1
Q
What is aortic sclerosis?
A
2
Q
History features for Aortic Stenosis?
A
- Chest pain/Angina, Dyspnoea, Syncope
- decreased exercise tolerance due to inability of heart to adeqautely increase SV to meet metabolic demands
- rheumatic fever
- risk factors similar to those of IHD (htn, ^cholesterol)
3
Q
Exam features for Aortic Stenosis
A
Pulse: plateau or anacrotic pulse or pulse may be late peaking and of small volume
Palpation: displaced hyperdynamic apex beat, thrill over aortic area
Auscultation
- narrowly split or reveresed S2 becasue of delayed LV ejection
- Mid-systoli ejection murmur maximal over aortic area + extending to carotids
- murmur loudest with patient sitting up in full expiration
4
Q
Ix for aortic stenosis
A
ECG: LVH + strain
CXR: normal until LV begins to fail, may see calcified aortic annulus or prominent ascending aorta from post-stenotic aortic dialtion
Echo: trileaflet vs. bileaflet aortic valve, thickening and calcification of aortic valve, decreased mobility of aortic valve leaflets, LV hypertrophy and LV systolic or diastolic dysfunction, measurement of AVA + transvalvular pressure gradients
Cardiac Cath: may be necessary when severity cannot be determined by echo
5
Q
How is the severity of aortic stenosis assessed
A
- symptoms do not correlate well with stenosis severity, patients with severe disease can be asymptomatic
- symptoms and average time to death post onset:
> exertional angina = 5 yrs
> exertional syncope = 3 yrs
> exertional dyspnoea = 2 years - signs indicating severe AS:
> thrill in aortic area
> LV failure (very late sign)
> paradoxical splitting of S2
> late peaking murmur
> presence of S4 - Echo
AVA cm2:
> 1.5= mild
1.0-1.5= Mod
<1.0 = severe
iAVA
<0.6 = severe
Mean gradient(mmHg)
<25 =mild
25-40 =mod
>40= Severe
Jet Velocity (m/s);
mild= <3
mod= 3-4
Sev= >4
Exercise stress testing
- not suitable for symptomatic patients, may be used to evaluate asymptomatic patients, hypotension or failure to increase BP with exercise = poor prognostic finding
6
Q
Stages of Aortic Stenosis
A
A: at risk of AS
B: Progressive AS
C1: Asymptomatic Severe AS
C2: Asymptomatic Severe AS with LV dysfunction
D1: Symptomatic Severe high gradient AS
D2: Symptomatic Severe low-flow/low-gradient AS with reduced LVEF
D3: Symptomatic severe low-gradietn AS with normal LVEF or paradoxical low-flow severe AS
7
Q
What is the avg rate of haemodynamic progression in pts diagnosed with AS
A
8
Q
Treatment of Aortic stenosis
A
- No medical treatment will improve or halt progression
-> avoidance of strenuous activity in severe AS
-> sodium restriction if heart failure present
-> gentle diuresis for volume overload as preload dependent
-> control hypertension but avoid vasodilators
->maintain sinus rhythm - Symptomatic patients require surgery because there is a 50% mortality rate at 2 years with medical therapy alone
-> Aortic Valve replacement is a class 1 indication for patients with:
1. symptomatic severe AS
2. asymptomatic severe AS with LVEF <50%
3. asymptomatic severe AS undergoing CABG or surgery on the aorta or other heart valves
-> TAVR has been shown to reduce mortality by 20% in patients with severe AS + coexisting conditions that exclude them as candidates for SAVR (surgical)
-> percutaneous aortic balloon valvuloplasty serves best as palliative therapy in severe symptomatic patients who are not surgical candidates + as a bridge to surgery in haemodynamicaly unstable adult patients
9
Q
Anaesthesia goals for Aortic Stenosis
A
10
Q
Dynamic manoeuvres to differentiate systolic murmurs
A
11
Q
Causes of Mitral Regurgitation?
A
12
Q
History for Mitral Regurgitation?
A
13
Q
Examination for Mitral Regurgitation
A
14
Q
Severity grading for Mitral Regurgitation
A
15
Q
Stages for Mitral Regurgitation?
A
16
Q
Medical management for Mitral Regurgitation?
A
17
Q
Surgical management of Mitral Regurgitation
A
18
Q
Causes of Mitral Stenosis
A
19
Q
Hx for Mitral Stenosis
A
20
Q
Ex for Mitral Stenosis
A
21
Q
Ix of Mitral Stenosis
A
22
Q
Severity of Mitral Stenosis
A
23
Q
Staging of Mitral Stenosis
A
24
Q
Medical management of Mitral Stenosis
A
25
Surgical Management of Mitral Stenosis
26
Hx and Ex for Aortic Regurgitation
27
Ix for Aortic Regurgitation
28
Severity and staging of Aortic Regurgitation
29
Medical mgmt of Aortic Regurgitation
30
Surgical Mgmt of Aortic Regurgitation
31
Which patients more typically have systolic versus diastolic heart failure?
32
Examination findings for LVF vs RVF?
33
Criteria for LVH on ECG
Voltage Criteria
Limb Leads
- R wave in lead I + S wave in lead III > 25 mm
- R wave in aVL > 11 mm
- R wave in aVF > 20 mm
- S wave in aVR > 14 mm
Precordial Leads
- R wave in V4, V5 or V6 > 26 mm
- R wave in V5 or V6 plus S wave in V1 > 35 mm (Sokolov-Lyon criteria)
- Largest R wave plus largest S wave in precordial leads > 45 mm
Non Voltage Criteria
- Increased R wave peak time > 50 ms in leads V5 or V6
- ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern
34
Ix for CCF
35
Severity classification for CCF
36
Management for CCF
37
Ix for a pt with a Hx of Ischaemia
38
Angina severity
39
Management for a pt with a hx of IHD?
40
Risk Factors for IHD
41
How do you manage coronary stents perioperatively?
42
Indications for thrombolysis
43
Classifications of cardiomyopathies?
44
Dilated Cardiomyopathy causes
45
Dilated Cardiomyopathy Hx and Ex
46
Dilated Cardiomyopathy Ix
47
Management of Dilated Cardiomyopathy
48
Hx and Ex for Hypertrophic Obstructive Cardiomyopathy
49
Ix for Hypertrophic Obstructive Cardiomyopathy
50
Treatment of Hypertrophic Obstructive Cardiomyopathy
51
Causes of restrictive cardiomyopathy
52
Hx and Ex for Restrictive Cardiomyopathy
53
Ix for restrictive cardiomyopathy
54
Anaesthesia for Restrictive Cardiomyopathy
55
What is AF?
56
Risk factors for AF
57
AF classification
58
Hx and Ex for AF
59
Ix for AF
60
Severity of AF?
61
CHADS2 and CHADSVaSc
62
Anaesthetic considerations and AF
63
Antiarrhythmic Classification
64
PPM indications
65
ICD Indications
66
Anaesthesia and a PPM/ICD
67
What is Long QT syndrome
68
Hx for Long QT syndrome
69
DDx for long QT
70
Operative management of long QT
71
Drugs that alter the QT
72
What is Brugada Syndrome?
73
Dx for Brugada
74
Presentation of Brugada
75
Anaesthetic Considerations for Brugada
76
What is pulmonary hypertension
77
Hx and Ex for pulm Hypertension
78
Ix for Pulm Htn
79
Classification of pulm HTN
80
Severity of pulm HTN
81
Variables used to determine the prognosis of pulm HtN
82
Medical mgmt for pulm Htn
83
Surg Rx for pulm HTN
84
Perioperative M&M for pulm HTN
85
Predictors of a poor outcome in non-cardiac surgery and pulm HTN
86
Intra-op goals for pulm HTN
87
Management options for intra op pulm hypertensive crisis
88
Hx for Peripheral Vascular Disease
89
Ex for Peripheral Vascular Disease
90
Ix and severity of Peripheral Vascular Disease
91
Management of Peripheral Vascular Disease
92
Anaesthesia for Peripheral Vascular Disease
93
Hx and Ex for Atrial Septal Defect
94
Ix and severity for Atrial Septal Defect
95
Anaesthesia in the context of an Atrial Septal Defect
96
Ventricular Septal Defect incidence and examination features
97
Ventricular Septal Defect Ix and severity
98
Anaesthetic considerations for a Ventricular Septal Defect
99
Causes of heart transplant and survival
100
Hx for a heart transplant recipient
101
Ex for a heart transplant recipient
102
Ix for a heart transplant recipient
103
Post heart transplant management
104
Anaesthetic considerations for a post transplant patient
105
Characteristics of emphysema vs chronic bronchitis
106
RFs for COPD
107
Hx for COPD
108
Ex for COPD
109
Ix for COPD-all
110
mMRC dyspnoea scale
111
Severity of COPD
112
Rx COPD
113
GOLD ABCD criteria
114
Criteria for Oxygen therapy with COPD
115
RFs for post-op pulm comp in the context of COPD
116
Risk reduction strategies to decrease the incidence of post-op pulm complications
117
Diagnostic criteria for RVH on an ECG
118
What is bronchiectasis and its causes
119
Hx for Bronchiectasis
120
Ex for Bronchiectasis
121
Ix for Bronchiectasis
122
Rx for bronchiectasis
123
Anaesthetic considerations for bronchiectasis
124
Hx asthma
125
Ex asthma
126
Ix asthma
127
Asthma severity
128
Causes of Restrictive Lung Disease
129
Hx Restrictive Lung Disease
130
Ex Restrictive Lung Disease
131
Ix Restrictive Lung Disease
132
Anaesthetic considerations for Restrictive Lung Disease
133
Pneumothorax classification
134
Pneumothorax Hx
135
Pneumothorax Ex
136
Pneumothorax Ix and severity
137
What is OSA
138
OSA Hx and Ex
139
OSA Ix
140
OSA Rx
141
Causes of OSA
142
RFs for OSA
143
STOP BANG questionnaire
144
Components of a polysomnogram
145
Cystic Fibrosis associated mortality?
146
Hx for Cystic Fibrosis
147
Ex for Cystic Fibrosis
148
Ix for Cystic Fibrosis
149
Dx of Cystic Fibrosis
150
Cystic Fibrosis Rx
151
Hx for lung Cancer
152
Ex for Lung Cancer
153
Ix for lung Cancer
154
Post lung surgery management based on ppoFEV1
155
Flow volume loop for emphysema
156
Flow volume loop for unilateral main-stem bronchial obstruction
157
Flow volume loop for upper airway obstruction
158
Flow volume loop for a variable extrathoracic upper airway obstruction
159
Flow volume loop for a variable intrathoracic upper airway obstruction
160
Flow volume loop for a restrictive lung disease
161
Flow volume loop for neuromuscular weakness
162
Hx for lung transplant
163
Ex for lung transplant
164
Ix post lung transplant
165
Mgmt post lung transplant
166
Types of acute liver failure and the syndrome that occurs with it?
167
Hx for liver failure
168
Ex for liver failure
169
Ix for liver failure
170
Kings colleg criteria for selection of liver transplant recipients
171
Causes of chronic cirrhosis
172
Hx for Chronic Liver Disease
173
Ex for Chronic Liver Disease
174
Ix for Chronic Liver Disease
175
Severity of Chronic Liver Disease as per childs pugh and prognosis
176
Severity of Chronic Liver Disease as per MELD
177
Paeds liver failure scoring?
178
Complications of CLD
179
Rx for CLD
180
Effects of haemochromotosis
181
Hx for haemochromotosis
182
Ex for haemochromotosis
183
Ix for haemochomatosis
184
Rx for haemachromotosis
185
What is wilsons and the results of it?
186
Hx for wilsons
187
Ex and Ix for wilsons
188
Rx for wilsons
189
Hep C Hx and Ex
190
Hep C Ix and Rx
191
Hep B overview
192
CKD causes
193
CKD Hx
194
CKD Ex
195
Ix for CKD
196
CKD Mgmt
197
CKD mgmt based on eGFR
198
Systemic Manifestations of CKD
199
Findings suggestive of inadequate haemodialysis
200
Hx in a haemodialysis pt
201
Ex for a haemodialysis pt
202
Ix for a haemodialysis pt
203
Optimisation for a haemodialysis pt
204
Cause of acromegaly
205
Hx for acromegaly.
206
Ex for acromegaly.
207
Ix for acromegaly
208
Signs of active acromegaly
209
Rx of acromegaly
210
Causes of acromegaly?
211
Diabetes types
212
Diabetes history
213
Diabetes Ex
214
Diabetes criteria
215
Complications of diabetes
216
Diagnostic triad of DKA and typical breathing patter
217
Hyperparathyroid classification
218
Symptoms of hypercalcaemia
219
Rx for hypercalcaemia?
220
Rx for hypercalcaemia
221
Causes of hypoparathyroidism
222
Hx and exam for hypocalcaemia
223
Causes of hypercalcaemia?
224
Causes of hypocalcaemia?
225
Causes of hyperthyroidism
226
Thyroid neck exam
227
Hyperthyroid systemic exam
228
Hyperthyroid Ix
229
Hypothyroid causes
230
Hypothyroid systemic exam
231
Hypothyroid Ix
232
Hypothyroidism Rx
233
Causes of Cushings
234
Hx and Ex for cushings
235
Ix and Dx for cushings
236
Rx for cushings
237
Physiological effects of excess cortisol secretion
238
Complications post pituitary surgery
239
Pathophysyology of myotonic dystrophy
240
Clinical features of myotonic dystrophy
241
Hx for myotonic dystrophy
242
Ex for myotonic dystrophy
243
Ix for myotonic dystrophy
244
Rx for myotonic dystrophy
245
DDx of muscle weakness in a male patient
246
Clinical features and Hx for Duchenne's Muscular Dystrophy
247
Ex for Duchenne's Muscular Dystrophy
248
Ix for Duchenne's Muscular Dystrophy
249
Rx and anaesthetic issues with Duchenne's Muscular Dystrophy
250
Clinical features and Hx for ALS
251
Exam for ALS
252
ALS severity
253
ALS Rx and anaesthetic considerations
254
Guillain Barre Syndrome clinical features and Hx
255
Guillain Barre Syndrome Exam
256
Guillain Barre Syndrome Ix and Dx
257
Guillain Barre Syndrome DDx
258
Guillain Barre Syndrome Rx and anaesthetic considerations
259
Indications for Guillain Barre Syndrome intubation
260
How is plasmapheresis + IV Immunoglobulin administered?
What are the side effects and contraindications?
261
M&M associated with Guillain Barre Syndrome
262
DDx motor neuropathy
263
DDx sensory neuropathy
264
DDx painful neuropathy
265
UMN vs LMN lesion
266
Ex for upper limb neuropathy
267
Ex for lower limb neuropathy
268
Clinical features of Multiple Sclerosis
269
Hx for Multiple Sclerosis?
270
Ex for Multiple Sclerosis?
271
Ix and Dx for Multiple Sclerosis
272
Rx of Multiple Sclerosis
273
Anaesthetic considerations for Multiple Sclerosis
274
Clinical features of Myasthenia Gravis
275
Severity of Myasthenia Gravis
276
Hx for Myasthenia Gravis
277
Ex for Myasthenia Gravis
278
Rx for Myasthenia Gravis
279
Anaesthetic considerations for Myasthenia Gravis
280
Give an overview of myasthenic syndrome
281
Compare Myasthenia Gravis and Myasthenic syndrome
282
Causes of Parkinsons Disease
283
Hx for Parkinsons Disease
284
What are the 4 cardinal signs for Parkinsons Disease on examination?
TRAP
Tremor -resting
Rigidity -cogwheel
Akinesia/bradykinesia -slowness of movement
Postural instability -failure of postural 'righting' reflexes leading to poor balance and falls
285
Parkinsons Disease Rx
286
Anaesthetic implications of Parkinsons Disease
287
DDx of symmetrical polyarthropathy
288
Rheumatoid Arthritis Hx
289
Rheumatoid Arthritis Ex
290
Rheumatoid Arthritis Ix and Dx
291
Rheumatoid Arthritis Rx
292
Extra-articular manifestations of Rheumatoid Arthritis
293
Hx for Ankylosing Spondylitis
294
Ex for Ankylosing Spondylitis
295
Ix for Ankylosing Spondylitis
296
Dx for Ankylosing Spondylitis
297
What is systemic sclerosis
298
Hx for systemic sclerosis
299
Ex for systemic sclerosis
300
Ix for systemic sclerosis
301
Dx of systemic sclerosis
302
Rx for systemic sclerosis
303
Anaesthetic considerations for systemic sclerosis
304
What is Raynaud's Phenomenon
305
Rx and anaesthetic considerations for raynauds
306
What is SLE
307
Hx for SLE
308
Ex for SLE
309
Ix for SLE
310
Dx of SLE
311
Rx for SLE
312
What is Antiphospholipid Syndrome
313
Hx marfans
314
Ex marfans
315
Ix marfans
316
Dx marfans
317
Rx marfans
318
Marfans anaesthetic considerations
319
clinical features of elhers danlos syndrome
320
Ehlers-danlos syndrome considerations
321
What is sarcoidosis
322
Hx for Sarcoidosis
323
Ex for Sarcoidosis
324
Ix for sarcoidosis
325
Rx for sarcoidosis
326
Haemophilia types
327
Hx and Ex for haemophilia
328
Ix and severity of haemophilia
329
Mgmt of haemophilia
330
What is Chronic Regional Pain Syndrome (CRPS) and its types
331
Hx for Chronic Regional Pain Syndrome (CRPS)
332
Ex for Chronic Regional Pain Syndrome (CRPS)
333
Ix for Chronic Regional Pain Syndrome (CRPS)
334
Rx and anaesthetic implications for Chronic Regional Pain Syndrome (CRPS)
335
Hx for Charcot-Marie Tooth
336
Ix for Charcot-Marie tooth
337
Ex for Charcot-Marie Tooth
338
Symptoms of fredrichs ataxia
339
Granulomatosis with polyangiitis (Wegener granulomatosis) Ex
340
Hx for Granulomatosis with polyangiitis (Wegener granulomatosis)
341
What is the **principle** of enhanced recovery after surgery (ERAS)?
Integrated, multidisciplinary approach
## Footnote
Aim to expedite return to baseline health and functional status, reduce hospital length of stay.
342
List the **intraoperative anaesthetic strategies** for enhanced recovery after surgery (ERAS).
* Use short acting hypnotic agents (e.g. propofol, sevoflurane)
* Avoid midazolam premedication
* Avoid long-acting opioids
* Avoid long acting NMBAs
* Lung protective ventilation
* Fluid management
* Temperature monitoring and forced air warmer
## Footnote
These strategies aim to minimize complications and enhance recovery.
343
What are the **intraoperative surgical strategies** for enhanced recovery after surgery (ERAS) in colorectal surgery?
* Laparoscopic surgery
* Avoid peritoneal drains
## Footnote
These strategies help reduce recovery time and complications.
344
List the **postoperative anaesthetic strategies** for enhanced recovery after surgery (ERAS) in colorectal surgery.
* Multimodal analgesia (paracetamol, NSAIDs)
* Dexamethasone for antiemesis and analgesia
* Local infiltration at port sites
* Resumption of diet within hours
* Early mobilisation
* Avoid NG tube
* Early IDC removal
* Postoperative CRP measurement
## Footnote
These strategies are designed to enhance recovery and minimize complications.
345
What does the **ASA physical status classification system** classify?
Health of patients prior to surgery
## Footnote
It helps assess the risk of anesthesia and surgery.
346
List the **ASA scoring system**.
* ASA 1: normal healthy patient
* ASA 2: Patient with mild systemic disease
* ASA 3: Patient with severe systemic disease
* ASA 4: Patient with severe systemic disease that is a constant threat to life
* ASA 5: Moribund patient not expected to survive without the operation
* ASA 6: Declared brain dead patient
## Footnote
Each class has associated mortality rates.
347
Define **frailty**.
Multidimensional geriatric syndrome characterised by a decline of physical and cognitive reserves
## Footnote
Leads to increased vulnerability.
348
How may **frailty** affect a patient's hospital stay?
Increases with age, associated with falls, longer stays, difficulty recovering, and mortality
## Footnote
Identifying frailty can help in managing patient care.
349
What are the components of the **FRAIL index**?
* Feeling fatigued most or all of the time?
* Resistance against gravity (difficulty walking up 10 stairs)
* Ambulation (difficulty walking 300 metres unaided)
* Illnesses (having 5 or more)
* Loss of >5% of weight in 12 months
## Footnote
This index helps in assessing frailty.
350
What is **1 MET**?
1 Metabolic equivalent
## Footnote
Represents the oxygen consumption of an adult at rest.
351
What constitutes the **anterior circulation** of the brain?
* ICA
* MCA
* ACA
## Footnote
Supplies blood to the frontal and parietal lobes.
352
What are the clinical features associated with an **MCA stroke**?
* Contralateral hemiparesis
* Hemisensory defect
* Homonymous hemianopia
* Aphasia
## Footnote
Higher centres affected, face and arm > leg.
353
What is the **modified rankin score** used for?
Degree of disability or dependence after stroke
## Footnote
Helps in assessing the outcome of stroke patients.
354
What are the **contraindications for tPA** in acute embolic stroke?
* Platelets < 100
* INR >1.7
* NOAC last dose <48hr
* Major surgery <14 d
* Head trauma/spinal surgery within past 3 months
## Footnote
These contraindications help prevent complications.
355
What is the aim of **endovascular clot retrieval** in acute stroke?
Restore perfusion to ischaemic penumbra
## Footnote
This procedure is crucial for salvaging brain tissue.
356
What are the **timing requirements** for endovascular clot retrieval in acute stroke?
* Early window <6h
* Extended window 6-24hr (DAWN trial)
## Footnote
Timing is critical for successful outcomes.
357
What is the purpose of **surgical decompression** in malignant MCA syndrome?
Prevents secondary brain stem ischaemia
## Footnote
Performed within 48 hours to reduce mortality.
358
What is **secondary prevention of stroke**?
Treatment aimed at preventing further strokes
## Footnote
Includes antiplatelets, statins, and risk factor modification.
359
What is the **baseline BP target** in clot retrieval for acute embolic stroke?
* Maintain baseline BP within 20%
* AHA <220/120
* Blue book <180/110
## Footnote
These targets are crucial for managing blood pressure during the procedure.
360
What are the **BP targets** post revascularization in acute embolic stroke?
* Relax BP to prevent hemorrhagic transformation
* AHA <180/100
* Blue book <160
## Footnote
Lowering BP is essential to reduce the risk of complications.
361
In a **ruptured cerebral aneurysm/AVM**, what should be done if there is clinical evidence of raised ICP?
* Insert ICP monitor
* Lower BP to maintain CPP >70
## Footnote
This approach helps manage intracranial pressure effectively.
362
What is the **incidence of perioperative stroke**?
1:1000
## Footnote
Mostly ischemic (embolic) strokes, not due to hypoperfusion.
363
How much does **perioperative stroke** increase 30-day mortality?
8x increase
## Footnote
This highlights the severe implications of stroke during the perioperative period.
364
For how long does a stroke increase **perioperative risk**?
Up to 9 months post stroke
## Footnote
This leads to a higher risk of stroke during surgeries performed within this timeframe.
365
What are the strategies to **optimize a (previous) stroke patient** prior to surgery?
* Defer at least 3 mo after ischemic stroke, preferably 9 mo
* Continue aspirin
* Document pre-existing deficit
* Statin therapy (continue or start if high risk)
## Footnote
These strategies aim to minimize risks associated with surgery.
366
What are the **intraoperative aims** if a recent stroke patient attends for emergency surgery?
* Maintain cerebral DO2
* Avoid intraoperative hypotension (±20% of baseline)
## Footnote
These aims are critical for ensuring patient safety during surgery.
367
List the **postoperative strategies** to reduce stroke risk.
* Restart antiplatelet and anticoagulant medications as appropriate
* BP control within 20% of patient's baseline
## Footnote
These strategies help mitigate the risk of stroke after surgery.
368
What are the **goals when managing perioperative stroke**?
* Early detection
* Identification of correct signs
* Appropriate management: ineligible for thrombolysis
## Footnote
These goals are essential for effective stroke management.
369
True or false: **Perioperative stroke** is brain infarction that occurs during surgery or within 30 days after surgery.
TRUE
## Footnote
It can be either ischemic or hemorrhagic in origin.
370
List the **risk factors for hemorrhagic stroke**.
* Hypertension
* Coagulopathy
* Amyloid angiopathy
* Cerebral aneurysm
* AVM
* Moya Moya disease
* Trauma
## Footnote
These factors significantly increase the risk of hemorrhagic stroke.
371
What are the **patient risk factors associated with perioperative stroke**?
* Older age (>85)
* History of prior stroke or TIA
* Hypertension
* AF
* Valvular heart disease
* Cardiovascular disease
* Renal disease
* Diabetes
* Smoker or COPD
* Patent foramen ovale
* Migraine with or without aura
* Carotid disease
## Footnote
These factors contribute to the likelihood of experiencing a stroke during the perioperative period.
372
What is the **most common mechanism** of perioperative stroke?
Mostly ischemic
## Footnote
The incidence is approximately 1:1000.
373
Which patients should be **bridged for anticoagulation** prior to non-cardiac surgery?
* CHADS2 >3
* Metallic heart valves
* Recent stroke/TIA
## Footnote
Multidisciplinary discussion regarding bridging is essential for high-risk patients.
374
What is the **stroke risk** in a patient who undergoes surgery after a recent CVA?
68x higher risk if performed within 3 months
## Footnote
The highest risk occurs after 72 hours when cerebral dysregulation begins.
375
What are some **anaesthetic factors** that may help minimize perioperative stroke?
* Avoid intraoperative hypotension
* Neuropsychological monitoring may be of benefit
## Footnote
These factors can play a role in reducing stroke risk during surgery.
376
List the **pre-operative strategies** to reduce postoperative pulmonary complications.
* Smoking cessation, ideally >8 weeks
* Optimisation of COPD, asthma
* Pre-operative oral hygiene
* Pre-operative exercise and pulmonary rehabilitation
* Patient education re lung expansion manoeuvres
## Footnote
These strategies are vital for improving postoperative outcomes.
377
What are the **high-risk procedures** for postoperative pulmonary complications?
* Upper abdominal
* Open aortic aneurysm repair
* Open thoracotomy
* Head and neck operations
## Footnote
These procedures carry the greatest risk of complications.
378
What is the **rate of PONV in anaesthesia**?
* Vomiting = 30%
* Nausea = 50%
* High risk PONV = 80%
## Footnote
These rates indicate the prevalence of postoperative nausea and vomiting.
379
What is the **apfel PONV risk score**?
* 0, 1, 2, 3, 4 points = 10, 20, 40, 60, 80% risk respectively
## Footnote
This score helps assess the risk of PONV based on patient factors.
380
What is **PDNV**?
Post discharge nausea and vomiting
## Footnote
This condition can occur after patients leave the hospital.
381
What is the **NNT for prevention of nausea or vomiting with 4 mg of ondansetron**?
* NNT = 6 for vomiting
* NNT = 7 for nausea
## Footnote
Ondansetron is effective in reducing the incidence of PONV.
382
What are the **known/positive overall risk factors for PONV**?
* Female
* Previous PONV or motion sickness history
* Young age (<50)
* Non smoker
## Footnote
These factors increase the likelihood of experiencing PONV.
383
What are the **intra-operative implications of chronic high alcohol intake**?
* Higher propofol/opioid dosing required
* Coagulopathy - higher bleeding times and more frequent bleeding episodes
## Footnote
These implications can affect anaesthetic management.
384
What is an example **screening question for risky alcohol use**?
How many times in the past year have you had five or more drinks in a day (four for women)?
## Footnote
A response of one or more indicates risky alcohol use.
385
What is the expected effect of **chronic high alcohol intake** on metabolism of anaesthetic agents?
More rapid metabolism
## Footnote
This can affect the efficacy and duration of anaesthesia.
386
What is a potential **coagulopathy** effect of chronic high alcohol intake?
Higher bleeding times and more frequent bleeding episodes
## Footnote
This increases the risk of complications during surgery.
387
List the **preoperative implications** of chronic high alcohol intake.
* Cardiac disease
* Liver disease
* Risk of alcohol-induced cardiomyopathy
* Risk of arrhythmias
## Footnote
These implications can significantly affect anaesthetic management.
388
Give an example **screening question** for risky alcohol use.
How many times in the past year have you had five or more drinks in a day (four for women)?
## Footnote
A response of one or more indicates unhealthy use.
389
Outline the **Alcohol Use Disorders Identification Test (AUDIT-C)**.
* Screening test for alcohol use disorders
* 3 questions each scored 0-4
* Score of 4/12 in men or 3/12 in women positive
## Footnote
Questions assess frequency and quantity of alcohol consumption.
390
What are the **classes of interstitial lung disease**?
* Idiopathic
* Granulomatous
* Connective tissue disease
* Occupational
* Drugs
* Atypical pneumonia
* Miscellaneous
## Footnote
These classes help in diagnosing and managing lung diseases.
391
What is the **most common type** of interstitial lung disease?
Idiopathic pulmonary fibrosis
## Footnote
Also known as fibrosing alveolitis.
392
List the **risk factors** for interstitial lung disease.
* Smoking
* Occupational exposure
* Systemic disease
* Iatrogenic factors
## Footnote
These factors can causatively or acceleratively affect lung health.
393
How may **pulmonary function tests** be altered by restrictive lung disease?
* Low FEV1 and FVC -> ratio maintained
* Reduced TLC (<80% of normal)
* Reduced DLCO (sometimes <80% of normal)
## Footnote
These changes indicate restrictive lung pathology.
394
List clinical examination findings in **restrictive lung disease**.
* Hypoxia
* Cyanosis
* Tachypnoea
* Clubbing
* Reduced chest expansion
* Fine late inspiratory crackles
* Signs of RV failure/PAH
## Footnote
These findings help in clinical assessment of lung function.
395
What are the **findings of a HRCT** of restrictive lung disease?
Several characteristic patterns depending on disease
## Footnote
For example, IPF is characterised by usual interstitial pneumonia (UIP) pattern.
396
List the **causes of upper lobe fibrosis**.
* Silicosis
* Sarcoidosis
* Coal workers pneumoconiosis
* Histiocytosis
* Ankylosing spondylitis
* Allergic bronchopulmonary aspergillosis
* Radiation
* TB
## Footnote
These conditions can lead to specific lung damage patterns.
397
List the **causes of lower lobe fibrosis**.
* Rheumatoid
* Asbestosis
* Scleroderma
* Cryptogenic organizing pneumonia
* Other - idiopathic, drugs
## Footnote
Identifying these causes is crucial for treatment.
398
How do we **grade the severity** of restrictive lung disease?
* Dyspnea severity grades
* Roizens
* Medical research council (MRC) classification
* Objective measures of functional capacity
## Footnote
These grading systems help in assessing disease impact.
399
Discuss **supportive and definitive medical treatment** for all forms of restrictive lung disease.
* Home O2
* Palliative care
* Treat infections early
* Definitive = lung transplantation
## Footnote
Treatment strategies vary based on disease severity and type.
400
What is the specific medical treatment for **idiopathic pulmonary fibrosis**?
Anti-fibrotics
## Footnote
These medications slow progression and reduce mortality.
401
What is the specific medical treatment for **cryptogenic organizing pneumonia**?
Corticosteroids
## Footnote
These are used to reduce inflammation.
402
What is the specific medical treatment for **hypersensitivity pneumonitis**?
* Remove trigger
* Corticosteroids
## Footnote
Addressing the cause is crucial for effective management.
403
What is the specific medical treatment for **sarcoidosis and connective tissue disorders**?
* Corticosteroids
* Immunosuppressants (Azathioprine, Mycophenolate, Cyclophosphamide)
## Footnote
These treatments help manage inflammation and immune response.
404
List the **pre-optimisation** strategies for restrictive lung diseases.
* Respiratory consult
* Exclude + optimise PAH/RV failure
* Smoking cessation
* Secretion clearance
* Treat infections
* Continue specific therapy
## Footnote
These strategies improve patient outcomes before surgery.
405
What are **intraoperative issues** specific to restrictive lung diseases?
* Reduced FRC
* Rapid desaturation
* Apnoea poorly tolerated
* Rapid wash in and out of volatiles
* Reduced lung compliance
* High airway pressure
* Risk of barotrauma
## Footnote
These issues require careful anaesthetic management.
406
Discuss an **intraoperative ventilation plan** for restrictive lung disease.
* Consider modified RSI to reduce apnoea time
* Lung protective ventilation
* Low tidal volume: High respiratory rate
## Footnote
This approach minimizes complications during surgery.
407
What are the **common comorbidities** associated with idiopathic pulmonary fibrosis?
* Pulmonary hypertension (PH)
* Obstructive sleep apnea (OSA)
* Chronic obstructive pulmonary disease (COPD)
* Lung cancer
* Ischemic heart disease
* Gastroesophageal reflux disease
## Footnote
These comorbidities complicate management and prognosis.
408
What are the **postoperative respiratory issues** with patients having idiopathic pulmonary fibrosis?
* Risk of exacerbation
* Risk of atelectasis
## Footnote
These risks are heightened by pain and require careful management.
409
List the **features in the ARISCAT score** for postoperative pulmonary complications.
* Age >50, >80
* Respiratory infection in last month
* Incision - intrathoracic, upper abdominal
* Sats <96%, ≤90%
* Category (emergency surgery or elective)
* Anaemia Hb<100
* Time (duration of surgery) >2 hours
## Footnote
This scoring system helps predict the risk of complications.
410
List the **causes of chronic obstructive pulmonary disease (COPD)**.
* Genetic (A-1 antitrypsin deficiency)
* Environmental (Smoking, Occupational exposure)
* Pollution
* Recurrent childhood infection
* Low birth weight
## Footnote
Understanding these causes aids in prevention and management.
411
What are the **history findings** on COPD?
* Chronic cough
* Sputum
* Dyspnoea
* Acute exacerbation (Increased sputum, Tachypnoea, Wheeze)
## Footnote
These findings are crucial for diagnosis.
412
List the **examination findings** on COPD.
* Cachexia
* Tachypnoea
* Hyperinflation
* Barrel-shaped chest
* Increased AP diameter
* Pursed lip breathing
* Accessory muscle use
* Reduced chest expansion
* Hyper-resonant percussion
* Reduced breath sounds +/- wheeze
## Footnote
These findings help in assessing the severity of the disease.
413
What is the **spirometry finding** in COPD?
Diagnosis = FEV1/FVC ratio <0.7
## Footnote
This is a key diagnostic criterion for COPD.
414
What are the **DLCO findings** in COPD?
* Reduced - emphysema
* Normal - chronic bronchitis
## Footnote
These findings help differentiate between types of COPD.
415
List the **CXR findings** in COPD.
* Hyperinflation
* Flattened diaphragm
* Narrowed mediastinum
* Reduced lung markings
* >8-10 posterior ribs
* >6 anterior ribs
## Footnote
These findings assist in visual diagnosis of COPD.
416
List the **CT Chest findings** in COPD.
* Airspace enlargement
* Alveolar septal destruction
* Bronchial wall thickening
* Bullae
## Footnote
These findings provide detailed insights into lung structure.
417
How is the **severity of COPD classified**?
* GOLD stages (A-D)
* Lung function severity (GOLD class I-IV)
* Objective functional capacity
## Footnote
This classification guides treatment decisions.
418
How is the **GOLD class** different from **GOLD stage**?
* GOLD class -> severity of airflow obstruction (I-IV)
* GOLD stage -> prognosis and treatment grade (A-D)
## Footnote
Understanding this distinction is important for management.
419
What are the **disease modifying treatments** available for COPD?
* Smoking cessation
* Home O2 (PaO2 < 55)
* Preventative options (Pulmonary rehab, Vaccinations)
## Footnote
These treatments aim to improve quality of life and reduce exacerbations.
