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Finals Revision > Anaesthetics/Acute care > Flashcards

Anaesthetics/Acute care Flashcards

1
Q

What is seen on CXR with diaphragm rupture?

A

Indistinct hemidiaphragm
Bowel loops in thorax
Displacement of mediastinum

-> surgical repair

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2
Q

What is flail chest?

A

When chest wall disconnects from thoracic cage, usually due to multiple rib fracs

Assoc w pulmonary contusion

Abnormal chest movement

Avoid over-hydration/fluid overload

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3
Q

What is seen on CXR with aortic rupture from deceleration injury?
If no sign on CXR when should it be suspected?
What test then?

A
  • widened mediastinum
  • depression of bronchus/tracheal deviation

Presence of persistent hypotension - contained haematoma formation - but lung markings at peripheries (so not tension pneumo)

CT angio

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4
Q

Propofol:

  • MOA?
  • Onset?
  • Positive extra effect?
  • Negative effects?
  • Main uses?
A
  • GABA receptor agonist
  • Rapid onset, rapidly metabolised with little accumulation
  • Anti-emetic
  • Myocardial depression, pain at IV site
  • Maintaining sedation in ITU,, total IV anaesthesia and daycare surgery
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5
Q

Sodium Thiopentone:

  • MOA
  • Onset?
  • Negative effects?
  • Use?
  • Useful for maintenance infusion?
A
  • A type of barbiturate (potentiates GABAa)
  • Rapid onset
  • Metabolites build up quickly, marked myocardial depression, little analgesic effect
  • Rapid sequence induction
  • No
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6
Q

Ketamine:

  • MOA?
  • Positive effects?
  • Negative effects?
  • Uses?
A
  • NMDA antagonist
  • Strong analgesia, very little myocardial depression
  • Nightmares
  • Induction of anaesthesia and when haemodynamically unstable
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7
Q

Etomidate

  • MOA?
  • what is it useful in?
  • Negative effects?
A
  • Potentiates GABAa
  • Safe in cardiac disease or haemodynamically stable

Negatives:

  • No analgesia
  • May cause adrenal suppression
  • Post-op vomiting common
  • Myoclonus
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8
Q

Why is end tidal CO2 measured in ET tube?

A

To ensure not in oesophagus

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9
Q

Why is humidified air used in tracheostomy?

Where is it widely used?

A
  • dries secretions of throat

- ITU

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10
Q

What is commonly used for day surgery?
Is it suitable for high pressure ventilation (PEEP)?
Does it control gastric contents?

A

Laryngeal mask

Not suitable for PEEP

No control of gastric contents

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11
Q

What provides optimal airway management?

A

ET tube

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12
Q

What anaesthetic agent is hepatotoxic?

A

Halothane - should be avoided in hepatic dysfunction

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13
Q

What surgeries are guaranteed to have a high blood loss and require cross match 4-6 units? (6)

A
  • Total gastrectomy
  • Oophorectomy
  • Oesophagectomy
  • Elective AAA repair
  • Cystectomy
  • Hepatectomy
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14
Q

What surgeries require cross match 2 units blood as high likelihood of requiring transfusion? (2)

A
  • Salpingectomy for ruptured ectopic

- THR

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15
Q

Adverse effects of volatile liquid anaesthetics?

A
  • Myocardial suppression
  • Malignant hyperthermia
  • Halothane: hepatotoxic

Used for induction and maintenance of anaesthesia

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16
Q

Negative effects of NO anaesthetic?
When should it be avoided?
Uses?

A

May diffuse into gas-filled body compartments and increase pressure

Avoid in e.g. pneumothorax

Maintenance of anaesthesia and analgesia (labour)

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17
Q

Features of central lines?

A

Multiple lumens, so useful for multiple infusions

Lumens are narrow though so don’t allow fast rate of infusion

IJV preferred but slightly more difficult
Femoral easier access but more prone to infection

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18
Q

Where are intraosseous lines mostly used?

A

Paeds

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19
Q

When are tunnelled lines e.g. Hickmans used?

What actually are they?

A

Useful for patients requiring long-term therapeutics

Inserted into IJV and tunnelled under skin and anchored to tissues. Can have injection port under the skin

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20
Q

What is a PICC line?

A

Peripherally inserted central cannula

Popular for establishing central venous access - inserted peripherally so less prone to major complications than conventional central lines

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21
Q

Problems with PVC’s?

Why are they good?

A

Unsuitable for administration of vasoactive drugs e.g. inotropes, or irritants e.g. TPN (except in very short term)

Wide lumen so good for rapid infusion

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22
Q

Size order of PVC’s smallest to largest?

A 
Blue
Pink
Green
Grey
Orange
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23
Q

Lidocaine:

  • MOA?
  • drug interactions?
  • toxicity?
A

Blocks Na channels in axons

B blockers, ciprofloxacin, phenytoin (as hepatic ally metabolised)

Toxicity: CNS overactivity ten depression, cardiac arrhythmias
Rx: IV 20% lipid emulsion

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24
Q

When is adrenaline CI to be added to local anaesthetic?

Why is it used?

A
  • End arteries e.g. fingers
  • Pt taking MAOI or tricyclic antidepressants

Prolongs duration of action and allows much higher doses

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25
Q 
Presentation of malignant hyperthermia?
Why does it happen?
Causative agents?
Ix?
Rx?
A
  • Hyperpyrexia and muscle rigidity following administration of anaesthetic
  • AD inherited trait from Chr19 - causes excessive release of Ca2+ from sarcoplasmic reticulum of skeletal muscle
  • Halothane and suxamethonium
  • CK raised
    Contracture test with halothane and caffeine

Dantrolene (prevents Ca2+ release from SR)

(also happens with antipsychotics - may have similar aetiology)

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26
Q

When are nasopharyngeal airways useful for?

When can they not be used?

A

Pt having seizure - cannot use oropharyngeal

Well tolerated in low GCS

Basal skull fractures

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27
Q

When is suxamethonium contraindicated and why?

A

Penetrating eye injuries or acute close angle glaucoma - increases intra-ocular pressure

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28
Q 
Example of a polarising NM blocker?
MOA?
Adverse effects?
When is it used?
Reversal?
A

Suxamethonium

Binds nicotinic Each receptors, causing persistent depolarisation of the motor end plate

Malignant hyperthermia
Transient hyperkalaemia
Fasciculations

Muscle relaxant of choice for rapid sequence induction

No reversal

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29
Q

Example of a non-depolarising NM blocker?
Adverse effect?
Reversal?

A

Rocuronium, atacurium

Hypotension

Neostigmine (Acetylcholinesterase inhibitor)

30
Q

What is a paralytic ileus?
What else can cause it?
What is it important to check as these can contribute to it?

A

Pseudo-obstruction due to lack of peristalsis after surgery, especially involving the bowel

Chest infection, MI, stroke and AKI

Deranged electrolytes - K, Mg and PO4
(replace these IV as bowel not working)

31
Q

What fluid is preferred post-op?

Who should be reviewed?

A

Hartmann’s or Ringer’s lactate

If urinary Na <20

32
Q

If a patient is oedematous and hypovolaemic, what do you treat first?

A

Hypovolaemia

Then follow this by a negative balance of Na and water, monitored using Na in urine

33
Q

What metabolic derangement can saline cause?

A

Hyperchloraemic metabolic acidosis

34
Q

Commonest causes of post-op pyrexia <5 days?

A
  • Blood transfusion
  • Cellulitis
  • UTI
  • Physiological systemic inflammatory reaction (usually within a day)
  • Pulmonary atelectasis
35
Q

Commonest causes of post-op pyrexia >5 days?

A

VTE
Pneumonia
Wound infection
Anastamotic leak

36
Q

When to stop drinking before theatre?

Eating?

A

Stop drinking clear fluids 2 hours before
(water, fruit juice NO bits, coffee, tea NO milk, ice lollies all count)

Stop drinking non-clear fluids and eating 6 hours before

37
Q

Rule of thumb for insulin?

A

If HbA1c <69 and minor procedures then usual insulin regime

If poorly controlled or fasting requires missing >1 meal then change to variable rate insulin

38
Q

Metformin in surgery?

A

Only if taking 3 doses per day

Omit lunchtime dose on day of surgery

39
Q

Sulfonylureas in surgery?

A

On day of surgery:

  • if taking once daily, omit dose
  • if taking twice daily, omit morning dose
40
Q

DPP4 inhibitors in surgery?

41
Q

GLP1 analogues in surgery?

42
Q

SGLT2 inhibitors in surgery?

A

Omit on day of surgery

43
Q

Once daily insulins in surgery (e.g. Lantus, Levemir)?

A

Reduce dose by 20% day before AND on day of surgery

44
Q

Twice daily insulins in surgery (Novomix 30, Humulin M3)?

A

No change on day before

Half the usual morning dose, leave evening dose unchanged on day of surgery

45
Q

Prep for carcinoid surgeries?

A

Octreotide

46
Q

Prep for parathyroid surgery?

A

Methylene blue to identify gland

47
Q

Prep for thyrotoxicosis surgery?

A

Lugols iodine or medical therapy

48
Q

Prep for colonoscopy/bowel surgery?

A

Bowel prep (laxative) day before

49
Q

What nerve is injured in axillary node clearance?

A

Long thoracic

50
Q

What nerve can be injured in carotid endarterectomy?

A

Hypoglossal nerve

51
Q

What surgery might cause SIADH and therefore hyponatraemia?

A

Neurosurgery

52
Q

When should women stop taking contraceptive pill/HRT prior to surgery?

53
Q

What pharmacological anticoagulation is preferred in patients with CKD?

A

unfractioned heparin

54
Q

How long is anticoagulation needed for after:

  • elective hip replacement?
  • elective knee replacement?
A

Hip - 28 days

Knee - 14 days

55
Q

What are the central veins?

A

Neck - internal jugular

Chest - subclavian or axillary

Groin - femoral

56
Q

What biochemical problems does a paralytic ileus cause?

A

Hypovolaemia and electrolyte deficiency (low Na and K)

AKI can develop with high creatinine and urea

CRP may be high as well

Vomiting may occur but these changes are apparent before the vomiting

(presents with tachycardia, hypotension, tachypnoea, tense abdo but no guarding)

57
Q

When is NG tube contraindicated?

A

Head injury - risk assoc with tube insertion

58
Q

What is good about nasojejunal feed?

Is it safe after oesophageal/gastric surgery?

A

Avoids pooling of food in stomach (and risk of aspiration)

yes

59
Q

How is feeding jejunostomy inserted?
Use?
Risks?

A

Surgically

Long term feeding after upper GI surgery

Tube displacement, peritubal leakage (and peritonitis)

60
Q

How is a PEG tube inserted?

A

Endoscopically and percutaneously

Not possible in those who cannot undergo endoscopy (e.g. oesophagectomy)

Risks: aspiration, leakage at insertion site

61
Q

When is TPN used?
Problem with infusion?
Long term risk?

A

Enteral feeding contraindicated

Phlebitic - central vein

Long term use assoc w fatty liver and deranged LFT’s

62
Q

Principle of nutrition in surgery?

A

Want to use the most physiological method that is safe and possible

63
Q

Can NG tube be used it pt is intubated?

64
Q

Nutrition choice if loop ileostomy?

A

Normal oral nutrition

65
Q

If a patient is on prednisone long-term, what drug should be prescribed before surgery?

A

Hydrocortisone

66
Q

Wind, water, wound, walking for post-op fever?

Any time?

A

Wind - day 1-2 - pneumonia, aspiration, PE

Water - day 3-5 - UTI (esp if catheterised)

Wound - day 5-7 - surgical site infection/abscess

Walking - day 5+ - DVT/PE

Any time - drugs, transfusion reactions, sepsis, line contamination

67
Q

What can occur with intra-abdominal sepsis causing deranged LFT’s?

A

Portal vein thrombosis

68
Q

What drugs impair healing?

A

NSAIDs
Steroids
Immunosuppressants
Anti-neoplastic drugs

69
Q

How to tell difference between biliary leak and perforation after cholecystectomy?

A

Biliary leak:

  • Severe RUQ pain and tenderness
  • May be tachycardic, but is normotensive, no sepsis/peritonism, no pyrexia
  • Some bile in intra-abdominal drain

Perforation:
- Severe RUQ pain, sepsis, systemically unwell

70
Q

Where to avoid placing cannulas if diabetic?

71
Q

What is suxamethonium apnoea?

A

AD inherited condition

Small subset of population lack specific acetylcholinesterase required to break down suxamethonium, meaning its effects are prolonged - need to be mechanically ventilated in ITU until it wears off

Finals Revision (29 decks)

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