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PERI-OPERATIVE CARE Flashcards

1
Q

What is the pre-operative NBM guidance?

A

No food or dairy products for 6 hours

No clear fluids for 2 hours

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2
Q

What drugs should be stopped pre-operatively?

A

CHOW

Clopidogrel 7 days before
Hypoglcyaemics
OCP/HRT-4 weeks before (advise alternative contraception)
Warfarin-5 days covered by LMWH
INR <1.5 so may have to revese warfarin with PO Vitamin K

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3
Q

What drugs should be altered pre-operatively?

A

Long-term steroids: Must be continued to avoid Addisonion crisis
(5mg PO prednisolone = 20mg IV hydrocortisone)

Sub-cut insulin- May switch to variable rate IV infusion

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4
Q

What drugs should be commenced pre-operatively?

A

LMWH (except neck or endocrine surgeries)

TED Stockings (not in peripheral vascular disease, peripheral neuropathy, skin graft or severe eczema)

ABx profylaxis if orthopaedic, vascular or GI

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5
Q

How should Diabetes Mellitus be managed pre-operatively?

A

TYPE 1

  • Morning list
  • Reduce subcut insulin by 1/3
  • Omit morning insulin and commence on variable IV pump (sliding scale)
  • 5% dextrose while NBM
  • Check BM 2 hourly
  • Continue until eating and drinking and overlap insulin by giving SC 20 min before meal and stopping IV 30-60 min after

DMT2

  • Stop metformin on morning
  • Stop all others 24 hours before
  • Commence on variable IV pump (sliding scale)
  • 5% dextrose while NBM
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6
Q

Which surgeries require bowel prep?

A

Laxative or enema to clear colon

Left hemicolecttomy/Sigmoid colectomy/Abdo-perianal resection: PHOSPHATE ENEMA ON THE MORNING

Anterior resection: PICOLAX the day befre or PHOSPHATE ENEMA ON THE MORNING

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7
Q

Pre-operative RAPRIOP

A 
Reassurance
Advice: NBM
Prescription-drug changes
Referral- ITU or HDU bed?
Investigations
Observations 
Patient understanding and follow up
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8
Q

What should be assessed pre-operatively?

A

History

PMHx:

  • CVD
  • Respiratory disease
  • Renal disease
  • Endocrine disease

PSurgicalHx
PAnaesthetic Hx

Drug Hx

FHx:
MALIGNANT HYPERPYREXIA

Social Hx:
Smoke/drink

General and airway examination

MUST screening and dietician input

Blood tests:
FBC, U&E, LFTs, Clotting, Group and Save/Cross match

ASA grading

ECG
CXR
Pregnancy test
Sickle-cell test
MRSA
Urinalysis
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9
Q

What are the ASA grades?

A

I-full health no systemic conditions
II-well managed (mild) systemic conditions
III-sever systemic condition that affects function
IV-systemic condition that is a constant threat to life
V-patient will die without operation
VI-organ harvesting

E if emergency

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10
Q

What is the Hierarchy of feeding methods?

A

Unable to eat sufficient calories: Oral Nutritionsl Supplements

Unable to take sufficient calories orally OR dysnfunctional swallow: NGT

Blocked/dysfunctional oesophagus: GASTROSTOMY PEG/RIG

Stomach inaccessible OR outflow obstruction: JEJUNOSTOMY

Jejunum inaccessible or intestinal failure: PARENTRAL NUTRITION

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11
Q

How is the timing of surgery determined when Parentral nutrition is required?

A

Sepsis: correct any infection
Nutritional support
Anatomy of GI tract defined for planning of surgery
Procedure once all of the above

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12
Q

How is Blood grouped?

A

Presence of A or B antigens on RBC surface

Can give O-ve to anyone because no A, B or Rhesus ANTIGENS so nothing to attack

AB+ve can recieve from anyone because there are no no A,B or Rhesus ANTIBODIES so they can’t attack any of the donor antigens

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13
Q

What blood tests are there to prepare for (potential) transfusion?

A

Group and Save: determines blood group, screens for any atypical antibodies but no blood is issued

THEN

Crosshmatch: Blood is mixed with donor blood to see if there’s immune reaction. If no reaction then Blood issued.

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14
Q

What groups require specific blood types?

A

CMV -ve blood should be given in pregnancy, intra-uterine transfusions and neonates <28 days

(Risk of sensoineural hearing loss and cerebal palsy)

Give irradiated blood products to reduce risk of Graft V Host in at risk populations:

  • Recieving from 2’or 3’ family members
  • Hodgkin’s lymhoma
  • Recent Haematpoietic stem cell transplant
  • Alemtuzumab therapy
  • Purine analogue chemotherapy
  • Intra-uterine transfusions
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15
Q

How are Blood Products administered?

A

GREEN 18G or GREY 16G cannula (to avoid haemolysis of blood cells through narrow tubes) must be through a BLOOD GIVING SET (not normal fluid) which contains a filter

Observe before, 12-20 min in, 60 minutes in, when finished

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16
Q

What are the types of blood products?

A

Packed red cells

Platelets

Fresh Frozen Plasma

Cryoprecipitate

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17
Q

What is Packed Red Cells?

A

RBCs

Acute blood loss
Chronic anaemia where Hb <70g/L (or <100 g/L in CVS disease)
Symptomatic anaemia

I unit should increase Hb by ~10g/L

Administer over 2-4 hours (bust be <4 hours)

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18
Q

What are Platelets (blood product)?

A

Haemorrhagic shock in trauma patients

Profound thrombocytopenia (<20x10^9; normal 150-400)

Bleeding with thrombocytopenia <50x10^

Administer over 30 minutes

1 Adult Therapuetic dose should increase plasma levels by 20-40 x 10^9

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19
Q

What is Fresh Frozen Plasma?

A

Clotting factors

DIC
Haemorrhage 2’ to liver disease
All massive haemorrhage (after 2nd unit packed RBCs)
Reverse Warfarin

30 minutes

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20
Q

What is Cryoprecipitate?

A

Fibrinogen, von Willebrands Factor, Factor VIII and Fibronectin

DIC with fibriogen <1g/L
von Willebrands disease
Massive haemorrhage

STAT

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21
Q

How is post-operative haemorrhage classified?

A

PRIMARY bleeding: within the intra-operative period and should be resolved during the operation

REACTIVE bleeding: <24 hours often due to ligature slip or missed vessle

SECONDARY bleeding: 7-10 days due to erosion of a vessle due to spreading infection

22
Q

What are the clinical features in Class I Haemorrhagic shock?

A 
< 750 ml
< 15%
< 100 bpm
BP Normal
R.R. 14-20 MOST SENSITIVE
Urine output >30ml/hr
23
Q

What are the clinical features in Class II Haemorrhagic shock?

A 
750-1500ml 
15-50%
100-120 bpm
BP Normal 
R.R 20-30 MOST SENSITIVE
Urine output 20-30 ml/hr
24
Q

What are the clinical features in Class III Haemorrhagic shock?

A 
1500-2000ml
30-40%
120-140
BP Decreased
R.R 30-40 MOST SENSITIVE
Urine Output 5-20 ml/hr
25
What are the clinical features in Class IV Haemorrhagic shock?
``` >2000ml >40% >140 bpm BP decreased R.R > 40 MOST SENSITIVE Urine Output <5 ml/hR ```
26
What are the Patient risk factors for PONV?
Female Previous PONV or motion sickness Use of opioid analgesics Non-smoker
27
What are the Surgical risk factors for PONV?
Intra-abdominal laparoscopic surgery Intracranial or middle ear surgery Squint surgery (highest incidence of PONV in children) Gynaecological surgery, especially ovarian Prolonged operative times Poor pain control post-operatively
28
What are the Anaesthetic risk factors for PONV?
``` Opiate analgesia Inhalational agents (e.g. Isoflurane) Prolonged anaesthetic time Spinal anaesthesia Intraoperative dehydration or bleeding Overuse of bag and mask ventilation (due to gastric dilatation) ```
29
How is PONV managed?
Prophylactic: - Reduce opiates, volatile gases and avoid spinal where possible - Prophylactic antiemetics - Dexamethasone at induction Conservative: - Adequate fluid hydration - Adequate analgesia - Ensure no obstruction Anti-emetics
30
Where is vomiting and nausea controlled?
Vomiting centre in the medulla oblongata Chemoreceptor trigger zone
31
What drugs can be used for PONV?
``` - 5HT-receptor antagonists (Ondasetron) - Dexamethasone - Phenothiazines (Prochlorperazine) - Antihistamines (Cyclizines) - Dopamine receptor antagonist (Domperidone) ```
32
Cyclizine
Antihistamine Oral or IV Avoid in acute porphyrias Drowsniess
33
Domperidone
Dopamine-receptor antagonist Oral Avoid in cardiac disease Drowsiness, dry mouth, malaise
34
Metoclopramide hydrochloride
Oral, IM or slow IV Not after GI surgery and other GI issues Extrapyramidal effects, Gynaecomastia and Galactorrhoea
35
Ondasetron
Specific 5HT3 Oral, IM, IV, SUPP Avoid in long QT Constipation, flushing, headache
36
What are the causes of Delerium?
- Hypoxia (post-operatively) - Infection (commonly UTI or LRTI) - Drug-induced (benzodiazepines, diuretics, opioids, or steroids) or drug withdrawal (alcohol or BZNs) - Dehydration - Pain - Constipation - Urinary retention - Endocrine (e.g. hyponatraemia, hypernatraemia, or hypercalcaemia)
37
What are the risk factors for Delerium?
``` Age >65yrs Multiple co-morbidities Underlying dementia Renal impairment Male Sensory impairment (hearing or visual) ```
38
What are the causes of Pyrexia?
Infection Iatrogenic (e.g. drug or transfusion reaction) VTE- P.E Unknown origin >38'C for >3wks unknown cause
39
What are the causes of Infective Pyrexia post-operative?
``` WIND resp (atelectasis) 1-2 WATER UTI 3-5 WALK VTE 4-6 WOUND 5-7 days WONDER ABOUT DRUGS ```
40
What is Malignant Hyperthermia?
A.D genetic suseptiility to volatile anaesthetic agents Induce the release of stored caclium from muscle cells causing the muscle fibres to contract: - MUSCLE RIGIDITY -> rhabdomyolysis - FEVER rise >2'/hr - Tachycardia - Hyperkalaemia - Hypercapnia - Increased O2 consumption Treat with DANTROLENE and cool rapidly and hyperventilate with 100% O2
41
What are the effects of Anaesthetics on the CNS?
Reticular activating system is depressed -> loss of consciousness Thalamus supress-reduced sensory information transmission Hippocampus-reduced memory formation Brainstem reduced resp Spinal cord-dorsal horn- analgesia and motro activity
42
What are the types of Anaesthesia?
General Regiona: large, specific regions by blocking transmission from the spine to the area e.g. SPINAL or EPIDURAL Local: peripheral nerve block Dissociative: ketamine inhibits transmission of nerve pulses from lower to high brain centres
43
What is the MAC?
Minimal Alveolar Concentration: concentration at which 50% of recipients fail to rmove to surgical stimuli
44
What are the features of an ideal IV agent?
INDUCE ANAESTHESIA - Act rapidly (in one arm-brain circulation) - Quick and complete recovery (no hangover) - No exctatiory phenomena - Analgesic properties - Minimal cardio resp effects - No interactipns - No hypersensitivity - No post-op phenomena eg. nausea or hallucinations
45
What are the IV anaesthetic agents?
Propofol Thiopental Sodium Ketamine Etomidate
46
What are the features of an ideal Inhaled agent?
MAINTAIN ANAESTHESIA - low solubility in blood and tissue - resistant to degredation - no injurous effects on vital tissue - administered in known and reliabel concentration
47
What are the inhalation agents?
Isoflurane: irritant to airway Sevoflurane: agent of choice (fast onset low irritation) Desflurane: rapid onset, low fat absorption so good for obesity
48
What are the stages of Anaesthesia?
Induction: Propofol + inhaled agents + adjuncts Maintenance: maintain anaesthetic depth Recovery: agents with drawn and function monitored
49
What are the depth stages of Anaesthesia?
1. Analgesia 2. Excitement- delerium and aggression (PROPOFOL REDUCED THIS) 3. Surgical Anaesthesia MAC 1.2-1.5 profound CNS depression, relaxed SkM and ventilation needed 4. Resp paralysis and depth if MAC >2.2
50
What are the 7As of Anaesthesia?§
Analgesia Antacid Antiametic Anxiolytic Amnesia Anti-autonomics Antibiotics
51
What are the Neuromuscular blockers?
DEPOLARIZING: Suxamethonium -> apnoea Partial agonist for ACh receptors NON-DEPOLARIZING: - Rocuronium - Vecuronium - Atracurium
52
What are the elements of ERAS?
Enhanced Recovery After Surgery Pre-op: - Education - Healthy as possible - Optimising medical management (incl. stop smoking and alcohol) - Fasting: 6hrs solids/2hrs clear fluids/ give 12.5% carbohydrate drink within 2 hrs Intra-op: - Multimodal and opioid-sparing analgesia (avoid short acting benzos) - Multimodal PONV prophylaxis - Minimally invasive - Fluid therapy Post-op: - Adequate analgesia for early movement - Early oral intake food/fluid - MDT follow-up

FINALS (13 decks)

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