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Anaesthetics Flashcards

1
Q

How to evaluate a difficult airway?

A 
LEMON 
Look 
Evaluate (3-3-2)
Mallampati score 
Obstruction 
Neck mobility
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2
Q

How to assess for ventilation difficulty?

A 
BONES
Beard
Obesity 
No teeth 
Elderly 
Snoring hx
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3
Q

What is the 3-3-2 rule?

A

3 fingers should fit in mouth
3 fingers from mandible to hyoid (hyoid-mental distance)
2 fingers in superior laryngeal notch (thyroid mouth distance)

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4
Q

What are the Mallampati scores?

A 
1 = full view of uvula 
2 = body + base of uvula 
3 = base of uvula 
4 = only hard palate + tongue, no other structures visible
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5
Q

What are the indications for CBC pre-op?

A

Major surgery needing group + screen or X match
Chronic CV, pulmonary, renal or hepatic disease
Malignancy
Anaemia
Bleeding diathesis
Myelosuppression
Pt <1 y/o

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6
Q

What are the indications for sickle cell screen pre-op?

A

Genetically predisposed pt

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7
Q

What are the indications for INR + aPTT pre-op?

A

Anticoagulant therapy
Bleeding diathesis
Liver disease

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8
Q

What are the indications for electrolytes + creatinine pre-op?

A 
HTN
Renal disease 
DM
Pituitary or adrenal disease 
Vascular disease 
Digoxin 
Diuretics
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9
Q

What are the indications for fasting glucose pre-op?

A

DM

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10
Q

What are the indications for ECG pre-op?

A 
Heart disease
DM
SAH/ ICH
CVA
Head trauma
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11
Q

What are the indications for chest xray pre-op?

A

New or worsening resp symptoms

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12
Q

What are the ASA grades?

A 
1 = healthy, fit 
2 = mild systemic disease eg controlled HTN
3 = severe systemic disease eg COPD 
4 = incapacitating disease, constant threat to life eg acute resp failure 
5 = moribund pt not expected to survive eg ruptured AAA
6 = brain dead
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13
Q

What medications should be stopped pre-op + in what timeframes?

A

Oral antihyperglycaemics - avoid on morning of surgery
ACEi + ARBs = avoid on day of surgery
Warfarin (bridge with heparin), aspirin, clopidogrel etc
Stop herbs 1 week before

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14
Q

What medications should be adjusted pre-op?

A

Insulin, prednisone, bronchodilators

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15
Q

What is the BP target pre-op?

A

<180/110

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16
Q

What considerations should be taken pre-op with someone with CAD?

A

Min 60 days after MI before non-cardiac surgery in absence of coronary intervention
If operation has to occur, invasive ICU monitoring is required
Consider giving BB peri-op (particularly for high risk surgery eg vascular surgery)

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17
Q

What advice should be given re smoking pre op?

A

Abstain for 8 weeks pre-op

If unable, 24hrs increases O2 availability

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18
Q

What are non-selective BB?

A

Labetalol, nadolol = block both B1 + B2

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19
Q

What considerations are involved with asthma?

A 
Increased risk of bronchospasm with intubation 
Short course (1 week) of pre-op corticosteroids + inhaled B2 agonists decreases risk 
Use cardio-selective BB such as metoprolol + atenolol 
Delay surgery by 6 weeks if URTI develops
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20
Q

What increases risk of aspiration?

A 
Decreased LOC 
Delayed gastric emptying (narcotics, DM, non fasted for 8 hrs) 
Decreased sphincter competence 
Increased abdo pressure 
Unprotected airway
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21
Q

Fasting guidelines

A 
8hrs = meal including meat, fried or fatty food 
6hrs = light meal eg toast or infant formula 
4hrs = breast milk 
2hrs = clear fluids
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22
Q

Considerations for pts with haematological disorders

A

Pre-op treatment to increase Hb (iron, erythropoietin)
Modify anti-coagulants
Administer reversal agents if needed

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23
Q

Considerations for pts with DM

A

Target blood glucose <10 in critical pts, <7.8 in stable pts
Use insulin therapy
Hold oral hypoglycaemics
Consider cancelling surgery if metabolic abnormality present eg DKA, HHS or if glucoe over 22.2-27.7

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24
Q

Considerations for pts with hyperthyroidism

A

Can cause sudden release of thyroid hormone (thyroid storm) so treat with BB and pre-op prophylaxis

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25
Q

What is the pre-anaesthetic checklist?

A

SAMMM
Suction - connected + working
Airways - all equipment present
Machine - connected, pressures ok, vaporizers full
Monitors - connected + working
Medications - IV fluids ready, emergency meds ready

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26
Q

What are the guidelines to the practice of anesthesia + patient monitoring?

A

An anesthetist present
Completed pre-anesthetic checklist - ASA class, NPO policy, Hx + Ix
Peri-op record: HR + BP every 5 mins, O2 sats, end tidal CO2, dose + route of drugs + fluids

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27
Q

What routine monitoring is required for all cases?

A

Pulse oximeter, BP, electrocardiography, capnography (for GA + sedation 4-6), agent specific gas monitor

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28
Q

What other monitoring should be available?

A

Temp probe, nerve stimulator, stethoscope, lighting, spirometry, manometer to measure ETT cuff pressure

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29
Q

How is anaesthetic depth monitored?

A

End tidal inhaled anesthetic monitoring, EEG monitoring (Bispectral index monitor)

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30
Q

What findings suggest inadequate depth of anaesthesia?

A

Blink reflex present, HTN, tachycardia, tearing or sweating

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31
Q

What elements need monitoring?

A 
Anesthetic depth 
Oxygenation 
Ventilation 
Circulation 
Temperature 
Urine output
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32
Q

Describe the anatomy of the airway - the borders of the pharyngeal airway, what the glottic opening is + where the trachea begins + bifurcates

A

Pharyngeal airway extends from posterior aspect of nose to cricoid cartilage
Glottic opening is narrowest segment of laryngeal opening
Trachea begins at level of thyroid cartilage, C6, and bifurcates at T4-5 (approx sternal angle)

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33
Q

What are the definitive + non-definitive methods of supporting the airway?

A 
Definitive = ETT, surgical airway 
Non = jaw thrust, oro + nasopharyngeal airway, bag mask ventilation, LMA
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34
Q

What equipment is needed for intubation?

A 
Monitors 
Drugs 
Suction 
O2 source + oro/ naso airways 
Laryngoscope 
ETT
Stylet + syringe for tube cuff inflation
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35
Q

What meds can be given through the ETT?

A 
NAVEL 
Naloxone 
Atropine 
Ventolin 
Epinephrine 
Lidocaine
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36
Q

What are the indications for an ETT?

A 
Pt airway 
Protects against aspiration 
Positive pressure ventilation 
Pulmonary toilet (suction)
Pharmacological administration
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37
Q

What is the sizing for LMA?

A 
40-50kg = 3
50-70kg = 4 
70-100kg = 5
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38
Q

What is the sizing for ETT?

A

Male = 8-9mm
Female = 7-8mm
Paed uncuffed >2 = age/ 4 + 4mm

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39
Q

What is the proper positioning for intubation?

A

Align 3 axis (mouth, pharynx + larynx)

Sniffing position = flexion of C5/6, bow head forward, extension of C spine at atlanto-occipital joint (C1)

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40
Q

Where is the laryngoscope tip placed?

A

In epiglottic vallecula

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41
Q

What is the DDx for poor bilateral breath sounds after intubation?

A 
DOPE 
Displaced ETT
Obstruction 
Pneumothorax 
Esophageal intubation
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42
Q

What is the foreign body reflex in the trachea?

A

Sympathetic response due to stimulation of CN9 + 10

Causes tachycardia, dysrhythmias, myocardial ischaemia + increased BP

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43
Q

Risks of ETT too deep or too shallow

A

Too deep = right sided tension pneumothorax, left sided atelectasis
Too shallow = extubation, vocal cord trauma, laryngeal palsy

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44
Q

Where should the tip of the ETT be?

A

Midpoint of trachea, 2cm above carina

Proximal end of cuff at least 2cm below vocal cords

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45
Q

What cm mark should be at the corner of the mouth for the ETT?

A

Men - 20-23cm

Women = 19-21cm

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46
Q

How to confirm ETT placement?

A 
Direct = visualising ETT pass through cords, visualising ETT in trachea 
Indirect = ETCO2, auscultate breath sounds, bilateral chest movement, condensation, no abdo distension, refilling of reservoir bag
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47
Q

What is the Cormack-Lehane classification of laryngeal view?

A 
1 = all laryngeal structures revealed 
2 = posterior laryngeal 2A (posterior vocal cords) 2B (arytenoids) 
3 = larynx concealed, only epiglottis 
4 = neither glottis nor epiglottis
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48
Q

What to do if intubation unsuccessful after induction?

A

Call for help
Ventilate with bag mask
Consider returning to spontaneous ventilation/ waking pt

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49
Q

What is the goal of O2 therapy?

A

O2 sats >90%

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50
Q

When is cyanosis detected (+ frank cyanosis)?

A

SaO2 <85%

Frank cyanosis at <67&

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51
Q

What are low flow systems?

A

0-10L/min
Acceptable if tidal vol 300-700ml, RR <25, consistent ventilation pattern
eg nasal cannula

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52
Q

What FiO2 is supplied with a nasal cannula?

A

At 1-6L/min = 24-44%

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53
Q

What are reservoir systems?

A

Reservoir accumulates O2 eg face mask or non-rebreathe mask

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54
Q

What FiO2 is supplied with a face mask + non-rebreathe mask?

A

Face mask = 55% at 10L

Non-rebreathe = 80% at 10-15L

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55
Q

What are high flow systems?

A

Flow up to 50-60L

E.g. venturi mask ranging from 24-50%

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56
Q

What are the indications for mechanical ventilation?

A

Apnea
Hypoventilation
Acute resp acidosis
Intraoperative positioning
To deliver positive end expiratory pressure (PEEP)
If there is increased intrathoracic pressure

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57
Q

What are the airway complications of mechanical ventilation?

A

Tracheal stenosis, laryngeal oedema
Ventilator induced lung injury (barotrauma)
Nosocomial pneumonia

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58
Q

What are the cardiac complications of mechanical ventilation?

A

Reduced venous return
Reduced cardiac output
Hypotension

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59
Q

What are the neuromuscular complications of mechanical ventilation?

A

Muscle atrophy

Increased ICP

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60
Q

What are the metabolic complications of mechanical ventilation?

A

Hyperventilation = decreased CO2

Alkalemia

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61
Q

How do you monitor ventilator therapy?

A

Pulse oximetry, end tidal CO2

Regular ABGs

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62
Q

Pts who develop a pneumothorax while being ventilated need what?

A

Chest tube

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63
Q

How can ventilation help with hypoxaemic resp failure?

A

Helps improve V/Q match
Provides O2
Recruits atelectatic lung segments
Decreases interpulmonary shunt

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64
Q

How can ventilation help with hypercapnic resp failure?

A

Augments alveolar ventilation
Decreases work of breathing
Allows resp muscles to rest

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65
Q

What is assist-control or volume control ventilation?

A

Every breath has pre-set tidal volume + rate or minute ventilation
Ventilator initiates breath if no pt effort

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66
Q

What is pressure control ventilation?

A

Minimum frequency set, pt may trigger breaths above ventilator
All breaths delivered at preset constant inspiratory pressure
Changes in compliance + resistance affect tidal volume

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67
Q

What is synchronous intermittent mandatory ventilation?

A

Ventilator provides controlled breaths (either with VC or PCV)
Pts can breathe spontaneously between controlled breaths

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68
Q

What is pressure supported ventilation?

A

Pt initiates all breaths + ventilator supports each breath with pressure
Useful for weaning off ventilator

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69
Q

What is high frequency oscillatory ventilation?

A

High breathing rate, very low tidal volumes

Used in neonatal/ paeds resp failure

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70
Q

What is non-invasive positive pressure ventilation?

A

BiPAP + CPAP

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71
Q

Causes of decreased end tidal CO2?

A 
Hyperventilation 
Hypothermia 
Decreased pulmonary blood flow 
V/Q mismatch 
PE 
Pulmonary edema 
Air embolism
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72
Q

Causes of increased end tidal CO2?

A

Hypoventilation
Hyperthermia
Improved pulmonary blood flow eg after resuscitation or hypotension
Low bicarbonate

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73
Q

Causes of hypothermia intra-op

A

Environment

Open wound

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74
Q

What is the impact of hypothermia (<36)?

A

Increased risk of wound infections due to impaired immune function
Increased period of hospitalisation
Reduced platelet function increasing blood loss
Triples incidence of VT
Decreases metabolism of anaesthetics prolonging recovery

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75
Q

Causes of hyperthermia intra op

A 
>37.5 
Drugs - atropine 
Blood transfusion reaction 
Infection
Thyrotoxicosis 
Malignant hyperthermia 
Over-zealous warming efforts
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76
Q

Which cardiac arrests are shockable vs not?

A 
Shockable = VT + VF 
Not = PEA + asystole
77
Q

What are the reversible causes of cardiac arrest?

A 
5Hs + 5Ts
Hypothermia 
Hypovolaemia 
Hypoxia 
Hydrogen ions (acidosis) 
Hypo/hyperkalaemia 
Tamponade 
Tension pneumothorax 
Toxins 
Thrombosis (pulmonary or cardiac)
78
Q

What are the SVTs?

A 
Narrow complex 
Sinus tachycardia
AF/ flutter 
Accessory pathway mediated 
Paroxysmal atrial tachycardia
79
Q

What are the wide complex tachycardias?

A

VT, SVT with aberrant conduction

80
Q

What are causes of sinus tachycardia?

A

Shock/ hypovolaemia/ blood loss
Anxiety/ pain/ light anaesthesia
Full bladder
Anaemia
Febrile illness/ sepsis
Drugs - atropine, cocaine, dopamine, epinephrine, ephredrine, isoflurane, isoproterenol, pancuronium
Addisonian crisis, hypoglycaemia, malignant hyperthermia + transfusion reaction

81
Q

What is the boundary for tachy + bradycardia?

A

Tachy >150

Brady <50

82
Q

What are the causes of sinus bradycardia?

A

Increased parasympathetic tone vs decreased sympathetic tone
Hypoxemia
Arhythmias
Baroreceptor reflex due to increased ICP or BP
Vagal reflex
Drugs - opioids, edrophonium, neostigmine, halothane, digoxin, BB
High spinal anaesthesia

83
Q

What are the causes of intra-op shock?

A 
SHOCA
Sepsis or spinal 
Hypovolaemia/ haemorrhagic 
Obstructive 
Cardiogenic 
Anaphylactic
84
Q

What are the causes of intra-op HTN?

A 
Inadequate anaesthesia causing pain 
Pre-existing HTN 
Hypoxemia
Hypervolemia 
Increased ICP 
Full bladder 
Drugs - ephedrine, epinephrine, cocaine, phenylephrine, ketamine
Allergic reaction 
Malignant hyperthermia 
NMS/ serotonin syndrome
85
Q

What is the total requirement for fluids?

A

Total = maintenance + deficit + ongoing loss

86
Q

What is the average total requirement due to what losses?

A

2500 =
200 GI loss
800 insensible losses (resp, sweat)
1500ml urine

87
Q

What should the maintenance rate not exceed?

A

No more than 3ml/kg/hr

88
Q

When are there increased requirements for fluids?

A 
Fever
Sweating 
GI losses 
Adrenal insufficiency 
Hyperventilation 
Polyuric renal disease
89
Q

When are there decreased fluid requirements?

A

Anuria
SIADH
Highly humidified atmospheres
CHF

90
Q

What are the maintenance electrolyte requirements?

A 
Na+ = 3 mEq/kg/d
K+ = 1 mEq/kg/d
91
Q

How much is the total body water?

A

60% of male body weight

50% of female body weight

92
Q

What does the total Na content + [Na+] determine?

A 
Content = ECF volume 
Conc = ICF volume
93
Q

What causes Na+ loss?

A 
GI losses
Insensible losses 
Haemorrhage 
Renal loss 
Diuretics 
Osmotic diuresis 
Hypoaldosteronism 
Salt wasting nephropathies 
Diabetes insipidus 
Decreased CO
Hypoalbuminaemia (cirrhosis, nephrotic syndrome) 
Capillary leakage (pancreatitis, rhabdomyolysis, ischemic bowel, sepsis)
94
Q

How should chronic hyponatraemia be corrected?

A

Slowly over 48hrs to avoid central pontine myelinosis

95
Q

What % body water loss classifies mild, mod + severe dehydration, and what are the S+S?

A 
3% = decreased skin turgor, sunken eyes, dry mucus membranes, dry tongue, reduced sweating 
6% = oliguria, hypotension, tachycardia, cool extremities, reduced filling of veins, haemoconcentration, apathy 
9% = profound oliguria, compromised CNS function +/- altered sensation
96
Q

What are crystalloid fluids - which ones are used + what is the fluid: blood loss ratio?

A

Salt-containing solutions distributed in ECF only
Use Ringer’s lactate for routine replacement + large infusions as saline can cause hyperchloraemic acidosis
3ml infusion for 1ml of blood loss

97
Q

What are colloid fluids - which ones are used + what is the fluid: blood loss ratio?

A

Includes protein colloids (albumin + gelatin) + non-protein (dextrans + starches)
Distributes in intravascular volume
1:1

98
Q

What is the blood volume of infants, males + females?

A

Blood volume:
Infant = 80ml/kg
Female = 60ml/kg
Male = 70ml/kg

99
Q

What are the transfusion infection risks for HIV, Hep C + B, HTLV, bacterial sepsis, West Nile virus?

A 
HIV = 1 in 21 million
Hep C = 1 in 13 million 
Hep B = 1 in 7.5 million 
HTLV = 1 in 1-1.3 million 
Bacterial sepsis = 1 in 40,000 from platelets + 1 in 250,000 from RBC
West Nile virus = No cases since 2003
100
Q

Describe the process of routine induction

A 
Equipment prep 
100% O2 for 3 mins or 4-8 vital capacity breaths 
Use induction agent 
Use muscle relaxant 
Bag mask ventilation 
Posterior pressure on thyroid cartilage 
Intubate, inflate cuff, confirm ETT position 
Secure ETT + begin ventilation
101
Q

Describe the process of RSI

A

Equipment prep
100% O2 for 3 mins or 4-8 vital capacity breaths
Use fast-acting induction agent - pre-determined dose
Use muscle relaxant (Sch or Roc) immediately after
Selick maneuver (cricoid pressure)
Intubate once paralysed, inflate cuff, confirm ETT position
Secure ETT + begin ventilation

102
Q

Which volatile anaesthetics are most soluble to least soluble?

A

Halothane > Isoflurane > Sevoflurane > Desflurane > NO2

103
Q

What is the class, action, indication, cautions, dosing + special considerations for propofol?

A

Class = alkylphenol - hypnotic
Action = inhibitory at GABA synapse, decreased cerebral metabolic rate, decreased ICP, SVR, BP + SV
Indication = induction, maintenance, TIVA
Cautions = pts who can’t tolerate sudden BP drop (eg fixed cardiac output/ shock)
Dosing = 2.5-3mg/kg
Special considerations = reduce burning at IV site by giving with lidocaine.
Decreased post-op sedation, less N+V

104
Q

What is the class, action, indication, cautions, dosing + special considerations for thiopental?

A

Class = short-acting barbiturate - hypnotic
Action = inhibitory at GABA synapse. Decreased CPP, CO, BP, respiration + reflex tachycardia
Indication = induction, anticonvulsants, obstetrics
Cautions = uncontrolled hypotension, shock, cardiac failure
Dosing = 3-5mg/kg
Special considerations = long lasting post-op sedation
Accumulates with repeat dosing

105
Q

What is the class, action, indication, cautions, dosing + special considerations for ketamine?

A

Class = phenylcyclidine derivative
Action = NMDA antagonist, increased HR, BP, SVR, resp depression, smooth muscle relaxation
Indication = trauma, hypovolaemia, asthma
Cautions = TCA meds interact causing HTN, also caution in psychotic pts
Dosing = 1-2mg/kg
Special considerations = emergence reactions.
Pretreat with glycopyrrolate to decrease salivation

106
Q

What is the class, action, indication + cautions for benzos?

A 
Class = Anxiolytic 
Action = Inhibitory at GABA. Minimal cardiac depression
Indication = sedation, amnesia, anxiolysis 
Cautions = marked respiratory depression
107
Q

What is the class, action, indication, cautions, dosing + special considerations for etomidate?

A

Class = imadazole derivative - hypnotic
Action = decreases conc of GABA required to activate receptor. CNS depression
Indication = induction, poor cardiac function, uncontrolled HTN
Cautions = PONV, venous irritation
Dosing = 0.3mg/kg
Special considerations = causes adrenal suppression, causes myoclonic movements during induction

108
Q

What is the MAC + effect on CNS, resp + cardiac system of sevoflurane?

A 
MAC = 2 
CNS = increased ICP
Resp = decreased TV, increased RR, bronchodilation 
CVS = less decrease of contractility, stable HR
109
Q

What is the MAC + effect on CNS, resp + cardiac system of desflurane?

A 
MAC = 6
CNS = Increased ICP
Resp = decreased TV, increased RR, bronchodilation
CVS = tachycardia w/ increase in concentration
110
Q

What is the MAC + effect on CNS, resp + cardiac system of isoflurane?

A 
MAC = 1.2
CNS = decreased cerebral metabolic rate, increased ICP
Resp = decreased TV, increased RR, bronchodilation
CVS = decreased BP + CO, increased HR
111
Q

What is the MAC + effect on CNS, resp + cardiac system of enflurane?

A 
MAC = 1.7
CNS = ECG seizure like activity, increased ICP
Resp = decreased TV, increased RR, bronchodilation
CVS = stable HR, decreased contractility
112
Q

What is the MAC + effect on CNS, resp + cardiac system of halothane?

A 
MAC = 0.8
CNS = increased ICP + cerebral blood flow 
Resp = decreased TV, increased RR, bronchodilation
CVS = decreased BP, CO, HR + conduction
113
Q

What is the MAC + effect cardiac system of N20?

A 
MAC = 104
CVS = decrease HR in paeds pts with existing heart disease
114
Q

What is MAC?

A

Minimum alveolar conc needed to prevent movement in 50% of pts in response to surgical stimulus

115
Q

What factors increase MAC?

A

Chronic alcohol use, hyperthyroidism, hyperthermia, stimulants, young age

116
Q

What factors decrease MAC?

A

Acute alcohol intoxication, hypothermia, sedating drugs, advanced age, drugs (opioids + benzos)

117
Q

How does MAC change for every decade of life?

A

Decreases by 6%

118
Q

What is MAC-intubation?

A

1.3

119
Q

What is MAC-block adrenergic response?

A

1.5

120
Q

What is MAC-awake?

A

0.3-0.4

121
Q

What is the action, intubating dose, onset, duration, metabolism, indications + SE of succinylcholine (SCh)?

A

Action - mimics Ach causing prolonged depolarisation, initial fasciculations seen then paralysis secondary to block ACh receptors
Intubating dose = 1-1.5
Onset = 30-60s
Duration = 3-5 mins
Metabolism = hydrolysed by plasma cholinesterase
Indications = intubation, increased risk of aspiration, short procedures, ECT, laryngospasm
SE = low HR, increased salivation, hyperkalaemia, trigger malignant hyperthermia, increased ICP/ IOP, fasciculations

122
Q

Contraindications to SCh?

A

MH, myotonia, high risk for hyperkalaemia

Relative: myasthenia gravis, open eye injury

123
Q

What is the intubating dose, onset, duration + metabolism of mivacuronium?

A

Intubating dose = 0.2
Onset = 2-3 mins
Duration = 15-25 mins
Metabolism = cholinesterase

124
Q

What is the mode of action of non-depolarising muscle relaxants?

A

Competitive blockage of postsynaptic ACh receptors preventing depolarisation

125
Q

What is the order or non-depolarising muscle relaxants, from short to long acting?

A 
Short = Mivacuronium - Rocuronium 
Int = Vecuronium - Cisatracurium 
Long = Pancuronium
126
Q

What is the intubating dose, onset, duration + metabolism of rocuronium?

A

Intubating dose = 0.6-1
Onset = 1.5 mins
Duration = 30-45 mins
Metabolism = Liver (major) + renal (minor)

127
Q

What is the intubating dose, onset, duration + metabolism of vecuronium?

A

Intubating dose = 0.1
Onset = 2-3 mins
Duration = 45-60 mins
Metabolism = Liver

128
Q

What is the intubating dose, onset, duration + metabolism of cisatracurium?

A

Intubating dose = 0.2
Onset = 3 mins
Duration = 40-60 mins
Metabolism = Hofmann eliminations

129
Q

What is the intubating dose, onset, duration + metabolism of pancuronium?

A

Intubating dose = 0.1
Onset = 3-5 mins
Duration = 90-120 mins
Metabolism = renal (major) + liver (minor)

130
Q

Which non-depolarising muscle relaxants release histamine?

A

Mivacuronium

131
Q

How are reversal agents used?

A

Administered when there is some recovery of blockade (muscle twitch)
Reverse effects of non-depolarising
Anticholinergic agents (atropine, glycopyrrolate) are given simultaneously to minimised muscarinic effect of reversal agents

132
Q

What is the action of reversal agents?

A

Sugammadex = selective relaxant bnding agent

Neostigmine, edrophonium = ACh inhibitors

133
Q

Dose, recommended anticholinergic + onset of pyridostigmine?

A

Slow onset
0.1-0.4 mg/kg
Give with glycopyrrolate 0.05mg

134
Q

Dose, recommended anticholinergic + onset of neostigmine?

A

Intermediate onset
0.04-0.08 mg/kg
Give with glycopyrrolate 0.2 mg

135
Q

Dose, recommended anticholinergic + onset of edrophonium?

A

Intermediate onset
0.5-1 mg/kg
Give with atropine 0.014mg

136
Q

What is the dose + action of sugammadex?

A

Action - encapsulates roco + vecu + decreases amount of agent available at NMJ
2-16 mg/kg

137
Q

What are the complications of early extubation?

A

Aspiration

Laryngospasm

138
Q

What are the complications of late extubation?

A

transient vocal cord incompetence, oedema, pharyngitis, tracheitis

139
Q

How to treat laryngospasm?

A

Sustained pressure with bag mask valve at 100%
Low dose propofol (0.5-1 mg/kg)
Low dose succinylcholine (0.25 mg/kg)

140
Q

What is regional anaesthesia?

A

LA applied around peripheral nerve

No CNS depression

141
Q

What landmarks indicate L4 + T7?

A 
L4 = between iliac crests 
T7 = tip of scapula
142
Q

What is the classic presentation of a dural puncture headache?

A

Onset 6h - 3d after puncture
Postural component
Occipital or frontal localisation
+/- tinnitus, diplopia

143
Q

What structures are penetrated outside to inside for a spinal/ epidural?

A 
Skin
SC fat 
Supraspinous ligament 
Interspinous ligament 
Ligamentum flavum 
EPIDURAL
Dura
Arachnoid 
SPINAL
144
Q

What are the differences between spinal + epidural?

A

Epidural has a slower onset (15 mins)
Effectiveness can be variable with epidural
Spinal uses smaller dose of LA
Epidural can give continuous infusion due to catheter

145
Q

Mode of action of LA

A

Bind to receptors on cytosolic side of Na+ channel, inhibiting Na+ flux + blocking impulse conduction

146
Q

How is LA metabolised?

A 
Esters = broken down by plasma + hepatic esterases, excreted by kidneys 
Amides = broken down by hepatic oxidases (P450) + excreted by kidneys
147
Q

What are the types of LA?

A 
Ester = procaine, tetracaine 
Amide = lidocaine, bupivacaine
148
Q

What factors affect choice of LA?

A

Onset of action (lower pKa = higher conc of LA = faster onset)
Duration of effects (influenced by protein binding)
Potency (influenced by lipid solubility)
Potential for toxicity

149
Q

What is the order of duration, from short to long, of LA?

A

Short: chloroprocaine (15-30 mins)
Lidocaine
Bupivacaine
Ropivacaine (2-8hrs)

150
Q

What are the effects in order of appearance of LA toxicity?

A 
Numbness of tongue, metallic taste, tingling 
Disorientation, drowsiness 
Tinnitus 
Visual disturbances 
Muscle twitching 
Unconsciousness 
Convulsions 
CNS depression
151
Q

What are the effects on the CVS of LA toxicity?

A

Vasodilation
Hypotension
Decreased contractility
Bradycardia

152
Q

What is the treatment for LA toxicity?

A 
Get help
100% O2, manage ABCs 
Diazepam to prevent seizures 
Manage arrhythmias 
Intralipid 20%
153
Q

Where not to use LA with epinephrine?

A 
Ears
Fingers
Toes 
Penis 
Nose
154
Q

How to treat PONV?

A 
Dimenhydrinate (Gravol) 
Metoclopramide (Maxeran) - not with bowel obstruction 
Prochlorperazine (Stemetil)
Ondansetron (Zofran) 
Granisetron (Kytril)
155
Q

What are RF for PONV?

A

Young age
Female
Hx of PONV
Non-smoker
Type of surgery = ophtho, ENT, abdo/ pelvic, plastics
Type of anaesthetics = N2O, opioids, volatile agents

156
Q

How can post-op HTN be treated?

A

IV nitroglycerin, hydralazine, CCB ot BB

157
Q

What is the definition of pain + nociception?

A 
Pain = perception of nociception, occurs in brain 
Nociception = detection, transduction, transmission of noxious stimuli
158
Q

How is pain classified?

A

Temporal eg acute vs chronic

Mechanism eg nociceptive vs neuropathic

159
Q

When should NSAIDs be used with caution?

A 
Asthma 
Coagulopathy 
GI ulcers 
Renal insufficiency 
Pregnancy, 3rd trimester
160
Q

What are the common SE of opioids?

A 
N/V 
Constipation 
Sedation 
Pruritus 
Abdo pain 
Urinary retention 
Resp depression
161
Q

What to consider prescribing alongside opioids?

A

Breakthrough dose
Anti-emetics
Laxative

162
Q

What are the PCA parameters?

A 
Loading dose 
Bolus dose 
Lockout interval 
Continuous infusion 
Maximum 4h dose
163
Q

What are the nociceptive pathways in labour + delivery?

A 
Labour = cervical dilation + effacement stimulates visceral nerve fibres at T10-L1
Delivery = distension of vagina causes somatic impulses via pudendal nerve at S2-S4
164
Q

What are the anaesthetics considerations in pregnancy?

A 
Increased blood volume + increased RBC mass 
Decreased SVR = decreased BP 
Decreased MAC 
Delayed gastric emptying 
Increased abdo pressure 
Increased risk of aspiration
165
Q

What are the options for analgesia during labour?

A

Psychoprophylaxis = Lamaze method (breathing)
Systemic meds = risk of resp depression (opioids if delivery not expected within 4hrs)
Inhalational analgesia = 50% nitrous oxide
Neuraxial = hypotension most common SE, epidural given as it keeps motor function intact

166
Q

What respiratory differences are there for paeds?

A 
Anatomical differences = large head, short trachea, large tongue, adenoids + tonsils 
Narrow nasal passages 
Epiglottis is longer, U shaped 
Faster RR
Less oxygen reserve 
Greater V/Q mismatch 
Greater work of breathing
167
Q

What CVS differences are there for paeds?

A

High HR + low BP

CO is dependant on HR

168
Q

What other differences are there for paeds?

A

Vulnerable to hypothermia
MAC of halothane increased
NMJ is immature - increased sensitivity to muscle relaxants
Vulnerable to hypoglycaemia
Higher dose requirements because of higher TBW
Greater permeability of BBB - opioids more potent

169
Q

What is malignant hyperthermia?

A

Hypermetabolic disorder of skeletal muscle
Uncontrolled increase in intracellular Ca+
Autosomal dominant
Triggered by inhalational agents + SCh

170
Q

What are the signs of MH?

A 
Increased O2 consumption 
Rise in ETCO2
Increase in minute ventilation 
Tachycardia 
HTN
Rigidity 
Hyperthermia
171
Q

What are the muscular symptoms of MH?

A

Trismus (masseter spasm)
Rhabdomyolysis
Rigidity

172
Q

Complications of MH

A 
Coma 
DIC 
Rhabdomyolysis 
Hyperkalaemia 
ARDS
173
Q

Management of MH

A

Some Hot Dude Better Get Iced Fluids Fast

Stop triggering agents 
Hyperventilate 
Dantrolene 2.5mg/kg every 5 mins 
Bicarbonate 
Glucose + insulin 
IV fluids, cool pt to 38
Fluid output, consider furosemide 
Tachycardia - prepare to treat VT
174
Q

What is abnormal pseudocholinesterase?

A

Hydrolyzes SCh + mivacurium

Abnormal = prolonged muscular blockage

175
Q

When are naso + oropharyngeal airways useful?

A

Naso - better tolerated but not to be used in ?basal skull fracture

176
Q

What is the most common cause of obstruction when a pt is under GA?

A

Tongue

177
Q

How do you measure endotracheal tube size?

A

Internal diameter in mm

178
Q

What is the best indicator that the endotracheal tube is in place?

A

Expired CO2

179
Q

What is the WHO checklist for surgery?

A

Checklist for surgery safety
Before induction of anaesthesia
Before skin incision
Before patient leaves operating room

180
Q

How to measure oro + nasopharyngeal airways?

A 
Oro = incisors to angle of jaw 
Naso = tip of nose to tragus of ear
181
Q

What are supraglottic airways?

A

Sit abutting the larynx above vocal cords
Not definitive due to risk of aspiration
Good for short/ low risk procedures

182
Q

What is a laryngeal mask airway?

A

Reusable supraglottic device

183
Q

What is an iGel?

A

Single use supraglottic device

184
Q

What is Yankaur suction used for?

A

To clear oropharynx

185
Q

Describe endotracheal tubes + sizing

A

7 in women, 8 in men
Small hole in end called Murphy’s eye = used for ventilation if end is obstructed
Tube should sit at 20-24cm at the teeth

186
Q

What is a bougie used for?

A

Can be moulded + used for difficult airways

187
Q

What are neuromuscular blockers + the 2 types?

A

Muscle relaxants used in GA

Non-depolarising (compete with acetylcholine = “iums”) or depolarising (suxamethonium)

188
Q

CEPOD surgery classifications + examples

A 
1 = immediate life or limb saving (ruptured AAA) 
2 = urgent (hours) eg compound fracture 
3 = expedited (days eg tendon/ nerve injury)
4 = elective

Anesthetics (6 decks)

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