Operative Care Flashcards
What are the broad aims of the pre-operative assessment?
Communication Education - ERAS Establish rapport Optimize patient - weight loss, glucose control Plan Assess risk Consent
Involves:
- history (medical, family)
- Examination (Mallampati)
- Investigations (ECG, Exercise tolerance, Spirometry)
- Protocols (with holding certain drugs etc)
Done by:
- GP
- Surgical team
- Anaesthetist
- Nurse
<p>Surgical Safety checklist, what are the components?</p>
<p>Before induction of anaesthesia: Sign in
Before Incision: Time out / surgical pause
Before Patient leaves operating theatre: Sign out</p>
<p>Before the induction of anaesthesia, what check list must be completed?</p>
<p>Pt confirmed, and is aware of procedure.
Site is marked
Anaesthesia safety check is done
Pulse oximeter is on pt and is working
Check allergies of pt again
Is there a difficult in airway
Is there a risk of >500ml loss of blood</p>
<p>Which patients are at increased risk of developing VTE?</p>
<p>Medical:
- reduction in mobility for >3 days
~~~
Surgical:
- Hip surgery
- knee surgery
- GA >90mins time
- surgical admission of inflammatory or intra abdominal causes
-
~~~
General risk factors:
- >60 years
- BMI >35
- Known clotting disorders
- active cancer
- Oral contraception
- HRT
- >1 serious core morbidity
- ICU admission
- Pregnancy or 6 weeks postpartum
- varicose veins
- dehydration</p>
<p>What types of VTE are available for patients?</p>
<p>TED Stockings
LMWH - enoxaparin
- 20mg prophylactic, 40mg treatment
- given prior to surgery
Fondaparinux
- 2.5mg
- given 6 hours post surgery
Unfractionated heparin</p>
<p>Where should you not cannulate on a diabetic patient with neuropathy?</p>
<p>Foot</p>
<p>What must you use to clean a post surgical wound with?</p>
<p>Sterile Saline up to 48 hours post surgery.
after 48 hours patient may use normal water, shower etc.
if there has been an opening or infection following 48 hours, then sterile water should be used.</p>
<p>Following surgery, if a patient develops DIC, what should be done?</p>
<p>Clotting studies
Platelet counts
Advice of haematology
FFP may be given - up to 4 units in meantime
cryoprecipitate may also be given</p>
<p>List some of the causes of pyrexia post operatively:</p>
<p>0-5 days:
- Blood transfusion
- cellulitis
- atelectasis
- SIRS
>7 days
- P.E
- pneumonia
- Wound infection
- Anastomotic leak</p>
<p>Following surgery the patient is extubated but fails to make any respiratory effort. They are re-intubated and sent to ITU. 24 hours extubation is attempted again and they make succeed making a full recovery. what has likely happened?</p>
<p>Suxamethonium apnea
| - congenitally lack amounts of acetylcholinesterase which break Suxamthonium</p>
<p>What procedure is less likely to cause adhesions?</p>
<p>laparoscopy</p>
<p>If a female is on the oral contraceptive pill, when should she stop before surgery?</p>
<p>4 weeks</p>
<p>What system can be used to assess an individual's fitness levels for anaesthesia?</p>
<p>The American Society of Anesthesiology physical status system
ASA
ASA I - Normal healthy
ASA II - well controlled comorbidities
ASA III - Poorly controlled comorbidities, BMI >40, previous MI/ stroke, pacemakers, End stage Renal failure
ASA IV - Constant ongoing threat to life comorbidity, recent M.I/ Stoke <3 months, DIC
ASA V - Without surgery patient will likely die
ASA VI - declared brain dead</p>
<p>List some points which can be done to help avoid surgical complications:</p>
<p>WHO checklists
Prophylactic antibiotics (if needed)
Assess DVT risk
Mark site of surgery
Be aware of coupling injuries when using diathermy
Inferior epigastric artery is often injured during ports for laparoscopic surgery</p>
<p>What is a serious reaction that can occur with anaesthesia which is passed on in families? what is the gene and how is it inherited?</p>
<p>Malignant hyperthermia
RYR1 gene
Autosomal Dominant fashion</p>
<p>How is a oropharyngeal airway measured to fit and list some advantages of it:</p>
<p>From incisors to angle of the jaw.
- no paralysis required
- Easy to put in
- used as a bridge for definitive airway
- can be used for short procedures</p>
<p>What are the two most worrying causes of a fever postoperatively that one wants to rule out?</p>
<p>Thrombosis
Infection
*these usually occur a few days later</p>
<p>What is the best investigation for an anastomotic leak?</p>
<p>CT contrast of abdomen</p>
<p>If an anastomotic leak occurs what must you immediately do?</p>
<p>Phone consultant
| - patient needs to go back to surgery</p>
<p>What are the fasting guidelines to induction of GA?</p>
<p>6 hours prior no food
2 hours prior no fluids</p>
<p>What are the symptoms of malignant hyperthermia?</p>
<p>Increasing high fever
Muscle rigidity</p>
<p>When should diabetics be operated on during the allocated slots and why?</p>
<p>First thing, to prevent poor BM control</p>
<p>What is a contraindication to use of LMAs?</p>
<p>Not being fasted
| - they offer little protection against reflux</p>
<p>If a patient is on prednisolone and is going for surgery, what medication should they be prescribed?</p>
<p>Hydrocortisone</p>
<p>If a patient on warfarin is going for elective surgery, then what should be done regarding the warfarin?</p>
<p>~5 days prior to surgery stop warfarin and start on LMWH</p>
<p>What tests should be conducted for an elective case?</p>
<p>Pre admission clinic - for medical issues
Blood tests - FBC, U&amp;Es, LFTs, Group and Save
Urinary analysis
Pregnancy test
Sickle cell test
ECG/ Chest xray</p>
<p>If a patient has malignant hyperthermia family history what drug should be especially avoided?</p>
<p>Suxamethonium</p>
<p>What are some complications of TPN?</p>
<p>Sepsis
Vessel irritation
Hyperosmolarity
Cholestasis - leading to LFT derangements
Fluid overload
Lack of vitamins
Re-feeding syndromes - cut has atrophied</p>
<p>How is an insulin dependant diabetic managed the day of the operation?</p>
<p>Minor surgery:
Omit Preoperative insulin - monitor blood glucose every 4 hours.
- restart once normal oral diet has started
Marjory surgery:
Commence IV insulin sliding scale pre-operatively.
- continue until diet is re-established.
- check sugars every 4 hours
- restart normal routine at half dose when diet resumes</p>
<p>How should oral - controlled diabetic patients be managed before surgery?</p>
<p>Omit medication preoperatively</p>
<p>When should aspirin be continued preoperatively?</p>
<p>When there is a high risk of thrombosis</p>
<p>Which medicines need to be withheld 24 hours prior to surgery?</p>
<p>K+ sparing diuretics
ACE inhibitors
Angiotensin II blockers</p>
<p>What drug should be increased prior to surgery?</p>
<p>Steroids
| - during surgery the stress response will increase and cortisol will be more in demand</p>
How is malignant hyperthermia tested for and how is it picked up during the surgery?
Muscle biopsy
Family history
- noticed during surgery due to increased CO2
- increased metabolic activity
What is another complications of anesthesia other than malignant hyperthermia?
Suxamethonium apnea
- patient won’t be able to breath when they first wake up.
Anticholinesterase deficiency
What medications must be stopped prior to surgery?
CHOW
C- Clopidogrel
- 7 days
- aspirin may be continued
H - hypoglycemia medication
- 24 hours prior unless metformin - should be stopped morning off
- if insulin - 1/3rd night before and sliding scale day off surgery
O - oral contraceptive
- 4 weeks prior
W - warfarin
- 5 days prior. placed on LMWH
What bowel prep is needed and for what surgeries?
Left hemicolectomy
Rectosigmoid
Anterior perineal resection
Anterior resection
*all require phosphate enema
The threshold for blood transfusion is <7g/L. what is the target following administration?
7-9g/L
Why should RhD+ not be given to a woman, even if she is RhD-?
Although she is negative and thus the antibodies she produces won’t target her own cells.
if she becomes pregnant and that child is RhD+ then the antibodies produced can cross the placenta and attack the RhD+ blood in the child.
At every stage of blood product requesting, strict adherence has to be done. what are these adherences?
Using 3 points of identification
Receiving consent from patient
Labeling at bedside of patient.
- pre- made stickers are not allowed
Completing transfusion request at bedside
What observations should be done whilst the patient is receiving transfusion of blood?
Before the start of the transfusion
15-20 mins after starting the transfusion
1 hour after transfusion
At completion
What cannulas can blood be transfused through and why?
18G or 16G
- green or grey
due to haemolysis through smaller cannulas
What are the duration times that blood products must be delivered in by?
Packed RBCs - 4 hours
Platelets - 30 mins
FFP - 30 mins
Crycipotate - stat
What are malnourished patients at risk of post surgery?
Increased infection rates
Wound break down
Skin break down
What screening tool for malnourishment can be used and should be carried out for every patient pre-surgery?
MUST
Malnourished universal screening tool
*this can be done by any healthcare professional.
Following this a nutritional assessment needs to be carried out by a registered dietician
What are the basics ideas of ERAS from a surgical prospective?
Reduction in NIL by Mouth time
- 2 hour prior for clear liquids
Carbohydrate loading pre-surgery
Use minimally invasive surgery where possible
Minimise use of drains and NG tubes where possible
Rapid induction of post operative feeding
- enteral feeding within 24 hours of uncomplicated G.I surgery
Early mobilisation
Once disease of infection has been ruled out, how can a high output stoma be managed?
Reduction in hypotonic fluids
Reduce gut motility
Reduce secretion
- PPI use
Low fibre
- reduced water movement into the bowel
WHO salt reduction
What is ERAS?
Enhanced Recovery After Surgery
evidence based perioperative elements which are thought to enhanced recovery and reduce post surgical complications.
What are some patient factors that increase the likelihood of surgical site infection?
Extremes of age
Poor nutrition
Diabetes
Immunosuppression
Co - existing infection
smoking
What are some operational factors that increase the likely hood of surgical site infection?
Insertion of surgical drain
Shaving
- if this needs to be done use of electrical shaver
Foreign materials
Site of procedure
- skin fold
Poor skin closure
How should a surgical wound site be managed?
Removal of strictures and clips
- This allows drainage to occur to remove the pus
Drainage of pus or discharge
Empirical antibiotics
*remember tailor the antibiotics to the most likely organisms. i.e. enteric wounds are likely E.Coli
Frequent monitoring
Assessing for signs of sepsis
In wound dehiscence what should the management be?
Analgesia
IV fluid
Broad antibiotics
Cover wound with Saline soaked gauze
**immediate surgical intervention
When carrying out the pre-operative assessment - what type of medical history are you interested in?
Cardiac
- MI
- Exercise tolerance
- Heart failure
Respiratory
- breathlessness
- asthma
- obstructive sleep apnea
Diabetes
Kidney failure
Liver failure
MSK
- rehabilitation issues
Drugs
- anticoagulants
- anti-hypertensives
When carrying out investigations pre-operatively, there is a particular blood investigations you should always consider and is based upon the risk of the patient:
Group and save
Cross match
What are the Surgery grades?
Grade 1: Minor - Excision of skin
Grade 2: Intermediate: Repair of inguinal hernia, varicose veins, tonsils
Grade 3: Major - Total abdominal hysterectomy, endoscopic resection of organ
Grade 4: Major +: Total joint replacement, lung operations
When may a patient need to go onto TPN?
What are some complications?
Severe pancreatitis
Severe Crohn’s disease
Short bowel syndrome
Receiving intense chemotherapy
- sepsis
- Hyperosmolarity
- Vitamin Deficiency
- cholestasis
- pancreatic insufficiency
What are some common complications of laparoscopic surgery?
Surgical emphysema
- due extra-peritoneal air
Reflex bradycardia in response to abdominal distension
Deep inferior epigastric injury
What is a risk factor for developing anaphylactic reaction to blood transfusion?
IgA deficiency
- often these people produce anti- IgA which interacts with the IgA donor blood
What blood should IgA deficient receive?
Washed RBCs
IgA deficient donors blood
What are some complications of postoperative pain?
Neuro:
- delirium
Cardiovascular
- Tachy
- Hypertension
- DVT - lack of movement
Respiratory
- Decreased tidal volume
- atelectasis
- LRTI
G.I
- N&V
- Ileus
GU:
- urinary retention
Delayed discharge
How can post operative pain be graded?
Verbal rating
Verbal numerical
Visual Analogue
Pictorial
What medications should be used in neuropathic pain?
Amitriptyline
Gabapentin
How can patients fluid status be measured post operatively?
Fluid in and Out charts
- includes urine output
Daily Weights
U&Es
What are the daily fluid requirements for a patient?
Water: 25ml/kg/ day
Na2+: 1mmol/kg/day
K+: 1mmol/kg/day
Glucose 50g/ day
What drug can be given prophylactically to reduce symptoms of PONV?
Dexamethasone
What are the most appropriate medications for PONV?
Gastric stasis/ NOT obstruction:
- Metoclopramide
Obstruction:
- Hyoscine
Metabolic:
- Metoclopramide
Opioid induced:
- Ondansetron
- Cyclizine
Name 2 non - Pharmacological measures to reduce pain in patients:
Reduce anxiety
Check they are positioned correctly
What is the nutritional support needed for in a high output stoma based upon?
Length of bowel from the stoma
the longer the bowel, the less nutritional support.
very short bowels may require TPN
What are the durations for post procedural prophylaxis?
Elective hip replacement:
LMWH 10 days followed by aspirin
or
28 days LMWH
Knee replacement:
LMWH: 14 days + stockings
or
Aspirin 14 days
Fragility fractures:
LMWH - continue until mobile
What type of VTE is used in renal failure?
unfractioned heparin
