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DPD > anaesthetics intra-op > Flashcards

anaesthetics intra-op Flashcards

1
Q

pre-op routine tests NICE

A
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2
Q

which drugs are controlled

A

Drugs that are in ‘controlled’ - opiods, ketamins, ie drugs of abuse

drugs that might be given in a drug error eg K looks like NaCl - accidentally give K = death

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3
Q

what is positive pressure ventilation

A

where air is forced by a mechanical ventilator into a non-breathing patient

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4
Q

benefits of positive pressure ventilation

A

improved CO elimination

improved oxygenation

relief from exhaustion as the work of ventilation is removed

High concentrations of oxygen (up to 100%) may be administered accurately.

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5
Q

what is positive end expiratory pressure

A

If adequate oxygenation cannot be achieved, a positive airway pressure can be maintained at a chosen level throughout expiration;

by attaching a threshold resistor valve to the expiratory limb of the circuit.

to re-expand underventilated lung areas -> reducing shunts and increasing PaO2.

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6
Q

what can ventilators control

A
  • Tidal volume—which provides precise control of volume and PaCO2 (ie volume controlled)
  • Pressure necessary to inflate the lungs (ie pressure controlled)—which re-duces risk of barotrauma
  • I:E ratio (I:E= the ratio of inspiratory to expiratory time)
  • Respiratory rate
  • Inspiratory time.

Other controls may be available to adjust:

  • Inspiratory flow waveform
  • End-tidal pause.
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7
Q

risks/considerations when using positive pressure ventilation

A
  • Everyone’s lungs blow up to a different volume – so if you put a fixed pressure you avoid barotrauma
    • But you could cause volume trauma
  • If have empysema – less ability for lungs to expand – so if you put pressure in = possible damage to the lungs – potentially blown lobe
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8
Q

acute mx of asthma

A
  • O SHIT ME
    • Oxygen
    • Salbutamol
    • Hydrocortisone or prednisolone
    • Ipratropium
    • Theophylline
    • Magnesium sulphate
    • Everything else
  • Can go into T1 or 2 resp failure
    • If in type 2 – exhausted, not ventilating properly
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9
Q

acute Mx of pneumothorax

A
  • Tension = CVS problems, high/low HR, low BP
  • Needle aspiration
  • Drain if not tensioning

Never ventilate someone with a pneumothorax – put pressure into the lungs – force air out of the hole – make a tension pneumothorax – lung collapses as it gets smaller and smaller

surgeons can do chest compressions

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10
Q

mx of haemothorax

A

drain

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11
Q

Mx of anaphylaxis

A
  • Adrenaline
  • Steroids – hydrocortisone
  • Antihistamine
  • Keep them in hospital because have second spikes of anaphylaxis
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12
Q

Mx of aspiration in surgery

A
  • Turn pt head down
  • Suction
  • Might need AB when they go onto the wards
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13
Q

indications for invasive blood pressure monitoring

A

intra-arterial in high risk or long cases,

significant co-morbidities

when difficult IV access is anticipated,

when pt seriously ill and need titrated vasoactive medicine

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14
Q

indications for non-invasive BP monitoring

A

measured in all cases,

needs to be maintained within 10% of the patients normal BP -

give vasopressor drugs or ionotropic drugs to raise

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15
Q

indications for invasive monitoring

A
  • Pt factors
  • Surgical factors
  • Beat to beat BP
  • Electrolyte
  • Long surgery
  • Blood loss
  • Pt unwell
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16
Q

cautions with arterial lines

A
  • If think there might be a clot you need to open up the line and let the blood come out so that the clot can be removed
  • Need to flush regularly so that reduce chances of there being a clot
  • The clot might come out in the saline when you take everything out
  • If flush and there is a clot there, the clot will go distally because it is an arterial line = ischemia of finger
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17
Q

why give fluids in surgery

A

because have been starved - so increase blood vol and rehydrate

hypotensive

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18
Q

colloids

A

stay in intravascular space

people are allergic

use crystalloids

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19
Q

considerations with crystalloids

A

don’t use plasmalyte if increase in K, or kidney problems

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20
Q

triggers for giving a blood transfusion

A
  • If haemorrhage
  • Loss certain percentage of blood vol/hr
  • Ongoing severe blood loss – Hb 80 in IHD, Hb 70 in normal

if have HbS - might give prophylactic transfusion

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21
Q

why do people get cold in surgery

A

drugs cause vasodilation - lose heat

lower the threshold for body to warm itself up

stop shivering - muscle relaxant

spinal blocks SNS response to temperature - no shiver or goosebumps

the drugs going into the system are cold

not conscious so can’t do behavioural response

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22
Q

why is a low body temperature a problem

A
  • Reduces coagulation because the enzymes work slower
  • Reduce drug metabolism because liver enzymes work slower
  • Unpleasant when wake up because SNS kicks in = shiver etc
  • Worse wound healing – wound infection
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23
Q

how is body temperature increased theatre

A
  • Bair hugger
  • Warming the IV fluids
  • Warm gasses through the humidifier
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24
Q

indications for an arterial line

A
  • Monitor BP if previous cardiac problem - beat to beat
  • cardiac surgery
  • py really inwell - sepsis, need to know readings to monitor
  • Look at glucose - dm
  • Look at blood gases

surgical factor - blood loss

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25
Q

importance of team brief

A

gives everyone a voice - so they feel empowered to point out any mistakes or things that are going wrong

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26
Q
A

oropharyngeal airway

guedel airway

27
Q
A

Bag and mask airway

28
Q
A

ET tube

29
Q
A

I-gel

supraglottic airway

not definite airway

30
Q

pre-op when do you do UE, FBC, BM

A

most patients

if Hb <100g/L tell anaesthetist

UE important if:

  • starved
  • dm
  • diuretics
  • burns
  • hepatic or renal disease
  • ileus
  • parenterally fed
31
Q

pre-op cross match

A

blood type is identified and units are allocated to patient

32
Q

group and save

A

blood type identified and held

waiting crossmatch if required

33
Q

when do you do an ECG pre-op

A

if >55yrs or poor exercise tolerance

hx of myocardiac ischemia

HTN

rheumatic fever

or other heart disease

34
Q

when do you do an echo pre-op

A

if suspicion of poor LV function

35
Q

when do you do pulmonary function tests

A

if known pul disease or obesity

36
Q

when do you do lateral cervical spine XR

A

flexion and extension views

hx of RA/ankylosing spondylitis/Down’s

to see if difficult intubation

37
Q

when do you do MRSA screen pre-op

A

according to local policy

not CI to surgery

place last on list to minimise risk, and prophylaxis AB

document

38
Q

when would you do specific blood tests pre-op

A

LFT - jaundice, malignancy, alcohol abuse

amylase - acute abdo pain

blood glucose - if dm

drug levels

clotting studies - liver/renal disease, DIC, massive blood loss, if on valproate/warfarin/heparin

TFT if thyroid disease

sickle test - Africa, west indies, mediterranean, and if origins in malarial areas - including most of india

39
Q

indication for LA

A

if unfit/unwilling to undergo GA

local nerve blocks eg brachial plexus or spinal blocks (CI if anticoagulated, or local infection)

use long acting LA eg bupivacaine

40
Q

epidural anaesthesia

A

anaesthetizing pain fibres L3/4 space is usually used. (in labour of T10-S5)

safe and effective

reduced catecholamine secretion

can be regularly topped up - catheter is left in epidural space

help lower BP in pre-eclampsia

Before siting an epidural, check platelet count is >75x10(9),

insert wide-bore IV access

Full aseptic technique

monitor BP every 5min for 20min, and record block height and density.

Continuous electronic fetal monitoring is required.

It is not uncommon to see a fetal bradycardia following epidural insertion due to maternal hypotension. Give IV fluids—it almost always recovers.

Top-ups are required ~2-hourly. Recall anaesthetist if inadequate pain relief within 30min.

If the epidural is used for LSCS, remember that the block will take longer to establish compared with spinal.

41
Q

complications of epidural anaesthesia

A

failure to site

patchy block

hypotension

dural puncture (<1:100)

post-dural puncture headache

transient or permanent nerve damage (extremely rare)

increased risk of operative vaginal delivery

42
Q

benefits of combined spinal epidural anaesthesia

A

quicker pain relief

option of prolonging with the epidural

43
Q

spinal anaesthesia

A

used for most C sections

reaasier than epidurals

produce dense block

single injection - so may wear off if the procedure is lonh (>2hrs)

more profound hypotension than an epidural

44
Q

summarise regional anaesthesia

A

regional anaesthesia is split into peripheral nerve blocks or neuraxial anaesthesia

aim is to reduce nerve conduction of painful impulses to higher centres via the thalamus where the perception of pain occurs

either used alone or as a supplement to GA by gibing prolongued and effective postoperative analgesia

especially useful for operations on the lower limbs and abdo where avoidance of GA is preferable because of co-morbidities (cardiac and pul)

may still cause loss of airway and need same resus fascilites as for GA

locating peripheral nerves need US or peripheral nerve stimulators to minimise nerve trauma and maximise success rates

45
Q

continuous regional anaesthesia

A

involves placement of a catheter near nerve to allow continuous delivery of LA, as compared to a single dose of LA

46
Q

adrenaline with LA

A

slows systemic absorption of LA = increases LA duration

useful in areas of increased vascularity eg intercostal blocks where risk of systemic absorption is higher

systemic effects from adrenaline are especially hazardous in CVS disease or raised BP

contraindicated in digital or penile blocks, and around the nose or ears (risk of local ischemia)

47
Q

lidocaine

A

max dose in healthy adult =3mg/kg IBW

48
Q

prilocaine

A

moderate onset, dose is 3-5mg/kg IBW.

MAx 400mg,

low toxicity - drug of choice for bier’s block (IV regional anaesthesia)

49
Q

bupivacaine

A

(t1/2=3hrs) = slow onset and prolonged action.

More cardiotoxic than the others.

CI in bier’s block.

Dose for local infiltration is 2mg/Kg IBW to a max of 150mg

50
Q

levobupivacaine

A

isomer of bupivacaine, less cardiotoxic.

Dose for local infiltration or peripheral nerve block: 2mg/kg (max 150mg).

Use <150mg (use 5–7.5mg/mL solution) for epidural; <15mg for intrathecal.

51
Q

ropivacaine

A

(t1/2=1.8h) dose 2mg/Kg IBW, less cardiotoxic than bupivacaine, less motor block when used epidurally.

CI for IV regional anaesthesia (Bair’s block) and paracervical block in anaesthetics

52
Q

tetracaine

A

(t1/2=1h) slow onset, high toxicity.

eye drops for topical anesthesia and now topically as an alternative to EMLA.

Also available as a gel (combined with adrenaline and lidocaine) for open wounds

53
Q

benefits of regional anaesthesia

A
  • Spinal = less chronic pain after the surgery
  • Better for the patient
  • Less anaesthesia needed
  • Patients recover better
  • Epidural used if long surgery because you can attach a catheter, also top and bottom so pt can mobilise faster
54
Q

administering spinal anaesthesia

A
  • at L3/4 – feel the release of pressure
  • weighted - Need to know what time it goes in so you can test how well it is working.
  • Because weighted can tilt the pt so that the bolus moves so that it is more effective

use in a short op

55
Q

administering epidural

A

reduce tension syringe – when tension reduces know in the epidural space – don’t go further otherwise pierce dura = post puncture headache

  • Skin, subcutaneous tissue, supraspinous ligament, intraspinous ligament, ligamentum flava

use in long operation and post-op

opioids and anaesthetics are given into the epidural space by infusion or boluses

56
Q

conduct of anaesthesia

A

principles - hypnosis, analgesia, muscle relaxation

induction - IV propofol or thiopental, or gaseous sevoflurane or nitrous oxide mixed in with Ox

airway control - facemask or oropharyngeal airway, or intubation - intubation needs muscle relaxation with a depolarising/non-depolarising neuromuscular blocker

maintenance of anaesthesia - either volatile agent added to nitrous oxide ox mix, or high dose opiates with mechanical ventilation, or IV anaesthesia eg propofol

recovery - change inspired gases to 100% ox, stop anaesthetic infusions and reverse muscle paralysis. Extubate when spontaneously breathing - ox by facemask

57
Q

signs of LA toxicity

A

peri oral tingling and paraesthesia

progressing to drowsiness, seizures, coma and cardioresp arrest

Mx - ABC resus, lipid emulsion

58
Q

paracetamol

A

0.5-1g/4hr PO

(up to 4g daily;

15mg/4hr IV over 15mins

in children <50Kg; up to 60mg/kg/d)

caution in liver impairment

59
Q

NSAIDS

A

ibuprofen

  • 400mg/8hr PO
  • for musculoskeletal pain and renal or biliary colic

CI

  • peptic ulcer
  • clotting disorders
  • anticoags
  • in children due to risk of Reye’s syndrome

cautions

  • asthma
  • renal/hepatic impairment
  • HF
  • IHD
  • pregnancy
  • elderly
60
Q

morphine and diamorphine

A

morphine - 10-15mg/2-4h IV/IM

diamorphine - 5-15mg/2-4h PO, SC, slow IV - but may need much more

can give transdermal (once baseline requirements are established) or sublingual

61
Q

CI of opioids

A

hepatic failure

head injury

62
Q

reversal of opioids

A

naloxone (100-200mcg IV followed by 100mcg increments every 2mins until responsive

63
Q

SE of epidural analgesia

A

less because the drug is more localised

watch for resp depression and LA induced autonomic blockade (reduced BP)

64
Q

adjuvant analgesics

A

radiotherapy for bone cancer pain

anticonvulsants

antidepressants

gabapentin or steroids for neuropathic pain

antispasmodics eg hyoscine butylbromide (buscopan 10-20mg/8hr PO/IM/IV) for intestinal or renal tract colic

if brief pain relief needed - inhaled NO2 with 50% O2 as entonox with an on-demand valve

Transcutaneous electrical nerve stimulation (TENS), local heat, local or regional anaesthesia, and neurosurgical procedures (eg excision of neuroma) may be tried but can prove disappointing.

DPD (38 decks)

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