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Final > General > Flashcards

General Flashcards

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
Q

Why might beta-blockers work to lower perioperative mortality?

A

Reduce O₂ demand
- Prevent tachycardias
- Negatively ionotropic
Reduce cardiac events

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26
Q

Guidelines of perioperative beta-blockade

A

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

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27
Q

Duration of antiplatelets following coronary intervention

A

Drug eluting stents (DES) - dual for 6-12 months
Bare metal stent (BMS) - dual for 4-6 weeks
Balloon angioplasty - dual for 2 weeks

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28
Q

Describe bridging therapy for antiplatelet treatment

A

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
Q

Define Enhanced Recovery

A

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
Q

Benefits of ERAS? (4)

A

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
Q

What are the 4 elements of ERAS?

A

Pre-op assessment, planning andpreparation
Reducing thephysical stressof the operation
Standardisedimmediate perioperative management
Early Mobilisation

32
Q

What are the benefits of goal directed fluid therapy?

A

Reduced LOS for major abdominal, gynae and urological surgery
Reduced PONV
Reduced gut hypoperfusion
Reduced GI complications (ileus, delayed feeding)

33
Q

What is the FTc? (2)

A

The duration of flow during systole corrected to a HR of 60
Doppler parameter
Normal FTc: 330-360ms

34
Q

Causes of increased FTc?

A

Reduced afterload/resistance (i.e. vasodilated)

35
Q

Causes of decreased FTc?

A

Increased afterload - peripheral vasoconstriction, underfilled

36
Q

What is Peak Velocity?

A

The highest blood velocity detected during systole (left ventricular contractility/inotropy)

37
Q

What are typical Peak Velocity values?

A

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
Q

What does a low Peak Velocity suggest? (2)

A

Failing left ventricle
Excessive afterload

39
Q

What is the general management for peri-operative diabetes?

A

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
Q

How to transfer VRIII to usual regimen

A

Establish normal eating / drinking
Restart previous regimen and dose
After first dose of S/C insulin, stop VRIII 30 mins later

41
Q

Pre-operative blood conservation techniques

A

Anaemia clinics
Iron tablets / infusions
EPO - early enough (6 weeks+)
Stopping antiplatelets
Disease optimisation
Micro-sample collection
Normovolaemic haemodilution

42
Q

Intra-operative blood conservation techniques

A

Meticulous surgeons
Warming
TEG
Minimally invasive if possible
Aprotinin
Tranexamic acid
Cell salvage
Off pump surgery
Platelet mapping
Tight and dry CPB

43
Q

Post-operative blood conservation strategies

A

Restrictive transfusion thresholds
Autologous transfusions
Warming

44
Q

What did NAP5 Study?

A

AAGA

45
Q

What were the basic findings of NAP 5?

A

471 reports of AAGA
Delay in reporting 0-62 years since incident
Incidence 1:19000

46
Q

Incidence of AAGA?

A

1:19000
1:136000 if no NMBA

47
Q

High risk groups of AAGA?

A

NMBA use 1:8000
Cardiothoracic anaesthesia 1:8600
Obstetrics / C sections 1:670

48
Q

What is the likely long term psychological impact of AAGA?

A

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
Q

What are the risk factors/recommendations for AAGA at induction?

A

Risk factors
- Thiopental
- RSI
- Obesity
- NMB
- Difficult airway management
- Long transfer gap from AR to OR

Recommendations
- Checklist following transfer

50
Q

What are the causes of/recommendations for AAGA at emergence?

A

Nearly all due to residual NMB
Recommendations
- Ensure NMB monitors used
- Check reversal at end of case

51
Q

What are the risk factors for AAGA?

A

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
Q

What are the caveats to TIVA in the context of AAGA?

A

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
Q

What does NAP 5 have to say about AAGA following sedation?

A

“Reports of AAGA after sedation represent a failure of communication between anaesthetist and patient and should be readily reduced or eliminated byimproved communication, management of expectations and
consent processes.”

54
Q

What did NAP 4 study?

A

Major complications of airway management in the UK

55
Q

How many anaesthetics are given each year in the UK? What is their typical airway management?

A

Approx 2.9 million GAs/year
56% - supraglottic airway device (SAD)
38% - tracheal tube
5% - face mask

56
Q

What were the key findings of NAP 4?

A

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
Q

What did NAP 3 study?

A

Major complications of central neuraxial block in the UK

58
Q

What were the basic findings of NAP3?

A

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
Q

How is type 2 diabetes diagnosed? (4)

A

HbA1C > 48 mmol/L (>6.5%)
A random venous plasma glucose concentration≥ 11.1 mmol/lor
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 glucosein an oral glucose tolerance test (OGTT)

60
Q

What is impaired fasting glucose?

A

Fasting glucose 6.1 - 7 mmol/L

61
Q

What are the recommendations from “The measurement of adult blood pressure and management of hypertension before elective surgery”Anaesthesia 2016

A

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
Q

Define and categorise hypertension

A

Stage 1: 140-159 / 90-99
Stage 2: 160-179 / 100-119
Stage 3/severe: >180 / >120

63
Q

What does 15 mL (1 unit) of cryoprecipitate contain? (5)

A

Fibrinogen (150-250 mg)
Factor VIII (80-150 IU)
Factor XIII (80-100 IU)
von Willebrand factor (50-75 IU)
Fibronectin

64
Q

What is the parkland formula?

A

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
Q

Describe the physiological role of magnesium

A

Natural calcium antagonist
Na/K ATPase co-factor
cAMP magnesium dependent
NMDA receptor antagonist
Decreases ACh release at NMJ
Inhibits clotting cascade

66
Q

What is the recommended cut off patient dose for peri-operative steroid replacement?

A

> 5mg prednisolone for ≥1 month

67
Q

What are the recommendations for steroid replacement?

A

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
Q

Give the equivalencies for steroidsP

A

Hydrocortisone 20mg

Prednisone / prednisolone 5mg
=
Methylprednisolone 4mg
=
Dexamethasone 0.75mg

69
Q
A

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