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Anaesthetic Viva Flashcards

(44 cards)

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1
Q

What drugs can be given via ETT?

A

Adrenaline 0.1mg/kg - 5mg in adult

Needs to be at least 3x IV dose
NAVAL
Naloxone, Atropine, Vasopressin, Adrenaline, Lignocaine

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2
Q

What is the dose of adrenaline in LAST?

A

Reduce to 50-100mcg to reduce risk of arrhythmia

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3
Q

What is the dose of intralipid?

A

Intralipid 20%
1.5ml/kg + 15ml/kg/hour
At 5 mins give another 1.5ml/kg bolus and double infusion
After another 5 mins give another 1.5ml/kg bolus
Max dose 12ml/kg
Refer for ECMO or continue CPR for 90 mins

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4
Q

What are the adverse effects of intralipid?

A

Pyrexia + seizures

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5
Q

What are the clinical features of LAST?

A

Neuro then cardiac
Perioral tingling, tinnitus, nystagmus, seizures/coma, apnoea
Hypotension, Arrhythmia
Cardiovascular collapse

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6
Q

What is the immediate management of LAST?

A

Stop further administration of LA
Call for help. Delegate tasks. Use cognitive aid.
Secure airway, hyperventilate, control seizures - midazolam>propofol
Intralipid 20%
1.5ml/kg + 15ml/kg/hour
Repeat up to 2 further bolus at 5 min intervals and double infusion at 5 mins
Max dose 12ml/kg

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7
Q

What is the DAS extubation guideline?

A

Plan/Prepare/Perform

Airway risk factors
-known difficult airway
-airway deterioration (trauma, bleeding, odema)
-restricted access (pins/screws/drain)
-Obesity/OSA (difficult BMV)
-Aspiration risk
Airway - supraglottic check - laryngoscope
Glottic - cuff leak - >110ml per tidal volume
Infraglottic - bronchoscopy or CT

General
-Cardiovascular - inotrope/vasopressors
-Resp - O2 req, PEEP, PS
-Neuro - GCS, muscle strength
-Metabolic/Temperature - ABG
-Special surgical/medical conditions

Optimise
Time - in hours
Location - in OT
Monitoring/Assistance - DA + ENT
Equipment - difficult airway trolley and bronchoscope

Assess
Low or High risk
Awake extubation
Airway exchange catheter
Postpone
Tracheostomy

Post extubation care
PACU/HDU/ICU - handover/documentation/monitoring/observation/staffing and experience

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8
Q

What are the advantages of Airway Exchange Catheter?

A

Cook AEC - difficult extubation
Can railroad or jet in emergency
83cm long, cannot fit bronchoscope

Aintree - LMA to ETT
56cm, fits slim green AMBU bronchoscope

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9
Q

What can be done to lower “venous bleeding”?

A

Lower CVP (3-5)

Positioning - Reverse trendelenburg
Low PEEP

Restrictive fluids pre-resection (1-2ml/kg/hr)
Deepen anaesthetic
GTN
Frusemide/Mannitol

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10
Q

Headache in pregnancy differentials

A

Obestetric - pre-eclampsia
Neurological
Benign - tension, cluster, migraine
Sinister - meningitis, SAH, Cerebral venous sinus thrombosis, stroke
Other - hyponatreamia, hypoglycemia, hypovolemia, drug withdrawal

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11
Q

Pregnancy GA considerations

A

Aspiration prophylaxis - sodium citrate + metoclopramide
Ramped position + L lateral tilt
VL
Surgeons prepped and draped
Paeds in room
RSI

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12
Q

MRI safety consideration

A

Remote anaesthesia
Limited access to patient - long lines, anaesthetic circuit
Ferromagnetic safety -patient/staff, pre-scan checklist, device MR conditional - PPM, MR pat down - remove phone, keys, stethoscope, increased vigilance with new staff
Noise/Burns protection - earplugs - fibreoptic ECG cables
Emergency evacuation - MR safe bed/staff available
Transfer destination ready to receive patient

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13
Q

Ruptured cerebral aneurysm

A

Communicate with proceduralist
Endovascular repair vs Transfer to OT for open procedure
Call for help
Secure airway/100% O2, turn up flows
SBP <160
Reverse heparin with protamine 1mg per 100 units over 10mins
Improve conditions - breath-hold, slow HR
ICP management - hyperventilate, paralysis, switch to TIVA, mannitol 1g/kg = 5ml/kg
Prepare for MTP
Prepare for transfer to OT
Open - MAP 50-60, atropine 24mg, Thiopentone 250mg up to 10mg/kg

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14
Q

Child difficult IV

A

Non pharm
-Reassurance, distraction, play therapy, parental assistance
-Ultrasound
-Infra-red transillumination
-Heat packs
Pharm
EMLA
Premedication -midazolam 0.5mg/kg, max 15mg wait 20mins, clonidine 4mcg/kg max 200mcg wait 45mins, ketamine 5mg/kg wait 20mins
Nitrous oxide
IM ketamine 4mg/kg

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15
Q

Hypertension under anaesthesia

A

Confirm reading
Pain/surgical stimulus/Tourniquet/Surgical infiltration of adrenaline
Light anaesthesia/Awareness
- stop vasoactives
- increase depth of anaesthetic/give opioid/check cannula/infusions/vapouriser
Hypercapnia (↑MV)
Full bladder
↑ICP
Rare - pheochromocytoma/thyroid storm/MH/drug interaction (MAOI, cocaine)

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16
Q

Airway Fire safety prevention

A

Oxygen/Fuel/Ignition

Close communication
Bucket of saline within arms reach
Fire extinguisher in room

Reduce FiO2 to 30%
Minimise fuel in surgical field - saline soaked gauze, laser resistant ETT, fire resistant drapes, iodine prep
Minimise diathermy/laser - announce clearly before use

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17
Q

Actual Fire in theatre - action

A

RACE
Remove - anyone in immediate danger
Alert - activate fire alarm or CODE RED
Contain - close windows/doors if no one is inside
Extinguish/Evacuate - extinguish small fires or evacuate. CO2 or ABE powder for electrical fire.

CO2 Fire extinguisher

PASS
Pull pin
Aim
Squeeze
Sweep

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18
Q

Tracheostomy emergency

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A

Call for help - ENT, ICU, Theatres, skilled airway assistant
Cognitive aid - confirm grade upper airway, indication/timing/type of tracheostomy
Difficult airway trolley
Fibreoptic scope
Video laryngoscope

Look listen feel
Assess for breathing - start CPR
Vitals, ETCO2

Apply oxygen to both face and tracheostomy

Remove speaking valve, attachment and inner tube
Pass suction catheter - determine patency

Unable to pass - deflate the cuff
Reassess

If no improvement, remove tracheostomy

Apply oxygen above
BMV, NPA, Guedels
LMA
Re-intubation orally - cuff beyond stoma

Stoma - paeds face mask or LMA

Reintubation stoma - small tracheostomy tube or ETT 6.0 or Aintree fibreoptic

19
Q

Paediatric URTI - proceed or delay?

Study These Flashcards
A

2-3x more likely to have peri-operative resp adverse events (laryngospasm, bronchospasm, apnoea)
If URTI within 2 weeks of anaesthesia

Higher if
Patient - atopy or reactive airways disease, exposure to smoking, younger than 1 years old, premature, airway abnormalities (subglottic stenosis, Pierre Robin, cleft palate, laryngotracheamalacia)
Surgical - ENT or airway surgery. Urgency
Anaesthetic - inhalational induction, airway instrumentation (ETT>LMA>mask), TIVA maintenance, lack of experience of anaesthetist and skilled assistant

Shared decision making- Surgeon, Parents, HDU

Delay for 2 weeks if - oxygen requirement, fever, moist cough, lethargic
Younger than 1, pre mature, chronic conditions
Asthma
Airway surgery
Intubation required

Proceed if - minor symptoms - runny nose, dry cough
Urgent surgery
Short duration of surgery
Experienced team
Social factors -
Multiple cancellations, Long distance travelled

20
Q

What are the components of consent in a child?

Study These Flashcards
A

Gillick Competenance - common law
- fully understands proposed treatment, risks, alternatives and consequences of no or delayed treatment. No age is set.
- If a child is not competent, parental consent must be obtained.
Minor’s cannot refuse lifesaving intervention

21
Q

DKA diagnosis and treatment

Study These Flashcards
A

Diabetes or BSL >11. Ketones>1.0 pH <7.3
IVF resuscitation - crystalloids 20ml/kg
K replacement - K>4.0
Insulin 0.1units/kg/hr - aim to reduce BSL by 2-5mmol/h

22
Q

SGLT2i euglycemic ketoacidosis - diagnosis

Study These Flashcards
A

Ketones >1.0, BE more negative than -5.
Start insulin 0.1units/kg/h + dextrose 5% 100ml/h
Keep BSL 5-10 and Ketones <1
Consult endocrine for peri-op management

Stop infusion if no DKA and eating >50%
Restart SGLT2i >48h after full diet

23
Q

Modified Parkland formula

Study These Flashcards
A

3-4ml/kg x TBSA
Warmed Hartmanns
>20% adults, >10% paeds (dermal and full thickness burns)
1/2 in 8h since burn and 1/2 over next 16h
Aim UO 0.5-1ml/kg/hr, 1-2ml/kg/hr if electrical or inhalational injury

24
Q

Tertiary Burns unit transfer

Study These Flashcards
A

Adult >20%, Paeds >10%
Intubated
Inhalational injury
Head/neck
Circumferential
Severe chemical/electrical injury
Any escharotomy or fasciotomy
Age + %TBSA >100 = poor prognosis

25
Burns analgesia (agitated and intoxicated)
Apply oxygen and monitoring Morphine 10mg then 2.5mg boluses to max 20mg Ketamine 10mg boluses to max 50mg Secure airway for patient and staff safety
26
Fluid assessment in burns/intoxicated/pain
Vitals are unreliable (RR, HR, BP) Most reliable - lactate, haematocrit, TTE, IVC diameter and collapsibility (1cm from hepatic vein 2.0cm or less or >50% collapsible, CVP Inputs since burn
27
Advantages of Regional
-avoids airway complications - CICO, aspiration, sore throat, dental damage -avoids haemodynamic compromise -less risk of anaphylaxis -faster recovery, earlier mobilisation -less nausea/vomiting, pain and opioid consumption, delirium, post-op cognitive dysfunction
28
Disadvantages of Regional
-failure, bleeding, infection, nerve damage - temporary/permanent, LAST, anaphylaxis -patient needs to lie flat and cooperate for the duration of surgery -no motor block from ankle -needlestick/sharps injury to staff -conversion to GA mid case always more risky than from start
29
Advantages of GA
-Patient is unconscious and unaware -Still surgical field -Controlled ventilation -Faster onset -No time limit
30
Hyperosmolar Hyperglycemia State -diagnosis and treatment
-relative insulin deficiency -BSL >30, hypovolemia up to 10L negative, altered LOC -serum osmol >320 -2x Na + BSL + Urea -IV fluid resuscitation - isotonic crystalloid 30ml/kg -Art line -Monitor and correct electrolytes - usually hypoK, replace K -IV insulin 0.1 units/kg -Identify and treat infection or MI as precipitant -Aim to reduce BSL by <5mmol/h , hourly BSL and ABG -Consult Endo/HDU
31
Local +/- sedation vs GA from start
Cooperation - cognitive impairment, language barrier, anxiety Lie flat and still- heart failure, back pain, tremor Aspiration - GORD/GLP1 agonist, fasting status Obstruction - OSA
32
Hyperkalemia - severity, causes
Mild 5.5-6.0 Mod 6.0-7.0, Severe >7.0 Increase production - haemolysis, rhabdomyolysis, tumour lysis Shift - resp or metabolic acidosis Decreased elimination - CKD Medication - ACEI, spironolactone
33
Hyperkalemia - treatment
Treatment Stabilise myocardium - Calcium gluconate 10% 10ml Hyperventilate Shift intracellularly - Salbutamol 5mg neb, Insulin 0.1u/kg + dextrose 50% 50ml, NaHCO3 8.4% 1ml/kg Frusemide 40mg IV Resonium 30g PR Dialysis Response to treatment Proceed if K<6.0 or ECG changes resolved Avoid Sux, acidosis
34
Neurogenic shock - cause, treatment
Injury above T6, reduced cardioaccelerator fibres T1-T4 =bradycardia, veno/vasodilation below level of injury, reduced venous return - hypotension Fluid bolus 250ml repeat, Vasopressors MAP>70 (spinal cord perfusion) Avoid/minimise Vagal stimulation - suction/NGT insertion/intubation - treat atropine 600mcg, may need external pacing
35
Pre-eclampsia - definiton
After 20/40 SBP >140, DBP >90 Proteinuria
36
Severe Pre-eclampsia -diagnosis
BP >160/110 -oliguria -haemolysis -transaminitis/RUQ pain -low platelets <100 -APO/Chest pain -headache -severe IUGR
37
Severe pre-eclampsia - treatment
Oral agents - labetalol 100-400mg TDS, nifedipine 60mg bd, methyldopa 1g TDS IV - GTN 50mcg, labetalol 10-20mg over 10min, hydralazine 5-10mg over 10min Aim for SBP 140/90 MgSO4 4g over 20mins, 1g/h MAGPIE NNT 50 for severe, NNT 100 for moderate Check Mg 1.5-3.5, toxic 4mmol, stop Seizure give another 2g over 20mins
38
Which papillary muscle is most likely to rupture and why?
Posteromedial - only supplied by RCA
39
Headache post epidural - work up and treatment
-Postural headache that gets better with lying flat -typically 24-72 hours post dural puncture -Rule out red flag signs - fever, meningism, severe photophobia, neurological deficits - saddle anaesthesia, urinary retention/faecal incontinence, seizures - neuro review/MRI * Conservative - hydration, bedrest, caffeine * Pharmacological - paracetamol, ibuprofen, oxycodone * Conflicting/low level evidence - synacthen, dexamethasone, sumitriptan * Regional - sphenopalatine/greater occipital blocks Definitive - epidural blood patch
40
Tachycardia - differentials
Check rhythm and BP Rule out anaphylaxis/VT/VF/new AF Most common - light anaesthesia, pain from surgical stimulus, hypovolemia (bleeding, fasting, sepsis) Cardiac - arrhythmia, ischemia Resp - hypercarbia, hypoxia Shock - pneumothorax/PE, tamponade Electrolytes - hypo K/Mg Hypermetabolic - hyperthermia, hyperthyroidism, anaemia, Hypoglycemia Drug withdrawal
41
Paeds aspiration - bronchoalveolar lavage
1ml/kg up to 20ml Up to 3 times Keep intubated and send to ICU ventilated
42
Obesity - considerations
Difficult BMV/Intubation/FONA. Fast desaturation, ↑aspiration risk. Difficult IV/regional/neuraxial/surgery Manual handling - extra staff, hovermat, troop pillow, bed extensions, bariatric bed Screen for OSA/OHS/RV failure. Multimodal analgesia, minimise opioids. NIV post op/HDU Screen for HTN, T2D, fatty liver, Obese cardiomyotpathy - LAD, prolonged QT, flat T waves and small QRS
43
Upper arm motor
Musculocutaneous C5/C6/C7- elbow flexion Axillary C5/C6 - arm abduction, ext rotation Radial C5-T1 - wrist, elbow extension, supinate Median C5-T1 - finger, wrist flexion, pronate, abduct thumb Ulnar C8/T1 - finger, wrist flexion, adduct thumb
44
Sciatic nerve block

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