Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

James' final FRCA SOE > Neuro > Flashcards

Neuro Flashcards

(67 cards)

Start Studying
1
Q

Anaesthetic considerations for patient with SAH requiring aneurysmal coiling?

A

General considerations:
1. Critically unwell patient undergoing emergency high-risk procedure will require an experienced senior anaesthetist, ODP and emergency help if available

  1. Time-critical therefore full stomach, aspiration risk
  2. Remote site anaesthesia - lack of familiar monitoring/equipment, out of hours with less help around, limited access to patient during procedure, lack of appropriate recovery area

Pathology specific considerations:
1. Unsecured aneurysm with potential for bleeding
- Avoidance of extremes of blood pressure and reversal of coagulopathy

  1. Potential increased ICP
    - Maintenance of CPP 60-70mmHg (MAP 80-90)
    - PaO2 , PaCO2, normothermia, euglycaemia, venous drainage considerations
    - May require EVD before or after if evolving hydrocephalus
  2. Potential medical complications
    - Neurogenic pulmonary oedema
    - Myocardial dysfunction due to catecholamine surge
    - Electrolyte disturbance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Anaesthetic goals for patient with SAH requiring aneurysmal coiling/clipping?

A
  1. Haemodynamic control and monitoring
    - Minimisation of transmural pressure to avoid rebleeding
    - Invasive arterial blood pressure monitoring and CVC for noradrenaline
    - Avoidance of acute hypertensive episodes such as pressor response to laryngoscopy
    - Keep SBP <160mmHg (AHA guideline 2012)
    - Keep MAP>85mmHg to prevent ischaemia
  2. Protection from secondary brain injury
    - CPP 60-70, MAP 80-90
    - Control ICP (normocapnia, venous drainage)
    - Reduce CMRO2 - normothermia, barbiturates
    - Euglycaemia (BSL <11mmol/L
    - Vasospasm and seizure prophylaxis
  3. Smooth postoperative emergence with good analgesia and prevention of coughing and vomiting (ICP)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Anaesthetic “how to” - myasthenia gravis?

A
  1. Pre-operative hx/exam/ix
    - Usual anaesthetic history with detailed assessment of respiratory, bulbar and muscle weakness
    - Exclusion of other autoimmune conditions e.g. RA
    - Hx and optimisation of immunosuppresants and anticholinesterase inhibitors
    - Airway assessment - thymoma may rarely cause tracheal obstruction
    - Consent to possibility of post-op mechanical ventilation
  2. Peri-operative mx.
    - Avoidance of sedative premeds due to resp muscle weakness
    - Steroid cover if >5mg prednisilone daily
    - Continuation of usual anticholinesterase inibitors
    - NM monitoring throughout case
    - Deepening of inhalational agents to intubate (avoid NMBDs)
    - Much lower dose than normal of NDMDs (10% usual dose)
    - Higher dose of Sux (2.6x normal dose)
    - Avoidance of using muscle relaxant reversal with neostigmine as may precipitate cholinergic crisis
  3. Post-operative
    - Assessment of TOF
    - Most patients can be exubated but some may require I+V in ICUs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the anaesthetic goals in a patient with Myasthenia Gravis?

A
  1. Minimize risk of aspiration (prophylaxis, RSI)
  2. Minimize risk of perioperative respiratory failure (judicious NMBs & opioids) & anticipate need for post-op ventilation
  3. Minimize risk of myasthenic or cholinergic crisis
  4. Optimize neuromuscular function
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What 7 nerves are blocked in scalp block?

A

Supraorbital
Supratrochlear
Zygomaticotemporal
Auricotemporal
Greater auricular nerve
Greater occipital nerve
Lesser occipital nerve

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

Anaesthetic considerations of Lambert-Eaton syndrome?

A
  1. May be first presenting feature of cancer - need to ix
  2. Autonomic dysfunction
    - Inc. pulmonary aspiration risk due to delayed gastric emptying
    - Hypotension
  3. Increased sensitivity to depolarising and N-D muscle relaxants
    - Titrate against NM monitoring
  4. May need post-op ventilation in ICU
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

You have a patient with raised ICP. What are the concerns around intubation?

A

High risk patient group.
1. Will require RSI or modified RSI due to unknown fasting status.
2. Apnoeic period may result in hypoxaemia or hypercapnoea
- Inc. CO2 causing vasodilation and high ICP
- Hypoxaemia causing reduced cerebral o2 delivery and worsening 2ndary brain injury
3. Vasodilatory effect of induction agent risk hypotension below impaired ability of brain to compensate
4. Hypertensive response to laryngoscopy risks hypertension beyond impaired ability to compensate risking further inc. in ICP or worsening bleeding in traumatic H.I
5. Despite low GCS an induction agent is important to reduce cerebral metabolic rate and protect brain from inc. ICP

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

How might you intubate a patient with raised ICP?

A

RSI or modified RSI +- MILS (if concern r: H.I)
3-minutes of pre-oxygenation
Rapid acting opioid e.g. alfentanil to obtund sympathetic response to laryngoscopy
Induction with low dose propofol OR thiopentone 4mg/kg OR ketamine 1mg/kg
Suxamethonium achieves intubating conditions in 45s vs 60-90s rocuronium
Consider apnoeic oxygenation with BMV or optiflow
Suggamadex not an option
Tape tube vs. tieing (not obstruct JV drainage)

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

Principles of managing the ventilated patient with raised ICP

A

Deep sedation (propofol/opioid)

Frequent NMBD boluses to prevent coughing/straining

Maintain MAP >80 or >90 to maintain CPP >60mmHg

Position pt. head up and remove collar (assuming no C-spine injury)

Aim PaO2 >13kPa

Minimise PEEP

Aim PaCO2 4.5-5.0 or ETCO2 4.0

Consider hyperosmolar therapy if blown pupil, midline shift
- 20% mannitol 0.5g/kg
- 3% hypertonic saline 2mls/kg

Normoglycaemia 4-11mmol/L

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

What are the indications for intubation and ventilation in GBS patient?

A
  1. Bulbar involvement
    - Inability to cough, swallow, protect airway
  2. Respiratory muscle fatigue
    - Clinical assessment or spirometry (FVC<1L or 10-15ml/kg)
  3. Blood gas analysis showing hypercapnoea
  4. Autonomic instability

Slow recovery means most patients will require tracheostomy t

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

What is your anaesthetic approach to a patient with scoliosis?

A

Pre-op assessment:
Hx, exam, Ix with particular attention to
- Potential co-morbidities such as neuromuscular syndromes duchenne’s M.D (with cardiomyopathy)
- Assessment of restrictive lung deficit - RV function on echo, spirometry, functional capacity
- Pre-op pain, are they a patient with chronic or neuropathic pain pre-op

Intra-operative (PRIMADE TIME) positioning, resus, iv access, monitoring, assistance, drugs, equipment, transpost/transfer, induction, maintanance, emergence
- Prone positioning for long period time
- IV access/monitoring - art line (blood loss potential), wide bore access, consider CVC if co-morbid or surg. factors
- Armoured ETT
- Blood loss factors - TXA, art line, cell salvage, blood products available
- Induction/maintanance ?avoid repeat NMBD, TIVA as >0.5 MAC interferes with spinal monitoring
- Emergence - aim for extubation immediately post op to allow neuro assessment

Post-op (AD) analgesia, disposition
- Multi-modal analgesia with opioid sparing techniques - NSAIDS, ketamine iv, epidural catheter placed surgically
- Allows early mobilisation/physio
- Likely crit care as disposition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Anaesthetic considerations of prone position?

A

Airway
- Risk of ETT dislodgement on proning/deproning
- Endobronchial intubation

Respiratory
- Abdominal compression can splint diaphragm causing atelectasis, V/Q mismatch
- Allen table allows abdomen to hang freely

Cardiovascular
- Compression of abdomen causes decrease in CO due to IVC compression
- Inc. pressure of epidural/vertebral wall plexuses causes inc. surgical bleeding

Neuro/disability
- Dislodgement or kinking of TIVA lines on proning inc. risk of awareness

Peripheral injuries
- Face (ring not suitable), nose pressure and eye pressure
- Arms - shoulder/elbow angle <90deg, elbows flexed, hands pronated
- Breasts, genitalia
- Knees bent
- Ankles not extended

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

Complications of prone positioning?

A
  1. Brachial plexus injury - in particular ulnar
  2. Facial damage
  3. Ophthalmic injury
    - External compression, haemorrhage/hypotension, head down all inc. damage
    - Perm blindness risk 1:100,000
  4. Lateral cutaneous nerve of thigh
  5. Macroglossia - impaired venous drainage via lingual/pharyngeal veins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the options for anaesthesia for neuro interventional radiology?

A
  1. Conscious sedation
    Adv - no time delay (‘time is brain’), clinical neurological monitoring, stable haemodynamics

Disadvan - unprotected airway, patient movement

  1. General anaesthesia
    Adv - airway protection, patient immobility

Disadvan - haemodynamic instability, lack of neuro monitoring, time delay

Problem is that the patients with the biggest compromise and most likely to benefit are more likely to need a GA due to agitation, seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What issues are there with neurointerventional environment?

A

Remote site anaesthethesia. Implications =

Training/familiarity
Equipment, lack of access to airway equipment and drugs
Personnel - may not have anaesthetic assistant
Means of summoning help - further away
Radiation issues
- shielding: lead aprons, thyroid collars, lead screens, eyewear
- Undiagnosed pregnancy risk

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

What is endovascular coiling?

A

Feeding microcatheters into cerebral circulation via femoral artery catheter to deploy platinum coils into aneurysm sac until it becomes occluded

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

Advantages and disadvantages of endovascular coiling?

A

Advantages:
Less invasive than clipping
Lower cost
Better for posterior circulation aneurysms
ISAT trial 2002 - coiled = 24% death/disability at 1 year vs 31% clipping

Disadvantages:
Cant coil all aneurysms (e.g. wide necked, small aneurysms)
Complications - ischaemia, bleeding, vasospasm
Need neurosurgeon if complication occurs
Higher chance need re-treatment

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

Anaesthetic “how to” - neuroradiology?

A

Pre-op assessment:
Usual anaesthetic assessment
Attention to - grading of SAH, ICP monitoring, other co-morbidities
ICP>20mmHg is contraindication
Ix - G+S, coag screen
Be aware of neurosurgery they may have to mx. complications

Location:
Neuroradiology suite. Carries own implications (separate flashcard)

Intra-operative:
Positioning - supine, difficult to access airway/cannulas
Resus drugs - drawn up
IV access+ IABP monitoring, act sampling, maintaining CPP
Monitoring - AAGBI, temp monitoring + warmer, urinary catheter
Assistance - may be difficult, remote
Drugs
Equipment
Transport
Induction - GA vs sedation, smooth, maintain CPP
Maintanence - propofol sedation, dexmed, immobility important
Emergence - smooth emergence

Post-op:
Analgesia/Disposition.
Simple analgesia. NeuroHDU/ICU likely

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

Dose of hyperosmolar therapy for raised ICP?

A

20% mannitol 0.5g/kg

3% hypertonic saline 2ml/kg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Patient with spinal cord injury - indications for intubation?

A

Hypoxaemia despite O2 therapy
Impending airway obstruction for other reasons e.g. laryngeal fracture
Reduced GCS and not maintaining airway
Hypercapnoea/inadequate ventilation e.g. flail
Poor cough
Facilitate imaging
Protect spine in un-coperative patients

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

Anaesthesia considerations for ACDF surgery?

A

Haemodynamic instability
- Myelopathy patients may have Aut. involvement causing excessive hypotension risking spinal cord ischaemia
- Therefore art line pre-induction

Laryngoscopy
- Potential for impingement of cord, use VL and bougie

Airway
- Difficult access, reinforced ETT left side of mouth

Positioning
- Supine, head up for venous drainage

Post op considerations
- Haematoma
- Vocal cord palsy
- DIFFICULT re-intubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is within the posterior fossa

A

Most inferior to cranial fossae
Contains cerebellum, brainstem and lower cranial nerves

Comprised of
- Occipital bone postero-inferiorly
- Temporal bone anteriorly and laterally
- Sphenoid bone anteriorly and medially

Roof is tentorium cerebelli

Compact with poor compliance, small tumour = high ICP with risk of brainstem compression

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

What is within the posterior fossa

A

Most inferior to cranial fossae
Contains cerebellum, brainstem and lower cranial nerves

Comprised of
- Occipital bone postero-inferiorly
- Temporal bone anteriorly and laterally
- Sphenoid bone anteriorly and medially

Roof is tentorium cerebelli

Compact with poor compliance, small tumour = high ICP with risk of brainstem compression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is an acoustic neuroma?
AKA vestibular schwannoma Benign tumour of myelin-forming Schwann cells of vestibular nerve (8th) Features: Unilateral hearing loss, tinnitus, imbalance, unsteadiness, vertigo (VIII) LARGE TUMOURS affect V and VII CN Proximity to VII necessitates EMG monitoring
26
Posterior fossa "how to" pre-op
Usual anaesthetic assessment + Evaluation of cranial nerve dysfunction Assessment for presence of raised ICP
27
Posterior fossa "how to" intra-op
Positioning - supine or park bench Resus drugs drawn up IV access secured on uppermost limb Monitoring including art line awake if high ICP and EMG monitoring + BIS + temp + IDC Airway = reinforced ETT Drugs + Ex drawn up Induction - smooth haemodynamically stable avoid CPP hypoperfusion and hypertension, high dose remi Single dose muscle relaxant Maintain with TIVA Extubation smooth extubation no coughing/straining and ICP spikes
28
Issues specific to posterior fossa surgery
Intraoperative brainstem handling may cause cardiovascular instability, hypertension and bradycardia Optimise physiology to maximise CPP Avoid hypoxia PaCO2 4.5-5.0 Temp control Plasma glucose 4-11mmol/L MAP >80 Obtund sympathetic response V. emetogenic so antiemetics
29
What are the classic features of spinal epidural abscess and what other features may be present?
Classic triad 1. Back pain 2. Fever 3. Abnormal neurology Other features 1. Nerve root pain 2. Motor weakness 3. Sensory deficit 4. Bowel/bladder dysfunction 4 Stages: 1. Back pain affected site 2. Nerve root pain radiating from affected area 3. Motor weakness, sensory deficit, bladder/bowel dysfunction 4. Paralysis
30
Causes of epidural abscess
90% Staph Aureus Remainder strep and gram -ve anaerobes
31
AAGBI BEST EPIDURAL PRACTICE
Monitored by staff aware of significance and action required in response to abnormal values Monitoring - HR and BP - RR - Sedation score - Temp - Pain score - Degree of motor and sensory block
32
What is required for venous air embolism to occur
1. Source of gas 2. Communication between this source and venous system 3. Pressure gradient enabling movement of gas 1ml/kg rapidly embolised can be fatal
33
Signs of venous A.E
Depends on volume of air, rate of entrainment, patient awake/anaesthetised Rapid entrainment - Classic cardiovascular embolic phenomenon: tachy, hypotension, hypoxaemia Neurological - confusion, focal signs, dec. GCS ECG abnormalities
34
VAE pathophysiology
AIr lock - Air in rv occupies it and prevents blood flow into pulmonary circulation Inflammation in pulmonary arterioles Small bubbles of air into RV and pulm. circ Mico emboli in pulmonary arterioles Paradoxical A.Emboli through patent FO may pass into arterial circ causing coronary or cerebral signs
35
Prevention of venous A.E
Avoiding sitting position - sitting craniotomy high risk Raised venous pressure at operative site - iv fluid loading, +ve PEEP Jugular venous compression has been reported Minimising time venous circulation open to atmosphere Minimising bubbles in IV lines
36
Immediate management of VAE
I would CONFIRM the reading Send for HElp (may or may not do) Whilst SCANNING the patient, surgical field, monitors and equipment Alert SURGEONS and consider stopping surgery Apply 100% oxygen, hand ventilate patient, CPR and ALS if cardiac arrest, giving vasopressor /fluid if hypotension Specific measures include - Surgeon to floor field with sterile saline and compress wound edges - Raise venous pressure at operative site by increasing venous pressure, lowering below right atrium -Consider aspirating air from right sided IJV cvc
37
What procedures are associated with VAE
Craniotomy Radical neck dissection Thyroidectomy THR C. section Placenta removal Anaesthetic - CVC - Blood products rapid infuser
38
What is myotonic dystrophy
A rare multisystem neuromuscular disorder characeterised by skeletal muscle myotonia, cardiac and respiratory sequelae It poses specific risks to anaesthesia
39
Clinical features of myotonic dystrophy
Skeletal Muscle - Myotonia (incomplete relaxation) - Distal muscle weakness - reduced hand dexterity, foot drop - Muscle wasting Cardiac - Conduction defects - Cardiomyopathy Resp - Restrictive lung defect - OSA Neuro - Intellectual impairment GI - Bulbar symptoms - Aspiration risk Endrocrine -Testicular atrophy - Insulin resistance Facial features - Frontal balding - Wasting of facial muscles
40
Genetics of myotonic dystrophy
Chromosome 19 Trinucleoside repeat disorder Autosomal dominant 4/100,000 incidence
41
Anaesthetic "how to" - myotonic dystrophy
Regional favoured over GA Pre-op: - MDT input - R/v of notes - thorough hx/exam/ix - Avoidance of premeds Intra-op - Monitoring - art line due to risk of conduction abnormality - Access to external pacing Induction - RSI due to risk of aspiration - Avoid sux --> masseter spasm, laryngospasm, hyperkalaemia Maintanence - Volatile or TIVA Emergence - Neostigmine may induce myotonia - NM monitoring may induce myotonia Post op - Increased sensitivity to sedatives and analgesics - HDU/ITU
42
What is NF1
Neurofibromatosis Type 1, - Tumours are neurofibromas of peripheral nervous system
43
What is NF2
Neurofibromatosis Type 2, - Tumours are neurofibromas of Schwann cells (bilateral vestibular schwannomas)
44
Complications of posterior fossa surgery
Complications specific to posterior fossa 1. Emetogenic +++ 2. Lower CN palsies including loss of pharyngeal reflexes 3. CV instability 2ndary to stimulation of pons/medulla General complications of neurosurgery 1. Hydrocephalus 2. CSF leak --> pseudomeningocele 3. CNS infection 4. Pneumocephalus Complications specific to positioning 1. Sitting position - venous pooling and low CPP 2. Venous air embolism 3. Macroglossia 4. Peripheral nerve injury e.g. brachial plexus, peroneal nerve (lateral / park bench)
45
Neurofibromatosis and anaesthesia
Airway - Laryngoscope and intubation difficult by neurofibromas of tongue/pharynx/larynx Resp - Mediastinal neurofibromas compress/distort bronchial tree - Kyphoscoliosis associated with neurofibromas = restrictive defect CV - HTN - renal artery stenosis/coarctation/phaechromocytomas GU - Difficult catheterisation CNS - Vertebral deformities/spinal tumours - Epilepsy/LD CNS
46
Cutaneous features of neurofibromas
Cafe-au-Lait spots Axillary freckling Lisch nodules
47
Doses of agents in status treatment
Pre-hospital 10-20mg diazepam PR 20mg midazolam buccal IV agents: Lorazepam 0.1mg/kg Levitiracetam 60mg/kg over 15mins. Max 4500mg Phenytoin 15-18mg/kg Sodium Valproate 40mg/kg. Max 3000mg Phenobarbital 10-15mg/kg
48
Definition of status epilepticus
Medical emergency traditionally defined as more than 30 minutes of continuous seizure activity 2015 new definition recognised importance of early treatment which is failure to terminate seizure after 5 minutes
49
Physiological changes associated with seizure
Compensatory and non-compensatory stage (>30-60mins post activity) Initial compensatory stage: - Sig. increase in CMRO2 - Catecholamine release increases CO (tachycardia, hypertension) - Consequent increase in cerebral blood flow / ICP - Limb movements generate lactate Decompensation stage: - Failure of cerebral autoregulation and failure of increased CO to sustain neuronal activity - Neuronal ischaemia and death - Cerebral oedema, raised ICP Sustained muscle contraction = Rhabdo, Hyperkalaemia, Acidosis
50
What anaesthetic drugs caution with in epilepsy
Etomidate use associated with post-op seizures Alfentanil increases EEG activity Pethidine risks of seizures Antiemetics - extrapyramidal side-effects of dopamine antagonists confused with seizure activity (prochlorperazine, metoclopramide, droperidol)
51
Advanced MS and anaesthesia considerations
1. Depolarising muscle relaxants - Suxamethonium may precipitate a life-threatening hyperkalaemia in immobile patients 2. ND muscle relaxants - Patients may be v. sensitive, ensure full reversal (especially if take baclofen) 3. Autonomic dysfunction may lead to significant hypotension on induction 4. Steroid therapy - periop steroid replacement required 5. Bulbar disease - Increased risk of reflux - Increased risk of post-operative pulmonary complications
52
Current evidence of neuraxial blockade in labour
Does NOT increase the risk of caesarian section compared with systemic analgesia Does NOT prolong the 1st stage of labour MAY prolong the 2nd stage of labour MAY increase the rate of instrumental vaginal delivery
53
C. section in the obese parturient
Neuraxial blockade preferred, spinal or epidural top up If GA if required: - Ramped position with left uterine displacement - Preoxygenation with high flow nasal oxygen (THRIVE) - Availability of laryngoscopes including short handled - Dosing of propofol and rocuronium by lean body mass - Dosing of suxamethonium by total body mass
54
Tell me about the pituitary gland
A pea sized gland located in the sella turcica Has an anterior and posterior lobe Major endocrine gland in neuroendocrine axis Co-ordinates activity of other organs
55
Name tumours of pituitary
Prolactinoma Acromegaly Cushing's disease Craniopharyngioma Meningioma
56
Features of prolactinoma
Commonest pituitary secretory adenoma (30% Micro <1cm or Macro >1cm Men = hypogonadism, erectile dysfunc Women = amennorhoea, gallactorhoea Mass effect - headache, field defects Raised prolactin levels
57
Features of acromegaly and anaesthetic implications
GH secreting tumour Effects: Mass = headache, field defects GH specific Soft tissue swelling - hands, lips, nose, ears, carpal tunnel sx, OSA Systemic: HTN, diabetes Skull: frontal bossing Lower jaw enlarged, teeth spacing Organomegaly - cardiomyopathy, vocal cords, hepatosplenomegaly, maccroglosis Anaesthetic implications: 1. Difficult airway 2. Cardiomyopathy 3. Ins. resistance 4. Post op OSA
58
Features of cushing's disease and anaesthetic implications
ACTH secreting tumour, excessive cortisol by adrenal glands Clinical effects: Skin - fragile thin skin Central obesity, hump, moon face, stretch marks, hirsutism Insulin resistance Immune function impaired Reduced fertility Osteoporosis Irritability, poor sleep Refractory HTN Dx. late night cortisol, 24hr free cortisol Anaesthetic implications: 1. Cardiac changes - longstanding LVH 2. Friable skin/veins, difficult access, positioning meticulous 3. OSA common4 4. Periop glucose mx.
59
Disadvantages of trans-sphenoidal approach
CSF leak - rhinorrhoea Meningitis risk Pituitary dysfunction (panhypopituitarism, DI) CN injury
60
Improving operative conditions during trans-sphenoidal sx
May require hypercarbia PaCO2 up to 8kPa - Increased cerebral blood flow - mild inc. in ICP - Pushes down pituitary from suprasellar portion Lumbar drain another option - Insert through Tuohy into intrathecal space L3/4 - Injection of saline increased ICP pushes down pituitary - Risks CSF infection, PDPH
61
What does the Montgomery ruliing say about consent?
Doctors must take reasonable care to ensure patient's are aware of ANY MATERIAL RISKS involved in recommended treatment and any reasonable alternatives or varied treatments
62
What is a material risk ?
a risk that a reasonable person in the patient's position would likely attach significance to, or a risk that the healthcare provider is or should be reasonably aware the patient would consider significant. Essentially, it's a risk that would influence a patient's decision about whether or not to undergo a treatment or procedure.
63
What is required for consent to be valid?
1. Provided with enough information to make a decision - The procedures proposed any why - Material risk and alternatives 2. Must be acting voluntarily - without coercion 3. Must have capacity to make decision
64
What is required for pt. to have capacity
Able to 1. Understand information given 2. Weigh up 3. Retain 4. Communicate
65
What is the legal framework for consent with impaired capacity
Mental Capacity Act 2005
66
What happens if patient lacks capacity
Remember capacity is decision specific - may be able to consent to some procedures but not others Establish if pt has advanced directive Establish if they have appointed LPA If not, treat in best interests - Consult family/friends
67

James' final FRCA SOE (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions