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1
Q

List 6 NB differences between the paediatric an adult a/w?

A 
Large tongue
High pharynx
Long, narrow epiglottis
Narrow cricoid rings
Short trachea
Anteriorly angled vocal chords
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2
Q

List 5 symptoms or signs of an acute attack of porphyria?

A

Acute NB bcuz can lead to life threatening rxns to certain drugs:

Autonomic NS dysfunction :
Abdominal pain, V, nausea, HTN, tachycardia

Peripheral neuropathy:
Resp muscle paralysis, flaccid quadriparesis

Bulbar involvement:
Resp dysF, aspiration

Cerebral involvement:
Anxiety,mental depression/agitation, coma

Other: dark urine, hypo- ( Cl,Na,K) inappro ADH secretion

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3
Q

List Ix for general anesthetic cesaerian section?

Think mom and baby

A 
Severe fetal distress
Low platelet count
Maternal hypovoleamia
Placenta preavia
Severe stenotic valvular lesions
Cyanotic congenital cardiac conditions
Anatomical anomalies & prev lumbar surgery
Septiceamia
Local sepsis
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4
Q

Contra Ix for ketamine?

A 
Raised ICP
Psychiatric Px
Raised IOP or open eye surgery
Situations of incr. O2 demand are undesirable
    - HTN
    - tachycardia
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5
Q

What is meant by train of four (TOF)?

Fade?

A 
ToF:  4 twitches, 2 sec apart
Measuring neuromuscular function: NDMR
Ratio between
Last and first contraction 
Induced by Peri N stim = whether NMB is still functional - ratio of 0.8 then resp muscle recovered.

When 4th twitch absent = 75% blocked
3rd = 80% block
2nd = 90% block
75- 90 % for Sx procedures

Fade: if present - ND block of 75%
Gradual diminishing of evoked response during prolonged/ repeated nerve stimulation
Also positive feed back mech of Ach (presynaptically) blocked by muscle relaxant.

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6
Q

5 conditions which may prolong the duration of action of suxamethonium?

A

Atypical psuedo-cholinesterase (genetic) - less affinity for sux = leads to scoline apneoa

Other ND drugs -usually helps with fasciculations

Opiate, inhalation agents

Hypothermia

Phase 2 block -high doses and also def. Pseudocholinesterases

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7
Q

Ramsay sedation scale:

Indication of pt responsivenss under sedation

A

Awake - pt anxious or agitated or both. 1
Levels: -pt cooperative, orientated, tranquil. 2
- pt responds to commands only. 3
Asleep - brisk repsonse to ligh glabellr tap. 4
Levels: - sluggish response 5
- no response. 6

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8
Q

With the aid of graph- show effect of arterial hypoxemia on the minute ventilation in an awake pt and a pt subjected to general anesthetic?

A

X- axis : PaO2
Y- axis : minute vol

Negative exponential line for normal
Much lower line = lower minute volume for hypoxeamia

So in essense Normally we will compensate for drop in PaO2 by increasing minute ventilation (increase rate of breathing)… This we pick up by the rising CO2 levels in the blood.
But when ventilated this reflex is lost en the patient becomes hypoxic due to the hypoventilation - Her we can rather up the PaO2 to 40 % in the recovery room.

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9
Q

Explain autoregulation and review the graph:

A

Autoregulation maintains a constant blood flow b/w certain pressure.
Once parameters exceeded, flow will become pressure dependent - leading to inadequate oxygen delivery / increased pressures.

The shift is 25 % outside of the normal autoregulation curve.
Either need to postpone Sx for 6 months to get bp contoled or if emergency ( cant wait )
sx can cont but…
The hypertensive pts BP must be maintaned within 25% of original pressure to prevent drop in flow.

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10
Q

List criteria that must be achieved before pt can be d/c after conscious sedation?

A

Full mental recovery

Not within 2 hours of admin pharm. antagonist

Vitals to normal:
Arterial sats preop value on room air
Pulse and BP within 10% of preop value
No orthostatic hypotension ( below 20% decr. Acceptable)

Patient:
Walking,  not dizzy
Void urine
No N /V
Adequete pain relief

Patient must have responsible adult picking up
Not driving or operating machinary for a day
Contact number of dr.

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11
Q

With re to peri operative fluid therapy:

  1. Fluid requirements are calculated acc. to 4,2,1 rule. How much fluid would a 40kg person require ? (ml/ hr)
  2. What is the aim of peri operative fluid management?
  3. Name the most common electrolyte abnormality in the post op period?
A
  1. 4x 1-10kg ; 2 x 11-20kg ; 1 times >20kg
    40+20+ 20 = 80ml/hr
  2. Replace deficit ; supply maintenace fluid; restore
    losses
    AIM: maintain
    Circulation
    Normal serum electrolyte concentrations
    Normoglyceamia
  3. HypoNa
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12
Q

Which of inhalation anesthetic agents are metabolised most by the liver?

Name hepatotoxic metabolite formed during the metabolism of the above IAA?

To which disorder can this metabolite lead?

A

Halothane

Trifluoroacetyl-moiety

Halothane hepatitis

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13
Q

List the cuff requirements to accurately measure BP on the arm?

A

Inflatable cuff with pressure gauge
Diameter of upper arm + 20%
(Generally 14cm in adult)

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14
Q

Minumum req for monitoring circulation during anesthesia?

A

ECG
BP and HR every 5 min
Other monitor (clinical or invasive)

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15
Q

How can you determine whether a pts muscle strenth is adequate after reversal of NMB?

What are the clinical signs to look for?

Type of nerve stimulators?

A

Clinical signs
Nerve stimulator

Sustained hand grip
Head lift > 5 sec
Able to touch nose
Clench tongue depressor b/ teeth
MIP > 20 cm H2O
Vital capacity > 15ml/kg
No paradoxical mvmnt

Single twitch / ToF/ double burst / post tetanic twitch count

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16
Q

What monitor can be used to Ix the depth of anesthesia (hypnosis)?

Clinical signs
Processed electrocephalogram

A

Geudels levels of anesthesia

Bisprectral index BIS
Entropy monitoring
Auditory evoked potentials
Somatosensory evoke potentials

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17
Q

What is a capnograph?

A

A monitpr that measure the end tidal CO2 thus the carbon dioxide at the end of each resp cycle.

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18
Q

List the drugs that can be used in the preop period in a pregnant woman to reduce the risk and results of aspiration of stomach content during C/S?

A

Sodium citrate
Metoclopromide
Oral ranitidine

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19
Q

How would you medicate an anxious 5yr old who req GA?

A

Midazolam/ lorazepan

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20
Q

Possible CI for administering sedative premedication to pt?

A 
Infants/ elderly
Frail/ debilitated
Decr. LOC
Intracranial pathology -ICP
A/w obstruction
Severe Lung disease/resp distress
Hypovoleamia / shock
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21
Q

List 5 neurotransmitters involved in N and V and a pharmacological antagonist?

Explain combination anti emetic therapy for prophylactic PONV?

Will ginger root be effective for PONV?

A

Dopamine - droperidol. (D2) - NV caused by opiods and CI in pt with already prolonged QT interval
Metoclipramide- ineffective for prophylaxis PONV

Ach - hyoscine hydrobromide/ scopolamine (muscurinic) - opiod induced vomiting - sfx are sedation, comfusion, dry mouth

Histamine - cyclizine, promethazine (H1) - middle ear surgery - IV leads to tachy and hypotension.

5- Ht (serotonin) - granisetron, ondansetron (5HT3) - headch and GIT upset - replaced cannabis in cancer pt nausea

Antidopaminergic (extrapyramidal sfx)
Anticholinergics
Antihistamines( extrapyramidal sfx)
Antisertonergic

Other:
Encephalins (opiod r)
Substance P ( neurokinin 1 r) - antagonist :
Aprepitant

also steroids: dexamethasone

it is better to use 2 antiemetic drugs that work on 2 different receptors. Antisero and antidopa OR antisero and steroid.

no

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22
Q

Principle of a vaporizor?

A

FGF thru the vaporisor
Part is diverted to the vaporisor
Part bypasses (splitting ratio)
Diverted part is shunted through anesthetic vapor and meets up again with bypassed portion when it is then admin to pt.

Cooling is prevented by keeping a constant vapour pressure of 1- 10 cm H2O

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23
Q

What will you take into consideration when deciding how to manage a diabetic pt for surgery?

A

Type of surgery
Medication the pt is on
Blood glucose control of pt

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24
Q

Define pain?

What is a nociceptor? nociceptive?neurogenic?

Plasticity?

Hyperalgesia?

Windup? Allodynia?
Neurogenic and Neuropathic pain?
Chronic pain state?
Anelgesia?

A

Unpleasant sensory and emotional experience
Ass with actual or potential tissue damage
Neuroendocrine phenomena

just because you cannot comm verbally does not mean you do not feel any pain.

The emotional component determines the perception to pain.

pain receptor which is sensitive to preferentially a noxious stimulus.
Acute pain 2dary to tissue damage
Chronic pain due to structual/functional damage to nerve.

Pain pathway is greater/lesser than intensity of stimulus.

Sensation is experienced as excessive and out of proportion to stimulus.
Primary :at site of injury (cytokines, neurotrans…)
Secondary: hyperexcitability of spinal nerves.

Repetitive C firbe stimulation leads to prolonged dorsal horn activity.
Pain due to stimulus that does not normally provoke pain.

Pain due to primary lesion / dysfunction in peripheral/ central nervous system.

Pain that cont. after tissue damage has healed.

State where you feel no or little pain to otherwise painfull stimulus.

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25
Define hyperalgesia? | allodynia?
Sensitized C- fibres Pain receptors dont adapt, but become hyper- excitable Increased response to stimulus that is normally painfull. Pain experienced both from site of injury and from surrounding tissue (allodynia) - pain due to stimulus that normally does not provoke pain.
26
Define primary and secondary hyperalgesia?
Primary: Changes that occur at site of injury - tissue damage and inflammation Secondary: Hyperexcitability of spinal neurons so that previously innocuous stimuli are now painfull
27
Define windup? | When best to rx and what complx if not rx adequately?
Prolonged dorsal horn activity after repetitive C fibre stimulation. Rx acutely- easier to mx pain Chronic refractive pain
28
Re pre operative fasting: | list the NPO rules:
Min fasting periods: in hours 1. Clear fluids. 2 2. Breast milk. 4 3. Formula milk. 6 4. Non-human milk 6 5. Light meal. 6 6. Fatty meal. 8
29
Define what is meant by | Light meal and clear fluids?
``` Clear fluids: Black tea / coffee Fruit juice w/o pulp Carbonated drinks No alcohol ``` Light meal: Liquid and toast
30
List the factors that delay stomach emptying?
``` Pain, stress, anxiety Opioids Vagotomy Fatty meal Pregnancy Diabetes GIT obstruction ```
31
T/F: 1. Latrodectism is a syndrome caused by the release of peripheral neurotransmitters such as ACh and NorA. Also GABBA (Lactrodectus spider- black widow) 2. Morphine is potential poison with high inherent toxicity. 3. The clinical picture of acute organophosphate poisoning is comparable to that of effects of neostigmine. 4. Cocaine causes pronounced peripheral vasodilation. 5. Obidoxime - is a cholinesterase reactivator 6. The most serious types of mushroom poisoning present with sx and signs within 6 hours of ingestion. 7. Boomslag venom causes a prolongation of clotting time, leading to bleeding complications 6-24hours after an effective bite. 8. Scombroid poison develops after ingestion of fish of which the cold chain has been broken. 9. Saxitoxin is the cause of paralytic shellfish poisoning. 10. Theophylline poisoning is usually ass with severe hyperkaleamia.
1. True 2. False 3. True - both inhibit cholinesterases 4. False - vasoconstrictor 5. False 6. false - after 6 hours 7. True 8. True 9. True 10. False - HYPOkaleamia
32
List negative features of etomidate (5 Bs) (IV induction agent) incr. affinity of GABBAa receptor for benzodiazepines Can also inhibit plasma cholinesterases. Hypoalbunimic states- effects are much higher. dos NOT have anelgesic properties, only LOC Almost no effect on circulation Best for hypersensitive pt.
``` Braak. - emetogenic Beweeg - movement upon injection Baie duur - expensive Brand - burns on injection Bynier - adrenal supression ```
33
List complications of suxamethonium? Short acting muscle relaxant (within 60 sec for 12-16 min) DMR = ass with fasciculations (bind to nic-R) Not inactivated by cholinesterases. Once in blood - removed by plasma cholineesterases. Prolonged action because of reduced plasma cholE: Pregnancy, hepatic disease, burns, malnutrition
Bradycardia (Ach, rx: prior atropine/glycopyrulate) Hyperkaleamia (arrythmias/cardiac arrest) - can be used immediately after but not after 48 hrs) Incr IOP, (sustained contraction of extra ocular muscle) ICP ( PaCO2 due to fasciculations) Masseter muscle rigidity COMMON Fasciculations ( can be prevented) ``` Anaphylaxic rxn Scoline apnoea( due to genetic def / absence of enz - longer duration of action) ``` Malignant hyperthermia : Hypercapnia, tachycardia, hyperthermia, metAcid
34
List 5 advantage of a laproscopic technique over n open surgery? Take note PONV problematic - give dexamethasone and ondansetron before ending surgery 1. Pt position (trendelenburg) 2. Insufflation with CO2 3. Pneumoperitoneum and intra abd pressure ( threshold pressure
1. Small incision 2. Decr post op pain and discomfort 3. Shorter hosp stay 4. Early ambulation 5. Less scar formation
35
Name 2 dangerous and 3 safe nesthetic drugs in a pt with porphyria? ``` GA: Induction Inhalation Neuromuscular Analgesia ``` Regional:
``` Dangerous: *Barbiturates( thiopentone) * Etomidate Enflurane rather not Pethedine rather not NSAID rather not Theoretically not lignocaine ``` ``` Safe: Propofol N2O (halothane) All inhalants. Bupivacaine ( local anesthetics) NDMR and reversals Opiates and midazolam ```
36
Advantage and disadvantage of Entonox as anelgesic during labour? Other ways for anelgesia: Pharma and non pharma way. Ketamine Pethidine/ fentanyl / morphine Epidural (gold standard)
``` Advantages: Pt can admin. herself Inexpensive No effect on labour process/ baby Ultra short acting ``` Disadvantages Maternal hypoxia Sedation N and V
37
Define the MAC
Minimum Alveolar concentration: Concentration at which 50% of subjects given the drug will not move in response to a specific painful stimulus. Also the end point at which to measure and compare the potencies of IAA
38
List factors that can effect MAC:
Age. (Maximal at 6m, decrease by 6% per decade ) Body temp (if low MAC decr) Pregnancy (decr. MAC) Opioid / benzodiazepine co admin (decr. MAC) - ceiling effect. Severe alteration in physiology (cardiac shock) decr it.
39
List 3 advantages of a Jackson rees mod of Ayer T piece / Mapleson F breathing system?
``` Allows spontaneous breathing Simple, lightweight, inexpensive Low resistance Minimal dead space No valves that can malfunction ```
40
Name 5 findings that would obligate you to postpone surgery in achild with a runny nose?
Children are obligate nose breathers, thus anything obstructing the nose can lead to compromised breathing If pt had upper resp infection - laryngospasm can occur up to 6 weeks after that. Child also rapidly desaturates: Oxygen consumption. Twice of adult. Alveolar ventilation higher due to increased RR ( tidal vol same as adult). - child falls and awakes quicker. High Closing volume. Laryngospasm or loss of volume will lead to collapse/shunting. Anatomic shunts. Right to left shunts due to patent ductus arteriosus due to increased presure in pilm artery. (Hypoxia,hypercarbia,acidosis)
41
List the 10 effects of opioids, mediated by their action on the CNS? 8 How to reverse rigidity? How to avoid? What can be given if pt gets the shivers? Other:
Anelgesia (supra spinal, spinal, peripheral) Anesthesia (reduce MAC by 60-70% and less IV induction drug also) Muscle rigidity (activ. Of kappa R) Pupils (miosis) - opiod abuse Thermoragulation threshold reduced - start shivering at lower temp than normal. Euphoria (reduce anxiety, agitation) Naloxone - give muscle relaxant pre Pethidine Resp depression CVS(hypotension, bradycardia, cardiac depression) GIT( NVC) Pruritis
42
List 5 conditions that predispose to abnormal incr in serum K after admin of suxamethonium?
1. Burns 2. Trauma 3. Muscular disease 4. Neurological disorders 5. Sepsis 6. Immobolity
43
List the clinical features of supine Hypotensive syndrome during pregnancy? Biggest problem of spinal anesthesia. For a sensory block of T4 you will still get 2 levels higher sympathetic outflow block, leading to bradycardia which will potentiate the hypotension. Early dx is of grave importance to prevent mortality. Take bp /min for 20 min. Then / 5 min. Comm to exclude dizziness and nausea which preludes hypotension. use of fluid with vasopressor : Phenylephrine: tachycardia, stenotic lesions, severe
``` HypoT Bradycardia Sweating Nausea Anxiety, dizziness Pallor ```
44
What is the cause of hypotensive supine syndrome in pregnancy? How can one prevent this?
Aortacaval compression due to lying in the supine position after 20 weeks of pregnancy. ALSO extended block of sympath fibres = venous and arterial dilation. And bradycardia. Turn mom onto her left side and administer oxygen Avoid lying in supine position after 20 weeks of pregnancy, rather left lateral position. Admin crystalloids prior/during block to lower vasopressor needed to maintain systolic (100mmHg) Colloids actually better but anaphalactic. If PR slows give antocholinergic to inhibiy parasympathetic comtrol ( atropine)
45
Classify LA - local anesthetics and give 2 examples of each. NB concepts: Low pKa - rapid onset More lipid soluble - slow onset and more potent
Esters. - cocaine - procaine (slow onset, low potency) - tetracaine Amide - lignocaine (rapid onset, low potency) - mepivicaine (interm onset, low potency) - bupivacain ( slow onset, high potency)
46
T/F: 1. Tachycardia is detrimental to ischeamic myocardium. 2. Tachycardia during mitral stenosis is beneficial to the CO. 3. Beta adrenergic blockers must be stopped preoperatively. 4. Beta adrenergic blockers prevent perioperative myocardial infarction.
1. True 2. False 3. False 4. True
47
Pt has pH of 7.2 BE of -7 Weighs 60 kgs What is the equation that is needed to calculate the amount of bicarb needed to correct the acidosis. How many ml of 4.2% NaHCO3 solution will be req in the pt above. 4.2% solution contains 0.5 mEQ/ml
Weight (kg) x BE x0.3 = mEq of bicarb req. 60 x 7 x 0.3 = 126 mEq and thus 326ml of 4.2% bicarb
48
What does SIRS stand for?
Systemic inflammatory response syndrome
49
MOD?
Multiple organ dysfunction
50
In septic shock there is myocardial suppression: on which day after the onset of septic shock is this at a max? On which day will cardiac function be normal? T/F: viruses cannot cause SIRS
Day 2 Day 10 False, they can
51
Re CPR T/F: 1. Best speed for cardiac compression: 80-100pm 2. Open cardiac massage is better than external cardiac massage. 3. Asystole is initially rx with external defib. 4. During VF there is a direct relationship bw neuro outcome and time before succesful defib. 5. Calcium is used as a matter of routine in CPR. 6. A capnograph is a good monitor of pulmonary blood flow. 7. After cardiac arrest in hosp: 50% of pts will be d/c in good functional neuro outcome 8. Excessive bicarb admin will result in metabolic alkalosis. 9. Excessive bicarb admin will result in a resp venous acidosis. 10. Adrenaline 0.5-1mg should be given IV every 3 minutes. 11. Reversible causes of asystole? How to rx them?
1. True 2. True 3. False 4. True 5. False 6. True 7. False 8. False 9. True 10. True 11. Hyperkaleamia - calcium chloride Hypoxia - effective alv ventilation, 100%oxygen Vagal compress( traction eye/abd organs) - release of stimulus and atropine ``` Other: Pneumothorax Cardiac tamponade Hypoglyceamia Acidosis ```
52
What does FRC stand for? What is it? How does GA affect FRC? what induction agent does not cause effect on FRC?
Functional residual capacity = ERV + RV Also allows for continues gas exchange The sum of volumes remaining in the lung after normal expiration Decr it by 15-20% but not progressive rather immediate (within minutes). - remains low for hours to days after anesthesia. Irrespective of breathing spontaneously, of ventilation, of muscle relaxant. Not in sitting position. Ketamine.
53
Which ventilation strategy will overcome the effect of anesthetics on FRC? Regarding capacity of lung and reserve. ``` What will this mean: V/q Compliance Vd/Vt A/w resistance ```
Minimum inspired oxygen of 30 % during GA. Immediately postop. 40 % oxygen. Preoxygentation - 100% oxygen thru tight fitting mask for 3 minutes. Decr. - low PaO2 Decr. - incr. work of breathing Incr. - incr. in PaCO2 and work Incr -incr in work
54
Why will the pt wake up if the emergency oxygen is left open on the AM?
The emergency oxygen does not flow through the vaporisor and thus bypasses directly to the pt - diluting the final gas mixture and the anesthetic.
55
T/F: 1. Antihypertensive drugs must be stopped prior to surgery? 2. Variation of 30% in BP during anesthesia (compared to the preop value) is acceptable. 3. Autoregulation gives the relationship bw perfusion pressure an stroke volume. 4. Uncontroled HTN will improve CO.
1. False 2. False 25% 3. False - blood flow 4. False
56
If a pt dies because of submersion - he dies due to fluid in the lungs - T/F?
False, drowning is due to hypoxia. | in 10-12% of cases the lungs are found to be dry as result of laryngospasm.
57
What is the single most important action you should do if a pt who suffered a near drowning accident is brought to your consulting rooms in an unconscious state.
Give 100% oxygen
58
Tabulate difference between sea and fresh water near drowning with reference to : Serum K Intravascular volume
Serum K. Intravascular vol Fresh. Low. High Sea. Normal/ high. Low
59
Name 3 joints that may be affected in an Diabetic pt that can lead to a problematic airway?
Temporomandibular joint TMJ Atlanto-occipital joints AOJs Cervical spine joints CSJs
60
A diabetic is well controled on short acting sulphonureum. | He must undergo large surgery, will you stop the medication and change to insulin sliding scale?
Yes- Flow diagram: Approach: Diabetic scheduled elective surgery Control - good Minor ( cont oral rx) Major ( periop 6 hourly short acting subcut insulin sliding scale*) - bad. Minor * Major *
61
``` Pt with non- ketotic hyperosmolar coma, Must undergo anesthesia. Weight: 70kg SerumNa: 152mmol/L What is his total fluid deficit? ``` Give formula used.
(Mass x 0.6) x(normal Na)/ (measure Na) = TBW (Normal TBW for this mass) -( current TBW)= fluid deficit Thus (70 x 0.6) x (140)/(152)= 38.68L (70x0.6)- 38.68 = 3.32L being the fluid deficit
62
List the minimum monitoring req that must be applied during anesthesia? 10
Standard 1 1. Qualified dr. 2. Dedicated to anesthetic care 3. Present at all times Standard 2 4. Must monitor ventilation, oxygenation, circulation and temp continually. Ability must Exist to measure NM function too. Ventilation Qualitative clinical signs ETT/LMA - capnograph Ventilator - disconnecting alarm Oxygenation Oxygen analyser with low O2 alarm Pulse oximeter and pt color Circulation ECG BP and HR every 5min Other monitor(clinical or invasive)
63
List posssible causes of postop confusion in elderly pts?
DIMTOP ``` Drugs: anticholinergics, benzo, alcohol Infection Metabolic: hypoG, electrolyte abnormalities (Na) Trauma: hypoperfusion, fat embolism Oxygen: hypoxia, hypercapnoea Psychiatric - psychosis Pain ```
64
Write formula for calculating BMI and for ideal body weight? At which BMI is one regarded as: 1. Overweight 2. Obese
BMI: weight/ height^2 Kg/ m^2 1. > 25 2. > 30
65
Name 3 types of nerves involved in pain:
A beta A delta C fibres
66
Define windup? 2 sites where it can occur? Name neurotransmitters involved in windup?
Prolonged dorsal horn activity after repetitive C fibre stimulation. Peripheral and Dorsal horn of spinal cord. Glutamate (excitatory amino acid) Substance P Calcitonin gene related peptide Prostaglandins are released that increase neurotransmitters and aggrevates pain thru positive feedback.
67
Advantages and disadvantages of Halothane?
Adv: Smells okay - inhalation induction Bronchodilator ``` Disadv: Halothane hepatitis. HEPATOTOXIC Malignant hyperthermia Cardiac Sfx Postop N and V Suppress breathing response to hypox and hyperCapnia Myocardial supression ```
68
How will you minimize the risk of PONV?
ID high risk pt ( risk scoring) Use two or more antimetics ( diff. Receptors) Other Minimize : intraop use of opioids Neostigmine Consider regional anesth. And adeq. Hydration.
69
Name 5 CI for regional anesthesia in C/S? Also indications for GA in C/S. ``` Cardiac Obstetric Infection Coagulation Other * relative ```
Cardiac HypoVol ; stenotic lesion(severe); cyanotic congenital cardiac lesions Obstetric Severe fetal distress (fetal bradycardia) Low platelets
70
Tabulate the advantages of Ayer T piece breathing circuit? | And disadv
``` Adv: Simple tubes, lightweight, can be coaxial Minimal DS No valves Low resistance to breathing Economical for controled ventilation Inexpensive Facilitates scavenging of waste gasses ``` Disadv: High FGF during spontaneous breathing If co axial: inner tube may disconnect or break The entire tube space becomes DS - leading to severe alveolar hypoventilation Atmospheric pollution with IAA
71
Define third space losses? | At what rate must it be replaced?
Fluid loss as result of tissue oedema and transcell fluid displacement. Functionally this fluid is not available to the vascular space - sodium rich fluid sequestered into damaged tissue. Balanced salt solution is the best replacement and volume distribution correlates roughly with the degree of tissue manipulation and injury. - intra abdo procedures with small incisions = 2ml/kg/hr - major bowel resection= 5ml/kg/hr
72
What is the ideal HB value for elective procedures? | Review graph
10 g/ dl Balance bw reology ( slowed microvascular flow due to increased viscosity) AND Optimal oxygen carrying capacity
73
``` T/F re inadequacy of preparation of a diabetic who is admitted for major elective surgery. Thus cannot receive the surgery. 1. Ketonuria 2. BG >9 mmol/ l 3. Glycosuria 4. Metabolic acidosis 5. Proteinuria ```
1. True 2. True 3. False 4. True 5. False
74
Arrange following anesthetic breathing circuits in order of effectivity with re to the minimum FGF that can be used with safety during spontaneous breathing. Put circuit with safest lowest FGF first Ventilation?
Circle Magill (M-A) Bain (M-D) Circle Bain Magill Thus nb to understand that For spontaneous breathing Magill is better. But for ventilation the T piece is better.
75
Give the formula for calculating minute volume of ventilation:
Tidal volume x freq of breathing | Tidal volume = Va + Vd alveolar ventilation , deadspace ventilation
76
Give the FGF of the following for 1. Spontaneous breathing 2. Controled ventilation M - DEF M-A Circular Also what is the MV of adult?
M-DEF 1. 2-3 x MV 2. 1x MV M-A 1. 0.7 x MV 2. 2-3 x MV Circular: relative unimportant 70ml/kg/ min minute volume for normal person
77
List groups of pt with increased risk of vomiting/ regurgitation and possible aspiration, during anesthetic induction?
``` Pregnant GERD Full stomach GIT obstruction, incl ileus Incr intra abd pressure IAP Difficult airway Emergency, pain, opioids Stress Obesity? ```
78
List three groups of agents you woud like to admin preoperatively in circumstance of incr aspiration risk with anethetic induction.
PPIs - omeprazole H2antagonist - ranitidine Non - particulate antacid - sodium citrate
79
A derc. In BP is common after administration of spinal anesthetics. 1. What is the reason for the decr. in BP? 2. When would you institute therapy? 3. Briefly explain how you would Rx the hypoT?
``` 1. Spinal causes sympathectomy of spinal roots Anywhere from T1-L2 - depending on where block is. Effects: Vasodilation (venpus and arterial) Venous pooling and derc. CO Drop in SVR (arterial vasodilation) Thus BP = COx SVR Drop in BP ``` 2. MAP
80
What vasocontrictors can you use to rx low BP with spinal block?
Alpha and Beta agonists 1. Ephedrine : 5-10mg 2. Etilephrine : 1-2mg Effortil Pure alpha agonist: can cause bradycardia (Baroreceptor response) 3. Phenylephrine : 50-100microgram
81
``` Ypu are ventilating a pt under GA (has NMB and is paralyzed) Refer to: 1. Mechanism of work 2. Resultant tidal volume 3. Inspiratory pressure ``` What will happen? A: Ventilator is a pressure generator type ventilator- how will the ventilator react if there is uncoupling of the pt from the ventilator? B: ventilator is a volume type - how will it react if there is partial obstruction of the inspiratory limb of the breathing circuit? What will the tidal volume be if you are using a flow type ventilator. Settings: Insp time: 1.5 sec Insp flow: 500ml/sec
A: Ventilator will cont to deliver volume because the preset inspiratory pressure cannot be reached. B: flow rate will increase to deliver the set tidal volume within the allotted time. Pressure = flow/resistance thus pressure will increase Normal pressure is 20cm H2O and this might drastically be exceeded if the obstruction persists *** inspiratory time 1.5sec and insp.flow 500ml/sec This 750ml
82
Which opioid is best lowers the MAC the most when used with IAA? Review graph What do you call this rxn?
Morphine Synergistic rxn
83
Ketamine as anelgesic: | 4 situations
Usefull as supplement to regional anesthetics when pt still experinces intraop pain / discomfort Provide anelgesia with dressing changes for burn pts. Very low dose ( 0.05) potentiate epidural anelgesia, also derc tendency to develop chronic pain. Enhances, sparing effect, reduce sfx of opiods

anesthesiology (7 decks)

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