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anaesthetics Flashcards

1
Q

components of pre-op assessment

A

History of PC
Surgical, anaesthetic and medical history
Systems review
Drug history and allergies Incl. OTC, OCP, HRT
Social: smoking, weight, exercise tolerance
Examination: Mallampati, Thyromental and sternomental distance, General examination
Cardiovascular: chest pain, palpitations, SOBOE, syncope, orthopnoea, FHx of CVD
Respiratory: SOB, cough, infections, wheeze, asthma, COPD, OSA, smoker
Gastrointestinal: reflux, heartburn, liver/renal disease
Misc: diabetes, CVA, epilepsy, issues with cervical spine/RA/OA

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2
Q

ASA scoring

A
  1. normally healthy
  2. mild systemic disease, no limitation in activity
  3. severe systemic disease, limitation of activity, not incapacitating
  4. incapacitating systemic diseases which poses a threat to life
  5. moribund, not expected to survive 24h even with operation
  6. brain dead patient whose organs are being removed for donor purposes

suffix E denotes emergency

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3
Q

NCEPOD categories

A

1-immediate
2-urgent
3-expedited
4-elective

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4
Q

NCEPOD 1

A

immediate

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5
Q

NCEPOD 1

A

immediate - within minutes
Life/limb/organ saving intervention
Ruptured AAA, control of haemorrhage, coronary angioplasty

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6
Q

NCEPOD 2

A

urgent-hrs
Acute onset/deterioration that threatens life/limb/organ
Debridement and fixation of fracture, bowel perforation

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7
Q

NCEPOD 3

A

EXPEDITED – Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.

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8
Q

NCEPOD 4

A

elective
Planned or booked in advance of hospital admission

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9
Q

food/drink requirements before elective surgery

A

Few sips of water, 30mLs of water with tablets
Clear fluids (incl. black tea/coffee): >2h
Breast milk: >4h
All other (incl. chewing gum/formula/milk): >6h
Alcohol: >24h

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10
Q

type of anaesthesia in emergency surgery

A

rapid sequence induction

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11
Q

common risks anaesthetic

A

Postop nausea and vomiting
Dizziness
Blurred vision
Aches/pains
Bladder problems
Pain on injection of blood
Bruising/soreness/itch
Sore throat, damage to lips
Confusion

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12
Q

uncommon risks anaesthetic

A

Slow breathing
Worsening of existing medical conditions
Chest infection
Muscle pains
Damage to teeth
Awareness during operation

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13
Q

rare risks anaesthetic

A

Damage to eyes
MI, stroke
Serious allergy
Nerve damage
Equipment failure
Death: 5/1 million

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14
Q

reasons surgery is cancelled

A

Current respiratory tract infection
Poor control of drug therapy
Recent MI
Poor bloodwork
Inadequate preparation
Untreated hypertension, uncontrolled AF
Logistical issues

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15
Q

safety checklist for anaesthetic

A

Identity
Procedure
Consent
Equipment check
Site marked
Allergies
Aspiration risk
Anticipated blood loss : >500mL or >7mL/kg if child
Team member introduction
Patient-specific concerns

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16
Q

what does general anaeshtesia do

A

Amnesia
Analgesia
Akinesis

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17
Q

how does general anaesthesia cause akinsesis

A

Movement: action potential at neuromuscular junction releases ACh, depolarises nicotinic receptors, causes muscle contraction

Non-depolarising: atracurium, rocuronium, pancuronium
Depolarising: suxamethonium

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18
Q

how does general anaesthesia cause amnesia

A

Induction: induce loss of consciousness in 1 arm-brain circulation time (IV), 10-20 seconds
Last 4-10 minutes
Propofol, thiopentone, ketamine, etomidate

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19
Q

propofol uses

A

Most commonly used for induction
Total IV anaesthesia
quick
excellent suppression of airway reflexes
decreases PONV

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20
Q

SE/risks/CI propofol

A

pain on injection, apnoea, involuntary movements
egg/soya allergy
compromised airway

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21
Q

thiopentone uses

A

Typical RSI
Anticonvulsant
quick
antiepileptic properties

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22
Q

SE/CI thiopentone

A

Bronchospasm
Intraarterial: thrombosis and gangrene
Barbiturate allergy, Hypovolaemia, Airway obstruction

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23
Q

uses of ketamine

A

Short procedures
Paediatrics
“In the field”
slow
Dissociative anaesthesia
Anterograde amnesia

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24
Q

SE/CI ketamine

A

Nausea and vomiting, emergence phenomenon
Hypertensive, history of stroke/raised ICP/IOP
Psychiatric patients

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25
Q

uses etomidate

A

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

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26
Q

SE/risks etomidate

A

Adreno-cortical suppression , high incidence of PONV

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27
Q

amnesia in general anaesthetic

A

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

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28
Q

inhalational agents for general anaesthesia

A

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

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29
Q

general anesthesia sequence

A

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

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30
Q

rapid sequence induction

A

Reduces risk of aspiration
Preoxygenation
Sellick’s manoeuvre
Induction then immediately muscle relaxant

Classic: thiopentone + suxamethonium

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31
Q

post op mx

A

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

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32
Q

risks post op nausea and vom

A

Patient: female, previous PONV, anxious, motion sickness, non-smoker, obesity

Anaesthesia: opiates, etomidate, NO2, volatile agents, dehydration

Surgery: laparotomy, gynae, abdo, neuro, ENT, eye

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33
Q

prevention post op nausea and vom

A

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

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34
Q

routes of administration for local anaesthetics

A

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

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35
Q

local anaesthetics and doses

A

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

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36
Q

what to do if rxn to local anaesthetics

A

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

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37
Q

total spinal anaesthesia

A

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

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38
Q

risks spinal anaesthesia

A

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

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39
Q

CI spinal anaesthesia/epidural

A

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

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40
Q

epidural anaesthesia

A

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

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41
Q

risks epidural anaesthesia

A

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

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42
Q

resp acidosis causes

A

Severe asthma, COPD, hypoventilation

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43
Q

resp alkalosis causes

A

Hyperventilation, panic attack, aspiring poisoning

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44
Q

metabolic acidosis causes

A

DKA, lactic acidosis, salicylate poisoning

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45
Q

metabolic alklaosis causes

A

Loss of acid (severe vomiting), NG drainage

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46
Q

mild dehydratio

A

4% body wt lost
loss skin turgor
dry mucous membranes

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47
Q

moderate dehydration

A

5-8% body wt lost
oliguria
tachycardia, hypotension

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48
Q

severe dehydration

A

> 8% body wt lost
profound oliguria
CVS collapse

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49
Q

crystalloids

A

NaCl, dextrose, dex-saline, Hartmann’s

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50
Q

benefits crystalloid

A

can infuse rapidly, readily available, cheap

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51
Q

risks crystalloids

A

overperfusion pulmonary oedema

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52
Q

colloids

A

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

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53
Q

pros colloids

A

fluid stays in circulation if capillary membrane normal

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54
Q

risks colloids

A

no oxygen carrying capacity, ?anaphylaxis

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55
Q

HDU/ICU level

A

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

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56
Q

normal ICP

A

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

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57
Q

cerebral blood flow

A

cerebral perfusion pressure / cerebrovascular resistance

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58
Q

cerebral perfusion presure

A

mean arterial pressure – intracranial pressure

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59
Q

features raised ICP

A

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

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60
Q

how does spinal anaesthesia work

A

The needle goes into CSF

THROUGH ligaments AND dura

Local anaesthetic is injected as a bolus, which lasts around 2 hours

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61
Q

how does epidural anaesthesia work

A

The needle goes
BETWEEN ligaments AND dura

And a catheter is passed

Local anaesthetic can be given through the catheter as an infusion

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62
Q

where do spinal and epidural anaesthetic anaesthetise

A

Only allow you to operate below the highest nerve root affected by the block

Which normally means below the T10 dermatome
(below the umbilicus)

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63
Q

lidocaine

A

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

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64
Q

local anesthetic agents

A

lidocaine
bupivicaine

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65
Q

bupivicaine

A

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

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66
Q

reasons sedative drugs are given

A

Reduce anxiety (anxiolysis)

Reduce consciousness

Reduce irritability (of the airway)

Induce amnesia

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67
Q

short term sedaties e.g.

A

IV Midazolam
Endoscopy
Regional anaesthesia

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68
Q

long term sedatives e.g.

A

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

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69
Q

IV hypnotics

A

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

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70
Q

definitive airway

A

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

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71
Q

when is CPAP used

A

type 1 RF (low or normal CO2)

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72
Q

when is BIPAP used

A

T2RF (high CO2)

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73
Q

cause T1RF

A

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

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74
Q

how does CPAP work

A

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

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75
Q

T2RF

A

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

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76
Q

how does BIPAP work

A

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

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77
Q

volume control ventilation

A

Pressure increases
Target volume reached
Ventilator stops
Expiration occurs

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78
Q

pressure-control ventilation

A

Pressure constant
Target time reached
Ventilator stops
Expiration occurs

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79
Q

where is volume control ventilation used

A

mainly thetres

80
Q

where is pressure controled ventilation used

A

mainly ITU-protects lungs from too high pressure

81
Q

why are muscle relaxants used

A

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

82
Q

non-depolarising muscle relaxants

A

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

83
Q

depolarising muscle relaxants

A

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

84
Q

anticholinergics

A

Atropine
Glycopyrrolate
Treat bradycardia
Common under anaesthesia

85
Q

beta agonist

A

Dobutamine
ITU
Used in heart failure

86
Q

alpha agonist

A

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

87
Q

vasoconstrictor administration

A

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

88
Q

what to give when BP and HR are low

A

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

89
Q

fluid to use for vol replacement

A

Hartmann’s
Saline

90
Q

vascath

A

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

91
Q

WHO pain ladder

A

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

92
Q

cautions for paracetamol

A

liver faiilure
elderly

93
Q

how do NSAIDs work

A

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

94
Q

NSAID SE

A

Peptic ulcers

Acute kidney injury

Blood-thinning

95
Q

how does aspirin work

A

It inhibits thromboxane A2
(a prostaglandin)

This stops platelet aggregation
(hence ‘blood-thinner’)

96
Q

SE opioids

A

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

97
Q

how does ondansetron work

A

5HT3 receptor - works on serotonin

98
Q

how does cyclizine work

A

H1 - orks on histamine

99
Q

uses cyclizine

A

travel sick
post op
can cause tachycardia if administer quick

100
Q

how do Domperidone
Metoclopramide
Prochlorperazine
work

A

on dopamine - D2

101
Q

Prochlorperazine use?

A

vertigo

102
Q

ondansetron use

A

post op N+V

103
Q

metoclopramide use

A

Vomiting after acute opioid administration

104
Q

IV indcution

A

rapid onset, depresses airway reflexes, apnoea common

105
Q

inhalational induction

A

slow, irritates airay, usually keep breathing

106
Q

types of opiod

A

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

107
Q

remifentanil

A

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

108
Q

codeine

A

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

109
Q

tramadol

A

Acts on numerous receptors
Noradrenaline
Opioid
Serotonin
Oral or intravenous

110
Q

warfarin and surgery

A

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.

111
Q

LMWH and surgery

A

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.

112
Q

NOACs and surgery

A

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

113
Q

antiplatelets and surgery

A

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.

114
Q

Antihypertensives and antiarrhythmics and surgery

A

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.

115
Q

anticonvulsants and surgery

A

Patients should continue their normal anticonvulsant therapies unless otherwise indicated.

116
Q

diabetic meds and surgery

A

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.

117
Q

steroids and surgery

A

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.

118
Q

hormonal therapies and surgery

A

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.

119
Q

anti-depressants and surgery

A

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.

120
Q

herbal medicines and surgery

A

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

121
Q

common pre-op meds

A

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.

122
Q

pre-op ix

A

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.

123
Q

HTN and surgery

A

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.

124
Q

anaemia and surgery

A

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

125
Q

surgical severity score

A

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

126
Q

principles of enhanced recovery

A

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

127
Q

PCA

A

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.

128
Q

RF post op N+V

A

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

129
Q

preventing post op N+V

A

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

130
Q

mx post op N+V

A

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.

131
Q

common post op complications

A

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

132
Q

fasting rules

A

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

133
Q

GA triad

A

Hypnosis
Muscle relaxation
Analgesia

134
Q

risks of GA

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

135
Q

RF malignant hyperthermia

A

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.

136
Q

sx malignant hyperthermia

A

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

137
Q

mx malignant hyperthermia

A

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

138
Q

adverse effects epidural

A

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

139
Q

analgesic ladder

A

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

140
Q

SE NSAIDs

A

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

141
Q

CI NSAIDs

A

Asthma
Renal impairment
Heart disease
Uncontrolled hypertension
Stomach ulcers

142
Q

SE opioids

A

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

143
Q

reasons for ICU

A

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

144
Q

complications ICU

A

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

145
Q

T1RF

A

Normal pCO2 with low PaO2 indicates

146
Q

T2RF

A

Raised pCO2 with low PaO2

147
Q

respiratory acidosis

A

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.

148
Q

resp alkalosis

A

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

149
Q

causes metabolic acidosis

A

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

150
Q

causes metabolic alkalosis

A

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

151
Q

oxygen therapy

A

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

152
Q

CPAP

A

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).

153
Q

NIV

A

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

154
Q

positive inotropes

A

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)

155
Q

negative inotropes

A

Negative inotropes act to reduce the contractility of the heart. Examples are:

Beta-blockers
Calcium channel blockers
Flecainide

156
Q

vasopressors

A

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)

157
Q

antimuscarinics in CV

A

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.

158
Q

VITAMIN differentials

A

Vascular
Infective or inflammation
Trauma
Autoimmune
Metabolic
Iatrogenic/idiopathic
Neoplasic

159
Q

define shock

A

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

160
Q

types of shock

A

anaphylactic
septic
hypovolaemic
neurogenic cardiogenic

161
Q

fluid resus

A

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

162
Q

mean arterial BP

A

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

163
Q

classification breathlessness

A

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

164
Q

assessing functional status

A

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

165
Q

STOP BANG

A

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

166
Q

surgery in patients on long term steroids

A

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

167
Q

epidural and VTE prophylaxis

A

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

168
Q

How much would you expect one unit of blood (approx. 250mls) to raise the haemoglobin count by?

A

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

169
Q

major haemorrhage

A

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.

170
Q

complications transfusion

A

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

171
Q

DASI

A

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

172
Q

WHEN TO echo before surgery

A

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%

173
Q

WHEN TO GIVE blood transfusion

A

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

174
Q

troponin

A

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

175
Q

causes raised trop

A

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

176
Q

GCS

A

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

177
Q

mx hypoglycaemia

A

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

178
Q

causes hypoglycaemia

A

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

179
Q

RSI

A

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

180
Q

poor progonsis in paracetamol OD

A

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

181
Q

mx paracetamol OD

A

nacetylcysteine

182
Q

anticoag and surgery

A

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.

183
Q

oestrogen and surgery

A

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).

184
Q

anti HTN and surgery

A

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

185
Q

diabetes meds and surgery

A

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

186
Q

mx DM in surgert

A

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

187
Q

Why might blood sugar be elevated in an unwell surgical patient

A

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

188
Q

What problems may hyperglyaemia cause in a surgical patient

A

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

189
Q

when to restart diabetic meds after surgery

A

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

190
Q

DKA

A

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

191
Q

mx DKA

A

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

192
Q

severe DKA

A

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

193
Q

risks too much IV fluid

A

Fluid overload, hyponatraemia, hypokalaemia
Cerebral oedema

194
Q

electrolyte disturbances in DKA tx

A

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

195
Q

signs hypovolaemia

A

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

196
Q

maintenance IV fluids

A

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)

finals (31 decks)

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