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

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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


Physical
PHYSICAL

Most reliable preoperatively

Skin 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.


Laboratory
LABORATORY

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


Hemodynamic
HEMODYNAMIC

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


PULMONARYARTERY 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


Pulse pressure variation
PULSE 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


Highest SBP = 100 mmHgHighest DBP = 60 mmHgLowest SBP = 90 mmHgLowest DBP = 55 mmHgHPP = 100 – 60 = 40 mmHgLPP = 90 - 55 = 35 mmHgDifference btw HPP & LPP = 40 – 35 = 5 mmHgMean PP = (40+35) / 2 = 37.5 mmHgtherefore the PPV = (5/37.5) x 100 = 13.3%> 12% indication of hypovolaemia ~ respond fluidvolume, < 8% non-responders, 8-12 grey area


Intravenous fluids
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)


  • 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


Perioperative fluid therapy
PERIOPERATIVE 3X volume needed using colloidsFLUID THERAPY

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

  • Maintenance fluid requirements

  • 70 kg person fasting for 8h amounts to:

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


BLOOD 3X volume needed using colloids

  • Volume

  • Oxygenation

  • Clotting


  • Prem 95ml / kg 3X volume needed using colloids

  • Neonate 90ml / kg

  • > 3month 80ml / kg

  • > 1y 70ml / kg

  • MABL = 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


  • DO 3X volume needed using colloids2 = CO × CaO2

    = (70 × 72) × [ (Hb × 1,34 × SaO2 ) +

    (0,031 × PaO2) ]

    = 5 × 200ml

    = 1000ml/min

  • Extraction ~ 200ml/min


Complications of blood transfusions
COMPLICATIONS OF BLOOD TRANSFUSIONS 3X volume needed using colloids

HEMOLYTIC REACTIONS

Involves specific destruction of transfused RBC by

recipient’s antibodies, less common – hemolysis

recipient’s RBC due to transfusion of antibodies

ACUTE HEMOLYTIC REACTIONS

Fatal 1:100000

In 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


Management of reaction
MANAGEMENT OF REACTION 3X volume needed using colloids

  • Hemolytic reaction suspected ~ stop transfusion

  • Recheck identity bracelet against blood slip

  • Draw blood for Hb, compatibility, platelet count & coagulation studies

  • Urinary catheter inserted & urine checked for Hb

  • Osmotic diuresis initiated with mannitol & iv fluids

  • Presence of rapid blood loss – Platelets & FFP


Delayed hemolytic reactions
DELAYED HEMOLYTIC REACTIONS 3X volume needed using colloids

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

  • Extravascular hemolysis

  • Mild – malaise, jaundice & fever 2-21 days after

  • Treatment primarily supportive


Nonhemolytic reactions
NONHEMOLYTIC REACTIONS 3X volume needed using colloids

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


Anaphylaxis
ANAPHYLAXIS 3X volume needed using colloids

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

Signs:

Resp: Bronchospasm, laryngeal oedema

CVS: Circulatory collapse – hypotension

Skin: Wheel & flare


Management 3X volume needed using colloids

Initial Therapy

- Stop drug

- Call for help

- Airway management

- Feet elevation

- Drug Rx Adrenaline:

0.5 – 1mg IMI/10min

50 – 100μg IVI/ 1min (hypotension)


Secondary Therapy 3X volume needed using colloids

- 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


Investigations: 3X volume needed using colloids

-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 


Obesity
OBESITY 3X volume needed using colloids

BMI– Body Mass Index is the weight (kg) divided by the square of the height (m)

Normal range 18-25

Overweight >27

Obese >30

Morbid obesity >35

Massive 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


  • Distribution – truncal, buttocks 3X volume needed using colloids

  • 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


  • Cardiovascular - 3X volume needed using colloids 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


Laryngospasm
LARYNGOSPASM 3X volume needed using colloids

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


Management 3X volume needed using colloids

  • Avoid painful stimuli

  • Remove irritants from airway

  • 100% oxygen

  • CPAP mask, jaw thrust

  • ? Deepen anaesthesia

  • Intractable: Muscle relaxation and intubation


Pacemakers
PACEMAKERS 3X volume needed using colloids

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


Pacemaker code
Pacemaker code 3X volume needed using colloids

  • 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


Pacemaker code1
Pacemaker code 3X volume needed using colloids


Icd code
ICD code 3X volume needed using colloids


Anaesthetic implications 3X volume needed using colloids

- 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


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