Rote learning Flashcards
What are the 6 risk factors in Lee’s RCRI?
Hx coronary artery disease
Cerebrovascular disease
CCF
insulin-dependent DM
Pre-op Cr >177micromol/L
surgery: suprainguinal vascular or intra-peritoneal or intrathoracic
What are the % risk MACE (MI, cardiac arrest or death) with each point on the RCRI? Why may these be higher than the original numbers?
0=3.9%
1=6%
2=10%
3+=15%
The original studies used CK & excluded emergency pts; more recent external validation studies used the more sensitive troponin & included some emergency pts
What are the thresholds for BNP & NT-pro-BNP which are associated with significantly increased risk of 30-day death or nonfatal MI?
> =92mg/L for BNP & >=300mg/L for NT-proBNP
What are the tube sizes for paediatrics?
Neonate <3kg is size 3 uncuffed
>3kg= size 3 cuffed (micro-cuff)
6/12 size 3.5 cuffed
18/12 size 4
from 2, age/4 + 4 (but minus 1 for cuff)
Essentials for SAQs
Address THE QUESTION through:
What’s the main issue/concern/conflict
Timing (emergent/urgent/elective) for optimisation
Risk stratification & informed consent
WHERE is the surgery (eg. tertiary centre, daylight hours cathlab/cardiology available)
What’s the WHO (from NYHA) functional classification for pulmonary hypertension?
Class I Patients with pulmonary hypertension but without resulting limitation of physical activity. Ordinary physical activity does not cause undue dyspnea or fatigue, chest pain or near syncope.
Class II Patients with pulmonary hypertension resulting in a slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope.
Class III Patients with pulmonary hypertension resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes undue dyspnea or fatigue, chest pain or near syncope.
Class IV Patients with pulmonary hypertension with inability to carry out any physical activity without symptoms. These patients manifest signs of right heart failure. Dyspnea and/or fatigue may even be present at rest. Discomfort is increased by any physical activity.
What’s the mortality for pts with pulmonary HTN undergoing non-cardiac surg? morbidity?
What accounts for 60% of cases of periop mortality in pulmonary HTN?
1-18%
15-40%
Respiratory failure
What’s the updated definition of pulmonary HTN? What are the traditional cutoff values for grading severity of pulmonary HTN via the gold standard (PA catheterisation)? which pressure used?
MEAN pulmonary artery pressure >20mmHg & PVR >=3 wood’s units
Normal PAP is 25/8 with mean 15
mild 20-40mmHg
moderate 41-55mmHg
Severe >55mmHg
What distance on the 6MWT is considered significantly elevated M/M?
<=300m
TAPSE Cut-off values suggested for echocardiography?
TAPSE <17 mm indicates right ventricular systolic dysfunction
TAPSE <14 mm indicates a poor prognosis in patients with chronic heart failure
What VO2 max is 600m on the 6MWT?
15mL/kg/min
Definition of pulmonary HTN?
mPAP >=20mmHg on resting R) heart Cath
what recipe for PVB catheter?
0.2% ropivacaine, 20mL boluses 3-hourly
What are the STOP-BANG cutoffs?
low <3
intermediate risk 3-4
high risk >=5
How does STOP-BANG score correlate with risk of OSA?
Score 3 vs. 0-2, risk of OSA is 2.5 fold
4 vs. 0-2, OSA risk 3 fold
5 vs. 0-2, OSA risk 5 fold.
6 vs. 0-2, OSA risk 6 fold.
7 or 8 vs. 0-2, risk OSA 7 fold.
What are the AHI cutoffs for OSA severity on sleep study?
mild 5-14
moderate 15-30
severe >30
What are the items on the STOP-BANG questionnaire?
snore loudly
excessive daytime sleepiness
observed apnoeas?
Hypertension diagnosed?
obesity (BMI >35kg/m2)
Age >50
Neck circumference >=40cm
gender male
What’s the R-R interval with valsalva & normal values?
Ratio of the highest HR generated with valsalva (in phase 2) divided by lowest HR achieved (in phase 4) within 30 secs of the HR peak- normal >1.21, abnormal <1.10
How supplement K+ in DKA? when supplement?
10mmol K+ in 90mL Nsaline, supplement when potassium <4
What’s normal Hb for females?
120g/L
What’s co-phenylcaine?
5% lignocaine, 0.5% phenylephrine
What’s pituitary apoplexy?
acute haemorrhagic infarction of pituitary gland- where the blood supply is compromised by tumour or pregnancy. may occur with obstetric haemorrhage (Sheehan’s syndrome), major surgery, head injury, sickle cell crisis.
acute failure anterior lobe function, posterior lobe usually preserved.
severe headache, nausea & vomiting, visual field defects, cranial nerve palsies, failure of lactation in parturient.
Rx by management of adrenocortical failure (IV fluids, hydrocortisone, urgent transsphenoidal decompression).
What’s Fr size?
external diameter x3
What size bronchoscope do you need down a DLT if positioning requires confirmation?
2.5-3.5mm
What’s felypressin?
a non-catecholamine vasoconstrictor, chemically related to vasopressin, little antidiuretic or oxytocin-like actions, often added to LA such as prilocaine.
While NAdr may be useful for the “at risk” RV as it supports coronary perfusion by increasing aortic root pressure, at what doses does it increase PVR? what doses is it usually limited to for pts developing RV dysfunction?
> 0.5microg/kg/min
therefore, usually limit it to doses <0.2microg/kg/min
At what doses is vasopressin used as a vasopressor for pts with an “at risk” RV where NAdr has failed, given that vasopressin is not associated with incr PVR & may in fact be associated with decreased PVR at low doses?
1-4 units/min
At what doses is dobutamine generally given for RV failure?
2-5microg/kg/min
At what doses may dopamine be given to improve RV function in the setting of pulmonary vascular dysfunction? limitation?
<5microg/kg/min, tacchyarrhythmias
At what doses may IV milrinone augment RV function (improved contractility) with reduced RV afterload (reduce PA pressures)?
0.25-0.5microg/kg/min
What dose of digoxin may acutely improve CO by 10% in pts with RV failure without affecting HR?
1mg
what’s the change in BP (mmHg) per cmH2O?
1cmH2O = 0.75mmHg
What does biostate contain?
Human plasma-derived product, contains 50IU/mL FVIII & 100IU/mL vWF
vWF concentrates if <50IU/dL for pts with type 2 & 3 or those with type 1 where it can’t be raised with DDAVP
How prepare & administer dexmedetomidine for sedation?
into 20mL so 1mcg/mL
1mcg/kg bolus (could be 0.5mcg/kg if particularly concerned re hypoT/Brady) over 20 mins
then 0.2mcg/kg/hr (even up to 0.7mcg/kg/hr if require deep sedation eg. at stimulating points during awake craniotomy)
clear fluid guidelines?
adults up to 400mL 2hrs prior to procedure.
paediatrics: clear fluids (no > 3mL/kg/hr) up to 1hr prior to anaesthesia.
How to classify CKD?
grade 1 is GFR >=90mL/min
grade 2 is GFR 60-89mL/min
grade 3a is 45-59mL/min
grade 3b 30-44mL/min
grade 4 15-29mL/min
grade 5 <15mL/min
How to administer dantrolene?
20mg diluted into 60mL sterile water, give 2.5mg/kg total body weight
dosing for naloxone
1-4microg/kg, it comes in 0.4mg vial, dilute to 20mL
categories of hypothermia
mild 32-35degC
moderate 28-32degC
severe <28degC
NAGMA?
Methanol & other toxic alcohols
Uraemia
DKA
Pyroglutamic acidosis
Iron overdose
Lactic acidosis
Ethylene glycol
Saligylates
HAGMA?
Pancreatic secretion loss
Acetazolamide
Normal saline intoxication
Diarrhoea
Aldosterone antagonists
Renal tubular acidosis type 1
Ureteric diversion
Small bowel fistula
Hyperalimentation (TPN)
How to manage severe hypoglycaemia?
IV 25g of 50% glucose
What would you class as mild, moderate & severe hypercalcaemia?
<3mmol/L
mod 3-3.5
severe >3.5mmol/L
What would you class as mild, moderate & severe hypermagnesemia?
2-3mmol/L (nausea, flushing, headache, lethargy, drowsiness, diminished deep tendon reflexes) *for pre-eclampsia Rx, therapeutic serum [Mg++] is 1.7-3.5mmol/L
3-5mmol/L (somnolence, hypocalcaemia, absent deep tendon reflexes, hypotension, bradycardia, ecg changes)
> 5mmol/L (flaccid paralysis, apnoea, resp failure, CHB, cardiac arrest (resp failure usually precedes cardiac arrest)
Normal magnesium?
0.85-1.1mmol/L
what’s normal serum calcium (total?)
2-2.5mmol/L
At what rate should remi be run as a component of TIVA or with volatile?
0.05-0.3mcg/kg/min
How to execute cough less remi wakeup?
have remi running at >=0.1mcg/kg/min, extubate when the pt can follow commands (typically before spont resp efforts or recovery of airway reflexes)
Overall incidence of AAGA from NAP5? if no NMBD?
1 per 19,000
<1 per 130,000
Whats Adj40BW?
uses an adjustment factor of 0.4, providing an adjusted body weight in pts who are >20% of their ideal body weight, useful to account for distribution of drugs to non-lean tissues in obesity
This is:
Adj40BW = ideal body weight + (0.4 x (TBW - IBW))
How to calculate ideal body weight (the body weight associated with lowest mortality)?
height - 100 for males, 105 for females
Which drugs use ideal body weight & examples? exceptions to these rules?
water-soluble, eg: midazolam, ketamine, NDMBs, remi
exceptions= opioids & local anaesthetics, which should be based on lean and ideal body weight, respectively, in the obese
rocuronium=LBW
LMA sizing is based on ideal body weight, as are tidal volumes
How to calculate paediatric ideal body weight?
<8yo 2x age (yrs) + 9
>8: 3x age (yrs)
Nutshell summary of PADDI trial
multicentre international noninferiority trial with 8700 pts having GA for noncardiac surgery
risk SSI within 30 days of surgery similar if pts had 8mg IV dexamethasone vs placebo so do not consider risk of surgical site infection a reason to avoid dexamethasone
results similar in pts with & without diabetes
Does neostigmine significantly increase risk of PONV?
No
What are the APFEL risk factors for adults? % risk with each score?
female
non-smoker
postop opioids
Hx PONV or motion sickness
0=10%
1=20%
2=40%
3=60%
4=80%
What are the some risk factors for PONV for children? % risk with each score?
age >=3yo
Surgery >=30mins
strabismus surgery
Hx POV or FHx PONV
10%
10%
30%
50%
70%
What are pre- intra- and post-op risk factors for PONV in children in the 2020 4th Consensus Guidelines for Mx of PONV?
Pre:
Age >=3yo
post-pubertal female
Hx POV/PONV/motion sickness
FHx PONV
Intra:
strabismus surgery
otoplasty
adenotonsillectomy
surgical time >=30mins
volatiles
Postop:
long-acting opioid
What are pre- intra- and post-op risk factors for PONV in children in the 2020 4th Consensus Guidelines for Mx of PONV?
Pre:
Age >=3yo
post-pubertal female
Hx POV/PONV/motion sickness
FHx PONV
Intra:
strabismus surgery
otoplasty
adenotonsillectomy
surgical time >=30mins
volatiles
Postop:
long-acting opioid
What are pre- intra- and post-op risk factors for PONV in children in the 2020 4th Consensus Guidelines for Mx of PONV?
Pre:
Age >=3yo
post-pubertal female
Hx POV/PONV/motion sickness
FHx PONV
Intra:
strabismus surgery
otoplasty
adenotonsillectomy
surgical time >=30mins
volatiles
Postop:
long-acting opioid
which pts can’t use scopolamine patch? instructions for use? other side effects/precautions?
angle closure glaucoma
place at least 2hrs pre-induction, remove it within 24hrs postop
dry mouth, blurry vision. confusion/agitation esp in elderly or those w baseline cognitive impairment.
ondansetron paeds dosing
and dex
and metoclopramide
0.1mg/kg, up to 4mg
0.15mg/kg, up to 4mg
shouldn’t use UNLESS can’t use the other antiemetics & must NEVER use in chn <1yo (prolonged clearance). EPS 20x higher in children! if must use, 0.1mg/kg max 10mg.
Does adding droperidol to ondansetron increase the risk of QT prolongation?
the risk exists for either drug but it’s not additive
What are congenital causes of the long QT syndrome?
Jervell and Lange-Nielsen syndrome: profound bilateral sensorineural hearing loss from birth & long QT syndrome. very rare.
Romano-Ward syndrome: the most common form of congenital long QT syndrome.
Idiopathic