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Test Yourself !

1.1 Describe three methods of assessing a patients exercise capacity preoperatively.

1.2 Describe the bedside assessments that you could use to try and predict difficulty with
tracheal intubation.
1.3 Describe the characteristics that define each of the ASA grades. What ASA grade would you assign to a 67year-old woman with type II diabetes, hypertension, a BMI of 38 and exercise tolerance of 100m on the flat and

1.4 In the preoperative assessment clinic, what investigations would you do on a 70-year-old woman, with
controlled hypertension and COPD from smoking 20 cigarettes per day for 50 years, who is scheduled for a total
hip replacement and why?
1.5 A 43-year-old woman seen in the clinic prior to having a laparoscopic cholecystectomy is assessed as being
ASA II due to well controlled hypertension. She asks what are the risks of having a general anaesthetic? What
would you tell her?

Mild or early:
circumoral paraesthesia;
numbness of the tongue;
visual disturbances;
slurred speech;
mild hypotension and bradycardia.
Severe or late:
grand mal convulsions followed by coma:
respiratory depression and eventually apnoea;
cardiovascular collapse with profound hypotension
and bradycardia;
_ cardiac arrest.

Management of LAST
Stop giving the local anaesthetic immediately,
get help;
Maintain the airway using basic techniques.

Tracheal intubation will be needed if the

protective reflexes are absent to protect against
Give oxygen (100%) with support of ventilation
if inadequate;
Raise the patients legs to encourage venous
return and start an IV infusion of crystalloid or
colloid. Treat a bradycardia with IV atropine;
Treat convulsions with diazepam 510mg IV.
If the patient has a cardiac arrest, start lipid emulsion
give 1.5 mL/kg 20% lipid emulsion (approximately
100 ml) over 1 min;
start an infusion of 20% lipid emulsion at a rate of
15 mL/kg/h.
Prevention of LAST

TABLE 1. Recommendations for Preventing LAST

& There is no single measure that can prevent LAST in clinical
& Use the lowest effective dose of local anesthetic (dose = product
of volume _ concentration) (I, C).
& Use incremental injection of local anestheticsVadminister 3- to
5-mL aliquots, pausing 15Y30 secs between each injection.
When using a fixed needle approach, eg, landmark,
paresthesia-seeking, or electrical stimulation, time between
injections should encompass 1 circulation time (30Y45 secs);
however, this ideal may be balanced against the risk of needle
movement between injections. Circulation time may be increased
with lower-extremity blocks. Use of larger dosing increments
would dictate the need for longer intervals to reduce the
cumulative dose from stacked injections before an event of LAST.
Incremental injection may be less important with ultrasound
guidance, given that frequent needle movement is often used
with the technique (I, C).
& Aspirate the needle or catheter before each injection, recognizing
that there is 2% false-negative rate for this diagnostic
intervention (I, C).
& When injecting potentially toxic doses of local anesthetic, use of
an intravascular marker is recommended. Although epinephrine
is an imperfect maker and its use is open to physician judgment,
its benefits likely outweigh its risks in the majority of patients
(IIa, B):
) Intravascular injection of epinephrine 10Y15 Kg/mL in adults
produces a Q10-beat HR increase or a Q15Ymm Hg SBP
increase in the absence of A-blockade, active labor, advanced
age, or general/neuraxial anesthesia.
) Intravascular injection of epinephrine 0.5 Kg/kg in children
produces a Q15Ymm Hg increase in SBP.
) Appropriate subtoxic doses of local anesthetic can produce
subjective symptoms of mild systemic toxicity (auditory
changes, excitation, metallic taste, etc) in unpremedicated
) Fentanyl 100 Kg produces sedation if injected intravascularly
in laboring patients.
& Ultrasound guidance may reduce the frequency of intravascular
injection, but actual reduction of LAST remains unproven in
humans. Individual reports describe LAST despite the use of
ultrasound-guided regional anesthesia. The overall effectiveness
of ultrasound guidance in reducing the frequency of LAST
remains to be determined (IIa, C).