Wednesday, October 23, 2013

1. Tranexamic acid (lysine derivative, binds plasminogen and prevents conversion to plasmin and activation of fibrinolysis) reduces all-cause mortality in bleeding trauma patients, with no increase in incidence of DVT/PE/stroke. {Lancet, CRASH-2 trial: international multicenter randomized placebo-controlled trial, total N>20,000}. The most amazing part of this is that they managed to get an N of 20,000 in a placebo controlled RCT. Additional analysis shows that transexamic acid should be given as soon as possible after trauma; it decreases mortality when given within 3 hours, but actually slightly increases it when given after 3 hours. In total knee replacement surgery, it decreases bleeding, transfusion need, and does not increase risk of DVT; benefit is increased when it is given early-on in surgery.
2. Oral airways: correct length is corner of mouth to angle of mandible. Any shorter, and it'll be pushing against the tongue and actually can cause irritation that worsens airway collapse.
3. FiO2 achievable with NC, around 30-40%; with non-rebreather mask (valves to prevent breathing in room air or exhaled air), closer to 70-80%.
4. Systolic BP at which you lose ability to palpate pulses: radial around 80, femoral around 60, and carotid around 40.
5. Mask induction vs IV induction: IV induction is faster (you blaze through stage 2), you have more control, and you already have an IV through which you can push drugs if something goes wrong. Mask induction is slower, especially in adults; in kids its pretty fast because they're smaller and the gas distributes faster. Benefits of mask induction is you don't have to stick an awake person, which is especially helpful in peds. Sevo is the gas of choice for mask induction, as it is the least irritating-- des and iso are pretty unpleasant to breathe in. If you have a particularly squirmy, uncooperative kid, the best thing to do is hold him down, mask him with 8% sevo and hope he goes under before he breaks loose.
6. If you overdose phenylephrine, if someone is young and healthy with good organs and they can take the hypertension/bradycardia, you can just wait it out. If someone is old and you're worried about cerebral hemorrhage or acute decompensated heart failure, then reverse with a short-acting vasodilator like nitroglycerin. Nitroprusside is more powerful, and must be dosed more carefully. You can also use a-antagonists like phenoxybenzamine and phentolamine.
7. When you would reach for albumin over crystalloids when volume resuscitating: 
-Hypoalbuminemic patients: End stage liver failure, burns
-People who can't tolerate large volumes: CHF, renal failure
8. Induction agents: 
-Fentanyl/Midazolam: old school. You need massive doses of these two to induce general anesthesia, and because of that (and their relatively longer-acting nature), the patients will be out for a long time and will likely take a long time to be extubated. Benefits are that this combo is extremely cardioprotective (more so than etomidate). It does not cause cardiac depression or hypotension. In big cardiac surgery cases with patients with bad hearts, you want to use these.
-Propofol: 1-2mg/kg for adults, 3-4 mg/kg kids since kids redistribute and metabolize so much faster and more efficiently. Pros: On fast (30 seconds) off fast (end of effect is redistribution, not metabolism/excretion; redistribution half life is 2-4 mins), abolishes pharyngeal reflexes so good to use to put in ET/LMA. Associated with less post op n/v. Cons: Causes most hypotension and apnea, burns going in to the IV (give lidocaine first), higher risk of infection given weird suspension of drug in oils.
-Etomidate: Pros: less myocardial depression than propofol, and doesn't cause tachycardia like ketamine: good for old people with subpar hearts but not undergoing major cardiac surgery. Cons: burns even worse than propofol, possible adrenal insuffieincy.
9. Transfusions:
-As aforementioned, @ 7 for most people, @10 for people with serious cardiorespiratory illness. Never transfuse past 12-- you get no more O2 carrying benefit and you do start to get sludging. This is extremely relevant post microsurgery (i.e. flaps), where sludging in small vessels can cause serious damage.
-FFP is roughly equivalent to pRBC for volume; cryo is a smaller volume so good for people you don't want to volume overload.
-Exchange transfusions take time to set up
-Irradiated blood kills off the white cells; this is important for people that are immunosuppressed (post chemo, transplant) and those with immune deficiency
10. Demerol 12.5 mg stops postoperative shivering very effectively.

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