WikiAnesthesia - User contributions [en]

Glycopyrrolate

2024-09-30T13:20:16Z

Oliviamsutton:

{{Infobox drug reference
| trade_names =
| drug_class =
| drug_class_color = anticholinergic
| uses =
| contraindications =
| routes =
| dosage =
| dosage_calculation = glycopyrrolate
}}

Glycopyrrolate is an anticholinergic drug commonly used in anesthesia to treat bradycardia and decrease secretions. It notably does not cross the blood-brain barrier and consequently has very few central effects.

== Uses ==

* Treat reflex bradycardia due to vasovagal reactions
* Reduce secretions (salivary, tracheobronchial, pharyngeal)
* Use in conjunction with neostigmine to prevent neostigmine's muscarinic effects such as bradycardia in neuromuscular blocking reversal

== Contraindications ==

=== Absolute contraindications ===

=== Precautions ===

== Pharmacology ==

=== Pharmacodynamics ===

==== Mechanism of action ====

==== Adverse effects ====

=== Pharmacokinetics ===

== Chemistry and formulation ==

== History ==

== References ==

[[Category:Drug reference]]

Surgical Procedure Guide

2023-08-18T18:47:46Z

Oliviamsutton: Created blank page

Intro to the BWH Pain Rotation

2023-08-02T18:19:04Z

Oliviamsutton: Blanked the page

2022-10-20T20:50:15Z

Oliviamsutton:

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

An amniotic fluid embolism (AFE) is a rare but serious condition with high morbidity and mortality. It is characterized by cardiopulmonary collapse and disseminated intravascular coagulation (DIC). It is the second-leading cause of peripartum maternal death in the US and number one cause of peripartum cardiac arrest. <ref>{{Citation|last=Haftel|first=Anthony|title=Amniotic Fluid Embolism|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK559107/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32644533|access-date=2022-10-20|last2=Chowdhury|first2=Yuvraj S.}}</ref>

== Anesthetic implications ==

=== Preoperative optimization ===

=== Intraoperative management ===

=== Postoperative management ===

== Risk Factors==
Risk factors for the development of AFE are advanced maternal age, multiparity, male fetuses, and trauma. Induction of labor has also been found to increase risk for AFE.

== Pathophysiology ==
AFE is poorly understood. It is thought to originate from a disruption of the placenta-amniotic interface with the subsequent entry of amniotic fluid and fetal elements (such as hair, meconium, squama, and mucin) into the maternal circulation. Upon entering the pulmonary tree, intense pulmonary vasoconstriction occurs. This may be associated with concomitant bronchoconstriction. The hemodynamic result is acute pulmonary arterial obstruction, dilatation of the right ventricle and the right atrium, and significant tricuspid regurgitation. The right ventricular enlargement causes the intraventricular septum to bow into the left ventricle creating obstruction and systolic dysfunction, further raising pulmonary artery pressure and decreasing cardiac output. Hypoxemia and hypotension lead to sudden cardiovascular collapse.

Normally, pregnancies are procoagulant, to begin with, and the introduction of amniotic fluid and fetal elements trigger inflammatory mediators activating the coagulation cascade and fibrinolytic systems resulting in DIC.

== Signs and symptoms ==

== Diagnosis ==
The American Society for Maternal-Fetal Medicine, after a consensus symposium has created its criteria for AFE, which require the following:

# Sudden cardiopulmonary collapse, or hypotension (systolic blood pressure less than 90 mmHg) with hypoxia (SpO2 less than 90%)
# DIC, according to the international society on thrombosis and hemostasis (ISTH) definition
# Symptomatology either during labor or during placental delivery (or up to 30 minutes later)
# No fever

== Management==
The cornerstone of AFE management is prompt cardiopulmonary resuscitation of the mother with rapid evacuation of the fetus.

For the mother, this includes securing the airway, effective ventilation, pressors as appropriate, and fluid management. After intubation, large bore intravascular access should be obtained for resuscitation.

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

Amniotic fluid embolism

2022-10-20T20:47:48Z

Oliviamsutton: added info

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

An amniotic fluid embolism (AFE) is a rare but serious condition with high morbidity and mortality. It is characterized by cardiopulmonary collapse and disseminated intravascular coagulation (DIC). It is the second-leading cause of peripartum maternal death in the US and number one cause of peripartum cardiac arrest. <ref>{{Citation|last=Haftel|first=Anthony|title=Amniotic Fluid Embolism|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK559107/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32644533|access-date=2022-10-20|last2=Chowdhury|first2=Yuvraj S.}}</ref>

== Anesthetic implications ==

=== Preoperative optimization ===

=== Intraoperative management ===

=== Postoperative management ===

== Risk Factors==
Risk factors for the development of AFE are advanced maternal age, multiparity, male fetuses, and trauma. Induction of labor has also been found to increase risk for AFE.

== Pathophysiology ==
AFE is poorly understood. It is thought to originate from a disruption of the placenta-amniotic interface with the subsequent entry of amniotic fluid and fetal elements (such as hair, meconium, squama, and mucin) into the maternal circulation. Upon entering the pulmonary tree, intense pulmonary vasoconstriction occurs. This may be associated with concomitant bronchoconstriction. The hemodynamic result is acute pulmonary arterial obstruction, dilatation of the right ventricle and the right atrium, and significant tricuspid regurgitation. The right ventricular enlargement causes the intraventricular septum to bow into the left ventricle creating obstruction and systolic dysfunction, further raising pulmonary artery pressure and decreasing cardiac output. Hypoxemia and hypotension lead to sudden cardiovascular collapse.

Normally, pregnancies are procoagulant, to begin with, and the introduction of amniotic fluid and fetal elements trigger inflammatory mediators activating the coagulation cascade and fibrinolytic systems resulting in DIC.

== Signs and symptoms ==

== Diagnosis ==
The American Society for Maternal-Fetal Medicine, after a consensus symposium has created its criteria for AFE, which require the following:

# Sudden cardiopulmonary collapse, or hypotension (systolic blood pressure less than 90 mmHg) with hypoxia (SpO2 less than 90%)
# DIC, according to the international society on thrombosis and hemostasis (ISTH) definition
# Symptomatology either during labor or during placental delivery (or up to 30 minutes later)
# No fever

== Treatment ==

=== Medication ===

=== Surgery ===

=== Prognosis ===

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

2022-07-20T15:07:13Z

Oliviamsutton:

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = PIV x1-2, radial a-line (to draw frequent ACTs and monitor BP)
| monitors = Standard
| considerations_preoperative =
| considerations_intraoperative = Have lead available for frequent imaging. Have heparin available and small syringes for ACTs
| considerations_postoperative =
}}

A femoral endarterectomy is a procedure with the goal of restoring patency to an occluded femoral artery and restoring vascular supply to the tissue. It involves a groin incision where the surgeon directly opens the femoral artery and removes the plaque, then closes the artery, at times with a synthetic patch.

== Overview ==

=== Indications ===
Partial or total occlusion of the femoral artery from atherosclerosis and/or PAD.

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Most of these patients have significant PAD. Many of these patients have comorbid CAD, HTN
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

* A-line is always required for frequent ACT draws plus BP management
* 1-2 18G PIVs

=== Induction and airway management ===

* GA with ETT due to need for muscle relaxation

=== Positioning ===

* Supine with arms tucked. C-arm or other fluoro device will be present and obstructing access to patient at times.

=== Maintenance and surgical considerations ===

* Muscle relaxation is usually required
* Heparin should be available and drawn up, as well as syringes for drawing ACTs
** Protamine should be available but may not always be given.
* BP should be maintained close to patient's baseline, but always check with the surgeon

=== Emergence ===

* Avoid hypertension with emergence, which may challenge the new graft and incision. Have downers available to treat temporary HTN, such as labetalol.

== Postoperative management ==

=== Disposition ===

* Usually PACU > floor, patients stay 1-2 nights in the hospital

=== Pain management ===

=== Potential complications ===

* Hemorrhage, stroke (embolization due to plaque rupture), groin hematoma

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Femoral artery endarterectomy

2022-07-20T15:01:28Z

Oliviamsutton: started page

{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = PIV x1-2, radial a-line (to draw frequent ACTs and monitor BP)
| monitors = Standard
| considerations_preoperative =
| considerations_intraoperative = Have lead available for frequent imaging. Have heparin available and small syringes for ACTs
| considerations_postoperative =
}}

A femoral endarterectomy is a procedure with the goal of restoring patency to an occluded femoral artery and restoring vascular supply to the tissue. It involves a groin incision where the surgeon directly opens the femoral artery and removes the plaque, then closes the artery, at times with a synthetic patch.

== Overview ==

=== Indications ===
Partial or total occlusion of the femoral artery from atherosclerosis and/or PAD.

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Most of these patients have significant PAD. Many of these patients have comorbid CAD, HTN
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

2022-03-15T22:52:07Z

Oliviamsutton: Skeletonized

== Why Antibiotics? ==
In 1984 a study including 51 acute care hospitals in New York State found that surgical site infection (SSI) was the most common adverse surgical event (and the second most common adverse event overall). Perioperative antibiotic prophylaxis – administration of abx prior to surgery to prevent surgical site infections, but best practice also includes sterility (surgeon and instruments), skin prep (clipping hair, allowing skin antiseptic to dry) Barash, Paul G. Clinical Anesthesia. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009. Print. SSIs- now a marker of quality of care in the US, Medicare no longer reimburses for certain SSIs (ie mediastinitis after cardiac surgery, SSIs post-bariatric surgery & some orthopedic procedures)

=== Timing of prophylaxis ===
Antibiotic therapy should be given within 60 min (ideally: 15-45 mins) prior to surgical incision for adequate serum drug tissue levels at incision. • Exception IV vanco/cipro (requires longer infusion) • If a proximal tourniquet is used, the entire antibiotic dose should be administered before the tourniquet is inflated. • Exceptions to pre-incision antibiotics: • check for active ongoing antibiotic therapy, may not be indicated for surgery, surgeon declined, or delay until after a specimen is sent for culture. Timing of prophylaxis Rates of Surgical-Wound Infection Corresponding to the Temporal Relation between Antibiotic Administration and the Start of Surgery • The number of infections and the number of patients for each hourly interval appear as the numerator and denominator, respectively, of the fraction for that interval. The trend toward higher rates of infection for each hour that antibiotic administration was delayed after the surgical incision was significant (z score = 2.00; P<0.05 by the Wilcoxon test). Classen DC, et. Al. (1992) The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. The New England Journal of Medicine 326:281-286.

Types of Wounds (per CDC/NHSN)

Clean procedures (1.3 to 2.9% rate of surgical site infection) • Uninfected operative wound closed primarily in which no inflammation is encountered and respiratory, GI, genital, or uninfected urinary tracts are not entered. • Common skin flora: CoNS, MSSA/MRSA and strep • Clean-contaminated procedures (2.4 to 7.7% rate of SSI) • Operative wounds in which the respiratory, GI, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. • Common bugs are skin flora, gram-negative rods, Enterococci. If surgery involves a viscus, pathogens reflect endogenous flora of the viscus or nearby mucosa • Contaminated procedures (6.4 to 15.2% rate of SSI) • Open fresh, accidental wounds. Also, operations with major breaks in sterility, gross spillage from the GI tract, and incisions in which acute non-purulent inflammation is encountered • Dirty or infected (7.1 to 40.0% rate of SSI) • Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera.

== 2017 SHC Surgical Antimicrobial Prophylaxis Guidelines ==
Surgery Preferred Agent Beta-lactam allergy Cardiac Surgery/Vascular/Thoracic Cardiac device insertion (PM implant) Other General Surgery (hernia, breast) Neurosurgery Orthopedics Plastic Surgery Cefazolin Vancomycin (preferred) Clindamycin can be used as an alternative. Based on 2015 SHC Antibiogram, 81% MSSA susc to clinda vs 100% MSSA susc to vanc Cardiac Surgery w/ prosthetic material Cefazolin + Vancomycin Vancomycin Gastroduodenal Cefazolin Vancomycin + Gentamicin Biliary Tract Cefazolin Metronidazole + Levofloxacin Colorectal, Appendectomy Cefazolin + Metronidazole Metronidazole + Levofloxacin Gynecological (hysterectomy/Cesarean) Cefazolin Clindamycin + Gentamicin Urology These are EMPIRIC abx recs when no preoperative urine cx available or culture negative. Ask urology team for recs. If clean: Cefazolin If clean contaminated (eg open or lap with ileal conduit)- cefoxitin If prosthetic material involved, should add gentamicin x1 dose Gentamicin + Clindamycin1 If clean: (skin incision only)- clinda1 If clean-contaminated: metronidazole + levofloxacin 1sub vanc for clinda if MRSA due to clinda poor urinary penetration Head & Neck Clean or ear/sinonasal: Cefazolin If contaminated (include oral mucosa breach)- Cefazolin+ Metronidazole Clindamycin *Based on 2013 consensus guidelines from American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS) and the Society for Healthcare Epidemiology of America (SHEA) Selected 2017 SHC Dosing and Re-dosing Guidelines Antimicrobial Recommended Dose Re-dosing (hrs) Notes Cefazolin <120kg- 2g >120kg- 3g Peds: 30mg/kg, max 2g 4 Can bolus over 3 minutes** Clindamycin 900mg 6 Give over 30 minutes Vancomycin <80kg – 1g 80-99kg- 1.25g 100-120kg- 1.5g >120kg- 2g Adult and Peds 15mg/kg 12 Give over 30-60 minutes, or <10mg/min; whichever is longer) Can be given 60-120min prior to incision (long half life) Ampicillin-Sulbactam 3g 2 Give over 15-30 minutes Aztreonam 2g 4 Cefoxitin 2g 2 Ceftriaxone 2g 24 Ciprofloxacin 400mg 8 Give over 60 minutes Contraindicated in pregnancy Ertapenem 1g 24 Give over 30 minutes Gentamicin 5 mg/kg (single dose) If CrCl<20, 2mg/kg (single dose or consult Rx) 24 Dilute to <1mg/cc Give over 30-120 minutes (risk of ototo/nephrotoxicity with bolus) Levofloxacin 500mg 24 Metronidazole 500mg 12 Give over 20-60 minutes *As a general rule, for drugs with a greater therapeutic index, you can administer them faster

== Allergies and Interactions ==
Penicillins and 1st & 2nd generation cephalosporins have similar side change with some risk of cross-reactivity • Cephalothin (1st cephalosporin) marketed in 1964; cross-reactivity with penicillin allergy noted to be 5-10%. This over-generalization of cross-reactivity has resulted in the avoidance of all cephalosporins, not just cephalothin, in patients labeled as penicillin allergic • Some of this cross-reactivity is historically thought to be due to cross-contamination during manufacturing • True incidence of allergy in patients with a reported history of PCN allergy is less than 10%. • Only IgE-mediated reaction (type I, immediate hypersensitivity reactions) are true allergic reactions. • Encourage skin testing to simplify future antibiotic choices • The cross-reaction rate between PCN and 1st & 2nd cephalosporins is 1-10% • Cross-reaction rate between 3rd generation cephalosporins and PCN approaches 0%! • History of PCN allergy is a general risk factor for allergic manifestations to antibiotic administration that may not be specific to cephalosporins

Perioperative Antibiotic Decision Algorithm From Vorobeichik, et. al. Anesthesia & Analgesia, 2018

Allergies and Interactions • If the allergic reaction to PCN is only erythema or pruritis, many attendings still give a cephalosporin, but always check with your attending • However, hx of anaphylactic reaction to PCN is an absolute contraindication to cephalosporins. • Type 1 anaphylactic reaction to antimicrobials occur 30- 60 minutes after administration • Test dose: Not always done. However, it may be prudent to give 1ml of the antibiotic first to see if the patient will have a reaction. This test dose only decreases the anaphylactoid reaction, not anaphylaxis • Allergic reactions are more likely from neuromuscular blockers than antibiotics

== Penicillin Allergy Pathway for Antibiotic Prescriptions ==
From Vaisman, et al. JAMA 2017

== Endocarditis Prophylaxis ==
Patients at increased risk: – Prosthetic cardiac valve (including transcatheter-implanted prostheses and homografts) – Prosthetic material used for cardiac valve repair, including annuloplasty rings and chords – Previous history of infective endocarditis – Unrepaired cyanotic congenital heart disease or completely repaired congenital heart defect within the first 6 months. – Cardiac transplant patients who develop cardiac valvulopathy • Procedures at risk • Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa (not all dental procedures) • Upper respiratory tract: only if it is incised or biopsied • Procedures on infected skin, skin structure, or musculocutaneous tissue • GI/GU: prophylaxis no longer recommended • Bacterial Endocarditis prophylaxis – Ampicillin 1-2gm IV, 30min prior to surgery AND Gentamicin 1.5mg/kg IV, 30min prior to surgery – IF PCN allergic, use cefazolin or ceftriaxone 1gm IV, or clindamycin 600mg IV • Mitral valve prolapse/HoCM/Bicuspid AV do not need prophylaxis because, while there is increased risk for IE, the most serious adverse outcomes of IE do not usually occur in patients with these conditions.

== ITE tip ==
Which of the following antibiotics does NOT augment neuromuscular blockade? a. Clindamycin b. Neomycin c. Streptomycin d. Erythromycin Answer: d. Cephalosporins also do not affect neuromuscular blockade.

WikiAnesthesia - User contributions [en]

Glycopyrrolate

Surgical Procedure Guide

Intro to the BWH Pain Rotation

BWH Pain Attending Preferences

BWH Pain Attending Preferences

BWH Pain Attending Preferences

Intro to the BWH Pain Rotation

Amyotrophic lateral sclerosis

Femoral nerve block

Pneumonectomy

Pneumonectomy

Pneumonectomy

Pneumonectomy

Pneumonectomy

Dental extraction

Dental extraction

Amniotic fluid embolism

Thyroidectomy

Uterine rupture

Uterine rupture

Uterine rupture

Amniotic fluid embolism

Amniotic fluid embolism

Amniotic fluid embolism

Amniotic fluid embolism

Tetralogy of Fallot

Tetralogy of Fallot

Myotonic muscular dystrophy

Myotonic muscular dystrophy

Femoral artery endarterectomy

Femoral artery endarterectomy

Table of contents

Transcarotid Artery Endovascular Revascularization

Antibiotics

Esophagectomy

Esophagectomy

Ivor Lewis esophagectomy

HSS

HSS

HSS

HSS

HSS

Suprapubic cystostomy

Orchiectomy

Nephrectomy

Lithotripsy

Cystectomy

Brachytherapy

Cystoscopy

Antibiotics