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Hot topics. Poorly answered questions Feb14 Phaeochromocytoma Antiplatelet therapy (CEACCP 2010) Day case surgery in children (CEACCP 2011) TCI Propofol.

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Presentation on theme: "Hot topics. Poorly answered questions Feb14 Phaeochromocytoma Antiplatelet therapy (CEACCP 2010) Day case surgery in children (CEACCP 2011) TCI Propofol."— Presentation transcript:

1 Hot topics

2

3 Poorly answered questions Feb14 Phaeochromocytoma Antiplatelet therapy (CEACCP 2010) Day case surgery in children (CEACCP 2011) TCI Propofol Drug errors (SALG, MHRA) #NOF (NICE, AAGBI)

4 High yield resources RCoA – Chairman’s report – Their books – The website; 120 MCQs/30 SBAs The website; 120 MCQs/30 SBAs – The Gas newsletter The Gas newsletter – The Candidate newsletter The Candidate newsletter CEACCP Guidelines & publications: – SALG SALG – AAGBI – National Audit Projects – NICE – NCEPOD

5 Continuing Education in Anaesthesia, Critical Care and Pain (CEACCP) The RCOA writes the exam and is involved in the production of CEACCP > 70 topics a year in CEACCP Topical and pitched at final FRCA level Now has podcast (as does BJA)

6 CEACCP 2013 – 6 topics asked from this journal Posterior fossa tumours Anaesthesia for shoulder surgery Burns Sympathetic blocks Cerebral Palsy Awareness

7 CEACCP 2012 – 6 topics asked from this journal Chemotherapy Ultrasound EVARs Pulmonary Embolism Nutrition Head and facial injuries

8 POTENTIAL TOPICS

9 Guidelines & Reports NICE: – Head injury – IV fluids in hospital – AF management – Neuropathic pain – Acute Kidney Injury – Depth of anaesthesia NHS England – Never events NCEPOD – Tracheostomy care – Sepsis (in-progress) – Alcohol – Subarachnoid haemorrhage National Audit Projects – 3: regional – 4: airway – 5: awareness – 6: anaphylaxis

10 Guidelines & Reports NICE: – Head injury – IV fluids in hospital – AF management – Neuropathic pain – Acute Kidney Injury – Depth of anaesthesia NHS England – Never events NCEPOD – Tracheostomy care – Sepsis (in-progress) – Alcohol – Subarachnoid haemorrhage National Audit Projects – 3: regional – 4: airway – 5: awareness – 6: anaphylaxis

11 AAGBI – Post anaesthetic recovery guidelines – Perioperative Care of the Elderly (esp. delirium) – Regional anaesthesia in pts with abnormal coag. – Dental damage (SALG) RCoA – Remote site anaesthesia – Child protection – Safe sedation – Diabetes

12 AAGBI – Post anaesthetic recovery guidelines – Perioperative Care of the Elderly (esp. delirium) – Regional anaesthesia in pts with abnormal coag. – Dental damage (SALG) RCoA – Remote site anaesthesia – Child protection – Safe sedation – Diabetes

13 CEACCP- Advance Access Iatrogenic airway injury LA toxicity Anaesthesia in patients with established SCI Perioperative SVT Placental structure, function and drug transfer Smoke inhalation End-of-life care Fire safety Tracheostomy management Awake intubation Inherited disorders coagulation

14 CEACCP- Advance Access Iatrogenic airway injury LA toxicity Anaesthesia in patients with established SCI Perioperative SVT Placental structure, function and drug transfer Smoke inhalation March ‘13 End-of-life care Fire safety Tracheostomy management March ‘14 Awake intubation Inherited disorders coagulation

15 CEACCP- Advance Access Iatrogenic airway injury LA toxicity Anaesthesia in patients with established SCI Perioperative SVT Placental structure, function and drug transfer Smoke inhalation March ‘13 End-of-life care Fire safety Tracheostomy management March ‘14 Awake intubation Inherited disorders coagulation

16 CEACCP- Main Journal Major spinal surgery Paracetamol Rhabdomyolysis ICU management of the morbidly obese Chronic pain and depression Awake craniotomy Assessment of high risk patient Intrathecal drug delivery COPD and anaesthesia Traumatic brain injury Post op cognitive dysfunction in cardiac surgery Acute spinal cord injury

17 CEACCP- Main Journal Major spinal surgery Paracetamol Rhabdomyolysis ICU management of the morbidly obese Chronic pain and depression Awake craniotomy Assessment of high risk patient Intrathecal drug delivery COPD and anaesthesia Traumatic brain injury Post op cognitive dysfunction in cardiac surgery Acute spinal cord injury

18 CEACCP- Main Journal Major spinal surgery Paracetamol Rhabdomyolysis ICU management of the morbidly obese Chronic pain and depression Awake craniotomy Assessment of high risk patient (crossover with NELA) Intrathecal drug delivery COPD and anaesthesia Traumatic brain injury (crossover with NICE) Post op cognitive dysfunction in cardiac surgery Acute spinal cord injury

19 TOPICS

20 Traumatic Brain Injury NICE guidelines, cover following: – ‘bypass’ criteria for head injury – Indication and timing of CT in ED – Cost effectiveness of strategies to image cervical spine – Information provided to pt & relatives after discharge

21 Depth of anaesthesia/Awareness NICE guidance recommends use of EEG-based DoA monitoring in pts at risk of: – Adverse effects of deep anaesthesia – Higher risk of awareness Rate of awareness probably higher than previously quoted NMB most implicated risk factor MAC >0.7 considered protective Benzos/N 2 O NOT protective

22 Modified Brice questionnaire as used in recent SNAP-1 audit

23 IV fluid therapy NICE Dec 13 (NCEPOD 1999) 1.Assessment – history, clinical examination, current medications, clinical monitoring and laboratory investigations – Monitoring of urinary sodium may be helpful in patients with high-volume gastrointestinal losses 2. Routine maintenance – 25–30 ml/kg/day of water and – approximately 1 mmol/kg/day of K +, Na + & Cl - and – approximately 50–100 g/day of glucose to limit starvation ketosis (50g in 1l of 5% dex)

24 3. Fluid resuscitation – crystalloids with Na 130–154 mmol/l – bolus of 500 ml over less than 15 minutes – Do not use tetrastarch for fluid resuscitation. – Consider HAS 4–5% for fluid resuscitation only in patients with severe sepsis

25 4. Replacement & redistribution – Adjust prescription to account for existing fluid and/or electrolyte deficits or excesses, ongoing losses or abnormal distribution. – Seek expert help if: gross oedema severe sepsis hyponatraemia or hypernatraemia renal, liver and/or cardiac impairment post-operative fluid retention and redistribution malnourished /refeeding

26

27 Subarachnoid haemorrhage NCEPOD document 2013 – “Managing the Flow” CEACCP article in 2013 Neurocritical Care Society issued consensus guidelines of critical care management of aneurysmal SAH in 2011

28 85% caused by aneurysmal rupture Other causes: AV malformations, trauma F > M, age Investigations: – Non contrast CT (>95% sensitivity on day 0) – MRI – LP (after 12 hours)

29 WFNS Scale Survival rates may be as low as 10-20% in those in groups 5 & 6

30 Anaphylaxis 6 th National Audit Project 2013 CEACCP article AAGBI guidelines 2009

31 Allergic/non-allergic (term ‘anaphylactoid’ now obsolete) Previous exposure is not required in non- allergic anaphylaxis Atopy is a risk factor for NMBA sensitivity Sensitization from non-anaesthetic agents (Detergents  NMBD, Pholcodeine  Suxamethonium, smoking  antibiotics, fruit  latex)

32 Investigation MCT – ASAP, 1-2 hours, 24 hrs or later Skin testing 4-6 weeks (skin prick vs intradermal – more sensitive) Drug challenge is only way to exclude clinical allergy Future anaesthesia – – Written information, MDT, Alert bracelet, Yellow card, AAGBI database, – Safe options- regional, volatiles, BZP, Remi, – Full monitoring, IV access, Pre-O 2, vasopressors ready

33 Emergency Laparotomy / NELA ASGBI – Issues in Professional Practice – Emergency General Surgery 2012 NELA – National Emergency Laparotomy Audit Dec 2012 – ongoing Mortality in High Risk Emergency General Surgical Admissions BJS Symons et al Emergency surgery – Standards for unscheduled surgical care 2011 RCS Guidance on the provision of anaesthesia services for emergency surgery RCoA

34 Variability between trusts & between weekdays and weekends High 30 day mortality – 15.6% RCS - Dedicated team, prioritization over elective activity, audit and review, consultant lead in all specialties RCoA (organisational) : consultant lead at all times, equipment eg warming, cell saver, invasive monitoring, goal directed therapy (CQINN)

35 Pre-op – optimization if appropriate, Formal risk assessment using eg p-POSSUM: if estimated mortality >10%- – consultant delivered care – post-op level 2 or 3 – Any emergency laparotomy OOH should get level 1 care – Consultant decision making, pt centred, family communication Intra-op – Temp, thromboprophylaxis, antibiotics, CO monitor Post op – critical care/outreach/EWS

36 Paediatric Analgesia MHRA Guidance 2013 – Codeine should not be used in any child under 12 or in any child with OSA – Ultra-Fast metabolisers to morphine (genetic variant of P450 CYP2D6) APA guidelines re: alternative opioids in children 2013 Alternative – Oral morphine 100mcg/kg

37 MHRA : Dose greater than 75mg/kg/day constitutes an overdose requiring treatment APA and BNFc currently recommend 90mg/kg/day APA Summary : – in hospital up to 90mg/kg/day is fine – Out of hospital should be decreased to 75mg/kg/day (i.e 18.75mg/dose QDS) – IV paracetamol maximum doses 60mg/kg/day or 30mg/kg if <10kg.

38

39 Alcohol Sources: – NCEPOD – Measuring the Units 2013 – Anaesthesia for patients with liver disease 2010 (CEACCP) – NICE guidelines – acute upper GI bleeding June Poor care identified in terms of : – Fluid management – Inadequate intervention to stop bleeding – Over-sedation leading to aspiration – Failure to escalate to critical care in patients with acute deterioration

40 NICE guidance (bleeding) – Early endoscopy – all patients with ARLD who present with bleeding should be given antibiotics and terlipressin (3/5 days) until the outcome of their endoscopy is known. – Consider TIPSS if variceal bleeding not controlled by band ligation Best prognostic scores once on ICU are SOFA or acute physiology based scores rather than traditional liver scores.

41 RA and patients with abnormalities of coagulation

42 Lists acceptable time intervals after anticoagulant drugs for RA Pre-eclampsia/ thrombocytopaenia: – increased risk – >100 low risk Need to consider risk of block as well as pt’s coag Other abnomalities of coagulation “special circumstances” – Trauma – Sepsis – Massive Transfusion – Uraemia – Liver Failure – DIC

43 Dental damage under anaesthesia SALG has members from RCoA, AAGBI and NHS England (NPSA) Dental damage during anaesthesia guidelines issued in July 2012 Previous SAQ (2009) poorly answered

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45 Safe Sedation RCoA guidance 2012 – Appropriate training – Trained assistant – Define level of sedation aiming for – Oxygen, ETCO2/ AAGBI monitoring – Specific recovery monitoring – Discharge criteria

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47 Anaesthesia in patients with SCI Autonomic dysreflexia – Caused by stimulation below level of lesion – Commoner in higher lesions eg above T6, and complete (cf incomplete) – Presentations Inc BP >20% Headache/flushing/sweating/chills – Consequences Raised ICP Seizures Cardiac eg MI

48 Management of Autonomic Dysreflexia. Petsas A, and Drake J Contin Educ Anaesth Crit Care Pain 2014;bjaceaccp.mku024 © The Author Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please

49 Resp function – Lesions >C3 vent dependant – Lesions C3-5 variable need for vent – Lesions C6-8 may need NIV – Approx 5 th of cervical SCI pts have tracheostomy Musculoskeletal – Spasticity (baclofen /pump) – Osteoporosis – Extrajunctional Ach receptors

50 Anaesthetic management flowchart. Petsas A, and Drake J Contin Educ Anaesth Crit Care Pain 2014;bjaceaccp.mku024 © The Author Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please


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