WELCOME TO MY BLOG
From this land of hundred thousand welcomes -'cead mile failte' I wholeheartedly add another welcome to you all.
''KNOWING IS NOT ENOUGH;WE MUST APPLY.
WILLING IS NOT ENOUGH;WE MUST DO...''Goethe''.
Now I need to think differently from how I had to think in medical school and in fact in my life.After years of training in Anaesthesia,intensive care medicine and Pain medicine, I am still learning how to survive in this complex world of Medicine.
Just as our capacity for learning will depends on thinking,our capacity for thinking well depemnds on learning.
Applying the Socratic method of teaching,Aristotile taught Alexander to look for facts and patterns among a variety of sources and integrating them in a systematic and insightful manner that was useful for solving the specific problem .
This blog is specially for Anaesthetists in training who are aspring to cultivate qualities such as analytical reasoning,intellectual honesty,and critical thinking and risk taking while everything and everyone is open to being challenged with evidence based medicine.
If you get my point ,enjoy my blog in persuit of your success
in life.
****At this juncture I would like to thank my son Mr Madhu Kasyap Chamarti and my friend Mr Satyanarayana Jabisetty for their continued effort in working on this blog. And finally I dedicate this site to my late father Dr.CV Subbarao garu, Professor of Anaesthesia,one of our earlier Anaesthetists in 60s&70s.in South India.***
LEARNING CURVE IS ALWAYS LINEAR- (every day we learn new things)
NEEDLE FREE PAIN RELIEF
ionsys ' - (fentanyl HCI iontophoretic transdermal system )
-an innovative advance in post op PCA
-pre programmed ,battery operated system releases measured doses of fentanyl with two touches of button.
-imperceptible electric current actively transports fentanyl into blood stream via skin.
-saftey and tolerability profile for moderate to severe pain.
Surviving Sepsis Campaign: International guidelines for
Management of severe sepsis and septic shock: 2008
Provided an update to the original Surviving Sepsis Campaig clinical management guidelines, of Severe Sepsis and Septic Shock,” published in 2004.
Designed by Modified Delphi method with a consensus conference of 55 international
experts,
Used the Grades of Recommendation, Assessment, Development
and Evaluation (GRADE) system to guide assessment of quality of evidence from
high (A) to very low (D) and to determine the strength of recommendations.
Key recommendations, listed by category,
include
· early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C);
· blood cultures before antibiotic therapy (1C);
· imaging studies performed promptly to confirm potential source of infection (1C);
· administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D);
· reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C);
· a usual 7–10 days of antibiotic therapy guided by clinical response (1D)
· source control with attention to the balance of risks and benefits of the chosen method (1C);
· administration of either crystalloid or colloid fluid resuscitation (1B);
· fluid challenge to restore mean circulating filling pressure (1C);
· reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D);
· rising filing pressures and no improvement in tissue perfusion (1D);
· vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure >65 mm Hg (1C);
· dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor
therapy (1C);
· stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy
(2C);
· recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients).
· In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7–9 g/dL (1B);
· a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C);
· head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A);
· to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C);
· protocols for weaning and sedation/analgesia (1B);
· using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B);
· avoidance of neuromuscularblockers, if at all possible (1B);
· institution of glycemic control (1B),
· targeting a blood glucose <150 mg/dL after initial stabilization (2C);
· equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B);
· prophylaxis for deep vein thrombosis (1A);
· use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors(1B);
· consideration of limitation of support where appropriate (1D).
Recommendations
· specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C);
· dopamine as the first drug of choice forhypotension (2C);
· steroids only in children with suspected or proven adrenal insufficiency (2C);
· and a recommendation against the use of recombinant activated protein C in children (1B).
Conclusions:
There was strong agreement among a large cohort of internationalexperts regarding many level 1 recommendations for the best current care
of patients with severe sepsis.
Evidenced-based recommendations regarding the
acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients. (Crit Care Med 2008; 36:296–327)
GASMAN"S VAPOURS
A typical night call in a busy tertiary hospital-events unplugged714.ie - FiIRST 0N CALL-UNPLUGGEDThe day started like any other dayWakeup alarm:6.00am,Thursday.Left house at 06.30 am aiming to reach hosp before traffic builds up. One of the most horrible experience in Dublin -traffic ,a real nightmare.07.20am -arrival in car park usual place. Cereal bar+actimel07.40am -OT complex usual good mornings,etc.Rota board-Xray 10 during day -714 on call night (theatre call). Not bad, I thought.Went to T2 to load my drugs for Xray 10./MRI .Why can’t they call INR (interventional neuro radiology) like those crazy Americans. Heard that there are 5 GA kids for MRI and 2 emergency coils. Enough for the day.Dr X1- OK Bit of Fun.they call here crack. Good to work with him. Time passes.. Very entertaining person.Looked at emergency board. Somebody in the night shift took time to express their calligraphic talent. I know that girl, short Kerala girl, climbs a stool to reach the top of the board.Hopefully the board will be cleared by the time I took over the714 night bleep. This bleep is carried by person working in Richmond ICU(neuro).his job is a pity. They call it as taxi service rather a glorified portering service to take patients for scans.One day I took 6 patients to scan, may be a record.Flash…the other day the recovery people were giving their statistics.54 is no. of pts they recovered on Monday,46 on Tuesday, 41 on Wednesday , may be the number comes down , I suppose today. Thinking about the day ahead.Anyhow long way to think of my night. Last Friday while I was on call there are only 2 cases on board @05.oopm but ended up doing 3 neurosurgical cases. The 4th one we postponed one craniotomy. The patient 30 yr old with Eisenmenger syndrome with Brain abcess.The senior neurosurgical registrar with lot of grumbling and rumbling is not at all happy with us showing all sort of resentment.we were trying to explain the complexity of the case, anaesthetic point of view, but the poor man couldn’t understand the difference of NO and N2O, the importance of TOE in this case.Afterall he won’t be reading the nicely presented article about Eisenmegers complex in the recent journal of ‘Anaesthesiology’.Anyhow coming to present day.Recently my collegue was telling he did 3 AAA s and the 4th one was transferred elsewhere. That is Beaumont.The scene MRI suite: Started with 5 yr old kid, then 3month old baby. My consultant wanted to do that casee himself and asked me to start with that 12 yr old. Quite obvious .He also warned me that the parents of that 12 yr old kid bit fussy. Quite natural. Poor fellow ,the patient had craniotomy yrs ago and spent most of his life in various hospitals and so th parents. They know the in and out of our hospital system. He came for his regular follow up. The mother with her authoritative tone warned me that her boy needs GA only.He is very troublesome. No gimmicks. They don’t work. That too only gas induction . She already smelt my usual approach using all my social skills.. She might have seen enough of people like me in her life. She further told me that she bribed 40 euros to the boy for accepting Gas. I have no choice. My consultant is already in with that 3 month old kid, whose parents are some medical people and one of their friends who is working in this hospital is anxiously waiting for her case to finish ,is also watching all the fun happening here.O.K. Here we go. I turned on my Sevo with both parents and a porter as stand by for my help. Surprise surprise. No body was holding him He took the mask for himself. And started breathing and went into transition very quickly, like our meditation -deep sleep.Oh My God.. I have never seen such a smooth inhalation induction in my life. I remembered my Ether days, putting kids to sleep for tonsillectomy with simmelbush mask , my old EMO apparatus and red rubber tubes. And how those kids struggle.Eureka,.. A novel approach to put the kids to sleep .. Wonderful premedication , no text books described yet. Bribe the kids with money. It works. Money makes many things. It’s correct. A gentle pat on my back from my consultant, complementing me. You have to complement the parents, I said.Then the other kids. No money involved here. They are to small for that. May be they realise later when they grow.Lunch time. ‘RATATOUILLE’ are running in my stomach. I have to run to ‘GUSTEAU’S’ kitchen to grab something. I am a culinary genius my self. I can cook my own food, of course Indian, the very Indian.Then those two emergency coils in the so called X -Ray 10 (INR)Felt bit scary. Remembered my last coil on Tuesday .That unfortunate 30 yr old who bled almost at the end of the procedure. Panic situation. I remembered the scene.Protamin one to one dose. I thought at that time why can’t they change the heparin units to mgs.Easy to calculate in emergency situations like this.Red cap/blue cap 1000 iu /5000 iu .ml .. all confusion. Many episodes of errors in administration of heparin in literature. Nobody wants to address this.Any how I am careful. Usual human tendencyTo my surprise our 12-8 colleague (late shift)came to my rescue in the radiology suite to relieve me for lunch. Poor fellow, his job is relieve people for lunch . He has to report to theatre co-ordinator who directs him to relieve his/her theatre juniors to start with.(after-all their responsibility!…)I couldn’t understand how he ended up here at this early hour (for him). Usually nobody bothers that, there is one existing in this remote part of the world doing coils without lunch. There are days I had my lunch at 3 pm .We both put the first patient to sleep and I went for my lunch only to be back in 10 minutes. I call it hand to mouth time. I can’t afford more than that. I am not a nurse or porter for that matter to have protected time breaks.. First break, second break , then lunch break ,tea break and so on n on n on…Though I won’t believe in re-incarnation, my religion believes. Suppose if God asks me what you want to be in your next birth , my options are recovery nurse, anaesthetic nurse, porter and my list goes on..5 pm : I have just finished my last coiling, thanks God everything went well and brought that last patient to recovery. My regular consultant has already left long time ago to attend an important meeting, after duly handing over me to another consultant on theater.He is just waiting for me at the anaesthetic office to grab me to depute to his theatre to relieve his junior(again his responsibility!..) But he is kind enough to allow me for a quick cup of coffee again cup to lip time..( remember .. you are not a nurse..) The case Whipples .. Going on for the last 5 hours..an hour or two to go. I like this consultant’s approach.. ‘KISS’ approach .( Keep It Simple Stupid.) Two 14 G needles and PCA morphine. Works well .No problems. Recovery staff are happy. If they are happy, anaesthetist is happy . If they both are happy patient is happy. If the patient is happy , surgeon is happy. The vicious cycle. If all ends well hospital CEO is happy and if he is happy Mary Harney will be happy. Country is prospering. Health sector is in good hands. So , the moral of the story .Who is responsible for the country to be happy. It’s you .. You stupid fellow.Just I was just about to finish my whipples , 313 Reg. dashed inside to give me my next assignment . To finish of the next door Fem-pop bypass, which was happening for many hours. These vascular people… 313 Reg handed over the case to me ,informing that blood will come in another 5 minutes and platelets will arrive at 07.15 pm. Forget about platelets, even blood didn’t arrive till 07.30 pmMeanwhile vascular surgeon is threatening me abot platelets. ‘ I am not responsible if patient bleeds. What happened to platelets.He started giving out to me. I asked the nurse in charge. Poor girl , she has already called blood bank umpteen times. The technician at the other end threatening girl not call them again and if platelets arrive he will call us to collect.After all these platelets have to come from central bank, previously we used to call ‘pelican house’ probably there from Viking days. After European expansion (these eastern European invasion) it moved to St James’s complex.The case is about to be finished ,but no sign of platelets yet. The 313 Reg came to discuss with vascular team about our next case an Above knee amputation for another 80 yr old vasculopath , also on aspirin and plavix. Same story no platelets - ordered have to come from our once upon a time ‘pelican house’A vascular surgeon who operates on vessels is not responsible for bleeding and blames anaesthetist for bleeding and expects anaesthetist to get platelets. Imagine the scene- anaesthetist going on a bicycle to central blood bank in the busy Dublin traffic and bring platelets for the patient on aspirin and plavix.Do you remember the ‘cyclone’ courier with long funny hair, tattoos all over the body going on a bicycle with a walky-talky.One good news . The lap appendix on the board disappeared.Probably the surgical registar is too lazy to do it in the middle of the night.At l\ast the only thing left on the board is 16 yr old blocked VP shunt.( on hold)09.30 pm- dinner time.My muslim brothers have already broakenthei fast and looking forward for the next day’s celebrations.EID Mubarak to them.10.00pm- coffee room. Chat with night staff. Serious discussions- heated arguments.. Ireland’s recent failure in world cup rugby..England’s preparations for semis , Euro qualifiers .. Sports skills mixed with vocabulary skills . Lot of F*** words . Two interns and even one consulatant joined them. Wickipedic knowledge..bit of crack..Not for me. I am a cricket maniac…I came out to see what ‘s happening.Still blocke shunt on hold. Night sister got a call from neuro reg the csf report came normal and they are going ahead with the so called blocked shunt.Sudenly I got a bleep from Resus.31 yr old .. Obstructed airway . .. Wanted me immediately.. No more details.I also didn’t expect anything but to run to casualty.What is the shortest way! Long corridor via x-ray . Takes time. So decided to go via ICU -St Patrick’s ward . I collected emergency drugs from ICU , informed the ICU nurse in charge about possible admission obstructed airway for ventilation.First question she asked me Is he MRSA?Jesus I am going to attend a real life saving emergency and MRSA is the last thing to come to mind.I just laughed and ran to Resus.Scene-A&E Resus (RED AREA they call) - usual busy. Lot of activity. Quick glance all over.All the patients looked to me as reasonably stable.There is one patient behind the curtains. I was expecting that patient to be my obstructed airway.Surprisingly the neuro surgical registrar came out behind the curtatins with folded hands. Jesus what this fellow is doing with my obstructed case,Did he intubate!!, . He greeted me and told me that after you sort out that obstructed case we will go ahead with the blocked shunt. I am not doing this blocked shunt this night , may be tomorrow, pointing out the patient behind the screen.The patient behind the screen is very happy with those words and smiling at me. So he is not my obstructed airway. Then For Heaven’s sake where is my obstructed airway., I asked the nurse.As she was showing me the patient the A&E registrar came to me and started giving details about the patient who looked reasonably comfortable but for mild to moderate resp distress, like a COAD patient.with an obvious neck swelling.
ESRD pt on regular haemodialysis developed anaphylaxis/angio-oedema after taking some medications. what medication? He has shown a travel bag full of medications, tablets ,syrups, inhalers etc,.when I opened the bag the only striking tablets I have noticed is a pack op perindopril tablets. O k that’s enough , I thought. Now I now the diagnosis. I still remember that elderly lady from st James’s hospital who was admitted twice in my call only.angio-oedema due to ace inhibitors. I never tubed her . very scary to look at her face, so much swollen.. Humanly impossible to intubate. This man is not that scary looking. I could be able to communicate with the pt.He is holding a pen and paper and giving history. I asked him to open his mouth expecting some Mallampati 3 or 4. My God I couldn’t see anything .only back of the tongueThe whole tongue is so swollen occupying the whole of mouth and touching the hard palate. Believe it or not ,You can’t pass even a fine bore catheter..I don’t know what grade you call this Mallampati 5/6/7…there is also some right sided neck swelling. The A&E reg is very anxious about this patient. and gearing up the staff for intubation. He has already received some adrenaline.piriton and hydrocortisone.Very enthusiastic reg. I told him my plan of action. I am not going to intubate him in A&E. I am taking him to Theatre. and observe him . Meanwhile give him some dexamethasone and some Racemic adrenaline nebs. I also told him to give ranitidine. I instructed them to call ENT reg immediately. I rushed to theatre to inform theatre people and my 313 on call person. Very sensitive lady. Appreciated my anxiety. Immediately called. 212 reg(ICU) on call to take care of theatre patient . my self and 313 reg asked the recovery staff to prepare difficult intubation trolly including fiberoptic scope ready .Difficult intubation trolley is chest of draws with full of junk. God knows what is inside. Most of anaesthetists don’t know what it contains. At the need of hour it’s very difficult to find what we need.. we both rushed to A&E and brought that pt to recovery and prepared his nose for scopy.Meanwhile ENT reg came with his nasoendoscope. We informed both consultants on call (theatre and icu).about the situation here. At this time what we need is little bit of presence of mind. We have to be calm and cool. I went to ENT theatre to pick my bits and pieces- North pole nasal end tracheal tubes. which I used to put in difficult intubations blindly. as a lost resort. Back home experience. So we decided our plan of action. To keep him under observation till we finish our pending night emergencies on hand. and shift him to ICU. for further observation. Though very scary situation, we didn’t hurry to do any thing drastic. Thanks God pt is also very co-operative and showing some signs of improvement. But he constantly threatening us there is some pain in the back of his throat and swelling is increasing inside.The ENT surgeon did nasoendoscopy and has shown to us . His entire supraglottic airway is swollen, but his larynx looked normal. what a beautiful piece of equipment. I don’t know why we don’t keep nasoendoscope in our armamentarium; at least it should be part of our difficult airway trolley, real magic wand. We sticked to our plan. Shifted the patient to icu later and kept him under strict vigilance of an expert icu nurse. It’s like a timebomb.Next comes our long awaited blocked shunt patient.16 yr old 5th year leaving cert student with GCS 15/15,PERL, moving all limbs with stable hemodynamics.. Narrating his school stories and gossips. Is he a blocked shunt, I thought, to do in the middle of the night!! Any how, venkat you are not Neuro surgeon . you are carrying 714 bleep. Your job is to do the case whatever the surgeons decide and whenever the theatre nurses decide. The priorities are different here, NCEPOD has given the definitions of urgent, emergency, elective surgeries. They won’t apply here.Preparing for the case. Getting drugs ready. Anaesthetic nurse.. Wait a minute.. do we have anaesthetic nurse in our hospital !!. Yes I remember seeing them at times in the day time .they appear when a consultant is putting a patient to sleep to talk him or her to tell some gossip and hospital politics. Our consultants like them because they love gossip.At times there will be somebody will hand over a tube at the time of intubation and disappear. May be they are the so called anaesthetic nurses.We put the patient to sleep. 11.30 pm. Neuro surgeon started the case at about 12.30 AM. one hour to put the knife after the pt goes to sleep. I say that is the earliest. I have even waited for two hours on couple of occasions for the actual surgery to start..12.30…01.30...02.30 am no progress .surgery still going on. Trying to get some csf from ventricle. No sign of a drop. Is the well dried up! Some drops at times! Is it CSF. Grumble. If not do you think urine will come from there! Sorry not a good time for humour. In the meantime some frantic calls to neurosurgical consultant by phone. Getting some instructions. Finally he has to come to finish of doing a EVD on the other side. I have sent 313 reg to sleep long time back after the pt went to sleep , as she has to travel next morning to SanFrancosco for ASA conference direct from hospital to airport.Acually ,I have started the trend .Few weeks ago , I went to SFO direct from hospital after my call and on my return, I came direct from airport to work after my brief holiday. Finally the case was finished @ 04 30 AM. I checked the pt in recovery. Satisfied. Nurse in recovery is too happy and asked me to go and take some rest. And so off to my room first time since morning to get some sort of break. I was complementing myself about my stamina. Since I woke up at 06.00 Am till now almost 22 hours literally on my toes without even relaxing a bit, I am working. Time to take a short nap, I thought.) 06.00 AM bleep.. Call from theatre. It’s 313 reg. I went to theatre .Surprise. Same scene. Same patient. Same surgical team. Still working. What happened? Am I dreaming!! Did I go sleep walking to my room leaving this patient.313 reg explained the situation? After I left pt started to desalt and behaving abnormally. So the team decided to take back to theatre. They tried to contact me but in haste they couldn’t bleep me properly. I didn’t receive any bleep. I have checked. I took over from 313 reg. the case and finished and took him to ICU post op.It’s 8 00 am .My colleagues are slowly arriving .A sigh of relief . My call is coming to an end. No.. no .. not yet I have to do pain round with pain nurse. But I have to wait till she is readyfor my round, sorry her rounds. You have to follow her faithfully to do whatever she says.Only thing , I remember I have done is change all p r n paracetamol to regular dosage.10.00 am finally home. sweet home. What a call. I am still alive , I thought after reaching home esp post call with 27 hrs continuous work without any break dealing with very life saving situations and taking critical decisions ,braving Dublin traffic esp. on M50.. God is great still keeping me fit and healthy.DISCLAIMER: All the events occurred are real. very true, with no offence to any one concerned above. I fully respect and regard the systems and policies in place of this hospital. And I respect all my colleagues and staff.I have brought this, adding bit of fun and humour. I just want to highlight under what circumstances we work in the service of our patients day and night at a stretch. Some times I wonder are we doing justice. Is it humanly possible to work in this critical care area without any breaks? Can a pilot fly an aeroplane non- stop 24 hours safely? If he is responsible for the lives of passengers, are we not responsible for the lives of our patients.What about EWTD? Is it a joke? How long it will take to implement!!What about the new consultant contacts!! Another farce!!God save the anaesthetists
PRIMARY VIVA contd
NERVOUS SYSTEM:
NERVE ACTION POTENTIAL,NERVE FIBRE TYPES,NICOTINE Ach RECEPTOR,MUSCLE SPINDLE,GCS,
MAC vs O/G co efficient,PAIN PATHWAYS,GATE CONTROL THEORY,SYMPATHETIC REFLEX ARC,SYMPATHETIC NERVOUS SYSTEM,PARASYMPATHETIC NERVOUS SYSTEM,VALSAVA MANOEUVRE,EFFECTS OF POSTURE ON ARTERIAL &VENOUS PRESSURES,BLOOD BRAIN BARRIER,RETICULAR ACTIVATING SYSTEM,CSF, CEREBRAL BLOOD FLOW,CEREBRAL METABOLISM,ICP,
MONTOE KELLY HYPOTHESIS,KNEE JERK, MUSCLE TONE,
RENAL PHYSIOLOGY:
NEPHRON,GFR,RPF,RENAL TUBULAR FUNCTION,COUNTER CURRENT MECHANISM,KIDNEY- SODIUM, KIDNEY- H+ion,
METABOLISM
OSMOLALITY,OSMOLARITY,BMR, RESPIRATORY QUOTIENT,RESPIRATORY EXCHANGE RATIO,CARBOHYDRATE METABOLISM, PROTIEN METABOLISM, FAT METABOLISM,TEMPARATURE REGULATION,HYPOTHERMIA,HYPERTHERMIA,ACID BASE BALANCE,ANION GAP,ECF VOLUME,ESSENTIAL AMINO ACIDS,CALCIUM METABOLISM,CYTOKINES-SEPSIS,MARKERS OF NUTRITIONAL STATUS,STARVATION,BODY FLUID COMPARTMENTS,MAGNESIUM,
PARENTERAL NUTRITION,ENTERAL NUTRITION,VITAMINES,TRACE ELEMENTS,
GIT:
SWALLOWING REFLEX, MECHANISM OF VOMITING,LOWER ESOPHAGEAL REFLEX, GASTRIC SECRETION,LIVER BLOOD FLOW,LIVER FUNCTIONS,COMPOSITION OF BILE,PHYSIOLOGY OF NAUSEA&VOMOITING,PONV,MENDELSON'S SYNDROME,
ENDOCRINE:
INSULIN, GLUCAGON,IDDM,NIDDM,PITUTARY HORMONES,HYPERTHYROID,HYPOTHYROIDISM,CORTISOL,ALDOSTERONE,PARATHYROID&VITAMINE D,METABOLIC RESPONSE TO TRAUMA,
IMMUNITY:
NORMAL RESPONSE OF THE BODY TO INFECTION,CELLULAR IMMUNITY, HUMORAL IMMUNITY,CYTOKINES,IMMUNOMODULATION
SEPSIS CASCADE,
PREGNANCY
MENSTRUATION,,EMBRYO DEVELOPMENT,FETAL CIRCULATION,PHYSIOLOGICAL CHANGES IN PREGNANCY,
FRCA EXAM TOPICS
Final FRCA TOPICS
ANATOMY+ REGIONAL ANAESTHESIA
AUTONOMIC NERVOUS SYSTEM
BRAIN/SPINAL CORD/
VERTEBRAE –ALL
EPIDURAL ANATOMY
SKULL-SKULL FORAMINA
CEREBRAL BLOOD FLOW
CSF
CRANIAL NERVES
DERMATOMES/MYOTOMES
ORBIT/EYE BLOCKS
TRIGEMINAL BLOCK
DENTAL BLOCKS/MANDIBLE
MOUTH/NOSE/PHARYNX/LARYNX
TRACHEA
LARYNX-LARYNGOSCOPIC VIEW
REGIONAL FOR AWAKE INTUBATION
TRACHEOBROCHIAL TREE
LUNGS/PLEURA
MEDIASTINUM
CAROTIDS
INTERNAL JUGULAR
SUBCLAVIAN
CORONARY BLOOD FLOW
HEART
CERVICAL BLOCKS-SUPERFICIAL/DEEP
STELLATE GANGLION BLOCK
FIRST RIB
BRACHIAL PLEXUS
INTERCOSTAL BLOCKS/.RIBS
DIAPHRAGM
ANTECUBITAL FOSSA
VENOUS DRAINAGE OF HEAD/ARM/LEG
PARAVERTEBRAL BLOCK
COELIAC PLEXUS BLOCK
LUMBAR PLEXUS BLOCK
INGUINAL CANAL/FIELD BLOCK
PENILE BLOCK
FEMORAL/3-1 BLOCK/OBTURATOR/LAT.CUTN.
MEDIAN/RADIAL/ULNAR/WRIST/ELBOW BLOCKS
SCIATIC/ KNEE/ ANKLE BLOCKS
COMPLICATIONS OF REGIONAL ANAESTHESIA
PHYSIOLOGY:
ACID BASE BALANCE
ACTION POTENTIALS
ALVEOLAR AIR EQUATION
ANAEMIA
BLOOD PRESSURE-CONTROLE
BLOOD GROUPS
BODY FLUIDS
BASAL METABOLIC RATE
BOHR EFECT
BOHR EQUATION
CARDIAC OUTPUT
CARDIAC CYCLE
CARDIAC FAILURE
COGENITAL HEART DEFECTS/VALVULAR DEFECTS
CEREBRAL CIRCULATION/CEREBRAL BLOOD FLOW
CSF
CELL BIOLOGY
CARBOHYDRATES/PROTEINS/FATS
COAGULATION
CONTROL OF RESPIRATION
CONSCIOUS NESSAND SLEEP
CORONARY BLOOD FLOW
DIGESTION
DISORDERS OF RESP.MECHANICS/GAS EXCHANGE/GAS TRANSPORT
DEPTH OF ANAESTHESIA
DEHYDRATION
DIURESIS
ECG/ARRHYTHMIAS
ELECTROLYTE DISTURBANCES AS
ENDOCRINE DISEASES OF SIGNIFICANCE IN ANAESTHESIA
FLUID BALANCE
FUNCTION OF LUNG/LIVER/KIDNEY
FETAL CIRCULATION
GIT
HYPOVOLEMIA/SHOCK
HAEMOGLOBIN/ABNORMALITIES
HYPERTENSION
HEPATIC FAILURE
HALDANE EFFECT
HORMONES AFFECTING KIDNEY
HYPOTHERMIA/HYPERTHERMIA
HYPOVOLEMIA/SHOCK
HYPOXIA
HAEMORRHAGE
HIGH ALTITUDE
INFANCY &CHILDHOOD
ISCHEMIC HEART DISEASE
IMMUMNE RESPONSE
INTRA CRANIAL PRESSURE
INFLAMMATORY RESPONSE
JAUNDICE
KIDNEY PHYSIOLOGY
KIDNEY FUNCTION/FAILURE
LUNG MECHANICS
LUNG FUNCTION TESTS/LUNG VOLUMES
LIVER PHYSIOLOGY
METABOLISM/BODY TEMPARATURE
MECHANICS OF BREATHING
MUSCLE PHYSIOLOGY
MALIGNANT HYPERTHERMIA
MUCOSAL BARRIER
NAUSEA/VOMITING
NERVE PHYSIOLOGY
NEURO MUSCULAR JUNCTION
NEONATAL PHYSIOLOGY
PAIN-MECHANISMS
OESOPHAGEAL REFLEX
ONE LUNG ANAESTHESIA
OXYGEN
O2 DISSOCIATION
O2 FLUX/CARRIAGE
PREGNANCY- NORMAL/ABNORMALCHANGES
PHYSIOLOGY OF LABOUR
RENAL BLOOD FLOW
STARLING FORCES
STARVATION/OBESITY
STRESS RESPONSE
TEMPARATURE REGULATION
TRAUMA-METABOLIC AND HORMONAL RESPONSE
FRCA final exam - Theory questions
FRCA Theory questions
1. What are the clinical features and specific investigations of post operative pulmonary thromboembolism? Discuss the management
2. 80 year lady requires surgery for fracture neck of femur –
Anesthetic management? Advantages and disadvantages of genl vs regional
3 Discuss the rational and the methods used to prevent the development of aspiration pneumonitis in an obstertric patient.
4 What are the indicatons, complications and contraindications of nasotracheal intubation?
Discuss the preoperative assessment and preparation of the nasal cavity for nasotracheal intubation.
5 You are called urgently to the A&E-resuscitation Unit to attend to a 55 year –old in status asthmatics. Weight 120kg, height 5ft 5 in (165cm), pa02 6kpa and paC02 12kpa,Sa02 75%.
Discuss Airway management and general resuscitation of this patient in A&E.
Inter hospital transfer of this patient.
6 A 40year old female patient with a history of heavy alcohol abuse has a severe haematemesis. She is icteric, obtunded, oliguric and is scheduled for an emergency oesophagoscopy and injection of varices. Discuss your perioperative and intensive care management plan for this patient.
7 In a adult undergoing general anaesthesia for major surgery
Discuss the differential diagnosis of intraoperative hypotension.
How would you manage this condition?.
8 An aggressive young man suffering from schizophrenia is admitted for drainage of a dental abscess he is in pain and has trismus.
Discuss pre-operative methods to control his aggressive behaviour.
Discuss induction of general anaesthesia and airway protection.
9 An adult is to undergo posterior fossa craniotomy for tumour resection.
a) What are the advantages and disadvantages of the sitting position for this procedure?
b) Which monitors may help detect and treat venous air embolism during surgery?
10 Discuss the anaesthetic management for a 35 year old patient requiring a transphenoidal hypophysectomy for acromegaly
11 A 25 year old man has sustained 40 percent burns in a house fire .
a) Outline the initial management on arrival in the accident and emergency unit.
b) Discuss the fluid regimen for the first 48 hours .
12 Discuss the preoperative management of a 75 year old male with a six months history of gastrointestinal symptoms undergoing total gastrectomy .
13 a)Discuss –how you would best assess the adequacy of subarachnoid block for caesarian section.
b) which is the most appropriate intervertebral space for a subarachnoid block and why ?
14 Outline the initial management of an unconscious 70kg adult patient who has lost 2000mls of blood.
a) Discuss lactic acidosis in trauma patient.
15 Guillian Barre syndrome- ICU management *.Discuss strategies to control ICP at inductionof Emergency genl. anaesthesia
16 Anaesthetic implications for a neonate undergoing inguinal hernia repair
17 Difference between Fuel cell and Clarke electrode
18 Which Cranial nerve is tested by which Test for Bran Stem death?
19 85 yr old lady for thyroid surgery. She has stridor and thyroid enlargement with retro-sternal extension.* Discuss airway management. What are the potential post thyroid complications.
20 54 yr old man IDDM(Wt60 kg)presents with end stage renal failure and is scheduled for A-V fistula creation.* Preop. evaluation and preparation for surgery * Anaesthetic technique you would use and rationale for your choice.*
21 .30 yr old man (70Kg) , hypotensive and unconscious is admitted to A&E following RTA.*Discuss initial management of hypovolaemia . *Specify Airway management you would adopt.*
22 70 Yr old with severe Rheumatoid arthritis who is to undergo above knee amputation.*Post op pain management.*
23 40 yr old female with two day history of epigastric pain is found at laparotomy to have ac pancreatitis. Discuss management.
24 Differentiate Cardiac tamponade from Cardiac contusion in a patient who has sustained blunt chest trauma and developes hypotension and increased CVP..
25 60 yr old IDDM require urgent amputation of infected foot.He is obtunded ,hypotensive,tachycardiac and hyponatraemic.Urine shows ++++ glucose and ketones. Discuss periop management.
26 Differential diagnosis and management of post op hypotension in recovery room following laparoscopic cholecystectomy in 60 yr old male with IHD.
27 Anaesthetic issues involved in the management of 37 yr old male with Down syndrome presenting for Cataract surgery.
28 18 yr old RTA is admitted in A&E with Compound fracture of Femur..He has sudden deterioration of LOC and Dilated Pupil ,Discuss differential .diagnosis and patient management.
29 75 yr old male with history of Frequency and Nocturia presents in acute retention.He has history of Angina at rest &ECG picture of LBBB.* Preop investigations and principles of anaesthetic management of the patient
30 Anaesthetic management of emergency appendicectomy in a 18 yr old primi with 10 week pregnancy
FELLOWSHIP EXAMS - FINAL- SHORT NOTES QUESTIONS
Short Notes- final FRCA Exams UK &IRELAND
GABAPENTIN
MONITORING DEPTH OF ANAESTHESIA
RECOMBINANT FACTOR VII A
HIGH AIRWAY PR. ALARM
ILMA
EPIDURAL OPIOD ADMINISTRATION
LASER SURGERY-HAZARDS & APPROPRIATE AIRWAY MANAGEMENT
STELLATE GANGLION BLOCK
CRICOID PRESUURE PERIOP BETA BLOCKADE
CHOLINESTERASE DEFICIENCY
INHALED NITRIC OXIDE
TROPONIN I
MIXED VENOUS O2 SATS
ATENELOL
REFLEX SYMPATHETIC DYSTROPHY
BIPAP
METOLAZONE
GLYCOPYRROLATE
SICKLE CELL DISEASE
AWAKE INTUBATION
PERCUTANEOUS TRACHEOSTOMY
MAGNESIUM SULPHATE IN PREGNANACY
APGAR SCORE
DOUBLE LUMEN TUBES
ONE LUNG VENTILATION
ACE INHIBITORS
MIDAZOLAM
ALBUMIN
ROCURONIUM
REMIFENTANYL
MALIGNANT HYPERPYREXIA
EVOKED POTENTIALS
ANKLE BLOCK
PHARMACOLOGICAL PROPHYLAXIS AGAINST ASPIRATION PNEUMONITIS
PARACETAMOL OVERDOSAE
SICKLE CELL DISEASE
SEDATION IN ICU
PROTEIN C
INTRAOPERATIVE TEMP MONITIORING
MONITORING NEUROMUSCULAR MONITORING
NORMOVOLAEMIC HAEODILUTION
REGIONAL ANAESTHESIA I A PT WITH PET
CLONIDINE
DICLOFENAC
REGIONAL ANAESTHESIA FOR AMBULATORY SURGERY
ANTIBIOTIC PROPHYLAXIS IN VALVULAR HEART DISEASE IN A PT UNDERGOING DENTAL EXTRACTION
CAPNOGRAPHY
POST OP COMPLICATIONS FOLLOWING THYROIDECTOMY
PA CATHETERIZATION INCREASES MORTALITY?
RHABDOMYOLYSIS
PERINATAL MORTALITY
PREOP INVESTIGATIONS FOR AMBULATORY SURGERY
HEP B AND ANAESTHETIST
STELLATE GANGLION BLOCK
PROBLEMS IN MONITORING A 4 YR OLD CHILD FOR MRI
CLOSED CIRCUITE ANAESTHESIA
LOW FLOW ANAESTHESIA
BLOOD CONSERVATION
HIGH PRESSURE ALARMCISATRACURIUM
TRAMADOL
ENTERAL NUTRITION
SLEEP APNOEA
SPINAL CORD MONITORING
COMPLICATIONS OF MASSIVE BLOOD TRANSFUSION
COAXIAL ANAESTHETIC BREATHING SYSTEM
COELIAC PLEXUS BLOCK
EYE BLOCKS
POPLITEAL BLOCK
PARAVERTEBRAL BLOCK
DEXMEDETOMIDINE
VASOPRESSIN
SODIUM BICARB – INDICATIONS
AIR EMBOLISM
SODIUM NITROPRUSIDE
GELOFUSINE
ROPIVICAINE
TRIGEMINAL NEURALGIA
SAFETY FEATURES OF ANAESTHETIC MACHINE
COMPARE SEVOFLURANE AND ISOFLURANE
SYMPATHETIC SUPPLY OF EYE
CO POISIONING
LAMINAR & TURBILANT FLOW
LOG DOSE RESPONSE CURVE
ACH RECEPTOR
ODC IN DIFFERENT TYPES OF HYPOXIA
VENTILATOR INDUCED LUNG INJURY
CORMACK&LEHANE CLASSIFICATION
PREANAESTHETIC CHECK OF CIRCLE BREATHING SYSTEM
RED BLOOD CELL SALVAGE
FLUID REQUIREMENT OF A CHILD WHO SUSTAINE 35%BURNNS
CSF CIRCULATION
PERIOP EVALUATION OF VOLUME STATUS IN ADULT
STRABISMUS SURGERY
ECG CHANGES IN HYPERKALAEMIA
INFORMED CONSENT
POST OP NAUSEA& VOMITING –CURRENT MANAGEMENT
ERRORS IN 1)PULSE OXYMETRY 2)CAPNGRAPHY
TIVA
EPHEDRINE AND PHYNYLEPHRINE IN OBSTETRIC ANAESTHESIA
Some of the following articles which i find are of interest in Feb 2009 issue of BJA:
Third National UK Audit Project of the Royal College of Anaesthetists on major complications of central neuraxial block (CNB), published in Feb 2009 issue of the British Journal of Anaesthesia.:The data are reassuring and suggest that CNB has a low incidence of major complications, many of which resolve within 6 months. Worth reading.
Conversion of epidural labour analgesia to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure:
Intraoperative conversion to GA may increase both maternal and fetal risks. Strategies to reduce the incidence may include early recognition of inadequate labour analgesia and reliable assessment of adequacy of surgical anaesthesia. True.
Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: meta-analysis of randomized trials:
Intrathecal morphine decreases pain intensity at rest and on movement up to 24 h after major surgery. Morphine-sparing is more pronounced after abdominal than after cardiac–thoracic surgery. Respiratory depression remains a major safety concern!
Antifibrinolytics in cardiac surgical patients receiving aspirin: a systematic review and meta-analysis:
While conventional practice is to discontinue aspirin prior to elective cardiac surgery there is evidence that its continuation may be associated with improved perioperative outcomes.
A systematic review and meta-analysis of the literature is done to address the question of the effects of antifibrinolytic agents in cardiac surgery patients maintained on aspirin in terms of both efficacy and adverse events.
They found no difference in the rates of adverse events between groups but observed a trend towards a reduced risk for the composite outcome of thrombotic complications. Antifibrinolytic agents are effective for reducing both chest-tube drainage and transfusion requirements in cardiac surgical patients receiving aspirin. Tey found no difference between antifibrinolytic and placebo in terms of adverse events but the population was predominantly low-risk. Further studies are required to determine the optimal balance between antiplatelet and antifibrinolytic effects in cardiac surgery.
Comparative study of topical anaesthesia with lidocaine 2% vs levobupivacaine 0.75% in cataract surgery:
Topical anaesthesia with levobupivacaine 0.75% was more effective than lidocaine 2% in preventing pain and improving patient and surgeon comfort during cataract surgery, with similar toxicity
Plain articaine or prilocaine for spinal anaesthesia in day-case knee arthroscopy: a double-blind randomized trial:
Spinal anaesthesia with plain articaine 50 mg resulted in a faster recovery of motor function and earlier spontaneous voiding compared with plain prilocaine 50 mg. Surgical anaesthesia was not different. The incidence of transient neurological symptoms (TNS) was low.
Comparison of the i-gel with the cuffed tracheal tube during pressure-controlled ventilation:
The authors claim ' i-gel can be used as a reasonable alternative to tracheal tube during PCV with moderate airway pressures. '
- Topics in January issue of BJA to follow:
Ondansetron anaphylaxis
PHYSIOLOGY :
cvs-1 STARLING FOCES 2)STARLING'S LAW 3)FICK PRINCIPLE 4)CARDIAC CYCLE WITH PR VOL CURVES5)BLOOD VOLUME 6)MIXED VENOUS O2 SATURATION 7)HOW DOES BLOOD CARRY O2 8)CORONARY CIRCULATION 9)FOETAL CIRCULATION 10)PORTAL CIRCULATION 11ARTERIO- VENOUS O2 DIFFERENCE 12)REGULATION OF BLOOD PR.
13)BLOOD GROUPS 14)CARDIAC MUSCLE/SKELETAL MUSCLE/SMOOTH MUSCLE
15)CONDUCTION PATHWAYS OF HEART 16)CARDIAC ACTION POTENTIAL &SA NODE ACTION POTENTIAL
17)PRESSURE VOLUME LOOPS 18)ANAEMIA 19)CLOTTING MECHANISM
19)PRELOAD-AFTER LOAD -CONTRACTION OF MYOCARDIUM
20)CARDIAC OUTPUT 21-HEART IN EXERCISE 22)THE FAILING HEART
23)CAROID BODIES &SINUSES 24)VALSALVA MANOEUVRE 25)OXYHAEMOGLOBIN& MYOGLOBIN CURVES 26) LEFT VENTRICULAR FUNCTION 27)AUTOREGULATION OF BLOOD FLOW 28)PHYSIOLOGICAL CHANGES OF ALTITUDE 29)PHYSIOLOGICAL RESPONSE TO BLOOD LOSS 30)LYMPH &FUNCTIONS
RESPIRATORY SYSTEM:
1)TRACHEO BROCHEO ALVEOLAR AIRWAY & LUNG LOBES
2)LUNG VOLUMES &FLOWS 3)FRC 4)DEAD SPACE-ANATOMIC&PHYSIOLOGIC
5)FICK'S LAW OF DIFFUSION 6)O2 UPTAKE ALONG PULMONARY CAPILLARY
7)MEASUREMENT OF DIFFUSING CAPACITY 8)COMPARISON OF PR.s IN PULM.&SYSTEMIC CIRCULATIONS. 9)PULMONARY VASCULAR RESISTANCE
10)DISTRIBUTION OF BLOOD FLOW IN LUNG 11)O2 TRANSPORT FROM AIR TO TISSUES(cascade) 12)SHUNT EQUATION 13)VENTILATION -PERFUSION RATIO & INEQUALITY 14)ALVEOLAR GAS EQUATION 15)HOW GASES ARE MOVED TO PERIPHERAL TISSUES -ODC CO2 CARRIAGE - CO2 DISSOCIATION CURVE-
16)ACID BASE STATUS -HENDERSON-HASSELBALCH EQUATION
17)PRESSURE VOLUME CURVE 18)COMPLIANCE 19) SURFACE TENSION
20)REGIONAL DIFFERENCE IN VENTILATION 21)RELAXATION PR. VOL. CURVES OF LUNG&CHEST WALL 22)AIRWAY RESISTANCE 23)WORK OF BREATHING
24)HOW GAS EXCHANGE IS REGULATED 25) GAS EXCHANGE IN EXERCISE
26)RESP.CHANGES IN ALTITUDE 27)O2 TOXICITY 28)PLACENTAL GAS EXCHANGE
29)PULMONARY FUNCTION TESTS 30)GAS EQUATIONS & DEFINITIONS
