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Phase 4 Question Knowledge > Anaesthetics + Critical care > Flashcards

Anaesthetics + Critical care Flashcards

1
Q

Pre-op assessment

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, rest etc
  • 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/drink before surgery

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

Diabetes for op

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

Emergency cases for op

A

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

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5
Q

Special preparations for surgery

A

Thyroid surgery – vocal cord check.

Parathyroid surgery – consider methylene blue to identify gland.

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.

Surgery for carcinoid tumours – will need covering with octreotide.

Colorectal cases – bowel preparation (especially left sided surgery)

Thyrotoxicosis – lugols iodine/ medical therapy.

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6
Q

Steroids for op

A
  • for pts on long term steroids
  • major surgery - hydrocortisone with pre-med then 6-8hrly for 3d
  • hydrocortisone for 24hrs
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7
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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8
Q

Triad of general anaesthesia

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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9
Q

Antiemetics 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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10
Q

Emergence

A
  • waking up whilst paralysed
  • use nerve stimulator
  • Train of four (TOF) stimulation - muscle twitches 4x with same strength if worn off (weakens if not)
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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
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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

Cocaine

A
  • salt, supplied in paste
  • apply to nasal mucosa
  • used in ENT
23
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
24
Q

Prilocaine

A
  • Less cardiotoxic - used for Biers block / regional blocks
  • max dose plain 6mg/kg, adrenaline 9mg/kg
25
Q

Regional anaesthesia

A
  • Numb specific nerve
  • Use US to inject
  • May use in combination with GA to reduce pain
26
Q

Spinal anaesthetic

A
  • 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
27
Q

Epidural anaesthesia

A
  • 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
28
Q

Tracheostomy

A
  • 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)
29
Q

Difficult airway

A
  • Plan A - laryngoscopy with tracheal intubation
  • Plan B - i-gel
  • Plan C - face mask ventilation and wake pt up
  • Plan D - cricothyroidotomy
30
Q

ASA classifications

A

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

31
Q

Malignant hyperthermia

A
  • 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
32
Q

IV access

A

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
33
Q

Nutrition in surgical patients

A

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
34
Q

Post-op pyrexia

A

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)

35
Q

Cx of periop hypothermia

A
  • 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
36
Q

VTE prophylaxis

A

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
37
Q

Wound healing

A
  • haemostasis
  • inflammation
  • regeneration
  • remodelling
    ….
38
Q

Scars

A

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
39
Q

Pain mx

A

Various bits + bobs in notes
….

40
Q

Levels of care

A

Level 1 - general acute ward
Level 2 - HDU
Level 3 - ICU - needing organ support

41
Q

Scoring systems to predict mortality at ICU admission

A

APACHE - acute physiology and chronic health evaluation
SAPS - simplified acute physiology score
MPM - mortality prediction model

42
Q

Nutritional support in ITU

A
  • dietician involvement
  • enteral - mouth, NG tube, PEG
  • TPN - via central line
43
Q

ICU cx

A

-ventilator-associated lung injury - volutrauma, barotrauma….
- VAP
- catheter-related bloodstream infections
- catheter-associated UTIs
- mucosal disease
- deliriun
- VTE
- critical illness myopathy / neuropathy

44
Q

CV / resp / renal support

A

see notes…..

Phase 4 Question Knowledge (30 decks)

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