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3 - Specialities > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

Triad of anaesthesia

A

Analgesia
Hypnosis
Relaxation

GA: HYPNOSIS, relaxation, analgesia
Muscle relaxants: RELAXATION
Opiates: ANALGESIA, hypnosis
LA/RA: ANALGESIA, relaxation

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2
Q

Main potential anaesthetic problems

A 
R-eflux
O-besity
A-irway
R-airities (malignant hyperpyrexia, cholinesterase deficiency)
S-pine
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3
Q

Investigations to be carried out as part of a pre-op assessment are determined by…

A

NICE guidelines
take into account…

  • ASA grade (1-6)
  • Co-morbidities
  • surgery grade

Examples: ECG, Exercise tolerance test, (stress) Echo, Myocardial perfusion scan, Cardiac catheterisation, CT coronary angiogram, Saturations, ABGs, CXR, Peak flow measurements, FVC/FEV, Gas transfer, CT chest

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4
Q

Cardiac risk index, high risk of surgical complications if…

A

> 4 of…

High risk surgery
Ischaemic heart disease
Congestive heart failure
Cerebrovascular disease 
Diabetes
Renal failure
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5
Q

Parts of a pre-op assessment

A

Assess (history, examination, investigations)
Identify high risk (various assessment tools)
Optimise health
Minimise risk
Inform and support patients’ decisions
Consent

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6
Q

General anaesthesia works by…

A

Hyperpolarising neurones (largely by opening chloride channels) – prevents them from firing

((processes lost “from the top down”, reflexes relatively spared))

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7
Q

Most common method of induction and maintenance for general anaesthetic

A

IV induction –> inhalational maintenance

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8
Q

IV induction of general anaesthetic usually uses…

+ how can specific concentrations be achieved

A

Propofol

o Specific concentrations can be achieved using a Target Controlled Infusion (TCI) pump system (calculations based on patient’s age, sex and size)

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9
Q

Inhalational induction of general anaesthetic uses…

+ what measurements are used to control the concentrations

A

Halogenated hydrocarbons, e.g. sevoflurane

  • Alveolar partial pressure ≈ arterial concentration
  • MAC = Minimum Alveolar Concentration to produce anaesthesia
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10
Q

Risks to an unconscious patient

A 
Airway (obstruction/ aspiration)
Temperature
Loss of protective reflexes (e.g. corneal)
VTE risk
Pressure areas
Consent/ identification
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11
Q

Minimum monitoring of an unconscious patient requires…

A 
SpO2 (peripheral capillary oxygen saturation)
ECG 
NIBP (non-invasive BP)
FiO2 (fraction of inspired oxygen)
ETCO2 (amout of CO2 in exhaled air)
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12
Q

Extra monitoring of the unconscious patient may include…

A 
Respiratory parameters
Temperature
Urine output
Invasive venous/ arterial monitoring
Processed EEG
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13
Q

The triple airway manouvre

A

head tilt,
chin lift,
jaw thrust

(painful so unconscious if tolerated)

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14
Q

Apparatus to maintain (keep open + unobstructed) the airway:

A

Anaesthetic face mask
Oropharyngeal (Guedel) airway
Laryngeal mask airway (e.g. i-gel)

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15
Q

To PROTECT (not just maintain) the airway, you must use…

A

Endotracheal intubation
- Cuffed tube in the trachea protects the airway from contamination

((Inserted using a muscle relaxant and laryngoscope ))

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16
Q

Reasons to intubate:

A
  • Protect airway from gastric contents (e.g. unfasted patient)
  • Use of muscle relaxants
  • Need for tight control of blood gasses (neurosurgery)
  • Restricted access to airway (maxillo-facial surgery)
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17
Q

echanism of emergence/ awakening from IV / inhalational general anaesthetic

A

IV: Rapid recovery as drug leaves circulation

Inhalational: agent is breathed off due to reversal of concentration gradient

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18
Q

Muscle relaxants are used in anaesthesia when…

A

Immobility is essential (e.g. microscopic surgery/ neurosurgery)

Body cavity surgery (relaxation allows access)

((requires ventilation and intubation))

19
Q

Relaxation without hypnosis =

A

awareness

20
Q

Function of intraoperative analgesia

e.g. Opiates

A

Contribute to the hypnotic effect of GA

Suppression of reflex responses to pain

Prevent arousal due to pain

21
Q

Mechanism of action of local/ regional anaesthetics

A

Block Na+ channels, preventing axonal excitation

22
Q

benefits of local/ regional anaesthetics compared to GA

A

Relative sparing of CVS and respiratory function compared to GA

23
Q

Nociceptive (physiological/inflammatory) pain

Cause + characteristics

A

Caused by obvious tissue injury/ illness, Protective function

Sharp +/- dull, Well localised

24
Q

Neuropathic pain

Cause + characteristics

A

Caused by:

  • Nervous system damage (e.g. nerve trauma, diabetic pain)
  • Nervous system dysfunction (e.g. chronic tension headache, fibromyalgia)

Burning, shooting +/- numbness, pins and needles, Not well localised

25
Q

Paracetamol: advantages and disadvantages

A

Advantages:

  • cheap and safe
  • given orally, rectally, IV
  • good for mild pain alone/ moderate in combination

Disadvantages:
- liver damage in overdose

26
Q

NSAIDs: examples, advantages and disadvantages

A

E.g. diclofenac, ibuprofen, aspirin

Advantages:

  • cheap, generally safe
  • good for nociceptive pain
  • best with paracetamol (synergism)

Disadvantages:

  • GI + renal side ADRs
  • bronchospasm in sensitive asthmatics
27
Q

Mild opioids: examples, advantages and disadvantages

A

E.g. codeine, dihydrocodeine

Advantages:

  • cheap + safe
  • mild-moderate, acute, nociceptive pain
  • best with paracetamol

Disadvantages:

  • constipation
  • bad for chronic pain
28
Q

Strong opioids: examples, advantages and disadvantages

A

E.g. morphine, oxycodone, fentanyl

Advantages:

  • cheap, generally safe
  • given orally IV, IM, SC
  • moderate-severe acute nociceptive pain
  • chronic cancer pain

Disadvantages:

  • constipation, resp depression in high dose
  • misunderstandings about addiction
  • 1st pass metabolism means oral dose must be 3x higher
29
Q

Antidepressants used for pain relief: examples, mechanism, advantages and disadvantages

A

E.g. amitriptyline, duloxetine

Mechanism: increases descending inhibitory signals

Advantages:

  • cheap, safe in low dose
  • good for neuropathic pain

Disadvantages:
- anti-cholinergic side-effects

30
Q

Anticonvulsants used for pain relief: examples and mechanism

A

E.g. gabapentin, carbamazepine, sodium valproate

Mechanism: reduce abnormal firing of nerves (good for neuropathic pain)

31
Q

Tramadol: composition, advantages and disadvantages

A

Composition:
- mixed weak opiate + serotonin (5HT) / noradrenaline (NA) reuptake inhibitor

Advantages:

  • less resp depression
  • can be used with opiates + simple analgesics

Disadvantages:

  • nausea + vomiting
  • nasty withdrawal
32
Q

Ketamine mechanism

A

NMDA receptor (glutamate receptor) antagonist

(often used in ED as doesn’t drop BP)

33
Q

Nefopam mechanism

A

Mixed:

  • NMDA receptor (glutamate receptor) antagonist
  • serotonin (5HT) / noradrenaline (NA) reuptake inhibitor
34
Q

“other” analgesics….

(not simple analgesics or opioids)

A

Antidepressants (e.g. amitriptyline)
Anticonvulsants (e.g. gabapentin)
Tramadol (mixed weak opiate + 5HT/NA reuptake inhibitor)
Ketamine (NMDA receptor antagonist)
Nefopam (mixed NMDA receptor antagonist + 5HT/NA reuptake inhibitor)
Topical agents (e.g. Capsaicin)

35
Q

WHO pain ladder for nociceptive pain:

A

Mild: paracetamol (+/- NSAIDs)

Moderate: paracetamol (+/- NSAIDs) + codeine/ alternative

Severe: paracetamol (+/- NSAIDs) + morphine

((ok to start at top of the ladder, but must move down through every rung))

36
Q

Treatment of neuropathic pain

NOT responsive to WHO pain ladder

A

Use alternative analgesics (e.g. amitriptyline, duloxetine, gabapentin)

Non-drug treatments !

  • RICE
  • nursing care
  • surgery
  • acupuncture
  • massage
  • TENS
  • Psychological treatments
37
Q

The RAT approach to pain management

A

R-ecognise
A-ssess
T-reat

38
Q

Methods to assess severity of pain

A 
Verbal rating score
Numerical rating score (0-4)
Visual analogue scale
Smiling faces (paeds)
Abbey pain scale (for confused patients)
Functional pain
39
Q

Types of respiratory failure:

A

o Type 1: oxygenation failure

o Type 2: oxygenation and ventilation failure

40
Q

Management of respiratory failure in critical care

A

Heated humidified high-flow (HHHF) therapy/ high flow nasal oxygen (HFNO)

Non-invasive ventilation (NIV)

Intubation

41
Q

Definition of shock

A

Acute circulatory failure* resulting in cellular hypoxia

(*Cardiac Output (CO) is hard to measure so BP is used as a marker)

42
Q

Treatment of circulatory/ cardiovascular failure (shock)

A

1st line = fluids

2nd line = CV failure drugs
- Vasopressors (cause vasoconstriction), E.g. metaraminol, noradrenaline

  • Inotropes (improve cardiac contractility), E.g. adrenaline, dobutamine
43
Q

Potential causes of neurological failure:#

+ concerning features

A

 Metabolic (DKA)
 Trauma
 Infection
 Stroke

((concerning features:

  • uneven pupils
  • Cushing’s reflex (response to ↑ICP: ↑BP, ↓HR, irregular RR)
  • Failure to maintain airway
  • GCS<8))

3 - Specialities (4 decks)

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