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Anaesthetics Flashcards

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1
Q

What is the ASA grading system?

A

Grade I; normal healthy patients, non smoker, no/ minimal alcohol intake

Grade II; mild systemic disease such as well controlled diabetes or hypertension, current smoker, obesity (BMI; 30-40), mild ling disease

Grade III; severe systemic illness such as poorly controlled diabetes/ hypertension/ COPD. morbid obesity (>40), history of ACS/ stroke/ TIA >3 months ago

Grade IV; severe systemic illness that is a constant threat to life e.g MI/ stroke/ severe valve problems, TIA within 3 months, sepsis, severely reduction in ejection fraction

Grade V; moribund patients not expected to survive operation such as ruptured abdominal aortic aneurysm, massive bleed, intracranial haemorrhage with mass effect

Grade VI; patient is declared brain dead and whose organs are being removed for

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2
Q

Causes of airway compramise?

A

Anaphylaxis
Thermal injury
Neck haematoma
Wheeze
Surgical emphysema
Reduced consciousness

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3
Q

Simple airway manoeuvres?

A

Suction; if visible blood, vomit, secretions or foreign body
Turn patient onto side
Head tilt and chin lift
Jaw thrust
Hook both fingers under the angle of the jaw and lift mandible forwards

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4
Q

Airway adjunct options?

A

Oropharyngeal airway; Guedel
Rigid plastic tube
Nasopharyngeal airway
Flexible rubber tube

Suppraglottic airway;
Laryngeal mask airway
i-Gel

Endotracheal tube

Surgical airway;
Tracheostomy
Cricothyroidotomy

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5
Q

Causes of C-spine injury?

A

Motor vehicle collisions
Falls from height
Diving accidents
Sports-related injuries, particularly contact sports and high-velocity sports
Direct impact to the head or neck
Acts of violence such as gunshot wounds or stabbings

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6
Q

Signs and symptoms of C-spine injury?

A

Neck pain
Decreased range of motion in the neck
Focal neurological deficits, such as weakness or numbness in the arms or legs
Signs of spinal shock, including flaccid paralysis and loss of bowel or bladder control

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7
Q

Differentials for C-spine injury?

A

Whiplash injury
Thoracic/ lumbar spine injury
MSK injuries
Traumatic brain injuries

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8
Q

What is the NEXUS critieria?

A

Used to identify low risk of C-spine injury, unlikely if the following are met;

Normal level of alertness
No evidence of intoxication
No painful distracting injuries
No focal neurological deficit
Absence of midline cervical tenderness

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9
Q

Investigations for C-spine injury?

A

History and examination
NEXUS criteria
CT spine

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10
Q

Management of C-spine injury?

A

Airway management
Semi-rigid collar
Secure heads with blocks and tape

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11
Q

How should signs of shock be investigated post operatively?

A

FBC
U+E
CRP
Cultures

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12
Q

What is a central line?

A

Catheter into large vein of neck, chest or groin used to administer fluids, obtain diagnostic tests, monitor specific medical conditions

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13
Q

Risk factors for central line complications?

A

Operator skill
Patient anatomy
Type and location of central line
Sterile technique
Duration of catheter placement

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14
Q

How are central line complications classified?

A

Mechanical
Infectious
Thrombotic

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15
Q

Examples of central line complications?

A

Air embolism
Bleeding
Pneumothorax
Infection
Phrenic nerve palsy

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16
Q

Medications which should be stopped prior to an operation?

A

Clopidogrel; 7 days
Warfarin; 5 days
LMWH; the night before
ACE-i; the day before
Short acting insulin preparation should be stopped the morning of the surgery
Sulphonylurea; held day of surgery
COCP; 4 weeks before

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17
Q

What is an epidural anaesthesia?

A

Injection of local anaesthetic into the epidural space around L3-L4 or L4-L5 vertebral level

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18
Q

Risks of epidural?

A

Maternal hypotension
Low pressure headache
Epidural haematoma

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19
Q

Monitoring after epidural anaesthesia?

A

Continuous CTG

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20
Q

Indications for fluid resuscitation?

A

Systolic BP <100mmHg
Heart rate >90bpm
Capillary refill >2s
Cool peripheries
Respiratory rate >20bpm
NEWS ≥5
Dry mucous membranes

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21
Q

Normal daily fluid requirements?

A

25-30mL/kg/day water
1mmol/kg/day sodium
1mmol/kg/day potassium
1mmol/kg/day chloride
50–100g/day glucose to limit ketosis

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22
Q

Basics of fluid resuscitation?

A

Identify cause of fluid deficit and respond appropriately
Fluid bolus of 500mL crystalloid over <15 minutes
Reassess using ABCDE approach
Further fluid boluses (up to 2000mL) may be required

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23
Q

What is lactic acidosis?

A

Commonest cause of metabolic acidosis due to raised lactic acid levels (>4mmol/L)

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24
Q

Aetiology of lactic acidosis?

A

Type A; tissue hypoxia
Hypoperfusion
Cardiogenic shock e.g. left ventricular failure
Hypovolaemia
Sepsis
Regional ischaemia (e.g. limb or mesenteric ischaemia)
Gangrene
Cardiac arrest
Hypoxaemia
Respiratory failure
Severe anaemia
Carbon monoxide poisoning
Methaemoglobinaemia
Increased oxygen demand
Seizures
Strenuous exercise

Type B; No tissue hypoxia
Type B1 - underlying disease
Liver failure
Malignancy
Renal failure
Thiamine deficiency
Diabetic ketoacidosis (DKA)

Type B2 - drugs or toxins
Salicylates
Paracetamol
Beta-agonists (e.g. salbutamol)
Propofol
Metformin
Antiretrovirals (e.g. zidovudine)
Alcohols (e.g. ethanol, methanol, ethylene glycol)
Cyanide

Type B3 - congenital metabolic defects
Mitochondrial disorders
Glycogen storage disorders
Primary lactic acidoses (e.g. pyruvate dehydrogenase deficiency)
Organic acidaemia (e.g. maple syrup urine disease)

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25
Symptoms of lactic acidosis?
Hypotension Tachycardia Confusion Prolonged capillary refill time Cool peripheries Oliguria
26
Signs of lactic acidosis?
Tachypnoea Kussmaul's breathing
27
Differentials for lactic acidosis?
Ketoacidosis Uraemia Drugs; salicylates, iron, metformin, isoniazid, ciclosporin Poisoning; methanol, ethylene glycol, sulphur
28
Management for lactic acidosis?
Treat underlying cause A to E approach Supplementary O2 IV fluid resuscitation Monitor urine output
29
Complications of lactic acidosis?
Hypotension (secondary to both vasodilation and myocardial depression) Arrhythmias Coma Seizures
30
What is local anaesthetic toxicity?
When systemic levels of local anaesthetic exceed the maximum safe dose leading to bloackade of sodium ion channels disrupting neuronal function
31
What is the maximum safe dose of lidocaine?
3mg/ kg
32
Signs and symptoms of local anaesthetic toxicity?
Numbness or tingling around the mouth Restlessness/agitation Tinnitus Shivering Vertigo/dizziness Subtle tremors of the face and extremities Hypertension Tachycardia Decreased consciousness Respiratory depression Hypotension Apnoea Seizures Sinus bradycardia Ventricular arrhythmias Asystole
33
Differentials for local anaesthetic toxicity?
Hyperventilation syndrome Panic attack Seizures Cardiac arrhythmia
34
Investigations for local anaesthetic toxicity?
Observations monitoring ECG
35
Management of local anaesthetic toxicity?
Stop drug Continuous ECG monitoring Lipid emulsion- 20% intralipid at a dose of 1mL/ kg every 3 minutes followed by infusion of 0.25ml/kg/min
36
What is malignant hyperthermia?
Life threatening crisis triggered by exposure to volatile inhalation anaesthetics or suxamethonium
37
Epidemiology of malignant hyperthermia?
More common in younger males, possibly due to higher rates of surgery
38
Aetiology of malignant hyperthermia?
Autosomal dominant mutation in ryanodine receptor 1 gene Resulting in abnormal calcium regulation within muscles leading to increased calcium in sarcoplasmic reticulum
39
Signs and symptoms of malignant hypertermia?
Rapid increase in body temperature Muscle rigidity Metabolic acidosis Tachycardia Increased exhaled carbon dioxide
40
Differentials for malignant hyperthermia?
Neuroleptic malignant syndrome Serotonin syndrome Sepsis
41
Investigations to diagnose malignant hyperthermia?
Blood gas; metabolic acidosis, increased creatinine kinase Temperature
42
Management of malignant hyperthermia?
Discontinue trigger IV dantrolene Restore temperature; ice pack, cool IV fluids, cooling blanket Correct acidosis and electrolyte abnormality
43
How can position of NG tube be confirmed?
Measure pH of NG tube aspirate Erect chest X-ray
44
What is CPAP?
Used in type 1 respiratory failure Provides positive pressure to keep alveoli open for a longer period of time to facilitate gas exchange
45
What is BiPAP?
Used in type II respiratory failure with two different levels of positive pressure on inspiration and expiration
46
Criteria to start NIV?
Patient awake and able to protect airway Co-operative patient Consideration of quality of life of patient
47
Contraindications to NIV?
Facial burns Vomiting Untreated pneumothorax Severe co-morbidities Haemodynamically unstable Patient refusal
48
Pre-operative management options of anaemia?
Oral iron if >6 weeks until planned surgery IV iron if <6 weeks until planned surgery B12/folate replacement Erythropoiesis‐stimulating agent (ESA) therapy Transfusion if profound anaemia and surgery cannot be delayed
49
Post operative management options of anaemia?
Transfusion IV iron Oral iron
50
Peri-operative management of steroids for patients who require long term therapy?
Switch oral steroids to 50-100mg IV hydrocortisone. If there is associated hypotension then fludrocortisone can be added. For minor operations oral prednisolone can be restarted immediately post-operatively. If the surgery is major then they may require IV hydrocortisone for up to 72 hours post-op.
51
Complications of poor peri-operative management of diabetes?
Hyperglycaemia Hypoglycaemia DKA Lactic acidosis
52
Rules for hypoglycaemia agents on day of surgery?
Metformin (taken once daily) Take during the morning of surgery DDP-IV inhibitors Take during the morning of surgery GLP-1 analogues Take during the morning of surgery SGLT-2 inhibitors Omit the day of surgery due to the risk of DKA Insulin Schedule the patient as early on the theatre list as possible, minimising the amount of time the patient is nil by mouth. If on long-acting insulin, this should be continued but reduced by 20%. Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth. Continue infusion until the patient is able to eat post-operatively. Switch to the normal insulin regimen around their first meal.
53
Causes of post operative N+V?
Infection Hypovolaemia Pain Paralytic ileus Drugs
54
Management of post operative nausea and vomiting?
Non pharmacological; minimise patient movement, analgesia, IV fluids Pharmacological; 5HT3 receptor antagonist; ondansetron H1 receptor antagonist; cyclizine D2 receptor antagonist; prochlorperazine Dexamethasone Metoclopramide
55
What is a poor urine output post operatively?
Decreased urine volume output after surgical procedure, less than 0.5ml/kg/ hour
56
Causes of post operative poor urine output?
Pre-renal: This results from decreased blood flow to the kidneys. Hypovolaemia Hypotension Dehydration Renal: This is due to intrinsic damage to the kidney tissues. Acute tubular necrosis Post-renal: This occurs due to obstructions that prevent urine from being expelled from the body. Benign prostatic hypertrophy Effects of drugs such as anticholinergic or alpha adrenoreceptor antagonists, often used in anaesthetics Pain following surgery, particularly hernia operations Psychological inhibition Opiate analgesia
57
Signs and symptoms of poor urine output?
Decreased frequency or volume of urination Hypotension and tachycardia (pre-renal causes) Abdominal pain or discomfort, particularly after hernia operations (post-renal causes) Symptoms of drug side effects such as dry mouth, blurred vision, and constipation (post-renal causes due to anticholinergic drugs)
58
Investigations to identify cause of poor urine output?
Urine output measurement Urinalysis Blood; U+E USS KUB
59
Management of poor urine output?
Correct fluid an electrolyte imbalance Manage underlying cause Urinary catheterisation
60
Rules for pre-operative fasting?
Clear fluids upto 2 hours pre-op, includes water, fruit juice, coffee/ tea without milk IV fluids Last meal should be 6 hours pre-op
61
What is rapid sequence induction?
Coordinating the administration of rapidly acting induction agents to produce anaesthesia and muscle relaxation, followed by prompt intubation, securing airway with minimal risk of aspiration Roles in RSI; Airway Drug preparation Monitoring of vital signs Drug administration Cricoid pressure
62
Sequence of rapid sequence induction?
Preparation Involves ensuring the environment is optimised, equipment is available and staff are ready Preoxygenation Involves the administration of high flow oxygen for 5 minutes prior to the procedure Pretreatment May involve administration of opiate analgesia or a fluid bolus to counteract the hypotensive effect of anaesthesia Paralysis The administration of the induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium) Protection and positioning Cricoid pressure should be applied to protect the airway following paralysis. In line stabilisation may be required in some cases. Placement and proof Intubation is performed via laryngoscopy, with proof obtained (direct vision, end-tidal CO2, bilateral auscultation) Post-intubation management Taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents
63
What is suxamethonium apnoea?
Defect in plasma cholinesterase enzyme required to metabolise suxamethonium resulting in a prolonged period of paralysis
64
Signs and symptoms of suxamethonium apnoea?
Prolonged paralysis following administration Little/ no effort to cough or breathe spontaneously
65
Differentials for suxamethonium apnoea?
Myastensia gravis Botulism Poliomyelitis
66
Management of suxaethonium apnoea?
Intubation and ventilation until they can breathe on their own Avoid use of suxamethonium in future
67
What is SIRS?
Systemic inflammatory response syndrome diagnosed if one or more of the following is present Temperature >38 or <36 degrees Centigrade Heart rate >90 Respiratory rate >20 White cell count >12 or <4 x10^9/L
68
Causes of major trauma?
Road traffic accidents Falls (considered a dangerous mechanism of injury if height greater than 1 metre or 5 steps) Assault (including non-accidental injury in babies and children) Sports injuries Accidents at work
69
Classification of TBI?
Based on GCS; Mild - GCS 14-15 Moderate - GCS 9-13 Severe - GCS 3-8
70

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