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4th year medicine > preoperative medicine and critical care > Flashcards

preoperative medicine and critical care Flashcards

1
Q

airway manoeuvres

A

chin lift

jaw thrust

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2
Q

D - disability

A

GCS
AVPU
glucose

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3
Q

mean arterial pressure minimum normal

A

> 60/65 normal

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4
Q

sepsis 6

A

take 3:

  • lactate - elevated if >2
  • blood cultures (before abx)
  • urine output

give 3:

  • abx - broad spec
  • fluid - 30ml/kg crystalloid for hypotension or lactate >4
  • O2
  • add vasopressors if hypotension to maintain MAP >65
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5
Q

fluid challenge

A
  • 10-30ml/kg bolus crystalloid STAT

repeat to response
decrease dose if possible heart failure (5ml/kg)
colloids are out

Hartmanns, plasmalyte: like saline, but more physiological

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6
Q

type 1 vs type 2 respiratory failure

  • blood gas levels
  • causes
A 
TYPE 1:
hypoxia 
- low O2 (unable to supply O2) 
- low CO2 
- causes: pneumonia, pulmonary embolism, pulmonary fibrosis, pulmonary oedema 
TYPE 2:
hypoxia + hypercapnia
- low O2 
- high CO2 (unable to eliminate CO2)
- low pH (acidosis) 
- causes: asthma, COPD, pneumothorax, muscular dystrophy, chest deformities, opioid, benzo overdose
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7
Q

blood products

A
  • ongoing haemorrhage:
  • -> 2222 “major haemorrhage”
  • Hb unhelpful if actively bleeding
  • check FBC and clotting regularly to correct coagulopathy:
  • FFP
  • platelets
  • cryoprecipitate (fibrinogen)
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8
Q

fasting times for surgery

A

6hrs for solids

2 hrs for liquids

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9
Q

diabetes surgery fasting

A
  • stop oral hypoglycaemic
  • half dose of long acting insulin (patients can become ketotic)
  • monitor
  • may need variable rate insulin infusion
  • met formin does not cause hypoglycaemia (don’t need to stop)
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10
Q

ASA grade

A

ASA 1: normal healthy
ASA 2: mild systemic disease
ASA 3: severe systemic disease (co-morbidities)
ASA 4: constant threat to life - no surgery
ASA 5: not expected to survive with/out surgery

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11
Q

Pain ladder

A

mild intermittent:
- paracetamol 1g qds PRN

mild constant:
- reg paracetamol 1g qds
+
PRN NSAIDs (oral ibuprofen 400mg tds)

moderate:
- regular paracetamol 
\+
regular NSAIDs or if unable to do oral, PR diclofenac 50mg tds
\+ 
regular codeine phosphate 30-60mg qds

paracetamol + codeine can be prescribed as co-codamol 30/500 two tablets up to qds

severe:
ORAL INTAKE 
- regular paracetamol
\+
- regular NSAIDs
\+ 
- pro morphine (oramorph) 10mg every 2hrs 
NO ORAL INTAKE:
- regular PR paracetamol 
\+ 
regular NSAIDs (PR diclofenac) 
\+ 
IV morphine protocol 
or 
patient-controlled analgesia/epidural analgesia
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12
Q

epidural analgesia

A

catheter into spinal column but outside meninges - local anaesthetics/ opioids into nerve roots

can cause hypotension

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13
Q

post operative complications

A 
MI
stroke 
thrombo-embolic 
renal failure 
haemorrhage 
pneumonia 
sepsis/SIRS
wound infection 
re-operation
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14
Q

venous blood gas:

low pH
high CO2
low O2
bicarb normal

diagnosis

A

type 2 respiratory failure (low O2, high CO2)

respiratory acidosis

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15
Q

venous blood gas:

low pH
normal CO2
normal O2
bicarb low

diagnosis

A

metabolic acidosis

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16
Q

venous blood gas:

pH normal
O2 normal
CO2 low
bicarb adjusted

diagnosis

A

respiratory acidosis with metabolic compensation

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17
Q 
85yrs 
2 days after hemiarthroplasty 
moderately severe COPD 
O2 sats 89% with nasal cannula at 2L/min O2
RR: 20-25bpm 
comfortable

next action?

A

non-urgent CXR

raised RR
diseased lungs –> increased risk of post-op complications e.g. atelectasis

target sats for COPD: 88-92%
therefore no indication for extra O2 or blood gas

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18
Q

target O2 sats in COPD

A

88-92%

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19
Q

max flow rate in nasal cannulae

A

3L per min

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20
Q 
61yrs 
abdo pain, dehydration and vomiting 
an 'acute abdomen'
suspected perforated colon 
early warning score (EWS) of 1 due to raised temp 
so far management has been:
- O2
- IV cannulation &bolus fluids 
- urinary catheter 
- bloods incl lactate, FBC
- urgent CT abdo booked

next action?

A

blood culture

signs of sepsis –>
sepsis 6

take blood cultures before giving abx if poss

lactate can be measured from a venous sample

may need to go to theatre but CT prior to this

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21
Q

where is intraosseous access most commonly obtained

A

proximal tibia

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22
Q

at which stage of the procedure is it too late to prevent the wrong site being operated on

A

the sign out stage

time out stage is last stage where it can be changed

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23
Q

what is a good anaesthetic agent for haemodynamically unstable patients

A

ketamine

preserves blood pressure and does not cause cardiosuppression

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24
Q

which anaesthetic should be given for excision on digits (fingers and toes)
should adrenaline be given?

A

lidocaine - local anaesthetic
ring block - 1%

do not give adrenaline as can cause digital ischaemia
- normally given to prolong effects of local anaesthetic

25
Q

what can hypothermia during anaesthesia cause

A
  • excess blood loss due to reduced ability to clot
  • reduced wound healing
  • infection

can get hypothermia in anaesthesia

26
Q

which anaesthetic has anti-emetic properties

A

propofol

propofol is rapid acting

27
Q

what comes first in shock tachycardia or hypotension

A

tachycardia first

28
Q

RUQ pain + bilious fluid in intraabdo drain following cholecystectomy

A

biliary leak

29
Q

american society of anaesthesiologists (ASA) classification

A

ASA 1:
- normal healthy patient. (healthy, non-smoking, no or minimal, alcohol use)

ASA 2:
- mild systemic disease - without functional limitations

ASA 3:
- severe systemic disease - substantive functional limitations

ASA 4:
- severe systemic disease that is constant threat to life e.g. recent MI, stroke, valve dysfunction, sepsis

ASA 5:
- moribund patient who is not expected to survive without operation e.g. ruptured AAA, massive trauma

ASA 6:
- declared brain dead patient whos organs are being removed for donor purposes

30
Q

how is susceptibility to malignant hyperthermia inherited

A

by autosomal dominance

31
Q

causative agents of malignant hyperthermia

A

usually seen after administration of anaesthesia

causes:

  • halothane
  • suxamethonium
  • antipsychotics (neuroleptic malignant syndrome)
32
Q

management for malignant hyperthermia

A

dantrolene

33
Q

causes of post operative fever

A

day 1-2: wind: pneumia, aspiration, PE

day 3-5: water: UTI
day 5-7: wound: infection at surgical site or abscess
day 5+: walking: DVT or PE
any time: drugs, transfusion reactions, sepsis, line contamination

34
Q

cause of pneumonia post operative

A

complication of poor post operative pain management

35
Q

when should LMWH be started for elective hip replacement surgery

A

LMWH (e.g enoxaparin) 6-12hrs after surgery

LMWH for 10 days then aspirin for further 28days

36
Q

when are nasopharyngeal airways contraindicated

A

with suspected or known base of skull fractures

use oropharyngeal airway instead

37
Q

periorbital ecchymosis and mastoid process bruising

A 
mastoid process bruising (battle's sign)
periorbital ecchymosis (raccoon eyes)

signs of basal skull fracture

can also have CSF rhinorrhoea

38
Q

who is sensitive to non-depolarising paralysis agents (e.g. rocuronium)

A

myasthenia gravis
Lambert-Eaton myasthenic syndrome (weakness of proximal muscles and improves with use)

give suxamethonium instead

39
Q

isolated fever in well patient in first 24hrs following surgery

A

physiological reaction to operation

40
Q

drug to reverse benzos

A

flumazenil

41
Q

anaesthetic agent with anti-emetic effect

A

propofol

used in day cases

42
Q

halothane anaesthetic agent side effect

A

hepatotoxic

43
Q

anaesthesia of choice in haemodynamically unstable patients

A

ketamine

due to little myocardial depression

44
Q

20ml of 2% solution

how much of the solid is present in mg

A

400mg

general rule: 1% means 1g dissolved in 100ml

therefore 2% = 2g in 100ml
as this is 20ml: 2g / 5 = 400mg

45
Q

risk of using hypotonic (0.45%) saline in paediatric patients

A

risk of hyponatraemic encephalopathy

46
Q

anastomotic leak presentation

A

post op >5days
very sick with sepsis
pain
hard abdo

47
Q 
fever 
tachycardia 
recent surgery - hemicolectomy
abdo soft not distended
tender around midline wound
discharge seeping through dressing
A

wound infection

usually presents >5 days post op

48
Q

anaesthetic agent causing malignant hyperthermia

A

suxamethonium
halothane
antipsychotics - neuroleptic malignant syndrome

49
Q

mx for malignant hyperthermia

A

dantrolene

50
Q

how far in advance do you need to stop the oral contraceptive pill before general anaesthetic surgery

A

4 weeks - for elective under general anaesthetic

51
Q

do you need to stop the contraceptive pill before local anaesthetic surgery

A

no

52
Q

thyroid surgery preparation

A

vocal cord check

53
Q

thyrotoxicosis surgery prep

A

lugols iodine/ medical therapy

54
Q

surgery for carcinoid tumour prep

A

covering with octreotide

55
Q

non-haemolytic febrile reaction to transfusion mx

A

fever, chills
slow of stop transfusion
paracetamol
monitor

56
Q

minor allergic reaction to blood transfusion

A

pruritis, urticaria

temporarily stop transfusion
antihistamine
monitor

57
Q

anaphylaxis to blood transfusion

A

hypotension, dyspnoea, wheezing, angioedema

stop transfusion
IM adrenaline
ABC support: O2, fluids

58
Q

acute haemolytic reaction to transfusion

A

incompatible blood e.g due to human error

fever, abdo pain, hypotension

stop transfusion
confirm diagnosis: check identity and blood product
send blood for direct coombs test, repeat typing and cross-matching
fluid resus

4th year medicine (8 decks)

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