Anaesthesia I and II Flashcards
What are the 11 points of airway assessment?
Dentition Mouth open (3/finger or 3cm) Neck movement (>90 degree) Thyro mental (7cm) Jaw protrusion Laryngoscopy (same pt state?) Cricoid present Short neck BMI Defect/injury Mallanpati
What is the mallanpati score?
1: sp, fp, uv
2: sp, fp, base of uv
3: sp only
4. Only hard pallet
3&4 indicate difficult
What is the ultimate aim of an airway assessment?
Can we ventilate
Can we intubate
Can we crico
What are the signs of a difficult bag mask?
Beard Obese Thin No teeth Physical defect Small jaw Apnoea/snoring Mallanpati 3&4
What is the cormack and lehane system?
1: full cord view
2: cords partially covered by epiglottis
3: epiglottis only
4: pharynx only
What is Cooks modified classification of laryngoscopy?
2a: posterior glottis
2b: aretynoids only
3a: epiglottis - can lift
3b: epiglottis - fixed
2b/3a: restrictive - bougee
3b/4: difficult - advanced technique
What are signs of difficult LMA insertion?
Limited mouth open
Oral masses
Large tongue
Reduced neck flexion
What are signs of a difficult cricothyroidotomy?
Obese Neck mass Deviated trachea Reduced neck movement Radiotherapy
Describe cricoid pressure.
C6 level Full ring occluded oesophagus Other hand behind neck (lateral, unstable) 30-40N Reduce insufflation and aspiration Might hinder view (Sellicks manoeuvre)
What are the risks of cricoid pressure?
Oesophageal rupture
Cspine instability
Bruise
Reduced view
What is BURP?
Backward
Upward
Rightward
Improve view by manipulation neck cartilage
What is the ASA system?
Health status
1: fit and well
2: mild disease
3: function limiting disease
4: severe/life threatening
5: die without surgery
6: brain dead
What are cardiopulmonary function tests?
METs: measure energy cost - normal is 6 (jog)
TUG: sit to stand, walk 3m and return - <10s
Cardiopulmonary exercise testing: cycle or treadmill with increasing resistance until must stop - graphs gases and stats
What is FEV1 and FVC?
FEV1: forces expiratory volume in 1 second
FVC: total expiration volume after maximal inhale
FEV1/FVC = 80%
What is FRC and CC?
FRC: amount of gas remaining in lungs after expiration
CC: volume of gas in lungs at which small airways start to collapse
What factors increase closing capacity?
Age
Disease
Smoking
Supine
What is hypertension and hypotension?
> 140/90
Vessel damage/aneurysm
<90/60
Brain injury/stroke
What is MAP?
Mean arterial pressure
Sys+(2xdia) / 3
Normal is 60
What is the Glasgow coma score for eyes?
(4)
1: none
2: open to pain
3: open to voice
4: spontaneous open
What is the Glasgow coma score for verbal?
(5)
1: none
2: incomprehensible sounds
3: inappropriate words
4: confused
5: orientated
What is the Glasgow come score for motor?
(6)
1: none
2: extension to pain (decerebrate)
3: flexion to pain (decorticate)
4: withdraw from pain
5: localise to pain
6: obey commands
What is the Glasgow coma score?
Conscious state
Score 3-15
<13 poor
E4V5M6
What is AVPU?
Patient response Alert Voice Pain Unresponsive
Patient can respond via eye, verbal or motor
What are the 7 factors of neurovascular assessment?
Pain Pallor Pulse Parasthesia Paralysis Poikilothermia Pressure
What are the positives for oxygen therapy?
Increase reserve Reduce effort and strain on heart, energy Increase perfusion/circ Increase healing Reduce anaerobic - lactate Assist with sedated/opioid
What are the cons of oxygen therapy?
Dries airway Free radicals damage tissue Increase atelectasis due to wash out of N which remains in the alveoli Bad with laser High cost
How much oxygen is inspired and expired normally?
21% in
18% out
What is the FiO2 for nasal prongs?
25-45%
1-6L
Dries nostrils
What is the FiO2 for Hudson mask and with reservoir bag?
40-60%
6-10L
Reservoir bag contains valve which prevents CO2 entry
60-95%
6-max L
What is a Venturi mask?
Fixed conc mask Based on Bernoulli principle (^speed decreases pressure so more space) Entrains gas via Venturi effect Dial % and FR Up to 90%
Define hypoxia.
<94%
What are the 9 symptoms of hypovalaemia?
>15% loss Low systolic High diastolic then low High HR Capillary refill >2s High RR Low urine Pale/cold Reduced alert: anxious, confused, reduced conscious
What is a PCA?
Push button, lockout or basal rate Need IV and fluid One way valve on fluid line to prevent opioid travelling and bolusing O2 and pulse ox Additives: clonidine, naloxone, antiem Normal rate: 1ml, 5min, 12ml/hr max
What are the steps of an incorrect count?
Recount Inform team Search Magnet? X-ray Close Inform patient, document Incident form and refer patient
What are the minimum count items in an emergency?
Swabs
Sponges
Sharps
Incident form
Complete count ASAP
What must purposely retained items have?
X-ray detectable
Well documented
Hand over
What is the practitioners assurance act 2003?
Protect public by having mechanisms to ensure competence and fitness of practitioner
Mechanisms: Valid qualification Annual registration Practise within SOP Ongoing education Tribunal for discipline
What is the HDC Code of Health and Disability services consumer rights regulations 1996 for?
Promote and protect rights
Pt rights vs provider responsibilities
What are the 10 patient rights under the HDC Code of Health and Disability services consumer rights regulations 1996?
Respect (privacy, culture) Fair treat (no discrim, no coercion) Dignity and independence Proper standards (care, skill, quality) Communication (in way pt understand, fair enviro, Qs) Info (risk/ben, options, result) Consent/decision (accept/refuse) Support Teaching/research Complaint
What are the three aspects of the treaty?
Partnership
- working with to develop
Participation
- involved at all levels
Protection
- ensure level care, safe guard concepts
What are the 12 points of the Privacy Act 1994?
Purpose: necessary, relevant Source: from pt or reasonable Collection: pt aware and consent Manner: lawful, fair Storage: protect from loss, others Access: pt allowed Correction: attach statement Accuracy: regular check/update Retention: no longer than needed Limit use: primary purpose only Limit disclosure: can't give to others Unique ID: not unless needed for org
What are the exceptions to the privacy act?
If patient can't consent If secondary purposes relate to the consent If urgent care is needed If it lessens public risk If it is known public information
Who monitors the privacy act?
The privacy commissioner
Monitors, develops and investigates issues
What drug acts relate to technicians?
Medicines act
- only give under direct supervision
- follow direction
Misuse of drugs act
- only give under direct supervision
What is important about the theatre layout?
Double door to keep privacy, separate areas and maintain environment
Dirty - exit
Clean - entry
What are the different areas of restriction in the theatre block?
Unrestricted: public access
Semi: peripheral support area, storage, limited access, special attire
Restricted: OR, strict access and attire
What are the conditions of the theatre environment?
Laminar flow from centre ceiling out 20-24.4 degrees (comfort, microbes) Positive pressure (air out only) 55% humid (spark, humid) 20 air change per hour (3 fresh; other recycled - filtered, warmed) Scavenging to remove gases
What is an RCD?
Residual current device
Cut power if leak detected
Compares active to neutral line
What’s a LIM?
Line isolation overload monitor
On all critical equipment
Alarm and display leaked current
Does not cut power
What is a UPS?
Uninterrupted power supply
Back up hospital battery comes on if power cuts out
For essential equipment
What is body protected and cardiac protected?
Body - for procedures where skin is compromised
Uses RCD and LIM
Cardiac - for procedures where a conductor is near the heart
Uses RCD, LIM and equipotential earth
What is micro and macro shock?
Micro
10-100micro amp
When electrodes near heart
Macro
Large current through skin
Fibrillation occur at 100mA
What are the methods to manage a spill?
Stop work, turn off risky equipment, ventilate area, report Turn on PPE Contain spill using kit medium Collect spill in bucket Label and take to unit Ensure workplace safe before resuming
- incident form
What are the 8 pieces of equipment in a spill kit?
Absorbent Respirator Goggles Gauntlet glove Plastic apron Large plastic bag Bucket Neutraliser
What is sterilisation?
Complete destruction of all microbes and spores
Must decontaminate first
Correct method for equipment
What is disinfection?
Process of destroying microbes on non-living object; spores remain
(Antiseptic does the same but on living tissue)
What is decontamination?
Removal of bio burden and contaminants
Must occur first!
What is autoclave?
Steam and pressure
121 degrees
15psi
15min
Cheap, non-toxic, quick, enviro friendly
What is dry heat?
Hot air
160-170 degrees
2 hour
Item must be heat stable - glass
What is ethylene oxide?
Chemical/biocide Delicate items 500mg/L 58 degrees 40% humid 4 hour
High cost, long time, toxic
Need bio indicator
What is ionising radiation, UV light and U/S wave?
IR
High energy EM waves disrupt DNA eg a teddy
UV
Waves penetrate surface only
US (decontamination)
In solvent tank, waves vibrate liquid to remove debri
What are the 5 disinfectant factors?
Correct time Correct conc Temp pH Relevant to microbe
Must decontaminate first!!
What are 8 important factors for storage of equipment?
Room temp Good ventilation Secure Clean Well Ventilated Dry No sunlight Above ground level
What are the 5 moments of hand hygiene?
Before pt contact After pt contact Before a procedure After body fluid exposure After leaving pt surroundings
What is diathermy?
Mono: current from device to electrode pad
Bi: both electrodes mounted on device
Pad: large, hairless, flat, non-bony, close to site, not through heart
What are safety concerns or features of diathermy?
Bi is safer and ok for use with pacemaker Heat up internal metal work Patient touching metal may burn Poor pad contact - burn Electrical fault Fire risk High current Microshock risk
What are the layers from skin to subarachnoid space?
Skin Subcutaneous tissue Supraspinus ligaments Interspinus ligaments Ligamentum flavum Epidural space Dura mater Arachnoid mater Subarachnoid space
What is a spinal injection?
One off injection into subarachnoid space
Placed below L2 - ideally L3/4 to avoid spinal cord
Continuous spinal anaesthesia with a catheter is possible
What is the spinal needle?
26G pencil point
Atraumatic tip to side
Clear hub to see CSF
Stylet to avoid tissue core occlusion and strengthen shaft
Quinke: cutting bevel
Describe the spinal space.
Subarachnoid space
Inject at L3/4
Spinal cord ends L1 in adult and L3 in infants
Iliac crests indicate L4 (Tuffier’s line or intercristine)
What LA is used in spinals?
Bupivicaine 0.5%
Isobaric (plain)
Hyperbaric (heavy) with 8% glucose
Hyperbaric can produce a higher block by positioning the patient accordingly
What are the contraindications to a spinal anaesthetic?
Hypotensive problems eg aortic stenosis, hypovalaemia Back surgery Neurological disease Systemic sepsis Local sepsis Anticoagulant use
What are common complications of spinal anaesthesia?
Hypotension Bradycardia Total spinal Urinary retention Nerve damage PDPH Infection - abscess Bleeding - haematoma
What is the cause of a PDPH?
Caused by leaking CSF
causing pressure to drop and the brain to sink
Proportional to needle gauge and number of punctures
Less likely with atraumatic needle
24-48hr post procedure
Pain worse on standing, maybe absent in the morning and return on moving
Usually front with neck stiffness
What’s an epidural?
Placement of catheter into epidural space
Up to 3 days
Analgesia via top ups, continuous infusion or PCEA
Anywhere along vertebral column
Describe the epidural space.
Aka extradural
Potential space
How is an epidural placed?
Position patient Locate anatomy (Ensure IV; foetal monitor) Insert needle until resistance met Connect roulsen syringe and continue insertion until loss of resistance Introduce 4-5cm of catheter Check for blood/CSF Test dose Secure
What is an epidural test dose?
Checking for IV injection, spinal injection and production of a expected block
Why choose an epidural/spinal over GA?
Post op atelectasis and infection reduced
Pain relief = better breathing
Reduced post op MI
Reduced hypercoagulable response
Increased mobility reduced DVT
Improves intestinal mobility so eating sooner
What are the common complications of epidurals?
Dural puncture Headache Nerve injury Catheter migration Hematoma/abscess Respiratory depression Hypotension Pruritis Urinary retention Motor block IV injection
Compare a spinal drug dose with a epidural drug dose.
Spinal:
3ml of 0.5% bupivicaine
0.2 morphine
10-25mcg fentanyl
Epidural:
10-15ml of 0.1% bupivicaine
50-100mcg fentanyl (2mcg/ml)
Why might pethidine be the drug of choice for a spinal?
Has both opioid and LA properties so can be used as the sole drug
How is a PDPH treated?
Blood patch
Seals the leak and compresses dural space thereby raising pressure
Lateral position - minimise pressure at the site
Aseptic technique
Perform epi at same or lower space
Obtain 20ml blood
Inject slowly until given or pain which doesn’t ease occurs (in back)
Rest for 2 hours
What are the complications of a blood patch?
Backache Repeated dural puncture Neurological deficits Epileptiform fits Cranial nerve damage
What is the needle for an epidural?
Touhy 10cm needle 1cm markings Stylet to prevent tissue core 20degree atraumatic bevel (huber) to prevent dural puncture and trauma Normally 18G
What are the other components of an epidural pack?
Nylon/Teflon catheter Rounded distal end Side ports 5cm markings (1cm between 5-15cm) Proximal connects to lure lock and filter 0.22 micron filter Loss of resistance syringe
Compare a spinal block and epidural block.
Spinal: Excellent/dense block One off/catheter Less drug needed so less side effects Faster onset Higher PDPH Epidural: Patchy block Catheter allows ongoing relief/top up High infection risk Can titrate the drugs Can block higher High volume used so greater risk of total spinal, toxicity if misplaced
What is a CSE?
Combined spinal epidural
Touhy needle in place as per epidural
Spinal needle through - give dose
Remove spinal needle
Place epidural catheter and continue as per epidural
Gives fast onset, good block and ability to top up
How is an IVRA placed?
Measure BP IV into non surgical limb and one into surgical limb Apply tourniquet to limb - exsanguinate Inflate 50-100mmHg > systolic Inject LA Don't deflate for 15-20min
(If double cuff and tourniquet pain occurs; use proximal cuff to do block then change to distal cuff as this should be asleep)
What are the contraindications of IVRA?
Circulation problems
Crush injury
Sickle cell disease
PVD
What is a block needle?
Short/blunt bevel for minimal nerve trauma Lure lock Clear hub to detect IV Nerve stimulator connection 22G normally
How is a nerve stimulator used to assist regional blocks?
Introduce needle to skin
Attach to stimulator
High output (1-3mA) advance until nerve stimulated
Lower output (0.2mA) until maximal stimulation with minimal mA so that tip is close to nerve (if stim <0.2 might be intraneural)
As LA injected stimulation should stop (failure to stop might be intraneural)
What’s an insulated needle?
Teflon coated with exposed tip
Current passes from tip only to ensure accurate stimulation
What is a caudal extradural block?
Injection into epidural space of sacral spine for a block below the umbilicus in children
Can place catheter
What is the anatomy for a CEA?
Position left lateral with legs flexed
Sacral hiatus: tip of a triangle with base at posterior superior iliac spine
Sacral hiatus is also a triangle with base at sacral cornu and tip at 4th vertebra
How is a CEA placed?
Left lateral Define boundaries Nick the skin 22/20G cannula 60degree to skin from midpoint of sacral cornu Small give indicates penetration of membrane Flatten needle then advance Aspirate and inject LA Normal block 4-8hours
Why can’t a CEA be used in adults?
Difficult to find space
Sacral bones fused
Adipose reduces spread so not reliable
Spinal/epidural easier and better
