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Speciality teaching > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

What is the triad of anaesthesia?

A

Hypnosis
Analgesia
Relaxation

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2
Q

In relation to the triad of anaesthesia, what do opiates do?

A

Hypnosis and analgesia

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3
Q

In relation to the triad of anaesthesia, what do GAs do?

A

Hypnosis, analgesia (little except ketamine) and relaxation

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4
Q

In relation to the triad of anaesthesia, what do LAs do?

A

Analgesia and muscle relaxation

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5
Q

In relation to the triad of anaesthesia, what do muscle relaxants do?

A

Relaxation

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6
Q

Why is balanced anaesthesia required?

A

Increased control over individual components of triad and helps avoid overdosage

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7
Q

What are disadvantages of balanced anaesthesia?

A

Polypharmacy
Increased ADRs
Airway control needed

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8
Q

How can GAs be administered?

A

Inhaled or IV

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9
Q

How do GAs work?

A

Open Cl- channels -> hyperpolarise (less likely to fire) or suppress excitatory synaptic activity

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10
Q

How do inhaled GAs work?

A

Halogenated hydrocarbons that dissolve in membranes
Slow
Flexible maintenance

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11
Q

Discus the arterial and alveolar partial pressures of inhaled GAs.

A

Equal to each other

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12
Q

What is the MAC?

A

Minimum alveolar concentration

  • measures potency of drug
  • if low MAC then increased potency
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13
Q

How do you stop inhaled GAs?

A

stop agent, give gas, reduce alveolar concentration and then blood and then brain, consciousness will then return

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14
Q

Discuss uptake and excretion of inhaled GA.

A

Uptake and excretion both by lungs

lungs > blood > brain

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15
Q

How does IV GA work?

A

allosteric binding to GABA receptors

rapid onset and recovery

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16
Q

What are spared under GA?

A

Reflexes and some autonomic functions

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17
Q

What is vital to consider when using GA?

A

ABC Resuscitation

Airway management

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18
Q

How is IV GA redistributed around body?

A

Blood > viscera > muscle > fat (slowed uptake but larger stores therefore lipid soluble drugs important)

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19
Q

What is TCI?

A

Targeted controlled infusion pump used to achieve accurate infusions of blood or brain concentrations

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20
Q

What is the most common sequence of administration of GA?

A

IV induction then inhalation maintenance

nb: alternative IV maintenance with propofol or remifentanyl

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21
Q

What is the most common drug used for IV induction?

A

Propofol

others e.g thiopentone

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22
Q

How fast is IV induction?

A

Rapid - one “arm-brain” circulation approx 20s

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23
Q

Give an example of a drug used for gas induction.

A

Devoflurane (halothane)

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24
Q

What are planes of anaesthesia?

A

Analgesia/sedation
Excitation
Anaesthesia (light –> deep)
Overdose

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25
Q

What type of GA induction is slower with more obvious “planes” of anaesthesia?

A

Inhaled

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26
Q

What is needed during induction of anaesthesia?

A

Quietness
Administer Gas or IV agent
Careful monitoring of conscious level
Airway maintenance

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27
Q

How do you monitor consciousness?

A 
Loss of verbal contact 
Movement 
Respiratory pattern (can sometime hyperventilate first)
Processed EEG 
"Planes" of anaesthesia
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28
Q

What is the triple airway manoeuvre?

A

Head tilt/chin lift/jaw thrust

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29
Q

Why is the triple airway manoeuvre always required in GA?

A

Airway maintenance since loss of muscle tone and tongue rests on pharyngeal wall

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30
Q

What simple apparatus is used after the triple airway manoeuvre?

A

Face mask
Oropharyngeal (guedel) airway
NPA

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31
Q

What happens when you insert a guedel into a “light” patient?

A

Vomiting or larngospasm

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32
Q

What does an LMA do?

A

Maintains but doesn’t protect airway

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33
Q

What does an I-gel not protect from?

A

Aspiration

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34
Q

What are causes of airway obstruction?

A

Ineffective triple airway manoeuvre

Airway device apposition or kinking

Laryngospasm

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35
Q

What is laryngospasm?

A

Reflex adduction of vocal cords in semi-conscious state

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36
Q

What is the management of larnygospasm?

A

Avoidance

Timing of extubation and airway manoeuvre

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37
Q

Why can aspiration occur?

A

Loss of protective airway reflexes e.g gag swallow

Foreign material in lower airway e.g gastric contents, blood, surgical debris

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38
Q

Compare airway maintenance and airway protection.

A

Maintained if opened and unobstructed

Protected only when conscious and in charge of own reflexes or if cuffed tube below vocal cords.

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39
Q

What is endotracheal intubation?

A

Placement of a cuffed tube in trachea

Oral route most common

Laryngeal reflexes must be abolished

Can be carried out in awake patient using LA and fibre-optic scope

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40
Q

Why intubate?

A

Protect airway from gastric contents

Need for muscle relaxant e.g laparotomy

Shared airway with risk of blood contamination

Need for tight control of blood gases esp CO2 levels in neurosurgery

Restricted airway access e.g maxfax

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41
Q

What are risks to the unconscious patient?

A 
Airways
Temperature
Loss of other protective reflexes e.g corneal, joint position 
VTE
Consent and identification 
Pressure areas
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42
Q

What are potential positions of a patient under GA?

A 
Supine
Lithotomy 
Prone 
Lying on side
Sitting
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43
Q

What is the basic “minimum” monitoring during anaesthesia?

A 
SpO2
ECG
NIBP
FiO2
ETCO2
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44
Q

What a potential complications with anaesthesia?

A

Airway, Breathing, Circulation, Related to technique or position, awareness

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45
Q

What are risk factors of awareness while under GA?

A 
GA C-section 
Major trauma
Cardiac surgery 
Chronic CNS depressant use
Previous episode of awareness 
Paralysed and ventilated
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46
Q

What are the steps for awakening?

A 
Reverse muscle relaxant 
Anaesthetic agents off
Resume spontaneous respiration 
Return of airway reflexes 
Extubation
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47
Q

What else is controlled post-op?

A

Pain
Airway
N&V

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48
Q

What is critical care?

A

Initial assessment and management of respiratory failure and CVS failure or neurological failure

and fluid management

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49
Q

Describe the two types of respiratory failure.

A

1 - oxygenation failure

2 - oxygenation and ventilation failure

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50
Q

What type of respiratory failure is a high flow nasal cannula used for?

A

Type 1

Can be given in HDU

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51
Q

What type of respiratory failure is NIV given to?

A

Type 2 respiratory failure

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52
Q

What is shock?

A

Acute circulatory failure with inadequate or inappropriately distributed tissue perfusion resulting in cellular hypoxia

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53
Q

Name types of shock

A 
Distributive (Septic)
Hypovolaemic
Anaphylactic
Neurogenic
Cardiogenic
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54
Q

What does SV equal?

A

Preload/contractility/afterload

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55
Q

What is given for cardiovascular failure?

A
  • Vasopressors - metaraminol, noradrenaline

- Inotropes - adrenaline, dobutamine

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56
Q

How do we measure cardiovascular failure?

A

Arterial line or central line

57
Q

What are benefits of a central line in critical care?

A

stay in for a week and allow administration of strong meds e.g noradrenaline

58
Q

What are central lines not useful for?

A

Fluid resuscitation

59
Q

What are vasopressors used for?

A

Alpha Cause vasoconstriction

if enough fluid in vascular tree but not in correct place

60
Q

What are inotropes?

A

Given if pump failure and cardiogenic shock to improve contractility of heart.

61
Q

What is a colloid?

A

A fluid with large molecules in it

62
Q

What is a crystalloid?

A

A fluid with small molecules e.g sodium chloride, plasmalite

63
Q

How much fluid should be given?

A

30ml/kg is sensible limit

64
Q

What are causes of neurological failure?

A

Metabolic
Trauma
Infection
Stroke

65
Q

What is the physiological impact on the CVS of anaesthetics?

A

Depress CVS centre

- decrease sympathetic outflow, -ve inotropic/chronotropic effect on heart, increased vasodilation

66
Q

What does the negative inotropic effect of anaesthetics have on CO?

A

Reduces CO

67
Q

What does increased venodilation from anaesthetics do to the CVS?

A

Reduced venous return and CO

68
Q

What anaesthetic does not depress the CVS and respiratory system?

A

Ketamine

69
Q

What does MAP equal?

A

CO x SVR

70
Q

What do anaesthetics do to the respiratory system?

A

Reduce hypoxic and hypercapnia drive
Reduced TV
Increased RR
Decreased FRC (VQ mismatch, reduced lung volumes)

71
Q

What happens to the respiratory system with opiates?

A

Preserves TV but reduced RR

72
Q

What are indications for muscle relaxants?

A

Ventilation and intubation
Immobility essential
Body cavity surgery e.g laparotomy

73
Q

What are problems from muscle relaxants?

A

Awareness
Incomplete reversal
Apnoea

74
Q

Why is intraoperative analgesia given?

A

Prevent arousal
Opiates contribute to hypnotic effect of GA
Suppress reflex response

75
Q

Give examples of local anaesthetics.

A

Lignocaine
Bupivicaine
Ropivacaine

76
Q

What type of anaesthetic does not cause hypnosis and patient retains consciousness/awareness?

A

Local anaesthetic

77
Q

How do local anaesthetics work?

A

Block Na+ channels (prevent AP firing)

78
Q

What system is not usually affected by local anaesthetic?

A

Respiratory

79
Q

Name a risk of local anaesthetic use.

A

Local anaesthetic toxicity.

80
Q

What is TIVA?

A

Total Intravenous Anaesthesia
- General anaesthesia using a combination of agents given solely by the intravenous route and in the absence of all inhalation agents

81
Q

Why is pre-op assessment important?

A

Trauma associated with surgery –> stress response, fluid shifts, blood loss, CVS, Resp and metabolic stress

82
Q

What are important considerations in pre-op assessments?

A
  • Known co-morbidities
  • Unknown pathologies
  • Nature of surgery
  • Anaesthetic techniques
  • Post-op care
83
Q

What is the role of the anaesthetics pre-op?

A 
Assess
Identify high risk
Optimise
Minimise risk 
Inform and support patient decisions 
Consent
84
Q

What are the levels of post-op care?

A

1 - monitor every 1/2 hours on ward

2 - HDU suppor

3 - still ventilated, ICU support

85
Q

Why is pre-op assessment important?

A

Reduces anxiety, delays, complications, length of stay, mortality

86
Q

When can you do a pre-op assesment?

A

Elective planned surgery (primary care, pre-assessment clinic), urgent surgery, emergency surgery

87
Q

What is involved in a pre-op assessment?

A

Hx
Ex
Ix

88
Q

What is important in a pre-op history?

A
  • Severity and control of known co-morbidities (especially heart and lung function)
  • Systematic enquiry of unknown co-morbidities
  • Ability to withstand stress
  • Drugs/allergies
  • Previous surgery/anaesthesia
  • Potential problems e.g obesity, reflux, airway, malignant hyperpyrexia
89
Q

What do the NICE guidelines suggest for pre-op assessment?

A

ASA grade
Surgery grade
Co-morbidities

90
Q

What Ix could be carried out pre-op?

A

LINK WITH CO-MORBIDITIES:

CVS: ECG, exercise intolerance, echo, stress echo, cardiac catheterisation, CT coronary angiogram

Resp: Sats, ABG, CXR, Peak flow, FVC/FEC, CXR, Gas transfer, CT chest

91
Q

Describe the ASA grading score.

A

1: healthy
2: mild to moderate systemic disturbance
3: severe systemic disturbance
4: Life threatening
5: Moribund patient
6: Organ retrieval

92
Q

Is ASA useful?

A

Not all the time, e.g patient with MS would be ASA 3 but could be a Paralympian

93
Q

What scores can be used pre-op?

A

Cardiac risk index
Exercise tolerance - METS
Surgical outcomes risk tool (SORT)

94
Q

What are the 6 factors considered in a cardiac risk index?

A 
High risk surgery 
IHD
CHF
Cerebrovascular disease
DM
Renal failure
95
Q

What lifestyle factors are considered pre-op?

A

Smoking, alcohol, cannabis, obesity, exercise

96
Q

What is pre-habilitation?

A

Encouraged by anaesthetists pre-op - prescribed exercise

–> improved outcomes

97
Q

What medications would you continue pre-op?

anti-diabetics 
anticoagulants 
Inhalers
Anti-anginals
Anti-epileptics
A

Inhalers
Anti-anginals
Anti-epileptics

98
Q

What are benefits of treating pain?

A

Physical
Psychological
For family
For society (lower health costs)

99
Q

How is pain classified?

A

Duration (Acute, chronic or acute on chronic), cause (cancer or non-cancer), mechanism (nociceptive or neuropathic)

100
Q

What is nociceptive pain?

A

Obvious tissue injury or illness

Described as sharp or dull and is well localised

101
Q

What is neuropathic pain?

A

Nervous system damage or abnormality

Tissue injury may not be obvious

No protective function

102
Q

How is neuropathic pain described?

A

Burning, shooting +/- numbness, pins and needles

103
Q

What causes cardiovascular response to pain?

A

Brainstem

104
Q

What is the first and second relay system of pain?

A 
1st = dorsal horn 
2nd = thalamus
105
Q

Give examples of neuropathic pain.

A

Nerve trauma
Diabetic pain
Fibromyalgia

106
Q

How do you treat neuropathic pain?

A

Hard to treat, patients have to live with a certain degree of pain

107
Q

What are the pathological mechanisms of neuropathic pain?

A

Increased receptor numbers
Abnormal sensitisation of central and peripheral nerves

Chemical changes in dorsal horn

Loss of normal inhibitory modulation

108
Q

What are simple analgesics?

A

Paracetamol

NSAIDS

109
Q

Name mild and strong opioids.

A

Mild = codeine

Strong = morphine, fentanyl

110
Q

What is tramadol?

A

analgesic - mixed opiate and 5HT/NA reuptake inhibitor

111
Q

What is ketamine?

A

Analgesic NMDA receptor antagonist

112
Q

What types of analgesias work at the periphery?

A

NSAIDS
Local anaesthetics
Non drugs - RICE

113
Q

What analgesia works at spinal cord level?

A

Non drug: Acupuncture, massage, TENS
LAs
Opioids
Ketamine

114
Q

What analgesia works at the brain level?

A

Non-drug: psychological

Drug treatments: paracetamol, opioids, amitriptyline, clonidine

115
Q

What is a disadvantage of paracetamol?

A

Liver damage in overdose

116
Q

What routes can paracetamol be given?

A

Orally, rectally or IV

117
Q

What is the best treatment option for nociceptive pain?

A

NSAIDs given with paracetamol (synergism)

118
Q

What are potential side effects of NSAIDS?

A

GI and renal SEs and bronchospasm in sensitive asthmatics

119
Q

What should you do when giving paracetamol IV?

A

Reduce dose, especially for under 50kg patients (can cause liver failure)

120
Q

What are disadvantages of tramadol?

A

Nausea and vomiting

121
Q

What are advantages of tramadol?

A

Less respiratory depression

Can be used with opioids and simple analgesics

122
Q

What is morphine good for?

A

Mild-severe acute nociceptive pain (e.g post-op pain)

Chronic cancer pain

123
Q

How can morphine be given?

A

IV, IM, SC

124
Q

What are disadvantages of morphine?

A

Constipation
Respiratory depression in high dose
Misunderstanding about addiction

125
Q

Compare the oral dose of morphine with IV/IM/SC dose.

A

Oral dose = 2/3x IV/IM/SC dose

126
Q

How does amitriptyline work?

A

Modulate pain, increase noradrenaline in spinal cord

127
Q

What are advantages of amitriptyline?

A

Good for neuropathic pain

Treats depression and poor sleep

128
Q

What are disadvantages of amitriptyline?

A

Anti-cholinergic side effects e.g glaucoma and urinary retention

129
Q

What are anticonvulsants such as carbamazepine useful for with regards to pain?

A

Reduce abnormal firing of nerves

–> good for neuropathic pain

130
Q

How do you work out what drugs to give for nociceptive pain?

A

WHO Pain ladder

131
Q

How do you work out what drugs to give for neuropathic pain?

A

use alternative alagesics and/or psychological and non drug treatments. Not WHO pain ladder

132
Q

What is the RAT model for management of pain?

A

Recognise (ask patient or family etc, look)

Assess (Severity, type, other factors)

Treat (drugs, non drugs)

133
Q

How do you assess pain?

A 
Verbal rating score
Numerical rating score 
Smiling faces
Visual analogue scale 
Abbey pain scale (if confused)
134
Q

What should you consider when assessing pain?

A

Pain score at rest and with movement

How does pain affect patient?

Type? Acute, chronic, cancer/non-cancer, nociceptive, neuropathic

Other factors e.g physical, psychological, social

135
Q

What are non-drug treatments for pain?

A 
RICE
Nursing care
Surgery 
Acupuncture
Massage
TENS
Psychological
136
Q

What are drug treatments for nociceptive pain based on pain ladder?

A

Mild –> paracetamol (+/- NSAIDS)

Moderate –> ) + codeine/alternative

Severe –> + morphine

137
Q

What should you do as nociceptive pain resolves ?

A

Move down WHO pain ladder

138
Q

As pain ladder isn’t usually used for neuropathic pain. What drugs could you prescribe?

A

Amitriptyline
Gabapentin
Duloxetine

Speciality teaching (4 decks)

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