Download presentation
Presentation is loading. Please wait.
Published byLinda Richards Modified over 10 years ago
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 ANESTHESIA
43
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 Scopolamine
82
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
Similar presentations
© 2025 SlidePlayer.com Inc.
All rights reserved.