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YEAR 4 ACC ME > Anaesthetics > Flashcards

Anaesthetics Flashcards

1
Q

What are the normal ranges for sodium and potassium in the blood and why is there such a difference?

A

Sodium: 135-145mmol/L
Potassium: 3.5-5.0mmol/L

Sodium mostly exists in the extracellular compartment (ECF and blood), potassium mostly exists in the intracellular compartment

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2
Q

What are the daily requirements of water, sodium and potassium?

A

WATER: 30-40ml/kg (approx 2-3L for average adult)
SODIUM: 1-2mmol/kg (approx 70-140mmol/L for average adult)
POTASSIUM: 0.5-1/0mmol/kg (approx 35-70mmol/L for average adult)

***these are the sorts of levels we should aim for when prescribing MAINTENANCE FLUIDS

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3
Q

What kinds of things cause FLUID LOSS?

A 
Poor oral intake (elderly, dysphagia, unconsciousness, fasting NBM)
Increased requirements (Trauma, burns, post-operative)
Increased loss (fever, sweating, bleeding, D&V, renal loss)
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4
Q

How do we classify fluid loss?

A

As mild, moderate or severe
MILD
- 4% body weight, loss of skin turgor and dry mucus membranes
MODERATE
- 5-8% body weight, oliguria, tachycardia and hypotension
SEVERE
- >8% body weight, profound oliguria and CVS collapse

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5
Q

What are some crystalloids and what are some examples?

A

They are water soluble substances dissolved in solution. They can be rapidly administered but can cause pulmonary oedema
NaCl 0.9%
Dextrose
Haartmans

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6
Q

What is in NaCl and what are some risks?

A

(0.9% mean 9g in 100ml) - contains 154mmol/L Na and 154mmol/L Cl
So about the right amount of sodium but there is a risk of hyperchloraemic acidosis

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7
Q

What is in dextrose and when should it be used?

A

5% = 50g per L water

Good if people have glucose requirements

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8
Q

What is in Haartman’s and what are some benefits of using it?

A 
Na - 131
Cl - 111
K - 5
Ca 2
Lactate 29

this is much more isotonic and the patient is at less risk of becoming hypokalaemia

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9
Q

What are some examples of colloids? Where are they sometimes used?

A 
Gelfusin 
Voluven 
Volulyte 
Albumin 
Sometimes used in trauma but rarely elsewhere
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10
Q

What is a fluid challenge?

A

Getting IV access with a wide bore cannula and administering 250-500mL of fluid as quickly as possible (usually 10-15mins) and monitoring for a response (BP, HR, UOP, JVP)

If an unwell patient hasn’t improved after 3 fluid challenges then need senior support

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11
Q

What is an example of a good maintenance fluid regimen in a 70kg man?

A

0.9% NaCl + 40mmol K over 8 hours
5% dextrose + 20mmol K over 8 hours
5% dextrose + 20mmol K over 8 hours

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12
Q

Why will people need more than just maintenance fluid after surgery?

A

People loose fluids during surgery (on average 600-900mL) so they will need some extra fluids before they’re placed on a maintenance regime

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13
Q

How do you manage fluid therapy in fever?

A

Add 10% extra fluids for every degree of fever

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14
Q

What should you ask in the history of a pre-operative assessment? Use A-E approach

A

AIRWAY

  • any dental work? caps or crowns?
  • any problems with your jaw
  • any problems with your neck? arthritis etc

Previous anaesthetics?

  • any previous PMHx of GA? any severe reaction? any PONV? pain relief problems? (also what did they have done)
  • any FHx of any problems with GA?

RESPIRATORY SYSTEM

chronic conditions:
- obstructive sleep apnoea
- COPD
- asthma
- any restrictive lung disease
(take a full hx of whatever you find to assess severity & risk with GA)

acute lung problems
- any cough? new breathlessness? fever? other signs of infection?

social history

  • how far can you walk on the flat? (why do you stop? SOB or joint pain etc?)
  • smoking (current or past) - PERSUADE THEM THAT LONGER THEY STOP BEFORE SURGERY, EVEN IF JUST A DAY, THE BTTER THEIR RECOVERY WILL BE!

CARDIOVASCULAR HISTORY

chronic CV conditions:

  • high blood pressure (find out their normal)
  • angina
  • previous heart attacks
  • previous heart surgery
  • heart failure

Qs to assess severity

  • chest pain (on exertion or random)
  • paroxysmal nocturnal dyspnoea
  • orthopnoea
  • exercise tolerance (if not already asked)

DISABILITY

neuro PMHx

  • epilepsy
  • neuromuscular disorders
  • nerve damage (mainly to protect yourself)

other ‘disability’ PMHx

  • diabetes (DON’T FORGET!!)
  • thyroid problems?
  • stroke / TIA

EXPOSURE

GI history

  • reflux? (could affect airway)
  • any other problems with liver? gut?
  • time of last meal (if operation imminent)
  • alcohol consumption?

other history

  • any kidney problems?
  • ANY CHANCE YOU COULD BE PREGNANT?
  • any other reasons you see the GP or been into hospital or surgeries?
  • current meds/allergies
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15
Q

What ongoing medical conditions in particular should you ask about during anaesthetic history?

A

IHD, diabetes, HTN, asthma, COPD, liver or kidney disease. Always ask how well controlled these are

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16
Q

What should you examine in a pre-operative assessment?

A

Neck movement, jaw opening and dental health (dentures, caps, crowns or loose teeth)
Mallampati
General examination (listen to heart and chest, feel abdomen, feel peripheries, feel calves for swelling or tenderness)

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17
Q

What is the mallampati score?

A

I - complete visualisation of soft palate
II - Complete visualise of uvula
III - Can only see base of uvula
IV - Cannot see soft palate

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18
Q

What is the ASA-GRADING for surgery?

A

1 - completely safe no ongoing disease
2 - Chronic disease but with no functional impairment (e.g. well controlled diabetes, HTN or smoker)
3 - Severe chronic disease with functional impairment e.g. angina or COPD
4- Severe angina, ESRD or liver disease
5 - Moribund patient who is unlikely to survive with or without operation
6 - Brainstem dead patient for transplant

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19
Q

What are the surgical grades for the operation?

A

1 (minor) - skin excision or toenail removal
2 (intermediate) - hernia repair or tonsillectomy
3 (major) - hysterectomy or thyroidectomy
4 (major+) - C/S, joint replacement, thoracic operational or radical dissection

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20
Q

What investigations does EVERYONE get in pre-operative assessment?

A

FBC, U&E, clotting and and group and save

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21
Q

What are some extra investigations for specific things in pre-operative assessment?

A

LFTs for liver or billiard op
Sickle cell screen for Afro-Caribbean patients
TFTs if they’re on thyroxine
CXR if ICU care might be required
Echo if they’ve got valve problem or murmur
Spirometry if lung disease
PT

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22
Q

What must you correct before the operation if found to be abnormal?

A

INR (with vit K or platelets/FPP/cryoprecipitate)

Anaemia

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23
Q

What is the general rule for stopping medications before an operation?

A

In general omit on the day of operation and resume the day after

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24
Q

What more specific medications must be stopped before operation?

A 
Warfarin  - stop 5 days before 
DOACs - stop 24h before 
LMWH - stop 48h before 
Aspirin/clopidogrel - stop 7 days before 
Insulin - don't have morning dose 
Oral hypoglycaemic - avoid on day of op 
Diuretics/ACE-is - avoid on day of 
Long-term steroids - consider switch to hydrocortisone 
COCP - stop 4 weeks before
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25
Q

What are the fasting guidelines before an operation?

Prolonged fasting 5 sx

Gastric emptying is prolonged by (8)

A

No food for 6 hours before (have dinner nil else)
No milk for 4 hours before
No alcohol for 24hrs
Only clear fluids until 2 hours before (allowed 30ml before surgery)

1) Headache
2) Hypotension/dehydration
3) Hypoglycaemia
4) Increased risk PONV
5) Increase anxiety

1) DM
2) pregnancy
3) fat
4) renal failure
5) reflux
6) head injury
7) alcohol
8) anxiety

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26
Q

How much oxygen can be given through nasal cannulas?

A

1-6L (most commonly 2L)
1L/min - 24%
2L/min - 28%
4L/min - 36%

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27
Q

How much oxygen can be given through a simple face mask (hudson)?

A

5-10L (CO2 can accumulate if the flow is less than 5L)

Not very reliable

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28
Q

What demonisations are there of venturi devices? In whom are they commonly used?

A

24 (2L), 28 (4L), 35 (8L), 40 (10L) and 60% (15L)

Good in CO2 retainers (COPD) to control concentration of O2

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29
Q

How much oxygen can be given through a non rebreathe mask?

A

15L and probably gives up to around 85% - this is about as good as we can get unless we artificially ventilate someone

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30
Q

What options do we have if the patient need assistance with ventilation?

A

BAG-VALVE MASK
NIV
ET tube or airway adjunct

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31
Q

What are some examples of NIV?

3 Indications

A

CPAP and BiPAP
(CPAP pressure is continuous and BiPAP has different inspiratory and expiratory pressures)

1) pH <7.35
2) PCO2 >6
3) RR >23

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32
Q

How do you measure a Gedell airway?

A

HARD to HARD

Angle of the mandible to the front incisors

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33
Q

What are the average sizes of NP tubes? When should they not be used

A

7mm for women
8mm for men
Do not use if any suspicion of basal skull fracture

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34
Q

What are some examples of supraglottic airways?

A

Laryngeal mask airway (LMA) and iGEL

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35
Q

When are LMAs preferably used and how do you insert an LMA?

A

Used in shorter surgeries when an ET tube is not required or if you cannot intubate someone (easier to put in)
NOT A DEFINITIVE AIRWAY
Reflexes should be suppressed e.g. with propofol then insert with the curve of the airway (no need to rotate)

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36
Q

What kind if airway is an ET tube? How are the sized

A

Definitive

Sized by diameter - 7-8mm for women, 8-9mm for men

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37
Q

What is the process of inserting an ET tube?

A
  1. preoxygenate the patient
  2. Wait for the neuromuscular blockage (90-120s)
  3. Place the patient in the sniffing the morning air position
  4. Hold laryngoscope in L hand
  5. Insert the laryngoscope in the R hand corner of the mouth and slide it down between the tongue and the epiglottis
  6. then lift with your whole arm up and to the left
  7. Aim to visualise the vocal cord
  8. Insert the tube to just beyond the vocal cords
  9. Inflate the cuff of the tube, attach to the bag valve mask and look for signs that it is in the right place
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38
Q

What signs are there that the ET tube is in the right place?

A

Rising of the chest (symmetrically, if it is not symmetrical it might have gone too far down the R main bronchus)
Misting of the tube
EtCO2 properly traced (5 clear traces)
Pulse oximetry

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39
Q

What are some possible complications of ET tubing?

A

Breaking teeth with the laryngoscope
Incorrectly positioned tube (into oesophagus) if in doubt take it out
Right lung intubation if put too far down
Laryngospasm - especially if someone has asthma or COPD

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40
Q

What are the three types of anaesthetic?

A

Local, Regional, General

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41
Q

When putting someone under a general anaesthesia what three things do you need to achieve?

A

AMNESIA - unconscious and won’t remember
AKINESIA - cannot move
ANALGESIA - won’t be in pain or have a pain response

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42
Q

How do we achieve amnesia in general anaesthesia?

A

INDUCTION AGENTS - 1-2 arm-brain circulation times (10-20secs)
Then maintained with VOLATILE AGENTS/propofol infusion

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43
Q

Propofol
Dose
Pros (2)
Unwanted effects (3)

A
  1. 5-2.5mg/kg
    - Good suppression of airway reflexes
    - Prevents PONV

Unwanted:

  • Marked drop in HR and BP
  • painful to inject because it is lipid based
  • involuntary movements
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44
Q

Thiopentone
Dose
Pros (2)
Unwanted effects (4)

A

BARBITUATE

  • 4-5mg/kg doses
  • RSI
  • anti-epileptic properties + neuroprotective

Unwanted effects:

  • DROPS BP + INCREASES HR
  • rash and bronchospasm
  • needs to be injected intra-arterially = can lead to gangrene and thrombus.
  • AVOID in PORPHYRIA
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45
Q

Ketamine
Dose
Pros (1)
Unwanted effects (4)

Used for what procedures?

A

It is a DISSOCIATIVE ANAESTHETIC and is also profoundly analgesic/amnesic
- 1-1.5mg/kg - it is quite slow to act (90s)

Unwanted effects:

  • Increases HR + BP
  • bronchodilation
  • PONV
  • EMERGENCE PHENOMENON (vivid dreams and hallucinations)

Used for burn dressing change

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46
Q

What dose is etomiidate used in? In whom is it most suitable and what are some risks (4) and benefits (2)

A

0.3mg/kg

1) Haemodynamic stability and so is good in people with cardiovascular conditions
2) Lowest incidence hypersensitivity

  • Painful on injection
  • Involuntary movements
  • Adrenocorticoid suppression (don’t use in septic shock)
  • PONV
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47
Q

What agents are used to maintain anaesthesia?

What is sevoflurane, isoflurane & desflurane used for?

A

Volatile agents (desflurane, isoflurane, enflurane, sevoflurane and NO)
Sevoflurane
- sweet
- where IV access NA

Isoflurane
- organ donation (least effect on organ blood flow)

Desflurane

  • long operations (DESmond tutu lived for LONG time)
  • low lipid solubility
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48
Q

What is minimum alveolar concentration?

A

MAC - this is the minimum concentration of gas required to eliminate a reaction to a standard stimulus

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49
Q

What are the MACs of sevoflurane, desflurane, NO, enflurane and isoflurane?

A 
Sevo - 2%
Isoflurane - 1.15%
Desflurane - 6%
Enfluane - 1.6%
NO - 104% (low anaesthetic potency)
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50
Q

How does pain affect people under anaesthesia?

A

They don’t FEEL pain because this is a conscious interpretation. However, they do have nociceptors stimulated which can cause the physiological response of increased HR and BP. That’s why it’s important to give someone analgesics

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51
Q

What are some examples of short acting analgesics?

A

Fentanyl, ramifentanil, alfentanyl

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52
Q

What are some examples of long acting analgesics?

A

Morphine and oxycodone

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53
Q

Process of muscle contraction

A

AP arrives at neuromuscular junction –> influx of Ca –> Ach released –> depolarisation of nicotinic receptors –> influx of Na + efflux of K = contract

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54
Q

What are the two types of akinesis agents and how do their actions differ?

A

DEPOLARISING - constant depolarisation = fasciculations = desensitised to effects of Ach
Used for:
1) after suxamthonium to maintain muscle relaxation
2) facilitate tracheal intubation

NON-DEPOLARISING - competitive, block the nicotinic receptor without activating them

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55
Q

What is an example of a depolarising akinesis agent? What dose is it used in and what are 5 adverse effects?
What is used to counteract it?

A 
SUXAMETHONIUM:
1-1.5mg/kg 
OFTEN USED IN RSI 
SEs:
1) muscle pains
2) fasciculations
3) hyperkalameia
4) malignant hyperthermia
5) rise in ICP, IOP and gastric pressures

Dantrolene

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56
Q

What are 2 examples of short-acting non-depolarising agents?

Minutes

A

Atracurium and mivacurium

15 mins

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57
Q

What are 2 examples of intermediate acting akinesis agents?

Minutes

A

vecuronium and rocuronium

30-60 mins

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58
Q

What is an example of a long acting akinesis agent?

Minutes

A

pancuironium

>60

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59
Q

What is the main advantage of non-depolarising agents?

A

THEY ARE REVERSIBLE

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60
Q

How do we reverse non-depolarising agents?
2 SEs of it

Another agent - MOA & doses
2 SEs

A

Neostigmine - anti-cholinesterase that prevents breakdown of ACh increasing its conc so that it can outcompete akinesis agent
SEs:
1) Bradycardia
2) Bowel/bladder/bronchospasm

Sugammadex
- Reduces conc of non-depolarising agents at NMJ
- onset of reversal from shortest: rocuronium > vecuronium >> Pancuronium
- 16mg/kg immediate 
- 2-4mg/kg routine 
SEs:
1) Hypotension 
2) Airway complication
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61
Q

How can we prevent adverse effects of neostigmine?

A

Glycopyrrolate - anti-muscarinic (prevent SEs of neostigmine)

62
Q

What other drugs are often prescribed peri-operatively?

A

Anti-emetics and vaso-active drugs

63
Q

What class of drug is ondansetron?

A

5HT3 blocker - anti emetic

64
Q

What class of drug is cyclizine?

A

Anti-histamine anti-emetic

65
Q

What class of drug is metaclopramide?

A

Anti dopaminergic anti emetic

66
Q

What other anti-emetics are there and what classes are they?

A

Dexamethasone (steroid)

Prochlorperazine

67
Q

What vaso-active drug should you consider if someone’s HR and BP are low?

A

Ephedrine (rise in rate and contractility of heart)

68
Q

What vaso-active drug should you consider if someones BP is low but their HR is high?

A 
Phenylephrine - is more alpha selective and just causes vasoconstriction 
OR
Metaraminol (another vasoconstrictor)
69
Q

If someones hypotension is severe and non-responsive what drugs should you consider?

A

Adrenaline, Noradrenaline or dobutamine

70
Q

What is the sequence of events when putting someone under a GA?

A
  1. Oxygenate them
  2. Give them opioid (need to have painkiller before being tubed) - opioids take a little while to work
  3. INDUCTION AGENT (e.g. propofol to send them to sleep)
  4. Turn on volatile agent - keep them asleep
  5. Bag valve mask ventilate them to maintain oxygenation
  6. Insert the airway and ventilate them

READY FOR SURGERY

71
Q

What things should you consider prescribing for post-operative patient?

A

Analgesics - most patients will need some analgesic cover
Fluids - most patients will lose fluids during surgery so will need some element of replacement and then maintenance
Antibiotics - internal surgeries sometimes require prophylactic abx

72
Q

How do we manage pain post-operatively?

A 
Following guidelines from essential pain management (EPM)
RAT system of pain management 
- Recognise 
- Assess
- Treat
73
Q

How do we recognise pain?

A

If the patient is conscious they will tell you - pain is what the patient says it is
Pain response might be dulled in trauma when sympathetic surges of adrenaline dull the response

74
Q

How do we assess the pain?

A

Need to get an idea of WHERE it is
Need to get an idea of what the CHARACTER of the pain is like?
Get an idea of associated symptoms
Scale of 1-10: this gives idea of baseline

75
Q

What are the three classification strategies for pain?

A

Is it acute or chronic?
Is it cancerous or non-cancerous?
Is it neuropathic or nociceptive?

76
Q

What is nociceptive pain?

A

Sometimes called inflammatory or physiological pain this is pain that is in response to illness or injury
It has a protective function - is usually well localised

77
Q

What is neuropathic pain?

A

Nerve damage e.g. sciatica or CES
Does not have a protective function
Might be burning, shocking or feel hot/cold

78
Q

What is the difference between pain and nociception?

A

Pain is the cerebral input into nociception

79
Q

What is the nociceptive pathway?

A

Tissue injury - nociceptors are activated by cytokines such as PGs, histamine and leukotrienes
THEN EITHER TRAVELS in A-delta (fast response) or C pathway (later throbbing pain)
Signal carried to dorsal root ganglion in dorsal horn
Fibers decussate into contralateral spinothalamic tract
Run up into thalamus and pain is perceived
Stimulus is moderated by sending signal back down the descending pathway

80
Q

How does pain impact the surgical recovery process?

A

Physical immobility - e.g. chest pain limits breathing leading to infections
If someone has had lots of pain from one procedure might be less willing to have another
Longer stay in hospital and more time off work

81
Q

How does the body respond to pain?

A

Tachycardia and hypertension
GI N&V
RESP reduced VC and FRC
DVT and PE

82
Q

What are the three levels of the analgesic ladder?

A

0 - Paracetamol 1g PRN max 4g daily
1 - Paracetamol + NSAID (400mg) OR weak opioid e.g. codeine (30-60mg)
2 - Paracetamol + NSAID (400mg) + regular weak opioid e.g. codeine + strong opioid e.g. oromorph

83
Q

How does paracetamol work?

A

Inhibits PG production
Selective inhibitor of COX-3
Good anti-pyretic
Poor anti-inflammatory

84
Q

How do NSAIDs work?

A

COX-inhibitors

Block production of PGs and thromboxane which potentiate the action of cytokines on nociceptors

85
Q

What is the difference between COX-1 and COX-2?

A

COX-1 is a constitutive isoenzyme responsible for lots of homeostatic measures thus is the reason for lots of the side effects (bronchospasm, GI effects, renal, platelets)
COX-2 is a INDUCIBLE enzyme - responsible for inflammation

86
Q

Which NSAIDs are most COX-2 specific?

A

PARECOXIB and Celocoxib

87
Q

In whom are NSAIDs contraindicated?

A

Those prone to bleeding
Those with peptic ulcers
Caution with asthma
CI’d in renal failure - really excreted

88
Q

What are some examples of weak opioids and how do they work? Common doses?

A 
Codeine and tramadol 
Work by unregulated the signal from the descending pathway moderating pain (activate mu receptors)
Codeine: 30-60mg 
Tramadol: 50-100mg
Dihydrocodeine: 30-60mg
89
Q

What are some examples of strong opioids, how do they work and what kind of pain are they useful in?

A

Morphine, oxycodone and diamorphine
Strong OP3 receptor agonists
Work well on longer term C fibre pain and less for A-delta pain

90
Q

What are some examples of short acting opioids?

A

Fentanyl
Ramifentanil
Alfentanyl

91
Q

What are some side effects of opioids?

A

Drowsy, constipated, N&V, tolerance and dependence, hypotension
Respiratory depression - infrequent gulping breaths

92
Q

What methods of administration are there for post-operative morphine?

A

oromorph - works very quickly and is very effective - 20mg/hr PRN
IV morphine - common. Can given 10-20mg diluted into 1mg/mL IV dose is 1/3 oral dose
PCAS - patient gives themselves 1mg every 5mins - idea is that this stops spikes of analgesia - keeps constant level

93
Q

How do you dose paracetamol and ibuprofen?

A

Paracetamol you can have 1g (2 tablets) every 4 hours no more than 4 times a day (max 8 tablet per day)
Ibuprofen can take 400mg every 6-8 hours up to 3 times a day.

94
Q

What doses are appropriate for codeine, tramadol and morphine?

A

Codeine - 30-60mg every 4 hours up to 240mg every 24h
Tramadol - 50-100mg every 4 hours up to 400mg every 24h
Morphine - give them a 10mg dose titrated in over 10mins (they might not need all 10mg)

95
Q

What can you give for a patient who has had an overdose of opioids?

A

Naloxone

96
Q

Other than oral analgesics what other options do we have for managing pain post-operatively?

A

Local anaesthetic injections
Very often after surgery local anaesthetics are injected around the surgical site to numb it and block the pain
BUPIVACAINE IS OFTEN GIVEN

97
Q

What drugs are more often given for chronic pain and why?

A

Amitriptyline, Pregablin and gabapentin, Clonidine, corticosteroids, capsaicin

Different types of drugs are needed because chronic pain is more likely to be neuropathic in nature

98
Q

Other analgesia given during/after surgery & 2 most common?

A

Paracetamol (common)

NSAIDs
Diclofenac (ORAL)
Paracoxib
Ketorolac

Weaker opioids:
codeine
dihydrocodeine (common)

99
Q

What is the equation for cardiac output?

A

CO = SV X HR

100
Q

What is the equation for SBP?

A

SBP = CO X SVR

101
Q 
What effects do each of these noradrenergic receptors have?
Alpha 1 = vasopressor
Beta 1 = chronotrope & inotrope
Beta 2
Dopamine

1st line inotrope
1st line vasopressor

A

Alpha 1 - vasoconstriction = increased SVR
Beta 1 - increased HR (chronotrope) & contraction (inotrope)
Beta 2 - bronchodilation
Dopamine - increased renal blood flow

1st line inotrope - dobutamine
1st line vasopressor - noradrenaline (CAN ONLY BE GIVEN THROUGH CENTRAL LINE)

102
Q

What receptors does adrenaline act on & what type of vasoactive drug is?
At low rates it acts like…
At high rates it acts like…

A

a1, b1, b2
inotrope + chronotrope + vasopressor
At low rates - mainly inotropic (increase HR & BP
At high rates - mainly vasopressor (decrease HR & increase BP)

103
Q

What receptors does dobutamine act on & what type of vasoactive drug is it?

A

b1, b2
inotrope + chronotrope
Increase HR
Increase BP

104
Q

What receptors does noradrenaline act on & what type of vasoactive drug is it?

A

a1, b1

inotrope + vasopressor

105
Q

What receptor does phenylephrine act on & what type of vasoactive drug is it?

A

a1
vasopressor
Increase BP
Decrease HR

106
Q

What receptors does dopamine act on & what type of vasoactive drug is it?

A

a1, b1, dopamine

inotrope + chronotrope + vasopressor

107
Q

What effect does Ephedrine have on HR & BP?

A

Increase HR

Increase BP

108
Q

What effect does Metaraminol have on BP & HR?

A

Increase BP

109
Q

LA

Mechanism of action

A

Block sodium channels
Active in ionised form (unionised when crossing membrane)
More sensitive to LA if increased extracellular conc of K+
Analgesia first, then paralysis

110
Q

EMLA 50.50 is a topical anaesthetic made up of which 2 LAs

A

Prilocaine

Lignocaine

111
Q

3 short duration LA Esters
2 long duration LA Esters

Esters are associated with (2)

A
  1. 5-1hr
    1) Cocaine
    2) Benzocaine
    3) Procaine
  2. 5-6hr
    1) Amethocaine
    2) Tetracaine

Allergic reactions
Less ability to store for long

112
Q

3 medium duration LA amides
- max dose (with/without adrenaline) & duration

3 long duration LA amides
- max dose (with/without adrenaline) & duration

A 
0.5-2hr
Lignocaine 
- 3 --> 7
Prilocaine 
- 6 -->9
Mepivacaine 
- 3-->7
1.5-8hr
Bupivacaine/levobupivacane 
- 2-->2
Ropivocaine 
- 3
113
Q

Which LA is more toxic - lignocaine vs prilocaine?

A

lignocaine

114
Q

Which LA has reduced cardiotoxicity?

A

Levobupvacaine

115
Q

Which LA is used for nerve blocks, epidurals, spinals?

A

Bupivacaine

116
Q

What is used alongside LAs & why?

BUT never use it in (5)

A

ADRENALINE

  • LA causes vasodilation + adrenaline counteracts = vasoconstriction
  • reduces blood loss
  • increase LA duration
  • reduces toxicity by delaying LA absorption

NEVER use in:

1) End organs = ischaemia
2) HTN
3) IHD
4) PVD
5) thryotoxicosis

117
Q

LA dose calculation

A

0.25% bupivacaine
o Multiply % by 10 to get mg/ml
o 0.25% solution: 0.25 x 10 = 2.5mg/ml
• Multiply patients weight by max safe dose
o Eg. 60kg and 2mg/kg max dose = 120mg total dose
• Divide patients maximum safe dose by content of LA
o 120/2.5=48mL max
o For 0.5% bupivacaine = 120/5=24ml max

118
Q

2 main categories of LA toxicity (& sx in each)

A

Neurological toxicity 1st:

1) Excitatory sx
2) Tingling
3) Slurred speech
4) Tinnitus
5) Confusion/drowsy
6) Twitch
7) Convulsion

CV toxicity:

1) Initial tachy & HTN –> brady & hypotension
2) cardiac arrest

119
Q

How to treat LA toxicity?

A

Intralipid 20% 1.5mls/kg over 1 min

120
Q

RSI process (4 steps)

Who always gets RSI?

A

1) Preoxygenation
2) Induction - thiopentone, propofol
3) Muscle relaxant - suxamthonium (onset <1min, DOA 6 mins), rocuronium (onset <1min, DOA >30)
4) Cricoid pressure (prevent regurg) - remove after confirmation of tube position
- bilateral expansion, auscultation, moisture in expired air, EtCO2

<20wks pregnant

121
Q

What information to give patient regarding anaesthesia? (10)

A

1) Environmnet of surgical room
2) Need for IV access & drip
3) Invasive monitoring
4) What to expect
5) Induction (IV/inhalational)
6) Where they will wake up
7) Drains, catheters, drips
8) Possibility of blood transfusion
9) Risks
10) Questions

122
Q

4 Common & 6 rarer SEs of GA

A

Common:

1) Sore throat
2) Confusion
3) PONV
4) Damage to lips/tongue

Rarer:

1) chest infection
2) muscle pain
3) damage to teeth
4) awareness during operation
5) nerve damage
6) allergic reaction

123
Q 
SPINAL BLOCK 
- where is it given 
- how do you know you are in the correct position 
- what is it made up of
- onset
duration
A 
L2 - S2 into subarachnoid space 
Presence of CSF
LA +/- opioid 
Rapid onset 5-10mins
2-3hrs
124
Q

3 layers of spinal cord (inside-out)

Where is the CSF

Where does the spinal cord end
Where does the subarachnoid space end
Where does the epidural space end

A

Pia
Arachnoid
Dura

Subarachnoid

L1
S1
Sacrococcygeal hiatus

125
Q

EPIDURAL BLOCK

  • where is it given
  • how do you tell if in right place
  • when is it given
  • with what
  • onset
A 
above L1
POP of ligamentum flavum 
Longer operation - up to 72hrs
LA +/- opioid via catheter 
Slower onset - 15-30mins
126
Q

What layers are crossed in an epidural (6 steps)/spinal (9 steps)?

A

1) Skin
2) SC fat
3) supraspinous ligament
4) infraspinous lig
5) ligamentum flavum
6) epidural space
7) dura mater
8) arachnoid
9) subarachnoid

127
Q

6 advantages of spinal/epidural?

A

1) Less chance of chest infection
2) Less chance VTE
3) Pain relief post-op
4) Less PONV
5) Earlier return to drinking/eating
6) less confusion

128
Q

7 Complications of spinal/epidural

A

1) Urinary retention
2) Hypotension
3) Itching
4) PONV
5) Backache
6) Post dural puncture headache - worse sitting up, CSF leaks out & causes low pressure
7) paralysis for few hours post-op

129
Q

5 contraindications to spinal/epidural

A

1) Hypovolaemia
2) Aortic/mitral stenosis
3) Sepsis
4) Coagulopathy
5) Raised ICP

130
Q

Partial airway obstruction signs vs complete obstruction

A

PARTIAL

1) trachea tug (down on inspiration)
2) accessory muscles
3) Reduced expansion
4) stridor/wheeze/snoring

COMPLETE

1) see saw
2) silent chest

131
Q

VTE prophylaxis

- hip replacement

A

LMWH 10 days followed by aspirin 28 days OR LMWH 28 days + stocking OR rivaroxaban

132
Q

Tidal volume is how many ml

it is made up of 2 sections

A

500ml - enters & leaves with each breath
anatomical dead space (150)
alveolar ventilation (350)

133
Q 
Volume & definition: 
Inspiratory reserve volume 
Expiratory reserve volume
Residual volume
Total lung capacity 
Vital capacity
Functional residual capacity
A 
3000ml, extra inspired volume
1500ml, extra expired volume
1000ml, remaining after max expiration 
6000ml, after max inspiration
5000ml, max expiration after max inspiration 
2500ml, volume after quiet expiration
134
Q

Increasing resistance is seen in which resp disease?

Decreasing compliance is seen in which resp disease?

A

Obstructive

Restrictive

135
Q

What is ventilation & where is it highest?
What is perfusion & where is it highest?
Which increases more?

What is a shunt
What is dead space

Where is there a higher V/Q ratio?

A

The air that reaches the alveoli
The blood that reaches the alveoli via the capillaries
Bases & midzones receive both more ventilation + perfusion
Perfusion increases more towards base = V/Q mismatch

Shunt = perfusion but no ventilation
Dead space = ventilation but no perfusion

Apex (less blood & high ventilation)

136
Q

6 CPAP indications

2 BiPAP indications

A

1) pulmonary oedema
2) fluid overload
3) atelectasis
4) chest infection
5) chest wall trauma & hypoxic
6) sleep apnoea

1) COPD
2) MSK conditions with resp failure

137
Q

Before anaesthetic given must monitor 3 things

A

1) ECG
2) SPO2
3) NIBP

138
Q 
On an ultrasound what do these structures look like & why?
vessels 
bones 
soft tissues 
nerves
muscles/tendons
A 
VESSELS
black - anechoic 
BONES 
white - hyperechoic 
SOFT TISSUE 
grey - isoechoic 
NERVES 
honeycomb - hypo/hyperechoic 
MUSCLES/TENDONS 
grey/white - isoechoic with white strands
139
Q

What resolution & depth is used by:
high frequency transducers
low frequency transducers

What is gain

A

High resolution + low depth - superficial

Low resolution + high depth - deeper structures

brightness

140
Q

On a doppler blue/red means…

A

blue - away from probe

red - towards probe

141
Q

4 artefacts on USS

A

1) Shadowing
2) Acoustic enhancement (flaring) - deep to blood vessels, bladder, cysts, other fluid collections
3) Reverberation (multiple reflections underneath)
4) Comet tail (region of calcification)

142
Q

eFAST bedside USS can be used in 5 views

A

1) Peri-hepatic (right mid-posterior axillary line 11-12th rib)
2) Peri-splenic (left posterior axillary line 10-11 rib)
3) Pelvic
4) Pericardial
5) Anterior thoracic (2/4th rib)

143
Q 
incidence of PONV
risk factors (4)
A 
20-30%
previous PONV
female 
non-smoker 
post-op opioids
144
Q

which is better - codeine or dihydrocodeine & why?

A

dihydrocodeine - purer & more predictable

145
Q

non-pharmacological management for pain (acronym)

A 
RICE 
rest 
ice
compression
elevation
146
Q

which of oxycodone and morphine is better for:

  • renal impairment?
  • hepatic impairment?
A

renal failure = oxycodone is better

hepatic failure = morphine is better

147
Q

anaesthesia and diabetes:

  • how should manage diabetic meds, incl insulin, and fasting before an operation? 5 (be specific)
  • how and how often should blood glucose be monitored peri-operatively?
  • where should pts with diabetes be on the list?
A
  • omit oral hypoglycaemic agents the morning of surgery
  • take long-acting insulin in morning
  • omit short-acting insulin day of surgery
  • fast the normal amount of time
  • give variable infusion of insulin if need to

BMs should be measured every hour before, during and after op, until eating and drinking again
- if BM >10 intra-op then give some insulin

patients with diabetes should be first, or at least near top, of list, to prevent hypos

148
Q

anaesthesia and diabetes:
- what are the increased intra and post-op risks of surgery to consider? 5

and how to mitigate these

A

RISK OF ASPIRATION

  • delayed gastric emptying (dt autonomic neuropathy) (also, if type 2 DM, then may also be overweight, further increasing risk)
  • use an RSI if really concerned

HYPOS INTRA-OP

  • monitor BMs and put first on list to prevent
  • be hypervigilant as anaesthetic drugs will mask symptoms

RISK OF POST-OP MIs
- diabetes increases CV risk and most operation-related MIs occur post-op - also MIs in diabetes are often silent, so easier to miss

RISK OF POST-OP INFECTION

  • optimise diabetes control pre-op
  • ensure good wound care follow up

RISKS ASSOCIATED WITH RENAL FUNCTION

  • test UandEs pre-op
  • eg can retain more morphine than normal person, which abx use etc

nb they may also be tricky to intubate dt a large neck

149
Q

diabetes and anaesthesia:

  • pre-op questions to ask? 1
  • pre-op blood tests to do? 4
  • other pre-op tests to do/consider? 2
A
  • current blood sugar control (HbA1c and normal BM range)
  • UandEs
  • HbA1C
  • fasting blood glucose
  • BMs
  • urineanalysis (looking for proteinuria and microalbuminuria)
  • ECG (any ischaemic signs)

nb these are all to establish baseline and understand level of end-organ damage

150
Q

Considerations for anaesthesia for laproscopic surgery:

  • airway management? 2
  • affects on vitals? 2
A

try to avoid bag and mask, or do lots of little breaths (as don’t want to inflate stomach)

always intubate (ie not LMA) as increased risk of aspiration

  • drops BP (as pressure triggers parasympathetic response)
  • increases CO2 (absorbed in through capillaries)

YEAR 4 ACC ME (6 decks)

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