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OPENANESTHESIA
COVID-19 Resources. An otherwise healthy 45-year-old woman is seen at an ambulatory surgical center for release of Dupuytren's contracture. A brachial plexus block is performed using the axillary approach. Assuming that no other nerve blocks are performed, and that the axillary block successfully achieves a complete motor and sensoryblock in
PACEMAKERS/AICDS
NMBS: ED95 DEFINITION Definition. According to Miller, potency of a NMBD is best described as the effective dose – “The dose of a neuromuscular blocking drug required to produce an effect (e.g., 50%, 90%, or 95% depression of twitch height, commonly expressed as ED50, ED90, and ED95, respectively“. Thus, the ED95 is the amount of NMBD required toreduce twitch
MAXIMUM ABL CALCULATION Also, what is the allowable blood loss (ABL) of this patient if her Hct is 45? In the example above, EBV = 50kg x 65 (adult woman’s blood volume) = 3250 The initial Hct (Hi) = 45%, her current Hct The final lowest acceptable Hct (Hf) = 30% (What ever cut off is used clinically to decide how low the individual’s Hct will be allowed todrop.
THYROIDECTOMY: COMPLICATIONS Thyroidectomy Complications. Hypocalcemia (3-5%): most common cause of airway obstruction after 24 hours. Hematoma (1-2%): most common cause of airway obstruction within 24 hours. Recurrent laryngeal nerve injury (0.77%): usually causes unilateral damage, stridor, hoarseness. Wound infection (0.2-0.5%) HYPERMAGNESEMIA TREATMENT Hypermagnesemia requires close monitoring of the ECG, blood pressure, and neuromuscular function. Potentiation of the vasodilating and negative inotropic properties of anesthetics should be expected. Dosages of NMBAs should be reduced by 25–50%. A urinary catheter is required when diuretic and saline infusions are used to enhancemagnesium
DELAYED EMERGENCE: DIFFERENTIAL DIAGNOSIS Differential diagnosis of delayed emergence can be classified into one of three causes: drug effects, metabolic disorders, or neurologic disorders.If a patient doesn’t “wake” after an anesthetic you have to go down these three in that particular order. PHASE II DEPOLARIZING BLOCKADE The possibility of a phase II block should be suspected if succinylcholine is given as an infusion or if tachyphylaxis is noted with repeated doses. With regard to nerve stimulation, a phase II block has features of a non-depolarizing block (i.e., fade is seen with tetanic and train-of-four stimulation; there is post-tetanicpotentiation).
MULTIPLE SCLEROSIS: PERIOP MGMT Multiple Sclerosis is an autoimmune disease of inflammation, demyelination, and axonal damage to the central nervous system (Pasternak, 2008; Dorotta, 2002). The disease progression may be subacute with relapses and remissions or chronic and progressive. Treatments include corticosteroids, Interferon-beta, glatiramer acetate, azathioprine, and MANAGEMENT OF BRADYCARDIA IN THE OR Management of Bradycardia in the OR1. Bradycardia can be defined as a heart rate 35mmHg. Mean PA pressure > 25mmHg at rest. Mean PA pressure > 30mmHg during exercise. According to the 2009 Fourth World Symposium on Pulmonary Hypertension, the exercise criteria should be abandoned and only a mean PA of > 25 mmHg at restOPENANESTHESIA
COVID-19 Resources. An otherwise healthy 45-year-old woman is seen at an ambulatory surgical center for release of Dupuytren's contracture. A brachial plexus block is performed using the axillary approach. Assuming that no other nerve blocks are performed, and that the axillary block successfully achieves a complete motor and sensoryblock in
AORTIC STENOSIS
CARCINOID SYNDROME
Definition. Carcinoid tumors typically secrete excessive amounts of the hormone serotonin (although they may secrete many hormones). They arise from neuroendocrine cells throughout the body. Most commonly from organs derived from the primitive gut (90% come from distal ileum or appendix). Serotonin causes vasodilation, increased blood clotting MYOTONIC DYSTROPHY, INTRAOP MGT Myotonic dystrophy (dystrophia myotonica, DM) is a muscular disorder characterized by prolonged contraction and muscle relaxation, progressive muscle weakness, and wasting. Intraoperative management should aim to avoid triggering myotonia and should take into account that DM patients are at increased risk for the following: Metabolic POST SPINAL BACK ACHE Definition. Occurring in approximately 13% of those receiving a spinal anesthetic, a post spinal backache is postulated to occur secondary to a localized inflammatory response, often associated with a degree of muscle spasm. The backache is usually self-limited, lasting from a fewdays up to a week.
CARDIAC TAMPONADE: ANESTH MANAGEMENT Cardiac tamponade: Anesth management. In general terms, most patients presenting for a subxiphoid pericardial window should undergo the procedure under local anesthesia with spontaneous ventilation and as little sedation as possible. If local anesthesia cannot be performed (or if tamponde occurs during a general anesthetic), the following HYPERTROPHIC MYOCARDIAL DISEASE (CARDIAC ANESTHESIA)SEE MORE ONOPENANESTHESIA.ORG
DELAYED EMERGENCE: DIFFERENTIAL DIAGNOSIS Differential diagnosis of delayed emergence can be classified into one of three causes: drug effects, metabolic disorders, or neurologic disorders.If a patient doesn’t “wake” after an anesthetic you have to go down these three in that particular order. MULTIPLE SCLEROSIS: PERIOP MGMT Multiple Sclerosis is an autoimmune disease of inflammation, demyelination, and axonal damage to the central nervous system (Pasternak, 2008; Dorotta, 2002). The disease progression may be subacute with relapses and remissions or chronic and progressive. Treatments include corticosteroids, Interferon-beta, glatiramer acetate, azathioprine, and PULMONARY HYPERTENSION: DX Pulmonary artery hypertension is defined as having at least ONE of the following: PA systolic pressure > 35mmHg. Mean PA pressure > 25mmHg at rest. Mean PA pressure > 30mmHg during exercise. According to the 2009 Fourth World Symposium on Pulmonary Hypertension, the exercise criteria should be abandoned and only a mean PA of > 25 mmHg at restPACEMAKERS/AICDS
When thinking about pacemakers, it is useful to think of them in terms of what can go wrong. There are really only three disadvantageous events that can happen to a pacemaker during surgery – 1) the pacemaker can be destroyed 2) the pacemaker/AICD can fire when it shouldn’t 3) the pacemaker/AICD can fail to fire when it should. MAXIMUM ABL CALCULATION Also, what is the allowable blood loss (ABL) of this patient if her Hct is 45? In the example above, EBV = 50kg x 65 (adult woman’s blood volume) = 3250 The initial Hct (Hi) = 45%, her current Hct The final lowest acceptable Hct (Hf) = 30% (What ever cut off is used clinically to decide how low the individual’s Hct will be allowed todrop.
PEDIATRIC ANESTHESIA (ANESTHESIA TEXT) Pediatric Airway. The tongue is relatively larger, thus making a disproportionate contribution to airway obstruction and moving the glottis anteriorly (especially in children with craniofacial abnormalities, NMJ or CNS disease, tumors, hemangiomas, or URIs). Flexion of an infant’s head may collapse the airway. MYOCARDIAL INJURY/INFARCTION Early Management of Acute Myocardial Injury (MONA? ONA may be better) Chest pain can sometimes be relieved by nitroglycerin (0.4 mg SL q5m x 3), but often cannot (esp. if patient was already taking nitrates). Also, never give nitro in patients with right heart infarction or THYROIDECTOMY: COMPLICATIONS Thyroidectomy Complications. Hypocalcemia (3-5%): most common cause of airway obstruction after 24 hours. Hematoma (1-2%): most common cause of airway obstruction within 24 hours. Recurrent laryngeal nerve injury (0.77%): usually causes unilateral damage, stridor, hoarseness. Wound infection (0.2-0.5%)ABG: PULM EMBOLISM
Most commonly shows hypoxemia and hypocapnea (respiratory alkalosis) due to hyperventilation, keep in mind, however, that despite these “classic” findings, arterial blood gas analysis is NOT useful in diagnosis of pulmonary embolism.. The more massive the obstruction, the more severe the hypoxemia is likely to be, with an SpO 2 < 95% on room air being predictive for increased morbidity and DIGOXIN TOXICITY: ECG Digoxin acts as an anti-arrhythmic and inotrope through reversible inhibition of cardiac Na/K ATPase pumps. This results in increased intracellular sodium and calcium and decreased intracellularpotassium.More
DIGOXIN: TOXICITY
Digoxin belongs to a class of drugs known as cardiac glycosides that (1) improves contractility and (2) decreases conduction velocity atthe AV node.More
IV TO PO OPIOIDS
2. Calculate the total daily opioid dosage (long acting and break through) and convert to morphine equivalents (either IV or PO) using an equianalgesic dosing table. 3. Determine the new opioid analgesic to convert to and using equianalgesic dosing data (taking into consideration the limitations) convert to new opioid dose. 4. DIFFICULT MASK VENTILATION: PREDICTOR Difficult mask ventilation (DMV), defined as: “the inability of an unassisted anesthesiologist to maintain SpO2 >92%” is an uncommon but important scenario.MoreOPENANESTHESIA
COVID-19 Resources. An otherwise healthy 45-year-old woman is seen at an ambulatory surgical center for release of Dupuytren's contracture. A brachial plexus block is performed using the axillary approach. Assuming that no other nerve blocks are performed, and that the axillary block successfully achieves a complete motor and sensoryblock in
AORTIC STENOSIS
CARCINOID SYNDROME
Definition. Carcinoid tumors typically secrete excessive amounts of the hormone serotonin (although they may secrete many hormones). They arise from neuroendocrine cells throughout the body. Most commonly from organs derived from the primitive gut (90% come from distal ileum or appendix). Serotonin causes vasodilation, increased blood clotting MYOTONIC DYSTROPHY, INTRAOP MGT Myotonic dystrophy (dystrophia myotonica, DM) is a muscular disorder characterized by prolonged contraction and muscle relaxation, progressive muscle weakness, and wasting. Intraoperative management should aim to avoid triggering myotonia and should take into account that DM patients are at increased risk for the following: Metabolic POST SPINAL BACK ACHE Definition. Occurring in approximately 13% of those receiving a spinal anesthetic, a post spinal backache is postulated to occur secondary to a localized inflammatory response, often associated with a degree of muscle spasm. The backache is usually self-limited, lasting from a fewdays up to a week.
CARDIAC TAMPONADE: ANESTH MANAGEMENT Cardiac tamponade: Anesth management. In general terms, most patients presenting for a subxiphoid pericardial window should undergo the procedure under local anesthesia with spontaneous ventilation and as little sedation as possible. If local anesthesia cannot be performed (or if tamponde occurs during a general anesthetic), the following HYPERTROPHIC MYOCARDIAL DISEASE (CARDIAC ANESTHESIA)SEE MORE ONOPENANESTHESIA.ORG
DELAYED EMERGENCE: DIFFERENTIAL DIAGNOSIS Differential diagnosis of delayed emergence can be classified into one of three causes: drug effects, metabolic disorders, or neurologic disorders.If a patient doesn’t “wake” after an anesthetic you have to go down these three in that particular order. MULTIPLE SCLEROSIS: PERIOP MGMT Multiple Sclerosis is an autoimmune disease of inflammation, demyelination, and axonal damage to the central nervous system (Pasternak, 2008; Dorotta, 2002). The disease progression may be subacute with relapses and remissions or chronic and progressive. Treatments include corticosteroids, Interferon-beta, glatiramer acetate, azathioprine, and PULMONARY HYPERTENSION: DX Pulmonary artery hypertension is defined as having at least ONE of the following: PA systolic pressure > 35mmHg. Mean PA pressure > 25mmHg at rest. Mean PA pressure > 30mmHg during exercise. According to the 2009 Fourth World Symposium on Pulmonary Hypertension, the exercise criteria should be abandoned and only a mean PA of > 25 mmHg at restOPENANESTHESIA
COVID-19 Resources. An otherwise healthy 45-year-old woman is seen at an ambulatory surgical center for release of Dupuytren's contracture. A brachial plexus block is performed using the axillary approach. Assuming that no other nerve blocks are performed, and that the axillary block successfully achieves a complete motor and sensoryblock in
AORTIC STENOSIS
CARCINOID SYNDROME
Definition. Carcinoid tumors typically secrete excessive amounts of the hormone serotonin (although they may secrete many hormones). They arise from neuroendocrine cells throughout the body. Most commonly from organs derived from the primitive gut (90% come from distal ileum or appendix). Serotonin causes vasodilation, increased blood clotting MYOTONIC DYSTROPHY, INTRAOP MGT Myotonic dystrophy (dystrophia myotonica, DM) is a muscular disorder characterized by prolonged contraction and muscle relaxation, progressive muscle weakness, and wasting. Intraoperative management should aim to avoid triggering myotonia and should take into account that DM patients are at increased risk for the following: Metabolic POST SPINAL BACK ACHE Definition. Occurring in approximately 13% of those receiving a spinal anesthetic, a post spinal backache is postulated to occur secondary to a localized inflammatory response, often associated with a degree of muscle spasm. The backache is usually self-limited, lasting from a fewdays up to a week.
CARDIAC TAMPONADE: ANESTH MANAGEMENT Cardiac tamponade: Anesth management. In general terms, most patients presenting for a subxiphoid pericardial window should undergo the procedure under local anesthesia with spontaneous ventilation and as little sedation as possible. If local anesthesia cannot be performed (or if tamponde occurs during a general anesthetic), the following HYPERTROPHIC MYOCARDIAL DISEASE (CARDIAC ANESTHESIA)SEE MORE ONOPENANESTHESIA.ORG
DELAYED EMERGENCE: DIFFERENTIAL DIAGNOSIS Differential diagnosis of delayed emergence can be classified into one of three causes: drug effects, metabolic disorders, or neurologic disorders.If a patient doesn’t “wake” after an anesthetic you have to go down these three in that particular order. MULTIPLE SCLEROSIS: PERIOP MGMT Multiple Sclerosis is an autoimmune disease of inflammation, demyelination, and axonal damage to the central nervous system (Pasternak, 2008; Dorotta, 2002). The disease progression may be subacute with relapses and remissions or chronic and progressive. Treatments include corticosteroids, Interferon-beta, glatiramer acetate, azathioprine, and PULMONARY HYPERTENSION: DX Pulmonary artery hypertension is defined as having at least ONE of the following: PA systolic pressure > 35mmHg. Mean PA pressure > 25mmHg at rest. Mean PA pressure > 30mmHg during exercise. According to the 2009 Fourth World Symposium on Pulmonary Hypertension, the exercise criteria should be abandoned and only a mean PA of > 25 mmHg at restPACEMAKERS/AICDS
When thinking about pacemakers, it is useful to think of them in terms of what can go wrong. There are really only three disadvantageous events that can happen to a pacemaker during surgery – 1) the pacemaker can be destroyed 2) the pacemaker/AICD can fire when it shouldn’t 3) the pacemaker/AICD can fail to fire when it should. MAXIMUM ABL CALCULATION Also, what is the allowable blood loss (ABL) of this patient if her Hct is 45? In the example above, EBV = 50kg x 65 (adult woman’s blood volume) = 3250 The initial Hct (Hi) = 45%, her current Hct The final lowest acceptable Hct (Hf) = 30% (What ever cut off is used clinically to decide how low the individual’s Hct will be allowed todrop.
PEDIATRIC ANESTHESIA (ANESTHESIA TEXT) Pediatric Airway. The tongue is relatively larger, thus making a disproportionate contribution to airway obstruction and moving the glottis anteriorly (especially in children with craniofacial abnormalities, NMJ or CNS disease, tumors, hemangiomas, or URIs). Flexion of an infant’s head may collapse the airway. MYOCARDIAL INJURY/INFARCTION Early Management of Acute Myocardial Injury (MONA? ONA may be better) Chest pain can sometimes be relieved by nitroglycerin (0.4 mg SL q5m x 3), but often cannot (esp. if patient was already taking nitrates). Also, never give nitro in patients with right heart infarction or THYROIDECTOMY: COMPLICATIONS Thyroidectomy Complications. Hypocalcemia (3-5%): most common cause of airway obstruction after 24 hours. Hematoma (1-2%): most common cause of airway obstruction within 24 hours. Recurrent laryngeal nerve injury (0.77%): usually causes unilateral damage, stridor, hoarseness. Wound infection (0.2-0.5%)ABG: PULM EMBOLISM
Most commonly shows hypoxemia and hypocapnea (respiratory alkalosis) due to hyperventilation, keep in mind, however, that despite these “classic” findings, arterial blood gas analysis is NOT useful in diagnosis of pulmonary embolism.. The more massive the obstruction, the more severe the hypoxemia is likely to be, with an SpO 2 < 95% on room air being predictive for increased morbidity and DIGOXIN TOXICITY: ECG Digoxin acts as an anti-arrhythmic and inotrope through reversible inhibition of cardiac Na/K ATPase pumps. This results in increased intracellular sodium and calcium and decreased intracellularpotassium.More
DIGOXIN: TOXICITY
Digoxin belongs to a class of drugs known as cardiac glycosides that (1) improves contractility and (2) decreases conduction velocity atthe AV node.More
IV TO PO OPIOIDS
2. Calculate the total daily opioid dosage (long acting and break through) and convert to morphine equivalents (either IV or PO) using an equianalgesic dosing table. 3. Determine the new opioid analgesic to convert to and using equianalgesic dosing data (taking into consideration the limitations) convert to new opioid dose. 4. DIFFICULT MASK VENTILATION: PREDICTOR Difficult mask ventilation (DMV), defined as: “the inability of an unassisted anesthesiologist to maintain SpO2 >92%” is an uncommon but important scenario.More__
OPENANESTHESIA
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COVID-19 Resources
A 57-year-old woman has undergone cerebral aneurysm coil embolization under general anesthesia. She awakens but cannot move her right arm and leg and is having trouble following commands. An emergent head CT is performed. Air emboli are visible in the left middle cerebral artery territory. What is the MOST appropriate initial treatment?Air aspiration
Hyperbaric oxygen
Intravenous thrombolysis (alteplase)Heparin infusion
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DIGOXIN TOXICITY: ECG Digoxin acts as an anti-arrhythmic and inotrope through reversible inhibition of cardiac Na/K ATPase pumps. This results in increased intracellular sodium and calcium and decreased intracellularpotassium.
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THOMAS BEIN
Dr. Thomas Bein discusses his article “Invasiveness of Treatment Is Gender Dependent in Intensive Care: Results From a Retrospective Analysis of 26,711 Cases”
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E-CIGARETTE AND VAPING EPIDEMIC Dr. Debnath Chatterjee and Dr. Robin Deterding discuss the e-cigarette and vaping epidemic among adolescents in the U.S.Audio Player
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