Peri-Operative Care Flashcards
What is Malignant Hyperthermia?
Autosomal Dominant Disorder
Initial muscle rigidity followed by increased temperature under General Anaesthesia
Why should you check the airways in a Pre-Op Exam?
Degree of mouth opening
Teeth (Any loose?)
Palate (Mallampati Classification)
How far can they extend neck
What is the American Society of Anaesthesiologist Grade?
Grades a patient from I-VI, with increasing severity of disease
Subsequently gives a prediction of mortality from anaesthesia
What is a Group and Save?
Done when blood loss is NOT anticipated
Determines blood group/rhesus status/atypical antibodies
No blood is issued
What is a Cross - Match?
Done when blood loss IS anticipated
Mixed with donor blood to see if reaction happens
What should you advise patients regarding eating Pre-Op?
Stop Eating 6hrs before
Stop clear fluids 2hrs before
To prevent Aspiration Pneumonitis (gastric contents) or Aspiration Pneumonia (direct inhalation)
Using the mnemonic CHOW, what medications should be stopped Pre - Op?
Clopidogrel (7d before)
Hypoglycaemics
Oral Contraceptives/HRT (stopped four weeks before)
Warfarin (5d before)
How are T1DM patients managed Pre-Op? Give three features
-Should be first on the morning list
-Reduce the insulin dose by a 1/3 the night before
-Omit morning insulin and set up sliding scale of Actrapid
How are T1DM patients managed Post-Op?
After Op give SC Insulin 20 mins before first meal
Stop IV infusion 30-60 mins after first meal
How are T2DM patients managed Pre-Op? Give three features
-Metformin stopped the morning of the Op
-Others stopped 24hrs before
-if poor diabetic control or long surgery put on sliding scale of Insulin, given 5% Dextrose and managed the same as T1DM
How should Steroids be adapted in an operative scenario?
-Need to be continued due to risk of Addisonian Crisis
-HPA axis increases its activity in surgery due to ‘stress state’ which may end up supressing steroids
-Stress dose should be given
All Operative patients are started on LMWH, give an exception
Head and Neck Surgery
Give three contraindications to TED Stockings
Severe Peripheral Vascular Disease
Recent Skin Graft
Severe Eczema
Give three indications for prophylactic antiobiotics
Orthopaedics
Bowel Surgery
Vascular Surgery
What Bowel Procedures require preparation? How would you do so?
Left Hemicolectomy/Sigmoidectomy/AP Resection- Phosphate Enema the morning of
Anterior Resection - 2 sachets of PICO lax night before
Give four key considerations for fluid management
What is the aim? (Rescucitation/Maintenance/Replacement)
Most recent electrolytes
Comorbidities
Weight and Size
Describe the distribution of fluid in a 70kg man
42L Total
28L - Intracellular
14L - Extracellular (11L interstitial, 3L circulating)
Describe the target fluid compartment for different purposes
General Hydration - distributed across all fluid compartments
Rescucitation - Intravascular
Explain the fluid consideration in septic patients
Tight junctions between capillary endothelium breaks down causing fluid to leak out into tissues (therefore large volumes of IV fluid may be needed)
State four fluid outputs
Urine
Sweating
Respiration
Faeces
Give 4 features of fluid depletion OE
Reduced Skin Turgor
Decreased Urine Output
Orthostatic Hypotension
Increased Cap Refill Time
Give 2 features of fluid overload OE
Raised JVP
Oedema
State the daily requirements of Water, Na+, K+, Glucose
Water - 25ml/kg/d
Na+ - 1mmol/kg/d
K+ - 1mmol/kg/d
Glucose - 50g/d
What is a Crystalloid Fluid?
Contains mineral salts
Cheaper so used more often
Saline/Dextrose/Hartmanns
What is a Colloid Fluid?
Contains larger molecules
Higher Osmotic Pressure
Volplex/Blood
Give 2 examples of pathological fluid loss
Bowel Lumen in Bowel Obstruction
Retroperitoneum in Pancreatitis
At what concentration of Haemoglobin is a transfusion recommended?
<70g/L
Why is Rhesus D Status an important consideration in blood transfusions
- Not important if not pregnant as patients won’t attack their own RBC
- In pregnancy if first child is Rh positive to a Rh negative mother, antibodies against Rh will be formed, which will cause HND in second child
State the Universal Donor and the Universal Acceptor
Donor - O neg
Acceptor - AB pos
Who should be given CMV negative blood?
Pregnant Women, Intrauterine Transfusions, Neonates (<28d)
Can cause sensorineural deafness
Give 3 clinical features of administering blood
- Observations before/15 to 20 mins in/1hr/Completion
- Given through Grey (16G) or Green (18G) to reduce the risk of haemolysis
- Given via blood giving set (which includes a filter)
Give 3 clinical features of RBC transfusion
-Contains RBC only
-Indicated in Acute Blood Loss or Symptomatic Anaemia
-Given over 90-120 mins
Give 2 clinical features of Platelets transfusion
-Indicated in Haemorrhagic Shock, Profound Thrombocytopenia, Low Pre-Op Platelet
-Given over 30mins
Give 3 clinical features of FFP transfusion
-Contains Clotting Factors
-Indicated in DIC, Haemorrhage Secondary to Liver Disease, All Massive Haemorrhages
-Given over 30 mins
Give 2 clinical features of Cryoprecipitate transfusion
- Contains Fibrinogen, VWF, Factor VIII, Fibronectin
- Indicated in DIC with low fibrinogen or VWF, or massive haemorrhage
Give 2 scores which can be used to assess nutritional status
BMI
MUST Score
State the Hierarchy of Feeding Options
- Oral Nutritional Supplements
- NG Tube
- PEG/RIG
- Jejunostomy
- Intestinal Failure
Albumin levels were thought to be an indicator of nutritional status, why is this not the case?
Patients with Anorexia Nervosa have normal Albumin levels
How should nutrition be managed in an Enterocutaneous Fistula?
High - Enteral/Parenteral Nutrition
Low - Low Fibre Diet
Give four medical managements of a High Output Stoma
Reduce Hypotonic Fluids
Loperamide
PPI
Low Fibre
What is a High Output Stoma?
A high output stoma (HOS) is when the output causes the patient to become water, sodium and magnesium depleted.
Give three advantages of day case surgery
- Cheaper
- Lower infection rates
- Reduces waiting list
Give four requirements in order for a procedure to be able to be done as a day case
Minimal Blood Loss expected
Short operating time
No expected complications
No requirements for specialist aftercare
State three types of Haemorrhage
- Primary - Occurring within the intra-operative period
- Reactive - Occurring within the first 24 hours of surgery (due to slipped ligature or missed vessels from intraoperative hypotension and vasoconstriction)
- Secondary - Occurring 7 to 10d post op, normally infective erosion
Other than visible bleeding, give four clinical features of Haemorrhage
Tachycardia
Dizziness
Agitation
Reduced UO
State the classification of Haemorrhage from I-IV
I - <15% blood loss
II - 15-30% blood loss
III - 30-40% blood loss
IV - >40% blood loss
How does Haemorrhage post Neck Surgery present?
Primary Sign is airway obstruction - because pretracheal fascia only distends so far
What vessel is most at risk during Laproscopic procedures?
Inferior Epigastric Artery
Runs from External Iliac up Mid-Clavicular line
Define SIRS
- Systemic Inflammatory Response Syndrome
- Two or more of the following criteria: tachycardia (heart rate >90 beats/min), tachypnea (respiratory rate >20 breaths/min), fever or hypothermia (temperature >38 or <36 °C), and leukocytosis, leukopenia, or bandemia (white blood cells >1,200/mm3, <4,000/mm3 or bandemia ≥10%)
Define Sepsis
- SIRS + Evidence of Infection
- Life threatening Organ Dysfunction due to dysregulated host response to infection
Define Septic Shock
- Perisistent Hypotension despite fluid rescucitation
Describe the qSOFA score
RR>22/min
Altered Mental State
Systolic<100mmHg
Describe the 7C’s of Sepsis source identification on a surgical ward
Chest
Catheter
Cannula
Central Line
Collections
Cut
Calves (DVT)
What 3 situations should pain be assessed in?
In bed
Mobilising
Deep Breathing
Using the mnemonic IGRAB, state the side effects of NSAIDs
Interactions with other medications (eg Warfarin)
Gastric Ulcers
Renal Impairment
Asthma Sensitivity
Bleeding Risk (interacts with platelets)
Give an example of a weak and strong Opioid respectively
Weak - Codeine
Strong - Fentanyl
How do Opioids work as pain relief?
Work by activating the opioid receptors MOP, DOP and KOP in the CNS, modifying pain perception
Give four side effects of Opioids
Nausea
Constipation
Sedation
Respiratory Depression
What Opioid should be given in Renal Impairment?
Oxycodone or Fentanyl rather than Morphine
Give two points about co-prescribing with Opioids
- Paracetamol should be co-prescribed to reduce the requirements of opiates
- Do not co-prescribe weak and strong opioids as they competitively inhibit the same receptors
Describe the bioavailability of Morphine
Oral is 30%
SC/IV is 80%
What is Patient Controlled Analgesia?
Use of pumps that give IV bolus when patient presses a button
Analgesia is tailored to patient, and the amount they use it can be converted to a regular dose
What is Neuropathic Pain?
Irritation/Injury to nerves which present as shooting/stabbing pain
Describe the non pharmacological and pharmacological management of Neuropathic Pain
Non Pharmacological - CBT, Transcutaneous Nerve Stimulation
Pharmacological - Gabapentin, Amitryptyline, Pregabalin
Define Major Haemorrhage
Bleeding to the extent that the patient is in shock
Define Massive Haemorrhage
Loss of whole blood volume within 24 hours