1. Odd Ball Facts Odd Ball Facts Major Peter Strube CRNA MSNA APNP ARNP
It’s not about the nail!

2. 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.”
Maggie Fox NBC News
Oct. 31, 2013 at 6:32 PM ET

3. 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!

4. 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

5. 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.

6. 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….

7. Vaporizer at 1 MAC for middle-aged adult Enter Fresh Gas Flow in L/min
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/ml
Weight
Density
MAC
1 MAC
Desflurane
240
$115.00
$0.48
168.04
1.465
6.00
$16.41 ($8.20)
Sevoflurane
250
$172.22
$0.69
200.05
1.520
2.10
$9.47

8. Vaporizer at 1 MAC for middle-aged adult Enter Fresh Gas Flow in L/min
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)
Sevoflurane
250
$172.22
$0.69
200.05
1.520
2.10
$18.94

9. Caffeine---Antiemetic and Pain control?
Central Nervous stimulate
Number one consumed psychoactive drug
PDE inhibitor
Withdrawal headache
Via this action a secondary antiemetic; all subjective considering a few studies suggest it does not play a role
Awake sleep cycle
Increased sensitivity to catacteolamines
Spinal HA 9

10. 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

11. Different IDEAS Nasal fentanyl with BMTs
Toradol local at epidural/spinal site
Ephedrine IM at epidural or spinal site for OB site
Bicarb (remember the ionized and unionized lectures) with local
propofol mg nausea or infusion!
Magnesium for injection with propofol---Cool Thoughts!
Neo and Ephedrine in Propofol injection
Glass Vials 11

12. Glass Vials….. Glass Particles Contamination…
Filter needle use with ampules
Do you do it correct?

13. Different IDEAS LR and psych patients—more later… LR and Trauma
LR and blood
Writing on the IV bags---more later…
Lido and/or bicarb in the ett cuff
DID we also forget about COX-2 agonists….
Indigo carmine ----STRONG ALPHA RESPONSE!
Pall heat and moisture exchanger HME—1.67 Kilocalories 13

14. 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
Reduce amount of narcs needed: use acetaminophen or NSAIDs when possible. Cold for ortho surgery. Local anesthetics-SQ, field block, peripheral nerve, low dose epidural/caudal bupivacaine. 14

15. 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?
P6 Acupressure point
K-K9 acupuncture point Anesth Analg 2002;94:872–5
Capsicum Korean Acupuncture A&A 2002;95:1103-7 15

16. Non-pharmacologic Prevention of Surgical Wound Infection
Maintaining Normothermia
Supplemental Oxygen
Surgical Site Preparation
Smoking
Glucose Control
Vascular Volume
Pain Relief
Hypercapnia

17. Electricity….oh boy!! Prisoners and shackles? Ear rings? Piercing?
Goes in and goes out…
Bipolar
Bipolar 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.

19. A new anesthesia addiction!
????

20. Inhalant Abuse:
Volatile substances that produce chemical vapors that can be inhaled to induce a psychoactive or mild altering effect. They act on the central nervous system except for nitrates. Not sure where, but it appears dopamine is the area that this works on in the brain.
Broad range of chemicals but the common characteristic is they are rarely if ever taken by any route but inhalation.
Volatile: Vapors at room temp
Aerosols: sprays that contain a propellant and solvent
Gases: we use it all the time.
Nitrates: Poppers or snappers. They relax smooth muscle and dilate blood vessels. They alter moods and are sexual enhancers.

23. Inhalant Abuse:
Growing group of abused drugs…. Under 18 is the biggest group.
Easy to get and easy to use. You can pick it up anywhere
Inhalants cause severe damage to the lungs, liver, kidneys, bone marrow and the brain. Can cause suffocation, stroke, loss of consciousness and death
Sniffing or snorting
Spraying
Bagging
Huffing
Inhaling
Gasoline, glue, vegetable spray, hairspray, deodorant spray, paint thinner, transmission fluid, air freshener, Nitrites, Rush, Locker room popper, Whippets, Nitrous

24. 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.

25. What IV soln to you choose?
NS or LR?
Good for what situation?
Panic attacks… oh boy?

26. How Many Blades are there?
Are you just a miller or Mac?

27. Lots!!!---14 types Cranwall Jackson Janeway Reduced Flange Macintosh
Magill
Miller
Parrott
Phillips
Wisconsin
Robert-Shaw
Siker
Soper
Wisconsin-Hipple

28. 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!

29. 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?

30. Laryngeal Mask----Mid-Line, Supine
Adult and pediatric sizes
Inserted into hypopharynx, passed downward behind larynx, sealing glottic opening and enabling ventilation after cuff inflated
Slight bulging in tissues overlying larynx indicates mask in position
Allows positive pressure ventilation, can support airway when trachea can’t be visualized
“Can’t intubate/can’t ventilate” scenario
Does not protect against regurgitation/aspiration
Requires anesthesia for placement 30

31. LMA Stylet

32. 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

33. Glidescope—2001 General Surgeon Dr. Pacey Designed First scope

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

35. 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!

36. Physics?—This sucks… Beer-Lampert Laplace Poiseuille;s Bernoulli’s
Charles, Boyles, Gay-Lussac’s
Joule-Thompson
Oh my….

37. 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

38. 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

39. Tattoos
A 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: (2002)

40. Who controls the room temp?
You DO!!
SCIP:
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.

41. 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 41

42. PHYSIOLOGIC THERMOREGULATION
Kurz, A. ( 2008). Physiology of thermoregulation. Best Practice & Research Clinical Anaesthesiology, 22(4): 42

43. THERMOREGULATION UNDER ANESTHESIA43

44. HEAT REDISTRIBUTION PHENOMENON
Management: Prewarming
Management:
Intraoperative warming ∆
CORE T ° C
Management:
Intraoperative warming 44

45. Bair Hugger….
Bair paws…
I can heat and cool the pt with this mode!

46. Something New to be scared about now!

47. Dissolvables
There have been dissolvables in our market for 5 to 6 years:
Stonewall
Ariva
These are typically sold with the cessation products instead of with the tobacco products.
New dissolvable products that are not yet in Wisconsin include: Orbs, Strips, and Sticks. The tobacco industry is working on these new products. They’re currently being tested in some states but are not available in Wisconsin. Most of the test markets are located in cities with smoke-free policies and large college campuses. We still need to be aware of them because kids might be able to get their hands on them and eventually they’ll be in stores around our state.
Dissolvables are dried crushed tobacco leaves with bindings and flavorings
They are made from finely milled tobacco that is held together with food grade binders.
The products melt in the mouth within three to fifteen minutes, with the strips melting the fastest, and the sticks lasting the longest.
The amount of nicotine in dissolvable tobacco varies widely by brand and type, but some contain 3xs the nicotine in one cigarette.
Melts in the mouth within 3 to 15 minutes, requiring no spitting of tobacco juices.
Cigarette = 1 mg
Dissolvables = 0.6 – 3.1 mg nicotine
Photo source: 47

48. Point of Purchase
And at point of purchase. Right next to gum and candy. 48

49. 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
Prophylactic doses of droperidol (below 1 mg) are effective for PONV.
Recently, the FDA issued a “black box” warning for droperidol. The warning states that droperidol may cause death or life-threatening events associated with QT prolongation and torsades de pointes.
This warning is based on 10 reported cases (1.25 mg or below) in association with droperidol use over the approximately 30 years that it has been available on the market.
Interestingly, as of 2003, there has not been a single case report in a peer-reviewed journal in which droperidol, in doses used for the management of PONV, has been associated with QT prolongation, arrhythmias, or cardiac arrest. 49 49

50. 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) 50

51. Debunking Droperidol
Lets remove the black box…
Lipid Rescue….

52. 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???
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.) 52

53. Other Things to Remember!
Ask the question…. What about other treatments?

54. The Saving Grace! Wellbutrin 7.95 gms, Lomatrigine 4 grams
Wellbutrin 100mg/TID
Lomatrigine 300mg/QD

55. 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
Benadryl
Droperidol ???? 55

56. Proparacaine: DO NOT USE TETRACAINE
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 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 deeper and more severe than an abrasion
To diagnose a corneal abrasion, a topical anesthetic with a yellow dye called flourescein is placed into the eye. Under blue cobalt 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 special microscope called a slit lamp biomicroscope. If a microscope is not available, then a blue light called a Burton lamp may be used
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren) and ketorolac (Acular) are modestly useful in reducing pain from corneal abrasions
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 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 are lacking, but it is recommended that contact lenses be avoided until the abrasion is healed and the antibiotic course completed.
Proparacaine:
DO NOT USE TETRACAINE

58. IOP=25: Map > 70?

59. 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 59

61. 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! 61

62. This slide shows a typical presentation for a patient who experiences postoperative cognitive dysfunction. There are two businessmen talking at a cocktail party and the caption reads “Hi, I’m, I’m, I’m …..You’ll have to forgive me, I’m terrible with names.” This cartoon has a special significance for me because I have interviewed a patient with exactly this problem following total knee surgery. The patient was in her early 60’s and extremely fit. After surgery, she was able to return to playing tennis but could no longer remember a person’s given name. She had recently been at a social event with her mother and could not remember her mother’s name when she started to introduce her. After I discussed the possibility that her memory problem might be a result of the total knee surgery, she said : “I’m supposed to have my other knee fixed, but I am not going to do it because I can’t afford to lose any more of my memory.”

63. 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 testing
evidence of greater memory loss than one would expect due to normal aging
Postoperative cognitive dysfunction is defined as a “deterioration of intellectual function presenting as impaired memory or concentration.” This disorder is usually mild and may not be detected until days to weeks after surgery. It is only recently that publications about POCD in non-cardiac surgery have become commonplace because the diagnosis must be corroborated with neuropsychological testing and can only be made if there is evidence of greater memory loss than one would expect due to normal aging. This means the patient has to be tested prior to surgery and at least several weeks after surgery to determine if cognitive decline has occurred. This is not a part of normal clinical care and is a very expensive and time-consuming effort when included in research protocols.

64. Outcomes Following Major Surgery: Conclusions
POCD
Common in all age groups at hospital discharge
3 months after surgery, POCD is more common in adults age 60 years or older, with lower educational achievement
Associated with increased one-year mortality
Mortality
Increased by comorbidity
Anesthetic management has a significant effect
volatile agent use
cumulative deep anesthesia time
systolic hypotension
The findings of this study can be summarized as follows. First, postoperative cognitive dysfunction is common in all adults, regardless of age, at hospital discharge. At three months after surgery, cognitive problems are significantly higher in those patients aged 60 years or older. Patients with less than a high school education were at higher risk of postoperative cognitive problems, which is probably related to less preoperative cognitive reserve. Long-term cognitive decline is also associated with a higher mortality rate in the first year after surgery.
In addition to co-morbidity, anesthetic management also appears to exert a significant effect on mortality in the first year. Our results found an association between the use of volatile anesthetic agents, cumulative deep anesthesia time, and systolic hypotension and death within the first year after surgery.

65. 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 lives saved each year”
The fall Edition of the Anesthesia Patient Safety Newsletter was just released. In this edition, I was a co-author of an article entitled “Can We Alter Long-Term Outcome? The Role of Anesthetic Management and Inflammatory Response.” In this publication, we review the evidence that suggests that anesthetic management may contribute to the occurrence of remote adverse events. It is hard to imagine that the type of anesthesia or the depth of anesthesia during surgery really effects long-term outcomes. But I think it is possible that intraoperative management may lead to events in the immediate postoperative period such as delirium or respiratory problems. These events may predispose patients to worse long-term outcomes. If this is true, practicing anesthesiologists may be able to influence long-term outcomes by adjusting anesthetic regimens. If as a specialty we made an effort to reduce one-year mortality by just 5%, this would result in 40 to 50,000 lives saved each year.
Meiler, Monk et al. APSF Newsletter 2003; 18(3):33.

66. 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? 66

67. Exparel

68. Tumescent Liposuction
High volume low dose lidocaine mixed with epi for liposuction.
Is this best practice? Increased mortality?

69. New Paralytic?

70. 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…..

71. Gantacurium Dose: 0.5 mg/kg Fast acting with short duration
Exciting new group of drugs!
Key is: NO histamine release!

72. 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

73. 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 grams/kg can cause neuro defects
reported in infants

74. 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 tract conduct impulses to stimulate CTZ)
Pharyngeal afferents
(gagging)
The induction of PONV can occur by several mechanisms:
Surgical factors can cause enterochromaffin cells lining the gastrointestinal tract to release serotonin, which then activates vagal afferent 5-HT3 receptors in the gastrointestinal tract, sending impulses to the vomiting center located in the lateral reticular formation of the medulla.
The vomiting center receives impulses from the chemoreceptor trigger zone (located in the area postrema in the floor of the fourth ventricle), the brain cortex, and the vestibular apparatus.
Once impulses are received at the vomiting center, the vomiting cascade is initiated: the vomiting center sends efferent impulses to the respiratory, vasomotor, and salivary centers, and to various cranial nerves.
These areas then send impulses to the abdominal muscles, diaphragm, stomach, and esophagus, and emesis ensues.
Enterochromaffin cells in GI tract release serotonin, which binds to visceral 5-HT3 receptors
(mechanical or medication)
CTZ = chemoreceptor trigger zone. 74 74

75. Multi Modal example
Anticholinergic drugs (both scopolamine and robinul?? Atropine is better..) (anti muscarinic receptor antagonists) and H-1 antagonists such as dramamine and meclizine are very useful in motion sickness but are ineffective against substances that act directly on the chemoreceptor trigger zone
A lot of drugs we use, then trigger nausea and vomiting in the chemoreceptor trigger zone --- thus making the above listed drugs useless in this regard.
Antiemetic drugs should be combined to increase antiemetic activity while decreasing toxicity effects; for example, dexamethasone when given with 5HT-3 increases activity of both. Diphenylhydramine when given with metoclopramide increases the action of both while reducing the risk of EPS.
Hence; we need a multi modal attack against nausea and vomiting
Remember these of older drugs either forgotten or just not used anymore.
You still have the mainstay drugs to use…. 75

76. Oxygen
Hypoxia triggers cortical afferents which triggers the vomiting center which leads to the act of vomiting
One specific study showed a decreased rate of PONV
A second study trying to prove the first could not either prove or disprove the first study
Increased O2 levels (less than 80%) in orthopedics have been shown to decrease infection rates in total joints
Interesting thoughts? 76

77. 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 insults
Curr Opin Anesthesiol 2006;19:11-18

78. Ginger
Used for PONV as we talked about, motion sickness, vertigo, digestive aid for cramps and menstral relief
Increases Bile production….. Bad with gallbladder pt
Some studies look at killing Ovarian cancer cells, Used as a stimulant, antidepressant, gastro issues, constipation, HTN and delaying the onset of DM
Increases the perioperative bleeding risks
Stop at least two weeks prior to surgery
Small hint… if its green in can cause bleeding. 78

79. Ginger
Ginger contains anticoagulant components. It inhibits platelet aggregation by acting as an inhibitor of arachidonic acid, epinephrine and adenosine diphosphate and collagen.
This is also a dose dependent relationship
There is a reduction in thromboxane synthetase and prostaglandin synthetase and there was no reduction in bleeding time, platelet count or platelet function.
Ginger administered prior to induction of anesthesia can be prophylactic for PONV (1 gram) TOXIC is greater than 2mg/kg/day 79

80. 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 mg PO

81. Dramamine (Meclizine or Diphenhydramine mixed with either Theophylline or derivative or Theophylline)
Antihistamines: Dramamine and Meclizine
H-1 antihistamines act similarly to the anticholinergic agents suppressing transmission of neuronal impulses originating in the labyrinth. Used primarily to treat or prevent motion sickness
Motion sickness is a prime trigger for PONV
Both agents are available orally
Dramamine is available IV
Dose is MG IV (0.5mg/kg--Peds) 24hr coverage
Should be given with induction or post cord clamping
Works great with OB post C-section;
Remember sedative actions of this drug 81

82. Transdermal Scopolamine82

83. 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 83

84. 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

85. Hypotensive Thought Pattern
What is your order for treating Hypotension????
0 fluids
1 and 2; Neo and ephedrine
3 methylene blue
4 epi chip shots (5-10mcg)
5 vasopressin
What is 6 for you?
?? Glucagon 85

86. Hypotension Glucagon?? Not just for blood sugars anymore
Remember that boring lecture in school about how it relaxes the sphincter of oddiiiiiiiiii????
Glucagon is a positive inotrope
Increases C-amp
Actually treatment of choice for beta-blocker overdose
Dose 1mg/IV 86

87. Calcium for BP Renal patients
The kidney converts VIT-D to is physiologically active form D-3
The patient on chronic renal disease becomes hypocalcaemia because of calcium absorption from the intestine is impaired when there is a deficiency of vitamin D
Calcium is a positive inotrope
Replacement with Blood transfusions
Monitor Ionized Calcium levels 87