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Yr 4 - ACC > Corrections - Anaesthetics > Flashcards

Corrections - Anaesthetics Flashcards

1
Q

What is suxamethonium apnoea?

A

There is a deficiency in the enzyme that breaks down suxamethonium –> can lead to prolonged airway paralysis (can be several hours when normal time of sux. apnoea is 5 minutes).

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2
Q

Length of action of suxamethoium?

A

2-6 minutes

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3
Q

Mechanism of suxamethonium?

A

Mimics acetylcholine at the neuromuscular junction, binding to the post-synaptic membrane of the junction (preventing acetylcholine from binding).

NON-competitive binding.

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4
Q

Can suxamethonium be reversed?

A

No

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5
Q

Can non-depolarising muscle relaxants be reversed?

A

Yes:

1) cholinesterase inhibitors e.g. neostigmine

2) sugammadex

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6
Q

Effect of anticholinesterases such as neostigmine on suxamethonium?

A

These PROLONG the action of suxamethonium.

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7
Q

Presentation of suxamethonium apnoea?

A

Usually not apparent until it is time to wake the patient up.

At the end of the procedure the patient:

  • makes little effort to cough or breathe spontaneously
  • HR and BP rise
  • may sweat
  • pupils may dilate

This happens because the patient becoming aware but
is still paralysed.

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8
Q

Management of suxamethonium apnoea?

A

1) Neuromuscular
transmission should be monitored with a nerve stimulator.

2) Keep patient anaesthetised and ventilated.

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9
Q

Cause of suxamethonium apnoea?

A

Pseudocholinesterase deficiency

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10
Q

What type of respiratory failure can MND cause?

A

Type 2 (poor ventilation due to muscle weakness, leading to a build up of carbon dioxide and an acidosis).

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11
Q

What reading is used to confirm intubation?

A

End-tidal CO2

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12
Q

What are some signs of a basal skull fracture?

A

1) Periorbital ecchymosis (raccoon eyes)

2) CSF rhinorrhoea

3) Haemotympanum (presence of blood in the middle ear cavity)

4) Mastoid process bruising (battle’s sign).

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13
Q

What do dropping sats post-intubation indicate?

A

Oeseopageal intubation

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14
Q

What complication can long-term intubation result in?

A

Can result in physical communication between the trachea and the oesophagus due to the proximity of the structures and inflammation around the tube in the trachea –> tracheo-esophageal fistula.

Presents with choking after feeds.

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15
Q

What is the max number of doses of IV benzos that can be administered during convulsive status epilepticus?

A

A maximum of two doses

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16
Q

What is the only available specific and effective treatment for malignant hyperthermia?

A

IV dantrolene

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17
Q

What ASA grade is a patient who is a smoker but no medical conditions?

A

ASA II

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18
Q

What ASA grade is a patient who is a social alcohol drinker but no medical conditions?

A

ASA II

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19
Q

What ASA grade is a patient who has a BMI of 30-40?

A

ASA II

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20
Q

What ASA grade is a patient who has a BMI of >40?

A

ASA III

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21
Q

What ASA is a patient with well-controlled Diabetes Mellitus or HTN or mild lung disease?

A

ASA II

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22
Q

What ASA is a patient with poorly-controlled Diabetes Mellitus or HTN?

A

ASA III

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23
Q

What ASA grade is a patient with COPD?

A

ASA III

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23
Q

What ASA grade is a patient with alcohol dependence or abuse?

A

ASA III

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24
Q

What ASA grade is a patient with an implanted pacemaker?

A

ACE III

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25
Q

What ASA grade is a patient with a history of MI (>3 months)?

A

ASA III

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26
Q

What ASA grade is a patient with end stage renal disease?

A

ASA III

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27
Q

What ASA grade is a patient with a history of MI (<3 months)?

A

ASA IV

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28
Q

What ASA grade is a patient with sepsis?

A

ASA IV

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29
Q

What ASA grade is a patient with a ruptured AAA?

A

ASA V

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30
Q

Mechanism of lidocaine?

A

Blockage of sodium channels, disrupting the action potential.

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31
Q

How do you calculate a BMI?

A

Weight (kg) / height (m2)

E.g. man weighs 100kg and is 170cm tall

100 / 1.70^2 = 34.6

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32
Q

Where should a patient with diabetes be put on the operating list of the day?

A

Patient should be put first on the list to prevent complications of poor glucose control.

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33
Q

What investigations may be considered prior to elective surgery?

A

1) Consider pre admission clinic to address medical issues.

2) Blood tests including FBC, U+E, LFTs, Clotting, Group and Save

3) Urine analysis

4) Pregnancy test

5) Sickle cell test

6) ECG/ Chest x-ray

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34
Q

During an A-E situation, if you cannot get peripheral IV access within 2 minutes of presentation, what should you do?

A

Call a trained individual to attempt intraosseous access.

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35
Q

What is a potential, and serious, cause of new onset atrial fibrillation following gastrointestinal surgery?

A

An anastomotic leak

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36
Q

How soon post-op does an anastomotic leak usually present?

A

5-7 days post-op

37
Q

How can an anastomotic leak cause post-op AF?

A

Can cause systemic inflammation, which sensitises the pacemaker cells.

38
Q

How can an anastomotic leak be diagnosed?

A

Abdominal CT

39
Q

When should COCP be stopped prior to surgery?

A

4 weeks

40
Q

Mechanism of depolarising neuromuscular blocking drugs?

A

Binds to nicotinic acetylcholine receptors resulting in persistent depolarisation of the motor end plate.

41
Q

Mechanism of non-depolarising neuromuscular blocking drugs?

A

Competitive antagonist of nicotinic acetylcholine receptors

42
Q

Examples of non-depolarising neuromuscular blocking drugs?

A

Tubcurarine, atracurium, vecuronium, pancuronium

43
Q

What are the 2 key adverse effects of suxamethonium (Succinylcholine) i.e. a depolarising neuromuscular blocking drug?

A

1) Malignant hyperthermia

2) Hyperkalaemia (normally transient)

44
Q

What is the key adverse effect of non-depolarising neuromuscular blocking drugs?

A

Hypotension.

45
Q

Reversal agent of suxamethonium?

A

None

46
Q

Reversal agent of non-depolarising neuromuscular blocking drugs??

A

Acetylcholinesterase inhibitors (e.g. neostigmine).

47
Q

What is the muscle relaxant of choice for rapid sequence induction (RSI) for intubation?

A

Suxamethonium

48
Q

Give 2 contraindications for suxamethonium

A

1) penetrating eye injuries
2) acute narrow angle glaucoma

As suxamethonium increases intra-ocular pressure (IOP).

49
Q

Are CXRs routinely recommended before surgery?

A

No

50
Q

Which 4 classes of drugs impair wound healing?

A

1) NSAIDs

2) Steroids

3) Immunosupressive agents

4) Anti neoplastic drugs

51
Q

How should surgical wound be cleaned post-op?

A

Up to 48h post-op –> use sterile saline

Over 48h post-op –> patient can shower

52
Q

When should you consider a physiological systemic inflammatory reaction in post-op pyrexial patients?

A

Usually within a day following the operation AND no other signs of an underlying cause (e.g. BP, RR etc) i.e. fever is isolated.

A fever in the first 24 hours is most likely the result of an inflammatory response to tissue damage as a result of surgery.

53
Q

Which type of muscle relaxant can cause fasciculations?

A

Suxamethonium

54
Q

Which drug can reverse the action of benzos?

A

Flumenazil.

Since may benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug.

55
Q

Management of post-op ileus?

A

1) NG tube insertion for stomach decompression (symptom control)

2) Nil by mouth

56
Q

Management of local anesthetic toxicity can be treated?

A

IV 20% lipid emulsion

57
Q

Management of warfarin prior to surgery in patients at high VTE risk?

A

Stop 6 days before and commence treatment dose LMWH (this would then be withheld the evening before surgery, and mechanical prophylaxis used).

58
Q

What steroid can be used during the peri-op period for patients that are steroid dependent (i.e. >5mg prednisolone daily)?

A

Hydrocortisone

59
Q

How many mg of lidocaine is there in 20ml of 2% lidocaine?

A

2% means that 2g/20mg of drug are dissolved in 100ml.

2 x 10 = 20

20 x 20 = 400mg

60
Q

Why is Hartmann’s chosen over saline where large volumes of fluids are to be administered?

A

As excessive administration of saline can cause hyperchloraemic acidosis.

61
Q

What are early causes of post-op pyrexia (0-5 days)?

A

1) blood transfusion

2) cellulitis

3) UTI

4) physiological systemic inflammatory reaction (usually within a day following the operation)

5) pulmonary atelectasis

62
Q

What are late causes of post-op pyrexia (>5 days)?

A

1) VTE
2) pneumonia
3) wound infection
4) anastomotic leak

63
Q

What timeline can be used as a broad rule of thumb when determining the most likely causes of post-op fever?

A

Day 1-2: ‘Wind’ - pneumonia, aspiration, PE

Day 3-5: ‘Water’ - UTI (especially if patient was catheterised)

Day 5-7: ‘Wound’ - infection at surgical site or abscess formation

Day 5+: ‘Walking’ - DVT or PE

Any time: drugs, transfusion reactions, sepsis, line contaminations.

64
Q

Management of a post-op anastamotic leak?

A

Call consultant and take patient straight to surgery

65
Q

Via what line should total parenteral nutrition be delivered?

A

Via a central vein e.g. subclavian vein as it is strongly phlebitic.

66
Q

For elective total hip replacement, when should LMWH be commenced?

A

6-12 hours after surgery

67
Q

When should adrenaline alongside LA be avoided?

A

digits & penis as adrenaline can cause ischaemia in these settings

68
Q

How should sulfonylureas (e.g. gliclazide) be managed on day of surgery?

A

Omit on day of surgery.

Exception is morning surgery in patients who take BD - they can have the afternoon dose but omit morning.

69
Q

At what site is interosseous access most commonly obtained?

A

Proximal tibia

70
Q

What is the most appropriate management of insulin dependent diabetic patients who are:

a) undergoing major procedures (surgery requiring a long fasting period of more than one missed meal) or

b) whose diabetes is poorly controlled?

A

Will usually require a variable rate IV insulin infusion (VRIII).

71
Q

What does the ‘time out’ stage of the WHO surgical checklist refer to?

A

The period from induction of anaesthetic but before the first skin incision is made

72
Q

What are the 3 key stages of the WHO surgical safety checklist?

A

1) Sign in

2) Time out

3) Sign out

73
Q

Management of metformin on day of surgery (in surgery in morning) :

1) in patients taking OD or BD

2) in patients taking TDS

A

1) take as normal

2) miss lunchtime dose

74
Q

Why is suxamethonium contraindicated in penetrating eye injuries or acute narrow angle glaucoma?

A

As it raises intra-ocular pressure

75
Q

What is there a deficiency of in suxamethonium apnoea?

A

Pseudocholinesterase

76
Q

What must be given the day prior to a colonoscopy?

A

Laxatives

77
Q

2ary prevention in ischaemic stroke (i.e. after 14 days)?

A

Clopidogrel + statin

78
Q

What blood test can differentiate between a true seizure and a pseudoseizure?

A

Prolactin - levels are raised 10-20 mins after a true generalised tonic-clonic seizure

79
Q

How can myasthenia gravis affect muscle relaxants?

Why?

A

Patients with myasthenia gravis are very sensitive to non-depolarising agents.

Non-depolarising agents work by antagonism of nicotinic acetylcholine receptors in the motor end plate, producing paralysis by their blockade.

The myasthenic patient has fewer available nicotinic receptors due to autoimmune-mediated destruction, meaning that they are more sensitive to non-depolarising blockade.

80
Q

What 2 conditions can increase susceptibility to non-depolarising muscle relaxants (e.g. rocuronium)?

A

1) Myasthenia gravis

2) Lambert-Eaton syndrome

81
Q

How should insulin dose be adjusted on the day before and the day of surgery?

A

Note - this only applies to once daily long acting insulin.

Once daily insulin dose should generally be reduced by 20% on the day before and the day of surgery

82
Q

What is checked before the induction of anaesthesia (i.e. under the ‘sign in’ section)?

A

1) Patient has confirmed: Site, identity, procedure, consent

2) Site is marked

3) Anaesthesia safety check completed

4) Pulse oximeter is on patient and functioning

5) Does the patient have a known allergy?

6) Is there a difficult airway/aspiration risk?

7) Is there a risk of > 500ml blood loss (7ml/kg in children)?

83
Q

What VTE prophylaxis is required in patients underoging an elective hip replacement?

A

Both mechanical and pharmacological methods of VTE prophylaxis.

I.e.:

1) TED stockings once admitted

2) + LMWH (e.g. dalteparin sodium) - 6 hours post-op

84
Q

Which feeding option has a low risk of aspiration and thus safe for long term feeding following upper GI surgery?

A

Feeding jejunostomy

85
Q

How can poor post-op pain management result in pneumonia?

A

Significant pain can restrict patients to a shallow breathing pattern.

Lack of deep breathing is a risk factor for both atelectasis and RTIs.

86
Q

When does VTE typically present post-op?

A

5-10 days post-op

87
Q

What IV access is indicated for patients with long term therapeutic requirements?

A

Tunnelled lines such as Groshong and Hickman lines

88
Q

What is Milrinone?

A

A medication indicated for cardiac support in patients with acute heart failure, pulmonary hypertension, or chronic heart failure.

Mechanism: phosphodiesterase 3 inhibitor.

Action: works to increase the heart’s contractility and decrease pulmonary vascular resistance

89
Q

What class of medication is gabapentin?

A

Anticonvulsant

90
Q

What class of medication is neostigmine?

A

Cholinesterase inhibitor

Role - the reversal of the effects of non-depolarising neuromuscular blocking agents after surgery.

91
Q
A

Yr 4 - ACC (73 decks)

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