Clinical 2 Flashcards

Question

Anaesthesia aims in free flap surgery

Answer 1

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

Answer 2

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

Answer 3

2 nucleoside reverse transcriptase inhibitors - tenofovir + 1 - integrase inhibitor - non-nucleoside reverse transcriptase inhibitor - protease inhibitor SE neutropenia, anaemia, diarrhoea, hepatic

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

- 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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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)

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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)

Answer 17

global cardiorespiratory assessment 6min walk test incremental shuttle walk

Answer 18

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

Answer 19

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

Answer 20

- Acute MI 3-5days - unstable angina - unctonrolled arrhythmias - acute PE - Pulmonary oedema

Answer 21

- 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

Answer 22

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

Answer 23

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

Answer 24

- 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

Answer 25

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

Answer 26

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

Answer 27

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/

Answer 28

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

Answer 29

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

Answer 30

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,

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

- 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%

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

- 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

Answer 40

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

Answer 41

- 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

Answer 42

- 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

Answer 43

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

Answer 44

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

Answer 45

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

Answer 46

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

Answer 47

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

Clinical 2 Flashcards

(71 cards)