Anaesthesia - Short Cases Flashcards
Case scenario - Post-op Puking
Mrs Pugh is a 34 yo lady admitted to hospital on the day of surgery for a mastoidectomy. She has a cholesteatoma. She is otherwise healthy and only complains of motion sickness in cars and boats. She is a non-smoker and has never had surgery before.
- What patient factors increase the risk for PONV?
- What types of surgical procedures have a higher risk of PONV? (8)
Patient risk factors for PONV are:
1. Young age
2. Female
3. Non-smoking
4. History of previous PONV or motion sickness.
As a rough guide, the baseline incidence of PONV for patients with no risk factors is 10%, 20% if one risk factor, 40% if two, 60% if three and 80% if four.
Case Scenario - Post-Op Puking
Mrs Pugh is a 34 yo lady admitted to hospital on the day of surgery for a mastoidectomy. She has a cholesteatoma. She is otherwise healthy and only complains of motion sickness in cars and boats. She is a non-smoker and has never had surgery before.
- What can the anaesthetist do intra-operatively to reduce the risk of PONV? (7)
- What 5 therapies post-operatively are of benefit for patients who return to the ward with PONV?
Intra-operative methods employed by the anaesthetist to reduce PONV are:
1. Use of regional anaesthesia
2. Use of propofol for induction and maintenance of anaesthesia
3. Use of intraoperative supplemental oxygen (>70%)
4. Use of good hydration
5. Avoidance of nitrous oxide
6. Minimization of intraoperative and postoperative opioids
7. Avoidance of neostigmine when possible
- What will you tell her to do tonight and tomorrow morning with regards to her diabetic medications and fasting. If she was 1st on the afternoon list, (1.30pm start), what would your instructions be then?
- How will you control her blood sugars intraoperatively and in the early post-operative period
1st on morning list: eat normally today and take all regular medications tonight. No eating after midnight and withhold morning metformin and mixtard. Take other morning medications with a sip of water unless otherwise instructed.
1st on afternoon list: eat normally today and take all regular medications tonight. Have a light breakfast before 7am tomorrow morning. Take morning metformin and half of the usual mixtard dose as well as usual morning medications unless otherwise instructed and then fast from 7am. If in the rare chance she feels hypoglycaemic or has a recorded low blood sugar during the morning, drink a glass of clear sugar containing fluid, eg lemonade, apple/orange juice.
- What will you do with her metformin? Are there any concerns to metformin use in major surgery?
- 3 days post-operatively she begins to eat again, what will you do then for glucose control?
