Anaesthesia Essentials

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Definition of Terms General Anaesthesia: A drug-induced reversible state of unconsciousness characterized by amnesia, analgesia, muscle relaxation, and loss of autonomic reflexes. Preoxygenation: Administration of 100% oxygen prior to induction of anaesthesia to denitrogenate the functional residual capacity (FRC) and create an oxygen reservoir, increasing the duration of safe apnoea. Rapid Sequence Induction (RSI): A technique to secure the airway quickly in patients at high risk of aspiration, involving rapid administration of induction agents and neuromuscular blockers, followed by cricoid pressure and immediate intubation without bag-mask ventilation. Balanced Anaesthesia: The use of a combination of anaesthetic agents (e.g., hypnotic, analgesic, muscle relaxant) to achieve the components of general anaesthesia with fewer side effects than large doses of a single agent. Perioperative Phase: The entire period surrounding a surgical procedure, including the preoperative, intraoperative, and postoperative phases. Preoperative Checklist: A structured tool used to ensure that all necessary assessments, preparations, and checks are completed before surgery. Intraoperative Phase: The period during which the patient is undergoing surgery, from induction of anaesthesia to emergence and transfer to recovery. Postoperative Phase: The period following surgery, from transfer to recovery until discharge from the hospital or complete recovery. Pre-anaesthetic Clinic: A clinic where patients are assessed by an anaesthetist prior to surgery to optimize their medical condition and plan anaesthesia. Vigilance: The continuous state of alertness and observation maintained by the anaesthetist to monitor the patient's condition and the anaesthetic equipment. Regional Anaesthesia: Reversible loss of sensation in a specific area of the body produced by injecting local anaesthetic near nerves, without loss of consciousness. Spinal Anaesthesia: A type of regional anaesthesia where local anaesthetic is injected into the subarachnoid space (cerebrospinal fluid) to block nerve roots. Anaesthetic Machine: A device used to deliver a precisely controlled and continuous supply of medical gases (oxygen, nitrous oxide, air) and volatile anaesthetic agents to the patient. Circle System: A rebreathing anaesthetic circuit that allows for the rebreathing of exhaled gases after carbon dioxide absorption, conserving heat and moisture and reducing anaesthetic agent consumption. Low Pressure System: Part of the anaesthetic machine from the flowmeters to the common gas outlet, which is subjected to low pressure. Intermediate Pressure System: Part of the anaesthetic machine that receives gases from the high-pressure system and delivers them to the flowmeters, typically at a pressure of 45-55 psi. High Pressure System: Part of the anaesthetic machine that receives gases from compressed gas cylinders at cylinder pressure. Multiple Choice Questions (MCQs) Identify the monitoring that must be routinely commenced prior to a patient's transfer. a. Arterial blood pressure b. Temperature c. Neuromuscular transmission d. ECG e. Oxygen saturation 27 years old is transferred to the intensive care unit following an emergency surgery after road traffic accident, what information should the nurse anaesthetist not hand over to the ICU staff? a. Past medical history b. Mechanisms of injury and other associated injuries c. Types of dressing and sutures used intra-operatively d. Operative finding and blood loss e. Post operative instructions Which of the following is not the responsibility of the anaesthetist pre operatively? a. Carry out a thorough assessment of the patient, or if this has been done in the pre-operative assessment clinic, check that nothing has changed and no investigations are outstanding. b. Planning the date of discharge from hospital c. Ensure that a plan for intra and post operative pain relief has been made. d. Ensure that the patient is adequately prepared for theatre with relevant blood tests, ECGs and Xray satisfactory e. Discuss with the critical care department whether the patient is likely to need intensive care or high dependency care post-operatively Which of the following classified as controlled drugs? a. Propofol b. Alfentanil c. Thiopentone d. Bupivacaine e. Ephedrine 57 years old man is in the recovery ward post laparotomy for bowel obstruction. an anaesthetist is called and he is found to be unconscious, with poor respiratory efforts and have oxygen saturation of 88%. Which is the most appropriate initial response. a. give high flow oxygen via a hudson mask b. Call for help c. Suction his air way d. Try airway manoeuvres/ bag valve mask e. Place him in the recovery position Which of the following do not affect the ASA grading? a. Smoking b. Blood loss during surgery c. Hypertension d. Chronic renal disease e. None of the above Anxiolysis is a decreased response to which stimulus? a. Fear b. Pain c. Light touch d. Verbal commands e. Awareness General anaesthesia occurs in which sequence? a. I, M, Ms, A, U, R b. I, U, A, Ms, M, R c. Ms, A, I, M, U, R d. A, Ms, M, I, R, U e. M, A, U, Ms, M, R Note: This question refers to stages of anaesthesia, commonly described as: I-Analgesia, II-Excitement, III-Surgical Anesthesia, IV-Medullary Paralysis. The options provided do not directly map to these standard stages or common sequences of drug effects. Assuming "I" is Induction, "U" is Unconsciousness, "A" is Analgesia, "Ms" is Muscle relaxation, "M" is Maintenance, "R" is Reversal, a typical sequence might be Induction, Unconsciousness, Analgesia, Muscle Relaxation, Maintenance, Reversal, but without clearer definitions for the letters, it's ambiguous. No clear best answer from options. The best way to identify an oesophageal intubation? a. Seeing an endotracheal tube pass through vocal cords b. Observing chest wall movements during inspiration and expiration c. Hearing breath sounds during controlled ventilation d. Positive capnography trace e. All the above Core site of temperature monitoring is? a. Tympanic membrane b. Pulmonary artery c. Rectum d. Oesophagus e. None of the above Strategies to prevent aspiration pneumonia in a full stomach patient are all except? a. Regional anaesthesia with minimal sedation b. Premedication with metoclopramide c. Rapid sequence induction with positive ventilation (RSI usually avoids positive pressure ventilation unless absolutely necessary, to minimize gastric insufflation) d. Awake extubation e. None of the above Predictors of a difficult intubation are all except? a. Long upper incisors b. History of head and neck radiation c. Mallampati 3 & 4 d. Prominent overbite e. All the above (meaning all listed are predictors) A patient anaesthetized for surgery is put under mechanical ventilation, the best monitor to evaluate disconnection is? a. ECG b. Pulse oximeter c. ETCo2 d. FIO2 e. None of the above Which statement is FALSE regarding amnesia? a. Amnesia can either be present or absent in a conscious patient. b. Amnesia can either be present or absent in an unconscious patient. c. Amnesia effects are most closely related to the limbic structures of the CNS. d. Amnesia effects are most closely related to the spinal cord structures of the CNS. e. NONE of the above A complete general anaesthetic produces all the following, except? a. Sedation as a maximum effect b. Unconsciousness c. Muscle relaxation d. Unresponsiveness e. All the above (meaning all listed are produced) All the following are indicators for central cannulation, except? a. CVP monitoring b. Parenteral cannulation c. Anaesthesia induction d. Non accessibility of peripheral veins e. All the above Apnoea during spinal anaesthesia occur mostly due to? a. Phrenic nerve blockage C3 - C5 b. Total spinal (leading to high block and respiratory muscle paralysis) c. Hypotension with medullary hypoperfusion d. Local anaesthetic toxicity e. None of the above Adequate fluid resuscitation is indicated best by? a. Central Venous Pressure b. Urine output c. Heart rate d. Correction of previous hypotension e. All the above Which of the following does not affect the spread of spinal anaesthesia? a. Baricity of the anaesthesia solution b. Drug dose c. Speed of injection d. Site of injection e. All of the above (meaning all listed DO affect spread) Pain relief during first stage of labour require sensory blackage level of? a. L2 b. S2,3,4 c. T10 d. T4 e. L1 During epidural anaesthesia with 10 ml 2% Xylocaine, the patient develops respiratory depression and hypotension, which of the following is the cause of same? a. Anaphylaxis b. Drugs gone into the subarachnoid space (total spinal) c. Systemic toxicity of the drugs d. Speed of injection e. Position Which of the following can alternatively be used to epinephrine for resuscitation? a. Vasopressin b. Noradrenaline c. Atropine d. Amiodarone e. None of the above Which delivery system feature decreases the amount of anaesthetic gas the practitioner is exposed to? a. Regulators b. Vaporizers c. Safety shutoff valve d. Vacuum exhaust line (Scavenging system) e. Flow meter All inhalation general anaesthetic produces which effects? a. Increased myocardial contractility b. Depressed myocardial contractility c. Stimulate respiration d. Increase glomerular filtration in the kidney e. Depress respiration Which of the following is classified as controlled drugs? a. Propofol b. Alfentanil c. Thiopentone d. Bupivacaine e. Ephedrine True and False Questions REGARDING THE ROLE OF THE ANAESTHETIST PRE OPERATIVELY a. The anaesthetist should discuss the patient with the intensive care team if appropriate. TRUE b. The anaesthetist should carry out thorough assessment of the patient. TRUE c. The anaesthetist should gain consent for the operation. FALSE (Surgeon's primary responsibility) d. The anaesthetist should ensure that cross-matched blood is available if appropriate. TRUE e. The anaesthetist should make a plan for intra-operative and post-operative pain relief. TRUE WHICH OF THE FOLLOWING FACTORS INCREASE THE RISK OF RESPIRATORY COMPLICATION PERI OPERATIVELY? a. Age > 50 years. TRUE b. Smoking within 12 weeks of surgery. TRUE c. History of malignancy. FALSE (Not directly a primary respiratory risk factor) d. Chronic bronchitis. TRUE e. Obesity. TRUE STANDARD PRE OPERATIVE CHECKS PERFORMED IN THE ANAESTHETIC ROOM INVOLVES CHECKING a. If the patient has any allergies. TRUE b. Planned date of discharge from the hospital. FALSE c. The patient's date of admission to the hospital. FALSE d. Which ward the patient is coming from. FALSE e. Next of kin details. FALSE WHERE DOES PRE OXYGENATION PRODUCE THE GREATEST INCREASE IN STORED OXYGEN. a. Anatomical dead space. FALSE b. Arterial blood. FALSE c. Functional Residual Capacities. TRUE d. Tissues. FALSE e. Venous blood. FALSE IDENTIFY THE MONITORING THAT MUST BE ROUTINELY COMMENCED PRIOR TO A PATIENTS TRANSFER a. Arterial blood pressure. TRUE b. Temperature. TRUE (often done, but maybe not "routinely commenced prior to transfer" from OR to PACU in all cases, depends on local protocol) c. Oxygen saturation. TRUE d. Neuromuscular transmission. FALSE (Not routine for all transfers) e. ECG. TRUE During anaesthesia which of the following systems/parameters (among others) need continuous monitoring. a. Inspired oxygen concentration. TRUE b. routine use of BI spectral index analysis. FALSE (Not routine for all cases) c. end tidal carbon dioxide concentration. TRUE d. clinical signs of adequate circulation. TRUE e. all of the above. FALSE (due to b) These statements refer to monitoring a. Monitoring prevents adverse events in the peri-operative period. TRUE b. The introduction of routine monitoring is the main reason for the progressive reduction in anaesthesia related critical events in recent years. TRUE c. The surgeon can continue operating when an anaesthetic working single handedly is called upon to perform a brief lifesaving procedure nearby. FALSE (Patient safety requires full attention) d. The anaesthetic is not responsible for the provision of, maintenance, calibration and renewal of monitoring equipment. FALSE (Anaesthetist is responsible for ensuring equipment is functional) e. The use of a vapour analyser helps to prevent awareness or over-dosing by an inhalational agent. TRUE Venous thrombosis often occurs in normal vessels commonly in the deep veins of the legs and the pelvis. Which of the following may be considered as contributing/precipitating factors perioperatively? a. Hypercoagulability due to surgery, cancer, oestrogen therapy. TRUE b. Stasis of blood in legs due to immobility. TRUE c. Dehydration. TRUE d. Poor cardiac output. TRUE e. Obstructed venous return e.g. pregnancy, pelvic surgery, pneumoperitoneum. TRUE Which of the following are early signs of oesophageal intubation? a. ST segment depression on ECG. FALSE b. Bradycardia. FALSE c. Absent capnography waveform. TRUE d. No breath sound on auscultation. TRUE e. Desaturation on pulse oximetry. FALSE (Late sign) Which of the following apply when preoxygenating? a. A higher gas flow is needed with vital capacity breathing. FALSE (Doesn't affect gas flow directly, rather the technique) b. Low flow is suitable when using a circle system. FALSE (High flow is needed for rapid denitrogenation) c. A Hudson mask is suitable alternative to anaesthetic facemask. FALSE (Hudson masks are open systems, not suitable for preoxygenation) d. An end-expired oxygen concentration of 95% should be the target. TRUE e. A flow rate of at least 9 L/M should be used with a Bain system. TRUE (High flow needed for non-rebreathing circuits) The preoperative assessment clinic: a. Replaces the need for a preoperative visit by the anaesthetic. FALSE (It complements, not replaces, especially if new issues arise) b. Should ideally be situated in the theatre suite. FALSE c. Allow the surgeon to decide on the urgency of the operation. FALSE (This is a clinical decision by the surgical team) d. Allow the patient and their family to visit the ward they will be admitted to, prior to surgery. FALSE (This is a separate patient education/familiarization activity) e. Is ideally run by specially trained multi-disciplinary team with access to a consultant anaesthetist if required. TRUE Short Answer Questions State five benefits of the pre anaesthetic clinics. Optimizes patient's medical condition before surgery. Reduces perioperative morbidity and mortality. Allows for informed consent and patient education regarding anaesthesia. Reduces anxiety for the patient. Improves operating theatre efficiency by reducing cancellations and delays. Describe the sequence of anaesthetic events for a patient scheduled for surgery from arrival in the theatre leading up to transfer to recovery room. Arrival in Theatre/Anaesthetic Room: Patient identification, consent check, safety checklist (WHO), vital signs, IV access. Preoxygenation: Administration of 100% oxygen via face mask. Induction of Anaesthesia: Administration of IV induction agents, muscle relaxants (if needed), airway management (e.g., intubation). Maintenance of Anaesthesia: Administration of inhalational or intravenous anaesthetics, analgesics, muscle relaxants, fluid management, monitoring. Emergence from Anaesthesia: Discontinuation of anaesthetic agents, reversal of muscle relaxants, spontaneous ventilation, extubation (if intubated). Transfer to Recovery Room: Patient stable, airway patent, vital signs monitored during transfer. What are 6 the aims/benefits of pre-operative assessments? Identify co- morbidities and optimize chronic conditions. Assess anaesthetic risk and plan appropriate anaesthetic technique. Provide information and obtain informed consent from the patient. Reduce patient anxiety. Order necessary investigations. Prevent unforeseen cancellations or delays on the day of surgery. What are five factors that influence your choice of pre-operative investigations? Patient's age. Patient's medical history/co-morbidities. Type and invasiveness of surgery. Anaesthetic technique planned. Results of previous investigations. What are five determinants of patient safety during anaesthesia? Competent and vigilant anaesthetist. Functional and calibrated anaesthetic equipment and monitors. Thorough preoperative assessment and optimization. Adherence to safety protocols (e.g., WHO Surgical Safety Checklist). Effective communication within the perioperative team. What are the roles of anaesthetist pre-operatively? Patient assessment and risk stratification. Optimization of patient's medical condition. Discussion of anaesthetic options and obtaining informed consent. Prescribing pre-medication if necessary. Planning for intraoperative and postoperative care (e.g., pain management, critical care needs). What are the factors that increase the risk of respiratory complication peri-operatively? Advanced age. Smoking. Pre-existing lung disease (e.g., COPD, asthma). Obesity. Type of surgery (e.g., thoracic, upper abdominal). Emergency surgery. What are standard pre-operative checklist performed in the anaesthetic room? Patient identification (name, DOB, hospital number). Confirmation of surgical site and procedure. Allergies checked. NPO status confirmed. Blood products available (if cross-matched). Anaesthetic machine and drug checks completed. Monitoring applied and functional. What are the current standards that apply to anaesthesia practice? Monitoring standards (e.g., ECG, SpO2, NIBP, ETCO2, Temperature). Equipment safety checks. Preoperative assessment and consent. Airway management guidelines. Postoperative care standards. What are 5 anaesthetist's principal tasks during an operation? Maintain anaesthesia (administer agents). Monitor patient's vital signs and physiological parameters. Manage the patient's airway and ventilation. Administer fluids and blood products. Manage pain and ensure patient safety. Identify the monitoring that must be routinely commenced prior to patient's transfer? ECG Non-invasive Blood Pressure (NIBP) Pulse Oximetry (SpO2) Temperature End-tidal Carbon Dioxide (ETCO2) (if intubated/ventilated) Long Questions: Anaesthetic Machine Briefly discuss the following terms as they apply in anaesthesia a. Oxygen supply: Anaesthetic machines receive oxygen from cylinder banks (high pressure) or pipeline systems (intermediate pressure). Critical for patient ventilation and safety. b. Breathing systems: Circuits that deliver breathing gases and anaesthetic agents to the patient and remove carbon dioxide. Examples include circle systems, Mapleson circuits. c. Alarms: Safety features on anaesthetic machines and monitors that alert the anaesthetist to deviations from preset limits (e.g., high/low pressure, SpO2, ETCO2, disconnection). d. Adjustable Pressure Limiting (APL) valve: A user-adjustable valve in breathing circuits that releases excess gas to the scavenging system, preventing excessive pressure buildup in the patient's airway. e. Unidirectional valves: Valves in a circle breathing system that ensure gas flow in one direction, preventing rebreathing of exhaled gas until it has passed through the CO2 absorber. Discuss the principle of standard monitoring highlight all relevant key parameters (10) Standard monitoring in anaesthesia aims to continuously assess the patient's physiological status and detect adverse events promptly. Key parameters include: Electrocardiogram (ECG): Monitors heart rate, rhythm, and detects myocardial ischemia. Blood Pressure (BP): Non-invasive (NIBP) or invasive (IBP) measurement to assess cardiovascular stability and perfusion. Pulse Oximetry (SpO2): Measures arterial oxygen saturation, indicating oxygenation status. Capnography (ETCO2): Measures end-tidal carbon dioxide, reflecting ventilation adequacy and confirming tracheal intubation. Temperature: Monitors core body temperature to prevent hypothermia or hyperthermia. Inspired Oxygen Concentration (FiO2): Ensures correct oxygen delivery. Agent Analyzer: Measures inspired and expired concentrations of volatile anaesthetic agents. Neuromuscular Transmission Monitoring: Assesses depth of muscle relaxation and guides reversal. Urine Output: Indicator of renal perfusion and fluid balance. Clinical Observation: Direct observation of skin color, chest excursion, pupils, and overall patient appearance. Discuss the circle system and state 4 advantages and disadvantages of a circle system. A circle system is a rebreathing anaesthetic circuit where exhaled gases pass through a CO2 absorber before being rebreathed. It is characterized by unidirectional valves, a CO2 absorber, fresh gas inlet, reservoir bag, and an APL valve. Advantages: Conservation of heat and humidity: Reduces patient heat and moisture loss. Economical: Lower fresh gas flow (FGF) rates reduce anaesthetic agent consumption. Reduced environmental pollution: Less waste anaesthetic gas. Stable anaesthetic concentration: Allows for precise control of anaesthetic depth. Disadvantages: Complexity: More components, increasing potential for disconnections and malfunctions. Resistance: Higher resistance to breathing due to valves and absorber. Maintenance: Requires regular replacement of CO2 absorbent. Compliance: Gas compression in the circuit can affect tidal volume delivery, especially at low FGF. State four functions of breathing circuit (4) Deliver oxygen and anaesthetic gases to the patient. Remove carbon dioxide from exhaled gas. Allow for assisted or controlled ventilation. Provide a means for monitoring airway pressure and gas concentrations. State four features that optimise the function of a circle system design (4) Efficient CO2 absorbent (e.g., soda lime) to prevent rebreathing. Low-resistance unidirectional valves to minimize work of breathing. Minimal dead space within the circuit. Appropriate fresh gas flow rates to match patient's metabolic needs and anaesthetic depth. Long Questions: General Anaesthesia Define general anaesthesia General anaesthesia is a reversible, drug-induced state characterized by unconsciousness, amnesia, analgesia, muscle relaxation, and suppression of undesirable autonomic reflexes, allowing for surgical procedures to be performed without patient awareness or pain. Discuss the concept of preoxygenation (5) Preoxygenation involves administering 100% oxygen to a patient for several minutes prior to the induction of anaesthesia. The primary goal is to replace the nitrogen in the patient's functional residual capacity (FRC) with oxygen, effectively creating an oxygen reservoir. This denitrogenation significantly extends the duration of safe apnoea (the time a patient can tolerate without breathing before desaturation occurs) during induction and intubation, especially critical in patients with difficult airways or reduced pulmonary reserve. Explain why preoxygenation is beneficial during induction of anaesthesia (3) Preoxygenation is beneficial during induction of anaesthesia because it: Increases Oxygen Reserve: By filling the lungs with 100% oxygen, it maximizes the amount of oxygen available to the body during the apnoeic period after induction. Extends Safe Apnoea Time: This increased oxygen reserve delays the onset of hypoxemia, providing more time for airway management procedures, especially in cases of difficult intubation. Improves Safety Margin: It acts as a safety buffer, allowing the anaesthetist crucial time to secure the airway without the patient rapidly desaturating. Briefly discuss the concept of rapid sequence induction (RSI) (3) Rapid Sequence Induction (RSI) is an anaesthetic technique used for patients at high risk of pulmonary aspiration of gastric contents (e.g., full stomach, trauma, pregnancy). It involves: Preoxygenation: Maximizing oxygen reserve. Rapid Administration of Drugs: A potent intravenous induction agent and a rapidly acting neuromuscular blocking agent are given almost simultaneously. Cricoid Pressure: Application of pressure on the cricoid cartilage to occlude the oesophagus and prevent regurgitation (though its effectiveness is debated). Immediate Intubation: Tracheal intubation is performed without bag-mask ventilation (to avoid gastric insufflation) once muscle relaxation is achieved. How would you assess for satisfactory ventilation during anaesthesia (5) Satisfactory ventilation during anaesthesia is assessed through a combination of clinical signs and monitoring: Capnography (ETCO2): The most reliable indicator, showing a normal waveform and ETCO2 value (typically 35-45 mmHg). Chest Excursions: Observing bilateral, symmetrical chest wall movement. Auscultation: Listening for bilateral breath sounds over lung fields and absence of gastric sounds. Pulse Oximetry (SpO2): Maintaining adequate oxygen saturation. Airway Pressure: Monitoring peak inspiratory pressure and plateau pressure on the ventilator. Spirometry: Observing delivered tidal volumes and minute ventilation on the anaesthetic machine. What are some causes of hypothermia under anaesthesia (5) Redistribution of Heat: Vasodilation induced by anaesthetic agents causes core heat to redistribute to cooler peripheral tissues. Environmental Exposure: Cold operating room temperatures, exposed body surfaces. Cold IV Fluids/Blood Products: Administration of un-warmed intravenous fluids or blood. Cold Irrigation Fluids: Use of cold fluids for surgical site irrigation. Ventilation with Cold, Dry Gases: Breathing cold, unhumidified anaesthetic gases. Discuss the concept of anaesthesia and its triad (5) Anaesthesia is a state produced by drugs that allows medical procedures to be performed without pain or awareness. The "triad of anaesthesia" refers to the three primary components that constitute a complete general anaesthetic state: Hypnosis/Unconsciousness: Loss of consciousness, ensuring the patient is unaware of the procedure. Achieved with hypnotics (e.g., Propofol, Sevoflurane). Analgesia: Absence of pain sensation during and after the procedure. Achieved with opioids (e.g., Fentanyl, Morphine) or other analgesics. Muscle Relaxation: Paralysis of skeletal muscles to facilitate surgery and intubation. Achieved with neuromuscular blocking agents (e.g., Rocuronium, Succinylcholine). Some also include Amnesia (lack of memory) and Attenuation of Autonomic Reflexes as crucial components. What are the four aims of general anaesthesia? Unconsciousness (Hypnosis) Analgesia (Pain relief) Muscle Relaxation Amnesia State and briefly discuss five standards of monitoring during anaesthesia (10) Oxygenation: FiO2 Monitoring: Continuous measurement of inspired oxygen concentration. Pulse Oximetry (SpO2): Continuous monitoring of arterial hemoglobin oxygen saturation. Ventilation: ETCO2 Monitoring: Continuous monitoring of end-tidal carbon dioxide for intubated patients (or qualitative assessment for non-intubated). Clinical Observation: Observation of chest excursion, auscultation of breath sounds. Circulation: ECG: Continuous display of heart rhythm. Blood Pressure: Measurement of arterial blood pressure at least every 5 minutes. Heart Rate: Continuous monitoring. Temperature: Core Temperature Monitoring: Recommended for longer procedures, when clinically significant temperature changes are anticipated, or when hypothermia/hyperthermia is treated. Neuromuscular Function: Neuromuscular Monitor: When neuromuscular blocking agents are administered, a peripheral nerve stimulator should be used to assess the depth of blockade and guide reversal. Discuss at least 5 anaesthesia tools as they apply to the principle of anaesthesia. Anaesthetic Machine: Delivers precise mixtures of medical gases and volatile anaesthetics for hypnosis and amnesia. Laryngoscope/Video Laryngoscope: Enables direct or indirect visualization of the vocal cords for tracheal intubation, crucial for airway management and ventilation. Endotracheal Tube (ETT): Secures the airway, allows controlled ventilation, and prevents aspiration. Syringe Pumps/Infusion Pumps: Administer intravenous anaesthetics (e.g., Propofol for hypnosis), opioids (for analgesia), and muscle relaxants with precision. Monitors (ECG, SpO2, NIBP, ETCO2): Provide continuous feedback on the patient's physiological status, allowing for timely intervention to maintain homeostasis. As an anaesthetist briefly state three approaches you can employ to achieve anaesthesia. General Anaesthesia: Inducing a reversible state of unconsciousness, analgesia, and muscle relaxation. Regional Anaesthesia: Blocking nerve conduction to a specific region of the body (e.g., spinal, epidural, nerve blocks). Local Anaesthesia with Sedation: Using local anaesthetic at the surgical site combined with intravenous sedation to keep the patient calm and comfortable. Discuss the 4 members that make up the theatre team and their 3 roles each. Surgeon: Performs the surgical procedure. Obtains informed consent for surgery. Communicates with the anaesthetist and nursing staff about surgical progress. Anaesthetist: Administers and monitors anaesthesia. Manages the patient's vital functions during surgery. Ensures patient safety and comfort pre-, intra-, and post-operatively. Scrub Nurse (Instrument Nurse): Prepares and maintains the sterile surgical field and instruments. Assists the surgeon by handing instruments and supplies. Counts instruments, sponges, and needles with the circulating nurse. Circulating Nurse: Manages the overall nursing care in the operating room. Ensures patient safety, positioning, and comfort. Documents care, retrieves supplies, and communicates with other departments. Explain briefly at least two new trends in anaesthesia practice. Enhanced Recovery After Surgery (ERAS) Protocols: Multimodal, evidence-based perioperative care pathways designed to reduce surgical stress, accelerate patient recovery, and shorten hospital stays. This includes pre-habilitation, carbohydrate loading, opioid-sparing anaesthesia, early mobilization, and optimized pain management. Point-of-Care Ultrasound (POCUS): Increasingly used for vascular access (central and peripheral lines), regional anaesthesia (nerve blocks), gastric content assessment, and cardiac/pulmonary assessment, improving safety and efficacy. In your own words discuss the peri operative phases and give four activities that occur in each phase (20) The perioperative period encompasses the entire journey of a patient undergoing surgery, divided into three main phases: Preoperative Phase: This phase begins when the decision for surgery is made and ends when the patient is transferred to the operating room. Activities: Patient assessment and medical optimization (e.g., managing diabetes, hypertension). Obtaining informed consent for both surgery and anaesthesia. Pre-anaesthetic clinic visit for risk assessment and anaesthetic plan. Pre-operative investigations (e.g., blood tests, ECG, imaging). Patient education and anxiety reduction. Intraoperative Phase: This phase starts when the patient enters the operating room and concludes when they are transferred to the Post-Anaesthesia Care Unit (PACU). Activities: Application of standard monitoring (ECG, BP, SpO2, ETCO2, Temp). Induction and maintenance of anaesthesia. Airway management and ventilation. Fluid and blood product management. Positioning the patient and ensuring surgical site sterility. Postoperative Phase: This phase begins upon admission to the PACU and extends through recovery until the patient is discharged home or to another ward. Activities: Monitoring vital signs and level of consciousness. Pain management and assessment. Management of nausea and vomiting. Assessment for surgical complications (e.g., bleeding, infection). Fluid balance and airway patency management. There are many reasons why patients may not reverse adequately from neuromuscular block. Briefly discuss six of these reasons (6) Inadequate Dose of Reversal Agent: Insufficient dose of anticholinesterase (e.g., Neostigmine) or sugammadex. Profound Blockade: Too deep or prolonged neuromuscular block, making full reversal difficult or requiring more time. Hypothermia: Reduces liver and renal metabolism of muscle relaxants and impairs reversal agent effectiveness. Acidosis/Alkalosis: Metabolic disturbances can alter the efficacy of reversal agents. Renal/Hepatic Impairment: Impaired elimination of muscle relaxants, prolonging their action. Concomitant Medications: Drugs like aminoglycoside antibiotics, magnesium, or calcium channel blockers can potentiate neuromuscular blockade. Various problems with the airway can occur around the time of extubation. Hypoventilation or apnoea may occur after the tracheal tube is removed. Briefly discuss how you can safely prepare for extubation and how you can troubleshoot (6) Safe Preparation for Extubation: Adequate Reversal: Ensure full reversal of neuromuscular blockade (e.g., Train-of-Four ratio > 0.9). Consciousness/Airway Reflexes: Patient should be awake, following commands, with intact cough and gag reflexes. Ventilatory Parameters: Adequate spontaneous tidal volume, respiratory rate, and oxygenation (SpO2 > 94% on minimal FiO2). Head-up Position: To improve lung mechanics and reduce aspiration risk. Suction: Oral and tracheal suctioning to clear secretions before extubation. Troubleshooting Post-Extubation Hypoventilation/Apnoea: Verbal Stimulation/Jaw Thrust: First-line to stimulate breathing and open the airway. Bag-Mask Ventilation: Provide positive pressure ventilation with 100% oxygen if spontaneous breathing is inadequate. Re-intubation: If ventilation cannot be maintained or the patient rapidly deteriorates, re-intubate the trachea. Pharmacological Support: Administer additional reversal agents if residual block is suspected, or respiratory stimulants if indicated. Consider Causes: Review for residual anaesthesia, opioid overdose, respiratory muscle weakness, or airway obstruction. What are the four essential roles of a post anaesthetic care unit (4) Continuous monitoring of vital signs and neurological status. Management of pain, nausea, and vomiting. Maintenance of a patent airway and adequate ventilation/oxygenation. Early detection and management of postoperative complications. What is ISBAR hand over? (6) ISBAR is a structured communication tool used for effective handover of patient information, particularly in healthcare settings, to ensure clarity and reduce errors. It stands for: I - Introduction: Identify yourself, your role, and the patient. S - Situation: Briefly state the current problem, concern, or reason for communication. B - Background: Provide relevant patient history, clinical context, and recent events. A - Assessment: Summarize your assessment of the patient's condition, including vital signs, findings, and your interpretation of the problem. R - Recommendation: State what you believe needs to be done, or suggest a course of action. Briefly outline the optimal conditions that should exist before extubation is considered (5)? Adequate Reversal of Neuromuscular Blockade (e.g., train-of-four ratio > 0.9). Consciousness and Responsiveness (awake, following commands). Adequate Respiratory Drive (spontaneous breathing, good tidal volume, respiratory rate). Intact Airway Reflexes (cough, gag reflex). Hemodynamic Stability. How do you measure conscious level (4) Conscious level is typically assessed using scales or observations focusing on: Eye Opening: Spontaneous, to verbal command, to pain, or none. Verbal Response: Oriented, confused, inappropriate words, incomprehensible sounds, or none. Motor Response: Obeys commands, localizes to pain, withdraws from pain, abnormal flexion, abnormal extension, or none. Orientation: Awareness of person, place, and time. The Glasgow Coma Scale (GCS) is a standardized tool combining these elements. What can cause a change in conscious level (1) Changes in conscious level can be caused by a wide range of factors, including: Residual anaesthetic agents or sedatives. Hypoxia or hypercapnia. Hypoglycemia or hyperglycemia. Electrolyte imbalances. Neurological events (e.g., stroke, seizure, intracranial hemorrhage). Infection/Sepsis. Drug overdose or toxicity. The World Health Organization (WHO) Surgical Safety Checklist The WHO Surgical Safety Checklist was developed as part of the "Safe Surgery Saves Lives" initiative to standardize safety practices and reduce preventable surgical errors. It promotes effective communication and teamwork. Stages and Key Checks: Sign In (Before Induction of Anaesthesia): Patient confirmed: Identity, site, procedure, consent. Site marked: Yes/Not applicable. Anaesthesia safety check completed? Machine & medication. Pulse oximeter on patient and functioning? Does patient have: Known allergy? Difficult airway/aspiration risk? Risk of $\ge 500$ mL blood loss? Time Out (Before Skin Incision): Confirm all team members have introduced themselves by name and role. Surgeon, anaesthesia professional, nurse verbally confirm: Patient, site, procedure. Anticipated critical events: Surgeon reviews: Critical or unexpected steps, operative duration, anticipated blood loss. Anaesthesia team reviews: Patient-specific concerns. Nursing team reviews: Sterility (including indicator results), equipment issues or concerns. Is antibiotic prophylaxis given within 60 minutes? Is essential imaging displayed? Sign Out (Before Patient Leaves Operating Room): Nurse verbally confirms: Name of procedure recorded, instrument/sponge/needle counts are correct (or not applicable). Specimen labelled correctly (including patient name)? Does the surgeon, anaesthesia professional, and nurse review the key concerns for the recovery and management of the patient? Long Questions: Spinal Anaesthesia Define spinal anaesthesia Spinal Anaesthesia is a type of regional anaesthesia where a local anaesthetic drug is injected into the subarachnoid space (intrathecally), typically below the level of the spinal cord (usually L3-L4 or L4-L5 interspace), to produce temporary sensory, motor, and autonomic blockade. State four rules that must be observed whenever spinal anaesthesia is considered Patient consent must be obtained after thorough explanation. Strict aseptic technique must be followed to prevent infection. Resuscitation equipment and drugs must be immediately available. Careful patient selection and contraindication assessment. Briefly state four indications of spinal anaesthetic Lower limb surgery (e.g., hip/knee replacement). Urological procedures (e.g., TURP). Obstetric procedures (e.g., Cesarean section). Abdominal surgery below the umbilicus. Name four adverse effects that may be encountered during conduct of a spinal anaesthetic and their mediate management (4) Hypotension: Due to sympathetic blockade. Management: IV fluids, vasopressors (e.g., ephedrine, phenylephrine). Bradycardia: Also due to sympathetic blockade. Management: Atropine, vasopressors. Post-dural puncture headache (PDPH): Due to CSF leakage. Management: Bed rest, analgesics, caffeine, epidural blood patch. Nausea/Vomiting: Due to hypotension or cephalic spread. Management: Antiemetics, treat hypotension. Total Spinal: Accidental high block. Management: Airway support, ventilation, cardiovascular support. Long Questions: ASA State ASA classifications The American Society of Anesthesiologists (ASA) Physical Status Classification System: ASA I: A normal healthy patient. ASA II: A patient with mild systemic disease. ASA III: A patient with severe systemic disease. ASA IV: A patient with severe systemic disease that is a constant threat to life. ASA V: A moribund patient who is not expected to survive without the operation. ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes. An 'E' is added to denote an emergency procedure (e.g., ASA III-E). Long Questions: Anaesthetic Care Plan Discuss the principle of general anaesthesia management for a patient who has been scheduled for an exploratory laparotomy following acute abdomen. Describe the sequence of events for this patient from arrival in the anaesthetic room leading to transfer to recovery room (25) Principle of General Anaesthesia Management: General anaesthesia for an exploratory laparotomy aims to provide a reversible state of unconsciousness, analgesia, muscle relaxation, and loss of autonomic reflexes, allowing for surgical exploration and intervention for acute abdominal conditions. Key considerations include rapid sequence induction due to high aspiration risk, adequate analgesia, muscle relaxation for surgical access, and careful hemodynamic management due to potential fluid shifts and sepsis. Sequence of Events: Pre-anaesthetic Assessment and Preparation: Review Patient History: Focus on acute abdomen etiology, comorbidities, fluid status, last oral intake, allergies. Physical Examination: Airway assessment (Mallampati score, neck mobility), cardiac, respiratory, and neurological status. Investigations: Review recent labs (Hb, electrolytes, renal function, coagulation), imaging (X-rays, CT). Consent: Obtain informed consent for anaesthesia. Premedication: Consider antiemetics, H2 blockers/PPIs, or anxiolytics if appropriate, balancing aspiration risk. IV Access: Secure at least two large-bore IVs for rapid fluid/blood administration. Fluid Resuscitation: Initiate aggressive fluid resuscitation based on clinical status (e.g., crystalloids, colloids). Monitoring Setup: Attach standard monitors (ECG, NIBP, SpO2, ETCO2), consider invasive arterial line for continuous BP monitoring and ABG sampling, central venous line if indicated for severe hypovolemia/sepsis. Anaesthetic Room Arrival: Patient Identification: Verify patient ID, surgical site, procedure. WHO Surgical Safety Checklist: Complete Sign In. Preoxygenation: Administer 100% oxygen via tight-fitting face mask for 3-5 minutes to maximize oxygen reserve. Induction of Anaesthesia (Rapid Sequence Induction - RSI): Positioning: Head-up tilt to minimize aspiration risk. Cricoid Pressure: Apply cricoid pressure (if protocol dictates) just before induction agents. Induction Agents: Rapid IV administration of an induction agent (e.g., Propofol, Ketamine, Etomidate) followed immediately by a rapid-acting neuromuscular blocker (e.g., Succinylcholine, Rocuronium). Intubation: Perform tracheal intubation without bag-mask ventilation once muscle relaxation is achieved. Confirm tube placement (ETCO2, bilateral breath sounds). Release Cricoid Pressure: Once tracheal tube cuff is inflated and placement confirmed. Maintenance of Anaesthesia: Ventilation: Initiate mechanical ventilation, targeting normocapnia. Anaesthetic Agents: Maintain anaesthesia with volatile agents (e.g., Sevoflurane, Desflurane, Isoflurane) or total intravenous anaesthesia (TIVA) with Propofol. Analgesia: Administer opioids (e.g., Fentanyl, Morphine) and other analgesics (e.g., paracetamol, NSAIDs if not contraindicated). Muscle Relaxation: Continue neuromuscular blockade as needed for surgical exposure. Fluid Management: Continue IV fluid administration, consider blood products if significant hemorrhage occurs. Hemodynamic Stability: Closely monitor and manage BP, HR with vasopressors/inotropes as needed. Temperature Management: Maintain normothermia with warming devices. Monitoring: Continuous monitoring of all parameters, including urine output. Emergence from Anaesthesia: Surgical Closure: Begin reducing anaesthetic agents as surgery concludes. Reversal of NMB: Administer neuromuscular blockade reversal agents (e.g., Neostigmine, Sugammadex) once surgical need for relaxation ends. Awakening: Ensure patient is awake, following commands, and has adequate respiratory effort and protective airway reflexes. Extubation: Extubate once criteria for safe extubation are met (e.g., full reversal of NMB, adequate spontaneous ventilation, intact reflexes). Transfer to Recovery Room (PACU): Handover: Provide a comprehensive verbal handover (ISBAR) to PACU nurse, including patient history, intraoperative course, medications given, estimated blood loss, complications, and postoperative plan. Monitoring: Continue close monitoring of vital signs, conscious level, pain score. Postoperative Care: Ensure adequate analgesia, antiemetics, oxygen therapy, and fluid management.