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Peri-op care Flashcards

1
Q

What are the ASA grades

A

Grade 1: normally healthy

Grade 2: mild systemic disease

Grade 3: severe systemic disease

Grade 4: severe systemic disease, constant threat to life

Grade 5: not expected to survive without operation

E: emergency

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2
Q

Which scoring system is used to predict the ease of intubation

A

Mallampati

1 (easiest) - 4 (hardest)

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3
Q

What advice should be given to patients about fasting pre-op

A

Stop eating 6 hrs before surgery

Stop dairy products 6 hrs before surgery

Stop clear fluids 2 hrs before surgery

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4
Q

Which prescriptions need to be stopped pre-op

A

CHOW

Clopidogrel (7 days before, aspirin and other antiplatelets can often be continued)

Hypoglycaemics

Oral contraceptive pill or HRT (4 weeks before)

Warfarin (5 days before, switch to LMWH)

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5
Q

Which prescriptions need to be altered pre-op

A

Subcut insulin (change to IV variable rate insulin)

Long term steroids (need to continue due to addinsonian crisis, switch to IV if not able to take oral)

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6
Q

Which prescriptions need to be started pre-op

A

LMWH (discharge with 28 day prophylaxis)

TED stocking

Antibiotic prophylaxis (orthopaedic, vascular, GI)

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7
Q

What are the contraindications for TED stockings

A

Severe peripheral vascular disease

Peripheral neuropathy

Recent skin graft

Severe eczema

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8
Q

How do type 1 diabetics need to be managed pre-op

A

First patient on morning list

May need overnight admission

Night before: decrease SC insulin by 1/3

Don’t take morning insulin, start sliding scale

Whilst NBM: 5% dextrose infusion, check BM every 2 hours

Once eating and drinking again, transition from sliding scale back to SC insulin

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9
Q

How do type 2 diabetics need to be managed pre-op

A

If diet-controlled, no action needed

Metformin stopped on morning of surgery

Other meds stopped 24 hrs before surgery

Start sliding scale and dextrose

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10
Q

How might fluid depletion present

A

Dry mucous membranes

Reduced skin turgor

Decreased urine output

Orthostatic hypotension

Increased capillary refill time

Tachycardia

Low blood pressure

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11
Q

How might fluid overload present

A

Raised JVP

Peripheral/sacral oedema

Pulmonary oedema

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12
Q

What electrolyte imbalances are seen in vomiting

A

Low K+

Low Cl-

Alkalosis

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13
Q

What electrolyte imbalances are seen in diarrhoea

A

Low K+

Acidosis

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14
Q

Which patients need irradiated blood products

A

Receiving blood from 1st/2nd degree relative

Hodgkin’s lymphoma

Recent haematopoietic stem cell transplant

Anti-thrombocyte globulin

Purine analogue chemotherapy

Intra-uterine transfusion

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15
Q

When should checks be carried out when transfusing blood products

A

Before start

At 15-20 mins

At 1 hr

On completion

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16
Q

What are the different classes of bleeding related to operating

A

Primary bleed: during intra-op period, should be resolved during op

Reactive bleed; within 24 hrs of op, usually from slipped ligature or missed vessel

Secondary bleed: 7-10 days after op, erosion of vessel from spreading infection

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17
Q

How is post-op haemorrhage managed

A

A to E

Read op notes

Direct pressure if site visible

Urgent senior surgical review

Urgent blood transfusion

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18
Q

What are the 7 causes of pyrexia in surgical patients

A

Chest infection

Cut (wound infection)

Catheter (UTI)

Collection (abdomen, pelvis)

Calves (DVT)

Cannula (infection)

Central line (infection)

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19
Q

What are the risk factors for post-op nausea and vomiting

A

F>M

Younger age

Previous post-op N+V

Opioid analgesia use

Non-smoker

Prolonged operative time

Certain surgeries (intra-abdo laparoscopic, intracranial, middle ear, squint, gynae)

Poor pain control

Spinal analgesia

Intra-op dehydration/bleeding

Overuse of bag and valve mask

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20
Q

How can the time post-op suggest the source of post-op pyrexia

A

Day 1-2: respiratory cause

Day 3-5: urinary tract cause

Day 5-7: surgical site infection, abscess/collection

Any day: infected IV/central line

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21
Q

What is acute respiratory distress syndrome

A

A form of acute lung injury

Characterised by severe hypoxaemia and absence of cardiogenic cause

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22
Q

When does acute respiratory distress syndrome occur

A

When there is inflammatory damage to the alveoli, leading to:

Pulmonary oedema

Respiratory compromise

Acute respiratory failure

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23
Q

What is the Berlin definition of acute respiratory distress syndrome

A

Acute onset within 7 days

PaO2:FiO2 ratio < 300

Bilateral infiltrates on CXR

Alveolar oedema not explained by fluid overload or cardiogenic cause

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24
Q

What are the causes of acute respiratory distress syndrome

A

Pneumonia

Smoke inhalation

Aspiration

Fat embolus

Sepsis

Acute pancreatitis

Polytrauma

Major burns

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25
What are the phases of acute respiratory distress syndrome
Exudative: diffuse alveolar damage, direct alveolar and endothelial injury (cytokine and inflammatory mediators released) Proliferative: progressive restoration of alveolar-capillary membrane integrity, attempting to normalise alveolar structure, new surfactant production Fibrotic: extensive fibrin deposition across lungs, substantial long term morbidity (need LTOT or ventilator)
26
How might acute respiratory distress syndrome present
Worsening dyspnoea Rapid: hypoxia, tachypnoea, inspiratory crackles Acute onset
27
What are the differentials for acute respiratory distress syndrome
Congestive heart failure Interstitial lung disease Diffuse alveolar haemorrhage Drug-induced lung injury
28
What investigations are needed for acute respiratory distress syndrome
ABG Routine bloods CXR (diffuse bilateral infiltrates) ECHO (exclude cardiogenic causes)
29
How is acute respiratory distress syndrome managed
Ventilation Treat underlying cause Likely to need ITU (aim to limit inflammatory cascade and reduce alveolar injury)
30
What are the poor prognostic factors for acute respiratory distress syndrome
40% mortality Increased age Multiple co-morbidities Active malignancy Liver disease
31
What is post-op atelectasis
Partial collapse of small airways Develops in most post-op patients to some degree Precursor to more severe post-op respiratory complications
32
What are the risk factors for post-op atelectasis
Age Smoking GA use Pre-existing lung/neuromuscular disease Prolonged bed rest Poor post-op pain control (shallow breathing)
33
How might post-op atelectasis present
Respiratory compromise (increased respiratory rate, reduced oxygen saturations) Fine crackles Reduced sats Low-grade fever
34
What investigations are needed for post-op atelectasis
Clinical diagnosis CXR (small areas of airway collapse)
35
What is the management for post-op atelectasis
Deep breathing exercises Chest physio Analgesia Bronchoscopy (suck out pulmonary secretions)
36
Why are surgical patients predisposed to developing LRTIs
Reduced mobility Changes in commensals Debilitation Intubation
37
What is ventilator-associated pneumonia
HAP occurring > 48 hrs after tracheal intubation Tube interferes with normal protective upper airway reflexes (prevents cough, encourages aspiration of pharyngeal contents)
38
What is Virchow's triad
Abnormal blood flow (recent immobility) Abnormal blood components (smoking, sepsis, malignancy, inherited blood disorders) Abnormal vessel walls (atheroma formation, inflammatory response, direct trauma)
39
What is anastomotic leak
Leak of luminal contents from a surgical join Delays can lead to contamination of chest/abdomen (get severe sepsis) Until proven otherwise, consider in all post-op patients who: do not progress as expected, deteriorate after surgery
40
What are the risk factors for anastomotic leak
Medications (corticosteroids, immunosuppressants) Smoking Alcohol Diabetes Obesity/malnutrition Emergency surgery Longer intra-op time Peritoneal contamination Oesophageal-gastric or rectal anastomosis
41
How might anastomotic leak present
Abdominal pain Fever 5-7 days post-op Delirium Prolonged ileus Tachycardia Signs of peritonism Faeculent/purulent material/bile in drains
42
What investigations are needed for anastomotic leak
CT with contrast (shows presence of extraluminal contents) Urgent bloods (normal + clotting) VBG (assess level of tissue perfusion) Repeat group and save
43
What is the management for anastomotic leak
Early resus Senior input NBM Broad spectrum antibiotics IV fluids Catheter Consider percutaneous drainage Exploratory laparotomy if: septic, multiple collections, extensive washout, large drain inserted
44
What is post-op ileus
Deceleration/arrest of intestinal motility Functional bowel obstruction Very common in abdominal or pelvic ortho surgery Lengthens hospital stays
45
What are the risk factors for post-op ileus
Increasing age Electrolyte derangement Neurological disorders Use of anti-cholinergics Opioid use intra-op Pelvic surgery Extensive intra-op intestinal bleeding Peritoneal contamination Intestinal resection
46
How might post-op ileus present
Failure to pass flatulence or faeces Bloating and abdominal distension Nausea or vomiting Absent bowel sounds
47
What investigations are needed for post-op ileus
Bloods CT abdo-pelvis (rule out intra-abdominal collections or anastomotic leak)
48
What is the management for post-op ileus
NB, IV fluids Electrolyte monitoring Encourage mobilisation Reduce opiate analgesia
49
What are the prophylactic measures for post-op ileus
Minimise intra-op intestinal handling Avoid fluid overload Minimise opiate use Encourage early mobilisation
50
What are bowel adhesions
Fibrous bands of scar tissue Due to: congenital, surgery, intra-abdominal inflammation One of the main causes of bowel obstruction Associated with: female infertility, chronic pelvic pain
51
How might bowel adhesions present
Generally asymptomatic Effects of adhesions: obstruction, infertility, pelvic pain
52
What is the management for bowel adhesions
Tube decompression NBM Analgesia Surgery for: ischaemia, perforation, failure of conservative treatment Adhesiolysis Laparoscopic management
53
What is incisional hernia
Protrusion of the contents of a cavity through a previously made incision in the compartment wall Very common complication of abdominal surgery
54
What are the risk factors for incisional hernia
Emergency surgery Wound type BMI > 25 Midline incision Wound infection Pre-op chemo Intra-op blood transfusion Advancing age Pregnancy Steroid use Smoking Connective tissue disease
55
How might incisional hernia present
Non-pulsatile, reducible, soft and non-tender swelling at/near surgical wound site If incarcerated: painful, tender, erythematous In bowel obstruction: abdominal distension, vomiting, absolute constipation
56
What investigations are needed for incisional hernia
Clinical diagnosis Ultrasound/CT if diagnosis unclear
57
What is the management for incisional hernia
Suture repair Laparoscopic repair Open mesh repair
58
What is involved in intra-op glucose monitoring
For diabetic patients Measure BMs every 30 mins Consider sliding scale during procedure If glucose < 4: increase IV glucose rate, stop insulin infusion, check for improvement after 30 mins If glucose < 2: treat as hypoglycaemic emergency
59
What are the risk factors for surgical site infection
Extremes of age Poor nutritional state Diabetes Renal failure Immunosuppression Smoking Pre-op shave of site Lengthy operation Foreign material in surgical site Insertion of surgical drain Poor closure of wound
60
How might surgical site infection present
Usually 5-7 days post-op Spreading erythema Localised pain Pus/discharge Wound dehiscence Persistent pyrexia Deep infections: extensive wound breakdown, rarely need debridement and open wound care
61
What investigations are needed for surgical site infection
Wound swabs Bloods Blood cultures
62
What is the management for surgical site infection
Remove sutures/clips Allow pus to drain Empirical antibiotics
63
What is wound dehiscence
Wound fails to heal Wound sometimes re-opens after surgery
64
What are the classifications of wound dehiscence
Superficial: skin wound fails to heal, rectus sheath remains intact. Due to: localised infection, poorly controlled diabetes, poor nutritional status Full thickness: rectus sheath fails to heal and bursts, protrusion of abdominal contents. Due to: raised intra-abdominal pressure, poor surgical technique, critically unwell patient
65
What are the risk factors for wound dehiscence
Increasing age M>F Co-morbidities Steroid Smoking Obesity/malnutrition Emergency surgery Abdominal surgery Lengthy operation Wound infection Poor surgical technique Blood transfusion Poor tissue perfusion Radiotherapy Excessive coughing
66
How might wound dehiscence present
Visible opening of wound (5-7 days post-op) New bulging of wound Seepage of fluid Sudden increase in wound discharge
67
What investigations are needed for wound dehiscence
Clinical diagnosis Wound swabs
68
What is the management for wound dehiscence
Washout Simple wound care Vacuum-assisted closure Analgesia Broad spectrum antibiotics Cover in saline-soaked gauze Surgical closure
69
What is keloid scar
Abnormal proliferation of scar tissue Forms at site of skin injury Rises above skin level Projects beyond wound margins Does not regress 20-30s
70
What is the pathophysiology of keloid scar
Prolonged inflammatory phase in wound healing (immune cell infiltration of scar tissue) Excess fibroblast activity Increased deposition of ECM Tissue projects beyond wound margin
71
What are the risk factors for keloid scar
Ethnicity 20-30 Burns Ear lobe, shoulder, sternal notch Previous keloid formation
72
How might keloid scar present
Characteristic visual appearance Some have pain/itching/burning
73
What are the stages of keloid scar
Erythematous Brown/red Turn pale as they age
74
What scale is used to quantify features of keloid scar
Vancouver scale
75
What is the management for keloid scar
Intralesional steroids (downregulates proliferation of fibroblasts, inhibits collagen synthesis) Silicone gel Radiation therapy Surgery rare (high rates of recurrence)

Surgery (7 decks)

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