AnaesthesiaforMedicalStudentsReviewQuestions Chapter3:Preoperativeassessment **Problemidentification Cardiovascular:ischemicheartdiseaseriskformyocardialischaemia/infarctionin periopperiod o Hxforstabilityofangina,exercisetolerance o Considerationofvalvularheartdisease,arrhythmias,hypertension Respirology:cigarette,(stopfor8weeks,butstoppingfor24hstillimpartsbenefits) o COPDriskrespcomplications;asthmabronchospasm;ensurenoacute URTI o ExercisecapacitybyHx;restrictivelungdz,alteredcontrolofbreathing Neuromuscular:intracraniallesionseeksignsofedICP(nausea,vomiting, confusion,papilledema) o Pituitarylesions,TIAs/CVAs;SCIriskofcomplicationsoffailureandother shit;lowermotorneuronlesionsdocumentnervedeficitsbeforeusing

using regionalanaesthesia Endocrine:DM,thyroid,phaeochromocytoma,adrenalsuppression, GIHepatic:hepaticdz,GERD Renal:disordersoffluid/electrolytebalance,renalfailure Haematologic:anemias,coagulopathies Elderly:coexistingdiseaseanddiminishedorganfunction/organreserve Meds/allergies:needlist!Generallyptscantakeondayofsurgery o Exceptions;ASA,NSAIDs,insulin,oralhypoglycemics,antidepressants,MAOi Previousanaesthetics:responsetoprevious;FamHxofmalignanthyperthermiaand plasmacholinesterasedeficiency Surgeryproblems:ptsgeneralmedicalconditionandanticipatedintraoperative problems PhysEx:focusonairwayeval,CV,resp,othersystemswithsymptomsofdzfromHx o General:physicalandmentalstatus o Upperairway:teeth,opening(2fingers),thyromentaldistance(3fingers), TMJ(1finger)/cspinemobility(rememberthe321rule) o Lowerairway:resprate,thoraciccage,auscultation,peripheralsigns (clubbing,cyanosis) o CV:rate,rhythm,pressure,apicalimpulse,JVP,peripheraledema,S1/2, murmurs/S3/S4 Assessanatomyforarterialline/centralvenous/intravenousaccess Laboratorytesting: o Onlyifindicated o CBCwheresignifbloodlossanticipated,suspectedhaemdisorder,recent chemo o Lytesifptonantihypertensivemedications,ordiuretics,chemo, renal/adrenal/thyroiddisorders

o ECGforpts>50orHxofcardiacdz,HTN,periphvascdz,DM, renal/thyroid/metabolicdz o XrayfordebilitatingCOPD,asthma,inrespSxinpast6mos o Urinalysisforptsw/DM,renaldz,recenturinarytractinfection

1) DefinetheASAphysicalstatusclassification. IHealthypt IIMildsystemicdz;nofNallimitation IIISeveresystemicdz;definitefNallimitation IVSeveresystemicdz;aconstantthreattolife VMoribundpt;notexpectedtosurvivew/orw/outanoperationfor24hours 2) Howlongshouldelectivesurgerybepostponedfollowingamyocardialinfarction? Whatisthebasisofthisrecommendation? 6months,accordingtobothGoldmansCardiacRiskIndex,andDetskysMultifactorial Index,andthreeothercardiacstudies **Planningtheanaesthetic(5questionstoaskaboutptcondition) 1.Istheptsconditionoptimal? 2.Arethereanyprobswhichrequireconsultationorspecialtests? 3.Isthereanalternativeprocedurewhichmaybemoreappropriate? 4.Whataretheplansforpostopmanagementofthept? 5.Whatpremedicationifanyisappropriate? 3) Whatinformationshouldbeobtainedintheanaesthetichistory? HPI,Meds,Allergies,PMH/SurgHx,pastanaestheticHx,FamHxofanaestheticprobs, functionalinquiry,focusingoncardiorespsystems,NPOstatus,specificquestionsabout identifiedproblemlist 4) Whatcommonanaesthetictechniquescanbeusedtoprovideanaesthesiaforlower abdominalsurgery?(e.g.inguinalherniarepair) general,spinal(avoidintubationsympatheticstim[HR/BP],airwayreflexes [bronchospasm]) 5) A)Whatanaestheticrisksmightbeassociatedinapatientwhosmokesregularly?B) Whatinformationobtainedfromhistory,physical,orlaboratoryexaminationmight beusefulinassessingthisrisk?C)Aretheremeansofdecreasingtherisksof perioperativecomplicationsrelatedtosmoking? A)airwaysecretions,asthma,COPD,infections B)smokerscough,wheeze,medicationsforbreathing,limitstophysicalactivity/exercise tolerance,chronicinfections,asthma,COPD,CXR,PFT C)optmizept Chapter4:Premedication 1) Whyarepatientspremedicatedpriortosurgery? ptrelatedreasons:sedation,amnesia,analgesia,antisialogogueeffect,gastric acidity/volume,facilitateanaesthesiainduction

procedurerelatedreasons:Abxprophylaxis,gastricprophylaxis,corticosteroidcoverage, avoidreflexes(vagal),anticholinergic coexistingdiseases:continueptsownmeds,optimizeptsstatuspriortoprocedure(e.g. bronchodilators,nitroglycerine,blockers,Abx) 2) Whatarethegeneralcontraindicationstotheuseofbenzodiazepineoropioid premedications?(p.30generalcontraindicationstouseofpremedication) allergyorhypersensitivitytodrug;upperairwaycompromise/respfailure;hemodynamic instability/shock;decreasedlevelofconsciousnessorICP;severeliver,renal,thyroiddz; obstetricalpts;elderlyordebilitatedpts Chapter6:Intubationandanatomyoftheairway 1) Whatisthe123test? Usedtoassessseveralfactorsthatmayaffectdecisionsconcerningptsairwaymgmt. 1)IDanyrestrictedmobilityoftheTMJopenmouthwideaspossibleandnotemobilityat mandibularcondyle/TMjointspacecreatedb/ttragusofearandmandibularcondyleis ~1fingerbreadthinwidth 2)Mouthopening:atleast2fingers;noteloose/capped/missingteeth,bridges;with tonguemaximallyprotruded,shouldvisualizepharyngealarches,uvula,softpalate,hard palate,tonsillarbeds,posteriorpharyngealwall 3)Thyromentaldistancethyroidnotchtomentum;3cmpreferable 2) WhatdoesaclassIhypopharyngealviewmean?Whatstructuresarevisualizedina classIhypopharyngealview? adequateexposureoftheglottisduringdirectlaryngoscopyshouldbeeasilyachieved canseetongue,hard/softplate,uvula,pharyngealarches,tonsilarbeds,posterior pharyngealwall 3) WhatstructuresarevisualizedinagradeIIIlaryngealview? Onlyepiglottisandaportionofthearytenoids;possiblyahintofthespacebetweenthe vocalcords **Trachealintubation I. Positioningofpatient II. Openingpatientsmouth III. Performinglaryngoscopy IV. InsertionoftheETTthroughthevocalcordsandremovingthelaryngoscope V. Confirmationofcorrectplacement,andsecuringtheETT 4) Whatistheoptimalpositionoftheheadandneckforintubationusingdirect laryngoscopy? headandneckpositionedusingcombinationofbothcervicalflexionandatlantooccipital extension(thesniffingposition).Enablesalignmentofaxesofmouth/pharynx/larynx permitsdirectvisualizationoflarynxduringlaryngoscopy 5) Howistrachealintubationconfirmed?

ImmediateabsoluteproofobservingETTpassingthroughvocalcords;observingCO2 returningwitheachrespiration;visualizingtracheallumenthroughETTusingafibreoptic scope Indirectconfirmationlisteningoverepigastriumforabsenceofbreathsoundswith ventilation,observingchesttorise/fallw/+pressureventilation,listeningtoapexofeach lungfieldforbreathsoundswithventilation **IFINDOUBT,TAKEITOUT Ifunsureoftubeplacement,removeitandresumemaskventilationw/100%O2,stabilize ptandcallforhelp,ratherthanriskhypoxicinjuryandgastricaspiration. **IFINDOUBT,LEAVEITIN whenconsideringextubationafterptwasintubatedforatime,andthereareconcerns aboutsafeextubation,itissafertodelayextubation,continuetosupportventilation, ensuringhemodynamicstability,analgesia,andoxygenation,thanprematurelyextubating pt. 6) Name4simplemanoeuvresthatcanbeusedtoovercomeanupperairway obstruction. clearingtheairwayofanyforeignmaterial usingachinliftmanoeuvre usingajawthrustmanoeuvre insertinganoraland/ornasalairway positioningtheptontheirsideinthesemipronerecoveryposition Chapter7:Intubationdecisions 1) Whatlaboratorycriteriashouldyouusetoassesstheobjectiveneedforintubation andventilation? Oxygenation o PaO2<70mmHgwithFiO2=70% o AaDO2gradient>350mmHg(normalis15mmHg,andincreasesupto37 withincreasingage;PAO2=(PatmPH2O)xFiO2PaCO2/0.8 Ventilation o RR>35/mininadults(muscleswillfatigue) o PaCO2>60innormaladults o PaCO2>45instatusasthmaticus(andrising,despitemaximummedical mgmt) o RespiratoryacidosiswithpH<7.20inCOPDpts Mechanics o VC<15mL/kg(normalvitalcapacity=70mL/kgorapprox.5L;aVCof 15ml/kgisneededtocougheffectivelyandclearsecretions o NIF>25cmH2O(normalnegativeinspiratoryforceis~80to100cmH2O) 2) Whataresomeimportanthistoricalandclinicalfactorsthatsuggesttheneedto intubateandventilateapatient?

 Realorimpendingairwayobstruction(epiglottitis,thermalburns,mediastinal tumours) Protectionofairway(LOC,drugoverdoseetc.) Trachealbronchialtoiletptswhoareunabletocleartheirsecretions,theETT providesdirectaccessforsuctioningsecretions(e.g.,COPDw/pneumonia) Positivepressureventilationduringgeneralanaesthesia;otherindicationsforETT underGAinclude:longprocedure,difficultmaskventilation,operativesitenearpts airway,thoraciccavityopened,musclerelaxantsreqd,andifptindifficultposition tomaintainmaskanaesthesia Clinicalsignsofrespiratoryfailureandfatigue(diaphoresis,tachypnea,tachycardia, accessorymuscleuse,pulsusparadoxus,cyanosis) Shocknotimmediatelyreversedwithmedicaltreatment(i.e.notrespondingto medicalmgmtinfirst3545minutes) Chapter8:Laryngealmaskairway 1) WhatisthedifferencebetweenaLMAandanendotrachealtube? LMA:wideborePVCtubingwithdistalinflatablenonlatexlaryngealcuff;insertedw/o specialequipment,inbackofptspharynxw/softlaryngealcuffrestingabovevocalcords atjNoflarynxandesophagus ETT:genreqslaryngoscopeforinsertionintotrachea;passesthroughvocalcordsw/tip positionedinmidtrachea 2) Whywouldalaryngealmaskairwaybeusedratherthananendotrachealtube? ptswhohavenoIDdriskfactorsforaspirationandwhodonotreqintubationand controlledventilation makebedifficulttoobtainadequatesealw/facemaskinptsw/noteethorfullbeard,so LMAgoodforthosepts alsoLMAiseasytoinsert,canbepositionedw/minimalanaestheticdrugs(doesntreq musclerelaxants),doesntcauseasmuchtraumaandpositioningcomplicationsasETT, doesntcauseforeignbodyintracheareflexorlaryngospasm(whenremoved) Chapter9:Rapidsequenceinduction 1) WhatisthepurposeofaRSI? usedwhenaptreqGAwhohasbeenIDdashavingriskfactorsforgastricaspiration: LOC,trauma,mealw/in6hours,sphincterincompetencesuspected(GERD,hiatushernia, NGtube),edabdominalpressure(pregnancy,obesity,bowelobstruction,acuteabdomen) 2) DescribethesequenceofmanoeuvresusedinaRSI. 1.SetupIVaccess,cardiacmonitor,oximetry,andpossiblycapnography. 2.Planprocedureincorporatingassessmentofphysiologicstatusandairwaydifficulty. 3.Prepareequipment,suction,andpotentialrescuedevices. 4.Preoxygenate/denitrogenate:ptbreathes100%O2for35minutesorfor4vitalcapacity breathspriortoinductionofanaesthesia(doNOTbagventilate) 5.Considerpretreatmentagentsbasedonunderlyingconditions.*(e.g.Lidocaine,fentanyl, atropine)

6.Inducewithpotentsedativeagent. 7.Giveneuromuscularblockingagentimmediatelyafterinduction.(=fastactingmuscle relaxant,e.g.SCh) 8.BagmaskventilateONLYifhypoxic,considercricoidpressure.(Sellicksmanoeuvre: pressureoncricoidcartilagetocompressesophaguseagainstC6) 9.Intubatetracheaaftermusclerelaxationhasbeenachieved.(4560saftermuscle relaxantgiven).MustusecuffedETTtopreventaspirationofgastriccontents 10.Confirmplacementandsecuretube. 11.Providepostintubationsedationandpostintubationmanagement.(ventilatewhenETT inplaceandcuffinflated) 3) Whatisthepurposeofpreoxygenation? Getridofnitrogenandfloodalveoliw/oxygen,tobuymoretimebeforeaptdesats<90%, ifyoucandoyourshitright;e.g.takes2minutesforahealthypttodesatnormally,but takes6minutesifyoupreoxygenatefirst 4) Whichpatientsshouldberegardedasbeingatriskofpulmonaryaspirationof gastriccontents? LOC(drugoverdose,anaesthesia,headinjury,CNSpathology,traumaorshock) impairedairwayreflexes(prolongedtrachealintubation,localanaesthetictoairway, myopathies,CVA,LOC abnormalanatomy(Zenkersdiverticulum,esophagealstricture) GEcompetence(NGtube,elderly,pregnant,hiatushernia,obesity,curare) intragastricpressure(preggo,obese,bowelobstruction,largeabdotumours,ascites) delayedgastricemptying(narcotics,anticholinergics,fear,pain,labour,trauma,preggo, renalfailure,diabetes) 5) Whatmeasurescanbetakentodecreasetheriskofaspiration? preopfasting,H2antagonists/antacids(acidity),metoclopramide(motility), antiemetics,regional/localanaesthesiaratherthanGA,NGtubetoemptystomach,cricoid pressureoninductionofGA,extubationawakeonside Chapter10:monitoringinanaesthesia 1) Whatinformationdoestheanaesthetistusetoassessdepthofanaesthesia? GAlackofresponsetoverbalcommands,lossofblinkreflex(ifinadequatefacial grimacingtopainfulstimulus,ormovementofarmorleg) w/fullparalysisw/musclerelaxantsinadequateanaesthesiashownbyHTN, tachycardia,tearingorsweating excessiveanaestheticdepthcardiacdepression(bradycardia,hypotension),orif excessivemusclerelaxanthypoventilationandhypercapnia,hypoxemia 2) Whatinformationcanbeobtainedbymonitoringthecapnograph? CapnometryisthemeasurementoftheCO2concentrationduringinspirationand expiration capnogramisthecontinuousdisplayofthe[CO2]waveformsampledfromtheptsairway duringventilation Confirmationoftrachealintubation Recognitionofaninadvertentesophagealintubation 6

 3)

WhatconditionsmightresultinanETCO2measurementof20mmHgw/aPaCO2 measurementof40mmHg?(Seerightcolumn) edETCO2 edETCO2 ChangesinCO2production Hyperthermia Sepsis,thyroidstorm Hypothermia Malignanthyperthermia Hypometabolism Muscularactivity ChangesinCO2elimination Hyperventilation Hypoventilation Hypoperfusion Rebreathing Embolism Chapter11:intravenousanaestheticagents 1) Whydoptsawakenfromasleepdoseofthiopentalwithin5to10minutesofits administrationwhentheeliminationhalflifeisoftheorderof512hours? b/cthethiopentalhasmovedawayfromthebrainandisenteringthemoreslowly perfusedorgans,itsredistributionfromthebraintoothertissues/organs 2) Whywouldonechoosepropofoloverthiopentalasanintravenousinductionagent? ifptallergictothiopental,hasstatusasthmaticusorporphyria,liverdz,myxedema 3) Whenwouldonechooseketamineovereitherthiopentalorpropofolasthe intravenousinductiondrug? ketaminepreserveslaryngealandpharyngealairwayreflexes producesbothcentralsympatheticstimulationanddirectnegativeionotropiceffectonthe heartHR,BP,SVR,pulmartpressure,coronarybloodflow,myocardialoxygenuptake goodforanaestheticinductioninthesevereasthmaticptortheptwithcardiovascular collapserequiringemergencysurgery 4) Whataretheconcentrationsandinductiondosesofthiopentalandpropofol? Thiopental o Concentration:2.5%(25mg/mL) o Inductiondose:35mg/kg Propofol o Concentration:1%(10mg/mL)

Recogofaninadvertentextubationordisconnection AssessmentoftheadequacyofventilationandanindirectestimateofPaCO2 Aidsthediagnosisofapulmonaryembolism(airorclot) Aidstherecogofapartialairwayobstruction(e.g.kinkedETT) Indirectmeasurementofairwayreactivity(e.g.bronchospasm) Assessmentoftheeffectofcardiopulmonaryresuscitationefforts WhatrelationshipdoestheETCO2valuehavetothePaCO2? DuringGA,thePaCO2toETCO2gradientistypicallyabout5mmHg(PaCO25mmHg higher);increasesordecreasesinETCO2valuesmaybetheresultofeither increasedCO2productionordecreasedCO2elimination

o Inductiondose:2.53.0mg/kgforhealthy,unpremedicatedpt Whenpremedicationgiven,reduceto2.52.0mg/kg Elderly1mg/kg Chapter12:Musclerelaxants 1) Whatisthedifferencebetweenadepolarizingandnondepolarizingmuscle relaxant?Giveexamplesofeach. NONdepolarizingneuromuscularblockingagents CompetewithAChforthecholinergicnicotinicreceptor As[]ofmusclerelaxantattheNMJ,theintensityofmuscleparalysis Anticholinesteraseagents(neostigmine,edrophonium)inhibitthebreakdownof AChACh[]attheNMJcompetitivelyreversetheeffectsofanondepolarizing neuromuscularblockade Depolarizingneuromuscularblockingagents Succinylcholine(SCh)ismostfrequentlymusedmusclerelaxantusedbynon anaesthetists,andistheonlydrugofthisclassthatisclinicallyused Depolarizingmusclerelaxantsbindanddepolarizetheendplatecholinergic receptors Theinitialdepolarizationcanbeobservedasirregular,generalizedfasciculations occurringintheskeletalmuscles 2) WhataretheabsolutecontraindicationstotheuseofSCh? Inabilitytomaintainanairway Lackofresuscitativeequipment Knownhypersensitivityorallergy Positivehistoryofmalignanthyperthermia Myotonia(M.Congenita,M.Dystrophyica) PtsIDdasbeingatriskofahyperkalemicresponsetoSCh 3) WhichptsaresusceptibletohyperkalemiafollowingSCh? CholinergicreceptorslocatedonskeletalmusclemembranesoutsideofNMJcanbe dramaticallyincreasedinnumberovera24hrperiodwhenevernerveimpulse activitytothemuscleisinterrupted Ptswhohavesustained3rddegreeburnsortraumaticparalysis,neuromuscular diseaseslikemusculardystrophy,severeintraabdominalinfections,severeclosed headinjury,UMNlesions,ptsinrenalfailure GivingSChabnormallyhighfluxofK(duetoedreceptors)acuterisein potassiumtolevelsashighas13meq/Lsuddencardiacarrest 4) WhatistheconcentrationatwhichSChissupplied?Whatisthedoseforintubation? Formulatedat20mg/mL Intubationdose:(withcurarepretreatment)1.52mg/kgIVNOTE:Initialdoseof succinylcholinemustbeincreasedwhennondepolarizingagentpretreatmentusedbecause oftheantagonismbetweensuccinylcholineandnondepolarizingneuromuscularblocking agents. withoutcurarepretreatment1.1.5mg/kgIV 5) Whichdrugscanbeusedtoantagonizeaneuromuscularblock?

 Musclerelaxationproducedbynondepolarizingneuromuscularagentsmaybe reversedbyanticholinesteraseagentslikeedrophonium,neostigmine o PreventbreakdownofAChinNMJcompeteswithdrugtoallowreceptorto becomeresponsivetoreleaseofAChfromnerves o Theed[]sofAChalsostimulatethemuscariniccholinergicreceptors, resultinginbradycardia,salivation,andincreasedbowelperistalsis o Anticholinergicagentssuchasatropineandglycopyrrolateareadministered priortoreversal,toblocktheseunwantedmuscariniceffects Chapter13:Inhalationalanaestheticagents 1) WhatisMAC? SimilartoED50,theminimumalveolarconcentrationisthealveolarconcentrationin oxygenatoneatmospherethatwillprevent50%ofthesubjectsfrommakingapurposeful movementinresponsetoapainfulstimulussuchasasurgicalincision itisnecessarytoestablishananaestheticdepthequivalentto1.2to1.3oftheMACvalue topreventmovementin95%ofpts 2) Whatistherelationshipbetweentheanaestheticconcentrationthatissetonthe anaestheticvaporizerandtheanaestheticconcentrationintheptsbrain? theanaesthetictensioncascadeovertime thedelivered[]tendstobe>inspired>alveolar>brain increasingeitherthefreshgasflowrateoranaestheticconcentrationwillresultinafaster deliveryoftheinhaledanaestheticagenttothebrain(duetoafasterriseinthealveolar concentration) amountofalveolarventilation(VA=respratextidalvolume) intermsofalveolibraintime,thiswillbefasterwith: rateofbloodflowtobrain solubilityoftheinhalationalagentinthebrain differenceinthearterialandvenous[]softheinhalationalagent 3) Whatisdiffusionhypoxia? mayresultatendofanaesthetic asnitrousoxideisdiscontinued,thebodystoresofitarereleasedandfloodthealveoli, dilutingtheO2presentinthealveoli whenonlyroomairisadministeredattheendoftheanaesthetic,thedilutionofO2maybe sufficienttocreateahypoxicmixture,andresultinhypoxemia othercausesofhypoxemiaincludeanaestheticagents,neuromuscularblockade,painwith splintedrespirations administer100%O2attheendofananaesthetictoavoidthis 4) WhataretheMACvaluesofisoflurane,enfluraneandhalothaneinoxygen? Isoflurane:1.16% Enflurane:1.68% Halothane:0.75% Desflurane:6% Sevoflurane:2%

Chapter14:Narcoticagonistsandantagonists 1) Whatundesirableeffectsdoopioidshave? maycausedysphoricrxnswhenadministeredtoptswhoarenotexperiencingpain nausea,emesis respdepression(rate,minuteventilation;tidalvolume)slow,deepbreatihing vasodilationBP/SVR,bradycardia slowGImotilityconstipation/postopileus;biliarytracttonepptbiliarycolic; urinarybladdersphinctertonepostopurinaryretention anaphylaxis,bronchospasm,chestwallrigidity,pruritis 2) Nameanopioidantagonist.Whatdoseofthisdrugwouldbeappropriatetoreverse opioidinducedrespiratorydepression?What,ifany,areanypotentialproblemsof givingtoomuchofthisantagonist? Naloxone(Narcan) Givesmallincrementaldosesof40mcg Suddenreversaloftheanalgesiceffectsofopioidsmayresultifhighdosesof naloxonearegivenabruptreturnofpaincanresultinHTN,tachycardia,pulm edema,ventriculardysrhythmiasandcardiacarrest Continuousinfusionsof310mcg/kg/hrcanbeusedifsedationorrespdepression recur Chapter15:Localandregionalanaesthesia 1) Name2classesoflocalanaestheticagents,angiveexamplesofeach Amides:lidocaine(maxdose4mg/kg,7withepi),bupivicane(2.5mg/kg,3withepi) Esters:chlorprocaine(11mg/kg,14withepi) 2) WhatisPABA,andwhatroledoesithaveinlocalanaesthesia? Paraaminobenzoicacid,usedasapreservativeinlocalanaestheticsolutions,and mayincreaseaLAspotentialneuroandmyotoxicities 3) Name4techniquesofadministeringalocalanaestheticdrug. Topical,infiltrative,intravenousregional,peripheralneuralblockade,centralneural blockade 4) Whyisavasoconstrictoroftenusedwithalocalanaesthetic?Giveanexampleofa LAvasoconstrictoranditsconcentration.Whenwouldtheuseofavasoconstrictor becontraindicated? Vasoconstrictor(e.g.epinephrine,phenylephrine)usedtoretardvascular absorptiontoreducesystemicsideeffectsofLA Epinephrine[]stypically1:100000to1:200000 o 1:200000has5mcg/mLofepinephrine Vasoconstrictorscontraindicatedinfingers,toesandpenis 5) Whichregionalblockresultsinthehighest[]oflocalanaestheticintheblood? intercostalnerveblocksresultinthehighestpeaklocalanaestheticbloodconcentrations 6) Whatisthemaxrecommendeddoesofplainlidocaine,andoflidocainewitha vasoconstrictor? 4mg/kg;withepi7mg/kg

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7) Whymightaregionalanaestheticbegivenaswellasageneralanaesthetic? forpostoppainmgmt 8) Describesomeofthesignsandsymptomsoflocalanaesthetictoxicity. neurotoxicityimmediateandseverepainpathologicdamagetonerve myotoxicityhistologicalchangesinthetissues,buttransientandreversible 9) Describethestepsintreatinganacutelocalanaesthetictoxicity. ensureclearairway(suction,chinlift/jawthrust,airways,positioninginlatdecub) ensureadequateventilation(bag/mask,avoidhypoventilationLAuptake,consider intubation) providesupplementalO2(810L/minforambubagoxflow) AssesstheHRandrhythm,applymonitors(treatbradyw/atropine;useepiforprofound CVcollapse;considerearlyelectricalcardioversionforarrhythmias) AssesstheBPandperfusiondetermineresponsiveness(ifpthypotensive Trendelenburgposition;administerbolusofringerslactate;supportBPw/ephedrineor phenylephrine) stopseizures(protectptfrominjuryduringseizure;considerdiazepamorsodium thiopentaltostopseizure) 10)Whatisthedifferenceb/taspinalandanepiduralanaesthetic? botharecentralneuralblockade epiduralanaesthesiaisinjectingdrugsintotheepiduralspace(b/tligamentumflavumand duramater,exteriortospinalfluid);drugmustpassthroughmyelinsheathscoveringthe nerveroots duraactsasbarriertoepiduralLAmovingintotheCSFspace sloweronsetb/cnervesareinsulated;produceslessintenseblock req510timestheamountofLAthatwouldbeusedforspinalanaesthesia spinalanaesthesiainvolvespassinganeedlethroughepiduralspace,throughduraand intotheCSFspacethesubarachnoidspace,directlyincontactwiththebarenerveroots drugsproduceaveryrapidandintensenerveblock 11)Howmanymilligramsoflidocainearein20mLofa2%solution? 400mg Chapter16:Acutepainmanagement 1) Listthephysiologicaleffectsofacutepain. E.g.chest/abdoincisionw/outpainmgmtmusclesplinting, coughingatelectasisandpneumonia BarrageofnociceptivestimulisympathetictoneHTN,tachycardia, contractility/work o IfinsettingofO2supplymyocardialischemia,CHF,MI symptonealsointestinalsecretions,slowsgutmotility,smoothmuscle tonegastricstasisw/nausea,emesis,ileus,urinaryretention painstressresponsehypercoagulablestatePE,MI o alsoimmunocompetence,hypermetabolism,mobilizationofenergy storeshyperglycemia,largenetproteinlossesdelayedwoundhealing 11

 Chapter17:Chronicpain 1) Whatisthedifferenceb/tacuteandchronicpain? Acutepainisthenociceptionduetotissueinjuryandreleaseofnociceptiveagents Chronicpainisanunpleasantsensoryandemotionalexperienceassociatedwith actualorpotentialtissuedamage,ordescribedintermsofsuchdamage o So,doesntactuallyrequirepresenceoftissuedmg,andtendstolastwell beyondthehealingperiodoftissueinjury 2) WhatisRSD?WhatconditionsmayleadtothedevelopmentofRSD? ReflexSympatheticDystrophy o Varietyofconditionsincludingminorcausalgia,posttraumaticpain syndrome,Sudecksatrophy,shoulderhandsyndrome Pptfactorsincludeaccidental/surgicaltrauma,diseasestates Characterizedbypain,vasomotorchanges,autonomicdisturbances,delayed recoveryoffN,trophicchanges Commonoutcomeoforthopaedicinjuriesandindustrialaccidents(butno correlationb/tseverityofinjuryanddevelopmentofRSD;mustbepromptlyrecogd andtreated 3) WhatmodalitiesarecommonlyusedtotreatRSD? Earlytxwithsympatheticinterruptionresultsinpainreliefandreversesthe pathophysiologicalabnormalities

2) ContrastintramuscularandPCAopioidadministration IntermittentIMadministrationwidefluctuationsinserumopioidconcentrations periodsofoversedationalternatingwithperiodsofpoorpaincontrol IVPCAopioidadministrationrapidlyadjustedbyptanalgesic[]sofopioidsin serummaintainedforlongperiodsoftime 3) Whataretheadverseeffectsresultingfromtheadministrationofexcessiveopioid analgesics? Sedation,respiratorydepression,pruritis,edincidenceofnausea/vomiting 4) Whatnonopioidanalgesicagentsareavailableforthecontrolofacutepain? Aspirin,ibuprofen,indomethacin,naproxen,ketorolac(toradol),[gabapentin, acetaminophen) 5) Whatarethecontraindicationstoadministeringanonsteroidalantiinflammatory drug? AllergytoASAorotherNSAID;relativecontraindicationwhenthereisahxof asthma,nasalpolypsorangioedema Renalinsufficiency,CHF,pepticulcerdz,activeIBD,pregnancy/lactation,bleeding disorders 6) ListanappropriatedoseandschedulefortwocommonNSAIDsusedtocontrol acutepain. Ibuprofen400800mgPOq68h Ketorolac10mgPOq46h,maxpo40mg/day o 1030mgIMq46h,maxIM120mg/day

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5) 6)

Chapter18:Obstetricalanaesthesia 1) Whatissupinehypotensivesyndrome?Howcanitbeprevented? WhenthegraviduteruscompressestheIVCand/oraortawhentheparturientliesin thesupineposition(about15%ofptsasearlyas20tweek,freqin3rdtrimester) IVCcompressioncausesvenousreturntoheartsignsofshock:hypotension, pallor,sweating,nausea/vomiting,sinmentation o venouspressureinlowerextremitiesanduterusuterinebloodflow aortacompressionarterialhypotensioninuterusuterinebloodflowfetal distress/asphyxia Prevention:avoidsupineposition;liesonside;judicioususeoflumbarregional anaesthetics,whichcanexaggeratehypotensiveeffects 2) Whatfactorsmayinfluenceaptsexperienceofpainduringlabouranddelivery?

o Treatoriginalinjuriesproperlyandrapidly(removeforeignbodies, immobilize,repairshit,relievepain) o Txmodalitiesincludeearlyuseofsympatheticblocks,physio,psychotherapy, medicaltherapyandifthesefail,surgicalsympathectomy HowisadxofRSDmade? Criteriaare o Hxofrecentorremoteaccidentaloriatrogenictraumaordz o Ptcomplainsofpersistentpainthatisburning,achingorthrobbing o Oneormoreof: Vasomotor/sudomotorchanges Trophicchanges,edema,hypersensitivitytocold Muscleweaknessoratrophy o ReliefofSxobtainedafterregionalsympatheticblockade Whataretriggerpoints? Inmyofascialpainsyndrome,triggerpointsarehypersensitivepointsproducing pain,musclespasm,tenderness,stiffness,andweakness Inaffectedareas,tautmusclebandsmaybepalpable,arecalledTPs o Painfromtheseisdescribedassteady,deepandaching,andmaybe exacerbatedbystretch,cold,stress,fatigue,viralillnessesordirectpressure Name2surgicalconditionsthatmaypresentw/backpainandrequireemergency surgicalintervention. CaudaEquinaSyndrome o Discherniation,tumourmass,abscess o Signs:neurodeficitinlowerextremities(paralysis,lossofsensation),lossof bowelorbladdercontinence,weakness,depressedreflexes,saddle anaesthesia Aorticaneurysm o Leaking,dissecting,ruptured

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 Psychologicalstate,mentalpreparation,familysupport,medicalsupport,cultural background,primivsmultipara,sizeandpresentationoffetus,sizeandanatomyof pelvis,useofmedicationstoaugmentlabour(e.g.oxytocin),durationoflabour 3) Whatoptionsareavailablefordealingwiththepainoflabouranddelivery? Nothing,psychologicalsupport(coaches,partner,familymembers),behavioural modification(psychoprophylaxisLamaze),hypnotherapy,education(expectations, classes),massage,walking,sedatives,opioidanalgesics(+/antiemetics),epidural analgesia,spinalanaesthesia,generalanaesthesia 4) Whatarethemajorrisksofgeneralanaesthesiaintheparturientundergoinga caesareansection? AllparturientsconsideredtohavefullstomachandgastricprecautionsincludingRSI areindicatedwithGA Upperairwayedemaoccursinpregnancy;allparturientsconsideredtohave potentiallydifficultairwaytointubate GAintroducesrisksoffailedintubation,andriskofhypoxemiaand/orpulmonary aspirationofgastricacid GAcreatespotentialofhavingmaternaldrugstransferredtoneonateneonatal depressionandneedforresuscitation Chapter19:Basicneonatalresuscitation 1) WhatistheApgarscoreofababythatislimp,blue,hasnoresponseto oropharyngealsuctioning,aheartrateof60bpm,andirregulargaspingrespiratory efforts? APGAR:Appearance(colour),Pulse(HR),Grimace(reflexirritability),Activity (Muscletone),Respiration Muscletone0,Colour0,Reflexirritability0,HR<1001,Respiration1=2 2) Describethebasicstepsinneonatalresuscitation. Opentheairway o Positioning,suctionmouththennose,monitorheartrateforbradycardia, considerspecialendotrachealsuctioningindepressedinfant. Keeptheinfantwarmanddry o Overheadradiantheater,drytheinfant;thegentlestimulationwillalsohelp initiateandmaintainbreathing Physicalstimulation o Ifdrying/suctioningdonotinduceeffectivebreathinggentle slapping/flickingofsolesoffeet,orrubbinginfantsbackmaybeuseful o Donotwastetimecontinuingtactilestimifnoresponseafter1015s Evaluatetheinfant o Respirations:apneicorgaspinginfants(despitebriefstim)shouldreceive positivepressureventilation(PPV) o Heartrate:monitorbyauscultationorpalpation;if<100bpm,beginPPV, evenifinfantmakingsomerespiratoryefforts o Colour:presenceofcentralcyanosismeansinfantnotwelloxygenated; providefacemaskw/O2at5L/minuntilinfantbecomespink

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 **Adequateventilationisassessedby: Observingchestwallmotionandhearingbreathsoundsbilaterally **WhenshouldIstartchestcompressions? whenHRremains<80bpmdespitePPVwith100%O2 chestcompressionscanbediscontinuedwhentheHRis80bpm **Whatisthepropertechniqueforadministeringchestcompressionstoaninfant? 2methods o thumbmethod:fingersaroundback,thumbssidebysideoversternum,with downwarddisplacementofsternum o Twofingerapproach:middleandringfingersofonehandperpendicularto chestasfingertipsapplypressuretosternum;otherhandsupportsback below o Pressureenoughtoachieve1.5cmofdisplacement o 120compressionsperminute(2/sec) **The4commondrugsusedinresuscitationofthedepressedneonate: 1. Oxygen 2. Intravenousfluids 3. Epinephrine 4. Naloxone 4) Assuminganewborninfantweighs3kg,whatisthe[]anddoseofepinephrine,and howoughtitbeadministered? Epinephrine[]inneonateresuscitationissuppliedas0.1mg/mLdilution IVdoseis0.01to0.03mg/kg Ina3kginfant,0.25mLto0.75mLofepinephrinewouldbeanappropriatestarting dose IfIVrouteunavailable,epicanbegiventhroughETT o Shouldbedilutedw/12mLofsaline o IfinfantdoesnotrespondtoinitialETTdose,increasebyafactorof10(0.1 0.2mg/kg) 15

3) Whenispositivepressureventilation(PPV)indicatedinthenewborninfant? DescribethetechniqueofPPV. Ventilatorysupportrequiredwhenapneaorgaspingrespirationsarepresent,the HRis<100bpm,orcentralcyanosispersistsdespite100%O2 Mostneonatescanbeadequatelyventilatedw/abagmask o Theassistedventilatoryrateshouldbeb/t4060breathsperminute o Initiallunginflationpressuresmaybeashighas3040cmH2Otoovercome theelasticforcesofthelungsiftheinfanthasnottakeitsfirstbreath o Subsequentventilationshouldbeachievedwithairwaypressuresof1520 cmH2O

Chapter20:Intravenousfluidandbloodcomponenttherapy 1) Howarethehourlyanddailymaintenancefluidrequirementscalculated? Maintenancewaterrequirements Perhour Perday 1stto10thkg 4ml/kg 100ml/kg 11thto20thkg 2ml/kg 50ml/kg 21sttonthkg 1ml/kg 20ml/kg 2) Listconditionsthatmaybeassociatedwithasignificantpreoperativefluiddeficit. Fracturedhip,femur,pelvis;bowelobstruction;preoperativebowelprep;trauma; protractedvomitinganddiarrhea;burns;sepsis;pancreatitis 3) Whatisthedifferenceb/tacrystalloidandacolloid?Giveexamplesofeach. Crystalloidsolutionsaresaltcontainingsolutionsthataresemipermeabletocellular membranes o E.g.NS,RL,2/3,1/3IVsolutions ColloidIVsolutionscontainaggregatesofmoleculesthatresistdiffusionacross cellularmembranes o Maybesynthetic,e.g.pentaspan,hetaspan(?sp),dextran o Maybecollectedfromdonorbloodpool,e.g.albumen,plasma,wholeblood 4) Whichptsshouldconsiderautologousblooddonation?Forwhichpatientsisthisnot suitable? Preopcollectionofbloodfromaptwhoisscheduledtohavesurgery,andforwhom oneanticipatestheneedforaperioperativebloodtransfusion Notsuitableforptsw/bacterialorviralinfections,ptswithHb<110g/Landpts withunstableanginaorcriticalaorticstenosis 5) Calculatetheacceptableamountofbloodthatcanbelostin70kgmaleifhisinitial hemoglobinis140g/dL,andtheacceptedminimalhemoglobinaftersurgeryis 80g/dL. ABL=(HbiHbf)/HbixEBV o =(14080)/140x(70ml/kgx70kg=4900ml)=2100mL 6) WhatisthemostcommoncauseofanABOincompatiblebloodtransfusion? clericalerrorinpatientandbloodidentification 7) Name3differentbloodcomponentsthatmaybetransfused. Wholeblood:autologous Freshfrozenplasma:indicatedtoreplacecertainfactordeficiencies Platelets:aftermassivetransfusion,associatedwithabnormalbleedingand dilutionalthrombocytopenia **Potentialcomplicationsofbloodtransfusions Air(embolism) Plasma(Allergicrxn,dilutional Volume(circulatoryoverload) coagulopathy) Cold(hypothermia) Platelets(dilutionalcoagulopathy) RBCs(major/minorreactions) Biochem.(citratetoxicity, WBCs(febrilereaction) hyperkalemia,hypoCa)

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 Microaggreg.(Dyspnea) Infections(bacterial,viral, parasitic)

Immune(immunesuppression)

Chapter21:Commonperioperativeproblems **Severebradycardiamustbeassumedtobesecondarytohypoxemiauntilproven otherwise 1) Defineshock.Classifythedifferenttypesofshockandgiveexamplesofeach. Shock(Tintinallis) Type Comment HypovolemicCausedbyinadequatecirculatingvolume Cardiogenic Causedbyinadequatecardiacpumpfunction Obstructive Causedbyextracardiacobstructiontobloodflow Distributive Metabolicderangementsthatimpaircellularrespirationsuchascyanide toxicity,sepsis. Hypovolemicshockthemostcommontypeofshock,withlowcentralvenous pressureandlowpulmonarycapillarywedgepressure Distributiveshockischaracterizedbysystemicvasodilation,relativehypovolemia, andanincreaseincardiacoutput o Mostcommonformofthistypeissepticshock,whereateriovenousshunting atthetissuelevelresultsinanaccumulationoflacticacidandtissueanoxia Cardiogenicshockwhenheartfailstoperformitspumpingfunction,asaresultofa myocardial,valvularorelectricalproblem o Myocardialinfarctionisthemostcommoncause,wherecharacteristic findingsincludeanincreaseinCVP,PCWPandSVR Obstructiveshockoccurswhenthereisanobstructionpreventingcardiacfillingor emptying o Twoimmediatelytreatablecausesofitincludeatensionpneumothoraxand cardiactamponade **Nauseaandvomitingperioperativelymustbeassumedtobesecondarytobradycardia andhypotensionuntilprovenotherwise 2) Whataresometreatablecausesofanagitatedpostopstate? Upperairwayobstruction,residualparalysis,hypercarbia,andhypoxemiaareall potentstimulantswhichcanproduceanagitatedstate Commoncausesofagitationinelderlyptsarepainandbladderorboweldistension Excessivesedationcanbetreatedwithreversingagents,dependingonthecause Chapter22:Managingthecirculation 1) Whatarethebroadgoalsincontrollingthecirculation? Theprinciplegoalofcirculatorysupportistooptimizetissueperfusionwith oxygenatedblood 17

2) 3)

o Toachievethis,onemustassessandoptimizethepreload,afterload,heart rate,contractility,oxygentransportandorganperfusion Whatarethedifferencesb/tanalpha1andbeta1adrenergicagonist?Give examplesofeach. Alpha1,e.g.phenylephrine o Vasoconstrictionoftheskin,gut,kidney,liverandheart Beta1,e.g.isoproterenol o Increasedheartrate,myocardialconductionandcontractility Whatarethefactorswhichdeterminecardiacoutput? CO=HRxSV Thedeterminantsofcardiacoutputarepreload(theenddiastolicstretchoftheleft ventricle),theheartrate,thecontractility(themyocardiumsintrinsicabilityto performworkatanygivenlevelofenddiastolicfibrelength[preload]),andthe afterload(themyocardialwallstressoftheleftventricleduringejection)

Chapter23;Oxygentherapyandhypoxia 1) Listsomedevicesthatarecommonlyusedtodeliveroxygentospontaneously breathingpatients. Nasalprongs,simplefacemaskoxygen,Venturifacemask,nonrebreathingface maskwithreservoirbag 2) Whenshouldapuritanfacemaskbeused?Whenshouldoneuseamanual resuscitationdevice,suchasanambubagandmaskunit? Thepuritanmaskdeliversthehighestlevelofhumidifiedoxygen o Oxygenflowratesof>30L/mincanbeachieved,ensuringaconsistent inspiredoxygenconcentration o Shoulduseadoubleflowsetuporanonrebreathingfacemaskw/reservoir bagwhen>50%inspiredO2[]isrequired Theambubagandmaskunitisusedforprovidingprimaryairwaymgmtinpts requiringpositivepressureventilationandoxygenation o Canbeusedastheprimarysystemforairwaymgmtintheptrequiring ventilatorysupport 3) Listthefivecategoriesofconditionscausinghypoxemia. Hypoxemia:lowlevelofO2intheblood DecreasedFiO2 o edinspiredO2concentrationoredbarometricpressure(altitude) Decreasedalveolarventilation o Hypoventilation(2tosedativedrugsorpainiscommon) Increaseddeadspaceventilation(ventilationperfusioninequality) o RespondstosupplementalO2therapy o CausesincludehypovolemiaandhighairwaypressureswithPPV o Pulmonaryembolism,emphysema,bronchitis Increasedshunt o Perfusionofalveoliwithoutventilation,e.g.atelectasis,aspiration,CHF, pneumoniaandendobronchialintubationwithlobarcollapse

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 Decreaseddiffusion o Highaltitude,anemia,severeexercise o Pulmonaryfibrosis,emphysema,interstitialpulmonarypathology(e.g. sarcoidosis) 4) Listthefourcategoriesofconditionscausinghypoxia. Hypoxia:lowlevelofO2intheair,blood,ortissues Decreasedfunctionalhemoglobin o Anemia,hemoglobinopathies DecreasedPaO2 o Hypoxemia Decreasedtissueperfusion o Shockstates(hypovolemic,cardiogenic,distributive,obstructive) Cellularhypoxia o Histotoxicpoisoning(e.g.cyanide) Chapter24:Unusualanaestheticcomplications 1) WhatisMH? ArareclinicalsyndromethathasbeenobservedduringGA o Acutefulminantform,triggeredbycertainanaesthetic drugshypermetabolicstateduetoacuteuncontrolledskeletalmuscle metabolism o RapidincreasesinO2consumption,carbondioxideproductionandheat resultindesaturationorcyanosis,elevatedendtidalCO2valuesandrapid increasesintemperature 2) List2anaestheticagentsthatmaytriggeranMHreaction. SCh(depolarizingmusclerelaxant)andanyofthevolatileanaestheticagents (isoflurane,halothane,enflurane,sevoflurane) 3) WhichdrugisusedspecificallytotreatanMHreaction? Dantroleneskeletalmusclerelaxant(everyhospitalthatprovidesGAservicesis reqdtokeepacurrentstock[minimum36vials]ofdantroleneavailableintheir pharmacydepartment) 4) Whatstrategiesareusefulinreducingtheperioperativeriskofpulmonary aspirationofgastriccontents? Avoidimpairingairwayreflexes(chooselocalorregionalanaesthetic) Reducegastricvolumeandacidity o Fasting,gastricmotilityagents,H2blockers,antacids(sodiumcitrate), gastricemptyingbyNGtube Inptswithanticipateddifficultintubation,topicalizationandlocalanaesthetic blocksoftheupperairwayreduceschanceoffailedintubation,difficultmask ventilationandsubsequentgastricaspiration Ptsw/IDdriskfactorsforgastricaspirationwhorequireGAmusthaveRSI(see above) 5) Describethestepsusedtotreatananaphylacticreaction. TheABCsforanaphylaxis:

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o Airway,andadrenaline o Breathing,andBenadryl o Cyrstalloidsandcimetidine o Steroids Mgmtofanaphylaxisduringanaesthesia o Stopdrugorallergenadministration o Provide100%O2 o Discontinuesurgeryandanaesthesiaassoonasfeasible o Giveepi50100mcgIVwithhypotension,0.51.0mgIVwithCVcollapse o Epiinfusion0.050.2mcg/kg/min o Crystalloids(NS,RL)IV,mayreq24Lfora70kgadult,i.e.2550ml/kg o Diphenhydramine50mgiv o Cimetidine300mgIV,orranitidine50mgIV o Hydrocortisone100mgIV,ormethylprednisolone1mg/kgIVq6hx24h o Inhaledsalbutamolforbronchospasm o Avoidbetablockers

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