Tables are sterile only ____
Sterile areas are continuously ____
at the table level
kept in view
What are 4 causes of laryngospasm?
-foreign substances (secretions, ETT)
-visceral pain reflex (ie tug on peritoneum)
-extubation during light anesthesia
-oral airway (controversial)
What are the primary actions (x4) to take with laryngospasm?
! What is the 1st drug after to use after these interventions?
What other drug if needed?
-Head tilt/jaw thrust, 100% O2, positive airway pressure (30cm H2O) & call for assistant
-1.5 mg/kg lidocaine
-0.15-0.30 mg/kg anectine (5mg/kg IM/SL)
What are 2 complications from laryngospasm & how to treat each? (x2 tx for each)
-Neg press. Pulm Edema: tx with FiO2 & CPAP
-Laryngeal edema: neb. rac. epi. & IV corticosteroids
What is seen on EtCO2 with bronchospasm?
upstroke rises slowly
What are the top 4 treatments for bronchospasm?
1. R/O obstruction d/t migration or kinking of ETT, secretions
2. 100% FiO2 & ventilate with sufficient expiratory time
3. Deepen anesthesia
4. Give beta agonist (albuterol)
What is the average ICU stay d/t aspiration?
pH & volume dangerous with aspiration
Why do non-acidic aspirates lead to hypoxia?
destroys surfactant & leads to alveolar collapse & atelectasis
What s/s is seen 90% of the time with intraop aspiration?
What are the 1st 4 interventions if a pt aspirates?
1. suction ASAP
2. 100% FiO2
3. CPAP/PEEP for severe insult, atelectasis, or resp. fail
4. monitor fluid & cardiovascular status
What are 5 hallmarks of pneumothorax (excluding trachea deviation)
-increased PIP (1 lung ventilation)
-hypoxemia (1 lung ventilation)
-hypotension (decreased cardiac filling)
-increased CVP (obstructed cardiac filling)
What should be used & where to decompress a tension pneumothorax?
large bore angiocath (18ga & bigger) in 2nd intercostal space midclavicular line. Leave in place until chest tube.
! What is the triad of symptoms with fat embolism?
What are the treatments for pulmonary embolus? (x3)
Support hemodynamics (treat hypoTN aggressively)
What do you need as additional setup for laser surgery to airways?
What else must be done to prevent airway fires?
PVC ETT (least flammable) & Bottle of of NS ready
FiO2 to 23%
What is the ventilation technique with laser surgery?
jet ventilation through operating laryngoscope (aim at trachea)
(can give inhalation agents also but spont. vent. only & risk for hypercarbia, hypoventilation, & aspiration)
What to do if airway fire? (x4)
-stop ventilation & remove O2 source
-flood field with saline
-mask ventilate 100% FiO2
What property of plasma esterases does dibucaine test?
effectiveness (quality) not quantity
(homozygous still have normal quantity but inadequate quality)
Explain dibucaine effect on pseudoChE (x3)
Explain how each level affects succs duration.
-normal: ↓s ChE quality by 80% (it then rises back)
-heterozygous: ↓s it by 30-70% (anectine prolonged 1+ hrs)
-homozygous: ↓s it by 20% (16-25) (anectine prolonged 6-8 hrs)
What should be done postop if patient had atypical pseudoChE?
-Tell pt they are allergic to Sux!
What should be done in the event of recurarization?
-consider narcan/romazicon if d/t oversedation
-otherwise resedate pt & give additional reversal agents in divided doses
What is the treatment for DIC? (x3)
-remove underlying cause
What is the pathophysiology of MH? (x4)
-sarcoplasmic reticulum fails to sequester Ca leading to
-sustained muscle contraction &
What is the earliest sign & most sensitive sign of MH?
(can get >100mmHg with pH 7.0)
How quickly can temp rise with MH?
1-2°C every 5 min
What blood tests will be crazy out-of-whack with MH? (x4)
How should the room be set up for known hx of MH? (x4)
-change soda lime
-flush machine for 10 min with flush valve
What is the anesthetic plan for known hx of MH?
-preop meds ok (versed, fentanyl, etc.)
-epidural if possible
-GETA with dantrolene pretreatment
-use non triggering agents
-watch EtCO2 & temp closely
Dantrolene acts on the ____ receptor of skeletal muscle.
What does it do?
decreases Ca release from the SR
What is the dose of dantrolene for MH?
2.5 mg/kg (initial dose)
max of 20mg/kg
How is each vial of dantrolene mixed?
with 20 mL sterile H₂O
How is the best to cool the pt with MH?
gastric lavage (stop at 38 C or overshoot & shivering)
What are the interventions for MH? (x5)
2. Cool patient down
3. Lidocaine/Procainamide for PVCs
4. Na Bicarb 1-2 moles/kg
5. Treat HyperK
What is the most immediate intervention for hyperkalemic cardiac arrest?
What can help shift K into the cells? (x4)
What else can be done?
CaCl (stabalizes cardiac cells)
Diuretics/dialysis/kayexelate to remove K from body
____ is the usual bone cement used to stabilize implant with the bone in orthopedic surgeries (usually knees/hips)
What hemodynamic effects does methylmethacrylate have? (x2)
-vasodilation & ↓SVR (its exothermic or hot)
-intense heat can cause reflex bradycardia or cardiac arrest
What is the mechanism behind MMA embolisms?
heat from cement expands intramedullary gas & ↑ pressure forces fat & air into venous circulation
What is done by anesthesia to help prevent MMA embolisms? (x3)
-shut off nitrous (helps reduce expanding gas effect)
What is the main s/s of MMA embolisms?
HypoTN (sudden 30 sec after cement or later)
How is MMA embolism treated? (x2)
What are the s/s of bone cement implantation syndrome (BCIS)? (x5)
-acute pulm HTN
What are the treatments for bone cement implantation syndrome (BCIS)?
-support aortic pressure & R ventricle contractility (vasopressors- ie dopamine)
-augment RV preload (volume guided by CVP/PA cath)
-inhaled NO or prostacyclins
VAE occurs if operative field ___ above the R atrium
What is the most sensitive monitor for VAE?
(TEE → Precordial stethoscope → PA cath → EtCO₂ → Mass spectrometry [EtN₂])
What are the interventions for VAE? (x10)
1. Notify surgeon
2. Flood surgical field
3. Wax bone edges
4. Turn off N₂O
5. Neck veins compressed (↑s JVP)
6. Lower head to heart level
7. Avoid PEEP or valsalva (air through PFO)
8. Treat hypoTN with pressors & rapid volume
9. Aspirate air from PA cath (TEE/dopple guidance)
10. Try L lateral position with slight trendelenburg if arrest, if unsuccessful start CPR