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Year 4 ACC > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

What are the normal ranges for sodium and potassium in the blood and why is there such a difference?

A

Sodium: 135-145mmol/L
Potassium: 3.5-5.0mmol/L

Sodium mostly exists in the extracellular compartment (ECF and blood), potassium mostly exists in the intracellular compartment

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2
Q

What are the daily requirements of water, sodium and potassium?

A

WATER: 30-40ml/kg (approx 2-3L for average adult)
SODIUM: 1-2mmol/kg (approx 70-140mmol/L for average adult)
POTASSIUM: 0.5-1/0mmol/kg (approx 35-70mmol/L for average adult)

***these are the sorts of levels we should aim for when prescribing MAINTENANCE FLUIDS

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3
Q

What kinds of things cause FLUID LOSS?

A 
Poor oral intake (elderly, dysphagia, unconsciousness, fasting NBM)
Increased requirements (Trauma, burns, post-operative)
Increased loss (fever, sweating, bleeding, D&V, renal loss)
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4
Q

How do we classify fluid loss?

A

As mild, moderate or severe
MILD
- 4% body weight, loss of skin turgor and dry mucus membranes
MODERATE
- 5-8% body weight, oliguria, tachycardia and hypotension
SEVERE
- >8% body weight, profound oliguria and CVS collapse

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5
Q

What are some crystalloids and what are some examples?

A

They are water soluble substances dissolved in solution. They can be rapidly administered but can cause pulmonary oedema
NaCl 0.9%
Dextrose
Haartmans

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6
Q

What is in NaCl and what are some risks?

A

(0.9% mean 9g in 100ml) - contains 154mmol/L Na and 154mmol/L Cl
So about the right amount of sodium but there is a risk of hyperchloraemic acidosis

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7
Q

What is in dextrose and when should it be used?

A

5% = 50g per L water

Good if people have glucose requirements

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8
Q

What is in Haartman’s and what are some benefits of using it?

A 
Na - 131
Cl - 111
K - 5
Ca 2
Lactate 29

this is much more isotonic and the patient is at less risk of becoming hypokalaemia

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9
Q

What are some examples of colloids? Where are they sometimes used?

A 
Gelfusin 
Voluven 
Volulyte 
Albumin 
Sometimes used in trauma but rarely elsewhere
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10
Q

What is a fluid challenge?

A

Getting IV access with a wide bore cannula and administering 250-500mL of fluid as quickly as possible (usually 10-15mins) and monitoring for a response (BP, HR, UOP, JVP)

If an unwell patient hasn’t improved after 3 fluid challenges then need senior support

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11
Q

What is an example of a good maintenance fluid regimen in a 70kg man?

A

0.9% NaCl + 40mmol K over 8 hours
5% dextrose + 20mmol K over 8 hours
5% dextrose + 20mmol K over 8 hours

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12
Q

Why will people need more than just maintenance fluid after surgery?

A

People loose fluids during surgery (on average 600-900mL) so they will need some extra fluids before they’re placed on a maintenance regime

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13
Q

How do you manage fluid therapy in fever?

A

Add 10% extra fluids for every degree of fever

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14
Q

What should you ask in the history section of a pre-operative assessment?

A

Current illness (health in the past 2 weeks, any new problems or infections)
Exercise tolerance
Symptoms of apnoea (snoring, tired throughout day, headache)
ONGOING medical conditions and how well controlled
Anaesthetic history (personal and family)
Drug hx and allergies

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15
Q

What ongoing medical conditions in particular should you ask about during anaesthetic history?

A

IHD, diabetes, HTN, asthma, COPD, liver or kidney disease. Always ask how well controlled these are

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16
Q

What should you examine in a pre-operative assessment?

A

Neck movement, jaw opening and dental health (dentures, caps, crowns or loose teeth)
Mallampati
General examination (listen to heart and chest, feel abdomen, feel peripheries, feel calves for swelling or tenderness)

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17
Q

What is the mallampati score?

A

I - complete visualisation of soft palate
II - Complete visualise of uvula
III - Can only see base of uvula
IV - Cannot see soft palate

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18
Q

What is the ASA-GRADING for surgery?

A

1 - completely safe no ongoing disease
2 - Chronic disease but with no functional impairment (e.g. well controlled diabetes, HTN or smoker)
3 - Severe chronic disease with functional impairment e.g. angina or COPD
4- Severe angina, ESRD or liver disease
5 - Moribund patient who is unlikely to survive with or without operation
6 - Brainstem dead patient for transplant

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19
Q

What are the surgical grades for the operation?

A

1 (minor) - skin excision or toenail removal
2 (intermediate) - hernia repair or tonsillectomy
3 (major) - hysterectomy or thyroidectomy
4 (major+) - C/S, joint replacement, thoracic operational or radical dissection

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20
Q

What investigations does EVERYONE get in pre-operative assessment?

A

FBC, U&E, clotting and and group and save

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21
Q

What are some extra investigations for specific things in pre-operative assessment?

A

LFTs for liver or billiard op
Sickle cell screen for Afro-Caribbean patients
TFTs if they’re on thyroxine
CXR if ICU care might be required
Echo if they’ve got valve problem or murmur
Spirometry if lung disease

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22
Q

What must you correct before the operation if found to be abnormal?

A

INR (with vit K or platelets/FPP/cryoprecipitate)

Anaemia

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23
Q

What is the general rule for stopping medications before an operation?

A

In general omit on the day of operation and resume the day after

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24
Q

What more specific medications must be stopped before operation?

A 
Warfarin  - stop 5 days before 
DOACs - stop 24h before 
LMWH - stop 48h before 
Aspirin/clopidogrel - stop 7 days before 
Insulin - don't have morning dose 
Oral hypoglycaemic - avoid on day of op 
Diuretics/ACE-is - avoid on day of 
Long-term steroids - consider switch to hydrocortisone 
COCP - stop 4 weeks before
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25
What are the fasting guidelines before an operation?
No food for 6 hours before (have dinner nil else) No milk for 4 hours before Only clear fluids until 2 hours before - NBM
26
How much oxygen can be given through nasal cannulas?
1-6L (most commonly 2L) | 24-40% O2
27
How much oxygen can be given through a simple face mask (hudson)?
5-10L (CO2 can accumulate if the flow is less than 5L) | Not very reliable
28
What demonisations are there of venturi devices? In whom are they commonly used?
24, 28, 35, 40 and 60% | Good in CO2 retainers (COPD) to control concentration of O2
29
How much oxygen can be given through a non rebreathe mask?
15L and probably gives up to around 85% - this is about as good as we can get unless we artificially ventilate someone
30
What options do we have if the patient need assistance with ventilation?
BAG-VALVE MASK NIV ET tube or airway adjunct
31
What are some examples of NIV?
CPAP and BiPAP | CPAP pressure is continuous and BiPAP has different inspiratory and expiratory pressures
32
How do you measure a Gedell airway?
HARD to HARD | Angle of the mandible to the front incisors
33
What are the average sizes of NP tubes? When should they not be used
7mm for women 8mm for men Do not use if any suspicion of basal skull fracture
34
What are some examples of supraglottic airways?
Laryngeal mask airway (LMA) and iGEL
35
When are LMAs preferably used and how do you insert an LMA?
Used in shorter surgeries when an ET tube is not required or if you cannot intubate someone (easier to put in) NOT A DEFINITIVE AIRWAY Reflexes should be suppressed e.g. with propofol then insert with the curve of the airway (no need to rotate)
36
What kind if airway is an ET tube? How are the sized
Definitive | Sized by diameter - 7-8mm for women, 8-9mm for men
37
What is the process of inserting an ET tube?
1. preoxygenate the patient 2. Wait for the neuromuscular blockage (90-120s) 3. Place the patient in the sniffing the morning air position 4. Hold laryngoscope in L hand 5. Insert the laryngoscope in the R hand corner of the mouth and slide it down between the tongue and the epiglottis 6. then lift with your whole arm up and to the left 7. Aim to visualise the vocal cord 8. Insert the tube to just beyond the vocal cords 9. Inflate the cuff of the tube, attach to the bag valve mask and look for signs that it is in the right place
38
What signs are there that the ET tube is in the right place?
Rising of the chest (symmetrically, if it is not symmetrical it might have gone too far down the R main bronchus) Misting of the tube EtCO2 properly traced (5 clear traces)
39
What are some possible complications of ET tubing?
Breaking teeth with the laryngoscope Incorrectly positioned tube (into oesophagus) if in doubt take it out Right lung intubation if put too far down Laryngospasm - especially if someone has asthma or COPD
40
What are the three types of anaesthetic?
Local, Regional, General
41
When putting someone under a general anaesthesia what three things do you need to achieve?
AMNESIA - unconscious and won't remember AKINESIA - cannot move ANALGESIA - won't be in pain or have a pain response
42
How do we achieve amnesia in general anaesthesia?
INDUCTION AGENTS INITIALLY (propofol, thiopentone, etomiidate and ketamine) Then maintained with VOLATILE AGENTS
43
What dose is propofol used in and what are some risks and benefits?
1.5-2.5mg/kg Has a very good suppression of airway reflexes and goo at preventing PONV Causes a marked drop in HR and BP - need to compensate for this. Also can be painful to inject because it is lipid based
44
What dose is thiopentone used in and what are some risks and benefits?
This is a BARBITUATE that is commonly used in 4-5mg/kg doses It works much faster than propofol and thus is often used in RSI It also has anti-epileptic properties and is quite neuroprotective HOWEVER, it drops BP but INCREASES HR and can cause a rash and bronchospasm, it also needs to be injected intra-arterially meaning it can lead to gangrene and thrombus. AVOID in PORPHYRIA
45
What effects does ketamine have, what dose is it used in and what are some risks and benefits?
It is a DISSOCIATIVE ANAESTHETIC and is also profoundly analgesic DOSE: 1-1.5mg/kg - it is quite slow to act (90s) It increases HR and BP and causes bronchodilation which is good Can causes PONV and EMERGENCE PHENOMENON (vivid dreams and hallucinations)
46
What dose is etomiidate used in? In whom is it most suitable and what are some risks and benefits?
Used in 0.3mg/kg dose It confers good haemodynamic stability and so is good in people with cardiovascular conditions However it is painful on injection, can cause spontaneous movements and adrenocorticoid suppression (cortisol is suppressed for up to 72 hours suggesting it should not be used in very unwell who need the stress response), high PONV
47
What agents are used to maintain anaesthesia?
Volatile agents (desflurane, isoflurane, enflurane, sevoflurane and NO)
48
What is minimum alveolar concentration?
MAC - this is the minimum concentration of gas required to eliminate a reaction to a standard stimulus
49
What are the MACs of sevoflurane, desflurane, NO, enflurane and isoflurane?
``` Sevo - 2% Isoflurane - 1.15% Desflurane - 6% Enfluane - 1.6% NO - 104% ```
50
How does pain affect people under anaesthesia?
They don't FEEL pain because this is a conscious interpretation. However, they do have nociceptors stimulated which can cause the physiological response of increased HR and BP. That's why it's important to give someone analgesics
51
What are some examples of short acting analgesics?
Fentanyl, ramifentanil, alfentanyl
52
What are some examples of long acting analgesics?
Morphine and oxycodone
53
Where do the anti-kinetic agents act?
At the neuromuscular junction - NICOTINIC FIBRES lead to muscular contraction Ach
54
What are the two types of akinesis agents and how do their actions differ?
DEPOLARISING - These act in a similar way to the Act NT but they are broken down very slowly so they go into the receptors but then block them NON-DEPOLARISING - these block the nicotinic receptor without activating them
55
What is an example of a depolarising akinesis agent? What dose is it used in and what are some adverse effects?
SUXAMETHONIUM - 1-1.5mg/kg OFTEN USED IN RSI | Can cause muscle pains, fasciculations, hyperkalameia, malignant hyperthermia, rise in ICP, IOP and gastric pressures
56
What are some examples of short-acting non-depolarising agents?
Atracurium and mivacurium
57
What are some examples of intermediate acting akinesis agents?
vecuronium and rocuronium
58
What is an example of a long acting akinesis agent?
pancuironium
59
What is the main advantage of non-depolarising agents and the main reason they are used?
THEY ARE REVERSIBLE
60
How do we reverse non-depolarising agents?
With neostigmine - an anti-cholinesterase that prevents breakdown of ACh increasing its conc so that it can outcompete akinesis agent?
61
What is the problem with neostigmine and how can we prevent this?
It is NON-SELECTIVE for nicotinic and also works on muscarinic receptors leading to bradycardia and dry mouth etc. We can give GLYCOPYRROLATE to prevent this
62
What other drugs are often prescribed peri-operatively?
Anti-emetics and vaso-active drugs
63
What class of drug is ondansetron?
5HT3 blocker - anti emetic
64
What class of drug is cyclizine?
Anti-histamine anti-emetic
65
What class of drug is metaclopramide?
Anti dopaminergic anti emetic
66
What other anti-emetics are there and what classes are they?
Dexamethasone (steroid) | Prochlorperazine
67
What vaso-active drug should you consider if someone's HR and BP are low?
Ephedrine (rise in rate and contractility of heart)
68
What vaso-active drug should you consider if someones BP is low but their HR is high?
``` Phenylephrine - is more alpha selective and just causes vasoconstriction OR Metaraminol (another vasoconstrictor) ```
69
If someones hypotension is severe and non-responsive what drugs should you consider?
Adrenaline, Noradrenaline or dobutamine
70
What is the sequence of events when putting someone under a GA?
1. Oxygenate them 2. Give them opioid (need to have painkiller before being tubed) - opioids take a little while to work 3. INDUCTION AGENT (e.g. propofol to send them to sleep) 4. Turn on volatile agent - keep them asleep 5. Bag valve mask ventilate them to maintain oxygenation 6. Insert the airway and ventilate them READY FOR SURGERY
71
What things should you consider prescribing for post-operative patient?
Analgesics - most patients will need some analgesic cover Fluids - most patients will lose fluids during surgery so will need some element of replacement and then maintenance Antibiotics - internal surgeries sometimes require prophylactic abx
72
How do we manage pain post-operatively?
``` Following guidelines from essential pain management (EPM) RAT system of pain management - Recognise - Assess - Treat ```
73
How do we recognise pain?
If the patient is conscious they will tell you - pain is what the patient says it is Pain response might be dulled in trauma when sympathetic surges of adrenaline dull the response
74
How do we assess the pain?
Need to get an idea of WHERE it is Need to get an idea of what the CHARACTER of the pain is like? Get an idea of associated symptoms Scale of 1-10: this gives idea of baseline
75
What are the three classification strategies for pain?
Is it acute or chronic? Is it cancerous or non-cancerous? Is it neuropathic or nociceptive?
76
What is nociceptive pain?
Sometimes called inflammatory or physiological pain this is pain that is in response to illness or injury It has a protective function - is usually well localised
77
What is neuropathic pain?
Nerve damage e.g. sciatica or CES Does not have a protective function Might be burning, shocking or feel hot/cold
78
What is the difference between pain and nociception?
Pain is the cerebral input into nociception
79
What is the nociceptive pathway?
Tissue injury - nociceptors are activated by cytokines such as PGs, histamine and leukotrienes THEN EITHER TRAVELS in A-delta (fast response) or C pathway (later throbbing pain) Signal carried to dorsal root ganglion in dorsal horn Fibers decussate into contralateral spinothalamic tract Run up into thalamus and pain is perceived Stimulus is moderated by sending signal back down the descending pathway
80
How does pain impact the surgical recovery process?
Physical immobility - e.g. chest pain limits breathing leading to infections If someone has had lots of pain from one procedure might be less willing to have another Longer stay in hospital and more time off work
81
How does the body respond to pain?
Tachycardia and hypertension GI N&V RESP reduced VC and FRC DVT and PE
82
What are the three levels of the analgesic ladder?
0 - Paracetamol 1g PRN max 4g daily 1 - Paracetamol + NSAID (400mg) OR weak opioid e.g. codeine (30-60mg) 2 - Paracetamol + NSAID (400mg) + regular weak opioid e.g. codeine + strong opioid e.g. oromorph
83
How does paracetamol work?
Inhibits PG production Selective inhibitor of COX-3 Good anti-pyretic Poor anti-inflammatory
84
How do NSAIDs work?
COX-inhibitors | Block production of PGs and thromboxane which potentiate the action of cytokines on nociceptors
85
What is the difference between COX-1 and COX-2?
COX-1 is a constitutive isoenzyme responsible for lots of homeostatic measures thus is the reason for lots of the side effects (bronchospasm, GI effects, renal, platelets) COX-2 is a INDUCIBLE enzyme - responsible for inflammation
86
Which NSAIDs are most COX-2 specific?
PARECOXIB and Celocoxib
87
In whom are NSAIDs contraindicated?
Those prone to bleeding Those with peptic ulcers Caution with asthma CI'd in renal failure - really excreted
88
What are some examples of weak opioids and how do they work? Common doses?
``` Codeine and tramadol Work by unregulated the signal from the descending pathway moderating pain (activate mu receptors) Codeine: 30-60mg Tramadol: 50-100mg Dihydrocodeine: 30-60mg ```
89
What are some examples of strong opioids, how do they work and what kind of pain are they useful in?
Morphine, oxycodone and diamorphine Strong OP3 receptor agonists Work well on longer term C fibre pain and less for A-delta pain
90
What are some examples of short acting opioids?
Fentanyl Ramifentanil Alfentanyl
91
What are some side effects of opioids?
Drowsy, constipated, N&V, tolerance and dependence, hypotension Respiratory depression - infrequent gulping breaths
92
What methods of administration are there for post-operative morphine?
oromorph - works very quickly and is very effective - 20mg/hr PRN IV morphine - common. Can given 10-20mg diluted into 1mg/mL IV dose is 1/3 oral dose PCAS - patient gives themselves 1mg every 5mins - idea is that this stops spikes of analgesia - keeps constant level
93
How do you dose paracetamol and ibuprofen?
Paracetamol you can have 1g (2 tablets) every 4 hours no more than 4 times a day (max 8 tablet per day) Ibuprofen can take 400mg every 6-8 hours up to 3 times a day.
94
What doses are appropriate for codeine, tramadol and morphine?
Codeine - 30-60mg every 4 hours up to 240mg every 24h Tramadol - 50-100mg every 4 hours up to 400mg every 24h Morphine - give them a 10mg dose titrated in over 10mins (they might not need all 10mg)
95
What can you give for a patient who has had an overdose of opioids?
Naloxone
96
Other than oral analgesics what other options do we have for managing pain post-operatively?
Local anaesthetic injections Very often after surgery local anaesthetics are injected around the surgical site to numb it and block the pain BUPIVACAINE IS OFTEN GIVEN
97
What drugs are more often given for chronic pain and why?
Amitriptyline, Pregablin and gabapentin, Clonidine, corticosteroids, capsaicin Different types of drugs are needed because chronic pain is more likely to be neuropathic in nature

Year 4 ACC (24 decks)

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