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Y3 Surgery > Anaesthetics and perioperative care > Flashcards

Anaesthetics and perioperative care Flashcards

1
Q

Dropping sats following intubation →

A

? oesophageal intubation - does not allow for adequate lung ventilation

Capnography should also be present to confirm the correct siting

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2
Q

When is jaw thrust preferred over head-tilt/chin-lift?

A

suspected c-spine injury

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3
Q

When are oropharyngeal airways most commonly used?

A

bridging to more definitive airway

Easy to insert and use
No paralysis required
Ideal for very short procedures

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4
Q

Laryngeal masks are commonly used in day surgery.

Why are they unsuitable in non-fasted patients?

A

Poor control against reflux of gastric contents

Also not suitable for high pressure ventilation

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5
Q

When are tracheostomies useful? What is the issue with them?

A

Reduces the work of breathing (and dead space)
May be useful in slow weaning
Dries secretions - requires humidified air

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6
Q

Abdominal pain, bloating and vomiting following bowel surgery →

A

?postoperative ileus

deranged electrolytes can contribute so measure K+, magnesium and phosphate

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7
Q

Volatile liquid anaesthetics (isoflurane, desflurane, sevoflurane) are used for induction and maintenance of anaesthesia. What are their potential adverse effects?

A

Myocardial depression
Malignant hyperthermia
Halothane (not commonly used now) is hepatotoxic

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8
Q

Nitrous oxide is used for maintenance of anaesthesia and analgesia. What is the main contraindication?

A

May diffuse into gas-filled body compartments → increase in pressure.

Should therefore be avoided in certain conditions e.g. pneumothorax

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9
Q

What is propofol used for?
Mechanism of action?
Adverse effects?

A

Use:
Very common induction agent for GA and also used in ICU for ventilated patients
Has some anti-emetic effects - useful for patients with a high risk of post-op vomiting

MOA:
potentiates GABAa

ADRs:
* Pain on injection (due to activation of the pain receptor TRPA1)
* Hypotension

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10
Q

What is thiopental good for?
Mechanism of action?
Adverse effects?

A

Use:
highly lipid soluble so quickly effects brain

MOA:
barbituate, potentiates GABAa

ADRs:
laryngospasm

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11
Q

What is Etomidate good for?
Mechanism of action?
Adverse effects?

A

Use:
Causes less hypotension than propofol and thiopental during induction and is therefore used in haemodynamic instability

MOA:
Potentiates GABAA

ADRs:
* Primary adrenal suppression (secondary to reversibly inhibiting 11β-hydroxylase)
* post-op vomiting
* Myoclonus

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12
Q

What is Ketamine good for?
Mechanism of action?
Adverse effects?

A

Use:
* Acts as a dissociative anaesthetic.
* Doesn’t cause a drop in blood pressure so useful in trauma

MOA:
Blocks NMDA receptors

ADRs:
* Disorientation
* Hallucinations

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13
Q

What are the oral fluids/fasting rules before surgery?

A

patients having surgery may drink clear fluids until 2 hours before their operation
clear fluids are water, fruit juice without pulp, coffee or tea without milk and ice lollies

Patients are generally advised to fast from non-clear liquids/food for at least 6 hours before surgery

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14
Q

How is nasogastric feeding administered?
Contraindication?
Risk?

A

Usually administered via fine bore naso gastric feeding tube
May be safe to use in patients with impaired swallow

Often contraindicated following head injury (esp basal skull fractures) due to risks associated with tube insertion

Complications relate to aspiration of feed or misplaced tube

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15
Q

When is naso-jejunal feeding used?

A

Safe to use following oesophagogastric surgery

Insertion of feeding tube more technically complicated (easiest if done intra operatively)

Avoids problems of feed pooling in stomach and risk of aspiration

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16
Q

What is a feeding jejunostomy?
Risks?

A

Surgically sited feeding tube
May be used for long term feeding
Low risk of aspiration and thus safe for long term feeding following upper GI surgery

Main risks are tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis

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17
Q

Who is Total Parenteral Nutrition (TPN) used in?
Where should it be inserted?
Risk of long term use?

A

definitive option in those patients in whom enteral feeding is contra indicated

Should be administered via a central vein (e.g. subclavian) as it is strongly phlebitic and would collapse peripheral veins

Long term use is associated with fatty liver and deranged LFTs

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18
Q

What is the guidance for use of metformin peri-operatively?

A

take as normal leading up to surgery

on day of surgery:
if taken BD take as normal
if taken three times a day, omit lunchtime dose

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19
Q

What is the guidance for use of sulfonylureas peri-operatively?

A

prior to admission take as normal

on day of surgery:
if taken once daily in the morning omit the dose that day
if taken BD, omit the morning dose for morning surgeries or both doses for afternoon surgeries

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20
Q

How should gliptins and GLP-1 analogues be used perioperatively?

A

take as normal throughout including on day of surgery

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21
Q

How should SGLT-2 inhibitors (gliflozins) be used peri-operatively?

A

take as normal prior to admission, omit completely on the day of surgery

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22
Q

How should once daily insulins (e.g. Lantus, Levemir) be used peri-operatively?

A

Dose reduction of 20% the day before and the day of surgery

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23
Q

How should twice daily Biphasic or ultra-long acting insulins (e.g. Novomix 30, Humulin M3) be used peri-operatively?

A

on the day of surgery:
Halve the usual morning dose. Leave evening dose unchanged

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24
Q

Outline the American Society of Anaesthesiologists (ASA) classification

A

ASA I = A normal healthy patient

ASA II = A patient with mild systemic disease Examples include: current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes /Hypertension, mild lung disease

ASA III = A patient with severe systemic disease Substantive functional limitations

ASA IV = A patient with severe systemic disease that is a constant threat to life (e.g. MI/HF/stroke)

ASA V = A moribund patient who is not expected to survive without the operation

ASA VI = A declared brain-dead patient whose organs are being removed for donor purposes

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25
Which surgical patients are considered to be at higher risk of VTE?
hip/knee replacement hip fracture GA and a surgical duration of > 90 minutes surgery of the pelvis or lower limb with GA and a surgical duration of > 60 minutes acute surgical admission with an inflammatory/intra-abdominal condition surgery with a significant reduction in mobility
26
Advice for women on COCP/HRT approaching surgery?
stop for 4 weeks leading up to surgery
27
What is the most suitable course of action for a patient on warfarin about to have major abdo surgery?
Stop his warfarin and commence treatment dose low molecular weight heparin
28
Outline the timings of the most common causes of post-op fever
Day 1-2: 'Wind' - Pneumonia, aspiration, pulmonary embolism Day 3-5: 'Water' - Urinary tract infection (especially if the patient was catheterised) Day 5-7: 'Wound' - Infection at the surgical site or abscess formation Day 5+: 'Walking' - Deep vein thrombosis or pulmonary embolism Any time: Drugs, transfusion reactions, sepsis, line contamination
29
Why does poor post-op pain management carry a risk of pneumonia?
period of significant pain = shallow breathing lack of deep breathing is a risk factor for both atelectasis and respiratory tract infections
30
Isolated fever in well patient in first 24 hours following surgery?
physiological reaction to operation
31
Surgical diabetic patients are likely to have what 3 things?
increased risk of wound & respiratory infections increased risk of post-operative AKI increased length of hospital stay
32
Most patients taking only oral antidiabetic drugs may be managed by manipulating medication on the day of surgery, depending on the particular drug. What are the exceptions? How would you manage these patients?
if more than one meal is to be missed patients with poor glycaemic control risk of renal injury (e.g. low eGFR, contrast being used) in such cases a VRIII should be used
33
Which insulin dependent patients can be managed post-op by adjustment of their normal insulin regime as opposed to starting a VRII?
patients treated with insulin who have good glycaemic control (HbA1c < 69 mmol/mol) and are undergoing minor procedures
34
Excessive infusions of any intravenous fluid carry what risk?
development of tissue oedema and potentially cardiac failure excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis so Hartmans solution may be preferred
35
Why should you avoid of using hypotonic (0.45%) sodium chloride in paediatric patients?
risk of hyponatraemic encephalopathy
36
How should a patient with a v low Hb the day before surgery be managed?
Pre-operative blood transfusion
37
What is the agent of choice for rapid sequence of induction?
Sodium thiopentone- rapid onset of action Metabolites build up quickly Unsuitable for maintenance infusion
38
Which drugs are patients with myasthenia gravis very sensitive to?
Non-depolarising agents, such as rocuronium (blocks nicotinic receptors) The myasthenic patient has fewer available nicotinic receptors meaning that they are more sensitive to non-depolarising blockade may require more prolonged ventilation
39
When would you Cross-match 2 units for surgery?
transfusion likely Salpingectomy for ruptured ectopic pregnancy, total hip replacement
40
When would you Cross-match 4-6 units for surgery?
transfusion definite Total gastrectomy, oesophagectomy, hepatectomy, oophorectomy, cystectomy, Elective AAA repair
41
cause of new onset atrial fibrillation following gastrointestinal surgery?
anastamotic leak
42
What is the muscle relaxant of choice for rapid sequence induction for intubation? ADR? Contraindications?
Suxamethonium (succinycholine) ADR: transient hyperkalaemia, fasciculations Contraindications: patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure
43
What is required prior to surgery for patients taking 10mg or more of prednisolone?
Hydrocortisone supplementation to prevent Addisonian crisis
44
what is local anaesthetic toxicity? How can it be treated?
initial overactivity of the central nervous system (CNS) and subsequent depression either due to intravenous administration or excess usage It can be treated with IV 20% lipid emulsion (the most commonly used brand is Intralipid).
45
Which anaesthetic agent has one of the strongest analgesic effects?
ketamine
46
Which anaesthetic agent reverses the action of midazolam?
Flumazenil
47
Which anaesthetic agent is associated with hepatotoxicity?
Halothane It should be avoided in patients with hepatic dysfunction, and scavengers should be used in theatres as accumulation of the drug may be harmful to theatre staff
48
How does lidocaine work? ADRs?
it is an amide - blockage of sodium channels ADRs: nausea, dizziness, tinnitus and tremor.
49
How are surgical patients at low and high risk of VTE managed?
low risk - anti-embolism compression stockings (TED stockings) high risk - TED stockings + pharmacological prophylaxis drugs: Fondaparinux sodium (SC injection) LMWH e.g. enoxaparin Unfractionated heparin (UFH) (alternative to LWMH in patients with CKD)
50
Best method to obtain IV access in a child who is peripherally shut down?
intraosseous infusion - proximal tibia
51
Best method of IV access for long term chemo in a patient who is peripherally shut down?
Hickman line- most reliable long term option Most Hickman lines are inserted under local anaesthesia with image guidance
52
Best method of temporary IV access in a patient who is haemodynamically stable with good veins?
20 G (pink) peripheral cannula
53
Long term mechanical ventilation in trauma patients + choking and bringing up sputum after meals = ?
tracheo-oesophageal fistula formation
54
When should LMWH be started in relation to hip replacement surgery?
6-12 hours after surgery
55
What bowel prep is required leading up to colonoscopy?
laxatives the day before no food 24hours before procedure
56
What is malignant hyperthermia? How should it be managed?
autosomal dominant disorder presenting as a hypermetabolic crisis -hyperthermia, hypercapnia, tachycardia, muscle rigidity, rhabdomyolysis, and arrhythmia commonly associated with volatile inhalational anaesthetic agents and the muscle relaxant succinylcholine (suxamethonium) IV dantrolene therapy
57
Complications of perioperative hypothermia?
Coagulopathy: increased intra-operative blood loss Prolonged recovery from anaesthesia Reduced wound healing: local vasoconstriction which reduces perfusion to the skin Infection Shivering: significant increase in metabolic rate which can result in myocardial ischaemia in some patients
58
What are the recommendations for post-op wound cleaning?
Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery.
59
What drugs may impair wound healing?
Non steroidal anti inflammatory drugs Steroids Immunosupressive agents Anti neoplastic drugs
60
Outline the use of cocaine in anaesthesia
cocaine hydrochloride- used in paste form as a local anaesthetic applied topically to the nasal mucosa in ENT surgery It has a rapid onset of action and causes marked vasoconstriction.
61
Use of Bupivacaine?
much longer duration of action than lignocaine so may be used for topical wound infiltration at the end of surgical procedures cardiotoxic and is therefore contra indicated in regional blockage in case the tourniquet fails
62
agent of choice for intravenous regional anaesthesia e.g. Biers Block?
Prilocaine
63
Which patients may need an ECG before surgery?
over 65 before major surgery diabetics and patients with renal disease before intermediate surgery
64
What is suxamethonium apnoea?
Pseudocholinesterase deficiency - rare abnormality in the production of plasma cholinesterases increased duration of action of muscle relaxants e.g. suxamethonium and will cause resp arrest unless pt is ventilated
65
Name the key transfusion reactions
Got a bad unit G raft vs. Host disease O verload T hrombocytopaenia A lloimmunization B lood pressure unstable A cute haemolytic reaction D elayed haemolytic reaction U rticaria N eutrophilia I nfection T ransfusion associated lung injury
66
What is the blood transfusion threshold and Hb target?
Without ACS: threshold = 70 g/L target = 70-90g /L With ACS threshold = 80 g/ L target = 80-100 g/ L
67
How quickly should one unit of red cells be transfused?
emergency = STAT non urgent = over 90-120 minutes
68
Irradiated blood products are required in patients following bone marrow and stem cell transplants for what reason?
to prevent graft versus host disease (depleted of T lymphocytes)
69
How is TRALI differentiated from TACO?
hypotension in TRALI vs hypertension in TACO
70
How should TRALI be managed?
Titrate oxygen, give IV fluids and consider escalation of care
71
Which blood product is most likely to cause an iatrogenic septicaemia with a Gram-positive organism?
Platelets - stored at room temperature
72
The first step in management of any suspected transfusion reaction is what?
stop the transfusion!!!
73
Fever, abdominal pain, hypotension during a blood transfusion →
acute haemolytic reaction due to RBC destruction by IgM-type antibodies
74
Hypotension, dyspnoea, wheezing, angioedema during a blood transfusion →
anaphylaxis
75
What is the universal donor of FFP?
AB RhD negative blood
76
What are the key steps to take before initiating a blood transfusion?
Process for blood transfusion: 1. Confirm patient identity 2. Check compatibility 3. Check expiry date and unit number 4. Inspect bag for integrity of plastic casing 5. Blood out of fridge over 30 mins should be transfused within 4 hours or discarded 6. Record everything
77
What is involved in blood conservation technique?
1.Increase red blood cell mass – e.g. correct iron deficiency 2.Reduce peri-operative blood loss – e.g. op for regional not GA where possible 3.Optimising transfusion practice – allogenic transfusion/ autologous transfusion (cell salvage)
78
When should you stop warfarin pre-op? DOAC?
warfarin = 4-5 days DOAC = 2 days
79
What factors increase risk of post-operative nausea and vomiting?
young female non-smoker PMH of motion sickness use of volatile anaesthetics

Y3 Surgery (8 decks)

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