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Interview Preparation > Clinical - Post-op Complications > Flashcards

Clinical - Post-op Complications Flashcards

1
Q

Initial treatment for acute MI

A
  • Morphine
  • Oxygen
  • Nitrates
  • Aspirin
  • Inform cardiology to plan for reperfusion
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2
Q

Risk factors for acute MI

A
  • Smoking
  • Hypercholesterolaemia
  • DM
  • HTN
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3
Q

What is a silent MI

A

Painless infarct, common in diabetics and the elderly

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4
Q

Complications of acute MI

A
  • Rhythm disorder
  • Heart failure
  • Circulatory failure
  • VTE
  • Pericarditis
  • Free wall rupture
  • Papillary muscle rupture
  • Dressler’s syndrome
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5
Q

Outline the approach to the unwell surgical patient

A
  • A-E
  • Focused history and examination
  • Chart review
  • Review of available results
  • Decide and plan
  • Stable = daily management plan
  • Unstable = definitive treatment and diagnosis
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6
Q

Outline the infective causes of post-op pyrexia by day

A
  • Any = line infection
  • 1-2 = respiratory source
  • 3-5 = respiratory or urinary source
  • 5-7 = surgical site infection or abscess/collection
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7
Q

Non-infective causes of post-op pyrexia

A
  • Iatrogenic = drugs
  • VTE
  • Prostehtic implantation
  • Physiological
  • Unknown origin
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8
Q

Describe why post-op patients get atelectasis

A
  • GA gases irritate the respiratory mucosa and increase mucous secretion
  • Muscle relaxants reduce post-op respiratory effort
  • Ventilation risks barotrauma and alveolar collapse
  • Laparoscopy splints diaphragm to reduce air entry at bases
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9
Q

Outline the SIRS criteria

A

Two or more of:

  • Pyrexia >38 or <36
  • Tachycardia >90
  • Tachypnoea >20
  • WBC >12 or <4
  • Acutely altered mental state
  • BM >6.6
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10
Q

What is the sepsis 6 and where is it derived?

A

Derived from the ‘surviving sepsis campaign’. It aims to improve survival rates by optimising treatment given in the first 6 hours.

  1. High flow O2
  2. Blood cultures
  3. Lactate
  4. IV antibiotics
  5. IV fluids
  6. Urine output
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11
Q

Define septic shock

A

Refractory hypotension in the presence of invasive infection

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12
Q

Define sepsis

A

SIRS + documented source of infection

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13
Q

Define severe sepsis

A

Sepsis + altered organ perfusion or dysfunction

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14
Q

How can you judge you have achieved adequate fluid resuscitation

A
  • CVP between 5-10cmH2O

- Urine output >30ml/hr

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15
Q

How would you approach a confused patient assessment?

A
  1. Work with the nurses to try verbal de-escalation techniques to move the patient to a safe place
  2. Perform clinical assessment using A-E structure to ensure the patient is stable
  3. Attempt to take a history. Assess her capacity and decide whether a formal MCA/DOLS is required
  4. Discuss with the nurses to establish whether this is new confusion.
  5. Review the medical notes, drug chart, anaesthetic chart to establish a potential cause
  6. Perform some basic bedside tests including BM and urine dip to exclude reversible causes
  7. Examine the patients for lines, catheters, etc. that could present a source of infection
  8. Take a blood panes
  9. Decide whether CXR is required
  10. D/W NOK
  11. D/W Registrar
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16
Q

Outline the KDIGO AKI criteria

A
  1. An abrupt reduction in kidney function with creatinine rise >26
  2. A percentage increase in creatinine >50%
  3. A reduction in urine output of <0.5ml/kg/hr for >6 hours
17
Q

What are the 5 golden rules of renal failure in a surgical patient

A
  1. Kidneys can’t function without adequate perfusion
  2. Renal perfusion is dependent on adequate blood pressure
  3. A surgical patient with poor urine output usually requires more fluid
  4. Absolute anuria is usually due to obstruction
  5. Poor urine output in a surgical patient is not a furosemide deficiency
18
Q

What are the common causes of renal failure? (structure this)

A
  1. Pre-renal: Hypovolaemia, sepsis, low CO
  2. Intrinsic: ATN, ischaemic injury, nephrotoxic injury, abdominal compartment syndrome, hepatorenal syndrome
  3. Post-renal: bladder outflow obstruction, bilateral ureteric obstruction
19
Q

What is Acute Tubular Necrosis?

A

Renal failure resulting from injury to the tubular epithelial cells, there are two types:

  1. Ischaemic injury - following any cause of shock resulting in a fall in renal perfusion
  2. Nephrotoxic injury - from drugs, toxins, myoglobin (from rhabdomyolysis)
20
Q

How can Pre-renal AKI be differentiated from ATN?

A
  • Pre-renal = the concentrating ability of the tubular system is retained, producing urine with high osmolarity, high urea, high creatinine, and low sodium
  • ATN = low osmolar urine with high sodium and low urea/creatinine
21
Q

How would you approach the assessment of a patient in AKI?

A
  1. I would adopt a CCrISP protocol and adopt an A-E approach
  2. I would treat any life threatening issues if they arose
  3. I would take a focused history focusing on potential causes of AKI including nephrotoxic drugs and look for symptoms of fluid overload such as PND
  4. I would perform a focused examination of their fluid status, abdomen, and catheter
  5. I would review the patients drug, observation, and fluid balance charts
  6. I would perform basic bedside tests including urine dip and ECG (if hyperkalaemic)
  7. I would take a blood panel
  8. I would arrange a renal USS
  9. I would arrange a CXR to exclude pulmonary oedema
  10. I would look for reversible causes and act urgently to:
    - Restore and maintain renal perfusion
    - Relieve any obstruction
    - Oxygenate the tubules
    - Remove/avoid toxins
    - Identify and treat underlying cause
  11. I would alert my SpR and the medical SpR if required
22
Q

List the reversible causes of post-op AF

A
  • Electrolyte abnormalities
  • Hypoxia - PE
  • Hypotension
  • Hypervolaemia
  • Infection
  • Severe anaemia
  • Hyperthyroidism
  • Pulmonary oedema
23
Q

List the risk factors for post-op AF (structure this)

A
  1. Patient factors:
    - Age
    - Male gender
    - Current smoker
    - ASA 3 or 4
    - CCF
    - COPD
    - IHD
    - Structural or valvular heart disease
    - DM
  2. Surgical factors:
    - Abdominal and vascular surgery
    - Intra-operative hypotension >10 minutes
24
Q

List the complications of AF

A
  • Stroke
  • TIA
  • Heart failure
  • Increased risk of mortality
25
Q

What is the most common cause of wound dehiscence?

A

Infection

26
Q

Risk factors for wound dehiscence (structure this)

A 
Pre-operative:
- Immunosuppression 
- Jaundice 
- Vitamin C deficiency 
- Malnutrition 
- Steroid use 
-  Previous surgery 
- DM 
- Smoking 
Intraoperative:
- Surgical technique 
- Increased bowel handling 
Postoperative:
- Chronic cough
27
Q

Signs of wound dehiscence

A
  • Pink fluid sign = produced by peritoneal exudate tinged with blood and is a precursor to complete dehiscence
  • Open wound, visible fat and fascia
28
Q

How would you manage wound dehiscence?

A 
Resuscitation:
1. IV access 
2. IVF
3. Analgesia 
Early Treatment:
1. Cover any exposed viscera with saline soaked dressings 
2. Give IV antibiotic cover
29
Q

How is wound dehiscence definitively managed?

A

Superficial:
- Continue regular wound lavage and dressings
- For large defects consider VAC therapy
Complete:
- Resuturing in theatre
- Laparostomy

30
Q

Risk factors for anastomotic leak

A 
Technique:
- Tension 
- Poor anatomical blood supply 
Local Factors:
- Obstruction 
- Ischaemia 
- Peritonitis 
Systemic:
- Shock 
- Age 
- Malnutrition 
- Immunosuppression
31
Q

How should anastomotic leak be definitively managed?

A
  • Collection showing localised leak = US-guided drainage
  • Major leak = re-operation with exteriorisation of suitable ends of small and large bowel (ITU and nutrition team should be involved)
32
Q

How would you manage a suspected intestinal fistula

A
  1. CCriSP protocol
  2. SNAP Protocol:
    - Sepsis = obtain adequate drainage
    - Nutrition = provide nutritional support
    - Anatomy = delineate using imaging (CT with contrast)
    - Procedure = ultimately aim for repair but delay until patient is well enough

Interview Preparation (9 decks)

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