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Surgery > Peri-op care > Flashcards

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
Q

What are the phases of acute respiratory distress syndrome

A

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)

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26
Q

How might acute respiratory distress syndrome present

A

Worsening dyspnoea

Rapid: hypoxia, tachypnoea, inspiratory crackles

Acute onset

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27
Q

What are the differentials for acute respiratory distress syndrome

A

Congestive heart failure

Interstitial lung disease

Diffuse alveolar haemorrhage

Drug-induced lung injury

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28
Q

What investigations are needed for acute respiratory distress syndrome

A

ABG

Routine bloods

CXR (diffuse bilateral infiltrates)

ECHO (exclude cardiogenic causes)

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29
Q

How is acute respiratory distress syndrome managed

A

Ventilation

Treat underlying cause

Likely to need ITU (aim to limit inflammatory cascade and reduce alveolar injury)

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30
Q

What are the poor prognostic factors for acute respiratory distress syndrome

A

40% mortality

Increased age

Multiple co-morbidities

Active malignancy

Liver disease

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31
Q

What is post-op atelectasis

A

Partial collapse of small airways

Develops in most post-op patients to some degree

Precursor to more severe post-op respiratory complications

32
Q

What are the risk factors for post-op atelectasis

A

Age

Smoking

GA use

Pre-existing lung/neuromuscular disease

Prolonged bed rest

Poor post-op pain control (shallow breathing)

33
Q

How might post-op atelectasis present

A

Respiratory compromise (increased respiratory rate, reduced oxygen saturations)

Fine crackles

Reduced sats

Low-grade fever

34
Q

What investigations are needed for post-op atelectasis

A

Clinical diagnosis

CXR (small areas of airway collapse)

35
Q

What is the management for post-op atelectasis

A

Deep breathing exercises

Chest physio

Analgesia

Bronchoscopy (suck out pulmonary secretions)

36
Q

Why are surgical patients predisposed to developing LRTIs

A

Reduced mobility

Changes in commensals

Debilitation

Intubation

37
Q

What is ventilator-associated pneumonia

A

HAP occurring > 48 hrs after tracheal intubation

Tube interferes with normal protective upper airway reflexes (prevents cough, encourages aspiration of pharyngeal contents)

38
Q

What is Virchow’s triad

A

Abnormal blood flow (recent immobility)

Abnormal blood components (smoking, sepsis, malignancy, inherited blood disorders)

Abnormal vessel walls (atheroma formation, inflammatory response, direct trauma)

39
Q

What is anastomotic leak

A

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
Q

What are the risk factors for anastomotic leak

A

Medications (corticosteroids, immunosuppressants)

Smoking

Alcohol

Diabetes

Obesity/malnutrition

Emergency surgery

Longer intra-op time

Peritoneal contamination

Oesophageal-gastric or rectal anastomosis

41
Q

How might anastomotic leak present

A

Abdominal pain

Fever

5-7 days post-op

Delirium

Prolonged ileus

Tachycardia

Signs of peritonism

Faeculent/purulent material/bile in drains

42
Q

What investigations are needed for anastomotic leak

A

CT with contrast (shows presence of extraluminal contents)

Urgent bloods (normal + clotting)

VBG (assess level of tissue perfusion)

Repeat group and save

43
Q

What is the management for anastomotic leak

A

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
Q

What is post-op ileus

A

Deceleration/arrest of intestinal motility

Functional bowel obstruction

Very common in abdominal or pelvic ortho surgery

Lengthens hospital stays

45
Q

What are the risk factors for post-op ileus

A

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
Q

How might post-op ileus present

A

Failure to pass flatulence or faeces

Bloating and abdominal distension

Nausea or vomiting

Absent bowel sounds

47
Q

What investigations are needed for post-op ileus

A

Bloods

CT abdo-pelvis (rule out intra-abdominal collections or anastomotic leak)

48
Q

What is the management for post-op ileus

A

NB,

IV fluids

Electrolyte monitoring

Encourage mobilisation

Reduce opiate analgesia

49
Q

What are the prophylactic measures for post-op ileus

A

Minimise intra-op intestinal handling

Avoid fluid overload

Minimise opiate use

Encourage early mobilisation

50
Q

What are bowel adhesions

A

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
Q

How might bowel adhesions present

A

Generally asymptomatic

Effects of adhesions: obstruction, infertility, pelvic pain

52
Q

What is the management for bowel adhesions

A

Tube decompression

NBM

Analgesia

Surgery for: ischaemia, perforation, failure of conservative treatment

Adhesiolysis

Laparoscopic management

53
Q

What is incisional hernia

A

Protrusion of the contents of a cavity through a previously made incision in the compartment wall

Very common complication of abdominal surgery

54
Q

What are the risk factors for incisional hernia

A

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
Q

How might incisional hernia present

A

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
Q

What investigations are needed for incisional hernia

A

Clinical diagnosis

Ultrasound/CT if diagnosis unclear

57
Q

What is the management for incisional hernia

A

Suture repair

Laparoscopic repair

Open mesh repair

58
Q

What is involved in intra-op glucose monitoring

A

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
Q

What are the risk factors for surgical site infection

A

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
Q

How might surgical site infection present

A

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
Q

What investigations are needed for surgical site infection

A

Wound swabs

Bloods

Blood cultures

62
Q

What is the management for surgical site infection

A

Remove sutures/clips

Allow pus to drain

Empirical antibiotics

63
Q

What is wound dehiscence

A

Wound fails to heal

Wound sometimes re-opens after surgery

64
Q

What are the classifications of wound dehiscence

A

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
Q

What are the risk factors for wound dehiscence

A

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
Q

How might wound dehiscence present

A

Visible opening of wound (5-7 days post-op)

New bulging of wound

Seepage of fluid

Sudden increase in wound discharge

67
Q

What investigations are needed for wound dehiscence

A

Clinical diagnosis

Wound swabs

68
Q

What is the management for wound dehiscence

A

Washout

Simple wound care

Vacuum-assisted closure

Analgesia

Broad spectrum antibiotics

Cover in saline-soaked gauze

Surgical closure

69
Q

What is keloid scar

A

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
Q

What is the pathophysiology of keloid scar

A

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
Q

What are the risk factors for keloid scar

A

Ethnicity

20-30

Burns

Ear lobe, shoulder, sternal notch

Previous keloid formation

72
Q

How might keloid scar present

A

Characteristic visual appearance

Some have pain/itching/burning

73
Q

What are the stages of keloid scar

A

Erythematous

Brown/red

Turn pale as they age

74
Q

What scale is used to quantify features of keloid scar

A

Vancouver scale

75
Q

What is the management for keloid scar

A

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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