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Anaesthetics Flashcards

1
Q

How long can you have clear fluids before surgery?

A

2 hrs clear fluids ( water, black tea, black coffee, fruit juice without pulp)

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2
Q

How long can you have breast milk before surgery?

A

4 hours

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3
Q

How long can you have milk or a light meal before surgery?

A

6 hours

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4
Q

What can gastric emptying be delayed by?

A

Metabolic causes: DM, End Stage Renal failure
Anatomical causes: Pyloric stenosis
Mechanical: Increase IAP: pregnancy, obesity
Trauma ( head injury)
Others : High fat content, anxiety

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5
Q

What is the indication for rapid sequence induction?

A

Full stomach for any reason

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6
Q

How should you preoxygenate in rapid sequence induction?

A

three minutes, 5 full vital capacity breaths, EtO2 concentration > 90
Rationale: replace FRC with oxygen

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7
Q

What drugs with doses do you use in rapid sequence induction?

A

Thiopentone: 4 – 5 mg/kg, onset: 15 -30 seconds duration, Duration of action: 4- 8 minutes
Propofol: 1.5 – 2.5 mg/kg, Onset: 30 seconds, DOA: 2 – 6 minutes
Sux: 1 -1.5 mg/kg: DOA 6 minutes

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8
Q

What else do you do in rapid sequence induction?

A

Cricoid Pressure: 10 N – 30N]
Apnoeic ventilation
Confirmation of tube position

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9
Q

What are important CV factors to ask about in pre op assessment?

A

Chest pain ( site, duration, severity, radiation, aggravating relieving factors)
PND, Orthopnoea, Exercise tolerance
Pacemakers

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10
Q

How do you measure exercise tolerance in a pre op assessment?

A

Ex tolerance: 1 MET: eating and dressing, 3 METs: light household activity or walk 100 m @ 2-3 mph, 4 METs: climb a flight of stairs, 6-7 METs: short run
MET (metabolic equivalents)
Difficult to assess someone with orthopaedic disease

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11
Q

What are the standard CV investigations pre op?

A

Routine +

ECG, Echo (exercise or stress as indicated)

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12
Q

When are people high risk with CV disease pre op?

A

MI < 1 month, Unstable angina: high risk

Post CABG after 5 years risk is same

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13
Q

If someone has hypertension pre op what do you do?

A

HT: DBP > 115 Treat for 4 weeks, < 115 look for End organ disease

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14
Q

What are important considerations in pre op assessment in those with RA?

A 
Joints: TM joint, Cricoarytenoid joints ( glottic stenosis), Atlantoaxial subluxation (neck Xray)
CVS: asysmptomatic pericardial effusion
RS: pulmonary nodules and fibrosis
Anaemia
Renal impairment
Peripheral neurpathy
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15
Q

What investigations should you do pre op in someone with RA?

A 
FBC
U &amp; Es
CxR
ECG
Cervical spine X-ray
PFT, Echo, ENT opinion if indicated
Prepare for a difficult airway
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16
Q

What respiratory things should you ask about pre op?

A

Chest infection: cough, sputum

COPD: SOB, Smoking

Dyspnoea grading: 0: normal, 1: unlimited walk, grade 2: 200- 400 metres, grade3: kitchen to bathroom, Grade 4: at rest

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17
Q

If they have asthma, what are important things to know/ do pre op?

A

Assess control, nebulised bronchodilators, NSAIDS

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18
Q

How does someones function change over weeks after they stop smoking?

A

24 -48 hrs: CO levels normal and ciliary function improves,
2 weeks: mucus secretions decrease, bronchial and airway reactivity normal
4 weeks: improvement in smaller airways
2 –6 weeks: Paradoxical increase in secretions
8 weeks: normalised: recommended

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19
Q

When should you stop nicotine pre op?

A

stop 12 hrs: effect on sympathetic system and Increased cardiovascular reserve

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20
Q

What should you do post op with sleep apnoea patients?

A

Admit overnight in HDU if GA with opiods

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21
Q

What are important considerations pre op in those with diabetes?

A 
CVS: HT, silent MI, autonomic neuropathy
RS: increased infection
Renal: renal failure
Airway: thickening soft tissues d/t glycosylation: 
Limited joint mobility syndrome
GI: delayed gastric emptying
Eyes: cataracts
Others: infection
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22
Q

How should you manage diabetic patients peri operatively?

A

Avoid, hypo and hyperglycemia (14mMol)
Monitor glucose and electrolytes
Sliding scale

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23
Q

What investigations should you do pre op in diabetic patients?

A

BM, urine- glucose and ketones
ECG
Electrolytes
First on list

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24
Q

How should you assess an airway pre op?

A 
History
Examination
Mallampatti
Teeth
Thyromental Distance
Sternomental distance
Neck movement
1-2-3
Cormack &amp; Lehane
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25
Q

What is mallampati scoring?

A

Class I: Soft palate, uvula, fauces, pillars visible.
Class II: Soft palate, major part of uvula, fauces visible.
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible.

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26
Q

What investigations should you do pre op and on who?

A

FBC:
Males > 40 years, All females, anaemia, Major Sx
ECG:
Age > 50, Cardiac disease, ECG < year acceptable if no change in cardiac status
U & Es
> 60 years, renal disease, diuretics, major Sx
CxR
Respiratory/cardiac disease, suspecting TB pulmonary Mets,
Sickle test:
African origin with unknown sickle status
Others
Blood Glucose: DM, Glycosuria
Urinalysis: all patients
Coagulations screen: bleeding tendency, anticoagulation therapy

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27
Q

What is the safe dose of Lignocaine without adrenaline ?

A

safe dose 3mg/kg

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28
Q

What is the safe dose of Lignocaine with adrenaline?

A

safe dose 7mg/kg

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29
Q

What is the safe dose of Bupivacaine / levobupivacaine ( with or without adrenaline)?

A

safe dose 2mg/kg

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30
Q

What does the % mean on local anaesthetic?

A

% means gm/100ml i.e, 1% is 1gm/100ml i.e. 1000mg/100ml i.e. 10mg ml

Rule: multiply %with 10 and it gets you mass in mg/ml i.e. 1% is 1X10 mg/ml 10mg/ml

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31
Q

What are the short acting local anaesthetics?

A

Prilocaine, lignocaine

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32
Q

What are the long acting local anaesthetics?

A

Bupivacaine, Levobupivacaine, Ropivacaine

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33
Q

What are the signs and symptoms of local anaesthetic toxicity?

A

Excitatory signs (due to inhibition of inhibitory pathways in amygdala) such as circumoral numbness (earliest), tongue paresthesia, dizziness, , restlessness and agitation often precede CNS depression (slurred speech, drowsiness, unconsciousness)

Sudden alteration in mental status, severe agitation or loss of consciousness

Muscle twitching heralds the onset of tonic tonic-clonic seizures

Respiratory arrest often follows

Cardiac arrythmias: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur

Local anaesthetic (LA) toxicity may occur some time after an initial injection

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34
Q

What is the treatment for local anaesthetic toxicity?

A

Stop injecting the LA

Call for help

Maintain the airway

Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing plasma pH in he presence of metabolic acidosis)

Confirm or establish intravenous access

Control seizures: give a benzodiazepine, thiopental or propofol in small incremental doses

Assess cardiovascular status throughout

Give intravenous lipid emulsion

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35
Q

How much of stuff do you need in fluids?

A

Water 30 - 40ml/kg Energy 30 – 40kcal/kg Sodium 1-2mmol/kg Potassium 1mmol/kg

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36
Q

What are the risk factors for post op nausea and vomiting?

A

Patient : Female, Previous PONV / Motion sickness, non smokers, obesity
Anaesthesia: opiates, dehydration, gastric dilatation etc
Surgery: ENT, eye, laparotomy, gynaecological
Organisational: no protocols

37
Q

What are your Anti serotonergic anti emetics?

A

Ondansetron, Granisetron

38
Q

What are your Anti dopaminergic anti emetics?

A

Metoclopramide, domeperidone

39
Q

What are your Antihistaminic anti emetics?

A

Cyclizine, Promethazine, diphenhydramine

40
Q

What other anti emetics can you give?

A

Dexametasone, Nabilone, Lorazepam
Antimuscarinics: Hyoscine, Dicyclomine
Neuroleptics: Chlorpromazine, Prochlorperazine, Haloperidol

41
Q

What is propofol and what is it used for?

A

Isopropyl phenol
Induction agent

used for Induction, Sedation, TIVA

42
Q

What are the side effects of propofol?

A 
Apnoea
Hypotension
Pain
Myoclonus
Contraindicated in patients with egg allergy or soya allergy
43
Q

What is the dose of propofol?

A

1.5 – 2.5 mg/kg induction

44
Q

What are the side effects of morphine?

A 
Respiratory depression
Nausea vomiting
Pruritis
Hypotension
Bronchospasm – histamine release
Dysphoria
45
Q

What is the MoA of Atropine?

A

Muscarinic antagonist

46
Q

What are the side effects of Atropine?

A 
Decreased secretions
Reduced gastroesophageal sphinctor tone
Urinary obstruction
Tachycardia
Confusion in elderly
47
Q

What is the dose of Atropine?

A

10 -20 mcg/kg

48
Q

What type of drug is adrenaline?

A

Endogenous Catecholamine

49
Q

What is adrenaline used for?

A

anaphylaxis,
bronchodilator,
inotrope,
Prolongation of local anaesthetic action etc

50
Q

What are the adverse effects of adrenaline?

A 
HT,
tachycardia, 
anxiety, 
hyperglycemia, 
arrythmias, 
administer via central line
51
Q

What are the effects of midazolam?

A

Anxiolytic / sedative , anterograde amnestic, hypnotic,

anticonvulsant, skeletal muscle relaxant,

52
Q

What ar the uses of midazolam?

A

Procedural sedation (often in combination with an opioid, such as fentanyl),
Preoperative sedation (orally in children),
Induction of general anesthesia, and for
sedation of ventilated patients in critical care units.

53
Q

What is the dose for midazolam?

A

The initial intravenous dose as 1 mg
(should not exceed 2.5 mg in a normal healthy adult).
Administer over at least 2 minutes and
allow an additional 2 or more minutes to fully evaluate the sedative effect.

54
Q

What is the safe dose of prilocaine?

A

Prilocaine: 6mg/kg

55
Q

What are the three types of anaesthetics?

A

General anaesthesia
Total loss of sensation

Regional anaesthesia
Loss of sensation to a region or part of body

Local anaesthesia
Topical, Infiltration

56
Q

What are the three As of general anaesthesia?

A

Amnesia –
lack of response and recall to noxious stimuli – Unconsciousness

Analgesia –
pain relief

Akinesis –
immobilisation / paralysis

57
Q

What do induction agents do?

A

Induce loss of consciousness in one arm-brain circulation time (intravenous) 10 – 20 seconds
Duration of action: 4-10 minutes

58
Q

What are inhalation agents used for?

A

: usually used for maintenance of amnesia

59
Q

What are the different induction agents?

A

Propofol

Thiopentone

Ketamine

Etomidate

60
Q

What is propofol and why is it good and bad?

A

Lipid based (white emulsion)
Excellent suppression of airway reflexes
Decreases incidence of PONV

Unwanted effects:
Marked drop in HR and BP
Pain on injection
Involuntary movements

61
Q

What is thiopentone and why is it good and bad?

A

Barbiturate (dose 4 – 5 mg/kg)

Faster than propofol
Used mainly for rapid sequence induction
Antiepileptic properties and protects brain

Unwanted effects
Drops BP but rise in HR
Rash / Bronchospasm
Intraarterial injection: thrombosis and gangrene
Contraindicated in Porphyria
62
Q

What is ketamine and why is it good and bad?

A

Dissociative anaesthesia
Anterograde amnesia and profound analgesia
Dose: 1 – 1.5 mg/kg

Slow onset (90 seconds)
Rise in HR/BP, Bronchodilation

Unwanted effects:
Nausea and vomiting
Emergence phenomenon: vivid dreams, hallucinations

63
Q

What is etomidate and why is it good and bad?

A

Rapid onset (Dose 0.3 mg/kg)

Hemodynamic stability
Lowest incidence of hypersensitivity reaction

Unwanted effects:
Pain on injection
Spontaneous movements
Adreno-cortical suppression
High incidence PONV
64
Q

What does continuous etomidate infusionlead to?

A

Continuous intravenous administration of etomidate leads to adrenocortical dysfunction. Cortisol levels have been reported to be suppressed up to 72 hours after a single bolus of etomidate. For this reason, many authors have suggested that etomidate should never be used for critically ill patients with septic shock because it could increase mortality.

65
Q

What are the four different inhalation agents?

A

Isoflurane
Sevoflurane
Desflurane
Enflurane

66
Q

How do you differentiate between the different inhalation agents?

A

Sevoflurane: Sweet smelling, used for Inhalational induction

Desflurane: Low lipid solubility, Rapid onset and offset, Long operations

Isoflurane - Least effect on organ blood flow

67
Q

What is MAC?

A

Minimum Alveolar Concentration

Concentration of the vapour that prevents the reaction to a standard surgical stimulus (traditionally a set depth and width of skin incision) in 50% of subjects

68
Q

What are the MACs for the inhalation agents?

A 
Nitrous oxide: 104%
Sevoflurane: 2%
Isoflurane : 1.15%
Desflurane : 6%
Enflurane : 1.6 %
69
Q

When are short acting opioids used in anaesthetics?

A

Intra-op analgesia, suppress response to laryngoscopy, surgical pain

Rapid onset, high potency

Fentanyl, Remifentanil,Alfentanil

70
Q

When are long acting opioids used in anaesthetics?

A

Intra-op and post-op analgesia

Morphine, Oxycodone

71
Q

What is the most commonly used analgaesic?

A

Paracetamol

72
Q

Most commonly used oral opioid in adults?

A

Codeine

73
Q

Intravenous NSAIDS?

A

Ketorolac, Parecoxib

74
Q

How are muscles stimulated?

A

As action potential arrives at NM junction, Acetylcholine is released which causes depolarisation of Nicotinic receptors leading to muscle contraction.

75
Q

What are the two groups of muscle relaxants?

A

Depolarising: which act similar to acetylcholine on nicotinic receptors but are very slowly hydrolysed by acetylcholinesterase. Therefore they cause muscle contraction, muscle then fatigues and relaxes.

Non depolarising: they block the Nicotinic receptors therefore muscle relaxes.

76
Q

What is the depolarising muscle relaxant with dose, indication and adverse effects?

A

Suxamethonium: (dose 1 -1.5 mg/kg)
Rapid Sequence Induction (Rapid onset - Rapid offset)

Adverse effects
muscle pains, 
fasciculations,
hyperkalemia
malignant hyperthermia, 
rise in ICP,IOP and gastric pressure
77
Q

What are the short acting non-depolarising muscle relaxants?

A

Atracurium, mivacurium

78
Q

What are the intermediate acting non-depolarising muscle relaxants?

A

Vecuronium, rocuronium

79
Q

What are the long acting non-depolarising muscle relaxants?

A

Pancuronium

80
Q

How do you reverse non-depolarising muscle relaxants?

A

Neostigmine & Glycopyrrolate

81
Q

How does neostigmine work and why is it paired with glycoopyrelate?

A 
Anti-cholinesterase
Prevents breakdown of acetylcholine
Muscarinic effects of acetylcholine: 
Bradycardia etc.
Combined with antimuscarinic agent:  			Glycopyrrolate

Side effects : nausea and vomiting

82
Q

What proportion of people get PONV?

A

20 -30 % after general anaesthesia

83
Q

What are the different anti emetic agents?

A 
5HT3 blockers: Ondansetron
Anti-histamine: Cyclizine
Steroids: Dexamethasone
Phenothiazine: Prochlorperazine (Stemetil)
Anti-dopaminergic: Metoclopramide
84
Q

What does ephidrine do?

A

Rise in HR and contractility leading to rise in BP (direct and indirect action, alpha (α) & β receptors

Low BP, low HR

85
Q

What does Phenylepherine do?

A

Rise in BP by vasoconstriction (Direct action, α receptors), drop in HR

Low BP, High HR

86
Q

What does metaraminol do?

A

Rise in BP by vasoconstriction (Direct and indirect action, predominant α receptors)

Low BP, High HR

87
Q

Which vaso active drugs are used in severe cases?

A

Noradrenaline
Adrenaline
Dobutamine

88
Q

What is the 6 step process in LMA insertion?

A 
Oxygenation
Opioid (Fentanyl/ Alfentanyl)
Induction agent (Propofol)
Turn on Volatile agent (sevoflurane/ isofl.)
Bag valve mask ventilation 
LMA insertion
89
Q

What is the 7 step process in intubation?

A 
Oxygenation
Opioid (Fentanyl/ Alfentanyl)
Induction agent (Propofol)
Muscle relaxant
Turn on Volatile agent (sevoflurane/ isofl.)
Bag valve mask ventilation 
Endotracheal intubation

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