Anaesthesia IV Week 6-12 Flashcards
What is the “cover” from
Cover abcd stand for?
Circulation, colour, capnography Oxygen delivery, analyser, oximeter Vaporiser, ventilator ETT, eliminate machine Review monitor and equipment
What is the “abcd” in cover abcd stand for?
Airway
Breathing
Circulation
Drugs
Be aware of air and allergy
What does “a swift” from a swift check stand for?
Air embolism, anaphylaxis, air in pleura, awareness Surgeon, sepsis Wound, water intoxication Infarct, insufflation Fat syndrome, full bladder Trauma, tourniquet
What does “check” from a swift check stand for?
Catheter (IV, chest drain), cement Hypo/hyperthermia, hypocalcaemia Embolus, endocrine Check K+, keep patient asleep
What is cover abcd and a swift check for?
Diagnostic aides
Cover abcd should be used whilst scanning
A swift check can help to eliminate and diagnose problems
What is “scare”?
Scan: routine checking per 5min using cover abcd
Check: when suspect something not right
Alert/ready: recognise a problem looks so call for help
Emergency: full response
What increase risks of bronchospasm?
Infection
Smoking
asthma
What might cause a laryngospasm?
Suctioning
Surgical stimulus
Secretions
What is “isbar”?
Identify: who, where, role
Situation: what happening, diagnosis, operation
Background: clinical details
Assessment: what problem is
Recommendation: what required, risks, assign responsibility
Why are air embolisms common in neuro surgery?
Veins in cranium held open
If in sitting position (head above heart) air may be entrained
What are causes of air embolisms?
Entrainment in vessels Unprimed lines Insufflation Entrainment in lines Pressure bags Long bone surgery
What are the symptoms of an air embolism?
Low ET CO2 Low sats Low BP High HR ECG changes
What is the treatment of air embolisms?
Call for help
Inform surgeon: irrigate, lower site, soaked swabs, entry point
100% oxygen
Stop nitrous
Consider CPR
Left side down to prevent travel to ventricles
Aspirate with CVL or hyperbaric chamber
What problem does an air embolism impose?
Too much air in the ventricles means the heart cannot pump properly
Most air is removed by lungs
Left lateral keeps air in RA
Problem with babies who have PDA as can then reach left heart and go to brain
What are the symptoms of anaphylaxis?
Low BP Bronchospasm High pressure High HR Urticaria
What is the treatment of anaphylaxis?
Help
Stop causative agent
100% o2 airway?
Arrest? - CPR algorithm
Adrenaline 50-100mcg IV 1:10000 (0.5mg 1:1000 IM) repeat 5 minutely
Rapid infuse fluids
Also: adrenaline infusion (0.4mcg/kg/min), neb adrenaline, inotrope, salbutamol, trytase testing, extra lines, steroid and antihistamine
What are the common causes of anaphylaxis?
Latex AB Relaxant Chlorhexidine Colloid
What are the times for trytase testing?
1 hour
4 hour
24 hour
What are the symptoms of a pneumothorax?
Resp distress or difficult to ventilate Tracheal deviation High HR Low BP Neck vein distension Misplaced apex beat Reduced sound on one side Low sats Unilateral chest rise
What is the treatment of a pneumothorax?
Help
100% oxygen
Nitrous off
Insert large IV into the 2nd intercostal space of the mid clavicular line
Or 5th intercostal space of the mid Axillary line
What might cause of pneumothorax?
Trauma Nearby nerve blocks Central lines Surgical causes CPR Traumatic intubation Drains
What are the symptoms of fat embolism syndrome?
Neurological changes Respiratory distress Low sats Low BP Arrest
What is the problem with water intoxication?
Circulatory overload
Electrolyte disturbance such as hyponatraemia
What is bradycardia and the treatment?
<40bpm Help 100% oxygen (volatile off?) Exclude hypoxia in children Stop surgical stimulus Atropine 0.6mg If remain: adrenaline or transcutaneous pacing Consider CPR
What is the treatment of hypoxia?
Help 100% o2 - confirm on analyser Ensure circulation remains Hand ventilate Check equipment Auscultation of chest Consider: suction catheter, reintubate, F/O look, X-ray, ABG
What is the treatment for hypotension?
Help 100% o2 - volatile down Check pulse and equipment Head down Open fluids - pressure Vasopressors Consider CPR Find the cause More IV access
What are the symptoms of laryngospasm?
Strider Inspiratory obstruction Tracheal tug Paradoxical breathing Low sats Low HR
What is strider and paradoxical breathing?
Strider: abnormal high pitched inspiratory noise
Paradoxical: chest moves inward on inspiration instead of out
What is the treatment of laryngospasm?
Help 100% o2 Jaw thrust/chin lift Peep/CPAP Deepen anaesthetic Check airway clear Sux/atropine and intubate
What is considered a high airway pressure and what’s the treatment?
>40cmh2o Help Inform surgeon - stop stimulus 100% o2 Manual ventilation Check equipment Check airway: suction Cath, et position, auscultation Bronchospasm: salb + adren Pulm oedema: GTN + peep
What are the progressive symptoms of local anaesthetic toxicity?
Tingling of lips and mouth Ringing in ears Confusion Seizure ECG changes Cvs collapse - arrest
What is the treatment of LA toxicity?
Stop LA Help 100% o2 Consider intubation Treat seizure Control cvs - CPR or drug therapy Give intralipid!!!
How is intralipid used during LA toxicity?
20%
Bolus: 1.5ml/kg over one minute
Infusion: 15ml/kg/Hr (0.25ml/kg/min)
If still unstable 5min after bolus, repeat bolus every 5 min up to 3 times and double the infusion rate
Maximum 12ml/kg cumulative dose
What are the early symptoms of MH?
Prolonged massater spasm with sux High ETco2 High RR High HR Arrhythmia
What are the developing symptoms of MH?
0.5 degree increase in temperature every 15min Respiratory and metabolic acidosis High potassium Sweating Cvs instability Low sats and mottled skin Muscle rigidity
What are the late symptoms of MH?
Cola urine - myoglobinuria
High CK
Coagulopathy
Arrest
What is the treatment of MH?
Help Stop trigger agents - remove Switch to TIVA MH box - task cards (Dantrolene is priority) 100% o2, hyperventilate, FGF>15 with vapor free filters Insert additional lines Swap fluids to cold saline Ice pack body Swap soda lime Treat other factors Investigations Dantrolene mixing
What is the dose of dantrolene?
2.5mg/kg IV bolus every 10-15min and repeat up to 30mg/kg
What drugs are used to treat the other factors?
Acidosis: sodium bicarbonate
Potassium: insulin in dextrose
Arrhythmia: amiodarone, lignocaine
Who is susceptible to MH?
Family history
Diagnosed MH
Raised Creatine kinase
Rare muscle disorders
How is the anaesthetic machine prepared for a known MH case?
Should be first on list
Remove vaporisers and sux -
Flush circuit for 90sec using 15L/min on the ventilator with test lung attached
Insert vapor free filters
Replace all consumables while still maintaining a flush of 15L/min
Keep FGF above 10L/min for first 90 minutes of the case
What are the aims of haemorrhage treatment and other drugs which could be considered?
MAP > 50
Laboratory goals
Other drugs:
Calcium
Insulin for high potassium
Tranexamic acid
What is the treatment of cardiac arrest?
Help
100% o2
Start CPR
Attach defibrillator (200J)
Assess the rhythm
Shockable: 1mg adren after second shock and every second cycle, amiodarone 300mg after third shock
Non-shockable: adrenaline 1mg and repeat every second cycle
During CPR: achieve airway, attach capnography, IV access
What are the 4H and 4T?
Hypoxia Hypovalaemia Hyper/hypokalaemia other metabolic disorders Hyper/hypothermia Tension pneumothorax Tamponade Toxins Thromboembolism
What is post resuscitation care of a cardiac arrest?
Reevaluate abcde 12 lead ECG Treat cause Paed: Reevaluate oxygen and ventilation Adult: aim for 94-98% O2, normocapnia and normoglycaemia Target temperature management (cool)
What is the symptoms of aspiration?
Laryngospasm Obstruction Bronchospasm Crackles Hypo ventilation Dyspnoea Low sats
What is the treatment of aspiration?
Help Intubate Suction, 100% o2, peep Bronchoscope and lavage Bronchodilator X-ray
What should be done if the patient is regurgitating?
Place head down Suction Cricoid Gentle CPAP bag mask Intubate
What are the symptoms of a bronchospasm?
High pressure Low sats Wheeze Low tv High co2
What is the treatment of bronchospasm?
Help 100% o2 Stop any stimulation Deepen Check tube or intubate Adren or salbutamol Find and treat cause
What might cause a bronchospasm?
Anaphylaxis
Irritation
Aspiration
Differential: pneumothorax, oesophageal intubation, too light
What is asthma?
Reversible airflow obstruction
Smooth muscle construction
Inflamed bronchial wall
Increased mucus production
What is COPD?
Chronic bronchitis or emphysema
Obstruction of airflow
Non reversible
From prolonged exposure to irritant
Narrowing from inflammation, scar tissue and multiplying epithelial cells
Reduced elasticity causes collapse on expiration causing gas trapping
Enlarged mucus glands and reduced cilia function creates cough and mucus plugs
What is chronic bronchitis?
A productive cough on most days for over 3 years
Inflamed bronchi
Productive cough for more than 3 months each year for 2 consecutive years
What is emphysema?
Dilatation and destruction of alveolar which weaken and rupture causing reduced surface area for exchange
Alpha1 anti trypsin deficiency: allow WBC to attack lung tissue
What are common COPD irritants?
Smoking
Occupational hazards
Pollution
Repeated infections
What is a pink puffer?
Emphysema Thin Breathless High RR Hypoxic Barrel chest Pursed lips
What is a blue bloated?
Bronchitis Overweight Poor respiratory effort Hypoxic - blue Peripheral oedema Co2 retention
What is Cor pulmonale?
Enlargement of right heart from lung disease
High pressure in lung vessels means difficult to pump here therefore it backs up in the right heart so it works harder
What are normal blood gases?
Ph 7.35-7.45
O2 85-100 mmHg
Co2 35-45
Be +3/-3 mmol/L
What are the anaesthetic considerations for COPD?
Pre optimise (neb) Avoid H1 drugs Not for SV Not ideal to lie flat RV failure? Suction catheter Extubate awake
What affects do anaesthetic have on the respiratory system?
Low FRC (quick hypoxia) Low Cc (collapse before end expiration - gas trap) Atelectasis V/q mismatch Reduced pharyngeal tone Increased secretions Low MV Infection risk
What is rheumatoid arthritis?
Autoimmune inflammatory More common females Reduced movement due to joint swelling, pain and stiffness Chronic pain Symmetrical
What are the articular problems with rheumatoid arthritis?
Temporomadibular: mouth opening reduced
larynx obstructed by nodules
Atlantoaxial subluxation: neck motion limited, movement may compress cord
What are the non articular problems with rheumatoid arthritis?
Cardiac: CAD, HD, aortic regurgitate Resp: pleural effusion, reduced chest compliance Chronic anaemia - monitor Neuropathy, dry eye, cord compression Immunosuppressants!! Renal failure DI
What is diabetes mellitus?
Insulin stimulates glucose uptake into cells
Type 1: immune mediated, IDDM, pancreas doesn’t produce insulin, deficiency, Tx: insulin
Type 2: NIDDM, cells don’t respond to insulin or not enough is produced, resistance, Tx: diet, exercise, oral, insulin
What are the systemic complications of DM?
CAD, PVD, poor circulation, HTN, IHD
Neuropathy, autonomic neuropathy - vessels can’t constrict to compensate - hypotensive easily
High infection risk
Kidney failure, high creatinine
Retinopathy
Delayed gastric emptying, reflux (RSI)
Thickened soft tissues: limited joint mobility syndrome - DI
Why is Hartmans solution not ideal in DM?
Contains lactate which is converted to glucose in the fasted state which could Potentiate hyperglycaemic state
What are the symptoms of DM?
Weight loss Thirst (polydypsia) Polyuria (frequent urine) Polyphagia ( hunger) Blurred vision Headache Fatigue Reduced healing
What is diabetes insipidus?
Deficiency of pituitary hormone ADH which regulates kidney function. Creates thirst and increased urine
What is gestational diabetes?
Development of high blood sugar during pregnancy. Foetus creates higher need and hormones may disrupt normal insulin. Mother has higher risk of developing T2DM later in life
What are the rules with insulin/dextrose infusions?
Deliver through same line Fluid through volumetric pump Insulin through syringe driver Anti reflux valve on glucose line to prevent bolus of insulin Check regularly
What is hypoglycaemia and the treatment?
<4mmol/L
Cause brain death
50ml of 50% glucose IV
1mg glucagon IM/IV
Why is potassium added to DM regimes?
Dextrose/insulin can cause low potassium levels so needs replacing. Usually added to dextrose bag
What is DKA?
Diabetic ketoacidosis
Not enough insulin to use glucose so fat gets metabolised for energy which produces poisonous ketones
Fluid shifts to ECF
Caused by missed insulin, infection, first presentation of DM
What are the symptoms and treatment of DKA?
Reduce alertness High RR Fruit breath Nausea and vomiting Dehydration
Insulin and fluid; add potassium later
What is obesity?
> 30 kg/m2
How is BMI calculated?
Weight/height2
What are the systemic effects of obesity on the cardiac system?
High blood volume High CO, SV, BP CAD, IHD, HTN Atherosclerosis LV hyper trophy
What are the systemic effects of obesity on the respiratory system?
High oxygen consumption from more tissue and supporting muscles High CO2 Low FRC and CC Low compliance Osa
What are other systemic effects of obesity?
High abdominal pressure More gastric acid High aspiration risk Low liver function Likely NIDDM DI Poor IV access Increased infection
What pharmacology effects so obese patients pose?
Changed Vd due to less water and more fat
Higher plasma cholinesterases
Lipophilic drugs have a higher Vd and duration - anaesthetic
LA in central blocks need reduced dose as less space (more fat)
LA and GA drugs based on ideal weight
What is PVD?
Circulation disorder caused by narrowing, blockage or spasms in blood vessels.
From athersclerosis/plaques
Reduce flow and O2 to tissue
Can be functional: no damage to structure, change from other factors eg temp
Organic: changed structure - plaque
What are the anaesthetic considerations for PVD?
60% will have CAD Difficult to manage BP as hardened vessels are less compliant - art line Cardiac events/stroke risk - invos or RA Optimise pre op DVT care Pressure area care 5 lead ECG? Warming
What ventilator settings can help with COPD?
Change I:E
Peep
What is osa?
Frequent episodes of apnoea during sleep
>5/hr or >30/night
10 seconds is apnoea
What is preeclampsia?
Condition of pregnancy
Symptoms: HTN, oedema, proteinuria
Can cause seizures and coagulopathy
Treatment: hypotensives and bed rest, deliver baby in unstable
What might cause a PPH?
Retained placenta preventing the uterus from contracting
What is placenta previa and accretia?
Previa: placenta attached to wall close to or covering cervix
Accretia: placenta grows through to myometrium
Increta: grows into myometrium and muscle layer
Percreta: grows through myometrium onto surrounding structures
What is an amniotic fluid embolism?
Amniotic fluid or fetal cells enter mothers circulation and cause an allergic-like response
How does the obstetric DAS differ?
Maximum 2+1 attempts intubation
Maximum 2 attempts at supraglottic
It is an RSI
How is adrenaline used in anaphylaxis and in cardiac arrest?
Anaphylaxis: 50-100mcg IV or 0.5mg IM
Cardiac arrest shockable: 1mg every second cycle
Cardiac arrest non-shockable:
1mg immediately then every second cycle
How does the paediatric cardiac arrest algorithm differ?
2 breaths: 15 compressions
Charge to 4J/Kg
Shockable: 10mcg/Kg 2nd loop
5mg/kg amiodarone 3rd shock
Non-shockable: 10mcg/Kg immediately and every 2nd loop
How does the paediatric algorithm for anaphylaxis differ to adult?
Adrenaline 10mcg/kg IM of 1:1000
Repeat 3-5 minutes
20ml/kg fluid bolus
Draw the algorithm for CPR.
See notes
What are the four classes of hypovalaemic shock?
1: <15%
2: 15-30%
3: 30-40%
4: >40%
What are the signs of shock, lower airway obstruction and upper airway obstruction in anaphylaxis?
Shock: hypotension
Upper airway: strider, swelling
Lower airway: wheeze
How does paediatric MTP work?
Ring blood bank
Ensure X match
Alpha: 0-10Kg
Bravo: 11-20Kg
Charlie: 21-45Kg
Each weight tare has different products arriving in each box with a certain volume to be given of each.
Remember tranexamic acid, warming and lab checks
What is in each MTP box?
Box1: 2xRBC, 2xFFP Lab check, tranexamic Box2: 4xRBC, 4xFFP, 3xCryo Box3: 4xRBC, 4xFFP, 1xPlate Lab check Box4: 4xRBC, 4xFFP, 3xCryo Alternate box 3&4, lab check/30min
What’s the purpose of the guardian of the box?
Overseas safe management of the box IV certified nurse/tech/MO May be theatre coordinator Guardian initials box when arrived Check pt ID on form against that on box Select one at a time for checking
What reversal agents are used?
Sug reverses vecuronium and rocuronium
Neo reverses all non-depolarises except mivacurium
What could be some patient, equipment and machine causes of a high airway pressure?
Aspiration Spasm Pulmonary oedema Tension pneumothorax Kinked tube Tube moved and against trachea Tube in too far; one bronchi Filter blocked Tubing occluded by a FB Run over tubing Valve stuck Ventilator malfunction Pressure relief valve failure (Disconnect circuit, on bag, squeeze to eliminate machine and circuit)
What are the steps of MTP?
- Massive bleeding and shock or coagulopathy
- Initiate 777: MTP, location. This will contact relevant ppl
Correct forms with either emergency blood or box 1. Send via runner; wait - Give 3 units of RBC
- Activate: Call blood bank: MTP, clinician and guardian
Ensure X match sent
Request each box as needed by form
Consult the additional treatment thresholds with lab results
Cancel MTP ASAP
Warming, lines, fluid, level1, testing
What are methods of dealing with obstetric bleeding?
IR: balloon catheters into internal iliac vessels prior to case and inflated at time of delivery
Intrauterine tamponade with a saline filled Bakri balloon
Cross match prior
Cell salvage with care
Uterotonics
Hysterectomy
Bimanual compression of uterus
Why is magnesium used in eclamptic patients?
It is used to control an initial seizure and an infusion is used to prevent any more
