Odd Ball Facts
Major Peter Strube
CRNA MSNA APNP ARNP
pstrube3000@yahoo.com
It’s not about the nail!
http://www.youtube.com/watch?v=4EDhdAHrOg
Midwives and nurses are as good as docs
-- and sometimes better, WHO finds!!
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Cometto and colleagues around the world looked at all the studies they could find on the quality of
care delivered by non-physicians. They settled on 53 that looked specifically at the quality of care
delivered — and at how happy patients were with the care they got.
“The evidence shows there aren’t statistically significant differences,” Cometto said. “The quality of
care they provide is comparable to physicians. In some cases, for specific services, they actually
outperform physicians.”
The American Society of Anesthesiologists recently spoke out against what it sees as the overuse of
nurse-anesthetists. “Somehow there has become the notion that you can take physician extenders
and replace physicians,” said Dr. Jane Fitch, a former nurse anesthetist who is now a physician
anesthesiologist. “We are really concerned about patient safety.”
http://www.nbcnews.com/health/midwives-nurses-are-good-docs-sometimes-better-who-finds8C11506820
Maggie Fox NBC News
Oct. 31, 2013 at 6:32 PM ET
The Ground Rules:
Recognition of Problem:
Immediate Anesthesia Management:
Treatment:
Follow-up, after action review:
Think differently: Don’t forget basics
If we don’t remember our history we are
doomed to repeat it!
Information You should know?
Average cost per minute of time in OR
$20-$80/min varies by case
Average PACU charge $4-8/min ***
Ranges by 30 minute time blocks
Economic Impact – for each incident of
nausea/vomiting that is avoided:
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Avoid resource utilization costs: Patients who vomit
spend an average of 43 minutes longer in the PACU at a
cost of $85 for nausea and $138 for vomiting.
Save the cost of rescue treatment: $283 (minimum)
to treat patients who experience PONV
For surgical centers: PONV delays may result in an
ambulance transfer to a hospital costing $300 - $900 and
result in an admission costing $1,200 to more than $2,400
per day.
Desflurane
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Time to extubation decreased with
Desflurane: 20-25% decrease.
Dexter et al. Anesthesia Analg; 2010
What if you save 7 minutes on a basic
case?
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$140 savings…wow….
Agent Cost Based on MAC
Enter Time in
minutes
Vaporizer at 1 MAC for middle-aged adult
Size of
Enter Fresh Gas Flow in
L/min
Molecular
bottle
m
l
Cost/Un
it
Cost/
m
l
Desfluran
e
240
$115.00
$0.48
Sevofluran
e
250
Generic
60
$172.22
$0.69
Weight
168.04
200.05
2 (1)
Cost of
Density
1.465
1.520
MAC
6.00
2.10
1 MAC
$16.41
($8.20)
Desflurane
$9.47
Sevoflurane
Agent Cost Based on MAC
Vaporizer at 1 MAC for middle-aged adult
Size of
Generic
bottle
ml
Enter Time in
minutes
120
Enter Fresh Gas Flow in
L/min
2(1)
Molecular
Cost/Uni
t
Cost/m
l
Weight
Cost of
Density
MAC
1 MAC
Desflurane
240
$115.00
$0.48
168.04
1.465
6.00
$32.81 (16.41)
Sevofluran
e
250
$172.22
$0.69
200.05
1.520
2.10
$18.94
Desflurane
Sevoflurane
Caffeine---Antiemetic
and Pain control?
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Central Nervous stimulate
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Number one consumed psychoactive drug
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PDE inhibitor
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Withdrawal headache
Via this action a secondary antiemetic; all subjective considering
a few studies suggest it does not play a role
Awake sleep cycle
Increased sensitivity to catacteolamines
Spinal HA
Caffeine
Oral and IV Caffeine;
Very effective for temporary relief
75-80% effective in initial treatment, but 48 hour follow
up revealed that all patients had a return of their
headache
Believed to work by blocking adenosine receptors which
in turn leads to vasoconstriction of cerebral blood vessels.
Methylxanthines derivitive such as, caffeine may also stimulate sodium-potassium pumps to
increase CSF production, which can aid in headache relief.
Treatment with IV caffeine was not associated with a decrease in the number of patients who
required EBP.
SE of Methylxanthines deriviative; CNS stimulation, seizures, gastric irritation and cardiac
dysrhythmias, limited used with patients with CV disease
Different IDEAS
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Nasal fentanyl with BMTs
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Toradol local at epidural/spinal site
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Ephedrine IM at epidural or spinal site for OB site
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Bicarb (remember the ionized and unionized lectures) with local
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propofol 20-30 mg nausea or infusion!
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Magnesium for injection with propofol---Cool Thoughts!
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Neo and Ephedrine in Propofol injection
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Glass Vials
Glass Vials…..
Glass Particles Contamination…
Filter needle use with ampules
Do you do it correct?
Different IDEAS
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LR and psych patients—more later…
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LR and Trauma
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LR and blood
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Writing on the IV bags---more later…
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Lido and/or bicarb in the ett cuff
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DID we also forget about COX-2 agonists….
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Indigo carmine ----STRONG ALPHA RESPONSE!
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Pall heat and moisture exchanger HME—1.67 Kilocalories
Non-Pharmacologic Methods To
decrease PONV
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Reduce swallowing blood, if possible
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Hydrate well---Very effective!
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Administer glucose containing solutions? Is this a reality in OR
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Beware of patients who are strongly vagotonic and have syncope
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Caution in assuming upright position postop—Orthostatic 6-20% dehydrated
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Don’t let patient get hypotensive.
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Don’t let patient move head rapidly.
Don’t let at-risk patients watch TV postop? Motion sensative
More Non-Pharmacologic
Methods for PONV
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Acupuncture—really exciting information!
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Acupressure
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over “P6” point of wrist (3cm prox. to distal wrist crease, between the
tendons of palmaris longus and flexor carpi radialis)
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over K-K9 acupuncture point (middle phalanx of 4th finger) applied
bilaterally
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Alcohol Pad—Quese Ease!
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Do we really need our pt’s to drink and eat before discharge? Why?
Non-pharmacologic Prevention of
Surgical Wound Infection
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Maintaining Normothermia
Supplemental Oxygen
Surgical Site Preparation
Smoking
Glucose Control
Vascular Volume
Pain Relief
Hypercapnia
Electricity….oh boy!!
Prisoners and shackles?
Ear rings? Piercing?
Goes in and goes out…
Bipolar
Bipolar is a different type which prevents widespread tissue coagulation. Part held
by surgeon is like a forceps, current entering one prong and leaving by the
other. Thus no grounding plate required. Useful for example in neurosurgery
where there is no convenient spot for a grounding plate, and greater precision
is necessary.
Valleylab.com has an extensive educational presentation on all aspects of
electrosurgery.
A new anesthesia addiction!
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????
Inhalant Abuse:
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Volatile substances that produce chemical vapors that can be inhaled to
induce a psychoactive or mild altering effect. They act on the central
nervous system except for nitrates. Not sure where, but it appears
dopamine is the area that this works on in the brain.
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Broad range of chemicals but the common characteristic is they are
rarely if ever taken by any route but inhalation.
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Volatile: Vapors at room temp
Aerosols: sprays that contain a propellant and solvent
Gases: we use it all the time.
Nitrates: Poppers or snappers. They relax smooth muscle and dilate
blood vessels. They alter moods and are sexual enhancers.
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Inhalant Abuse:
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Growing group of abused drugs…. Under 18 is the biggest group.
Easy to get and easy to use. You can pick it up anywhere
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Inhalants cause severe damage to the lungs, liver, kidneys, bone marrow
and the brain. Can cause suffocation, stroke, loss of consciousness and
death
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Sniffing or snorting
Spraying
Bagging
Huffing
Inhaling
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Gasoline, glue, vegetable spray, hairspray, deodorant spray, paint thinner,
transmission fluid, air freshener, Nitrites, Rush, Locker room popper,
Whippets, Nitrous
Do you write on your IV or put tape on it?
ISMP also cautions against writing an expiration
date directly on the bag, because volatile
chemicals from the ink may leach into the
solution.
http://www.accessdata.fda.gov/psn/printer.cfm?id=186
What IV soln to you choose?
NS or LR?
Good for what situation?
Panic attacks… oh boy?
How Many Blades are there?
Are you just a miller or Mac?
Lots!!!---14 types
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Cranwall
Jackson
Janeway
Reduced Flange
Macintosh
Magill
Miller
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Parrott
Phillips
Wisconsin
Robert-Shaw
Siker
Soper
Wisconsin-Hipple
Basic Rules:
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Suxx does not suck..
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Nobody has ever had a allergic reaction to a ET Tube!!
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Nobody gets sued for leaving it in to long
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If your thinking about intubating should have already
done it!
New Term: Pre-Mature Extubation!
Did you realize?
There are nearly 50 basic airway tools…
That doesn’t even count the multiple
variations of these tools and other tools
not cited in the May 2012 Airway update.
Current discussion in the Airway Society is?
Laryngeal Mask----Mid-Line, Supine
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Adult and pediatric sizes
Inserted into hypopharynx, passed downward behind larynx,
sealing glottic opening and enabling ventilation after cuff
inflated
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Slight bulging in tissues overlying larynx indicates mask in
position
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Allows positive pressure ventilation, can support airway when
trachea can’t be visualized
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“Can’t intubate/can’t ventilate” scenario
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Does not protect against regurgitation/aspiration
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Requires anesthesia for placement
LMA Stylet
LMA Cost Savings!
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If we do 5 cases with a Classic LMA per day this costs:
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5 (per day) x 5 (days/wk) x 52 (wks/year) = 1300 LMAs x $
6.5= $ 8,450
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If we instead choose a Supreme LMA for all of these:
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1300 x $ 18.5 = $ 24,050
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Classic LMA$ 6.50
Flexible LMA$ 12.0
Supreme LMA$ 18.5
Glidescope—2001 General Surgeon Dr.
Pacey Designed First scope
Verothan Stylet-60% curve
(90% Success rate)
Tonsillectomy and Adenoids
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This is a airway issue….
Perfect conditions should be present ask about 2nd and 3rd hand smoke and
URI’s
LMA vs ETT
Use of a pre-op anticholinergic
Post-op bleeding..
Pain control is very important
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OSA>>>> increased improvement in school and focus post tonsils
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LMA is the best way to go!----OFIRMEV!
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Physics?—This sucks…
Beer-Lampert
Laplace
Poiseuille;s
Bernoulli’s
Charles, Boyles, Gay-Lussac’s
Joule-Thompson
Oh my….
Sneezing with peribulbar or
retrobulbar Block?
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Photic sneeze reflex
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ACCHO
Autosomal Dominat Compelling Helio-Opthalmic
Outburst reflex
25% of population evoked by the bright light.
Trigeminal
Vocal Cord Dysfunction
Has your patient been short of breath and anxious in the
PACU?
What did you do?
Versed may have been a better choice??
Remimidazolam? What’s next?
Strange end-point
Tattoos
A Medline and EMBASE search of the English
literature using the key words: spinal,
epidural, tattoos, tattooing, complications
did not find any reports or concerns
regarding neuraxial anesthesia through
tattooed areas. However, one might
postulate that there could be long-term
implications from depositing a pigmented
tissue core in the epidural or subarachnoid
space.
Based on the limited information available it is
possible that inserting an epidural or spinal
needle through a tattoo could cause longterm problems such as arachnoiditis or a
neuropathy secondary to an inflammatory
reaction, but we don’t know.
Canadian Journal of Anesthesia 49:1057-1060
(2002)
Who controls the room temp?
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You DO!!
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SCIP: http://www.sjhlex.org/documents/Physicians/SCIP_Poster_Full_Size.pdf
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Temperature must be equal to or greater than 96.8° F within 30 minutes prior to
anesthesia end time or immediately 15 minutes after anesthesia end time.
It costs on average between $2500-$7000 per pt for complications related to
hypothermia. Infection being the most common.
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YOU CONTROL THE TEMP.
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WE need to change the mind set of the operating room.
SUMMARY OF OUTCOMES Of NORMOTHERMIA
Decreased:
Time spent in ICU
43%
Need for mechanical ventilation
34%
Need for blood transfusion
40%
PRBC
85%
FFP
79%
Platelets
78%
Surgical site infections
64%
Postop MI
44%
Mortality rates
55%
41
THERMOREGULATION UNDER ANESTHESIA
HEAT REDISTRIBUTION PHENOMENON
Management:
Prewarming
∆
CORE
T °C
Management:
Intraoperative
warming
Management:
Intraoperative
warming
Bair Hugger….
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Bair paws…
I can heat and cool the pt with this
mode!
Something New to be scared about now!
Dissolvables
Photo source: http://tobaccocommons.com/tag/camel-strips/
Point of Purchase
Droperidol
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Prophylactic doses (<1 mg) are effective against PONV
FDA issued a ‘black box’ warning:
 Droperidol may cause death or life-threatening events
associated with QT prolongation and torsades de
pointes
 Labeling changes based on 100 unique spontaneous
cardiovascular adverse events
Addition of black box warning has restricted use
Droperidol:
The FDA Box Warning
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Droperidol has been used for over 40 years
Why a problem now?
No evidence of adverse events in published trials
No published case reports
An association does not prove cause and effect
If prolonged QTc is an issue then 5HT3 antagonists should
also carry the same warning
At least 3 cases of VT associated with 5HT3 administration
No “denominator” provided (or available)
Debunking Droperidol
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Lets remove the black box…
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Lipid Rescue….
Lipid Rescue
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20% lipid solution
1.5 ml/kg over 1 minute
Follow immediately by a infusion at rate of 0.25mg/kg/min (17.5
ml/min for a 70 kg adult)
Repeat dose if no improvement – and double the infusion rate
Max of 10 mg/kg???
www.lipidrescue.org
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Airway Management
TX seizures
ACLS------limit epi
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What about Propofol? (Propofol is 1%) Lipid based?
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Peanuts – peanut oil used in Fresenius propoven
(a propofol product from Europe showing up in hospitals in the U.S.)
Other Things to Remember!
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Ask the question…. What about other
treatments?
The Saving Grace!
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Wellbutrin 7.95 gms, Lomatrigine 4 grams
Wellbutrin 100mg/TID
Lomatrigine 300mg/QD
Many classes of compounds bind and
inhibit Na channels
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Local anesthetics
General anesthetics
Ca channel blockers
2 agonists
Tricyclic antidepressants
Substance P antagonists
Many nerve toxins
Benadryl
Droperidol ????
The cornea is the clear, dome-shaped outer area of the eye. It lies in front of the colored part of the
eye (iris) and the black hole in the iris (pupil). The outermost layer of the eyeball consists of the
cornea and the white part of the eye (sclera). A corneal abrasion is basically a superficial cut or
scrape on the cornea. A corneal abrasion is not as serious as a corneal ulcer, which is generally
deeper and more severe than an abrasion
To diagnose a corneal abrasion, a topical anesthetic with a yellow dye called flourescein is placed
into the eye. Under blue cobalt light, the part of the cornea abraded will be stained by the dye and is
easily seen by the examiner. The area and depth of the abrasion can be easily seen under a special
microscope called a slit lamp biomicroscope. If a microscope is not available, then a blue light called
a Burton lamp may be used
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren) and ketorolac
(Acular) are modestly useful in reducing pain from corneal abrasions
If antibiotics are used, ointment (e.g., bacitracin [AK-Tracin], erythromycin, gentamycin [Garamycin])
is more lubricating than drops and is considered first-line treatment. In patients who wear contact
lenses, an antipseudomonal antibiotic (e.g., ciprofloxacin [Ciloxan], gentamycin, ofloxacin [Ocuflox])
should be used, and contact lens use should be discontinued. Clinical trial data are lacking, but it is
recommended that contact lenses be avoided until the abrasion is healed and the antibiotic course
completed.
Proparacaine:
DO NOT USE TETRACAINE
IOP=25: Map > 70?
Post-op Visual Loss (POVL)
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Prolonged prone position may lead to
ischemic optic neuropathy
Precipitating factors include
hemodilution, periorbital edema,
excessive crystalloid administration,
hypotension, trendelenburg position
Methylmethacrylate
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Insertion of this cement assoc w/↓ BP
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Attributed to absorption of volatile
monomer of methylmethacrylate and/or
Embolization of air and bone marrow
during femoral reaming
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D/C N2O before bone cement placed
Adequate hydration, maximizing
oxygenation will minimize ↓ BP
w/cementing
Bone reimplantation syndrome!
Postoperative Cognitive Dysfunction
Deterioration of intellectual function presenting as
impaired memory or concentration
Not detected until days or weeks after anesthesia
Duration of several weeks to permanent
Diagnosis is only warranted if:
corroborated with neuropsychological testing
evidence of greater memory loss than one would
expect due to normal aging
Outcomes Following Major Surgery: Conclusions
POCD
Common in all age groups at hospital discharge
3 months after surgery, POCD is more common in adults age 60
years or older, with lower educational achievement
Associated with increased one-year mortality
Mortality
Increased by comorbidity
Anesthetic management has a significant effect
volatile agent use
cumulative deep anesthesia time
systolic hypotension
Summary
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“Anesthetic management, directly or indirectly, may contribute to the biology of
remote adverse events”
“Practicing anesthesiologists may be able to influence long-term outcomes by
adjusting anesthetic and adjuvant regimens”
“Reducing one-year mortality in the elderly by just 5% would translate to 40,000 50,000 lives saved each year”
Meiler, Monk et al. APSF Newsletter 2003; 18(3):33.
Beach chair position
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VAE may occur since
operative site is higher than
heart
Nerve injury may occur
w/upper extremity trauma
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Radial nerve w/humerus fx
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Keep BP… Neo Gtt?
Exparel
Tumescent Liposuction
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High volume low dose lidocaine mixed with
epi for liposuction.
Is this best practice? Increased mortality?
New Paralytic?
Gantacurium
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Is this a new Generation being born of NMB?
Based on amino acid pathway--olefinic
This drug is chemically degraded by rapid
adduction to L-cysteine and removes Chlorine
These two routes make it unavailable to bind to
acetycholine receptor
Does not require Liver, Kidneys, Tempature or pH
Two exciting analogs…
There has always been a search for the new
Suxx…..
Gantacurium
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Dose: 0.5 mg/kg
Fast acting with short duration

Exciting new group of drugs!
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Key is: NO histamine release!
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L-Cysteine
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Dissolved in concentration of 200mg/ml
Antidote for New class of Muslce relaxants

Olefinic isoquinolinium Diester NMB
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Takes advantage of this pathway
Naturally occuring amino acid
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Only works with new group of NMB’s
L-Cysteine

Human Studies: IV administration of exogenous L-Cysteine
induced faster recovery.

Dose in Studies: 5-50mg/kg
 (average dose is 10mg/kg)
Compared to Edrophonium reversal with atropine. Did not need to
give antimusarinic agent.
Reversed in 1 minute
There are risks…High doses: (added to TPN) but 1-1.5 grams/kg can
cause neuro defects
reported in infants
Pathophysiology of PONV
Cerebral cortex
(sight, smell, taste)
CTZ in the area postrema of the
fourth ventricle (medication)
Vestibular apparatus
(motion)
(Vagal afferents in GI tract
conduct impulses to stimulate CTZ)
Pharyngeal afferents
(gagging)
Enterochromaffin cells in GI
tract release serotonin, which
binds to visceral 5-HT3
receptors
(mechanical or medication)
CTZ = chemoreceptor trigger zone.
Multi Modal example
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Anticholinergic drugs (both scopolamine and robinul?? Atropine is better..) (anti
muscarinic receptor antagonists) and H-1 antagonists such as dramamine and
meclizine are very useful in motion sickness but are ineffective against
substances that act directly on the chemoreceptor trigger zone
A lot of drugs we use, then trigger nausea and vomiting in the chemoreceptor
trigger zone --- thus making the above listed drugs useless in this regard.
Antiemetic drugs should be combined to increase antiemetic activity while
decreasing toxicity effects; for example, dexamethasone when given with 5HT3 increases activity of both. Diphenylhydramine when given with
metoclopramide increases the action of both while reducing the risk of EPS.
Hence; we need a multi modal attack against nausea and vomiting
Remember these of older drugs either forgotten or just not used anymore.
You still have the mainstay drugs to use….
Oxygen
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Hypoxia triggers cortical afferents which triggers the vomiting
center which leads to the act of vomiting
One specific study showed a decreased rate of PONV
A second study trying to prove the first could not either prove or
disprove the first study
Increased O2 levels (less than 80%) in orthopedics have been
shown to decrease infection rates in total joints
Interesting thoughts?
Perioperative clinical factors &
immune function
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Supplemental perioperative
oxygen improves postop
outcomes
FiO2 of 0.8 doubles subcut
O2 tension & halves postop
wound infection rate
Supplemental O2 ↓ PONV
after laparoscopies &
laparotomies
Preconditioning w/O2 may
improve organ function after
liver tx & outome after spinal
ischemia insults
Curr Opin Anesthesiol 2006;19:11-18
Ginger
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Used for PONV as we talked about, motion sickness, vertigo, digestive aid for cramps
and menstral relief
Increases Bile production….. Bad with gallbladder pt

Some studies look at killing Ovarian cancer cells, Used as a stimulant, antidepressant,
gastro issues, constipation, HTN and delaying the onset of DM
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Increases the perioperative bleeding risks
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Stop at least two weeks prior to surgery
Small hint… if its green in can cause bleeding.
Ginger
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Ginger contains anticoagulant components. It inhibits platelet
aggregation by acting as an inhibitor of arachidonic acid,
epinephrine and adenosine diphosphate and collagen.
This is also a dose dependent relationship
There is a reduction in thromboxane synthetase and
prostaglandin synthetase and there was no reduction in
bleeding time, platelet count or platelet function.
Ginger administered prior to induction of anesthesia can
be prophylactic for PONV (1 gram) TOXIC is greater
than 2mg/kg/day
Meclizine-Antivert

H-1 blocker, central anticholinergic properties

Depresses Labyrinth and vestibular stimulation

Has some mild Local Anesthestic activity

Elderly can increase CNS confusion

Heavily metabolized by Liver and Kidneys…..becareful!
Becareful with any cholinergic sites…example Glaucoma

Dose is 25-50 mg PO

Dramamine
(Meclizine or Diphenhydramine mixed with
either Theophylline or derivative or
Theophylline)

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Antihistamines: Dramamine and Meclizine
H-1 antihistamines act similarly to the anticholinergic agents suppressing
transmission of neuronal impulses originating in the labyrinth. Used primarily
to treat or prevent motion sickness

Motion sickness is a prime trigger for PONV
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Both agents are available orally
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Dramamine is available IV
Dose is 25-50 MG IV (0.5mg/kg--Peds) 24hr coverage
Should be given with induction or post cord clamping
Works great with OB post C-section;
Remember sedative actions of this drug
Transdermal Scopolamine
Pharmacokinetics of
Transdermal Scopolamine
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Detected in plasma within 4 hr, peak within 24 hr
Crosses placenta and blood blood-brain barrier
Extensively metabolized
Half-life 9.5 hr after patch removal
− Potential drug interactions
− Decreased absorption of oral drugs
− Additive CNS effects with sedatives, tranquilizers, alcohol
− Additive anticholinergic effects with antihistamines,
TCAs,muscle relaxants
Atropine

Both atropine and scopolamine cross the BBB and placenta


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Tertiary Amine
Competetive antagonist for muscarinic acetylcholine receptors
Strong Parasympathetic response

Atropine with Neostigmine?
Atropine is a better bronchodilator and produces more tachycardia than scopolamine

Central Anticholinergic Syndrome! Beware…
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Intrathecal Atropine? Several Case Studies… Dose 100 mcg
IV Dose.. Adult 0.5 mg Peds 25 mcg/kg Please dilute in the IV bag

Organophasphate poisoning with 2 PAM Cloride

Hypotensive Thought Pattern

What is your order for treating Hypotension????

0
1
3
4
5

What is 6 for you?

?? Glucagon
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fluids
and 2; Neo and ephedrine
methylene blue
epi chip shots (5-10mcg)
vasopressin
Hypotension

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
Glucagon??
Not just for blood sugars anymore
Remember that boring lecture in school about how it relaxes the
sphincter of oddiiiiiiiiii????

Glucagon is a positive inotrope

Increases C-amp


Actually treatment of choice for beta-blocker overdose
Dose 1mg/IV
Calcium for BP


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Renal patients
The kidney converts VIT-D to is physiologically active form D-3
The patient on chronic renal disease becomes hypocalcaemia
because of calcium absorption from the intestine is impaired
when there is a deficiency of vitamin D

Calcium is a positive inotrope

Replacement with Blood transfusions

Monitor Ionized Calcium levels
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