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Year 3 - Surgery > Care Of The Surgical Patient > Flashcards

Care Of The Surgical Patient Flashcards

1
Q

What is suspended in human plasma?

A

Human plasma (55%)

  1. RBCs (45%)
  2. Buffy coat (1%)
    • WBCs
    • Platelets
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2
Q

Four blood transfusion components?

A

Whole blood donation

  1. RBCs
    • Severe anaemia from trauma or surgery
    • 42 days in fridge
    • 10 years in freezer
  2. Fresh frozen plasma
    • Coagulation deficiency correction
    • Plasma loss from burns or bleeding
    • 1 year in freezer
  3. Concentrate of platelets
    • Low platelet levels or functional problems
    • 5 days at room temperature
  4. Cryoprecipitate
    • Fibrinogen deficiency
    • 1 year in freezer
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3
Q

Red cell transfusion

  1. Indication
  2. Dose
A

RBCs

  1. Increase O2
    Replace blood loss
  2. One unit for a 10g/L Hb increase in a 70kg patient
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4
Q

Platelet Transfusion

  1. Indication
  2. Dose
A

Platelets

  1. Prophylaxis in thrombocytopenia
  2. One therapeutic dose can increase count by 20x10^9/L
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5
Q
  1. FFP
    • Indication and dose
  2. Cryoprecipitate
    • Indication and dose
A
  1. Fresh Frozen Plasma (10-15ml/kg)
    • Clotting factors
    • Coagulation factor deficiencies
    • DIC and massive haemorrhage
  2. Cryoprecipitate (10 units/ 2 pools for adult)
    • Clinically significant bleeding
    • Fibrinogen below 1.5g/l
    • Fibrinogen and factor VIII
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6
Q

Which blood types contain A and/or B antibodies?

A

A antibodies - B blood or O Blood
B antibodies - A blood or O blood

No antibodies - AB blood

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7
Q

Pathophysiology of ABO never events

A
  1. Anti-A binds to A antigens or Anti-B to B antigens
  2. Agglutination
  3. Complement activation
  4. Cytokines, Haemolysis
  5. Shock, renal failure, DIC
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8
Q

How many Rhesus Antigens?

A
  1. There are 5 Rh antigens (C,c,D,E,e)
  2. Rhesus D is most important.
  3. If antigen present, D positive.
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9
Q

Alloantibodies significance

A
  1. Antibodies (not ABO) produced when exposed to different blood through transfusion or pregnancy
  2. Problem in multiple transfusions
    • Amount/frequency dependant
    • Immune response dependant
    • Immunogenicity (of antigens) dependant
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10
Q

Prevention of HDFN?

A

To prevent Haemolytic Disease of the Foetus and Newborn (HDFN)

  1. D negative or Kell negative girls and women should not be transfused with D or K positive red cells
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11
Q

Examples of Alloantibodies

A

Alloantibodies

  1. Duffy
  2. Kell
  3. Kidd
  4. Lewis
  5. Lutharen
  6. MNS
  7. P
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12
Q

Two ways of requesting blood

A
  1. Group and screen (checked including for antibodies)

2. Cross-match (can be electronic)

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13
Q

What blood can be given in emergency, and what are the risks?

A
  1. O negative

2. May have unknown alloantibodies

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14
Q

Points in transfusion process

A
  1. Decision to transfuse
  2. Request/prescreption
  3. Sampling
  4. Lab testing
  5. Collection from storage
  6. Administration
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15
Q

Blood sampling for transfusion

-	Good Practice (5 points)
A
  1. 1 historic blood group in the computer for the lab to issue components
  2. ID positively
  3. 3 points of ID
  4. Label at patient’s side (never pre-label)
  5. 15-30 minutes monitoring after transfusion
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16
Q

Acute Haemolytic Transfusion Reaction

- Symptoms

A

Acute haemolytic transfusion reaction

  1. Fever
  2. Dyspnoea
  3. Pain
    - Chest, abdo, flank, bck
  4. Hyptension
  5. Mucous membrane bleeding
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17
Q

Definition of consent?

A

Consent is:

A Precondition
1. Autonomous decision-making
2 Lawful medical treatment

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18
Q

Touching a patient without consent

- Commits:

A

Touching a patient without consent
- Commits:

  1. Tort
    • Wrongful act or civil wrong
    • Resulting in suffering/loss/harm
  2. Crime
    • Subject to criminal law
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19
Q

Treatment without consent

- What action can result?

A

Treatment without consent

  1. Action for battery or negligence (Tort)
  2. Action for battery or crime of assault
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20
Q

Consent

- Three legal requirements

A

Three legal requirements of consent:

  1. Given voluntarily (not coerced, overt or covert)
  2. Capacity to consent
  3. Understand the nature of the treatment
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21
Q

Montgomery

  1. What changed?
  2. When
A

Montgomery

  1. What changed?
    • Patients must be aware of material risks
    • Must be aware of reasonable alternatives
  2. When
    • 2015 (Lord Kerr and Lord Reed)
22
Q

Pre-op
- Drug management

  1. CHOW
  2. Anti-caogs
  3. AED
  4. Beta-blockers
A

Pre-op drug management

C. Clopidogrel
- Stop 7 days before surgery

H. Hypoglycaemics

  • Metformin and pioglitazone as normal
  • SU, DPPIV, GLP-1: omit on day of surgery
  • Start VRIII insulin if missed two meals
  • Continue long acting insulin
  • Stop short acting insulin on morning of surgery

O. OCP/HRT

  • Stop 4 weeks before
  • Start 2/52 later if mobile

W. Warfarin

  • Stop
  • Bridge LMWH 5 days till day before
  • Bridge LMWH after for 1 day
  1. Anti-coags
    - Balance risk of haemorrhage
    - Avoid epidural, spinal, regional
  2. Beta block as usual
  3. AED
    - Give as usual
    - IV or NG post-op
23
Q

Bowel prep

  1. Indication
  2. Drugs
A

Bowel prep

Indications

  1. Left sided ops
  2. Not usually in rigt sided
  3. Controversial
    - Dehydration & electrolytes
    - Liquid contents and leak

Drugs

  1. Picolax
    - Picosulfate and Mg Citrate
  2. Klean-Prep
    - Macrogol
24
Q

Prophylactic Abx

- Operative indications

A

Prophylactic Abx

  1. GI surgery
  2. Joint replacement
25
Q

Prophylactic ABx

- Operative Regimens

A

Prophylactic ABx regimens
- 15-60 minutes before surgery

GI (eg. broad spec.)

  1. Biliary
    - IV Cef + Met
  2. CR or Appendicectomy
    - Cef + Met TDS
  3. Vascular (eg. Strep)
    - IV Co-amox TDS
  4. MRSA
    - Vanc
26
Q

ASA Grades

A

ASA

  1. Normally healthy
  2. Mild systemic disease
  3. Severe and limits activity
  4. Systemic, threatening life
  5. Moribund (24h)
27
Q

Pre-op assessment

- Insulin

A

Pre-op insulin

  1. Long acting
    - Stop night before
  2. AM insulin
    - stop if morning surgery
28
Q

Insulin

- Sliding scale

A

VRIII

  1. Aim for 7-11mM
    - Hourly CPG
  2. 5% dex, 20mmol KCL
  3. 50units Actrapid
29
Q

Insulin

- Post-op

A

Post-op insulin

  1. Stop when tolerating food
  2. SC regimen around meals
30
Q

Non-ID-DM

- Pre-op Insulin

A

Non-ID-DM

  1. If CBG>10mM treat as ID-DM
    - Omit morning drugs
  2. Resume oral drugs with meals post-op
31
Q

Pre-op assessment

- Steroid dependent

A

Steroids and surgery

  1. Increase steroid for stress
  2. Major surgery
    - IV Hydrocortisone 3/7
  3. Minor surgery
    - Hydrocortisone for 24 hrs
32
Q

Pre-op assessment

- Jaundice

A

Pre-op jaundice

  1. ERCP
  2. Risk renal failure
  3. Risk cholangitis
  4. Avoid morphine pre-med
  5. Clotting
    - Check
    - Consider vit K
  6. Cef+Met
33
Q

Pre-op

- Antithrombotic drugs

A

Pre-op antithrombotics

1. Continue aspirin/clopidogrel  - Stop 7 days if high risk
  1. Stop warfarin and check INR
34
Q

Pre-op Warfarin

- High VTE Risk

A

Pre-op warfarin VTE risk

  1. Stop warfarin 5d pre-op
  2. Bridging LMWH
  3. Stop LMWH 12-18 pre-op
  4. Restart LMWH 6h post op
  5. Restart warfarin D2
  6. Stop LMWH
    - When INR >2
35
Q

Emergency surgery

- Warfarin

A

Emergency surgery warfarin

  1. Stop warfarin
  2. Vit K
    - Slow IV
  3. FFP or PCC cover
36
Q

Post-op pyrexia

- Classifications

A

Post-op pyrexia

  1. Early
    - 0-5 days
  2. Delayed
    - 5+ days
37
Q

Post-op pyrexia

- Early causes

A

Early post-op pyrexia

  1. Transfusion/drug reaction
  2. SIRS to trauma
  3. Atelectasis
  4. Infections
    - UTI
    - Thrombophlebitis
    - Cellulitis
38
Q

Post-op pyrexia

- Delayed causes

A

Delayed post-op pyrexia

  1. Pneumonia
  2. VTE
  3. Wound infection
  4. Leak
  5. Collection
39
Q

Post-op pneumonia

- Mx

A

Post-op pneumonia mx

  1. Analgesia
  2. Physio + Cough
  3. ABx
40
Q

Post-op collection

- Mx

A

Post-op collection mx

  1. ABx
  2. Drainage
  3. Washout
41
Q

Post-op collection

- Locations

A

Post-op collections

  1. Pelvic
  2. Paracolic
  3. Small bowel
    - Interloop spaces
  4. Subphrenic
  5. Lesser sac
  6. Hepatorenal recess
    - Morrison’s space
42
Q

Post-op cellulitis

- Mx

A

Post-op cellulitis mx

  1. IV Benpen
    - Strep
  2. PO Pen V + Fluclox
    - Staph
43
Q

DVT

- Mx

A

DVT mx

  1. DOAC
    - Three months

OR

  1. Warfarin
    - Five day LMWH bridge

AND

  1. Stockings
44
Q

Post-op assessment

- Urinary retention

A

Post-op retention

  1. Fluid status
  2. Palpable bladder
  3. Drips/drains/stomas/CVP
  4. 50mo NS and aspiration
  5. Fluid challenge
45
Q

Post-op Hypotension

- CHOD causes

A

Post op HTN CHOD

C ardiogenic

  • MI
  • Overload

H ypovolaemia

  • Inadequate fluids
  • Haemorrhage

O bstructive
- PE

D istributive

  • Sepsis
  • Neurogenic
46
Q

Delirium Causes

- Delirium

A

Delirium

D rugs
E yes, ears, sensory
L ow O2
I nfection
R etention
I ctal
U nder-hydration
M etabolic
47
Q

Fluid balance

- Average insensible

A

Fluid balance

- 700-800 insensibles

48
Q

TPN

- Macro requirements (1,2,3,4)

A

TPN /kg/24h

1g Protein
2g Carbs 
3g Fat
40 Kcal (20+)
0.4g Nitrogen (0.2+)
49
Q

TPN

- Delivery

A

TPN Deliver

ST
1. CV catheter

LT
2 . Hickman
3. PICC

50
Q

Refeeding

- Electrolyte derangements

A

Refeeding syndrome change

  1. Potassium low
  2. Magnesium low
  3. Phosphate low
51
Q

Refeeding syndrome

- Mx

A

Refeeding syndrome mx

PO4 supplements

  1. Parenteral
  2. PO
52
Q

C-Spine

- NEXUS

A

C-Spine Nexus

  1. No neck pain
  2. No head injury
  3. No distracting injury
  4. No abnormal neurology
  5. Alert and oriented
  6. No drugs or alcohol

Year 3 - Surgery (7 decks)

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