Anaesthetics Flashcards
1
Q
T/F glass shows up on xray
A
T. It’s radio-opaque
2
Q
Best anaesthetic for short procedure?
A
Lidocaine & bupivicaine are both commonly used local anaesthetics, but lidocaine has a faster onset and shorter duration of action, making it more suitable for short procedures.
3
Q
Initial pain relief for suturing
A
Lidocaine and paracetemol
4
Q
What can cold spray be used for
A
Cold spray is a volatile compound which evaporates to cool the skin and relieve pain. Cold spray can be useful in closed injuries, but should not be used on an open wound.
5
Q
Which nerve fibres are affected by local anaesthetics
A
They act on small unmyelinated C fibres, which transmit pain and temperature sensation, before the larger A fibres, which transmit touch and power.
6
Q
What channels do local anaesthetics act on
A
Local anaesthetics inhibit the influx of sodium into the cell.
7
Q
What is the time of onset of lidocaine
What is the duration of action
A
4 minutes onset
2hrs duration of action
8
Q
How can lidocaine be made more effective, and less painful on injection
A
More effective: The addition of adrenaline causes local vasoconstriction and delays anaesthetic washout into the circulation, so that its effect can last longer. There is also less bleeding.
Less painful on injection: Subcutaneous injection is made less painful by using anaesthetic warmed to room temperature, and injecting slowly through a small needle.
9
Q
When must you not add adrenaline to local anaesthetic
A
When injecting into digits, you should not add adrenaline to your local anaesthetic as it can cause ischaemia.
10
Q
What are the potential side effects of local anaesthetics
A
Can affect neural processes in the cardiovascular and central nervous systems, causing cardiac arrhythmias, neurotoxicity and central respiratory depression.
They can also cause allergic reactions, resulting in minor urticaria or in the worse scenario, anaphylaxis.
11
Q
Lidocaine overdose affects which system at lower and higher concentration
What about bupivocaine
A
Primarily affects CNS:
- light-headedness,
- dizziness,
- drowsiness
Secondarily, and at higher plasma levels, the cardiovascular system:
- myocardial depression,
- peripheral vasodilatation -> hypotension and bradycardia)
Bupivocaine is actually cardiotoxic so is worse for the cardiovascular effects
12
Q
Symptoms of lidocaine overdose
A
Light headiness
Convulsions
Perioral Paraesthesia
Hypotension
13
Q
What type of molecule is lidocaine
A
Lidocaine is an amide-based local anaesthetic
14
Q
What is the mechanism of action of lidocaine
A
It penetrates the interior of an axon and then reversibly blocks the sodium channels by binding to a receptor in those channels.
This prevents the generation of action potentials when a critical number of the channels are blocked.
15
Q
Where is lidocaine metabolised
A
In the liver, and is excreted in the urine
16
Q
Order the nerve fibres in terms of which are first affected by lidocaine, through to last
A
Pain fibres
Autonomic fibres
Coarse touch
Motor
Related to fibre diameter i.e. smaller the most sensitive, as few channels need to be blocked to reach the analgesic threshold. Thus, light touch may still be preserved even when the patient cannot feel pain. Motor nerves are the last to be blocked.
17
Q
What is regional anaesthetic?
A
Using local anaesthetic to anaesthetise a specific body region
18
Q
What is spinal anaesthetic
A
A regional anaesthetic:
Spinal where local anaesthetic is injected into the intrathecal space at the lower lumbar region – usually L3/4
19
Q
What is epidural anaesthetic
A
A regional anaesthetic:
Epidural where local anaesthetic is injected into the epidural space, usually via a catheter inserted into and left in the space for at least the duration of surgery
20
Q
What is a field block
A
A regional anaesthetic:
Field block where local anaesthetic is infiltrated into the inguinal region before and during surgery.
21
Q
What is a Bier’s block and brachial plexus block
A
Regional anaesthetic techniques
A Bier’s block is a regional technique for anaesthetising the forearm and Brachial plexus blocks are for shoulder and upper limb surgery.
22
Q
T/F regional anaesthetic agents have no effect on the CNS
A
True, unless:
1) Overdose
2) Spinal anaesthesia (other than this, it affects the peripheral nerves)
23
Q
T/F patients undergoing surgery with regional anaesthesia are always awake
A
F.
Patients undergoing surgery under regional anaesthesia are often given sedative drugs or the technique is combined with a general anaesthetic.
24
Q
What is the most frequently used regional anaesthesia and why
A
Bupivacaine (often known by it’s trade name Marcaine) is the most frequently used local anaesthetic agent in regional anaesthesia because of its long duration of action
(compare this to lidocaine (=lignocaine) which is used in short suturing procedures due to its shorter duration of action)
25
What is the time of onset and the duration of action of bupivacaine
Onset: 5-10 minutes
Action: 4-8hrs
26
What is xylocaine
Xylocaine is the trade name for a mixture of lignocaine and adrenaline and is used for local anaesthetic infiltration only
(NOT FOR USE IN EXTREMETIES!)
27
Ketamine is what type of anaesthetic
General anaesthetic
28
T/F. Spinal anaesthetic affects CVS more than respiratory problem
True.
It is good for patients with resp conditions (APART from the fact that they have to be able to lie flat)
But it has an effect on BP particularly in younger patients
You wouldn't use it for someone with an outflow obstruction (e.g AS) , for example
29
Why does the spinal anaesthetic affect the CVS
Because it also blocks autonomic fibres as well as the c fibres
30
When you inject a spinal anaesthetic, how comes it doesn't go everywhere and paralyse you everywhere
Because it settles in the CSF. It is given with a glucose solution.
So it tends not to affect the cervical cord as much
31
What type of local anaesthetics are most commonly used in anaesthetics
Mostly amides, as it's more stable and has less side effects.
Esters, e.g. cocaine, are LAs and are sometimes used in ENT surgery. They are very good at vasoconstricting the nose (which is why some celebs have lost their nasal bridge!)
32
What anaesthetic is found in the magic cream for blood taking in kids.
When else is it used
Amethocaine.
Also used in eye surgery to numb the cornea (good for eyedrops after too)
33
What is pKa
The pKa is the pH at which a soltuion is 50% ionised and 50% unionised
34
What is the pKa of lidocaine vs bupivocaine and what is the effect
pKa of lidocaine is 7.4, which is the same as the physiological pH
So the 50% unionised is what will get through the lipid layers of the nerves.
Bupivoicaine has a pKa of 8.1 so at physiological pH, most of the molecules are in the ionised form, so it takes a lot longer for it to penetrate the nerve fibres
So pKa is related to speed of onset
35
Why is bupivocaine more potent than lidocaine
Because it's more lipid soluble so you need less of it.
36
What is the standard dose of bupivocaine vs lidocaine
10ml 0.5% (50mg) - Bupivocaine
10ml 2% (200mg)- lidocaine
Bupivocaine is much more potent
37
Does bupivocaine or lidocaine last longer
And why
Bupivoicaine
Bupivocaine has more 'claws'. It holds on tighter to the local proteins so it doesn't get pulled away from the blood stream as quickly
38
What is the maximum dose of lidocaine.
What happens when you add adrenaline
4mg/Kg
But when you add adrenaline, that increases to 7mg/Kg (because it vasoconstricts so less gets into systemic circulation)
39
Which lifestyle changes are important before anaesthetic
atients should be advised to stop smoking as this increases the risk of both anaesthetic and surgical complications.
Patients who quit for more than four weeks prior to surgery have a decreased risk of complications.
However patients who quit for shorter periods may paradoxically have an increased risk of complications in comparison to those who continue to smoke
40
When should antihypertensives be stopped before surgery
In most cases antihypertensive medication should be continued up till the day (including the morning) of surgery.
41
When are prophylactic antibiotics given before surgert
Antibiotics for surgical prophylaxis are given as a single dose close to the time of skin incision, usually at induction of anaesthesia.
42
What if you find that your patient is anaemic in a pre-operative assessment
Anaemic patients should be investigated and treated before non-urgent surgery.
Evidence suggests correcting anaemia leads to improved post-operative outcomes.
43
What Hb concentration should trigger transfusion in patients WITHOUT cardiovascular disease
In the absence of cardiovascular disease, it is accepted that there is no clear benefit in transfusing patients unless the Hb concentration is less than 80 g/l. Some institutions accept an even lower trigger of 70 g/l.
44
t/f if there is no cardiovascular compromise you should give patients o neg
f
n absence of cardiovascular compromise, there is time to administer blood that has been appropriately cross matched to the patients blood group. Therefore, a group and save should be obtained. 2 units should be cross matched and administered the patient, rather than receiving emergency O negative blood.
45
How can blood loss in surgery be minimised
- Use regional anaesthesia where possible (e.g. in orthapaedic surgery)
- Haemagolbin levels should be measured during preoperative assessment and should be corrected preoperatively where possible to avoid post-operative transfusion
- Using intraoperative cell salvage techniques
46
What happens to white cells in blood in the UK
In the UK all blood undergoes leukodepletion, where the donor blood is filtered to remove white cells to minimise risk of transmission of vCJD. Blood may also be irradiated, which destroys the DNA in the white cells and prevents graft versus host disease.
47
What is cryoprecipitate
Cryoprecipitate is a blood component rich in fibrinogen and used specifically when a patient has low levels, which can occur in massive haemorrhage or Disseminated Intravascular Coagulation (DIC)
48
What is fresh frozen plasma
Fresh frozen plasma is used to replace clotting factors.
49
What is the cause of early postoperative fever
Early postoperative fever (within the first 24 hours after surgery) is most likely to be due to the systemic inflammatory response to surgical trauma.
50
What is the management of early posteroperative fever if clinical examination does not point to an infective cause
There is no indication to do anything else at this point other than symptom management.
Prescribe an antipyretic agent
51
If a patient conitnues to have fever after 48hrs following the operation, what should you do
Sepsis screen, at least blood cultures, sputum and urine samples.
Urinary and respiratory tract infections are common causes of HAI.
Antibiotics should not routinely be prescribed for postoperative pyrexia. Evidence for infection must be present or highly suspected and cultures obtained prior to starting antibiotics.
The routine use of cephalosporins has been shown to increase the rates of MRSA and Clostridium Difficille infection and should be avoided.
52
How does a post-operative urinary tract infection usually present
Urinary tract infection may be the cause of postoperative fever, but the condition is usually asymptomatic. Therefore, investigations of postoperative fever should always include urinalysis.
53
Why are perioperative patients hypovolaemic
Both absolute and relative hypovolaemia:
ABSOLUTE: Blood and fluid losses and preoperative starvation
RELATIVE: Vasodilating effects of anaesthesia and the inflammatory response to surgery
54
How would you investigate a hypotensive per-operative patient to assess whether they are hypovolaemic
The only appropriate test in this list is to attempt to elevate the legs.
This should increased venous return to the heart and increase the stroke volume which will increase the BP.
An increase in blood pressure may indicate hypovolaemia although a negative response does not rule out hypovolaemia.
You shouldn't stand them up, as it may cause them to faint.
55
What effect would poorly controlled pain have on the BP
Pain is likely to increase the patient’s blood pressure. Good analgesia is essential, relief of pain normally causes blood pressure to fall.
56
What is the use of MAP?
MAP is considered to be a useful number to represent the perfusion of organs in the body.
As a general rule a MAP above 60 is required to sustain adequate organ perfusion in a fit patient.
Patients who are hypertensive may require a higher MAP.
57
How is MAP calculated
Mean arterial blood pressure (MAP) = diastolic pressure + 1/3 (pulse pressure)
58
How is pulse pressure measured
ulse pressure = systolic pressure–diastolic pressure
59
When is hydrocortisone used
ydrocortisone is indicated as a second line drug for hypotension secondary to an anaphylactiod reaction, which is not the case here.
60
What is POAF
Postoperative atrial fibrillation (POAF) is common after surgery
61
What are the complications of POAF
Even though POAF can be self-limiting, it may be associated with:
- hemodynamic derangements,
- postoperative stroke,
- perioperative myocardial infarction,
- ventricular arrhythmias or
- heart failure.
62
How might AF be managed post-operatively
ECG, regular obs, IV access and bloods.
Ascertain RFs, to calculate CHADVASc to assess need for thromboembolism prophylaxis
Call cardiology registrar
```
If stable:
Rhythm control (amiodarone, digoxin)
Rate control (b blocker)
```
If unstable, may require electric cardioversion (see AF management in cardio!)
63
What is the atmospheric pressure
100kPa
64
What is atmospheric pressure of oxygen
21kPa
65
What is the pressure of oxygen in the alveolus
16kPa
66
What account for the difference in the pressure of oxygen between the air and the alveoli
We humidify the air we breathe in, displacing some of the o2 with water, taking it from 21kPa and 16kPa
67
What is the difference between the pressure of oxygen in the alveoli, vs in the pulmonary arterioles
It is not very different at all, both are at around 16kPa.
That's because the transfer of oxygen across the alveolar wall is extremely efficient
68
What is the difference between the pressure of oxygen in the blood of the pulmonary veins and the blood in the ABG. What causes this difference
The blood in the pulmonary veins before it gets back to the heart is 16kPa.
The blood in the artery that you measure in ABG will be at around 10-13kPa normally.
There is a difference here because there is some physiological shunting of blood in the lungs (i.e. not all the blood that travels through the pulmonary circulation gets oxygenated, even in a normal person). This is due to the VQ mismatch.
Also, some deoxygenated blood that has come from the myocardium drains straight into the left side of the heart. So this will bring down the pressure of oxygen in the arterial blood too, compared to the pulmonary vein blood.
69
Why does the pressure of oxygen in the ABG reduce in pneumonia
Because the lobe affected by pneumonia will poorly oxygenate the blood passing around it.
This is because of the fluid in the lobe.
So there is more shunting
70
A patient in A and E has a high pH, a normal o2 and and high Co2.
Can you be sure that they're just anxious
You need to know if they're on any oxygen.
If they're on oxygen, yet they have a normal oxgyen ABG, it probably means they're hypoxic without the added oxygen
71
T/F aspirin and anticoagulants MUST be stopped before operation
T, they need to be stopped >5 days preoperative
72
NICE pre-operative guidelines
//
73
What must you ask all women about before surgery
On the day of surgery, sensitively ask all women of childbearing potential whether there is any possibility they could be pregnant.
Carry out a pregnancy test with the woman's consent if there is any doubt about whether she could be pregnant.
74
T/F you should routinely test for sickle cell disease and sickle cell trait before surgery
F
Do not routinely offer testing for sickle cell disease or sickle cell trait before surgery.
Ask the person having surgery if they or any member of their family have sickle cell disease.
75
T/F there is no need to routinely test HbA1c in non-diabetics, but if they are a diabetic, they need an up to date HbA1c
T
1.5.1Do not routinely offer HbA1c testing before surgery to people without diagnosed diabetes.
.6.1People with diabetes who are being referred for surgical consultation from primary care should have their most recent HbA1c test results included in their referral information.
1.6.2Offer HbA1c testing to people with diabetes having surgery if they have not been tested in the last 3 month
76
T/F Chest x rays should be done before all surgery
F
| 1.8.1Do not routinely offer chest X‑rays before surgery.
77
T/F ECG should be routinely done before surgery
Do not routinely offer resting echocardiography before surgery.
1.9.2Consider resting echocardiography if the person has:
a heart murmur and any cardiac symptom (including breathlessness, pre‑syncope, syncope or chest pain) or
signs or symptoms of heart failure.
78
tonsillectomy counts as what type of surgery according to NICE surgery grade
Intermediate
79
Excising skin lesions is what kind os surgeyr
Minor
80
Total joint replacement is which kind of surgery
Major/complex
81
What do the ASA1-4 mean
ASA 1
A normal healthy patient
ASA 2
A patient with mild systemic disease
ASA 3
A patient with severe systemic disease
ASA 4
A patient with severe systemic disease that is a constant threat to life
ASA 5
Patient would die very soon without surgery
ASA 6
Brain-dead patient (organ harvesting
+
E to any of the above if it's an emergency op
82
Before major surgery, all ASA levels should have FBCs and haemostasis
F......
Only FBCs
83
What is possum score
The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) assesses morbidity and mortality for general surgery.
It derives an accurate prediction of mortality
84
What does possum not include
The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) assesses morbidity and mortality for general surgery.
Helps patients to make informed decision about surgery
85
What are the key risk factors for surgery
Age (due to comorbodities such as cognitive and functional impairement, malnutrition and frailty)
Exercise capacity
Family history
Medication history (alcohol, smoking, illicit drug use and also prescribed, over the counter and alternative drugs)
86
What family history is important to know about for surgery
Complications of anaesthesia (may have malignant hyperthermia, which is an inherited complication, autosomal dominant)
87
What is the rule of thumb for medications and surgery
Most should be taken up to the morning of surgery, apart from some key exceptions
88
When should MAOi be stopped before surgery and why
2 weeks.
| It can have drug-drug interaction with the anaesthetic agents used in surgery
89
When should SSRI be stopped and why
It should be stopped 3 weeks before CNS surgery
90
Should oral contraceptive pill be stopped before surgery
It is usually stopped 4-6 weeks before planned surgery, especially in patients with high VTE risk (due to risk of VTE)
91
When should aspirin be stopped before surgery, what about clopi
Aspirin- 7days, clopi- 5 days
| unless extremely high cardiovascular risk
92
When shoudl warfarin be stopped before surgery
>5 days
93
Do you need to stop taking COX-2 inhibitors/non-aspirin NSAIDS before surgery
If there is not a significant bleeding risk in surgery, then no.
But is there is, then it should be discontinued before the operation, timing depending on the NSAID
94
What lung function tests would show a risk factor for surgery `
FEV1 <70% or FEV1/FVC <65% or predicted are risk factors for complications aftery surgery
95
What are the criteria for day-case surgery
SELECTION OF PATIENTS:
- Social factors (carer after at least 24hrs including to take them home)
- Medical factors (determined by functional status, not ASA, obesity doesn't preclude from day surgery).
- Surgical factors (proceudre should not carry a risk of serious postoperative complications e.g. haemorrhage or cardiovascular instability, controllable post op symptoms, mobile)
96
t/f day case surgery suitability depends on ASA
F... it depends on functional capacity not the ASA status
97
What medications should be avoided in those with obstructive sleep apnoea
Avoidance of
postoperative opioid medication in these patients is
advised.
The optimal technique, if possible, is regional
anaesthesia
They are identified using the STOP-Bang questionnaire
98
What are the conditions for patients being discharged from the surgical day case unit
Patients should be able to mobilise before
discharge, for example, walking with an arm in plaster, but if
full mobilisation is not possible, appropriate venous
thromboembolism prophylaxis should be instituted and
maintained
99
What level of mortality risk would necessitate admission to HDU/ITU
More than 5% risk of death
100
What optimisation and perioperative control is needed for:
Diabetes
Optimisation:
Glycolayted Hb
Peri-operative control:
When to use insulin sliding scales
101
What optimisation and perioperative control is needed for:
HTN
Optimisation:
When to treat (BP>160/80)
Peri-operative control:
Maintain 20% of normal BP
102
What optimisation and perioperative control is needed for:
IHD
Optimisation:
Symptomatic (for major procedure) OR if they have ECG abnormality
Peri-operative control:
BP & HR control. Consider post operative HDU
103
What optimisation and perioperative control is needed for:
asthma
Optimisation:
symptomatic?signs?
Peri-operative control:
Medications according to BTS guidelines
104
What optimisation and perioperative control is needed for:
COPD
Optimisation:
symptomatic?signs?
Peri-operative control:
Medications according to BTS guidelines
105
What optimisation and perioperative control is needed for:
anticoagulatns
Optimisation:
why? stop or not?
Peri-operative control:
INR?APTR <1.5
Antiplatelets/LMWH resumption
106
What optimisation and perioperative control is needed for:
sickle cell
Optimisation:
haem review
Peri-operative control:
good care: warm, hydrated, analgesia, infection free
107
When would someone need to go on insulin sliding scale
Most type 2 diabetics can just be on metformin
If it's a type 1 diabetic or someone who is nil by mouth for ages, then you might need it
108
What patients usually go first in the list
Diabetics
109
What FEV1 predicts need for postoperative ventilation
FEV<40% indicartes need for postoperative ventilation so they would need to go for ITU
110
```
When should you do:
-ECG
-Echo
-Stress echo
pre-operatively
```
- ECG: ischaemia, arrhythmias, baseline
- Echo: LV function and valves
- Stress echo- low/int/high risk of ischaemia
111
What can you use for exercise tolerance if they can't really move much
You can stress the heart by using dobutamine to see how well it can cope
112
What is class 1, 2, 3 and 4 in the Mallampati score
1: complete visualisation of soft palate
2: complete visualisation of the uvula
3: visualisation of only the base of the uvula
4: soft palate not visible at all
113
What is the point of nil by mouth
Reduce aspiratiojn risk
114
What is theusual guidance for nil by mouth
Food: 6hr
Water: 2hr
115
What is the caveat for nil by mouth
Reflux, obesity, slow gastric transit e.g. trauma
Then you may have food in the stomach still
116
What might increase gastric time
Peritonitis might cause an ileus
Trauma and opioids
117
When might IV fluids be needed
Intravenous (IV) fluids should only be prescribed for patients whose needs cannot be met by oral or enteral routes.
- Patient NBM for medical or surgical reason (bowel obstruction, ileus, pre-operatively)
- Patient is vomiting or has severe diarrhoea
- Patient hypovolaemia due to blood loss (blood products likely required in addition to IV fluid)
118
What are the 2 types of IV fluids
1) Crystalloids- solutions of small molecules in water (e.g. sodium chloride, hartmann's, dextrode)
2) Colloids- solutions of larger organic molecules (ambulin, gelofusine)
119
Why are colloids used less than crystalloids
they carry a risk of anaphylaxis and research has shown that crystalloids are superior in initial fluid resuscitation
120
What is the difference between sodium chlorine 0.9% (normal saline) and sodium chloride 0.18%/glucose 4%
Sodium chlorine 0.9% (normal saline) is ISOTONIC and used for resuscitation or maintenance. Na concentration is 154, Cl is 154.
Sodium chloride 0.18% / Glucose 4% is HYPOTONIC and used for maintenance only. Na is 30, Cl is 30 and glucose is 40
121
What is hartmanns solution used for
Isotonic
Used for resuscitation/maintenance
Na 131, K 5, Cl 111, glucose 29
122
What is anaphylaxis
Acute life-threatening multisystem syndrome caused by sudden release of mast cell- and basophil-derived mediators into the circulation
123
Differentiate the types of anaphylaxis
Immunology:
IgE mediated or immune complex/complement mediated
Non-immunologic:
mast cell or basophil degranulation without the involvement of antibodies (e.g. reactions caused by vancomycin, codeine, ACE inhibitors).
124
When might anaphylaxis occur with blood products
Anaphylaxis may occur following repeated administration of blood products in patients with selective IgA deficiency (as a result of formation of anti-IgA antibodies)
125
What investigations should be done after an anaphylaxis
Allergen skin testing: identify allergen
IgE immunoassays: RASTs to identidy food specific IgE in the serum
126
Management of anaphylaxis
ABC approach
Secure airway- give 100% o2. Inform anaesthetist
Adrenaline IM (0.5mL of 1:1,000), can be repeated every 10 minutes
Antihistamine IV (10mg chlorpheniramine)
Steroids IV (100mh hydrocortisone)
IV crystalloid or colloid (probably not, they carry risk of anaphylaxis to stick with crystalloid!) to maintain blood pressure. If hypotensive, lie patient flat with head tilted down (lift legs)
Treat bronchospasm with salbulatol +/- ipratropium inhaler. Aminophylline IV may be necessary
127
What is a side effect of using barbiturates in surgery
```
Barbiturates
such as
thiopental
can be used for
anesthetic
inductions. These medications lower
blood pressure
by depressing the medullary vasomotor center, causing global vasodilation and peripheral pooling of blood.
```
128
What is the normal physiological response to barbiturates
```
Physiologically
, the
baroreceptor
response to barbiturate induced
hypotension
elicits a
reflex tachycardia
that maintains normal
cardiac output
. In addition, the central vagolytic effect of
barbiturates
is a minor factor in this
compensatory
response.
```
129
Which drugs can blunt the physiological response to barbiturates
```
If the
baroreceptor
response is blunted, a profound decrease in
cardiac output
can occur with
barbiturate
administration, as the patient's systemic
hypotension
is not compensated by
increased heart rate
. In particular,
congestive heart failure
and β-adrenergic blockers such as
metoprolol
can interfere with the
physiologic
compensation. Due to lack of a
compensatory
response, these patients can suffer a severe drop in
cardiac output
when given
barbiturates
.
```
130
When do you transfuse somebody who doesn't have sepsis, acute coronary syndrome or neurological injury
Only when their Hb falls below 70.
You then aim to get them in the range 70-90 with transfusion.
Be less confident of using Hb trigger of 70 if the patient is elderly, has significant cardiorespiratory co-morbidities or inadequate tissue oxygenation
131
When do you transfuse somebody with severe sepsis
If early (<6hr from onset), transfuse to the target of Hb 90-100
If late (>6hr from onset), transfuse to the target of Hb>70
132
When do you transfuse for someone :
TBI
SAH
If they have TBI and delayed cerebral ischaemia, transfuse to Hb 90
If they've had SAH, transfuse to target of 80-100
133
When should you transfuse someone with ACS
With ACS:
Target Hb >80-100
With stable angina:
Target Hb >70
134
What is the use of a bag mask valve?
It's got a valve because it's only meant to be used on patients that aren't breathing themselves (apnoeic)
You rig it up to the oxygen output on the wall, and you compress the bag to deliver oxygen, whilst maintaining a seal with the mask around the patient's mouth
It can delivery 90-100% oxygen
It's not a definitive airway because it doesn't go into the trachea, it's just a mask sitting over their mouth
135
What is the use of a nasopharyngeal/oropharyngeal airway
Read the bag mask valve first.
Now these devices are for use in addition to a bag mask valve, when the airway is obstructed e.g. if they have a big tongue, you can put an OPA in. If they are seizing, you can put an NPA in.
It's not a definitive airway because it doesn't go into the trachea, it's just a mask sitting over their mouth
136
What is a supraglottic device? Is it a definitive airway
It is not a definitive airway
It sits above the level of the vocal cords.
It seals off the epiglottis and can be used to deliver o2
It's not a definitive airway because it doesn't go into the trachea, it's just a mask sitting over their mouth
137
What is an endotracheal tube
This is a definitive airway.
It is passed through the vocal cords into the trachea, and a cuff is then inflated when it is in the trachea, to fix it in place.
Intubation is required to fit the tube
138
Outline the WHO pain ladder
Step 1: Non opioid- paracetemol/NSAID
Step 2: Weak opioid (codeine)
Step 3: Strong opioid (morphine)
139
What is the mechanism of action of ondansetron
Antiemetic
5HT3R antagonist
4-8mg
140
Side effects of ondansetron
Bradycardia
| Long QT
141
MOA of clyclizine
Antiemetic
H1-R antagonist
142
Side effects of clyclizine
Tachycardia and anti-cholingeric (dry mouth, increased heart rate, urinary retention, blurred vision)
143
MOA of dexamethasone
Corticosteroid
144
Side effects of dexamethason
Hyperglycaemia
Perineal burning
145
Mechanism of action of metachlopramisde
Central DA2 R antagonist
146
Side effects of metaclopramide
Extrapyramindal symptoms
147
Mechanism of action of prochlorperazine
DA antagonist
148
Side effects of prochlorperazine
Extrapyramindal symptoms
| Long QT syndrome
149
What is necessary for warming in surgery
You need to keep temp >36.
If procedure is longer than 30 mins use a bair hugger
If it's a longer procedure still, consider fluid warming
