetric Surgery in Pregnancy 214
10 Peripartum Cardiac Arrest 215
11 Peripartum Cardiomyopathy 217
12 Placental Abruption 218
13 Postpartum Hemorrhage 219
14 Preeclampsia 221
15 Uterine Inversion 224

199
 Amniotic Fluid Embolism

Considerations
1. Life threatening condition with multi-system derangements:
o CNS: seizures, coma
o Cardiovascular: hypotension, cardiovascular collapse,
biventricular failure
o Respiratory: pulmonary edema, ARDS
o Hematological: coagulopathy
2. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
3. Need for immediate cardiopulmonary resuscitation & correction of
coagulopathy
4. Need for multidisciplinary management including the ICU

Clinical Features (tend to happen suddenly)

 Premonitory symptoms (restlessness, agitation, numbness, tingling)
 Hypotension, biphasic cardiovascular collapse:
o First phase (initial 15-30 min): RV failure & acute pulmonary
hypertension
o Second phase: LV failure
 Hypoxemia, respiratory failure
 Coagulopathy
 Seizures/coma

Management
1. Call for help, code blue
2. If cardiac arrest → follow ACLS guidelines with obstetrical
modifications:
o Supradiaphragmatic IV
o Left uterine displacement
o Chest compressions higher on sternum than usual
o Early intubation
o Prepare for peri-mortem cesarean section; if no ROSC within 4
minutes of resuscitation, aim for delivery within 5 minutes of
resuscitation
3. Ventilate/oxygenate: intubate, 100% O2
4. Fluid resuscitate in increments, avoid fluid overload that may lead to
pulmonary edema or RV over-distension

200
 5. Support circulation with vasopressors initially, may need inotropes in
2nd phase:
o Start with norepinephrine
o Add inodilators if needed: dobutamine, milrinone
6. Establish invasive monitoring: arterial line, central venous access &
CVP monitoring
7. Call for transesophageal echocardiography
8. Treat coagulopathy:
o Initiate massive hemorrhage protocol
o Correct INR/PTT & platelets
o Ensure normothermia & normocalcemia
9. Fetus management:
o Institute fetal monitoring
o Deliver fetus if fetal distress or maternal cardiopulmonary
arrest
10. Post resuscitation care in ICU

Differential Diagnosis
 Obstetrical:
o Placental abruption
o Eclampsia
o Uterine rupture or laceration
o Uterine atony
o Peripartum cardiomyopathy
 Non-obstetrical:
o Myocardial infarction
o Pulmonary embolism
o Sepsis
o Anaphylaxis
o Venous air embolism
o Transfusion reaction
 Anesthetic:
o High neuraxial
o Local anesthetic toxicity
o Medication error

201
 Antepartum Hemorrhage

Considerations
1. Emergency situation
2. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
3. Potential for maternal massive hemorrhage, hemodynamic
instability & lethal triad (coagulopathy, acidosis, hypothermia)
4. Potential for fetal distress & need for FHR monitoring
5. Discussion with obstetrics to determine the extent & cause of
hemorrhage & whether emergency cesarean is required

Management
1. Simultaneous diagnosis & management in collaboration with
obstetrics
2. Monitors (maternal & fetal), O2, & start 2 large bore IVs
3. Obtain history, perform physical examination including airway
exam & intravascular volume status
4. Resuscitate to goal end points including FHR stability
5. Gather resources, get help, have OR set up for emergency cesarean
section & possible massive hemorrhage:
o Rapid transfuser
o Massive transfusion protocol
o Blood conservation techniques (cell saver, tranexamic acid,
avoid lethal triad)
6. If emergency cesarean, will likely need GA (provided airway is
reassuring) & titrated induction with ketamine & succinylcholine

Differential Diagnosis for Antepartum Hemorrhage

 Placenta previa (painless)
 Placenta abruption (painful)
 Uterine rupture (true emergency)
 Vasa previa (lethal to fetus, ok for mom)
 Other less serious causes

Conflicts
 Full stomach (RSI) vs. hemodynamic instability & need for titrated
induction
 Difficult airway vs. STAT cesarean section
202
 Breech Presentation

Considerations
1. ↑ risk of maternal mortality, morbidity, & complications (infection,
perineal trauma, hemorrhage)
2. ↑ risk of fetal complications:
o Preterm delivery
o Birth trauma
o Major congenital anomalies
o Umbilical cord prolapse
o Hyperextension of the head
o Spinal cord injuries with deflexion
o Arrest of after-coming head
o Intrapartum asphyxia
o Intrapartum fetal death
3. Considerations of external cephalic version if performed
4. Recommended mode of delivery is cesarean section but vaginal
delivery can be attempted with term singleton with adequate pre-
planning (Canadian guidelines 2009)
5. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)

Management
1. Analgesia for labor:
o Early epidural if possible
o The patient MUST NOT PUSH IN 1st stage of labor → might
push a lower extremity through her partially dilated cervix,
which may result in fetal head entrapment
2. Anesthesia for vaginal breech delivery:
o Delivery preferred in the OR should emergency cesarean be
required → always be ready to convert to GA!
o Epidural strongly recommended
o Very high risk including:
 Umbilical cord compression
 Fetal head entrapment
3. Anesthesia for cesarean delivery:
o Neuraxial or GA
o Possible need for uterine relaxation, have
nitroglycerin available
o May require larger incision or a vertical incision
4. Fetal head entrapment:

203
o Nitroglycerin IV 100-400mcg OR nitroglycerin SL 400-800mcg
o Likely need STAT GA: RSI (propofol/succinylcholine) & start 2-
3 MAC of volatile to relax uterus
o Be ready to support hemodynamics, control hemorrhage

204
 Cervical Cerclage

Considerations
1. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
2. Risk of membrane rupture and degree of cervical dilation may
dictate mode of anesthesia
3. Potential need for uterine relaxation and avoidance of coughing,
straining, position changes that provoke bulging and rupture of
membranes
4. Considerations for fetus:
o Risk of preterm labor and need for fetal monitoring, avoidance
of contraindicated medications (NSAIDS) after 32 weeks

Management
1. Depends on degree of cervical dilation with standard options of
spinal, epidural or GA for transvaginal cerclage
2. Pudendal nerve block often inadequate
3. If no cervical dilation:
o Typically spinal (or epidural) anesthesia requiring a T10 to S4
block (cervix: T10-L1 & vagina / perineum: S2-4)
4. If cervical dilation present:
o Goals: produce adequate analgesia, prevent increase in
intrauterine/intraabdominal pressure
o Type of anesthesia depends on presence of bulging
membranes and need for uterine relaxation:
 Spinal:
 Risk of sitting position and lumbar spine flexion
leading to bulging of membranes, rupture and
subsequent fetal death
 Consider placing spinal/epidural in lateral position
 Dose: 7.5 mg isobaric bupivacaine with fentanyl 15
mcg; alternative is 40 mg lidocaine
 Epidural:
 Midlumbar, 2% lidocaine with 5 mcg/mL
epinephrine (10-15 mL total volume) with 100 mcg
fentanyl for T8 block
 General:
 Indicated if bulging membranes in order to facilitate
uterine relaxation with volatile anesthetics

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  Risks: coughing, bucking, vomiting leading to
rupture of membranes, avoidance of GA in second
trimester in terms of anesthetic exposure to fetus
& risk of preterm delivery as well as risks of GA to
parturient
 CAS monitors, aspiration prophylaxis, left uterine
displacement, RSI, maintain normal CO2, 0.5-1
MAC volatile plus opioid, fetal
monitoring, avoidance of NSAIDS (ductus closure)
5. Removal of cervical cerclage:
o Removed at 37-38 weeks; earlier if rupture of membranes or if
labor begins
o McDonald cerclage suture removal requires no anesthesia
o Shirodkar suture removal requires anesthesia due to suture
epithelialization; options are spinal or epidural
o Some highly epithelialized sutures may require cesarean
section
o If epidural catheter placed consider leaving it in as labor may
ensue within a few hours

206
 Dyspnea in Pregnancy

Considerations
1. Distinguish physiological vs pathological dyspnea
2. Focused differential diagnosis for pathological dyspnea (cardiac vs.
respiratory vs. pregnancy-specific)
3. Perform a thorough physical exam & order appropriate investigations
(e.g. labs, ECG, echo, PFTs, V/Q scan)
4. Liaise with internal medicine/obstetrics to diagnose & treat the
underlying cause
5. Need for intrapartum invasive monitoring & postpartum monitoring in
ICU/high acuity unit
6. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)

Pathological vs. Physiological Dyspnea

Differential Diagnosis
1. Cardiac:
o Cardiomyopathy (dilated/hypertrophic/restrictive)
o Valvular heart disease (AR, AS, MR, MS)
o Pulmonary hypertension & RV failure
o Cardiac ischemia
o Congenital heart disease
o Arrythmias/heart block
o Pericardial (percarditis/tamponade)
2. Respiratory:
o Infections
o Restrictive: interstitial lung disease, cystic fibrosis,
neuromuscular disease, scoliosis
o Obstructive: asthma, COPD
o Pneumothorax

207
 o Anaphylaxis (bronchospasm)
3. Pregnancy-specific:
o Severe preeclampsia/eclampsia
o Amniotic fluid embolism
o Pulmonary embolism (more common post-partum)
o Tocolytic induced pulmonary edema
o Peripartum cardiomyopathy (last month of pregnancy or during
first 5 months post-partum)
o High neuraxial blockade
4. Others:
o Anemia
o Hypothyroidism
o Hepatic dysfunction

208
 External Cephalic Version

Considerations
1. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
2. Must have continuous FHR monitoring during procedure
3. Complications (although uncommon) associated with the procedure:
o Transient & persistent FHR abnormalities
o Vaginal bleeding
o Placental abruption
o Fetomaternal hemorrhage (+ Kleihauer-Betke test)
4. Potential need for STAT delivery (have personnel, equipment, OR
available)
5. Mode of anaesthesia (controversial):
o Have full discussion with obstetrician & patient
o Some evidence that neuraxial may ↑ success rates
o Options: no anesthetic, IV analgesia, neuraxial (low vs high
dose)

209
 Fetal Distress

Considerations
1. Emergency situation with little time to optimize
2. Considerations of pregnancy, full stomach, 2 patients
3. Need for intra-uterine resuscitation & possible need to expedite
delivery
4. Differential diagnosis to consider:
o Maternal shock: excessive epidural/total spinal, sepsis,
hemorrhage, cardiomyopathy
o Maternal Fever
o Cord prolapse
o Placental abruption
o Uterine hypertonus
o Intrathecal narcotics (avoid CSE in women whose fetuses have
decels)
o Pregnancy induced hypertension
o Uterine rupture
o Footling breech
5. Need discussion with obstetrics regarding urgency of the distress &
need for STAT delivery, maternal safety is the guiding factor

Intra-uterine Resuscitation
 Fluid bolus (1-2 L crystalloid)
 Supplemental O2
 Left uterine displacement
 Tocolysis: Stop oxytocin, consider nitroglycerine (1-2 sprays
sublingual or 50-400 mcg IV)
 Vasopressors to maintain uteroplacental perfusion

Reassuring (CLASS I or NORMAL) FHR Pattern

 A baseline fetal heart rate of 110 to 160 bpm
 Absence of late or variable FHR decelerations
 Moderate FHR variability (6 to 25 bpm)
 Early decelerations & accelerations may be present or absent

Non-reassuring (Class III or ABNORMAL) FHR Pattern:

WORRISOME!

210
  Absent baseline FHR variability
 Recurrent late decelerations
 Recurrent variable decelerations
 Bradycardia
 Sinusoidal pattern

Indeterminate (Class II) FHR Patterns: WATCH & SEE

 The fetus may not be acidotic; however, continuation or worsening of
the clinical situation may result in fetal acidosis
 Examples: tachycardia, minimal or marked variability, absent
variability without recurrent decelerations, absence of accelerations
without absent variability, recurrent late or variable decelerations
without absent variability, & prolonged decelerations

211
 Multiple Gestation

Considerations
1. Considerations of pregnancy, full stomach, 3 patients
2. ↑ Maternal complications:
o ↑ aorto-caval compression
o ↑ desaturation
o PPROM
o Preterm labor
o Prolonged labor
o Pre-eclampsia/eclampsia
o Placental abruption
o DIC
o Operative delivery
o Uterine atony
o Antepartum & PPH
3. ↑ Fetal complications:
o Preterm delivery
o Congenital anomalies
o Polyhydramnios
o Cord entanglement
o Umbilical cord prolapse
o IUGR
o Twin-to-twin transfusion
o Malpresentation
o ↑ mortality

Anesthetic Management
 If trial of labor & vaginal delivery as per obstetrics (most obstetricians
allow a trial of labor if both twins have vertex presentation):
o Ensure very good epidural & 2 large bore IV's
o Ensure OR & personnel ready for stat GA at any time
especially for delivery of twin B
o Have nitroglycerine available: uterine relaxation may be
required to facilitate internal version & breech extraction of twin
B
 If cesarean section (more common scenario):
o Ensure 2 large bore IV's & active cross match
o Epidural, spinal, & GA all safe for cesarean section
o Aortocaval compression & rapid desaturation are exaggerated
in this population

212
o Have nitroglycerine ready for uterine relaxation
o Be prepared for post partum hemorrhage, need for
resuscitation & uterotonics
o Neonatal resuscitation team must be present

213
 Non Obstetric Surgery in Pregnancy

Considerations
1. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
2. Maintenance of uteroplacental perfusion:
o FHR monitoring when possible
o Avoid hypoxemia, hypotension, acidosis
3. Risk of preterm labour:
o Obstetrical consult with consideration of steroids for lung
maturity & magnesium for brain protection
4. Surgical considerations of a gravid uterus
5. Anesthetic drug effects on fetus (FHR changes, teratogenicity)

Goals & Conflicts

1. Delay nonelective surgery to the second trimester if possible
2. Optimize & maintain normal maternal physiologic function
3. Optimize & maintain uteroplacental blood flow & oxygen
delivery (guided by FHR monitoring)
4. Preparations for preterm labour:
o Fetal lung maturity
o Availability of NICU
5. Avoid teratogens
6. Avoid stimulating the myometrium (oxytocic effects) to prevent
preterm labour
7. Use regional anesthesia if possible

214
 Peripartum Cardiac Arrest
Considerations
1. Two patients with efforts focused on maternal resuscitation
2. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
3. Need for modified ACLS techniques:
o Supradiaphragmatic IV
o Left uterine displacement
o Chest compressions higher on sternum than usual
o Early intubation
o Prepare for peri-mortem cesarean section; if no ROSC within 4
minutes of resuscitation, aim for delivery within 5 minutes of
resuscitation
4. Rapid diagnosis & treatment of underlying etiology:
o BEAU-CHOPS, H'sT's, MgSO4 toxicity, local anesthetic toxicity
5. Aggressive interventions for difficult resuscitation (cardiopulmonary
bypass, hypothermia, internal cardiac massage)

Differential Diagnosis
BEAU-CHOPS + H'sT's:
 B leeding/DIC
 E mbolism: coronary/pulmonary/AFE
 A nesthetic complications (high spinal, aspiration, failed airway, local
anesthetic toxicity)
 U terine atony
 C ardiac disease (MI/ischemia/aortic dissection/cardiomyopathy)
 H ypertension/preeclampsia/eclampsia
 ther: differential diagnosis of standard ACLS guidelines ("H'sT's")
o Hyper-/hypokalemia, hypothermia, hypovolemia, hydrogen ion
(acidosis), hypoxia
o Tension pneumothorax, tamponade (cardiac),
thrombus (coronary, pulmonary), toxins
 P lacenta abruptio/previa
 S epsis

Gestational Age & Viability

 Fetal viability begins at approximately 24-25 weeks
 Estimate gestational age:
o < 20 weeks: urgent cesarean section need not be considered
because a gravid uterus of this size is unlikely to significantly
compromise cardiac output

215
o 20-23 weeks: consider cesarean section for maternal
resuscitation NOT survival of infant
o > 24 weeks: cesarean section within 5 minutes for maternal
& fetal resuscitation

216
 Peripartum Cardiomyopathy

Background
 Definition: new heart failure that develops in the last month of
pregnancy or in the first 5 months postpartum
 Echocardiogram findings: global dilation & dysfunction, strict criteria
for EF ≦ 45%

Anesthetic Considerations
1. High risk cardiac patient & a very high risk of maternal/fetal M&M
2. Management at a cardiac centre in a multidisciplinary team setting
3. Management of cardiac medications & possible anti-coagulation

Anesthetic Management
 Detailed review of functional capacity, echocardiogram, cardiology
consults, & medications
 Epidural, spinal, & GA are acceptable if goals met
 Neuraxial may be contraindicated if patient anticoagulated
 Set up OR for vasopressors, inotropes
 Manage in a tertiary cardiac centre with invasive monitoring (arterial
line, ± CVP/PAC) + TEE capability
 Post-op ICU

217
 Placental Abruption

Considerations
1. Emergency with high maternal & fetal morbidity/mortality
2. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
3. Need to determine severity of abruption, amount of hemorrhage &
degree of maternal/fetal compromise
4. Comorbidities associated with abruption:
o Hypertension, pregnancy-induced hypertension, smoking,
cocaine, EtOH, advanced maternal age, multiparity, multiple
gestation, trauma, premature rupture of membranes,
polyhydramnios
5. Mobilization of resources & personnel:
o Multidisciplinary (2nd Anesthesiologist/anesthetic assistant,
obstetrician, pediatrician, hematology/blood bank, ICU)
o Resources (rapid infusers, blood products/massive transfusion
protocol, uterotonics/tocolytics, invasive monitoring, tranexamic
acid, cell salvage, rFVIIa)

Management
 Urgency of delivery depends on severity of abruption
 Establish large bore IV access, draw blood work, ensure close
maternal & fetal monitoring, cross match & prepare for massive
hemorrhage
 Labor & vaginal delivery with epidural is safe for partial abruption
without significant hypovolemia or coagulopathy
 Urgent cesarean for more significant abruption with maternal or fetal
compromise:
o GA with RSI (ketamine & succinylcholine) if hemodynamic
compromise
o Aggressive volume resuscitation
o Invasive monitors
 Control & treat hemorrhage:
o Massive transfusion protocol, rapid infuser, avoid
acidosis/hypothermia/coagulopathy
o Use of uterotonics
o Blood conservation techniques: tranexamic acid, cell saver,
rFVIIa, surgical technique

218
 Postpartum Hemorrhage (PPH)

Considerations
1. Emergency situation, little time to optimize
2. Physiological changes of pregnancy, Full stomach
3. Determine severity of hemorrhagic shock & resuscitate to goal end-
points
4. Ddx for PPH:
o Tone: Uterine atony (by far most common)
o Tissue: Retained product, Placenta accreta
o Trauma: Lower genital tract lacerations, Vascular injury
o Thrombin: Coagulopathy
 Aquired (ITP, PIH, DIC, TTP)
 Prexisting (vWD, hemophilia)
o Turn out: Uterine inversion
5. Avoid the lethal triad: hypothermia, acidosis, coagulopathy
6. Multidisciplinary management & need for extra help
7. Consider early intubation if patient deteriorating

Anesthetic Management
1. Simultaneous diagnosis & management
2. Get extra help, liaise with Obstetrics re: type of bleed
3. Resuscitate to goal end-points & declare massive transfusion if
appropriate
4. Treat hypothermia, acidosis, coagulopathy
5. Send off frequent blood work including CBC, ABG, Lactate,
INR/PTT/Fibrinogen, Ca
6. Uterotonics:
o Oxytocin = 1st line: 5 IU IV push, then 20-40 IU in 250 mL of
normal saline, infused IV at 500-1000 cc/hr
o Hemabate: IM 0.25 mg, q15min PRN (max 8
doses). Contraindications: asthma, pulmonary HTN,
hypoxemia
o Ergot: IM 0.2-0.25 mg, IV 0.125-0.25 mg. Contraindications:
HTN, pre-eclampsia, CAD
o Misoprostol: PR 800-1000 mcg, Buccal/SL 400-600 mcg
7. Gather resources: rapid infusers, blood products/MTP,
uterotonics/tocolytics, invasive monitoring, TXA, cell salvage, rFVIIa
8. Utilize blood conservation: Cell saver, Tranexamic acid (TXA),
possible rFVIIa

219
9. Consider surgical control of bleeding: Bilateral uterine massage, B
lynch suture, packing, aortic cross clamp, uterine artery ligation,
embolization (IR), hysterectomy
10. If intubating:
o Pre-induction arterial line if possible
o Anti-acid prophylaxis
o Titrated induction & accept aspiration risk
o Ketamine as induction medication

220
 Preeclampsia

Considerations
1. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)
2. Multisystem disease:
o Airway: edema → even more difficult
o CNS: seizures, intracranial hemorrhage (ICH), cerebral
edema, ↑ ICP
o Respiratory: pulmonary edema (secondary to
hypoalbuminemia & hypertension)
o CVS: relatively hypovolemic, ↑ SVR, hyperdynamic,
hypertensive crisis, LV dysfunction
o Renal dysfunction: oliguria, ATN
o Coagulopathy: thrombocytopenia, MAHA, risk of DIC
o HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets)
3. ↓ uteroplacental perfusion, IUGR, placental abruption, premature
labour & delivery
4. Medications: antihypertensive/anticonvulsant therapy (including risk
of MgSO4 toxicity)
5. Potential delivery & resuscitation of premature infant:
o Steroids if gestational age < 34+6
o MgSO4 for neuroprotection if gestational age < 31+6
6. Consider delivery:
o If severe preeclampsia at any gestational age
o If non-severe preeclampsia > 37 wks gestational age

Goals
 BP control (sBP <160 mmHg, dBP <110 mmHg) (SOGC 2014)
 Prevent end-organ complications (seizures, ICH, ischemia)
 Optimize fluid status
 Optimize uteroplacental perfusion
 Excellent labour analgesia to mitigate adverse effects of pain
 Prevent complications if general anesthesia:
o Failed airway
o Hypertensive crisis

Anesthetic Options
1. Anesthetic technique depends on:
o Fetal distress

221
 o Airway assessment
o Platelets/coagulation profile
2. Choices:
o Epidural:
 Preferred technique
 Allows for titration of local anesthetic & IV fluids
(minimizes risk of BP fluctuations & pulmonary edema)
 If using for cesarean, consider not adding epinephrine
(may decrease uteroplacental perfusion)
o Spinal:
 Traditionally relatively contraindicated in severe
preeclampsia for fear of marked hypotension, but recent
studies (as per Chestnut) suggest spinal may
be appropriate
o GA:
 Least desirable
 Risk of ICH from hypertension secondary to intubation
& ↑ possibility of difficult intubation secondary to airway
edema
3. Chestnut suggests the following for platelets:
o < 50: neuraxial technique contraindicated
o 50-80: risk vs benefit (consider trend, function, other
coagulation investigations)
o > 80: likely safe
o SOGC 2014 guidelines suggest > 75 is safe unless
coagulopathy, falling platelet count or other antiplatelet agents

Management of Eclamptic Seizure

1. SOGC 2014 guidelines:
o Primary immediate goals:
 Stop convulsions with MgSO4 (4g bolus over 20min, then
1g/hr)
 Establish a patent airway
 Prevent major complications (e.g., hypoxemia,
aspiration)
 Phenytoin & benzodiazepines should NOT be used for
eclampsia prophylaxis or treatment, unless there is a
contraindication to MgSO4 or it is ineffective
2. Further obstetric management:
o Antihypertensive therapy (labetolol 10-20mg IV or hydralazine
5-10mg IV)
o Induction or augmentation of labor
o Expeditious (preferably vaginal) delivery

222
 o Fetal bradycardia typically occurs during &/or immediately after
a seizure but does not mandate immediate delivery unless it is
persistent
3. Considerations of magnesium therapy:
o Interaction with NdMRs (nondepolarizing muscle relaxants):
 Increases the potency & duration of NdMRs
(titrate/reduce dose)
 Directly inhibits acetylcholine release & postmembrane
sensitivity to acetylcholine
 No change in succinylcholine (onset & duration
unchanged, use standard dose)
o Effects on uterine tone:
 Potential PPH as a tocolytic agent; however, studies
demonstrate no increase in blood loss
 Have uterotonics available, group & screen completed
o Interaction with calcium channel blockers (specifically
nifedipine)
o Possibly greater hypotensive effects

223
 Uterine Inversion

Considerations
1. Emergency situation
2. Postpartum hemorrhage with need for massive transfusion
3. Facilitation of uterine reduction: tocolytics (nitroglycerin, volatile
anesthetics)
4. Treatment of uterine atony after reduction (medical & surgical)
5. Pregnancy considerations (difficult intubation, aspiration, ↓ time to
desaturation, aortocaval compression, 2 patients)

Goals & Conflicts

 RSI in the setting of a patient in hypovolemic shock
 Safely manage airway avoiding aspiration & hypoxemia
 Aggressive fluid resuscitation
 Close communication with obstetrician during titration of tocolytic
therapy

Management
1. Confirm diagnosis: postpartum hemorrhage, hypovolemic shock,
mass in introitus/vagina
2. Mobilize resources, obstetrician STAT, establish management plan:
o To OR for definitive treatment
o Assemble skilled help
o Notify blood bank, prepare for massive transfusion
3. Begin fluid resuscitation, large bore IV access, rapid transfuser, blood
products to OR
4. Tocolytic therapy: nitroglycerin 100-400 mcg IV boluses (chase with
phenylephrine boluses), volatile anesthesia following RSI (low dose
or no ketamine)
5. Followed by uterotonic therapy:
o Oxytocin 40 units per 1 L crystalloid or duratocin 100mcg IV
slow push
o Ergonovine 0.2mg IM & 0.2mg IV slow push
o Carboprost (hemabate) 0.25mg IM or intramyometrial
o Misoprostol 800-1200mcg rectal

224
PEADIATRICS

225
 Contents

Topic Page No.

1 Airway Foreign Body 227
2 Bronchopulmonary Dysplasia 229
3 Cerebral Palsy 231
4 Cleft Lip & Palate 232
5 Congenital Diaphragmatic Hernia 233
6 Craniofacial Dysostosis 235
7 Croup/Laryngotracheobronchitis 236
8 Down Syndrome 237
9 Duschenne Muscular Dystrophy 238
10 Epiglottitis 239
11 Fontan Physiology 240
12 Former Premature Infant 243
13 Mucopolysaccharoidosis 244
14 Necrotising Enterocolitis 246
15 Omphalocele & Gastroschisis 247
16 Pediatric Patient 248
17 Pierre Robin Syndrome 249
18 Premature Infant 250
19 Pyloric Stenosis 251
20 Scoliosis 253
21 Tetrology of Fallot 254
22 Tonsillectomy 256
23 Tracheoesophageal Fistula 257

226
 Airway Foreign Body (FB)

Considerations
1. Emergency, full stomach/aspiration risk
2. Pediatric patient considerations
3. Potential for airway obstruction & respiratory complications:
o Ball-valve effect & barotrauma
o Bronchospasm, laryngospasm
o Edema
o Post obstructive pneumonia/sepsis
4. Rigid or flexible bronchoscopy, esophagoscopy:
o Shared airway
o Immobility required
o Ventilatory strategies, spontaneously-breathing method
preferred

Goals
1. Maintain spontaneous ventilation (avoid hyperinflation/barotrauma,
FB dislodgement/airway obstruction)
2. Provide adequate analgesia for rigid bronchoscopy (avoid
coughing/airway trauma)
3. Effective teamwork with ENT throughout
4. Prevent airway complications

Conflicts
1. Uncooperative patient vs. spontaneous ventilation
2. Deep anesthesia vs. spontaneous ventilation
3. Shared airway vs. ventilation/oxygenation/deep anesthesia

Optimization
1. Establish IV
2. ENT STAT, call for OR & second anesthesiologist or anesthesia
assistant
3. Hold child in position of comfort if upper airway FB or with affected
lung down if lower airway FB
4. Bronchodilators
5. Humidified O2, heliox
6. Aspiration prophylaxis (can delay case for 8 hrs if child stable)
7. Dexamethasone to reduce swelling
227
 8. Glycopyrrolate to dry secretions
9. Spontaneously breathing induction methods:
o Total IV anesthesia:
 Titrate to RR 12-16 or 50% of baseline before stimulation
of the child
o Inhalational with sevoflurane
10. Once anesthesized, perform staged stimulation/laryngoscopy &
topicalization with lidocaine
o Staged approach example steps:
 Jaw thrust
 Insert oral airway
 Do direct laryngoscpy & spray with lidocaine

Complications
 Bronchospasm
 Laryngospasm on awakening
 Inadequate ventilation
 Pneumothorax, BPF (ball valve)
 Unable to ventilate, hypoxemia
 Complete airway obstruction:
 Push FB into a mainstem bronchus
 Hypertension, tachycardia, tachyarrhythmias
 Pulmonary hemorrage
 Post obstructive pneumonia

228
 Bronchopulmonary Dysplasia (BPD)

Background
 BPD is a clinical diagnosis defined as O2 dependence at 36 weeks'
postconceptual age or O2 requirement (to maintain PaO2 > 50 mm
Hg) beyond 28 days of life in infants with birth weights of less than
1500 g
 Most significant symptoms in 1st year of life, many with mild disease
become asymptomatic but reactive airways may remain

Considerations
1. Pulmonary dysfunction:
o Hypoxemia & hypercarbia
o Hyperinflation & bullae
o Reactive airways disease
2. Associated pulmonary hypertension, RV dysfunction & risk of
perioperative pulmonary hypertension crisis/RV failure
3. Post-op disposition & pain management:
o Maximize ventilatory function to decrease complications
o Regional, neuraxial & adjuncts whenever possible
4. Former premature infant with possible previous intubation
o Airway: subglottic stenosis, tracheomalacia/bronchomalacia
o CNS: seizures, hydrocephalus, cerebral palsy
o Cardiovascular: PDA, cardiomyopathies
o GI: GERD, malnutrition, swallowing problems (risk of
aspiration)
5. Management of medications:
o Diuretics
o Stress dose steroid if on chronic steroids

Optimization/ Management
 Treat & optimize any acute respiratory decompensation
 Regional if possible
 If GA:
o Deep anaesthesia
o Ventilatory settings as asthma (longer expiratory time, slow-
normal RR)
o Consider LMA to avoid tracheal stimulation
 Avoid ↑ PVR:

229
o Avoid hypoxia, hypercapnia (although mild hypercapnia is ok
given they have obstructive pattern), acidosis, sympathetic
surges, ↑ airway pressures, hypothermia

230
 Cerebral Palsy (CP)

Background
1. A disorder of movement & posture due to a static encephalopathy
2. Huge spectrum of presentation: almost asymptomatic to completely
dependent
3. Caused by a cerebral insult in the immature brain that occurred
prenatally, perinatally, or during infancy
4. The motor deficit may manifest as:
5. Hypotonia
o Spasticity
o Extrapyramidal features such as choreoathetoid/dystonic
movements or ataxia

Considerations
1. ↓ C-spine mobility & possible difficult intubation
2. Aspiration risk (GERD/↓lower esophageal sphincter tone)
3. Pulmonary:
o Recurrent aspiration & pulmonary impairment
o Scoliosis & ↑ bleeding risk during scoliosis surgery
o Rule out pulmonary HTN/RV failure
4. CNS:
o Developmental delay/lack of cooperation
o Seizure d/o
o Hydrocephalus
5. Altered response to anesthetics:
o ↓ MAC of volatiles & longer emergence
o ↑ sensitivity to muscle relaxants
o Volatiles & succinylcholine NOT contraindicated
6. Difficult IV access, monitoring, & positioning due to contractures
7. Ex-premature conditions
8. ↑ risk of hypothermia

231
 Cleft Lip & Palate

Considerations
1. Potential difficult airway (especially bag mask ventilation):
o Careful airway plan required
o Ensure direct laryngoscope does not enter cleft!
2. Swallowing dysfunction:
o Lung soiling, restrictive lung disease
o Malnutrition
3. Associated craniofacial disorders/congenital diseases:
o Pierre-Robin
o Cogenital heart disease in 20%
4. Post-op airway complications:
o Laryngospasm
o Edema/obstruction (surgery makes airway management more
difficult)

Goals
1. Assess airway for bag mask ventilation, laryngoscopy, & establish
sequential airway plan
2. Evaluate for congenital heart disease & other congenital
abnormalities
3. Safe post-op airway management

232
 Congenital Diaphragmatic Hernia

Background
 Diaphragmatic hernia with intestinal contents in chest
 90% left sided
 Lung will be underdeveloped & newborn could have persistent
pulmonary hypertension
 Delayed surgery is preferred to stabilize prior to closure
 Conventional ventilation with permissive hypercapnia is now
favoured
 Other therapies:
o Surfactant
o High-frequency oscillatory ventilation, in addition to nitric oxide

Considerations
1. Emergency situation
2. Critically ill neonate
3. Hypoplastic lungs:
o Respiratory insufficiency (hypoxemia, hypercarbia, acidosis)
o Permissive hypercarbia may be required
o Consider HVO or ECMO
4. Pulmonary hypertension:
o Potential for RV failure/↓ cardiac output
o Consider inhaled nitric oxide
5. Transitional circulation:
o Potential for R→L & L→R shunting
o PDA
6. Delayed surgical repair, resuscitation is first priority
7. NICU required

Resuscitation
1. Call NICU
2. Indication for immediate intubation (no bag mask ventilation)
3. NG to decompress stomach
4. ABG, chest x-ray, echocardiogram
5. Umblical artery/vein lines
6. Lung protective ventilation strategy:
o Target SaO2 > 85% & permissive hypercapnia (PaCO2 <65
mmHg, pH >7.25)
o PCV or PSV PIP < 25 cmH2O

233
 o Inspiratory time 0.35 s
o PEEP 3-5 mmHg
o RR < 65
o Consider HVO, iNO or ECMO
7. Pulmonary hypertension:
o Consider inhaled nitric oxide
o Inotropes
8. Fluid: target MAP 45-50 mmHg
9. Sedation: opioids & benzodiazepines, thoracic epidural
10. Avoid NMB

234
 Craniofacial Dysostosis (Alperts, Crouzons,
Pfeiffers)

Background
 Alpert syndrome:
o Difficult bag mask ventilation (high arched palate, choanal
atresia)
o Difficult airway: cervical spine fusion, tracheal stenosis
o ↑ ICP
o Congenital heart disease (10%) & other malformations
o Developmental delay
o Syndactyly
 Crouzons:
o Difficult bag mask ventilation & intubation. Patients may be
significantly obstructed requiring early tracheostomy
o Mild developmental delay
o No visceral or extremity invovement
o Potential for ↑ ICP

Considerations
1. Pediatric patient
2. Difficult airway: BMV, intubation:
o Midface hypoplasia
o Airway obstruction (OSA)
3. CNS:
o May have ↑ ICP
o Visual loss, developmental delay
4. For skull surgery:
o Long surgery (blood loss, hypothermia, positioning injuries)
o Venous air embolism
5. Discharge to PICU

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 Croup/Laryngotracheobronchitis

Considerations
1. Pediatric patient considerations
2. Possible airway difficulty & complications:
o Consider double set-up, rigid bronchoscope, spontaneously
breathing patient
o Obstruction, laryngospasm
o Respiratory fatigue/failure
o Super infection with bacterial trachietis possible
3. Dehydration, need for volume replacement
4. PICU & extubation plan

Treatment
1. Nebulized epinephrine 0.5 ml/kg of 1:1000 to max 5 ml q15-20 min
2. Dexamethasone 0.6 mg/kg PO or 0.15-0.3 mg/kg IV
3. Budesonide 2 mg via neb (2 ml)
4. Humidified O2
5. Heliox
6. Approach to intubation:
o Perform in OR with difficult airway cart & ENT +/- rigid
bronchoscopy
o Use small endotracheal tube, cuffed & stylet

236
 Down Syndrome

Considerations
1. Potential for atlanto-axial (AAI) or atlanto-occipital instability &
neurologic injury with neck manipulation
2. Potential for difficult bag mask ventilation (but not usually intubation):
o Large tongue,↑ oropharyngeal soft tissue, small mouth,
subglottic stenosis, high arched palate
o Tonsillar & adenoid hypertrophy
3. Possible obstructive sleep apnea:
o Pulmonary hypertension/RV dysfunction
o Sensitive to sedatives/hypnotics
4. Developmental delay/cooperation problems
5. Associated congenital heart disease (up to ½):
o Cushion defect (AVSD) = #1
o VSD, ASD, TOF
o Pulmonary hypertension
6. Other medical issues:
o Obesity
o Accelerated coronary disease & valvulopathy (MVP, AI)
o Hypothyroidism
o GI: duodenal atresia or stenosis, TEF, Hirschsprungs, celiac
disease
o Heme: polycythemia, leukemia, immune deficiency
o Joint laxity (careful with positioning)
o Early Alzheimer’s dementia

Goals
1. Rule out & manage AAI: neurologic exam/history & flexion-extension
views of c-spine
2. Airway adjuncts such as a video laryngoscope
3. Skin topicalization for IV start
4. Sedation (midazolam may be paradoxical)
5. Arrange post-op monitoring
6. Overnight oximetry useful

Conflicts
 Unstable C-spine vs uncooperative patient with developmental delay:
o Consider IM/PO sedation to facilitate IV placement
 Ketamine 5 mg/kg IM, 7 mg/kg PO
 Midazolam 0.5 mg/kg PO (max dose 20 mg)
o Inhalational induction may be problematic in an adult with
DS due to obesity, OSA, uncooperative nature

237
 Duchenne Muscular Dystrophy

Background
 X-linked recessive degenerative disease of skeletal & smooth muscle
that usually first manifests in males of 2-5 years of age
 Becker muscle dystrophy is essentially a milder form of Duchenne

Considerations
1. Possible difficult airway if macroglossia
2. Aspiration risk: bulbar weakness, ↓ gastric motility
3. Succinylcholine/volatile anesthetics contraindicated due to
rhabdomyolysis/hyperkalemia risk, use total IV anesthesia
4. Pulmonary:
o Possible obstructive sleep apnea:
 Sensitivity to sedatives/hypnotics
 Pulmonary hypertension/RV failure
o Restrictive lung disease from scoliosis & respiratory muscle
weakness
o Risk of perioperative respiratory failure
o Impaired cough reflex (atelectasis, recurrent aspirations)
5. Cardiovascular:
o Dilated cardiomyopathy:
 Tall R waves in precordial leads, ↑ R:S, deep Q in I, aVL,
V5-6
o Mitral regurgitation common (due to papillary muscle
involvement from LV dilation)
o Conduction defects & arrhythmias common (atrial, SVT, AV
nodal)
6. CNS: mild cognitive impairment is common
7. Medications: ACE inhibitors, beta-blockers, steroids (may need
stress dose)

Conflicts
 RSI vs. succinylcholine
 Prolonged postoperative ventilation
 Advanced directive discussions

238
 Epiglottitis

Considerations

1. Impending airway obstruction:

o Difficult bag mask ventilation & intubation
o Do not upset child or manipulate airway
2. Emergency: risk of aspiration, ↓ time to optimize
3. Sepsis & need for early goal-directed therapy
4. Pediatric patient considerations
5. Post-op disposition: PICU & plan for extubation once process
resolved

Management
1. Call for ENT ("double set up") & maintain spontaneous ventilation
2. Use smaller endotracheal tubes (1-3mm smaller)
3. OR set up with second anesthetist or anesthesia assiant & difficult
airway cart, rigid bronchoscopy & tracheostomy set
4. Skin topicalization for IV start
5. Obtain CBC & blood cultures
6. Fluid bolus 20 ml/kg, repeat prn
7. Aspiration prophylaxis ranitidine 0.5 mg/kg & maxeran 0.1 mg/kg
8. Glycopyrrolate 10 mcg/kg to dry secretions
9. Small styletted ETT (cuffed preferable)
10. Spontaneouly-breathing induction with sevoflurane or
propofol/remifentanil if IV, then intubate
11. IV antibiotics, fluids, PICU post-op:
o Antibiotics: cloxacillin, cetriaxone, ampicillin, clindamycin +/-
vancomycin
12. Extubation plan: ensure there is a leak & swelling has
resolved. Then extubate in the OR & be prepared for re-intubation
13. Don't use steroids empirically but consider if extubation has proven
difficult after several days of antibiotic therapy

239
 Fontan Physiology
Background

 Fontan is a palliative procedure for patients with functional

univentricular physiology
 Selection criteria for performance of Fontan are: adequately sized
pulmonary arteries; low PVR; good LV function & the presence of
sinus rhythm
 The driving force for blood flow through the pulmonary circulation is
the difference between central venous pressure (CVP) & atrial
pressure
o There is no active pumping of blood through the lungs
o Cardiac output is essentially completely dependent on
pulmonary blood flow
o Therefore, hypovolemia is tolerated very poorly

Considerations
1. Congenital heart disease patient with altered cardiac anatomy &
potentially other congenital anomalies
2. Hemodymanic & ventilatory goals of Fontan circulation (see below)
3. High risk cardiac patient:
o Consider surgery at tertiary cardiac centre
o Consultation with cardiology
o Perioperative TEE invaluable
4. Single ventricle pathophysiology:
o Venous congestion: protein loosing enteropathy, kidney
disease, hepatic failure, failure to thrive
o Arrhythmias, embolic stroke, anticoagulation
o LV dysfunction
o Hypoxemia & hyperviscosity
5. Medication management (possible beta blockers, ACE
inhibitors, anticoagulants, diuretics)
6. Consideration of bacterial endocarditis prophylaxis if applicable
7. Possible ↑ risk of bleeding
8. Postoperative monitoring in HAU/ICU

Anesthetic Principles

1. Hemodynamic principles:
o Systemic venous pressure: keep full/avoid dehydration
o Pulmonary vascular resistance (PVR) = keep low:

240
  Avoid hypercarbia, hypoxemia, acidosis, stress, pain,
high intra-thoracic pressures
o Cardiac rhythm: strict sinus
o Ventricular function: maintain
o Systemic vascular resistance: maintain
2. Fluid management: guided by CVP or TEE (TEE very useful)
o Vascular capacitance is ↑ in the Fontan patient; more fluid may
be required than anticipated based on the formula commonly
used to calculate fluid requirements.
3. Ventilatory strategy:
o Spontaneous ventilation is best as it enhances venous return &
pulmonary blood flow
o For PPV: limit peak inspiratory pressure (< 20 cmH2O), use
low respiratory rates (< 20 bpm), short inspiratory times, avoid
excessive PEEP, moderately elevated tidal volumes (10–15
mL/kg), ensure adequate intravascular volume.
4. ↑ bleeding potential: coagulation factor deficiencies, antithrombotic
therapy, venous collaterals, & venous hypertension
5. Postoperative concerns:
o Maintaining volume status, acid-base balance, & cardiac output
are essential in the postoperative period: ensure adequate
hydration & aggressively manage low cardiac output with
IV hydration & inotropes
o Adequate analgesia improves pulmonary mechanics &
oxygenation; enhanced vigilance is required to avoid the
effects of hypercapnia secondary to opioids
o Treat postoperative nausea & vomiting to permit adequate
hydration, prevent dehydration & electrolyte loss, & allow the
patient to resume their medication regimen

Pregnancy Considerations

1. Case reports exist

2. Titrated epidural is probably the safest technique as it does not
worsen PVR; caution with ↓ in preload so ensure well-hydrated,
reduction in afterload is probably desirable
3. Labor is NOT contraindicated, but needs to occur in a cardiac centre
with invasive monitoring (arterial line) & with assisted 2nd stage
4. If cearean section: best to use epidural technique
5. If GA required, use strategies mentioned above

Laparoscopy Considerations
1. Case reports exist
2. Detailed discussion with surgeon ahead of time
241
3. Minimize insufflation pressures or do staged insufflation & see effects
4. Avoid high intrathoracic pressures, ↓ preload, & hypercarbia
5. If cannot tolerate, may need an open technique

242
 Former Premature Infant

Considerations
1. Current post conceptual age & apnea risk
2. Congenital anomalies or syndromes
3. Complications of prematurity:
o Airway: tracheal stenosis & malacia, subglottic stenosis,
aspiration risk from GERD
o Pulmonary: bronchopulmonary dysplasia, reactive airways,
bullae, O2 dependency
o Cardiovascular: cardiomyopathy, persistent pulmonary
hypertension of the newborn (PPHN)
o CNS: intraventricular hemorrhage, intracranial
hemorrhage, cerebral palsy, hydrocephalus, seizure disorders
o Others:
 Retinopathy of prematurity
 GERD/swallowing difficulties
 Kidney disease

243
 Mucopolysaccharidosis (Hunters and Hurlers)

Background

 The mucopolysaccharidoses (MPS) are the result of a deficiency of

lysosomal enzymes that cleave mucopolysaccharides
(glycosaminoglycans)
 An accumulation of mucopolysaccharides occurs in the brain, heart,
liver, bone, cornea, & tracheobronchial tree. There are seven types
& several subtypes of MPS, each with various clinical presentations
 Multisystem diseases but airway is the main concern:
o difficult intubation 53%
o failed intubation 23%

Considerations
1. Review the patient's particular type of mucopolysaccharidoses &
clinical features
2. Airway:
o Difficult to impossible airway (BMV & DL) that worsens with
time:
 Macroglossia
 Hyperplasia of adenoids, tonsils, pharyngeal tissue
 Friable tissues
 ↓ TMJ
o Possible atlantoaxial instability (only for Morquio’s or MPS-IV)
o Difficult surgical airway (short neck, retrosternal trachea)
3. Respiratory:
o RLD: recurrent pulmonary infections, pectus excavatum
& kyphoscoliosis
o OSA, pulmonary hypertension
o Possible need for post-operative ventilatory support
4. Cardiac:
o Cardiomyopathy
o Diffuse CAD from coronary artery deposition
o Valvulopathy: AI, MR
5. Neuro:
o Potential developmental delay, uncooperative
o Dural thickening can result in compressive myelopathy
o Developmental delay

244
 o Hydrocephalus
6. Others:
o Hepatosplenomegaly
o Hepatic dysfunction
o Periop risk of hypoglycaemia
o Metabolic acidosis due to inability to convert lactic acid to
glycogen (avoid ringer’s)
o Hemorrhagic diathesis due to platelet dysfunction

Goals
1. Safe establishment of airway:
o Consider awake fiberoptic intubation
o If uncooperative: spontaneous breathing fiberoptic intubation
o Surgical backup for rigid bronchoscopy & tracheostomy
immediately available
2. Avoid/minimize resp-depressants if possible
3. Perioperative monitoring of of serum glucose, minimization of fasting
times when possible
4. Pre-operative identification & optimization of cardiac system

245
 Necrotizing Enterocolitis

Considerations

1. Premature infant considerations

2. ↑ risk of aspiration:
o Bowel obstruction, dilated bowel loops, pneumatosis
intestinalis
3. Associated multisystem derangements:
o Hypoxia
o Sepsis, hypovolemia
o DIC, thrombocytopenia
o Metabolic acidosis
4. Associated conditions:
o Birth asphyxia, hypotension, respiratory distress syndrome,
patent ductus arteriosus, recurrent apnea, intestinal
ischemia, systemic infections

Goals/Conflicts

1. Optimize multisystem abnormalities of prematurity

2. Prevent aspiration (consider RSI):
o Conflict with sepsis/hypovolemia & hemodynamic stability
3. Anticipate & optimize fluid, electrolyte, glucose derangements
4. Ensure good IV access (or central line above the diaphragm)
5. Ensure continuous temperature monitoring & maintain normothermia
6. Correction of coagulopathy

246
 Omphalocele and Gastroschisis

Background
1. Both are defects of anterior abdominal wall that permit external
herniation of abdominal viscera
2. Omphalocele: contents are covered by a sac formed by the
peritoneal membrane (up to 3/4 of omphalocele cases are associated
with other congenital defects including cardiac anomalies & trisomy
21)
3. Gastroschisis: hernia sac does not cover the herniated abdominal
viscera. Therefore, the bowel is exposed to the external
environment

Considerations
1. Neonate considerations
2. Sequelae of open abdomen:
o Aspiration
o Hypothermia
o Fluid & electrolyte abnormalities
o Sepsis
3. Discussion with surgeon regarding primary versus staged closure
4. Abdominal compartment syndrome after closure:
o Shock/cardiac dysfunction, ↓ venous return
o Acute kidney injury
o Restrictive lung disease/respiratory failure
o ↓ splanchnic & liver blood flow (prolonged drug effect)
5. Congenital heart disease considerations if present with omphalocele

Management
1. Needs RSI or awake intubation
2. Needs muscle relaxation for closure
3. Arterial line likely needed
4. Potential for fluid shifts + need for ongoing resuscitation
5. Avoid hypovolemia, coagulopathy, acidosis, hypothermia
6. Likely back to NICU intubated

247
 Pediatric Patient

Considerations
1. Uncooperative patient
2. Altered airway anatomy
3. ↑ risk of laryngospasm
4. Rapid desaturation on induction
5. ↑ vagal tone & potential for bradycardia
6. Rate-dependent cardiac output
7. Altered phamacokinetics/dynamics:
o ↑ MAC
o Immature liver & kidney function
o ↑ total body water

248
 Pierre Robin Syndrome

Considerations
1. Pediatric patient considerations
2. Difficult airway due to micrognathia, mandibular hypoplasia,
glossoptosis:
o Improves with age
o Difficult bag mask ventilation & intubation
3. Obstructive sleep apnea:
o Pulmonary hypertension, cor pulmonale
o Negative pressure pulmonary edema
o May need to be nursed prone
4. GERD, aspiration pneumonias

Airway Management
1. If intubation required:
o May be impossible: maintain spontaneous ventilation
o Inhalational induction vs. titrated TIVA induction followed by
asleep fibreoptic intubation
o Strongly consider having an ENT surgeon equipped with a rigid
bronchoscope on standby
o Airway obstruction:
 Oral & nasal airways, pull tongue forward, consider
suturing to lip, prone position
 LMA placement followed by fibreoptic intubation through
the LMA
 Nasal fiberoptic bronchoscopy
 Lightwand
2. If intubation not required (e.g. myringotomy & tubes):
o IV/IH induction followed by LMA placement
o Attempt to maintain SV
o If airway obstruction occurs, paraglossal laryngoscopy may
relieve obstruction & allow oxygenation to resume
o Maintain with TIVA

249
 Premature Infant

Considerations
1. Altered airway anatomy
2. Other physiologic derangements of prematurity:
o Pulmonary: respiratory distress syndrome, bronchopulmonary
dysplasia, rapid desaturaiton, post-op apnea, persistent
pulmonary hypertension
o Cardiovascular: HR/preload dependant cardiac output,
transitional circulation/PDA, bradycadia, congenital heart
disease
o CNS: intraventricular hemorrhage, seizures, retinopathy of
prematurity, apnea
o GI: GERD, NEC
o Metabolic: Impaired temperature & glucose regulation
o Hematology: anemia, thrombocytopenia
3. Altered pharmacology:
o ↑ volume of distribution
o Opioid sensitivity
o ↓ clearance, protein binding, metabolism, ↓ MAC
o Immature renal & hepatic function
4. Difficult IV access
 Post op apnea monitoring

Goals

1. Ensure optimization of multisystem derangements including

respiratory, cardiovascular, hepatic, renal, hematological
2. Anticipate fluid, electrolyte, glucose derangements, & optimize
preoperatively
3. Ensure continuous temperature monitoring & maintain normothermia

250
 Pyloric Stenosis

Considerations
1. Medical but not surgical emergency
2. Infant considerations
3. High aspiration risk
4. Resuscitation of metabolic derangements:
o Hypovolemia
o Metabolic alkalosis
o Hypochloremia
o Hyponatremia
o Hypokalemia
5. Post-op dispostion & apnea monitoring

Goals
1. Correction of volume deficit & acid/base & electrolyte abnormalities
prior to pylormyotomy
2. Prevent aspiration (OG/NG, RSI)
3. Appropriate post-operative apnea monitoring

Conflicts
 Resuscitation vs. surgical timing
 RSI vs. hypovolemia

Optimization & management

1. Restore intravascular volume:
o NS 10-20ml/kg IV boluses
o Maintenance D5/NS + KCl 20-40 mEq/L
o Clinical signs to assess (HR, BP, fontanelles, mucous
membranes, skin turgor, urine output, capillary refill)
2. Correct electrolyte & acid/base disturbances:
o Na > 130
o K>3

251
 o Cl > 90
o HCO3 < 27
o Urine output > 1cc/kg/hr
3. Vital signs normal for age (HR ~150, SBP >/= 60)
4. Empty stomach: OG/NG in supine, lateral x2
5. RSI or awake intubation, suggested RSI method with cricoid applied:
o NG suction in supine/R+L lateral
o Atropine 20mcg/kg
o Propofol 3mg/kg & succinylcholine 2mg/kg
6. Post-op analgesia
o Avoid narcotics post-op
o Preop PR acetaminophen 40 mg/kg
o Local anesthetic infilitration (BPV 0.25% 1cc/kg)
7. Post-op apnea monitoring

252
 Scoliosis

Considerations
1. Etiology: idiopathic vs. non-idiopathic:
o Associated comorbidities (Marfan’s, NF Scheurmann’s disease,
DMD, congenital)
2. Potential difficult airway secondary to back curvature, neck
involvement
3. Restrictive lung disease:
o pHTN with cor pulmonale; postop respiratory failure; prolonged
ventilation
4. Cardiac involvement with idiopathic (MVP), Duchenne muscular
dystrophy (CM, coarctation, CHD)
5. Surgical consideration: worse for kyphoscoliosis
o Blood loss; hypothermia; airway edema;
o Positioning:
 Prone: VAE, positioning injuries, POVL
 Lateral: OLV if thoracic approach
o Monitoring: wake-up test/SSEP/MEP’s
6. Post-op pain control: clonidine, gabapentin, ketamine, opioids

Goals/Conflicts

1. Avoid exacerbations of pHTN (hypoxemia, hypercarbia, acidosis,

hypothermia, light anesthesia & pain)
2. Balance perfusion pressure to spinal cord vs. need for mild
hypotension to minimize blood loss:
o TXA, cell saver
3. Manage anesthetic agents to allow adequate monitoring of spinal
cord integrity (SSEPs/MEPs)
4. Vigilance for life threatening complications of VAE or major vascular
injury
5. Optimize for postoperative wean from ventilation:
o Dexmedetomidine, ketamine, acetaminophen, morphine
infusions

253
 Tetralogy of Fallot

Background
Congenital heart defect resulting in right to left shunt, characterized by:

1. Large VSD
2. Aorta that overrides RV & LV
3. RVOT obstruction
4. Right ventricular hypertrophy

Considerations

1. Complex congenital heart disease with high risk of perioperative

cardiac complications
2. Both fixed & dynamic RVOT obstruction:
o Fixed RVOT obstruction: variable R → L shunt & pulmonary
blood flow
 Dynamic RVOT obstruction (infundibular spasm): ↑ R to
L shunting & hypoxia
3. Associated conditions:
o Paradoxical embolus – avoid air bubbles in lines
o Thrombophilia 2’ to polycythemia
o 25% have another congenital abnormality
o Tracheoesophageal fistula & trisomy 21
4. SBE prophylaxis
5. No AIR in IVs!

Anesthetic Goals/Conflicts

1. Hemodynamic goals:
o Full preload: stiff RV, stent open RVOT
o ↓ contractility to reduce dynamic RVOT obstruction
o Maintain afterload to minimize R → L shunt & promote
pulmonary blood flow
o Avoid ↑ PVR (hypoxia, acidosis, aggressive PPV/PEEP)
2. "Tet spell": sudden hypoxia/acidosis due to infundibular spasm or ↓
systemic vascular resistance (SVR): causes ↑ R → L shunt:
o 100% O2 +/- gentle PPV
o Fluid bolus
o Sedation (↓ sympathetic drive): morphine 0.1mg/kg

254
 o Knee chest position (↑ SVR & preload)
o Phenylephrine 5 mcg/kg, propanolol 0.1-0.3mg/kg (to ↓
infundibular spasm)

Induction Options for Patient with Unrepaired TOF Undergoing Non-

cardiac Surgery

1. Goals are to prevent significant R → L shunt:

o Avoid ↑ PVR
o Avoid ↓ SVR
o Avoid myocardial depression
o Keep full preload
2. Options include:
o Sevoflurane induction then place IV then paralyze then ETT
o If IV → ketamine IV (2mg/kg), then paralyze, then ETT
o Avoid propofol/remifentanil in these kids to prevent reduced
SVR/contractility

Repaired Tetralogy of Fallot: Most kids get definitive repair in 1st

year of life
1. The repair:
o Patch closure of the ventricular septal defect (VSD), thereby
separating the pulmonary & systemic circulation
o Enlargement of the RVOT, relieving obstructed pulmonary flow
o RVOT enlargement is accomplished by relieving pulmonary
stenosis, resecting infundibular & subinfundibular muscle
bundles, &, if necessary, by a transannular patch, creating
unobstructed flow from the right ventricle (RV) into the
pulmonary arteries
2. Chronic problems after repair that may arise:
o Chronic pulmonary regurgitation
o Pulmonic stenosis
o RV enlargement & dysfunction
o Aortic root & valve dilation
o Arrhythmias

255
 Tonsillectomy

Considerations
1. Indication for surgery: obstructive sleep apnea (OSA), recurrent
infections
2. Potential OSA: difficult bag mask ventilation, pulmonary
hypertension/RVF, respiratory depressant sensitivity, post-op
monitoring
3. Shared airway, oral rae ETT
4. Need for smooth emergence (dexmedetomidine)
5. Post-op complications: bleeding, negative pressure pulmonary
edema, airway obstruction, apnea, PONV, pain
6. Postoperative disposition (day surgery vs. admission vs. PICU)

Post-Tonsillectomy Bleed
1. Considerations:
o Emergency with limited time to optimize
o Full stomach: RSI is essential, ensure gastric
decompression at the end
o Potential for hypovolemia, ensure aggressive resuscitation
o Potentially difficult airway due to blood
 Call for help
 Have 2 suctions ready
 Styletted ETT
2. Conflicts:
o Full stomach vs. hemodynamic instability
o Full stomach vs. difficult airway
o Volume resuscitate vs. emergency surgery for potential airway
obstruction

Criteria for Admission Post-op

1. Age < 3 years
2. Severe OSA
3. Coagulation disorder
4. Comorbid serious systemic disorders
5. Child with craniofacial abnormality (e.g. Down Syndrome, Treacher
Collins, Goldenhar, Crouzon, Pierre Robin, CHARGE)
6. Situation not consistent with close observation (social issues,
extended travel time)

256
 Tracheoesophageal Fistula

Background

1. May be diagnosed antenatally on prenatal U/S

2. Presents as excessive oral secretions, with coughing & cyanosis
during feeds
3. Unable to pass NG into stomach
4. Usually repaired w/in 24 hours of birth to minimize risk and
complications of aspiration
5. Types: I-III (see picture below)

Considerations
1. Aspiration risk
2. Risk of dehydration/acidosis
3. GI distension can compromise ventilation
4. May require urgent gastrostomy decompression
5. Intraop surgical retraction can compress airways, major vessels,
& heart
6. Associated conditions
o VACTERL
o Cardiac anomalies: preop echo required
o Prematurity

257
Management
1. Decompress blind upper pouch with NG to suction
2. Raise head to reduce risk of aspiration
3. Advance ETT into right mainstem; slowly withdraw until bilateral
breath sounds heard
4. Goal: tip of ETT between carina & fistula
5. Spontaneous ventilation is preferred
6. Low airway pressures if PPV required
7. Avoid N2O (gastric distension)

258
Psychiatry

259
 Contents

# Topic Page No.

1 Electroconvulsive Therapy (ECT) 261
2 Monoamine Oxidase Inhibitors (MAOI) 262
3 Neuroleptic Malignant Syndrome 263
4 Serotonin Syndrome 265

260
 Electroconvulsive Therapy (ECT)
Considerations
1. Unprotected airway & remote location
2. Significant physiological changes:
o CNS: ↑ cerebral blood flow & O2 consumption, ↑ICP
o Cardiovascular:
 Initial phase (parasympathetic): bradycardia, hypotension
 Later phase (sympathetic): tachycardia, dysrhythmia,
HTN, ↑ systemic & myocardial O2 consumption
o ↑ IOP, ↑ intragastric pressure
o Transient apnea/hypoventilation
3. Contraindications:
o Absolute: Pheochromocytoma, MI <3 months, Recent CVA <1
month
o Relative: ↑ICP, Severe cardiac disease (conduction defects,
poorly controlled CHF/IHD), Aortic & cerebral aneurysms, High-
risk pregnancy
4. Co-morbid disease in patients with mental illness; often elderly
5. Use of concurrent medications (TCAs, MAOIs, etc)
6. Need for brief motor relaxation to prevent physical harm to patient

Goals
 Amnesia
 Prevention of physical injury
 Control of hemodynamic changes
 Rapid recovery
 Minimal interference with seizure activity:
o If available, methohexital superior to propofol
o If propofol interfering with seizure activity: consider reducing
dose, adding remifentanil or etomidate

Conflicts
 “Full stomach”: use NDMR to intubate & reverse
 Hx pseudocholinesterase deficiency/MH: use NDMR & reverse

Pregnancy Considerations
 NOT contraindicated
 Obtain obstetrical consultation & plan for fetal monitoring
 Aspiration prophylaxis & consider intubation if >20 weeks GA
 Resources readily accessible in event of neonatal or obstetrical
emergency

261
 MAOI (Monoamine Oxidase Inhibitors) Therapy

Background
 Inhibit breakdown of norepinephrine & serotonin, & also inhibit
hepatic microsomal enzymes. These may result in:
o Risk of hypertensive crisis with norepinephrine release
o CNS 'type I' reaction: risk of serotonin syndrome under certain
conditions resulting in agitation, headache, fever, seizures,
coma, & death
o CNS 'type II' reaction: ↓ hepatic opioid metabolism & thus
opioid build-up causing sedation, respiratory depression, &
cardiovascular collapse

Considerations
1. Indication for MAOIs: depression, anxiety, psychosis, hypotension,
narcolepsy, headache
2. Continuation vs discontinuation of MAOI pre-op:
o May need to consult prescribing physician (psychiatry,
neurology)
o If possible, try to discontinue 2 weeks pre-op with a tapering
regimen
o If cannot discontinue: be mindful of systemic effects below &
avoid inpatient diets containing high amounts of tyramine
3. Risk of severe hypertension if sympathetic stimulation
or sympathomimetic drugs:
o Avoid light anesthesia
o Avoid ketamine, pancuronium
o Avoid indirect acting vasopressors such as ephedrine
o Avoid foods contaning high amounts of tyramine (cheese,
wine)
4. Risk of CNS adverse reactions:
o Type I reaction leading to serotonin syndrome: avoid
anticholinergics & meperidine
o Type II reaction from accumulation of opioids: need to monitor
closely for adverse events, opioid use not necessarily
contraindicated & have been safely used
5. Altered response to anesthetic agents:
o ↑ MAC due to ↑ concentrations of CNS norepinephrine
o Possible prolonged succinylcholine effect
o Exaggerated hypotension with neuraxial techniques
o Direct acting vasopressors only, consider ↓ doses

262
 Neuroleptic Malignant Syndrome (NMS)

Background
 Rare, potentially fatal condition due to antipsychotic drug therapy
 May reflect dopamine depletion in the CNS
 Can occur anytime during the course of antipsychotic treatment but
often is manifest during the first few weeks of therapy or following an
↑ in drug dosage.
 Clinical manifestations usually develop over 24-72 hours, remember
the mnemonic FEVERS:
o F ever
o E ncephalopathy
o V ital signs unstable
o E levated labs
o R igidity (vs myoclonus in serotonin syndrome)
o S weating

Considerations
1. Emergency situation, full stomach
2. Potentially life-threatening situation with high mortality:
o ↓ LOC: coma which may mandate airway management
o Autonomic instability: tachycardia, hypertension, cardiac
dysrhythmias (most likely cause of death)
o Hypermetabolic state: fever, severe muscular rigidity, volume
depletion
o Tachypnea & potential respiratory insufficiency from
hypoventilation/rigidity
o Rhabdomyolysis, renal failure, acidosis
3. Psychiatric patient, potentially uncooperative

Management
1. Resuscitation & ICU monitoring following trigger
2. Stop offending agents
3. Supportive treatment: cooling, treat acidosis/electrolyte
abnormalities, hemodynamic support
4. Pharmacologic (case reports, no strong evidence):
o Bromocriptine: PO/NG 2.5 mg q8-12 hrs
o Dantrolene: IV 2.5mg/kg bolus, up to 10mg/kg/day

263
 o Amantadine: initial dose is 100 mg PO/NG & titrated upward as
needed to a maximum dose of 200 mg q12h
o Benzodiazepines
5. Rule out other high risk conditions on differential diagnosis
6. "Trigger free” anesthetic in patients with history of NMS
(controversial)

264
 Serotonin Syndrome

Background

 A potentially life-threatening adverse drug reaction due to ↑ CNS

serotoninergic activity, characterized by the mnemonic MAD HOT:
o M yoclonus
o A utonomic instability
o D elirium, D iarrhea,
o HOT (fever)
 It is seen with therapeutic medication use, drug interactions, & self-
poisoning

Considerations
1. Multisystem effects of serotonin excess:
o CNS: seizure, altered LOC
o CVS: tachycardia & HTN, autonomic instability, arrhythmia
o MSK: rigidity, rhabdomyolysis, hyperkalemia & renal failure
o Hyperthermia; DIC
 Psychiatric patient: co-operation, informed consent/substitute
decision maker

Anesthetic Management
1. Stop offending agent
2. Admit to ICU/HAU
3. Supportive care & sedation:
o Benzodiazepines very useful for sedation
o Support ventilation & oxygenation
o Fluid resuscitation
o Treat hyperthermia
4. Autonomic instability:
o Hypotension: use direct acting vasopressors, reduced doses
initially
o Hypertension: use phentolamine, nitroprusside, esmolol
5. Specific antidote is cyproheptadine (potent antihistamine & serotonin
antagonist):
o Initial: 12 mg followed by 2 mg every 2 hours or 4-8 mg every 6
hours
o DO NOT use bromocriptine (a serotonin agonist, may
exacerbate serotonin syndrome), dantrolene (no evidence)
Rule out other differential diagnosis (e.g., MH, NMS, thyrotoxicosis)

265
Rare Coexisting Disease

266
 Contents

# Topic Page No.

1 Amyloidosis 268
2 Glycogen Storage Disease 269
3 Hereditary Angioedema (C1 Esterase Deficiency) 270
4 Hereditary Hemorrhagic Telengiectasias 272
5 Huntington’s Disease 274
6 Neurofibromatosis 275
7 Periodic Paralysis 277

267
 Amyloidosis
Background
 Refers to the extracellular tissue deposition of fibrils
 Primary amyloidosis: is a plasma cell disorder marked by the
accumulation of immunoglobulin light chains.
 Secondary amyloidosis: is observed in association with several other
conditions, including multiple myeloma, rheumatoid arthritis, & a
prolonged antigenic challenge, such as may be produced by chronic
infection

Considerations
1. Difficult airway: macroglossia, laryngo-tracheo-bronchial tree
involvement, stridor
2. Aspiration risk
3. Multisystem infiltrative disease:
o Cardiovascular:
 Restrictive cardiomyopathy
 Diastolic dysfunction
 Complete heart block
 Risk of sudden death
 Coronary heart disease
o Respiratory: interstitial lung disease
o Renal: nephrotic syndrome & renal failure
o GI: dysphagia, risk of aspiration secondary to
autonomic/peripheral neuropathy
o Nervous system: autonomic neuropathy, mixed sensory/motor
neuropathy
o Heme: bleeding risk → factor X deficiency, ↓ coagulation
factors, platelet dysfunction
4. Potential co-existing secondary causes: e.g. multiple myeloma &
rheumatoid arthritis
5. Medications: steroids/chemotherapy

Goals & Conflicts

 RSI for possible gastroparesis, aspiration risk vs. potential difficult
airway
 Prior to neuraxial/regional technique:
o Document pre-existing neurodeficits
o Confirm coagulation profile & clinical assessment of
coagulopathy
 Mindful of restrictive cardiomyopathy, hemodynamic instability due to
autonomic neuropathy
268
 Glycogen Storage Disorders

Background
 Inherited disorders caused by abnormalities of enzymes that regulate
glycogen synthesis & breakdown
 3 common features with all these disorders:
o Acidosis secondary to fat & protein metabolism
o Risk of hypoglycemia secondary to the failure to metabolize
glycogen to glucose
o Cardiac & hepatic dysfunction secondary to destruction of
normal tissue by accumulated glycogen

Considerations
1. Careful monitoring of glucose & give D5W during fasting periods
2. Careful evaluation of cardiac & hepatic function
3. Careful review of previous anesthetics & obtain endocrinology
consultation before surgery
4. Monitor glucose & pH intra-op
5. Avoid lactate containing solutions (they cannot convert lactate to
glycogen)

269
 Hereditary Angioedema (C1 Esterase Deficiency)

Background
 A hereditary disorder that results in angioedema without urticaria
 Due to autosomal dominant deficiency or dysfunction of C1 esterase
inhibitor → release of vasoactive mediators → vascular permeability &
edema formation
 Presents as recurrent bouts of angioedema involving the extremities,
face, oropharynx, larynx, GI, and/or GU tract lasting 24-72 hours

Considerations

1. Potential acute life threatening airway edema & obstruction that is

not treated by conventional methods such as steroids, epinephrine
& antihistamines
2. Need to avoid triggers: oral/dental surgery, laryngoscopy, trauma,
infection, stress/light anesthesia
3. Need for prophylaxis prior to surgical procedures & availability of C1
esterase inhibitor to treat acute attacks
4. Need for postop monitoring (onset may be delayed 60 mins to 36
hours after trigger)

Goals
 Pre-op prophylaxis (see management)
 Avoid/minimize triggers
 Gentle airway manipulation
 Regional anesthesia if feasible
 Ensure ready availability of treatment modalities for acute attack
including difficult airway kit/surgical airway

Management
1. Prophylaxis
o C1INHRP (C1 esterase inhibitor replacement protein)
o Androgens (if C1INHRP not available) e.g. danazol (2.5 to 10
mg/kg per day to a maximum of 600 mg/day), beginning five
days before and extending for five days after the procedure.

270
 o TXA (not as good as C1NHRP or Androgens)

2. Treatment of Acute Event

o C1 inhibitor concentrate (25 units/kg)
o FFP (2-4 units) to replace the deficient enzyme
o NOT HELPFUL: androgens, epinephrine, antihistamines,
antifibrinolytics

271
 Hereditary Hemorrhagic Telangiectasias (HHT)
(Osler-Weber-Rendu Disease)

Considerations
1. Risk of excessive bleeding from variety of surfaces/organs:
o Nose: epistaxis (nasal intubation contraindicated)
o Upper airway hemorrhage (potential for difficult airway)
o Spinal AVM: risk of paralysis from epidural hematoma (image
before neuraxial technique!)
o Pulmonary hemorrhage requiring lung isolation
o Cerebral AVM: risk of intracranial hemorrhage
o GI bleeding
o Hepatic AVM: portal HTN, high output heart failure
2. Paradoxical emboli from intrapulmonary shunts (AVM): de-air lines!
3. Chronic anemia with potential for a difficult cross-match
4. Coagulopathy: low grade DIC, reduced platelet function

Goals & Conflicts

1. May present for laser treatment of epistaxis, embolization of
pulmonary AVMs, craniotomy for AVM resection, treatment of GI
bleeding
2. Thorough preoperative workup if suspected AVMs:
o Pulmonary AVM: chronic hypoxemia, risk of pulmonary
hemorrhage
o Renal & liver function
o Spinal MRI to rule out spinal AVM prior to neuraxial anesthesia
o Rule out preoperative anemia, group & screen
o Antibiotic prophylaxis if AVMs
3. Intraoperative care:
o De-airing of all lines
o Avoidance of airway manipulation if telangiectasias are present
o Avoid nasal intubation if history of epistaxis
o Modify anesthesia if high-output cardiac failure

Pregnancy Considerations
 High risk for worsening of AVMs during pregnancy & peripartum
period
 Pulmonary hemorrhage, intracerebral & spinal hemorrhage, GI
bleeding

272
 Shunt-induced high output cardiac failure
 Systemic embolism
 Spinal MRI prior to epidural & spinal anesthesia
 Avoid HTN during anesthetic management

273
 Huntington's Disease

Background
 Autosomal dominant inherited disease characterized by progressive
neurodegeneration
 Clinical features: choreiform movements, depression, & dementia
 Onset is typically between 35-40 years of age, but can be as late as
80 years. The disease continues to progress for several years
with death occuring 17-20 years after diagnosis & is usually from
malnutrition or aspiration pneumonitis

Considerations
1. Bulbar dysfunction with risk of aspiration
2. Dementia, potentially uncooperative, end of life care, advanced
directives, DNR status
3. Anesthetic medications:
o All IV anesthetics OK, caution with slower recovery
o NDMRs are ok, but may require ↓ dose
o Succinylchonline is ok, but duration may be longer due to ↓
plasma cholinesterase activity
o Neuraxial/regional is ok, document pre-existing deficits
4. Preoperative sedation using butyrophenones such as droperidol or
haloperidol may be helpful in controlling choreiform movements

274
 Neurofibromatosis

Background
 Cafe au lait spots are the most characteristic finding
 2 types: NF-1 (more common) & NF-2
 Neurofibromas nearly always involve the skin, but they can also occur
in the deeper peripheral nerves & nerve roots & in or on viscera or
blood vessels innervated by the autonomic nervous system

Considerations
1. Potential difficult airway:
o Airway obstruction/distortion from laryngeal, pharyngeal,
tongue, cervical tumors
o Macrocephaly & macroglossia
o Tumors can be very vascular
2. Respiratory:
o Restrictive lung disease (kyphoscoliosis ~25%)
o Potential for pulmonary fibrosis from parenchymal tumours
o Pulmonary hypertension/RV failure
o Mediastinal neurofibroma: may present with cardiopulmonary
complaints
3. Cardiovascular:
o Hypertension
 Usually essential, secondary: RAS >>
pheochromocytoma (<1%)
o Dysrhythmias, idiopathic cardiomyopathy
o RV outflow tract tumour
4. CNS:
o ↑ ICP (5-10% have intracranial tumors, hydrocephalus) +/-
contraindication to neuraxial
o Seizure disorder
o Cognitive deficits, learning disabilities
o Peripheral neuropathy
5. Unpredictable response to NMB drugs:
o Variable responses (sensitivity or resistance to succinylcholine,
sensitivity to NDMR)
6. Difficult regional & epidural/spinal, may be contraindicated if spinal
neurofibroma
7. Possible endocrine problems: pheochromocytoma, hypoglycemia,
pituitary tumours, hyperparathyroidism, medullary thyroid carcinoma

275
Optimization/Consults
1. Neurology: optimize ICP, antiepileptics
2. Cardiology/endocrine: optimize antihypertensives
(phenoxybenzamine) if pheochromocytoma
3. Consider MRI (r/o ↑ICP) if planning regional technique
4. Respirology: if restrictive lung disease
5. Conflicts:
o ↑ICP vs neuraxial
o Spinal neuromas vs neuraxial
o ↑ ICP vs difficult airway

Pregnancy Considerations
 Higher maternal complications
 If pelvic/abdominal neurofibromas → cesarean section necessary
(dystocia, obstructed labor or respiratory embarrassment)
 Higher fetal complications: preterm labor, IUGR, abortion
 GA: very cautious of difficult airway & underlying hypertension
 Neuraxial: must have imaging (MRI/CT) of spine before
epidural/spinal

276
 Periodic Paralysis
Background
 Due to hereditary skeletal muscle ion channelopathies
 Hyperkalemic periodic paralysis:
o Episodes of myotonia & muscle weakness that may last for
several hours
o Weakness can occur during rest after strenuous exercise,
infusion of potassium, metabolic acidosis, or hypothermia
o The hyperkalemia is transient & occurs only at the time of
weakness
o Acute attacks can be fatal because of cardiac dysrhythmias or
respiratory failure
o A chronic myopathy frequently develops in older patients
o Treatment consists of a low potassium diet & the administration
of thiazide diuretics
 Hypokalemic periodic paralysis:
o Paralysis can be produced by a ↓ in serum potassium levels
caused by strenuous exercise, infusion of glucose and insulin,
or ingestion of carbohydrates & sodium rich food
o Paralysis usually affects the limbs and trunk, but spares the
diaphragm. Chronic muscle weakness occurs in most patients
as they age

Considerations
1. Risk of periodic paralysis attacks, with potential for respiratory failure
& cardiac dysrhythmias
2. Avoid triggers of attacks:
o Hyperkalemic Periodic Paralysis (attacks when K >5.5)
 K infusion
 Metabolic acidosis
 Hypothermia
o Hypokalemic Periodic Paralysis (attacks when K <3.0):
 Glucose/insulin infusion & other K lowering shift drugs
 ↓K
 Hypothermia
 Carbohydrate load
3. Sensitivity to NDMRs: use ↓ dose, continuous monitoring with twitch
monitor
4. Avoid succinylcholine (due to ↑ K) in hyperkalemic periodic paralysis
(ok with hypokalemic periodic paralysis)
5. Frequent electrolyte monitoring esp. K

277
Renal

278
 Contents

# Topic Page No.

1 Acute Kidney Injury 280
2 Chronic Renal Failure 281
3 TURP & TURP Syndrome 282

279
 Acute Kidney Injury (AKI)

Considerations
1. Higher risk of peri-operative morbidity & mortality
2. Altered pharmacology
3. Dysregulation of volume status, acid-base (metabolic acidosis), &
electrolytes

Management
1. Consult nephrology
2. Avoid further renal insults:
o Maintain euvolemia
o Maintain adequate renal perfusion: MAP > 65
o Avoid nephrotoxins: contrast dye, NSAIDs,
aminoglycoside antibiotics
3. Identify & treat underlying cause:
o Replace intravascular volume
o Optimize cardiac output & blood pressure
o Correct any outflow obstruction (e.g., BPH)
o Stop nephrotoxic medications
4. Know indications for hemodialysis:
o Acidosis
o Electrolyte disturbances (↑ K)
o Intoxication (e.g. methanol, ethylene glycol)
o Volume overload
o Uremia

Conflicts
 RSI with succinylcholine vs. high K+
 Need for contrast vs. AKI
 Need for surgery vs. AKI

280
 Chronic Renal Failure

Considerations
1. Gastroparesis & risk of aspiration
2. Dysregulation of volume status, acid-base (metabolic acidosis), &
electrolytes(↑ K, ↓ Na, ↓ Ca, ↑ PO4, ↓ glucose, ↑ triglycerides)
3. Coexisting diseases & end-organ complications:
o Autonomic dysfunction with hemodynamic instability
o Pulmonary: pulmonary edema from low albumin, ↓ forced vital
capacity, atelectasis
o Cardiac: LV dysfunction, hypertension, coronary disease, heart
failure, pericarditis, pericardial effusion, arrythmias
o Hematologic: anemia/thrombocytopenia
4. Altered pharmacokinetics due to ↓ elimination, acidosis,
hypoalbuminemia
5. Potential difficult IV access
6. Cr > 200 independent risk factor for cardiac complications &
mortality

Conflicts
 Hyperkalemia vs. need for emergency surgery/RSI
 Hemodynamic instability vs. RSI

Goals
1. Optimize electrolytes, volume status, comorbidities
2. Avoid worsening renal failure (avoid nephrotoxins, maintain adequate
volume status)
3. Coordinate perioperative dialysis if on hemodialysis
4. If on peritoneal dialysis: consider draining it to optimize respiratory
function
5. Avoid compromising dialysis access (AV fistulas, indwelling IV lines,
PD ports)

281
 TURP & TURP Syndrome

Considerations
1. Coexisting disease common in this population
o Coronary disease, acute kidney injury, elderly
2. Considerations of intraoperative complications:
o TURP syndrome ~2%
o Fluid overload/pulmonary edema; electrolyte abnormalities;
dysrhythmias hyperglycinemia (blindness), hyperammonemia
(encephalopathy), hypothermia
o Concealed hemorrhage
o Bladder perforation ~ 1%
o Septicemia (usually gram negative)
o DIC (rare complication associated with prostate cancer)
3. Positioning: lithotomy with nerve injury; hemodynamic &
respiratory effects of trendelenberg position
4. Choice of anesthetic: GA or spinal

Goals & Conflicts

 Optimization of co-existing diseases
 Prevention or early recognition of TURP syndrome
 Attention to blood loss & appropriate replacement
 Conflict: preference for neuraxial technique to monitor CNS
symptoms vs. any contraindications to neuraxial
 Problems in PAR include: post-op delirium, hypotension, respiratory
distress (need to consider comorbidities)

TURP Syndrome
1. Presentation: due to fluid overload & hyponatremia:
o Classic triad: hypertension, bradycardia, & mental status
changes
o Pulmonary: pulmonary edema, ↑ JVP
o Cardiovascular: arrhythmias, hypertension
o CNS: pupillary reflex sluggish or absent with glycine toxicity but
intact with cerebral edema
2. Prevention:
o Appropriate irrigation agent, minimize resection time,
hemostasis, avoid high irrigating pressures (limit bag height to
30-40cm, frequent drainage), avoid hypotonic IV fluids, check

282
 electrolytes in patients with renal failure (metabolic
abnormalities, hyponatremia)
3. Treatment:
o Inform surgeon to terminate procedure ASAP
o Oxygenation & circulatory support
o Consider invasive monitoring if hemodynamically unstable
(arterial line, CVP)
o Blood work (electrolytes, creatinine, glucose, CBC, ABG)
o 12 lead ECG
4. Correction of hyponatremia:
o Near-normal serum osmolality & asymptomatic: no
interventions to correct serum sodium are recommended even
in the presence of hyponatremia
o Mild symptoms (serum Na > 120 mEq/L): fluid restriction & loop
diuretic (furosemide 40-120 mg)
o Symptomatic, life-threatening hypoosmolality & serum Na <
120 mEq/L (rare with modern techniques) can be treated with
hypertonic saline (rarely necessary):
 Start @ 100cc bolus & assess for resolution of symptoms
or Na > 120 mEq/L
 Can give 2 more boluses
 Start at rate of 50-100 cc/h (do not exceed correction of >
1.5 mEq/L/h because rapid correction of serum sodium is
associated with central pontine myelinolysis (osmotic
demyelination syndrome) & cerebral edema
 Diuresis with furosemide & fluid restriction:
 Stop 3% saline once symptoms subside or serum
Na > 120 mEq/L: treat remaining hyponatremia
with diuresis & normal saline or fluid restriction
o Seizure treatment as necessary
o Transfer to ICU for ongoing care in severe cases
o q1h blood work (Na, K)
o Frequent CNS assessment

283
Respiratory & Thoracics

284
 Contents

# Topic Page No.

1 Anterior Mediastinal Mass 286
2 Asthma 288
3 Bronchiectasis 290
4 Bronchopleural Fistula 291
5 Bullous Lung Disease 293
6 COPD 294
7 Cystic Fibrosis 295
8 Esophagectomy 297
9 Lung Cancer 299
10 Massive Hemoptysis 300
11 Mediastinoscopy 301
12 Obstructive Sleep Apnea 302
13 Pneumonectomy 304
14 Post Lung Transplant 307
15 Pulmonary Embolism 308
16 Restrictive Lung Disease 310
17 Smoking 311
18 Thymectomy 312

285
 Anterior Mediastinal Mass (AMM)

Background
 The anterior mediastinal space is bordered by the sternum anteriorly,
the middle mediastinum comprising the heart & great vessels
posteriorly, the thoracic inlet superiorly, & the diaphragm inferiorly
 The most frequent of causes of AMMs are:
o Lymphoma
o Thymoma
o Germ cell tumours
o Metastatic lesions
o Bronchogenic masses
o Thyroid mass

Considerations
1. Risk of cardiopulmonary collapse upon induction of anesthesia:
o Tracheobronchial obstruction, dynamic hyperinflation
o RVOT obstruction, cardiac chamber compression
2. Possible SVC syndrome:
o Airway edema & potential for difficult intubation
o ↑ intracranial pressure
o Unreliable upper extremity IVs
3. Underlying etiology & comorbid disease:
o Cancer 4 M’s (mass effects, metastases, medications,
metabolic abnormalities)
o Myasthenia gravis, Eaton-Lambert, thyroid, lymphoma
o Pericardial/pleural effusions
4. Need for preoperative risk stratification based on symptoms & CT
findings:
o Low risk: asymptomatic or mildly symptomatic, without postural
symptoms or radiographic evidence of significant compression
of structures
o Intermediate risk: mild to moderate postural symptoms,
tracheal compression < 50%
o High risk: severe postural symptoms, stridor, cyanosis, tracheal
compression > 50% or tracheal compression with associated
bronchial compression, pericardial effusion or SVC syndrome
5. Considerations of surgical procedures (e.g., mediastinoscopy) &
feasibility of performance under local/sedation

286
Goals & Conflicts
1. Multidisciplinary optimization & planning:
o Optimize medically prior to procedure (steroids, radiation,
chemotherapy)
o Perform procedures/biopsies under local if possible
o Guide approach by CT findings (> 50% tracheobronchial
obstruction) & positional symptoms (supine dyspnea, pre-
syncope)
2. Cautious approach to general anesthesia, if it is necessary:
o Maintain spontaneous ventilation & awake during ETT
placement distal to obstruction
o Avoid positive pressure ventilation & muscle paralysis if
possible
3. Planning for intraoperative crisis:
o Preoperative cardiopulmonary bypass
o Invasive monitors & lines, lower extremity IVs
o Rigid bronchoscopy & thoracic surgeon immediately available
during anesthetic induction
o Stretcher immediately available for repositioning: prone,
decubitus
4. Complications: complete airway obstruction with dynamic
hyperinflation, cardiac arrest from obstructive shock, hemorrhage
from SVC syndrome, cardiac tamponade

287
 Asthma

Considerations
1. Risk of perioperative respiratory complications:
o Bronchospasm, mucous plugging, pneumothorax, atelectasis,
pneumonia
2. Possible pulmonary hypertension & RV failure
3. Need for preoperative optimization:
o Treatment of bronchospasm, infection, atelectasis
4. Avoidance of triggers & exacerbating factors:
o Avoid general anesthesia, endotracheal intubation, histamine
releasing medications, light anesthesia
5. Medication management:
o Continue usual inhalers pre-operatively
o Stress dose steroids if recent high dose steroid use

Goals & Conflicts

1. Assess preoperative respiratory function for stability:
o Stable symptoms (sputum, bronchospasm), PFTs, imaging,
ABG
o Assess for pulmonary hypertension, cor pulmonale
2. Medical optimization: bronchodilators, glucocorticoids, antibiotics,
BiPAP
3. Anesthetic management principles:
o Avoid airway instrumentation
o Blunt airway reflexes: deep anesthesia, topical local
anesthetics, opioids
o Bronchodilation: avoid histamine releasing medications (e.g.,
morphine), use ketamine, volatiles, MgSO4, salbutamol,
ipratropium, epinephrine
o Permissive hypercapnia: ↓ respiratory rate, ↑ expiratory time,
adequate tidal volumes
o Monitor intrinsic PEEP, presence of dynamic hyperinflation
& pulmonary tamponade
o Postoperative monitoring for bronchospasm, respiratory failure

Severe Asthma Exacerbation Treatment Options

1. Salbutamol 2.5-5mg via nebulizer q20 minutes
2. Ipratropium 500mcg via nebulizer q20 minutes
3. Corticosteroids:

288
 o Prednisone PO 40-60mg single dose
o Methylprednisolone 60-80mg IV q6-12h
4. Epinephrine if anaphylaxis suspected or severe asthma refractory to
standard therapy:
o Dose is 0.3-0.5mg IM/SC or 10-50 mcg IV bolus, followed by
infusion @ 2-10 mcg/min
5. Magnesium for life-threatening exacerbation: 2g IV over 20 min
6. Heliox & humidified O2 (conflicting studies)
7. Anesthetics:
o Ketamine
o Propofol
o Volatiles all are bronchodilators but sevoflurane is likely best
choice
8. Leukotriene receptor antagonists (only PO available in Canada)
9. Always consider noninvasive PPV as rescue before intubation
10. If intubation & ventilation:
o Use permissive hypercapnia
o Use low respiratory rates: start at 10-12 breaths/minute but
may need lower rates
o Use prolonged expiratory time (e.g. I:E ratios 1:3, 1:4, or even
1:5)
o Tidal volume 6-8cc/kg
o FiO2 to achieve PaO2 >60mm Hg
11. ECMO as last resort

289
 Bronchiectasis

Considerations
1. Etiology & co-existing disease: cystic fibrosis, COPD, TB, congenital
2. Risk of postoperative pulmonary complications:
o Mixed restrictive & obstructive lung disease
o Risk of intraoperative bronchospasm, pneumothorax,
pulmonary tamponade
o Recurrent pulmonary infections, mucus plugging
o Hypoxemia, hypercarbia, V/Q mismatch
o Pulmonary hypertension, cor pulmonale
3. Potential need for lung isolation due to massive hemoptysis & active
bronchial infection
4. Medications including need for steroid replacement

Goals & Conflicts

1. Maintain integrity of healthy lung in setting of infection & hemorrhage
with lung isolation
2. Preoperative optimization of infection & bronchospasm with
antibiotics, steroids, bronchodilators
3. Optimize intraoperative ventilation to avoid barotrauma, dynamic
hyperinflation, pulmonary tamponade
4. Arrange for possibility of postoperative ventilation, high acuity care

290
 Bronchopleural Fistula (BPF)

Considerations
1. Etiology of BPF & associated urgency:
o Trauma, empyema/abscess, bullous disease, post lung
resection, carcinoma
2. Comorbid disease:
o Chronic obstructive lung disease, malignancy, coronary artery
disease, arrhythmias
3. Absolute indication for lung separation:
o Pathophysiological impact of positive pressure ventilation
 Ineffective ventilation (with chest tube in place)
 Tension pneumothorax (without chest tube in place)
 Systemic air embolus
o Protection of healthy lung from soiling
4. Repeat thoracotomy considerations:
o Hemorrhage
o Sepsis, septic shock
o Postoperative analgesia
o Postoperative ICU disposition for PPV

Goals & Conflicts

 Need for lung isolation prior to PPV in order to prevent
pathophysiological complications as outlined above
 Balanced with possible full stomach, difficult airway, hemodynamic
instability, limited functional reserve
 Rapid sequence lung isolation techniques:
o Regional anesthesia
o Awake fibreoptic intubation: single lumen ETT +/- bronchial
blocker, double lumen ETT prior to GA
o Asleep intubation with spontaneous ventilation prior to isolation
o Modified RSI with no or limited PPV prior to lung isolation
o Double lumen ETT preferred to bronchial blocker to support
suctioning, optimal ventilation & isolation
 Need for resuscitation & stabilization prior to OR:
o Fluids, vasopressors, antibiotics, chest tube placement
o If no chest tube in place prior to OR, thoracic surgeon must be
immediately available to place a chest tube
 Intraoperative goals:
o Lung protective ventilation
o Restrictive fluid strategy

291
 o Maintenance of normothermia & normal metabolics
 Optimization to facilitate postoperative extubation:
o Resuscitation
o Bronchial suctioning
o Bronchodilators
o Extubation to BiPAP

292
 Bullous Lung Disease

Considerations
1. Etiology with associated considerations:
o Chronic obstructive lung disease, congenital, carcinoma,
infection/abscess
2. Absolute indication for lung isolation due to pathophysiological
sequelae:
o Bronchopleural fistula, infection/sepsis, obstructive lung
physiology causing airspace expansion during PPV with risk of
pneumothorax, restrictive lung physiology & mass effect
3. Patient co-morbidities & limited physiological reserve
4. Need for pre-op assessment as per 3-legged stool approach:
o Respiratory mechanics
o Gas exchange
o Cardio-respiratory interaction

Goals & Conflicts

1. Patients may present for non-thoracic surgery with lung cysts, blebs,
bullae
2. Use local & regional techniques if feasible
3. Maintain spontaneous ventilation if feasible with supraglottic
device or ETT
4. If PPV required then employ lung isolation
5. Lung isolation techniques:
o Options: double lumen ETT, bronchial blocker, endobronchial
tube
o In a patient with marginal lung function, consider
lobar/segmental isolation with a bronchial blocker
6. Avoid PPV prior to lung isolation:
o RSI
o Awake fiberoptic intubation
o Inhalational induction
7. Have a surgeon skilled in chest tube placement immediately
available if the need arises, but do not place prophylactic chest tube

293
 Chronic Obstructive Lung Disease (COPD)

Considerations
 High risk of perioperative pulmonary complications including
respiratory failure
 Physiological changes:
o Mechanical: bronchospasm, mucous plugging, obstructive
physiology, bullous disease, pneumothorax, pulmonary
tamponade, chronic hypoxemia/hypercarbia
o Cardiovascular: pulmonary hypertension, cor pulmonale
 Etiology & associated co-morbid disease:
o Smoking, coronary artery disease, hypertension, cystic fibrosis,
bronchiectasis
 ↑ sensitivity to respiratory depressant effects of anesthetic agents
 Medications including recent steroid use

Goals & Conflicts

 Optimization prior to elective procedures:
o Treat bronchospasm, atelectasis, infection, pulmonary edema
o Risk stratify, assess for cor pulmonale
 Intraoperative goals of care:
o Regional/neuraxial anesthesia preferred to GA
o Multimodal analgesia, limit sedative analgesics
o Lung protective ventilation balanced with obstructive lung
ventilation strategies:
 Prevent dynamic hyperinflation & barotrauma:
 Long I:E, low peak pressure, low tidal volume, slow
rate, permissive hypercapnea
o Maintain normothermia, normal metabolics
 Postoperative disposition including need for PPV & ICU
 Stress dose steroids if indicated

COPD Severity Based on Airflow Obstruction

294
 Cystic Fibrosis

Considerations
1. High risk for perioperative pulmonary complications
2. Pathophysiologic sequelae:
o Pulmonary: mucous plugging, chronic pneumonia,
bronchiectasis & hemoptysis, bronchospasm, pneumothorax,
mixed restrictive & obstructive lung physiology, bullous
disease, hypoxemia/hypercarbia
o Cardiovascular: pulmonary hypertension, cor pulmonale
3. Extra-pulmonary disease:
o Anemia of chronic disease
o GERD, sinusitis
o Hepatic: abnormal transaminases, cirrhosis, portal
hypertension, coagulopathy
o Pancreatic insufficiency & diabetes
o Chronic malnutrition, cachexia, deconditioning
4. CF-related medications: oxygen, bronchodilators, mucolytics,
antibiotics, steroids, insulin, pancreatic enzymes

Goals & Conflicts

 Preoperative optimization in collaboration with respiratory medicine
 Avoidance of GA if feasible
 Intraoperative management principles:
o Lung protective ventilation
o Aggressive pulmonary toilet, bronchodilation, hydration
o Avoid prolonged ventilation
o Multimodal analgesia with limited sedating analgesics
o Avoid exacerbation of pulmonary hypertension
 Postoperative high acuity setting with aggressive respiratory therapy
 Verify normal coagulation parameters prior to neuraxial/regional

Pregnancy
 Very high risk patient & ↑ risk of low birth weight babies & pre-term
delivery:
o Vaginal delivery:
 Ensure monitored setting, consider invasive monitoring if
significant cardiorespiratory dysfunction

295
  Epidural is an excellent choice to reduce hyperventilation
& stress, but titrate carefully to T10 to prevent respiratory
muscle weakness
o Cesarean delivery:
 Epidural preferred:
 Careful titration of epidural to avoid high block
 GA is acceptable but remember goals:
 Prevent perioperative bronchospasm
 Frequent suctioning for pulmonary toilet
 Appropriate ventilatory settings, especially to avoid
air trapping/pneumothorax
 Post-op monitoring in HAU/ICU, chest
physiotherapy, pulmonary optimization
 NIPPV to treat respiratory failure

296
 Esophagectomy

Considerations
1. High risk for postoperative morbidity & mortality
2. Identify surgical approach & associated considerations
3. Possible need for lung isolation
4. Comorbid disease processes:
o Full stomach & high risk for aspiration
o Malnourishment, deconditioning, anemia, coagulopathy
o Smoker, chronic obstructive lung disease, coronary artery
disease, hypertension, diabetes mellitus
5. Cancer 4M's:
o Mass effects, medications, metastases, metabolic
abnormalities
6. Prolonged surgery with severe hemodynamic insults:
o Need for invasive monitors & access
o Lung protective ventilation
7. Maintenance of anastamotic integrity:
o Thoracic epidural anesthesia
o Judicious fluid administration & vasopressor usage
o Optimize oxygen delivery

Goals & Conflicts

 Preoperative:
o Assessment of 4M’s
o Optimization of comorbidities
o Planning for postoperative care
 Intraoperative:
o Aspiration prophylaxis
o RSI due to high risk of aspiration
o Thoracic epidural
o Arterial & central venous access, large bore IV access
o Lung isolation & lung protective ventilation
o Planning for repositioning
o Preparations for severe hemodynamic instability especially
during blunt mediastinal dissection
o Restrictive fluid strategy with vasopressors PRN to treat
epidural-related vasoplegia
o Surgical approach:
 Ivor Lewis: laparotomy, right thoracotomy
 Transhiatal: laparotomy, left neck

297
  Three hole
 Left thoracoabdominal
 Laparoscopic/thoracoscopic
o Surgical considerations:
 Prolonged surgery
 Need for one lung ventilation
 Intraoperative repositioning
 Hemodynamic instability: intrathoracic dissection,
supraventricular arrhythmias
 No vascular access left neck
 Postoperative:
o Greatest mortality risk of all thoracic surgery
o Attempt postoperative extubation & plan for high acuity stay
o Monitor for: aspiration pneumonia, respiratory failure,
anastamotic dehiscence with empyema, mediastinitis, septic
shock, arrhythmias, CHF

298
 Lung Cancer

Considerations
1. Potentially compromised respiratory function with risk of perioperative
respiratory complications
2. 4M’s:
o M ass effects: obstructive pneumonia, lung abscess, SVC
syndrome, tracheobronchial distortion, Pancoast’s syndrome,
recurrent laryngeal nerve or phrenic nerve paresis, chest wall
or mediastinal extension
o M etabolic effects: Lambert–Eaton syndrome, hypercalcemia,
hyponatremia, Cushing’s syndrome
o M etastases: particularly to brain, bone, liver, & adrenal
o M edications: chemotherapy agents, pulmonary toxicity
(bleomycin, mitomycin), cardiac toxicity (doxorubicin), renal
toxicity (cisplatin)
3. Need for lung resection, mediastinoscopy/bronchoscopy, non-
thoracic surgery
4. Comorbidities including smoking, chronic obstructive lung disease,
coronary artery disease, hypertension
5. Management of cancer pain with multimodal approach
6. Goals of care & DNR status

299
 Massive Hemoptysis
Considerations
1. Emergency, full stomach, limited time to optimize
2. Etiology of hemorrhage & patient comorbidities:
o Infection (tuberculosis), bronchiectasis, malignancy,
arteriovenous malformation, pulmonary artery catheter, trauma
3. Difficult airway & requirement for rapid lung isolation to prevent
contralateral contamination & asphyxia
4. Facilitation of subsequent definitive treatment: bronchial artery
embolization, lung resection
5. Resuscitation of hemorrhagic shock
Goals
 Prompt mobilization of resources (OR, surgeon, interventional
radiology) & effective communication between various parties
 Rapid management: airway protection, resuscitation & stabilization,
localization of bleeding site, & administration of specific therapy
 Rapid isolation of non-bleeding lung (double lumen tube vs bronchial
blocker vs endobronchial intubation; bleeding lung down)
 ↓ bleeding: bleeding lung up after selective bronchial intubation
(↓ effective pulmonary artery pressure on that side), CPAP to
bleeding lung (for tamponade effect), reversal of anticoagulation
 Optimization of oxygenation & ventilation to both lungs (good lung
down, CPAP to bleeding lung)

Management
1. Mobilize resources, call thoracic surgery
2. Monitors, large IVs x2, 100% O2
3. Lateral position with bleeding side down
4. Call for blood, resuscitate if hemodynamically unstable, correct
coagulopathy
5. Secure airway if problems with gas exchange:
o Best done in the OR with thoracic surgeon/rigid bronchoscope
available
o Awake intubation vs RSI
o Double lumen tube vs single lumen tube endobronchially or
with bronchial blocker
6. High frequency jet ventilation may be life saving
7. Suction, suction, suction
8. Once isolated, CPAP to bleeding side may help tamponade the
bleeding site
9. May need to urgently go to OR for rigid bronchoscopy or thoracotomy

300
 Mediastinoscopy

Considerations
1. Limited access to airway
2. Indication for procedure: lung cancer staging, biopsy of anterior
mediastinal mass & associated patient comorbidities
3. Surgical approach: cervical vs anterior (Chamberlain)
4. Potentially life threatening complications: hemorrhage,
pneumothorax, airway disruption, stroke
5. Monitoring: perfusion monitoring of right arm, consider lower
extremity IV, BP monitoring left arm (avoid fictitious BP)
6. Need for quiet surgical field & airway control

Goals
 Optimize surgical conditions: deep anesthesia, paralysis
 Safe care of anterior mediastinal mass
 Preparation for transfusion: large bore IV, cross match, consider
lower extremity IV

Conflicts
 Deep anesthesia +/- paralysis vs anterior mediastinal mass
 Cerebrovascular disease & innominate compression
 Contraindications:
o Previous mediastinoscopy or surgery in anterior mediastinum
o Relative: SVC syndrome, tracheal deviation, thoracic aortic
aneurysm, radiation

Complications
1. Hemorrhage (aorta, superior vena cava, pulmonary artery ) → may
need urgent/emergent thoracotomy
2. Innominate artery compression → stroke
3. Recurrent laryngeal nerve injury
4. Phrenic nerve injury
5. Tracheal injury
6. Pneumothorax, pneumomediastinum
7. Chylothorax
8. Esophageal injury
9. Venous air embolism
10. Bradycardia, arrhythmias

301
 Obstructive Sleep Apnea (OSA)

Considerations
 Potentially difficult BMV & intubation
 ↑ sensitivity to sedatives/hypnotics
 Potential for cardiorespiratory changes:
o Hypoxia, hypercarbia (chronic)
o Obesity hypoventilation syndrome
o Polycythemia
o Pulmonary hypertension, RV hypertrophy, RV dysfunction
 Comorbid disease:
o Obesity, diabetes, coronary artery disease, congenital
syndromes affecting the airway
 ↑ risk of perioperative complications → require intensified monitoring:
o Obstruction with induction
o Apnea & desaturation in PACU

Goals
 Safe establishment of airway
 Minimize risk of postoperative respiratory depression:
o Minimize long acting narcotics (systemic & neuraxial) due to
patient sensitivity & risk of opioid-induced upper airway
obstruction
 Provide monitoring adequate to decrease morbidity from
postoperative apnea

Conflicts
 Aspiration risk (RSI) vs. OSA (difficult airway)
 Desire to minimize narcotic use vs. contraindication/inability for
regional

STOP-BANG Questionnaire: ≥3 features indicates high risk of

OSA
 S noring
 T ired excessively
 bserved apneas
 P ressure (hypertension)
 B MI > 35

302
  A ge > 50
 N eck circumference > 40 cm
 G ender = male

Apnea Hypopnea Index & Severity of OSA

 Mild = 5-15
 Moderate = 15-30
 Severe = >30

303
 Pneumonectomy

Considerations
1. Determine physiological suitability for procedure by assessing
predicted postpneumonectomy pulmonary function:
o ppoFEV1 > 40%
o ppoDLCO > 40%
o VO2 max > 15 mL/kg/min (> 4 METS)
o Consider V/Q scanning for all pneumonectomies &/or if
ppoFEV1 < 40%
2. Assess & optimize cardiorespiratory comorbidities:
o Coronary artery disease & arrhythmias (atrial fibrillation)
o Smoking, chronic obstructive lung disease
o Pulmonary hypertension
o 4M’s of lung malignancies (mass effects, metastases,
medications, metabolic abnormalities)
3. Method of lung isolation as determined by:
o Type of resection: right vs left, sleeve
o Patient factors: difficult airway, anatomical distortion
4. Management of hypoxemia during one lung ventilation
5. Perioperative management to avoid acute lung injury:
o Fluid restriction (< 20cc/kg first 24 hours)
o Lung protective ventilation with open lung techniques (tidal
volume 4-6cc/kg, peak pressure < 40 cmH2O, plateau
pressure < 30 cmH2O, PEEP/FiO2 for oxygen saturation >
90%)
6. Postoperative pain management strategies: thoracic epidural,
paravertebral block
7. Postoperative complications:
o Acute lung injury/respiratory failure (aka post-pneumonectomy
pulmonary edema)
o Cardiac herniation (see below)
o Arrhythmias, especially atrial fibrillation
o Myocardial ischemia
o Bronchopleural fistula
 Signs & symptoms: fever, productive cough, hemoptysis,
subcutaneous emphysema, & persistent air leak from a
chest tube
o Hemorrhage
o Pulmonary embolism
o Myocardial infarction

304
Goals
 Determine suitability for resection with “3-legged stool” approach:
o Respiratory mechanics, gas exchange, cardio-respiratory
interaction
 Preoperative optimization: smoking cessation, pulmonary
rehabilitation, treatment of lung infections & bronchospasm
 Pristine intraoperative management: thoracic epidural, fluid
restriction, lung protective ventilation, avoidance of hypothermia

Conflicts
 Requirement for curative treatment vs predicted inability to tolerate
lung resection
 Lung protective ventilation vs contraindication to hypercarbia
(pulmonary hypertension, intracranial hypertension, cardiac
ischemia)
 Fluid restriction vs chronic kidney disease
 Need for thoracic epidural but requirement for full anticoagulation
(mechanical heart valve, severe CHADS2, DVT/PE)

Cardiac Herniation
1. Emergent OR required
2. Occurs after chest closure due to pressure difference between the
two hemithoraces; if a pericardial defect is present, this pressure
difference may result in the heart being extruded through the defect
3. The patient should NOT be placed on the operative side in the
dependent position after a pneumonectomy because of the risk of
cardiac herniation
4. Mortality > 50%
5. Pathophysiology:
o Right pneumonectomy: impaired venous return (obstructive
shock) → tachycardia, ↑ CVP, hypotension, shock, acute SVC
syndrome
o Left pneumonectomy: myocardial compression → MI,
arrhythmias, LVOT obstruction
6. Differential diagnosis:
o Massive intrathoracic hemorrhage, pulmonary embolism,
mediastinal shift
7. Management principles:
o Definitive management is operative repair → notify surgeon
immediately & prepare OR
o 100% O2

305
o Support with vasopressors & inotropes
o Check chest tube & ensure not on suction (as this would suck
the heart further into the empty hemithorax)
o Inject air into chest tube to reduce herniation
o Position with the operative side up to minimize cardiac
compression

306
 Post Lung Transplant Patient

Considerations
1. Allograft physiology:
o Heterogeneous compliance, impaired cough, disrupted
lymphatics
2. Need for differential lung ventilation if single lung transplant
3. Extrapulmonary features of underlying disease requiring transplant
(e.g., sarcoidosis, cystic fibrosis):
o Pulmonary hypertension, RV failure
4. Complications:
o Allograft rejection
o Vascular & bronchial anastamotic complications
5. Immunosuppression:
o Strict aseptic techniques, watch for infection
o Side effects: hematologic, renal, hepatic

Goals/Conflicts
 Assess allograft function, anastamotic integrity, end-organ function
 Employ regional/neuraxial anesthesia if feasible
 If endotracheal intubation & PPV are required:
o Consider differential lung ventilation
o Lung protective ventilation to allograft & CPAP with 100%
oxygen to native lung
o Restrictive fluid strategy
 Strict aseptic technique, avoidance of manipulation of airways,
prophylactic antibiotics

307
 Pulmonary Embolism

Considerations
1. Acute life threatening hypoxemia, RV failure, cardiogenic shock, PEA
arrest
2. Hemodynamic goals:
o Support RV filling/contractility, minimize pulmonary vascular
resistance, maintain preload
o High risk of cardiac collapse upon initiation of PPV
3. Life saving maneuvers: thrombolysis, thrombectomy, inotropes,
pulmonary vasodilators
4. Perioperative bridging of anticoagulation, always consider IVC filter

Management
1. Admission to monitored setting
2. O2 supplementation as required
3. Consultation with ICU/respirology
4. Start anticoagulation immediately (IV heparin, low molecular weight
heparin)
5. If anticoagulation contraindicated → insert IVC filter
6. Hemodynamic instability: similar to treatments of pulmonary
hypertension:
o Vasopressors to maintain RV perfusion
o Intravascular fluid therapy as per CVP, PAC, TEE
 Cautious especially with RV dysfunction: only 500-1000
cc at a time
o Inotropes if RV dysfunction: dobutamine, epinephrine
o Inodilators: milrinone
o Pulmonary artery dilators: nitric oxide, epoprostenol (flolan)
7. Intubation & ventilation:
o Avoid if possible
o If necessary:
 Very high risk for cardiac collapse
 Ensure pre-induction arterial line/central line if possible
 Have vasopressors in-line
 Titrated induction with avoidance of
hypoxemia/hypercarbia (bag mask once not breathing)
 Avoid high intrathoracic pressures, hypercarbia
& hypoxemia
8. Thrombolytic therapy:
o Indications:

308
  Shock: sBP <90 or ↓ sBP of 40 from baseline
 Cardiac arrest
 Severe hypoxemia
 RV dysfunction
 Patent foramen ovale
o Dose: tPA 100mg IV over 2 hours
9. Embolectomy:
o Catheter embolectomy
o Surgical embolectomy
10. ECMO if all else fails

309
 Restrictive Lung Disease

Considerations
1. Potential difficult BMV & rapid desaturation (↓ FRC)
2. Altered respiratory physiology:
o Hypoxemia (V/Q mismatch)
o ↓ compliance & risk of barotrauma → pneumothorax
o Pulmonary hypertension & cor pulmonale
3. ↑ risk of perioperative respiratory complications:
o Pneumonia, pneumothorax, respiratory depression (sensitive to
opioids), respiratory failure
o Higher risk if VC < 15 ml/kg, FVC <50% or 500cc, or pCO2 >45
cmH2O
o Cancel elective procedures if there is an acute & reversible
process
4. Management may include the use of high performance ventilator,
using small tidal volumes with rapid rates, may require post op
ventilation & ICU care
5. Co-morbid disease/etiology:
o Autoimmune disease, connective tissue disease, idiopathic
pulmonary fibrosis, acute respiratory distress
syndrome, malignancy, obesity, neuromuscular, drug effects
6. Medications:
o Steroids, immunosuppressives, oxygen, pulmonary
hypertension treatments
o History of bleomycin, amiodarone use

Goals
1. Preoperative optimization (limited)
2. Minimally invasive (local anesthetic or regional) or maximum support
(slow wean)
3. Lung protective ventilation:
o Low tidal volume, fast respiratory rate, inverse ratio, pressure
control, PEEP
4. Minimize exposure to oxygen if previous bleomycin use
5. Avoid precipitants of pulmonary hypertension (hypercarbia, hypoxia,
acidosis, pain)
6. Excellent pain management to minimize risk of postoperative
respiratory failure

310
 Cigarette Smoking

Considerations
 Limited respiratory reserve
 Methemoglobinemia, carboxyhemoglobinemia, nicotinic induced
tachycardia & increased MVO2
 ↑ risk perioperative respiratory complications:
o Atelectesis
o Hypoxemia
o Bronchospasm
 Associated diseases:
o Chronic obstructive lung disease
o Coronary artery disease
o Reactive airways
o Lung cancer

Goals
 Education regarding benefits of pre-operative smoking cessation
when possible
 Expect improved oxygen delivery by 24-48 hrs, ↑ mucous production
& ↑ expectoration from 2 days to 4 weeks, improved postoperative
infection rate due to improved tissue oxygenation, reduced risk of
pulmonary complications after 8 weeks

311
 Thymectomy

Considerations
1. Indication usually Myasthenia Gravis (see "Myasthenia Gravis" page
for more detail):
o Risks: aspiration, perioperative respiratory failure, cholinergic
or myasthenic crises
o Treatments: immune suppression, plasmapheresis,
pyridostigmine
o Altered response to neuromuscular blocking drugs (NMBs):
 Sensitive to NdMR (nondepolarizing muscle relaxants)
and resistant to succinylcholine
2. Anterior mediastinal mass considerations (see "Anterior Mediastinal
Mass" page for more detail)
3. Postoperative analgesia for median sternotomy
4. Potential need for lung isolation to improve surgical exposure

Goals/Conflicts
 Preoperative assessment & optimization of myasthenia
gravis patients: preoperative plasmapheresis, multidisciplinary
discussion
 Minimize risk of aspiration
 Minimize risk of perioperative respiratory failure (judicious use of
NMBs & opioids; epidural analgesia)
 Minimize risk of myasthenic or cholinergic crisis
 Discuss surgical approach with surgeon & need for lung isolation

312
Skin & Musculoskeletal

313
 Contents

Topic Page No.

1 Achondroplasia 315
2 Ankylosing Spondylitis 316
3 Ehlers Danlos 317
4 Marfan’s Syndrome 318
5 Osteogenesis Imperfecta 320
6 Rheumatoid Arthritis 321
7 Scleroderma 323
8 Stevens-Johnson Syndrome 325
9 Systemic Lupus Erythematosus (SLE) 326
10 Wegner’s Granulomatosis 328

314
 Achondroplasia

Considerations
1. Potential difficult airway:
o Difficult bag mask ventilation, subglottic stenosis, facial
anomalies, cervical spine instability (odontoid hypoplasia)
o Possible atlantoaxial instability (AAI)
2. Pulmonary complications:
o Kyphoscoliosis, obstructive & central sleep apnea, restrictive
lung disease, possible cor pulmonale
3. Neurologic complications:
o Spinal stenosis, hydrocephalus (cervical kyphoscoliosis) +/- VP
shunt
4. Difficult neuraxial anesthesia: kyphoscoliosis, narrow epidural space,
prolapsed discs, deformed vertebral bodies
5. Difficult IV access, regional/neuraxial, monitoring & positioning

Goals
1. Safe establishment of airway
2. Avoid neck hyperextension (brainstem compression)
3. Identification & optimization of cardiorespiratory complications
4. Goals for pulmonary hypertension if applicable

Pregnancy Considerations
 Cesarean section required due to fetal:pelvic disproportion
 Titrated epidural (spinal spread is unpredictable) is best, but epidural
may also be difficult

315
 Ankylosing Spondylitis

Considerations
1. Potential difficult airway
2. Risk of ↓ c-spine mobility/fusion/instability
3. Atlanto-axial subluxation possible
4. Multisystem disease with extra-articular features:
o Cardiac: aortic insufficiency, myocarditis, conduction defects,
cardiomegaly, cardiomyopathy, pericardial effusion
o Respiratory: restrictive lung disease from parenchymal fibrosis
& chest wall musculoskeletal disease
o Neuro: spondylolisthesis (cord compression), uveitis
o Heme: anemia of chronic disease
5. Difficult/impossible regional & neuraxial anesthesia due to poor
positioning, axial spine fusion, epidural space obliteration, &
underlying radiculopathies/neuropathic pain
o Higher risk epidural hematoma (ASRA)
o Paramedian might be a better approach
6. Medications: NSAIDS, steriods, immunomodulators: marrow
suppression, platelet dysfunction, renal impairment, need for steroid
coverage, ↑ infection risk

Goals
1. Minimize c-spine manipulation with airway management, consider
AFOI, videolaryngoscopy, lighted stylet
2. Management of multisystem disease features,
especially cardiopulmonary
3. Patient positioning
4. Recognition of difficult neuraxial & unpredictable response to
neuraxial local anesthetics

Pregnancy Considerations
1. Complicated due to difficult airway & difficult neuraxial technique,
have multiple plans in place
2. For neuraxial: consider paramedian approach & ultrasound guidance

316
 Ehlers Danlos

Background
 A type of connective tissue disorder
 Characterized by skin hyperextensibility, joint hypermobility, & tissue
fragility
 Classified into 6 types: classic, hypermobility, vascular,
kyphoscoliosis, arthrochalasia, dermatosparaxis
o Vascular type associated with ↑ risk of death

Considerations
1. Multisystem disease:
o High risk of bleeding & friable tissue → affects ETT placement,
regional techniques, invasive lines
 Desmopressin useful if bleeding
o Cardiovascular: mitral regurgitation, proximal aortic
dilatation, conduction abnormalities,
o Spontaneous ruptures: bowel, uterus, or major arteries
o Skin laxity/fragility & joint hypermotility
2. ↑ risk pneumothorax: keep low airway pressures
3. Regional anesthesia is relatively contraindicated due to hematoma
risk

Pregnancy Considerations
1. Very difficult management, requires multidiscplinary effort
2. High risk of preterm labor, uterine rupture, & hemorrhage
3. Neuraxial relatively contraindicated, may need GA
4. If vascular type, recommendations are either termination of
pregnancy or cesarean section before 32 weeks

317
 Marfan's Syndrome

Considerations
1. Airway problems:
o Possibly difficult: high arched palate
o Potential cervical spine (C1/2) ligamentous instability
o TMJ laxity & potential dislocation with laryngoscopy
2. Multisystem disease:
o Cardiovascular dysfunction
 Valvular disease (AI, MR, MVP)
 Aortic arch aneurysm, aortic rupture & dissection risk
 MIs secondary to medial necrosis of the coronary
arterioles
 Arrhythmias & conduction defects
o Respiratory dysfunction:
 Scoliosis, pectus carinatum/excavatum & restrictive lung
disease, pulmonary hypertension, cor pulmonale
 Spontaneous pneumothorax (bullous lung disease),
emphysema
o Ocular: lens dislocation, retinal detachement, glaucoma
3. Potentially difficult positioning & regional anesthesia
o Rule out dural ectasia

Goals
1. Minimize ↑ in aortic wall tension through avoidance of sustained ↑ in
sytolic BP
2. Establish airway with minimal c-spine movement
3. Maintain hemodynamic goals of associated valvular lesions
4. Lung protective ventilation considering restrictive lung disease &
potential bullae
5. Careful positioning (lax joints & potential peripheral nerve injury)
6. Post-op pain (neuraxial or regional preferrably), post-op disposition
7. These patients are for elective aortic repair when ≥ 5cm

Potential conflicts
 Coexisting aortic root dilation (need to reduce cardiac output) vs
MR/AI/LV dysfunction

318
Pregnancy Considerations
1. If ∅ symptoms & aorta diameter < 4cm → no special considerations &
vaginal delivery ok
2. If aortic root dilatation/AI → multidisciplinary management with
cardiology/cardiac surgery/obstetrics
3. Some authorities recommend cesarean section for aortic diameter >
4.5cm, labor if > 4 & < 4.5cm
4. Issues:
o Airway might be even more difficult
o Neuraxial very good option for vaginal delivery &
cesarean section
o Aortic dilatation with risk dissection/rupture
o Monthly echocardiography during pregnancy
o Big focus is to reduce shear forces on aorta
o Consider very early epidural
o Need invasive monitoring
o Drug therapy to prevent tachycardia & elevated BP (keep
systolic < 120mmHg) = labetalol good agent
o Avoid ergotamine due to hypertension risk
5. Dural ectasia:
o NOT an absolute contraindication to epidural placement but
higher risk for failed block & dural puncture & PDPH
o Widening of the dural sac, asymptomatic or may present with
low back pain, headache, or proximal leg pain, weakness, or
numbness
o Consider CT/MRI

319
 Osteogenesis Imperfecta

Background
 Rare, autosomal dominant, inherited disease of connective tissue
that affects bones, the sclera, & the inner ear, bones are extremely
brittle

Considerations
1. Difficult airway: ↓ C-spine mobility, fragile C-spine with fracture risk,
mandibular fractures, large head, short neck, brittle teeth
2. Kyphoscoliosis & pectus excavatum
3. Possible restrictive lung disease, pulmonary hypertension, & RV
dysfunction
4. Cardiac involvement (aortic regurgitation & mitral regurgitation)
5. ↑ risk of fractures:
o BP cuffs may be hazardous
o Careful positioning & padding essential
o Succinylcholine fasciculations may cause fractures
6. Bleeding tendency secondary to ↓ platelet function possible
7. Hypermetabolic: prone to hyperthermia but not malignant
hyperthermia (MH) risk

Conflicts
1. Full stomach/RSI vs. difficult airway
2. Regional vs. bleeding tendency
3. Monitoring/positioning vs. brittle bones

Pregnancy Considerations
1. ↑ obstetrical risks:
o High incidence cephalo-pelvic-disproportion → mandatory
cesarean section
o Higher incidence intra-partum & post partum hemorrhage
2. ↑ risk uterine rupture/pelvic fracture
3. Even more difficult airway
4. Succinylcholine can cause bone fractures: give defasciculating
NdMR or use rocuronium
5. Potential contraindication to regional due to platelet dysfunction: if
patient history reassuring along with platelet count/INR/PTT, go
ahead with regional
320
 Rheumatoid Arthritis

Considerations
 Potential for difficult airway & unstable c-spine:
o TMJ involvement, atlanto-axial instability (AAI)*, cricoarytenoid
arthritis
 Multisystem disease:
o Respiratory: interstitial fibrosis, pulmonary hypertension,
pleural effusions
o Cardiovascular: pericarditis, AI, pericardial effusions,
conduction system defects, LV dysfunction, accelerated CAD
o CNS: peripheral neuropathy resulting from nerve compression,
carpal tunnel syndrome, & tarsal tunnel syndrome are
common, chronic pain
o Renal: chronic renal failure possible (drugs, amyloidosis,
vasculitis)
o Heme: chronic anemia, thrombocytopenia, neutropenia (Felty’s
syndrome)
 Medication side effects: corticosteroids, NSAIDs,
immunosuppressives (cyclosporine, cyclophosphamide,
methotrexate), stress dose steroids if needed
 Technical difficulties with lines & patient positioning, fragile skin

Goals
 Safe establishment of airway & preservation of c-spine integrity
 Careful positioning & documentation of pre-existing neurologic
symptoms
 Rule out systemic disease & manage any existing abnormalities,
especially cardiopulmonary

Pregnancy Considerations
 Obstetric management: vaginal delivery is
preferred, cesarean section is reserved for obstetrical indications
 Anesthesia:
o Regional definitely ok if platelets within normal limits
o Document pre-existing injuries
o If GA: very cautious airway management!!

321
*Approach to AAI
 Indications for X-ray are controversial
 Indications suggested in literature:
o Severe disease requiring steroids, methotrexate,
& immunosuppressants
o Obvious symptoms
o Disease >10 years
 On X-ray distance from the anterior arch of the atlas to the odontoid
process > 3 mm confirms the presence of atlantoaxial subluxation
 This abnormality is important, because the displaced odontoid
process can compress the cervical spinal cord or medulla or occlude
the vertebral arteries. When atlantoaxial subluxation is present, care
must be taken to minimize movement of the head & neck during
direct laryngoscopy to avoid further displacement of the odontoid
process & damage to the spinal cord. It is helpful to evaluate
preoperatively whether there is interference with vertebral artery
blood flow during flexion, extension, or rotation of the head & cervical
spine. This can be accomplished by having the awake patient
demonstrate head movement or positioning that can be tolerated
without discomfort or other symptoms.

322
 Scleroderma

Considerations
 Potential difficult airway (microstomia, ↓ neck mobility, bleeding
nasal/oral telangiectasia)
 Aspiration risk (esophageal dysmotility, hypotonic lower esophageal
sphincter)
 Multi-system disease:
o Cardiovascular: hypertension, coronary disease, myocardial
fibrosis & LV failure, arrhythmia
o Resp: restrictive lung disease, pulmonary fibrosis, pulmonary
hypertension, cor pulmonale
o Renal failure & “renal crisis”
o Skin: raynaud's, vasoconstriction, sensitive to cold:
 Radial arterial line may be contraindicated
 Consequences of dermal thickening, contractures:
o Difficult vascular access/positioning/monitoring
o Nerve entrapment/pain syndromes
1. Medications: immunosuppressant, vasodilators (ACE inhibitors), pain
medications

Anesthetic Goals/Issues
2. Secure airway safely & avoid aspiration:
o Potential difficulty with bag mask ventilation, laryngoscopy &
surgical technique
o Consider regional over GA
3. Recognize several potential precipitants for hemodynamic instability:
o Volume depletion, hypertension
o Myocardial dysfunction, arrythmia, pulmonary hypertension, cor
pulmonale
4. Avoid precipitants of:
o Vasoconstriction episodes: e.g., hypothermia, sympathetic
stimulation
o Pulmonary hypertension
5. Address pulmonary disease
6. Potential for hypoxemia (fibrosis), acute lung injury/barotrauma
(restrictive lung disease)
7. Post-op ventilation

323
Conflicts
1. Aspiration vs. cardiac disease & hemodynamic instability
2. Aspiration vs. difficult airway
3. ? difficult regional vs. risk of post-op ventilation
4. TEE vs compromised esophagus

Treatment of Limb Raynaud's Crisis Due to Arterial Line

1. Emergency situation
2. Warm limb
3. Consult vascular surgery
4. Consider sympathetic block (i.e., stellate ganglion)

Pregnancy Considerations
1. Essentially as above
2. Very careful airway management & aspiration prevention
3. Possible prolonged neural blockade reported in literature so very
carefully titrated epidural warranted

324
 Stevens-Johnson Syndrome

Considerations
1. Severe life threatening drug reaction with high morbidity/mortality
2. Possible difficult airway (edema & ulcerations)
3. Respiratory:
o Hypoxia
o Hypersecretions
o Pulmonary edema & ARDS
o Blebs & pneumothorax
o Tracheobronchitis
4. Cardiovascular:
o Septic shock common cause of death
o Hypovolemia, third spacing
5. Renal: electrolyte abnormalities, renal failure
6. Significant pain requiring multimodal analgesia

Treatment
1. Transfer to ICU/burn unit
2. Institute supportive care:
o Fluid & electrolyte management (fluids: use parkland formula in
acute phase)
o Analgesia
o Nutritionional support
o Temperature management
o Antibiotics for superinfections
3. Adjunctive therapies (all controversial, no good evidence):
o Steroids if indicated
o IVIG
o Cyclosporine
o Plasmapheresis
o Anti-TNF monoclonal antibodies

325
 Systemic Lupus Erythematosus (SLE)

Considerations
1. Potential difficult airway but usually NOT an issue:
o C-spine arthritis
o Cricoarytenoid arthritis
o Recurrent laryngeal nerve palsy
2. Multisystem complications of SLE:
o CNS: central & peripheral sensorimotor & autonomic
neuropathies, seizure, stroke, mood, confusion, organic
disease, transverse myelitis
o Cardiovascular: pancarditis with myocarditis (conduction
disease, CHF), pericarditis (effusions/tamponade), non-
infectious endocarditis (aortic & mitral regurgitations),
accelerated coronary disease, hypertension, pulmonary
hypertension
o Pulmonary: restrictive lung disease (ILD, pleuritis, effusions),
pulmonary hypertension/RV failure, infection, pulmonary
hemorrhage.
o Renal: lupus nephritis, CRF
o Hematology: antiphospholipid-Ab syndrome common, risk of
thromboembolism, anemia, thrombocytopenia, leukopenia
factor deficiency (VIII, IX, XII) with implications for regional
anesthesia
o Liver dysfunction can occur
o MSK: vasculitis, arthritis, joint immobility, migratory polyarthritis
3. Medications:
o Steroids (Cushings/hyperglycemia/adrenal suppression/need
for stress dose)
o Immunosuppresants/antimalarials
o NSAIDs
o Anticoagulants/ASA
4. Potential for acute exacerbation with surgery, stress, infection &
pregnancy
5. Obstetric & cardiac anesthesia, especially in those with aPL
antibodies or APS, requires multidisciplinary management at a
specialist center

Pregnancy Considerations
 ↑ risk of preterm labour & intrauterine fetal death
 Multidisciplinary management: rheumatology, obstetrics, anesthesia

326
 Potential coagulopathy may contraindicate use of neuraxial → ensure
early hematology consult
o ↑ PTT can have 2 causes:
 Presence of lupus anticoagulant: just a lab abN so
clinically ok for neuraxial, these patients can actually be
hyper-coagulable
 Autoantibodies against specific coagulation factors (e.g.,
VIII, IX, XII): risk of true coagulopathy → neuraxial
contraindicated
 Document any pre-existing central or peripheral sensorimotor &
autonomic neuropathies prior to regional technniques
 Potential for neonatal lupus & congenital heart block

327
 Wegener's Granulomatosis

Considerations
1. Potential difficult airway: laryngeal stenosis, subglottic stenosis,
tracheal stenosis, friable bleeding tissue
2. Multisystem granulomatous disease:
o CNS: cerebral aneurysms, peripheral neuropathy
o Cardiovascular: cardiac valve destruction, conduction defects,
myocardial ischemia
o Pulmonary: sinusitis, pulmonary fibrosis, pulmonary
hypertension, pneumonia, hemoptysis, & bronchial destruction
o Renal: hematuria, renal failure
3. Possible contraindication to arterial line due to peripheral arteritis
4. Medications includuing immunosupressants

Goals & Conflicts

1. Careful airway management
2. Document neurologic deficits prior to regional techniques
3. May present with massive hemoptysis & require emergency lung
isolation

328
Toxicities

329
 Contents

# Topic Page No.

1 Acetaminophen Overdose 331
2 ASA Toxicity 332
3 Beta Blocker Overdose 334
4 Cocaine Toxicity 336
5 Cyanide Toxicity 338
6 Digoxin Toxicity 339
7 MDMA (Ecstasy) 341
8 Methamphetamines 342
9 Organophosphates 343
10 Tricyclic Antidepressants (TCA) 344

330
 Acetaminophen Toxicity

Considerations
1. Emergency situation, full stomach
2. Co-intoxications may exist
3. Uncooperative patient (encephalopathy, toxic ingestions, suicidality)
4. Multisystem effects of acute liver injury/failure (usually only > 24
hours after ingestion):
o CVS: hypotension
o CNS: encephalopathy, cerebral edema
o GU: renal failure
o GI: nausea/vomiting, acute hepatic failure
o Hematology: anemia (GIB), coagulopathy
5. Early provision of therapy:
o Oral activated charcoal < 1hr
o N-acetyl cysteine (NAC) according to treatment nomogram
6. Disposition to ICU for monitoring & supportive care

Pregnancy Considerations
1. Identical management with NAC nomogram (both acetaminophen &
NAC cross placenta)
2. Multdisciplinary: obstetrics, pediatrics, NICU consultations
3. Risk of fetal compromise:
o FHR monitoring
o Consider caesarean section

331
 Aspirin Toxicity

Background
 Aspirin is converted to its active metabolite salicylic acid, salicylates at
toxic levels are metabolic poisons that:
o Uncouple oxidative phosphorylation
o Interfere with the Krebs cycle
o Lead to accumulation of lactic acid & ketoacids

Considerations
1. Emergency/full stomach
2. Consider other toxins
3. Potentially life threatening emergency requiring monitoring:
o Arterial line for frequent BW
o Consult toxicology/ICU/nephrology
4. Severe acidosis:
o Severe AGMA (keto-lactic) with compensatory respiratory
alkalosis
o ↓ pH favours tissue (e.g. brain) passage → toxic effects
5. Respiratory:
o Respiratory alkalosis is compensatory
mechniasm as alkalinization assists renal elimination
o Cautious intubation: will not tolerate apnea & ICU ventilator
required
o Non-cardiogenic pulmonary edema can occur
6. Central nervous system:
o Uncooperative & co-intoxications
o Profound ↓ LOC
o Cerebral edema
o Neuroglycopenia
7. Assess severity & timing:
o Activated charcoal if < 1hour
o Serums ASA levels (note that peak levels can be delayed by 6
hours)

Treatment
1. Rapid assessment & stabilization of ABCs
2. GI decontamination with activated charcoal:
o 1st dose:1g/kg up to 50 grams PO,followed by 25 g POq2h x 3

332
3. Volume resuscitation unless cerebral or pulmonary edema is present
4. Empirical glucose if altered LOC even if normal serum glucose
5. Urine alkalinization with NaHCO3:
o Bolus: 1 meq/kg IV bolus
o Maintenance: 150 meq NaHCO3 in 1 L of D5W,
 Start 2x maintenance
 Titrate to urine pH > 7.5.
 Continue until serum salicylate < 30 mg/dL
o Monitor & avoid
 Volume overload
 Hypokalemia
6. Avoid intubation if possible but it may be necessary for:
o Airway protection
 Lavage/charcoal
 GCS < 8
 Too agitated & delirious for medical procedures such
as CVC placement & hemodialysis
o Severe hypoxemia from ASA-induced pulmonary edema
o Maintenance of hyperventilation if respiratory failure occuring
(compensation for AGMA)
7. Hyperventilate:
o An abrupt ↓ in salicylate-induced hyperventilation may lead to
life-threatening acidosis
o ICU ventilator available
8. Hemodialysis indications:
o Coma or cerebral edema
o Pulmonary edema or fluid overload (limits NaHCO3
administration)
o Renal failure that interferes with salicylate excretion
o Lethal salicylate concentration > 100 mg/dL (7.2 mmol/L)
o Refractory AGMA despite aggressive management

333
 Beta Blocker Toxicity

Considerations
1. Emergency situation (PALS, ACLS algorithms), full stomach
2. Multidisciplinary care: toxicology, CCU, ICU, nephrology for dialysis
3. Multisystem effects:
o Cardiovascular: bradycardia, arrhythmias, hypotension, cardiac
arrest
o Respiratory: bronchospasm
o Metabolic: hypoglycemia, hyperkalemia
o CNS: stupor, coma, seizures
4. Comorbid disease (CAD, CHF, atrial fibrillation, dysrhythmias,
HOCM)

Treatment
1. Airway/ventilation/oxygenation
2. Follow ACLS/PALS algorithms + consult toxicology/CCU/ICU
3. Consider gastric decontamination with activated charcoal if within 2
hours of ingestion
4. Bradycardia: atropine, pacing if needed
5. Hypotension:
o Fluid therapy
o Glucagon: 5-10mg IV bolus then 2-5mg/hr infusion (PALS 50-
150 mcg/kg)
o High dose insulin: 1 U/kg/hr insulin + 1g/kg/hr glucose
 Replace K+ if < 2.5
o Vasopressors (high doses may be required)
 Epinephrine 50-100 mcg/min
o Calcium chloride 1 g IV boluses
6. Arrhythmia/wide QRS:
o Cardiovert
o Bicarbonate: 1-2 meq/kg IV boluses with maintenance infusion
if needed
o Magnesium 2g boluses
o Avoid other antidysrhythmic drugs such as class Ia & Ic
7. Advanced therapies:
o Dialysis: only for atenolol, nadolol, sotalol
o Intralipid
o ECMO
o IABP
o Ventricular assist device (VAD)

334
8. Hypoglycemia: D50W
9. Seizures: benzodiazepines
10. Special considerations:
o Propanolol causes sodium channel blockade with QRS
widening (treat with NaHCO3)
o Sotalol causes potassium efflux blockade with long QT
(monitor for Torsades)

335
 Cocaine

Considerations
1. Emergency/full stomach
2. Uncooperative/co-ingestions/agitated
3. Multisytem effects:
o Airway: nasal septal necrosis
o CNS: CVA/ICH, seizure, agitation, uncooperative, ↑MAC
o Cardiovascular:
 HTN, tachycardia
 Arrhythmias
 Coronary vasospasm resulting in angina or MI
 Cardiomyopathy
 Aortic dissection
 Unopposed alpha with beta blockade
o Respiratory:
 RLD: crack lung, aspiration
 Pneumothorax, pneumomediastinum
 Bronchospasm
o Hematologic: DIC, thrombocytopenia
o Renal: renal infarction, rhabdomyolysis
o GI: ischemia, ulceration, perforation

Conflicts
1. Difficult airway in an uncooperative patient
2. RSI in a patient with hemodynamic instability
3. Regional anesthesia in an uncooperative patient or coagulopathy
4. Placental abruption, uncooperative OB patient, difficult airway

Anesthetic Management
1. Delay OR if possible to optimize & allow for effects of cocaine to
wane
2. Monitor in high acuity setting/ICU
3. Full CAS monitors, 5 lead ECG & arterial line
4. Treat adrenergic crisis & uncooperative status with benzodiazepines
as first line
5. Chest pain management:
o Consult cardiology urgently & keep broad ddx
o Start with midazolam

336
 o Consider NTG & phentolamine (1-2.5 mg q 5-15 minutes)
o Avoid beta blockers
6. If need for urgent GA:
o Pre-induction arterial line
o Treat adrenergic tone as above
o Deep titrated GA, avoid ketamine, accept aspiration risk
7. Wide complex tachycardia: NaHCO3 1-2 meq/kg until hemodynamic
stability & QRS <120 ms
8. Postoperative discharge to high acuity/ICU

337
 Cyanide Toxicity

Considerations
1. Life threatening emergency with high morbidity/mortality
2. Need to consult medical toxologist or poison control & treat
appropriately without delay
3. Coexisting diseases:
o Burns: carbon monoxide poisoning, smoke inhalation
o Co-ingestions

Treatment
1. Consult toxicology/ICU
2. Secure airway & administer 100% O2
3. Ensure all medical personnel have suits & respirators; decontaminate
the patient (strip & discard clothing, wash all surfaces with soap &
water)
4. Antidotes:
o Cyanide scavengers:
 IV hydroxocobalamin = 1st line (dose = 70mg/kg, repeat
X1 if needed)
 Nitrate such as IV sodium nitrite &/or inhaled amyl nitrite
 Downside is formation of methemoglobin & can
cause hypotension, so hydroxycobalamin may be
preferred
5. Sodium thiosulfate: 25 mL of 50% solution:
o In the body, HCN is broken down by rhodanase, which
detoxifies cyanide to thiocyanate
o This process can be accelerated by provision of sodium
thiosulfate, which provides a store of sulfane sulfur for the
enzyme

338
 Digoxin Toxicity

Background
 Digoxin works by ultimately ↑ cardiac myocyte Ca+
 Excessive intracellular calcium may cause delayed after-
depolarizations, which may result in premature contractions & trigger
arrhythmias
 Digoxin has a narrow therapeutic window & the following factors can
affect concentrations or enhance toxicity:
o Renal impairment
o Hypovolemia
o Hypokalemia
o Hypomagnesemia
o Hypernatremia
o Acidosis
o Drug interaction
o Poisoning/ingestion
o MI
 ECG findings are:
o ↑ PR
o ↓ QTc
o ST segment depression
o Diminished amplitude or inversion of T waves

Considerations
1. Medical emergency that needs consultation with toxicology &
cardiology
2. Need for monitoring (ICU/high acuity unit)
3. Cardiac arrhythmias which may be lethal:
o Ectopy & tachycardia: PVCs, bigeminy, VT, VF
o Cardiac arrest from asystole, VF (usually fatal)
o Bradyarrhythmia from ↑ vagal tone
 AV junctional & heart blocks

Treatment
1. Admit to monitored unit
2. Consult toxicology & cardiology
3. Draw digoxin level
4. Antidote = digibind (Fab)

339
 o Dosing:
 Known ingested digoxin dose: give 2 vials of Fab for
every mg of digoxin ingested
 Chronic toxicity or dose unknown, calculate # of vials as
per this formula:
 serum digoxin concentration (ng/ml) X weight
(kg)/100
 If can't wait for serum levels or life-threatening toxicity:
give 10-20 vials
o Hyperkalemia is common with digitalis toxicity, but do not treat
with K+ lowering agents as digibind on its own will lower K+ &
any more correcting can cause hypokalemia (which worsens
digoxin toxicity)
5. Volume resuscitation if hypotension
6. Replace K+ & Mg as necessary
7. Arrhythmias: follow standard ACLS algorithms
8. Avoid calcium even if hyperkalemic because patients have
intracellular hypercalcemia & can worsen situation

340
 MDMA (Ecstasy) Toxicity

Considerations
1. Sequelae of MDMA overdose:
o Cardiovascular: hypertension, tachyarrhythmias
o CNS: cerebral edema, seizures, anxiety
o Renal: acute hyponatremia, rhabdomyoloysis
o Metabolic: hyperthermia
2. Risk of DIC & multi-organ failure leading to coagulopathy & impaired
drug metabolism/secretion
3. Co-ingestions
4. Need for invasive monitoring & ICU admission

Treatment
1. Admit to monitored setting
2. Consult toxicology if needed
3. Cancel any elective surgery
4. Rx of sequelae:
o Hypertension
 Benzodiazepines as first line agent until BP normalized
or patient sedated
 If benzodiazpines inadequate, use vasodilators such as
NTG, NTP, or phentolamine
 Beta blockers are contraindicated
o Seizures & agitation: use benzodiazepines
o Hyponatremia
 Usually mild & will resolve in 12-24 hrs with water
restriction
 If severe (< 120): use hypertonic 3% NS 100cc boluses
q10 min
o Hyperthermia:
 Severe (> 41ºC): immerse in ice bath
 Moderate: use cooling blankets, cool water mist, fanning

341
 Methamphetamines (Crystal Meth) Toxicity

Considerations
1. Multi-system effects of acute abuse:
o CNS: possible ↑ ICP, seizures, uncooperative, ↑ MAC
o Cardiovascular: hypertension, tachycardia, cardiac
dysrhythmias, acute coronary syndromes, cardiovascular
collapse (due to dehydration, neurotransmitter depletion,
metabolic acidosis)
o Metabolic: hyperthermia, malnutrition, metabolic acidosis,
rhadbomyolysis,
2. Chronic amphetamine abuse:
o ↓ MAC & refractory hypotension (depletion of catecholamine
stores)
o Physiologic dependence
o Withdrawal management
3. Need for universal precautions

342
 Organophosphate Toxicity

Considerations
1. Life threatening emergency situation
2. Multisystem failure:
o Respiratory: weakness & respiratory failure, bronchospasm,
hypoxemia
o Cardiovascular: hemodynamic instability
o CNS: seizures, ↓ LOC
3. Decontamination/exposure to medical personnel

Treatment
1. Intubation & ventilation as appropriate
2. Consult toxicology, ICU
3. Atropine 2-5 mg IV (often need 15-20 mg) until ↓ secretions &
adequate tidal volumes
4. Pralidoxime 1000-2000 mg IV, then 1000mg q12h, DO NOT give
pralidoxime without atropine
5. Benzodiazepines for seizures, phenytoin ineffective
6. Paralysis for airway management:
o Note: succinylcholine may result in prolonged paralysis due to
inhibition of acetylcholinesterase by these compounds
o ↑ doses of rocuronium may be needed due to competitive
inhibition at the neuromuscular junction

343
 TCA Toxicity

Background
 Multi-system effects due to:
o Blockade of cardiac fast sodium channels
o Antagonism of:
 Central & peripheral muscarinic acetylcholine receptors
 Peripheral α-1 adrenergic receptors
 Histamine (H1) receptors
 CNS GABA A receptors
 Greatest risk of seizure & arrhythmias occurs in first 6-8 hours of
TCA ingestion

Considerations
1. Emergency/full stomach
2. Co-ingestants
3. Life threatening multi-system effects:
o CNS: sedation, coma, seizures
o CVS: tachyardia, hypotension, myocardial dysfunction, lethal
arrhythmias
o Anticholinergic toxidrome (red, hot, mydriasis, dry, delirium)

Treatment
1. Consult toxicology/ICU immediately
2. Admit to monitored setting
3. Intubate & hyperventilate (promotes alkalosis)
4. Sedation with benzodiazepines & propofol (to ↑ seizure threshold)
5. Gastric decontamination (if ingestion < 1hr & airway is protected)
6. Hypotension: fluids & vasopressor (norepinephrine)
7. QRS > 100 ms = high risk of arrhythmias & seizures:
o NaHCO3
 2-3 mEq/kg then 3 amps/L at 250 ml/hr or 2x
maintenance
 Goals: QRS < 100, stable BP, sodium ~ 150, pH ~ 7.5
 3% NaCl if pH > 7.50 & persistent QRS elevation
8. Arrhthmia treatment (VT/VF):
o Run ACLS/defibrillate
o Lidocaine 1 mg/kg
o MgSO4 if prolonged QTc or Torsades develops
o Amiodarone/procainamide contraindicated

344
 9. Seizures:
o Treat with midazolam
o Do NOT use phenytoin
10. Intralipid for cardiac arrest or refractory hypotension
11. ECMO as last resort
12. Hemodialysis NOT effective

Contraindicated Therapies
1. Anti-arrhythmic drugs:
o Class IA (e.g., procainamide) & class IC agents (e.g.,
flecainide) due to their inhibition of rapid sodium channels
(similar to TCA effect)
o Class III agents (e.g., amiodarone) due to QTc prolonging
effect
2. Phenytoin
3. Flumazenil: can induce seizures

345
Vascular

346
 Contents

Topic Page No.

1 Abdominal Aortic Aneurysm Repair (Open) 348
2 Carotid Endarterectomy 349

347
 Abdominal Aortic Aneurysm (AAA) Open Repair

Considerations
1. Potential for hemorrhage, large fluid shifts & hypothermia
2. Cross-clamp level & cross-clamp/unclamp physiology
3. Associated comorbid disease (coronary disease, hypertension
diabetes, renal failure, COPD, smoking)
4. Perioperative organ dysfunction (cardiac, renal, visceral, spinal cord
ischemia) & complication (MI/renal failure/heart
failure/paralysis/death)
5. Postoperative pain control & monitoring in high acuity unit/ICU
6. For ruptured AAA, add the following:
o Full stomach, limited time to optimize
o Emergency procedure requiring immediate OR
o Need for extra help, second anesthesiologist
o Hemorrhagic shock with high mortality (85%)

Goals
1. Adequate resuscitation of massive hemorrhage to goal end points
2. Management of comorbidities
3. Minimize hemodynamic changes associated with aortic cross
clamping & unclamping

Conflicts

1. Hemodynamic instability vs. full stomach and need for RSI

2. Requirement for immediate OR vs. resuscitation

348
 Carotid Endarterectomy

Considerations
1. Shared airway
2. Significant hemodynamic fluctuations:
o X-clamp: hypertension, tachycardia, increased myocardial O2
demands
o Carotid sinus manipulation: bradycardia, hypotension
3. Coexisting disease (CAD, DM, HTN, PVD, CKD, CVD, smoking,
advanced age)
4. Neuromonitoring (usually EEG, cerebral oximetry, TCD, stump
pressure)
5. Complications:
o CNS: CVA (ischemic/embolic), hyperperfusion syndrome, CN
dysfunction
o Cardiovascular: MI, labile BP (hypertension/hypotension)
o Airway: hematoma, airway obstruction/loss, RLN injury
6. Perioperative medication management (ASA, plavix,
antihypertensives, statins)

Anesthetic Goals
1. Maintain stable hemodynamics
2. Optimize cerebral perfusion & protect myocardium
3. Crisp emergence with awake patient ready for neurological exam
4. Smooth emergence to minimize risk of bleeding

Anesthetic Options
1. GA vs. regional (superficial cervical plexus block ) vs. local
2. Carotid artery stenting also an option if patient unsuitable for an
anesthetic

349
 Part 3
GUIDELINES

350
 Contents

Topic Page No.

1 Hypertensive Disorders of Pregnancy 352
2 Sepsis Guidelines 358
3 Postoperative Nausea Vomiting 363
4 Obstructive Sleep Apnea Guidelines 369
5 Severe Traumatic Brain Injury 373
6 ERAS 378
7 Perioperative Cardiac Risk Assessment 381
8 Antibiotic Prophylaxis for Infective Endocarditis 385

351
 Hypertensive Disorders of Pregnancy
SOGC Hypertensive Disorders of Pregnancy 2014

1 Definition
2 Classification
3 Risk Factors
4 Prevention
5 Treatment
6 Steroids for Fetal Lung Maturity
7 Timing of delivery
8 Method of Delivery
9 Anesthetic Management
10 MgSO4
11 HELLP Syndrome
12 Postpartum

352
 Definitions:
Hypertensive Disorders of Pregnancy (HDP)

HTN in pregnancy:
1. SBP ≥140 mmHg and/or DBP ≥90 mmHg (avg of ≥2 measurements @ least
15 mins apart in same arm)
2. Resistant HTN: need for 3 antihypertensives for BP control @ ≥20 wks gest
3. Severe HTN: SBP ≥160 mmHg or DBP ≥110 mmHg
4. Significant proteinuria: ≥0.3 g/d (24 hr collection) or ≥20 mg/mmol (random
urine)
o Suspect if dipstick ≥1+ protein

HELLP syndrome
o Hemolysis
o Elevated Liver enzymes
o Low Platelets
 Adverse condition: increases risk of severe complications (see table)
 Serious complication: warrants delivery (see table)

Classification

1. Pre-existing HTN (pre-pregnancy or <20 wks gest)

2. Gestational HTN (develops @ ≥20 wks gest)
with or wihtout comorbid conditions (ex DM, renal dz)
3. Preeclampsia: gestational HTN + new proteinuria or ≥1 adverse condition or
serious complication

353
 In “pre-existing HTN” population: resistant HTN, new or worsening proteinuria,
≥1 adverse condition or serious complication
4. Severe preeclampsia: preeclampsia complicated by ≥1 serious complication
Warrants delivery regardless of gestational age
5. Other hypertensive effects” (ex-transient HTN, white-coat, masked HTN)

Risk factors
1. Personal or family hx of HDP
o 1st pregnancy
2. Multiple pregnancy
o New partner
3. Chronic medical dz (HTN, DM, renal dz, antiphospholipid antibody
syndrome)
o Maternal age ≥40 yrs
o Abnormal uterine artery Doppler <24 wks gest, IUGR

Prevention (in @ risk popn)

1. Low dose ASA
2. +/- prophylactic LMWH (if previous placental complication)
3. May be useful
o L-arginine
o ↑ rest @ home in 3rd trimester
o ↓ workload/stress
4. Not recommended
o Calorie restriction in overweight pregnant patients
o Weight maintenance in obese pregnant pts
o Antihypertensive Rx to prevent preeclampsia
o Vitamins C & E

Treatment

1. Severe HTN
o Inpatient care if severe HTN/preeclampsia
o Lower BP to SBP <160 mmHg & DBP <110
 Initial Rx in hospital
 Short-acting nifedipine capsules 5-10 mg po q30 min prn
 Hydralazine 5-10 mg IV q30 min prn
 Labetalol 20-80 mg IV q30 min prn
 Alternatives: NTG infusion, po methyldopa, po labetalol, po
clonidine
 Postpartum: po captopril
 Refractory HTN: SNP
 Nifedipine & MgSO4 can be used contemporaneously
 MgSO4 not recommended as sole anti-HTN Rx
o Continuous FHR monitoring until BP stable
2. Non-severe (SBP 140-159 mmHg, DBP 90-109 mmHg) w/o comorbid
conditions

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 o Lower BP to SBP 130-155 mmHg & DBP 80-105 mmHg
 Methyldopa 250-500 po bid-qid
 Labetalol 100-400 mg po bid-tid
 Nifedipine XL 20-60 mg po od
o No ACE-Is or ARBs in pregnancy
o Atenolol & prazosin not recommended prior to delivery
3. Non-severe w/ comorbid conditions
o Lower BP to SBP <140 mmHg & DBP <90 mmHg
 Same Rx as above
o Captopril, enalapril, or quinapril ok postpartum (even if breastfeeding)

Antenatal corticosteroids for fetal lung maturity

1. Consider if preeclampsia @ ≤34+6 wks gest
2. Consider if gestational HTN @ ≤34+6 wks gest & delivery contemplated w/in
next 7 days
o Consider rescue dose if @ ≤34+6 wks gest & continued high risk of
preterm delivery, ≥7 day after initial course
3. Consider if plan for elective c-section @ ≤38+6 wks gest

Timing of Delivery
1. Severe preeclampsia
o Mandatory obs consult
o Immediate delivery (vaginal or c-section) - regardless of gest age
2. Non-severe preeclampsia
o <24 wks gest: counselling should include info re delivery w/in days
o 24+0 to 33+6 wk gest: expectant mgt (only in perinatal centres w/ capacity
to care for very preterm infants)
o 34+0 to 36+6 wks gest: insufficient evidence to make recommendation
o ≥37+0 wks gest: immediate delivery recommended
3. Non-severe preeclampsia w/ HELPP syndrome
o 24+0 to 34+6 wk gest: consider delaying delivery to give corticosteroids
o ≥35+0 wks gest: consider for immediate delivery

Method of Delivery

1. Vaginal delivery considered unless c-section reqd for usual obstetric

indications
o Cervical ripening if vaginal delivery planned & cervix unfavourable
2. If gestational age not near term + fetal compromise: may benefit from
emergency c-section
3. Continue anti-HTN Rx throughout L&D to keep SBP <160 mmHg & DBP<110
mmHg
4. Active mgt of 3rd stage w/ oxytocin
o Do not use ergometrine if HDP

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Anesthetic Management

1. Inform anesthesia when pt w/ preeclampsia is admitted to delivery suite

2. Early epidural insertion to control labour pain (if no contraindications)
3. For C-section: can use epidural, spinal, CSE, or GA (if no contraindications)
4. No routine fixed IV fluid bolus prior to neuraxial anesthesia
5. Fluids
o Minimize IV & po fluid intake to avoid pulm edema
o No routine fluid admin to treat oliguria (<15 ml/hr x 6 hrs)
o No dopamine or furosemide for persistent oliguria
o Tx hTN d/t neuraxial anesthesia with phenylephrine or ephedrine
6. Monitoring
o Art line if BP control is difficult or severe bleeding
o CVP not routinely recommended
 If inserted, use to monitor trends, not absolute values
o PA catheter not recommended unless specific indication
 Only use in ICU setting
7. Coagulation
o Platelet (plt) count on admission to L&D
o Neuraxial technique appropriate if:
 Preeclampsia (w/o coagulation concerns)
 Plt count ≥75
 Low dose ASA & adequate plt count
 UFH ≤10,000 IU/day subcut 4 hrs after last dose
 ?ok immediately after last dose w/o delay
 UFH >10,000 IU/day subcut if normal aPTT 4 hrs after last dose
 IV heparin if normal aPTT 4 hrs after last dose
 LMWH 10-12 hrs after prophylactic dose or 24 hrs after
therapeutic dose
MgSO4

1. 1st line tx of eclampsia

2. Prophylaxis against eclampsia if severe preeclampsia
3. Consider for prophylaxis if non-severe preeclampsia with: severe HTN,
headache, visual symptoms, RUQ pain, epigastric pain, plt <100, progressive
renal insufficiency, and/or elevated liver enzymes
4. Dose: 4g IV loading dose then 1g/hr
o No routine monitoring of Mg levels
5. No phenytoin or BDZs for eclampsia prophylaxis or tx unless contraindications
to MgSO4 or MgSO4 is ineffective
6. If pre-existing or gestational HTN, consider MgSO4 for fetal
neuroprotection if imminent preterm birth (w/in 24 hrs) @ ≤31+6 wks gest
o Don’t delay delivery to give MgSO4 if maternal and/or
fetal indications for emergency delivery

HELLP syndrome

1. Platelet transfusion

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 o plts <20: prior to delivery
o plts 20-49: prior to C-section; prior to SVD if excessive bleeding, plt
dysfxn, rapidly falling plts count, coagulopathy
o plts ≥50: consider if excessive bleeding, plt dysfxn, rapidly falling plts
count, coagulopathy
o Do not transfuse plts if strong suspicion of HIT or TTP-HUS

Postpartum

1. Measure BP @ peak postpartum BP (3-6 days postpartum)

2. Evaluate women w/ postpartum HTN for preeclampsia
3. Consider continuing antiHTN tx postpartum
4. Treat severe postpartum HTN to keep SBP <160 mmHg & DBP <110
mmHg
5. Keep BP <140/90 mmHg in women w/ co-morbidities (consider tx in women
w/o co-morbidities)
6. Keep BP <130/80 mmHg in women w/ pre-gestational DM
7. AntiHTN agents generally acceptable with breastfeeding:
o Nifedipine XL
o Labetalol
o Methyldopa
o Captopril, enalapril
8. No NSAIDs postpartum if HTN difficult to control, evidence of kidney dysfxn,
or low plts
9. Consider postpartum thromboprophylaxis if preeclampsia

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 Sepsis Guidelines

1 Definition
2 Initial Resuscitation
3 Fluid Therapy
4 Vasopressors and Inotropes
5 ARDS Ventilation Strategies
6 Use of Corticosteroids
7 Bicarbonate Therapy
8 Blood Products
9 Glucose Control
10 Renal Replacement Therapy
11 VTE Prophylaxis
12 Stress Ulcer Prophylaxis

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Definitions (as per Society of Critical Care Medicine & the European Society of
Intensive Care Medicine)

 Sepsis:
Organ dysfunction caused by a dysregulated host response to
infection. Organ dysfunction is ≥2 points on the SOFA score (see
below)
 Septic Shock:
Patients with sepsis who despite adequate fluid resuscitation require
vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg and
have a lactate >2 mmol/L

SOFA (Sequential Organ Failure Assessment) Score

Points
1 Pulmonary: PaO2/FiO2
>400 0
301 to 400 1
≤ 300 2
101 to 200 with ventilator support 3
≤ 100 with ventilator support 4
2 Coagulation: Platelets (/mm3)
> 150 K 0
101 – 150 K 1
51 – 100 K 2
21 – 50 K 3
≤ 20 K 4
3 Liver: Bilirubin (mcmol/L)
20 0
20 – 32 1
33 – 101 2
102 - 204 3
> 204 4
4 Cardiovascular
Hypotension absent 0
Mean arterial pressure <70 mmHg 1
On dopamine ≤5 mcg/kg/min or any dobutamine 2
On dopamine >5 mcg/kg/min, epinephrine ≤0.1 3
mcg/kg/min or norepinephrine ≤0.1 mcg/kg/min
On dopamine >15 mcg/kg/min or epinephrine >0.1 4
mcg/kg/min or norepinephrine >0.1 mcg/kg/min
5 Brain: GCS Score
15 0
13 – 14 1
10 -12 2
6 -9 3
>6 4
6 Kidney: Renal Function

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 Creatinine 110 mcmol/L 0
Creatinine 110-170 mcmol/L 1
Creatinine 171-299 mcmol/L 2
Creatinine 300-440 mcmol/L or urine output 200-500 3
cc/day
Creatinine >440 mcmol/L or urine output <200 cc/day 4

Initial Management & Resuscitation

1. Draw blood cultures (aerobic + anaerobic) prior to antibiotic therapy

2. Start with broad spectrum antibiotics within 1 hour of sepsis diagnosis &
assess for need for source control
3. Resuscitate with initial crystalloid fluid bolus of 30cc/kg with the following
goals:
o MAP >65 mmHg. Apply vasopressors if MAP goal not
acheived with fluids
o Use dynamic* hemodynamic variables to guide fluid
resuscitation
 Static variables such as CVP not recommended
o Lactate clearance

Dynamic variables include:

 Passive leg raises
 Fluid challenges against stroke volume measurements
 Variations in systolic pressure, pulse pressure, or stroke volume to changes in
intrathoracic pressure caused by mechanical ventilation

Fluid Therapy in Sepsis

1. Use dynamic variables to assess fluid-responsiveness

2. Crystalloids (or a balanced solution or NS) should be first line with an initial
bolus of 30cc/kg
3. Do NOT use hydroxyethyl starches (associated with ↑ morbidity & possible
↑ mortality)
4. Consider albumin if significant amounts of crystalloid have been used
5. Continue fluid boluses as long as there are hemodynamic improvements
based on either dynamic (e.g. pulse pressure or stroke volume variation) or
static variables (e.g. arterial pressure, heart rate)

Vasopressors & Inotropes in Sepsis

1. Initial MAP target = 65 mmHg. Use an arterial line when possible

2. Norepinephrine = 1st line vasopressor

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 3. Vasopressin (up to 0.03 units/min) or Epinephrine can be added if a second
vasopressor is needed
4. Dopamine can be used as an alternative vasopressor agent to norepinephrine
in very select patients (e.g., bradycardic patient who is at low risk of
tachyarrhythmias). Dopamine is not useful for renal protection
5. A trial of dobutamine infusion up to 20mcg/kg/min can be added to
vasopressors in presence of low cardiac output or hypoperfusion despite
adequate intravascular volume/MAP
6. Phenylephrine should be avoided (insufficient evidence, potential for
splanchnic vasoconstriction)

Sepsis-induced ARDS Ventilation Strategies

1. Use tidal volumes of 6cc/kg

2. Pleateau pressure <30 cm H2O
3. Use PEEP to avoid alveolar collapse & titrate ↑ as needed
4. Use recruitment maneuvers in sepsis patients with severe refractory
hypoxemia due to ARDS
5. Consider prone positioning in sepsis-induced ARDS patients with a
Pao2/Fio2ratio ≤ 100mm Hg
6. Head of the bed elevated between 30-45º to reduce aspiration risk & to
prevent the development of VAP
7. Consider noninvasvie ventilation (NIV) if thought to be more beneficial than
intubation. But no strong recommendation to use NIV
8. Use neuromuscular blocking agents (NMBAs) for ≤ 48 hours in adult patients
with sepsis-induced ARDS & Pao2/Fio2 ratio < 150mm Hg (possible ↑ survival
& ↓ barotrauma)
9. Establish weaning protocols & allow for frequent spontaneous breathing trials
to eventually discontinue mechanical ventilation once the patient meets
extubation criteria
10. If absence of hypoperfusion & need for fluid resuscitation, use a conservative
fluid strategy

Use of Steroids
1. Do NOT routinely use hydrocortisone in septic shock
2. Consider IV hydrocortisone 200mg per day if adequate fluid resuscitation +
vasopressors have failed to restore hemodynamic stability
3. Taper hydrocortisone once vasopressors are no longer necessary
Bicarbonate Therapy

1. Do NOT use sodium bicarbonate therapy to improve hemodynamics or to

reduce vasopressor requirements in patients with hypoperfusion-
induced lactic acidosis with pH ≥ 7.15
2. Possible adverse effects of uncertain clinical significance:
o Sodium & fluid overload
o ↑lactate & Paco2

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 o ↓serum ionized calcium

Blood Products
1. pRBC: Transfuse only when Hgb <70 g/L, unless there is myocardial
ischemia, severe hypoxemia, or acute bleeding
2. Platelets transfusion thresholds:
o No bleeding: If < 10,000/mm3
o High risk of bleeding: If < 20,000/mm3
o Active bleeding, surgery, or invasive procedures: If < 50,000/mm3
3. FFP: Transfuse only if coagulation abnormality + active
bleeding/surgery/invasive procedure
4. Erythropoietin to treat anemia: Not routinely recommended

Glucose Control

1. Keep blood glucose ≤10 mmol/L (≤180mg/dL) & avoid hypoglycemia

2. Monitor blood glucose every 1 to 2 hours until glucose values & insulin
infusion rates are stable, then every 4 hours thereafter in patients receiving
insulin infusions

Renal Replacement Therapy (RRT)

1. Either continuous or intermittent RRT can be used in patients who meet

dialysis criteria
2. Do NOT routinely use RRT in patients with ↑ Cr or oliguria
3. Use the continuous method in hemodynamically unstable septic patients

Venous Thromboembolism (VTE) Prophylaxis

1. If no contraindication, use VTE prophylaxis with LMWH preferrred over UFH

2. Combination of pharmacological + mechanical VTE prophyalxis is
recommended, when possible
o Mechanical = intermittent pneumatic compression (IPC) and/or
graduated compression stockings
3. When pharmacological VTE prophylaxis is contraindicated, use mechanical
VTE prophylaxis

Stress Ulcer Prophylaxis

1. Use stress ulcer prophylaxis if mechanical ventilation >48 hrs or coagulopathy

(platelets <50,000/m3 or INR >1.5)
2. Either proton pump inhibitors or H2 receptor antagonists are reasonable

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 Postoperative Nausea & Vomiting Guidelines

1 Identifying Patient at Risk

2 Reducing Baseline Risk
3 Prophylaxis Approach
4 Treating PONV
5 Non Pharmacological Options

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Identifying Patients at Risk
Apfel Simplified Risk Score for PONV is used to determine need for
prophylaxis. Risk factors are:
1. Female Sex
2. History of PONV or Motion Sickness
3. Non-smoker
4. Use of Postoperative Opioids

Number of Apfel risk factors & risk of PONV:

 0 = 10%
 1 = 20%
 2 = 40%
 3 = 60%
 4 = 80%

Other known risk factors:

 Younger age <50
 General anesthesia
 Use of volatile anesthetics and nitrous oxide
 Duration of anesthesia
 Type of surgery (cholecystectomy, laparoscopic, gynecological)

Risk categories based on number of risk factors:

 Low: 0-1
 Medium: 2-3
 High: 4 or more

Reducing Baseline Risk

1. Avoiding general anesthesia by using regional anesthesia

2. Avoiding volatile anesthetics & nitrous oxide
3. Using propofol to induce & maintain anesthesia
4. Reducing opioids
5. Adequate hydration

Prophylaxis Approach

Number of Agents to Give

 Low: No prophylaxis
 Medium: Give 1-2 medications
 High: Give 3 or more medications

Suggested Combination Therapy

364
  Never combine drugs from the same class
 Most widely studied are 5-HT3 receptor antagonists or
butryphenones + dexamethasone. For example, if giving 2 IV drugs:
o Ondansetron 4mg + dexamethasone 4mg
o Droperidol 0.625 mg + dexamethasone 4mg
o Haldol 1 mg + dexamethasone 4mg

Drugs

1. 5-HT3 Receptor Antagonists

Specific Drugs

 Ondansetron = Gold standard

o 4mg IV at the end of case
o NNT = 6 for prevention of vomiting & 7 for prevention of nausea
 Granisetron
o 0.35-3 mg (5-20mcg/kg) IV
o As effective as ondansetron
 Palonosetron
o 0.075mg IV
o Effective for 24 hours & superior to ondansetron 4mg IV for PONV
prevention

When to Administer

 Ondansetron & Granisetron most effective when given at end of surgery

 Palonosetron is usually given at the start of surgery

Adverse Events
NNH listed is for Ondansetron
 Constipation (NNH = 23)
 ↑ Liver Enzymes (NNH = 31)
 Headache (NNH = 36)
 ↑ QTc: rare especially for 4mg Ondanestron IV dose

2. Corticosteroids

Dexamethasone

 Prophylactic dose for PONV = 4-5mg IV

 Other beneficial benefits when used in higher doses of 0.1mg/kg or 8 mg IV in
adults:
o better analgesia
o ↓ sore throat & muscle pain
o ↓ difficult falling asleep

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Methylprednisolone

 40mg IV effective

3. Butyrophenones

Droperidol

 0.625-1.25 mg IV at the end of surgery

 Efficacy similar to ondansetron for PONV prophylaxis
 NNT = 5 for both nausea & vomiting prevention
 QTc prolongation issues:
 FDA "black box" restriction 2001; however, doses used for PONV prophylaxis
unlikely to ↑ QTc. Studies show equal QTc effects to Ondansetron

Haloperidol

 0.5-2mg IV or IM at the end of surgery

 With these low doses, sedation does not occur & cardiac arrhythmias are
unlikely
 QTc prolongation is possible with Haldol, but studies have not shown higher
risk than Ondansetron
 Extrapyramidal side effects are rare with one study suggesting 1/806 patients
or 0.1%

4. Phenothiazines

Perphenazine

 2.5-5mg IV/IM
 Relative risk reduction of 0.5 with 5mg IV, with no increase in sedation or
drowsiness

Metoclopramide
 NOT a good prophylactic or therapeutic agent for PONV at standard doses
 NNT for metoclopramide 10, 25, 50mg for PONV at 24 hrs = 30,16, & 11,
respectively. Dyskinesia or extrapyradmial symptoms reported at 0.3%, 0.6%,
& 0.6% respectively
5. Antihistamines

Dimenhydrinate

 1mg/kg IV as recommended dose

 Antiemetic may be similar to ondansetron but not sufficient studies for optimal
timing or dose

366
Meclizine

 Very few studies but 50mg PO Meclizine plus ondansetron 4mg IV alone may
be more effective than either ondansetron or meclizine alone

6. Others

Propofol

 Intraoperative subhypnotic doses at 20mcg/kg/min or higher can reduce

PONV by up to 25%
 Small doses (20mg PRN) can be used as PONV rescue therapy in PACU

Alpha-2-Agonists (Clonidine & Dexmedetomidine)

 Perioperative use may have weak antinausea effect, possibly due to opioid
sparing effects

Mirtazapine

 30mg PO + dexamethasone 8mg reduced late PONV by >50% when

compared to dexamethasone alone

Gabapentin

 Preoperative gabapentin was associated with a significant reduction in PONV

(RR= 0.60), nausea (RR = 0.34), & vomiting (RR = 0.34) at 24 hours (Meta-
analysis, Anesth Analg. 2016 Apr;122(4):976-85)

Midazolam

 2mg IV 30 min prior to end of case as effective as ondansetron

4mg. Combination of the 2 drugs was even more effective

7. NK-1 Receptor Antagonists

Aprepitant

 40-80mg PO within 3 hours of induction of anesthesia

 Routine use not yet established
 Appears to be more effective than ondansetron in preventing PONV in the first
24-48 hours

Treating PONV
1. Treatment options are the same drugs described previously
2. If prophyalxis was used → use a drug from another class to treat PONV

367
 o Repeating the medication given for PONV prophylaxis within the first 6
hours after the initial dose conferred no additional benefit.
3. If NO prophylaxis was given → start with a low dose 5-HT3 antagonist (e.g.
Ondansetron 1mg)
o The 5-HT3 antagonists are the only drugs that have been adequately
studied for the treatment of existing PONV.
4. Alternative treatments for established PONV include:
o Dexamethasone, 2 to 4 mg IV
o Droperidol, 0.625 mg IV, or promethazine 6.25 to 12.5 mg IV
o Propofol, 20 mg as needed, can be considered for rescue therapy in
patients still in the PACU & is as effective as ondansetron.

Non-Pharmacological Options

P6 Acupuncture Stimulation

 Efficacy = prophylactic antiemetics such as ondansetron, droperidol,

metoclopramide, cyclizine, & prochlorperazine
 The timing of trans-cutaneous acupoint electrical stimulation does not impact
PONV, with similar reductions being achieved with stimulation initiated before
or after induction of anesthesia
 Neuromuscular stimulation over the median nerve also reduces the incidence
of PONV in the early postoperative period, particularly when tetanic stimulation
is used

Adequate IV Hydration

 No difference between crystalloid vs colloids

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 Obstructive Sleep Apnea

1 Screening (STOP BANG)

2 Inpatient vs Outpatient Management
3 Preoperative Preparation
4 Intraoperative Management
5 Postoperative Management
6 Perioperative Risk Calculation

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STOP-BANG Screening for OSA

Screening Questions

 Snoring: loud snoring

 Tiredness: being tired, fatigued, or sleepy during daytime
 Observed Apneas: others have observed patient stop breathing during sleep
 Pressure: diagnosed with hypertension
 BMI: >35
 Age" >50
 Neck circumference: >40cm
 Gender: Male

How to Use
 Scoring:
o ≥3: high risk of having OSA
o <3: low risk of having OSA
 Sensitivity for various AHI levels:
o AHI >15: 93%
o AHI >30: 100%
 Specificity
o AHA >15: 43%
o AHA >30: 37%

Inpatient vs Outpatient Management

 Insufficient evidence either way

 Team discussion needed
 Things to consider:
o Sleep apnea status
o Anatomical and physiologic abnormalities
o Status of coexisting diseases
o Nature of surgery
o Type of anesthesia
o Need for postoperative opioids
o Patient age
o Adequacy of post discharge observation
o Capabilities of the outpatient facility: The availability of emergency
difficult airway equipment, respira- tory care equipment, radiology
facilities, clinical laboratory facilities, and a transfer agreement with an
inpatient facility should be considered in making this determination

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Preoperative Preparation
 Preoperative initiation of CPAP should be considered, particularly if OSA is
severe. For patients who do not respond adequately to CPAP, NIPPV should
be considered. In addition, the preoperative use of mandibular advancement
devices or oral appliances & preoperative weight loss should be considered.
 A patient who has had corrective airway surgery (e.g.,
uvulopalatopharyngoplasty, surgical mandibular advancement) should be
assumed to remain at risk of OSA complications unless a normal sleep study
has been obtained & symptoms have not returned.
 Remember potentially difficult airway
 Things to examine:
o Evaluation of the airway
o Nasopharyngeal characteristics
o Neck circumference
o Tonsil size
o Tongue volume

Postoperative Management
Risk factors for post-op Respiratory depression
 Severity of the sleep apnea
 Systemic opioids
 Use of sedatives
 Site & invasiveness of surgical procedure
 The potential for apnea during rapid eye movement (REM) sleep on the third
or fourth postoperative day (i.e., “REM rebound”), as sleep patterns are
reestablished.

Post-op Analgesia/Sedation
 Consider regional if possible
 If epidural post-op, weigh cons/benefits epidural opioids vs local alone
 If PCA, avoid continuous background infusion
 Consider multimodal analgesia (NSAIDs, tylenol, etc)
 Caution using any sedatives

Oxygenation
 Use supplemental oxygen
 Use CPAP/BiPAP if they were on it. Use their own device as it improves
compliance

Other Points
 Positioning: if possible, place in non-supine positions
 Hospitalized patients who are at ↑ risk of respiratory compromise from OSA
should have continuous pulse oximetry monitoring after discharge from the
recovery room. Continuous monitoring may be provided in a critical care or
stepdown unit, by telemetry on a hospital ward

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  Frequent or severe airway obstruction or hypoxemia occurs during
postoperative monitoring, initiation of nasal CPAP or NIPPV should be
considered.

Perioperative Risk Calculation

 Each category scored out of 3

o Add Score A & higher of B or C to get final score.
 Score 4 = ↑ risk
 Score 5/6 = Significantly ↑ risk

372
 Guidelines for Management of Severe Traumatic
Brain Injury (TBI)
Adapted from Guidelines for the Management of Severe TBI, 4th Ed., September
2016, Brain Trauma Foundation.

1 Treatment for TBI

2 Monitoring
3 Threshold

373
Treatments for TBI

1. Decompressive craniectomy (DC)

 Not recommended to improve outcomes (GOS-E score) @ 6

months
 ↓ ICP
 ↓ days in ICU
 Large DC (≥12x15 cm) better than small DC (mortality & neuro
outcomes)

2. Prophylactic hypothermia

 Hypothermia may have neuroprotective effects & can reduce ICP

o Risks: coagulopathy, immunosuppression, cardiac
dysrhythmias, death
 Prophylactic = administered early after injury & prior to ↑ ICP
 Therapeutic = used as tx for refractory ↑ ICP
 Early (w/in 2.5 hrs), short-term (48 hrs) prophylaxis is not
recommended

3. Hyperosmolar therapy

 Useful to ↓ ICP
 Insufficient evidence to support specific recommendations re
type of agent (ex mannitol, hypertonic saline) and means of
administration
o Hypertonic saline may be more effective than mannitol to
↓ ICP but no difference in short-term mortality

4. CSF drainage

 EVD in closed position allows for monitoring of ICP; open position

allows CSF drainage
 EVD (zeroed @ midbrain) w/ continuous CSF drainage may ↓ ICP
burden more effectively than intermittent drainage
 Consider CSF drainage if initial GCS <6 (w/in 12 hours of injury)

5. Ventilation therapies

 Severe TBI pts require definitive airway protection (risk pulm

aspiration, compromised resp drive/fxn)
 Normal ventilation (w/ PaCO2 35-45 mmHg) is currently
the goal in absence of cerebral herniation
 Prolonged prophylactic hyperventilation (PaCO2 ≤25
mmHg) not recommended
 Hyperventilation may be used as a temporizing measure to ↓
ICP (ex if cerebral herniation)

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6. Anesthetics, analgesics, & sedatives

 Used for prophylaxis and/or control of ICP and seizures

o Prevent unnecessary movement, coughing/straining
o Suppress cerebral metabolism
 S/E: hTN, ↓ cardiac output, ↑ intrapulm shunting; can cause ↓ CPP
 Recommendations:
o High-dose barbiturates to control refractory ↑ ICP (not for
prophylaxis)
 Ensure hemodynamic stability during rx
 Propofol useful to control ICP
o Not to improve mortality or 6-month outcomes
o Caution w/ high doses (PRIS)

7. Steroids

 Not recommended to improve outcome or ↓ ICP

o High-dose steroids may be associated with ↑ mortality

8. Nutrition

 TBI is a/w ↑ energy expenditure early after injury

 Recommendations:
o Feed pts to attain basal caloric replacement @ least by
the 5th day & @ most by the 7th day (↓ mortality)
o Transgastric jejunal feeding (↓ VAP)
o Insufficient evidence to make recommendations on glycemic
control & vitamins/supplements

9. Infection prophylaxis

 TBI pts are @ ↑ risk of hospital-aquired infxns (VAP, central line

infxns, EVD infxns, etc)
 Recommendations:
o Early trach to ↓ mech vent days (when benefit > risk)
o Povidone-iodine oral care not recommended to ↓ VAP
 May ↑ risk of ARDS
o Consider antimicrobial-impregnated catheters to prevent
catheter-related infxns from EVD

10. DVT prophylaxis

 VTE risk ↑s w/ TBI severity

 Recommendations:
o LMWH or low-dose UFH may be used w/ mechanical
prophylaxis
 ↑ risk of expansion of ICH
 Consider if brain injury is stable & benefit > risk

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 11. Seizure prophylaxis

 Early post-traumatic seizures (PTS) = w/in 7 days of injury

o Not a/w worse outcomes
 Late PTS = after 7 days of injury
 Post-traumatic epilepsy (PTE) = recurrent seizures >7 days after
injury
 Recommendations:
o Prophylactic phenytoin or valproate not recommended
to prevent late PTS
o Phenytoin recommended to ↓ early PTS (when benefit >
risk)
o Insufficient evidence to recommend levetiracetam over
phenytoin

Monitoring
 ICP monitoring:
o Manage severe TBI pts using info from ICP monitoring (↓ in-
hospital & 2-week mortality)
 CPP monitoring:
o Manage severe TBI pts using guidelines-based recommendations
for CPP monitoring (↓ 2-week mortality)
 Advanced cerebral monitoring:
o Consider jugular bulb monitoring of arteriovenous O2 content
diffn (AVDO2) to assist w/ mgt decisions (↓ mortality & improve
outcomes @ 3 & 6 months post-injury)

Thresholds
1. BP
o ↓ SBP associated with worse outcomes
o Recommendations:
 Consider maintaining SBP ≥100 mmHg for pts 50-69
yrs or ≥110 mmHg for pts 15-49 or >70 yrs (↓ mortality,
improve outcomes)
2. ICP
o Recommendations:
 Treat ICP >22 mmHg; higher levels a/w ↑ mortality
 Combo of ICP values & brain CT findings may be used to make
mgt decisions
3. CPP
CPP = MAP – ICP
o
Recommendations:
o
 Target CPP between 60 & 70 mmHg for survival & favourable
outcomes
 Avoid aggressive attempts to maintain CPP >70 mmHg w/
fluids/pressors (↑ risk ARDS)
4. Advanced cerebral monitoring

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o Goal of medical mgt of severe TBI = ensure optimal nutrient delivery to
brain through period of abnl physiology & brain swelling following injury
o Recommendations:
 Jugular venous sat <50% may be a threshold to avoid (↓
mortality, improve outcomes)

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 Enhanced Recovery After Surgery (ERAS)
Goal of ERAS is to improve quality of perioperative care – attenuate loss of
functional capacity & accelerate recovery process (attenuate surgical stress,
maintain postop physiologic functions)
Outcomes: ↓ postop morbidity, ↓ LOS in hospital, ↓ costs

1 Preoperative
2 Intraoperative
3 Postoperative

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Preoperative
 Risk scoring systems: identify patients at risk of complications, stratify periop
risk
 Optimize medical disease (smoking/alcohol cessation, optimize medical
conditions according to international guidelines)
 Pre-anesthetic medication:
o Avoid long-acting anxiolytics/opioids
o Avoid short-acting benzodiazepines in the elderly
 Preop fasting:
o Allow clear fluids until 2 hours, solids until 6 hours prior to induction
o Preop oral CHOs unless “full stomach”

Intraoperative
 PONV prophylaxis
 Careful titration of anesthetics
 Ensure full recovery of neuromuscular blockade (TOF >0.9)
 Maintain normal PaO2; avoid hyperoxia
 Maintain normothermia
 Maintain normoglycemia (treat glucose >10 mmol/L, avoid hypoglycemia)
 Fluid therapy: maintain fluid homeostasis; avoid fluid excess & organ
hypoperfusion
o Avoid 0.9% saline; use balanced crystalloid solutions
 Opioid-sparing analgesia

Postoperative
 Optimal analgesia w/ minimal side effects (opioid-sparing strategies)
o Regional anesthesia
 Thoracic epidural (T6-T11): gold standard in open abdominal
surgery
 TAP blocks, continuous wound infusion
o Multimodal regimens
 NSAIDs, acetaminophen
 IV lidocaine infusion
 Consider gabapentinoids, IV ketamine, high-dose steroids
 Postop delirium
o Prevention: avoid prolonged fasting, deep anesthesia, delirogenic rx;
maintain sleep-wake cycle
o Systematic delirium screening
o Symptom-oriented treatment
o Rule out potential underlying medical causes
 Postop ileus: Multimodal prevention strategies
o Laparoscopic if possible
o TEA, opioid-sparing strategies
o Avoid excess fluid, mobilization, early feeding/gum chewing, no
prophylactic NGT

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 Early mobilization
o Multidisciplinary approach
o Daily targets & recording of physical activity

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CCS Perioperative Cardiac Risk Assessment
2017

1 Timing of Surgery
2 Preoperative Cardiac Risk Assessment
3 Preoperative Investigations
4 Perioperative Medication Management
5 Postoperative Management

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Timing of Surgery

1. Emergency surgery (acute life- or limb-threatening condition)

o Recommend against delaying surgery for risk assessment
2. Urgent (e.g. acute bowel obstruction, hip #) or semiurgent surgery
(e.g. surgery for cancer w/ potential to metastasize)
o Preop risk assessment if pt’s history/physical exam suggests
potential undiagnosed severe obstructive intracardiac
abnormality, severe pHTN, or unstable cardiovascular
condition(e.g. unstable angina, acute stroke)
3. Elective surgery
o Preop risk assessment if ≥45 yrs or 18-44 yrs w/ known significant
CVS disease

Significant CVS Disease

 CAD
 CVD
 PVD
 CHF
 Severe pHTN
 Severe obstructive intracardiac abnormality (aortic stenosis, mitral stenosis,
HOCM)

Risk Assessment: Revised Cardiac Risk Index

(RCRI)
1 point for each of:

1. CAD/IHD (Hx MI, +exercise test, ischemic CP or nitrate use, ECG w/

pathological Q waves; pts w/ prev CABG or angioplasty meet criteria if they
have these findings post-procedure)
2. CVD (CVA or TIA)
3. CHF (Hx heart failure, pulm edema, PND, S3 gallop or bilat rales on exam,
CXR showing pulm vasc resistance)
4. Preop Insulin Use
5. Preop creatinine >177 µmol/L
6. High risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular)

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Preoperative Investigations

1. Measure preop brain natriuretic peptide (BNP) or NT-proBNP to enhance

periop cardiac risk estimation in:
o ≥65 yrs
o 45-64 yrs w/ sig CVS dz
o RCRI ≥1

BNP ≥92 mg/L or NT-proBNP ≥300 ng/L a/w ↑ risk of death or MI 30 days post-
noncardiac sx

2. No routine echo, coronary CTA, exercise or cardiopulmonary exercise

testing, or pharmacological stress echo or radionuclide imaging
o Urgent echo if suspected undiagnosed severe obstructive intracardiac
abnormality or severe pHTN
o Consider echo if suspect cardiomyopathy (may be reasonable to do
postop)

3. No preop prophylactic coronary revascularization for pts w/ stable

CAD undergoing noncardiac sx

Perioperative medication management

1. No initiation or continuation of ASA for prevention of periop cardiac events

o D/C chronic ASA ≥3 days preop to ↓ bleeding risk
 Restart when risk of surgical bleeding has passed (ex 8-10 days
after major noncardiac sx)
o Exceptions:
 Recent coronary artery stent
 CEA
 +/- certain surgical interventions (ex free flap, acute limb
ischemia)

2. No α2 agonist or β-blocker initiation w/in 24 hrs of surgery

o Continue chronic β-blockers perioperatively
 If preop hTN, consider ↓ing or holding preop β-blocker dose

3. Withhold ACEI and ARBs 24 hrs preop

o Consider restarting POD2 if hemodynamically stable

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 4. Continue chronic statin tx periop

5. Facilitate smoking cessation preop (Ideally ≥4 wks preop)

o Smoking cessation counselling, nicotine replacement therapy

Postoperative Management

1. Daily troponin for 48-72 hrs postop in pts w/ ↑ NT-proBNP/BNP preop

o If no preop BNP, measure in at risk patients (>5% risk CVS death or
nonfatal MI @ 30 days)
o Myocardial injury after noncardiac surgery (MINS) = peak troponin T
≥0.03 ng/mL believed to bed/t myocardial ischemia
 Often asymptomatic
 a/w ↑ 30 day mortality

2. Postop ECG in PACU for same group of pts monitored w/ postop troponin

3. Suggest shared-care mgt (ex anesthesiologist, cardiologist, geriatrician,

internist) of pts w/ ↑ NT-proBNP/BNP preop and “@ risk” pts

4. Initiate long-term ASA & statin tx in pts who suffer myocardial

injury/infarction postop

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Antibiotic Prophylaxis for Infective Endocarditis (IE)
Guidelines
Adapted from ACC/AHA guidelines 2007:

Indications

1. Prosthetic heart valves, including bioprosthetic and homograft valves

2. A previous history of IE
3. Unrepaired cyanotic congenital heart disease, including palliative shunts and
conduits
4. Completely repaired congenital heart defects with prosthetic material or
device during the first six months after the procedure (whether placed by
surgery or by catheter intervention)
5. Repaired congenital heart disease with residual defects at the site or adjacent
to the site of the prosthetic patch or prosthetic device
6. Valve regurgitation due to a structurally abnormal valve in a transplanted
heart

Eligible Procedures

1. Dental procedures with mucosal penetration

2. Procedures involving respiratory tract incision (including bronchial biopsy)
3. Procedures involving infected skin/musculoskeletal tissue

Perioperative IV Antibiotic Regimens

1. No penicillin allergy: Ampicillin 2g OR Cefazolin/Ceftriaxone 1g

2. If penicillin allergy:
3. Cefazolin/Ceftriaxone 1g (DO NOT USE IF SEVERE PENICILLIN ALLERGY)
4. Clindamycin: 600mg
5. Vancomycin: 15 to 20 mg/kg, with max 2 g per dose

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 Pulmonary Hypertension

Considerations
1. Potential for acute perioperative right ventricular (RV) dysfunction
& hemodynamic collapse
2. Optimize pulmonary pressures & right heart function:
o Avoid hypoxia, hypercarbia, acidosis, hypothermia,
sympathetic stimulation (pain), high PEEP
o Cautious fluid administration
o Maintain RV perfusion
3. Associated conditions (see table below)
4. Medication management:
o Anticoagulation
o Calcium channel blockers
o Vasodilators (e.g. sildenafil)
o Prostacyclin analogs (e.g. epoprostenol/flolan)
o Endothelin antagonists (e.g. bosantan)
o Diuretics
5. Need for invasive monitoring, optimized analgesia & post-op
disposition
6. Potential or R → L shunt through PFO: hypoxemia & paradoxical
emboli

Goals
 Make all attempts to optimize pulmonary vascular resistance
(PVR) before surgery
 Avoid ↑ in PVR (minimize pain, sympathetic stimulation, hypoxia,
hypercarbia, acidosis, optimize airway pressures)
 RV failure management principles:
o Optimize RV rate & rhythm: sinus & normal-high rate
o Optimize RV filing
o Maintain RV perfusion & inotropy
o ↓ PVR

Conflicts
 Pulmonary hypertension & laparoscopy:
o ↑ PaCO2, sympathetic stimulation = bad
o Case is longer than open
 Ortho cases with cement, joint replacement (embolic risk)
 Hemodynamic stability vs need for RSI

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Pregnancy Considerations
 Hemodynamic goals:
o Prevent ↑ PVR
o Maintain intravascular volume & venous return
o Avoid aortocaval compression
o Maintain adequate systemic vascular resistance
o Avoidance of myocardial depression during general
anesthesia
 Mode of delivery:
o Controversial
o Multidisciplinary meeting required
o Termination of pregnancy definitely an option as maternal
mortality is high
o Scheduled cesarean section in a controlled setting might be the
optimal route
 Monitoring:
o High acuity environment preferably in a center with cardiac
surgery expertise
o Standard CAS monitors + 5 lead ECG
o Arterial line & central line essential
o PAC a consideration but must weigh risk vs. benefits
 Anesthetic technique:
o A carefully titrated epidural likely the best option
o Avoid ↓ SVR & treat hypotension with fluids/pressors
o Single shot spinal should be avoided as it can cause severe
hemodynamic instability
o Continuous spinal has been used successfully (slow & careful
titration)
o General anesthesia has been used successfully
o Potential hazards of GA include ↑ PA pressure during
laryngoscopy/intubation, adverse effects of PPV on venous
return, & negative inotropic effects of certain anesthetic agents
o May consider a gentle narcotic-based induction/maintenance,
any fetal narcotic effects should be easily reversible
o Avoid ergotamine & carboprost; use oxytocin & misoprostol

Managing Acute Episodes/Acute RV Failure = 4 Principles

1. RV Rate & Rhythm: keep sinus & high-normal rate
2. RV perfusion & inotropy: maintain with vasopressor/inotrope combo
(e.g. norepinephrine & milrinone or epinephrine alone)

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 3. RV filling: optimize with CVP, PAC, TEE
4. ↓ PA pressures:
o Avoid hypercarbia, hypoxemia, acidosis, hypothermia, high
airway pressures
o Use pulmonary vasodilators:
 Nitric oxide: 20-40ppm
 Inhaled flolan
 Milrinone: 0.25-0.75 mcg/kg/min; possible loading dose is
50mcg/kg over 10 min

WHO Pulmonary Hypertension Classification

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