Peri Op Flashcards

Question

Neuro comps early

Answer 1

Hypoglycaemia and not waking Drugs Diabetic is risk factor for brain injury ``` Pain Hard to measure Bad Many dimensions Physical Functional - agg/ reliev, disab Behavioural - rubbing, guarding, grimacing Affect - dep Cognition - understanding ``` Confusion/ agitation Hypothermia and shivering

Answer 2

``` PONV Ileus Intra abdominal surgery Drugs (Urinary retention) ```

Answer 3

Patient factors: child, female, anxiety, motion sickness, history Surgical factors Gynae, ENT, c(operation to rectus muscle), GI, breast, long duration Anaesthetic factors Gases, opioids, pain, dehydration Adverse effects Dehydration, oral medication, delayed discharge, aspiration, distress, poor surgical outcome

Answer 4

``` Prevention Treat pain Hydration Anti-emetics Ondansetron Cyclizine/ Proclorpermazine Dexamethasone ```

Answer 5

``` Low BP - drugsw, epidurals, vol loss How can you tell if hypertension is due to hypovolaemia? Hypertension - Pain, pre op BP MI Day 3 most common Pre op ECG important Risk factors Prevention VTE DVT/PE ```

Answer 6

Risk assess before | Early mobilization, hydration, pain/vomiting control

Answer 7

Pneumonia | PE

Answer 8

``` Obstruction Adhesion Wound break down Dehiscence - wound coming apart at surgical incision Graft failure ```

Answer 9

Yes CCBs and BBs | Not diuretics or ACEi

Answer 10

I. A normal healthy patient II. A patient with mild systemic disease (obesity 30-40) III. A patient with severe systemic disease IV. A patient with severe systemic disease that is a constant threat to life V. A moribund patient who is not expected to survive without the operation. VI. A declared brain-dead patient whose organs are being removed for donor purposes The addition of an 'E' indicates emergency surgery.

Answer 11

Until discharge

Answer 12

Fully conscious, able to maintain airway Resp and sats are satisfactory CVS stable with no cardiac irrgulaity/ bleeding. Pulse and BP acceptable. Pain and emesis controlled, suitable analgesic and antiemetic prescribed O2 and IV prescribed

Answer 13

5HT antagonists e.g. Ondansetron, (Metaclopramide) - Blocks vagal afferent and central vomiting centre Dopamine (D2) antagonist e.g. Prochloperazine, Metaclopramide (also anticholin), Domperidone - increase gastric emptying, antagonises chemoreceptor trigger zone in medulla. D2 can cause Prolactin and extrapyradimal. H1 antagonists e.g. Cyclizine (also antimuscurinic) - motion sickness and opioid. Acts on vomiting centre Corticosteroid e.g. dexameth (unknown MoA), not licensed for PONV, used in surgery Prochlorperazine first line unless risk of extrapyramidal. Cyclizine can be first line but CI in HF (low BP). If first doesn't work use one with different MoA. Metoclopramide ineffective for PONV

Answer 14

sleepiness, dry mouth, constipation, and trouble with vision.[5] More serious side effects include low blood pressure and urinary retention

Answer 15

An unpleasant experience specific to the individual assoc with actual or potental damaged and described in terms of such damage (chronic >3 months prehaps without identifiable cause) Better pt outcomes

Answer 16

FACES - children NRS - numical rating scale FLACC - Faces, legs, activity, cry and consolability 2m-7y (0-2 for each)

Answer 17

Non opioids - para/NSAID Weak opioids e.g. codeine/ tram Strong opiods - morphine, oxycodeine, diamorphine Intervention Optional adjuvant at each stage

Answer 18

Base of skull fractures (good for seizures or low GCS) bruising behind the ears, bruising around the eyes, or blood behind the ear drum.[1] A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and can result in fluid leaking from the nose or ear.[1] Meningitis

Answer 19

hyperchloraemic acidosis (relative loss of bicarb?)

Answer 20

Risk of acute renal injury in sepsis | Anaphylaxis

Answer 21

Transmission of painful stimulus without consciousness Pain requires consciousness - what the patients says * The perception of physical pain * Non conscious neural traffic originating with trauma or potential traum tissue * Pain is a complex, unpleasant awareness of a sensation * Modified by experience, expectation, immediate context, culture ect.

Answer 22

* Tranduction – activation of nociceptors * Transmission – replay of action potentials along nociceptive fibres to CNS * Modulation – by other peripheral nerve or CNS mechanism * Perception – where its felt interpreted by the brain.

Answer 23

``` Brain Paacetamol opioids Water therapy (drinking loads of water upon waking), hypnosis, personality Spinal cord TENS - Transcutaneous electrical nerve stimulation for MSK pain - pads on hips Opioids, capsaicin (chilli), LA Periphery NSAIDs, LA ```

Answer 24

Caution in liver failure and <50kg

Answer 25

Phase 2 normally | Some does phase 1 to NAPQI

Answer 26

Cauting in renal failure, bleedig, fluid retention, bronchospas, (10% of asthmatics), Gi disturbance

Answer 27

COX 1 - lining of stomach and clotting | COX 2 - Pain fever and inflammation

Answer 28

``` Variable metab (CYP) Resp dep Constipation Available IV 10x less potent than morphine ```

Answer 29

x 5-10 times less potent than morphine Oral, IM IV Inhibits Na and 5HT reiptake - interact with SSRI and TCA Lowers seizure threshold - epilepsy

Answer 30

Can be used as TIVA | Remifentanil is approximately twice as potent as fentanyl, and 100-200 times as potent as morphine.

Answer 31

``` Longer lasting in higher doses Can be spinal or epidural Patches and lozenges for chronic pain Onset in 3.5mins 80 to 100 times more potent than morphine ```

Answer 32

Short term pain relief e.g. Manipulation of fractures Obtunds (dulls) the stimulation of laryngoscopy Sedation or analgesia in theatre Al -fentanyl faster onset than fentanyl Stays in fat and gives side effects including delayed depression It is an analogue of fentanyl with around 1/4 to 1/10 the potency of fentanyl and around 1/3 of the duration of action, but with an onset of effects 4x faster than fentany (10-25x morphine?)

Answer 33

Used as reference Titrate to avoid ADRs Morphine 6 glucoronide is metabolite which is 13 times more potent Oromorph is not controlled

Answer 34

Prodrug 2-4 times more potent than morphine More lipid soluble

Answer 35

Oromorph - 50% 1st pass so need x2 | Oxycodone, Oxynorm

Answer 36

True allergy is rare (often insensitivity) If insensitive: Titrate Pre administed anti emetic drug Give antihistamines IN true allergy uyse RA and LA, Para and NSAIDs, Entonox, antispasmodics

Answer 37

``` Clonidine - a2 adrenergic agonist and imidazoline receptor agonist Spinal or IV Ket LA infusion Regional, wound, IV Gabapentin Midazolam, Diazepam Chloral hydrate - enhances GABA ```

Answer 38

EMLA - Eutectic mixture of LA (procaine/ lidocaine)

Answer 39

``` Epidural LA into extradural space Last 5 days as an epidural catheter is inserted Full paralysis? Spinal anaesthetic LA Into CSF surrounding spinal cord Lasts 2-3 hours ```

Answer 40

``` 50mg morphine/ 50ml saline syringe, computer controlled 1mg bolus given 5 min lockout Plasma levels vary less Higher satisfaction scores ```

Answer 41

Anaesthesia - without sensation (still feel pain) | Analgesia - without pain

Answer 42

INferior epigastric artery

Answer 43

A group and save is the sample processing • It consists of a blood group and an antibody screen to determine the patients group and whether or not they have atypical red cell antibodies in their blood. If atypical antibodies are present the laboratory will do additional work to identify them Department of Clinical Haematology H.91 Page 2 of 3 March 2015 V1.0 Transfusion Laboratory FAQ’s Authorised by: Julie Staves This is a controlled document and therefore must not be changed • A crossmatch is when the laboratory actually provides red cells products for the patient. It is not possible for the lab Cross match (total 1-2 hours) electronic cross match only if negative Ab screen (takes 1 hour total, including G&H) serological cross match of patients plasma with donor cells if positive Ab screen (takes 2 hours total)

Answer 44

GS low chance of transfusion e.g. Hysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomy Cross match 2 units if likely Salpingectomy for ruptured ectopic pregnancy, total hip replacement Crossmatch 4-6units if definite chance Total gastrectomy, oophorectomy, oesophagectomy Elective AAA repair, cystectomy, hepatectomy

Answer 45

1) Before the induction of anaesthesia (sign in) 2) Before the incision of the skin (time out) 3) Before the patient leaves the operating room (sign out).

Answer 46

Patient has confirmed: Site, identity, procedure, consent Site is marked Anaesthesia safety check completed Pulse oximeter is on patient and functioning Does the patient have a known allergy? Is there a difficult airway/aspiration risk? Is there a risk of > 500ml blood loss (7ml/kg in children)?

Answer 47

Haemostasis - minutes to hours, vasospasm, platelet plug and clot Inflammation - days 1-5, neutrophils, GFs, fibroblasts, clot substritution, matrix regen Regeneration - Platelet derived GF, fibroblasts and epithelial cells are stimulates, angiogenesis - granulation tissue Remodelling - 6 weeks to 1 year

Answer 48

``` Excessive collagen Nodules Randomly arranged fibrils within Confined to wound From a full thickness dermal injury May lead to contracture ```

Answer 49

``` Excessive collagen Beyond boudarie No nodule May be trivial injury Do not regress and may recur if removed ```

Answer 50

DMARDs NSAIDs Steroids Anti neoplastic drugs

Answer 51

Laproscopic

Answer 52

Most Hickman lines are inserted under local anaesthesia with image guidance. They have a cuff that usually becomes integrated with the surrounding tissues. This requires a brief dissection during line removal. into internal JUg VEin and tunneled under skin

Answer 53

nsertion is more difficult and most operators and NICE advocate the use of ultra sound. Coagulopathies may lead to haemorrhage following iatrogenic arterial injury. Femoral lines are easier to insert and iatrogenic injuries easier to manage in this site however they are prone to high infection rates. Internal jugular route is preferred. They have multiple lumens allowing for administration of multiple infusions. The lumens are relatively narrow and thus they do not allow particularly rapid rates of infusion.

Answer 54

Post-operative ileus is a common complication in colorectal surgery due to intra-operative bowel handling. Management is conservative with nasogastric tube insertion for stomach decompression for symptom control and placing the patient nil by mouth to allow bowel rest. The recommencement of fluids/light diet should be in stages and guided by the clinical state of the patient.

Answer 55

removal of urinary catheter, constipation, immobility, opiate analgesia, infection, haematuria and benign prostatic hyperplasia

Answer 56

Pseudocholinesterase deficiency (also known as suxamethonium apnoea) is a rare abnormality in the production of plasma cholinesterases. This leads to an increased duration of action of muscle relaxants used in anaesthesia, such as suxamethonium. Respiratory arrest is inevitable unless the patient can be mechanically ventilated safely while waiting for the circulating muscle relaxants to degrade.

Answer 57

Hypotension/ brady (loss of symp) Loss of badder control (catheter always placed) pruitis Headaches Sickness Resp depression (diaphragm and intercostal muscles) Epidural analgesia typically involves using the opiates fentanyl or sufentanil, with bupivacaine or one of its congeners Side effects common to opiods Bupivacaine has caused several deaths by cardiac arrest when epidural anaesthetic has been accidentally inserted into a vein instead of the epidural space. Causes excitation followe by depression if IV.

Answer 58

Elderly Short term decline in cognitive function, especially memory and executive function that may last from a few days to a few weeks after surgery >60 risk of long term cognitive damage

Answer 59

Drugs - Midazolam - Sedative - Alc cessation - Substance abuse Infection - UTI - Advanced cancer - Organ failure - Substance abuse Hypoxia - Decreased cerebral perfusion Other - Dehydration and nutritional status Age Dementia/ stroke/ parkinsons ``` Just as likely under regional than GA More likely under major ops MOre likely with high alcohol Higher ASA Lower educational level HIstory of strokw MCI, Cardiac surgery ```

Answer 60

``` Avoid hypoxia - monitoring Social contacts Day-night rhythm Early discharge Nutritional status and hydration ```

Answer 61

1. The doctor carrying out the proposed procedure or investigation. 2. Another doctor or health professional provided that they have been suitably trained, have sufficient knowledge of the proposed procedure and understand the risks associated.

Answer 62

Impairment of disturbed functioning of the mind Patient unable to make a decision In relation to the second question, the MCA says a person is unable to make a decision if they cannot: understand the information relevant to the decision retain that information use or weigh up that information as part of the process of making the decision Communicate it Situation and time specific not patient specific

Answer 63

This is a right subcostal or Kocher incision. This is commonly used for open liver or gallbladder surgery. When access to the left lobe of the liver is required, a right subcostal incision is combined with a left subcostal incision and the two joined at the xiphoid. This incision is referred to as a rooftop incision.

Answer 64

Caudate = posterioir and superior Quadrate = posterior and inferior Left and right lobes

Answer 65

This shows an upper midline laparotomy. This is used for access to the upper abdominal organs. In emergency situations when access to all four quadrants of the abdomen is required, a full midline laparotomy is employed, extending the incision above and below the umbilicus for a suitable distance.

Answer 66

This shows an upper midline laparotomy. This is used for access to the upper abdominal organs. In emergency situations when access to all four quadrants of the abdomen is required, a full midline laparotomy is employed, extending the incision above and below the umbilicus for a suitable distance.

Answer 67

This is a Lanz incision and is commonly used for open appendicectomy.

Answer 68

Not frequently - sometimes right to avoid awkward full midline when looking for pathology

Answer 69

This shows a Pfannenstiel incision. This is commonly emplyed for gynaecological surgery (Caesarean section, hysterectomy) because the incision is hidden below a female’s bikini line.

Answer 70

Inspection – is the patient comfortable, distressed, obviously distended, dehydrated, jaundiced, anaemic? Is there evidence of previous surgery? ii) Palpation – is there tenderness, guarding, rigidity, the presence of any organomegaly or masses. iii) Percussion – is the abdomen tympanitic (resonant percussion note throughout which occurs with gaseous distention of the large bowel in obstruction or with free intraperitoneal air in perforation)? Is there dullness in the flanks suggesting free fluid or ascites iv) Auscultation – are there bowel sounds present? Additional tests – shifting dullness, groin / inguinoscrotal examination, pelvic examination (rectal and or vaginal).

Answer 71

are there bowel sounds present? Bowel sounds are frequently absent in the presence of peritonitis or for the first few days after surgery (ileus). Are they normal in frequency? Bowel sounds become more frequent in the presence of intestinal obstruction. In small bowel obstruction, they have a high pitched, tinkling character (akin to a small volume of liquid being shaken in a bottle). In gastric outlet obstruction, a gastric succusion splash may be audible. To elicit this, a stethoscope is placed in the left upper quadrant and patient is gently shaken from side to side. Make sure you explain this test to the patient beforehand. v) Additional tests – shifting dullness, groin / inguinoscrotal

Answer 72

A laparoscopic appendectomy has a shorter hospital stay, shorter recovery time, and lower infection rates. Bleeding Wound infection (peritonitis) Blocked bowels Abcess (pus filled bowel) needing drainage

Answer 73

Excessive bleeding Wound infection Incisional hernia

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Peri Op Flashcards

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