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Surgery > Peri-Op Care > Flashcards

Peri-Op Care Flashcards

1
Q

Who needs special considerations when it comes to surgery?

A
  • Pregnant ladies
  • Diabetics
  • Pts on steroids
  • Pts with thyroid disease
  • Pts with cardiorespiratory
  • Pts with renal/hepatic disease
  • Pts with neuro disease

Come back to this, its in the surgery oxford handbook

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2
Q

What are some urinary complications of surgery?

A

AKI
Urinary retention
UTI

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3
Q

How many criteria are there for diagnosing AKI?

A

3

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4
Q

What are the criteria for diagnosing AKI?

A
  • ≥50% rise in serum creatinine from baseline within last 7 days
  • Increase in serum creatinine by ≥26.5mmol/l within 48 hours
  • Urine output <0.5mls/kg/hour (oliguria) for more than 6hrs
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5
Q

How many stages of AKI are there?

A

3

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6
Q

What is stage 1 AKI?

A

Creatinine 1.5-2 times the baseline, and oliguric for 6-12 hours

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7
Q

What is stage 2 AKI?

A

Creatinine 2-3 times the baseline , and oliguric for 12+ hours

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8
Q

What is stage 3 AKI?

A

Creatinine >3 times the baseline plus either:

  • <0.3ml/kg/h for 24hours + OR
  • anuric for 12 hours +
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9
Q

How can AKI be divided according to causes?

A

Pre-renal
Renal
Post-renal

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10
Q

Which class of cause of AKI is the most common peri-op?

A

Pre-renal

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11
Q

Give some examples of causes of pre-renal AKI

A 
Sepsis
Dehydration
Haemorrhage
HF
Liver failure -> hepatorenal syndrome
Intra-operative damage
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12
Q

Give some examples of causes of renal AKI

A

Nephrotoxins

Parenchymal disease eg glomerulonephritis

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13
Q

Give some examples of causes of post-renal AKI

A 
Stones (at any level)
Tumours
Retroperitoneal fibrosis
Acute urinary retention
Blocked catheter
Prostate enlargement
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14
Q

What are the steps in assessing a pt with AKI?

A 
Hx
Examination
Bedside tests
Investigations
Imaging
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15
Q

On examination of a pt with AKI, what should we assess?

A

Fluid status
Bladder - palpable?
Catheter - is it draining?
Nephrotoxins on drug chart?

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16
Q

What bedside tests can we do when assessing AKI?

A

Urine dip
Bladder scan
Use sepsis tool to check for possible sepsis

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17
Q

What investigations can we do for AKI?

A 
FBC
U&amp;Es ****Creatinine****
CRP
LFTs
Ca2+
Lactate (ABG)
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18
Q

When is imaging used for AKI? What do we look at?

A

In severe cases to look at kidneys, ureters, and bladder

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19
Q

Is AKI serious?

A

Yeah, its classified as an emergency situation

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20
Q

If pre-renal AKI is suspected, what is a good first step?

A

Fluid challenge - 250-500ml over 15 minutes and reassess, repeat as necessary

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21
Q

WRT fluids, in AKI what else should we monitor?

A

Urine output with a fluid balance chart. Escalate to catheter if necessary.

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22
Q

Ultimately, how is AKI treated?

A

Treat the cause and monitor

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23
Q

What are the 3 most common signs/symptoms of urinary retention?

A
  • Little or no urine passed post-op
  • Sensation of needing to void but being unable
  • Suprapubic mass (dull to percussion)
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24
Q

Alongside clinical assessment, what is the most important investigation for retention?

A

Pre- and post-void bladder scan for residual volume

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25
Q

What could unstable renal function suggest in retention?

A

High pressure retention

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26
Q

How should retention be managed?

A

Conservatively for most patients as post-op retention usually resolves itself

Catheterise if not resolving, then TWOC. If failed TWOC, recatheterise and TWOC again in 1-2 weeks

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27
Q

What organisms commonly cause UTIs?

A

E. coli ***

Klebsiella sp.
Enterobacteur sp.
Proteus sp.
Pseudomonas sp.
Staphylococcus sp.
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28
Q

What symptoms are common for UTIs?

A

Urinary frequency, urgency, and dysuria

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29
Q

O/E what is common for UTIs?

A

Suprapubic pain

Pyrexia

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30
Q

Who should UTI be considered in?

A

Sepsis
Pts with delirium
Pts in acute retention

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31
Q

What shows up on a urine dipstick for a UTI?

A

Nitrites and leukocytes elevated +- blood

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32
Q

What is sterile pyruia?

A

Presence of elevated wbcs in urine without evidence of organisms

ie leukocytes without nitrites

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33
Q

What can cause sterile pyuria?

A

Inadequately treated UTI
STI
Renal stone

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34
Q

What are the basic steps in management of UTIs?

A

Ensure pt is well hydrated and has good urine output

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35
Q

What is the definitive management of a UTI?

A

Abx according to local guidlines

eg LNR - uncomplicated -> trimethoprim or nitrofurantoin

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36
Q

What should be done with a UTI in a pt with a catheter?

A

Change any long-term catheter in-situ in the presence of a UTI

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37
Q

What is subcutaneous emphysema?

A

A known complication of laparoscopic surgery. Air/gas enters the subcut tissues of the chest.

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38
Q

How can subcutaneous emphysema be identified?

A

O/E - Pt short of breath, “rice krispie” feel over chest when pt breathes.

Radiograph - If anteroir chest wall affected -> able to see leaf like outline of pec major. Other muscles/overlying structures can be viewed in an unusual way.

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39
Q

What is the recommended cut off HbA1c for pre-op surgical pts?

A

48mmol/mol (6.5%)

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40
Q

What is the recommended range for pre-op cap glucose?

A

6-10mmol

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41
Q

Why are we worried about glycaemic control in the peri-op period?

A

Hyper and Hypo glycaemia can affect healing, prolong hospital stays, and cause complications

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42
Q

How is hyperglycaemia caused in the peri-op period?

A

Body is under stress -> more catabolic hormones released eg cortisol, GH, glucagon

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43
Q

What can peri-op hyperglycaemia cause?

A

DKA or HHS

Post-op sepsis, endotheial dysfunction, cerebral ischaemia

Impaired wound healing *****

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44
Q

Why is hypoglycaemia in a surgical patient important to avoid?

A

It is hard to recongise when a pt is anaesthetised so if hypoglycaemic for prolonged period of time -> neurological damage

Also leads to poor wound healing

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45
Q

What does the management of diabetic pts peri-op depend on?

A

How there diabetes is controlled - i.e. is it well controlled, is it oral meds, is it insulin etc?

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46
Q

How should diabetics be managed for minor operations?

A

Oral-controlled - give normal regimen
Insulin-controlled - omit insulin on the day before surgery, monitor blood glucose every 4 hours, restart insulin once back on food

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47
Q

How should diabetics be managed for major operations?

A

Oral-controlled - omit long acting drugs pre-op. Monitor BS every 4 ours, if over 15mmol/L -> IV insulin
Insulin-controlled - IV insulin sliding scale when NBM. Restart insulin once oral diet restarts.

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48
Q

What % of all healthcare infections are surgical site?

A

Up to 16%

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49
Q

What is the rate of infection for orthopaedic procedures?

A

Less than 1%

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50
Q

What is the rate of infection for large bowel procedures?

A

Over 10%

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51
Q

How many statements are there about how we can prevent surgical site infections?

A

7

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52
Q

In terms of skin prep, what are 2 of the statements to prevent surgical site infections?

A

Don’t do hair removal unless required - if needed, use clippers.
Have a bath/shower day of or before surgery - some pts given antispetic wash

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53
Q

Other than skin prep, what do we do to prevent srgical infections?

A

Abx prophylaxis
Normothermia maintained pre-, during, and post-op
Give advice on wound dressing and care

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54
Q

What does abx prophylaxis choice depend on?

A
  • Type of operation
  • Mesh or prosthetic used
  • Pt factors
  • Length of procedure
  • Organisms common to the site
  • Local guidelines
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55
Q

What pt factors increase risk of infection?

A

ASA score more than 2

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56
Q

What is classed as a “clean” wound?

A

Ops where no inflammation is encountered, and resp, alimentary, and GU tracts aren’t entered

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57
Q

What is classed as a “clean-contaminated” wound?

A

Ops where resp, alimentary, or GU tracts entered but with no significant spillage

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58
Q

What is classed as a “contaminated” wound?

A

Acute inflammation is encountered, visible wound contamination

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59
Q

What is classed as a “dirty” wound?

A

Pus is present during op, prev perforated hollow viscus, or open injury for more than 4 hours

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60
Q

In general terms, what qualities should abx prophylaxis have?

A

Narrow spectrum, less expensive

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61
Q

When should abx prophylaxis be given?

A

Iv abx within an hour before skin incised, as close to incision time as possible

Half life should cover the operation

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62
Q

How long should we give abx prophylaxis for for arthroplasry?

A

Up to 24 hours

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63
Q

What are the different types of pain?

A 
Nociceptive
Somatic
Visceral
Chronic
Phantom
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64
Q

What are the 2 different types of nociceptor fibres?

A

Aẟ fibres

C fibres

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65
Q

Which type of nociceptor fibres are the fast response ones?

A

Aẟ fibres

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66
Q

Why are Aẟ fibres faster than C fibres?

A

They are myelinated

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67
Q

Why do we give pain relief?

A

It’s the human thing to do!

Also reduces stress response
Allows for early mobilisation
Allows for deep breathing and coughing

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68
Q

Why is a reduced stress response a good thing?

A

Reduced sympathetic response and lower BP -> lower O2 demand -> reduced risk of ischaemic events and faster healing

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69
Q

Why is early mobilisation good?

A

Prevent DVT

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70
Q

Why is deep breathing and coughing good?

A

Prevention of atelectasis and pneumonia

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71
Q

How do we give pain relief?

A

According to the WHO analgesic ladder

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72
Q

What is the first step of the WHO analgesic ladder?

A

Non-opiod +- adjuvants e.g. regular pracetamol or NSAID

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73
Q

What is the second step of the WHO analgesic ladder?

A

Weak opiod with non-opioid e.g. codeine PRN

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74
Q

What is the third step of the WHO analgesic ladder?

A

Strong opioid e.g. PRN oramorph

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75
Q

What is the top step of the WHO analgesic ladder?

A

Loading dose of opiate (IV/IM)

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76
Q

What regional anaesthesia is available?

A

Spinal, epidural, peripheral nerve blocks

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77
Q

What is an epidural?

A

Continuous infusion

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78
Q

What are the components of Virchow’s triad?

A

Stasis, coagulation changes, vessel wall damage

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79
Q

How do we assess VTE risk?

A

Assess risk factors of VTE and risk factors for bleeding

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80
Q

What factors increase VTE risk?

It’s a long list

A
  • Active cancer or treatment for cancer
  • Age over 60
  • Dehydration
  • Critical care admission
  • Known thrombophilias
  • Obesity
  • PHx of VTE
  • Significant co-morbidity
  • HRT
  • COCP
  • Varicose veins with phlebitis
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81
Q

What increases risk of bleeding, and therefore is part of VTE assessment?

A
  • Active bleeding
  • Acquired bleeding disorder
  • LP/epidrual/spinal within next 12 hours or past 4 hours
  • Acute stroke
  • Thrombocytopenia
  • Uncontrolled HTN
  • Inherited bleeding disorder
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82
Q

What does unfractionated heparin bind to?

A

Anti-thrombin III

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83
Q

How do we give heparins?

A

IV or S/C

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84
Q

How quickly can heprain wear off?

A

2-4 hours

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85
Q

What can be administered to reverse heparin?

A

Protamine

86
Q

What is the best way to get oxygen into a critically ill patient?

A

High-flow oxygen

87
Q

How can fluids be divided?

A

Into crystalloids and colloids

88
Q

What do all crystalloids contain?

A

Water and salt/sugar

89
Q

What do all colloids contain?

A

Water and protein

90
Q

What crystalloid fluids are available?

A 
NaCl
5% Dextrose
4% Dextrose + 0.18% saline
Hartmanns
NaHCO3
91
Q

What colloid fluids are available?

A

Gelofusine/Volplex (gelatin)
Haemaccel
HAS 4.4% or 20%

92
Q

What are the reasons for fluid prescription?

A

Resuscitation
Maintenance
Replacement

93
Q

Other than reason for fluids, what do we need to take into account?

A

Weight and size of pt
Co-morbidities
Reason for admission
Current electrolyte balane

94
Q

How much of total body fluid is intracellular?

A

2/3

95
Q

Of the fluid left in the extracellular fluid, how much goes where?

A

1/5 in intravascular

4/5 in interstitium

96
Q

What is the distribution aim of maintenance fluids?

A

Distribute fluid into every compartment

97
Q

What is the distribution aim of resuscitation fluids?

A

Increase intravascular volume to increase tissue perfusion

98
Q

Why do septic pts need loooooots of fluids?

A

Capillary endothelial junctions become very leaky & vascular permeability increases so lots of fluid needed to maintain intra-vascular volume.

99
Q

How much fluid do we need in a day?

A

~2.5 Litres for a 70kg man

100
Q

What is important for a pt NBM?

A

Fluid replacement via parenteral route

101
Q

What do we look for in a ?fluid depleted pt?

A
  • Dry mucous membranes
  • Reduced skin turgor
  • Decreased urine output
  • Orthostatic hypotension
  • Increased cap refill time
  • Tachycardia
  • Low BP
102
Q

What signs will a fluid overloaded pt exhibit?

A
  • Raised JVP
  • Peripheral/sacral oedema
  • Pulmonary oedema
103
Q

How much water does a person need a day?

A

25mL/kg/day

104
Q

How much Na+ does a person need per day?

A

1.0 mmol/kg/day

105
Q

How much K+ does a person need per day?

A

1.0 mmol/kg/day

106
Q

How much glucose does a person need per day?

A

50g/day

107
Q

What is a surgeons favourite fluid?

A

Hartmann’s solution

108
Q

How should a reduced urine output be managed?

A

Aggressively, with fluid challenge, and monitor urine output

109
Q

Why don’t we use colloids much?

A
  • Evidence suggests they aren’t much better than crystalloids
  • High cost
  • Risk of hypersensitivity rxns
  • Risk of coagulopathy
110
Q

What can happen to a patient who is given fluids when they don’t really need them?

A

Hyperchloraemic metabolic acidosis

111
Q

How many classes of shock are there?

A

4

112
Q

How much blood is lost in Class II shock?

A

Over 750mL

113
Q

How much blood is lost in Class III shock?

A

1.5-2L

114
Q

How much blood is lost in Class IV shock?

A

Over 2L

115
Q

In terms of %s, whats a good way to remember the amount of blood volume lost in each class of shock?

A

Tennis scores!

Class I - 0-15%
Class II - 15-30%
Class III - 30-40%
Class IV - >40%

Geddit???

116
Q

In terms of %s, whats a good way to remember the amount of blood volume lost in each class of shock?

A

Tennis scores!

Class I - 0-15%
Class II - 15-30%
Class III - 30-40%
Class IV - >40%

Geddit???

117
Q

What are the important blood grouping systems?

A

ABO and Rhesus

118
Q

Which Rhesus group is the most significant?

A

Rhesus D

119
Q

Which ABO group is the universal donor?

A

O negative

120
Q

Which ABO group is the universal acceptor?

A

AB positive

121
Q

What is group and save?

A

Blood sample is sent to determine pts blood group and screens for atypical antibodies. No blood is issued

122
Q

What is crossmatching?

A

Blood sample is sent and physically mixed with donor blood to see if any immune reactions take place. Blood can then be issued if no reaction occurs.

123
Q

What kind of blood is it important to give to pregnant women and neonates, as well as for intra-uterine transfusions? Why?

A

CMV negative blood

CMV can lead to sensorineural deafness and cerebral palsy

124
Q

Who do we give irradiated blood products to?

A
  • Pts getting blodd from 1st or 2nd degree family
  • Pts with Hodgkins lymphoma
  • Pts having certain types of chemo
  • Pts with recent HSC transplants
  • Intra-uterine infusions
125
Q

How should blood be prescribed?

A

Individually for each unit given

126
Q

What size cannula should blood products be given through? Why?

A

18G (green) or 16G (grey). The cells with haemolyse in a narrow tube due to shearing forces.

127
Q

When and how should patients recieving blood be assessed?

A

Before infusion, 15-20 minutes in, at 1 hour, and at completion.

Baseline obs looking for reaction to the blood product (antibodies, infection etc)

128
Q

What does a blood giving set contain that a normal fluid giving set doesn’t?

A

A filter in the chamber

129
Q

What are the different blood products?

A

Packed red cells
Platelets
Fresh frozen plasma
Cryoprecipitate

130
Q

Tell me about packed red cells…

A

RBCs given over 2-4 hours for acute blood loss, chronic anaemia Hb <70, or symptomatic anaemia.

131
Q

How much should one unit of packed red cells improve a pts Hb by?

A

~10g/L

132
Q

Why do we need a new group and save for subsequent transfusions?

A

The pt may develop autoantibodies to donor surface antigens, unless its within ~3 days

133
Q

Tell me about platelet transfusions…

A

Platelets given over 30 minutes for haemorrhagic shock in trauma, profound thrombocytopenia, bleeding with thrombocytopenia, or a pre-op platelet level of less than 50x10^9/L

134
Q

How much should one ATD of platelets increase platelet levels by?

A

20-40 x 10^9/L

135
Q

Tell me about fresh frozen plasma…

A

FFP contains mainly clotting factors, and is given over 30 minutes for DIC, any haemorrhage secondary to liver disease, and all massive haemorrhages (alongside packed red cells).

136
Q

Tell me about cryoprecipitate….

A

Contains fibrinogen, vWF, Factor VIII, and fibronectin, given stat for DIC with fibrinogen <1g/L, von Willebrands disease, or massive haemorrhage.

137
Q

Why do we need to know if a surgical pt is pregnant?

A

There are changes is anatomy and physiology that we need to account for

138
Q

In the first trimester of pregnancy, what do we need to account for surgically?

A

Teratogenic drugs could harm foetus

Lower oesophageal sphincter tone reduced so increased risk of reflux andaspiration if supine

139
Q

In the second trimester of pregnancy, what do we need to account for surgically?

A

Teratogenic drugs

Increased risk of UTIs, VTE, and superficial infections

140
Q

In the third trimester of pregnancy, what do we need to account for surgically?

A

Drugs that may induce labour
Displacement of abdominal visceral structures
Risk of hypotension if supine

141
Q

What do we balance the risk of miscarriage by GA against?

A

Risk of sepsis from untreated surgical pathology

142
Q

Why is diagnostic laparoscopy contraindicated in pregnancy?

A

Pneumoperitoneum can affect pregnancy

143
Q

Why is the COCP important in surgery?

A

It increases the risk of thromboembolic disease

144
Q

What should we do in a female pt on the COCP who needs elective surgery?

A

If surgery is medium or high risk, stop the pill at least 1 month prior to surgery

145
Q

What should we do in a female pt on the COCP who needs urgent/emergency surgery?

A

If medium risk procedure, operate with full thromboprophylaxis

If high risk procedure, operate with extended prophylaxis

146
Q

Pre-op, what should we do for pts on long term steroids?

A

Continue them to prevent Addisonian crisis. Switch to IV if can’t take orally.

147
Q

What are some important contraindications for LMWH?

A

Endocrine/neck surgery
Peptic ulcer disease
Previous cerebral haemorrhage

148
Q

When should warfarin be stopped pre-op?

A

Usually 5 days prior to surgery

149
Q

What is target INR for surgery?

A

<1.5

150
Q

How should we reverse warfarinisation?

A

PO vitamin K
or
IV Vit K 5mg - works within 12 hours

If need to reverse ASAP, give Prothrombin complex concentrate or FFP

151
Q

When should clopidogrel be stopped prior to surgery?

A

7 days beforehand - bridge with aspirin

152
Q

How is LMWH given?

A

S/C

153
Q

Why is LMWH better than unfractionated heparin?

A

Less protein binding to dose response is more predictable

154
Q

How is LMWH cleared?

A

By the kidneys

155
Q

Name some direct thrombin inhibitors…

A

Dabigatran

Argatroban

156
Q

What nerve can be damaged during a posterior triangle lymoh node biopsy?

A

Accessory nerve

157
Q

What nerve can be damaged when surgery involves a posterior approach to the hip?

A

Sciatic

158
Q

What nerve can be damaged when legs are in the Lloyd Davies position during surgery?

A

Common peroneal

159
Q

When can the long thoracic nerve be damaged during surgery?

A

If an axillary lymph node clearance is done

160
Q

Which nerves are at risk when operating on pelvic cancer?

A

Pelvic autonomic nerves

161
Q

After thyroid surgery, what nerve damage should we look out for, and how should it be investigated?

A

Recurrent laryngeal nerve damage causing a hoarse voice.

Laryngoscopy

162
Q

I break my arm and they repair it in surgery. Which nerves could they have damaged in the process?

A

Ulnar and median nerves

163
Q

When can the hypoglossal nerve be damaged during surgery?

A

During a carotid endarterectomy

164
Q

Give some examples of surgeries where only group and save is necessary as chance of transfusion is unlikely.

A 
Hysterectomy (simple)
Appendicectomy
Thyroidectomy
Elective lower segment caesarean section
Laparoscopic cholecystectomy
165
Q

Give some examples of surgeries where crossmatching of 2-6 units of blood is necessary as chance of transfusion is likely.

A

Salpingectomy for ruptured ectopic

Total hip replacement

166
Q

Give some examples of surgeries where crossmatching of 4-6 units of blood is necessary as chance of transfusion is definite.

A 
Total gastrectomy
Oophrectomy
Oesophagectomy
Elective AAArepair
Cystectomy
Hepatectomy
167
Q

What contraception is important to stop in the pre-op period?

A

Oestrogen containing contraceptives

168
Q

Why do oestrogen containing contraceptives need to be stopped in the pre-op period?

A

They increase the risk of VTE

169
Q

When should oestrogen containing contraception be stopped before surgery?

A

Ideally a full month before surgery. However if it is an emergency procedure, full/extended thromboprophylaxis should be used.

170
Q

Why is a pt on steroids at a specific perioperative risk?

A

They reduce neutrophil and fibroblast function and immune response. This increases susceptibility to infection, inhibits wound healing, and can cause osteoporosis (important for orthopedic procedures)

171
Q

If a pt on long term steroids suddenly has them stopped, what can happen?

A

Addisonian crisis

172
Q

Why are surgical pts on long term steroids at risk of an addisonian crisis?

A

Surgery increases stress on the body so steroid use increases - if only source is exogenous steroids then supply can’t meet demand.

173
Q

What are the features of an addisonian crisis?

A
  • Lethargy/malaise
  • Abdo pain (poorly localised)
  • N+V
  • Hypotension
  • Hypoglycaemia
  • Hyponatraemia
  • Coma
  • Death
174
Q

How should an addisonian crisis be managed?

A
  • IV dexamethasone 100mg QDS/400mg infusion over 24 hours
  • Fluid resus
  • IV dextrose (titrated against blood sugar)
175
Q

How should a pt on steroids be managed pre-operatively?

A
  • Wean dose of steroids if possible
  • If not possible to wean, IV steroids should be prescribed on the morning of surgery, continuing until the pt can restart oral steorids
176
Q

What dose of prednisolone is considered no significant and therefore need to peri-operative steroid cover?

A

5mg per day

This equates to:
1.6mg batamethasone and dexamethasone
40mg hydrocortisone
8mg methylprednisolone

177
Q

What is the normal cortisol secretion from the adrenals?

A

About 30mg/day.

This is roughly equivalent to 7.5mg of prednisolone

178
Q

How does cortisol secretion change post-operatively?

A

There is normally a rise for around 3 days post op.

179
Q

What dose of hydrocortisone is given at induction for minor surgery to cover a pt on steroids?

A

25mg

180
Q

What dose of hydrocortisone is given for moderate surgery to cover a pt on steroids?

A

25mg IV at induction
25mg IV every 8 hours for 24 hours

Then resume normal PO regime

181
Q

What dose of hydrocortisone is given for major surgery to cover a pt on steroids?

A

50mg IV at induction

50mg IV every 8 hours for 48-72 hours until PO medication restarted.

182
Q

What is the most important thing for a thyroid patient having surgery?

A

That they are euthyroid at the time of surgery. As such, all thyroid medication can be taken on the morning of surgery.

183
Q

What are the principles of enhanced recovery after surgery?

A

Optimisation of patient before, during, and after surgery, to help them recover more quickly following surgery

184
Q

Pre-operatively, what can be done according to the ERAS protocol?

A
  • Pt education
  • Optimisation of medical management
  • Optimisation of fasting guidance
185
Q

Intra-operatively, what can be done according to the ERAS protocol?

A
  • Multimodal and opioid-sparing analgesia
  • N&V prophylaxis
  • Minimally invasive surgery
  • Fluid therapy
186
Q

Post-operatively, what can be done according to the ERAS protocol?

A
  • Good pain control
  • Early oral intake
  • MDT follow-up
  • Early mobilisation
187
Q

What is the NICE guideline for water requirements for maintenance fluids?

A

25 mL/kg/day

188
Q

What is the NICE guideline for Na requirements for maintenance fluids?

A

1.0 mmol/kg/day

189
Q

What is the NICE guideline for K requirements for maintenance fluids?

A

1.0 mmol/kg/day

190
Q

What is the NICE guideline for glucose requirements for maintenance fluids?

A

50g per day

191
Q

What electrolyte imbalances are common in dehydration?

A

High urea:creatinine ration

High PCV

192
Q

What electrolyte imbalances are common in vomiting?

A

Low K+
Low Cl-
Alkalosis

193
Q

What electrolyte imbalances are common in diarrhoea?

A

Low K+

Acidosis

194
Q

Why are malnourished patients poor surgical candidates?

A

Surgery causes physiological stress -> hyper-metabolic state and catabolic response.

195
Q

How are patients screened for malnourishment?

A

Using MUST tool

196
Q

How is malnourishment detected on MUST screening managed?

A

Expert input from dietician

197
Q

What method of feeding is suggested if a pt is unable to eat sufficient calories?

A

Oral nutritional supplements

198
Q

What method of feeding is suggested if a pt is unable to eat sufficient calories orally or has dysfunctional swallowing?

A

NG tube feeding

199
Q

What method of feeding is suggested if a pt is has oesophageal blockage or dysfunction?

A

Gastrostomy feeding (PEG/RIG)

200
Q

What method of feeding is suggested if a pt has inaccessible stomach or outflow obstruction?

A

Jejunal feeding

201
Q

What method of feeding is suggested if a pt has intestinal failure or inaccessible jejunum?

A

Parenteral nutrition

202
Q

What kinds of post-operative haemorrhages are there?

A
  • Primary bleed
  • Reactive bleed
  • Secondary bleeding
203
Q

What is a primary haemorrhage in a surgical patient?

A

Bleding that occurs within the intra-operative period.

204
Q

What is a reactive haemorrhage in a surgical patient?

A

A bleed that occurs within 24 hours of the operation

205
Q

What is a secondary haemorrhage in a surgical patient?

A

A bleed that occurs 7-10 days post-op, usually due o infection or vessel erosion

206
Q

Why is haemorrhage following neck surgery so worrying?

A

Can cause airway obstruction as pretracheal fascia only extends so far.

207
Q

How should airway compromise secondary to hameorrhage in neck surgery be managed?

A
  • Remove skin clips and deep layer sutures
  • Haematoma removal

All at bedside as no time to get patient to surgery!

208
Q

How can pain be measured objectively?

A

According to clinical features such as tachycardia, tachypnoea, hypertension, and sweating/flushing.

209
Q

Why is it important to assess pain at rest and during mobilisation?

A

Because if a pt is in pain on mobilisation, they will be reluctant to mobilise early.

210
Q

What is it important to do with analgesia on discharge?

A

Wean the pt down the analgesia ladder

Surgery (11 decks)

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