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Hot topics
Question breakdown SAQ 2006-2011
30
Questions
25
20
15
10
5
0
Category
9
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6
5
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1
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Question Breakdown 2011-2013
Poorly answered questions Feb14
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Phaeochromocytoma
Antiplatelet therapy (CEACCP 2010)
Day case surgery in children (CEACCP 2011)
TCI Propofol
Drug errors (SALG, MHRA)
#NOF (NICE, AAGBI)
High yield resources
• RCoA
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Chairman’s report
Their books
The website; 120 MCQs/30 SBAs
The Gas newsletter
The Candidate newsletter
• CEACCP
• Guidelines & publications:
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SALG
AAGBI
National Audit Projects
NICE
NCEPOD
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)
CEACCP 2013 – 6 topics asked from
this journal
• Posterior fossa tumours
• Anaesthesia for
shoulder surgery
• Burns
• Sympathetic blocks
• Cerebral Palsy
• Awareness
CEACCP 2012 – 6 topics asked from
this journal
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Chemotherapy
Ultrasound
EVARs
Pulmonary Embolism
Nutrition
Head and facial injuries
POTENTIAL TOPICS
Guidelines & Reports
• NICE:
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Head injury
IV fluids in hospital
AF management
Neuropathic pain
Acute Kidney Injury
Depth of anaesthesia
• NHS England
– Never events
• NCEPOD
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Tracheostomy care
Sepsis (in-progress)
Alcohol
Subarachnoid
haemorrhage
• National Audit Projects
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3: regional
4: airway
5: awareness
6: anaphylaxis
Guidelines & Reports
• NICE:
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Head injury
IV fluids in hospital
AF management
Neuropathic pain
Acute Kidney Injury
Depth of anaesthesia
• NHS England
– Never events
• NCEPOD
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Tracheostomy care
Sepsis (in-progress)
Alcohol
Subarachnoid
haemorrhage
• National Audit Projects
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3: regional
4: airway
5: awareness
6: anaphylaxis
• 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
• 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
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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
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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
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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
CEACCP- Main Journal
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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
CEACCP- Main Journal
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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
CEACCP- Main Journal
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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
TOPICS
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
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/N2O NOT protective
Modified Brice
questionnaire as used in
recent SNAP-1 audit
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)
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
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
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
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85% caused by aneurysmal rupture
Other causes: AV malformations, trauma
F > M, age 40-60
Investigations:
– Non contrast CT (>95% sensitivity on day 0)
– MRI
– LP (after 12 hours)
WFNS Scale
Survival rates may be as low as 10-20% in those in groups 5 & 6
Anaphylaxis
• 6th National Audit Project
• 2013 CEACCP article
• AAGBI guidelines 2009
• Allergic/non-allergic (term ‘anaphylactoid’
now obsolete)
• Previous exposure is not required in nonallergic anaphylaxis
• Atopy is a risk factor for NMBA sensitivity
• Sensitization from non-anaesthetic agents
(DetergentsNMBD, Pholcodeine 
Suxamethonium, smoking  antibiotics, fruit
 latex)
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
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 2013. Symons et al
• Emergency surgery – Standards for unscheduled
surgical care 2011 RCS
• Guidance on the provision of anaesthesia services for
emergency surgery 2013. RCoA
• 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)
• 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
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
• MHRA : Dose greater than 75mg/kg/day
constitutes an overdose requiring treatment
• APA and BNFc currently recommend
90mg/kg/day
• 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.
http://onlinelibrary.wiley.com/doi/10.1111/j.1460-9592.2012.03838.x/pdf
Alcohol
• Sources:
– NCEPOD – Measuring the Units 2013
– Anaesthesia for patients with liver disease 2010
(CEACCP)
– NICE guidelines – acute upper GI bleeding June
2012.
• 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
• 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.
RA and patients with abnormalities of
coagulation
• Lists acceptable time
intervals after
anticoagulant drugs for
RA
• Pre-eclampsia/
thrombocytopaenia:
– 75-100 increased risk
– >100 low risk
• Need to consider risk of
block as well as pt’s
coag
• Other abnomalities of
coagulation “special
circumstances”
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Trauma
Sepsis
Massive Transfusion
Uraemia
Liver Failure
DIC
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
Safe Sedation
• RCoA guidance 2012
– Appropriate training
– Trained assistant
– Define level of sedation aiming for
– Oxygen, ETCO2/ AAGBI monitoring
– Specific recovery monitoring
– Discharge criteria
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
Management of Autonomic Dysreflexia.
Petsas A , and Drake J Contin Educ Anaesth Crit Care Pain
2014;bjaceaccp.mku024
© The Author 2014. Published by Oxford University Press on behalf of the British Journal of
Anaesthesia. All rights reserved. For Permissions, please email:
[email protected]
• Resp function
– Lesions >C3 vent dependant
– Lesions C3-5 variable need for vent
– Lesions C6-8 may need NIV
– Approx 5th of cervical SCI pts have tracheostomy
• Musculoskeletal
– Spasticity (baclofen /pump)
– Osteoporosis
– Extrajunctional Ach receptors
Anaesthetic management flowchart.
Petsas A , and Drake J Contin Educ Anaesth Crit Care Pain
2014;bjaceaccp.mku024
© The Author 2014. Published by Oxford University Press on behalf of the British Journal of
Anaesthesia. All rights reserved. For Permissions, please email:
[email protected]