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Anesthesia Notes and Discussion
Anesthesia Notes and Discussion
1. Spinal anatomy
a. Draw and label the diagram of lumbar vertebra. Enumerate the layers of spinal
canal from skin to dural space.
2. Spinal anesthesia
a. What is spinal anesthesia?
Spinal anesthesia also called subarachnoid block is a form of regional anesthesia
involving the injection of local anesthetic (with or without adjuvants) into the
subrachnoid space generally through a fine needle.
b. What are the contraindications of central blockade? What are the complications of
central blockade?
The following are the contraindications of central blockade:
Absolute contraindications:
1. Patient refusal
2. Known allergic reactions to local anesthetic of choice
3. Infection at the site of injection
4. Severe hypovolemia
5. Coagulopathy or bleeding diathesis
6. Increased ICP
7. Severe aortic stenosis
8. Severe mitral stenosis
Relative contraindications:
1. Sepsis
2. Unco-operative patient
3. Preexisting neurological deficit
4. Severe spinal deformity
5. Stenotic valvular lesions
3. Neurophysiology
a. What is the importance of cerebral blood flow?
Cerebral blood flow varies with the metabolic activity of the brain. In gray mater the
flow is around 80 ml/100g/min and in white mater it is 20 ml/100g/min thus the
average of 50 ml/100g/min. Skull is a rigid structure with fixed volume of blood, CSF,
and cells. Increase in one component directly increases the intracranial pressure. On
the other side, flow rates below 20-25 ml/100g/min are usually associated with
cerebral impairment, flow between 15-20 ml/100g/min produce flat EEG, and flow
rates below <10 ml/100g/min usually associated with irreversible brain damage.
4. Respiratory physiology
a. What are the devices used for oxygen therapy? What are the indications of 100%
oxygen?
Devices used for oxygen therapy are:
Low flow or Variable performance devices:
a. Nasal canula: FiO2 range from 0.21 to 0.44 with oxygen flow rate
ranging from 1 to 5-6 L/min. However, the actual FiO2 delivered to the
patient is determined by oxygen flow, nasopharyngeal volume, and the
patient’s inspiratory flow (depends both on Vt and inspiratory time)
b. Simple mask: with FiO2 ranging from 0.3 to 0.6 at oxygen flow rate 5
to 8 L/min.
c. Mask with reservoir: At flow 5 L/min can deliver FiO2 upto 0.5.
d. Nasal mask
e. Partial rebreathing mask
f. Nonrebreathing mask: with flow upto 15 L/min can provide FiO2 upto
1.0.
Fixed performance or High flow devices:
a. Anesthesia Bag-Mask-Valve system
b. Air entraining venture masks
c. Air entraining nebulizers
6. Hypothermia
a. What is hypothermia?
b. What are the adverse effects of hypothermia?
8. Capnography
a. What is capnography?
b. Capnograph show a reading of ‘0’ after intubation. What may be the possible
causes and how do you manage them?
c. What other information does a capnograph provide?
9. Muscle relaxants
a. What are the properties of an ideal muscle relaxant?
b. How do you classify muscle relaxants?
c. Explain the differences between them.
10. TIVA
a. What is TIVA?
b. What are the benefits of TIVA?
3rd Year Final Assessment – 7th Batch – Paper II – From my memory bank
1. Early recovery after surgery
a. What are the elements of ERAS?
b. What will be your intraoperative management?
c. What are the benefits of ERAS?
2. Sepsis
a. Write down the criteria for SIRS and sepsis.
b. What will be your approach to prevent organ dysfunction?
3. Hyperthyroidism
a. A 25 year male with h/o trauma 3 days back. On traction for fracture of lower limb
planned for surgery. He has fever, tachycardia, and hypertension. On OT, pethidine 50
mg + Phenargan 25 mg given but still he’s hypertension, and tachycardia. He’s
sweating and anxious. On examination of the neck, slightly enlarged thyroid is found.
b. What are the possible causes in this case?
c. What additional investigations will you order for this case?
d. What are the features in favor of thyroid storm?
4. AKI
a. What is AKI?
b. What are diagnostic criteria for AKI?
c. What are the risk factors present in this patient?
5. VAE
a. What is paradoxical air embolism?
b. How will you diagnose venous air embolism?
c. What are the preventive measures and how will you treat a case of venous air
embolism?
6. You are asked to place a central venous catheter in a 3 year child in ICU. After one
hour of catheter placement, the child had hypotension and fall in oxygen saturation.
What is the possible cause? Outline your approach to management of this case.
7. A 3 years child is planned for an ophthalmic surgery. He has runny nose and cough
but looks ok otherwise.
a. What will be your approach to preanesthetic assessment?
b. Will you take this case or not? Why?
c. What will be your anesthetic management?
9. Neuropathic pain.
a. What is neuropathic pain? Give examples
b. What are the signs and symptoms of neuropathic pain?
c. What is the pharmacological management of neuropathic pain?
10. A 25 years full term pregnant parturient has non-progress of labor and is kept on
oxytocin infusion. She complains of acute severe tearing abdominal pain which
subsided after some time. But she developed PV bleeding. Her BP – 80/40 mmHg;
Pulse – 130/min.
a. What is the diagnosis?
b. How will you prepare this case?
c. Anesthetic management?
Other questions:
1. Criteria for home discharge after day care surgery.
2. List strategies for postoperative pain management in day care surgery.
Multiple factors, including the type of surgery, pain threshold, patient age, and
expectations, affect the experience of postoperative pain
Patients with high anxiety, chronic pain and opioid tolerance experience
difficult postoperative pain control and should be identified early.
Postoperative pain management in day care surgery should begin before the
patient goes for surgery.
Patient should be provided with information about the likely extent and
duration of pain after surgery.
Should be advised about simple measures to reduce pain like maintaining
comfortable position, raising the swollen limbs, and benefits of distraction
technique.
Prevention is the mainstay of management of pain.
PCM:
Oral paracetamol displays peak plasma concentration within 30–60 min; i.v.
paracetamol instantaneously with onset of pain relief after 5–10 min.
NSAIDs:
Have opioid sparing effect.
Opioids:
Intraoperative administration of short-acting opioids remains the mainstay of
treatment (to reduce the incidence of PONV)
Other analgesia:
NMDA receptor antagonists and alpha 2 agonists: have opioid dose reduction effect as
part of balanced multimodal analgesia; esp the use of gabapentin.
Colloids:
Are either derived from
1. Plasma proteins: eg. Albumin 5% and 25%; plasma protein fractions 5% (both are
heated to 60 deg Celsius to decrease the transmission of hepatitis and other infections)
2. Synthetic glucose polymers:
Dextrose starches: (Dextran 40 and Dextran 70), have anti-platelet actions;
infusion >20 ml/kg/day can interfere with blood typing, prolong bleeding times and
are associated with kidney failure; can be antigenic as well.
Hetastarch (HES): multiple formulations based on concentration, molecular
weight, degree of starch substitution, and ration of hydroxylation between C2 to C6
positions. It is non antigenic. Coagulation studies and bleeding times are not
significantly altered.
Gelatins: associated with histamine mediated allergic reactions
Uses of Propofol:
1. Induction of anesthesia
2. Maintenance of anesthesia: Because of small context sensitive half time;
10 minutes when infused for less than 3 hours and 40 minutes when
infused upto 8 hours of infusion.
3. Antiemetic
4. Antipruritic
5. Treatment of laryngospasm
6. Anticonvulsant property
Q. Define capnography.
Ans: Capnograph is an instrument that displays, in addition to digital data, a
capnogram the graphic representation of CO2 concentration or partial pressure over
time (time capnography) or displayed in terms of volume (volume capnography)
Two types: Mainstream and Sidestream (aspirate gas from the system at 50-
400mL/min)
Mechanism:
CO2 strongly absorbs IR light particularly at wavelength 4.3 micrometer. The IR light
absorbed is proportional to the concentration of the absorbing molecules, such as
CO2, such that concentration of the molecule can be determined by comparing the
measured absorbance against a known standard.
Q. What is 2,3 DPG? How is it produced in the RBC? List the causes that
increase the production of 2,3 DPG?
Ans: 2,3 DPG is a special intermediate of glycolysis especially in RBC which is
rapidly consumed under conditions of normal oxygen tension. But, when hypoxia is
present in peripheral tissues, 2,3 DPG can accumulate to a significant levels within
hours. At these concentrations, it binds to Hb and decreases the affinity of Hb to
oxygen molecules. There is rightward shift of the oxygen-Hb dissociation curve
which implies that the affinity of Hb to oxygen is reduced, thus there is increased
unloading of oxygen to tissues exposed to hypoxic condition.
Mechanism of production:
Glucose--- (Hexokinase) Glucose-6-phosphate(Phosphogluco isomerase)
Fructose 6-phosphate 2,3 DPG
1. Body:
Medical gas cylinders are storage devices made principally of steel along with other
alloys like molybdenum and aluminium (MRI compatible) and carbon fibers.
These have flat or concave base with tapered screw that attaches to a valve.
2. Valve:
Cylinders are filled and discharged through a valve attached to the neck of the
cylinder. Valves are made of bronze or brass. Parts of valve include: 1. Port: this is the
point of exit for the gas from the cylinder. 2. Stem: is rotated during opening and
closing of the valve.
3. Pressure relief valve:
Every cylinder is fitted with a pressure relief valve whose purpose is to vent the
cylinder’s contents to the atmosphere if enclosed gas increase to dangerous level
commonly of ruptured disc or fusible plug type.
Medical gas cylinders are available in different sizes and capacities named E, H, D.
The gases are stored in either gaseous form (oxygen, air, N2) at pressures ranging
from 1800-2000 psig or in liquid form (N2O) at pressure of 760 psig.
B. Yoke assembly:
Yoke assembly is a device that provides attachment of gas cylinders to anesthesia
machine maintaining a unidirectional flow of gases from cylinder to machine and
provides adequate sealing to prevent leakage. The assembly is indexed and each one
is specific to a cylinder of a particular gas preventing accidental connection of a
wrong gas cylinder. It consists of the following parts:
1. Body: Principle framework and supporting structure.
2. Screw: tighten cylinder in the yoke
3. Nipple: Through which gas enter the machine
4. Index pin: prevent attaching of a wrong cylinder. The index pin for different
gases are: oxygen (2,5), N2O (3,5), CO2 (1,6), Air (1,5), Heliox (2,4)
5. Washer: make seal between cylinder and the yoke
6. Filter: removes the particulate mater
7. Check valve assembly: for unidirectional flow of gases.
c. Pressure Gauge:
Cylinder pressure is usually measured by Bourdon’s pressure gauge which is a
flexible tube which straightens when exposed to a gas pressure causing a gear
mechanism to a move a needle pointer.
The pointer reads zero when the cylinder is empty, the cylinder is turned off and when
all the gas has been removed from the machine.
Q. What is FRC? How do you measure FRC? What are the factors that affect
FRC? What is the implication of FRC in general anesthesia and central
neuraxial blockade?
Ans: FRC is the amount of air that remains in the lungs at the end of normal
exhalation. At this volume the inward elastic recoil of the lung matches with the
outward elastic recoil of the chest (including the resting diaphragmatic tone)
Risks of PONV is: 10% with no risk factors, 20%, 40%, 60%, and 80% with 1, 2, 3,
and 4 risk factors.
Risks of PDNV is: 10% with no risk factors, 20%, 30%, 50%, 60% and 80% with 1,
2, 3, 4, and 5 risk factors.
Q. Landmarks for:
1. Supraclavicular Brachial Plexus Block:
Place the patient in a supine position with the head turned toward the non-
operative side.
Palpate the posterior border of the sternocleido - mastoid muscle at the C6
level and roll your fingers laterally over the anterior scalene muscle until they
lie in the interscalene groove (the groove may be harder to identify below the
C6 level because of the overlying omohyoid muscle).
Then move your fingers laterally down the interscalene groove until they are
approximately one centimeter from the mid-clavicle.
This location is the initial insertion site for the needle.
Standing at the patient’s head, direct the needle toward the axilla, as
demonstrated.
2. Interscalene Approach:
Place the patient supine with the head turned toward the nonoperative side.
Identify the cricoid cartilage, which indicates the C6 level.
Palpate the lateral border of the sternocleidomastoid muscle (SCM), and move
your fingers laterally into the interscalene groove (between the anterior and
middle scalene muscles).
Ensure that the clavicular head of the SCM, rather than the more medial
sternal head, is being palpated.
The external jugular vein often crosses the border of the SCM muscle at this
point.
If this is the case, the initial needle insertion should be posterior to the vessel
Initial needle insertion (at the level of C6) is indicated by an “X”.
Q. What is statistical error?
Ans: Statistical error is defined as the discrepancy or uncontrolled variation between
an observed (or measured) value and the value predicted by a specification, standard
or model.
Q. What is p value?
Ans: The P value, or calculated probability, is the probability of finding the observed,
or more extreme, results when the null hypothesis (H 0) of a study question is true –
the definition of 'extreme' depends on how the hypothesis is being tested.
Q. Components of RSI
Ans:
1. Preparation for expected intubation and also for the potential complication of a
difficult or failed intubation.
a. Environment: resuscitation room, monitoring, IV access, position on
trolley, drugs- drawn up, labelled, ready.
b. Equipment: two functioning laryngoscopes fitted with appropriate
blade, ET tube- including one size smaller.
2. Preoxygenation
3. Pretreatment: with lidocaine, atropine or opioids, fluid bolus
4. Paralysis with induction: STP 5 mg/kg, Sux 1.5 mg/kg
5. Protection and positioning
6. Placement with proof
7. Post-intubation management
Contraindications to RSI:
1. Difficult airway
2. Contraindications to Sux
3. Cervical spine injury (do awake fiberoptic intubation)
Should also be supported (if possible) by formal assessment of exercise tolerance eg.
Stair climbing or 6MWT (Where CPET is unavailable, a 6min walk test distance of
>563m indicates an anaerobic threshold of >11mL/kg/min)
Importance:
1. Restrictive lung disease: differentiate between intrinsic lung disease vs other
causes of restriction (eg. Chest problems)
2. Obstructive lung disease: differentiate between emphysema and other causes
of obstructive airway.
3. Normal value is 17-25 ml/min/mm Hg.
V/Q scan.
1. Reports the likelihood of PE.
2. Useful in the assessment of patients for lung parenchymal resection to predict
the effect of resection on overall pulmonary performance (like improvement of
lung function after resection of non-ventilated/perfused lung segment)
Q. Classify vaporizers.
Vaporizers are classified as:
a. Location
a. In circuit/low resistance/Draw over: OMV, EMO
b. Out of circuit/high resistance/plenum vaporizer: TEC, Penlon, Aladdin
b. Specificity
a. Agent specific: TEC, Vapor 19.1, Penlon
b. Agent non specific: Goldman
c. Method of vaporization
a. Flow over: TEC, Penlon, Vapor 19.1, Goldman
b. Injection: TEC 6, Siemens
c. Bubble through: Copper Kettle
d. Flow over or bubble through: Boyle’s bottle
d. Temperature compensation:
a. Automatic thermocompensation: TEC- bimetallic strip (bronze,
nickel), Vapor 19.1- metal rod, EMO: ether filled bellows
b. Supplied heat: TEC 6
c. No thermocompensation: Boyle’s bottle, Goldman
d. Manual compensation: Copper kettle
e. Electronic: Aladdin
e. Concentration calibrated vs measured flow (copper kettle)
Q. What does a low resistance vaporizer mean to you? What are the four advantages
of low resistance vaporizer?
Low resistance vaporizer (eg. EMO, OMV) are in-circuit vaporizer used in draw over
anesthesia.
They have several advantages:
1. Low cost
2. Simple design, compact
3. Agent non specific
4. Not affected by altitude
5. Can be used in mass casualties
Q. Define neuropathic pain. Give examples. What are the signs and symptoms of
neuropathic pain? How do you manage neuropathic pain?
Ans.
Neuropathic pain is a very common component of a wide range of pain states, usually
resulting from neural damage, including acute and chronic post-operative pain and
pain secondary to advanced malignancy. It is a complex condition which often has
profound negative physical, psychological, and social impacts.
- LA/LA-opioid mixtures:
o Continuous lumbar epidural analgesia most versatile and commonly
employed technique analgesia for first as well as for subsequent
vaginal delivery/CS if necessary.
Walking epidural:
Very dilute LA mixtures in epidural (0.625%) generally do not produce motor
blockade and may allow some patients to ambulate.
Test dose in epidural:
Should be injected between contractions to help reduce the false positive signs of IV
injection (tachycardia due to painful contraction)
Drug given: after 5 min when signs of IV and intrathecal injection is absent total
10 ml of 0.0625%-0.125% of Bupivacaine or 0.1-0.2% of Ropivacaine combined with
50-100 mcg Fentanyl (in 5 ml increments waiting 1-2 min between doses). OR
alternatively, continuous epidural infusion using 0.0625-0.1% Bupi and 1-5 mcg/ml
Fentanyl at 10 mL/h
OR, a patient controlled epidural analgesia (PCEA).
F/b monitoring with frequent BP for 20-30 min or until the patient is stable.
Treatment:
- Immediate steep Trendelenburg or keen chest position
- Manual pushing of the presenting fetal part back up into the pelvis until
immediate CS under GA can be performed.
- If the fetus is not viable, vaginal delivery is allowed to continue.
Arrest of dilation: when the cervix undergoes no further change after 2 h in the active
phase of labor.
Protracted active phase: slower than normal cervical dilation defined as less than 1.2
cm/h in a nulliparous and less than 1.5 cm/h in multiparous.
Prolonged deceleration phase: when cervical dilation slows markedly after 8 cm. The
cervix becomes very edematous and appears to lose effacement.
Prolonged 2nd phase (disorder of descent): as a descent of less than 1 cm/h and 2 cm/h
in nulliparous and multiparous respectively.
Drug of choice:
Oxytocin is DOC in the treatment of uterine contractile abnormalities.
Administration: IV at 1-6 mU/min and increased in increments of 1-6 mU/min every
15-40 min depending on the protocol.
Use of amniotomy is controversial.
Management is expectant: as long as the fetus and mother are tolerating the prolonged
labor.
When trial of oxytocin is unsuccessful or when malpresentation or CPD is also
present, operative vaginal or CS delivery is indicated.
Breech presentation
- Occur in 3-4% of deliveries.
- Increase neonatal mortality and incidence of cord prolapse >10X.
Management:
- ECV may be attempted after 34 weeks of gestation and prior to the onset of
labor (obstetrician may administer tocolytic agent at the same time)
o Role: ECV can be facilitated and its success rate improved by providing
epidural analgesia with 2% lidocaine and fentanyl.
o When unsuccessful: it can also cause placental abruption and
umbilical cord compression necessitating immediate CS.
o Role of epidural in Breech:
Need for breech extraction doesn’t appear to be increased
when epidural is used for labor if labor is established prior to
activation of epidural.
Epidural anesthesia may decrease the likelihood of trapped
head because of relaxation of the perineum.
o If at all, head gets trapped even during regional, urgent RSI and GA to
relax uterus OR alternatively, Nitroglycerin 50-100 mcg IV may be
administered.
Obstetric H’ge:
Placenta Previa:
- Occurs if the placenta implants in advance of the fetal presenting part.
- 0.5% of pregnancies.
- Increase risk in females with:
o Previous CS or uterine myomectomy
o Multiparity
o Advanced maternal age
o Larger placenta
- Anterior lying placenta previa increases the risk of excessive bleeding for CS.
C/F:
o usually presents as painless vaginal bleeding.
o Often severe h’ge can occur at any time.
Management:
- When gestation <37 weeks and bleeding is mild to moderate: treated with
bed rest and observation.
- When >37 weeks: delivery by CS.
- Patient with low-lying placenta may rarely be allowed to deliver vaginally if
bleeding is mild.
- Active bleeding or unstable patients: require immediate CS under GA.
Preparation:
- Two large-bore IV catheters inplace
- Replacement of IV volume deficits.
- Blood must be available for transfusion.
Abruptio Placenta:
- Premature separation of normal placenta complicates approximately 1-2% of
pregnancies.
- Mild (grade I), moderate (II), severe (grade III)- 25%.
- Risk factors:
o HTN
o Trauma
o Short umbilical cord
o Multiparity
o Prolonged premature rupture of membrane
o Alcohol abuse
o Cocaine use
o Abnormal uterus
C/F:
- Painful vaginal bleeding
- Uterine contraction and tenderness
- An abdominal USG can help in the diagnosis
Choice of anesthetics:
- Based on urgency for delivery, maternal hemodynamic stability and any
coagulopathy (severe abruption may cause coagulopathy particularly after
fetal demise- fibrinogen levels <150 mg/dL d/t activation of circulating
plasminogen (fibrinogen) and the release of tissue thromboplastins that
precipitate DIC; platelet counts low and factors V and VIII are low, Fibrin split
products increased.).
- Bleeding may remain concealed inside the uterus and cause underestimation
of blood loss.
Management:
- Life threatening condition
- Emergency CS
- Massive blood transfusion
- Replacement of coagulation factors and platelets.
Uterine rupture
- Relatively uncommon.
- Occurs d/t:
o Dehiscence of scar from previous CS, extensive myomectomy or
uterine reconstruction.
o Intrauterine manipulations or use of forceps (iatrogenic)
o Spontaneous rupture following prolonged labor in patients with
hypertonic contractions (oxytocin use), fetopelvic disproportion, or
very large thin and weakened uterus.
C/F:
- Frank H’ge
- Fetal distress
- Loss of uterine tone
- Hypotension
- Occult bleeding into the abdomen
- Abrupt onset of continuous abdominal pain and hypotension.
T/t:
- Volume resuscitation
- Immediate laparotomy typically under GA
- Ligation of internal iliac arteries (hypogastric) with or without hysterectomy.
Chorioamnionitis:
Principal maternal complications are:
o Premature or dysfunctional labor
o Intra-abdominal infection
o Septicemia
o PPH
Fetal complications:
o Acidosis
o Hypoxia
o Septicemia
C/F:
Fever (>38 deg C)
Maternal and fetal tachycardia
Uterine tenderness
Foul smelling or purulent amniotic fluid
Lab: TLC (only if markedly elevated >15000/micL), CRP (>2 mg/dl), Gram staining
of amniotic fluid
Considerations:
Use of regional anesthesia in chorioamnionitis is controversial (chance of
development of meningitis or epidural abscess)
Concerns over hemodynamic stability: particularly in patients with chills, high
fever, tachypnea and changes and mental status or borderline hypotension.
May have covert signs of septicemia, thrombocytopenia, or coagulopathy.
Hypertensive Disorders:
HTN during pregnancy can be classified as:
o Pregnancy induced HTN: also referred to as preeclampsia
o Chronic HTN: that preceded pregnancy
o Chronic HTN with superimposed preeclampsia
Preeclampsia:
o Is defined as SBP >140 mm Hg or DBP >90 mm Hg after the 20th WOG
accompanied by proteinuria (>300 mg/d) and resolving within 48 h
after delivery.
o Complicates about 7-10% pregnancies.
o Severe preeclampsia causes 20-40% of maternal deaths and 20% of
perinatal deaths.
o Maternal deaths are usually d/t stroke, pulmonary edema, hepatic
necrosis or rupture.
o Severe features: BP >160/110 mm Hg, Proteinuria >5g/d, Oligura <500
ml/day, elevated serum creatinine, IUGR, pulmonary edema, CNS
manifestations (headache, visual disturbances, seizures, stroke),
hepatic tenderness, or HELLP syndrome.
o Proposed theories for Preeclampsia:
Increased pressor response: increased sensitivity to AII
preceding onset of PIH
Prostaglandins: Decreased PGI2 and
Eclampsia:
o Preeclampsia + Seizure
Pathophysiology and Manifestations:
o Vascular dysfunction of the placenta resulting in abnormal metabolism
of prostaglandin.
o In preeclampsia: Elevated TXA2 and decreased PGI2
TXA2 is a potent vasoconstrictor and promoter of platelet
aggregation, PGI2 is a potent vasodilator and inhibitor of
platelet aggregation.
o Endothelial dysfunction may reduce production of NO and increase
production off ET-1 (a potent vasoconstrictor and platelet aggregator)
o Marked vascular reactivity and endothelial injury reduce placental
perfusion and lead to widespread systemic manifestations.
T/T:
o Bed rest
o Sedation
o Repeated administration of antihypertensives
Labetalol: 5-10 mg IV
Hydralazine: 5 mg IV
Magnesium sulphate
Q. How do anesthetic agents cross the placenta? Examples of agents crossing and
not-crossing the placenta.
Ans.
Anesthetic agents enter the fetus side through placenta by way of diffusion.
Diffusion of anesthetic agents through the placenta is mostly dependent upon:
Diffusion constant which is dependent upon
o Molecular weight of substance
o Protein binding
o Lipid solubility
o Degree of ionization
Membrane surface area
Concentration of drugs on maternal side
Concentration of drug on fetal side
Membrane thickness
Timing of administration
Drugs that easily cross the placenta are:
Induction agents: STP, Propofol, Ketamine (however at conventional doses,
these drugs do not cause fetal depression)
Opioids
Drugs that do not easily cross the placenta are:
Muscle relaxants- big molecules (gallamine however crosses)
Treatment is of underlying cause e.g. antibiotics for infection and oxygen if hypoxic.
Haloperidol 2.5mg IV increased to 5mg PRN can be used to settle an agitated patient.
Thiamine and diazepam might also useful.
Repeated orientation, familiar surroundings, family, sensory aids and re-establishing day-night cycles are
useful “non medical” therapies.
6. Post-op CVA/TIA
7. Sleep disordered breathing:
a. Reason unclear
b. 2/3rd of elderly have frequent episodes of desaturation and apnea
during sleep and diminished response both to hypercapnia and
hypoxia.
8. Renal system:
a. Risk of renal failure
b. Reasons: pre-renal causes, drugs, and sepsis, etc.
9. DVT:
a. More prone for DVT and PE
b. Advanced age, prior thromboembolism, malignancy, immobility,
pelvic, hip and orthopedic surgery, central lines, are risk factors.
c. Appropriate pharmacologic and non-pharmacologic prophylaxis
recommended.
10. Nutrition
CASE OF TURP
Prostate gland:
A fibromuscular gland weighing 20 g and underlies the apex of the male
bladder and surrounds the prostatic portion of the urethra.
Developmentally 2 lobes, anatomically 5 lobes median and 2 lateral lobes
most commonly undergo BPH
Nerve supply: From prostatic plexus (from inferior hypogastric plexus)
Afferent pain fibers from prostate, urethra and bladder mucosa from S2, 3,
and 4.
Pain fibers from over stretched bladder travel with sympathetic fibers T12,
L1 and L2.
Post-operative period:
a. TURP syndrome
b. Clot retention
c. Bleeding
d. Post-operative cognitive dysfunction
e. Transient bacteremia/sepsis
i. Causes
1. Release of bacteria from prostatic tissue
2. Pre-op indwelling urinary catheter
3. Pre-op UTI
f. Coagulopathy:
i. < 1%
ii. Causes:
1. Dilutional thrombocytopenia
2. DIC d/t release of prostatic particles rich in
thromboplastin into blood
3. Local release of fibrinolytic agents (plasminogen and
urokinase)
iii. Treatment: FFP, platelets, ACA
o Hypothyroidism:
Causes: Hashimoto’s thyroiditis, thyroid destruction (from
radioactive iodine or surgery), pituitary or hypothalamic
disease.
Symptoms: CVS: Bradycardia, pericardial effusion,
reduced plasma volume, RS: pleural effusions, CNS: slow
development, mental slowing, excessive sleepiness,
depressed mood, GI: delayed gastric emptying,
constipation, impaired hepatic drug metabolism, Others;
fatigue, modest weight gain, cold intolerance, menorrhagia,
muscle cramps, dry coarse hair, dry skin, large tongue,
swelling of legs, etc.
Associated endocrine disorders:
o MEN 2A: Medullary Ca of thyroid, Pheochromocytoma,
Parathyroid hyperplasia
o MEN 2B: Medullary Ca of thyroid, Pheochromocytoma, Mucosal
Neuromas
o MEN 1: Pituitary adenoma, Parathyroid hyperplasia, Pancreatic
tumors like insulinoma
Thyroid malignancies:
o Papillary, medullary, follicular, and anaplastic
o Sx of distant metastasia- lung, bones, liver, etc.
History of taking of any medications: dose, duration, previous TFT
o Common S/E of antithyroid drugs:
Agranulocytosis
Hepatotoxicity: Immunoallergic hepatitis seen with PTU
Vasculitis: arthritis, vasculitic rash, skin ulcerations, etc.
Approximately 100 mcg of thyroid hormone synthesized from gland each day
(90% T4 and 10% T3)
99.98% of T4 and 99.8% of T3 is bound to protein in blood.
o Dalrymple sign (Stare sign): white of the sclera is seen d/t upward
retraction of the eyelids
o Lid-lag (von Graefe’s sign): lid lag when looking downward
o Joffroy’s sign: absence of forehead wrinkling when looking upwards
with face tilted downwards.
o Exophthalmus (Grave’s disease): d/t immune mediated inflammation
of the retro-orbital fat.
o Moebius sign: lack of convergence of eyeball
What is sick euthyroid syndrome?
Ans:
Euthyroid sick syndrome is described as abnormal thyroid function tests that occur in
the setting of acute and severe nonthyroidal illness without preexisting hypothalamic-
pituitary and thyroid gland dysfunction. Most common findings are low T3, T4 and
TSH. Reversible after recovery from the illness. Administration of thyroid hormones
in this situation is controversial and not shown to improve outcomes. May be an
adaptive response or a maladaptive response.
Thyroid storm:
o Is a condition in which patient’s metabolic, thermoregulatory and
cardiovascular compensatory mechanisms fail in a patient with
hyperthyroidism.
7 Ps:
Phluid
PTU
Potassium Iodide
Prednisolone (steroid)
Propranolol
Paracetamol
Precipitating factors
Myxedema coma.
Loss of brain function as a result of severe, longstanding hypothyroidism.
Mostly seen in elderly, more in females.
Triggers:
o Drugs (sedatives, narcotics, anesthesia, lithium, and amiodarone)
o Infections
o Stroke
o Trauma
o Heart failure
o GI bleeding
o Hypothermia
o Missing thyroid medications