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Page 1 of 217
DR.MAZEN AL SOHAIBANI.
He was kind enough to share them with his residents. They describe the important
points-anesthetic concerns- in most common anesthesia topics, to help you prepare for
the vaiva/case scenario exam.I hope that you will find them helpful in your exam as well
as in your clinical works as it was for me.
A:airway.
B:breathing/respiaratory system
C:circulation/heart condition.
D:drugs.
M:metabolic concerns..lytes/glucose/ABG..etc.
G:gastrointestinal system.
THA Page 2 of 217
Usually elderly Pt
If a revision blood loss and it takes longer Epidural or GA
Look for the cause of arthritis # due to CV disease (syncope) avascular necrosis
due steroids, infarction (sickle cell disease)
Spinal Vs GA less risk of PE with spinal and blood loss
A, B, C look under elderly, and other co-existing diseases
Consider Autologus blood donation
Lab: ECG, CBC….. depend on the co-existing diseases
If suspect a difficult A/W GA, due to position
Intra-op: risk of PE (cement, BM, fat) consider art-line in Pt with CV disease
Post-op: need to anticoagulated, pain epidural or PCA
DDx of circulatory collapse intra-op: PE, MI, total spinal, anaphylaxis
Thalassemia Page 3 of 217
Ethnic: Mediterranean, African-American, middle east and Asian
-thalassemia
o major (homozygote) (Cooley’s anemia) severe, need treatment
o intermediate (hetro)
o minor (hetro)
o manifest after 1st year of life, when Hb F disappears.
-thalassemia
o 4 genes for the -chain synthesis
o 1 gene deletion silent carrier.
o 2 genes deletion mild microcytic anemia.
o 3 genes deletion severe hemolytic anemia.
o 4 genes deletion hydrps fetalis
GI absorption of iron and with multi-Tx iron overload
hemochromatosis .
treatment :
o Tx and folate in mild form
o Multi Tx and iron chelating agent in the severe form
o Splenectomy
The Myotonias Page 4 of 217
delayed relaxation of skeletal muscle after voluntary contraction,
myotonic contracture is not relieved by regional, NDMR, or deep GA.
Relaxation may be induced by infiltration of the muscle with local anesthetic.
caused by genetic abnormalities that produce defects in sodium or chloride
channels or proteins which alter ion channel function in muscle cells
giving drugs that Na influx into the cell and delay return of membrane
excitability,like quinine, tocainide, or mexilitene, may relax myotonic
contracture.
Myotonic Dystrophy (Steinert's Disease)
is the most common form of the myotonias and the most severe.
AD inherited disorder (1 in 8000), S/S during the 2nd and 3rd decades of life.
clinical features associated with myotonic dystrophy: muscle degeneration,
cataracts, premature balding, DM, thyroid dysfunction, adrenal insufficiency,
gonadal atrophy, cardiac conduction abnormalities.
Cardiac abnormalities LV diastolic dysfunction, cardiac failure is rare.
o AV block , A.fib, or flutter, ventricular dysrhythmias.
o 1st -degree AV block may actually precede the onset of clinical symptoms
o Sudden death may be a result of the abrupt onset of 3rd -degree AV block.
Thoracic trauma: Page 5 of 217
ACLS, and in addition to other injuries
Heart and major vessels
Chest wall flail chest > 3 ribs# need intubation with PEEP
Esophageal
Diaphragm initially no S/S then CXR diagnostic
Lung parenchyma contusion
Tracheal, bronchial injury with blunt trauma Pt may have stridor,
wheezing, dyspnea S: subQ emphysema, pneumomediastinum, air leak, loss
of expiratory volume
Due to association with other injury, mainly c-spine DLT is difficult to insert
so consider other option
If chest tube drain >1L initially or >200ml/h open
When putting a C-line have it in the same side of the chest injury
Always be careful with PPV which can worse the hemodynamic with
tamponade, and convert a pneumo to a tension pneumo
Complication of chest injury empyema, recurrent pneumo, persistence air
leak, BPF
TOF Page 6 of 217
Most common cyanotic CHD, F=M
VSD, RVH, overriding aorta, RVOTO(sub, valvular, supra)
70% have bicuspid aortic valve, 10% LAD from RCA
CXR: pul vascular marking, Rt aortic arch, ECG: RAD, RVH
Tet spells: hypercyanotic attaches peak 2-6 m, by age 6y ferq & severity
Initiated by feeding, crying, defecation
Any thing that PVR or SVR tet spells (PO2, PCO2, acidosis) Rt
to Lt shunt
S/S: clubbing, cyanosis, polycythemia
Pre-op: avoid dehydration, and don’t upset them
Hemodynamic goals:
o Preload
o R/R slow and sinus
o cont
o SVR
o PVR
A N/A
TOF, obst Page 7 of 217
Corrected TOF, not risk, and no special precautions
May have a residual or recur VSD, or pul outflow tract obstruction
All TOF need Echo for that reason
12-ECG may have arrhythmias, or conduction abnormality after the repair
So for residual defect manage as TOF
hemodynamic Goals:
o preload
o R/R slightly maintain sinus
o Cont maintain, or slightly
o Afterload maintain, avoid sudden in SVR
No spinal
early epidural is desirable, may PVR
Consider art-line
Tonsillectomy and Adenoidectomy Page 8 of 217
Peds considerations
Indication: recurrent tonsillitis, OSA, abscess
A tonsils size(0-+4(75%)), A/W obstruction wheezing , stridor
B OSA with snoring, O2 sat, cor pulmonale, chest retraction and RR
C CHD need Abx prophylaxis, Rt heart failure ECG, CXR, Echo
D over counter meds may contain ASA
Induction normal
Intra-op avoid NSAID’s , give zofran and decadron
Post-op:
o N&V, dehydration, pain, bleeding see other card
o Pul edema due to relief of the obstruction frothy pink secretion in
the ETT, sat, wheezing, RR
o DDx anaphylaxis , CHF, volume overload, ARDS, aspiration
o Mx supportive ETT, PPV with PEEP, O2 , diuretics
o Usually subsided with in 24 hrs
Transplanted heart Page 9 of 217
High risk of infection mainly cholecystitis
The efferent denervation is permanent, while some may retain afferent
innervations
The response to exercise in normal heart is by HR, in a transplanted heart it’s
by SV, with little and delayed in HR
They are preload dependent
ECG may shows both donor and recipient P waves
No vagal input No bradycardia
But they response to stress(hypoxia, PCO2) by HR but it’s delayed
Premature CAD, with in 3 yrs, mainly without angina, if they have Aff pain
The main symptom is dyspnea
C altered response to stress, and drugs, CAD, maintain preload
D atropine and pancuronium No effect, Neostgmine may slow HR,
Norepi -effect, Adenosine effect, in addition to the side effect of
immunosuppressant drugs, may need stress dose steroids, and Abx coverage
M adrenal suppression, glucose intolerance
Heme anemia, thrombocytopenia
Trauma in pregnancy Page 10 of 217
Blunt
Closed head injury is the major cause of death
Other risks:
o Uterine rupture
o Placenta Abruption
o Fetal injury
o Spleen and liver rupture
Penetrating
GSW, stabbing
Burn
Same rule of nines apply to pregnant Pt
With inhalation injury CO poisoning the fetus has a higher affinity to CO
than the mother
Apply the same ATLS, maintain LUD
Have fetal US done, and continue FHR monitor
TURP-TURB: Page 11 of 217
Distilled H2O hemolysis not used any more
Sorbitol converted to fructose hyperglycemia, and to lactate acidosis, also
well cause osmotic diuresis and dehydration
Glycine(inhibitory neurotransmitter) transit blindness ammonia
encephalopathy
TURP Syndrome:( water intoxication syndrome)
S/S mild (restlessness, nausea, SOB, or dizziness) to severe (seizures, coma, HTN,
bradycardia, or CV collapse).
In the awake patient: a classic triad of symptoms in both SBP and DBP
associated with an in pulse pressure, HR, and mental status changes.
Volume overload Lt heart failure pul edema
CNS S/S due to both the type of irrigation and the severity of in serum Na
Management:
o ABC, 100% O2, intubate
o Notify the surgeon to terminate the procedure
o Consider DDx: over-sedation hypercarbia, hypoxia,
Anaphylactic reaction if CV collapse, diabetic coma
o 12 leads ECG, and invasive monitoring art line, CVP
Tylenol overdose Page 12 of 217
A single dose of 10-15g can produce liver injury, 25g fulminant hepatic failure
Ingestion even a lower dose with alcohol the chance of hepatic failure
Tylenol normally detoxified by conjugation to glutathione, but with overdose
glutathione depleted metabolized by P-450 to a toxic compound
First few hr after N&V, RUQ pain with or without obtundation
After 24h symptom disappear and Pt looks well
24-72h liver failure appear, with possible ATN, and cardiotoxicity
Poor prognosis with Phos, coaglupathy, encephalopathy and acidosis
bilirubin correlate with survival
Management:
o ABC
o Mucomyst, with best result if given 12-20h after ingestion
o Roughly 150mg/kg over 15min, then 50mg/kg over 4h then 100mg/kg
over 16h
o Look at the nomogram
Ulcerative Colitis Page 13 of 217
A may have Ankylosing spondylitis difficult A/W, with S/S bowel
obstruction RSI
B possible restrictive lung disease with ank-spond
C AR, hypovolemia
D steroids (stress dose)
M electrolytes imbalance, K , metabolic acidosis, albumin, adrenal
insufficiency
G obstruction, perforation
Upper Ext nerve injury: Page 14 of 217
Ulnar:
sensation over the 4th and 5th fingers
Muscle wasting, unable to grip a paper between fingers
Median:
Loss of skin sensation over the lateral 3 ½ of the palm of the hand
Weakness of wrist flexion, when making a fist the index and middle
finger remain straight, also loss of thumb flexion
Radial:
If the injury at the axilla unable to extend the forearm (triceps)
If in the spiral groove wrist drop
MCN:
Loss of arm flexion (biceps), loss of sensation over the lateral aspect of the
forearm
Axillary N
Loss of skin sensation over the lower ½ of the deltoid muscle, with
weakness of arm abduction
URTI Page 15 of 217
Need to distinguish from allergic rhinitis
incidence of croup, bronchospasm, and laryngospasm
If emergency or urgent surgery proceed, and anticipate the above problems
If elective, and < 1yr postponed
If elective, >1 yr temp postponed
Elective > 1yr normal temp P/E purulent secretion, LRTI postponed
= = = = clear proceed to surgery
How long to postponed for, if too long, the child may end up with another episode
of URTI, So 2-4 wks is reasonable
Uterine Rupture Page 16 of 217
Risk see box 37-1 chestnut
Mainly fetal distress and bleeding
A & B onst
C hypovolemic shock, hypotension
Heme bleeding, anemia
Mx
See abruption card
Basically same management they come for stat C/S due fetal distress
VAE: Page 17 of 217
When the surgical field > 5cm above the Rt atrium.
40-50% in the sitting position, if known PFO, avoid sitting position
Dx. By TEE the most sensitive then pericardial doppler, placed in the Rt
sternal border 3rd to 6th intercostal space, which detect 0.25ml of air
Miller all Pt going for N.surgery in sitting position need to have CVP
Mx: 100% O2
Notify the surgeon, flood the surgical field with saline gauze
Wax the bone edges
Compress the jugular vein
Head down
Aspirate through the CVP
D/C N2O, and PEEP which may cause paradoxical embolism
von Willebrand's Disease Page 18 of 217
AD, 3types I, II, III(very rare), group O blood have 20-30% less vWF
Prolonged bleeding time, N PT and PTT
I (70-80%) vWF, IIA also function abnormal, IIB they have
thrombocytopenia which aggravated by giving DDAVP (C/I).
Pregnancy vWF
Rx DDAVP 0.3ug/kg 1hr prior to surgery.
DDAVP may cause fibrinolysis by releasing t-PA so consider giving TXA
Cryo have vWF , recombinant Vwf.
Hematology consult, Possible HIV +
Do gentle intubation, avoid blind suctioning, avoid Regional anesthesia
VSD Page 19 of 217
Rare in adult , with S/S depend on the size, and PVR, the larger, and the lower
PVR more severe symptom
small asymptomatic, load pansystolic murmur Lt sternal border, with normal
ECG and CXR
mod also asymptomatic, with biventricular enlargement on CXR
large when pul blood flow > systemic, S/S early as 4 wks, Lt Rt change to
Rt Lt cyanosis
hemodynamic goals:
o Preload
o R/R N and sinus
o Cont slight
o Afterload
o PVR
Pre-op Abx prophylaxis
A N/A
B pul edema
C shunt, CHF, low forward CO
White Cell–Related Transfusion Reactions Page 20 of 217
Febrile Reactions:
antibodies to the HLAs after multiple Tx, 1% of all RBC transfusions.
the patient experiences a temp of more than 1°C within 4 hrs of a blood Tx and
defervesces within 48 hours.may also develop chills, respiratory distress, anxiety,
headache, myalgias, nausea, and a nonproductive cough.
Febrile reactions can be treated with acetaminophen
should be distinguished from a hemolytic transfusion reaction (direct Coombs test)
Graft-versus-Host Disease (GVHD)
the donor lymphocytes may become engrafted, proliferate, and establish an
immune response against the recipient.
Patients at risk for GVHD include organ transplant recipients, neonates who have
undergone a blood-exchange Tx, and patients immunocompromised by many other
disease processes. GVHD typically progresses rapidly to pancytopenia, and the
fatality rate is very high
Also when a genetic relationship exists between the donor and the recipient
GVHD has been reported with the transfusion of whole blood, packed RBCs,
granulocytes, platelets, and fresh, not frozen, plasma. It has not occurred following
transfusion of FFP, cryoprecipitate, or frozen RBCs
Wilms tumor Page 21 of 217
A delayed G. emptying RSI
B lung mets, chemo, and radiotherapy effect
C HTN, severe if both kidneys involved CHF, renin secretion
D chemo
R hyperaldosternism(2nd) K
H severe anemia, low PLT, acquired vWD possible need F VIII concentrate
M art,and central line
Lab X-match, Lytes CBC
other upper body IV access
Potential intra-op problem IVC obstruction CO
Tumor in the IVC embolic phenomena
Post-op ICU backup
mazen m a z e n
h o m e o f f i c e ,
AAA Elective Page 22 of 217
Long procedure, large fluid shift, and high risk of blood loss
A N/A
B potential COPD
C CAD, HTN,
Renal border line function
In the pre-op evaluation: concentrate on cardiac function with detailed H/P and
work up
Lab: CBC-D, BUN, creat, Lytes, Mg, ECG, CXR, PFT, ABG, Echo if available
Consider optimizing any medical condition pre-op by meds, consultation, and
further evaluation.
X-match for at least 6 U of blood, have FFP ready
Consider Epidural to do it as a combined technique
Have the cell saver in the room, IV worming device, with blood set
Lines: Big 14G peripheral IV, Art line, CVP/PAC, bear hugger
Monitors: standard + 5 leads ECG, Foley, temp, art-line, CVP/PAC, TEE
Induction: routine, modify on cardiac status
Before induction have inotrops and vasodilators ready to go
Abruptio placenta Page 23 of 217
Risk with cocaine abuse, smoking, trauma, previous abruption, age
Most common cause of DIC, risk ante-postpartum hemorrhage, fetal hypoxia
The bleeding could be concealed, and can have 2500ml of blood
DDx placenta previa, uterine rupture
A obst
B obst
C hypovolemic shock,
Heme anemia, coaglupathy DIC
R ARF from both shock, and DIC
Fetus Demise, hypoxia,
Mx:
Depend on the severity, usually partial managed conservative with bed rest
ABC, RSI, GI prophylaxis, induction with Ketamine, LUD
Lab CBC, Lytes, BUN, creat, PT, PTT, fibrinogen, D-dimer , X-match
Monitor Art line, CVP/PAC, fetal monitoring , large IV
Synto may not work atony consider ergot, hemoabt(PGF2), may end up
need hysterectomy
Achondroplasia: Page 24 of 217
A potential difficult A/W, foramen Magnum Stenosis Avoid neck
extension , OSA
B Kyphoscoliosis Restrictive lung disease
C Cor-pulmonale, pul HTN
CNS hydrocephalus, possible ICP, central sleep apnea
Lab CXR, C-spine, CT, MRI base of the skull, PFT, ECG, Echo, in
addition to the regular blood work
Acromegaly Page 25 of 217
99% from pituitary adenoma
A large tongue , epiglottis, large nose difficult intubation and mask fitting
Need FOI, possible vocal cord paralysis, and subglottic stenosis smaller
ETT, and potential post-op A/W obstruction
B OSA
C HTN, Cardiomegaly, cardiomyopathy, arrhythmias, CHF, hemodynamic
instability (ECG, CXR, Echo)
D steroids for other pituitary problems
N neuropathy (document), adenoma effect ? pressure vision
M DM, hyperthyroid,
Position nerve compression
Monitors art line
ACT Page 26 of 217
Mainly for depression, possible difficult to obtain an accurate medical history
C/I: Pheo, pregnancy, recent CVA and MI, SOL with ICP, and long bone #
The main effect is on the CVS:
o Initial PSN effect with hypotension and bradycardia, even arrest
o Followed by intense SNS activation with HTN, tachycardia, arrhythmias
and ICP and IOP
Review the old anesthetic record for the dose, and any problems may had
happened
Also review all Pt med (TCA, MAOI) avoid indirect sympathomimetics, also
be careful when direct acting drugs exaggerated response
Monitors standard CAS monitors, consider invasive monitoring in sick Pt
Pt with pacemaker or AICD not C/I have the magnet in the room, know what is
the program
Acute liver dysfunction Page 27 of 217
M&M
Postponed if not an emergency
History of alcohol, drugs, exposure to toxins at work
A LOC
B hypoxia, hyperventilation, V/Q mismatch
D altered drug metabolism
M lytes abnormalities
Renal impairment
CNS encephalopathy
Heme coags abnormalities
Avoid sedation pre-op
Correct coags pre-op
Intra-op avoid hypoxemia, and hypotension both hepatic blood flow
Acute pericarditis, and effusion Page 28 of 217
Most common cause is viral infection
Post-MI Dressler Syndrome
S/S diffuse chest pain, with diffuse ST-elevation in ECG pericardial leads,
with sinus tachy, chest exam friction rub.
Consider Echo, if suspected effusion or tamponade
Normal pericardial fluid 20-30 ml,
o In chronic effusion the pericardium can accommodate up to 1000
ml, without S/S of tamponade
o But in acute effusion as low as 200 ml can give symptoms
Adrenal Insufficiency (Addison disease): Page 29 of 217
Need 90% destruction of the adrenal gland to produce symptoms
primary (Addison's disease) is idiopathic adrenal insufficiency due to
autoimmune destruction. causes both a gluco and a mineralocorticoid
deficiency.
Hashimoto's thyroiditis in association with autoimmune adrenal insufficiency
is termed Schmidt's syndrome.
Other: bacterial or fungal infections, metastatic cancer, sepsis and
hemorrhage.
Secondary: anterior pituitary fails to secrete sufficient quantities of ACTH.
from tumor, infection, surgical ablation, or radiation therapy.( less severe S/S,
aldosterone is maintained
S/S Wt loss, muscle weakness, BP, abd/back pain due bleeding, N&V,
hyperpigmenation in primary only
Dx by ACTH stim test
Adult with repaired CHD Page 30 of 217
Type of CHD,
When, What, and Where, (Repair)
Understand the physiology of the repair
Residue, Sequelae, and the complication of the repair.
Follow up with cardiologist, recent Echo, if not ask for one
Discuss the case with a college who knows more about CHD(peds cardiac
anesthetist)
The Need for SBE prophylaxis
High risk for arrhythmia (pads on) for pacing, cardioversion, or shock
Have inotrops support ready.
In case of shunt be meticulous about air in the IV, use saline instead of
air for epidurals.
In case of pulmonary HTN have NO in the room
AI Page 31 of 217
Well tolerated in pregnancy
hemodynamic Goals:
o preload maintain, LUD
o R/R slightly maintain sinus
o Cont maintain, avoid cardiodepressant
o Afterlaod
Epidural is good
Airway foreign body Page 32 of 217
Emergency and potential life threatening
In addition to peds consideration
Brief H/P AMPLE, depend on the Severity of the symptoms and
hypoxemia may consider CXR( most are radiolucent), but may see
atelectasis
Do inhalation induction with Sevo, Avoid PPV, minimal support if needed
Assess the eye for depth (see later)
The dilemma Full stomach Vs need of maintaining spontaneous
Ventilation
Once the eye in stage III do direct laryngoscopy Lidocaine spray
May give IV bolus of propofol upon the removal of the foreign body
Consider a dose of decadron , and racemic Epi
Airway laser surgery: Page 33 of 217
Risk for both the patient and OR personal
Knew what is the indication papiloma, stenosis, neoplasm PFT, flow volume
loop, CT
The airway is shared with the surgeon close communication
Eyeglasses and laser mask, Pt eyes closed, covered with wet gauzes, and metal
shields, cover the exposed skin with wet towels
Consider glyco pre-med
Use laser-metal ETT, and fill the cuff with NS with methylene blue
Avoid N2O, use the lowest FiO2 possible < 40%, other Jet ventilation
Pt need to be completely paralyzed
In case of airway fire remove ETT, have 60 cc syringe filled with NS ready,
after controlling the fire asses the airway damage, and ongoing fire, avoid high
Fi02 initially till you make sure that there is no ongoing fire direct
laryngoscope, bronchoscope with possible lavage and CXR, reintubate with new
ETT, keep intubated, Abx, and steroids ICU post-op
CO2 laser only 0.01 mm penetration less bleeding and edema post-op
With Nd-YAG laser deeper penetration, and risk of air embolism
The metal-ETT are bigger than the PVC tubes so use one size smaller
Equations Page 34 of 217
alveolar gas equation:
Shunt equation
Ecstasy:
serotonin and dopamine level
C HTN arrhythmia
H DIC,
MSK rhabdomyolysis
M+R lytes abnormality, ARF
Fetus toxicity
Mx
Amyloidosis: Page 37 of 217
Extracellular deposition of amyloid type protein
A macrogolssia, tracheal stenosis (smaller ETT)
B pul edema from CHF
C arrhythmias, restrictive myopathy, CHF, autonomic dysfunction
Renal CRF, nephritic syndrome
Heme Factor X deficiency
Lab/DI: CBC, lytes, BUN, Creat, CXR, PFT/ flow volume loop, ABG,
ECG, ECHO, coags
Monitoring: CAS, Art-line, CVP/PAC, TEE
Avoid Regional if coagulopathic
The main goal intra-op is to maintain U/O, avoid any nephro-toxic drugs
Have an ICU backup
Amyotrophic Lateral Sclerosis (ALS) Page 38 of 217
Degenerative disease of the CNS with involvement of both UMN and LMN
S/S Asymmetric weakness, reflex, fasciculation and muscle atrophy
A bulbar involvement Aspiration mod RSI
B respiratory failure
C
D Sux C/I, sensitivity to NDMR,
M abnormal glucose and Ca metabolism, with thyroid dysfunction
Do Regional technique better
If GA: Mod RSI, ICU post-op
Anesthesia for organ donation: Page 39 of 217
COMMON PHYSIOLOGIC DERANGEMENTS AFTER BRAIN DEATH
Condition Cause
Hypotension Hypovolemia (DI; hemorrhage) Neurogenic shock
APR
For rectal Ca, with possible bowel obstruction
Usually in elderly with other co morbidities
With bowel prep fluid deficit hypotension upon induction
A RSI (b. obstruction)
C hypovolemia, elderly
Position lithotomy, jackknife
Monitors CAS, art line, temp, foley
Pain PCA, epidural
Arnold chiari malformation Page 46 of 217
It’s one of the chiari malformation it’s type II
associated with myelomeningocele
present for posterior fossa decompression and repair of myelomeningocele and
insertion of shunt
on of the main issue is position during induction due to myelomeningocele,
may put a donut where the defect is in the hall, if big may have to the induction
in lateral position then turn prone
A potential difficult airway, due to hydrocephalus awake intubation
B vocal cords paralysis trach, resp depression due to post fossa compression
C bradycardia
CNS the defects, and CN palsy
position as above
AS Page 47 of 217
Mild well tolerated
Mod/severe not well tolerated
hemodynamic Goals:
o preload maintain, LUD, treat hypovolemia aggressively
o R/R slightly maintain sinus treat arrhythmia aggressively
o Cont maintain, avoid cardiodepressant
o Afterlaod , avoid sudden in SVR
Need are-line, CVP/PAC risk of arrhythmia with insertion, to maintain
PCWP =18
GA opioids, mix kitamine/STP
Have the crash cart in the room, pads on the Pt
ASD:
3 types: ostium secundum @ foramen ovale
Asthma: Page 48 of 217
H/P: how bad is the asthma? Severity? Frequency? Any hospital or ICU admission
in the past, if yes when was the last one, how he/she manage the asthma at home,
or need ER visit, Exam: V/S, A/E , wheezing
Review PFT results pre-post bronchodilators, and optimize pre-op
If Pt is steroids (PO) dependent asthma consider steroids coverage peri-op
Pre-med -agonist, Anticholenergics,
Induction: IV Lidocaine, avoid STP, intubate deep, may consider LMA
Maintenance: avoid any histamine releasing drugs,
Emergence: consider extubate deep, IV Lidocaine pre-extubation
Consider regional anesthesia to avoid intubation
Autonomic hyperreflexia: Page 49 of 217
Post spinal cord injury above T-7 70-75%, following the resolution of
spinal shock, 2-3 weeks after injury
Stimulation below the level of transection Severe HTN with bradycardia
A potential difficult A/W, unstable C-spine, aspiration risk (FOI), (RSI)
B respiratory reserve and volumes, risk of aspiration, pneumonia, PE,
respiratory failure PFT, ABG, post-op vent (ICU)
C hyperreflexia, orthostatic hypotension, assess the volume status. ECG,
D (Sux C/I), have anti-HTN ready (Niprid) N. stimulator show resistance
N deficit
Neuraxial best is a good choice but may be difficult to assess the level of
the block too high, or too low
Hyper-reflexia may happen post-op due to bladder or rectal distension.
Sequelae CV collapse, arrhythmias, pul edema, stroke, seizure, death
AVM: Page 50 of 217
M>F, 10-40yrs
S/S parenchymal hemorrhage, SAH, Sz, motor/sens deficit
In Peds Vein of Galen AVM hydrocephalus + high output cardiac failure
A LOC
B aspiration during Sz
C CHF
CNS Sz, LOC, ICP
Pt may have (NPPB) normal perfusion pressure breakthrough cerebral
hyperperfusion with normal CPP
o Rx: diuretics, hypervent, mild hypothermia, N-low MAP, high dose STP
The rest of management like Aneurysm
High risk of bleeding blood in the room
Airway laser surgery: Page 51 of 217
Risk for both the patient and OR personal
Knew what is the indication papiloma, stenosis, neoplasm PFT, flow
volume loop, CT
The airway is shared with the surgeon close communication
Eyeglasses, Pt eyes closed, covered with wet gauzes, and metal shields
Consider glyco pre-med
Use laser-metal ETT, and fill the cuff with NS with methylene blue
Avoid N2O, use the lowest FiO2 possible, other Jet ventilation
Pt need to be completely paralyzed
In case of airway fire remove ETT, have 60 cc syringe filled with NS
ready, after controlling the fire asses the airway damage direct
laryngoscope, bronchoscope with possible lavage and CXR, reintubate with
new ETT consider ICU post-op
EEG FREQUENCY RANGES Page 52 of 217
Delta rhythm (0–3 Hz) Deep sleep, deep anesthesia, or pathologic states (e.g.,
brain tumors, hypoxia, metabolic encephalopathy)
Theta rhythm (4–7 Hz) Sleep and anesthesia in adults, hyperventilation in
awake children and young adults
Alpha rhythm (8–13 Hz) Resting, awake adult with eyes closed; predominantly
seen in occipital leads
Beta rhythm (>13 Hz) Mental activity, light anesthesia
Hyponatremia < 130 Page 53 of 217
or in serum Na & in ECV & PV, so it’s result from excess or deficit of water
total body Na regulated by aldosterone and ANP, where serum [Na] by ADH
S/S depend on the rate and severity of of Na: loss of apatite, N&V, cramps, weakness,
LOC, coma and seizure
Acute CNS S/S is due to cerebral edema
What is the serum osmolality see figure
Cerebral salt wasting syndrome, mediated by BNP, independent of SIADH, risk head
trauma, tumor, SAH, and infection
SIADH see other card
Rx < 120 with 3% NS @ 1-2 ml/kg/hr to serum Na 1-2 mEq/l/hr only for few hrs, not
more than 25 mEq/l/48 hrs
Rapid correction abrupt brain dehydration central pontine myelinolysis mild (transient
behavioral disturbances or seizures) to severe (including pseudobulbar palsy and
quadriparesis).Within 3 to 4 weeks of the clinical onset of the syndrome, areas of
demyelination are apparent on MRI, risk factors (alcoholism, poor nutritional status, liver
disease, burns, and hypokalemia) , cerebral hemorrhage and CHF
Once serum Na > 120 fluid restriction is enough , Also treat the underlying causes
To calculate the net water loss necessary to [Na+] in hyponatremia, use the following equation:
Current [Na+] × current TBW = desired [Na+] × desired TBW TBW= 0.6x wt
INDICATIONS FOR ONE-LUNG VENTILATION Page 54 of 217
ABSOLUTE
1. Isolation of each lung to prevent contamination of a healthy lung
a. Infection (abscess, infected cyst) b. Massive hemorrhage
2. Control of distribution of ventilation to only one lung
a. Bronchopleural fistula b. Bronchopleural cutaneous fistula
c. Unilateral cyst or bullae d. Major bronchial disruption or trauma
3. Unilateral lung lavage
4. Video-assisted thoracoscopic surgery
RELATIVE
1. Surgical exposure—high priority
a. Thoracic aortic aneurysm
b. Pneumonectomy
c. Upper lobectomy
2. Surgical exposure—low priority
a. Esophageal surgery
b. Middle and lower lobectomy
c. Thoracoscopy under general anesthesia
Omphalocele and Gastroschisis Page 55 of 217
o Impaired blood supply to the herniated organs, and intestinal obstruction
o Major intravascular fluid shift and dehydration full-strength balanced salt
solution
o Hypothermia and hypoglycemia
A possible difficult airway Beckwith-Wiedemann syndrome consists of
mental retardation, hypoglycemia, congenital heart disease, a large tongue, and
an omphalocele.
B respiratory failure
C CHD in 20% of infants with omphalocele.
Induction: NG aspirate gastric content then RSI , need large IV , possible
central, and arterial line
Post-op keep intubated
Stroke & TIA: Page 56 of 217
Hemorrhagic or ischemic
Etiology: Atherosclerosis, embolic MI, A.fib, VHD, post-op CEA,
trauma, severe HTN
A LOC, loss of A/W reflux (RSI)
B hypoventilation
C HTN, CAD, VHD, A.fib, arrhythmias ECG, Echo
D anti-PLT, ASA, coumadin
N LOC
Peri-op
Avoid swinging in BP, and hyperglycemia
With chronic HTN the cerebral autoregulation curve shifted to the Rt
Bioterrorism Page 57 of 217
Use of nerve gases which are a potent Ach.esterase inhibitor and cause a
cholinergic crisis
A mass casualty with both physical trauma and gas intoxication
Healthy soldiers Vs civilian with different age groups and other co-
morbidities
The amount, duration and the rout of exposure are the major determine of
the clinical course of intoxication
Exposure to vapor gives respiratory symptoms (SOB, wheezing,
bronchorrhea) with rapid cardiopulmonary collapse (muscarinic effect)
Where dermal exposure slow, and gradual S/S local muscle twitches
and fasciculation (nicotinic effect) then resp failure, also carry more risk
to the health care personal with direct contact
All the nerve gases causes irreversible inhibition to AchE in both central
and peripheral NS
The key point in the management is to give the antidote ASAP, and protect
the health care personal
BKA Page 58 of 217
For PVD, DM, gangrene, trauma, tumor
Most of the Pt with major co-morbidities e.g. CAD, PVD, DM, COPD,
CVA, Sepsis, CRF,
H/P standard + depend on the co-morbidities
Lab also as above
Options: GA Vs spinal/epidural may the incidence of phantom limb
pain, but look for C/I
monitors standard + depend on the above co-morbidities
Position risk of ischemic necrosis (pads)
EBL 250 ml
The use of tourniquet bleeding, but be aware of risk thrombus
embolization PE
Post-op pain(epidural, nerve block, PCA), DVT (S/C heparin), MI, CVA,
infection, bleeding
BPF and Empyema Page 59 of 217
Causes: after pulmonary resection for carcinoma, traumatic rupture of a
bronchus or bulla ( barotrauma or PEEP), penetrating chest wound, or
spontaneous drainage into the bronchial tree of an empyema cavity or lung
cyst
PPV contamination of the healthy lung, loss of air with alveolar
ventilation and CO2 retention, and potential tension Pneumothorax
In case of empyema with BPF drain the empyema under LA with chest tube
under suction, then do a CXR, then may fix the BPF under GA
GA options ( the main target is to avoid PPV)
o Awake intubation with DLT
o Gas induction and maintaining spontaneous ventilation
o RSI
Keep FiO2 always 1, and avoid N2O
For non-surgical management: DLT and resting the affected lung, or use of
HFJV
Keep a high index of suspicion for tension Pneumothorax
Brain death Page 60 of 217
―irreversible cessation of all function of the entire brain, including the cortex
and brain stem, determined in accordance with accepted medical standards‖
Serum albumin
g/100 mL >3.5 3.0–3.5 <3.0
Electrolyte Disturbances
Ca2+ Ca2+ K+ K+
Rate <100 <100 <100 <100
Rhythm Regular Regular Regular Regular
PR interval Normal Normal/ Normal Normal
QT interval T flat/U wave T peaked QT
Craniosynostosis: Page 80 of 217
May associated with other syndrome Crouzon’s syndrome (MH)
Main issues: difficult A/W, massive blood loss, VAE, ICP
A possible difficult A/W maxillary hypoplasia, large tongue, micrognethia
Awake FOI, multi masks and blads
B tracheal stenosis, tracheomalacia, OSA
C CHD ASD, TOF, PDA
D Avoid ketamine and sux
M lytes abnormality
N ICP, seizure disorder, mental retardation
Have a big IV access, blood in the OR
If only one suture short procedure, if > 1 , long with risk of bleeding
so need art line, CVP, IV wormer , bear hugger, Foley cath
If involve below the orbit A/W swelling keep intubated post-op (ICU)
till the swelling subsided
Creutzfeldt - Jakob disease Page 81 of 217
human spongiform encephalopathies.
The other two diseases in this group are kuru and Gerstmann-Straussler syndrome.
Pathologically, these disorders are characterized by vacuolation of brain tissue and neuronal
loss. caused by an unusual infectious agent—a prion. A prion is a small proteinaceous
infectious agent. Prions are resistant to alcohol, formalin, ionizing radiation, proteases, and
nucleases, but can be inactivated by heat (autoclaving), phenol, detergents, and extremes of
pH.
incubation time is long (years)
The typical clinical characteristics include subacute dementia, myoclonus, and EEG
changes.
Management of Anesthesia
Because of the transmissibility of the disease, appropriate precautions should be taken to
protect other patients and health care providers.
A prone to aspirate gastric impaired swallowing function and decreased activity of laryngeal
reflexes.
C autonomic dysfunction abnormal CV responses to anesthesia and vasoactive drugs.
DBecause lower motor neuron dysfunction succinylcholine should be avoided.
Crohn's Disease Page 82 of 217
A RSI for S/S of bowel obstruction
B N/A
C hypovolemia
D Steroids (stress dose), immunosuppressant
G obstruction, fatty liver, cirrhosis, perforation
R amyloidosis
Heme chronic anemia, iron def, vit B12, folate
M hypovolemia, K, 3rd space loss, albumin free fraction of drugs
MSK arthritis with ROM
Cushing Syndrome :( Glucocorticoid Excess) Page 83 of 217
Cortisol function: 1- maintain BP by converting Norepi epi, 2- anti-
inflammatory, 3- Na retention, and K excretion, 4- hyperglycemia by
gluconeogenesis, and glucose uptake by the cells
Exogenous therapy (most common) > 21 days
Bilateral adrenal hyperplasia due to ACTH from pituitary adenoma or non-
endocrine tumor (lung, kidney, pancreas)
A possible difficult A/W, mucosa easily traumatize
B OSA
C HTN, volume overload
D steroids (stress dose), avoid etomidate, titrate NDMR
N emotional, psycosis
M DM, K, met alk, Addison crisis
MSK osteopenia, muscle wasting
Immun infection
Post bilateral adrenalectomy may need mineralocorticoid replacement in day 5,
give 0.05–0.1 mg·day–1 of fludrocortisone
CV diseases in pregnancy Page 84 of 217
Lt Rt shunt e.g. ASD, VSD, PDA are well tolerated in pregnancy
The main keys in management for anesthesia are
o Avoid air bubble in the IV
o For epidural insertion use saline instead of air both due to risk of
paradoxical air embolism
o Pain catecholamine SVR shunt RV failure
o So early epidural is desirable
o Slowly titrate the epidural, and avoid spinal sudden SVR convert
the shunt to Rt Lt
o Give O2 all the time
CVP Waveform Components Page 85 of 217
compare to SEP, EEG records the spontaneous brain activity with higher
amplitude, while the SEP have a smaller amplitude in response to a specific
stimuli.
Ehlers-danlos Syndrome: Page 95 of 217
CTD, abnormal metabolism of type III collagen
A avoid A/W traumatization
B spontaneous Pneumothorax, Avoid high airway pressure
C MR, Arrhythmias, consider SBE prophylaxis
Heme bleeding disorder with normal coags profile
Anticipated problem bleeding
Obstetric premature labor & bleeding
Avoid Regional Anesthesia
Eisenmenger Syndrome Page 96 of 217
Chronic Lt Rt shunt changes to Rt Lt
Pregnancy S/S due to SVR
hypoxia IUGR, demise
high rish of thromboembolic event mainly post partum
Hemodynamic Goals:
o preload maintain, avoid AC compression LUD
o R/R maintain normal sinus
o Cont maintain, avoid cardiodepressant
o Afterload maintain, avoid sudden in SVR
o PVR avoid by hypoxia, acidosis, PCO2
Consider inhaled NO, O2 all the time, with pulse oxi
Monitors Art-line, PAC/CVP
For the 1st stage single shot spinal opioids
2nd stage may consider slow titrating epidural
Be aware that they could be anticoagulated
For C/S crash cart in the room, with pads on the Pt
Epidural have better outcome than GA careful titrate LA
Electric shock and lightning strike Page 97 of 217
Electric shock
o Direct effect of the current
o Conversion of electric to heat energy
Factors determine the nature and severity: magnitude of energy delivered,
resistance to current, type of current, current pathway, and duration of
contact
o Bone and skin have a high resistance
o Blood vessels, muscle, nerve have a low resistance
o The skin resistance can be by moist and convert a low voltage to a
life threatening shock
o Alternating current is more dangerous than a direct current
o Transthoracic (hand-hand) are more dangerous than vertical ones
o VF more common with alternating, while asystole more with direct
o Respiratory arrest due to CNS effect (medulla), tetanic contraction of
resp muscles, and prolonged paralysis
o Consider C-spine precaution, and other injuries
o Potential burn to the face early intubation
Cardiac Conditions Associated With Endocarditis Page 98 of 217
Endocarditis prophylaxis recommended
High-risk category
Prosthetic cardiac valves, including bioprosthetic and homograft valves
Previous bacterial endocarditis
Complex cyanotic CHD (eg, single ventricle states, TGA, TOF)
Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category
Most other congenital cardiac malformations (other than above and below)
Acquired valvar dysfunction (eg, rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvar regurgitation and/or thickened leaflets
Endocarditis prophylaxis not recommended
Negligible-risk category (no greater risk than the general population)
Isolated secundum atrial septal defect
Surgical repair of ASD, VSD, or PDA (without residua beyond 6 mo)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation
Physiologic, functional, or innocent heart murmurs
Endocarditis Prophylaxis Page 99 of 217
Dental, oral, esophageal, and respiratory
o Adult: Ampicillin 2g IV 30 min pre-op
o Peds: Ampicillin 50mg/kg within 30 min of starting
o Allergy to Amp Clindamycin 600 mg , Peds 20mg/kg
GU/GI
o High risk: Amp & Gent
Adult 2g/ 1.5/kg max 120mg
Peds 50mg/kg & 1.5 kg
Allergy to Amp Vanco and Gent, 1g for adult and
20mg/kg for peds
o Moderate risk: Amp alone
Same as above dose
Allergy to Amp Vanco also the same dose
Epidermolysis Bullosa Page 100 of 217
inherited or acquired
loss of intercellular bridges and separation of the skin layers intradermal
fluids accumulation and bulla formation.
3 types
o simplex benign
o junctional rarely survive beyond early childhood
o dystrophic.
Systemic manifestations and Anesthetic considerations:
o A very fragile m.m bledding & bulla formation with fixation of
the tongue difficult intubation
use a lot of lubricant on the ETT, and avoid suctioning
o skin: very fragile avoid tapes for IV and ETT, avoid tourniquet, BP
cuff must be pad with cotton
o GI: esophageal stricture malnutrition anemia, cardiomyopathy
o CVS: cardiomyopathy and MVP
o Lytes: loss of albumin hypovolemia and electrolytes imbalance
o Associated diseases: D.M, hypercoagulation, porphyria cutanea tarda,
multiple myoloma
Epiglottitis Page 101 of 217
an emergency and life threatening condition
1-7 y.o, most common pathogen is H. influenzae, with incidence due to vaccine
The main conflict is difficult airway with risk of aspiration
Other DDx is retropharyngeal abscess
Rapid onset within 24h, high grade fever, and the kid is sitting foreword, mouth
opening and drooling, inspiratory stridor, with toxic appearance
Need to managed in the OR, keep the kid with the parents, and do a gas induction
without starting an IV, in the presence of the ENT surgeon in the room, and the
difficult airway cart in the room
Do a gas induction with Sevo, and maintain spontaneous ventilation
Use a smaller ETT, and have different sizes ready
After Intubation keep sedated and transfer to ICU, and need to be kept intubated
for 24-72h, with Abx therapy
After intubation risk of pul edema
NO NO NO muscle relaxant
Give atropine
Epilepsy: Page 102 of 217
H/P: why(pathology: head injury, tumor, CVA, bleeding), frequency, type, last
aepisode, S/S of ICP
Meds: what, dose, to be taken in AM
A N/A
B possible frequent aspiration
C tuberous sclerosis, drugs effect (cardiotoxicity)
D resistance to NDMR with phenytoin, enzyme induction with pentobarb,
hepatic toxicity with carbamazepine, other: aplastic anemia, avoid any drugs that
may seizure threshold.
Epilepsy surgery Page 103 of 217
Hx type generalized, focal, absence, with, or without Aura
Review all meds, mainly anticonvulsant metabolism of NDMR
Discuss with the surgeon the anesthetic plan GA Vs sedation with LA
May need awake test with speech mapping
In case of sedation use a judicious amount of sedation, O2 by NP, and
keep communication with Pt all the time
In case of A/W obstruction D/C sedation gtt, 100% O2 LMA, ETT
In addition to the standard CAS monitoring, if an Art-line needed have in
the same side of the lesion e.g. Rt temporal Rt radial art line
Avoid any pre-med that may change the seizure threshold, also avoid any
long acting anticonvulsant
Ethylene Glycol poisoning Page 104 of 217
Found in: detergent, antifreeze, polish
The toxic metabolite Glycolic acid is responsible for the metabolic acidosis
with anion gap, and osmolar gap
S/S depend on when they present and at which stage:
o Stage I (30min-12hr) CNS with hallucination, coma, Sz, tetany
o II (12-24hr) Cardioresp HTN, tachycardia, pul edema
o III (24-72hr) Renal flank pain, Ca oxalate in the urine
Management:
o ABC
o Lab: CBC-D, Lytes, BUN, creat, EG level, ABG, Osmolality, CXR,
ECG
o Monitors: ECG, art-line, pulse oxi, Foley cath
o ECG QT, Lytes Ca
o Gastric lavage
o Depend on the serum level of EG whether to give EtOH or not or to
start HD
Familial Periodic Paralysis Page 105 of 217
Two forms: hyperkalemic, and hypokalemic, both AD inherited diseases.
intermittent, acute episodes of skeletal muscle weakness. Attach may last hours
or days.
Hyperkalemic Periodic Paralysis.
evidence of myotonia as well as episodes of muscle weakness.
caused by a sodium channel mutation.
Episodes of weakness lasting several hours can occur: during rest after exercise,
infusions of KCl, metabolic acidosis, or hypothermia.
The weakness may be so severe as to produce respiratory distress.
hyperkalemia is often transient, occurring only at the onset of weakness.
K levels measured during the episode of weakness may be N or even
Treatment consists of a low-K diet and the administration of thiazide diuretics.
Consider glucose containing solution pre-op during fasting.
Hypokalemic Periodic Paralysis.
More common. caused by a calcium channel mutation.
Fat Embolus Syndrome Page 106 of 217
associated with multiple traumatic injuries and surgery for long bone #
Risk factors include:male sex, age (20–30 years), hypovolemic shock,
intramedullary instrumentation, rheumatoid arthritis,
The incidence of FES in isolated long bone fractures is 3–4%, and the
mortality rate ranging from 10 to 20%.
CRITERIA FOR DIAGNOSIS OF FAT EMBOLUS SYNDROME
o MAJOR
Axillary/subconjunctival petechiae
Hypoxemia (PaO2 < 60 mm Hg; FIO2 < 0.4)
CNS depression (disproportionate to hypoxemia)
Pulmonary edema
o MINOR
Tachycardia (>110 beats·min–1)
Hyperthermia
Retinal fat emboli
Urinary fat globules
platelets/hematocrit (unexplained)
Flow volume loop Page 107 of 217
Fluids Page 108 of 217
Blood volume
o Preterm 100 ml/kg
o Newborn 85 ml/kg
o Up to 2y 75 ml/kg
o 2-puberty 70 ml/kg
Maintenance use the rule 4-2-1, add the deficit using the same rule from NPO
and replace it 50% in the first hr, and the rest in the nest 2 hrs
Glucose requirement for neonate 4-6 mg/kg/min
D10W 100mg/ml of glucose
Dehydration
o Based on body wt in infant 5% mild, 10% mod, 15% severe
o >15 kg 3% mild, 6% mod, 9% severe
Clinical signs
Mild mod severe
Urine anuria
Mucosa slight dry Dry parched
Fontanel N sunken marked sunken
Eye N sunken marked sunken
Gestationl diabetes Page 109 of 217
maternal/fetal M/M, risk of C/S
In addition to obstetric consideration
A Stiff joint syndrome difficult A/W
B
C hypovolemia, ANS dysfunction hypotension with R.anesthesia
D insulin
M hypoglycemia, DKA, HNKC
CNS ANS dysfunction,
R renal dysfunction
Fetus/neonate hypoglycemia, hypothermia, bili, lethargy
Lab: CBC-D, Lytes, BUN, Creat, ECG, ABG (PRN)
Pre-med GI,
Review White classification for DM its according to the severity
Guillian barre’ Syndrome Page 110 of 217
Widespread inflammatory demyelination of peripheral and ANS
It’s ascending in nature, LMN involvement ? caused by viral infection GI, flu
A full stomach, difficult intubation if TMJ involvement
B respiratory involvement
C arrhythmia, autonomic dysfunction
D NO Sux, (K), sensitivity to NDMR
GI bowel obstruction
CNS demyelination
Pre-op: PFT, ABG, CXR, ECG, CBC, Lytes
Before induction have an art-line in place, unpredictable response to intubation
and induction, consider CVP, have N. stimulator in place
Post-op: continue mech vent (ICU)
In Pt with previous disease assess for residual neuropathy, and do PFT
In pregnancy premature labor, epidural OK, avoid Spinal severe
hypotension
Head and spinal cord injury Page 111 of 217
15% of CO to the brain, with CBF of 50ml/100g/min
Pathophysiology:
TBI primary injury is due to hematoma, contusion, or DAI, the secondary is
an exacerbation of neuronal damage from change in CBF, and systemic factors
e.g. BP, hypoxia, severe PCO2, anemia, temp, Sz
Hypotension is the most important factor poor prognosis
The effect of ICP CPP, and herniation
The Autorgulation of CBF is disrupted, but PCO2 reactivity is preserved with
in magnitude, it’s very important to maintain SBP > 90
ICP maintain O2, adequate cerebral drain head up, adequate pain/sedation,
PCO2 30, mannitol .25-1g/k, hypothermia
Anesthesia goals:
o Optimize CPP, avoid ischemia, avoid drugs/tech ICP, avoid CMRO2
Exam: GCS, pupils, brainstem reflex, focal/lateralization neuro signs
Lab: CT-head, CBC, Coags, Lytes, toxicology screen
Induction: RSI, use lido, sux , inline stabilization.
Monitors: routine, art line, CVP, ICP, temp
Table 25-4. DERIVED HEMODYNAMIC VARIABLES Page 112 of 217
Name Calculation Units
CI CO/BSA l·min–1·m–2
SVR (MAP-CVP/CO) X 80 dyne-cm·s–5
PVR (MPAP-PCWP/CO) X 80 dyne-cm·s–5
Stroke index SI CI/heart rate cc·beat–1·m–2
Preload: Contractility:
Hypovolemia Ischemia
Venodilation (spinal) Valve dysfunction
Tamponade CHF
Tension Pneumothorax Drugs
R&R:
Too fast and too slow Afterload:
Arrhythmias Drugs
Anaphylaxis
Other (may affect any component): Sympathectomy
Electrolytes imbalance Hyperthermia
Acid-base sepsis
Hypoxia & hypercarbia
Hypothyroidism Page 126 of 217
Hashimoto’s thyroiditis may associated with other autoimmune disease e.g.
SLE, RA, DM, hypoparathyroidism, Addison’s disease.
May associated with amyloidosis.
A goiter altered A/W anatomy, with possible A/W obstruction
B OSA, hypoventilation, response to PCO2 and PO2, sensitivity to
narcotics, pul edema
C bradycardia, CHF, heart block, hypotension, edema
GI gastric emptying aspiration
M Na, possible SIADH, hypothermia, possible Addison’s disease
postponed if severe hypothyroid Pt until at least partially treated.
The management of hypothyroid patients with symptomatic CAD has been
a subject of particular controversy. In symptomatic patients or unstable
patients with cardiac ischemia, thyroid replacement should probably be
delayed until after coronary revascularization.
Maintain normal body temperature.
Consider adrenal insufficiency when intra-op hypotension not responding
to fluids and inotrops.
ICP: Page 127 of 217
Normal ICP < 10 mmHg, to convert to cmH2O X by 1.32
A LOC, aspiration risk
B resp failure
C arrhythmias, hemodynamic instability, MI (ECG, Echo)
D avoid sux
N ICP, LOC, risk of herniation
M DI, SIADH, cerebral salt wasting
Monitors: routine, artline, ICP, CVP
Mx: 1- hyperventilate PaCO2 25-30 good only for 6 hrs
2- diuretics mannitol 0.25- 1.0 g/kg over 10 min, Lasix 0.5-1.0 mg/kg
3- Steroids need 6-24 hrs to work
4- head elevation
5- Barbiturate
6- CSF drain
Avoid neck twisting obstruction of IJ, avoid hyperglycemia
Maintain CPP, MAP > 60, avoid PEEP if possible
IHD Page 128 of 217
Apart from atherosclerotic disease, other causes are: collagen vascular disease,
sickle cell disease, pheo, PIH, cocaine abuse
Avoid ergot, synto OK
Need continues sat and ECG monitor
Epidural is good prevent catecholamine and hyperventilation which
PCO2 coronary vasospasm
Neo is a better choice
Epidural best for C/S
Immediate Hemolytic Transfusion Reactions Page 129 of 217
Catastrophic and life threatening with mortality 20-60%
Hemolysis of the donor RBC ARF, DIC, death
Intravascular and extravascular (RES)
Antibodies anti-A,B, Kell, Kidd, Lewis, and anti-Duffy
Ag-Ab complex activate Hageman factor(XII) kinin bradykinin
capillary permeability, also complement histamine , serotonin
S/S: fever, chills, N&V, diarrhea, rigor, flushing, hypotension, tachy, chest and
abdominal pain
Under GA most of S/S are masked only hypotension, tachycardia, bleeding,
Hemoglobinuria
Management: (keep index of suspicion)
o Stop Tx, re-check blood,
o 3 main objectives:
Maintain BP volume, inotrops
Preserve renal function diuretics, alk the urine (NaHCO3)
Prevent DIC no specific therapy, maintain BP, prevent stasis
o Blood sample should be collected in EDTA tubes for re-X match, direct
coombs test ( for definitive diagnosis)
INDICATIONS FOR ONE-LUNG VENTILATION Page 130 of 217
ABSOLUTE
1. Isolation of each lung to prevent contamination of a healthy lung
a. Infection (abscess, infected cyst) b. Massive hemorrhage
2. Control of distribution of ventilation to only one lung
a. Bronchopleural fistula b. Bronchopleural cutaneous fistula
c. Unilateral cyst or bullae d. Major bronchial disruption or trauma
3. Unilateral lung lavage
4. Video-assisted thoracoscopic surgery
RELATIVE
1. Surgical exposure—high priority
a. Thoracic aortic aneurysm
b. Pneumonectomy
c. Upper lobectomy
2. Surgical exposure—low priority
a. Esophageal surgery
b. Middle and lower lobectomy
c. Thoracoscopy under general anesthesia
Infratentorial Intracranial Tumors Page 131 of 217
Those tumors produce a mass effect on the brain stem, and ICP by obst hydro
A CN involvement + LOC unprotected A/W RSI
B Resp depression
C brady, HTN, arrhythmias ST-changes , prolonged QT
CNS ICP, LOC
Position sitting risk of VAE , CV instability in elderly, risk SC compression
Prone see other card
Monitors as Supratentorial tumors
Induction also the same
Post-op:
o need for continuous CV monitoring 24-48 hrs
o HTN is a common problem post-op, need to treated aggressively other
wise intracranial bleeding and edema
o Manipulation of CN IX, X, XII loss pharyngeal sensation may need
to keep intubated
ITP Page 132 of 217
More common in young female, characterize by thrombocytopenia with
petechiae, where major cause of mortality is intracranial bleed
The main ttt is steroid, if not working splenectomy
Consider DDx: TTP, drug induced thrombocytopenia, Connective T disease,
HIV, other in preg PIH, DIC, essential thrombocytopenia
The main issues with Anesthesia Are
o A avoid traumatize the airway
o Avoid Regional
o Risk of bleeding PLT Tx
In Preg antibodies cress the placenta affect the fetus CNS bleed C/S
TTP
It’s: thrombocytopenia, fever, renal dysfunction, hemolysis, CNS involvement
Sz, and jaundice
ttt Tx plasma, plasmaphoresis, IVIG, steroids
also the same issues as ITP regarding anesthesia
Kidney Tx Page 133 of 217
Of course for CRF
A RSI for possible gastroparesis
B pul edema if volume overloaded
C hyper/hypovolemia, pericardial effusion, pericarditis, arrhythmias
D altered drugs pharmacokinetics
G Gastroparesis
M K, secondary hyperparathyroidism with Ca and phos
Heme PLT dysfunction secondary to uremia
Lab CBC-D, CXR, ECG, Lytes, BUN, creat, X-match
monitorsCAS, Art-line, foley, CVP
Goals maximize the renal perfusion at the time of graft reperfusion by
maintaining a high BP, intravascular volume, and diuresis with lasix, and
mannitol
Possible problem Bleeding
Post-op pain epidural, PCA
Lower Ext nerve inury: Page 134 of 217
Lumbosacral trunk:
Foot drop, with loss of ankle dorsiflexion
L5 dermatome loss of sensation lateral leg
In obstetric with prolonged labor and difficult vaginal delivery
Obturator:
Weakness of hip adduction and internal rotation
Peroneal N
With prolonged lithotomy position
At the knee level (injury) foot drop, with no sensory deficit
Femoral N:
Due to pelvic Sx, prolonged hip flexion, abduction, external rotation during
the 2nd stage of labor, as well as lithotomy position
Walking OK, but unable to claim stairs, with loss of the patellar reflex
Meralgia paresthetica(Lateral femoral cutaneous nerve)
tingling, numbness, burning sensation over the lateral thigh
resolve spontaneous after giving birth
Ludwig's Angina Page 135 of 217
An emergency and life threatening situation
generalized septic cellulitis of the submandibular region
occurs after dental extraction, especially of the second or third mandibular molars
it’s bilateral, involves 3 fascial spaces: submandibular, submental, and sublingual
Early S/S: chills, fever, drooling of saliva, inability to open the mouth, and
difficulty in speaking.
hemolytic streptococci, aerobic and anaerobic, including gas-forming bacteria
The infectious process may spread into the thorax, causing empyema, pericarditis,
pericardial effusion, and pulmonary infiltrates, Pneumothorax, necrotizing fasciitis
Review the CT/MRI, CXR for Pneumothorax
A difficult, difficult A/W
B hypoxia, pneumonia, effusion, empyema
C dehydration, pericardial effusion, pericarditis
Have the ENT surgeon in the room, scrubbed, and the neck is prepped, and the
difficult airway cart in the room, consider a reinforced and small size ETT
Awake FOI, give glycopyrolate, other option is inhalation induction
Post-op keep intubated to ICU until swelling subsided
Lung volumes and Page 136 of 217
capacities
Page 137 of 217
TABLE 30–7. Underestimation of Left Ventricular End-Diastolic Pressure
SITE OF
CONDITION CAUSE OF DISCREPANCY
DISCREPANCY
7 main types with progressive and variable rate in losing of muscle function.
Duchenne’s muscular dystrophy
The most common, and the most severe form.
Due to lack of protein Dystrophin.
Painless degeneration of the skeletal muscle.
X-linked trait (boys)
S/S 2-5 yrs old.
In the wheelchair by age of 12.
The affected muscle may become enlarged, due to fatty infiltration.
Death by 15-25.
Secondary to CHF and pneumonia.
Serum CK reflect the progression of the disease, with 30-300 folds above
normal, later with complete degeneration the level well .
Smooth muscle involvement GI hypomotility and gastroparesis.
CVS
o myocardial degeneration loss of R-wave in the lateral leads
o contractility dilated cardiomyopathy, and arrhythmias
MVP: Page 155 of 217
More common in young female than in male
May associated with other disease e.g. marfan syndrome, connective tissue
disease.
Risk of endocarditis, stroke, arrhythmias, sudden death
If associated with MR or CHF, Pt could be on ACEI, -blockers, Diuretics,
antiarrhythmics, anticoagulants
P/E late systolic click, if MR late systolic murmur
A N/A unless associated with other disease
B if CHF plu edema, ? scoliosis restrictive lung defect
C CHF, Arrhythmias, Endocarditis prophylaxis
D avoid histamine releasing drugs, and ketamine
CNS Stroke, anxious Pt may benefit from pre-op meds
Hemodynamic goals
Preload maintain
Contractility avoid
R & R sinus, little fast
Afterload avoid , better
Myasthenia Gravis Page 156 of 217
Osserman and Genkins classification:
• Class I—ocular symptoms only
• Class IA—ocular S’s with EMG evidence of peripheral muscle involvement
• Class IIA—mild generalized symptoms
• Class IIB—more severe and rapidly progressive symptoms
• Class III—acute, presenting in weeks to months with severe bulbar symptoms
• Class IV—late in the course of the disease with severe bulbar symptoms and marked
generalized weakness
autoimmune disease with anti-acetylcholine receptor antibodies, F>M
Abnormal thymus glands 75% of pts(85% show hyperplasia; 15% thymoma).
75% of pts either go into remission or are improved post-op
Medical ttt: anticholinesterase, steroids, other immunosuppressant (azathioprine,
cyclophosphamide, cyclosporine)and plasmapheresis.
underdosage ―myasthenic crisis‖ whereas overdosage will produce a
―cholinergic crisis.‖ Excessive doses of cholinesterase inhibitors produce
abdominal cramping, vomiting, diarrhea, salivation, bradycardia, and skeletal
muscle weakness that mimics the weakness of myasthenia , to differentiate
Myasthenic Syndrome (Lambert-Eaton Syndrome) Page 157 of 217
Associated with small cell ca of the lung
IgG antibodies against Ca channel in the presynaptic membrane Ach
release in response to nerve stimulator
M>F, age 50-70
Mainly proximal muscle weakness
A
B rarely respiratory failure
C autonomic dysfunction orthostatic hypotension
D sensitive to both Sux and NDMR, Pt could be on diaminopyridine Sz
Keep high index of suspicion in a Pt with Lung Ca
Consider Art-line
Page 158 of 217
NALS Page 159 of 217
Exam table goes trend for drainage and reverse trend to PO2
Avoid hypothermia VO2 metabolic acidosis
Assess for choanal atersia usually cyanotic and resp depression at rest, pink
when crying
If Apgar score < 8 with not resp depression give O2 by ―blow by‖
So If not breathing or cyanotic suction the A/W, warmth, dry, tactile
stimulation by rubbing the back, flicking the soles of the foot, give O2 not
breathing or HR < 100 PPV with initial P 30-40 cmH2O for 4-5 sec to open
the alveoli, the vent @ rate 40-60 min if HR > 100, and Pink ongoing care, if
HR < 60 PPV and start Chest compression for 30 sec if still HR < 60 five
Epi ….. Bicarb………..
For vent I:E = 1:1, @ 40-60 min, after the 1st breath the P 20-30 cm H2O
For chest compression to vent 3:1 1,5:0.5 sec 90:30 pre minute
Chest compression using two thumbs just below a line drown between two
nipples to compress the AP diameter by 1/3 to ½
Intubation can be considered at any time
If Vent without ETT for > 2-3 min decompress the stomach
Necrotizing fasciitis Page 160 of 217
Emergency and life threatening with high mortality rate
Possible underlying disease: DM, alcoholism, malnutrition, renal and CV
diseases
Septic shock, possible under resuscitated
A full stomach RSI
B ARDS, respiratory failure, pul edema
C septic shock with SVR, CO
M lactic acidosis, lytes abnormalities
R ARF
CNS LOC
Lab and Mx as septic shock
Post-op ICU
Neonatal Considerations: Page 161 of 217
In addition to the pediatrics considerations
Metabolic risk of hypoglycemia S/S: apnea, convulsion
Glucose infusion @ 4-8 mg/kg/min
hyperglycemia cerebral hemorrhage, glucosuria H2O and
lytes depletion
Physiological jaundice alter drugs pharmacokinetics, and free
bili kernicterus, which by hypoxia, acidosis, hypothermia
Renal Na loss, immature renal function
CNS fragile cerebral vessels risk of IVH by hypoxia, hypercarbia,
Na, fluctuation in BP, low Hb, rapid administration od NHCO3
Eye ROP maintain O2 sat 90-95% or PO2 50-70
Peri-op nerve injury: Page 162 of 217
History:
Symptoms: pain, paresthesia, motor weakness, where, when did it start
Presence of risk factors or conditions that may have neuropathy as a
symptoms: DM, Obesity, R Arthritis, PVD, smoking, alcohol,
Drugs that may cause neuropathies chemo, anti-virals
Review anesthetic records, OR note for documentation of padding, position
A block done or not if yes any symptom at the time of the block pain or
paresthesias with injection
If the surgical procedure done in the same side ? surgical complication
or prolonged use of a tourniquet, also BP cuff may cause injury
Exam:
V/S, complete neurological exam, and mainly examining the affected side
sensory, motor, reflex, and looking for any pressure demarcation
Also assess for nerve or dermatomal distribution
Obtain a Neurology consult for further evaluation and need for nerve
conduction study, and possible MRI
Sensory only F/U in 2wks, motor further evaluation
Neuraxial Anesthesia and anticoagulation Page 163 of 217
IV heparin e.g. vascular Sx delay IV heparin 1hr post catheter
placement, and catheter removal 2-4 hr after the last dose or one hr before
the next dose
S.C heparin also delay catheter placement 2-4 hrs, or delay the heparin 1 hr
post catheter placement
LMWH: needle placement 10-12hrs after the last dose of LMWH, if Pt
receiving a higher dose 1mg/kg delay 24hr
Post-op 1st dose of LMWH delay 24 hr, and may keep the catheter until
next AM, give LMWH 2hrs later
Anti-PLT: plavix ?? no data, but better at least 10 days before needle
placement, NSAID are OK
Pt on oral med (Warfarin) stop 5 days per-op INR= 1.4 is OK
Neurofibromatosis Page 164 of 217
AD, café-au-lait spots >6, with > 1.5 in diameter, with CNS vascular and
skin involvement, and short stature
Could be a part of MEN IIB
A difficult intubation, due to laryngeal or tracheal compression
B restrictive lung defect, interstitial lung disease, possible mediastinal mass
C HTN due to renovascular, Pheo, coarctation, Wilm’s tumor
CNS Astrocytoma, meningioma (ICP), spinal cord tumor, Sz disorder
M diffuse endocrine disorder as well as carcinoid tumor
MSK Kyphoscoliosis
Regional Anesthesia could be difficult, Avoid if there is spinal cord
tumor
Lab CBC, Lytes, BUN, creat, ECG, Echo, CXR, PFT with F/V loop
Neuroleptic Malignant Syndrome (NMS) Page 165 of 217
S/S include fever, rhabdomyolysis, tachycardia, hypertension, agitation, muscle
rigidity, and acidosis, mental changes, and stupor, hypoxia, acidosis, CK, and
myoglobinuria
The mortality rate is unknown, but may be as high as 20%. Dantrolene is an
effective therapeutic modality in many cases of NMS.
there are significant differences between the two. MH is acute, whereas NMS
often occurs after longer term drug exposure.
Phenothiazines and haloperidol or any of the newer potent antipsychotic agents
alone or in combination are usually triggering agents for NMS
Sudden withdrawal of drugs used for Parkinson's disease may also trigger NMS
(ECT) with Sux does not appear to trigger the syndrome.
does not seem to be inherited, .
possible due to dopamine depletion in the CNS by psychoactive agents.
bromocriptine, a dopamine agonist, is often useful in treatment of NMS
with dehydration, rapid titration of triggering drugs, and psychomotor agitation
Other DDx: CNS diseases meningitis, tumor,
Non-obstetrical surgery during pregnancy Page 166 of 217
Obstetric consideration
Risk of abortion and premature labor
Minimize the amount of drugs as much as possible
Use only the drugs that are known to be safe(STP, Sux, NDMR, Opioids,
Ketamine, Etomidate)
If urgent Sx consider delay to the 2nd trimester
Have an obstetric consultation
For GA < 16 wks have FHM pre, and post op, for >16 wks have it intra-op
for abdominal procedure consider a transvagainal monitor
FHR variability present @25-27 wks
Maintain normal maternal BP, Oxygenation, acid-base status, avoid
aortocaval compression
For pelvic and lower limb and upper limb consider regional technique
For laparoscopic procedures max peritoneal inflation pressure 8-12 mm Hg
For spinal or epidural give a fluid bolus before
Always give reflux prophylaxis, and do RSI, with maintaining LUD
Obesity Page 167 of 217
A difficult intubation
B OSA, pickwickian syndrome, restrictive defect, with FRC and Pul HTN
C HTN, CAD, pul HTN with cor-pulmonale, RV and LV dysfunction
GI GERD, gastric acidity, fatty liver with liver dysfunction
M DM
D calculate the drug dosage according to the lean body mass
H/P evidence of OSA, and RV/LV dysfunction snoring, orhtopnea,
PND, EXAM RV/LV failure
LAB CBC-D, Lytes, BUN, Creat, ABG, PFT, ECG,LFT, and consider
Echo
Difficult IV access, and regional anesthesia
Obstetric considerations: Page 168 of 217
Physiological and anatomical changes
A difficult A/W, Full stomach, ,RSI
B easy desat FRC, VO2
C hyperdynamic state, Aortocaval compression BP, UP blood flow
D MAC, cholinesterase, albumin Free F of drugs, placental drug
transfer
GI/Hepatic full stomach, gastric empting, liver enzyme
Omphalocele and Gastroschisis Page 169 of 217
o Impaired blood supply to the herniated organs, and intestinal obstruction
o Major intravascular fluid shift and dehydration full-strength balanced salt
solution
o Hypothermia and hypoglycemia
A possible difficult airway Beckwith-Wiedemann syndrome consists of
mental retardation, hypoglycemia, congenital heart disease, a large tongue, and
an omphalocele.
B respiratory failure
C CHD in 20% of infants with omphalocele.
Induction: NG aspirate gastric content then RSI , need large IV , possible
central, and arterial line
Post-op keep intubated
M intravascular volume, with lytes abnormality
Organophosphate poisoning Page 170 of 217
Bind to acetylcholinestrase enzyme
S/S: Nicotinic: muscle weakness, fasciculation
Muscarinic: DUMBELS syndrome
D diaphoresis, diarrhea
U urination
M miosis
B bradycardia, bronchorrhea, bronchospasm
E Emisis
L lacremation
S salivation
A salivation, aspiration
B Respiratory failure, , bronchorrhea, bronchospasm
C hypotension, bradycardia, shock, arrhythmias, QT(poor prognosis)
D Avoid aminoglycosids ABx
M lytes abnormalities, acidosis, dehydration
GI N&V, diarrhea
Osteogenesis Imperfecta: Page 171 of 217
A connective tissue disorder with 4 subtypes
Multiple #, short stature, blue sclera
A deformity of the base of the skull, vertebral # Awake FOI
B kyphoscoliosis restrictive lung defect
C Cor-pulmonale
Heme impaired PLT function
Other hemolytic anemia’s: Page 172 of 217
Spherocytosis:
Membrane defect abnormal shape RBC hemolysis
May have a hemolytic crisis which can triggered by infection and folate
deficiency
May come for splenectomy
G6PD Deficiency:
RBC enzyme defect
Can have a hemolytic crisis if exposed to some food and drugs: Fava beans,
PNC, Tyhlenol, antimalarial drugs, methylene blue, ASA in large dose
Usually happened 2-5 day after ingestion
May have DIC
Oxygen Delivery and Oxygen Consumption Page 173 of 217
Oxygen Delivery.
Oxygen delivery is a function of arterial oxygen content (Cao2) and cardiac output.
Cao2 is expressed as the number of milliliters of oxygen contained in 100 ml of
blood and is calculated as follows:
Cao2 = (Hgb × 1.34 × Sao2) + (0.003 × Pao2)
DO2 = CO × Cao2
Oxygen Consumption.
O2 consumption = CO x (CaO2-CvO2)
A: flexion contracture difficult airway due to limited mouth opening, motility, LOS
tone GERD need RSI
B: A major cause of M&M, Chronic aspiration, Diffuse lung fibrosis restrictive lung
disease, diffusion capacity
C: risk of IHD, fibrosis of the conductive system arrhythmia, cardiomyopathy CHF,
systemic and pulmonary HTN, pericarditis effusion tamponade, with systemic HTN
intravascular volume hypotension , Raynaud’s phenomenon in 70% risk of ischemia
with art-line
CNS: peripheral and cranial nerve neuropathy
o Eye: conjunctivitis and corneal abrasion
Scoliosis Sx Page 203 of 217
Need two stage Sx, 1st anterior approach to release the anterior spinal artery, and
diskectomy, the 2nd stage to posterior instrumentation
The scoliosis could be secondary to muscular disease ( muscular dystrophy)
A Reflux RSI
B Restrictive lung disease, risk of PPC (pneumonia, atelectasis)
C myopathy, arrhythmias
D avoid Sux
Heme consider autologus blood donation pre-op
Consult (ICU, Heme), talk to the Pt regarding awake test
Lab:CBC-D, Lytes, BUN, creat, X-match, CXR, PFT, ABG, ECG, Echo if needed
OR: blood in the OR, bear hugger, Art-line, IV wormer
Position: prone check all pressure points, and frequent checking
May consider deliberate hypotension if there is no C/I, with that HR will , so
consider -blockers
SSEP: if latency by 10% or amp by 60% BP, ask the surgeon to stop
Volatiles have the least effect on SSEP See SSEP card
Post-op: pain, PPC, ICU
SEP Page 204 of 217
Any injury will cause in latency & amplitude
SSEP 50% in amp to surgical maneuver significant
Cortical ( SSEP, VEP) are more vulnerable to anesthetic drug effect
brain stem/subcortical (SSEP, BAEP) are more resistance
key points:
maintain a constant anesthetic level, and avoid any sudden changes
or a bolus doses of any drugs
maintain and control other factors that may affect the SEP like
temp, BP, PaO2 and PaCO2
Effect of inhalational agents:
SSEP all lat/amp, except enf /, N2O 0/
VEP all lat/ amp
BAEP alt/0 amp
Effect of IV drugs:
All drugs lat/ amp except ketamine and etomidate /, with 0/
effect on the VEP and no effect on BAEP at regular doses
Septic shock: Page 205 of 217
A LOC, full stomach
B resp failure, ARDS, pul edema
C low or high output failure, SVR,
D Abx, APC, steroids, inotrops, vasopressors
Met lactic acidosis, base deficit, K, lytes disturbance, adrenal insufficiency
Renal ATN, ARF
Heme thrombocytopenia, DIC
Management:
ABC
ECG, Sat, Art-line, CVP/PAC, frequent ABG,
Lab: CXR, ABG, ECG, CBC-D, Blood C/S, sputum, and urine, lytes, BUN,
creat, LFT, PT, PTT, Fibrinogen, D-dimer, ACTH stim test, if suspecting a
source of infection do further investigation e.g. TEE or TTE for ? edocarditis,
abdominal CT…..
Early goal directed therapy( CVP 8-12, MAP >65, Urine>0.5ml/kg/hr,
SvO2>70%)
Broad spectrum ABx
Class I Class II Class III Class IVPage 206 of 217
Blood loss (ml) 750 750–1500 1500–2000 2000
Blood loss (%) 15 15–30 30–40 40
HR (per min) <100 >100 >120 140
Blood pressure Normal Normal
Pulse pressure Normal or
RR 14–20 20–30 30–40 <35
Urine ml/hr 30 20–30 5–15 Negligible
Mental status Slightly Mildly Anxious and Confused,
anxious anxious confused lethargic
Fluid (3:1 rule)‡ Crystalloid Crystalloid Crystalloid + Crystalloid +
blood blood
Shoulder Sx: Page 207 of 217
Arthroplasy, and arthroscopy, and rotator cuff repair
Use of a beach chair position VAE risk
Limited access to the airway tighten the connection, reinforce with tap
Possible eye and ears injury
Avoid excessive head rotation brachial plexus injury
Options GA, interscalene or combined
Assess the arm before doing the block for any neurological deficit
Risk of post-op neurological deficit the level of the injury is at the level
of the trunk (same as interscalene) difficult to determine the cause (surgical
Vs block) Neurapraxia 90% resolve within 3-4 months
Inappropriate Secretion of Antidiuretic Hormone (SIADH) Page 208 of 217
Causes: head injuries,intracranial tumors, pulmonary infections, small cell
carcinoma of the lung and hypothyroidism.
Clinical manifestations
occur as a result of a dilutional hyponatremia, serum osmolality, and a reduced
urine output with a high osmolality. Weight gain, skeletal muscle weakness, and
mental confusion or convulsions are presenting symptoms. Peripheral edema
and hypertension are rare. The diagnosis of the (SIADH) is one of exclusion,
and other causes of hyponatremia must first be ruled out. The prognosis is
related to the underlying cause of the syndrome.
Treatment:
Pt with mild/mod H2O intoxication is restriction of fluid intake to 800 ml·day–
1
.
Pt with severe water intoxication associated with hyponatremia and mental
confusion may require more aggressive therapy, with the iv administration of a
hypertonic saline solution. This may be administered in conjunction with lasix
Caution must be observed in patients with poor LV function. Isotonic saline is
substituted for hypertonic solutions once the serum Na is in a safe range.
Sickle cell anemia Page 209 of 217
The defect in -chain, position 6 glutamic acid substituted by valine
3 types of crisis
o hemolytic further anemia
o sickling pain & vaso-occlusive
o Aplastic may cause death.
Ethnic background: Mediterranean and African-American.
In infancy Hb F is protective.
% of Hb S
o trait (mild)
o < 50% is Hb S
o sickling do not occur under normal physiological conditions
o may happen under extreme conditions e.g severe hypoxemia.
o Disease (severe)
o Hb S > 75% may up to 95%
o Could be associated with other abnormal Hb e.g Hb C
o Pt with Hb SC have a normal Hb level, but at a greater risk of sickling.
Pre-op you need to knew what is the result of the Hb electrophoresis.
mortality with in the number of the painful crisis in adult per-year.
Status asthmaticus Page 210 of 217
Emergency and life threatening
Result in respiratory failure with hypoxia, hypercarbia, and
respiratory/metabolic acidosis
Management:
o ABC, 100% O2
o Intubate deep/ also may consider BiPAP
o Ventoline, ipratrupium bromide, steroids, thiophylline, leukotrine
inhibitor, ABx if suspect infection
o Other consider Ventoline IV, Isoprel/pei gtt, Ketamine, BNZ
o Last volatile agent, and paralyze
o Ventilation: volume control Vt 6-10ml/kg, PEEP 5-10, target
normal PO2, pH, and PCO2, keep the platue pressure < 30cmH2O
o If need switch to pressure control
o Also may consider Heliox
o Be aware of AutoPEEP disconnect the bag, if on vent reverse
ratio ventilation
Stroke & TIA: Page 211 of 217
Hemorrhagic or ischemic
Etiology: Atherosclerosis, embolic MI, A.fib, VHD, post-op CEA,
trauma, severe HTN
A LOC, loss of A/W reflux (RSI)
B hypoventilation
C HTN, CAD, VHD, A.fib, arrhythmias ECG, Echo
D anti-PLT, ASA, coumadin, Avoid Sux, N. stimulator resistance
N LOC, neuro deficit
Peri-op
Avoid swinging in BP, and hyperglycemia
With chronic HTN the cerebral autoregulation curve shifted to the Rt
Supratentorial Intracranial Tumors Page 212 of 217
Review Pt overall medical condition
Focus on Neuro-evaluation: LOC, S/S of ICP: headache, N&V, papilledema,
unilateral pupil dilation, and the presence and extent of focal neurological deficit
May have fluid and lytes abnormality
Review CT/MRI head
Lab: CBC, lytes, BUN, creat, ECG
The main effect of Supratentorial masses is intracranial HTN
The main anesthetic goal is to maximize the therapeutic modality to ICP, and to
avoid any factor that may ICP
ICP control SEE ICP card
Monitoring: Standard + Art line, CVP, Foley cath, for the art-line have the
transducer at the level of external auditory meatus ( level of circle of Willis)
Induction: may need RSI, if CN involvement or LOC, give Lidocaine IV, with
other standard induction drugs, Avoid Sux
Maintenance: Isoflurane, No N2O
Emergence: give Lidocaine IV 90 sec before extubation, and consider using
antihypertensive Meds(labetolol), assess for any neurological deficit
Systemic Lupus Erythematosus Page 213 of 217
A cricoarytenoid arthritis hoarseness, stridor, or airway obstruction (awake
intubation), post-extubation edema
B effusion, pneumonitis, pul HTN, and alveolar hemorrhage. high correlation
of pul HTN with Raynaud's phenomenon in patients with SLE.(CXR, PFT)
C pericardial effusion, tamponade, Cardiomyopathy, cardiac conduction
abnormalities, ventricular function, and coronary arteritis, noninfectious
endocarditis (Libman-Sacks endocarditis) mitral insufficiency (ECG, ECHO)
D immunosuppressants (corticosteroids) or cytotoxic drugs
(cyclophosphamide, azathioprine, cyclosporine),avoid Drug-induced lupus
quinidine, hydralazine, methyldopa, captopril, enalapril, clonidine, isoniazid,
Hanti-phospholipid antibodies thromboembolic complications, anemia
R common cause of M&M in patients with SLE, CRF
CNS seizures, stroke, dementia, psychosis, and peripheral neuropathy
GI peritonitis, pancreatitis, bowel ischemia, protein-losing enteropathy, and
lupoid hepatitis
Tamponade: Page 214 of 217
Emergency and life threatening
In acute as little as 200 ml cause S/S
In chronic up to 1000 ml cause S/S
Causes:
o Infection: bacterial, viral, fungal, TB
o Inflammatory disease with vasculitis: R.Arthritis, SLE, scleroderma
o Metabolic: RF, myxedema
o Radiation, malignancy, trauma, post-heart
Pathophysiology: VEDV, SV, CO, SBP, CVP, Rt=Lt pressure
Dx by keeping in mind a high index of suspicion with clinical S/S and lab
Beck’s triad: hypotension, distended neck veins, muffled heart sound
S/S: tachypnea, BP, narrow pulse pressure, HR, pulses paradoxus
Signs of systemic hypoprefusion: oliguria, lactic acidosis, cool extr
DDx: tension Pneumo, RV infarction, Pul HTN, cardiac herniation
ECG: diffuse ST-changes, low voltage
Lab: ECG, Echo, CXR, CT
TCA overdose: Page 215 of 217
Gives anticholinergic syndrome, So no Atropine
Cardiac toxicity is the major cause of death
No correlation between serum level and symptom
A LOC RSI
B depression, ARDS
C toxicity, QT, wide QRS, sinus tach, heart block, hypotension due
contractility, and vasodilation by -blockade, arrest
CNS hallucination, coma, seizure
M metabolic acidosis
Management:
o ABC
o Gastric lavage
o Activated charcoal 1g/kg with 60 ml sorbitol
o Bicarb is the Key in the management 2 mEq/kg bolus then infusion
150mEq in 850 D5W to maintain pH 7.45-7.50
o For Vent arrhythmia give Lidocaine, Class 1A,1C are C/I
o Hypotension Norepi gtt
o Bradycardia Isoprel or pacing No Atropine
TEF Page 216 of 217
30% premature, associated CHD, and VATER, VACTREL syndromes
Depend on the infant stability if stable complete repair, if not stage repair, with
insertion of G-tube under LA, the ligation of the fistula, and reanastomosis of the
esophagus
A subglottic stenosis
B resp distress, RDS, pneumonia
C CHD, decompensation and CHF
M dehydration, metabolic acidosis
Worm up the room, big IV, standard CAS monitors, Art-line
Lab CBC-D, lytes, ABG, Cap gas or VBG, CXR, Echo, X-match with 2U peds
in the room
Give atropine, not muscle relaxant until chest open,
Inhalation induction bronch, then intubate after further mask ventilation to
deepen the Pt, have different size ETT, after intubation with the bevel directed
posteriorly, listen to the chest and initially intubate the Rt main bronchus, with
listening to the chest withdraw the tube slowly till you here bilateral breath sound.
Consider caudal epidural for post-op pain
Run maintenance fluids with glucose maintenance as well
Page 217 of 217