Care of The Surgical Patient Flashcards
1
Q
How long should clopidogrel be stopped before surgery?
A
7 days
2
Q
When should warfarin be stopped before surgery?
A
5 days
3
Q
Advice to patients with medically managed T2DM on day of surgery?
A
Omit morning dose of gliclazide, take metformin as usual
4
Q
What are the basic tenants for ERAS (enhanced recovery after sugrery)?
A
Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
Pre-operative carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation
5
Q
What should be transfused to patients with massive haemorahge?
A
Blood products and clotting factors (fresh frozen plasma)
6
Q
When should platelets be tranfused?
A
Active bleeding and thrombocytopenia (platelets < 50)
7
Q
When might prothrombin complex concentrate be transfused?
A
Patients taking warfarin that are actively bleeding
8
Q
Risk factors for post op N&V?
A
Female History of motion sickness or previous PONV Non-smoker Use of postoperative opiates Younger age Use of volatile anaesthetics
9
Q
What is ondansetron?
A
5HT3 receptor antagonist
anti-emetic
10
Q
In what patients should ondansetron be avoided?
A
Prolonged QTc interval
11
Q
What is cyclizine?
A
Histamine (H1) receptor antagonist
12
Q
In which patients must cyclizine be used with caution?
A
Elderly
HF
13
Q
Where is CCK (choleystokinine) released from?
A
Duodenum
14
Q
What electrolyte disturbances may normal saline cause?
A
Hypernatermia
Metabolic acidosis due to Cl-
15
Q
Post up pyrexia- 5 ws?
A
Wind - days 1-2 (chest infx)
Water - days 3-5 (UTI)
Walking - days 4-6 (VTE)
Wound - days 5-7 (surgical site infection, intrabdominal collection)
Wounder about drugs - days 7+ (blood products, IV cannulas, analgesia)
16
Q
Common urinary problems post-surgery?
A
Urinary retention
UTI
AKI - cathterisation, surgery complications
17
Q
Respiratory surgical complications?
A
Atelectasis - airway obstruction due to bronchil secretions
Chest infection/pneumonia
PE
ARDS
18
Q
What are the major causes of death post-surgery?
A
DVT
VTE
19
Q
DVT investigation?
A
Doppler USS
20
Q
Most common sign of PE?
A
Tachycardia
21
Q
What is wound dehiscense?
A
Serious complication with mortality up to 30%
7-10 days post op
Steroid dressing covering whole wound
Analgesia
Early return to theatre for resuturing under GA
22
Q
Prevention of post-op complications?
A
Weight control Optimal nutritional status Correct anaemia Adeuqete post op analgesia Prophylactic abx Shorter operative times reduce incidence of ileus VTE prophylaxis Fluid balance Catheters (prevent retention or AKI)
23
Q
How can insufficient pain management cause respiratory complications?
A
Shallow breathing
Atelectisis, resp infection
24
Q
Common anesthetics?
A
Volatile liquid
Nitrous oxide
IV: propofol (good induction agent and has anti emetic affects)
25
Complications of GA?
```
Anaphylaxis
Aspiration pneumonitis
Peripheral nerve damage (lying still for long time)
Damage to teeth
Air embolisim
Mallignant hyperthermia
Pneumothorax
```
26
Post op complications that tend to be associated with family history?
Mallignant hyperthermia
27
Immediate complications post-op?
```
Primary haemorrhage
Reactionary haemorrhage
Basal atelectasis
Shock
Low UO
```
28
Early post-op complications?
```
Pain
Acute confusion
N+V
Fever
Secondary haemorrhage
Pneumonia
Wound or anastomoses dehistence
DVT
Acute urinary retention/UTI
Post op wound infection
Paralytic illeus
Bowel obstruction due to fibronous adhesions
```
29
PE anticoagulation?
Apixaban (DOAC) - not pregnant
| Enoxaparin (LMWH) - pregnant
30
Pain in compartment syndrome?
Out of proportion to the clinical picture
31
Why can reperfusion cause?
Cell death, potassium released from inside the cell
Reperfusion
Hyperkalemia
32
What complication is more common in laprocopic surgery than open?
Bradycardia (abdo full of gas, vasovagal stimulation)
33
What are the 7 P's forming the sequence of RSI?
```
Preperation
Peroxygenation
Pretreatment
Paralysis
Protection and positioning
Placement and proof
Post intubation management
```
34
What happens in the preparation phase of rapid sequence induction?
Ensuring the environment is optomised
Equipment is ready and available
Staff are ready
35
What happens in the pre-oxygenation phase of rapid sequence induction?
Administration of high flow oxygen 5 mins before the procedure
36
What happens in the pre-treatment phase of rapid sequence induction?
Administration of opiate analgesia
| Fluid bolus to counteract and hypotensive action of anesthesia
37
What happens in the paralysis phase of rapid sequence induction?
```
Induction agent (propofol, sodium thiopentone)
Paralysing agent (Suxamethonium or Rocuronium)
```
38
What happens in the protection and positioning phase of rapid sequence induction?
Circoid pressure should be applied to protect the airway following paralysis
In line stabalisation may be required
39
What happens in the placement and proof phase of rapid sequence induction?
Intubation performed via laryngoscopy with proof obtained (direct vision, end-tidal CO2, bilateral ascultation_
40
What happens in the post-intubation phase of rapid sequence induction?
Taping or tying of the endotracheal tube, initiating mechanical ventilation and sedating agents
41
What is the 'third space'
The “third space” refers to areas of the body that do not normally contain fluid and where fluid collection is not functional or desirable. This includes areas such as the:
```
Peritoneal cavity (forming ascites)
Pleural cavity (forming pleural effusions)
Pericardial cavity (forming a pericardial effusion)
Joints (forming joint effusions)
```
42
The extracellular space is 1/3 of total body fluids, which further spaces can it be subdivided into?
```
Intravascular space (inside blood vessels) – 20% of the extracellular fluid
Interstitial space – the functional tissue space between and around cells – 80% of the extracellular fluid
The “third space” – the “third” extracellular space
```
43
What is third spacing?
Third-spacing refers to fluid shifting into this non-functional third space. Often this refers to the development of oedema, as excessive fluid moves into the interstitial space. It also refers to the development of ascites, effusions or other non-functional fluid collections within the body. When fluid moves into a non-functional space, this may come at the expense of the intravascular space, resulting in hypotension and reduced perfusion of tissues.
44
What are insensible fluid losses?
Insensible fluid loss is a term that refers to fluid output that is difficult to measure, such as through respiration (breathed out), in stools, through burns and from sweat. This varies a lot and can only be estimated. It may account for a large volume (over 800mls per day) in patients with significant diarrhoea, high stoma output or sweating with a high fever.
45
Signs of hypovolemia?
```
Hypotension (systolic < 100 mmHg)
Tachycardia (heart rate > 90)
Capillary refill time > 2 seconds
Cold peripheries
Raised respiratory rate
Dry mucous membranes
Reduced skin turgor
Reduced urine output
Sunken eyes
Reduced body weight from baseline
Feeling thirsty
```
46
Signs of fluid overload?
```
Peripheral oedema (check the ankles and sacral area)
Pulmonary oedema (shortness of breath, reduced oxygen saturation, raised respiratory rate and bibasal crackles)
Raised JVP
Increased body weight from baseline (regular weights are an important way of monitoring fluid balance)
```
47
Indications for IV fluids?
Resuscitation (e.g., sepsis or hypotension)
Replacement (e.g., vomiting and diarrhoea)
Maintenance (e.g., nil by mouth due to bowel obstruction)
48
Why is fluid assesment in a patient with third-spacing deceptive?
Patients with third-spacing may have a low level of fluid in the intravascular space, but excessive fluid in other areas (such as the interstitial space or peritoneal cavity). This can give signs of hypovolaemia (e.g., hypotension, tachycardia and prolonged capillary refill time) and signs of fluid overload (e.g., oedema and ascites).
49
What is in a 1 litre bag of normal saline solution?
1 litre of water
154 mmol sodium (note that this is a lot of sodium, and lots of saline can result in hypernatraemia)
154 mmol chloride
50
Examples of crystalloids?
```
0.9% sodium chloride (“normal saline”)
5% dextrose
0.18% sodium chloride in 4% glucose
Hartmann’s solution
Plasma-Lyte 148
```
51
What does a 1L bag of 5% dextrose contain?
1 litre of water
No electrolytes (note that lots of hypotonic fluid can result in hyponatraemia and oedema)
50 g of glucose
52
What does a 1l bag of Hartmann's solution contain?
```
1 litre of water
131 mmol sodium
111 mmol chloride
5 mmol potassium
2 mmol calcium
29 mmol lactate (helps to buffer the solution – reducing the risk of acidosis)
```
53
Example of when a colloid might be used?
Human albumin solution in decompensated liver disease (patients with ascitic drains) that help correct reduced oncotic pressure in the intravascular space secondary to inadequete albumin production by the liver
54
NICE guidelines on the approximate requirements of IV maintenance fluids?
25 – 30 ml / kg / day of water
1 mmol / kg / day of sodium, potassium and chloride
50 – 100 g / day of glucose (this is to prevent ketosis, not to meet their nutritional needs)
55
What type of transfusion carries the greatest risk of transfusion related lung injury (pulmonary infiltrates seen on CXR)
The risk of transfusion associated lung injury is greatest with plasma components.
56
What is ASA grade I?
ASA I grading is given to a healthy patient who does not smoke or drink with a BMI < 30kg/m².
57
What is ASA grade III?
ASA III grading is given to a patient with severe systemic diseases such as poorly controlled diabetes, hypertension, chronic obstructive pulmonary disease, or morbid obesity (BMI > 40kg/m²).
58
What is ASA grade IV?
ASA IV grading refers to a severe systemic disease that is a constant threat to life including ongoing cardiac ischaemia or recent myocardial infarction, sepsis and end-stage renal disease.
59
What is ASA grade V?
ASA V grading refers to a moribund patient who is not expected to survive without the operation including a major trauma patient or significant haemorrhage/bleeding.
60
What is ASA II?
Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension, mild lung disease
61
What is ASA VI?
A declared brain-dead patient whose organs are being removed for donor purposes
62
When does delayed transfusion reaction occur?
Complications of transfusions that are classified as "delayed" occur days to weeks following the transfusion event
63
How might a patient with transfusion associated circulatory overload appear?
In hours after the transfusion, become increasingly short of breath and develop an oxygen requirement to maintain saturations
64
What is mallignant hyperthermia?
condition often seen following administration of anaesthetic agents
characterised by hyperpyrexia and muscle rigidity
cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion
neuroleptic malignant syndrome may have a similar aetiology
65
What is the management of mallignant hyperthermia?
dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum
66
Surgery / sulfonylureas on day of surgery?
omit on the day of surgery
| exception is morning surgery in patients who take BD - they can have the afternoon dose
67
What is Pseudocholinesterase deficiency (also known as suxamethonium apnoea)?
Pseudocholinesterase deficiency (also known as suxamethonium apnoea) is a rare abnormality in the production of plasma cholinesterases. This leads to an increased duration of action of muscle relaxants used in anaesthesia, such as suxamethonium. Respiratory arrest is inevitable unless the patient can be mechanically ventilated safely while waiting for the circulating muscle relaxants to degrade.
68
Warfarin reversal in major bleeding?
Major bleeding - stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
69
How should MRSA +tive pts (colonisation not infection) be managed before surgery?
Nasal mupirocin + chlorhexidine for the skin
70
Management of post-op illeus?
NBM
Daily bloods
encourage mobilisation reduce opiod analgesia
