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Anaesthesia CAM > General > Flashcards

General Flashcards

1
Q

what are the common complications of intubation?

A
  1. Failure/oesophageal
  2. Damage- lips gums teeth pharynx aretenoid dislocation nasal injury vocal cord damage
  3. Badness; laryngospasm/bronchospasm/tracheal or oesophageal perforation/mediastinitus
  4. physiological; tachycardia/hypertension/desaturation/hypercarbia
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2
Q

What anesthetic techniques facilitate rapid awakening?

A

Avoidance of premeds. NO2/des/sevo. Remifentanil. Mivacurium.

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3
Q

What is the optimal patient position for intubation?

A

Elevate patients head by 8-10cm, extend head at atlanto-occipital joint. Table at height of xiphysternum. Ramping PRN.

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4
Q

what is the physiological basis for pre-oxygentaion? How long should it happen for?

A

O2 FOR 3min/6 VC breaths/etO2 >70. Physiological basis- denitrogenation of FRC, OXYGENATION OF FRC, longer time for desaturation. Normal VO2 250mL/min–> so normal FRC is 2.4L–> 13% O2 ie 300mL of O2 to consume ie until sats less than 90%

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5
Q

What are the current fasting guidelines?

A

Clear liquids 2 hours. Breast milk 3 hours. Solids 6 hours.

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6
Q

What measures can be used to risk aspiration risk?

A

Sodium citrate, PPIs 12 and 2 hours before, metoclopramide, ranitidine in pregnancy, cricoid pressure.

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7
Q

What is the standard intubation plan?

A
  1. DL
  2. VL
  3. LMA
  4. BMV +/- adjuncts
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8
Q

What are the complications of neuro axial block?

A

Minor; hypotension, tachy/brady, N/V, failure 1/20, PDPH 1/200

Major; Permanent nerve injury 1/30000, conversion to GA

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9
Q

What changes occur with pneumoperitoneum? Outline anaesthetic management.

A

A - increased risk of regurg –> ETT
B - increased pressure, deceeased frc, decreased compliance, VQ mismatch
C - increased vr, then decreased. Increased tpr, decreased CO. Increased arrythmia risk
D - Increased ICP

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10
Q

Outline changes with prone position and management

A

A - ETT displacement; taping, protection
B - decreased frc/tv ; low tv increased rate
C - increased vr
D - eye injuries, nose injury, breast injury

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11
Q

What are the risk factors and mx of PONV?

A

Patient - hx, female, non smoker, hypovolemia
Anesth factors - inhalational/opiates/NO/neostigmine
Surgical factors - Breast/gyn/eye/ENT/lap/neuro/gu, thyroid/shoulder

Mx: dex 5ht3, maxolon, droperidol, stemetil, ivf

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12
Q

Management of post op delerium? Causes?

A

Treat cause or if nil clear cause –> antipsychotic.

Causes:
Hypoxia/hypercarbia
Dementia
Metabolic/electrolyte
Hypogylcemia
Drugs (antichol/bdz/opiate/betablocker)
Etoh withdrawal
Insufficeint reversal
Acute CNS/seizure
Infection
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13
Q

What is multimodal analgesia?

A

Combination of interventional analgesia and systemic pharmacotherapy. Aims include better control, early mobilisation and early consumption.

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14
Q

What level does an epidural need to be at for

  • labour
  • LSCS
A

LABOUR T10-S4

LSCS T4-S5

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15
Q

Outline management of a high spinal block?

A

A - ETT asap
B - 100% O2, ventilate
C - CPR PRN, Atropine/pressors, L lat tilt and displacement
D - DELIVER BABY IN <4MIN

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16
Q

Outline approach to hypoxia.

A

Sats <94% –> hypoxia
Start high flow O2 and hand ventilate with large TVs.
Check probe.
Call for help PRN
Patient- check airway, ventilate and listen, looking at larynx, check HR/BP and give bolus, review for potential drug effect and mistake.
Equipment - check O2, check circuit and switch to bag.

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17
Q

What are the causes of an increased etco2?

A

Commonly: decreased rr, exhausted soda lime, ventilator setting, fresh gas flow setting

Increased production:

  • endogenous (sepsis/MH/TSH/NLMS/reperfusion)
  • exogenous (bicarb/CO2 insufflation/TPN/soda lime)

Decreased excretion:

  • circuit; airway obstruction, dead space, decreased gas flow, valve malfunction, vent settings
  • lungs; rr, bronchospasm, copd
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18
Q

What are the risk factors for PONV?

A

Patient- history, female, non smoker, hypovolemia
Anesth- inhalational/opiates/NO/neostigmine
Surgical- breast/gyn/eye/ent/lap/neuro/gu/shoulder/thyroid

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19
Q

Management of potential PONV

A 
Dex
Zofran
D2- maxolon/droperidol/stemetil
IVF
?Chewing Gum
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20
Q

Outline approach to tachycardia and cause?

A 
Plan- is it an arrythmia? --> treat
Is it pain/lack of depth? --> treat
Doez the tachycardia have a secondary cause?
- volume
- drugs
- htn
- tsh/phaeo
- sepsis/anaphylaxis/mh/tamponade/pe
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21
Q

Outline approach to bradycardia

A

Treat- low bp–> atropine, normal bp –> ephedrine/glyco
Is there a block? YES- treat; pace/manual/chemiczl

If no block, find cause:

  • primary (athlete)
  • secondary (metabolic, drugs, hypothyroid, raised icp, hypothermia)
  • anesthesia (hypoxia, volatile, relaxant, narcotic, anticholinesterase, spinal, vasopressor)
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22
Q

What is a MET? What activities correspond with different METS.

A 
2 cooking
3 1-2 blocks
5 1-2 FOS
7 tennis
10 run/swim
23
Q

Outline management of AS?

A

Low normal heart rate
SR
Volume loading
High normal bp

24
Q

Outline anesthetic management of AR?

A

High normal HR
adequate volume loading
Low normal bp
Maintain contractility

25
Q

Outline management of mitral stenosis

A 
Low normal hr
SR
Adequate preload
High normal bp
Avoid hypercarbia/acidosis/hypoxia/pulm htn
26
Q

Outline management of Mitral regurg

A

High normal hr
Adequate preload
Low normal bp
Decrease pulmonary vascular resistance

27
Q

What are the rules for anesthesia and URTI?

A

Fever and cough–> cancel
Rhinnorhea/CLD –> cancel

Child with URTI; 5-10X’S risk of spasm

Urti 2/52 postpone
Lrti 4/52 postpone
Bronchiolitis 6/52 postpone

28
Q

Outline implications and management of copd under anesthesia?

A

A - airway irritability; avoid ett if possible, appropriate oxygen

B - pulmonary htn - avoid desat
Risk of PTX - low pulmonary pressures
Bronchospasm/laryngospasm - use of adjuncts
Atelectasis - peep/recruitment

C - rvf

D - avoid histamine releasing drugs
Extubate in sitting position
Consider regional
Bronchospasm–> treat

29
Q

Outline anesthetic implications and management of OSA

A

A - increased obstruction –> adjuncts, avoid premeds
B- decreased sats–> increase fiO2
Atelectasis–> recruit/PEEP
Maintain post op sats to pre op

C - RVH + pulm htn

D - avoid large amounts of opiates
Multimodal analgesia
Quick wake up

30
Q

Outline anesthetic implications and management of CCF

A

A - smooth ett
B - avoid hypoxia/hypercarbia/increased intrathoracic pressure–> low tv/decreased pressure
C - optimise preload, contractility, afterload. Avoid negative inotropy, tachycardia, high sbp and low diastolic
Art line, consider CVC- dobutamine and norad
D - analgesia post op

31
Q

Outline anesthetic implications nd management of CRF

A

A - nil, recognise they are high risk
B - increased acidosis/hyperkalemia–> avoid low rr/hypercarbia
C - avoid morphine, tramadol, nsaids. Decrease thio/BDZ by 30%
D - anemia, hyperkalemia. Avoid sux
E - vec/roc –> prolonged action, decrease LA doses by 25%

32
Q

Outline anesthetic implications and management in recent stroke

A

Delay if non urgent. Within 6 weeks –> 20x’s risk. Hyperkalemia with sux if hemiplegia <6/12 ago

A - neck posture- vertibrobasillar insufficiency
B - avoid hypercarbia/hypotension
C - maintain normal hemodynamics
D - assess neuro post op, early intervention
E - clexane coverage, continue aspirin

33
Q

What are the causes of distributive shock?

A

Sepsis
Anaphylaxis
Acute adrenal insufficiency
Neurogenic shock

34
Q

What are the causes of hypovolemic shock?

A 
Blood loss
3rd space sequestration (burns, peritonitis, pancreatitis, sbo)
GI loss
Renal loss - DI/DKA
Skin loss - burns, sweating
35
Q

What are the causes of cardiogenic shock?

A

IHD - ami, mr, acute vsd, venfricular free wall rupture, lv aneurysm
Cardiomyopathy
Trauma- contusion
Infection - myocarditis
Lv outflow tract obstruction- HOCM/AS
LV inflow tract obstruction - MS/LA myxoma
Iatrogenic

36
Q

Outline the physiology behind shock

A

BP = CO × TPR
CO = HR × SV
SV made from preload, contractility and afterload

37
Q

What are the clinical features of anaphylaxis?

A 
Cardiovascular collapse 88%
Erythema 45%
Bronchospasm 36%
Oedema 25%
Rash 13%
Urticaria 8.5%
38
Q

What is the management of anaphylaxis?

A 
Call for help
A - maintain
B - ventilate, 100%
C - adrenaline 500mcg q5min
Hydrocortisone 50-100mcg
Ivf bolus 
Antihistamines
39
Q

What are the clinical features of local anesthetic toxicity?

A

CNS - circumoral numbness, tingling, vertigo, tinnitus, slurred speech, seizures

CV - hypotension (smooth muscle relaxation/myocardial depression), wide pr/qrs, arrythmias

40
Q

Outline the management of LA toxicity

A 
Midaz/prop for seizures
ALS - avoid la and betablockers
Intralipid- 1.5mL/kg bolus +/- 2 further
Intralipid infusion
CPR at least 1 hour
41
Q

What are the clinical features of venous air embolism?

A

Signs- hypotension, tachycardia/arrythmia, pulmonary hypertension, SUDDEN etco2 drop, hypoxia

High risk in neurosurg, operations where operative site is higher then right atrium.

42
Q

Outline the management of venous air embolism

A 
Tell surgeon to flood field with saline
Fio2 100%
Supportive care
Aspirate air from central line
Aim to get in left lateral position
43
Q

Outline approach for failure to awake from anesthetic

A 
Confirm agents are off
Check tof/reversal
Opiate/benzo reversal
Reversal of inhalational with physiostigmine
BSL/VBG/BP/NA/Temp
Neuro exam, CT + EEG
If persistent, ICU and repeat ct 8 hours
44
Q

What are the absolute and relative contraindications to neuroaxial block?

A

Absolute

  • patient refusal
  • infection at needle site
  • sig coagulopathy
  • hypovolemic shock
  • raised icp
  • AS

Relative

  • systemic infection
  • neurological symptoms
  • mild coagulopathy
  • harrington rods
45
Q

What is thr time period between anticoagulants and safe spinal anesthesia?

A 
Clexane proph > 12 hours, therapeutic > 24 hours
NSAID/aspirin --> whenever
Clopidogrel > 7 days
Warfarin INR < 1.4 + cease 4-5/7
Dabigatran/rivaroxaban > 48 hours
Apixiban > 24 hours
46
Q

What is the dose of adrenaline in neonatal resus?

A

10-30mcg/kg

IE 0.1-0.3mL of 1:10000

47
Q

Outline anesthetic handover

A
  1. Patient and pre existing condition
  2. Anesthesia and complications
  3. Surgery and complication
  4. Analgesia/PONV/fluids/ebl/UO
48
Q

What are the twitch criteria for reversal?

A

2 or more TOF
1 DBS
> 10 PTC

49
Q

What is the dose of sugammadex?

A

2mg/kg for reversal

16mg/kg for immediate reversal post dose

50
Q

What is the mechanism of action, benefits and side effects of tramadol?

A

Synthetic centrally acting opiate with snri like activity
Decreased rate of tolersnce and abuse
Decreased resp depression/constipation
Increased nausea and vomitting

51
Q

What is the mechanism of action, benefits and side effects of NSAIDs

A

Cox inhibition–> decreased pg/pc/txa2

Contraindications:
Gih
Liver failure 
Ccf
Hypovolemia
Crf
Hyperkalemia
Asthma if affected
Sig htn
52
Q

What dose is used for spinal in non pregnant patients?

A

Marcain 0.5% 2.5-3.2mL

53
Q

What are the anesthetic implications and management of upper gih?

A 
A - ETT with RSI, maxolon prior
B - increase fiO2
Monitor for aspiration
Treat as ards if aspiration present
C - IVC x 2 + IVF
Art line
Rbc's consider MTP
D - PPI, consider octreotide
E - disposition

Anaesthesia CAM (2 decks)

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