Vertebral IgbodyCB

Thyroid cartilage JfA

Cricoid cartilage —+3

Trachea

T0

© Nicole Clough 2014

Child Upper Airway

Temperature Regulation

• vulnerable to hypothermia

• minimize heat loss by use of warming blankets, covering the infant’s head, humidification of inspired

gases, and warming of infused solutions

I

|

i

Central Nervous System i

• MACof halothane is increased compared to the adult (0.75% adult, 1.2% infant,0.87% neonate)

• NM) is immature for the first 4 wk of life, and thus, there is an increased sensitivity to nondepolarizing relaxants

• parasympathetics mature at birth,sympathetics mature at 4-6 mo; thus, there is an autonomic

imbalance

• infant brain is 12% of body weight and receives 34% of CO (adult:2% body weight and 14% CO)

Glucose Maintenance

• infants <1 yr can become seriously hypoglycemic during preoperative fasting and postoperatively if

feeding is not recommenced assoon as possible

• after 1 yr, children are able to maintain normal glucose homeostasis in excess of 8 h

Pharmacology

• higher dose requirements because of higher TBW (75% vs. 60% in adults) and greater volume of

distribution

• barbiturates/opioids more potent due to greater permeability of BBB

o

£

M

I. Large head

2 Newborns are obligate nasal breathers

3.Adenoid and tonsils

4.Larger tongue in proportion to mouth

5. Smaller pharynx

6 Larger and more flaccid epiglottis

7. Larynx is more superior and anterior

8 Narrowest point at cricoid cartilage

9.Trachea Is more narrow and less rigid

Figure 18. Comparison of paediatric

vs. adult airway +

A29 Anesthesia Toronto Notes 2023

• muscle relaxants

• non-depolarizing

immature NM), variable response

depolarizing

must pre-treat with atropine or may experience profound bradycardia and/or sinus node

arrest due to PNS > SNS (also dries oral secretions)

more susceptible to arrhythmias, hyperkalemia, rhabdomyolysis, myoglobinemia,

spasm, and malignant hyperthermia

ETT Siring in Paediatrics

Diameter (mm) of tracheal tube in

children after 1 year - (age/4) 4

length (cm) of tracheal tube - (age/2)

*12

masseter

See landmark Anesthesiology trials table lor more

information on a study by Su n et a I..2016. which

details tbe association between a single general

anesthesia exposure prior age 3G months and

neurocognitive outcomes in later childhood.

Uncommon Complications

Malignant Hyperthermia

•hypermetabolic disorder ofskeletal muscle

•due to an uncontrolled increase in intracellular Ca 2<(because of an anomaly of the ryanodine

receptor that regulates Ca 2 tchannel in the sarcoplasmic reticulum ofskeletal muscle)

•autosomal dominant inheritance

•incidence of 1-5 in 100000, may be associated with skeletal muscle abnormalities such as dystrophy or

myopathy

•anesthetic drugs triggering MH include:

all inhalational agents except nitrous oxide

• depolarizing muscle relaxants:SCh

Signs of Malignant Hyperthermia

• unexplained rise in ETCO2

• increase in minute ventilation

• tachycardia

. rigidity

• hyperthermia (late sign)

Clinical Picture

•onset:immediate or hours after contact with trigger agent

increased O2 consumption

increased ETCO2 on capnograph

tachycardia/dysrhythmia

tachypnea/cyanosis

diaphoresis

HTN

hyperthermia (late sign)

•muscularsymptoms

trismus (i.e. masseterspasm) common but not specific for MH (occurs in 1% of children given

SCh with halothane anesthesia)

tender,swollen muscles due to rhabdomyolysis

trunk or total body rigidity

Bask Principles of MH Management

"Some Hot Dude Better Get Iced Fluids

Fast"

Stop all triggering agents, give 100%

0.

Hyperventilate

Dantrolene 2.5 mg/kg every 5 min

Bicarbonate

Glucose and insulin

IV fluids:cool patient to 38°C

Fluid output: consider furosemide

Fast Heart [tachycardia]:be prepared

to treat VT

Complications

•coma

•D1C

•rhabdomyolysis

•myoglobinuric renal failure/hepatic dysfunction

•electrolyte abnormalities (e.g. hyperkalemia) and secondary arrhythmias

•ARDS

•pulmonary edema

•can be fatal if untreated

Prevention

» suspect MH in patients with a family history of problems/death with anesthetic

•avoid all trigger medications, use vapour-free equipment, use regional anesthesia if possible

•central body temp and b I CO 2 monitoring

Malignant Hyperthermia Manager

Based on Malignant Hypcrlhermia Association of the U.T.|M

1. notify surgeon, discontinue volatile agents and SCh, hyperventilate with 100% O2 at flows of 10 L/min

or more, halt the procedure assoon as possible

2. dantrolene 2.5 m

repeat untilt

3. bicarbonate 1-2 mbq/kg if blood gas values are not available for metabolic acidosis

4. cool patients with core temperature >39°C

lavage open body cavities,stomach, bladder,rectum; apply ice to surface;infuse cold saline IV

• stop cooling if temperature is <38°C to prevent drift to <36°C

5.dysrhythmias usually respond to treatment of acidosis and hyperkalemia

use standard drug therapy except Ca -^channel blockers as they may cause hyperkalemia and

cardiac arrest in presence of dantrolene

merit

HAUS] Guidelines. 2008

g/kg IV, through large-bore IV if possible

here is control ofsigns of MH; up to 30 mg/kg as necessary

n

u

+

A30 Anesthesia Toronto Notes 2023

6. hyperkalemia

• treat with hyperventilation, bicarbonate, glucose/insulin, calcium

• bicarbonate 1-2 mEq/kg 1 V'

, calcium chloride 10 mg/kg, or calcium gluconate 10-50 mg/kg for

life-threatening hyperkalemia and check glucose levels hourly

7. follow ETCO’

, electrolytes, blood gases, creatine kinase (CK), core temperature, urine output/colour

with Foley catheter, coagulation studies

if CK and/or potassium rises persistently or urine output falls to <0.5 mL/kg/h, induce diuresis to

>1 mL/kg/h urine to avoid myoglobinuric renal failure

8.maintain anesthesia with benzodiazepines, opioids, and propofol

9. transfer to 1CU bed

Abnormal Pseudocholinesterase

• pseudocholinesterase hydrolyzes SCh and mivacurium

• individuals with abnormal pseudocholinesterase will have prolonged muscular blockade

• SCh and mivacurium are contraindicated in those with abnormal pseudocholinesterase

• if SCh or mivacurium are given accidentally, treat with mechanical ventilation until function returns

to normal (do not use cholinesterase inhibitors as it will cause rebound neuromuscular blockade once

cholinesterase inhibitor effect is terminated)

Appendices

Difficult Tracheal Intubation in Unconscious Patient

3:

o

( Optimized primary approach to intubation unsuccesslul ]

QC < Q

-

I

;

s

( Does lacemask or SGD venlilation maintain adequate SpO,?

I

1

£

o

X YES NO

Can oxygenate

you have TIME for other option

Cannot oxygenate

you have NO TIME for other option

o

QC

c o t<

ii Failed oxygenation

Up to 2 further intubation attempts

•Alternative device

•Different operator

OR proceed directly to exit strategy

Succeeds

2

£

<

Failed intubation

One attempt at SGD il

Options — consider not already tried

• Awakening patient (not always

feasible or appropriate)

• Proceeding with case (or

temporizing) using face mask or SGD

ventilation

• Obtaining expert help or equipment

for additional controlled intubation

attempt

• Cricothyrotomy or tracheotomy (in

rare circumstances only)

>- CD >- O >

z ®

LU

LU Failed

LU

CD

cc <

C/3 LU oc

s LU

t

f

Cricothyrotomy

Figure 19. Difficult tracheal intubation encountered in the unconscious patient

SGD - uipf•glOtllC devkO

ri

Reprinted with permission, law JA, Broemllng N. Copper RM. et at. The difficult eirwny with recommendutions for imimigement

- Part 1- Difficult

tracheal intubation encountered in an unconsdous/induccd patient.Can J Anesth 2013;60:1089-1118.

L J

+

AL GRAWANY

A31 Anesthesia Toronto Notes 2023

Difficult Tracheal Intubation

^

Is local or regional

anesthesia leasbile for

surgical case?

(Airway exam or history predicts difficult tracheal intubation )

A

If general anesthesia is induced . .. NO

i

« Is tracheal intubation predicted to succeed in no more than 3 attempts?

2.IItracheal intubation fails,will face mask or SGO ventilation succeed?

I

... and are other patient and contextual issues favourable?

1. Rapid oxygen desaturation unlikely with onset of apnea?

2. Little risk of aspiration once unconcsious?

3. No obstructing airway pathology?

4. Additional skilled help available?

5. Clinician skilled in planned technique(s) and equipment available?

YES NO fl Significant risk of failed

oxygenation if induced

Low risk of failed oxygenation

if induced

'

f

’i

Consider intubation after induction

of general anesthesia

•e g. IV induction (e.g.RSI)

•e.g. inhalational induction

Is awake intubation feasible?

•Patient can cooperate

•Situation acuity permits

Other options

•e.g. induction with "double

set-up" preparation for

immediate cricothyrotomy

or tiacheotomy

Consider awake

intubation/techniques

•e.g. awake oral/nasal

•e.g. awake tracheotomy

YES NO

Figure 20. Anticipated difficult tracheal intubation

SGD = supraglottic device

Reprinted with permission:Law JA.Broemling N.Copper RM.et al.The difficult airway with recommendations for management

- Part 2 - The

anticipated difficult airway.Can J Anesth 2013;60:1119-1138.

r1

L J

+

A32 Anesthesia Toronto Notes 2023

Advanced Cardiac Life Support Guidelines

Adult Cardiac Arrest CPR Duality

•Push hard Winches 15 cmll and fast

1100 120'mini and allow complcta chest

recoil

• Mimrmto interruptions in compressions

• Avoid excessive ventilation

• Rotate compressor every 2 min,or sooner

if fatigued

•If no advanced airway,30:2

compression ventilation ratio

• Quantitative wavrrform capnography

If P.ujflO minHg, attempt to improve

CPR quality

Shock Energy

1

Start CPR

• Give oxygen

• Attach monitor/defibrillalor

I

[Rhythm shockable?

J

Yes I No

Y

^

Asystole/PEA j

•Biphasic:Manufacturer recommendation

(e g initial dose of 120 200 J).if unknown,

use maximum available Second and

subsequent doses should be equivalent,

and hiohei doses may be considered

•Monophasic: 360 J

Drug Therapy

•Epinephrine IV/10 Dose: 1 mg every

3 5 min

• Amiodarone IV/10 Oosc:

First doso 300 rna bolus

Second dose ISO mg

• lidocainc IV/10 Dose:

- First dose:M.5 mg/kg

- Second dose:0.5-0.75 mg/kg

10

CPR 2 min

• IV/10 access

Y

11

Rhythm shockable?

J

CPR 2 min

*

IV/10 access

* Epinephrine every 3-5 min

* Consider advanced airway,

capnography

Advanced Airway

6 •Endotracheal intubation 01 supragloftic

advanced airway

• Waveform capnography or capnomotiy

to confirm and monitor ET tuba placomont

• Once advanced airway in place,give t

breath every 6 sec 110 breaths/minl with

continuous chest compressions

CPR 2min

• Epinephrine every 3-5 min

• Consider advanced airway,

capnography

Yes [ Rhythm shockable? ]

*

No ^

Rhythm shockable?

J Return of Spontaneous CirculetionIROSCI

• Pulse and blood pressure

• Abrupt sustained increase inP ,

(typically >40 mmHgl

• Spontaneous arterial pressure wavas

with intra - arterial monitoring

i2r

CPR 2 min

• Treat reversible causes

8 Reversible Causes CPR 2 mill

• Amiodarone or lidocaine

• Treat reversible causes

Hypovolemia

Hypoua

Hydrogen ion lacidosrsl

Hypo /hyperkalemia

- Hypothermia

Tension pneumothorax

Tamponade,cardiac

Toxins

Thrombosis,pulmonary

Thrombosis, coronary

f Rhythm shockable? 1

No Yes

Y

13 Goto

5 or 7

*

If no signs ol return of spontaneous

circulation (ROSC),go lo 10 or 11

* II ROSC. goto

Post-Cardiac Arrest Care

* Consider appropriateness of

continued resuscitation

Figure 21. Adult cardiac arrest algorithm

Reprinted with permission:Punchal AR. B.utus JA. Cabanas JG.et ul. Part 3: Adult Basic and Advanced life Support: 2020 American Heart Association

Guidelines for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care.Circulation 2020;142:S366-S4G8.

r1

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A33 Anesthesia Toronto Notes 2023

Adult Tachycardia with a Pulse

1 Assess appropriateness tor clinical condition

Heart rate typicallyi150/min if tachyarrhythmia

2

Identify and treat underlying cause

• Maintain patent airway; assist breathing

as necessary

• Oxygen (if hypoxemic)

• Cardiac monitor to identify rhythm;

monitor blood pressure and oximetry

• IV access

• 12-Lead ECG,if available

Doses/Details

Synchronized Cardioversion

Refer to your specific device's

recommended energy level to

maximize fust shock success

Adenosine IV Dose:

First dose.6 mg rapid IV push; follow

with NS flush

Second dose:12 mg if required

£ « ;

4

Synchronized cardioversion

• Consider sedation

Yes *

If regular narrow complex,

consider adenosine

3

Persistent tachyarrhythmia

causing:

• Hypotension?

• Acutely altered mental status?

• Signs of shock?

• Ischemic chest discomfort?

• Acute heart failure?

Antiarrhylhmic Infusions tor

Stable Wide OHS Tachycardia

Procainamide IV Dose:

20 SO mg.min until oirhylhmia

suppressed,hypotension ensues,

QRS duration increases >50%, or

maximum dose 17 rngfkg given

Maintenance infusion: 1 4 mg/min

Avoid if prolonged QT or CHF

Amiodarone IV Dose:

First dose ISO mg over 10 min

Repeat as needed if VT recurs

Follow by maintenance infusion of

1 mg/mm for first 6h

Sofalol IV Dose:

100 mgll.Smgi’kgl over 5 min

Avoid if prolonged QT

6

Consider

• Adenosine only

if regular and monomorphic

• Antiarrhythmic infusion

• Expert consultation

No

5 Wide QRS Yes ?

i

).12 s

No

If refractory, consider

• Underlying cause

• Need to increase energy

level for next cardioversion

• Addition of anti-arrhythmic drug

•Expert consultation

7

• Vagal maneuvers

• Adenosine (il regular)

• (JBIocker or calcium channel

blocker

• Consider expert consultation

<

Figure 22. Adult tachycardia with a pulse algorithm

Reprinted with permission:ACLS Provider Manual.Copyright 2020 American Heart Association. Inc.

Adult Bradycardia with a Pulse

1r

Assess appropriateness for clinical condition

Heart rate typically <5Q/min if bradyarrhythmia

Identify and treat underlying cause

• Maintain patent airway;assist breathing as necessary

• Oxygen (if hypoxemic )

• Cardiac monitor to identify rhythm;

monitor blood pressure and oximetry

• IV access

• 12-Lead ECG if available; do not delay therapy

• Consider possible hypoxic and toxicologic causes

Doses/Details

Atropine IV Dose:

First dose: 1 mg bolus

Repeat every 3-5 min

Max:3 mg

Dopamine IV Infusion:

Usual infusion rate is

5-20 g/kg per minute.

Titrate to patient response;

taper slowly.

Epinephrine IV infusion:

2-10 g per minute infusion.

Titrate to patient response.

Causes:

•Myocardial ischemia/infarction

•Drugs/toxicologic (e.g.

calcium-channel blockers,

p-blockers,digoxin)

•Hypoxia

•Electrolyte abnormality (e g.

hyperkalemia)

3

Persistent bradyarrhythmia

causing:

• Hypotension?

• Acutely altered mental status?

•Signs of shock?

• Ischemic chest discomfort?

•Acute heart failure?

*[Monitor and observe^

Yes

Atropine

If atropine ineffective:

• Transcutaneous pacing

and/OR

* Dopamine infusion

OR r i

L J

* Epinephrine infusion

'’

Consider:

* Expert consultation

• Transvenous pacing +

Figure 23. Adult bradycardia algorithm

Reprinted with permission:ACLS Provider Manual.Copyright 2020 American Heart Association.Inc.

A3-1 Anesthesia Toronto Notes 2023

Landmark Anesthesiology Trials

Trial Name Reference Clinical Trial Details

INTRAOPERATIVE MANAGEMENT

NtJM 1996; 334:1209 1216 Title:Perioperative Hormolhcrmia to Reduce the Incidence olSurgical Wound Infection and Shorten Hospilalication

Purpose:1o lest ilhypothermia increases susceptibility lo surgical wound infection and lengthens hospitalization.

Methods:Colorectal surgery patients (n- 200) were randomly assigned to routine intraoperative thermal care (hypothermia group)

or additional warming(normothermia group in a double blind protocol). Vfounds evaluated daily until discharge and at 2 wh clinic

visit.Wounds with pus and positive cultures were considered infected.

Results:Intraoperative core temperature was found lo be significantly different inboth groups. Normothermia group had fewer

infected wounds,earlier suture removal,and prolonged hospital slay of 2.6 d (20%).

Conclusion:Hypothermia itself may delay healing and predispose patients lo wound infections.

Title:VolatileAnesthetics vs.Total Intravenous Anesthesia for CardiacSurgery

Purpose:Volatile agents have cardioprotective effects which could improve clinical outcomes in cardiacsurgery patients.

Methods:Multicenter,single blind, controlled tiial.Patients scheduled to undergo elective CABG were randomly assigned to an

intiaoperativc anesthetic regimen that included a volatile anesthetic (dcsflurane.isollurane,or sevoflurane) or lo TIVA.Ihe primary

outcome was all- cause mortality al1yr.

Results: A total ol 5400 patients were randomized. No significant difference between the groups with respect to all- causemorlality

was seen at1yr (2.8% in the volatile anesthetics group and 3.0% in the TIVA group:RR,0.94;95% Cl.0.69 to1.29; P

_

0.71).or at 30

d (1.4% and1.3%.respectively;RR.1.11:95% Cl.0.70 to 1.76).There were no significant differences between the groups in any of the

secondary outcomes or in theincidence of prespecified adverse events,including Ml.

Conclusion: Among patients undergoing elective CABG.anesthesia witha volatile agent did not result insignificantly lower deaths

at 1yr than TIVA.

Study ol Wound Infectionand

Temperature

MYRIAD IIEJM 2019:380:1214-1225

POSTOPERATIVE MANAGEMENT

IMPACT IIEJM 2004;350:2441-2451 Title:A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting

Purpose:To compare the efficacy of six well-established antiemetic strategies andlo determine the extent to which efficacy could

be improved by combining two or three interventions.

Methods:Patients (n'$199) were randomly assigned lo receive prophylactic antiemclics Independently,in combination or placebo.

Primaiy outcome was nausea and vomiting within 24 h after suigery.

Results:Ondansetron,dexametliasone.and droperidol each reduced risk olpostoperative nausea and vomiting by 26%.Propofol

reduced risk by 19%,and nitrogen by 12%.Relative risks associated with combined interventions could be estimated by multiplying

Ihe relative risks associated with each intervention.Absolute risk reduction vras a critical function of patients'baseline risk.

Conclusion:All interventions were similarly effective and acted independently.The safest or least expensive should be used first.

Moderate-risk patients may benefit from a single intervention andhigh-risk palienls fiom multiple interventions.

Title:Dexametliasone vs.Standard Ireatmcnl lor Postoperative Nausea andVomiting inGastrolntcslinal Surgery: Randomised

Controlled Trial(DREAMS Trial)

Purpose:Whether preoperative dexametliasone reduces postoperative nausea and vomiting (P0NV) inpatients undergoing elective

bowel surgery and whether itis associated with other measurable benefits during recovery from surgeiy.

Method:Pragmatic two-arm parallel

-group randomized trial wilh blinded postoperative care and outcome assessment.

Results: Administration of 8 mg IV dexametliasone alinduction was associated wilh lower rales of vomiting within 24 h olsuigery

(NHI-13) and reduced need lor nnliemetics up lo 72 h (NNI-8) vs. standard of care.

Conclusions: A single dose of dexamethasonc at induction of anesthesia significantly leduccs incidence of P0NV and need lor lescue

antiemetics postoperatively with no increase in adverse events.

Anesth Analg 2019:129:1512- Title:Comparison of Intraoperative Sedation With Dexmedetomidinevs.Propofol onAcute Postoperative Pain in Total Knee

Arthroplasty Under SpinalAnesthesia: A Randomized Trial

Purpose:Compare Ihe postoperative analgesic effect of intraoperative sedation wilhdcxmcdctomidine (OCX) vs.propofol.

Methods:Patients (n *

48) were enrolledand randomly assigned lo either DEX or propofol group.After the initial predetermined

loading dose,drug infusion rate vras determined according lo sedalion level. Cumulative amounts of PCA fenlanyl were recorded at

24-48 h postoperatively (primary outcome).Ihe postoperativenumerical rating scale for pain was assessed at 6.12,24.and 48 h

(secondary outcome).

Results: DEX significantly reduced postoperative fentanyl consumption at allof the studies time points.Ihe numerical rating scale

for pain was significantly lower atall timepoints.

Conclusion:Intraopcralivc DEX sedalion was associated with a small bul clinically impoilanlreduction inpostoperative opioid use

alter total knee arthroplasty.

Title:Effect of EEG-Guided Anesthetic Administration onPostoperative Delirium Among Oldei Adults Undergoing Major Surgery:The

ENGAGES RCT

Purpose:To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium.

Methods: RCT of 1232 adults >60 yr old undergoing major surgeiy and receiving guided anesthetic.Patients randomized 1:1lo

receive EEG -guided anesthetic administration or usual care.Primary outcome was incident delirium during postoperative days1- 5.

Results: Delirium during postoperative days1- 5 occurred in 26.0% olIhe guided group and in 23.0% of the usual care group|P-.22).

Median end- tidal volatile anesthetic concentration was significantly lower in the guided group than theusual care group,andmedian

cumulative time with EEG suppression was significantly less (7 vs.13 min;difference.-6.0 [95% Cl,-9.9 to -2.11).

Conclusion:Tltere is no difference in postoperative delirium between EEG- guided anesthetic or usual care of older adults.

DREAMS BMJ 2017:357:j14SS

Comparison of

IntraoperativeSedalion With 1518

Dcxmedclomidincvs.Propofol

on Acute Postopcralive Pain

m Total Knee Arthroplasty

Under Spinal Anesthesia: A

Randomized Trial.Shin et al..

2019

ENGAGES JAMA 2019:321:473-483

ri

L J

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A35 Anesthesia Toronto Notes 2023

Trial Name Reference Clinical Trial Details

COMPLICATIONS

Association Between a Single JAMA 2016:315:2312-2320

General Anesthesia Exposure

Before Age 36 Months and

Neurocognilive Outcomes in

taler Childhood.Sun el al..2016

Title:Association Between a Single General Anesthesia Exposure Before Age 36Months and Heurocognitive Outcomes in Later

Childhood

Purpose:To examine if a single anesthesia exposure in otherwise healthy young children was associated with impaired

neurocognilive development and abnormal behaviour inlater chidhood.

Methods:Sibling matched cohort study.Included sibling pairswithin 36 mo in age and currently 8-15 y/o witha single exposurelo

GA during inguinalhernia surgery In the exposed sibling and noanesthesia exposure in the unexposed sibling,before age 36 mo.

The primary outcome was global cognitivelundion III}).Secondary outcomes included domain- specific neurocognilive functions and

behaviour.

Results:Sibling pairs (n^105) wereincluded,with age of testing around 10 y/o.Mean10 scores between exposed siblings and

unexposed siblings werenot significantly different.Nosignificanl differences in mean scores were found between sibling pairs in

memory/learning,motor/processing speed,visuospalial function,attention,executive function,language,or behaviour.

Conclusions: Among healthy children with a single anesthesia exposure bclore age 36 mo. compared with healthy siblings withno

anesthesia exposure,(here were no statistically significant differences in neurocognilive outcomes.

Title:Tranexamic Acid in Patients Undergoing Noncardiac Surgery

Purpose: To assess the efficacy of tranexamic acid in reducing bleeding in non-cardiac surgery.

Methods:9535 patients were randomized to receive tranexamic acid or a placebo during surgery.Life -threatening bleeding,major

bleeding,and bleeding into a critical organ were assessed.

Results: A bleeding event occurred in 433 of 4757 patients in the treatment group as opposed to 561bleeding events in the placebo

group.

Conclusion:Iheuse of tranexamic acid was shown to significantly reduce the number of bleeding events innon-cardiac surgery.

POISE- 3 NEJM 2022:386(21):1986

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Apfel CC.laara E.Koivuranta M.elal. A simplified risk scoie for predicting postoperative nausea and vomiting:conclusions from cross validations between two centers.Anesthesiology 1999:91:693-700.

Apfelbaum JL,Connis RI.et al.Committee onStandards and Practice Parameters,Practice Advisory for Preanesthesia Evaluation.Anesthesiology 2012:116:522-538.

Apfelbaum JL,Hagberg CA.Caplan RA,et al.Practice guidelines for management of the difficult airway:an updated Report by the American Society of

Anesthesiologists task force on management of the difficult airway.Anesthesiology 2013;118|2):251-270.

Arbous MS. Meursing AE.van Kleef JW.elal.Impact of anesthesia management characteristics on severe morbidity and mortality.Anesthesiology 2005:102:257-268.

Barash P.Cullen BE. Sloetling RK. elal.Clinical anesthesia.7th ed.Philadelphia:lippincolt. 2013.

Bell RM.Dayton MT,Lawrence Pf. Essentials of surgical specialties.Philadelphia: Lxppxncott. 2000. Anesthesiology 1 67.

Blanc VE.Tremblay NA.The complications of tracheal intubation: A new classification with review of the literature.Anesth Analg 1974:53:202-213.

Brandstrup B. Tonnesen K.Beier-Holgersen R.et al.Effects of intravenous fluid restriction on postoperative complications:Comparison of two perioperative fluid regimens -A randomized assessor-blinded

multicenter trial.Ann Surg 2003:238:641-648.

Carlisle J,Stevenson CA.Drugs for preventing postoperative nausea and vomiting.Cochrane DB Syst Rev 2006:3.

Chung E.Subramanyam R.Liao P.elal.High STOP- Bang score indicates a high probability of obstructive sleep apnooa.Br J Anaesth 2012:108:768-775.

Collins VJ. Physiologic andpharmacologic bases of anesthesia. Philadelphia:Lippincolt.1996.

Cr alt IM, Upton PM. Key topics in anesthesia,clinical aspects,3rded.Oxford: BIOS Scientific. 2001.

Dobson 6.Chowl,Eilteaul.etal.Guidelines to the practice olanesthesia - Revised Edition 2021.Can J Aneslh 2021:68:92-129.

DREAMS TrialCollaborators and West Midlands Research Collaborative.Oexamethasone versus standard treatment for postoperative nausea and vomitingin gastrointestinal surgery:randomised controlled trial

(DREAMS Trial).BMJ 2017;357:j14S5.

Duke J.Anesthesia secrets.4th ed.Philadelphia:Mosby,2010.

frank SM,Pleisher LA.Breslow MJ.el al.Perioperatrve maintenance of normothermia reduces the incidenceof morbid cardiac events:a randomizedclinical trial.JAMA 1997;227:1127-1134.

Elersher LA.Eleischmann KE. Auerbach AD. clal. 2014 ACC/AHA guideline on perioperative cardiovascular evaluationand management of patients undergoing noncatdiac surgery:executive summary:a report of

Ihc American Collegeof Cardiology/Amctican Heart Association Task force on Practice Guidelines. Circulation 2014:130:2215 - 2245.

Gupta R.Gan TJ.Perioperative fluid management to enhance recovery.Anaesthesia 2016:71:40 45.

Hebert PC,Wells G.Blaychman MA.etal.Amulticenler,randomized,controlled clinical trialof transfusion requirements incrilical care.NEJM 1999:340:409-417.

Henderson JJ, PopatMT.Latto IP.et al.Difficult Airway Society guidelines for management of the unanticipateddifficult intubation.Anaesthesia 2004;59:675-694.

Hudcova J.McNicol E.Ouah C.et al.Patient controlled opioid analgesia vs.conventional opioid analgesia for postoperative pain.Cochrane DB Syst Rev 2006:4.

Joshi GP.Medical Intelligence:Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery.Anesth Analg 2005;101:601-605.

Kalanl H.Grant D.Mitchell J.Principles of medical pharmacology. 7th ed.New York: Oxford University Press. 2006.

longeron0,Masso E.Huraux C.el al.Prediction oldifficult mask ventilation.Anesthesiology 2000:92:1229 -1236.

law JA.Bioemluig N.Cooper RM.et al. The difficult anway with recommendations for management-Part1-Difficult tracheal intubation encountered inanunconscious/induced patient.Can J Anesth

2013:60:1089-1118.

Law JA.Broemling N.Cooper RM.et al.The difficult airway with recommendations for management-Part 2- The anticipated difficultairway.Can J Anesth 2013:60:1119-1138.

Lee A,fan LTY.Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting.Cochrane DB Syst Rev 2009:2.

Leighton BL.HalpernSH.The effects of epidural analgesia on labour,maternal,andneonatal outcomes:A systematic review.Am J Obstet Gynecol 2002:186:569-577.

lette J. Waters D, Bernier H.el al.Pteoperaliveand long- term cardiac risk assessment predictive value of 23 clinical descriptors.7 multivariate scoring systems,and quantitative dipyridamole imaging in 360

patients. Ann Surg 1992:216:192-204.

Levine WC. Alldin RM.Alston 1A.et al.Clinical anesthesia procedures of the Massachusetts General Hospilal. 8th ed.Philadelphia:Lippineoil. 2010.

liccaidi G. Salzillo A. DeBlasio f.el al. Control of asthma lor reducing the risk of bronchospasm in asthmatics undergoing general anesthesia and/or intravascular administration of radiographic contrast media.

Curr Med Res Opin 2009;25:1621-1630.

MacDonald NE,O'Brien Sf.Delage G.Canadian Paediatric Society Infectious Diseases andImmunization Committee:Transfusion and risk of infection in Canada Update 2012.Paediatr Child Health 2012:17:102-111.

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Mangano DT.Browner WS.Hollenberg M.etal.long-term cardiac prognosis following non-cardiac surgery. JAMA 1992:268:233-240.

Mangano DT.layugEl.Wallace A.elal. Effect of atenolol on mortality and cardiovascular morbidity after non cardiac surgery.

Mcrskcy H. Bogduk N.Classification of chronic pain descriptions of chrome pain syndromes and definitions of pain terms.2nd c

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Cardiology and Cardiac Surgery

Hardil Bhatt, Akachukwu Nwakoby, Jeremy Rosh, and Emily Tam, chapter editors

Karolina Gaebe and Alyssa Li, associate editors

Wei bang Dai and Camilla Giovino, EBM editors

Paul Dorian, Douglas Ing, and Bobby Yanagawa,staff editors

Acronyms

Basic Anatomy Review

Coronary Circulation

Cardiac Anatomy

Differential Diagnoses of Common Presentations

Chest Pain

Loss of Consciousness

Local Edema

Generalized Edema

Palpitations

Dyspnea

Cardiac Diagnostic Tests

Electrocardiography Basics

Approach to ECGs.

Classical Approach to ECGs

Alternative PQRSTU Approach to ECGs

Cardiac Biomarkers

Ambulatory ECG

Echocardiography

Stress Testing

Cardiac Catheterization and Angiography

Coronary Angiography

Magnetic Resonance Imaging

CARDIAC DISEASE

Arrhythmias

Mechanisms of Arrhythmias

Bradyarrhythmias

Supraventricular Tachyarrhythmias

Pre-Excitation Syndromes

Ventricular Tachyarrhythmias

Sudden Cardiac Arrest

Electrophysiologic Studies

Electrical Pacing

Implantable Cardioverter Defibrillators

Catheter Ablation

Ischemic Heart Disease

Chronic Stable Angina

Acute Coronary Syndromes

Treatment Algorithm for Acute Coronary Syndrome

Coronary Revascularization

Heart Failure

Congestive Heart Failure

Sleep-Disordered Breathing

Cardio-oncology

Myocardial Disease.

Myocarditis

Dilated Cardiomyopathy

Hypertrophic Cardiomyopathy

Restrictive Cardiomyopathy

Left Ventricular Noncompaction Cardiomyopathy

Cardiac Transplantation

Ventricular Assist Devices

Extracorporeal Membrane Oxygenation

Cardiac Tumours

Valvular Heart Disease

Infective Endocarditis

Rheumatic Fever

Valve Repair and Valve Replacement

Choice of Valve Prosthesis

Prosthetic Valve Management

.C2 Summary of Valvular Disease

.C2 Pericardial Disease

C 2

Acute Pericarditis

Pericardial Effusion

Cardiac Tamponade

.C5 Constrictive Pericarditis

Extracorporeal Circulation....

Cardiopulmonary Bypass

Cardiac and Neurological Protection during Cardiopulmonary

Bypass

Common Medications

C7

Antiarrhythmics

Landmark Cardiac Trials..

C7 References

C61

C68

C70

C74

C80

C19

C19

C30

C40

,C45

,C50

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Cl Cardiology and Cardiac Surgery Toronto Notes 2023

C2 Cardiology and Cardiac Surgery Toronto Notes 2023

Acronyms

CRT-D LVOT left ventricular outflow tract

MAP mean arterial blood pressure

MAT multifocal atrial tachycardia

myocardial infarction

myocardial perfusion imaging

mitral regurgitation

MS mitral stenosis

MVD multivessel coronary artery

disease

MVP mitral valve prolapse

MUGA multigatcd acquisition scan

NSR normal sinus rhythm

NSTEMI non-ST elevation myocardial SA

infarction

NYHA New York Heart Association

OMT optimal medical therapy

OPCAB off-pump coronary artery bypass SCO

OS opening snap

PAC premature atrial contraction

PCI percutaneous coronary

intervention

RBBB right bundle branch block

RCA right coronary artery

RCC right coronary cusp

RCM restrictive cardiomyopathy

RIMA right internal mammary artery

RITA right internal thoracic artery

RLSB right lower sternal border

radiofrequency

right ventricle

RVAD right ventricular assist device

RVH right ventricular hypertrophy

RVOT right ventricular outflow trunk

sinoatrial

SAM systolic anterior motion

SAVR surgical aortic-valve

replacement

sudden cardiac death

SEM systolic ejection murmur

SGLT2 sodium-glucose colransporter 2

SNS sympathetic nervous system

SOBOE shortness of breath on exertion

A atrium

abdominal aortic aneurysm

arterial blood gas

angiotensin converting enzyme CVP

inhibitor

advanced cardiovascular life DOAC

cardiac resynchronization

therapy defibrillator

cardiovascular

central venous pressure

dilated cardiomyopathy

direct oral anticoagulant

deep vein thrombosis

enteric coated ASA

extracorporeal membrane

oxygenation

end diastolic pressure

ejection fraction

electrophysiology studies

forced expiratory volume in the

first second

hypertrophic cardiomyopathy

heart failure

heartfailure with preserved

ejection fraction

heart failure with reduced

ejection fraction

heart failure survival score

hypertrophic obstructive

cardiomyopathy

hypertension

implantable cardioverterdefibrillator

Infective endocarditis

internal mammary artery

internalthoracic artery

jugular venous pressure

left atrium

left anterior descending artery

left atrial enlargement

left bundle branch

left bundle branch block

left coronary artery

left coronary cusp

left circumflex artery

left internal mammary artery

left internal thoracic artery

left lower sternal border

low molecular weight heparin

left ventricle

left ventricular assist device

left ventricular ejection fraction

left ventricular hypertrophy

AAA

AB.

'

- cv

ACEI Ml

DCM MPI

ACLS MR

support DVT

ACS acute coronary syndrome

ACT activatedclotting time

AFib atrial fibrillation

acute kidney Injury

aortic regurgitation

ARB angiotensin receptor blocker EPS

ARDS acute respiratory distress

syndrome

ARM angiotensin receptor-neprilysin HCM

inhibitor

aortic stenosis

ASA acetylsalicylic acid (Aspirin'

)

ASD atrial septal defect

AV atrioventricular

AVNRT atrioventricular nodalre-entrant HFSS

tachycardia

AVR aortic valve replacement

AVRT atrioventricular re-entrant

tachycardia

BIMA bilateral internal mammary

artery

BBB bundle branch block

8NP brain natriuretic peptide

8PM beats per minute

BiVAD biventricular assist device

CABG coronary artery bypass graft LAD

CAD coronary artery disease

CCB calcium channel blocker

CHD coronary heart disease

CM cardiomyopathy

CMR cardiovascular magnetic

resonance imaging

CO cardiac output

COPD chronic obstructive pulmonary LITA

disease

CPB cardiopulmonary bypass

CRT cardiac resynchronization

therapy

CRT-P cardiac resynchronization

therapy pacemaker

ECASA

ECMO

RF

RV

AKI EDP

AR EF

FEVi

HB

AS HFpEF

HFrEF

PCSK9 proprotein convertase subtilisin/ STEMI ST elevation myocardial

kexin type 9

PCWP pulmonary capillary wedge SV

pressure

PDA posterior descending artery

pulmonary embolism

PEA pulseless electrical activity

PFO patent foramen ovale

posterior interventricular artery

PMI point of maximal impulse

PND paroxysmal nocturnal dyspnea

PR pulmonary regurgitation

pulmonary stenosis

pulmonary trunk

PTCA percutaneous transluminal

coronary angioplasty

peptic ulcer disease

PVC premature ventricular

contraction

PVD peripheral vascular disease

PVR pulmonary vascular resistance V

right atrium

RAAS renin-angiotensin-aldosterone VFib

system

right atrial enlargement

RBB right bundle branch

HOCM infarction

stroke volume

SVC superior vena cava

SVR systemic vascular resistance

SVT supraventricular tachycardia

SYNTAX synergy between percutaneous

coronary intervention with taxus

and cardiac surgery

TAVI transcatheter aortic-valve

Implantation

TAVR transcatheter aortic-valve

replacement

TEE transesophageal

echocardiography

TIA transient ischemic attack

tricuspid regurgitation

tricuspid stenosis

TTE transthoracic echocardiography

UA unstable angina

ventricle

HTN

ICO

PE

IE

IMA

ITA PIV

JVP

LA

LAE PS

LBB PT

LBBB

LCA

LCC PUD TR

LCx TS

LIMA

LLSB

LMWH RA VAD ventricular assist device

ventricular fibrillation

valvular heart disease

ventricular septal defect

ventricular tachycardia

venous thromboembolism

Wolff-Parkinson- White

LV

LVAD VHD

LVEF RAE VSD

LVH VT

VTE

WPW

Basic Anatomy Review

Coronary Circulation

• arterial supply to the heart arises from the right and left coronary arteries, which originate from the

root of the aorta

. RCA:

conus artery

acute marginal branches

AV nodal artery

. PDA or PIV

• LCA:

LAD

- septal branches

- diagonal branches

LCx

- obtuse marginal branches

• dominance of circulation

» determined by whether the RCA or the LCx supplies the PDA

right-dominant circulation: PDA and at least one posterolateral branch arise from RCA (80%)

left-dominant circulation: PDA and at least one posterolateral branch arise from LCx (15%)

balanced circulation: dualsupply of posteroinferior LV from RCA and LCx (5%)

• the sinoatrial (SA) node is supplied by the SA nodal artery,which may arise from the RCA (60%) or

LCA (40%)

• the AV node is supplied by the AV nodal artery, which may arise from the RCA (90%) or LCx (10%)

• most venous blood from the heart drainsinto the RA through the coronary'sinus, although a small

amount drains through Thebesian veins into all four chambers, contributing to the physiologic R- L

shunt

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C3Cardiology and Cardiac Surgery Toronto Xotes 2023

Lettmam coronary artery ILCA)

Left circumflex artery (LCx)

,Left anterior descending(LAOI Right coronary

artery (RCAI

'

Septal perforator I

\

) Obtuse marginal

Conus artery

Diagonal

AV nodal /

arteiy j

Posterior

-