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James Mitchell's Anaesthetics Notes James Mitchell’s Anaesthetics Notes August 2001 Section 1: Physiology Section 2: Pharmacology A. Cellular A. General B. Respiratory 1. Pharmacodynamics 1. Anatomy 2. Pharmacokinetics 2. Control 3. Pharmacokinetics of 3. Mechanics inhalational agents 4. Ventilation 4. Variability in response 5. Diffusion 5. Pharmaceutics 6. V/Q matching B. Specific 7. Gas transport 1. Sedatives 8. Circulation 2. Opioids 9. Tests 3. Pain 10. Applied physiology 4. NSAIDs C. Cardiovascular 5. Intravenous anaesthetics 1. Structure and function 6. Inhalational anaesthetics 2. Electrical properties 7. Relaxants 3. Cardiac output 8. Anticholinesterases 4. Peripheral vasculature 9. Anticholinergics 5. Control 10. Local anaesthetics 6. Regional circulations 11. Autonomic nervous system 7. Applied physiology 12. Adrenoceptor blockers 8. Measurement 13. Antihypertensives D. Renal 14. Antidysrhythmics E. Fluids and Electrolytes 15. Antiemetics F. Acid-Base 16. Histamine & serotonin G. Nervous system 17. Diuretics H. Muscle 18. Coagulation I. Liver 19. Obstetrics J. Haematology 20. Endocrine K. Nutrition & Metabolism 21. Gastrointestinal L. Thermoregulation 22. Intravenous fluids M. Immunology 23. Poisoning & Antimicrobials N. Endocrine 24. New developments O. Maternal 25. Psychotropics P. Fetal & Neonatal C. Statistics Q. Gastrointestinal R. Physics and Measurement Section 3: Practice of Anaesthesia A. Anaesthesia E. Obstetrics & Gynaecology 1. Assessment 1. Labour and delivery 2. Drug reactions 2. Gynaecology 3. Fluids F. Paediatrics 4. Complications G. Anatomy 5. Inherited Conditions 1. Thorax 6. Pain 2. Abdomen and pelvis 7. Miscellaneous 3. Lower Limb B. Equipment 4. Back 1. Measurement 5. Upper Limb 2. Monitoring 6. Head 3. Physics 7. Neck 4. Vaporizers & gas delivery 8. Miscellaneous 5. Miscellaneous H. Regional C. Medicine I. Intensive Care 1. Cardiology J. Trauma and Resuscitation 2. Endocrinology 1. General principles 3. Gastroenterology 2. Burns 4. Haematology 3. Other injuries 5. Metabolic 4. Remote anaesthesia 6. Neurology K. Principles 7. Respiratory 1. Statistics 8. Oncology 2. Ethics 9. Renal 3. Economics 10. Miscellaneous 4. Policies D. Surgery 1. Cardiac 2. Vascular 3. Neurosurgery 4. Orthopaedics 5. Urology 6. ENT 7. Thoracic 8. Upper GI 9. General 10. Miscellaneous About these notes These notes are my study notes from preparing to sit the ANZCA Primary exam in 1997 and the ANZCA Fellowship exam in 2000. A few people wanted a copy of my notes in early 1998, so I made some photocopies. I have been asked if I mind them being copied or distributed; I don’t mind as long as they aren’t modified and are correctly attributed as my work. Of course they’re not exclusively my own work, they have been prepared from the standard texts and from notes from people I have studied with. All the graphs and diagrams I have redrawn myself. The quality is pretty variable and some topics are not covered in the detail required for the exams. This is because I find the process of making notes far more useful than having them. Early on I started writing prose paragraphs, but most of the material is in outline format. There’s probably not much point in trying to give advice about studying for these exams; depending on how your assessments at school were performed, the Primary exam is between the 15th and 30th set of exams you will sit so you probably have a fair idea of how to study. The significant difference is that for many registrars it is the first time they will fail an exam. So how did I study? I started reading the parts of the texts I found interesting about 18 months before I sat the Primary. I was working as a psychiatric resident so I had plenty of time. I prepared notes on a few of the less important topics to get warmed up before tackling the major physiology topics (respiratory and cardiovascular) in detail. I was part of a study group of five from about eight months before the exam. We met once a week for four or five hours. We started by choosing major topics from the red book, splitting up the objectives on that topic between us and each preparing notes to present and share at the weekly session. Later we started going through an old written paper, sharing out the questions between us and each preparing a marking scheme or “model answer” to our questions so that if we did the other questions as timed exam practice we got a marking scheme to assess our answers with. The last couple of sessions we did previous exams strictly to time. Study for the Fellowship was similar except that we had to go though the MCQ bank as well. We went through it twice, the second time focussing on the new questions from the previous exam and also the marker questions. The syllabus wasn’t as clearly defined as for the Primary, so the notes are correspondingly somewhat haphazard in their coverage. Can you have the notes in electronic format? The answer is yes and no. They are all ClarisWorks/AppleWorks files on my Mac but they don’t export well as Word or HTML (or anything else except EPS) without a lot of tweaking. If I get around to making them into PDFs then I’ll let you have a copy. James. [email protected] April 2000. Texts used Primary Pharmacology Wood & Wood Stoelting: Pharmacology and Physiology in Anaesthetic Practice Katzung: Pharmacology Rang, Dale & Ritter: Pharmacology Cass: Pharmacology for Anaesthetists Statistics Miller: Anaesthesia Physiology Guyton: Textbook of Medical Physiology Ganong: Physiology Despopoulos: Color Atlas of Physiology Berne & Levy: Cardiovascular Physiology Vander: Renal Physiology West: Respiratory Physiology Nunn: Applied Respiratory Physiology Brandis: The Physiology Viva Physics & Measurement Davis, Parbrook & Kenny: Basic Physics and Measurement in Anaesthesia Miller: Anaesthesia Fellowship Practice of anaesthesia Miller: Anaesthesia Clinical Anaesthesia Procedures of the Mass. General Brown: Regional Anaesthesia Cousins & Bridenbaugh: Neural Blockade Shnider & Levinson: Anaesthesia for Obstetrics Lippincott-Raven Interactive Anaesthesia Library on CD-ROM ATLS Handbook ANZCA Policy Documents Australian Anaesthesia Biennial Anatomy Black & Chambers: Essential Anatomy for Anaesthesia Equipment Rosewarne: Anaesthetic Equipment Russell: Equipment for Anaesthesia and Intensive Care Supplemental (used for occasional reference) Oh: Intensive Care Manual Stryer: Biochemistry Harrison’s Principles of Internal Medicine Souhami & Moxham: Medicine Gray’s Anatomy RCPA Manual of Pathology Tests MIMS Annual NHMRC and AHA websites The main anaesthetic journals Lots of other books left over from undergraduate medicine A. Cellular Physiology a. Describe the cell membrane and its properties. b. Describe the functions of mitochondria, endoplasmic reticulum and other organelles. Plasma membrane semipermeable lipid bilayer 7.5 nm thick phospholipids, cholesterol proteins structural pumps active ion/molecule transport channels receptors clathrins cluster to endocytose bound ligands insulin & other peptides, lipoproteins, viruses enzymes intercellular connections tight junctions desmosomes belt with bands of filaments containing actin spot central stratum of filaments hemi- epithelial cell to connective tissue gap junctions connexons allow molecules up to 800 d to pass rise in Ca2+ closes Cytoplasm Golgi complex vesicles → secretory granules Endoplasmic reticulum (rough and smooth) RNA → protein transcription in ribosomes glycosylation of proteins formation of vesicles and lysosomes Lipid droplets Lysosomes merge with (auto-)phagocytic vacuoles and release ribonuclease, deoxy~, phosphatase, glycosidases, arylsulfatases, collagenase, cathespins release of enzymes into the cell causes damage in vit A toxicity, ?gout enzyme defects cause lysosomal storage disorders Mitochondria separate DNA (female lineage) outer and inner membrane with cristae operate the citric acid cycle “cellular respiration” → ATP Secretory granules Centrioles 2 cylinders and right angles near nucleus made of 9x3 microtubules form the mitotic spindle in cell division Microfilaments long fibres of actin 4-6 nm diameter operate microvilli and attach to belt desmosomes Microtubules 25 nm diameter tubules made of α and ß tubulin (5 nm thick) maintain cell shape, constantly form and disassemble Cilia Cellular metabolism 1.A.1 James Mitchell (November 5, 2001) contain 9x2 +2 microtubules and basal granule of 9x3 microtubules Nucleus Chromosomes 2x22 + sex chomosomes composed of DNA (2.5x109 base pairs), histones contain genes, promoters, enhancers, junk Nucleolus site of RNA synthesis by transcription Envelope with perinuclear cisterns very permeable to allow RNA out c. Explain mechanisms of transport of substances across cell membranes. Diffusion rate determined by (Fick’s Law) chemical gradient electrical gradient cross-sectional area of boundary thickness of boundary Donnan Effect non-diffusible ions affect diffusion of other ions. ratio of diffusible cations between compartments equals inverse ratio of diffusible anions. Solvent drag unimportant effect. Solvent bulk flow carries solute. Filtration rate determined by pressure gradient surface area of boundary permeability of boundary Osmosis solvent molecules cross a membrane to a region of higher activity of a non-diffusible solute. P=nRT/V Carrier-mediated transport facilitated diffusion transport usually of large, non-ionized molecules down a concentration/electrical gradient across the cell membrane via membrane proteins. e.g. glucose uptake active transport transport of molecules or ions against of concentration or electrical
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