GA and surgery

Question 1

local anaesthetics

Answer 1

used to treat or prevent pain during or after procedure, simple and quick with fast recovery, pressure and movement still felt, injects/ creams/ gel, epidural or spinal, peripheral nerve block

Question 2

how does local anaesthetic work

Answer 2

they work by entering the cell binding to the Na+ channel, preventing Na+ transport and thus stopping the conductance through the nerve and preventing the transmission of pain signal to the brain

Question 3

GA

Answer 3

purpose is to create a loss of awareness and temporary block in gross response to stimuli. It inhibits skeletal muscle contraction and autonomic responses, components= coma and muscle relaxations and analgesia

Question 4

stages of GA- 1 and 2

Answer 4

1- premedication- provides decreased anxiety, helps with pain relief/ sedation and amnesia, less common
2- induction- IV propofol, +/- sevoflurane and +/- intubation

Question 5

stages of GA- 3 and 4

Answer 5

3- maintenance- when surgery starts, continuation of anaesthetic, IV analgesics and muscle relaxants
4- reversal- begins before the surgery has finished with the reduction in the anaesthetic drugs and reversal of paralysis with neostigmine

Question 6

effect of GA on respiratory system

Answer 6

GA has a detrimental effect on respiratory function, FRC lowered which encroaches on CV and reduces lung compliance, increases airway resistance and leads to atelectasis, dependent lung collapse within 15 mins of induction, risk of absorption atelectasis, inhalation of dry/cold gas increase mucous viscosity and affects surfactant production, impaired CNS regulation of breathing leading to hypoventilation+supine position= atelectasis, handling pleura has negative effect on diaphragm function

Question 7

other GA complications

Answer 7

decreased CO, nausea and vomiting, urine retention and constipation, anaphylaxis, MI and CVA, awareness during anaesthesia

Question 8

common surgery seen in cardiorespiratory physio

Answer 8

general, thoracic, cardiac, vascular, head and neck, breast

Question 9

cardiorespiratory complications of surgery- atelectasis

Answer 9

pain, position (effects FRC), drowsiness- immobile- reduced depth of breathing and FRC, disruption of diaphragm, pleural effusion, higher effect on upper abdominal and thoracic surgery, atelectasis leads to more atelectasis

Question 10

cardiorespiratory complications of surgery- hypoxaemia and chest infection

Answer 10

hypoxaemia- decreased hypoxic vasoconstriction because of anaesthetic gases, atelectasis, oxygen hungry= REM stage of sleep affect- oxygen saturation drops especially at night
chest infection- normal to have increased temp post op for 38 hours, anything more= infection

Question 11

other complications of surgery

Answer 11

pain, anxiety/stress/depression, fatigue, nausea, urine retention/constipation, wound infection- needs to be quickly identified and treated quickly, cognitive dysfunction, haemorrhage, DVT/PE, nerve injuries, fluid imbalance, hypothermia, hypertension

Question 12

aim of PT in surgical patient- increased lung volume and clear secretions

Answer 12

lung- mobilize/exercise, positioning, breathing exercise, adjuncts
clear secretions- mobilise/exercise, positioning, breathing exercises, adjuncts

Question 13

aim of PT in surgical patient- to rehabilitate and promote independence

Answer 13

mobilise/exercise, ADL, home visits, post-op rehab

Question 14

pre-rehabilitation of prehab

Answer 14

a proactive approach designed to enhance functional capacity of an individual to enable them to withstand the stresses of surgery, associated with lower post-op complications and earlier restoration of functional state, MDT approach= nutrition/ psychological and behavioural, programme= personalised

Question 15

post-op complications of surgery of GA

Answer 15

chest- atelectasis and infections, wound complications, pulmonary oedema, cardiovascular problems and MI, shock, DVT, acute renal failure, reduced gut motility, nausea/vomiting, psychosis, nerve damage, pressure sores, tooth loss or chipping

Question 16

vascular surgery

Answer 16

aneurysm or atherosclerosis, common ones are abdominal aortic aneurysm (AAA), aortic bifemoral and thoracic aortic aneurysm (TAA)

Question 17

what is an aneurysm and atherosclerosis

Answer 17

they are a result in the degeneration of the media and elastic lamina of an artery wall- bulges and weaknesses at risk of rupturing, atherosclerosis leads to blocking of the artery which can lead to tissue death

Question 18

AAA

Answer 18

major occur below the renal arteries, open or trans femoral/endovascular procedures, open=horizontal or vertical incision, cross clamping above and below the affected area and inserting Dacron tubing, carries an 80% mortality rate, monitoring of size in electives consider operation if >5cm

Question 19

Transfemoral or endovascular- AAA

Answer 19

transfemoral or endovascular (EVAR)= avoids extensive abdominal incision, minimises clamp time and reduced risks of GA as done under local

Question 20

thoracic aortic aneurysm

Answer 20

less common, some patients with an AAA will have a thoracic extension, often need an aortic valve replacement as well, open surgery or thoracic endovascular aortic repair (TEVAR)

Question 21

thoracic aortic aneurysm- 4 types

Answer 21

type 1- affects descending thoracic and proximal abdominal aorta, type 2- affects all descending and abdominal aorta, type 3- affects distal thoracic and all of the abdominal aorta, type 4- affects upper aorta from which the visceral arteries arise

Question 22

aortobifemoral bypass- aortobifemoral

Answer 22

performed in patients with atheroscleoric disease of the infrarenal aorta and iliac arteries. patients have symptoms of claudication, impotence and poorly healing ulcers, examination usually reveal absent or very weak femoral pulses

Question 23

head and neck

Answer 23

commonly cancer related (squamous cell carcinomas), tumours may involve- oral cavity/ oropharynx/ larynx and hypopharynx, partial and radical neck dissections, laryngectomy

Question 24

head and neck- procedures may include

Answer 24

split skin grafting, musculocutaneous flaps (pec minor), radial forearm flaps, fibula free flaps, rectus abdominius flaps, organ transposition

Question 25

head and neck- common post op chest complications

Answer 25

nature of surgery, at risk of aspiration, tracheostomy (temporary or permanent), long surgery, previous health state (smokers, excess alcohol, nutritionally poor)

Question 26

intercostal drains (ICD)-

Answer 26

used to restore normal sub-atmospheric pressure in pleural space by allowing air and fluid to escape, this allows underlying lung to expand

Question 27

intercostal drains (ICD)- used for

Answer 27

treating pneumothorax and haemothorax, placed at end of thoracic surgery

Question 28

how do ICD works

Answer 28

as pressure change surface level of fluid in collection tube swings, air bubbles out but can’t pass under the water to get back into pleura, if air bubbles through drain it indicates a leak in the visceral pleura and the drain is still required, as lung fully re-expands bubbles gradually stops

Question 29

ICD- handling

Answer 29

when handling patient keep drain below level of chest, avoid-disconnecting kinking stretching tube, observe changes- drainages and air leaks, normally not clamped but look out for this especially if considering positive pressure based treatment

Question 30

ICD placement- apical and basal

Answer 30

apical- more anterior drain is apical. It drains air
basal- more posterior is baal and drains fluid
the drains are placed on gravity taking the blood lowermost and air rising. ICD’s must never be placed above chest level or liquid contents will siphon into the pleural space