SAQ Flashcards
How would you identify a patient with autonomic neuropathy associated with diabetes?
What are the anaesthetic implications?
CVS-orthopaedic presyncope, exertional dyspnoea separate from other CVS disease eg IHD
GIT - early satiety , nausea and vomiting, nocturnal diarrhoea, erectile dysfunction, urinary retention/ incontinence - barium swallow
History of long standing or poorly controlled
Exam CVS -Resting tachycardia 90-130, reduced HR variability <15bpm, Postural hypotension >20mmHg lying ->standing 2 mins
Blunted HR response to modified Valsalva
Investigations
ECG - tachycardia, prolonged QT
Positive tilt table test
Positive gastric emptying study
Pre Op
Overall CVS morbidity/mortality double
Increased Risk of dysrhythmias
Often associated LV dysfunction - further
Risk of CVS instability on induction, position changes, and blood loss
- place arterial line, check euvolemic, slow position changes .
RSI - and ETT / gastroparesis
Place arterial line -> flucuating BP with exaggerated response to stimuli
Altered baroceptor response and may not develop reflex tachycardia with GA and Neuraxial = hypotension
Positioning - head up - hypotension - need vasopressor
head down / supine - hypertension - GTN
Blood loss - wont tolerate need to keep euvolaemic
Sympathomimetics - may have exagerrated responses and need to consider dose reduction eg trial 0.25mg metaraminol.
Discuss key areas of concern in your preoperative assessment of a patient for excision of large tonsillar mass
KEY AREAS:
Assess airway
Other comorbidites
Adjacent Structures
Mass effects and Plan for induction
- evidence of dysphagia, dysphonia , postural dyspnoea suggesting mass effect on airway, may have difficulty positoning with intubation, may not tolerate supine, difficult face mask ventilation and intubation.
Need to consider airway technique, including awake tracheal intubation , AFOI, I would review CT, fibreoptic nasal endoscopy and d/w ENT surgeon
Adjacent Structures/Metastatic Spread
- may require neck dissection / flap
- more extensive surgery , operative bloodloss, operative time.
- consider pre op Hb, need for HDU post operatively
Patient Comorbidities
- Age - HSV, SCC
If older likely to have significant ETOH/ Smoking intake
may have COPD
Functional Assessment - and cardiovascular risk factors
OSA - may not be able to use CPAP post op
Minimal time to optimise as cancer sugery
Post op disposition - depending on planned surgery , patient comorbidites and effect of airway post op.
30 year old with bilateral fractured femurs
Diagnosed with Fat embolism syndrome
Outline Pathophysiology
Describe principles of management
FES - rare - respiratory failure, neurocognitive defect, petechial rash death
Occurs predominantly post long bone fractures >95%
Two Theories:
Mechanical: embolised fat occluded pulmonary vasculature -> increased PAP -> V/Q mismatch and hypoxia
Increased RV pressure -> strain RV failure
Arteriovenous shunt w patent PFO –> microemboli TIA/CVA
Biochemical:
SIRS response to circulating fat emboli
increase free fatty acids - > myocardial depression and ARDS
increased cytokins -> capillary leakage and vascular haemmorhage –> disseminated intravascular coagulopathy
Mgmt
No definitive treatment all supportive
Prevent if possible -> early immobilisation an operative fixation, limit intramedullary pressure when reaming, use intramedullary ventilation
Supportive
A - may need intubation if hypoxic and confused
B - ARDS Ventilation
C- Support RV may need inotropes/ pulmonary vasodilators
D - exclude all other causes of acute confusion eg stroke, drug withdrawal, delirium
monitor for coagulopathy - risk of DIC consider thromboelastographic
Most patients recover spontaneously, findings are transient and reversible often within a few days.
Some severe cases can persist beyond a week
7 year old non verbal severe spastic cerebral palsy for cystoscopy
Describe important features of CP relevant to planning anaesthesia for the procedure
What are the advantages and disadvantages of inhalational induction in this child
Non verbal is associated with poorer outcomes, lower intellect and potentially increased anxiety.
Associated comorbidities
Restrictive lung disease - due to prematurity , poor cough, aspiration and scoliosis - ensuring they dont have a current LRTI - may require HDU post op if significant lung disease
Epilepsy ~50% of CP - identify trigger, and frequency of seizures - ensuring seizure medications continued perioperatively to minimise seizure risk
Muscle contractions/Spasticity - ensuring baclofen continued periop, consider vascular access, and positioning on surgical table.
Malnourished - low fat content risk - intraop hypothermia
Airway / bulbar dysfunction - increased aspiration risk, usually PEG/NGT fed, often poor dentition , spasticity can cause TMJ dislocation - care with airway manipulation
Periop anxiety - often high due to recurrent hospital admissions and operations, need to be mindful engage with parents/carers consider premed.
GAS INDUCTION
Advantages
avoids distress with IV access
can mantain spont breathing
suitable for impaired/uncooperative child
can induce in comfortable position eg wheelchair
Disadvantage
Higher aspiration risk
Slower induction time compared to IV
increased excitement phase -> increased laryngospasm
cannot use in MH susceptible
increased emergence delirium compared to TIVA
A patient is planned to undergo prolonged steep head down surgery
Outline potential anaesthetic implications in this position in this situation
Describe how you would modify your anaesthetic plan to minimise these.
Airway - prolonged sleep head down - increased risk of airway oedema, endobronchial intubation
-level out as soon as possible, perform cuff leak test prior to extubation,
risk of endobronchial intubation, recheck ETT position, auscultate lungs once head down
Ventilation - increased intraabdominal pressure + gravity effects - decreased FRC, atelectasis, v/q mismatch - hypoxia. / increased intrathoracic pressure - -> airway pressure -> volu/barotrauma or decreased TV
Use NM
An obese 55 year old has undergone a sleeve gastrectomy which finished an hour ago. PACU blood pressure is 190/110.
How would you approach?
I would review the patient in PACU
Determine baseline reading to see if one off or part of trend
Confirm the reading as Obese - ensuring appropriate cuff size to confirm accuracy of measurement
I would then take a history from the patient looking for causes of HTN
acute: pain, nausea and vomiting and urinary retention.
chronic: hypertension and if they had taken their regular medication.
Determine if any end organ damage eg migraine and visual disturbance
MANAGMENT
IF reversible acute condition treat first eg opioids
If not and no evidence of end organ damage i would give Hydralazine 5mg Q20mins IV aiming to return to within 20% baseline BP
If they have not take regular meds chart - with gastrectomy can they eat??
Ward follow up.
You are asked to initiate an opioid PCA service in your hospital,
How would you ensure patient safety?
What are the key components to include in designing an order form?
Design - Stakeholders engagement - surgeon, nurses, anaesthetists
Equipment - standardised and safety devices
Protocol - Referral - Patient selection, High risk patients (Obese, OSA), nursing requirement observations, o2 requirements, oximetry. APS
Implementation and Education - Training of staff
Audit and Follow up
PCA Order Form Patient details Drug Order Prescriber O2 requirement Emergency drug order
68 with severe Parkinsons disease for elective right hemicolectomy . Current meds are levodopa/bensrazide and selegiline (MAO)
What clinical features of PD affect anaesthesia? 50
Justify your perioperative drug management plan 50
Airway - bulbar dysfunction, drooling, risk of aspirations
Breathing - restrictive lung disease - difficult spontaneous ventilation, increased OSA and sensitivity to opioids
Circulation - autonomic dysfunction -
increased incidence of arrhythmias
CNS - dementia - difficult consent, increased risk post op delirium,
Tremor - difficult IV access, and monitoring eg NIBP or SpO2 if sedated
Ridgidty - positioning
PREOP
Continue all PD medications to avoid withdrawl syndrome - Arrange to be first on OT list to minimise delay and fasting, can have tablets with small H20 - low aspiration risk
INtraop
Long case and bowel surgery
- after GA place NGT and continue PD medications (short T1/2) and risk of withdrawl
Avoid any D2 antagonists eg droperidol , metoclopramide as will precipitate PD crisis.
Use TIVA to minimise PONV risk so can resume oral diet asap
Avoid serotinergic contraining drugs eg Tramadol as on MAOI and risk of Serotonin Syndrome
Also avoid Ondansetron as 5HT3 antagonist and could also precipitate SS
Post Op
Aim to resume oral diet ASAP
If develops illeus - early discussion with PD specialist regarding Iv/transdermal dopamine agonist
Explain your approach to VTE in patients undergoing total knee replacement
PREOP
REally THrombotic risk vs bleeding risk
Patient Factors
Surgical Factors - revision, bilateral
Determine VTE risks eg previous VTE, prothrombotic conditions, obesity, reduced mobility.
Contraindications to LMWH eg renal failure, allergy
Educate on VTE risk and need for LMWH for ~3/52 post op to ensure compliance
INTRAOP TEDS and SCDs to non operative limb Multimodal analgesia including adduction canal - minimise pain promote early mobilisaiton Intraop anticoagulation Temperature regulation Patient positioning
Post OP
Ensure LMWH charted
TEDS/SCDs on non op leg
Adaquate analgesia to promote mobilisation and physio
Prior to d/c patient education on LMWH for next few weeks
Educate patient that needs to contact doctor if develops sign of VTE or swollen leg.
A patient on a morning endoscopy list is planning to return home in a taxi. She has already taken her morning colonoscopy prep
What are your considerations for discharge planning for this patient?
Guidlines
Care of responsible adult for 12-24hrs post procedure
Patient has spent last few days preparing for procedure with bowel prep
Determine indication of procedure ? Discuss urgency of procedure with proceduralist
If alternative care arrangements can be made eg with family member or overnight admission.
Discussion of patients wishes eg stay overnight , delay procedure
If discharged without procedure -follow up re welfare and rebooking
Determining how this was missed in booking process to avoid this situation in future.
70M post radical prostatectomy under GA, on emergence crushing central chest pain, restless cold clammy. BP 90/50, HR 110, SpO2 95% via hudson
ECG = widespread STEMI in anterior leads
IMMEDIATE MANAGEMENT
TREATMENT PRIORITIES
Anterior STEMI - LAD Lesion
Alert Theatre Staff
Get assistance and resus trolley with defibrillator
Optimise myocardial supply/demand
A- ensure patent - talk to patient, reassure, give analgesia
B SpO2 >94% , avoid hypoxia and hyperoxia
C - BP 90/50 ,HR 114
- aim MAP >65 n, DBP >40 as LAD territory
HR 60-80
Balance of perfusion vs demand
Ix hypotension - 2nd contractility, LAD, Preload bleeding/under resus, Afterload - residual anaesthetic agent
Correct fluid state with IV fluid and metaraminol if required
Check Hb >90 - O2 delivery
Treat chest pain with IV fentanyl - decrease SNS
Once BP improved eg SBP >100, give GTN S/L 400mch then consider infusion
Repeat serial ECG, troponin UEC. Consider arterial Line
Periop TTE if avaviliable
D/W cardiology regarding reperfusion
Stabilisation of patient - goals above Reperfusion vs Anticoagulation MDT with cardiology/surgeons thrombolysis contraindicated with recent surgery needs angiogram
risk/benefit of antiplatelets and recent surgical patient . D/W surgeon what they will accept eg aspirin
Transfer-
Dependning on location may need time critical transfer ideally 90mins to cath lab.
You are asked to assess a 35 woman on labout ward. uncontrolled HTN @ 34 weeks. BP 180/110 and urianalysis 3+ of protein
Her obstetrician wants to deliver her ASAP
Outline your management to optimise her status prior to transfer
Patient has severe PET with end organ dysfunction
BP Management
Aim >160/90 to decrease stroke/seizure risk
target 140/90 placenta perfusion dependant (avoid hypotension)
1) labetalol 20mg IV Q10mins Max 80mg
2) Hydralazine 5mg Q20mins Max 20mg
Seizure prophylaxis
Commence Mg infusion - 4g over 30mins then 1g/hour
Monitor for SE resp depression/loss of deep tendon reflexes
Assess for end organ damage eg HELLP
FBC + Film - haemolysis, thrombocytopaenia - or falling
UEC - acute kidney injury LFT/Coag - hepatic dysfunction ASSESS FLUID STATUS - CVS - fluid balance (hard) assess for pulmonary oedema restrict fluids <80ml.hr
ENdure 16G IVC, Group and Hold
Fetus CTG monitoring to determine fetal status
Theatre - determine urgency with OBS and availiability of theatre space
ACROMEGALY
OUTLINE FEATURES
HOW DOES THIS DIAGNOSIS AFFECT YOUR ANAESTHETIC MANAGEMENT?
ACROMEGALY is a result of excessive growth hormone and IGF-1
ISSue
airway - mandibular and maxillary enlargement , macroglossia, hypertrophy of epiglottis, thickening of vocal cords.
Bagmask ventilation may be more difficult use adjuncts
Use videolaryngoscope electively, may need smaller ETT
CVS
HTN/LVH/Arrhythmias and cardiomyopahty - biventricular failure –> ECG/TTE , cardiology review, HTN management with octrotide, IAL, maintain MAP
RESP
OSA –> preop screening STOPBANG and HCO3 if not on CPAP, Caution with long acting opioids, Cant use CPAP post op -> HDU
ENDO
Glucose intolerance and T2DM – monitor BSL, may need insulin infusion aim BSL 6-10
TSH - may be low endocrine review check TFTs, check for giotre
ACTH - may be low - may need stress dosing of steriods - confrim with endo. Avoid dex as affects post op testing
NErve injury - positioning / padding
What is EBM?
Describe the features of a systematic review, indicating how it may influence your practice of anaesthesia.
EBM is the conscientious explicit and judicious use of current based evidence in making decision about care of an individual patient
System Review
Identify clinical question
Define inclusion and exclusion criteria
extensive international literature research
Select and appraise all relevant research
- eg quality of evidence, inclusion criteria.
Extraction of data
Analysis of data
Presentation and interpretation of results
Large systematic review are designed to collate all empiric evidence and analyse it with a view to minimise bias and this provide more reliable findings.
A large Systematic review may influence practice as a significant result may change national/international guidelines.
Allows evidence for judicious use of knowledge in a clinical situation for an individual patient
Classify the causes for patient awareness under general anaesthesia
Evaluate the use of BIS in reducing the RISK of awareness
PATIENT
- inadequate drug dose - obesity, tolerance -ETOH
unable to delivery sufficient dose - unstable, trauma, cardiac
ANAESTHESIA
Human error - wrong dose, unfamiliar drug, eg STP, NDMB
difficult airway, experience, out of hours
Equipment - cannula failure, pump failure, error in monitoring, failure in titration.
Awareness is RARE Cochrane review Low grade evidence BIS vs CLinical Signs in general population (B-aware) In high risk bIS vs ETAG no difference
Overall rare but devestating i use it with TIVA and NDMB + IN CONJUNCTION WITH FASTIDIOUS MONITORING AND PREPERATIOn
