Blue Book Topics Flashcards
Perioperative Med - Discuss how to interpret iron studies
1) Check Hb - evidence of anaemia
Discuss the indications for hyperbaric medicine 2019
Air or gas embolism Arterial Insufficiency - central retinal artery occlusion - enhancement of healing in selected wound problems Carbon monoxide poisoning Gas gangrene Compromised flaps/grafts Decompression sickness Refractory osteomyelitis
Contraindications to hyperbaric ? 2019
Absolute
- Untreated pneumothorax
-premature infants - retrolental fibroplasia
-
Bleomycin - increased O2 can lead to irreversable restrictive lung diease.
- Disulfram - blocks production of superoxide dismutase which protects against oxygen toxicity
- Cisplatin - HBOT may increase drug effect at tissues and decrease wound healing.
Relative contraindications: Pregnancy Asthma Thoracic Surgery Empysema with Co2 retention Hx of seizures
Complications of HBOT 2019
Claustrophobia Hypoglycaemia Middle ear barotrauma oxygen toxicity seizure progressive myopia - reverses days - weeks cumulative pulmonary oxygen toxicity pulmonary barotrauma
What is restless leg syndrome? BB 2019
What are the anaesthetic implications?
RLS is a common neurological sensorimotor disorder characterised by the urge to move one’s legs (less commonly trunk and arms).
It is associated with unpleasant paraesthesia deep within the legs during periods or activity and improves with movement.
Affects children and adults . Peak incidence 65yrs
Profound effect on quality of life.
Can be primary or secondary
Primary (idiopathic) - genetic component - autosomal dominant. Mechanism suggested to be dopamine dysfunction and iron deficiency in brain (brain imaging) and iron is a co factor for dopamine and dopamine receptor function.
Secondary -
IDA, pregnancy, renal failure, rheumatic disease
TREATMENT Non Pharm Good Sleep Hygiene - Avoid daytime naps No alcohol and caffiene Exercise Massage
Drugs
Alpha 2 delta ligands - Pregabalin and Gabapentin
- good evidence, though can cause somnolence, dizziness, depression, weight gain.
Dopamine agonists
Parmipexole - positive impact on quality of life
risks - augmentation, nausea, vomiting, fatigue,
ergoline derivatives ( levodopa associated with cardiac valve retroperitoneal , pericardial and pulmonary fibrosis.
Minimal evidence for opioids and benzos
ANAESTHETIC IMPLICATIONS
Continue drug therapy!
Premedication with pregab/benzos may be useful
AVOID Dopamine antagonists - haloperidol, metoclopramide droperidol
AVOID Tramadol - serotonic effect
AVOID SSRI/SNRI/TCA - serotini and dopamine metabolism
Aviod opiod anatagonists - naloxone
Volatiles/ Propofol/Ketamine OK NDMB ok LA ok ondansetron dex ok Oxycodone ok
May not tolerate sedation / LA only
Early mobilisation for symptom relief
Monitor iron levels if worried IDA post op (long term)
Define Post Op Delirum
What is the pathophysiology?
What are risk factors?
BB 2019
DSM-V
1) disturbance in attension and awareness
2) develops over a short time, acute change from baseline and fluctuates over the day.
3) additional disturbance in cognition (language, memory, perception)
4) A and C are not better explained by pre exisiting, established or evolving neurocognitive disorders.
PATHPHYSIOLOGY
exact mechanism not known
accepted that aceute central cholenergic deficiency plays a role
could also be decreased GABA-ergic activity or abnormalities in serotonin or melatonin pathways.
RISK FACTORS PREDISPOSING Age>65 cognitive impairment hearing and visual impairment severe illness Polypharmacy Pooor functional status
PRECIPITATING Surgery - Hip Fracture, aortic surgery, long surgery INfection Hypoxia, Hypercarbia Na low or high renal failure.
What is your perioperative management of delirium? BB 2019
PRE OP Screen eg 4AT or MoCA Educate patient and family Polypharmacy, ETOH use Consider geriatrician referral
INTRA OP No clear evidence on technique Light vs deep not clear Ketamine - no dif but emergence phenomenon Dex MEd - maybe but needs more study Avoid hypothermia Avoid hypotension
POST OP
SCREEN REGULARLY
Pain Relief
Non pharm - sleeping, mobilising , sleep hygiene
