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ACC > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

What are the three principles of general anaesthesia?

A

Amnesia - lack of response and recall to noxious stimuli (unconsciousness)
Analgesia - pain relief
Akinesis - immobilisation/paralysis

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2
Q

Why is akinesia important?

A

People can still move in their sleep, therefore important to stop this

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3
Q

What are the three main types of anaesthesia?

A

general - total loss of sensation

regional - loss of sensation to a region or part of body

local - topical, infiltration (to site of intervention)

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4
Q

What are induction agents?

A

Medications which induce a loss of conscious

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5
Q

How long do induction agents take to work?

A

‘one arm-brain circulation’ (how long it takes for blood to get from arm to brain)
10-20 seconds

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6
Q

What is routinely monitored in pts. undergoing anaesthetic?

A 
ECG
SpO2
NIBP
Airway gas monitoring
Airway pressure 
Nerve stimulator and temp. (if indicated)
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7
Q

When might you use a nerve stimulator to monitor a patient on anaesthetic?

A

If pt. is undergoing muscle relaxant

to check whether the effects are wearing off, esp. at the end of the operation

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8
Q

What are the 4 key induction agents?

A

Propofol
Thiopentone
Ketamine
Etomidate

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9
Q

Which is the most commonly used induction agent?

A

Propofol

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10
Q

What does propofol look like?

A

White emulsion

lipid based

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11
Q

What are the benefits of propofol?

A

Excellent suppression of airways

Decreases incidence of PONV

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12
Q

What dose of propofol should be used?

A

1.5-2.5 mg/Kg

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13
Q

What are the unwanted effects of propofol?

A

Marked drop in HR and BP
Pain on injection
Involuntary movements

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14
Q

How commonly used is thiopentone?

A

1-2% of pts.

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15
Q

What type of drug is thiopentone?

A

barbiturate

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16
Q

When is thiopentone mainly used? why?

A

Used mainly in rapid sequence induction

acts faster than propofol

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17
Q

What are the benefits of ketamine?

A

Dissociative anaesthesia

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18
Q

What is the most appropriate anaesthetic for a pt. requiring a burn dressing?

A

Ketamine

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19
Q

What is the most appropriate anaesthetic for a pt. undergoing an arm operation under GA with an LMA?

A

Propofol

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20
Q

What is the most appropriate anaesthetic for a pt. with Hx of heart failure requiring a general anaesthetic?

A

Etomidate

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21
Q

What is the most appropriate anaesthetic for a pt. with intestinal obstruction requiring an emergency laparotomy?

A

Thiopentone

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22
Q

What is the most appropriate anaesthetic for a pt. with porphyria coming for an inguinal hernia repair?

A

Propofol (NOT thiopentone)

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23
Q

How long is does the action of an induction agent last?

A

4-10 minutes

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24
Q

What is usually used to maintain amnesia after the 4-10 mins?

A

Inhalation/volatile agents

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25
Q

What are the benefits of thiopentone?

A

Anti-epileptic and cerebra-protective

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26
Q

What are the unwanted effects of thiopentone?

A

Drop in BP, but rise in HR
Rash/bronchospasm (due to histamine release)
Intra-arterial injection: thrombosis and gangrene

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27
Q

When is thiopentone contra-indicated?

A

Porphyria

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28
Q

What is the dose of thiopentone?

A

4-5 mg/Kg

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29
Q

What is the dose of ketamine usually given?

A

1 - 1.5 mg/Kg

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30
Q

What is the onset of ketamine?

A

90 seconds (slow onset)

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31
Q

What does ketamine do to HR and BP?

A

Increases both

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32
Q

What is the effect of ketamine on the airways?

A

Bronchodilation

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33
Q

What are the unwanted effects of ketamine?

A

Nausea and vomiting

Emergence phenomenon: vivid dreams, hallucinations

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34
Q

What are the benefits of etomidate?

A

Rapid onset
haemodynamic stability
low incidence of hypersensitivity reaction

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35
Q

What is the dose of etomidate?

A

0.3 mg/Kg

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36
Q

What are the unwanted effects of etomidate?

A

pain on injection
spontaneous movements
adreno-cortical suppression
high incidence PONV

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37
Q

How are inhalation anaesthetic agents administered to patients?

A

via vaporisers (turns liquid drugs in to inhalable gas)

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38
Q

What are four main amnesic inhalation agents?

A

isofulrane
sevoflurane
desflurane
enflurane

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39
Q

What are the benefits of the sevoflurane?

A

sweet smelling

can also be used in inhalation induction (eg. if pt. scared of needles/paeds/IVDU

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40
Q

What are the benefits of desflurane?

A

Low lipid solubility

Rapid onset and offset

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41
Q

Why is desflurane used in long operations?

A

Because low lipid solubility, leaves body more easily, therefore recovery is quicker

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42
Q

What are the benefits of isoflurane?

A

least effect on organ blood flow

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43
Q

What does MAC stand for?

A

Minimum alveolar concentration

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44
Q

What is the definition of minimum alveolar concentration?

A

The concentration of vapour that prevents the reaction to a standard surgical stimulus (traditionally a set depth and width of skin incision)
in 50% of subjects.

What constitutes 1 MAC is different in different inhalants

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45
Q

What is the MAC of nitrous oxide?

A

104%

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46
Q

What is the MAC of sevoflurane?

A

2%

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47
Q

What is the MAC of isofulrane?

A

1.15%

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48
Q

Is ketamine a good analgesic?

A

yes, causes profound analgesia

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49
Q

What does ketamine (in particular) do to the memory of a patient?

A

Causes anterograde amnesia

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50
Q

What is the MAC of desflurane?

A

6%

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51
Q

What is the MAC of enflurane?

A

1.6%

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52
Q

How does one change the MAC of vapour being given?

A

Adjust dial on vaporiser

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53
Q

What is the best inhalation agent for a long, 8 hour, finger re-implantation? Why?

A

Desflurane

Low lipid solubility - quick recovery from anaesthetic (pt. will be under for a long time due to length of op)

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54
Q

What is the best inhalation agent for a paediatric patient, with no IV access? Why?

A

Sevoflurane

Sweet smelling and no needle needed for induction (therefore less distressing for child when placing cannula)

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55
Q

What is the best inhalation agent for organ retrieval from a donor? Why?

A

Isoflurane

Doesn’t impact organ blood flow

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56
Q

Do analgesics take more or less time to work than induction agents? How much time? What impact does this have on when it is given to the patient?

A

More time

about 1-5 minutes

generally given before the induction agents (make ventilation interventions less uncomfortable for pts.)

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57
Q

What class of analgesia is generally given to pts. in surgery?

A

opioids

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58
Q

When are short-acting opiates used in anaesthetics?

A

Intra-op analgesia: to suppress response to laryngoscopy, surgical pain

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59
Q

What are key features of the short-acting, intra-op. opiates given in theatre?

A

rapid onset

high potency

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60
Q

Give three examples of the short-acting opioids used in theatre? Which one is most commonly used?

A

Fentanyl (most commonly used)
Remifentanil
Alfentanil

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61
Q

Give three examples of the long acting intra-op/post-op analgesia given to pts.

A

Morphine

Oxycodone

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62
Q

Which analgesic is given in almost all surgical patients?

A

paracetamol

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63
Q

When are long-acting opioids generally used in theatre?

A

intra-op

post-op

given just before end of surgery so pt. wakes up pain free

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64
Q

What other analgesics can be given to patients recovery from surgery?

A

Paracetamol (most commonly used)

NSAIDS: diclofenac, parecoxib (IV), Ketorolac (IV)

Weak opioids: tramadol, dihydrocodeine (most common one given)

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65
Q

What is the most commonly used oral opioid in adults?

A

codeine

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66
Q

Give 2 examples of IV NSAIDS

A

Ketorolac

Parecoxib

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67
Q

How is akinesia achieved in anaesthetics?

A

Muscle relaxants

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68
Q

Briefly explain what happens at a neuromuscular junction to cause muscle contraction

A

Action potential arrives at NM junction, by travelling along axon

Causes calcium channels to open (calcium floods in to end of exon)

Causes vesicles to merge with membrane at NM, release ACh

Ach binds to nicotinic receptors

This causes depolarisation of the nicotinic receptors

This causes muscle contraction

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69
Q

What are the two groups of muscle relaxants?

A

Depolarising

Non-depolarising

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70
Q

How do depolarising muscle relaxants work?

A

Act similar to ACh on nicotinic receptors
BUT V. SLOWLY HYDROLYSED BY AChesterase

Cause muscle contraction (fasciculations all over body)

Muscles fatigue and then relax

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71
Q

What are the draw-backs/things to be mindful of when using depolarising muscle relaxants?

A

Fasciculations can cause cell breakdown in muscle, which can cause hyperkalaemia

Its often wake up feeling achey

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72
Q

How do non-depolarising muscle relaxants work?

A

Block nicotine receptors (competitive inhibitor)

Causes muscles to relax

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73
Q

Give an example of a depolarising muscle relaxant

A

Suxamethonium

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74
Q

What does of suxamethonium would you give?

A

1-1.5 mg/Kg

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75
Q

What are the adverse effects of suxamethonium?

A 
Muscle pains
Fasciculations
Hyperkalaemia
Malignant hyperthermia
Rise in ICP, IOP (wouldn't be ideal in opthalmic surgery) and gastric pressure
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76
Q

When is suxemethonium most commonly used?

A

In rapid sequence induction

has rapid onset and rapid offset

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77
Q

Do non-depolarising muscle relaxants have more or less side effects than depolarising?

A

Less

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78
Q

Do non-depolarising muscle relaxants have a faster or slower onset of effect than depolarising?

A

slower onset (take more time)

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79
Q

What is the duration of a depolarising muscle relaxant? long, short or variable?

A

Short

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80
Q

What is the duration of a depolarising muscle relaxant? long, short or variable?

A

variable (depending on drug given)

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81
Q

Give some examples of short-acting non-depolarising muscle relaxants

A

Atracurium

Mivacurium

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82
Q

Give some examples of intermediate-acting non-depolarising muscle relaxants

A

vecuronium

rocuronium

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83
Q

Give some examples of long-acting non-depolarising muscle relaxants

A

pancuronium

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84
Q

How does one reverse the effects of a muscle relaxant?

A

Neostigmine (+glycopyrrolate to prevent cardiac muscle being effected (otherwise, bradycardia is caused))

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85
Q

What happens if neostigmine given without glycopyrrolate? What class of drug is glycopyrrolate? How does this impact heart rate?

A

Bradycardia
Anti-muscarinic agent

Blocks muscarinic effects of ACh, which are increased due to administration of neostigmine

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86
Q

What is neostigmine?

A

Anti-cholinesterase (binds to acetylcholinesterase)

Increases amount of ACh by preventing it being broken down at NM junction

Increases ability for muscular contraction

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87
Q

What are side effects of neostigmine?

A

Nausea and vomiting

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88
Q

What would one do at the end of surgery?

A

Stop anaesthetic vapours
Give oxygen
Perform throat suction
Reverse muscle relaxation

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89
Q

What other key drugs would you consider giving a pt. post-operatively? (excluding analgesia) Why?

A

Anti-emetics

Nausea and vomiting v. common after general anaesthesia

Vomiting can cause increased hospital stay, increased bleeding, incisional hernias and aspiration pneumonia

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90
Q

Why might you prescribe a patient vaso-active drugs intra-operatively?

A

To treat hypotension (v. dangerous if left untreated)

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91
Q

What are the classes of anti-emetic agents? Give examples each class.

A 
5HT3 blockers: ondensetron
Anti-histamines: cyclizine
Steroids: dexamethasone
Phenothiazine: prochlorperazine
Anti-dopaminergic: metaclopramide
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92
Q

What are the three most-commonly used anti-emetics in anaesthetics (in order of commonness)

A

1) Ondansetron (used in about 95% of pts.)
2) Dexamethasone
3) Cyclizine

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93
Q

Which are the most commonly used vaso-active drugs given in intra-operative hypotension?

A

Ephedrine
Phenylephrine
Metaraminol

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94
Q

Which vaso-active drugs are given in severe hypotension whilst under anaesthetic (eg. in ICU)?

A

Noradrenaline
Adrenaline
Dobutamine

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95
Q

How does ephedrine effect BP and HR? What receptors do they work on?

A

Rise in HR (and contractility) = RISE IN BP

alpha and beta receptors

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96
Q

How does phenylephrine and meteraminol effect BP and HR? What receptors do they work on?

A

RISE IN BP
DROP in HR

alpha and beta receptors

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97
Q

If you wanted to increase a patients’ BP and HR, which vaso-active drug(s) would you use?

A

Ephedrine

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98
Q

If you wanted to increase a patients’ BP, but reduce HR, which vaso-active drug(s) would you use?

A

Phenylephrine

Metaraminol

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99
Q

Which vast-active agent would you use in intensive care or severe sepsis?

A

Noradrenaline

Adrenaline

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100
Q

Put the following elements of general anaesthesia using and LMA in order:
Opioid (fentanyl/afentanyl)
Oxygenation
Bag valve mask ventilation
Induction agent (propofol)
Turn on volatile agent (sevoflurane/isoflurane)
Insert LMA

A

1) Oxygenation
2) Opioid
3) Induction agent
4) Turn on volatile agent
5) Bag valve mask ventilation
6) LMA insertion

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101
Q 
Put the following elements of general anaesthesia using intubation in order:
Opioid (fentanyl/afentanyl)
Oxygenation
Bag valve mask ventilation
Induction agent (propofol)
Turn on volatile agent (sevoflurane/isoflurane)
Endotracheal intubation
Muscle relaxant
A

1) oxygenation
2) opioid
3) induction agent
4) muscle relaxant
5) turn on volatile agent
6) bag valve mask ventilation
7) endotracheal intubation

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102
Q

What is the ASA (american Society of Anaesthesiologists) grading?

A

Physical status classification system for assessing fitness for surgery

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103
Q

What is ASA grade 1?

A

Healthy pt.

No systemic disease

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104
Q

What is ASA grade 2? Give some examples of pts. who might fall in to this category.

A

Mild-moderate systemic disease with no functional limitation
eg. asthma
life-style/medication controlled diabetes

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105
Q

What is ASA grade 3? Give some examples of pts. who might fall in to this category.

A

Severe systemic disease
Imposing functional limitation on pt.
eg. stable angina, insulin-dependent diabetes

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106
Q

What is ASA grade 4? Give some examples of pts. who might fall in to this category.

A

Severe systemic disease which is a constant threat to life

eg. unstable angina, heart failure, end-stage COPD

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107
Q

What is ASA grade 5? Give some examples of pts. who might fall in to this category.

A

Moribund pt.
Not expected to survive with or without operation
eg. isachaemic bowel, severe head injury, palliative care op.

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108
Q

What is ASA grade 6? Give some examples of pts. who might fall in to this category.

A

Brainstem-dead pt. whose organs are being removed for donor purposes

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109
Q

What is added to the ASA grading to show that the cases are an emergency?

A

‘E’ suffix

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110
Q

What is the ASA grade of a normal fit healthy patient

A

1

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111
Q

What is the ASA grade of a 70 yr old pt., on ICU with non-survivable brain injury for insertion of an ICP monitor?

A

5

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112
Q

What is the ASA grade of a pt. with well-controlled asthma or hypertension?

A

2

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113
Q

What is the ASA grade of a moderately obese diabetic patient on insulin?

A

3

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114
Q

What is the ASA grade of a 20 yr old pt. with severe head injury from a road traffic accident?

A

At least 4

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115
Q

What are the different surgical grades?

A

Grade 1 (minor): eg. removal of moles, lipomas, nails etc.

Grade 2 (intermediate): eg. IND of abscesses, tonsillectomy, hernia repair

Grade 3 (major): eg. fracture repair, appendectomy

Grade 4 (major +): joint replacement, bypasses, lung surgery, GI surgery, emergency laparotomy

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116
Q

What grade of surgery is an emergency laparotomy?

A

4

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117
Q

what grade of surgery is an in-growing toe nail surgery?

A

1

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118
Q

What grade of surgery is a knee arthroscopy?

A

2

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119
Q

What grade of surgery is a fracture NOF fixation?

A

3

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120
Q

What pre-operative investigations are required in a normal pt under the age of 60?

A

FBC (if SG > 3)
U&Es (if SG > 4)
ECG not needed

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121
Q

What pre-operative investigations are required in a normal pt aged 60-80?

A

FBC (if SG > 2)
U&Es (if SG >3)
ECG (if SG >3)

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122
Q

What pre-operative investigations are required in a normal pt over the age of 80?

A

FBC
U&E
ECG
NO MATTER WHAT SURGICAL GRADE

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123
Q

What comorbidity would make you want to do an FBC before surgery (no matter what SG)?

A

Severe renal disease

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124
Q

What comorbidity would make you want to a U&Es before surgery (no matter what SG)?

A

renal or CVS disease

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125
Q

What comorbidity would make you want to do an ECG before surgery (no matter what SG)?

A

renal or CVS disease

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126
Q

Which routine investigations are usually not indicated in surgery (except for in specific patients)?

A 
INR
APTT
CXR
urine analysis
serum glucose
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127
Q

What special investigation would you do for a patient with afro-carribean or +ve family Hx?

A

test for sickle cell - sickling test (or ask GP if they’ve been tested - if born in UK)

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128
Q

What special investigation would you do for a female patient of child-bearing age (14-45)?

A

urine pregnancy test

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129
Q

What special investigation would you do for a patient requiring ICU admission or respiratory disease with ASA 3 or 4?

A

CXR

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130
Q

If a patient is not fit for surgery, what would you do?

A

Try and optimise health eg. prescribe ABX, refer back to GP for treatment/stabilisation

May need to reschedule surgery

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131
Q

How long do patients have to be fasted from solid food prior to surgery?

A

6hrs

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132
Q

A 20 year old man is scheduled for elective tonsillectomy. He had a slice of toast with tea 4 hours ago. Is he fit for surgery?

A

NO

Fasted from solids <4 hours prior to surgery

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133
Q

Why do we try and minimise period of time pts. need to fast?

A

Discomfort for pt
Hypoglycaemia risk
Risk of dehydration
Reduced rate of recovery

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134
Q

What is the purpose of fasting patients?

A

To prevent aspiration of gastric contents

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135
Q

What is the gastric emptying time of water?

A

10-20 mins

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136
Q

How long must a patient NOT have water/clear fluids for, before surgery?

A

2 hours

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137
Q

How long must a patient NOT have breast milk for, before surgery?

A

4 hours

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138
Q

How long must a patient NOT have animal milk for, before surgery? why?

A

6 hours

Because it curdles with acid, therefore forms a solid in stomach

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139
Q

How long must a patient NOT have boiled sweets/chewing gum for, before surgery?

A

2 hours

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140
Q

How long must a patient NOT have alcohol for, before surgery?

A

24 hours

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141
Q

30 yr old M, had tea at 6pm yesterday and had 50 mL of water 30 mins before surgery. Is he fit for surgery? Why/why not?

A

NO
water consumed <2hrs prior to surgery
50mL - too large a quantity

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142
Q

30 yr old M, had dinner at 6pm yesterday and is down for the afternoon list (starting at 1:30pm). You see him at 7am on the morning. Is he fit for surgery and what could you do to avoid adverse effects of prolonged fasting?

A

tea and toast within the next half an hour

set up some fluids (to prevent dehydration)

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143
Q

40 yr old M, had a full meal an hour ago, was involved in road traffic accident and has an open fracture of femur. Is he fit or unfit?

A

Unfit, but would undergo surgery anyway (danger of death is higher from INACTION)

Would do Rapid-sequence induction (RSI)

144
Q

What is the indication for RSI?

A

Minimise risk of expiration if pt. likely to have full stomach

145
Q

What are some metabolic factors that delay gastric emptying?

A

diabetes (due to neuropathy), ESRD

146
Q

What are some anatomical factors that cause delayed gastric emptying?

A

pyloric stenosis

147
Q

What are some mechanical factors that cause delayed gastric emptying?

A

hiatus hernia, pregnancy, bowel obstruction, obesity

148
Q

What trauma can cause delayed gastric emptying?

A

traffic accidents, head injury

149
Q

What are some other causes of delayed gastric emptying?

A

opiates
high fat content
anxiety

150
Q

How do you know that an intubation tube is in the right place?

A 
Breath sounds 
Chest movement
CO2 on the monitor *DEFINITIVE
Moisture in the tube (misting)
Seeing tube go through cords
151
Q

Using CEPOD classification, what is immediate/emergency surgery?

A

Immediate life/limb/organ-saving intervention – resuscitation simultaneous with intervention.
Normally within minutes of decision to operate.

152
Q

Using CEPOD classification, what is urgent surgery?

A

Intervention for acute onset/deterioration of potentially life/limb/organ-threatening conditions
eg. fixation of many fractures, relief of pain or other distressing symptoms.
Normally within hours of decision to operate.

153
Q

Using CEPOD classification, what is expedited/scheduled surgery?

A

Patient requiring early treatment
Condition is not an immediate threat to life, limb or organ survival.
Normally within days of decision to operate.

common eg. cancer excision

154
Q

Using CEPOD classification, what is elective surgery?

A

Intervention planned or booked in advance of routine admission to hospital.
Timing to suit patient, hospital and staff.

155
Q 
Using hemicolectomy as the intervention, give an example of this being used as:
Immediate surgery
Urgent
Expedited
Elective
A

Immediate: perforation
Urgent: obstruction
Expedited: cancer
Elective: polyps, diverticulitis

156
Q

60 yr old M
1/12 Hx of chest pain (3-6 times a day)
Due for elective cholecystectomy
FBC, ECG, clotting screen was done 2 months ago

Is pt. fit or unfit for surgery? why/why not?

157
Q

60 yr old M
1/12 Hx of chest pain (3-6 times a day)
Due for elective cholecystectomy
FBC, ECG, clotting screen was done 2 months ago

What is the current ASA grade?

A

3 (not 2 because he’s not well controlled)

158
Q

60 yr old M
1/12 Hx of chest pain (3-6 times a day)
Due for elective cholecystectomy
FBC, ECG, clotting screen was done 2 months ago

What is the surgical grade?

A

3 (if open)

2 (if laparoscopic)

159
Q

60 yr old M
1/12 Hx of chest pain (3-6 times a day)
Due for elective cholecystectomy
FBC, ECG, clotting screen was done 2 months ago

What should you do before he can be considered for surgery?

A

do an ECG to check for no immediate heart problem

Refer back to GP (may need to write letter)

160
Q

60 yr old M
1/12 Hx of chest pain (3-6 times a day)
Due for elective cholecystectomy
FBC, ECG, clotting screen was done 2 months ago

What investigations may be useful?

161
Q

60 yr old M
1/12 Hx of chest pain (3-6 times a day)
Due for elective cholecystectomy
FBC, ECG, clotting screen was done 2 months ago

What can be gained for re-scheduling the case?

A

Can anaesthetise more safely if know cardiac function

Patient can be re-assured that they are safe to undergo surgery

Opens slot for another pt. (in some cases)

162
Q

What is the definition of pain?

A

Unpleasant sensory or emotional experience

with/without associated tissue damage

163
Q

How do we feel pain? (how does the sensation of pain travel from source to brain?)

A

First order neurone - site of injury (dorsal root ganglion), through spinal nerve, to spinal cord (cell body of first order neuron)
ON IPSILATERAL SIDE OF BODY

Second order neurone - spinal cord to thalamus
Nerve decussates
Axons gather to form spinothalamic tract

Third order neurone - thalamus to somatosensory cortex (in post-central gyrus of parietal lobe)

164
Q

How is pain intensity measured in Leeds?

A

Pain intensity score 0-3

165
Q

What analgesic would you prescribe for pain intensity score 0?

A

PRN paracetamol

166
Q

What analgesic would you prescribe for pain intensity score 1?

A

Regular paracetamol

PRN weak opioid and/or NSAID

167
Q

What analgesic would you prescribe for pain intensity score 2?

A

Regular: paracetamol, weak opioid, NSAID
PRN: strong opioid

168
Q

What analgesic would you prescribe for pain intensity score 3?

A

Regular paracetamol, NSAID

Regular strong opioid OR PCAS OR epidural/single shot spinal

169
Q

What is a common dose of paracetamol?

A

1 gram QDS

170
Q

What is a common dose of diclofenac?

171
Q

What is a common dose of codeine phosphate?

A

30-60 mg QDS

172
Q

What is a common dose of tramadol?

A

50-100 mg QDS

173
Q

What is a common dose of ibuprofen?

A

400 mg TDS

174
Q

What is a common dose of dihydrocodeine preparations?

175
Q

What a common dose of oramorph?

A

5-20 mg 4 hourly

176
Q

When (in anaesthetics) might you NOT give NSAIDS after surgery?

A

if there is a risk of bleeding after surgery
stomach problems
kidney problems

177
Q

Suggest an analgesic regimen for a 20 yr old healthy student that has just undergone an elective tonsillectomy

A

Pain intensity 2, therefore: paracetamol, ibuprofen, codeine

178
Q

Suggest an analgesic regimen for a 44 year old lady that has just undergone an elective abdominal hysterectomy. She told you pre-operatively that codeine has made her feel sick in the past

A

Paracetamol
Ibuprofen
Could use codeine with anti-emetic
Could use oromorph for break-through pain
COULD also use epidural, spinal block or TAP block

179
Q

Suggest an analgesic regimen for a 72 year old man with COPD and HTN that has just had a laparotomy for small bowel obstruction

A

Paracetamol, ibuprofen
Could use epidural (reduce sensation at site of pain)
OR
Patient-controlled analgesia (opioids)

180
Q

What are key features of patient controlled anaesthesia?

A

Patient is delivered about 1 mg dose IV of opioid per press of button
5 minute lock out period
Records what the patient has used

Safety: small boluses, lock-out period, opioid overdose = drowsiness = patient unable to keep pressing

181
Q

How do local anaesthetics work?

A

Block transmission of nerve impulses transiently

inhibit sodium channels on the nerve fibres (along axons)
Stops transmission of nerve impulse along first order neurone

therefore, information does not reach the brain

182
Q

What are the different types of local anaesthetics available?

A

Esters

Amides

183
Q

Name some amide local anaesthetics

A 
Lignocaine (lidocaine)
Bupivacaine
Mepivacaine
Prilocaine
Ropivicacaine 
levobupivocaine
184
Q

Name some esther local anaesthetics

A 
Benzocaine
Cocaine
Procaine	
Chloroprocaine
Tetracaine (amethocaine)
185
Q

Why might adrenaline be given alongside local anaesthetic?

A

prolong duration of anaesthesia
reduce systemic absorption
reduce surgical bleeding
increase the intensity of blockade.

186
Q

What is the max. dose of lignocaine one can prescribe? (WITHOUT adrenaline)

187
Q

What is the max. dose of lignocaine one can prescribe? (WITH adrenaline)

188
Q

What is the max. dose of bupivacaine (or levobupivacaine) one can prescribe? (WITHOUT adrenaline)

189
Q

What is the max. dose of bupivacaine (or levobupivacaine) one can prescribe? (WITH adrenaline)

A

2 mg/Kg (same as WITHOUT adrenaline)

190
Q

What is the max. dose of prilocaine one can prescribe? (WITHOUT adrenaline)

191
Q

What is the max. dose of prilocaine one can prescribe? (WITH adrenaline)

192
Q

What does EMLA stand for?

A

Eutectic mixture of local anaesthetics

193
Q

What does EMLA contain?

A

50:50 mixture of lignocaine and prilocaine

194
Q

You are in theatre anaesthetising an 60Kg woman for a laparotomy. At wound-closure, the surgeon asks you how much local anaesthetic he is allowed to safely infiltrate into the wound to help reduce post-operative pain.

You decide to suggest bupivacaine (or levobupivicaine) because it is the longest-acting local anaesthetic available to you, but how much do you tell him to use?

Comes in concentrations of 0.25% and 0.5%

A 
0.25% = 2.5 mg per ml
bupivacaine max dose: 2 mg/Kg
pt. 60 Kg
60 x 2 = 120
120/2.5 = 48
You would prescribe 48 mls of bupivacaine

if using 0.5% (5 mg per ml) = 24 mls needed

195
Q

Is Na a major intracellular or extracellular ion?

A

extracellular (mostly in the extracellular space)

196
Q

Is K a major intracellular or extracellular ion?

A

intracellular (higher concentration inside cell)

197
Q

Where do large particles like proteins and hydroxyethyl starch mainly stay? What does this do to the water concentration in blood?

A

in blood

holds water out in blood

198
Q

What is a person’s daily requirement of water?

A

25-35ml/kg

199
Q

What is a person’s daily requirement of energy?

A

30-40kcal/kg

200
Q

what is a person’s daily requirement of sodium?

A

1-2 mmol/kg

201
Q

what is a person’s daily requirement of potassium?

A

0.5-1mmol/kg

202
Q

is calcium generally found mainly intracellular or extracellularly?

A

extracellularly

203
Q

how many mls of water are lost by the body as ‘obligatory losses’?

A

1500ml a day

204
Q

What is sodium loss always accompanied by?

A

water loss

205
Q

What can cause decreased intake of fluids?

A 
being elderly
dysphagia
unconsciousness
fasting 
NBM
206
Q

What can cause increased loss of fluids?

A

fever/sweating
hyperventilation
GI losses (vom, diarrhoea)
renal loss (diuretics)

207
Q

What can cause an increased requirement for fluids?

A

trauma
burns
post-operative

208
Q

Where is fluid lost from in obligatory loss?

A

skin 500ml
Kidneys 500 ml
Lungs 400 ml
Gut 100 ml

209
Q

How does acute stress affect fluid balance?

A

leads to salt and water retention

210
Q

What counts as oliguria?

A

urine output <0.5ml/kg/hr

211
Q

List some crystalloid fluids

A

NaCl
dextrose
Dex/saline
Hartmans/Ringers/Compound sodium lactate

212
Q

List some colloids:

A

gelofusin
voluven
volulyte

213
Q

List some blood/bloo-like products:

A

red cells

albumin (HAS)

214
Q

What is a crystalloid (definition)?

A

Water soluble crystalline substance capable of diffusion through a semi-permeable membrane

can equilibrate across membrane

215
Q

What are the benefits of crystalloids?

A 
can rapidly infuse large volumes
readily available
cheap
equilibrate with large fluid compartments
short duration in circulation
216
Q

What are the disadvantages of crystalloids?

A

Risk of over-perfusion/pulmonary oedema

217
Q

What is the sodium chloride content of 1L 0.9% NaCl?

A

9g of NaCl per L

BECAUSE

% means gm/100ml - therefore 0.9gm/100ml
1L = 10 x 100ml

0.9 x 10 = 9

218
Q

How many mmol o f sodium and chloride ions are in 1L of saline?

A

154 of each

219
Q

If you are aiming to increase plasma volume by 1L, how much NaCl would you have to give?

220
Q

Where does saline go when given IV?

A

ALL EXTRACELLULAR

25% intravascular
75% interstitial

221
Q

What is the danger of giving too much sodium chloride (with relation to the chloride levels)?

A

hyperchloraemic acidosis

222
Q

What are some side effects of NaCl?

A 
abdo pain
nausea
hypercholoraemic acidosis
metabolic acidosis
high Cl and low bicarb
223
Q

What does Hartmann’s solution contain?

A 
Balanced salt solution
Na 131
Cl 111
K 5
Ca 2
Lactate 29
224
Q

Where does Hartmann’s go when given IV?

A

ALL IN EXTRACELLULAR FLUID (similar to sodium chloride)

225
Q

How much dextrose does 1L of 5% dextrose solution contain? What else is in the solution?

A

50g dextrose per litre of water

226
Q

How many calories are in 1g of dextrose? Roughly how many calories are in 1L of dextrose?

A

3.4Kcal

170Kcal

227
Q

How many litres of 5% dextrose need to be given to increase plasma volume by 1L?

228
Q

Where does the glucose in dextrose go once it is in the body?

A

glucose taken up by cells

liquid distributes throughout body water

229
Q

What is the content of 4% dextrose/0.18% NaCl (dec-saline)?

A 
40g dextrose (136Kcal)
30mmol Na/Cl
230
Q

What is the distribution of dec-saline?

A

similar to 5% dextrose

231
Q

What is the risk of dex-saline?

A

hyponatraemia

Free water = dilution = risk of hyponatraemia

232
Q

How much hartmann’s would you need to increase plasma volume by 1L?

233
Q

What’s a colloid?

A

A dispersion or suspension of finely divided particles in a continuous medium
NOT a solution

234
Q

Where does the fluid from a colloid go?

A

stays in circulation (if cell membrane is normal)

?more effective in resuscitation

235
Q

What are the disadvantages of colloids?

A

all contain NaCl - risk of hypercholoraemic acidosis

no oxygen carrying ability

236
Q

List some gelatine colloids

what is the gelatine stored in?

A

gelofusine
haemaccel
volplex

NaCl

237
Q

What is the half life of the gelatine colloids (in the plasma)?

238
Q

What is HAS?

A

Human albumin solution

pooled human plasma

239
Q

where does HAS go once given IV?

A

stays within intravascular space unless capillary permeability is abnormal

240
Q

What are the benefits of giving a patient blood?

A

ideal replacement for acute blood loss
expands intravascular volume
oxygen carriage

241
Q

what are some potential disadvantages of giving a patient blood?

A

transfusion reactions
infection risk
expensive

242
Q

Is blood crystalloid or colloid?

243
Q

How much of a 70Kg male’s body weight is water?

244
Q

How much of the 60% fluid that makes up a 70Kg male, is intracellular?

245
Q

How much of the 60% fluid that makes up a 70Kg male, is extracellular?

A

20%
(15% interstitial (3/4s)
(5% plasma (1/4))

246
Q 
Prescribe an IV fluid regimen for the next 24 hours for the following patient:
55yr old female
50Kg
ASA1
Elective total abdominal hysterectomy
fasted from midnight

what are the different combinations?

A

Water requirement: 40ml/Kg/day = 2000ml

Na requirement: 1.5 mol/Kg/day = 75mmol

K requirement: 1 mol/Kg/day = 50mmol

1L of dex-saline + 20 mmol K
followed by another bag of this.
Each over 8 hours.

(dex saline: 0.18% saline with 4% dextrose with 20 mmol K+)

60 mmol Na, 40 mmol K, 2000 ml

OR

Hartmann’s 500mL
Dextrose 5% 500mL + 10 mmol K
Dextrose 5% 1000ml + 20 mmol K

65 mmol Na, 32.5 mmol K, 2000 ml water, less chloride

247
Q

Prescribe an IV fluid regimen for the next 24 hours for the following patient:
80yr old male
Constipation, vomiting, abdo pain
Dx subacute bowel obstruction
Booked for acute theatre list following a.m.
pulse rate 120 bpm; BP 90/60; urine output 15ml/hr

A

Fluid challenge, see response

Replace deficit

(colloid boluses according to clinical response)

70kg and old: 100mmol Na, 60mmol K, 2500mL water.

Replace ongoing losses

500mL 0.45% saline with 5% dex
2L of 0.18% saline with 4% dex with 20 mmol K+

100 Na
40 K
13 gm glucose

248
Q

How would you assess fluid status?

A

Hands: temperature
skin turgor
increased cap refill time

Radial pulse: Increased rate, might be hard to feel

Carotid pulse: weak
JVP: not visible (or CVP low)

Face: dry skin
sunken eyes
dry lips
dry mucous membranes

Chest: reduced cap refill
Extra heart sounds (overloaded)
Tachycardia
Crackles (pulmonary oedema)

abdo: ascites

Legs: oedema

Look at: urine output
fluid balance chart
drug chart (diuretics or things that cause retention)
U+Es

249
Q

What might be signs of mild fluid deficit?

A

4% body weight lost
reduced skin turgor
dry mucous membranes

250
Q

What might be signs of moderate fluid deficit?

A

5-8% body weight lost
oliguria
tachycardia
hypotension

251
Q

What might be signs of severe fluid deficit?

A

> 8% body weight loss
profound analgesia
CVS collapse

252
Q

What are some common causes of abnormal fluid loss?

A

NG suction, vomiting, bowel problems

surgery

bleeding

Hyperventilation
Fever

Burns

Hyperglycaemia
diuretics

253
Q

What electrolytes are contained in 1L of 0.9% saline?

A 
Na: 154
Cl: 154
K: 0
Ca: 0 
Dextrose: 0
254
Q

What electrolytes are contained in 1L of Hartmann’s?

A 
Na: 131
Cl: 111
K: 4
Ca: 2
Dextrose: 0
255
Q

What electrolytes are contained in 1L of Gelatins?

A 
Na: 154
Cl: 125
K: 0
Ca: 0
Dextrose: 0
256
Q

What electrolytes are contained in 1L of 5% dextrose?

A 
Na: 0
Cl: 0
K: 0
Ca: 0
Dextrose: 5g
257
Q

What electrolytes are contained in 1L of 0.45% saline with 5% dex?

A 
Na: 77
Cl: 77
K: 0
Ca: 0
Dextrose: 5
258
Q

What electrolytes are contained in 1L of 0.18% saline with 4% dex WITH 20mmol K?

A 
Na: 31
Cl: 31
K: 20
Ca: 0
Dextrose: 4
259
Q

What electrolytes are contained in 1L of 0.18% saline with 4% dex WITH 40mmol K?

A 
Na: 31
Cl: 31
K: 40
Ca: 0
Dextrose: 4
260
Q

When might you avoid using Hartmann’s?

A

In patient with AKI

261
Q

What’s included on the WHO surgical safety checklist?

A 
Sign in:
Introductions
Pt identity
Surgical procedure and site
Anaesthetics equipment 
Allergies
Difficult airway risk
Risk of blood loss
Time out:
introductions
patient name
procedure and site
blood loss
specific requirements/investigations
any critical or unexpected steps

any patient specific concerns
patient ASA grade
what monitoring equipment and other specific levels are required?

Sterility confirmation
Equipment issues or concerns

Surgical site infection bundle
VTE
imaging displayed

Sign out:
Name of procedure recorded
Counts
Specimens labelled
Equipment problems identified that need to be addressed
Key concerns for recovery and management
262
Q

How do positive inotropes increase the contractility of the heart?

A

By increasing the concentration of intracellular calcium or increasing the sensitivity of receptor proteins to calcium (in the cardiac muscle)

263
Q

Give some examples of positive ionotropes:

A 
digoxin
amiodarone
calcium
(nor)epinephrine ((nor)adrenaline)
catecholamines eg: dopamine, dobutamine
theophylline
264
Q

Give some examples of negative inotropes:

A

beta-blockers
CCB
some anti-arrhythmias (incl. flecanide)

265
Q

What are vasopressors?

A

Drugs that cause vasoconstriction, therefore increase BP (MAP)

266
Q

when might positive inotropes be used?

A

decompensated congestive heart failure, cardiogenic shock, septic shock, myocardial infarction, cardiomyopathy, etc.

267
Q

When might vasopressors be used?

A

When BP is low eg. shock

268
Q

Give some examples of common vasopressors:

A 
(nor)epinephrine ((nor)adrenaline)
phenylephrine
dobutamine
ephedrine
steroids
(digoxin)
269
Q

What are some immediate and early post op complications?

A

Immediate: bleeding - haemorrhage, basal atelectasis and renal impairment

Early: MI, DVT/PE, pneumonia, other infections, confusion, renal failure

270
Q

What are some late post-op complications?

A

wound dehiscence

incisional hernia

271
Q

what are the different sections of GCS and what are the max scores for each?

A

Eyes: 4
Voice: 5
Motor: 6

272
Q

What does AVPU stand for?

A

Alert
Voice
Pain (GCS about 8)
Unresponsive

273
Q

If a patient becomes unwell following surgery, how should you manage them?

A

A-E

Appropriate investigations based on symptoms/background/clinical findings

274
Q

What are common post-op airway problems?

A

decreased muscle tone (?drugs)
secretions
sleep apnoea/body habits
laryngospasm

275
Q

What are less common post-op airway complications?

A

oedema/wound haemoatoma/recurrent laryngeal nerve palsy

foreign body

276
Q

List some causes of post-op hypoxia? How would you manage these initially?

A

alveolar hypoventilation

ventilation-perfusion mis-match: atelectasis, bronchopneumonia, aspiration, pneumothorax, pulmonary oedema

circulatory problems:
increased oxygen utilisation
low cardiac output (hypotension)

Oxygen
news/physio/ABX
Critical outreach

277
Q

what are some causes of post-op hypotension?

How would you manage this?

A

Low pre-load: Hypovolaemia

Low after-load:
vasodilation - rewarming, regional block, sepsis, anaphylaxis

Other: 
myocardial dysfunction
arrhythmias
tension pneumothorax
pulmonary embolism

IV access
Fluid challenge
Exclude bleeding
Exclude arrhythmias

278
Q

List some causes of post-operative nausea and vomiting

A

Patient factors: motion sickness, anxiety, non-smoker, pain response

Anaesthetic factors: opioids, etmoidate, N2O and volatile

Surgical factors: gynae, abdominal, middle ear, neurosurgery, ophthalmic

279
Q

How would you manage post-operative nausea and vomiting?

A

exclude hyperaemia and hypotension

Drugs:
Ondansetron (5 HT3 antagonists)
Cyclizine (anti-histamine)
Prochlorperazine (dopamine antagonist)

acupuncture at P6 (wrist)

280
Q

List some causes of post-op hypertension:

A 
pre-operative hypertension (drug omission)
hypoxia/hypercapnia
pain
agitation/confusion
urinary retention

arrhythmias: AF in elderly
electrolyte imbalance

DVT/PE

281
Q

What should you cover in the handover of a patient between anaesthetist and recovery team?

A

Patient details, operation and theatre.
◗ Underlying medical disorder.
◗ Allergy information.
◗ Anaesthetic technique including airway management.
◗ Peri-operative course and complications.
◗ Appropriate prescription charts available.
◗ Post-operative plan documented.
◗ Plan for continued invasive monitoring documented.
◗ Immediate concerns for the patient.

282
Q

When might PPI (lansoprazole) or H2 blockers (ranitidine) be used in anaesthesia?

A

Pre-operatively (reduce reflux)

Post-operatively (reduce effect of post-op dexamethasone analgesia)

283
Q

Which PPI is often used in anaesthesia?

A

lansoprazole

284
Q

Which H2 blocker is often used in anaesthesia?

A

ranitidine

285
Q

What circumstances might you premeditate someone for?

A 
Anxiety (benzodiazepines)
Amnesia (lorazepam/midazolam)
Analgesia (opioids)
Antivagal effects (hyoscine or glycopyrrolate)
Antiemetics
286
Q

What are different types of regional anaesthesia - how is this done?

A

Spinal anaesthesia
epidural anaesthesia
peripheral nerve block

injection near a cluster of nerves to number the area of the body that requires surgery

287
Q

When might regional anaesthesia be appropriate?

A

GI/liver: epidural, spinal or paravertebral nerve block eg. colon resections, surgery of stomach, intestines or liver

Gynaecology: hysterectomy, pelvic procedures, cesarean sections

ophthalmology

orthopaedics eg. fixing structures, amputations (if patients don’t want GA), arthroplasty

controlling pain in procedures of chest or oesophagus

urology: prostatectomy, nephrectomy

vascular surgery

288
Q

What is the purpose of pre-operative assessment?

A
  1. Allay fear and anxiety
  2. Identify potential anaesthetic difficulties and medical conditions
  3. Improve safety by assessing and quantifying risk.
  4. optimise and plan of the peri-operative care
  5. Provide an opportunity for explanation and discussion (consent)
289
Q

What are some of the complications of fasting?

A 
headache
light-headedness
discomfort
increased anxiety
increased incidence of nausea and vomiting
dehydration
hypotension
metabolic disturbances
290
Q

What is pre-oxygenation? Why is this done?

A

Tight-fitting face mask
3 mins or 5 full VC breaths OR oxygen >90

Rationale: replace FRC with oxygen

291
Q

What are the traditional RSI drugs (and how can this be commonly modified)?

A

Thiopentone 4-5 mg/kg
onset 15-30 seconds
action 4-8 minutes

suxemthonium 1-1.5 mg/kg
action 6 minutes

(propofol 1.5-2.5 mg/kg
onset 30 secs
action 6 minutes

rocuronium
onset 1 min (if large dose))

292
Q

Other than pre-oxygenation, what other techniques are used in RSI?

A

Cricoid pressure - remove after confirmation of tube position
no ventilation

293
Q

What is a common regimen of paracetamol?

294
Q

What is a common regimen of diclofenac?

295
Q

What is a common regimen of codeine phosphate?

A

30-60 mg

QDS

296
Q

What is a common regimen of tramadol?

A

50-100mg QDS

297
Q

What is a common regimen of ibuprofen ?

298
Q

What is a common regimen of dihydrocodeine?

299
Q

What is a common regimen of oramorph?

A

5-20mg

4 hourly

300
Q

What would you prescribe for pain intensity 1?

A

Paracetamol + NSAID + Weak opioid (e.g. Codeine Phosphate, Dihydrocodeine, Tramadol)

301
Q

What would you prescribe for pain intensity 2?

A

pain intensity 1 + oramorph

302
Q

What would you prescribe for pain intensity 3?

A

eg. Paracetamol + NSAID + Regular Oramorph or PCAS or Epidural or spinal or peripheral nerve block

303
Q

when might NSAIDS be contraindicated?

A

Sensitive bronchospasm, peptic ulcer disease, bleeding concerns, renal impairment, caution in Ischaemic Heart Disease, Hypertension and Stroke

304
Q

what type of anaesthetic agent is used for: wound infiltration, nerve blocks, central neuraxial blocks?

A

local anaesthetics

305
Q

You are anaesthetising a young man for a tendon repair of his left forearm following a work accident. He tells you that he is around 90kg. After speaking to the patient, he is keen to have the operation done under regional anaesthesia, avoiding the need for a general anaesthetic.

You decide that you would like to use 2% lignocaine (quicker acting, shorter duration than bupivacaine) to inject around his brachial plexus in the supraclavicular area and use 30 mL of the solution.

Is this safe?

A

How many mls of 2% lignocaine can be used?

90kg and 3mg/kg maximum dose = 270mg total dose

2% = 20 mg/ml = 270/20 = 13.5mls maximum therefore not safe to use 30 mls

What about:

1% lignocaine: 27 ml
2% lignocaine with adrenaline :this will allow up to 7mg/kg of lignocaine (630 mg = 31.5 mls)

306
Q

How would you immediately manage someone with local anaesthetic toxicity?

A

Immediate management

Stop injecting/stop surgery

Call for help and crash trolley

A: maintain airway, may need ET tube

B: 100% oxygen, ensure adequate lung ventilation (hyperventilation may help by increasing plasma pH in presence of acidosis)

C: IV access
Give benzo, thiopentone or propofol
get bloods (eg. ABG/VBG)
Lipid emulsion bolus (may need to repeat after 5 mins and then again after 10 mins)

307
Q

How does intralipid work?

A

reduces the concentration of free local anaesthetic by absorbing it up from the blood

308
Q

After immediate management, how would you treat a patient who’d suffered severe local anaesthetic toxicity?

A

Circulatory arrest: manage in-line with protocols (CPR etc.)

IV lipid emulsion (intralipid) infusion - while continuing CPR

Without circulatory arrest: manage hypotension, bradycardia, tachycardia.

309
Q

How would you follow up someone who’d suffered with local anaesthetic toxicity?

A

Transfer to clinical area

Exclude pancreatitis: daily amylase/lipase

Report to UK national patient safety agency

310
Q

What is the bolus dose of 20% intralipid?

A

1.5 ml/Kg over 1 min

311
Q

What is the initial dose and rate of 20% intralipid infusion that should be given to someone with local anaesthetic?

A

15 ml/Kg/hr

312
Q

When might you need to give the two further bolus doses of intralipid?

A

Cardiovascular stability not restored

Adequate circulation deteriorates

313
Q

When might you double the rate of 20% intralipid infusion to 30ml/Kg/h?

A

after 5 mins if:
Cardiovascular stability not restored
Adequate circulation deteriorates

Continue infusion until stable and adequate circulation restored or max dose of lipid emulsion given

314
Q

What is the maximum cumulative dose of 20% intralipid that can be given?

315
Q

What are the three lanes of the spinal cord?

A

(from inside out)
pia mater
arachnoid mater
dura mater

316
Q

Where is the CSF present?

A

between Pia and arachnoid (ie. subarachnoid space)

317
Q

Into which space is a spinal block given?

A

subarachnoid space

between pia and subarachnoid space

318
Q

Where does the epidural space lie?

A

between dura mater and vertebral canal

319
Q

In to which space is an epidural given?

A

epidural space (between dura mater and vertebral canal)

320
Q

Where does the spinal cord end?

A

lower border of L1

321
Q

Where does the subarachnoid space end?

322
Q

Where can you do a spinal block?

A

below L2
Up to S2

L4/5
L3/4
L2/3
(choose lowest level)

323
Q

Where does the epidural space?

A

saccoroccygeal hiatus

324
Q

Where can you do an epidural?

A

Any level, but risk of damage to cord if it is done above level of L1

325
Q

When might an epidural be given at a thoracic level?

A

laparotomy

326
Q

How is a spinal anaesthesia usually administered?

A

single shot of small volume of anaesthesia
(2-3 mls LA with/without opioid)

DIRECTLY IN TO CSF

327
Q

What is the onset of spinal anaesthesia? Is this faster or slower than an epidural?

A

5-10 mins

faster, epidural 15-30 mins

328
Q

What is the onset of epidural anaesthesia? Is this faster or slower than an a spinal?

A

15-30 mins

slower, spinal 5-10 mins

329
Q

Is spinal or epidural anaesthesia more reliable?

A

spinal is more predictable and reliable

epidural effect reliant on catheter position (unilateral blocks, missed segments, patchy blocks)

330
Q

Does spinal or epidural anaesthesia have a denser block?

A

Spinal: denser block, particularly motor

Epidural: less motor block

331
Q

How long does spinal anaesthesia last? Is this more or less than an epidural?

A

2-3 hours (may last longer, esp. if opioid is used)

Less than an epidural (up to 72 hours)

332
Q

How long does epidural anaesthesia last? Is this more or less than a spinal?

A

Up to 72 hours

More than spinal (2-3 hours - can be longer if opioid given)

333
Q

What are the advantages of epidural or spinal over opioids?

A

can be used in patients with respiratory disease

painful wounds my lead to reduced lung expansion and increased risk of post-op respiratory complications

Patients in whome IV analgesics are less desirable eg. sleep apnea, PONV

334
Q

When might you use spinal analgesia or epidurals?

A

C-section
lower limb ortho
peri-anal surgery

335
Q

When might you use spinal analgesia or epidurals for analgesia?

A

intra-abdo surgery/laparotomy (epidural for intra-operative and up to 72 hours post-operative analgesia)

336
Q

What would you want to know about a patients cardiovascular health in a pre-operative assessment?

A

PMH: IHD, HTN, angina, Heart failure

Often a result of co-exisiting problems: DM, renal disease, PVD, respiratory disease or CVD

Chest pina
PND
Orthopnoea
Exercise tolerance
Pacemakers
337
Q

How is exercise tolerance measured?

A

METS (metabolic equivalents)

1 MET: eating and dressing

3 METS: light household activity or walk 100m

4 METS: climb two flights of stairs

6-7 METS: short run

338
Q

Which cardiovascular signs would make you consider a patient as high-risk for undergoing anaesthetics?

A

MI <1 month ago

Unstable angina

339
Q

What DBP is considered dangers for surgery? How would you try and change this?

A

> 115
Treat for 4 weeks to get <115
Look for end-organ damage

340
Q

If a patient had a history of heart problems (esp. recently), what investigations would you do?

A

Routine + :

ECG
Echo
Exercise or stress-test as indicated

341
Q

What would you want to know about a patients respiratory health in a pre-operative assessment?

A 
Chest infection Sx
COPD
SOB
Smoking
Dyspnoea grade
Asthma (controlled etc.)
Sleep apnoea
342
Q

What are the different dyspnoea grades?

A

0: normal
1: unlimited walk
2: 200-400 meteres
3: kitchen to bathroom
4: at rest

343
Q

How would you manage a patient with asthma prior to surgery?

A

assess control
nebuliser salbutamol
FIND OUT WHETHER THEY HAVE REACTION TO NSAIDS

344
Q

What would you recommend to a patient re. stopping smoking prior to surgery?

A

Stop 12 hours: increased cardiovascular reserve
24-28 hours: CO levels normal and ciliary function improves
2 weeks: mucus secretions decrease, bronchial and airway reactivity normal
4 weeks: improvement in smaller airways
2-6 weeks: paradoxical increase in secretions

8 weeks: normalised - recommended

345
Q

What should you do for a patient with sleep apnoea, undergoing GA (with opioids)?

A

Arrange overnight HDU bed

346
Q

What are the systemic effects of rheumatoid arthritis (that might be important to find out pre-operatively)?

A

Joints: TM joint
Glottic stenosis
Atlanta-axial subluxation (NEED NECK XRAY)

CVS: asymptomatic pericardial effusion

RS: pulmonary nodules and fibrosis

Anaemia

Renal impairment

Peripheral neuropathy

347
Q

What are the systemic effects of rheumatoid arthritis (that might be important to find out pre-operatively)?

A 
Joints: TM joint
Glottic stenosis (circa-arytenoid joints)
Atlanta-axial subluxation (NEED NECK XRAY)

CVS: asymptomatic pericardial effusion

RS: pulmonary nodules and fibrosis

Anaemia

Renal impairment

Peripheral neuropathy

348
Q

What investigations would you like to do pre-operatively for a patient with RA?

A

Bloods: FBC
U&Es

Imaging: 
ECG
CXR
Cervical spine xray
Echo

PFT or ENT opinion

Prepare for difficult airway

349
Q

What are the systemic effects of DM that you would be concerned about pre-operatively?

A

CVS: HTN, Silent MI, autonomic neuropathy

RS: INCreased infection risk

Renal: renal failure

Airway: thickening sont tissue

GI: delayed gastric emptying

Eyes: cataracts

Others: infection risk

350
Q

How would you manage a patient with DM pre-operatively?

A

Avoid hyper/hypos
monitor glucose and electrolytes
?sliding scale insulin

Prep: BG
urine glucose and ketones
ECG
U&amp;Es
First on list
351
Q

What’s included in an airway assessment?

A 
Hx (health problems or previous difficult airway)
Examination
Mallampattie scale
teeth
thyromental distance
sternomental distance
neck movement
1-2-3
cormack and lehane
352
Q

What are some symptoms of local anaesthetic toxicity?

A 
excitatory signs: circumoral numbness
tongue parasthesia
dizziness
restlessness
agitation

CNS depression: slurred speech, drowsiness, unconsciousness

Sudden altered mental status, agitation and loss of consciousness

Muscle twitching, tonic-clonic seizures

respiratory arrest

cardiac arrhythmias

353
Q

What do modern anaesthetic machines NOT allow anaesthetists to do by accident?

A

hypoxic mixture (full nitrous)

more than one vaporiser

354
Q

How does atropine work?

What dose is given?

What are the side effects?

A

muscarninc antagonist

10-20 micrograms/kilo

decreased secretions
reduced gastro-oesophageal tone
urinary retentions
tachycardia
confusion (in elderly)
355
Q

What are the effects of midazolam?

What is the dose?

What can it be used for?

A 
anxiolytic/sedative
anterograde amnesic
hypnotic
anti-convulsant
skeletal muscle relaxant

1mg-2.5mg MAX
administer over at least 2 mins

Procedural sedation
pre-operative sedation (orally in children)
Induction of GA
sedation of ventilated patients in ICU

ACC (6 decks)

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