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Table 16.3 (continued) Problem Differential diagnosis Pulseless electrical activity (PEA) Severe electrolyte abnormality Myocardial infarction Severe metabolic acidosis Pneumothorax Pericardial tamponade Remarks COMMON INTRAOPERATIVE PROBLEMS ● 257 Treat underlying causes. with acetaminophen or ibuprofen and diphenhydramine, and usually do not result in any significant sequelae. Non-immunogenic problems related to transfusion often occur with massive transfusion (>4 units of packed red blood cells). Complications include hypothermia, hyperkalemia, dilution of coagulation factors, thrombocytopenia, and citrate toxicity causing hypotension. Severe transfusion reactions most commonly occur because of clerical or transporting error after typing and crossmatching blood. Careful checking of blood products with patient identification is the best single measure to prevent these types of reactions. Management of a severe transfusion reaction is found below in Table 16.4. Miscellaneous Intraoperative Problems Foley (bladder) catheters: If the Foley catheter was working but suddenly stopped putting out urine, check to see that it is not disconnected, kinked, or obstructed. This should be done before giving fluids or diuretics. A malfunctioning Foley catheter may be the reason for low urine output. Nasogastric (NG) or orogastric (OG) tube related problems: The nasogastric or orogastric tube will need ongoing care to maintain patency. This is how the GI tract remains decompressed during surgery and in the perioperative period. Keep both lumens open by occasionally injecting small amounts of air into each lumen while applying suction to the suction lumen. If the NG or OG is not working, it may be coiled or knotted. If possible, ask the surgeon to palpate it. If not, withdraw the NG/OG while maintaining suction. If the NG or OG does not come out with a little traction, do not force it: 1% of the time
258 ● ANESTHESIA STUDENT SURVIVAL GUIDE Table 16.4 Management of a suspected severe transfusion reaction. Action Rationale Remarks Stop transfusion immediately Replace infusion set with saline Limit exposure Mild fevers or urticarial reactions usually do not require stopping the transfusion; they can be treated with diphenhydramine, acetaminophen or ibuprofen, and famotidine + epinephrine if wheezing occurs. Monitor carefully Limit exposure Give 100% oxygen Hemolysis will limit the useful carrying of O by Hb 2 If hypotension/ bronchospasm, give epinephrine 50 mcg iv to 100 mcg Supports blood pressure and bronchodilates Consider IV corticosteroids Helps inhibit the immune response and anaphylactoid hypotension Give bronchodilators through the breathing circuit or ETT Send the blood bag, infusion set, a fresh urine sample, a fresh T&C to the blood bank. Consider central line placement Helps bronchodilate more specifically and gently than epinephrine The blood bank will initiate their protocol for finding the cause of the reaction. This may help diagnose hypovolemia in the face of oliguria Place Foley catheter Monitor urine out every hour and check for hemoglobinuria Monitor serum K + , BUN, Cr Follow renal failure by these electrolytes. Send a Coombs’s test (direct and indirect) and serum haptoglobin Indirect: used for typing and crossmatching Check serum haptoglobin Haptoglobin binds free Hb with high affinity If bacteremia suspected, give broad-spectrum antibiotics Prevent fulminant sepsis Give small doses as needed to support blood pressure; Use norepinephrine or dopamine to support blood pressure if needed. Hydrocortisone 150–300 mg Albuterol Most serious transfusion reactions are a result of bookkeeping or other clerical errors in checking and matching blood Direct: answers the question if hemolysis is immune-mediated If haptoglobin is low, hemolytic anemia has occurred
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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30 ● AnesthesiA student survivAl
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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● ● ● AnesthesiA eQuiPment An
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Table 11.3 Data typically obtained
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Anesthetic Techniques: General, Sed
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Anesthetic techniques: GenerAl, sed
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Table 12.2 Stages of general anesth
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Table 12.6 (continued) Anesthetic t
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Anesthetic Techniques: Regional Ant
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Figure 13.2 Surface anatomy for neu
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Table 13.1 Risks of neuraxial anest
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Anesthetic techniques: reGionAl ●
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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