1
Q
what is day case surgery
A
- Patient admitted for surgery and discharged on the same day
2
Q
what patient factors make them suitable for day case
A
Medical - optimised and stable co-morbidities not requiring major post operative care.
Social
- understands proceedure and post op requirments - analgesia and complications
- has an escort to drive home
- has a carer for first 24 hours at home
3
Q
what surgical factors make it suitable for day case
A
- surgery that allows E+D soon after surgery
- no major risks of post op complications
- no significant post op pain and analgesia requirements
4
Q
Describe the anaesthetic management for day case surgery
A
- spinal vs GA - spinal allows speedy recovery.
- good antiemetic cover
- good analgesia - short acting agents (NSAIDs and para) to avoid excess opioid use
- avoid techniques that prolong recovery e.g. femoral nerve block causes weakness
- routine IV fluids
- consultant led service
5
Q
What is required for discharging day case patients
A
- written and verbal post op instructions
- discharge letter to GP
- contact no. for hospital provided
- not able to sign legal documents or drive heavy machinery for 24 hours after GA
6
Q
is obesity or OSA a contraindication for day case
A
- no , patient specific
- may require longer monitoring in recovery
- avoid long acting opioids , pain needs to be managed without opioids before discharge
- CPAP at home
7
Q
List features of a local anaesthetic drug that make it ideal for use for day case spinal anaesthesia
A
quick onset of analgesia and motor - allowing quick time to operate
fast offset and recovery - predictable
minimal incidnece of adverse effects
8
Q
List benefits of spinal anaesthesia for day case surgery
A
- less risk of airway events
- less PONV
- better pain management post op and hence less need for opioids
- less delirium in eldery
- patient alert and can retain more information
- quicker recovery
9
Q
Advantage and disadvantage of unilateral spinal anaesthesia
A
pros = patient may prefer having sensation/motor control of one side, quicker return of urinary function, reduced incidence of hypotension
disadvantages= increased risk of wrong sided block, delays as patient has to lie on one side for 10 mins
10
Q
Give 2 drugs that can be used for spinal day case – state the dose and duration for surgical anaesthesia provided
A
2% prilocaine = 40mg - 2ml , lasts 90 mins
1% 2-chloroprocaine = 40mg , 4ml , lasts 60mins
ideal as short acting
11
Q
List factors that increase risk of PONV after spinal
A
high block and hypotension - increased risk if elderly, pre op dehydration, CVS disease
use of intrathecal opioids
failed block - anxiety and pain leading to vagal response, converting to GA or use of opioids
12
Q
List factors increasing risk of urinary retention after a spinal
A
Anaesthetic
* longer acting agents - bupivacaine
* intrathecal opioids
* ++ fluids and bladder distention
* anticholinergic use - glycopyrolate (e.g. if high spinal)
patient factors
* age
* pre existing voiding issues - BPH
surgical factors
* inguinal hernias, urological surgery, perianal surgery
13
Q
List patient risk factors for the development of vertebral canal haematoma
A
- Risk of bleeding:
o Anti-coagulants
o Liver disease
o Von Willebrand diseae - Difficult spinal
o Scoliosis
o Obesity - Other – age, female
14
Q
Acceptable INR, platelet and APTT for spinal for elective surgery
A
INR < 1.4
plts > 75 x 10 ^9 / l
APTT - normal 20-35seconds
15
Q
How long after removal of epidural catheter can treatment dose LMWH be restarted (and when to stop LMWH before placement)
A
before placing epidural
- stop treatment dose for 24 hrs
- stop prophylactic for 12 hrs
after removal can restart LMWH after..
- 4hours - prophylactic
- 6hrs treatment
16
Q
What surgeries can use robotic surgery?
A
urological - prostate
gynae and general
cardiothoracic
ortho - hips
17
Q
What is an example of a robot used in robotic surgery?
A
Da Vinci
18
Q
What are the advantages of robotic surgery
A
- less damage to tissues - reduced post op pain , less bleeding
- increased sterility - reduced post op infections
- better cosmotic
- quicker recovery and reduced hospital stay
compared to laparoscopic
- better dexterity - increased range of movement
- better visualisation - 3D imaging / depth perception
- better tactile sensory feedback
19
Q
What are the disadvantages of robotic surgery compared to laparoscopic
A
expensive
time consuming
requires training
patient movmeent can have serious consequences
can take time to undock in emergencies
20
Q
anaesthetic and surgical risks/ considerations of robotic surgery?
A
anaesthetic -
* less access
* steep trendelenberg/ pneumoperitoneum and physiological
* deep NMBA needed
* prolonged surgery - careful pressure area Mx, temp Mx and fluids
surgical
- vascular complications harder to manage
- bleeding can be insidious
- venous air embolus
21
Q
contraindications of robotic surgery?
A
- Mostly from positioning : Morbid obesity , severe IHD, severe RHF, significant respiratory disease, raised ICP
inexperienced surgeon / anaesthetist
22
Q
What are the effects of steep Trendelenburg & pneumoperitoneum
A
- A:
o Endobronchial intubation / accidental extubation
o Oedema and post op stridor /macroglossia and obstruction - leak test - B:
o Reduced FRC atelectasis, shunting, hypoxia
o Increased pressure barotrauma - C:
o Reduced preload and increased afterload – reduced CO
o RH strain from increased thoracic pressures , LH strain from afterload – ischaemia
o Vagal stimulation from pneumoperitoneum
o Air embolus - D:
o Orbital oedema - regular inspection
o Cerebral oedema / raised ICP – from less venous drainage and raised CO2 (vasodilation) - limit fluids
o Reduce CO can also precipitate strokes - E:
o Reflux / aspiration from high gastric pressures
o Reduced renal / splanchnic perfusion
o Compartment syndrome - Other
o Hypercapnia and respiratory acidosis from pneumoperitoneum
o Patient falling off
o oral ulceration from reflux of gastric content
23
Q
How is the robot set up and patient positioned?
A
- robot placed in between pts legs - lithotomy
- trendelenberg 30-45 degrees
- camera placed in umbilicus incision
24
Q
What are the causes of V:Q mismatch in robotic surgery
A
- pneumoperitoneum and reduced FRC / atelectasis and shunting
- low CO
- anaesthetic gases - loss of hypoxic vasoconstriction
25
What risks are there to positioning for robotic surgery and solutions that can be taken?
sliding off bed - non slip gel pad, straps
nerve injuries - good padding
pressure sores - good padding, regularly reposition
compartment sydnrome - level out intermitently, avoid intermittent compression boots/ stocking
cerebral oedema / facial oedema - minimise fluids, regularly inspect and level
26
What damage are the eyes at risk of in robotic surgery
- Oedema
- Increased pressure
- Chemical injury from gastric reflex
- abrasion as normal
27
What are the complications of reverse Trendelenburg ?
venous pooling - DVT
reduced venous return and hypotension - poor cerebral perfusion and post op cogntive dysfunction. other organ hypoperfusion
risk of VAE if surgery above the heart
28
What happens in the event of an emergency during robotic surgery
emergency undocking protocol followed
1. call for help/ alert team / buzzer
2. turn on lights
3. release trocars
4. undock robot
5. manaage - CPR/ laparotomy
emergency open laparotomy kit should be readily available in each theatre in case of emergency
29
What are trocars
sharp objects placed into the abdomen to allow gas insufflation and to pass tools into the abdomen in laparoscopic / robotic surgery
30
What are the potential complications of trocar insertion
tissue injruy - bowel, liver, bladder
vessel injury - arterial (immediately apparent), venous (insidious due to high pressure of abdomen may minimise initially)
31
what is a CO2 embolus?
rare complication of laparoscopic surgery whereby excess CO2 enters circulation and causes embolus effects.
can enter directly via injection of CO2 into vessels accidentally
OR via absorption from pneumoperitoneum
32
What are the clinical features of CO2 embolus
hypoxia, hypotension, tachycardia
raised CVP / pulmnary artery pressures
drop in EtCO2
cardiac arrest
paradoxical embolus and neurological effects
33
How is a CO2 embolus managed?
alert team / surgeon
100% O2
deflate abdomen
compress any sources of bleeding where CO2 entering
head down and left lateral tilt (durant manouvre) - places air bubble away from RV outflow tract
increase MV - remove CO2
supportive - vasopressors
34
List 2 reasons why CO2 gas is used for pneumoperitoneum in robotic surgery
doesnt support combustion with diathermy
relatively soluble and thus high risk of embolus syndrome
35
Complications of gas inflation of the peritoneum
air embolus syndrome
surgical / subcut emphysema
pneumoperitoneum physiological effects
36
List surgical and anaesthetic factors that contribute to the risk of developing compartment syndrome of the lower limbs during robotic surgery
position - lithotomy, intermittent compression devices / anti embolic stocking, steep trendelenberg
anaesthetic - hypotension, lack of fluids, need for vasopressors
surgical - long duration
37
List neurological complications related to positioning for robotic surgery
peripheral - common peroneal nerve (lithotomy) and brachial plexus (shoulder rolls)
central - orbital oedema and visual distrubance / potential blindness. cerebral oedema and delayed emergence / post op cognitive dysunction
38
Give advantages of laparoscopic surgery compared to open
- less bleeding
- less inflammation and post op pain, less opioids
- Reduced surgical stress response
- Reduced risk of surgical site infections
- Quicker healing – smaller wound / unlikely to get wound dehiscence , reduced hospital stay
- Less evaporative losses and risk of dehydration / electrolyte disturbance
- Reduced gut handling, therefore reduced ileus and quicker return to normal enteral feeding
- Cosmetic – smaller scar
39
List 2 risks specifically associated with laparoscopic surgery
- Damage to organs/ vessels from insertion of instruments
- Haemorrhage may be harder to control
- Accidental insufflation of vessels with CO2 – gas embolus
- Longer surgical procedure – requiring longer GA
- Excessive pneumoperitoneum
o Vagal response – brady/ asystole
o CVS collapse from reduced venous return / increase in SVR
o Reduced FRC
40
List patients co-morbidities which may contraindicate laparoscopic surgery
CVS instability
severe HF - where high SVR / low preload will cause decompensation
R to L shunt - high Pulmonary pressures will worsen shunt
raised ICP
retinal detachment
severe obesity
41
What surgery requires Trendelenburg and reverse Trendelenburg
- Upper GI = reverse Trendelenburg
- Lower GI = Trendelenburg
42
What determines if MAP is high or low in laparoscopic surgery
MAP = CO x SVR
increases SVR but lower CO
- Factors increasing BP
o Compression of aorta / increased SVR
o Sympathetic response to stretch of peritoneum
o Activation of RAAS from stress response
- Factors decreasing
o Compression of IVC and increased after load – reduces CO
o Worse if hypovolaemic
o Pneumoperitoneum – trigger vagal response and bradycardia – reduced CO
43
What happens if the intrabdominal pressure is 20mmHg or more
- Decrease in liver and kidney arterial and venous blood flow
- Drop of GFR
- Drop in gut mucosal blood flow
- Increased thoracic pressures
- Increased ICP
44
What pressures are normal in laparoscopic surgery
- 12-15mmHg
- >20 is avoided as this has unwanted affects on CVS, gut perfusion, ICP and intrathoracic pressure
45
What are the risk factors for a strong vagal response to laparoscopic surgery
- Young female patients
- Gynaecological / tension on pelvic organs
- Rapid CO2 inflation rate
46
how is vagal response to pneumoperitoneum managed?
- Stop surgeon / declare incident/ call for help / switch of CO2 inflation
- Give atropine 600ug IV
- If asystolic – chest compressions
47
What patients are at risk of complications from positioning
- Elderly and frail
- Low / high BMI
- Diabetes
- Arthritis
- osteoporosis
48
What are the surgical/ anaesthetic risks for harm from positioning
- Unusual position – prone, lateral, laparoscopic , steep Trendelenburg
- Long operation
- GA – unconscious and cant feedback
49
What is the mechanism for nerve injury from poor positioning
- Compression, ischaemia, direct trauma (cutting) , tension / stretch
- Neuropraxia = mild / temporary due to compression or stretch
- Axonotmesis = damage to axon but peri and epineurium in tact
- Neurotmesis = damage to all layers, rarely completely resolves
50
how can nerve injruy in anaesthesia be minimised?
- Padding
- Secure with straps/ non slip
- Tape eyes closed
- Awareness of risks associated with positions e.g. regular levelling out
51
What is well leg compartment syndrome
- Hypoperfusion of leg in surgery can result in ischaemia and rise in pressure
- From trendlenberg and pneumoperitoneum (low CO)
- More likely in longer surgery, larger muscle mass, obesity, PVD
- Can flatten table every few hours to avoid
52
How is cardiac arrest in prone position managed?
- Eliminate obvious cause e.g. release surgical stimulus, head down for venous air embolus
- Ensure Mayfield clamp is released
- Can do CPR in the prone position
- If CPR not effective, cover wound and position supine
53
What is the criteria for referral for bariatric surgery i.e. gastric sleeve surgery etc
- BMI >40 or >35 plus significant disease that could be improved by weight loss (HTN/diabetes)
- Weight loss not achieved through other methods
- Patient is general fit for surgery and commits to long term follow up
54
What is a Tier 3 obesity service
weight management programme
for those severe / complex obesity
that benefit from MDT support - physio, dietician, pscyh, surgeon , physician
can be used to prepare patients for surgery
55
options for bariatric surgery?
restrictive surgery - reduce size of stomach = sleeve gastrectomy OR adjustable gastric band
reduction in absorption capacity by reducing small bowel = Roux En Y gastric bypass.
56
what are the frequent complications of weight loss surgery?
short term - VTE, bleeding, anastomotic leak , wound infections
long term = strictures and obstruction, nutritional deficiencies, reflux
57
what are the precautions for surgery in those who have a gastric band
risk of reflux / aspiration
need ET tube and potentially RSI
58
What is the meaning of transgender?
- Transgender or gender diverse individual is a term that refers to people who identify with a gender which is different to that of their sex assigned at birth
- This could be the opposite gender or it could be a non-binary gender (not female or male)
- They may or may not have transitioned
59
What are the different potential methods of gender transition?
- Physical measures – chest binders
- Hormonal therapy
- Surgery
60
Outline the hormonal agents used for male to female transition and implications to anaesthesia/surgery
- Oestrogen supplements
o Oral / transdermal
o VTE risk. Risk of heating / compressing transdermal. Implication of suggamadex
- Anti-androgens
o Spironolactone – risk of AKI and hyperkalaemia – withhold periop
o Cyproterone – synthetic progesterone – liver failure risk
o Bicalutamide = CYP450 inhibitor – increases midazolam and warfarin
61
Outline the hormonal agents used for female to male transition and implications to anaesthesia/surgery
- Testosterone
o Increased OSA, weight gain, HTN
62
What types of surgery are available for male to female transition
- Breast augmentation
- Penectomy and vaginoplasty
- Voice surgery
o Cricothyroid approximation – tenses cricothyroid membrane
o Feminisation laryngoplasty – reduces diameter of larynx to raise pitch
- Mandible and chin reduction surgery
o Distorts anatomy , difficult airway
- Thyroid reduction surgery – distorts front of neck
63
What types of surgery are available for female to male transition
- Massectomy
- Vaginectomy + hysterectomy
- Implant prosthetic penis
- H&V
o Voice surgery – injection laryngoplasty
o Mandible implants
o Thyroid augmentation – rib grafted to thyroid
64
What considerations are there for transgender individuals in the obstetric setting
- They may find vaginal examination frustrating - use a chaperone
- They may be frustrated at the heteronormative set up of obstetric services
- Gender neutral language – chest feeding, front hole, birthing person
65
How does gender diversity affect pharmacokinetics
- TCI models should use gender assigned at birth
- May be inaccurate if transitioned with hormones / surgery
66
How does gender diversity affect blood results
- Creatinine / egfr measurements take into account gender
67
What is meant by the term free flap reconstruction?
- Autologous tissue from donor site is removed and attached to a distant recipient site where new microvascular anastomoses are made usually with a single artery and vein
- Unlike a graft, a flap maintains its own blood supply
68
What different types of flaps do you know?
- Local flap – tissue moved from an area very close to defect
o Rotational – tissue rotated around pivot point but remained attached to original site
o Pedicle flap – tissue left attached at donor site but transferred up (no rotation)
- Free flap
o Distant site and completely removed
69
What types of surgery might free flaps performed
- For wounds not suitable for primary / linear closure
- Commonly used in reconstructive surgery e.g.
o Trauma
o Malignancy – reconstruction post mastectomy or H&N cancers
o Facial reconstruction
70
What are the stages of free flap transfer
- Flap elevation and clamping of vessels
- Primary ischaemia as blood flow ceases and anaerobic metabolism
- Reperfusion at anastomoses
71
What pre op measures may improve flap survival ?
- Appropriate patient selection
o Contraindications include hypercoaguable states, sickle cell , polycythaemia
- Smoking cessation – at least 4 weeks before
o Improves nicotine induced vasoconstriction
o Carbon monoxide related hypoxia
o Hypercoagulable
- correct anaemias
- Weight loss if appropriate
72
What are the key overall aims when anaesthetising someone for free flap surgery?
- Minimise primary ischaemia of flap
o Mostly related to surgical time and technique
o Flaps not involving muscle tolerate a longer ischaemia time
- Optimise flap reperfusion and minimise secondary ischaemia
o Optimise perfusion (hagen poiseulle equation) – good arterial pressure, minimise venous pressure, optimise viscosity and prevent excess peripheral vasoconstriction (normothermia, analgesia etc)
pain management for donor site - consider regional
73
Describe methods for optimising perfusion of a free flap after anastomoses
- Variables of hagen Poiseuille equation
**- Arterial pressure**
o Adequate filling , avoid excessively deep anaesthesia, use of vasopressors with caution – want to get good BP but not get peripheral vasoconstriction
o Dobutamine preferred over norad = ionodilator rather than vasoconstriction
**- Minimise venous pressure**
o Avoid excessive fluids and oedema – CO monitoring for directed fluids
o Good depth/ muscle relaxation/ remi to avoid straining / coughing
o Head up, avoid excess PEEP, avoid tube ties
**- Optimise viscosity**
o Haematocrit 30-35% is optimum – balances viscosity with O2 carrying capacity
o Maintain normothermia
**- Avoid vasoconstriction / radius**
o Temp control, pain management (sympathetic), vasopressor use.
74
What are the post op measures that should be taken after free flap surgery?
- Identifying flap failure / secondary ischaemia early
- Clinical monitoring
o Flap colour
o Cap refil
o Skin turgor
o Skin temp
o Bleeding on pin prick
o Transcutaneous doppler
- If signs of failure – early return to theatre
75
Describe appearance of flap with impaired arterial supply and that of impaired venous drainage..
- Arterial supply = cool, pale, delayed cap refil, lack of bleeding on pin prick
- Venous = warm, purple/ blue, swollen, venous bleeding on pin prick
76
What are the causes of flap failure?
- Usually related to surgical cause / complication
- Insufficient arterial supply – vasospasm, thrombosis, defective anastomoses
- Insufficient venous drainage – oedema or defective anastomoses
- Reperfusion injury to flap – microvascular failure
- Infection
77
What causes flap oedema?
- Excess fluids
- Excess flap handling
- Prolonged primary ischaemia time and inflammation
78
Give 2 surgical causes of flap failure
- Excess handling – oedema
- Inadequate anastomoses
- Increased primary ischaemic time will lead to more reperfusion injury / inflammatory mediator release
- Poor asepsis and infection
79
List the pre op patient factors that may increase risk of flap failure
- Risk of infection
o Diabetes – poorly controlled
o Chemotherapy / immunosuppression
- Risk of thrombosis
o Coagulopathies
o Cancer
o Polycythaemia
- Reduced O2 supply
o Anaemia
o Smoker – vasoconstriction, tissue hypoxia , impaired oxygenation at lungs
- Poor healing
o Nutrition e.g. cancer patients
80
What are the analgesic considerations in free flap surgery ?
- The free flap is denervated and insensate and no direct sympathetic innervation
- Donor site can be painful – regional/ multimodel
- Pain management is important as sympathetic response – vasoconstriction and poor blood supply
81
Give an example of a pedicled flap donor site and free flap donor site used in reconstructive breast surgery..
free flaps
- TRAM = transverse rectus abdominis myocutaneous
- superior and inferior gluteal muscles
- transverse myocutaneous gracilis (TMG)
pedicle
- latissimus dorsi flap
82
What is an absolute contraindication for free flap transfer
Sickle cell and untreated polycythemia rubra vera – flap failure rate is high from microcirculatory ‘sludging’ and hypercoagulability
83
What ate the benefits of free flap reconstruction
- better wound healing and vascularisation
- less infection
- better cosmetic outcome
- better functional out come
compared to grafts
84
Give the equation that determines blood flow through vessels
85
What procedures require anaesthetic input in the cardiac cath lab
- Acute
o Airway protection after acute coronary syndrome
o Sedation for cardioversion for unstable arrhythmia
- Elective
o Cardioversion
o Ablation
o Inserting pacemakers / ICDs
86
What are the principles for ablation of arrhythmias
- Arrhythmias are often re-entrant in nature and travel through a critical point
- This can be identified by electrophysiological mapping
- Ablation cauterises the tissue at this point rendering it electrically inert
- E.g. radiofrequency ablation or cryo-ablation or laser balloon ablation
87
Which arrhythmias may respond to ablation?
- AF – usually arises from LA, paroxysmal responds well
- Atrial flutter – usually from RA
- AVNRT
- AV re-entry tachycardias e.g. WPW
- VT
88
How is ablation carried out for AF and what are the complications
- Ablation catheter into femoral vein – to RA and then across atrial septum to LA via foramen ovale
- Complications = perforation of atrium, perforation of aorta, cardiac tamponade
89
What are the anaesthetic options for ablation procedures? Pros/ cons
**- GA**
o Useful for prolonged procedure
o allows transoesophageal echo to assess rare complications
o less movement improves accuracy of mapping
**- Sedation with LA**
o Useful to avoid supressing arrhythmia and thus success can be identified
90
List advantages and disadvantages of providing anaesthesia in CCU rather than theatre
- Advantages
o No need to transfer unstable patient
o Minimises delays to treatment
o Close availability to cardiology specialist equipment, drugs , staff
o Don’t delay emergency list in theatres
- Disadvantages
o Remote anaesthesia – unfamiliar environment
o Potential lack of monitoring e.g. capnography
o Lack of access to full range of anaesthetic drugs and equipment
o Fewer skilled anaesthetic staff e.g. ODP / other anaesthetist – so less timely support in times of emergencies
o Less equipped recovery facilities
91
List patient factors that must be taken into consideration when choosing the anaesthetic technique for cardioversion
- Fasting status
- Presence of reflux
- Anticipated difficult airway / OSA
- Patient cooperation / preference
- Post cardioversion plans e.g. transferring elsewhere to cath lab for another procedure.
- Medical hx and allergy status
92
State anaesthetic complications that can occur as a consequence of cardioversions
- Aspiration
- Cardiovascular instability due to anaesthetic agents and arrhythmias
- loss of airway - hypoxia
- hypoventilation - hypercap / hypoxia
- laryngospasm
- Risk of awareness
93
State non-anaesthetic complications as a result of cardioversions
- Arterial embolization causing stroke
- Asystole / PEA/ VF
- Burns
- Electrical injury to staff
94
How does emergency and elective cardioversion differ in terms of an anaesthetic
- Emergency
o May be unstarved
o Unstable
o Remote hospital locations
95
List issues relevant to anaesthesia for ablation procedures that must be considered compared to cardioversion
- Lengthy procedure – care of pressure points , temp monitoring, may not tolerate sedation
- Use of radiography – staff protection , limited access to patient due to C arm
- Low light levels – difficulties in drug management and patient monitoring
- May require arterial line or transoesophageal echo
- needs pt to be very still for precision
96
What is ECT
- Electrical shock delivered to cerebral hemispheres to induce a grand mal convulsion for specific duration (15-120 seconds)
- Used in the treatment of psychiatric disorders such as severe depression
97
What are the Indications for ECT
- Severe medication resistant depression – especially associated with psychomotor retardation,
- Bipolar/ mania
- Catatonia
- psychosis and schizophrenia
98
How is ECT performed
- Electrodes placed on skull
- 30-45 joules of energy for 1-1.5 seconds
- The aim is to produce a tonic clonic seizure lasting between 15-120 seconds
- Repeat twice a wek for up to 12 treatments
99
Where can the electrodes be placed – pros and cons of each method
- Unilateral electrode placement
o Both electrodes on the non-dominant hemisphere
o minimises cognitive side effects
o Less clinically effective
- bilateral electrode placement
o Electrodes are placed on both sides
o Most effective for clinical improvement
100
What are the physiological consequences of ECT?
- Airway
o Risk of laryngospasm
o Increased salivation – parasympathetic
o Risk of aspiration - Increased gastric pressure and hence reflux
- Cardiovascular effects
o Initial parasympathetic discharge – bradycardia, occasional asystole
o Then followed by sympathetic discharge – tachycardia, HTN, sweating, lacrimation,
o increased myocardial O2 consumption and risk of ischaemia
o Risk of post procedure myocardial stunning with reduced ejection fraction – risk of heart failure
- Cerebral
o Increased cerebral O2 requirments
o Increased ICP
o Risk of haemorrhage
o Risk of TIA
o Risk of status epilepticus
o Reduced cognitive function after – memory loss, concentration, disorientation
- MSK
o Injuries
o Myalgia
101
List types of physical injury that can occur during ECT
- Dental damage – due to seizure plus bite block
- Intra oral damage – biting
- MSK – fractures
- Myalgia due to seizure or use of suxamethonium
102
CONTRAINDICATIONS TO ECT
- Raised ICP / space occupying lesion
- Recent stroke
- Unprotected cerebral aneurysm
- Recent MI within 3 months or unstable angina
- Uncontrolled HF
- Severe systemic HTN
- Unable spinal fracture or severe osteoporosis
103
Why are premedications not used for ECT
- Cant use benzos as the whole aim is to induce a seizure
104
List patient specific pre-operative considerations for ECT
- Psychiatric illness may make it difficult
o to conduct a proper pre op assessment
o unknown compliance to medications and fasting rules
o Capacity for consent – patient may be under section
- Anaesthetic assessment should include
o assessing significant reflux (as unlikely to tube)
o dentition as bite block is used
o rule out contraindication e.g. significant IHD or HF etc
- Check for ICD / pacemakers
o Deactivate ICD and pacemakers should set to fixed mode
- Remote site anaesthesia considerations
- Current medications
o lithium can exacerbate NMBA , MOAI – hypertensive crisis
105
How would you anaesthetise a patient for ECT
**PREPARE**
- IV access, AABGI , trained assistant , airway equipment available and emergency drugs and resuscitation equipment
- Atropine/ glyco incase of asystole (parasymp activation) and benzos for seizures > 2 mins
**- Induction**
o propofol
o Suxamethonium – relaxation to protect from MSK injury
- Bite guard introduced
**Other**
- O2 via facemask / ventilated to induce hypocapnia
o Hypocapnia reduces seizure threshold
106
What was the traditional anaesthetic agent used in ECT
- methohexitone – short duration and convulsant properties
107
What are the issues with consent in ECT
- MH condition can impair the patients capacity
- If the patient lacks capacity
o And is not detained under mental health act = mental capacity act is used and a patient representative is consulted (family member or independent mental capacity advocate )
o And is detained under the mental health act – formal independent second opinion must be arranged
108
List anaesthetic implications of lithium treatment…
- Potentiates NMBA
- Possible reduction in anaesthetic dose requirements - reduces MAC
- Renal excretion – NSAIDs reduce its elimination and can result in toxicity
- Risk of nephrogenic diabetes insipidus
- Narrow therapeutic index – risk of toxicity, check levels
- Risk of serotonin syndrome
- Omit for 24 hours prior to anaesthesia for major surgery
109
List anaesthetics implications of fluoxetine treatment
- inhibits CYP450 - codeine and tramadol
risk of bleeding with NSAIDs
risk of serotonin syndrome
110
State the field contour within which the MR environment is defined
- This is the area within which there is risk of projectile damage, heating and risk to implanted devices
- 5 Gauss
- A.k.a the 5 gauss line
111
State the SI unit for magnetic flux density
- Tesla
112
PROS and CONS of MRI imaging
Advantages of the MRI
- Non ionising
- Good for soft tissue
- High resolution
Disadvantages of an MRI
- Long scan duration
- Claustrophobic and noisy
- Large magnet can be dangerous and special monitoring equipment needed
- Expensive
113
Why may an anesthetized patient need to go to MRI
- Ventilated ICU patient
- During surgical proceedute e.g. neurosurgery
- Patients with movement disorders
- Uncooperative – children, learning disabilities , anxiety
114
What are the risks of taking an anaesthetised patient to MRI
- Remote anaesthesia
o Unfamiliar environment
o Lack of trained anaesthetic staff
o Special MR safe equipment
o Lack of access to patient
- Static magnetic field
o Projectiles of ferromagnetic material e.g. O2 cylinders
o Ferromagnetic objects in the eye e.g. shrapnel – may be disloged – vitrous haemorrhage
o Pacemakers inactivated / reprogrammed
- Induction of currents
- Acoustic noise – ear protection required
-
- Radiofrequency heating
o Burns through conductive material e.g. ECG leads / metal in clothing
- Helium escape
o Hypoxic environment
115
What is meant by the terms MR safe and MR conditional in relation to equipment used in MRI scanner room
- MR safe – devices that pose no MR related hazards to patients or staff when used according to instructions
- MR conditional – equipment that is safe to use in MR under specific conditions e.g. below certain magnetic field strength
- MR unsafe = hazardous in MR environment and can not be used
116
List precautions that should be taken to prevent burns caused by monitoring equipment in an MR scanner
- Use only MR safe equipment
- Check all equipment prior to use – i.e. still intact and no breach to insulating surfaces
- Fibreoptic cables for ECG leads and pulse oximetry = eliminate induced electrical current and burns to underlying skin
- Do no allow cables to cross each other as induction of current can result from capacitance coupling
- Ensure leads are positioned to exit scanner down the centre – minimies contact with radiofrequency coils
- Separate leads from patients’ skin with e.g. foam insulating
117
List other precautions you would take to minimise the risks associated with MRI
general:
- checklists
- questionaire for staff and patient
- remove ferromagnetic objects from pockets
- awareness of helium quenching in emergency
- ear protection
anaesthetic
- circuits adequate length
- secure airway - wont have access
- emergency drugs ready - anaphylaxis to contrast
118
When should gadolinium contrast be avoided
allergy
eGFR < 30
pregnancy
dont repeat within 7 days
119
contraindications to MRI scan
- aortic balloon pump / VAD
- neurostimulators
- recent clips / implants neurosurgically
- orthopaedic implants
- intrathecal drug delivery systems
- programmable shunts for hydrocephalus
- some ICD and pacemakers
120
examples of critical event in the MR scan
- Projection of ferromagnetic object – patient / staff may become injured/ trapped
- Patient deterioration / cardiac arrest
- In these events quenching may be necessary
121
define hypothermia?
body temp < 35 degrees
mild = 32 to 35
moderate 28- 32
severe < 28
122
List adverse systemic effects of hypothermia
- Respiratory
o Increased risk of pneumonia
o Apnoea below 24 degrees
o Shift in O2 dissociation curve to left
- CVS
o Arrhythmias
o Cardiac arrest
- Neuro
o Reduced cognition – slurred speech, confusion
GI + GU
o Reduced insulin release and high BMs
o Reduced motility – affects nutrition
o Diuresis and electrolyte disturbance
- Haematological
o Reduced platelets and function and clotting factor function – prone to bleeding
o Impaired immune function – risk of infection
o Increased viscosity - VTE
- Pharmacological
o Increases tissue solubility of volatile agents – slower recovery of GA / reduced MAC
o Reduces hoffman degradation
o Reduces hepatic metabolism and prolonged action of aminosteroids
123
List changes to standard ALS that is made when treating a patient with hypothermia in cardiac arrest
- rewarm ideally with extracorporeal life support as fast as possible
- Withhold adrenaline if temp < 30
- Increase administration of adrenaline to 6-10mins if core temp is 30-34
- If VF persists after 3 shocks, delay further shock until temp >30
124
What are the mechanisms for heat loss in theatre / methods to prevent
radiation - 40% - ambient temp
convection - 30% - laminar air flow
conduction - 5% - contact with cold e.g. fluids , forced air blanket can help
evapouration- 15% - minimally invasive surgery, HME
125
ECG changes seen with hypothermia...
increased PR
bradycardia
J waves after QRS
ventricular arrhythmias - VF when less than 28 degrees
126
clinical scenarios hypothermia occurs?
trauma - drowning, blood loss , burns
medical - hypothermia
General anaesthesia
127
how quickly should we rewarm patients
0.5 degrees / hr
unless in cardiac arrest
128
2 drugs than treat post op shivering
clonidine
pethidine
doxapram
(ensure pt is warm first)
129
What are the methods of rewarming
- Passive
o Dry / remove wet clothing
o Warm environment
o Blankets
- Active
o Forced air warmers
o Chemical heat pads
o Warm IV fluids
o Warmed humidified gases
130
Define heat stroke
medical emergency defined by
- temp > 40.6
- anhydrosis
- altered mental state
131
how is heat stroke classified?
classical - elderly in hot climate
exertional - young person excising in heat
132
clinical features of heat stroke?
CVS: tachycardia, hypotension (from vasodilation), arrhythmias
CNS - lethargy, headache, low GCS , seizures
GI/ GU
- AKI
- electrolytes - hypokalaemia (hyperventilaiton, catecholamines and sweating)
- N&V
Haem - DIC
MSK - rhabdomyolysis
133
how is heat stroke managed?
rapid cooling
aim < 38.9
methods - ice cold packs, cold IV fluids, cold air (artic sun), ECMO/haemodialysis with cold fluids
134
Describe how body temperature homeostasis is normally achieved
maintained between 36-37.5
**sensors** = temp receptors peripherally and centrally (spinal cord, brain, internal organs)
- Cold = A delta fibres, Hot C fibres = lateral spinothal
**control centre** - hypothalamus
anterior hypothalamus = responds to warm
posterior = responds to cold
**effectors**
- increase heat production - BMR, shivering, erector pili, brown fat thermogeneisis
- increase heat loss = vasodilation, sweating, behaviour
135
describe the changes to body temperature in threatre - from induction to maintainance
redistibution - vasodilation
linear phase - mechanisms of heat loss (radiation, convection etc)
plateau - homeostasis achieved
136
how does regional anaesthesia affect temperature
drop in temp due to
-sympathetic block - vasodilation and redistribution
- sensory block - cant feel cold
- motor block - lack of shivering
137
what are the risk factors for PONV
- Patient
o Females, anxiety, travel sickness, previous PONV
o NON SMOKER – biggest risk factor
- Anaesthetic
o N20, neostigmine, inhalation (TIVA protective)
- Surgical
o Middle ear, squint surgery, neurosurgery (posterior fossa), gynae and breast
138
What is the APFEL score
scoring for PONV in adults
- female
- previous PONV
- non smoker
- peri op opioids use
each gives 20% risk
139
List some anti-emetic strategies
TIVA
regional > GA
prophylaxis - dex & ondan
avoid N20
suggamadex > neostigmine
IV fluids / good hydration
minimise/ avoid opioids
140
How should antiemetics be given based on apfel
- 0 – no antiemetics
- Risk score 1 or 2 – give 2 antiemetics
- Risk score >2 – give 3 or 4 antiemetics
141
risks or complications of PONV
aspiration
electrolyte disturbance
dehydration
delayed discharge
increase ICP / ocular presssure
wound dehiscence
reduce patient satisfaction
142
non pharmacological methods to manage / prevent PONV
gum chewing / pepermint
acupunture
IV fluids
cold packs on head
143
Causes of delayed emergence after anaesthesia...
PHARM AND NON PHARM
**Pharmacological**
- Opioids, Benzodiapines , Ongoing anaesthetic effects – poor clearance / elderly etc
- Residual NMBA
- Central anticholingeric syndrome
- Serotonin syndrome
**non pharm**
- Neurological - Stroke / TIA, Seizure
- Metabolic
o Electrolyte disturbance - hyponatraemia
o Hypoglycaemia / hyperglycaemia (DKA)
o Hypothermia
o CO2 narcosis
o Severe hypothyroid
144
What may precipitate prolonged sedation from benzos ?
* pharmacogenetics - individuals response to metabolism
* Co administration with alfentanil - both use same CYP450 isoenzyme
* Using drugs that inhibit CYP450 e.g. fluconazole
* Synergistic effect with opioids
* age and increased effects for same dose
145
How do opioids cause delayed emergence ?
* sedative effect - opioid receptor
* increase respiratory centres CO2 threshold for increasing ventilation
* metabolities of morphine are still active
146
Which factors prolong NMBA
* lithium
* Magnesium
* Gentamicin / aminoglycosides
* Hypothermia - reduces breakdown + hoffman
* Genetic factors - sux apnoea
* Acquired causes of cholinesterase deficiency e.g liver failure , pregnancy
* Myasthenia gravis / Eaton lambert
147
What factors may contribute to hypoglycaemia
* accidental overdose of insulin in diabetes
* Alcoholic
* Starvation
- elderly / neonates
* Liver disease
148
List comorbidities associated with delayed emergence
neurological - dementia/ cognitive impairment , epilepsy , neuromuscular disorder - GBS etc
resp - OSA / obesity hypoventilation / COPD
metabolic - hypothyroidism, diabetes
renal / hepatic - impaired clearance CYP450 and cholinesterases, linked to metabolic disturbance (electrolytes, hypoglycaemia)
genetic - sux apnoea
149
Give reasons why elderly patients are at increased risk of delayed return to consciousness after GA
- Decline in CNS function increases sensitivity to anaesthetic and sedative drugs
-
- Increased fat proportion compared to muscle and other tissue and this acts as a sink for anaesthetic agents
-
- Impaired kidney / liver function with age
150
List reasons for delayed consciousness after GA for cardiac surgery with bypass
- Hypothermia and rapid rewarming
- Haemorrhagic stroke associated with anticoag
- Embolic stroke – thrombi from vessel manipulation, air from bypass circuit
- Ischaemic stroke due to inadequate MAP to maintain CPP
- Electrolyte and acid base disturbance
151
List the steps taken when a patient presents with delayed consciousness after GA
- Ensure full AABGI monitoring and ventilating
- Ensure anaesthetic agents are off and fully reversed NMBA = MAC / BIS / TOF
- Neurological assessment= GCS , Pupils
- Check temp and BMs
- Check ABG for acid base, electrolytes, O2 and CO2
- Review anaesthetic chart
- Consider naloxone / flumazenil / suggamadex
- CT head
152
What are the risks of continuing antiplatelet therapy in patients having neurosurgery / biopsies
- Intracranial bleed – limited access to control bleed if stereotactic, neuro deficit
- Extracranial bleed – e.g. femoral artery in intravascular procedures or upon entry into skull
- Haematoma and mass effects on brain
153
What are the risks of stopping DUAT in those with coronary stents
- Stent thrombosis
- MI / ischaemia
154
What approaches can be applied to reduce risk of stopping DUAT in those with coronary stents for other procedures
- onsite interventional radiologist incase of stent thrombosis
- bridge with short acting GPIIb / IIIa - tirofiban/ apciximab
- bridge with short acting P2Y12 - cangrelor
- continue aspirin in high risk pts
155
when are GPIIb/IIIa inhibitors used?
tirofiban / apciximab
short acting - half life 10 mins
used during stening process
156
what is coronary angioplasty and stenting?
- Coronary angioplasty is balloon dilation of a narrowed / occluded coronary artery
- coronary stent is a wire mesh tube that holds open the artery
o bare metal stent
o drug eluting stents – covered in anti proliferating agent
157
2 methods of coronary stent failure?
- in stent re stenosis
o proliferation and migration of the vascular smooth muscle cells through the lumen of the vessel forming neointima
- stent thrombosis
o at points of contact with vessel, local damage triggers coagulation
158
what are the differences between drug eluting and bare metal stents and their need for antiplatelets
- drug eluting stent = coated in antiproliferative material to prevent neointima growth
o less risk of re-stenosis and thrombosis
o however initially risk is higher for thrombosis
o antiplatelets for 12 months
- bare metal stents – overall long term higher risk of restenosis/ thrombosis
o DUAT = 1 month
- Take monotherapy life long for both
159
How do you manage surgery in patients with stents
- Post pone non urgent surgery – till 1 yr after stent insertion / 1 month for bare metal stent
- Other wise risk vs benefit
o Low risk bleeding surgery – continue DUAT
o High risk e.g. neuro – proceed with single antiplatelet (aspirin), bridge with short actings (tirofiban) but stop clopidogrel 7 days before.
o Emergency surgery – platelet transfusion and TXA
- Therefore overall consider
o Type of stent
o Time stent was put in place
o Urgency of surgery
o Risk of bleeding
o Risk of thrombosis
160
State the minimum time period of DAPT following PCI with DES before aspirin alone can be given when proceeding with urgent non cardiac surgery
- One month (ideally 1 year)
- If patient at high risk of stent thrombosis then may indicate waiting 6 months
- The approach to managing drug eluting stents is now very individualised
161
List 4 patient factors that have been found to increase risk of bleeding in DUAT
age, previous spontaneous bleed, low Hb/ leucocytosis , reduced creatinine clearance
162
Which score is used to individualise length of DAPT therapy to assess someones bleeding risk
PRECISE - DAPT score
163
Which patient factors increase risk of thrombosis following PCI with Drug eluting stents
smoking
diabetes
previous MI
previous PCI prior to this stent
congestive HF / EF < 30%
164
Which types of surgery should aspirin as well as other antiplatelets be stopped due to high risk
neurosurgical - brain / spine
opthalmic
vascular reconstructions
165
List antiplatelets and their mechanism
166
How can perioperative risk be assessed?
- risk scores / risk prediciton models
- functional capacity assessment - CPET / 6 min walk
- general assessment of comorbidities
167
give examples of risk scores
goldman cardiac risk index
lees revised cardiac risk index
ASA score
168
What is the ASA grade
- American society of anaesthesiologists
- Simple and familiar tool to assess patients perioperative risk / comorbid status
- ASA 1 = healthy
- ASA 2 = mild systemic comorbidity , well managed
- ASA 3 = severe systemic disease
- ASA 4 = severe systemic disease, constant threat to life
- ASA 5 = moribund patient not expected to survive without the operation
- ASA 6 = brainstem death for organ donation
169
What is Lee’s revised cardiac risk index
risk scoring tool to predict risk of major cardiac event
simplified from goldmans
6 variables = hx of IHD, CCF, CKD, CVD, Insulin diabetes and high surgical risk
0 points = class 1 = 4 %
1 point = class 2 = 6%
2 points class 3= 10%
3 points = class 4 = 15%
170
pros and cons of lees revised cardiac risk index
pros - cheap, simple , quick , non invasive
cons -underestimates some groups e.g. elderly
171
what is the goldman cardiac risk index score?
- Uses 9 weighted variables to give a score out of 53.
- 25 points = 50% risk of cardiac event.
172
What is a risk prediction model
a model to predict % M&M based on real data sets and algorithms
173
what is P-POSSUM
portsmoth physiological and operative severity score for the enumeration of M&M
- Applicable for emergency and elective surgery in major general, urological and vascular ops
- Includes both patient and operative variables
- Estimates a 30 day M&M
174
what are the disadvantages of the P-POSSUM score?
prediction of intra op findings
overestimation sometimes
contains subjective elements
175
what is the NELA score?
- National emergency laparotomy audit
- uses the NELA risk assessment rool – based on NELA data set
- Estimates a 30 day mortality for patients undergoing laparotomies based on multicentre data
176
key standards of NELA
- CT scan reported prior to surgery if required
- Abx given within 1 hr if septic
- Risk of death documented before surgery
- Arrive to theatre in appropriate time
- High risk patients ( > 5 %) – consultant anaesthetics, post op ITU
177
What operations / patients are excluded from NELA data
- Oesophagus, appendix , gall bladder surgery
- Gynaecological pathology
- Trauma
- Patient and family request
178
What are the disadvantages of NELA
- Doesn’t estimate morbidity
- Requires estimation of intra op findings
179
What is the SORT score
- Surgical outcome risk tool
- 30 day mortality predicted by 6 variables
180
What is the NCEPOD classification
national confidential enquiry of patient outcome and death
categories surgery on urgency
181
What are the classes in NCEPOD
1. Immediate – life, limb or organ saving intervention. ASAP . E.g. AAA
2. Urgent – potentially life threatening acute onset condition. May threaten survival of limb/ organ. Within hours E.g. laparotomy for perforation , testicular torsion
3. Expedited - early treatment but no immediate threat to life/ limb/ organ E.g. tendon repair
4. Elective – planned or booked in advance to routine hospital admission E.g hernia repair
182
What is required for consent to be valid
- Provide patient with enough information for decision to be made - informed
- Information must include – type of procedure and why, risks and consequences , alternatives
- Patient must have capacity and act voluntarily
- has not verbally / written withdrawn
183
What qualifies as having capacity
- Understands information
- Retains info long enough
- weighs up pros and cons
- able to communicate decision
184
what does the mental capacity act 2005 state
- capacity is decision specific
- assumed to have capacity unless proven otherwise
185
if there is lack of capacity , what other methods of decision making should be used?
- any advanced directive?
- Lasting power of attorney
- Otherwise best interests – involve family/friends/ independent mental capacity advocate
186
What is meant by the use of restraint for those who lack capacity
- Restraint can be used in an individuals best interest to administer medical treatment or protect them from harm
- Restraint may be physical or pharmacological
- Should be proportional to the seriousness of that harm
187
what is DoLs?
- Deprivation of liberty = being under continuous supervision and control and not free to leave
- Soon to be replaced by liberty protection safeguards
188
What are the 6 principles of safeguarding proposed by Care Act 2014
accroynm = EPPPPA
empowerment - support in making their own decision/ involvement
Prevention = prevent harm and neglect
protection = protect + support those at risk
proportionality = use least intrusive measure propotional to risk
partnership = MDT + family involvement
Accountability = clear responsibilities and roles
189
How much O2 needed for transfer
- Litres of O2 required = 2x (MV + bias flow ) x duration of transfer in minutes
- Bias flow = that required to drive ventilator
190
How much volume in a cylinder
- CD = 460L
- Large size G = 3400L
- Larger size H = 6900L
- UK ambulances carry 2x size F = each hold 1360L
191
What is clinical governance
clinical framework whereby healthcare organisations are accountable for continually improving care and standards of health service
192
What are the pillars of clinical governance
- Education and training
- Clinical audit
- Clinical effectiveness
- Staff management
- Patient and public involvement
- Risk management
- Information management
193
What is the difference between significant incident and near miss and never event
- Significant incident = event that requires investigation involving death or serious injury
- Near miss = an event that if not for luck / skilful management would have lead to harm
- Never event = serious and largely preventable patient safety incident
194
How do intermittent pneumatic compression devices work?
- Inflate 10x / min
- To 35mmHg
- Mimics muscle pump and prevents stasis
- Also promotes fibrinolysis
195
Contraindications to anti-embolic stockings
- PVD
- Cellulitis
- Burns
- Severe peripheral neuropathy
196
NICE guidelines r.e. thermoregulation in thratre
measure temp every 30 mins
> 500ml of fluid - use warmer
- cant anaesthetise if < 36 degrees
197
define sedation
- Use of medication to depress the CNS to give a reduced level of consciousness to relieve anxiety and pain
- whilst maintaining the airway, spontaneous ventilation and haemodynamic stability
- To facilitate diagnostic or therapeutic procedure
198
What is the American society of anaesthesiologist (ASA) continuum of sedation
- Classification of level of sedation based on the need for airway or respiratory interventions needed, CVS stability and response to voice / pain
**- Minimal sedation / anxiolysis**
o No impairment in airway reflexes, ventilation and CVS
o There is normal response to verbal stimulus. But patient feels relaxed
**- Moderate conscious sedation**
o airway reflexes are intact and respiratory drive is reduced but adequate.
o CVS maintained.
o Response to light tactile stimulus. Sleepy
**- Deep sedation –**
o may require some airway / ventilation intervention, CVS usually maintained
o response is to painful stimulus
**- GA**= requires airway and ventilation support and may be haemodynamically unable. No response to pain/ voice
199
What monitoring is required for procedural sedation
- AABGI – including capnography
200
What are the complications of sedation
- Airway – loss, aspiration
- Breathing – hypoventilation – hypercapnia, hypoxia
- Circulation – hypotension
- Other – allergies
201
What drugs are available for sedation
- Propofol TCI
- Remifentanil TCI
- Ketamine
- Midazolam – IV or oral
- Dexmedetomidine
- Remimazolam
- N20
202
What is remimazolam and its benefits
- New ultra short acting benzodiazepine
- Fast onset – 1 to 3 mins
- Rapid metabolism by plasma esterases – rapid offset - good for short day case procedures
- Not dependant on organ metabolism – good for comorbid
203
Give some pharmodynamic / kinetic properties of ketamine that are advantageous for conscious
preserves airway reflexes
preserves respiratory drive
provides analgesia too
CVS stable
good for asthma / bronchospasm
204
What are the pharmacokinetic proprieties of N20 that are useful as a conscious sedative
quick onset and short acting - titratable to stimulating periods
patient can have control
analgesia too
full recovery - can drive home
no cannula needed
205
Pros and cons of propofol as a sedative agent
pros - familiar, antiemetic, sedation and anxiolysis
cons - loss of airway reflexes, CVS instability, resp drive
206
What are the pros and cons of dexmedetomidine as a sedative agent
pros - titratable, preserves resp drive, analgesia, shorter half life and wears off quicker than clonidine
cons - less familiar , no TCI model
207
How is dexmedetomine given fro sedation
- Loading dose = 1ug/kg
- Infusion = 0.5 ug/kg/min
208
when is dexmedetomidine contraindicated?
hypotension
known allergy
2nd/ 3rd degree HB
209
Pros and cons of remifentanil
pros - TCI model, rapid on/ offset , analgesia + sedation, non organ dep metabolism , short context sensitive half life
cons - hypotension, brady, apnoea , PONV
210
What are the guidelines around fasting for sedation
- International consensus states that clinically significant aspiration during sedation is negliable
- Risks of fasting out weight risks of aspiration
- Avoid unnecessary fasting
- Assess each case individually
o High risk – OSA / difficult airway / severe systemic disease , bowel obstruction/ hiatus hernia – risk of needing airway interventions is high = normal fasting guidelines
211
How are patients prepared for safe discharge after sedation
- Need an escort unless N20 used
- Clear instructions on when safe to drive
212
What did NAP 7 find with regards to sedation
- Sedation has less complications than general across both elective and emergency procedures
- Including airway and haemodynamic complications
- Requires more vigilance but overall actually better outcomes for patient
213
Give some sedation scoring sustems
Richmond agitation sedation scale (RAS)
modified ramsey sedation scale
ASA continuum of sedation
214
Routes for conscious sedation for children
oral - midazolam, clonidine, ketamine
IV - as above, propofol , dexmedetomidine
intranasal - midazolam, diamorph, dexmedetomidine
buccal - midazolam
inhalation - N20
IM - ketamine
215
Contraindications to sedation
pt refusal
allergy to sedative drug
airway - aspiration risk, difficult airway
OSA
apnoea in kids
216
What does the medical royal colleges recommends the organisation provides for safe sedation?
training
agreed protocols
robust audit system
217
During a procedure, child become anxious, how do you manage
- Stop procedure temporarily
- Reassurance
- Administer further sedation with caution
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
