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FINALS > PERI-OPERATIVE CARE > Flashcards

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
Q

What are the clinical features in Class IV Haemorrhagic shock?

A 
>2000ml
>40%
>140 bpm
BP decreased
R.R > 40 MOST SENSITIVE
Urine Output <5 ml/hR
26
Q

What are the Patient risk factors for PONV?

A

Female
Previous PONV or motion sickness
Use of opioid analgesics
Non-smoker

27
Q

What are the Surgical risk factors for PONV?

A

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
Q

What are the Anaesthetic risk factors for PONV?

A 
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
Q

How is PONV managed?

A

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
Q

Where is vomiting and nausea controlled?

A

Vomiting centre in the medulla oblongata

Chemoreceptor trigger zone

31
Q

What drugs can be used for PONV?

A 
- 5HT-receptor antagonists
(Ondasetron)
- Dexamethasone
- Phenothiazines
(Prochlorperazine)
- Antihistamines
(Cyclizines)
- Dopamine receptor antagonist
(Domperidone)
32
Q

Cyclizine

A

Antihistamine
Oral or IV

Avoid in acute porphyrias

Drowsniess

33
Q

Domperidone

A

Dopamine-receptor antagonist
Oral

Avoid in cardiac disease

Drowsiness, dry mouth, malaise

34
Q

Metoclopramide hydrochloride

A

Oral, IM or slow IV

Not after GI surgery and other GI issues

Extrapyramidal effects, Gynaecomastia and Galactorrhoea

35
Q

Ondasetron

A

Specific 5HT3
Oral, IM, IV, SUPP

Avoid in long QT

Constipation, flushing, headache

36
Q

What are the causes of Delerium?

A
  • 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
Q

What are the risk factors for Delerium?

A 
Age >65yrs
Multiple co-morbidities
Underlying dementia
Renal impairment
Male
Sensory impairment (hearing or visual)
38
Q

What are the causes of Pyrexia?

A

Infection
Iatrogenic (e.g. drug or transfusion reaction)
VTE- P.E
Unknown origin >38’C for >3wks unknown cause

39
Q

What are the causes of Infective Pyrexia post-operative?

A 
WIND resp (atelectasis) 1-2
WATER UTI 3-5
WALK VTE 4-6
WOUND 5-7 days
WONDER ABOUT DRUGS
40
Q

What is Malignant Hyperthermia?

A

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
Q

What are the effects of Anaesthetics on the CNS?

A

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
Q

What are the types of Anaesthesia?

A

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
Q

What is the MAC?

A

Minimal Alveolar Concentration: concentration at which 50% of recipients fail to rmove to surgical stimuli

44
Q

What are the features of an ideal IV agent?

A

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
Q

What are the IV anaesthetic agents?

A

Propofol
Thiopental Sodium
Ketamine
Etomidate

46
Q

What are the features of an ideal Inhaled agent?

A

MAINTAIN ANAESTHESIA

  • low solubility in blood and tissue
  • resistant to degredation
  • no injurous effects on vital tissue
  • administered in known and reliabel concentration
47
Q

What are the inhalation agents?

A

Isoflurane: irritant to airway
Sevoflurane: agent of choice (fast onset low irritation)
Desflurane: rapid onset, low fat absorption so good for obesity

48
Q

What are the stages of Anaesthesia?

A

Induction: Propofol + inhaled agents + adjuncts

Maintenance: maintain anaesthetic depth

Recovery: agents with drawn and function monitored

49
Q

What are the depth stages of Anaesthesia?

A
  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
Q

What are the 7As of Anaesthesia?§

A

Analgesia
Antacid
Antiametic

Anxiolytic
Amnesia

Anti-autonomics

Antibiotics

51
Q

What are the Neuromuscular blockers?

A

DEPOLARIZING:
Suxamethonium -> apnoea
Partial agonist for ACh receptors

NON-DEPOLARIZING:

  • Rocuronium
  • Vecuronium
  • Atracurium
52
Q

What are the elements of ERAS?

A

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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