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Surgery - DONE > PERI-OPERATIVE CARE > Flashcards

PERI-OPERATIVE CARE Flashcards

1
Q

What is the Hb threshold for administering?

A

70g/L

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2
Q

How are blood groups matched?

A

ABO system

Group D of the rhesus system

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3
Q

What does RhD+ or RhD- refer to?

A

Presence or absence of Rhesus D surface antigens

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4
Q

What proportion of the population is RhD+?

A

85%

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5
Q

What will happen if a RhD- patient is given RhD+ blood?

A

They will make an antibody to RhD+ blood (but they don’t attack their own cells)

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6
Q

When will rhesus D mismatch cause a problem?

A

In pregnancy as anti-D antibodies can cross the placenta

A woman with RhD- blood becomes pregnant with a RhD+ baby, during childbirth the comes into contact with the foetal blood and develops Rh+ve antibodies

Her second pregnancy is also with a Rh+ve foetus and antibodies cross the placenta and attack the foetal RBCs causing haemolytic disease of the newborn

(In an emergency setting a man can be given RhD+ blood although this is not ideal)

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7
Q

What are blood tests before a blood transfusion?

A

Group and save - determines patients blood group (ABO and RhD) and screens for abnormal antibodies (used when blood loss is not anticipated)

Crossmatch - physically mixing the blood to observe for any immune reaction (used when blood loss is anticipated)

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8
Q

When should CMV-negative blood products be used?

A

During pregnancy

Intra-uterine transfustions

Neonates

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9
Q

Why are irradiated blood products used?

A

Reduce the risk of graft-versus-host-disease

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10
Q

Who should recieve irradiated blood products?

A
  • Blood from first/second degree family members
  • Patients with Hodgkin’s Lymphoma
  • Recent haemopoietic stem cell transplanrs
  • After Anti-Thymocyte Globulin (ATG) or Alemtuzumab therapy
  • Those recieving purine analogues as chemo
  • Intra-uterine transfusions
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11
Q

When should patients recieve observations during transfusions??

A

- Before transfusion starts

- 15-20 mins after

- At 1 hour

- At completion

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12
Q

How should blood products be administered?

A

Green (18G)

Grey (16G) cannula

To prevent cell haemolysis

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13
Q

What are the different types of blood products?

A

Packed red cells (red blood cells)

Platelets

Fresh frozen plasma (clotting factors)

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14
Q

When are packed red cells given? How quickly?

A

Acute blood loss

Chronic anaemia

Within 4 hours of coming out of the store

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15
Q

How much should 1 unit of blood increase a patients Hb by?

A

10g/L

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16
Q

Why are more recent G&Ss required (3 days)?

A

As patients given RBCs may produce autoantibodies to donor surface antigens

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17
Q

When are patients given platelets? Over how long?

A

Haemorrhagic shock or profound thromobocytopaemia, administered over 30 minutes

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18
Q

When should FFP be given?

A

DIC

Any haemorrhage secondary to liver disease

Over 30 mins

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19
Q

What is cryoprecipitate? When is it given?

A

Major constituent = Fibrinogen, vWF, factor VIII and fibronectin

Given for DIC with fibrinogen and vWillebrands disease

STAT

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20
Q

What are some general complications of blood transfusions?

A

Clotting abnormalities - due to dilution of packed red cells (FFP and platelets should be given for patients recieving more than 4 units)

Electrolyte abnormalities - hypocalcaemia (from the calcium binding agen in the preservative) and hyperkalaemia (due to partial haemolysis)

Hypothermia

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21
Q

What are some transfusion-specific complications?

A

ACUTE:

  • Acute haemolytic reaction (ABO incompatability - donor red cells are destroyed)
  • Transfusion associated circulatory overload
  • Transfusion related acute lung injury
  • Mild allergic reaction (itching - treated with antihistamine e.g. chlorphrenamine)
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22
Q

How to patients with acute haemolytic reaction present?

A

Urticaria

Hypotension

Fever

Haemoglobinuria

Reduced Hb

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23
Q

What test confirms an acute haemolytic reaction?

A

Positive direct antiglobulin test

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24
Q

How does transfusion associated circulatory overload present?

A

Dyspnoea and features of fluid overload

Obtain a CXR and treat with oxygen and diuretics

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25
Q

What are some delayed transfusion complications?

A

Infection e.g. Hep B, Hep C, HIV, syphilis, malaria

Graft vs host disease (normally non-irradiated blood) due to a HLA mismatch (causes macropapular rash to toxic epidermal necrolysis)

Iron overload due to repeated transfusions (e.g. thalassaemia) Organs affected include liver (cirrhosis), pancreas (diabetes), joints (arthralgia), skin (hyperpigmentation)

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26
Q

What are the advantages of day case surgery?

A
  • Shorter inpatient stay
  • Lower infection rate

- Cheaper

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27
Q

What is the criteria for day-case surgery?

A

Minimal blood loss

Short operating time <1hr

No intra-operative or post operative complications

No specialist aftercare

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28
Q

What are the pre-operative elements to the enhanced recovery after surgery?

A
  • Patient education regarding surgery
  • Encourage weight loss and smoking/alcohol cessation
  • Solids until 6 hours pre-op
  • Clear fluids until 2 hours pre-op
  • Loading with 12.5% carb beverage within 2 hours of surgery
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29
Q

What are the intra-operative steps to ERAS?

A
  • Use of opiod-sparing analgesia e.g. regial anaesthesia
  • Use minimally invasive surgery
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30
Q

What are the post op elements to ERAS?

A
  • Adequate pain control
  • Early oral intake
  • Multi-displinary post-op patient follow up
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31
Q

What proportion of the total body weight is water?

A

2/3 (2/3 is intracellular fluid and 1/3 is extracellular)

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32
Q

How is the fluid in the extracellular space divided?

A

1/5th is intravascular and 4/5th in the interstitium

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33
Q

What are insensible losses of fluid?

A

Losses from non-urine sources

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34
Q

How can fluid depletion be examined for?

A
  • Dry mucous membranes / reduced skin turgour
  • Decreasing urine output
  • Orthostatin hypotension

Worsening = increased cap refil, tachycardia, low BP

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35
Q

How to examine for fluid overload?

A
  • Raised JVP
  • Peripheral oedema
  • Pulmonary oedema
36
Q

What are the daily requirements for water, Na+, K+ and glucose?

A

Water = 25 mL/kg/day

Na+ = 1 mmol/kg/day

K+ = 1 mmol/kg/day

Glucose = 50g/day

37
Q

Where can 3rd space losses be?

A

Into bowel lumen (bowel obstruction) or into the retroperitoneum (as in pancreatitis)

38
Q

What are some crystalloids?

A

5% Dextrose (only dextrose and water - used in fluid maintenance - no calorific value)

Normal saline 0.9% NaCl used in resuscitation and maintenance regimes

Hartmann’s - more physiological than normal saline (contains lactate - do not confuse with lactic acid, can’t then use lactate - conjugate base - as marker of acidosis)

39
Q

Give an example of a colloid?

A
  • High albumin solution (used in decompensating liver disease)
40
Q

What are malnourished patients at risk of?

A

Reduced wound healing

Increased infection rates

Increased skin breakdown

41
Q

What screening tool for malnutrition can be used?

A

Malnutrition universal screening tool

42
Q

How may disease-related cachexia be noted?

A
  • Muscle wasting
  • Loose skin
  • Clothes not fitting
  • Apthous ulcers
  • Angular cheilitis
43
Q

What is the preferential order or feeding?

A

Oral nutritional supplements

Nasogastric tube feeding

Gastrostomy feeding (PEG)

Jejunal feeding (jejunostomy)

Parenteral nutrition

44
Q

What does a low serum albumin reflect?

A

Chronic inflammation

Proteinuria

Hepatic dysfunction

45
Q

What are the basic components of enhanced recovery after surgery?

A

- Reduction in nil by mouth

- Pre op carb loading

- Minimally invasive surgery

- Minimising the use of drains and nasogastric tubes

- Rapid reintroduction of feeding post op

- Early mobilisation

46
Q

Why do entero-cutaneous fistulae not necessitate parenteral nutrition straight away?

A

Proportion of ECF that heal spontaneously with PN is relatively small so strategy should be supporting nutrition prior to a likely surgical repair

47
Q

How are high and low ECF treates respectively?

A

High (jejunal) = enteral or parenteral nutrition

Low (ileum/colon) = low fibre diet

48
Q

What is the pre-op assessment for?

A

Identify any co-morbidities that may lead to patient complications

49
Q

What PMH should be elicited in pre-op assessments?

A
  • CVD (HTN and exercise tolerance, risk of cardiac even increases during anaesthesia)
  • Respiratory disease
  • Renal disease
  • Endocrine disease
50
Q

What are some pre-op assessment questions?

A
  • Previous operations?
  • Anaestheia before?
  • Drug history? Drug allergies?
  • Malignant hyperpyrexia?
  • Smoking / alcohol intake
51
Q

What does ASA grade 5 indicate?

A

Not espected to servive without operation

52
Q

What pre-op investigations are there?

A
  • FBC: anaemia or thrombocytopenia
  • U&Es: assess baseline renal function for IV fluids
  • LFTs: assessing synthesising function
  • Clotting screen: warfarin users, haemophila A/B
  • Group and save
53
Q

What pre-op imaging is there?

A
  • ECG for a baseline
  • CXR: e.g. for those with resp illness and no CXR in 12 months, smoking history
  • Additional: Pregnancy testing, Sickle cell test, Urinalysis, MRSA swabs
54
Q

What classification correlates with difficulty of intubation?

A

Mallampati classification

55
Q

When should patients stop eating foot / dairy products?

When should patients stop clear fluids before surgery?

A

Food = 6 hours before

Clear fluids = 2 hours before

56
Q

Why do patients fast before surgery?

A

Reduces risk of pulmonary aspiration

57
Q

What prescriptions to stop before surgery and when?

A

Clopidogrel - 7 days prior to surgery due to bleeding risk

Hypoglycaemics

COCP - 4 weeks due to risk of DVT

Warfarin - 5 days

58
Q

What drugs to alter before surgery?

A

Subcut insulin switched to IV variable rate insulin infusion

Long-term steroids - musch be continued IV hydrocortisone

59
Q

What drugs to start peri-operatively?

A

LMWH - based on VTE risk assessment (with exception of neck/endocrine surgical patients)

TED stockings - below knee ted stockings (exception of PVD, recent skin grafts and severe eczema)

Antibiotic prophylaxis - patients havign orthopaedic, vascular or GI surgery have prophylactic antibiotics

60
Q

How are patients with T1DM treated peri-operatively/

A

First on the morning list

Night before surgery reduce subcut insulin dose by 1/3 and omit morning insulin and commence an IV variable rate insulin infusion pump (‘sliding scale’ with actrapid)

Prescribe 5% dextrose and check capillary glucose every 2 hours

Continue until eating then overlap their IV variable rate insulin

61
Q

How are patients with T2DM treated?

A
  • If diet controlled then no action required
  • If on metformin this should be stopped mornign of surgery and other oral hypoglycaemics stopped 24 hours before
  • Patients then put on IV variable rate insulin along with 5% dextrose
62
Q

When is bowel prep needed? What is given?

A

Left hemi-colectomy, sigmoid colectomy or abdominal-perineal resection: Phosphate enema morning of surgery

Anterior resection: 2 sachets of picolax the day before

63
Q

What are the 3 types of delerium?

A
  • Hypoactive - lethargy and reduced motor activity
  • Hyperactive - agitation and increased motor activity
  • Mixed - fluctuations throughout the day
64
Q

What are the risk factors for delerium?

A

Age>65

Multiple co-morbidities

Underlying dementia

Renal impairment

Sensory impairment

65
Q

What are the common causes of delerium?

A

Hypoxia (post-operatively)

Infection (UTI or LRTI)

Drug induced (benzo, diuretics, opiods) or drug withdrawals

Constipation or urinary retention

Electrolyte abnormalities (hyponatraemia, hypernatraemia, or hypercalcaemia)

66
Q

How to assess a delerious patient?

A
  • Get a collateral history from family
  • When did it start?
  • Any symptoms of an underlying cause?
  • Co-morbidities and previous baseline cognition
  • Previous episodes?
  • Drug history?
67
Q

What test can be used for delerium?

A

Abbreviated mental test

Mini-mental state examination

68
Q

What to review in a patient with delerium?

A

Review observations

Drug chart

Signs of infection (surgical site infection)?

Signs of pain?

Signs of constipation or urinary retention?

69
Q

What are some examples of AMT questions?

A

Age

Time to nearest hour

Address (for recall at end)

70
Q

What is the confusion screen for post-op patients?

A

Bloods - FBC, U&Es, Ca2+, TFTs, glucose, B12, folate

Blood culture / wound swab

Urinalysis and or CXR

CT head (if relevant)

71
Q

How to manage delerium?

A

Identified cause of delerium treated: abx/ nasal oxygen/ laxatives

Nursed in quiet environment with clocks and regular sleeping pattern promoted

Encourage oral fluid intake, provide analgesia

Haloperidol is 1st line sedative treatment

72
Q

When does post-op nausea and vomiting usually occur?

A

Within first 24-48 hours post surgery

73
Q

What are the consequences for PONV?

A

Increased anxiety for future surgical proceduces

Increased recovery time and hospital stay

Aspiration pneumonia

Incisional hernias

74
Q

What are some risk factors for post-op nausea and vomiting?

A
  • Female
  • Age (decreases throughout life)
  • Previous PONV or motion sickness
  • Opiod analgesics
  • Non-smoker
  • Intra-abdominal laparoscopic surgery
  • Middle ear surgery
  • Gynaecological surgery
  • Poor pain control post surgery
75
Q

What areas in the brain control vomiting and nausea? What are the relevant neurotransmitters?

A

Vomiting centre in the medulla (Histamine and 5HT3 receptors)

Chemoreceptor trigger zone outside the BBB in 4th ventricle (Dopamine and 5HT3 receptors)

76
Q

What are the neurotransmitters targetted in the GI tract?

A

Dopamine

77
Q

What is the first priority with a patient with PONV?

A

Ensure they are stable - if not A-E?

78
Q

What to consider with PONV assessment?

A

Operation likely to cause PONV?

Which anaesthetics?

Which antiemetic?

Consider infection, GI causes (post-op ileus, bowel obstruction), metabolic causes (hypercalcaemia, uraemia, DKA), medication (antibiotics, opiods), CNS causes (raised ICP), or anxiety.

79
Q

How to manage post-op nausea and vomiting?

A
  • Fluid hydration
  • Adequate analgesia
80
Q

What is the anti-emetic of choice?

A

Impaired gastric emptying: prokinetic e.g. metoclopramide (dopamine antagonist) or domperidone (dopamine antagonist) unless bowel obstruction if suspected

Bowel obstruction: hyoscine (anti-muscarinic) can help to reduce secretions

Metabolic imbalance e.g. uraemia, electrolyte imbalance or cytotoxic agents should have metoclopramide

Opiod induced: ondansetron (5-HT3 receptor antagonist) or cyclixine (H1 histamine receptor antagonist)

81
Q

What are the consequences of poor-post op pain control?

A

Slower recovery: reluctant to mobilise = slower restoration of function

Not breathing as deeply: inadequate ventilation and atelectasis = hospital acquired pneumonia

82
Q

What are the steps to the pain ladder?

A

1st = simple analgesia paracetamol / NSAIDs (inhibit synthesis of prostaglandins reducing inflammation)

2nd = weak opiates (codeine/tramadol) reassess after 2 hours

3rd = strong opiates (morphine / fentanyl) can cause constipation and nausea (possibly sedation, confusion and respiratory distress)

83
Q

What are the side effects of NSAIDs?

A

Interactions (e.g. with warfarin)

Gastric ulceration (consider PPI when prescription is long term)

Renal impairment (use NSAIDs sparingly here)

Asthma sensitivity (triggers asthma in 10% of patients)

Bleeding risk (effect on platelet function)

84
Q

How long does morphine take to work:

Orally

IM

IV?

A

Orally = 20 mins

IM = 15 mins

IV = 2-3 mins

85
Q

When are patient controlled analgesia usually started?

A

In theatre

86
Q

What is an advantage and disadvantage of PCA?

A

Advantage = analgesia which is tailored to requirements, risk of overdose is negligible and is accutate

Disadvantage = prevent patient from mobilising, not for learning difficulties

87
Q
A

Surgery - DONE (9 decks)

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