Learning Outcomes Flashcards
define frailty
“susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge”
the triad of anaesthesia
the triad: analgesia, opiates and general anaesthetic agents feeding into “analgesia(removal of unpleasant stimulus), hypnosis, relaxation(muscle relaxation).”
biochemistry of general anaesthetic agents
interfere with neuronal ion channels by hyperpolarising them to reduce action potentials. Either inhalation to dissolve via membranes or I.V and bind to GABA receptors to open chloride channels.
physiology of general anaesthetic
Cerebral function lost from top down starting with complex processes, with reflexes relatively spared. IV rapid unconsciousness but rapid recovery. Blood level is very high but falls, muscle picks up the drug slowly but the effect is large because of the relative mass of skeletal muscle, fatty tissue picks up drug even more slowly but stores it due to solubility.
depolarising physiology of muscle relaxants
Depolarising (NMBS) depolarise motor end plate, render post-junctional membrane refractory to further stimulus.
physiology of non-depolarising muscle relaxants
Neuromuscular block non depolarising physiology competitive block of nicotinic acetylcholine which prevents the opening of sodium channels
central effects of general anaesthesia
depresses CV centre by reducing sympathetic outflow, ionotropic effect on the heart particularly on the cardiac output, reduced vasoconstrictor tone leading to vasodilation.
direct effects of general anaesthesia
: negative inotropic, vasodilation and venodilation decreased venous return and cardiac output.
respiratory effects of general anaesthesia
depressant reduces hypoxic and hyperbaric drive, decreased tidal volume, paralyse cilia and decrease Function respiratory capacity.
local anaesthetics physiology
sodium channel blockers, prevent propagation of action potential. LA molecules must pass into axon to block sodium channel from within, must be un-ionised to cross membranes
limiting factor of local anaesthetic
toxicity, absorption > rate of metabolism = high plasma levels
effects of local anaesthetic
Retain awareness, lack of global effects and proportional to anaesthetised area. All effects of RA are due to sympathectomy due to LA blockage of mixed spinal nerves.
spinal injection of local anaesthetic is in
the subarachnoid
epidural injections of local anaesthetic is in
extradural
how does one monitor consciousness during anaesthesia
loss of verbal contact, visually with movement, respiratory pattern and processed EEG.
monitoring
respiratory parameters, ECG, NIBP, FiO2, ETCO2, Agent monitoring, temperature, urine output, NMJ, arterial monitoring,
triple airway manoeuvre
Head tilt/chin lift/ jaw thrust.
potential of airway maintenances during anaesthesia
face mask triple airway manoeuvre oropharyngeal airway laryngeal mask airway endotracheal intubation
oropharyngeal airway guidance
only tolerated in unconscious patient, may cause vomiting or laryngospasm
laryngeal mask airway guidance
cuffed tube mask, maintain airway but doesn’t protect. I-gel, easy insertion.
endotracheal intubation guidance
placement of cuffed tube in trachea: - protects from aspiration, artificial ventilation, prevents risk of blood contamination, strict control of blood gas
how to counteract the toxicity of anaesthesia
used alongside vasoconstrictors to reduce blood flow to reduce absorption
toxicity risk factors for anaesthesia
Toxicity depends on dose used, rate of absorption, patient weight and drug.
signs of anaesthetic toxicity
twitching, tinnitus, drowsiness, convulsion, coma and CV arrest
laryngospasm is
forced reflex adduction of vocal cords, may result in complete obstruction. Maye be caused by excitation phase on anaesthesia.
anaesthesia induction
induction Iv with propofol, thiopentone + others.
anaesthesia induction in children
gas induction sevoflurane
what are the planes of anaesthesia?
analgesia
excitation (hyperreflexia)
anaesthesia
overdose
type 1 respiratory failure
oxygenation failure
type 2 respiratory failure
oxygenation and ventilation failure
types of shock
distributive, hypovolaemic, anaphylactic, neurogenic, cardiogenic
stroke volume consists of
preload/contractility/afterload
fluid challenge recommendation
30ml/Kg
comprehensive geriatric assessment refers to
assess and manage illness in older people. Determine the problems, what domains and what can be reversed. Leads to a management plan tailored for the individual. It is a MDT exercise.
statistical outcomes of performing CGA
more likely to be alive and living at home 6 months or 1.25, p<0.001, NNT17
less likely to be living in a residential care 0.78, p<0.001.
extrinsic causes of incontinence
physical state, mobility, confusion, drinking too much, medication, constipation, social
intrinsic causes of incontinences
bladder too weak or too strong, outlet too weak or too strong
risk factors for incontinences
menopause, weak pelvic floor muscles, older man with BPH, blocked urethra, bladder stones, stroke, MS, prolonged catheterisation.
stress incontinence symptoms
: urine leak on movement, coughing, laughing, squatting
urinary retention with overflow incontinence symptoms
poor urine flow, double voiding, hesitancy, post micturition dribbling
urge incontinence symptoms
sudden urge to pass urine immediately, very disabling.
neuropathic bladder symptoms
secondary to neurological disease, no awareness of bladder filing resulting in overflow incontinence.
stress incontinence Tx
PT, oestrogen cream and duloxetine. Surgical TVT/colposuspension
kegel exercises, biofeedback, vaginal cones, pelvic floor stimulators
urinary retention with overflow incontinence Tx
treat with alpha blockers, or anti-androgens or surgery (TURP). May need catheters.
urge incontinence Tx
anti-muscarinic, bladder retraining. May also use beta 3 adrenoceptor agonists to relax detrusor.
Neuropathic bladder Tx
; parasympathomimetics (toxic, only for the young and fit) catheter usually only effective treatment
alternative Tx from incontinence
incontinence pads urosheaths intermittent catheters long term urinary catheter suprapubic catheter
what percentages of all in-patients will suffer cognitive impairment
20-30% of all in-patients
what percentages of people post surgery suffer from cognitive impairment
50%
what percentages of people at end of life suffer cognitive impairment
85%
signs and symptoms of delirium
Disturbed consciousness, change In cognition, acute onset and fluctuation. May also present with disturbance of sleep cycle, disturbed psychomotor behaviour and emotional disturbance.
assessments for delirium
Typically recognised through the 4AT. DO NOT USE DIPSTICK TESTS FOR THE DIAGNOSIS OF UTI IN THE ELDERLY.
non-pharmacological Tx for delirium
re-orientate early mobility correction of sensory impairment normalise sleep cycle avoid catheter discharge early
pharmacological Tx for delirium
stop drugs
sedate early but only as last resort. Consultant or registrar decision.
delirium is a risk factor for
future development of dementia, delirium or frailty syndromes.
WHO definition of alt. medicine
“broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system”
what percentage of the population use alt. medicine
80%
what percentage of Scottish GP practices recommend CAMS
60%
what percentage of maternity staff recommend CAMS
30%
why do patients use CAMS
health control, dissatisfaction with conventional medicine, lack of modern medicine holistic approach, concerns over prescriptions, aligns with their values. Thinks its safe, natural and harmless.
preoperative investigations
CV ECG Exercise tolerance test ECHO myocardial perfusion scan cardiac catheter CT coronary angiogram
Resp. saturations ABG CXR Peak flow FVC/FEV gas transfer CT chest
what to do with concurrent medications before undergoing anaesthesia
continue as normal usually especially inhalers, anti-anginal and ant-epileptics. Exception is to maintain anti-diabetic medication and anti-coagulants.
per increase in metabolic equivalents leads to what percentage reduction in mortality?
15%
categories of pain
duration; acute, chronic, acute on chronic
cause; cancer, non-cancer
mechanism; nociceptive(inflammatory, well localised, sharp or dull) , neuropathic (burning, shooting, numbness, not well localised).
peripheral pain Tx
RICE, NSAIDS, local anaesthetics
spinal cord Tx for pain
acupuncture, massage, TENS, local anaesthetics, opioids, ketamine.
brain Tx for pain
psychological, paracetamol, opioids, amitriptyline, clonidine.
nociceptive pain Tx
NSAIDS, codeine, morphine
is codeine good for chronic pain?
no
chronic cancer pain Tx
morphine
neuropathic Tx
amitriptyline, anticonvulsants
RICE stands for
rest
ice
compression
elevation
RAT
recognise
assess
treat
mild pain on the ladder Tx
paracetamol (+/- NSAIDS)
moderate pain on the ladder Tx
paracetamol (NSAIDS + codeine/alt)
severe pain on the ladder Tx
paracetamol (NSAIDS + morphine)
hospital inpatient prevention for falls
ensure vision and mobility aids and call bell in reach, consider bed rails, regular obs, tell people.
hospital inpatient has fallen what signs/symptoms and condition would they be in
Drugs (decrease BP/HR/awareness)( increase urine output, sedation, hallucinations, dizzy).
very likely to be acutely unwell, significant injury possible
MDT tests for patient falls in-patient
MDT (eye test, ECG, BP, incontinence questionnaire, MMSE, gait and balance, osteoporosis screen)
the patient presenting to the hospital after a fall causing injury
likely to be well patient, difficult and multifactorial falls
if in A+E for a fall what do you consider?
ABCDE, check CK for rhabdomyolysis, skin injury etc
MDT assessments for an A+E fall
(eye test, ECG, BP, incontinence questionnaire, 4AT, MMSE, gait and balance, osteoporosis screen) CT if head injury, glucose. If pain on moving a joint then x-ray. .
history of a fall in A+E
history (memory of fall, palpitations, on turning, near misses, exertion, sensory) also urinary, gait, drugs.
examination points for a fall in A+E
Examination for CN, neglect, cerebellar signs, Parkisons, BP, HF, respiratory disease, abdominal, prostate, kyphosis etc). also neuro and coordination of feet, Rombergs and gait.
G.P. practice cost of drugs
974 million
five R’s of good prescribing
Right patient right dose Right route right drug right time
the role of MHRA
Medicine and healthcare products regulatory agency:
post marketing surveillance, assessment and authorisation, devices, quality control, clinical trials regulation.
ensures that human medicines meet acceptable standards on safety, quality and efficacy. Ensures that the sometimes-difficult balance between safety and effectiveness is achieved.
the role of the SMC
Scottish medicines consortium
make decisions on the cost effectiveness of new/existing pharmaceutical products in respect of their use in NHS Scotland. Use of 3 month assessment process.
medication marketing authorisation refers too
ensures meets the standards of safety, quality and efficacy. Granted for periods up to 5 years.
medication off label refers too
prescribed out with the terms of marketing authorisation
unlicensed medication use refers to
no marketing authorisation
POM refers too
prescription only medicines. Usually new medicines are given out this way.
osmolarity refers too
measure of solute concentration per unit volume of solvent.
osmolality refers too
: measure of solute concentration per unit mass of solvent.
tonicity refers too
measure of osmotic pressure gradient between two solutions.
fluid distribution is
2/3rd’s fluid intracellular
1/3rd fluid extracellular (20% of this is intravascular).
sodium recommendation daily
1mmol/kg/day
potassium daily recommendation
– 1mmol/Kg/day
glucose daily recommendation
(50-100g/day)
hypovolaemia symptoms
nauseous, thirsty, flat veins, cool peripheries, no sweat, low or postural BP and high HR, concentrate oliguria
hypervolemia symptoms
feels breathless, not thirsty, veins distended, warm and oedematous extremities, sweaty, high BP, high HR, dilute urine
hypovolaemia treatment
needs resuscitation fluids if low B.P. or rehydration fluids -> plug the leak.
hypervolemia treatment
no more fluids, possibly diuretics if respiratory compromised.
Dextrose properties
Total body water, moves through all compartments, isotonic.
Dextrose use
Useful in chronic dehydration, hypernatremia, not used in resus or low albumin.
crystalloids properties
utilitarian, remain in ECF, high sodium load
crystalloids use
Useful in acute dehydration, AKI, resus not in long term maintenance, hypernatremia.
plasma expanders use
colloid stays in IVS (blood, TPN) useful in liver patients select intra-operative and not much else.
four step approach for fluids admin
patient’s volume status?: ABDDE
patient need IV fluids?
how much fluid do they need?: work out deficits (insensible loss is 400-800mls)
what types of fluid do they need?: (5 R’s)
five R;s of fluid resus
Resus routine maintenance replacement redistribution re-assessment
routine maintenance fluid refers too
IV fluids if not orally or enterally possible
replacement fluid refers too
IV additional to maintenance to correct deficit but only some
A pharmacokinetics for the elderly
altered rate but not extent of absorption (delayed response) such as reduced saliva production.
D pharmacokinetics for the elderly
reduced body mass, increased fat, reduced body water. Protein binding reduced and increase blood brain barrier permeability.
M pharmacokinetics for the elderly
hepatic affected by decreased liver mass, decreased liver blood flow. Toxicity risk increased and reduced first pass metabolism.
E pharmacokinetics for the elderly
renal function decreases with age, reduced clearance and increased half-life.
pharmacodynamics in elderly
receptor binding
decreased receptor numbers
altered translation of a receptor initiated cellular response.
what help is available in altering drug dosages for geriatric care
BNF, Beers criteria, STOPP-START, NHS polypharmacy guidance.
what drugs most commonly cause ADRS In the elderly
NSAIDS
diuretics
warfarin.
what drugs cause the most adverse effects in the elderly
anticholinergics and sedatives though.
