Quick Reference/Review

Pre-Anesthesia Evaluation
o Cardiac Patient decreased exercise tolerance important sign if a!le to clim! "#
flights of stairs$ cardiac reserve pro!a!l% intact
Post-&' infarction risk sta!ili(es at )-*+ after * months
Perioperative &' mortalit% #,-),+
'f no prior &'$ perioperative risk ,-./+
0ccur in 12-3# hrs post-op
4o elective surger% within * months of &'
Prior Cardiac 5urger% or P6CA is not contraindication to surger%
Contraindication to surger% 7 &' 8. month$ uncompensated C9:$ severe
A5 or &5
Evaluation
&a;or risk unsta!le coronar% s%ndrome
'ntermediate risk mild angina$ prior &'$ C9:$ <&
&inor risk age$ a!normal E=>$ arrh%thmia$ decreased functional
capacit%$ stroke$ uncontrolled 964
5tudies E=>$ 9olter$ stress test$ technetium ??m$ thallium imaging$
coronar% angiograph%
o C0P<
Explain o!struction
<etermine severit% and responsiveness to al!uterol$ get P:6@s$ CAR if
highl% s%mptomatic
'ncreased risk if pre-op P6@s 8),+ predicted
Also helpful to determine home 0# reBuirement$ hospitali(ation histor%$
and which medicines used how often
o <&
Catch for signs and s%mptoms of m%ocardial d%sfunction$ cere!ral
ischemia$ 964$ renal disease
Correct h%pogl%cemia$ <=A$ and l%tes !efore surger%
&aintain glucose !etween .#,-.2,
Reglan D 9# !locker
5igns of autonomic neuropath% impotence$ 964$ neurogenic !ladder$
orthostasis
&a% also develop arthropath% leading to difficult cervical extension- 'f
cannot put palms and fingers flat together$ likel% to have more difficult
airwa% due to lack of extension-
&alignant 9%perthermia skeletal muscle h%permeta!olic s%ndrome
o 6riggering anesthetics halothane$ esflurane$ isoflurane$ desflurane$ sevflurane$
succin%lcholine
o >ene Ca channel of skeletal muscle sarcoplasmic reticulum with decreased
reuptake of Ca
o 5%mptoms increased 9R$ increased !reath rate$ increased etC0# Emost
sensitiveF$ unsta!le GP$ c%anosis$ coca-cola colored urine
Hate signs E*-#1 hrsF increased temperature$ muscle swelling$ heart
failure$ <'C$ liver failure
o Confirm diagnosis !% large difference !etween venous C0# and arterial C0#
o Ha!s Respirator% and meta!olic acidosis$ h%poxia$ h%perkalemia$
h%percalcemia$ high m%oglo!in$ high CP=$ m%oglo!inuria
o 'ncidence .I##,$,,, .I1,$,,, with succin%lcholine
o &ortalit% .,+ overall$ 3,+ without dantrolene
o :uture anesthesia no pretreatment with dantrolene$ flush anesthesia machine
o 6A
. - Call for help
# - 5top volatile anesthetic
/ .,,+ 0#
1 &anuall% h%perventilate
) 5witch to a clean !reathing circuit
* 5top surger%$ maintain on sedative-h%pnotic anesthesia
3 <antrolene #-)mg/kg Emixed with sterile waterF B ., minutes to max dose
of .,mg/kg- &aintenance dose at .mg/kg B *hrs for 3# hours-
2 Correct meta!olic acidosis with 4aC90/ .-#mg/kg$ Correct high =D
? Cool patient with iced 'J 45$ and cold fluids in gastric lavage$ in
peritoneal or thoracic cavit% if open$ and PR
., &aintain urine output with mannitol or lasix- <o not use CCG@
o 'J :luids EHR$ 45F
o &aintenance E1D#D.F D 4P0 time E&aintenance K L hrsF D Evaporative loss E.-
2cc/kg/hrF
Hocal Anesthetics
o Esters 1 MiN in name Ei-e- novocaineF$ meta!oli(ed !% plasma
pseudocholinesterases- 0ne of its meta!olites is PAGA$ which causes allergic
reactions Ei-e- with Procaine and 6etracaineF- C5: has no esterases- 5ulfa allergic
patients-
o Amides 2+ MiNs in name Eie- Hidocaine$ GupivicaineF$ meta!oli(ed !% liver
en(%mes$ ma% cause methemeglo!inemia Eprilocaine$ !upivicaineF$ allergic
reaction rare$ some !ad h%peractivit% reactions
o &echanism decrease permea!ilit% to 4a ions$ !inds to 4a channel in inactivated
state$ no threshold potential reached$ affects rapid firing nerves first$ m%elinated
""" unm%elinated
o Contraindications h%persensitivit%$ severe heart !lock$ CPC s%ndrome
o 6oxicit% often follows predicta!le pattern of tinnitus$ perioral num!ness and
tingling$ sense of doom$ sei(ure$ coma-
Cardio decreased phase 'J depolari(ation$ increased PR$ wide QR5
Pulmonar% phrenic/intercostal nerve paral%sis
C45 di((iness$ circumoral num!ness$ tinnitus$ !lurred vision$ excitator%
signs C45 depression
&uscle toxic in;ected '&
Hidocaine known to decrease coagulation
Airwa% &anagement
o H&A su! for E6 tu!e as long as inflation ma% !e used as guide for intu!ation
Propofol used for induction relaxes ;aw
=eep in place until patient opens mouth on arousal
Complications aspiration$ mucosa in;ur%$ lar%ngospasm/coughing
Contraindication risks for gastric aspiration such as >ER<$ pregnanc%$
recent meal
&endelssohn@s 5%ndrome
o Aspiration pneumonia secondar% to aspiration of gastric contents
o 6A supportive admission to 'CO$ continued intu!ation$ respirator% therap%$
suctioning$ 0#$ no anti!iotics$ Buestiona!le steroids
Anti!iotics onl% used in presence of positive culture- 5hould not !e given
prior to this-
o Pneumonia dela% surger% 2-.# hours$ P0 antacids$ 9# !lockers$ Reglan$ rapid
seBuence$ on suction after intu!ation$ suction of phar%nx
o Risk anesthesia$ muscle relaxants$ trauma$ full stomach$ dela%ed gastric
empt%ing$ pregnanc%$ o!esit%$ impaired HC5 tone
o 5x d%spnea$ tach%pnea$ increased 9R$ whee(ing$ CAR with lower lo!e
infiltrates$ h%poxia
Rapid 5eBuence 'ntu!ation used in an%one at risk for aspiration- &a;or difference is
that there is no !ag-mask ventilation following induction$ as this could introduce air into
the >' track causing vomiting-
.- Preparation check Allergies$ Medications$ Past med hx$ Last meal$ Events
surrounding incident EAMPLEF- Also check supplies and monitors-
#- Preox%genate .,,+ for / minutes
/- Pre-treat opioids to reduce s%mpathetic response to intu!ation$ raglan and !icitra
to reduce risk of gastric aspiration s%ndrome
1- Paral%sis and anesthesia 'J induction followed immediatel% !% succin%lcholine$
often use propofol due to its anti-emetic action
)- Pass tu!e immediatel% following fasiculations from succin%lcholine
*- Post-tu!e management tape tu!e$ opioids$ etc$ etc-
Extu!ation Criteria
o 6idal volume " )cc/kg
o Respirations spontaneous and "2/min
o 4': of -., to -.)
o Patient showing purposeful movement
o 6emperature of /) C or greater
o 9emod%namic sta!ilit%
o Pa0# P *, on :i0# 1,$ Pco# Q )) mm9g
Har%ngospasm
o Children at especiall% high risk
o 6r% to !reak first !% giving high positive pressure
o 'f cannot !reak$ must use succin%lcholine to paral%(e patient to !ag-mask or re-
intu!ate-
Pre-op Room Prep Checklist
Machine machine checkout$ 0# cali!ration$ gas level
Suction
Monitors A line$ central line$ Pulse 0x$ GP$ E=>$ G'5
Airwa% lar%ngoscope$ oral airwa%$ mask$ tu!e$ 0>$ 6emp pro!e
IJ alcohol$ needle$ flush on heplock$ tape$ 'J:
Drugs propofol$ etomidate$ paral%tic$ narcotic$ versed$ phen%toin$ atropine$ epinephrine$
succin%lcholine
Special$ Seat
La!s t%pe and cross$ 9R9$ coags