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1
Q

What is the Declaration of Helsinki? (3)

A

Set of ethical principles related to medical research on human participants
Must be:
1. Volunteers
2. Informed consent
3. Wellbeing of individuals overrides population
4. Research only if likely to benefit population

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2
Q

What are the 4 pillars of medical ethics? (4)

A
  1. Beneficence - doing good
  2. Non-malevolence - not doing bad
  3. Autonomy - right to make own decision
  4. Justice - treat fairly, equity not equality
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3
Q

Give an example of a good communication type in pre-hospital care

A

Hand’s off handover

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4
Q

Which risk factors are on Koivuranta’s PONV score?

A

Female gender
Non-smoking status
History of PONV
History of motion sickness
Duration of surgery >60 min

0 = 17% (baseline)
1 = 18%
2 = 42%
3 = 54%
4 = 74%
5 = 87%

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5
Q

Describe the Apfel simplified score

A

PONV scoring system:
Female gender
History of PONV / motion sickness
Non-smoking status
Postoperative use of opioids

0 = 10%
1 = 20%
2 = 40%
3 = 60%
4 = 80%

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6
Q

What is the POVOC score?

A

Scoring system for PONV in children

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7
Q

What are the risk factors in the POVOC score?

A

DASH
Duration ≥30 min
Age ≥3 yr
Strabismus surgery
History of POV in the child or relatives

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8
Q

Provide 3 scoring systems for PONV (3)

A

Koivuranta - Adult
Apfel - Adult
POVOC - Children

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9
Q

Define perioperative high risk

A

> 5% perioperative mortality

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10
Q

Why is establishing risk so important?

A

High risk patients account for12.5% of casesbut80% of perioperative mortality

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11
Q

What were the main NCEPOD (2011) findings for “high risk” patients

A

“High risk” was arbitrarily defined by anaesthetist
Only 20% were identified
6.2%30-day mortality
1/4 had artlines
5%had cardiac output monitoring
22%went to HDU/ITU immediately postop
50%who died never went to ITU

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12
Q

Identification methods for “High-Risk Patients”

A

Clinical judgement
ASA
P-POSSUM - M&M for gen surg
Euroscore (cardiac)
Surgery Type
CPEX

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13
Q

List high risk surgical operations (4)

A

Open aortic
Major vascular
Peripheral vascular
Urgent body cavity

Cardiac and thoracic surgery - CABG, clam shell
Vascular operations - AAA
Gastrointestinal operations - laparotomy

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14
Q

List the highest risk perioperative co-morbidities. Give % 30 day mortality

A

Documented cirrhosis (8.9%)
CCF (8.2%)
Arrhythmia (5.7%)
CVA (4.4%)
Diabetes (on insulin) (4.1%)
Ischaemic heart disease (3.8%)
Cancer (3.8%)

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15
Q

What is the perioperative role of echo?

A

Resting - information made no difference in 1 year outcomes (40,000 patient retrospective review)
Dynamic - identifying inducible ischaemia, improved outcomes

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16
Q

What is the role of perioperative CT angiography?

A

Can identify those with coronary artery disease (CAD)
Indications for treatment remain the same as for non-surgical patients

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17
Q

How should you care for high risk patients?

A

Optimise medical co-morbidities
Plan appropriate:
- Monitoring
- Fluid management
- Analgesia
Decide on appropriate post op care

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18
Q

What is CPEX? (2)

A

An incremental workload stress test
A dynamic test of global cardiorespiratory function

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19
Q

What are the phases of CPEX? (4)

A
  1. Baseline recording (3 mins)
  2. Unloaded cycling (1-3 mins)
  3. Graded increasing resistance
  4. Rest (10 mins)
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20
Q

What is prehabilitation? (1)

A

Process of enhancing an individual’s functional capacity to enable them to withstand a forthcoming stressor such as major surgery

Often multimodal -
1. Medical optimisation
2. Physical exercise
3. Nutrition
4. Psychological support

Increases VO2 max by 20-30%.
Mitigates impact on VO2 by chemotherapy.
Unclear if any survival benefit

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21
Q

Outcome benefits of prehabilitation? (3)

A

Reduced length of stay
Reduced postoperative pain
Fewer postoperative complications
Reduced cost per case to the health service

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22
Q

What are positive CPEX indicators for ward level care post major surgery?

A

AT > 11 ml/min/kg
No myocardial ischaemia
Ve/V̇O₂ < 35

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23
Q

What are the positive CPEX indicators for HDU care post major surgery?

A

AT > 11 ml/kg/min
Detectible myocardial ischaemia or;
Ve/VO2 > 35

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24
Q

What are the positive CPEX indicators for ITU care post major surgery?

A

Aortic or oesophageal surgery
AT < 11 ml/min/kg

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25
Why might beta-blockers work to lower perioperative mortality?
Reduce O₂ demand - Prevent tachycardias - Negatively ionotropic Reduce cardiac events
26
Guidelines of perioperative beta-blockade
Continue if already on Intermediate/high risk for myocardial ischaemia: consider starting peri-op > 2 revised risk factors - consider starting peri-op Do not start on day of surgery Try to start earlier if going to do so
27
Duration of antiplatelets following coronary intervention
Drug eluting stents (DES) - dual for 6-12 months Bare metal stent (BMS) - dual for 4-6 weeks Balloon angioplasty - dual for 2 weeks
28
Describe bridging therapy for antiplatelet treatment
Initiated 5 days pre-op at time of stopping clopidogrel Cangrelor (P2Y12 inhib) - stop infusion 1-6 hours pre-op Tirofiban (GIIb/IIIa inhib) - stop 3-6 hours pre-op Eptifibatide (GIIb/IIIa inhib) - stop 4-12 hours pre-op
29
Define Enhanced Recovery
Evidence based approach that helps people recover quicker after major surgery Principles: 1. Assessing risk + fitness 2. Optimising preop - prehab 3. Reducing starvation with carb drinks 4. Minimally invasive where possible 5. Clear + structured approach to post-op management 6. Early mobilisation + nutrition
30
Benefits of ERAS? (4)
Reduced surgical site infection Improved patient experience Reduced length of stay Reduced healthcare costs Reduction in complications Reduced physiological stress Maintenance + support of homeostasis + physiological function Reduced waiting list times Reduced on the day cancellation
31
What are the 4 elements of ERAS?
Pre-op assessment, planning and preparation Reducing the physical stress of the operation Standardised immediate perioperative management Early Mobilisation
32
What are the benefits of goal directed fluid therapy?
Reduced LOS for major abdominal, gynae and urological surgery Reduced PONV Reduced gut hypoperfusion Reduced GI complications (ileus, delayed feeding)
33
What is the FTc? (2)
The duration of flow during systole corrected to a HR of 60 Doppler parameter Normal FTc: 330-360ms
34
Causes of increased FTc?
Reduced afterload/resistance (i.e. vasodilated)
35
Causes of decreased FTc?
Increased afterload - peripheral vasoconstriction, underfilled
36
What is Peak Velocity?
The highest blood velocity detected during systole (left ventricular contractility/inotropy)
37
What are typical Peak Velocity values?
90-120 cm/s (20 year old) 70-100 cm/s (50 year old) 50-80 cm/s (70 year old) These are NOT physiological targets
38
What does a low Peak Velocity suggest? (2)
Failing left ventricle Excessive afterload
39
What is the general management for peri-operative diabetes?
Early identification of high risk patients Day of surgery admission is default Minimise starvation (consider list order) Resume normal diet ASAP Analgesia/antiemesis to support early eating - If missing 1 meal → modify patient's own meds - Missing 2+ meals → start VRIII (variable rate IV insulin infusion) - Continue long acting insulin whilst on VRIII Hourly BM intra-op/post-op
40
How to transfer VRIII to usual regimen
Establish normal eating / drinking Restart previous regimen and dose After first dose of S/C insulin, stop VRIII 30 mins later
41
Pre-operative blood conservation techniques
Anaemia clinics Iron tablets / infusions EPO - early enough (6 weeks+) Stopping antiplatelets Disease optimisation Micro-sample collection Normovolaemic haemodilution
42
Intra-operative blood conservation techniques
Meticulous surgeons Warming TEG Minimally invasive if possible Aprotinin Tranexamic acid Cell salvage Off pump surgery Platelet mapping Tight and dry CPB
43
Post-operative blood conservation strategies
Restrictive transfusion thresholds Autologous transfusions Warming
44
What did NAP5 Study?
AAGA
45
What were the basic findings of NAP 5?
471 reports of AAGA Delay in reporting 0-62 years since incident Incidence 1:19000
46
Incidence of AAGA?
1:19000 1:136000 if no NMBA
47
High risk groups of AAGA?
NMBA use 1:8000 Cardiothoracic anaesthesia 1:8600 Obstetrics / C sections 1:670
48
What is the likely long term psychological impact of AAGA?
41% experience moderate/severe long term sequelae - PTSD Best predictors of long term harm were: - Distressed at time of event - Sensation of awake paralysis Understanding of what was happening at the time, reassurance, and early support helped to mitigate this risk
49
What are the risk factors/recommendations for AAGA at induction?
Risk factors - Thiopental - RSI - Obesity - NMB - Difficult airway management - Long transfer gap from AR to OR Recommendations - Checklist following transfer
50
What are the causes of/recommendations for AAGA at emergence?
Nearly all due to residual NMB Recommendations - Ensure NMB monitors used - Check reversal at end of case
51
What are the risk factors for AAGA?
Drug factors - Thiopental - TIVA - NMBA Patient factors - Women - Young adults - Obesity - Previous history of AAGA Subspecialties - Obstetric - Cardiothoracic - Neurosurgical Organisational factors - Emergency - OOH - Junior anaesthetists
52
What are the caveats to TIVA in the context of AAGA?
Less common when using TCI Many cases associated with disconnection/failure of delivery Transferring from volatile to TIVA particularly high risk More coming in transfer of paralysed patients outside theatre
53
What does NAP 5 have to say about AAGA following sedation?
“Reports of AAGA after sedation represent a failure of communication between anaesthetist and patient and should be readily reduced or eliminated by improved communication, management of expectations and consent processes.”
54
What did NAP 4 study?
Major complications of airway management in the UK
55
How many anaesthetics are given each year in the UK? What is their typical airway management?
Approx 2.9 million GAs/year 56% - supraglottic airway device (SAD) 38% - tracheal tube 5% - face mask
56
What were the key findings of NAP 4?
Failure to assess airway Failure to act on airway assessment Failure to plan for failure Fixation with intubation Inappropriate use of SAD SAD used in difficult airways with no backup plan Obese patient twice as likely to have difficult airway High failure of cannula cricothyroidotomy (60%) Aspiration was the single commonest cause of death Failure to interpret capnography correctly 1/3rd of events occurred at extubation/recovery 1/4 of all major airway events was from ICU/A&E
57
What did NAP 3 study?
Major complications of central neuraxial block in the UK
58
What were the basic findings of NAP3?
700,000 CNB 46% Spinals vs 41% Epidurals 45% Obstetric vs 44% Perioperative Permanent injury following CNB 1/24,000 - 1/54,000 Death following CNB 1/50,000 - 1/140,000 Over-represented groups included: Epidurals (60%) CSEs Perioperative analgesia (80%) 2/3rd of injury initially judged severe resolved fully
59
How is type 2 diabetes diagnosed? (4)
HbA1C > 48 mmol/L (>6.5%) A random venous plasma glucose concentration ≥ 11.1 mmol/l or A fasting plasma glucose concentration ≥ 7.0 mmol/l (whole blood ≥ 6.1 mmol/l) or Two hour plasma glucose concentration ≥ 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT)
60
What is impaired fasting glucose?
Fasting glucose 6.1 - 7 mmol/L
61
What are the recommendations from “The measurement of adult blood pressure and management of hypertension before elective surgery” Anaesthesia 2016
Pre-op assessment doesn’t need to measure BP if primary care has documented < 160/100 mmHg GPs should refer for elective surgery, and secondary care should accept, if BP < 160/100 GPs should refer patients who are established on antihypertensives, but are refractory Elective surgery should proceed if BP <180/110 when measured in clinic
62
Define and categorise hypertension
Stage 1: 140-159 / 90-99 Stage 2: 160-179 / 100-119 Stage 3/severe: >180 / >120
63
What does 15 mL (1 unit) of cryoprecipitate contain? (5)
Fibrinogen (150-250 mg) Factor VIII (80-150 IU) Factor XIII (80-100 IU) von Willebrand factor (50-75 IU) Fibronectin
64
What is the parkland formula?
Calculation of fluid loss in patient's with burn 4ml x weight (kg) x total % burns Half given in first 8 hours, half given in 16 hours
65
Describe the physiological role of magnesium
Natural calcium antagonist Na/K ATPase co-factor cAMP magnesium dependent NMDA receptor antagonist Decreases ACh release at NMJ Inhibits clotting cascade
66
What is the recommended cut off patient dose for peri-operative steroid replacement?
>5mg prednisolone for ≥1 month
67
What are the recommendations for steroid replacement?
Hydrocortisone 100 mg by IV injection at induction in adult with adrenal insufficiency from any cause, followed by a continuous infusion of hydrocortisone at 200 mg/24h For ANY surgery - minor or major
68
Give the equivalencies for steroidsP
Hydrocortisone 20mg = Prednisone / prednisolone 5mg = Methylprednisolone 4mg = Dexamethasone 0.75mg
69

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