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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
Outline management of mitral stenosis
``` Low normal hr SR Adequate preload High normal bp Avoid hypercarbia/acidosis/hypoxia/pulm htn ```
26
Outline management of Mitral regurg
High normal hr Adequate preload Low normal bp Decrease pulmonary vascular resistance
27
What are the rules for anesthesia and URTI?
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
Outline implications and management of copd under anesthesia?
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
Outline anesthetic implications and management of OSA
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
Outline anesthetic implications and management of CCF
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
Outline anesthetic implications nd management of CRF
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
Outline anesthetic implications and management in recent stroke
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
What are the causes of distributive shock?
Sepsis Anaphylaxis Acute adrenal insufficiency Neurogenic shock
34
What are the causes of hypovolemic shock?
``` Blood loss 3rd space sequestration (burns, peritonitis, pancreatitis, sbo) GI loss Renal loss - DI/DKA Skin loss - burns, sweating ```
35
What are the causes of cardiogenic shock?
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
Outline the physiology behind shock
BP = CO × TPR CO = HR × SV SV made from preload, contractility and afterload
37
What are the clinical features of anaphylaxis?
``` Cardiovascular collapse 88% Erythema 45% Bronchospasm 36% Oedema 25% Rash 13% Urticaria 8.5% ```
38
What is the management of anaphylaxis?
``` Call for help A - maintain B - ventilate, 100% C - adrenaline 500mcg q5min Hydrocortisone 50-100mcg Ivf bolus Antihistamines ```
39
What are the clinical features of local anesthetic toxicity?
CNS - circumoral numbness, tingling, vertigo, tinnitus, slurred speech, seizures CV - hypotension (smooth muscle relaxation/myocardial depression), wide pr/qrs, arrythmias
40
Outline the management of LA toxicity
``` Midaz/prop for seizures ALS - avoid la and betablockers Intralipid- 1.5mL/kg bolus +/- 2 further Intralipid infusion CPR at least 1 hour ```
41
What are the clinical features of venous air embolism?
Signs- hypotension, tachycardia/arrythmia, pulmonary hypertension, SUDDEN etco2 drop, hypoxia High risk in neurosurg, operations where operative site is higher then right atrium.
42
Outline the management of venous air embolism
``` Tell surgeon to flood field with saline Fio2 100% Supportive care Aspirate air from central line Aim to get in left lateral position ```
43
Outline approach for failure to awake from anesthetic
``` 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
What are the absolute and relative contraindications to neuroaxial block?
Absolute - patient refusal - infection at needle site - sig coagulopathy - hypovolemic shock - raised icp - AS Relative - systemic infection - neurological symptoms - mild coagulopathy - harrington rods
45
What is thr time period between anticoagulants and safe spinal anesthesia?
``` 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
What is the dose of adrenaline in neonatal resus?
10-30mcg/kg | IE 0.1-0.3mL of 1:10000
47
Outline anesthetic handover
1. Patient and pre existing condition 2. Anesthesia and complications 3. Surgery and complication 4. Analgesia/PONV/fluids/ebl/UO
48
What are the twitch criteria for reversal?
2 or more TOF 1 DBS > 10 PTC
49
What is the dose of sugammadex?
2mg/kg for reversal | 16mg/kg for immediate reversal post dose
50
What is the mechanism of action, benefits and side effects of tramadol?
Synthetic centrally acting opiate with snri like activity Decreased rate of tolersnce and abuse Decreased resp depression/constipation Increased nausea and vomitting
51
What is the mechanism of action, benefits and side effects of NSAIDs
Cox inhibition--> decreased pg/pc/txa2 ``` Contraindications: Gih Liver failure Ccf Hypovolemia Crf Hyperkalemia Asthma if affected Sig htn ```
52
What dose is used for spinal in non pregnant patients?
Marcain 0.5% 2.5-3.2mL
53
What are the anesthetic implications and management of upper gih?
``` 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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