Odd Ball Facts

Major Peter Strube CRNA MSNA APNP ARNP

pstrube3000@yahoo.com

It’s not about the nail!

http://www.youtube.com/watch?v=-4EDhdAHrOg

Odd Ball Facts

Midwives and nurses are as good as docs

-- and sometimes better, WHO finds!!

Cometto and colleagues around the world looked at all the studies they could find on the quality of care delivered by non-physicians. They settled on 53 that looked specifically at the quality of care delivered — and at how happy patients were with the care they got.

“The evidence shows there aren’t statistically significant differences,” Cometto said. “The quality of care they provide is comparable to physicians. In some cases, for specific services, they actually outperform physicians.”

The American Society of Anesthesiologists recently spoke out against what it sees as the overuse of nurse-anesthetists. “Somehow there has become the notion that you can take physician extenders and replace physicians,” said Dr. Jane Fitch, a former nurse anesthetist who is now a physician anesthesiologist. “We are really concerned about patient safety.”

http://www.nbcnews.com/health/midwives-nurses-are-good-docs-sometimes-better-who-finds-8C11506820

Maggie Fox NBC News Oct. 31, 2013 at 6:32 PM ET

The Ground Rules:

Recognition of Problem:Immediate Anesthesia Management:Treatment:Follow-up, after action review:

Think differently: Don’t forget basics

If we don’t remember our history we are doomed to repeat it!

Information You should know?

Average cost per minute of time in OR$20-$80/min varies by case

Average PACU charge $4-8/min ***

Ranges by 30 minute time blocks

Economic Impact – for each incident of

nausea/vomiting that is avoided: Avoid resource utilization costs: Patients who

vomit spend an average of 43 minutes longer in the PACU at a cost of $85 for nausea and $138 for vomiting.

Save the cost of rescue treatment: $283 (minimum) to treat patients who experience PONV

For surgical centers: PONV delays may result in an ambulance transfer to a hospital costing $300 - $900 and result in an admission costing $1,200 to more than $2,400 per day.

Desflurane

Time to extubation decreased with Desflurane: 20-25% decrease.

Dexter et al. Anesthesia Analg; 2010

What if you save 7 minutes on a basic case? $140 savings…wow….

Agent Cost Based on MAC

Enter Time in minutes

60

Vaporizer at 1 MAC for middle-aged adult

Enter Fresh Gas Flow in L/min

2 (1)

Size of

Molecular Cost of

Generic bottle ml

Cost/Unit

Cost/m

l

Weight

Density

MAC 1 MAC

Desflurane

240 $115.00

$0.48 168.04 1.465 6.00 $16.41 ($8.20) Desflurane

Sevoflurane

250 $172.22

$0.69 200.05 1.520 2.10 $9.47 Sevoflurane

Agent Cost Based on MAC Enter Time in minutes

120

Vaporizer at 1 MAC for middle-aged adult

Enter Fresh Gas Flow in L/min

2(1)

Size of Molecular Cost of

Generic bottle ml

Cost/Unit

Cost/ml

Weight Density MAC 1 MAC

Desflurane

240 $115.00 $0.48 168.04 1.465 6.00 $32.81 (16.41) Desflurane

Sevoflurane

250 $172.22 $0.69 200.05 1.520 2.10 $18.94 Sevoflurane

Caffeine---Antiemetic Caffeine---Antiemetic and Pain control? and Pain control? Central Nervous stimulateCentral Nervous stimulate

Number one consumed psychoactive drugNumber one consumed psychoactive drug

PDE inhibitorPDE inhibitor

Withdrawal headacheWithdrawal headache Via this action a secondary antiemetic; all subjective Via this action a secondary antiemetic; all subjective

considering a few studies suggest it does not play a roleconsidering a few studies suggest it does not play a role

Awake sleep cycleAwake sleep cycle Increased sensitivity to catacteolaminesIncreased sensitivity to catacteolamines Spinal HASpinal HA

Caffeine

Oral and IV Caffeine;

Very effective for temporary relief

75-80% effective in initial treatment, but 48 hour follow

up revealed that all patients had a return of their

headache

Believed to work by blocking adenosine receptors which

in turn leads to vasoconstriction of cerebral blood vessels.

Methylxanthines derivitive such as, caffeine may also stimulate sodium-potassium pumps to increase CSF production, which can aid in headache relief.

Treatment with IV caffeine was not associated with a decrease in the number of patients who required EBP.

SE of Methylxanthines deriviative; CNS stimulation, seizures, gastric irritation and cardiac dysrhythmias, limited used with patients with CV disease

Different IDEASDifferent IDEAS

Nasal fentanyl with BMTsNasal fentanyl with BMTs

Toradol local at epidural/spinal siteToradol local at epidural/spinal site

Ephedrine IM at epidural or spinal site for OB siteEphedrine IM at epidural or spinal site for OB site

Bicarb (remember the ionized and unionized lectures) with localBicarb (remember the ionized and unionized lectures) with local

propofol 20-30 mg nausea or infusion!propofol 20-30 mg nausea or infusion!

Magnesium for injection with propofol---Cool Thoughts!Magnesium for injection with propofol---Cool Thoughts!

Neo and Ephedrine in Propofol injectionNeo and Ephedrine in Propofol injection

Glass VialsGlass Vials

Glass Vials…..

Glass Particles Contamination…Filter needle use with ampules

Do you do it correct?

Different IDEASDifferent IDEAS

LR and psych patients—more later…LR and psych patients—more later…

LR and TraumaLR and Trauma

LR and blood LR and blood

Writing on the IV bags---more later…Writing on the IV bags---more later…

Lido and/or bicarb in the ett cuffLido and/or bicarb in the ett cuff

DID we also forget about COX-2 agonists….DID we also forget about COX-2 agonists….

Indigo carmine ----STRONG ALPHA RESPONSE!Indigo carmine ----STRONG ALPHA RESPONSE!

Pall heat and moisture exchanger HME—1.67 Kilocalories

Non-Pharmacologic Methods To decrease PONV

Reduce swallowing blood, if possible

Hydrate well---Very effective!

Administer glucose containing solutions? Is this a reality in OR

Beware of patients who are strongly vagotonic and have syncope

Caution in assuming upright position postop—Orthostatic 6-20% dehydrated

Don’t let patient get hypotensive.

Don’t let patient move head rapidly.

Don’t let at-risk patients watch TV postop? Motion sensative

More Non-Pharmacologic Methods for PONV

Acupuncture—really exciting information!

Acupressure

over “P6” point of wrist (3cm prox. to distal wrist crease, between the

tendons of palmaris longus and flexor carpi radialis)

over K-K9 acupuncture point (middle phalanx of 4th finger) applied

bilaterally

Alcohol Pad—Quese Ease!

Do we really need our pt’s to drink and eat before discharge? Why?

Non-pharmacologic Prevention of Surgical Wound Infection

Maintaining Normothermia Supplemental Oxygen Surgical Site Preparation Smoking Glucose Control Vascular Volume Pain Relief Hypercapnia

Electricity….oh boy!!

Prisoners and shackles?Ear rings? Piercing?

Goes in and goes out…

BipolarBipolar is a different type which prevents widespread tissue

coagulation. Part held by surgeon is like a forceps, current entering one prong and leaving by the other. Thus no grounding plate required. Useful for example in neurosurgery where there is no convenient spot for a grounding plate, and greater precision is necessary.

Valleylab.com has an extensive educational presentation on all aspects of electrosurgery.

A new anesthesia addiction!

????

Inhalant Abuse: Inhalant Abuse:

Volatile substances that produce chemical vapors that can be inhaled to Volatile substances that produce chemical vapors that can be inhaled to induce a psychoactive or mild altering effect. They act on the central induce a psychoactive or mild altering effect. They act on the central nervous system except for nitrates. Not sure where, but it appears dopamine nervous system except for nitrates. Not sure where, but it appears dopamine is the area that this works on in the brain. is the area that this works on in the brain.

Broad range of chemicals but the common characteristic is they are rarely if Broad range of chemicals but the common characteristic is they are rarely if ever taken by any route but inhalation. ever taken by any route but inhalation.

Volatile: Vapors at room tempVolatile: Vapors at room temp Aerosols: sprays that contain a propellant and solventAerosols: sprays that contain a propellant and solvent Gases: we use it all the time.Gases: we use it all the time. Nitrates: Poppers or snappers. They relax smooth muscle and dilate blood Nitrates: Poppers or snappers. They relax smooth muscle and dilate blood

vessels. They alter moods and are sexual enhancers. vessels. They alter moods and are sexual enhancers.

Inhalant Abuse:Inhalant Abuse:

Growing group of abused drugs…. Under 18 is the biggest group. Growing group of abused drugs…. Under 18 is the biggest group. Easy to get and easy to use. You can pick it up anywhereEasy to get and easy to use. You can pick it up anywhere

Inhalants cause severe damage to the lungs, liver, kidneys, bone marrow Inhalants cause severe damage to the lungs, liver, kidneys, bone marrow and the brain. Can cause suffocation, stroke, loss of consciousness and and the brain. Can cause suffocation, stroke, loss of consciousness and deathdeath

Sniffing or snortingSniffing or snorting SprayingSpraying BaggingBagging HuffingHuffing Inhaling Inhaling

Gasoline, glue, vegetable spray, hairspray, deodorant spray, paint thinner, Gasoline, glue, vegetable spray, hairspray, deodorant spray, paint thinner, transmission fluid, air freshener, Nitrites, Rush, Locker room popper, transmission fluid, air freshener, Nitrites, Rush, Locker room popper, Whippets, NitrousWhippets, Nitrous

Do you write on your IV or put tape on it?

ISMP also cautions against writing an expiration date directly on the bag, because volatile chemicals from the ink may leach into the solution.

http://www.accessdata.fda.gov/psn/printer.cfm?id=186

What IV soln to you choose?

NS or LR?

Good for what situation?

Panic attacks… oh boy?

How Many Blades are there?

Are you just a miller or Mac?

Lots!!!---14 types

Cranwall Jackson Janeway Reduced Flange Macintosh Magill Miller

Parrott Phillips Wisconsin Robert-Shaw Siker Soper Wisconsin-Hipple

Basic Rules: Suxx does not suck..

Nobody has ever had a allergic reaction to a ET Tube!!

Nobody gets sued for leaving it in to long

If your thinking about intubating should have already done it!

New Term: Pre-Mature Extubation!

Did you realize?

There are nearly 50 basic airway tools…

That doesn’t even count the multiple variations of these tools and other tools not cited in the May 2012 Airway update.

Current discussion in the Airway Society is?

Laryngeal Mask----Mid-Line, SupineLaryngeal Mask----Mid-Line, Supine

Adult and pediatric sizesAdult and pediatric sizes

Inserted into hypopharynx, passed downward behind larynx, Inserted into hypopharynx, passed downward behind larynx, sealing glottic opening and enabling ventilation after cuff sealing glottic opening and enabling ventilation after cuff inflatedinflated

Slight bulging in tissues overlying larynx indicates mask in Slight bulging in tissues overlying larynx indicates mask in positionposition

Allows positive pressure ventilation, can support airway when Allows positive pressure ventilation, can support airway when trachea can’t be visualizedtrachea can’t be visualized ““Can’t intubate/can’t ventilate” scenarioCan’t intubate/can’t ventilate” scenario

Does not protect against regurgitation/aspirationDoes not protect against regurgitation/aspiration

Requires anesthesia for placementRequires anesthesia for placement

LMA Stylet

LMA Cost Savings!

If we do 5 cases with a Classic LMA per day this costs:

5 (per day) x 5 (days/wk) x 52 (wks/year) = 1300 LMAs x $ 6.5= $ 8,450

If we instead choose a Supreme LMA for all of these:

1300 x $ 18.5 = $ 24,050

Classic LMA$ 6.50 Flexible LMA$ 12.0 Supreme LMA$ 18.5

Glidescope—2001 General Surgeon Dr. Pacey Designed First scope

Verothan Stylet-60% curve (90% Success rate)

Tonsillectomy and Adenoids

This is a airway issue…. Perfect conditions should be present ask about 2nd and 3rd hand smoke and URI’s LMA vs ETT Use of a pre-op anticholinergic Post-op bleeding.. Pain control is very important

OSA>>>> increased improvement in school and focus post tonsils

LMA is the best way to go!----OFIRMEV!

Physics?—This sucks…

Beer-LampertLaplacePoiseuille;sBernoulli’sCharles, Boyles, Gay-Lussac’sJoule-Thompson

Oh my….

Sneezing with peribulbar or retrobulbar Block?

Photic sneeze reflex ACCHO Autosomal Dominat Compelling Helio-

Opthalmic Outburst reflex

25% of population evoked by the bright light.

Trigeminal

Vocal Cord Dysfunction

Has your patient been short of breath and anxious in the PACU?

What did you do?

Versed may have been a better choice??

Remimidazolam? What’s next?Strange end-point

TattoosA Medline and EMBASE search of the English

literature using the key words: spinal, epidural, tattoos, tattooing, complications did not find any reports or concerns regarding neuraxial anesthesia through tattooed areas. However, one might postulate that there could be long-term implications from depositing a pigmented tissue core in the epidural or subarachnoid space.

Based on the limited information available it is possible that inserting an epidural or spinal needle through a tattoo could cause long-term problems such as arachnoiditis or a neuropathy secondary to an inflammatory reaction, but we don’t know.

Canadian Journal of Anesthesia 49:1057-1060 (2002)

Who controls the room temp? You DO!!

SCIP: http://www.sjhlex.org/documents/Physicians/SCIP_Poster_Full_Size.pdf

Temperature must be equal to or greater than 96.8° F within 30 minutes prior to anesthesia end time or immediately 15 minutes after anesthesia end time.

It costs on average between $2500-$7000 per pt for complications related to hypothermia. Infection being the most common.

YOU CONTROL THE TEMP.

WE need to change the mind set of the operating room.

SUMMARY OF OUTCOMES Of NORMOTHERMIA

Decreased:

Time spent in ICU 43%

Need for mechanical ventilation 34%

Need for blood transfusion 40%

PRBC 85%

FFP 79%

Platelets 78%

Surgical site infections 64%

Postop MI 44%

Mortality rates 55% 41

THERMOREGULATION UNDER ANESTHESIA

HEAT REDISTRIBUTION PHENOMENON

∆CORE T ° C

Management: Prewarming

Management:Intraoperative

warming

Management:Intraoperative

warming

Bair Hugger….

Bair paws…

I can heat and cool the pt with this mode!

Something New to be scared about now!

Dissolvables

Photo source: http://tobaccocommons.com/tag/camel-strips/

Point of Purchase

Droperidol

Prophylactic doses (<1 mg) are effective against PONV

FDA issued a ‘black box’ warning: Droperidol may cause death or life-threatening

events associated with QT prolongation and torsades de pointes

Labeling changes based on 100 unique spontaneous cardiovascular adverse events

Addition of black box warning has restricted use

Droperidol:The FDA Box Warning

Droperidol has been used for over 40 years Why a problem now? No evidence of adverse events in published trials No published case reports An association does not prove cause and effect If prolonged QTc is an issue then 5HT3 antagonists

should also carry the same warning At least 3 cases of VT associated with 5HT3

administration No “denominator” provided (or available)

Debunking Droperidol

Lets remove the black box…

Lipid Rescue….

Lipid Rescue

20% lipid solution 1.5 ml/kg over 1 minute Follow immediately by a infusion at rate of 0.25mg/kg/min

(17.5 ml/min for a 70 kg adult) Repeat dose if no improvement – and double the infusion

rate

Max of 10 mg/kg??? www.lipidrescue.org

Airway Management TX seizures ACLS------limit epi

What about Propofol? (Propofol is 1%) Lipid based? Peanuts – peanut oil used in Fresenius propoven (a propofol product from Europe showing up in hospitals in the U.S.)

Other Things to Remember!

Ask the question…. What about other treatments?

The Saving Grace!

Wellbutrin 7.95 gms, Lomatrigine 4 grams

Wellbutrin 100mg/TID Lomatrigine 300mg/QD

Many classes of compounds bind and inhibit Na channels

Local anesthetics General anesthetics Ca channel blockers 2 agonists Tricyclic antidepressants Substance P antagonists Many nerve toxins

BenadrylDroperidol ????

The cornea is the clear, dome-shaped outer area of the eye. It lies in front of the colored part of the The cornea is the clear, dome-shaped outer area of the eye. It lies in front of the colored part of the eye (iris) and the black hole in the iris (pupil). The outermost layer of the eyeball consists of the eye (iris) and the black hole in the iris (pupil). The outermost layer of the eyeball consists of the cornea and the white part of the eye (sclera). A corneal abrasion is basically a superficial cut or cornea and the white part of the eye (sclera). A corneal abrasion is basically a superficial cut or scrape on the cornea. A corneal abrasion is not as serious as a corneal ulcer, which is generally scrape on the cornea. A corneal abrasion is not as serious as a corneal ulcer, which is generally deeper and more severe than an abrasiondeeper and more severe than an abrasion

To diagnose a corneal abrasion, a topical To diagnose a corneal abrasion, a topical anesthetic with a yellow with a yellow dye called flourescein is placed called flourescein is placed into the eye. Under blue into the eye. Under blue cobalt light, the part of the cornea abraded will be stained by the dye and is light, the part of the cornea abraded will be stained by the dye and is easily seen by the examiner. The area and depth of the abrasion can be easily seen under a easily seen by the examiner. The area and depth of the abrasion can be easily seen under a special microscope called a special microscope called a slit lamp biomicroscope. If a microscope is not available, then a blue . If a microscope is not available, then a blue light called a Burton lamp may be usedlight called a Burton lamp may be used

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren) and ketorolac Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren) and ketorolac (Acular) are modestly useful in reducing pain from corneal abrasions (Acular) are modestly useful in reducing pain from corneal abrasions

If antibiotics are used, ointment (e.g., bacitracin [AK-Tracin], erythromycin, gentamycin If antibiotics are used, ointment (e.g., bacitracin [AK-Tracin], erythromycin, gentamycin [Garamycin]) is more lubricating than drops and is considered first-line treatment. In patients who [Garamycin]) is more lubricating than drops and is considered first-line treatment. In patients who wear contact lenses, an antipseudomonal antibiotic (e.g., ciprofloxacin [Ciloxan], gentamycin, wear contact lenses, an antipseudomonal antibiotic (e.g., ciprofloxacin [Ciloxan], gentamycin, ofloxacin [Ocuflox]) should be used, and contact lens use should be discontinued. Clinical trial data ofloxacin [Ocuflox]) should be used, and contact lens use should be discontinued. Clinical trial data are lacking, but it is recommended that contact lenses be avoided until the abrasion is healed and are lacking, but it is recommended that contact lenses be avoided until the abrasion is healed and the antibiotic course completed. the antibiotic course completed.

Proparacaine:Proparacaine:DO NOT USE TETRACAINEDO NOT USE TETRACAINE

IOP=25: Map > 70?

Post-op Visual Loss (POVL)

Prolonged prone position may lead to ischemic optic neuropathy

Precipitating factors include hemodilution, periorbital edema, excessive crystalloid administration, hypotension, trendelenburg position

Methylmethacrylate

Insertion of this cement assoc w/↓ BP Attributed to absorption of volatile

monomer of methylmethacrylate and/or

Embolization of air and bone marrow during femoral reaming

D/C N2O before bone cement placed Adequate hydration, maximizing

oxygenation will minimize ↓ BP w/cementing

Bone reimplantation syndrome!

Postoperative Cognitive Dysfunction

Deterioration of intellectual function presenting as impaired memory or concentration

Not detected until days or weeks after anesthesia

Duration of several weeks to permanent

Diagnosis is only warranted if:corroborated with neuropsychological testingevidence of greater memory loss than one would

expect due to normal aging

Outcomes Following Major Surgery: Conclusions

POCDCommon in all age groups at hospital discharge3 months after surgery, POCD is more common in adults

age 60 years or older, with lower educational achievement

Associated with increased one-year mortality

MortalityIncreased by comorbidityAnesthetic management has a significant effect

volatile agent usecumulative deep anesthesia timesystolic hypotension

Summary

“Anesthetic management, directly or indirectly, may contribute to the biology of remote adverse events”

“Practicing anesthesiologists may be able to influence long-term outcomes by adjusting anesthetic and adjuvant regimens”

“Reducing one-year mortality in the elderly by just 5% would translate to 40,000 - 50,000 lives saved each year”

Meiler, Monk et al. APSF Newsletter 2003; 18(3):33.

Beach chair position

VAE may occur since operative site is higher than heart

Nerve injury may occur w/upper extremity trauma

Radial nerve w/humerus fx

Keep BP… Neo Gtt?

Exparel

Tumescent Liposuction

High volume low dose lidocaine mixed with epi for liposuction.

Is this best practice? Increased

mortality?

New Paralytic?

Gantacurium

Is this a new Generation being born of NMB? Based on amino acid pathway--olefinic This drug is chemically degraded by rapid

adduction to L-cysteine and removes Chlorine These two routes make it unavailable to bind

to acetycholine receptor Does not require Liver, Kidneys, Tempature or

pH Two exciting analogs…

There has always been a search for the new Suxx…..

Gantacurium

Dose: 0.5 mg/kg Fast acting with short duration

Exciting new group of drugs!

Key is: NO histamine release!

L-Cysteine

Dissolved in concentration of 200mg/ml Antidote for New class of Muslce relaxants

Olefinic isoquinolinium Diester NMB

Takes advantage of this pathway Naturally occuring amino acid

Only works with new group of NMB’s

L-Cysteine Human Studies: IV administration of exogenous L-Cysteine

induced faster recovery.

Dose in Studies: 5-50mg/kg (average dose is 10mg/kg)

Compared to Edrophonium reversal with atropine. Did not need to give antimusarinic agent.

Reversed in 1 minute

There are risks…High doses: (added to TPN) but 1-1.5 grams/kg can cause neuro defectsreported in infants

Pathophysiology of PONV

Cerebral cortex

(sight, smell, taste)

CTZ in the area postrema of the

fourth ventricle (medication)

Vestibular apparatus

(motion)

(Vagal afferents in GI tractconduct impulses to stimulate CTZ)

CTZ = chemoreceptor trigger zone.

Pharyngeal afferents

(gagging)

Enterochromaffin cells in GI tract release serotonin, which binds to visceral 5-HT3 receptors

(mechanical or medication)

Multi Modal exampleMulti Modal example Anticholinergic drugs (both scopolamine and robinul?? Atropine is Anticholinergic drugs (both scopolamine and robinul?? Atropine is

better..) (anti muscarinic receptor antagonists) and H-1 antagonists better..) (anti muscarinic receptor antagonists) and H-1 antagonists such as dramamine and meclizine are very useful in motion sickness such as dramamine and meclizine are very useful in motion sickness but are ineffective against substances that act directly on the but are ineffective against substances that act directly on the chemoreceptor trigger zonechemoreceptor trigger zone

A lot of drugs we use, then trigger nausea and vomiting in the A lot of drugs we use, then trigger nausea and vomiting in the chemoreceptor trigger zone --- thus making the above listed drugs chemoreceptor trigger zone --- thus making the above listed drugs useless in this regard.useless in this regard.

Antiemetic drugs should be combined to increase antiemetic activity Antiemetic drugs should be combined to increase antiemetic activity while decreasing toxicity effects; for example, dexamethasone when while decreasing toxicity effects; for example, dexamethasone when given with 5HT-3 increases activity of both. Diphenylhydramine given with 5HT-3 increases activity of both. Diphenylhydramine when given with metoclopramide increases the action of both while when given with metoclopramide increases the action of both while reducing the risk of EPS.reducing the risk of EPS.

Hence; we need a multi modal attack against nausea and vomitingHence; we need a multi modal attack against nausea and vomiting

Remember these of older drugs either forgotten or just not used Remember these of older drugs either forgotten or just not used anymore.anymore.

You still have the mainstay drugs to use….You still have the mainstay drugs to use….

OxygenOxygen

Hypoxia triggers cortical afferents which triggers the Hypoxia triggers cortical afferents which triggers the vomiting center which leads to the act of vomitingvomiting center which leads to the act of vomiting

One specific study showed a decreased rate of PONVOne specific study showed a decreased rate of PONV

A second study trying to prove the first could not either A second study trying to prove the first could not either prove or disprove the first studyprove or disprove the first study

Increased O2 levels (less than 80%) in orthopedics have Increased O2 levels (less than 80%) in orthopedics have been shown to decrease infection rates in total jointsbeen shown to decrease infection rates in total joints

Interesting thoughts?Interesting thoughts?

Perioperative clinical factors & immune function

Supplemental perioperative oxygen improves postop outcomes

FiO2 of 0.8 doubles subcut O2 tension & halves postop wound infection rate

Supplemental O2 ↓ PONV after laparoscopies & laparotomies

Preconditioning w/O2 may improve organ function after liver tx & outome after spinal ischemia insultsCurr Opin Anesthesiol 2006;19:11-18

GingerGinger

Used for Used for PONVPONV as we talked about, motion sickness, vertigo, digestive aid for as we talked about, motion sickness, vertigo, digestive aid for cramps and menstral reliefcramps and menstral relief

Increases Bile production….. Bad with gallbladder ptIncreases Bile production….. Bad with gallbladder pt

Some studies look at killing Ovarian cancer cells, Used as a stimulant, antidepressant, Some studies look at killing Ovarian cancer cells, Used as a stimulant, antidepressant, gastro issues, constipation, HTN and delaying the onset of DMgastro issues, constipation, HTN and delaying the onset of DM

Increases the perioperative bleeding risksIncreases the perioperative bleeding risks

Stop at least two weeks prior to surgeryStop at least two weeks prior to surgery

Small hint… if its green in can cause bleeding.Small hint… if its green in can cause bleeding.

GingerGinger

Ginger contains anticoagulant components. It inhibits Ginger contains anticoagulant components. It inhibits platelet aggregation by acting as an inhibitor of arachidonic platelet aggregation by acting as an inhibitor of arachidonic acid, epinephrine and adenosine diphosphate and collagen. acid, epinephrine and adenosine diphosphate and collagen.

This is also a dose dependent relationshipThis is also a dose dependent relationship

There is a reduction in thromboxane synthetase and There is a reduction in thromboxane synthetase and prostaglandin synthetase and there was no reduction in prostaglandin synthetase and there was no reduction in bleeding time, platelet count or platelet function. bleeding time, platelet count or platelet function.

Ginger administered prior to induction of anesthesia Ginger administered prior to induction of anesthesia can be prophylactic for PONV (1 gram) TOXIC is can be prophylactic for PONV (1 gram) TOXIC is greater than 2mg/kg/daygreater than 2mg/kg/day

Meclizine-Antivert H-1 blocker, central anticholinergic properties

Depresses Labyrinth and vestibular stimulation

Has some mild Local Anesthestic activity

Elderly can increase CNS confusion

Heavily metabolized by Liver and Kidneys…..becareful! Becareful with any cholinergic sites…example Glaucoma

Dose is 25-50 mg PO

DramamineDramamine(Meclizine or Diphenhydramine mixed (Meclizine or Diphenhydramine mixed with either Theophylline or derivative with either Theophylline or derivative or Theophylline)or Theophylline)

Antihistamines: Dramamine and MeclizineAntihistamines: Dramamine and Meclizine

H-1 antihistamines act similarly to the anticholinergic agents H-1 antihistamines act similarly to the anticholinergic agents suppressing transmission of neuronal impulses originating in the suppressing transmission of neuronal impulses originating in the labyrinth. Used primarily to treat or prevent motion sicknesslabyrinth. Used primarily to treat or prevent motion sickness

Motion sickness is a prime trigger for PONVMotion sickness is a prime trigger for PONV

Both agents are available orallyBoth agents are available orally

Dramamine is available IVDramamine is available IV Dose is 25-50 MG IV (0.5mg/kg--Peds) 24hr coverageDose is 25-50 MG IV (0.5mg/kg--Peds) 24hr coverage Should be given with induction or post cord clampingShould be given with induction or post cord clamping Works great with OB post C-section; Works great with OB post C-section; Remember sedative actions of this drugRemember sedative actions of this drug

Transdermal Scopolamine

Pharmacokinetics of

Transdermal Scopolamine

Detected in plasma within 4 hr, peak within 24 hr Crosses placenta and blood blood-brain barrier Extensively metabolized Half-life 9.5 hr after patch removal − Potential drug interactions − Decreased absorption of oral drugs − Additive CNS effects with sedatives, tranquilizers, alcohol − Additive anticholinergic effects with antihistamines,

TCAs,muscle relaxants

Atropine Both atropine and scopolamine cross the BBB and placenta

Tertiary Amine Competetive antagonist for muscarinic acetylcholine receptors Strong Parasympathetic response

Atropine with Neostigmine? Atropine is a better bronchodilator and produces more tachycardia than scopolamine

Central Anticholinergic Syndrome! Beware…

Intrathecal Atropine? Several Case Studies… Dose 100 mcg IV Dose.. Adult 0.5 mg Peds 25 mcg/kg Please dilute in the IV bag

Organophasphate poisoning with 2 PAM Cloride

Hypotensive Thought Hypotensive Thought PatternPattern

What is your order for treating Hypotension????What is your order for treating Hypotension????

0 fluids0 fluids 1 and 2; Neo and ephedrine1 and 2; Neo and ephedrine 3 methylene blue3 methylene blue 4 epi chip shots (5-10mcg)4 epi chip shots (5-10mcg) 5 vasopressin5 vasopressin

What is 6 for you? What is 6 for you?

?? Glucagon?? Glucagon

HypotensionHypotension

Glucagon?? Glucagon?? Not just for blood sugars anymoreNot just for blood sugars anymore

Remember that boring lecture in school about how it Remember that boring lecture in school about how it relaxes the sphincter of oddiiiiiiiiii???? relaxes the sphincter of oddiiiiiiiiii????

Glucagon is a positive inotropeGlucagon is a positive inotrope

Increases C-ampIncreases C-amp

Actually treatment of choice for beta-blocker overdoseActually treatment of choice for beta-blocker overdose Dose 1mg/IVDose 1mg/IV

Calcium for BPCalcium for BP

Renal patientsRenal patients The kidney converts VIT-D to is physiologically active The kidney converts VIT-D to is physiologically active

form D-3form D-3 The patient on chronic renal disease becomes The patient on chronic renal disease becomes

hypocalcaemia because of calcium absorption from the hypocalcaemia because of calcium absorption from the intestine is impaired when there is a deficiency of intestine is impaired when there is a deficiency of vitamin Dvitamin D

Calcium is a positive inotropeCalcium is a positive inotrope

Replacement with Blood transfusionsReplacement with Blood transfusions

Monitor Ionized Calcium levelsMonitor Ionized Calcium levels

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