Anaesthetics + Perioperative Care Flashcards
What ASA is a normal healthy patient?
ASA I
What ASA is a brain-dead patient?
ASA VI
What ASA is a patient who will likely die without surgical management?
ASA V
How does BMI differ between ASA II and III
II: >30
III: >40
A social drinker with tight diabetes control is an ASA?
II
How does MI history differ between ASA III and IV
>3 months = III
<3 months = IV
What ASA is someone with end stage renal disease?
Regular dialysis: III
no dialysis: IV
When should you avoid TED stockings
Peripheral artery or neuropathy
Fragile or allergy prone skin
Improper fit (deformity, oedema)
VTE prophylaxis in acutely ill, palliative, psychiatrically ill
LMWH
fondapirinux sodium if above contraindicated
VTE prophylaxis in renal impairment
LMWH or UFH
May need to reduce dose
VTE prophylaxis in a cancer patient
NOT ROUTINE IF MOBILE/RECEIVING THERAPY
If a myeloma patient was receiving -lidomides + steroids, what VTE prophylaxis would you give?
Aspirin 75 or 150mg
OR
LMWH
What post-op VTE regimens would you give for an elective hip?
10 days LMWH then aspirin 75/150mg for another 28 days
OR
LMWH 28 days + VTE stockings until discharge
OR
Rivaroxaban
Post-op VTE meds for elective knee
14 days 75/150mg aspirin
OR
14 days LMWH + VTE stockings until discharge
OR
Rivaroxaban
Post-op VTE meds for fractures of pelvis, hip and prox femur
Month long regimen of
LMWH from 6-12 hours post-op
Fondapirinux 6 hours post-op where there is low risk of bleeding
Which diabetic medication do you change THE DAY BEFORE surgery?
Once daily insulin
Reduce dose by 20%
On surgery day, what do you do
a) in the morning
b) in the afternoon
if the patient is on metformin?
For both
OD/BD: take normally
TDS: Omit lunchtime dose
On surgery day, what do you do
a) in the morning
b) in the afternoon
if the patient is on glicliazide
Morning
OD: omit
BD: omit morning dose
Afternoon
OD or BD: omit
On surgery day, what do you do
a) in the morning
b) in the afternoon
if the patient is on a -flozin?
Omit all on day of surgery
On surgery day, what do you do
a) in the morning
b) in the afternoon
if the patient is on lantus
Reduce dose by 20% for day before and of surgery
On surgery day, what do you do
a) in the morning
b) in the afternoon
if the patient is on novomix/humulin 3
Twice daily/biphasics
Half morning dose, don’t change evening dose
What two diabetic drugs are taken as normal the day before and of surgery?
- gliptins (DPPIV inhibitors)
- tides (GLP-1 analogues)
Patient gets a fever on day 1 post-op; what is the likely cause? how would you treat it?
Wind (1-2), water (3), wound (5), walking (5-7), wonder drug (7+)
Ateclasis
Sit upright, breathing exercises
Patient gets a fever day 7 post-op, what is the cause?
Wind (1-2), water (3), wound (5), walking (5-7), wonder drug (7+)
Patient gets a fever day 5 post-op, what is the likely cause?
Wind (1-2), water (3), wound (5), walking (5-7), wonder drug (7+)
What causes a fever day 6 post op?
Wind (1-2), water (3), wound (5), walking (5-7), wonder drug (7+)
DVT/PE
What causes a fever on post op day 3?
Wind (1-2), water (3), wound (5), walking (5-7), wonder drug (7+)
UTI
What action should be taken pre-op if the blood loss in surgery is
Unlikely
Likely
Definite
U: G+S
L: Cross match 2 units
D: 4-6 units
When should blood transfusion be given in patients normally and with ACS
normal: 70g/L or under
ACS: 80g/L or under
Patient with clinically significant (not haemorrhage) bleeding with APTT >1.5, what do you give?
FFP
150-220ml
Patient with clincially signficant bleeding with DIC with fibrinogen conc <1.5g/L
Fibrinogen <1.5g/L so cryoprecipitate
When can cryoprecipitate be given prophylactically?
Surgery with significant bleeding risk
fibrinogen <1/0g/L
What can be given to reverse severe bleeding or IC haemorrhage?
Prothormbin complex concentrate
When can TXA be useful in bleeding trauma?
Bolus then infusion within 3hours of bleeding
How do the IV anaesthetics work?
Most potentiate GABA-A inhibition
Ketamine blocks NMDA receptors
When is propofol to be used with caution?
Haemodynamic instability as causes hypotension
What side-effect of propofol can be useful post-op?
Anti-emesis for high risk patients
Which anaesthetics are useful in haemodynamic instability
KETAMINE
Etomidate also lesser hypotension than propofol/thiopental
Which anaesthetic agent causes adrenal suppression?
Etomidate
What anaesthetic casues hallucinations?
Ketamine
Which drugs can induce malignant hyperthermia?
Suxamethonium
Volatile anaesthetics
How is suxamethonium different from the other muscle relaxants?
Depolarising NM blocker
Causes MH, hyperkalaemia and AChase insufficiency
Cannot reverse with neostigmine
Order the following drugs’ duration time from shortest to longest
Suxamethonium
Atracurium
Vecuronium
Pancuronium
S
V
A
P
What airway methods are best for shorter procedures?
Oropharyngeal
Laryngeal mask
What airway method is good in reduced GCS? When can you not use it?
Nasopharyngeal
Basilar skull fractures
What is the downside of laryngeal masks/
Poor reflux control
What airway method is good for optimal control for long and short term ventialtion?
ET tube
Regarding lidocaine, what..
Circumstances is it cautioned?
Is used to treat it?
Low liver function or protein
20% lipid emulsion
Regarding surgical nutrion options, which
Have low aspiration risk?
Are useful in those who cant enterally feed?
Naso-gastric, Naso-jejunal and feeding jejunostomy
TPN
Aside from diabetc drugs, what drugs do you continue on the day of surgery?
B-blockers
Blood pressure meds
Diuertics for heart failure
When does the COC pill need to be stopped before surgery?
4-6 weeks prior
When does St. John/s wort and epehdra need to be stopped before surgery?
2 weeks prior
When does the clopidogrel need to be stopped before surgery?
7 days
When do DOACs (including treatment dose rivaroxiban) need to be stopped before surgery?
2 days
When does Lithium, ACEIs and rivaroxiban (non-treatment dose) need to be stopped before surgery?
Day before (rivaroxiban 18hrs)
When do K+ sparing drugs, metformin and gliciazide need to be stopped?
Morning of surgery
What is done for insulin dependents if they are going to miss >1 meal/eGFR <60 or use of contrast media
Sliding scale insulin from NBM start
