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Anaesthetics / Critical Care Flashcards

1
Q

what does a pre-op assessment involve?

A

Hx
- PC - op, indication
- previous anaesthetics - method, problems, cx, malignant hyperthermia, sux apnoea
- DHx, allergies
- PMHx - all systems, quantify severity
- FHx
- SHx - drink, smoke, ADL, living situation

Examination
- CV, resp + abdo
- ECG, ECHO, CPET
- baseline bloods - FBC, U/E, LFTs, clotting, G+S

Airway assessment
- mouth opening
- jaw subluxation
- C-spine extension
- mallampati
- dentition

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2
Q

food and drinks rules before surgery?

A
  • clear fluids >2hrs
  • foods >6hrs
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3
Q

diabetes for operations

A
  • on insulin with good glycaemic control (HbA1c<69) - if minor procedure - just adjust usual insulin regimen
  • surgery with long fast / 1+ missed meal / poorly controlled DM - VRIII
  • VRIII with OHAs if 1+ meal missed, poor glycaemic control, or risk of renal injury
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4
Q

rules for emergency cases needing op?

A

stabilise, resus, consider abx/blood
consent + inform relatives

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5
Q

special considerations for thyroid surgery?

A

Thyroid surgery – vocal cord check.
Parathyroid surgery – consider methylene blue to identify gland.
Thyrotoxicosis – lugols iodine/ medical therapy.

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6
Q

special considerations for SNB, thoracic duct surgery, pheochromocytoma surgery and colorectal cases

A

Sentinel node biopsy – radioactive marker/ patent blue dye.

Surgery involving the thoracic duct – consider administration of cream.

Pheochromocytoma surgery – will need alpha and beta blockade.

Colorectal cases – bowel preparation (especially left sided surgery)

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7
Q

steroid considerations for op?

A
  • for pts on long term steroids
  • major surgery - hydrocortisone with pre-med then 6-8hrly for 3d
  • hydrocortisone for 24hr
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8
Q

Drugs to stop pre-op?

A

Insulin
- Sliding scale for major surgery
- Reduce bedtime dose + omit morning dose in minor surgery

Lithium
- Day before major surgery

Anticoagulants/platelets
- Warfarin 5d before with LMWH bridging (give dose vit K if INR>1.5 on day of)
- Antiplatelets 5-7d before
- Aspirin variable

cOCP/HRT
- 4wks before major, restart 2wks after

K sparing diuretics
- Day of surgery

Oral hypoglycaemics
- Metformin 48hrs before, restart 4d later when renal function ok

Perindopril / ACEi
- 24hrs before

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9
Q

triad of general anaesthesia + drug examples for each?

A

Analgesia
- fentanyl
- alfentanil
- remifentanil
- morphine

Hypnosis
IV
- propofol
- ketamine
- sodium thiopentone
- etomidate
Inhaled
- sevofluorane, desflurane, isoflurane
- NO

Muscle relaxation - block NMJ (ACh blocked)
Depolarising
- suxamethonium
Non-depolarising
- rocuronium
- atracurium
Reversal
- neostigmine (AChE inhibitor)
- sugammadex - non-depolarising

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10
Q

antiemetic options post op

A
  • ondansetron - serotonin antagonist - beware long QT
  • dexamethasone - corticosteroid - caution diabetics/immuno
  • cyclizine - H1 receptor antagonist - caution HF/elderly
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11
Q

risks of GA?

A
  • Sore throat
  • Post-operative N+V
  • Accidental awareness
  • Aspiration
  • Dental injury
  • Anaphylaxis
  • CV events - MI, stroke, arrhythmias
  • Malignant hyperthermia
  • Death
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12
Q

Propofol (hypnotic)

A
  • GABA receptor agonist
  • rapid onset, burns on IV injection, rapidly metabolised, anti-emetic, BP drops
  • TIVA
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13
Q

Ketamine (hypnotic)

A
  • NMDA receptor antagonist
  • analgesia, may dissociate pt (nightmares/hallucinations), BP stable
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14
Q

Sodium thiopentone (hypnotic)

A
  • barbiturate - potentiates GABA
  • rapid onset, BP drops, unstable for maintenance
  • lipid soluble
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15
Q

Etomidate (hypnotic)

A
  • potentiates GABA
  • little CV instability, may suppress adrenals
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16
Q

Suxamethonium (relaxant)

A
  • depolarising - binds to AChR - persistent depolarisation at NMJ
  • fast onset, muscular contraction before paralysis
  • adverse effects - hyperkalaemia, malignant HTN
  • CI - AACG
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17
Q

Atracurium (relaxant)

A
  • non-depolarising - competitive antagonist of AChR
  • lasts 30-45mins
  • histamine release on administration -> facial flushing, tachycardia, hypotension
  • broken down in tissues
  • neostigmine to reverse
18
Q

Vecuronium (relaxant)

A
  • non-depolarising, lasts 30-40mins
  • degraded by liver/kidney
  • reverse with neostigmine
19
Q

Pancuronium (relaxant)

A
  • pancuronium
  • 2-3min onset, 2hr duration
  • partially reverse with neostigmine
20
Q

Rocuronium (relaxant)

A
  • non-depolarising
  • sugammadex reversal
21
Q

Lidocaine

A
  • amide
  • blocks Na channels in axon - prevents depolarisation
  • hepatic metabolism, protein bound, renally excreted
  • intralipid if OD
  • max dose - 3mg/kg plain, 7mg/kg + adrenaline
22
Q

Bupivacaine

A
  • binds to intracellular Na channels, blocks Na influx, prevents depolarisation
  • longer duration than lidocaine
  • cardiotoxic
  • levobupivacaine - less cardiotoxic/vasodilation
  • max dose - plain 2mg/kg, +adrenaline 2mg/kg
23
Q

Prilocaine

A
  • Less cardiotoxic - used for Biers block / regional blocks
  • max dose plain 6mg/kg, adrenaline 9mg/kg
24
Q

Regional anaesthesia

A
  • Numb specific nerve
  • Use US to inject
  • May use in combination with GA to reduce pain
25
Spinal anaesthetic
- Aka central neuraxial anaesthesia - For c-sections, NOF repair, TURP - LA injected into CSF, within subarachnoid space - Needle inserted around L3/4 or L4/5 - Check it works with cold spray
26
Epidural anaesthesia + possible adverse effects
- For analgesia - Most commonly during labour, or post-operatively after laparotomy - Insert catheter into epidural space, outside dura mater - Levobupivacaine +/- fentanyl inserted – diffuses into tissues + nerve roots Adverse effects - Headache if dura is punctured – CSF leaks from dural tap - Hypotension - Motor weakness in legs - urgent anaesthetic review needed – catheter may be sited in subarachnoid space - Nerve damage - Infection, meningitis - Haematoma – may cause spinal cord compression - Prolonged second stage labour - Increased probability of instrumental delivery
27
tracheostomy + indications
- Hole in neck to access trachea - Held in place with stiches or soft tie (trach tie) Indications - Resp failure with requirement for long term ventilation - Prolonged weaning from ventilation (eg ICU pt weak after illness) - Upper airway obstruction (tumour, head/neck surgery) - Mx of resp secretions – pts with paralysis - Reduce risk of aspiration (eg pts wth unsafe swallow / absent cough reflex)
28
Difficult airway stepwise plan
- Plan A - laryngoscopy with tracheal intubation - Plan B - i-gel - Plan C - face mask ventilation and wake pt up - Plan D - cricothyroidotomy
29
ASA classifications
ASA I – normal, health patient - Eg non-smoker, no disease ASA II – mild systemic disease - Mild disease, no functional limitations – eg current smoker, pregnancy, controlled DM/HTN ASA III – severe systemic disease - Functional limitations – eg poorly controlled DM, COPD, BMI>40, active hepatitis, >3mo ago of MI/CVA ASA IV – severe systemic disease that is constant threat to life - <3mo hx of MI/CVA, cardiac ischaemia, valve dysfunction, HF with reduced ejection fraction ASA V – moribund patient not expected to survive without operation - Eg ruptured AAA, massive trauma, intracranial bleed, ischaemic bowel ASA VI – brain-dead patient, organs being removed for donor purposes
30
malignant hyperthermia- definition, Px, Ix and Mx
- hypermetabolic response to anaesthesia - from excessive release of Ca from SR in skeletal muscle - halothene, suxamethonium, antipsychotics - autosomal dominant risk Px - hyperthermia - increased CO2 production - tachycardia - muscle rigidity - acidosis - hyperkalaemia Ix - raised CK - contracture tests with halothane + caffeine Mx - dantrolene - prevents Ca release from SR
31
IV access options
Peripheral venous cannula - no inotropes / irritant drugs - eg TPN Central line - IJ, subclavian, femoral - vas cath - 2/3 lumens - portacath - port under skin, connects to subclavian vein IO - via marrow cavity Tunnellled lines - Gsoshong / Hickman lines Peripherally inserted central cannula (PICC) - insert peripherally, lumen ends centrally - pulmonary artery catheter - Swan-Ganz
32
Nutrition in surgical patients
Oral - easiest - CI'd after certain procedures NG - via fine bore NG tube - Cx - aspiration of feed, misplaced tube - eg impaired swallow - CI'd head injury Nasojejunal - avoids problems of feed pooling in stomach + aspiration risk - insertion more complicated Feeding jejunostomy - surgically sited feeding tube - can be long term - low asp risk Percutaneous endoscopic gastrostomy (PEG) - Combined endoscopic and percutaneous tube insertion - must be able to tolerate OGD TPN - where enteral feed CI'd - need central line - phlebitis risk - long term use - fatty liver, deranged LFTs
33
post op pyrexia?
Early causes (0-5d) - Blood transfusion - Cellulitis - UTI - Physiological systemic inflammatory reaction (usually within day) - Pulmonary atelectasis Late causes (>5d) - VTE - Pneumonia - Wound infection - Anastomotic leak 4 Ws – wind, water, wound, what did we do (iatrogenic)
34
Cx of periop hypothermia
- Coagulopathy, increased blood loss - Prolonged anaesthetic recovery - Reduced wound healing - local vasoconstriction - Infection - poor site healing, reduced no of immune cells - Shivering - increased metabolic rate, myocardial ischaemia in some populations
35
VTE prophylaxis
RFs - reduced mobility, ortho surgery, >90mins surgery, acute surgical admission, cancer/chemo, >60yo, thrombophilia, BMI>35, comorbidities, critical care admission, HRT/cOCP, varicose veins, pregnant, <6wks post partum Mx - compression stockings - intermittent pneumatic compression device - fondaparinux / enoxaparin / heparin / doac - mobilise asap after surgery, ensure hydrated
36
wound healing steps
- haemostasis - inflammation - regeneration - remodelling
37
scar types
Hypertrophic scars - excessive collagen Keloid scars - excessive collagen, extends beyond scar Drugs which impair wound healing - NSAIDs, steroids, immuno, anti-neoplastic Closure - delayed primary - leave open, close before granulation tissue forms - secondary - allow granulation tissue to form
38
what are the 3 levels of care?
Level 1 - general acute ward Level 2 - HDU Level 3 - ICU - needing organ support
39
Scoring systems to predict mortality at ICU admission
APACHE - acute physiology and chronic health evaluation SAPS - simplified acute physiology score MPM - mortality prediction model
40
ICU cx
-ventilator-associated lung injury - volutrauma, barotrauma.... - VAP - catheter-related bloodstream infections - catheter-associated UTIs - mucosal disease - deliriun - VTE - critical illness myopathy / neuropathy

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