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BOARDS BOARDS NOTESNOTESPart IPart I

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Spinal anesthesia Spinal anesthesia may affect the may affect the

abdominal muscles abdominal muscles important in important in

FORCED FORCED EXPIRATIONEXPIRATION

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Oculo-cardiac reflex – Oculo-cardiac reflex – repeated stimulation repeated stimulation

produces LESS produces LESS response due to response due to

reflex fatiguereflex fatigue

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Platelets produced Platelets produced by the bone marrow by the bone marrow

have a 10 day have a 10 day survival.survival.

RBCs have a 120 day RBCs have a 120 day survivalsurvival

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A patient on ASA has A patient on ASA has decr. Plt function. If decr. Plt function. If you transfuse plts, you transfuse plts, BT will be nl for 4 BT will be nl for 4

hourshours

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Icreased PVR is seen Icreased PVR is seen with hypoxia, with hypoxia, hypercapnia, hypercapnia,

acidosis, acidosis, hyperinflation, hyperinflation,

atelactasis, increased atelactasis, increased sympathetic sympathetic stimulation, stimulation,

increased Hct.increased Hct.

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CBF is the opposite CBF is the opposite of Pulm blood flow – of Pulm blood flow – CBF goes UP with CBF goes UP with

hypoxia, hypercapniahypoxia, hypercapnia

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Hyperventilation will Hyperventilation will decrease ICP but decrease ICP but only for 6-8 hoursonly for 6-8 hours

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Flumazenil – start is Flumazenil – start is 1 minute… peak is 5 1 minute… peak is 5 minutes… duration is minutes… duration is short. careful with short. careful with

diazepamdiazepam

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SNP – direct vasodil – SNP – direct vasodil – short acting. short acting.

Tachyphylaxis is the Tachyphylaxis is the FIRST sign of toxicity FIRST sign of toxicity

= increasing dose = increasing dose requirements.requirements.

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Cyanide: SNP Cyanide: SNP decomposes (not decomposes (not enzymatic) to NO enzymatic) to NO and Cyanide. The and Cyanide. The

cyanide is converted cyanide is converted in the liver by in the liver by

enzymes to enzymes to thiocyanate with a thiocyanate with a

sulfur donor.sulfur donor.

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Renal disease may Renal disease may help cyanide tox help cyanide tox

because more sulfur because more sulfur donor will be donor will be

retainedretained

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Lidocaine toxicity – Lidocaine toxicity – max dose 5 mg/kg – max dose 5 mg/kg –

increases to 7 mg/kg increases to 7 mg/kg with epiwith epi

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TCA – slows AV node TCA – slows AV node conduction. exag conduction. exag response to EPI, response to EPI,

EPHEDRINE, EPHEDRINE, ATROPINEATROPINE

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Atonomic hyperreflexia Atonomic hyperreflexia – transection higher – transection higher

than T6. prevent than T6. prevent reaction with GA OR reaction with GA OR

Regional. you see HTN Regional. you see HTN and BRADYcardia. Not and BRADYcardia. Not an issue during first 1-2 an issue during first 1-2

weeks after injury.weeks after injury.

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Spinal shock – first 1-Spinal shock – first 1-2 weeks. 2 weeks.

HYPOtension, HYPOtension, bradycardia, bradycardia,

areflexia.areflexia.

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SUX is safe with SUX is safe with spinal cord spinal cord

transaction for the transaction for the first 48 hoursfirst 48 hours

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Sickle Cell Disease Sickle Cell Disease patients are at risk patients are at risk of mortality post-op of mortality post-op from infection. Goal from infection. Goal

HbS < 40%HbS < 40%

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Carcinoid tumor – Carcinoid tumor – most found in GI. most found in GI.

appendix mostappendix most

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porphria – avoid porphria – avoid barbiturates and barbiturates and

etomidateetomidate

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anorexics ironically anorexics ironically have delayed gastric have delayed gastric emptying. beware emptying. beware

hypokalemiahypokalemia

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NO – deficiency leads NO – deficiency leads to HTN, angina, to HTN, angina,

erectile dysf. excess erectile dysf. excess leads to shock leads to shock (septic picture)(septic picture)

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cryo – give if cryo – give if bleeding and bleeding and

fibrinogen levels are fibrinogen levels are less than 80less than 80

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Von Willebrand’s Von Willebrand’s disease – most disease – most

common inherited common inherited bleeding disorder. bleeding disorder.

most are most are heterozygousheterozygous

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VWd – if bleeding, VWd – if bleeding, give DDAVP – then, if give DDAVP – then, if

need to, cryo.need to, cryo.

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VWfactor – 1) VWfactor – 1) mediates platelet mediates platelet

adhesion, 2) carrier adhesion, 2) carrier protein for factor protein for factor

VIIIVIII

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enoxaparin – low mol enoxaparin – low mol wt heparin – wait 10-wt heparin – wait 10-12 hours after last 12 hours after last dose before putting dose before putting

epiduralepidural

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anterior spinal artery anterior spinal artery syndrome – flaccid syndrome – flaccid paralysis – sudden, paralysis – sudden,

painlesspainless

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ASAS – unlike ASAS – unlike epidural hematoma – epidural hematoma – ASAS shows nothing ASAS shows nothing

on CT scanon CT scan

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Antithrombin III – Antithrombin III – binds thrombin, binds thrombin,

INACTIVATING itINACTIVATING it

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allergic reactions – allergic reactions – anaphylaxis = anaphylaxis =

mediated by Ab. mediated by Ab. anaphylactoid – no anaphylactoid – no

Ab. no diff clinicallyAb. no diff clinically

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HyperadrenocorticisHyperadrenocorticism (Conn’s) – HTN, m (Conn’s) – HTN,

hyperglycemia, hyperglycemia, hypokalemia, hypokalemia,

hirsuitism, obesity, hirsuitism, obesity, osteoporosisosteoporosis

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Lambert-Eaton Lambert-Eaton Myasthenic Syndrome – Myasthenic Syndrome –

problem with ACh release problem with ACh release causes upregulation of causes upregulation of

post-synaptic receptors – post-synaptic receptors – resulting in increased resulting in increased

sensitivity to depolarizers sensitivity to depolarizers and nondepolarizers.and nondepolarizers.

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Myasthenia Gravis – Myasthenia Gravis – antibodies to post-antibodies to post-synaptic receptors – synaptic receptors –

resulting in resulting in sensitivity to sensitivity to

nondepolarizers and nondepolarizers and resistance to resistance to depolarizersdepolarizers

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CP kids have a CP kids have a higher incidenc of higher incidenc of

reflux and reflux and hypothermia. no hypothermia. no

problem giving them problem giving them SUXSUX

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OxyHb absorbs more OxyHb absorbs more infrared light (940 infrared light (940 nm) while DeoxyHb nm) while DeoxyHb absorbs more red absorbs more red

light (660 nm)light (660 nm)

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Atropine is NOT Atropine is NOT indicated in neonatal indicated in neonatal

resuscitation. the resuscitation. the problem is usually problem is usually respiratory – not respiratory – not vagal or cardiacvagal or cardiac

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Short-term smoking Short-term smoking abstinence: abstinence:

decreases carboxyHb decreases carboxyHb levels, normalizes levels, normalizes

the OxyHb curve. but the OxyHb curve. but INCREASE in INCREASE in

sputum, post-op Cxsputum, post-op Cx

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Glascow – highest = Glascow – highest = 15. lowest = 3. If 15. lowest = 3. If

score is 8, mortality score is 8, mortality is 50%. kids survive is 50%. kids survive head injuries more head injuries more

than adultsthan adults

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Epidural clonidine Epidural clonidine enhances the action enhances the action

of BOTH epid of BOTH epid narcotics and epid narcotics and epid local anestheticslocal anesthetics

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histamine mediates histamine mediates type I reactions, type I reactions, increases cardiac increases cardiac

inotropyinotropy

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protamine is base – protamine is base – made from salmon made from salmon

sperm. heparin is an sperm. heparin is an acid – made from cow acid – made from cow or pig gut. together – or pig gut. together –

inactive salt.inactive salt.

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The main difference The main difference between soda lime and between soda lime and

baralyme is the baralyme is the presence of water and presence of water and

silica in soda lime. both silica in soda lime. both contain about 80% contain about 80% calcium hydroxidecalcium hydroxide

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Oxygen tank (green) Oxygen tank (green) holds 660 Liters – holds 660 Liters – when full it reads when full it reads

2200 psi – able to tell 2200 psi – able to tell volume based on volume based on pressure until the pressure until the

tank is emptytank is empty

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Nitrous Oxide tank Nitrous Oxide tank (blue) holds 1590 (blue) holds 1590

Liters – when full it Liters – when full it reads 750 psi – reads 750 psi – UNABLE to tell UNABLE to tell

volume by pressure… volume by pressure… only by weight of only by weight of

tanktank

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Whole blood has Whole blood has more preservatives more preservatives

and is more likely to and is more likely to cause citrate toxicity cause citrate toxicity

than PRBCthan PRBC

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Tank Color:Tank Color:OXYGENOXYGEN

N2ON2OAIRAIRCO2CO2N2N2

HeliumHelium

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Carboxyhemoglobin - Carboxyhemoglobin - - - cherry red blood- - cherry red blood

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The only resp The only resp parameter that is the parameter that is the same in adults and same in adults and

kids is the TV which kids is the TV which is 6-8 mL/kgis 6-8 mL/kg

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Magnesium SulfateMagnesium Sulfateprolongs muscle prolongs muscle relaxation and relaxation and decreases MACdecreases MAC

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Stored PRBC – with Stored PRBC – with time, become more time, become more acidic, with more acidic, with more

lactate, less bicarb, lactate, less bicarb, less 2,3-DPG, less 2,3-DPG,

increased [K+]increased [K+]

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Oxygen consumption Oxygen consumption drops 7% for every drops 7% for every

drop in body temp of drop in body temp of 11C.C.

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Hypothermia – below Hypothermia – below 3232C, sedation. C, sedation.

below 30below 30C, narcosis. C, narcosis. below 28below 28C, C,

dysrhytmias. below dysrhytmias. below 2020C, asystoleC, asystole

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Child’s classification: Child’s classification: albumin, bilirubin, albumin, bilirubin, nutrition, ascites, nutrition, ascites,

PT, encephalopathyPT, encephalopathy

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Etomidate – N/V, Etomidate – N/V, pain on injection, pain on injection,

myoclonus, hiccups, myoclonus, hiccups, adrenal suppressionadrenal suppression

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dantrolene reduces dantrolene reduces CaCa++ ++ release. SE = release. SE =

N/V, weaknessN/V, weakness

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Buprenorphine is not Buprenorphine is not reversed with narcanreversed with narcan

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Phase I – Phase I – depolarizers – cannot depolarizers – cannot be antagonized. no be antagonized. no

fade.fade.

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Phase II – redoses of Phase II – redoses of depolarizers or with depolarizers or with

nondepolarizersnondepolarizers

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Methohexital – elim Methohexital – elim ½ life shorter, ½ life shorter,

activates epileptic activates epileptic foci, cleared faster. foci, cleared faster.

same Vdsame VdREDUCES seizure REDUCES seizure

thresholdthreshold

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Pancuronium and Pancuronium and Gallamine – cause Gallamine – cause

tachycardiatachycardia

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Morcizine – Morcizine – phenothiazine used phenothiazine used

for venricular for venricular arrythmias – Type I arrythmias – Type I

Na+ channel blockerNa+ channel blocker

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Cimetidine – reduces Cimetidine – reduces liver blood flow – liver blood flow –

inhibits cytochrome inhibits cytochrome P-450 systemP-450 system

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Alfenta – fastest Alfenta – fastest onset – does not onset – does not

accumulateaccumulate

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cromolyn has NO cromolyn has NO place in an acute place in an acute

asthma attackasthma attack

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Clonidine decreases Clonidine decreases MAC, narcotic req, MAC, narcotic req,

BP variability, musc BP variability, musc rigidity (due to rigidity (due to

narcs)narcs)

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Pseudocholinesterase – Pseudocholinesterase – function red by function red by

aminoglycosides, aminoglycosides, neostigmine, neostigmine, vecuronium, vecuronium,

pancuronium, pancuronium, echothiophate.echothiophate.

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Narcotic relative potency:Narcotic relative potency: Demerol = 80 Demerol = 80Morphine = 10Morphine = 10

Methadone = 10Methadone = 10Hydromorphone = 2Hydromorphone = 2

Alfentanyl = 0.75Alfentanyl = 0.75Fentanyl = 0.1Fentanyl = 0.1

Remifentanil = 0.1Remifentanil = 0.1Sufentanil = 0.01Sufentanil = 0.01

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Thiopental: decr CO, Thiopental: decr CO, MAP. neg inotrope, MAP. neg inotrope,

venodilatorvenodilator

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Extrapyramidal Extrapyramidal reactions caused by reactions caused by

droperidol (dyskinesia, droperidol (dyskinesia, swallowing probs, swallowing probs,

grimacing, oculogyric grimacing, oculogyric spasm) can be blocked spasm) can be blocked with diphenhydraminewith diphenhydramine

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Cyanide tox seen Cyanide tox seen with SNP, Na-nitrate, with SNP, Na-nitrate, hydroxycobalamine, hydroxycobalamine,

Na-thiosulfateNa-thiosulfateFIRST sign is FIRST sign is tacyphylaxistacyphylaxis

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SUX SUX bradycardia bradycardia via stim of cardiac via stim of cardiac

muscurinic receptors muscurinic receptors in SA nodein SA node

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Phenothiazines treat Phenothiazines treat schizophrenia. schizophrenia. SE=sedation, SE=sedation,

depression. potentiate depression. potentiate depressant effects of depressant effects of

narcotics, lower seizure narcotics, lower seizure threshold, interfere threshold, interfere with guanethidinewith guanethidine

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TCA – raises MAC. TCA – raises MAC. incr NE availability incr NE availability

incr response to incr response to ephedrineephedrine

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PVR goes up with PVR goes up with badness (acidosis, badness (acidosis,

hypoxia, hypoxia, hypercapnia, Hct?)hypercapnia, Hct?)

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Gallamine (muscle Gallamine (muscle relaxant causing relaxant causing tachycardia) is tachycardia) is

excreted exclusively excreted exclusively by the kidneyby the kidney

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Myasthenia gravis – Myasthenia gravis – resistant to SUX. resistant to SUX.

Myasthenic Myasthenic syndrome – sensitive syndrome – sensitive

to SUXto SUX

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reserpine depletes reserpine depletes catecholamines – catecholamines –

sens to EPI, resistant sens to EPI, resistant to Epherineto Epherine

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Physiostigmine is the Physiostigmine is the only AChI that only AChI that

crosses the BBB (S.S. crosses the BBB (S.S. says it phytes in the says it phytes in the

brain)brain)

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Meperedine has the Meperedine has the greatest decrease in greatest decrease in cardiac contractility cardiac contractility

and the MOST and the MOST histamine releasehistamine release

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ECHOTHIOPHATE – ECHOTHIOPHATE – like mustard gas – like mustard gas – beware using SUXbeware using SUX

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histamine – most histamine – most release with d-Tuboc. release with d-Tuboc.

some with SUX, some with SUX, atrav, MIVatrav, MIV

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potentiate muscle potentiate muscle relx: relx:

aminoglycosides, aminoglycosides, MgSO4, local anesth, MgSO4, local anesth, diuretics, dantrolene, diuretics, dantrolene,

HYPOKALEMIAHYPOKALEMIA

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MAO-inhibitors – MAO-inhibitors – exag response to exag response to

pressors – pressors – HYPERPYREXIA with HYPERPYREXIA with

MeperidineMeperidine

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porphyria – avoid porphyria – avoid barbiturates, barbiturates,

etomidateetomidate

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don’t mix clonidine don’t mix clonidine and naloxone – may and naloxone – may

get bad HTNget bad HTN

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N-flurane is bad for N-flurane is bad for N-eurosurgery – N-eurosurgery – increases CSF increases CSF

production and may production and may cause seizurescause seizures

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hypokalemia reduces hypokalemia reduces dose requirement for dose requirement for

nondepolarizers, nondepolarizers, increases dose of increases dose of

reversalreversal

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pseudocholinesteraspseudocholinesterase half-life is about 12 e half-life is about 12

hourshours

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Diaphragm is the last Diaphragm is the last to weaken and the to weaken and the first to return (N.T. first to return (N.T.

says it’s one lazy says it’s one lazy muscle)muscle)

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Jaundice caused by Jaundice caused by acute parenchymal acute parenchymal

disease has the disease has the highest highest

morbidty/mortalitymorbidty/mortality

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RSD – best therapy is RSD – best therapy is a sympathetic blocka sympathetic block

Ori - 2003Ori - 2003

Digoxin – inhibits Digoxin – inhibits Na/K ATPase Na/K ATPase Na Na, ,

Calcium releaseCalcium release, , contractilitycontractility

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decreases HR. In decreases HR. In failing heart, failing heart, O2 O2

demand. In nl heart, demand. In nl heart, demanddemand

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Myasthenia gravis – Myasthenia gravis – tx is AChI. Beware tx is AChI. Beware

these inhibit these inhibit pseudochol.. ester LA pseudochol.. ester LA

last longerlast longer

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Line Isolation – Line Isolation – alarm if leak >2-5 alarm if leak >2-5 mA. No protection mA. No protection from microshockfrom microshock

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Oculo-cardiac reflex – Oculo-cardiac reflex – ciliary nerves – ciliary nerves –

ophthalmic div of ophthalmic div of trigem – gasserian – trigem – gasserian –

vagusvagus

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Occulo-cardiac reflex Occulo-cardiac reflex occurs most often in occurs most often in strabismus surgeriesstrabismus surgeries

Ori - 2003Ori - 2003

Flumazenil – can Flumazenil – can reverse portal-reverse portal-

systemic systemic encephalopathy. who encephalopathy. who

knew?knew?

Ori - 2003Ori - 2003

hydralazine – lupus-hydralazine – lupus-like syndrome, like syndrome,

pancytopenia, drug pancytopenia, drug fever, rashfever, rash

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fat embolism- fat embolism- petechial petechial

hemorrhage – chest, hemorrhage – chest, axilla, sholder. rarely axilla, sholder. rarely

limbs or abdomenlimbs or abdomen

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hypoparathyroidism – hypoparathyroidism – hypocalcemia hypocalcemia

hypotension, hypotension, LARYNGOSPASM, LARYNGOSPASM, cramps, weaknesscramps, weakness

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FRC can be FRC can be measured by: Helium measured by: Helium dilution, N2 washout, dilution, N2 washout,

or body or body plethysmographyplethysmography

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TV generally does TV generally does not vary with agenot vary with age

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Hemophilia A = Hemophilia A = Factor V defic. PTT is Factor V defic. PTT is high – a factor assay high – a factor assay will tell which factor will tell which factor

is lowis low

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protamine – generalized protamine – generalized hypotension if given hypotension if given quickly, anaphylaxis quickly, anaphylaxis (fish allergies- not (fish allergies- not

shellfish, NPH shellfish, NPH exposure), pulmonary exposure), pulmonary hypertension (can lead hypertension (can lead to pulmonary edema)to pulmonary edema)

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ADH - ADH - H2O H2O reabsorption. body reabsorption. body tries to diurese and tries to diurese and

dump Na. tx for dump Na. tx for SIADH is H2O SIADH is H2O

restrictionrestriction

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DDAVP – tx in DDAVP – tx in vonwillibrand’s dz, tx vonwillibrand’s dz, tx

for platelet for platelet dysfunction, tx for dysfunction, tx for Diabetes InsipidisDiabetes Insipidis

Ori - 2003Ori - 2003

Pre-eclampsia – Pre-eclampsia – related to related to placental placental

perfusion perfusion prostaglandin, prostaglandin,

renin, renin, angiotensin, angiotensin, aldosteronealdosterone

Ori - 2003Ori - 2003

MgSO4 – enhances MgSO4 – enhances blocking effects of d-blocking effects of d-tubo and SUX. Mag tubo and SUX. Mag

inhibits plasma inhibits plasma cholinesterasecholinesterase

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Parkinson’s – Parkinson’s – continue all meds continue all meds

throughout peri-op. throughout peri-op. avoid SUX (avoid SUX (K), K),

droperidol, droperidol, ketamine?ketamine?

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Autonomic Autonomic Hyperreflexia – due to Hyperreflexia – due to

an interruption of an interruption of cortical fibers that cortical fibers that

tonically inhibit spinal tonically inhibit spinal reflexes. Occurs if reflexes. Occurs if transection above transection above

splanchnic outflow (T6)splanchnic outflow (T6)

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Carcinoid – usually in Carcinoid – usually in GI. may secrete GI. may secrete insulin, ACTH, insulin, ACTH, melatoninSH, melatoninSH,

gastrin, glucagons, gastrin, glucagons, histaminehistamine

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symptoms – flushing, symptoms – flushing, diarrhea, wheezing, diarrhea, wheezing,

anxiety, anxiety, HR, HR, salivation, salivation,

lacrimation, lacrimation, hyperthermiahyperthermia

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if carcinoid venous if carcinoid venous blood goes to liver blood goes to liver before body, you before body, you

won’t see SE. usually won’t see SE. usually only with metsonly with mets

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nitrous – teratogenic nitrous – teratogenic due to due to UBF as UBF as

opposed to effect on opposed to effect on methionine methionine synthetasesynthetase

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DKA – volume DKA – volume volume volume.. IV volume volume.. IV insulin, replace K, insulin, replace K, Mg, P. Don’t give Mg, P. Don’t give

bicarbbicarb

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predictors of post-op predictors of post-op pulm cx – FVC<70%, pulm cx – FVC<70%, FEV1<2L, FEV1/FVC FEV1<2L, FEV1/FVC <35%, DLCO <50%<35%, DLCO <50%

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A VO2 max = max O2 A VO2 max = max O2 consumption is good consumption is good

indicator. if < 15 indicator. if < 15 mL/kg/min, mL/kg/min, morb/mortmorb/mort

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SENSORY FOOT: SENSORY FOOT: saphenous from saphenous from

femoral and (deep femoral and (deep and super peron, and super peron,

post tib, sural) from post tib, sural) from sciaticsciatic

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saphenous – saphenous – anteromedial foot. anteromedial foot.

deep peron – medial deep peron – medial dorsal, b/w 1dorsal, b/w 1stst,2,2ndnd

toestoes

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super peron – dorsal super peron – dorsal foot, all toes. post tib foot, all toes. post tib

– heel, sole. sural – – heel, sole. sural – lateral footlateral foot

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atropine fever – atropine fever – caused by caused by

suppression of suppression of sweating. hot as sweating. hot as

hare, blind-bat, dry-hare, blind-bat, dry-bone, red-beetbone, red-beet

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Demerol – met is Demerol – met is normeperedine normeperedine

CNS irritant CNS irritant (seizures), renally (seizures), renally

excreted. ½t is 15-20 excreted. ½t is 15-20 hrshrs

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Ondansetron – Ondansetron – serotonin type-3 serotonin type-3

receptor antagonistreceptor antagonistmost common SE is most common SE is

HEADACHEHEADACHE

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CarboxyHb CarboxyHb false false SpO2. ½t is 5 hrs on SpO2. ½t is 5 hrs on

RA. dec to 30’ on RA. dec to 30’ on FiO2 of 1.0. visual FiO2 of 1.0. visual disturb commondisturb common

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kids do not become kids do not become hypotensive after hypotensive after spinal or epidural spinal or epidural anesthesia. they anesthesia. they

recover from blocks recover from blocks faster (M.H. says this faster (M.H. says this

is bologna)is bologna)

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patients with chronic patients with chronic COPD have a larger COPD have a larger

FRCFRC

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citrate – added to citrate – added to banked blood in order banked blood in order

to bind Ca++ to prevent to bind Ca++ to prevent clotting. during massive clotting. during massive

transfusions, most of transfusions, most of the citrate load comes the citrate load comes from FFP and plateletsfrom FFP and platelets

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pacemaker pacemaker electrodes – in electrodes – in

atrium atrium p wave. R p wave. R vent vent LBBB. L vent LBBB. L vent

RBBB RBBB

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epidural opioids - epidural opioids - predominant site of predominant site of action at superficial action at superficial

layer of dorsal horn – layer of dorsal horn – substantia gelatinosa substantia gelatinosa

= LAYER II= LAYER II

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-stat – temperature -stat – temperature correction – better correction – better

electrochem electrochem neutrality, cerebral neutrality, cerebral

autoreg. autoreg. in in outcomeoutcome

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pH-stat – used more pH-stat – used more in pediatric cardiac in pediatric cardiac

cases – if sample cases – if sample reads 7.4 at 37° and reads 7.4 at 37° and the pt is cold, raise the pt is cold, raise

the pH.the pH.

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cimetidine inhibits cimetidine inhibits P-450 P-450 slows met of slows met of

propranolol and propranolol and diazepamdiazepam

Ori - 2003Ori - 2003

absorbents both have absorbents both have 80% CaOH. soda lime 80% CaOH. soda lime has NaOH, Baralyme has NaOH, Baralyme has BaOH. both 4-8 has BaOH. both 4-8

mesh sizemesh size

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Sevo degrades to Sevo degrades to Compound A. Compound A.

bara>soda. DES bara>soda. DES degrades to carbon degrades to carbon

monoxide in monoxide in dessicateddessicated

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Reglan Reglan prolactin prolactin secretion secretion

galactorrhea. avoid galactorrhea. avoid in BRCA pts?in BRCA pts?

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PTU – inhibits PTU – inhibits synthesis of throid synthesis of throid hormone, periph hormone, periph

conversion of T4conversion of T4T3T3

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Congen Diaphragm Congen Diaphragm Hernia – more on Left.. Hernia – more on Left.. assoc with L ventricular assoc with L ventricular hypoplasia: Rhypoplasia: RL shunt, L shunt,

pulmonary HTN, pulmonary HTN, hypoxemia, acidosis, hypoxemia, acidosis,

hypercapnia.hypercapnia.

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plan should be to plan should be to sink suction sink suction

catheter, intubate, catheter, intubate, ventilate gently to ventilate gently to avoid baro, beware avoid baro, beware

pneumopneumo

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pre-eclampsia – after pre-eclampsia – after 2020thth week, twins, week, twins, primigrav, DM, primigrav, DM,

polyhydramnios, polyhydramnios, economic depressedeconomic depressed

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sequelae= seizures, sequelae= seizures, coagulopathy, DIC, coagulopathy, DIC,

pulm edema, hepatic pulm edema, hepatic dysfunctiondysfunction

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beware SNP in beware SNP in pregnancy. cyanide pregnancy. cyanide

can cross the can cross the placenta and the placenta and the

fetus does not have fetus does not have the thiosulfatethe thiosulfate

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TRIMETHAPHAN – TRIMETHAPHAN – direct smooth muscle direct smooth muscle relaxant, autonomic relaxant, autonomic ganglia ACh receptor ganglia ACh receptor

blockerblocker

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used in tx of used in tx of autonomic autonomic

hyperreflexia. CO hyperreflexia. CO drops due to drop in drops due to drop in

preload.preload.

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beware – it can beware – it can inhibit plasma inhibit plasma

cholinesterase and cholinesterase and double the duration double the duration

of SUXof SUX

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metabolic O2 metabolic O2 requirements are requirements are

about 3 mL/kg/minabout 3 mL/kg/min

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Vapor pressure Vapor pressure changes with temp – changes with temp –

as as temp, the temp, the vaporizer allows vaporizer allows more flow by the more flow by the

agentagent

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nitrous limit in the nitrous limit in the OR is <25 PPM. OR is <25 PPM.

volatile is less than 2 volatile is less than 2 PPMPPM

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omphalocele – omphalocele – hernial or amniotic hernial or amniotic

sac, assoc cong sac, assoc cong abnormalitiesabnormalities

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ejection fraction is ejection fraction is computed as stroke computed as stroke

volume / end volume / end diastolic volumediastolic volume

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dopaminergic dopaminergic activity is activity is

INHIBITORY. avoid INHIBITORY. avoid phenothiazines, phenothiazines,

droperidol, raglandroperidol, raglan

Ori - 2003Ori - 2003

alfentanil has been alfentanil has been assoc with acute assoc with acute

dystonic reactions in dystonic reactions in untreated untreated

parkinsonians. who parkinsonians. who knew?knew?

Ori - 2003Ori - 2003

smoking shifts the smoking shifts the oxyHb curve to the oxyHb curve to the left. shifts back 12 left. shifts back 12 hours after quitinghours after quiting

Ori - 2003Ori - 2003

The MOST important The MOST important factor in closure of factor in closure of

the ductus arteriosus the ductus arteriosus after birth is the after birth is the

PaO2.PaO2.

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as PaO2 goes up, as PaO2 goes up, pulm vasodilation pulm vasodilation occurs, PVR drops, occurs, PVR drops, and pulm press < and pulm press <

systemicsystemic

Ori - 2003Ori - 2003

Magnesium Magnesium deficiency – CNS deficiency – CNS

irritability, muscle irritability, muscle spasm, arrhythmias. spasm, arrhythmias.

often see often see hypoKalemiahypoKalemia

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oculocardiac reflex – oculocardiac reflex – may be augmented may be augmented by hypoxia and/or by hypoxia and/or

hypercarbiahypercarbia

Ori - 2003Ori - 2003

venous air embolism venous air embolism (VAE) – detection by (VAE) – detection by

sensitivity: sensitivity: TEE>Doppler>PAP>TEE>Doppler>PAP>

PEtCO2>COPEtCO2>CO

Ori - 2003Ori - 2003

FFP indications: replace FFP indications: replace deficit of factors V and deficit of factors V and VIII, reverse coumadin, VIII, reverse coumadin, AntiThrombin III def, AntiThrombin III def,

immunodeficiency states, immunodeficiency states, thrombocytopenic thrombocytopenic

purpura, NOT volume purpura, NOT volume expansionexpansion

Ori - 2003Ori - 2003

albumin does not albumin does not carry with it the risk carry with it the risk

of Hepatitisof Hepatitis

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pulmomary fibrosis pulmomary fibrosis pulmonary HTN, pulmonary HTN,

VC, VC, TLCTLC

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-agonists - -agonists - glucose, glucose, insulin, insulin,

K+K+

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early decels = type I early decels = type I – head compression – – head compression –

vagal response – vagal response – normalnormal

Ori - 2003Ori - 2003

late decels = type II – late decels = type II – hypoxic / acidotic – hypoxic / acidotic –

chemoreceptor reflex chemoreceptor reflex – look out!– look out!

Ori - 2003Ori - 2003

variable decels =variable decels =type III – cord type III – cord

compression usually compression usually go awaygo away

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heparin is the heparin is the anticoagulant of anticoagulant of

choice in pregnancy – choice in pregnancy – does not cross the does not cross the

placentaplacenta

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normal pulmonary normal pulmonary shunt is due to the shunt is due to the

thebesian and thebesian and bronchial veins. bronchial veins.

about 2-5% of COabout 2-5% of CO

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Local anesthetics are Local anesthetics are weak bases. if baby is weak bases. if baby is acidotic, LA becomes acidotic, LA becomes

BH+ on baby side BH+ on baby side and get trappedand get trapped

Ori - 2003Ori - 2003

maternal acidosis maternal acidosis and hypercapnia and hypercapnia

potentiate placental potentiate placental uptake of local uptake of local

anesthetics? (BW anesthetics? (BW says this is a No-No)says this is a No-No)

Ori - 2003Ori - 2003

porphyria attacks: porphyria attacks: colicky abd pain, colicky abd pain, N/V, limb pain, N/V, limb pain,

confusion. triggers confusion. triggers include barbit, include barbit, etomidate, lidoetomidate, lido

Ori - 2003Ori - 2003

glycine (for TURP)- glycine (for TURP)- can be associated can be associated

with ammonia with ammonia toxicity and may lead toxicity and may lead

to CNS symptomsto CNS symptoms