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anaesthetics Flashcards

1
Q

what does the pre-op care depend on

A

Patient co-morbidities & medication
- Type of surgery : minor/intermediate/ complex (including
haemorrhage risk)
- Setting: elective OR emergency

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2
Q

what are the different ASA levels

A

ASA 1: Healthy patient
• ASA 2: Mild systemic disease. No functional
limitation ie exercise tolerance - no problem climbing 2flights
• ASA 3: Moderate systemic disease. Have
functional limitation
• ASA 4: Severe systemic disease that is a constant
threat to life
• ASA 5: Moribund patient. Unlikely to survive 24
hours, with or without treatment
• Postscript E indicates emergency surgery

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3
Q

summarise POSSUM

A

o Based on physiological parameters at time, whether emergency or not, operative variables
o Number produced has been validated
o Risk discussion with pt – risk benefit ratio in favour – and if not what does that mean
 In peri-op have more invasive monitoring
 Post-op if mortality >5% - ITU or high dependency unit (HDU)
 If surgeon quotes 1% mortality risk for pt – high risk but for HDU guidelines its 5%

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4
Q

what is important when considering comorbidities

A

optimisation and peri-operative control

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5
Q

control for dm

A

look at HbA1c and see how well controlled

think when to use insulin sliding scales

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6
Q

control for HTN

A

optimisation - when to treat (>160/80)
control - maintain within 20% of normal BP in primary care settings, not in hospital – often high when come in for surgery.
= reduced morbidity and mortality. If 1 hypotensive episode = morbidity and mortality

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7
Q

IHD control

A

optimisation - Symptomatic (or major
procedure) /ECG anomaly
BP & HR control. Consider post
operative HDU

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8
Q

asthmatic and COPD control

A

optimisation: Symptomatic? Signs?

Medication – BTS Guideline

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9
Q

anti-coagulants control

A

optimisation - why are they on them, can we stop them or not
INR/APTR <1.5
Anti-platelets/LMWH
resumption?

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10
Q

sickle cell control

A

haematology review

good care - warm, hydrated, analgesia, infection free

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11
Q

considerations for day surgery

A

social - Patient consent, carer, home setup, can they manage at home
medical - Fitness, stable chronic, obesity not
preclude, comorbidities
surgical - Complication risks, controllable post op
symptoms, mobile, how major the surgery is

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12
Q

when should you consider further investigations

A

dependant on pt and background state
Bloods test anomalies : anaemia, renal dysfunction
Lung function tests : Baseline ABG’s, FEV1<40% (predictor for
postoperative ventilation)
cardiac:
ECG - ischemia, arrhythmia, dm - multisystem disease, HTN
echo - poor functional status (LV function and valves) and reasonable size op/GA
stress echo - gives low/intermediate/high risk index of ischemia - used to quantify ischemia

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13
Q

things to ask in an anaesthetics Hx

A 
o	Whether had anaesthetic before and problems 
o	FH of problems 
o	Malignant hyperpyrexia 
o	Suxamethonium apnoea 
o	Both genetically based and run in fam 
o	Drug rn/longer to recover, or awareness, or not take long to recover 
comorbidities, Ex tolerance 
medication/allergies 
smoking/Etoh/recreational drugs
teeth - dental work 
airway - mallampati, neck movement 
NBM
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14
Q

mallampati socre

A

 1 - Should be able to see all soft pallet and uvula
 2 – still uvula, not all of soft pallet
 3 – some uvula and not all, ie just base
 4 – complete obliteration – no uvula or soft pallet
 Ask open mouth and stick tongue out

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15
Q

why do you ask about neck extension

A

makes a difference for intubation

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16
Q

why starve before surgery

A

reduce aspiration risk – if when put to sleep have food in stomach/acid that comes up into mouth – airway reflex don’t work – go into lungs – high mortality attached to it – strict about NBM

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17
Q

how long do you starve for

A

food 6hr
Water 2hrs
caveat if reflux, obese, slow gastric transit eg trauma = reduced transit time – different times

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18
Q

how do you prescribe opioids

A

o Make sure on form – dose, strength, formulation, total quantity – dosage in words and figures and quantity need supplied for that period of time
o Length and duration time required for
handwritten

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19
Q

summarise oropharyngeal airway

A

called guedel airway
 3 4 5 size - from angle of mandible to side of mouth
 Airway adjuncts (not airway in own right) - used with bag mask ventilation
 Slits in behind the tongue – allow passage to continue and makes ventilation easier

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20
Q

summarise bag-mask-valve airway

A

 For pt apnoeic/resp failure
 One way valve – drive against the lungs
 Cant breathe against
 So doesn’t work with spontaneous ventilation
 Reservoir opens up more ox to be drawn in
 FiO2 60-90% – fraction of inspired oxygen

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21
Q

endotracheal tube

A

o Connector on R hand side
o Labelled with internal diameter
o Markings along tell you how long at teetc
o Pilot balloon – where but air in – connected to balloon at end of tube
o Black marker should be at cords
o Balloon sit below
o This is a definitive airway – cuffed tube in trachea sealing it off (ET, tracheolaryngeal tube)

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22
Q

supraglotic airway

A 
o	Igel – sits above the vocal cords 
o	LMA 
o	At bottom- gastric port - traverse in parallel to main ox conduit 
o	Different size 3 4 5 
o	Paed smaller 1 2 
o	Single use
o	Latex 
not definitive airway
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23
Q

benefits and features of Igel

A

15mm connector - reliable connection to any standard catheter mount or connection
clearly displayed product info- quick easy reference, confirmation of size and weight preference
position guide - adult size only - confirmation of optimum insertion depth
non-inflatable cuff - made from soft gel-like material allowing ease of insertion and reduced trauma
gastric channel - enhance safety - allows for suctioning, passing of NG tube and venting
integral bite block - reduces possibility of airway channel occlusion
buccal cavity stabiliser - aids insertion and elimates potential for rotation
epiglottic rest - reduces possibility of epiglottis down folding and airway obstruction

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24
Q

what is the need for the 5 steps to safer surgery

A

o Safety checklist by WHO in developed and non-developed countries – benefits 30-40% improvement in mortality
o Allows a rolling team – communicate with everybody from different teams

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25
steps in the 5 steps to safer surgery
team brief - go through list and introduce yourself, go through order when pt comes - sign in in the anaesthetics room - check no major allergies, all monitoring in place, have blood if needed, site marked, difficult airway/anaesthetic risk time out before incision - pts name, allergy, metal work, make sure surgeon know operating on the correct side, equipment sterile, count correct, anaestetics set up, special requirements and concerns, ASA, essential imaging/tests available, duration of op, expected blood loss, any special equipment needed, hair removal, AB, pt warming, glycaemic control, VTE prophylaxis undertaken sign out - comfirm procedure done and everything accounted for sign out before pt leaves theatre - has throat pack been removed, swab insturment and needle/sharp count correct, any equipment issues, correct procedure performed and recorded, specimens labelled, post op - analgesia,AB, VTE prophylaxis, fluid management inc blood, care iof drain/NG debrief - end of day
26
what do you need to consider for VTE prophylaxis
``` mobility RF bleeding risk o No different from Virchow’s triad – stasis, OCP, cancer, preg, bleeding risk – pt and type of sugery – high bleeding risk – don’t want VTE prophylaxis. Thrombophilia – more prone to DVT and PE – give longer period and involve haematologist o Drug chart prompt you for it ```
27
summarise the WHO pain ladder
step 1 - non-opioid eg aspirin, paracetamol or NSAID +- adjuvant step 2 - weak opioid - for mild to moderate pain eg codeine/tramadol +-non-opioid +- adjuvant step 3 - strong opioid - for mod to sever pain eg morphine/oxycodone +-non-opioid +- adjuvant
28
what anti-emetics are best to use
cyclizine/ondansetron - have best number needed to treat (NNT) these and dexamethosone NNT are in single figures - very effective whereas Metoclopramide and Prochlorperazine NNT are in teens so use these 2nd line
29
ondansetron mechanism, SE and dose/route
``` 5HT3R-antagonist Bradycardia Long QT syndrome CI in pregnancy 4-8mg TDS PO/IV ```
30
cyclizine mechanism, SE and dose/route
``` H1 R antagonist Tachycardia Anti-cholinergic can cause delerium make young women high 50mg TDS PO/slow IV/IM ```
31
dexamethasone mechanism, SE and dose/route
``` corticosteroid Hyperglycaemia Perineal ‘burning’(transient) 4-8mg BD /IV ```
32
metoclopramide mechanism, SE and dose/route
``` Central DA2 R antagonist Extrapyramidal SE’s acute dystonic reactions involving facial and skeletal muscle spasms and oculogyric crises 10mg TDS PO/IV ```
33
prochlorperazine mechanism, SE and dose/route
DA antagonist Extrapyramidal SE’s Long QT syndrome 12.5mg BD / IM
34
why do you need temperature control in surgery
o Normal homeostasis disrupted under GA  Wake up better Better outcomes  Enzymes operate in certain temp – other wise denature, tight temp boundaries – clotting prolonged if temp low  If pt bleeding considerably and not keeping them warm, not coag and temp not helping
35
ways to keep pt warm
keep temp >36 degrees o procedure >30mins = Bair hugger o longer procedure = Warm up fluids o Specific heat capacity of water – in winter changes more slowly temp o Warm fluid more effective in warming pt than convection heating through Bair hugger
36
resp emergency - asthma outside of theatre
ABC O2 -Start high flow oxygen and gain IV access Salbutamol nebulised 2.5-5mg Hydrocortisone 100 mg IV 6 hourly or prednisolone orally 40–50 mg/day. Ipatropium nebulised 0.5 mg (4–6 hrly salbutamol IV if not responding (250 mcg slow bolus then 5–20 mcg/min). Theophylline/Aminophylline Magnesium 2g IV over 20 minutes In extremis (decreasing conscious level or exhaustion) adrenaline may be used: nebuliser 5 ml of 1 in 1,000; Senior clinician only: IV 10 mcg (0.1 ml 1 : 10,000) increasing to 100 mcg (1 ml 1 : 10,000) depending on response
37
caution with aminophylline
tight therapeutic index – be careful with
38
periop management of asthma
B2 agonist - salbutamol/terbutaline/salmeterol - convert to nebulised form - high dose may reduce K, causes tachycardia and tremor anticholinergic drug - ipratropium - nebulised inhaled steroids - beclomethasone/budesnoide/fluticasone - if on >1500mcg/day of beclomethasone, adrenal suppression may be present oral steroid - prednisolone - continue as IV hydrocortisone until taking orally (1mg pred = 5mg hydrocortisone) if >10mg/day - adrenal suppression likely leukotriene inhibitor (anti-inflammatory effect) - montelukast/zarfirlukast - restart when taking oral med mast cell stabaliser - disodium cromoglycate - inhaler phosphodiesterise inhibitor - aminophylline - continue where possible - effectiveness in asthma debated, in severe asthma consider converting to an infusion periop (checking levels 12hrly)
39
identifying a tension pneumothorax
has no lung markings, deviated trachea and mediastinal shift = tension
40
treatment of tension pneumothorax
o Treat with large bore 16G (grey) catheter or orange 14G – 2nd ICS MCL – needle aspiration – decompress as temporary measure before drain – byes time
41
triggers of anaphylaxis
``` stings nuts food AB anaesthetics drugs contrast media latex hair dye hydatid ```
42
anaphylaxis recognition - airway
Airway swelling, e.g., throat and tongue swelling (pharyngeal/laryngeal oedema). The patient has difficulty in breathing and swallowing and feels that the throat is closing up. • Hoarse voice. • Stridor – this is a high-pitched inspiratory noise caused by upper airway obstruction. rest.
43
recognising anaphylaxis - breathing problems
``` • Shortness of breath – increased respiratory rate. tripod position • Wheeze • Patient becoming tired. • Confusion caused by hypoxia. • Cyanosis (appears blue) – this is usually a late sign. spo2 <92% • Respiratory arrest ```
44
recognising anaphylaxis - circulation problems
Signs of shock – pale, clammy. • Increased pulse rate (tachycardia). • Low blood pressure (hypotension) – feeling faint (dizziness), collapse. • Decreased conscious level or loss of consciousness. • Anaphylaxis can cause myocardial ischaemia and ECG changes even in individuals with normal coronary arteries -> Cardiac arrest.
45
treatment of anaphylaxis
ABC adrenaline IM when confirmed diagnosis chlorphenamine and hydrocortisone IM or slow IV fluid as supportive measure HDU or ITU depending on how well recover if pt fit and healthy - will be fine body just pushed to extreme of old with heart disease already = MI, stroke, renal failure – hard to predict how they would be afterwards
46
what do you monitor in anaphylaxis
pulse oximetry ECG BP
47
when should you transfuse blood
o 70Hb – unless IHD or neuro disease or severe sepsis – give blood to keep Hb >90 o Depend on how stable – ongoing losses and quick – make judgement call
48
what is NEWS
based on simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present to, or are being monitored in hospital.
49
what physiological parameters form the basis of NEWS
``` RR sats temperature SBP pulse rate level of consciousness ```
50
how does NEWS work
score allocated to each measure magnitude of score reflecting how extreme the parameter varies from the norm score is then aggregated - uplifted if on ox parameters are already routinely measured in hospitals and recorded on clinical chart
51
signs that pt is deteriorating
portsmouth sign - HR is higher than SBP | happens over period of time, RR up, sats down
52
what is the most sensitive parameter
• RR v sensitive – geared around met state of human – if met state not good ie acidotic – RR driven up
53
interpretation and response to NEWS scores
1-4 = low = monitor min 12hrly - monitor NEWS with every set of obs 5-6 or individual parameter 3 = medium = monitor hourly, nurse inform med team, urgent assessment by clinician, clinical care in env with monitoring fascilities 7 or more - high - continuous monitoring of vital signs - nurse immediately inform the med team at SpR, emergency assessment by clinical team with critical care competencies and someone with advanced airway skills, consider transfer to HDU, or ITU
54
what is SIRS
systemic inflammatory response syndrome day 1-2 after surgery – all changes of sepsis w/o infective focus temp >38 or <36 HR >90 RR >20 or PaCO2 <32mmHg WBC >12000/mm3 or <4000/mm3 or >10% immature bands
55
what is sepsis
SERS and infection
56
management of sepsis
Early recognition and early broad spectrum AB important, fluid to resus – supportive measurement within 3hrs - measure lactate level - obtain blood cultures prior to admin of AB - admin broad spectrum AB - Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L "Time of presentation" is defined as the time of triage in the emergency department within 6hr - Apply vasopressors in ITU/anaesthetics (for hypotension that does not respond to initial fluid resuscitation) ; maintain a mean arterial pressure (MAP) ≥65 mm Hg - In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion. - Re-measure lactate if initial lactate elevated - give idea of how utilised ox is by the tissues
57
indictation for anti-emetics
previous post-anaesthesia illness bowel surgery – because moving it around a lot – more likely to get ill Young women tend to get ill more
58
what is given in VTE prophylaxis
compression stockings | LMWH or heparin
59
SE of hyoscine/atropine
``` anticholinergic = tachycardia urinary retention glaucoma sedation - esp in elderly ```
60
SE of opioids
``` resp depression reduced cough reflex N and V constipation urinary retention hypotn sedation ```
61
SE of thiopental (induction agent)
laryngospasm
62
SE of propofol (induction agent)
resp/cardiac depression | pain on injection
63
SE of volatile agents eg isoflurane
N and V cardiac/resp depression vasodilation hepatotoxicity

DPD (38 decks)

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