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Phase 4 > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Name 5 common examples of procedures that require local anaesthetic

A

Skin Suturing after skin laceration

Minor surgery to remove skin lesions

Hand surgery (Carpal tunnel syndrome)

Performing Lumbar Puncture

Inserting a central line

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2
Q

Name 4 local anaesthetics

A

Lidocaine

Cocaine

Bupivacaine

Prilocaine

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3
Q

What typically causes local anaesthetic toxicity? (2)

A

Inadvertent venous or arterial injection

High dose of ingested or topically administered local anaesthetic-containing preperations.

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4
Q

Name 4 factors that contribute to the concentration of local anaesthetic that can enter systemic circulation

A

Total Dose

Rate of administration

Route and location of administration

Presence or not of adrenaline in preparation

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5
Q

What is the typical half life of most local anaesthetic preparations? (2)

A

2 hours

(Bupivacaine 5 hours)

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6
Q

Name 5 early clinical features of local anaesthetic toxicity

A

Tinnitus

Difficulty with visual focus

Dizziness/lightheadedness

Anxiety/Agitation/Confusion

Perioral and/or tongue numbness

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7
Q

Name 4 severe features of local anaesthetic toxicity

A

CNS: Seizures/Coma

Cardio: Bradycardia, Hypotension, Conduction blocks, Ventricular dysrythmias

Resp: Respiratory depression, apnoea

Methaemoglobinaemia: Blue mucous membranes progressing to CNS.

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8
Q

Name 4 investigations used for local anaesthetic toxicity

A

UEC (Urea, Electrolytes and Creatinine)

ABG

Methaemoglobin concentration

ECG

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9
Q

What may an ECG show in local anaesthetic toxicity?

A

Evidence of Sodium Channel Blockade;

Prolonged PR
Prolonged QRS
Large terminal R waves in aVR

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10
Q

How is methaemoglobinaemia treated? (local anaesthetic toxicity)

A

Methylene Blue

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11
Q

How are ventricular dysrythmias treated? (local anaesthetic toxicity)

A

Sodium Bicarbonate

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12
Q

What is the antidote for local anaesthetic toxicity?

A

IV Lipid Emulsion (intralipid 20%)

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13
Q

Name 4 potential adverse effects of lipid emulsion infusion

A

Anaphylaxis

Pancreatitis

Venous Embolism

Pulmonary hypertension

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14
Q

Give one use for cocaine as an anaesthetic

A

ENT Surgery

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15
Q

What ion channel do anaesthetics block? What does this prevent?

A

Blocks Sodium Channels (and thus sodium influx into cells)

Prevents depolarization (and this stops action potential propagation)

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16
Q

What local anaesthetic is used at the conclusion of surgical procedures and why?

A

Bupivacaine

Has a longer half life (5 hours) so has a longer analgesic effect

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17
Q

Give one adverse effect of bupivacaine

A

Cardiotoxic

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18
Q

What are the doses of Lignocaine, Bupivacaine and Prilocaine WITHOUT adrenaline?

A

Lignocaine - 3mg/Kg

Bupivacaine - 2mg/Kg

Prilocaine - 6mg/Kg

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19
Q

What are the doses of Lignocaine, Bupivacaine and Prilocaine WITH adrenaline?

A

Lignocaine - 7mg/Kg

Bupivacaine - 2mg/Kg

Prilocaine - 9mg/Kg

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20
Q

What the effect does adrenaline have on local anaesthetics? (2)

A

Prolongs the duration of action at the site of injection.

Also has a vasoconstrictive effect, so decreases bleeding

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21
Q

Give 2 contraindications for adrenaline use (local anaesthetics) (2)

A

In patients taking MAOIs (monoamine oxidase inhibitors - Isocarboxazid, Selegiline)

In patients taking Tricyclic antidepressants (Amitriptyline, Imipramine)

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22
Q

Describe general anaesthesia

A

Making a patient unconscious

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23
Q

Describe regional anaesthesia

A

Blocking feeling to an isolated area of the body (e.g a limb)

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24
Q

What is used to control a patient’s breathing when under GA?

A

Intubation or Supraglottic Airway Device (SAD) + Ventillaiton

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25
Q

Why is fasting important for patients undergoing GA?

A

Empty stomach reduces the risk of stomach contents refluxing into the oropharynx (throat) and being aspirated into the trachea.

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26
Q

What can happen if gastric contents is aspirated into the lungs?

A

Pneumonitis (inflammation of lung tissue)

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27
Q

When is the risk of aspiration highest during GA?

A

Before and during intubation, and when they are being extubated.

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28
Q

Describe the pattern of fasting for an operation under GA (2)

A

6 hours no food or feeds before an operation

2 hours of no clear fluids (fully nil by mouth)

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29
Q

What is preoxygenation and why is it important? (2)

A

Period (before being put under GA) where the patient receives several minutes of 100% oxygen.

Gives patient reserve oxygen for the period between when they lose consciousness and are successfully intubated and ventilated.

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30
Q

Name 3 medications which may be given before a patient is put under GA. Describe why they are given.

A

Benzodiazepines (Midazolam) - Relaxes muscles and reduces anxiety

Opiates (fentanyl/afentanyl) - To reduce pain and reduce hypertensive response to laryngoscope

Alpha-2-adrenergic agonists (clonidine) - Help with sedation and pain

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31
Q

What is used to gain control of the airway during emergency operations?

A

Rapid Sequence Induction/Intubation

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32
Q

What is the biggest concern of Rapid Sequence Induction/Intubation? What precautions are put in place to prevent this? (2)

A

Aspiration of stomach contents into lungs.

Position bed upright to reduce reflux up the oesophagus.

Cricoid pressure (pressing on cricoid cartilage in the neck) to compress the oesophagus and prevent refux.

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33
Q

What is the triad of general anaesthesia?

A

Hypnosis
Muscle relaxation
Analgesia

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34
Q

What is the purpose of hypnotic agents in GA? How can they be given?

A

Hypnotic agents make the patient unconscious. Can be given IV or Inhaled.

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35
Q

Name 2 IV Hypnotic Agents

A

Propofol (most common - Used to Induce GA)

Ketamine

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36
Q

Name 2 Inhaled Hypnotic Agents

A

Sevoflurane (most common- Used to maintain GA)

Nitrous Oxide

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37
Q

Describe the pattern of use for IV and Inhaled hypnotic agents.

A

IV medication is used as an Induction Agent (to induce unconsciousness)

Inhaled medications are used to Maintain GA during the operation

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38
Q

What is the purpose of muscle relaxants in GA? How do they work?

A

Purpose - To relax and paralyse muscle, making intubation and surgery easier

MOA - Block the action of Acetyl Choline at the NMJ.

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39
Q

Name 2 categories (and drugs) of muscle relaxants used in GA

A

Depolarising (Suxamethonium)

Non-depolarising (rocuronium and atracurium)

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40
Q

What can be used to reverse the effects of neuromuscular blocking medications (muscle relaxants)?

A

Cholinesterase inhibitors (neostigmine)

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41
Q

What is used to reverse the effects of depolarising muscle relaxants, such as rocuronium and vecuronium?

A

Sugammadex

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42
Q

Give 2 adverse effects of volatile liquid anaesthetics (such as isoflurane, desflurane and sevoflurane)

A

Myocardial depression

Malignant Hyperthermia

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43
Q

What is the MOA of Propofol?

A

Potentiates GABAa

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44
Q

What is the MOA of Ketamine?

A

Blocks NMDA receptors

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45
Q

Why is Ketamine useful in trauma?

A

As it doesn’t drop blood pressure

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46
Q

Name 4 drugs used as analgesia in GA

A

Opiates;

Fentanyl
Alfentanil
Remifentanil
Morphine

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47
Q

Name 3 antiemetics used in GA and their state their MOA

A

Ondansetron (5HT3 receptor antagonist)

Dexamethasone (corticosteroid)

Cyclazine (Histamine H1 receptor antagonist)

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48
Q

Where may ondansetron be contraindicated?

A

In patients at risk of Prolonged QT interval

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49
Q

Where may Dexamethasone be used with caution?

A

In diabetic or immunocompromised patients

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50
Q

Where may Cyclizine be used with caution?

A

In Heart Failure or Elderly Patients

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51
Q

Describe Emergence and how it is tested (2)

A

Emergence describes the process of waking a patient from GA.

Can be tested by:

Ulnar Nerve Stimulation (Watch thumb twitch)

Facial Nerve Stimulation (watch Orbiculares Oculi muscle twitch)

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52
Q

What is the train-of-four (TOF) stimulation?

A

Describes when a nerve is stimulated 4 times;

If the muscle responses remain strong, this indicates the muscle relaxant has worn off.

If the muscle responses get weaker with additional stimulation, this indicates the muscle relaxant hasn’t fully worn off.

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53
Q

Give 2 common adverse effects of GA

A

Sore throat

Post operative nausea and vomiting

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54
Q

Give 5 significant risks of GA

A

Accidental awareness (waking during the anaesthetic)

Aspiration

Dental injury (2nd to laryngoscope used for intubation)

Anaphylaxis

Malignant hyperthermia (rare)

55
Q

Describe malignant hyperthermia. What is it associated with?

A

Potentially fatal hypermetabilic response to anaesthesia

Associated with;

Volatile anaesthetics (isoflurane, sevoflurane and desflurane)

Suxamethonium

56
Q

Give 6 symptoms of malignant hyperthermia

A

Increased Body Temperature (hyperthermia)
Increased Carbon Dioxide Production
Tachycardia
Muscle Rigidity
Acidosis
Hyperkalaemia

57
Q

How is malignant hyperthermia treated? What is the MOA?

A

Dantrolene

Depresses excitation-contraction coupling in skeletal muscle. Binds to ryanodine receptor 1 and decreases intracellular calcium concentration.

(ryanodine receptors mediate the release of calcium from the sarcoplasmic reticulum)

58
Q

Name 5 muscle relaxants

A

Suxamethonium
Atracurium
Vecuronium
Rocuronium
Pancuronium

59
Q

What can be used to reverse the effects of muscle relaxants (such as Vecuronium)? What is its moa?

A

Neostigmine (Acetylcholinesterase inhibitor)

60
Q

Give an example of a Depolarizing Muscle Relaxant (1). What is their MOA?

A

Succinylcholine (Suxamethonium)

Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plate

61
Q

Give an example of a Non-Depolarizing Muscle Relaxant (4). What is their MOA?

A

Tubcurarine
Atracurium
Vecuronium
Pancuronium

Competitive antagonist of nicotinic acetylcholine receptors.

62
Q

What is the muscle relaxant of choice for rapid sequence induction for intubation? And Why?

A

Succinylcholine (Suxamethonium)

Has the fastest onset and shortest duration of all muscle relaxants.

63
Q

When may suxamethonium be contraindicated? (2)

A

Penetrating eye injuries
Acute narrow angle glaucoma

(As suxamethonium increases intraocular pressure)

64
Q

Give 1 adverse effect of Non-depolarizing muscle relaxants

A

Hypotension

65
Q

What agent can be used to reverse the effects of rocuronium or vecuronium (muscle relaxants)? What is its moa?

A

IV Sugammadex

Selectively binds to rocuronium or vecuronium, preventing them form binding to and antagonising acetyl choline receptors at the NMJ.

66
Q

When should Sugammadex use be avoided?

A

If creatinine clearance is <30mL/minute

67
Q

Define Minimum Alveolar Concentration (MAC). Why is it important?

A

The concentration of inhaled anaesthetic within the alveoli at which 50% of people do not move in response to a stimulus.

Important as it provides a correlation between anaesthetic dose and immobility

68
Q

Define Shock

A

Shock describes an abnormality of the circulatory system that results in reduced organ perfusion and tissue oxygenation.

If untreated, can lead to Multiple Organ Failure and Death.

69
Q

Name 3 types of shock that result from reduced cardiac output

A

Hypovolemic Shock

Cardiogenic Shock

Obstructive Shock

70
Q

Name 3 types of shock that result from reduced systemic vascular resistance

A

Septic Shock

Anaphylactic Shock

Neurogenic Shock

71
Q

Give 4 causes of hypovolemic shock

A

Haemorrhage (internal or external)

Vomiting/Diarrhoea

Burns

Diuresis (excessive urination)

72
Q

Give 4 causes of cardiogenic shock

A

Myocardial infarction

Myocarditis

Cardiac arrhythmia

Negatively inotropic drug overdose (Beta Blockers/Calcium Channel Blockers)

73
Q

Give 3 causes of obstructive shock

A

Tension pneumothorax

Massive PE

Cardiac Tamponade

74
Q

How is Blood Pressure Calculated?

A

BP = Cardiac Output x Systemic Vascular Resistance

75
Q

How is Cardiac Output Calculated?

A

CO = Heart Rate x Stroke Volume

76
Q

What 3 factors determine stroke volume

A

Preload

Myocardial contractility

Afterload

77
Q

Define preload

A

The ventricular wall tension at the end of diastole (reflects the degree of myocardial muscle fibre stretch)

78
Q

Define afterload

A

Afterload is the ventricular wall tension at the end of systole and is the resistance to anterograde blood flow.

79
Q

How may a shocked patient present on an ABCDE?

A

A - Airway may be compromised by reduced conscious level

B - Hypoxia and/or Tachypnoea (may have Kussmaul’s breathing)

C - Cold, pale peripheries, CRT >3s, Tachycardia, Hypotension, Oliguria, Anuria

D - Confusion, Drowsiness, Unconsciousness

E - Mottled Skin

80
Q

What are the sepsis 6?

A

Give 3, Take 3

Give: IV Fluid, IV Antibiotics, Oxygen

Take: Blood Cultures, FBC, Lactate `

81
Q

Describe the initial management of shock

A

ABCDE

Maintain Patent Airway (manoeuvres, adjunctsm ect)

High Flow Oxygen 15L/min to keep sats >94%

Attach ECG, BP monitor and Pulse Oximeter

Obtain IV access (large) and take bloods (Blood gas for pH and Lactate)

IV Fluid Resuscitation (500ml 0.9% Saline STAT)

Urethral catheterisation and fluid balance monitoring (Aim for Urine Output of >0.5ml/kg/hour)

Consider referral to HDU/ICU if BP fails to respond

82
Q

What blood type is universally used for blood transfusions where the blood type is not known?

A

O negative

83
Q

Give one complication of long-term intubation. How may it present? (3)

A

Tracheo-oesophageal fistula formation

Presents with productive cough (yellow/brown mucus), chocking after feeds, aspiration pneumonia.

84
Q

Excessive administration of IV 0.9% sodium chloride solution can cause what? (2)

A

Hyperchloraemic acidosis.

Increased chorice. Kidney removes bicarbonate to maintain electroneutrality > low bicarbonate > acidosis

85
Q

What is the ASA Physical Status Classification System used for?

A

To assess and communicate a patient’s pre-anaesthesia medical co-morbidities.

86
Q

Define ASA 1-6

A

ASA 1 - A normal healthy patient

ASA 2 - A patient with mild systemic disease (smoker, social alcohol, pregnancy, obesity, controlled DM/HTN)

ASA 3 - A patient with severe systemic disease (poorly controlled HTN, DM, COPD, Obesity - BMI >40 ect)

ASA 4 - A patient with severe systemic disease that is a constant threat to life (recent MI, TIA, sepsis, DIC ect)

ASA 5 - A morbidund patient who is not expected to survive without the operation (ruptured aortic aneurysm, massive trauma ect)

ASA 6 - A declared brain-dead patient whose organs are being removed for donor purposes

87
Q

What ASA category does pregnancy fit under?

A

ASA 2

88
Q

What is the most appropriate form of intubation used to prevent airway obstruction caused by poor pharyngeal tone (snoring)?

A

Oropharyngeal tube

89
Q

Where is intraosseous access typically undertaken? When is this preferred?

A

At the anteromedial aspect of the proximal tibia.

Typically preferred in paediatric practice.

90
Q

Should diabetic patients continue metformin before surgery? Why?

A

Yes. Continue as normal the day before surgery.

As diabetics have an increased risk of post-operative infection and delayed wound healing due to poor glycaemic control.

91
Q

A 48-year-old lady undergoes a redo thyroidectomy for a multinodular goitre.

24 hours post operatively she develops oculogyric crises and diffuse muscle spasm.

What has occurred and what is the management?

A

Likely developed hypocalcaemic tetany

Mx - Intravenous Calcium

92
Q

What nerve is most commonly injured during a Posterior Triangle Lymph Node Biopsy?

A

Accessory Nerve

93
Q

What nerve is most commonly injured during a Posterior Approach to the Hip?

A

Sciatic

94
Q

What nerve is most commonly injured in the legs in the Lloyd Davies Position?

A

Common peroneal

95
Q

What surgeries commonly require patients to be in the Lloyd Davies Position?

A

Colorectal or Pelvic Surgeries

96
Q

What nerve is most commonly injured during Axillary Node Clearance?

A

Long Thoracic

97
Q

What nerve is most commonly injured during pelvic cancer surgery?

A

Pelvic autonomic nerves

98
Q

What nerve is most commonly injured during thyroid surgery?

A

Recurrent Laryngeal Nerve

99
Q

What nerve is most commonly injured during carotid endartectomy?

A

Hypoglossal nerve

100
Q

What nerve is most commonly injured during Upper Limb Fracture Repairs?

A

Ulnar and Median Nerves

101
Q

A 22-year-old female is extubated following an uncomplicated surgery. Following, no respiratory effort is made and she is re-intubated and ventilated.

She is monitored in the intensive care unit and all observations are normal.

She is weaned from the ventilator 24 hours later successfully. What complication has occurred?

A

Suxamethonium Apnoea.

A small subset of the population have an autosomal dominant mutation that leards to a lack of a specific acetylcholinesterase in the plasma which acts to break down suxamethonium (this terminating it’s muscle relaxant effects).

Because of this, the effects of suxamethonium are prolonged and the patient needs to be intubated and ventilated for much longer.

102
Q

Why should hypotonic (0.45%) saline use be avoided in paediatric patients?

A

Increases risk of hyponatraemic encephalopathy (confusion, headache, disturbance of gait)

103
Q

Name an agent which reverses the effects of midazolam. What is it’s moa?

A

Flumazenil.

MOA- Antagonises the effects of benzodiazepines by competitively binding to GABA binding sites.

104
Q

Why do patients require close monitoring after treatment with flumazenil?

A

Flumazenil - Used to reverse action of benzodiazepines.

Benzo’s have a longer half life than flumazenil.

105
Q

Give 1 common post-operative complication of abdominal surgery.

A

Ileus

106
Q

What symptoms may a patient with an ileus present with?

A

Fluid and Electrolyte Loss (Before N&V)

Nausea and Vomiting

Abdominal distension

Absolute constipation

107
Q

What is the treatment for an Ileus?

A

Wide bore Nasogastric Tube

Replacement with IV fluid (until bowel becomes motile again)

108
Q

Define Group and Save and describe its use.

A

Refers to sending off a sample of a patient’s blood to establish their blood group.

The sample is saved in case they require their blood to be matched for a transfusion.

Conducted when there is a small likelihood that the patient will require a blood transfusion.

109
Q

Define Blood Crossmatching and describe its use

A

Describes taking one or more units of blood from the shelf and assigning it to a patient in case they require a quick blood transfusion.

Conducted when there is a high likelihood that the patient will require a blood transfusion (so the blood is ready to go if required)

110
Q

Name 4 surgeries where only a Group and Save is appropriate

A

(transfusion unlikely)

Hysterectomy (simple)
Appendicectomy
Laparoscopic cholecystectomy
Thyroidectomy

111
Q

Name 2 surgeries where Crossmatching 2 units of blood may be appropriate.

A

(transfusion likely)

Salpingectomy for ruptured ectopic pregnancy

Total hip replacement

112
Q

Name 5 surgeries where Crossmatching 4-6 units of blood may be necessary.

A

(Transfusion definitely required)

Total gastrectomy
Ooophorectomy
Oesophagectomy
Elective AAA repair
Cystectomy

113
Q

What anti-diabetic medications are safe to take during the peri-operative period? (2)

A

DPP-4 inhibitors (gliptins)

GLP-1 analogues (tides)

114
Q

What anti-diabetic medications should be omitted on the day of surgery. And why? (2)

A

SGLT-2 Inhibitors (Empagliflozin, Dapagliflozin). (Can increase risk of diabetic ketoacidosis during periods of dehydration or acute illness)

Sulphonylurea (Gliclazide). (Can cause hypoglycaemia in patients in a fasted state)

115
Q

What does Capnography measure? What can it be used to confirm?

A

Measures the concentration of carbon dioxide in exhaled air.

Can be used to confirm successful tracheal intubation (as CO2 concentrations will increase during exhalation and decrease during inhalation)

116
Q

What is entropy (in the context of anaesthesia?

A

Entropy monitoring assesses the depth of anaesthesia by assessing a patient’s electroencephalogram.

It assesses the effect of anaesthetic drugs.

117
Q

Nasopharyngeal airways are contraindicated when?

A

Suspected or known Basal Skull Fractures

(Periorbital ecchymosis - Raccoon eyes) and CSF rhinorrhoea are 2 signs of basal skull fracture)

118
Q

What are the 4 stages of wound healing?

A

Haemostasis
Inflammation (Days 1-5)
Regeneration (Days 7-56)
Remodelling (from 6 weeks to 1 year)

119
Q

Describe the haemostasis phase of wound healing (2)

A

Occurs minutes to hours following injury

Vasospasm in adjacent vessels, platelet plug forms and generation of a fibrin rich clot occurs.

120
Q

Describe the inflammation phase of wound healing (3)

A

Occurs on days 1-5 post injury,

Neutrophils migrate into the wound (function impaired in diabetes).

Basic fibroblast growth factor and vascular endothelial growth factor are released.

121
Q

Describe the regeneration phase of wound healing (4).

A

Occurs on days 7-56 post injury.

Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells

Fibroblasts produce a collagen network

Angiogenesis occurs and the wound resembles granulation tissue.

122
Q

Describe the remodelling phase of wound healing.

A

Occurs from 6 weeks to 1 year (longest phase)

Fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction.

Collagen fibres are remodelled

Microvessels regress leaving a pale scar.

123
Q

Describe hypertrophic scars

A

Scars with excessive amounts of collagen.

Tissue is CONFINED to the extent of the wound itself

124
Q

Describe Keloid Scar

A

Similar to hypertrophic, where excessive amounts of collagen are within the scar.

Keloid scars however PASS BEYOND the boundaries of the original injury.

125
Q

Name 4 drug classes which impair wound healing

A

NSAIDs
Steroids
Immunosuppressive agents
Anti neoplastic drugs

126
Q

What 3 modalities is GCS split into

A

Eye Opening

Verbal Response

Motor Response

127
Q

Describe eye opening criteria in GCS

A

E4 - Spontaneously
E3 - To Voice
E2 - To Pain
E1 - None

128
Q

Describe verbal response criteria for GCS

A

V5 - Conversation
V4 - Confused
V3 - Words
V2 - Sounds
V1 - None

129
Q

Describe Motor Response criteria for GCS

A

M6 - Obeys commands
M5 - Localises
M4 - Withdraws
M3 - Flexes
M2 - Extends
M1 - None

130
Q

Use GCS to give 2 indications for CT scan in Adults

A

GCS <13 initially

GCS <15 at 2 hours post injury

131
Q

What is the recommended neuro obs frequency? (4)

A

Half hourly until GCS = 15
The half hourly for 2 hours
Then hourly for 4 hours
Then 2-hourly

132
Q

What can contribute to the development of a post-operative ileus? What blood test is it important to do to investigate this?

A

Deranged electrolytes (Potassium, Magnesium and Phosphate)

U&Es

133
Q

What is the recommended VTE prophylaxis for patients undergoing elective hip replacements?

A

TED Stockings + Dalteparin Sodium started at least 6 hours post-operation

134
Q

When (and why) is ketamine preferred over propofol as an induction agent for anaesthesia?

A

In Trauma.

As Ketamine doesn’t cause a drop in blood pressure.

Phase 4 (1 decks)

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