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y3 surgery > Peri- operative care > Flashcards

Peri- operative care Flashcards

1
Q

How long should a pt not eat or drink dairy products for before surgery?

A

6hrs

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2
Q

How long before surgery should a pt stop drinking clear fluids?

A

2hrs

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3
Q

Why should a pt go into surgery with an empty stomach?

A

to reduce risk of aspiration when they put the pt under general anaesthetic and try to intubate

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4
Q

What causes the pt to reflux gastric contents when under general anaesthetic?

A

Many of the medications (propofol, sevoflurane, opioids) decrease lower oesophageal sphincter tone and the cough reflex is inhibited

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5
Q

In emergencies, how is risk of gastric reflex reduced?

A

NG tube and stomach drainage + rapid sequence induction (press on coracoid, minimal ventilation time)

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6
Q

What drugs need to be stopped prior to surgery? (4)

A 
CHOWD
Clopidogrel
Hypoglycaemics
Oral contraceptives 
Warfarin 
DOACs
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7
Q

How long before surgery does clopidogrel need to be stopped?

A

7 days before, cover with aspirin if minimal bleeding risk

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8
Q

Describe the management of a pts warfarin as they prepare for surgery (how long before should you stop it, what is INR needed, how do you restart)

A
  • stop it 5 days before
  • make sure INR <1.5 before op
  • if INR now low enough night before, give PO Vit K
  • restart at normal dose the evening/ day after surgery and continue with LMWH until INR in range as warfarin prothombotic initially
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9
Q

What should be given to a pt on warfarin who needs emergency surgery?

A
  • check INR

- give Vit K and FFP as needed

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10
Q

How should DOACS be managed pre op? (for high/ low risk sugery and for good and bad renal function)

A
  • If normal renal function and low risk procedure stop them 24 hrs before and restart 6-12 hrs after
  • if higher risk, stop 48her before and start 48 hrs later
  • check factor Xa levels if eGFR <50, for dabigatran check PT and APTT
  • if abnormal renal function, seek guidance
  • Give LMWH for VTE prophlaxis as normal
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11
Q

Should aspirin be stopped prior to surgery?

A

Not unless the surgical bleeding risk is very high, in which case stop 3 days before and start 7 days after. Give tranaxaemic acid in emergencies.

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12
Q

How should pts on dural antiplatelet therapy be managed pre op?

A
  • if low bleeding risk surgery= continue both

- if high risk= defer surgery or continue with aspirin only

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13
Q

Why are oral contraceptives stopped pre op and how long before surgery should they be stopped?

A

As they increase VTE risk

Stop 4 weeks before

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14
Q

What prescriptions are need before most operations? (3)

A
  • LMWH
  • anti emolic stockings
  • antibiotic prophylaxis
  • analgesia
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15
Q

Give 3 contra indications of LMWH and for what surgeries may they not be given?

A

Acute bacterial endocarditis, major trauma, epidural anaesthesia, haemophilia, peptic ulcer (not absolute), recent cerebral haemorrhage
Dont give for most neck or endocrine surgery

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16
Q

What dose of dalteparin is given for medium risk surgeries?

A

2500 units, 6pm night before surgery and then every evening theyre in hospital for

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17
Q

What dose of dalteparin is given for higher risk surgery? (eg general, vascular or oethopaedic surgery)

A
  • 5000 units if renal function is good

- on night before surgery and then thereafter

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18
Q

How long should LMWH be continued for, for hip and knee replacements?

A 
hip= 28 days 
knee= 14 days
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19
Q

Why do you not give dalteparin before and until at least 4 hrs after a spinal epidural?

A

risk of spinal epidural haemoatoma which can cause cord compression, ischaemia and infarction

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20
Q

Which surgeries require a phosphate enema on the morning of surgery? (4)

A
  • left hemicolectomy
  • anterior resection
  • sigmoid colectomy
  • abdo peroneal resection
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21
Q

What bloods need to be done pre op?

A
  • FBC (make sure not anaemic or infection)
  • U&E (check renal function for clearance of anaesthetics and other drugs)
  • INR (if on warfarin)
  • Group and save (X match if hgiher risk surgery)
  • LFTs (for metabolism of some drugs)
  • clotting screen (pick up any clotting disorders)
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22
Q

What important anaesthetic complication should you ask the pt if they have a FHx or PMH of pre op?

A

malignant hyperthermia

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23
Q

What imaging may be requested pre op? (2)

A
  • ECG (everyone- for baseline incase of post op ischaemia and to check for arrhythmias which may complicate anaesthetic)
  • CXR (if resp illness, any cardio resp symptoms, smoking history or from TB endemic areas)
  • any diagnostic/ or assessment images such as CT or MRI
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24
Q

Other than bloods and imaging, what other investigations may be requested pre op? (4)

A
  • pregnancy test
  • sickle cell test (if hx, fhx or afrocarribbean descent)
  • MRSA swab nostils +/- perineum
  • urinalysis (not routine)
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25
Q

What may increase insensible losses (water losses through sweating, respiration, faeces- normally accounts for 1L per day)

A
  • febrile
  • tachypnoeic
  • diarrhoea
  • sepsis
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26
Q

Why are pts with bowel obstruction very fluid deplete? What blood results will indicate dehydration in this context?

A
  • 3rd space losses (increase osmitc gradient causes litres to be lost into peritoneum and bowel)
  • vomiting
  • will cause raised haematocrit and urea
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27
Q

what electrolyte changes does vomiting cause?

A
  • Loss of H+ and Cl- and K+ from stomach
  • causes metabolic alkalosis
  • hypokalaemia exacerbated by kidneys excrete K+ and cells take up K+ to preserve intravascular H+
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28
Q

What is the daily requirement for water?

A

25-30ml/kg/day - 1.75 L in 70kg person

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29
Q

What are daily requirements for Na, K and glucose?

A

Na and K= 1mmol/kg/day (70mml in 70kg person)

Glucose= 50g/ day

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30
Q

What is the difference between hartmans and normal saline?

A

Hartmans has slightly less Na and Cl- and so has a slighly lower osmotic pressure
Hartmans has 5mmol/L K+

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31
Q

Outline a fluid maintenance regime for the 70kg pt with no significant comorbities?

A
  • 500ml NS with 20mmol K+ over 8 hrs
  • 1L 5% dextrose with 20mmol/l K+ over the next 8hrs
  • 500ml 5% dextrose with 20mmol K+ over 8 hrs
  • or 2L 4% dextrose/ 0.18% saline with 40mmol KCl- (will give 60 mmol NaCL, 80mmol K and 80g glucose)
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32
Q

What pt factors may mean you need to design a bespoke fluid regime?

A
  • renal pts
  • pts with cardiac impairment
  • elderly, frail cachectic pts
  • arranged U&E
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33
Q

What is the definition of a reduced urine output?

A

urine output <0.5ml/kg/hr

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34
Q

How should a reduced fluid output be managed?

A
  • check the catheter is working properly// chart is filled in correctly
  • A-E assessment
  • give fluid challenge of 250 or 500ml over 15-30 mins and see how they respond
  • alternatively can give 1l over 1 hr if simple dehydration
  • give repeated challenges up to 2L or until BP/ output is restored
  • If 2L given, seek expert help
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35
Q

What may cause a fluid deficit// reduced fluid output?

A
  • third space losses (usualy bowel obstruction or pancreatitis)
  • diuresis
  • tachypnoeic
  • febrile
  • diarhhoea
  • vomiting
  • sepsis
  • AKI
  • cardiac failure
  • inadequate fluid management
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36
Q

What biochemical disturbance does diarrhoea cause? (3)

A
  • loss of HCO3-, K+ and Na+ in stool

- leads to hyponaturaemia, hypokalaemia and acidosis

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37
Q

Why do you often get decreased urine output and sodium retention post op?

A
  • sympathetic activation-> cortisol release -> raas activation -> retain Na+
  • also retain K+ so DONT give K+ in 1st bag post op
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38
Q

When may an NG tube be used to feed?

A
  • unable to take sufficient calories orally despite lots of encourangement
  • dysfunction swallow
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39
Q

When may a pt be PEG fed (into stomach)

A
  • oesophagus blocked or dysfunction
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40
Q

When is jejunal feeding (jejunostomy) used?

A
  • stomach inaccessible, dysfunctional or outflow obstruction
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41
Q

When may parenteral nutrition be used?

A

jejunum inaccessible or intestinal failure

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42
Q

what screening tool is used to asses malnutrition?

A
  • MUST tool
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43
Q

What can cause low albumin?

A
  • chronic inflammation
  • protein losing enteropathy
  • proteinurea (nephrotic syndrome)
  • hepatic dysfunction
  • NOT MALNOURISHMENT (very very rarely)
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44
Q

When can general and non general surgery start tolerating enteral feeding?

A
  • non GI surgery= almost immediatly

- GI- within 24hrs

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45
Q

How can enterocutaneous. high fistula (jejunal) and lower fistula be managed?

A
  • enterocutaneous (most heal spontaneously, some need surgery)
  • high fistula (jejunal)- needs enteral or parenteral support
  • lower fistula can be treated with low fibre diet
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46
Q

How are high output stomas managed?

A
  • ix cause: stool culuture, med review, CT if ?intra abdo sepsis or obstruction
  • reduce oral hypotonic fluid intake to 500ml/day, give loperamide and codeine, PPIs and low fibre diet (constipate them basically)
  • manage complications: AKI, low Na/Mg/K, malnutrition
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47
Q

What may cause a high output stoma?

A
  • gastric acid hyper secretion (short bowel syndrome)
  • infection (pre stomal ileitis)
  • sepsis
  • meds (prokinetics, withdrawl of opiates, metformin)
  • partial obstruction
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48
Q

How can pain be assesed?

A
  • subjective: pain scale (mild, mod, severe)

- objective: tachycardia, tachypnoea, hypertension, sweating, flushing, unwilling to mobilise, agitation

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49
Q

Describe the WHO pain ladder

A

1: non opioid (parcetamol) + adjunct (ibuprofen)
2: weak opioid (codeine-> tramadol) + non opioid adjunct (naproxen, diclofenac)
3: stong opioid (oral morphine-oxycodone, IV morphine- methadone- diamorphine-> fentanyl) + non opioid
4: nerve blocks, epidurals
- Neuropathic pain better managed with amitryptyline or gabapentin/ pregablin

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50
Q

What are the cautions/ side effects of using NSAIDS? (5)

A

I GRAB

  • Interactions (warfain)
  • Gastric ulceration (add PPI if long term)
  • Renal impairment
  • Asthma (triggers 10% asthma pts)
  • Bleeding risk (due to effect on platelet function)
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51
Q

give 4 side effects of opioids

A
  • constipation (give laxative- lactulose)
  • nausea (antiemetic- cyclizine)
  • sedation
  • confusion
  • resp depression
  • pruritis
  • tolerance and dependence (rare)
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52
Q

What should you use instead of morphine in renal impairment?

A

Oxycodone or fentanyl

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53
Q

How long dose IV, oral and IM morphine take to work?

A 
IV= 2-3 mins
IM= 15 mins
Oral= 20mins
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54
Q

How should t1 diabetics insulin be managed pre, intra and post op?

A
  • on night before reduce SC inslulin by 1/3
  • omit morning insulin and start IV variable rate insulin of 50mls NS and 50 units actrapid
  • while nil by mouth (and intra op) give 5% dextrose at 125ml/hr and check BMS every 2 hrs
  • continue until can eat and drink, give SC insulin 20 mins before meal and then stop IV infusion 30-60 mins after
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55
Q

How should a t2 diabetic on oral hypoglycaemics be managed perioperatively?

A
  • stop metformin on morning of surgery and other hypoglycaemics 24 hrs before
  • put on variable rate insulin and 125ml/hr dextrose same as for t1 if theyre poorly controlled or theyll miss >2 meals
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56
Q

Why is it important to monitor BMs intra op?

A

They cannot report symptoms of it and signs are hidden by anaesthetic. May get hypoglycaemic from starvation. It also helps avoid them getting ketoacidosis.

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57
Q

What usually happens to BMs post op? what should the post op BM target be?

A

they increase as cortisol release suppresses insulin release
target 6-12

58
Q

How should pts on steroid be managed preoperatively?

A
  • swap them to IV hydrocortisone (roughly 20mg for every 5mg po pred they normally have)
  • post op increase IV hydrocort dose (no guidelines on how much by)
59
Q

Why is addisonians crises hard to detect intra and post op? What should you look out for on the biochemistry?

A
  • lethargy, N+V, confusion and reduced GCS are signs of addisonians but can also be due to anaesthetic and analgesia
  • look out for LOW SODIUM, LOW GLUCOSE, HIGH POTTASSIUM
60
Q

What abx should be given for GI surgery?

A
  • gentamicin single dose 30 mins before op

- add metronidazole if colon resection

61
Q

What abx should be given for open biliary surgery? what for ERCP?

A
  • IV cefuroxime and IV metronidazole 30 mins before

- IV gent for ERCP

62
Q

What abx should be given for joint replacement surgery?

A
  • Iv cefurozime or IV fluclox and gent 30 mins before
63
Q

What abx should be given for closed # surgery and open # admission, debridement and surgery?

A
  • closed: IV fluclox 30 mins before
  • open: IV co amox (1.2g within 1 hr of admission and until operation, clindamycin if allergic)
  • Iv cefuroxime and met and gent at first debridement and IV gent again 30 mins before skeletal stabilisation and closure
64
Q

What is pre op hb aim? What is done if it is less than aim?

A

aim for >70g/L

if below this give RBC transfusion, should increase it by about 10

65
Q

How long dose Xmatch and G&S take? What is involved in each and when is each done?

A 
G&amp;S= 40 mins, determines blood group and screens for atypica antibodies, use if no blood loss anticipated
Xmatch= 80 mins, does blood group, antibodies and also mixes blood to see if theres a reaction, done if anticipate blood loss
66
Q

What is irradiated blood and when is it used?

A

Where leukocytes have been destroyed to reduce risk of graft vs host reactions. Used if pts with hodgkins lymphoma, familly members, stem cell transplants, purine analogue chemo or intrauterine infusions

67
Q

When must a pt have obs done if theyre getting a transfusion?

A

At start, 20 mins in, 1 hr in and at completion

68
Q

What is atelectasis? What causes it?

A

partial collapse of small airways, most pts get it post op to some degree, its thought to be due to airway compression, alveolar gas resorbtion intra op and impairment of surfactant production

69
Q

How does atelectasis present?

A
  • varying degrees of airway compromise
  • usually increased RR, reduced O2 sats, fine crackles
  • sometimes low grade fever but no other infective signs
  • usually within 24hrs of the op
70
Q

How is atelectasis managed?

A
  • o2 if hypoxic
  • deep breathing exercises and chest physio
  • pain control may help them to breath deeply
  • broncoscopy may be needed to suction out pulmonary secretions but this is rare
71
Q

What is acute respiratory distress and what can cause it

A
  • acute lung injury w/ severe hypoxaemia and no cardiogenic cause, due to inflammation and subsequent pulmonary odema
  • causes inc pneumonia, aspiration, fat embolism, polytrauma, smoke inhalation, acute pancreatitis, sepsis
  • many of which occur around surgery (hence the relevance)
72
Q

How does acute respiratory distress present?

A
  • worsening dyspnoea, acute onset (<7 days) w/ identifable cause
  • hypoxia, tachycardia, tachypnoea, inspiratory crackles
  • bilateral infiltrates on CXR
73
Q

How is ARDS managed?

A
  • NIV initially
  • ITU admission as will likely need intubation
  • maintain minimum intravascular pressure you can for perfusion of tissues to reduce odema
  • treat cause (abx, etx
  • corticosteroids are being used less and less–> lol not now covids about
74
Q

How should post op pneumonia be managed?

A
  • bloods, ABG, sputum and blood cultures, d dimer (think PE), CXR, ECG (MI)
  • O2 therapy
  • IV abx (co amox likely as HAP)
  • ? aspiration pneumonia and chemic pneumonitis- will require ITU as difficult to treat
75
Q

Why are DVT/ PE risk increased by surgery?

A
  • long period of immobolisation
  • surgery–> trauma–> stress response–> prothombotic
  • cancer, sepsis etc frequently alongside
76
Q

What is the use in doing a WELLS score for DVT?

A

directs investigations:

  • if 0= unlikely DVT
  • if 1= maybe DVT do d dimer
  • if >1 probably DVT do duplex USS
77
Q

How is DVT treated?

A

DOAC such as apixaban for 3 months

78
Q

What may cause hyperkalaemi post op? (3)

A
  • AKI
  • blood transfusions
  • diuretics or ACEi
  • excessive K+ treatment
  • adrenal insufficiency
79
Q

How may hyperkalaemia present?

A

blood abnormality, paraesthesia, weakness, N+V, palpitations, cardiac arrest

80
Q

What may cause hypokalaemia post op? (5)

A
  • excessive diuretic use
  • gi losses (vomiting, diarrhoea)
  • steroids
  • excessive insulin
  • too many salbutamol nebs
  • inadequate replacement when pt NBM
81
Q

How may hypokalaemia present?

A
  • usually asymptomatic

- may get cramps, muscle weakness, paraesthesia, constipation or tetany

82
Q

What changes are seen on ECG of hypokalaemia?

A
  • T wave flattening/ inversion
  • U wave
  • ST depression
83
Q

When correcting significant hypokalaemia with IV fluids, why should the K+ be run with normal saline and NOT dextrose?

A

dextrose causes glucose and so insulin spike which can make hypokalaemia worse

84
Q

What may cause hypovolaemic hypernaturaemia post op?

A
  • diuretics (usually loop)
  • dehydration/ fluid restriction (usually due to burns, D+v or sweating, poor oral intake)
  • ATN or HHS
85
Q

What is most likely cause euvolaemic hypernaturaemia post op?

A
  • diabetes insipidus usually after pituitary surgery
86
Q

What may cause hypervolaemic hypernaturaemia post op?

A
  • giving them too many bags of normal saline or hartmans

- steroid dose too high

87
Q

How is hypernaturaemia managed? what is risk of rapid correction?

A
  • find cause and replace fluid deficit if hypovolaemic
  • oral water or 5% dextrose if unconscious
  • 0.9% saline if hypovolaemic
  • aim to reduce sodium by 10mmol/L/ day, doing it too quick can lead to cerebral odema
88
Q

What could cause hyponaturamia?

A
  • post op hyponaturamia is common due to stress response and if they get given lots of dextrose before it’ll dilute the sodium
  • vomiting or diarrhoea (low urine conc)
  • diuretics (high urine conc)
  • SIADH (high urine conc, euvolaemic)
  • acute fluid overload
  • heart failure or liver cirrhosis
  • ATN
89
Q

How should hyponaturamia be managed? What is risk of rapid correction?

A
  • close fluid monitoring
  • Iv fluids- dont correct too rapidly due to risk of central pontine demyelination
  • monitor renal function
  • treat cause
90
Q

What may cause post of hypoglycaemia?

A
  • accidental insulin OD
  • lat gastric dumping syndrome (large scale movement of gastric contents, usually after gastric bypass)
  • liver disease
  • adrenal insufficiency
91
Q

How is gastric dumping syndrome managed?

A
  • small volume, more frequent meals

- avoid simple carbs

92
Q

What factors increase risk of anastomotic leak?

A
  • steroids
  • smoking
  • diabetes
  • obesity
  • malnutrition
  • emergency surgery
  • peritoneal contamination
  • oesphageal gastric or rectal anastamosis
93
Q

How do anastomotic leaks present?

A
  • abdo pain + fever 5-7 days post op

- usually peritonism, sepsis

94
Q

How should anastomotic leaks be investigated?

A

CT CAP with contrast, urgent bloods inc lactate, G&s and blood cultures

95
Q

How are anastomotic leaks initially managed?

A
  • A-E resus
  • sepsis 6
  • urgent senior r/v
  • NMB
  • work up for surgery depending on CT results
96
Q

What is the definitive management for anastomotic leaks?

A
  • If <5cm- conservative with abx
  • if >5cm, percutaneous drainage, exploratory laparotomy.
    Colorectal anastomosis usually need stomas
97
Q

How may bowel adhesions present?

A
  • many asymptomatic
  • may cause bowel obstruction
  • may cause chronic pain or infertility
98
Q

How should bowel obstruction due to adhesions be managed?

A
  • A-E assessment
  • tube decompression if uncomplicated
  • keep NMB
  • IV fluids and analgesia
  • If they get ischaemia, peforation or failed conservative management then need laparoscopic (or open) adhesionolysis +/- removal of affected bowel
99
Q

What are RFs for incisional hernias?

A
  • smoking
  • infection
  • obesity
  • midline incision
  • pre op chemo
  • pregnancy
  • advanced age
  • chronic cough
  • diabetes
  • steroids
  • connective tissue disease
  • emergency surgery
100
Q

How are incisional hernias managed?

A

You can do laparoscopic or open mesh (for larger) or suture repairs (for smaller), but this causes pain, seroma formation or bowel injury and so tend to be avoided as only 6-15% incarcerate and 2% of these strangulate

101
Q

What causes post op constipation?

A
  • low fibre diet
  • low fluid intake
  • less activity/ movement
  • opioids
  • iron supplements
  • BOWEL OBSTRUCTION PANIC
  • hypercalcaemia
  • hypothyroid
  • multifactoral
  • post op ileus
102
Q

How is constipation managed?

A 
- if absolute and features of bowel obstruction->  CT + contrast 
If not:
- laxatives 
- enemas
- manual evac
103
Q

What laxatives are best for opioid induced and soft stool constipation?

A
  • stimulants like senna or picosulphate
104
Q

What laxatives are best for hard stool and chronic constipation?

A
  • softeners: lactulose, movicol, ispahgula husk
105
Q

What is post op ileus?

A

Arrest of decellaration in intestinal motility so is a functional bowel obstruction.

106
Q

What are the clinical features of post op ileus?

A
  • failure to pass flatus or faeces (absolute constipation)
  • bloating
  • distension
  • N+V (usually later)
  • high NG tube output
  • absent bowel sounds
107
Q

How is post op ileus managed?

A
  • bloods (esp U&E as fluid shift can cause AKI)
  • CT with contrast to diagnose and rule out leaks/ adhesions/ collections
  • daily bloods
  • encourage mobilitsation
  • stimulate (senna, picosulphate) laxatives
  • reduce opioids
  • NG tube on free drainage
  • wait for the bowel to start up again
108
Q

Give 3 risk factors for keloid scars

A
  • black or asian
  • age 20-30
  • burns
  • previous keloid scars
109
Q

Whats the difference between keloid scars and hypertrophic scarring?

A
  • hypertrophic scarring stays within the boarders of the wound margin
  • hypertrophic scarring appears soon after injury and then regresses
  • hypertrophic scars tend to improve on surgical intervention
110
Q

How can keloid scars be managed?

A
  • intralesional steroids
  • silicone gel
  • radiation therapy
  • wont do any harm so can just leave it
111
Q

Give 5 risk factors for surgical site infections

A
  • old or young age
  • poor nutrition
  • DM
  • smoking
  • immunosurpression
  • pre op shaving
  • foreign material in site
  • insertion of surgical drainage
  • poor or no wound closure
  • procedures at skin creases
  • long post op stay
    They tend to happen 3-7 days post op
112
Q

How should surgical site infections be managed

A

1 remove suture/ clips so pus can drain
2 drain pus
3 empirical abx
4 monitor closely for systemic infection

113
Q

How is superficial wound dishiscence managed?

A

wash with saline and then pack, wound will have to heal by secondary intention and may take weeks. Vacuum assisted closure can speed this up.
Infection prevention becomes v important

114
Q

How is full thickness wound dishiscense managed?

A

IV fluids, broad specturm abx, analgesia, cover wound in saline soaked gauze, return to theatre for reclosure with large interrupted sutures

115
Q

What may cause an AKI in the peri-op setting?

A
  • sepsis
  • dehydration
  • haemorrhage
  • nephrotoxins
  • urinary retention or blocked catheter
116
Q

What drugs should be stopped or reduced if a pt develops an AKI? (7)

A
  • NSAIDS
  • ACEi
  • ARBs
  • aminoglycosides
  • K+ sparing diuretics (reduce risk of hyperkalaemia)
  • reduce metformin (risk of lactic acidosis)
  • reduce LMWH
117
Q

What causes urinary retention in the peri op setting?

A
  • uncontrolled pain
  • constipation
  • infection
  • anaesthetic agents (epidurals)
  • blocked catheter
118
Q

How is urinary retention managed in post op setting?

A
  • most will recover spontneously
  • catheterise overnight and TWOC next day
  • if TWOC fails look for other causes and give 1-2 week catheter
  • discharge and TWOC in community setting
119
Q

Describe the clinical features of anaphylaxis

A
  • sudden hypotension which is unresponsive to a fluid challenge
  • airway compromise
  • facial angiodema
  • urticial rash
  • feeling of impending doom
120
Q

What is the immediate management of anaphlyaxis? (5 drugs, inc doses)

A
  • A-E assessment
  • often need intubation so call anaesthetists
  • high flow O2
  • bronchodilators (salbutamol nebs 2.5mg, aminophylline 500mg IV)
  • IM adrenaline 1:1000 0.5mg
  • chlorphenamine IM or IV 10mg
  • hydrocortisone IM or IV 200mg
121
Q

What is the longer term management after an anaphylactic reaction? (5)

A
  • monitor every 15 mins until stable
  • then 4 hrly
  • review drug and food chart for allergens
  • measure mast cell tryptase ASAP after recovery, 1-2 hrs and 24 hrs later
  • make sure theyve got an epipen
122
Q

What is involved in the CAM ICU score for delirium?

A

Acute onset change in mental status + inattention + altered consciousness or disorganised thinking

123
Q

Give 3 risk factors for post op delirium?

A
  • > 65
  • dementia
  • sensory impairment
  • male
  • renal impairment
  • emergency surgery
124
Q

List 8 common causes of delirium

A

HICUPEDD

  • Hypoxia
  • Infection (kidney, bladder, lungs, wound)
  • Constipation
  • Urinary retention
  • Pain
  • Endocrine abnormalities
  • Drugs (benzos, diuretics, opioids, steroids)
  • Dehydration
125
Q

How should delirium be investigated initially? give a reason for each

A
  • FBC (? infection)
  • U&E (? electolyte abnormalities- esp Ca2+, AKI)
  • TFTs (derangement can cause)
  • Glucose (hypo or hyper can cause)
  • B12 and folate (can cause)
  • blood cultures (?infection)
  • wound swabs ?infection
  • urinalysis ?infection
  • CXR, CT head if appropriate
126
Q

Other than managing the specific cause, would should delirium be managed?

A
  • quiet area
  • regular routines
  • clocks
  • photos
  • relative visits
  • sleeping pattern
  • oral intake
  • analgesia
  • haloperidol if need sedative
127
Q

What are the 3 types of peri op haemorrhage

A

Primary: intraop bleeding, resolved in surg but needs monitoring
Reactive: within 24 hrs of op, usually from ligature slip or missed vessel (due to hypotension and vasoconstriction)
Secondary: 7-10 days post op due to erosion of vessel from spreading infection

128
Q

Describe the clinical features of class 1 (15%) and class 2 (15-30%) haemorrhage?

A

1: HR <100// BP normal// RR 14-20// urine output normal
2: HR 100-120// BP normal// RR 20-30// urine output 20-30 ml/hr

129
Q

Describe the clinical features of class 3 (30-40%) and 4 (>40%) haemorrhage?

A

3: HR 120-140// BP decreased// RR 30-40// urine output 5-20
4: HR >140// BP decreased// RR >40// urine output <5

130
Q

How is post op haemorrhage managed?

A
  • A-E
  • IV access and fluid resus, activate major haemorrhage protocol for RBC, FFP and platelet transfusions as appropriate
  • Direct pressure to bleeding site if visible
  • urgent senior r/v
  • imaging as appropriate (usually contrast CT)
131
Q

What may be needed for neck surgery reactive bleeding and why?

A
  • bedside airway rescue: take out suture and suction haematoma
  • the neck fascia only distends so much, so can close trachea and cause resp distress
132
Q

What vessels are most often injured in laparoscopic surgery and why?

A
  • inferior epigastric vessels (arise from external iliac and run up in front of rectus muscle)
  • often injured by port insertion and isnt noticed at the time due to gas inflation keeping them compressed
133
Q

Give 4 risk factors for post op N+V (PNOV)

A
  • Previous PNOV
  • motion sickness
  • use of opioids
  • intercranial surgery
  • prolonged surgery
  • inhalation anaesthetic
  • intra op dehydration or bleeding
  • overuse of bag and mask ventilation (due to gastric dilation)
  • young
  • female
134
Q

What may cause PNOV?

A
  • surgery and anaesthetic itself
  • post op ileus
  • bowel obstruction
  • infection
  • metabolic (hypercalcaemia, uraemia, DKA)
  • raised ICP
135
Q

How can PNOV be avoided?

A
  • use minimal amounts of opioid, volatile agents and spinal anaesthetic
  • prophylactic anti emetic therapy
  • dexamethasone at time of induction
136
Q

How should PNOV be managed if its caused by metabolic/ biochem imbalance, opioids and by impaired gastric emptying?

A

Metabolic= Metoclopramide (dopamine antagonist)
Opioid: Ondansetron (serotonin antagonist) or cyclizine (histamine antagonist)
Impaired gastric emptying: Metclopramide or domperiodone

137
Q

How many days post op are urinary, resp and surgical site/ abscess/ central line infections most common?

A

Day 1-2 most likely resp
3-5= urinary
5-7= surgical site/ abscess/ central line

138
Q

What may cause a post op fever?

A
  • infection
  • drugs (abx or anaesthetics)
  • transfusion reactions
  • VTE (can cause low grade fever but very rare not to have other clinical features)
  • prosthesis implantation (can cause low grade fever with no other signs of infection)
139
Q

Define pyrexia of unknown origin and state what they most commonly end up being?

A
  • fever for 3 weeks with no obvious cause despite 1 week of inpatient investigations
  • 30% infection unknown cause, 30% lymphoma or other malignancy, 30% vasculitis, ct disease or drug reactions, 10% idiopathic
140
Q

What abx are used for central line infections

A

flucloxacillin

141
Q

What abx are used for intra abdominal infections

A

cefuroxime + metronidazle

y3 surgery (7 decks)

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