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Surgery > Peri-operative Care > Flashcards

Peri-operative Care Flashcards

1
Q

What patients fit into ASA grade 1?

A

A normal healthy patient. No smoking, minimal alcohol use.

Mortality: 0.1%

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2
Q

What patients fit into ASA grade 2?

A 
Mild systemic disease. All patients older than 80 years are put into this category. 
Currently smoking.
Social alcohol drinker.
Obesity
Well controlled diabetes
Mild lung disease

Mortality: 0.2%

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3
Q

What patients fit into ASA grade 3?

A

Severe systemic disease. This from any cause that imposes a definite functional limitation on their activity - eg. chronic obstructive pulmonary disease.

Mortality: 1.8%

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4
Q

What patients fit into ASA grade 4?

A

Incapacitating systemic disease which is a constant threat to life.

Mortality: 7.8%

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5
Q

What patients fit into ASA grade 5?

A

A moribund patient unlikely to survive 24 hours with or without surgery.

Mortality: 9.4%

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6
Q

What pre-operative testing will ASA grade I adults need?

A

ECG if >40

U&Es if >60

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7
Q

What pre-operative testing will ASA grade II adults with cardiovascular disease need?

A

All require an ECG

Consider CXR if >40
FBC, U&Es and Urinalysis

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8
Q

What is malignant hyperpyrexia and how can it affect anaesthesia, and what is the immediate treatment?

A

Rare, autosomal dominant condition: on administration of certain anaesthetics (halothane, suxomethonium), CO2 levels, temperature and HR will increase, masseter spasm occurs and muscle cells are damaged.

Dantrolene is the immediate treatment

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9
Q

What is suxomethonium apnoea?

A

Suxomethonium is a muscle relaxant
The enzyme plasma cholinesterase is used to break down suxomethonium in the body, and the effects of the drug usually last 3-4 minutes.

In suxomethonium apnoea, the individual lacks the enzyme so the body remains paralysed for up to 8 hours, therefore the patient cannot breathe.

Treatment: continuous ventilation

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10
Q

Why can you not give volatile anaesthetics in a patient with Duchenne muscular dystrophy?

A

Risk of hyperkalaemic cardiac arrest or rhabdomyolysis

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11
Q

What is hypokalaemic periodic paralysis and how does this affect anaesthesia?

A

Hyperkalaemic periodic paralysis is autosomal dominant and is marked by episodes of flaccid weakness that resolve spontaneously.

There is an increased risk of pre and post operative paralysis as paralysis occurs whenever potassium falls.

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12
Q

What are the rules for preoperative fasting for children?

A

6 hours for solid food
2 hours for breast milk
1 hour for clear fluids

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13
Q

What are the rules for preoperative fasting for adults?

A

All healthy elective patients even with co-morbidities are allowed to drink clear fluids up until 2 hours of their surgery.

6 hours for solid food.

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14
Q

In patients with diabetes mellitus, how should pre-operative fasting be managed?

A

In those who will only miss one meal, do not give an insulin sliding scale and instead adjust their dosage of tablets.

In those who will miss more than one meal, offer a sliding scale insulin (give glargine/lantus alongside this and reduce by 20% after surgery)

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15
Q

In patients who miss more than one meal, the guideline is to offer a sliding scale insulin. However, what criteria need to be met for some patients to do this?

A

Patients who take metformin only or are on lifestyle modifications alone should only start a sliding scale if their capillary blood glucose is greater than 12mmol/L on two separate occasions.

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16
Q

In pre-operative patients with diabetes, what is the recommended first line substrate solution for a sliding scale insulin?

A

5% dextrose in 0.45% sodium chloride

and

0.5% KCL

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17
Q

How often should capillary blood glucose be measured in diabetic patients during surgery?

A

Hourly

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18
Q

What are the blood glucose targets in diabetic patients for the pre-operative and post-operative period?

A

6-10mmol/L in pre-operative, anaesthetised and sedated patients and those taking hypoglycaemic drugs (insulin, sulfonylureas)

Down to 3.5mmol/L is safe in AWAKE patients who are not taking hypoglycaemic drugs and are not on a sliding scale. In those who are on a sliding scale, the range is 6-12.

You can not operate on a patient if the HbA1c is >8.5%

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19
Q

What is the emergency treatment of hypoglycaemia in diabetics in the peri-operative period?

A

Glucogel and 20% dextrose

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20
Q

If a patient is hyperglycaemic pre-operatively, what do you do?

A

Check if capillary blood ketones are greater than 3. If >3, cancel surgery, if <3:

Type 1 diabetes: give S/C rapid acting insulin (NovoRapid). 1 unit will drop BG by 3mmol

Type 2 diabetes: give S/C rapid acting insulin (NovoRapid) 0.1unit/kg

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21
Q

How would you manage a known obstructive sleep apnoea patient pre-operatively?

A

Mild OSA (AHI 5-15): proceed routinely

Moderate OSA or above: refer for CPAP or BIPAP.

Patients on established CPAP should continue therapy and bring their device to hospital. OSA patients will usually require prolonged post-operative recovery in HDU.

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22
Q

How would you manage a suspected obstructive sleep apnoea patient pre-operatively?

A

Use the STOP-BANG questionnaire.
Those with scores >5:

With co-morbidities and/or undergoing major elective surgery: refer for polysomnography

Without co-morbidities and undergoing minor surgery: refer for pulse oximetry overnight alone

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23
Q

How would you monitor a OSA patient intra-operatively?

A

High risk patients: manage with senior anaesthetist and surgeon

Monitor: pulse oximetry, ECG, BP, invasive arterial monitoring

Airway: pre-oxygenate adequately. Intubate and ventilate.

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24
Q

If GA is mandatory with OSA patients, what anaesthetics should you give?

A 
Short acting (desflurane, propofol)
Limit opioid use
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25
Q

How long before surgery should you stop warfarin?

A

5-7 days before surgery

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26
Q

How long before surgery should you stop apixaban?

A

1 day before surgery

If kidney function is bad, 2 days

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27
Q

What antibiotics may you need to stop before surgery?

A

Tetracycline and and neomycin as they increase neuromuscular blockade

28
Q

When should you stop and re-start the COCP in relation to surgery?

A

Stop 4 weeks before surgery and re-start 2 weeks after surgery

29
Q

How do you manage a patient that is on digoxin before and after surgery?

A

Continue up to and including the morning of surgery

Check for toxicity (ECG, plasma K+ and Ca2+)

30
Q

How can TCAs affect surgery?

A

Enhance adrenaline and may cause arrythmias

31
Q

What is the DVT prophylaxis you should give before surgery?

A

Graduated compression stockings

Moderate risk: LMWH 20mg 2 hours pre-op then 20mg/24hrs

High risk: LMWH 40mg 12h pre-op then 40mg/24h

32
Q

If a patient has MRSA what prophylactic antibiotics should you give?

A

Vancomycin or teicoplanin

33
Q

What pre-operative antibiotic regimen would you give for appendicectomy/colorectal resections and open biliary surgery?

A

Single dose of IV piperacillin/tazobactam 4.5mg/8h

34
Q

What pre-operative antibiotic regimen would you give for oesophageal or gastric surgery?

A

1 dose of IV gentamicin

35
Q

What pre-operative antibiotic regimen would you give for vascular surgery?

A

1 dose of IV piperacillin/tazobactam

Add metronidazole if at risk of anaerobes

36
Q

What anti-emetics are best to use in surgery?

A

Ondansetron is the most effective agent, metoclopramide is also used

37
Q

What antacids are used in surgery?

A

Ranitidine 50mg IV or omeprazole if there is an aspiration risk

38
Q

What anxiolytics are used in surgery?

A

Lorazepam or temazepam

In children, oral meds such as midazolam are used as first choice. Give oral premedication 2h before surgery

39
Q

What is the main side effect of thiopental?

A

Laryngospasm

40
Q

What is the main side effect of propofol?

A

Respiratory/cardiac depression, pain on injection

41
Q

What is the main side effect of volatile agents such as isofluorane?

A

Nausea and vomiting
Cardiac depression
Respiratory depression
Vasodilation

42
Q

Outline the typical ‘conduct of anaesthesia’ before surgery

A

Induction (IV propofol)
Airway control (guedel airway, muscle relaxation with a neuromuscular blocker)
Maintenance of anaesthesia (volatile agent/high dose opiates)
Recovery (100% oxygen)

43
Q

What is the anaesthetic of choice for rapid sequence induction? What is the muscle relaxant of choice?

A

Sodium thiopentone as it has an extremely fast onset of action
Suxomethonium is the muscle relaxant of choice

44
Q

What anaesthetic most commonly results in post operative vomiting?

A

Etomidate

45
Q

What anaesthetic has the strongest analgesic effects?

A

Ketamine

46
Q

What are the early causes of post operative pyrexia?

A

Blood transfusion
Cellulitis
UTI
Atelectasis

47
Q

What are the late causes of post operative pyrexia?

A

VTE
Pneumonia
Anastomotic leak
Wound infection

48
Q

List four common causes of post operative confusion

A

Hypoxia
Drugs (opioids, sedatives)
Urinary retention
MI or stroke

49
Q

What can post operative hypertension be caused by?

A

Pain
Urinary Retention
Idiopathic HTN
Inotropic drugs

Oral cardiac medicines including antihypertensives should be continued throughout the perioperative period even if NBM

50
Q

When talking to an examiner about post operative complications, how should you subdivide the causes?

A

1) From the anaesthetic (e.g. respiratory depression)
2) From surgery in general (wound infection, haemorrhage)
3) From the specific procedure

51
Q

When are naso gastric feeding tubes contra-indicated?

A

Contra indicated following head injury due to risks associated with tube insertion

Complications are aspiration of feed or misplaced tube

52
Q

List one benefit of naso jejunal feeding

A

Avoids food pooling in stomach (therefore decreased aspiration risk)

53
Q

How long do you give VTE prophylaxis to following elective hip surgeries?

A

LMWH for 28 days combined with anti-embolism stockings

54
Q

How long do you give VTE prophylaxis to following elective knee surgeries?

A

LMWH for 14 days combined with anti-embolism stockings

55
Q

How long do you give VTE prophylaxis to following a fragility fracture?

A

Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility

56
Q

Following orthopaedic surgery, when does NICE recommend you begin LMWH treatment?

A

6-12 hours after surgery

57
Q

If you suspect an anastomotic leak, what imaging modality would diagnose this?

A

Abdominal CT

58
Q

What anaesthetic agent is hepatotoxic?

A

Halothane

59
Q

What medications can slow bone healing after surgery?

A

NSAIDs

60
Q

What are three factors that can predispose a patient to pressure ulcers?

A

Incontinence
Immobility
Malnourishment

61
Q

What is Grade 1 of pressure ulcers?

A

Non blanchable erythema of intact skin

62
Q

What is Grade 2 of pressure ulcers?

A

Partial thickness skin loss involving epidermis, dermis or both
The ulcer is superficial and presents clinically as an abrasion or blister

63
Q

What is Grade 3 of pressure ulcers?

A

Full thickness skin loss involving damage to or necrosis of underlying subcutaneous tissue.

64
Q

What is Grade 4 of pressure ulcers?

A

Extensive destruction or damage to muscle, bone or other supporting structures.

65
Q

How do you manage a pressure ulcer?

A

Hydrocolloid dressings and hydrogels

Possible surgical debridement

66
Q

What are the basic points to remember behind the Waterlow score?

A

Incontinence is measured, the more incontinent the higher the point.
The older you are, the bigger point you score.
Females score more than males.
Neurological deficit is 5 points
Recent surgery is scored for
State of skin is measured

Surgery (3 decks)

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