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CSP > Anaesthesia > Flashcards

Anaesthesia Flashcards

1
Q

What is the purpose of pre-operative assessment? (3)

A
  1. ensures the patient is as fit as possible for the surgery and
    anaesthetic
  2. minimises the risk of late cancellations by ensuring that all essential
    resources and discharge requirements are identified and co-ordinated
  3. establishes
    that the patient is fully informed and wishes to undergo the procedure
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2
Q

When should pre-op be scheduled?

A

In scheduled and elective cases ideally an initial pre-operative assessment should be
performed immediately following the decision to operate

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3
Q

What are the NCEPOD categories? (4)

A

NCEPOD 1: Immediate life saving operation, resuscitation simultaneous
with surgical treatment - within 1 hour

NCEPOD 2: Operation as soon as possible after resuscitation - within 24 hours

NCEPOD 3: An early operation, but not immediately life-saving - within 3 weeks

NCEPOD 4: Operation at a time to suit both patient and surgeon

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4
Q

What are the guidelines on food and drink prior to anesthesia?

A
  • 6 hours for solid food, infant formula, or other milk.
  • 4 hours for breast milk.
  • 2 hours for clear non-particulate and non-carbonated fluids.
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5
Q

What patient groups should have FBC in pre-op?

A
  • All adult women
  • Men over the age of 60 years
  • Cardiovascular, Respiratory, Renal or Haematological disease
  • Major surgery
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6
Q

What patient groups should have U+Es in pre-op?

A
  • All patients over 60 years
  • Cardiovascular, Respiratory and renal disease
  • Diabetics
  • Patients on steroids, diuretics, ACE inhibitors
  • Cardiovascular and major surgery
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7
Q

What patient groups should have ECG in pre-op?

A

All patients over 60 years
Cardiovascular, Renal disease
Diabetics
Cardiothoracic surgery

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8
Q

What patient groups should have chest X-ray in pre-op?

A

Cardiovascular and respiratory disease
Malignancy
Major thoracic and upper abdominal surgery

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9
Q

What are the MAJOR clinical predictors of increased perioperative cardiovascular risk? (4)

A

Major predictors mandate intensive management, which may result in delay or
cancellation of surgery unless it is emergent.

• Unstable coronary syndromes:
– Recent MI (>7 days but ≤30 days) with evidence of important ischemic risk
by clinical symptoms or noninvasive study.
– Unstable or severe angina. May include “stable” angina in patients who are
unusually sedentary.

• Decompensated congestive heart failure.

• Significant arrhythmia:
– High-grade atrioventricular block.
– Symptomatic ventricular arrhythmias in the presence of underlying heart
disease.
– Supraventricular arrhythmias with uncontrolled ventricular rate.

• Severe valvular disease.

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10
Q

What are the INTERMEDIATE clinical predictors of increased perioperative cardiovascular risk? (4)

A

Intermediate predictors are well-validated markers of enhanced risk of perioperative
cardiac complications and justify careful assessment of the patient’s current status.

  • Mild angina pectoris (Canadian Cardiovascular Society Class I or II).
  • Prior myocardial infarction by history or pathological waves.
  • Compensated or prior congestive heart failure.
  • Diabetes mellitus
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11
Q

What are the MINOR clinical predictors of increased perioperative cardiovascular risk? (6)

A

Minor predictors are recognized markers for cardiovascular disease that have not been
proven to independently increase perioperative risk.

• Advanced age.
• Abnormal electrocardiogram (LVH, LBBB, ST-T abnormalities).
• Rhythm other than sinus (e.g. atrial fibrillation).
• Low functional capacity (e.g. Unable to climb one flight of stairs with a bag of
groceries).
• History of stroke.
• Uncontrolled systemic hypertension.

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12
Q

What are HIGH cardiac risk surgical procedures? (4)

A

• Emergent major operations, particularly in the elderly.
• Aortic and other major vascular surgery.
• Peripheral vascular surgery.
• Anticipated prolonged surgical procedures associated with large fluid shifts and / or
blood loss.

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13
Q

What are INTERMEDIATE cardiac risk surgical procedures? (5)

A 
Carotid endarterectomy.
• Head and neck surgery.
• Intraperitoneal and intrathoracic surgery.
• Orthopoedic surgery.
• Prostate surgery.
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14
Q

What are LOW cardiac risk surgical procedures? (4)

A
  • Endoscopic procedures.
  • Superficial procedures
  • Cataract surgery.
  • Breast surgery.
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15
Q

What are the preoperative risk factors for post operative respiratory complications?

A 
• Age > 60 years
• Smoking
• Obesity
• Chronic lung disease, in particular, if the patient is symptomatic at the time of
surgery
• Abnormal chest signs
• Abnormal chest radiograph
• PaCO2 > 6 kPa
• Impaired cognitive function
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16
Q

What is seen in the FVC, FEV1 and FEV1/FVC% in restrictive lung disease?

A

FVC: decrease
FEV1: decreased
FEV1/FVC%: normal

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17
Q

What is seen in the FVC, FEV1 and FEV1/FVC% in obstructive lung disease?

A

FVC: normal
FEV1: decreased
FEV1/FVC%: decreased

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18
Q

What are the strategies to improve outcomes in patients at risk of respiratory complications peri-operatively? (6)

A

• Cessation of smoking
• Treat airflow obstruction with bronchodilators
• Antibiotics: in active infectio
• Delay surgery: if surgery is elective and chest / systemic symptoms are still active
• Chest physiotherapy
• Patient education: breathing exercises, continuous positive airway pressure (CPAP)
etc.

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19
Q

How should a diabetic patient be managed pre-operatively? (3)

A
  1. Diabetic medication should be omitted on the morning of surgery.
  2. The procedure should be scheduled as early as possible on the list, preferably first.
  3. Aim to return the patient as soon as possible to usual diet and medication routine.
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20
Q

What is the mallampati classification for airways? (4)

A

Class 1: Tonsillar pillars, soft palate and uvula are seen.
Class 2: Part of uvula and soft palate are seen. Base of tongue masks tonsillar pillars
Class 3: Only soft palate visible
Class 4: Even soft palate is not visible.

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21
Q

What is the Wilson RIsk Sum system of predicting difficult intubation?

A
  1. Obesity
  2. Restricted head and neck movements
  3. Restricted jaw movements
  4. Receding mandible and
  5. Buck teeth.

Each of the above factors are scored between 0 to 2 to give a maximum score of 10 and a
minimum score of 0. A score more than 2 is considered to be significant in predicting
difficult intubation.

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22
Q

What is the aim of airway management?

A

clear or bypass the obstructed airway, assist or

replace spontaneous ventilation and protect the lungs from aspiration

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23
Q

What are the supra-glottic devices for airway management? (2)

A

Bag and mask

LMA/I-Gel

24
Q

What are the infra-glottic devices for airway management? (3)

A

Tracheal tube
Cricothyroidotomy
Tracheostomy

25
Q

What are the causes of airway obstruction? (5)

A
  • tongue falling back
  • regurgitation of food or blood
  • foreign body
  • spasm of laryngeal muscles die to stimulation of upper airway
  • laryngeal oedema (burns, inflammation, oedema)
26
Q

What is inspiratory stridor caused by?

A

caused by obstruction at or above laryngeal level

27
Q

What is expiratory wheeze caused by?

A

obstruction of the lower airways

28
Q

What is gurgling caused by?

A

due to presence of liquid or semisolid material in the major airways

29
Q

What is snoring caused by?

A

due to partially occluded pharynx by the tongue or palate

30
Q

How should oropharyngeal airways be sized?

A

vertical distance between the patient’s incisors and the angle of the mandible

31
Q

Complications of oropharyngeal airway? (3)

A

Too small airway can push the tongue backwards and worsen the airway
obstruction. Too large airway can bypass the laryngeal inlet and fail to correct the
airway obstruction.

Vomiting or laryngospasm can occur if the glossopharyngeal and laryngeal
reflexes are intact.

Damage to teeth, dislodgement of caps, crown, mucosal trauma and bleeding can
occur.

32
Q

Complications of nasopharyngeal airway? (2)

A

o Trauma to the nasal mucosa, turbinates and adenoids

o Bleeding

33
Q

In what patients is a nasopharyngeal airway contraindicated? (2)

A

suspected base of skull fracture

bleeding diathesis

34
Q

What are the indications for tracheostomy?

A

• To bypass the airway obstruction:
o For certain surgical procedures – e.g. laryngectomy.
o Trauma involving upper airway when tracheal intubation is likely to be
impossible.
o Inhalation of hot smoke or corrosives – e.g. after burns.
o Laryngeal dysfunction due to vocal cord palsy or tracheomalacia.
o Congenital anomalies such as glottic stenosis.

• For tracheal toilet – for long term care of patient with neuromuscular weakness or
coma.

• In ICU – for mechanical ventilation more than few days.

35
Q

Complications of endotracheal intubation? (7)

A
  1. Difficult or impossible to intubate
  2. Cardiovascular response: Laryngoscopy and tracheal intubation produces sympathetic
    stimulation resulting in tachycardia and hypertension
  3. Damage to the teeth, soft tissue injury of the oropharynx, trauma to the larynx, and
    trachea.
  4. Pulmonary aspiration during the process of induction of general anaesthesia
  5. Oesophageal intubation – endotracheal intubation should be confirmed by capnometry
  6. Tracheal tube displacement and blockage of the
    tube with secretions.
  7. In patients with unstable cervical spine, laryngoscopy and tracheal intubation may cause further damage.
36
Q

Why is endotracheal intubation considered to be superior to other advanced airway management techniques? (3)

A
  1. Airway is reliably isolated from foreign material in the oropharynx.
  2. Suction of inhaled particles from the lower respiratory tract is possible.
  3. More effective ventilation of lungs
37
Q

What is general anaesthesia?

A

a tetrad of amnesia (unconsciousness), analgesia, control of autonomic reflexes and muscle relaxation.

38
Q

What are the rapidly acting IV anaesthetic agents? (4)

A
  • Barbiturates e.g. thiopental sodium, methohexitone
  • Imidazole e.g. etomidate
  • Hindred phenols e.g. propofol
  • Steroids e.g. pregnenolone
39
Q

What are the slower-acting IV anaesthetic agents? (3)

A
  • Phencyclidine e.g. ketamine
  • Benzodiazepines e.g. midazolam
  • Large dose of opioids: alfentanil, fentanyl, remifentanil
40
Q

Why are IV anaesthetic agents used? (5)

A
  • To induce general anaesthesia
  • As a sole agent for anaesthesia for short operations
  • To maintain anaesthesia after induction by giving intravenous infusion
  • To provide sedation, e.g. in ITU and as an adjunct to regional anaesthesia
  • To treat status epilepticus
41
Q

What are the commonly used inhaled anaesthetic agents? (3)

A

isoflurane,
sevoflurane,
desflurane

42
Q

What drugs are used for local anaesthetics? (3)

A

lignocaine,
bupivacaine,
prilocaine

43
Q

What drugs are used as muscle relaxants in anaesthesia?

A

Depolarising muscle relaxants: suxamthnium

Non-depolarising muscle relaxants: Vecuronium, Atracurium, Mivacurium

44
Q

What is the minimum monitoring that should be used during anaethesia? (4)

A
  • Pulse oximeter
  • Blood pressure
  • ECG (3 lead)
  • Capnograph
45
Q

In what situations may a pulse oximeter reading not be accurate? (8)

A

o Presence of abnormal haemoglobins such as carboxy haemoglobin and
methaemoglobin.
o Anaemia (below 8g/dl)
o Dyes like methylene blue leads to false low reading
o Reduced peripheral circulation due to vasoconstriction (hypovolaemia,
hypotension, cold) or peripheral vascular disease results inaccurate reading.
o Venous congestion may result in low readings.
o Bright ambient light can affect the accuracy of pulse oximeter.
o Motion artefacts such as shivering or seizure activity can result in inaccurate
reading.
o Presence of nail varnish may cause falsely low readings

46
Q

What are the disadvantages of non-invasive BP recording? (4)

A

o Inaccurate in the presence of arrhythmias.
o Not possible to have continuous measurement.
o Not reliable in extremes of BP (underestimates when too high and vice versa).
o Pressure effects when used for prolonged time and frequent reading resulting in petechiae, nerve palsy.

47
Q

What are the indications for invasive BP monitoring? (3)

A

o Cases where rapid blood pressure changes is anticipated as in cardiovascular
disease, major blood loss, cardiac surgery, intracranial surgery and induced hypotension
o Need for frequent arterial blood gas analysis
o Cases where non-invasive blood pressure may be inaccurate: arrhythmias, morbidly obese patient

48
Q

What are the disadvantages of invasive BP monitoring? (4)

A

o Arterial obstruction and distal ischaemia can occur due to thrombus, haematoma
o Bleeding
o Infection
o Accidental injection of drugs.

49
Q

What is capnography?

A

It is the measurement of carbon dioxide concentration (ETCO2) in each breath of the respiratory cycle

50
Q

What is regional anaesthesia?

A

Regional anaesthesia involves the introduction of drugs with the intention of blocking the
nerve supply to a specific part of the body such as a limb

51
Q

How is regional anaesthesia achieved?

A

using local anaesthetic drugs that block nerve conduction

52
Q

What are the types of regional anaesthesia? (5)

A

A. Central Neural Blocks
oSpinal anaesthesia (intrathecal or subarachnoid block)
oEpidural anaesthesia
oCaudal anaesthesia
B. Peripheral Nerve Blocks
C. Intravenous Regional Anaesthesia (IVRA)
D. Topical and Infiltration anaesthesia
E. Others: Intrapleural analgesia, ophthalmic anaesthesia

53
Q

What are the advantages of regional anaesthesia? (8)

A
  1. Conscious patient - able to warn of adverse effects (during carotid surgery, and
    trans-urethral resection of prostate), less interruption of oral intake.
  2. Avoidance of adverse effects of general anaesthesia like nausea, vomiting, sore
    throat and hang over.
  3. Effects of general anaesthesia respiratory function and mechanics can be avoided
    when appropriate regional technique is chosen.
  4. Avoids hazards of unconsciousness like aspiration of gastric contents, anatomical
    damage to skin, joints, nerves etc.
  5. Better postoperative pain relief, decreased narcotic use, faster recovery.
  6. It reduces stress response to surgery.
  7. Reduced blood loss particularly with pelvic and hip surgery.
  8. Decreased incidence of pneumonia, and DVT.
54
Q

What are the complications of regional anaesthesia? (4)

A
  1. Technical: failure of the technique, direct trauma to nerves and blood vessels
    (bleeding and haematoma), pneumothorax with intercostal and intrapleural block.
  2. Excessive local anaesthetic volume can result in total spinal during epidural and
    phrenic nerve block during brachial plexus block.
  3. Those related to specific technique: Hypotension, bradycardia and headache
    following spinal or epidural analgesia. Rare possibility of nerve injury with
    peripheral nerve blocks.
  4. Drug related: Local anaesthetic toxicity due to intravascular injection or systemic
    absorption, overdose of local anaesthetic, anaphylactoid reaction and methaemoglobinaemia (prilocaine)
55
Q

What are the contraindications to regional anaesthesia?

A

o Absolute: Patient refusal, anaesthetist’s inexperience and localised infection at the
site.

o Relative: Abnormal anatomy or deformity, coagulation disorders, neurological
disease.

CSP (5 decks)

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