General Flashcards
What is the declaration of Helsinki?
- Volunteers
- Informed consent
- Wellbeing of individuals overrides population
- Research only if likely to benefit population
What are the 4 pillars of medical ethics?
1) beneficence 2) non-maleficence 3) equipoise 4) justice
Give an example of a good communication type in pre-hospital care
Hand’s off Handover
Which risk factors are on Koivuranta’s PONV score
female gender, non-smoking status, history of PONV, history of motion sickness, and duration of surgery >60 min
Describe the scoring of Koivuranta’s PONV score
0 = 17% (baseline) 1 = 18% 2 = 42% 3 = 54% 4 = 74% 5 = 87% ROC = 0.71
Describe the Apfel simplified score
PONV scoring system: female gender, history of PONV or motion sickness, non-smoking status, and postoperative use of opioids
How does the Apfel PONV score relate to PONV risk?
0 = 10% 1 = 20% 2 = 40% 3 = 60% 4 = 80%
What is the POVOC score?
Scoring system for PONV in children
What are the risk factors in the POVOC score?
duration of surgery ≥30 min, age ≥3 yr, strabismus surgery, and history of POV in the child or relatives
Provide 3 scoring systems for PONV
Koivuranta - Adult Apfel - Adult POVOC - Children
Define perioperative high risk
> 5% perioperative mortality
Why is establishing risk so important?
High risk patients account for 12.5% of cases but 80% of perioperative mortality
What were the main NCEPOD (2011) findings for “high risk” patients
- “High risk” was arbitarily defined by anaesthetist
- 20% were identified
- 6.2% 30-day mortality
- 1/4 had art lines
- 5% had cardiac output monitoring
- 22% went to HDU/ITU immediately postop
- 50% who died never went to ITU
Identification methods for “High-Risk Patients”
- Clinical judgement
- ASA
- P-POSSUM
- Euroscore (cardiac)
- Surgery Type
- CPEX
List high risk surgical operations
- Open aortic
- Major vascular
- Peripheral vascular
- Urgent body cavity
List the highest risk perioperative co-morbidities. Give % 30 day mortality
- Documented cirrhosis (8.9%)
- CCF (8.2%)
- Arrhythmia (5.7%)
- CVA (4.4%)
- Diabetes (on insulin) (4.1%)
- Ischaemic heart disease (3.8%)
- Cancer (3.8%)
What is the perioperative role of echo?
- Resting - information made no difference in 1 year outcomes (40,000 patient retrospective review)
- Dynamic - identifying inducible ischaemia improved outcomes
What is the role of perioperative CT angiography?
- Can identify those with CAD
- Indications for treatment remain the same as for non-surgical patients
How should you care for high risk patients?
- Optimise medical co-morbidities
- Plan appropriate:
- Monitoring
- Fluid management
- Analgesia
- Decide on appropraite post op care
What is CPEX?
An incremental workload stress test. A dynamic test of global cardiorespiratory function
What are the phases of CPEX?
- Baseline recording (3 mins)
- Unloaded cycline (1-3 mins)
- Graded increasing resistance
- Rest (10 mins)
What is pre-habilitation?
- A cardiac rehab like program.
- Increases VO2 max by 20-30%.
- Mitigates impact on VO2 by chemotherapy.
- Unclear if any survival benefit
What are positive CPEX indicators for ward level care post major surgery?
- AT > 11 mL/min/kg
- No myocardial ischaemia
- Ve/VO2 < 35
What are the positive CPEX indicators for HDU care post major surgery?
- AT > 11 mL/kg/min
- Detectible myocardial ischaemia or;
- Ve/VO2 > 35
What are the positive CPEX indicators for ITU care post major surgery?
- Aortic or oesophageal surgery
- AT < 11 mL/min/kg
Why might beta-blockers work to lower perioperative mortality?
- Reduce O2 demand
- Prevent tachycardias
- Negatively ionotropic
- Reduce cardiac events
Guidelines of perioperative beta-blockade
- Continue if already on
- intermediate/high risk for myocardial ischaemia - consider starting peri-op
- > 2 Revised risk factors - consider starting peri-op
- Do not start on day of surgery
- Try to start eariler if going to do so
