anaesthetics Flashcards

Question

uses etomidate

Answer 1

Trauma/head injury to avoid brief hypotension Lowest incidence of hypersensitivity reactions

Answer 2

Adreno-cortical suppression , high incidence of PONV

Answer 3

Maintenance agents Often inhalational Isoflurane, sevoflurane, desflurane, enflurane Propofol infusion in TIVA

Answer 4

Sevoflurane: Most common inhalational induction, Good for paeds (sweet smell). risk addiction Desflurane: Long operations, Surgery in obese. CV depressant Isoflurane: organ transplants. Irritant: coughing, laryngospasm, breath holding

Answer 5

Preoxygenation Opioid Induction agent Inhalational agent Bag valve mask ventilation Muscle relaxant Endotracheal intubation

Answer 6

Reduces risk of aspiration Preoxygenation Sellick’s manoeuvre Induction then immediately muscle relaxant Classic: thiopentone + suxamethonium

Answer 7

Stop anaesthetic vapours Give oxygen Throat suction Reverse muscle relaxation Once breathing: inspect mouth, remove ET tube, O2 by facemask Recovery

Answer 8

Patient: female, previous PONV, anxious, motion sickness, non-smoker, obesity Anaesthesia: opiates, etomidate, NO2, volatile agents, dehydration Surgery: laparotomy, gynae, abdo, neuro, ENT, eye

Answer 9

Intra-op antiemetics: Ondansetron 4-8mg, dexamethasone 4-8mg Post-op antiemetics: Cyclizine 50mg TDS Acupuncture point P6

Answer 10

Tissue infiltration: around incision Peripheral nerve block: e.g. femoral Plexus block: e.g. brachial Epidural/spinal Topical: EMLA (eutectic mixture of LA, 1:1) Mucosal: ENT procedures

Answer 11

lidocaine: 3mg/kg without adrenaline, 7 with bupivocaine: 2mg/kg without adrenaline, 2 with prilocaine: 6mg/kg without adrenaline, 9 with

Answer 12

Stop injecting LA HELP A: maintain airway, ?ET tube B: 100% oxygen, adequate lung ventilation C: IV access, haemodynamic stability D: control seizures (benzos/thiopentone/propofol) E: intralipid

Answer 13

small vol directly into CSF 5-10 mins onset dense block anaesthesia duration 2-3h, analgesia duration longer

Answer 14

Total spinal block, urinary retention, permanent neurological damage (v rare)

Answer 15

Anticoagulant states, local sepsis, shock, hypovolaemia, raised ICP, fixed output (aortic stenosis), unwilling patient Neurological disease (if procedure blamed for change in state), ischaemic heart disease, spinal deformity, bowel perforation

Answer 16

larger vol as must cross dura leave catheter in 15-30 mins onset less dense duration titratable for 72h

Answer 17

Dural puncture, headache, total spinal block, epidural haematoma/abscess

Answer 18

Severe asthma, COPD, hypoventilation

Answer 19

Hyperventilation, panic attack, aspiring poisoning

Answer 20

DKA, lactic acidosis, salicylate poisoning

Answer 21

Loss of acid (severe vomiting), NG drainage

Answer 22

4% body wt lost loss skin turgor dry mucous membranes

Answer 23

5-8% body wt lost oliguria tachycardia, hypotension

Answer 24

>8% body wt lost profound oliguria CVS collapse

Answer 25

NaCl, dextrose, dex-saline, Hartmann’s

Answer 26

can infuse rapidly, readily available, cheap

Answer 27

overperfusion pulmonary oedema

Answer 28

Gelofusion, starches (voluven, volulyte,) albumin, blood

Answer 29

fluid stays in circulation if capillary membrane normal

Answer 30

no oxygen carrying capacity, ?anaphylaxis

Answer 31

Level 0: normal ward, obs 4 hourly Level 1: risk of deteriorating, recently discharged from higher levels Level 2: single organ support Level 3: advanced respiratory support (invasive ventilation) OR support of 2+ organs

Answer 32

7-15mmHg If >25mmHg small volume increase raises ICP a lot

Answer 33

cerebral perfusion pressure / cerebrovascular resistance

Answer 34

mean arterial pressure – intracranial pressure

Answer 35

Headache: worse in morning, coughing, bending down Vomiting: without nausea Eyes: papilloedema, dilated pupils, impaired eye movements Cushing’s triad: increased systolic BP, bradycardia, Cheyne-Stokes respiration Personality/behaviour changes Children: bulging fontanelle, increased head circumference, high pitched cry, cranial suture separation

Answer 36

The needle goes into CSF THROUGH ligaments AND dura Local anaesthetic is injected as a bolus, which lasts around 2 hours

Answer 37

The needle goes BETWEEN ligaments AND dura And a catheter is passed Local anaesthetic can be given through the catheter as an infusion

Answer 38

Only allow you to operate below the highest nerve root affected by the block Which normally means below the T10 dermatome (below the umbilicus)

Answer 39

Immediate onset|15 minutes duration Small procedures – laceration repair, chest drains, big cannulae

Answer 40

lidocaine bupivicaine

Answer 41

Regional, spinal & epidural 10 minute onset 2 hours anaesthesia|12-24 analgesia

Answer 42

Reduce anxiety (anxiolysis) Reduce consciousness Reduce irritability (of the airway) Induce amnesia

Answer 43

IV Midazolam Endoscopy Regional anaesthesia

Answer 44

Infusions: IV propofol +/- alfentanil Intensive care Intubated patients for theatre or transfer

Answer 45

propofol thiopenthal - quick, used in emergencies ketamine - used in CVS instability

Answer 46

Cuffed tube below the vocal cords to create a seal and prevent aspiration correctly positioned ET tube or tracheostomy

Answer 47

type 1 RF (low or normal CO2)

Answer 48

T2RF (high CO2)

Answer 49

This is caused by a problem of Inadequate Oxygenation This is due to Alveolar Collapse eg pneumonia Or Fluid in the alveoli eg left heart failure

Answer 50

Continuous Positive Airway Pressure Maintains a minimum airway pressure In disease: Alveolar collapse occurs OR Fluid fills the lungs With CPAP: Alveolus is held open AND/OR Fluid is forced out of the lung

Answer 51

Inadequate ventilation Instead of normal lung expansion Alveolar expansion is limited eg COPD, muscular dystrophy

Answer 52

biphasic/Bilevel Positive Airway Pressure Type 2 RF - inadequate ventilation, Insufficient alveolar expansion As inspiration occurs, BiPAP adds further INSPIRATORY PRESSURE (IPAP) Further expanding the lung This increases lung expansion and ventilation

Answer 53

Pressure increases Target volume reached Ventilator stops Expiration occurs

Answer 54

Pressure constant Target time reached Ventilator stops Expiration occurs

Answer 55

mainly thetres

Answer 56

mainly ITU-protects lungs from too high pressure

Answer 57

the opening to the trachea (the glottis) is relaxed for intubation muscles are relaxed enough for surgery patients do not ‘fight’ ventilators

Answer 58

Routine anaesthesia 120-180s onset Atracurium, rocunorium, vecuronium COMPETITIVELY INHIBIT ACh

Answer 59

Emergencies 30s onset Suxamethonium – only example (non-competitive): binds, Causes contraction, Then keeps pore open, Preventing further contraction

Answer 60

Atropine Glycopyrrolate Treat bradycardia Common under anaesthesia

Answer 61

Dobutamine ITU Used in heart failure

Answer 62

stimulate α receptors Which are found in peripheral vessels Causing vasoconstriction Which increases BP (via systemic vascular resistance)

Answer 63

Peripheral Via cannula: Phenylephrine, Metaraminol Or Central Via central line Noradrenaline

Answer 64

You can give a combined α & β agonist e.g. ephedrine

Answer 65

Hartmann’s Saline

Answer 66

A ‘vascath’ is a large bore catheter we insert into a central vein The filter extracts blood, filters it and puts it back uses: fluid overload, metbolic, uraemia, posioning, hyperkalaemia

Answer 67

Mild: Paracetamol, NSAID Moderate: Codeine,Tramadol Severe: Morphine

Answer 68

liver faiilure elderly

Answer 69

inhibit cyclo-oxygenase (COX) which is involved in prostaglandin synthesis (invovled in peripheral inflammation)

Answer 70

Peptic ulcers Acute kidney injury Blood-thinning

Answer 71

It inhibits thromboxane A2 (a prostaglandin) This stops platelet aggregation (hence ‘blood-thinner’)

Answer 72

sedation miosis hypotension bradycardia reduced RR/apnoea N+V constipation urinary retention itching

Answer 73

5HT3 receptor - works on serotonin

Answer 74

H1 - orks on histamine

Answer 75

travel sick post op can cause tachycardia if administer quick

Answer 76

on dopamine - D2

Answer 77

post op N+V

Answer 78

Vomiting after acute opioid administration

Answer 79

rapid onset, depresses airway reflexes, apnoea common

Answer 80

slow, irritates airay, usually keep breathing

Answer 81

weak: Codeine, Tramadol strong: Morphine, Oxycodone, Methadone, Buprenorphine modified release: Fentanyl patch, Morphine Sulphate tablets, Oxycontin

Answer 82

Ultrashort acting with rapid onset/offset Metabolised differently to other opioids Very wide therapeutic index Infusion only

Answer 83

prodrug (needs metabolising) Broken down to morphine Contraindicated in children Oral or IM -- NOT intravenous

Answer 84

Acts on numerous receptors Noradrenaline Opioid Serotonin Oral or intravenous

Answer 85

For minor superficial surgery (e.g. ophthalmic or minor dental procedures) warfarin may not need to be omitted (however guidelines vary, so always consult local guidance). For all other surgical interventions, the last dose of warfarin should be given 6 days before the procedure. For emergency surgery or surgery where warfarin was not omitted, check INR and consider reversal with Vitamin K or other agents according to procedure and timeframe. This needs to be discussed with the surgical and anaesthetic team involved in the case. “Bridging therapies” refers to the use of alternative anticoagulation therapy, such as short-acting low molecular weight heparin (LMWH), during the pre- and immediately postoperative period. Your hospital trust will have a protocol on this.

Answer 86

Unfractionated heparin is short-acting and normally given via IV infusion. It must be stopped 4 hours before neuraxial block with evidence of a normal APTT. LMWH is longer acting and administered subcutaneously. Following “prophylactic dose LMWH”, a neuraxial block cannot be performed for 12 hours. Following “treatment dose LMWH”, this is increased to 24 hours.

Answer 87

Rivaroxaban clearance is dependent on dose and renal function: Prophylactic dose with creatinine clearance >30ml/min – 18 hours before neuraxial block. Treatment dose with creatinine clearance >30ml/min – 48 hours before neuraxial block Dabigatran – wait 48 hours before neuraxial block Apixaban – wait 48 hours before neuraxial block

Answer 88

Aspirin, dipyridamole and NSAIDs can be continued as per patient’s usual prescription unless there are confounding factors such as deteriorating renal function. Clopidogrel causes irreversible platelet inhibition and therefore should be stopped 7 days before surgery and/or neuraxial intervention.

Answer 89

angiotensinogen converting enzyme (ACE) inhibitors should be withheld on the morning of major surgery. If unsure, contact the anaesthetic team. Beta-blockers should be continued as per the patient’s normal prescription unless otherwise instructed. Patients on digoxin will need an ECG and blood tests to exclude hypokalaemia.

Answer 90

Patients should continue their normal anticonvulsant therapies unless otherwise indicated.

Answer 91

Oral hypoglycaemic agents such as metformin should be omitted on the day of surgery. It is important the surgical and anaesthetic teams are aware of diabetic patients listed for surgery as they will need to be first on the operative list to minimise the starvation period. Diabetic patients that will be missing more than one meal due to fasting and operative time should be considered for insulin-dextrose sliding scale therapy during the perioperative period.

Answer 92

Patients who take more than 5mg prednisolone daily will need supplementary steroids during the perioperative period. Dose and duration are dependent on normal steroid regimen and severity of the surgery. See BNF guidelines for more information. The anaesthetist should be made aware of patients requiring additional peri-operative steroid treatment.

Answer 93

The oral contraceptive pill (OCP) can increase the risk of deep vein thrombosis (DVT) in patients who will be immobile post-op. The OCP should, therefore, be stopped in this patient group, or if not possible, additional measures to ensure adequate venous thromboembolism (VTE) prophylaxis should be considered. The same is true of some hormone replacement therapies. Tamoxifen is used in the management of breast cancer and should only be stopped if the risk of VTE outweighs the risk of interrupting treatment.

Answer 94

Monoamine oxidase inhibitors (MAOi) can have dangerous interactions with certain anaesthetic drugs. If a patient is on a MAOi, it is essential that the anaesthetist responsible for the patient at the time of surgery is informed. Patients taking lithium should have a lithium level and U&Es checked, along with TFTs before proceeding to surgery.

Answer 95

Herbal medications such as St John’s Wort and ephedra should be stopped 2 weeks before surgery.

Answer 96

Analgesics Paracetamol and codeine are given for their analgesic effects during surgery. NSAIDs are given if there are no patient or surgical contraindications. Antacids Ranitidine or omeprazole can be given to minimise stomach acid and reduce the risk of aspiration during induction. Anxiolytics Anxious patients, or patients requiring procedures pre-operatively such as peripheral nerve blocks or invasive line insertions, can be given anxiolytic medications such as midazolam. This is done at the discretion of the anaesthetist. Anti-sialagogue Occasionally patients will be given medication such as glycopyrrolate to reduce oral secretions prior to airway instrumentation.

Answer 97

An ECG: >80 y/o, >60y/o and surgical severity >3, Cardiovascular or renal disease FBC: If > 60y/o and surgical severity >2 All adults with surgical severity >3, Severe renal disease U&Es and creatinine: > 60y/o and surgical severity >3, All adults with surgical severity >4, Renal disease, Severe cardiovascular disease Sickle cell test: Families with homozygous disease or heterozygous trait Pregnancy test - Should be performed in all women of reproductive age. Baseline CXR: Should be performed for all patients scheduled for post-op critical care admission. Cardiopulmonary exercise testing (CPET) CPET is useful for assessing cardiovascular and respiratory functional capacity.

Answer 98

This can be difficult to assess on the day of surgery as pre-op nerves can raise blood pressure. If a patient’s BP is greater than 180mmHg systolic or 110mmHg diastolic on the day of surgery, the operation should be postponed until hypertension is under control. Inform the GP as BP management should be done in partnership with primary care. The patient’s BP needs to be 160/100 mmHg or lower in the community prior to the operation.

Answer 99

Anaemia (Hb <13g/dL in men AND women) necessitates further investigation. An anaemic patient requires investigation and optimisation before surgery to avoid peri-operative blood transfusion. Your trust should have guidelines on investigation and management of anaemia, but thorough history, examination and haematinics are a good place to start. Inform the patient’s GP and ensure they are involved in any further investigations and treatment decisions

Answer 100

Grade 1 – diagnostic endoscopy, laparoscopy, breast biopsy Grade 2 – inguinal hernia, varicose veins, adenotonsillectomy, knee arthroscopy Grade 3 – total abdominal hysterectomy, TURP, thyroidectomy Grade 4 – total joint replacement, artery reconstruction, colonic resection, neck dissection

Answer 101

Good preparation for surgery (e.g., healthy diet and exercise) Minimally invasive surgery (keyhole or local anaesthetic where possible) Adequate analgesia Good nutritional support around surgery Early return to oral diet and fluid intake Early mobilisation Avoiding drains and NG tubes where possible, early catheter removal Early discharge

Answer 102

involves an intravenous infusion of a strong opiate (e.g., morphine, oxycodone or fentanyl) attached to a patient-controlled pump. This involves the patient pressing a button as pain starts to develop, for example during a contraction in labour, to administer a bolus of this short-acting opiate medication. The button will stop responding for a set time after administering a bolus to prevent over-use. Only the patient should press the button (not a nurse or doctor). Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, antiemetics for nausea, and atropine for bradycardia. The anaesthetist may prescribe background opiates (e.g., patches) in addition to a PCA, but avoid other “as required” opiates whilst a PCA is in use. The machine is locked to prevent tampering.

Answer 103

Female History of motion sickness or previous PONV Non-smoker Use of postoperative opiates Younger age Use of volatile anaesthetics

Answer 104

Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval Dexamethasone (corticosteroid) – used with caution in diabetic or immunocompromised patients Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patient

Answer 105

Ondansetron (5HT3 receptor antagonist) – avoid in patients at risk of prolonged QT interval Prochlorperazine (dopamine (D2) receptor antagonist) – avoid in patients with Parkinson’s disease Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patients Some local guidelines also refer to the P6 acupuncture point on the inner wrist. There is evidence that pressure to this area can reduce nausea.

Answer 106

Anaemia Atelectasis is where a portion of the lung collapses due to under-ventilation Infections (e.g., chest, urinary tract or wound site) Wound dehiscence is where there is separation of the surgical wound, particularly after abdominal surgery Ileus is where peristalsis in the bowel is reduced (typically after abdominal surgery) Haemorrhage with bleeding into a drain, inside the body creating a haematoma or from the wound Deep vein thrombosis and pulmonary embolism Shock due to hypovolaemia (blood loss), sepsis or heart failure Arrhythmias (e.g., atrial fibrillation) Acute coronary syndrome (myocardial infarction) and cerebrovascular accident (stroke) Acute kidney injury Urinary retention requiring catheterisation Delirium refers to fluctuating confusion and is more common in elderly and frail patients

Answer 107

6 hours of no food or feeds before the operation 2 hours of no clear fluids (fully “nil by mouth”) - now sip till send

Answer 108

Hypnosis Muscle relaxation Analgesia

Answer 109

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

Answer 110

Volatile anaesthetics (isoflurane, sevoflurane and desflurane) Suxamethonium There are genetic mutations that increase the risk of malignant hyperthermia. These are inherited in an autosomal dominant pattern.

Answer 111

Increased body temperature (hyperthermia) Increased carbon dioxide production Tachycardia Muscle rigidity Acidosis Hyperkalaemia

Answer 112

dantrolene. Dantrolene interrupts the muscle rigidity and hypermetabolism by interfering with the movement of calcium ions in skeletal muscle.

Answer 113

Adverse effects: 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, including meningitis Haematoma (may cause spinal cord compression) When used for analgesia in labour, the risks include: Prolonged second stage Increased probability of instrumental delivery

Answer 114

Step 1: Non-opioid medications such as paracetamol and NSAIDs Step 2: Weak opioids such as codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors) Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine Other medications may be combined with the analgesic ladder for additional effect (called adjuvants) or used separately to manage neuropathic pain. These are: Amitriptyline – a tricyclic antidepressant Duloxetine – an SNRI antidepressant Gabapentin – an anticonvulsant Pregabalin – an anticonvulsant Capsaicin cream (topical) – from chilli peppers

Answer 115

Gastritis with dyspepsia (indigestion) Stomach ulcers Exacerbation of asthma Hypertension Renal impairment Coronary artery disease, heart failure and strokes (rarely)

Answer 116

Asthma Renal impairment Heart disease Uncontrolled hypertension Stomach ulcers

Answer 117

Constipation Skin itching (pruritus) Nausea Altered mental state (sedation, cognitive impairment or confusion) Respiratory depression (usually only with larger doses in opioid-naive patients)

Answer 118

Following major surgery (e.g., aortic aneurysm repair) Severe sepsis Major trauma Following cardiopulmonary resuscitation Organ failure (acute respiratory, renal or liver failure)

Answer 119

Ventilator-associated lung injury Ventilator-associated pneumonia Catheter-related bloodstream infections (e.g., from central venous catheters) Catheter-associated urinary tract infections Stress-related mucosal disease (erosion of the upper gastrointestinal tract): Damage to the stomach mucosa occurs mainly due to impaired blood flow. It increases the risk of upper gastrointestinal bleeding Delirium Venous thromboembolism Critical illness myopathy: muscle wasting and weakness during critical illness Critical illness neuropathy: degeneration of the sensory and motor nerve axons

Answer 120

Normal pCO2 with low PaO2 indicates

Answer 121

Raised pCO2 with low PaO2

Answer 122

Low pH (acidosis) with a raised PaCO2 indicates a respiratory acidosis. This suggests the patient is acutely retaining CO2 (unable to get rid of it), and their blood has become acidotic. Raised bicarbonate indicates that the patient chronically retains CO2. Their kidneys have responded by producing additional bicarbonate to balance the acidic CO2 and maintain a normal pH. This is usually seen in patients with chronic obstructive pulmonary disease (COPD). In an acute exacerbation of COPD, the kidneys cannot keep up with the rising level of CO2, so the patient becomes acidotic despite having higher bicarbonate than someone without COPD.

Answer 123

hyperventilation syndrome (e.g., due to anxiety) and patients with a pulmonary embolism. Patients with a PE will have a low PaO2, whereas patients with hyperventilation syndrome will have a high PaO2

Answer 124

Raised lactate – lactate is released during anaerobic respiration (indicating tissue hypoxia) Raised ketones – typically in diabetic ketoacidosis Increased hydrogen ions – due to renal failure, type 1 renal tubular acidosis or rhabdomyolysis Reduced bicarbonate – due to diarrhoea (stools contain bicarbonate), renal failure or type 2 renal tubular acidosis

Answer 125

Metabolic alkalosis results from the loss of hydrogen (H+) ions. Hydrogen ions can be lost from: Gastrointestinal tract – due to vomiting (the stomach produces hydrochloric acid) Kidneys – usually due to increased activity of aldosterone, which results in hydrogen ion excretion Increased activity of aldosterone can be due to: Conn’s syndrome (primary hyperaldosteronism) Liver cirrhosis Heart failure Loop diuretics Thiazide diuretics

Answer 126

Nasal cannula: 24 – 44% oxygen Simple face mask: 40 – 60% oxygen Venturi masks: 24 – 60% oxygen Face mask with reservoir (non-rebreather mask): 60 – 95% oxygen

Answer 127

CPAP (continuous positive airway pressure) involves a constant 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 (adding positive end-expiratory pressure), for example, in obstructive sleep apnoea. CPAP does not technically involve “ventilation”, as it provides constant pressure and the job of ventilation is still dependent on the respiratory muscles. Therefore, CPAP is not technically classed as non-invasive ventilation (NIV).

Answer 128

Non-invasive ventilation (NIV) involves using a full face mask, hood (covering the entire head) or a tight-fitting nasal mask to blow air forcefully into the lungs and ventilate them. It is not pleasant for the patient but is much less invasive than intubation and ventilation. It is a valuable middle-point between basic oxygen therapy and mechanical ventilation. BiPAP is a specific machine that provides NIV. BiPAP stands for Bilevel Positive Airway Pressure. Generally, the term NIV is used instead of BiPAP, as BiPAP refers to a specific machine rather than the therapy. NIV involves a cycle of high and low pressure to correspond to the patient’s inspiration and expiration: IPAP (inspiratory positive airway pressure) is the pressure during inspiration – where air is forced into the lungs EPAP (expiratory positive airway pressure) is the pressure during expiration – stopping the airways from collapsing

Answer 129

Positive inotropes act to increase the contractility of the heart. This increases cardiac output (CO) and mean arterial pressure (MAP). They are used in patients with a low cardiac output, for example, due to heart failure, recent myocardial infarction or following heart surgery. Most positive inotropes are catecholamines. Catecholamines stimulate the sympathetic nervous system via alpha and beta-adrenergic receptors. Examples of positive inotropes that are catecholamines are: Adrenaline Dobutamine Isoprenaline Noradrenaline (weak inotrope and mostly a vasopressor) Dopamine (not an inotrope at lower infusion rates)

Answer 130

Negative inotropes act to reduce the contractility of the heart. Examples are: Beta-blockers Calcium channel blockers Flecainide

Answer 131

Vasopressors are medications that cause vasoconstriction (narrowing of blood vessels). This increases the systemic vascular resistance and consequently mean arterial pressure (MAP). Vasopressors are commonly used by anaesthetists as a bolus dose or in ICU as an infusion to improve patient’s blood pressure and, therefore, tissue perfusion. Severe sepsis is a common example of a condition where they may be used. Common vasopressors are: Noradrenaline (given as an infusion via a central line) Vasopressin (given as an infusion via a central line) Adrenaline (given as an infusion via a central line or as a bolus in an emergency) Metaraminol (given as a bolus or an infusion) Ephedrine (given as a bolus) Phenylephrine (given as a bolus or an infusion)

Answer 132

Glycopyronium is an antimuscarinic medication used to treat bradycardia, often during operations. Antimuscarinic medication work by blocking acetylcholine receptors. Atropine is another antimuscarinic medication used to treat bradycardia.

Answer 133

Vascular Infective or inflammation Trauma Autoimmune Metabolic Iatrogenic/idiopathic Neoplasic

Answer 134

a life-threatening, generalised form of acute circulatory failure with inadequate oxygen delivery to, and consequently oxygen utilisation by, the cells leading to cellular hypoxia

Answer 135

anaphylactic septic hypovolaemic neurogenic cardiogenic

Answer 136

An isotonic fluid should be used for fluid resuscitation. This usually means a choice of either: 0.9% saline Hartmann’s solution Plasma-Lyte 148 An ABCDE assessment of the patient is used to determine their fluid status. Signs such as hypotension, tachycardia and prolonged capillary refill time indicate the need for fluid resuscitation (see above for a full list). Establish the underlying cause of the hypovolaemia (e.g., sepsis). The NICE guidelines suggest: An initial 500 ml fluid bolus over 15 minutes (“stat”), followed by reassessment with an ABCDE approach Repeat boluses of 250 – 500 mls of fluid if required, each time followed by a reassessment Seek expert help if the patient is not responding, particularly after 2 litres of fluid

Answer 137

the value of the mean arterial pressure is normally derived from the systolic blood pressure and diastolic blood pressure of the patient. The mean arterial pressure is often used for the indication of the blood flow, being considered a more faithful and accurate measurement than the systolic blood pressure Diastolic + ⅓(systolic - diastolic) Less than 60is bad =organ dysfunction Less than 50 = blood not reaching brain

Answer 138

1= breathless on strenuous exercise 2=slight hill 3=on flat 4= less than 100m 5= daily activities

Answer 139

The WHO performance status classification categorises patients as: 0: able to carry out all normal activity without restriction 1: restricted in strenuous activity but ambulatory and able to carry out light work 2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours 3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden 4: completely disabled; cannot carry out any self-care; totally confined to bed or chair. METS 1= existing 4= housework >4= walk up 2 flights stairs without stopping. ENOUGH FOR MOST OPERATIONS 7=Cycle/golf/ Walk 4mph Over 7= Jogging

Answer 140

for obstructive sleep apnoea STOP BANG SCORE: do you snore loudly(can hear through closed door) tired/fatigue/sleepy in day, observed stop breathing in sleep, HTN, BMI>35, age >50, neck circumference >40cm, male Score 4 or more needs investigations - sleep studies (monitor sats and ECG/BP), Epworth sleepiness scale

Answer 141

Patients with adrenal atrophy resulting from long-term corticosteroid use may suffer a precipitous fall in blood pressure unless corticosteroid cover is provided during anaesthesia and in the immediate postoperative period. Anaesthetists must therefore know whether a patient is, or has been, receiving corticosteroids (including high-dose inhaled corticosteroids). Follow sick day rules and increase dose due to stress of surgery Over 10mg/day regular will need acute supplementation (additional steroid cover): usually give IM hydrocortisone on day of surgery, TDS hydrocortisone first 24hr then increase normal steroids 10-20% for approx 3w. If mild op may just need single bolus IM. for significant e.g. knee replacement need at least 24h IM supplementation

Answer 142

Don't give first dose LMWH - dalt until 6hrs after epidural. Don't take epidural out until more than 24hrs last dose If on treatment dose dalterparin need to wait 24h to remove

Answer 143

should raise the hemoglobin of an average adult by 1 g/dL (10 g/l)and the hematocrit by 3%

Answer 144

Major haemorrhage is variously defined as: Loss of more than one blood volume within 24 hours (around 70 mL/kg, >5 litres in a 70 kg adult), 50% of total blood volume lost in less than 3 hours, Bleeding in excess of 150 mL/minute.

Answer 145

Thrombocytopenia Hypothermia Dilution coag factors Electrolyte imbalance -k and ca Acid base disturbance Vol overload Oxygen affinity reduced Transfusion associated lung injury

Answer 146

Duke Activity Status Index (DASI), Estimates functional capacity. The higher the score (maximum 58.2), the higher the functional status Take care of self e.g. eating, dressing, bathing, using the toilet Walk indoors Walk 1–2 blocks on level ground Climb a flight of stairs or walk up a hill Run a short distance Do light work around the house e.g. dusting, washing dishes Do moderate work around the house e.g. vacuuming, sweeping floors, carrying in groceries Do heavy work around the house e.g. scrubbing floors, lifting or moving heavy furniture Do yardwork e.g. raking leaves, weeding, pushing a power mower Have sexual relations Participate in moderate recreational activities e.g. golf, bowling, dancing, doubles tennis, throwing a baseball or football Participate in strenuous sports e.g. swimming, singles tennis, football, basketball, skiing

Answer 147

Consider resting echocardiography if the person has: * a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or * signs or symptoms of heart failure. Before ordering the resting echocardiogram, carry out a resting electrocardiogram (ECG) and discuss the findings with an anaesthetist Normal ejection fraction 60-70%

Answer 148

Current NICE guidelines recommend a restrictive haemoglobin concentration threshold of 70 g/L for those who need red blood cell transfusions (without any major haemorrhage or acute coronary syndrome) and a haemoglobin concentration target of 70-90 g/L after transfusion Maybe sooner as HF should have higher threshold

Answer 149

a globular protein complex involved in muscle contraction. It occurs with tropomyosin in the thin filaments of muscle tissue T and I Sensitive to myocardium

Answer 150

If rises muscle is damaged Cardiac causes; MI Congestive heart failure, acute or chronic Stable coronary artery disease Myocarditis (and endocarditis, pericarditis) Tachy- or bradyarrhythmias, or heart block Hypertension Cardiac contusion/trauma including surgery, ablation, pacing Aortic dissection Aortic valve disease Hypertrophic cardiomyopathy Non cardiac: PE, severe pulmonary hypertension Renal failure COPD Diabetes Acute neurological event Drugs and Toxins

Answer 151

Eye-opening spontaneously=4 points Eye-opening to sound=3 points Eye-opening to pain=2 points No response=1 point Orientated=5 points Confused conversation=4 points Inappropriate words=3 points Incomprehensible sounds=2 points No response=1 point Obeys command=6 points Localises to pain=5 points Withdraws to pain=4 points Flexion decorticate posture=3 points Abnormal extension decerebrate posture=2 points No response=1 point

Answer 152

IM glucagon 1mg Hypoglycaemia which causes unconsciousness is an emergency. Patients who are unconscious, having seizures, or who are very aggressive, should have any intravenous insulin stopped, and be treated initially with glucagon. If glucagon is unsuitable, or there is no response after 10 minutes, glucose 10% intravenous infusion, or alternatively glucose 20% intravenous infusion should be given. Glucose 50% intravenous infusion is not recommended as it is hypertonic, thus increases the risk of extravasation injury, and is viscous, making administration difficult. A long-acting carbohydrate should be given as soon as possible once the patient has recovered and their blood-glucose concentration is above 4 mmol/litre (e.g. two biscuits, one slice of bread, 200–300 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due). Patients who have received glucagon require a larger portion of long-acting carbohydrate to replenish glycogen stores (e.g. four biscuits, two slices of bread, 400–600 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate containing meal if due). Glucose 10% intravenous infusion should be given to patients who are nil by mouth. Adults with symptoms of hypoglycaemia who have a blood-glucose concentration greater than 4 mmol/litre, should be treated with a small carbohydrate snack such as a slice of bread or a normal meal, if due. Any patient with a blood-glucose concentration less than 4 mmol/litre, with or without symptoms, and who is conscious and able to swallow, should be treated with a fast-acting carbohydrate by mouth. Fast-acting carbohydrates include Lift® glucose liquid (previously Glucojuice®), glucose tablets, glucose 40% gels (e.g. Glucogel®, Dextrogel®, or Rapilose®), pure fruit juice, and sugar (sucrose) dissolved in an appropriate volume of water. Hypoglycaemia which does not respond (blood-glucose concentration remains below 4 mmol/litre after 30–45 minutes or after 3 treatment cycles), should be treated with intramuscular glucagon or glucose 10% intravenous infusion. In alcoholic patients, thiamine supplementation should be given with, or following, the administration of intravenous glucose to minimise the risk of Wernicke's encephalopathy

Answer 153

exogenous drugs (alcohol, insulin sylphoylureas), pituitary insufficiency, liver failure, Addison, islet cell tumour and immune hypoglycaemia, non pancreatic neoplasm, malaria with quinine

Answer 154

is an airway management technique that produces inducing immediate unresponsiveness (induction agent) and muscular relaxation (neuromuscular blocking agent) and is the fastest and most effective means of controlling the emergency airway

Answer 155

INR > 3.0 Plasma creatinine > 200 micromol/L Blood pH < 7.3 Signs of encephalopathy (mental confusion, drowsiness, spatial disorientation, asterixis) Discuss with quaternary liver center: clotting, acidotic, encephalopathy

Answer 156

nacetylcysteine

Answer 157

Anticoagulants need to be stopped before major surgery. The INR can be monitored in patients on warfarin to ensure it returns to normal before the operation. Warfarin can be rapidly reversed with vitamin K in acute scenarios. Treatment dose low molecular weight heparin or an unfractionated heparin infusion may be used to bridge the gap between stopping warfarin and surgery in higher-risk patients (e.g., mechanical heart valves or recent VTE), and stopped shortly before surgery depending on the risk of bleeding and thrombosis. DOACs (e.g., apixaban, rivaroxaban or dabigatran) are stopped 24-72 hours before surgery depending on the half-life, procedure and kidney function.

Answer 158

Oestrogen-containing contraception (e.g., the combined contraceptive pill) or hormone replacement therapy (e.g., in perimenopausal women) need to be stopped 4 weeks before surgery to reduce the risk of venous thromboembolism (NICE guidelines 2010).

Answer 159

Ramipril: Angiotensinogen converting enzyme (ACE) inhibitors should be withheld on the morning of major surgery. Now changed so take on morning (varies between hospital) Don't take Sartans on the morning

Answer 160

Oral hypoglycaemic agents such as metformin should be omitted on the day of surgery. It is important the surgical and anaesthetic teams are aware of diabetic patients listed for surgery as they will need to be first on the operative list to minimise the starvation period. Diabetic patients that will be missing more than one meal due to fasting and operative time should be considered for insulin-dextrose sliding scale therapy during the perioperative period. SGLT2 inhibitors are oral glucose lowering medications which include DAPAGLIFLOZIN, CANAGLIFLOZIN and EMPAGLIFLOZIN. These agents can cause EUGLYCAEMIC DIABETIC KETOACIDOSIS in fasted patients undergoing major surgery. They should therefore be STOPPED one week before the date of surgery long acting insulin some say stop and just have VRIII, some say continue long acting with VRIII

Answer 161

T2DM: no VRII if operated on first - will be only missing 1 meal (breakfast), Unless bm over 12 T1DM: VRII: intravenous insulin infusion of a variable rate according to regular capillary blood glucose measurements with the aim of controlling serum glucose levels within a specified range. The VRIII is usually accompanied by an infusion of fluid containing glucose to prevent insulin-induced hypoglycaemia.5% Dextrose with 20/40mmol/l KCL at 125ml/hr if serum k is 3.5-5.5mmol/l If BM over 10 deliver with saline, under with glucose containing fluid

Answer 162

Stress response: Increased levels of cortisol, catecholamines, glucagon, GH and increased gluconeogenesis and glycogenolysis

Answer 163

Raises risk of surgical site infection, poor wound healing, deranged u and es - k, dehydration, myocardial infarction and stroke

Answer 164

Diabetic meds: Target blood glucose is 6-10 for all patients although (4-11) is acceptable. Random venous glucose and UEC to be checked prior to procedure. Check BM in morning and then 1 hourly during procedure and 2 hourly during recovery phase in first 24 hours. (This may be done 4 hourly if patient is stable and all BMs <10) If random glucose or BM>11 commence VRIII. Note that serum potassium and renal function must be monitored at 12 hours and thereafter at least every 24 hours or more frequently (if abnormal) for patients on intravenous insulin. Restart usual medications when able to take normal oral diet - less of a rush for T2DM. If type 1 don't stop sliding scale until normql insulin resumed

Answer 165

Ketoneaemia >3mmol/l or ketouria >2 on stick Blood glucose >11mmol/l Venous bicarbonate below 15mmol/l or venous pH less than 7.3 Hyperglycemia, ketosis, acidosis

Answer 166

Action 1: Commence 0.9% sodium chloride solution (use a large bore cannula) via an infusion pump - 1l over 60m Action 2: Commence a fixed rate intravenous insulin infusion (FRIII). (0.1unit/kg/hr based on estimate of weight) 50units human soluble insulin (Actrapid® or Humulin S®) made up to 50ml with0.9% sodium chloride solution. If patient normally takes long acting insulin analogue (glargine, detemir, degludec) continue at usual dose and Time

Answer 167

Venous bicarbonate <5 GCS <12 PH <7 ketones >4 Brady or tachycardia

Answer 168

Fluid overload, hyponatraemia, hypokalaemia Cerebral oedema

Answer 169

Mainly hypokalaemia as potassium is needed to transport glucose into cells, having supplementary potassium to IV fluid or using Harttmans which includes potassium whole isotonic saline does not

Answer 170

Hypotension (systolic < 100 mmHg) Tachycardia (heart rate > 90) Capillary refill time > 2 seconds Cold peripheries Raised respiratory rate Dry mucous membranes Reduced skin turgor Reduced urine output Sunken eyes Reduced body weight from baseline Feeling thirsty

Answer 171

Maintenance IV fluids are used for the shortest time possible where the patient is unable to take fluid orally, for example, while nil by mouth waiting for surgery or in bowel obstruction. As soon as they are able to meet their nutritional needs orally, the IV fluids should be stopped. The NICE guidelines give approximate requirements of maintenance IV fluids: 25 – 30 ml / kg / day of water 1 mmol / kg / day of sodium, potassium and chloride 50 – 100 g / day of glucose (this is to prevent ketosis, not to meet their nutritional needs)