Effects on organ systems

Cardiovascular ketamine increases arterial blood pressure, heart rate, and cardiac output. The direct myocardial depressant effects of ketamine (large doses) are unmasked by sympathetic blockade or patients who are catecholamine depleted. 2. Respiratory ventilation is minimally affected with normal doses of ketamine. Ketamine is a potent bronchodilator. 3. Cerebral ketamine increases cerebral oxygen consumption, cerebral blood flow, and intracranial pressure. E. Drug interactions...

Systemic effects of ophthalmic drugs

Anticholinesterases (echothiophate, phospholine iodide) systemic absorption leads to inhibition of plasma cholinesterase which may lead to prolongation of the duration of action of succinylcholine. Takes 3 weeks for pseudocholinesterase levels to return to 50 of normal. The metabolism of mivacurium and estertype local anesthetics may also be affected. B. Cholinergics (pilocarpine, acetylcholine) used to induce miosis toxicity may manifest in bradycardia or acute bronchospasm. C....

Orotracheal intubation

Head position place the head in the sniffing position if there is no cervical spine injury. The sniffing position is characterized by flexion of the cervical spine and extension of the head at the atlanto-occipital joint (achieved by placing pads under the occiput to raise the head 8-10 cm). This position serves to align the oral, pharyngeal, and laryngeal axes such that the passage from the lips to the glottic opening is most nearly a straight line. The height of the OR table should be...

Hydrocortisone Solu Cortef

Actions anti-inflammatory, antiallergic, mineralocorticoid effect stimulation of gluconeogenesis inhibition of peripheral protein synthesis membrane stabilizing effect. Indications adrenocortical insufficiency, inflammation and allergy, cerebral edema from CNS tumors, asthma. Dose (acute adrenal insufficiency) adult 100 mg bolus IV, then 300 mg day IV 3 divided doses or as a continuous infusion older children 1-2 mg kg dose IV, then 150-250 mg day IV in 3-4 divided doses infants young children...

For 3 days Dose ped

Anti-inflammatory immunosuppressant 0.121.7 mg kg day IV IM PO in divided doses every 612 hrs pulse therapy 15-30 mg kg day once daily for 3 days. Status asthmaticus load 2 mg kg IV, then 1 mg kg dose every 6 hrs. Lupus nephritis 30 mg kg IV every other day for 6 doses. Acute spinal cord injury 30 mg kg IV over 15 minutes, followed in 45 minutes by a continuous infusion of 5.4 mg kg hr for 23 hrs. Clearance hepatic metabolism renal elimination. Contraindications serious infections except septic...

Aminocaproic Acid Amicar

Actions stabilizes clot formation by inhibiting plasminogen activators (fibrinolysis inhibitor) and plasmin. Indications excessive acute bleeding from hyperfibrinolysis, chronic bleeding tendency antidote for excessive thrombolysis. Dose loading dose of 100-150 mg kg IV over the first 30-60 minutes followed by constant infusion of 33.3 mg kg hour for about 8 hours or until bleeding controlled. Most common regimen for adult 5 gram loading (started prior to skin incision) followed by constant...

Amiodarone Cordarone

Actions inhibits adrenergic stimulation, decreases A-V conduction and the sinus node function, prolongs the PR, QRS, and QT intervals, and produces alpha- and beta-adrenergic blockade. Indications refractory or recurrent ventricular tachycardia or VF, SVT, PSVT. Dose (cardiac arrest) adult 300 mg IVP consider repeating 150 mg IVP in 3-5 minutes, max dose 2.2 gm IV 24 hours ped 5 mg kg IV IO. Dose (tachyarrhythmias-adult) load with 150 mg IV over first 10 minutes (may repeat 150 mg every 10...

Anesthetic management

Blood pressure should be kept within 10-20 of preoperative levels. B. Many patients with hypertension display an accentuated hypotensive response to induction (unmasking of decreased intravascular volume) followed by an exaggerated hypertensive response to intubation. C. Techniques used to attenuate the hypertensive response to intubation 1. Deepening anesthesia with a volatile agent. 2. Giving a bolus of narcotic fentanyl, 1-5 mcg kg alfentanil, 15-25 mcg kg sufentanil, 0.25-0.5 mcg kg or...

Apnea of prematurity

Premature infants less than 50-60 weeks postconceptional age (gestational age plus chronological age) are prone to postoperative episodes of obstructive and central apnea for up to 24 hours. B. Risk factors include low gestational age at birth, necrotizing enterocolitis, neurologic problems, anemia (< 30 ), hypothermia, and sepsis. C. Elective or outpatient procedures should be deferred until the preterm infant reaches the age of at least 50 weeks postconception. If surgery planned,...

Preoperative

Preoperative evaluation of morbidly obese patients for major surgery should include a chest x-ray, EKG, arterial blood gas, and PFTs. 2. The airway should be carefully examined since these patients are often difficult to intubate as a result of limited mobility of the temporomandibular and atlanto-occipital joints, a narrowed upper airway, and a shortened distance between the mandible and increased soft tissue. 3. All obese patients are at an increased risk of aspiration and should be...

Aspirin Acetylsalicylic Acid

Actions irreversibly inhibits platelet cyclo-oxygenase, inhibits the formation of platelet-aggregating substance thromboxane A2 platelet aggregation, acts on hypothalamus heat-regulating center to reduce fever. Indications treatment of mild to moderate pain, inflammation, and fever adjunctive treatment of Kawasaki disease used for prophylaxis of myocardial infarction and transient ischemic episodes. Dose (adult) analgesic and antipyretic 325-650 mg every 4-6 hours PO or rectal anti-inflammatory...

Atropine Sulfate

Actions competitive blockade of acetylcholine at muscarinic receptors increases cardiac output, dries secretions, antagonizes histamine and serotonin. Indications bradycardia antisialagogue exercise-induced asthma, antidote for organophosphate pesticide poisoning, mydriasis and cycloplegia. Dose (antisialagogue) adult 0.2-0.4 mg IV ped 0.01 mg kg dose IV IM. Dose (bronchospasm) 0.025-0.05 mg kg dose in 2.5 ml NS q6-8 hours via nebulizer (min dose 0.25 mg max dose 1 mg). Dose (bradycardia) adult...

Complications

Anesthetic level recedes faster in children than 2. Hypotension is rare in children under 10 years. 3. Contraindicated in children with CNS anatomic defects and a history of grade III-IV intraventricular hemorrhage. 3. Caudal and lumbar epidural anesthesia A. Dural sac in the neonate ends at S3. B. Caudal epidural provides excellent postoperative analgesia for circumcision, hypospadias repair, orchiopexy, herniorrhaphy and some orthopedic procedures. 1. Infants 22g catheter placed (40-50 mm)...

Facet joint syndrome

Pain from facet joints tend to be localized to the back with radiation to the buttock and posterior thigh (and rarely below the knee joint). Pain also occurs with extension and rotation of the spine. Accounts for about 15 of low back pain. 2. Diagnosis can be make by diagnostic blockade with local anesthetic. Radiological studies are rarely helpful in making the diagnosis. 3. Medial branch rhizotomy can provide long-term analgesia for facet joint disease in the lumbar and cervical spine.

Monitoring

Intraarterial blood pressure monitoring is mandatory. 2. Additional hemodynamic monitoring should be based primarily on the patients underlying cardiac function. Carotid endarterectomy is not usually associated with significant blood loss or fluid shifts. 3. Cerebral monitoring electroencephalogram and somatosensory evoked potentials (SSEP) have been used to determine the need for a shunt. C. Despite technique mean arterial blood pressure should be maintained at or slightly above the patient's...

Monoamine oxidase inhibitors

Mechanisms blocks the enzyme monoamine oxidase, thus inhibiting the breakdown of monoamines results in increased neurotransmitters epinephrine, norepinephrine, and dopamine requires 2 weeks to achieve inhibition and 2-4 weeks for clinical effects. 2. Adverse effects orthostatic hypotension, agitation, tremor, seizures, muscle spasms, urinary retention, paresthesias, jaundice, tyramine-induced hypertensive crisis (e.g., some cheeses, chianti wine, chocolate, liver, fava beans, avocados)...

Physiologic changes associated with brain death

Cardiovascular instability is a common feature, secondary to loss of neurologic control of the myocardium and vascular tree. Fluid resuscitation should be used to keep systolic blood pressure greater than 100 mmHg and mean arterial pressure greater than 70 mmHg. 2. Central diabetes insipidus may occur from hypothalamic failure resulting in extreme salt and water wasting from the kidneys. Massive loss of fluid and electrolytes that may occur. Aqueous pitressin should be administered in doses of...

Discontinuation from cardiopulmonary bypass

Pressure maintenance transfuse from CPB reservoir to maintain left atrial pressure or PA occlusion pressure. Optimal filling is determined by blood pressure, cardiac output, and direct observation of the heart. A. Maintenance of hemodynamics (see table) 1. Low cardiac output (despite adequate filling pressure and rhythm) may indicate the need for a positive inotrope. Consider dopamine, dobutamine, amrinone and epinephrine. 2. High cardiac output but low BP consider a vasoconstrictor. RV...

Cardiovascular Physiology

Cardiopulmonary Hemodynamic Parameters Normal intervals (each small block 0.04 sec) Lead Changes Due to Injury Ischemia With Artery Area of Damage LV dysfunction, CHF, BBBs, complete heart block, PVC LV dysfunction, AV nodal block in some Hypotension, sensitivity to nitroglycerin and morphine RV, inferior wall LV, posterior wall LV Hypotension, supranodal and AV-nodal blocks, atrial fib flutter, PACs Either LCA (circumflex) or RCA (posterior descending branch) LCA left coronary artery RCA right...

Cardiovascular toxicity

Local anesthetics depress myocardial automaticity (spontaneous phase IV depolarization) and reduce the duration of the refractory period (manifesting as prolonged PR interval and widening QRS. B. Myocardial contractility and conduction velocity are depressed at higher concentrations. Smooth muscle relaxation causes some degree of vasodilation (with the exception of cocaine). C. Cardiac dysrhythmia or circulatory collapse is often a presenting sign of local anesthetic overdose during general...

Factors that increase endtidal CO2

Anesthetic breathing circuit error. C. Faulty circle absorber valves. 6. Improved blood flow to lungs after resuscitation D. Causes of decreased end-tidal CO2. 2. Apnea, total airway obstruction, or circuit disconnection. 3. Inadequate sampling volume or sampling tube leak. 4. Incorrect placement of sampling catheter. 8. Decreased blood flow to lungs (reduced cardiac output). 1. Increased baseline if increased, patient is receiving CO2 during inspiration. Sources...

Clinical manifestations

Cardinal manifestations hypertension, paroxysmal headaches, palpitations and diaphoresis. B. Other manifestations include tachycardia, flushing, anxiety, tremor, hyperglycemia, polycythemia, cardiomyopathy, intracerebral hemorrhage, decreased intravascular fluid volume, and weight loss. C. Unexpected intraoperative hypertension and tachycardia maybe first indication of undiagnosed pheochromocytoma. D. Diagnosis is confirmed by abnormally high levels of catecholamines or catechol metabolites...

Minimum alveolar concentration MAC

The minimum alveolar concentration of an inhalation agent is the minimum concentration necessary to prevent movement in 50 of patients in response to a surgical skin incision. 2. The minimum alveolar concentrations required to prevent eye opening on verbal command, to prevent movement and coughing in response to endotracheal intubation, and to prevent adrenergic response to skin incision have been defined. These are called MAC Awake, MAC Endotracheal Intubation, and MAC BAR (for blockade of...

Combined spinalepidural for labor

Combined spinal epidural may be useful for patients presenting in early labor because the spinal can be given to help with early labor pain, while the epidural can be activated after the patient is in active labor. B. Spinal 25 mcg fentanyl or 10 mcg Sufentanil in 1 cc PF saline. C. An epidural is initiated as noted above after the pain returns. 6. Paracervical block local anesthetic is injected in the submucosa of the fornix of the vagina lateral to the cervix only effective during the...

Complications of the LMA

Possibility of regurgitation and pulmonary aspiration. B. Oral and pharyngeal mucosa injury during insertion of the LMA. C. Laryngospasm and coughing (may occur in lightly anesthetized patient). D. Negative pressure pulmonary edema after improper placement in spontaneously breathing patient. E. The failure to function properly in the presence of local pharyngeal or laryngeal disease. F. The need for neck extension in the patient with cervical spine disorder. ETT endotracheal tube * cuffed...

Patterns of stimulation

Single twitch supramaximal stimulus (0.2 ms at a frequency of 0.1 Hz) the height of the muscle twitch is determined as a percent of control. Used to monitor the onset of neuromuscular blockade. 2. Tetanic stimulus frequencies vary from 50 to 200 Hz. 3. Posttetanic single twitch measured by single-twitch stimulation 6-10 seconds after a tetanic stimulations. 4. Train-of-four denotes four successive 200 microsecond stimuli in 2 seconds (2 Hz). The ratio of the responses to the first and fourth...

Pharmacologic characteristics see table

Temperature hypothermia prolongs blockade by decreasing metabolism and delaying excretion. 2. Acid-base balance respiratory acidosis potentiates the blockade of most nondepolarizing relaxants and antagonizes the reversal. 3. Electrolyte abnormalities hypokalemia and hypocalcemia augment a nondepolarizing block. Hypermagnesemia potentiates blockade. 4. Age neonates have an increased sensitivity to nondepolarizing agents. 5. Drug interactions drugs that potentiate nondepolarizing relaxants...

Desmopressin Acetate DDAVP

Actions synthetic analog of human ADH used to treat neurogenic diabetes insipidus enhances reabsorption of water in kidneys by increasing cellular permeability of the collecting ducts promotes release of coagulation factors (procoagulant factor VII, von Willebrand factor) from vascular endothelium. Indications diabetes insipidus controlling bleeding in patients with hemophilia A, von Willebrand's disease and thrombocytopenia (uremia) primary nocturnal enuresis. Preparation dilute IV to 0.5 mcg...

Diltiazem Cardizem

Actions calcium channel antagonist that slows conduction through SA and AV nodes, dilates coronary and peripheral arterioles, and reduces myocardial contractility. Indications angina pectoris, temporary control of rapid ventricular rate during atrial fibrillation flutter conversion of paroxysmal supraventricular tachycardia to normal sinus rhythm, hypertension. Dose (oral tablet) adult 30-120 mg PO 3-4 times day dosage should be increased gradually, at 1- to 2- day intervals until optimum...

Empiric regimen for perioperative supplementation

Patients taking less then 10 mg prednisone day do not require supplementation. B. For patients taking greater then 10 mg prednisone day consider 1. For major surgery give usual daily dose with premedications, cortisol 25 mg IV on induction, then 100 mg IV by infusion over the next 24 hours. Resume daily dose postoperatively. 2. For minor surgery give usual daily dose with premedications and cortisol 25 mg IV on induction. Resume daily dose postoperatively.

Enalapril Enalaprilat Vasotec

Actions competitive inhibitor or angiotensin-converting enzyme (ACE) results in lower levels of angiotensin II which causes an increase in plasma renin activity and a reduction in aldosterone secretion. Indications hypertension, congestive heart failure, left ventricular dysfunction after myocardial infarction. Preparation enalapril is PO enalaprilat is IV. Dose (hypertension) adult 2.5-5 mg day PO (enalapril) then increase as required (usual dose 1040 mg day in 1-2 divided doses) 0.625-5 mg...

Ephedrine

Actions alpha- and beta-adrenergic stimulation, norepinephrine release at sympathetic nerve endings (indirect). Indications hypotension, nasal congestion, bronchospasm. Dose (adult) 5-50 mg dose IV or 25-50 mg dose IM SC. Dose (ped) 0.2-0.3 mg kg dose. Clearance mostly renal elimination. Adverse effects may cause hypertension, dysrhythmias, myocardial ischemia, CNS stimulation, decrease in uterine activity. Comments minimal effect on uterine blood flow avoid in patients taking monoamine oxidase...

Epinephrine Racemic Vaponefrin

Actions mucosal vasoconstriction (see epinephrine). Indications airway edema, bronchospasm. Dose (adult) inhaled via nebulizer 0.5 mL of 2.25 solution in 2.5-3.5 mL of NS q1-4 hr prn. Dose (ped > 2 yrs) inhaled via nebulizer 0.25-0.5 mL of 2.25 solution in 2.5-3.5 mL NS. Dose (ped < 2 yrs) inhaled via nebulizer 0.25 mL of Comments rebound airway edema may occur.

Translaryngeal transtracheal nerve block

Landmarks cricothyroid membrane (located between the thyroid cartilage superiorly and the cricoid cartilage inferiorly). 2. Insert a 20 g angiocath, bevel up, at the upper edge of cricoid cartilage in the midline. Aspirate for air to confirm placement. Remove the needle, leaving only the angiocatheter. Inject 3-5 cc of 24 lidocaine solution at end inspiration. This will usually result in a vigorous cough. 7. Oral intubations after proper preparation of the patient, oral intubation can be...

Fiberoptic Assisted Tracheal Intubation

Indications upper airway obstruction, mediastinal mass, subglottic edema, congenital upper airway abnormalities, immobile cervical vertebrae, verify position of a double-lumen endobronchial tube. 2. Nasal technique after the patient's nares and nasopharynx are anesthetized and vasoconstricted, the tracheal tube is passed through the naris into the posterior nasopharynx. The lubricated bronchoscope is then passed through the tracheal tube until the epiglottis and glottic opening are visualized...

General considerations

Indications TIAs associated with ipsilateral severe carotid stenosis (> 70 occlusion), severe ipsilateral stenosis in a patient with a minor (incomplete) stroke, and 30-70 occlusion in a patient with ipsilateral symptoms (usually an ulcerated plaque), emboli arising from a carotid lesion, large ulcerated plaque. B. Operative mortality is 1-4 (primarily due to cardiac complications). C. Perioperative morbidity is 4-10 stroke is the most common and expected major complication during and...

Head trauma

Glasgow Coma Scale (GCS) correlates with the severity of injury and outcome. Total score possible 3-15. 1. Best motor response 6-obeys commands 5-localizes pain 4-withdrawals 3-flexion decorticate rigidity 2-extension decerebrate rigidity 1-no motor response. 2. Best verbal response 5-oriented, conversant 4-disoriented, conversant 3-inappropriate words 2-incomprehensible sounds 1-no verbalization response. 3. Eye opening 4-spontaneous 3-to verbal stimulation 2-to pain 1-no response. B....

HELLP syndrome

HELLP syndrome hemolysis, elevated liver enzymes, low platelets. B. Incidence 4-12 of severe PIH patients. C. Reported perinatal mortality 7.7-60 maternal mortality 3.5-24.2 . D. Diagnostic criteria platelet count less than 100,000 mm3, hemolysis by peripheral smear and increased bilirubin greater than 1.2 mg dL, SGOT greater than 70 U L and LDH greater than 600 U L. E. High incidence of maternal complications including abruptio placenta, coagulopathy (DIC, prolonged PT and PTT), acute renal...

Inhaled Anesthetics

Well tolerated (non-irritant, sweet odor), even at high concentrations, making this the agent of choice for inhalational induction. 2. Rapid induction and recovery (low blood gas coefficient) 3. Does not sensitize the myocardium to catecholamines as much as halothane. 4. Does not result in carbon monoxide production with dry soda lime. 1. Less potent than similar halogenated agents. 2. Interacts with CO2 absorbers. In the presence of soda lime (and more with barium lime) compound A (a vinyl...

Intraarticularintralesional 440 mg up to

Antiinflammatory immunosuppressant 2-60 mg day PO in 1-4 divided doses to start, followed by gradual reduction in dosage to the lowest possible level consistent with maintaining an adequate response. PO 2-60 mg in 1-4 divided doses. IM (sodium succinate) 10-80 mg day once daily. IM (acetate) 40-120 mg every 1-2 weeks. IV (sodium succinate) 10-250 mg over several minutes repeated as needed every 4-6 hrs. Status asthmaticus load 2 mg kg dose IV (sodium...

Lane

Lidocaine, atropine, naloxone, and epinephrine. 2. Drugs administered via the endotracheal route should be diluted to a volume of 3-5 mL of normal saline or followed by a 3-5 mL normal saline flush, followed by several positive-pressure ventilations. Summary of Basic Life Support Techniques Pediatric Emergency Drugs and Defibrillation 0.1-0.2 mg kg subsequent doses doubled Give rapid IV bolus max single dose 12 mg Max single dose 0.5 mg in child, 1.0 mg in adolescent 5 mg kg (may be increased...

Laparoscopic Surgery

Contraindications (relative and absolute) increased intracranial pressure, patients with ventriculoperitoneal or peritoneojugular shunts, hypovolemia, CHF, previous abdominal surgery with significant adhesions, morbid obesity, pregnancy, and coagulopathy. 2. Pulmonary effects laparoscopy creates a pneumoperitoneum with pressurized Co2 (pressures up to 30 cm H2O). The resulting increase in intraabdominal pressure displaces the diaphragm cephalad, causing a decrease in lung compliance and an...

Laryngospasm and laryngeal edema

Laryngospasm is a forceful involuntary spasm of the laryngeal musculature caused by sensory stimulation of the superior laryngeal nerve. Triggering stimuli include pharyngeal secretions or extubating in stage 2. The large negative intrathoracic pressures generated by the struggling patient in laryngospasm can cause pulmonary edema. B. Treatment of laryngospasm initial treatment includes 100 oxygen, anterior mandibular displacement, and gentle CPAP (may be applied by face mask). If...

Malignant hyperthermia treatment protocol

Stop triggering anesthetic agent immediately, conclude surgery as soon as possible. Continue with safe agents if surgery cannot be stopped. B. Hyperventilate 100 oxygen, high flows, use new circuit and soda lime. C. Administer dantrolene 2.5 mg kg IV repeat every 5-10 minutes until symptoms are controlled or a total dose of up to 10 mg kg is given. D. Correct metabolic acidosis administer sodium bicarbonate, 1-2 mEq kg IV guided by arterial pH and pCO2. Follow with ABG. E. Hyperkalemia...

Management of anesthesia

Preoperative all elective surgery should be postponed until the patient is rendered euthyroid with medical treatment. Preoperative assessment should include normal thyroid function tests, and a resting heart rate < 85 beats min. The combination of beta antagonists and potassium iodide is effective in rendering most patients euthyroid in 10 days. Consider esmolol when surgery cannot be delayed. Antithyroid medications and beta-blockers should be continued through the morning of surgery. B....

Management of hypoxia during onelung anesthesia

Increase oxygen to 100 . B. Change tidal volume (8-15 cc kg) and ventilatory rate. C. Periodic inflation of the collapsed lung with 100 oxygen. D. Continuous insufflation of oxygen into the collapsed lung. E. Adding 5 cm H2O of continuous positive airway pressure (CPAP) to the collapsed lung. F. Adding 5 cm H2O of positive end expiratory pressure (PEEP) to the ventilated lung. G. Adding additional CPAP, followed by additional PEEP. H. Early ligation of the ipsilateral...

Methylene Blue Urolene Blue

Actions low dose promotes conversion of methemoglobin to hemoglobin high dose promotes conversion of hemoglobin to methemoglobin less useful than sodium nitrate and amyl nitrite. Indications antidote for cyanide poisoning and drug induced methemoglobinemia an indicator dye for genitourinary surgery. Dose (marker) 100 mg (10 mL of 1 solution) IV. Dose (methemoglobinemia) 1-2 mg kg IV of 1 solution over 10 minutes repeat q1 hr prn. Clearance tissue reduction, urinary and biliary elimination....

Miscellaneous notes

Total dose for children should not exceed the adult dose. B. Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillin. C. Patients already taking antibiotics for another reason should be given an agent from a different class for endocarditis prophylaxis. D. Patients at risk for endocarditis who undergo open heart surgery should have prophylaxis directed primarily at staphylococci. E. Cardiac...

Mitral stenosis

Etiology is almost always rheumatic. B. Normal mitral valve are is 4-6 cm2. Symptoms occur when valve area is reduced to 2.5 cm2 and become severe with valve area below 1 cm2. Patients with valve areas between 1.5 cm2 and 2.0 cm2 are generally asymptomatic or have only mild symptoms on exertion. C. Features dyspnea on exertion atrial fibrillation (secondary to increased left atrial pressure and distention of the LA) pulmonary edema pulmonary hypertension tachycardia right ventricular...

Myocardial sensitizers halothane

Indirect catechol stimulators droperidol, ephedrine, TCAs, chlorpromazine, glucagon, metoclopramide. D. Monitors intraarterial catheter in addition to standard monitors consider central venous pressure monitoring. E. Intraoperative after tumor ligation, the primary problem is hypotension form hypovolemia, persistent adrenergic blockade, and prior tolerance to the high levels of catecholamines that abruptly ended. F. Postoperative hypertension seen postoperatively may indicate the presence of...

Nadolol Corgard

Actions competitively blocks response to beta1- and beta2-adrenergic stimulation does not exhibit any membrane stabilizing or intrinsic sympathomimetic activity. Indications treatment of hypertension and angina pectoris prevention of myocardial infarction prophylaxis of migraine headaches. Dose (adult) initially 40-80 mg day, increase gradually by 40-80 mg increments at 3-7 day intervals until optimum response is obtained with prolong slowing of heart rate doses up to 160-240 mg day in angina...

Narrow Complex Supraventricular Tachycardia Stable

Attempt therapeutic diagnostic maneuver A. Vagal maneuvers (carotid sinus pressure is contraindicated in patients with carotid bruits avoid ice water immersion in patients with ischemic heart disease). B. Adenosine 6 mg rapid IVP (over 1-3 seconds) may repeat with 12 mg rapid IVP in 1-2 minutes for a total of 30 mg. A. Preserved heart function no DC cardioversion, amiodarone, beta-blocker, or calcium channel blocker. B. Impaired heart (EF < 40 or CHF) no DC cardioversion, amiodarone. 3....

Nicardipine Cardene

Actions dihydropyridine calcium channel blocker, producing a relaxation of coronary vascular smooth muscle and coronary vasodilation. Indications short-term treatment of hypertension, chronic stable angina. Dose (adult) Oral 20-40 mg 3 times day, allow 3 days between dose increases. Oral (sustained release) 30-60 mg twice daily. IV 5 mg hr increased by 2.5 mg hr every 15 minutes (max of 15 mg hr). Clearance hepatic metabolism renal elimination. Contraindications severe hypotension, second or...

Nitroglycerin

Actions vasodilation through nitric oxide-induced relaxation of vascular smooth muscle venous dilation greater than arterial dilation (decrease of preload > decrease of afterload), coronary artery dilation, decreased systemic vascular resistance, decreased pulmonary vascular resistance. Indications myocardial ischemia, hypertension, congestive heart failure, pulmonary hypertension, esophageal spasm, controlled hypotension. Preparation (ped) weight (kg) x 6 mg of drug in 100 mL 1 mL hr 1 mcg...

Omeprazole Prilosec

Actions potent proton pump inhibitor suppresses gastric acid secretion by inhibiting the parietal cell H+ K+ ATP pump. Indications gastric acid hypersecretion conditions gastritis gastroesophageal reflux (GERD) erosive gastritis peptic ulcer disease prevention of acid aspiration pneumonitis during surgery. Dose (adult) Duodenal ulcer 20 mg day PO for 4-8 weeks. GERD or severe erosive esophagitis 20 mg day for 4-8 weeks maintenance therapy for erosive esophagitis 20 mg day. Gastric ulcer 40 mg...

Omphalocele and gastroschisis

Gastroschisis defect in abdominal wall lateral to umbilicus no hernial sac no associated congenital anomalies. B. Omphalocele defect in abdominal wall at the base of the umbilicus hernial sac present associated with congenital anomalies (trisomy 21, cardiac anomalies, diaphragmatic hernia, bladder anomalies). C. Management decompress stomach before induction intubate awake or asleep avoid nitrous oxide insure adequate muscle relaxation replace third-space fluid loses aggressively the neonate...

Oxytocin Pitocin

Actions produces rhythmic uterine smooth muscle contractions by increasing sodium permeability cause vasodilation of smooth muscle (renal, coronary, and cerebral) stimulates breast milk flow during nursing. Indications postpartum hemorrhage, uterine atony, augment labor. Dose (induction of labor) adult 0.001-0.002 units minute IV, increase by 0.001-0.002 units every 15-30 minutes until contraction pattern has been established max dose of 20 milliunits min. Dose (postpartum bleeding) adult 10-40...

Peripartum Hemorrhage

Placenta previa abnormal implantation of the placenta in the lower uterine segment incidence is 0.1-1.0 (higher in subsequent pregnancies) presents with painless vaginal bleeding typically around the 32nd week of gestation potential for massive blood loss risk factors include prior uterine scar, prior placenta previa, advanced maternal age, and multiparity. 2. Abruptio placentae premature separation of a normally implanted placenta after 20 weeks of gestation incidence is 0.2-2.4 may present...

Phenobarbital Luminal Solfoton

Actions suppresses discharge and spread from epileptic foci. Indications management of generalized tonic-clonic and partial seizures neonatal seizures febrile seizures sedation sleep disorders anxiety. Dose (adult) Sedation 30-120 mg day PO IM in 2-3 divided doses. Hypnotic 100-320 mg IM IV SC at bedtime. Hyperbilirubinemia 90-180 mg day PO in 2-3 divided doses. Preoperative sedation 100-200 mg IM 60-90 min before procedure. Dose (ped) Sedation 2 mg kg PO 3 times day. Hypnotic 3-5 mg kg IV IM...

Postanesthesia Care Unit Pain Control see

Moderate to severe postoperative pain in the PACU A. Meperidine 25-150 mg (0.25-0.5 mg kg in children). B. Morphine 2-4 mg (0.025-0.05 mg kg in children). 2. Nonsteroidal anti-inflammatory drugs are an effective complement to opioids. Ketorolac 30 mg IV followed by l5 mg q6-8 hrs. 3. Patient-controlled and continuous epidural analgesia should be started in the PACU.

Postoperative management

Monitoring of blood glucose must continue postoperatively. Pheochromocytoma (catecholamine excess) 1. Definition catechol-secreting tumors usually located in an adrenal gland. Most pheochromocytomas produce both norepinephrine and epinephrine. Endogenous catecholamine levels should return to normal levels within 1-3 days after successful removal of the tumor. Overall mortality 0-6 .

Postoperative Neurologic Complications

Delayed awakening the most frequent cause of a delayed awakening is the persistent effect of anesthesia or sedation. Other causes include recurarization, severe hypothermia, hypoglycemia, and neurologic disorders. 2. Emergence delirium (agitation) is characterized by excitement, alternating with lethargy, disorientation, and inappropriate behavior. Potential causes include arterial hypoxemia, hypercapnia, pain, unrecognized gastric dilation, urinary retention, and previous administration of...

Premedication for Adult Cardiac Surgery

Traditional premedications have included morphine 0.1-0.15 mg kg IM, scopolamine 0.3-0.4 mg IM (0.2 mg for patients older than 70 yrs), diazepam 0.15 mg kg or lorazepam 0.06 mg kg PO approximately 1-2 hours prior to surgery. Same day admission patients often receive IV fentanyl and a benzodiazepine (i.e., versed) to provide anxiolysis and pain relief instead of IM predications. 2. The dose of premedication should be reduced in patients with critical aortic or mitral stenosis, those undergoing...

QRS duration wide for age approximately 008 seconds

Probable ventricular tachycardia uncommon in most children seen in congenital heart disease, cardiomyopathy, myocarditis B. Immediate cardioversion with 0.5-1.0 J kg (may increase to 2 J kg). C. Consider alternative medications 1. Amiodarone 5 mg kg IV over 20-60 minutes or 2. Procainamide 15 mg kg IV over 30-60 minutes or 3. Lidocaine 1 mg kg IV bolus. 4. Identify and treat possible causes hypoxemia, hypovolemia, hypothermia, hyper hypokalemia, cardiac tamponade, tension pneumothorax,...

Secondary ABCD survey

Consider possible causes hypoxia, hypovolemia, hyper- hypokalemia and metabolic disorders, hypothermia, hydrogen ion acidosis, tension pneumothorax, cardiac tamponade, toxic therapeutic disturbances (such as tricyclics, digitalis, beta-blockers, calcium channel blockers), pulmonary embolism, and acute myocardial infarction. 5. Epinephrine 1 mg IVP, repeat every 3 to 5 minutes. 6. Atropine 1 mg IVP (if PEA rate less then 60 bpm), repeat every 3 to 5 minutes as needed, to a total does of 0.04 mg...

Stages of labor

First stage this stage begins with the onset of regular contractions and ends with full cervical dilation. Pain during the first stage is caused by uterine contractions and cervical dilatation. Pain is carried by the visceral afferent fibers (T10 to L1). Pain at the end of the first stage signals the beginning of fetal descent. B. Second stage this stage begins with full cervical dilation and ends with delivery of the infant. Pain in the second stage of labor is due to stretching of the...

Terbutaline and ritodrine

Selective beta-2 agonist beta-2 stimulation also produces bronchodilation and vasodilation and may result in tachycardia may cause dysrhythmias, pulmonary edema, hypertension, hypokalemia, or CNS excitement. B. Terbutaline dose 10 mcg min IV infusion titrate to a maximum dose of 80 mcg min. C. Ritodrine dose IV infusion of 0.1-0.35 mg min. 4. Magnesium sulfate is used most commonly in PIH, but it is also used as a tocolytic (see section on magnesium sulfate).

Terbutaline Brethine

Actions selective beta2 adrenergic agonist that relaxes bronchial smooth muscle and peripheral vessels Indications bronchospasm tocolysis. Dose (adult) bronchospasm 0.25 mg SC repeat in 15-30 min prn, max 0.5 mg within 4 hr period, 2.5-5 Dose (ped) 3.5-10 mcg kg dose SC every 15-20 Clearance hepatic metabolism renal elimination. Adverse effects may cause dysrhythmias, pulmonary edema, hypertension, hypokalemia, nervousness, tremor, headache, nausea, tachycardia, CNS excitement, palpitations....

Tonsillectomy and adenoidectomy

Manifestations lymphoid hyperplasia can lead to upper airway obstruction, obligate nasal breathing, and pulmonary hypertension evidence of airway obstruction, snoring, and apnea should be noted. B. Management anesthesia induction can be either inhalational or IV and maintenance provided by nearly any means strict attention to airway patency, hemostasis, and observation until the child is awake and in control of airway and secretions postoperative vomiting is common. C. Postoperative bleeding...

Watch for the following

Hypotension venous cannula problems (kink, malposition, clamp, air lock), inadequate venous return (bleeding hypovolemia, IVC obstruction), pump problems (poor occlusion, low flows), arterial cannula problem (misdirected, kinked, partially clamped, dissection), vasodilation (anesthetics, hemodilution, idiopathic, allergic), transducer or monitoring malfunction (stopcocks the wrong way). B. Hypertension pump problems (increased flow), arterial cannula misdirected), vasoconstriction (light...

Anticholinesterases

Mechanism of action Cholinesterase inhibitors inactivate acetylcholinesterase by reversibly binding to the enzyme increasing the amount of acetylcholine available to compete with the nondepolarizing agent. 2. In excessive doses, acetylcholinesterase inhibitors can paradoxically potentiate a nondepolarizing neuromuscular blockade and prolong the depolarization blockade of succinylcholine. 3. Anticholinesterases increases acetylcholine at both nicotinic and muscarinic receptors. Muscarinic side...

Myelodysplasia

Manifestations failure of neural tube closure can result in abnormalities ranging from spina bifida to myelomeningocele (abnormality involving vertebral bodies, the spinal cord and the brain stem). Ninety percent of myelomeningocele patients have Arnold-Chiari malformation (downward displacement of the brain stem and the cerebellar tonsils through the cervical spinal canal with medullary kinking, blocking normal circulation of the CSF and leads to progressive hydrocephalus. B. Management...

Perioperative betaadrenergic blockade

Has been shown to reduce the incidence of intraoperative and postoperative ischemic episodes and appears to be superior to prophylaxis with a calcium channel blocker alone. B. Eligibility is determined by the presence of any two minor criteria (age greater than 65, hypertension, current smoker, cholesterol greater than 240 mg dL, or non-insulin dependent diabetes) or any single major criterion (high-risk surgical procedure, history of transient ischemic attack or stroke, insulin dependent...

Pertinent cardiac history

Cardiac reserve limited exercise tolerance in the absence of significant pulmonary disease is the most striking evidence of decreased cardiac reserve. If a patient can climb several flights of stairs without symptoms, cardiac reserve is probably adequate. B. Angina pectoris an increase in heart rate is more likely than hypertension to produce signs of myocardial ischemia. C. Previous myocardial infarction the incidence of myocardial reinfarction in the perioperative period is related to the...

Dose treatment of drug extravasation

Adult 5-10 mg diluted in 10 mL NS infiltrated into area of extravasation within 12 hrs. Ped 0.1-0.2 mg kg diluted in 10 mL NS infiltrated into area of extravasation within 12 hrs. Dose diagnosis of pheochromocytoma Children 0.05-0.1 mg kg dose IV IM, maximum single dose 5 mg. Adult 5 mg IV IM. Dose surgery for pheochromocytoma hypertension Adult 5 mg IV IM given 1-2 hrs before procedure, repeat prn q2-3 hrs. Children 0.05-0.1 mg kg dose IV IM given 1-2 hrs before procedure, repeat prn every 2-4...

Uptake of the inhaled anesthetic

Solubility The solubility of inhaled anesthetics is defined as the amount of anesthetic agent required to saturate a unit volume of blood at a given temperature and can be expressed as the blood gas partition coefficient. The more soluble the agent, the greater the uptake into the pulmonary capillaries. The solubility of the inhalation agent in blood is the most important single factor in determining the speed of induction and recovery in individual patients. B. Cardiac output A high cardiac...

Hydroxyzine Vistaril

Actions antagonizes action of histamine on H1 receptors CNS depression antiemetic. Indications anxiety, nausea and vomiting, allergies, sedation. Dose ped 2-4 mg kg day PO divided every 6-8 hrs 0.5-1 mg kg dose IM every 4-6 hrs as needed. Dose adult antiemetic 25-100 mg dose IM every 4-6 hrs as needed anxiety 25-100 mg PO 4 times day max 600 mg day preop sedation 50-100 mg PO or 25-100 mg IM pruritus 25 mg PO 3-4 times day. Clearance hepatic P-450 metabolism renal elimination. Adverse effects...