lectures Flashcards
Factors that affects surgical outcomes
Patient- age, sex, socioeconomic status, aerobic fitness, comorbidities
Surgical- emergency, minimally invasive, duration, blood loss, tumour (size), adhesions, surgical experience
Environment- cleanliness, temperature
How do you categorise surgical complications
- Clavien Dindo classification
- From 1 to 5
Causes of post op pyrexia
- Cut: wound infection
- Collection: pelvic or subphrenic abscess
- Chest: infection or pulmonary embolism
- Cannula: infection
- Central venous catheter: infection
- Catheter: urinary tract infection
- Calves: DVT
X ray vs CT in bowel obstruction
CT abdomen
More accurate, useful for severity and risk of complications eg perforation/ischaemia.
15mSV radiation.
Abdominal x-ray
No obstruction on AXR does not exclude obstruction.
Unlikely to show cause.
0.7mSV radiation.
Large bowel obstruction
6cm upper limit normal
9cm upper limit normal (caecum)
Pouches – Haustra, Thicker than Small Bowel
Gas proximal to blockage
Collapse distal
Small bowel obstruction
3cm upper limit normal
More central
Valvulae conniventes- bands across the bowel
T wave inversion
Myocardial ischaemia
ECG signs of PE
S1Q3T3- right sided heart strain can cause a PE
PE- sinus tachycardia is the most common ECG finding
What report deals with the dying
Neuberger report
Key steps for caring for the dying
- The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes.
- Sensitive communication takes place between staff and the person who is dying and those important to them.
- The dying person, and those identified as important to them, are involved in decisions about treatment and care.
- The people important to the dying person are listened to and their needs are respected.
- Care is tailored to the individual and delivered with compassion –
Warning score 0-4
Low risk
Ward based response
Red score in any parameter of NEWS
Low/medium
Urgent ward response
Eary warning score 5-6
Medium risk
Urgent response
Early warning score 7+ risk and response
High
Urgent/emergency response
GCS eyes
4 Spontaneous
3 To sound
2 To pressure
1 None
GCS verbal
5 Oriented
4 Confused
3 Words
2 Sounds
1 None
GCS motor
6 Obey commands
5 Localizes pain
4 Normal flexion
3 Abnormal flexion
2 Extension
1 None
Who are classified as vulnerable adults
Older people
People with learning disabilities
Mental health patients
People who are ill and need help functioning
Physically disabled people
Trauma
Those who have gone through domestic abuse/homelessness
Q sofa
RR >22
GCS <15
SBP <100mmHg
Identifies patients with an infection who may be at a greater risk of sepsis
Difference between aspetic and sterile
aseptic- contamination free, no harmful bacteria
sterile- entirely free of germs not even nice ones
Transition from theatre to recovery to wards
30 min obs post surgery
Can go to ward if BP stable, and resp rate is above 12
1:1 care post op
Main principles of wound management
Haemostasis
Cleaning the wound
Analgesia
Skin closure
Dressing
Follow up advice
Wound management: how is haemostasis achieved
Pressure, elevation, tourniquet, suturing
Wound analgesia
Lidocaine 3ml/kg
How is skin closed on a wound
Steri strips, tissue adhesive, sutures, staples
How do you dress a wound
First layer = Non adherent (wet)
Second layer = Absorbent material
Top layer = Soft gauze tape
Steps of primary intention healing
1) Haemostasis: prevention of infection by scab formation
2) Inflammation: remove cell debris and pathogens
3) Proliferation: cytokines released by inflammatory cells drive proliferation of fibroblasts and granulation tissue
4) Remodelling: collagen fibres are deposited within the wound to provide strength in region
Steps of secondary intention healing
1) Haemostasis: large fibrin mesh forms
2) Inflammation: more intense than in primary intention
3) Proliferation: granulation tissue forms at the bottom of the wound
4) Remodelling: inflammatory response resolves, wound contraction may occur
How would you detect bleeding post op
Decreased Hb and increased platelets
How can you detect paralytic ileus
Peristalsis ceases
Types of infection after surgery
1-2 days post op: lung infection
3-5 days post op: UTI
4-6 days post op: PE/DVT
5-7 days post op: site infection ad abcess formation
7+ days post op: allergy
Intra op enhanced recovery
Use of multimodal and opioid sparing analgesia
N and V prophylacis
Minimally invasive surgery
Goal directed fluid therapy
Post op enhanced recovery
Adequate pain control
Early oral intake
MDT follow up
Role of the outreach team
Post critical care follow up
High risk patient referrals from wards
Education and training
Critical care patient transfers
Management of trackys
Advanced life support
Cardiac arrest and emergency airway team
Normal urine output
1ml/kg/hr
Different levels of care
Level 0: normal ward care
Level 1 care: those at risk of deterioration or stepping down from a higher level. Can be ,managed on an acute ward with help from the critical care team
Level 2: HDU. support for a single failing organ system or post op
Level 3: ICU. Patients requiring respiratory support or support with 2+ failing organ system
Level 1 pain ladder
Mild pain
Non opioid analgesics
NSAIDs
Aspirin
Paracetamol
Level 2 pain ladder
Moderate pain
Weak opioids
Tramadol
Codeine
+/- non opioid analgesics
Level 3 pain ladder
Severe pain
Strong opioids
Morphine
Buprenorphine
Fetanyl
Methadone
+/- Non opioids
Clean surgery
An incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered
Clean contaminated surgery
An incision through which the respiratory, alimentary or genitourinary tract is entered under controlled conditions but with no contamination encountered.
Contaminated surgery
An incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered.n
Adrenaline side effects
Muscle necrosis
Necrotising fasciitis
Dizziness
HTN
Palpitations
Amiodorone contraindications and side effects
Contraindications: Severe conduction disturbances, Bradycardia
Side effects: arrhythmias, corneal defects, thyroid disease, hepatotoxicity
Adenosine contraindications and side effects
Contraindications: asthma, copd, AV block, severe hypotension
Side effects: bradycardia, AV block, paraesthesia, throat discomfort
What percentage of O2 does a nasal canulase deliver
24-30%
max flow: 4L/min
Oxygen percent for non re-breathe masks
70%
Venturi mask
A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air. Regardless of resp rate and flow pattern.
What are human factors
Interaction between the employee, their equiptment and the surrounding envioronment. Through understanding these processes, changes can be made to reduce human error.
Examples of human factors
Learning styles
Behaviour and attitudes
Values
Leadership
Teamwork
Design of equipment and processes
Communication and organisation culture
Delirium screening tools
4AT
CAM
Dementia screening tool
MMSE
Braden score
Pressure sores. Uses sensory perception, nutritional status, friction and shear, activity, moisture and mobility to find the risk of developing a pressure sore.
