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Phase 3b > ACC > Flashcards

ACC Flashcards

1
Q

3 components of anaesthesia and sedation

A

hypnosis
analgesia
muscle relaxant

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2
Q

3 types of local anaesthetic technique

A
  • local
  • regional - target specific nerves
  • neuraxial - spinal/epidural
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3
Q

spinal anaesthesia - subarachnoid block

A
  • needle into CSF
  • bolus injected
  • lasts ~ 2h
  • rapid onset
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4
Q

layers a spinal goes through

A
  • skin - supraspinous ligament - interspinous ligament - ligamentum flavum - dura
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5
Q

epidural

A
  • catheter into extradural space
  • continuous infusion
  • larger doses and slower onset
  • anaesthesia or analgesia
  • thoracic or lumbar
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6
Q

mechanism of local anaesthetics

A
  • reversibly block Na channels so inhibit action potential
  • affect smaller, unmyelinated nerves first
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7
Q

order of block and affects of nerves affected by local anaesthetics

A

o B fibres - autonomic (vasodilatation)
o C and Aδ fibres - pain and temperature
o Aβ fibres - light touch and pressure
o A⍺ and Aγ fibres - motor and proprioception

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8
Q

use of adrenaline with local

A
  • causes vasoconstriction which reduces bleeding and prolongs local (reduces tissue uptake)
  • don’t use adrenaline in end arteries
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9
Q

lidocaine

A
  • Immediate onset|15 minutes duration
  • Small procedures
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10
Q

bupivacaine

A
  • Regional, spinal & epidural
  • 10 minute onset
  • 2 hours anaesthesia|12-24 analgesia
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11
Q

opioids and local

A

used in epidurals alongside local anaesthetic for pain relief and improves the effect of locals

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12
Q

what is sedation

A

drugs given to reduce anxiety, reduce consciousness, reduce airway irritability, induce amnesia

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13
Q

short term sedation

A
  • IV Midazolam
  • Endoscopy
  • Regional anaesthesia
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14
Q

long term sedation

A

IV propofol +/- alfentanil

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15
Q

IV vs inhaled hypnotic drugs

A

-IV has rapid onset and depresses airway reflexes, apnoea common
- inhaled has slower onset but may irritate airway (normally keep breathing)

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16
Q

3 inhaled hypnotics

A
  • Isoflurane – cheapest, used for maintenance
  • Desflurane – maintenance, wears off quickly
  • Sevoflurane – induction and maintenance
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17
Q

3 IV hypnotics

A
  • Propofol – quick, most common, also an antiemetic, fast redistribution and recovery of consciousness
  • Thiopental – quick, emergency anaesthetic
  • Ketamine – used in CVS instability, also analgesic
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18
Q

simple airways

A
  • Airway manoeuvres – head tilt, chin lift, jaw thrust
  • Facemask – basic, for bag-mask-ventilation (BMV)
  • Oropharyngeal – Guedel airway device in mouth to aid BMV
  • Nasopharyngeal – aids BMV, used in seizures
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19
Q

advances airway

A
  • Laryngeal mask – sits above laryngeal inlet, iGel, spontaneous breathing, insert blind
  • Endotracheal – insert with laryngoscope, enters trachea, cuff inflated to protect the airway
  • Tracheostomy
20
Q

T1RF

A
  • Inadequate oxygenation due to alveolar collapse (eg pneumonia) or fluid in the alveoli (eg left HF)
21
Q

CPAP

A
  • T1RF
  • maintains minimum airway pressure to keep lungs open and force fluid out.
22
Q

T2RF

A

inadequate ventilation due to limited alveolar expansion

23
Q

BiPAP

A
  • Biphasic/Bilevel positive airway pressure
  • Used for insufficient alveolar expansion T2RF
  • Has a base expiratory pressure (CPAP) then increases for an inspiratory pressure to help expand the lungs
24
Q

non-polarising muscle relaxants

A

o Routine and emergency anaesthesia
o 120-180s onset
o Atracurium, rocuronium (rapid onset), vecuronium
o Competitively inhibit Ach preventing depolarisation and contraction

25
Q

depolarising muscle relaxants

A

o Emergencies
o 30s onset
o Suxamethonium – is 2 Ach molecules bolted together so binds to two sites simultaneously (non-competitive) causing contraction then keeps pore open so prevents further contraction

26
Q

drugs used to increase HR

A
  • anticholinergics - inhibit ACH (vagus nerve)
  • beta adrenoceptor agonists - increase HR and contractility by stimulating beta receptor in myocardia cells (dobutamine using in ITU for HF)
27
Q

anticholinergics used to increase HR

A

o Atropine – crossed BBB, quick acting
o Glycopyrrolate – doesn’t cross BBB, slower acting, commonly used under anaesthesia for bradycardia

28
Q

managing low BP with vasoconstrictors

A
  • Alpha agonists – increase BP by causing vasoconstriction in peripheral vessels
  • Vasoconstrictors may be peripheral vi cannula (phenylephrine, metaraminol) or central via central line (noradrenaline)
29
Q

managing low BP and HR

A
  • combined beta and alpha agonist (ephedrine)
    o Adrenaline also has both effects but is very potent so only used in arrests/ITU
30
Q

fluid distribution

A

– 60% of body weight, 70kg adult has 42L
o Intracellular fluid – 2/3 TBW
o Extracellular fluid – 1/3 TBW
- Interstitial fluid – 2/3 ECF
- Intravascular fluid – 1/3 ECF

31
Q

fluid composition

A

o ICF – Na 8mmol/l, K 151mmol/l
o ECF – Na 140mmol/l, K 4 mmol/l

32
Q

crystalloid fluid

A

o Water + electrolytes
o Rapidly moves from intravascular space
o Hypertonic – draws fluid into the intravascular compartment
o Hypotonic – shifts fluid out of the intravascular compartment
o e.g. 0.9% saline (can cause hyperchloraemia), Hartmann’s (contains K+ , do not use in renal failure), Plasmalyte, dextrose-saline, dextrose (5, 10, 50%)

33
Q

colloid fluid

A

o Contains large insoluble molecules e.g. proteins
o Stays in intravascular space
o Attract water from cells into blood vessels - short term effect
o e.g. all blood products, human albumin solution, gelatins and starches (no longer used)

34
Q

fluid used t manage volume replacement

A

Hartmann’s
Saline

35
Q

pain management ladder

A
  • mild – paracetamol, NSAIDS
  • moderate – codeine, tramadol
  • severe – morphine
36
Q

NSAIDS

A
  • inhibit COX
  • COX 1 makes protective prostaglandins (gastric mucosa, platelet aggregation)
  • COX2 makes inflammatory prostaglandins
  • reduces prostaglandin synthesis but increase leukotrienes so can’t use in asthma
  • SE - peptic ulcers, AKI, blood thinning (especially aspirin which inhibits thromboxane A2)
37
Q

opioids vs opiates

A
  • Opioids are synthetic, opiates are natural opioids
38
Q

pre-op opioids

A

o Weak – codeine, tramadol
o Strong – morphine, oxycodone, methadone, buprenorphine
o Modified release – fentanyl patch, morphine sulphate tablets, oxycontin

39
Q

intra-op opioids

A

o Rapid onset/offset
o Fentanyl/alfentanil – injections or infusions, fentanyl more potent but slower acting
o Remifentanil – ultrashort acting with rapid onset/offset, metabolised differently to other opioids, wide therapeutic index, infusion only

40
Q

post-op opioids

A

o Codeine – prodrug (metabolised into morphine in liver), contraindicated in children, oral/IM
o Tramadol – acts on noradrenaline/opioid/serotonin receptors, oral/IV
o Morphine – oral

41
Q

critical care opioids

A

o Alfentanil – infused drugs accumulate over time, alfentanil best for low accumulation
o Morphine – for ongoing pain, will accumulate, often used as PCA (patient controlled analgesia)

42
Q

triggers of vomit centre

A
  • Higher centres – emotion (fear, anxiety)
  • Cerebellum – vestibular system
  • Solitary tract nucleus – pharynx, GI tract
  • Chemoreceptor trigger zone – blood-borne emetic
43
Q

Serotonin (5HT-3) receptor antagonists for antiemetics

A
  • ondansetron
  • acts on CTZ and GIT for drugs and visceral stimuli
  • avoid in QT prolonging drugs (SSRI, antipsychotics)
44
Q

D2 receptor antagonists for antiemetics

A
  • Metoclopramide, domperidone
  • Site of action – CTZ, upper GIT
  • Mechanism – prokinetic: relaxes the pylorus, reduces lower oesophageal sphincter tone, increases gastric peristalsis
  • Side effects – diarrhoea, extrapyramidal side effects with metoclopramide e.g. acute dystonia. Domperidone does not cross BBB so no effect
  • don’t use in GI obstruction/perforation
45
Q

H1 receptor antagonists for antiemetics

A
  • Cyclizine, cinnarizine, promethazine
  • Site of action – vomiting centre, vestibular system
  • use in motion sickness and vertigo
  • avoid in prostatic hypertrophy as can cause urinary retention
46
Q

rough guide to antiemetic use

A
  • Ondansetron – post op N/V, after acute opioid administration
  • Cyclizine – post op, motion sickness, after acute opioid admin
  • Metoclopramide – long term opioid use (can reduce constipation aswell)
  • Domperidone – premedication for patients at risk of POST OP n/v
  • Prochlorperazine – vertigo
47
Q

post-op N+V risk factors

A
  • Patient Factors - Female, Previous PONV, History of travel sickness, Non-smoker
  • Surgical factors - ENT, gynae, and GI procedures
  • Anaesthetic factors - Peri-operative opioid use, Gastric insufflation during intubation, Volatile anaesthetics, NO2 use, Duration of anaesthesia

Phase 3b (5 decks)

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