Notes for the Final FRCA, by Kay Davies Risk Assessment for Non-Cardiac Surgery Goldman risk factors – 1977 Age>70 5 MI within 6 months 10 Signs of heart failure (raised JVP, third heart sound) 11 Aortic stenosis 3 Rhythm other than sinus 7 More than 5 PVCs in 1 min 7 Poor general medical status: 3
PO2 <8, K+<3, HCO3-<20, Urea >18, creat>270, Deranged LFTs, Bedridden from non-cardiac cause
Emergency surgery 4 Intrathoracic, GI, Aortic surgery 3
Risk of Death Severe CVS complications Detsky cardiac risk index modification of Goldman in 1986, correlates better with perioperative morbidity MI <6 months 10 MI >6 months 5 Canadian Cardiovascular Society angina class 3 10 Canadian Cardiovascular Society angina class 4 20 Unstable angina within 6 months 10 Pulmonary oedema within 1 week 10 Pulmonary oedema at any time 5 Rhythm other than sinus 5 More than 5 PVCs per min 5 Critical aortic stenosis 20 Poor general health 3 Age >70 5 Emergency surgery 4 High risk if more than 15 points Duke Activity Status Index 1 MET is 3.5ml O2/kg/min Poor functional activity:
1-4 MET - Light housework Shower/dress without stopping Walk on level ground at 2.5 mph
5-7 MET - Climb flight of stairs without stopping Walk briskly > 4mph on flat Light gardening
>7 METS - Digging in garden Carrying upstairs Strenuous sports, cycling uphill, jogging
ACTIVITY
Hoovering/ sweeping floor/ carrying groceries
Canadian Cardiovascular Society Classification of Angina Class 0 - Asymptomatic Class I - Angina with strenuous exercise Class II - Angina with moderate exercise Class III - Angina walking 1 to 2 level blocks or climbing 1 flight of stairs Class IV - Inability to perform any physical activity without angina Classification of BP Optimal <120/80 Normal <130/85 High Normal <139/89 (therefore hypertension is defined as >140/90) Grade 1 hypertension (mild) >140/90 and <159/99 Grade 2 hypertension (moderate) <179/109 – treat (ie>160/100) Grade 3 hypertension (severe) >180/110 - treat Grade 1 isolated systolic hypertension SBP140-159, DBP<90 Grade 2 isolated systolic hypertension SBP>160 , DBP<90 – treat American College of Cardiology and American Heart Association Guidelines for Peri-operative Evaluation for non-cardiac surgery –1996, updated 2003 Patient risks: MAJOR RISK MODERATE RISK MINOR RISK
Decompensated cardiac failure Compensated cardiac failure
Surgical risks: HIGH RISK INTERMEDIATE RISKS MINOR RISKS
An algorithm is then used to determine what level of investigations the patient needs pre-operatively. AAGBI Indications for intubation and ventilation in head injury – 2006 GCS less than or same as 8 Deteriorating GCS by 2 or more points Seizures PaO2 <13 on O2 PaCO2 >6 Spontaneous tachypnoea PaCO2 <4 Bilateral fractured mandible Copious bleeding into the mouth Loss of protective laryngeal reflexes Child-Pugh Classification of Liver disease for Assessment of Outcome or all Types of Surgery
Mortality Paediatrics Neonate first 28 days of life or < 44 weeks post conception Infant 1 months to 1 year Child > 1 year to adolescence Low Birth Weight <2500g Premature <37/40 NCEPOD Classification 1
Within days, suitable for day-time emergency list
Levels of Care Level 1
Step-down from higher levels At risk of deteriorating, needing 4 hourly obs Specialised staff for epidurals, PCA & tracheostomy care
Pre-op optimisation Extended post-op care Abnormal physiological parameters 1:2 nurse:patient
(ITU) Monitoring and support of 2 or more organs
Co-morbidity of 1 or more organ systems and who need support for an acute reversible failure of another organ. 1:1 nurse:patient Levels of Evidence Level Description
Single RCT, with narrow confidence interval
Systematic review of case control studies
Case series/ poor quality cohort/ case control studies/ non-experimental
Grades of Recommendations Grade
Level 4 studies or extrapolated from level 2 or 3 studies
Level 5 evidence or inconclusive studies at any level
WHO Criteria Diabetes Mellitus – 1999 Fasting blood glucose >7 mmol/l on 2 days
OGT: blood glucose >11 at 2 hours and at least one other time during the test OGT: if blood glucose is 7-11 at 2 hours or one value is >11, this is impaired Diagnosis DKA PH <7.3 HCO3- <16 Anion gap >16 Ketones in blood or urine Respiratory Failure Type I - PaO2<8, PaCO2≤ 6.7 Type II - PaO2<8, PaCO2≥ 6.7 Peri-operative Steroids Patient on steroids: <10mg/day, no additional cover
>10mg/day and minor surgery, 25 mg hydrocortisone on
induction >10mg/day and moderate surgery, above plus 100 mg/day for
24 hours >10mg/day and major surgery, above plus 100 mg/day for 72 hours
<3 months, treat as if on steroids >3 months, no peri-op steroids POISE Trial Perioperative ischaemic evaluation study Multicentre blinded randomised controlled trial of metoprolol vs placebo in 10,000 at risk patients undergoing noncardiac surgery. It will determine the impact of perioperative metoprolol on cardiovascular events (cardiovascular death, non-fatal MI or non-fatal cardiac arrest) in at risk patients during the 30 day post-operative period. Collaborative Eclampsia Trial – Lancet 1995 Compared magnesium with diazepam and phenytoin in 1687 women with eclampsia in developing countries. 52% lower risk of recurrent convulsion using magnesium compared to diazepam. 67% lower risk of recurrent convulsion using magnesium compared to phenytoin, also the foetal morbidity was lower. COMET Study – Lancet 2001 Comparative Obstetric Mobile Epidural Trial 1054 woment in nulliparous labour in 2 obstetric units Women randomised to receive traditional 0.25% bupivacaine top-ups, CSE (1ml 0.25% bupivacaine and 25mcg fentanyl intrathecally with epidural topups 0.1% bupivacaine with fentanyl) or low dose infusion 0.1.5 bupivacaine and 2 mcg/ml fentanyl.
Lower rates of instrumental delivery and Caesarian section with the low dose infusion and CSE groups but not much difference between each of these groups. 50% less bupivacaine used with the CSE group. Contant 2001 In Traumatic brain injury, CPP randomised to >70mmHg gives a 5 x greater risk of ARDS, which increases risk of poor outcome. Therefore the minimum CPP is 60mmHg and CPP>60 mmHg to be avoided. 60mmHg shown to be the critical CPP threshold by Juul 2000 with no extra benefit using 70mmHg. CRASH-Lancet 2004 Corticosteroid Randomisation After Significant Head Injury TBI and GCS< or the same as 14. Randomised to methylprednisolone infusion for 48 hours or placebo. After 10008 patients the trial was stopped as the mortality within 14 days was significantly higher in the steroid treated group than placebo. Hypertonic Saline – Critical Care Medicine 2005 A RCT on the effect of 200ml 20% mannitol solution and 100ml 7.5% saline/6% dextran solution in raised ICP. The hypertonic saline with the dextran caused a greater decrease in ICP and a significantly longer duration of action. NASCIS III IV methyl-prednisolone 30mg/kg over 15 mins followed 45 minutes later by 5.4mg/kg/hr for 23 hours, decreased the severity of long term sequelae if given within 8 hours of spinal cord injury. This is statistically significant but not clinically significant. Low dose dopamine doesn’t prevent ARF in early renal dysfunction ANZICS Clinical Trials Group – Lancet 2000 Double-blinded RCT. In patients with early renal dysfunction, dopamine does not reduce the need for RRT, reduce rises in creatinine or the number of patients reaching a creatinine threshold. Hypothermia after Cardiac Arrest Study Group- NEJM 2002 Multicentre trial with blinded assessment of outcome. Patients with an out of hospital VF cardiac arrest, who were resucitated, were randomised to 24 hours of mild hypothermia 32ºC to 34ºC or to normothermia. 75 of 137 patients in the hypothermia group had a favourable outcome at 6 months (55%), compared with 54 out of 137 patients in the normothermia group (39%). In ARI our inclusion criteria for therapeutic hypothermia are: GCS 3-5 Out-of hospital witnessed collapse with initial rhythm VF in an adult. 5-15 minutes down time (before start of resuscitation) Not more that 60 minutes to ROSC Target temperature 33+/- 0.5ºC Exclusion criteria: SBP<90mmHg Other cause of coma Pregnancy Coagulopathy Immediate verus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries – NEJM 1994 Non-blinded RCT. Patients with on scene initial SBP<90 mmHg. For every 13 patients in whom fluid resuscitation was delayed, compared to immediate resuscitation, one extra patient survived. These victims were young and we cannot assume that the same principal is applicable to other patients hypotensive in the pre-operative period eg AAA SAVE Study Captopril 50mg tds given post-MI with associated poor LV function can reduce mortality by 40 lives per 1000 patients and results in fewer MI’s or hospitalisation over a 3.5 year period. CARE Trial Pravastatin saved 150 fatal and non-fatal CVS events per 1000 patients treated for 5 years post-MI. with average cholesterol levels. Late Steroid Rescue in ARDS Can prevent the proliferative phase and reduce fibrosis. From 7 to 15 days give 2mg/kg methylprednisolone and reduce the dose over 32 days. PAFC use does not alter post-operative outcome – NEJM 2003 Single-blinded RCT. ASA III/IV patients over 60 years for elective or urgent abdominal, thoracic, vascular or hip fracture surgery. In high risk patients undergoing surgery, PAFC together with GDT did not reducce mortality. There was a higher use of all interventions in the PAFC group and also a higher incidence of PE, but no difference in length of hospital stay. Albumin increases mortality in critically ill patients Systemic review of RCT BMJ 1998 No evidence that albumin reduces the mortality in critically ill patients with hypovolaemia, burns or hypoalbuminaemia. Also for every 17 patients given albumin, compared to crystalloid, one additional patient dies
The SAFE study (a comparison of Saline and Albumin for Fluid resuscitation – NEJM 2004) was a multicentre double-blinded RCT with 6997 patients with a heterogeneous group of patients. This went on to show that there was no difference in 28 day mortality between the two. PROWESS – 2001 Protein C Worldwide Evaluation in Severe Sepsis 6.5% reduction in 28 day mortality (21%relative risk reduction) ie NNT = 16 ADDRESS – NEJM 2005 Administration of Drotrecogin alfa activated in early severe sepsis 11000 patients Showed that if there was single organ failure or APACHE <25 then APC caused increased mortality. INDICATIONS APC:
2 organ failure of <48 hours duration APACHE > or the same as 25 or increased risk of death Evidence of infection and septic shock producing 3 out of 4 SIRS criteria Receiving full card on ITU and not improving No contraindications
CONTRAINDICATIONS: Paediatrics (4x increased risk ICH)
Within 30 days surgery Active/internal bleeding Haemorrhagic stroke within 3 months Intracranial/spinal surgery/head injury within 2 months Trauma with increased risk of life threatening bleeding Epidural Intracranial neoplasm/mass lesion/evidence of Other Pain Scores: Magill Pain Questionnaire The original questionnaire was long and difficult for many to complete. A short form containing 15 words was developed. The first 11 words are SENSORY descriptive words, the next 4 words are AFFECTIVE and the EVALUATIVE component uses a 5 point scale for present pain intensity and a Visual Analogue Scale. Oswestry Disability Index and Roland Disability Questionnaire For assessment of back pain Brief Pain Inventory This includes:
Pain intensity at worst /best and at the time of evaluation % pain relief from medication Duration of pain relief Exacerbating and relieving factors Aspects of Pain belief Level of interference with ADLs Memorial Pain Assessment Cards These are 3 separate Visual Analogue Scales for PAIN, PAIN RELIEF and MOOD. The card is folded so you only see one scale at a time. It is very quick and results correlate with longer evaluations of pain and mood. LANNS Pain Scale Leeds Assessment of Neuropathic Symptoms and Signs. This includes: 5 QUESTIONS:
Ds the pain pricking/tingling/pins and needles? 5 Does it affect the colour of the skin? 5 Is the skin abnormally sensitive? 3 Does the pain occur in bursts/like an electric shock? 2 Is it hot/burning? 1
Cotton wool allodynia 5 Pinprick threshold altered 3
If total > 12 out of 24, this is neuropathic pain (80% specific, 85% sensitive) Neuropathic Pain Scale – Galer 8 PAIN DESCRIPTIONS: short GLOBAL UNPLEASANTNESS: 0 – 10
hot cold skin sensitivity itching deep pain surface pain Guidelines to look at: AAGBI Guidelines- blood transfusion, consent, Jehovah’s witnesses, day surgery, MH, monitoring, safe transfer of patients with brain injury, MRI, perioperative care of elderly NICE Guidelines- April 2007 new guidelines for massive PE NCEPOD Recommendations and recent audits CEMACH you can download the executive summary and also read the anaesthesia section SIGN GUIDELINES: Management of hip fractures, Blood transfusion, Post-operative assessment BRITISH HYPERTENSION SOCIETY GUIDELINES Other Reading: Your Primary notes or books Key Topics in Critical Care Key Topics in Chronic Pain Key Topics in Anaesthesia Handbook of Anaesthesia A-Z of Anaesthesia –Yentis Clinical Notes for the FRCA –Charles Deakin CEPD articles – you can get them on disc/ online / printed collated copies SAQ Tips: Just print out all the past questions from the FRCA or Royal College website and do as many as you can as similar topics get repeated. Simon Bricker’s “SAQs in Anaesthesia” is invaluable. MCQ Tips: Loads of practice and answer as many as you can. Many MCQs from “Guide to the FRCA Examination: the final” (order form the college website) and the FRCA website came up in the exam, so do them/repeat them a few days before the exam. VIVA Tips: Don’t skimp on anatomy. Pester lots of people for practice, especially those who have done the exam recently. “The Anaesthesia Science Viva” book (Simon Bricker) is excellent as is “The Clinical Anaesthesia Viva” book (Mills/Maguire/Barker). I also found “Clinical Data Interpretation in Anaesthesia and Intensive Care” by Bonner/Dodds interesting to read. More people fail the clinical science viva, so going through your Primary basic science viva books again may be useful, as well as giving viva practice to those sitting the Primary. In the clinical viva, you have 10 minutes to go though a case before the viva. They will invariably ask you to summarise the case and state what the main problems are, so prepare this answer. Also think what further information in the history and what further investigations you would like to get, whether you would anaesthetise the patient, how you would optimise them for surgery, pre-induction, induction, maintenance, monitoring, analgesia, extubation and post-operative care. There are viva courses you can go on too for even more practice.- Coventry/Liverpool/London/Cambridge.