Quick Phrases Flashcards
(33 cards)
Describe your induction technique for a patient with severe aortic stenosis
My goals for this induction is to maintain preload, after load, and sinus rhythm.
I will achieve this by running a GA.
- Prior to induction, I will site art line, run fluid to maintain euvolaemia, and commence metaraminol infusion.
- I will use high dose fentanyl and a slow titrated, low-dose propofol infusion, in order to prevent hypotension, and blunt the sympathetic response to laryngoscopy. I will then give 100mg of rocuronium for intubation.
You are called to ICU to intubate a morbidly obese, hypoxic patient. What are your priorities?
This is likely going to be a difficult airway.
My priorities are to
1) optimise oxygenation
2) prepare thoroughly for a difficult airway with safe rescue strategies.
3) minimising aspiration risk
4) ensure adequate resource for airway management in a remote location.
How are you going to intubate a morbidly obese, hypoxic patient in ICU?
Preparation:
- Difficult airway trolley + experienced airway assistant.
- Ramp patient, then pre-oxygenate upright with NIV.
- Ensure adequate IV access, arterial line, and end-tidal monitoring.
Induction:
- Perform RSI with alfentnail, propofol, rocuronium, then lie patient flat.
- Intubate with videolaryngoscope as plan A, and confirm placement with EtCO2.
How would you modify your induction for a patient with raised intracranial pressure?
My goals for this induction is to:
1) Maintain cerebral perfusion and oxygenation.
2) Prevent rise in ICP.
3) Acknowledge risk of aspiration.
Preparation:
- Temporise with mannitol and head up position.
- Ensure adequate IV access, arterial line, and infusions.
Induction:
- Slow uptitration of propofol and remifentanil, with metaraminol to maintain a MAP of 80 to 90.
- Once unresponsive, give 100mg rocuronium.
- Gentle laryngoscopy to secure airway.
You have a patient with ongoing massive haemorrhage in theatre needing urgent anaesthesia. How would you induce this patient?
My goals are:
- Rapid onset anaesthesia.
- Maintain sympathetic drive and permission hypotension.
- Minimise risk of aspiration.
To achieve this, I will perform a GA with RSI.
- Ensure well working IV access and art line if time permits.
- Induce with 1mg/kg ketamine, 100mg rocuronium, apply cricoid, then secure the airway with a video laryngoscope and a size 8 ETT.
I will ensure that massive transfusion protocol is ongoing, and maintain SBP of 80-100 throughout.
You are asked to anaesthetise a patient with severe pulmonary hypertension for an elective laparoscopic cholecystectomy. How would you approach induction?
My goals are:
1. Prevent further rise in PVR
2. Maintain perfusion and function of the right heart.
To achieve this, I will
- Ensure adequate IV access, arterial line, CVC prior to induction. Vasopressor and pulmonary vasodilators ready.
- Arrange for second anaesthetist with TOE expertise.
- Adequate pre-oxygenation for EtO2 of >0.9.
- I will perform a modified RSI with 2mg midaz, 300microg fentanyl, 40mg propofol, and 100mg rocuronium, and secure airway with a videolaryngoscope.
- Actively avoid hypoxia, hypercapnia, acidosis, and excessive sympathetic stimulation. Maintain MAP of 65 at all time.
What vasopressor, inotropes, and pulmonary vasodilators will you use for a patient with severe pHTN?
Vasopressors:
- Noradrenaline at 1-10microg/min.
- Vasopressin at 1-3 units/hr
Pulmonary vasodilators:
- Inhaled NO at 20-50ppm.
- Milranone at 0.25microg/kg/min. Can also use nebulise dose at 5mg.
Inotropes
- Dobutamine 1-5 mic/kg/min
You are asked to anaesthetise a child with active post-tonsillectomy bleeding for surgical control. What are your priorities?
My priorities are:
1) Volume resuscitation with crystalloid and blood products.
2) Rapidly secure the airway to minimise aspiration risk.
3) Prepare for difficult airway due to anatomical distortion and active bleeding.
How will you induce this child with active post-tonsillectomy bleed?
I will achieve my priorities by:
- Team briefing on difficult airway plan, with adequate rescue management including a ENT surgeon on standby.
- Ensure adequate IV access and ongoing volume resuscitation.
- Prepare 2x functioning suctions, bottle of saline, adequate lighting, videolaryngoscope.
- Attempt pre-oxygenation with child upright. Induce with 3mg/kg propofol and 1mg/kg of sux. Cricoid on once child lied flat.
- Intubate with videolaryngoscope and an appropriately sized ETT. Limit amount of attempts and progress through pre-planned rescue techniques.
What are the types of pacemaker?
Single chamber or dural chamber.
Uni-ventricle or biventricular.
Biventricular typically a cardiac resynchronising device
Intralipid dose
Side effect of intralipid?
1.5ml/kg bolus
15ml/kg/hr
Second bolus after 5 mins, or double infusion rate.
Max 12ml/kg
Metabolic - fat overload syndrome, hyperglycaemia, hyperlipidaemia
Hepatic steatosis
Fat embolism, pulmonary HTN, ARDS
Bundle for cerebral ischaemic protection?
- Supply: MAP 65, SpO2>95%, Hb >80 (100 in TBI), normoglycemia
- Demand: reduce CMRO2, adequate anaesthesia, antiepileptic, hypothermia, analgesia
Bundle for spinal ischaemic protection
Optimise perfusion - MAP 90, Hb >100, avoid hypoxia and hypercapnia.
Reduce CSF pressure by lumbar drain to keep <10mmHg
Reduce demand - hypothermia
Early detection with lower limb neuro monitoring
Surgical - staged procedure, distal aortic perfusion, reduced duration of surgery
Steps for crashing onto bypass
Incision, sternotomy, vessel exposure, heparinise 400u/kg ACT >480s, cannulate vessels, initiate CPB with perfusionist
Considerations for coming off bypass
Airway confirm
B - check ventilation and oxygenation. Address high airway pressure
C - check epicardial pacing wires, TOE for contractility.
D - drugs (anti-arrhythmic, inotropes, vasopressors, anaesthetic agents), ensure adequately anaesthetised.
Protamine 1mg for 100u initial heparin dose. Reduce by 30%.
Electrolytes + BSL + Hb
Rewarming
Surgical - haemostats, de-airing.
Complications of aortic dissection
Tamponade
Rupture
Ischaemia
Arrhythmia
Acute AR
How would you anaesthetise a patient for pulmonary vein isolation for AF
Mode - GA
Method - TIVA to avoid PONV, groin haematolma
Monitoring - art line, TOE probe, transcutaneous pads
Drugs - heparin, ACT 350s
Well secured line and tube for long procedure in remote location.
Surgical issues for pulmonary vein isolation
Long procedure.
Remote location.
Septal puncture.
Arrhythmia risk.
Anticipated complications - groin haematoma, tamponade, malignant arrhythmia.
PACU calls for issues with hypotension post AF ablation - ddx?
Attend to patient.
Main Ddx - bleeding from groin, cardiac tamponade.
Must rule out - hypovolaemia, cardiac ischaemia, anaphylaxis.
Approach to anaesthtising patients -
Preparation - equipment, drugs, personnel, specialised equipment.
Airway plan - A, B,C, D
Induction drugs
How do you rapidly rule out any machine error causing high airway pressure?
bag ventilate the patient with AMBU
Differentials for high airway pressure post induction.
Ddx include
Patient: bronchospasm, pneumothorax, anaphylaxis, aspiration
Machine: obstruction in circuit or HME
Tube: kink, sputum plug, endobronchial migration.
What is auto-PEEP?
How can you measure this?
The positive pressure left within the alveolar at end of expiration, typically due to air trapping, and can lead to dynamic hyperinflation.
Measured by using an expiratory hold.
Measure PEEP - Set PEEP = intrinsic PEEP .
How do you insert a double lumen tube?
I will pre oxygenate the patient and induce anaesthesia with muscle relaxation.
Then perform a direct laryngoscopy, and insert the DLT with the distal curvature anteriorly.
Once through cords, remove the stylet, and rotate counterclockwise 180 degrees
Advance tube until snug.
Inflate tracheal and bronchial cuffs, plus confirm position with fiberoptic scope.
