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anaesthetics Flashcards

1
Q

where does general anaesthetic provide sensensibility

A

whole body

implies loss of consciousness and global lack of awareness

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2
Q

where does regional anaesthetic provide sensensibility

A

an area or region of the body

Nerve and plexus blocks

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3
Q

where does local anaesthetic provide sensensibility

A

local relevant area - direct to tissue being anaesthetised

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4
Q

what type of anaesthetics are spinal/ epidurals

A

regional

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5
Q

what is the triad of anaesthetics

A

hypnosis
analgesiia
relaxation (skeletal muscle)

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6
Q

what does hypnosis mean

A

unconscious

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7
Q

what is the aim of pain relief

A

removal of perception of unpleasant stimulus

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8
Q

what are some problems of balanced anaesthesia

A

¥ Polypharmacy - Inc chance of drug reactions / allergies
¥ Muscle relaxation - requirement for artificial ventilation, means of airway control
¥ Separation of muscle relaxation & hypnosis – awareness – patients awake from wrong dose yet paralysed so unable to communicate

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9
Q

what are the principles of balanced anaesthesia

A

¥ Different drugs to do different jobs
¥ Titrate doses separately & therefore more accurately to requirements
¥ Avoid overdosage
Control over individual components of the triad

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10
Q

how are general anaesthetics given

A

inhaled (maintenance) or IV (induction)
(Inhalational agents dissolve in lipid membranes Direct physical effect
Intravenous agents -allosteric binding e,g. GABA receptors also open chloride channels)

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11
Q

what ion channel is sully targeted in GA and why

A

chlorine

Hyperpolarise neurones = Less likely to “fire” (suppress excitatory synaptic activity)

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12
Q

after GA what functions are lost first

A

most complex then primitive lost later

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13
Q

are reflexes spared in GA

A

yes

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14
Q

what must be managed when the patient is under GA

A

airway and cardiovascular

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15
Q

what is the name of the pump system that allows accurate infusion to achieve specific blood or brain concentrations of agents using complex pharmacokinetic algorithms

A

target controlled infusion (TCI)

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16
Q

what is a problem with IV anaesthesia and how is this controlled

A

can’t measure drug concentration in real time

Use computers to calculate a guess

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17
Q

are IV anaesthesia drugs fat or water soluble

A

fat - cross membrane quickly

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18
Q

what is the rapid recovery form IV anaesthesia due to

A

drug leaving the circulation and moving to other parts of the body eg muscle and viscera organs

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19
Q

list some anaesthetics that are given IV

A

thiopentone

propofol

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20
Q

list some anaesthetics that are inhaled

A

halogenated hydrocarbons

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21
Q

which organ does the uptake and excretion of inhaled anaesthestics

A

lung
(concentration gradient - lungs > blood > brain
cross alveolar BM easily
arterial concn equates closely to alveolar partial pressure)

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22
Q

what is the MAC (mean alveolar concentration) a measure of (inhaled anaesthetic)

A

measure of potency
low number = high potency
(less concentration to produce the same affect)

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23
Q

why are really high doses of inhaled anaesthesia given for induction

A

gas down the concentration gradient in to the patients blood and finally brain to achieve a high enough partial pressure there to produce unconsciousness

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24
Q

what is the main role of inhalation agents

A

extension or continuation of anaesthesia

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25
Q

what are the central CVS effects of GA

A

depress cardiovascular centre
reduce sympathetic outflow
negative inotropic/chronotropic effect on heart
reduced vasoconstrictor tone → vasodilation

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26
Q

what do anaesthetics do to respiratory system

A

depress
Reduce hypoxic and hypercarbic drive
Decreased tidal volume & increase rate
paralyse cilia

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27
Q

what is the exception to all anaesthetics being CVS depressant

A

ketamine

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28
Q

why does CO fall under anaesthesia

A

vasodilation reduces venous return to the heart

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29
Q

what are the differences between anaesthetic and opiate respiratory depression

A

opiate - preserves tidal volume, low respiratory rate

anaesthetic - reduced tidal volume, high respiratory rate

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30
Q

why do some post op patients need anaesthetics for several days

A

greatly reduced lung volume can interfere with ventilation/ perfusion matching

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31
Q

what are indications for muscle relaxants

A

ventilation & Intubation
when immobility is essential - microscopic surgery, neurosurgery
body cavity surgery (access)

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32
Q

list some problems with muscle relaxants

A

awareness
incomplete reversal → airway obstruction, ventilatory insufficiency in immediate post op period
apnoea = dependence on airway & ventilatory support

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33
Q

why is anaesthetic given intra-operatively

A

Prevention of arousal (pain)
Opiates contribute to hypnotic effect of GA
Suppression of reflex responses to painful stimuli (hypertension, tachycardia)

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34
Q

which system is relatively spared in regional anaesthetic compared to general

A

respiratory

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35
Q

what are the 7 steps in the process of anaesthesia

A 
pre-opeartive assessment
preparation 
induction 
maintenace (monitoring)
emergence
recovery 
post operative assessment
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36
Q

what is the time of onset for IV induction of anaesthetic

A

one arm brain circulation - 20s

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37
Q

do you remain conscious with local and regional anaesthetics

A

yes

CVS derangement proportional to size of area

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38
Q

what is a limiting factor for use of local anaesthetic

A

toxicity

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39
Q

why is toxicity a risk factor in local anaesthetics

A

absorption > rate of metabolism = high plasma levels

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40
Q

what things does the toxicity of LA depend on

A

dose used
rate of absorption (site dependant - perfusion)
patient weight
drug ( bupivacaine > lignocaine > prilocaine )

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41
Q

list some signs and symptoms of local anaesthetic toxicity

A 
Circumoral and lingual numbness and tingling
Light-headedness
Tinnitus,  visual disturbances
Muscular twitching
Drowsiness
Cardiovascular depression
Convulsions
Coma
Cardiorespiratory arrest
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42
Q

why are some areas easier to block with LA than others (differential block)

A

different nerve fibre types - thickness and myelination

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43
Q

what makes pain fibres easier to block with LA than motor fibres

A

thinner and less myelinated

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44
Q

during anaesthesia what is a cough depednent on

A

abdominal muscles (expiratory function)

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45
Q

during anaesthesia which is more spared, inspiration or expiration

A

inspiration (instercostaals and accessory muscles higher root nerves)

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46
Q

list some considerations in the pre-operative preparation of GA

A

Planning - checklist - Right patient, right operation
Right (or left) side
Pre-medication (sedatives/ analgesia)
Right equipment, right personnel Drugs drawn up
IV access - Monitoring

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47
Q

what agents may be used for the IV induction of anaesthesia

A

Propofol - standard, less hangover, quick, less side effects

thiopentone - barbiturate, maternity hospital

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48
Q

why do you need good airway control in GA

A

apnoea very common

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49
Q

what drug may be used for the gaseous induction of anaesthesia

A

sevoflurane

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50
Q

in what patients is gaseous induction of anaesthesia better than gaseous

A

younger children

IV drug users

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51
Q

what is the triple airway manoeuvre in airway maintenance

A

head tilt, chin lift, jaw thrust

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52
Q

what manoeuvre can solve an airway obstruction but to loss on tone from the tongue

A

jaw thrust

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53
Q

what is the minimum monitoring in anaesthetics

A

SpO2, ECG, NIBP, FiO2, ETCO2

temperature, urine output

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54
Q

what is a common post operative side effect of anaesthesia

A

nausea and vomitting

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55
Q

what are different planes of anaesthesia

A

analgesia
excitation
anaesthesia
overdose

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56
Q

list some different methods of airway management

A 
Oropharyngeal airway (Guedel) 
Laryngeal mask 
endotracheal intubation
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57
Q

which patents can tolerate a Oropharyngeal airway (Guedel

A

unconscious

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58
Q

what is a laryngeal mask airway

A

Cuffed tube with ‘mask’ sitting over glottis

Maintains, but does not protect the airway

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59
Q

what reflex must be abolished before endotracheal intubation

A

laryngeal

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60
Q

what is the most common airway complication

A

Ineffective Triple Airway Manoeuvre

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61
Q

list some complications of airway management

A

Ineffective Triple Airway Manoeuvre
Airway device malposition or kinking
laryngospasm
aspiration - gastric contents, blood, surgical debris

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62
Q

what is the only thing that protects the airway from contamination

A

cuffed tube in the trachea

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63
Q

list reasons for intubating

A

Protect airway from gastric contents
Need for muscle relaxation artificial ventilation
Shared airway with risk of blood contamination- e.g. tonsillectomy in ENT
Need for tight control of blood gases
Restricted access to airway - e.g. Maxillo-facial surgery

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64
Q

what are anaesthetic risks to an unconscious patient

A 
“Airway, Airway, Airway”
Temperature
Loss of other protective reflexes - eg corneal, joint position (dislocate shoulder) 
Venous thromboembolism risk
Consent & Identification
Pressure areas
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65
Q

what are the main complications of anaesthesia

A

airway, breathing, circulation
related to techniques. position
awareness

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66
Q

what are some of the anaesthetists roles pre-op

A 
Assess patient as whole for procedure 
Identify high risk  - high morbidity and mortality 
Optimise patients to minimise risk 
Inform and support patients decisions
Consent from patient
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67
Q

should you continue a patients medications before an operation

A

mostly
especially Inhalers, Anti-anginals, Anti-epileptics,
Most cardio/ respiratory medications

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68
Q

what medications should be discontinued before an operation

A

anti-diabetic medication

anticoagulants (if safe to stop)

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69
Q

what is the point in an anaesthetists pre-op assessment

A

Reduces;
Anxiety
Delays Cancellations (resources)
Complications Length of stay Mortality (well planned)

70
Q

what things may be asked in the history for an anaesthetist’s pre-op assessment

A

Known co-morbidities (Severity, Control)
Unknown co-morbidities - (Systemic enquiry, Clinical examination)
Ability of withstand stress - Exercise tolerance, Reason for limitation, Cardio-respiratory disease focus
Drugs and allergies - DDIs
Previous surgery and anaesthesia reaction

71
Q

describe the ASA grading of surgical patients

A

ASA1 - Otherwise healthy patient
ASA2 -Mild to moderate systemic disturbance
ASA3 - Severe systemic disturbance
ASA4 - Life threatening disease
ASA5 - Moribund patient (ASA6 Organ retrieval)

72
Q

list some risk assessment tools for pre-op anaesthesia

A

GUPTA perioperative cardiac risk
Surgical outcome risk tool American college of surgeons surgical risk calculator
STOP-BANG questionnaire P-POSSUM/ CR-POSSUM/ Q-POSSUM/ V-POSSUM

73
Q

what things are considered in the cardiac risk index for anaesthesia pre op assessment

A

High risk surgery Ischaemic heart disease
Congestive heart failure Cerebrovascular disease
Diabetes Renal failure

74
Q

what is the METS way of measuring exercise tolerance

A

Without getting breathless -
Walk around the house- 2 METS
Do light housework - 3 METS
Walk 100-200 metres on the flat- 4 METS
Climb a flight of stairs or walk up a hill - 5 METS
Walk on the flat at a brisk pace - 6 METS
Play golf, mountain walk dance, or any form of exercise - 7 METS
Run a short distance - 8 METS
Do either strenuous exercise or heavy physical work - 9 METS
(15% reduction in mortality risk per MET score point)

75
Q

list some things a patient can do pre-op to improve their outcomes

A

Optimum medical control - Hypertension, Ischaemic heart disease, Heart failure,Asthma, COPD, Epilepsy, Diabetes
Lifestyle – smoking, alcohol, obesity,
exercise - improve fitness

76
Q

what are the 0-3 levels of care

A

0 - primary care
1- Ward-based
2- High dependency unit – single organ support
3- ITU – multi-organ support

77
Q

where is the only place invasive ventilation can be done

A

ITU

78
Q

what is the main difference in the need for HDU and ITU

A

HDU -single organ support

ITU - multiple organ support

79
Q

what are the nice guidelines for Na+ fluid replacement

A

1 – 2mmol/kg/day

80
Q

what are the nice guidelines for K+ fluid replacement

A

0.5 – 1mmol/kg/day

81
Q

what are the nice guidelines for max fluid replacement

A

25-30ml/kg/day

82
Q

what are the nice guidelines for glucose replacement

A

50-100g/day

83
Q

how would you support GI failure

A

unblocking any blockages
stenting
TPN with a nasogastric tube.

84
Q

how would you support renal failure

A

dialysis

85
Q

how would you support pancreatic failure

A

support diabetes, digestive enzyme control

86
Q

what are the outcomes of liver failure

A

self limiting
transplant
die

87
Q

what GCU will be intubated below

A

8

88
Q

how would you support brain failure

A

Ensure the brain is getting O2 and CO2 clearance by vasodilation/ vasopressin, drugs to stop vasospasm, manage raised ICP, sedate, moderate temperature for tissue recovery.

89
Q

what are the fatality rates of ITU

A

25-30%

90
Q

what are benefits of a tracheostomy over a endotracheal tube in ITU

A

inserted in neck so don’t need sedation of gag reflex

91
Q

what are the 2 jobs of the lungs

A

get O2 in

get CO2 out

92
Q

which respiratory failure is more common in ITU

A 
type 1 
(easier to treat - give O2)
93
Q

what is the most sensitive marker of a deteriorating patient

A

increasing RR - tachypnoea

94
Q

what 4 was can oxygen be given in critical care

A 
High-flow nasal cannula. – max 4l a min 
Facemask – 10L/min 
CPAP. 
Intubation and invasive ventilation. 
ECMO.
95
Q

what are peoples normal o2 sats

A

99% on 21% O2

96
Q

why do people find high flow nasal cannulas uncomfortable

A

cold dry air blasted up nose

97
Q

what is the best treatment of type 2 respiratory failure in critical care

A

invasive ventilation

98
Q

what does positive pressure from ventilators do to the lungs

A

ventilators opens lung up so blood can be oxygenated

also cause lung damage so shorten time

99
Q

why is CO hard to measure

A

difficult to measure SV

100
Q

what drugs speed up the heart

A

chronotropes

101
Q

what drugs affect the contractility of the heart

A

inotropes (beta1 agonists)

102
Q

what drugs affect the pre load or after load of the heart

A

pre - fluids

after - vasopressors

103
Q

what type of drugs are vasopressors

A

alpha-1 agonists - constrict blood vessels (mostly veins) - noradrenaline

104
Q

give an example of a vasopressor drug

A

noradrenalien/ adrenaline

alpha-1 agonist

105
Q

where are central lines most commonly placed and why

A

R interval jugular vein - goes straight to SVC

106
Q

what is a benefit of central lines over peripheral cannulas

A

can be left in for 7-10 days but a cannula only 3 days

107
Q

what is lactate a marker of

A

tissue of hypo perfusion (produced in anaerobic metabolism)

>2 abnormal, >4 really bad

108
Q

what is pain

A

an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

109
Q

what is the number 1 disease for years lost to disability worldwide

A

lower back pain

110
Q

what are the physical benefits or treating pain

A

Improved sleep, Better appetite

Better movement Fewer medical complication e.g. heart attack, pneumonia

111
Q

what are the psychological/social benefits of treating pain

A 
Reduced suffering
Less depression, anxiety 
better family ember
able to keep working
lower health costs 
contribute to community
112
Q

what is the difference between acute and chronic

A

Acute:Pain of recent onset and probable limited duration
Chronic: Pain lasting for more than 3 months, lasting after normal healing, often with no identifiable cause
Can get acute on chronic (flare up )

113
Q

what are the 3 most common classifications for pain

A

acute vs chronic
nociceptive vs neuropathic
cancer (progressive) vs non- cancer

114
Q

how long does chronic pain last

A

> 3 months

115
Q

what is the difference between nociceptive and neuropathic pain

A

nociceptive - damage to afferent nerves

neuropathic - nervous system damage or abnormality

116
Q

what type of pain has a physiological protective function

A

nociceptive

117
Q

how is nociceptive pain commonly described

A

Sharp ± dull, Well localised (or visceral)

118
Q

how is neuropathic pain commonly described

A

Burning, shooting ± numbness, pins and needles, Not well localised (all over)

119
Q

give examples of neuropathic pain

A 
nerve trauma
diabetic pain (neuropathy), fibromyalgia
chronic tension headache (dysfunction)
very common after thoracic surgery (intercostal nerves)
120
Q

what are the pathological mechanisms involved in neuropathic pain

A

Increased receptor numbers – amplification
Abnormal sensitisation of nerves –Peripheral or Central – ie light touch
Chemical changes in the dorsal horn – neurotransmitters, neuromodulators, noradrenaline, serotonin, Ca
Loss of normal inhibitory modulation

121
Q

what are the 4 steps of pain physiology

A

1 peripheral tissue injury
2 travels up spinal cord (spinothalamic)
3 brain - thalamus secondary relay station, pain perception in cortex
4 modulation - descending pathway from brain to dorsal horn to decrease signal

122
Q

what chemicals do tissues release in response to pain

A

prostaglandin

substance P

123
Q

what are pain receptors called

A

nociceptors

124
Q

what type of nerves do pain signals travel in

A

A(delta)

C fibres

125
Q

what treatments can be given to target the peripheral tissue injury (pain)

A

RICE (rest, ice, compression, elevation),
NSAIDs
LA (damp down response – C fibres, Aδ

126
Q

what is the 1st and second relay station for pain

A

1st - dorsal horn

2nd - thalamus

127
Q

where do pain fibres cross the spinal cord

A

at the level they enter

128
Q

describe the route of the 1st and 2nd nerve in the physiology of pain

A

1st - tissue to dorsal horn

2nd - opposite side of spinal cord

129
Q

what treatments can be used to target the spinal cord in pain management

A

acupuncture, massage, TENS

Local anesthetics, opioids, ketamine

130
Q

where does pain perception occur

A

cortex of brain

131
Q

what is the gate theory of pain

A

Gate theory of pain - painful signal travels into dorsal horn interneuron can be switched off - this can be stimulated by Abeta nerve and stop pain firing

132
Q

what treatments target the brain for pain management

A

paracetamol, opioids, amitriptyline, clonidine, psychological (cognitive behavior therapy)

133
Q

what is the physiology of modulation of pain

A

Descending pathway from brain to dorsal horn

Usually decreases pain signal

134
Q

list 2 classes of simple analgesics

A

paracetamol

NSAIDs

135
Q

what are advantages of paracetamol

A

Cheap, safe, Can be given orally, rectally or intravenously

136
Q

what are disadvantages of paracetamol

A

liver failure in overdose

137
Q

what is the antidote to opiates

A

naloxone

138
Q

give examples of mild opiods

A

codeine

dyhydrocodeine

139
Q

give examples of strong opiods

A

Morphine, Oxycodone, Fentanyl

140
Q

what are advantages of mild opiates

A

Cheap, safe, Good for mild-moderate acute nociceptive pain,

Best given regularly with paracetamol (synergism)

141
Q

what are disadvantages of mild opiates

A

Constipation, Not good for chronic pain

142
Q

what are advantages of strong opiates

A 
Cheap
generally safe
Can be given orally, IV, IM, SC
 Effective if given regularly
Got an antidote.
Good for Mod-severe acute nociceptive pain (e.g. post-op pain), Chronic cancer pain
143
Q

what are disadvantages of strong opiates

A 
Constipation
Respiratory depression in high dose
nausea, 
addiction (Controlled drug, 
not good for neuropathic
144
Q

are opiates good for neuropathic pain

A

no

145
Q

what is tramadol

A

(Mixed opiate and 5HT/NA reuptake inhibitor)

plus inhibitor of serotonin and noradrenaline reuptake (modulation

146
Q

what are advantages of tramadol

A

Less respiratory depression, can be used with opioids and simple analgesics, Now a controlled drug

147
Q

what is amitriptyline

A

tricyclic antidepressant (TCA

148
Q

what are advantages of amitriptyline

A

cheap, safe in low dose, good for neuropathic pain, also treats depression, poor sleep

149
Q

what are disadvantages of amitriptyline

A

Anti-cholinergic side effects (e.g. glaucoma, urinary retention)

150
Q

what anticonvuslantsa re used for pain manangemtn

A

gabapentin (Neurontin)
sodium valproate (epilim)
carbamazepine (tegretol)
membrane stabilisers – reduce abnormal firing of nerves (Good for neuropathic pain)

151
Q

what is ketamine

A

NMDA Receptor antagonist

152
Q

how may LA be administered

A

Epidural
Intrathecal
Wound Catheters Local Infiltration of wounds
Nerve Plexus Catheters (brachial/ femoral/ sciatic)

153
Q

name a topical agent used to manage neuropathic pain

A

capsaicin

154
Q

list ways to assess pain

A

Verbal rating score – no, mild, moderate, severe, excruciating
Numerical rating score – 0-10 – most people don’t like numbers, hard to interpret
Visual analogue scale – line with scale
Smiling faces – paediatric
Abbey pain scale - confused patients, looks at pain and patient behaviour

155
Q

list some non-drug methods of managing pain

A

Physical - Rest, ice, compression, elevation
Surgery
Acupuncture, massage, physiotherapy
Psychological- Explanation – expected, Reassurance
Counselling – positive psychology

156
Q

where on the WHO pain ladder do you start with mild pain

A

Start at Bottom of Pain Ladder

157
Q

where on the WHO pain ladder do you start with moderate pain

A

Bottom of Pain Ladder plus Middle Rung

158
Q

where on the WHO pain ladder do you start with severe pain

A

Bottom of Pain Ladder plus Top of Ladder.

Miss out the middle

159
Q

is it ok to start at the top of the WHO pain ladder

A

severe/ unbearable pain

160
Q

would you stop NSAIDs or paracetamol first

A

NSAIDs as more adverse effects

161
Q

what type of pain is the WHO ladder for

A

nociceptive NOT neuropathic

162
Q

what is step 1 of the WHO pain ladder

A

aspirin, NSAIDs, paracetamol

163
Q

what is step 2of the WHO pain ladder

A

mild opiods eg codeine

164
Q

what is step 3 of the WHO pain ladder

A

strong opiods e.g. morpheine

165
Q

what does the RAT assessment stand for

A

R - recognise
A- assess
T - treat

166
Q

what drugs should be used for neuropathic pain

A

Amitriptylline, Gabapentin, Duloxetine

167
Q

what is involved is the ‘Recognise’ of RAT assessment

A

Does the patient have pain? Ask, Look (frowning, moving easily, sweating)
Do other people know the patient has pain? Other health workers, Patient’s family

168
Q

what is involved is the ‘Assess’ of RAT assessment

A

Severity - pain score at rest and with movement, how is pain affecting the patient? Can they move, cough, work
Type – acute, chronic, cancer, non-cancer, nociceptive, neuropathic (burning/ shooting, phantom limb, pins and needles, numbness)
Other factors – other illnesses (physical), lack of social support, home circumstances, work (social), anger, anxiety, depression (psychological)

169
Q

how should you treat moderate nociceptive pain

A

Paracetamol (± NSAIDs)

170
Q

how should you treat mild nociceptive pain

A

Paracetamol (± NSAIDs) + codeine/ alternative

171
Q

how should you treat severe nociceptive pain

A

Paracetamol (± NSAIDs) + morphine

172
Q

what should you always remember to do when treating your patient for pain

A

Reassess the patient: Is your treatment working?

Are other treatments needed? Up or down pain ladder

specialities (4 decks)

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