This document discusses best practices for perioperative fluid management. It notes that perioperative fluid management can be complicated due to factors like fasting, bowel preps, and surgical stress that can cause fluid and electrolyte imbalances. The goals of perioperative fluid management are hemodynamic stability, adequate tissue perfusion, avoidance of fluid overload, and avoidance of acute kidney injury in order to achieve best surgical outcomes. Different fluid management strategies are discussed for the preoperative, intraoperative, and postoperative periods including restricted versus liberal or goal-directed approaches using fluid biomarkers. Enhanced Recovery After Surgery (ERAS) protocols emphasize individualized fluid plans guided by physiologic targets as part of multimodal care.
This document discusses fluid and blood therapy. It begins by outlining the goals of fluid management during surgery and introduces the concepts of fluid deficits, insensible losses, and third spacing. It then critiques the classical fluid management strategy of aggressive fluid replacement and presents evidence that restrictive fluid protocols reduce complications. The document advocates goal-directed fluid therapy using cardiac output monitoring. It also discusses fluid choices, transfusion triggers, blood component therapy, and complications of blood transfusion.
Barnes-Jewish Hospital spent nearly $1 million on anesthetic gases in 2016, with two-thirds of the costs from desflurane. Using the lowest safe fresh gas flow rates can maximize efficiency and minimize costs by reducing wasted gases. Low flow anesthesia, using fresh gas flows of 0.5-1 L/min for desflurane and 1 L/min for sevoflurane in most cases, can lower costs while maintaining patient safety. Care must be taken to avoid hypoxic mixtures when using low fresh gas flows.
- A study evaluated the use of intraoperative methadone for short-stay and true same-day ambulatory surgery patients. For true same-day surgery patients, those who received 0.15 mg/kg methadone required less intraoperative and postoperative opioids, had lower postoperative pain scores after discharge, and consumed fewer opioids in the 30 days following surgery compared to controls. For short-stay patients, results showed similar benefits with methadone doses of 0.1-0.2 mg/kg. The study demonstrated that a single intraoperative dose of methadone can decrease postoperative opioid requirements and consumption compared to short-acting opioids.
Anesthesia for Dental extractions in patients with heart diseaseHelga Komen
This document discusses dental procedures in complex cardiac patients. It notes that while dental extraction is generally a minor procedure, risks are much higher for cardiac patients. One study found major adverse outcomes in 8% of cardiac patients undergoing dental extraction, including 38% mortality. The document discusses strategies for assessing cardiac risk and optimizing medication management for dental procedures in complex patients. This includes considerations for timing after cardiac events or stents, continuing beta blockers and statins, and managing anticoagulants when possible. The goal is reducing infective endocarditis risk while avoiding perioperative cardiac complications.
The document discusses extubation of difficult airways. It notes that while respiratory adverse events at induction of anesthesia have decreased, rates of death or brain damage during tracheal extubation have remained unchanged, suggesting more education is needed. Among failed extubation claims since 2000, 94% resulted in death or permanent brain damage. The document provides definitions for extubation failure and at-risk extubation. It discusses patient risk factors and causes of extubation failure, and reviews guidelines from the American Society of Anesthesiologists and Difficult Airway Society for developing an extubation strategy.
This document discusses best practices for perioperative fluid management. It notes that perioperative fluid management can be complicated due to factors like fasting, bowel preps, and surgical stress that can cause fluid and electrolyte imbalances. The goals of perioperative fluid management are hemodynamic stability, adequate tissue perfusion, avoidance of fluid overload, and avoidance of acute kidney injury in order to achieve best surgical outcomes. Different fluid management strategies are discussed for the preoperative, intraoperative, and postoperative periods including restricted versus liberal or goal-directed approaches using fluid biomarkers. Enhanced Recovery After Surgery (ERAS) protocols emphasize individualized fluid plans guided by physiologic targets as part of multimodal care.
This document discusses fluid and blood therapy. It begins by outlining the goals of fluid management during surgery and introduces the concepts of fluid deficits, insensible losses, and third spacing. It then critiques the classical fluid management strategy of aggressive fluid replacement and presents evidence that restrictive fluid protocols reduce complications. The document advocates goal-directed fluid therapy using cardiac output monitoring. It also discusses fluid choices, transfusion triggers, blood component therapy, and complications of blood transfusion.
Barnes-Jewish Hospital spent nearly $1 million on anesthetic gases in 2016, with two-thirds of the costs from desflurane. Using the lowest safe fresh gas flow rates can maximize efficiency and minimize costs by reducing wasted gases. Low flow anesthesia, using fresh gas flows of 0.5-1 L/min for desflurane and 1 L/min for sevoflurane in most cases, can lower costs while maintaining patient safety. Care must be taken to avoid hypoxic mixtures when using low fresh gas flows.
- A study evaluated the use of intraoperative methadone for short-stay and true same-day ambulatory surgery patients. For true same-day surgery patients, those who received 0.15 mg/kg methadone required less intraoperative and postoperative opioids, had lower postoperative pain scores after discharge, and consumed fewer opioids in the 30 days following surgery compared to controls. For short-stay patients, results showed similar benefits with methadone doses of 0.1-0.2 mg/kg. The study demonstrated that a single intraoperative dose of methadone can decrease postoperative opioid requirements and consumption compared to short-acting opioids.
Anesthesia for Dental extractions in patients with heart diseaseHelga Komen
This document discusses dental procedures in complex cardiac patients. It notes that while dental extraction is generally a minor procedure, risks are much higher for cardiac patients. One study found major adverse outcomes in 8% of cardiac patients undergoing dental extraction, including 38% mortality. The document discusses strategies for assessing cardiac risk and optimizing medication management for dental procedures in complex patients. This includes considerations for timing after cardiac events or stents, continuing beta blockers and statins, and managing anticoagulants when possible. The goal is reducing infective endocarditis risk while avoiding perioperative cardiac complications.
The document discusses extubation of difficult airways. It notes that while respiratory adverse events at induction of anesthesia have decreased, rates of death or brain damage during tracheal extubation have remained unchanged, suggesting more education is needed. Among failed extubation claims since 2000, 94% resulted in death or permanent brain damage. The document provides definitions for extubation failure and at-risk extubation. It discusses patient risk factors and causes of extubation failure, and reviews guidelines from the American Society of Anesthesiologists and Difficult Airway Society for developing an extubation strategy.
Eras thoracic komen dec 2020. e:a:c conferenceHelga Komen
This document discusses the implementation of an enhanced recovery after surgery (ERAS) protocol for lung surgery at Barnes-Jewish Hospital. It provides an overview of ERAS, the development of their lung surgery ERAS protocol, and the key elements of the preoperative, intraoperative, and postoperative protocol. The multidisciplinary team implemented the protocol in 2018 and continues monitoring outcomes through regular meetings and quality improvement audits to optimize recovery for patients undergoing lung surgery.
Jet ventilation is a form of mechanical ventilation that uses very high respiratory rates and small tidal volumes delivered via a jet of gas. It can be used supraglottically or subglottically for procedures involving the airway. Key indications are subglottic and tracheal stenosis. The jet ventilator provides active insufflation of gas while exhalation is passive. Gas exchange occurs via mechanisms like laminar flow and Taylor dispersion. Precautions must be taken to ensure adequate ventilation and monitoring of end-tidal CO2. Complications can include barotrauma, pneumothorax, or difficulty ventilating.
The document provides information about the Post Anesthesia Care Unit (PACU):
1) The PACU is where patients recover from anesthesia and surgery and are monitored until stable for discharge.
2) The PACU bridges the period from return of consciousness to cardiovascular stability.
3) Standards for PACUs include monitoring patients, staffing requirements, policies for admission and discharge, and guidelines for managing common postoperative complications.
This document describes a case of a 67-year-old female patient who experienced an allergic reaction during induction for a laparoscopic cholecystectomy. During induction with sufentanil, thiopental, and rocuronium, the patient developed a rash and then went into deep hypotension, difficult ventilation, and asystole, requiring 45 minutes of CPR. She was admitted to the ICU and had left hemiplegia. Skin testing 3 months later showed a positive reaction only to rocuronium. The document discusses the incidence of anesthesia allergies, predicting allergies, and alternatives when an allergy is identified.
The document provides a summary of the history and operations of the Mayo Clinic in Rochester, Minnesota from its founding in 1883 to present day. It details the Clinic's expansion to additional locations, contributions to medical research and innovations, education programs, and status as a renowned medical center focused on patient-centered care.
The document summarizes the 30th Congress of ESPEN held in Firenca, Italy from September 13-16, 2008. Main topics discussed at the congress included the chronic critically ill patient, oxygen delivery and tissue metabolism in sepsis, metabolic therapies in intensive care, and the impact of nutrition on cancer risk and tumor metabolism. Presentations also addressed early nutritional support in ICU patients, modulation of the inflammatory response through fatty acid supplementation, hydration in surgical patients, and the clinical use of glutamine supplementation.
The document summarizes the 2010 recommendations of the European Society of Anesthesiology on neuraxial anesthesia and antithrombotic drugs. It provides time intervals that should elapse between taking different antithrombotic medications and performing neuraxial blocks or catheter removals based on the half-lives of the drugs. It also discusses preoperative versus postoperative thromboprophylaxis and considerations for various classes of antithrombotic agents including heparins, anti-Xa agents, direct thrombin inhibitors, vitamin K antagonists, and platelet aggregation inhibitors.
Perioperative ischemia–reperfusion injury of the heart
Antikoagulansi i regionalna anestezija
1. Lijekovi protiv zgrušavanja
krvi i regionalna anestezija
Helga Komen Ušljebrka, Mladen Horvat, 7.11.2007., Klinika za
anesteziologiju, reanimatologiju i intenzivno liječenje, KBC
Rijeka
4. • J.V. Llau et al. Anticlotting drugs and
regional anaesthetic and analgesic
techniques: comparative update of the
safety recommendations. Eur J
Anaesthesiol 2007; 24:387-398.
• Review
• najrecentnija kompilacija preporuka za korištenje lijekova koji mijenjaju
hemostazu, uz primjenu tehnika regionalne anestezije (RA), bazirano na
preporukama koje je publicirao SEDAR (Sociedad Espańola de
Anaestesiología y Reanimación)
• preporuke su bazirane na farmakološkom profilu lijekova
• epiduralna hemoragija !
6. Lijekovi koji mogu interferirati s RA
• Nije postignut univerzalni konsenzus oko minimalnih
zadovoljavajućih uvjeta glede hemostaze kod primjene
tehnika regionalne anestezije !
• Trenutni uvjeti minimalne hemostaze:
- broj Tr ≥ 50 000 µL-1
- INR (International normalized ratio) ≤ 1.5
- PTT ≥ 45 s
7. Regionalna anestezija kod bolesnika na
terapiji nisko molekularnim heparinom
• aktivacija antitrombina
• enoxaparin, dalteparin, nadroparin, bemiparin, tinzaparin
Karakteristike niskomolekularnih heparina
Lijek T/2(min) Max. Omjer Profilaktič Terapeut-
djelovanje anti- ka doza /24 ska doza
(h) Xa/anti-IIa h
Enoxaparin 129-180 2-4 3,8:1 2000-4000 100 kg –1 12
(Clexane) h –1
Dalteparin 119-139 2,8-4 2,7:1 2500-5000 100 kg –1 12
(Fragmin) h –1
8. Regionalna anestezija kod bolesnika na
terapiji nisko molekularnim heparinom
• Dosadašnje preporuke tromboprofilakse NMH-om:
- preoperativno - 12 sati prije op. zahvata
- postoperativno - 12 sati poslije op. zahvata
• Preporuke SEDAR-a:
- preoperativno - 12 sati (tromboprofilaksa) odnosno 24 sata (th. doza) prije
op. zahvata
- postoperativno - 6 sati nakon postavljanja epiduralnog katetera
- kateter može biti uklonjen (najveći rizik krvarenja!) 12 sati nakon
zadnje doze NMH. Iduća doza NMH slijedi min. nakon 6 sati
(ASRA - 2 sata)
9. Regionalna anestezija kod bolesnika na
terapiji nisko molekularnim heparinom
• sve preporuke su bazirane na ekstrapolaciji
farmakokinetike lijeka bez jasne potpore bilo kojoj shemi
• u slučaju krvarenja koje se javilo pri punkciji, prvo
davanje NMH-a prolongira se na 24 sata po punkciji
→ slobodna procjena rizika DVT
10. Regionalna anestezija kod bolesnika na
terapiji antiagregacijskim lijekovima
• Indicirani u prevenciji arterijske trombolize (ishemična srčana bolest,
cerebrovaskularna bolest, bolesti perifernih arterija, etc.)
• Prema mehanizmu djelovanja:
- antagonisti receptora adenozin difosfata (klopidogrel - Pigrel)
- antagonisti receptora GPIIb/IIIa (tirofiban)
- lijekovi koji povećavaju nivo cAMP u trombocitima
(dipiridamol)
- ireverzibilni inhibitori enzima ciklooksigenaze 1(COX 1)
(acetilsalicilna kiselina - ASA).
NSAIDs inhibiraju reverzibilno COX 1 (različitim
intenzitetom) (indometacin, ketorolak)
11. Regionalna anestezija kod bolesnika na
terapiji antiagregacijskim lijekovima
• Preporuke SEDAR-a:
- Regionalna anestezija kod bolesnika pod utjecajem ASA ili NSAID
- nema kontraindikacija za izvođenje RA kod navedenih
bolesnika, (pod uvjetom da se primjenjuje jedna vrsta lijeka).
Preoperativno ukidanje navedenih lijekova povećava rizik od
kardiovaskularnih i neuroloških komplikacija.
- Regionalna anestezija kod bolesnika pod utjecajem
tienopiridinima
- Preporuča se ukidanje klopidogrela (Pigrela) 7 dana prije, a
tiklopidina (Tagren) 10 dana prije RA. Ponovno uvođenje odmah nakon
izvođenja RA
- Kombinirana terapija - poštivati pojedine preporuke za lijekove
12. Regionalna anestezija kod bolesnika na
terapiji oralnim antikoagulansima
• Inhibiraju gama-karboksilaciju vitamin K ovisnih faktora koagulacije i
proteina C i S.
• Monitoring antikoagulacije putem određivanja INR-a
• Akenokumarol (EU) - vrijeme normalizacije INR-a je 3 dana, varfarin
(USA) - vrijeme normalizacije INR-a je 5 dana
• Preoperativno ukidanje OA minimalno 3-5 dana i uvođenje NMH
• Obavezno određivanje INR-a preoperativno
• SEDAR : INR≤1,5; ASRA: INR<1,5
• Ponovno uvođenje OA postoperativno odmah!
- Oprez kod EPK!
13. Regionalna anestezija kod bolesnika na
terapiji nefrakcioniranim heparinom
• Potiče inhibitorno djelovanje enzima antitrombina III na faktore IIa,
Xa, I Ixa, a u manjoj mjeri i na faktore XIa, XIIa i kalikrein
• Aplikacija parenteralnim putem (iv, sc.)
• t/2 varira između 30 min. i 150 min, ovisno o dozi
• Preporuke SEDAR-a:
- iv. aplikacija - ukinuti barem 4 sata prije RA ili vađenja
katetera
- ponovno uvesti 1 sat po vađenju katetera ili RA
- sc. aplikacija - nema kontraindikacija za RA
14. Regionalna anestezija kod bolesnika na
terapiji fibrinoliticima
• Bolesnici obično dobivaju i neki od lijekova iz
antiagregacijske skupine ili antikoagulanse
• SEDAR - RA najranije 24-36 h po dobivenoj terapiji
(koagulogram – fibrinogen! i trombelastogram)
• BARA - apsolutna
kontraindikacija!
• administracija fibrinolitika nije preporučljiva prije 10-tog
dana od punkcije nekompresibilne žile
