General Flashcards
1
Q
What is the declaration of Helsinki?
A
- Volunteers
- Informed consent
- Wellbeing of individuals overrides population
- Research only if likely to benefit population
2
Q
What are the 4 pillars of medical ethics?
A
1) beneficence 2) non-maleficence 3) equipoise 4) justice
3
Q
Give an example of a good communication type in pre-hospital care
A
Hand’s off Handover
4
Q
Which risk factors are on Koivuranta’s PONV score
A
female gender, non-smoking status, history of PONV, history of motion sickness, and duration of surgery >60 min
5
Q
Describe the scoring of Koivuranta’s PONV score
A
0 = 17% (baseline) 1 = 18% 2 = 42% 3 = 54% 4 = 74% 5 = 87% ROC = 0.71
6
Q
Describe the Apfel simplified score
A
PONV scoring system: female gender, history of PONV or motion sickness, non-smoking status, and postoperative use of opioids
7
Q
How does the Apfel PONV score relate to PONV risk?
A
0 = 10% 1 = 20% 2 = 40% 3 = 60% 4 = 80%
8
Q
What is the POVOC score?
A
Scoring system for PONV in children
9
Q
What are the risk factors in the POVOC score?
A
duration of surgery ≥30 min, age ≥3 yr, strabismus surgery, and history of POV in the child or relatives
10
Q
Provide 3 scoring systems for PONV
A
Koivuranta - Adult Apfel - Adult POVOC - Children
11
Q
Define perioperative high risk
A
> 5% perioperative mortality
12
Q
Why is establishing risk so important?
A
High risk patients account for 12.5% of cases but 80% of perioperative mortality
13
Q
What were the main NCEPOD (2011) findings for “high risk” patients
A
- “High risk” was arbitarily defined by anaesthetist
- 20% were identified
- 6.2% 30-day mortality
- 1/4 had art lines
- 5% had cardiac output monitoring
- 22% went to HDU/ITU immediately postop
- 50% who died never went to ITU
14
Q
Identification methods for “High-Risk Patients”
A
- Clinical judgement
- ASA
- P-POSSUM
- Euroscore (cardiac)
- Surgery Type
- CPEX
15
Q
List high risk surgical operations
A
- Open aortic
- Major vascular
- Peripheral vascular
- Urgent body cavity
16
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%)
17
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
18
Q
What is the role of perioperative CT angiography?
A
- Can identify those with CAD
- Indications for treatment remain the same as for non-surgical patients
19
Q
How should you care for high risk patients?
A
- Optimise medical co-morbidities
- Plan appropriate:
- Monitoring
- Fluid management
- Analgesia
- Decide on appropraite post op care
20
Q
What is CPEX?
A
An incremental workload stress test. A dynamic test of global cardiorespiratory function
21
Q
What are the phases of CPEX?
A
- Baseline recording (3 mins)
- Unloaded cycline (1-3 mins)
- Graded increasing resistance
- Rest (10 mins)
22
Q
What is pre-habilitation?
A
- A cardiac rehab like program.
- Increases VO2 max by 20-30%.
- Mitigates impact on VO2 by chemotherapy.
- Unclear if any survival benefit
23
Q
What are positive CPEX indicators for ward level care post major surgery?
A
- AT > 11 mL/min/kg
- No myocardial ischaemia
- Ve/VO2 < 35
24
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
25
What are the positive CPEX indicators for ITU care post major surgery?
* Aortic or oesophageal surgery
* AT \< 11 mL/min/kg
26
Why might beta-blockers work to lower perioperative mortality?
* Reduce O2 demand
* Prevent tachycardias
* Negatively ionotropic
* Reduce cardiac events
27
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 eariler if going to do so
28
Duration of antiplatelets following coronary intervention
* DES - dual for 6-12 months
* BMS - dual for 4-6 weeks
* Balloon angioplasty - dual for 2 weeks
29
Describe bridging therapy for antiplatelet treatment
* Initiated 5 days pre-op at time of stopping clopidogrel
* Tirofiban - stop 3-6 hours pre-op
* Eptifibadine - stop 4-12 hours pre-op
30
Define Enhanced Recovery
* An evidence based process for non-daycase surgery deisgned to:
* Improve patient outcomes
* Reduce length of stay
* Reduce complications
* Reduce financial burden
* By employing:
* Organisational change and training
* Standardised perioperative care
* Active patient engagement
31
What are the primary outcomes demonstrated in ERAS?
* Better outcomes
* Reduced LOS
* Increased number of patients treated
* ? Mortality (1 orthopaedic study)
32
What are the 4 elements of ERAS?
1. Pre-op assessment, planning and **preparation**
2. Reducing the **physical stress** of the operation
3. **Standardised** immediate perioperative management
4. **Early Mobilisation**
33
What are the benefits of goal directed fluid therapy?
* Reduced LOS for major abdominal, gynae and urological surgery
* Reduced PONV
* Reduced gut hypoperfusion
* Redcued GI complications (ileus, delayed feeding)
34
What is the FTc?
The duration of flow during systole corrected to a HR of 60. Normal is 330-360ms
35
Causes of increased FTc?
* Low afterload (i.e. vasodilated)
36
Causes of decreased FTc?
* Increased afterload
* Peripheral vasocontriction
* Underfilled
37
What is Peak Velocity?
The highest blood velocity detected during systole, (left ventricular contractility/ionotropy).
38
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
39
What does a low Peak Velocity suggest?
* Failing left ventricle
* Excessive afterload
40
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
* Use the term "variable rate IV insulin infusion"
* If missing just breakfast, modify patients own meds
* Missing \> 1 meal, place on VRIII
* Continue long acting insulin whilst on VRIII
* Hourly BM intra-op/post-op
41
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
42
Pre-operative blood conservation techniques
* Anaemia clinics
* FeSO4 tablets / infusions
* EPO
* Stopping antiplatelets
* Disease optimisation
* Micro-sample collection
* Normo-volaemia haemodilution
43
Intra-operative blood conservation techniques
* Meticulus surgeons
* Warming
* TEG
* Aprotonin
* Tranexamic Acid
* Cell salvage
* off pump surgery
* Platelet mapping
* Tight and dry CPB
44
Post-operative blood conservation strategies
* Restrictive transfusion thresholds
* Autologus transfusions
* Warming
45
What did NAP 5 Study?
Accidental Awareness under GA
46
What were the basic findings of NAP 5?
* 300 cases reviewed (Delay 0 - 62 years)
* 141 Certain/Probable cases of AAGA
* 17 Awake paralysis
* 7 AAGA in ITU
* 32 AAGA after sedation
47
What is the incidence of AAGA?
* Baseline risk 1:19,000
* 1:136,000 if not using NMB
* High risk groups included:
* 1:8,000 if using NMB
* 1:8,600 Cardiothoracic anaesthesia
* 1:670 Caesarean section
48
What is the likely long term psychological impact of AAGA?
* 41% experience moderate/severe long term sequelae
* 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
* Check list 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
* NMB
* Patient factors
* Women
* Young adults
* Obesity
* Previous history of AAGA
* Subspecialties
* Obstetric
* Cardiothoraccic
* 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 comming 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
How many recommendations does NAP 5 make?
* 64 in total
* 7 National
* 12 Instituational
* 45 Personal
55
What did NAP 4 Study?
Major complications of airway management in the UK
56
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
57
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
* Innapropriate 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 (significantly over-represented)
58
What did NAP 3 Study?
Major Complications of Central Neuraxial Block in the United Kingdom
59
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.
60
How is type 2 diabetes diagnosed?
* 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).
61
What is impaired fasting glucose?
Fasting glucose 6.1 - 7 mmol/L
62
What are the recommendations from "The measurement of adult blood pressure and management of hypertension before elective surgery" *Anaesthesia 2016*
1. Pre-op assessment doesn't need to measure BP if primary care has documented \< 160/100 mmHg
2. GPs should refer for elective surgery, and secondary care should accept, if BP \< 160/100
3. GPs should refer patients who are established on antihypertensives, but are refractory
4. Elective surgery should proceed if BP \<180/110 when measured in clinic
63
Define and categorise Hypertension
Abnormally high blood pressure, categorised as:
1. Stage 1: 140-159 / 90-99
2. Stage 2: 160-179 / 100-109
3. Stage 3: 180-209 / 110-119
4. Stage 4: \> 210 / \> 120
64
What does 15 mL (1 unit) of cryoprecipitate contain?
* Fibrinogen (150-250 mg)
* Factor VIII (80-150 IU)
* Factor XIII (80-100 IU)
* von Willebrand factor (50-75 IU)
* Fibronectin
65
What is the parkland formula?
4 ml × weight (kg) × total percentage of burns.
Half the fluid should be given in the first eight hours and the remaining fluid over the next 16 hours.
66
Describe the physiological role of magnesium
* Na/K ATPase co-factor
* cAMP magnesium dependend
* NMDA receptor antagonist
* Decreases Ach release at NMJ
* Inhibits clotting cascade
* Calcium antagonist
67
What is the recommended cut off patient dose for peri-operative steroid replacement?
10mg predniolone at any point within the past 3 months
68
What are the recommendations for steroid replacement?
* Minor surgery
* 25 mg hydrocortisone at induction
* Moderate surgery
* Take normal steroid
* 25 mg hydrocortisone at induction
* 100 mg hydrocortisone over 1 day
* Major surgery
* Take normal steroid
* 25 mg hydrocortisone at induction
* 100 mg hydrocortisone/day for 3 days
69
Give the equivalencies for 10 mg Prednisolone (include betamethasone, beclomethasone, cortisone acetate, hydrocortisone, methylprednisolone and deflazacort)
* betamethasone = 1.5 mg
* beclomethasone = 1.5 mg
* cortisone acetate = 50 mg
* hydrocortisone = 40 mg
* methylprednisolone = 8 mg
* deflazacort = 12 mg
