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Year 4 ACC > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Basic techniques to stabilise an airway (2)

A

Head tilt chin lift

Jaw thrust

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2
Q

% of O2 in 15L via NRBM/Reservoir mask

A

85%

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3
Q

Indication for an airway adjunct

A

Airway patent on manoeuvre but stops when not

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4
Q

How do you measure the size of Oropharyngeal airway needed

A

Angle of mandible to incisors

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5
Q

CI for Oropharyngeal airway

A

Conscious

Gag reflex

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6
Q

Indication for Nasopharyngeal airway

A

Cannot tolerate OPA because they are conscious

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7
Q

CI for NPA

A

Basal skull fracture (Panda eyes and Battle’s sign)

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8
Q

How do you measure the length of the NPA an individual requires

A

Tragus to incisor

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9
Q

Size of NPA for males and females?

A

M= 7

F=6

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10
Q

Nasal cannulae oxygen delivery?

A

1-6L/Min

Max 40% O2

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11
Q

Hudson mask/simple face mask oxygen delivery?

A

5-10L

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12
Q

Venturi mask advantage?

A

Controlled amount of 02 delivery

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13
Q

O2 delivery from a venturi mask in increasing order

A 
Blue= V24= 2-4L/min
White= V28= 4-6L/min 
Yellow= V35= 8-10L/Min
Red= V40= 10-12L/Min
Green=V60= 12-15L/Min

(Vx= % O2 delivered)

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14
Q

When using the bag-valve mask how many breaths per min and how hard do you squeeze it?

A

12/min

1/3rd volume of the bag

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15
Q

Requirements for NIV?

A 
Alert
Conscious
Co-operative
Cough
Can maintain own airway 
Own resp effort is good
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16
Q

Indication for CPAP

A

Acute hypoxic respiratory failure

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17
Q

Indications for BIPAP

A

Hypercapnic COPD exacerbation

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18
Q

Size of LMA in males and females

A 
Male= 4
Female= 3
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19
Q

If not anaesthetist is present what airway is 1st line in a cardiac arrest

A

LMA

ET tube them if anaesthetist is present

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20
Q

ET tube size in Males and Females

A 
M= 9 +/- 0.5
F= 8 +/- 0.5
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21
Q

Where do the two black lines go when the ET tube is inserted

A

On either side of the vocal cords

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22
Q

How do you hold a laryngoscope and where does it go?

A

Left hand
Valecular
(use chin lift)

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23
Q

How do you confirm the position of an ET tube?

A 
Capnograph- CO2 in expiration 
Auscultate over lungs- Apices and bases +/- Stomach
Direct visualisation
Misting in tube
Symmetrical chest movement 
\+/- Sats rising
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24
Q

Early and late complications of an ET tube

A

Early- Trauma, aspiration, airway obstruction, hypoxia if prolonged attempts

Late- Infection, mucosal damage, vocal cord injury
Tracheal stenosis

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25
Q

Indications for a tracheostomy

A 
Emergency access
Upper airway obstruction 
Impaired resp function E.G Head trauma
Assist in ventilation weaning
Long term ventilation
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26
Q

Indications for a cricothyroidotomy

A

Emergency airway

Obstruction at or above larynx

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27
Q

Process of anaesthesia (6 steps)

A

Pre-op assessment

IV access/Monitoring (14G-24G)

Induction

Analgesia + muscle relaxation

Maintain AMNESIA, AKINESIS AND ANALGESIA

Reversal

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28
Q

How is amnesia achieved

A

Induction agent lasting 4-10 mins

Maintained via inhalation/volatile agents

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29
Q

Advantages and disadvantages to Propofol

A

+ Suppresses airway reflexes
+ Decreased PONV

  • Involuntary movements
  • Marked reduction in HR & BP
  • Pain upon injection
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30
Q

What is propafol

A

Induction agent to induce amnesia
lipid based therefore white emulsion
1.5-2.5 mg/kg

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31
Q

What is thiopentone

A

Barbituate used to induce amnesia
4-5mg/kg
Used for RSI

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32
Q

Advantages and disadvantages to thiopentone

A

+ RSI (FAST ONSET)
+ Anti-epileptic so protects the brain

  • BP decrease with HR increase
  • Rash
  • Bronchospasm
  • CI in porphyria
  • Thrombosis and gangrene if intra-arterial as blocks arterioles
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33
Q

When is Ketamine used as an induction agent

What form of amnesia does it cause?

A

Good as sole anaesthetic for short procedures E.G burn dressing change
1-1.5 mg/kg

Dissociative= Profound analgesia and anterograde amnesia

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34
Q

Advantages and disadvantages to Ketamine

A

+ Slow onset (90s)
+ Increase in HR & BP
+ Bronchodilatation

  • N&V
  • Emergence phenomenon- vivid dreams and hallucinations
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35
Q

What is Etomidate

A

Steroid based induction agent
Rapid onset
Use if you want to minimise haemodynamic instability

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36
Q

Advantages and disadvantages to etomidate

A

+Haemodynamic stability
+ No impact on BP
+ Lowest hypersensitivity risk

  • Pain upon injection
  • High incidence of PONV
  • Spontaneous movements
  • Adreno-cortico suppression
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37
Q

What 2 methods are used to maintain amnesia?

A

Total IV anaesthesia- Propofol infusion via IV + Fentanyl

Inhalation anaesthesia using an inhalation agent

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38
Q

Inhalation agents- Benefits of Isoflurane

A

Lowest impact on organ blood flow

Good if an organ donor!

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39
Q

Inhalation agents- Benefits of Sevoflurane

A

Sweet smelling
Good for children
Inhalation induction

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40
Q

Inhalation agents- Benefits of Desflurane

A

Rapid onset and offset- Does not accumulate in fat!

Good for long operations

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41
Q

What is the minimum alveolar concentration

A

Concentration of vapour that prevents reaction to a set depth and width of skin incision in 50% of patients
BUT provides amnesia in 100%

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42
Q 
MAC of:
Nitrous oxide
Sevoflurane
Isoflurane 
Desflurane
Enflurane
A 
Nitrous oxide- 104%
Sevoflurane- 2%
Isoflurane- 1.15%
Desflurane- 6%
Enflurane- 1.6%
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43
Q

When are short acting analgesics used?

Give examples of them.

A

Intra-operatively, suppress response to layrngoscope, surgical pain

Remifentanil, Alfentanil, Fentanyl

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44
Q

Of Remifentanil, Alfentanil and Fentanyl which is most potent with the fastest onset?
Which can be given IV?

A

Remifentanil> Alfentanil>Fentanyl

Remifentanil- IV

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45
Q

Which NSAIDS can be given IV

A

Parecoxib

Ketorolac

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46
Q

In a surgical setting when should morphine/Oxycodone be given?

A

Intra- or Post-operatively

If the former then give 15-20 mins before the end of the operation

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47
Q

Give examples of short,Int and long acting non-depolarising muscle relaxants

A

Short- Atracurium, Mivacurium (30 mins)

Int- Rocuronium, Vecuronium (30-60 mins)

Long- Pancuronium (60+ mins)

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48
Q

Mechanism of action and Properties of non-depolarising muscle relaxants

A

Blocks Nicotinic R preventing depolarisation by Ach

Slow onset, variable duration, fewer side effects

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49
Q

Mechanism of action of depolarising muscle relaxants

A

Mimic Ach so bind nicotinic receptors inducing a contraction/fasiculations (PHASE 1)

Desensitisation to the efffcts of Ach with muscle fatigue and relaxation

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50
Q

What is Suxamethonium

A

A non-depolarising muscle relaxant
1-1.5 kg/mg
Quick onset and offset (use in RSI)

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51
Q

Suxamethonium Side effects?

A

Fasiculations, Pain, HYPERkalaemia, Prolonged apnoea
Inc ICP/IOP/Gastric pressure
Malignant hyperthermia

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52
Q

How do you reverse suxamethonium related malignant hyperthermia

A

Dantrolene

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53
Q

What reversal agent potentiates the action of Suxamethonium

A

Neostigmine

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54
Q

What is neostigmine?

What must it be given with?

A

Anti-cholinesterase so prevents Ach breakdown to can reverse the action of non-depolarising muscle relaxants

Add an anti-muscarinic like glycopyrolate to prevent bradycardia

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55
Q

Drawbacks of neostigmine

A

N&V, cannot reverse profound block, slow onset and peak at 7-11 mins

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56
Q

What is sugammadex?

A

Causes water soluble complex formation to immediately reverse the effects of a muscle relaxant
Nil effect on nicotinic receptors
16 mg/kg if wanting immediate reversal

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57
Q

Drawbacks of sugammadex

A

Hypotension
Airway compromise if lower dose
VERY EXPENSIVE SO ONLY USE WHEN NECESSARY

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58
Q

What is Ephedrine

A

Inotropic agent acting on alpha and beta receptors

Increases both HR and BP

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59
Q

What is phenylephrine?

A

Inotropic agent acting directly on alpha receptors
Increase in BP (B/C VASOCONSTRICTION)
Decrease in HR

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60
Q

What is metaraminol?

A

Inotropic agent mixed direct/indirect action mostly on alpha receptors
Increase in BP (B/C vasoconstriction)
Decrease in HR

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61
Q

Inotropic agents used in ICU/Sepsis

A

NorA, Adrn, Dobutamine

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62
Q

What % of GA patients will vomit?

A

20-30% without medication

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63
Q

When would you give sodium citrate/H2 antagonist (antacid)

A

Aspiration risk E.G in Obstetrics/Obese/GORD/Difficult airway

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64
Q

Process of anaesthetic reversal

A

Stop vapours
Give O2
Throat suction
Reverse muscle relaxation

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65
Q

What are the two types of LA?

A

Esters- lipid soluble hydrophobic aromatic group (Procaine, Benzocaine, amethocaine, cocaine)

Amides- Charged hydrophilic group (Ropivacaine, Prilocaine, Levobupivacaine) REMEMBER BY HAVING 2 ‘i’ in their name

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66
Q

Max dose of Lignocaine

A

3

7 with adrenaline

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67
Q

Max dose of Bupivacaine/Levobupivacaine

A

2 (no change with adrenaline)

68
Q

Max dose of Prilocaine

A

6

9 with adrenaline

69
Q

When should you not use adrenaline

A

On terminal regions like the penis or digits

70
Q

What is LA toxicity? Describe the presentation.

A

Exceeding max safe dose leading to Na+ channel blockage in the brain and heart

Confusion/Drowsiness/Coma/Convulsions/Light headedness/slurring of speech
Tingling around mouth
Excitatory symptoms
Muscle twitching
CV toxicity
71
Q

How does LA toxicity impact the CV system?

A

Initial Tchycardia + HTN

Later hypotension and bradycardia

Leading to heart block and ventricular arrhythmias

72
Q

Treatment of LA assoicated cardiac arrest

A

Intralipid 1.5 mls/kg
Keep doing CPR for 1 hour as intralipid takes a while to work
Iv Benzo if convulsing
Atropine if bradycardia persists + raise legs to treat hypotension

73
Q

Steps to working out safe dose of LA

A

Work out max dose of drug in mg by multiplying max dose (mg/kg) by weight (kg)

Convert % of drug into mg/ml by multiplying by 10 (0.25%= 2.5mg/ml)

Divide Max dose (mg) by aforementioned how much mg/ml can be used (mg/ml)

Final figure in Ml

74
Q

Where does the SC end?

A

Lower border of L1

75
Q

Where does the SA space end?

A

S1

76
Q

Where does the epidural space end?

A

Sacrococcygeal hiatus

77
Q

Where does a spinal block inject into

A

Subarachnoid space

78
Q

Where does an epidural inject into

A

Epidural space

79
Q

Where can you do a spinal block?

A

L2 to S2
The lower the safer!
Harder past L5

80
Q

Where can you do an epidural block?

A

Any level;

Risk SC damage if above L1

81
Q

Benefits of Spinal/epidural over opiate analgesia

A 
Fewer post-op respiratory complications 
Less PONV
No precipitation of obstructive sleep apnoea 
Less chance of infection 
Decreased CV/Resp impact
82
Q

How do you test for spinal onset?

A

Cold spray

Ice cube

83
Q

Describe a spinal block

A

5-10 min onset Lasts 2-3 hours
RAPID ACTION
Dense motor block

84
Q

Describe an epidural

A

LA +/- Opioid
10-15 min onset (Slower than spinal)
lasts up to 72 hours
Catheter can provide continuous infusion

85
Q

CI for spinal/epidural

A

Increased ICP (coning risk)
Aortic/Mitral stenosis
Sepsis
Coagulopathy

86
Q

Ways in which pain can be classified

A

Duration
Cause
Mechanism- Nociceptive vs neuropathic
Perception

87
Q

What is nociceptive pain

A

Obvious tissue injury
Well localised
Dull if visceral
Sharp if muscles/bones/skin

88
Q

What is neuropathic pain

A

Nervous system damage/abnormality
No protective function
Poorly localised
Neuro symptoms

89
Q

Are alpha delta or C nerves faster?

A

Alpha delta- Faster sharp pain

C nerves- Persistent pain (Burning)

90
Q

How do you treat acute nociceptive pain

A

Reverse WHO ladder
Trauma or Post-op!
Step down as pain improves

91
Q

Key pain Q

A

How long
Cause
Pain mechanism

92
Q

What is clonidine?

A

Alpha agonist.
Works centrally to ameliorate pain
Decreases BP
Sedative effect

93
Q

Minimum recommended fasting time for:
Solids
Milk
breast fed infants

A

Solids- 6 hours
Milk- 6 hours
breast fed infants- 4 hours

94
Q

Minimum recommended fasting time for:
Clear fluids
Alcohol
Boiled sweets/chewing gum

A

Clear fluids- 2 hours
Alcohol- At least 24 hours
Boiled sweets/chewing gum- Avoid but carry on with surgery

95
Q

What is the lowest ml of fluid associated with morbidity in surgery

A

30ml

96
Q

Impact of prolonged fasting

A

Headache, Anxiety, N&V, Dehydration, Hypotension, Metabolic disturbance

97
Q

Factors impacting gastric emptying

A

Diabetes, CKD, Pyloric stenosis, Pregnancy, Obesity, Head trauma

98
Q

Up to what time are children allowed H20 before surgery

A

1 hour before

99
Q

Rapid sequence induction- indication

A

Full stomach

Use cuffed ET tube

100
Q

RSI 3 phases

A

1) Preoxygenation with 3 mins tight fitting face mask or 5 full VC breaths
2) Induction with thiopentone or propofol + Recuronium or suxamethonium
3) Cricothyroid pressure + no ventilation (gentle if desaturate) + remove once ET tube in

101
Q

Side effects of GA

A

Sore throat, tissue damage, confusion memory loss

Infection is uncommon as is teeth damage.

Eye damage is rare

102
Q

Phases to pre-op assessment

A 
Introduction/Details
Previous anaesthetic Hx
Exercise tolerance
General health
CVS/Resp/GI- Inc DM/Neuro/MSK/Dental
DHx
SHx
FHx- Problems with anaesthetic 
Fasting check- clear fluids oly 6 hrs before then NBM 2 hours before 
Examination and Mallampati score
103
Q

ASA grading

A 
1- Healthy
2- Mild-mod sys disease with no limitation
3- Severe sys disease with limitation 
4- Constant threat to life
5- Not expected to survive
104
Q

Pre-op investigations if:
>80
60-80
<60

A

> 80- FBC, U&Es, ECG
60-80- SG>3 get all above, FBC only if SG2
<60- SG>3 get FBC (+U&Es if SG>4)

105
Q

Surgical grades 1-4

A

1- Minor (Skin excision)
2- Intermediate (Tonsillectomy)
3- Major (Hysterectomy)
4- Major + (Joint replacement, thoracic)

106
Q

RF for post-op N&V

A

Young. Female. Anxious. Etomidate. No2. Opiates. Volatile agents. Abd surgery

107
Q

Treating intra-operative N&V

A

Ondansetron or Dex

108
Q

Treating recovery N&V

A

Ondansetron is generally considered to be 1st line

Dexamethasone, cylizine, prochlorperazine are all alternatives

109
Q

Post op fluid aims

A

Replace loss and achieve optimum SV/CO

110
Q

What factors impact the speed of LA

A

Baricity, conc, volume, level of injection, speed of injection

111
Q 
CEPOD examples for 
Immediate
Urgent
Scheduled 
Elective
A

Immediate- life/organ saving, resus, AAA, fasciotomy
Urgent- 6 hours- Potentially life threatening, hours available for resus
Scheduled- 24-58 hours- Not an immediate threat to life (Tumour excision that if left could bleed)
Elective- Planned to suit patient

112
Q

Order of process for GA + Intubation

A 
Oxygenation 
Opioid 
Induction 
Volatile agent
Bag-mask
Muscle relaxant
ET intubation
113
Q

Order of process for GA + LMA

A 
Oxygenation 
Opioid 
Induction 
Volatile agent
Bag-mask
LMA insertion
114
Q

What is high frequency USS?

A

7-18Hz
Poor depth
Linear probe
SUPERFICIAL STRUCTURES

115
Q

What is low frequency USS?

A

2-6Hz
Curvilinear probe
DEEP STRUCTURES

116
Q

What primarily generates resolution on an USS?

A

Frequency

117
Q

How and why do you adjust depth on an USS?

A

Want subject in the centre

so start with high depth and then adjust

118
Q

How and why do you adjust gain on an USS?

A

Artificial multiplication of a structure

Better able to see deeper structures

119
Q

Blood moving away is generally what colour on a doppler USS?

A

Blue

120
Q

Blood moving towards is generally what colour on a doppler USS?

A

Red

121
Q

What is a FAST scan?

A

Focussed Assessment Sonography for Trauma
Detects fluid/bleeding
Low specificity to cannot rule in
Misses retroperitoneal bleeds

122
Q

Mallampati scores
1->4
What score signifies a difficult intubation?

A

1- See everything
2- See whole uvula (cannot see ant/post pillars completely)
3- Only uvula base
4- Soft palate not visible

3&4= Difficult intubation

123
Q

What are your goals for treating shock?

A 
Normalise lactate
UO>0.5
MAP>65
Central venous oxygen sats >70%
CVP 8-12 mmHg
124
Q

Examples of vasopressors

A

Noradrenaline, Phenylephrine, Vasopressin, Metarminor

125
Q

Examples of inotropes

A

Adrenaline, Dobutamine, Isoprenaline, Ephridine

126
Q

When would you use Noradrenaline in shock?

A

Low CO

Septic shock

127
Q

In what type of shock are vasopressors like NA, Vasopressin, phenylephrine indicated

A

Distributive

128
Q

In what type of shock are inotropic agents like dobutamine indicated

A

Cardiogenic

129
Q

What does CVP inform you of?

A

Fluid status, look at trend post-fluid

130
Q

Key signs of shock

What compensatory signs may be seen

A

Hypotension (NOT ESSENTIAL…)
High lactate (>3)
BE

131
Q

A bounding pulse can be a sign of what type of shock

A

Distributive

132
Q

What is Beck’s triad?

A

Tamponade

Hypotension, Inc JVP, Pul oedema, Faint heart sounds

133
Q

Describe obstructive shock

A 
Afterload problem (Outflow block)
PE, Tamponade, Pneumothorax, Fluid overload
134
Q

Poor prognostic signs in hypovolaemic shock

A 
BP<90
Low GCS
Mottled
Unresponsive to fluid 
Ongoing bleed
135
Q

What are the 4 types of shock

A

Hypovolaemic
Cardiogenic
Obstructive
Distributive

136
Q

Levels of care 0-3

A

0- Normal ward
1- Inc deterioration risk (CC Outreach)
2- Single failing organ system/Major burns
3- ICU (MULTI-ORGAN FAILURE)

137
Q

If a patient comes to ICU their clinical state must be…

A

Potentially reversible

Long term health means patient can benefit from intensive care

138
Q

How do you assess volume status

A 
UO 
HR
inc albumin inc urea (if dehydrated)
Haematocrit (inc if dehydrated)
creatinine 
Skin turgor 
BP
139
Q

What is the 4, 2, 1 rule for fluid maintenance?

A

4ml/kg/hr for 1st 10kg Wx
2ml/kg/hr for next 10kg
1,l/kg/hr for remaining ideal Wx

Most adults 20-30ml/kg/hr

140
Q

On an echo what does the IVC size suggest about the type of shock?

A

Small IVC- Hypovolaemia
Dilated IVC- Decreased contractility, so likley cardiogenic
Loss of normal structure= Tamponade? Obstructive shock

141
Q

Parasternal echo veiw shows…

A

Transverese of long axis view

142
Q

Apical echo view shows…

A

4 chambers

143
Q

Subcostal echo view shows…

A

IVC- N.B. Should collapse <50% on insp)

Can also have a 4 chamber view

144
Q

What is T1RF?

A

Hypoxaemia because V/Q Mismatch

Pneumonia, asthma, COPD, pneumothorax, ARDS, CHD, Bronchiectasis, Pul. HTN

145
Q

What is T2RF?

A

Hypoxaemia and Hypercapnia due to ventilatory failure

Neuromuscular- Flail chest
COPD/ASTHMA when severe and tired
Oedema
Loss of Resp drive 
Hypoventilation 
Trauma
146
Q

What is the pathophysiology of ARDS?

A

Lung damage secondary to severe systemic illness
Induces a rise in inflammatory mediators
Increases cap permeability, Non-cardiogenic pul.oedema, Multi organ failure

147
Q

What is Fi02?

A

Fraction of inspired oxygen

Helps to contextualise hypoxia

148
Q

What is the main indicator for oxygen?

A

Hypoxaemia NOT BREATHLESSNESS

149
Q

What does CPAP do to the airways?

A

Splints them open to improve FRC

Net effect to ameliorate V/Q mismatch

150
Q

Type of respiratory failure where CPAP is used?

A

T1RF

151
Q

How does BIPAP work?

A

CPAP + additional pressure to support ventilation

Increasing TV

152
Q

Type of respiratory failure where BIPAP is used?

A

Hypercapnic COPD exacerbations
MSK conditions where there is respiratory failure

HELPS VENTILATION

153
Q

Problems with ET tubes and sedation

A

Hypotension
Gastroparesis
Immobility
Pneumonia risk

154
Q

Signs of increased ICP

A

Pupillary dilatation
Sluggish then fixed pupillary reflexes
Aphasia
Reduced consciousness/GCS

155
Q

How do you manage increased ICP in ICU?

A 
Avoid pyrexia
Prevent seizures
Elevate head to 30 degrees
Sedation
Ameliorate hypoxia and hypercapnia 
Hypertonic saline 
Mannitol (Inc blood osmolarity)
Decompressive craniotomy
156
Q

What is a poor prognostic sign on CT after brain injury?

A

Loss of differentiation

Looks hazy grey

157
Q

Secondary brain injury precipitated by…

A

Hypoxia
Hypoperfusion
Hypoglycaemia

158
Q

What does renal failure indicate about end organ perfusion in a critical care context?

A

Poor end organ perfusion

Look for anuria and increased serum creatinine

159
Q

Complications of renal failure?

A

Uraemia- Encephalopathy, Pericarditis, Coagulopathy
Fluid overload
Metabolic acidosis
Hyperkalaemia

160
Q

5 major principles of the MCA?

A 
Presumption of capacity 
Support to make own decisions 
Able to make an unwise decision 
Best interests checklist if no capacity
Least restrictive option that infringes on freedom least
161
Q

Principles of capacity

A

Understand, Retain, Weigh up, Communicate

162
Q

What is futility?

A

Low treatment efficacy

Physiological (Quantitative/Qualitative) or cost-based

163
Q

What is death?

A

Irreversible loss of capacity for breathing and consciousness

164
Q

How do you confirm brainstem death?

A

Continuous loss of Cardio-resp function for 5 minutes
Pupils, Supra-orbital pressure, corneal reflex

May still have beating heart…

165
Q

Deceased donors must be Dx by how many consultants?

The death must be what?

A

3
Also must be on ventilator
Predictable and controlled death!

166
Q

Process of organ donation in brainstem death

A

Test to confirm death > optimise physiology > Mobilise team > Organ retrieval

TAKEN TO THEATRE ONCE RETRIEVAL TEAM HAS ARRIVED

167
Q

Process of organ donation in circulatory death

A

Mobilise team > Stop support> Death within time constraint> Dx death > Organ retrieval

Potential for stand down therefore not definitely going to theatre like in brainstem death, plus team is mobilised earlier

Year 4 ACC (3 decks)

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