1
Q
Concerns with substance use and SUD (substance use disorder) during pregnancy?
A
- limited/no pre-natal involvement
- late gestational age presentation to services
- suffer from stigma
- more likely to experience shame, fear and worried about legal/social service input
2
Q
Goals for management of substance abuse disorder during pregnancy?
A
- stopping/reducing substance
- reducing effects of substance use and withdrawal on mother and fetus
- prevention, diagnosis and treatment of co-morbidities
- preventing risky behaviour with IVDU
- encouraging postitive changes - employment, stable housing
3
Q
Associated risk of tobacco use in pregnancy?
A
LBW, spontaneous abortion, miscarriage, preterm, praevia, abruption.
4
Q
Associated risk of marajuana use in pregnancy? Considerations for anaesthesia?
A
LBW, cannabinoid hyperemesis syndrome, abruption, preterm, hypertensive disorders.
5
Q
Associated risks of cocaine use in pregnancy? Acute and chronic.
A
Acute - pre-eclampsia/eclamptic like Sx
Chronic - abruption, PROM, seizures and migraines
6
Q
2023 American heart association recommend what in the initial treatment of high blood pressure and psychomotor agitation due to cocaine overdose? And what else can also be used to help treat?
A
Benzo
Also - calcium channel blocker, alpha-1 antagonist and nitrates.
7
Q
What drugs should be avoided in pregnancy patients (and all patients for that matter) who are taking regular cocaine/MDMA/LSD?
A
Ephedrine and ketamine
8
Q
What screening method can be used to indentify in utero opioid exposure. And what is a limitation of this>
A
Meconium aspirate/sampling
9
Q
Benefits of methadone vs buprenorphine.
A
Methadone:
- QTc prolongation
- may require more freq doses due to increased metabolism in pregnancy
- potent analgesic but short half life therefore may need to be split into divided doses in labour. Long half life for suppression of withdrawal symptoms.
Buprenorphine:
- less QTc prolongation
- higher peri-delivery and post-op pain scores
- substances with increased intrinsic activity should be used in neuraxial (fent/morphine)
10
Q
Labour/Delivery and caesarean considerations for patients with opioid use disorder?
A
Labour/delivery
- increased monitoring and pain scores
- lipohilic opioid in patients with buprenorphine
- clonidine and dexmed can be used for breakthrough/put in epidural
- stick to standard clinical practice when treating of breakthrough pain
C-section:
- neuraxial > GA
- neuraxial opioids are recommended
- conisder continuing epidural especially in no TAP
- NSAID and paracetamol to be used in multimodal approach.
11
Q
What is the ideal paediatric perioperative tidal volume?
A
6-10ml/kg
12
Q
What is the reccomended PEEP in children?
A
3-5. PEEP required to prevent atelectasis as children have high closing capacity. PEEP should ideally be tailored and optimised for each patient, (PEEP adjusted to zero end-exp transpulmonary pressure)
13
Q
What are the important factors when thinking about lung protective ventilation in children?
A
Driving pressure - no more than 15 - ideally around 5
Mechanical power (inversely related to driving pressure and increased by increased ventilatory frequency
Tidal volume
PEEP
Tailored ventilation after recruitment manoeuvres with low TV and PEEP
14
Q
Define driving pressure/how is it calculated?
Over what driving pressure should be avoided in children?
A
Driving pressure is the difference between PEEP and plateau pressure.
Avoid over 15
15
Q
What is the definition of mechanical power?
A
The amount of energy that is delivered to lung during mechanical ventialtion
16
Q
How is high frequency ventilation designed to optimise a child’s ventilation and what are the two main types? What is different about the expiratory phases?
A
High freq vent keeps lung open to prevent atelectasis (optimises lung expansion) and maintains VT with volumes at or above dead space
17
Q
What changes would you make when ventilating a paediatric patient with asthma?
A
- Decrease insp pressure (<40cmH2O) and tidal volumes (5-8ml/kg)
- Prolonged exp phase and therefore I:E of 1:3/1:4
- allow permissive hypercapnia
18
Q
Pros and Cons of short bevel needle?
A
Short bevel = blunt. Less likely to cause trauma to nerve but if it does trauma is worse. Better tactile feedback with ‘pops’. Require more force to insert through skin and fascia.
19
Q
Pros and cons of long bevel needle?
A
Sharp, less tactile feedback. More likely to cause neural or penetrate perineurium damage, if causes damage, damage is not as severe.
20
Q
Should inplane or out of plane catheter insertion be used for
a)femoral b)popliteal sciatic
A
a) in plane
b) OOP
21
Q
What 5 tips can be used for catheter placement? (if struggling)
A
- firstly expand perineural space with fluid (if using nerve stim then use dextrose)
- then pull back 0.5cm while turning needle 45 degrees
- pass catheter 3cm past target if superficial nerve and 5cm if deep if at target. hydrodissection can help with this.
- confirm using USS/nerve stimulator
- use needle path to preserve efficacy - i.e intramuscular path or under fascia iliaca keeps secure
22
Q
Risks of peripheral nerve catheters?
A
Infection
Vascular damage
Local anaesthetic toxicity
Difficult threading
Dislodge/migrate
23
Q
For a facial plane catheter - what type of catheter is best? What type of regimen is best? What other catheters and regimens are there?
A
Facial plane best = multi fenestrated as opposed to single hole which is better for individual nerve catheters
Regimen - intermittent boluses (can also have continuous infusion - not as effective according to evidence)
24
Q
How can you confirm correct placement of nerve catheter?
A
USS or nerve stimulator
25
What are the clinical features of a migraine?
(premonitory symptoms)
1. prodrome
2. aura(1/3 of patients)/no aura
3. headache
4. postdrome
26
What are red flag features of migraines that require further investigation? (5)
Thunderclap
> 50 years old
A/W systemic symptoms
A/W focal neurlogical defecit/papilloedema
Valsalva-positive (worse on bending/sneezing)
27
What are the different types of migraine? (classification according to ICHD-3)
Migraine with aura
Migraine wihtout aura
Chronic migraine
Complications of migraine
Probable migraine
Episodic syndromes associated with migraine
28
Classification of migraines without aura?
5 attacks with the following
- headache lasting 4-72 hours
2 from
- unilateral
- pulsating
- mod to severe
- exacerbated by routine activity
1 of
- N+V
- photophobia
29
Classification of migraines with aura? What are the types of aura? What aura symptoms are required for a diagnosis
At least 2 attacks a/w aura
One or more of the following reversible neurological symptoms
- visual, sensory, speech/language, motor, brainstem, retinal
Aura symptoms (3 of following)
30
Difference between acute and chronic migraine?
Acute < 15 times/month - Chronic more than
31
Examples of migraine premonitory symptoms?
Fatigue
Neck stiffness
Mood change
Concentration difficulty
Nausea
Photophobia
Food craving
32
Examples of post-dromal symptoms?
Neck stiffness
Fatigue/tiredness
Bowel and bladder changes
Hunger
Cognitive impairment
Mood changes
Feeling hungover
33
Examples of positive and negative aura?
Positive
- flashing lights
- wavy/jagged lines
- tinnitus
- paraesthesia
Negative
- blind spots/tunnel vision
- hearing loss
- limb weakness
34
What are the risk factors (1) and triggers of migraine?
Main risk factor = genetics and FHx
Triggers
- stress
- lack of sleep
- dietary factors (caffeine and alcohol)
- hormones
35
What are the 'simple' ACHD conditions. Native and repaired.
What are the complex ACHD conditions?
(everything else is moderate)
Simple native:
- small isolated ASD/VSD
- MILD pulmonary stenosis
Simple repaired:
- ASD/VSD without significant residual shunt or ventricular enlargement
- PDA
Complex:
- TGA
- Fontans
- Hypoplastic left heart (or single ventricle physiology)
- Cyanotic congenital heart defect (repaired and unrepaired)
- Mitral/pulmonary atresia
36
How can ACHD be classified? Describe each classification.
Functional and Anatomical classification.
Functional
A - not effecting end organ, functional status, asymptomatic with no sequelae
B - symptomms, minor haemodynamic alteration (mild to moderate mild ventricular dysfunction/arrythmia not requiring treatment)
C - moderate to severe haemodynamics, end organ dysfunction responding to treatment (severe ventricular dysfunction, significant pHTN)
D - end organ damage refractory to treatment, end-stage/life-threatening (severe pHTN, eisenmengers).
Anatomical
Simple, mild, moderate, complex.
37
What are the important pre-operative questions for a patient with ACHD?
What type of lesion and classification in AHA scoring system?
Systemic complications?
Previous interventions?
Functional status?
Implications of surgery?
38
What signs on echo indicate high probability of pulmonary hypertension?
D-shaped LV
Right V hypertrophy/dilation
TR
Enlarged pulmonary arteries.
39
What are normal PAP pressures.
What pressures correlate with mild, moderate and severe pHTN?
Normal < 20
Mild 20-24
Mod 25-39
Severe > 40
40
What other co-morbidities are common in ACHD?
Renal disease
Anxiety/depression
Restrictive lung disease (nearly half)
Thrombosis and bleeding - due to anticoagulants, endothelial damage from lines, thrombosis due to stasis
41
Periop considerations of patient with ACHD?
Arryhtmias
Anticoagulation
Endocarditis cover (severe classification going for dental surgery).
Cognitive imparment
42
Prevalence of VAP?
10-15%
43
Definition of VAP?
Presence of new lung infiltrate with fever, leukocytosis and a decline in oxygenation.
44
Risk factors for VAP?
Patient: Age, male, diabetes, smoke exposure, immunosupression.
Admission related: admission with disorder of consciousness, burns/trauma, prev abx exposure and increased duration of invasive ventilation
45
What are the casutative organisms of VAP?
GNEG: Klebsiella pneumoniae, e.coli, pseudomonas aeuriginosa
GPOS: S. aureus
46
What are the 4 main constituents of a VAP bundle (+other constituents?)
1) head up
2) spontaenous breathing trial
3) VTE
4) stress ucler prophylaxis
- minimise disconnection from circuit, frequent sub glottic suctioning, monitoring cuff pressure, chlorhex to mouth
47
What would be a sensible abx of choice for
- early onset VAP
-late onset VAP (5 days since I+V)
- Co-amaox
- mero/taz
48
What is central sensitisation? (8 marks)
= a state of pain gain amplification persisting beyond tissue healing
1. increased excitability of nociceptive neurones in spinal and supra-spinal pain circuits
2. recruitment of non-nociceptive pathways (AB fibres)
3. decreased inhibitory control - tipping the excitation/inhibition balance towards excitement
4. Activation of non-neuronal cells - glial cells (where cannabinoids can work)
5. Change to cognitiona dn affective influences.
49
Why does the monro-kellie doctrine not apply directly to elderly? (initially)
Brain atrophy leading to more intracranial space and a delayed presentation of intracerebral bleeds
50
How would you navigate intubation in a trauma patient?
Presumed C-spine injury (MILS)
Presumed difficult airway (therefore use VL)
Use RSI checklist for emergency intubation
51
What are the 3 principles of damage control resuscitation? and the difference in elderly trauma?
- Minimise blood loss
- Prevent and treat coagulopathy (combining haemostatic resuscitation with surgical haemorrhage control).
- Maximise oxygen delivery
Permissive hypotension used in exceptional circumstances (high pressure arterial bleed)
52
What measures of shock should be used in the elderly? What markers may be potentially unreliable?
Urine output, CRT, tacypnoea, cerebration
Unreliable: BP/HR
53
What is the trauma triad?
Hypothermia, acidosis and coagulopathy
54
What does major haemorrhage pack 1 and 2 contain?
1:1 RBC/FFP
1:1:1:1 - RBC/FFP/PLT/CRYO
55
What are the neuro changes in elderly and significance in trauma?
Cognitive dysfunction - difficulty in rehab
Atrophy and delayed presentation
Cerebrovascular disease - more susceptible to delirium
Impaired auroregulation
Sparring use of opioids
56
What are the resp and CV changes in elderly and significance in trauma?
CV: IHD, increased SVR, reduced efficacy of baroreceptor, greater reliance on atrial kick, LVH, smaller number of pacemaker cells and increased likelihood of arrhythmia.
Resp:
Decreased lung capacity, increased closing volume, reduced lung and chest wall compliance, weaker resp muscles
57
What are the MSK/renal changes in elderly and significance in trauma?
MSK: OA/osteoperosis, decreased muscle mass, thinnin gof skin
Renal: decrease nephron function and number, decreased renal blood flow, reduced eGFR, vascular changes
58
What are the indications for intubation in elderly trauma?
Decreased GCS
Agitation in TBI
Unable to protect airway
inadequate ventilation/oxygenation
predicted decompensation
59
What 3 tools can be used in elderly trauma?
Clinical frailty score CFS
Geriatric Trauma Outcome Score GTOS
Trauma specific frailty index tsfi
60
% risk of adverse events in airway management in critically unwell patients?
45
61
What airway assessment tool can be used on critical care?
MACOCHA
Mallampatti
obstructive sleep Apnoea
C-spine
mouth Opening
Coma
Hypoxia
Anaesthetist operator (or not)
62
What are 4 mechanisms of CV collapse during/post intubation on critical care?
- Pre-existing hypovoleamic/haemorrhagic shock
- Vasoplegia and negative inotropic effect of induction agents
- Increased PVR and subsequent RV failure with IPPV. LV systolic/diastolic dysfunction
- NMB and IPPV reducing pre-load
63
Strategies to optimise oxygenation on induction on critical care?
Pre-ox with CPAP
Apnoeic/peroxygenation with HFNO2
Maximise FRC volume
64
What should always be used before during and after an airway procedure on critical care?
Waveform capnography
65
Definition of pain?
Unwanted/unpleasant sensory and emotional experience caused by to actual or perceived tissue injury
66
What are the 3 types of pain?
Neuropathic, nociceptive, nociplastic
67
Name 4 excitatory chemicals in sensory/peripheral neurones
CCK, NO, Glutamate and substance P
68
Excitatory neurotransmitters in interneurones (dorsal columns) (2)
Glutamte and ACh (nicotinic)
69
What are the excitatory and inhibitory neurotransmitters/chemicals in descending pathyway?
Inhibitory: Serotonin, noradrenaline, opioids, GABA and glycine
Excitatory: Serotonin, noradrenaline, oxytocin (inhibitory only), Serotonin, noradrenaline, glutamate, CCK.
70
Define allodynia, paraesthsia, hyperalgesia, dysaesthesia
Allodynia - pain experienced from non-noxious stimuli
Hyperalgesia - exaggerated pain experienced from noxious stimuli
Dysaesthesia - altered/abnormal pain sensation
Paraesthesia - unusual sensation
71
Describe the 3 grades of acute on chronic liver failure?
Grade 1 - single organ failure
Grade 2 - two organ failures
Grade 3 - 3+ organ failures
72
What precipitates acute on chronic liver failure?
Infection
Alcohol hepatitis
Viral hepatitis
Variceal bleed
Hepatotoxic drugs
Cardiac failure
Ischameic hepatitis
Surgery
73
What are the two main pathophysiological processes in ACLF?
Systemic inflammation
Immune dysfunction
74
What are the 2 scoring systems for chronic liver disease?
What is the scoring system for acute on chronic liver failure?
Child-pugh
MELD - model for end stage liver disease
CLIF-C OF (organ failure). There is a specific CLIF-C OF ACLF
75
What constitutes the CLIF-C score?
Liver - Bili
Kidney - Creat
Brain - encephalopathy - west haven
Circulation - MAP/vasopressor support
Coag - INR
Lung - PaO2/FiO2 ratio
76
When assessing someone with acute on chronic liver failure's suitability for critical care, what 4 considerations must be taken?
Co-morbidities
Degree of organ failure
Age
Precipitant of ALCF
77
Where do intracranial aneurysms most commonly occur? (and what artery is the most common)
Circle of willis at bifurcations and mostly in anterior cerebral and posterior circulation. Most common is middle cerebral artery.
78
What risk factors increase chances of cerebral aneurysmal rupture?
Hypertension
Age > 70
Finnish/Japanese
Size
Prev SAH from aneurysm
79
What method of treatment is preferred for posterior circulation aneurysms?
Coiling
80
Pros and Cons of clipping and coiling?
Clipping: Decreased recurrence, higher 30 day mortality, good for large and complex aneurysms, longer recovery
Coiling: decreased recovery, decreased 30 day mortality, superior for POCS, increase risk of rebleed
81
Describe the WFNS scale
1. GCS 15 - no motor deficit
2. GCS 13-14 no motor
3. GCS 13-14 motor
4. GCS 7-12
5. GCS < 7
82
When may temporary clips be used?
Control of intra-op rupture
Clip readjustment
83
Strategies to reduce cerebral ischaemia during temporary clipping?
Controlled hypertension to improve collateral flow
Decreased CMRO2
84
If there is an intraoperative vessel rupturewhat are the risk factors?
What are the key management strategies?
RF: HTN, prev aneurysmal rupture, located in anterior communicating artery and sac size
Mx:
- Can induce brief hypotension with adenosine (contraindiacted in asthma/COPD, CAD, conduction abnormalities.
- reduce CMRO2
- team communication is key
85
What % of GBS patients suffer from respiratory failure?
20-30%
86
How does Miller- Fisher differ?
Opthalmoplegia, ataxia and areflexia
87
What is the risk score used in GBS to assess the likelihood of resp compromise in GBS?
Modified Erasmus GBS Respiratory Insufficiency Score.
- bulbar weakness
- time from weakness to admission
- neck flexion
- bilateral hip flexion
(out of 32)
88
Complications of GBS?
Aspiration
Atelectasis and HAP/VAP
Autonomic-arrhythmias
including heart block needing PPM
Pain - nociceptive and neuropathic
DVT/PE
Pressure injuries
Complications from preceeding injuries
89
What are the 2 main causes of vasoplegic shock? What are the 3 main pathophysiological mechanisms of vasoplegic shock?
septic shock and post CPB
Endothelial leak, widespread vasodilation secondary to increased vasodilatory mediators, vascular hyporesponsiveness to vasopressors
90
Why do you get vascular hyporesponsiveness to catecholamines in vasoplegic shock?
Down regulation of receptors due to increased endogenous catecholamine release.
Increased secretion of vasopressin from p.pituitary leads to depleted stores
91
RF for developing vasoplegic shock post CPB?
Pre-op ACEi/ARBs
Concomittant vasodilatory drugs (milrinone)
Prolonged CPB
Impaired Ventricular dysfunction
92
How does methylene blue work?
Nitric oxide synthetase inhibitor
93
Adjuvant therapies for vasoplegic shock
Hydrocortisone
RRT
Hydroxocabalamin (last resort) not really adjuvant
94
Arterial supply of the pancreas?
Head and Uncinate: Branches of the SMA (to form the anterior inferior/superior pancreasticoduodenal artery) and of the Gastroduodenal (to form the posterior inferior/superior pacreaticoduodenal artery)
Body and Tail:
Splenic artery (branch of coeliac trunk
95
96
What are the indications for pancreatic resection?
Pancreatic cancer
Acute necrotising pancreatitis
Chronic pancreatitis
Pancreatic trauma
97
Risk scores that can be use for suitability for pancreatic resection surgery?
ACS NSQIP - adjusted for pancreatic resection
Heidelberg score
MSKCC score
Latter two have been proven to be superior in risk stratifying.
98
What are the pre-op risk factors associated with increased mortality/morbidity after pancreatic resection?
Age > 74
Male
BMI > 40
Pre-op sepsis
ASA > 2
Coronary disease
Dyspnoea on moderate exertion
Bleeding disorder
Prox/total pancreatectomy
99
What are VE/VO2 and VE/VCO2? What are their normal values and what values exhibit an increased risk of morbidity/mortality?
VE/VO2 = ratio of litres breathed (MV), consume 1L of oxygen. High numbers are bad and indicate pulm disease. During exercise the VE/VO2 ratio falls however near the AT it rises again as MV increases to rid CO2. This = the nadir. The lower the nadir the better. Nadir = sweet spot. Maximum efficiency. 30+ bad.
VE/VCO2 = how many litres breathed to eliminate 1L of CO2. Normal = 20-30. Over 40 = increased morbidity.
100
What are the main focuses of pre-optimisation before pancreatic resection?
Anaemia
Nutrition
BM control
Reduce alcohol and smoking
Correction of direct consequences of tumour: Coagulopathy, acute renal failure, immunosupression.
101
Analgesic options for pancreatic resection?
Epidural gold standard in many centres (however increases risk of pacreatic fistulae and increases ICU LOS)
Intrathecal opioids
Wound catheters
PCA
102
Specific intra-op considerations of pancreatic resection?
Glucose control
Fluid management - oedema increases risk of anastomotic failure
Positioning - if prolonged
Temperature management
Abx proph and likely re-dose
103
Post-op complications of pancreatic resection?
Pancreatic fistula
Haemorrhage
Abscess formation
Delayed gastric emptying
Respiratory failure
104
Pre-op ERAS for pancreaticoduodenectomy?
3-6 week programme
4 week abstinence from heavy alcohol consumption
Preop nutrition if lost over 15% body weight/BMI< 18.5
Avoid pre-op biliary drainage unless bili > 250
105
Peri-op ERAS recommendations for pancreaticoduodenectomy?
Pre-op fasting 6 and 2
Paracetamol pre-op
VTE with heparin
Single dose abx <60min pre incision
Thoracic epidural for open
opioid sparring multimodal post-op analgesia
PONV prophylaxis
106
Main presentation of vestibular schwannoma?
Hearing loss
Tinnitus
Loss of balance
107
What are the three main rteatment options for patients with VS?
Observation with serial imaging
Radiotherapy
Microsurgery
108
How can PONV be minimised in VS surgery?
Anti emetics
Hyoscine patch
Pre-op chemical labrynthectomy. X3 intra-tympanic injections of gentamicin to destroy vestibular function.
109
Pre-op considerations of VS microsurgery
Symptoms related to: - cranial nerve dysfunction
- brainstem dysfunction
- increased ICP
Optimisation of comorbiditiesIn
110
Intra-op considerations of VS microsurgery
- Completely immobile without NMBAs.
- Reinforced tube
- Secured with tape
- Short acting sedatives so neuro assessment can be carried out post-op
- art line
Neuroprotective measures and maintenance of CPP
111
Complications with microsurgery for VS?
- Facial nerve damage
- Trigeminocardiac reflex
- CSF leak
- meningitis
- stroke
- post-op haematoma
112
What is prehab?
Holistic preparation of a patient for an upcoming physiological stressor.
113
What are aspects of prehab?
Cessation of alcohol and smoking, managing anaemia and controlling BM (part of prehab and ERAS)
Exercised-based prehabilitation (resistance training and cardio)
Nutritional support - carb loading, immunonutrition and oral nutritional supplements
Education
CBT/relaxation
114
What is a MET?
Represents oxygen consumption at rest and is equal to 3.5mlO2/kg/min
115
What exercise is reccomended in pre-hab?
3 sessions a week of moderate aerobic training (3-6MET)(can still talk/not sing)
2 sessions a week of resistance training
116
Benefits of carb loading drink?
Reduces insulin sensitivity, shorter LOS, reduction in loss of lean body mass and muscle strength.
117
For the following give 1 extra consideration for prehab
- Lung Ca
- Head and Neck
- GI
- Prostate
Lung - resp muscle training
Head and Neck - Nutrition
GI - nutrition (resp muscle training for oesophagel Ca)
Prostate - pelvic floor
118
What actions - specific to jet ventilation - can be carried out to improve oxygenation and removal of CO2 in a patient? (Can also state what else you would do if patient is desaturating)
Increase fraction of Oxygen inspired
119
What surgeries is LFJV used for?
Short surgeries. Rigid bronchoscopy and airway surgeries.
120
What are the mechanisms for which ventilation occurs?
Bulk flow - mainly LFJV
Cardiogenic mixing
Co-axial/Laminar flow (air on edge of airway flows in reverse direction)
Pendeluft (emptying of alveoli at different time constants)
Molecular diffusion
121
Why might supraglottic jet ventilation generate higher pressures than subglottic?
- Entrainment of air
- double jetting - due to reflection of delivered gas off glottis and extra source of gas to be delivered next
- increased turbulent flow
- upward passage of gases only occurs in expiration phase (gas trapping more common)
122
What benefits does subglottic ventilation have? Where should the tip of the catheter reside?
What purpose does a double lumen catheter serve?
- less gas trapping (but risk of barotrauma greatly increased if airway obstructed as any further gas injected cannot escape
- upward passage of air in expiration
- less driving pressure
- less vocal cord movement
- little entrainment of air so therefore more predictable FiO2
- tip of catheter resides in mid/distal trachea
- double lumen catheter - delivers gas with one lumen and measures pCO2/airway pressures with the other
123
Relative contraindications to jet ventilation
Foreign Body
Airway trauma
124
Main cause of barotrauma in jet ventlaltion?
Unrecognised obstruction to gas flow
125
What are the physiological consequences of post-op AF?
Increased risk of:
- MI
- stroke
- acute heart failure
126
What are the pre-op risk factors for developing AF (8)
Increasing age
Male
High BMI
Diabetes
HTN
Renal disease
High MELD score
Pre-existing cardiac disease
127
What are the types of surgery most associated with post-op AF?
Cardiac - CABG/valvular surgeries (or both)
Use of CPB
Open abdominal
Thoracic
Vascular if involves cross clamp
128
What are the post-op factors for developing post-op AF?
Cessation of B-blocker
Cessation of ACEi
Electrolyte abnormalities
Critical illness
Prolonged ITU stay
129
What is the pathophysiological mechanisms of developing post-op AF? and why do they cause AF?
- Hypovoleamia/hypotension/Anaemia (due to myocardial ischaemia and altered conduction velocities)
- Electrolyte abnormalities (altered cellular conduction)
- Increased catecholamine release due to surgical stress/pain
- Hypoxia (causing increased PVR and myocardial ischaemia)
- Hypercarbia (increase PVR)
130
Pre-op, intra-op and post op prevention/risk reduction of post-op AF
Pre:
- Optimisation of risk factors.
- 7 days of statin pre-op if cardiac surgery.
- Do not stop beta blocker
Intra:
- avoid all intra-op risk factors
- vasopressin > norad
- dexmed use
- steroid use
- regional anaesthesia
- atrial pacing post-cardiac surgery
Post:
- initiation of beta blocker therapy after cardiac surgery
- amiodarone or non-dihydropyridine calcium channel blockers (diltiazem) second line
131
Management options of post-op AF. Initial (unstable and stable). Long-term.
Initial - unstable - shock
stable but symptomatic - amiodarone/flecanide etc
Stable asymptomatic - usually self limiting, beta blockers, amiodarone
Long term
Electrical or pharmacological cardioversion
Ablation therapy
- PVI
131
Definiton of anorexia nervosa?
Eating disorder associated with extreme fear of gaining weight.
132
CV complications of AN? (4)
Lower cardiac muscle mass and high SVR resulting in low CO. (in conjunction with low preload)
Arrhythmias
Increased SVR
PNS is activated in extremley low body weight therefore have bradycardia and hypotension
133
Haematological side effects with AN? (2)
Coagulopathies due chronic malnutrition. Vit K deficiency causing increased INR.
Bone marrow depression and resulting anaemia, leucopenia etc
133
Renal complications of AN? (5)
Kidney failure
Dehydration
Nephrolithiasis
Metabolic alkalsosi
Electrolyte disturbances
134
MSK S/E in AN? (2)
Osteoporosis (due to dysregulation of the parathyroid) and muscle wasting
135
Airway considerations with AN? (3)
Potential to have tracheal stenosis, large salivary glands, poor dentition
136
What intra-op complications can AN patients be at risk for?
- Aspiration due to gastric distenstion
- Fluid overload leading to CCF
- neuropathy
- hypothermia as temp reg severely impaired
137
Definition of CP?
Umbrella term for a group of movement and posture disorders that limit activity. Acquired pathology within the developing brain during pre/neonatal or early infancy.
138
Respiratory features of CP?
Chest infections due to aspiration pneumonitis
Neuromuscular scoliosis leading to restrictive lung defect
Increased salivation (often take anticholinergic)
Vomiting/regurg/reflux common
139
GI and MSK complications of CP?
GI - Reflux and dysphagia
Poor nutritional status - anaemia, dehydration and electrolyte abnormalilities
Chronic constipation
MSK - low bone density, fixed flexion deformities
139
Transfusion strategy for Sickle cell patient undergoing a) high risk surgery and b) low to medium risk surgery
High risk surgery aim for Hb ~ 100 with exchange transfusion and HbS < 30%
Low to medium risk aim for Hb ~ 100 with simple top up transfusion
140
Strategies for sickle patients who refuse transfusion
Improve endogenous erythropoeisis - EPO
Avoid blood loss
- meticulous haemostasis
- avoid increased blood sampling
- case by case decision on cell salvage
141
5 key triggers in sickle cell?
Hypoxia
Hypothermia
Pain
Dehydration
Acidosis
142
Pre-operative strategies for sickle patient? (apart from transfusion strat)
- MDT involvement - inc pain team and haematologist (should be anaesthetic lead, should be in done in sickle centre)
- functional assessment, consider echo for pHTN
- first on list, avoid prolonged fasting and consider sip till send
143
Intra-operative strategies for sickle patient?
Regional preferred as increases blood flow and superior analgesia
Meticulous fluid balance
Meticulous temperature
144
Post-op priorities in sickle cell patient?
Crisis prevention is main goal.
- oxygenate to keep SpO2 > 96% for at least 24 hours
- multimodal approach to analgesia and involve pain team early
- high index of suspicion for acute chest syndrome
- ensure LMWH used for all peri and post pubertal.
145
What is an appropriate analgesic strategy in someone who is breast feeding?
Multimodal
Para, NSAIDs ok
Opioids that are preferred - Morphine and dihydrocodeine
Opioids that are to be avoided - codeine and pethidine
Also no Aspirin
146
What is the preferred anti-emetic in breast feeding?
Ondansetron. Metoclopramide and domperidone may increase lactation which may be problematic in someone who has just stopped.
147
WHO recco for breastfeeding?
Why is breastfeeding good?
At least 6months of breastfeeding to acheive optimal growth. Up to and beyond 2 years.
148
Advantages of breast feeding>
Immune function for baby - antibodies in breastmilk
Maternal benefits - reduction in BRCA and Ovarian Ca and T2DM
149
Risk of sudden breastfeeding cessation
Mastitis
Infant dehydration/cows milk allergy
Early unwanted cessation of breastfeeding.
150
Chemo and breastfeeding advice?
Avoid during chemo
Wait 14 days from last session before resuming.
151
Overall goals of RRT?
Fluid removal - solute and water
Electrolyte correction
Acid-base correction
152
RRT process of filtration called?
What sized molecules does RRT filter?
What is the RRT buzz word?
What effects this buzz word?
Convection
Middle size (dialysis small)
Solute drag
Flow rate and transmembrane pressure
153
H-dialysis - solute clearance achieved by?
Diffusion
154
What are the hypothesised benefits of continuous over intermittent RRT?
- More haemodynamic stability
- increased removal of inflammatory mediators (benefit in sepsis)
- superior management of fluid balance
- better preservation of cerebral perfusion in acute brain injury
155
What is international consensus on RRT dose?
20-25ml/kg/hr
156
How does citrate work as an anticoag?
Adv and Disadv of its use?
Chelates calcium, removed in effluent fluid.
Adv: regional (not systemic), filters last longer without clotting, reduced heparin exposure and HIT, decreased requirement for blood products
Disadv: requires hypocalcaemia infusion, causes hypomagnasaemia, can cause acidosis due to citrate build up, can cause alkalosis due to conversion of citrate to bicarb.
157
What is the most commonly used outcome measure of disability after stroke?
modified rankin scale - mRS
158
Inclusion and Exclusion criteria for endovascular thrombectomy? (5) + (6)
Inclusion:
- Anterior circ occlusion all ages
- proximal, large vessel occlusion
- within 6 hours of onset OR over 6 hours but salvageable penumbra
- mRS < 3
- NIHSS > 5
Exclusion:
- intracranial haemorrhage/intracranial mass
- significant disability mRS > 3 pre-stroke
- terminal illness <6 months to live
- bleeding diathesis
- uncontrolled hypertension
- extensive stroke with irreversible damage
- NIHSS < 5
- difficult vascular anatomy (bilateral carotid stenosis)
-
159
LA vs GA for thrombecetomy?
LA: intra-op neurological assessment, quicker time to puncture, minimise haemodynamic changes
GA: immobility, increased risk of hypotension, able to control ventialtion, conversion to GA intra-op associated with bad outcomes
160
When is GA for thrombectomy advised?
N+V, agitation, POCS, reduced GCS
161
Physiological goals during thrombectomy?
And BP goal post?
- BP 140-180/within 10% of normal BP (metaraminol/labetalol)
- PCO2 4.5-5 and PO2 >94%
- normothermia and BM 6-10
BP goal post-op < 180/105
162
Complications following thrombectomy?
Following thrombolysis - bleeding from puncture site, haemorrhagic transformation
Thrombectomy
- 10% intracranial haemorrhage from vessel rupture (heparin to be reversed with protamine)
- dissection of vessel intracranial or femoral
- vasospasm
- thromboembolic events
- pseudoaneurysm
- retroperitoneal haemorrhage
- limb isachaemia
163
SOBA pre-op red flags and considerations if present?
- ECG changes
- Resting sats < 94%
- Bicarb > 27 indicates OSA
- IHD/CVA
Considerations:
- pre-op CPAP
- sleep studies
- echo?
164
Different types of obesity and the co-morbidities associated with them?
Central Obesity
- increase risk of difficult airway, co-morbidities and metabolic syndrome
Peripheral obesity?
165
SOBA guidance for equipment required intra-op?
Airway:
- oxford pillow
- HFNO2/CPAP
- VL
- difficult airway equipment
Other
- suitably sized operating table
- sideboards
- large BP cuff
- USS machine
- pneumatic VTE
166
Anaesthetic considerations for obese patient?
Induction:
- CPAP/HFNO2 for pre-ox
- patient self position on operating table in ramp position
- consider pre-med antacid/analgesia
- minimise time from induction to ventilation time
Intra-op:
- minimise long acting opioids/sedatives
- DVT proph
- think pressure areas
Extubate
- full reversal
- extubate and recover sitting up
167
Name drugs that should be given according to
a) lean body weight (4)
b) adjusted body weight (3)
c) total body weight (2)
a) LBW - propofol induction, fent, morphine, alfentanil
b) propofol infusion, suggamadex, neostigmine
c) sux, LMWH
168
3 core ARDS criteria?
- within a week of a known clinical insult
- diagnostic radiological findings - bilateral opacities on CXR/CT, bilateral b-lines on USS
- not fully explained by heart failure/overload
169
What is the criteria for ARDS in a non-ventilated patient?
PEEP > 5 with CPAP/ flows of >30L/min on HFNO2 and PF ratio <40, or SF ratio < 315
170
What is severity criteria for ARDS in ventilated patient?
PF ratio:
Mild: 26.6-39.9
Moderate: 13.3-26.6
Severe: <13.3
171
What are the top 4 risk factors for abruption, praevia, accreta?
Abruption
- smoking/drug abuse
- previous abruption
- pre-eclampsia/HTN
- prev c-section
Praevia
- multiple pregnancy
- advanced age
- IVF
- prev c-section
Accreta
- prev c-section
- prev hx of accreta
- prev uterine surgery
- current placenta praevia
172
What are the risk factors for impacted fetal head?
- primiparous
- birth weight >4kg
- g.age > 37weeks
- prolonged 2nd stage
- 2nd stage c-section
- moulding
- junior obstetrician
- epidural
173
What are 3 obstetric and 3 anaesthetic manouvres that can be carried out when managing impacted fetal head?
obstetric from above
- reverse breech
- hysterotomy extension
obstetric from below
- vaginal push manoeuvre
- fetal pillow
Anaesthetic
- lower bed and head down
- tocolytic med (400mcg GTN SL, 250mcg terbutalline SC)
174
What are the changes in physiological coagulation during pregnancy?
Increase in:
- fibrinogen
- clotting factors VII, VIII, X + XII
- decrease in protein S and resistance to protein C (anticoagulants)
Decrease in:
platelets - largely dilutional gestational thrombocytopenia with increased consumption and turnover.
175
What are the main causes of PPH?
Uterine atony, trauma, primary coag disorder, acquired coag disorder, abnormal placentation
176
What are the constituents of cryo?
fibrinogen, VIII,XIII, VWF
177
Potential issue with FFP in PPH?
Can cause hypofibrinogenaemia due to conten of 2.5g/L and thrid trimester conc of 5g/L
178
What are the maternal consequences following pain during LSCS?
PTSD, not wanting to have another pregnancy, chronic surgical pain, postnatal depression
179
What are the RCOOA risk % of
spinal:
- conversion to GA
- additional analgesia
epidural:
- conversion to GA
- additional analgesia
Spinal conversion to GA - 2%
Spinal additional analgesia - 5%
Epidural conversion to GA - 5%
Epidural additional analgesia 15%
180
Risk factors for failed spinal/pain in c-section?
Patient:
- Low BMI
- substance use
Surgical:
- prolonged surgery
- urgency of surgery
- preterm
181
Risk factors for failed epidural/pain in c-section?
Patient:
- high BMI
- substance use
Surgical:
- prolonged surgery
- urgency of surgery
Anaesthetic:
- non-obstetric anaesthetist
- increased pain during labour
- more than 2 epidural top ups
182
Theoretical ED95 of 0.5% heavy bupivicaine in spinal for LSCS?
11.5mg / ~2.4ml
183
What are the 6 critical steps in prevention/management of intra-operative pain during LSCS?
Thorough consent
Optimisation of LA block with opioids and rigorous testing
Communications with patient and surgeon
Intraoperative pain management
Consideration of conversion to GA
Documentation and follow up
184
What 3 drugs should be consIdered if patient declines GA in LSCS?
Fentanyl - 25-50mcg
Alfentanil - 250 - 500mcg
Ketamine - 10mg
185
What techniques can be carried out for 'at risk' extubation as per DAS guidelines?
- Awake extuabtion
- Remifentanil extubation
- Laryngeal mask exchange
- Airway exchange catheter
If not safe:
- tracheostomy
- postpone extubation
186
What is the key difference between hypertensive urgency and emergency? and malignant hypertension?
Emergency has established HMOD = Hypertension mediated organ damage.
Malignant hypertension is when there is microvangiopathy - i.e hypertensive retinopathy/thrombotic angiopathy.
187
What BP do you need to be classified as severe HTN?
Sytolic > 180
Diastolic > 110
(or both)
188
What investigations need to be carried out in a patient with severe HTN or any of the emergencies?
ECG + Echo
CXR
CT aortogram
Fundoscopy
Urine dip and microscopy
Neuro exam +/- CT/MRI brain
Bloods:
FBC, U+Es
Trop, BNP
Bilrubin, LDH, Haptoglobin
Coombs test
189
'compelling conditions' (require reduction within 1 hour)
BP targets in first hour for:
- ACS
- acute aortic syndrome
- Pre-eclampsia/eclampsia/HELLP
- phaeochromocytoma crisis
- MH with encephalopathy
ACS - < 140
Acute aortic syndrome - <120
Pre-eclampsia et al - <140 (and diastolic less than 105)
Phaeochromocytoma - <140
MH - < 20-25% reduction in MAP
190
What endocrine abnormalities can be secondary cause of HTN?
- cushing syndrome
- hyperthyroidism
- hyperaldosteronism
- phaeo
191
What is odds and risk ratio?
When does an odds ratio indicate that there is no difference between groups?
Odds ratio is event/non-event
Risk ratio = risk of event occurring in exposed/risk of event occurring in unexposed
When the odds ratio is in and around 1
192
What does a funnel plot show?
Likelihood of publication bias
193
What are the difficulties with publication bias?
Publication bias
Language bias
Replication bias
Requirement of homogenous study groups
194
What is NNT?
Number needed to treat.
Amount of patients needed to treat to prevent 1 death.
195
What non-invasive pre-natal testing can be used to detect Down syndrome?
USS nuchal translucency
Maternal blood biomarkers and cell-free DNA
196
Most common cardiac abnormalities in T21?
AVSD
TOF
Combined AVSD and TOF
Single ASD or VSD
197
Airway manifestations of T21?
And potential other resp issues?
Micrognathia
Macroglossia
Mid face hypoplasia
Hypotonia/obstructive adenoids and OSA
Laryngomalacia
Sub-glottic stenosis
198
What is the main MSK abnormality T21 suffer from?
C1/2 atlanto-axial instability/subluxation. Laxity of transverse ligament.
199
What Cardiac (3), otolaryngology (2), General surgery (2), opthalmology (1) procedures would a child with T21 have?
AVSD repair
VSD repair
TOF repair
Grommets
Adenoid/tonsillectomy
MLB
Gastrostomy, duodenostomy
Strabismus
200
What endocrine abnormalities may a child with T21 most commonly suffer witih?6
Subclincal hypothyroid
Diabetes
201
What are the pre-operative considerations with someone with Trisomy 21
Psychiatric/behavioural/premedication input.
OSA assessment
Echo - especially if high clinical suspicion of PH
Smaller tube available
Anti-muscarinic available as prone to bradycardia
Consider PICU for moderate to high risk patients.
Questions regarding C1/2 symptoms - paraesthesia etc
202
What are the post-operative considerations in a patient with T21?
HFNO2/CPAP
Pain relief as may not be able to communicate pain
203
What consists of a low, very low and extremely low birth weight?
LBW 2.5kg
VLBW 1.5kg
LBW 1kg
204
Airway and respiratory issues of prematurity?
Easily obstructed airway - due to compliant soft-tissues, poorly coordianated muscle groups (pharyngeal) and congenital/acquired pathology - laryngomalacia, subglottic stenosis etc.
Weak and easily fatiguable muscles.
Immature lung function leading to stiff and non-compliant lungs - decreased surfactant, under developed alveoli and inelastic lung parenchyma that is prone to atelctasis and gas trapping
Dysregulated central control of respiration - blunted chemoreceptor response and biphasic response to hypoxia (hyperventilate -> apnoea and bradycardia)
205
Define apnoea, how can apnoea be classified, causes of apnoea (in premature infant)
Cessation of airflow for more than 20s or less with pallor/cyanosis/bradycardia.
Central or obstructive (or both)
Hypoxia
Hypothermia/hyperthermia
Neurohormonal response to surgery
Hypoglycaemia
Anaemia
Sedative drugs
Post-op pain
206
Cardiac consideration for premature infants?
- Fixed SV due to increase fibrous > contractile tissue.
- Increased ischaemia in over filled ventricle compromising coronary circulation
- decreased repsonse to endogenous catecholamines as adrenergic system working near 100%
- inotropy relies on exrtacellular calcium due to underdeveloped t-tubules and SR so normocalcaemia a priority
- awareness of PDA, A/VSD
207
Haematological/GI/Temp issues with pre-term infants?
Anaemia with inability to increase erythropoiesis
Predisposition to anaemia due to increase blood sampling, reduced red blood cell life span and iron depletion (growth and malnutirtion)
Vit-k and non vit k dependent clotting factors are low. Platelet counts low.
GI
- Hypoglycaemia due to minimal glycogen stores with limited ketogenesis/lipolysis
- Hyperglycaemia due to defective insulin secretion - a/w with IVH and NEC
- NEC - most common GI emergency
- GORD
Temp
- increase BSA, decrease brown fat and inability to be able to shiver = cold as fuck
208
Renal issues with pre-term
Decrease number of nephrons (60% formed in 3rd tri).
Increased TBW, decreased clearance and abnormal electrolyte handling (hyponatraemia) with acidosis.
209
Airway management in the premature (pointers)
- Neutral head positioning with shoulder roll
- may require glyco/atropine to attenuate vagal response to laryngoscopy
- uncuffed tube
- VL recommended
210
What happens to compliance and PVR at FRC?
Compliance at its greatest at FRC
PVR at its lowest
211
When would you get
a) normal A-a gradient and hypoxaemia
b) a low A-a gradient and hypoxaemia
Normal A-a gradient with low FiO2 and hypoventilation
Low A-a gradient due to shunt
212
What is shunt?
When blood from right heart reaches left heart without being oxygenated
213
What are the intrapulmonary (4), intracardiac (2) and physiological (2) causes of shunt?
Pneumonia
ARDS
Atelectasis
ASD/VSD with Eisenmengers
R->L with PFO
Thebesian veins
Bronchial veins
214
Name 6 causes of increased dead space in critical care
ARDS
PE
COPD
Increased and unaccounted for apparatus
Low CO
Increased alveolar pressure due to MV
215
What are the reasons for hypoxia (2) and hypercarbia (4) in a patient with COPD?
Hypercarbia: increased V/Q, decreased MV, decreased TV due to hyperinflation, hypoventialtion.
Hypoxia: hypoventialtion, low V/Q mismatch
216
How does cardiac output worsen hypoxaemia in a patient with a low V/Q mismatch (shunt)?
Decreased CO causes increased oxygen extraction and a decreased SvO2. Decreased oxygen content of venous admixture worsens returned bloods PaO2 and therefore increases shunt.
217
What are the 3 main benefits of proning?
Increased V/Q matching due to increased anterior perfusion. Improving oxygenation in patients with posterior atelectasis and or consolidation.
Decreased compressive effect of abdominal organs on lungs
Improved drainage of secretions
218
What nerve is effected in meralgia paraesthetica?
Lateral cutaneous nerve of the thigh
219
What is the incidence of meralgia paraesthetica?
4.8-32/100,000 (0.04-0.3%)
220
What patients are at an increased risk of developing meralgia paraesthetica?
Obese
Diabetic
Pregnant
Males
221
What are the 4 causes of meralgia paraesthetica and list at least 2 in each category
Idiopathic: Obesity, pregnancy, leg length discrepancy
Iatrogenic:
- Direct: IM injection, inguinal hernia repair
- Indirect: LSCS c-section, gynae/onc surgeries (lithotomy)
Metabolic: diabetes, alcoholism
222
Where type of nerve is LFCN and where does it arise from?
Sensory
Dorsal aspect of the lumbar ventral rami (L2-3)
223
3 types of treatment for meralgia paraesthetica?
Conservative: weight loss, avoid tight clothing, physio
USS injetion of LA and corticosteroid
Surgical - neurolysis/neurectomy
224
What cancers can be associaTumouted with increase pain in survivors?
Leukaemia, lymphoma, lung, breast and rectal
225
What are the 4 broad mechanisms (with a minimum of 3 e.g for each) that pain can occur in cancer survivors?
Tumour related
- mass effect
- paraneoplastic effect
- cancer induced bone pain
- ventral sensitisation
Treatment related
- chemo
- radio
- surgical
- immuno
Associated conditions
- hypercalcaemia
- osteoporosis
- prolonged immobility
Unrelated conditions
- chronic primary pain
- MSK conditions
226
How can tumours cause central sensitisaton and bone pain?
Metabolically active and secrete numerous chemicals sensitising nociceptors.
Primary Ca/secondary mets can cause bone pain, increasing osteoclast activity. Causes neuropathic and inflammatory bone pain.
227
What are the more common surgeries that result in chronic post-surgical pain?
Limb amputations, breast, thoracic.
228
How does radiotherapy cause pain? What can the pain be categorised as? 3 examples of each.
Induces tissue damage via inflammation and oxidative stress.
Acute and chronic radiation fibrosis syndrome.
Acute - oral mucositis, oesophagitis, proctitis
Chronic - oesophageal stricture, osteonecrosis of the jaw, peripheral neuropathy, lower GI stricture
229
What pain can chemotherapy cause? What are it's risk factors and what chemo causes it?
CIPN - chemotherapy induced neuropathic pain
RF: diabetes, smoking, renal failure, pre-existing neuropathy
Platinum compounds: Cisplatin
Vincra Alkaloids: Vinicristine
230
What do ESMO (European Society for Medical Oncology) recommend for mild, moderate, severe, breakthrough and neuropathic pain?
Mild - NSAID/paracetamol
Moderate - weak opioids (codeine etc) in combo with non-opioids
Severe - oral morphine first line, for rapid use IV opioid
Breakthrough - immediate release opioids
Neuropathic - gabapentanoid/TCA
231
What are the best anti-neuropathic pain medications in neuropathic cancer pain?
TCAD
SNRI (duloxetine)
Gabapentin
Pregablin
232
What are the 4 pre-operative interventions that can contribute to safe and effective management of pain in obese patients?
Evaluation - co-morbidities, RF for hyperalgesia/chronic pain
Education - patient education programmes, set realistic expectations
Engage - increasing level of activity
Empowerment - given tools that can measure functional status - 6 minute walk/PEFR
233
What analgesic is best for those with obesity (if possible state recommended dose)
Paracetamol (max 4g/day)
Ibuprofen (reduce LOS and overall opioid consumption)
Dexmedetomidine - 0.4-0/4mcg/kg/hr IDEAL BW. (Does not reduce resp depression/airway tone)
Lidocaine - 1-2mg/kg/hr LEAN BW. (Anti-inflammatory, antihyperalgesic and opioid sparing effect)
Ketamine (IDEAL body weight)
Adjunctive - Magnesium, dexamethasone.
234
What are the 3 anti-hyperalgesics?
Lidocaine, dexmedetomidine, ketamine
235
List 6 patient-relatedand 4 surgery-related risk factors for
postoperative pulmonary complications following non-cardiothoracic surgery.
Patient:
Age > 60
ASA > 2
COPD with evidence of disease on CXR
Smoking
Liver Disease
CCF
Surgical:
Prolonged surgery over 3 hours
Emergency surgery
Type of surgery: abdominal etc
236
List five reasons for which it may be acceptable to delay surgical fixation in a patient
presenting with a fractured neck of femur?
Hb < 80
Uncontrolled diabetes
Correctible tachyarrythmia with HR > 120
Reversible coagulopathy
Na <120 or >150
K <2.8 or >6.0
Chest sepsis
Acute heart failure
237
List four patient factors that increase the 30-day mortality risk in patients admitted with hip fracture.
Advancing age
Male sex
Institutional living pre-op
>2 or more active co-morbidities
Anaemia
Reduced cognitive function
238
State 5 blood test abnormalities that you might see on a paediatric patient with meningococcal septicaemia
Acidosis
Hypoglycaemia
Hypokalaemia
Hypocalcaemia
Hypomagnesaemia
Anaemia
Coagulopathy
239
A child with meningococcal septicaemia continues to be hypotensive despite resuscitation with intravenous fluids. State a
further 5 steps in your ongoing Rx?
Consider vasopressors - adrenaline or noradrenaline
Consider vasopressin if high dose catecholamine is required
Correct acidosis
Correct hypocalcaemia
Discussion with PICU
Consider shock dose hydrocortisone
240
Name a classification system for Placenta Accreta Spectrum (PAS) disorders (1 mark) and complete the following grades: (5 marks)
Name = ……International Federation of gynaecologists and obstetricians (FIGO)
i) Grade 1 = Often found post partum, villi adhere to myometrium (accreta) .
ii) Grade 2 = Deeper invasion of villi into myometrium .(Increta)
Grade 3 = percreta
iii) Grade 3a = Invasion into and contained by serosa
iv) Grade 3b = Invasion into bladder
v) Grade 3c = Invasion into structures beyond bladder
241
How do you measure Spinal Cord Perfusion Pressure (SCPP)
SCPP = MAP -CSFP
Aim for MAP > 80 and CSFP 10-15 during thoracoabdominal aorta work.
242
3 types of chemo. Class and drug eg.
Vinicristine - Vinca Alkaloid
Platinum compounds - Cisplatin
Methotrexate - Antimetabolite and antifolate.
243
What is the doppler effect?
Change in the perceived frequency of a sound wave when the sound wave is moving in relationship to the observer
244
Describe how an oesophageal doppler probe measures cardiac output?
Probe placed in oesophagus, so tip faces towards descending aorta at T5/6
Velocity of RBCs measured using doppler equation
Cross sectional area of aorta is assumed using algorithm based on patient age, mass, height.
Velocity-time integral gives stroke distance. CO product of stroke distance, aortic diameter and heart rate.
245
Limitations of ODM
Contraindicated in oesophageal pathology
Requires anaesthetised patient
Assumed values
- laminar flow in aorta
- cross sectional area
- parallel positioning
246
What is the mOsm/kg of Hartmann's, NaCl 0.9% and Nacl 0.18% with 4% glucose?
Hartmann's - 278
Nacl 0.9% - 308
NaCl 0.18%/4% glucose - 284
247
What is the Na/Cl and K+ content of Hartmann's, NaCl 0.9% and Nacl 0.18% with 4% glucose?
Hartmann's - 131,111,5
Nacl 0.9% - 154,154,0
NaCl 0.18%/4% glucose - 31,31,0
248
5 features of significant congenital heart disease
Failure to thrive
Frequent chest infection
Parents report cyanosis
Reduced exercise tolerance
Syndrome a/w CHD
FHx of CHD
249
What are features seen on an ECG in a patient with ASD?
Prolonged PR interval
RBBB
FRCA FINAL
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