*part Ii Stuff To Remember

Front 1

World Federation Neurosurgeons (WFNS) SAH grading

Back 1

Score correlates with mortality

Front 2

Child-Pugh Classification

Back 2

Operative mortality:

Score:
5-6 = Class A = low risk < 5%
7-9 = Class B = moderate risk 25%
10-15 = Class C = high risk > 50%

Front 3

Apgar Score

Back 3

- Apgar’s are taken at 1 and 5min
- Memory aid:
 Activity (muscle tone)
 Pulse
 Grimace (reflex irritability)
 Appearance (colour)
 Respiration

Front 4

CHADS2

Back 4

CHADS2=0, no therapy or Aspirin only is recommended
­CHADS2=1, either Aspirin or Warfarin is recommended (depending on patient preferences)
­CHADS2 ≥ 2 should be managed with lifelong Warfarin (target INR 2.0-3.0)

­Overall risk of stroke in non-valvular AF is around 5% per year
­Warfarin reduces risk of CVA from 5% to 1% per annum
Risk of major bleed 0.5% per annum

Front 5

Aortic Stenosis Severity (Echo)

Back 5

AHA Guidelines

Front 6

Mitral Stenosis Severity (Echo)

Back 6

AHA Guidelines

Front 7

Pulmonary Hypertension Severity (Echo)

Back 7

­Based on mean PAP:
 Mild: 25-35
 Moderate: 35-45
 Severe: >45mmhg
­
Based on RVSP:
 >40 has likely PHTN
 50-60 moderate
 >60mmhg as severe

Front 8

RIFLE Criteria

Back 8

Front 9

LeFort Fractures

Back 9

Front 10

Obstructive Lung Disease Severity

Back 10

Severity based on FEV1% of predicted values (GOLD report on COPD 2011)
ᵒ Mild (stage 1) : >80% predicted
ᵒ Moderate (stage 2): 50-80% predicted
ᵒ Severe (stage 3): 30-50% predicted
ᵒ Very Severe (stage 4) : <30% predicted

Front 11

STOP BANG

Back 11

Snoring: loud snoring (can be heard through closed doors)
Tiredness: daytime somnolence
Observed apnoea
Plood pressure: Hx of hypertension

BMI: >35
Age: >50
Neck Circumference: >40cm
Gender: male

>3 = High risk of OSA → refer for sleep testing

Front 12

ARDS Severity

Back 12

Front 13

Soda Lime - Contents and reaction

Back 13

Contains:
94% calcium hydroxide
5% sodium hydroxide
1% potassium hydroxide
An indicator – such as ethyl violet
Silica – increases hardness of the granules, minimising formation of alkaline dust which can be an airway irritant if inhaled

The active ingredient is the sodium hydroxide, which acts as a catalyst, and is not actually consumed in the reaction:

CO2 + H20 ↔ H2CO3
2NaOH + H2CO3 → Na2CO3 + 2H2O + heat
Na2CO3 + Ca(OH)2 → CaCO3 + 2NaOH + heat

Front 14

Diastolic Heart Failure Echo Assessment

Back 14

Transmitral flow velocity
­ E wave: peak filling velocity in early diastole
­ A wave: peak filling velocity in late diastole
­ E/A relationship
 Normal:
E/A is > 1
As atrial kick only contributes 30% of filling
 Mild DD aka ‘Impaired relaxation’
E/A is <1
Relaxation is impaired and atrial contraction contributes relatively more to ventricular filling
 Moderate DD aka ‘Pseudonomral filling’
E/A normalises to E>A
Compliance and relaxation reduced → impaired early diastolic filling and raised LAP → E >A
Differentiated from normal by assessing transmitral flow with valsalva
 Severe DD aka ‘Restrictive filling’
E >> A
LV compliance is extremely low → high LAP → high velocity E wave

Front 15

PONV

Apfel Simplified Risk Score

Eberhart Simplified Risk Score

Back 15

Apfel Simplified Risk Score – In Adults
­Four risk factors
 Female sex
 Non-smoker
 Hx of PONV or motion sickness
 Use of postoperative opioids
­ Risk Score:

0 RF (baselines risk) = 10%, 1 RF = 20%, 2 RF = 40%, 3RF = 60%, 4 RF = 80%


Eberhart Simplified Risk Score – In Children
­Four risk factors
 Age > 3
 Surgery >30 mins
 Hx of POV, or PONV in 1st degree relative
 Strabismus surgery
­ Risk Score:

0 RF (baselines risk) = 10%, 1 RF = 10%, 2 RF = 30%, 3RF = 55%, 4 RF = 70%

Front 16

MELD Score

Back 16

Model for End-Stage Liver Disease (MELD) Score

Uses bilirubin, creatinine and INR

MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.57[Ln serum creatinine (mg/dL)] + 6.43

Score correlates to 3month mortality

Front 17

ECG Lead sensitivity

Back 17

V5 = 75%
V4 + V5 = 90%
II + V4 + V5 = 98%

Front 18

Classification of breathing Circuits

Back 18

A
ᵒ A spring loaded pop off valve located near the face
ᵒ Gas flow enters at other end near reservoir bag

B & C
ᵒ Pop off valve at face with FGF also near patient.
ᵒ Reservoir bag and tubing are a blind limb where FGF, dead space and alveolar gas collect

D,E,F
ᵒ FGF near patient, excess gas popped off at other end

Efficiency
Spontaneous ventilation: A>DFE>CB
Controlled ventilation: DFE> BC >A
­
DEF are commonly used, ABC very uncommonly used

Front 19

Mapleson A

Back 19

Efficiency
SV: FGF = MV
CV: FGF = 3xMV

Front 20

Mapleson B & C

Back 20

Efficiency
SV: FGF = 2xMV
CV: FGF 50% > than MV required

B more efficient with CV as has reservoir tube

Front 21

Mapleson D

Back 21

D most efficient for CV

Bain's = modified D
- SV: 2-3xMV
- CV: 1-2xMV

Front 22

Mapleson E & F

Back 22

Mapleson E (Ayre's T-piece)
- FGF of 3xMV required in SV

Mapleson F (Jackson Reese Modification)
- FGF 2-3xMV required

­The volume of the reservoir tubing should be at least 1/3rd of the patient’s tidal volume. If the volume is too large, rebreathing may occur, and if too small, ambient air may be entrained

Front 23

Lung Segments

Back 23

Front 24

Thoracics Cardiopulmonary Testing

Back 24

CPEX
­VO2max >20 mL/kg/min (or >15ml/kg/min & FEV1 >40% predicted) = low risk of respiratory complications
­VO2max <15 mL/kg/min = high risk of morbidity and mortality
­VO2max <10 mL/kg/min = 40-50% mortality, consider non-surgical management

Stair Climb
­One “flight” = 20 steps at 6 inches/step
­Climbing five flights = VO2max >20 mL/kg/min
­Climbing two flights = VO2max of 12 mL/kg/min
Patient unable to climb two flights is at extremely high risk

6MWT
­Distance correlates well with VO2max
Distance <600m correlates to a VO2max <15 mL/kg/min and also correlates with a fall in oximetry (Spo2) during exercise
­Drops in SpO2 > 4% during exercise are associated with increased morbidity

Front 25

Define:
- Quality Assurance
- Alternative Medicine
- Attributes of the anaesthetist
- Impairment
- Autonomy
- Beneficence
- Non-malificence
- Paternalism
- Justice

Back 25

QA: “an organised process that assesses and evaluates health services to improve practice or quality of care”
Steps = planning, implementation, review, setting standards

Alternative Medicine
"Any substance which may be used by an individual for its effects on health or disease process, that is not recognised by the regulatory authorities of that country for these properties"

Attributes of the anaesthetist
- Communicator, Collaborator, Medical Expert, Manager, Professional, Health Advocate, Scholar Teacher

Impairment
when a colleague’s behaviour consistently departs from the expected behaviour set out in these codes of conduct, and impacts on his or her performance

Autonomy: recognises the rights of individuals to make decisions regarding their own health – self-determination
Beneficence: ­ A practitioner should act in the best interest of the patient
Non-Maleficence: ­ A practitioner has a duty not to harm patients
Paternalism: ­ A practitioners decision to act for a patients good without regard for the patients conception of what would be good in the given situation
Justice: ­The greatest good for the greatest number of people

Front 26

Classification of Head Injury

Back 26

Mild = GCS 13-15
 Need to monitor / CT
 Watch for BOS fracture, intoxication, vomiting, etc

Moderate = GCS 9-12
 High risk of morbidity
 Intubate and ventilate if not cooperative for CT
 Monitor 24 hrs

Severe = GCS <9
Resuscitate
Evaluation / Diagnosis
Surgical Mx
Monitoring
ICU

Front 27

Current Thresholds

MACROSHOCK
Sensation
Pain
Muscular contraction
Respiratory insufficiency
VF and burning

MICROSHOCK

Back 27

MACROSHOCK
Sensation is about 1 mA
Pain at 10mAmp
Muscular contraction at 16 mA (i.e. ‘let go’ threshold)
Respiratory insufficiency at 50 mA
VF and burning at > 100 mA

MICROSHOCK
0.05- 0.1mA (i.e. 1/1000 macroshock level & 1/100 sensation level)
Electrocution causing VF can occur below the level of perception

Front 28

Circuit breaker current flow trigger

RCD trigger

LIM limits

Back 28

Circuit breaker current flow trigger = >10mA for 1/10sec

RCD trigger: 5-10mA difference, triggers in 40milisec

LIM limits: Prospective Hazard Current (P.H.C.) of 5mA

Front 29

ANATOMY

Subcostal
Ilioinguinal/iliohypogastric
Genitofemoral
Pudendal
Femoral
Lateral femoral cutaneous
Sciatic
Obturator
Pudendal branches

Cardiac veins

Spinal Cords Blood Supply

Back 29

Subcostal = lateral cutaneous branch of T12

Ilioinguinal/Iliohypogasric = Lateral cutaneous branches of L1
- Above ASIS - travel between TA & IO
- Below ASIS - ilioinguinal between TA & IO, iliohypogastric between IO & EO

Genitofemoral = L1, L2

Pudendal = anterior divisions S2-4

Femoral = L2-4

Lateral femoral cutaneous = L2,3

Sciatic = L4-5, S1-3

Obturator = L2-4

Pudendal Branches: inferior rectal nerve, dorsal nerves of the penis, perineal branch


Cardiac veins
- Great cardiac vein (anterior IV groove, runs with LAD)
- Middle cardiac vein (inferior interventricular groove (with PDA)
- Small cardiac vein (base of heart, with marginal branch of RCA)

Spinal Cord Blood supply
- Anterior spinal artery (from vertebral artery at level of forament magnum)
- Radicular branches (lower cervical, lower thoracic, upper lumbar, adamkiewicz)
- Posterior spinal artery x 2 (from posterior inferior cerebellar artery)
- Venous drainage: radicular veins empty into epidural venous plexus

Front 30

Myasthenia Gravis - Predictors of need for Post-Op Ventilation

Back 30

Predictors for need of post-op ventilation:
ᵒ Major body cavity surgery
ᵒ Disease duration of longer than 6 years
ᵒ Presence of chronic respiratory disease unrelated to MG
ᵒ Daily dose of pyridostigmine >750 mg + significant bulbar dysfunction
ᵒ Vital capacity < 2.9 L

Front 31

Dental Blocks

Anterior Superior Alveolar
Middle Superior Alveolar
Posterior Superior Alveolar
Inferior Alveolar
Nasopalatine
Greater palatine

Back 31

Anterior Superior Alveolar
- Above lateral incisior/canine in mucobuccal fold

Middle Superior Alveolar
- Above 2nd maxillary premolar in mucobuccal fold, aim toward infraorbital foramen

Posterior Superior Alveolar
- Above 2nd MOLAR in mucobuccal fold. Needle at 45 degrees, aim superiorly, medially, laterally

Inferior Alveolar
- Maximally open the mouth, injection point is the mucosa immediately between the upper and lower molars

Nasopalatine
- V2 branch, supplied maxillary anterior palate from
canine to canine
- Inject into incisive foramen

Greaterpalatine
- V2 branch, supplied Palatal soft tissue from maxillary canine back
- Insertion is ~1cm medial from 1st/2nd maxillary molar on the hard palate

Front 32

LARYNX ANATOMY

EXTRINSIC MUSCLES

INTRINSIC MUSCLES
Abductors of the cords
Adductors of the cords
Sphincters to vestibule
Regulators of cord tension

Back 32

­Sternothyroid
­Thyrohyoid
­Inferior constrictor of the pharynx


Abductors of the cords: posterior cricoarytenoids

Adductors of the cords: lateral cricoarytenoids, interarytenoid

Sphincters to vestibule: aryepiglottics, thyroepiglottics

Regulators of cord tension: cricothyroids (tensors), thyroarytenoids (relaxors), vocales (fine adjustment)