Mitral stenosis is a narrowing of the mitral valve that causes obstruction of blood flow from the left atrium to the left ventricle. Rheumatic fever is the most common cause. Symptoms range from none in mild cases, to shortness of breath with exertion in moderate cases, to shortness of breath at rest in severe cases. Diagnosis is made through echocardiogram which can assess the severity based on metrics like mitral valve area and pressure gradients. Treatment depends on symptoms and severity, ranging from medications and lifestyle changes in mild cases, to balloon valvuloplasty or surgical commissurotomy in moderate to severe cases. Anesthetic management aims to avoid tachycardia and
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
Preoperative Incidental Detection & Anaesthetic Management of Valvular Heart ...Md Rabiul Alam
Surgical and Anaesthetic management of a patient with diseased heart is always challenging. Specially it sweats more when the issue is PREGNANCY. It demands skillful and sophisticated handling of the patient. Moreover, when the finding is incidental, a single break of concentration can be fatal.
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Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
3. INTRODUCTION
Mitral stenosis is the narrowing of mitral orifice as a result of
diffuse thickening of valve leaflets by fibrous tissue and calcific
deposits.
ETIOLOGY
Most common cause of mitral stenosis is rheumatic heart
disease.
Females are affected more than males.
Less common – carcinoid syndrome, left atrial myxoma, cor
triatriatum, rheumatoid arthritis, systemic lupus erythematosus
congenital.
Pure MS approximately in 40% rheumatic heart disease.
Time gap of development symptoms from rheumatic fever –
two decade in developed country but 5 – 15 yrs in developing
country
4. PATHOLOGY
Thickening of valve leaflets and cusps become rigid.
Fusion of mitral commissures.
Shortening and fusion of chordae tendinae.
All the changes leads to funnel shaped (fish mouth) valve.
Calcification immobilize the leaflets and narrows the orifice
further.
Initial insult is rheumatic but later changes may be a process
resulting from trauma to the valve caused by altered flow
pattern due to initial deformity.
Thrombus formation and arterial embolisation occur.
5. PATHOPHYSIOLOGY
Cardiac changes-
Normal valve area: 4-6 cm2
Mild mitral stenosis:
MVA 1.5-2.5 cm2
Minimal symptoms
Mod mitral stenosis
MVA 1.0-1.5 cm2 usually does not produce symptoms at rest
Severe mitral stenosis
MVA < 1.0 cm2
Symptoms at rest
Mean gradient:
>10 mmHg Severe
5-10 mmHg Moderate
<5 mmHg Mild
6. Right Heart Failure:
Hepatic Congestion
↑JVP
Tricuspid Regurgitation
RA Enlargement
Pulmonary HTN
Pulmonary Congestion
Atrial Fib
LA Thrombi
LA Enlargement
LA Pressure
RV Pressure Overload
RVH
RV Failure
Obstruction of diastolic inflow
Prolonged early diastolic
mitral inflow &delayed filling
Pressure volume loops shifted
to left so LVEDP and LVEDV
are↓
PATHOPHYSIOLOGY
7. PULMONARY CHANGES
Pulmonary arterial hypertension results as-
Increased left atrial pressure.
Pulmonary arterial constriction.
Interstitial edema in the wall of the small pulmonary vessels.
Organic obliterative changes in the pulmonary vascular bed.
At last if there is severe pulmonary arterial
hypertension→Tricuspid
regurgitation
Pulmonary incompetence
Reduced lung compliance and increased work of breathing.
Right heart failure.
8. HEMODYNAMIC CHANGES THAT OCCURS AT VARIOUS
STAGES OF SEVERITY OF MITRAL STENOSIS
SEVERITY→ MILD
(1.5-2.5 cm2)
MODERATE
(1.1-1.5 cm2)
SEVERE
( < 1cm2 )
Left atrial
pressure N ↑ ↑↑
Pulmonary
arterial pressure N ↑ ↑↑ or ↑↑↑↑
Cardiac output
N N ↓ or ↓↓↓
Left atrial
pressure ↑ ↑↑
Pulmonary
arterial pressure ↑ ↑↑
Cardiac output
↑ ↑
AT
R
E
S
T
E
X
E
R
C
I
S
E
9.
10. NATURAL HISTORY OF
MS
Continuous progressive, life-long disease
Slow, stable early course, latent period of 20-40
yrs from RF to onset of symptoms
Onset of symptoms to disability- 10 yrs
Atrial fibrillation- 30-40%
Causes of death
CHF
Systemic embolism
Pulmonary embolism
Infection
11. HISTORY & CLINICAL EXAMINATION
History of Rheumatic fever.
SYMTOMS
1. SOB – commonest (in mild MS, by sudden change in HR, vol-status, or CO e.g.
severe exertion, excitement, fever, severe anemia, paroxysmal AF or other
Tachycardia, Preg, thyrotoxicosis. As MS progress, lesser stress ppt. dyspnea &
also orthopnea, PND due to pulmonary venous hypertension.)
2. Palpitations
3. Cough
4. Haemoptysis (from rupture of pulm. Bronchial venous connections 2ndary to PVH/
never fatal)
5. Easy fatiguability and syncope( due to reduced cardiac output)
6. Attacks of ac. Resp. distress ( pulm. edema)
7. Aytypical angina- Chest pain in 10–15% of pts, even in the absence of
atherosclerosis; etiology often remains unexplained but may be emboli in the
coronary circulation or acute RV pressure overload
8. Hoarseness due to compression of left recurrent laryngeal nerve by enlareged left
atrium (Ortner‟s Syndrome)
9. Oedema, ascites
10. Mitral facies or malar flush
11. Recurrent pulmonary infections
12. Symptoms of thromboembolic complications (e.g. stroke, ischaemic limb)
12. NYHA FUNCTIONAL CLASSIFICATION OF
PATIENT WITH HEART DISEASE
CLASS Ι - Asymptomatic
CLASS ΙΙ –Symptoms with ordinary activity but comfortable
at rest.
CLASS ΙΙΙ –Symptoms with minimal activity but comfortable
at rest.
CLASS ΙV – Symptoms at rest
13. EXAMINATIO
N
General Examination
Decubitus: may be orthopnoeic
Cyanosis : Present in severe MS with ac. pulm. edema
Oedema : Bilateral pedal edema, accentuated in CCF
Neck vein: Engorged in CCF
Prominent „a‟ wave in pulm. HTN
Pulse - low volume. Rhythm- usually regular, irregular in AF
BP: usually low. Cold extremities.
RESPIRATION: may be tachypnoeic
Tender Hepatomegaly.
14. SYSTEMIC EXAMINATION
INSPECTION -- no deformity of precordium,
-- no venous prominence seen,
-- visible pulm. Art. pulsation in left 2nd ICS in
pulm. HTN
Palpation:
Small volume pulse
Tapping apex-palpable S1
Palpable S2
Thrill- Diastolic thrill over apical
area, best palpable in left lateral
position at the height of exp
Left parasternal heave
Auscultation:
Loud S1
P2 component accentuated.
A2-P2 Split.
S2 to OS interval inversely proportional
to severity
Diastolic rumble: length proportional to
severity
In severe MS with low flow- S1, OS &
rumble may be inaudible
Diastolic murmur (Graham-Steel)- high
pitched murmur heard at the cardiac
base secondary to pulmonary
regurgitation.
15. Clinical assessment of
severity
• Assessing the A2 - OS gap- Inversely proportional
to severity
• Duration of the diastolic murmur- directly
proportional to the length of the murmur
• Assessing the severity of PAH
16.
17. INVESTIGATIO
NS
Complete Haemogram
Blood sugar
Serum Electrolytes
Liver function tests
Renal Function tests
Chest X- Ray
ECG
Echocardiography
CT brain (in special cases)
18. Chest X-Ray
Slight increase in the transverse
diam. of heart
Straightening of left border of cardiac
silhouette.
Double contour of the right border of
heart
Enlarged pulmonary conus
Small Aortic knob.
Dilatation of the upper lobe
pulmonary veins- Moustache or antler
sign.
Backward displacement of the
esophagus by enlarged left atria.
19.
20.
21.
22.
23. ELECTROCARDIOGRAPHY
LA enlargement
Manifest as a P wave lasting> 0.12 msec with prominent
negative deflection of its terminal component (duration: > 0.04
msec; amplitude: >0.10 mV) in V1;
Broad, notched P waves in lead II, III and aVF.
Atrial fibrillation
F wave replacing P wave if atrial fibrillation develops
Right Ventricular hypertrophy
Right axis QRS deviation, and tall R waves in V1 suggest RV
hypertrophy
24.
25.
26. ECHOCARDIOGRAPHY
Diagnosis of Mitral Stenosis
Assessment of hemodynamic severity
mean gradient, mitral valve area, Left atrial pressure, pulmonary artery pressure
Extent of restriction of valve leaflets
Assessment of size and function of the Ventricles.
Reevaluation of patients with known MS with changing symptoms or signs.
F/U of asymptomatic patients with mod-severe MS
Anatomic suitability of percutaneous mitral balloon valvotomy (PMBV).
27. Cormier‟s Grading of Mitral Valve Anatomy
Based on ECHO
ECHO group Mitral Valve Anatomy
GROUP 1 Pliable non-calcified anterior mitral leaflet and mild subvalvular
disease( thin chordae >/=10 mm long
GROUP 2 Pliable non-calcified anterior mitral leaflet and severe
subvalvular disease(thickened chordae>10mm)
GROUP 3 Calcification of mitral valve of any extent, as assessed by
fluroscopy, whatever the state of subvalvular apparatus
28. Treatment Modalities of Mitral
Stenosis Asymtomatic/ Mildly symptomatic Mitral stenosis
Diuretics for congestive symptoms and restriction of salt intake.
Drugs for rate control
Prophylaxis against infective endocarditis
Warfarin to patients with history of AF or thromboembolism
Symtomatic Mitral Stenosis- unless there is a contraindication, mitral
valvotomy is performed in symptomatic patients with moderate or severe isolated
MS. Mitral valvotomy can be carried out by two techniques-
1. PMBV
2. Surgical( Open) Valvotomy using Cardiopulmonary Bypass.
Succesful valvotomy is defined by a 50% reduction in the mean mitral valve
gradient and a doubling of the mitral valve area.
Severe Mitral Stenosis/ Valve morphology not favourable for
PMBV/ MS with MR- Surgical Commissurotomy or MVR should be
carried out.
29. Predictors of poor outcome after surgical
procedure
Age>65 yrs
Presence of CAD
LV dysfunction
Severe pulmonary hypertension
RV dysfunction
Associated Co-Morbidities.
30. PREOPERATIVE MEDICATIONS
Antianxiety drugs decrease tachycardia associated with anxiety.
Drugs used for heart rate control should be continued until the time of
surgery.
If diuretics are used treat hypovolemia and hypokalemia if associated.
Antibiotics for surgical and infective endocarditis prophylaxis.
Anticoagulant therapy- based on following rationales:-
1. Acceptable INR for surgery- An INR <1.5 is generally acceptable
2. Risk of bleeding-
a) Discontinuation of warfarin is essential for the procedures associated
with a high risk of bleeding
b) Discontinuation of warfarin is usually not necessary for the
procedures associated with a low risk of bleeding
31. 3. Risk of thrombosis
Management steps
Low risk of thrombosis High risk of thrombosis
AF without additional risk factors AF + either h/o stroke/TIA or >risk factors such as recent
CHF,HTN,Age>70 yrs, diabetes
DVT/PE occuring more than 3 months ago DVT/PE occuring in past 3 months.
Hypercoagulable state without recent
thrombotic episode
Hypercoagulable state with recent thrombotic episode
Newer model mechanical aortic prosthesis
and any tissue valves
Mechanical mitral prosthesis and old model aortic prosthesis
Low risk of thrombosis High risk of thrombosis
Discontinue warfarin 5 days prior to surgery Discontinue warfarin 5 days prior to surgery
Check INR the day before surgery, ensure
target INR<1.5
Start prophylactic or therapeutic LMWH
Restart warfarin at pre-op dose as soon as
hemostasis is assured and only after epidural
catheters are removed
Last dose of LMWH is not given any later than 24 hrs before the
procedure.
Recheck INR within one week after starting
warfarin and then at regular intervals.
Check INR the day before surgery, ensure target INR<1.5
Restart LMWH/ warfarin at pre-op dose as soon as hemostasis is assured
MANAGEMENT
32. 4. Timing of procedure
If urgent or emergent procedures are to be undertaken in < 4-5
days and warfarin reversal is required, it may be satisfactory to
give 1-2 mg of Vitamin K orally in order to reverse the effect of
warfarin. When reversal of anticoagulation is required within 6
hours, intravenous Vitamin K and Octaplex® is required(Virally
Inactivated Plasma-Derived Concentrate). FFP can be given if
Octaplex is not available.
5. Type of anaesthesia.
a) Local and general anesthesia can be safely administered to
a patient on warfarin.
b) Neuraxial blocks (e.g., epidural analgesia, spinal anesthesia
and retrobulbar blocks) should not be performed on patients
on warfarin
34. Anesthetic management
The main objectives are-
To avoid tachycardia.
To maintain sinus rhythm. Aggressively treat new onset atrial fibrillation
pharmacologically or with direct cardioversion especially in the hemodynamically
compromised patient .
Avoid large, rapid falls in SVR. This is compensated for by increasing HR, which can
worsen cardiac function.
To avoid hypovolemia and fluid overload.
Avoid factors that may increase pulmonary artery pressure (PAP)
35. Effects of altered
hemodynamics
Adverse
effects
Result Mechanism
Bradycardia CO Low cardiac
output
Tachycardia CO filling time
AF CO LV
filling/no atrial
kick
Preload CO LV filling
SVR CO stroke
volume
SVR CO SV (due to
tachycardia
related
filling time)
36.
37. Why tachycardia is
detrimental?
Increased HR (sinus tachycardia, AF)
shortened diastolic filling period
diminished time for LA emptying
increased pressure gradient across MV
and increased LA pressure.
AF – additionally causes loss of „atrial
kick‟ further reduction of LV filling
reduced cardiac out put.
38. MONITORING
Noninvasive monitoring like HR, BP
, ECG, RR, SpO2.
Invasive monitoring depends upon-
1. Complexity of the operative procedure.
2.Magnitude of physiological impairment.
The concomitant use of invasive hemodynamic
monitors is recommended in symptomatic
patients with critical stenosis.
39. ANAESTHESIA
TECHNIQUE REGIONAL ANAESTHESIA
Patients may be very sensitive to the vasodilating effect of spinal and
epidural anesthesia.
Epidural is preferable over spinal anesthesia because of the more gradual
onset.
Rapid prehydration should be avoided, and slow titration of local anesthetic
solution is recommended to minimise hemodynamic changes.
When treating hypotension, phenylephrine is preferred over
ephedrine, which may increase the HR.
Epinephrine-containing local anesthetic solutions are best avoided due to
concerns about potential tachycardia.
Combined spinal–epidural (CSE) with an intrathecal opioid combined with a
dilute epidural infusion minimizes sympathetic block and concomitant
hypotension---can be considered as a good option.
Surgery under Peripheral Nerve Blocks can be the best anesthetic
technique wherever possible
Hypothermia to be avoided as it increases PVR.
40. GENERAL ANAESTHESIA
PREANAESTHETIC MEDICATIONS
Avoid premedication with anticholinergics to avoid tachycardia.
Opioids like fentanyl are used to give analgesia. Use generous
amounts of opioids to abolish hemodynamic response to
intubation. It will also decrease the requirement of induction
agents.
Antianxiety drugs decrease tachycardia associated with
anxiety
Epidural analgesia with opioids can be considered safely as a
supplement to GA whenever needed.
PREOXYGENATION
Adequate preoxygenation to avoid any degree of hypoxia.
41. INDUCTION
General Anaesthetics with/without Muscle Relaxation
There is no single “correct” agent. Any drug can be used
as long as hemodynamic goals are met.
Patients with moderate to severe MS generally have slow
circulation that prolongs arm-brain circulation time.
Induction agents should be double diluted and given
slowly in titrated doses.
Etomidate is the best agent for hemodynamic stability, but
thiopentone can be used instead.
Propofol should be avoided as it can lead to precipitous
hypotension.
Ketamine to be avoided as it causes tachycardia.
Induction with volatile anaesthetics to be avoided- causes
decreased SVR and cardiac output , hypotension.
42. MUSCLE RELAXATION
For muscle relaxation agents that do not release histamine are
preferred as histamine causes tachycardia and hypotension.
Steroidal group of muscle relaxants does not cause histamine
release. Example are- VECURONIUM, ROCURONIUM except
PANCURONIUM.
Benzylisoquinolinium group causes histamine release.
Example are –ATRACURIUM, CISATRACURIUM,
MIVACURIUM.
Succinylcholine also causes slight release in histamine
43. MAINTAINENCE
Oxygen + Air + High dose narcotic or volatile
anaesthetics such as isoflurane, desflurane or
sevoflurane at low vol%
Halothane is best avoided due to its arryhthmogenic
potential and high incidence of junctional rhythm
which can be disastrous in a patient with mitral
stenosis.
In patients with PAH, nitrous oxide is best avoided
due to its effect on pulmonary resistance.
Deep plane of anaesthesia should be maintained.
Ensure appropriate ventilation and proper fluid
therapy.
44. If there is intra-op tachycardia
1. Deepen the plane and ensure adequate analgesia
2. Use beta blockers like esmolol/propranolol or calcium
channel blockers like diltiazem.
If atrial fibrillation occurs ventricular rate can be controlled with
esmolol, propranolol, diltiazem , digoxin or amidarone.
For sudden supraventricular tachycardia –cardioversion.
DRUG LOADING DOSE MAINTENANCE
AMIODARONE 15mg/min for 10 min 0.5-1mg/ min for 6hrs
DIGOXIN 0.25mg 2hry until 1mg 0.125-0.25mg/day
DILTIAZEM 0.25mg/kg over 3-5 mins 5-15 mg/hr
ESMOLOL 500microg/kg over 1min 50ug/kg/min
METOPROLOL 5mg over 3-5 mins x 3
doses
1.25-5mg 6hrly
VERAPAMIL 5-10mg over 3-5 mins 2.5-10 mg/hr
45. Reversal of anesthesia.
Nondepolarising muscle relaxants is achieved
slowly with neostigmine and glycopyrrolate to
reduce drug induced tachycardia caused by
glycopyrrolate.
Post operative management
Proper pain management to avoid tachycardia.
Risk of pulmonary edema and right heart failure
continue so cardiovascular monitoring should be
continued.
Oxygen supplementation until adequate
oxygenation is established.
Management of post op hypothermia and
shivering.
46. Why does pregnancy aggravate the
symptoms of mitral stenosis?
Increase in blood volume by 30-50% -increase in capillary
hydrostatic pressure – pulmonary edema.
Decrease in SVR
Increase in HR 10-20 beats/min – reduced diastolic filling time of
LV
Increase in CO by 30-50% - increase in transvalvular gradient –
rise in LA pressure
During labour and delivery sympathetic stimulation – rise in HR
and CO
Sudden rise in venous return due to autotransfusion and IVC
compression –decompensation
Atrial enlargement in pregnancy – atrial fibrillation
Hypercoagulability – thromboembolic risk
During pregnancy pts symtomatic status increases by 1 or 2
NYHA class.
47.
48. Anti coagulation
Indications for anticoagulation
Patient with AF
Prior embolic event
Severe MS with left atrial dimension 55 mm
on ECHO
Heparin for first trimester
Warfarin 12-36 weeks
After 36 weeks changed to heparin
titrated to APTT level