Preparing For Theatre Flashcards
what are the reasons for cannulation?
- Infuse IV fluids
- Give IV induction anaesthetic agents
- IV medication
- Withdraw venous blood
what are the best sites for cannulation?
cubital fossa basilic cephalic median cubital dorsum of hand
what areas should be avoided for cannulation?
- veins distal to previous IV site
- Joints or bony prominences
- Sclerosed or thrombosed veins
- Dominant hand
- Limb affected by axillary clearance
- Veins with overlying cellulitis or skin breakdown
- AV fistula
what are the possible complications of cannulation?
- Thrombophlebitis
- Extravasation
- Hyperteonic or irritant fluid infusion may result in phlepbitis and require larger veins
- Haematoma
- Nerve, tendon or ligament damage
- Infection from cannulae left in situ
- Vasovagal syncope
give some examples of causes of sinus bradycardia?
hypothyroidism
beta blockers
normal
describe the features of sick sinus syndrome?
sinus formation problem
• In elderly
• Fibrosis of SAN and peri-nodal tissue
• Intermittent failure of impulse generation and propagation
• Long pauses between p waves
• Ectopic
• Tachyarrhythmias (tachy-brady syndrome)
what is 1st degree heart block?
increased PR interval (>5small squares)
what is 2nd degree heart block?
- Type 1: wenckeback – gradually increasing PR interval until missed beat
- Type II: PR iinterval remains same but proportion of p waves not conducted to ventricles (2:1 or 3:1)
what is complete heart block?
- Atrial activity occurs independently of ventricular escape rhytyhm
- Measure p wave and QRS rate – they should be regular (assuming no AF)
describe types of supraventicular tachycardia?
narrow QRS
irregular - AF
regular - sinus tachycardia, AVNRT, AVRT
describe AVNRT
Accessory pathway in AV node, heart continually generate impulses to ventricles
describe AVRT?
- Secondary pathway between atria and ventricles so continued activation from atria to ventricles, especially problematic in AF
- WPW: leads 1 / V3 , short PR, delta wave
describe ventricular tachycardia?
- Broad QRS
- VT
- VF
- Torsades
what are the causes of ST elevation?
- Acute MI
- Pericarditis
- High take off
what are the causes of ST depression?
- Ischaemia
* Digoxin – reverse tick on ECG
what are the causes of T wave inversion?
- Normal variant
- Ischaemia
- Ventricular hypertrophy
- Bundle branch block
- Digoxin
what are the types of anaesthesia?
local
regional - central neuraxial blockage, nerve blockades
general
what is local anaesthetic?
small area numbed for minor surgery
what is regional anaesthetic?
larger region
• Central neuraxial blockage – spinal/epidural (INR less than 1.5 for these procedures)
• Nerve blockades – entire limb in isolation, stay awake during operation, can be combined with general§
what is general anaesthesia?
unconscious
IV or inhaled drugs
what needs to be taken into consideration when performing preoperative optimisation?
- Type of surgery – minor, intermediate, major/complex
- Urgency of surgery - timescale
- Comorbidities and functional status – ASA grade
what is ASA 1?
normal health patent
what is ASA 2?
patient with mild systemic disease
what is ASA 3?
patient with severe systemic disease that is not a constant threat to life
what is ASA 4?
patient with severe systemic disease that is a constant threat to life
what is ASA 5?
moribund patient not expected to survive with ot without surgery
what are the aspects of anaesthetic preoperative assessment?
- Functional status: activities of daily living, cardiopulmonary exercise test
- Medical history : diabetes (infection risk, ACS, HbA1c <69), RA (cannulation and positioning difficulty),
- Medications and allergy - medications (stop ACE, ACEII on day of surgery)
- Preoperative tests: NICE guidelines
- Airway assessment :
- Previous anaesthesia: suxamethonion apnea
what are the fasting guidelines for surgery?
- Solids- 6 hours
- Clear fluids – 2 hours
- Aspiration risk (aspiration pneumocytis)
how can a patient be optimised for theatre?
- Correct fluids
- Correct electrolyte imbalances
- Optimise heart rate
- Anticoagulation and VTE prohylaxis
- Availability of blood for theatre
- Analgesia and antiemetics
give examples of minor surgeries?
excising skin lesion
draining breast abscess
give examples of intermediate surgeries?
primary repair of inguinal hernia
excising varicose veins in the leg
tonsillectomy or adenotonsillectomy
knee arthrosopy
give examples of major or complex surgeries?
total abdominal hysterectomy endoscopic resection of prostate lumbar discectomy thyroidectomy total joint replacement lung operations colonic resection radial neck dissection
for a patient with ASA grade 1 what investigations are required prior to
- minor surgery
- intermediate surgery
- major surgery
- none
- none
- FBC, kidney function (risk of AKI), ECG (if >65)
for a patient with ASA grade 2 what investigations are required prior to
- minor surgery
- intermediate surgery
- major surgery
- none
- kidney function (if risk of AKI), ECG (if CV, renal or diabetes comorbidites)
- FBC, kidney function, ECG
for a patient with ASA grade 3/4 what investigations are required prior to
- minor surgery
- intermediate surgery
- major surgery
- kidney function (risk of AKI, ECG)
- FBC (CV or renal disease), haemostasis (if chronic liver disease), kidney function, ECG, lung function/arterial blood gas
- FBC, haemostasis, kidney function, ECG, lung function/arterial blood gas
when should a patient attend a pre-assessment clinic prior to surgery?
2 weeks prior to surgery patient has appointment with nurse to assess and discuss suitability and discussion with anaesthetist
what is included on an anaesthetic assessment sheet?
- 3 points of ID
- height, weight, HR, BP, temp
- ask patient what operation they’re having
- ASA grade
- elective or emergency?
- drug history
- alcohol, tobacco etc
- allergies
- airway and dentition
- examination
- investigations
- discussion with patient
- your name, grade, signature, date
what score system is used to assess airway?
mallampati score
what are the different classes of the mallampati score?
1 - complete visualisation of soft palate
2 - complete visualisation of uvula
3 - visualisation of only base of uvula
4 - soft palate not visible
what medications should not be administered on the day of surgery?
ACE inhibitors ARBs alpha blockers diabetic medication diuretics
what medications should be discussed with surgical team regarding administration on day of surgery?
anticoagulants antiplatelets COCP/ hormonal replacement therapy cytotoxic chemotherapy cytokine modulators methotrexate MAOI tamoxifen
what medications should be given on the day of surgery?
anti-anginals anti-arrythmics anti-epileptics anti-parkinson medication (except selegiline) anti-psychotics anti-retrovirals asthma/COPD medication beta blockers calcium channel blocker cardiac glycosides diabetes - metformin, pioglitazone H2 receptor antagonist immunosuppresants lithium long term benzos long term opioids nitrates PPIs statins steroirds thyroid hormone
describe chin lift?
- Contraindicated in cervical spine injury
- Tilt head back by pushing down on forehead
- Place tips of finger under chin and pull mandible up
describe jaw thrust?
- Preferred in patients with spine injury
- Palms on temple and fingers under mandible, lift mandible upwards with fingers
describe guedel oropharyngeal airways?
- Unconscious patients
- Open mouth and inspect if viable (suction if needed)
- Hollow tube with tip at end, semicircular, correct size is needed (insciors or mouth to tragus of ear
- Insert upside down with tip pointing upwards when it touches back of throat rotate 180 degrees
- Don’t secure in place in case of gagging
describe nasopharyngeal airway?
- Unconsious/semi conscious patients (less gag reflex), may be only way in maxofacial injury
- Check for viability (if basal skull fracture don’t attempt)
- Bevelled tip, size by matching diameter with the little finger and distance from nostril to meatus of ear
- Apply water lubricant
- Approach from behind
- Push bevel end through most patent nostril push posteriorly (twist to help push through)
describe big valve mask?
- Positive airway pressure
- Apnoeic
- Resp rate to slow or fast for tidal volume
- Self inflating back, fitted to oxygen reservoir,
- One way flow
- Tight seal around nose and mouth (too big if extends over chin)
- Two person technique
- Place mask over nose and mouth (C shapes with both bands, other fingers under jaw and pull upwards slightly
- Second person squeeze bag every 5 seconds
describe the process of cricothyroidotomy?
- Cant intubate, cant oxygenate situation and cal for help
- Continue trying to oxygenate
- Extend neck
- Laryngeal handshake to identify larynx, place indx finger on cricothyroid membrane
- Stabilise larynx and stretch skin between fingers
- Transverse stab incision, feel pop as it enters trachea, keep scalpel perpendicular turn 90 degress sharp edge to feet,
- Use bougie and push angle tip down scalpel blade until into trachea, advance gently 10-15cm and remove scalpel
- Advance tracheal tube to trachea twisting as you do
- Remove bougie
- Attach circuit and give oxygen, inflate cuff
- Recheck depth of tube and secure
describe induction of anaesthesia?
- Standard: IV – analgesia (phenyonyl followed by propofol -hypnotic agent)
- Inhalational – volative agent eg sevofluorane in oxygen and n2o
- Muscle relaxation: if intubation required or surgery needs still patient, can be depolarising (suxamethonium) or non depolarising (atrocurium, rocuronium, vecuronium)
- Airway: chin lift jaw thrust, airway adjuncts, supralottic devices, endotracheal intubation
describe maintenance of anaesthesia?
- Volatile agents – via anaesthetic machine
- IV maintenance of propofol with opioid
- analgesia
- positioning
- warming
- fluid balance
- other drugs
describe emergence from anaesthesia?
- Analgesia and anti-emetics
- Muscular function restored
- Maintenance agents switches off
- Extubation
- May be agitated or confused
Describe recovery from anaesthesia?
- Patients closely monitored – vital signs, pain scores, postoperative complications
- Pain relief – opioids, regional anaesthetic
- Other drugs, anti-nausea
describe nitrous oxide?
- Maintanence of anaesthesia
- 50-66% in oxygen
- Unsatisfactory as anaesthetic on its own
- Analgesia without loss of consciousness: mixture of 50% oxygen and nitrous oxide
describe volatile liquid anaesthetics?
- Isoflurane – stable heart rhythm, preferred inhalational anaesthetic in obstetrics
- Desflurane – rapid acting volatile liquid anaesthetic with 1/5 potency of isoflurane. Irritant to respiratory tract so isn’t recommended for induction of anaesthesia
- Sevoflurane – rapid acting volatile liquid more potent than desflurane, quick emergence and recovery. Non irritant so often used for inhalational induction of anaesthesia
describe IV anaesthetics?
- Propofol – infuction or maintenance in adults and children, rapid recovery, less hanover effect
- Thiopental sodium – barbiturate, induction,no analgesic properties, sedative effects for 24 hours
- Etomidate – rapid recovery, less hyptension than the others, higher incidence of extraneous muscle movements (Minimise with opioid analgesic or short acting benzodiazepine
- Ketamine – rarely used, less hypotension than thiopental sodium and propofol. Mainly used in paediatric anaesthesia especially for repeated administration. Slower recovery, high incidenceof extraneous muscle movements. High incidence of hallucinations, nightmares, transient psychotic effects which can be reduced by benzodiazepine eg diazepam or midazolam
describe recognition of local anaesthetic toxicity?
sudden alteration in mental state, severe agitation of loss of consciousness, without tonic clonic convulsions
cardiovascular collapse - sinus bradycardia, conduction blocks, asystole, ventricular tachyarrhythmias
what is the immediate management of local anaesthetic toxicity?
stop injecting LA call for help maintain airway 100% oxygen and ensure adequate lung ventilation establish IV access control seizures - benzo, thiopental, propofol in small incremental doses assess cardiovascular status blood for analysis?
what is the treatment of local anaesthetic toxicity if the patient is in circulatory arrest?
- cpr
- manage arrhythmias
- consider cardiopulmonary bypass
- give IV lipid emulsion (continue cpr)
what is the treatment of local anaesthetic toxicity in a patient without circulatory arrest?
use conventional therapies to treat - hypotension, bradycardia, tachyarrhythmia
consider IV lipid emulsion
describe the follow up for a patient with local anaesthetic toxicity?
transfer to clinical area with equipment and staff until sustained recovery
exclude pancreatitis - daily amylase or lipase for 2 days
report cases to national patient safety agency
what are the physiological effects of pain on the cardiovascular system?
- increase pulse, BP, CO
- decrease vascular diameter
- arrythmia
- impaired circulation
- MI
what are the physiological effects of pain on the blood?
elevated coagulation
thromboses
PE
what are the physiological effects of pain on the locomotor system?
increased muscle tone
protective posture
decreased mobilisation
increased pneumonia
what are the physiological effects of pain on metabolism?
increase blood glucose and protein metabolisation
decreased wound healing
increased exhaustion
what are the physiological effects of pain on the stomach and intestines?
- gastro-intestinal atonia
- nausea
- vomiting
- constipation
- cramps
what are the physiological effects of pain on the immune system?
immunosuppresion
increased infection risk
what are the psychological effects of pain?
- Depression
- Anxiety
- Difficulty functioning – family, work
- Costs
- Hospital stay
- Unable to contribute to community
how can pain be classified?
acute or chronic
cause - cancer/non cancer
mechanism of pain - nociceptive, neuropathic
- what is acute pain?
2. what is chronic pain?
- less than 3 months eg appendicitis
2. more than 3 months - exists after injurt has healed, may be no identifiable cause eg back pain
- what is nociceptive pain?
2. what is neuropathic pain?
- Obvious tissue injury or illness. Protective function. Sharp or dull. Well localised. Responds to analgesics
- Tissue injury may not be obvious. Nervious system damage. Burning, shooting, numbness. Not well localised. Poor response to conventional analgesics
what are the 4 steps in the nociceptive pathway regarding the physiology of pain?
- periphery - tissue injury, release of chemicals, stimulation of nociceptors, A delta, C nerve to spine through dorsal root ganglion
- spinal cord - dorsal horn is 1st relay station
- brain - thalamus is 2nd relay station
- modulation -
what is the RAT approach to pain assessment?
recognise
assess
treat
RAT
describe recognition of pain?
- Does the patient have pain
- Ask
- Look
- Do others know that they have pain
RAT
describe assessment of pain?
- What is the pain score at rest and movement
- How does the pain affect patient
- Can the patient move, cough, tolerate physiotherapy
- Can they work
- Acute or chronic -how long
- Cancer or non cancer - cause
- Nociceptive or neuropathic – mechanism
- Physical factors eg other illness, pmh
- Psychological -depression, anxiety
- support
- Measuring tools - verbal rating, smiley face scale
RAT
describe treatment of pain?
- Pharmacological or non pharmacological
- Rest, ice, compression, elevation
- Surgery
- Physiotherapy, acupuncture, massage, TENS
- Psychological
- Explanation
- Reassurance
describe step 1 on the WHO analgesic ladder?
mild pain
• Simple analgesics
• Paracetamol
• Ibuprofen
describe step 2 on the WHO analgesic ladder?
moderate pain
• Mild opioid eg codeie or tramadol
• Continue simple analgesics
describe step 3 on the WHO analgesic ladder?
severe pain
• Strong opioid eg morphine
• Continue simple analgesics
paracetamol
- indications
- advantages
- disadvantages
- mild pain, moderate and severe pain with other medications
- cheap, safe, PO, PR, IV
- liver damage in overdose
ibuprofen
- indication
- advantages
- disadvantages
- mild, moderate or severe nociceptive pain
- cheap, safe short term
- gastric and renal side effects, interferes with clotting, oral only
tramadol
- indication
- advantages
- disadvantages
- dosing
- nociceptive and neuropathic pain, oral or IV route
- safe, useful for different pain types, can be used with morphine
- nausea and vomiting, confusion
- low oral bioavailability, oral dose 2-3x highe than IV, IM, SC, tolerance - increased dose over time
amitriptyline
- indication
- advantages
- disadvantages
- neuropathic pain
- cheap, safe in low dose, treats depression, poor sleep
- harmful in overdose, dry mouth, drowsiness, urinary retention
gabapentin
- indication
- advantages
- disadvantages
- neuropathic pain
- safe and effective
- drowsiness, dose needs to be increased slowly
what are the issues with giving
- too little fluid
- too much fluid
- kidney injury
2. heart failure, pneumonia
gabapentin
- indication
- advantages
- disadvantages
- neuropathic pain
- safe and effective
- drowsiness, dose needs to be increased slowly
what are fluid requirements for a 60kg person?
- Sodium 1mmol/kh/day
- Potassium 1mmol/kg/day
- Fluid volume 25-30ml/kg/day
- Glucose 50-100g/day
what are the 5R’s of fluid management?
- Resuscitation
- Replacement
- Routine maintenance
- Redistribution
- Reassessment
what are fluid requirements for a 60kg person?
- Sodium 1mmol/kh/day
- Potassium 1mmol/kg/day
- Fluid volume 25-30ml/kg/day
- Glucose 50-100g/day
what is in hartmanns?
sodium
potassium
chloride
isotonic
what is in 0.9% NaCl?
sodium
chloride
isotonic
what is in plasma?
sodium
potassium
chloride
what is in 0.18% NaCl
4% dextrose?
sodium
chloride
glucose
hypotonic
what is in plasma?
sodium
potassium
chloride
what is the purpose of routine fluid maintenance?
- Replaces normal ongoing losses
* Are they able to meet their fluid/electrolyte requirement orally/enterally?
describe fluid resuscitation?
- 500mls crystalloid 15 mins. – chek response
- Caution in cardiac ailure, renal failure, elderly, consider 250ml bolus
- If no improvement after 2000ml call for help
- If haemorrhage replace with blood products
what is the purpose of routine fluid maintenance?
- Replaces normal ongoing losses
* Are they able to meet their fluid/electrolyte requirement orally/enterally?
what is the criteria for a patient to be discharged from PACU?
- Be awake, oriented, alert, easily arousable to verbal stimuli, and able to summon assistance if necessary.
- Have a patent airway, breathe spontaneously, and maintain a satisfactory level of blood oxygenation (usually greater than 92% on room air).
- Have active airway protective reflexes.
- Be hemodynamically stable with acceptable vital signs for 15 to 30 minutes.
- Possess a core body temperature of not less than 36° C (96.8° F).
- Have no active bleeding or apparent postsurgical complications.
- Have controlled and tolerable levels of postoperative pain.
- Be free from vomiting and, if necessary, have an antiemetic regimen in place
what are the risk factors for post operative nausea and vomiting?
- Female
- Age – declines throughout adult life
- Opioid use
- Non smoker
- Type of surgery
- Anaesthetic factors – type
what are the prophylactic measures for post operative nausea and vomiting?
- Anaesthetic measures: reduce opiates, reduce volatile gases, avoid spinal
- Prophylactic antiemetic therapy
- Dexamethasone at induction of anaesthesia
what are the pharmaceutical meausures for post operative nausea and vomiting?
- Multimodal therapy – add a different antiemetic to that given in theatre
- Impaired gastric emptying – prokinetic agent (metoclopramide, domperidone, hyoscine)
- Suspected metabolic or biochemical imbalance: metoclopramide
- Opioid induced nausea and vomiting: ondansetron or cyclizine
what are the conservative measures for post operative nausea and vomiting?
- Fluid hydration
- Adequate Analgesia
- No obstructive causes
