Fundamentals of anaesthetics

Question 1

What do the pre-operative investigations that are done depend on

Answer 1

Patient co-morbidities & medication
Type of surgery : minor/intermediate/ complex (including haemorrhage risk)
Setting: elective OR emergency

Question 2

Which score is used to as a common peri-operative risk system

Answer 2

ASA and POSSUM

Question 3

Outline ASA

Answer 3

ASA 1: Healthy patient
ASA 2: Mild systemic disease. No functional limitation
ASA 3: Moderate systemic disease. Have functional limitation
ASA 4: Severe systemic disease that is a constant threat to life
ASA 5: Moribund patient. Unlikely to survive 24 hours, with or without treatment

Question 4

What is POSSUM

Answer 4

Can be used to explain to patient if risk is high or not

-Mortality & morbidity risk

Pre-operative: risk discussion

Peri-operative: Need for Invasive monitoring?

Postoperative: Over 5% mortality risk should -> HDU/ITU post operative

Question 5

How do you optimise and what is the perioperative control for: Diabetes

Answer 5

Optimise: Glycosylated Hb

Perio-operative control: When to use Insulin Sliding scales?

Question 6

How do you optimise and what is the perioperative control for: HTN

Answer 6

Optimise: When to treat? (BP>160/80)

Perio-operative control: Maintain 20% of normal BP

Question 7

How do you optimise and what is the perioperative control for: IDH

Answer 7

Optimise: Symptomatic (or major procedure) /ECG anomaly

Perio-operative control: BP & HR control. Consider post operative HDU

Question 8

How do you optimise and what is the perioperative control for: asthma/COPD

Answer 8

Optimise: Symptomatic? Signs?

Perio-operative control: Medication according to BTS

Question 9

How do you optimise and what is the perioperative control for: anticoagulants

Answer 9

Optimise: Why? Stop or not?

Peri-op: INR/APTR <1.5
Anti-platelets/LMWH resumption?

Question 10

How do you optimise and what is the perioperative control for: sickle cell

Answer 10

Optimise: Haem review

Peri-op: Good care- warm, hydrated, analgesia, infection free

Question 11

Who and what surgery is suitable for day surgery

Answer 11

Social: Patient consent, carer, home setup

Medical: Fitness, stable chronic, obesity not preclude

Surgical: Complication risks, controllable post op symptoms, mobile

Question 12

When should you consider investigations for surgery: blood test anomalies

Answer 12

: anaemia, renal dysfunction

Question 13

When should you consider investigations for surgery: lung function tests

Answer 13

Baseline ABG’s, FEV1<40% (predictor for postoperative ventilation)

Question 14

When should you consider investigations for surgery: cardiac

Answer 14

ECG – ischaemia, arrhythmias, baseline

Echo – LV function & valves

Stress echo – low/int/high risk of ischaemia

Question 15

Mallampati score, neck movement

Answer 15

……..

Question 16

Why are patients starved before surgery

Answer 16

Reduce aspiration risk

Question 17

What is the usual starve guidance

Answer 17

Food : 6 hours

Water: 2 hours

Question 18

Which patients are at increased risk of aspiration during surgery

Answer 18

Bowel obstruction, reflux disease, trauma (causing slow gastric transit, opioids

Question 19

What do you need to include to prescribe opioids

Answer 19

The dose
The form
The strength (where appropriate)
The total quantity or dosage units of the preparation in both words and figures
For instalment prescriptions, specify the instalment amount AND instalment interval

You must write how often to take in numbers and words

Question 20

USE THE ANAESTHETIC SLIDE FOR PRESCRIPTION

Answer 20

……..

Question 21

How is the oropharyngeal tube sized up

Answer 21

Compare the oropharyngeal tube from the corener of the mouth to the angle of the mandible

Question 22

When is oropharyngeal tube used

Answer 22

To help to bag a patient

Question 23

When do you use the bag-mask-valve

What oxygen can it deliver

Answer 23

When somebody is apnoiec only (not when a patient is trying to breathe because of the valve)

Can deliver up to 100% o2

Question 24

What is a definitve airway

Answer 24

a tube placed in the trachea with cuff inflated below the vocal cords

Question 25

Is an endotracheal tube a definitive airway

Answer 25

Yes it is

Question 26

Is a supraglottic device a definiive airway

Answer 26

No

Question 27

5 steps to safer surgery

Answer 27

........

Question 28

What does one need to consider for VTE

Answer 28

Mobility Risk factors Bleeding risk

Question 29

How is dalteparin usually given

Answer 29

Sub cut

Question 30

What is the MOA, SE and dose/route of the following antiemetics; Ondansetron

Answer 30

5HT3R-antagonist Bradycardia Long QT syndrome 4-8mg TDS PO/IV

Question 31

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Answer 31

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Question 32

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Answer 32

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Question 33

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Answer 33

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Question 34

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Answer 34

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Question 35

What temperature do you want to keep people at

Answer 35

Keep temp>360 C

Question 36

How do you maintain temperature dor someone with a procedule longer than 30 minutes? What about longer procedure?

Answer 36

Procedure>30mins --> Bair hugger Longer procedures --> consider fluid warming

Question 37

How do you manage an acute asthmatic (severe bronchospasm outside of theatre)

Answer 37

A,B,C O2 -Start high flow oxygen and gain IV access Salbutamol nebulised 2.5-5mg Hydrocortisone 100 mg IV 6 hourly or prednisolone orally 40–50 mg/day. Ipatropium nebulised 0.5 mg (4–6 hrly) • IV salbutamol if not responding (250 mcg slow bolus then 5–20 mcg/min). Theophylline/Aminophylline Magnesium 2g IV over 20 minutes

Question 38

When might adrenaline be used in severe bronchospasm

Answer 38

NB- In extremis (decreasing conscious level or exhaustion) adrenaline may be used: nebuliser 5 ml of 1 in 1,000; Senior clinician only: IV 10 mcg (0.1 ml 1 : 10,000) increasing to 100 mcg (1 ml 1 : 10,000) depending on response.

Question 39

Learn the table of drugs slide 38

Answer 39

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Question 40

How do you treat a severe tension pneumothorax

Answer 40

You can put a large bore cannula in the 2nd ICS Chest drain might take too long in this situation

Question 41

Triggers for anaphylaxis

Answer 41

Stinhgs, nuts, food, Abx, anaesthetic drugs, contrast media

Question 42

How might you recognise anaphylaxis

Answer 42

Airway problems: Airway swelling, e.g., throat and tongue swelling (pharyngeal/laryngeal oedema). The patient has difficulty in breathing and swallowing and feels that the throat is closing up. Hoarse voice. Stridor – this is a high-pitched inspiratory noise caused by upper airway obstruction. Breathing problems: • Shortness of breath – increased respiratory rate. • Wheeze • Patient becoming tired. • Confusion caused by hypoxia. • Cyanosis (appears blue) – this is usually a late sign. • Respiratory arrest.

Question 43

Anaphyaxis treatment

Answer 43

Legs up, adrenaline, IV fluids, chlorphenamine and hydrocortisone???

Question 44

When to transfuse generally

Answer 44

if fit and well, then when Hb <70 If they have acute conroanary syndrome, sepsis, neuro injusty, is when Hb is <90

Question 45

What is the early warning scores

Answer 45

, based on simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present to, or are being monitored in hospital

Question 46

What are the paramteres used for NEWS score

Answer 46

``` 1  respiratory rate 2  oxygen saturations 3  temperature 4  systolic blood pressure 5  pulse rate 6  level of consciousness. ```

Question 47

What score is low medium and high

Answer 47

0 or 1-4 is low 5-8 (or individual parameter scoring 3)= medium Aggregate 7 or more= high

Question 48

What is sepsis

Answer 48

Infection + systemic inflammatory response syndrome

Question 49

What is SIRS

Answer 49

Systemic inflammatory response syndrome Two or more of Temp >38 or <36 heart rate>90bmp Resp rate >20/min White cell count

Question 50

What to do if recognise sepsis within 3 hrs

Answer 50

1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L "Time of presentation" is defined as the time of triage in the emergency department

Question 51

What to do if recognise sepsis within 6hrs

Answer 51

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) ; maintain a mean arterial pressure (MAP) ≥65 mm Hg 6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion. 7. Re-measure lactate if initial lactate elevated.

Question 52

Indications for ABG

Answer 52

To obtain & interpret oxygenation levels To assess for potential respiratory derangements To assess for potential metabolic derangements To monitor acid-base status To assess carboxyhaemoglobin in CO poisoning To assess lactate To gain preliminary results for electrolytes and Haemoglobin Can be conducted as a one off sample or repeated sampling to determine response to interventions

Question 53

Contraindications for ABG

Answer 53

Local infection Distorted anatomy Presence of arterio-venous fistulas Peripheral vascular disease of the limb to be sampled Severe coagulopathy or recent thrombolysis

Question 54

Sampling error for ABG

Answer 54

Presence of air in the sample collection of venous rather than arterial blood an improper quantity of heparin in the syringe, or improper mixing after blood is drawn delay in specimen transportation

Question 55

Complications related to ABG

Answer 55

``` Haematoma Nerve damage Arteriospasm or involuntary contraction of the artery Aneurysm of artery Fainting or a vasovagal response ```