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Medicine > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Local anaesthesia

A

small area numbed to facilitate minor surgery for dental extraction or excision of skin lesion

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2
Q

Regional anaesthesia

A

larger area numbed, can be divided into central neuraxial blockade and nerve blocks.
Central neuraxial blockade refers to spinal or epidural anaesthesia
Nerve block can result in a whole limb being numb in isolation.
patient can remain awake but it can also be combined with sedation or full general anaesthetic

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3
Q

Spinal/Central Neuraxial anaesthesia

A

local anaesthetic is injected into the cerebrospinal fluid, within the subarachnoid space. L3/4 or L4/5 spaces.

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4
Q

Epidural anaesthesia involves injection of local anaesthetic into the epidural space around

A

the L2-3 or L3-4 vertebral level.

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5
Q

Adverse effects of epidural anaesthesia

A

Headache if the dura is punctured, creating a hole for CSF to leak from (“dural tap”)
Hypotension
Motor weakness in the legs
Nerve damage (rare)
Infection
Haematoma (may cause spinal cord compression)
Meningitis ( very rare, more so in spinal than epidural )

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6
Q

General anaesthesia

A

patient rendered unconscious by IV or inhaled drugs. Described triad is hypnosis, analgesia and muscle relaxation

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7
Q

Solid fasting guidelines

A

6 hours

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8
Q

Clear fluid fasting guidelines

A

2 hours

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9
Q

When Clopidogrel and aspirin should be stopped

A

7 days before surgery

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10
Q

When warfarin should be (generally) stopped

A

5 days before surgery and instead patients should be on low molecular weight heparin until the night before

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11
Q

When ACE inhibitors and ARBS should be stopped

A

the day before surgery

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12
Q

When should The pill/HRT be stopped

A

4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile).

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13
Q

Switch oral steroids to

A

50-100mg IV hydrocortisone
oral steroids may be started again 48-72 hours post-op provided the patient is eating and drinking again

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14
Q

Diabetic patients and surgery

A

A HbA1c < 69mmol/mol within 3 months of surgery is the aim in the elective setting.
Hold all oral diabetic medication on the morning of the procedure.
If the patient is on insulin then switch to sliding scale infusion when they start NBM (restart when they can eat).
Restart all oral medication the morning after surgery.
For some operations (particularly those that do not require contrast media) metformin does not need to be stopped
minimise meals missed to 1, clear advice on regular medications,
monitor CBG every hour under general anaesthetic.
For the majority of patients, the variable rate i.v. insulin infusion (VRIII) is required to control the diabetes and maintain optimal glycaemic control of 6–10 mmol litre
Where possible patients with diabetes are put first on the list

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15
Q

Diabetes drugs:

A

Insulin should be held on the day of surgery (only the short-acting preparations)
sulfonylureas should be held on the day of surgery
metformin can be given as normal for short procedures. For longer procedures when the patient is not eating and drinking for several days metformin should be held and variable-rate insulin prescribed.

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16
Q

Safe to take before and on day of surgery

A

beta blocker
calcium channel blocker

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17
Q

Anaemia classification

A

Haemoglobin <130g/L (men) or <120g/L (women)

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18
Q

Pre-operative management of anaemia

A

Oral iron if >6 weeks until planned surgery
IV iron if <6 weeks until planned surgery
B12/folate replacement
Erythropoiesis‐stimulating agent (ESA) therapy
Transfusion if profound anaemia and surgery cannot be delayed

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19
Q

Anaesthetic preoperative assessment

A

Functional status - exercise tolerance, ADL
Medical history
Medications and allergy
Preoperative tests- consider ECHO, group and save, crossmatch, ECG, bloods
Airway assessment
Previous anaesthesia

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20
Q

Premedications in general anaesthesia

A

Oxygen
BDZ- relax muscles,reduce anxiety
Analgesia- at least paracetamol
Opiates -reduce pain and reduce the hypertensive response to the laryngoscope
Alpha-2-adrenergic agonists (e.g., clonidine)- help with sedation and pain
PPI/H2 antagonists - Managing regurgitation and aspiration risk for high risk patients.
Antimuscarinics- infrequent use,reduce airway secretions in certain patient groups or prevent bradycardia in paediatric patients

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21
Q

Rapid Sequence Induction/Intubation

A

used to gain control over the airway as quickly and safely as possible where a patient is intubated in an emergency scenario and detailed pre-planning is not possible

designed to ensure successful intubation with an endotracheal tube as soon as possible after induction to protect the airway

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22
Q

steps forming the sequence of RSI

A

Preparation
Preoxygenation
Pretreatment
Paralysis- induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium)
Protection and positioning- Cricoid pressure,In line stabilisation in some cases.
Placement and proof- Intubation is performed via laryngoscopy, with proof obtained (direct vision, end-tidal CO2, bilateral auscultation)
Post-intubation management- Taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents

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23
Q

compartment syndrome presents with the 5 P’s:

A

P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles eg passive flexion of the toes. pain medications are not effective.
P – Paresthesia
P – Pale
P – Pressure (high)
P – Paralysis (a late and worrying feature)

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24
Q

Sodium thiopentone

A

Extremely rapid onset of action making it the agent of choice for rapid sequence of induction
Marked myocardial depression may occur
little analgesia

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25
Q

Ketamine

A

NMDA receptor antagonist
May be used for induction of anaesthesia
Has moderate to strong analgesic properties
Produces little myocardial depression making it a suitable agent for anaesthesia in those who are haemodynamically unstable
May induce state of dissociative anaesthesia resulting in nightmares

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26
Q

Etomidate

A

favorable cardiac safety profile
No analgesic properties
Unsuitable for maintaining sedation as prolonged (and even brief) use may result in adrenal suppression
Post operative vomiting is common
Causes less hypotension than propofol and thiopental during induction and is therefore often used in cases of haemodynamic instability

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27
Q

Thiopental

A

A type of barbiturate (potentiates GABAA)
Adverse effects: Laryngospasm
Highly lipid-soluble so quickly affects the brain
useful in head trauma as it can lower the intracranial pressure;

28
Q

Nitrous oxide

A

May act via a combination of NDMA, nACh, 5-HT3, GABAAand glycine receptors
Adverse effect is that it ​​may diffuse into gas-filled body compartments → increase in pressure. Should therefore be avoided in certain conditions e.g. pneumothorax

29
Q

Muscle relaxants

A

block the neuromuscular junction from working
given to relax and paralyse the muscles. This makes intubation and surgery easier. There are two categories:
Depolarising (e.g., suxamethonium)
Non-depolarising (e.g., rocuronium and atracurium)

30
Q

Sugammadex

A

used specifically to reverse the effects of certain non-depolarising muscle relaxants (rocuronium and vecuronium).

31
Q

Suxamethonium

A

Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plate
choice for rapid sequence induction for intubation

32
Q

Suxamethonium adverse effects

A

Malignant hyperthermia, Hyperkalaemia(normally transient)
May cause fasciculations
Contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

33
Q

Non depolarising

A

Competitive antagonist of nicotinic acetylcholine receptors
Egs include Tubcurarine, atracurium, vecuronium, pancuronium
Adverse effect of Hypotension
Acetylcholinesterase inhibitors (e.g. neostigmine) can reverse

34
Q

Significant risks of general anaesthesia include:

A

Accidental awareness (waking during the anaesthetic)
Aspiration
Dental injury, mainly when the laryngoscope is used for intubation
Anaphylaxis
Cardiovascular events (e.g., myocardial infarction, stroke and arrhythmias)
Malignant hyperthermia (rare)
Death

35
Q

Malignant hyperthermia

A

Rare but potentially fatal hypermetabolic response to anaesthesia
autosomal dominant mutation

36
Q

Malignant hyperthermia presentation

A

Patients typically present at the induction of general anaesthesia with
- increased body temperature
- muscle rigidity
- metabolic acidosis
- tachycardia
- increased exhaled carbon dioxide. Rhabdomyolysis can lead to myoglobin in urine–> dark brown

37
Q

risk of malignant hyperthermia is mainly with

A

Volatile anaesthetics (isoflurane, sevoflurane and desflurane)
Suxamethonium

38
Q

Malignant Hyperthermia treatment

A

treated with dantrolene, a muscle relaxant

39
Q

Local anaesthetic toxicity features

A

Numbness or tingling around the mouth
Restlessness/agitation
Tinnitus
Shivering
Vertigo/dizziness
Subtle tremors of the face and extremities
Hypertension
Tachycardia
Decreased consciousness
Respiratory depression
Hypotension
Apnoea
Seizures
Sinus bradycardia
Ventricular arrhythmias
Asystole

40
Q

Local anaesthetic toxicity management

A

Stop administration of local anaesthetic!
ABCDE approach including ECG monitoring
Lipid emulsion (20% intralipid) 1mL/kg every 3 minutes up to a dose of 3mL\kg
Initiate lipid emulsion infusion at a rate of 0.25mL\kg\min
Maximum total dose = 8mL\kg

41
Q

Suxamethonium apnoea

A

occurs in individuals who have a defect in the plasma cholinesterase enzyme which normally breaks down Suxamethonium.
Leads to sustained action of the drug

42
Q

Suxamethonium apnoea clinical features

A

prolonged period of paralysis following administration of Suxamethonium.
Rapid desaturation and apnoea.

43
Q

three steps to the analgesic ladder:

A

Step 1: Non-opioid medications such as paracetamol and NSAIDs
Step 2: Weak opioids such as codeine and tramadol
Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine

44
Q

Hyoscine butylbromide

A

muscarinic antagonist that will act to decrease pain, nausea and secretions by acting to block muscarinic receptors that cause increased gastric secretions and motility

45
Q

ASA classification

A

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

ASA II- A patient with mild systemic disease eg obesity (BMI 30 - 40), well-controlled Diabetes

ASA III - A patient with severe systemic disease eg COPD,End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis

ASA IV- A patient with severe systemic disease that is a constant threat to life

ASA V - A moribund patient who is not expected to survive without the operation eg ruptured abdominal/thoracic aneurysm

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

46
Q

Propofol

A

Hypnotic IV agents
induction agent (to induce unconsciousness)
GABA receptor agonist

47
Q

Propofol benefits

A

Rapid onset of anaesthesia
anti emetic properties

48
Q

Propofol adverse effects

A

Pain on IV injection
hypotension
Moderate myocardial depression

49
Q

Simple airway manoeuvres

A

Suction: if visible vomit, blood, secretions or foreign body
Head tilt/chin lift
Jaw thrust

50
Q

Oropharyngeal airway (OPA) e.g. Guedel

A

Device sits in pharynx and aligns to cover the airway
Easy to insert and use
No paralysis required
Ideal for very short procedures

51
Q

Nasopharyngeal airway (NPA)

A

create an air passage from outside the nostril to the pharynx (throat).
Useful in patients with a sensitive gag reflex when using OPA
They are often used in emergency scenarios
Contraindicated in base of skull fracture

52
Q

​​Laryngeal mask airway (LMA)

A

Supraglottic Airway Device with inflatable cuff
Sits over the top of the larynx
Very easy to insert
Poor control against reflux of gastric contents
Paralysis not usually required

53
Q

I-gel

A

a type of non-inflatable SAD that uses a gel-like cuff that moulds to the larynx.

54
Q

Endotracheal Intubation

A

The tip of the endotracheal tube is inserted through the mouth, throat (pharynx), larynx and vocal cords into the trachea
Inserted using a laryngoscope. Used for prolonged mechanical ventilation.​​Provides optimal control of the airway once cuff inflated
Paralysis often required
Higher ventilation pressures can be used

55
Q

Tracheostomy

A

hole is made in the front of the neck with direct access to the trachea. A tracheostomy tube is inserted through the hole into the trachea and held in place with stitches or soft tie around the neck
Reduces the work of breathing (and dead space)
May be useful in slow weaning
Percutaneous tracheostomy widely used in ITU
Dries secretions, humidified air usually required

56
Q

Cricothyrotomy

A

incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma

57
Q

Non-invasive ventilation options

A

CPAP (continuous positive airway pressure)
BiPAP (bilevel positive airway pressure)

58
Q

CPAP

A

constant positive pressure added to the lungs to keep the airways expanded.
It is used to maintain the patient’s airways in conditions where they are likely to collapse,T1RF adds,covid, sleep apnoea

59
Q

BiPAP

A

Bilevel positive pressure
involves a cycle of high and low pressure to correspond to the patient’s inspiration and expiration
T2RF
not as commonly used

60
Q

Contraindications for Starting NIV

A

Facial burns
Vomiting
Untreated pneumothorax
Severe co-morbidities
Haemodynamically unstable
Patient refusal

61
Q

Inclusion Criteria for Starting NIV

A

Patient awake and able to protect airway
Co-operative patient
Consideration of quality of life of patient

62
Q

Mechanical Ventilation

A

other forms of respiratory support (e.g., oxygen and NIV) are inadequate/ contraindicated.
used to move air into and out of the lungs. Patients generally require a level of sedation , as it can be uncomfortable/ distressing.
endotracheal tube (ETT) or tracheostomy is required to connect the ventilator to the lungs

63
Q

Extracorporeal Membrane Oxygenation (level 3)

A

most extreme form of respiratory support and is very rarely used.
used where respiratory failure is not adequately managed by intubation and ventilation
Blood is removed from the body, passed through a machine where oxygen is added and carbon dioxide is removed, then pumped back into the body.

64
Q

medications that should continue before surgery include

A

antiepileptics, Parkinson’s medications, asthma inhalers, beta-blockers, proton pump inhibitors, thyroid medications, steroids, immunosuppressants and cancer drugs.

65
Q

medications that should be stopped include

A

ACE inhibitors, angiotensin-II receptor antagonists, diuretics, antiplatelet/anticoagulant medication, lithium and nonsteroidal anti-inflammatory drugs, coco

Medicine (72 decks)

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