Anaesthetics And General Surgery Flashcards
What is anaesthesia?
Loss of sensation
What are the three main types of anaesthesia?
- Local
- Regional
- General
What types of anaesthetics are directed to specific parts of the body?
Local and regional anaesthetic
How do drugs that cause anaesthesia work?
By blocking the signals that pass along nerves to the brain.
Define, a technique in which tthe use of a drug produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the droid of sedation.
Conscious sedation
Name a rapid onset short-acting GA drug? can be used as a sole anaesthetic in short 15 mins procedures or to supplement further anaesthetic agents.
Thiopentone
What is suxamenthonium apnoea?
This occurs when a patient has been given suxamenthonium ( a muscle relaxant) but does not have the enzymes to metabolise it so they remain paralysed for quite a few hours, and may not be able to breathe properly at the end of anaesthetic.
Define,
an inherited disorder of skeletal muscle only triggered by certain anaesthetic drugs, where abnormal accumulation of calcium in muscle cells leads to hyper metabolism, muscle rigidity and muscle breakdown.
Malignant hyperthermia
What are the key features of malignant hyperthermia?
- Unexplained increase in expired CO2 concentration
- Unexplained tachycardia
- Unexplained increase in oxygen requirement
- Temperature increase
What is the only drug effective at limiting the malignant hyperthermia process?
Dantrolene
How would you manage a patient with malignant hyperthermia?
- give dose of dantrolene every 10 minutes
- actively cool the patient
What monitoring is required whilst anaesthesia is being given?
- blood pressure cuff
- saturation probe
- ECG dots
What type of drugs are used as premedication and to reduce the amount of other agents required for anaesthesia?
Benzodiazepines
Name three common drugs used to induce anaesthesia?
- propofol
- thiopental
- etomidate
What type of drug is usually administered in a mixture of oxygen and air or nitrous oxide, and also commonly used to maintain anaesthesia for the duration of a surgery?
Inhalational drug
How many stages of anaesthesia are there?
4
Describe stage 1 of anaesthesia?
Loss of consciousness
Describe stage 2 of anaesthesia?
- Excitement or delirium
- coughing, vomiting and struggling may occur
Describe stage 3 of anaesthesia?
- laryngeal reflex is lost, pupils dilate
Describe stage 4 anaesthesia?
Cessation of respiration to death
What were the side effects of opium use for laughing gas?
- hallucinogenic
- addiction
- respiratory depression
- death
How is nitrous oxide an unpleasant drug to use?
Makes people feel sick
What substance is still used as an hallucinogenic agent and for supplemental anaesthesia?
Nitrous oxide
Why would muscle relaxants be used for anaesthesia?
Because they cause muscle paralysis and allow intubation and also surgical access to body cavities
Name a short-acting muscle relaxant?
Suxamenthonium
Name a long-acting muscle relaxant? (Lasts for over 30 mins)
Atracurium/rocuronium
What is absolutely vital to maintain in a patient during anaesthesia?
Airway patency
What device helps to lift an unconscious patients tongue away from the posterior pharyngeal wall?
Guedel airway device
What is the purpose of definitive management of airways using a loringoscope and endotracheal tube?
- Loringoscope helps to position and place endotracheal tube
- Endotracheal tube effectively isolates the lungs from any stomach continents that may be passively regurgitated into the mouth upon anaesthesia (stops aspiration)
What is elective surgery?
Surgery that is planned in advance and a date is set so patient is prepared
What it’s open surgery?
Where a surgeon uses a scalpel to make an incision and entry into abdominal cavity
What is laparoscopic surgery?
Uses small insidious, ports and use of a celery which gives into abdomen allowing us to visualise abdomen.
What are the benefits of laparoscopic surgery over open surgery for a patient?
- less trauma to abdominal wall
- shorter recovery time for patients
What does NCEPOD stand for?
National confidential enquiry into patient outcome and death
Why was NCEPOD developed?
To reduce mortality on patients requiring emergency surgery
What is NCEPOD?
A national fare work of referral for patients and allows senior staff to expedite unwell patients and communicate effectively with theatre staff regarding the urgency of surgery.
What are the four NCEPOD categories of intervention?
- Immediate
- Urgent
- Expedited
- Elective
What type of surgery is described:
Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.
Expedited
What system records patients vital signs and allows identification if an Ill patient.
National early warning system (NEWS)
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
Define, care given prior to an operation?
Pre-operative care
Define, care given under anaesthetic whilst getting an operation?
Peri-operative care
What is patient clerking?
An overall assessment of a patients condition at the time of admission
What medications need to be stopped prior to GA?
- ACE inhibitors
- anti-hypertensives
In pre-operative care, what needs to be assessed?
1.Blood investigations
2. Assess risk of DVT
3. Assess risk of haemorrhage
4. ECG for baseline cardiac activity
If a patient is fasting , what will they require prior to surgery?
Maintenance fluids and fluid assessment
What is the best maintenance fluid therapy for fasting patients in pre-operative assessment?
0.18% saline with 4% dextrose +/_ K+ (20-40mmol/l) based on 1ml/Kg/hour
What does ABG stand for?
Arterial blood gas sample
What is meant by taking a “surgical pause”?
Undertake a WHO safety check list
What does the term “ acute abdomen” represent?
The rapid inset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology that requires urgent surgical intervention
Name three common causes of acute abdomen?
- Appendicitis
- Pancreatitis
- Gastric ulcer
Define, inflammation of the appendix commonly caused by an obstruction of the appendix?
Appendicitis
What is a faecolith?
A stony mass of compacted faeces
What is normally the cause of appendicitis?
Faecolith
What quadrant of the lower torso does appendicitis pain usually present in?
Right iliac fossa
What are the associated symptoms of appendicitis?
- nausea and vomiting
- anorexia
- constipation or diarrhoea
- pyrexia
- tachycardia
- Rovsings positive
What is meant by rovsings sign?
Refers to the pain felt in the right lower abdomen upon palpation of the left side of the abdomen.
Positive sign = indicative of acute appendicitis
What investigations are important to carry out in possible cases of acute appendicitis?
Full blood count (FBC)
Urine examination
Abdominal ultrasound (USS)
Pregnancy test if female
Why is it important to take a FBC in cases of suspected acute appendicitis?
It shows will show raised white cell and neutrophil count (leukocytosis)
What are management options for acute appendicitis?
- NBM (nothing by mouth)
- analgesia
- hydration
- antibiotics
- appendicectomy
What are the most common causes of acute pancreatitis?
Alcohol and gallstones
What is the main symptom of acute pancreatitis?
Epigastric pain which radiates to the back
What are the management options for acute pancreatitis?
- IV fluid replacement
- analgesia
- NBM
- oxygen
If someone has acute pancreatitis, what will blood tests show?
An elevated serum amylase
What is the investigation for acute pancreatitis in the first instance?
Ultrasound imaging
What is the investigation for acute pancreatitis, where there is suspected necrosis?
CT scan
What are the 5 complications that can arise from pancreatitis?
- fluid collections
- pseudocyst formation
- necrosis
- abscess
- haemorrhage
What causes renal colic?
Renal stones wither partially or fully blocking outflow of urine from kidney
What are the main associated symptoms of renal colic?
- flank pain ( loin to groin)
- rigors (shivers)
- haematuria
- tachycardia
- reduced urine output
- pyrexia
What is the investigation used for renal colic?
CT scan of KUB (kidney, ureter and bladder)
Give the term used for inflammation of the gall bladder?
Acute cholecystitis
What is the most common cause of acute cholecystitis?
Gall stones
In acute cholecystitis, where is pain most likely to present?
Right upper quadrant of torso
What are the main symptoms of acute cholecystitis?
Fever and tachycardia
What is Murphy’s sign?
For patients with acute cholecystitis. Ask patient to take in and hold a deep breath whilst palpating the right subcostal area.
What would indicate that an individual is Murphy’s positive?
If pain occurs upon palpation of right subcostal area (gall bladder)
What are the two investigations required for acute cholecystitis?
- ultrasound imaging to see if gall stones are present
- MRI scan
What does ERCP stand for and when would it be used?
Endoscopic retrograde cholangio pancreatography
- used to remove gall stones from gall bladder in cases of acute cholecystitis
What are symptoms of small bowel obstruction?
Vomiting and abdominal pain
What are symptoms of large bowel obstruction?
Abdominal distension and absolute constipation
What is a common cause of small bowel obstruction?
Adhesion from previous abdominal surgery
What is the main cause of large bowel obstruction?
Malignancy
What is meant by pseudo-obstruction?
Where there are signs and symptoms of intestinal obstruction, however doctor is not able to observe or find anything blocking the bowels
What are the three types of pain?
- somatic
- visceral
- neuropathic
What type of pain is dental pain?
Largely somatic
What analgesic is contra-indicated in CVD?
Diclofenac
What are side effects of opiates?
- nausea and vomiting
- constipation
- respiratory depression or toxicity
What is the presentation of someone with opiate toxicity?
- reduced consciousness
- pin-point pupils
- hypotension
- seizures
- muscle spasms
- cyanosis from respiratory depression
What’s is the medical emergency management of someone with opiate toxicity?
Give the patient naloxone 0.4-2.0mg IV at intervals of 2-3minutes with max dose of 10mg
Define, irregular or infrequent defecation which may or may not be painful?
Constipation
What is hypochloremic alkalosis?
A disease state where acidosis occurs due to a significnat decline of chloride in the body
What are the consequences of vomiting due to:
- depletion of water and HCl- in the body?
- loss of potassium
- Hypochloremic alkalosis
- Hypokalaemia
Define the potassium ion level for hypokalaemia?
K+<3.5mmol/l
Define the potassium ion level for hyperkalaemia?
K+>5.5mmol/l
What is a direct effect of renal compensation for acid loss?
Hypokalaemia
What can be the severe consequences of electrolyte imbalance?
Cardiac arrhythmia and death
If dehydration is suspected, what assessment should be carried out?
Fluid balance assessment
What are common causes of poor wound healing?
- Diabetes
- Infection
- Irradiation (e.g. chemotherapy)
- Drugs (e.g. steroids)
- Nutritional deficiencies
What protein will be raised in any instance of infection or inflammation?
CRP (C-reactive protein)
What does SIRS stand for?
Systemic inflammatory response system
What is sepsis defined by?
SIRS
Describe when SIRS is diagnosed?
Diagnosed when there are two or more of:
- temperature <36 degrees Celsius or >38 degrees Celsius
- HR >90bpm
- respiratory rate >20bpm
- WCC <4 or >12
- blood glucose >7.7mmol/l
What are the 6 simple things you must do in the first hour of sepsis to double patients chance of survival?
- Give high flow oxygen
- Take blood cultures
- Give IV antibiotics
- Give a fluid challenge
- Measure lactate
- Measure urine output
What are the three types of haemorrhage?
- Primary
- Reactive
- Secondary
What type of haemorrhage is described:
Continuous bleeding which occurs during surgery
Primary haemorrhage
What type of haemorrhage is described:
Bleeding appears stable until BP rises
Reactive haemorrhage
What type of haemorrhage is described:
Occurs 1-2 weeks post-operatively and usually due to infection
Secondary haemorrhage
What is the active major haemorrhage protocol?
Gain IV access ASAP
What type of IV access is preferable in the case of major haemorrhage?
Bilateral antecubital fossa with 2 wide bore cannula
How many classes of Haemorrhagic shock are there?
4
What class of Haemorrhagic shock is described?:
Blood loss: <750ml
Blood loss %: <15%
Pulse rate: <100
BP: normal
RR: 14-20
Urine output: >30ml
Symptoms: normal
Class I
What class of Haemorrhagic shock is described?:
Blood loss: 1500-2000ml
Blood loss %: 30-40%
Pulse rate: >120
BP: decreased
RR: 30-40
Urine output: 5-15ml
Symptoms: confused
Class III
What class of Haemorrhagic shock is described?:
Blood loss: 750-1500ml
Blood loss %: 15-30%
Pulse rate: >100
BP: normal
RR: 20-30
Urine output: 20-30ml
Symptoms: anxious
Class II
What class of Haemorrhagic shock is described?:
Blood loss: >2000ml
Blood loss %: >40%
Pulse rate: >130
BP: decreased
RR: >35
Urine output: <5ml
Symptoms: lethargic
Class IV
What are the main signs of DVT (thrombus)?
- swollen calf
- warm/tender calf
- pitting oedema
- erythema
After surgery, what are patients 20-25% likley to develop?
DVT
What is used to prevent and manage DVT after surgery?
- compression stockings
- low-molecular weight heparin (LMWH)
If there is a proven DVT with no obvious caused, what would this suggest?
Malignancy
How would you investigate a pulmonary embolism?
With a CT pulmonary angiogra
What are the most common causes for delirium?
Infection or alcohol withdrawal
How would you treat delirium in a medical emergency?
Haloperidol 0.5-2mg (antipsychotic)
