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Acute Care > Anaesthetics General > Flashcards

Anaesthetics General Flashcards

1
Q

Which anti-hypertensives must be stopped before surgery

A

Stop ACEi and diuretics on day of surgery as they have a risk of prolonged hypotension
Only exception is if the diuretic is being used for heart failure

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2
Q

How do you manage someone’s antiplatelets before surgery

A

Should stop anti-platelets 7 days before surgery as this allows new platelets to come back into circulation

However, aspirin is a grey area. half life is 24 hours and risk of bleeding is relatively low so now usually continue until the day before then stop.

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3
Q

What surgery MUST aspirin be stopped 7 days before

A

Intracranial surgery - neurosurgery
Orthopaedics
Bleeds would be very high risk

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4
Q

How should warfarin be managed prior to surgery

A

Should be stopped 5 days before surgery and then restarted post-op

If on for low risk reason like AF then stop completely with no replacement is fine

If high risk like mechanical valve, recurrent PE they are high clot risk so give bridging therapy (stop warfarin for 5 days, give LMWH on day 4 and 5 then restart)

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5
Q

How should DOACs be managed prior to surgery

A

These needs stopped 2 days before and can be restarted - easier to manage

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6
Q

How long should someone fast before surgery

A

Should fast for at least 6 hours pre-op - this is the timing of gastric emptying
Stop drinking 2 hours - can sip till send (sip small amounts of water to reduce dehydration)

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7
Q

How should you manage diabetics prior to surgery

A

They are at risk of both hyper (due to body stress) and hypos (due to fasting)
Make them 1st on list to minimise risk from fasting (hypo risk)
Monitor glucose regularly
Get them back into usual routine as fast as possible
IV insulin can be used in more complex case

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8
Q

When is jaw thrust preferable to head tilt chin lift

A

If there suspicion of C-spine pathology

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9
Q

What are the 2 types of airway adjunct

A

Oro-pharyngeal or Guedel airway

Naso-pharyngeal airway

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10
Q

How do you size a oro-pharyngeal airway

A

Roughly the distance between the patient’s incisors and the angle of the jaw
Better to be slightly too big than too small

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11
Q

How do you size a naso-pharyngeal airway

A

Length corresponds to the distance between the tip of the patient’s nose to the tragus/earlobe
If too long it might make them gag

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12
Q

When should you remove an oro-pharyngeal airway

A

If the patient starts gagging

NP is better tolerated

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13
Q

How much O2 can be delivered via nasal cannula

A

1-4L/min

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14
Q

Which type of mask is needed for high flow (15L/min) O2 delivery

A

Non-rebreather

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15
Q

How can reduced consciousness lead to airway obstruction

A

There is a decrease in muscle tone which results in posterior displacement of the tongue and soft palate which can block the airway
This may be as a result of drugs, neurological conditions, anaesthetics or patients in critical condition

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16
Q

When are naso-pharyngeal airways used

A

If patient is not deeply unconscious

If they have a clenched jaw trismus or maxillofacial injuries

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17
Q

What is the major contraindication to nasopharyngeal airway use

A

Base of skull fracture

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18
Q

What are the signs of a clear airway on bag-mask ventilation

A

Misty, Chesty, Tracey

  • mask misting
  • smooth respiratory mechanics of the chest
  • square wave capnography trace
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19
Q

Where are supraglottic airways positioned

A

Inserted into the oropharynx

The cuff at the bottom forms a seal around the laryngeal opening - above the epiglottis

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20
Q

What are the absolute contraindications to supraglottic airways

A

History of gastric reflux or hiatus hernia
Intra-abdominal pathology
Pregnancy
Recent major trauma or administration of opiates
Morbid obesity
Gastroparesis

This is due to aspiration risk

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21
Q

What is the only total contraindication to endotracheal intubation

A

Total airway obstruction of the upper airway preventing laryngeal access and necessitating a front-of-neck-airway

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22
Q

List some potential complications of endotracheal intubation

A

Dental damage
Damage to other structures such as trachea or larynx
ETT may go down the wrong hole into the oesophagus
ETT may go too far down into the bronchi

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23
Q

When is a front-of-neck intubation needed

A

If the patient is not being oxygenated but cannot be intubated

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24
Q

Where is a front-of neck airway placed

A

In the cricothyroid membrane into the trachea

Called a cricothyroidotomy

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25
Q

Describe the ‘ladder’ of critical care

A

Ward based
HDU - single organ failure
ICU - multi-organ failure and/or ventilation

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26
Q

What conditions may present post-ICU survival

A

PTSD, anxiety etc
Muscle weakness
Fatigue
Long term renal and respiratory support needed

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27
Q

When would you use CPAP vs BiPAP

A

CPAP - gives pressure on expiration. Used for type 1 resp failure and pulmonary oedema.

BiPAP - also gives inspiratory pressure so better for type 2 resp failure and hypercapnia as helps decrease CO2

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28
Q

Those with end stage lung disease may not be accepted for mechanical ventilation - true or false

A

True
They would be unlikely to be able to wean off it - will never recover their resp function
Often considered a terminal event and discussed in AD - support until end of life

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29
Q

What is ECMO

A

A way of oxygenating the blood outwith the body - bypasses heart and lungs
Used for severe respiratory failure

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30
Q

How are vasopressors a used

A

In vasodilatory, neurogenic or distributive shock

e.g. in sepsis, anaphylaxis etc

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31
Q

How do vasopressors work

A

Primarily alpha-adrenergic Used in vasodilatory/distributive shock
Causes venoconstriction - increases venous return (and CO etc)
And arterial constriction - increases SVR

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32
Q

How do positive inotropes work

A

Primarily beta-adrenergic stimulation

Increase cardiac output by increased contractility

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33
Q

How are inotropes used

A

In states of low CO such as cardiogenic shock

When hypotension is caused by poor contractility and has not responded to fluids

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34
Q

What are the first line fluids in the critically ill

A

Crystalloids such as Hartmann’s

Balanced solutions like this are better than saline alone

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35
Q

If drug treatment fails, how can you treat cardiogenic shock

A

Intra-aortic balloon pump

  • inflate in diastole to increase pressure and improve coronary filling
  • deflates in systole to reduce afterload and myocardial O2 demand
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36
Q

When would you need a central venous catheter

A

Monitoring of Central Venous Pressure
Venous Access for Haemodialysis
Venous Access for Cardiac Pacing
Administration of Inotropes, cytotoxic agents

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37
Q

List some immediate complications of central venous catheter insertion

A 
Arterial puncture 
Haemorrhage  Pneumothorax / haemothorax 
Air embolism 
Cardiac arrhythmia
Damage to nearby structures - eg trachea, oesophagus, thoracic duct, nerves
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38
Q

List some late complications of central venous catheter insertion

A

thrombosis
infection
endocarditis
cardiac or valve rupture

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39
Q

Where should a central venous catheter sit

A

The tip should be at the entrance to the right atrium

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40
Q

What is a vasopressor

A

A substance which increases the systemic vascular resistance

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41
Q

What is an inotrope

A

A substance that affects the force of muscular contraction, either positively or negatively.
When discussing medication we mean positive ones - increase contraction

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42
Q

Inotropes must always be given by infusion through a central venous catheter - true or false

A

True

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43
Q

List examples of positive inotropes

A

Adrenaline

Dobutamine

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44
Q

List examples of vasopressors

A

Nor-adrenaline
Metaraminol
Adrenaline
Ephedrine

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45
Q

What happens to pO2 as air moves through the body

A

It decreases

Highest in atmospheric gas and gets lower as it moves through the steps of respiration - lowest in mitochondria

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46
Q

How does hypovolaemic shock cause hypotension

A

It decreases preload - the amount of blood getting back to the heart

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47
Q

How does cardiogenic shock cause hypotension

A

It decreases myocardial contractility

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48
Q

How does septic/neurogenic shock cause hypotension

A

It decreases afterload - the resistance the heart is beating against
decreased SVR

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49
Q

List signs of shock

A

Tachycardia, tachypnoea and vasoconstriction (waiting for BP drop is dangerous)
Decreased urine output
Decreased conscious level
Acid Base Abnormality - Metabolic Acidosis/Respiratory compensation

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50
Q

How is haemorrhagic shock classed

A

4 classes based on how much blood has been lost.

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51
Q

Where is the majority of body fluid stored

A

As the intracellular fluid - 2/3

Rest is extracellular - interstitial and plasma

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52
Q

List examples of crystalloid fluids

A

Saline
Hartmann’s
Dextrose

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53
Q

What are the benefits of crystalloid fluids

A

Easily available

Cheap

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54
Q

What are the cons of crystalloid fluids

A

Variable volume of distribution (can end up in undesirable spaces) - easily diffuses through a semi-permeable membrane

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55
Q

What are the benefits of colloid fluids

A

Stays in intravascular space - does not diffuse through membranes due to large protein/carb particles
Expands plasma volume - draw in water from interstiital fluid
Relatively expensive

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56
Q

What are the cons of colloid fluids

A

Risk of anaphylaxis

No proven benefit over saline in hypovolaemia

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57
Q

List examples of colloid fluids

A

Gelofusine

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58
Q

What are the benefits of using blood to resus

A

Well recognised
Good colloid - stays in intravascular space
Replaces ‘like with like’
Carries oxygen well

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59
Q

What are the drawbacks of using blood to resus

A 
Expensive
Risk of transfusion reactions 
Infection risk etc
Packed red cells does not contain platelets and 
clotting factors
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60
Q

What type of pain is usually seen in acute scenarios

A

Nociceptive
Direct response to injury (physical, chemical), or
other pathology - proportionate

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61
Q

How can under-treated pain affect the cardiovascular system

A 
Tachycardia
Hypertension
Increased peripheral vascular resistance
Increased myocardial oxygen consumption
Myocardial ischaemia
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62
Q

How can under-treated pain affect the respiratory system

A 
Decreased lung volumes
Atelectasis
Decreased cough and sputum retention
Infection
Hypoxaemia
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63
Q

How can under-treated pain affect the GI system

A

Decreased gastric and

bowel motility

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64
Q

How can under-treated pain affect the GU system

A

Urinary retention

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65
Q

How can under-treated pain affect the MSK system

A

Muscle spasm

Immobility

66
Q

How can under-treated pain affect the endocrine system

A

Increased catabolic hormones and decreased anabolic hormones

Insulin resistance

67
Q

How can under-treated pain affect the patient psychologically

A

Anxiety and fear
Depression
Sleeplessness

68
Q

Is it better to use high doses of one drug or lower doses of multiple drugs to treat acute pain

A

Best done by using a combination of drugs
from different classes -so lower doses of
each drug can be used

69
Q

If someone with an opiate problem needs analgesia what do you give them

A

If they are already prescribed Methadone then continue at same dose

If not already in progranne, do not start methadone! Give normal opioids plus extra to control pain but monitor closely

70
Q

As required pain medication should be avoided in patients with substance abuse issues - true or flase

A

True

Better to aim for a stable plasma opioid level- e.g. with long acting opioids

71
Q

Which medications are typically used for chronic pain

A

Maintained on opioids - regular dose plus breakthrough
Regular paracetamol/NSAID as baseline
May need to consider other adjuvant analgesics

72
Q

Which analgesic should be avoided in renal failure

A

NSAIDs

Those with many active metabolites - may accumulate due to decreased renal function

73
Q

How do you convert oral morphine to IV or IM

A

Divide by 2-3

IV dose needs to be lower

74
Q

How does paracetamol work

A

Inhibits prostaglandin synthesis in the CNS

75
Q

What is the typical dose of paracetamol

A 
1 gram (2x500mg tabs) 6 hourly - max 4x daily 
Dose will need reduced if patient is below 50kg
76
Q

How do NSAIDs work

A

These drugs inhibit the enzyme cyclo-oxygenase [cox]

1 and 2

77
Q

What are the contraindications to NSAID use

A 
GI bleeding - old or new 
Active peptic ulcers 
Coagulopathy 
Renal impairment 
Aspirin or NSAID allergy
78
Q

When should NSAIDs be used with caution

A 
Elderly
Dehydration
Asthmatics
Certain types of surgery, e.g. - plastic or eye 
surgery, some orthopaedic surgery
Cardiac failure
Pregnancy
Concurrent medication e.g. anticoagulants
79
Q

How do you reverse respiratory depression caused by opioids

A

Give oxygen
Adjust dose or stop delivery of opioid until
situation satisfactory
If necessary give naloxone and titrate to effect

80
Q

Clinical opioids act on which receptor

A

μ (mu) opioid receptor.

81
Q

How is morphine metabolised

A

Metabolised in the liver to M6G and M3G
M6G is responsible for the analgesic effect.
These have longer half-lives than morphine and are excreted via the kidney

82
Q

How does tramadol work

A

Centrally acting synthetic analgesic

Has mu opioid receptor activity and inhibits the uptake of noradrenaline and serotonin

83
Q

Tramadol should be avoided in which patients

A

Epileptics
Not suitable as the sole analgesic in
morphine-dependent patient

84
Q

What are the benefits of tramadol

A

Doesn’t build tolerance
Lower abuse potential
Less respiratory depression
Less constipation

85
Q

When is patient controlled analgesia used

A

Post-op pain
Severe non operative pain e.g. pancreatitis, fractured
ribs

86
Q

What is used for patient controlled analgesia

A

The usual prescription is a 1 mg bolus of morphine with a 5 minute lockout-i.e. the patient can receive up to 12 mgs morphine per hour.
Bolus dose and lock-out period can both be varied

87
Q

What are the contraindications to patient controlled analgesia

A 
Patient inability to comprehend the 
technique e.g. extremes of age
Patients inability to press the button e.g. 
severe rheumatoid
Patient rejection
Ward staff must be trained appropriately
88
Q

What are the complications of epidural anaesthesia

A

Spinal haematoma
Abscess
Cannot be used if patient is anti-coagulated

89
Q

Cyclizine is which type of anti-emetic

A

Antihistamine - H1 antagonist

90
Q

Ondasentron is which type of anti-emetic

A

5HT3 antagonists

91
Q

Prochlorperazine and metoclopramide are which type of anti-emetic

A

Antidopaminergic

92
Q

Hyoscine is which type of anti-emetic

A

Anticholinergic

Good for motion sickness

93
Q

What is the definition of chronic pain

A

Lasting > 3 months

Typically after normal healing has occurred

94
Q

List primary causes of circulatory/cardiac inadequacy

A 
Ischaemia
Myocardial infarction
Hypertensive heart disease
Valve disease
Drugs
Electrolyte abnormalities
95
Q

List secondary causes of circulatory/cardiac inadequacy

A 
Asphyxia
Hypoxaemia
Blood loss
Septic shock
Any Shock
96
Q

what is nociceptive pain and describe how it feels

A

Also called physiological or inflammatory pain
Pain occurring after obvious tissue injury or illness - protective
Typically sharp and well localised - may have associated ache

97
Q

what is neuropathic pain and describe how it feels

A

Pain due to nervous system damage or abnormality
May not have obvious injury

Typically burning/shooting pain with numbness, pin and needles etc.
Not well localised

98
Q

Chronic pain is typically a complex mix of nociceptive and neuropathic pain - true or false

A

True

99
Q

What is nociception

A

How signals get from the site of injury to the brain

100
Q

Describe the peripheral section of the nociceptive pathway

A 
Get the initial tissue injury 
Triggers release of chemicals 
This stimulates the nociceptors - pain receptors
Signal travels in Aδ or 
C nerve to spinal cord
101
Q

Describe the spinal section of the nociceptive pathway

A 
Dorsal horn is the
first relay station
Aδ or C nerve 
synapses with second nerve here 
Second nerve crosses and  travels up opposite side of 
spinal cord in the spinothalamic tract
102
Q

Describe the brain section of the nociceptive pathway

A

The thalamus is the
second relay station - nerve connects here
This has connections to many other parts of the brain - cortex, stem etc
Pain perception
occurs in the cortex

103
Q

Describe how the nociceptive pathway is modulated

A 
Descending pathway 
from brain to dorsal 
horn
Usually decreases 
pain signal
104
Q

Give examples of pain caused by nervous system damage

A

Nerve trauma

Diabetic pain/neuropathy

105
Q

Give examples of pain caused by nervous system dysfunction

A

Fibromyalgia

Chronic tension headache

106
Q

List pathological mechanisms through which pain sensation can be increased

A

Increased receptor numbers
Abnormal sensitisation of nerves
Chemical changes in the dorsal horn
Loss of normal inhibitory modulation

107
Q

Which treatments are good for peripheral pain

A

RICE
Anti-inflammatories
Local anaesthetic

108
Q

Which treatments are good for pain arising from the spinal cord

A

Locals
Opioids
Ket

109
Q

What are the main adverse effects of codeine

A

Constipation

Also not great for chronic pain

110
Q

In which type of pain is addiction most likely

A

Chronic, non-cancer pain

111
Q

What is the main adverse effect of tramadol

A

Nausea and vomiting

112
Q

Which drugs are good for neuropathic pain

A

Amitriptyline

Anti-convulsants - gabapentin, sodium valproate and carbamazepine

113
Q

What is the main adverse effect of amitriptyline

A

Anti-cholinergic side effects

e.g. glaucoma, urinary retention

114
Q

How does amitriptyline treat pain

A

Increases descending inhibitory signals

Helps modulate pain

115
Q

How do anti-convulsants treat pain

A

Reduce abnormal firing of nerves

Also called membrane stabilisers

116
Q

What are the treatable/reversible causes of cardiac arrest

A 
4 H's 4 T's 
Hypoxia
Hyovolaemia 
Hyper/hypokalaemia 
Hypothermia 
Toxins 
Tamponade - cardiac 
Tension pneumothorax 
Thrombosis - coronary or pulmonary
117
Q

How often should adrenaline be administered during ALS

A

every 3-5 mins

118
Q

How often should amiodarone be administered during ALS

A

After the 3rd shock

119
Q

How do you treat a SVT

A

Vagal manoeuvres
If ineffective give adenosine
If that doesn’t work give verapamil or a beta-blocker

120
Q

How do you treat acute AF

A

Beta-blocker - rate control
Consider digoxin or amiodarone if evidence of heart failure
2nd line is DC shock
Anticoagulate if duration > 48hrs

121
Q

How do you treat acute bradycardia

A

Atropine - 500mcg IV

If not enough repeat dose up to 3mg max and consider adrenaline, isoprenaline or TC pacing

122
Q

What dose of glucose is given in acute hypoglycaemia

A

100mI of 10% Glucose

123
Q

What should the HbA1c be before elective surgery is considered

A

<69mmol/mol (8.5%)

Otherwise discuss with the diabetes team (especially if over 12%

124
Q

What post-op complications can be caused by hyperglycaemia

A

Wound infection and cardiac problems

125
Q

What post-op complications can be caused by hypoglycaemia

A

Hypoglycaemia can be masked by sedation or general anaesthesia. In extreme cases this may cause irreversible brain damage

126
Q

Patient’s become more prone to hypos post-op - why is this

A

They will have been fasted prior to their procedure

Paradoxically the surgical stress response may mean that patients become more prone to hyperglycaemia and insulin resistance after major surgery

127
Q

There is an association between asthmatics with nasal polyps and sensitivity to NSAlDs - true or false

A

True

128
Q

In general cardiac medication should be given over the peri-operative period - true or false

A

True - most are cardioprotective

Exceptions - ACEi, diuretics, anti-coag and anti-plat

129
Q

Typically you are aiming for an INR of 1.5 for surgery - true or false

A

True

Exceptions- dental work or urological ops

130
Q

Patients who have had a venous thrombo-embolic event 9 months ago are considered high risk of another thrombo-embolic event - true or false

A

False

Once 3 months has passed, these patients are not considered high risk.

131
Q

If there is no excessive bleeding post-operatively then warfarin should be restarted at the patient’s usual dose on the day of the procedure - true or false

A

True

Recheck INR 48 hours after restarting

132
Q

Raised urea and creatinine can indicate dehydration - true or false

A

True

Even pre-renal failure due to hypovolaemia

133
Q

What is the minimal acceptable urine output

A

0.5ml/kg/hr

134
Q

What is the risk of large, rapid NaCl infusion

A

Hypernatraemia and acidosis

The influx of negative Cl- ions causes H+ to rise to balance it out

135
Q

Which fluid department is depleted in pure dehydration

A

All

Plasma, interstitial and ICF

136
Q

Which fluid department is depleted in hypovolaemia

A

Just the plasma

137
Q

Which fluid department is depleted in

A

The ECF

Plasma + Interstitial fluid

138
Q

Should PPIs be continued on day of surgery

A

Yes

139
Q

How do benzodiazepines work

A

They bind to the GABA receptor in the CNS and increase the receptor affinity for GABA
Ion movement across the cell membrane is increased which hyperpolarises the cell membrane and reduces firing of neurons.
Leads to CNS depression

140
Q

List anesthetic induction agents

A 
Propofol 
Thiopentone
Etomidate
Midazolam
Ket
141
Q

Most anaesthetic agents work on which receptor

A

Majority are GABA mediated

142
Q

Which drugs can be used for inhalational anaesthesia

A

Nitrous oxide and sevoflurane

Used in kids or if difficult IV access

143
Q

Which drugs can be used for maintained anaesthesia

A

Nitrous oxide
Sevoflurane
Desflurane
Isoflurane

144
Q

How are neuromuscular blocking agents used in anaesthetics

A

Given to relax or paralyse muscles
Facilitate intubation
Improve surgical conditions (ie. relax abdominal wall)

145
Q

List examples of neuromuscular blocking agents

A

Non-depolarising - atracurium and rocuronium

Depolarising - Suxamethonium
Patient will twitch for a short time with this one

146
Q

How do local anaesthetics work

A

Reversible blockade of sodium channels, inhibiting transmission of action potentials in nerve cells.

147
Q

What is the max dose of 1% lidocaine used

A

4mg/kg

148
Q

Why is adrenaline sometimes given alongside local anaesthetci

A

It prolongs the duration of action by causing local vasoconstriction
therefore dont give to end artery regions!

149
Q

Why should metoclopramide be avoided in women under 60

A

Can cause oliguric crisis

150
Q

Which bloods can be used to help diagnose dehydration

A

Urea and Electrolytes

Creatinine

151
Q

What are the normal daily potassium requirements

A

1 mmol/kg

152
Q

What are the normal daily sodium requirements

A

2mmol/kg

153
Q

What are the normal daily water requirements

A

25-30ml/kg

2 litres for a 70kg man

154
Q

How should naloxone be administered

A

40 microgram increments titrated to effect and reassess the patient

155
Q

Poor control of blood glucose in the peri-operative period is associated with which complications

A

An increased risk of wound infection
Increased cardiovascular complications
Irreversible brain damage

156
Q

What is the correct dose and route of adrenaline for administration during cardiac arrest

A

1mg IV

157
Q

What is the correct dose and route of adrenaline for administration during anaphylactic shock

A

0.5mg IM

158
Q

Delayed (up to 12 hours) respiratory depression can occur in patients with spinal or epidural opioid administration - true or false

A

True

159
Q

What are the common side effects of using opioids in the epidural space

A

Itch

160
Q

What are the common side effects of using local anaesthetic alone as a block in the epidural space

A

Hypotension
Partial block
Post dural puncture headache
Nausea

Acute Care (3 decks)

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