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Med Student Finals > Anaesthetics & Clinical Biochemistry > Flashcards

Anaesthetics & Clinical Biochemistry Flashcards

1
Q

Pre-Assessment

History (2)

A

PMH: MI, asthma/COPD, rheumatic fever, liver/renal disease, dental problems, neck problems (eg. RA), reflux/vomiting, recent GA
FH: malignant hyperthermia, sickle cell disease

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2
Q

Pre-Assessment

Examination (4)

A

General: frailty, obesity, observations
Airway and dentition
Neck ROM
Cardio and resp exam

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3
Q

Pre-Assessment

Investigations (7)

A

ECG: >60 + ASA >3 OR any CVD OR severe renal disease
FBC: >60 + ASA >2 OR severe renal disease
U&E + creatinine: >60 + ASA >3 OR any age + ASA >4 OR any renal/CV disease
Pregnancy test
Sickle cell tests: if any FH, African/Afro-Caribbean
CXR: if scheduled for critical care or any recent respiratory illness
LFT: alcoholism, malignancy, jaundice

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4
Q 
Pre-Assessment
ASA Classification (6)
A

ASA I: normal healthy patient
ASA II: mild systemic disease/smoker/drinker/obesity/pregnancy
ASA III: severe systemic disease
ASA IV: severe systemic disease that is a constant threat to life
ASA V: moribund and not expected to survive procedure
ASA VI: declared brain dead- organs being removed for donor purposes

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5
Q 
Pre-Assessment
Special Considerations (8)
A 
No food <6h before procedure 
No fluids <2h before procedure 
All diabetics should be 1st on list and omit medication other than insulin (variable rate infusion) 
Stop warfarin 5d before 
Aspirin: stop for non-cardiac surgery 
Clopidogrel: stop for 5d before 
NSAIDs: stop due to renal and anti-platelet effects 
COCP: stop 4wks before
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6
Q

Principles of Anaesthesia

Triad of anaesthesia (3)

A

Hypnosis: unconsciousness by general anaesthetic agents (eg. propofol IV) and opiates
Analgesia: removal of noxious stimuli to prevent arousal and reflex response to pain by opioids and local anaesthetic (eg. remifentanil)
Relaxation: immobility for artificial ventilation or body cavity surgery by muscle relaxants, GA agents and opiates

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7
Q

Conduct of Anaesthesia

Induction (2)

A

IV: establish IV access, pre-oxygenate with 100 O2, give co-induction agents eg. fentanyl, give sleep inducing agent (GA) eg. propfol
Inhalational: indicated by patient request, difficult IV access, children, airway obstruction, either sevofluorane + O2 OR nitrous oxide + sevofluorane, establish IV access once asleep

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8
Q

Conduct of Anaesthesia

Airway (3)

A

Initially: triple manoeuvre (head tilt, chin lift, jaw thrust) with bag mask ventilation
Subsequent maintenance: laryngeal mask airway or endotracheal intubation
Protection: only if cuffed tube in trachea to protect airway from inflammation (endotracheal intubation) - indicated if muscle relaxants

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9
Q

Conduct of Anaesthesia

Ventilation (1)

A

Indications: use of muscle relaxants for specific procedure or as part of a balanced anaesthesia for a long procedure

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10
Q

Conduct of Anaesthesia

Maintenance (3)

A

Inhalational: agent + either spontaneous breathing through LMA OR ventilated and have muscle relaxants
Total IV anaesthesia: maintenance is with propofol and remifentanyl
High dose opiates with mechanical ventilation: rarely use due to risk of awareness

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11
Q

Perioperative Monitoring and Care

Monitoring (9)

A

General: sweating and lacrimation indicate complication
Respiration: rate + depth
Temp: risk of hypothermia
BP: use intra-arterial line if long case or high risk case
Pulse oximetry
ECG
CVP: helps differentiate hypovolaemia from reduced cardiac function
Urine output
Capnography: low end tidal CO2 can indicate emboli

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12
Q

Perioperative Monitoring and Care

Care (3)

A

Temp: hypothermia risk, warm environment with warming blankets and warmed IV fluids
Loss of protective reflexes: corneal reflexes so taping of eyes shut
Positioning: use cushioning to prevent pressure sores

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13
Q

Perioperative Complications

Failure to intubate (4)

A

Plan A: tracheal tube
Plan B: LMA
Plan C: bag/mask ventilation or wake up patient if able
Plan D: needle/surgical cricothyroidectomy

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14
Q

Perioperative Complications

Bronchospasm (1)

A

Occurs as part of own entity or with anaphylaxis

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15
Q

Perioperative Complications

Laryngospasm (1)

A

Cords firmly shut

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16
Q 
Perioperative Complications
Malignanct hyperthermia (2)
A

Rare autosomal dominant (chr 19) life-threatening condition

Triggered by suxamethonium or volatile agents causing excessive release of calcium

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17
Q

Perioperative Complications

Aspiration (1)

A

Due to active vomiting or passive regurgitation

18
Q

End of Anaesthesia

Reversal (4)

A

Change inspired gases to 100% O2
Stop anaesthetic drug infusions
Use a peripheral nerve stimulators to check spontaneous muscle relaxant reversal has occurred, then reverse with neostigimine and an anticholinergic (eg. atropine) to prevent muscarinic side effects (bradycardia, salivation)
Once spontaneously breathing, remove tube and administer O2 via facemask for as long as required

19
Q

Post-Operative Care

Post-operative analgesia (3)

A

Initial: strong opioids eg. morphine and peripherally acting drugs eg. paracetamol
Restoration of oral route: weak opioids eg. codeine and peripherally acting drugs
Final: peripherally acting drugs alone

20
Q

Post-Operative Care

Post-operative fluids (2)

A

Prescribe for requirements and always use Hartmann’s as electrolyte balanced
If haemodynamically stable then restart oral intake

21
Q

Post-Operative Care

Post-operative VTE prophylaxis (9)

A 
Any surgery >90min at any site or >60 min at lower limbs/pelvis 
Any patient >60 
Anyone with thrombophilia 
Anyone with previous thrombosis 
BMI >30 
COCP/HRT 
If pregnant or <6w post-partum 
If >1 significant medical co-morbidity 
Early mobilisation, compression stockings
22
Q

Post-Operative Complications

Nausea + vomiting (4)

A

25% of post-op patients
Vomiting centre in medulla: higher centres stimulated by sedatives, middle ear stimulated by nitrous oxide
At higher risk if female, opioid/nitrous oxide use
Use ondansetron, prochloperazine or cyclizine

23
Q

Post-Operative Complications

Pyrexia (1)

A

Look for underlying cause (eg. peritonism, chest infection, UTI, wound infection, meningisim, endocarditis)

24
Q

Post-Operative Complications

Confusion (1)

A

Due to hypoxia, drugs (opiates, sedatives), urinary retention, MI/stroke, infection

25
Q

Post-Operative Complications

Hypotension (2)

A

Due to hypovolaemia

May show signs of dehydration or wound/abdomen haemorrhage

26
Q

Post-Operative Complications

Reduced urine output (3)

A

May be due to anuria (blocked/malsited catheter or urinary retention)
May be due to oliguria (inadequate replacement of lost fluid or AKI)
Signs: palpable bladder (retention), volume depletion

27
Q 
Post-Operative Complications
Wound dehiscence (3)
A

Subacute infection from inadequate aseptic technique leads to more rapid suture breakdown
Pink serous discharge followed by evisceration of the bowel
Put guts back into abdomen, put on sterile dressing, give antibiotics

28
Q

Post-Operative Complications

Haemorrhage (3)

A

Primary: continuous bleeding starting during surgery, replace blood loss and if severe return to theatre for adequate haemostasis
Reactive: haemostasis appears secure until BP rises and bleeding starts, replace blood and re-explore wound
Secondary: usually caused by infection 1-2 weeks post-op

29
Q 
Post-Operative Complications
Anastomotic Leak (2)
A

Leak of luminal contents from surgical join

Causes generalised sepsis causing mediastinitis or peritonitis depending on site of leak typically 507 days post op

30
Q

Post-Operative Complications

Adhesions (1)

A

Fibrous bands form in abdominal or pelvic surgery leading to future chronic pain

31
Q

Post-Operative Complications

Ileus (1)

A

Fluid sequestration and loss of electrolytes following GI surgery

32
Q

Fluids

Definitions (5)

A

Diffusion: movement of solute from high to low concentration, membrane must be solute permeable
Osmosis: movement of water from high to low concentration, membrane must be solute impermeable
Osmolarity: measure of solute concentration per unit volume of solvent
Osmolality: measure of solute concentration per unit mass of solvent
Tonicity: measure of osmotic pressure gradient between 2 solutions

33
Q

Fluids

Crystalloids (3)

A

5% dextrose: maintenance fluid, hypotonic and iso-osmotic
0.9% sodium chloride: resuscitation or maintenance fluid (but don’t use as lone maintenance as excessive saline replacement leads to hyperchloraemic acidosis), isotonic
Hartmann’s solution: resuscitation or maintenance fluid, isotonic, more similar to plasma than normal saline

34
Q

Fluids

Colloids (2)

A

Proteins with large molecular weights that aim to maintain a high plasma oncotic pressure to keep fluid within the intravascular compartment but limited benefit in resuscitation
Human albumin solution: for decompensated liver disease, temporarily increases plasma oncotic pressures allowing intravascular volume to be maintained

35
Q 
Fluids 
Assessing Needs ( 3)
A

Pulse, BP, cap refill , JVP, peripheral + pulmonary oedema, postural hypertension
NEWS, fluid balance charts
Assess complex fluid or electrolyte replacement or abnormal distribution issues eg. existing deficits/excesses, ongoing abnormal losses, abnormal distribution- if no issues then routine maintenance, if issues then replacement and redistribution

36
Q 
Fluids 
Resuscitation Fluids (6)
A

If systolic BP <100
If HR >90
If RR >20
If NEWS >5
500ml crystalloid containing 130-154mmol/l over <15 minutes
Then reassess and if still in need of fluid resuscitation give further 250-500ml crystalloid (continue to reassess then seek expert help after >200mml given)

37
Q 
Fluids 
Maintenance fluids (3)
A

If no requirement for fluid resuscitation, no shock and no abnormal losses or distribution and unable to meet requirements orally or enterally
Normal daily fluid and electrolyte requirements: 25-30ml/kg/d water, 1mmol/kg/day sodium, potassium + chloride, 50-100g/day glucose (eg. glucose 5% contains 5g/100ml)
Stop IV fluids when no longer needed

38
Q

Fluids

Replacement Redistribution Fluids (5)

A

If there are complex fluid or electrolyte replacement or abnormal distribution issues
Fluid/electrolyte deficits/excesses: dehydration, fluid overload, hyperkalaemia/hypokalaemia
Ongoing abnormal fluid/electrolyte losses: vomiting, NG tube loss, biliary drainage loss, diarrhoea, ongoing blood loss, insensible loss (sweating, fever, dehydration)
Redistribution issues: gross oedema, severe sepsis, hypo/hypernatraemia, post-op fluids, malnutrition/refeeding
Prescribe by adding or subtracting from routine maintenance, adjusting for all other sources of fluid and electrolytes

39
Q

Fluids

Complications of Fluid Management (6)

A 
Pulmonary oedema 
Hyponatraemia 
Hypernatraemia 
Peripheral oedema 
Hyperkalaemia 
Hypokalaemia
40
Q 
Fluids 
Burns Fluids (2)
A

Parkland’s formula: TBSA of burn x weight x4

Half the fluid administered in 1st 8 hours

41
Q 
Fluids 
Paediatrics Fluids (3)
A

Resuscitation: 0.9% saline 20ml/kg bolus over <10 mins
Rehydration: replace losses
Maintenance: 1st 10kg 4ml/kg, 2nd 10kg 2ml/kg then 1ml/kg per hour 0.9% saline + 5% dextrose or glucose

Med Student Finals (23 decks)

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