Gems, Numbers, Things You Need To Remember

Front 1

Planning:

Back 1

P Plan + prepare OT

R Resuscitation

I Intravenous Access

M Monitoring

E Equipment (includes skilled assistant!)

T Team Time Out

I Induction

M Maintenance

E Emergence

D Disposition

Front 2

Surgical sieve

Back 2

V Vascular

I Infective

T Traumatic

A Autoimmune

M Metabolic

I Idiopathic

N Neoplastic

D Drugs

Front 3

Parkland formula for burns

Back 3

Parkland formula is:

Fluids = 4ml/(kg)*(%burn)

To be given over 24 hours. Half given over the first 8 hours, the other half over the remaining 16 hours. The fluid of choice is Hartmann’s solution

Front 4

Maximum allowable blood loss calculation for paediatric patients

Back 4

Max = EBV * (HctS - HctT)/HctS

= (Estimated blood volume) x [(Starting Hct) - (Target Hct)] / (Starting Hct)
OR
= (EBV) x Starting Hb - Target Hb/Starting Hb


If bleeds more than 1EBV, then start FFP

Front 5

Estimated blood volume by age?

Back 5

= 95mL/kg in premature neonates
= 85mL/kg in neonates
= 80mL/kg in toddlers
= 70mL/kg in adults and children over 3 years

Front 6

Current of:

Macroshock
Microshock

Back 6

Macroshock: >10mA

Microshock: >100uA

Front 7

Motor functions of:

Radial nerve
Median nerve
Ulna nerve

Back 7

Radial: This is the motor nerve supplying the triceps and brachioradialis and the extensor muscles of the hand.

Median: (LOAF) the lateral two lumbricals, opponens pollicis, abductor pollicis brevis, and in many people the flexor pollicis brevis.

Ulna: all the small muscles of the hand (except the LOAF muscles), flexor carpi ulnaris and the ulnar half of flexor digitorum profundus. Includes adductor pollicis in the thumb.

Front 8

CHADS2

Back 8

Congestive heart failure
Hypertension
Age > 75
Diabetes
Secondary prevention of prior TIA or CVA

Front 9

CHADS risk of CVA per year by score

Back 9

0: 2%
1: 3%
2: 4%
3: 6%
4: 8.5%
5: 12.5%
6: 18%

Front 10

Components of Child-Pugh score

Back 10

Bilirubin
Albumin
PT or INR
Ascites
Hepatic encephalopathy

Front 11

NNT

Back 11

1
_________________________________________________________
probability(with intervention) - probability(control)

Front 12

ANZCA labelling guidelines

Back 12

Intra-arterial: Red (red/black border)
Intravenous: Blue (blue/black border)
Central venous: White with blue/black border
Neural: Yellow
(Intrathecal solid black border, epidural yellow/black border, regional white background with yellow/black border)
Subcut: Beige
Miscellaneous: Pink

Front 13

Revised trauma score takes into account:

Back 13

GCS
SBP
RR

Front 14

Aortic Stenosis - haemodynamic goals

Back 14

Slow, Sinus, Full, Tight

Front 15

Mitral Stenosis - haemodynamic goals

Back 15

Slow, Sinus, Full, Tight, Avoid PHT

(avoid hypercarbia, hypoxaemia, and acidosis)

Front 16

Aortic Regurgitation - haemodynamic goals

Back 16

Fast, full, loose

(Heart rate >90, adequate volume loading, low SVR, maintain contractility)

Front 17

Mitral Regurgitation - haemodynamic goals

Back 17

Fast, Full, Loose + avoid PHT

(avoid hypercarbia, hypoxaemia, and acidosis)

Front 18

Aortic stenosis - severity

Mean valve gradients (mmHg):

Back 18

Mean gradient (Note that this will become less sensitive as the ventricle starts to fail)
Normal: <12
Mild: 12-25
Moderate: 25-40
Severe: 40-50
Critical: >50

Front 19

Aortic stenosis - severity

Aortic valve cross-sectional area cm2

Back 19

AVA cm2
Normal 3-4
Mild 1.5 - 2.0
Moderate: 1.0 - 1.5
Severe: <1.0
Critical: <0.6

Front 20

Myotomes C1-S2

Back 20

C1/C2-neck flexion/extension
C3-neck lateral flexion
C4-shoulder elevation
C5-shoulder abduction
C6-elbow flexion/wrist extension
C7-elbow extension/wrist flexion
C8-thumb extension
T1-finger abduction
L2-hip flexion
L3-knee extension
L4-ankle dorsi-flexion
L5-great toe extension
S1-ankle plantar-flexion
S2-knee flexion

Front 21

Poiseuille's Equation

Back 21

F = ΔP.r^4
η.L

Front 22

Pulmonary artery catheter insertion

Back 22

Rule of 10's

RA: 20cm
RV: 30cm
PA: 40cm
PCWP: 50cm

Front 23

Double lumen ETT size, depth of insertion

Length to carina

Back 23

DLETT Size: (from Miller 6th ed)

137-165cm: 35-37 Fr

165-178cm: 37-39 Fr

180-193cm: 39-41 Fr

Airways tend to be larger than would be predicted by height in COPD / bronchiectasis

__________________________________________________

DLETT depth of insertion:

Height 170cm size = 29cm
+/- 1cm for every 10cm of height

__________________________________________________

Normal length to carina:

Males 27 cm

Female 23cm

Front 24

Pre-emptive vs preventative analgesia

Back 24

Pre-emptive: Pre-operative treatment is more effective than the same treatment after incision / surgery
Preventative: Postoperative pain is reduced.

Front 25

METs
1
3
4
5
8

Back 25

1 - at rest
3 - walking 1-2 blocks
4 - raking leaves, gardening
5 - climbing one FOS
8 - Jogging, rapidly climbing stairs

Resting or basal oxygen consumption (VO2) of a 70-kg, 40-year-old man in a resting state is 3.5 mL per kg per min.

Front 26

Informed consent requires:

Back 26

Information:
1) Who is doing the treatment
2) What it involves
3) Why it is being done

Competency:
1) Understand
2) Retain
3) Use (to make a decision)

Communicate that decision.

Front 27

Severe aortic stenosis
Aortic jet velocity
Peak gradient
Mean gradient
Valve area
Valve area indexed against BSA

Back 27

>4m/s
>65mmHg
>40mmHg
<1.0 cm^2
<0.6 cm^2/m^2 BSA

Front 28

Warm ischaemic times in DCD

Back 28

Heart: N/A
Lungs: 1 hour
Kidney: 2 hours
Liver=pancreas: 30 mins

Front 29

Cold ischaemic times in DBD

Back 29

Heart: <4 hours
Lungs: 6-8 hours
Liver=pancreas: 12 hours
Kidneys: 18 hours

Front 30

Sensitivity

Back 30

SNOUT
True positive rate
Likelihood of a person with disease having a positive test
=TP/TP+FN

Front 31

Specificity

Back 31

SPIN
True negative rate
Likelihood of a person without the disease having a negative test
=TN/TN+FP

Front 32

Positive predictive value

Back 32

Chance of having a disease given a positive test
=TP/TP+FP

(Relies on prevalence)

Front 33

Negative predictive value

Back 33

Chance of not having a disease given a negative test
=TN/TN+FN

(Relies on prevalence)

Front 34

Cryoprecipitate contains:

Back 34

F VIII
Fibrinogen
Fibronectin
FXIII
vWF

Front 35

Rule of Nines

Back 35

Head 9%
Torso 18% front and 18% back
UL 9% each
LL 18% each
Groin 1%

Front 36

Propofol infusion syndrome

Back 36

Acute refractory bradycardia leading to systole in the presence of one or more of the following:
- Metabolic acidosis (BE < -10)
- Rhabdomyolysis or myoglobinuria
- Lipaemic plasma
- Enlarged or fatty liver

Most common in paediatric patients

Safe dose of propofol considered to be 1-4 mg/kg/h for prolonged sedation in ICU

Front 37

Aortic dissection classification

Back 37

Stanford A:
Ascending aorta +/- arch +/- descending

Stanford B
Only descending aorta distal to the L subclavian.

Debakey 1: Ascending + arch + descending
Debakey 2: Ascending only
Debakey 3: Descending distal to the L subclavian

Front 38

Neonatal resus

Back 38

Resus:1) Stimulate (If heavily mec stained AND flat, can consider ETT + suctioning before stimulation. No evidence it improves outcomes)2) If HR < 100 open airway, PEEP +/- ventilate, air first, then O2After 30s vent:3) If HR < 60 after 30 seconds of adequate ventilation CPR, 3:1, 100% O2, consider ETT90 compressions, 30 breaths per minuteAfter 60s CPR:4) If HR remains < 60 after 1 minute, epinephrine 10-30 mcg/kg, consider 10mL/kg fluid bolus6) Consider naloxone / NaHCO3

Front 39

NYHA classification

Back 39

I : no symptoms and no limitations in ordinary physical activiy
II: Mild symptoms and slight limitations in ordinary daily activity
III: Marked limitation
IV: SOBAR

Front 40

CHA2DS2-VAS

Back 40

CCF (1), HTN (1), Age >75 (2), DM (1), Prior stroke or TIA (2),Vascular disease (1), Age 65-74 (1), Sex (female 1, male 0).

Front 41

Unsafe in porphyria:

Back 41

Unsafe in porphyria (according to ceaccp article)

Thiopentone (barbiturates in general)
Ketamine
Sevoflurane
?Etomidate
?Levobupivacaine (note bupivacaine and lignocaine are safe)
?Ropivacaine
Oxycodone
Diclofenac
Rifampicin
Erythromycin
Ephedrine
?Metaraminol
?Dexamethasone
?Hydrocortisone

Front 42

How much 3%NaCl to give to raise [Na+] by 1 mmol/L?

Back 42

Calculate total body water as 0.6 x body weight (kg), e.g. for a 70 kg man, TBW = 42 litre

2 x TBW is the number of millilitres of NaCl 3% which will raise serum [Na] by 1 mmol/litre,

e.g. 2 x 42 = 84 ml of NaCl 3% over 1 h will raise serum sodium by 1 mmol/litre

Front 43

Survival with AS

Back 43

SOB 2 years
Syncope 3 years
Angina 5 years

Front 44

Brugada syndrome

Back 44

ST elevation V1-V3
Incomplete RBBB
Often presents with syncope or sudden death

Front 45

GOLD criteria

Mild COPD
Moderate COPD
Severe
Very Severe

Back 45

COPD. All need FEV1/FVC < 0.7

Mild: FEV1 > 80%
Moderate: FEV1 50-79%
Severe: FEV1 30-49%
Very Severe: FEV1 < 30% OR <50% and respiratory failure

Front 46

Time after stent before non-cardiac surgery

Back 46

Balloon angioplasty: 4 weeks

BMS: 6 weeks (45 days may be a safer number)

Drug-eluting stent: 12 months (if DAPT must be stopped for surgery)

AMI (if no evidence of further tissue at risk on stress testing) - 6 weeks

AHA guidelines 2009

Front 47

AHA:

Active cardiac conditions which should be dealt with before elective surgery:

Back 47

Unstable angina OR MI within last 6 weeks - need assessment to see if more myocardium is at risk


NYHA IV or new onset CHF


Significant arrhythmias
Mobitz II
3e HB
Symptomatic ventricular arrhythmias
SVT with rate >100 at rest
Symptomatic bradycardia

Significant valvular disease
AS - symptomatic / mean pressure gradient >40 mmHg / valve area <1.0 cm^2
Symptomatic mitral stenosis - SOBOE / exertional pre-syncope / CHF

Front 48

AHA:

Clinical Risk Factors:

Back 48

• history of ischemic heart disease;
• history of compensated or prior HF;
• history of cerebrovascular disease;
• diabetes mellitus; and
• renal insufficiency (Cr greater than 175)

Front 49

Airway Anatomy

Back 49

Cartiladges:

Unpaired:
Cricoid
Thyroid
Epiglottis

Paired:
Arytenoid
Corniculate (little horns that sit on the arytenoid)
Cuneiform (slender bows that sit in the aryepiglottic fold)

Membranes & ligaments

External:
Cricotracheal ligament
Cricothyroid membrane
Thyrohyoid membrane

Internal:
Quadrangular membrane (Runs from epiglottis to arytenoids. Superior margin is the aryepiglottic fold)
Vestibular fold (aka ventricular fold aka false cords): attached identically to vocal cords, but slightly cephalad and lateral.
Cricovocal - superior border is vocal ligament / cords. Attached to cricoid arch, and then as for vocal cords. Vocal cords: attached anteriorly to thyroid, posteriorly to vocal process of arytenoid.

Arytenoid:
Synovial joint articulation with cricoid
Muscular and vocal processes

Nerves: (all arise from vagus nerve)
Sensory:
Superior laryngeal nerve (internal branch) from cords up
Recurrent laryngeal nerve from cords down

Motor: (Nucleus ambiguus via CrNX)
Superior laryngeal nerve (external branch) supplies cricothyroid
RLN supplies intrinsic muscles of the larynx other than cricothyroid

Muscles:
Sphincter:
Aryepiglotticus
Oblique interarytenoid
Thyroepiglotticus

Glottic aperture
Posterior crico-arytenoid - ABduction (only muscle that opens glottis)
Transverse interarytenoid - ADduction
Lateral crico-arytenoid - closure

Cord length
Thyroarytenoid (Shortens cords)
Vocalis (tenses cords)
Cricothroid (muscle) (Lengthens cords)

Blood supply:
Superior laryngeal artery (from thyroid artery)
Inferior laryngeal artery (from thyrocervical trunk which follows same course as RLN from subclavian artery)

Front 50

Apfel Score:

Back 50

Previous PONV

Female

Non-smoker

Post-op opiods

0: 10%

1: 20%

2: 40%

3: 60%

4: 80%

Other risk factors:

Laparoscopic

Gynaecological

?Cholecystectomy

Strabismus

Prolonged

Dehydration

N2O

Regional reduces risk

Management:

0 risk factors: expectant

1-2 risk factors: 1 or 2 interventions

2> risk factors: multimodal approach

Front 51

Hyperthyroidism

Back 51

Tachycardia, arrhythmia, lid lag, exopthalmous, thin hair, tremmor, weight loss, sweating, abdominal pain, N+V, CHF

Front 52

Airway compression

Back 52

Dysphagia

Voice changes

Stridor

Positional breathlessness

Front 53

Standard monitors (PS18)

Extras for long case

Back 53

Oxygen analyser

Volatile analyser

Disconnection / ventilator failure alarm

ECG

NIBP +/- IBP

CO2

SpO2

Temperature

+/- Entropy of BiS

Long case extras:

Big drip / art line visible and accessable

PNS

UO

FAWB +/- fluid warmer

Thromboembolism prophylaxis

Front 54

Epidural space anatomy

Back 54

Anterior border posterior longitudinal ligament

Posterior: ligamentum flavum

Part of vertebral canal

Venous plexus (mostly anterior) and fat

Foramen magnum to sacral hiatus

Laterally periosteum of the pedicles and the intervertebral foramina

Crossed by nerve roots transiting from spinal canal to vertebral foramina

Axial margin is dura

Front 55

Upper Limb

Back 55

Musculocutaneous: flexor compartment of arm

Sensory: lateral antebrachial cutaneous nerve

Median: flexor compartment of forearm and thenar eminence (Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis)

Sensory: Palm of hand, anterior thumb and non-ulna fingers

Ulna: small muscles of hand, flexor carpii ulnaris, ulna component of flexor digitorum profundus

Sensory: medial finger and a half

(from medial cord: medial brachial cutaneous nerve, medial antebrachial cutaneous nerve)

C5,6,7,8,T1:

Radial: Extensors of upper arm.

Radial turns into posterior interosseous nerve: extensors of forearm

Sensory: posterior of hand, particularly thumb

Intercostobrachial (T1-2): sensory medial upper arm

C5,C6 Axillary nerve: sensory: badge area over deltoid

Front 56

Blood supply of spinal cord

Back 56

Blood supply to the spinal cord comes from costocervical and intercostal arteries in the thorax, and lumbar, iliolumbar and sacral arteries.

Vertebral arteries arise from subclavian arteries, and enter the transverse foramen from C6 up until they fuse to form the basilar artery.

Single central anterior spinal artery arises at the level of the foramen magnum from the fusion of branches of the two vertebral arteries, then as it descends receives blood from radicular arteries. From the posterior inferior cerebellar arteries arise one posterior spinal artery per side, which are then supplemented by posterior branches of radicular arteries.

The artery of Adamkiewicz is the vessel relevant to thoracic aneurysm repair. 80% of the time it is on the left, and it is usually at T10, but may be from T7-L4. It is the largest vessel supplying the cord.

Front 57

Paravertebral space anatomy

Back 57

Starts at T1, extends to T12

Medial wall formed by vertebral bodies, intervertebral discs and vertebral foraminae.

Anteriorly parietal pleura and innermost intercostal membrane

Posteriorly by the transverse processes of the thoracic vertebrae, the heads of the ribs, and the superior costotransverse ligament.

Front 58

Sub-Tenon's space

Back 58

Cavity bound by tenon's capsule and the sclera, which should appear shiny and white, and be relatively avascular.

Extends around the globe.

Occular muscles and their fascia penetrate Tenon's capsule to attach directly to the sclera

Front 59

Eye innervation

Back 59

Eye innervation

II: Sensory (light)

III oculomotor: Levator palpabrae (lifts lids). All other eye movements. Edinger-westphal -> ciliary ganglion -> parasympathetic control, pupillary constriction, accommodation

IV: Trochlear: Superior oblique. Pulls down and out, paralysis causes up and in.

V: parasympathetics + pain (ophthalmic branch V2)

VI: Abducens: Pulls laterally. Medial gaze if not functional.

VII: parasympathetic supply to lacrimal glands

Pupillary light reflex: Afferent CrN2. Efferent: CrN3 via edinger-westphal nucleus

Sympathetic stimulation: From T1 via stellate ganglion, travels with arteries. Horners: Enopthalmos, ptosis, pupillary constriction, absent sweating on ipsilateral face, conjunctival injection.

Front 60

Lower limb nerve supply

Back 60

Femoral nerve arises from L2,3,4 and supplies motor to quads, and sensation to anterior thigh and medial aspect of leg variably down to foot as the saphenous nerve. A sub-sartorial block aims to target the femoral nerve after the motor branches to quads have split off. It is performed by ultrasounding sartorius, identifying the femoral artery under the fascia, and then placing a large volume of local into this space.

Saphenous nerve supplies medial foot variably up to toes. Can also be blocked with a fan of local from anterior tibial margin to medial malleolus

All the rest are from sciatic, which arises from L4.5,S1,2

Sural nerve supplies lateral edge of foot and maybe some of the sole. It is formed from both the common peroneal and tibial arteries posteriorly (before the common peroneal wraps around the fibula). Block with LA from lateral malleolus to achilles.

Posterior tibial nerve: supplies the sole of the foot, except the lateral and proximal segments. Blocked by identifying the posterior tibial artery on the medial side of the leg. Should be posterior to artery.

Superficial peroneal nerve: supplies top of foot and toes, except 1st and 2nd toe webspace. Blocked with fan of local from anterior to lateral malleolus.

Deep peroneal nerve: supplies webspace between 1st and 2nd toes, medial side of first toe.

Locate anterior tibial artery, should be lateral.

Front 61

Fetal circulation

Back 61

Umbilival vein -> ductus venosis -> IVC -> RA -> FO -> LA -> LV -> aorta, preferential flow to brain. DA connects to descending aorta after left subclavian divided.

Front 62

Bronchial anatomy

Back 62

Trachea: semi-circular lumen, carina is sharp. Right and left main bronchus are large, without any bifurcations in sight

Posterior longitutinal muscle: trachealis. At carina, trachealis divides very evenly. Looks like the prow of a ship travelling through water. Cannot see further bifurcations from level of carina.

LMB: 5cm

RMB: 3cm

In 10% of patients, RUL bronchus can be very proximal, at the level of the carina

RUL: trifurcation

Right bronchus intermedius (RBI)

Leads to RML and RLL. RLL is usually significantly larger (150%) than the RML. In contrast the left bifurcation is 50:50.

RLL has 5 segments, one superior segment, and 1+3 lower segments. In contrast the LLL has 4 segments.

LMB: 5cm. No trachealis. LUL and LL orifices are roughly even in size.

LUL bronchus splits in 2. Lingula has two segments immediately visible.

LLL bronchus has 1+3 segments

Expect carina to be at 27cm in men, 23cm in women.

Front 63

Airway calculations for children

Back 63

Weight: (Age + 4) x 2

ETT (Age/4)+4

ETT Depth: (age/2) + 12

Front 64

OSA screening

Back 64

S - Snores loudly

T - Tired

O - Observed apnea

P - Hypertension

B - BMI > 35

A - Age > 50

N - Neck circumference >40cm

G - Gender (Male)

Refer for more investigation if 3+/8

2/8 or less - 100% sensitive

3/8 or more - 27% specific

4/8 - 50%

6/8 - 90%

8/8 - 99%

Front 65

Pre-operative assessment for lung volume reduction surgery

Back 65

Standard assessment PLUS

1) Airway assessment for DLT
- standard airway assessment recognising that DLTs are bulkier and thus more difficult to insert
- Tracheal and bronchial measurements to estimate DLT size
- Patient height to estimate depth
2) Cardiac risk assessment and optimisation
- Exercise function (>5 FOS = 20ml/kg/min VO2)
- ECG, TTE, cardiopulmonary exercise testing (>15mL/kg/min VO2)
3) Respiratory risk assessment and optimisation
-FEV1 >40% ppo
-DLCO >40% ppo
-V/Q scan, ABG, CT scan
4) Multidisciplinary team involvement - surgeons, oncologists, anaesthetists to formulate patient specific plan
5) Explain process and discuss risks with patient. Obtain consent.

Front 66

Cognitive errors relevant to anaesthesia

Back 66

Anchoring: focusing on one issue and losing situational awareness

Confirmation bias: only seeking or givng weight to infomation that supports the desired diagnosis

Omission bias: hesitation in starting emergency manoevre for fear of causing harm

Premature closure: failure to consider a full differential

Sunk costs: Unwillingness to abandon a failin procedure due to time / energy invested

Front 67

Pulmonary hypertension severity

Back 67

Pulmonary Hypertension is defined as a mean pulmonary artery pressure (PAP) >25mmHg at rest with a pulmonary capillary wedge pressure <12mmHg.

Pulmonary hypertension is considered moderately severe when mean PAP >35mmHg.

Right ventricular failure is unusual unless mean PAP is >50mmHg.

Front 68

Fat Embolism

Back 68

Hypoxic
Hypercapnic
ARDS

Tachycardic
Hypotensive
ECG changes of right heart strain (S1Q3T3)

DIC
Oliguria
Petechial rash in upper body takes hours to appear

Front 69

Changes in capnography

Back 69

Exponential decline:
Hypotension
Embolism
Circulatory arrest
Sudden severe hyperventilation

Sudden decrease (but not to zero)
Circuit leakage
Obstructive airways / high airway pressures

Sudden drop to zero
Kinked ETT
Total disconnection
Ventilator defective
CO2 analyser defective

Sudden change in baseline
CO2 absorber saturated
Calibration error
Water drops in analyser

Front 70

Warfarin reversal

Back 70

INR > 1.5 and life-threatening bleeding

Vit K 5-10mg

Prothrombinex-VF 50u/kg

FFP 150-300mL

(FFP 15mL/kg if prothrombinex unavailable)

INR > 2 and critically significant bleeding

Vit K 5-10mg

Prothrombinex-VF 35-50u/kg based on INR

(FFP 15mL/kg if prothrombinex unavailable)

Any INR with minor bleeding

Vit K 0.5-1mg

Front 71

Coronary blood supply

Back 71

Coronary circulation:

http://www.vhlab.umn.edu/atlas/coronary-arteries/circumflex-artery/index.shtml

Aortic root -> Left coronary and Right coronary ostia

L side supplies LA, LV, +/- some of posterior RA and SN
R side supplies RA, RV, posterior, usually SN, AVN

L coronary ostium -> left coronary artery (=left main)
-> anterior interventricular branch (=LAD) (supplies anterior, and anterior 2/3 of inter ventricular septum)
->L circumflex branches off and runs in atrioventricular groove, branches into L marginals supply LV

R coronary ostium -> RCA which runs in R atrioventricular groove (gives off R marginal branch which runs to apex, SA nodal artery, AV nodal artery) until it passes posteriorly, and then it branches into the posterior interventricular branch



Venous Drainage:

Coronary sinus drains into RA, most of blood supply
Anterior cardiac veins drain directly into ventricles
Thebesian veins also drain directly into ventricles

Front 72

Professional attributes

Back 72

P Professional - ethical, confidential, policies

A Advocate for patient health

X Expert - medical knowledge, vigilant, safe

M Manager - finite health resource management

E Educator / Scholar

C Collaborator - MDT approach

C Communicator - informed consent, conflict resolution

Front 73

Stridor

Back 73

Inspiratory: Supraglottic

Biphasic: glottic / subglottic

Expiratory: tracehobronchial

Front 74

Infective endocarditis prophylaxis

Who is at risk?

What procedures?

Back 74

High Risk

Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous infective endocarditis

Congenital heart disease IF
<6/12 of repair with prosthetic material
Residual defect adjacent to prosthetic material
Unrepaired cyanotic defects

Cardiac transplantation with post-transplantation valvulopathy

Rheumatic heart disease in Indigenous Australians only.



Procedures:

Incision in mouth mucosa
Biopsy or surgery in respiratory mucosa

GIT:
Vaginal delivery after prolonged labour
Lithotripsy

Any procedure in the presence of infection
Eg: incision and drainage of abscess.

Front 75

Assessment of child with a murmur:

Red Flags?

Reassuring features?

High risk lesions?

Low risk lesions?

Back 75

Red flags for investigation of paediatric murmurs before anaesthesia:

Age < 1 year
Tachypnea
Recurrent chest infections
ECG evidence of ventricular hypertrophy
Cyanosis
Family history of sudden death
Failure to thrive
Sweating
Feeding difficulties
Syndromic

Radio-radial delay
All thrills.
Late systolic, pan-systolic, and diastolic murmurs. Harsh.
Signs of RHF.

OK to proceed:
Asymptomatic child over 1 year, normal ECG, no thrill. Early systolic or soft venous hum, OK to proceed.
Innocent: blowing, musical, vibratory


High risk (need to be done in specialist centre)
Single ventricle circulation
Unrepaired
Decompensated
PHT
Coronary artery abnormalities
Ventricular failure
Obstructive valvular disease

Low risk
Repaired isolated ASD / VSD
Repaired PDA

Front 76

Quality assurance cycle

Back 76

Planning:
Define topic, data to be collected and how it will be analysed. Literature review.

Implementation:
Monitor current practice
Critical incidents (analyse frequency, causes, contributing and mitigating factors, outcomes)
Peer review (M&M, random review, practice review by a peer)
Staff or patient reports.
Patient surveys
RCA

Identify risks of injury or adverse outcomes.

Implement changes where problems are identified.
Specific change based on literature review, and consultation with involved disciplines, taking a multidisciplinary approach.

Review:
Monitor effects of changes made on identified risks and adverse outcomes

Set standards:
Write guidelines, regulations etc.

Front 77

Peer review

Back 77

Participation in M&M meetings
Reviews of randomly selected cases
Practice review of an anaesthetist by a peer

Front 78

External reporting

Back 78

Mortality and morbidity committees
Adverse reaction committees
Sentinel events programs
Critical incident reviews

Front 79

Epidural anatomy

Back 79

The spine is bound by pia mater. CSF bathes it, and is surrounded by arachnoid mater, which is itself surrounded by dura mater. The epidural space is everything outside the dura mater, but bound by;

Superiorly bound by the foramen magnum
Inferiorly by the sacral hiatus
Anteriorly by the posterior longitudinal ligament
Posteriorly by the ligamentum flavum
Laterally by the periosteum of the pedicles and the intervertebral foraminae.

Front 80

Long QT management

Back 80

Cardiology referral, beta-blockade

Pre-med. K+, Mg2+. Defib and facility for TV pacing. Minimise drugs that prolong.

Induction: avoid sux and thio. Ablate response.

Maint: Sevo safest

Emergence: avoid glyco and atropine

Treat TDP with magnesium as first line (Mg 2g over 2-3 mins. K+>4.5)

Defib for VF.

Front 81

Med Viva

Back 81

Disease:

Risks

Progression

Treatment

?Side effects

Functional state

Front 82

LMA sizes

Back 82

LMA sizes (Drug Doses Frank Shann Book)

<5kg = 1
5-10kg = 1.5
10-20kg = 2
20-30kg = 2.5
30-50kg = 3.0
50-70kg = 4.0
70-100kg = 5.0
100kg = 6