Module B Flashcards
Fascia Iliaca Block
Performed using ultrasound-guided approach or a landmark
The fascia iliaca compartment is a potential space lying between the fascia ilaca anteriorly and the iliacus and psoas muscles (iliopsoas) posteriorly
Indications: analgesia for fractured neck of femur (safe, cheap and effective)
Works by affecting the femoral, obturator and the lateral cutaneous nerves with a local anesthetic
Urinary urge incontinence
Urine leaks due to intense urge to pass urine
1st line tx: antimuscarinic drugs e.g. oxybutynin, tolterodine, and solifenacin
2nd line tx: mirabegron (β3 agonist)
Urinary stress incontinence
Defined as: physical movement or activity e.g., coughing, laughing, sneezing, running or heavy lift which puts pressure/stress on bladder, causing urine leakage
Non-medical management: pelvic floor exercises, and caffeine intake reduction
Medical tx: duloxetine (serotonin/norepinephrine reuptake inhibitor)
Small bowel bacterial overgrowth syndrome
Excessive amounts of bacteria in the small bowel
RFs: scleroderma, neonates with GI abnormalities, DM
Symptoms: chronic diarrhoea, bloating, flatulence, abdominal pain (resemble IBS)
Dx: hydrogen breath test, small bowel aspiration and culture (not commonly used as invasive), abx trial
1st line tx: rifaximin (low systemic absorption, good intraluminal target)
2nd line tx: co-amoxiclav or metronidazole
Acute ascending cholangitis
Bacterial infection of biliary tree (typically E. coli)
RF: gallstones
Charcot’s triad: fever, jaundice, RUQ pain
Reynold’s pentad: fever, jaundice, RUQ pain, confusion, hypotension
Ix: raised inflammatory markers (WBC), bilirubin, and ALP
Mx: IV abx, and ERCP after 24-48 hours to relieve obstruction via biliary drainage
Reynolds’ pentad
Fever, jaundice, RUQ pain, confusion, hypotension
Use: diagnosis of obstructive ascending cholangitis
Charcot’s triad
Fever, jaundice, RUQ pain
Due to ascending cholangitis (an infection of the bile duct in the liver)
Alvarado score
Clinical scoring system used in the diagnosis of acute appendicitis: Migration of pain Anorexia Nausea Tenderness in RLQ Rebound tenderness Elevated temperature Leucocytosis Shift of WBC to the left (neutrophils >75%)
Acute appendicitis
Commonest acute abdomen presentation
Px: periumbilical pain migrating to RIF, N&V, mild pyrexia, anorexia, diarrhoea(rare)
Dx: Rovsing’s sign, rebound tenderness
Alvarado score used, raised WBC (neutrophils), raised inflammatory markers, negative pregnancy test, USS to confirm absence of alternative pelvic organ pathology (may observe free fluid - pathological in males)
Tx: appendicetomy with prophylactic IV abx given preoperatively
Rovsing’s sign
palpation in the LIF causes pain in the RIF
Murphy’s sign
Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.
Group & Save
Blood taken to determine patient’s blood group then serum is saved for rapid cross-matching if required
Rigler’s sign
AKA double wall sign seen on abdominal x-ray that identifies a pneumoperitoneum with gas outlining both sides of the bowel wall,i.e. gas within the bowel’s lumen and gas within the peritoneal cavity
Pancreatitis causes
I GET SMASHED
I - idiopathic
G - gallstones; genetic (cystic fibrosis)
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion
H - hyperlipidaemia/hypercalcaemia/hyperparathyroidism (metabolic disorders)
E - ERCP
D - drugs (tetracyclines, furosemide, azathioprine, thiazides and many others)
Anaesthesia definition
Drug induced reversible loss of consciousness which allows surgery and invasive procedures
Triad of anaesthesia
Hypnosis = unconsciousness
Analgesia = pain relief
Muscle relaxant = paralysis
Pre-operative assessment
Doctor or nurse meets pt
History, examination, appropriate tests
Discuss risks of surgery and anaesthesia
Advise regarding alternatives (including non-operative interventions) to encourage pt to be involved in shared decision making
Suggest modifiable risk factors e.g. smoking cessation, weight loss, dietary recommendations, stopping/starting new drugs
Regional anaesthesia
May be with/out GA
E.g. peripheral nerve block, spinal (subarachnoid), epidural, local anaesthetic field block, plexus nerve block
3 aims of WHO surgical checklist
Reduce risk of wrong sites surgery
Encourage communication between all team members
Ensure there are no preventative errors
Timeline of anaesthesia
Induction = transition from awake to anaesthetised Maintenance = keeping a patient unconscious & paralysed + perioperative care Emergence = reversal of unconsciousness and paralysis Recovery = monitor vital signs, pain, possible complications (e.g. airway control, eating, drinking, speaking)
Induction of anaesthesia
1st stage of anaesthesia timeline: IV or inhalational
IV = analgesia and hypnotic agent e.g. fentanyl and propofol
Inhalation = volatile agent e.g. sevoflurane with O2 and air or N2O
Muscle relaxant given if intubation required or surgery requires pt to be immobilised
Preoperative assessment on day of operation
Anaesthetic hx + past problems
FH of anaesthetic problems (rare)
PMH - CV, Resp, DM, fits/seizures, epilepsy
DH + allergies
Metal work - important for diathermy
SH - excessive alcohol intake ↑anaesthetic required
Airway assessment - loose teeth, caps, crowns, dentures; Mallampati score, flexion/extension of neck, number of fingers in mouth
Mallampati score
Class 1: soft palate, fauces, pillars, uvula visible
Class 2: soft palate, fauces, part of uvula visible
Class 3: base of uvula visible, soft palate visible
Class 4: hard palate only visible
Higher class results in more difficulty controlling airway during anaesthetic
MAC
Minimum alveolar concentration
Defined as the fraction of volume of the anesthetic present in the inspired air that provides sufficient analgesia in 50% of patients, meaning that patients will not respond to an extremely painful stimulus such as surgical skin incision
Determines potency of inhalational anaesthetics as the MAC is inversely related to the anaesthetic potency (1/MAC = potency)
EC50
Effective concentration required to produce 50% of the maximum possible response
Determines potency of drug
ED50
ED50 is the median effective dose that produces a desired beneficial effect in 50% of the population
Therapeutic index
A measurement of the safety of a drug
Malignant hyperthermia
A subclinical myopathy in which general anesthesia triggers an uncontrollable contraction of skeletal muscle that leads to a life-threatening hypercatabolic state and increase in body temperature
Autosomal dominant - mutation in ryanodine receptor type 1 on sarcoplasmic reticulum causing an accumulation of intracellular calcium in skeletal muscle that leads to its overactivation and hypermetabolism
Signs and symptoms: tachycardia, tachypnoea, cyanosis, rigidity, hyperthermia (up to 45ºC)
Tx: stop responsible agent, 100% oxygen and give Dantrolene (inhibits ryanodine receptors to prevent calcium release)
2:1 M:F
70% mortality rate if not rapidly treated, risk reduces to <10% with treatment
Airway management during induction
Head tilt, chin lift, jaw thrust manoeuvres
Adjuncts e.g. Guedel airway, nasopharyngeal airway
Supraglottic device - laryngeal mask airway, iGel
Endotracheal intubation
Maintenance of anaesthesia
Volatile agents delivered via anaesthetic machine with measured concentrations with oxygen and air
IV maintenance with propofol and opioid infusions
Intraoperative care
- Analgesia - to reduce sympathetic response + smooth emergence
- Positioning - adapt neutral position with padding to prevent nerve and pressure injury
- Warming - at risk of hypothermia
- Fluid balance - IV fluids and monitoring
- CVS manipulated to offset hypotensive effects of anaesthesia e.g. IV fluids, alpha and beta adrenoceptors agonist (ephedrine and metaraminol), antimuscarinic cholinergic drugs
- Blood and product transfusion
- Antibiotics
- Post-operative drugs e.g. DVT prophylaxis, analgesia, pt’s current drugs
Emergence from anaesthesia involves…
Analgesia and anti-emetics
Muscular function restored by reversing paralysis
Maintenance agents switched off once muscle control demonstrated
Extubation e.g. ET or LMA
Monitor for immediate post-operative complications
Recovery
Monitor pt: vital signs (HR, BP, RR, SpO2), pain scores, ABCDE approach to post-operative complications
Pain relief and anti-emetics
Transfer to ward, day care unit, ITU
Patient involved in enhanced recovery program
Train of 4 stimulation
A technique to assess neuromuscular blockade in patients receiving anesthesia. Four electric stimuli are administered along the ulnar nerve every 2 seconds; the number of twitches of the adductor pollicis muscle are counted
Zero twitches indicates profound block; 1–2 twitches indicate partial block.
Hydrogen breath test
SIBO
Lactose intolerance breath test
Use:
CT enterography with IV contrast
Use:
Nausea
Vague, disagreeable sensation of queasiness or feeling sick to the stomach, that may be followed by vomiting
