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Y3 Surgery > Anaesthesia > Flashcards

Anaesthesia Flashcards

1
Q

What age should you be cautions with using anaesthesia?

A

(Said in the trauma meeting 18/03/2024)
< 2

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2
Q

What is hydroxycarbamide used for?

A

Sickle cell disease, myeloid leukemias, polycythemia vera

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3
Q

What hemoglobin level renders blood transfusion?

A

The NICE guidelines recommend giving blood transfusions to people with low levels of haemoglobin (a protein in red blood cells that carries oxygen) only if it drops below 70 g/L and they don’t have any major bleeding or heart problems.

After the transfusion, the target haemoglobin level should be between 70 and 90 g/L. This means the aim is to keep the haemoglobin level within this range to ensure enough oxygen is carried around the body, but not to exceed 90 g/L to avoid potential complications.

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4
Q

How does lidocaine work?

A

Lidocaine acts by prolonging the inactivation of sodium channels, thus as the voltage-gated sodium channels will not open, an action potential will not be generated

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5
Q

What are some early causes of post-op pyrexia (0-5 days)?

A
  • Blood transfusion
  • Cellulitis
  • Urinary tract infection
  • Physiological systemic inflammatory reaction (usually within 24 hours)
  • Pulmonary atelctasis
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6
Q

What are some late causes of a post-op fever? (>5 days)

A
  • VTE
  • Pneumonia
  • Wound infection
  • Anastomotic leak
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7
Q

What are inhaled options for a general anaesthesia?

A

Inhaled options for a general anaesthetic include:

Sevoflurane (the most commonly used)

Desflurane (less favourable as bad for the environment)

Isoflurane (very rarely used)

Nitrous oxide (combined with other anaesthetic medications – may be used for gas induction in children)

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8
Q

Advantages of ketamine

A
  • Keeps breathing
  • Doesn’t drop blood pressure

Used in emergencies

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9
Q

Indications for nitrous oxide

A

Gas and air
Pain relief for pregnant women- you become more unaware
Become more confused
Alters pain threshold

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10
Q

How can you remember drugs to stop before surgery?

A

CHOW

Clopidogrel – stopped 7 days prior to surgery due to bleeding risk; aspirin and other anti-platelets can often be continued and minimal effect on surgical bleeding

Hypoglycaemics – see ‘Diabetes Mellitus’ below

Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) – stopped 4 weeks before surgery due to DVT risk. Advise the patient to use alternative means of contraception during this time period.

Warfarin* – usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin
Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before

*Direct Oral AntiCoagulants (DOACs), such as Rivaroxaban, Apixaban, or Edoxaban, will also need stopping pre-operatively, however the duration of this depends on the type used.
ACEI need to be stopped on the day
You can continue with Aspirin

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11
Q

How many days do patients take low dose prophylactic low weight molecular heparin?

A

28 days

With TED stockings

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12
Q

What is the difference between group and save and cross-match?

A

A G&S determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies; the process takes around 40 minutes and no blood is issued
A G&S is recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected
A cross-match involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places; if it does not, the donor blood is issued and can be transfused in to the patient, otherwise alternative blood is trialled
This process also takes ~40 minutes (in addition to the 40 minutes required to G&S the blood, which must be done first), and should be done pre-emptively if blood loss is anticipated

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13
Q

Examples of local anaesthetics and drug reactions

A

Bupivacaine and lidocaine

Lidocaine
- Drug interactions: Beta blockers, ciprofloxacin, phenytoin

Bupivicaine
- It is cardiotoxic and is therefore contra indicated in regional blockage in case the tourniquet fails.

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14
Q

When would you request an echocardiogram?

A
  1. ECG changes
  2. Heart murmur
  3. Signs or symptoms of heart failure
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15
Q

Why should you always have a high index of suspicion with sick children?

A

Take a long time to get very poorly
Can seem to be fit and well (running around) but still be compensating.

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16
Q

What neurological conditions do you have to ask about?

A

Seizures/epilepsy
Stroke/TIA
Muscle weakness
Severe arthritis

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17
Q

What is MET with exercise tolerance?

A

One MET is the amount of energy used while sitting quietly. Physical activities may be rated using METs to indicate their intensity. For example, reading may use about 1.3 METs while running may use 8-9 METs. METs can also be translated into light, moderate, and vigorous intensities of exercise.

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18
Q

What do you ask for in a cardiovascular history?

A

IHD/MI/Angina
Heart failure
Hypertension
Stents

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19
Q

Benefits for CRT

A

CRT- increases EF by 15%

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20
Q

What do you do to prevent reflux in an emergency when the patient can’t fast?

A

Rapid sequence- compress the oesophagus as they might have a full stomach

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21
Q

How do you manage patients on insulin before surgery?

A

Patients on insulin will often need their doses adjusting pre-operatively, and any prolonged or major surgery will likely need the patient placed on a variable rate intravenous insulin infusion (VRIII) (often termed a “Sliding Scale”), that is often continued for a short period post-operatively as well.

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22
Q

Haematological history

A

Anaemia
Bleeding disorders
DVT/PE
Sickle cell disease

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23
Q

Between what two anatomical layers do you do a spinal block?

A

Between the arachnoid mater and pia mater

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24
Q

As a rule of thumb, one unit of RBC increases Hb by how much?

A

10g/l

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25
Q

How does suxamethonium work?

A

Suxamethonium is a depolarising muscle blocker used to blunt airway reflexes during the induction of anaesthesia. Normally it is broken down rapidly by plasma cholinesterases, thus the effects wear off within a few minutes. If the enzyme is mutated then the breakdown can take much longer – up to 4 h.

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26
Q

How does malignant hyperthermia present?

A
  • Muscle rigidity in the masseter (clenched jaw)
  • Increased oxygen uptake
  • Increased carbon dioxide
  • Hyperkalemia
  • Tachycardia
  • Metabolic acidosis

Triggered by suxamethonium and volatile anaesthetics (sevoflurane and isoflurane)

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27
Q

How is malignant hyperthermia treated?

A

IV Dantrolene (stops calcium release from the muscles)

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28
Q

In Haematological pre-operative assessment, what do you need to consider in the oxygen carrying capacity of the blood?

A
  • Anaemia
  • Correcting?
  • Is the surgery planned/urgent
29
Q

Hemostatic competence- likely to excessively bleed?

A
  • Bleeding history
  • Low platelet count
  • Any antithrombotic medication (anticoagulants, antiplatelets)
30
Q

Venous thrombotic risk assessment- likely to clot?

A
  • Personal or family history of thrombosis
  • Patient factors
  • Operative/post-operative factors
31
Q

Cellular immune competence

A

Is the patient neutropenic or more likely to get infections?

32
Q

How long does a group and save last?

A
33
Q

When would you do group and save before surgery?

A
34
Q

What steps do you do to manage pre-op anaemia in an elective surgery?

A
  • Correct any cause eg B12 or iron replacement, EPO injections
  • May not need correction e.g mild anaemia due to B-thal trait, minor op
  • Remember to investigate the underlying cause
  • There may be a specialsit pre-op anaemia clinic to help you
  • May need to liase with GP and/or other specialists and delay surgery
35
Q

Do you give oral iron replacement therapy straight away in anaemia?

A

Start oral iron replacement straight away
Not unreasonable to give a trial or oran replacement
You will have wasted weeks by the time you wait for the blood tests to come back

36
Q

What specific clinic is run for orthopaedic surgery?

A

Pre-op anaemia clinic for orthopaedic surgery

37
Q

Is heart failure a diagnosis?

A

No
Something has caused that heart failure

38
Q

How do you manage pre=op anaemia in an emergency?

A

Need to consider:
- current physiological state
- rate of fall in Hb
- anticipated blood loss
- underlying co-morbidity e.g cardiac disease

No absolute Hb cut off

Red blood cell transfusion may be needed so urgent group and save plus cross-match required

  • What options are there for red cell transfusion in an emergency
    In trauma, tranexamic acid may be used to reduce bleeding

Are there any drugs contributing to the bleeding?

39
Q

How do you get hold of blood in an emergency?

A

Major hemorrhage protocol

40
Q

What is the universal donor blood group?

A

O negative
Rhd negative

41
Q

Does everyone get a clotting screen?

A

Only if they have a positive bleeding history.

42
Q

What questions could you ask someone to assess their bleeding risk if they have not had surgery before?

A

Tooth extraction surgery?
Post-partum bleeding

43
Q

What is the difference between INR and PT?

A

INR is basically a more standardized version of PT

PT may not be the same in each lab

44
Q

What is the purpose of a group and save?

A

Identifying the blood group and screening for antibodies
Can be done in advance of the transfusion

45
Q

When will you need a group and save within 72 hours?

A

IF a more recent transfusion

46
Q

When will you need a G&S sample within 28 days?

A
  • Never previously transfused
  • Last transfusion >3 months ago
  • Not pregnant
  • No known red cell antibodies
47
Q

How long will a cross matched blood sample take in an emergency?

A

40 minutes

48
Q

How long do red cells last?

A

Need to be used from the blood bank within 30 minutes

49
Q

What clotting factors does the intrinsic pathway test?

A

VIII, IX, XI and common pathway

50
Q

What clotting factors does the extrinsic pathway test?

A

VII and common pathway

51
Q

What does thrombin time test?

A

Test of fibrinogen

52
Q

What is the difference between Hemophilia A and B?

A

Key Differences
Deficient Factor:
Haemophilia A: Factor VIII
Haemophilia B: Factor IX
Prevalence:
Haemophilia A is more common than Haemophilia B
Treatment:
Specific replacement therapy differs (Factor VIII for Haemophilia A, Factor IX for Haemophilia B)

Both cause hemoarthrosis

53
Q

When do you use peri-op bridging?

A

If a patient is on warfarin it is usually stopped 5 days prior to surgery
Use LMWH to bridge the gap
LMWH is stopped 12 hours prior to surgery

54
Q

When are antiplatelets normally stopped before surgery?

A

5 days prior to surgery

55
Q

When would you give fresh frozen plasma?

A

Correction of non-specific coagulation defects in a bleeding patient with long clotting times (massive hemorrhage or DIC)

56
Q

When would you give cryoprecipitate?

A

Correction of low fibrinogen (2 pooled units typically raises fibrinogen by 1g/l)

57
Q

When is prothrombin complex concentrate given?

A

Concentrate of factors II, VII, IX and X- warfarin reversal for life or limb threatening haemorrhage

58
Q

Should you give FFP to hemophilia patients?

A

No you are giving them more clotting factors than they need

59
Q

Patient on long-term warfarin for AF has had recent course antibiotics following an increase in warfarin dose. Admitted after a fall with an intra-cranial bleed. Is a fit candidate for neuro-surgery.

INR - 8

What action should be taken?

A
  • Stop warfarin
  • Give vitamin K
  • Give PCC
60
Q

What is a consequence of hypothermia before/during surgery?

A

Excessive bleeding
As the proteins and enzymes in our body are designed to work at optimum pH and temperature, any deviation from this will effect their function.

61
Q

What is ASA1?

A

A normal healthy patient
Healthy, non-smoking, no or minimal alcohol use

62
Q

What is ASA2?

A

A patient with mild systemic disease
Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension, mild lung disease

63
Q

What is ASA3?

A

A patient with severe systemic disease
Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled Diabetes Mellitus/Hypertension, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history (>3 months) of Myocardial infarction, Cerebrovascular accidents

64
Q

What is ASA4?

A

A patient with severe systemic disease that is a constant threat to life
Examples include (but not limited to): recent (< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

65
Q

What is ASA5?

A

A moribund patient who is not expected to survive without the operation
Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intra-cranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

66
Q

What is ASA6?

A

A declared brain-dead patient whose organs are being removed for donor purposes

67
Q

What anaesthesia would you choose in an emergency where the patient had not fasted?

A

Rapid sequence induction

Use of a Depolarising Muscle Relaxant:

Drug Choice: The commonly used depolarising muscle relaxant in RSI is Suxamethonium (Succinylcholine).
Rapid Onset and Short Duration: Suxamethonium acts very quickly (within 30 to 60 seconds) and has a short duration of action (4 to 6 minutes), allowing for rapid intubation and swift securing of the airway.
Reduced Risk of Vomiting: The rapid onset of muscle relaxation helps to quickly secure the airway with an endotracheal tube, reducing the time the patient is at risk of vomiting and aspirating.

68
Q

What drugs are used in rapid sequence induction?

A

Typical RSI Drug Combination Example:
Pre-oxygenation: To fill the lungs with oxygen and provide a reserve during apnoea.
Induction Agent: Propofol 1-2 mg/kg IV or Etomidate 0.2-0.3 mg/kg IV.
Muscle Relaxant: Suxamethonium 1-1.5 mg/kg IV or Rocuronium 1.2 mg/kg IV.
Adjunct (if needed): Fentanyl 1-2 mcg/kg IV for analgesia.
Summary:
Induction Agent: Propofol, Thiopental, Etomidate, or Ketamine.
Muscle Relaxant: Suxamethonium or Rocuronium.
Optional Adjuncts: Opioids (e.g., Fentanyl), Lidocaine, Atropine.

69
Q

Examples of less cardiotoxic local anaesthetics

A

Prilocaine
Bupivacaine

Y3 Surgery (7 decks)

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