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Surgery > General pre-op and risks > Flashcards

General pre-op and risks Flashcards

1
Q

Aims of Anaesthesia (4)

A 
1. No conscious awareness of
pain
2. Still surgical field
3. Anxiolysis, sedation or
complete hypnosis
4. Cardiorespiratory stability
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2
Q

7 A’s of Anaesthesia

A
  1. Allergy
  2. Aspirations
  3. Apnea
  4. Access
  5. Activity levels/function
  6. Aortic stenosis
  7. Airway assessment
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3
Q

Items to discuss with anethetist

A
  1. Previous anaesthesia
  2. Family history->malignant hyperthermia, bleeding, reactions to anaesthesia
  3. Medications->considerations to cease/withhold
  4. CVD risk: comorbidities, risk factors
  5. CNS: stroke, TIA, seizures
  6. Respiratory: smoke, asthma, triggers, bronchitis
  7. LFTs, OSA, ABG
  8. Airway examination
  9. Endocrine, thyroid, obesity
  10. Fluid status
  11. Strategy for blood replacement
  12. GIT aspiration risk
  13. Arthritis
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4
Q

Pre-aneathetic exam

A
  1. Open mouth
  2. Presence of teeth
  3. Size of tongue
  4. Subluxation of TMJ
  5. Relative position of larynx
  6. CV and respiratory
  7. Assess recent blood
  8. Signs and symptoms of reason for operation
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5
Q

Management of acute post-operative pain

A
  1. NSAIDS
  2. Paracetamol
  3. Opioids
    a. PCA 1mg morphine bolus with 5-8 minute lockout
    b. Consider tramadol if no PCA
  4. Epidural
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6
Q

Preoperative checklist

A 
1. Bloods and investigations
FBC, UEC, LFTs, crossmatch GH, INR, glucose (some will depend on patient)
2. IV cannula
3. ECR + CXR
4. Drug chart: Regular medications, Analgesia, Antiemetic, Antibiotics, Heparin, compression stockings
5. Consent
6. Mark side/site
7. Inform anaesthetics
8. Inform theatre
9 Infections risk
10. NBM >2 hr preop clear fluids, >6-8 h for solids
11. Catheter if required
12. Post-op physioT
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7
Q

Specific complications of surgery: laparoscopic, biliary, thyroid, breast

A
  1. Laparoscopic: conversion to open procedure
  2. Biliary: damage to common bile duct, anastomic leak, retained stone with another surgery, post hepatic jaundice, stricture, pancreatitis
  3. Thyroid: bleeding->airway compromised, hypocalcemia, hypothyroid, recurrent and superficial laryngeal nerve palsy, voice different for few days (intubation and swelling)
  4. Breast: lymphedema, seroma, hematoma, brachial plexus injury
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8
Q

Specific complications of surgery: arterial, colonic, SB surgery, splenectomy

A
  1. Arterial: graft infection, AV fistula, graft failure
  2. Colonic: damage to other structures, leakage, ileus, adhesions
  3. SB: damage to surrounds, leak, ileus, short gut, adhesions
  4. Splenectomy: damage to surrounds, acute gastric dilitation, sepsis/future infections->will need vaccinations
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9
Q

Specific complications of surgery: GU, hemorrhoidectomy, prostate, gastrectomy

A
  1. GU: Damage, ureters, subfertility
  2. Hemorrhoidectomy: stenosis
  3. Prostate: blood in urine/ejaculate initially, urethral stricture, retrograde ejaculation, incontinence and impotence
  4. Gastrectomy: dumping syndrome, weight loss, malabsorption, ulceration of stomach, tumor, blind loop syndrome, abdominal fullness/early satiety
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10
Q

General surgical risks

A 
1. Anaesthetic
Toxic->brady, asystole, dizzy, NV, CNS depression
Failure
MI, stroke
Allergy
Death
2. Surgical
Hemorrhage
Infection of wound, other
Impaired healing
Surgical injury
Atelectasis, pneumonia, ARDS
VTE
Sepsis
Urinary retention
UTI
Electrolyte disturbances
Antibiotic colitis
Pressure sores
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11
Q

ASA system

A
  1. Healthy person.
  2. Mild systemic disease-
    X interfere normal activity
  3. Severe systemic disease-
    limits normal
  4. Severe systemic disease-
    that is a constant threat to life.
  5. A moribund person who is not
    expected to survive without the operation-
    wont live >24 hours
  6. A declared brain-dead person whose
    organs are being removed for donor purposes.
    E- signifies emergency
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12
Q

What are the two types of skin prep/antiseptics commonly used in surgery and their mechanism of action?

A
  1. Benidine (Iodine-based) - destroys wide range including staph by iodisation of microbial proteins
  2. Chlorhexidine gluconate - disinfect mucous membrane, bactericidal via binding phospholipids and disrupting cell wall integrity.
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13
Q

What is the ASA classification? (5)

A

Determines patient status

  1. Fit for age
  2. Patient has systemic disease that does not interfere with normal activity
  3. Systemic disease that limits normal activity
  4. Systemic disease that is constant threat to life
  5. Patient not expected to survive 24 hours
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14
Q

Common types of sutures and their use

A

Polytetrafluoroethylene = for arteries, Syn, Mono, Non
Plain catgut = nat, multi, Ab
Silk & linen = Nat, multi, Non

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15
Q

Monofilament vs multifilament

A

Monofilament pass through skin easily, less reactive, more difficult to handle and secure.
Multifilament are braided or twisted thread, easier to handle and . knot, but more likely to harbour micro-organisms.

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16
Q

What is the purpose of a surgical drain?

A
  1. remove blood or serous fluid which would otherwise accumulate in operative area
  2. Provide track or line of minimal resistance so that potentially harmful fluids can drain away from p particular site (e.g. drain placed into an intra-abdominal abscess cavity)
17
Q

Post-splenectomy management

A

Vaccinations: S. pneumonia, meningococcal, H. Influenza (encapsulated bacteria)

Antibiotics - amoxycillin script given at first sign of infection

18
Q

What are the types of nasogastric tubes?

A
  1. Levin: single lumen - administration of medications or nutrition
  2. Salem sump: double lumen (one for suction and drainage and other for ventilation to reduce pressure and prevent gastric mucosa from being drawn into catheter)
  3. Moss: (surgery): radiopaque tip & three lumens. First, positioned & inflated in cardia, serves as a balloon inflation port. 2nd is oesophageal aspiration port, 3rd duodenal feeding port.
19
Q

Complications of NG tube insertion?

A

Aspiration
Tissue damage
Induce gagging/vomiting

20
Q

How to prevent adhesions?

A

Laparoscopy (rather than laparotomy)
Minimize/avoid contomination
Avoid non-absorbable sutures and ligatures except for abdo wall closure
Avoid powered gloves

21
Q

What does valid consent involve?

A

patient must be competent (<18, able to understand and communicate information and its consequences)
Informed all information disclosed and discussed
Free from coercion
Understanding of benefits and risks checked

22
Q

What do you need to outline to the patient

A

BRA BAD
Benefits of surgery
Risks
Alternative options
Before - pre-operative assessment & management
After - immediate post-operative care (analgesia, diet, expectations, returning to normal activity), give (info, scripts, work cert, discharge), follow up
During - anaesthesia and procedure

23
Q

What drugs do you need to stop prior to surgery?

A 
CHOW 
Clopidogrel and anti-platelets 
Hypoglycaemias (metformin etc)
OCP (4 weeks prior) 
Warfarin &amp; NOACs (bridged with heparin)
24
Q

What drugs do you need to start prior/just after surgery?

A

TED stockings
LMWH or UFH (prophylactic dose for DVT)
Antibiotics (indications - GI, urological or cardiovascular)

25
Q

How to optimise diabetics for major surgery?

A

Morning surgery to minimise fasting
Measure BGL hourly for hypoglycaemia)
Withhold metformin morning of (other hypoglycaemics 24 hours prior)
If hyperglycaemic (>10mmol/L commence supplemental insulin subcut

T1DM: cut basal insulin by 1/3 to avoid hypos and omit morning insulin and continuous insulin infusion pump with glucose-insulin infusion for 24h post-op.

Surgery (9 decks)

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