Differential Diagnosis & Treatment:

Monitors:
1. Standard ASA monitors: noninvasive BP, pulse oximeter, 5 lead EKG (II and V5 with ST
segment analysis), capnography, temperature
2. Arterial line: hemodynamic monitoring, frequent ABGs, cardiac hx
3. Central Venous Catheter: difficult PIV, vasoactive medication, measure CVP for trending
for fluid assessment, PAC placement, transvenous pacing
4. Pulmonary Arterial Catheter: measure PA pressures, calculate SVR, PVR, PCWP, CI,
SvO2 (cardiac & liver transplants), severe LV dysfxn, pulmonary HTN, valvular
abnormalities
5. TEE
6. Bladder Catheter
7. Neuro: SSEP, MEP, BEP, VEP, EEG

Physical Exam Findings:

• Blown pupil, papilledema, seizures --> ⇑ ICP
• JVD, pedal edema, rales, HSM! CHF, cirrhosis, pulmonary edema, fluid overload
• Systolic murmur that radiates to carotids ! AS
• Expiratory wheezes ! asthma, COPD
• Rebound, guarding, rigid abdomen! perforation

Hypotension:
1. Surgical bleeding
2. Surgical manipulation (IVC compression)
3. Too much anesthestic (VA, IV)
4. Dehydration/hypovolemia (NPO status, bowel preparations, insensible losses)
5. PE
6. Tension pneumothorax
7. MI
8. Sympathectomy from regional anesthesia
9. Cardiac Tamponade
10. Spinal Shock
11. Tourniquet release
12. Clamp release/Reperfusion

Hypertension:
1. Pain
2. Anxiety
3. Light anesthesia
4. MI
5. Uncontrolled pre-operative hypertension
6. Pheochromocytoma
 7. Thyroid Storm

Myocardial Ischemia:
1. 100 % oxygen
2. Treat anemia with blood transfusion to increase O2 carrying capacity
3. +/- B blockers
4. +/- NTG
5. +/- Anticoagulants (aspirin &/or heparin)
6. 12-lead EKG + cardiac enzymes (Troponin & CK-MB)

Hypoxia:
1. Mainstem intubation
2. Esophageal intubation
3. Mucous plug
4. Bronchospasm/laryngospasm (post-extubation croup)
5. (Tension) Pneumothorax
6. PE
7. Aspiration (head down, turn to the side, suction, no steroids, no antibiotcs, no BAL)
8. Postoperative atelectasis/decreased FRC
9. Pulmonary edema (negative pressure pulmonary edema)
10. Airway edema

Pulmonary Edema:
1. Neurogenic from increased catecholamines
2. Negative pressure pulmonary edema
3. Acute CHF (from a-fib)
4. Fluid overload
5. Pre-eclampsia
• Treatment: PEEP, 100% FiO2, +/- diuretics, morphine, VD to decrease afterload and help
forward flow

PE/VAE/AFE:
1. Discontinue N2O
2. Apply 100% O2
3. IVF + vasopressors (epinephrine) as needed
4. Aspirate air bubbles from central line
5. Craniotomy: flood surgerical field with cold saline
6. Laparoscopy: head down, left lateral decubitus position (trap air bubbles in right atrium)

Hypermetabolic States:
1. Malignant Hyperthermia
2. Thyrotoxicosis
3. Neuroleptic Malignant Syndrome
 4. Pheochromocytoma
5. Fever, Sepsis

Infective Endocarditis:
Indications:
1. Hx of previous IE
2. Prosthetic Valve
3. Cardiac transplant with valvulopathy
4. Congenital heart diease:
a. Unrepaired
b. Repaired with prosthetic device in last 6 mo
c. Repaired with residual defects
Prophylaxis: amoxicillin (PO), ampicillin, cefazolin (1st generation cephalosporin), ceftriaxone
(3rd generation, increased gram negative coverage), if pencillin allergy use clindamycin
Surgeries: dental procedures and endoscopies with biopsy (do NOT routinely provide
prophylaxis for vaginal delivery, EGD, colonoscopy, bronchoscopy, TEE)

Side Effects of Steroids:

1. Hyperglycemia
2. HTN
3. Electrolyte abnormalities
4. Impaired wound healing
5. ⇑ Risk of infection
6. Fluid Retention
7. Psychosis

Uterine Atony/Hemorrhage (PEOKA):

1. Uterine massage
2. Oxyctoin IV (hypotension & HR ⇑) or intrauterine
3. Prostaglandin F2 alpha (IM 200 mcg)
4. PGE
5. Ergot (methergine) IM or intrauterine (never IV! coronary vasospasm or HTN)
6. Intrauterine ballon for tamponade
7. IR for iliac artery embolization
8. Hysterectomy

Headache DDx:
1. Tension HA
2. Caffeine withdrawal
3. Cortical Vein Thrombosis
4. Meningitis
5. PDPH
6. Cerebral ischemia
 7. Sinusitis
8. Migraine
9. Subarachnoid Hemorrhage (SAH in preeclampsia)

PDPH:
• Signs & symptoms: n/v, neck stiffness, photophobia, front-occipital location, tinnitus,
improves when supine, worsen when upright
• Treatment: IVF (increase CSF production), IV (500 mg x 1-2) or PO caffeine (300 mg
q6), abdominal binder, epidural blood patch (check coags), migraine medications
(Excedrin or sumatriptan to cause VC)
• Usually self-limited to 1 week
• R/O other etiologies for HA; consider imaging and neurology consult

R ⇒ L Shunts:
• Avoid increases in PVR and decreases in SVR
• Requires PDA (aorta connects to pulmonary artery) to allow mixing
• Inhalational induction: slows induction; Intravenous induction: speeds up
1. Tetraology of Fallot (PROV)
2. Truncus Arteriosis
3. Tricupsid Atresia
4. Transposition of the Great Vessels

L ⇒ R Shunts:
• Avoid decrease in SVR and increases in PVR
• Inhalational induction: no change; Intravenous induction: slows down
1. ASD
2. VSD
3. PDA
• Normally closes after birth as neonate takes 1st breath which causes a decrease in
PVR and causes blood flow to go through lungs
• Shunt between PA and aorta that allows oxygenated blood to bypass fetal lungs
and go from pulmonary to systemic circulation
• PDA keep open by prostaglandin secreted; can close PDA with indomethacin
(NSAID that inhibits prostaglandin synthesis)

Retinopathy of Prematurity:
• Risk Factors: decreased birth weight (1500 gm), decreased gestational age (<32 wks),
anemia, hyperoxia
• Goals to keep SaO2 92-95% with PaO2 60-70 mm Hg with minimal amount of FiO2

Respiratory Distress Syndrome in Newborns:

• Related to neonates born before 34-35 wks, thus decreased or no surfactant production !
alveoli are prone to collapse and atelectasis
 • Treatment: in utero—steroids to mom; after delivery, exogenous surfactant to neonate
• Long-term complications: broncho-pulmonary dysplasia, persistent fetal circulation

Premature & Term Neontates & Anesthesia:

• Do NOT require pre-medication with narcotics or BZDs, can administer antisialogues
• Do NOT require (much) anesthestic as they have immature brains! usually can get away
with treatment with opioids and paralytics
• Complications: IVH, ROP (<44 wks), postoperative apnea (<50-60 wks), hypoglycemia
(low glycogen stores), hypothermia, all organ systems are immature

N2O Effects:
1. Concentration effect
2. Diffusion Hypoxia: during emergence, washout of nitrous oxide can dilute O2 in alveoli
and lead to hypoxia
3. Expand air spaces: pneumocephalus, lung bullae, bowel (⇑ PONV), pneumoperitoneum,
pneumothorax
4. ⇑ PVR

PONV:
• RF: female, non-smoker, opioid, VA & N2O use, hx of PONV/motion sickness, type of
surgery (ob/gyn, ENT, abdominal, ophtho), dehydration
• Treatment: TIVA with propofol (avoid VA, N2O, opioids, etomidate), hydration, 5HT3
antagonists, droperidol (DA antagonists, caution with QT prolongation, avoid in EPS &
Parkinson’s), Compazine (phenothiazine), metoclopramide (prokinetic), consider regional
anesthesia, acupuncture, and steroids (decadron)

Delayed Emergence:
1. CVA/cerebral ischemia
2. Residual NM blockade
3. Residual anesthetic
4. Opioid overdose
5. Hypoglycemia
6. Electrolyte abnormalities: hypo/hyper Na+
7. Hypothermia
8. Hepatic/Renal insufficieny! impaired drug metabolism

Perioperative Beta Blocker:

• Indications:
1. Chronic BB use
2. Valvular disease
3. CAD (ischemia with poor FC)
4. Chronic heart failure
• Contraindications to BB:
 1. HR< 60 bpm
2. Caution in asthma/COPD
3. Heart block/SSS
4. Heart failure with EF < 30%
5. SBP < 110

Elevated ICP:
• Normal CPP 80-100 mmHg
1. Cerebral aneurysm
2. Tumor
3. Hydrocephalus
4. SAH
5. Subdural hemorrhage
• Treatment:
1. Hyperventillation cautiously, do NOT go below PaCO2 < 28-30 mm Hg as this
can cause cerebral ischemia
2. Head elevation to ensure adequate venous drainage.
3. CSF drainage
4. Mannitol (osmotic) diuretic
5. Lasix (loop) diuretic
6. Hypothermia
7. Barbiturates to induce burst suppression and decrease CMRO2

Cervical Spine Damage:

• Views to obtain: anterior/posterior, odontoid, lateral x-rays from C1-T1
• Still can miss 7% of ligamentous injuries! maintain manual in-line stabilization
• Criteria to clear c-spine:
1. No cervical pain or tenderness
2. No parathesias or neurologic deficits
3. Normal mental status
4. No distracting pain
5. Age > 4 y/o

Spinal Shock:
• Occurs d/t recent injury to spinal cord
• S/S: flaccid paralysis, loss of temperature regulation (pt at risk for hypothermia), loss of
sensation, loss of cardioaccelerator fibers (will not see tachycardia in response to
hypovolemia), sympathectomy causing VD and hypotension
• IVF to increase PL, secure airway if needed
• SCH ok within first 24-48 hours of injury, avoid thereafter d/t risk of hyperkalemic
cardiac arrest d/t proliferation of Ach receptors

Autonomic Hyperreflexia:
 • Seen in pts with spinal cord injuries at T6 or above
• Associated with cutaneous (pain) or visceral (bowel or bladder) distention that results in
sympathetic discharge! HTN below the lesion with subsequent bradycardia d/t
activation of carotid sinus, VD above the lesion! flushing, HA.
• Treatment: tell surgeon to stop, deepen anesthestic, administer VD agents (SNP, NTG),
place arterial line and monitor for subsequent complications: retinal, cerebral, SAH,
seizures, MI, pulmonary edema.

Hypothermia Effects:
1. ⇓ CMRO2
2. ⇑ PVR, ⇑ SVR
3. Arrhythmias
4. ⇑ Myocardial O2 consumption from shivering
5. ⇓ Hepatic and renal metabolism
6. ⇑ Coagulopathy from platelet dysfunction
7. Hyperglycemia
8. Leftward shift of oxy-Hgb curve (decreased O2 delivery to the tissues)

Chronic Alcohol Use:

1. Encephalopathy
2. Withdrawal/DT (within 72 hours of discontinuation)
3. Cardiomyopathy
4. Cirrhois
5. Impaired coagulation (increased risk of bleeding)
6. Nutritional deficiency (Wernicke-Korsakhoff Syndrome ! replace MVT, B12, Folate)
7. Thromobocytopenia

Cirrohosis:
• Systemic manifestations: encephalopathy, HPS (intrapulmonary shunt) cardiomyopathy,
hyperdynamic circulation (⇑CO & ⇓ SVR) with intravascular depletion, portal HTN,
esophageal varices, thrombocytopenia and bleeding (⇓ coagulation factor production
from liver), electrolyte abnormalities and HRS.

Autonomic Neuropathy:
• Seen in poorly- controlled diabetes, results from excessive glycosylation of ANS
• Symptoms:
1. HTN
2. Resting tachycardia
3. Gastroparesis
4. Orthostasis
5. Impotence
6. Lack of tachycardia with hypovolemia
Metabolic Alkalosis:
1. Volume contraction from diuretics
2. Over-administration of LR (lactate gets converted to HCO3-)
3. NGT/vomiting (lose HCl! hypoK, hypoCl metabolic acidosis)

Metabolic Acidosis:
• Check Anion Gap (Na+- (Cl-+HCO3-)
• Increased AG MA: MUDPILES
• Non AG MA:
1. Diarrhea/fistula (loss of HCO3-)
2. RTA
3. HyperCl MA from over-administration of normal saline

NaHCO3 Effects:
1. ⇑ Serum osmolarity
2. ⇑ Serum Na
3. Leftward shift of Hgb-O2 curve ! decreased O2 unloading to tissues
4. HypoK
5. Additional generation of CO2 that worsens acidosis

Blood Transfusions:
• Emergency blood release: O-, if no O-, then give O+
1. Effects of massive transfusion: hyperK, acidosis, hypothermia, hypoCa (from citrate
anticoagulant), leftward shift of oxy-Hgb curve as there is ⇓ 2-3, DPG, Dilutional
Coagulopathy & Thrombocytopenia
•
• Acute hemolytic reactions:
-D/t antigens on donor RBCs presented to recipient immune system with
agglutination and subsequent activation of the complement system! intravascular
hemolysis
-Treatment: stop transfusion, return to blood bank after rechecking, administer
IVF, vasopressors, 100% O2, emergent blood give O-, check labs (PTT, PT/INR, plts,
LDH, haptoglobin), maintain UOP with mannitol, lasix, NaHCO3.

Thromboelastography (TEG):
• Measures the viscoelastic properties of blood during clot formation, evaluates clot
formation, strength and stability
• Reaction time (R time): time to clot formation, indication of coagulation factors
• α-Angle: speed of clot formation, deficiency of fibrin formation
• Maximum amplitude: indication of clot strength via platelet number &function
Rheumatoid Arthritis:
• Vasculitis that develops as result of immune complex deposition
• Systemic manifestations: concern for difficult airway (atlanto-axial subxulation,
decreased TMJ movment, crico-arytenoiditis), pericarditis, pericardial effusion,
interstitial lung disease, pulmonary fibrosis, renal impairment, anemia
• Treatment: steroids, DMARDS (methotrexate, azathiopurin), NSAIDs (gastric ulcer, RF,
decreased platelet function)
• Airway Evaluation: cervical x-rays (anterior, posterior and lateral), if odontoid process
separation from atlas > 3mm be concerned, consult neurosurgery.

Digoxin Toxicity:
-Therapeutic levels 0.5-2.0 ng/mL
-Toxicity is potentiated by hypoK, hypoMg, hyperventilation, hyperCa2+

Sickle Cell Disease:

• Substitution of Valine for glutamic acid at 6th position in Beta chain of hemoglobin!
Hgb S! more prone to abnormal shape in blood vessels (sickling)! decrease lifespan
compared to normal Hgb (nl 120 days)! prone to hemolysis, microvascular occlusions,
ischemia to end organs
• Co-morbidities: cardiomegaly, autosplenectomy, CHF, pulmonary HTN, renal
insufficiency, acute chest syndrome, painful crisises, increased risk of infection
• Treatment: exchange transfusion for Hgb S < 40%, transfuse blood for hct of 30% to
increase O2 carrying capacity, pain control, hydration
• Intraoperative goals: avoid hypothermia, hypoxia, hypercarbia (increases PVR),
dehydration, touriquets, acidosis, hypotension, treat infection

Malignant Hyperthermia:
• S/s: tachycardia, tachypnea, increase in ETCO2, hyperthermia, mixed acidosis, muscle
rigidity, hyperK
• DDx: NMS, pheochromocytoma, thyroid storm
• Treatment: discontinue VA & Sch, 100% O2, hyperventilation, dantrolen (2.5 mg/kg up to
10 mg/kg) in sterile water, IVF, pressors, mannitol (to maintain UOP and protect
kidneys), treat hyperK with CBILD, cooling, invasive monitors (a-line, foley, CVP),
NaHCO3 for acidosis (pH < 7.1)
• Complications: MH relapse in perioperative period, ARF, DIC
• Post-op workup: Creatine Kinase levels, halothane-caffeine test with muscle biopsy

Aspiration Pneumonitis:
• RF: obesity, pregnancy, SBO, gastroparesis (autonomic neuropathy), recent food
ingestion (last 6-8 hours heavy meal), GERD hx, incompetent LES
• Prophylaxis: NGT, nonparticulate antacid, metoclopramide (prokinetic agent), H2
blocker, reverse T-burg, cricoid pressure with RSI, +/- awake FOB
 • Treatment: trendelenburg postion, turn head sideways, suction oropharynx, apply cricoid
pressure, +/- intubation (low threshold), ICU admission, bronchoscopy only to remove
particulate material, no BAL, steroids or prophylactic antibiotics indicated.
• Increased mortality if aspiration is particulate (volume > 25 mL) and pH < 2.5

Pediatric Conditions associated with Cardiac Defects:

1. Pierre Robin (vs Treacher Collin) syndrome
2. Omphacele (vs. Gastrochisis)
3. CDH
4. TEF
5. Down’s Syndrome

Tracheoesophageal Fistula/ Esophageal Atresia:

• Type C is most common 80% of cases; upper esophagus ends in blind pouch, lower
esophagus connects to trachea
• Consider VACTERAL: physical exam to look for vertebral and limb abnormalities, renal
ultrasound and echo to look for cardiac defects
-Induction & intubation concerns:
1. Aspiration: place OGT in blind pouch, decompress stomach with gastrostomy tube
2. Gastric distention
3. Difficult intubation: mask induction with cricoid to maintain spontaneous ventilation,
awake DL, avoid PPV as will inflate stomach and increase risk of aspiration
4. Hypotension/cardiac instability from congenital cardiac defects
-Intubation: ideally place ETT into right mainstem bronchus and withdrawal until hear b/l
breathe sounds, then ETT will be distal to fistula but will allow oxygenation & ventilation of
both lungs

1. Congenital Diaphragmatic Hernia:

Foreign Body Aspiration:

-Anesthetic goals: maintain spontaneous ventilation (inhalational induction) as PPV can push
foreign body distally into the airway and to avoid complete airway obstruction
-DDx: FB, croup, epiglottitis, RAD, anaphylaxis
-S/S: no fever, stridor, hoarseness, wheezing, retractions, increased accessory muscle use
-CXR: Do NOT delay bronchoscopy for CXR; most objects are radiolucent and not well
visualized on CXR, may see hyperinflation in RAD or atelectasis distal to obstruction
-OR: aspiration prophylaxis (if time & IV available), ENT with rigid bronchoscope, mask
induction, spray ETT with lidocaine
-If complete AW obstruction occurs, push FB distally into bronchi and do one lung ventilation or
try to quickly retrieve
-Complications: chemical pneumonitis with pneumonia, atelectasis, hypoxemia