Paediatrics

Question 1

Give four examples of acute emergencies in surgery

Answer 1

Ruptured aorta
Rupture ectopic pregnancy
Trauma mainly stab heart and unstable bleeding gunshot
Imminently threatened airways

Question 2

How long should you take to perform an acute emergency surgery?

Answer 2

Within 1 hour

Question 3

Give three examples of elective surgery

Answer 3

Cataracts surgery
Removal of benign tumors
Tonsillectomy

Question 4

Give four examples of cold emergencies

Answer 4

Stable
Closed fractures
Changing of dressings
Cancer surgery

Question 5

Give two examples of surgeries that should be done with 6 hours

Answer 5

Stable appendicitis
Open fractures requiring washing out

Question 6

Give two examples of surgeries that should be performed within 1-3 hours

Answer 6

Acute abdomen due to bowel perforation and ectopic pregnancy threatening to rupture

Question 7

How long should it take before and urgent surgery is performed

Answer 7

Done within 24 hours

This includes laparotomy form intestinal obstruction and appendicetomy

Question 8

What is the risk of adverse events for emergency surgery as compared to planned or elective surgery?

Answer 8

10X more

Question 9

What is the objective of emergency anaesthesia?

Answer 9

emergency anaesthesia is to allow correction of the surgical pathology with minimum risk to the patien

Question 10

List 5 potential complications that occur during emergency anaesthesia intraoperatively

Answer 10

Hypovolemia, hypotension, vomiting, dysrhythmias and adverse reaction to drugs in the presence of electrolyte abnormalities or renal dysfunction.

Question 12

Outline 8 factors that increase perioperative risk

Answer 12

• Limited time to assess and prepare patient
• Uncertain diagnoses, e.g. laparotomy for ‘acute abdomen’
• Risk of aspiration
• Body fluid, electrolyte and acid base derangements
• Anaemia and coagulation abnormalities
• Coexisting diseases and poorly controlled chronic medical problems
• Pain and its pathophysiological effects
• After-hours surgery and anaesthesia with junior and/or inexperienced staff

Question 13

Name three things about the current condition of the patient that should be focused on during preoperative assessment in emergency surgery

Answer 13

Metabolic derrangement
Fluid status and risk of aspiration

Question 14

Name two agents groups that can have masked intravascular depletion

Answer 14

Elderly: Poor baroreceptor reflexes
Young patients: Compensation

Question 16

State the best initial investigation in emergency surgery

Answer 16

Arterial blood gas:

Others: Hb, U&E with creatinine and glucose

Question 17

How long should you wait before performing surgery after the intake of the following:
a. Clear fluids
b. Solids and non human milk
c. Breast milk

Answer 17

• Clear fluids 2 hours
• Breast milk 4 hours
• Non-human milk 6 hours (this includes infant formula)
• Light meal 6 hours

Question 18

Why is non human milk considered a solid?

Answer 18

Milk is considered a solid because when mixed with gastric juice it
thickens and congeals into curds.

Question 19

Differentiate between vomiting and regurgitation

Answer 19

Vomiting is an active process, with expulsion of stomach contents into the pharynx by contraction of
the diaphragm. It occurs at lighter planes of anaesthesia, during induction or emergence. Vomitus
above the vocal cords may stimulate spasm of the cords and apnoea leading to hypoxia.

Regurgitation is a passive process, occurs at any time, often “silent” and usually at deeper planes of
anaesthesia; when laryngeal reflexes are reduced or paralysed. There is passive flow of stomach
contents through the gastro-oesophageal junction into the pharynx, aided by gravity and a full stomach
or an incompetent gastro-oesophageal sphincter mechanism.

Question 20

List 10 patients who are at a risk of aspiration

Answer 20

• Full stomach
• Gastric outlet obstruction
• History of gastric reflux
• Abnormal oesophageal anatomy or function
• Emergency procedures
• Trauma
• Difficult airway management
• Pregnancy and labour
• Paediatrics due to immature gastro-oesophageal sphincter
• Morbid obesity (BMI > 35 kg m-2)
• ASA III or IV
• Decreased level of consciousness (LOC)
• Pain
• Muscle weakness

Question 21

In anaesthesia when is full stomach suspected? 6

Answer 21

Obstructed peristalsis
Delayed gastric emptying
Absence or abnormal peristalsis
Recent fluid or solid intake

Question 22

List three causes of obstructed peristalsis

Answer 22

Gastric cancer
Pyloric stenosis
Small or large bowel obstruction

Question 23

List three causes of ileus

Answer 23

Postop
Metabolic due to either hypokalemia, DKA or uraemia
Drug induced by anticholinergics and opioids

Question 24

List 6 causes of decreased gastric emptying

Answer 24

o Shock
o Diabetes
o Trauma
o Pregnancy and labour
o Fear, pain and anxiety
o Opioids

Question 25

State three cornerstones of the prevention of aspiration pneumonia

Answer 25

Empty the stomach Neutralise the stomach acid Have a correct anesthetic technique especially for RSI and awake intubation

Question 26

Name three drugs that prevent aspiration pneumonitis during surgery by neutralising the stomach acid

Answer 26

Sodium citrate Ranitidine Omeprazole

Question 27

Name three ways in which the stomach can be kept empty before and during surgery.

Answer 27

NPO status Nasogastric tube to drain the stomach Prokinetic drugs such as metoclopramide 10 mg IV 30 min pre-operatively

Question 28

List 8 signs of aspiration

Answer 28

Signs of aspiration • None (silent) especially with depressed level of consciousness on O2 supplementation • Decreased O2 saturation • Coughing • Tachypnoea • Tachycardia • Hypotension • Decreased lung compliance • Wheezes and crackles • Postoperative pulmonary disease • Chest X-ray may show diffuse infiltrates (usually right lower or upper lobe)

Question 29

State the first line management of aspiration during surgery

Answer 29

Give oxygen (may need 80% O2) as required to maintain Hb concentration>95% MInimize further aspiration risk

Question 30

State three ways to minimise further aspiration in the , management of aspirwtion

Answer 30

o Left lateral position (left side down – This allows intubation in that position if required) o Head down (encourages passive flow of contents of the pharynx out of the mouth) o Oropharyngeal suction before ventilation.

Question 31

Is the insertion of ETT required in the management of aspiration?

Answer 31

Only if ventilation and suction if the trachea is done

Question 32

Is bronchoscopy preferred over PPV in the management of aspiration?

Answer 32

Yes

Question 33

Should antibiotics and steroids be given routinely in the management of aspiration?

Answer 33

Nope

Question 34

State late management of aspiration that can be considered.

Answer 34

o Nasogastric tube to help empty stomach o Monitor respiratory function o Chest X-ray looking for oedema, collapse and/or consolidation

Question 35

What is the mostt common type of anaesthetic in emergency surgery

Answer 35

General anaesthesia Note: it is important to consider the patient’s clinical condition and its haemodynamic and pharmacological implications, e.g. hypovolaemia, hypokalaemia, uraemia and sepsis during all phases of the anaesthetic

Question 37

Is propofol advisable in emergency settings?

Answer 37

Nope

Question 38

When should the induction drug doses be reduced?

Answer 38

If a patient is shocked

Question 39

State a disadvantage of conduction with short acting opioids.

Answer 39

these agents may depress LOC or airway reflexes increasing risk of aspiration.

Question 40

What is the preferred agent for the maintenance of anaesthesia in emergency setting

Answer 40

Sevoflurane Alternative: Isoflurane or desflurane Why:It is titratable and shorter-acting, while being more availableand lessexpensivethandesfluran

Question 41

Why should a low dose of volatiles be used for the maintenance of anaesthesia in an emergency surgery?

Answer 41

They causes some degree of vasodilation

Question 42

What is the preferred choice for induction of anaesthesia in unstable shocked patient?

Answer 42

High-dose short-acting opiates, e.g. fentanyl or remifentanil, and minimal induction agent or volatile. Note: They should be monitored in the ICU