Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Final FRCA SOE > Clinical 2 > Flashcards

Clinical 2 Flashcards

1
Q

Intraoperative awareness

A

recall of events during general anaesthesia either due to inadequate delivery of anaesthetic or patient resistance to sufficient dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Classification of AAGA

A

Implicit awareness: implicit memories without conscious recall, but may alter behaviour
Explicit awareness: conscious recall

Michigan classification classes
0 - no awareness
1 - isolated auditory perception
2 - tactile stimulation without pain
3 - pain
4 - paralysis without pain
5 - pain and paralysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Risk factors

A

Patient
- previous awareness
- obesity
- young females
- difficult airway
Anaesthetic
- TIVA ??
- Thiopentone
- Muscle relaxants
Surgical
- GA ceasarean
- cardiac
Organisational
- out of hours
- junior anaesthetist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Awareness incidence

A

1:19,000
1:8200 cardiac
1:670 cesarean
no neuromuscular blocking drugs 1:136,000

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Criteria for referral for bariatric surgery

A

BMI > 40
BMI 35-40 with disease that might improve with weight loss
weight loss not achieved despite all appropriate strategies
long term follow up commitment
Tier 3 obesity service - MDT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Weight loss procedures

A

Restrictive - small gastric pouch, limited outlet
- sleeve gastrectomy
- gastric band
Malabsorptive
- limit size of stomach shortens route of absorption
- roux-en-y bypass

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

General considerations in bariatric surgery

A

difficult procedures e.g. venous, arterial, RA
difficult airway
positioning
monitoring - IABP may ne needed
equipment - hover mattress, bariatric table

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Carcinoid syndrome

A

results from secretion of vasoactive substances by carcinoid tumours leading to flushing, diarrhoea, right heart failure.
Carcinoid crises
- exaggerated profound cardiorespiratory responses with bronchospasm, tachycardia, labile BP
- might be precipitated by surgery, anesthesia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Carcinoid tumours

A

arise from enterochromaffin cells - neuroendocrine cells, 2/3 gut 1/3 bronchi
primary tumour symptoms - release of vasoactive substances e.g. histamine, serotonin, VIP or mass effect
carcinoid heart disease - right heart filure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

work up carcinoid

A

CT
urine HIAA - serotonin metabolite or serum chromaffin A
ocrtreotide - somatostatin analogue, reduces mediator release pre op
CVS work up
symptomatic - bronchodialtors, antidiarrhoeals, treatment of heart failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Anaesthesia for carcinoid

A
  • continue octreotide
  • IABP pre induction
  • avoid histamine release (atracrium, morphine)
  • severe hypotension - IV octreotide 10-20ug
  • hypertension - labetalol
  • epidural may reduce crises
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Cataract surgery

A

GA
Ads - controlled, anaesthesia and akinesia, high patient satisfaction
Disads - costly, personnel, equipment, risk of GA, starvation
RA
Ads - time and cost efficient, anaesthesia and akinesia excellent, no fasting
Disads - less controlled than GA, complications
Topical
- Ads - time and cost efficient, no effect on vision, avoid risks of GA and ocular risks of RA
- Disads - least controlled, purely sensory

Day case cataract - continue anticoagulants and antiplatelts INR < 3.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Eye RA

A

Sharp needle
- Retrobulbar - highest complications. lat 1/3 lower orbital ridge, advance until equator estimated then medial and superior. intraconal.
- Peribulbar - extraconal, medial cants
Blunt needle
- sub-tenons - tenon capsule thin layer or CT separates globe from optic nerve. sub-tenon potential space between sclera and tenon. better tolerated, less risk but chemises and subconjunctival haemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Sub-tenon block

A
  • topical anaesthesia - tetracaine 0.5%
  • lower nasal quadrant
  • look up and out
  • forceps to lift conjunctiva and and tenons fascia
  • westcott scissors to cut
  • passage of westcott scissors to make superio-medially
  • sub tenon cannula - advance along contour of eyeball until syringe vertical
  • aspirate and inject 3-5ml 0.5%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Robot assisted surgery

A

ads
- better ergonomics for surgeon
- 6 degrees of freedom
- elimination of undesirable movements e.g. tremor
Disads
- loss of haptic feedback
- patient movement potentially disastrous (robot fixed)
- human factors - poor access to patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

delayed emergence from anaesthesia

A

pharmacological
- benzos
- opioids
- NMBDs
- central anticholinergic syndrome
non-pharmacological
- metabolic - glucose, sodium, hypothermia
- neuro - intracranial event, seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

sux apnoea

A

autosomal recessive
4 alleles - usual 96% homozygotes
0.001% homozygous for silent - no enzyme
- dibucaine number - higher the better enzyme function
acquired
- pregnancy
- ever, renal, cardiac failure
- malnurtiion
- cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

ECT

A

30-45J energy 1-1.5s
aim for 20-50s seizure
unilateral - less cognitive effects, less effective
bilateral - normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

NELA standards

A
  • CT scan reported prior to surgery
  • Abx within 1 hr of sepsis diagnosis
  • risk of death documented pre-op
  • arrival to theatre in appropriate timescale
  • high risk patients should have consultant anaesthetist, surgeon and HDU
    Risk assessment tool - 5% + high risk (30day mortality)
    Exclusions - oesophagus, appendix, gallbladder, vascular, gynae, trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

ERAS

A

MDT approach to perioperative care aiming for faster, safe recovery and discharge. common features - education and engagements of MDT, patient education, early feeding and mobilisation, multimodal analgesi

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

enhanced recovery interventions

A

pre-op
- education
- prehabilitation
- optimising co-morbidities
- investigating and treating anaemia
admission
- minimis fasting
- glucose drink
anaesthesia
- multimodal analgesia including regional
- GD fluid
- minimis PONV
surgery
- minimally invasive, minimal drains
post-op
- early feeding and mobilisation
- multimodal analgesia with pain team input
- removal of lines as soon as possible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

ERAS benefits

A

reduced stress response - neuroendocrine, inflammatory
reduced ileus
reduce cardiorespiratory complications
increased muscle strength
reduced LOS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Flaps

A

free - flap - autologous tissue detached from remote donor site and transferred to recipient, with circulation restored by microvascular anastomoses
pedicle - flap remains connected to donor site by intact vascular pedicle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Free flap surgery

A

wounds not suitable for primary closure
- mastectomy - DIEP, TRAM
- head and neck cancers
- post trauma
Stages
1. flap elevation and clamping of vessels
2. primary ischaemia - blood flow ceases, anaerobic metabolism 60-90mins
3. reperfusion - arterial and venous anastomoses

contraindicaions - sickle cell, polycythaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Anaesthesia aims in free flap surgery

A

minimise primary ischaemia = primarily surgical time
optimise flap perfusion and minimise secondary schema -optimised by normothermia, low SVR, adequate filling, 30% haematocrit (HP)

Flap failure
- arterial - defective anastomosis, thrombosis, spasm
- venous defective anastomosis, compression, thrombosis
- oedema - prolonged ischaemia, excessive fluid

HDU
- colour
- dopplers
- temperature
- CRT

donor site is painful

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

HIV / AIDS

A

retrovirus infecting CD4 t lymphocytes causing destruction and immunodeficiency
seroconversion –> asymptomatic
AIDS CD4 < 200 or AIDs defining illness - oesophageal candidiasis, kaposi sarcoma, CNS lymphoma, PCP
opportunistic infectins
- PCP
- fungi e.g. cryptococcus
- viruses eg cmv
- TB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

HAART

A

2 nucleoside reverse transcriptase inhibitors
- tenofovir
+ 1
- integrase inhibitor
- non-nucleoside reverse transcriptase inhibitor
- protease inhibitor

SE neutropenia, anaemia, diarrhoea, hepatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Specific principles in liver resection

A

Child-Pugh / MELD risk assessment
Bleeding - cross match, wide bore access
Coagulopathy correction
Pringle manoeuvre - occlusion of PV and HA - reduce bleeding but also reduce venous return and increase afterload
Low CVP < 5
TXA
Drug metabolism affected e.g. roc, opiate, middaz
Analgesia - consider epidural but coagulation
IPPV and PEEP reduced hepatic blood flow but increase bleeding risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Pancreatic resection

A

Whipples = pancreaticoduodenectomy - distal stomach, duodenum, bile duct, gall bladder. Distal pancreatectomy = spleen as well
intra-op - glycemic monitoring, restrictive fluid balance

30
Q

Anaesthetic considerations following lung transplant

A

Denervated lung
- suppressed cough reflex
- impaired sputum clearance
- possible heart denervation
Care with intubation - avoid disrupting anastomosis - cuff just distal to vocal cods and monitored
strict fluid balance - beware pulmonary oedema
single lung transplant - may have different compliance and differential ventilation

31
Q

perioperative implications of immunosuppression

A
  • immunophilin binding - tacrolimus, ciclosporin - prevent T cell activation. associated with renal dysfunction
  • nucleic acid synthesis inhibitors - azathioprine - block lymphocyte proliferation
  • steroids - blod inflammtory cytokines
    Anaemia, thrombocytopenia, leucopenia.
    strict asepsis
32
Q

Penetrating eye injury

A

Normal IOP 10-21mmhg.
rise in IOP may cause extrusion of vitreous humour
RSI, avoid ketamine and sux
drug to obtund laryngoscopy reflex
volatile or TIVA, avoid N20
Head up position, PaCO2 4.5-5, sats 94-98%
avoid coughing, straining on emergence (LMA exchange)
Raised IOP
- ensure adequate depth, avoid obstructed venous blood flow
- mannitol, acetazolamide 500mg iv

33
Q

Management of kidney stones

A

non-invasive
- extracorporeal shock wave lithotripsy
invasive
- ureteric stenting
- lasering
- percutaneous nephrolithotomy
- open or laparoscopic removal

34
Q

PCNL considerations

A

positioning
- lithotomy for stent
- then prone or prone oblique for nephrostomy insertion
- reinforced ETT, head arm leg chest pelvis support
Nephrostomy risk - pneumothorax, renal pelvis rupture

35
Q

Phaechromocytoma

A

catecholamine secreting tumour of the adrenal medulla
classic presentation - headaches, sweating, palpitations
- HTN 90%
- Incidental
1/3 autosomal dominant. May be associated with other tumours - MEN 2, Von-Hippel Lindau, Neurofibromatosis
Dx - plasma metaneprhins, urine VMA
imaging

36
Q

Pre-op management of phaeochromocytoma

A

MDT
Sympathetic blockade
BP control
- Alpha blockage first then beta (unopposed alpha - hypertensive crisis)
- Alpha - doxzosin (selective a1), phenoxybenzamine (non-selective)
HR control
- Beta - selective B1 e.g. atenolol.
Myocardial function - echo for function
Restore circulating volume - fluid intake
reverse glucose / electrolyte derangement (hypoglycaemic agents)
Aim for BP < 130/80 (old was aim for orthostatic hypotension, nasal congestion)

37
Q

Intra-op management phaeo

A

monitoring - arterial, CO, CVC
Open - epidural
Avoidance of perioperative catecholamine release
- intubation, surgical stimulus
- avoid sympathomimetic drugs - ketamine, ephedrine
- use magnesium, remifentanil
minimise response to tumour handling
- Phentolamine - alpha antagonists vasodilator. bolus 1-2mg, short duration
- sodium nitroprusside, GTN - vasodialtor
- esmolol - selective B1 antagonist. rapid onset / offset. 500ug.kg
Hypotension following tumour removal
- Stop hypotensives, optimise fluid
- noradrenaline
- vasopressin
Post op
- critical care
- BP support
- Glcaemic support
- hypoadrenalism - steroid

38
Q

Perioperative risk assessment

A

allows targeted optimisation
provides information for patient selection and informed consent
History examination
Risk score
Risk prediction models
Functional assessment

39
Q

Risk scores

A

simple, population based risk
ASA 1-6
Lee’s revised cardiac risk - not applicable to emergencies

40
Q

Risk prediction models

A

Aim to provide individualised risk
P-Possum - emergency and elective major general and urological and vascular. physiological and operative variables. 30d morbidity and mortality
NELA - 30d mortality in em laparotomy in UK. physiological and operative variables
ACS-NSQIP - big data set, 30 d mortality, morbidity, return to theatre qol. time consuming
SORT - 30 day mortality, 6 variables (non-cardiac non-euro)

41
Q

functional risk assessment

A

global cardiorespiratory assessment
6min walk test
incremental shuttle walk

42
Q

CPET

A

dynamic, non-invasive cardiorespiratory assessment during exercise to determine functional capacity
if unable to increase oxygen delivery to match increase in perioperative oxygen consumption likely to have complications
aid risk prediction, resource allocation, comorbities identified

43
Q

CPET

A

measurements - expired gas, 12 lead, SPO2, BP
Metabolic gas exchange - VO2, VCO2, RER (VCO2/VO2)
9 panel plot
? maximal effort
? ECG changes
Key variables
- VO2 peak max rate of o2 consumption < 15ml/kg/min high risk
- AT - point at which o2 demand exceeds delivery - rise in CO2 excretion
- vent efficiency for CO2 VE/VCO2 - lugns ability to excrete co2

44
Q

Cpet contraindications

A
  • Acute MI 3-5days
  • unstable angina
  • unctonrolled arrhythmias
  • acute PE
  • Pulmonary oedema
45
Q

Intraoperative aims of kidney transplant

A
  • Ensure perfusion of graft - MAP > 90
  • paralysis particularly during anastomosis
  • immunosuppression - reduce early rejection, methylprednisolone and biological agent after induction
  • CVC, art line (although wary of fistula sites)
  • drugs adjustment according to renal function
  • multimodal analgesia avoiding NSAIDs
  • Mannitol . dopamine nil evidence
  • careful fluid
46
Q

Atlanto-axial subluxation

A

Axis (C2) and atlas (C1)
AAI - Ligament laxity, erosion of peg, leading to movement of peg of C2 away from C1
movement in flexion can lead to spinal cord compression
can move ant, post, lateral
4mm space = AAS in adults

47
Q

Robotic surgery

A

Ads
- greater surgical dexterity (6 degrees of freedom)
- allow visualisation in 3d
- remove unwanted movements - tremor
Disads
- loss of haptic feedback
- need space
- longer
- expense of robot
- poor access to pt
- undocking in emergency takes time

48
Q

Anaesthetic considerations of robotic surgery

A
  • glaucoma / intracranial pathology trend. pos
  • likely ability to cope with pneumoperitoeum
  • intraop
    • airway - limited access. well secured
    • PEEP, TV 6-8, plat press < 30. MV sufficiency to handle co2
    • CVS monitoring
    • NMB.. must be kept completely still
    • NGT
    • analgesia multimodal, regional
    • careful positioning
    • leak test priot to extubation
49
Q

Massive UGI bleed

A

A-E
Risk assess - Blatchford (risk of needing intervention) Rockall - pre and post endoscopy risk of re-bleed
GA - airway control, less frightening, better control, better procedural conditions
May need ketamine, volume rhesus, vasopressors, minimise DOA
Varices - band/adrenaline/thermal. need abx and terlipressin. balloon tamponade with sengstacken-blackmore tube, 48hr
TIPS

50
Q

porphyria

A

group of inherited disorders leading to altered heme synthesis, usually autosomal dominant
Acute - AIP
non-acute - porphyria cutanea tarda
Acute attack - when haem synthesis is increased, leads to buildup of intermediates. physiological stress, alcohol, fasting, drugs
clinical features - neurovisceral - CNS, PNS, ANS - abdominal pain, nausea, vomiting, tachycardia, distal weakness, seizures, psychiatric
Diagnosis - porphyrin precursors - porphobilinogen, ALA

51
Q

Porphyria and anaesthesia

A

precipitants of crisis
- starving - reduce time, RSI
- unsafe drugs - barbiturates, ketamine, etomidate, halothane, deemed, abx clairhtyrmocine
- check with specialist / BNF
remvoe precipirNRA
- GIVE haem arginate - large vein/

52
Q

Anaesthetic consdierations of prone position

A

Airway
- ETT dislodgement
- Endobronchial
Breathing
- If abdominal contents not free, can splint diaphragm and reduce compliance
CVS
- abdominal compression reduced venous return and CO
Occular
- POVL - CRAO, ION
Compression
- brachial plexus
- face
breasts
genitals
ankles
knees

53
Q

Complications of prone positioning

A

Brachial plexus injury - poor positioning of arms
Facial damage (head rings leads to pressure sores, pressure necrosis)
Ophtalmic injury
Lat cutaneous nerve of thigh
Macroglossia - impaired venous drainage

54
Q

Clinical features of infective endocarditis

A

Sub-acute
- fever
- weight loss
- night sweats
- anemia
- embolic phenomenon- laneway lesion, splinter haemorrhages
Acute
- dyspnoea from pulmonary oedema
- shock - cardiogenic, septic
- septic emboli - cerebral, gut, renal,

55
Q

Risk factors for endocarditis

A

Cardiac
- rheumatic heart disease
- bicuspid aortic valve
- valve replacement
- indwelling pacemaker
Non-cardiac
- immunosuppression
- IVDU
- indwelling long line

56
Q

Dukes criteria

A

2 major, 1 major + 3 minor, or 5 minor
Major
- oscillating cardiac mass on echo
- 2 separate positive blood culture
Minor
- fever
- embolic lesions
- risk factor
- immunilogical phenomena e.g. osler node
- micro evidence not reaching major

organisms
- strep viridans, bovis
- staph aureus, coag negative
- enterococci

57
Q

marfans

A

rare autosomal dominant connective tissue disorder affecting multiple systems due to defect in fibrillar gene
Clinical features
Resp
- spont pneumothorax
- emphysema
CVS
- Aortopathy - dissection
- dilated aortic root
- aortic regurgitation
- MV / TV prolapse
Occular
- retinal detachment
MSK
- tall
- aracnodactylyl
- scolious
- pecvtus excavatum
- hypermobility

58
Q

Aortic regurgitation in Marfans

A
  • dyspnoea, PND, fatigue, exertional chest pain
  • wide pulse pressure, Quinke sign, waterhammer pulse
  • early diastolic murmur
    ECG - LVH
    CXR - boot chaped heart
    Echo - regurgitant fraction - % return to the LV from aorta mild < 30% severe > 60%
59
Q

Haemodynamic goals in AR

A
  • rate - high normal 80-90 (reduce diastolic time)
  • SVR - low normal
  • euvolaemia
  • maintain contraciltty
  • maintain sinus rhythm
60
Q

Anaesthetic considerations of marfans

A
  • airway - prognathism, TMJ dislocation
  • breathing - pneumothorax, pulm complications from kyphoscoliosis
  • CVS - risk of dissection- obtund laryngoscopy, control BP
    positioning - hyper mobility
61
Q

Thoracic pre-op assessment

A

high risk surgery
pneumonectomy 5-10% mortality
Assessment
- cardiac. Lees
- mortality . thoracoscore
- dyspnoea- ppo

62
Q

BPF presentation

A

early
- dyspnoea
- persistent bubbling from chest drain
- fall in air fluid level serial CXR
- tension pneumothorax
late
- fever
- non-specific signs
- dyspnoea

63
Q

ventilation strategy BPF

A
  • isolate the fistula and ventilate one lung
  • low TV, low PEEP, low pressure pressure control if IPPV. SV if poss
  • hfjv
  • vv-ecmo, allowing ultra low volume ventilation
    Treatment
  • large bor chest drain
  • abx for empyema
  • endobronchial occlusion
  • surgical thoracoplasty / stapling
64
Q

rigid bronchoscopy indictations

A

diagnositc
- lesion inspection
- biopsy
therapeutic
- removal of foreign body
- stent insertion

65
Q

Anaesthetic considerations for rigid bronchoscopy

A
  • airway and ventilation - shared, conventional ventilation difficult, obstruction, unprotected
  • cvs - stimulating
  • maintenance - unreliable volatile delivery, conventional circuit not used - tiva
  • stimulation - coughing, need topicalisation
  • iatrogenic bleeding
66
Q

Ventilation options during bronchoscopy

A
  • positive pressure - jet ventilator, lo frequency 4 atmospheres. passive exhalation. can’t control fio2 or co2. barotrauma
  • apnoeic oxygenation - high flow, need patent airway, high co2, variable timeframe
  • SV - may be difficult due to opiate, paralysis
67
Q

jet ventilation

A

small tidal volumes from high velocity jet
venturi effect entrains air
pasive expiration
HFJV supraphysilgocail 1-10Hz
- bulk convection
- pendelluft
- supraglottic, subglottic, transtracheal

68
Q

massive haemoptysis

A

airway - DLT or single lumen endobronchial
non-surgical management
- tamponade (lung deflation)
- vasoconstrictor - adrnelaine
- laser / cryotherapy
- IR

69
Q

Amniotic fluid embolism

A

fetal material enters maternal circulation
phase 1 - mast cell degranulation, pulmonary artery vasospasm, pHTN, RV failure, hypoxaemia, hypotension
phase 2 -LV failure, endothelial activation, DIC

70
Q

Multiple pregnancy

A

exagerrated version of singleton pregnancy
resp
- FRC further reduced, O2 consutpion cufrther increased - desaturation
- CVS - blood volume up to 40% greater than singleton, Hb less increase, greater physiological anaemia. CO 20% greater than singleton. greater aorocaval compression. grater blood loss. geater PET risk
- CNS - greater cephalad spread of regional
- GI - greater abdomina pressure - more reflux
Obstetric consideration
- if twin 1 cephalic, can consider vaginal birth
- 2 CTG
- shorter 1st stage
- twin 2 can be prolbematinc to deliver

71
Q

MBRRACE 2023

A

Direct
- Haemorrhage
- PE
- Sepsis
- PET
- AFE
Indirect
- mental health
- Covid-19
- Sepsis
- Cardiac

Deprivation, ethnic minority ++
Maternal death = up to 42 days
direct = obstetric complications of preganncy
indirect = pre-existing disease or disease occuring during pregnancy unrelated to pregnancy itself

Final FRCA SOE (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions