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Final Year > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Why doe sthe patient need to be fasted before general anaesthetic

A

Reduces the reflux of stomach contents into oropharynx (throat) then aspiration into trachea

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2
Q

How does reflux then aspiration lead to pneumonia

A

gastric contents in lungs creates aggressive inflammatory response

leads to pneumonitis - inflammation of lung tissue

then aspiration pneumonia

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3
Q

When is there the highest risk of aspiration during general anaesthetic

A

before, during intubation
at extubation

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4
Q

what are the fasting rules for operations under general anaesthetic

A

6 hours no food or feeds
2 hours no clear fluids - fully nil by mouth

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5
Q

What is preoxygenation

A

100% oxygen for a few minutes before being put under so they have a reserve for the period when they lose consiousness and are successfully intubated and ventilated

in case they are difficult to intubate or anaesthetist has difficult

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6
Q

What are the three classic classes of medications that patients may be given before anaesthetics

A

Benzodiazepines - relax muscles and reduce anxiety - midazolam

Opiates - fentanyl / alfentanyl - reduce pain and hypertensive response to laryngoscope

Alpha-2-adrenergic agonists - clonidine - help sedation and pain

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7
Q

What is used in emergency scenarios to get control of the airway

A

rapid sequence induction/intubation

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8
Q

What maneouvres can be used to prevent aspiration in RSI?

A

press down on cricoid cartilage (cricoid pressure) to press the oesophagus down

Position the patient pore upright

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9
Q

What is the triad of general anaesthesia

A

Hypnosis
muscle relaxation
analgesia

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10
Q

How can hypnotic agents be delivered

A

intravenous
inhalation

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11
Q

What do hypnotic agents do

A

make the patient unconscious

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12
Q

What are the intravenous options for hypnotic agents

A

propofol (most common)
ketamine
thiopental sodium (less common)
etomidate (rare)

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13
Q

What are the inhaled option for general anaesthetic

A

Sevoflurane (most common)
Desflurane (less favourable - bad for environment)
Isoflurane (rare)
Nitrous oxide (kids)

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14
Q

What are volatile anaesthetic agents

A

liquids at room temperature and need to be vapourised into a gas to be inhaled

e.g. sevoflurane, desflurane and isoflurane

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15
Q

What acts quicker, inhaled or IV general anaesthetic agents?

A

IV agents

Commonly, an intravenous medication will be used as an induction agent (to induce unconsciousness), and inhaled medications will be used to maintain the general anaesthetic during the operation. Inhaled medications need to diffuse across the lung tissue and into the blood, where it takes a while for them to reach an effective concentration. IV agents have a head start, as they are infused directly into the blood and so can quickly reach an effective concentration.

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16
Q

What is TIVA?

A

Total intravenous anaesthetia used for induction and maintenance - most commonly propofol

nicer recovery compared with inhaled options

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17
Q

What are the two classes of muscle relaxants

A

Depolarising
Non-depolarising

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18
Q

What are some examples of muscle relaxants?

A

Suxamethonium (depolarising)
Rocuronium and Atracurium (Non-depolarising)

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19
Q

What is the purpose of muscle relaxants in general anaesthetic?

A

To relax and paralyse muscles
Makes surgery and intubation easier

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20
Q

How can you reverse muscle relaxants

A

Neostigmine - cholinesterase inhibitor for depolarising muscle relaxants - for suxamethonium

Sugammadex for non-depolarising ones - rocuronium and vecuronium

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21
Q

Where do muscle relaxants act?

A

At the neuromusclular junction - Acetylcholine is blocked from stimulating a response from the muscle

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22
Q

Which opiates are most frequently used

A

Fentanyl
Alfentanil
Remifentanil
Morphine

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23
Q

Which antiemetics are given post-procedure for prophylaxis

A

Ondansetron
Dexamethasone
Cyclizine

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24
Q

What class of drug is ondansetron

A

5HT3 receptor antagonist

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25
Q

When is ondansetron avoided

A

in patients with a risk of prolonged QT interval

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26
Q

When should dexamethasone be avoided

A

in diabetics or immunocompromised patients

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27
Q

What class of drug is cyclizine

A

Histamine (H1) receptor antagonist

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28
Q

When should cyclizine be avoided

A

Elderly patinets and heart failure

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29
Q

How can you test if the muscle relaxant has worn off

A

Nerve stimulator
Ulnar nerve - thumb movements / twitches
Facial nerve stimulation for orbiulares oculi muscle movement (stimulate four times - Train-of-four)

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30
Q

What is the Train-of-Four stimulation

A

nerve is stimulated four times
if it remains strong, muscle relaxant has worn off
If it weakens, it hasn’t worn off
Medication can be used to reverse the effects of the muscle relaxant

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31
Q

Whata re the risks of general anaesthesia

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

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32
Q

What is malignant hyperthermia

A

Fatal hypermetabolic response to anaesthesia

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33
Q

Which drugs have a higher risk of causing malignant hyperthermia

A

Volatile anaesthetics (isoflurane, sevoflurane and desflurane)
Suxamethonium
Antipsychotics - NMS

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34
Q

What are some signs of malignant hyperthermia

A

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

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35
Q

How cna you treat malignant hyperthermia

A

Dantrolene

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36
Q

How does dantrolene work

A

Interupts the msucle rigidity and hypermetabolism by interfering with movement of calcium ions in skeletal muscle

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37
Q

What is central neuraxial anaesthesia

A

it is a spinal anaesthetic / spinal block

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38
Q

What is central neuraxial anaesthesia used for

A

Hip fracture repairs
Transurethral resection of the prostate
C-sections

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39
Q

Into which area is the anaesthetic injected for central neuraxial anaesthesia?

A

Subarachnoid space into CSF

Usually into L3/4 or L4/5

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40
Q

How long will it take for central neuraxial anaesthesia to wear off

A

1-3 hours

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41
Q

What is epidural anaesthesia and when is it used?

A

in pregnant women in labour and post-operatively after a laparotomy

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42
Q

What medication is used in epidural anaesthesia?

A

Levobupivicaine with or without fentanyl

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43
Q

Where is the epidural anaesthetic injected

A

into the epidural space

outside the dura mater, separate from the spinal cord and CSF

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44
Q

What are some adverse effects of epidurals

A

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

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45
Q

What are some dangers of epidural in pregnancy

A

Prolonged second stage
Increased probability of instrumental delivery

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46
Q

What is allodynia

A

pain is experienced with sensory inputs that don’t cause pain

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47
Q

How do you treat local anaesthetic toxicity

A

IV 20% lipid emulsion

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48
Q

What does pain threshold mean

A

It’s the point at which a sensory input is reported as painful, e.g. temperature applied to akin to measure the pain at which the heat is interpretted as pain

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49
Q

What is a pain tolerance

A

a person’s response to pain

biological, psychological and social factors

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50
Q

What are the two groups of nerve fibres that transmit pain

A

C fibres - unmyelinated and small diameter
A-delta fibres - myelinated and larger diameter

51
Q

How do C-fibres transmit pain

A

Slowly and they produce a dull and diffuse pain sensation

52
Q

How do A-delta fibres transmit pain

A

Fast and they produce a sharp and localised pain sensation

53
Q

Up which spinal tracts does pain get transmitted?

A

Spinothalamic and spinoreticular tract

54
Q

Where in the brain is pain interpreted

A

Thalamus and cortex

55
Q

What is neuropathic pain

A

Abnormal functioning or damage of the sensory nerves

56
Q

What are some features of neuropathic pain

A

Burning
Tingling
Pins and needles
Electric shocks
Loss of sensation to touch of the affected area

57
Q

What are the two common scales to measure pain

A

Numerical rating scale (NRS)
Visual analogue scale (VAS)

58
Q

What are the three steps of the WHO analgesic ladder

A

Step 1: Non-opioid - paracetamol and NSAIDs
Step 2: Weak opioids - codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors)
Step 3: Strong opioids - morphine, oxycodone, fentanyl and buprenorphine

59
Q

Which medications can be used for neuropathic pain, or as adjuvants with the analgesic ladder?

A

Amitriptyline - TCA
Duloxetine - SNRI
Gabapentin - anticonvulsant
Pregabalin - anticonvulsant
Capsaicin cream (topical) - from chilli peppers

60
Q

What are the main side effects of NSAIDs

A

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

61
Q

Contraindications of NSAIDs

A

Renal failure
Asthma
Heart disease
Uncontrolled HTN
Stomach ulcer

62
Q

Side effects of opioids

A

Constipation
Skin itching (pruritus)
Nausea
Altered mental state
Respiratory depression

63
Q

What medication is used to reverse opioids

A

Naloxone

64
Q

How do you calculate the rescue dose of an opioid for somone in chronic pain?

A

Rescue does is 1/6 of the background 24-hour dose

65
Q

How is subcut opioid dose converted to IV?

A

IV is 1/10 the dose of subcut

66
Q

Which opioids can be given as patches?

A

Buprenorphine (5mcg = 12mg oral morphine)
Fentanyl (12mcg = 20mg of oral morphine)

67
Q

What needs to be on-hand when administering patient-controlled anaesthesia

A

Naloxone - resp dep
Antiemetics - nausea
Atropine - bradycardia

68
Q

What options are there for managing chronic pain (NICE guidelines 2021)

A

Supervised group exercise programs
Acceptance and committment therapy (ACT)
CBT
Acupuncture
Anidepressants (amitriptyline, duloxetine or SSRI)

69
Q

Which medications should patients not be started on for Chronic Primary Pain?

A

Paracetamol
NSAIDs
Opiates
Pregabalin
Gabapentin

70
Q

What medications can be used in chronic secondary pain?

A
  1. Paracetamol and topical NSAIDs
  2. Oral NSAIDs +/- PPI
  3. Opiates - e.g. codeine
71
Q

What questionnaire is used to assess neuropathic pain

A

DN4 questionnaire

72
Q

What is the first-line medication for trigeminal neuralgia?

A

Carbamazepine - refer to specialist if this doesn’t work

73
Q

What is the standard ET tube size for men and women

A

7 - 7.5 mm for women
8 - 8.5 mm for men

74
Q

What can be used to check the pressure in the cuff of an ET tube?

A

Manometer

75
Q

What part of the tube can provides security in the event that the main opening at the tip of the ETT becomes occluded?

A

Murphy’s eye - an extra hole in the side of the tip that gas can flow through

76
Q

What is a laryngoscope with a camera called?

A

McGrath laryngoscope

77
Q

What can be used to assist intubation if the vocal cords cannot be visualised?

A

Bougie

The bougie is inserted into the trachea. The endotracheal tube slides along the bougie into the correct position in the airway. The bougie is then removed, and the endotracheal tube remains in place.

78
Q

What is the name given to pain and restriction in opening the jaw

A

Trismus

79
Q

What types of supraglottic airway devices are there?

A

Inflatable cuff SADs = laryngeal mask airways
Non-inflatable SADs = I-gel (moulds to the larynx)

80
Q

What is a guedel

A

an oropharyngeal airway

81
Q

What is a contraindication for inserting a nasopharyngeal airway

A

Base of skull fracture

82
Q

How do you measure the correct size for a OPA and NPA?

A

OPA = from centre of mouth to angle of jaw
NPA = edge of the nostril to the tragus of the ear

83
Q

What are the stages to do in the cases of an unanticipated difficulty intubating a patient according to the Difficult Airway Society (DAS) guidelines 2015?

A

Plan A – laryngoscopy with tracheal intubation
Plan B – supraglottic airway device
Plan C – face mask ventilation and wake the patient up
Plan D – cricothyroidotomy

84
Q

Why would you want an arterial catheter

A

Measuring blood pressure real-time
ABG samples

85
Q

Where is a central venous catheter inserted?

A

Internal jugular vein
Subclavian vein
Femoral vein

86
Q

Where does the tip of the CVC sit?

A

vena cava

87
Q

Which medications would need to be given through a CVC?

A

inotropes
amiodarone
high-potassium fluids

88
Q

What are Swan-Ganz catheters?

A

Pulmonary artery catheters

89
Q

What is used to monitor pulmmonary artery wedge pressure?

A

Pulmonary artery catheter

90
Q

What is a portacath?

A

central venous catheter

There is a small chamber (port) under the skin at the top of the chest that is used to access the device. This chamber is connected to a catheter that travels through the subcutaneous tissue and into the subclavian vein, with a tip that sits in the superior vena cava or right atrium.

The port can be seen as a bump on the chest wall and felt through the skin

a needle is inserted through the skin into the port, allowing injections to be given or infusions to be set up

91
Q

Which type of CVC lasts the longest?

A

Portacath

low chance of infection, fully internalised under the skin

92
Q

What scoring systems can predict mortality at time of admission to ICU

A

APACHE (Acute Physiology and Chronic Health Evaluation)
SAPS (Simplified Acute Physiology Score)
MPM (Mortality Prediction Model)

93
Q

What are the types of respiratory failure?

A
  • Low PaO2 indicates hypoxia and respiratory failure
  • Normal pCO2 with low PaO2 indicates type 1 respiratory failure (only one is affected)
  • Raised pCO2 with low PaO2 indicates type 2 respiratory failure (two are affected)
94
Q

What does a raised bicarbonate indicate?

A

Chronic CO2 retention - COPD patients

95
Q

Why do patients in acute exacerbation of COPD become acidotic?

A

Kidneys cannot keep up with rising level of CO2

The patient then becomes acidotic despite having higher bicarb than someone without COPD

96
Q

In respiratory alkolosis, how can you differentiate between hyperventilation syndrome and PE?

A

PE = low PaO2
Hyperventilation syndrome = high PaO2

97
Q

When will there be a reduced bicarbonate?

A

Renal failure
Type 2 renal tubular acidosis
Diarrhoea

98
Q

Which patients will get metabolic alkalosis?

A

Loss of H+ ions

Increased activity of aldosterone in kidneys
Vomiting - stomach produces HCl

99
Q

Which conditions cause an increased activity of aldosterone?

A

Conn’s syndrome
Liver cirrhosis
Heart failure
Loop diuretics
Thiazide diuretics

100
Q

What electrolyte abnormality can suxamethonium cause

A

Hyperkalaemia

101
Q

How does lidocaine work

A

Blocks sodium channels

102
Q

When might suxamethonium be contraindicated

A

Hyperkalaemia
Penetrating eye injury
Acute narrow angle glaucoma

103
Q

What intervention reduces incidence of intra-abdominal lesions

A

Laparoscopic approach over open surgery

104
Q

What monitoring equipment measures the concentration of CO2 exhaled during intubation

A

Capnography

105
Q

What is the likely organism in a wound infection post-surgery?

A

Staph aureus

106
Q

Should COCP / HRT be stopped before surgery? If so, when?

A

Stopped 4 weeks before surgery

107
Q

What might be the cause of isolated fever in a patient 24hrs post surgery

A

Physiological response to surgery

108
Q

What two differentials would you want to exclude in a patient presenting with pyrexia 24hrs post surgery?

A

Thrombosis
Infection

109
Q

At what time frame would a wound infection present post-operatively?

A

48 hrs

110
Q

What is the medication of choice for rapid sequence induction?

A

Suxamethonium

111
Q

At what BMI are patients classed ASA II?

A

30 - 40

112
Q

When is the “time out” stage of the WHO checklist

A

Before the first skin incision is made

113
Q

What is the imaging modality used in an anastomotic leak

A

Abdo CT

114
Q

Which anaesthetic agent has inherent anti-emetic properties?

A

Propofol

115
Q

How should total parenteral nutrition be administered?

A

Subclavian line

Because it is strongly phlebitic

116
Q

If a patient has diabetes, what management protocol is normally used for surgery?

A

Put them first on the list

Prevents complications of poor BM control

117
Q

What complication can occur in long-term mechanical ventilation in trauma patients?

A

Tracheo-oesophageal fistula

118
Q

What is the inheritance pattern in malignant hyperthermia

A

50%

119
Q

When should dalteparin sodium be started for VTE prophylaxis

A

at least 6 hours post surgery

120
Q

Which induction agent should be used in trauma patients to avoid drops in BP?

A

Ketamine - doesn’t cause a drop in BP

121
Q

What should be used to clean surgical wounds 0-48hrs post-surgery

A

Sterile saline

122
Q

After how many hours post-surgery may a patient shower safely?

A

48 hours

123
Q
A

Final Year (7 decks)

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