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Surgery > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Why are patients fasted before GA/operations?

A
  • Empty stomach reduced reflux into oropharynx + aspirating into trachea
  • Prevent pneumonitis and aspiration pneumonia
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2
Q

How long before operations are patients fasted for?

A
  • 6 hours-> no food

- 2 hours before-> no clear fluids

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3
Q

What is pre-oxygenation?

A
  • Few minutes of 100% oxygen during GA

- Gives O2 reserve for when unconscious + intubating

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4
Q

What is the triad of general anaesthesia?

A

Hypnosis + muscle relaxation + analgesia

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5
Q

What ‘premedications’ are given in GA?

A
  • Benzos (eg midazolam)-> relax muscles + anxiety, amnesia
  • Opiates (fentanyl)-> analgesia + reduce response to laryngoscope
  • Alpha-2 adrenergic agonists (eg clonidine)-> sedation + pain
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6
Q

What is rapid sequence induction and when is it done?

A
  • Quick + safe control of airway using drugs to induce neuromuscular blocking + immediate unresponsive + cricoid pressure
  • Emergencies or when reflux risk (not fasted or pregnancy)
  • Higher risk of aspiration
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7
Q

What is used for the hypnosis aspect of GA?

A
  • IV-> propofol, ketamine, thiopental sodium
  • Volatile agents-> sevofluorane
  • Often IV for induction + inhaled to maintain
  • Or TIVA (total IV anaesthetic)
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8
Q

What is TIVA?

A

Total IV anaesthesia-> propofol usually + better recovery

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9
Q

What is used for the muscle relaxation aspect of GA?

A
  • Depolarising-> suxamethonium
  • Non-depolarising-> rocuronium, atracurium
  • Block NMJ
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10
Q

How can muscle relaxant agents used in GA be reversed?

A
  • Neostigmine for NMJ blockers

- Sugammadex-> for non-depolarising

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11
Q

What is used for analgesia in GA?

A

Opiates-> fentanyl, alfentanil, morphine

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12
Q

What antiemetics are commonly used in GA?

A
  • Ondansetron-> 5HT3 antagonist
  • Dexamethasone-> steroid
  • Cyclizine-> H1 receptor antagonist
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13
Q

When should ondansetron be avoided?

A

Long QT syndrome (or risk of)

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14
Q

When should dexamethasone be avoided?

A

Diabetes or immunocompromised

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15
Q

When should cyclizine be avoided?

A

Heart failure or elderly

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16
Q

How can the wearing off of muscle relaxants be tested during GA emergence?

A

Nerve stimulator-> test muscle response (ulnar/facial nerve) + see if train-of-four (if strong after 4 goes)

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17
Q

What are some of the risks of GA?

A
  • Sore throat
  • N+V
  • Awareness
  • Aspiration
  • Dental injury
  • Anaphylaxis
  • CV events
  • Malignant hyperthermia
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18
Q

What is Malignant hyperthermia?

A

Rare but fatal hypermetabolic response to anaesthetics (volatile + suxamethonium usually)

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19
Q

What can put a patient at risk of Malignant hyperthermia?

A

Family history-> autosomal dominant mutation

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20
Q

What are the symptoms and signs of Malignant hyperthermia?

A
  • Increased temp
  • Increased CO exhalation
  • Tachycardia
  • Muscle rigidity
  • Acidosis
  • Hyperkalaemia
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21
Q

What is a peripheral nerve block?

A
  • Local anaesthetic into area around nerve
  • Distal area numbed
  • Done under US guidance
  • May use nerve stimulator to check
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22
Q

What is a spinal block?

A
  • Central neuraxial anaesthesia

- Local anaesthetic into CSF within subarachnoid space (L3/4 or L4/5)

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23
Q

Where is a spinal block inserted?

A

L3/4 or L4/5-> below spinal cord

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24
Q

How is a spinal block tested?

A

Cold spray along area

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25
Q

When might spinal block be performed?

A
  • Caesarian
  • TURPs
  • Hip fracture repair
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26
Q

What is epidural anaesthesia?

A
  • In labour or post-op after laparotomy
  • LA infused into epidural space (outside dura)
  • Goes into spinal cord + tissues
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27
Q

What medications are used in epidural anaesthesia?

A

Levobupivacaine +/- fentanyl

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28
Q

What is a dural tap?

A

When dura punctured + CSF leaks during epidural

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29
Q

What are the side effects of epidural anaesthesia?

A
  • Hypotension
  • Motor weakness in legs
  • Nerve damage
  • Infection
  • Haematoma
  • Headache (dural tap)
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30
Q

What are the risks of using epidural anaesthesia in labour?

A
  • Prolonged 2nd stage

- Increased probability of instrumental delivery

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31
Q

What might indicate that epidural anaesthesia has been inserted into the wrong place?

A

Unable to straight leg raise-> may be in CSF (spinal block)

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32
Q

What is used for LA?

A

Lidocaine

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33
Q

When might LA be used?

A
  • Skin sutures
  • Minor surgery
  • Dental + hand surgery
  • LP
  • Central line
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34
Q

What is endotracheal intubation?

A
  • ETT is flexible tube with cuff (balloon) inflated by syringe
  • Used for mechanical ventilation in GA
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35
Q

How might an endotracheal tube be guided in?

A
  • Laryngoscope (eg McGrath)
  • Bougie-> plastic
  • Stylet-> stiff metal wire
  • Awake fibre-optic intubation-> through nose or mouth, eg during trismus
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36
Q

What are supraglottic airway devices?

A
  • Laryngeal mask airway (LMA) or I-Gel
  • Alternative to ETT
  • Tip at top of oesophagus + cuff around larynx
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37
Q

What is an oropharyngeal airway?

A
  • Guedel-> rigid + create air passage between teeth + base of tongue
  • Use to ventilate with face mask + bag before SAD/ETT
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38
Q

How are guedel airways inserted?

A
  • Measured from centre of mouth to angle of jaw

- Upside down + rotate past tongue

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39
Q

What is a nasopharyngeal airway?

A

Flexible tube through nose + create airway to pharynx

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40
Q

How is nasopharyngeal airway measured?

A

Edge of nostril to tragus of ear

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41
Q

What is a major risk of nasopharyngeal airway?

A

Epistaxis

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42
Q

What is a contraindication of nasopharyngeal airway?

A

Base of skull fracture

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43
Q

How is a tracheostomy performed?

A
  • Direct access to trachea through hole
  • Held in place with stitches or soft tie
  • Under GA or LA
  • Outer (stays in place) + inner (can clean/change) tube
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44
Q

What are the 4 steps of managing a difficult airway?

A
  • Laryngoscopy + tracheal intubation
  • Supraglottic airway device
  • Face mask ventilation + wake up
  • Cricothyroidotomy
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45
Q

What is an arterial line and why is it used?

A
  • Cannula in artery (eg radial)
  • Accurately monitor BP
  • Take ABGs
  • NOT to put meds in
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46
Q

What is a central line?

A
  • Central venous catheter
  • Long thin tube with 3-5 lumens
  • In large vein-> internal jugular, subclavian, femoral-> vena cava
  • Give medications
  • Take samples
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47
Q

What is a PICC line?

A
  • Peripherally inserted central catheter
  • Long thin tube into peripheral vein-> tip into IVC or RA
  • 1-2 lumens
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48
Q

What is a tunnelled central venous catheter?

A
  • Eg-> Hickmann line
  • Long + thin-> enters skin on chest + into SC tissue-> tip in SVC/RA
  • Cuff when more permanent
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49
Q

What is a pulmonary artery catheter?

A
  • Through central vein, right heart then pulmonary artery

- Close cardiac function monitoring

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50
Q

What is a portacath?

A
  • Type of central venous catheter
  • Port under skin of chest to access
  • Tip in SVC or RA
  • Needle through skin into port for injections/infusions
  • Long term eg chemo
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51
Q

What is the definition of pain?

A

Unpleasant sensory + emotional experience associated with or resembling acute or potential tissue damage

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52
Q

What should be considered even though pain is thought to be subjective?

A
  • Everyone handles differently

- Accept the patient’s experience even when no underlying cause/tissue damage

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53
Q

What is a pain threshold?

A

The point at which a sensory input is described as pain

54
Q

What is allodynia?

A

Pain experienced with sensory inputs that don’t normally cause pain

55
Q

What is pain tolerance?

A
  • The person’s response to pain
  • 2 people may be affected differently to same stimulus
  • Many biopsychosocial factors
56
Q

What is the basic physiology of pain?

A
  • Sensory (signal to pain receptors) + affective (emotional) aspects
  • Nociceptors at ends of nerves detect damage-> along afferent nerves (primary afferent nociceptors)-> spinal cord
  • Up cord via spinothalamic + spinoreticular tract-> to brain (thalamus + cortex)
  • May be C fibre or A-delta fibres
57
Q

What are C-fibres and what do they transmit?

A
  • Unmyelinated + small
  • Slow transmission
  • Dull + diffuse pain
58
Q

What are a-delta fibres and what do they transmit?

A
  • Myelinated and large
  • Fast transmission
  • Sharp/local pain
59
Q

What main sensory inputs generate a pain response?

A
  • Mechanical (pressure)
  • Heat
  • Chemical (prostaglandins)
60
Q

What is referred pain and why does it happen?

A
  • Pain in 1 area that isn’t at site of damage
  • As nerves can share innervation of multiple body parts
  • Pain in 1 area creates more sensitivity in spinal cord from signals in other areas
61
Q

What is neuropathic pain?

A

Abnormal function or damage to sensory nerves causing pain

62
Q

What are the features of neuropathic pain?

A

Burning, tingling, pins + needles, electrick shocks, loss of touch sensation

63
Q

What can be used to assess if pain is neuropathic?

A

DN4 questionnaire-> likely is if answer 4/10 or more

64
Q

What can be used for neuropathic pain?

A
  • Amitriptyline
  • Duloxetine
  • Gabapentin
  • Pregabalin
  • Tramadol-> for rescues/flares
  • Physio
  • Psych input
  • Capsaicin cream
  • Carbamazepine-> trigeminal neuralgia
65
Q

What medications should be stopped pre-surgery?

A

CHOW

  • Clopidogrel
  • Hypoglycaemics
  • OCP/HRT-> 4 weeks before
  • Warfarin-> 5 days before + bridging
66
Q

What medications should be altered pre-surgery?

A
  • Insulin-> switch to variable rate

- Long term steroids-> give IV hydrocortisone

67
Q

What medications should be started pre-surgery?

A
  • VTE prophylaxis
  • Antibiotic prophylaxis
  • Bowel prep
68
Q

What are the common sources of infection and problems post-surgery?

A
  • Respiratory-> 1-2 days
  • Urine-> 3-5 days
  • Walk-> 4-6 days
  • Wound-> 5-7 days
  • Drugs-> 7+ days
69
Q

What are some common post-op problems?

A
  • Confusion
  • Decreased UO
  • N+V
  • Bleeding
  • DVT/PE
70
Q

What does the WHO analgesic ladder consist of?

A
  • Step 1-> non-opioids (paracetamol, NSAIDs
  • Step 2-> weak opioids (codeine, tramadol)
  • Step 3-> strong opioids (morphine, oxycodone, fentanyl, buprenorphine)
  • Adjuvants can be used throughout
71
Q

What are ‘adjuvant’ medications?

A
  • Amitriptiline-> TCA
  • Duloxetine-> SNRI
  • Gabapentin-> anticonvulsant
  • Pregabalin-> anticonvulsant
  • Capsaicin creams
72
Q

What dose of opioids are used for breakthrough pain?

A

1/10 to 1/6 of patient’s daily background dose (over 24 hours)

73
Q

How much IV/IM/SC morphine is equivalent to 10mg of oral morphine?

A

5mg-> 1/2 dose for same effect

74
Q

How much oral codiene or tramadol is equivalent to 10mg of oral morphine?

A

100mg-> 10x dose for equivalent

75
Q

How much oral oxycodone is equivalent to 10mg of oral morphine?

A

6.6mg

76
Q

How much IM/IV/SC diamorphine is equivalent to 10mg of oral morphine?

A

3mg

77
Q

How much buprenophine (patch) is equivalent to 12mg/24 hours of oral morphine?

A

5mcg/hour

78
Q

How much fentanyl (patch) is equivalent to 30mg/24 hours or morphine?

A

12mcg/hour

79
Q

What benefits does post-op analgesia have for the patient?

A
  • Pain relief
  • Helps mobilise
  • Ventilate lungs-> reduce infection + atelectasis
  • Good oral intake
80
Q

What is patient-controlled analgesia?

A
  • IV strong opiate bolus when press button
  • Stops responding for set time after each-> prevent overuse
  • As required opiates stopped when on this
  • Need naloxone, antiemetics + atropine around
81
Q

What is chronic pain?

A

Pain present or recurring in 1 or more areas over 3 months or longer

82
Q

What is the pathophysiology of chronic pain?

A
  • Sensitisation of primary afferent nociceptors by frequent stimulation
  • Increases activity of sympathetic NS
  • Increased muscle contraction in response to pain
83
Q

What are some options for managing chronic pain?

A
  • Group exercise
  • Acceptance and commitment therapy (ACT)
  • CBT
  • Acupuncture
  • Antidepressants
  • WHO analgesic ladder (when secondary to disease)
84
Q

What can be used to predict a patient’s mortality on ICU?

A

APACHE-> acute physiology + chronic health evaluation

85
Q

What is a complication of TPN?

A

Thrombophlebitis-> prevented by using central not peripheral line

86
Q

What are the potential complications of ICU admission?

A
  • Ventilation-associated lung injury
  • Ventilation-associated pneumonia
  • Catheter-related blood infections
  • Catheter-related UTIs
  • Stress-related mucosal disease (upper GI)
  • Delirium
  • VTE
  • Critical illness myopathy
  • Critical illness neuropathy
87
Q

What is a normal pH value on ABG?

A

7.35-7.45

88
Q

What is a normal PaO2 value on ABG?

A

10.7-13.3 kPA

89
Q

What is a normal PaCO2 level on ABG?

A

4.7-6.0 kPa

90
Q

What is a normal HCO3 level on ABG?

A

22-28 mmol/L

91
Q

What is a normal base excess on ABG?

A

-2 to +2

92
Q

What is a normal lactate level on ABG?

A

0.5-1mmol/L

93
Q

What is FiO2?

A
  • Fraction of inhaled O2
  • 21% in room air
  • Can increase with venturi masks
94
Q

What does type 1 respiratory failure look like on ABG?

A

Normal pCO2 + low PaO2

95
Q

What does type 2 respiratory failure look like on ABG?

A

High pCO2 + low PaO2

96
Q

What does respiratory acidosis look like on ABG?

A
  • Low pH
  • High PaCO2
  • Acute CO2 retention-> makes blood acidic (broken down to H2CO3)
97
Q

What does respiratory alkalosis look like on ABG?

A
  • High pH
  • Low Co2
  • High O2
  • Raised RR or hyperventilation or PE
98
Q

What does metabolic acidosis look like on ABG?

A
  • Low pH
  • Low bicarb
  • Causes-> high lactate, high ketones, increased H+ (renal failure), low bicarb (diarrhoea or renal failure)
99
Q

What does metabolic alkalosis look like on ABG?

A
  • High pH
  • High bicarb
  • Loss o
100
Q

What can cause respiratory alkalosis?

A

Raised RR or hyperventilation or PE

101
Q

What can cause metabolic acidosis?

A
  • high lactate
  • high ketones
  • increased H+ (renal failure)
  • low bicarb (diarrhoea or renal failure)
102
Q

What can cause metabolic alkalosis?

A
  • Loss of H+ (vomiting)

- High aldosterone causing H+ loss-> Conn’s, cirrhosis, HF, loop or thiazide diuretics

103
Q

What can cause high bicarb?

A

Chronic CO2 retention-> takes a while to be produced in kidneys so not raised if not chronic

104
Q

What is acute respiratory distress syndrome?

A

Severe inflammation of lungs secondary to sepsis or trauma

105
Q

What is the pathology of acute respiratory distress syndrome?

A
  • Atelectasis-> alveoli + tissue collapse
  • Pulmonary oedema
  • Decreased lung compliance-> less inflation
  • Fibrosis
106
Q

What are the symptoms and signs of acute respiratory distress syndrome?

A
  • Distress
  • Hypoxia not responding to therapy
  • Bilateral infiltrations on CXF
107
Q

How is acute respiratory distress syndrome managed?

A
  • Respiratory support
  • Prone-> improves blood flow + secretion clearance
  • Fluid management
  • PEEP-> positive end expiratory pressure to prevent further lung collapse
108
Q

What is PEEP?

A
  • positive end expiratory pressure -> pressure remains in airways after exhalation
  • to prevent further lung collapse
  • can use in nasal cannulae, NIV, mechanical ventilation
109
Q

What are some options for respiratory support?

A
  • High flow nasal cannulae
  • Venturi mask
  • Face mask
  • Non-rebreathe mask
  • NIV-> CPAP or BiPAP
  • Mechanical ventilation-> ETT, tracheostomy
  • Extracorporeal membrane oxygenation?
110
Q

What is BiPAP?

A

Cycle of high + low pressure used-> IPAP + EPAP (inspiratory + expiratory)

111
Q

What is CPAP?

A
  • Continuous pressure to keep airway expanded
  • Maintains when likely to collapse
  • Similar to PEEP
112
Q

What are the settings on mechanical ventilation machines that can be altered?

A
  • FiO2
  • RR
  • Tidal volume
  • Inspiration:expiration
  • Peak flow rate
  • Peak inspiratory pressure
  • PEEP
113
Q

What are the different modes on mechanical ventilation machines?

A
  • Volume-controlled-> tidal per breath
  • Pressure controlled
  • Assist controlled-> breaths triggered by patient or machine
  • CPAP
114
Q

What is extracorporeal membrane oxygenation?

A
  • Blood through machine where O2 added + CO2 taken
  • Like dialysis
  • Rarely used
115
Q

What is cardiac output?

A
  • Stroke volume x heart rate
  • Preload + afterload + contractility + heart rate
  • Volume of blood exiting heart after each contraction
116
Q

What is preload?

A

Amount that the heart muscle is stretched when filled with blood (pre-contraction)

117
Q

What is afterload?

A
  • Resistance the heart overcomes to eject blood from the LV

- Resistance after aortic valve

118
Q

What can raise the afterload?

A
  • Aortic stenosis

- HTN

119
Q

What is contractility?

A

Strength of the heart muscle contraction

120
Q

What is systemic vascular resistance?

A

Resistance in circulation that the heart overcomes to pump blood around

121
Q

What is the stroke volume?

A

Volume of blood ejected with each beat

122
Q

What is the mean arterial pressure?

A
  • CO + SVR
  • Average BP through whole cycle
  • Need for adequate tissue perfusion
123
Q

When should fluid status be monitored?

A
  • Acutely unwell eg sepsis
  • When suspect overload-> CHF, pulmonary oedems
  • Before giving inotrope + vasopressor meds
124
Q

How can fluid status be monitored?

A
  • Input-output chart
  • Weight after diuretics
  • Central venous pressure-> estimates preload
125
Q

What are inotropes?

A

Meds that alter the contractility of the heart

126
Q

What are positive inotropes?

A
  • Increase heart contractility, output + MAP
  • Given when low cardiac output
  • Egs-> adrenaline, milrinone, levosimendan
127
Q

What are negative inotropes?

A
  • Reduce contractility of heart

- Egs-> CCBs, beta blockers, flecainide

128
Q

What are vasopressors?

A
  • Vasoconstrict + increase SVR
  • To improve BP + tissue perfusion
  • EGs-> noradrenaline, vasopressin, adrenaline, ephedrine, metaraminol, phenylephrine
129
Q

What are antimuscarinics?

A
  • Block acetylcholine receptors

- Egs-> Glycoryronium, atropine

130
Q

What is an intra-aortic balloon pump?

A
  • Used in cardiogenic shock, ACS or surgery

- Mimic heart contractions-> inflate in diastole + deflate in systole

131
Q

What are the indications for acute dialysis?

A

AEIOU

  • Acidosis
  • Electrolyte imbalance-> eg hyperkalaemia
  • Intoxication
  • Oedema
  • Uraemia
132
Q

What is haemodialysis?

A
  • Blood through semi-permeable membrane + solute out into dialysate (fluid)
  • Acute, continuous (24 hours) or intermittent (eg 3-12 hours then break)

Surgery (8 decks)

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