Pitifully Perfusing
GASP!
"That one that begins with a D..."
It's all in your head
Miscellaneous
100
32yo M with no PMH underwent maxillary ORIF under GETA. MAPs in preop in the 80s. EBL was 20ml. Pt got 2L of LR during the case. Now in the PACU, pt has MAPs in the high 50s and is still very somnolent but with normal respirations. THIS end of surgery anesthesia practice prior to leaving the OR is to blame for this scenario.
What is a deep extubation?
Pt was extubated deep to prevent bucking given facial surgery and so still has considerable gas on board causing vasodilation.
100
68yo F with no sig PMH underwent R THA with a CSE and sedation. In PACU she has MAP of 70, HR of 60, very shallow respirations with RR 6 and spO2 of 88% on 8L NC. She is minimally responsive to verbal stimulation and groans to painful stimuli. Her pupils measure 2mm b/l. This drug should be administered to treat her resp depression.
What is naloxone aka Narcan.
0.04mg is typical starting dose. Half life is 30-80mins so if a pt had a significant dose of a longer acting opioid eg diluadid or morphine towards the end of the case they may need additional Narcan doses.
100
preop tylenol, gabapentin, meloxicam, regional anesthesia, lidocaine gtts, precedex gtts, ketamine
Opioid sparing multimodal analgesia. Evidence supports these as well as other ERAS measures in reducing post op complications by allowing return of function more quickly.
100
29yo F underwent EGD with bx with MAC. Pt arrives to PACU with VSS and initially staring at the ceiling but sluggishly responsive to painful stimuli. In 15 mins she starts thrashing in the bed still appearing confused and speaking nonsensically. This NMDA blocking drug was likely used as part of her MAC.
What is ketamine?
Ketamine is becoming more popular for induction of GA and as an adjunct for maintaining sedation and pain control. It is favorable in trauma because it does not significantly induce hypotension or bradycardia nor does it tend to cause apnea. Especially without coadmin with benzo or propofol it is associated with emergence delirium.
100
38yo M underwent debulking of laryngeal tumor/neck dissection with free flap under GETA using awake fiberoptic intubation. Pt arrives in PACU with VSS, alert. He soon oddly c/o ringing in his ears and has progressively worsening muscle twitches. 30mins later the pt starts to have a seizure. This widely used type of drug is likely to blame.
What is a local anesthetic (presumably lidocaine)?
Significant local anesthetic systemic toxicity (LAST) is relatively rare (<1% for regional anesthesia). Situations in which multiple forms of LA are given (regional, IV adjunct, topical) and accidental intraarterical injection increase odds. Sx include peri-oral numbness, tinnitus, muscle twitching and can advance to seizures, arrhythmias and CV collapse. Discontinuing gtts, patches etc, o2 support, sz tx with midaz, and lipid emulsion are cornerstone of tx.
200
32yo M with no PMH underwent maxillary ORIF under GETA. MAPs in preop in the 80s. EBL was 20ml. Pt got 2L of LR during the case. Now in the PACU, pt has MAPs in the high 50s, a HR in the 90s and is still very somnolent but with normal respirations. Intravenous injection of THIS is most appropriate as tx.
What is phenylephrine. (40-120mcg)
Neo is a pure alpha 1 agonist so increases SVR. It can cause reflexive bradycardia and so would not be favorable if HR <60ish. Neo and a anticholinergic (glycopyrrolate) or ephedrine is more favored in such a situation.
200
This is a high pitched noise made on inspiration that can occur post extubation related to upper airway edema.
What is stridor?
What is the tx?
200
63yo F s/p TAH under GETA complains of 11/10 pain in PACU. There are some unusual drug shortages and you end up giving the pt a less common mod-long acting opioid. 30 minutes later the pt becomes borderline hypotensive and complains of severe diffuse pruritus and appears to have a faint urticarial rash. This was the likely medication.
What is morphine?
Moreso than other opioids morphine tends to cause significant histamine release resulting in peripheral vasodilation and itching. This can be abated by antihistamines like benadryl.
200
79yo M with pmh PVD, HTN, HLD underwent R CEA under GETA. In PACU he arrives still quite sedated with VSS. When he wakes up a bit you notice he is tending to keep his vision to the right and his left hand grip is significantly weaker than his right. This is the adverse outcome most likely exhibited in this patient.
What is a peri-op stroke?
Cardiac and vascular surgery are higher risk for brain hypoperfusion and clot disruption. Efforts are made to place intraop shunts, use cerebral oximetry and evoked potential monitoring to prevent strokes but risks are still 1-5% for CEA. When deficits are noted the surgery team should eval the CEA site with US for patency and then consider re-opening vs heparin vs tPA.
200
After giving 8mg of zofran to an 82yo F with schizophrenia you see THIS rhythm on the monitor.
What is Torsades de pointes?
Tdp is a polymorphic ventricular tachycardia often preceded by prolonged QT intervals that may still produce a pulse but is typically unstable (hypotension inducing). Zofran and many psych meds, some abx can prolong QT as seen in this pt. Tx is 1-2g MgSO4 and rest of ACLS for typical unstable vtach.
300
45yo F with PMH of HTN, UC undergoes lap converted to open bowel resection under GETA for 3 hrs. EBL was 250. 1.5L of LR given intraop. Baseline MAP was in the 90s. On arrival to PACU MAP is 61. Pt is mentating ok, RR 17. This pt most likely falls into this classification of shock.
What is hypovolemic shock?
Long NPO times, insensible fluid losses from large abd incisions, under-resuscitation all set up for being fluid down.
300
Breathing spontaneously with Vt >3ml/kg, hemodynamically stable, following commands, able to sustain a head lift, positive cuff leak
What are extubation criteria.
The Rapid Shallow Breathing Index (RSBI) is RR/Vt. Despite limitations, is one of most established criteria.
Also would consider secretion burden or evolving processes on CXR before extubating in ICU.
300
36yo F s/p lap chole under GETA arrives in the PACU with VSS including a temp of 37C. She is alert and oriented but cannot seem to stop shivering despite layers of blankets. This medication can be used to quell this issue.
What is meperidine.
Postoperative shivering is a relatively common phenomenon that is not always associated with reduction in body temp but can also be related to surgical stress itself. Meperidine has the best evidence over other opioids for treatment.
300
For example: Current intracranial hemorrhage, active internal bleeding, recent (within 3 months) intracranial or intraspinal surgery, serious head trauma, intracranial neoplasm, arteriovenous malformation, aneurysm, known bleeding diathesis, severe uncontrolled hypertension
What are absolute contraindications to tPA (alteplase)?
Pt's over 18 diagnosed with acute ischemic stroke with ongoing neuro deficits and symptom onset less than 4.5hrs that do not meet these and some other relative exclusion criteria are eligible to benefit from iv thrombolytics like tPA.
300
52yo M only PMH DM2 s/p DDKT under GETA arrives in PACU alert and somewhat SOB satting 88% on 6L NC but HDS with a 4L CVC and 2 PIVs for access. 30m later his SOB has gotten worse and an ABG confirms paO2 of 49. He now has RR 26 and HR 115, MAP 50s. You hear distinctly absent breath sounds on the pts right. A CXR is obtained confirming this suspected dx.
What is a tension PTX? PTX can occur after 1-6% of CVL placements and may initially go unnoticed. In the setting of PPV, PTX often worsen. This pt with worsening resp distress becoming HD unstable with CXR showing tracheal deviation is displaying tension physiology and would benefit from immediate needle thoracostomy and then CT placement.
400
Mathematically, MAP is the product of these two factors.
MAP - CVP = CO x SVR
and CO = HR x SV
so MAP = HR x SV x SVR
SV is dependent on contractility, preload, and afterload (Frank Starling curve)
400
16yo M underwent shoulder surgery from a football accident with IS block and GETA. The CA1 tells you that he had a rough wakeup with laryngospasm requiring a dose of succinylcholine to break. Pt is in respiratory distress and coughs up some frothy pink secretions. He is satting 85% on 8L NC. This is name of the phenomenon this pt is likely suffering from.
Negative Pressure Pulmonary Edema.
NPPE results when a spontaneous breath's negative pressure is blocked by a closed glottis such as during laryngospasm. Especially in young male athletes this force can be over -100cm water which causes hydrostatic gradients favoring the pulling of fluid into lung interstitium thus causing a flash pulmonary edema.
400
72yo F with a PMH of stage 4 lung cancer underwent ACDF of C2-C6 with neuromonitoring necessitating TIVA. She arrives in PACU alert, fairly calm, and VSS. Within the next 15 minutes, however she begins to complain about unbearable pain to the point of becoming hysterical despite being given sufficient immediate acting opioids. This is the drug used intraop that is likely responsible.
Remifentanil.
During a TIVA, propofol gtts are often combined with an opioid gtt like Remi to ensure depth of anesthesia when paralytics and gas cannot be used (neuromonitoring). Because of Remi's very short context sensitive half time which while convenient for titrating can precipitate an acute form of opioid withdrawal - opioid induced hyperalgesia syndrome.
400
31yo F underwent R knee meniscal repair and osteotomy with CSE and sedation. In PACU she has VSS and is alert. After some time she appears ready for DC to PSU, she sits up to drink water and complains of severe headache than then improves when she lies back down. This is the likely diagnosis.
What is a post dural puncture headache?
Neuraxial anesthesia (spinal, epidural, CSE) carries the risk of PDPH. General incidence <3% but if accidental dural puncture with epidural needle (wet tap) occurs incidence 81-88%. The headache is often positional and can be a/w nausea, stiff neck, and vision change. Bedrest, hydration, caffeine and epdidural blood patch can be tx.
400
A 62yo F with reported CHFrEF, HTN is s/p a lengthy ex lap for abdominal abscesses. In PACU she is minimally responsive and MAPs are in mid 50s with monitor showing SR in the 80s. She received 1.5L intraop with an EBL of 350. THIS modality can be used to determine what type(s) of shock are being demonstrated prior to giving more fluids.
What is Limited Bedside TTE? :)
The five views of focused assessment of transthoracic echocardiography (FATE) can reveal contractility using various metrics for EF and valve excursions as well as fluid status by looking at chamber sizes and IVC caliber changes. This can help rule out acutely decompensated CHF, MI, PE, and hypovolemia from blood or insensible loss as causes of hypotension.
500
23yo M polytrauma including C5 SCI and multiple fx undergoes ORIF for open femur fx with GETA. EBL was 250ml and pt received 2L LR and 250 of albumin intraop. In PACU his MAP is 55 and HR 50. The patient appears to be in THIS type of shock.
What is neurogenic aka spinal shock.
SCI causes a loss of sympathetic tone to peripheral vasculature leading to a distributive shock (low SVR). If the level of injury is above the cardiac accelerator fibers (T1) they are more likely to be unable to increase their HR to compensate for hypotension.
500
55yo M with severe GERD undergoes urgent ex lap for a stab with GETA. The CA1 mentions that this pt had significant volume vomiting during the RSI process. He has been awaiting a been and boarding in PACU overnight. Initially satting 99% on RA by the next AM he is satting 85% on NRB and with increasing work of breathing. CXR shows RLL infiltrates. This is the likely diagnosis causing the respiratory failure.
What is aspiration pneumonitis/PNA?
RSI attempts to reduce likelihood of aspiration events but not always succesfull. NonNPO status, GERD, esophageal dysmotility, gastroparesis increase the risks. Aspiration of gastric contents in the supine position has a predilection for settling in the RLL. Often the V/Q mismatch resulting in resp failure takes more than 6 hrs to develop.
500
A 45yo F undergoing a lumbar discectomy who is a current heroin user receives a number of multimodal agents pre and intraoperatively for pain. The CA1 misdoses this mineral used as adjunct analgesic and the patient arrives in PACU with characteristic diminished DTRs.
Magnesium sulfate
Poorly understood but thought to be related to activity at NMDA receptors, MgSO4 does have evidence as an intraop adjunct in reducing pain scores and opioid use in some post op populations.
500
78yo M with PMH PVD, ESRD on HD, cirrhosis undergoes LE angiography with MAC. Pt arrives to PACU somnolent but with VSS, RR of 8. Over the next hr pt remains sluggishly responsive x 4 and intermittently obstructs his airway requiring an NPA and maneuvering. His pupils are 5mm and reactive. This drug could be given to reverse the likely buildup of toxic metabolite.
What is flumazenil?
Flumazenil is a GABAa competitive antagonist and so displaces benzos (and similar) drugs from the receptor reversing their sedative effects within 1-2 mins. Redosing may be needed as flumazenil's HL is 30mins and many benzos last longer. In this pt, normal doses of midaz may have lead to built up metabolites given the liver and renal failure.
500
Final Jeopardy!!!
47yo M s/p partial esophagectomy arrives in PACU in some resp distress satting 88% on 6L NC otherwise VSS. 30mins later resp distress worsens to the point of RR 29 and pt is barely able to speak despite being on NRB mask. ABG confirms hypoxemia. While awaiting a chest XR THIS is the next step in treating this hypoxia.
What is intubation and mechanical ventilation?
Ordinarily the pathway for increasing FiO2 would be NC, sFM, face tent, NRB, HFNC and then NIPPV ie BIPAP. In pts with upper GI surgery involving fresh anastomoses such as this NIPPV is contraindicated given the airway pressure can be directed at the anastomoses and cause leaks.