Introduction to surgery

Question 1

What is pre-operative care?

Answer 1

The preparation and assessment, physical and psychological, of a patient before surgery.

Question 2

What are the aims of pre-operative assessment?

Answer 2

Including explaining procedures, their associated risks and aftercare.
Informed decisions.
Identifying co-existing medical conditions and how to optimise the patient’s health, while appreciating the urgency of their operation.

Question 3

What can you do to advise a patient pre-surgery during the preoperative assessment?

Answer 3

Discuss improvable factors to help support patients to b e as fit as possible (including smoking cessation, reducing alcohol, better nutrition and taking regular moderate physical exercise).
Identify patients with a high risk of preoperative complications and identify their appropriate level of postoperative care.
Describe the process of discharge planning.

Question 4

What should you do as part of the preoperative assessment of a patient?

Answer 4

Identify the variable that provide prognostic information for all patients planning to undergo surgery.
Explain the details of the preoperative anaesthetic history and assessment, including airway assessment, previous anaesthesia exposure, and any adverse reactions.

Question 5

What is the perioperative physical assessment score?

Answer 5

ASA 1: Healthy patient.
ASA 2: Mild systemic disease. No functional limitation.
ASA 3: Moderate systemic disease. Definite functional limitation.
ASA 4: Severe systemic disease that is a constant threat to life.
ASA 5: Moribund patient. Unlikely to survive 24hrs, with or without treatment.
Postscript E indicates emergency surgery.

Question 6

What is the grade of surgery?

Answer 6

Relates to invasiveness of surgery.
Grade 1: Minor procedures, e.g. diagnostic endoscopy, breast biopsy.
Grade 2: Inguinal hernia repair, varicose veins, adenotonsillectomy, knee arthroscopy.
Grade 3: Total abdominal hysterectomy, TURP, lumbar discectomy, thyroidectomy.
Grade 4: Major procedures, e.g. total joint, artery reconstruction, colonic resection, radical neck dissection.

Question 7

What tests are required preoperatively for an ASA 1 grade patient?

Answer 7

FBC: yes.
Haemostasis: not routinely.
Kidney function: consider in people at risk of AKI.
ECG: consider for people aged over 65 if no ECG results available from past year.
Lung function/ABG: not routinely.

Question 8

What tests are required preoperatively for an ASA 2 grade patient?

Answer 8

FBC: yes.
Haemostasis: not routinely.
Kidney function: yes.
ECG: yes.
Lung function/ABG: not routinely.

Question 9

What tests are required preoperatively for an ASA 3 or 4 grade patient?

Answer 9

FBC: yes.
Haemostasis: consider in people with chronic liver disease; if people taking anticoagulants need modification of their treatment regimen, make nan individualised plan in line with local guidance; if clotting status needs to be tested before surgery (depends on local guidance), use point-of-care testing.
Kidney function: yes.
ECG: yes.
Lung function/ABG: consider seeking advice from a senior anaesthetist ASAP for people who are ASA grade 3 or 4 due to known or suspected respiratory disease.

Question 10

What are the essential preoperative investigations required for all surgical patients?

Answer 10

FBC, U+Es, creatinine.
ECG.
If appropriate: pregnancy test, sickle cell test, chest x-ray.

Question 11

What are the basic fasting guidelines for children and adults?

Answer 11

NBM for more than 6hrs.

Can drink clear fluids up to 2hrs before procedure.

Question 12

What are the associated medical conditions that concern us pre-surgery wrt fasting?

Answer 12

Difficult airway, obesity, cardiac disease, respiratory disease, GI disease.
Renal failure.
Diabetes.
Haematological disorders- anaemia, sickle cell anaemia.
Allergic reactions, and those rendering patients at high risk.
Additional investigations for specific illnesses, such as cardiopulmonary exercise testing to evaluate both cardiac and pulmonary function.

Question 13

What are some common conditions that can affect preoperative care?

Answer 13

Ischaemic heart disease.
Congestive cardiac.
Chronic respiratory.
Diabetes.
Liver or kidney.

Question 14

What is the cardiac risk index?

Answer 14

1 procedure-related risk factor: intrathoracic surgery, intra-abdominal sugar, or suprainguinal vascular surgery.
5 patient-related risk factors: ischaemic heart disease; congestive heart failure; history of stroke or TIA; creatinine >2.0mg/dL; insulin dependent diabetes mellitus.
Poor functional capacity: patients who become breathless and/or have chest pain while climbing a flight of stairs, walking on level ground at 4km/hr, or performing heavy work around the house.

Question 15

Who is an echocardiogram required for preoperatively?

Answer 15

Exacerbation or new onset of cardiac symptoms (e.g. dyspnoea, chest pain, syncope).
Patients with moderate or severe valvular regurgitation or stenosis who have not had an echo in the past year.

Question 16

Who is an ECG required for preoperatively?

Answer 16

Patients with >1 RCRI risk factor and one of the following:

• age >65 years
• COPD
• peripheral vascular disease
• arrhythmias

Question 17

Who is a CXR required for preoperatively?

Answer 17

Surgeries of the head and neck, thorax, upper abdomen.
Clinical features and/or a history of cardiac or pulmonary disease, e.g. COPD, congestive heart failure.
>60yrs.
ASA score >2.
Hypoalbuminaemia.
Emergency procedures.
Prolonged surgeries >3hrs.

Question 18

Who is pulmonary function tests required for preoperatively?

Answer 18

Unexplained dyspnoea or exercise intolerance in patients who are about to undergo thoracic or upper abdominal surgery.
Patients with COPD or bronchial asthma who have not had a baseline pulmonary function test.

Question 19

Differential of pain in right hypochondriac region.

Answer 19

Cholelithiasis.
Biliary colic.
Acute cholecystitis.
Acute cholangitis.
Acute hepatitis.
Liver abscess.
Budd-Chiari syndrome.
Portal vein thrombosis.
Pancreatitis.
Duodenal ulcer.
Nephrolithiasis.

Question 20

Differential of pain in flank regions.

Answer 20

Nephrolithiasis.
Pyelonephritis.
Constipation.
Infectious colitis.
Ischaemic colitis.

Question 21

Differential of pain in right iliac region.

Answer 21

Appendicitis.
Nephrolithiasis.
Pyelonephritis.
Infectious colitis.
Inflammatory bowel disease.
Inguinal hernia.
Ovarian cyst/torsion.
Ectopic pregnancy (unilateral).
PID (bilateral).

Question 22

Differential of pain in epigastric region.

Answer 22

Acute MI.
Acute pancreatitis.
Chronic pancreatitis.
Peptic ulcer disease.
GERD.
Gastritis.
Functional dyspepsia.
Gastroparesis.

Question 23

Differential of pain in umbilical region.

Answer 23

Appendicitis.
Constipation.
Small bowel obstruction.
Large bowel obstruction.
Inflammatory bowel disease.
IBS,.
Gastroenteritis.
Ischaemic colitis.
Abdominal aortic aneurysm.

Question 24

Differential of pain in suprapubic region.

Answer 24

Cystitis (UTI).
Acute urinary retention.
Appendicitis.
Inflammatory bowel disease.
Ovarian cyst.

Question 25

Differential of pain in left hypochondriac region.

Answer 25

Splenomegaly.
Splenic infarct.
Peptic ulcer.
Gastritis.
Nephrolithiasis.

Question 26

Differential of pain in left iliac region.

Answer 26

Diverticulosis/ diverticulitis.
Nephrolithiasis.
Pyelonephritis.
IBS.
Infectious colitis.
Inguinal hernia.
Ovarian cyst/ torsion.
Ectopic pregnancy (unilateral).
PID (bilateral).

Question 27

How should patients be monitored post-operatively?

Answer 27

Monitor BP, pulse, oxygen saturation, temperature, urine output, and surgical drain output.
If a patient has a urine output <0.5mL/kg/hr for >6hrs, check catheter patency.
Supportive care in intubated patients.
Pain management according to WHO analgesic ladder.
Stress ulcer prophylaxis with PPIs.
Thromboprophylaxis with low-dose LMWH or UFH before and after surgery, especially for immobile, bedridden patients.
Incentive spirometry and breathing exercise in order to prevent lung atelectasis.
Fluids: replacement of ongoing fluid loss and maintenance fluid therapy.
Enteral nutrition should be started ASAP to prevent villous atrophy.
Daily examination of the surgical wound.
Early mobilisation.
Monitor bowel opening for stasis.

Question 28

How do you assess and manage fluid status post-operatively?

Answer 28

Remind yourself of patient’s medical history, either past or ongoing.
Examine the patient and look at the observations, urine output, and fluid balance chart.
Assess the fluid status looking at lying and standing BP, HR, JVP, and mucous membranes.
Ensure you auscultate the chest and look at the peripheries for oedema.
Scan the drug chart to see if any drugs may be affecting fluid balance and whether any changes can be made.
Check the patient’s electrolytes- does any action need to be taken, or do these point to specific fluids to use?
Does the patient have any ongoing fluid and electrolyte losses that need to be taken into account?
Can fluids be taken orally instead of IV?

Question 29

Which patients are in need of fluid optimisation?

Answer 29

Diarrhoea and vomiting.
Where the patient has been immobile/debilitated for a prolonged period prior to admission (which has decreased fluid intake).
Elderly patients with reduced renal function that makes fluid balance maintenance more challenging.
Drugs that lower renal fluid exchange functions.
Low BMI patients in whom ‘normal’ fluid loss volumes will be more significant.

Question 30

What are the different types of fluid used for optimisation?

Answer 30

Hartmann’s, normal 0.9% saline, dextrose.

Question 31

What are the different types of nutritional support?

Answer 31

Oral.
Nasogastric.
Gastro/jejunostomy.
Parenteral.
TPN.

Question 32

What is the epidemiology of complications of surgery?

Answer 32

Patients who have complications are more likely to die, even 5 years after surgery.
About 20,000-25,000 deaths occur every year in UK hospitals following surgery, of which about 80% occur in a small group of ‘high risk patients’.
These patients account for 10% of surgical inpatients and are at increased risk of mortality and morbidity.

Question 33

What is the epidemiology of complications of surgery?

Answer 33

Patients who have complications are more likely to die, even 5 years after surgery.
About 20,000-25,000 deaths occur every year in UK hospitals following surgery, of which about 80% occur in a small group of ‘high risk patients’.
These patients account for 10% of surgical inpatients and are at increased risk of mortality and morbidity.

Question 34

What are some acute complications of surgery? <24hrs.

Answer 34

Secondary to GA.
Haemorrhage or anaemia.
Hypovolaemia.
Respiratory compromise.
Uncontrolled pain.
Emboli.
Damage to surrounding structures.

Question 35

Case 1: 65y/o aorto-bifemoral bypass in the morning, develops acute onset abdominal pain and pyrexia, rigidity of bowel, raised lactate and metabolic acidosis.
How would you manage this case?

Answer 35

Call senior- patient needs to return to theatre, so preoperative prep again.
Bloods: FBC, U+Es, clotting factors, cross match, etc.
Fluids.
Catheterise to monitor input and output.
CXR if breathing compromised.
NBM?
IV access?
Assessment of the patient’s airway patency, vital signs, and level of consciousness.
Surgical site (intact deressings with no signs of overt bleeding).
Patency of drainage tubes.
Body temperature (hypo/hyperthermia).
Patency/rate of IV fluids.
Circulation/sensation in extremities after vascular or orthopaedic surgery.
Level of sensation after regional anaesthesia.
Pain status.
Nausea/vomiting.

Question 36

How should patients be monitored in the first 24hrs post-surgery?

Answer 36

Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every 1-2hrs for at least the first 8hrs.
Body temperature must be monitored, since patients are often hypothermic after surgery, and may need a warming blanket or warmed IV fluids.
Respiratory status should be assessed frequently, including assessment of lung sounds (auscultation) and chest excursion, and presence of an adequate cough.
Fluid intake and urine output should be monitored every 1-2hrs.
If the patient does not have a urinary catheter, the ladder should be assessed for distension, and the patient monitored for inability to urinate.
If the patient had a vascular or neurological procedure performed, circulatory status or neurological status should be assessed as ordered by the surgeon, usually every 1-2hrs.
The patient may require medication for nausea or vomiting, as well as pain.
Patients with a patient-controlled analgesia pump may need to be reminded how to use it.
Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and eventually walk.
Movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear.

Question 37

How should patients be monitored after the first 24hrs post-surgery?

Answer 37

Vital signs can be monitored every 4-8hrs if the patient is stable.
The incision and dressing should be monitored for the amount of drainage and signs of infection.
The hospitalised patient should be sitting up in a chair at the bedside and ambulating with assistance by this time.
Respiratory exercises are still performed every 2hrs.
Bowel sounds monitored, patient’s diet gradually increased as tolerated, depending on type of surgery.
Monitor for evidence of potential complications.

Question 38

What are the possible early complications >24hrs post-surgery?

Answer 38

Leg oedema, redness and pain (DVT).
Shortness of breath (PE).
Dehiscence (separation) pf the incision or ileus (intestinal obstruction).
Delirium.
DVT/PE.
Infection/sepsis.
Poor wound healing/dehiscence.
Reperfusion injuries.
Pressure sores.
Late haemorrhage

Question 39

What are the possible late complications post-surgery?

Answer 39

Damage to local structures leading to loss of function.
Scarring.
Chronic pain.
Recurrence/failure of surgery.

Question 40

What are the signs and symptoms of early sepsis?

Answer 40

Respiratory acidosis.
Decreased cardiac output.
Hypoglycaemia.
Increased arteriovenous oxygen difference.
Cutaneous vasodilation.

Question 41

Case 2: 21y/o female, 5hrs post lap chole: tachycardia (110), cool peripheries, BP 90/50, urine output 30mL/hr, complaining of abdominal pain.
How would you manage this patient?

Answer 41

Concerned about sepsis/ hypovolaemic shock.
What is her temperature?
Bloods.
Abdominal examination: shows bruising and distension, concerned about haemorrhage.
USS abdo.

Question 42

Which of the following physical examination findings may be seen in patients with dehydration?

a) capillary refill of 4s
b) capillary refill of 1s
c) hypertension
d) bradycardia
e) increased skin turgor

Answer 42

Capillary refill of 4s.

Question 43

Which of the following is true about abdominal pain?

a) Peptic ulcer pain is usually experienced in the hypogastrium
b) The pain of IBS is usually well localised
c) The pain of oesophagitis is usually retrosternal in site
d) The pain of pancreatitis usually radiates to the groin.

Answer 43

The pain of oesophagitis is usually retrosternal in site.

Question 44

Which of the following is true about an abdominal mass?

a) A pulsatile mass is always due to an aortic aneurysm
b) An enlarged kidney is dull to percussion
c) A large mass arising out of the pelvis which disappears following urethral catheterisation is caused by an ovarian cyst
d) An indentible mass is caused by faecal loading of the colon

Answer 44

An indentible mass is caused by faecal loading of the colon.