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Year 3 - Surgery > 8.02 - Post-Operative Care > Flashcards

8.02 - Post-Operative Care Flashcards

1
Q

How can pain be clinically assessed?

A

Subjectively: ask the patient to grade their pain on a scale of mild, moderate or severe.

Objectively: clinical features of pain include tachycardia, tachypnoea, hypertension, sweating and flushing.

Each patient should be assessed when mobile, taking a deep breath and when in bed.

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2
Q

What ar e the consequences of poor pain control?

A

Slower recovery - patients with poorly controlled pain are reluctant to mobilise, in turn resulting in slower restoration of function and rehabilitation capacity.

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3
Q

What is the WHO analgesic ladder?

A

A method for approaching pain-relief, providing a strategy for titrating analgesia to treat pain.

  1. Simple analgesia
  2. Weak opiates
  3. Strong opiates

As patients recover, it is important to move down the ladder to wean down the analgesia.

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4
Q

Give some examples of simple analgesics.

A
  • paracetamol
  • NSAIDs (e.g. ibuprofen / diclofenac)

NSAIDs work by inhibiting the synthesis of prostaglandins, reducing the inflammatory response causing the pain. They are frequently used intra-operatively and to treat musculoskeletal pain.

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5
Q

Give the adverse effects of NSAIDs.

HINT: I-GRAB

A
  • interactions with other medications
  • gastric ulceration (consider adding PPI)
  • renal impairment
  • asthma sensitivity (triggers 10% of individuals with asthma)
  • bleeding risk (effects platelet function)
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6
Q

Give some examples of

a) weak opiates

b) strong opiates

A

a) codeine

b) morphine, oxycodone, fentanyl

Opiates activate opioid receptors, which are distributed throughout the central nervous system.

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7
Q

Give the adverse effects of opiates.

A
  • constipation
  • nausea
  • sedation / confusion
  • respiratory depression
  • tolerance
  • dependence
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8
Q

Give the advantages and disadvantages of patient controlled analgesia.

A

PCA involves the use of intravenous pumps that provide a bolus dose of an analgesic when the patient presses a button. These are either started in theatre or on the wards, when the use of strong oral opiates is inadequate.

They can be titrated to give background infusions of analgesia if needed and the analgesic agent used can also vary (e.g. opiates, local anaesthesia).

See the image attached for pros and cons.

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9
Q

What is neuropathic pain?

A

Pain that results from irritation or injury directly to the nerves, presenting with shooting or stabbing pains.

Following surgery, the prevalence of neuropathic pain is as high as 10%, frequently encountered in orthopaedic or vascular surgery.

The WHO ladder (ie. NSAIDs and opiates) will not relieve neuropathic pain.

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10
Q

How is neuropathic pain managed?

A

NSAIDs and opiates will not relieve neuropathic pain, therefore alternative pharmacological therapies should be commenced.

For example:
- gabapentin
- amitriptyline
- pregabalin

Non-pharmacological treatment includes cognitive behavioural therapy, transcutaneous electric nerve stimulation (TENS), or capsaicin cream (typically for localised pain).

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11
Q

In order to diagnose sepsis, what is needed?

A
  • presence of a known or suspected infection
  • clinical features of organ dysfunction (SOFA score ≥2)
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12
Q

What is the qSOFA score?

A

A shortened version of the full SOFA criteria, designed to allow for the rapid assessment of potential sepsis.

  • respiratory rate ≥22/min
  • altered mental state
  • systolic blood pressure ≤100mmHg

Any patient with a known or suspected infection and a qSOFA ≥2 should be investigated and managed for sepsis as necessary.

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13
Q

Outline how sepsis should be investigated and managed.

A

Sepsis 6:

  1. Oxygen
  2. IV fluid therapy
  3. Blood cultures
  4. IV antibiotics
  5. Routine bloods, including lactate
  6. Monitor urine output

Ensure seniors are involved early in the care of septic patients; ask nursing staff to take hourly observations and to inform you if there is any deterioration of the patient.

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14
Q

What investigations should be taken to identify the source of infection in a septic patient?

A
  • urine dip +/- culture
  • CXR
  • swabs (e.g. surgical wounds)
  • operative site assessment (CT or USS)
  • cerebrospinal fluid sample (via LP)
  • stool culture
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15
Q

When should involvement of intensive care be considered when managing a septic patient?

A
  • evidence of septic shock
  • lactate > 4.0mmol
  • failure to improve from initial management
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16
Q

What is septic shock?

A

Defined as sepsis with hypotension, despite adequate fluid resuscitation, or requiring the use of inotropic agents to maintain a normal systolic blood pressure.

17
Q

What are the common causes of pyrexia in a surgical patient?

HINT: Seven C’s:

A
  • chest (infection)
  • cut (wound infection)
  • catheter (UTI)
  • collections (abdomen, pelvis)
  • calves (DVT)
  • cannula (infection)
  • central line (infection)
18
Q

What is the most common cause of pyrexia in the post-operative patient on days:

a) 1-2

b) 3-5

c) 5-7

A

a) respiratory source (or the body’s physiological response to surgery)

b) urinary tract source

c) surgical site infection or abscess formation

Other causes of post-operative pyrexia include drug-induced reaction and VTE.

19
Q

What are the risk factors for post-operative nausea and vomiting (PONV)?

A
  • female gender
  • previous PONV
  • motion sickness
  • opioid analgesia
  • non-smoker
  • ear surgery
  • prolonged operative times
  • poor pain control
  • inraoperative dehydration
20
Q

Outline the roles of the chemoreceptor trigger zone and vomiting centre in the pathophysiology of PONV.

A

Chemoreceptor trigger zone is stimulated by dopamine, sending stimuli to the vomiting centre. The vomiting centre controls and coordinates the movements involved in vomiting, so if stimuli is sufficient then vomiting is initiated.

21
Q

How is a patient with PONV managed?

A
  • A-E assessment
  • adequate fluid hydration
  • adequate analgesia
  • pharmacological anti-emetics
22
Q

Define the main categories of haemorrhage that can occur in the surgical patient:

a) primary bleeding

b) reactive bleeding

c) secondary bleeding

A

a) bleeding that occurs within the intra-operative period

b) bleeding that occurs within 24 hours of the operation, commonly from a slipped ligature or missed vessel*.

c) bleeding that occurs 7-10 days post-operatively, commonly due to erosion of a vessel from a spreading infection.

*vessels can be missed intra-operatively due to intra-operative hypotension and vasoconstriction, meaning only once blood pressure normalises post-operatively will this bleeding occur.

23
Q

What are the clinical features of haemorrhagic shock?

A
  • tachycardia
  • diziness
  • agitation
  • tachypnoea
  • decreased urine output

Hypotension is often a late sign of haemorrhagic shock, occuring when the compensatory mechanisms are not sufficient.

24
Q

How should post-operative haemorrhage be managed?

A
  1. A-E assessment
  2. Direct pressure to the bleeding site
  3. Urgent blood transfusion if moderate to severe - may need to activate major haemorrhage protocol
  4. Ensure early senior involvement
25
Q

Define delirium.

A

An acute confusional sate, characterised by a disturbed consciousness and reduced cognitive function.

26
Q

Give the three main types of delirium.

A
  1. Hypoactive delirium (most common): lethargy and reduced motor activity.
  2. Hyperactive delirium (most recognised): agitation and increased motor activity.
  3. Mixed agitation: marked by fluctuations throughout the day.
27
Q

What are the risk factors for delirium?

A
  • age >65yrs
  • underlying dementia
  • renal impairment
  • male gender
  • sensory impairment
28
Q

What are the common causes of delirium?

A
  • hypoxia (post-operatively)
  • infection (UTI or LRTI)
  • drug-induced (benzodiazepines, diuretics, opioids)
  • drug withdrawal (alcohol, benzodiazepines)
  • dehydration
  • pain
  • constipation
  • urinary retention
  • electrolyte abnormalities
29
Q

How would you investigate a post-operative patient presenting with confusion?

A

Confusion screen:
- bloods (FBC, U&Es, Ca2+, TFTs, glucose)
- blood culture
- wound swabs
- urinalysis
- CXR

30
Q

How should delirium be managed?

A

Identify the cause of delirium and treat the cause.

Prevent worsening of delirium by encouraging oral fluid intake, providing adequate analgesia and monitoring bowel movements.

Sedatives should be used sparingly in any acutely confused patient - haloperidol (first line) and lorazepam (elderly) can be prescribed.

Year 3 - Surgery (30 decks)

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