1
Q
features of liver anatomy / physiology that make it ameanable to resection?
A
segmental and each segment has its own blood supply.
can remove segments without affecting others
has ability to regenerate through hyperplasia
2
Q
importance of pre op assessment in hepatic resection
A
likely frail - anaemia of chronic disease, hepatic failure, immune defiecency from cancer/ treatment, deconditioned from recent op.
optimisation reduces risk of post hepatic liver failure
3
Q
List the pre op clinical features that increase risk of post hepatectomy liver failure after HCC resection
A
age > 65
high ASA
cirrhosis / high child pugh
obesity
diabetes
malnutrition
(planning to resect a larger segment of liver)
4
Q
how much liver should remain after resection to reduce risk of post hepatic liver failure?
A
leaving < 20 % is contraindicated and between 20-30 % is associated with high risk
if cirrhotic then leave more
Minimum safe FLR: 20% (normal liver), 30–40% (steatohepatitis or chemo-injury), ≥50% (cirrhosis).
5
Q
reasons for liver resection
A
main one is metastasis from colorectal Ca
also HCC, choliangiocarcinoma, hepatic trauma or donation
6
Q
scoring pre op in liver resections
A
MELD
Child Pugh
7
Q
how would you prepare someone pre op for liver resection surgery
A
Standard + airway
Scoring systems
optimise glycaemic control and weight loss - reduces risk of PHLF
optimise cardiovascular issues - ECHO / Pulmonary function / CPET
recent chemo / radiotherapy - screen for related issues
complications of liver disease - coagulopathy, jaundice - optimise
need for ascitic drain first
Assessment of functional liver reserve after resection - scanning
8
Q
role of neoadjuvant chemo in liver resection
A
shrink tumour size and aid improve resection. improve overall survival
however complications associated with chemo - e.g. cardiomyopathy, arrhtyhmias. Resection usually delayed for 4-6 weeks after chemo finished
9
Q
What additional investigations and monitoring are required for patients having liver resections
A
- Arterial line
- Point of care testing – ROTEM
- Blood product – X match
- Potential CVP monitoring
10
Q
what interventional methods can be used pre op to reduce post hepatectomy liver failure?
A
portal vein ligation - the portal vein segments supplying the liver that is to be resected is embolised pre op causing blood to divert to functional liver and cause hypertrophy of this .
11
Q
What analgesia is recommended in hepatic resection surgery
A
multimodal - simple , thoracic epidural, intrathecal morphine , continous infeusion catheters.
minimise opioids - liver metabolism
thoracic epidurals are less favoured now due to hypotension and reduced mobility post op
12
Q
how can the risk of bleeding intraop in liver resection be minimised
A
bleeding depends on inflow through hepatic artery and portal vein and outflow through hepatic vein.
the inflow can be controlled by pringle manouvre (intermittent clamping of hepatic artery and portal vein) - can cause haemodynamic instability - communication between anaesthetst and surgeon
hepatic vein drains directly to IVC so cannot be occluded
Keep CVP < 5cmH20
surgical instruments used that minimise bleeding
topical haemostatic agents
TXA
ROTEM and clotting products
13
Q
how is CVP kept below 5cmH20 in liver resections?
A
- minimial PEEP, fluid restriction, vasodilators , diurects, remifentanil infusions, reverse trendelenberg, GTN IV
risk of hypovolaemia and CVS instability and renal hypoperfusion
14
Q
What pharmacodynamic/ kinetic considerations are there for patients having liver resections
A
- Absorption – alterations in first pass metabolism
- Distribution – changes to Vd with ascites, changes to plasma protein binding
- Metabolism – reduced CY450 / liver function
- Drug dosing may need altering
15
Q
State 2 pharmacokinetic changes to midazolam in patient with chronic liver failure
A
- Reduced plasma protein – higher proportion of unbound drug
- Reduced hepatic metabolism
16
Q
what are the indication for pancreatic resection?
A
- Cancer – adenocarcinoma, neuroendocrine (insulinoma), metastatic
- Pancreatitis – resection of necrotic lesion
- Trauma
17
Q
What types of pancreatic resection are there?
A
whipples = pancreaticoduodenectomy - head of pancreas tumours
distal pancreatectomy = tumours of body / tail
18
Q
What risk factors are often associated with patients having pancreatic resection
A
- May have had neo-adjuvant chemo and side effects
- May have pancreatic insufficiency – diabetes
- Usually in a lot of pain – difficult analgesia
19
Q
What palliative procedures are available for pancreatic tumours
A
- Biliary stents
- Coeliac plexus blocks
- Duodenal stents
20
Q
what is a TIPS proceedure?
A
- Transjugular intrahepatic portosystemic shunt
- Endovascular procedure via IJV – connects portal vein and hepatic vein using a stent
- Blood can flow from portal to systemic resistance = To reduce portal pressure
21
Q
What are the concerns regarding sedation for TIPS procedure
A
- Risk of exacerbation of hepatic encephalopathy
- Risk of reflux – high gastric pressures from ascites
- Risk of desaturation – hypoventilation and quicker desats due to low FRC / impaired pulmonary function.
- Prolonged procedure – may not tolerate – pain and anxiety
22
Q
What are the intra operative complications of TIPS procedure
A
- Endovascular complications – pneumothorax, brachial plexus injury, carotid puncture
- Arrhythmias from passing catheter to RA
- Massive haemorrhage – portal vein / hepatic artery
23
Q
What are the complications after TIPS?
A
- Encephalopathy occurs more commonly after tips because toxins bypass liver
- Precipitation of HF – increases preload
- Sepsis
- Stent occlusion/ thrombosis
24
Q
What are the treatments for raised portal pressure?
A
- Fluid and salt restriction
- Treat complications
o Drain pleural/ ascitic fluid
o Band varices - TIPS = transjugular intrahepatic portosystemic shunt
25
What is a living donor nephrectomy
- Kidney is taken from living donor for transplantation
26
categories of living donors in the UK
- Directed = donor and recipient know eachother e.g. close family
- Paired = 2 potential families want to donate, incompatible with their own relative so match with others in the same situation
- Altruistic = not known to eachother
27
How are living donors assessed pre op
- Standard pre op
- Specifics
o Psychological assessment
o Ensure fully informed consent and risks understood
o Medical assessment of risks to them during surgery and post op
28
What factors increase risk to donors when transplanting kidneys
- Age
- Co-morbidities
- Obesity
- Right sided nephrectomy required – more challenging
- Refuse blood products
29
How are patients pre-assessed prior to receiving a cadaveric renal transplant
- Standard pre op
- Specific comorbidities to look at
o End stage renal failure
o Diabetes
o HTN
o Polycystic kidneys
- Dialysis status – type and frequency, fistulas
- Ix – bloods, ECG, CXR
30
What are the general risks for renal transplant surgery
- Recipient likely to be comorbid with ESRF
- Out of hours with little time to optimise
31
What 3 indications are there for dialysis prior to cadaveric transplantation
AEIOU
32
List aspects of dialysis that should be ascertained prior to surgery
- Type and frequency of dialysis
- Site of lines / fistulas – protect intra op
- Acid base and electrolyte status
- Volume status
- Recent heparin use
33
State periop transfusion threshold for renal transplant
- 70 g/l
34
List the specific concerns in renal transplant patients regarding blood transfusion
- Risk of hyperkalaemia
- Risk of overload
- Risk of hyper viscosity affecting perfusion to the graft
- Risk of alloimmunisation complicating graft compatibility
- Risk of CMV infection due to immunosuppressed state
35
What are the intra op aims during renal transplant
- Perfusion of transplanted graft
o Ensure MAP >90 – fluids and vasopressors
o Good anastomoses required – paralysis will help with this
- Immunosuppression
o Reduces cellular rejection
o Methylpred plus biologic agent administered post induction
- Avoid intra op complications of renal failure
o Correct hyperkalaemia
o Avoid suxamethonium
o Caution with renal excreted drugs – roc, morphine
36
What monitoring is required for renal transplant surgery
- AABGI
- Arterial line (only if dialysis site not affected)
- CVP
37
what is the use of mannitol in renal transplant surgery
diuretic
mops up free radicals
38
What is the importance of careful fluid management in renal transplant
- Maintaining graft perfusion
o Good BP / CO
o Avoid hyperviscosity
- Avoid overload
39
What considerations are there for aterial cannulation in renal transplant patients
- Do not perform in same limb as fistula
- If performed in another limb, may damage artery for future fistula
- However better monitoring for perfusion of graft and regularly take VBG for electrolyte monitoring
- Risk vs benefit
40
What is rituximab? and side effects
- Monoclonal Ab to B cells CD20 – immunosuppression used for transplants
allergy / anaphylaxis, cytokine release syndrome, angioedema , fever
41
What are the principles of post op care after transplant surgery?
- HDU / ITU
- Multimodel analgesia –
o PCA with oxycodone/ fentanyl, renal dosing
o TAP block
o local anaesthetic wound catheter
o Regular paracetamol
- Careful fluid balance – guided by CVC / MAP
42
How is delayed graft function due to acute tubular necrosis avoided?
- Minimise warm ischaemia time =
o time between cutting off blood supply of donor to cooling
o connecting to new blood supply – avoid delays in anastomosis
- Minimise cold ischaemic time
- Optimise recipient factors – hypotension/ hypoperfusion, nephrotoxic drugs, good anastomoses, immunosuppression.
43
What intra operative strategies of recipient can improve graft function
- MAP > 90mmHg
- Immunosupressants at induction
- Avoid nephrotoxins
- Avoid hypovolaemia – good fluid balance, consider CVC and CO monitoring
44
What are pheochromocytomas?
- Catecholamine secreting neuroendocrine tumours - enterochromaffin cells
- Normally arise from adrenal medulla and secrete NA and to a lesser extent dopamine
- Mostly benign, some can be malignant with spread to the liver.
- Some are hereditary
- Some are bilateral
45
who are pheochromocytomas most common in?
30-50 yrs
M= W
46
What pattern of inheritance are hereditary pheochromocytomas
MEN sydnrome = multiple endocrine neoplastic
auto dom
also linked to neurofibromatosis
47
What is a paraganglionoma
- Neuroendocrine catecholamine secreting tumour found outside of the adrenals
48
characteristic features of pheochromocytomas?
sweating, headaches, tachycardia/ palpitations, HTN
intermittent in nature
other - weight loss, anxiety, nausea
49
What biochemical investigations can confirm presence of pheochromocytoma
- **Plasma free metanephrines** = most sensitive
o Plasma metanephrine and normetanephrine (breakdown products) – present event between attacks
- **24 hour urinary catecholamines**
o Epinephrine, norepinephrine and VMA
50
What radiological investigations can confirm pheochromocytomas
CT / MRI / PET
51
What are the pre operative objectives for pheochromocytomas
- B control – alpha blockade and then B blockade
- Correction of volume depletion – encourage salt and water
- HR and rhythm control
- Electrolyte and glycaemic control
52
How would you assess adequacy of CVS optimisation pre op
- Blood pressure – normotension < 130/80
- Absence of postural drop
- Normal ST segments
- Absence of tachyarrhythmias
53
What drugs are commonly used for pheochromocytomas pre op
- Alpha blockade
o Phenoxybenzamine, (phentolamine - emergency) , doxazocin (selective)
- B blockade
o Atenolol, propranolol
54
How does phenoxybenzamine and phentolamine compare
- Both non selective alpha blockers
- Phenoxybenzamine irreversible = is longer acting and good for pre op BP management
- Phentolamine reversible = is shorter acting and good for HTN crisis
55
When is phenoxybenzamine started in pheo’s
- 1-2 weeks pre op
- Stopped 48hrs before op to prevent intra op hypotension
56
What is the importance of starting B blockers after alpha blockers
- If B blockers started before SVR managed may result in cardiac failure as heart is less able to contract against high afterload.
Plus risk of HTN crisis as B blockers block some vasodilation
57
What is catecholamine resistant hypotension and why does it occur
- Hypotension that does not respond to catecholamines
- Due to use of pre op alpha blockers – blocking receptors
- Also down regulation of receptors from chronically elevated catecholamines
58
Name a drug that can be used to treat catecholamine resistant hypotension during surgery to remove pheochromocytoma and state its mechanism
- Vasopressin
- Vasoconstriction via V1 receptors and increased water retention at collecting duct via V2
59
Perioperative considerations
intra op catecholamine release
- good opioid cover at induction /laryngscopy
- avoid sympathomimetic drugs - ket/ ephedrine
- minimise tumour handling
- anti HTN - increase anaesthetic, phentolamine , MgSO4, sodium nitroprusside, esmolol / labetolol
hypotension after tumour removed
- may be resistant to catecholamines - vasopressin
intra op monitoring - CVC and arterial line
post op
- hypoglycaemia risk
- risk of hypoadrenalism - immediate steroids if both adrenals removed.
60
What is MEN syndrome
multiple endocrine neoplasia
autosomal dominant
MEN 1 = parathyroid, pancreas, pituirary
MEN 2 = pheo, parathyroid, medullary thyroid
61
what is carcinoid ?
clinical presentation caused by release of vasoactive mediators from neuroendocrine tumours e.g. serotonin or histamine
flushing, diarrhoea, hypotension, RHF
62
does carcinoid syndrome always present in pts with carcinoid tumours
- No, only 10%
- Because mostly in the gut and the vasoactive mediators are cleared by first pass metabolism
- Carcinoid syndrome occurs if there is metastasis
63
what is carcinoid crisis?
severe resp / CVS changes
hypotension, tachycardia and bronchospasm
can be precipitated by anaesthetic / surgical factors
64
what are carcinoid tumours?
enterochromaffin cell tumours - neuroendocrine
release vasoactive mediators - serotonin, histamine, VIP, sub P
2/3 GI tract, some respiratory
65
what are the symptoms of carcinoid tumours?
- Carcinoid syndrome – flushing, diarrhoea, RHF / hypotension
- Tumour itself – obstruction, respiratory compromise
66
Why do patients with carcinoid get RHF
- Fibrous thickening of endocardium and tricuspid / pulmonary disease
67
How are carcinoid tumours diagnosed
serum chromogranin A
urinary 5HIAA
CT contrast
isotope scanning - labelled octreotide
68
How are patients with carcinoid tumours optimised pre operatively (specific to this)
Octreotide - to minimise hormone release, 2 weeks prior to surgery and infusion at induction
CVS work up - ECHO for RHF, tricuspid and pulmonary valve disease
symptomatic treatment - bronchodilators, electrolytes, HF management, loperamide
69
what is octreotide ?
somatostatin analogue - binds somatostatin receptors
- inhibits hormone secretion – VIP, serotonin and others
70
how is intra op carcinoid crisis managed and avoided
IV octreotide
avoid other drugs that release histamine - morph/ atracurium
invasive BP monitoring
71
how long is octreotide continued post op
7-10 days, slow wean
72
what is an oesophagectomy?
complex surgical proceedure removing oesophagus and mobilsing stomach into chest to make anastomoses
significant M&M
73
Pre op considerations for oesophagectomy
likley to be co-morbid - malignancy, reflux, neoadjuvant chemo, malnutrition
poor functional capacity and major op = CPET testing?
ITU post op planning
74
Perioperative management for oesophagectomy
AIRWAY
* reflux risk / rsi
* double lumen tube / OLV
CVS:
* risk of arrhtyhmias and haem instability - arterial line and CVC
* blood loss - X match
pain/ other
* thoracic epidural
* NGT under surgical guidance past the anastomoses
post op
* ITU
* chest physio
75
what are the surgical approaches to oesophagectomy?
transhiatal approach - via laparotomy (for lower tumours)
ivor lewis = lapartomy + right thoracotomy
Mckeown = laparotomy + right thoracotomy + cervical anastomoses
minimally invasive - thoracoscopic / laparoscopic
76
what are the complications of oesophagectomy
early - arrhythmias, anastomotic leak, recurrent laryngeal nerve injury, pneumonia
late - strictures, reflux, dumping syndrome
77
What are the issues with patients with transplants
immunocompromised - risk of infection, other side effects of these drugs
altered physiology - e.g. heart denervated
the pathological process still present
78
How is the physiology of transplanted heart different
- Denervation
o Loss of resting parasympathetic tone – HR sits at around 90bpm
o Poor tolerance to hypovolaemia
o Altered pharmacology – need to use direct acting drugs e.g. adrenaline and beta blockers. Atropine / ephedrine wont have any effect
79
Why does coronary artery disease develop in transplanted hearts
- Graft vs host – inflammation
- Normal risk factors
- Angina may not be felt due to denervation and thus not treated
- immunosupression drugs cause HTN
80
What are the anaesthetic considerations for transplanted lungs
lack of innervation - reduced cough and mucosal sensation so increased secretions and pnuemonias
hypoxic vasoconstriction is intrinsic
avoid injury to tracheal anastomosis during intubation
81
What are the implications of immunosuppression for transplant recipients
tacrolimus and ciclosporin = calcineurin inhibitors
immunosup, HTN, renal toxic .
tac = diabetes
steroids - dose needs doubling
strict asepsis due to overall immunosupression
82
How is a cystectomy performed?
- Bladder removed
- Further urinary tract modifications –
o neobladder
o via ileal conduit -ureters into small bowl
- can be open, laparoscopic or robotic
83
what are the metabolic disturbances following ileal conduit
- hyperchloremic metabolic acidosis with normal anion gap due to absorption of secreted ions
o chloride in exchange for bicarbonate
o sodium secreted in bowel in exchange for H+
- often need to take bicarbonate supplements
84
What is TURP syndrome?
Iatrogenic syndrome caused by excess absorption of hypotonic irrigation fluid into the circulation increased intravascular volume and acute hyponatraemia/ hypo-osmolarity
85
What are the clinical features of TURP
- Hyponatraemia and hypo-osmolarity cause neurological complication
- Raised ICP and cerebral oedema
o Burning sensation to hands/ face
o Headache, visual disturbance, N&V
o Confusion, restless
o Seizure and coma
- Respiratory – pulmonary oedema
o Dyspnoea, hypoxia
- CVS
o Congestive HF, arrhythmias
86
What is the most common irrigation fluid used in the UK
glycine 1.5%
osmolarity 220
87
why is glycine used for TURP
non conductive, transparent so good visibility and non-haemolytic when absorbed
88
Non conductive fluid is not as essential as previously – how come and what is the advantage
- Now use bipolar resectoscopes / diathermy
- So isotonic fluids can be used
- TURP syndrome is less common with isotonic solutions
89
Describe the pathophysiology of TURP syndrome
- Hypotonic fluid used for irrigation
- Water leaves via osmosis into systemic circulation
- Glycine also passes into systemic circulation and is metabolised to ammonia and water
o Further dilution
o Glycine acts as an inhibitory NT – toxic – causes headaches, transient blindness and myocardial depression
o Glycine potentiates NMDA – seizures and encephalopathy
90
What are the properties of an ideal irrigation fluid
- Inert
- Transparent
- Non-conductive
- Non haemolytic
91
What are the intra op signs and symptoms of TURP
- Respiratory = hypoxia , high pressures (pulmonary oedema)
- CVS = arrhythmias, HTN initially and then hypotension with CHF
- Neurological = may not be obvious intra op
92
How is TURP syndrome managed
- Stop the procedure
- Stop IV fluids
- Support airway breathing and circulation
- Diuretics – furosemide 40mg only if acute pulmonary oedema
- Treat seizures & Magnesium – to stabilise seizures / arrhythmias
- Severe hyponatraemia = hypertonic saline
- Correct slowly
93
Give an advantage and disadvantage of treating TURP with furosemide
- Removal of free water in event of pulmonary oedema
- Worsens hyponatraemia
94
Give 2 complications of rapid correction of hyponatraemia
- Central pontine myelinolysis – CN involvement (dysarthria/ dysphagia), locked in syndrome, spastic quadriparesis (water leaves and shrinks neurons causing demyelination)
- Hypervolaemia
- Oedema and seizures – if over corrected
95
Give 2 ECG features of hyponatraemia
- Broad QRS complex
- T inversion
96
What are the anaesthetic options – pros and cons – for TURP procedure
- Spinal and awake
o Early detection of TURP
o Quick recovery
o Good post op analgesia
o No need for airway instrumentation and complications
o However patient discomfort from lying flat/ lithotomy
o Not suitable if movement disorder / cough
- GA
o Less anxiety / more comfortable
o Less movement
o Cant detect TURP
o Airway complications
97
What spinal block is required for TURP
- T10
- Bladder sympathetic fibres go as high as T11
98
How is TURP prevented
- Spinal anaesthesia – early detection
- Limit resection time to < 1 h
- Keep hydrostatic pressures of irrigation fluid below certain level
- Don’t use hypotonic IV fluids
- Treat intra op hypotension with vasopressors rather than fluid
99
Give 5 reasons why patient ovarian cancer is an increased risk of DVT
malignancy - proinflammatory / procoagulant effect
immobility - venous stasis unwell from chemo/ previous surgery
chemotherapy - endothelial inflammation / dysfunction
N&V - dehydration
presence of long term CVC
presence of pelvic mass inhibiting venous return
100
Give benefits of using neuraxial techniques for patient having a laparotomy for ovarian cancer
reduces opioids and side effects + good for cancer progression
better post op pain + mobilisation - reduces pneumonia and DVT
less stress response to surgery
101
What are the complications of hyperthermic intraperitoneal chemotherapy
hyperthermia
electrolyte disturbance
AKI
coagulopathy
hyperglycaemia
haemodynamic instability
102
List components of ERAS for reducing surgical site infections after gynae surgery
- Chlorhexidine based skin preps
- Prophylactic antibiotics
- Avoid hypothermia
- Avoid hyperglycaemia
- Avoid unnecessary drains
103
What are the benefits of TIVA in gynae cancer surgery
- Anti emetic – higher risk in cancer, females, gynae surgery
- Found to reduce incidence of cancer recurrence
- Short acting opioids good for recovery / side effects post op
104
What anaesthetic considerations are there in patients with gynae cancer
- Ascites
o physiological effects e.g. aspiration risk, reduced FRC
o pharmacokinetics of NMBA
o Pre op drainage?
- Coagulopathy
o From malignancy / liver dysfunction
o Correction?
- Toxic effects of chemo
o especially cardiac and renal and bone marrow suppression
o U&E, FBC, ECHO , ECG
- Increased VTE risk
o Due to cancer, immobility from surgery, chemotherapy inflames vessels
- N&V risk
o extra antiemetic, TIVA
- Malnutrition
o from cancer/ chemo – dietician involvement pre and post op
- Post op planning ITU bed
- Pain management
o epidural / rectus sheath / multimodel
o PCA oxy/fentanyl may be more appropriate if renal failure.
o Involve acute pain team
105
types of lymphoma
hodgekins
non hodgekins - more common
106
how do cancers of lymphatic system present?
lymphadenopathy , splenomegaly, hepatomegaly
B symptoms - weight loss, low grade fever, night sweats, fatigue
mass effects
107
How are lymphomas staged?
- I = single lymph node
- II = 2 or more lymph nodes, same side of diaphragm
- III = lymph nodes on both sides of diaphragm
- IV = disseminated involvement e.g. spleen
- Plus add A or B – B if B symptoms present
108
Give possible airway concerns in a patient with stage 4B Hodgkins requiring an open splenectomy
- **Lymphadenopathy** compressing airway
o Oropharyngeal or cervical lymphadenopathy – difficult laryngoscopy / obstruction
o Tracheal compression from mediastinal lymphadenotathy
- **Fibrosis of soft tissues around airway from previous radiotherapy**
o Neck stiffness – difficult position
o Reduced mouth opening
- **Mucositis from chemotherapy**
o Bleeding an oedema
109
What are the symptoms of airway obstruction from mediastinal mass?
- Positional dyspnoea – orthopnoea
- Stridor
- Cough
- Low sats
110
Give possible Respiratory concerns in a patient with stage 4B Hodgkins requiring an open splenectomy
- Mediastinal mass/ Lymphadenopathy – compression and atelectasis or bronchial compression = hypoxia / shunting
- Radiation pneumonitis and fibrosis from cancer/ chemo/radio – restrictive lung disease
- Increased risk of infection – immunocompromised
increased O2 consumptions from hypermetabolic state
111
How should you manage oxygenation in those on bleomycin
- Bleomycin toxicity – fibrosis – target sats 88-92%
112
Give possible CVS concerns of patients with Hodgkin’s lymphoma
- **Chemo induced cardiotoxicity**– cardiomyopathy, HF. Myocarditis, pericarditis, arrhythmias
- **Radiation induced heart damage** – cardiomyopathy, valve dysfunction , pericarditis
- **Compression of vessels by tumour** e.g. mediastinal lymphadenopathy – reduced pre load / CO
- **Difficult IV access** due to multiple previous and exposure to chemo
113
What are the signs of SVC compression by mediastinal mass
- Distended neck veins , upper limb swelling, facial swelling
- Cough, dyspnoea
- Pemberton sign – elevate arm above head – facial flushing, cyanosis and dyspnoea
114
What are the principles (pre op, intra op) of anaesthesia in patients with mediastinal mass?
**- pre op**
o CT/ MRI - establish anatomy in relation to airways and SVC
o Echo
o High dose steroids if tumour is large
**- Intra op**
o maintain spontaneous ventilation - the positive pressure may precipitate airway / SVC compression.
o Awake extubation
115
How do you manage airway obstruction secondary to mediastinal mass after induction
- Call for help
- 100% O2
- Position in lateral position
- Use IPPV + PEEP
- Rigid bronchoscope may be needed to identify level of obstruction
116
How could you manage CVS compression/ compromise due to mediastinal mass in anaesthesia
- Adequate filling – IV fluids
- Reduce anaesthetic depth
- Reposition patient
- Sternotomy to elevate mass
117
Symptoms and signs relating to a mediastinal mass that suggest significant periop risk
- Orthopnoea - Patients present with symptoms that are positional
- Cough when supine
- Stridor
- Wheeze
- Syncopal symptoms
118
Findings on imaging in those with mediastinal mass that are predictive of significant perioperative risk
- Reduction in tracheal cross sectional area
- Carinal or bronchial compression
- Great vessel compression
- Pericardial effusion
119
Possible causes of anterior mediastinal mass in children
- Lymphoma
- ALL
- Vascular malformations
- Non – haematological malignancy
120
Approaches to reduce the size of the mediastinal mass to improve safety of the anaesthetic
- Steroids
- Pre op chest radiotherapy
?neoadjuvant chemo
121
What are the haematological concerns pre op in hodgkins lymphoma?
- Anaemia – chemo / radio / cancer
- Thrombocyptopenia
- Immunosuppressed – low WCC
- Difficulties with cross matching – previous transfusions
- Need for irradiated blood
122
What are the renal concerns pre op in hodgkins lymphoma?
- Infiltration of tumour into kidneys – nephrotic syndrome / CKD
- AKI/ CKD from chemo / radiotherapy
123
How would you manage post op analgesia after splenectomy from Hodgkins disease
- Oral – paracetamol regular, NSAIDs may be contraindicated if renal disease / bleeding risk
- Renal dose of morphine may be needed
- Neuraxial – contraindicated if clotting
- PCA – fentanyl and oxy in renal disease
rectus sheath / tap block
124
Vaccinations required after splenectomy
influenza - yearly
covid
pneumococcal - 5 yrly
meningitis B, ACWY
125
What is the optimum timing of vaccinations in those having splenectomy
2 weeks before proceedure atleast
126
indications for splenectomy ?
sickle cell - hypersplenism, sequestration crisis
trauma and bleeding
infarction
lymphomas
ITP
splenomegaly - portal HTN / EBV
127
How does a splenectomy help in immune thrombocytopenic purpura
- Stops splenic destruction of platelets If they are not responding to medical management
128
What are the perioperative considerations in someone with ITP having a splenectomy
thrombocytopenic - no neuraxials, transfusion only AFTER spleen repmoved, platelet count can be improved with steroids
likely on steroids - cover
anaemia ? from bleeding - transfusion
129
State 3 immunological functions of the spleen in adults
- Storage of white blood cells e.g. T cells and B cells waiting for activation
- Antigen presentation to lymphocytes and activation of adaptive immunity
- Macrophages to remove antibody coated stuff from blood stream
130
What are the indications for conservative management of traumatic spleen rupture
- Retaining spleen for immunological function
- Avoiding major surgery and risks
131
How would you decide on surgical or conservative management of traumatic spleen injury
- Haemodynamic stability
- Grade of injury on CT
- Need for laparotomy for other injuries
132
Who is splenic artery aneurysm rupture most common in
obstetric - T3
more common in multigravida
133
what is the most common reason for emergency laparotomy?
- Intestinal obstruction – 50%
- Then perforation
134
outline conduct of anaesthesia for an emergency laparotomy...
**- Pre op assessment**
o Risk stratification – Hx, Examination, NELA
o MDT – surgeon, anaesthetist, ITU
o Optimisation as best possible – Abx, resuscitation, electrolyte and Hb correction
o Family discussions
**- Induction**
o RSI – NGT + suctioning before
o Arterial line
**maintainance**
fluids - evapourative losses, catheter, VBGs
normothermia
**extubation**
o Suitability depends on respiratory function/ oxygenation and acid base status and vasopressor requirements
aspirate NGT
135
Which laparotomy patients need post op critical care
NELA > 5%
requiring vasopressors
abnormal acid / base
high O2 requirment / ventilation need
136
How would you manage post op analgesia after laparotomy
multi model - paracetamol, morphine PCA
Rectus sheath catheter / TAP block
ketamine / clonidine
137
what equiptment is needed for an RSI
- AABGI monitoring
- Tipping trolley
- Suction
- Drugs ready including emergency drugs
- Airway equipment prepared – have bouje and 2 size tubes ready + Emergency airway equipment
- Trained assistant
138
What is the RSI procedure
- Optimise position and have everything prepared
- Pre -oxygenate ETO2 > 0.9
- Drugs – fentanyl , propofol/ ketamine, roc / sux
- Cricoid 10N --> 30 N
139
drug doses in RSI
propofol 1-2mg/kg - based on pt
roc 1-1.2mg /kg
sux 1.5mg/kg
fentanyl 1-2 ug/kg
140
What are the indications of an RSI
- Non fasted – emergency
- Reflux – hiatus hernia, obstetrics > 16 weeks, gastroparesis (diabetes, GLP1), trauma
141
complications of RSI
aspiration
CVS instability
awareness
142
scoring stools
Glasgow Blatchford score - clinical and lab data - urea, Hb, BP, HR, comorb (cardiac disease) and other.
rockall score - pre and post endoscopic data
143
what are parameters for rockall score?
- Age, BP, comorbidity
- Diagnosis – on endoscopy – e.g. malignant is worst prognosis
- Evidence of current / recent bleeding during endoscopy
144
How urgently does endoscopy need to be performed for UGIB?
within 2 hours if unstable/ still bleeding
145
anaesthetic plan for endoscopy for UGIB
pre op - blood , x match 4 units + FFP
RSI - ketamine, roc, fent . 2 suctions
arterial line
vasopressors ready
BIS - reduce anaesthetic
146
How are variceal bleeds managed
A to E , blood transfusion, terlipressin
Endoscopy - within 2 hours if bleeding
* adrenaline injection
* banding
* thermal / sclerotherapy
if cant be controlled
- Sengstaken blakemore tube - held in the fundus to tamponade bleed - keep in for 48hrs
- TIPS - transjugular intrahepatic portosystemic shunt
antibiotics e.g ceftriaxone = gram neg (and gram positive cover)
147
causes of non-variceal bleeds
ulcer, tumour, mallory weiss tear
148
management options for non-variceal bleeds
adrenaline injection
clipping
cauterisation
PPI
149
what is terlipressin
synthetic vasopressin - causes sphlanchnic vasoconstriction
reduces portal blood flow and hence drops portal blood pressure
150
what is porphyria?
rare group of inherited disorders of haem biosynthesis
deficiency in enzymes results in build up of porphyrins which are neurotoxic
auto dom
151
clases of porphyria?
acute
- acute intermittent porphyria - most common
-5ALA dehydrate deficiency
chronic
- porphyria cutanea tarda
152
Describe haem synthesis and the link to porphyria
- Glycine and succinylCoA ALA (via ALA synthase)
- Then to porphobilinogen (ALA dehydrate)
- Then to uroporphyrinogen (PDG deaminase)
- Eventually to haem
- in porphyria may have deficiency in ALA dehydrate or PDG deaminase
153
What factors can precipitate acute porphyria attack?
starvation
stress
alcohol binge
certain drugs - etomidate, ketamine, alcohol, rifampicin
menstruation
154
What are the clinical features of acute porphyria
4 Ps =
Painful abdomen - abdo pain, nausea and vomitting
Polyneuropathy - weakness and parasthesia
psychological - confusion, seizures, pyschosis, coma
port strained urine
autonomic too
155
How is an acute porphyria attack diagnosed?
urinary porphobilinogen = protect from light
plasma ALA and porphobilinogen levels
156
how is acute porphyria managed and prevented?
prevent
- avoid drugs triggering
- routine IV glucose
treat
- support
- IV glucose
- Haem arginate via CVC (protect from light)
157
how does haem arginate work?
blocks production of ALA by topping up supply of haem
158
drugs that precipitate porphyria?
ketamine, thio, etomidate
clarithromycin and rifampicin
dexmedetomidine
alcohol
159
what are the periop concerns for nissens fundoplication?
- High risk of reflux – RSI / ET tube , pre op antiacid / PPI
- Pneumoperitoneum with associated complications
- Reverse Trendelenburg + associated complications – slipping off, venous pooling and DVT
160
For laparoscopic appendectomy what positioning is used and what are the risks
- Usually trendelenberg positon with a right lateral tilt
- Risk of falling – secure with straps
- Padding of pressure point
- Prolonged trendelenberg
o Risk of cerebral oedema – post op delirium
o Upper airway oedema – post op stridor
o ET migration
o Reduced FRC / V:Q
o Leg compartment syndrome
161
What are the common reasons for liver transplant?
- Cirrhosis and liver failure
o Alcoholic liver disease
o Non alcoholic fatty liver disease
o Autoimmune
o Viral hepatisis
- Hepatocellular carcinoma
- Acute liver failure
o Drug induced – paracetamol OD
o Viral
162
What are the anaesthetic considerations in liver transplant surgery
- Risk of haemorrhage – X match, cell salvage, correct coagulopathy , ROTEM
- Painful – thoracic epidural may be contraindicated in coagulopathy
163
Post op complications following liver transplant
**- Early**
o Bleeding
o Graft failure
o Portal vein thrombosis
o Hepatic artery thrombosis
o Sepsis
o AKI
**- Late**
o Immunosuppressant related
o Graft refection
o Recurrent disease
164
Describe the graphics of a ROTEM / TEG and each value given and what it represents
- R time = reaction time - how long it takes clot to form, based on clotting factors = FFP
- K time = how quickly it forms i.e. time taken to certain clot thickness = based on fibrinogen
- Alpha angle = represents speed = fibrinogen
- Maximum amplitude = strength of clot = platelets and fibrinogen
- LY30 = lysis 30 = how stable it is – the max amplitude at 30 mins after MA. E.g. low in hyperfibrinolysis (DIC, trauma, fibrinolytic therapy) = TXA
165
What are the causes of oesophageal perforation?
* iatrogenic - bouje, OGD
* Boerhaave syndrome
* Oesophageal foreign body- battery
* Tumour
* Chemical ingestion
166
Clinical features of oesophageal perforation
* chest pain
* Vomiting / retching
* Dysphagia
* SIRS response
* Surgical emphysema- neck and chest
167
Management of oesophageal perforation:
* A-E / resuscitation
* Broad spec Abx
* NBM , parenteral nutrition
* PPI
* May need surgery if non contained leak
FINAL
flashcards
Decks in class (20)
# Cards
-
final SOE - last 2 weeks1012
-
High yield747
-
OBSTETRICS351
-
CRITICAL INCIDENCE139
-
ITU486
-
NEUROLOGY350
-
CRQ / MCQs201
-
OPTHALMIC ANAESTHESIA87
-
physics118
-
ANATOMY & REGIONAL437
-
PAEDS308
-
PERIOPERATIVE MED367
-
MISC & OTHER217
-
CARDIO389
-
Airway / H&N278
-
NAP studies64
-
general167
-
trauma186
-
THORACIC SURGERY and OLV76
-
Vascular68
