Extra From Class Flashcards
What are the four DAS plans?
A: face mask ventilation and tracheal intubation
B: maintain oxygenation - SAD
C: face mask ventilation
D: emergency front of neck access
What is DAS plan A?
Face mask ventilation and tracheal intubation - optimise position - pre O2 - adequate NMB - direct/video laryngoscopy (3+1) - external manipulation (BURP) - bougee - remove cricoid - maintain O2 and anaesthesia Success --> confirm capno Fail --> declare failed intubation
What is DAS plan B?
Maintain oxygenation: SAD - 2nd generation - change device or size (max 3) - O2 and ventilate Success --> wake, intubate via SAD, proceed on device, Trache/crico Fail --> declare failed SAD
What is DAS plan C?
Face mask ventilation - if can't - paralyse - final attempt - 2 person technique with adjuncts Success --> wake Fail --> declare CICO
What is DAS plan D?
Emergency front of neck access
- scalpel bougee
- call for help
- 100% O2
How is a scalpel bougee technique performed?
Help 100% O2 upper airway Ensure NMB Position to extend neck Laryngeal handshake to ID membrane Transverse stab with scalpel Turn blade 90 degree caudal (sharp) Slide bougee tip along blade into trach Railroad lubricated 6.0 Parker ET Ventilate, cuff up and confirm Secure in place
What is is a scalpel bougee pack?
Scalpel size 10
Bougee
6.0 Parker tip
Chlorhexidine swab
How is the scalpel bougee technique handled in a non-palpable neck?
8-10cm vertical incision caudad to cephalad
Blunt dissect with fingers to separate tissue
ID and stabilise larynx
Continue as with palpable neck
What is the post op care following a DI?
Make airway management plan Monitor for complications Complete airway alert form Explain to patient Send report to GP
What is the post op care following cricothyroidotomy?
Postpone surgery unless life threatening
Urgent surgical review of site
Document and follow up as in DI
What is the cuff and collar system?
On a sleeve index system
Ring placement and diameter is individualised for each gas on the gas hose and bollard connector
Outlet sleeve and corresponding groove on hose can couple
What must you know about the anaesthetic agent in order to make a safe vaporiser?
SVP: in order to know what splitting ratio is required
MAC: in order to know range for the dial
How does ET control differ from simply setting a vaporiser?
On ET the machine varies the amount of vapour delivered so that the ET is always the same even if the exhaled amount or circulating flow changes. If simply set then the same amount is constantly delivered but may differ in circulation due to changing flow rates. You may deliver much less.
Why is ET better measurement than Fi?
ET reflects patient blood level well and is easier to measure.
What are the valves on an ambu bag?
End:
+p valve (outside) to relieve
-p valve to entrain
One way valve so gas goes forward when squeezed
Front:
Duckbill valve: open on insp and close once delivered, pulls back on refill to prevent air entrainment and ensure expiratory gases flow out peep valve. One way valve prevents expiratory gas entering bag.
How does the aisys anti hypoxic system work?
Programmed not to allow a mix of less than 25% O2
Electronic system
Cannot select a mixture less than 25%
Gas analyser alerts if occurs
What is a total spinal?
High dose LA in the CSF causing it to travel high and block vital pathways. Intercostals/diaphragm get blocked Tingling arms/hands Dyspnoea Hypoxia Hypotension Blocked nose (sympathetic vasoD) Reduced conscious state
What is intra osseous?
Into bone marrow Non-collapsible Systemic venous access Compares to IV for dosing For emergencies, difficult IV and paediatrics Lasts 24 hours Can deliver drugs and fluids Hand bolus or P bag fluids
What are the general principles to placing an IO?
Prep skin prior Consider LA Appropriate needle Push needle through skin to bone The IO hub has a black line which should be visible above the skin prior to penetrating the bone (good size) Pull trigger and apply pressure until a change in R is felt Remove stylet; needle should be firm Secure with supplies dressing Attach flushed EZ connector Aspirate for marrow/blood Flush IO before use (ensure no oedema) Need pressure bag for fluids
How is an IO placed for proximal tibia?
Adult: 3cm below patella 2cm medial along flat aspect Paed: 1cm below and 1cm medial along flat aspect
How is an IO placed in the proximal humerus?
Place patient hand on abdomen to get 90degree at elbow
Palpate for “ball”
Locate surgical neck (ball on tee)
1-2cm higher than the neck is the greater tubercle and this is insertion point
Aim 45 degree down and drill until hub meets skin
What areas can the IO be placed?
Antero-medial tibia
Distal tibia
Distal anterior femur
Proximal humerus (superior site for speed and flow rate)
Proximal/distal ends of long bones where spongy bone exists
Sternum not ideal!!!
What are the risks of IO?
Extravasation of fluid or drug into tissue Compartment syndrome Necrosis Infection Fracture Growth plate injury Fat microemboli
What are the contraindications of IO?
Fracture in bone Absence of landmarks Infection at site Previous attempt on same bone within 48 hours Osteoporosis or other bone disease Elderly high risk fracture
What is an AED?
Delivers electrical energy to heart to simultaneously depolarise cells to allow stable rhythm to establish
Automated external defibrillator
What are the properties of modern AED?
DC energy: more effective, less damage, less arrhythmia
Transformers (to increase V) converters (turn AC to DC) and capacitor (store)
Biphasic: electrical current in one direction for set time then reverses for remaining time. Optimal delivery. Uses less peak current so low damage
What is a cheat drain?
Into the pleural space
Drains air, blood and reinflates lung
Air tight system with underwater seal allows air exit without re-entry
Chamber kept 100cm below cheat to maintain -P
If lifted, fluid can siphon into chest
Oscillations indicate patency. Absence may indicate blocked, kinked, lost -P or lung has fully re-expanded
How does a paediatric airway and respiratory system differ to an adult?
Narrow at cricoid vs glottis Large structures Larynx C2-C3 anterior vs C3-C6 Fast/slow and deep/shallow cycle 7-10ml/kg vs 10ml/kg Low FRC High RR: 24- (age/2) 2x the metabolic rate
How does the paediatric CVS system differ to that of an adult?
Higher compliance Large blood volume (80ml/kg vs 70) More TBW (75-80% vs 55-60%) Higher hb >130 Higher HR >60 Lower BP (sys= 80 + (agex2) Higher CO
Why do paeds desaturated quickly?
Reduced alveolar cluster Underdeveloped intercostals CC within TV Low FRC High metabolic rate
What other body systems are considered in paeds for anaesthetic?
Immature liver and kidney function Low carb stores so hypoglycaemia occurs BBB more permeable to agent Thermoregulation: high SA to volume Minimal SC fat Reduced vasoC and shiver mechanism Brown fat metabolism in infants to produce heat - high energy and O2 use
What are the paediatric emergency drug doses?
Suxamethonium
1-2 mg/kg (-3 for IM)
Atropine
10-20 mcg/kg (-30 for IM)
Adrenaline
10 mcg/Kg IV/IM
What is the normal CO2 range?
35-45
> 45 is hypercarbia
<35 is hypocarbia
What can cause a high CO2?
Hypoventilation Hyperthermia/sepsis Tourniquet release High CO Bronchial intubation Soda lime exhausted
What can cause a low CO2?
Hyperventilation
Reduced CO (caution not treading to arrest/PE)
Hypothermia
System leak
What can cause an inclined plateau on CO2 trace?
Obstructive lung disease
Blocked airway/tube
Aspiration, spasm, anaphylaxis
What can cause a raised CO2 baseline?
Exhausted like Rebreathing Sticky valves Insufficient FGF Excessive dead space
What can cause decreasing co2?
PE
Cardiac arrest
Tamponade
What does oesophageal and bronchial intubation look like on CO2?
Oesophageal:
Small ETCO2 dropping off
Bronchial:
A bifid wave noticed in phase III
What are the phases of CO2 tracing?
1 is the baseline and is end inspiratory phase
2 is the upstroke and is expiration
3 is the alveolar plateau
0 is the downstroke and is the beginning of next inspiration
What are the problems and considerations for prone patients?
High IOP
Difficult airway access
Risk optical nerve/retinal damage resulting in blind
Reduced abdominal compliance limiting diaphragm movement
High airway pressure/reduced vent
Neutral neck position
Neutral shoulders and elbow position
Pressure: genitals, breasts, knees, feet, nose and eyes
What are the problems and considerations for patients in lithotomy or Lloyd Davis position?
Reduced perfusion to legs Increased venous return Pooling/DVT legs Compartment syndrome legs Pressure: peroneal, sciatic nerves Hips should be >90 degrees to body
What are the problems and considerations for patients in lateral position?
Care with lower shoulder - axillary roll for brachial plexus Front and back support at hips to protect and away from abdomen Support upper arm in neutral position Lower arm in neutral/safe position Pillow between knees Pad lower foot Neutral neck Limited airway access
What are the problems and considerations for patients in beach chair position?
Air embolism Stroke/brain injury hypoxic BP reading inaccurate: head is higher than heart Neutral and strapped head/neck Limited airway access Ensure eyes well taped Arm supports padded and at correct height Sciatic nerve Pooling/DVT in legs Reduced venous return
What are the problems or considerations when a patient is head down?
Good venous return
Good brain perfusion
Aspiration protection
Reduced ventilation/high pressures
Low FRC, atelectasis, V/Q mismatch
Likely regurgitation
High ICP/IOP
What are the problems and considerations for head up positions?
Optimal lung compliance
Low CO
Brain injury risk
DVT/pooling in legs
Air manolis M
What is the range for a cuff pressure monitor?
14-24 cmh2o
Keep below 30
Why are uncuffed tubes better in paeds historically?
The narrowest point of the paed airway is the cricoid cartilage and this is where the cuff sits. If damage occurs then swelling could occur I.e causing narrowing of the already narrowest point!! Small airway means small swelling causes closure.
In an adult the narrowest point is the cords and the cuff sits below this therefore doesn’t matter so much
Why is PCV best for paediatrics?
(12-15cmH2O)
Less trauma risk
Compensate for a leak around an uncuffed tube
What is the chest depth, bpm and joules for CPR?
1/3 chest
100 bpm
200J (360 next shock)
What are the differentials to MH?
Sepsis
Thyroid storm
Drug use
Inadequate anaesthesia
How do you change gas cylinder?
Slowly close valve Release remaining P and close Wipe new cylinder; clean hands Check content via label Ensure cylinder restrained Check regulator valve matches cylinder Remove seal and crack cylinder Check intact heat detection tag Ensure regulator clean and attach it Open slowly to full position then closed one quarter turn
What is the process for body fluid exposure and needle stick injury?
Report to coordinator Wash area with soap and water Obtain testing kit Complete the form Test staff members blood Test patients blood (CONSENT) Complete lab forms for tests - send Complete accident form Entry in patients notes (If known HIV+ contact infectious diseases for prophylaxis)
What is an example of isbar?
Identify Self, patient and site Situation What is going on? (DI) Background Clinical background (op, stats) Assessment What do I think problem is Recommend What I recommend, assign responsibility, any risks
What are the 10 standard precautions?
Hand hygiene Gloves Gown/apron Face protection (mask, goggle) Care with sharps Respiratory hygiene/cough etiquette Environmental cleaning Linen Waste management Reprocessing reusables
What are three examples of supine?
Mastectomy
AAA
Appendix
What are three examples of lateral?
Lobectomy
THJR
Nephrectomy
What are three examples of prone?
Spinal fusion/decompression
Posterior fossa surgery
Percutaneous stone removal
Achilles’ tendon repair
What are three examples for beach chair?
Total shoulder replacement
Craniotomy
ORIF humerus
What are three examples of Lloyd Davis?
Hartmans
Anterior resection
Vaginal hysterectomy
What are three examples of lithotomy?
Haemorrhoidectomy
TURP
Ureteroscopy
Draw a circle circuit.
-
What is normal Hb?
115-155 g/L
What is normal ACT?
80-120 seconds
>480 for bypass
What is normal CVP?
0-8 mmHg
What is normal glucose?
4-8 mmol/L
What is normal INR?
0.8-1.2
The higher the number the thinner the blood
10 things to consider for a known MH case.
First on list TIVA Remove triggers Flush machine Replace consumables Vapour free filter Keep high flows for 90min MH box in theatre Insert temp probe Team awareness/plan
10 things to consider for blood administration.
Consent X match sent? Correct form complete 2 person checking Product correct, in date, viable Warming Filter Document correctly Rate of infusion Standard precautions:glove, biowaste
Who is susceptible to latex allergy?
Healthcare workers Cerebral palsy Spina bifida Atopic people Allergy to banana, kiwi, avocado
What are physical indicators?
Part of the steam steriliser
Record readings from inside
What are chemical indicators?
Patches/tape which are heat or chemical sensitive and change colour when the conditions are met
Eg Bowie Dick in the steam steriliser
What are biological indicators?
Inoculated strip on non-pathogenic bacteria with similar life conditions to those harmful
What are methods of disinfection?
Thermal wash:
Jets of hot water/soap
Chemical:
Eg glutaraldehyde
Pasteurisation:
High heat
Why hand hygiene before and after glove use?
Maybe punctured
Hot and moist hands breed organisms
Can contaminate upon removal
When do gloves need changing?
Between procedures
Between patients
When defected
When going from dirty to non-contaminated area (patient to drug trolley)
Why use gowns or eye protection?
If in close contact occurs
When splashes of fluids may occur
What are transmission based precautions?
To be used in addition to standard precautions when a patient is confirmed or suspected to be colonised by organisms transmissible via contact, droplet or airborne routes
What are contact precautions?
Spread by direct or indirect contact with patient or environment
MRSA
Scabies
Excessive wound drainage
Noro or rotavirus
What are droplet precautions?
Spread by close respiratory or mucus membrane contact with respiratory secretions
Flu
Pertussis
Meningococcal
What are airborne precautions?
Remain infectious over long distances when suspended in air and transmitted by inhaling those airborne particles
Chicken pox
Measles
TB
What are isolation precautions?
For patients who are immune suppressed
Eg bone marrow transplant patients
What is the PPE for contact precautions?
Anti microbial soap or alcohol hand rub Gloves Gown Red linen bag (water soluble liner) Infectious waste - inside room Alert receiving area Disinfect environment
What is the PPE for droplet precautions?
Normal soap or alcohol hand rub Gloves Gown as per standard precautions Surgical mask on entry and exit Red linen bag Infectious waste - inside room Disinfect environment Alert receiving area - pt wear mask
What is the PPE for airborne precautions?
Normal soap or alcohol hand rub Gloves Gown per standard precautions Particulate respirator mask (N95) on prior to entry and remove after leaving Normal linen Normal waste Alert receiving area - pt wear mask Normal environment cleaning
What is the PPE for protective isolation?
Normal soap or alcohol hand rub Gloves Gown as per standard Don't need mask Normal linen Normal waste Alert receiver - pt wear N95 Clean equipment before use
What are some other points to consider in transmission precautions?
Minimise entry/exit Minimum people Minimum equipment Minimise time in the room Have a 'clean' helper
What is the general rule for where to put on and remove PPE?
Put on outside and remove inside prior to leaving
Except for N95 mask
Hand hygiene before exit
If transporting body fluid, wait and remove in sluice room
What is important about the N95 mask?
It must be fitted correctly
Ensure this prior to entering room and do not remove until exited
What is the sequence for PPE on?
Gown
Mask
Goggle
Glove
What is the sequence for PPE off?
Glove (treat outside of glove as dirty, roll into a ball)
Goggles (remove by ends of handles)
Gown (unfasten and pull away from neck touching inside only, turn inside out and roll up)
Mask (only touch the ties)
What solution should be used for cleaning?
Disinfection only required for contact or droplet precautions
Use presept or chlorwhite
What is MRSA?
Methicillin resistant staphylococcus aureus
Skin and mucus mems
May cause infected skin lesions
Any patient having a procedure should be screened
Decolonisation treatment exists
Hospital elsewhere within 2 years treated as precautions
3 sets of swabs must be clear (24hr between)
What is ESBL?
Extended spectrum beta-lactamase producing organism
GI inhabitants
Inactivates penicillin
Low risk (standard precautions)
High/mod risk: any incontinence, stoma, catheter, large wounds, trache
Any ESBL klebsiella - high risk
What is VRE?
Vancomycin resistant enterococci
Intestine inhabitants
What is the age of consent?
Not defined
Must be competent and have the capacity to do so and it is assumed that near 16 they are
Depends on procedure, risks and maturity of person
Why is subtenon better than peribulbar?
More appropriate in long axial length and anticoagulated patients
How long should hand hygiene take?
30s ABHR
60s soap and water
What’s the default P setting for jet vent?
1 bar or 15 psi
1 bar = 100 kPa
(1 kPa = 10 cmH2O)
What’s the amps for a manual nerve stimulator?
About 70 mA
30-80 mA in Oxford
What can be done if the spinal or epidural for a Caesarian section is not sufficient?
Prior to start:
Either re-site an epidural or repeat the spinal. Otherwise try the other technique or GA
Intra op:
N2O, IV opioid, surgical infiltration or GA
Why is GTN useful in obstetrics?
It relaxes the uterus making surgery easier
What are the bougee sizes?
14 Fr
10 Fr
6 Fr
What is in the sign in?
Lead by anaesthetist
Before induction
Confirm pt, procedure, site and side Allergies Difficult airway G&S/blood available Special equipment available
What is in the time out?
Lead by surgeon
After position; before incision
Team introductions Reconfirm pt, procedure, site and side Correct imaging Other drugs Intra-op DVT prophylaxis Concerns/anticipated events
What is in the sign out?
Lead by nurse
Before patient leaves
Count correct Correct procedure recorded Specimens labelled/sent Post operative DVT Equipment issues Concerns for post-op management
What is in the obstetric sign in?
Lead by anaesthetist after OT arrival (nurse for cat1)
Patient confirms ID, procedure, consent Category displayed NICU called Allergies Difficult airway G&S or blood available
What is in the obstetric time out?
Lead by surgeon before incision
Team intro
Reconfirm pt and procedure
AB given?
Concerns or anticipated events
What is in the obstetric sign out?
Lead by nurse before pt leaves
Counts correct Correct procedure recorded Specimens labelled/sent Post-op VTE prophylaxis Equipment issues Post-op concerns
How do u fit an N95 mask?
Wash hands
Cup in hand and place on face - under chin to nose
Top elastic on then bottom one
Mould metal around nose
With hands covering front of mask perform leak test by breathing out sharply and feeling for any leak around nose or sides. Reposition/pinch nose piece and repeat seal test
What is the alternate oxygen control?
Turns on when there is an electronic gas mixer failure. It has an independent pathway via the vaporiser to the circle with gas being controlled by the alternate flowmeter manually. AA may be useable depending on the nature of the failure.
Also use in an ASD screen fail
Automatic and manual activation
What is HIV and the precautions?
Human immunodeficiency virus
Transmission via blood/body fluid
Standard precautions
What is hepatitis and the precautions?
Inflammation of the liver
Viral
Transmission via blood/body fluid or faeces
Standard precautions
Contact for type A incontinence
What is CJD and the precautions?
Creutzfeldt -Jacob disease
Affects brain tissue
Transmission via contact with CNS tissue
Normal reprocessing; yellow waste; disinfect
Mask, glove, apron with yellow gown over, visor
What are the common problems with one lung ventilation?
A shunt
Hypoxia
Adjust settings to optimise O2 and CO2
PEEP to lung to optimise
Ongoing hypoxia not appropriate
What products cannot be put through the rapid infuser?
Platelets and cryoprecipitate
What are arytenoids and faucial pillars?
Arytenoids are cartilage which help cords move
Faucial pillars are muscle folds which help swallowing
What is bipap?
Bilevel positive airway pressure
Set level on pressure on inspiration with less pressure on expiration so expiring is easier
What do u need for an epidural?
Sterile PPE Spinal tray Skin prep LA, syringe and filter needle Saline 2xIV3000 and mefix
How is laryngoscope blade cleaned?
Disassembled
Thermal wash
Autoclave
What is hellp?
Associated with pre eclampsia
Haemolysis, elevated liver enzymes, low platelets
How does Das for obstetrics differ?
RSI
2+1 for plan A
Plan B is SAD (Max. 2) or face mask
Plan C is CICO (exclude laryngospasm first)
What are some factors which determine whether to proceed or wake an obstetric patient?
Maternal condition Fetal condition Expertise of anaesthetist Obesity Surgical risks Fasting status
What are the general steps to Das extubation?
Plan Prepare Low risk (awake or deep) or high risk algorithm (Awake only or postpone/Trache) Recovery HDU / ICU
What does RACE stand for?
Rescue/remove
Activate alarm
Confine
Extinguish/evacuate
What is allens test?
To assess arterial supply prior to cannulation
Hand is held up and clenched for 30 seconds
Both arteries are occluded
Hand open - should appear blanched
Ulnar pressure released while maintaining radial pressure
Colour should return otherwise don’t cannulate this radial artery
What is on the anaesthetic assistant MH task card?
MH box Art line CVL Soda lime Restock drugs
Trauma set up
See notes
Obstetric set up
See notes
Paediatric set up
See notes
Regional block set up
See notes
MH case set up
See notes
Write out the MTP algorithm
See notes
What is the standard for SOP?
Work within SOP
Responsible for the safety of others
ANZCA/NZATS
Promote quality assurance
Practise that protects from harm
What is the standard for professionalism?
Responsible for own practice
Promote equality
Comply with HDC, treaty and cultural needs
What is the standard for roles and responsibilities?
Provide dedicated professional, technical and clinical assistance.
Work in partnership
Systematic approach
What is the standard for Professional development?
Be committed to CPD
Attend education
Member of professional group
What are the four nzats standards?
Professionalism
SOP
Professional development
Roles and responsibilities
What is critical, semi-critical and non-critical?
Critical: penetrates the skin, membranes or vascular network or parts normally sterile - STERILISE
Semi: contact with membranes/body fluid - DISINFECT/STERILISE (ours!!)
Non: touched in tact skin only
10 considerations for MRSA
Last on list Signs outside OT Alert PACU Reduce equipment in room Reduce people in room Get a clean helper PPE on before contact; off before exit Yellow waste Water soluble linen bags Disinfect environment
What is in a suxamethonium ampoule?
100mg in 2ml
50mg/ml
What is in a atropine ampoule?
600mcg in 1ml
What is in an adrenaline ampoule?
1mg in 1ml
OR
1mg in 10ml (100mcg in 1ml)
Why are the blood universals the way they are?
RBC is O-
These have no surface antigens for the recipient to attack
Plasma is AB
These have no antibodies that will attack the recipient
How long can fluids be in the warmer and what’s the purpose of the outer packet?
2 weeks
To show that it hasn’t been tampered with
Why is CJD extra concerning and what should be done regarding cleaning?
It has prions which are very hard to destroy
Destroy all instruments and consumables
What is high vs low level disinfection?
Low level cannot kill mycobacterium
High level will kill everything except the spores
What’s the process for unconsented emergency blood?
Two doctor consent but should attempt to obtain the views of the patient
What are the steps to a blood product check prior to transfusing?
Two person check:
- Patient ID
Wrist bracelet against the consent and product form
- Consent
Consent is correct and agreed
- Blood product
Correct patient, product, type, batch number, expiry date and looks good
What does the guardian of the box do?
Signs to receive the box on the card attached
Checks the forms match the ID on the box
Selects products for checking
How long do charcoal filters last and what’s the flush time for preparation vs crisis?
12 hours
Machine preparation flushing is 10 L/min
Crisis flows are 15 L/min
What are the ‘during CPR’ considerations?
IV/IO Airway adjunct Oxygen Capnography Minimise interruption
