Peri Op

Question 1

Pre op history

Answer 1

PMHx;importantly cardiac, renal, endocrine and respiratory- can indicate response to surgery/anaesthetics. Sickle cell?

PAHx; How did they previously react to anaesthetics? Any vomiting with past anaesthesia?

PSHx; Any previous surgeries?

DHx, FHx, SHx

Question 2

Pre op
Examination
Investigations

Answer 2

General examination including cardiac, resp and abdo.

Airway examination- to assess for intubation compatibility.

FBC, U+Es, LFTs, clotting, G+S
Imaging with ECG, CXR.

May also do pregnancy test, sickle cell screen, urinalysis.

Question 3

Pre op management

Answer 3

RAPRIOP

Reassurance

Advice- Stop foods 6hrs before, clear liquids 2hrs before.

Prescriptions-
(I) Drugs to stop; CHOW. Stop clopidogrel 7 days before, hypoG, OCCP 4 weeks before and Warfarin 5 days before.
(II) Drugs to alter; insulin and steroids may need to increase dose and change IV.
(III) Drugs to start; LWMH. If major op start 28 days before. TED stockings; unless contraindicated or vascular surgery. Abx prophylaxis.

Referral- ITU/HDU bed post op?

Investigations

Observations

Pt understanding and follow up

Question 4

Management of diabetic pt

Answer 4

Should be on morning lists.
T1DM-
Admit night before and reduce subcut basal insulin by 1/3. Stop morning insulin and start on IV sliding scale.
Whilst pt NBM give IV dextrose at 125ml/hr and check BG every 2hrs.
If person wishing to start eating again start subcut rapid acting insulin 20 mins before the meal and stop sliding scale 30-60mins after eating.

T2DM-
If on hypoG. Stop metformin morning of surgery and other hypoG 24hrs prior. Then when NBM continue with sliding scale and dextrose just as above.

Question 5

Fluid prescription

Answer 5

Either maintenance, resuscitation or replacement.

Maintenance- Need 25ml/kg/day of water, 1mM/kg/day of Na and K, 50g/day of glucose. 1L Dextrose has 50g glucose and 1L saline has 154mM Na.
Therefore use Na first to get the calculated Na, then make up with dextrose. Infuse over 8hrs each for 3 bags.

Resuscitation- Decide on either 250 or 500ml over 15-30mins, depending on pt type.

Replacement- Consider any third spacing, losses, more stool?

Question 6

Fluid Management-

Answer 6

Fluid given either for replacement, maintenance or resuscitation.
Maintenance-
Na- 1mM/kg/day
K- 1mM/kg/day
Glucose- 50g/day
Water- 25ml/kg/day

Replacement-
250/500ml within 15-30 mins if severely fluid deprived.

Question 7

Blood transfusion-

Answer 7

NICE- Need 70g/L of HB for RBC transfusion.
Ensure women get the correct Rhesus group blood always, to avoid haemolytic disease of the new-born.
Universal donor- O-ve, Acceptor- AB+ve

Requesting blood- 3 forms of ID, consent, written label, write at bedside. Should make separate requests each time.
Green/Grey cannula to avoid shearing of RBC

Question 8

Transfusion types-

Answer 8

Irradiated blood products- For pts at risk of graft-versus-host-disease; inc pts with Hodgkins lymphoma, receving from 1st/2nd degree relative, IUD, chemo.

Packed Red Cells- Chronic iron deficiency, acute blood loss. Over 2-4hrs.

FFP- Has clotting factors; for massive haemorrhages of haemorrhages from liver disease, DIC. Over 30 mins.

Platelets- For haemorrhagic shock, profound thrombocytopenia. Over 30 mins.

Cryoprecipitate- vWF, fibrinogen. For DIC, vW disease. Stat

Question 9

Malnourishment-

Answer 9

Malnourished pt will have increased risk of infection, poorer wound healing and skin breakdown post op.
Conduct MUST score to work out if malnourished. Should increase nutrition but try not to delay surgery. Best way of feeding is orally.
NEED THE ASSISTANCE OF A DIETICIAN!!

Intra op nutrition- Give carb loading pre op, reduce NBM quicker, minimal invasive, early remobilisation.

Post op most pts can safely tolerate orals within 24hrs.

Question 10

Enhanced Recovery After Surgery (ERAS)-

Answer 10

Pre op- Ensure optimal health (wt loss and exercise), medicine optimisation (reduce smoking and alcohol), stop solids 6hrs and clear fluids 2hrs prior op, give carb loading drink 2hrs pre op, pt education about op.

Intra op- Minimal invasion, opioid sparing analgesia, post op N+V prophylaxis.

Post op- Early oral intake, mobilisation, adequate pain control.

Question 11

Day Case Surgery-

Answer 11

Ensure pt adheres to eating and drinking requirements prior. Review meds.
Examples of DCS include- inguinal hernia repair, pregnancy termination, cataract, varicose veins etc.

Social factors- Ensure informed consent and pt has someone to escort them home and provide care in first 24hs post op.
Medical- Ensure pt suitable for DCS.

Question 12

Post op haemorrhage-

Answer 12

Primary- Intra op bleed, correct intra op, monitor post op.
Reactive- Within 24hrs of op. May be due to missed vessel, which vasoconstricted due to pressure of op.
Secondary- Erosion of BV, due to infection.

Need AE assessment, give immediate fluid resus, seek seniors, provide transfusion if moderate-severe bleed, apply pressure to site if visible.

If post (para)thyroidectomy, early sign is airway obstruction- need immediate correction at bedside.
If post laparoscopic suspect inferior epigastric bleed.
If post angiography suspect retroperitoneal leak of external iliac.

Question 13

Sepsis-

Answer 13

Can rapidly diagnose if source of infection + qSOFA of 2+. (RR>22, altered mental state, sys<100)
Identify the source of infection, manage with sepsis 6.
Septic shock if sepsis + hypotension, where fluid not made improvement, and now using inotropes. Need critical care unit.

Question 14

Acute Pain Control-

Answer 14

Simple Analgesia- Paracetamol, NSAIDs.
Weak opiates- codeine
Strong opiates- morphine, oxycodone, fentanyl (use the two later if renal failure).
Ensure to review constantly to allow effective titrating up and down.

Question 15

Post op N+V-

Answer 15

Can impair recovery post op.
RF include female, opiate use (inc anaesthetics), spinal anaesthesia, previous PONV, prolonged operating time, non- smoker etc.
Management:
Prophylactic- Anti-emetics, anaesthetics (reduce opiates and volatile gases, spinals).
Conservative- Analgesia, fluid hydration, NG tube (avoid aspiration).
Pharmaceuticals- Anti emetics depending on the cause.

Question 16

Pyrexia-

Answer 16

Post surgery any day could be due to line infections.
1-2 days- chest infection
3-5 days- urine infection
5-7 days- wound infection
Non infectious causes include DVT, iatrogenic, unknown origin.

Conduct sepsis investigations inc CXR.
If infectious need Abx. Non- infectious find cause. Give fluid, analgesia and anti-pyrexials.

Question 17

Delirium-

Answer 17

Hypoactive- Lethargic and reduced motor. (Most common)
Hyperactive- Agitated and increased motor.
Mixed

Question 18

Post op Atelectasis-

Answer 18

Partial collapse of small airways leading to accumulation of pulmonary secretions, predisposing to complications, occurring within 24hrs post op.
RF: Age, GA, smoking, increased surgery duration etc.
Increased RR, decrease O2 sat +/- pyrexia, fine crackles.
CXR
Manage with deep breathing exercise + analgesia to encourage deep breathing.
Give prophylactic chest physio post surgery.

Question 19

Post op pneumonia-

Answer 19

Likely to get HAP because RF; deceased motility (reduced chest ventilation), immunosuppression, change in commensals, intubation (VAP is common HAP , 48hrs post mech ventilation).
Also RF; Age, smoking, respiratory disease.

NB- aspiration likely affecting R middle/lower lobe.

Question 20

VTE- (i.e. DVT/PE)

Answer 20

Assess VTE risk on admission and within 24hrs/if change.
DVT Wells <1 unlikely DVT-do DD. >1 likely DVT do US.
PE Wells<4 unlikely PE- do DD. >4 likely PE do CTPA.
Prophylaxis includes medical and mechanical (stockings not used in PAD, peripheral oedema or local skin conditions).

Question 21

ARDS-

Answer 21

Acute lung injury (<7 days), pt has severe hypoxaemia w/o cariogenic cause.
Direct causes; pneumonia, smoke, aspiration, fat embolus.
Indirect causes; sepsis, acute pancreatitis, polytrauma, major burns.
Present with worsening dyspnoea leading to hypoxia and tachypnoea.
Treat underlying and give supportive management, ITU.

Question 22

Anastomotic Leak-

Answer 22

Leak of luminal contents 5-7 days post surgery. RF; emergency surgery, smoking, alcohol, obesity, DM etc.
Present with fever and ab pain, need CT contrast abdo/chest.
Manage NBM, IV Abx, fluids, surgical washout/exploration + stoma if major leak.

Question 23

Post op ileus-

Answer 23

Reduced bowel function- functional bowel obstruction.

RF; Older, electrolyte imbalance, intestinal handling, opioids. Should reduce modifiable RF prophylactically.

Manage; daily bloods, NBM, encourage mobilisation, reduced opiates.

Question 24

Bowel Adhesions-

Answer 24

Can cause SB obstruction, infertility and chronic pelvic pain.
Conservative management in uncomplicated SBO- decompression, NMB, IV fluids, analgesia.
Surgical if persistent, ischaemia or perforation.

Question 25

Incisional Hernia-

Answer 25

Hernia at the site of scar.
RF: obese, midline scar, emergency surgery, old age etc.
Usually asymptomatic.
Manage conservatively if small and not fit for surgery. Otherwise can consider surgical repair.

Question 26

Constipation-

Answer 26

Common post op complaint. Perform DRE!
Hard stool/chronic- use stool-softening laxative- movicol/lactulose.
Post op ileus/opiod induce- stimulant laxative- senna.
Resistant cases- Manual evacuation or enema.

Question 27

AKI-

Answer 27

50%+ increase in serum creatinine over 7 days.
26.5mM+ increase in serum creatinine within 48hrs.
<0.5ml/kg/hr urine output for >6hrs.

Severity depends on creatinine level relative to baseline.
Stage 1: 1.5-1.9x baseline
Stage 2: 2-2.9x baseline
Stage3: >3x baseline

Question 28

Acute Urinary Retention-

Answer 28

RF: Male, >50yrs, previous retention, pelvic/uro surgery etc.
Assess with dip and ultrasonic bladder scan.
Manage conservatively, if not managing then catheterise.

Question 29

UTI-

Answer 29

Common post op.
RF; Female, >60yrs, pregnancy, catheter, previous retention.
Test with dip, MC&S, may need bladder scan.
Treat with hydration, empirical Abx and monitor UO.

Question 30

HypoG-

Answer 30

Dizzy, sweating, tingling lips and extremities, tremor, slurred speech, tachycardia/pnoea.
Common cause is iatrogenic with insulin/hypoglycaemics.
Manage conscious pt- oral glucose and monitor 2hrly, if not improved then IV.
Unconscious- Stabilise airway, then IV glucose, if can’t get access then IM glucagon.
Intra op check BM every 30 mins for diabetic.

Question 31

HyperK-

Answer 31

Caused commonly by post op AKI, K+ sparring drugs/ACEi etc.
Usually asymp but paraesthesia, muscle weakness, palpitations.
Treat by protecting myocardium, reducing serum K+ and reducing body K+.
Investigate with bloods, VBG, ECG.

Question 32

HypoK-

Answer 32

Even small drops can lead to cardiac arrhythmias.
Caused by increased loss (diuresis, vomiting, diarrhoea, burns etc), decreased intake, intracellular shifts (alkalosis, XS insulin etc).
Treat with oral K+, if not effective then IV.
Investigate with bloods, VBG, ECG.

Question 33

HyperNa-

Answer 33

Hypovolaemic- diuretics, dehydration, ATN etc
Euvolemic- DI
Hypervolaemic- XS saline.
Usually XS thirst but also neurological deficits common.
Manage cause i.e. fluid replenishment, correct Na.
DONT ADJUST NA TOO QUICKLY TO AVOID CEREBRAL OEDEMA!!

Question 34

HypoNa-

Answer 34

Most common post op electrolyte imbalance. Can lead to oedema- poor wound healing, raised ICP, cerebral oedema etc.
Hypovolaemia- Diuretics
Euvolemic- SIADH
Hypervolaemia- ATN
Usually asymp but profound- significant cerebral dysfunction.
Manage with fluid balance, IV fluids, replace Na, monitor renal etc.