Intra-operative and Post-operative Care

Question 1

Sleep vs unconsciousness vs aneasthesia?

Answer 1

Sleep: recurring lowered LOC associated with decreased response to external stimuli from which person can be readily roused

Unconsciousness: State of unawareness where the patient is incapable of responding to sensory stimuli or of having subjective experiences, but somatic and autonomic reflexes to pain and noxious stimuli still occur

Anaesthesia: State of drug induced hypnosis which is distinct from unconsciouness, accompanied by loss of motor response to noxious stimuli

Question 2

Depth/stage of anaesthesia?

Answer 2

1: Analgesia: from the beginning of induction to LOC
2: Excitement: from LOC to automatic breathing (may be breath-holding, vomiting, coughing, swallowing, gagging)

3: Surgical:
- Light: from onset of automatic respiration until eyeballs become fixed
- Medium: increasing intercostal paralysis
- Deep: diaphragmatic respiration

4: Overdose: From onset of diaphragmatic paralysis to apnoea and death (all reflex activity lost and pupils widely dilated)

Question 3

Patient’s reaction to surgical stimuli?

Answer 3

Somatic:

• Obvious: frank movement of extremities, laryngospasm
• Subtle: wrinkling of forehead, vocalisation, irregular breathing, breath-holding

Sympathetic: tachycardia, HPT, sweating, lacrimation

Question 4

Progressive loss of reflexes in anaesthesia from induction to deep anaesthesia?

Answer 4

Voluntary control of eye movement lost first
Eyelash reflex
Eyelid reflex
Swallowing, retching and vomiting
Conjunctival reflex
Muscular tone
Corneal reflex
Glottic reflexes
Pupillary light reflex lost last

Question 5

Causes of a depressed LOC?

Answer 5

Trauma
Infective/inflammatory
Neoplastic
Metabolic (hypoxia, hypercarbia, acidosis, hypoglycaemia)
Drugs (anaesthesia, poisons)

Question 6

Care of the unconscious/anaesthetised patient?

Answer 6

Immediate care:
Airway
Breathing
Circulation
Drugs
DEFG - Dont ever forget glucose

Monitoring: intra-operatively and post-op

Long-term care: ICU

Question 7

When can a patient be transferred TO the recovery room?

Answer 7

Once:

1. A patent airway can be maintained
2. Ventilation is adequate
3. Cardiovascular function is stable

Question 8

What to do on arrival in recovery room?

Answer 8

ID patient
Breif summary of patients hx and surgery
Anaesthetic given and any complications
Present condition of patient and physiological parameters
Instructions for monitoring and investigations
Instructions for pain management, fluid therapy and O2

Question 9

List the common post-operative anaesthetic problems?

Answer 9

Airway obstruction (tongue, laryngospasm uncommon)
Hypoventilation (pain, residual muscle relaxant)
Hypoxaemia
Hypotension (hypovolaemia, opiates, cardiac failure)
Hypertension (pain, pre-existing disease, fluid overload)
Shivering
Somnolence
Delirium
PONV

Question 10

Assessing patient fitness for discharge from recovery room to ward?

Answer 10

Aldrete Score
Score of 0, 1 or 2 assigned to objective signs
Recorded every 15 minutes
Patient leaves when score >9

ACTIVITY: 0 - unable to move any limbs, 1 - able to move 2 limbs voluntarily/on command, 2 - able to move 4 limbs voluntarily/on command

RESPIRATION: 0 - apnoeic, 1 - dyspnoeic/limited breathing, 2 - deep-breathe and cough adequately

CIRCULATION: 0 - BP > 50% change from pre-anaesthetic level, 1 - BP 20-50% change, 2 - BP 90% on RA

CONSCIOUSNESS: 0 - Not responding, 1 - Arousable on calling, 2 - fully awake

COLOUR on RA/SATS: 0- cyanosed, 90% on O2 40%, 2 - Pink, SATS >90 on RA

Question 11

Assessing fitness for discharge from hospital?

Answer 11

PADSS (post anaesthetic discharge scoring system)
Score of 9/10 must be present before discharge

AMBULATION and MENTAL STATE: 2 - fully awake and ambulant, 1 - fully awake or ambulant, 0 - neither

PAIN or N&V: 2 - minimal, 1 - moderate, 0 - severe

BLEEDING: 2 - minimal, 1 - moderate, 0 - severe

VITAL SIGNS: 2 - 20% of preoperative level, 1 - 20-40% of preoperative level, 0 - >40% of preoperative level

INTAKE/OUTPUT: 2 - per os fluids and voided, 1 - per os fluids or voided, 0 - neither

Question 12

LT care for a prolonged coma?

Answer 12

Respiratory (infection, atelectasis, hypostatic pneumonia, hpoventilation due to central respiratory depression etc. may necessitate respiratory support and airway monitoring)

Circulation (fluids, electrolyes, DVT prophylaxis etc.)

Nutrition (enteral or TPN, constipation)

CNS (GCS, eye care)

Musculo-skeletal (joint and muscle damage, pressure point care)

Renal (UTI common, avoid catheterisation if possible)

Metabolic control (glucose, electrolytes, acid-base)

Physiotherapy and general care (chest, contracture prevention, mouth care, regular turning, pain relief, sedation)