Critical Care Flashcards
What are the contrindications for surgery?
- Assess general health
- Stage IIIb or IV (i.e. metastases present)
- FEV1 < 1.5 litres is considered a general cut-off point*
- Malignant pleural effusion
- Tumour near hilum
- Vocal cord paralysis
- SVC obstruction
What are some examples of a muscle relaxant?
- Suxamethonium - best for RSI
- Vecuronium - slow and not used for RSI
What drugs are used for induction of anaesthesia?
- Ketamine
- Nitrous oxide
- Propofol
How does a depolarising neuromuscular drug like suxamethonium work?
Nicotinic acetylcholine agonist
What are the adverse effects of suxamethonium?
- Malignant hyperthermia
- Hyperkalaemia
What drug is important to prescribe before surgery for a patient taking steroids?
Hydrocortisone
What is the best induction agent for haemodynamically unstable patients?
Katamine
What is the most common bacteria for infecting post op wounds?
Staph aureus
What does an isoalted fever within 24 hours of operation mean?
Physiologocal reaction to operation
How long before surgery does the oral contraceptive pill need to be stopped?
4 weeks
What can a new onset AF mean after a gastrointestinal surgery?
Anastomotic leak
WHAT ARE THE MOST LIKELY CAUSES OF POST-OP PYREXIA (0-5 DAYS)
- Blood transfusion
- Cellulitis
- Urinary tract infection
- Physiological systemic inflammatory reaction (usually within a day following the operation)
- Pulmonary atelectasis - this if often listed but the evidence base to support this link is limited
What are the most likely caues of post-operative pyrexia (>5 days)?
- Venous thromboembolism
- Pneumonia
- Wound infection
- Anastomotic leak
What is the antidote to benzodiazepines?
Flumanzenil
What are the general rule of thumb for patients taking diabetic medication and surgery?
- Patients treated with insulin who have good glycaemic control (HbA1c < 69 mmol/mol) and are undergoing minor procedures, can be managed during the operative period by adjustment of their usual insulin regimen
- (Surgery requiring a long fasting period of more than one missed meal) or whose diabetes is poorly controlled, will usually require a variable rate intravenous insulin infusion (VRIII)
- Most patients taking only oral antidiabetic drugs may be managed by manipulating medication on the day of surgery, depending on the particular drug. There are some exceptions to this:
- if more than one meal is to be missed
- patients with poor glycaemic control
- risk of renal injury (e.g. low eGFR, contrast being used)
- in such cases a VRIII should be used
What is first line for patients with low urine after an operation?
500ml 0.9% normal saline fluid challenge
What can cause excessive bleeding in surgery?
Intra-operative hypothermia
What is the antidote to local anesthetic?
Lipid emulsion
What is the prefered method of feeding for a comatose, intubated patient?
NG tube
Which vein is total parenteral nutrition delivered through?
Subclavian line
What should warfarin be changed to pre-operatively?
LMWH
What is the treatment of malignant hyperthermia?
Dantrolene
What is a tracheostomy useful for?
Long term weaning
Which part of the colon is removed in a right hemi-colectomy?
Ceacum
Where should you not canculate a diabetic patient?
The foot
WHAT ARE THE DIFFERENT SIZES OF CANNULAS?
When is levothyroxine ok to take before surgery?
Before and the day of
When are beta blockers safe to take before surgery?
Before and the day of surgery
When are calcium channel blcokers safe to take before surgery?
Before and the day of
Which surgery requires prophylactic antibitoics?
Appendicectomy
WHAT IS A BROAD RULE OF THUMB FOR ASSESSING PATIENTS WITH A POSTOPERATIVE FEVER?
Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
Any time: Drugs, transfusion reactions, sepsis, line contamination.
Which induction agent has good anti-emetic properties?
Profofol
What is a side effect of suxamethonium?
Increases intra-occular pressure
What adjunct can you not use when you see clear fluid leaking out of one nostril?
What doees this indicate?
Nasopharyngeal airway
Basal skull fracture
What prep is needed for a colonoscopy?
Laxatives taken the day before
What are the three phases of an operation?
- Before the induction of anaesthesia (sign in)
- Before the incision of the skin (time out)
- Before the patient leaves the operating room (sign out)
What does the % mean on solution?
1g is dissolved in 100ml
How does lidocaine work?
Blocks sodium channels disrupting the action potential
What do you do if a patient is still suffering from hoarse voice 3 days after thyroid surgery?
Laryngoscopy
What is the complication of excessive sodium chlroide?
Hypercholraemic acidosis
What do you clean a surgical wound up to 48 hours after surgery?
Sterline saline
When should you use tap water for cleaning a wound?
If wound has opened
When can a patient start showering after surgery?
48 hours
What is the protocol for these surgeries for ordering blood products?
Laproscopic cholecystectomy
Total gastrectomy
Elective lower segment caesarean section
Laproscopic cholecystectomy - Group and save
Total gastrectomy - Cross-match 2-6 units depending on local protocols
Elective lower segment caesarean section - Group and save
WHAT IS A POSTOPERATIVE ILEUS?
Postoperative ileus (sometimes referred to as paralytic ileus) is a common complication after surgery involving the bowel, especially surgeries involving extensive handling of the bowel. There is reduced bowel peristalsis resulting in pseudo-obstruction.
What are the features of a postoperative ileus?
- abdominal distention/bloating
- abdominal pain
- nausea/vomiting
- inability to pass flatus
- inability to tolerate an oral diet
What is an important investigation for a postoperative ileus?
Deranged electrolytes can contribute to the development of postoperative ileus, so it is important to check potassium, magnesium and phosphate.
What is the management for postoperative ileus?
- nil-by-mouth initially, may progress to small sips of clear fluids
- nasogastric tube if vomiting
- IV fludis to maintain normovolaemia
- additives to correct any electrolyte disturbances
- total parenteral nutrition
- occasionally required for prolonged/severe cases
What is the general rule for changing insulin the day of surgery?
Reduce by 20%
What are the different ordering of blood products for surgery?
Where is IO most commonly performed?
Proximal tibia
When should nitrous oxide be used with caution?
In patients with a pneumothorax
What are the rules for sufonylureas with surgery?
Omit on day of surgery
Can take afternoon dose if BD
How can you diagnose an anastomotic leak?
Abdo CT
Which class of medications slow bone healing?
NSAIDs
What airway adjunct can be used in a low GCS before intubation is done?
Oropharyngeal airway
