Critical illness

Question 1

What are the common allergens in an operating theatre

Answer 1

Latex, abx, muscle relaxants, anaesthetic induction agents, egg lecithin in propofol, colloid infusions, blood products

Question 2

What dosage and route of adrenaline should be given in anaphylaxis

Answer 2

0.5mg, 0.5 ml 1:1000 IM, usually lateral thigh

Question 3

What blood tests can be performed to confirm anaphylaxis

Answer 3

Serum tryptase/mast cell tryptase and mast cell histamine

Question 4

As well as adrenaline and fluids what other medication should be given to patients with anaphylaxis after initial resuscitation

Answer 4

Nebulised salbutamol for wheeze

Chlorphenamine Iv slow 10mg, hydrocortisone Iv 200mg

Question 5

Clinical features of anaphylaxis

Answer 5

Rash/itch
SM contraction, vasodilation, capillary leakage
Bronchospasm, nausea, diarrhoea
Angiodema
Shock

Question 6

what are the major post-op changes in water and electrolyte balance which influence management after an operation

Answer 6

Secretion of ADH in response to pain and low volume urine, oliguria 24-36 hrs

Reduction in renal Na excretion 36-48 hours

Increased K excretion greater with tissue damage

Question 7

What are the principles of fluid replacement following minor surgery

Answer 7

Not normally necessary if oral intake after 1-2 hr and no PONV or high risk

Failing to drink/prolonged surgery then after 4-6 hr Maintainance needed

1.5ml/kg, take into account deficits from fasting

1-1.5 mmol/kg Na

Normally add 20mmol k to each bag

Question 8

What are the principles of fluid Maintainance after major surgery

Answer 8

Take into account features eg losses into drains. Bleeding, pyrexia, epidurals, level of tissue trauma

1.5ml/kg plus extra 10% every degree pyrexia

Sodium 1-1.5 mmol/kg/24h

Potassium 1mmol/kg/24h,

Aim for hb 9g/dl. If >500ml loss replace with n saline/hartmanns, >1000 consider transfusion

Question 9

What antihistamine(s) are used as antisickness. MOA, dosage, route

Answer 9

cyclizine, 50mg/IV/IM/tablets . It may have effects directly on the labyrinthine apparatus and on the chemoreceptor trigger zone. Antimuscarinic

Question 10

What 5HT3 antagonists are used as antisickness. MOA, dosage, route

Answer 10

Ondansetron,block vagal efferents in CTZ and gut. 4-8mg slow IM/IV or tablet

Question 11

Ondansetron is a ….

Answer 11

5HT3 antagonist

Question 12

…. is a 5HT3 antagonist

Answer 12

Ondansetron,

Question 13

Cyclizine is a …..

Answer 13

Cyclizine is an antihistamine

Question 14

….. is an antihistamine

Answer 14

Cyclizine is an antihistamine

Question 15

What are the contraindications/cautions of using cyclizine

Answer 15

severe HF, prostatic hypertrophy, hepatic disease, renal impairment, urinary retention, suceptibility to CA glaucoma, pyloroduodenal obstruction

Question 16

what are the indications for use of cyclizine

Answer 16

any N+V, labrynthitis, vertigo, motion sickness, radiation sickness

Question 17

What are the indications for using ondansetron

Answer 17

prophylaxis PONV and chemo

Question 18

what are the contraindications for using ondansetron

Answer 18

hepatic impairment, QT interval prolong, pregancy, breast feeding

Question 19

metoclopramide, droperidol, prochlorperazine are ……

Answer 19

metoclopramide, droperidol, prochlorperazine are dopamine antagonists

Question 20

…. are dopamine antagonists

Answer 20

metoclopramide, droperidol, prochlorperazine are dopamine antagonists

Question 21

What dopamine antagonists are used as antisickness. MOA, dosage, route

Answer 21

Metoclopramide 10mgIV/IM/PO, domperidone, prochlorperazine(12.5mgIM) Act against agents that stimulate CTZ eg opiods, anaesthetic drugs, chemo. Prokinetic efffect. Prochlorperazine has action against D2 and 5HT receptors in CTZ

Question 22

Indications for dopamine antagonists

Answer 22

PONV , chemotherapy, radiotherapy, Prochlorperazine vertigo, labrynthitis, opiates and GA, psycosis

Question 23

Contraindications of dopamine antagonists

Answer 23

metochlopramide; GI obstruction, haemorrhage, breast-feeding, hepatic/renal disease, epilepsy, pregnancy, elderly/children

Prochlorperazine; hypotension likely, elderly, comatose, hepatic/renal disease, epilepsy, parkinsons

Question 24

What investigations are important in managing dka

Answer 24

Fbc/crp (sepsis)
U and e (renal function/k/acidosis
Glucose
Blood ketones
VBG
LFT/amylase/trop t/ ECG/CXR

Question 25

Management of DKA

Answer 25

Insulin (0.1units/kg/hr Fluids (1l n/s over 1 hr, 1l/2hr +/-k x 2, same again over 4hrs K+ (total body k low due to osmotic diuresis. With treatment EC k will fall. <14, 10%dextrose 125ml/hr through 2nd cannula. Adjust to maintain 8-14 Prophylactic enoxaparin Treat underlying cause Reg monitoring bm and blood ketones and any

Question 26

Possible comps of DKA

Answer 26

Gastroparesis (consider ng), Cerebral odema reduced gcs, (rare but commoner in children) Fluid o load Rarely raised cl None resolving acidosis (?administration probs, sepsis) Hypokalemia

Question 27

What are the sepsis six

Answer 27

Administer high flow oxygen. Take blood cultures Give broad spectrum antibiotics Give intravenous fluid challenges (2l in 500 bolus checking after each) Measure serum lactate and haemoglobin Measure accurate hourly urine output

Question 28

What are the SIRS criteria

Answer 28

Body temperature less than 36°C(96.8°F) or greater than 38°C(100.4°F) Heart rate greater than 90 beats per minute Tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg) White blood cell count less than 4000 cells/mm³ (4 x 109 cells/L) or greater than 12,000 cells/mm³ (12 x 109 cells/L); or the presence of greater than 10% immature neutrophils (band forms) band forms greater than 3% is called bandemia or a "left-shift." SIRS can be diagnosed when two or more of these criteria are present

Question 29

What are the criteria for diagnosing Kai

Answer 29

Rise in creatinine >26micromol/l in 48h Rise in creatinine > 1.5 x best figure in last 3/12 Urine output