Anesthesia and comorbidities

Question 1

what are the effects of DM on CVS

Answer 1

1. Myocardial infarction
2. Hypertention
3. iscahemic heart disease
4. Cardiomyopathy
5. Cerebrovascular acccident

Question 2

What are the effects of DM on the Nervous System

Answer 2

Increased risk of stroke
autonomic and peripheral neuropathy

Question 3

What are the effects of DM on Respiratory system

Answer 3

increased risk of perioperative chest infections

Question 4

Effectsof DM on GIT

Answer 4

Gastroparesis-reflux

Question 5

effects of DM on renal

Answer 5

increased risk of renal failure

Question 6

effects of DM on musculoskeletal

Answer 6

Stiffening of ligaments around the joints leading to limited mobility and cause proteolysis which affects wound healing

Question 7

In a patient with DM what’s important in preop assessment

Answer 7

FBC
HBA1C
U&Es
Cr
ECG
Urine protein

Question 8

intra op what’s the blood glucose level are we targeting

Answer 8

6 and 8

Question 9

which group is treated as minor surgery

Answer 9

if the patient is expects to eat within 4 hrs of the operation

Question 10

management of well controlled dm/minor surgery/normal fbs

Answer 10

Non insulin dependent diabetics:
First on the list
Omit oral hypoglycemics
Blood sugar monitoring:
- 1 hr pre-op
- at least once intra-op or every hour if procedure extends more than an hour
Post op 2 hourly until eating, then 8 hrly

Insulin dependent diabetics: type 2/type 1
First on the list
Omit normal sc insulin if glucose<7mmol/l
Give half normal insulin if glucose > 7mmol/l
Blood sugar monitoring:
- 1 hr preop
- atleast once intraop
-Post op 2 hourly until eating, then 4 hrly
Restart normal sc insulin with first meal

Question 11

management for major surgery

Answer 11

Plan includes patients for minor surgery whose admission blood glucose is > 7mmol/dl
Check blood sugar and potassium pre-op
Omit oral hypoglycemics or normal sc insulin
Start on IVF
Start IV insulin sliding scale (in the ward)
Blood glucose measurement:
-2 hourly from start of sliding scale
- hourly intraop
-Hourly post op until 4 hrs then 2 hrly.

Question 12

PERIOPERATIVE RISKS ASSOCIATED WITH SEVERE UNTREATED HTN

Answer 12

Associated with serious post op complications e.g MI, Cerebral hemorrhage/infarction, renal failure

Question 13

PRE-OP CONSIDERATIONS TO MAKE in a patient with HTN

Answer 13

Is the HTN primary or secondary?
Is the surgery urgent or not?
Is regional anaesthesia possible for the proposed surgery or not?
Does the patient have any evidence/signs of end organ damage?
Stage 1 and 2 HTN should not be delayed surgery

Question 14

Pre-op antihypertensive management need not to be interrupted except for the following medications:

Answer 14

ARBs
ACE inhibitors

Question 15

ISSUES TO CONSIDER WHEN ADMINISTERING ANEASTHESIA TO EPILEPTIC PATIENTS

Answer 15

Many antiepileptic drugs induce liver enzymes that can lead to reduced activity/ duration of action of anaesthetic drugs
Avoid hyperventilation as it leads to hypocarbia causing reduced blood flow
Avoid prolonged starvation to minimize metabolic disturbance

Question 16

DRUGS TO AVOID IN EPILEPTICS

Answer 16

Ketamine due to dissociative anesthesia
Propofol thought to cause postoperative seizure-like activity ( controvesial)
Methohexitone- related to Thiopentone but precipitates seizures in epileptics

Question 17

ANEASTHETIC DRUGS OF CHOICE IN EPILEPITICS

Answer 17

Thiopentone- can be used for status epilepiticus as well
Majority of inhalation agents except Enflurane

Question 18

in an asthma patient during preop assessment its important to ask ..?

Answer 18

Ask about triggers including drugs eg. Aspirin, latex products
Exercise tolerance
Signs of URTI- may need to postpone elective surgery if present.
Last acute attack/admission

Question 19

INVESTIGATIONS ini asthma patient preoperatively

Answer 19

Peak flow: Serial measurements are more informative than a single reading
Response to bronchodilators
Spirometry
Blood gases in severe asthma particularly prior to major surgery

Question 22

what drugs should be avoided in asthma patients

Answer 22

Avoid drugs associated with histamine release ( morphine, atracurium, mivacurium

Question 23

PERIOPERATIVE RISKS IN POORLY CONTROLLED ASTHMATIC PATIENTS

Answer 23

Have increased risk of:
-bronchospasms
-sputum retention
-atelectasis
-infection
-respiratory failure
Need to ‘hold’ elective surgeries until the patient is stable

Question 24

SAFE ANAESTHETIC DRUGS IN ASTHMATICS

Answer 24

Induction agents- Propofol, Ketamine, Midazolam, Etomidate
Opioids-Pethidine, fentanyl, alfentanyl
Muscle Relaxants- Vecuronium, suxamethonium, rocuronium, pancuronium
Volatiles- Halothane, isoflurane, enflurane, ether ( Nitrous oxide