Peri-Operative Care Flashcards
How much fluid do we give to children for resuscitation?
20ml/kg in <15 mins
10ml/kg in Trauma
How do we give maintenance fluids for children?
4ml/kg/h for their first 10kg
2ml/kg/h for the next 10kg
Then 1ml/kg/h every kg after
How do you calculate a child’s 24h fluid deficit?
%dehydration x their weight (kg) x 10
What are some signs to look for in a dehydrated patient?
Dry mucous membranes, reduced skin turgor, low urine output, orthostatic hypotension, increased cap refill, tachycardia, low BP
What are some signs of fluid overload to look for in a patient?
Raised JVP, peripheral/sacral oedema, pulmonary oedema
Which fluid would you not use in a hyperkalaemic patient?
Hartmann’s
What are some complications of blood product transfusions?
Transfusion related acute lung injury, transfusion associated circulatory overload, iron overload, hyperkalaemia, allergic reaction
In which patients would NSAIDs be inappropriate or contraindicated?
Patients with asthma, renal impairment, heart disease, uncontrolled hypertension, stomach ulcers
What are the key side-effects of opioids?
Constipation, pruritus, nausea, altered mental state, respiratory depression
What are some non-pharmacological options for chronic pain management detailed in NICE guidelines?
Supervised group exercise programs, acceptance and commitment therapy, CBT, acupuncture
What questionnaire can be used to assess likelihood of neuropathic pain?
DN4 questionnaire
What are the four first line treatments for neuropathic pain?
Amitriptyline, duloxetine, gabapentin, pregabalin
What is first line medication for trigeminal neuralgia?
Carbamazepine
How long must a woman stop taking an oestrogen containing contraception or HRT before surgery?
4 weeks- to reduce risk of VTE
How would a patient’s steroid regime (on long term steroids) change following surgery?
Double their normal does for a couple days once E/D
Additional IV hydrocortisone at induction and immediately post op
How does the stress of surgery alter blood glucose levels?
It will cause blood sugar levels to rise however fasting may lead to hypoglycaemia (greater risk)
How do we reduce risk of VTE following surgery?
LMWH/DOAC, intermittent pneumatic compression, anti-embolic compression stockings, early mobilisation
How long does a patient need to fast before surgery as a general rule?
6 hours for food
2 hours for clear fluids
What are some risk factors for post-op nausea and vomiting?
Female, young, non-smoker, history of motion sickness, use of post operative opiates, use of volatile anaesthetics
What are prophylactic anti-emetics given at the end of surgery?
Ondansetron, cyclizine, dexamethasone
What are some examples of rescue anti-emetics used in post op period if nausea and vomiting occur?
Ondansetron, prochlorperazine, cyclizine
How can you define major haemorrhage
- loss of more than one blood volume within 24 hours
- lost 50% total blood volume <3 hours
- losing >150ml/min
What questions would you ask to assess bleeding risk before surgery?
Personal history: excessive bleeding or bruising, excess bleeding after previous procedures, known bleeding disorder
FHx
DHx: anticoagulants, anti platelets, warfarin
What blood test can you do to assess coagulation?
PT, APTT, thrombin time, fibrinogen level, anti Xa, factor assays, platelet count
When would you stop an anti-platelet drug before surgery?
5 days before
When would you stop warfarin before surgery?
5 days
When would you stop a DOAC before surgery?
Roughly 2 days before if normal renal function
What fluid loss is not included on fluid balance chart? How much is this?
Insensible losses which is usually 800ml
What things do you want to check in patients notes before you prescribe then fluids post op?
Intra op blood loss, anaesthetic chart, U+Es, drug chart, current, fluid balance chart, fluid prescription
How do sodium and potassium levels change from the stress response from surgery?
Increased water and sodium retention, more potassium excreted
How many grams of glucose is in a litre of 5% dextrose solution?
50g
What electrolyte imbalances are commonly seen with vomiting?
Hypokalaemia, alkalosis, low Cl-
If a patient is nil by mouth for more than 3 days what should you consider?
Total parenteral nurition
What electrolyte imbalances re commonly seen with diarrhoea?
Hypokalaemia, acidosis
What makes up to AMT (abbreviated mental test)?
Age, time, where they are, year, home address, recognition of two persons/objects, date of birth, year of Second World War, name of current monarch, count back from 20
what bloods are included in a confusion screen?
B12, folate, thyroid, FBC, U+Es, Calcium, glucose,
What investigations other than bloods can be considered in a confusion screen?
Wound swabs/blood cultures, urinalysis, CXR, CT head (only if relevant)
What are common causes of delirium post-operatively?
Hypoxia, constipation, pain, infection, dehydration, drugs, urinary retention
What are the 3 categories a post-surgical haemorrhage can be put into?
Primary bleeding- occur intraoperatively
Reactive bleeding- occurs within 24 hours of operation
Secondary bleeding- occurs 7-10 days post-op
What are clinical features of haemorrhagic shock?
Tachycardia, dizziness, agitation, raised resp rate, decreased urine output
Hypotension is a late sign (do not assume patient not bleeding because of normal BP)
Generally how would you manage a post-surgical haemorrhage?
A-E assessment, apply pressure to bleeding site if possible, senior review, fluid resuscitation and blood products
What are risk factors for post-op nausea and vomiting?
Female, younger age, previous PONV or motion sickness, opioid analgesia, non-smoker
Long op time, poor post op pain management
Overuse of bag and valve mask ventilation (gastric dilation)
What are some alternative causes of nausea and vomiting in a post operative patient?
Infection, bowel obstruction/ileus, metabolic causes (hypercalcaemia, uraemia, DKA), medications, raised ICP, anxiety
What are some conservative measures to manage post op N+V?
Adequate hydration, analgesia and consider NG tube insertion
What anti-emetics are preferred for opioid induced post-op N+V?
Ondansetron or cyclizine
What are some complications of poor post-op pain management?
Longer recovery- reluctance to mobilise
Not breathing deep enough- atelectasis, hospital acquired pneumonia
What are side effects of NSAIDs (using the mnemonic I-GRAB)?
I- interactions with other meds like warfarin
G- gastric ulceration (consider PPI cover when long term)
R- renal impairment (use sparingly with poor renal function)
A- asthma insensitivity (trigger in 10% of asthmatics)
B- bleeding risk (from effect on platelet function)
What are some examples of weak and strong opioids?
Weak- Codeine
Strong- Morphine, fentanyl, oxycodone
When giving opioids what other meds should you consider prescribing concurrently?
Laxatives and anti-emetics
Why would you not give weak and strong opioids in combination?
They competitively inhibit the same receptors so will weaken effects of eachother
Why should renal function be checked when prescribing analgesia?
NSAIDs best avoided in poor renal function
Certain opioids like morphine best avoided as wont be excreted and more likely to overdose
How long does morphine take to work through different routes?
Orally- 20 minutes
IV- 2-3 minutes
IM- 15 minutes
What are some non-pharmacological treatment options for neuropathic pain?
TENS machine, capsaicin cream
What are the most common infections seen post-operatively?
Infected IV or central lines
1-2 days post-op: respiratory source
3-5: resp or urinary source
5-7 surgical site infection/abscess formation
Other than infection what can cause pyrexia in a post-op patient?
Drug induced reaction
