EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect,...

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EVALUATION EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary ≈ fluid therapy - Modalities should complement one another

Transcript of EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect,...

Page 1: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

EVALUATIONEVALUATION

Clinical – History & PhysicalLaboratoryHemodynamic- All parameters are indirect, nonspecific

measures of volume - Serial evaluations necessary ≈ fluid therapy- Modalities should complement one another

Page 2: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

PHYSICALPHYSICAL

Most reliable preoperativelySkin turgor, hydration of mucous

membranes, fullness of peripheral pulse, capillary refill, resting HR & BP and changes from the supine to sitting or standing position, urinary excretion and fontanels in babies.

Page 3: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

LABORATORYLABORATORY Serial hematocrits Arterial blood pH Urinary specific gravity/osmolality >1.01/450

mOsm/kg Serum blood urea nitrogen (BUN)-to-creatinine

ratio > 10:1

Indirect indices of volume, esp intraoperatively Only X-ray signs reliable measures of volume

overload – Kerly B lines or intestitial markings

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HEMODYNAMICHEMODYNAMIC CENTRAL VENOUS PRESSURE (CVP) Cardiac output is based on the Frank starling mechanism

where force of contraction is determined by the initial fiber length and the contractility of cardiac muscle to determine stroke volume

We do not measure stroke volume, so pressure is used as a surrogate

The placement of a central venous catheter with its tip at junction SVC & RA provides measurable parameter of volume status or preload of patient

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PULMONARY ARTERY PRESSURE In the normal individual CVP measurement provides a

reasonably accurate estimate of the filling pressures of both R & L atria. In some situations not, and infusion of fluids or inotropic agents titrated against CVP may not result in optimum cardiac function

LV failure with pulmonary oedema Interstitial pulmonary oedema of any cause Chronic pulmonary disease Valvular heart disease

Page 6: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.
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PULSE PRESSURE VARIATIONPULSE PRESSURE VARIATION

Ventilation causes changes in intrathorasic pressure, influences cardiac filling

Responsible variation in BP during ventilation Identify highest and lowest BP Subtract highest DBP from highest SBP and

lowest DBP from lowest SBP Render pulse pressure variation Divide diff btw HPP & LPP by mean X 100

Page 8: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Highest SBP = 100 mmHgHighest SBP = 100 mmHgHighest DBP = 60 mmHgHighest DBP = 60 mmHgLowest SBP = 90 mmHgLowest SBP = 90 mmHgLowest DBP = 55 mmHgLowest DBP = 55 mmHg

HPP = 100 – 60 = 40 mmHgHPP = 100 – 60 = 40 mmHgLPP = 90 - 55 = 35 mmHgLPP = 90 - 55 = 35 mmHg

Difference btw HPP & LPP = 40 – 35 = 5 mmHgDifference btw HPP & LPP = 40 – 35 = 5 mmHgMean PP = (40+35) / 2 = 37.5 mmHgMean PP = (40+35) / 2 = 37.5 mmHg

therefore the PPV = (5/37.5) x 100 = 13.3%therefore the PPV = (5/37.5) x 100 = 13.3%> 12% indication of hypovolaemia ~ respond fluid> 12% indication of hypovolaemia ~ respond fluid

volume, < 8% non-responders, 8-12 grey areavolume, < 8% non-responders, 8-12 grey area

Page 9: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

INTRAVENOUS FLUIDS

Crystalloids, Colloids or both Crystalloids ~ aqueous sol low-molecular-weight

ions (salts) ± glucose Colloids ~ high-molecular-weight sub :- Protein colloids – Albumin :- Non protein colloids – gelatins (haemaccel, gelofusin) hydroxyethylstarchs (voluven, venofundin) sugars (dextrans)

Page 10: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Replacing intravascular volume deficit with crystalloids ~ 3X volume needed using colloids

Intravascular fluid deficits ~ more rapidly corrected using colloid solutions

Surgical patients ~ extracellular fluid deficit > intravascular deficit

Rapid administration of large amounts of crystalloids (>4-51) more frequently associated with significant tissue oedema

Intravascular ½ life crystalloids 20-30 min, colloids ½ life 3-6 hours

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PERIOPERATIVEPERIOPERATIVEFLUID THERAPYFLUID THERAPY

Replacement: pre-existing deficits, maintenance requirements and surgical wound losses

Maintenance fluid requirements

Weight Rate

For the firs 10 kg 4ml/kg/h

For the next 10-20 kg Add 2ml/kg/h

For each kg above 20 kg Add 1mi/kg/h

70 kg person fasting for 8h amounts to:

(40 + 20 + 50) ml/h X 8h = 880 ml

Page 12: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

BLOOD

VolumeOxygenationClotting

Page 13: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Prem 95ml / kgNeonate 90ml / kg> 3month 80ml / kg> 1y 70ml / kgMABL = EBV × ( I Hct – F Hct) /

Mean Hct

Mean Hct = ( I Hct + F Hct ) / 2

Whole blood = ( F Hct – I Hct) × Kg × 2.5

Packed RBC = (F Hct – I Hct) × Kg × 1,5

Page 14: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

DO2 = CO × CaO2

= (70 × 72) × [ (Hb × 1,34 × SaO2 ) +

(0,031 × PaO2) ]

= 5 × 200ml

= 1000ml/min Extraction ~ 200ml/min

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COMPLICATIONS OF COMPLICATIONS OF BLOOD TRANSFUSIONSBLOOD TRANSFUSIONS

HEMOLYTIC REACTIONSInvolves specific destruction of transfused RBC byrecipient’s antibodies, less common – hemolysisrecipient’s RBC due to transfusion of antibodies

ACUTE HEMOLYTIC REACTIONSFatal 1:100000In awake patients – chills, fever, nausea, chest and flank pain.In anaesthetized pts -↑ temp, ↑HR, hypotension,hemoglobinuria and diffuse oozing in surgical field. Disseminated intravascular coagulation & renal shutdown Severe with as little as 10-15ml ABO-incompatibility

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MANAGEMENT OF MANAGEMENT OF REACTIONREACTION

Hemolytic reaction suspected ~ stop transfusionRecheck identity bracelet against blood slipDraw blood for Hb, compatibility, platelet count

& coagulation studiesUrinary catheter inserted & urine checked for HbOsmotic diuresis initiated with mannitol & iv

fluidsPresence of rapid blood loss – Platelets & FFP

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DELAYED HEMOLYTIC REACTIONS

Following ABO & Rh-compatible transfusion, 1 – 1.6% chance antibodies against Kell, Duffy, Kidd etc antigens

Extravascular hemolysisMild – malaise, jaundice & fever 2-21 days

afterTreatment primarily supportive

Page 18: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

NONHEMOLYTIC REACTIONS

Sensitization of the recipient to donor white cells, platelets or plasma proteins

Febrile reactions Urticarial reactions Anaphylactic reactions Noncardiogenic pulmonary oedema Graft-Versus-Host disease Posttransfusion purpura Immune suppression

Page 19: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

ANAPHYLAXISANAPHYLAXIS

Definition: Allergic condition which results from an antibody-antigen reaction rapidly after the antigen entered the systemic circulation.

Signs:Resp: Bronchospasm, laryngeal oedemaCVS: Circulatory collapse – hypotensionSkin: Wheel & flare

Page 20: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

ManagementInitial Therapy

- Stop drug- Call for help - Airway management- Feet elevation- Drug Rx Adrenaline:

0.5 – 1mg IMI/10min 50 – 100μg IVI/ 1min (hypotension)

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Secondary Therapy- Antihistamines- Corticosteroids- Catecholamine infusion Adrenaline 0.05 – 0.1 μg/kg/min- Blood gas acidosis consider

Bicarbonate 0.5-1 mmol/kg- Airway evaluation before extubation- Bronchodilators in persistent

bronchospasm

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Investigations:-Only after emergency treatment has been completed- Dx on clinical grounds- Bloods: Serum tryptase concentration

1 hour after reaction 10ml red top centrifuge and store @ -20ºC until send to Lab

- Patient and GP must be alerted toward the reaction and drug causing it.

Potentially

Page 23: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

OBESITY

BMI – Body Mass Index is the weight (kg) divided by the square of the height (m)Normal range 18-25Overweight >27Obese >30Morbid obesity >35Massive morbid obesity >40? modeling not <18

 Broca Index - normal weight (kg) = height (cm) minus 100 for males or 105 for females- children weight (kg) = 10 + 2 age

 

Page 24: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Distribution – truncal, buttocks Respiratory - Difficult intubation - FRC - work of breathing, chest compliance - risk of aspiration: gastric volume,

: Hiatus hernia

:intra- abdominal pressure

- Obstructive sleep apnea esp after GA or

opioids, PCA ~ safer Nocturnal CPAP nasal oxygen mask Apnea monitor

Page 25: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.
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Cardiovascular - blood volume and CO Difficult: IV access

: BP measurement (cuff size –20% > arm

diameter ) arterial line PCA better than IM opiods Tromboprophylaxis & mobilization post-op  Medical conditions – Diabetes mellitus, Cushing’s

syndrome, hypothyroidism, syndromes (Prader-Willi or Lawrence-Moon-Biedl)

Table max 150kg

Page 28: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

LARYNGOSPASMLARYNGOSPASM

Definition – Acute glottic closure by the vocal cords

  Presentation – Crowing or absent inspiratory sounds and marked tracheal tug

Differential diagnosis - Bronchospasm - Laryngeal trauma / airway oedema - Recurrent laryngeal nerve damage - Tracheomalacia - Inhaled foreign body - Epiglottitis or croup

Page 29: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Management Avoid painful stimuli Remove irritants from airway 100% oxygen CPAP mask, jaw thrust ? Deepen anaesthesia Intractable: Muscle relaxation and intubation

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PACEMAKERS

  Indications – Third degree heart block

Mobitz type II block

Trifassicular block: RBBB

: Left ant/post hemiblock

: First degree heart block

Sick sinus syndrome

Symptomatic bradycardia

Post MI, HOCM, torsade de pointes

Page 31: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Pacemaker codePacemaker code Position 1- chamber(s) paced Position 2- chamber(s) sensed Position 3-response to a sensed elect. Signal Position 4- rate modulation Position 5- multi-site pacing

Page 32: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Pacemaker codePacemaker code

1 2 3 4 5Chamber paced

Chamber sensed

Response Rate modu lation

Anti-tachycardia

A=atrium

V=ventricle

D=dual

0=none

A=atrium

V=ventricle

D=Dual

0=none

I=inhibit

T=trigger

D=dual

0=none

R=rate mod

P=pacing

S=shock

D=dual

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ICD codeICD code

1 2 3 4Shock chamber

Chamber anti-tachy pacing

How tachy is sensed

Pacemaker code

0=none

A=atrium

V=ventricle

D=dual

0=none

A=atrium

V=ventricle

D=dual

E=intracardiac electrogram

H=haemodynameans

above

Page 34: EVALUATION Clinical – History & Physical Laboratory Hemodynamic - All parameters are indirect, nonspecific measures of volume - Serial evaluations necessary.

Anaesthetic implications

- Follow up clinic, function- Pre-op ECG : Absence of all spikes may represent

appropriate sensing or total failure!- Loss of capture : Hypokalaemia After defibrillation MI over lead Toxic levels of local anaesthetic Lead dislodgement - Bipolar diathermy safe- MRI