Primary FRCA > Part 3: Applied Clinical Anaesthesia > Flashcards

Part 3: Applied Clinical Anaesthesia Flashcards

Integrate knowledge of airway management, perioperative physiology, patient safety, communication, ethics, and human factors in anaesthetic practice. (157 cards)

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1
Q

What is the earliest time point at which you would consider replacing a tracheostomy after a new one has been inserted?

A

7 days

This allows enough time for the tract to mature (reduces risk of subsequent misplacement).

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2
Q

What are the cardiovascular consequences of a high spinal injury?

A
  • Decreased SVR (loss of sympathetic tone)
  • Decreased preload
  • Bradycardia (loss of sympathetic fibres to heart)
  • Autonomic dysreflexia
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3
Q

At what point after a spinal cord injury is there a risk of hyperkalaemia with suxamethonium?

A

48 hours onwards

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4
Q

What are the indications for doing a CT head scan within 1 hour of injury?

A
  • GCS < 13 on initial assessment in ED
  • GCS < 15 two hours after injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture
  • Post-traumatic seizure
  • Focal neurological deficit
  • More than one episode of vomiting
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5
Q

What are the targets for neuroprotective ventilation?

A
  • Normoxia: > 8 kPa
  • Normocapnia: 4.5-5.0 kPa
  • PEEP > 5 cm H2O
  • Normotension: MAP > 90 mm Hg (normal CPP is 60-80 mm Hg)
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6
Q

How many times more radiation exposure do you get with a CT chest compared to a chest X-ray?

A

70 times

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7
Q

How far above the carina should the bevel of the endotracheal tube be positioned in an adult with the head in a neutral position?

A

3-7 cm

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8
Q

How would the presence of an ICD affect your anaesthetic management?

A
  • Switch off ICD (cardiac physiologist or magnet)
  • Place external defibrillator pads
  • Avoid monopolar diathermy
  • Avoid suxamethonium (fibrilliations can be misinterpreted as VF)
  • Intraoperative warming (shivering can be misinterpreted as VF)
  • Post-op ICD check by cardiac physiologist
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9
Q

What is a never event?

A

Serious incident that is wholly preventable because guidance or safety recommendations are available at a national level.

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10
Q

Give examples of perioperative never events.

A

SURGICAL

  • Wrong site surgery
  • Retained foreign object (e.g. swabs)

MEDICATION

  • Wrong route (e.g. IV local anaesthetic)
  • Insulin overdose

GENERAL

  • ABO incompatible transfusion
  • Enteral feeding via misplaced NG tube
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11
Q

Outline the Le Fort classification for midface fractures.

A
  • Le Fort 1: transverse fracture through maxillary sinuses
  • Le Fort 2: oblique across zygomaticomaxillary suture, inferior orbital ridge and nasal bridge
  • Le Fort 3: horizontal above the zygomatic arch and through the lateral and medial walls of the orbit
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12
Q

How can traumatic epistaxis be controlled?

A
  • Nasal packing (e.g. Rapid Rhino)
  • Manual reduction of fractures
  • Embolisation
  • External carotid artery ligation
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13
Q

What are three signs of an effective cough in a choking child?

A
  • Crying or verbal response to questions
  • Loud cough
  • Can take breath in before coughing
  • Fully responsive
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14
Q

How would you manage a choking 5-year-old patient with an ineffective cough?

A

CONSCIOUS: 5 back blows then 5 abdominal thrusts

UNCONSCIOUS: open airway, 5 rescue breaths, start CPR

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15
Q

Why are button batteries so dangerous to swallow?

A
  • Generates hydroxide ions at negative pole
  • Can cause alkaline corrosive injury to mucosa resulting in perforation
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16
Q

Within what time period should surgical fixation of a neck of femur fracture take place?

A

36 hours

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17
Q

How do you perform a leak test in a breathing system?

A
  • Set all gas flows to zero
  • Close APL
  • Occlude outlet
  • Press oxygen flush to increase pressure to 30 cm H2O
  • Ensure pressure remains elevated for 10 seconds
  • Open APL valve to decrease pressure
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18
Q

When is a rise in troponin detectable after an infarct and how long does it last?

A
  • Detectable: 3-6 hours
  • Peak: 12 hours
  • Duration: 14 days

NOTE: CK-MB rises within 4 hours of injury

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19
Q

Describe approaches to topicalising the airway before awake fibreoptic intubation.

A

NASOPHARYNX

  • Cocaine solution 1.5 mg/kg
  • Lidocaine 5% + phenylephrine 0.5%

OROPHARYNX

  • Lidocaine 4% (gargle 4-5 mLs)
  • Lidocaine 10% (3-4 sprays)

OTHER

  • Nebulisation of lidocaine 4%
  • Spray as you go (lidocaine 4% sprayed through working channel of fibreoptic scope)
  • Translaryngeal (via needle through cricothyroid membrane)
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20
Q

After performing a needle cricothyroidotomy, what precautions must you take to prevent barotrauma?

A

Ensure the chest is deflating after the first inflation.

If not, insert a second cannula for expiration.

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21
Q

Outline the paediatric ALS algorithm.

A

5 initial rescue breaths
Then 15:2 ratio of compressions to breaths

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22
Q

How do you size a Guedel airway?

A

Midpoint of incisors to angle of mandible.

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23
Q

What rate of chest compressions would you administer in ALS?

A

100-120/min

NOTE: In paediatrics, aim for 1/3 of chest depth with compressions.

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24
Q

What dose of intravenous and intraosseous adrenaline is used in paediatric cardiac arrest?

A

10 µg/kg

(0.1 mL/kg of 1 in 10,000)

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25
What **fluid bolus** is administered in paediatrics resuscitation?
20 mL/kg
26
What **intravenous dose** of adrenaline is used in intra-operative anaphylaxis?
100 µg 1 mL of 1 in 10,000 10 mL of 1 in 100,000
27
Why are amide local anaesthetics **preferred** to ester local anaesthetics?
* Better penetration * Faster onset * Longer duration * Less histamine release (PABA)
28
What are some indications for an **intercostal nerve block**?
* Breast surgery * Rib fractures * Intercostal drain insertion * Thoracic surgery * Upper abdominal surgery (superficial block only)
29
How would you perform a **stellate ganglion block**?
**POSITION**: supine with neck extension **PARATRACHEAL**: Insert needle between trachea and carotid sheath at the level of the cricoid and Chassaignac's tubercle (C6) ## Footnote NOTE: You aim for C6 to avoid the lungs and vertebral artery.
30
List some indications for a **stellate ganglion block**.
* Complex regional pain syndrome * Refractory angina * Phantom limb pain * Raynaud syndrome
31
What are some **features** of a successful stellate ganglion block?
* Horner syndrome * Increase in temperature of limb
32
What **criteria** need to be fulfilled before brainstem testing is carried out?
* Apnoea and mechanically ventilated * Established cause of irreversible brain injury (e.g. trauma) * Exclusion of reversible causes
33
Briefly outline the steps involved in **brainstem death testing**.
* Pupillary light reflex * Corneal reflex * Vestibulo-ocular reflex * Gag reflex * Cough reflex Apnoea test: no breathing with PaCO2 > 6 kPa Repeat by two senior clinicians, twice.
34
What **volume** of local anaesthetic is needed in a lumbar epidural per segment blocked?
2 mL per segment ## Footnote NOTE: For spinal anaesthetics it is around 0.2 mL per segment.
35
How many **ribs** should you be able to see anteriorly and posteriorly in a chest X-ray with adequate inspiration?
Anterior: 5-6 Posterior: 8-10
36
Why can massive blood transfusion lead to **metabolic alkalosis**?
Citrate in the blood products is metabolised to bicarbonate by the liver.
37
List **contraindications** for a Bier's block.
* Peripheral vascular disease * Sickle cell disease * Infection in the limb * Local anaesthetic toxicity
38
What are the **different approaches** to anaesthetising for eye surgery?
* Topical * Peribulbar (extraconal) * Retrobulbar (intraconal) * Sub-Tenon's (episcleral)
39
What anaesthetic agent is used for a **sub-Tenon's block**?
2% lidocaine with 1 in 200,000 adrenaline 7.5 U/mL of hyaluronidase ## Footnote NOTE: Hyaluronidase facilitates diffusion of local anaesthetic solution within the orbit.
40
What are some **complications** associated with ophthalmic regional block?
* Retrobulbar haemorrhage * Subconjunctival haemorrhage * Chemosis * Optic nerve damage * Globe perforation * Infection * Oculocardiac reflex
41
What sternomental and thyromental distances are suggestive of a **difficult intubation**?
* Thyromental < 6 cm * Sternomental < 12 cm
42
What are the components of a **STOP-BANG score** and how do you interpret it?
**STOP** (symptoms & history): * Snoring * Tired * Observed apnoea * Pressure (blood) **BANG** (patient characteristics): * BMI > 35 kg/m² * Age > 50 years * Neck circumference > 40 cm * Gender = Male 3-4 = intermediate risk 5+ = high risk
43
What does the **SORT score** predict?
Estimates the risk of death within 30 days of inpatient surgery.
44
What is **Lee's cardiac risk index** used for?
Estimates risk of cardiac complications after noncardiac surgery. ## Footnote NOTE: Score of 3 or more is associated with 10% risk.
45
What is **P-POSSUM** used for?
Predicts postoperative mortality and morbidity for any type of surgery.
46
# Define: flail chest
Three or more adjacent ribs fractured in at least two places, creating a free-floating segment of chest wall that moves paradoxically.
47
What measures should be taken in cases of **delayed emergence**?
* Check ET anaesthetic agent * Naloxone * Reversal of NMB (check TOF) * Capillary glucose * Temperature * Arterial blood gas (check pCO2, pH and Na) * Check pupils (intracranial event)
48
Outline the management of a **tracheostomy emergency**.
1. apply O2 to mouth and tracheostomy (use capnography) 2. remove speaking valve and inner tube 3. pass suction catheter 4. deflate cuff 5. remove tracheostomy tube 6. standard oral airway manoeuvres with stoma covered or ventilate via stoma 7. attempt oral intubation or intubation of stoma
49
How **long** after the initial dose of levobupivacaine through an epidural will you feel the effects?
15-20 mins
50
What are the risks of applying **cricoid pressure**?
* Makes intubation more difficult * Oesophageal rupture (if applied during active vomiting)
51
Where should you perform needle decompression of a **tension pneumothorax**?
2nd intercostal space at the midclavicular line or the 4th or 5th intercostal space at the midaxillary line.
52
What are some complications associated with the **sitting position** for surgery?
* Postural hypotension * Venous air embolism * Brachial plexus injury
53
What **measures** should be taken ahead of a planned tracheostomy/ETT change?
* Stop enteral feed * Aspirate NG tube * Preoxygenate * Prepare equipment and drugs for intubation * Check previous laryngoscopy grade * Suction trachea, pharynx and subglottic suction port
54
What **measures** can be taken to reduce the chances of a tracheostomy tube becoming blocked?
* Regular suctioning * Humidification of inspired air * Cannula with inner tube
55
Which specific complication is associated with **interscalene blocks**?
Phrenic nerve palsy ## Footnote The phrenic nerve runs on the anterior aspect of the anterior scalene.
56
State the **periods of omission** for antiplatelet agents prior to neuraxial blockade?
* **Aspirin, NSAIDs, dipyridamole**: continue * **Clopidogrel and Prasugrel**: 7 days * **Ticagrelor**: 5 days * **Tirofiban and Eptifibatide**: 8 hours * **Abciximab**: 48 hours
57
Why do local anaesthetics **preferentially exert their effects** on sensory nerves compared to motor nerves?
They bind more readily to inactivated or open sodium channels and so affect nerves with a rapid firing rate (e.g. sensory nerves) compared to motor nerves. Sensory nerves are also generally smaller than motor nerves.
58
How is an **interscalene block** performed?
Involves injecting local anaesthetic around the TRUNKS of the brachial plexus as it passes through the groove between the anterior and middle scalene muscle at the level of the cricoid cartilage.
59
What is the **best nerve** to stimulate when monitoring neuromuscular blockade?
Ulnar nerve ## Footnote Innervates adductor pollicis and is easily accessible during surgery. It is also more sensitive to NMBs than the diaphragm and larynx meaning that its recovery suggests that more critical muscles have likely recovered fully.
60
Outline the **AAGBI guidance** regarding how long heparin and warfarin should be discontinued for prior to neuraxial anaesthesia.
* UFH (IV or SC, treatment or prophylaxis): 4 hours or normal APTTR * LMWH (prophylactic dose): 12 hours * LMWH (treatment dose): 24 hours * Warfarin: INR < 1.4
61
How does the ALS algorithm for cardiac arrest change if the **core temperature is < 30 degrees**?
If shockable, a total of 3 DC shocks should be administered. If these fail, do NOT shock further until rewarmed to over 30 degrees. Do NOT administer adrenaline if core temp < 30 degrees. Increase adrenaline dosing interval to every 6-10 mins if temperature 30-34 degrees (as drug metabolism slows).
62
What is the **current recommendation** for intraoperative steroid cover in steroid-dependent patients?
For those on > 5 mg prednisolone equivalent daily for 4 weeks or longer: * **Option 1**: hydrocortisone 100 mg IV at induction, then continuous infusion of 200 mg over 24 hours * **Option 2**: dexamethasone 6-8 mg IV (covers next 24 hours)
63
Describe the mechanism underpinning **organophosphate poisoning**.
Organophosphates phosphorylate the esteratic site of AChE. Inhibition becomes irreversible as the phosphorylated AChE reacts very slowly with water resulting in a rise in a widespread rise in synaptic ACh concentrations.
64
Outline the step-by-step management of **bronchospasm**.
1. 100% Oxygen 2. Increase volatile (not desflurane) 3. Beta-2 agonist 4. Magnesium, ketamine, ipratropium, hydrocortisone, aminophylline ## Footnote NOTE: Desflurane should NOT be increased because it is an airway irritant.
65
Outline the **AAGBI guidance** on DOAC discontinuation before neuraxial anaesthesia.
* **Rivaroxaban** (prophylaxis): 18 hrs * **Rivaroxaban** (treatment): 48 hrs * **Apixaban** (prophylaxis): 24-48 hrs * **Dabigatran**: * CrCl > 80: 48 hrs * CrCl 50-80: 72 hrs * CrCl 30-50: 96 hrs ## Footnote NOTE: Next drug dose after catheter removal can be given at 6 hours.
66
Which feature of **intrathecal anaesthesia** is the most important factor in determining the duration of the block?
Dose of the drug
67
What are the **differences** in the parts of the brachial plexus blocked by supraclavicular, infraclavicular, and interscalene blocks?
* **Supraclavicular**: blocks trunks and divisions * **Infraclavicular**: blocks cords * **Interscalene**: blocks roots
68
What mechanism underpins transfusion associated **acute lung injury**?
**Donor antibodies** (usually anti-HLA or anti-neutrophil) activating **recipient neutrophils** in the pulmonary vasculature, leading to capillary leak and non-cardiogenic pulmonary oedema
69
What are some causes of **increased airway pressure**?
* **ANAESTHETIC**: blockage in circuit, inappropriate ventilator settings, oesophageal intubation * **SURGICAL**: capnoperitoneum, head down positioning * **PATIENT**: laryngospasm, bronchospasm, anaphylaxis, aspiration, pulmonary oedema, mucus
70
What are some potential causes of **intraoperative hypertension**?
* **ANAESTHETIC**: inadequate anaesthesia, analgesia or neuromuscular blockade, drug error * **SURGICAL**: tourniquet, vasopressor administration by surgeon * **PATIENT**: missed antihypertensives, thyrotoxicosis, phaeochromocytoma
71
List some causes of **intraoperative bradycardia**.
* **ANAESTHETIC**: remifentanil, digoxin, high intrathoracic pressure, reflex bradycardia (metaraminol), local anaesthetic systemic toxicity * **SURGICAL**: capnoperitoneum * **PATIENT**: previous medications (beta blockers, calcium channel blockers, digoxin)
72
Describe how you would set the pacer output for **transcutaneous pacing**.
* Increase pacer output from 60 mA until capture (spikes align with QRS) * Confirm both electrical AND mechanical capture (femoral pulse) * Set pacer output at 10 mA above capture
73
List some causes of **intraoperative tachycardia**.
* **ANAESTHETIC**: inadequate analgesia or anaesthesia, drug error, hypovolaemia, anaphylaxis * **SURGICAL**: intense stimulation, bleeding, circulatory embolus * **PATIENT**: primary cardiac arrhythmia, electrolyte disturbance, malignant hyperthermia
74
List some causes of **perioperative hyperthermia**.
* **ANAESTHETIC**: excessive warming, blood transfusion * **SURGICAL**: sepsis, surgical devices (e.g. diathermy) * **PATIENT**: neuroleptic malignant syndrome, serotonin syndrome, thyrotoxicosis, malignant hyperthermia, alcohol withdrawal, sympathomimetic syndrome
75
What are the transfusion goals in **massive intraoperative haemorrhage**?
* Hb > 80 g/L * Platelets > 75 * PT and APTT < 1.5 * Fibrinogen > 1 g/L ## Footnote Avoid DIC (maintain BP, treat acidosis, avoid hypothermia, treat hypocalcaemia and hyperkalaemia).
76
What is the risk of nerve damage with **neuraxial anaesthesia**?
* Temporary: 1 in 1857 * Permanent: 1 in 20,000 * Paralysis: < 1 in 80,000
77
What is the risk of anaphylaxis in the **perioperative period**?
1 in 10,000
78
What are the **different types of Lundberg waves** you'd see on ICP monitoring and what are they suggestive of?
Lundberg A: plateau waves, suggestive of impending herniation (Cushing's reflex) Lundberg B: rhythmic spikes every 30-120 seconds, cerebral vasospasm Lundberg C: low amplitude oscillations every 7-15 secs which represents NORMAL central venous homeostasis
79
What are the components of the **Apfel score**?
1. Female sex 2. Non-smoker 3. History of PONV or motion sickness 4. Planned use of post-operative opioids
80
List key differences between the **respiratory systems** of children and adults.
* **Narrowest airway point**: Child - cricoid cartilage; Adult - true vocal cords * **Minute ventilation**: Child - higher (100-150 ml/kg/min vs 60 ml/kg/min) * **Basal oxygen consumption**: Child - higher (6 vs 3.5 ml/kg/min) * **Epiglottis**: Child - larger
81
What is the formula for the **correct QT interval**?
QTc = QT/√RR RR = RR interval ## Footnote This is known as Bazett's formula.
82
What **combination** of anaesthetic agents would minimise rises in intracranial pressure?
* Thiopentone * Rocuronium * Isoflurane
83
Which **reflexes** are tested in brainstem death testing?
* Pupillary light (II + III) * Corneal (V + VII) * Facial pain (V + VII) * Vestibulo-ocular reflex (VIII + III/IV/VI) * Gag reflex (IX + X) * Cough reflex (X + X)
84
What are the **three components** of the DOTS classification of unwanted drug effects?
* Dose-Relatedness (at normal dose or overdose) * Time-Relatedness (during treatment, or independent of duration) * Susceptibility (e.g. age, sex)
85
What are some **key considerations** for how you would extubate a patient following a tonsillectomy?
* **Awake** - ensure that they are very awake and able to protect their own airway before extubation * **Deep** - extubate in the left lateral position so that any airway secretions/blood will come out of the mouth
86
What **dose of dantrolene** is used in malignant hyperthermia?
2.5 mg/kg bolus ## Footnote Then 1 mg/kg as required up to a maximum of 10 mg/kg (usually every 10-15 mins)
87
What are the clinical features of a **life-threatening asthma attack**?
* PEF <33% of best or predicted * SpO2 <92% * Silent chest, cyanosis, or feeble respiratory effort * Arrhythmia or hypotension * Exhaustion, altered consciousness * Normal PaCO2 * PaO2 < 8 kPa irrespective of treatment with oxygen * Acidosis
88
What are the clinical features of a **severe asthma attack**?
* Peak expiratory flow (PEF) 33–50% of best (use % predicted if recent best unknown). * Can't complete sentences in one breath. * Respiration > 25breaths/minute. * Pulse >110beats/minute.
89
What **clinical features** should make you consider a possible diagnosis of malignant hyperthermia?
Unexplained rise in ETCO2, heart rate and oxygen consumption
90
What are the **key aspects** of managing **malignant hyperthermia**?
* Immediate cooling * Dantrolene administration * Supportive care * Monitor vital signs * Treat complications * Prevent recurrence
91
What are the **main consequences** of malignant hyperthermia which require diagnosis and treatment?
* Acidosis (give bicarbonate) * Hyperkalaemia * Myoglobulinuria (forced alkaline diuresis) * DIC (blood products) * Tachyarrhythmias * Compartment syndrome
92
Which **cervical vertebra** is most commonly fractured?
C2
93
What are the **Korotkoff sounds**?
1. appearance of clear tapping (SBP) 2. softer 3. louder tapping (MAP) 4. softer 5. disappearance (DBP)
94
How **high** should you inflate the blood pressure cuff when taking manual blood pressure?
20-30 mm Hg above the point at which the radial pulse disappears.
95
What **fresh gas flow** is required for spontaneous and controlled breathing via a Jackson-Rees modification of an **Ayre's T piece**?
* Spontaneous ventilation: ~200–300 mL/kg/min * Controlled ventilation: ~100 mL/kg/min
96
What **fresh gas flow** is required for spontaneous and controlled breathing via a **Bain circuit**?
Spontaneous ventilation: 150 mL/kg/min Controlled ventilation: 70 mL/kg/min
97
What are some advantages and disadvantages of a **Jackson-Rees circuit**?
**Advantages**: low resistance, simple, allows visual monitoring. **Disadvantages**: needs high flows, risk of obstruction/barotrauma, causes gas pollution.
98
# Define: breathing system
A breathing system is the assembly that supplies fresh gases, removes CO₂, and allows patient ventilation safely.
99
What are the **life-threatening features** of the adult tachy- and bradycardia algorithms?
* Shock * Syncope * Myocardial ischaemia * Severe heart failure
100
What are **two key ways** in which the obstetric cardiac arrest algorithm differs from the adult cardiac arrest algorithm?
* Left lateral tilt * Perimortem C-section if no ROSC after 5 mins
101
What are some specific **reversible causes** of cardiac arrest that are more likely to be seen in obstetric patients?
* High spinal * Local anaesthetic toxicity * Amniotic fluid embolism
102
Where should you check oxygen saturation in a **neonate**?
Right hand (pre-ductal)
103
When should mast cell tryptase levels be sent after a suspected case of **anaphylaxis**?
* Immediately * 2-3 hours * 24 hours (baseline) ## Footnote AFTERCARE: Refer to allergy clinic, report anaphylaxis to MHRA.
104
What factors promote **heat loss** during anaesthesia?
* **PATIENT**: elderly, paediatric, hypothyroid * **SURGICAL**: open surgery of moist body cavity, cold irrigation fluids, prolonged case * **ANAESTHETIC**: vasodilating agents, paralysis, cold IV/blood products
105
What is the purpose of a **three bottle chest drain**?
* Bottle 1: Collection chamber (fluid) * Bottle 2: Water-seal chamber * Bottle 3: Suction control bottle — open to atmosphere, limits the amount of negative pressure applied ## Footnote NOTE: Indicated when suction needs to be applied (e.g. persistent pneumothorax, incomplete lung expansion, post-thoracic surgery).
106
What is the purpose of a **two bottle chest drain**?
* Bottle 1: Collection chamber (fluid) * Bottle 2: Water-seal chamber ## Footnote NOTE: This is used for conditions where you want to drain fluid and air.
107
What is the **atlanto-dental interval** and what are the normal ranges?
Distance between the posterior surface of the anterior arch of the atlas (C1) and the anterior surface of the odontoid process (dens) of the axis (C2). Adult < 3 mm Child < 5 mm ## Footnote NOTE: Raised interval is suggestive of atlanto-axial subluxation.
108
List conditions that are associated with **atlanto-axial instability**.
* Down syndrome * Ankylosing spondylitis * Rheumatoid arthritis * Ehlers-Danlos syndrome
109
What different parts of the **brachial plexus** are targeted by the following regional blocks? * Interscalene * Supraclavicular * Infraclavicular * Axillary
* **Interscalene**: Roots * **Supraclavicular**: Trunks & Divisions * **Infraclavicular**: Cords * **Axillary**: Terminal Branches
110
What is the sensitivity and specificity of the **Mallampati score**?
SENSITIVITY: 50% SPECIFICITY: 90%
111
What is **Wilson's score**?
Tool for assessing difficult airways Based on: weight, head and neck movement, jaw movement, receding mandible, buck teeth Score of 4+ out of 10 is suggestive of difficult airway Sensitivity: 75% Specificity: 90%
112
What factors affect the absorption of irrigation fluid leading to **TURP syndrome**?
* Duration of surgery * Hydrostatic pressure of irrigation fluid * Size of prostatic veins exposed
113
What are the **clinical manifestations** of TURP syndrome?
* EARLY: restlessness, confusion, nausea * CVS: hypertension, bradycardia * SEVERE: pulmonary oedema, seizures, coma * LAB: hyponatraemia
114
What combination of agents is used for anaesthesia for **electroconvulsive therapy**?
SHORT-ACTING Propofol + Suxamethonium Usually bag-mask ventilated
115
Outline some **safety measures** when taking an intubated patient to MRI.
* DRUGS: emergency drugs, paralysis, maintenance of anaesthesia * EQUIPMENT: airway equipment, Ambu bag, Mapleson C, 2 oxygen cylinders, monitor, sufficient length tubings on circuit/capnography/monitors * MONITORS: standard AAGBI with long cables, MRI safe * PERSONNEL: trained ODP, porter
116
What are some factors to consider when determining whether a patient is appropriate for **day case surgery**?
* PATIENT: functionally fit, has someone to take them home, low risk of complications, stable post-op destination * SURGICAL: operation does not require special post-operative support (e.g. new stoma), can mobilise afterwards * ANAESTHETIC: judicious use of regional anaesthesia, short-acting drugs
117
Outline the management of a **needle stick injury**.
1. Wash and encourage bleeding 2. Report to line manager, occupational health and Datix 3. Risk assess and check immunisation status 4. PEP (HAART, HBV vaccine + immunoglobulin) 5. Investigations (patient and staff) 6. Follow-up with OH
118
What are the main treatments used for **pre-eclampsia**?
**ANTIHYPERTENSIVES**: nifedipine (10 mg), labetalol (50 mg IV), hydralazine (5 mg IV) **MAGNESIUM**: 4 g bolus, then 1 g per hour infusion, 2 g for recurrent seizures
119
Outline the management of **thyroid storm**.
* Supportive * Propylthiouracil * Lugol's Iodine * Propranolol * Steroids (reduces peripheral conversion of T4 to T3)
120
Outline the management of **myxoedema coma**.
* IV thyroid hormone replacement * IV steroids
121
How is **magnesium toxicity** treated?
1 g of calcium gluconate
122
How should an adrenaline infusion be set up in **refractory anaphylaxis**?
1 mg in 100 ml 0.9% sodium chloride via peripheral IV; start at 0.5 - 1.0 ml/kg/hr
123
Outline the classification of **antepartum haemorrhage**.
* Minor APH < 50 ml * Major APH 50-1000 ml with no shock * Massive APH >1000ml
124
Aside from blood products, which other medications should be administered in **obstetric major haemorrhage**?
* Tranexamic Acid 1 g IV (can repeat after 30 mins) * IV Fluid Boluses (until blood available) * 10 mL 10% calcium chloride ## Footnote NOTE: Perform TEG/Rotem.
125
What are the main causes of **obstetric haemorrhage**?
* TONE: uterine atony * TISSUE: retained placental tissue * TRAUMA: lacerations at birth * THROMBIN: clotting abnormalities
126
Which **uterotonic agents** can be given in obstetric major haemorrhage?
* Syntometrine or ergometrine IM * Oxytocin IV 5 units or infusion * Carboprost 250 µg IM * Misoprostol 1000 µg PR
127
Outline the management of a **high neuraxial block**.
* A & B: high flow oxygen, intubate and ventilate if apnoeic * C: treat bradycardia and hypotension ## Footnote Check height of block.
128
Outline the management of **DKA**.
* **Insulin**: 0.1 u/kg/hr IV * **Fluids**: Rapid 0.9% NaCl to restore volume, then 0.9% NaCl + K+ (based on VBG), add 10% glucose when glucose <14 mmol/L * **Targets**: ketone fall ≥0.5 mmol/L/hr, bicarb rise ≥3 mmol/L/hr, glucose fall ≥3 mmol/L/hr, resolution = ketones <0.6 & pH >7.3 * **Monitoring**: hourly cap glucose/ketones, VBG at 1, 2, 2-hourly, electrolytes 4-hourly
129
List features of **adenoid hyperplasia** in children.
* Mouth breathing * Snoring * OSA * Chronic nasal discharge * Recurrent otitis media * Feeding issues
130
What device is used by ENT surgeons to widen the surgical field for **tonsillectomy**?
Boyle-Davis mouth gag
131
# Define: massive transfusion
* >1 blood volume in 24 hours * >50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg)
132
What measures can be taken to reduce the risk of **CVC-related infections**?
* Aseptic technique * Skin prep (2% chlorhexidine + 70% alcohol) * Sterile transparent dressing with antimicrobial disc * Clean hub before use * Regular inspection of sites * Antibiotic impregnated CVCs (minocycline and rifampicin or chlorhexidine)
133
What are some **key differences** in the chest X-ray appearances of a child compared to an adult?
* Thorax shape: Child = round; Adult = rectangular * Heart size: Child = relatively larger (CT ratio up to 0.6); Adult = smaller (<0.5) * Ribs: Child = horizontal; Adult = downward sloping * Thymus: Child = prominent sail-shaped shadow * Bone ossification: Child = growth plates visible
134
What are the **obstetric risks** associated with use of epidural analgesia?
* Increase in 2nd stage of labour * Increased risk of instrumental delivery
135
What mix is usually used for **epidural analgesia** in obstetrics?
Levobupivacaine 0.1% plus fentanyl 2 micrograms/mL
136
What scoring system is used to assess the degree of motor block in **epidural anaesthesia**?
Bromage Score
137
What checks should you do before administering an **epidural top up**?
* Aspirate (no blood/CSF) * Test dose (e.g. 3 mL lidocaine 2% with adrenaline) * Check sensory level to cold/pin-prick * Check catheter position and fixation
138
Which medications are given as **post-exposure prophylaxis** following a needle stick injury?
* HBV Vaccine * HB Immunoglobulin (if known non-responder or unvaccinated) * HAART (emtricitabine, tenofovir disoproxil and raltegravir) ## Footnote NOTE: There is no Hep C PEP.
139
How do you administer an **epidural top up** for a **Caesarean section**?
AIM: convert T10 labour block to T4 surgical anaesthetic. * Aspirate + Test Dose (3 mL 2% Lidocaine) * Top Up Dose: 10-20 mL of 2% Lidocaine + Adrenaline (1:200,000) + Fentanyl (50-100 mcg) * May add bicarbonate * Administer in 5 mL aliquots, aiming for T4 (nipple line)
140
What are the benefits of adding an opioid to **epidural or spinal anaesthesia**?
* Improves block quality * Reduces the need for high volume LA
141
# Define: pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
142
What neurotransmitters are released by **first order pain neurones**?
* Glutamate * Aspartate * Substance P ## Footnote NOTE: Inhibitory neurotransmitters include enkephalins and GABA.
143
What is the **gate theory** of pain?
Pain signals are modulated in the substantia gelatinosa. Inhibitory interneurons can reduce transmission. The gate opens via C and A-delta fibers, and closes via A-beta fibers, descending inhibitory fibers, and enkephalinergic interneurons.
144
List **clinical measures** of the depth of anaesthesia.
* Isolated forearm technique * Lower oesophageal contractility
145
What are some **important MRI-specific considerations** for an anaesthetised patient?
* FERROUS IMPLANTS: Risk of movement, heating, artefacts * FERROUS EQUIPMENT: Only MR safe/conditional items * MONITORING: MR safe ECG, BP, SpO₂; short leads to prevent burns; machines outside Faraday cage with long circuits. * ANAESTHESIA: Use MR conditional pumps/machines; standard machines outside 100 G line with extended circuits.
146
What **measures** can be taken to reduce the risk of PONV?
* PRE-OP: benzodiazepines, hydration, reduce fasting time * POST-OP: TIVA, avoid nitrous, analgesia (including regional), dexamethasone, antiemetics
147
What **storage solutions** are used for blood?
* Acid-Citrate-Dextrose: 21 days, citrate for anticoagulation, dextrose for energy * Citrate-Phosphate-Dextrose: 28 days * CPDA-1 (+ adenine): 35 days * Saline-Adenine-Glucose-Mannitol (SAGM): allows more plasma removal for coagulation factor use.
148
In addition to the standard risks associated with blood transfusion, what **risks** are particularly important to be wary of in cases of massive transfusion?
* Thrombocytopenia (dilutional) * Coagulation factor depletion * Hypocalcaemia (3 g of citrate per unit of blood and liver can only metabolise 3 g every 5 mins) * Hyperkalaemia (conc may be over 30 mmol/L) * Acidosis (blood contains lactate) * Hypothermia
149
What measures can be taken to limit the need for **perioperative blood transfusions**?
* Set transfusion thresholds * Pre-donation (ahead of elective surgery) * Hypotensive anaesthesia * Antifibrinolytics (e.g. tranexamic acid) * Cell salvage
150
What are the main clinical features of **serotonin syndrome**?
* Agitation and confusion * Muscle rigidity * Hyperreflexia and clonus * Autonomic instability (hyperthermia, tachycardia) * Seizures * Rhabdomyolysis * Renal failure
151
What weight range can an **Ayre's T-piece** be used for?
< 20 kg
152
At what **stage** in a pregnancy would you be concerned about delayed gastric emptying and aorto-caval compression?
* Teratogenic Window: 4-10 weeks * Delayed Gastric Emptying: > 12 weeks * Aorto-Caval Compression: > 20 weeks
153
What **features** after administering a test dose through an epidural catheter may make you suspect intrathecal catheterisation?
* Fast block onset (< 10 mins) * Motor block * Hypotension * Higher block level than expected ## Footnote NOTE: Make everyone aware, only anaesthetist should give top ups.
154
How would you perform an **epidural blood patch**?
* 20-25 mL of blood taken via venepuncture * Senior anaesthetist performs repeat epidural and 20 mLs of blood slowly injected into epidural space ## Footnote NOTE: This is usually offered after conservative measures have failed.
155
What can be used for **epidural top ups**?
* 10 - 20 mls Lidocaine 2% + 1: 200,000 adrenaline * 10 - 15 mls Ropivacaine 0.75% * 10 - 20 mls Levobupivacaine 0.5%
156
Why is general anaesthesia more of a risk in patients with **pre-eclampsia**?
* More airway oedema * Pressor response from laryngoscopy causes dangerous rise in BP ## Footnote NOTE: Early epidural analgesia should be recommended because it will help with blood pressure control.
157
What oral antihypertensives can be used for **peri-partum hypertension**?
* Labetalol (PO): 200 mg * Nifedipine (PO): 20 mg
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