General Flashcards
What are the components of the WHO Checklist?
Three phases.
Sign in - led by anaesthetist, check the patient in, machine checks, anaesthetic concerns
Time out - led by surgeon, patient check, antibiotics, equipment check and sterility, VTE plan
Sign out - led by scrub team, procedure check, counts, specimens, equipment problems, postoperative plan
What is the audit cycle?
Identify issue
Define standards
Collect data
Analyse/interpret data
Implement change
Reaudit
How should patients with a pacemaker or ICD be managed intraoperatively?
Establish make and model
Ensure has had review by cardiac physiologist within 3 months and discuss case with them
Avoid diathermy, particularly monopolar, keep to short bursts or use ultrasonic dissectors
Some pacemakers can be deactivated by magnets, but not all.
How do cutting and coagulation diathermy work?
Passing high frequency AC to produce heat - 300kHz –> 10MHz
-Cutting = continuous low frequency
-Coag = intermittent high frequency
-Blend = continuous low frequency + intermittent high frequency
What is the difference between monopolar and bipolar diathermy?
Monopolar –> instrument –> patient –> plate (70cm2) (high power 400W)
Bipolar –> forceps ends (low power 50W)
How may groin hernias be classified?
European hernia society guidelines
1) Primary/recurrent
2) Size of defect
- 1 <1.5cm
- 2 1.5-3cm
- 3 >3cm
3) Site of defect (Lateral, medial, femoral)
What is the Shouldice technique?
Tissue repair of inguinal hernia
4 layers
- Deep upper TF –> lower TF (M–>L)
- Sup Upper TF –> Inguinal ligament (L –> M)
- Internal oblique/TA –> deep Inguinal ligament (L –> M)
- Internal oblique/TA –> sup Inguinal ligament (M –> L)
What are the risk factors for urinary retention after hernia repair?
Age
Laparoscopic approach
GA
What is the incidence and risk factors for chronic pain after hernia repair?
10-12% - bothersome in 0.5-6%
RF
- preop = young, female, preop pain, recurrence
- periop = less experienced, open, heavyweight mesh
- postop = complications, high post op pain
What are the management options for chronic pain after hernia repair?
–EHS guidelines
MDT
Consider LA/Steroid blocks
Consider triple neurectomy and mesh explantation after at least 1 year
RFA may be helpful
What would be an appropriate local anaesthetic choice for groin hernia repair?
Combination of lidocaine with adrenaline (7mg/kg) and bupivicaine (2.5mg/kg)
20mls 1% L+A
20mls 0.5% Bupivicaine
70kg.
What factors are important in the pharmacokinetics of LAs?
Protein binding - ability of drug to bind membrane proteins –> longer duration, less risk of toxicity
Lipid solubility - greater solubility == greater penetration of nerve membranes and increased rate of onset
-pKa - pH at which there is balance of ionised and non-ionised LA.
—Lower pKa, higher proportion in non-ionised form, more readily absorbed and more rapid onset
—Higher pKa, slower onset, more prolonged
What are the components of an enhanced recovery pathway?
Pre-admission - patient optimisation, comorbidities/anaemia addressed, patient education
Admission - day of surgery, carbohydrate loading, avoidance of bowel prep
Intra-op - minimally invasive, goal directed fluid management, individualised pain management, avoid tubes where possible
Post-op - early mobilisation, enteral nutrition and removal of tubes. Daily achievement goals
What are the criteria for discharge on ERAS?
1) Good pain control with oral analgesia
2) Eating and drinking without IVFs
3) Independently mobile
What structures drain lymph into the superficial inguinal nodes?
Skin and subcutaneous tissue of abdominal wall below umbilicus, perineum, buttocks, external genitalia and lower limbs
What is gynaecomastia and its common causes?
Benign proliferation of glandular male breast tissue. Consider pseudogynaecomastia
- Physiological (30% neonatal, puberty, old age)
- Drug (20%, protate cancer drugs, cardiac, retroviral - Spironolactone, steroids, cannabis)
- Pathological causes (25%, hyperthyroidism, alcohol, cirrhosis, testicular malignancy)
- Idiopathic (25%)
What endocrine tests should be sent for assessment of gynaecomastia?
B-HCG, LH, testosterone, oestrogen, prolactin and AFP
Also renal, liver, thyroid function
What are the classical stages of Hidradenitis supparativa?
Three stages described by Hurley
1 - single/multiple abscesses
2 - recurrent abscesses with tract formation
3 - multiple tracts and abscesses involving a whole area
What is a hydrocele and how may they be classified?
An accumulation of fluid around the testis in the tunica vaginalis
Communicating (associated with hernia)
Non-communicating
How may hydroceles be repaired surgically?
Inguinal approach
- high ligation of PPV in infants
Scrotal approach
- Jaboulay procedure - resection of most of sac leaving a cuff of tissue which is everted and sutured along the cord
What are the surgical concerns for patients with Sickle-cell anaemia?
Vaso-occlusive crises precipitated by infections acidosis, dehydration, hypoxia, surgical trauma.
Ensure Hb >10.
Acute chest syndrome - 2/3 days post surgery, pulmonary infiltrates on chest x-ray
What is the embryological origin of a thyroglossal cyst?
The foramen caecum develops at the base of the tongue at about 4 weeks
Forms the thyroid which migrates to the 5th Cervical vertebrae between 1st and 2nd branchial arches
Along this tract cysts or ectopic thyroid tissue can be found, most commonly at the level of the thyroid
What USS findings would suggest pyloric stenosis in infants?
Thickness of >3mm or length >15mm
What are the typical findings of dehydration in infants?
Mild 1-5% - <24 hours
Moderate 6-10% - loss of skin turgor, weight loss, sunken eyes/fontanelle, lethargy, dry membranes
Severe 11-15% - skin mottling, CV instability, neurological involvement