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Transcript: Anesthesia Case Study HPI: Pt. is a 50 year-old Hispanic woman with diabetes, HTN, and a BMI of 54. She has been experiencing bilateral knee pain for the past several years, and was referred to the orthopedic service. She presents today for total left knee arthroplasty. Obesity The Issue TKA among morbidly obese is more costly and more likely to have negative outcomes Weight loss options should be considered for these patients Weight maintenance options should be explored for those not already fat. Outcomes Given the enormous gravity and high cost of obesity, is TKR a cost-effective intervention among the morbidly obese? Is it effective at all? Questions? "Morbid Obesity and Excessive Hospital Resource Consumption for Unilateral Primary Hip and Knee Arthroplasty". The Jounral of Arthroplasty, Dec. 2010. Purpose: Estimate number of THA or TKA performed on the morbidly obese, and estimate economic impact of morbid obesity on hospital resource use. Findings: 20,964 TKA (4.2%) were morbidly obese. When controlling for sex, age, race, and primary payer, TKA consumes 7% ($1025) more hospital resources than nonobese patients. Epidemiology Conclusion More than 1/3 of adults are obese. 17% of children aged 12-19 are obese. Health care costs attributable to obesity in 1998: $78.5 billion Health care costs attributable to obesity in 2008: $147 billion Currently 10% of health care costs Resource Consumption "Total Knee Replacement in the Morbidly Obese: A Literature Review". ANZ Jounral of Surgery, Sept. 2010.. Purpose: evaluate outcomes of TKR in the morbidly obese Findings: clinical and functional measures improve after surgery. However, deep prosthetic infection was 3-9 times more prevalent than in controls. Furthermore, TKA did not result in weight loss. Therefore, morbidly obese patients should be counseled to lose weight before pursuing surgery. Cost

Chemistry Anesthesia Presentation

Transcript: Kaitlyn Almquist Anesthesia General Anesthesia C12H18O Propofol John B. Glen Origin Uses Physical and Chemical Properties https:/ Reaction Phenol, 2,4,6-tris(1-methylethyl)- Phenol, 2-(1-methylethyl)- Propofol Phenol, 2,4-bis(1-methylethyl)- Interesting Facts Sources

Epidural Anesthesia Presentation

Transcript: Epidural anesthesia decreases pulmonary function during labor. Lung function is decreased during the procedure due to the motor blockade. Women that have severe asthma or chronic pulmonary disease need to put this information into consideration. An epidural anesthesia is the best method of anesthesia for postoperative outcome and has the lowest chance of postoperative pulmonary complications (Groeben 290). The purpose of this analysis is to provide an overview for anesthesiologists, obstetrics professionals, and women considering an epidural anesthesia (Merrill 1). Anesthesia and analgesia are interchangeable terms, analgesia is just one general aspect of anesthesia. Works Cited Thesis Statement Epidural Anesthesia and Health Risks Neurological Deficits Following Epidural or Spinal Anesthesia (Halpern et al.) Effects of Epidural vs Paternal Opioid Analgesia on the Progression of Labor Epidural anesthesia provides numerous benefits for women in labor. It prevents both, the adverse biochemical changes and stress during labor. The procedure also prepares women for the possibility of forceps, cesarean section, or the delivery of a second twin without the need for general anesthesia. This method is also beneficial for women with pre-eclampsia; this method suppresses noradrenaline contractions, instead producing beneficial haemodynamic changes ( Reynolds 751). Epidural Analgesia in Obstetrics Paralysis can occur after an epidural anesthesia procedure. The paralysis occurs in three out of fifty thousand women that have an epidural anesthesia during labor. The paralysis has lasted from seventy two hours up to four months after the procedure (Kane 150).The paralysis could have been caused by being administered a toxic chemical or by a chemical contamination of the anesthesia (Kane 159). " Epidural anesthesia for women in labor may be beneficial at the time of labor, but it is not always beneficial for women in the long run" (Merrill 1). Epidural Anesthesia and Pulmonary Function Women that experience labor at night have to deal with the increased risk of an unintentional dural puncture in the lower back. The unintentional dural puncture is caused from the anesthesiologist being fatigued, motor skills not as sharp, and less focused. A dural puncture can occur at any time of day this causes backaches and headaches for an unspecified duration after the epidural anesthesia procedure (Aya 666). Increased Risk of Unintentional Dural Puncture in Night-time Obstetric Epidural Anesthesia Epidural Analgesia Compared With Combined Spinal-Epidural Analgesia During Labor in Nulliparous Women Epidural anesthesia prevents walking during labor, for the procedure causes a motor blockade. A combined spinal-epidural anesthesia injection is a one time injection that allows for movement. This procedure is a one time injection, unlike an epidural anesthesia which remains in during labor. Since this method does not cause a motor blockade their is no chance of paralysis (Nageotte et al.). Images found on google images

Anesthesia Case Presentation

Transcript: REVIEW OF SYSTEMS Standard PACU monitoring (EKG, sO2, NIBP, temp) Pain can be treated with Hydromorphone in 0.2mg doses PONV can be treated with additional doses of Zofran 4mg q4h to maximum of 16mg Maintain normal hemodynamics (BP and HR within 20% of baseline) QUESTION 1 PATIENT AND PROCEDURE ANALYSIS: ASA 3 PLAN Induction & Airway ALL at age 6 treated with Anthracycline chemotherapy HTN (Controlled on metoprolol (baseline 142/75)) N/V and motion sickness (No treatment) Diagnosed OSA (patient snores loudly and wakes up at night) - does not tolerate his nasal CPAP BPH CVA (without deficit) preceding heart transplant Gout (Takes prenisone, recent flare up s/p prednisone dose increase) HLD Works out every other day (heavy weight lifting and cardio) Discussion with surgeon regarding positioning prone position may require ETT intubation, which will require relaxation and subsequent reversal. Research shows that ProSeal LMA can be inserted and used in the prone position, and provides a seal up to 30cm H2O, reducing induction-incision time and increasing intraoperative hemodynamic stability (Brimacombe, et al, 2007) (Wekseler, et al, 2007) ultimately decided on a lateral position with the ProSeal LMA H&P reviewed Review tests as indicated from H&P TTE, Dobutamine Stress Echo, EKG, Right Heart Catheterization, Cardiac Consult (heart transplant, HTN) BUN, SCr, Renal Consult (kidney transplant) CBC (rectal bleeding) Plan discussed with patient. Consent signed and confirmed. Renal Positioning: left lateral position with right arm free draped T&S verified at blood bank Standard ASA Monitors 16-20g x 1 IV required Fluids at 5-8mL/kg/hr Ancef 1g Disposition planning: to PACU, then home thorough report to PACU nurse, verifying understanding of patient considerations Emergence Anthracycline induced cardiomyopathy s/p Orthotopic Heart Transplant in 2000 GETA with no complications noted Echo showed moderate LVH, with normal LV function (EF 55-60%) Right Heart Cath showed RV systolic pressure of 24-38 mmHg, PAP of 24/11 mmHg and Cardiac Index of 2.4 L/min/m2 Dobutamine Stress Echo from 6/2014 showed no evidence of ischemia EKG was NSR at 90 BPM CXR showed no evidence of cardiomegaly Cardiac consult: stable cardiac function with normal LV function and no evidence of vasculopathy Maintenance Cardiac Transplanted Heart transplanted heart has no sympathetic, parasympathetic, or sensory innervation, and the loss of vagal tone results in a higher than normal resting heart rate no sympathetic response to surgical stimulation, intubation, or hypovolemia is "Preload Dependent" because the heart cannot increase its rate to increase cardiac output (severed connection to carotid baroreceptors) When hepatic and renal function are normal, there is no contraindication to the use of any anesthetic drug. (Akhtar, 2012) Case reports show refractory bradycardia leading to asystole after administration of anticholinesterase neostigmine (unresponsive to anticholinergic treatment because of denervation of the heart) Indirect acting sympathomimetics are ineffective at increasing heart rate - must use epinephrine or isoproterenol EF 55-60%, negative stress echo with excellent exercise tolerance, and the patient will continue his beta blocker perioperatively. With an understanding of transplanted cardiac physiology, there is no contraindication to the planned procedure. QUESTION 2 Other PAST MEDICAL HISTORY Cancer QUESTIONS At conclusion of surgery, LMA should be removed deep to prevent coughing/bucking and potential dehiscence at surgical site adequate Vt (at least 5mL/kg) and RR (10-20/min) should be used as guides RR can guide fentanyl during emergence Treat hypotension with phenylephrine, Hypertension with Labetalol or fentanyl If plan B must be used, treat refractory bradycardia during reversal with epinephrine Transfer patient to PACU with 3L O2 via NC, give detailed report to PACU nurse, including recommendations QUESTION 4 How is the innervation of the transplanted heart different from the native heart? Akhtar, S. (2012). Ischemic Heart Disease. In Hines, R. L. & Marschall, K.E. (Eds), Stoelting's anesthesia and co-existing disease (pp. 1-30). Philadelphia: Elsevier Saunders. Brimacombe J. R., Wenzel V., Keller C. (2007) The proseal laryngeal mask airway in prone patients: A retrospective audit of 245 patients. Anaesthesia Intensive Care, 35(2):222-5. Jaffe, R. A. (2014). Anesthesiologist's manual of surgical procedures. Philadelphia: Walters Kluwer Health. Morgan, G.E., Mikhail, M. S., Murray, M. J. (2006). Clinical anesthesiology. McGraw Hill. Weksler N., Klein M., Rozentsveig V., Weksler D., Sidelnik C., Lottan M., Gurman G.M. (2007). Laryngeal mask in prone position: Pure exhibitionism or a valid technique. Minerva Anestesiology 73(1-2):33-7. Which special considerations do we take for the kidney transplant recipient? Prednisone (recently increased to 40mg) (will take DOS) Lopressor 25mg (will take DOS) ASA 81mg (continued in

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