ACC Flashcards
Anesthetics:
how are drugs checked before administering them? (5)
what do you do before giving it IV? (1)
- Check the drug
- Check the ampoule
- Check the dilution
- Check the syringe
- Check the route of administration
It is good practice to always flush each intravenous drug with 0.9 % NaCI; this is to prevent incompatible drugs precipitating.
Controlled drugs:
where to store controlled drugs? (1)
where to put excess drug in ampoule? (1)
name the 3 controlled drugs commonly used in surgery? (3)
- locked container
- squirt into sharps bin
- benzo
- cocaine
- opioids e.g. fentanyl, morphine, afentanil etc
- ket actually isn’t one! but treated like one in most places
- anesthetist and ODP/anesthetic nurse
- twice daily checks of # of ampoules made by 2 trained members of staff a day!!
What are the three main blood bourne viruses?
- Hep B
- Hep C
- HIV
ICU:
What is critical care?
Critical care is an umbrella term which encompasses both level 3 (ICU) and level 2 (HDU) care
Level 2= Patients requiring more detailed observation or intervention, including support for a single failing organ system or postoperative care and those ‘stepping down’ from higher levels of care. (HDU). Nurse ratio 2:1
Level 3=requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure and is provided on critical care units commonly known as intensive care units (ICUs) or intensive treatment/therapy units (ITUs)1:1 nursing care
Conditions which may require critical care unit admission
- AKI
- brain injury (type 1, type 2, and due to systemic disease)
- post cardiopulmonary arrest
- post trauma (send to majr trauma centre)
- respiratory failure: ARDS, pneumonia, pulmonar oedema
- shock
- postoperative (planned or unplanned!)
ICU:
Purpose of central venous catheters? (5)
- Infusion of drugs (esp irritants e.g. noradrenaline, amiodarone and total parenteral nutrition)
- rapid volume infusions
- invasive haemodynamic monitoring
- central venous access for regular blood sampling, pacing wire insertions and emergency access when peripheral cannulation is not achieved
- to facilitate renal support therapy, plasmapheresis and exchange transfusions
ICU:
types of neurological monitoring? (2)
examples of each?
1- non-invasive
GCS, clinical observations, neurological examinations, electroencephalography (measures electrical activity in brain using electrodes on the scalp)
2- invasive intracranial pressure (ICP) monitor and intraventricular drain (EVD) for drainage of CSF for either diagnostic or therapeutic reasons
ICU:
Scoring system to predict mortality in ICU? (1)
what does it encompass? (3)
APACHE II
- acute physiology score
- age
- chronic health problems
A&E:
complications of MI? (9)
- cardiac arrest: often as MI–> VF–> arrest
- cardiogenic shock
- chronic heart failure: give loop diuretics, ACEi and BBs
- tachyarrythmias: VF (most common form of death post-MI), VT
- bradyarrhythmias: AV block more common in inferior MIs
- pericarditis: 48 hrs post transmural MI (pericardial rub, pericardial effusion and pain worse lying flat)
- Dressler’s syndrome: 2-6 weeks post-MI, autoimmune against new myocardium; fever, pleuritic pain, pericardial effusion and raised ER
- L ventricular aneurysm: persistent ST elevation and L ventricular failure –> stroke
- L ventriular free wall rupture (!!)
- ventricular septal defect: acute heart failure and pan-systolic murmur–> surgery ASAP!
- acute mitral regurgitation; ischaemia or rupture of papillary muscle, early-to-mid systolic murmo
A&E:
acute MI ECG changes with timings?
1- hyperacute T waves
2- ST elevatation
3- T waves inverted in first 24 hours
4- pathological Q waves hours-days then persist forever
remember: posterior MI causes ST depression NOT elevation
Pre-operative assessments:
what changes what investigations you get? (2)
what investigations are considered? (6)
what should you also consider? (1)
- ASA level of patinet
- Grade of the surgery (minor (level 1)/ intermediate (level 2)/ severe (level 3/4))
- Consider pre admission clinic to address medical issues.
- Blood tests including FBC, U+E, LFTs, Clotting, Group and Save
- Urine analysis
- Pregnancy test
- Sickle cell test
- ECG/ Chest x-ray
-VTE risk and plan
Pre-operative assessments: what investigations do you get for: minor surgery? intermediate? major?
what to do extra if: female? (1) diabetic? (1) when to do: urine test? (1) CXR? (1) what to check in FHx? (1)
- pregnancy test (if relevant and consent obtained)
- HbA1c if not tested within last 3 months, if they have look at referral letter
- if the presence of UTI would influence the decision to operate
- CXR never routine
- if heart murmor AND any cardiac symptom (SOB, syncope, pre-syncope, chest pain) OR signs/Sx heart failure
- test for sickle cell if FHx
Which routine tests do you do for minor, intermediate and major surgery for:
ASA1?
ASA2?
ASA3/4?
MINOR ASA 1 : none ASA 2: - U&E if risk of AKI - ECG if CVD, renal or diabetes ASA 3/4: - FBC if CVS/renal disease and not recently investigated - hemostasis if chronic live disease - U&E - ECG - possibly ABG
INTERMEDIATE: ASA 1: none ASA 2: - U&E if risk of AKI - ECG if CVD/ diabetes/ renal disease ASA 3/4: - basically all again
MAJOR: - FBC for all ASA 1: - U&E if risk of AKI - ECG >65 ASA 2: - FBC - U&E - ECG ASA 3/4: everything (FBC, U&Es, ECG, haemostasis if liver disease, consider lung function/ABG) https://www.nice.org.uk/guidance/ng45/chapter/recommendations
What is periorbital ecchymosis? (1)
what is it a sign of? (1)
raccoon/ panda eyes
often accompanied by CSF rhinorrhoea
= basal skull fracture
Trauma:
signs of basal skull fracture? (4)
what airway adjunct should be avoided? (1)
- periorbital ecchymosis
- CSF rhinorrhoea
- haemotympanum
- mastoid process bruising (battle’s sign)
nasopharyngeal airway is (relatively) contraindicated as risk of inserting it into the cranial cavity
(also avoid in coagulopathy)
Anaesthetics:
which patients shouldn’t get LMA? (2)
- unfasted - it has poor control against reflux
- morbid obesity
patients don’t have to be completely asleep for LMAs
Post-operative: How to assess who needs VTE prophylaxis? (2) mechanical prophylaxis? (2) pharmacological prophylaxis? (3) drugs to stop? (1) other? (2)
- assess risks
- compare risk of VTE to risk of bleeding
- anti-embolism (compression) stockings
- intermittent pneumatic compression device
one of:
- fondaparinux sodium (SC) or rivaroxaban (DOAC)
- LMWH e.g. eoxaparin
- Unfractionated heparin if CKD
- stop OCP 4 weeks pre surgery
- mobilise ASAP
- ensure hydration
VTE prophylaxis:
which surgeries automatically require anticoagulation? (3)
when is surgery not a risk factor for VTE? (1)
when is BMI a risk factor? (1)
- elective hip
- elective knee
- fragility fractures of pelvis, hip or proximal femour
- if <90 mins or <60 mins if surgery of lower limb
- > 35
Anesthetics:
in a hemodynamically unstable patient e.g. post motorbike crash, what induction agent is best? (1)
how does this drug work? (1)
Look at BP and HR!
Ketamine is best if hypotension
also an analgesic
remember that kid screaming post-accident on his bike on the Ambulance show, also causes antreograde amnesia so they won’t remember it!
- NMDA receptor antagonist
Anesthetics:
side effects of non-depolarising neuromuscular blockers? (1)
depolarising? (3)
treatment for hyperthermia? (1)
Non-depolarising:
- hypotension
Depolarising: (succinylcholine/ suxamethonium)
- malignant HYPERthermia
- hyperkalaemia
- increases introcular pressure –> contraindicated in acute/ narrow eye injuries
IV dantrolene
(an autosomal dominant disorder that leads to a susceptibility of patients to malignant hyperthermia with depolarising)
A&E:
Treatment of benzodiazepine overdose? (1)
Flumazenil
A&E:
Treatment for paracetamol overdose? (1)
N-acetylcystine
What do haematinic blood tests check? (1)
nutrients required for the formation of blood cells: iron, vit B12, folate
What special preparation is required for: thyroid surgery? (1) parathyroid surgery? (1) sentinel node biopsy? (1) involving thoracic duct? (1) pheochromocytoma? (1) carcinoid tumours? (1) colorectal? (1) thyrotoxicosis? (1)
- vocal cord check
- methylene blue to indentify gland
- radioactive marker/ patent blue dye
- cream
- alpha and beta blockade
- cover with octreotide
- bowel preparation
- medial therapy
What properties do benzodiazepines have? (5)
anxiolytic, hypnotic, anticonvulsant, muscle relaxant, and amnesic
NOT analgesic
Anesthetics:
In what ways are complications averted in surgery?
- WHO checklist
- prophylactic antibiotics
- VTE risk and prophylaxis
- MARK site of surgery
- tourniquets used with caution
- handle tissues with care
- be aware of coupling injuries using diathermy
- Remember the danger of end arteries and in situations where they occur avoid using adrenaline containing solutions and monopolar diatherm
Anaesthetics:
Patients with myasthenia gravis and Lambert-Eaton syndrome are particularly vulnerable to which part of general anaesthetics? (1)
how do you differentiate the symptoms of each? (2)
- MG patients are susceptible to non-depolarising and resistant to depolarising agents
- LEMS patients are susceptible to both depolarising and non-depolarising
- MG gets worse with use, i.e. later on in the day
- LEMS gets better with use
Anasthetics:
why is adrenaline added to local anaesthetics? (2)
who is it contraindicated in? (1)
constricts vessels so:
- prolongs duration
- permits usage of higher doses (apart from in bupivacaine)
lignocaine = 3mg/kg - 7mg/kg (with adrenaline
bupiva = 2mg/kg
prilocaine = 6 -> 9mg/kg
( These are a guide only as actual doses depend on site of administration, tissue vascularity and co-morbidities.)
- patients taking MAOIs or TCAs
Long-term ventilation:
a patient on long-term intubation gets abdominal distension and right sided consolidation, with raised WCC - what complication has happened? (1)
tracheo-oesophageal fistula formation (air into esophageal and gastric contents back)
- once endotracheal tubes are inserted they rarely aspirate, it normally occurs in the early stage
Surgery:
when can paralytic ileus occur other than surgery? (4)
what type of obstruction is it? (1)
PSEUDO-OBSTRUCTION
- chest infections
- MI
- stroke
- AKI
Deranged electrolytes can contribute to the development of paralytic ileus, so it is important to check potassium, magnesium and phosphate.
Post-operative pyrexia: early causes (days 0-5)? (5) late causes (>5 days)? (4)
- cellulitis
- blood transfusion
- UTI
- pulmonary atelectasis
- physiological systemic inflammation reaction (usually within a day following the operation)
INFECTION OR THROMBUS:
- VTE
- penumonia
- wound infection
- anastomotic leak
Anesthetics:
if you cant get IV access in a cardiac arrest, what should you do? (1)
go for intraosseous (IO) access
Surgery:
which drugs impair wound healing? (4)
- NSAIDS
- steroids
- immunosuppressants
- anti neoplastic drugs
ICU: most common nosocomial infection? (1) define it? (1) what increases it's likelihood? (1) what scoring systems aid diagnosis? (2)
ventilator-associated pneumonia (VAP) - occurs 48 hours or more after tracheal intubation
cause by microaspirations around the cuff of the tracheal tube
- longer intubation = higher risk
- clinical pulmonary infection score
- HELICS: Hospital In Europe Link for Infection Control though Surveillance
ICU:
definition of late and early onset VAP? (2)
what is late-onset associated with? (1)
- early-onset: within first 4 days
- late-onset- 5 days+ after admission
- late-onset usually assocaited with drug resistant microorganisms
Common causative pathogens of VAP include Gram negative bacteria such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species, and Gram-positive bacteria such as Staphylococcus aureus.
ICU:
how do they avoid VAP?
- avoid uncesarry intubation (NIV if possible)
- airway tube: try use one with subglottic
- hand washing
- isolation of infectious patients suction ports
- minimize duration of VAP (assess frequently if they can be extubated)
- true to reduce bacterial load in secretions: (1) decontamination of respiratory tract with chlorhexidine gel, (2) minimizing acid reflux drugs e.g. H2-receptor antagonists and PPIs
- reduce micro aspiration: avoid supine positioning, maintain endotracheal tube cuff seal, use suction to remove subglottic secretion pooled above endotracheal cuff
ICU:
what are the gastrointestinal complications of invasive ventilation? (2)
why do these occur? (1)
- stress-related mucosal damage: stress ulcers –> most common cause of GI bleeding in ICU, use PPIs
- GI hypomotility : ICUs have protocols to follow which may involve prokinetics (metolopromide), sometimes neostigmine
- splanchnic hypoperfusion
Anaesthetics: doses of local anaesthetics: Bupivacaine? (1) Lignocane? (1) Prilocaine? (1)
Bupivacaine / levobupivacaine ( with or without adrenaline): 2 mg/kg
Prilocaine: 6mg/kg
Lignocaine without adrenaline: 3 mg/kg
Lignocaine with adrenaline: 7 mg /kg
Anaesthetics:
how are local anaesthetics defined? (3)
what affects pattern of toxicity?
- REVERSIBLY prevents transmission of the nerve impulse
- in the REGION to which it is applied
- WITHOUT affecting consciousness
Joined by either an ester link or an amide link.
- route of administration
- speed at which toxic plasma level occurs
(if rises slowly the CNS is affected first)
Anaesthetics:
symptoms of local anaesthetic toxicity?
management: two things to do? (2)
A-E approach? (4)
Symptoms are generally excitatory, possibly due to inhibition of inhibitory neurons via GABA receptors. Patients may report perioral and tongue paraesthesia, a metallic taste, and dizziness, then develop slurred speech, diplopia, tinnitus, confusion, restlessness, muscle twitching and convulsions. At higher plasma levels there is widespread sodium channel blockade with more generalised neuronal depression leading to coma followed by respiratory arrest and then cardiac arrest
- STOP INJECTING IT
- call for help
- A: maintain and if necessary, tracheal tube
- B: give 100% O2 and ensure adequate lung ventilation
- C: IV access
- D: control seizures: benzodiazepines, thiopental or propofol, consider drawing blood for analysis,
If circulatory arrest: start CRP, use standard protocols - give IV lipid emulsion
Postoperative pain: what affect does it have on cardiovascular system? (3) respiratory? (4) GI? (2) other? (2)
- tachycardia
- hypertension
- increased myocardial O2 demand
- decreased vital capacity
- decreased FCR
- basal atelectasis
- resp infection
- ileus
- N&V
- urinary retention
- DVT+PE