Leadership & Management – Merrill & Reid Social behaviour types/personalities. Know who you are and who you are dealing with.
Anaesthesia for PH/protecting RV – Goldilocks. Not overloaded, not undefiled, must be just right.
Pulmonary Hypertension: sPAP>40mmHg, mPAP>25. sPAP = RAP + 4x[TRVmax]^2
ECG: strain pattern. RAD. ST depression V1- V4
On echo: TR Vmax = underestimate.
RHS: TAPSE<15mm, RV thickness >5mm (in diastole)
Tips: Open, not laparoscopic surgery. A-line + CVC. Avoid ketamine/des/N2O (as they increase PVR). fiO2 0.6, PEEP 5-8. PaCo2 4-4.5. Warm everything. Post-op HDU/ICU. Phone a friend – local/own PH unit. Should they be for full MOS? What is disease trajectory? Beware NYHA Class 3-4.
Signs of problems: High CVP + low BP, low SpO2, reduced end organ perfusion. Consider cautious fluid bolus 150-200ml OR diuretic. Optimise ventilation, Keep in SR (Amiodarone +/- DCCV), avoid b-blocker. Start norad +/- vasopressin. Then adrenaline. Then milrinone. Then iNO, epoprostenol
Think: Is it the culprit or a bystander? Is it treatable? What further investigations (imaging, bloods, bx) will help?
Mortality: encephalopathy > ascites + bleed > other
Citrate RRT seems to be safe. However need to consider low Ca2+:Ca2+ ratio. Monitor for accumulation + toxicity
Use albumin for high volume replacement. Evidence only for paracentesis.
Adrenal dysfunction, so consider steroid (hydrocortisone 50mg qds) if increasing vasoconstrictor.
In GI bleeed -> start NG feed early (despite ‘protein load’ )
BM ventilation usually is biggest challenge. DL usually is ok – though increased difficult predicted in neck circ > 40 cm (especially > 50cm) + MP3. Apples worse than pears.
Proposed induction strategy:
Pre-O2 in ramped position, fiO2 0.8, PEEP 5-10
Early iGel instead of BMV
If predicted difficult DL/VL + can’t access neck think AFOI
Need patient centred (not doctor centred) outcome measures. Ideally standardised.
On fatigue. Samn Perelli scoring system.
In UK all population at risk of Vit D def which increases mortality which can be treated/reversed with treatment. Jury is out on ICU treatment of Vit D, however screening and treatment may be prudent/pragmatic.
VITDAL – ?
Currently in progress VITALISE, VIOLET
Vit D3 better than cholicalciferol.
Should we screen pre-op?
Consider having electronic frailty index (based on Rockwood method). Works with EMIS and SystemOne.
Assessment methods: Gait speed, Clinical Frailty Score, Edmonton Frailty Score