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Anaesthetics Flashcards

0
Q

How long must a patient fast after eating a light meal or milk?

A

6 hours

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1
Q

How long must a patient fast after drinking alcohol?

A

24 hours

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2
Q

How long must a patient fast after drinking breast milk?

A

Breast milk has less fat than regular milk. Less fat means less to thicken in the stomach, so requires less time to empty from the stomach. So 4 hours!

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3
Q

How long must a patient fast after drinking clear juice, tea, or water?

A

2 hours

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4
Q

What amount of water is acceptable for patients to swallow their tablets with before surgery?

A

30mls

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5
Q

Is a patient chewing gum or sucking on boiled sweets before their operation?

A

Yes, but this should be avoided as it can increase stomach acid which contributes to gastric volume

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6
Q

What is involved in preoxygenation in rapid sequence induction?

A

Preoxygenate with a tight fitting mask with high flow oxygen for three to five minutes, or ask the patient to take five vital capacity breaths. The mask is not removed until laryngoscopy.

This replaces the two litres of functional residual capacity in the lungs with oxygen, allowing eight minutes without ventilation before hypoxemia

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7
Q

After preoxygenation, what is the next step of rapid sequence induction

A

Application of cricoid pressure (10N) to occlude the oesophagus- this is not removed until the tube is in the right place

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8
Q

After cricoid pressure is applied, what is the next step of RSI?

A

Thiopentone (4-5mg/kg) is administered and lasts for 4-8mins, immediately followed by suxamethonium (1.5-2.5 mg/kg) which lasts for six minutes. Cricoid force increased at loss of consciousness.

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9
Q

What occurs after induction and the administration of suxamethonium in RSI?

A

Fasciculations occur 45-60 seconds after suxamethonium

After this, intubate

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10
Q

What five factors indicate the tube is correctly placed?

A 
Misting of the tube
Breathing sounds heard on auscultation
Expired CO2 detected on the monitor
See tube pass vocal cords
Chest expansion
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11
Q

What are the standard induction doses of propofol, Thiopentone, etomidate, and ketamine?

A

Propofol- 1.5-2.5 mg/kg
Thiopentone- 4-5
Etomidate- 0.3
Ketamine- 1-1.5

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12
Q

How long does each induction drug take to work?

A

Thiopentone- 20-30s
Propofol- 45-60s
Etomidate- 30-40s
Ketamine- 90s

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13
Q

How long does each induction drug last?

A

Etomidate- 3-6 mins
Propofol- 4-7 mins
Thiopentone- 9-10 mins
Ketamine- 10-12 mins

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14
Q

What are the physiological and unwanted effects of propofol?

A 
Decrease in HR and BP
Apnoea for 60s
Pain on injection
Involuntary movements
Reduced post op nausea and vom
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15
Q

What are the unwanted and physiological effects of Thiopentone?

A

Antiepileptic properties and cerebroprotective

Decreases BP but increases HR!

Causes rash and bronchospasm

Causes thrombosis if injected into arteries

Contraindicated in porphyria

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16
Q

What are the physiological and unwanted effects of etomidate?

A

Haemodynamically stable
Least likely to cause hypersensitivity

Pain on injection
Involuntary movements
Most likely to cause post op N+V
Suppresses cortisol levels- do not use in sepsis

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17
Q

What are the physiological and unwanted effects of ketamine?

A

Increases HR and BP!
Dissociative effects may be distressing for patients

Causes bronchodilation!

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18
Q

What is the minimum alveolar concentration?

A

Concentration of vapour that prevents reaction to a standard surgical stimulus in 50% of subjects

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19
Q

What are the minimum alveolar concentrations of the inhaled anaesthetics?

A 
Nitrous oxide- 104%
Sevoflurane- 2%
Isoflurane- 1.15%
Desflurane- 6%
Enflurane- 1.6%
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20
Q

What factors increase the MAC?

A 
Infants, children
Hyperthermia
Hyperthyroidism
Hypernatraemia
Chronic alcohol or opioid use
Increased catecholamines
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21
Q

What factors decrease MAC?

A 
Neonates
The elderly
Hypothyroidism
Hyponatraemia
Acute alcohol intake
Acute opioid, benzo intake
Lithium
Magnesium
Pregnancy
Anaemia
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22
Q

When is sevoflurane used?

A

For inhalational induction, due to its sweet smell

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23
Q

When is desflurane used?

A

For long operations, as it has low lipid solubility and therefore does not get absorbed into fat, reducing the time needed to wear off

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24
When is isoflurane used?
Isoflurane does not effect organ blood flow Therefore it is useful for organ transplantation operations
25
What is the purpose of short acting opioid analgesics? And give examples
To reduce autonomic responses to surgery and laryngoscopy Fentanyl, remifentanil, alfentanil
26
What is the purpose of long acting opioid analgesics in anaesthetic?
For intraoperative and postoperative analgesia Morphine, oxycodone
27
What NSAIDs are typically used for analgesia in anesthestics?
Diclofenac Parecoxib- usually given IV Ketorolac- usually IV
28
When are NSAIDS contraindicated in anaesthesia?
High risk of bleeding eg vascular surgery Bleeding disorders Asthma Renal dysfunction History of GI bleeds Concurrent use if ace inhibitors, nephrotoxic drugs
29
Which weak opioids are commonly used in anaesthesia?
Tramadol | Dihydrocodeine
30
Which neuromuscular blockers are depolarising and how do they work?
Bind to acetylcholine receptors at neuromuscular junctions and are very slowly hydrolysed by acetylcholinesterase. Therefore short period of muscle fasciculations lasting 40-60s. Suxamethonium
31
What are the uses and side effects of suxamethonium? And it's dose
1-1.5mg/kg Used in rapid sequence induction due to its rapid onset ``` Adverse effects: Muscle pains Fasciculations Hyperkalaemia Malignant hyperthermia Rise in icp, iop, gastric pressure ```
32
How do the non-depolarising neuromuscular blockers function?
Block nicotinic receptors on neuromuscular junctions without activating the muscle, competing with acetylcholine
33
What are the short, intermediate, and long acting non-depolarising neuromuscular blockers?
Short- mivacurium Intermediate- vecuronium, rocuroniun Long- pancuronium All have relatively slow onset and less side effects than depolarising drugs
34
What drugs reverse neuromuscular blockade?
Neostigmine This is an acetylcholinesterase inhibitor Often given with glycopyrrolate, an antimuscarinic, to counter the unwanted increase in acetylcholine in parasympathetic synapses causing bradycardia, N+V It doesn't work on suxamethonium
35
What proportion of patients experience post operative nausea and vomiting?
25% May result in aspiration pneumonia, bleeding, and incisional hernias
36
Whig patients are more at risk of PONV
Female patients Non smokers Patients who experience motion sickness or previous PONV Patients on opioids as part of anaesthesia Patients with two or more of these should receive two anti emetics
37
Which drugs are used to increase BP and how do they work?
Ephedrine- increase heart rate and contractility Phenylepherine- increase vasoconstriction, reduce HR Metaraminol- increase vasoconstriction So use ephedrine if low HR, phenylephrine and metaraminol if high HR
38
Where do each of the three neurons travel?
First order neuron: sensory nerve with free nerve endings, cell body in dorsal root ganglion 2nd neuron: crosses midsection to join lateral spinothamic tract 3rd neuron: thalamus to primary sensory cortex on post central gyrus
39
What post operative analgesia would you recommend for a operation with a pain intensity score of 1?
Paracetamol 1g QDS (4g max 24 hr dose) Ibuprofen 200-400mg TDS prn Avoid in asthma, kidney disease, IHD, peptic ulcer
40
What post operative analgesia would you recommend for a operation with a pain intensity score of 2?
Reg paracetamol and ibuprofen as per PIS 1 And Codeine 30-60mg QDS max 240mg in 24 hours
41
What post operative analgesia would you recommend for a operation with a pain intensity score of 3?
Reg paracetamol and NSAID as per PIS 2 And PCAS morphine Epidural/single shot Spinal
42
What is a typical PCAS regimen?
1mg morphine bolus 5 minutes lockout period 12 mg max in an hour
43
How so local anaesthetics work?
Prevent Na+ influx to depolarise first order neuron This prevents transmission of signal further in the pathway Local anaesthetics block only the anatomical area being infiltrated and areas distal from this point
44
Which local anaesthetics are esters?
Procaine Cocaine Amethocaine
45
Which local anaesthetics are amides?
``` Mepivacaine Bupivacaine Lidocaine Lignocaine Prilocaine ```
46
What is the maximum dose of lignocaine, with and without adrenaline?
Lignocaine With adrenaline: 3mg/kg Without adrenaline: 7mg/kg Comes in 1% and 2% concentration 1% = 10mg in 1ml
47
What is the maximum dose of bupivacaine with and without adrenaline?
Bubivacaine With adrenaline: 2 mg/kg Without adrenaline: 2mg/kg
48
What is the max dose of prilocaine with and without adrenaline?
6mg/kg without adrenaline | 9mg/kg with adrenaline
49
Why is the max dose of a local anaesthetic increased when used with adrenaline?
Adrenaline is a vasoconstrictor so it decreases the amount of local anaesthetic which is removed by the blood Therefore more LA can be used because the LA stays where you want it to
50
How would your use of LA change when treating a large area?
If larger lesions, more LA is required to cover the area, so give with adrenaline Use more dilute solutions to cover more area
51
Where does he subarachnoid space end?
S2
52
Where can you do a spinal block?
Below L1 | But usually between L3/4
53
Where does the epidural space end?
S4/5 | At the sacricoccygeal hiatus
54
Where can you do am epidural block?
Any level, but the higher up you go the more risk there is of spreading to brain, causing apnoea, hypotension etc
55
What LA is used with spinal analgesia?
Heavy bupivacaine as it is more dense than CSF and sinks in the subarachnoid space
56
What are the characteristics of spinal anaesthesia?
Lasts 2-3 hours- longer with opioids Intense motor block Quick onset
57
What are the characteristics of epidural anaesthesia
Slower onset Less motor blocking Can put in catheter- patient control
58
What is the CEPOD definition of an immediate/emergency operation?
An operation to treat a medical condition risking life and/or limb Resuscitation simultaneous with intervention Occurs within minutes of decision to operate Eg fasciotomy, AAA
59
What is the CEPOD definition of an urgent operation?
An intervention for acute onset or clinical deterioration of potentially life/limb threatening conditions. Occurs within hours of decision to operate
60
What is the CEPOD definition of a scheduled/expedited operation?
Patient requiring early treatment whee the condition is not an immediate threat to life/limb/organ survival Occurs within days of decision to operate Eg hip replacement, cholecystectomy, repair of tendon
61
What is the CEPOD definition of an elective operation?
Intervention planned or booked in advance of routine admission to hospital Timing to suit patient, hospital and staff
62
What is ASA grade 1?
A healthy patient with no systemic disease
63
What is ASA grade 2?
Mild to moderate systemic disease with no functional limitation
64
What is an ASA grade 3 patient?
Severe systemic disease imposing functional limitation on patient
65
What is an ASA grade 4 patient?
Severe systemic disease which is a constant threat to life
66
What is an ASA grade 5 patient?
Moribund patient who is not expected to survive with or without the operation
67
What is an ASA grade 6 patient?
A brainstem dead patient whose organs are being removed for donor purposes
68
What are examples of grade 1 (minor) surgery?
Cystoscopy Drainage of abscess Excision of skin lesions
69
What is an example of a grade 2 (intermediate) surgery?
Elective appendicectomy | Inguinal hernia
70
What is an example of a grade 3 (major) surgery?
Hysterectomy | Thyroidectomy
71
What is an example of a grade 4 (major+) surgery?
Joint replacement Thoracic operations THR Radical neck dissections
72
What are contraindications to epidural or spinal anaesthesia?
Hypovolaemia- patient likely to experience fall in CO as compensatory vasoconstriction is lost Low cardiac output Local skin sepsis - infection risk Coagulopathy - risk of epidural haematoma Raised ICP- risk of precipitating coning
73
What are complications of central neural blockade via spinal/epidural
Hypotension and bradycardia- due to sympathetic blockade causing vasodilation. If blockade extends above T5, cardio accelerator nerves are blocked and unnopposed vagal tone causes bradycardia Nausea and vomiting Post dural puncture headache - persistent leak of CSF
74
What are the early and late signs of local anaesthetic toxicity?
Early - circumpolar paraesthesia, numbness of tongue, visual disturbances, lightheadedness, slurred speech Late - grand mal convulsions with coma, respiratory depression, cv collapse, hypotension, bradycardia
75
Why do all patients require oxygen after anaesthesia?
To counter the effects of diffusion hypoxia if nitrous oxide has been given To compensate for any hypo ventilation To compensate for vq mismatch To meet the increased oxygen demand when shivering
76
What temperature is a unit of packed RBCs kept at?
2-6 degrees
77
How long may a unit of packed RBCs kept for? (Shelf life)
42 days
78
How quickly must a unit of packed RBCs be transfused after removal from the fridge?
Within 30 mins The unit can be transfused over a maximum of an hour
79
At what haemoglobin conc is blood transfusion indicated?
Always if hb is <8g/dl in patients with cardio or resp disease, over 65 etc
80
What are the risks of RBC transfusion?
Acute haemolytic transfusion reaction - usually ABO incompatibility because if clerical error - Haemolysus, shock, Renal failure Bacterial contamination - rare Transfusion related acute lung injury Allergy Viral infections - although every donation tested for hep B, hep c, HIV
81
What causes prolonged apnoea when using suxamethonium?
Pseudocholinesterase deficiency resulting in insufficient enzyme to metabolise suxamethonium Period of apnoea is dependent on whether patient is heterozygotic or homozygotic for the faulty allele
82
What is the dose of dexamethasone and when is it given during anaesthesia?
4-8 mg IV Given at induction, as causes perineal flushing in awake patients
83
What is the dose of ondansetron, and when is it given?
4-8mg IV Given at end of surgery
84
What is the dose and side effects of cyclizine?
50mg IV given at end of surgery As prn drug: 25mg TDS May cause tachycardia due to anti vagal properties
85
When and how is Amethocaine used?
Given topically at site of IV cannulation 4% ametop cream Effective in 45 minutes
86
What is the dosage of paracetamol? Oral and IV, children and adults
20mg/kg oral 15mg/kg IV Up to 50 kg, when the adult dose is given which is 1g paracetamol IV (perfalgan)
87
What is the dose of morphine?
0.1mg/kg IV Often 10mg IV morphine prescribed in post op recovery in the 'once only' section
88
What is the dose of codeine?
0.5mg/kg
89
How are lmwh used in venous thrombolaxis?
Started on admission or evening before surgery Dalteparin- 2500u Enoxaparin- 2000u Tinzaparin- 3500u
90
What agent reverses rocuronium?
Suggamadex

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