1
Q
Why is there a lower threshold for RSI in trauma cases?
A
Trauma is associated with delayed gastric emptying.
2
Q
How is a transversus abdominis plane block performed and which nerves does it target?
A
Infiltrate LA into plane between internal oblique and transversus abdominis
Nerves: iliohypogastric, ilioinguinal and subcostal
NOTE: it covers T7-L1
3
Q
What is the formula for the correct QT interval?
A
QTc = QT/√RR
RR = RR interval
This is known as Bazett’s formula.
4
Q
What are the specific requirements of giving warmed fluids?
A
Pressurise to 300 mmHg and warmed with a recirculation fluid at 42 degrees.
5
Q
What combination of anaesthetic agents would minimise rises in intracranial pressure?
A
- Thiopentone
- Rocuronium
- Isoflurane
6
Q
What intra-abdominal pressure is suggestive of abdominal compartment syndrome?
A
> 20 mm Hg
7
Q
What is the difference between anaphylactic and anaphylactoid reactions?
A
Anaphylactic is IgE mediated and occurs on repeat exposure to a drug.
Anaphylactoid is non-IgE mediated and can happen on first exposure. It is caused by massive mast cell or basophil degranulation in the absence of immunoglobulins.
8
Q
State the equations for working out the length of CVC insertion based on height.
A
- Right IJV: height/10
- Left IJV: height/10 + 4
- Right subclavian: height/10 - 2
- Left subclavian: height/10 + 2
9
Q
What causes TRALI and what are the main features?
A
SOB and pulmonary oedema around 30 mins after the transfusion.
Donor antibodies react with recipient leukocytes leading to capillary leak.
10
Q
What is the difference between tachyphylaxis and tolerance?
A
- Tachyphylaxis: rapidly diminishing response to repeated drug administration, usually due to depletion of transmitter stores (e.g. ephedrine).
- Tolerance: loss of response over longer period of time, due to transcriptional changes, bigger dose needed to achieve same effect (e.g. opioid abuse).
11
Q
What can toxic doses of long-acting acetylcholinesterase inhibitors cause?
A
SLUDGE syndrome (salivation, lacrimation, urination, defecation and emesis)
E.g. organophosphate poisoning
Treated with atropine or pralidoxime
12
Q
What are the most common triggers for intraoperative anaphylaxis?
A
- Antibiotics (particularly Teicoplanin)
- Muscle relaxants
- Chlorhexidine
- Blue Dye
13
Q
What is the maximum cumulative dose of intralipid?
A
12 ml/kg over 30-60 mins
14
Q
What energy should be used for intraoperative DC cardioversion for unstable tachycardia?
A
1 J/kg
(50-100 J)
15
Q
What are the risk factors for PONV?
A
- PATIENT: female, non-smoker, previous PONV, motion sickness
- ANAESTHETIC: N2O, opiates, etomidate, neostigmine, hypotension
- SURGICAL: middle ear, ophthalmic, gynaecological
16
Q
What are the key principles of managing a traumatic brain injury patient?
A
- Maintain oxygenation
- Maintain normocapnia
- Maintain CPP (60-70 mm Hg)
- Reduce ICP (sedate and paralyse to avoid straining, mannitol and hypertonic saline)
- Reduce CMRO (treat pyrexia, prevent seizures, normoglycaemia)
17
Q
Which type of oxygen cylinder is found in an ambulance?
A
Two size F oxygen cylinders in a manifold.
Each cylinder contains 1360 L.
18
Q
What are the sources of fuel in the theatre environment?
A
- Alcohol-based skin prep
- Drapes
- Dressings
- Hospital gowns
- Intestinal gases
19
Q
What are the sources of ignition in the theatre environment?
A
- Faulty electrical equipment
- Surgical diathermy
- Laser surgery
- Defibrillator
- Static
20
Q
What measures are taken in airway surgery involving a laser to minimise risk to the patient?
A
- Avoid high FiO2.
- Use non-reflective matte black surgical instruments to minimise reflection.
- Use laser in bursts rather than continuous.
- Use laser tube (non-flammable, aluminium wrapped, double cuff filled with saline).
21
Q
How do you manage an airway fire?
A
- Declare critical incident and call for help.
- Switch off laser.
- Flood operative site with saline.
- Stop ventilation and EXTUBATE.
- Bag ventilate.
- Once fire is extinguished, examine airway with fibreoptic scope.
22
Q
Why is too low humidity a problem in the operating theatre?
A
- Increased risk of static build up (particularly important with LASER).
- Increased evaporative fluid loss from patient.
23
Q
Why is too high humidity a problem in the operating theatre?
A
- Predisposes to microbial growth
- Unpleasant working environment
NOTE: Optimal humidity is 40-60% at 20 degrees.
24
Q
What are the risks associated with perioperative hypothermia?
A
- Delayed wound healing
- Impaired coagulation
- Increased blood loss
- Increased post-operative pain
- Increased risk of infection
- Delayed recovery from anaesthesia
- Prolonged drug metabolism
- Prolonged hospital stay
25
Where can **core temperature** be monitored intraoperatively?
* Nasopharynx (ETT gas leak can affect reading)
* Distal oesophagus (not affected by tracheal gases)
* Pulmonary artery (most accurate)
* Tympanic membrane (easy but can be inaccurate)
## Footnote
LESS RELIABLE: rectum, bladder
26
What are the **key NICE guidelines** regarding temperature control in the peri-operative period?
* Measure temp every 30 mins.
* Keep patients covered where possible.
* > 500 mL IV fluids should be warmed, all blood products should be warmed.
* Forced air warmer if > 30 mins
* All irrigation fluids should be warmed.
## Footnote
POST OP: temp every 15 mins in recovery, 4 hourly on the ward
27
What's the **minimum monitoring** for anaesthesia as per AAGBI?
* Pulse oximeter
* NIBP
* ECG
* Inspired and expired O2, CO2, N2O and volatile agent
* Airway pressure
* Peripheral nerve stimulator (if NMB used)
* Temperature (if > 30 mins)
28
Which **commonly used anaesthetic drugs** don't affect BIS?
* N2O
* Xenon
* Opioids
## Footnote
NOTE: Ketamine can increase BIS.
29
Outline the classification of **awareness**.
**IMPLICIT**: implicit memories exist without conscious recall, but behaviour after event may change
**EXPLICIT**: conscious recall either spontaneously or on direct questioning (may be with or without pain)
Incidence: 1 in 20,000
30
What are some **risk factors** for awareness?
**ANAESTHETIC**: Induction and intubation, Transfer from anaesthetic room to theatre, use of muscle relaxants
TIVA (supposedly)
**PATIENT**: female, young adults, obesity, difficult airway
**SURGICAL**: obstetric, cardiac, thoracic, neurosurgical
31
What **measures** are taken to reduce the risk of electrical injury?
**GENERAL**: regular maintenance of equipment, appropriate humidity, antistatic shoes, antistatic flooring
**EQUIPMENT DESIGN**: class 1 (earthed), class 2 (double insulated) and class 3 (SELV)
**MAINS DESIGN**: equipotential bonding, isolation transformers, circuit breakers
32
Outline the **longer-term management** of an airway fire.
* Patients usually become increasingly hypoxaemic over 48 hours
* May be sensible to keep patient intubated and transfer to ITU
* Dexamethasone
* Humidified oxygen
33
What are the **main forms** of Creutzfeldt-Jakob disease?
* Sporadic (MOST COMMON)
* Familial
* Variant (due to exposure to BSE)
* Iatrogenic
34
What are the **indications** for administering anaesthesia for an MRI scan?
* Ventilated ICU patients
* Patients with movement disorders
* Uncooperative patients (children, learning disability)
* Anxiety/claustrophobia
35
What are the **hazards** of administering anaesthesia in the MRI environment?
* Static magnetic field (dangerous projectiles, ferromagnetic foreign bodies, pacemakers)
* Acoustic noise (ear damage)
* Radiofrequency heating
* Quenching (release helium rapidly creating hypoxic environment)
36
How many **air changes** per hour are necessary in a theatre environment?
15 per hour
## Footnote
NOTE: Labour suite is 5 per hour.
This is to rapidly dilute and remove microbes and particles, maintain positive pressure and ensure stable sterile environment.
37
What is **APRV**?
* Airway pressure release ventilation
* Pressure-controlled variant where the ventilator maintains a high pressure during a LONG INSPIRATORY phase.
* Pressure is released during a short expiratory phase to clear CO2.
## Footnote
Aims to keep lung units open longer and reduce atelectrauma.
38
By what **mechanism** does high frequency oscillatory ventilation work?
Delivers high respiratory rates (120-200/min) and low tidal volumes (below dead space).
* **Pendelluft**: Air moves between alveoli with different time constants, enhancing mixing.
* **Taylor dispersion**: Oscillatory shear flow spreads oxygen more effectively than molecular diffusion.
* **Bulk convection**: More O₂ absorbed than CO₂ produced, creating negative pressure that draws gas into alveoli.
39
What is **jet ventilation**?
* Delivery of small tidal volumes (1-3 mL/kg) from a high-velocity jet of oxygen.
* Venturi effect entrains more air.
* Followed by passive exhalation.
40
What are the **approaches** to jet ventilation?
* Supraglottic (rigid bronchoscope)
* Transtracheal (cricothyroid)
* Subglottic (catheter into larynx)
41
What is the **difference** between high frequency jet ventilation and high frequency oscillatory ventilation?
Jet ventilation shoots gas in one direction (jet bursts, passive exhalation), while HFOV oscillates gas back and forth (active inspiration and expiration, with constant mean pressure).
42
What are **some complications** of high frequency jet ventilation?
* Barotrauma
* Exposure to unhumidified gas (mucosal irritation, ulcers)
* Hypercapnia
43
What is the **triad** of heat stroke?
* Altered mental status
* Anhidrosis
* Core body temperature above 40.6 degrees
## Footnote
NOTE: This happens when heat loss mechanisms are impaired (e.g. humidity limiting sweat evaporation).
44
What is **neuropathic pain**?
Pain caused by a lesion or disease of the somatosensory nervous system.
## Footnote
PNS: diabetic neuropathy, Herpes zoster
CNS: MS, spinal cord injury
45
What is **spinal shock**?
Acute spinal cord injury will interrupt supraspinal pathways meaning that gamma motor neurones become inactive.
Muscles become hypotonic or flaccid.
After 2-6 weeks, gamma motor neuron activity increases leading to increased muscle tone.
46
Outline the pathophysiology of **malignant hyperthermia**.
Autosomal dominant (Chr 19).
Abnormal **RyR** causes uncontrolled Ca²⁺ release from **SR**.
Leads to tetany, consuming ATP and oxygen, generating heat, and increasing CO₂ and lactate.
**Dantrolene** blocks RyR, preventing further Ca²⁺ release.
Incidence: 1 in 100,000 general anaesthetics.
47
Above what **vertebral level** is neurogenic shock more likely?
T6
## Footnote
Interruption of sympathetic outflow leads to profound arteriolar vasodilation.
NOTE: Above T1 would lead to bradycardia due to denervation of the heart.
48
Describe the **manifestations** of anterior spinal cord syndrome.
Fine touch, vibration and proprioception spared (dorsal columns)
Loss of all other motor and sensory function (paraplegia and loss of pain/temp sensation).
## Footnote
NOTE: Causes include aortic dissection, disc herniation and iatrogenic from aortic aneurysm surgery.
49
Describe the **manifestations** of central cord syndrome.
* Upper limb weakness (worse than lower limb)
* Cape-like sensory loss over shoulders and arms
## Footnote
NOTE: Caused by neck hyperextension injuries.
50
How long do platelets, red cells, FFP and cryoprecipitate **last in storage**?
* **Platelets**: 5–7 days
* **RBCs**: 35–42 days (refrigerated)
* **FFP**: 1 year frozen (24 h after thawing)
* **Cryoprecipitate**: 1 year frozen (4–6 h after thawing/ pooling)
51
How **soon** after removal from a blood bank storage fridge do red cells need to be administered?
* Ideally start within 30 mins.
* Complete within 4 hours.
52
Why are pregnant patients at particularly **increased risk of aspiration** during anaesthesia?
* Progesterone relaxes the lower oesophageal sphincter.
* Mechanical displacement of the stomach and duodenum (increased intragastric pressure lowers barrier pressure).
53
How does pregnancy **affect** epidural pressure?
Increases (+1 cm H2O) due to venous engorgement of epidural venous plexus secondary to mechanical compression of IVC by gravid uterus.
54
What **additional risks** does general anaesthesia confer in the pregnant population?
* Risk of reflux (> 12 weeks)
* Difficult airway (large breasts, short neck, increased mucosal vascularity)
* Busy environment (nurses, midwives)
* Decreased FRC (prone to desaturation)
* Increased O2 consumption
55
Describe **differences** between the adult and neonatal airway.
* Large head, prominent occiput
* Short neck
* Long, U-shaped epiglottis
* Narrowest at cricoid
* Optimal position: head in neutral position
56
Describe **differences** between the adult and neonatal respiratory systems.
* Higher oxygen consumption (7 vs 3 mL/kg/min)
* Low FRC (due to compliant chest wall)
* Gastric distension splints diaphragm
* ODC shifted left (less effective offloading)
57
Describe **differences** between the adult and neonatal cardiovascular system.
Stiff, fibrous and non-compliant ventricles meaning stroke volume can't increase much (can become overloaded with excess fluids).
Blood volume of 90 mL/kg at birth, compared to 70 mL/kg after age of 14 years.
58
Describe differences between the adult and neonatal **central nervous systems**.
1. Immature blood-brain barrier (increased sensitivity to central depressant drugs)
2. Vagal reflexes are very active
3. Increased MAC
59
Why do **neonates** lose heat more rapidly than adults?
* High surface area to weight ratio
* Limited subcutaneous fat
* High minute ventilation
* Poor shivering response
60
Why is hypothermia common in **anaesthetised patients**?
* Cold ambient temperature
* Exposed skin/cavities
* Paralysis prevents shivering
* Hypothalamic set-point is lowered by GA
* Vasodilation
61
What are the risks of **perioperative hypothermia**?
* Increased blood loss
* Increased wound infection
* Prolonged stay in recovery/hospital
* Arrhythmias
62
What are the **three main theories** that underpin ageing?
* Telomeres
* Oxidative damage
* Accumulation of somatic mutations
63
What drugs are used to manage **hyperkalaemia**?
* 10 mL 10% calcium chloride (or 30 mL 10% calcium gluconate)
* 10-20 mg salbutamol nebuliser
* Sodium bicarbonate 1.26%
* Calcium resonium
* Patiromer (8.4 g OD)
* Sodium zirconium cyclosilicate (10 g TDS)
## Footnote
NOTE: Consider haemofiltration and haemodialysis.
64
What are the guidelines for **pre-operative fasting**?
* **Clear fluids**: 2 hours
* **Solids/Non-clear fluids**: 6 hours
**PAEDS**
* **Clear fluids**: 1 hour
* **Breast milk**: 4 hours
* **Solids**: 6 hours
65
# Define:
the stress response
It is a complex neuroendocrine and inflammatory response to physiological stress.
## Footnote
NOTE: Autonomic and sensory afferents can trigger the response via the hypothalamus, or it can be mediated by hormones and cytokines.
66
What are the **adverse consequences** of the stress response?
* **Sympathetic stimulation**: hypertension, tachycardia, increased myocardial work
* **Hyperglycaemia**: poor wound healing, infection
* **Protein catabolism**
* **Electrolyte disturbance** (mineralocorticoids)
* **Fluid overload** (ADH, mineralocorticoids)
* **Thromboembolism** (procoagulant state)
67
How can you **reduce** the stress response to surgery?
* Epidural/spinal anaesthesia (prevent initiation)
* Opioids
* Maintaining normothermia
* Minimally invasive surgical techniques
68
What are some **disadvantages** of cell salvage?
* Clotting factors are lost
* Amniotic fluid can be mixed in obstetric haemorrhage
* Cancer - malignant cells may not be removed
69
What is **porphyria**?
Rare inherited disorders of haem biosynthesis.
**CLASSIFICATION**
* **Acute**: acute intermittent porphyria
* **Chronic**: porphyria cutanea tarda
**FEATURES**
* **Visceral**: abdominal pain, vomiting, hypertension
* **Neurological**: seizures, coma, weakness
70
How is porphyria **diagnosed**?
Urine porphobilinogen
## Footnote
Sample needs to be protected from light. If positive, blood and faecal tests, and genetic tests should be arranged.
71
Outline the management of **porphyria**.
* Remove **trigger**
* **Glucose**: 200 g/day enterally or IV (catabolic state promotes porphyrin production)
* **IV Haem Arginate**: suppresses hepatic production of porphyrin precursors
* **Supportive**: analgesia, antiemetics, anticonvulsants
72
# Define:
addiction
Biopsychosocial disorder characterised by compulsively seeking to achieve a desired effect (e.g. intoxication) despite harm and adverse consequences to self and others.
73
Outline the management of **paracetamol overdose**.
* < 1 hour: activated charcoal
* Plasma level at 4 hours
* If above treatment graph: NAC
* If significant overdose (> 150 mg/kg): NAC
* NAC is given over 21 hours
74
Describe the pathophysiology of **aspirin overdose**.
Uncouples oxidative phosphorylation, increasing VO₂ and CO₂ production. Causes respiratory alkalosis and metabolic acidosis.
CLINICAL
* Tachycardia
* Sweating
* Tinnitus
* Blurred vision
75
Outline the treatment of **aspirin overdose**.
* Activated charcoal
* Urinary alkalinisation (increase elimination)
* RRT
76
What is **Reye syndrome**?
* Widespread mitochondrial damage in children
* Leads to encephalopathy, cerebral oedema and hepatic failure
* Triggered by aspirin
77
What is **Brugada syndrome**?
Inherited cardiac sodium channelopathy associated with an increased risk of ventricular fibrillation and sudden cardiac death.
## Footnote
NOTE: May be unmasked by fever, cardiac ischaemia, electrolyte disturbance or drugs.
78
Describe the ECG appearance of **Brugada syndrome**.
Coved ST elevation > 2 mm in more than one of leads V1-V3
79
What are the **specific perioperative considerations** for someone with Brugada syndrome?
* Check pre-operative electrolytes
* Propofol infusion can precipitate arrhythmias
* Local anaesthetics should be used with caution
* If VT/VF developed --> defibrillate
* Amiodarone should be avoided
## Footnote
NOTE: Quinidine is used in the long-term treatment of Brugada syndrome.
80
How long should the main oral anticoagulants be withheld for **ahead** of neuraxial blockade?
* **Warfarin**: INR < 1.4
* **Dabigatran**: 48-96 hours depending on renal function
* **Rivaroxaban**: 48 hours
* **Apixaban**: 24-48 hours
81
How long should heparins be withheld **before** neuraxial blockade?
* UFH: 4 hours or normal APTT ratio
* Prophylactic LMWH: 12 hours
* Treatment Dose LMWH: 24 hours
82
Describe the pathophysiology of **heparin-induced thrombocytopaenia**.
Immune system forms IgG antibodies against heparin when it is bound to platelet factor 4 (PF4).
IgG-Heparin-PF4 complex triggers platelet activation resulting in small clots and a drop in platelet count.
## Footnote
NOTE: Antibodies take 5 days to develop.
83
What **alternatives** to heparin can be used in people at risk of HIT?
* Fondaparinux
* Danaparoid (mixture of 3 LMWHs)
84
Describe the clinical features of **serotonin syndrome**.
* **COGNITIVE**: agitation, confusion, hallucinations
* **AUTONOMIC**: hyperthermia, sweating, dilated pupils, diarrhoea
* **SOMATIC**: hyperreflexia, clonus, tremor
85
Describe how the **Apfel score** is interpreted.
0 = 10%
1 = 20%
2 = 40%
3 = 60%
4 = 80%
## Footnote
NOTE: The POVOC score is used in paediatrics (duration > 30 mins, age > 3, history of PONV, strabismus).
86
What are **fungi**?
* Kingdom of organisms
* Slow growing eukaryotes with rigid cell walls surrounding their membrane
## Footnote
Those that cause infections are subclassified as:
- Moulds (e.g. Aspergillus)
- Yeasts (e.g. Candida)
87
What are some **risk factors** for developing fungal disease?
* **IMMUNOSUPPRESSION**: chemotherapy, HIV, haematological malignancy
* **RESPIRATORY**: COPD, bronchiectasis
* **IATROGENIC**: TPN, central venous lines
88
Which **cohort of patients** are continuous subcutaneous insulin infusions recommended for?
Children > 12 years and adults who are struggling to maintain their HbA1c < 69 mmol/mol or are experiencing frequent hypoglycaemic episodes
89
Between what **range** should blood glucose be maintained in the perioperative period?
6-10 mmol/L
90
Outline the management of **organophosphate poisoning**.
* Atropine 2-4 mg IV given 5-10 mins apart to achieve antimuscarinic effects
* Pralidoxime 30 mg over 5-10 mins
91
In addition to an axillary nerve block, which additional nerve block would need to be performed to manage **tourniquet related pain**?
Intercostobrachial nerve block
92
What are some **features** of smoke inhalation that might indicate that the patient's airway is at risk?
* Singeing of eyebrows/eyelashes/nasal hair
* Swelling of face/lips/tongue
* Cough, wheeze or stridor
* Soot in nose or mouth
93
What are some **methods** of estimating total body surface area burned?
* Wallace's Rule of Nines
* Lung-Browder chart
* Patient's Palmer Surface (1%)
94
By what **mechanism** can an infection lead to diabetic ketoacidosis?
Physiological stress due to infection can cause an increase in cortisol and adrenaline. This antagonises insulin leading to hyperglycaemia and increased lipolysis (and ketogenesis).
95
What **antacid prophylaxis** should be given to a pregnant patient undergoing a general anaesthetic?
* Ranitidine 150 mg PO (once listed)
* Sodium citrate (30-60 mL of 0.3 M) just before induction
96
Which common anaesthetic drugs should be avoided in **renal failure**?
* **MUSCLE RELAXANTS**: aminosteroids, suxamethonium
* **ANALGESICS**: NSAIDs, morphine
97
What are some **predictors** of difficult bag-mask ventilation?
* Age > 55 years
* BMI > 25
* History of OSA
* Beard
* Edentulous
* Facial abnormalities
98
What is the **point** of inserting a cricothyroid cannula in an anticipated difficult airway?
* Provides a rapid, last-resort oxygenation route if conventional airway management fails.
* Can be used for jet ventilation.
99
How do you insert a **cricothyroid cannula**?
* Identify and mark cricothyroid membrane
* Infiltrate with 5 mL 1% lidocaine
* Insert cricothyroid cannula with 2 mL of saline in a 5 mL syringe connected
* Advance cannula slightly caudal whilst aspirating
* Stop advancing needle when bubbles aspirated and feed cannula in
* Confirm intra-tracheal position by attaching capnography
100
What are the advantages and disadvantages of neuraxial anaesthesia vs general anaesthesia for a **Caesarean section**?
**ADVANTAGES**
* Awake mother
* Avoids risk of aspiration
* Partner present/birth experience
* Minimal drug exposure for foetus
**DISADVANTAGES**
* Hypotension
* Partial block
* Risks of blockade (PDPH, nerve damage, spinal haematoma, paralysis)
101
What is a **post-dural puncture headache** and what are the main clinical features?
* Headache due to CSF loss from spinal canal
* Usually at 24-72 hours after dural puncture
* Severe frontal positional headache (worse when standing/straining, relieved by lying)
## Footnote
NOTE: Risk of 1 in 300.
102
When are blood tests taken for **mast cell tryptase** in a case of suspected anaphylaxis?
* As soon as practical after onset
* 1-2 hours after
* 24 hours (provides baseline value)
## Footnote
NOTE: Mast cell tryptase concentration falls to normal after 6-24 hours.
103
How are **blood products** checked?
1. Patient Identifiers (first and last name, date of birth, patient ID number).
2. Check these against blood component label.
3. Blood ID number should be checked against the unit to be transfused.
104
What are the **life-threatening features** of acute asthma that requires intubation?
* PEFR < 33%
* SpO2 < 92%
* Silent chest
* Cyanosis
* Feeble respiratory effort
* Arrhythmia
* Hypotension
* Exhaustion
* Altered consciousness
* Raised PaCO2
105
What **ventilator settings** are best in a bronchospastic patient?
* Low tidal volumes (6 mL/kg)
* Low respiratory rate
* Long expiratory time (I:E ratio of 1:4)
* PEEP < 5 cm H2O
* Permissive hypercapnia
* Limit peak airway pressure to 33 cm H2O
106
List some causes of **delayed emergence**.
* Hypothermia
* Drugs (e.g. benzodiazepines)
* Psychiatric disease
* Local anaesthetic toxicity
* Severe hypothyroidism
107
What equipment is needed for an **emergency scalpel cricothyroidotomy**?
* Scalpel with number 10 blade
* Bougie
* Cuffed 6 mm ET tube
108
What is the most likely cause of **intraoperative ischaemic ECG changes**?
Hypotension leading to reduced coronary perfusion.
109
How long should you continue CPR for in **local anaesthetic systemic toxicity**?
* Recovery can take over an hour.
* Use a Lucas device if available.
110
In which **conditions** would hydrocortisone be a better option than dexamethasone for perioperative steroid replacement?
Primary and secondary hypoaldosteronism would require a hydrocortisone infusion because it has both mineralocorticoid and glucocorticoid effects.
## Footnote
NOTE: Dexamethasone is a pure glucocorticoid.
111
What is an **important consideration** when anaesthetising a patient with a mitral valve lesion?
* Prevent worsening of pulmonary hypertension (hypoxia, hypercarbia, acidosis).
* Maintain sinus rhythm.
112
What are some **important principles** to consider when anaesthetising patients with regurgitant valvular disease?
* High/normal heart rate (shorter diastolic time means less time to regurgitate)
* Low SVR (maintains forward flow)
113
What is an appropriate bolus dose for a **rectus sheath catheter**?
15 mL of 0.25% levobupivacaine
114
Outline the criteria for **SIRS**.
* Temp >38 or < 36
* HR > 90 bpm
* RR > 20 /min or PaCO2 < 4.3 kPa
* WCC > 12 or < 4
115
How does anaesthesia **affect** the immune system?
* Disrupts physicochemical barriers
* Exposure to allergens (e.g. suxamethonium)
* Stress response (impairs immune cell function)
* Volatiles (impair NK cell activity)
116
What are some methods of **assessing frailty**?
* Rockwood frailty index
* PRISMA 7 questionnaire
117
What **measures** can be taken to reduce airway resistance in an anaesthetised patient?
* Bronchodilatory effect of volatile anaesthetics
* Applying PEEP
* LMAs (protect against loss of airway tone and have wide tubing)
118
What are the clinical features of a **total spinal**?
* Loss of consciousness
* Apnoea
* Hypotension, bradycardia (due to vasodilation and loss of sympathetic innervation)
119
Describe the classification of **acute spinal cord injuries**.
* Level of injury (e.g. T1)
* Stability of vertebral column (e.g. unstable)
* Extent of neurological injury (e.g. incomplete)
120
Describe the effects of complete spinal cord injury on the gastrointestinal tract.
* Loss of sympathetic: unopposed vagal activity leads to increased gastric acid secretion
* Loss of parasympathetic (pelvic splanchnic nerves): increased colonic transit time, constipation
121
What are the clinical features of **cauda equina syndrome**?
* Severe leg weakness
* Saddle anaesthesia
* Autonomic dysfunction (urinary retention)
122
Outline the physiological changes that take place in **pregnancy**.
* **RESP**: difficult airway, increased minute ventilation (due to tidal volume), decreased FRC, increased VO2
* **CVS**: increased blood volume, increased CO (due to increase in SV and HR), aortocaval compression (from 20 weeks')
* **GASTRO**: increased risk of reflux
* **HAEM**: increased WCC, decreased platelet, hypercoagulable
* **RENAL**: increased GFR
* **HEPATIC**: decreased plasma protein concentration
123
How can post-operative pulmonary complications be **minimised**?
* **PREOP**: patient risk stratification, selection of appropriate surgical technique (laparoscopic vs open)
* **INTRAOP**: regional anaesthesia, PEEP, lung protective ventilation, avoiding 100% O2, reversal of NMB
* **POSTOP**: pain relief
124
In what ways might you want to alter **gastrointestinal physiology** in the perioperative period?
* Reduce stomach acidity (antacids and drugs influencing acid secretion)
* Drugs affecting gastric motility (e.g. metoclopramide)
125
What are the **main additives** in a unit of red cells and what are their roles?
* **CITRATE**: chelates calcium, prevents coagulation
* **PHOSPHATE**: maintains ATP and 2,3-DPG levels (preserves RBC function)
* **DEXTROSE**: energy source
* **ADENINE**: substrate for ATP synthesis (extends shelf-life)
## Footnote
NOTE: There is a small amount of plasma and white cells in the unit.
126
What are the **constituents** of FFP and cryoprecipitate?
* **FFP**: All plasma proteins + full range of clotting factors, used for general coagulation support.
* **Cryoprecipitate**: Concentrated source of fibrinogen, factor VIII, vWF, and factor XIII, used when specific factor replacement is needed.
127
Describe the storage, shelf-life and thawing requirements for **packed red cells**.
* Storage: 2-6 °C
* Shelf-Life: 35-42 days
* Thaw: not required
* Use Within: 4 hours
128
Describe the storage, shelf-life and thawing requirements for **FFP**.
* Storage: -18 °C
* Shelf-Life: 1 year
* Thaw: 30-37 degree water bath
* Use Within: 4 hours (room temp), 24 hours (fridge)
## Footnote
NOTE: This is the same for cryoprecipitate, except it cannot be kept for 24 hours in the fridge once thawed.
129
Describe the storage, shelf-life and thawing requirements for **platelets**.
* Storage: 20-24 °C
* Shelf-Life: 7 days
* Thaw: not needed
130
What are the types of **hypersensitivity reaction**? Provide examples.
* **Type 1**: IgE-mediated (anaphylaxis)
* **Type 2**: antibody-mediated (e.g. haemolytic anaemia)
* **Type 3**: immune-complex (SLE)
* **Type 4**: contact dermatitis
131
What are the **main differences** between the fluid compartments of a neonate and an adult?
Neonates: higher TBW (80%), higher ECF fraction (50%), smaller ICF fraction
## Footnote
This means they are more susceptible to dehydration, fluid overload with excess IV fluids, altered drug distribution, electrolyte derangement and heat loss.
132
Which **cardiovascular medications** should be omitted on the day of an operation?
* ACE inhibitors and ARBs
* SGLT2 inhibitors
* ADP receptor antagonists
133
What are the **risks of seroconversion** when exposed to HIV, Hep B or Hep C via a needle stick injury?
* HIV: 0.5%
* Hep B: 20%
* Hep C: 5%
## Footnote
NOTE: Hep B immunoglobulin and vaccine can be given, HAART can be given for HIV immediately, Hep C has no PEP.
134
How can the eye be **injured** in anaesthesia?
* Corneal abrasion (direct trauma)
* Exposure keratitis (drying out)
* Chemical injury (cleaning solutions)
* Pressure (prone position)
135
Outline the **Armitage formula** for caudal blocks in children.
* **Lumbosacral**: 0.5 mL/kg
* **Thoracolumbar**: 1 mL/kg
* **Mid-thoracic**: 1.25 mL/kg
Maximum: 20 mL
## Footnote
Recommended: 0.25% bupivacaine.
136
What are some indications for a **tracheostomy**?
* Head and neck cancer
* Emergency CICO
* Weaning from ventilation
137
What is the typical composition of **heavy bupivacaine**?
0.5% bupivacaine with 80 mg/mL (8%) dextrose
138
What are the **two most effective positions** in which to place the defibrillation pads?
* Anteroposterior
* Anteroapical
139
Describe what happens to the heart during **defibrillation**.
* Depolarisation of entire myocardium
* Enters refractory state and arrhythmia ends
* Pacemaker cells initiate new electrical impulse (which hopefully propagates along normal pathways)
140
What are the indications for using a **throat pack**?
* Prevent blood entering the stomach during ENT/maxfax.
* Stabilisation of endotracheal tube in prone patient.
141
Describe how to insert a **classic LMA**.
* Deflate LMA
* Apply lube to back of cuff
* Hold LMA with index finger at junction of cuff and tube
* Push LMA backwards along hard palate
* Insert LMA with index finger fully into mouth until resistance is felt
* Inflate cuff with recommended volume
142
What are some **advantages** of using an LMA?
* Less skill required than intubation
* Used for spontaneous and controlled ventilation
* Neuromuscular blockers NOT required
* Minimal haemodynamic disturbance at insertion
* Can be used as part of DAS guidelines
143
What are the **three main types** of ventilator-associated lung injury?
* **Atelectrauma**: caused by repetitive opening and closing of alveoli.
* **Volutrauma**: overdistension of alveoli due to excessive tidal volume.
* **Barotrauma**: excessive airway pressures causing alveolar rupture.
144
How is **Allen's test** performed?
* Patient clenches fist for 30 seconds
* Compress radial and ulnar arteries
* Unclench hand (appears blanched)
* Ulnar artery released - if sufficient flow, colour should return within 15 seconds
145
What is this pattern on **capnography** suggestive of?
Wearing off of neuromuscular blockade (patient is trying to make respiratory efforts).
146
List indications for **central venous access**.
* Irritant drugs
* ECMO and RRT
* Pacing wires
* Cardiac output monitoring
* CVP monitoring/venous sats
* Blood sampling
* Poor peripheral access
147
What **BIS range** is suggestive of surgical anaesthesia?
40-60
## Footnote
NOTE: 60-85 is suggestive of sedation.
148
How do you size a **blood pressure cuff**?
* Cuff should cover at least 2/3 of upper arm.
* Cuff bladder should be at least 20% wider than arm diameter.
149
What are some **consequences** of regular non-invasive blood pressure measurement?
* Nerve palsies
* Digital ischaemia
* Petechial haemorrhages
150
What risks are associated with CT scans in an **anaesthetised patient**?
* Ionising radiation
* Anaesthesia in remote environment
* Risk of transfer from bed to CT
* Risk of accidental extubation
* Physical separation from patient
151
What are the **mechanisms** by which regional anaesthesia can cause peripheral nerve injury?
* **MECHANICAL**: direct damage
* **PRESSURE**: due to intraneural injection --> ischaemia
* **CHEMICAL**: toxic effects of LA
* **VASCULAR**: direct trauma or occlusion of vasa vasorum
152
What **measures** reduce the risk of nerve injury in regional anaesthesia?
* Perform in awake patients
* Short-bevelled blunt-tipped needles
* Monitor injection pressure
* Ultrasound
153
Which **surgical positions** are most commonly associated with common peroneal nerve injury?
* Lithotomy
* Lateral decubitus (less common)
## Footnote
NOTE: Risk can be reduced by padding the outer aspect of upper fibula and avoiding prolonged lithotomy position.
154
What positioning will place the brachial plexus at risk during **general anaesthesia**?
* Shoulder abduction > 90 degrees
* Excessive head rotation
* Excessive neck lateral flexion
155
How **common** are dental injuries in general anaesthesia?
1 in 4500
## Footnote
NOTE: Soft tissue injuries of oropharyngeal cavity are present in around 50% of patients.
156
What are the risks of **epidural analgesia**?
* Hypotension
* Inadequate block (1 in 50 need GA)
* High block
* Post-dural puncture headache (1 in 100)
* Epidural haematoma
* Temporary (1 in 2000) and permanent (1 in 20,000) nerve damage
* Paralysis (< 1 in 80,000)
157
What **checks** do you perform to ensure an epidural catheter is in the right place?
* Meniscus drop
* Hold catheter below epidural site for 20-30 seconds and look for blood tracking
* Flush catheter
* Test dose of local anaesthetic
158
What is the **meniscus drop test** to ensure that the epidural catheter is in the right place?
Hold the meniscus upright and watch the fluid drain downwards (epidural space is slightly subatmospheric).
159
What **test dose** of local anaesthetic checks if the epidural catheter is in the right place?
10 mL of low-dose mix (0.1% bupivacaine + 2 mcg/mL fentanyl) or 3 mL of 2% lidocaine.
Enough to confirm an intrathecal catheter without causing total spinal.
Check after 5 mins for sensory or motor block.
160
List sites you could use for **intraosseous access**.
* Proximal tibia (MOST COMMON)
* Distal tibia
* Distal femur
* Humeral head
* Sternum
161
How would you administer the first fluid bolus through an intraosseous needle in an **awake patient**?
* Slow injection of lidocaine
* Use 50 mL syringe or pressure-bag to deliver fluid bolus
162
What are some contraindications for **IO line insertion**?
* Bone trauma proximal to site
* Infection overlying site
* Prosthesis
163
What are some complications of **intraosseous access**?
* Compartment syndrome
* Damage to growth plate
* Fracture
* Osteomyelitis
164
What are **four perioperative reasons** for inserting an arterial line?
* Anticipated haemodynamic instability (e.g. unwell laparotomy)
* Anticipated use of vasoactive drugs
* Frequency blood sampling
* Non-invasive BP is unreliable (e.g. morbid obesity)
165
How much pressure is applied on the **cricoid**?
* 10 N awake
* 30 N asleep
166
List contraindications for **spinal anaesthesia**.
* Local infection
* Bleeding disorders
* Severe aortic stenosis
* Raised ICP
* Local anaesthetic allergy
167
What is **transient neurological syndrome** with regards to spinal anaesthesia?
* Pain or dysaesthesia in the buttocks/legs after uncomplicated spinal block
* Starts within hours and lasts days
* More common with lidocaine
168
What are some advantages and disadvantages of **adding opioids** to a spinal anaesthetic?
**ADVANTAGES**
* Improves quality of block
* Reduced post-operative analgesic requirements
* Reduced opioid side-effects
**DISADVANTAGES**
* Itching
* Urinary retention
* Delayed respiratory depression
169
How **long** can a tracheostomy tube be kept in for before needing changing?
* Usually 30 days if there is an inner cannula
* It is 7-10 days for a tube without an inner cannula
Primary FRCA
flashcards
Decks in class (17)
# Cards
-
Anatomy for Anaesthesia223
-
Physiology: Respiratory303
-
Physiology: Cardiovascular179
-
Physiology: Renal, Hepatic & GI63
-
Physiology: Neuro, Endo, & Haem237
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Pharmacokinetics and Pharmacodynamics213
-
Pharmacology: Inhalational & Intravenous Agents232
-
Pharmacology: Analgesics & Muscle Relaxants160
-
Pharmacology: Emergency & Miscellaneous Drugs251
-
Part 1: Physics & Equipment242
-
Part 2: Physics & Equipment227
-
Part 3: Physics & Equipment232
-
Part 4: Physics & Equipment217
-
Statistics & Evidence-Based Practice36
-
Part 1: Applied Clinical Anaesthesia165
-
Part 2: Applied Clinical Anaesthesia169
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Part 3: Applied Clinical Anaesthesia157
