Monday, October 14, 2013

1. More facts about coagulation: 
-Factor XIII important for polymerizing fibrinogen and solidifying clots.
-Hemophilia A is much more common than B (85%/15%)
-Bleeding into the joints/muscles should be treated after 3-5 hours, bleeding into head and neck, GI, or brain should be treated within 30 min-1 hour.
-Cryo has F VIII but not F IX.
-Contraindications for FFP: immunodeficiency, availability of a specific factor treatment.
-Desmopressin will increase F VIII levels in someone with <1% activity of F VIII by 2-4%; in someone with much higher levels of activity, it may increase up to 8%.
2. Arterial lines measure BP more accurately and in real-time (vs intermittently) compared to an external blood pressure cuff. They are also good for frequent blood sampling for ABG. They are useful in surgeries where you expect significant changes in blood pressure or blood volume (large fluid shifts/blood loss). They are also useful in surgeries where it is important to track the ABG closely (i.e. intracranial surgery where blood [CO2] affects cerebral perfusion, or lung resection where you're worried about ventilation or oxygenation)
3. Central lines have 2 primary functions: 
-Central access to give drugs that would be unsafe to give in peripheral lines: i.e. pressors, where you may cause ischemia of distal organs, or CaCl, which can cause wicked burns.
-Monitoring: particularly CVP, which assuming no lung pathology, is a proxy for ventricular end-diastolic pressure i.e. preload. This way, if the person becomes hypotensive, you can determine if it is cardiogenic, vasogenic, or hypovolemic.
4. Inhaled anesthesia effects: 
-decreases the amplitude of evoked potentials-- relevant for neuro/spine surgery.
-increases RR, decreases TV
-causes peripheral vasodilation; this redistributive volume alone can cause a 1.5 degree C drop in core body temperature. When patients are hypothermic, coagulation factors and platelets worsen, bleeding risk increases.
-bronchodilation: can be used to treat status asthmaticus.
5. LMA: less invasive, less risk of dental injury, less spasm of bronchi or larynx (esp in asthmatics), however its placement is less secure esp the smaller LMAs in kids and it does not protect against aspiration. It is only able to be used in patients who are spontaneously breathing (no paralytics), where the risk of aspiration is low and the surgery is <2-3 hours (because any more than that and you will start accumulating gastric juices that can then be aspirated.
6. ET: more invasive, more complications; more secure, protects against aspiration. Use in patients at increased risk of aspiration (bad GERD, DM gastroparesis, emergency surgery where the pt has not had time to be NPO for long enough, surgery >2-3 hours), laproscopic surgery-- because the air in the belly increases intraabdominal pressure, means higher vent pressures are required for adequate ventilation, and >20 cmH20 pressure ventilating via LMA will lead to filing stomach with air, making the surgeon's job harder.
7. Dealing with bronchospasm while intubated: albuterol into endotracheal tube (much of the drug will get stuck to the walls of the tube, so give 10-20 puffs and chase with air), or can increase dose of inhaled anesthetics, i.e. "go deeper", since they cause bronchodilation.
8. Adult airways are cylindrical, kids are conical with the smallest diameter at the cricoid cartilage (only tracheal cartilage that is a complete ring). When intubating adults, a cuff is needed to obstruct a portion of the trachea to deliver effective positive pressure beyond it; but if the right diameter tube is chosen, a cuff is theoretically not necessary in children since the cricoid cartilage should act as a seal against air regurgitation. However IRL, estimating the correct size may be difficult, requiring several attempts and the associated mucosal trauma that always accompanies multiple attempts of any sort of invasive procedure. The problem with a cuff is that it reduces the diameter of the tube that you can use-- this is mostly relevant in neonates/NICU babies where the tubes are already so small that even a small reductions will significantly reduce airflow.
9. Pressure of the ET tube or its cuff on the walls of the tracheal mucosa can cause ischemia or even future stenosis; in order to minimize this risk, fill the cuff/fit the tube to leak at a pressure of 20cmH20: less than that and you won't be able to ventilate adequately, tighter than that and you'll cause unnecessary damage.
10. EKG in surgery for non-cardiac patients: 
-5 leads in most adults (can see arrhythmia, some ischemia changes although no precordial leads)
-3 kids in most kids: rhythm only, cannot see ischemia, since you're rarely worried about ischemia in kids.

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