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4th Year ACC > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Propofol dose?

A

1.5-2.5 mg/kg

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2
Q

Thiopentone dose?

A

4-5 mg/kg

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3
Q

Ketamine dose?

A

1-1.5 mg/kg

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4
Q

Etomidate dose?

A

0.3 mg/kg

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5
Q

Benefits of propofol?

A
  • Good suppression of airway reflexes – no laryngospasm.

* ↓Incidence of PONV.

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6
Q

Benefits of thiopentone?

A
  • Faster than propofol

* Antiepileptic properties and protects brain.

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7
Q

Benefits of ketamine?

A

• Dissociative amnesia and profound amnesia

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8
Q

Unwanted effects of propofol?

A
  • ↓HR and BP
  • Pain on injection
  • Involuntary movements
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9
Q

Unwanted effects of thiopentone?

A
  • ↓BP but ↑HR
  • Histamine release –> rash/bronchospasm
  • Intrarterial injection –> crystalise in smaller vessels –> thrombosis + gangrene
  • Contraindicated in prophyria
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10
Q

Unwanted effects of ketamine?

A
  • N + V

* Emergence phenomenon – vivid dreams, hallucinations

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11
Q

Benefits of etomidate?

A
  • Rapid onset
  • Haemodynamic stability
  • Lowest incidence of hypersensitivity reaction
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12
Q

Unwanted effects of etomidate?

A
  • Pain on injection
  • Spontaneous movements
  • Adreno-cortical suppression
  • High incidence PONV
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13
Q

General stuff about propofol?

A

• Lipid based (white emulsion)

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14
Q

General stuff about thiopentone?

A

• Used for rapid sequence induction

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15
Q

General stuff about ketamine?

A
  • Slow onset (90 secs)

* Sympathetic stimulation –> ↑HR/BP, bronchodilation

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16
Q

General stuff about etomidate?

A

• Shouldn’t use in critically ill patients with septic shock –> ↑mortality

Steroid injection

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17
Q

What is MAC?

A

Minimum alveolar concentration or MAC is the concentration of a vapour in the lungs that is needed to prevent movement (motor response) in 50% of subjects in response to surgical (pain) stimulus.

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18
Q

Nitrous oxide MAC?

A

104%

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19
Q

Isoflurane MAC?

A

1.15%

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20
Q

Sevoflurane MAC?

A

2%

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21
Q

Deflurane MAC?

A

6%

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22
Q

Enflurane MAC?

A

1.6%

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23
Q

Benefits of isoflurane?

A

• Least effect on organ blood flow - good for transplant

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24
Q

Benefits of sevoflurane?

A
  • Sweet smelling
  • Inhalational induction
  • Good if you don’t want to do multiple cannula attempts while awake, or if scared of needles etc.
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25
Q

Benefits of deflurane?

A
  • Rapid onset and offset
  • Low lipid solubility –> pt will wake up faster after op.

Good for long operations

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26
Q

Suxamethonium dose?

A

1-1.5 mg/kg

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27
Q

Mechanism of suxamethonium?

A

Act similar to Ach on nAchR but are very slowly hydrolysed by AchE. Cause fasciculation, muscle then fatigues and relaxes.

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28
Q

Side effects of suxamethonium?

A
  • Muscle pains
  • Fasciculations
  • Hyperkalaemia
  • Malignant hyperthermia
  • ↑ICP, ↑IOP and ↑gastric pressure – don’t use in patients with eye injury –> expulsion of eyeball contents.
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29
Q

Mechanism of non-depolarising muscle relaxants?

A

Compete with Ach for nAchR.

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30
Q

Benefits of non-depolarising muscle relaxants?

A

• Slow onset and variable duration – less side effects.

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31
Q

Short-acting non-depolarising muscle relaxants?

A

Atracurium, Mivacurium

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32
Q

Intermediate-acting non-depolarising muscle relaxants?

A

Vecuronium, Rocuronium

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33
Q

Long acting non-depolariisng muscle relaxants?

A

Pancuronium – cannot reverse within 1 hou

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34
Q

Name a muscle relaxant reversal agent?

A

Neostigmine - anti-cholinesterase, prevents breakdown of Ach

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35
Q

Adverse effects of neostigmine?

A

• Ach is ↑ all over body –> antimuscarinic effects (↓HR etc.)

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36
Q

What is neostigmine combined with?

A

• Combined with antimuscarinic agent – Glycopyrrolate - blocks muscarinic receptors so neostigmine only effective at NMJ.

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37
Q

Short acting opioids?

A
  • Fentanyl
  • Alfentanil
  • Remifntanil
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38
Q

Long acting opioids?

A
  • Morphine

* Oxycodone

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39
Q

General stuff about short-acting opioids?

A
  • Take longer than induction agents (1-5 minutes) – give before induction agent.
  • Intra-op analgesia, suppress response to laryngoscopy, surgical pain.
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40
Q

Name some analgesics that can be given IV?

A

Paracetamol
Parecoxib
Kertorolac
Dihydrocodeine

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41
Q

3 drugs used for hypotension?

A

Ephedrine
Phenylepherine
Metaraminol

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42
Q

Action and mechanism of ephedrine?

A

↑HR + ↑inotropy  ↑BP

Direct and indirect action – α and β receptors

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43
Q

Action and mechanism of phenylepherine?

A

Vasoconstriction + ↓HR –> ↑BP

Direct action – α receptors

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44
Q

Action and mechanism of metaraminol?

A

Vasoconstriction –> ↑BP

Direct and indirect action – predominantly α receptors

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45
Q

3 drugs used in severe hypotension/ICU

A

Noradrenaline, Adrenaline, Dobutamine

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46
Q

Anti-emetics and their types?

A

Ondansetron (1) - 5HT3 blocker

Dexamethasone (2) - Anti-histamine

Cyclizine (3) - Steroid

Prochlorperazine (Stemetil) - Phenothiazine

Metaclopramide - Anti-dopaminergic

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47
Q

What is Mallampati score?

A

I - complete visualization of soft palate

II - complete visualization of the uvula

III - visualization of only the base of the uvula

IV - soft palate not visible at all

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48
Q

List of things to cover in perioperative assessment?

A 
CVS
Resp
Airway
Previous anaesthetic history
GI
PMH
Medication Hx
History of allergies
Examination
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49
Q

Things to ask in CVS?

A

Chest pain (SOCRATES), hypertension, PND, orthopnoea, exercise tolerance

50
Q

Things to ask in resp?

A

Asthma, any evidence of chest infection i.e. cough, smoking

51
Q

Things to ask in airway?

A

Teeth, dentures, neck movements, mouth opening (Mallampatti score)

52
Q

Things to ask in previous anaesthetic history?

A

Any problems, PONV, pain relief, family history of anaesthetic problems

53
Q

Things to ask in GI?

A

History of GORD, last meal time

54
Q

Things to ask in PMH?

A

Diabetes, epilepsy, renal disease, thyroid problems, TIA, stroke or other

55
Q

Purpose of perioperative 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 plan of peri-operative care
  5. Provide opportunity for explanation and discussion (consent – only needs to be verbal for anaesthesia).
56
Q

Why aren’t perioperative investigations done in all patients?

A
  • Expensive
  • Labour intensive
  • May delay surgery
  • Associated morbidity: pain, haematoma, infection etc.
57
Q

What things affect what perioperative investigations are necessary?

A

Age
ASA grade
Nature of the surgery

58
Q

What is ASA grading?

A
  • A physical status classification system for assessing fitness for surgery
  • For emergency cases the suffix ‘E’ is used.
59
Q

Summary of ASA grading?

A

1 - A healthy patient with no systemic disease

2 - Mild to moderate systemic disease with no functional limitation.

3 - Severe systemic disease imposing functional limitation on patient

4 - Severe systemic disease which is a constant threat to life

5 - Moribund patient who is not expected to survive with or without the operation

6 - A brainstem-dead patient whose organs are being removed for donor purposes.

60
Q

Summary of surgical grading?

A

1 - (minor) Excision skin lesion; Cystoscopy: Drainage of an abscess

2 - (intermediate) Inguinal hernia; Tonsillectomy

3 - (major) Hysterectomy; Thyroidectomy

4 - (major+) Joint replacement; thoracic operations, Total hip replacement, Radical neck dissection

61
Q

Which investigations do people >80yrs get?

A

FBC, U+E, ECG

62
Q

Circumstances where <60s need investigations?

A

FBC - SG >3
U+E - SG >4
ECG - never

63
Q

Circumstances where 60-80 need investigations?

A

FBC - SG >2
U+E - SG >3
ECG - SG >3

64
Q

Special circumstances for investigations?

A
  • African / Afro-Caribbean origin or positive family history : Sickle test
  • Women: Pregnancy test for women who may be pregnant.
  • Intensive care admission, Respiratory disease in ASA 3 or 4: CXR
65
Q

What questions need to be asked if patient is not fit for surgery?

A
  • Is the surgery emergency or elective?
  • How will any further investigations add to management?
  • If I postpone, what benefit will the patient get? (i.e. better physiology, reduced risk etc.)
66
Q

Problems with inadequate fasting?

A

Pulmonary aspiration. As low as 30 mL can be associated with significant morbidity and mortality.

67
Q

Problems with prolonged fasting?

A

Headache, light-headedness, discomfort, increased anxiety, increased incidence of N+V, hypotension, metabolic disturbances.

68
Q

Fasting time for solids and milk-containing drinks?

A

6 hours - fat in milk curdles and thickens

69
Q

Fasting time for breastfed infants?

A

4 hours - human milk has less fat

70
Q

Fasting time for clear fluids?

A

2 hours - Clear means you can see through the fluid. Minimal sip (30mL allowed to take tablets).

71
Q

Fasting time for alcohol?

A

24 hours - delays gastric emptying

72
Q

Fasting time for boiled sweets/chewing gum?

A

Avoid but carry on with surgery - Leads to increased gastric volume and acidity.

73
Q

Indication for rapid sequence induction?

A

Full stomach for any reason i.e. high risk of aspiration.

74
Q

What are factors that delay gastric emptying?

A
  • Metabolic = diabetes, end stage renal failure
  • Anatomical causes = pyloric stenosis
  • Mechanical = pregnancy, obesity
  • Trauma = RTA, head injury
  • Others = high fat content, anxiety
75
Q

Process of rapid sequence induction? (preoxygenation)

A

Preoxygenation

  • Tight fitting face mask for three minutes or 5 full vital capacity breaths, EtO2 concentration > 90
  • Rationale: replace functional residual capacity (FRC) with oxygen
76
Q

Process of rapid sequence induction? (Drugs)

A
  • Thiopentone: 4 – 5 mg/kg, onset: 15 -30 seconds duration, Duration of action: 4- 8 minutes
  • Propofol: 1.5 – 2.5 mg/kg, Onset: 30 seconds, DOA: 2 – 6 minutes
  • Suxamethonium: 1 -1.5 mg/kg: DOA 6 minutes
77
Q

Process of rapid sequence induction? (Technique)

A
  • Cricoid Pressure: (Cricoid cartilage is a complete ring)
  • No ventilation
  • Remove cricoid after confirmation of tube position (EtCO2) + other signs (direct visualisation, moisture in expired air, chest expansion, chest auscultation)
78
Q

What are the four CEPOD classifications?

A

Immediate/emergency
Urgent
Expedited/scheduled
Elective

79
Q

Description/example of emergency surgery?

A

◦ Immediate life, limb or organ-saving intervention.
◦ Resuscitation simultaneous with intervention.
◦ Normally within minutes of decision to operate.

Repair of ruptured aortic aneurysm, Fasciotomy

80
Q

Description/example of urgent surgery?

A

◦ Intervention for acute onset or clinical deterioration of potentially life or limb threatening conditions.
◦ Time available for resuscitation.
◦ Normally within hours of decision to operate.

Debridement plus fixation of fracture, Intestinal perforation

81
Q

Description/example of expedited/scheduled surgery?

A

◦ Patient requiring early treatment where the condition is not an immediate threat to life or limb. ◦ Normally within days of decision to operate.

Repair of tendon and nerve injuries, Excision of tumour with potential to bleed or obstruct

82
Q

Description/example of elective surgery?

A

◦ Intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff. (18 weeks initiative)

Elective AAA repair, Laparoscopic cholecystectomy

83
Q

Describe physiology of pain?

A
  1. First order neuron - Site of injury –> dorsal root ganglion (cell body of 1st order neurons) –spinal cord (peripheral nerve like radial nerve).
  2. Second order neuron - Spinal cord –> thalamus (lateral spinothalamic tract)
  3. Third order neuron. Thalamus –> Somatosensory area one and two in post central gyrus of parietal cortex (thalamo-cortical pathways)
84
Q

`Dose of paracetamol?

A

1 gram QDS

85
Q

Dose of ibuprofen?

A

400mg TDS

86
Q

Dose of diclofenac?

A

50mg TDS

87
Q

Dose of dihydrocodeine?

A

30mg QDS

88
Q

Dose of coedine phosphate?

A

30-60mg QDS

89
Q

Dose of tramadol?

A

50-100mg QDS

90
Q

Dose of oramorph?

A

5-20mg 4 hourly

91
Q

Contraindications/ cautions for NSAIDs?

A

Sensitive bronchospasm, peptic ulcer disease, bleeding concerns, renal impairment

  • Caution in IHD, hypertension and stroke. Some agents, particularly COX2s, have been associated with higher risk of MI and stroke.
92
Q

Principle of PCA?

A

A syringe pump containing the analgesic drug is connected to the patient’s IV cannula and the patient uses a button to request a bolus of analgesia.

A safe steady state of analgesia using frequent small boluses to maintain rather than ‘spikes’ of alternating pain and analgesia with PRN medications.

93
Q

Typical regimen of PCA?

A

1mg Morphine allowed every 5 minutes (‘lock-out’ period)

94
Q

Lock-out period in PCA?

A

The patient can press the button as often as they feel is required but the device will only allow a bolus to be administered every 5 minutes.

95
Q

Inherent safety mechanisms in PCA?

A
  • Small bolus doses
  • Lock-out period (usually 5 minutes)
  • Opioid overdose will usually lead to drowsiness therefore patient will not be able to keep pressing. - Better monitoring for the patient through use of dedicated observation charts
96
Q

Mechanism of local anaesthetics?

A

Local anaesthetics block the transmission of the nerve impulse transiently.

Inhibition of Sodium channel in axon preventing K/Na exchange and transmission of nerve impulse

The sensory information is blocked at the site of application and does not reach the brain

97
Q

What two groups are LAs composed of?

A

Lipid-soluble hydrophobic aromatic group + charged, hydrophilic amide group.

Joined together by either an ester or amide link –> ESTERS and AMIDES

98
Q

Examples of esters?

A
  • Procaine, amethocaine (Ametop), cocaine (not really used anymore)
99
Q

Examples of amides?

A
  • Ropivacaine, levobupivacaine, bupivacaine, mepicaine, prilocaine
100
Q

Maximum dose of lignocaine with and without adrenaline?

A

3mg/kg

7mg/kg with adrenaline

101
Q

Max dose of bupivocaine/ levobupivocaine with and without adrenaline?

A

2mg/kg SAME WITH ADRENALINE

102
Q

Max dose of prilocaine with and without adrenaline?

A

6mg/kg

9mg/kg with adrenaline

103
Q

Which local anaesthetic is longest acting?

A

Bupivacaine/levobupivacaine

104
Q

Which LA is quicker acting, shorter duration?

A

Lignocaine

105
Q

How to calculate safe dose of local anaesthetic?

A
  • % concentration –> multiply by 10 –> content of LA in mg/ml (0.25% bupivacaine contains 2.5mg/ml)
  • Calculate max dose – multiply max dose in mg/kg by weight
  • Divide max dose by concentration in mg/ml
106
Q

Features of local anaesthetic toxicity?

A
  • Tingling around mouth
  • Ringing in ears
  • Tonic-clonic seizure
  • Cardiovascular/ respiratory failure after
107
Q

Management of LA toxicity?

A
  • ABCDE approach
  • 100% oxygen
  • Call for help
  • Tell surgeons to stop
  • Send for crash trolley and intralipid
  • Start IV fluids
  • If no palpable pulse/poor respiratory effort –> initiate basic/advanced life support as per algorithms, good supportive care.
  • Consider use of intralipid – reduces concentration of free local anaesthetic by absorbing it from the blood.
108
Q

What are the layers of the spinal cord?

A
  1. Dura mater
  2. Arachnoid mater
  3. Pia mater
109
Q

What level does the spinal cord end?

A

Lower border of L1

110
Q

Where does subarachnoid space end?

A

S2

111
Q

Between which vertebrae can spinal be done?

A

Below L2 and up to S2

L2/3
L3/L4
L4/L5

(Lowest level possible to minimise risk of damage to spinal cord)

112
Q

Where does the epidural space end?

A

saccrococcygeal hiatus.

113
Q

Where can epidural be done?

A

Any level - but risk of damage to the cord if it is done above the level of L1.

114
Q

Where would epidural be done for labour and laparotomy respectively?

A

Labour - same as spinal

Laparotomy - thoracic level (hypotension)

115
Q

Differences in essence of spinal and epidural?

A

Spinal = single shot injection of small volume anaesthesia mix (2-3 mls LA +/- opioid) directly into CSF

Epidural = Infiltration of LA +/- opioid mix via epidural catheter

116
Q

Differences in onset of spinal and epidural?

A

Spinal = more rapid onset (5-10 mins)

Epidural = Slower onset (15 -30 minutes)

117
Q

Differences in predictability between spinal and epidural?

A

Spinal = more predictable/reliable for anaesthesia

Epidural = Effect is reliant on catheter position (e.g. unilateral blocks, missed segments, patchy blocks etc.)

118
Q

Differences in density of block between spinal and epidural?

A

Spinal = denser block, particularly motor

Epidural = less motor block

119
Q

Differences in duration of block between spinal and epidural?

A

Spinal = Good anaesthesia for 2-3 hours, analgesia may last longer (especially if opioid used)

Epidural = Usually used for titratable anaesthesia/analgesia for a longer period (up to 72 hours)

120
Q

Advantages of regional anaesthesia over opioids?

A

Better in patients with respiratory disease as painful wounds may lead to reduced lung expansion and increased risk of post-op respiratory complications, patients in whom intravenous analgesics may be less desirable (e.g. obstructive sleep apnoea, PONV) etc.

4th Year ACC (9 decks)

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